We investigated the tolerability of docetaxel with cyclophosphamide (TC) therapy as a postoperative adjuvant chemotherapy for primary breast cancer. The subjects were 35 patients who received 4 courses of TC therapy (docetaxel 60mg/m² and cyclophosphamide 600mg/m²) every 3 weeks as adjuvant chemotherapy following surgical resection with curative intent for invasive breast cancer from April 2006 to January 2008. Thirty-three (93%) of the 35 patients completed 4 courses of TC therapy. The remaining 2 patients did not complete it due to myalgia of grade 4 and general eruption of grade 2, respectively. The most common adverse event of grade 3 or 4 was neutropenia (30 cases [86%]), followed by anorexia (3 cases [8%]), nausea (2 cases [5%]), myalgia and general malaise (one case each [3%]). Febrile neutropenia was noted in 3 (8%) of the 35 patients. The median dose-intensity of docetaxel following the completion of 4 courses of TC therapy was 19.2mg/m²/week (range : 17.1-20.0). These findings suggested that Japanese patients can tolerate 4 courses of TC therapy as a postoperative adjuvant therapy under appropriate management.

View full abstract

(Objective) Intraabdominal hemorrhage due to pancreatic fistula (PF) is a rare complication of gastric cancer surgery. We report our evaluation of the therapeutic strategy for managing this complication at our institution.
(Material and Methods) Between January 1997 and September 2007, a total of 1176 patients underwent gastric cancer surgery at our institution. Fifteen patients developed intraabdominal hemorrhage arising from PF after surgery. We investigate the therapeutic management for these patients and their outcomes.
(Results) In 1176 patients, 78 patients (6.6%) developed PF and 15 patients (1.3%) developed intraabdominal hemorrhage arising from PF after surgery. It is suggested that the pancreatic injury caused by lymphnode dissection and combined resection take part in the incidence of the complication. With regard to hemostasis and prognosis, the outcomes of interventional radiology (IVR) were similar to those of surgical hemostasis.
(Conclusion) In the case of intraabdominal hemorrhage due to PF, early management using IVR is important.

View full abstract

It is very difficult to estimate the anastomotic site of biliary reconstruction. Especially in complicated cases such as cholangitis, cholelithiasis or local recurrence, PTC (Percutaneous transhepatic cholangiography) or PTCS (Percutaneous transhepatic cholangioscope) would be needed and bear the burden. Our aim is to evaluate the diagnostic potential of DIC-CT using peripherally enhanced multi-detector row CT at the same time (Dual contrast DIC-CT) in 20 patients with biliary reconstruction. On the work station, the diameter of anterior, posterior and left bile duct and anastomotic site were calculated by vessel analysis software in 15/20 cases (75%), 15/20 (75%), 10/18 (55.5%) and 16/24 anastomoses (66.6%) respectively. Virtual cholangioscopes were also visualized by another software in 15/20 cases (75%), 11/20 (55%), 10/18 (55.5%) and 11/20 (55%) respectively. Causes of failures on vessel analysis and virtual cholangioscope were pneumobilia, insufficient secretion and/or flowing of meglumine iotroxate (Biliscopin). Thickness of biliary duct walls in chronic cholangitis and peri-biliary cystic lesions in cases with transient unknown fever were observed by Dual contrast DIC-CT in each case. This examination would be useful for patients with biliary reconstruction to estimate intrahepatic bile duct and the anastomotic site less invasively.

View full abstract

A 63-year-old female patient operated for left breast cancer received on adjuvant chemotherapy via an implanted central venous catheter port. When heparin was flushed into the port after six months from completion of the chemotherapy, she complained pain on her right upper chest. An X-ray film revealed that the catheter was ruptured and its tip was found to be in the right lower pulmonary artery. It was removed via the right femoral vein, and she was discharged on the next day. Rupture of catheter should be considered when CV ports were placed, so we report our case with review of some literatures on this subject.

View full abstract

A 47-year-old woman came to the emergency room in our hospital because of intensifying abdominal pain after a hard blow on her left chest. She was diagnosed with having a traumatic splenic injury by an abdominal enhanced CT scan. She underwent emergency splenic hemostasis and drainage. Although she had been suffered from Graves' disease, she had discontinued the treatment for hyperthyroidism by her own judgement since three years earlier. Diffuse swelling of the thyroid gland was pointed out on preoperative palpation of the neck. Before and during operation, tachycardia, excessive sweating and fever occurred continuously. Two days after the operation, acute respiratory failure appeared. These symptoms and signs revealed thyroid crisis, and so immediate intensive treatment including anti-hyperthyroidism drugs was performed. She was saved and discharged on the postoperative day21.
Thyroid crisis is life-threatening and must be kept in mind in the treatment for patients with hyperthyroidism. Early initiation of treatments for a suspected event might contribute to save the patient's life.

View full abstract

An 84-year-old female patient had noticed a mass on her neck for the past 20 years but left it untreated. In Feb. 2003, she fell down and fractured her right radius and came to the orthopedic clinic of our hospital, when the mass on the neck was pointed out, and was referred to us. The mass was a big one with the maximum diameter of 18 cm, but the patient did not have respiratory difficulty nor hoarseness, except the palpable mass and some uncomfortable feeling. CT study of the neck revealed a conglomerated multinodular tumor, arising from the right lobe of the thyroid, heterogeneous in its content and compressing the surrounding tissue with a clear margin. The tumor was thought to be resectable and a surgical resection was performed. and the postoperative pathohistological diagnosis was follicular thyroid carcinoma. The patient has been fallowed for 5 years without recurrence of the cancer.

