Serum tissue polypeptide antigen (hereafter referred as TPA), CEA and complements were simultaneously measured in 64 breast cancer patients, in 75 healthy women and in 14 women with benign breast diseases.
1) TPA-and CEA-positive rates of primary breast cancer before surgery were 40% for TPA and 36.4% for CEA; both had noticably larger ranges than benign breast diseases.
2) Mean levels and positive rates of TPA, CEA and C4 increased according to the stage of the cancer, TPA having the strongest such tendency (p<0.010.05).
3) There was a correlation between TPA and tumor size, (length×width²/2) (P<0.01).
4) With wide lymph node metastasis, TPA showed a higher level (N₂, n₂ or more).
5) There wasn't any correlation between TPA and histological types of breast Ca.
6) By the combination assay of TPA and CEA, higher positive rates were gained.
These data indicate that TPA would be an excellent tumor marker for breast cancer, with a high clinical evaluation.

View full abstract

Nutritional assessment was performed in 41 patients with squamous cell carcinoma of the esophagus to clarify factors associated with nutritional deficiency. Six parameters, i.e., body weight, triceps skin fold, arm muscle circumference, creatinine/height index, serum albumin and serum transferrin were measured on admission, after preoperative radiation therapy, and at four as well as eight weeks after surgery. The assessment indicated that, on admission, nutritional deficiency clearly existed in esophageal cancer patients. Out of factors including age, dysphagia, stage of cancer and cellular immunity in patients on admission, dysphagia and stage of cancer were associated with nutritional deficiency. The effect of treatments for cancer on nutritional status was also assessed. The parameters of nutrition were markedly depressed by the surgery with or without preoperative radiation therapy. These results indicate that treatments including surgery and radiation, dysphagia and stage of cancer, especially the former two, are critical factors associated with nutritional deficiency in esophageal cancer patients.

View full abstract

Our experience with pancreatic cysts has been reviewed. There were 11 pancreatic pseudocysts, one cystadenocarcinoma and one parasitic cyst (Fasciola sp.) in our department over a 15-year period. Eight of the pancreatic pseudocysts (72.7%) were subsequent to pancreatitis. The sites of the pseudocysts were the pancreatic head in five, the body in four and the tail in two. A patient with cystadenocarcinoma whose initial complaint was palpable abdominal mass had a huge single cyst arising from the tail.
Laboratory findings showed the elevation of serum amylase levels in 76.9% and leucocytosis in 40%. Ultrasonography and CT-scanning were useful in the early detection of the pancreatic cysts and the rate of diagnosis was 76.9%, but the differentiation of pseudocyst from cystadenocarcinoma was difficult by these techniques. Rupture of the pseudocyst into the gastrointestinal tract and the peritoneal cavity was observed in one patient, resulting in death.
Operative procedures for pseudocysts were external drainage in three, cystojejunostomy in five, and cystogastrostomy and pancreaticoduodenostomy in one each. Postoperative bleeding from an infected cyst was noted in a patient after cystogastrostomy requiring excisional reoperation. A patient with cystadenocarcinoma initially underwent cystojejunostomy because there was no evidence of malignacy in the frozen section, but reoperation was required after three months because of promptly malignant pictures.
It is concluded that cycts clinically suspected of malignancy should be subjected to excisional operation including pancreatectomy and/or splenectomy.

View full abstract

The present report demonstrates the bowel sound of ileus by dividing the findings of the spectral arrays into fourtypes.
The microphone was attached to the McBurney point, and the bowel sound was recorded on a tape recorder. The spectral arrays were obtained by a continuous analysis of the sound frequencies (0-1200Hz) with the signal processer.
The bowel sound in healthy adults consisted of 200-550Hz with peak frequency at 340Hz, and the high frequency sound above 900Hz was scazcely observed.
Type 1 and 2: This sound was recorded by the simple obstruction as a metallic sound. Its feature is that a high frequency sound above 900Hz is seen sporadically or together. The pattern where the location of peak sounds is below or above 550Hz was classified into 1 and 2 types respectively. In case of type 2, the width of the peak sound extended to the high frequency range.
Type 3: This sound is observed in the strangulating obstruction. This pattern is that a high frequency sound above 900Hz is not seen, and the peak frequency was shifted to the high frequency range. In type 3, the pattern where the width of peak frequency was narrow and isolated suggested the necessity of an operation.
Type 4: This pattern was seen in the paralytic ileus.Alow peak was observed sporadically.
This finding of spectral arrays of bowel sounds in the ileus is a useful tool for critical diagnosis of ileus and in decision to operate.

