Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association)
Online ISSN : 1882-5133
Print ISSN : 1345-2843
ISSN-L : 1345-2843
Volume 69, Issue 2
Displaying 1-44 of 44 articles from this issue
ORIGINAL ARTICLE
  • Kazunori NAKAGUCHI, Katsuyuki NAKANISHI, Shoichiro FUJITA, Yasunori WA ...
    2008 Volume 69 Issue 2 Pages 281-286
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    The aim of this study was a presentation of whole–body MRI (WB–MRI) technique with diffusion–weighted imaging (DWI) as a screening tool for bone metastases in patients with breast cancer. Seventy–one patients with breast carcinoma underwent both bone scintigraphy (BS) and WB–MRI at 1.5T. The maximal longitudinal field of view was 200 cm. The total spine was imaged in the sagittal plane with a three–station approach for two image sets (fast spin–echo T1–weighted images and short tau inversion recovery images), accompanied by coronal images were acquired with a seven–station approach for two image sets (fast field echo T1–weighted images and short tau inversion recovery images). DWI was then acquired using background body suppression with b–value 600 sec/mm2. Metastatic lesions were confirmed by follow–up examination over 10 months. WB–MRI was superior to BS in predicting lesion origin with a specificity of 98.5% (scintigraphy 84.7%) and an efficiency of 98.6% (scintigraphy 85.9%). In 6 bone metastases cases, WB–MRI identified 22 lesions, while BS identified 17 lesions. WB–MRI with DWI may be an effective method of total body screening for bone in the patients with breast carcinoma.
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  • Kenji HIGAKI, Shoichiro OHTANI, Ryuuji KIN, Kyoko MASUMURA, Teppei OHN ...
    2008 Volume 69 Issue 2 Pages 287-292
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    From January 2001 to June 2006, surgical procedures were conducted on 115 cases (87 cases of positive lymph node metastasis cases) belonging to stage II to stage III, excluding T4d who had underwent primary systemic chemotherapy supplemented with FEC following mainly weekly paclitaxel. The number of cases with the primary focus showing a histologic effect of Grade 3 was 24 (20.9%) out of 115 cases. On the other hand, the number of cases whose lymph node metastases became histologically negative was 47 (54.0%) out of 87 cases of positive lymph node metastases. As the above result indicates that primary systemic chemotherapy can be expected to produce effect also on metastatic lymph nodes greater than that on the primary focus, it is considered that metastatic lymph nodes can also be a new target of primary systemic chemotherapy.
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  • Kenichi HASHIZUME, Satoru SUZUKI
    2008 Volume 69 Issue 2 Pages 293-297
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report clinical study of the Regent prosthesis (St. Jude Medical, St. Paul, MN, USA) for aortic stenosis using Doppler echocardiography. Methods : From December 2004 to May 2006, six patients (mean age, 60.2±7.3 years) underwent aortic valve replacement with a 19–mm or 21–mm Regent prosthesis for aortic stenosis. The results of pre–and post–operative echocardiography were evaluated. Echocardiography was performed to measure the mean left ventricle–aorta pressure gradient, left ventricular mass index, left ventricular diastolic diameter, % fractional shortening and effective orifice area index before the operation, at discharge and 2, 6 and 12 months after surgery. Results : There were no hospital deaths or complications. Left ventricular mass index and left ventricular diastolic diameter decreased remarkably during the postoperative period (p<0.001). The postoperative left ventricle–aorta pressure gradient remained low, and the effective orifice area index was greater than 0.85 cm2/m2 or 12 months after surgery. Conclusions : In patients with the Regent prosthesis for aortic stenosis, postoperative left ventricular mass index and left ventricular diastolic diameter decreased remarkably and good hemodynamics was maintained during 12 months after operation without patient–prosthesis mismatch.
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CLINICAL STUDIES
  • Masashi KUROBE, Kazuhiko YOSHIDA, Takao OHKI, Katsuhiko YANAGA
    2008 Volume 69 Issue 2 Pages 298-301
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    Percutaneous endoscopic gastrostomy (PEG) is frequently used in patients with hypopharyngeal cancer to establish enteral access for feeding. In this report we describe a 59–year–old man with advanced squamous cell carcinoma (SCC) of the hypopharynx who had undergone placement of a PEG button by "pull" technique for dysphagia. Three months later, the patient developed metastatic SCC at the PEG site.
    Cancer metastasis to the PEG site is a very rare but serious complication after this procedure. Fifty–five cases of PEG site metastasis in patients with head and neck cancer have been reported in the English literature, and only two cases in the Japanese literature. Most of the patients underwent PEG placement by means of the "pull" technique. The direct seeding through instrumentation might be the most likely cause. To prevent this rare complication, other techniques such as open gastrostomy need to be considered, and long–term close follow–up after PEG placement is recommended.
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  • Satsuki UEDA, Yasuhiro TAMAKI, Masatsugu OKISHIRO, Toshihiro OKABE, Sh ...
    2008 Volume 69 Issue 2 Pages 302-307
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We report two cases of primary angiosarcoma of the breast, involving a 28–year–old woman with a tumor 7 cm in diameter in the right breast and a 44–year–old woman with a 2–cm mass in the left breast 14 months after mastectomy for a large angiosarcoma in the right breast. MRI scan showed repid and prolonged enhancement in the dynamic study in both cases. According to a review of 47 patients with the disease including ours reported between 1932 and 2007 in Japan, the mean age and mean tumor diameter were 39 years and 8.3 cm respectively. Mastectomy was performed for 42 patients (89.4%), while no axillary lymph node metastasis was reported. Thirty patients (63.8%) involved distant metastases in the mean follow–up time of 24.2 months, and 20 (42.6%) of then died. Kaplan–Meier analysis showed significantly better prognosis in patients with a tumor 2 cm or smaller in diameter than those larger than 2 cm.
