It is more important on ultrasound diagnosis to be visualized tumor echo image before be discussed the image feature. We examined what kinds of cancer tumor to be not visualized tumor echo in retrospective clinical data. Objective cases is 291 cases specially in SSD-650CL of 741 female cases to be carried out ultrasound examination and operated. Cases with no visualized tumor echo were found 19/264 cases 7.2% in more 1.0cm of tissue seize and 5/27 cases 18.5% in less than 1.0cm. Tumor echo could not be visualized 3/9 cases 33.3% in non invasive and 11/29 37.9% in intraductal spreading invasive type (invasive ductal carcinoma with a predominant intraductal component), and 6/234 2.6% in no spreading type. In papillary adenocarcinoma tumor echo could not visualized 18/122 cases 14.8%, and 0/120 0.0% in scirrhous tumor. Tumor echo could not found 12/48 25.0% cases in papillary tumor of more than 3.0cm and 6/13 46.3% in intraductal spreading type of this. Tumor echo can not be visualized some times in intraductal spreading type if this tumor is large.

View full abstract

To study whether a correlation existed between initial and contralateral spontaneous pneumothorax (SP) in metachronous bilateral SP, we studied 47 of 48 patients with metachronous bilateral SP treated at our hospital from 1995 to 2000. One patient was omitted because of secondary SP due to Marfan's syndrome.
The incidence of bilateral SP was 2.3% for simultaneous and 13.6% for metachronous bilateral SP. The age distribution for the first initial SP episode in metachronous bilateral SP was younger than in all SP, but that for the first contralateral SP episode was very similar to that for all SP.
The mean interval between initial and contralateral SP was 82.7 months in surgically treated cases for initial SP and 43.4 months in nonsurgical cases. Of the 47.34 (72.3%) developed contralateral SP after only l episode of initial SP without recurrence and 18 (38.3%) underwent surgery for initial SP, although 63.3% of patient with SP were treated surgically in this period.
We found no correlation between initial and contralateral SP and left and right SP appear to be independent in metachronous bilateral SP. Metachronous bilateral SP is therefore not an operative indication for bilateral one-stage surgery.

View full abstract

An investigation was made on a series of 47 patients with spontaneous pneumothorax after thoracoscopic surgery. Postoperative recurrence was shown in four patients, six operations (10.5%). The causes for these recurrences were thought to be insufficient resection of bulla in one operation and oversight or growth of bulla in five operations. In thoracoscopic surgery for spontaneous pneumothorax, careful observation and sufficient resection of bulla may be crucial and observation and investigation of further growth of bulla after surgery would be needed.

View full abstract

Twenty cases of perforation of the small intestine who were operated on at the hospital in a recent 6-year period from January 1995 to December 2000 were retrospectively studied. There were seven cases of traumatic and 13 cases of non-traumatic perforation of the small intestine. Their ages ranged from 17 to 89 years, and the male-to-female ratio was 13 to seven. We had great difficulty in making the diagnosis of the disease and no correct diagnosis had been made before surgery. Even patients who had beed strongly suspected to have the disease had amounted to only seven (35%). It took 36 hours or less from the onset of the symptoms to operation in most cases. Operative procedures included excision of the small intestine in seven patients, ileocecal resection in four and resection of diverticulum in one. They had a relatively good prognosis. Hospital death occurred in four out of 20 patients, and three of these four patients died of other disease around one month after the operaion. There was only one patient who likely died of small bowel perforation with peritonitis.

View full abstract

A total of 32 patients with diverticulitis of right side of the colon were examined. They were 23 males and nine females with a mean age of 42.1 years. Of these 32 patients with initial diverticulitis, all patients received ultrasonography, 22 patients received computed tomography (CT), and 28 patients (87.5%) were diagnosed as having diverticulitis. Three patients with initial diverticulitis underwent an emergency operation, and the remaining 29 patients remitted conservatively. Five patients underwent enterectomy for treatment of initial diverticulitis. Of 27 patients with initial diverticulitis who did not undergo enterectomy, eight patients (29.6%) experienced recurrence of diverticulitis. A total of ten patients with initial and recurrent diverticulitis underwent an enterectomy for prevention of recurrence of diverticulitis. No recurrence of diverticulitis occurred in all the ten patients including two patients who had postoperative complications but remitted conservatively. Diverticulitis of right side of the colon was diagnosed by ultrasonography and CT with a high diagnosing rate, that contributed to avoid unnecessary emergency operation. In the vast majority of cases, diverticulitis of right side of the colon is relieved conservatively, but often recurs. These patients should be strictly followed up.

View full abstract

A case of unusual multifocal phyllodes tumor with repeated subsequent recurrences is reported. A 40-year-old woman was seen at the hospital because of a tumor in the upper outer quadrant of the left breast. These were previous histories of undergoing excisions of the same region at the ages of 28, 32, 38 and 39. These tumors had been first diagnosed as fibroadenoma, and then finally diagnosed as benign phyllodes tumor at the age of 39. In the present case, ultrasonography and computed tomography (CT) scans showed multiple tumors in the different 3 areas in her left breast. Although we performed a wide excision (breast conserving surgery) according to the patient's strong willingness, her left breast was mostly occupied by multiple tumors. After the operation, the patient recovered quickly, and has been kept in a good dondition without any evidence of recurrence for more than 6 months. The histopathological findings showed growth of both epithelial and stromal components with weak cellular atypia and low cellularity, and no mitotic figures in stromal cells. These findings indicated benign phyllodes tumor for all tumors.
The etiology of phyllodes tumor, relationship to fibroadenoma, the mechanism of multifocal recurrence with or without malignant change, and the prognosis of this disease are discussed.

