We treated 17 patients with enterocutaneous fistulas present more than 14 days despite conservative treatment, including total parenteral nutrition, with fibrin glue injected into the fistula tract after sinography. The first injection closed 12 fistulas. The second injection closed 4 more. Fistulas with longer tracts were easier to close than those with shorter tracts. Fistulas with a daily output exceeding 100ml could be closed with this treatment.

View full abstract

We investigated prognostic factors affecting the survival after recurrence of breast cancer, especially effects of systemic therapy. Consecutive 229 patients with recurrent breast cancer at the hospital from 1960 to 2001 were subjected to the study. They were grouped into two groups; patients before 1981 and those after 1982 when chemoendocrine therapy was started. On a univariate analysis, period of recurrence, stage, operative procedure, axillary lymph node status, disease-free interval and site of recurrence were significant prognostic factors. Survival time of the patients with local recurrence and bone metastasis was longer than that of the patients with lung, liver and brain metastases. In bone, lung and brain metastases, more prolonged survival time was recorded in the period after 1982 than before 1981. On a multivariate analysis, disease-free interval, site of recurrence, period of recurrence and axillary lymph node status remained independently associated with survival after recurrence. We conclude that systemic therapy like chemoendocrine therapy could prolong survival time after recurrence in the patients with bone, lung and brain metastases of breast cancer.

View full abstract

We studied consecutive 36 patients with advanced gastric carcinoma who underwent a pancreaticoduodenectomy (PD) at our hospital in the last 20 years (PD group), in terms of outcomes and indications of PD. These results were compared with 78 patients undergoing a subtotal or total gastrectomy (non-PD group) for advanced carcinoma occupied the lower third of the stomach and diagnosed as Si or N3 in the same period. The 5-year survival rate in the PD group was 34.2%, versus 11.9% in the non-PD group. When the 5-year survival rates were compared, in patients with macroscopically infiltrating tumors into the pancreas head, the PD group provided a significantly better long term result (36.9%) than the non-PD group (12.6%) (P=0.0258). On the contrary, there were no significant survival advantages in patients with microscopically infiltrating tumors into the pancreas head, or n3 metastasis between the PD and the non-PD groups.
PD for advanced gastric carcinoma situated in the lower third of the stomach is recommended for patients with invasion to the pancreas or metastasis to the lymph nodes around the pancreas head, if PD is tolerated by them.

View full abstract

To clarify the efficacy of hepatectomy in noncolorectal cancer metastasis to the liver, we studied 29 liver metastases (LM) patients undergoing hepatectomy.
In synchronous LM due to gastric cancer, 7 patients undergoing hepatectomy (Hx group) included fewer H3 patients or patients with extrahepatic disease compared to 36 without hepatectomy (Hx-group). Although overall survival (OS) was better in the Hx group than in the Hx-group, no difference was seen between 2 groups excluding H3 patients and patients with concomitant extrahepatic disease. In metachronous LM, despite all hepatectomy patients belonging to H2, OS was better in the Hx group than in the Hx-group (P<0.05). All 6 with LM due to ovarian cancer had extrahepatic metastasis. OS was better in the Hx group than in the Hx-group (P<0.05). Two with LM due to gastrointestinal stromal tumor (GIST) had peritoneal dissemination. Two of 3 with recurrent residual liver metastasis underwent repeat hepatectomy and were alive 43 and 107 months after initial hepatectomy.
From these results, we concluded hepatectomy was effective in metachronous H2 or less LM due to gastric cancer only when no extrahepatic diseases was involved. Hepatectomy should thus be conducted aggressively in LM due to ovarian cancer and GIST regardless of concomitant extrahepatic disease.

View full abstract

A 65-year-old man with tetralogy of Fallot who reported dyspnea on effort but declined surgery developed severe cyanosis with breathlessness indicating surgical intervention. Thanks to his favorable cardiac anatomy and preserved systemic condition despite his age, total repair was possible. His recovery was uneventful and clinical status dramatically improved. In selected cases of high-aged tetralogy of Fallot, total correction is thus possible, dramatically ameliorating symptons.

View full abstract

An operated case of quadricuspid aortic valve is reported. A 58-year-old woman was admitted to the hospital because of aortic regurgitation. With echocardiography and aortic angiography, quadricuspid aortic valve was diagnosed. Aortic regurgitation was rated as grade III according to Seller. Aortic valve replacement was performed with a 21mm Carbomedics prosthetic valve uneventfully. The aortic valve showed two equal larger cusps and two equal smaller cusps, which was regarded as type C by the Hurwitz's classification. An accessory cusp was situated between the right and non-coronary cusps, and adhered to the right coronary cusp at the right coronary commissure. No coronary abnormality was involved. Quadricuspid aortic valve is a rare abnomaly, but it must be considered as a malformation which leads to severe valve failure in adulthood.

View full abstract

An operated case of a spontaneous arterio-venous fistula at the iliac region in a patient on chronic hemodialysis is reported. A 71-year-old man who had undergone chronic hemodialysis for 4 years was admitted to the department because of a pulsatile abdominal mass associated with bruit and thrill. Angiography showed a right common iliac artery aneurysm and an arterio-venous fistula. At surgery, a firm mass was detected around the lower part of the abdominal aorta which closely resembled to an organized hematoma. The aneurysm was localized to the right iliac region, and was resected with the closure of the arterio-venous fistula. The blood flow to the lower extremity was established by an aortoexternal iliac bypass using an 8mm-Hemashield ^® graft. After the operation, a transient ischemic brain attack occurred and was successfully treated without any neurological deficit. The patient was discharged 4 weeks after the operation. In this case, chronic hemodialysis with strict water control may cover cardiac failure due to arterio-venous fistula for a long time.