View full abstract

A 76-year-old woman, pointed out having a tumor in the vicinity of the right areola of mammary gland on a screening mammography (MMG), was seen at the hospital for close exploration. On palpation a clearly demarcated movable hard tumor with the diameter of 0.8cm and smooth surface was felt in the vicinity of the areola in the right C area. MMG revealed a circular and distinctly outlined tumor, which showed the same concentration as the mammary gland did, in the vicinity of the right areola. On ultrasonography, the tumor showed a solid echo pattern, was circular in shape, and was distinctly outlined ; the internal echo was hypo to iso-echoic and the posterior echo was enhanced. Fine needle aspiration cytology gave a result of "indeterminate", and so an excisional biopsy was performed. Pathologically there were adenosis like ducts of all sizes in the central part, chondrification was prominent in the periphery of the tumor, and breast pleomorphic adenoma was thus diagnosed. The patient is followed in the clinic. No signs of recurrence have been noted at present when about one year has elapsed after the operation.

View full abstract

Angiosarcoma of the breast is rare, and the correct diagnosis of disease requires a precise histopathological procedure. We present a case of low-grade angiosarcoma of the breast. A 38-year-old woman had a lump and pain in the left breast. She was followed with a diagnosis of mastopathy. Six months later, the lump increased in size. A soft tumor 5.2 cm in diameter was palpated in the areola area with purpura lesions. Core needle biopsy resulted in a diagnosis of angiosarcoma.
Mastectomy was performed, and the final histopathologic finding was largely low, partly intermediate-grade angiosarcoma. Following surgery, she underwent irradiation of the chest wall and has been followed closely.

View full abstract

A 57-year-old female developed a 1-cm-diameter left breast mass positioned in the C region of the left breast. There was no nipple discharge and no axillary lymph node swelling. On ultrasonography and mammography an invasive ductal cancer was suspected. On aspiration cytology, a malignant cells were diagnosed ; cell clusters with large and small sized, atypical nuclei were seen. A left partial mastectomy with an axillary lymph node dissection for early breast cancer (T1N0M0) was dune. On histopathology, a proliferation of small tumor cells forming trabecule was noted. Since no spindle cells were present between the cancer cells and the cartilaginous matrix, a matrix-producing carcinoma (MPC) was diagnosed.

View full abstract

We report a case of male breast cancer presented histologial findings of invasive micropapillary carcinoma (IMP), which is extremely rare.
A 77-year-old man who had noticed a left breast tumor at the end of April 2000 was seen at the hospital in August. An oval-shaped tumor about 5cm in diameter was palpated in the left breast. Fine needle aspiration cytology diagnosis was adenocarcinoma, and left mastectomy with lymph node dissection (Auchincloss method) was performed. The histopathological diagnosis was IMP.
Since 1993 when IMP was reported by Siriaukgul and others as a subtype of invasive ductal carcinoma, it has been received attention as a histological type which has extended lymphatic tumor emboli invasion as well as lymph node metastasis, and resultantly carries poor prognosis among invasive carcinomas, though few reports have been described.
IMP shows following characteristic histopathological findings : cuboidal to columnar cells with eosinophil cytoplasm form micropapillary carcinoma foci which are associated with connective interstitial tissue without vessels ; and they are surrounded by spaces of fine fibrocollagenous stroma via circumferential spaces. IMP is believed to be comparatively easily diagnosed with HE staining, however, there are no differences from common types of breast cancer in the peak incidence of age, tumor diameter, and macroscopic findings and hence preoperative diagnosis of IMP is difficult. In this case we could not differentiate between IMP and common breast cancers based on clinical and imaging findings. It might be important for decision-making of diagnosis and treatment to assess a possibility of IMP by preoperative fine needle aspiration cytology.

View full abstract

A 44-year-old patient came to the outpatient clinic with the complaint of a tumor in her right breast found by self-palpation of the breast on Feb. 2, 2007. On palpation a mass of 3.1 × 3.0cm in size was felt in C area of her right breast and it was observed that the right breast was clearly smaller than the left breast with the right areola higher than the left side. With mammographic, ultrasonographic and needle biopsy studies, a diagnosis of breast cancer (Class V) was made. CT study revealed possible absence of the right major pectoralis, minor pectoralis and anterior serratus muscles. No functional deficit of the right arm was observed preoperatively. A mastectomy (Kodama method) was performed on March 24, 2005 at our institution. The major pectoralis, minor pectoralis and anterior serratus muscles were absent. Pathohistological study revealed a 2.3 × 2.0 cm in size papillotubular carcinoma with stage IIA, f, pT2, n0, M0. Immunohistological study revealed ER(+), PgR(+), Her2(++). Breast carcinoma arising in congenital absence of pectoralis muscles are extremely rare. We report a case here with some review of literatures.

View full abstract

We report here a case of local recurrence developed 34 years after radical mastectomy for left breast cancer. A 75-year-old woman who had undergone radical mastectomy at the age of 38 was admitted to the previous hospital because of a gradually enlarging anterior chest mass and bleeding from it. CT scan demonstrated that the mass had invaded the mediasterunum and pericardium. Incisional biopsy provides the pathological diagnosis of solid-tubular carcinoma expressing estrogen receptor, progesterone receptor and HER2. Diagnosed as recurrence of breast cancer, administration of anastazole and trastuzumab was started and radiation therapy up to 61Gy was given. She was referred to our hospital after her removal. Trastuzumab was withdrawn due to adverse side effects, but the chest wall mass became smaller and diappeared in July 2007. The partial remission has been maintained by endocrine therapy with anastazole, as of 2 years after the initiation of therapy for recurrence.

View full abstract

This case was a 59-year-old woman with T3 N3a M0, ER-negative, PgR-negative, and HER2-positive breast carcinoma. After four cycles of CEF followed by four cycles of Docetaxel and weekly Trastuzumab, the primary tumor of the breast and axillary lymph node achieved a clinical complete response, and subsequently breast-conserving surgery and radiotherapy were performed. pCR was determined by microscopic examination of the excised tumor and lymph nodes, and was defined as no residual invasive cancer in either one. However, local inflammatory breast recurrence occurred five months after surgery. Generally, inflammatory breast recurrence is unfavorable, however prognosis of inflammatory recurrence after neoadjuvant chemotherapy followed by surgery is not known because of the few reports.
We present here a patient who achieved pCR after preoperative chemotherapy but there was a inflammatory recurrence of the breast five months after surgery.