View full abstract

Merkel cell carcinoma in a rare but very aggressive neuroendocrine skin carcinoma mainly occurring in the head and neck of elderly patients, but cases of breast metastasis are considered unusual. We report a rare case of breast metastasis in Merkel cell carcinoma of the lower eyelid.
A 58-year-old woman reported an asymptomatic tumor on the left lower eyelid and an asymptomatic swelling on the parotid gland. Both tumors were radically dissected. Histological studies indicated Merkel cell carcinoma originating from the eyelid and metastasizing to the parotid gland and cervical lymph nodes.
Five months after surgery, the patient reported 1.8cm mass on the right breast. Histological needle biopsy diagnosis indicated a malignant tumor, and the right breast with axillary lymph nodes was resected. Cervical postoperative radiotherapy of 46 Gy was delivered and adjuvant chemotherapy added. Histological and immunohistological studies showed a metastasizing Merkel cell carcinoma lesion in the mammary gland.
Four months after the breast operation, computed tomography revealed multiple metastastic lesions in the superior mediastinum, pancreas and left adrenal. The patient died 9 months after the breast operatson.

View full abstract

A case of apocrine adenocarcinoma arising in the right axillae is reported. The patient was a 59-year-old man who developed a mass lesion in the right axillae. A radical excision of the tumor and regional axillary lymph node dissection were performed. The histologic and immunohistochemical features were consistent with a diagnosis of apocrine adenocarcinoma. The neoplastic cells were positive for EMA and GCDFP-15. Postoperative adjuvant chemotherapy was administered. Although apocrine adenocarcinoma is rare, we suggest that surgical treatment may be essential; postoperative chemotherapy could be effective in the case of regional lymph node metastasis.

View full abstract

A 77-year-old man who had undergone low anterior resection suddenly lost consciousness when he tried to leave his bed on postoperative day (POD) 4. He exhibited dyspnea, cyanosis, and shock, and 4.8×10⁵ units of urokinase (i.v.) was given immediately after the onset based on a diagnosis of acute pulmonary thrombo-embolism (PTE). The diagnosis was confirmed by CT and an arteriogram that showed multiple emboli and cutoff signs in branches of the pulmonary arteries. A Greenfield catheter was introduced into the IVC to prevent re-embolism, and anticoagulant therapy with urokinase and heparin was carried out for 5 days and followed by oral warfarin. The patient recovered from the attack and left the hospital symptom-free on POD 21. The incidence of postoperative PTE in Japan has recently been increasing, and thus prevention of postoperative PTE should be considered, especially for high risk patients, such as elderly, obese, and cancer patients.

View full abstract

A 59-year-old man was admitted to the hospital because of a tumor shadow in the right lower lung field on a chest X-ray film in September 2000. The patient had been followed after a wide excision with chemotherapy for malignant fibrous histiocytoma (MFH) in the left leg in January 1995. He was entirely asymptomatic and further examinations could not detect any other lesions or metastasis. The tumor was considered to be metastasis of MFH because of his past medical history, and an operation was performed via a muscle-sparing thoractomy in October 2000. The tumor was situated between the right middle lobe and right lower lobe growing prominently from the lung. The tumor was removed with partial resections of the adjacent parts of the right middle lobe and right lower lobe. The tumor was 7.3×5.9cm in diameter and the cut surface was solid and whitish with a central calcification. Histopathologically the diagnosis was made as grade 3, conventional type chondrosarcoma. Primary chondrosarcoma of the lung is a rare disease and only 12 cases of this disease have been hitherto reported in Japan including the present case.

View full abstract

This paper presents a long-term surviving patient after early gastric cancer with two times of nodular type lung metastases which were successfully treated by a distal gastrectomy and two pulmonary resections. A 68-year-old man underwent a distal gastrectomy for early gastric cancer. As serum levels of tumor markers increased and a chest CT scan revealed a mass lesion in the right upper lobe of lung, a pulmonary lobectomy was performed 8 years after the first operation. Nine years after gastrectomy and 1 year after the second operation, a chest CT scan revealed two mass lesions in the right lung (S4, S10). He underwent video-assisted partial pulmonary resections. All specimens of the lung tumors showed the same well-differentiated adenocarcinoma as that of gastric cancer. The patient is still alive 15 years after the first operation. It is said that the prognosis is poor in patients with recurrent pulmonary metastasis after operation for gastric cancer. Whenever metastatic lung cancers developed in multiple lesions, or occur many times, we can expect a long survival after complete resection of the metastatic lesions. Surgical treatment must be considered for nodular type of metastatic lung cancer after operation for gastric cancer.

View full abstract

Patient 1, a 61-year-old man, who had undergone a left lobectomy of liver followed by ethanol local injection therapy for hepatocellular carcinoma (HCC) involving from S3 to S4 and S8 in October 1994, experienced bilateral multiple pulmonary metastases in April 1996. Chemotherapy using a venous reservoir catheter resulted in disappearance of the right pulmonary metastatic foci and a shrinkage of the left pulmonary foci. And then a left partial pneumonectomy was successfully performed.
Patient 2, a 57-year-old woman, who had undergone a right lobectomy of the liver for HCC (S8) in April 1988, was found having solitary metastasis of the left lung and a tumorous lesion in the liver (S2) in February 1999. These lesions were diagnosed as pulmonary metastasis and intrahepatic recurrence, respectively. In August of the year, a lateral partial segmentectomy of liver and a left upper partial lobectomy of lung were successfully performed.
Patient 3, a 20-year-old woman, who had undergone an extended right lobectomy of liver for HCC in October 1988, was found having a solitary metastasis of the right lung in June 1992. A right partial excision of lung was successfully performed in August of the year. All these patients have been alive and free from recurrence up to now.
This paper deals with aggressive surgical treatments for pulmonary metastasis of HCC after hepatic surgery, with favorable prognosis.

