Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association)
Online ISSN : 1882-5133
Print ISSN : 1345-2843
ISSN-L : 1345-2843
Volume 71, Issue 1
Displaying 1-50 of 57 articles from this issue
Original Article
  • Nozomu MURAKAMI, Shinichi KADOYA, Keiko MURASUGI, Nana MAKINO, Yasuko ...
    2010 Volume 71 Issue 1 Pages 1-8
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    After group categorization based on prognosis prediction by the Palliative Prognostic Index (PPI), the duration from the intervention by the palliative care team until the patient's death, time until shifting to care at home, and period for home care were comparatively investigated in nine patients with end-stage cancer who were shifted to home care and 20 patients who were treated until their deaths in the hospital. A questionnaire survey was carried out for analysis as to the visiting nursing station in six patients who received care at home until their deaths. Concequently, there was no difference between home care cases and hospital cases in the period from the intervention by the palliative care team to the patient's death. The questionnaire survey showed that about half of the patients became unable to eat soon after shifting to home care. In addition, five of the six patients who had shifted to home care were satisfied but half of family members answered to feel uneasy deeply. Accordingly, the timing of shifting to home care was considered appropriate, but aggravation of eating status of the patients and insufficient family care might be the problems to be solved.
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  • Hideo MATSUMOTO, Hisako KUBOTA, Haruaki MURAKAMI, Masaharu HIGASHIDA, ...
    2010 Volume 71 Issue 1 Pages 9-14
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    Purpose : We inspected the feasibility of minimally invasive surgery for superficial esophageal cancer, the trans-hiatal approach without thoracotomy.
    Matearial : We examined the surgical outcomes of 33 superficial esophageal cancer whose cancer had invaded the submucosal layer and who underwent resection in our hospital between April 2003 and April 2009.
    Method : The patients who had tumor invasion of within the sm1 and no metastasis to the upper and middle mediastinum lymph nodes were operated on by the trans-hiatal esophagectomy (THE). The other patients were underwent ordinary trans-thoracic esophagectomy (TTE). After the operations, we recommended adjuvant chemoradiation therapy for all patients whose tumor were histropathologically proved to involve the sm2 layer as well as the vessels and/or lymphatic duct.
    Result : Of our 33 cases, nine were diagnosed as pM1 or pM2. Two were diagnosed as pM3, one of which had lymph node metastasis. Eleven cases were diagnosed as pSM1, four as pSM2, and seven as pSM3 ; and lymph node metastasis was observed in 4 pSM1 cases (36%), 2 pSM2 cases (50%) and 5 pSM3 cases (71.4%).
    The five-year survival rate in all cases was 89.6%. The five-year survival rate by operating method was 100% in THE cases or 80.9% in TTE cases. The rates by tumor depth of invasion was 100% in pM1-2 cases, 92.3% in pM3-SM1 cases and 78.8% in pSM2-3 cases.
    Conclusion : It is concluded that the surgical outcome of THE in accordance with our indication criteria is equal to that of TTE for superficial esophageal cancer.
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  • Masaji HASHIMOTO, Shinji MINE, Jin MORIYAMA, Kazuhisa EHARA, Syuichiro ...
    2010 Volume 71 Issue 1 Pages 15-20
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The incidence of biliary tract stones after gastrectomy has been widely reported to be high, about 15%. In this study the treatments of post-gastrectomy biliary tract stones were retrospectively examined because laparoscopic cholecystectomy for gallstones and endoscopic bile duct lithotomy have become standard therapeutic options. We enrolled 2978 cases operated on for gallstones and 2627 cases of gastrectomy from 1992 to 2007.
    Symptomatic biliary tract stones were complicated in 2% (53 patients) of post-gastrectomy patients. The rate of bile duct stones in post-gastrectomy patients was higher than that in non-gastrectomy patients. Laparoscopic cholecystectomy for gallstones was feasible. Endoscopic bile duct lithotomy followed by laparoscopic cholecystectomy was considered to be good therapeutic option in the patients in whom endoscopic bile duct intervention could be performed. On the other hand, choledochoenterostomy might be another option in the patients in whom endoscopic bile duct intervention could not be performed.
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Case Reports
  • Takefumi KATSUKI, Mitsuhiro NAKAMOTO, Takayuki TORIGOE, Yoshifumi NAKA ...
    2010 Volume 71 Issue 1 Pages 21-24
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 52-year-old woman was diagnosed as having a nodular goiter eight years prior and was followed using ultrasound. In July 2008, she was taken to hospital by ambulance since she developed dyspnea, cyanosis, and a disturbance of consciousness. Endotracheal intubation was performed. A computed tomography (CT) scan revealed a giant thyroid tumor extending from the neck to the anterior upper mediastinum with marked tracheal stenosis ; she was transferred to our hospital for treatment. Based on fine needle aspiration cytology, anaplastic carcinoma was ruled out. During surgery, the tumor compressed but did not infiltrate the surrounding tissue ; the tumor had a clear margin. A total thyroidectomy was carried out via a cervical incision. On histopathology, the tumor was diagnosed as a minimally invasive, well differentiated, follicular carcinoma. Endotracheal extubation was performed on P.O.D. 4 and the patient's postoperative course was uneventful. Since 1983 there have been only 4 cases of well differentiated follicular carcinoma of the thyroid causing tracheal stenosis reported in Japan. Follicular tumors of the thyroid have the potential of causing tracheal stenosis ; careful follow-up is recommended for patient's with these tumors.
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  • Keiko KOBAYASHI, Hiroshi NAKAGOMI, Kazushige FURUYA, Masato OMORI, Mic ...
    2010 Volume 71 Issue 1 Pages 25-30
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The patient was a 42-year-old woman who noticed a lump in her breast and was examined by a local physician, who referred her to our hospital. Mammography showed a category 4, polygonal mass, 13 mm in size, with unclear margins at its boundaries in the upper inner quadrant of the left breast, and ultrasonography revealed a polygonally-shaped isoechoic lesion with clear margins and no interruption of the anterior margin, diagnosed as category 4. Magnetic resonance imaging (MRI) showed that the mass was densely stained in the early contrast period. Because the mass was class III according to fine-needle aspiration cytology and was diagnosed as atypical ductal adenoma by Mammotome biopsy, partial mastectomy was performed. Tumor tissue was positive on thyroglobulin and TTF-1 staining, indicating that it was derived from the thyroid gland. When the patient was asked about her history of thyroid disease, she mentioned that she had undergone endoscopic thyroidectomy for thyroid follicular adenoma at another hospital seven years earlier. Based on the location of the mass, the patient was diagnosed with port-site implantation occurring after endoscopic thyroidectomy. This case demonstrates the possibility that port-site implantation may occur even in cases diagnosed as benign thyroid adenoma, and it provides a useful reference for future endoscopic surgery.
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  • Takashi KUISE, Mitsuya ITO, Shoichiro OTANI, Kenji HIGAKI, Shinichi TA ...
