Background : We evaluated revised Hasegawa's dementia scale (HDS-R) in elderly patients who had operations for gastric cancer or colorectal cancer and we assessed its predictive value in occurrence of postoperative delirium. Method : 121 patients underwent HDS-R test before surgery from Jun., 2006 to Dec., 2007. We assessed age, gender, past history, ASA, PNI, PS, preoperative hospital stay and HDS-R score as preoperative factors. And we also assessed location of cancer, operation time, bleeding, approach, difficulty of surgery, ICU admission, WBC, CRP, morbidity, oral intake as surgical factors. Result : 23 patients (19.0%) developed postoperative delirium. In patients whose HDS-R score was 25 or lower, 14 patients (40.0%) developed postoperative delirium. Univariate analysis identified PNI, HDS-R score, CRP, oral intake as significant factors. But multivariate analysis identified only HDS-R score as independent predictor of occurrence of delirium (OR13.514, 95%CI4.878-37.037, p<0.001). Conclusion : We could conclude that elderly patients whose HDS-R scores were 25 or lower had high risk of postoperative delirium.

View full abstract

Purpose
The purpose of this study is to evaluate the effect of primary systemic therapy (PST) on ER, PgR and HER2 expression changes in patients with primary breast cancer.
And also, we examined the correlations between response to chemotherapy and these expression changes.
Patients and Methods
From June 2003 to December 2007, 100 non-pCR breast cancer patients treated with primary systemic therapy (PST group) and 29 non-primary systemic therapy (control group) patients with adequate tissue samples were identified.
ER, PgR, and HER2 expressions were analyzed in core needle biopsies and final surgical specimens.
Changes between the two groups were compared to determine if the alternations were due to the chemotherapy.
Results
The changes of ER did not show significant difference in 7% (7/100) of PST group and in 6.9% (2/29) of the control group.
However, the change of PgR showed a significant difference in 22% (22/100) of PST group and in 3.4% (1/29) of the control group (p=0.025).
About the status of HER2, we did not observe changes in the control group, but 43.5% (10/23) of HER2 positive cases in PST group changed from positive to negative.
Expression of PgR and HER2 significantly changed in pathological response Grade2 cases (P=0.017, P=0.003).
Discussion
Tumor heterogeneity is considered as a possibility of the cause of the changes of PgR and HER2, but because these expressions significantly changed in patients with chemotherapy response Grade2, it is suggested that the expressions of PgR and HER2 may change by PST.

View full abstract

We evaluated the clinical significance of lymphatic and blood vessel invasion (pathological ly and v factor) in 1549 breast cancer cases treated by operation from 1986 to 2005. We classified them from 0 to 3 depending on the extent of vessel invasion. According to this classification, both ly and v factors correlated well with disease-free and overall survival in all cases. Vessel invasion was appropriate as a prognostic factor for breast cancer, and our study suggested that it should be considered as a useful prognostic factor in the intermediate risk group rather than in the low risk group as is presently recommended in the St. Gallen consensus meeting.

View full abstract

In the past 19-years period, we treated 24 cases with perforated gastric carcinoma, and operated 23 cases. The incidence was 1.5% of all the surgical cases of gastric cancer, and 24.0% of all the gastric perforation cases. Twenty patients underwent emergency surgeries. Correct preoperative diagnosis was made in 10 cases (50%), but 7cases already had been diagnosed as gastric cancer before perforation. There were 6 Stage III tumors and 7 IV tumors. Gastrectomy was performed in 18 cases which contained 11 cases of curative resections. Curability A, B). Twelve patients were treated palliatively (Curability C). The extent of lymph node dissection was D0 in 8, and D1 in 3. Two patients in curability A had long-term survivals, but 9 patients in B did not surrive. Mortality rate was 26.1% (6/23), and 5 cases were in Curability C. To establish the diagnosis as cancer after the perforation is not always easy. The poor risk patients should receive minimum treatments. If the preoperative diagnosis is correct, and the patient is in good condition, curative resection should be performed. But when the diagnosis is unclear, we leave the case in palliative surgery and a two-stage treatment is chosen as an option.

View full abstract

Laparoscopic appendectomy (LA) has been suggested useful in the treatment of acute appendicitis (AA). However, LA has not yet been confirmed as the standard treatment of AA. The aim of this present study is to compare the clinical outcome of LA to open appendectomy (OA).
Between January 2006 and March 2008, 53 out of 174 patients with AA underwent La and the other 121 patients underwent OA in our hospital. Retrospective review of the surgical outcome was performed between LA and OA groups.
Hospital stay was significantly shorter in LA group than in OA group (p<0.001).
The incidence of surgical site infection (SSI) tends to be lower in LA group than in OA group. These results suggest that laparoscopic appendectomy for acute appendicitis is a safe procedure that has significant clinical advantages over the conventional surgery. We think that it can become a popular operative method after solving some problems, such as initial technical training, possible complications and reimbursement in medical insurance.

View full abstract

Recent reports have described the use of 3D-CT images for preoperative simulation or intraoperative navigation in patients undergoing laparoscopic surgery. At our hospital, a completely filmless PACS (picture archiving and communication systems) was introduced in April 2008. At the same time, an Aquarius Net Station was adopted as a 3D-CT image transmission system. This system allowed us real-time access to 3D-CT images of blood vessels (analogous to the visual field yielded by a laparoscope insertion via a port) in the wards (before surgery) and in the operating room (during surgery). We began to utilize this system as a virtual laparoscopy for preoperative simulation and intraoperative navigation in patients undergoing laparoscopic sigmoidectomy. The use of this system has facilitated identifying the location and arrangement of blood vessels and assessing the morphological features of vascular branches. In addition, the safety of preoperative and intraoperative processes and manipulations has been enhanced by the use of this system. The high value of this system is reported herein.

