Fifty-three cases of congenital cervical cyst and fistula, including 38 cases of thyroglossal duct cysts, 12 of branchial cleft fistulas, and 3 of pyriform sinus fistulas are reported. There were 24 males and 29 females. The age of the subjects at the time of the operation varied from 5 months to 70 years, and 64 percent of the cases were less than 15 years old.
Thirty cases (79%) of thyroglossal duct cyst and 7 cases (58%) of branchial cleft fistula occurred up until the age of 15. The main symptoms were a cystic mass in the former, and fistulas in the latter. Signs of infection were found in 14 cases (37%) of the former, and in 4 cases (33%) of the latter.
Three pyriform sinus fistulas emerged as cervical abscesses, acute suppurative thyroiditis and mediastinal abscesses. In one case that could not be diagnosed by the usual pharyngoesophagography, and in confirming a comunication tract of the fistula during surgery, fistulography with a rigid bronchoscope proved to be useful diagnosis method.
The most important task in the operative therapy of congenital cervical cysts and fistulas is to prevent a relapse of the disease. Therefore, a reliable operation based on accurate anatomical knowledge is required.

View full abstract

Twenty-three operative cases of thyroglossal duct cyst, including a case of squamous cell carcinoma, in a recent one decade were studied for clinical factors such as sex, age, duration to operation after detection of the tumor, sites, operative procedures, and postoperative course, as well as for histological findings. Moreover, a necessity of resection of the hyoid bone was discussed in terms of etiology, in conjunction with a review of the pertinent literature. As a result, no significant difference was noted in the male-to-female ratio. As to the age at the first diagnosis, most patients in the ENT and pediatric surgery fields were under 10 years old, which might reflected that the disease is congenital one. On the other hand, patients in the department of general surgery were predominantly over 20 years of age. Disease-period with less than one year was common, the lesions being frequently found between the hyoid bone and thyroid cartilage. Twenty-two cases were operated on according to Sistrunk method, of which one had recurrence but has been well for 8 years after extended reoperation. No recurrence was observed in cases without resection of the hyoid bone, however, in the literature more frequent recurrence was noted in non-resection cases compared to resection cases. Pathological recognition of a few fistels and their branches suggested the importance of wide resection of surrounding tissues as well as partial resection of the hyoid bone to prevent recurrence. We should remember a possible occurrence of papillary carcinoma derived from remnant thyroid tissues or squamous cell carcinoma deriving from fistel epithelium, though it is rare.

View full abstract

One hundred and eighty patients with histological node negative breast cancer operated on during the period between 1976 and 1985 at our institute were studied for prognostic factors in an attempt to single out the high risk group for recurrence. The medial duration of follow-up was 94 months; 24 (13%) patients have had a recurrence to date.
The recurrence rate was significantly related to tumor size, histological type and histological grade. Disease free survival was significantly related to tumor size and histological grade, but not to histological type. These three prognostic factors were encoded as the prognostic score, and 171 patients except for nine of histological special type were divided into three groups of increasing gravity according to the prognostic score. The differences between the groups were significant for the recurrence rate and disease free survival. The recurrence rates for the three groups were respectively 7.4, 16 and 25%, whears they were 92, 83 and 74% for disease free survival. According to these prognostic socres, 28 patients (16%) having the poorest prognosis of early recurrence and short survival after recurrence were singled out as the high risk group for recurrence.
We concluded that analysis of node negative breast cancer using polyfactors according to the prognostic score might be useful in singling out the high risk group for recurrence indicated for systemic adjuvant chemotherapy.

View full abstract

Operatated cases for peptic ulcer experienced at our department in a recent one decade until 1989 were subjected to a study of their changes. Subjects were 170 cases, comprising of 117 (68.8%) of gastric ulcer, 45 (26.5%) of duodenal ulcer, and 8 (4.7%) of both ulcers. When all subjects were divided into the first 5 years and the latter 5 years, there was no significant change in the incidence by diseases between both periods, but total number of operated cases decreased to 67 cases in the latter period from 103 cases in the first period (by 35.0%), with an abrupt decrease in numbers of intractable cases (p<0.01). On the contrary, bleeding or perforating cases increased (p<0.01-0.05). Emergency operation cases increased in its rate as well as number in the latter period (p<0.01), especially for gastric ulcers. As a probable factor for this increase in emergency operations, an increasing tendency of primary occurrence of ulcers as well as aging of the patients is indicated. In the latter 5 years, a prolongation of disease-period can be observed. From the above, careful observation of the clinical course entertaining surgical treatment would be necessary, especially for primary peptic ulcers developed in relatively aged patients.