    2010 Volume 71 Issue 1 Pages 31-35
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    Phyllodes tumor of the breast which accounts for about 0.3-0.5% of all female breast tumors is extremely rare in men. No male cases of the disease have been reported in Japan as far as we could review via Ichushi-web and PUBMED, and only 11 male cases have been seen in the literature. Here we report a male patient with a huge breast tumor which was surgically removed and accordingly diagnosed as phyllodes tumor by pathological examinations, together with a review of the literature.
    A 28-year-old man was referred to the hospital because of an enlarging left breast tumor. There were no noteworthy family histories as well as medical histories. Contrast-enhanced MRI showed an 8cm-sized and well-defined tumor with a segmental margin in the left breast, and almost homogeneously and gradually intensifying enhancement pattern in the inside. A fine needle aspiration biopsy gave no malignant findings, but no definite diagnosis was made. According to patient's preference, the tumor was surgically removed for the purpose of diagnosis and treatment. The histopathological diagnosis was phyllodes tumor of the male breast which is extremely rare.
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  • Shinichiro KUBO, Masahiko IKEDA, Ryoko ONO, Kunihiro OMONISHI, Tatsuak ...
    2010 Volume 71 Issue 1 Pages 36-40
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A woman in her 70s noticed a mass in her right breast and visited our hospital. A 17 mm mass was observed in the E region (nipple-areola region) of her right breast. Mammography revealed a high-density, spiculated mass. Ultrasonography revealed a globular, 15 mm low-echoic mass. When fine-needle aspiration cytology was performed, invasive ductal carcinoma (solid-tubular carcinoma) was suspected. Since the cells had light-green stained, finely granular cytoplasm, the possibility of neuroendocrine differentiation was also considered. A needle biopsy was performed and the tumor was positive for chromogranin A, CD56 and synaptophysin, indicating the presence of neuroendocrine carcinoma. Consequently, the patient was diagnosed with neuroendocrine carcinoma. After a right-sided mastectomy and a sentinel lymph node biopsy were performed, the diagnosis of neuroendocrine carcinoma was confirmed.
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  • Yuichiro MARUYAMA, Hiroyuki HORIUCHI, Etsuyo OGO, Ryuichi KAWAHARA, Hi ...
    2010 Volume 71 Issue 1 Pages 41-44
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of invasive breast cancer with duodenal obstruction due to peritoneal dissemination. A 55-year-old woman with right breast cancer was seen previously at another hospital and underwent right mastectomy in 2006. The other relapse sites could not be detected. She underwent examination for vomiting. As the patient showed no symptomatic improvement in response to conservative treatment, a laparotomy was performed. Peritoneal dissemination to the greater omentum and duodenal obstruction due to peritoneal dissemination were diagnosed.
    We performed gastro-jejunostomy, by the modified Devine method. She has remained alive without bowel obstruction for 6 months to date while being treated with cytotoxic chemotherapeutic agents.
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  • Masahiro WADA, Tomonori FUJIMURA, Motomu TANAKA, Kohichi SUGIURA, Ken ...
    2010 Volume 71 Issue 1 Pages 45-51
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 56-year-old woman visited our emergency department because of abdominal bloating. She had a history of undergoing surgery for left breast cancer at the age of 42. On physical examination, only abdominal distension and mild tenderness were noted. An abdominal plain X-ray revealed ileus, and an abdominal CT scan revealed intestinal obstruction starting from the sigmoid colon. Lower gastrointestinal endoscopy showed a whole-circumferential stenosis of the sigmoid colon, but no evidence of tumorous lesion was present on the mucosal surface. Operative findings showed numerous white nodules in the abdominal cavity, and peritoneal dissemination was thus diagnosed. The stenosis of the sigmoid colon was confined within a markedly narrow segment. Granular white nodules were visible macroscopically in the enlarged ovaries bilaterally. Hartmann's operation and resection of the tumor of the left ovary were conducted.
    Histopathologically, metastasis of the previous breast cancer was present in the muscular layer of the sigmoid colon. This paper presents this case of ileus associated with recurrent peritoneal dissemination and metastasis to the gastrointestinal tract of breast cancer, together with discussion of the literature.
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  • Mitsufumi ENDO, Toshiaki AOKI, Akihiko TSUCHIDA, Tatsuya AOKI
    2010 Volume 71 Issue 1 Pages 52-56
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 71-year-old woman who had undergone left breast-conserving surgery in 2003 was introduced to our hospital because of local recurrence and lymph node metastasis in April 2008. Combination therapy with capecitabine and docetaxel was started in the middle of May. In June, she was admitted to the hospital because of melena. Colonoscopy revealed an extensive ulcerated lesion in the rectal mucosa. We suspected drug induced rectal ulcer and changed to FEC 100 therapy after symptomatic remission was gained with conservative treatment. In September she was re-admitted to the hospital because of constipation and anal pain. Colonoscopy showed stenosis of the lumen of the rectum, but there were not malignant lesions. Because the symptoms due to stenosis were not improved, colostomy was made in October. Operative findings revealed absence of peritoneal metastases, but thickening of the rectal wall was observed. A transanal needle biopsy detected metastasis from breast cancer. Our report is of the 10th case of rectal metastasis of breast cancer in the Japanese literature. We must bear in mind that rectal stenosis in a patient with a history of breast cancer can be metastasis of breast cancer. Further development of adjvant chemo therapy might diversify relapse sites from the disease.
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  • Kuniyuki GOMI, Syoji KAJIKAWA, Kou SHIMADA, Kazuyuki YAZAWA, Hiroshi S ...
    2010 Volume 71 Issue 1 Pages 57-61
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    An 82-year-old woman undergoing right hemicolectomy for ascending colon cancer was pathologically diagnosed with a StageIII Solid poorly differentiated adenocarcinoma, and was given adjuvant tegafur uracil. Three months postoperatively, tumor markers rose and positron emission tomography (PET) detected swollen abdominal paraaortic, mediastinal and left supraclavicular lymph nodes. We diagnosed extensive lymph node metastasis from colon cancer and changed the chemotherapy to mFOLFOX6. Left breast swelling, rubor, and skin nodules gradually appeared. Left breast enhancement on computed tomography (CT) suggested imflammatory breast cancer. Pathological biopsy diagnosis of skin nodules indicated metastasis from ascending colon cancer. The patient died one year and two months after surgery. Metastatic breast cancer from colorectal cancer is rare and that mimicking inflammatory breast cancer has not previously been reported in Japan. This rare case is reported and discussed.
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  • Toshihito HANAOKA, Hiromitsu SUZUKI, Kazuhiko NAKAGAWA, Tetsuji FUKUHA ...
