We analyzed opportunities of detecting recurrence of breast cancer in consecutive 148 patients with recurrent breast cancer. Detection rates of local recurrence were 62.1%, 31.0%, and 6.9% with physical examination, subjective symptoms, and increased tumor markers, respectively. Detection rates of regional lymph node recurrence were 69.4%, 13.9%, and 11.1% with physical examination, subjective symptoms, and increased tumor markers, respectively. Detection rates of lung metastases were 56. 5%, 21.7%, 13.0%, and 8.7% with increased tumor markers, chest Xray, CT, and subjective symptoms. Detection rates of pleural metastases were 42.9%, 35.7% and 21.4% with subjective symptoms, increased tumor markers and CT. Detection rates of bone metastases were 45.3%, 30.2%, and 20.8% with subjective symptoms, bone scans and, increased tumor markers. Detection rates of liver metastases were 53.8% and 46.2% with CT and increased tumor makers. Detection rates of recurrence in the preserved breast were 76.3% and each 7.7% with physical examination, MMG, subjective symptoms, and increased tumor markers, respectively. Detection rate of brain metastases was 75.0% with subjective symptoms. It is desirable that the patients operated on for breast caner are followed up with careful history, physical examination, determination of tumor markers and CT scanning.

View full abstract

Purpose: Reconstruction using anastomotic instruments in gastrointestinal surgery still has complications such as leakage and stenosis. Whether completely everted triangular anastomosis is effective in preventing the anastomotic complications was studied. Methods: By using isolated bovine large bowel, completely everted triangular anastomosis was compared with the ordinary triangular anastomosis which consisted of inverted suturing in the base of a triangle. From results of the preliminary experiment, clinical study for the all-everted triangular anastomosis was performed. Fifteen patients (surgery for esophagus: two, stomach: eight, colon: five cases) were reconstructed by all-everted triangular anastomosis (Group A). Group A was compared to Group B, which consisted of thirty patients with the ordinary triangular anastomosis. Results: In the experimental model, the staple line of completely everted triangular anastomosis was straight, while that of the ordinary one was not. The mean anastomotic caliber of the former was larger than that of the latter. Anastomotic leaks observed were 6.7% in both groups (2/30vs. 1/15), and anastomotic stenosis occurred in four patients in Group B (0vs. 13.3%). Conclusions: Completely everted triangular anastomosis is safe and seems to be associated with less chance of anastomotic stenosis.

View full abstract

Purpose: The purpose of this study was to evaluate the efficiency of intraoperative radiotherapy (IORT) combined with surgical resection.
Methods: Subjects were consecutive 69 patients with pancreatic cancer treated with surgery alone (n=31) or surgical resection combined with IORT (n=38) in a 13 year period between 1991 and 2003. We evaluated the effects of IORT against local recurrence of cancer and patients' survival, retrospectively. Furthermore, clinicopathological factors affecting the 5-year survival rate in the two groups were comparatively investigated.
Results: The IORT group showed a significantly lower local recurrence rate of cancer than that in the surgery alone group (7.8% and 22.6%, respectively; p<0.05). The 5-year survival probability in the IORT group was significantly higher than that in the surgery alone group (29.9% and 3.4%. respectively: p<0.05). According to the Japanese classification of pancreatic cancer, cancers located in the pancreas body or tail, no local residual cancer post operative procedure (R0), low grade local cancer progression (t1, 2), and low grade intrapancreatic neural invasion (ne0, 1) were significantly better prognostic factors in the IORT group than those in the surgery alone group. There were no significant differences between the both groups in the 5-year survival rate in terms of the sex of the patients, cancer of the pancreas head, histological type, more than R1, the presence of lymph node involvement, ne2-3, and clinical stages.
Conclusion: IORT is a useful intraoperative adjuvant therapy for pancreatic cancer, when the curative resection is achieved. Our data have suggested that IORT suppresses the local recurrence of cancer and provides the significant survival benefit for those patients.

View full abstract

Laparoscopic exploration of the common bile duct (CBD) is slowly gaining in popularity. The aim of this study was to evaluate the efficacy of transcystic duct approach (TC). We experienced a total of 300 cases of CBD stones which were managed laparoscopically. The procedure was completed laparoscopically in 295 cases (98.3%), with TC in 140 cases, and with choledochotomy in 145 cases. TC was successful in 140 of 195 patients (68.2%). New technique and equipment improved the success rate up to more than 90%. Two management options were compared as to operation time, lengths of hospital stay, postoperative complications and recurrence of stones. TC showed significantly short operating time, short hospital stay, low morbidity rate and low recurrence rate compared with those of choledochotomy. TC proved its safty and efficacy. Another advantage is that it leaves lower choledochal sphincter intact. This is an important benefit, especially for young adults. An investigation of learning curve disclosed that each surgeon would require experiences with approximately 50 cases to become skillful.
In our opinion, TC should be the treatment of choice whenever possible.

View full abstract

Among many operative procedures for inguinal hernia in adults, Kugel method which has a variety of benefits has increasingly employed in recent years. Compared with other tension free procedures, Kugel method is a simple procedure requiring less operative manipulations. However, it is a difficult point of Kugel method that the acquaintance of skill demands experiences in some degree, because we are anatomically unfamiliar to the preperitoneal cavity at where a patch is placed. In this study we calculated the learning curve of operating time in 38 cases in which one surgeon had performed Kugel method for 16 months after the introduction of it, in order to draw the number of cases to acquire the skill. Moreover a comparison was made between these 38 cases and another 37 cases in which mesh plug method was performed before the introduction of Kugel method. Average operating time was 29.6 min in Kugel method versus 47.3min in mesh plug method. It is inferred that reliable operating skill is able to be attained by experiences with 15-20 cases for one surgeon. Although Kugel method demands experiences in some degree, once surgeons are versed in the technique and the method would become an advantageous method which would promise reliable performance in a very short time.