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  • Takanobu SATO, Hidefumi TSUNOZAKI, Takeo IWAMA
    2008 Volume 69 Issue 2 Pages 308-312
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    The patient was a 42–year–old female performed conservative surgery for left breast cancer, followed by postoperative radiation therapy at a total dose of 56 Gy. About two months after completion of irradiation, cough and fever developed. Lung infiltrates were initially localized in the irradiated area, but later spread to unirradiated areas in both lungs. We clinically diagnosed this case as radiation–induced bronchiolitis obliterans organizing pneumonia (BOOP) by TBLB findings. After initiation of prednisolone regimen the clinical symptoms and infiltrates seen in the radiograph disappeared. In the course of tapering the prednisolone dose, new infiltrative shadows developed in the unirradiated areas in both lungs. The increased dose of predonisolone resulted in a rapid improvement of the clinical symptoms and chest radiograph abnormalities. Following several bouts of recurrences of BOOP which had been successfully managed by prednisolone regimen, the patient has been free from recurrence, as of one year after withdrawal of prednisolone.
    It is important to be aware of this type of pulmonary complication in patients given breast radiation after conserving surgery for breast cancer.
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  • Naohiro SHIMAKAGE, Mayuko YOSHIZAWA, Kenzo TAJIMA
    2008 Volume 69 Issue 2 Pages 313-318
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We report a case of invasive micropapillary carcinoma (IMP) of the breast which was diagnosed as breast cancer by performing Mammotome® biopsy for left axillary lymph node metastasis. The patient was a 62–year–old woman who visited the department of internal medicine in our hospital because of abnormal findings at a medical checkup for lung cancer in June 2005. A chest plain CT scan showed swelling of left axillary lymph node, and then she was referred to the surgical department for close exploration of breast cancer in July of the year. Mammography (MMG) revealed clustered circular microcalcifications of category 3 in the left AC area, but no tumor was demonstrated by ultrasonography of the breast. Hence we decided to follow her clinical course thereafter. MMG performed in February 2006 showed unchanged calcifications. Herical CT scan done on the same day showed scattered dotty images in the AC area of the left breast and swollen left axillary lymph node, but no tumor was identified. The lymph node swelling became prominent and metastasis was suggested, so that Mammotome® biopsy was performed for the calcifications in the left AC area to search the primary lesion in May 2006. Papillary tubular adenocarcinoma was thus diagnosed. Following modified radical mastectomy, the histopathological diagnosis of the resected material was IMP.
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  • Keitaro HASUDA, Shoichi HASUDA
    2008 Volume 69 Issue 2 Pages 319-322
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    Primary carcinoid of the breast is very rare. Only 50 cases of primary carcinoid tumor of the breast have been reported in the Japanese literature. We report a case of this disease with a review of the literature.
    A 60–year–old woman had a palpable tumor of 1.8cm in diameter in the AE region of the left breast. Ultrasound examination showed an irregular shaped low echoic tumor. Core needle biopsy demonstrated ductal carcinoma, and so the patient underwent partial mastectomy with ipsilateral axillary lymph node dissection. Hematoxylin and eosin (HE) stains showed a carcinoid–like appearance. The tumor was positive in both chromogranin A and synaptophysin stains. No lymph node metastasis was seen. The cells of the tumor were found to be positive for both estrogen and progesterone receptors. Based on the above findings, the tumor was diagnosed as primary carcinoid tumor of the breast.
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  • Saori MURAMATSU, Shoichiro KOIKE, Koh NAKAZAWA, Tadahiro SHIMIZU, Fumi ...
    2008 Volume 69 Issue 2 Pages 323-327
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report a case of invasive micropapillary carcinoma (IMPC), mucinous IMPC and mucinous carcinoma of the breast. A 67–year–old woman was seen at the hospital for a nodule on her right breast. The tumor was 15 mm in diameter and palpable in C area of the right breast. A fine needle aspiration biopsy cytology offered the most likely diagnosis of malignant tumor. We carried out a mammotome biopsy and diagnosed to be IMPC and mucinous carcinoma. A modified radical mastectomy with lymphadenectomy was performed. The pathological diagnosis after the operation was IMPC, mucinous IMPC and mucinous carcinoma, 10 × 12 mm. Following 4 courses of EC therapy and weekly TXL, the patient has been well without recurrence under treatment with anti–estrogen.
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  • Sumitaka YAMANAKA, Hiromasa ARAI, Yasushi RINO, Munetaka MASUDA
    2008 Volume 69 Issue 2 Pages 328-331
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    A rare case of thymus hyperplasia with myotonic dystrophy was reported. A 22–year–old man with myotonic dystrophy underwent close examination by his physician, and an anterior mediastinal mass was incidentally discovered by computed tomography. He had the surgery, and histopathological examination proved the tumor was thymus hyperplasia. After surgery, he suffered from postoperative pain and could not properly expectorate sputum due to muscular depression. However, the respiratory status was maintained without the assistance of a respirator.
    Afterward he gradually recovered, and was able to leave the hospital at postoperative day 12. No critical complication developed in this case, but various case reports indicated difficulty with respiratory management in the perioperative period. We consider that a sufficient explanation for the patient and preparedness against various complications were important in the operation of patients with myotonic dystrophy.
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  • Kenji NEZU, Hiroshi TAKAHASHI, Kinya MATSUOKA, Teiri SAGAWA, Ken SAKAI
    2008 Volume 69 Issue 2 Pages 332-336
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 22–year–old woman with lower abdominal pain consulted our emergency hospital for intra–abdominal bleeding after being referred from a local hospital. Abdominal enhanced CT showed a left ovarian cyst, extravasation from an adjacent blood vessel, and intra–abdominal bleeding. She developed anemia and dyspnea following admission. Chest X–ray and CT showed severe left hemothorax and she was identified as having sanguineous pleural fluid by the insertion of a thoracic catheter. She underwent laparoscopic surgery, and the bleeding point was identified as the rupture of an ovarian cyst. Total fluid passage through the thoracic catheter was 650 ml, and intra–operative abdominal bleeding was 500 ml. The properties of both were the same. We noted the leakage of contrast media through a diaphragm fossula, from the thoracic cavity to the abdominal cavity. We thought that intra–abdominal bleeding into the thoracic cavity occurred through the diaphragm fossula, leading to the rise in intra–abdominal pressure by intra–abdominal bleeding and negative pressure in the thoracic cavity due to respiratory movement. Only 2 case reports of the kind were found in Japan, including the present case. We present this case together with a review of the literature.