View full abstract

We report three cases of Aromonas hydrophila infection that occurred after gastroenterological surgery. The first case was a 79-year-old male in whom the gallbladder and common bile duct were resected due to gallbladder cancer. On the first postoperative day (POD), his heart rate increased and his blood pressure decreased. His platelet count decreased, and subcutaneous bleeding was noted around the drain. DIC was suspected, and intensive care was given. However, the patient died 52 hours after surgery. Post huvnously, Aromonas hydrophila was identified in the sputum, the gastric juice, the arterial blood, the drain discharge and the wound discharge. The second case was a 73-year-old male. A total esophagotomy was performed due to the esophageal cancer. On the second POD, surgery was again required due to panperitonitis. A wound infection was noted at the fifth POD. Aromonas hydrophila was identified on the seventh POD. The wound was fully opened. Though the wound infection was cured, the patient was died due to a pulmonary embolism. The third case was a 72-year-old male. A sigmoidectomy was performed due to fibromatosis of the sigmoid colon. A wound infection was seen or the fifth POD. Aeromonas hydrophila was identified on the ninth POD. An intra-abdominal abscess was identified, and drainage was instituted. The patient was cured. Though Aromonas hydrophila infection is rare, it should be Kept in ming in patients who have had gastroenterological surgery.

View full abstract

We encounterd a patient who had multiple bone metastases with hyperthyroglobulinemia which occurred 8 years after an operation for follicular adenoma of the thyroid. The patient was a 43-year-old female who had undergone left hemithyroidectomy for a left thyroid tumor 8 years before this presentation, when the tumor was pathologically diagnosed as atypical adenoma. One year before this presentation, she underwent close exploration for remarkably increased serum thyroglobulin level (7867ng/ml), however, no cause could be determined due to the absence of either local recurrence or distant metastasis. Thereafter her serum thyroglobulin levels still increased to 12000ng/ml. Close explaration demonstrated multiple bone metastases and follicular thyroid carcinoma was diagnosed based on a bone biopsy. She underwent total thyroidectomy to remove the remaining thyroid and thereafter radioactive iodine treatment was started on the postoperative day 34. Her serum thyroglobulin levels have been decreasing and she is doing well at present. A careful and periodic follow-up for a long time in mandatory for follicular tumors of the thyroid even in patients in whom their tumors are diagnosed as benign.

View full abstract

A 71-year-old woman developed a palpable mass with an obvious pulse that was located at the 12-o'clock position in the right breast. On Ultrasound, an anechoic mass surrounded by a hypoechoic region was seen. Thus, a thrombus was suspected. On doppler sonography, there was obvious flow, and an arterial waveform was seen within the mass. Chest enhanced CT scan showed that the mass was fed from the branches of the lateral thoracic artery and the internal thoracic artery. A diagnosis of breast pseudoaneurysm was made, and the tumor was removed. On gross pathology, a comparatively thick vessel was found to be surrounded by organized thrombus. On histopathology, the vessel was found to be composed of failed middle and internal membranes, it was surrounded by thrombus and connective tissue. A diagnosis of breast pseudoaneurysm was made. Breast pseudoaneurysm is very rare. To date, there have been no published case reports in Japan. This paper deals with the present case, as well 10 previously reported non-Japanese cases.

View full abstract

A 64-year-old female had noticed a lump in her left breast by herself. On physical examination, a firm irregular mass measuring approximately 1.5 cm in its dimension in the lower outer quadrant of the left breast was palpable. Ultrasonography showed a hypoechoic nodule with a regular margin. Mammography revealed a well demarcated mass with microcalcification and spicula. The tumor was diagnosed as breast carcinoma by a fine needle aspiration biopsy. The patient underwent a breast conserving surgery with sentinel lymph node biopsy. The nodular tumor measured 1.2 × 1.0 × 0.8 cm. Histopathologically, the tumor was composed of predominantly proliferation of myoepithelial cells with scattered glandular epithelial lined spaces. Immunohistochemically, EMA and CK were positive in glandular epithelial cells, and CK, S-100, α-SMA, CD10, vimentin, p53 and MIB-1 were positive in myoepithelial cells. Many mitoses in myoepithelial cells and central necrosis were observed. Therefore, the tumor was diagnosed as a malignant adenomyoepithelioma. To our knowledge, 107 cases of the adenomyoepithelioma including our case were reported from 1986 in Japan. This is the eleventh report of a case of malignant adenomyoepithelioma.

View full abstract

We report an extremely rare case of breast cancer located in the nipple.
A 74-year-old woman developed swelling and redness of the left nipple. Inflammation of the nipple was suspected, but on pathology, a diagnosis of a solid tubular carcinoma was made. A modified radical mastectomy with axillary lymph node dissection was performed. On histology, the tumor was found to almost completely involve the nipple ; there was no lymph node metastasis.

View full abstract

Metastasis of prostate cancer to the breast is rare. We report our experience of one case of prostate cancer with metastases to the breast. The patient, an 85-year-old man, was diagnosed with prostate cancer (T3N0M1, stage D2) in March 1997, since when endocrine therapy had been conducted. He was examined at our hospital in November 2007 with painful left mammary gland mass as chief complaint. An approximately 1-cm tumor was detected in the left breast (C area) by palpation, mammography and ultrasound. Since this was diagnosed as scirrhous carcinoma by a percutaneous needle biopsy,, a partial mastectomy was performed. It tested positive for both prostate-specific antigen (PSA) stain and prostate acid phosphatase (PAP) stain in a postoperative histopathological examination, and therefore was diagnosed as prostate cancer with metastases to the breast. While prostate cancer with metastases to the breast can be difficult to diagnose by diagnostic imaging or fine needle aspiration cytology (FNAC) , immunostaining seemed useful in differential diagnosis. Prostate cancer with metastases to the breast leads to a poor prognosis in terminal-stage patients, and the partial mastectomy was of little clinical significance.

View full abstract

We report a case of osteonecrosis of the jaw in association with bisphosphonate treatment for bone metastases from breast cancer that developed seven months later after the last cycle of zoledronate. An 81-year-old woman underwent modified radical mastectomy for right breast cancer in June 2001. She received tamoxifen for postoperative adjuvant therapy. Bone metastases developed in December 2001 and she received several kinds of chemoendocrine therapy until June 2004, at which time treatment was discontinued due to adverse reactions. As metastatic progression of the disease was observed, treatment with pamidronate and tamoxifen was initiated in September 2004. Pamidronate was changed to zoredoronate in June 2006. In January 2007, two teeth were extracted due to periodontitis and zoledronate was discontinued. Zoledronate treatment was resumed from March 2007 ; however it was stopped again because of renal dysfunction in July 2007. The patient complained of continuous mandibular pain in February 2008, at which time a diagnosis of osteonecrosis of the jaw was made. Given the long half-life of these drugs, osteonecrosis of the jaw can remain a potential complication for years after bisphosphonate therapy. Therefore, patients should be counseled to receive regular follow-up with a dentist after treatment with bisphosphonates.