View full abstract

We report a case of a pseudo aneurysm which arose from the transverse cervical artery (TCA), that ruptured 22 days after hemi-thyroidectomy for thyroid cancer. A 58-year-old woman was admitted to our hospital for a 2.2×1.2cm thyroid cancer in the left lobe. She simultaneously had hypertension. We performed a left hemi-thyroidectomy and cervical lymph node dissection. Thirteen days after the operation, the patient presented acute left neck swelling and the pain associated with stridor. Color Doppler ultrasonography showed a jet-like blood flow into the aneurysm from the artery. Angiography revealed a ruptured aneurysm of the left TCA associated with active extravasation of contrast. Endovascular coil embolization was performed to remove the pseudo aneurysm completely occluding the TCA. Her left neck swelling gradually decreased, and she was discharged 13 days after.

View full abstract

Granulomatous lobular mastitis is a rare benign tumor and very difficult to differentiate from breast cancer. We report two cases of granulomatous lobular mastitis which were diagnosed by mammotome biopsy.
Case 1: A 41-year-old woman was admitted because of two left breast tumors. One tumor was 18×15mm in size and located in C region of the breast, and the other was 20×15mm in size, located in the AC region, and suspected to be breast cancer.
Case 2: A 51-year-old woman was admitted because of an abnormal shadow on mammography. A tumor was 28mm×25mm in size, located in the BA region of the breast, and suspected to be breast cancer.
In both cases, the tumors were unable to be diagnosed by aspiration biopsy cytology, so mammotome biopsy under ultrasonic scans was performed. The histopathological diagnosis was granulomatous lobular mastitis of the breast without malignancy.

View full abstract

We report here a rare case of cystic hypersecretory carcinoma of the breast. A 45-year-old woman presented with a mass in her left breast, which had been already examined at another hospital and diagnosed as adenocarcinoma by aspiration cytology. Physical examination revealed a mass measuring 1.5cm in diameter in the upper and outer quadrant of the left breast. Mammography demonstrated regional and pleomorphic calcifications. The tumor appeared to be a multicystic lesion ultrasonographically. Mastectomy with axillary lymph node dissection was performed. Histopathologic examination revealed multiple cysts of different sizes containing an eosinophilic material. The epithelial cells of the cysts were diagnosed as micropapillary carcinoma. In some foci, invasive components were present. The diameter of the tumor in the specimen was 6cm. Histopathologically, the final diagnosis of the tumor was cystic hypersecretory carcinoma with minimal invasion. Estrogen and progesterone receptors were negative. There was no evidence of nodal metastasis. The patient is alive and well 16 months after the operation.

View full abstract

Adenoid cystic carcinoma of the breast is a rare entity and is designated as specific breast cancer. This paper deals with such a rare case of adenoid cystic carcinoma of the breast with some consideration on the results of immunostaining with KIT which was added in this case. The patient was an 81-year-old woman complaining of a right breast mass. On mammography, the tumor was visualized as a tumor shadow of high density. Ultrasonography showed some cystic portions in the tumorous shadow. At surgery, extirpation of the tumor and sampling of the right axillary lymph nodes were performed. Histopathological studies demonstrated adenoid structure and false ductal structure, so that adenoid cystic carcinoma of the breast was diagnosed. No metastatic lymph nodes were involved in the sampled nodes.
In this case the tumor cells were negative for estrogen and progesterone receptors (ER and PgR), while positive for Vimentin and KIT. There have been no reports on expression of KIT in adenoid cystic carcinoma of the breast like in this case in Japan. Thus we consider that such very specific immunological trait can contribute to make differentiation of the disease from other breast cancers. Further the prognosis of this malignancy is favorable and once a complete excision of the local lesion is carried out, axillary lymph node dissection may not be demanded.

View full abstract

We report a rare case of lobular carcinoma of the axillary accessory breast with a review of the literature. A 58-year-old woman was seen at the hospital because of a left axillary tumor. A hard tumor, 3cm in diameter, was found in her left axillary portion. No tumor was palpable in the left breast, and the left axillary lymph nodes were not palpated. Lobular carcinoma was diagnosed on aspiration cytology. Accessory breast cancer was strongly suspected, but the possibility of communication with the proper mammary tissue could not be ruled out. Consequently, a left partial mastectomy and axillary lymph node dissection were performed. Examination of the resected material showed no communication between the axillary tumor and the mammary duct. Accessory breast cancer of the axilla was definitely diagnosed. The patient has been administered anticancer agents (CEF: cyclophosphamide, epirubicin, and 5-fluorouracil (5-FU))) as postoperative adjuvant chemotherapy, and has been free from metastasis as of 8 months after the operation. This paper also presents a review of the literature in terms of diagnosis and treatment for lobular cancer of accessory breast.

View full abstract

We report a case of occult and inflammatory breast cancer developed after chemotherapy for pericardial metastasis.
A 32-year-old female was admitted to the hospital because of dyspnea in July 1997. Chest X-ray and CT scan of the chest revealed effusion in the pericardial space. Subsequently, pericardiocentensis was done and pericardial fluid was aspirated. Cytological examination of the aspirated speicemen showed adenocarcinoma cells. TBLB showed no malignancy, but we suspected that she had pericarditis carcinomatosa due to metastasis of lung cancer. No abnormalities of the breasts were revealed. Local and systemic chemotherapy was started and a complete respose (CR) was achieved. However, 2 months later, she was seen at the hospital because of redness and swelling of the right breast. Fine needle aspiration biopsy showed adenocarcinoma cells, and inflammatory breast cancer was diagnosed. She underwent a right modified radical mastectomy with lymph node dissection. Clinicopathological studies confirmed that the right breast cancer was the primary origin of the pericardial metastasis. She died of bilateral lung metastasis. 1 year after the first admission.