View full abstract

During the course of post-operative enteral nutrition in cases of gastric cancer, the changes occurring in the intestinal microflora and their relationship to clinical symptoms or biochemical examination levels were investigated. Nutritive agents used were Elental, Besvion and Hinex-R, each of which had a different carbohydrate composition. The subjects were divided into three groups: Elental group (group E), Besvion group (group B) and Hinex-R group (group H). Diarrhea occurred in 40% of cases in groups E and H and in 10% of those in group B while enteral nutrition was being carried out. Observation of the changes in intestinal microflora during use of the nutritive agents revealed that anaerobes decreased to 1/100-1/10000 in the three groups due to the antibiotics used postoperatively. There were different changes in Bifidobacterium among the three groups, in particular a marked decrease in groups E and H, both during and after the use of antibiotics which was not marked in group B, the levels of which returned to those existing preoperatively. These results were considered to be caused by the difference in carbohydrates contained in the nutritive agents, suggesting that in group B, the nutritive agent of which contained not only dextrin but also galactose, glucose and lactose, the carbohydrates accelerated an increase in Bifidobacterium, inhibiting the occurrence of diarrhea. Hardly any changes in electrolyte, GOT, GPT, LDH, BUN, creatinine and serum protein (T-p) were found, showing levels within the normal range. It was therefore thought that there was no relation between changes in intestinal microflora and biochemical examination levels.

View full abstract

Recently, application of a pulling-up retractor (divised by Morioka) to a transabdominal approach has facilitated dissection of the lymph nodes in the lower mediastinum and diffuse removal of the esophagus. In addition, application of an EEA type autosuture has made intramediastinal anastomosis at the middle or inferior esophagus possible.
At present, this procedure is commonly undertaken as the curative operation for carcinoma of the gastric cardia with esophageal invasion of less than 3cm. Out of 41 operations for carcinoma of the gastric cardia over the last three years, 36 were transabdominal procedures and the others were transthoracic ones. EEA was used in 22 of these 36 cases. Anastomotic insufficiency occurred in 7.1% of the sutured group, while none in the EEA or transabdominal group suffered from this complication. Pulmonary complications were noted in 7.1% of the sutured group, 13.6% of the EEA group and 20.0% of the transabdominal group.
We concluded that application of the pulling-up retractor and autosuture in transabdominal surgery is very useful for carcinoma of gastric cardia with esophageal invasion because this makes it possible to dissect the lymph nodes of the lower mediastinum and remove the esophagus sufficiently.

View full abstract

During the last 17 years, six cases of traumatic diaphragmatic hernia have been encountered in Tokyo Metropolitan Bokuto Hospital. The male: female ratio was 5:1 and the patients ranged in age from six to 66, with a mean of 42 years.
They were grouped into the three time phases proposed by Carter et al in 1951: three in the acute phase, one in the interval phase and two in the phase of obstruction or strangluation. Two patients in the acute phase died of associated abdominal viscereal injury shortly after surgery, and the other four were treated uneventfully.
We concluded that operative repair should be undertaken without further delay as soon as the diagnosis is made.
In the phase of obstruction or strangulation in particular, early decompressive maneuver of the herniated organ is required.

View full abstract

A group of young patients (aged under 30) with early gastric cancer was compared with other groups divided by age and its characteristics were investigated clinicopathologically.
Our nine patients (ten lesions) accounted for 2.0% of the overall patients with early gastric cancer. The male to female ratio was 3.5:1, which was higher than that in the other age groups. Most patients complained mainly of epigastralgia and the period of suffering was 25 months on average. As for gross types, nine of the ten lesions were of the depressed type. In the total cases of early gastric cancer, many cases of the depressed type were found in the under 50age groups. In the group of 50 years old or more, the number of cases of protruded type gradually increased with age, exceeding the number of cases with depressed type in the 70 or more age groups. As for histologic types. differentiated type was found in three cases and undifferentiated type was found in seven. The number of cases with differentiated type increased with age, amounting to 90% a of the cases over 70 years of age. As for location of the lesion, eight lesions were located at M, and the percentage of the lesions at that location in this group was higher than in any other age group. As for vascular invasion and lymphnode metastasis, there were no large differences as compared with the other age groups. Prognosis was good except for one case in which the patient died of recurrent diseases, and five of nine patients have survived for more than five years.