View full abstract

We have performed video-assisted thoracic surgery (VATS) for 3 patients with spontaneous hemopneumothorax. In the two male patients who were brought into our hospital by ambulance because of back pain, their chest X-ray films and CT scans revealed pneumothorax and pleural effusion. Large quantities of blood were drained from the thoracic cavity. Because of continuous bleeding and massive clotting, emergency surgery with VATS was performed 8 or 12 hours after the onset of the disease inpatient 1 or 2 respectively. In the remaining male patient with pneumothorax complaining of back pain, large quantities of blood were suddenly drained 24 hours after admission, and he went into shock. Emergency surgery with VATS was thus done. In all these patients, we were able to identify bleeding points from the funicular structure on the pleural cupula and emphysematous bullae of the apex of the lung by using VATS. Their post-operative courses were uneventful. Emergency VATS is recommended for spontaneous hemopneumothorax.

View full abstract

We report a case of a solitary fibrous tumor of the pleura which recurred to the liver and lung 20 years after the initial surgery.
A 76-year-old woman, who had undergone resection of a localized fibrous mesothelioma of the pleura of left thoracic wall at the age of 55, was referred to our hospital because of abnormal shadows on a chest roentgenogram. A chest CT scan revealed multiple pulmonary nodules and a mass 18 mm in diameter in the left lobe of the liver. Close exploration of the whole body was performed with a suspicion of metastatic tumors, but no primary lesion was detected. The patient was decided to be followed as her wishes. Nine months later, a follow-up CT scan revealed that the liver tumor enlarged to 31mm in diameter, then partial hepatectomy was performed. The histopathological diagnosis was solitary fibrous tumor which was pathologically similar to that of the pleural tumor resected before. Thus the liver and lung tumors were diagnosed as distant metastases of the solitary fibrous tumor of the pleura developed after 20 years had elapsed following the initial surgery. SFT can recur after a long-term disease-free period, but in this case, local metastasis is common and distant metastasis like in our case is rare. SFT would require a long-term follow-up by radiological examinations.

View full abstract

We report two cases of basaloid squamous carcinoma of the esophagus associated with other primary cancer.
In case 1, a 68-year-old man was admitted to the hospital complaining of dysphagia. An endoscopy showed an elevated lesion with a small shallow depression in the abdominal esophagus. An abdominal CT scan performed preoperatively revealed an elevated tumor in the urinary bladder. Transurethral resection of the bladder tumor was performed, followed by middle and lower esophagectomy with reconstruction using a stomach tube. The patient has been free from recurrence, as of 22 months after the surgery. In case 2, a 68-year-old man was admitted to the hospital because of a 2-month history of dysphagia. An endoscopy showed an ulcerative lesion from the abdominal esophagus to esophagogastric junction, and a slightly depressed lesion in the lower body of the stomach, simultaneously. Middle and lower esophagectomy and total gastrectomy were performed, but bone metastasis occurred soon after the surgery.
Following radiochemotherapy, the patient is still alive as of 8 months after the surgery.
As esophageal carcinoma is often associated with other organ malignancy, basaloid squamous carcinoma of the esophagus can also be associated with other primary cancer. Accordingly preoperative examination and careful postoperative follow-up are recommended for such patients.

View full abstract

A male patient in his late 70s, while under the influence of alcohol, accidentally drank an acid detergent. Ten days later, he was admitted due to epigastric pain and hematemesis. Gastrointestinal endoscopy revealed a hemorrhage from an ulcer located in the posterior wall of the superior gastric body. Hemostasis was performed. The patient was admitted. Endoscopy done one day postadmission showed a circumferential erosion extending from immediately below the cardia to the inferior gastric body. However, there was no mucosal injury of the esophagus pylorus. The patient had a cicatricial stenosis involving the cardiac region and gastric body, which prevented oral ingestion. Total gastrectomy and R-Y reconstruction were performed 43 days postadmission. During surgery, the findings were suggestive of corrosive gastritis with marked fibrosis of the submucosal layer. This type of gastritis is associated with ingestion of tissue-damaging drugs such as acid/alkaline agents of varying grades. Commonly, corrosive esophagitis develops concomitantly. Cicatricial stenosis is frequently found in the pyloric region. Stenosis involving the cardiac region and gastric body without organic esophageal and pyloric changes, as found in this case, is rare.

View full abstract

A 26-year-old man developed upper abdominal discomfort. His past history included tuberculous peritonitis diagnosed 6 months earlier ; since that time, he was on anti-tuberculous drug, INH, RFP, and EB, therapy. On upper gastro-intestinal series and gastric endoscopy, a submucosal tumor with an ulceration at the 12 o'clock position was found to be located at the lower greater curvature. Abdominal CT showed a 5-cm-diameter tumor located at the lower greater curvature of the stomach ; the tumor extended to the abdominal wall. The biopsy revealed only necrotic tissue. Therefore, a fine needle aspiration biopsy via EUS was obtained. This specimen was Mycobacterium tuberculosis PCR-positive. Based on these findings, gastric tuberculosis was diagnosed. Given the patient's clinical course, this lesion was thought to be anti-tuberculous drug-resistant. No tuberculous lesions were detected in any other organs. Thus, a tumor resection with a partial gastrectomy was performed. The diagnosis of gastric tuberculosis was confirmed on pathology. The patient was successfully treated and discharged. We report an unusual case of gastric tuberculosis and review the relevant literature.

View full abstract

A case of a gastrointestinal stromal tumor located in the reconstructed gastric tube after esophagectomy for thoracic esophageal cancer that was treated by tumor enucleation.
A 78-year-old man, who 15 years earlier had thoracic esophageal cancer and required a transhiatal esophagectomy, as well as reconstruction using a gastric tube via the retrosternal route, presented with dysphagia. A submucosal tumor in the reconstructed gastric tube was diagnosed. On pathology of an ultrasound-guided fine needle biopsy specimen, a gastrointestinal stromal tumor (GIST) was diagnosed. The patient was treated with imatinib. However, the tumor continued to increase in size. The patient also developed severe adverse effects. Therefore, a surgical resection was done. Taking into account the patient's background, surgical stress, and curability, we treated the patient by enucleating the tumor. On histology, the tumor was found to have been completely resected, the lesion was c-kit-positive, CD 34-positive, S-100-negative, and Ki-67-5% positive, with 0 to 1 mitoses per 10 high power fields. One year after surgery, the patient is well and without any signs of recurrence.