View full abstract

A 54-year-old woman had been aware of a left breast tumor for 15 years. In December 2003, the patient recognized ulceration and bleeding from the tumor. At the first visit, a 12×11-cm bulged tumor with an ulcer and bleeding was seen on her left breast, with small nodules of the skin around the tumor. Several elastically hard lymph nodes were palpable at the left axilla and supuraclavicular. Core needle biopsy cytology showed invasive ductal carcinoma. The diagnosis of a local advanced cancer of the left breast, T4b N3c M0 Stage III C, was made. Following neoadjuvant chemotherapy at one term, a standard radical mastectomy was performed in May 2004. Pathological examination showed a scirrhous carcinoma that penetrated the center of a benign phyllodes tumor and infiltrated the greater pectoral muscle, suggesting that invasive ductal carcinoma may have originated from inside a benign phyllodes tumor. It is extremely rare for a phyllodes tumor to be associated with a breast cancer on the same time and side of the breast; only 27 cases including our patient have been reported in Japan. Moreover, only 10 cases of a breast cancer that originated from inside a phyllodes tumor have been reported.

View full abstract

A case of advanced breast cancer with no bone metastasis complicated by humoral hypercalcemia of malignancy was reported. The patient was a 46-year-old woman who complained of general fatigue, anorexia and vomiting during chemotherapy consisting of docetaxel and cyclophosphamide for liver and lung metastases from breast cancer. The laboratory data showed a remarkable incrcase in serum calcium (9.7mEq/l) and PTHrP (555pmol/l) without elevation of PTH (13pg/l). Bone scintigraphy, Xray and CT revealed no bone metastases. The lumbar vertebra bone density fell 77%-92%. Based on these findings, the diagnosis was humoral hypercalcemia of malignancy complicated by advanced breast cancer with no bone metastases.
Serum calcium was well controlled for a long time by antihypercalcemic therapy consisting of intravenous saline, incadronate, corticosteroid and calcitonin accompanied by chemotherapy with epirubicin.
Even if bone metastases are not evident in breast cancer patients, the clinician should keep in mind the possibility of humoral hypercalcemia of malignancy.

View full abstract

A 19-year-old man showed an abnormal shadow in the right superior mediastinum on a chest X-ray film. On admission, labolatory data showed anemia and a rise in CRP level. Chest CT scan revealed a 4-cm, well circumscribed right paratracheal mass. Enhanced magnetic resonance imaging scan showed a marginal enhancement. It was diagnosed as an inflammatory bronchogenic cyst and thoracoscopic surgery was performed. Complete excision of the tumor was performed without difficulty. After the surgery his laboratory abnormalities returned to normal ranges. Histopathologically, the tumor which was solid and pale yellow in color was diagnosed as mixed type of Castleman's disease. Cases of localized Castleman's disease are predominantly of hyaline vascular type and rarely of plasma cell or mixed type. Although patients with hyaline vascular type are mostly asymptomatic, those with plasma cell type or mixed type often present with systemic symptoms and abnormal laboratory data. We report a rare case of localized Castleman's disease of the mixed type.

View full abstract

A 77-year-old man sustained an inferior myocardial infarction. Four months later, echocardiography and left ventricular cineangiogram suggested the aneurysm communicated through a small orifice. At operation the inferiorly positioned aneurysm was not so adherent, and was opened directly. The small orifice was closed with a felt patch to cover the pericardium inside. Microscopic examination of the aneurysm wall showed myocardial tissue. We treated a rare case of pseudo-false aneurysm by left ventricular plasty, and the postoperative left ventricular function was satisfactory.

View full abstract

An about 40-year-old female patient who had been treated for multiple endocrine neoplasia (MEN) type 1 syndrome was referred to us because of difficulties in swallowing and in raising the neck. The patient was diagnosed as having myasthenia gravis with thymoma, and underwent extended thymectomy. Pathological examination revealed that thymoma was classified as type B2 according to WHO classification, and in Stage I according to Masaoka's classification. In addition, a multilocular cyst was demonstrated with clear separation from the thymoma. The histologic features of the cyst were compatible with those reported by Suster and Rosai, who suggested that it arises from processes of reactions to an acquired inflammatory change. Surveillance CT scans of the chest that had been sequentially taken for follow-up of MEN type 1 syndrome in another hospital suggested that the thymoma developed first and occurrence of the thymic cyst was afterward.

View full abstract

A 60-year-old man was referred to us for a detailed evaluation of a pulmonary nodule associated with bloody sputum. He had been taking antibiotics under the diagnosis of organizing pneumonitis confirmed by transbronchial lung biopsy. Although the pulmonary nodule had markedly decreased in size, the patient intermittently showed reduced bloody sputum. But surgery for differential diagnosis and control symptoms was postponed by the patient himself for a few months.
Afterwards thoracotomy was performed to control a refractory massive hemoptysis. Left upper segmentectomy including resection of the phrenic nerve was needed because of rigid adhesions between the mediastinal pleura and the phrenic nerve adjacent to the pulmonary mass. The postoperative pathological diagnosis revealed pulmonary actinomycosis, although the frozen section histopathological findings indicated lymphoma. He was treated with oral antibiotics for three months after definitive diagnosis. In patients with pneumonitis showing air space consolidation and recurrent bloody sputum, it is important to consider the possibility of pulmonary actinomycosis for the differential diagnosis and to confirm the diagnosis as early as possible to avoid extended resections.

View full abstract

A 54-year-old woman was admitted to our hospital for further examination of an abnormal chest X-ray shadow. Chest CT showed a tumor with ground-glass opacity and pleural indentation in segment3 (S3) of the right lung. Lung cancer was suspected according to the FDG-PET/CT and the radiological findings, but a definitive diagnosis was not obtainted by bronchoscopic examination. Under a provisional diagnosis of lung cancer, the patient underwent resection of right upper lobe by video-assisted thoracic surgery (VATS). Intraoperative histopathological examination revealed MALT lymphoma. The patient recovered uneventfully, and there has been no sign of recurrence for 1 year since the surgery. MALT lymphoma should be considered if lung cancer is suspected on the basis of imaging study alone.