View full abstract

In the present patient with the rupture of gastric varix complicated by portal hypertension, a bulky hepatic artery-to-portal vein fistula (hereafter referred to as hepatic A-P fistula) was noted in the anterosuperior region of the right hepatic lobe from angiography performed preoperatively, and a partial hepatectomy inclusive of the heaptic A-P fistula was carried out successfully. Ever since Sacks reported a death from digestive tract hemorrhage in 1892, 47 cases of hepatic A-P fistula have been reported up to last year. In the present patient, hepatic A-P fistula may not have been the sole cause of the gastric vein rupture because of the presence of post hepatitic cirrhosis. However, our diagnosis was iatrogenic hepatic A-P fistula, as the symptoms of portal hypertension appeared subsequent to liver biopsy and the similar cases have been reported before. Palliative treatment, such as ligation of the hepatic artery, is conventional in such cases. However, as hepatectomy guided by operative ultrasonography has become a safe and positive therapy regardless of the location of the fistula, the authors undertook direct resection of the hepatic A-P fistula along with Hassab's procedure for gastric varix and upper gastric dissection.

View full abstract

Two cases of postoperative ruptured pseudoaneurysm of the hepatic artery are reported.
The first was 36-year-old woman, who was diagnosed as suffering from congenital choledochal cyst associated with bile duct stone. Resection of the choledochal cyst and hepaticojejunostomy were performed.
The second patient was a 60-year-old man, who was diagnosed as suffering from bile duct carcinoma involving the hepatic hium. Pancreatoduodenectomy and resection of the hepatic hulum were performed.
On the 11th P.O.D. (first case) and the 33rd P.O.D. (second case), massive hematoemesis and melena occurred, with attendant hypovolemic shock.
Emergency arteriograms showed pseudoaneurysm of the hepatic artery, which ruptured into the jejunum.
Aneurysmectomy and ligation of the hepatic artery were performed.
The first patient recovered safely, but the second died four hours after the operation.
Pancreatic fistula seemed to be the causes of these two postoperative pseudoaneurysms of the hepatic artery.
Emergency arteriography confirmed the diagnosis of these two cases. A review of 12 cases of postoperative ruptured pseudoaneurysms of the hepatic artery in the literature was made.

View full abstract

A 44-yearold man was admitted to our hospital with right back pain and fever. Endoscopic retrograde cholangiographic pancreatography (FRCP) revealed fusiform dilatation of the extrahepatic bile duct with an anomalous junction, the pancreatic duct joining the choledochus. Cholecystectomy, resection of bile duct and hepaticojejunostomy were performed. Pathological examination showed papillotubullar adenocarcinoma of the gallbladder.
The second patient was a 47-year-old woman, who complained of right upper quadrant pain and fever. Abdominal echography showed a tumor of the gallbladder protruding into the lumen. ERCP revealed diffuse dilatation of the extrahepatic and intrahepatic bile ducts with an anomalous junction, the pancreatic duct joining the choledochus. The gallbladder was not visualized. Gallbladder carcinoma was suspected. Cholecystectomy, resection of bile duct with regional lymph nodes and hepaticojejunostomy were performed. The operative diagnosis was Stage I carcinoma. The pathologic diagnosis was papillotubullar adenocarcinoma.
Reviewing the Japanese literatures, an anomalous junction of the pancreaticobiliary ductal system was frequently found in cases of congenital biliary dilatation with gallbladder carcinoma. This fact suggests that this anomaly may be one of the oncogenic factors for this type of malignancy.

View full abstract

A case of benign duodenocolic fistula found in a 76-year-old man is reported. His chief complaints were abdominal distension, upper abdominal pain, nausea and vomiting. Gastrointestinal fluoroscopy easily revealed a duodenocolic fistula, and enema fluoroscopy and endoscopy also showed the presence of a fistula but no malignant findings. Biliary examination revealed a dilation of the common bile duct but the gallbladder was not visualized. Moreover, no gallstones were seen.
By surgery performed with the aim of closing the fistula, no malignant findings were found but a high-grade adhesion centering around the gallbladder was present. However, a fistula between the gallbladder and the duodenum was revealed by detachment of the adhesion. Each fistula was excised and closed. The post-operative course was uneventful.
Many cases of duodenocolic fistula are derived from malignant diseases, especially colonic carcinoma, and the benign cases is very rare. In Japan, only 12 cases of benign duodenocolic fistula have been reported in the literature, this case making the 13th.