    2010 Volume 71 Issue 1 Pages 62-66
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The patient was a 64-year-old woman with a history of diabetes. She developed bloody sputum and lung hemorrhage in June 2002 and was examined at our hospital. Thoracic computed tomography (CT) revealed a faint ground-glass opacity centered in the left upper lobe. Bronchoarteriography showed that the left bronchial artery was dilated in two places, and embolization was performed. Bloody sputum subsequently decreased, and the lung shadow also disappeared, but a small nodular shadow, 8 mm×5 mm in size, remained in the left upper lobe. The patient remained under observation, and in January 2003, lung hemorrhage reappeared, at which point left lobe resection was performed under video-assisted thoracoscopic surgery. Histological findings were bronchitis with granulation and partly pervaded by mucor fungus, leading to a diagnosis of pulmonary mucormycosis. Six years and two months after surgery, the patient has suffered no recurrence and is attending the diabetes clinic as an outpatient.
    Mucormycosis is a rare disorder with a poor prognosis that most often occurs in patients with depressed immune function. In the case described here, the patient suffered from diabetes, and the mucormycosis could be described as secondary, but saprophytic factors in the small nodular shadow in the left upper lobe in which the mucor fungus adhered and proliferated may also have been involved.
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  • Seijiro SATO, Toru SHIRATO, Ken-ichi TOGASHI
    2010 Volume 71 Issue 1 Pages 67-71
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The patient was a 59-year-old male who had no significant medical history. He developed breathing difficulties and was diagnosed as having a spontaneous pneumothorax based on X-ray findings. The chest CT revealed bullae in the apex and S6 region of the left lung, and an adjacent small nodule, 8 mm in diameter. A chest tube was placed, and he was discharged. However, the pneumothorax recurred the next month Surgery was done to remove the tumor and bullae. It was found that air was leaking from the bulla in the apex.
    On histology, the tumor had a herring bone pattern, mitosis was abundant, and the MIB-1 index was high ; a spindle cell sarcoma was suspected. Further examinations revealed that no other organ was the site of the primary lesion. Based on the immunohistochemistry results, pulmonary blastoma and synovial sarcoma were considered in the differential diagnosis. The fused gene characteristic of synovial sarcoma was not detected. Thus, a definite diagnosis could not be made. During 3 years and 9 months of follow-up, no sarcoma lesions have been identified ; the patient remains recurrence free.
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  • Takeshi MATSUTANI, Eiji UCHIDA, Hiroshi MARUYAMA, Seiji SUZUKI, Akihis ...
    2010 Volume 71 Issue 1 Pages 72-76
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 66-year-old woman was hospitalized because of dysphagia and weight loss. Esophagoscopy showed a type 3 tumor at the middle thoracic esophagus, and endoscopic biopsy confirmed adenocarcinoma of the esophagus. The CEA level before the operation was 43.3 ng/ml. Abdominal and chest CT examination revealed lymph node metastases. The clinical stage was III (T3, N2, M0). A subtotal esophagectomy with right thoracotomy was performed. The pathological diagnosis was Barrett's esophageal cancer, moderately differentiated adenocarcionma and lymph node metastases (pT3, pN2, sM0, ly1, v0, fStageIII). Barrett's epithelium was found from the esophagogastric junction to the anal margin of the tumor, but not on the oral side of the tumor. Immunohistological staining for CEA was positive. After surgery, the CEA level decreased to normal range. Adjuvant chemotherapy with docetaxel, cisplatin and 5-FU was administered. After this therapy, CT examination showed liver and lung metastases. We then conducted TS-1/CPT-11 as second-line chemotherapy. Her disease has remained stable since she undergwent this chemotherapy.
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  • Kunihiko KANEDA, Akiko OKAMOTO, Manabu TAKAMATSU, Masanori TAKAHASHI, ...
    2010 Volume 71 Issue 1 Pages 77-82
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a patient with squamous cell carcinoma of the esophagus who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) after receiving cisplatinum (CDDP) and 5FU. The 58-year-old woman was admitted to hospital complaining of dysphagia and an esophageal carcinoma was diagnosed. Surgery was planned to be done after neoadjuvant chemotherapy. She was treated by CDDP and 5FU. However, five days following chemotherapy, the patient developed a neurological disorder and severe general fatigue ; her serum sodium concentration decreased from 142 mEq/l to 111 mEq/l. SIADH induced by CDDP administration was diagnosed, based on her hyponatremic state, the hypo-osmolality of her serum, the hyperasmolality of her urine, and her inappropriate level of plasma vasopressin. Four weeks following neoadjuvant chemotherapy, a radical esophagectomy was performed. After the operation, the same chemotherapeutic regimen was given, and SIADH reoccurred. Thus, this case, the SIADH was thought to be induced not by the esophageal carcinoma but by CDDP.
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  • Shinichiro KAMEYAMA, Hiroyuki KOAMI, Tomonari ISHIMINE, Tsutomu ISA, F ...
    2010 Volume 71 Issue 1 Pages 83-86
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 47-year-old man had an omental patch repair for a perforated duodenal ulcer in December 2002. Due to a rebleed that occurred 8 days later, he required a distal gastrectomy with a Roux-en Y reconstruction for a duodenal ulcer. In October 2005 he developed systemic edema. Colonoscopy and upper gastrointestinal series revealed a gastrojejunocolic fistula. Partial resection of the gastrojejunostomy and the transverse colon including the fistula was performed in April 2006. The most common symptoms of this disease include diarrhea and weight loss. Therefore, it should be considered in the differential diagnosis in patients who develop these symptoms after a distal gastrectomy.
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  • Tadao MIZOGUCHI, Yoshikazu UENOSONO, Takaaki ARIGAMI, Sumiya ISHIGAMI, ...
    2010 Volume 71 Issue 1 Pages 87-93
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 77-year-old woman was admitted to our hospital because of an increasing gastric submucosal tumor with an intraluminal growth. Laparoscopic surgery was performed using 4 ports. After the location of the tumor was intraoperatively confirmed by an endoscope, the resection line was determined. The full thickness of the gastric wall was endoscopically incised at 4 sites around the tumor using a needle-knife. The lesion was laparoscopically removed from these incised sites using laparosonic coagulating shears. After temporary sutures using tractile fibers with a loop, a simple closure was performed by endocutter. The histopathological diagnosis was low-grade-GIST and the surgical margin was free from tumors. The patient was discharged without postoperative complications.
    In the treatment of GIST with an intraluminal growth, this approach is a useful and simple procedure with safety surgical margin and minimal removal of the stomach wall.
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  • Ryuichiro OHASHI, Yuji ONODA, Masaki TOKUMO, Tomo OKA, Toshiki YAMAKAW ...
    2010 Volume 71 Issue 1 Pages 94-98
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    Palliative bypass operations were performed in five cases with Y-limb obstruction due to peritoneal recurrence of gastric carcinoma. One distal gastrectomy and four total gastrectomies had formerly been done. All five cases underwent Roux-en-Y reconstruction. The histological type of gastric carcinoma was poorly differentiated adenocarcinoma in all patients. Peritoneal dissemination and/or intraperitoneal lavage cytology were positive in four cases. The average period from gastric resection to bypass surgery was 448 days, and from bypass surgery to death 82 days. Four cases could be discharged from the hospital, and two required home infusion therapy with parenteral nutrition. The average home stay period was 38 days. The clinical course of a 67 year-old lady is described as a representative case. Y-limb obstruction requires emergent treatment. However, it is difficult to decide surgical indications because of patients being end stage. Medical treatments should be given to every patient based on informed consent.