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  • Toshio NISHIKAWA, Fumiyuki INOUE, Yasunori ISHII, Masahiko TAKAHASHI, ...
    2008 Volume 69 Issue 2 Pages 337-340
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 76–year–old woman underwent an operation for ascending colon cancer on May, 2006 and adjuvant chemotherapy after that. She consulted our clinic for an abnormal shadow on chest CT at the end of April, 2007. The chest CT revealed multiple masses measuring 12×10 mm at maximum in the bilateral lung field. Some masses were solid and the other had cavitations. The cavitations were only about 3 mm thick at maximum. We thought that it was a lung metastasis of colon cancer from the clinical course and performed an operation. We removed some masses which were solid and with cavitations capable of partial resection. A perioperative quick pathological examination showed the moderately differentiated adenocarcinoma in all the resected masses. Since it was thought to be a metastasis of colon cancer, so finished the operation without removing the remaining masses. Although pulmonary metastasis of the malignant tumors including colon cancer with thin cavitations is rare, it is necessary to consider pulmonary metastasis in a case with pulmonary masses with thin cavitations and a history of malignant tumors.
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  • Katsuji SAWAI, Nobuhiko UEDA, Tamotu TOGAWA, Toshihisa KIMURA, Toshiha ...
    2008 Volume 69 Issue 2 Pages 341-346
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We experienced a relatively rare case of simultaneous presence of leiomyosarcoma and squamous cell carcinoma of the esophagus. A male patient in his sixties was referred to our hospital for a close examination of esophageal tomor. Endoscopic study revealed a protruded lesion in the upper intrathoracic esophagus, and a shallow ulcer lesion at the distal side. Biopsy study revealed atypical cells in the protruded lesion, and squamous cell carcinoma in the shallow ulcer lesion. With the diagnosis of multiple cancers of the esophagus, resection of the subtotal esophagus and dissection of lymph nodes of the cervix, thorax and abdomen, and the reconstruction using a gastric roll was performed with a thoracoscopic surgery. The protruded lesion was diagnosed as leiomyosarcoma, and the shallow ulcer lesion was diagnosed as cancer of esophagus in the excised specimen. A metastasis of leiomyosarcoma appeared in the upper lobe of right lung a year after the subtotal esophagectomy and resection of the upper lobe of right lung was performed. The patient has shown no sign of recurrence after the resection of the lung for six mounths. Leiomyosarcoma of esophagus is a rare disease, and a case of simultaneous occurrence of squamous cell carcinoma is very rare, therefore we reported this case here.
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  • Kaname MARUNO, Naoto FUKUDA, Yasuyuki SUGIYAMA, Kunio MIZUGUCHI
    2008 Volume 69 Issue 2 Pages 347-350
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 69–year–old male complained of tarry stool during the treatment of cervical spondylotic myelopathy in another hospital. He was endoscopically diagnosed as having gastric carcinoma (tub1). A type 3 lesion was observed near the lesser curvature in the anterior wall of the upper portion of the gastric body. He underwent total gastrectomy, splenectomy, cholecystectomy and D2 lymph node dissection on December 3rd, 2004. In the resected specimen, a wide elevated lesion was observed near the lesser curvature in the anterior wall of the upper portion of the body and an elevated lesion was located on the wide elevation on the lesser curvature. Histopathologically, the former was a prominent proliferation of nerve fibers in the submucosa and was diagnosed as amputation neuroma. The latter was early gastric carcinoma (tub1, sm1, ly0, v0,n0) with U1II ulcer scar. The cause of the amputation neuroma was considered to be the damage of Meissner′s plexus by the gastric carcinoma with ulcer scar. To our knowledge, this case in the first report of the amputation neuroma developed with gastric carcinoma without any previous operation of the stomach.
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  • Satoshi INADA, Hideki ARAGANE, Tomoko KATANO, Hitoshi YASUI, Keitaro K ...
    2008 Volume 69 Issue 2 Pages 351-354
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A case of skin metastasis from early gastric cancer without other organ metastases is very rare. A 72–year–old man was admitted to the hospital for control of diabetes mellitus. Upper endoscopy showed early ulcerative gastric cancer on the posterior wall of the gastric angle. We performed hand–assisted laparoscopic distal gastrectomy with lymphadenectomy. Pathological findings revealed an early gastric cancer with submucosal invasion and without lymph node metastasis. Four months after the operation, a subcutaneous tumor was palpable near the wound. The tumor was resected, and diagnosed as metastasic adenocarcinoma of gastric cancer.
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  • Norio HASUDA, Kozo KOSHIZUKA, Noboru OYACHI, Kunio TAKANO, Masahiko MA ...
    2008 Volume 69 Issue 2 Pages 355-359
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    The patient was a 39–year–old man who had undergone distal gastrectomy for gastric cancer at the age of 35. When the pathological diagnosis was made as 0–IIc, T1(m), N1, M0, tub2sig, ly0, v0, stageIB. Four years later the serum CA19–9 and ALP levels were elevated, but no metastatic leasions were pointed out by CT and echogram. PET–CT performed with a suspicion of cancer of unknown origin disclosed local uptake at the 2nd thoracic vertebra and ilium, and bone scintigram showed diffuse abnormal uptake (super bone scan). Disseminated carcinomatosis of the bone marrow from gastric cancer was diagnosed. Systemic chemotherapy was started, but the disease progressed to its termination.
    Disseminated carcinomatosis of the bone marrow from gastric cancer do not form a metastatic tumor. When the serum CA19–9 and ALP levels are elevated in gastric cancer patients, bone scintigram should be taken in consideration of a possibility of disseminated carcinomatosis of the bone marrow.