View full abstract

A 51-year-old man carpenter developed a sudden fit of coughing when he held the nails in his mouth while working, and swallowed several nails by mistake. While he ignored the event on that day, he developed bloody sputum on the following morning and consulted our hospital. Chest and abdominal radiography revealed opacities suggestive of nails, three in all: one in the lower lung field on the left side, and two in the digestive tract. Chest CT showed the nail in the airway in the S⁹ region of the lung. Abdominal CT showed the nails in the third portion of the duodenum and in the jejunum. The nail in the airway was removed by bronchoscopy, as it would have been difficult for the patient to eliminate it by natural expectoration. As to the two nails in the digestive tract, oral intake of the patient was withheld, and the clinical course was followed with the hope that the nailds would be passed out with the stools, while making preparations for emergency surgery. The bloody sputum stopped after the removal of the nail from the bronchus. One of the two nails in the digestive tract was naturally excreted on the day after admission, and the other was excreted 6 days later. No particularproblem occurred afterwards, and the patient was discharged.

View full abstract

An 84-year-old woman undergone a tumor resection and free skin grafting for Bowen's disease of left anterior chest wall in March, 1997 was admitted to the hospital in March, 2000. Besides, these were previous histories of undergoing a standard radical mastectomy for left breast cancer, a partial gastrectomy by laparotomy for a gastric ulcer, and a tumor resection by posterolateral thoracotomy for a left-solitary fibrous tumor of the pleura. This time, she was admitted because of ulceration of the free skin grafting performed in 1997. The left upper chest wall was resected together with the 3rd rib, and a defect was repaired by dividing the right pectoralis major musculocutaneous flap near the insertion at the crest of the greater tubercle of the humerus. As of 2 years after the operation, her respiratory function has remained at the preoperative level and she has no obstacle to everyday living.

View full abstract

The patient, who felt a sense of discomfort of the throat from the pharynx to larynx 7 days after he ate a dish of cooked flatfish and thereafter had fever and sense of discomfort in the chest, was brought into the hospital because of severe epigastric pain. An emergency operation was performed with a diagnosis of acute mediastinitis due to esophageal perforation. He underwent mediastinal drainage through two routes, trans-cervical and trans-diaphragma. Direct closure of the esophageal perforation was not performed, because the precise position of the esophageal perforation was unknown. In spite of the operation, mediastinitis developed into bilateral extra-pleural abscesses. Esophageal fiberscopy revealed the position of the enlarged esophageal perforation on the 9^th operative day. The second operation, an esophagostomy with a T tube and bilateral extra-pleural drainage was performed on the same day. After that, alternative prenomenon of bacteria developed, resulted in intractable MRSA mediastinits. We had great difficulty in the treatment, but finally, additional third and forth operation, the mediastinal irrigation with 0.2% povidone iodine solution and appropriately administrated antibiotics brought the mediastinitis under control. He was discharged from the hospital on foot on 135^th postperative day.

View full abstract

Carcinosarcoma is a rare entity of all esophageal neoplasms. Recently, the granulocyte-colony stimulating factor (G-CSF) producing tumor is acquiring increasing interest. We report an upper gastric tumor with marked leukocytosis and an elevation of the level of serum G-CSF, which was diagnosed as polypoid carcinosarcoma of the esophagus of the resected material.
A 79-year-old man was seen at the hospital because of a sense of food sticking in his throat. Leukocyte count was high, 28810/μl, and the level of serum G-CSF elevated to 231pg/ml. Gastrointestinal fiberscopic examination revealed a large polypoid tumor in the upper portion of the stomach. Total gastrectomy was performed for this tumor. The resected specimen showed a stalk of the tumor originating from the esophageal mucosa. Pathological diagnosis was carcinosarcoma of the esophagus, because this tumor contained both epithelial and sarcomatous components. Immnohistochemical study using G-CSF monoclonal antibody showed positive staining in the cytoplasm of the cancer cells. After the operation, leukocytosis and the elevated level of serum G-CSF were normalized.
In the case of mesenchymal tumor with leukocytosis without inflammatory findings, surgeons need to consider a probable G-CSF producing tumor. Moreover, carcinosarcoma of the esophagus must be kept in mind, when the tumor originates from the esophageal and gastric junction.

