Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association)
Online ISSN : 1882-5133
Print ISSN : 1345-2843
ISSN-L : 1345-2843
Volume 74, Issue 9
Displaying 1-50 of 59 articles from this issue
Original Articles
  • Isao NOZAKI, Naoto GOTOHDA, Tsuneaki FUJIYA, Norimasa FUKUSHIMA, Junya ...
    2013 Volume 74 Issue 9 Pages 2343-2348
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    We previously reported that the new standardized clinical pathways for distal gastrectomy (DG-path : restarting semi-solid food on postoperative day 3 and discharging on postoperative day 8-14) and for total gastrectomy (TG-path : restarting semi-solid food on postoperative day 4 and discharging on postoperative day 9-16) could be used safely. If DG-path can apply to TG safely, it will promote an early hospital discharge to TG patients and will make perioperative treatments for both DG and TG simpler and more convenient. We have conducted a multicentric study to clarify whether DG-path can be used safely for TG. The DG-path was followed in 167 TG patients. Then their clinical outcomes and clinical pathway variance were compared with those of 161 TG patients who followed the TG-path in the previous study. The median postoperative hospital stay was shorter in the DG-path (13 days) than in the TG-path (14 days). The incidence of severe complications was lower in the DG-path (4.2%) than in the TG-path (6.8%). Our outcomes suggest that DG-path can be used safely following TG without increasing postoperative complications. In conclusion, DG-path can be used for both DG and TG safely.
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  • Yoritaka NAKANO, Hideo TERASHIMA, Shuntaro TSUKAMOTO, Taichi MAFUNE, K ...
    2013 Volume 74 Issue 9 Pages 2349-2354
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Background : We introduced laparoscopic appendectomy as the first experience of laparoscopic surgery for trainee doctors, and evaluated the current state in the light of surgical outcomes and educational effects.
    Methods : From April 2011 to August 2012, consecutive 55 cases were conducted appendectomy by trainee doctors in our hospital, including 31 cases of open appendectomy (OS group) and 24 cases of laparoscopic appendectomy (LA group). Although trainee doctors had their first experience of laparoscopic surgery through LA, all of them had kept in practice using the dry box in advance. We made a comparative review of background factors and surgical outcomes between the two groups. A survey on attitudes toward LA was also carried out.
    Results : Between OA and LA groups, there were no significant differences in patient backgrounds. No significant differences were noted in the operating time, postoperative hospitay stay, and the incidence of surgical site infection. A questionnaire survey showed that LA had the advantage of securing the operative field and anatomical understanding compared to OA.
    Conclusions : When trainee doctors undertake LA as the first experience of laparoscopic surgery, the training with the dry box in advance allows for performing LA safely without prolonging operative time compared to OA. In addition, LA is thought to be beneficial in learning surgical anatomy.
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Clinical Experiences
  • Tomotaka SHIBATA, Natsuya KATADA, Masayuki NEMOTO, Shinichi SAKURAMOTO ...
    2013 Volume 74 Issue 9 Pages 2355-2358
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Achalasia sometimes requires a long time until it is diagnosed because it lacks abnormal findings on upper gastrointestinal endoscopy and barium meal study, and during the long time it has been treated as a psychological disease.
    In this study, we analyze our patients operated on for achalasia who had been treated as having a psychological disease, and clarify difficulties in making diagnosis of achalasia. We enrolled consecutive 65 patients who underwent laparoscopic surgery for achalasia in our hospital from October 1997 to May 2010. Fifteen out of the 65 (23%) patients had been received at least either one of upper gastrointestinal endoscopy or barium meal study, and were determined to have no abnormalities. Six out of these 15 patients had some histories of treatment for a psychological disorder. Those six patients had the classical types of esophageal achalasia without esophageal dilatation.
    Esophageal manometric study is important for patients with eating disorders or dysphagia who show no abnormalities on upper gastrointestinal endoscopy or barium meal study, because they can have some functional disease.
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  • Yoshiharu TAKENAKA, Takahiro SASAKI, Asako FUKUOKA, Hiroyuki HOSHINO, ...
    2013 Volume 74 Issue 9 Pages 2359-2363
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    [Objectives]
    Iatrogenic perforation occurs as a complication of endoscopic submucosal dissection (ESD) for colorectal cancer. Conservative treatment is effective and emergent surgery is not necessary in most ESD-associated perforations. However, if tumor resection is endoscopically or pathologically insufficient, radical surgery would be necessary after conservative treatment. Our study aimed to evaluate the availability of laparoscopy-assisted colectomy (LAC) for cases with enforced conservative treatment after perforation during ESD.
    [Methods]
    Between January 2009 and December 2012, we performed LAC for 5 cases after conservative treatment for perforation during ESD (Perforation Group), 9 cases in which radical surgery had been deemed necessary based on pathological findings after successful endoscopic resection (Non-Perforation Group), and 200 ordinary cases diagnosed with colorectal cancer (Control Group). We studied the surgical outcomes of these 3 groups.
    [Results]
    In 4 cases in the perforation group, adhesion caused by perforation was not detected and the LAC procedure was not very difficult. Between these 3 groups, there was no significant difference in operation time, blood loss, postoperative hospital days, and intraoperative and postoperative complications.
    [Conclusion]
    This study suggests that LAC is available for early colorectal cancer cases with enforced conservative treatment after perforation during ESD.
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  • Seiichiro YOSHIKAWA, Masaki FUKUNAGA, Yoshifumi LEE, Kunihiko NAGAKARI ...
    2013 Volume 74 Issue 9 Pages 2364-2369
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Aim : Palliative surgery for incurable malignancies is useful in relieving symptoms. These patients present with pain, and their general conditions is often poor. Therefore, pain related to surgery should be minimal, and the procedure must be minimally invasive. Thus, it is thought that laparoscopic surgery is suitable for surgical palliation procedures. The aim of this study was to assess the feasibility and efficacy of laparoscopic palliative operations.
    Method : A retrospective analysis of 43 patients who underwent laparoscopic palliative operations between 2005 and 2012 in our institution was done.
    Results : The mean duration of the operation was 119 minutes, and the mean blood loss was 25 mL. The incidence of postoperative complications was 10%, the symptom improvement rate was 98%, and the hospital mortality was 19%.
    Conclusion : Laparoscopic palliative surgery can be performed on patients with incurable malignancies provided a thorough preoperative assessment is done, and the surgery is skillfully executed.
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Case Reports
  • Nobuhiko KURATA, Yutaka MIZUNO, Toshihiro MORI, Masayuki MIYAUCHI
    2013 Volume 74 Issue 9 Pages 2370-2374
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Neurofibromatosis (NF) is an autosomal dominant inheritable disease, characterized by café au lait skin macules and multiple neurofibromas. A 58-year-old woman presented with a left breast lump which was first recognized about six months earlier. The physical examination showed that she had neurofibromas in the skin over the whole body and bilateral breast tumors. She was diagnosed with left breast cancer (T2N0M0) and right apocrine sclerosing adenosis. Left modified radical mastectomy (Bt+SN→Ax) and right probe lumpectomy were performed. The final histological examination revealed bilateral synchronous apocrine carcinomas. Since the resected specimen from the right breast was positive at the margin, a right modified radical mastectomy (Bt) was also performed. Immunohistochemistry of resected specimens showed that estrogen, progesterone receptors and HER2 were negative, but androgen receptors were positive. Bilateral breast cancers associated with NF have been reported recently and we concluded that bilateral synchronous breast cancers associated with NF must be carefully diagnosed and surgically removed.