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  • Takafumi HIRATA, Shuichi KUME, Tatsuo KUBOTA
    2010 Volume 71 Issue 1 Pages 99-103
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    Extramedullary plasmacytoma of the stomach is a very rare disease.
    A 66-year-old woman visited our hospital with upper abdominal pain and appetite loss. Endoscopy revealed three white slightly elevated lesions on the greater curvature from the lower body of the stomach. A biopsied specimen suggested gastric plasmacytoma without H.Pylori. We detected no other lesions or abnormal laboratory data, and thus performed a distal gastrectomy. After the operation, immunohistochemical findings showed atypical plasma cells with Russell bodies and monoclonalλchain staining. Tumor cells invaded the mucosal layer with no lymph node metastasis. The patient remains alive without recurrence 38 months after the operation.
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  • Shigeo YAMASHITA, Naoto TAKAHASHI, Atsushi WATANABE, Norio MITSUMORI, ...
    2010 Volume 71 Issue 1 Pages 104-108
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    While hospitalized in our department of internal medicine for the treatment of allergic purpura and nephrotic syndrome, a 61-year-old male patient developed abdominal pain. A workup revealed free gas in the abdominal cavity and the patient was diagnosed as having a perforated duodenal ulcer. He underwent CT-guided drainage and received proton-pump inhibitor (PPI) therapy while the dose of steroids was reduced. He underwent emergency surgery since the perforation recurred, but drainage alone was performed since the perforation was not identified at that laparotomy. Improvement in the patient's general condition was awaited. 2 weeks later, under the judgment that the patient was having intractable duodenal ulcer with posterior wall perforation, surgery was performed again. There was a large base of the ulcer in the upper half of the descending part of the duodenum and a flow of bile from the base was observed. Intraoperative cholangiography was performed and the cholangiogram from the ulcer base only showed the common bile duct. The patient was diagnosed as having choledochoduodenal fistula and selective gastric vagotomy, partial gastrectomy and cholecystojejunostomy were performed. The postoperative course was uneventful. The patient achieved remission and was discharged from the hospital. While peptic ulcers are usually managed with medical therapy such as PPI therapy, duodenal ulcers penetrating the common bile duct as in the patient of this case should be managed with surgical intervention.
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  • Akihiro OSAWA, Manabu WATANABE, Koji ASAI, Hiroshi MATSUKIYO, Tomoaki ...
    2010 Volume 71 Issue 1 Pages 109-113
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 64-year-old woman was admitted to the hospital with a diagnosis of obstructive jaundice. Abdominal ultrasonography, CT scan, upper gastrointestinal endoscopy, and ERCP provided the diagnosis of obstructive jaundice due to a tumorous lesion of the papilla of Vater. As a result of a biopsy, carcinoma of the papilla of Vater was diagnosed. After relief of obstructive jaundice by EBD, subtotal stomach-preserving pancreatoduodenectomy was performed. The histopathological diagnosis was adenoendocrine cell carcinoma.
    A total of 10 cases of adenoendocrine cell carcinoma of the duodenum, including our case, have been reported in the Japanese literature. The disease has a high grade malignant potential and carries an extremely poor prognosis even curative resection followed by adjuvant chemotherapy is performed. In this case hepatic metastasis has already been confirmed at the time of operation. Oral administration of S-1 as postoperative adjuvant chemotherapy failed to suppress the gradual progress of the disease, and the patient died 14 months after the operation. We here present this case of adenoendocrine cell carcinoma of the papilla of Vater, together with a review of the Japanese literature.
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  • Daisuke KITAMURA, Eiichiro SEKI, Hirohumi GONDA
    2010 Volume 71 Issue 1 Pages 114-118
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 70-year-old male patient with rectal cancer underwent Miles' operation in April 2005. In June 2006, a computed tomography (CT) scan revealed local recurrence in the presacral region and lung metastases. In July 2006, the patient received pelvic irradiation at a total dose of 50 Gy. He also received modified FOLFOX6 chemotherapy. After a total of 28 courses, a CT scan showed that local recurrence is a stable disease (SD) while yet lung metastases being a progressive disease (PD). In April 2008, therefore, he received FOLFIRI2 instead of modified FOLFOX6 in combination with bevacizumab. There was no change (NC) during a total of 19 courses. In Mach 2009, 5 days after the last dose, the patient suddenly developed abdominal pain and a fever and visited the outpatient department. A CT scan showed gastrointestinal tract perforation. The patient was diagnosed with peritonitis and underwent emergency surgery. Since an ileal perforation was observed, the small bowel was partially resected. Drainage was performed and an artificial anus was made in the ileum. Gastrointestinal tract perforation is one of the most serious adverse events associated with bevacizumab. Risk following irradiation is known to be high and it is considered that utmost care is required at treatment.
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  • Yuki HOMMA, Yosiro OBI, Nobuyuki KAMIMUKAI, Yutaka NAGAHORI, Tetsuo AB ...
    2010 Volume 71 Issue 1 Pages 119-122
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of ileus caused by an appendix epiploica. The patient was a 63-year-old man who was referred to our hospital with abdominal pain and vomiting. He had no history of previous abdominal surgery. He was diagnosed as having an ileus, and a long tube was inserted. He improved steadily over 7 days, but was then started on water. His acute abdominal pain reccurred. Therefore, a laparotomy was performed. During surgery, the ileum was found to be obstructed by a loop of appendix epiploica of the sigmoid colon. The appendix epiploica was resected, and the ileus was relieved ; bowel resection was not required.
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  • Junjiro KATSURADA, Masatoshi KAWAMURA, Takeo OGINO, Tsuyoshi TAKAHASHI ...
    2010 Volume 71 Issue 1 Pages 123-127
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The patient was a 76-year-old woman. Low anterior resection was performed for rectal cancer in 2004. The serum CEA level started to increase 16 months after the operation, and was 8.0ng/ml 19 months after the operation. Abdominal contrast CT revealed no abnormal findings. FDG-PET/CT was performed and a malignant tumor of the ileum was strongly suggested because of high FDG accumulation to the ileum. Therefore, we diagnosed metastatic small bowel cancer. She underwent laparotomy, and a partial resection of the ileum was performed. On histopathology, the intestinal tumor was diagnosed as a rectal cancer metastasis. Chemotherapy was conducted after the operation, and no signs of recurrence have been observed to date. We report a case of metastatic small bowel cancer discovered by FDG-PET/CT after surgery for rectal cancer together with a literature review.