View full abstract

Rectal metastasis due to breast cancer is quite rare. We report a case of rectal metastasis due to breast cancer diagnosed about eight years after the surgery. A 83-year-old woman underwent modified radical mastectomy with axillary lymph node dissection for left breast cancer about seven years and six months before. She complained of lower abdominal pain and abnormal defecation, and was admitted to our hospital with the suspicion of rectal cancer. Colon fiber showed a severe peripheral stenotic lesion in the rectum, but the pathological analysis of the mucosa was Group 1;proctitis. Barium enema revealed the lesion as a narrow segment about 10-cm long, and computed tomography showed right hydoronephrosis and swelling of the mediastinal lymph nodes. Furthermore, bone metastasis was suggested by diffusion weighed imaging of the magnetic resonance imaging. We concluded that it was impossible to perform a complete resection, so a colostomy was performed. Two months later, the tumor invaded the perianal lesion. We finally obtained the accurate diagnosis from needle biopsy. The rectal metastasis was indeed due to breast cancer. Our report was the 9^th case of rectal metastasis due to breast cancer in the Japanese literature.

View full abstract

We report a successful endovascular aneurysm repair (EVAR) for an aortic ruputure caused by pyothorax subsequent to anastomotic leakage after esophagectomy.
A 77-year-old man who underwent distal esophagectomy and esophagojejunostomy in the left thorax for esophageal cancer had anastomotic leakage and pyothorax. Massive hemorrhage was observed from a thoracic drainage tube at the 18th day after surgery, we supposed it to be aortic rupture, and performed emergency EVAR. No further hemorrhage occurred after EVAR, and then the leakage and pyothorax were resolved. The patient was discharged from the hospital on postoperative day 70.
Recently favorable therapeutic outcomes of EVAR for aortic aneurysms have increasingly been reported. EVAR is an effective option of treatment for aortic rupture in such a patient in a poor general condition as our patient.

View full abstract

We experienced three cases of spontaneous pneumothorax during pregnancy. First case : A 35-year-old woman developed right spontaneous pneumothorax at the 13^th gestational week. After tube drainage, she was discharged from our hospital with a good result. Second case : A 28-year-old woman developed left spontaneous pneumothorax at the 20^th gestational week. After tube drainage, pleurodesis using autologous blood was performed four times, after which she was discharged. Third case : A 37-year-old woman developed right spontaneous pneumothorax at the 28^th gestational week. After tube drainage, a persistent air leak for over one week required surgery. We performed VATS, but the minor air leak continued. She was discharged from our hospital after pleurodesis using autologous blood. They had no recurrence of pneumothorax, and delivered safely.
The effectiveness of pleurodesis using autologous blood several times was evaluated in 2 cases with spontaneous pneumothorax during pregnancy (one case performed after VATS). As side effects, only transient low-grade fever and slight chest pain were observed. These results indicate that this pleurodesis (with or without VATS) is a useful therapy for spontaneous pneumothorax during pregnancy.

View full abstract

A case of pulmonary cryptococcosis mimicking metastatic lung tumor in a 72-year-old man is reported. The patient had a significant past history of diabetes mellitus which was not controlled well for over 20 years and also had low anterior resection for stageII rectal cancer. An asymptomatic pulmonary mass was found by a routine follow-up chest radiography 18 months after the rectal surgery. Computed tomography revealed a 6mm in size mass in the lower lobe of the left lung, which grew to 17mm in three months after. We made a presumptive diagnosis of metastatic lung tumor, considering also the possibility of some benign tumor or inflammatory lesion as a differential diagnosis. He underwent a partial resection of segment 6 of the left lung by video-assisted thoracospcopic surgery. Pathologic examination disclosed obvious granulomatous inflammation with fungal bodies of cryptococcus positive for both Grocott and PAS staining. He received oral fluconazole administration for 6 months postoperatively while positive serum cryptococcal antigen persisted. As a lung lesion of cryptococcosis presents similar findings as a lung tumor in imaging study, awareness that an immunocompromised host such as diabetes mellitus patient may be more likely to be infected by fungus is important. Video-assisted thoracoscopic surgery is feasible and safe for those patients because of its less invasiveness.

View full abstract

A 51-year-old female required treatment for pleural mesothelioma. She had a left extrapleural pneumonectomy. The patient gave no history of occupational asbestos exposure. There were no factories associated with asbestos near her home. However, she was exposed to asbestos in Amagasaki where she was born and lived until she was 18 years old. The asbestos body count was determined for the resected lung ; 4027/g asbestos bodies were noted. Thus, the patient's asbestos exposure was conclusively documented.

View full abstract

Secondary achalasia refers to the development of clinical and radiographic findings similar to those of primary achalasia but occurring as a result of another underlying disorder, which usually involves malignancy.
A 71-year-old woman was diagnosed as having primary achalasia based on clinical imaging studies and received balloon dilation therapy in a previous hospital. Three months later, she was admitted to our hospital with progressive dysphasia and a 10-kg body weight loss. On medical examinations that included upper gastrointestinal radiography, CT scan, esophagoscopy and boring biopsy, the definitive diagnosis of abdominal esophageal cancer was made and the tumor type was determined to be diffusely infiltrative. The patient underwent lower esophagectomy through a transhiatal approach, followed by esophagogastric anastomosis. Pathohistological findings showed squamous cell carcinoma of the lower esophagus with regional lymph nodes metastasis, and the stage grouping was T3N1M0, StageIII.
A search of the Japanese literature regarding secondary achalasia due to cancer showed 16 previous reports, and about half of the patients experienced a delay before the definitive diagnosis was obtained because they were initially misdiagnosed as having primary achalasia. Therefore we describe the features of secondary achalasia, and discuss problems in the differential diagnosis from primary achalasia, with a special emphasis on Tucker's criteria.