View full abstract

The very rare complication of small intestinal injury due to blunt abdominal trauma involves delayed stenosis of the small intestine. In the present study, our experience of a case of blunt abdominal trauma which could be preoperatively diagnosed was totalized together with eight cases reported in Japan during the past 20 years and is reported in the light of the related literarure.
The patient, a 21-year-old man, visited our hospital with chief complaints of abdominal pain and vomiting 17 days after blunt abdominal trauma. Delayed stenosis of the small intestine due to the trauma was diagnosed after scrupulous examination, and the patient underwent surgery. As the stenosis was situated in the jejunum on the anal side 1.9m distant from Treitz's ligament, and the mesentery around the stenosis cicatrized, enterectomy was performed. Histopathological findings showed small intestinal ulcer. The cause of the stenosis was considered to be organic change caused by a circulatory disorder of the intestinal duct due to the mesenteric injury. In our case, a long intestinal tube (Dennis tube) was inserted, leading not only to improvement of ileus symptoms but also to useful determination of the site and the degree of stenosis.
With regard to the eight cases of this disease previously reported in Japan, all were in male subjects, with an age range of 4-60 years. The time elapsed from the trauma to the appearance of symptoms was 4-30 days, or 16 days on average. Each small intestinal stenosis was diagnosed by small intestinal radiography, angiography, laparoscopy and so on, used for preoperative diagnosis. As to the stenotic site in the small intestine, no definite tendency was found.

View full abstract

The number of reported cases of primary small intestinal carcinoma has recently been increasing. But its frequency is still low, its early discovery and diagnosis is difficult. A case of jejunal carcinoma preoperatively diagnosed by small intestinal fiberscopy is reported in the light of related literature.
The patient, a 34-year-old woman with the chief complaint of vomiting, was diagnosed as having jejunal carcinoma by double contrast radiography and fiberscopy of the small intestine, and she underwent partial jejunectomy and lymph-node excision. The lesion was located in the jejunum on the anal side 20cm distant from Treitz's ligament. Histopathological findings revealed that the lesion was a well-differentiated adenocarcinoma.
Preoperative diagnosis of primary small intestinal carcinoma is difficult as it occurs at low frequency, 0.1-0.3% of all carcinomas of the digestive tract and it sometimes has no symptom. Early discovery and diagnosis of primary small intestinal carcinoma is so important also from the prognostic aspect that it is necessary to perform double contrast radiology and fiberscopy of the small intestine whenever it is suspected. Its basic treatment is a surgical procedure and it has been reported that the five-year survival rate is 20%.

View full abstract

A housewife complaining of a nontender mass in the LUQ of the abdomen underwent cystojejunostomy for a unilocular cyst of the pancreatic tail at 33 years of age. A retention cyst was suspected upon histology of the cystic wall. The patient repalpated a similar mass three years following the surgery. She was readmitted on September 28, 1984, at 38 years of age, because of the enlarging mass. A multilocular cyst at the pancreatic tail was demonstrated upon abdominal ultrasonogram and CT. Under the diagnosis of pancreatic cystadenoma, the patient was reexplored. Removal of the mas with splenectomy and distal panceratectomy showed a 12×11×7cm, mass weighing 500g numerous cysts in its cross section. Lining cells of cuboidal and columnar epithelia without malignancy were demonstrated histologically. Pancreatic mucinous cystadenoma was evaluated following additional PAS and mucicarmin stainings. Mucinous cystadenoma has a malignant potential to cystadenocarcinoma. Twenty-seven cases including our own have been noted in the Japanese literature. Compared with serous cystadenoma, which is usually benign, mucinous cystadenoma showed frequency of 1.8 times, a prevalence of elderly patients, and higher occurrence in the pancreatic body and tail. Thorough excision is mandatory to prevent malignant change.

View full abstract

Insulinoma is noted for its specific clinical symptoms over a long period. Our experience of a case of insulinoma in which diagnosis of the involved site was very difficult in spite of its typical symptoms is reported.
The patient, an 80-year-old woman, visited our hospital with the chief complaint of repeated attacks of unconsciousness. Insulinoma was diagnosed by scrupulous examination, but detemination of the involved site was difficult. After each examination was repeated several times, angiography revealed the site and the nucleus of the tumor was excised. The postoperative course was uneventful.
Although clinical diagnosis of insulinoma has been getting easier with advance in each examination method, determination of its location before surgery is very important. New methods such as PTPC and perioperative echography exist, but are not yet generally used. Determination of the location by repeating various kinds of examinations is recommended. Angiography in particular is considered to be useful.