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  • Yoshihiro SUEMATSU, Mitsuhiro KAWATA, Kenichi OKAMURA, Sei MORIZUMI
    2013 Volume 74 Issue 9 Pages 2375-2379
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    The patient was a 60-year-old woman with acute coronary syndrome and acute heart failure. Coronary angiography revealed 3-vessel disease, including a left main trunk lesion. Intra-aortic balloon pump support was instituted and the patient was referred to us. Emergent off-pump coronary artery bypass grafting (OPCAB) was successfully performed. Postoperative coronary CT revealed patency of all the grafts, but also findings suggestive of left breast cancer. Two months later, partial mastectomy was performed. After radiation and chemotherapy, the patient is currently in good conditon as seen at the 42-month follow-up examination, with no recurrence of breast cancer or angina pectoris. Even in emergent or urgent cases, OPCAB may be beneficial to prevent extracorporeal circulation, which is considered to impair the immune system and increase the risk of malignancy.
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  • Nobumoto TOMIOKA, Takahito NAKAGAWA, Shuji TAKAHASHI, Shinich MATSUOKA ...
    2013 Volume 74 Issue 9 Pages 2380-2388
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    We present a case of a 51-year-old woman with a bulky tumor having ulceration on its surface with hemorrhage in her left axillary fossa. Palpation, mammography, ultrasonography and magnetic resonance imaging detected no tumor in her mammary gland. Primary axillary tumor was thus suspected. A punched biopsy showed poorly differentiated adenocarcinoma. The tumor excision was performed with dissection of its axillary lymph nodes. The immunohistochemistry was useful to diagnose it as breast cancer finally. Neither components of normal mammary gland nor structures of lymph node were present in the resected specimen, for that we had great difficulties in differentiating whether it was ectopic or occult breast cancer. Based on a review of the relevant literature, it would be reasonable to diagnose it as ectopic breast cancer rather than occult breast cancer because of the wide-spread ulceration on its surface having no metastasis to the adjacent lymph nodes in spite of its bulky mass more than 10 cm in maximum diameter. There were no tumor cells in the stump of the specimen or in the dissected lymph nodes. The patient has strictly been observed, while she is on postoperative medication with aromatase inhibitor (anastrozole) and oral tegaful/uracil (UFT).
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  • Shinya SATOH, Seigo TACHIBANA, Tadao YOKOI, Hiroyuki YAMASHITA, Ichio ...
    2013 Volume 74 Issue 9 Pages 2389-2393
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    A 39-year-old woman with a history of nephrolithiasis was referred for evaluation of primary hyperparathyroidism. She had a serum calcium level of 11.1 mg/dL, a phosphorus level of 2.6 mg/dL, and an intact PTH level of 148 pg/mL. On cervical ultrasonography no pathology was detected in the parathyroid glands. However, 99mTc-MIBI scintigraphy showed an abnormal up-take lesion in the middle mediastinum, and chest CT demonstrated a 1.5-cm, enhanced mass in the aortopulmonary window. The mass was removed during video-assisted thoracoscopic surgery (VATS), and on pathology, a parathyroid adenoma was diagnosed. The patient's serum calcium level and intact PTH level were normal on postoperative day 1. Although an ectopic parathyroid tumor in the mediastinum usually arises in the anterior or upper mediastinum, it can also rarely occur in the aortopulmonary window.
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  • Keizo MISUMI, Yoshinori YAMASHITA, Hiroaki HARADA, Kazuya KURAOKA, Kiy ...
    2013 Volume 74 Issue 9 Pages 2394-2398
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    A man in his fifties was admitted to our hospital with chest pain of two months duration. A 4-cm-diameter tumor was found at the sternal bone on chest computed tomography (CT). Despite intensive investigations the biopsy revealed primary unknown metastatic adenocarcinoma. He was diagnosed as having solitary sternal bone metastases on 18F-fluorodexyglucose (18F-FDG) positron emission tomography (PET)/CT. To achieve a macroscopic cure and for pain control, the sternal bone with skin, costalcartilage, and thymic fat tissue was radically resected with negative pathology margins. The defect was reconstructed using a Composix Mesh (Bard®) back of the costal bones and fourfold Marlex Mesh (Bard®) on the front. The primary site remained unknown even after postoperative histopathology. One and a half months after the operation, he developed multiple bone metastases and then died six months after the resection due to rapid progression despite systemic chemotherapy.
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  • Takashi OKAMOTO, Hiroyuki FUJISAKI
    2013 Volume 74 Issue 9 Pages 2399-2401
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Cardiac lipoma is a benign cardiac tumor, and its frequency is relatively rare. We report a case of cardiac lipoma which we found incidentally during echocardiography.
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  • Hiromichi FUJII, Takanobu AOYAMA, Yasuo SUEHIRO, Hiroyuki SEO, Yoshika ...
    2013 Volume 74 Issue 9 Pages 2402-2405
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    A 69-year-old man consulted a local hospital for the main complaint of general fatigue after arriving by bicycle. A left ventricular free wall rupture (LVFWR) after acute myocardial infarction was suspected by electrocardiogram, transthoracic echocardiography, and computed tomography. The hemodynamics were stable and consciousness was clear. Coronary angiography demonstrated total occlusion of the middle left anterior descending coronary artery (LAD). Pericardiotomy was performed after harvesting the left internal thoracic artery (LITA), because the hemodynamics were stable. The pericardial sac was filled with hematoma. Although there was about a 2-cm tear near the apex of the heart, bleeding was not confirmed. We diagnosed blow out type LVFWR and repaired by it by a sutureless method with a Tachocomb® tissue sealing sheet and fibrin glue. Intra-aortic balloon pumping was started to decrease the left ventricular pressure. Off-pump coronary artery bypass grafting of LITA to LAD was performed. The postoperative course was uneventful and the patient was discharged on the 25th postoperative day.
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  • Haruyoshi TANAKA, Takaya MIWA, Tomoki FUKUOKA, Kenji OSHIMA, Yasunori ...
    2013 Volume 74 Issue 9 Pages 2406-2411
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Isolated spontaneous celiac artery dissection is a rare entity, and there is still no consensus or guidelines available. A 42-year-old man presented with sudden upper left quadrant pain radiating to his left back. Physical examinations did not reveal signs of peritoneal irritation in the left upper quadrant, but only mild tenderness. Laboratory tests showed no abnormal findings other than leukocytosis. An emergency abdominal dynamic computed tomography (CT) showed the celiac artery dissected from its radix, with the proper hepatic artery occluded at its origin. We diagnosed it as isolated spontaneous celiac artery dissection, and began antihypertensive therapy as conservative treatment because his vital signs and general appearance were stable and liver functions were normal. Abdominal pain was reduced in a few days, and the patient left the hospital on the 17th hospital day. Six months later, another CT showed a spindle aneurysm of the common hepatic artery 17 mm in diameter, but after two years it did not become larger. We reviewed the literature on 68 isolated spontaneous celiac artery dissections.