View full abstract

A case of asymptomatic Bochdalek hernia in an adult is reported. An 80-year-old man complained of abdominal pain while he was hospitalized in the department of psychiatry in our hospital. After several examinations in the department of internal medicine, he was diagnosed with having intussusception and right side diaphragmatic hernia. When we enforced the jejunectomy at surgery for the former, we found a dorsolateral defect of the right side diaphragm through which the colon prolapsed to the thoracic cavity. Late stage adult Bochdalek hernia is relatively rare, and silent cases of the disease which is asymptomatic when it is detected are so rare that only three cases including the present case have been reported in Japan.

View full abstract

This paper presents a case of paraesophageal hiatal hernia accompanied by congenital connective tissue disease. A 41-year-old man was admitted to the hospital because of vomiting, left chest pain and dyspnea. Chest roentogenogram, chest computed tomography and upper gastrointestinal series revealed incarceration of the entire stomach into thoracic cavity with gastric volvulus. The patient was diagnosed as having paraesophageal hiatal hernia in which the entire stomach was incarcerated with gastric volvulus. Floppy Nissen fundoplication was performed under an open laparotomy.
From his childhood, he had joint hypermobility, skin hyperextensibility, and vessel fragility. On suspition of connective tissue disease, a skin biopsy was conducted. As a result, slightly narrowing of collagen fiber and haphazard fashion of elastic fibers with fragmentation were revealed. The pathological diagnosis was Ehlers-Danlos syndrome. This case indicates that we should take into consideration a possibility of Ehlers-Danlos syndrome in the treatment of esophageal hiatal hernia in relatively young patients.

View full abstract

A 67-year-old man reported nausea and appetite loss 1 day after eating persimmons. Upper gastrointestinal tract radiograph and endoscopy showed a gigantic bezoar. Because of repeated nausea and abdominal pain, the man was admitted and treated conservatively. One week after admission, we conducted an emergency gastrectomy due to perforation of the gastric ulcer. The post operative course was uneventful and the man was discharged. Early surgery is recommended if conservative therapy is not effective.

View full abstract

We have experienced a case of resected giant adenoma of the stomach which showed a rapidly enlarging tendency 12 years after an excision of total colon and rectum for familial adenomatous coli. The patient was a 45-year-old woman. In 1985, 12 years earlier, she had undergone an excision of total colon and rectum for familial adenomatous coli with cancer of the sigmoid colon, when multiple gastric adenomas have already been detected. Thereafter, one of these gastric adenomas started to enlarge abruptly, and was treated by surgical excision. In this patient, a possibility of cancer was ruled out by an intraoperative frozen section diagnosis. Long-term observation of her clinical course, however, would be mandatory, because the frequency of cancer change of gastrointestinal lesions associated with familial adenomatous coli is not low.

View full abstract

We have experienced a case of primary malignant lymphoma of the stomach associated with Sjögren's syndrome.
A 71-year-old male was admitted for surgery in our hospital with the diagnosis of malignant lymphoma of the stomach. Diagnosis of Sjögren's syndrome had been determined two years previously with the main complaints of xerostomia and xerophthalmia.
Total gastrectomy with lymph node excision was performed. The pathological findings were malignant lymphoma (non-Hodgkin's lymphoma of B-cell phenotype, diffuse, median cell type based on L.S.G. classification). Chemotherapy was given for the malignant lymphoma for 5 days. Prognosis was death from acute renal failure in 6 months postoperatively.

View full abstract

Encounters with synchronous or metachronous duplicate malignant neoplasms have incresed due to improved diagnostic modalities and an aging population.
Gastric malignant lymphoma is rarely coincidental with advanced sigmoid colon cancer.
A 68-year-old man admitted to our hospital with epigastralgia was found to have an ulcerative lesion at the gastric antrum endoscopically and diagnosed as malignant lymphoma (diffuse B cell type) on biopsy. We also found an apple-core-shaped stenosis at the sigmoid colon in a routine lower digestive tract examination. Endoscopical examination confirmed colon cancer.
We conducted distal subtotal gastrectomy and sigmoidectomy with lymph node dissection simultaneously. He was discharged after 2 postoperative courses of CHO chemotherapy and so far, shows no recurrence.
It is important that coincidental malignant tumors of the digestive tract be considered especially in diagnosing and treating patients with malignant digestive tract lymphoma.

View full abstract

Membranous stenosis of the duodenum is a rare congenital disorder. It is often diagnosed in childhood and rarely in adults. This paper describes a case of congenital membranous stenosis of the duodenum which was diagnosed in an adult.
A 52-year-old woman, who had had abdominal pains after too much eating since her childhood, was seen at the hospital because of abdominal pain one year earlier. Upper gastrointestinal series and upper gastrointestinal endoscopy revealed membranous stenosis at the descending part of duodenum. The papilla Vater was present at the oral side in the vicinity of the membranous portion. Retrograde cholangitis due to membranous stenosis of the duodenum was diagnosed and fasting and intravenous hyperalimentation were started. We recommended an operation for the membranous stenosis, but she denied it so that we decided to observe her clinical course. She was admitted to the hospital because of abdominal pain lasting for about 10 days in March, 2000. Under a laparotomy, a longitudinal incision of the descending part of duodenum was made, and the membranous material was incised and removed partially. The stenosis disappeared and the patient's postoperative course was uneventful. At the operation, it is important to confirm the localization of the papilla and to be careful not to injure the bile duct and pancreatic duct opening.