View full abstract

This paper presents a case of abscess of the gastric wall associated with intraabdominal abscess.
A 73-year-old woman was seen at the hospital because of abdominal pain and general fatigue. Echography visualized a swelling of the gallbladder. The patient was admitted with a diagnosis of acute cholecystitis and conservatively treated. Temporal symptomatic remission was attained but fever and an increase in CRP were noted. Abdominal CT scan revealed the swollen gallbladder and retention of alarge volume of ascites on the dorsum of both left hepatic lobe and spleen and on the posterior wall of the stomach, and so intraabdominal abscess was diagnosed. We performed a PTGBD which identified E. aerogenes and an intraabdominal abscess drainage which identified K. oxytoca and P. aeruginosa. After the drainage, purulent ascites decreased and we were able to initiate surgery. During surgery, an 8×6cm submucosal tumor like lesion was present under mucosa of the posterior wall of lower body of stomach. A distal gastrectomy and a partial resection of the transverse colon were performed. Purulent discharge similar to intraabdominal abscess was collected from the lesion, and its culture yielded K. oxytoca. Histological diagnosis was gastric wall abscess mainly involving SS. Considering the results of cultures with other findings, the intraabdominal abscess in this case might be caused by the gastric wall abscess.

View full abstract

A 59-year-old woman with abdominal pain was diagnosed as having a perforated submucosal stomach tumor (8.0×8.0cm) expanding toward the serosa using abdominal computed tomography. The patient underwent emergency surgery. A histological examination of the resected sample showed palisading spindle cells but little mitosis. The immunohistological findings were positive for CD34 and C-kit, and the lesion was diagnosed as a gastrointestinal stromal tumor of uncertain origin (GIST).

View full abstract

A case of gastric carcinosarcoma accompanied by a gastric gastrointestinal stromal tumor (GIST) is reported. A 72-year-old man complaining of upper abdominal discomfort was found to have a type 1 tumor in the upper portion of the stomach on a gastroscopy, and underwent a total gastrectomy. Histologically, the tumor was composed of adenocarcinoma and sarcoma components. Histological examinations also revealed a submucosal tumor, 5mm in diameter, in the middle portion of the stomach. Immunohistochemical examinations disclosed that the tumor was true carcinosarcoma and the concomitant submucosal tumor was gastric GIST. Of a total of 34 cases of gastric carcinosarcoma reported previously in Japan, only six cases were diagnosed as true carcinosarcoma by histological examinations including immunohistochemical stains. Clinical or pathological significance of the coexistence of carcinosarcoma and GIST in the stomach is still obscure. We report the present case for further accumulations of clinical cases of gastric true carcinosarcoma, because histogenetic mechanisms of gastric carcinosarcoma is still unclear.

View full abstract

A 66-year-old woman who had felt epigastric discomfort since September 2000 was admitted to the hospital because of melena in November. Upper gastrointestinal studies revealed a giant tumor in the upper body of stomach. With other examinations it was diagnosed as an advanced gastric cancer. Due to persistent gastric bleeding that demanded incessant blood transfusion she underwent an emergency surgery. The tumor grossly showed no invasion to the serosal surface of the stomach and metastases to the second group of lymph nodes was suspected from the swelling of the ceriac and hepatic lymph nodes (H0, P0, T2, N2, Stage IIIa). Total gastrectomy with second degree of dissection for lymph nodes was performed. The resected type 1 tumor was 10.5×8×2cm in size and covered with hemorrhagic and necrotic soft tissue. Pathohistological study of the tumor revealed choriocarcinoma coexisting with poorly differentiated adenocarcinoma; histological transition between the two malignancies was observed. Multiple hepatic metastases were visualized by computed tomography and the serum level of human chorionic gonadotropin β subunit was markedly elevated to 386.2ng/ml three morlths after the surgery. Postoperative chemotherapy was not given. The patient died of cancer six months after the operation.

View full abstract

A 45-year-old man was referred to the hospital for surgical therapy in 1998, because steroid therapy and lymphocyte eliminating therapy were unsnccessful for, ulcerative colitis (US) which was diagnosed in 1991 and recurred repeatedly. After admission, a gastric endoscopy showed a type 3 tumor in the greater curvature of the stomach. It was diagnosed as poorly differentiated adenocarcinoma on a biopsy. A distal gastrectomy, a subtotal colectomy, and an ileostomy were performed, followed subsequently by an ileal pouch-anal anastomosis. Pathologically the gastric cancer was diagnosed as M, Gre, type 3, ss n1, P0, H0 M0, por2, stage IIIa, and the UC as that of the colon in active stage.
It is uncommon that UC is a associated with gastric cancer, and there have been no cases of UC with gastric cancer in which both lesion are operated on simultaneously. Because the severity of UC and clinical stage of gastric cancer differ from patients to patients, there are a variety of therapies. In the treatment of intractable UC like in this case, subtotal colectomy and distal gastrectomy might be recommended to avoid possible aggravation after surgery.

View full abstract

We successfully treated a case of liver cirrhosis portsystemic collaterals concomitant, which had not been treated, with transvenous before distal gastrectomy for associated advanced gastric cancer. A 68-year-old woman who had been followed for liver cirrhosis, type C hepatitis, and esophageal varices for 6 years was diagnosed as having advanced gastric cancer (3 type) in the lower stomach. There was a history of undergoing a hysterectomy for uterine cancer and blood transfusion 25 years earlier, Angiography revealed portosystemic collateral shunt from the left gastric vein to vena cava. After balloon occlusion of the left subphrenic vein, retrograde transvenous obliteration of the left gastric vein using metallic coils and 50% of partial splenic arterial embolization were performed. After two weeks of nutritional support by intravenous hyper-alimentation and effective diuresis, edema of the upper extremities disappeared and body weight decreased by 6kg. Distal gastrectomy with D1 lymph node dissection and ligation of the collateral veins were performed with Billroth II reconstruction and Brown anastomosis. Clinical and pathological findings revealed poorly differentiated adenocarcinoma, T3 (se), N1 (1/23), CY0, P0, H0, and M0, and final stage was IIIA. She was treated following clinical path and discharged from the hospital on 17^th postoperative day. Clinical examination two year after the operation revealed no recurrence of gastric cancer and she is quite well.