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  • Mai FURUYA, Mitsuhiro KAWATA, Sei MORIZUMI, Yoshihiro SUEMATSU
    2013 Volume 74 Issue 9 Pages 2412-2416
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Endovascular stent-grafting of thoracic and abdominal aorta pathology is emerging as the preferred treatment strategy in high risk patients. A patient was a 93-year-old female with renal dysfunction and chronic respiratory failure, who complained of severe back pain and critical anemia. Computed tomography (CT) revealed a ruptured thoracoabdominal aortic aneurysm (TAAA), located just above the celiac trunk. The patient successfully underwent an endovascular stent-grafting, following bypass-grafting to the superior mesenteric artery (SMA) and the celiac artery (CA). Postoperative course was uneventful. Follow-up CT showed significant decrease of size of TAAA. A less invasive endovascular repair would be an alternative treatment for high risk patients such as this case.
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  • Takehito YOSHIYA, Masato KANZAKI, Tamami ISAKA, Hiroki TOKUMITSU, Taka ...
    2013 Volume 74 Issue 9 Pages 2417-2422
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    We have achieved emergency hemostasis for the recurrent bouts of hemoptysis by bronchial occlusion using Endobronchial Watanabe Spigot (EWS), followed by embolization of the bronchial artery responsible for the hemorrhage, in that the EWSs could be removed at the third month after the bronchial occlusion. The patient was a woman in her thirties. She had undergone left lobectomy and left cervical lymph node dissection for medullary carcinoma of the thyroid in her twenties, and resultantly she had had bilateral recurrent laryngeal neuroparalysis. She experienced recurrence to the right lobe of the thyroid in her thirties and a permanent tracheostoma was created for dyspnea. Three months later, she was brought into our hospital by ambulance because of hemoptysis. After admission, she had recurrent bouts of hemoptysis and she was referred to our department for the purpose of close examinations and treatment of recurrent hemoptysis. Bronchoscopy under general anesthesia revealed arterial bleeding from the inlet portion of the right B3. Thrombin solution was infused under bronchoscopy and EWSs were placed to achieve hemostasis. In addition the bronchial artery to the right upper lobe of the lung was embolized. Thereafter no hemoptysis had occurred and the EWSs were removed three months after the placement. No hemoptysis has occurred, as of one month after the removal.
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  • Yusuke TAKANASHI, Norikazu URABE, Shugo UEMATSU
    2013 Volume 74 Issue 9 Pages 2423-2427
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    A 36-year-old male cigarette smoker complained of chest pain and dyspnea and developed a left pneumothorax. Chest CT scan revealed a left pneumothorax, bilateral diffuse reticulonodular opacities, and a polycystic lesion. To make a definitive diagnosis, a lung biopsy followed by Talc poundrage for pleurodesis were performed under video-assisted thoracoscopic surgery. The biopsied specimen revealed the presence of S-100 protein and CD4-positive Langerhans cells in the broncho-bronchiolocentric nodular lesions. Therefore, pulmonary Langerhans cell histiocytosis (PLCH) was diagnosed. The post operative course was good, and the pneumothorax was cured immediately. The patient was instructed to stop smoking. There has been no recurrence of a pneumothorax during 6 months of observation. When a patient presents with secondary pneumothorax and a polycystic lesion, PLCH has to be considered in the differential diagnosis.
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  • Nobuo TSUNOOKA, Kyo HIRAYAMA, Keitaro INAZAWA
    2013 Volume 74 Issue 9 Pages 2428-2433
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    We report 2 cases of multiple benign lung-metastasizing leiomyoma in 2 women aged 51 and 58 years. In one case, the lesion was discovered on routine medical examination and in the other during examination for another disease. The lesions were multiple, large, bilateral nodules that were <12 mm in size without fluoro-D-glucose accumulation on positron emission tomography. Surgical biopsies were performed, and on histology, benign leiomyoma without mitosis was diagnosed. Immunohistological examination of the leiomyoma cells revealed the following features : negative for caldesmon, positive for alpha-smooth muscle actin, desmin, S-100, estrogen receptor, and progesterone receptor. Subsequently, one patient had a hysterectomy for a uterine myoma, whereas the other patient had a resection of a uterine myoma. In these 2 patients, benign lung metastasizing leiomyoma was caused by a uterine myoma ; they were followed without hormonal treatment being given.
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  • Akira GAKIYA, Tuyoshi TERUYA, Nobuhiro SHIMABUKURO, Atushi NAKACHI, Ma ...
    2013 Volume 74 Issue 9 Pages 2434-2440
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    A 37-year-old man was found to have an abnormal shadow on chest X-ray. Chest CT showed a solitary nodule in the right upper lobe. PET/CT showed accumulation in the lung nodule, para-aortic lymph node, left sixth rib, and second lumbar vertebra. A right upper lobectomy was done, and on histology, a malignant melanoma was diagnosed. Though a systemic examination was performed, the original lesion was not detected. He had had lentigo on his back ten years prior which spontaneously regressed three years ago. Thus, an exact diagnosis of the origin skin lesion could not be made Finally this case was diagnosed as a malignant melanoma of unknown primary origin.
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  • Kei YOSHINO, Satoru MOTOYAMA, Yusuke SATO, Tomohiko SASAKI, Akiyuki WA ...
    2013 Volume 74 Issue 9 Pages 2441-2445
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    We report a case of laparoscopic surgery in a young man with severe reflux esophagitis. A 27-year-old man with a 10-year history of an eating disorder was admitted with vomiting and weight loss. He was previously treated for symptoms of stress associated with his home environment at the Department of Psychosomatic Medicine. Several years later, upper gastrointestinal endoscopy revealed reflux esophagitis, and medical treatment using a proton pump inhibitor was started ; however, the symptoms did not improve, and clinical examination revealed a high degree of backflow from the stomach into the esophagus. pH monitoring for 24 h showed a fraction time of 14.3% with a pH <4, and manometry showed a loss of esophageal motility. We therefore conducted laparoscopic Nissen fundoplication, and the patient is in good condition with excellent passage and no regurgitation.
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  • Yukiko NISHIGUCHI, Tetsuya TANAKA, Tomoyoshi TAKAYAMA, Sohei MATSUMOTO ...
    2013 Volume 74 Issue 9 Pages 2446-2452
    Published: 2013
    Released on J-STAGE: February 25, 2014
    JOURNAL FREE ACCESS
    Endocrine cell carcinoma of the esophagus carries a poor prognosis due to its aggressive malignancy. We report a case of large cell neuroendocrine cell carcinoma managed by multidisciplinary treatment. A 54-year-old man who was found in esophagography to have a protruded lesion of the esophagus was referred to our hospital. Biopsy specimens were histologically diagnosted as squamous cell carcinoma. Stage II squamous cell carcinoma T2N1M0 was diagnosed and thoracoscopic esophagectomy with three-field lymph node dissection and reconstruction by a gastric tube was performed after neoadjuvant chemotherapy. The final diagnosis was large cell endocrine cell carcinoma, categorized as T2N4M0, Stage IVa. Postoperatively, he underwent adjuvant chemotherapy but recurrence to the lymph nodes and the pleura occurred 3 months after the surgery. Despite chemotherapy with other anticancer drugs, his condition took turn for the worse and best supportive care was carried out. He died 8 months after the first treatment. Although the prognosis of endocrine cell carcinoma of the esophagus is poor, there are some reports describing that multidisciplinary treatment is important to gain long-term survival. No collective opinion, however, has been established as yet. In selecting multidisciplinary treatment for the disease, we have to keep the prognosis of the disease in mind, determine anticancer effect early, and convert to best supportive care if the treatment is ineffective.