View full abstract

A 41-year-old man was admitted to the hospital because of an abnormal shadow on a chest X-ray film. Following close exprolation, right upper lobectomy was performed with a diagnosis of lung cancer. Histological examination revealed poorly differentiated adenocarcinoma (p-T2NOMO, stage IB). Four months after the operation, marked leukocytosis and anemia were noted. Serum G-CSF level was elevated. Abdominal CT scan revealed metastasis to the small intestine and enterectomy was performed. Both serum G-CSF and WBC were normalized after the operation. However 14 days after the operation, peritoneal dissemination was found and the patient died 45 days after the operation. Enzyme immunoassay demonstrated an apparent increase of G-CSF in serum. Immunohistological examination showed positive staining for G-CSF. Since G-CSF producing lung cancer as well as metastasis of lung cancer to the small intestine is comparatively rare, this case is reported with some bibliographical comments.

View full abstract

A 65-year-old man was seen at the hospital because of abdominal distension and nausea. Abdominal plain x-ray film showed the dilated ascending colon and niveau formation in the small intestine. Abdominal CT scan revealed the dilated ascending colon and dilated intestine in the mediastinum. No symptomatic remission was attained with conservative therapy by placing a long tube, and another abdominal CT scan showed retention of ascites. Then surgery was performed on the 4^th hospital day. We found an abnormal hiatus in the right-medial side of diaphragm which communicated with the mediastinum, and through the hiatus the greater omentum and a part of transverse colon were incarcerated. The postoperative course was uneventful and he was discharged from the hospital on the 17^th hospital day. He had a previous history of undergoing an open heart surgery by midline incision 3 years before admission when no hernia opening was demonstrated and he had no history of trauma. Accordingly it was etiologically thought that the external pressure added to the thorax at the open heart surgery might cause the diaphragmatic hernia in this case. Although the disease is a very rare entity, it must be kept in mind as a possible complication of surgery.

View full abstract

Since the first report of protein induced by Vitamin K antagonist (PIVKA-II) and AFP producing gastric cancer in 1992, some cases of PIVKA-II producing gastric cancer have been described. We encountered a case of primary advanced gastric cancer with liver metastasis and discussed PIVKA-II producing gastric cancer including previous cases. We describe the case of a 57-year-old woman with primary advanced gastric cancer with liver metastasis, who displayed high plasma levels of PIVKA-II (1534mAU/ml) and AFP (39160ng/ml). After total gastrectomy and hepatic right trisegmentectomy were performed, plasma levels of PIVKA-II returned to within the normal range, and 19 months after the operation she is alive with lung metastasis. Macroscopic findings of resected specimens revealed Borrmann type 2 advanced gastric cancer from cardia to esophago-cardiac junction. Localizations of PIVKA-II and AFP were determined from resected specimens of gastric cancer by using immunohisto-chemistry (IHC). Positive staining of both PIVKA-II and AFP within tumor cells in the stomach was demonstrated by IHC. These results indicate that tumor cells from gastric cancer may produce PIVKA-II and AFP. An aggressive tumor resection might be necessary to improve the prognosis of patients with PIVKA-II and AFP producing gastric cancer with liver metastasis.

View full abstract

A 91-year-old woman was referred to our hospital because of nausea and vomiting in December 2005. A chest X-ray showed a diaphragmatic hernia and a gastrointestinal tract gas shadow in the right thoracic cavity. CT scan disclosed prolapse of the gastric antrum, omentum and transverse colon via a Morgagni's hernia. An upper gastrointestinal endoscopy revealed a type 1 gastric cancer in the herniated stomach. We made a diagnosis of digestive tract obstruction due to gastric cancer in a Morgagni's hernia, and an operation was performed with an abdominal approach in January 2006. The herniated organs were returned to the abdominal cavity and the hiatus was closed by knotted sutures. The cancer was resected by distal gastrectomy. Morgagni's hernias with cancer in herniated organs are very rare and a literature review revealed that only two cases have been reported in Japan.

View full abstract

The patient was a 70-year-old man who had undergone cholecystectomy and choledochoduodenostomy for choledocholithiasis at the age of 28 and drainage operation with unknown procedures for a hepatic abscess at the age of 30. He was referred to our hospital under a diagnosis of gastric cancer with the chief complaint of epigastralgia in July 2001. Gastrointestinal fiberscopic findings showed type 3 advanced gastric cancer at the lesser curvature of the upper body and a choledochoduodenostomy, and contrast gastroduodenography demonstrated the left intrahepatic bile duct near the gastric cancer.
These findings indicated that the resection of hepatic abscess cavity and left intrahepatic bile duct-gastrostomy had been done at the previous operation for the hepatic abscess. Laparotomy also showed advanced gastric cancer and left intrahepatic bile duct-gastrostomy, necessitating resection of the bile duct-gastrostomy and total gastrectomy. The resected specimen showed the bile duct-gastrostomy at the center of the type 3 advanced gastric cancer, spreading in a concentric pattern. We report a rare case of gastric cancer caused by continuous stimulation of bile juice.

View full abstract

A 62-year-old man was admitted to our hospital because of a gastric tumor which was pointed out at another hospital when he visited for melena. Upper gastrointestinal endoscopy showed an elevated lesion with ulcer and slight ulceration proximal to the lesion in the lower body of the stomach. A biopsy resulted in adenocarcinoma. Distal gastrectomy with D2 lymph node dissection was performed under a diagnosis of gastric cancer. Histo pathological findings of the II c lesion showed tub2, sm1, ly0, v0 and those of the type2 tumor demonstrated proliferation of undifferentiated cells in the mucosa as well as submucosal layers. Immunohistochemical study showed CD56 and chromogranin A positive, and then we diagnosed this case as endocrine cell carcinoma.
We report a case of early endocrine cell carcinoma of the stomach which is comparatively rare, together with a review of the literature.

View full abstract

A 64-year-old man was diagnosed with early gastric cancer and idiopathic thrombocytopenic purpura. Preoperative administration of prednisolone increased the platelet cell count from 2.0•10⁴/mm³ to 10.3×10⁴/mm³. He underwent distal gastrectomy and splenectomy. Cardiac branches from the left gastric artery and the splenic artery were conserved.
The postoperative course was uneventful. He is alive without tumor recurrence, and the platelet cell count remains normal four years after surgery. We wish to stress the importance of conserving the blood flow to the remnant stomach.