View full abstract

In 10 relative noncurative gastric cancer cases, undergoing gasterectomy combined hepatectomy, the relationships between the prognosis and biological characters (including nuclear DNA contents and the immunohistochemical staining of tumor markers such as CEA and AFP) in both primary and liver metastatic foci were investigated.
Of the 10 cases 3 survive for more than 3 years, while, 5 out of the remaining 7 cases died of recurrence of cancer in the remnant liver. In 3 out of 5 long survival cases, the nuclear DNA contents showed low ploidy patterns in both foci. On the other hand, in 4 out of 5 short survival cases, it showed high ploidy patterns in both foci. The remaining one of the 4 had the multiplicity in nuclear DNA patterns, namely, it was low ploid in the primary but high ploid in the metastatic foci. In immunohistochemical CEA staining, one long survival case showed positive CEA in primary and negative one in the liver. It is suggested that the postoperative prognosis of the gastric cancer with liver metastasis might be related with the multiplicity in the biological characters between the primary and metastatic foci.

View full abstract

Nineteen cases of gastric carcinoma undergoing total gastrectomy were allocated at random to splenectomy group (10 cases) and splenectomy with splenic autotransplantation group (9), and the spleen graft survival, its regeneration, and the usefulness of the autotransplantation were determined in terms of serological factors. In the transplantation, 30%-40% of the spleen by weight was made into small tissue fragments and diffusely transplanted in the mesenteries of the transverse colon and small intestine. No severe postoperative complications were seen. In splenic scintigram using ^99m Tc-heat treated erythrocytes, 6 (75%) out of 8 cases under follow-up for 3 months or more showed positive findings. There was no significant difference between both groups in postoperative changes in platelet counts, immunoglobulin, cellular immune parameters such as T3, T4, T8, T4/T8, and NK activity. No clear resolution was given for effects of splenic transplantation on serological factors. However, this operative procedure was able to satisfy the radicalness in operation for gastric carcinoma, and to provide the regeneration of the spleen. It is indicated that this procedure, consisting of total gastrectomy, splenectomy and splenic transplantation, can be a possible candidate for radical operation for gastric carcinoma.

View full abstract

A recent 10 year-experience with 40 cases of multiple primary carcinoma of the large intestine and other organs was clinically studied. The 40 cases represented 4.8% of 835 cases operated on for colorectal carcinoma in the same period, including 11 synchronous, 27 heterochronous and 2 synchronous/heterochronous multiple carcinoma cases.
Among carcinoma in other organs, gastric carcinoma was the most common (53.5%). Multiple carcinoma cases were more common in males and in elders, and appeared to have a family history of cancer in a higher frequency than the 835 operated cases. The clinicopathological findings of colorectal carcinomas in 32 multiple primary malignant cases with resection of colorectal carcinoma were not so characteristic compared to the 658 resectable cases without carcinoma of other organs. The cumulative 5-year survival rate of the 31 cases with resection of both colorectal carcinoma and carcinoma of other organs was significantly lower than that of 658 resectable cases described above. In order to improve the prognosis of multiple carcinomas, we have to make more effort at improving the prognosis of primary malignant tumors of other organs, especially gastric carcinoma, in synchronous cases, and at detecting early the associated colorectal carcinoma in heterochronous cases, if another carcinoma of other organ preceded.

View full abstract

Excepting operation-related deaths, including deaths within 30 days after operation and hospital deaths, and absolute non-curative resection cases, 171 resected cases of Hepatocellular carcinoma (HCC) were classified into 3 groups in terms of Kobayashi's risk score, namely, group A (score 7.5 or above; 29 cases), group B (7.4-6.0; 94) and group C (5.9 or below; 48). Results were: 1) The number of cases with a score of 6.0 or above was 123 out of 171 cases (71.9%). 2) In comparison with the other 2 groups, both postoperative survival rate and non-recurrent rate were significantly poor in group A (p<0.05), and this reason might lie not only in the recurrence but also in possible multicentric cancer causing. 3) There were 4 factors involved in increasing the risk score from group B to group A, namely, HBs-Ag (+), alcholic history (+), familiar history of HCC (+) and AFP≥21 ng/ml. On the other hand, there were 2 factors involved in decreasing the risk score from group B to group C, namely, sex and age (p<0.01). 4) The mean size of tumors in group A was larger than that in group C. Tumors in stage I or II were lesser in group A than the other 2 groups (p<0.05), however, there was no significant difference among the 3 groups in 7 factors such as macroscopic type, fc, fc-inf, vp, im, Hr and tw.