View full abstract

The patient was a 59-year-old male who had received transthoracic esophagectomy and gastric tube reconstruction with cervical anastomosis for squamous call carcinoma of the thoracic esophagus in January 2002, when no abnormal endoscopic findings of the stomach were revealed. Thereafter he had been followed in the clinic. In May 2003, upper gastrointestinal endoscopy revealed multiple longitudinal red stripes of vessels in the gastric tube, but no recognizable dilatation of capillary vessels was seen. One year later, follow-up endoscopy revealed the dilation of the vessels. Laboratory studies showed severe anemia in March 2005 and upper gastrointestinal endoscopy revealed longitudinal red stripes of the dilated vessels, leading to the definitive diagnosis of bleeding from gastric antral vascular ectasia (GAVE). Endoscopic argon plasma coagulation (APC) method was performed to treat GAVE. After the therapy, GAVE disappeared, and remarkable improvement in anemia was attained.

View full abstract

A 67-year-old woman was admitted to the hospital because of persistent fever and left upper abdominal pain.
A submucosal tumor covering from the cardiac part to upper body of the stomach was revealed by an upper gastrointestinal endoscopy. Abdominal CT showed small enhancement of the tumor and an abscess of the left subphrenic space.
The patient underwent total gastrectomy, distal pancreatectomy and splenectomy with the preoperative diagnosis of gastrointestinal storomal tumor. The operative findings showed a large tumor with ulceration in the stomach and the tumor had a covered perforation with an abdominal abscess. Microscopic examination revealed the tumor to be composed of spindle-shaped cells arranged in trabecular bundles without any mitotic figures. Immunohistochemically, the tumor cells were positive for S-100 protein, but they were negative for c-kit, CD34, α-SMA and desmin, The final diagnosis was gastric schwannoma.

View full abstract

We experienced a rare case of gastric metastasis with pyloric stenosis of renal cell carcinoma. The patient is a 55-year-old man. He received right radical nephrectomy for cancer four years ago and partial resection of the liver for liver metastasis one year ago. He had a feeling of abdominal fullness and epigastric distress, and was carefully examined. Abdominal computed-tomography examination showed thickness of the pyloric ring. Barium enema examination showed pyloric stenosis. The area of pyloric stenosis did not reveal ulceration by an upper gastrointestinal endoscopy, and a membrane biopsy was performed in the narrowed area. A malignant finding was not revealed. We performed a wedge-shaped biopsy under laparotomy and gastro-jejunostomy. The result of the biopsy was a metastatic gastric cancer of renal cell carcinoma.

View full abstract

A 60-year-old male developed type 0-IIa+IIc gastric cancer. On gastrointestinal fiberscopy, an early gastric cancer that resembled a submucosal tumor was found in the lower gastric body. On histology, poorly differentiated adenocarcinoma was diagnosed. Computed tomography (CT) scans showed no lymph node metastases or liver metastases. A distal gastrectomy with a D1+B lymph node dissection and a Billroth-I reconstruction were performed. On pathology, the tumor was immunohistochemically positive for chromogranin A and synaptophysin. The tumor was diagnosed as a gastric small cell carcinoma. Primary gastric small cell carcinoma is rare and has a poor prognosis due to the presence of lymph node and liver metastases at the time of diagnosis. Most reports deal with patients who had advanced cancer. In this paper we report a very rare case that was diagnosed early and also review of the literature.

View full abstract

A 78-year-old male who for 2 years had been treated for liver cirrhosis developed bilateral leg edema, at our hospital. After admission, he was diagnosed as having gastric cancer with protein-losing gastroenteropathy based on endoscopy, RI scan, and gastric juice protein density. The patient's leg edema and hypoprotenemia were not caused by the cirrhosis but by the gastric cancer with a protein-losing gastroenteropathy. The patient's serum protein and albumin levels improved immediately post distal gastrectomy ; the patient no longer had leg edema.

View full abstract

A 63-year-old man with untreated diabetes mellitus was admitted to the hospital because of a 2-week history of epigastric pain and remarkable inflammatory reactions in October 2001. Pre-operative examination demonstrated typical features of type 4 gastric cancer and a biopsy revealed poorly differentiated adenocarcinoma. He underwent total gastrectomy and splenectomy. The histopathological findings revealed 0-IIc like advanced gastric cancer with diffuse suppurative gastritis, which mimicked type 4 gastric cancer.
Suppurative gastritis is a rare entity, which often poses problems in differentiation from type 4 gastric cancer. The knowledge that suppurative gastritis mimicks type 4 gastric cancer is important.

View full abstract

We report here a case of essential thrombocytemia (ET) with an advanced gastric cancer complication. She was a 78-year-old woman. Her upper endoscopic etamination 10 years earlier did not reveal any gastric cancer. Her case has met the diagnostic criteria for ET.
ET is a rare disease, and is sometimes complicated with thrombosis and/or bleeding. These may be caused by the platelet count and/or its functional failure. The complication may also occur due to transformation to acute leukemia or some other type of chronic myeloproliferative disorder (CMPD). However, the frequency of complication by gastric cancer is thought to be similar to its general occurrence.
We could manage for hyper-function or the platelet increase with the drugs for each purpose, but not for bleeding. In this case, though sometimes the platelet count exceeded 2 million/mm³, she showed no signs of thrombosis or bleeding. But when the platelet count was over 2 million/mm³, Ramunistin was administered.
Though no bleeding or thrombotic complications were involved in the operation for gastric cancer in this case, it is important to observe carefully the postoperative course and to prepare for acute change such as thrombosis and bleeding.