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  • Kazuteru WATANABE, Tamaki NOIE, Kei ITO, Yasushi HARIHARA, Kaoru FURUS ...
    2010 Volume 71 Issue 1 Pages 128-131
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of renal cell carcinoma (RCC) metastasis to the small intestine that was diagnosed preoperatively. A 68-year-old man who underwent right renal resection for RCC at age 58 was referred to our hospital with persistent melena. The focus of bleeding was not identified on upper gastrointestinal endoscopy or colonoscopy. Therefore, the small intestine was examined. The elevated mass was seen on capsule endoscopy. Double balloon enteroscopy revealed an ulcerative tumor in the ileum about 180 cm from the ileocecal valve. An endoscopic forceps biopsy specimen showed metastasis of RCC to the small intestine. The small intestine was partially excised. The histopathological diagnosis was metastasis of RCC. After 7 months, the small intestine was partially excised again for RCC recurrence to the small intestine. Metastasis of RCC to the small intestine is rare and difficult to diagnosis before surgery. However, early detection of RCC metastasis contributes to prognosis and QOL. Capsule endoscopy and double balloon enteroscopy should be used for patients suffering from past RCC.
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  • Yasukatsu TAKUSHI, Naoyuki YOKOYAMA, Shiro KUWABARA, Toshiyuki YAMAZAK ...
    2010 Volume 71 Issue 1 Pages 132-136
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of cecal cancer associated with acute appendicitis. A 74-year-old man was brought into our hospital by ambulance because of lower abdominal pain. There was muscle guarding in the right lower quadrant of abdomen. Abdominal CT scan showed ascites in the right lower abdominal cavity and intraabdominal free air. Emergency laparotomy was performed under a diagnosis of panperitonitis due to gastrointestinal perforation. The remarkably swollen appendix perforated with severe inflammation, and a tumor 2 cm in diameter was found in the cecum, necessitating ileocecal resection. The histopathological diagnosis was gangrenous appendicitis with cecal cancer, type 1, 3.5×2.5 cm in size, well differentiated adenocarcinoma (pSE, ly0, v0, n1, H0, P0, stageIIIa) and the operation resulted in curability A. The patient developed peritoneal dissemination 8 months after the surgery, despite adjuvant chemotherapy. Therefore, the patient was treated by another course of chemotherapy (FOLFOX6). Acute appendicitis caused by cecal cancer is rare. To avoid overlooking cecal cancer, it is important to consider intraoperative exploration.
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  • Koji DAIRAKU, Koshiro UEDA, Takahiro KAMOTA, Kentaro FUJIOKA
    2010 Volume 71 Issue 1 Pages 137-140
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The symptoms associated with intramesenteric perforation of the colon progress slowly compared to the symptoms associated with intraperitoneal perforation. This makes it difficult to confidently diagnose the condition. Should be stercoral peritonitis, then the prognosis is poor. We treated a case of intramesenteric perforation of the sigmoid colon with reproperitoneal emphysema. A 79-year-old man was admitted complaining of lower abdominal pain that had developed two days after a barium upper gastrointestinal tract study. On admission, abdominal CT scan revealed massive feces and residual barium in the sigmoid colon ; emphysematous changes were noted in the circumference of the sigmoid colon. Emphysematous changes were also diffusely present up to the pancreatic dorsal area in the retroperitoneal space. An emergency operation was performed under a diagnosis of perforation of the sigmoid colon. On laparotomy, a perforation was present in the mesenteric side of the sigmoid colon ; it was about 4 cm in diameter. Hartmann's operation was performed with resection of the perforated sigmoid colon. The patient was discharged on the 26th day after surgery. About 4 months after the operation, the patient had surgery to close his stoma. He is currently well.
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  • Kazuhiro MITSUYOSHI, Yasunobu ASAO, Chuji TAKAMURA
    2010 Volume 71 Issue 1 Pages 141-144
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of ulcerative colitis associated with cytomegalovirus infection causing a splenic abscess.
    A 75-year-old man with sepsis and high fever was brought into our hospital by ambulance. A abdominal CT scan disclosed a splenic abscess. We treated the abscess by ultrasonography-guided percutaneous drainage, but the fistula remnant was left. We thus conducted diverting transverse colostomy for persisting colonosplenic fistula. One month later, we successfully performed left hemicolectomy without splenectomy. The pathological diagnosis was ulcerative colitis with cytomegalovirus infection. Cytomegalovirus infection, which is at times associated with intractable ulcerative colitis, has recently been considered an refractory factor in ulceration and fistulation of ulcerative colitis. Colonosplenic fistula should be taken into account in cases of ulcerative colitis with cytomegalovirus infection.
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  • Takehiro SAKAI, Yuta OGURA, Junichi NARITA, Fuminori WAKAYAMA, Hiroyuk ...
    2010 Volume 71 Issue 1 Pages 145-149
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 65-year-old man was diagnosed as having small cell carcinoma of the lung ; he had cancer pain and was treated with anticancer drugs and oxycodone. The patient developed abdominal pain 17 days after the final anticancer drug treatment. His temperature was 39.7°C ; he had tenderness and muscular guarding in the right lower abdomen. His white blood cell count was 3,000/μl, and the serum CRP level was 1.53 mg/dl. Abdominal computed tomography (CT) showed colonic diverticulitis ; conservative therapy with antibiotics was started. Although the muscular guarding improved, tenderness and inflammatory change continued. Abdominal CT on the 5th hospital day showed a pericecal abscess. A laparotomy revealed a pericecal abscess due to perforation of colonic diverticulitis ; an ileocecal resection was performed. The patient was transferred to the department of respiratory medicine on the 26th postoperative day. Although the patient was treated with chemotherapy, he died 7 months after surgery. Conservative therapy for colonic diverticulitis is sometimes ineffective in patients undergoing chemotherapy for malignancies even if bone marrow suppression is not evident. Therefore, surgery should be considered based on a careful evaluation of the clinical and laboratory findings.
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  • Tatsunari FUKUOKA, Eiji NODA, Kiyoshi MAEDA, Toru INOUE, Yukio NISHIGU ...
    2010 Volume 71 Issue 1 Pages 150-153
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A man in his seventies who had undergone preoperative chemotherapy for bladder cancer and pulmonary metastasis followed by transurethral resection of the bladder tumor had been followed in the clinic. When about 8 months had elapsed after the operation, an abdominal CT scan showed swelling around the left common iliac artery and a tumor shadow in the ascending colon. Further a colonoscopy disclosed a type 1 tumor at the ascending colon. We performed right hemicolectomy for the ascending colon tumor and at the same time lymph node dissection around the left common iliac artery was done. As a result, both the ascending colon tumor and lymph nodes swelling around the right common iliac artery were histopathologically diagnosed as metastasis of bladder cancer.
    Since metastatic colon cancer is rare, this case is presented here with some bibliographical comments.
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  • Kanji ISHIHARA, Kazuhisa KANEDA, Masayuki SAKAE, Chie WATANABE, Syougo ...
