This study was designed to clarify the postoperative QOL and gastric emptying after conservative surgery for early gastric cancer. Five cases undergoing pylorus-preserving gastrectomy (PPG) and 11 cases undergoing wedge resection were comparatively investigated. The indications for pylorus-preserv-ing surgery were mucosal cancer on EUS, and the tumor which occupied M-region and was well-differentiated and elevated lesion with the size of less than 30mm on PPG. Wedge resection was indicated for elevated and flat lesions with the size of less than 30mm or depressed lesions without ulcerative fibrosis with the size of less than 15mm. The patient's QOL was evaluated in terms of the changes in oral intake and body weight, symptoms, findings of gastrofiberscopy (GFS) and gastric emptying by acetaminophen. The volume of oral intake and body weight recoverd to preoperative levels 6 months after the operation in 10 out of 11 wedge resection cases, but only one case of PPG recovered. The postprandial heavy feelings were observed in three cases of PPG. The bezoar was observed in four cases of PPG. The postoprandial heavy feelings and bezoar were not observed in wedge resection cases. The gastric emptying after both resections increased gradually as well as normal controls, but that in wedge resection tended to be late compared with normal controls.
In conclusion, the postoperative QOL in patients undergoing wedge resection as a more limited operation for early gastric cancer was well-preserved compared to PPG.

View full abstract

To clarify whether preoperative transcatheter arterial chemoembolization (TAE) improves the prognosis and incidence of recurrence in patients with hepatocellular carcinoma (HCC), 49 patients who had undergone curative hepatectomies for HCC were retrospectively examined. These 49 patients were divided into two groups for comparison; 24 patients who underwent preoperative TAE (group A) and 25 patients who did not (group B). No significant differences in outcome were observed between these two groups, except with regard to clinical stage. A significantly more patients in stage II were involved in the group A. Although no significant differences in the survival rate were found between group A and B, the 1, 3 and 5-year cumulative survival rates were 91.1%, 63.9% and 47.3% for group A and 86.3%, 68.0% and 46.6% for group B, respectively. Although no significant differences in the recurrence rate were found between group A and B, the 1, 2 and 3-year tumor-free survival rates were 76.3%, 31.8% and 25.4% for group A and 69.7%, 41.3% and 34.4% for group B, respectively. We suggest that pre-operative TAE is of little help from the standpoint of both recurrence and prognosis and consequently should not be routine procedure for resectable HCC.

View full abstract

To elucidate the clinical significance of MUC mucin expression in carcinoma of the gallbladder, studied the expression of MUC1 and MUC2 mucins immunohistochemically, and then the relationships between the degree of mucin expression and clinicopathological findings and prognosis. Subjects were 41 patients with carcinoma of the gallbladder. The immunoreactivities were divided into three grades: negative, low expression and high epression. The patients with a tumor showing higher expression of MUC1 significantly correlated with increasing depth of invasion and higher incidence of positive lymph node metastases (p<0.05). Although there was no statistical significance, the patients with a tumor showing higher expressin of MUCI tended to be in more advanced stage and to have a poorer prognosis. Contrary to MUC1, the patients with a tumor showing higher expression of MUC2 significantly correlated with lower incidence of peritoneal dissemination (p<0.05), and tended to have lower incidence of positive lymph node involvement. These results suggest that immunoreactivities of MUC1 and MUC2 mucin in carcinoma of the gallbladder correlate with clinicopathological factors such as depth of invasion, lymph node metastasis and peritoneal dissmination, and can be indicators of tumor progression.

View full abstract

In an operation for sigmoid colon cancer in a patient with congenital XI factor deficiency which was found preoperatively, perioperative bleeding was successfully controlled by replacing the XI factor with plasma pheresis. A 58-year-old man who had no previous history of abnormal hemostasis, was seen at the hospital because his stool was positive for occult blood at a medical checkup. Cancer of the sigmoid colon was diagnosed on a close exploration, and he was admitted for operation. Preoperative coagulation tests disclosed a prolongation of APTT. Close examination showed that the factor XI activity was as low as 1.8% and congenital XI factor deficiency was diagnosed. By replacing the factor XI with preoperative plasma pheresis, the activity was increased to 35% so that perioperative abnormal bleeding could be avoided for an operation for sigmoid colon cancer. And the patient presented direct increase in bilirubin during a fasting time before operation, showing an association of Gilbert syndrome.
Although congenital XI factor deficiency is a rare entity, the factor XI replacement with preoperative plasma pheresis is thought of value in performing laparotomies for such patients.

View full abstract

In this paper, we report a case of minute carcinoma of the thyroid appearing as distant metastasis to the rectus muscle. A 63-year-old man was seen at the hospital because of tumors on the anterior region of the neck and the left upper abdomen. We could palpate hard tumors, one was 3cm in diameter on the anterior region of the neck and the other was 1.2cm in diameter on the abdomen. We planned total thyroidectomy because we thought the rectus tumor to be the metastatic tumor from thyroid cancer but in the operation we found the tumor was completely isolated from the thyroid by the anterior neck muscle and no tumor was seen in the thyroid, so we preserved the thyroid. After the operation, a pathologist diagnosed the tumors as metastatic tumors from thyroid cancer. A total thyroidectomy was performed 2 weeks after the first operation. With close exploration of the resected thyroid, papillary carcinoma 1mm in diameter was detected. The patient remains healthy 20 months after the first operation and has had no evidence of recurrence, however, strict follow-up is important.

View full abstract

A 42-year-old woman was admitted to our hospital because of an eczematous lesion on an inverted right nipple. She was diagnosed with Paget's disease of the breast by clinical and cytological examina-tions. A palpable mass was not found in her right breast. A mammography showed only microcalcification within the nipple, and an ultrasonography showed no abnormal findings, such as a tumor shadow or duct ectasia. She was then examined using three-dimensional dynamic MRI (3D MRI) to assess the intramammary extent of Paget's disease as part of a pre-surgical examination. The 3D MRI findings showed a wide area of early enhancement, suggesting remarkable intraductal extension. We performed a sentinel lymphnode biopsy and, since sentinel lymphnode metastasis was not observed, a mastectomy without axillar disection. Histopathological findings revealed remarkable intraductal extension in the surgical specimen consistent with the early enhancement area on the 3D MRI findings. This demonstrates that 3D MRI is useful for the assessment of intraductal involvement in Paget's disease of the breast.