View full abstract

A 71-year-old woman visited our hospital after the diagnosis of early gastric cancer at a nearby hospital. Gastrointestinal endoscopy revealed a type II c gastric cancer on the anterior wall of the lower gastric body and no other findings were observed in our hospital. The carbohydrate antigen 19-9 (CA19-9) was increased to 132.4 U/ml. Under the diagnosis of early gastric cancer, a laparotomy was performed. As an operating finding, there was a gastric cancer in the gastric body, and in addition to this, there was a tumor of the pyloric ring. It had no communication between the pancreas. Postoperative histopathological findings of the tumor which located at the gastric body was poorly differentiated adenocarcinoma arose from gastric mucosa. And the tumor which located at the pyloric ring was an adenocarcinoma Heinrich type I arose from the ectopic pancreas. The report of adenocarcinoma arising from the ectopic pancreas in rare, and the treatment and the prognosis are largely unknown. Considering the elevated level of CA19-9 for the early gastric cancer, a more careful investigation of the high value of the CA19-9 was needed for the accurate diagnosis.

View full abstract

A 59-year-old man complaining of general fatigue and epigastralgia was admitted with a high grade fever. Upper gastrointestinal endoscopy revealed a type-2 gastric cancer ; based on the pathology of a biopsy specimen, a poorly differentiated adenocarcinoma was diagnosed. Laboratory tests indicated the presence of an inflammatory reaction (WBC 23,300/μl) ; no evidence of infection was observed. Thus, the patient's fever was thought to be related to his gastric cancer. The patient had a total gastrectomy and a transverse colectomy. Immediately after the operation, the fever and the increased WBC level decreased. On pathology the diagnosis was por1, se, pm(-), dm(-), ly1, v1, n3, stageIV. Adjuvant chemotherapy was given, but recurrence was detected 6 months after surgery. The serum granulocyte-colony stimulating factor (G-CSF) level was elevated (223 pg/ml), and G-CSF immunological staining was positive. Thus, a G-CSR-producing gastric cancer was diagnosed.

View full abstract

A 66-year-old woman was admitted to our hospital with the chief complaint of heart burn in September 2007. Endoscopic examination revealed a submucosal tumorous lesion which maintained the mucosal pattern without central depression on the posterior wall of the upper gastric body, measuring about 3cm in diameter. A biopsy of the elevation was reported to be GroupII. Endoscopic ultrasonography showed a homogeneous, hypo echoic mass localized in the submucosal to subserosal layer of the gastric wall. Laparoscopic partial resection of the stomach was performed under a diagnosis of submucosal tumor. Histologically the tumor was diagnosed as adenocarcinoma (tub1>por2, ss, ly2, v2, margin-). Extremely well-differentiated adenocarcinoma (EWDA) cells in mucosa had grown through the muscularis mucosae into the subserosa and transformed into poorly differentiated type. After ruling out possibilities of metastasis and invasion from other organ cancer, we scheduled total gastrectomy as the operation for advanced gastric cancer after the partial resection, but were forced to perform exploratory laparotomy because of peritoneal dissemination. Reports of EWDA resembling submucosal tumor in morphology are rare. We should be careful in treatment strategy because of difficulty in making the histological diagnosis of carcinoma on biopsy.

View full abstract

On endoscopy, a type 3 gastric cancer was found in a 70-year-old man. The tumor was located in the posterior wall from the angular notch close to the pyloric antrum ; on histology of the biopsy specimen, adenocarcinoma was diagnosed. Computed tomography demonstrated a low density lesion in the extrahepatic portal vein. Abdominal angiography showed occlusion of the main portal vein and the presence of venous collaterals. At surgery, no dissemination or hepatic metastases were found. A tumor thrombus was noted to extend from the left gastric vein up to the bifurcation of the portal vein. A distal gastrectomy with an en-bloc lymphadenectomy (D2) and removal of the tumor thrombus was performed. On pathology, a moderately differentiated tubular adenocarcinoma was diagnosed in the tumor and thrombus in the portal vein. The patient underwent adjuvant chemotherapy with TS-1. There has been no evidence of recurrence for more than 6 months.

View full abstract

A 56-year-old man complained of abdominal pain. On abdominal CT, free air and gastric wall thickening were noted. He was diagnosed as having a gastrointestinal perforation and peritonitis due to a suspected gastric cancer. Since his symptoms were not severe, emergency surgery was postponed. On endoscopy, a perforated gastric tumor was found. A distal gastrectomy with D2 lymphadenectomy and cholecystectomy was scheduled. A liver metastasis was found on laparotomy. Since a solid mass measuring 1.5 cm in diameter was detected in S3 of the liver, a partial hepatectomy was also done. On histopathology, the tumor located in the ventriculus of the stomach was diagnosed as a moderately differentiated adenocarcinoma. The final diagnosis was T3 N1 H1 P0 M0 fStageIV. Adjuvant chemotherapy using S-1 was given. Tumor markers, especially CA72-4, became transiently elevated two years later, but normalized after continuous adjuvant chemotherapy with S-1. There have been no signs of recurrence for 5 years. Generally, it is considered that gastric cancer patients with liver metastasis and a perforation have a poor prognosis. Therefore, we report this rare case that has shown a good postoperative course for 5 years.

View full abstract

Congenital duodenal obstruction or stenosis is a disease to account for about half of newborn cases of intestinal atresia and stenoses. Here we report a case of congenital duodenal stenosis treated by endoscopic membranectomy, together with a review of the literature. A 3-year-old girl was referred to the hospital because of vomiting which had started at the age of about 6 months in a frequency of 2 times daily and the frequency had decreased to one time monthly after initiation of weaning. The patient had been followed thereafter but her symptom did not improve until this referral when she was 3 years old. Congenital duodenal stenosis was diagnosed by X-ray studies, an upper gastrointestinal series and abdominal ultrasonography. Although endoscopic balloon dilatation was done, it was in effective. Endoscopic membranectomy done five days after the balloon dilatation was successful. She has had no signs of recurrent congenital duodenal stenosis as of 7 years after the operation.