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  • Takehiro SAKAI, Yoshitsugu YAMADA
    2008 Volume 69 Issue 2 Pages 360-364
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 56–year–old woman consulted a physician complaining of abdominal distension, and was diagnosed as having bowel obstruction. Endoscopic and histological examination revealed type 4 gastric cancer. In addition, advanced transverse colon cancer was suspected by colonoscopy. On the 9th hospital day, severe abdominal pain appeared and the patient was diagnosed as having generalized peritonitis due to perforation of the digestive tract. At laparotomy, the patients was diagnosed as having type 4 cancer of the stomach with perforation at the anterior wall of the gastric body and invasion to the transverse colon. Total gastrectomy with transverse colon resection was conducted. Histopathologically, the tumor was poorly differentiated adenocarcinoma with invasion to the transverse colon, and the final staging of the gastric cancer was T4, N1, H0, P1, CY0, M0, Stage IV, and the curability of the operation was B. Although the patient suffered subphrenic abscess and pancreatic fistula after surgery, she recovered. The patient started to take diet on the 36th postoperative day (POD52), and was discharged on POD52 after an adjuvant chemotherapy. Type 4 cancer of the stomach with perforation is rare. Moreover, the reports of primary resection of the stomach including other involved organs are very rare. The patients with type 4 cancer of the stomach with perforation should be treated considering patients general condition, histological confirmation of the carcinoma, curability, prognosis and quality of life.
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  • Nao YOSHIDA, Mitsugu KOCHI, Yoshifumi WATANABE, Susumu MOCHIZUKI, Taka ...
    2008 Volume 69 Issue 2 Pages 365-369
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    An 80–year–old man was admitted to our hospital because of upper abdominal pain. Physical examination revealed mild edema of the extremities and blood biochemical study revealed rerious hypoproteinemia (serum total protein : 4.9g/dl, serum albumin : 1.8g/dl). Gastrofiberscopy showed type 1 gastric cancer on the upper gastric body and type 2 gastric cancer on the pyloric part. Fecal excretion and clearance of alpa–1 antitripsin were high. Preoperative hyperalimentation and administration of an amino acid drug failed to increase serum protein level. He was diagnosed as having protein–loosing gastroenteropathy caused by gastric cancer. He underwent total gastrectomy and D2 lymph node dissection. The type 1 tumor, 10cm in diameter, showed cauliflower like form, and it was diagnosed as moderately differentiated adenocarcinoma with the depth of invasion of sm. The type 2 tumor, 9cm in diameter, was diagnosed as papillary adenocarcinoma and the depth of invasion was se. Postoperative course was uneventful and hypoproteinemia improved remarkably to TP of 6.8g/dl and Alb of 2.9g/dl on the postoperative day 16. If protein–loosing gastroenteropathy caused by malignant tumors are suspected like in this case, early surgery for the primary foci is the securest treatment because preoperative alimentary mangement is often difficult to improve the condition.
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  • Michihisa IIDA, Shigefumi YOSHINO, Tomio UENO, Kazuhiko SAKAMOTO, Masa ...
    2008 Volume 69 Issue 2 Pages 370-374
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 86–year–old man was admitted to our hospital with the complaint of leg edema. Blood examination showed hypoproteinemia (total protein 3.5 g/dl) and hypoalbuminemia (serum albumin 1.6g/dl). Upper gastrointestinal series and endoscopy showed 5 large tumors from the upper corpus to the antrum of the stomach. 99mTc–human serum albumin scintigraphy showed radio–labeled albumin accumulation in the lower third portion of the stomach. Gastric cancer with protein–losing gastroenteropathy was diagnosed, and a total gastrectomy was performed. Specimens of the resected stomach consisted of Borrman 4 type cancer (poorly–differentiated adenocarcinoma) and Borrman 1 type cancer (pappilotubular carcinoma). Histopathological findings showed that the final stage was stage IV with se, n2, H0, P0, CY1, and gastrectomy resulted in curability C. The hypoproteinemia improved soon after the operation, but the patient died of carcinomatous peritonitis 12 months after operation. We reported the case of a protein–losing gastric cancer with a review of the literature.
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  • Tomonari ASANO, Mitsuhiko KUSAKABE, Hiromi TANEMURA, Hiroo OSHITA, Tsu ...
    2008 Volume 69 Issue 2 Pages 375-379
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We report a case of small cell carcinoma (endocrine cell carcinoma) of the ampulla of Vater. A 54–year–old man was admitted to our hospital due to obstructive jaundice and loss of appetite. Endoscopic study identified a protruded tumor at the ampulla of the Vater. Histological examination showed round shaped atypical cells and positive staining for CD–56 and NSE immunohistochemically. From these fidings, this tumor was preoperatively diagnosed as small cell carcinoma of the ampulla of Vater. We performed subtotal stomach preserving pancreaticodeuodenectomy with regional lymph nodes dissection. Thereafter, 4 cycles of adjuvant chemotherapy with CBDCA and CPT–11 were also given. Nevertheless, the celiac lymph node metastasis was detected within half a year postoperatively. We conducted radiation with simultaneous chemotherapy with CDDP and VP–16. Responding to those therapies, matastatic lymph nodes were markedly decreased in size. However, the patient died of multiple organ failure following multiple bone metastases 247 days after the operation. Although only 35 cases of small cell carcinoma of the ampulla of Vater have been reported in Japan, prognoses of these cases are very poor. It is important to explore more effective multidisciplinary treatments in order to improve the prognosis of patient with extrapulmonary small cell carcinoma.
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  • Masako URATA, Seiji YUNOTANI, Ryuichiro SAMEJIMA, Masashi SAKAI, Toshi ...