View full abstract

A phyllodees tumor associated with breast cancer is extremely rare. We treated a begign phyllodes tumor associated with noninvasive ductal carcinoma. The 47-year-old, premenopausal woman had a 4×3cm tumor in the D portion of the left breast and underwent resection. Pathological examination revealed associated noninvasive ductal carcinoma. Mastectomy preserving the pectoral muscle with axillary dissection was then conducted. Both ER and PgR of these tumors were negative.
Only 20 cases of phyllodes tumor associated with breast carcinoma have, to our knowledge, been reported in Japan. Of these, 15 were ipsilateral and 5 contralateral. Average patient age was 48.2 years. Seven of the 20 phyllodes tumors were benign, 10 were malignant, and 3 were borderline. Histologically, breast carcinoma involved 8 noninvasive carcinomas (40.0%). This is a higher rate than usual. Papillotubular and tubular carcinomas numbered 8 (40.0%). Most of the associated breast carcinomas were welldifferentiated.

View full abstract

A 73-year-old woman, who noticed a tumor on the left side of neck a few days earlier, was seen at the hospital on December 5, 1997. A CT scan and a magnetic resonance image revealed a 5cm sized tumor locating from the left side of the neck to the left side of the aortic arch. A biopsy offered a diagnosis of leiomyosarcoma. On February 24, 1998, an operation was performed by a median sternotomy and an anterior thoracotomy through the left third intercostal space. The left brachiocephalic, left internal jugular, and left subclavian veins were obliterated by tumor ingrowth, and were subsequently resected. Macroscopically, leiomyosarcoma arising from a venous wall was suspected. Thereafter, until March 29 2000, metastases took place to the right thigh, left buttock, occipital scalp, right subclavian region, left breast, buttocks, lumber region, right thigh, right crus, and abdominal wall. For these recurrent metastases total of nine resections were performed. As of July 2000, the patient carries multiple hepatic metastase.
A mediastinal leiomyosarcoma is extremely rare. There has been no case report in Japan of repeated multiple metastases to the soft parts. This paper presents a case of mediastinal leiomyosarcoma with repeated multiple metastases.

View full abstract

A 40-year-old woman was transferred to the hospital because of severe dyspnea, extensive subcutaneous emphysema caused by a blunt chest trauma. Her chest X-ray film showed multiple rib fractures, left clavicle fracture, bilateral pneumothorax and massive subcutaneous/mediastinal air. After bilateral thoracostomy tubes were placed and an incision of the right pectoralis major muscle sheath was made, cardiopulmonary arrest developed. Resuscitation was made successfully, but a chest X-ray film showed no improvement of lung expansion despite of positive pressure breathing and thoracic drainage. As a bronchofiberscopy revealed transection of the left main bronchus, emergency operation was performed. Through the 4th intercostal space on the clamshell incision, the transected main bronchus and longitudinally lacerated bronchial membrane were repaired with interrupted 3-0 Vicryl sutures and reinforced with a rolled piece of woven Vicryl mesh. Balloon dilatation was needed for the stenosis of anastomosis 3 weeks postoperatively. One year later, the patient is doing well, while a 3D-CT scan revealed the stenosis as before.

View full abstract

A 40-year-old woman presented with sudden onset of lower abdominal pain followed by severe dyspnea. Abdominal CT scan revealed an ovarian tumor. Pulmonary artery embolism (PE) was suspected due to tachypnea, a decline of blood pressure and jugular vein distention. PE was confirmed by pulmonary arteriography. On the same day, tissue plasminogen activator (tPA) was selectively administrated into the pulmonary artery through a Swan-ganz catheter, and heparin was administrated continuously to ensure anticoagulation. On the following day, the ovarian tumor was removed by a left adnexectomy because the clinical signs improved. Histology of the ovarian tumor showed clear cell ovarian adenocarcinoma. Because thrombosis was detected by venography and a pulmonary perfusion scan revealed no perfusion defects after the selective infusion of tPA and anticoagulant therapy, the PE secondary to the ruptured ovarian tumor was believed to have been caused by deep venous thrombosis resulting from compression of the inferior vena cava by the ovarian tumor. Though we had difficulty in giving the priority to either a pertinent course of clinical therapy, thrombolytic therapy, or an operation for the ovarian tumor, the postoperative course was uneventful.

View full abstract

A 37-year-old man was admitted to the hospital because of massive hemoptysis. A chest X-ray film showed decreased radiolucency in the right lower lung field. A chest CT scan revealed enhanced nodule medial to the right A⁸. Bronchoscopic examination revealed a narrowing of the right B⁸. During examination, he coughed up massive blood. Emergency intubation was done and a right lower lobectomy of the lung was performed. Histologic examination of the resected specimen revealed that the pulmonary arterial aneurysm perforated into the bronchus. After the operation, he developed persistent disturbance of consciousness by hypoxic encephalopathy and pyothorax. He was discharged very much improved on the 9th postoperative month. Peripheral pulmonary arterial aneurysm has rarely been reported. The establishment of early diagnosis and treatment is important in managing the rupture of pulmonary arterial aneurysm that can cause hypovolemic shock and acute respiratory failure.