View full abstract

There are several problems in surgical resection of gastrointestinal stromal tumors (GISTs), according to their locations, especially the duodenum from its anatomical aspect. We experienced a case of GIST located in the 2^nd potion of the duodenum, which could be removed laparoscopically.
A 45-year-old woman presented with melena was diagnosed endoscopically as having a submucosal tumor with a central ulcer in the 2^nd portion of the duodenum. We tried to remove it laparoscopically as no liver and/or lymph nodes metastases were seen by preoperative imaging methods. The tumor was extirpated laparoscopically, and simple closure by endocutter completed the reconstruction after temporary sutures. The histopathological diagnosis of the resected tumor was GIST, with low risk. The patient was discharged from the hospital 7 days after the surgery, and recurrence has not been seen for more than 3 years.
Laparoscopic resection is reasonable for the GISTs even for those located in the duodenum, if the tumor diameter is in a range of 2-5cm.

View full abstract

We report a case of a 71-year-old woman with cancer of the papilla of vater which occurred 17 years after total gastrectomy with Roux-en-Y reconstruction for gastric cancer. She was asymptomatic but abdominal echogram revealed a huge tumor in the duodenum. Abdominal CT scan and MRI showed an irregular mass 4.5cm in diameter at the second to third portions of the duodenum and showed slight dilatation of the common bile duct and pancreatic duct. Pancreatoduodenectomy was performed and the pathological diagnosis was cancer of the papilla of vater. After total gastrectomy with Roux-en-Y reconstruction, careful follow-up by imaging methods is necessary for earlier detection of cancer of the duodenum, the common bile duct and the pancreas head.

View full abstract

Gastrointestinal perforation due to amyloidosis is rare and its prognosis is dismal. We report a case of small intestinal perforation due to secondary amyloidosis accompanied by chronic rheumatoid arthritis (RA).
A 68-year-old woman with a history of RA since the age of 40 was admitted to the hospital because of abdominal pain. Emergency operation was performed under a diagnosis of perforating peritonitis. Laparotomy revealed a perforation 5mm in diameter at the ileum 10cm from the ileocecal valve. Ileocecal region including the perforation and the affected ileum by ischemic change was resected. Mucosa of the resected ileum had multiple ulcers and perforation. Histopathologically, amyloid deposition was found in the submucosal vascular wall. The amyloid was identified as amyloid A protein by immunohistochemical staining. Amyloidosis in this patient might have been secondary to RA. Following surgery, the patient received intensive care with total parenteral nutrition and subsequent enteral nutrion. Her general condition became stable and she was discharged from the hospital very much improved.

View full abstract

The patient was a 91-year-old male. He developed vomiting and abdominal pain. An intestinal obstruction was diagnosed. He had no previous history of abdominal surgery. He had taken an NSAID for spinal canal stenosis for three years. Based on abdominal X-rays, a small-bowel obstruction was diagnosed. Surgical treatment was considered. The patient and his family did not consent to surgery. Therefore, conservative treatment was instituted. However, a cycle of recovery and symptom recurrence developed. Consequently, two months after the initial consultation surgery was performed. Intraoperative findings included many indurations that were palpable approximately 50 cm from the ileocecum toward the small bowel ; obstruction was observed at this location. Approximately 70 cm of ileum was resected, and the ileum was repaired using a side-to-side ileal anastomosis. The excised specimen had many membranous diaphragm-like obstructions in the ileum. On pathology a severely fibrotic submucosal layer and an increase in the number of chronic inflammatory cells were noted. A diagnosis of diaphragm disease of the ileum related to mucosal damage due to the use of an NSAID was diagnosed.

View full abstract

We report a case of axial volvulus of Meckel's diverticulum with an ectopic pancreas which contained intraductal papillary mucinous neoplasm (IPMN) like structure histopathologically. An 80-year-old man was admitted to our hospital because of ileus. Whirl sign was detected in the vicinity of the ileocecum on abdominal enhanced CT scan, and emergency operation was performed. Huge Meckel's diverticulum over 10 cm in length was detected in the antimesenteric site of the ileum, starting at a portion 150 cm proximal to the Bauhin's valve. The deverticulum was twisted clockwise by 180 degree. No mesodiverticular band or adhesional band was found, but an ectopic pancreas measuring 2 by 4 cm was observed on the tip of this diverticulum. Normal pancreatic tissue and dilated duct formation were observed by HE staining. In the epithelium of the ectopic pancreatic duct, mucin production was demonstrated by alcian blue. Distinct pattern of mucin expression revealed the pathological diagnosis of IPMN in the ectopic pancreas immunohistochemically.
Simple axial volvulus of Meckel's diverticulum without mesodiverticular band or adhesional band is extremely rare and only 17 other cases have been reported since 1983. No cases of Meckel's diverticulum with an ectopic pancreas which contained IPMN like structure like in this case have been reported in Japan.

View full abstract

We report a case of malignagnt lymphoma with recurrent bouts of ileus treated by laparoscopic surgery. A 71-year-old woman who had had recurrent episodes of abdominal pain and was resultantly diagnosed as having ileus was admitted to our hospital because of abdominal pain. The symptoms disappeared soon and she was discharged 3 days after admission. Four days later she visited our hospital again with a diagnosis of recurrence of ileus. Because she had previously undergone appendectomy and total hysterectomy, adhesive intestinal obstruction was the most likely diagnosis and laparoscopy-assisted surgery was performed. The intraoperative findings revealed no adhesions attributable to the ileus. But a tumorous lesion suggestive of serosal infiltration was noted about 120 cm oral from the Bauhin's valve. A minor median laparotomy was done and the tumor was found on palpation at the same site. A partial resection of the small intestine was performed. The tumor was diagnosed as malignant lymphoma (B cell type) by histopathological findings.