    2008 Volume 69 Issue 2 Pages 380-384
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We have experienced two cases of minute arteriovenous malformation (AVM) of the small intestine. Case 1 involved a 77–year–old woman suffering from intermittent intestinal bleeding, and case 2 involved a 90–year–old woman with a 3–day history of melena. In both cases, diagnosis by preoperative angiography was unsuccessful because of the size of the AVM lesions and the small amount of bleeding flow, though blood pool scintigraphy could show hot spots. Intraoperative endoscopy was useful to find the bleeding point of such minute AVM lesions as we could hardly detect without histopathological examination.
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  • Jo UNOTORO, Naohito TAKITA, Yoshimasa SUZUKI, Tetsuzo SHIOZAKI, Shuji ...
    2008 Volume 69 Issue 2 Pages 385-389
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    Ischemic enteritis of the small intestine is rather rare and often affectes aged patients with underlying diseases including hypertension, cerebrovascular disease, ischemic heart disease, and diabetes mellitus.
    A 32–year–old man visited a hospital because of abdominal distention. He had had occasional bouts of the symptom for 10 years. He had received conservative treatment for a suspected bowel obstruction in another hospital one year before visiting our hospital. Plain abdominal X–ray showed niveau sign in the small intestine. Abdominal CT scan showed a mass like lesion in the left lower abdominal quadrant which was continuous to the dilated small intestine. A contrast medium test of the small intestine showed a stenotic portion 4 cm in length which completely encircled the lumen and was located at about 200 cm anal side from the Treitz′s ligament. We diagnosed it as a tumor of the small intestine, and carried out partial resection of the small intestine which included four stenotic sites. Histopathological study revealed thinness of the mucosa and fibromuscular expansion of the submucosa which was associated with ischemic enteritis.
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  • Masayuki NAKAU, Tadashi MIYASHITA, Masato MAEDA
    2008 Volume 69 Issue 2 Pages 390-394
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 65–year–old female patient was admitted to investigate the cause of repeated melena. The patient had café au lait spots and dermal nodules over the whole body and was diagnosed as von Recklinghausen′s disease. CT study revealed multiple tumors and a mesenteric angiogram revealed multiple enhanced stainings along the superior mesenteric artery area coinciding with spread of the tumors. A gastrographine study of the small bowel revealed multiple diverticulae. Laparotomy was performed with suspicion of the source of bleeding either from the diverticulae or small bowel tumors. Confluence of extramural tumors of different sizes were observed along the jejunum and ileum. Resection of the segment of small intestine with confluence of the tumors was performed and sporadically spread tumors were also removed as much as possible. Immunopathological study of the tumor was positive in KIT and CD34 and was diagnosed as multiple intestinal GIST. The diverticulae were continuous with the tumor and was thought to be the cause of bleeding.
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  • Kizuku IMANISHI, Katsuhiro SANO, Nozomi UENO, Sigetoshi ICHII
    2008 Volume 69 Issue 2 Pages 395-398
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    The case is a 70–year–old woman. In October 1992, she was diagnosed as having metastatic cancer of the liver and paraaortic lymph nodes, but the primary site was uncertain. In January 1993, she was admitted to our hospital with the diagnosis of perforative peritonitis. We performed on emergency surgery. Because of thickening and stiffening of the wall with adhesion of pus in the distal ileum, we performed ileocecal resection. The pathologic diagnosis after the operation was diffusely infiltrating primary ileal cancer. The cancer of the small intestine growing diffusely in the longitudinal direction along the intestinal canal wall is extremely rare.
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  • Takanori HIRAIDE, Fumihiko YONEYAMA, Hideto OCHIAI, Hideo NAKAZAWA, Ei ...
    2008 Volume 69 Issue 2 Pages 399-404
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We report eight cases of perforation of the digestive tract by a fish bone treated at the hospital from December 2000 to September 2006. The male–to–female ratio was 7:1, with an age range from 59 to 89. The affected sites included the ileum in four, transverse colon in two, and sigmoid colon in one. Operation was performed in all cases. In five cases, perforating points were detected with operation, however, we could not find them in three cases of chronic inflammation type. All patients were completely cured following extraction of fish bones.
    All fish bones were able to be detected by MDCT. Before the introduction of MDCT, fish bones as well as calcification were detected in only two out of five cases.
    It is not hard for us to diagnose perforation of the digestive tract by a fish bone based on clinical history and the use of MDCT. However, fish bone remnant which is left in the body can require another operation. Thus it must be taken into consideration as a differential diagnosis for acute abdomen.
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  • Yoshihiro KITAYAMA, Yousuke YODEN, Nobuhiro OKAMOTO
    2008 Volume 69 Issue 2 Pages 405-408
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 43–year–old man who had been treated for cerebral paralysis was seen by his family physician for appetite loss and abdominal distension. He was treated unsuccessfully with medication, and was admitted for the treatment of paralytic ileus. Plain abdominal X–ray imaging showed a huge amount of intestinal gas distending the entire abdomen. Conservative treatment involving bed confinement and observation also was unsuccessful, and volvulus of the right colon indicated by colonoscope necessitated laparotomy. The ileocecal region was found to be twisted clockwise and the cecum was necrotic, necessitating ileocecal resection. The post operative course was uneventful, he began eating on postoperative day (POD) 10, and was discharged on POD 25.
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  • Hiroyoshi SENDO, Sachiyo SHIRAKAWA, Tohru NISHIMURA, Kunihiko KANEDA, ...
    2008 Volume 69 Issue 2 Pages 409-413
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    The patient was a 65–year–old man who had had recurrent bouts of polyuria, turbid urine and dysuria, despite treatments with medication under the diagnosis of acute prostatitis at the department of urology in our hospital for these several years. In March 2007 he visited the urological department because of the same symptoms. Urine culture yielded Escherichia coli, and the patient was diagnosed as having vesicosigmoidal fistula due to sigmoid colon diverticulitis by colonoscopy and abdominal CT scan, and then he was referred to our department of surgery. Contrast enema study revealed ileosigmoidovesical fistula. Resection of the sigmoid colon, part of the ileum and the rectum were perfomed along with colostomy in May of the year. Ileosigmoidovesical fistula due to sigmoid colon diverticulitis is very rare.