View full abstract

Recently, we experienced five cases of adrenal pheochromocytoma, one of which was associated with gastric cancer and another two with medullary carcinoma of the thyroid. In this paper, the preoperative localization of the tumor and surgical treatment of pheochromocytoma are discussed. Computed tomography and ultrasonography were quite useful for the diagnosis of the tumor localization, and nuclear magnetic resonance-CT (NMR-CT) and scintigrams made with [¹³¹I] metaiodobenzylguanidine ([¹³¹I]MIBG)-newly developed techniques-were also useful.
It was necessary in every case to control the blood pressure preoperatively by drugs such as labetalol-an α and β blocker-or prazosin-an α blocker.
The preoperative measurement of the circulatory blood volume was also necessary to prevent hypotension after the removal of the tumor.
The transabdominal approach was adopted in our cases, but the retroperitoneal approach would be advisable for patients in whom the localization of the tumor was clearly demonstrated preoperatively.

View full abstract

Two cases of malignant pheochromocytoma were reported.
The first case, a 40-year-old man, was admitted with the complaints of constipation and abdominal tumor. Marked hypertension was found. Computed tomography revealed a hypervascular mass at the bifurcation of the abdominal aorta. Laboratory investigation revealed elevated levels of VMA, norepinephrine and normetanephrine in the urine and of norepinephrine in the plasma. At laparotomy, an 8×5×4cm mass adherent to the aorta was removed. The blood pressure returned to normal for six months. Then, hypertensive symptoms recurred with metastasis to the liver and sacrum. He died nine months postoperatively.
The second case, a 21-year-old man, was admitted with the complaint of severe lumbar pain, He had had mild hypertension since the age of 18. Radiography revealed destruction of the third lumbar vertebra and computed tomography a large mass in the right flank. Laboratory investigation revealed elevated levels of VMA, dopamine, norepinephrine and normetanephrine in the urine and of norepinephrine in the plasma. At laparotomy, a 13.5×11.5×7.5cm mass was incompletely removed because of invasion to the inferior vena cava. Postoperatively, radiation therapy, total 11000rads was given. He is asymptomatic with metastatic foci a year after surgery.
A brief review of the literature was given.

View full abstract

A case of leiomyoma of the rectum, a relatively rare disease in Japan, is reported.
The patient, a 34-year-old woman, was discovered to have a tumor under the right mocosa of the rectum during her pregnancy and upon delivery. The tumor was diagnosed as benign leiomyoma by biopsy and the patient was put under course observation. Thereafter, she realized that her stool became thin and enlargement of the tumor was also recognized, so she was admitted to our hospital five years after the biopsy and underwent tylectomy. The tumor was 8×6×3.5cm in size. Histologic findings showed a leiomyoma consisting of definite spindle-shaped cells, without malignant indications. Her clinical course after discharge was uneventful and there have been no signs of relapse over the past one and a half years.
As the difficulty of histologically differentiating the benignancy from malignancy of this disease has been pointed out by various investigators, tylectomy is initially recommended, rectectomy being considered if malignancy is suspected after satisfactory examination of the biopsy sample or if there is any sign of relapse.

View full abstract

During the past five years, arterial reconstruction was performed in five cases of chronic maintenance hemodialysis for complications of arteriovenous fistula. The subjects were three males and two females. The cases of arteriovenous fistula with complications involved three cases of arteriovenous fistula between the cutaneous veins proximal to the brachial artery, one case of gore-tex graft arteriovenous fistula between the brachial artery and vein and one case of bovine graft arteriovenous fistula between the femoral artery and vein.
The complicatons for which arterial reconstruction was necessary involved four cases of intrafistular infection and one case of acute arterial embolism.
In the four cases of infection, autoplasty of the venous bypass was performed, bypassing the involvement and passing under the medial skin at the elbow joint area. This course was considered to be appropriate because the graft was not bent by movement of the joint.
In the one case of arterial embolism, embolectomy was performed with a Fogarty catheter.
The most troublesome complication was that of infection, and much care must be taken to prevent infection in arteriovenous fistulation or intrafistular puncture.

View full abstract