View full abstract

Congenital duodenal stenosis in infants is usually operated. We report a duodenal web with a cholecystoduodenal fistula in a 16-year-old male. He was affected with Down's syndrome, but his nutrition state had been good. He suddenly began vomiting and lapsed into dehydration, so he was admitted to our hospital. He jointly developed cholecystitis and a cholecystoduodenal fistula was formed. We operated and found a duonenal web on the oral side of the papilla of Vater. We excised his gallbladder and duodenal diaphragm, and then performed a duodenoplasty (horizontal suture after longitudinal incion). In the case of continuous vomiting, we should diagnose while taking duodenal stenosis into consideration.

View full abstract

In esophageal resections, it is generally difficult to perform reconstruction surgery for suture failure due to a wide range of necrosis of the head of gastric tube following retrosternal gastric tube reconstruction, in term of severe surgical stress for the patient. In this paper we present a new device of gastric tube reconstruction for a patient who developed a wide range of necrosis at the head of gastric tube 5 months after radical operation with retrosternal gastric tube reconstruction for esophageal cancer. The patient was a 65-year-old man whose elevated retrosternal gastric tube became a blind extremitas. The new device was to perform partial resection of the sternum at the anterior surface of healthy gastric tube, and then to implant a free jejunum between the cervical esophagus and gastric tube through the anterosternal subcutaneous route to complete reconstruction. It was successful in this case.
This operative procedure provides relatively less surgical stress than other procedures, and hence it is considered to be a beneficial surgical device for patients who have developed extended necrosis of a gastric tube resulting in a complete obstruction after retrosternal reconstruction.

View full abstract

We present a case of cholesterol embolism causing multiple perforations of the small intestine and peritonitis. The patient was a 76-year-old woman who had previous histories of hypertension, coronary artery bypass operation, hemodialysis for chronic renal failure, and grafting for an abdominal aortic aneurysm. Abdominal CT scan performed for the onset of abdominal pain and high fever showed intraabdominal free air. Surgery was performed with a diagnosis of gastrointestinal perforation, when multiple perforations were confirmed in the small intestine. Hence extended resection of the small intestine and formation of stoma at the small intestine were carried out. However, the patient died of rapid progress of hepatic failure, suture failure, and gastrointestinal bleeding after closure of the stoma. Pathological studies revealed cholesterol crystal in the small intestinal arteriolae and hepatic arteries that might cause small intestinal perforations and hepatic failure.
No radical therapies for cholesterol embolism have been established as yet, so that early diagnosis based on renal and dermal symptoms and prevention of the onset of the disease in other organs are necessary. In this country only four cases of the disease causing small intestinal perforation have been reported, in which those patients had a poor prognosis. We must pay special attention to gastrointestinal symptoms including abdominal pain and anal bleeding.

View full abstract

We reported a rare case of ischemic stenosis of the small intestine. A 75-year-old male was admitted to the hospital because of lower abdominal pain and vomiting. He underwent conservative therapy, and the inflammation has improved. But abdominal pain recurred repeatedly when he began oral intake. Since the double contrast study of small intestine showed the stenotic lesion in the small intestine, ileus symptoms did not improve by conservative treatment, and he was referred to the surgical department. The laparotomy was performed. At operation, the small intestine about 7cm in length and about 120cm distant from the Treitz ligament flared up and was edematous but not ischemic. The partial resection of about 50cm of small intestine was performed. In the excised specimen, thickening of the small intestinal wall was found. Microscopic examination revealed thickness and fibrosis in the muscular layer of the mucosa and submucosal layer, and it was diagnosed as ischemic enteritis.

View full abstract

Simple ulcer, which commonly occurs in the ileocecal region and is characterized by forming a large punched out ulcer, is an inflammatory intestinal disease of unknown origin. The patient was a 43-year-old woman complaining of abdominal pain. Colonoscopy showed deep ulcer at the ileocecal region. We diagnosed the patient as having simple ulcer and started medical treatment including administration of a steroid. However, the patient experienced relapses. Thus we performed laparoscopy-assisted removal of the ileocecal region. She has been well without complications and recurrence at present.
Simple ulcer is known for high probability of post-operative recurrence. We think laparoscopyassisted operation should be chosen positively because of its minimal invasion and lower risk of adhesion.

View full abstract

Crohn's disease is an inflammatory disease that repeatedly recurs and causes internal/external fistula formation. We encountered two patients with Crohn's disease showing an ileovesical fistula.
Patient 1, a 36-year-old male, developed abdominal pain, fever, pneumaturia, and fecaluria. He was diagnosed as having Crohn's disease at 19 years old. Cystoscopy revealed fecal inflow from the anterior wall of the bladder. Contrast studies of the small intestine showed an ileovesical fistulation. Partial vesical resection and partial iliac resection with the involved segment of the fistula were performed.
Patient 2, a 34-year-old male, developed lower abdominal pain, fever, and fecaluria. He was diagnosed as having Crohn's disease at 27 years old. Abdominal CT revealed an area of dense air in the bladder. Contrast studies of the small intestine showed an ileovesical fistulation. There was stenosis of the sigmoid colon due to Crohn's disease, and partial vesical resection, partial iliac resection with the involved segment of the fistula and partial resection of the sigmoid colon were performed.

View full abstract

This case concerns a 77-year-old man who visited the hospital in July 2005 due mainly to abdominal pain and vomiting. Diagnosed as a small bowel obstruction case, the patient received an indwelling ileus tube treatment. After conserved improvement, the hospitalization of the patient was terminated. On October 17 of the same year, the patient was rehospitalized due to appetite weakness and vomiting. The symptoms temporarily improved after the indwelling of an ileus tube, but a sudden abdominal pain was reported on October 25. By ileus tube scanning and abdominal CT, a small-intestine intussusception was identified and emergency laparotomy was performed. An intussusception caused by a small-intestine tumor of a 4cm diameter was found during the operation at a location 150cm from the Treitz ligament; consequently, a small-intestine portion including the tumor was resected. As the swelling of peripheral lymph nodes was observed, those lymph nodes were dissected. After a pathohistological observation which found a hyperplasia of spindle cells, the case was diagnosed as small-intestine GIST. Nuclear fission was scarce while the MIB-1 positive rate was 8%. With the metastasis of epithelioid tumor tissues found in three of the seven dissected lymph nodes, it was diagnosed as metastases of low malignancy small-intestine GIST to lymph nodes. The dissection of lymph nodes had been considered unnecessary due to the scarcity of GIST metastasis to lymph nodes, but the present case suggested a necessity of lymph node dissection for small-intestine GIST cases.

