Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association)
Online ISSN : 1882-5133
Print ISSN : 1345-2843
ISSN-L : 1345-2843
Volume 66 , Issue 5
Showing 1-50 articles out of 51 articles from the selected issue
  • Yuichi OTSUKA, Chikara KUNISAKI, Hirotoshi AKIYAMA, Hidetaka ONO, Masa ...
    2005 Volume 66 Issue 5 Pages 985-989
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We evaluated whether home enteral nutrition (HEN) is appropriate in discharge criteria after esophagectomy for esophageal cancer. Most causative factor for the indication of HEN was recurrent nerve palsy, which accounted for 22.2% of the patients (8/36) who applied for HEN. But in 67% (24/36) of the patients, the reasons of poor oral intake were not specified.
    The duration of postoperative hospital stay (p=0.90), changes in body mass index (p=0.97, 0.38, and 0.11) and prognostic nutritional index (p=0.99, 0.91, and 0.95) at 3rd, 6th, and 12th month after esophagectomy were not significantly different between HEN and non-HEN groups. In spite of induction of HEN, 22.2% (8/36) of the patients experienced body weight loss continuously during 12 months after the surgery. This indicated that the time of termination of HEN was not appropriate. A questionnaire survey to the patients who had HEN revealed that only 10% of the patients (1/10) felt difficulties in handling HEN but they requested that more supportive system should be established for the patients and their families. In conclusion, induction of HEN is one of the alternative discharge criterion after esophagectomy for esophageal cancer in patients with poor oral intake after esophagectomy and termination of HEN should be considered carefully.
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  • Kenji HIGAKI, Akito MORITA, Yoji KUBO, Takahiro MIMAE, Yasuhiro CHODA, ...
    2005 Volume 66 Issue 5 Pages 990-994
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Neo-adjuvant chemotherapy with paclitaxel followed by FEC was conducted on 36 cases of advanced breast cancer ranging from stage II A to III B with the tumor diameter exceeding 3cm. As a result, the clinical effect was rated as CR+PR=33/36 (91.7%) and the histological effect was rated as grade 3+grade 2=18/36 (50%). Breast-conserving surgery was accomplished in 86.1% (31/36) and the cancer positive rate of surgical margins was 5/31 (16.1%).
    Histological metastasis could not be demonstrated in 8/8 (100%) of NO, 13/17 (76.5%) of N1 and 1/8 (12.5%) of N2 with chemotherapy.
    Though the postoperative follow-up period is short, ipsilateral breast tumor recurrence and axillary lymph node recurrence have not been observed to date. The foregoing indicates the possibility that neoadjuvant chemotherapy can expand the indications of breast-conserving surgery and SNB. No consensus has been built for SNB at present, so that careful attitude is mandatory for performing SNB.
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  • Kazumasa FUJITANI, Toshimasa TSUJINAKA, Motohiro HIRAO, Takeshi SANO, ...
    2005 Volume 66 Issue 5 Pages 995-1000
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Purpose: The role of palliative gastric resection is still debatable for patients with gastric cancer having non-curative factors such as hepatic and peritoneal metastasis. A guestionnaire survey has been conducted in the Japan Clinical Oncology Group to find out the current status of the palliative resection and to define what patients are candidates for the randomized controlled trial (RCT) comparing the palliative resection with non-resection.
    Methods and Results: We sent a questionnaire to 30 facilities and recovered the filled questionnaire from 18. The results are: (1) Currently, the palliative gastric resection is preferred for patients with H1/2 liver metastasis or with P1/2 peritoneal metastasis in many hospitals. (2) Survival benefit obtained by the palliative resection is expected only in patients with H1 liver metastasis or with P0CY1/P1 peritoneal metastasis in many hospitals. (3) Randomized allocation to either the palliative gastric resection or probe laparotomy during the operation in patients whose metastasis is found intraoperatively is considered to be feasible in about half of the hospitals.
    Conclusion: This study shows that the patients with H1 liver metastasis or with P0CY1/P1 peritoneal metastasis are acceptable as candidates for RCT clarifying the significance of the palliative gastric resection. However, RCT may be infeasible in patients with resectable liver or peritoneal metastasis because we may be incapable of obtaining consents from both surgeons and patients. In conclusion, RCT should recruit all the patients with liver or peritoneal metastasis despite of its resectability.
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  • Kaname ISHII, Toru KAMATA, Yuichi HAYASHIDA, Katsuhiro YOSHIMOTO, Hide ...
    2005 Volume 66 Issue 5 Pages 1001-1007
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We have employed Roux-en Y reconstruction using a jejunal pouch (pouch RY) as a reconstructive method after distal gastrectomy to prevent stricture at the anastomosis and to improve “symptoms of the excised stomach”, and have observed postoperative clinical courses of those patients. The pouch RY with Billroth-I method (B-I) and the pouch RY are compared for postoperative outcomes and postoperative complaints. Thirty-one cases of B-I and 58 cases of pouch RY were enrolled in this study. A questionnaire survey was conducted to evaluate postoperative complaints of those patients. No significant difference in the incidence of postoperative complications was noted between the pouch RY and B-I groups. Although there was no significant difference in changing rate of postoperative body weight, the outcome of the pouch RY group was favorable. No significant differences were also observed in postoperative complaints asked by the questionnaire survey.
    It is concluded that the pouch RY bears comparison with B-I and has benefits in terms of the safety and prevention of anastomotic stricture compared with other methods of reconstruction, so that the pouch RY can be one of reconstructive methods after distal gastrectomy.
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  • Mitsuhiro NAKAMURA, Hiroki IKEUCHI, Hiroki NAKANO, Motoi UCHINO, Masaf ...
    2005 Volume 66 Issue 5 Pages 1008-1011
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Aim: To examine the relationship between the total dose of prednisolone before surgery and its adverse side effects in patients with ulcerative colitis (UC).
    Method: We enrolled 582 out of 634 patients with UC treated at the hospital from August 1984 to December, whose total dose of prednisolone had been calculated before surgery.
    Results: The most frequently occurred major side effect of prednisolone was osteoporosis, which was noted in 66% of cases. Medication for osteoporosis after surgery led to a significant improvement 12 months after the surgery, but did not result in normal values. The irreversible side effects of cataract, idiopathic osteonecrosis of the femoral head and thoraco-lumbar compression fractures significantly developed in the cases administered the total dose of 7000-10000mg of prednisolone.
    Conclusions: In the cases in which the total dose of prednisolone exceeds 7000mg, paticular attention must be paid to appearance of irreversible side effects and surgery before the appearance is desirable. Moreover, it is demonstrated that osteoporosis, the most common side effect, requires medical treatment for more than 1 year after the surgery.
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  • Shigehiro KURE, Tetsuya KANEKO, Shin TAKEDA, Soichiro INOUE, Akimasa N ...
    2005 Volume 66 Issue 5 Pages 1012-1015
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Background/Aims: Double duct sign, which is used to detect invasive cancer of the pancreatic head on endoscopic retrograde cholangiopancreatography (ERCP), is composed of co-strictures of the common bile and main pancreatic ducts. There have been no reports of the correlation between double duct sign and portal vein invasion.
    Methods: We enrolled 105 patients with pancreatic head cancer undergoing ERCP before radical pancreatoduodenectomy in our department from 1986 to 2003, and studied the correlations between double duct sign and pathologic factors including portal vein invasion.
    Results: Double duct sign significantly correlated with pathological invasion to the portal vein (P<0.001). In cancers of the pancreatic head which were double duct sign positive and had a tumor diameter of more than 2cm in CT scan, the diagnosis of portal vein invasion was made with the specificity of 76.9% and the positive predictive value of 72.7%. Double duct sign also significantly correlated with tumor size and perineural invasion (p<0.05).