View full abstract

We experienced a rare case of stomal local recurrence requiring resection 8 years and 10 months after relative curative surgery for type 4 gastric cancer. A 73-year-old man underwent total gastrectomy, splenectomy and D2 lymph node dissection for type 4 gastric cancer 16.0×11.0cm in diameter occupying the entire stomach on November 20, 1991. The histological type was nonsolid poorly differentiated adenocarcinoma, penetrating the serosa with n2 (25/72) lymph node metastasis and positive lymphatic and venous invasion. The proximal and distal margins were negative. Though the postoperative course was not eventful, stenotic feeling and weight loss appeared in April 2000. Cancer of the anastomotic region was pointed out, and the stomal tumor and part of both lungs and diaphragm were resected on September 20. The histological type was again nonsolid poorly differentiated adenocarcinoma invading the adjacent structures with positive lymphatic and venous invasion. The proximal, distal, and vertical margins were negative. It grew invasively deeper than the submucosa, and lacked views as a primary tumor, and both cancers showed the same result in special staining. Though it was clinically rare, it was diagnosed as stomal recurrence type 4 gastric cancer based on the histopathology. The man remains hale as a outpatient.

View full abstract

An 83-year-old man was admitted to the hospital for type3 gastric cancer at the posterior wall of the stomach. There were previous histories of pulmonary tuberculosis at the age of 25 and of undergoing a right hemicolectomy for ascending colon cancer nine months before admission. Following neoadjuvant chemotherapy with TS-1 and CDDP patient was operated on. At laparotomy, multiple small sized nodules on the peritoneum and mesenterium and a segmental strcture of the ileum were seen. They were macroscopically assumed to be peritoneal disseminations of gastric cancer, but no cancer cells were detected by fresh frozen section. Total gastrectomy and a partial resection of the ileum were performed. Pathologically, the small sized nodules on the peritoneum, mesenterium, and serosa of the ileum were diagnosed as tuberculous peritonitis. The postoperative couse was uneventful.
Recently tuberculosis is acquiring increasing interest as a revival infection. Although tuberculous peritonitis is rare, it must be differentiated from disseminating mesastasis during surgery for cancer, especially in patients with a past history of tuberculosis.

View full abstract

We experienced a rare case of gastrointestinal stromal tumor (GIST) of the duodenum. A 59-year-old woman was admitted to the hospital because of general fatigue due to anemia. Abdominal CT scan demonstrated a mass 8 cm in diameter adjoining the duodenum. Upper gastrointestinal endoscopy revealed a submucosal tumor at the duodenal l^st portion with ulceration. The patient was diagnosed with having a submucosal tumor of the duodenum. A partial resection of the duodenum was attempted but in vain due to a large defect of the duodenum distal gastrectomy with Billroth-II reconstruction was performed. Histopathological findings showed spindle cells with funicular pattern. Immunohistochemically, the tumor was negative for smooth muscle actin (SMA) and S-100 protein, but positive for c-kit and CD34 with localized positive staining for desmin and localized weakly positive staining for heavy caldesmon (HCD). Based upon these immunohistochemical results, the tumor was diagnosed as smooth muscle type GIST.

View full abstract

Two cases of non-specific ulcer of the small intestine are reported. Patient 1, a 34-year-old woman, had anemia and hypoproteinemia, but no bleeding point was detected by endoscopy. At laparotomy, deformity and some stenosis were ovserved in the terminal ileum, and a partial resection of the ileum was performed. She was diagnosed as having non-specific multiple ulcers of the small intestine based on macroscopic and microscopic findings. Patient 2, a 66-year-old man with chronic heart failure by regurgitation of tricuspid and mitral valve, had melena recurrently. No bleeding point could be detected by endoscopy, Endoscopy of the small intestine under laparotomy showed some small ulcers on the terminal ileum, and a partial resection of the ileum was performed. Histological examination of the resected specimen revealed non-specific ulcer that was suggestive of vasculitis. Both cases had a variety of conditions that would explain the genetic diversity.

View full abstract

Ischemic enteritis of the small intestine is a rare entity. Recently, gangrenous form is included in the entity except the temporary and stricturing forms, because difference among these three forms results from the degree of ischemia. We report a case of stricturing form of ischemic enteritis preceded by gangrenous form of ischemic enteritis and stricturing form of ischemic colitis. An 82-year-old woman was admitted to the hospital because of abdominal pain. Mitral regurgitation was noted on a cardiac echogram. Despite conservative management, the abdominal pain worsened. Abdominal CT scan showed massive ascites, and an exploratory puncture revealed it bloody. A laparotomy revealed necrosis of the small intestine covering 170cm in length. She underwent a resection of the small intestine. Subsequently, she underwent resections of stricturing segments of the descending colon and small intestine, 59 days and 104 days after the first operation, respectively. Macroscopic examinations of the resected small and large intestines revealed tubular stenosis, annular and segmental ulcer. Microscopic examinations of both specimens revealed ulcers with fibrosis. Consequently the diagnoses of ischemic enteritis and ischemic colitis were made. It is etiologically thought that three ischemic lesions developed in the small and large intestine due to thromi associated with mitral regurgitation in this case, and then necrosis and stricture heterochronously manifested. Although ischemic intestinal lesion is commonly solitary, this case suggests that multifocal and metachronous lesions can occur.