View full abstract

A 25-year-old woman, who had been pointed out having a round abnormal shadow in the left upper lung on a chest plain x-ray film in the department of internal medicine of this hospital about 4 years earlier, was referred to the department of surgery because of an increasing tendency of the abnormal shadow. The patient was admitted for a close study. Tumor markers and blood biochemical tests were within normal limits. Chest plain x-ray film and a chest CT scan revealed an about 2-cm sized round, well circumscribed abnormal shadow in the segment 8. TBLB yielded clear cell (class I). No malignancy was disclosed in other organs. From these findings, a left pulmonary benign tumor was diagnosed. A possibility of malignancy could, however, not be ruled out, so that we selected a surgery. Through a left axillary thoracotomy, a segmentectomy (S8) was performed. The intraoperative frozen section showed no malignancy. Pathohistologically the excised tissue was diagnosed as benign clear cell tumor.
Since clear cell tumor of the lung rare, this case is presented along with bibliographical comments.

View full abstract

We treated a patient with spontaneous esophageal rupture using transhiatal approach with median phrenotomy. A 45-year-old man went to a nearby hospital due to back pain after vomiting and was diagnosed with aneurysmal rupture of the descending aorta. He was transferred to our hospital and underwent a chest CT scan and esophagography that showed spontaneous esophageal rupture. Conservative therapy with bilateral chest drainage yielded no symptomatic remission. Respiratory failure necessitated emergency surgery 9 days after onset. Removal of the infected material, lavage, and drainage were conducted after exposure of mediastinum and bilateral thoracic cavity by laparotomy with median phrenotomy. The ruptured wall in the lower esophagus was directly closed and reinforced with a fundic patch. He then underwent feeding jejunostomy and tracheotomy. The postoperative course was uneventful except for respiratory dysfunction persisting perioperatively. A transhiatal approach with median phrenotomy is useful because it has less influence on pulmonary function than conventional intercostal thoracotomy and enables both posterior mediastinal and bilateral intrathoracic procedures under direct, wide vision. This transhiatal procedure may be applied to patients with spontaneous esophageal rupture, especially to of the lower esophagus.

View full abstract

Two cases of so called buried bumper syndrome (BBS) in which a bumper at the tip of a gastrostomy tube was buried in the abdominal wall following percutaneous endoscopic gastrostomy (PEG) are reported here. Patient 1, a 90-year-old man, had dysphagia for cerebral infarction and underwent a PEG. Thereafter, he became possible to eat by mouth and a gastrostomy tube was exchanged with Gas-trobutton^® The patient was seen at the department because of fever and pus discharge from the gastrostomy. Abdominal CT scan revealed a bumper buried in the peritoneal wall, and BBS was diagnosed. The Gastrobutton^® was percutaneously removed and his symptoms were subsided.
Patient 2, a 73-year-old man, underwent a PEG for dysphagia due to cerebral hemorrhage. Poor infusion from a gastostomy tube, and flare as well as swelling surrounding the gastrostomy developed, and then the patient was seen at the department. From abdominal CT and fistulographic findings, BBS was diagnosed. The gastrostomy tube was percutaneously removed and central venous nutrition was started. Thereafter, symptomatic remission was immediately obtained. Later on, a PEG for another lesion was performed.

View full abstract

A 55-year-old man was brought into the hospital because of abdominal pain due to ingestion of sulfuric acid for suicidal mean. Corrosive gastritis was diagnosed and the patient was conservatively treated. The symptoms were relieved by medical treatment and the patient was discharged from the hospital. Two months after acid ingestion, however, vomiting occurred frequently and the patient was re-admitted. Endoscopy and barium studies revealed severe mucosal erosion and stenosis at the upper body of the stomach. Thus, we performed a total gastrectomy. Specimen showed severe atrophy and thickening of the wall. On histological examination, fibrosis of the submucosal layer was remarkable. Postoperative course was uneventful, and the patient is doing well as of 3 years and 7 months. Gastrectomy is often necessary when severe scarring and fibrosis causes gastric outlet obstruction. Long -term follow-up of a patient who has taken corrosives is necessary.

View full abstract

A 75-year-old man maintained on hemodialysis for 3 years was admitted to the hospital for an elevation of ALP (455U/l). Abdominal ultrasonography revealed a dilatation from the intrahepatic bile duct to common bile duct. Abdominal CT scan revealed a tumor in the common bile duct. Duodenoscopy showed an elevation of the ampulla 2cm in diameter. Biopsy specimen was diagnosed as well-differentiated adenocarcinoma. ERCP and PTC revealed an eggshell defect at the lower dilated common bile duct. Pancreatoduodenectomy with D2 lymph node dissection was performed. Histologically, the tumor consisted with adenocarcinoma, Ac×b-Bi, pap, INFβ, intermediate, ly1, v1, pn0, pancla, d1, hw0, ew0, n0. Postoperative course was eventful for a minor leakage at the pancreatojejunostomy started in the 8th day after the surgery. The patient was discharged from the hospital 60 days after the operation. It is possible that patients with only ALP elevation and intrahepatic dilatation have advanced ampulla carcinoma as pancla, dl pathologically. Therefore, upper gastroduodenoscopy including ERCP is nessesary. This case suggests that intensive perioperative care enables regular hemodialysis patient with chronic renal failure to undergo highly stressful operation such as pancreatoduodenectomy, without critical complications.

View full abstract

This paper presents a case of intraperitoneal loose body with difficulty in differentiation from gastric calculus ileus. An 88-year-old man was admitted to the hospital because of abdominal pain and vomit. Plain abdominal roentgenogram and an abdominal CT scan revealed ileus and a calcification spot (6cm) in the right hypochondrium. Because of no anamnesis of laparotomy, we suspected gastric calculus ileus and performed a laparotomy. It revealed that a cause of ileus was obstruction due to wide ranging adhesion of the intestine, and a huge intraperitoneal loose body 6.8cm×6.5cm in size was present near the obstruction. Histopathological findings were compatible with intraperitoneal loose body. The strongest hypothesis is that intraperitoneal loose body originates from inflammation and detachment of epiploic appendage. We think that epiploic appeandage might participate in the origin of intraperitoneal loose body bnd intestinal adhesion in this case.