View full abstract

In a recent 11.5-year period from January 1989 to July 2000, six patients underwent surgery for primary adenocarcinoma of the duodenum, excluding the papilla of Vater. These cases accounted for 0.43% of all cases of gastrointestinal cancer operated on at the hospital. Common complaints were caused by stenosis and bleeding in most cases. There lesions were situated in the bulb in two cases, in the second portion in three cases, and in the third portion in one case. Macroscopically, five tumors were ulcerative type and the remaining one superficial protruded type. Microscopically, four of the six tumors invaded the pancreas with lymphatic invasion and lymph node metastasis. In half of the cases, lymph node No 13 was involved by the cancer, and lymph nodes No 6, 12, 14a, and 17 were also involved. Two patients whose cancer cells invaded the perineural space died of local recurrence of cancer in early postoperative course. In terms of lymph node involvement, gastroduodenectomy with lymphadenetomy of the hepatoduodenal ligament or pancreatoduodenectomy would be necessary for treatment of advanced carcinoma of the bulb, and pylorus-preserving pancreatoduodenectomy for that of the second and third portions.

View full abstract

We have experienced a patient with signet ring cell cancer of the duodenum. The tumor was unresectable and the patient was treated with combined therapy resulting in a decrease of serum level of CEA and 26 month-survival. A 58-year-old man presented with abdominal discomfort and high levels of serum CEA and CA19-9. We could not make the patient recognize his disease but continued to persuade him, and made him admit 11 months after the onset. Exploratory laparotomy indicated H₀P₁3T₃(SE)N₄ according to The General Rules for Gastric Cancer Study in Surgery and Pathology, H₀P₁M_(-)SEN₄₍₊₎ according to The General Rules for Colorectal Cancer Study in Surgery and Pathology. Radiation therapy (50Gy) and 2 times of chemotherapy (CDDP20mg for 5 days) were performed followed by 5 times of chemotherapy (CDDP10mg+5-FU250mg for 5 days) 13 months after the onset and 5 times of chemotherapy (FT 400mg) and oral chemotherapy (5-FUs). The serum level of CEA was dramatically decreased from 574mg/ml at the start of combined therapy and image findings showed no enlargement of the lesion nor development of new lesion. As the serum level of CEA was increased to 20.4mg/ml 19 months after the onset, 2 times of combined therapy with chemotherapy (CDDP+5-FU for 5 days) and thermotherapy were conducted on the day 3. However, the patient died from cancer 26 months after the onset, or 13 months after the treatment

View full abstract

A 71-year-old woman, being treated for diabetes at our hospital, suffered sudden massive anal bleeding. Gastrointestinal fiberscopy and colonoscopy failed to confirm bleeding site. Blood pool scintigraphy showed a hot spot above the urinary bladder and the adjacent vascular shadow. Superior mesenteric arteriography showed a dilated vein at the periphery of the ileal artery from early arterial to late venous phase. Angiographic computed tomography showed a deep stained mass of dilated veins beside the small intestine in the pelvic cavity, leading to a diagnosis of arteriovenous malformation of the ileum. At laparotomy, we found the mass of dilated veins on the mesenterium 40cm proximal to the ileocecal valve. Partial ileostomy was conducted including resection of the lesion.
The patient had advanced liver cirrhosis complicated by portal hypertension. We speculated that the congestion of superior mesenteric veins was associated with the occurrence of this condition, leading to the dilated draining vein.

View full abstract

A 14-year-old male patient complaining of abdominal pain was referred to the hospital because he developed sings of ileus despite medication by a practitioner. Examined upon referral and based on the clinical course and abdominal findings, the patient was thought to be a candidate for surgery. An emergency operation disclosed an ileal intussusception producing the colic, and entailed a partial enterectomy on a segment of the small intestine that failed to restore its normal color despite manual reduction. A lesion indicative of a submucosal mass was noted in the resected intestinal specimen, and appeared most likely to have constituted a forefront of the invagination. There was histopathologic evidence of an antimesentric tumor mass formed by the intestinal mucosa possessing a small lumen and the adjoining smooth muscle wall. The patient was considered to have a enterocystoma, which was one type of persistent omphalomesenteric duct, because it was not associated with any mesodiverticular band and was situated antimesenterically. The case is reported here, with a review of the literature, inasmuch as it seems a rare case of persistent omphalomesenteric duct other than Mecel's diverticulum.

View full abstract

A 72-year-old woman was seen at the hospital because of fecal like vaginal flour. There was a small opening 1mm in size at the surgical stump of vagina after a hysterectomy, from which discharge was observed. Fistulography visualized the small intestine. Enterovaginal fistula was diagnosed and a laparotomy was performed. During surgery, the ileum 15cm distal to the Bauhun valve formed a fistula with the vaginal stump. Associated resection of the ileum by 10cm in length with the vaginal stump was performed. Over 100 diverticula were present in the entire small intestine from the Treitz ligament and enterovaginal fistula due to deverticulitis was diagnosed. Diverticulosis is commonly found in the large intestine, but rarely in the small intestine. Of small vowel diverticula, congenital Meckel diverticulum is the most common. Diverticula of the small intestine are acquired false diverticula, and most of them are localized in the duodenum. Those arising in the jejunum and ileum are rare. This paper presents the case of enterovaginal fistula due to diverticulitis in which more than 100 diffused diverticula in the jejunum and ileum were seen at the operation, together with some bibliographical comments about small bowel diverticulosis.