View full abstract

In order to study the significance of the intraoperative radiation therapy (IORT), seventy patients who had extended pancreaticoduodenectomy (ExPD) for a carcinoma of the head of the pancreas during 1983 and 1990 were selected for this study.
These patients were compared for postoperative survival and local recurrence with or without IORT at a dose of 25 Gy by grouping as follows.
Grouping A: All 70 patients who had histologically curative or non-curative resection were divided into 16 receiving ExPD+IORT and 54, ExPD only. Grouping B: Fourty-two patients who had histologically curative resection were divided into 12 receiving ExPD+IORT and 30, ExPD only. Grouping C: Twenty-eight patients who had histologically non-curative resection were divided into 4 receiving ExPD+IORT and 24, ExPF only. As a result, the median survival rates in ExPD+IORT and ExPD only patients were 13 months and 13 months in grouping A; 13 months and 14 months in grouping B; and 14 months and 11 months in grouping, C, respectively, where no significant difference was noted. There was also no significant difference in the local recurrence, namely, the incidences of local recurrence in ExPD+IORT and IORT only patients were 75% and 50% in grouping A; 50% and 42% in grouping B; and 100% and 67% in grouping C, respectively.
These results showed that intraoperative radiation therapy at the dose of 25 Gy did not improve the median survival and local recurrence in patients undergoing extended pancreaticodenectomy for the carcinoma of the head of the pancreas.

View full abstract

In 170 cases of perforative peritonitis surgically treated at the institution during the past one decade, 24 cases were preoperatively associated with leukocytopenia of less than 5, 000/mm³. This decrease in white blood cell count was frequently found in aged patients or those with perforation of the large intestine. In these patients decreased white blood cell count increased soon after operation.
The mortality of leukocytopenia-associated patients was 12.5% without significant difference from that of no-leukocytopenia patients. However, in 11 patients concomitantly associating with hypotension on admission, the mortality was 27.3% versus null in 13 without hypotension. In the treatment operative procedure with less surgical invasion was selected, and postoperatively gamma-globulin preparations, plasma multi-enzyme inhibitors, H2-blockers were combinedly used. Leukocytopenia is reportedly a severe condition but appropriate treatment can save a life of such a fetal patient.

View full abstract

Preoperative intravenous administration of high-dose γ-globulin and platelet transfusion have produced a satisfactory control of operative and postoperative hemorrhage in cholecystectomy for massive intracystic bleeding of the gallbladder, in a 28-year-old male with aplastic anemia accompanied by severe thrombocytopenia (3, 000/μl) and marked prolongation of bleeding time (60 min), which has been known to be refractory to platelet transfusion. Gramma-globulin (10g/day) was administered intravenously for three preoperative days consecutively and platelet was transfused on the operative day. This resulted in an increase in the number of platelet up to 22, 000/μl and an operative loss of blood of approximately 500 ml. The postoperative course was uneventful. The mechanism of the thrombocyte-increasing observed in this case is unknown. It seems to be different from that in idiopathic thrombocytopenic purpura, since antiplatelet antibody has not been demonstrated in this patient.

View full abstract

A case of prepubertal gynecomastia accompanied by bloody discharge is reported here. An one-year-old male was taken to the hospital because of a right breast lump and bloody nipple discharge. There were no abnormalities in the history of delivery and lactation, patient's development, and the external genitalia. A subareolar blue penetrable tumor (1.7×1.4 cm) with soft elasticity, sufficient movability, clear rim, and flat surface was plapated. Serologic hormone test revealed normal levels for luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin, testosterone, estradiol, and progesterone. Since bloody nipple discharge continued, the tumor was excised. Histopathological examination revealed a dilated lactiferous duct and slightly edema-like interstitial tissues around the lactiferous duct. Based on these findings, this case was diagnosed as gynecomastia. Prepubertal gynecomastia is a rare disease. Some reports have pointed out congenital malformation and neoplasm for its etiology. We diagnosed this case as idiopathic prepubertal gynecomastia, because any causative factors were not identified. There are few reports on the disease complicated by bloody nipple discharge, and this case is likely important in terms of histopathology.

View full abstract

A case of recurred breast cancer 30 years after operation for the primary breast cancer in a 73-year-old woman was experienced. In April 1960, the patient when she was 43 years old underwent modified radical mastectomy for a right breast cancer. In February 1990, the patient was admitted to the hospital because of a right axillary tumor. A 5×4 cm unmovable and elastic hard mass was palpated, and serum NCC-ST-439 value was as high as 220 u/ml. On April 4, 1990, lumpectomy was carried out. The excised tumor was 5×4×3 cm in size and solid. Histologically it was comprized of adenocarcinoma, accompanying by no lymph node tissues nor breast tissues. Immuno-histologically α₁-lactoalbumin, DF-3, 115D8, and NCC-ST-439 were positive. Estrogen receptor in the tumor tissues was positive due to DCC method. No probable primary lesions were found in the other organs clinically, accordingly the tumor was considered a metastasis of the breast cancer to the axillary lymph nodes. As of 11 months after excision of the axillary tumor followed by radiation to the axilla, there is no signs indicating recurrence and serum NCC-ST-439 is in normal range (2.7 u/ml).