View full abstract

On routine colonoscopy a submucosal tumor located in the terminal ileum was found in a 52-year-old man. A histological diagnosis of carcinoid was made based on a biopsy specimen obtained from the ileal lesion. On abdominal CT scan, no evidence of distant metastasis was found. Therefore, an ileocecal resection with lymph node dissection was done. On macroscopic examination of the resected specimen, the tumor was 7 mm in diameter, and there was deep invasion into the submucosal layer of the terminal ileum. A regional lymph node metastasis was identified. In Japan ileal carcinoid is rare. Ileal carcinoid tumors are thought to have a higher malignancy potential compared to other gastrointestinal carcinoid tumors ; 21% of ileal carcinoid tumors smaller than 10 mm in diameter have regional lymph node metastasis. Therefore, patients with ileal carcinoid should have lymph node dissection irrespective of their tumors size.

View full abstract

A 45-year-old woman was seen at the hospital because of upper abdominal pain. There was a past history of undergoing modified radical mastectomy for left breast cancer (scirrhous carcinoma, T2N1, StageIIB) in July 2003. The tumor cells were ER-positive, PgR-positive, and HER-2 negative. Adjuvant hormone therapy was discontinued for reasons of her own. The patient complaining of upper abdominal pain was admitted to the hospital with a diagnosis of intestinal obstruction on June 15, 2006. A long intestinal tube was placed and intermittent continuous suction was performed. On the 5^th hospital day, fluoroscopic study through the ileus tube revealed stricture completely encircled the bowel near the subumbilical region. Primary small intestinal tumor or Crohn's disease was thus suggested and partial resection of the small intestine was performed. Histopathological studies showed invasive proliferation of small atypical cells from serosa to mucosal surface that was extremely similar to that of the breast cancer.
To the best of our knowledge, metastasis of breast cancer to the small intestine is so rare that only 20 surgical cases, including this case, have been reported in the Japanese literature. This case is presented here, together with some references.

View full abstract

We report a case of appendicitis caused by a foreign body. A 54-year-old man with a 2-day history of lower abdominal pain was referred to the hospital. On abdominal X-ray's a foreign body was seen in the right pelvic cavity. On CT scan, a high density spot was noted in an enlarged appendix. Given a diagnosis of appendicitis, emergency surgery was done. The appendix wall was thickened and indurated due to inflammation, an appendectomy was done. A tooth was found in the resected appendix. It is rare to find an appendicitis caused by an accidentally swallowed tooth.

View full abstract

Granular cell tumor is quite rare in the colon. A 60-year-old man was found to have a submucosal tumor measuring 5mm in diameter in the cecum by colonoscopy at a medical check-up. Chest and abdominal CT scan did not show any metastatic lesions. Endoscopic ultrasonography showed a homogeneously hypoechoic mass, which had reached to the middle of the submucosal layer. Since endoscopic treatment such as endoscopic polypectomy or endoscopic mucosal resection could not be indicated, we performed a laparoscopy-assisted ileocecal resection with D2 lymph node dissection. The pathologic diagnosis of the colectomy specimen was granular cell tumor of the colon. Immunohistologically, the tumor cells were positive for S-100 protein and neuron-specific enolase. Lymph node metastasis was absent. Here we report a case of laparoscopic resection of granular cell tumor in the cecum.

View full abstract

Diverticulosis of the colon is a common entity. But giant colon diverticulum is rare and only 12 cases have been described in the Japanese literature since 1983. We report a new case of giant diverticulum presented with positive reaction for occult blood and treated by laparoscopy-assited surgery. An initial occult blood test turned out positive in a 70-year-old male patient in January 2008. After some examinations we diagnosed this case as giant diverticulum of the sigmoid colon. He underwent laparoscopy-assisted surgery in April 2008. On the resected material the diverticulum was 60 × 35mm in external diameter and had thickened wall. There is no clear notion of etiology of giant diverticulum as yet. Partial intestinal resection including the diverticulum is a common therapy for the disease. In a review of the Japanese literature, other 12 cases have been reported. In most of the 12 cases, open surgery, was performed but laparoscopic surgery was successful in treating the disease in this case. Benign colonic diseases like in this case appear to be good candidates for laparoscopic surgery.

View full abstract

The patient was a 59-year-old man who visited our hospital with the chief complaint of left lower abdominal pain. On colonoscopy, an Is-type tumor (10 mm in diameter) was observed in the sigmoid colon, and an endoscopic mucosal resection (EMR) was performed. On histopathological examination, the tumor was a moderately-differentiated tubular adenocarcinoma (SM, ly1, v1, VM1) accompanied by a well-differentiated tubular adenocarcinoma in the marginal region, and a laparoscopic sigmoidectomy (D2) was performed. On histopathological examination of the resected intestinal specimen, a well-differentiated tubular adenocarcinoma was noted in the region of the EMR scar, and the lesion was graded pSM, ly1, v1, pN1, fStage IIIa. After the sigmoidectomy, the patient was treated with oral anticancer drugs and followed up. However, left lung metastases were found after 7 years and 9 months and 11 years and 3 months, respectively, and partial pneumonectomies were performed. As of 14 years and 1 month after the sigmoidectomy, no new metastasis has occurred, and the patient is under follow-up observation. Rarely but lung metastases from the SM colon cancer can occur. Pneumonectomy is expected to improve the prognosis, however it is necessary to accumulate more cases to elucidate the risk factors for recurrence and establish a surveillance system.

View full abstract

The dissection of lymph nodes has been considered to be unnecessary due to both the scarcity of lymph node metastasis in gastrointestinal stromal tumor (GIST) patients, and the poor prognosis of GIST with lymph node metastasis. We report GIST of the rectum with regional lymph node metastases in a 79-year-old woman who had a painful anal mass. On histology of the biopsy specimens, the CT scan, and the FDG-PET results GIST with widely spreading regional lymph node metastases was suspected. There fore, an abdominoperineal resection with a systematic regional lymph node dissection was done. GIST of the rectum with widely spreading regional lymph node metastases was diagnosed since on histopathology spindle-shaped cells were seen in the tumor and the lymph nodes were composed of spindle-shaped cells ; the tumor cells were positive on c-kit immunohistochemistry. The effectiveness of a systematic regional lymph node dissection, performed in the present case with rectal malignant GIST, should be checked by a meticulous follow up.