View full abstract

A 76-year-old female previously had a distal gastrectomy reconstructed using the BillrothII method due to gastric cancer. She developed hypogastric pain one day prior to admission. On arrival in the emergency room, she had abdominal rigidity ; an abdominal CT scan showed ascites and emphysema in the retroperitoneal space around the pancreatic head and duodenum. Emergency operation was performed under the diagnosis of generalized peritonitis due to gastrointestinal perforation. In the second portion of the duodenum, a perforated diverticulum, which included six brown stones, was identified ; in the region of the pancreatic head, severe inflammatory change was noted. An intraoperative diagnosis of a duodenal diverticular perforation accompanied by enteroliths was made. A pancreatoduodenectomy with a Whipple procedure reconstruction was done. On pathology, perforation and necrosis of the duodenal diverticulum, as well as pancreatitis, were noted. During the postoperative course, an anastomotic leakage of the pancreaticojejunostomy occurred which was cured with conservative treatment. We report a case with a perforated diverticulum of the descending part of the duodenum accompanied by enteroliths post Billroth II gastrectomy.

View full abstract

The first case was a 58-year-old female who developed epigastralgia. Based on the findings of an abdominal CT scan, she was diagnosed as having a left paraduodenal hernia. After bowel decompression, a laparoscopic hernia repair was performed. The second case was a 75-year-old female with a long history of abdominal distention. On abdominal CT scan, regional dilatation of the small bowel was seen in the left upper abdomen. She was diagnosed as having a left paraduodenal hernia, which was repaired during Hand Assisted Laparoscopic Surgery (HALS). A left paraduodenal hernia is an internal hernia that includes the small bowel which travels in the congenital fossa of the retroperitoneum (Landzert fossa) located on the right and dorsal side of the inferior mesenteric vein (IMV). In Japan only about 10% of left paraduodenal hernias are diagnosed preoperatively. We report two left paraduodenal hernia cases that were diagnosed preoperatively and treated laparoscopically.

View full abstract

During a routine medical check-up, a 71-year-old male was found to have an abnormal shadow on his chest X-ray. In October 2007 a PET examination was done to further elucidate the pulmonary nodule ; a high FDG accumulation (SUV 7.1) was found around the duodenal papilla. Cancer of the duodenal papilla was diagnosed based on gastroduodenoscopy findings. A pylorus-preserving pancreaticoduodenectomy with D2 lymph node dissection was performed. On histopathology, the 0.6-cm-diameter tumor was pT1 (Du0 Panc0) H0 P0 N0 M(-) pEM0 stage I. Compared to other periampullary neoplasms, cancer of the duodenal papilla has a relatively better prognosis in patients who have curative surgery. Recent diagnostic imaging system improvements colud result in the earlier detection of these tumors. Several reports have stated that PET is useful for diagnosing these type of cancers.

View full abstract

A-71-year-old woman complaining of epigastric pain and loss of appetite was admitted to our hospital. The blood test revealed anemia, malnutrition and imbalance of electrolytes. An upper gastrointestinal endoscopy revealed a type 2 tumor at the opposite site of the Vater's papilla in the second portion of the duodenum, with the histological examination revealing well differentiated adenocarcinoma. Barium meal examination showed the ascending colon through a duodenocolic fistula from the second portion of the duodenum. Angiography revealed tumor stain and encasement of vessels in the pancreaticoduodenal arcade. Primary duodenal cancer with a duodenocolic fustula was suggested, and an operation was performed. Tumor in the second portion of the duodenum invaded to the transverse colon, but there was no metastasis to the liver, nor peritoneal dissemination. Panceaticoduodenectomy with right hemicolectomy was performed. Postoperative course was uneventful, and the patient is currently free of disease 6 years postoperatively. We think panceaticoduodenectomy with right hemicolectomy is the procedure of choice for duodenocolic fistula due to carcinoma if the general condition of the patient is tolerable for major surgery.

View full abstract

Perforation of the digestive tract by ingested chicken bones is reratively rare and is difficult to diagnose preoperatively. A 61-year-old man was transferred from a local hospital with the diagnosis of bowel obstruction. The most tender point was in the right lower quadrant of the abdomen without rebound tenderness. Inflammatory reaction was noted on laboratory examination. Computed tomography showed dilatation and wall thickness of the small intestine in the right lower quadrant. Emergency operation was performed. On laparoscopic findings, there was pus like ascites and a foreign body protruding through the small intestine. The foreign body proved to be a chicken bone from the interview to the patient.

View full abstract

We report a rare case of recurrence of midgut volvulus in a late term after Ladd's procedure. A one-year and 3-month-old boy was brought into our hospital because of bilious vomiting. He had undergone Ladd's procedure because of malrotation and midgut volvulus 5 days after birth. He was diagnosed as having postoperative ileus and was admitted. Despite conservative therapy, the patient's general condition abruptly deteriorated on the third hospital day and abdominal CT scan demonstrated dilated intestine with abundant ascites. Emergency surgery was performed because strangulation ileus was suspected. The laparotomy demonstrated that midgut volvulus had reccurred and most of the intestine had necrotized. There was little intestinal adhesion. The necrotized intestine was resected after reduction of the volvulus. Postoperatively, the length of residual normal intestine was 40 cm and he developed short bowel syndrome. Although the recurrence of midgut volvulus after Ladd's procedure is a rare postoperative complication, we should not neglect it.