View full abstract

A case of adenoid cystic carcinoma of the breast in a 45-year-old woman is reported. She was admitted to the hospital because of a mass without tenderness in her right breast. On clinical examination there was a firm, well-circumscribed tumor with a diameter of 0.5 cm in the right upper-outer guadrant. Enlarged lymph nodes were not found. Ultrasound examination suggested malignant findings. A biopsy was performed to confirm the diagnosis. In its result, the tumor microscopically showed cribriform and solid areas with tumor cells which were small, uniform and poor in cytoplasm. The histochemical staining demonstrated a pattern of periodic acid-Schiff negative and alcian blue positive mucin in the pseudocystic spaces. Secondarily, wide excision and axillar hymph nodes dissection were performed. The axillary lymph node metastasis was not observed pathologically. It is now 18 months after the initial treatment, with free from recurrence.

View full abstract

Male breast carcinoma in a 16-year-old boy is reported. The patient complained of a palpable tumor. The tumor lacked in malignant findings by palpation and imaging methods. Cytodiagnosis resulted in class I-II. The tumor once diminished after needling, but after that, it became large again. Lumpectomy was performed. The excised tumor was diagnosed as mucinous carcinoma. Simple mastectomy without axillary lymph node dissection was carried out. Chemotherapy was not given and the patient is closely followed on an amvulant basis. There has been no recurrence, as of 2 years after surgery.
Male breast carcinomas are reportedly common in relatively aged men, particularly in their sixties. This case is the 4th in Japan, in which breast carcinoma occurred in men less than 20 years of age. There is a variety of etiologic hypotheses, and in this case any probable causes could not be clarified. The prognosis of male breast carcinomas in said not to be different from that of female breast carcinomas, if early diagnosis and radical operation can be successfully undertaken.

View full abstract

A case of right breast cancer with von Recklinghausen's disease is reported, together with a review of another 13 cases seen in the Japanese literature. A 72-year-old woman came to the hospital because of a right painless breast mass. There was a history of having a number of tumors in the whole body since her childhood. Biopsy offered a diagnosis of breast cancer. Right radical mastectomy was carried out. It was a breast cancer of t2n1αm0 in stage II.
Though von Recklinghausen disease is benign, its association with malignant tumors is often reported. Especially, in an association with a breast cancer, the detection of the breast cancer is often delayed because of the neighboring locations of both lesions. Among domestic cases-reported, no survivors for more than 4 years have been seen. Accordingly, when we encounter von Recklinghausen disease, systemic and careful exploration is essential, especially for possible association of breast cancer which is liable to be overlooked due to skin lesions.

View full abstract

Recklinghausen's disease is an inherited condition in which multiple neurofibromas are associated with spots of pigmentation of the skin, so-called Cafe au lait spots and often with malignant neoplasm. A case of advanced breast cancer with R's disease is reported.
A 46-year-old female was admitted to our hospital because of a left breast tumor with serous discharge. Metastasis to axillary lymph nodes, invasion to the chest wall and multiple metastasis of the bone were noted. The patient was diagnosed as having an advanced breast cancer (T4cN1bM1 Stage IV). After chemoendocrine therapy (per os), radical mastectomy and bilateral oophorectomy were performed.
In the literature, breast cancers with R's disease are commonly in an advanced stage more than stage II. The reason why this disease is found in an advanced stage, seems to lie in the existence of diffuse neurofibromas of the whole body skin. This case seems a good illustration suggesting the effectiveness of preoperative chemoendocrine therapy for advanced breast cancers.

View full abstract

Double chambered right ventricle (DCRV) is common in children, and rarely occurs in adults. Three operated cases of DCRV in a 46-, 46-, and 62-year-old patients are described. The peak systolic pressure gradient in the right ventricle was 110 mmHg in case 1, 80 mmHg in case 2, and 150 mmHg in case 3. A right ventriculotomy in a low pressure chamber was performed in cases 1 and 3, and a longituidinal right ventriculotomy from a low to high pressure chamber was used in case 2 associating with VSD. After surgery, the pressure gradient in the right ventricle disappeared but end-diastolic high pressure was recognized in all patients. It was suggested that deterioration of right ventricular diastolic compliance remains after surgery in adult patients with DCRV.

View full abstract

Primary tumors of the diaphragm are very rare, and we often have difficulties in differentiation from other tumors of adjacent organs. Here a case of fibromatosis originated from the diaphragm is reported.
A 15-year-old male student complained of abdominal tumor in the right upper quadrant. The chest X-ray examination showed a mild elevation of the right diaphragm. Ultrasonography and CT scanning revealed an ill-defined large mass at the level of the left inner segment of the liver.
A tumor of the liver was suspected and laparotomy was carried out. During surgery a large hard mass was found to arise in the right diaphragm, and to protrude into the abdominal cavity to compress the liver. There was no adhesion nor invasion to the adjacent organs including the liver. The tumor was excised with a part of the right hemidiaphragm and 4 ribs. The excised tumor measures 16×12.5×8 cm and weighed 640 gm.
On histological examination this tumor contained the components of a fibromatosis characterized by interlacing pattern of spindle cells and collagen fibers. There has been no sign of recurrence one year after operation.
We are able to collect a total of 53 cases with primary diaphragmatic tumor from the Japanese literature. Of the 53 cases fibromatosis was seen only in one case.