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  • Hiroaki KOMINAMI, Yasuhiro FUJINO, Kenntarou KAWASAKI, Kenichi TANAKA, ...
    2013 Volume 74 Issue 9 Pages 2453-2458
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 70-year-old man complained of weight loss (6 kg/6 months), anorexia, and night sweats. He had undergone distal gastrectomy for a duodenal ulcer 30 years previously. Upper gastrointestinal endoscopy revealed a ragged, irregular, and elevated lesion in the remnant stomach. Computed tomography and fluoroscopy revealed a massive tumor, exceeding 10 cm in diameter, in the remnant stomach lumen. A gastrointestinal stromal tumor (GIST) was diagnosed on endoscopic biopsy. The patient had a total remnant gastrectomy with splenectomy and Roux-en-Y reconstruction. On postoperative pathology, GIST with a mitotic index of 10/50 HPFs was demonstrated. The patient is alive without recurrence, 18 months after surgery, and he is receiving adjuvant chemotherapy with imatinib.
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  • Eisuke BOOKA, Takeshi NAGASE, Toshio KANAI, Shun IMAI, Tomotaka AKATSU ...
    2013 Volume 74 Issue 9 Pages 2459-2463
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    The patient was a 71-year-old man who had undergone total gastrectomy, D2, Roux-en-Y reconstruction, cholecystectomy, and splenectomy for gastric cancer in 1996. Although his clinical course had remained uneventful, he presented at our hospital in November 2011 with postprandial vomiting and reduced dietary intake since January 2011. An upper gastrointestinal screening revealed significant dilation of the blind extremity of the end-to-side anastomosis and a saccular dilated elevated jejunum on the oral side of a constriction. Surgery was performed in February 2012 for the elevated jejunum at the esophageal hiatus. Intraoperatively, the esophago-jejunal anastomosis was found to be located in the mediastinum ; furthermore, the jejunal segment on the anal side of the anastomosis was constricted by the diaphragm and the segment on the oral side was dilated. We surgically attached the esophagus on the oral side of the anastomosis to the diaphragm and cut the dilated blind extremity. After the surgery, the patient reported improved oral intake. We report a case of obstruction of the elevated jejunum at the esophageal hiatus long after total gastrectomy and Roux-en-Y reconstruction.
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  • Kohei OKAMOTO, Kenshu KAWANISHI, Hiroshi IMAMURA, Takashi IWAZAWA, Kei ...
    2013 Volume 74 Issue 9 Pages 2464-2469
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A case of gastric carcinosarcoma composed of small cell neuroendocrine carcinoma with rhabdomyosarcomatous differentiation in a septuagenarian Japanese male is presented. Grossly, a huge exophytic tumor (Borrman type-1) was observed on the lesser curvature of the upper portion of the stomach. The tumor was mainly composed of small cell neuroendocrine carcinoma, and no conventional adenocarcinomatous component was observed. It also contained a focal sarcomatous area of rhabdomyosarcomatous differentiation. Although there have been only two other reports describing small cell neuroendcrine carcinoma with sarcomatous components of the stomach, one of them had a conventional adenocarcinomatous component in addition to a small cell carcinoma component. This is an exceptionally rare case of gastric carcinosarcoma composed of pure small cell neuroendocrine carcinoma and rhabdomyosarcomatous components.
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  • Yukiko OSHIMA, Shin TESHIMA, Nobuki YAZAKI, Toshihiro SAITO, Kazunori ...
    2013 Volume 74 Issue 9 Pages 2470-2475
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    An 88-year-old man complaining of dyspnea and pedal edema was admitted to the hospital for severe anemia and leukocytosis. Upper gastrointestinal endoscopy and biopsy revealed a type-1 gastric cancer, moderately differentiated tubular adenocarcinoma, in the lower gastric body. The preoperative laboratory data revealed leukocytosis (30,500/μl) and high level of the serum granulocyte-colony stimulating factor (G-CSF) (119pg/ml). The most likely diagnosis was G-CSF-producing gastric cancer. Total gastrectomy was performed for bleeding control. Pathological findings were tub2, pT4a (SE), ly3, v3 pN3b (16/34), pPM0, pDM0, M1(LYM), and Stage IV ; tumor cells were positive in G-CSF immunological staining. The leukocyte count decreased after the surgery. G-CSF-producing gastric cancer was thus diagnosed. Despite best supportive care, he died of progression of liver and lymph node metastases 9 months after the surgery.
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  • Atsuki ARIMOTO, Hiroshi HASEGAWA, Eiji SAKAMOTO, Shunichiro KOMATSU, S ...
    2013 Volume 74 Issue 9 Pages 2476-2481
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 65-year-old man presented with a chief complaint of postprandial nausea. Upper endoscopy revealed a circumferential type 3 tumor in the gastric antrum and a submucosal tumor with depression at the superior duodenal angle. On biopsy, the gastric lesion was diagnosed as moderately-differentiated adenocarcinoma, but no definitive diagnosis was obtained for the duodenal lesion. Computed tomography (CT) showed wall thickening in the gastric antrum and a tumor with poor contrast enhancement in the pancreaticoduodenal region. Based on diagnoses of cancer of the gastric antrum and either a duodenal submucosal tumor or duodenal invasion of subpyloric lymph node metastasis, pancreaticoduodenectomy was performed. Histopathological examination of the resected sample yielded diagnoses of alpha-fetoprotein (AFP)-producing gastric cancer and hematogenous pancreatic metastasis. AFP-producing gastric cancer leading to hematogenous pancreatic metastasis is extremely rare, and the present case is reported, along with a review of the literature.
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  • Motohiro ITO
    2013 Volume 74 Issue 9 Pages 2482-2485
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    An 84-year-old woman who underwent gastrectomy with Billroth-II reconstruction 17 years earlier was seen at a neighboring hospital because of the abrupt onset of upper abdominal pain after lunch. Thereafter she vomited and was referred to our hospital on the next day. There were tenderness, muscular defense, and rebound tenderness in the right upper quadrant of abdomen. Blood examination revealed an increase in the inflammatory reaction. Abdominal contrast-enhanced CT scan showed abdominal free air and fluid collection in the caudal side of the third portion of the duodenum. From these findings, emergency operation was carried out with a diagnosis of perforation of the third portion of the duodenum 26 hours after the onset of the disease. Upon laparotomy there were about 300 ml of brownish ascites in the abdominal cavity and a perforated site with the size of a pin hole at the inferior wall of the third portion of the duodenum. No diverticulum or ulcerative lesion was seen at the perforated site. Operative procedures included simple closure of the duodenum, placement of a tube to the duodenum for decompression, and drainage of the abdominal cavity. The patient was discharged from the hospital on the 30th postoperative day. In this case we could not identify any secondary factors including ulceration, afferent loop syndrome, diverticulum, foreign body like a fish bone, trauma, and tumor. Idiopathic perforation in the third portion of duodenum was considered to be the final diagnosis.