    Conclusion: Double duct sign may contribute to assess histologic portal vein invasion preoperatively, especially in combination with tumor size as measured by computed tomography and ultrasonography.
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  • Yoshiko BAMBA, Takako KAMIO, Kei AOYAMA, Tetsuya OCHI, Shingo KAMEOKA
    2005 Volume 66 Issue 5 Pages 1016-1019
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 57-year-old woman who had been treated with estrogen replacement therapy for menopausal syndrome after hysterectomy for uterine cancer since 10 years earlier was referred to the hospital because she was pointed out breast abnormalities at a periodic examination elsewhere. Physical examination, palpation, and mammography revealed no abnormalities, however, ultrasonic study visualized multiple and scattered small tumors in the bilateral breasts which were 0.4-0.5cm in diameter with a high D/W ratio. Ultrasonography-guided cytodiagnoses of these tumors were class III. Then lumpectomies for 2 tumors of the right breast and 3 tumors of the left breast were performed under local anesthesia. As a result, invasive ductal carcinoma was diagnosed in all the resected materials. Bilateral mastectomy was carried out. All cancer foci were ER-positive and PgR-positive.
    It is indicated that the estrogen replacement therapy is a risk factor for carcinogenesis of the breast. This case of bilateral multiple non-palpable breast cancer diagnosed during estrogen replacement therapy is reported, together with a review of the literature.
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  • Yasuhiro SHUDO, Toyokazu AONO, Yasuhiro TANAKA, Shouki MIKATA
    2005 Volume 66 Issue 5 Pages 1020-1022
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a rare case of breast carcinoma with cartilaginous and osseus metaplasia.
    A 61-year-old woman was admitted to the hospital in June 2001 because of a mass in her left breast. Physical examination revealed a 21×20mm, discreate and elastic-hard mass in the CD region of her left breast. No axillary lymph nodes were palpable. With aspiration biopsy cytology, a diagnosis of breast cancer (T2, N0, M0 Stage IIA) was made and an operation (Bq+Ax) involving breast reconstruction with the latissimus dorsi flap pnocedure was performed on July 2001. The removed tumor was 20×18mm in diameter and solid. Histopathological examination revealed expansively growing breast carcinoma with cartilaginous and osseous metaplasia. In the region of adenocarcinoma, a component of solid-tubular carcinoma was dominant. No nodes were involved (0/10), and there was no lymph and blood vessel infiltration. ER and PGR were negative. She has no sign of recurrence for 40 months after the operation. Breast carcinoma with cartilaginous and osseous metaplasia belongs to a specific type of invasive carcinoma and accounts for 0.003-0.12% of all breast carcinomas. Only about 60 cases of breast carcinoma with cartilaginous and/or osseous metaplasia have been reported in Japan. We examine the clinical characteristics of this cancer.
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  • Masahiro MURAKAMI, Yoshiaki NAKANO, Tadashi ONISHI, Takeshi TONO, Hiro ...
    2005 Volume 66 Issue 5 Pages 1023-1026
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    This paper deals with a 55-year-old woman with bone marrow carcinomatosis of breast cancer. The patient had undergone a partial mastectomy for left breast cancer in June 1999, which was located in the left D area, was 15×15mm in diameter, invasive ductal carcinoma, scirrous type, f, tl, T1NXM1 stage IV, and both ER and PgR positive. Cancerous pleuritis and multiple bone metastases were found and systemic hormone therapy with toremifene and chemotherapy with cyclophosphamide, methotrexate, and 5-FU (VMF) were conducted. In October 2001, she was admitted to the hospital because of acute hemolytic anemia. Bone marrow examination to explore the cause revealed metastasis of adenocarcinoma. We thus diagnosed the case as microangiopathic hemolytic anemia (MHA) caused by bone marrow carcinomatosis of breast cancer. After hemolytic anemia improved by symptomatic treatment, docetaxel therapy was started carefully. Docetaxel therapy continued effectively for 10 times without recurrence of MHA or DIC on an ambulant basis. Finally she died of liver failure due to liver metastasis 45 months after the operation. In general bone marrow carcinomatosis is often associated with DIC and rapidly progresses to its termination, however, this patient could survive for a long time maintaining good QOL by effective systemic chemotherapy.
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  • Yuji SUGAWARA, Norio MOHRI, Takaaki NAGAE, Norishige MUKAI, Noboru YAM ...
    2005 Volume 66 Issue 5 Pages 1027-1031
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Takotsubo cardiomyopathy is a transient cardiac dysfunction of unknown cause. Emotional or physical stress has been described as one of the potential causes of this dysfunction. We experienced a patient with this type of cardiomyopathy occurring after major abdominal surgery. The present patient was a 59-year-old woman. She was admitted to the hospital because of jaundice. Intensive examinations to determine a causative lesion disclosed cholangiocarcinoma accompanied by gallbladder carcinoma. Bile drainage was established with an endoscopic procedure to treat obstruction of the common bile duct. Pancreatico-duodenectomy was performed after amelioration of jaundice. On the third postoperative day, respiratory failure occurred suddenly with the onset of pulmonary edema and mechanical ventilation support was started. The echocardiogram revealed left ventricular dysfunction with apical akinesis and basal normokinesis. The electrocardiogram revealed giant negative T wave in the pericordial leads. The left ventricular and respiratory functions recovered three days after the onset. The clinical course was uneventful thereafter. The coronary angiogram revealed no significant stenosis and takotsubo cardiomyopathy was definitely diagnosed. This type of cardiac dysfunction should be recognized as one of causes of acute pulmonary edema after abdominal surgery.
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  • Ichiro MORITA, Shin-ichiro KINOSHITA, Kazuo TANEMOTO
    2005 Volume 66 Issue 5 Pages 1032-1036
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 17-year-old woman, whose drug therapy for cough, headache, and slight fever was ineffective, was found to have a tumor shadow at the right lower lung field on a chest x-ray at another hospital and was admitted to the department of respiratory internal medicine in our hospital for close exploration. After bronchoscopy malignant small orbicular cell tumor was diagnosed. There was no distant metastasis. As the tumor became larger, the patient developed obstructive pneumonia, and she was transferred to our department of thoracic and cardiovascular surgery to undergo surgery. The tumor 8 cm in diameter arose from the S7 and partially invaded the middle lobe and adhered to the diaphragm. A right middle lower lobectomy and lymph node dissection were carried out. The pathological diagnosis was primitive neuroectodermal tumor (PNET). After the operation, the slight fever persisted and her strength was not restored. She was transferred to the department of respiratory medicine and was discharged without receiving chemotherapy. In addition to the slight fever back pain developed 2 months after the operation and she was admitted to the department of respiratory medicine again. Right pleural effusion was associated and its cytodiagnosis was class V recurrent PNET. Chemotherapy and radiation therapy were unsuccessful and the patient died of associated carcinomatous pericarditis 5 months after the operation.
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  • Yoshiro KOBE, Yoshikazu YAMAMOTO, Satoru TAKAISHI, Yoshiharu TOKORO, Y ...
    2005 Volume 66 Issue 5 Pages 1037-1040
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a patient with late onset of traumatic right diaphragmatic hernia presented with intestinal obstruction.
    The patient was a 79-year-old woman who had been diagnosed as having right hemothorax due to a traffic accident and successfully treated by inserting a tube thoracostomy elsewhere 3 years earlier. Six months after the treatment abnormal elevation of the right diaphragm was found, but asymptomatic patient had been followed until she was seen at another hospital because of vomiting when 3 years had elapsed after the injury. She was referred to the hospital with a diagnosis of traumatic right diaphragmatic hernia. Chest and abdominal CT scans revealed right intrathoracic hernia of which contents were the ileum, liver and gallbladder. She was operated on through an abdominal approach. A 7×5cm rupture was present on the right diaphragm and was closed by interupted suture Postoperative course was uneventful. The patient was discharged from the hospital on the 15th postoperative day.