View full abstract

A 79-year-old woman was referred to our hospital because of pyrexia and abdominal pain and difficult breathing. Abdominal ultrasonography and computed tomography showed a cystic mass of 7 × 7 cm in size in the right lobe of the liver. From examinations and clinical findings, we diagnosed that the patient had a liver abscess and cardiac insufficiency, and the treatment was started immediately with antibiotics and percutaneous transhepatic abscess drainage. On cytological study of the pus, no malignant cells were detected Colonscopic examination for defection of the cause of anemia, showed a rectal cancer. The rectal cancer was excised locally through transanal approach due to the cardiac insufficiency. Four months later, low anterior resection was performed because of remnant cancer in rectum after recovery of general candition. The resected specimen revealed a well differentiated adenocarcinoma a1 no ly1 v1, Stage II, microscopically. After the two-staged operation, the patient showed a favorable outcome without any major complications. The patient has been free from recurrence of hepatic abscess or rectal cancer, as of 3 years after the operation.

View full abstract

A patient, 72-year-old male, saw his private physician with the chief complaint of generalized malaise and loss of appetite of two months duration. The patient was referred to our hospital with diagnosis of a hepatic tumor and was admitted for further studies and possible treatment. Abdominal CT and echo study revealed a tumor of about 4cm in diameter size in S6 of the liver and a metastatic cancer or biliary cell carcinoma was suspected. Mesenteric arteriogram did not indicate the presence of hepatocellular carcinoma. A definite diagnosis was not able to be made by the image studies even though some type of malignant hepatic tumor was suspected. Echo guided needle biopsy of the liver was performed and it revealed a pathology of inflammatory cellular infiltration and proliferation of connective tissue, leading to the diagnosis of inflammatory pseudo-neoplasm. Fever and pain in the right hypochondrium followed that did not respond to a conservative treatment, therefore a partial hepatectomy was performed. Pathological diagnosis of the resected specimen coincided with the finding of the needle biopsy. Hepatic inflammatory pseudo-neoplasm is relatively a rare entity and to make diagnosis is often difficult. We experienced a rare case of hepatic inflammatory pseudo-neoplasm with difficult differential diagnosis from a malignant tumor and was finally diagnosed by a needle biopsy. We report the case here with some review of the literatures.

View full abstract

A 30-year-old man had a previous treatment for subarachnoid hemorrhage with implantation of a ventriculoperitoneal shunt (VP shunt) after a traumatic brain injury 13 years ago, and was managed with nasogastric tube feeding. He was admitted in our hospital 3 years ago because of aspiration pneumonia, but frequent aspiration pneumonia and vomiting made him managed by total parenteral nutrition with an indwelling decompression nasogastric tube for 3 years. He was referred to our division because of occulusion of the central venous catheter. Three months later after the nasojejunal tube-feeding, abnormal liver function and obstructive jaundice due to gall bladder and common bile duct stones appeared. Peroral endoscopic lithotomy was difficult because of inability of keeping an appropriate position due to generalized contracture. Surgical approach was also risky in such a deteriorated condition. Percutaneous transhepatic gallbladder drainage was immediately performed. Three months later after the drainage, ballon dilation of the pappila was performed through the cystic duct and common bile duct stones were removed. Another 3 months later, percutaneous transhepatic cholecystoscopic removal of the gallbladder stones was performed. We experienced a percutaneous transhepatic transcholecystoductrl lithotomy as an alternative therapy in a patient with a VP shunt and generalized contracture, who carried a high risk for surgical approach.

View full abstract

A 71-year-old man with chief complaint of icterus revealed total bilirubin of 11.9 mg/dl, direct bilirubin 9.4mg/dl, and ALP 1,223IU/l by a blood study.
The tumor marker CA19-9 revealed an abnormally high valve of 11,600u/l.
CT scan revealed slight dilatation of intrahepatic ducts, gallstones and a calcification, suspicious of a stone in the common file duct.
In addition, contras enhancement was seen in the wall of the distal bile duct.
As a cancer of the distal bile duct was suspected, PTCD was performed to decrease jaundice. Cytological study was negative. ERCP and EST were performed to break the calculus. Besides a tumor marker rise and a contras enhancement of the distal bile duct wall, no findings were detected to suspect malignancy.
Laparoscopic cholecystectomy was performed. Postoperative PTCD cholangiogram did not reveal stricture of the duct and CA19-9 value came down to 10.1u/l and the patient was discharged with uneventful course.
In case the possibility of malignancy cannot be ruled out like this case a careful evaluation of the studies is important in managing the case.

View full abstract

A 71-year-old man who had a previous cholecystectomy and an extrahepatic bile duct resection with bilateral hepaticojejunostomy for cholecystolithiasis developed recurrent cholangitis. On abdominal CT, mild dilatation of the intrahepatic bile ducts was noted ; no stones were seen.
Stricture of the choledochojejunostomy was suspected. Balloon dilatation of the stricture of the choledochojejunostomy and an endoscopic lithotomy were done via the jejunostomy with nasal endoscopy.
The outcome was excellent, and postoperatively the patient improved steadyily.

View full abstract

A 54-year-old woman with uncomfortable feeling on the upper abdomen was referred to our hospital. Laboratory data were normal in both biochemical enzymes and tumor markers. But abdominal ultrasonography, computed tomography (CT) demonstrated a cystic lesion containing papillary solid component in segment IV of the liver. Magnetic resonance imaging (MRI), especially magnetic resonance cholangio-pancreatic imaging (MRCP) demonstrated the tumor connected to the left intrahepatic bile duct. The solid components of the cyst was not stained angiography. We strongly suspected the tumor was a bile duct cystadenocarcinoma by imaging studies and carried out a segment IV of the liver and bile duct resection and reconstruction. Pathological diagnosis of the tumor was moderately differentiated adenocarcinoma, and the specimen of the bile duct was free from invasion. Since bile duct cystadenocarcinomas are rare, we report on this case with some literature reviews.