View full abstract

Torsion of small intestine is a rare entity and few patients are diagnosed preoperatively. Once it occurs, rapid and extensive necrosis over the small intestine develops and the patient follows a fafel course. This time, we successfully managed an adult patient with torsion of small intestine without bowel resection, by making the early diagnosis based on characteristic CT findings.
A 74-year-old man, who had upper abdominal pain after a breakfast and was diagnosed as having ileus based on an abdonimal plain x-ray film at another hospital, was seen at the hospital. Abdominal CT scan revealed a screwshaped small intestine involving the superior mesenteric artery as the center. Torsion of the small intestine was diagnosed. After admisiion, no aggravation of the abdominal pain nor increase in inflammatory response was noted and the patient was observed conservatively. On the 4th hospital day, however, an increase in CPK level was confirmed and the patient was operated on. At surgery, the entire small intestine was twisted counterclockwise by 180 degree, but no circulatory impairments such as intestinal necrosis were demonstrated. The intestinal obstruction was freed only by reducing the twisted intestine. And there appeared two jejunal diverticula at 45cm and 100cm from the Treitz' ligament. The patient was discharged from the hospital 30 days after the operation.

View full abstract

A small intestinal obstruction due to a gastrectomized bezoar is rare and is difficult to diagnose in preoperatively. We report an operated case of this disease.
A 65-year-old man, who had undergone gastrectomy and Billroth I reconstruction for gastric ulcer, was admitted to our hospital as an emergency case with a diagnosis of intestinal obstruction. After admission, intestinalgraphy using a long tube showed a defective shadow in the jejunum due to a mass.
We diagnosed the cause of the ileus preoperatively as a small intestinal tumor. During the operation, a hen's-egg-sized foreign body which impacted the jejunum was removed by incising the jejunum at a part of the foreign body.
We diagnosed the foreign body as a spilled gastrectomized bezoa. We perfomed partial resection of the jejunum because of an ulcer at the portion removed with the bezoa. The postoperative course was uneventful, the patient was discharged 24 days after the operation.
For ileus due to gastrectomized bezoars, the conservative therapy is ineffective.
So in all cases surgery (laparotomies) must be performed. In future, we want to try laparoscopic surgery for this condition.

View full abstract

A 78-year-old man was admitted to our hospital for lower abdominal pain. Intermittent melena was noted during anticoagulant therapy for acute arterial obstruction of the left lower extremity. A barium contrast radiograph revealed a cavity communicating with the jejunal lumen, and abdominal CT showed an air-containing tumor about 10cm in diameter. The pain on admission was likely to have been attributable to infection inside the tumor, because antibiotic administration relieved the pain. Subsequent development of systemic inflammatory responses and physical signs of peritoneal irritation were considered indications for an emergency operation. Laparotomy revealed purulent ascites and a jejunal tumor exhibiting extramural growth. Massive necrosis was observed on the cut surface of the resected tumor, which measured 11×12×9cm in size. In addition to the findings on histological examination after HE staining, immunostaining for c-kit was positive. As a result, the tumor was diagnosed as a GIST. We suggest that peritonitis is one of complications of GIST.

View full abstract

We report an 88-year-old woman with primary appendical intussusception. Contrast enema and colonoscopy showed a protuberant tumor of the cecum. Abdominal computed tomography and ultrasound imaging showed a cystic lesion in this tumor. At operation, right colectomy was done including a dissection of regional lymph nodes. The tumor originated around the orifice of the appendix and the appendix invaginated into the cecum. Pathological findings subsequently confirmed a cecal carcinoma, While appendical mucosa was only inflammatory change. We consider that the appendix was drawn into the cecum by cecal carcinoma.

View full abstract

It is rare for cecal cancer to be associated with acute appendicitis signs, making it difficult to diagnose preoperatively. Case 1, a 59-year-old woman, suffered appendix swelling and the ulceration of its base penetrating into the retroperitoneum, forming a perityphlic abscess necessitating ileocecal resection. As the resected specimen was pathologically diagnosed as cecal cancer and ew(+), so we reoperated soon thereafter. She survived 7 years after operation. Case 2, a 58-year-old man, had the operative finding that a perityphlic abscess had spread throughout the retroperitoneum, necessitating ileocecal resection and partial peritoneal resection. The resected specimen was pathologically diagnosed as cecal cancer and ew(+), requiring reopertion. The man died 14 months after the first operation. Case 3, a 74-year-old man, had the operative finding of gangrenous appendix a hard tumor in the cecum, swollen lymph nodes near the cecum, and many nodules in the peritoneum. Because of a diagnosis of peritoneal dissemination of cecal cancer, we conducted ileocecal resection and lymph node dissection. The man died 7 months after operation. In high-grade appendicitis with perityphlic abscess in middle and old age, it is very important to investigate the case in detail preoperatively and intraoperatively.