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  • Hideki MARUSHIMA, Hiroshi NIMURA, Norio MITSUMORI, Hironori ODAIRA, Hi ...
    2005 Volume 66 Issue 5 Pages 1041-1044
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a case of gastrointestinal stromal tumor (GIST) of the stomach with extensive peritoneal dissemination for which postoperative administration of STI571 was highly effective.
    A 57-year-old man was diagnosed as having a gastric submucosal tumor by upper gastrointestinal series at a medical checkup in August 2000. He was referred to the hospital in January 2002 for further work-up and treatment for the enlarging tumor. On physical examination, a hard tumor was palpable in the upper abdomen. Endoscopy demonstrated a giant submucosal tumor with a central ulcer in the lower posterior wall of the body of the stomach. Biopsy of the lesion was positive for c-kit, and immunohistochemical staining suggested GIST. Abdominal CT scan showed an outgrowing cystic tumor in the body of the stomach. Furthermore, extensive peritoneal dissemination was suspected. He underwent laparotomy and distal gastrectomy. Histopathology of the excised specimen confirmed the diagnosis of gastric GIST with extensive peritoneal dissemination. Postoperative chemotherapy with oral STI571 (400mg/day) was started. As of 36 months postoperatively, the patient remains free from disease.
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  • Fumiaki SHIMIZU, Tomohiro MATSUYAMA, Toshitaka MAEJIMA, Akira SUZUKI, ...
    2005 Volume 66 Issue 5 Pages 1045-1048
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Recently reports have increasingly been reported that the eradication of H. pylori is effective for idiopathic thrombocytopenic purpura (ITP) with H. pylori infection. In this paper we present a case of gastric cancer infected with H. pylori in which distal gastrectomy resulted in improvement of ITP.
    A 77-year-old man admitted to the hospital because of gastric cancer was diagnosed as having ITP from hematological studies; the platelet count was as low as 46, 000 and PA IgG was as high as 51ng/107 cells (the normal rage: 9.0_??_25.0). Operative procedures included distal gastrectomy and D2 lymph node dissection. With intraoperative administration of 10 units of platelet, the platelet count was gradually elevated after the operation up to 101, 000 on the 8th postoperative day. Thereafter the level was kept at around 100, 000 and no additional administration of platelet was required. Examination of the resected material disclosed H. pylori positive. The high PA IgG level dropped to 29ng and the platelet count was in the normal range, as of 4 months after the operation.
    It is thought that distal gastrectomy might have the same effect for ITP as the H. pylon eradication has, because ITP improved after the procedure for gastric cancer with H. pylori infection in this case.
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  • Nobuo HIRAYAMA, Shin-ichi MIYAZAKI, Hisahiro MATSUBARA, Taito AOKI, Yo ...
    2005 Volume 66 Issue 5 Pages 1049-1053
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    The patient was a 73-year-old man. There were previous histories of undergoing a distal gastrectomy with Billroth II reconstruction (B-II) for gastric cancer in 1982, a cholecystectomy for gallstones in 1988, and by a right thoracotomy and laparotomy, an esophagectomy and resection of the remnant stomach were carried out followed by an esophageal reconstruction using right colon through a subcutaneous route for esophageal cancer in 1994. Upper gastrointestinal series conducted for observation of his clinical course in 2001 revealed an irregularity of the mucosa at the anastomosis between the reconstructed colon and jejunum. A biopsy provided a diagnosis of adenocarcinoma. His surgical records clarified that the surgical margin of the remnant stomach was used for the anastomosis between the reconstructed colon and jejunum. Accordingly the distal part of the colon used for esophageal substitution, the small remnant stomach, a part of the jejunum connecting to the remnant stomach, and the lymph nodes along the colonic margin were excised. The reconstruction was performed according to the B-II style. The patient developed afferent loop syndrome after the operation, but he was discharged from the hospital very much improved after conservative treatment of the syndrome. The resected material revealed type 3, tub2, pT2(ss), ly2, v1, infβ, surgical margin negative, and one positive mural lymph node. The patient is on medication with oral antineoplastic agent (5FU) on an ambulant basis, and he has been free from any signs of recurrence at present.
    This is a case which has renewed our understanding that examinations are always required by keeping a possibility of another carcinogenesis after surgery for a malignant tumor in mind.
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  • Takuya OKUMURA, Kazuhiko FUKUMOTO, Kazuya OKAMOTO, Kenji SUZUKI, Yasuh ...
    2005 Volume 66 Issue 5 Pages 1054-1057
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 39-year-old woman was admitted to the hospital because of acute abdomen. Abdominal CT scan at arrival showed mobile of the descending colon and dilation of the small intestine between the stomach and pancreatic body and tail. Abdominal CT scan at abdominal attack showed the dilated small intestine that converged toward the inferior mesentric vein (IMV). Therefore she was diagnosed as having left paraduodenal hernia with mobile of the descending colon. Laparotomy showed mobile of the descending colon and the entire small intestine except for the end of the ileum that which was dislocated to the left side of the descending colon passed from behind the IMV. The small intestine by 110cm from the Treitz ligament was covered with hernial sac, and the remaining small intestine was uncovered. After the intestine was repositioned, the descending colon was fixed and a deficit on the mesentery of descending colon was closed. Left paraduodenal hernia usually has a hilum of which anterior wall consist of IMV, so this case was diagnosed as left paraduodenal hernia with two components with and without hernial sac.
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  • Tadashi SHIBATA, Hiroshi NARITA, Kenji KOBAYASHI, Tetsushi HAYAKAWA, K ...
    2005 Volume 66 Issue 5 Pages 1058-1062
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 46-year-old man, who had taken a medicine named mesalazine with a diagnosis of Crohn's disease for two years but stopped it recently in his own judgment, was seen at the hospital because of right lower abdominal pain. Remarkable rebound tenderness was present on the right lower abdomen, and an abdominal plain X-ray examination showed small intestinal gas suggestive of small intestinal ileus on the entire abdomen. In addition, abdominal CT scan showed hepatic portal venous gas (HPVG) in the entire liver. An emergency laparotomy was performed with a diagnosis of small intestinal ileus with HPVG. On surgical findings, there were wall thickening, stenosis and fistulization of the terminal ileum, but no necrotic or ischemic change of the bowel was found. Partial resection of the ileum involved the lesion was performed. Pathological findings of the specimen showed Crohn's disease of the small intestine. We finally diagnosed this case as simple small intestinal ileus due to Crohn's disease with HPVG. Postoperative course was favorable, and hepatic portal venous gas disappeared on the next day after the operation, and he left our hospital on the 19th postoperative day.
    Case reports of HPVG associated with Crohn's disease are extremely rare and this case is the second one in Japan.
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  • Hiroshi KAWASE, Yuma EBIHARA, Syunichi OKUSHIBA, Hiroyuki KATOH, Satos ...
    2005 Volume 66 Issue 5 Pages 1063-1066
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 63-year-old man, diagnosed as having simple ulcer of the small intestine and received medication and nutrition treatment for two months elsewhere, was transferred to the hospital because of acute abdominal distention and right lower abdominal pain. On admission, his abdomen distended, but he had no signs of peritonitis. A fist-sized tumor was palpated in the right lower quadrant. The laboratory data showed severe inflammation. Abdominal CT scan showed dilatation of the small intestine and wall thickening of the ileocecum. We determined intestinal obstruction caused by acute exacerbation of simple ulcer, and performed an ileocecal resection. Surgical findings showed 9 stenoses at the ileum, and then we excised the ileum about 60cm proximal to the Bauhin's valve. Histopathological studies revealed multiple punched out deep ulcers and non-specific acute inflammatory findings in the terminal ileum, and stenosis of the intestines caused by adhesions among these ulcers. Therefore, we diagnosed the case as intestinal obstruction due to acute exacerbation of multiple simple ulcer. The patient was discharged from the hospital on the 33rd day after the operation. He has been followed up for 6 months after the operation without evidence of recrudescence.