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  • Tomomi YAKABE, Atsushi MIYOSHI, Yuji NAKAFUSA, Yoshihiko KITAJIMA, Sei ...
    2008 Volume 69 Issue 2 Pages 414-417
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 76–year–old man had been aware of periproctal itching since he was 70years old. He had been using a commercial ointment for the itching.
    He suffered from lung and gastric cancer at the age of 73 and 74, respectively. He underwent right superior lobectomy for the lung cancer and distal gastrectomy for the gastric cancer. Thereafter, itching and eczema became worse, and he was referred to our hospital. The biopsy of the periproctal eczema revealed that the lesion was Paget′s disease. According to the mapping biopsy, paget cell was detected at 1cm oral side from dentate line.
    Abdominoperineal resection was performed. Extramammary anal Paget′s disease is often treated as intractable eczema. It is often associated with gastrointestinal cancer and other organ malignancy. The patient with intractable periproctal eczema should not be left out but further examination including the biopsy of the skin should be done.
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  • Yuji YASUI, Tomoichirou MUKAI
    2008 Volume 69 Issue 2 Pages 418-421
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    Adenosquamous cell carcinoma of the digestive organs is a comparatively rare entity. This paper deals with a case of adenosquamous cell carcinoma of the rectum presented with symptoms of pelvic peritonitis. The patient was a 44–year–old woman, who was referred to the department of gynecology in our hospital with a suspicion of endometriosis by a gynecological hospital at where she had been treated for lower abdominal pain on an ambulant basis. Some inflammatory disease was suggested by magnetic resonance imaging and CT scans, but a possibility of gastrointestinal disorder could not be ruled out. Barium enema study, endoscopic study and biopsy were carried out, and squamous cell carcinoma of the rectum was resultantly diagnosed. No distant metastases were demonstrated. Low anterior resection of the rectum was performed. The histopathological diagnosis was adenosquamous cell carcinoma. Despite postoperative chemotherapy and irradiation, the patient died on the 346th day after the operation.
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  • Hiroshi MATSUSHITA, Naoki ASAKAGE, Tetsurou YAMAMOTO, Takahisa SUZUKI, ...
    2008 Volume 69 Issue 2 Pages 422-426
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    An asymptomatic 51–year–old woman visited our hospital because of a polypoid lesion in the gallbladder pointed out by a physician. Except for a slight increase in γ–GTP, no abnormal findings including tumor markers were noted. Ultrasonography of the abdomen revealed a 16 × 18 mm broad–based polypoid lesion, accompanied by irregular structure of the wall partially. Abdominal CT scan showed a mass in the gallbladder as well. Because a possibility of a malignant tumor could not be ruled out completely, laparoscopic cholecystectomy was performed. In a histopathological examination, gland ducts made of cryptic cuticles, stomach fundus glands, and pyloric glands were identified in almost all layers. Thus heterotopic gastric mucosa in the gallbladder was diagnosed. Heterotopic gastric mucosa in the gallbladder is so rare that only 38 cases, including ours, have been reported in the Japanese literature. We present this case with some bibliographical comments, because it would have to be kept in mind as a differential diagnosis for a mass lesion in the gallbladder.
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  • Kenjiro HIRAI, Tsuyoshi TERASHIMA, Shinichi HOSOKAWA, Kazuo ONO, Eiji ...
    2008 Volume 69 Issue 2 Pages 427-432
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    We report a case of port site recurrence of gallbladder carcinoma in situ initially diagnosed as severe dysplasia after laparoscopic cholecystectomy (LC). A 70–year–old woman underwent LC because of cholelithiasis. The pathological diagnosis of the resected gallbladder was severe dysplasia. Twenty months after LC, a tumor developed in her abdominal wall near the umbilical port. Histological examination revealed the tumor was poorly differentiated adenocarcinoma. Pathological diagnosis as well as operative findings strongly suggested port site recurrence of gallbladder carcinoma. The mechanism of port site recurrence is considered as direct implantation of cancer cells when the specimen was taken out. The number of early stage gallbladder carcinoma diagnosed after LC is recently increasing as LC has widespread acceptance. Even when there is little likelihood of malignancy in preoperative examinations, possibility of unexpected cancer must be kept in mind and careful procedure should be employed.
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  • Yasuyuki KOSHIZUKA, Hirofumi KAMACHI, Toru TAKAHASHI, Munenori TAHARA, ...
    2008 Volume 69 Issue 2 Pages 433-437
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    The patient was an 88–year–old man undergone laparoscopic cholecystectomy with a diagnosis of polyp of the gallbladder at another hospital. Despite the definite diagnosis of gallbladder carcinoma made after the operation, he had been followed without undergoing additional resection. Abdominal CT scan performed 4 years 8 months after the operation disclosed a 4 × 5cm tumor on the right side of the navel. The patient had been followed until 5 years one month had elapsed after the operation, when he was first seen at our hospital for second opinion. Abdominal CT scan disclosed an enlargement of the tumor to 8 × 8cm in size and the cytodiagnosis was adenocarcinoma. Thus portal recurrence of gallbladder carcinoma was suggested. Since the lesion was localized, surgery was employed. The greater omentum, peritoneum, rectus abdominis muscle, and skin as well as the tumor were resected, and the abdominal wall was reconstructed by using composition mesh. Histopathological study identified recurrence of gallbladder carcinoma. The patient has been free from recurrence, as of one year 11 months after the second operation.
    Portal recurrence of gallbladder carcinoma generally carries poor prognosis, but the resection can bring about favorable prognosis if more than one year have elapsed after the initial operation and if the recurred lesion is localized.
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  • Ryo TSUNASHIMA, Masayuki TORI, Hiroki AKAMATSU, Shin MIZUTANI, Masahik ...
    2008 Volume 69 Issue 2 Pages 438-442
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report a case of a ruptured aneurysm of the pancreaticoduodenal artery with celiac axis compression syndrome (CACS).