View full abstract

A 70-year-old man was admitted to the hospital for close examination of hematochezia. Endoscopic colonoscopy revealed a pediculate polyp with the longer diameter of 4cm in the descending colon. Since endoscopic resection was considered to be difficult, a portion of the descending colon was resected surgically. The polyp consisted of mucosa and submucosal tissue. A part of its surface transformed by ulceration and hyperplastic changes, however, most parts were covered with normal mucosa. Only fibrogenesis and angiogenesis were observed in the submucosal layer. On the basis of the above findings, the polyp was considered to meet the criteria for colonic muco-submucosal elongated polyp (CMSEP). In the present case, not only the mucosa and submucosal tissue but also a part of the muscularis were elongated toward the pedicle of the polyp. It is suggested that meticulous care must be exercised in performing endoscopic treatment for CMSEP.

View full abstract

This paper presents a patient with α-fetoprotein (AFP) producing rectal cancer, that is believed to have a poor prognosis, survived for a long time by intensive therapies including radiation therapy.
A 54-year-old woman was seen at the hospital because of general fatigue. Close exploration disclosed rectal cancer and an operation was performed. Serum AFP level which was as high as 20, 100ng/ml before operation was normalized after the operation. Histopathologically AFP-producing rectal cancer was diagnosed. As the AFP level started to increase one year after the operation, metastases to the lymph nodes, lung, brain, and liver were confirmed. These lesions well responded to operation, chemotherapy, and especially radiation, and a long-term control for 3 years and 2 months could be attained.
We rarely encounter case reports of AFP-producing rectal cancer, and it is known that the cancer is often resistant to chemotherapy and has a poor prognosis. In this case, radiation therapy was effective for every metastatic lesion. This case might suggest a possibility that radiation therapy is a therapy of choice for AFP-producing rectal cancer.

View full abstract

We encountered a case of focal nodular hyperplasia (FNH) of the liver in which an abdominal ultrasound (power doppler technique) was helpful for diagnosis. A 36-year-old man complaining of nausea and vomiting was pointed out having a hepatic mass by an abdominal ultrasonography and admitted to the hospital. Abdominal ultrasound and B-mode visualized the mass as iso-echoic signal tumor in the left lateral segment of liver. Power doppler technique showed the blood flow signal that looked like spoke-wheel, and we suspected FNH of the liver. Computed tomography and a magnetic resonance imaging showed non-specific signs, but an angiography of the liver showed a spoke wheel appearance. So FNH was diagnosed. Ultrasonography can make various view planes by changing the direction of ultrasound beam. Power doppler technique is more helpful to detect the spoke wheel appearance than any other examinations. We think that power doppler technique should be attempted if the tumor is suspected of FNH.

View full abstract

A 60-year-old woman was seen at the hospital because of vomiting. Computed tomography and an abdominal ultrasonography revealed dilatation of the bilateral intrahepatic bile duct and intrahepatic stones. Percutaneous transhepatic biliary drainage (PTBD) was performed. Cholangiography suggested that this patient had undergone and excision of the dilated extrahepatic bile duct with hepaticojejunos-tomy (Roux-en-Y) for congenital bile duct dilatation. Anastomotic stenosis and defects in bilateral intrahepatic bile ducts were revealed. Bilateral intrahepatic bile ducts stones were observed by a percutaneous transhepatic cholangioscope (PTCS). Electrohydraulic lithotripsy (EHL) was made as much as possible. Dilation of anastomosis and re-hepaticojujunostomy were performed. EHL and balloon dilation by PTCS for bile duct stenosis were made frequently after the operation, and a complete removal of stones was comfirmed.

View full abstract

A case of laparoscopic choledocholithotomy in a patient with previous laparoscopic cholecystectomy after subtotal gastrectomy is reported. A 71-year-old man who had undergone subtotal gastrectomy with Billroth II reconstruction for duodenal ulcer was admitted due to acute cholecystitis. We conducted laparoscopic cholecystectomy after setting up the first trocar on near the right side of the navel with open laparotomy, another 3 trocars on the right upper quadrant of the abdomen under laparoscopic observation avoiding peritoneal adhesion. After trocar placement, adhesiolysis and Calot's triangle dissection were done. Cholecystectomy was completed by laparoscopy and the postoperative course was good. Eleven months after surgery, the patient was admitted with jaundice due to choledocholithiasis. We conducted laparoscopic choledocholithotomy with T-tube drainage and the patient had an uneventful recovery. Laparoscopic choledocholithotomy is thus feasible and effective in patients with previous laparoscopic cholecystectomy in ameliorating postoperative pain and shortening the hospital stay.

View full abstract

A 36-year-old woman was admitted to the hospital because of 10 month history of icterus and intermittent liver dysfunction on December 22, 1999. Abdominal ultrasonograph, CT scan and MRI study revealed a cystic lesion at the confluence of bile duct and cystic duct, and a PTCD study revealed stenosis of the common hepatic duct. An angiographic study disclosed no particular findings. Operation was performed on January 18, 2000. The cystic mass was present at the confluence of bile duct, and was able to be dissected from the bile duct, but impossible from the gallbladder. Cholecystectomy including the cystic mass was performed. Intra-operative cholangiography revealed no chages in the stenosis, and then a resection of the extra-hepatic bile duct and a choledocho-jejunostomy were performed. The resected specimen showed cystic degeneration of the cystic duct and mucinous jelly in the cyst. Histopathologically it was diagnosed as a mucinous cyst adenoma with multi-cystic lessions and ovarian-like stroma, which is so rare.