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  • Yuji IIDA, Yoshinori AOYAMA, Tomoyuki KUBOTA, Junko OYA, Makoto KATO
    2005 Volume 66 Issue 5 Pages 1067-1071
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 46-year-old man, diagnosed as having Crohn's disease when he had undergone a partial resection of the ileum for perforating peritonitis one year earlier and then had been treated with oral mesalazine and ingredient nutrient medication, was referred to the hospital because of abrupt onset of abdominal pain. Abdominal CT scan showed free air and the extended small intestine. Perforation of the small intestine due to acute aggravation of Crohn's disease was suspected, and a laparotomy was performed. There was no storage of ascites or perforated part of the intestine. A slight degree of wall thickening and numerous pneumatocystic changes were seen on the serosa of the ascending colon. He was diagnosed as having pneumatosis cystoides intestinalis owing to chronic inflammation of Crohn's disease and underwent drainage only. Postoperative course was uneventful and oral administration was resumed.
    Although reports on Crohn's disease associated with pneumatosis cystoides intestinalis are very rare, this condition must be kept in mind.
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  • Yoshiki HOSONO, Hiromi TANEMURA, Hiroo OSHITA, Akihiro KANNO, Mitsuhik ...
    2005 Volume 66 Issue 5 Pages 1072-1075
    Published: May 25, 2005
    Released: January 22, 2009
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    Von Recklinghausen's disease is neurofibromatosis and is characterized by cafeé-au-lait skin macules, fibromatous tumors and autosomal dominant inheritance. Many cases of the disease associated with various tumors have been reported. This paper deals with a case of malignant schwannoma associated with von Recklingausen's disease presented with serious anemia and an abdominal tumor.
    A 74-year-old man complaing of palpitation and dyspnea of effort was pointed out anemia and an abdominal tumor by his family doctor and was admitted to the hospital. On physical examinations, multiple tumors and cafe-au-lait spots were observed on the skin of the whole body, and a well-movable tumor was palpated in the lower abdomen. Anemia and an increase in soluble IL2 receptor were noted by blood tests, and a stool examination was positive for occult blood. The most likely diagnosis was an extramurally growing neoplasm of the small intestine. The patient was operated on with the diagnosis of small intestinal tumor associated with von Recklinghausen's disease, and a partial excision of the small intestine by 140cm in length including the tumor was performed. Immunohistologically the tumor was positive for S-100 protein and NSE and negative for SMA. Malignant schwannoma was thus diagnosed.
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  • Kimihiko UENO, Kazuya SAKATA, Kenichi TANAKA, Kunihiko HIRAOKA, Taichi ...
    2005 Volume 66 Issue 5 Pages 1076-1079
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 63-year-old man was admitted to the hospital because of lower abdominal pain. An emergency operation was performed with a diagnosis of diffuse peritonitis. At lapalotomy, we found multiple tumors of the ileum and a part of them penetrated to the ileal mesentery. Partial resection (70cm of the ileum) and regional lymph node dissection were carried out. Postoperative chemotherapy (CHOP) was started but he died 73 days after the operation. Histological diagnosis was primary T cell malignant lymphoma of the small intestine and enteropathy type according to the new classification of WHO. In addition these tumors were CD8 and CD56 positive by immunostain. It is inferred that the patient might have some poor prognostic factors so that he did not respond to postoperative chemotherapy and had such a grave prognosis.
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  • Takeshi ENDO, Hideki MATSUYAMA, Takafumi UENO, Masayuki HATANAKA, Yuta ...
    2005 Volume 66 Issue 5 Pages 1080-1084
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    An asymptomatic 51-year-old man was found to have an abdominal tumor by an abdominal urtrasonography conducted during clinical observation for diabetes. The tumor was visualized along the pancreatic lower edge with obscure border with the pancreas. Abdominal CT and magnetic resonance imaging scans showed that the tumor was hypervascular with necrosis inside on the border of the pancreas. An abdominal angiography revealed that the feeding artery was the first jejunal branch. The patient was operated on with a diagnosis of gastrointestinal stromal tumor (GIST) of the jejunum. A tumor measuring about 6cm in diameter was present in the jejunal wall at 3cm distal from the Treitz' ligament, and a partial resection of the jejunum was performed.
    Histopathological examination revealed that the main tumor was composed of spindle-shaped cells with proliferation in HE staining. Immunohistochemically, these cells were strongly positive for c-kit, so we definitely diagnosed the case as jejunal GIST of intermediate malignancy.
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  • Masahiro URAYAMA, Nobuo SEO, Keiji OHTA, Yasuaki KARUBE, Kiyoshi KAWAG ...
    2005 Volume 66 Issue 5 Pages 1085-1089
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 61-year-old man who had had anal bleeding since about the middle of October 2003 was seen at the hospital because of aggravating abdominal pain and fever which occurred on the day before. There were spontaneous pain, tenderness and muscular defense in the entire abdomen. The hemoglobin level was 5.3g/dl, showing severe anemia. Abdominal CT scan showed a tumor about 7cm in diameter continuing to the small intestine. Emergency operation was carried out with a diagnosis of gastrointestinal bleeding and peritonitis relating with the tumor. There was about 100ml of pus contamination in the abdominal cavity and peritonitis was identified. A tumor about 7cm in diameter was confirmed on the mesentery side of the small intestine 120cm distal from the Treitz' ligament. The tumor was composed of solid and cystic parts, the solid part continued to the intestine with bleeding and the cystic part perforated. The small intestine by about 20cm in length including the tumor was excised. The histopathological diagnosis was moderately malignant gastrointestinal stromal tumor (GIST) of the small intestine.
    GIST of the small intestine is primarily rare, especially GIST of the small intestine associated with gastrointestinal bleeding and peritonitis. This very rare case is reported here.
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  • Makoto KINOUCHI, Manabu SATO, Naoyuki KANEKO, Takashi DOI, Fusakuni KU ...
    2005 Volume 66 Issue 5 Pages 1090-1093
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 60-year-old man admitted to the hospital because of dysuria was found having right hydronephrosis and a tumor of the ileocecal region on abdominal CT scan and abdominal ultrasonography. He felt no abdominal tenderness. There were no abnormalities in laboratory data. Colonoscopy showed a submucosal tumor with a smooth surface at the appendiceal orifice, and abdominal CT scan showed a tumor with an unclear margin in the ileocecal region and right hydronephrosis due to obstruction of the right ureter by the tumor. Appendiceal tumor complicated with right hydronephrosis was suspected, and a right hemicolectomy with D3 lymph node dissection and a partial resection of the sigmoid colon were carried out. Histological findings reveled the tumor tissue as fibrous granuloma, and the submucosal tumor at the appendiceal orifice as a non-neoplastic lesion due to interstitial fibrosis.
    In making diagnosis of an ileocecal tumor, hydronephrosis and an ileocecal polypoid lesion should be kept in mind as symptoms of appendicitis. In such a case, we should decide the operative procedure according to intraoperative frozen section diagnosis to avoid over surgery.
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  • Tsutomu MAEDA, Tomoo WATANABE, Yoshiro ISHIBIKI, Yuichi TOMIKI, Kazuhi ...