View full abstract

A 60-year-old man who had undergone appendectomy about 40 years earlier consulted our hospital because of right lower abdominal pain. A surgical scar was found on the right lower abdominal region. Rebound tenderness and guarding were noted over the right lower quadrant. WBC was 16500/μL and CRP concentration 7.1mg/dL. Ultrasonographic examination demonstrated an appendiceal stump of about 20mm. Abdominal computed tomography demonstrated a 20mm appendiceal stump with calcification at the cecum and fat infiltration around the appendix. So we diagnosed the patient as having stump appendicitis and started administration of antibiotics and conservative management. On the following day, the symptoms became exacerbated and surgery was performed. An inflamed 25mm appendiceal stump was found. Stump appendectomy was performed. Pathological diagnosis was acute gangrenous appendicitis.
We tend to rule out the possibility of acute appendicitis from the diagnosis when we examine a patient whose appendix has been resected. However, we have to consider the possibility of stump appendicitis and it is important to make the diagnosis of stump appendicitis as early as possible. To prevent stump appendicitis, ligation of the base of the appendix under clear visualization is most important during primary open appendectomy or laparoscopic appendectomy.

View full abstract

The patient was a 57-year-old man. PET showed abnormal isotope accumulation in the vicinity of the horizontal part of the duodenum. The patient was operated on with a diagnosis of gastrointestinal stromal tumor (GIST) of the duodenum. The tumor about 3cm in diameter was present in a portion which was surrounded by the uncus of the pancreas, horizontal part of the duodenum, and right-sided transverse colon. To achieve an en-bloc resection, we performed pancreatoduodenectomy associated with right hemicolectomy and partial resection of right wall of the portal vein. Pathological findings disclosed that the tumor was 2.5cm in diameter, had grown partially involving the duodenal muscular layer, and connected with the muscular layer of the transverse colon. Histological findings showed trabecular arrangement of spindle shaped cells. Immunohistochemical studies revealed that the tumor cells were only positive for c-kit and negative for CD34, SMA, and S100. Thus GIST of the transverse colon was diagnosed. This case has suggested the usefulness of FDG-PET as a new diagnostic method of GIST.

View full abstract

The patient was a 65-year-old man who underwent a left hemi-colectomy for advanced descending colon and higher rectal carcinoma. After 3 months from the initial surgery, he complained of frequent bowel movement. Colon histology revealed anastomotic recurrence. Consequently, a histological diagnosis of poorly differentiated adenocarcinoma was made, and an operation with Microtaze coagulation therapy (MCT) was performed. The tumor diffusely invaded the small intestine, left ureter, and presacral space. Radiotherapy was applied to the pelvic region at a total dose of 60cGy. Chemotherapy with FOLFILI was administered for 1 cycle. However, the tumor continued to grow rapidly, and the patient died 9 months after the initial surgery. It is suggested that intraoperative peritoneal chemotherapy is necessary for high-risk patients with peritoneal dissemination.

View full abstract

A 80-year-old man underwent sigmoidectomy for sigmoid colon cancer on November 12, 2003, which was moderately differentiated adenocarcinoma, S, type2, 65×22mm in size, whole-circumferential growth, ss, P0, H0, M(-), lyl, vl, nl, D3, aw(-), ow(-), ew(-), curA, and stage III a. The patient had been treated with UFT-E 400mg daily for postoperative chemotherapy. The patient was admitted to the hospital because of abdominal distention 18 months after the operation. Results of laboratory studies showed serious anemia, hypoproteinemia, and the increased serum CEA. Abdominal CT scan showed portal vein thrombus, dilated portal vein with cavernous transformation, ascites, lymph node swelling, and intestinal edema. The portal vein thrombus extended from the portal vein to umbilical portion and to the right anterior and posterior segmental branches, and was markedly enhanced in the portal phase shown by dynamic CT. The thrombus was diagnosed as tumor thrombus. The patient received palliative care owing to difficulty in receiving even chemotherapy. Two months later, the thrombus grew into the splenic vein, but liver metastasis was not found by following abdominal CT scan. The patient died of exacerbation of general condition 23 months after the operation. There have been few cases of portal vein tumor thrombus without liver metastasis originating from colon cancer, and we report the case with a review of the literature.

View full abstract

A 76-year-old man saw a local medical doctor because of a sense of fullness in his upper abdomen. Tumor-like resistance and tenderness were recognized in his left hypochondrium and epigastrium, and he was referred to our hospital under suspicion of pylorus stenosis. Plain chest X-ray revealed dextrocardia, and plain CT revealed that all his abdominal organs were placed inversely. He was diagnosed with situs inversus totalis. Moreover, a large liver tumor was recognized in the right lobe which was located in the patient's left side. According to laboratory tests, both HBs Ag and HCV Ab were negative, but the serum level of AFP and PIVKA-II elevated. Angiography revealed tumor stain in right lobe, and this tumor was diagnosed as hepatocellular carcinoma. No aberrant vessels were detected. After TAE (transcatheter arterial embolization), hepatic right trisegmentectomy was performed. Microscopically, the tumor was diagnosed as a poorly-differentiated hepatocellular carcinoma appearing in the normal liver. We report this case with some bibliographical comments.

View full abstract

Cholecystoenteric fistulas have been reported to be a relatively rare complication of cholelithiasis, especially cholecystogastric fistula. At the beginning of the laparoscopic era, cholecystoenteric fistula was considered as an absolute contraindication for laparoscopic surgery. With development of surgical techniques and equipment, however, the number of cases in which cholecystoenteric fistula was treated laparoscopically have increased. We describe a case of laparoscopic surgery for cholecystogastric fistula with a gallstone in the stomach.