View full abstract

We recently treated a patient with coexisting mucinous cystadenoma of the pancreas and bile duct carcinoma. A 67-year-old woman was admitted due to abdominal pain and jaundice. Abdominal ultrasonography, computed tomographic scans, and magnetic resonance imaging showed a tumor with cystic lesions in the pancreatic body. Endoscopic retrograde panceatocholangiography (ERCP) showed that the main pancreatic duct and common bile duct were severely compressed. We suspected mucinous cystoadenoma, cystadenocarcinoma, with bile duct carcinoma. At surgery, the tumor was diagnosed as adenocarcinoma, and we conducted pancreatoduodenectomy. Pathlogically, the cystic tumor was a mucinous cyst adenoma of the pancreas, and was not related to bile duct carcinoma.

View full abstract

We report a relatively rare case of solid cystic tumor of the pancreas in a 35-year-old woman with Turner's syndrome whose tumor was found by abdominal ultrasonography at our hospital in August 1999. Computed tomography and magnetic resonance imaging showed a pancreatic solid cystic tumor. Chromosomal examination due to the woman's unusually short height and primary amenorrhea showed 46, X, i(q10)/45X and she was diagnosed with Turner's syndrome. Distal pancreatectomy was conducted in July, 2000. Histological examination confirmed with the diagnosis. Both estrogen and progesterone receptors were negative in tumorous parts of the resected specimen. Pancreatic tumor in a patient with Turner's syndrome is extremely rare and its origin is unknown.

View full abstract

We recently encountered a rare case of thyroid metastasis from renal cell carcinoma. A 74-year-old man underwent left radical nephrectomy for renal cancer in 1984, and tumor resections for right renal cancers in 1997 and 1998. An asymptomatic mass in the right lobe of the thyroid was revealed by computed tomography and ultrasonography in March 2000. Because the lesion was strongly suspected as metastasis from renal cancer following aspiration cytology, a right thyroidectomy was performed in July 2000. The histopathological examination confirmed the resected tumor was derived from renal cell carcinoma. The histological appearances were essentially the same in all the surgical specimens, suggesting that the primary renal cancer in the left kidney metachronously metastasized to the contralateral kidney and the thyroid. By reviewing the previous reports, left renal cancer is more likely to metastasize to the thyroid just as in the present case, probably via the pathway of the paravertebral plexus connected with the left renal vein.

View full abstract

We have experienced a case of renal cell carcinoma with multiple pancreatic metastasis 7 years after operation for the primary foci which was successfully removed by a total pancreatectomy.
A 65-year-old man was admitted to the hospital because of an abdominal tumor. There were previous histories of undergoing a left nephrectomy for left renal cancer (pT2N0M0, stage II) in November 1989; and undergoing removal of subcutaneous metastases in the left buttock and right upper arm during observation wihile he was administered oral 5FU in Mat 1993. Thereafter IFN-α at a dose of 25, 000, 000 units per 2 weeks had been administered. In January 1996, dorsal percutaneous metastasis occurred and was removed, when he was found to have an abdominal tumor as well. He was referred to the department with a suspicion of pancreatic tumor. Four metastatic foci extending the entire pancreas were diagnosed and a stomachpreserving total pancreatectomy was made iMarch of the year. In the resected material, four tumors with the diameters of 5.5, 2.0, 1.0, and 0.8cm respectively were present which were histologically diagnosed as pancreatic metastases of renal cell carcinoma. The patient's postoperative course was uneventful and he was discharged from the center. However, multiple hepatic metastasis occurred 16 months after the pancreatectomy and he died in April 2000.
Although pancreatic metastasis of malignant tumor rarely occurs and has a poor prognosis, pancreatic metastasis of renal cell carcinoma can be a candidate for operation and be expected to have a good prognosis.

View full abstract

We have experienced a case of torsion of the right ovarian pedicle with a dermoid cyst in a 2-year-old female infant. Torsion of the ovarian pedicle is primarily a disease of adult women, and the crisis in the infant is rare. This disease often presents with sudden onsets of gastrointestinal symptoms such as abdominal colic and vomiting, and surgeons often encounter the disease. It can be easily differentiated from other acute abdomen by palpating an abdominal tumor and by using diagnostic images such as ultrasonography and CT. In the present case, however, the preoperative diagnosis was retarded, because the mass was located in the right mesogastrium. In the infant, the ovarium is situated in the higher position, its supporting tissue is weak, and subsequently an ovarian cyst sometimes can be felt in the epigastrium. Therefore, it should be forbidden to exclude the ovarian cyst from probable diagnoses only from its location. Abdominal magnetic resonance imaging by the sagittal section was very useful for making the diagnosis of this disease

View full abstract

Hiatal hernia of the broad ligament of uterus is a rare entity. This time we successfully repaired hiatus hernia of the broad ligament of uterus through a laparoscopic operation. A 33-year-old woman was admitted to the department of gynecology in out hospital with a suspicion of ovarian bleeding. Conservative therapy was started, but ileus symptoms occurred 2 days later and the patient was referred to the department. An emergency operation was performed with a suspicion of strangulated ileus due to volvulus of the small intestine. Laparoscopic observation disclosed caliber change on the ileum about 10cm to the ileum. This impacted intestine was pulled out laparoscopically, with a successful repair of ileus. A hernia opening was confirmed in the right pelvic base, but we decided to shift to laparotomy in order to explore causes. As a result, the hernia opening was found to be an abnormal hiatus arisen in the right broad ligament of uterus. Since no intestinal necrosis developed, operative procedures included only suture and no resection of the intestine was needed.
In the treatment of the disease which presents difficulty in diagnosis and demands intestinal excision in a high frequency, laparoscopic operation is thought to be of value.