    2010 Volume 71 Issue 1 Pages 154-158
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    In the conservative treatment of ileus a long intestinal tube is widely used for decompression or as a stent. Rarely is perforation or intussusception is reported as a complication. However, reported cases of intussusception caused by long intestinal tube are increasing. An 82-year-old woman developed nausea and a sense of fullness. Abdominal X-ray and ultrasonography showed a very dilatated small intestine and ascending colon. She was diagnosed as having an ileus. A long intestinal tube was inserted for decompression ; her abdominal distension decreased. Under careful examination, a transverse colon cancer was detected. The long intestinal tube continued to function well. But 7 days later, she vomited again and the discharge from the long intestinal tube decreased. Her abdominal wall became distended, and a sausage-like, painless soft mass was palpable. An intussusception was diagnosed based on the abdominal CT findings. The patient had surgery ; a jejuno-jejunal ante-grade intussusception was noted 20 cm from Treitz's ligament. It is necessary to consider the possibility of intussusception, when a long intestinal tube is used for decompression, stenting, or after removal. During the insertion and after the removal of the long intestinal tube, it is important to observe the abdominal using ultrasonography and CT.
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  • Yoshiro ITATANI, Kazuyuki KAWAMOTO, Tadashi ITO, Keizo OGASAHARA, Kenj ...
    2010 Volume 71 Issue 1 Pages 159-163
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    A 70-year-old man developed proximal limb muscle pain and difficulty moving. He was diagnosed with rhabdomyolysis due to high serum creatine phosphokinase (CK) and creatinine levels. He was treated with rest and intravenous fluids, but was left with some muscle weakness and dysphagia. Therefore, he was referred to our hospital ; diagnosis of polymyositis was made based on his high CK level (3,059 IU/l), electromyogram, and femoral muscle MRI. He was also diagnosed as having sigmoid colon cancer and liver metastasis based on abdominal CT scan and colonoscopy results. He was thought that his polymyositis might have been due to his colon cancer. He had a sigmoidectomy and hepatectomy. After surgery his CK level immediately decreased to 585 IU/l and normalized over 3 months. His muscle strength gradually improved. It is known that dermatomyositis and malignancy can occur concominantly. However, polymyositis present concomitantly with colon cancer is rare.
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  • Yoshiyuki MORI, Hiroshi IINO, Fumihiko MITSUI, Tadashi HYUGA, Hideki F ...
    2010 Volume 71 Issue 1 Pages 164-168
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The patient was a 59-year-old man who underwent preoperative chemoradiotherapy for lower rectal cancer in February 2003, followed by low anterior resection in March 2003 (pStageIIIa). Anastomotic breakdown occurred after the surgery and colostomy was made. The drain region became a fecal fistula, but the fistula spontaneously closed. The colostomy was closed in May 2004 after confirming the absence of anastomotic breakdown by imaging. However, the fecal fistula recurred in the left lower abdomen in April 2005. Percutaneous infusion of fibrinogen failed to close the fistula. Then a contrast imaging catheter for ERCP was inserted by about 5 cm endoscopically via the anus and cyanoacrylate was infused. The fistula was closed and no recurrence has occurred as of 3 years and 10 months after the infusion. This case shows that a fistula due to anastomotic breakdown following digestive tract surgery, particularly after radiotherapy, may become intractable and difficult to treat. Endoscopic cyanoacrylate infusion was effective in our case.
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  • Yosihiro MORIGUCHI, Seiichiro YAMAMOTO, Shin FUJITA, Takayuki AKASU, Y ...
    2010 Volume 71 Issue 1 Pages 169-173
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    A 57-year-old woman had a low anterior resection for rectal cancer. In the eighth postoperative month, she underwent an abdominoperineal resection for an anastomotic recurrence. Thereafter she developed two intrapelvic recurrences. After the first recurrence, a hystero-oophorectomy was done ; for each recurrence the tumor was resected, and chemotherapy as well as radiotherapy were given. Seven months after the last therapy, she was diagnosed as having yet another intrapelvic recurrence. A total pelvic exenteration with sacratomy (TPES) was done. The pathological diagnosis was a well differentiated adenocarcinoma, and a complete resection was achieved. There were no signs of recurrence for six years at which time until she was killed in a traffic accident. Extended surgery for intrapelvic recurrent rectal cancer, often achieves a negative margin resection, which leads to long-term survival. Extended radical surgery might be beneficial for repeat intrapelvic recurrences.
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  • Kiichi SUGIMOTO, Masaki FUKUNAGA, Yoshihito IIDA, Masahiko SUGANO, Kaz ...
    2010 Volume 71 Issue 1 Pages 174-179
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    The development of a well-differentiated hepatocellular carcinoma with a diameter of 20 mm or larger is considered rare. Herein, we report a case of a well-differentiated hepatocellular carcinoma 70 mm in diameter with no dedifferentiation observed throughout the entire tumor on histopathololy. The subject was a male in his 50s who was diagnosed with hepatic hemangioma in August 2004. The 30-mm hepatic tumor developed into a 70-mm tumor by February 2006. Thus, the patient was referred to our hospital. Abdominal ultrosonography showed hypoechoic margin ; the interior of the tumor was comparatively isoechoic. Abdominal CT scan and angiography showed a densely-stained tumor margin and an arterial-predominant phase of the hypervascular tumor. Since a classical hepatocellular carcinoma was suspected, resection of the right hepatic lobe was performed. On histopathological examination, no dedifferentiation was observed throughout the entire tumor ; it was thus diagnosed as a well-differentiated hepatocellular carcinoma. To date, 3.5 years after the surgery no recurrences have been noted.
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  • Hiromichi MIYAGAKI, Shogo KOBAYASHI, Hiroaki NAGANO, Yutaka TAKEDA, Ma ...
    2010 Volume 71 Issue 1 Pages 180-186
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    Lemmel Syndrome, which is cholangitis and/or pancreatitis due to intraduodenal diverticulum, is rarely experienced. Indication for surgery is considered for severe and/or repeated symptoms. We report herein a case of Lemmel syndrome with pancreaticobiliary maljunction, with a review of the literature.
    A 49-year-old male complaining of general fatigue, upper abdominal pain, jaundice and nausea was admitted to our hospital in May 2008. Contrast-enhanced abdominal CT scan revealed the stenosis of the lower common bile duct due to duodenal diverticula, and thickening of the gallbladder wall. He was diagnosed as having Lemmel syndrome and suspected gallbladder cancer with acute pancreatitis and cholangitis. After recovery from these inflammations we conducted resection of the diverticulum and cholecystectomy with liver bed resection. Because intraoperative cholangiography revealed pancreaticobiliary maljunciton, we added bile duct resection and choledocojejunostomy. On the 16th post-operative day he was discharged without any complications. Of 97 previously reported cases, surgery was performed in 69 cases (71.1%) including 18 cases in which surgery was done for bouts of recurrence after conservative treatment. We consider that candidates for surgery must always be selected in terms of possible recurrence of the disease and complications.