    2005 Volume 66 Issue 5 Pages 1094-1098
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 48-year-old woman, who was under treatment for malignant rheumatoid arthritis at the department of internal medicine in our hospital, had recurrent abdominal pain and a palpable mass in the right upper quadrant of abdomen. Abdominal CT scan and barium enema showed that the cecum was invaginated in the transverse colon. Colonoscopy demonstrated an incomplete intussusception of the appendix into the cecum and villous change of the appendiceal mucosa; the colonic intussusception was already reduced. Histologic examination of a biopsy taken from the appendiceal mucosa revealed villous adenoma with severe atypia. Appendiceal intussusception caused by an appendiceal villous tumor was diagnosed and an ileocecal resection was performed. Microscopic findings revealed tubulovillous adenoma with severe atypia.
    Villous tumors of the appendix are complicated with intussusception in more than 50% of cases and have a high potential risk of malignancy (62%). Therefore, the extended radical surgery with lymph node dissection should be considerd to obtain a higher curability for appendiceal villous tumors than that by simple appendectomy.
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  • Nobuyuki TOHARA, Toshiki MIMURA, Miki ADACHI, Kota OKINAGA, Yasushi KU ...
    2005 Volume 66 Issue 5 Pages 1099-1104
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a case of mucinous cystadenocarcinoma of the appendix vermiformis resected by laparoscopy-assisted right colectomy.
    A 57-year-old woman, presenting with right lower quadrant abdominal pain, was conservatively treated in April, 2003, being suspected of acute appendicitis. In May, similar symptoms relapsed and subsided with another conservative therapy. The appendix was not visualized with barium enema. On colonoscopy, the ileocecal valve looked inflamed and the orifice of the appendix could not be confirmed. In September, the similar symptoms relapsed and an abdominal CT scan showed the inflamed cecum and terminal ileum. In October, laparoscopy-assisted right hemicolectomy was performed with a preoperative diagnosis of an ileocecal inflammatory tumor. The inflamed appendix had formed an inflammatory tumor, adhering to the cecum and terminal ileum, which was successfully resected en bloc. Histological examination revealed well differentiated mucinous cystadenocarcinoma in situ of the appendix vermiformis with no vessel invasion or lymph node involvement.
    Five cases including ours of mucinous cystadenocarcinoma of the appendix vermiformis resected by laparoscopic surgery have been reported in Japan. During the laparoscopic surgery, an extra care should be taken in manipulating the tumor to avoid intraperitoneal dissemination of the mucus and tumor cells that could subsequently develop pseudomyxoma peritonei.
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  • Naohiro NOMURA, Takaya MIWA, Yuki TAKEUCHI, Mitsuro KANDA, Masahiro SU ...
    2005 Volume 66 Issue 5 Pages 1105-1110
    Published: May 25, 2005
    Released: May 26, 2009
    JOURNALS FREE ACCESS
    A 74-year-old woman admitted to the hospital for close examination of anemia was found to have a flat elevated lesion with redness in the transverse colon by colonoscopy. Abdominal angiography revealed abnormal pooling of capillaries and early venous return in the lesion of the transverse colon. Total bilirubin was 3.4mg/dl and direct bilirubin 1.9mg/dl. The hepatic function was normal. Liver biopsy showed coarse brown granules in hepatocytes. Therefore AVM associated with Dubin-Johnson syndrome was diagnosed. Operative findings showed the brownish-black liver and a transverse colectomy was performed. After the operation total bilirubin level did not increase, but bloody stool persisted. By colonoscopy, AVM was observed in the sigmoid colon which might be the bleeding point. Argon plasma coagulation (APC) was performed for this lesion to lessen a load for the patient. The patient has been followed for 1 year after the treatment without evidence of recurrence.
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  • Naoko MASAOKA, Masayasu IKEJIRI, Shoichi HIROHARA
    2005 Volume 66 Issue 5 Pages 1111-1114
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    An 87-year-old woman was admitted to the hospital because of dizziness and breathless. Examination of blood revealed 5.3g/dl of hemoglobin, indicating serious anemia. There were histories of high blood pressure, chronic renal dysfunction, and gastric ulcer. Colonoscopy performed on the hospital day 7 identified a lesion of bleeding on the ascending colon. Despite endoscopic hemostatis, bleeding persisted. Colonoscopy performed on the hospital day 11 revealed other bleeding lesion on the ascending colon which was situated on the opposite side of the former lesion. Hemostasis was carried out endoscopically again. On the hospital day 13, bleeding started again. We considered that the bleeding could not be controlled by endoscopic procedure, and performed a right hemicolectomy on the 22nd hospital day. Pathological examination revealed 6 lesions of angiodysplasia on the resected colon.
    Colorectal angiodysplasia is one of the main causes of massive anal bleeding in elderly people. We report the case together with a review of the literature.
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  • Katsuya SOGAHATA, Tetsufumi SOMEYA, Takashi SATO, Toshihiko TORIGOE, N ...
    2005 Volume 66 Issue 5 Pages 1115-1118
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a case of rectal obstruction due to a huge submucosal hematoma formed after PPH stapled hemorroidectomy. The patient was a 69-year-old woman suffering from prolapse of pile for a month, which was diagnosed as third-degree hemorrhoids according to the Goligher classification. PPH was performed under spinal anesthesia. At surgery, and anal dilator was inserted into the anus, pursestring sutures were made for the entire circumference of the rectum by rotating a purse-string anoscope. When the sutures were pulled, she complained of crampy abdominal pain and nausea with a decrease of blood pressure and bradycardia. Four days after the operation, no defecation occurred, a soft mass was palpated in the lower rectum, and she felt severe pain around the anastomosis. Pelvic CT scan conducted on the postoperative day 7 showed a mass 7cm in diameter of the rectum, which was thought to be a submucous hematoma.
    PPH is thought to be a useful treatment with advantages in terms of less postoperative pain, safety, and early return to work. However, we must confirm that an easy use of PPH for hemorrhoidal diseases can be associated with complications and pursue to study more appropriate candidates and precise technique.
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  • Masatoshi KURODA, Yumiko TANAKA, Kazuo USAMI, Shinichiro YOSHITANI, Ic ...
    2005 Volume 66 Issue 5 Pages 1119-1124
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a case of multiple sigmoid colon cancer with non-invasive metastasis to the small intestine.
    A 62-year-old man was seen at the hospital because of dizziness and general fatigue since February 2002. Except for anemia detected on admission, there were no biochemical abnormalities. Slightly high levels of tumor markers were noted; CEA was 5.8ng/ml and CA19-9 was 181U/ml. Barium enema study revealed two filling defects in the sigmoid colon, and colonofiberscopy also showed a type 3 tumor according to ‘Japanese Classification of Colorectal Carcinoma’. The patient was operated on with a diagnosis of multiple sigmoid colon cancer. Besides the two sigmoid tumors, three tumors were found in the small intestine which were about 120cm distal from the Treiz' ligament, and 15 and 25cm from the ileum end during surgery. A sigmoidectomy (D3) and enterectomies at two portions of the small intestine were carried out. No malignant cells were demonstrated by peritoneal lavage cytology. Histopathologically these sigmoid and small intestinal lesions were moderately differentiated adenocarcinoma; the sigmoid colon cancer showed extremely severe venous invasion and the small intestinal lesions were mainly located in the submucosal structure. Accordingly non-invasive metastasis to the small intestine of sigmoid colon cancer was diagnosed. The patient has been treated with chemotherapy including 5FU, and recovered his social activities without recurrence, as of 2 years 7 months after the operation.
    To the best of our knowledge, there have been only eight cases of non-invasive metastasis to the small intestine like this case.