View full abstract

A 65-year-old man was admitted to our hospital complaining of right hypochondralgia and fever. Serum concentration of carbohydrate antigen 19-9 was elevated to 178U/ml. Ultrasonography and computed tomography revealed the thickened wall of the gallbladder and a heterogeneous mass with multiple low-density areas in the liver. Angiography demonstrated that the gallbladder wall and the hepatic mass were hypervascular. Based on these findings, we diagnosed gallbladder cancer with invasion of the liver. Extended cholecystectomy and partial resection of S4a and S5 hepatic segments were performed. Macroscopically, the resected specimen exhibited gallbladder wall thickening and a white-yellow mass in the fundus of the gallbladder infiltrating the liver parenchyma. Histological examination revealed xanthogranulomatous cholecystitis involving the liver, but without evidence of malignancy.

View full abstract

A 59-year-old woman was admitted to our hospital because of a high level of serum alpha-fetoprotein (AFP) by a checkup. Abdominal US, CT and MR revealed the filling image in the gallbladder, but did not reveal infiltration into the liver and the other organs from the gallbladder. We suspected carcinoma of the gallbladder and an extended resection of the gallbladder was carried out. The tumor measured 4.0cm×3.5cm, was located in the fundus of the gallbladder, and was filled with soft necrotic tissue in the gallbladder. Histopathologically, the tumor was poorly-differentiated adenocarcinoma. Immunohistochemically, the cancer cells were positive for AFP staining. After operation, the serum AFP level was normalized. The patient has been doing well with no evidence of recurrence after 14 months.

View full abstract

Lymphangiomyoma (LAM) is a rare entity occurring mainly in women in the reproductive generations, and is often accompanied with multiple lesions in the lower retroperitoneum and/or lethal spread to the lung and mediastinum. On the other hand, there have been only few reports of LAM confined within the retroperitoneum. We present a case of LAM of the retroperitoneum located on the posterior surface of the pancreas which is the ninth case, together with a review of the reported cases in Japan.
A 40-year-old woman was admitted to the hospital because of a retroperitoneal tumor on the posterior surface of the pancreas. Examinations revealed a polycystic mass located between the descending aorta and the inferior vena cava, with clear borders from adjacent organs. A diagnosis of retroperitoneal tumor was made and laparotomy was performed. The cystic tumor, filled with lymphatic fluid, did not invaded the surrounding tissues and was dissected enbloc easily. LAM was diagnosed with histological examinations postoperatively. The patient has been well without recurrence for 48 months after the operation.

View full abstract

A 64-year-old man underwent a distal gastrectomy with dissection of second group of lymph nodes for type 3 gastric cancer at the lower body of stomach. The gastric cancer was moderately differentiated adenocarcinoma invaded to serosa, and involved the second group of lymph nodes. Tumor makers gradually increased and the CEA level became 69.3ng/ml 22 months after the operation. Abdominal CT scan showed a 3-cm and 2-cm sized tumors which were adjacent each other in the diaphragm side of the spleen. No other prominent metastatic lesions were demonstrated, so that a splenectomy was performed. The two tumors were white in color and multinodular. Histopathologically the splenic tumors were adenocarcinoma, and were diagnosed as metastasis of gastric cancer. No lymph node metastasis was noted in the splenic hilum, and thus we considered that hematogenic metastasis had occurred in this case. He has been recurrence free as of 12 months after the operation.
In a review of the Japanese Journal of Igaku Chuo, so far only 13 cases of heterochronous splenic metastasis of gastric cancer, including our case, have been reported. A mean survival time after surgery was 14.5 months. As for 11 cases in which splenectomies were performed, six patients survive or survived more than one year. Thus we consider that the splenectomy for such patients has a meaning.

View full abstract

The patient was a 26-year-old man who had been given a depressor for the recent 2 years after having been diagnosed as to have hypertension at the age of 18. He was found to have bilateral adrenal tumors elsewhere and was referred to the hospital for further exploration. Tumors about 4cm in diameter were identified in the bilateral adrenal glands. Serum noradrenalin, urinary noradrenalin, normetanephrine and VMA levels were high and 131-I-MIBG scintigraphy revealed high radiotracer concentrations where were identical with the bilateral adrenal glands. Thus bilateral adrenal pheochromocytoma was diagnosed. Aiming at conserving the function, laparoscopy-assisted bilateral partial adrenalectomy was carried out. The patient was discharged very much improved on the postoperative day 7. The internal doses of adrenocortical steroid have gradually been decreasing.
Recently laparosopy-assisted surgery has safely been done even for adrenal pheochromocytomas, however, there have been few cases of bilateral adrenal pheochromocytoma in which laparoscopic surgery was performed in an one-step approach. We report a case of bilateral adrenal pheochromocytoma in which bilateral partial adrenalectomy was successfully performed by utilizing merits of the laparosopy-assisted surgery to conserve the function, together with some bibliographical comments.

View full abstract

A 39-year-old woman was admitted to our hospital, complaining of a painful subcutaneous tumor under the scar from a caesarean section three years ago. The tumor increased gradually and the pain became worse. No relation was found between the tumor pain and her menstrual cycle. The tumor was hard, 3cm in diameter, and strongly adhered to the anterior rectus sheath. We suspected a Schloffer tumor at first, and performed the tumor excision with a sutticient margin. Histological findings revealed endometrial cells with a hemorrhage, and we eventually diagnosed abdominal scar endometriosis. Many of this type of tumors occur after gynecological operation, and we sometimes confirm swelling, pain of the tumor, and blood discharge corresponding to the menstrual cycle. It is difficult to diagnose correctly in a case with no ostensible relation with the menstrual cycle, and a final diagnosis is often made from the pathological findings. We should keep in mind that abdominal scar endometriosis may occur after a gynecoligical operation.