View full abstract

A case of retrocecal type paracecal hernia which is relatively rare is presented. A 100-year-old male was admitted to our hospital because of sudden onset of abdominal pain. There was no previous history of abdominal surgery. On physical examination, the entire abdomen was distended and slightly tender without signs of peritonitis. X-ray showed the dilated small intestine with air fluid level. CT scan showed an incarcerated small intestinal loop behind the cecum that was deviated anteriorly. A laparotomy revealed that 50 cm of the terminal ileum was incarcerated into the retrocecal cavity. Retrocecal type paracecal hernia was diagnosed. Reduction of the incarcerated loop was followed by obliteration of the hernia orifice to prevent subsequent incarcreation. A dilated small intestinal loop behind the deviated cecum on CT is considered to be a strong sign of the presence of a retrocecal type paracecal hernia.

View full abstract

A 79-year-old man was referred to our hospital complaining of right lower abdominal pain. Abdominal enhanced CT revealed multilocular cystic lesion of the appendix. Our preoperative diagnosis was mucocele of the appendix, so we performed a laparotomy. Intraoperative findings showed swelling of appendix and mesoappendix. We diagnosed mucocele during the operation and performed ileocecal resection with lymphnode dissection. But histopathological diagnosis was diverticulitis of the appendix with no tumor lesion. Generally, multilocular cystic lesion of the appendix suggested mucocele. Ours is a rare case with lesions similar to mucocele from enhanced CT examination.

View full abstract

A 71-year-old man with left upper abdominal pain was admitted to our hospital. A fist-size mass was palpable in the left upper abdomen. Enhanced CT scan showed an inhomogeneous density mass with fatty and cystic components, which was continuous with the transverse colon. Barium enema revealed an obstruction of the transverse colon with crab finger sign. Colon intussusception was suspected on the basis of these findings. After the failure of reduction, an emergency laparotomy was performed. At surgery, we found a mass 3.5 cm in diameter at the proximal end of the appendix after relieving the intussusception. Right colectomy with standard lymph node resection was carried out. Macroscopically, the appendix was filled with mucus. Histological examination revealed a mucinous cystadenoma of the appendix. Mucocele of the appendix is a rare cause of intussusception, and preoperative diagnosis is often difficult without preoperative reduction. Mucocele of the appendix should be considered as a possible cause of colon intussusception, especially in cases with cystic mass at the site of intussusception.

View full abstract

The patient was a 70-year-old man who visited our ortpatient department with a chief compliant of right lower quadrant pain that had persisted for three days. Blood tests showed high levels of inflammatory markers, while abdominal contrast CT showed a mildly enlarged appendix, around which fluid retention accompanied by a septum was observed. The patient was diagnosed with acute appendicitis and periappendiceal abscess, and underwent emergency surgery on the same day. Laparoscopic observation revealed formation of a smooth-surfaced tumor in the appendix. Because the tumor had adhered to surrounding tissue, its removal resulted in wall rupture and a massive discharge of white pus. As laparoscopy was judged difficult to continue, it was converted to laparotomy. The adhesion was difficult to separate, and the ileocecal region was thus resected. The resected sample showed an appendix-like structure in the middle of a cyst (diameter, approximately 6 cm). Histopathological tests showed cystic dilatation of the appendix as well as papillary growth of the epithelium exhibiting nuclear enlargement in the lumen. However, no clear malignancies were found, and the patient was diagnosed with mucinous cystadenoma of the appendix with abscess formation. Although thrombosis of the superior mesenteric vein developed on postoperative day 2, it improved with conservative therapy, and the patient was discharged on day 35.

View full abstract

The patient was a 24-year-old male with Cornelia de Lange syndrome who was diagnosed to have ileus, with complaints of insufficient oral intake, fever and generalized convulsions. The patient was referred to us on the 4^th day of the onset of the disease and a long tube was inserted. Abdominal distension improved gradually and the long tube was clamped on the 15^th day, but it was reopened again as the abdominal distension recurred. He developed cardiopulmonary arrest on the 18^th day but was resuscitated successfully. After the improvement of the general condition an operation was performed on the 51^st day. The ileocecum was twisted and firmly adhered to the diaphragm. The ascending colon was found transected and obstructed without flow of blood in the right colic artery. Resection of the ileocecum with ileocolic anastomosis was performed. The postoperative course was uneventful. There are several reports on acquired intestinal atresia due to intestinal torsion or intussusception but this is the first report on an adult patient. In this case a partial necrosis of the intestine occurred due to ischemia caused by ileocecal torsion, and the decompression therapy was effective with development of limited peritonitis, and intestinal atresia was thought to have occurred in the healing process of ischemia.

View full abstract

We report a case of a colonic lipoma with a rare macroscopic morphology which was diagnosed by endoscopic resection, together with some bibliographical comments.
A 57-year-old man was pointed out that his fecal occult blood test was positive. Barium enema showed a sigmoid polyp approximately 3cm in diameter. Colonoscopy showed a pedunculated polyp with lobulated mucosal surface. Biopsy specimens revealed epithelial hyperplasia with a focus of dysplasia, and endoscopic resection against the polyp was performed. The resected polyp measured 3.5×3.0×2.0cm with a peduncle 1.5cm in diameter, and fat tissue was exposed to the surgical margin. Microscopically, the polyp was composed of mature fat cells which had proliferated in the submucosal layer. Epithelial hyperplasia was seen in the mucosa, but there was no evidence of neoplasm. The polyp was diagnosed as lipoma of the sigmoid colon. Although the lipoma was microscopically confirmed at the surgical margin, no additional resection was done for the lipoma because of absence of malignant evidence within the resected specimen.