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  • Terutoshi NAKAO, Toshihiro UCHIDA, Yoshitaka TSUKAMOTO
    2005 Volume 66 Issue 5 Pages 1125-1129
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a case of locally advanced rectal cancer in which a bladder conserving surgery provided favorable postoperative life for the patient.
    A 59-year-old man seen at the hospital because of abnormal defecation was diagnosed as having type 2 rectal cancer with invasion into the prostate and seminal vesicle by colonofiberscopy and magnetic resonance imaging scans. After no involvement of paraaortic lymph nodes was confirmed by intraoperative frozen section diagnosis, the bladder was conserved and the resection of the rectum associated with the prostate and seminal vesicle was performed. The histological stage was a2, n1 (+), P0, H0, M (-), and stage IIIa. It took about 5 weeks after the operation to attain fusion of an anastomosis between the remnant bladder and urethra. After discharge the patient's QOL has been good except urinary incontinence only in the night, and there have been no signs of recurrence as of 3 years after the operation.
    At present when the imaging diagnosis and operative technique have developed, more limited surgery to conserve the urinary bladder must be considered as possible as we can.
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  • Naoki HINO, Daisaku HARAUCHI, Hiromitsu TAKIZAWA
    2005 Volume 66 Issue 5 Pages 1130-1134
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 67-year-old man admitted to the hospital because of melena was found to have two elevated lesions of the rectum by barium enema study. Histologically the upper lesion was squamous cell carcinoma and the lower lesion was adenocarcinoma. We performed a transanal mucosal resection for adenocarcinoma and a low anterior resection of the rectum for squamous cell carcinoma. Chemotherapy with UFT and CDDP was performed after the operation. Melena developed again 3 months after the operation, and squamous cell carcinoma recurred to the scar of mucosal resection at the posterior wall of the lower rectum. An abdominoperineal resection of the rectum was performed but the tumor had invaded the sacrum. Despite intraarterial chemotherapy and radiation at 50Gy to the sacrum part, liver metastasis occurred and he died on the postoperative 15th month. Squamous cell carcinoma of the rectum has a poor prognosis and demands not only operation but also intensive therapies. However, no therapeutic guidelines for the disease have been established as yet because of its rare occurrence. It appears that only radiation therapy is effective in some cases. In this case recurrence might occur due to implantation during surgery. Particular attention must be paid to selection of surgical procedures.
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  • Takuji NAKA, Kenichi SUMI, Yoko MURATA, Ryuichi HAMAZOE
    2005 Volume 66 Issue 5 Pages 1135-1138
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 19-year-old man was accidentally found to have a tumor of 2cm in diameter in the S7 segment of the liver behind the base of the right hepatic vein by ultrasonography. He had no infection with hepatitis B or C virus, and his liver function, serum AFP and PIVKA-II levels were in normal values. A well-enhanced tumor was observed by computed tomography, magnetic resonance imaging, and angiography, however, there were no findings of central scar or spoke wheel appearance in the tumor. Partial resection of the liver was performed because it was difficult to differentiate from hepatocellular adenoma or hepatocellular carcinoma. Resected specimen showed that the tumor was 27mm in diameter and simple nodular type without capsule. Histopathological examination showed proliferation of hepatocytes without atypism, fibrosis and bile duct proliferation in the Glisson, but no central scar was seen in the tumor. Finally it was diagnosed as focal nodular hyperplasia (FNH).
    Although the characteristic findings of FNH are central scar, spoke wheel appearance and the existence of Kupffer's cell, few cases have such typical findings and we have difficulties in differentiation from hepatocellular carcinoma. Thoracolaparotomy by the right oblique incision is the best approach for operating around the base of the right hepatic vein safely.
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  • Ayako ENDO, Tetsunori YOSHIMURA, Tadao MURAYAMA, Hiroyuki MINAKUCHI, T ...
    2005 Volume 66 Issue 5 Pages 1139-1145
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We experienced a case of liver abscess, which was difficult to be differentiated from malignant liver tumor before surgery.
    A 73-year-old woman complaining of poor appetite, who had a history of surgery for a giant liver cyst, was introduced to the hospital because of a large liver mass. When she was admitted, her general condition was good with normal body temperature, and she had no abdominal symptoms. CT and magnetic resonance imaging scans revealed a polycystic liver mass with a thickened wall and septum enhanced. Angiography revealed tumor staining, encasement of the right hepatic artery and artery-portal vein shunt. Colonoscopy and barium enema examination disclosed rectal cancer. The liver mass was suspected to be malignant tumor, liver cystadenocarcinoma, metastatic tumor, or hepatocellular carcinoma. A low anterior resection of the rectum and a right anterior segmentectomy of the liver were performed. Histopathological examination showed no malignant cells in the liver mass and Klebsiella. pneumoniae was cultured from the pus. The definite diagnosis of liver abscess was made.
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  • Atsushi MITAMURA, Akiko AMAMOTO, Yu SUZUKI, Ko TAKEHANA, Yoshihiro END ...
    2005 Volume 66 Issue 5 Pages 1146-1150
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 67-year-old woman followed for cystic lesions of the right lobe of liver since 1998 was admitted to the hospital in August 2002, because these lesions showed an enlarging tendency on serial CT scans and she felt appetite loss and pain from the lower abdomen to right gluteal region lasting for about one month. Magnetic resonance imaging (MRI), endoscopic retrograde cholangiography, and digital substraction angiography indicated a malignant hepatic tumor. A right hepatic lobectomy was carried out on September 18. The histopathological diagnosis was papillotubular cystadenocarcinoma with invasion to the normal liver, EMA(+), CK7(+), CK20(+_??_-), and AFP(-). Postoperative course was uneventful and she was discharged on the postoperative day 19. She, however, developed malaise in early December and was readmitted to the hospital with a diagnosis of tumor recurrence because abdominal CT scan showed swelling of the paraaortic lymph nodes and serum CEA and CA19-9 were elevated. Anticancer chemotherapy was ineffective, and she died on April 22, 2003. Hepatic cysts are benign in most cases, however, careful long-term observation is required keeping a possibility of malignancy in mind, if the cyst is multilocular and has thickened or irregular wall.
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  • Ippei MATSUMOTO, Tetsuo AJIKI, Hidehiro SAWA, Takashi UEDA, Yasuhiro F ...
    2005 Volume 66 Issue 5 Pages 1151-1155
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 72-year-old woman admitted to the hospital because of severe epigastric pain and vomiting was diagnosed as having severe acute pancreatitis due to gallstones. After treatment for the pancreatitis, she underwent electire laparoscopic cholecystectomy. Preoperative abdominal ultrasonography showed numerous small gallstones of 3-5mm indiameter in the gallbladder. There was no evidence of bile and cystic duct variations and abnormalities assessed by magnetic resonance imaging cholangiopancreatography (MRCP). Intraoperative cholangiography (IOC) revealed two separate cystic ducts entering to the common bile duct. Double cystic duct (DCD) was diagnosed.
    DCD is very rare. To avoid unnecessary injury to the bile duct DCD must be kept in mind as one of possible anomaly of the biliary system in performing laparoscopic cholecystectomy. IOC is useful to identify DCD. A review of 27 cases of DCD including our case is also presented here.
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  • Toru YOSHIDA, Osamu SHIMOOKI, Yuko BABA, Tadashi ABE, Tamotsu SUGAI, S ...
    2005 Volume 66 Issue 5 Pages 1156-1160
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Traumatic neuroma arising from the biliary tract is rare and usually involves patients with a history of surgery and a tumor arising in the stump of the cystic duct. We report a case of traumatic neuroma of the gallbladder with no history of surgery.