View full abstract

A 55-year-old woman underwent laparoscopic cholecystectomy (LC) with a diagnosis of cholelithiasis at another hospital. She suffered from biloma 1 month postoperatively. About 16 months after operation, she visited our hospital because of right hypochondralgia. Abdominal radiography showed numerous metallic clips in the right upper abdomen. Abdominal computed tomography (CT) showed a low density area 5cm in diameter including one clip under the right lobe of the liver. Diagnosis of intraperitoneal abscess associated with a migrated clip after LC was made and ultrasonically guided percutaneous abscess drainage was done. A radiocontrast study through a drainage tube showed the intraperitoneal abscess including 1 clip. Pseudomonas aeruginosa was detected in a culture of pus collected through the drain. She was treated with drainage and antibiotics. Follow-up CT showed the abscess has shrunk 33 days after admission. The drainage tube was removed and she was discharged and remains disease-free and well 10 months later. No cases of intraperitoneal abscess associated with migrated clips after LC have been previously reported in the literature. This case suggests the need for awareness of probable latent complications following LC.

View full abstract

Mesenteric vein thrombosis (MVT) is a rare but lethal disease. We recently treated a patient with MVT probably caused by polycythemia vera (PCV). A 68-year-old woman with a prior medical history of PCV was admitted to our surgical unit for vague abdominal pain and vomiting. A CT scan of the abdomen showed MVT. Because there was no evidence of intestinal ischemia, the patient was treated with anticoagulation therapy. However, when a physical examination seven days later revealed signs of peritoneal irritation, surgery was performed immediately. Laparotomy demonstrated a large segment of necrotic small bowel, and resection of the long, infarcted intestine with primary end-to-end anastomosis was performed. Anticoagulation therapy was administered after the procedure, the patient progressed well, and there have been no signs of recurrence as of 12 months after the operation. This case demonstrates that early recognition of MVT in the clinical course of PCV, and appropriate treatment can improve the outcome.

View full abstract

We report a case of transomental hernia. A 13-year-old boy admitted for epigastric pain after overeating underwent abdominal CT, which showed the small intestine dilated at the anterior superior space of the stomach, and stricture of upper jejunum was observed in enterography. We conducted a laparotomy for a diagnosis of ileus due to internal hernia. At surgery, the small intestine was found to have herniated into the abnormal hiatus of the gastrocolic ligament, prolapsed through the reduced space of the lesser peritoneal sac, and returned to the peritoneal cavity. The incarcerated intestine was released without resection, and the abnormal hiatus was closed. We were able to preserve the incarcerated intestine due to the suitable decision of laparotomy.

View full abstract

This paper presents a case of omental torsion with necrosis which might be caused by inguinal hernia. A 62-year-old man was admitted to the hospital because of left inguinal bulging, left scrotum swelling and right lower abdominal pain. He had a sudden on set of urgent high fever as 38°C. On physical examination, tenderness and muscle defense were noted in the right lower abdomen. Computed tomography (CT) of the lower abdomen demonstrated a marked mass with concentric folds or an arrow pattern, and omental torsion with necrosis was suspected. On emergency laparotomy, most of the greater omentum was twisting and revealed hemorrhagic necrosis. The necrotic omentum with normal margin was resected and a repair of the left hernia was made. No malignancy was revealed pathologically. Postoperative course was uneventful. We reviewed 98 cases seen in the Japanese literature, including this case and present some notes about the disease. Without the knowledge of this disease, it is difficult to diagnose preoperatively in that. CT is helpful. No death have been reported.

View full abstract

We report a case of Dubin-Johnson syndrome associated with retroperitoneal leiomyosarcoma. A 72-year-old woman undergoing retroperitoneal leiomyosarcoma resection 2 years previously, had a history of jaundice since young. Abdominal CT scans revealed a recurrent retroperitoneal tumor invading the pancreas, stomach, and mediastinum. She was admitted for tarry stool and dizziness. Endoscopy showed an easily bleeding tumor in the stomach. Total bilirubin was 3.2mg/dl and direct bilirubin 2.6mg/dl. Continued bloody stool led us to conduct a laparotomy, where liver size was found to be within normal limits and the liver brownish-black. The retroperitoneal tumor was resected together with the stomach and distal pancreas. The mediastinal tumor was resected through the diaphragm. Microscopic findings showed the tumor to be leiomyosarcoma. Liver biopsy showed coarse brown granules in hepatocytes. The postoperative course was uneventful, without transient bilirubin elevation.

View full abstract

We have performed laparoscopy-assisted inguinal hernioplasty via the anterior approach, observing the state of the hernia laparoscopically, for 2 cases of recurrent inguinal hernia after mesh plug repair. In both cases, the hernia was repaired by inserting another mesh plug into the hernia orifice without removing the placed onlay mesh and plug. The patients have been doing well and there have been no signs of recurrence.
Open mesh plug hernioplasty under local anesthesia is adapted as our standard technique for inguinal hernia in adult patients. But for recurrent inguinal hernia after mesh plug repair, laparoscopy-assisted surgery allows easy and accurate recognition of the hernia sac and it is possible to perform a repair with a minimally invasive approach by inserting another mesh plug into the hernia orifice without performing unnecessary adhesiolysis in the inguinal canal. The laparoscopy-assisted anterior approach is a simple and reliable method for recurrent inguinal hernia after mesh plug repair, and thus from now on, this will be our method of choice.

View full abstract