View full abstract

A 32-year-old, pregnant woman, who had no previous history of operation, developed intestinal obstruction at 21st week of gestation. Abdominal exploration revealed a 40-cm portion of the small intestine which was elevated due to pregnancy, was strangulated by an adhesive fibrous band between the liver and anterior abdominal wall. The band was divided and the ischemic intestine was resected. She recovered from the surgery and was delivered a healthy female baby at term.
Intestinal obstruction during pregnancy is rare, and the most cases are of adhesive intestinal obstruction associated with a previous history of undergoing some abdominal surgery. The reason of perihepatic adhesion in this patient was unknown, however, intestinal obstruction by adhesions should not be excluded automatically in pregnant woman, even without a previous history of operation.

View full abstract

A 77-year-old woman complaining of abdominal pain was referred to the hospital because she developed peritoneal signs after about one-week conservative therapy with a diagnosis of ischemic enteritis at another hospital. On admission, a fist-sized tumor in the right lower abdomen was felt, and there were muscle guarding and rebound tenderness. On blood biochemical tests, WBC was 16900/mm³ and CRP was 19.5mg/dl, revealing high degree of inflammation. Peritonitis due to appendicitis was thought and an emergency operation was performed. During surgery, regional and transmual necrosis extending from the ileum 60cm distal to the terminal ileum to the ascending colon was confirmed. For that, a right colectomy including a portion of ileum 80cm in length was performed. Histopathologically no thrombi were observed in the main arteries and veins, and then nonocclusive mesenteric ischemia (NOMI) was diagnosed.
NOMI is a disorder with an extremely poor prognosis. We present the patient with NOMI whose life was successfully saved by the emergency operation, together with some bibliographical comments.

View full abstract

This paper presents a case of ileus caused by an appendix epiploica.
A 59-year-old woman who had an abdominal pain lasting for 4 days was admitted to the hospital with a diagnosis of ileus on May 24, 2000. Immediately after admission, an ileus tube was inserted. Fluoroscopic study of the small intestine revealed narrowing of the jejunum 50cm from the Treitz' ligament. So a laparotomy was performed on the 6th day after the insertion. During the operation, we observed that an appendix epiploica of the transverse colon extended long, which was once adherent to the mesentery of small intestine, and then further adherent to the small intestinal wall with its tip to form two loops; and that the small intestine was impacted into these two loops and obstructed. When the appendix epiploica was resected and ileus was relieved, no necrosis was seen there and no intestinal resection was needed. Pathological study revealed the appendix epiploica with bleeding and fibrosis.
In the case of ileus due to an appendix epiploica, intestinal obstruction is caused by oppression to the small intestine due to a cord, obstruction of the attached colon which is bent by adhesion, direct compression to the colon due to inflammation, and specific morphology. This is the 5th case of ileus caused by an appendix epiploica in Japan.

View full abstract

We report a case of perforative peritonitis due to radiation enteritis. An 88-year-old woman who had undergone pelvic irradiation for a gynecological malignancy was referred to our hospital due to hematomesis and epigastralgia with fever. We determined that she had perforative peritonitis, based on intraabdominal extrabowel gases in abdominal computed tomography. We conducted emergency operation to resect the damaged bowel, such as necrotic intestine combound with a damaged bladder in “frozen pelvis” and reconstruct jejuno-ascending colostomy. Pathological findings for resected specimens were compatible with radiation enteritis, such as excessive collagen deposition within the bowel wall, vasculitis, and intramural edema. The woman had a jejuno-subcutaneous fistula and suffered recurrent urinary infection or jaundice due to chronic hepatitis C after the surgical procedure. But eight months later, recovery enabled a successful second laparotomy to reconstruct the residual intestine. Even long after irradiation for malignant disease, radioactive damage to the body as a whole should always be considered.

View full abstract

A case of a submucosal tumor like elevated lesion of the cecum due to xanthogranulomatous inflammation, that is the first case report to our knowledge, is described. A 52-year-old woman was admitted to the hospital because of an ileocecal tumor. Colonoscopy and a contrast enema revealed a submucosal tumor like elevated lesion of the cecum. Ileocecal resection was performed, since a possibility of malignancy could not be ruled out. During surgery, the vermiform appendix and greater omentum were adherent to the cecum, and consequently a firm tumor was formed. Histologically, xanthogranulomatous inflammation was present mainly in the adherent portion and spreaded to the submucosa beyond the muscularis propria of the cecum. Xanthogranulomatous inflammation might cause a submucosal tumor like elevated lesion of the cecum. Although it is rare, the disease must be added to possible differential diagnoses for ileocecal tumors.

View full abstract

We report a case of severe obstructive colitis due to rectal cancer. A 73-year-old woman was admitted to our hospital with abdominal pain, diarrhea, and abdominal distension. Anal digital examination and colonoscopy revealed an annular rectal tumor. Plain abdominal X-ray and abdominal CT scan showed marked dilation of the intestine. Ileus due to obstructing annular rectal cancer was diagnosed. She went into shock 10 hours after onset and we conducted an emergency laparotomy. Obstructive colitis of the entire proximal colon and 2 necrotic lesions of the small bowel were found, necessitating total proctcolectomy and 2 partial resections of the small bowel with an ileostomy. Histological examination of the specimen showed ischemic changes of the bowel wall and Gram stain revealed the presence of Gram-positive rods within the colonic mucosa. We speculated that, in addition to microvascular hypoperfusion due to arteriosclerosis, bacterial proliferation in the large bowel and exotoxins produced rapid spread of the disease, making her condition critical.