View full abstract

An 83-year-old man consulted with a physician, complaining of dyspnea after 11 years of surgery for sigmoid colon cancer. The patient was diagnosed as having congestive heart failure by the chest X-ray. He was suspected of having dilated cardiomyopathy from the findings of electrocardiogram and cardiac ultrasonography. Examination of gastrointestinal tract was performed, because anemia was seen in laboratory findings on admission. A type 2 tumor was seen at the rectum, and was histologically diagnosed as an adenocarcinoma. After improvement of heart failure, Hartmann's operation for rectal cancer was performed under general anesthesia. The tumor was diagnosed as a poorly differentiated carcinoma, and the final staging of the rectal cancer was SS, N1, H0, P0, M0, StageIIIa. The patient was treated with a phosphodiesterase inhibitor and an antiarrhythmic agent during surgery and control of fluid and diuretics after surgery, and took a fine course without relapse of heart failure. The patient was suspected of having ischemic cardiomyopathy by the postoperative cardiac scintigraphy. The patient was discharged on the sixtieth postoperative day. Although 5 years have passed since the surgery for rectal cancer, neither relapse of heart failure nor recurrence of colorectal cancer were seen. Curative surgery for colorectal cancer under general anesthesia can be safely accomplished by careful preoperative evaluation and proper perioperative management in patients with heart failure due to cardiomyopathy, if heart failure is controlled properly.

View full abstract

An 88-year-old female patient came to our hospital with the chief complaint of vomiting coffee residue like material and mucous melena. Abdominal X-ray revealed dilatation of the small intestine with gas and pneumatosis of the descending colon. Abdominal CT revealed an image of extreme intra and extrahepatic portal venous gas. The patient was in shock in the emergency room with blood pressure of 60 mmHg and an emergent laparotomy was deemed impossible, therefore a conservative management with insertion of a long tube was performed. We experienced 2 other cases of portal venous gas in in-hospital elderly patients who were successfully treated with conservative managements. Portal venous gas arises most of the time in intestinal necrosis and is usually treated surgically. However, recently cases caused by viral enteritis are frequently observed and it is thought that surgical treatments are not necessarily needed. The case of pneumatosis cystoides intestinalis with portal venous gas that we report here seemed to be caused by severe enteritis with intestinal necrosis, but fortunately it was possible to manage conservatively.

View full abstract

Laparoscopic minimal invasive surgery is standard for diseases of the digestive tract. On the other hand, laparoscopic hepatectomy is not yet popular because it is difficult to control bleeding during liver transection. However, with the development of new surgical devices laparoscopic hepatectomy has gradually increased. We report a patient with synchronous liver metastasis from rectal carcinoma in whom a laparoscopic partial hepatectomy was done, which involved a hand-assisted procedure and the use of a vessel sealing system (Liga Sure _TM).

View full abstract

Schwannoma in the hepatic hilus is a rare tumor. In this paper we present two cases of benign schwannoma in the hepatic hilus, together with a review of the literature. Case 1 : A 75-year-old female patient showed benign schwannoma in the hepatic hilus which had been pathologically diagnosed previously. The tumor gradually grew from 2.5 cm to 4 cm, despite surgical resection. Case 2 : An 81-year-old male patient was referred to our hospital for a large mass in the hepatic hilus by ultrasonography. CT and MRI showed a tumor adjacent the hepatoduodenal ligament, and FDG uptake on PET was observed. Because of differentinal diagnosis including malignancy, surgical resection was done. The pathological diagnosis in both cases was benign schwannoma arising from the nerve plexus around the common hepatic artery.

View full abstract

An 80-year-old female had liver metastases from gastrointestinal stromal tumor (GIST) of the residual stomach. She was administered 400 mg/day of imatinib and remained well for 39 months. Four sites of metastases of GIST resistant to imatinib were detected and therefore, she underwent surgical resection combined with intra-operative hepatic radiofrequency ablation. After that, recurrence of liver metastasis was not observed. Although administration of imatinib is the first choice for the therapy of recurrent GIST, it is very difficult to select the proper treatment for secondary resistant GIST. It is demonstrated in this case the efficacy of surgical intervention for secondary resistant GIST.

View full abstract

A 66-year-old man who was under the treatment of chronic hepatitis C underwent abdominal US following detection of a high serum level of AFP (4,870 ng/ml), and the study revealed a hypervascular tumor, 7 cm in diameter, surrounded by the left lobe of the liver and the spleen. Hepatic angiography demonstrated that the feeding artery of the tumor originated from the proper hepatic artery. Based on these findings, the patient was diagnosed as a case of hepatocellular carcinoma (HCC) of extrahepatic growth type. Since a small nodule suggestive of HCC was found in the left lobe of the liver, left lobectomy was performed. Surgical findings revealed a pedunculated hepatic tumor. Several small nodules were found in the mesentery. Pathological diagnosis revealed that the pedunculated tumors were moderately differentiated HCC. The small nodules in the mesentery were diagnosed as peritoneal metastases from the HCC. Postoperatively , the AFP level decreased to 100 ng/ml, and he received postoperative oral chemotherapy using UFT after being discharged. The serum level of AFP was gradually increasing, however, the patient remains well without any apparent symptoms of dissemination even at three and half years after the surgery.

View full abstract

A 76-year-old man, who had undergone distal gastrectomy for early gastric cancer 14 months before admission, was found to have a hepatic tumor. Posterior segmentectomy of liver was carried out for the tumor 3 cm in diameter in the segment 6 (S6). Based on pathological examination and serum level of HBV-DNA, hepatocellular carcinoma (HCC) with the etiologic factor of hepatitis B virus (HBV) infection was diagnosed. Radiofrequency ablation (RFA) against recurred HCCs in the S4 and S8 was performed 27 and 29 months after the hepatic resection, respectively. Two months after the RFA, multiple HCCs recurred in the bilateral lobes of the liver, and nine times of taranscatheter arterial chemoembolization (TACE) were performed during two years. Since two months after the last TACE, multiple HCCs were observed, and we challenged oral administration of UFT (450 mg/day). Eight months after the administration, the tumors completely disappeared and the serum levels of PIVKA-II were normalized. The patient is doing well as of 4 months after CR. Oral administration of UFT could be one of the useful treatments for advanced HCC.