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  • Tomohiro SUGIYAMA, Hidenori TAKAHARA, Motoyasu TABUCHI, Naoki NAGAYOSI ...
    2013 Volume 74 Issue 9 Pages 2486-2490
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    We report a case of hepatic portal venous gas which was caused by ischemic enteritis with chronic obstruction of the superior mesenterium artery. The patient was a 73-year-old man previously diagnosed with hard arterioscleosis and an abdominal aortic aneurysm. He developed sudden abdominal pain after dinner and was admitted to our hospital. Abdominal enhanced CT showed hepatic venous gas, wall thickening in the terminal ileum and a defect in the origin of the superior mesenteric artery (SMA). CT done 14hours after the initial CT showed that the hepatic venous gas had disappeared.
    Since there were no symptoms of intestinal necrosis, conservative treatment was instituted. After 19 days the ileocolic artery was revasculared. The patient had a good outcome.
    It is necessary to consider revascularization as an option for the treatment of ischemic enteritis.
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  • Kouki WAKATA, Keiji KAJIHARA, Takafumi KUSABA, Yu SHIGEMASA, Hideki IK ...
    2013 Volume 74 Issue 9 Pages 2491-2496
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 66-year-old woman was referred to our hospital with abrupt onset of upper abdominal pain while performing aerobics at the gym. Abdominal computed tomography (CT) revealed a dendriform image of hepatic portal venous gas in the bilateral lobes of the liver. Conservative medical treatment was provided because the patient's symptoms remitted soon after examination. The portal venous gas image was found to have almost disappeared in the abdominal CT examination performed on day 2 after admission. On day 29, the patient complained of abdominal pain again, and imaging tests were performed. As these clearly indicated stenosis of the ileum, partial ileocecal resection was performed. The postoperative course was uneventful, and she was discharged on day 48. After five months, the patient presented upper abdominal pain twice after squash. Abdominal CT examination revealed superior mesenteric venous gas as previously indicated. The patient was in shock on admission. On emergency laparotomy, there was no intestinal ischemia or necrosis. Because imaging tests indicated stenosis of the ileum in the vicinity of the last anastomosis, we performed partial ileocecal resection on day 49. We present a rare case of NOMI with repeated stenosis of the ileum after initial improvement with conservative medical treatment.
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  • Ryoichi KATSUBE, Toshihiko WAKU, Naohiro SATO, Takeshi KANBARA, Masaic ...
    2013 Volume 74 Issue 9 Pages 2497-2501
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 65-year-old man who had an ileostomy created following total removal of the large intestine for ulcerative colitis had been on ambulatory treatment with chemotherapy at our hospital for stage IV lung cancer with metastases to the brain, liver and bone. He was seen at our clinic because of abdominal pain and prolapse of the stoma lasting since he got up in the morning. From macroscopic and abdominal CT findings, we determined that reduction might be difficult because the prolapsed intestine was seriously edematous and showed strong ischemic change. Emergency operation was thus performed. Detailed observation under general anesthesia revealed telescoping of a segment of the ileum within a neighboring segment of the ileum which had prolapsed through the stoma. The telescoped ileum including the normal portion was drawn out outside of the body, the intussusception was reduced by hands, and then resection of the necrotized intestine followed by a new creation of ileostomy was performed.
    Intussusception and prolapse of the ileum through the ileostomy is very rare and causes are still unknown. We consider that possible causes may include abnormal peristalsis which might occur due to spinal metastasis of lung cancer, in addition to increased abdominal pressure and creation of the ileostomy via the intraperitoneal route.
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  • Shoji SHIMADA, Akihiko SHIMADA, Tatsuya ONISHI, Hiroaki SEKI, Nobutaka ...
    2013 Volume 74 Issue 9 Pages 2502-2506
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 35-year-old woman in week 17 of pregnancy was seen at our hospital because of vomiting and abdominal pain. There was tenderness in the lower abdomen, and a tumor was palpable in the right lower quadrant of abdomen. Abdominal ultrasonography showed a 2-cm sized mass in the right lower quadrant of abdomen. Following an abdominal MRI scanning, intussusception was diagnosed and an emergency operation was performed on the same day. Laparotomy disclosed an ileocolic intussusception. Repair by means of Hutchinson's procedure revealed a diverticulum 60 cm proximal to the ileocecal valve which was considered to lead the intussusception. Partial resection of the small intestine by 4 cm in length including the diverticulum was performed. Histopathologically it was true diverticulum and we diagnosed the case as intussusception led by the Meckel's diverticulum. The postoperative course was uneventful. The patient gave birth by Cesarean section on the 5th day in week 39 of pregnancy.
    Symptoms of bowel obstruction during pregnancy are mimicking those accompanied by pregnancy, and every x-ray examination is generally avoided. Accordingly making the definite diagnosis is not always easy and prompt treatments are needed to eliminate adverse effects on both mother and fetus. Since it is extremely rare that intussusception caused by Meckel's diverticulum occurs during pregnancy, we present this case with a review of the literature.
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  • Ami WADA, Tsuyoshi TAKAHASHI, Yukinori KUROKAWA, Shuji TAKIGUCHI, Sato ...
    2013 Volume 74 Issue 9 Pages 2507-2512
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 62-year-old man who was performed laparoscopic-assisted total gastrectomy (LATG) for advanced gastric cancer 3 years and 7 months earlier, was suggested to have a tumor on the mesentery by computeed tomography. Because we confirmed a growth of the tumor and abnormal uptake of FDG to the tumor in PET-CT, we suspected locoregional recurrence or other malignant tumor in the mesentery. At first, we decided to perform laparoscopic surgery for the examination of the abdomen. It revealed a 30 mm elastic-hard solitary tumor in the mesentery of the jejunum, and there were no other tumors. We continued the laparoscopic procedures and finished the operation without injuring mesenchymal blood vessels. Microscopically, the tumor was composed of dense bundles of spindle cells. Immunohistochemical staining was positive for β-catenin. Based on these findings, the tumor was diagnosed historogically as a desmoid tumor. The patient remains well 6 months after this operation without any signs of recurrence.
    Surgical trauma was reported to be an important etiologic factor predisposing to desmoid growth. In this paper, we report a case of a desmoid tumor developed after LATG for which laparopsopic tumor resection was performed.
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  • Masatoshi HAYASHI, Kouya TOCHII, Kentarou KOKUBO, Kei TAKAHASHI, Mitsu ...