View full abstract

A case involved a 25-year-old woman, who had been suspected of having ulcerative colitis on a barium enema study in 1996. On April 18, 2000, when she returned to Japan, more than ten times per day of diarrhea, fever over 38°C, and abdominal pain started. On April 28, she was admitted to the hospital. Although no prominent blood was contained in stools, ulcerative colitis was diagnosed and concervative therapy was started. On the 4th hospital day, peritoneal signs were noted and an abdominal x-ray examination revealed dilated colonic gas image. Emergency operation was performed with a diagnosis of perforative genaralized peritonitis due to toxic megacolon. Upon laparotomy, the transverse colon significantly dilated, and there were small perforations in the cecum, transverse colon, and sigmoid colon. Subtotal colectomy, an ileostomy and sigmoidcolostomy were made. Histopathological findings included ulcers of Ul-III to IV in the cecum, transverse colon, and sigmoid colon. After the operation, the patient was associated with infection of the surgical wound and adhesive intestinal obstruction, but were successfully treated by conservative therapy. The patient was discarged from the hospital on July 11.
Prforation of ulcerative colitis is relatively rare. This paper presents our case together with 25 domestic cases as far as we could review.

View full abstract

A 58-year-old man was admitted to the hospital because of abdominal pain. A tumor was palpated in the upper abdomen. Abdominal plain X-ray film showed niveau. A barium enema study showed a crab-finger finding in the ascending colon leading to the diagnosis of intussusception. A hemispherical protrusion still remained after reduction of the intussusception. Colonoscopy also revealed submucosal tumor in the cecum. Abdominal CT scan and ultrasound showed a cystic tumor. The patient was diagnosed as having appendiceal mucocele associated with intussusception. On laparoscopy, appendiceal mucocele was found loosely attached to the retroperitoneum and invaginating into the cecum. Laparos-copy-assisted cecectomy was performed. The appendix, 12cm×3cm×3cm in size, was swollen and filled with mucin. Pathological diagnosis was mucinous cystadenoma of the appendix.
Laparoscopic procedure is very useful to the treatment of the appendiceal mucocele complicated with intussusception, in respects of the curability and less invasiveness.

View full abstract

An 88-year-old woman with dementia was seen at the hospital because of abdominal pain while she stayed at a healthy center for aged patients.
Chest X-ray film and an abdominal CT scan showed free air and a tumor of the ascending colon. Perforation of the intestine was diagnosed, and an emergency operation was performed.
During operation, we found a tumor of the ascending colon and a 5mm-sized perforation of the ileum in the oral side from the tumor. There was a stick like foreign body in the lumen of that intestine, We thought that this patient had misswallowed it because of her dementia. Resected specimen showed cancer of the ascending colon and perforation in the ileum. It was inferred that the foreign body stagnated by the cancer and had caused ileal perforation.
We should take care of occult malignant tumor and foreign body in the intestines on the aged patients with dementia.

View full abstract

We report herein a case of a colonic cancer in the blind loop following an operation for cancer of the ascending colon. An 85-year-old woman who had a history of undergoing an ileocolic resection with an end-to-side ileotransversal anastomosis for cancer of the ascending colon, 40 years earlier, was admitted to the hospital because of occult blood on December 2, 1999. On endoscopic examination, an advanced cancer was observed in the blind loop (17cm in length). The resection of the blind loop was performed. Histological diagnosis was a moderately differentiated adenocarcinoma and 7 tubular adenomas under 5mm in diameter.
Cancer in the blind loop was rare and only seven cases have been reported in the Japanese literature. Four of these seven cases were of bypass type and three cases were of blind segment type. Cancers of bypass type were in an advanced stage due to the difficulty of making the diagnosis. The mechanism and incidence of the cancers in the blind loop have been unknown. Change of bacterial flora in the blind loop might be a potential carcinogenesis. Further collection of clinical cases are necessary to determine the carcinogenesis in the blind loop.

View full abstract

A 60-year-old man was admitted to the hospital because of general fatigue. On 40th day after a resection of α-fetoprotein (AFP) producing cancer of the transverse colon, serum AFP increased again and an abdominal CT scan revealed a hepatic tumor. With a diagnosis of metastatic hepatic cancer, a lateral segmentectomy was performed. Histologically it was poorly differentiated adenocarcinoma which was almost the same as the cancer of the transverse colon; a part of the poorly differentiated tissues was positive for AFP immunostaining. Serum elevated AFP level rapidly decreased and was in normal limit 2 months after the second operation. There have been no signs of metastasis or recurrence in the liver and other celiac organs as of 24 months after the second operation.
So far clinical cases of AFP-producing colorectal cancer have rarely been reported. Most of them had severe hepatic metatasis and the resultant poor prognosis. Only seven patients including our patient underwent hepatectomy, one of whom died of cancer 3 months after hepatectomy. In the treatment of AFP-producing gastrointestinal cancer, close exploration for hepatic metastasis must be made on a usual basis and an early start of strict observation of clinical course after operation is demanded by measuring serum AFP and using imaging procedures. Further, it is essential to measure serum AFP levels from preoperative period for the treatment of GI cancers.

View full abstract

A 73-year-old man was admitted to the hospital for close examination of elevated serum levels of CEA and CA19-9 which were pointed out elsewhere one month before admission. There was a previous history of undergoing on emergency operation for peritonitis caused by perforation of rectal carcinoma about 4.5 years before admission. Abdominal CT scan and Ultrasonography showed a liver tumor, 5cm in diameter, in S6 and a localized dilation of the intrahepatic bile duct. A heterogeneous tumor accompanied by calcification and was enhanced marginally. Magnetic resonance imaging showed a low intensity mass on Tl-weighted images and an irregular high intensity mass on T2-weighted images. Magnetic resonance cholangiopancreography revealed a dilation of the posterior inferior segmental duct (B6). A S6 subsegmentectomy was performed under the diagnosis of metastatic liver tumor with tumor development in the bile duct. At operation, tumor embolus in the bile duct was observed by cutting the branch of B6. We finished a hepatectomy after removing the embolus. Resected specimen showed massive infiltration of the tumor into intrahepatic bile ducts with forming the tumor embolus. Histologically, the tumor, 6.0×4.0cm in size, was well-differentiated adenocarcinoma, similar to the rectal carcinoma. The definite diagnosis of hepatic metastasis of the rectal carcinoma was made.