View full abstract

A 28-year-old man was admitted to the hospital because of abrupt onset of anal bleeding on May 20, 2000. No abnormal findings were found on an emergency colonofiberscopy. Scintigraphy, angiography, and ectopic gastric mucosa scintigraphy also disclosed no abnormalities. Fluoroscopy of the small intestine showed a blind loop in the pelvis. Retrograde fluoroscopy of the ileum visualized a blind loop branched from the ileum about 80cm to the Bauhin valve. Intestinal bleeding due to Meckel's diverticulum was diagnosed. On June 16, 2000, a laparotomy was performed under spinal anesthesia and a 7cm, Y-shaped Meckel's diverticulum was confirmed at the ileum 90cm to the terminal ileum. The diverticulum was resected. Histopathological diagnosis was Meckel's diverticulum associated with ectopic pyloric glands.

View full abstract

We report a case of perforated gastrointestinal stromal tumor (GIST) of the ileum accompanied with von Recklinghausen's disease. A 54-year-old man with von Recklinghausen's disease was admitted to the hospital because of abdominal pain and fever. He was diagnosed as having suspected acute appendicitis and pan-peritonitis and underwent an emergency abdominal operation. Laparotomy showed a pelvic abscess with secondary appendicitis due to perforated ileum tumors. A partial resection of the ileum, an appendectomy and dorainage were performed. Immunohistochemically, the ileum tumor was positive for CD34 and negative for c-kit and was diagnosed as GIST. This is the 20th case of small intestinal GIST with von Recklinghausen's disease reported in Japan. We discuss such cases and those of perforated small intestinal GIST as well

View full abstract

A 54-year-old woman undergoing partial resection of the transverse colon developed ileus 9 days after operation due to a stricture of the anastomosis. Using colonoscopy, we inserted a retrograde bowel drainage tube over the stricture. The colon obstruction was relieved smoothly, but 2 days after insertion, the patient developed fever and abdominal pain. Infusion of contrast medium through the tube showed the ascending colon pressed and transformed by the top of the tube, which we removed, without ameliorating abdominal pain. Emergency surgery showed perforation of the large intestine, so we resected the perforated intestine. Transanal decompression tubes have become useful in managing colonic obstruction, but require careful use in decompression to avoid perforating the adjacent intestine.

View full abstract

A 51-year-old man was seen at the hospital because of anal pain. On physical examination, an internal hemorrhoid prolapsed from the anus, at where edema and swelling were observed. Fever and leukocytosis were also noted, but a radical operation for hemorrhoids was performed to relieve the symptoms. On the first postoperative day, redness and swelling of the anus and perianal skin were seen. On the 3^rd postoperative day, redness and swelling of the scrotum became prominent and redness extended to the right inguinal region. At that time, incisions and drainage were made on perianal area, scrotum and right inguinal region, a drain was indwelt, and lavage, 3-4 times daily, and total parenteral nutrition central venous catheterization were started. On the 4^th postoperative day, redness further extended from the subumbilical region to the contralateral left inguinal region, with necrosis of a part of the scrotum skin. Thereafter no extension of inflammation was observed, and the patient almost made a recovery in about 2 weeks. In this case, it is inferred that the operation might cause Fournier's gangrene, and we had to consider carefully about the time of operation. Further, sufficient drainage and frequent lavages were able to prevent further extension of inflammation after the onset of the disease, with resultant prevention of deterioration of the general condition.

View full abstract

We report an elderly case of ulcerative colitis accompanied by toxic megacolon preoperatively and by multiple organ dysfunction syndrome postoperatively. A 70-year-old woman had an initial attack of total-colitis type ulcerative colitis. A large dose of prednisolone was administered intravenously for a rather long period, but in vain toxic megacolon developed. A total colectomy with construction of an ileostomy and rectal mucus fistula was performed in an emergency surgery. The resected specimen revealed that the mucosa had detached extensively with islet-like or longitudinal placement of the ramaining mucosa. Histologically, large bacterial colonies were scattered on the intestinal surface where the mucosa was detached. After the surgery, DIC was complicated with marked thrombocytopenia, followed by ARDS, AGML, and liver dysfunction. In spite of these serious complications, the patient finally recovered with intensive cares. Early surgical intervention is advisable if an elderly patient with severe colitis does not respond to intensive intravenous administration of prednisolone.

View full abstract

Cytomegalovirus (CMV) enterocolitis is known as a complication of immunocompromised patients and its manifestation in immunocompetent patients is rare. This article presents a patient who developed multiple intestinal perforations by CMV enterocolitis. A 50-year-old man underwent a total gastrectomy for gastric cancer. Four weeks after the operation, multiple colonic perforations developed requiring an emergency total colectomy. Furthermore, ileal perforation occurred 10 days after the total colectomy. Immunohistochemical study of the resected specimen revealed CMV positive cell infiltration into the colonic mucosa. A diagnosis of CMV enterocolitis was made and ganciclovir was administered. After ganciclovir treatment, inflammatory change of the intestine diminished and the patient was discharged in a good condition. Most of the reported cases of CMV enterocolitis in Japan were associated with immunocompromised condition. However, CMV enterocolitis may develop in an otherwise normal patients and this is the first case of the disease appeared with multiple intestinal perforations during postoperative period.