    An 83–year–old woman was admitted to our hospital because of the sudden onset of hematemesis. Abdominal CT scan demonstrated an aneurysm in hematoma in the pancreas head. Angiography revealed an aneurysm of the inferior pancreaticoduodenal artery and obstruction of the celiac artery. Transcatheter embolization was unsuccessful because of arteriosclerosis, therefore operative procedure was proceeded. In the operation, as extrinsic compression to the celiac artery by the median arcuate ligament was revealed, decompression was made by releasing it. Furthermore, after confirming common hepatic arterial blood flow was enough and hepatopetal with electromagnetic flowmetry, we safely performed pylorus–preserving pancreaticoduodenectomy. The patient′s postoperative course was uneventful. In the treatment of ruptured pancreaticoduodenal aneurysms with celiac axis occlusion, we should bear in mind that intraoperative careful monitoring of hepatic arterial blood flow is necessary considering the possible involvement of CACS.
    Key words : celiac axis compression syndrome (CACS), Ruptured aneurysm of pancreaticoduodenal artery, Pylorus preserving pancreaticoduodenectomy (PpPD)
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  • Kaoru TAKESHIMA, Kazuo YAMAFUJI, Hideo BABA, Nobuhiko OKAMOTO, Hutoshi ...
    2008 Volume 69 Issue 2 Pages 443-447
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report a case of adenosquamous carcinoma of the pancreas discovered by examination of serum CEA. A 84–year–old man, who had been treated for hypertension by a cardiologist of our hospital, complained very slight left lower abdominal pain. He had a fecal occult blood test and a check of serum level of CEA. Elevated serum level of CEA led further examination and the patient was diagnosed to have a tumor in the body of the pancreas. A laparotomy was performed and pathological findings showed that the tumor was characterized by the coexistence of adenocarcinoma and squamous cell carcinoma. For the chief complaint such as in our case, a primary examination would often be confined to lower bowel and a negative fecal blood test could possibly have resulted in delay of the diagnosis of pancreas cancer. Our case suggests that we failed to diagnose cancer of pancreas due to a primary attension to the lower abdominal pain. This suggests the need of more careful examination of other organs and treatment in patients with lower abdominal pain.
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  • Kazuhiro SUZUMURA, Shinichi SAITO, Nobukazu KURODA, Yasukane ASANO, Ji ...
    2008 Volume 69 Issue 2 Pages 448-451
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 69–year–old man found to have a tumor of the pancreatic head elsewhere was admitted to our hospital for close exploration and treatment. Abdominal CT scan showed a heterogeneously enhanced mass about 1.5cm in diameter in the pancreatic head, as well as dilatation of the pancreatic duct and calcification of the aortic wall. Three dimensional CT (3D–CT) scan showed occlusion of the proximal celiac axis and common main stem of celiac artery (CA) and superior mesenteric artery (SMA). Further the inferior mesenteric artery (IMA), marginal artery of the colon and middle colic artery developed well. We thought that blood might be supplied from the IMA to CA and SMA. We performed pylorus–preserving pancreatoduodenectomy while being careful not to injure the colic artery.
    It is important to grasp the hemodynamics before pancreatoduodenectomy, for that 3D–CT scan appears to be useful.
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  • Akiko OKAJIMA, Hiroshi KOHNO, Atsushi KIMURA, Kyouji TSUGANE, Yasushi ...
    2008 Volume 69 Issue 2 Pages 452-456
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report a case of a 70–year–old female who had suffered a metastatic recurrence 21 years after an operation for a granulosa cell tumor. She was admitted to our hospital because of abdominal pain. Abdominal CT scan revealed four solid tumors, one of which was located close to the esophago–gastric junction and diagnosed as gastric submucosal tumor with gastrointestinal endoscopy. These tumors were completely excised and diagnosed histologically as recurred granulosa cell tumor, because they showed the same histological features as those of the resected specimen of an ovarian tumor at another hospital 21 years before admission and immunohistological findings specific for granulosa cell tumor were positive. No recurrence has seen up to now.
    The recurrence of granulosa cell tumor after a long course following the first operation is not rare. In the case of a patient with a gastric submucosal tumor or abdominal tumors who has a past history of operation for an ovarian tumor, the metastatic recurrence must be kept in mind.
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  • Yukinobu INOUE, Masatoshi TAKAHASHI, Takayuki HANAMOTO, Masao SUNAHARA
    2008 Volume 69 Issue 2 Pages 457-460
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 48–year–old woman, who had noticed a tumor at the navel in 2004 which had gradually become large with occasional mild pain as well as several episodes of pus discharge, was seen at the hospital in October 2006. A 2cm–sized hard tumor was palpated right under the umbilicus. Abdominal ultrasonograpy, CT scan, and MRI scan revealed a 3 x 2cm solid tumor right under the umbilicus, but it was difficult to make the definite diagnosis preoperatively. The diagnosis of heterotopic endometriosis was made based on histopathological findings.
    Although endometriosis arisen in the skin or subcutaneous structure of the umbilicus is relatively uncommon, the disease must be kept in mind as a differential diagnosis for an umbilical tumor in female patients.
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  • Byonggu AN, Yoshinari MOCHIZUKI, Yasuhiro SHIMIZU, Seiji ITO, Yasushi ...
    2008 Volume 69 Issue 2 Pages 461-465
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report a rare case of multiple intra–abdominal desmoid tumors originating from mesentery of the ascending colon and greater omentum. A 54–year–old man was admitted to our hospital for further examination of an abdominal tumor. He had no history of abdominal surgery, injury and familial adenomatous polyposis (FAP). The abdominal CT revealed a lightly enhanced mass (25×45mm in diameter) located in the colonic mesentery and invading the duodenum. Suspecting a GIST of the duodenum, we conducted laparotomy, which demonstrated the tumor originating from the colonic mesentery, involving the ileocolic artery, vein, and thrid portion of the duodenum. Moreover, two small nodules were also found at the greater omentum. We confirmed small nodules were peritoneal seedings from the main tumor at operation, and were able to remove the tumors completely by right hemi–colectomy with wedge resection of the duodenum. Histopathological examination revealed desmoid tumors with minimal nuclear pleomorphism and minimal mitotic activity. Thus, the tumors were finally diagnosed as multiple intra–abdominal desmoid tumors originating from mesentery of the ascending colon and greater omentum. The patient has shown no sign of recurrence in the 22 months follow–up since surgery.