View full abstract

We present a case of inflammatory pseudotumor of the liver with a review of the literature. An 81-year-old woman, who had undergone a pancreatoduodenectomy for carcinoma of the papilla of Vater 14 years earlier was seen at the hospital bacause of fever and liver dysfunction. Abdominal ultrasonography demonstrated hypoechoic mass 6.0cm in diameter in the area of S6 of the liver and an enhanced CT scan visualised a low density mass and enhancement around the tumor. Abdominal MRI showed a low intensity in T1 and high intensity in T2. Histological findings of needle biopsy specimen revealed only fatty degeneration. Since malignancy could not be completely ruled out, a partial hepatectomy was carried out. Excised specimen was a yellowish-white tumor with clear border. Histological findings showed granuloma consisted of plasma cells, histiocytes, lymphoidcytes, and fibrous cells. The diagnosis of inflammatory pseudotumor of the liver was established histologically. Inflammatory pseudotumor of the liver is so rare that 68 cases have been reported in the Japanese literature, and this is the first case of the disease in the aged over 80.

View full abstract

Hemophilia B is a relatively rare entity and particular attention must be paid for even small bleeding which can cause a fatal outcome. This time, we successfully and safely performed a hepatectomy to a patient with hemophilia B by supplying factor IX. The patient was a 67-year-old man who was diagnosed as having hemophilia B when he underwent an orthopedic surgery in 1984. There was a history of undergoing an uneventful laparoscopic cholecystectomy with transfusion of factor IX concentrate. At his medical check up, a low echogenic mass was detected in the segment 6 of liver by ultrasonography and he was referred to the department for resection of the liver tumor. On admission, the activated partial thromboplastin time (APTT) was slightly prolonged, and the serum factor IX activity was 18%. On the day before surgery, he was given 5000 U of facor IX, which increased his factor IX activity to 120%. The dose was calculated on the basis that transfusing factor IX at 1 U/kg increases the factor IX activity by about 1%. He received 5000 U of factor IX concentrate daily for 9 days and then 2500 U daily from day 8 to 12 after surgery. Partial hepatectomy was safely performed and the postoperative course was uneventful.
To our knowledge, this is the first report of successful hepatectomy to a hemophilia B patient. We describe the details of our management for this patient with hemophilia B.

View full abstract

This paper presents a case of hepatocellular carcinoma associated with congenital antithrombin III (ATIII) deficiency which was successfully operated on. A 65-year-old man was admitted to the hospital bacause of abdominal pain. The patient had a history of thrombosis of the lower leg and his two sons had been diagnosed as having congenital ATIII deficiency. Abdominal ultrasonography demonstrated a tumor in the right lobe of the liver. With close exploration, it was diagnosed as HCV positive chronic hepatitis and hepatocellular carcinoma. His preoperative ATIII activity was only 22% of the normal value. ATIII concentrates were administered to prevent perioperative thrombosis and a hepatectomy of the anterior segment was performed. Postoperatively not only ATIII concentrates but also fresh frozen plasma and protease inhibitor were administered, so that no complications including venous trombosis occurred during the postoperative course.

View full abstract

A 62-year-old man was admitted to the hospital because of upper abdominal pain. Abdominal ultrasonography and an abdominal CT scan revealed a hepatic tumor 7cm in diameter in the liver S8. In addition, an abdominal angiography showed lateral stricture like compression at the beginning of celiac artery and a dilatation of the pancreatic arcade artery. Hepatocellular carcinoma with celiac artery compression syndrome due to median arcuate ligament was diagnosed. Dissection of the median arcuate ligament and a subsegmentectomy of liver S8 were performed. Histopathological diagnosis was moderately differentiated hepatocellular carcinoma. Angiography after the operation disclosed that the stricture of celiac artery was improved, blood flow in the common hepatic artery and gastroduodenal artery became anterograde, and the dilatation of pancreatoduodenal arcade disappeared. We report the case, because to relieve the compression to the beginning of celiac artery with dissection of median arcuate ligament, which is a relatively easy procedure, is important, in cases in which TAE may be required postoperatively.

View full abstract

Primary endocrine cell carcinoma of the gallbladder is rare. We report a case of endocrine cell carcinoma of the gallbladder coexisted with adenocarcinoma in a 76-year-old woman. In preoperative examinations for gastric cancer, an abdominal computed tomography and an ultrasonography revealed a tumor in the fundus of the gallbladder. The intraoperative pathological diagnosis was adenocarcinoma of the gallbladder. Therefore, a liver bed resection with lymph node dissection was performed. The tumor showed nodular protruded type and was 19×18mm in size on diameter. Histological findings demonstrated that the tumor consisted of adenocarcinoma and endocrine cell carcinoma. In the area of endocrine cell carcinoma, the tumor cells revealed nest and trabecular pattern. Positive Chromogranin A and Grimelius stainings were observed in these cells. The definite diagnosis of adeno-endocrine cell carcinoma was made. Lymph node metastasis was seen in the hepatoduodenal ligament. A transition between these two type carcinomas was observed. The fact appeared to support a theory that endocrine cell carcinoma might be originated from adenocarcinoma. We consider that this endocrine cell carcinoma might have a high malignant potential, because lymph node metastasis and vascular invasion were observed in the early state.

View full abstract

A case of biloma which was silent and was removed following cholecystectomy is herein reported.
A 58-year-old woman was referred to the hospital because of a cystic mass below the right lobe of the liver which was found by an abdominal computed tomography at a periodic medical check-up. She had ha a cholecystectomy before 11 mouths and had no reoccuring sympotoms. Findings of abdominal ultrasonography and drip infusion cholangiography-computed tomography revealed the cystic mass to be 4cm in diameter. Biloma was suspected. After a laparotomy, a puncture to the cystic mass was performed, and the mass was diagnosed as biloma macroscopically because the fluid from the cystic tumor was like bile juice. This was confirmed by an intraoperative cystography which showed the cyst jutting out into the liver without communicating to the intrahepatic bile duct. The cystic mass was resected as possible as we can. The pathological diagnosis was that the pseudocyst consisted of fibroblast and no epithelium. The postoperative course was uneventfull. This disease requires to make the definite diagnosis with confirmation of bile juice in the cystic content, and thereby to treat the original cause.