    A 68-year-old man admitted to the hospital for gallbladder examination was found to have a suspicious gallbladder tumor and a submucosal tumor of the stomach by US, EUS and MRCP. Cholecystectmy and partial gastrectomy were performed. A 3×1cm peduncurated polyp was identified in the resected gallbladder. Postoperative pathological examination showed that the polyp surface was lined with hyperplastic epithelium and nerve fiber proliferated in the submucosal layer. Immunohistochemical study showed these lesions to be strongly positive for S-100 protein. The lesion was diagnosed as traumatic neuroma of the gallbladder.
    Injuries to nerve fibers commonly result in the development of neuromas. In our case without history of undergoing surgery, physical stimuli to nerve fibers due to the peduncurated gallbladder polyp was assumed to be the main cause of the neuroma.
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  • Koki HATA, Sadayuki SASAKI, Osamu ASAKO, Osamu KASAGAWA
    2005 Volume 66 Issue 5 Pages 1161-1165
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    We report a rare case of congenital choledochal cyst with intestinal malrotation.
    A 32-year-old woman was admitted to the hospital because of upper abdominal pain and back pain. Abdominal ultrasonography revealed a cystic mass in the hepatic hilum. Abdominal CT scan showed a giant cystic mass near the common bile duct. Upper gastrointestinal series showed the displacement of the horizontal portion of the duodenum and the entire small intestine to the right. The entire large intestine was located on the left, yielding a diagnosis of nonrotation by a barium enema study. Pancreaticobiliary maljunction was uncertain by endoscopic retrograde cholangio-pancreatography (ERCP). After percutaneous intrahepatic drainage under echo guidance of the cystic lesion, we performed an excision of the choledochal cyst with reconstruction of the biliary tract because of a suspicion of malignancy on cytology. Postoperative pathological examinations showed no evidence of malignancy.
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  • Masatoshi SHIGETA, Manabu SUDO, Masahiko ORITA, Tadahiko ENOKI, Shinji ...
    2005 Volume 66 Issue 5 Pages 1166-1169
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Peribiliary cysts are cystic dilatations of the peribiliary glands that are located exclusively in or around the hepatic hilum. A case of peribiliary cysts that caused a hilar bile duct stenosis is presented.
    A 72-year-old man had elevated liver enzymes. Radiologic examinations revealed a hilar bile duct stenosis, where cholangioscopy showed an elevated nodular lesion. Cholangiocellular carcinoma was suspected preoperatively. A laparotomy disclosed multiple small cysts in the hepatic hilum. Resection and de-roofing of the cysts were performed, and the stenosis of the bile duct was attenuated. The postoperative course was uneventful.
    Peribiliary cysts are often small in diameter, so it is difficult to distinguish these cysts from dilated bile ducts or edema of portal tracts if bile duct stenosis is present. It is important to recognize that peribiliary cysts might induce bile duct stenosis.
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  • Shuichi FUJIOKA, Tomoyoshi OKAMOTO, Takeyuki MISAWA, Yoshihiko TAKAO, ...
    2005 Volume 66 Issue 5 Pages 1170-1174
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 66-year-old man complaining of upper abdominal pain was admitted to the hospital for close exploration. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed a papillo-expansive tumor 55mm in diameter in the mid-portion of the common bile duct. Due to poor general condition of the patient including hemiparalysis from cerebral infarction, bilialy plastic stenting was chosen rather than radical operation. After 7 month's observation with self-medication of shark cartilage, ERCP exhibited a regression of the primary tumor to 15mm in diameter. After the patient discontinued the shark cartilage, however, the tumor started to grow again, then operation was performed. Extract of shark cartilage exerts a potent antiangiogenic action and the preparation of the extract 'neovastat' is under the Phase III clinical studies in the U. S. To our knowledge, no reports have been published of shark cartilage for bile duct cancer in the English literature. Our report implies that antiangiogenic therapy might be effective for bile duct cancer, which is well-known to show multi-drug resistance and poor response to chemotherapeutic modalities.
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  • Hisashi ISHIKURA, Hiroshi OKITU, Yoshiyuki FUJII, Akihiro SAKATA, Sugu ...
    2005 Volume 66 Issue 5 Pages 1175-1178
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 68-year-old man, who was under clinical observation for an abnormal chest shadow in the outpatient clinic, was found to have a 5-cm sized mass showing an extramural protrusion on the lesser curvature of the stomach by a periodic chest CT scan. There was a ridge with the size of 5cm near the posterior wall of the greater curvature which was thought to be oppressed from submucosal or extramural structure, and looked like a submucosal tumor. Laboratory data revealed slightly elevated level of CA19-9 in the serum. Gastrointestinal stromal tumor (GIST) of the stomach was diagnosed and laparotomy was performed. We enucleated the tumor from the pancreas easily. The cystic tumor was filled with yellowish viscous fluid and atheromatous material. On microscopic findings, the cyst wall was composed of stratified squamous epithelium, surrounded by abundant lymphoid tissues. Immunohistochemical study with CA19-9 antibody showed suggesting the relation of the disease with the pancreatic tissue. The tumor was subsequently diagnosed as a lymphoepithelial cyst of the pancreas. Preoperative diagnosis of lymphoepithelial cysts of the pancreas is still difficult. That is why he was misdiagnosed as gastric GIST by some imaging procedures. We need differential diagnosis for tumors around the stomach.
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  • Kosuke YANAI, Kazuyoshi NISHIHARA, Fujio KATSUMOTO, Toshinao MORI, Mar ...
    2005 Volume 66 Issue 5 Pages 1179-1183
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 64-year-old woman diagnosed as having right occult breast cancer underwent a right extended radical mastectomy (Stage III, solid tubular carcinoma) in February, 1990. Tamoxifen and tegafur uracil (UFT) were administered orally as adjuvant chemotherapy for five years after the operation. She was admitted to the department of gynecology in our hospital because of genital bleeding in May, 1998. She was diagnosed as having uterine body cancer, and underwent a semi-radical hysterectomy (Stage IIIc, small cell carcinoma), followed by 6 courses of adjuvant chemotherapy with carboplatin+etoposide. In March, 1999, periodic follow-up abdominal ultrasonography revealed pancreas body cancer. Distal pancreatectomy with intraoperative radiation therapy (25Gy)was performed (Stage II, well differentiated tubular adenocarcinoma). No signs of recurrence have been observed for five years and 10 months after the operation for the pancreas cancer. In the present case, the follow up study for the uterine cancer led to the early detection of the pancreatic cancer that resulted in the long-term survival of the patient.
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  • Junichi TAKA, Osamu YOSHITAKE, Shogo FUJITA, Masahiko MURAKAMI, Mitsuo ...
    2005 Volume 66 Issue 5 Pages 1184-1187
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Lymphocele is a frequent surgical complication after renal transplantation. We report the procedure and favorable results of laparoscopic fenestration for lymphocele after renal transplantation.
    A 40-year-old man developed lymphocele 7 days after receiving a living related graft. The lymphocele gradually enlarged causing hydronephrosis and impaired renal function. Percutaneous drainage and sclerotherapy were carried out, but no remission was attained. Then laparoscopic fenestration for the lymphocele was performed. The total operating time was 70 minutes and blood loss was minimal. The postoperative course was uneventful, and the hospital stay was 4 days. He has had no recurrence as of 11 months after the fenestration. We conclude that laparoscopic fenestration which is less invasive and requires a short hospital stay is a very beneficial procedure.
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  • Kazuo MOTOYAMA, Masashi ITO, Masayuki ANDO, Jun KANEKO, Takeshi SEKINE ...
    2005 Volume 66 Issue 5 Pages 1188-1193
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A case of bilateral ovarian metastasis of cancer of the ascending colon presented with Pseudo-Meigs' syndrome is reported.