View full abstract

Recent experience with 2 cases of cancer of the cervical esophagus associating with a thyroid cancer is described.
Both 2 cases were middle-aged women having an esophageal cancer in stage IV. They had synchronous double cancer, but one noticed a tumor in the anterior region of neck from 6 years before, whose esophageal cancer appeared to be preceded by thyroid cancer for several years.
Double cancer of the esophagus and thyroid is uncommon. When 10 such cases reported minutely including this case were reviewed, there were 7 cases of synchronous and 3 cases of heterochronous double cancer. The male-to-female ratio was 3:7, with an average age of 61.7 years. Most cases had stage IV cancers, leading to poor prognosis. All 3 cases of heterochronous duoble cancer had thyroid cancer as the first cancer, with a time interval to occurrence of esophageal cancer being about 6 years. Two of the 3 cases were of cancer of the cervical esophagus. Moreover, all 3 cases had received radiation therapy in the treatment of thyroid cancer. This fact as well as that in this case which had been irradiated for lymph node tuberculosis suggestes a possibility of radiation caused carcinoma.

View full abstract

A case of synchronous triple cancer which involved the tongue, breast and esophagus was experienced. A 58-year-old woman underwent right partial resection of the tongue with a diagnosis of tongue cancer. This was in stage I showing the histological feature of well-differentiated squamous cell carcinoma. The second neoplasm, a right breast cancer, was diagnosed about two months after the first operation. A modified radical mastectomy was done (stage II), and the solid tubular carcinoma was histologically revealed. Around 4 months after the second operation for breast cancer, poor appetite and a gradual body weight loss occurred, and then 3 months later, an esophageal cancer was detected. Biopsy specimen revealed moderately differentiated squamous cell carcinoma in an advanced stage. It was inoperable. Systemic chemotherapy failed to cure and the patient died 6 months later. In this paper clinical course as well as flow cytometric DNA analysis of this synchronous triple cancer which was performed by using these paraffin-embedded tissues is described. Triple carcinomas seen in the literature are also discussed.

View full abstract

A 40-year-old man visited the hospital because of tarry stool. Endoscopic examination revealed coagula at the cardiac part of the stomach, but no clear source of bleeding was revealed. The patient was admitted under a diagnosis of upper gastrointestinal bleeding of unknown etiology. Because of anemia and sustained tarry stool, blood transfusion was performed. Despite repeated endoscopic examinations, the bleeding source was still unclear. We inferred that any conservative therapies had limits in treating this case, and emergency operation was carried out on the 15th hospital day. Intraoperative endoscopy revealed a small amount of bleeding in the cardiac side of the stomach, but no bleeding source could be confirmed. Additional intra-abdominal abnormalities were not found. As a result of ruling out probable diagnoses, Dieulfoy's ulcer with its bleeding source locating nearby the cardiac part was suspected. Total gastrectomy was performed. Macroscopic and microscopic examinations of the excised specimen showed that the bleeding site lay in a large blood vessel of 1.5 mm in diameter exposed from a microulcer of ULII, 1.5 mm in diameter, locating the anterior wall mean the greater curvature about 2 cm analside from the cardiac part of the stomach. A diagnosis of Dieulafoy's ulcer was made. Postoperative course was uneventful, and the patient was discharged on the 21st hospital day. A rare and valuable case of Dieulafoy's ulcer which could be diagnosed histopathologically is presented.

View full abstract

Primary carcinomas of the duodenum excluding duodenal papilla are uncommon, especially double or multiple cancer.
This paper describes a case of primary multiple carcinoma of the duodenal supra-papillary portion, with a review of 115 cases seen in the Japanese literature from 1985 to 1990.
A 68-year-old woman was admitted because of upper abdominal discomfort and anorexia. Upper gastrointestinal series and gastrofluoroscopy revealed an irregular and elevated lesion with ulcer in the supra-papillary of the duodenum. The biopsy specimens showed adenocarcinoma. Pancreatico-duodenectomy and lymph node dissection were performed. Macroscopic findings of the resected specimen showed two separate lesions in the posterior wall of the supra-papillary duodenal portion, namely, a type IIa tumor (sm) mesurring 1.0×1.1 cm in size, and a Borrmann type 2 advanced tumor (pm) mesurring 3.7×2.2 cm in size with napking-ring stricture. Histological examination revealed that both tumors were papillotubular adenocarcinoma without lymph node metastasis and located separately. No adenoma elements were formed in and near the lesions.