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  • Osamu OKOCHI, Masashi HATTORI, Hidenobu MATSUSHITA, Kenji TSUBOI, Nobu ...
    2010 Volume 71 Issue 1 Pages 187-190
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of hilar cholangiocarcinoma recurrence in the abdominal wall involving the liver and stomach, in which we used a Composix Kugel Patch® to repair the abdominal wall defect. A 62-year-old man who had undergone extended right hepatectomy 3 years earlier was found to have an upper abdominal wall tumor, diagnosed by aspiration biopsy cytology as a recurrence. Computed tomography showed a 3×3×4 cm abdominal tumor invading the liver and stomach. He underwent tumor resection with partial liver and stomach resection. We repaired a 6×10 cm abdominal wall defect with a Composix Kugel Patch®. The infection-free postoperative course was uneventful and he has been followed up without recurrence. The prosthesis was useful for repairing the abdominal wall defect caused by malignant neoplasm recurrence.
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  • Hiroyoshi MATSUKAWA, Hiroshi SADAMORI, Hiroaki MATSUDA, Susumu SHINOUR ...
    2010 Volume 71 Issue 1 Pages 191-195
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 5-year-old girl was diagnosed as having persistent hyperinsulinemic hypoglycemia of infancy (PHHI) after birth. Medical treatment with octreotide prevented severe hypoglycemic attacks, but daily frequent blood sugar tests and supplementary snacks were needed to control the irregular onset of hypoglycemia. The patient was obese and had severe fatty liver due to the over-nutrition related to her hyperinsulinemia. The mapping of insulin levels by percutaneous transhepatic portal venous sampling revealed that the hyper-secretion of insulin occurred predominantly in the body to tail of the pancreas. She underwent a spleen-preserving distal pancreatectomy (SPDP). Diffuse type of nesidioblastosis was diagnosed. After surgery the octreotide could be discontinued, and her weight became nearly normal ; she did not have diabetes mellitus. In the treatment of PHHI, long-term medical control increases the risk of adverse drug effects ; on the other hand, a 95% subtotal pancreatectomy for PHHI refractory to medical control induces diabetes mellitus after a long period of time. Thus, a SPDP might have the potential to effectively deal with these issues.
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  • Satoshi KIYOTA, Masato OOKAWA, Takashi TSUKAZAKI, Ikuho KOYAMA, Yoshit ...
    2010 Volume 71 Issue 1 Pages 196-200
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    An external pancreatic fistula occurring after pancreaticoduodenectomy may become intracTable and difficult to treat. We report here a case in which interventional internal drainage was successfully used to treat a complete external pancreatic fistula following pancreaticoduodenectomy.
    The patient was an 80-year-old woman. Pancreaticoduodenectomy was performed to treat duodenal papillary carcinoma. Following the surgery, an intraperitoneal abscess developed as a result of rupture of the sutures of the pancreatojejunal anastomosis. The abscess cavity was converted to a fistula when internal drainage and other conservative treatment was performed, and a complete external pancreatic fistula was diagnosed by fistulography. Since imaging showed that the fistula and the jejunum were adjacent to each other, an internal drainage catheter was inserted into the jejunum from the pancreatic fistula under fluoroscopy and ultrasound observation ; it was placed within the jejunum to provide internal drainage. The patient's postoperative course was uneventful, and today, 13 months after undergoing internal drainage, the patient has no symptoms of pancreatitis or glucose tolerance abnormalities and is continuing to do well.
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  • Masahiro KAWABATA, Tsukasa IHARA, Masanori AKASHI, Akira MATSUNAGA, Ma ...
    2010 Volume 71 Issue 1 Pages 201-207
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 68-year-old man who had been followed for diabetes mellitus at another hospital developed poor appetite and weight loss from around July 2005. Upper gastrointestinal endoscopy performed at the hospital on August 6, 2005 revealed an elevated lesion about 5cm in diameter slightly proximal to the papilla of Vater at the descending portion of duodenum. Biopsy specimen disclosed only necrotic tissue without malignant findings. The patient was referred and admitted to our hospital for close exploration and treatment on September 5, 2005. Although no definite diagnosis was made before surgery, pylorus-preserving pancreato-duodenectomy was performed with a diagnosis of primary duodenal cancer on September 16. Histopathologically the tumor was present in the proper muscular layer of the duodenum, and was composed of adenocarcinoma (about 50%), squamous cell carcinoma and adenosquamous cell carcinoma (about 15%), and sarcomatoid tumor (about 35%). Furthermore ectopic pancreas coexisted with ductal adenocarcinoma in the proper muscuhlar layer, suggesting that the tumor had been derived from the pancreatic duct.
    In this paper we report this case of ductal carcinoma of the pancreas associated with sarcomatoid component in the duodenum which might be derived from the ectopic pancreas. The patient's postoperative course has been uneventful. Some bibliographical comments are also presented.
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  • Hiroki MORIYAMA, Taichi KOYAMA, Junichi TANAKA, Takeshi TERASHIMA, Shi ...
    2010 Volume 71 Issue 1 Pages 208-211
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    A 48-year-old woman developed sudden lower abdominal pain at midnight, and was emergently conveyed to our hospital. An abdominal pain CT suggested ileus. She was thus admitted. The abdominal pain worsened. Therefore, contrast CT was repeated and ascites was recognized and also deteriorating dilatation of the small intestine loop. Because the small intestine loop was revealed in a limited area and malposition of the intestinal tract was doubtful, with the possibility of an internal hernia in mind, an emergency operation was conducted about 15 hours later under a diagnosis of strangulated ileus of the small intestines. Laparotomy revealed an abnormal defect approximately 2cm in diameter in the sigmoid mesocolon, through which the small intestine had herniated, and had been strangulated. Thus, ileus was diagnosed due to the transmesosigmoid hernia. Only closing the defect after repositioning the herniated intestine allowed the operation to be finished without intestinal resection. On the fifth post-operative day, the patient was discharged. Transmesosigmoid hernia is rare and the Japanese literature was thus reviewed.
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  • Tsunehiko MARUYAMA, Toshiro TAKAGAKI, Nobuhiro OHKOHCHI, Yukio MORISHI ...
    2010 Volume 71 Issue 1 Pages 212-215
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    We report herein a case of mesenteric desmoid tumor of the small intestine. A 69-year-old man was being followed in our hospital for chronic obstructive pulmonary disease and hypertension. Because a blood test showed hypoalbuminemia and tumor marker elevation, abdominal CT was performed and a 20 cm in diameter tumor was detected. Although the tumor compressed the intestines, there was no apparent invasion of the intestinal tissue even on colonic enema. Tumor blood supply from a superior mesenteric artery was demonstrated on angiography. The origin was unknown, but surgery was performed under a presumptive diagnosis of intraabdominal tumor. The tumor was located in the mesentery 110cm from Treitz' ligament, and there was no adhesion around the circumference of the lesion. We resected the tumor along with the mesenterium and small intestine. The resected specimen showed a yellowish white solid tumor measuring 18×15×9cm, and weighing 1,400g. Pathologic examination showed loose growth of spindle-shaped cells with abundant fibrous stroma and hyalinization. Based on these findings, we established a diagnosis of the mesenteric desmoid tumor of the small intestine. The patient has been followed postoperatively for five years and there has been no sign of recurrence, to date.