View full abstract

We here report two cases of external iliac arterio-enteric fistula as a complication of chemoradiotherapy for colorectal cancer, in which hemorrhage was successfully controlled by endovascular covered stent placement.
Case 1: A 62-year-old woman who had undergone colostomy and chemoradiotherapy for unresectable rectal cancer was admitted to the hospital because of anal bleeding. Angiography showed a fistula between the right external iliac artery and rectum. Endovascular covered stent placement into the right external iliac artery was performed and hemorrhage was stopped. She died of cancer progression one month later. Case 2: A 52-year-old man who had undergone colostomy and chemoradiotherapy for unresectable sigmoid colon cancer was urgently admitted to the hospital because of massive anal bleeding and hemorrhagic shock. Angiography showed a fistula between the left external iliac artery and sigmoid colon. Endovascular covered stent placement same as case 1 was performed and hemorrhage was stopped. He died of cancer progression seven months later, but there was no major complication associated with the covered stent placement. Endovascular covered stent placement may be an effective option as an emergency treatment for hemorrhage due to iliac arterio-enteric fistula, especially for poor risk patients.

View full abstract

A 61-year-old man who had the abrupt onset of abdominal pain during sleeping was diagnosed as having intestinal obstruction following abdominal plain x-ray examination at another institution and was admitted to the hospital for further exploration. There were no previous histories of laparotomy and trauma. Abdominal CT scan showed remarkable dilatation of the entire small intestine. Symptomatic remission was attained by placing a long tube, but no decrease in discharge was observed and ileus was not released. Even after long intestinal tube fluoroscopy, the origin of the disease was still unknown. Thus the patient was operated on with a suspicion of possible existence of obstructive lesion including a tumor on the 13^th day after the onset of the disease. Laparotomy disclosed that the ileum about 30cm proximal to the terminal ileum was incarcerated through a 2-cm sized defect on serosa of the left lobe of mesentery of the sigmoid colon. Internal hernia of the mesentery of the sigmoid colon was diagnosed. The hernia was released, the defect was closed, and then the operation was finished without performing intestinal resection because of a slight degree of ischemia.
Internal hernia of the mesentery of the sigmoid colon has been reported in 27 cases, including our case, in the Japanese literature. Of these 27 cases, the defect in the left lobe is so rare to be reported in eight cases.

View full abstract

A 39-year-old man complaining of epigastric pain was admitted to our hospital and diagnosed by abdominal X-rays as having intestinal obstruction. He had no past history of abdominal surgery. Because abdominal computed tomography showed dilatation of the small intestine, the patient underwent conservative therapy using a long tube. Although symptomatic remission could be achieved with depression of the intestine, intestinal contrast study through the long tube still showed obstruction of the small intestine. Internal hernia was strongly suspected and so laparoscopic surgery was performed. Laparoscopic observation revealed that the expanded ileum went around the back of the sigmoid colon and incarcerated into a mesenteric defect on the left side of the sigmoid colon in a Richter-type manner. A diagnosis of intramesosigmoid hernia was made, and incarceration was easily reduced by dissection of the right side of the mesocolon forming the hernia sac without intestinal resection. The postoperative course was uneventful and the patient was discharged on the 7^th postoperative day. Internal hernia by sigmoid mesocolon is a rare disease, occurring in less than 5% of all internal hernias. We report a rare case of intramesosigmoid hernia, the incarceration of which was reduced by laparoscopic surgery.

View full abstract

A 68-year-old man with a previous history of hypertension was admitted to the department of internal medicine in our hospital because of the sudden onset of upper abdominal pain. Abdominal CT scan on admission showed no hepatic portal venous gas (HPVG). Twenty-one hours later, he was transferred to the department of surgery because he showed severe peritoneal signs in the whole abdomen, and his enhanced CT scan demonstrated the presence of an acute superior mesenteric artery (SMA) occlusion with HPVG. Emergency laparotomy was performed with a diagnosis of SMA occlusion with HPVG 24 hours after onset. There were severe boloody ascites and widespread bowel necrosis from jejunum to cecum. The necrotic bowel was resected and only a double stoma was performed on the lst operative day. After general recovery, following the 8th postoperative day, end-to-end jejunocolostomy was performed. The postoperative course was uneventful, and he was discharged on the 84^th postoperative day. Early diagnosis and laparotomy are important for improving the survival rate. There have been few reports on changes with time of HPVG, and therefore we report this case with a review of the literature.

View full abstract

Transomental hernia is a relatively rare disease and it is difficult to diagnose preoperatively. We experienced a case of transomental hernia successfully diagnosed by abdominal CT scan reoperatively.
A 78-year-old woman was brought into the hospital by ambulance because of clouding of consciousness. After admission, she had abdominal fullness. Abdominal CT scan showed ascites and the localized small intestine over the colon with dilatation and radial distribution of the mesentery. So we diagnosed the case as transomental hernia and performed an emergency open lapalotomy. The small intestine was necrosed by about 160cm starting at a site 120cm from the Treitz' ligament, the necrotizing portion was resected, and a jejunostomy was made. After her general condition became stable, the jejunostomy was closed, and the patient was discharged. In the treatment of patients with intestinal obstruction having no opened lapalotomy previously, internal hernias including transomental hernia must be kept in mind. It is important for early diagnosis to confirm the anatomic relations of organs and the presence of radial distribution of the mesentery using abdominal CT.

View full abstract

Two cases of necrotizing fasciitis developed after an operation for colon penetration into the retroperitoneum are reported. Case 1 was a 64-year-old man, for whom sigmoidectomy and drainage were performed for sigmoid colon cancer penetration with abscess formation. After operation, redness and swelling at the left femoral developed, and an X-ray showed subcutaneous air. A wide incision drainage and removal of necrosed fascia were perfomed. Culture of the purulent fluid revealed E.coli and Enterococcus feacalis. Case 2 was a 62-year-old man who under went ileocecal resection and drainage for cecum diverticulitis penetrating the retroperitoneum. After operation, redness and pain in the right abdomen developed. An incision at the inflammation site was performed, and underspreading necrotic fascia were observed. Culture of the purulent fluid showed iralic and halic. When redness of the skin accompanied with pain is observed following an operation for colon penetration into the retroperitoneum, surgical treatment must be performed immediately considering the possibility of necrotizing fasciitis.

View full abstract