View full abstract

A case of pneumatosis cystoides intestinalis is reported. An 84-year-old woman visited the hospital because of severe right hypochondrial pain. Abdominal X-ray examination revealed a free air in the intraperitoneal cavity. Though peritoneal irritation was mild, a possible occurrence of intestinal perforation could not be denied, because of her advanced age and the lasting abdominal pain. Lapalotomy was performed. Cholecystlithiasis accompanying by gallstones, duodenal diverticulum, and a number of intramural small cysts of the ileum were found, but there was no perforation. From pathological findings, a definite diagnosis of pneumatosis cystoides intestinalis was made. It is thought that the free air might attribute to the disease and severe pain to gall stones. Postoperative course was uneventful, and the patient was discharged from the hospital.

View full abstract

Iatrogenic superior mesenteric arteriovenous fistulas are rare in Japan. A nonsymptomatic superior mesenteric arteriovenous fistula, which was accidentally detected during a clinical examination for a pulsatile abdominal tumor, is reported. There was a history of small bowel resection for intestinal obstruction following appendectomy seven years before. Following successful resection of the arteriovenous fistula, aneurysmectomy and grafting were performed. After surgery continuous murmur disappeared and abdominal CT and angiography revealed decreased diameters of the superior mesenteric artery and portal vein. This cause might lie in the mass ligation of the blood vessels at the small bowel resection about seven years before. Postoperative course was uneventful.

View full abstract

Dieulafoy type ulcer was originally reported as a kind of characteristic ulcers of stomach which can cause massive bleeding. A recent experience with massive jejunal bleeding from tiny ulcer of Dieulafoy type as well as some device identifying the bleeding site intraoperatively is described.
A 39-year-old woman was admitted because of abdominal pain and large amount of melena. Angiography revealed massive bleeding from a peripheral region of the first branch of the jejunal temporarily artery into jejunal lumen. To control the massive bleeding, transarterial embolization (TAE) using metallic coil was performed. Since precise bleeding point was accurately identified during operation by means of radiographic device using metallic coil for TAE as a landmark, only small resection of the jejunal wall was performed. Pathological examination revealed characteristic features of Dieulafoy type ulcer such as small shallow ulcer, rupture of persistent caliber artery, and middle-sized serpentine arteries in the submucosal layer.

View full abstract

It is difficult to cirtificate the mesodiverticular band during the operation for complicated Meckel's diverticulum. A boy of 15-year-old with strangulation for the small intestine caused by a mesodiverticular band is described. He was admitted to our ward because of abdominal pain lasting for a day. There was tenderness over the abdomen, but muscular defense was not elicited. There were fluid levels in a plain abdominal X-ray film. An emergent lapalotomy revealed Meckel's diverticulum at the ileum of 80 cm oral-side from the ileocecal valve and a band between the tip of the diverticulum and the mesentery. The ileum of the oral-side by 30 cm was incarcerated into the fossa between the diverticulum and mesentery, and it was strangulated. After the ligation and cut of the band the diverticulum was resected in wedge-shaped. Histopathological examination showed ectopic gastric mucosa in the resected specimen. We reviewed 482 patients with Meckel's diverticulum, especially 38 patients with the mesodiverticular band, reported in the Japanese literature in recent 10 years.

View full abstract

A case of inflammatory fibroid polyp (IFP) developed in the ileum is reported.
A 56-year-old woman was admitted to the hospital because of several episodes of recurrent crampy abdominal pain after meals. Plain films of the abdomen revealed dilated loops of the small bowel with air-fluid levels. Mechanical small bowel obstrcution and an intraluminal mass were suspected on CT films. On exploratory laparotomy an intussusception of the small bowel was found. Enterectomy about 70 cm was performed. Histologically, the tumor, 3.2×2.8×2.8 cm in size, occupied the submucosa, and there was an ulceration on the top of the tumor. The inflammatory cell infiltration was composed predominantly of eosinophils and lymphocytes. The fibroblasts had disintegrated in the lumina muscularis mucosa. As a result, CT will become valuable to make a diagnosis of intraluminal tumor. The diagnosis and proper enterectomy for submucosal tumors in the small intestine, especially IFP, are discussed based on our experience as well as a review of the literature.

View full abstract

A case of malignant amelanotic melanoma of the small intestine in a 28-year-old man is described. Occasionally the patient experienced epigastric pain since 3 months earlier, and was noted to be anemic on his visit to the department of internal medicine. However, abdominal echo and upper gastrointestinal series revealed no abnormalities. On November 16, 1990, however, the patient was admitted to the department because of acute upper abdominal pain. On admission abdominal ultrasonography showed a low echoic tumor shadow in the center of the abdomen and the inner part of the tumor appeared as concentric laminated structure, which corresponded to the CT findings. With the diagnosis of intussusception, an emergency operation was carried out. In the ileum an intussusception involving a 3 cm tumor was recognized, and a partial resection of the small intestine was performed. Histologically, a poorly differentiated carcinoma was suspected. As anemia did not ameliorate after surgery, X-ray examination of the small intestine was conducted and disclosed a lot of tumorous lesions in the jejunum. Laparotomy was performed again for partial resection of the small intestine. Histologically, the tumor was diagnosed as malignant amelanotic melanoma. Chemotherapy with DTIC, ACNU, and VCR was carried out. The patient recovered his daily activities, as of 6 months after the operation.