    2013 Volume 74 Issue 9 Pages 2513-2516
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 62-year-old woman was admitted to our hospital because of abdominal pain. She had a history of total hysterectomy, bilateral salpingo-oophorectomy, and partial cysterectomy for uterine cervical cancer (squamous cell carcinoma [SCC] : keratinizing type), stage IIb, followed by neo adjuvant chemotherapy (5-FU, CDDP). Six months after the operation, she presented with abdominal pain and vomiting. Fluoroscopy via an ileus tube revealed an apple core lesion in the small intestine. Laparotomy revealed a tumor in the ileum and local recurrence of the uterine cervical cancer in the pelvis. We performed partial resection of the small intestine and sigmoid colostomy. The histological diagnosis was SCC of the small intestine compatible with metastasis of uterine cervical cancer. Metastasis from uterine cervical cancer to the small intestine is very rare.
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  • Hironori KOBAYASHI, Mikio FUJIMOTO, Shiro NAKAI, Katsunari MIYAMOTO, Y ...
    2013 Volume 74 Issue 9 Pages 2517-2521
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    An 11-year-old boy was admitted to our hospital because of lower abdominal pain. Contrast-enhanced abdominal CT scan revealed that the superior mesenteric vein was located to the left of the superior mesenteric artery, the ascending colon and the transverse colon had sifted to the left side of the abdomen, and the small intestine, to the right side of the abdomen. The swollen appendix was detected in the mid-lower abdomen. We diagnosed the case as acute appendicitis with intestinal malrotation, and performed emergency single-incision laparoscopic surgery under general anesthesia using two 5 mm ports inserted through a single 2-cm umbilicus incision. No abnormalities such as pedicle or Ladd ligament were found. The appendix was easily extracted from the intra-abdominal cavity through the small incision site of the umbilicus, and appendectomy was performed under direct vision. Single-incision laparoscopic assisted appendectomy was useful for acute appendicitis with intestinal malrotation.
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  • Wataru SUMIDA, Kazuo OOSHIMA
    2013 Volume 74 Issue 9 Pages 2522-2525
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    We experienced a case of congenital colon stenosis with multiple membranous lesions. A two-year-old girl was admitted to our hospital because of severe abdominal pain and frequent vomiting. Her condition indicated the necessity of urgent surgical intervention, so we decided to perform an emergency operation. We found four sites of stenosis in the colon which was also perforated at a stenotic site in the descending colon. The colon perforation appeared to be caused by an ulcer which developed from an ingested toy marble at the stenotic site. A double-barreled stoma was created in this operation, and the stoma was subsequently closed after 18 months. To date, the patient is in good health with no evidence of recurrence. Congenital colon stenosis is extremely rare, with only nine case reports published ; however, none of these reports described multiple membranous stenosis presented by colon perforation from an ingested small toy.
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  • Junichi YOSHIZAWA, Yohei OKUBO, Fumitoshi KARASAWA, Ataru NAKAYAMA, No ...
    2013 Volume 74 Issue 9 Pages 2526-2531
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 72-year-old woman visited our hospital because of epigastralgia and vomiting. She had had an incisional hernia about 25cm in diameter at the left lower quadrant of abdomen since around 40 years of age. Abdominal enhanced CT scan showed the sigmoid colon and the small intestine to have protruded into the incisional hernia, and enhancement efficacy of the small intestine was slightly reduced. However, there were no findings indicative of ileus, so we treated her conservatively after medical treatment. On the 3rd hospital day, no symptomatic remission was gained and abdominal enhanced CT scan showed disappearance of enhancement efficacy of the protruded small intestine into the incisional hernia and appearance of findings of ileus. We performed emergency operation. During the operation, the descending colon and the sigmoid colon protruded into the incisional hernia, and epiploic appendage of the sigmoid colon adhering to the sac caused strangulation of the small intestine. We performed dissection of the adhering epiploic appendage, small bowel resection, and repair of the incisional hernia.
    There have been few reports of ileus in an incisional hernia or strangulated ileus caused by epiploic appendage. We report our case, along with review of the relevant literature.
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  • Yoshihide NANNO, Fumitaka NAKAMURA, Kiyotaka IMAMURA, Naoya OKADA, May ...
    2013 Volume 74 Issue 9 Pages 2532-2535
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 77-year-old man with a medical history of hemophilia B, without regular follow-up, visited the local hospital, complaining of prolonged bloody stools. Blood tests revealed severe anemia (Hb 3.5 g/dL), and colonoscopy revealed type-2 colon cancer of the ascending colon. A computed tomography scan revealed a gastrointestinal stromal tumor (GIST) of the ileum. Recombinant factor-IX products were administered following Guidelines for The Management of Hemophilia. After treating the anemia and electrolyte imbalance, we performed single-port laparoscopic right hemicolectomy and partial resection of ileum. There were no complications during the surgery and in the post-operative period. The patient was discharged on post-operative day 7.
    Thus far, not much was known about the safety of laparoscopic surgery for hemophilia patients. Single-port laparoscopic right hemi colectomy provided good surgical outcome and could be one a safe and feasible choice for hemophilia patients with GIST.
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  • Kazumi IKENISHI, Yoshihide SHINO, Michihiro NARIKIYO, Kazushi NISHIO, ...
    2013 Volume 74 Issue 9 Pages 2536-2540
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    Malignant lymphoma of the colon is a rare disease and accounts for 0.1-0.7% of all malignant tumors of the colon. We report a case of malignant lymphoma of the colon in a 75-year-old male who underwent emergency surgery with a diagnosis of intussusception. The patient was admitted to our hospital complaining of abdominal pain and melena. On physical examination, his abdomen was hard with tenderness in the right lower quadrant, and his palpebral conjunctiva was anemic. Abdominal CT scan showed a tumor invaginated to the ascending colon. Emergency surgery was performed with a diagnosis of intussusception of the cecum tumor and severe melena. At laparotomy, the ileum was invaginated in the ascending colon with the cecum and the ascending colon. Thus, a right hemicolectomy was performed. Histological the tumor was diagnosed as diffuse large B-cell lymphoma (DLBCL). He was treated with chemotherapy postoperatively. No recurrence has occurred as of 15 months after the operation. We report this case with a review of the literature because intussusception in an adult due to malignant colon lymphoma is extremely rare.
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  • Hiroaki TANAKA, Takuto IKEDA, Yasuhiro OGURA, Yuuji UEDA, Yoshiya SIMA ...
    2013 Volume 74 Issue 9 Pages 2541-2545
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    Leiomyoma of the transverse mesocolon is very rare ; we report here the second known case in the Japanese literature. A 55-year-old woman was admitted to our hospital because of an intra-abdominal mass found on medical work-up. A fist-sized, hard, unmovable mass was palpated in the left upper abdomen. Echography revealed a well-defined, heterogeneous mass, and contrast-enhanced CT showed an 80×70×45-mm smooth mass with no contrast uptake. The preoperative diagnosis was an abdominal mass of unknown origin, and laparoscopic surgery was performed. The mass had grown on the surface of the transverse mesocolon without invasion to the surrounding tissue. The resected specimen was a white solid tumor. Histopathologic and immunohistologic studies revealed that it was c-kit (-), CD34(-), and SMA(+). The definitive diagnosis was leiomyoma arising from the transverse mesocolon. It is difficult to discriminate a benign leiomyoma from a malignant tumor because histologic findings do not always correspond with the grade of malignancy. After the operation, the patient has been free from recurrence over the last 2 years.