View full abstract

A 79-year-old man was seen at the hospital because of right upper abdominal pain intensified for 5 days and abdominal distention. Abdominal radiography showed dilated small intestine in the upper abdomen. Abdominal CT scan showed a marked fecal mass without ascited or free air in the right middle abdomen. Because of the presence of peritoneal stimulation symptoms, acute peritonitis was diagnosed and an emergency surgery was performed. At laparotomy, a tumor of the sigmoid colon and massive stool in the sigmoid mesentery about 5cm oral to the tumor were found. A Hartmann's method including resection of the sigmoid colon and infectious mesenterium was performed. These lesions were histopathologically diagnosed as intramesenteric penetration due to ischemic colitis. Only 23 cases of intramesenteric penetration, including three cases of the condition with colon cancer like this case, have been previously reported in the Japanese literature. Those authors reported to have difficulty in making preoperative diagnosis. Although colon perforation is usually accompanied by fecal peritonitis and a resultant dismal outcome, favorable outcome can be expected in intramesenteric penetration if an early and appropriate surgical treatment is performed.

View full abstract

A 62-year-old woman was admitted to hospital complaining of anal bleeding. An endoscopic examination revealed a group of elevated lesions, measuring 7mm in diameter, in the lower rectum and an elevated Type 1 lesion in recto-sigmoid colon. The results of biopsy on recto-sigmoid lesion showed well-differentiated adenocarcinoma. Prior to a low-anterior resection, an endoscopic mucosal resection (EMR) was conducted in the lower rectum. Pathological examination showed a MALT-type lymphoma that had invaded the submucosa. Ten days after the EMR, a low-anterior resection was performed to remove the recto-sigmoid carcinoma, and an additional local resection via the anus was conducted for the MALT lesion. Pathological examination of the recto-sigmoid colon showed a moderately differentiated adenocarcinoma (mp, n0, H0, P0, stage 1). No evidence of atypical cell involvement was present in the additional resected tissue of the lower rectum. No additional treatment was perfomed. The patient has been free from disease for 12 months. We also discuss the features of 49 cases, including the present case, of MALT lymphoma of the rectum that have been previously reported in Japanese medical literature. The present case of MALT lymphoma of the rectum and recto-sigmoid colon carcinoma is believed to be the first report of this condition in the Japanese literature.

View full abstract

Primary malignant melanoma of the anorectal region is a relatively rare entity and the prognosis is very poor. We experienced a case of malignant melanoma of the anorectal region. A 64-year-old woman complaining of defecation was found to have a blackish mass by endoscopic rectal examination at elsewhere. She was admitted to the hospital for detailed examinations. A biopsy specimen was diagnosed as anorectal malignant melanoma histologically and immunohistologically. Abdomino-perineal resection with D1 dissection was performed. The resected specimen showed a blackish tumor, 7.0×6.5cm in size, just on the dentate line. Macroscopic features were A1, P0, H3, M(-), N1(+), Stage IV. Microscopically, tumor cells with melanin granules invaded over the muscularis propria. The patient died of multiple liver metastasis 3 months after the operation. No effective multidisciplinary treatment for this disease has been established. We suggest that early discovery and early diagnosis of this disease are important for improving the prognosis.

View full abstract

A case of primary leiomyosarcoma of the liver is described along with a review of 74 patients with this lesion reported in the world literature up to the end of the year 2000. The patient was a 70-year-old woman complaining of a loss of appetite. Tumor markers were all normal and hepatitis serology tests were all negative. US demonstrated a large and relatively well-defined isotonic lesion in the right lobe of the liver. Contrast-enhanced CT scan demonstrated a well-defined and heterogeneously enhanced mass with peripheral enhancement. Extended lobectomy was considered impossible because of lower functional reserve of the remnant liver. The patient died eight months after the operation.
In a review of the 74 reported cases, the average age was 54.6 years and the male to female ratio was 36:38. Those tumors were situated mainly in the right lobe of the liver and seventy percent of the tumors measured over 10cm in diameter. The prognosis of this tumor was unsatisfactory and curative resection is the only procedure to make a contribution to long-term survival for more than 20 months. Although we have a difficulty in making preoperative diagnosis, the following images are reportedly characteristic of the tumor: hypoechoic and well-defined tumor on hepatic echography; high and low, and multiple cystic pattern of internal echo; and heterogeneous on enhanced CT.

View full abstract

A 69-year-old man with primary adenosquamous liver carcinoma admitted for upper abdominal discomfort was found in blood examination to have slightly abnormal liver disfunction, slightly elevated CEA, markedly increased CA19-9, and positive hepatitis C virus antibody. A liver tumor about 90mm in diameter was identified in the right robe by ultrasonography and computed tomography, necessiating extended right hepatic lobectomy based on a diagnosis of cholangiocellular carcinoma. Histolological examination showed primary adenosquamous liver carcinoma and adjacent cirrhotic liver change. The patient died of bone metastasis 7 months after surgery. Adenosquamous liver carcinoma is very rare and its clinicopathological features unknown. It shows no typical imaging features and preoperative diagnosis is difficult. Normal AFP, slightly elevated CEA, and high CA19-9, in serum are relatively typical of this disease, however as shown by our patient.