View full abstract

We herein report a case of signet ring cell carcinoma of the gallbladder. A 54-year-old woman was seen at the hospital because of present epigastralgia. Abdominal ultrasonography and computed tomography (CT) demonstrated a tumor covering from the fundus to body of the gallbladder. Arteriography demonstrated a tumor staining. Under a diagnosis of carcinoma of the gallbladder, she underwent an extensive cholecystectomy with regional lymph node dissection (D₂). The resected specimen revealed a papillary tumor, 6.5×5.5cm in size. Histopathologically, singnet ring cell carcinoma slightly invaded the liver bed, and metastasized to the regional lymph nodes. Postoperative course was uneventful, and she was discharged from the hospital 35 days after the operation. Abdominal CT scan showed enlargement of the paraaortic lymph nodes 4 months after operation. She died of the disease 11 months after the operation.

View full abstract

This paper deals with two patients with rupture of pseudoaneurysm of the common hepatic artery due to pancreatic fistula after a total gastrectomy with pancreatosplenectomy for gastric cancer, whose lives were successfully saved.
Patient 1, a 69-year-old man, underwent a total gastrectomy with pancreatosplenectomy for gastric cancer. After the operation, , pancreatic fistula and bleeding from a drain occurred. On the 22nd hospital day, an angiography was performed to conduct coil embolization for pseudoaneurysm, but bleeding due to rupture of the pseudoaneurysm was found. An emergency operation was performed, when the ruptured portion was detected in the vicinity of the root of common hepatic artery which was sutured for closure. Bleeding occurred again on the 42nd hospital day, hemostasis was successfully made by coil embolization again.
Patient 2, a 64-year-old man, underwent a total gastrectomy with pancreatosplenectomy as well as a left thoracotomy for gastric cancer. Pancreatic fistula was noted after the operation and massive bleeding occurred on the eighth hospital day which demanded an emergency operation. Ruptured portion was observed at the root of common hepatic artery and was sutured. However, rebleeding occurred 4 hours after the operation, and then the aorta was blocked over the diaphragm and ligated at the peripheries of the celiac and common hepatic arteries, with a successful hemostasis.

View full abstract

Neurinomas often arise in the cranial nerves and rarely occur in the pancreas. In this paper, we present a case of pancreatic neurinoma which was detected at an examination for anemia. A 41-year-old woman was admitted to the hospital because of dyspnea and anemia. A 4cm large cystic tumor of the pancreatic head was revealed by further examination. With a suspicion of mucinous cyst adenoma of the pancreatic head on operation was made. The tumor was cystic, seemed non-invasive, and was easily dissected from normal pancreatic parenchima around. So a simple tumor ectomy alone was required. Path ological diagnosis was benign pancreatic neurinoma (Schwannoma) of ancient type.
Pancreatic juice fistula occurred on the third postoperative day but cured by drain technique. In a review of the literature, more invasive operative procedures have been apt to be employed for pancreatic neurinoma, because it is a rare entity with difficulty in preoperative diagnosis and resultantly other pancreatic tumors are inferred before operation.

View full abstract

We report a case of extrapancreatically grown nonfunctional pancreatic endocrine tumor. The patient was a 75-year-old man who had been treated as having common bile duct stone. CT scan revealed a mass lesion at the splenic hilus. Serum gastrin level was slightly elevated to 250pg/ml. No apparent increase of tumor marker was noted. Enhanced CT scan and angiogram showed a hypervas-cular tumor beside the spleen. The patient was clinically diagnosed as having a splenic tumor, and was performed a removal of the tumor and a splenectomy. The tumor was found to be adjacent to the spleen and adhered to pancreatic tail. The definite diagnosis of extrapancreatically growing nonfunctional pancreatic endocrine tumor was made by immunopathological findings. Eleven cases including ours have been reported in Japan. It is usually difficult to determine whether a pancreatic endocrine tumor is benign or malignant histologically. In this case, no recurrence has occured as of 2 years and 9 months after the operation.

View full abstract

A 44-year-old woman was referred to the hospital because of uncontrollable bleeding from gastric ulcer. When an emergency operation was performed to stop bleeding, a tumor was incidentally found in the pancreas tail which was 7cm in diameter. Ultrasonography and computed tomography showed a cystic mass with calcification around the capsule, and septum inside. Magnetic resonance imaging showed a high intensity mass on TI and T2-weighed images. The mass was hypovascular. Endoscopic retrograde pancreatography did not show any defect and the tumor compressed the pancreatic duct. Laparotomy was carried out and the resected tumor was 7cm in diameter with a cystic cavity. The contents of the cyst was old coagulation of blood and necrotic tissue like mud abhered to the cystic wall. The histopathological diagnosis was non-functioning islet cell carcinoma.

View full abstract

An 85-year-old man developed idiopathic thrombocytopenic purpura (ITP) while treated for right thalamus infarct. Enhanced CT scanning of the abdomen also revealed an elevated lesion in the gallbladder and a tumor in the spleen whose peripheral area was slightly contrasted and whose interior part was of low density. The patient was diagnosed as having cancer of the gallbladder with ITP, and the splenic tumor was suggestive of metastasis of the cancer of the gallbladder to the spleen, hemangioma, hamartoma, or inflammatory pseudotumor. Preoperatively, the patient was treated with high-dose intravenous gamma globulin regimen, and underwent a cholecystectomy and a splenectomy after the number of platelets was elevated. The splenic tumor was histopathologically diagnosed as inflammatory pseudotumor, because in the tumor, fibroblasts deranged, and between fibroblasts inflammatory cells, mainly plasma cells, infiltrated. The tumor is benign but the cause has remained unknown. We have difficulty in making preoperative diagnosis. This paper presents the case with an analysis of 31 cases in the Japanese literature.