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  • Tomokazu TSUCHIDA, Takenori ADACHI, Nobuhisa HARA, Yasushige KASHIMA, ...
    2013 Volume 74 Issue 9 Pages 2546-2550
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 59-year-old man was admitted with constipation and lower abdominal pain. Plain abdominal radiographs showed a dilated colon, and abdominal computed tomography (CT) showed a thickened wall of the sigmoid colon. Colonofiberscopy showed the mass occupying the lumen of the sigmoid colon, and a trans-anal ileus tube was continuously inserted. After colon cleaning and decompression, enhanced CT showed the mass in the transverse colon and the liver, in addition to the sigmoid colon. The next day, a barium enema showed the obstruction of the descending colon caused by intussusception of the transverse colon mass. The added pressure reduced the intussusception. Surgery was performed 7 days after ileus tube insertion. Trans-anal ileus tube insertion is used in preparation for the obstructive colorectal cancer surgery, and is useful to detect proximal colon lesions. Complications of trans-anal ileus tube insertion such as bleeding, perforation, and ulceration have been reported. We report a case of intussusception caused by trans-anal ileus tube insertion. Intussusception should be noted as a complication of trans-anal ileus tube insertion because synchronous, multiple colorectal cancer is not considered a rare condition.
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  • Masaki HIROTA, Jyunichi HASEGAWA, Syoki MIKATA, Jyunzo SHIMIZU, Yokoku ...
    2013 Volume 74 Issue 9 Pages 2551-2556
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 70-year-old man who visited our hospital because of watery diarrhea and body weight loss he was diagnosed as having transverse colon cancer invaded the jejunum and sigmoid colon with enterocolic fistula formation. Left hemicolectomy (D3) and partial resection of the jejunum were performed. The transverse colon cancer had invaded the jejunum and the sigmoid colon to form a cancerous fistula connecting to the three different organs. Histopathological diagnosis was mucinous carcinoma with moderately differentiated tubular adenocarcinoma, classified as pSI (jejunum/sigmoid colon), pN0, sH0, sP0, cM0 Stage II. No relapse or metastasis has been detected for 5 years after the surgery. We believe that favorable prognosis can be expected in cases of colon cancer complicated by internal fistula, by performing a series of aggressive curative resections of the involved organs. We present the case a with literature review that incorporates the views shown there.
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  • Makoto ISHIDA, Syusei SANO, Takurou TERADA, Takeshi MITSUI, Yoshiko SU ...
    2013 Volume 74 Issue 9 Pages 2557-2561
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 64-year-old man with hypertension and angina was detected with a hepatic tumor by abdominal computed tomography (CT). Laboratory data revealed no apparent abnormalities ; however, serological test results were positive for hepatitis B surface antigen. Dynamic CT revealed low-density mass measuring 2 cm in diameter in Couinaud segment 8 with peripheral enhancement. Magnetic resonance imaging showed different signal intensities at the center and periphery of the mass in the hepatic phase enhancement with gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid, and diffusion-weighted imaging showed a high-intensity area. Hepatic resection of segment 8 was performed after the patient was diagnosed with intrahepatic cholangiocarcinoma while considering a differential diagnosis of sclerosing hepatic carcinoma or inflammatory pseudotumor. Intraoperatively, the mass was identified as a reddish, slightly bulging mass on the surface of the liver, which was a well-defined, whitish nodule with irregular shape on a cut surface. Histologically, it consisted of palisading granuloma surrounded by predominantly eosinophilic infiltration. Dead Anisakis larvae were detected in the necrotic area. Finally, the patient was diagnosed with hepatic anisakiasis.
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  • Kei KUSAMA, Shinji NAKATA, Harutsugu SODEYAMA, Taiichi MACHIDA, Akihit ...
    2013 Volume 74 Issue 9 Pages 2562-2566
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 37-year-old woman was admitted to our hospital because of upper abdominal pain. Ultrasonography in a routine medical check-up showed a liver tumor. Abdominal computed tomography (CT) showed a low density mass in the caudate segment of the liver (S1). Abdominal CT with contrast enhancement (CE) revealed a high density area 7.0 cm in diameter at the arterial phase, and the area was washed out at the late phase. Abdominal magnetic resonance imaging showed a low intensity mass on the T1-weighted image, a slightly high intensity mass on the T2-weighted image, and no signal decrease at the opposed-phase T1-weighted image. No fat component was identified. We could not completely rule out a possibility of hepatocellular carcinoma and performed left lobe hepatectomy. Macroscopically the tumor was solid 6.5×5.5×6.0 cm in size, and was encapsulated. Histopathologically the tumor was composed of only smooth muscles, but lipocytes were not included and the tumor had been encircled by a fibrous capsule. Smooth muscle cells consisting of major component of the tumor were positive for HMB-45 and α-SMA on immunohistochemical staining. Hepatic angiomyolipoma was finally diagnosed.
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  • Takeshi KOUJIMA, Yusuke WATANABE, Yoshikatsu ENDO, Takanori WATANABE, ...
    2013 Volume 74 Issue 9 Pages 2567-2571
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 78-year-old man in whom coronary artery bypass grafting (CABG) was performed with the left internal thoracic artery, saphenous vein, and right gastroepiploic artery (RGEA) in 2001 was admitted with hepatocellular carcinoma in February 2013. We performed a posterior segmentectomy. The RGEA was surrounded by a hard lesions ; however, thoracolaparotomy provided us a fine surgical view and allowed us to easily perform the surgery without synechiotomy around the RGEA. The problem with an epigastric operation after CABG using the RGEA is the risk of cardiogenic shock secondary to graft injury and spasm caused by mechanical stimuli. We believe that preoperative assessment of the cardiac function and condition of the RGEA graft, and the skills required to perform the surgery should be carefully considered.
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  • Masao SUNAHARA, Nobuaki KURAUCHI, Yusuke TSUNETOSHI, Shinsaku SUZUKI, ...
    2013 Volume 74 Issue 9 Pages 2572-2576
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 71-year-old man who was pointed out having a tumorous lesion in the liver during clinical observation for chronic hepatitis C was admitted to our hospital. Abdominal CT scan showed a lesion in the segment 4 of the liver which was enhanced in the early phase and was washed out. CT during arterial portography (CTAP) revealed an area in the segment 6 to where portal blood flow diminished. CT hepatic arteriography (CTHA) showed early enhancement but revealed no clear wash out in the late phase. Atypical multiple liver cancer was diagnosed and the patient was operated on. Based on histopathological and immunohistochemical findings, synchronous double hepatic cancer, consisting of cholangiolocelullar carcinoma in the segment 4 and hepatocellular carcinoma in the segment 6, was diagnosed.
    Both cholangiolocellular and hepatocellular carcinomas often have some underlying chronic hepatic disease as a background factor and so they provoke similar clinical features. However, synchronous occurrence of both malignancies is extremely rare and here we present the case together with a review of the literature.
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  • Satoshi KIYOTA, Ken GYOBU, Katu SAKABE, Genichi KANAZAWA, Hiromu TANAK ...