View full abstract

A 71-year-old woman was performed a choledocholithotomy and a papilloplasty for recurred choledocholithiasis. We recognized no bleeding from a T-tube through a postoperative course, and the T-tube was removed on the 17th day after the operation. Although a drop in hemoglobin was noted on the 20th day after the operation, there were no ulcer in the stomach, duodenum and no bleeding from the papilloplasty site. On the 27th day after the operation, massive hematemesis occurred, and then the patient went into hemorrhagic shock and respiratory arrest. After resuscitation, an emergency celiac and selective hepatic arteriography was performed. It demonstrated leakage of a contrast media from the branch of the right hepatic artery into the common bile duct. TAE was carried out and the bleeding was controlled successfully. The patient was discharged from the hospital a few days later without elevation of serum value of liver enzymes and liver abscess.

View full abstract

A 69-year-old woman was admitted to the hospital because of high fever and general fatigue lasting for about 2 months. Abdominal ultrasonography and an abdominal CT scan revealed a gallbladder mass with infiltration to the liver and duodenum. Biopsy specimens obtained from the infiltrative lesion of the duodenum by an endoscopy were diagnosed as squamous cell carcinoma. A pancreatoduodenectomy, a resection of the gallbladder bed, and a partial resection of the transverse colon were performed. Histological diagnosis was adenosquamous carcinoma of the gallbladder mainly composed of squamous cell carcinoma. She has been doing well without any signs of recurrence for more than 7 years after the operation. Squamous cell carcinoma of the gallbladder tends to invade the surrounding organs as a localized lesion and rarely metastasize to the distant organs. It is thought that long-term survival can be expected even for advanced gallbladder cancer by aggressive surgery, if it is histologically squamous cell carcinoma or adenosquamous carcinoma mainly composed of squamous cell carcinoma.

View full abstract

Splenic hamartoma is rare. We report such a case undergoing splenectomy. A 59-year-old man with left flank pain had pointed out a splenic tumor 1.5cm in diameter 7 years earlier. Computed tomography (CT) showed a splenic tumor 5cm in diameter that appeared low density, with the tumor margin enhanced by contrast medium. Ultrasonography (US) showed an about 6cm, well demarcated, hyperechoic tumor in the spleen with septum-like structures. Blood flow was confirmed along the tumor capsule and septum by power Doppler mode of US. Malignancy could not ruled out due to the tumor's growth, so we conducted a splenectomy. The 5×5×4cm tumor was dark red at the cut surface. Pathological examination showed it to be hamartoma derived from red pulp of the spleen.
Mild postoperative pancreatic juice leakage soon disappeared, and the man enjoyed favorable recovery, with left flank pain subsiding. He was discharged on postoperative day 14.
Although hamartoma is benign, surgery is indicated if the patient has obvious symptoms and malignancy cannot be ruled out. It is considerd appropriate to perform partial splenectomy to conserve splenic function.

View full abstract

We report a case of an inflammatory pseudotumor of the spleen which was found accidentally during an episode of constipation in a 58-year-old man. Ultrasonography revealed a 4cm solid mass in the spleen. Abdominal CT and magnetic resonance imaging scans showed the same lesion, which was enhanced in peripheral area. Abdominal angiography showed pale tumor stain. The splenic tumor was preoperatively diagnosed as a hamartoma. A laparoscopic splenectomy was, thus, performed in order to avoid probable spontaneous rupture of hamartoma. Laparoscopic findings showed a round mass measuring 5.6×4.3cm protruded from the lower pole of the spleen. The cut surface was solid and well defined from the normal splenic parenchyma. Pathological examination was an inflammatory pseudotumor of the spleen. This report indicates that the laparoscopic splenectomy which can be diagnostic as well as therapeutic procedure is useful for inflammatory pseudotumor of the spleen which often presents difficulty in preoperative diagnosis.

View full abstract

We experienced a case of vesico-sigmoidal fistula caused by a prolonged use of an indwelling urethral catheter. The patient was a 64-year-old woman who had suffered from right hemiplegia and left hemiparesis after cerebral infarction 13 years earlier and her urinary bladder had been drained for the recent 5 years with an 18Fr all silicon Foley catheter. She was admitted to the hospital because of fecauria and pneumatouria on September 27, 2001, and a cystoscopy and a cystogram revealed the vesicosigmoidal fistula.
Laparoscopy-assisted operation performed on October 4 disclosed that the sigmoid colon formed a hard adhesion to the bladder wall and the vesico-sigmoidal fistula was present in the adhesion. Laparoscopic partial resection of the sigmoid colon and a Hartmann's operation were performed and the urinary bladder was repaired by a minilaparotomy. Vesico-sigmoidal fistula in this case may have been caused by a long-term indwelling of a urethral catheter, although the common cause of the disease is inflammation due to Crohn's disease or diverticulitis. In this paper, we discussed vesico-sigmoidal fistula treated by laparoscopy-assisted operation.