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  • Tadahiro ISONO, Toshihiko KOBAYAHI, Hidetoshi WADA, Yukiko KONISHI, Yu ...
    2008 Volume 69 Issue 2 Pages 466-470
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    A 44–year–old male patient went through a physical check–up and was pointed out to have a mass with calcification near the lesser curvature of stomach. CT and MRI study revealed a well circumscribed mass, like spleen, of 3cm in diameter with calcification inside. With a suspected diagnosis of Castleman disease in the lesser omentum, based on the image studies, excision of the tumor was performed under laparoscopic surgery. The excised specimen was a solid mass with yellow–whitish cut surface and the pathological diagnosis was hyaline vascular type Castleman disease.
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  • Yamato KIKUCHI, Hideo NAKAZAWA, Fumihiko YONEYAMA, Eiji HAYASHI, Tetsu ...
    2008 Volume 69 Issue 2 Pages 471-474
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report a case of a laparoscopic resection of urachal remnant with omphalitis and cholelcystectomy for cholelithiasis that was found at the same time after the inflammtion subsided. A 78–year–old man was admitted to the hospital because of discharge from the umbilicus. Abdominal CT scan revealed high density area extending from the umbilicus to the top of the bladder. The most likely diagnosis was abscess of urachal remnant. Laparoscopic operation for urachal remnant and cholelithiasis was performed successfully after the local inflammation subsided. One more port was added after the cholecystectomy. The umbilical urachal fistula was divided from the bladder and removed through the subumbilical wound. The patient was discharged from the hospital on the postoperative day 4 without postoperative complications. This is the first case of laparoscopic resection of urachal remnant and simultaneous cholelecysteclomy performed in Japan. It is important to choose the place of ports according to the procedure planned.
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  • Masanori ODAIRA, Yoshinori SHIMIZU, Daisuke YASUDA, Jyunichi TAKA, Tak ...
    2008 Volume 69 Issue 2 Pages 475-479
    Published: 2008
    Released on J-STAGE: August 05, 2008
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    A 84–year–old woman was admitted to our hospital complaining of abdominal pain and abrupt nausea. The patient was immediately diagnosed as having ileus after receiving an abdominal X–ray examination. Pelvic CT scan revealed incarcerated small intestine between the pectineus muscle and external obturator muscles on both side. Diagnosis of incarcerated bilateral hernias was made, but the symptoms disappeared after the CT scan examination. Pelvic CT scan was performed again and it demonstrated no incarceration of small intestine. This finding confirmed that incarcerated obturator hernias had been reduced spontaneously. Thereafter, an elective laparotomy to repair the hernia using a mesh was carried out. A polypropylene mesh was attached to the peritoneum covering the obturator foramen, and the peritoneum was closed. The postoperative course was uneventful, and the patient was discharged from our hospital 10 days after the operation.
    Only 19 cases of synchronous bilateral obturator hernias, including the present case have been reported in Japan, and no case of spontaneously reduced synchronous bilateral obturator hernias has been reported.
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  • Takaaki ITO, Kiyoshi HIRAMATSU, Yuichi MACHIKI, Tadayuki SAKURAGAWA, T ...
    2008 Volume 69 Issue 2 Pages 480-483
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    We report an emergently operated case of linea alba hernia with impaction of the small intestine. An 80–year–old woman was seen at the emergency clinic in our hospital because of upper abdominal pain. She had been diagnosed as having an abdominal hernia three years earlier. She had an eggsized palpable mass lesion with severe tenderness in the upper abdomen. Enhanced CT scan revealed the herniation through the rectal muscle in the upper abdominal wall at where the small intestine was impacted. The manual reduction of the impacted small intestine was difficult. We diagnosed the case as linea alba hernia with impaction of the small intestine and performed an emergency operation. During surgery, the hernia opening 2cm in diameter was identified on the linea alba ; the hernia sac was dissected when the impacted intestine showed only congestion and involved no necrotic areas. We employed the tension free repair method without resecting the hernia sac and impacted small intestine. She has been free from symptoms of recurrence of the hernia with good quality of life.
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  • Naoto NISHIGORI, Satoru AKASHI, Takeshi MATSUYAMA, Masami IMANISHI, Ak ...
    2008 Volume 69 Issue 2 Pages 484-488
    Published: 2008
    Released on J-STAGE: August 05, 2008
    JOURNAL FREE ACCESS
    A 75–year–old woman, who visited our clinic after being bitten on her right first and second toes by a mamushi in August 2007, was admitted to the hospital to follow her clinical course. With progression of swelling, acute renal failure due to rhabdomyolysis, increases in serious inflammatory findings, and deterioration of respiratory condition developed. Thus the patient was referred to our emergency and critical care medical center. Mamushi bite was suspected based on observation of the course of symptoms, and mamushi antivenin and Cepharanthine were administered, though about one and a half days had elapsed since being bitten. The CPK value that had increased up to 112200 IU/l was promptly normalized after the administration of the antivenin. Acute renal failure, respiratory failure, and impaired hepatic function were confirmed, so that sustained hemodialysis and management with respirator were performed. The urine volume gradually increased from the 3rd week since being bitten, and the patient was freed from hemodialysis on the 4th week.
    The most common cause of deaths due to mamushi bites is acute renal failure that can result from mioglobulinemia due to rhabdomyolysis or renal toxicity carried by mamushi toxin itself. In this paper we present a patient with mamushi bite whose life was successfully saved by intensive cares including hemodialysis and management with artificial respirator in an acute phase.
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