    2013 Volume 74 Issue 9 Pages 2577-2581
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 73-year-old man had previously undergone endscopic sphincterotomy for common bile duct stones. He was admitted to our hospital due to acute cholecystitis with an absess in the right upper abdominal wall. Conservative therapy was unsuccessfull. He was refered to the department of surgery. Enhanced computed tomography showed an increase of the absess in the abdominal wall and thrombi in the left branch and the anterior branch of the portal vein.
    A drainage of the absess in the abdominal wall and conservative therapy was successfully performed for acute cholecystitis. Portal venous thrombosis also shrank, but remained at the umbilical portion, so a delayed laparotomy was performed. Laparotomy showed a cholecystocolic fistula. Cholecystectomy and wedge resection of the transverse colon was performed. He was discharged on postoperative day 30. We report a case of acute cholecystitis with portal venous thrombosis with a review of the literature.
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  • Yuki HIGASHI, Jun KINOSHITA, Katsunobu OYAMA, Sachio FUSHIDA, Takashi ...
    2013 Volume 74 Issue 9 Pages 2582-2586
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    Braonchobiliary fistula is a rare condition and intractable. We present a case of biliary pneumonia successfully treated with embolization through a percutaneous transhepatic cholangiodrainage tube for bronchobiliary fistula after surgery. A 64-year-old man received total gastrectomy with lymphadenectomy, partial hepatectomy, splenectomy and distal pancreatectomy for advanced gastric cancer. Eighteen months after surgery, a partial hepatectomy was performed to treat a hepatic recurrence. Because of severe adhesion, his right lung and diaphragm were injured and repaired intra-operatively. Two years after the partial hepatectomy, multiple liver metastases reappeared. Around the same time, feverance and bilious sputum also appeared. He was diagnosed with bilious pneumonia secondary to bronchobiliary fistula. Bilious pneumonia improved temporarily by antibiotic medication, but relapsed repeatedly. Percutaneous transhepatic cholangiodrainage was performed to reduce the biliary pressure, but the symptoms did not improve. Finally, he was completely cured by transbiliary embolization of the fistulae through a percutaneous transhepatic cholangiodrainage tube. We think that transbiliary embolization of intractable bronchobiliary fistula was a safe and effective treatment.
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  • Mitsuru KINOSHITA, Tsuyoshi HATSUNO, Hiroshi NAKAYAMA, Masato KATAOKA, ...
    2013 Volume 74 Issue 9 Pages 2587-2592
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    The first case was a 46-year-old woman. She had a history of excessive alcohol intake and a pancreatic tumor had been diagnosed. She was admitted to hospital with a bloody bowel discharge and abdominal pain. A mass, 27×32 mm in diameter, was seen in the pancreatic tail on abdominal CT ; it had a high interior absorption range. Based on 3D-CT angiography and endoscopic retrograde pancreatography, hemosuccus pancreaticus was diagnosed. Thus, the patient had a distal pancreatectomy and a splenectomy.
    The second case was a 73-year-old man. The patient had abdominal pain and black stools, a pancreastic tumor was suspected, and the patient was sent to our hospital for further testing. A mass, 7×8 mm in diameter, was found in the pancreatic tail, and sinistral portal hypertension was present (splenomegaly and gastric varices as well as splenic vein confinement on abdominal CT). Therefore, hemosuccus pancreaticus was diagnosed, and, the patient had a a distal pancreatectomy and a splenectomy.
    Both patients had them perforations in pancreatic ducts due to burst splenic aneurysms related to chronic pancreatitis.
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  • Suguru HASEGAWA, Tsutomu SATO, Eriko SAITO, Toshiki WAKABAYASHI, Sakae ...
    2013 Volume 74 Issue 9 Pages 2593-2597
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    When the common hepatic artery is occluded for some reason, the hepatic arterial blood flow is often maintained by various forms of collateral circulation. When pancreaticoduodenectomy (PD) is performed in such a case, how the collateral hepatic arterial blood flow is preserved is important. While a common collateral circulation depends on a route from the superior mesenteric artery (SMA) through the arcade around the pancreas to the gastroduodenal artery, a route from the left gastric artery through the gastric wall to the right gastric artery may develop in some cases. We describe a patient with a left-to-right gastric artery collateral circulation who required PD for early duodenal cancer. In this case, we were able to safely perform PD without arterial reconstruction by preserving this collateral circulation. In a case with such unusual hemodynamics, it is important to plan surgery based on computed tomographic arteriography and to monitor intraoperative blood flow.
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  • Toshiyuki WATANABE, Emi MIURA, Tomo KAKIHARA, Mayumi HARADA, Hiroshi N ...
    2013 Volume 74 Issue 9 Pages 2598-2603
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    At a follow-up visit after colonic polypectomy, a 52-year-old man complained of a 7-kg weight loss over the past 4 years. Abdominal computed tomography showed a 5-cm, well circumscribed, poorly enhanced mass in the spleen. Since the cross-sectional imaging findings did not exclude the possibility of malignancy, and the patient consented resection, we performed hand-assisted laparoscopic surgery (HALS) for splenectomy. The mass measured 6.5×5.0×4.0 cm. On section, it was whitish, solid, and contained multiple red-brown nodules. Histological examination showed multiple angiomatoid nodules in a fibrosclerotic stroma. The results of immunohistochemical analysis for CD34, CD8, CD31 indicated sclerosing angiomatoid nodular transformation (SANT). It is a very rare disease, and only 9 cases have been reported in Japan. Since it is difficult to diagnose SANT by imaging, its definitive diagnosis requires surgery.
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  • Toshihiko WAKU
    2013 Volume 74 Issue 9 Pages 2604-2609
    Published: 2013
    Released on J-STAGE: March 25, 2014
    JOURNAL FREE ACCESS
    A 78-year-old woman was admitted to our hospital because of pancytopenia. Biochemical analysis revealed high lactate dehydrogenase and soluble interleukin-2 receptor levels. Plasma adrenocorticotropic hormone, plasma noradrenaline, and urinary normetanephrine levels were elevated. Plasma adrenaline and urinary metanephrine levels were low. The plasma cortisol level was within normal ranges. Abdominal CT revealed 2 masses, both measuring 7 cm in diameter, in the adrenal gland, with comparable and homogeneous density. An FDG-PET scan showed intense FDG accumulation in both adrenal glands without abnormal FDG uptake in the extraadrenal regions. The bilateral adrenal tumors were highly suggestive of malignant lymphoma. To make a definite diagnosis, operative procedures such as laparoscopic biopsy of the right adrenal gland were performed. Pathological examination showed diffuse infiltration of large atypical lymphocytes. Immunohistochemical analysis showed that staining for B-lymphocyte-specific markers such as CD20 was exclusively positive in large atypical lymphocytes. Diffuse large B-cell lymphoma, which originated in both adrenal glands was diagnosed, and R-CHOP therapy was administered. Involvement of the central nervous system was noted 5 months after surgery, and the clinical course deteriorated rapidly thereafter. The patient died 8 months after surgery. The prognosis of patients with primary adrenal lymphoma seems to be dependent on the ability to make a definite diagnosis on the basis of laparoscopic biopsy and start accurate treatment without any delay.
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