    A 48-year-old woman complaining of general fatigue and dyspnea was admitted to the hospital because of anemia and right pleural effusion. A huge mass was palpable in the hypogastric lesion. Abdominal ultrasonography and computed tomography revealed a huge left ovarian tumor 25cm in diameter and a right ovarian tumor 5cm in diameter. Total colonoscopy revealed an apple-core lesion of the ascending colon. CEA level was 52.8ng/ml and CA125 level was 312U/ml. In confirmation of a diagnosis of ascending colon and ovarian cancer and pleural effusion due to Pseudo-Meigs' syndrome, a right hemicolectomy and a hystero-oophorectomy were performed. Bilateral ovarian metastasis of colon cancer was dignosed by immunostaining. The postoperative course was uneventful, pleural effusion decreasing remarkably. Close examination is necessary for female patients who have a pelvic tumor with pleural effusion and ascites by keeping this syndrome in mind. It appears to be important to detect the malignant tumor of the alimentary tract.
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  • Ken HAGIWARA, Masaaki HASHIZUME, Hajime TSUNODA, Nao YOSHIDA, Tadahiko ...
    2005 Volume 66 Issue 5 Pages 1194-1198
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 74-year-old woman was admitted to the hospital because of abdominal pain. Physical examination revealed rebound tenderness in the entire abdomen. On laboratory findings, strong inflammation was revealed. Abdominal CT and magnetic resonance imaging scans showed a 4.5×8.0cm irregular mass in the mesentery of proximal jejunum. Under the diagnosis of mesenteric panniculitis, we treated her conservatively. Symptomatic remission was gradually attained and she was discharged from the hospital. Follow-up CT scans conducted one and three months later showed a shrinkage of the mass. We report this rare case of mesenteric panniculitis of the jejunum diagnosed and improved without operation.
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  • Masaki AZUMA, Toshio NAKAMURA, Kiyotaka KURACHI, Tadataka HAYASHI, Sho ...
    2005 Volume 66 Issue 5 Pages 1199-1202
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 36-year-old man, who had recurrent bouts of lower abdominal pain and treated with a diagnosis of intestinal obstruction at another hospital since January, was referred to the hospital because of lower abdominal pain lasting for 4 days on September 3, 2004. The patient was admitted with a suspicion of intestinal obstruction on the same day. Abdominal CT scan showed thickening of the terminal ileum. A laparoscopy-assisted operation was performed to clarify the cause and treat the recurrent abdominal pain on September 6. Laparoscopic findings included thickening of wall of the terminal ileum and pus from the mesenterium. Abscess formation of the ileal mesenterium was diagnosed and an ileo-cecal resection was carried out. The resected specimen showed a diverticulum of the ileum about 2cm distal from the ileocecal valve and mesenteric abscess. Histopathological study revealed a false diverticulum penetrating the proper muscular layer of intestine with abscess formation of the mesenterium. The postoperative course was uneventful and the patient was discharged from the hospital on the 13th hospital day.
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  • Toru MORIOKA, Takehiro TAKAMA, Yutaka NAKATA
    2005 Volume 66 Issue 5 Pages 1203-1207
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Transepiploic hernia is a rare disease. This paper deals with two cases of this disease.
    Case 1: An 82-year-old woman who had the acute onset of abdominal pain, nausea, and vomiting after lunch was admitted to the hospital and underwent an emergency operation. About 30cm of the small intestine was impacted and strangulated in the hiatus near the inferior greater ometal free end. Because the impacted area became necrotic, the small intestine was resected. Case 2: An 82-year-old man was referred to the hospital because of the acute onset of epigastric pain and vomiting. An abdominal CT scan revealed ascites and the distended small intestine distributing in a radial manner from a point which seemed like a hernia hilus, anterior to the ascending and transverse colons. Obstruction of the small intestine due to transepiploic hernia was suspected. Initially conducted laparoscopy revealed bloody ascites and necrosis of the small intestine anterior to the right upper greater omentum, and a laparotomy was performed. Because at laparotomy the necrotic small intestine was impacted in an abnormal hiatus of the greater omentum, and then the greater omentum was incised and the small intestine was resected.
    Even in the case of ileus without past history of undergoing laparotomy, transepiploic hernia should be included in differential diagnoses. Abdominal CT scan and laparoscopy appear to be useful for making the diagnosis.
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  • Shun-ichi OSADA, Atsushi ISHIBE, Tetsuya TAKAHASHI, Yoshiro OBI, Ken Y ...
    2005 Volume 66 Issue 5 Pages 1208-1212
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 41-year-old woman, who was operated on for inguinal hernia at another hospital in October 2003, developed abdominal distention and heartburn after the operation and was referred to the hospital with a diagnosis of an abdominal tumor. Operation was performed on June 2, 2004. The tumor was present on the right side of the retroperitoneum, the superior margin of the tumor was adjacent to the liver and duodenum, the inferior margin to the common iliac artery and vein, and the inner side to the ureter; the ascending colon and right kidney were pushed up inward. The tumor was dissected from the surrounding retroperitoneum and resected associated with fascia of the iliopsoas muscle, while the right kidney was preserved. The resected tumor was 40×29×17cm in dimension and 7108g in weight. From pathological findings that the tumor was concomitantly composed of a part of storiform proliferation of spindle-shaped cells and a part where spindle-shaped cells were rough and had mucous matrix, malignant fibrous histiocytoma (MFH) was diagnosed. No signs of recurrence have been observed as of 5 months after the operation.
    Since giant retroperitoneal MFH is thought to be rare, this case is reported together with some bibliographical comments.
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  • Nagaki MATSUBARA, Hiromichi MIMOTO, Motoyuki ISHIGURO
    2005 Volume 66 Issue 5 Pages 1213-1215
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    A 50-year-old man, whose ascites became uncontrollable during treatment for alcoholic cirrhosis and whose abdomen showed distention with subsequent protrusion of the umbilicus, was referred to the hospital for surgical therapy. The umbilical hernia was dual-fist-sized and had a dark red surface. Abdominal CT scan showed prominent ascites and the hernia's center filled with ascites. The surface of the liver was uneven. Primary sutures of the abdominal wall were made at the first operation, but it resulted in dehiscence of the abdominal wall postoperatively. Second operation involving placement of a Denver shunt added to abdominal closure was successfully performed.
    Umbilical hernias in adults can cause dangerous complications such as incarceration and rupture, so that we are required to perform prompt therapies after due consideration of their probable causes.
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  • Yoshihiro TANAKA, Chiken SHIBUYA, Satoru YAMAMOTO, Makoto TAKEUCHI, At ...
    2005 Volume 66 Issue 5 Pages 1216-1220
    Published: May 25, 2005
    Released: January 22, 2009
    JOURNALS FREE ACCESS
    Among tumors of the soft parts, leiomyosarcoma rarely occurs, especially that primary arising in the pectral muscle. We report a 70-year-old man with leiomyosarcoma who had operated on three times for leiomyosarcoma arising in the pectral muscle originating from the smooth muscle of blood vessels. He noticed a subcutaneous nodule with no tenderness in the right precordia. A heterogeneous mass shadow, measuring 20×5mm in diameter, was detected in the right chest wall by US scanning. There were no color changes on the skin. An operation was performed with a diagnosis of locally recurred leiomyosarcoma. The operative procedure was wide spread surgical excision including the surrounded pectral muscle. Histological examination showed spindle-shaped tumor cells in a fascicular pattern in a whirlpool style with round-oval nucleus. Immunohistological analysis showed that the tumor cells were positive for both smooth muscle actin and vimentin but negative for keratin and NSE. Accordingly we diagnosed this case as local recurrence of leimyosaroma. Postoperative course was uneventful. No recurrence or metastasis has occurred as of 4 months after the operation. The patient is closely followed on ambulant basis. Some bibliographical comments are also presented.
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