View full abstract

A case of synchronous primary cancers in a patient who was found having a jejunal cancer during operation for a sigmoid colon cancer is reported. A 56-year-old man received medical checkup and positive occult blood and mild anemia were revealed.
Minute investigation disclosed a sigmoid colon cancer. At operation, another cancer was also found in the jejunum at 10 cm from the Treitz's ligament. The sigmoid colon cancer infiltrated into the pelvic peritoneum and left ureter, therefore, palliative resection of the sigmoid colon was performed. It was a well differentiated tubular adenocarcinoma. The jejunal cancer was of the ulcerating type (3×4 cm), and was a well differentiated papillotubular adenocarcinoma.

View full abstract

Retroperitonitis is often found after operation for various diseases of the digestive tract and kidney. We encountered a case of retroperitonitis in which rectal perforation led to perirectal abscesses, inflammation spread from the retroperitoneal cavity to the chest, neck and mediastinum, and retroperitonitis was demonstrated in association with subcutaneous emphysema of the chest. This case is reported with a review of the literature.
A 57-year-old male visited our hospital because of anal pain and malaise. Chest X-rays demonstrated subcutaneous emphysema. CT revealed abscesses containing gas and extending from the neck to mediastinum, thoracoabdominal wall, retroperitoneal cavity, and perirectal areas. The patient was successfully treated by the administration of antibiotics and drainage.
Retroperitonitis is likely to spread rapidly in a manner similar to phlegmon, and when it is associated with perforation of the digestive tract, it is often caused by mixed infection of Gram-negative rod-shaped bacteria and anaerobic bacteria with varying enzyme activities. Therefore, the condition may resist antibiotics, and the outcome is often unfavorable. Early detection and appropriate early treatment are considered to be needed.

View full abstract

Schwannomas of the digestive tract are rare, especially in the rectum. Recently we experienced a case of rectal schwannoma. A 56-year-old female was admitted to our department with the chief complaints of on coccygeal mass and flat stool. The patient was diagnosed as having an extramurally growing neurofibroma of the rectum by Ba-enema, colon fiber, CT, and needle biopsy. The operation was done.
Intraoperative frozen section diagnosis disclosed no malignancy, and simple resection of the tumor was carried out. The resected tumor, with dumbell-like shape, was pathologically diagnosed as schwanmoma. Histologically Antoni type A mixed with the type B was identified without malignancy.

View full abstract

True Meig's syndrome is characterized by ascites and hydrothorax associated with a fibroma of the ovaries, which disappear immediately after the ovarian tumor is excised. If a pelvic tumor other than fibroma is associated, it is called pseudo Meig's syndrome.
A 39-year-old woman was admitted to the hospital because of constipation and diarrhea. Based on digital examination and barium enema, she was diagnosed as having a rectal cancer. During examination of any metastases to other organs, pleural effusion, ascites, and a ovarian tumor were found. A diagnosis of metastases to the ovary and peritoneum from the rectal cancer was made, and operation was performed. During surgery no metastasis in the liver and peritoneum was found and a Krukenberg tumor was seen in the right ovary. Abdominoperineal excision of the rectum and right-lateral oophorectomy were carried out. In an early period after surgery pleural effusion and ascites were rapidly resolved, that might demonstrate this case was Meig's syndrome in a broad sense.

View full abstract

A 44-year-old middle-sized woman visited the hospital because of lower abdominal pain. Barium enema and lower abdominal series revealed a flat torous lesion in the rectum growing to make two steps and locating at about 5 cm distant from the anal ring, and about 1 cm oral-side from the dentate line. Biopsy showed a group V adenocarcinoma surrounded by adenoma of relatively great width. Accordingly, endoscopic polypectomy was inferred impossible, and surgical treatment was carried out. On operation an invaginating method which is capable of resecting the rectum under direct vision was selected among sphincter saving operations, and simultaneously covering colostomy was added. After absence of anastomotic leakage around the colon-to-anal anastomosed site was confirmed, transverse colectomy including colostomy was performed on the 49th day after the initial surgery. After that defecation was favorable. The patient was discharged from the hospital when he began having stable bowel movements with 2-3 times daily.