View full abstract

A 59-year-old man was seen at the hospital because of epigastralgia and vomiting. Hepatocystic enzyme and CA19-9 were elevated. Abdominal CT scan and ERCP revealed heterocentric stricture of the extrahepatic bile duct, and dilatation of the intrahepatic bile duct. The cytodiagnosis of the bile reported classII, and ova of Clonorchis sinensis were recognized. Clonorchiasis was successfully treated by praziquantel (a parasiticide). One month later, the stricture of the extrahepatic bile duct got worse, and CA19-9 level increased as well. We performed laparotomy because a possibility of associated bile duct carcinoma could not be ruled out. Extrahepatic bile duct carcinoma was diagnosed with frozen section intraoperatively. Furthermore metastasis to the para-aortic lymph nodes and a wide-ranging spread of the extrahepatic bile duct tumor were disclosed. We thus gave up resecting the carcinoma and performed only cholecystectomy and cholangiojejunostomy.
We sometimes encounter case reports on bile duct carcinoma associated with clonorchiasis. In the case of clonorchiasis, the possibility of cholangiocarcinoma should be considered in the differential diagnosis.

View full abstract

The patient was a 58-year-old woman with early-stage gallbladder carcinoma who concurrently developed suppurative cholangitis after the tumor became detached and descended into the common bile duct. After endoscopic papillotomy was performed to alleviate her condition, laparoscopic cholecystectomy was performed. Postoperative pathological tests showed that although the lesion had spread over the entire gallbladder, it was localized to the mucosa and the cystic duct had a negative margin. Therefore, the patient was followed up by observation. Tests conducted four years later showed liver metastasis in the posterior region of the right lobe of liver, and resection was performed. The lesion was mostly localized to the bile duct in the posterior region of the right lobe, and its histopathological features suggested that it was a recurrence of the preceding gallbladder carcinoma that had metastasized via the bile duct. Gallbladder carcinoma localized to the mucosa has been said to be completely curable by cholecystectomy alone, and no cases of liver metastasis via the bile duct such as in the present case have been reported. We report the present case as we believe that this possibility must be considered when planning treatment for early-stage gallbladder carcinoma.

View full abstract

A 79-year-old woman complaining of exertional short of breath and abdominal pain was pointed out severe anemia at another hospital, and abdominal ultrasonography performed at the same time suggested gallbladder stones and a gallbladder tumor. Thus the patient was referred to the department of gastroenterological medicine in our hospital. After admission to our hospital, she developed fever and right hypochondralgia, and then increases in inflammatory findings appeared in blood biochemical examinations. Association of acute cholecystitis was considered and administration of antimicrobial agents was started. Various imaging methods revealed an about 90mm-sized tumor image in the liver S4 and 5 which seemed to continue to the gallbladder. A cytodiagnosis of bile juice offered a strong suspicion of gallbladder carcinoma. The patient was operated on with a diagnosis of gallbladder carcinoma, acute cholecystitis, hepatic infiltration or hepatic abscess. Laparotomy disclosed a tumor about 90mm in diameter in the liver S4 and 5 which seemed to continue to the gallbladder as shown in the imaging finding obtained preoperatively. The resection of the liver S4a + 5, cholecystectomy, resection of the extrahepatic bile duct, and choledochojejunostomy were performed. The final histopathological diagnosis was “so-called carcinosarcoma of the gallbladder” in which adenocarcinoma components and spindle-shaped tumor cells coexist irregularly.

View full abstract

We report a case of severe portal vein thrombosis after Hassab's operation.
A 23-year-old woman was admitted to our hospital because of a left upper quadrant abdominal mass. Abdominal CT scan and angiography revealed splenomegaly, esophagogastric varices and obstruction of the splenic vein. Upper gastrointestinal endoscopy showed esophagogastric varices. Esophagogastric varices caused by obstruction of the splenic vein was diagnosed preoperatively and Hassab's operation was performed. After the operation, high fever and general malaise persisted. Abdominal CT scan revealed severe thrombi of the superior mesenteric and portal vein on the 10th postoperative day. She immediately treated with anticoagulant and antiplatelet therapies. On the 17th postoperative day, CT scan showed that the thrombi of the superior mesenteric and the portal veins were reduced. On the 48th postoperative day when she was discharged from our hospital, the thrombi were remained but the blood flow improved in the portal vein by ultrasonography.
Portal vein thrombosis occurs in 4.4-17.3% of all cases after splenectomy. The disease requires appropriate therapies because it can cause complete obstruction of the portal vein and superior mesenteric artery, and can do hepatic impairment and intestinal necrosis. Accordingly the disease must be kept in mind after Hassab's operation, and anticoagulant and antiplatelet therapies should immediately be started, if the onset is once confirmed.

View full abstract

The patient was a 51-year-old woman who was referred to the Internal Medicine department of our hospital after a splenic tumor 6 cm in size was detected during an examination in 2006. Although abdominal CT showed splenomegaly and areas of heterogeneous attenuation in the spleen, PET-CT showed only mildly increased FDG accumulation, a finding that did not strongly suggest malignancy. The patient was subsequently followed up on an outpatient basis, and no major changes were observed on imaging findings. However, because the possibility of malignancy could not be completely ruled out, splenectomy with distal pancreatectomy was performed. Although a large portion of the tumor was found to be angioma, proliferation of endothelial cells having an irregular arrangement or tendencies toward stratification and small size was observed in some parts, and the patient was diagnosed with hemangioendothelioma of intermediate malignancy. The patient followed a favorable postoperative course and was discharged 10 days after surgery. She is currently being followed up on an outpatient basis, and no findings indicating relapse have been observed at 8 months postoperatively.
Primary splenic tumors are rare, and among them hemangioendothelioma has been reported in only two cases in Japan. We report the present case with reference to literature.

View full abstract

A 77-year-old woman treated for hypertension developed an enlarging cystic tumor under the right diaphragm. Computed tomography revealed the presence of a cystic tumor, the origin of which was suspected to be the right adrenal gland. High urinary catecholamines and vanillylmandelic acid levels were noted. Metaiodobenzylguanidine (MIBG) scintigraphy demonstrated an abnormal accumulation of ¹³¹I in the tumor. Thus, a pheochromocytoma was diagnosed. A right adrenalectomy was done ; old blood and coagula were detected within a cyst. On histopathology, a pheochromocytoma with a pseudocyst was diagnosed.
To date, fewer than 50 cases of cystic pheochromocytoma have been reported. The condition is thus considered rare. It is important to differentiate a right adrenal gland tumor from a cystic lesion of liver.

View full abstract