View full abstract

Metastasis from renal cell carcinoma to the lung, liver and bone are common, but the pancreas is an uncommon metastatic site. We report the resection of a pancreatic metastasis from a renal cell carcinoma eight years after a nephrectomy. A 75-year-old woman underwent a left nephrectomy in December 1990. Eight years later, she was referred to our hospital with a pancreatic tumor, measuring 4×2cm in diameter on abdominal CT. Magnetic resonance cholangiopancreatography (MRCP) showed the compression of the common bile duct and the abrupt occlusion of the main pancreatic duct. Blood hormonel levels were within normal limits, except for somatostatin. From the above findings, a pancreatic metastasis from renal cell carcinoma was suspected, and a laparotomy was performed in March 1999. Ascites or peritoneal dissemination were not observed during the operation, and a pancreatoduodenectomy was performed. The pathological findings of the specimen showed a clear cell subtype carcinoma that closely resembled the previously resected renal cell carcinoma. The patient made an uneventful postoperative recovery and is doing well, with no evidence of recurrence.

View full abstract

Patient 1, a 45-year-old woman, was admitted to the hospital because of a palpable soft tumor with the size of azuki bean in an upper portion of the navel. The hernia content was preperitoneal fat. Patient 2, a 52-year-old man, felt a soft tumor with the size of 2cm in an upper portion of the navel. The hernia content was preperitoneal fat. Patient 3, a 32-year-old man, felt a soft tumor with the size of 4cm in an upper portion of the navel. The hernia content was preperitoneal fat and incarcerated greater omentum. Surgical procedures included laparoscopic observation from the abdominal cavity, followed by closure of the hernia opening with reinforcement of the white line by using mesh. It has been etiologically considered that linea alba hernia may arise from spaces between blood vessels and nerves, but many recent have denied the consideration. Laparoscopic findings in the patient 1 and 2, however, confirmed the presence of blood vessels penetrating the hernia which was thought to be one of etiologic factors. We think that wide-ranging reinforcement of the linea alba hernia by using mesh appears to be useful, because the disease tends to be multiple and only simple closure permits recurrence in a high rate.

View full abstract

A 54-year-old man was seen at the our hospital with a complaint of upper abdominal subcutaneous tumor. A mass was which resisted repositioning and was 3cm in diameter palpable in the upper abdomen. Only the mass was visualized by an abdominal CT scan, ultrasonography revealed a defect of the linea alba and a protrusion of hernia. Linea alba hernia was diagnosed, and an operation was performed. Upon laparotomy, there were herniated preperitoneal fat and a hernial sac from the linea alba. We think that preperitoneal fat caused the herniation.
Linea alba hernia is rare in Japan. We report this case of linea alba hernia successfully diagnosed with ultrasonography.

View full abstract

We experienced a case of internal herniation through an abnormal cul-de-sac in the right posterior lobe of broad ligament of the uterus which is considered to be a rare condition among of those internal hernias.
A 46-year-old woman was admitted to the hospital because of spontaneous pneumothorax. She underwent a partial resection of the lung with VATS. But she needed reoperation for relapse. She complained of acute onset of abdominal pain on the 16th postoperative day. Abdominal plain X-P showed niveau sign. Conservative therapy with a long tube did not provide symptomatic remission. Emergency laparotomy was performed under a diagnosis of strangulated ileus. A cul-de-sac in the right posterior lobe of broad ligament of the uterus was recognized. And, a trace of strangulation was found at a distance of 40cm from the ileocecal region. We diagnosed this case as intestinal obstruction caused by internal herniation through a defect in the right broad ligament. This cul-de-sac was closed by direct suture. Postoperative course was uneventful. CT findings such as displacement of the uterus caused by dilated small intestine is a significantrw feature for this disease.

View full abstract

Aiming at less surgical stress, we employed an inguinal approach for metachronous bilateral obturator hernia in an 87-year-old woman because she had ileus due to intestinal incarceration. After releasing the incarcerated hernia, the hernia opening was closed by Marlex-mesh. At the same time, the obturator foremen as well as femoral hiatus and posterior wall of the inguinal duct were also covered with Mesh for the prevention of possible hernia of the inguen or thigh. The patient had uneventful postoperative course following the both operations.
The inguinal approach appears to be very beneficial procedure in that it is less invasive and is able to prevent other hernias.

View full abstract

A 62-year-old man was transferred to the hospital with a diagnosis of ileus without previous history of laparotomy. Abdominal x-ray examination revealed air-fluid level formation. Intussusception of the small intestine was suspected on an abdominal CT scan. A fluoroscopic study after an ileus tube was indwelt revealed no causes and no remission of ileus was obtained. So the patient was operated on. During surgery, an ileum about 70cm to the terrninal ileum was impacted in the left lobe of the sigmoid mesentery with a change in color. The impacted intestine was resected.
Internal hernia of the sigmoid mesentery is rare among all internal hernias, especially that in the left lobe. This case is the second report of the disease involving the left lobe. In the treatment of ileus without previous history of undergoing a laparotomy, this disease must be kept in mind as a probable diagnosis.

View full abstract

We experienced a case of transomental hernia with herniated transverse colon. A 77-year-old man was seen at the hospital because of abdominal pain from the day before. He was treated conservatively, but no remission in clinical findings was noted. An abdominal X-ray film showed an enlarged gas shadow of possibly transverse colon. The abdominal distension was increased and leukocytopenia was mentioned. Consequently, a temporary transverse colostomy was made. After remission of severe infection, a laparotomy was carried out with a diagnosis of obstruction of the colon at the splenic flexure. At surgery, the transverse colon was found to have herniated through abnormal omental hiatus to the omental bursa and adhered. Omental hiatus was incised and the greater omentum and transverse colon were resected.
Of internal hernias, transomental hernia is rare, especially that with herniated transverse colon. So far 101 cases of transomental hernia have been reported in the Japanese literature. And only four cases of them had the herniated colon.

View full abstract