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  • Satoshi KUBOTA, Yoshinori KAGAWA, Hiroaki KATO, Junzo SHIMIZU, Kimimas ...
    2010 Volume 71 Issue 1 Pages 216-220
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    A 27-year-old male developed a swelling in his right inguinal area, and was as having a right inguinal hernia. However, during surgery, only a lipoma was found ; there was no hernial sac. The lipoma was excised. A right inguinal swelling presented again 10 months later, and he was readmitted 14 months after the initial operation. A right inguinal hernia was diagnosed because the lesion enlarged on standing. An operation was done. A hernia sac was not found during surgery. A lipoma was found that protruded through the internal inguinal ring at the lateral aspect of the cold. It was resected. On pathology, a well-differentiated liposarcoma was diagnosed. Abdominal enhanced CT showed that the mass extended from the inferior pole of the right kidney to the inguinal area. A retroperitoneal liposarcoma was diagnosed ; it was removed. Retroperitoneal liposarcoma presenting as an inguinal swelling is rare. In fact, only 7 cases including the present case have been reported in Japan. We report a rare case of a liposarcoma presenting as an inguinal swelling.
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  • Shunji KINUTA, Naoki KOSHIISHI, Masaru MATSUMURA, You HIRAI, Hiroshi W ...
    2010 Volume 71 Issue 1 Pages 221-224
    Published: 2010
    Released on J-STAGE: July 16, 2010
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    A 54-year-old man, with alcoholic cirrhosis and intractable ascites was admitted due to leakage of massive amounts of ascites. An abdominal CT showed rupture of the umbilical hernia and prolapse of the omentum. Emergency surgery was required. The prolapsed omentum was resected ; a 2 cm in diameter hernial orifice and massive ascites were found in the peritoneal cavity. An indwelling drain was placed into the peritoneal cavity, and the hernial orifice was closed. Postoperatively, the ascitic fluid was drained via the indwelling drain to decrease tension on the hernial orifice. There were no complications, and the patient was discharged.
    In adults rupture of an umbilical hernia is very rare. Only four cases, including our case, have been reported in Japan to date. In only two of these cases Moreover, intra-abdominal organ prolapse was present concomitantly.
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  • Tetsuhiro GOTO, Tomotake ARIYOSHI, Kentaro NAKAO, Nobuaki MATSUI, Mits ...
    2010 Volume 71 Issue 1 Pages 225-229
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    An 82-year-old man was seen at the department of internal medicine in our hospital because of abdominal pain and vomiting. There was no history of laparotomy. Thereafter he developed anal bleeding and emergency upper and lower gastrointestinal endoscopies disclosed bleeding from the small intestine. Following various examinations, strangulated ileus was suspected and emergency laparotomy was performed at our surgical department. Upon laparotomy, and about 76-cm portion of the jejunum 40cm apart from the Treitz ligament had been impacted and strangulated as it was sandwiched between the greater omentum and descending colon, where had become necrotic. The hernia opening was released and the necrotic intestine was removed. The postoperative course was uneventful, however, the patient died of aspiration pneumonia at a day when his discharge day became close.
    Internal hernias are comparatively rare and lack characteristic clinical findings, leading to difficulties in making the preoperative diagnosis. This case of internal hernia which was caused by the jejunal incarceration into the normal anatomical structures is considered rare, so that this case is reported here together with a review of the literature.
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  • Yuichiro KAWASAKI, Satoshi SUGAWARA, Hajime SATO, Takashi SAKAMOTO
    2010 Volume 71 Issue 1 Pages 230-234
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    The patient was a 74-year-old man who repeatedly repositioned his inguinal hernia. He was examined by a local physician with a chief complaint of vomiting and was referred to our hospital for further examination and treatment. At the time of initial examination, only distension of the abdomen was observed, with no swelling in the right inguinal area, rebound tenderness or muscle guarding. Abdominal X-ray revealed marked small intestinal gas, and abdominal computed tomography (CT) scanning showed spherical dilation of the small intestine in the lower right abdomen. Ileus was diagnosed, but as there were few abdominal findings and no distension of the right inguinal area, treatment by fasting and long tube insertion was started. As decompression was ineffective and the same findings were again observed on a further abdominal CT scan, surgery was performed. Part of the small intestine had protruded through the deep inguinal ring and was trapped in the anterior peritoneal cavity, resulting in ileus due to the false reduction of a right inguinal hernia. The intestine was repositioned using the water pressure method ; however, the incarcerated portion of the small intestine was resected due to concern regarding impaired blood flow to the strangulated area. The patient's postoperative course was favorable, and the patient was discharged from hospital 14 days postoperatively. False reduction of an inguinal hernia is extremely rare. This report includes a short discussion of the literature.
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  • Akihiro YASUMOTO, Hiromi TOKUMURA, Ken-ichi TAKAHASHI, Naoki MATSUMURA ...
    2010 Volume 71 Issue 1 Pages 235-238
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    We report a case of femoral hernia with incarceration of the vermiform appendix diagnosed using magnetic resonance (MR) imaging.
    An 83-year-old woman had a right groin swelling. Physical examination revealed an elastic hardened mass in the right femoral region. She had a slightly elevated CRP on admission. MR imaging showed a right femoral hernia with incarceration of the appendix ; emergency surgery was performed. The appendix was strangulated in the femoral ring at a point 2 cm from the tip of the appendix ; from this point ischemic changes were noted. Therefore, an appendectomy and a hernioplasty using McVay's procedure were performed. The patient's postoperative course was uneventful, and she was discharged from hospital on the 10th hospital day. We discuss the 18 cases (including this one) reported in the Japanese medical literature.
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  • Masashi FURUKAWA, Masahiko TAKEO, Mitsuo YAMAMOTO
    2010 Volume 71 Issue 1 Pages 239-242
    Published: 2010
    Released on J-STAGE: July 16, 2010
    JOURNAL FREE ACCESS
    Deep vein thrombosis (DVT) is common. However, it is rarely caused by an iliac artery aneurysm. Our patient was a 69-year-old man who initially presented with right leg swelling. He was diagnosed as having thrombophlebitis. Computed tomography scanning revealed a right iliac artery aneurysm and an inferior vena cava (IVC) thrombus ; the findings were confirmed on angiography. After the IVC filter was placed, the right common iliac artery aneurysm was repaired. After surgery, his right leg swelling disappeared. Six months later, no IVC thrombus was seen on CT.
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