View full abstract

Prostate cancer has become one of the fastest growing causes of death in Japan. We report a rare case of prostate cancer initially found due to a rectal stricture.
A 73-year-old man reporting difficulty in defecation and admitted treatment of suspected rectal cancer was found in colon fiberscopy and barium enema to have a stricture covering the entire circumference of the rectum. Although urinary complaints were denied, there were high levels of PSA and bone metastasis. Prostatic biopsy established the diagnosis of primary cancer arising in the prostate. Hormone therapy and radiotherapy effectively resolved the rectal stricture, and the man continues to undergo hormone therapy.

View full abstract

A 28-year-old woman complained of abdominal pain and lumbago and determined to have no gynecological lesions at a gynecological hospital was referred to the hospital in January 2001. When she was first seen, an elastic hard mass, about 6×5cm in diameter, was palpated in the right lower quadrant of abdomen. CT and MRI scans visualized a tumor spreading from the right side of the inferior versa cava to the ileocecal area, presumably originating from the mesentery or the postperitonium, while no lesions were detected by gastroduodenoscopy and colonoscopy. As we could not make definite preoperative diagnosis, an exploratory operation was performed on January 23. Surgical findings revealed that the lesion was an enlarged fist-sized lymph node on the mesentery of the ascending the colon. The tumor directly penetrated the duodenum, and intraoperative gastroduodenoscopy showed an invaded tumor in the second portion of the duodenum. Right hemicolectomy and a partial resection of the duodenum were carried out. Pathological study revealed that the tumor was tuberculous mesenteric lymphadenitis.Therefore administration of antituberculous drugs was started after the surgery.

View full abstract

A case of giant retroperitoneal cystic lymphangiora is reported. A 31-year-old woman who had developed abdominal distention after childbirth was seen at the hospital because of an increasing feeling of abdomonal pain and loss of appetite. Abdominal ultrasonogram and computed tomomgram showed a giant cystic tumor that compressed the stomach and intestine on the left side. But, no abdominal mass had been pointed out while pregnancy. She was diagnosed as having a retroperitoneal lymphangioma wich had enlarged after childbirth. Laparotomy revealed a giant retroperitoneal cystic lymphangioma occupied the left upper abdomen, which was 12.5×11.0×11.7cm in size with slight yellow serous fluid, and adhered to the superior mesenteric artery and sigmoid colon. Histopathological findings confirmed cystic lymphangioma. From 1997 to 2001, a total of 486 cases of lymphangioma have been reported in Japan including 51 cases involved the retroperitoneum. With a recent increase in widespread use of comprehensive physical checkup and endoscopic studies, intestinal or intraabdominal lynphangiomas have been increasingly reported. It is thought that endoscopic or laparoscopic surgery and a use of drugs such as OK-432 will increase.

View full abstract

We report a case of retroperitoneal leiomyosarcoma with lymph node metastasis.
A 48-year-old woman pointed out having an abdominal tumor was referred to the hospital. An infant's head sized, elastic-hard tumor was palpable in the right lower abdomen. Abdominal ultrasonography and CT scan visualized an enhanced tumor 10cm in diameter with heterogeneous center in the right lower quadrant of abdomen. Angiography showed an accumulation of a contrast material from the ileocolic artery. The patient was operated on with a diagnosis of a retroperitoneal tumor. During surgery, the tumor compressed the ascending colon and transverse colon forward and lymph nodes around the tumor swelled. So, a hemicolectomy associated with a right nephrectomy and excision of the group 3 and periaortic lymph nodes, and a tumorectomy were performed. On the resected material, a 12×10×9cm encapsulated, white and nodular tumor was present. The definite diagnosis of retroperitoneal leiomyosarcoma with lymph node metastasis was made.

View full abstract

A 72-year-old woman was admitted to the hospital because of a bulge at the left, lumbar area. Computed tomography (CT) and magnetic resonance imaging (MRI) offered a diagnosis of super lumbar hernia. At operation, a well defined 2cm defect in the Grynfelt-Lesshaft triangle was found and retroperitoneal tissue was found from the defect. A surgical hernia repair was performed using a PHS (PROLENE Hernia System ^® ). Postoperative course was uneventful. There have been no signs of recurrence as of 4 months after the operation.
Thirty-nine cases including ours have been reported in the Japanese literature so far. Surgical repair is generally recommended for super lumbar hernia. Two cases applied mesh-plug method with tensionfree herniorrhaphy were reported, but no cases using PHS have been reported. We present the first case and emphasize the usefulness of the procedure for super lumbar hernia.

View full abstract

It is rare, but lumber hernia may occur in two different portions, superior (Grynfelt-Lesshaft triangle) and inferior lumber triangle (Petit triangle). In this paper, we report a case of idiopathic superior lumber hernia.
An 82-year-old woman was referred to the hospital because of a soft mass at the left lower lumber portion, and admitted for further examination. The mass was about 7cm in diameter and elasticity was very soft. CT findings revealed a lumber muscle defect, sized about 5cm, and the ascending colon protruded into the extraperitoneal fat. With the diagnosis of superior lumber hernia, we performed a hernioplasty using PROLENE mesh. Since this operation is very simple and can be safely performed in a short time, it is suitable especially for the patients with high risks such as advanced age and complications.

View full abstract