View full abstract

A 70-year-old male with appetite loss and rapid weight loss had a dilation of the intrahepatic bile duct. The abdominal CT scan showed bead-like low intensity lesions, while the magnetic resonance cholangiopancreatography (MRCP) showed multiple cystic lesions located mainly along the portal area of the left lobe of liver, which were difficult to distinguish from the dilation of the intrahepatic bile duct. On endoscopic retrograde cholangiography, a round defect was noted in the left intrahepatic bile duct, as well as a stenosis and irregularly shaped biliary branches distal to the stenosis. No communications were present between the cystic lesions and bile ducts. On abdominal angiography, the main left portal vein was not seen, and the branches of the left hepatic artery exhibited corkscrew sign, which indicated portal hypertension, and left liver lobe atrophy was present. A left lobectomy was performed, since intrahepatic cholangiocarcinoma could not be ruled out. The resected specimen showed evidence of liver cirrhosis and multiple peribiliary cysts located along Glisson's sheath. Hepatic peribiliary cysts are rare and are usually treated conservatively. However, such patients inevitably have surgery since it is difficult to distinguish these cysts from malignant lesions. More precise diagnostic methods that would differentiate these conditions are required.

View full abstract

A 70-year-old man with chief complain of poor appetite consulted with our hospital. Computed tomography showed advanced cholangiocellular carcinoma (CCC) of the right hepatic lobe, 16cm in size with invasion to the inferior vena cava. Then, hepatic artery infusion chemotherapy (Leucovorin ; 30mg+cisplatin ; 10mg+5-fluorouracil ; 250mg/continuous for 5days for four weeks and resting for four weeks) was administered. After seven times of the courses of treatment in one year, tumor diameter was found to be reduced to 6cm, then surgical removal was performed. As an operative finding, the liver tissue was found to be hard around the tumor, therefore an extended right hepatectomy was performed to oftain a possible safety margin. The patient was discharged without any postoperative events. Standard treatment for advanced CCC has not yet been established, thereofore, some review of published literatures was done.

View full abstract

Four cases of surgical management of postoperative intractable pancreatic fistula were reported from 1999 to 2006. Patients were 2 men and 2 women with a mean age of 52 years (range, 26-71 years), who had undergone hepato-ligamento-pancreatoduodenectomy (HLPD) in 2, resection and reanastomosis of the jejunal limb after right hemicolectomy and pancreatoduodenectomy (PD) in 1, and necrosectomy in 1. The primary diseases were cholangiocellular carcinoma, gallbladder carcinoma, recurrence of hepatoduodenal ligament after surgery for ascending colon cancer, and acute necrotizing pancreatitis. The average interval between onset of pancreatic fistula and second operation was 5 months (range, 4-7 months). The surgical techniques for pancreatic fistula consisted of pancreatico-jejunostomy using the jejunal limb, a Roux-en-Y pancreatico-jejunostomy and a Roux-en-Y fistulojejunostomy. The average operating time was 180 minutes (range, 146-257 minutes) ; the average blood loss was 216 mL (range, 100-350 mL) ; and the average hospital stay was 24 days (range, 21-28 days). The postoperative course was uneventful, and none of them suffered recurrent disease. In our experience, surgical management for postoperative intractable pancreatic fistula is safe and effective without any complications or recurrence.

View full abstract

We report an unusual case with a large anaplastic carcinoma of the pancreas (spindle cell type). An 85-year-old female developed abdominal discomfort and appetite loss. On admission, a leukocytosis (16,800/μl) and an elevated sercum CRP of 12.7 mg/dl were found. On ultrasonography (US), a heterogeneous echoic mass which included a cystic portion, 15 cm in diameter, was found in the pancreatic body-tail. On abdominal computed tomography, an enhanced solid mass with on irregular margin and broad hemorrhagic necrosis within was noted. Magnetic resonance imaging scans revealed a slightly high-intensity mass with hemorrhagic change on T1-weighted images and a high-intensity mass on T2-weighted images. On abdominal angiography, a hypovascular mass that invased the splenic artery and vein was found. Over the next month, the tumor grew rapidly so as to exceed 20 cm in size. Based on the clinical and imaging findings, a preoperative diagnosis of pancreatic neoplasm with aggressive potency was made. The differential diagnosis included ; mucinous cystic tumors, solid-pseudopapillary tumor, and other undifferentiated carcinomas. The resected tumor had a sarcomatoid appearance it was a 24-cm, firm mass with hemorrhagic necrosis. On histopathology, spindle cell type anaplastic pancreatic carcinoma was diagnosed. Multiple hepatic metastases and peritonitis carcinomatosa developed in the early postoperative period, and the patient died only two months after surgery. This is the first report in the literature of a large spindle cell carcinoma of the pancreas that exceeded 20 cm. Our patient's lesion was aggressive, and the patient succumbed shortly after diagnosis.

View full abstract

The patient was a 46-year-old man who underwent pancreaticoduodenectomy for duodenal papillary cancer in May 1992. Postoperative pathological diagnosis was stage l papillary adenocarcinoma. On January 14, 2002, nine years after the operation, the patient presented with a chief complaint of epigastric pain. Gastroscopy revealed an elevated lesion in the posterior wall of body of stomach that was diagnosed as papillary adenocarcinoma on biopsy. In addition, abdominal CT showed a tumor shadow in the residual pancreas as well as invasion into the posterior wall of body of stomach, and the patient was diagnosed with pancreatic cancer that had developed in the residual pancreas. Total resection of the residual stomach and residual pancreas including the pancreaticojejunal anastomotic region was performed, in addition to splenectomy and partial resection of the transverse colon. Histopathological diagnosis was papillary adenocarcinoma that was extremely similar in morphology to the previous tumor. We report a rare case of resection of residual pancreatic cancer that developed in the residual pancreas nine years after pancreaticoduodenectomy for duodenal papillary cancer and exhibited histological similarities to the initial tumor with an interesting description of differentiation from metastatic recurrence.

View full abstract