View full abstract

A 47-year-old man with idopathic portal hypertension was admitted to our hospital for the management of recurrent bleeding esophageal varices. He had undergone total gastrectomy and esophagojejunostomy with the loope type reconstruction like the Billroth II because of bleeding esophago-gastric varices 10 years before. Injection sclerotherapy failed to control recurrent bleeding of the varices. Bleeding continued from the site of esophagojejunal anastomosis. The ligation of the vein of a jejunal segment which is ascending to the esophagus was done at the first operation. Bleeding was controlled for only ten months. But variceal bleeding occurred again. As the second operation, the vein of the ascending jejunal segment was anastomosed to the left renal vein with the disconnection from the portal vein. The patient died of amyotrophic lateral sclerosis 55 months after the shunt operation. The autopsy showed that the shunt was patent. Encephalopathy was not encountered after the operation. It is considered that total gastrectomy should be avoided for esophageal varices as possible as it allows, but if the varices recurs after total gastrectomy, this new selective shunt procedure may be recommended.

View full abstract

Two cases of insulinoma of which locations were successfully determined preoperatively are reported. Both two patients were admitted to our hospital because of loss of consciousness, and were suspected to have insulinomas by fasting blood sugar levels and blood immuno reactive insuline levels.
Ultrasonography, percutaneous transhepatic portal catheterization (PTPC), angiography and dynamic computed tomography showed that the tumors were solitary insulinomas arising in the head of the pancreas. By using intraoperative ultrasonography, the tumors could be removed not to damage the main pancreatic duct. The only curative treatment for the insulinoma is complete excision of the tumor. However, these tumors are often small and some are multiple, in that we have difficulties to determine their locations. Greater efforts using ultrasonography, CT, PTPC, and angiography combinedly would be necessary.

View full abstract

Seven cases of pancreatic islet cell tumor (3 of insulinoma, 2 of gastrinoma and 2 of non-functioning tumor) during a past-18 year period are reported. Furthermore, reports of non-functioning islet cell tumors seen in the literature were reviewed to clarify characteristic factors for malignant and cyst forming cases, especially in preoperative diagnostic imagings. In summary, to predict malignant progress, findings as vascular involvement (encasement, occlusion, AV shunt) in angiography and occlusion of pancreatic duct and common bile duct in ERCP were well reliable. Thirty percent of non-functioning tumors had cystic formation, almost of which were misdiagnosed as some cystic diseases, preoperatively. But making efforts to find tumor stain or intrusion in cyst by any diagnostic imagings will make possible to differentiate cystic neoplasms from benign pancreatic cysts as pseudocyst, and consequently operative management will be indicated. It may be still difficult to differentiated from other neoplastic cysts.

View full abstract

A 66-year-old woman visited our hospital because of general fatigue. A giant epigastral tumor was pointed out. The abdominal computed tomography revealed a tumor with a size of 15×12×6 cm had irregular internal shadows. A diagnosis of leiomyosarcoma was made by needle biopsy using the abdominal ultrasonography. An operation was performed under the preoperative diagnosis of leiomyosarcoma of the liver. The tumor was located between the liver and stomach and was distinguished from them clearly. The surface of the tumor was irregular and cystic. Intraabdominal leiomyosarcomas are uncommon, especially those arising in the lesser omentum. Fourteen cases of the leiomyosarcoma reported in Japan including this case are reviewed here and possible anatomical geneses are discussed.

View full abstract

We present a case of giant mucinous cyst adenoma which occurred in the sacrococcygeal region and developed evacuational disturbance. A 41-year-old woman, who underwent sacral tumor resection on her birth, noticed a slowly growing mass in the perianal region and developed evacuational disturbance. She was referred to our hospital for the evaluation of tumor. Image studies suggested a recurred sacrococcygeal teratoma.
The well-defined tumor was 1070 gm in weight and contained large amount of mucinous fluid. Histologically, it was mucinous cyst adenoma without any malignancy. There is no previous report of mucinous cyst adenoma occurred in the sacrococcygeal region, although it is common in the ovary and a few in the retroperitoneum. Histogenesis of sacrococcygeal cyst adenoma is unclear. We applied a technique of posterior gluteal thigh faciocutaneus flap because of a large amount of tissue and skin defect. This was proved to be useful from cosmetic and functional standpoint to cover the tissue defect as well as to reinforce the vulnerability of the pelvic floor after the resection of the tumor and some part of the levator ani muscle.

View full abstract

A case of necrotizing fascitis which came to hastily death derived from ceacum carcinoma is reported. A 72-year-old man was admitted to the hospital because of a right lower abdominal tumor. From barium enema and endoscopic examination on admission, a diagnosis of ceacum carcinoma was made. However, since the day before operation skin necrosis with blister in the right thigh appeared, and the penetration of ceacum carcinoma into the right thigh was suspected. After the incision and debridment of necrotic tissues, right hemicolectomy was performed. After operation the patient was accompanied by DIC and MOF, and died in the 2nd postoperative day.
Necrotising fascitis is a relatively rare and severe skin soft tissue infectious disease. It is also very rare that it is accompanied with a disease on gastroenterological surgery. The prognosis of this disease is so poor that the importance of adequate treatment entertaining a possible association of this disease is emphasized when we encounter a case presenting with vast skin necrosis with general symptoms, even if there is no external injury.

View full abstract