Fifth-five materials including primary lesions and lymph node metastasis from 15 cases of advanced gastric carcinoma were evaluated for DNA ploidy patterns, proliferation index (PI), proliferating cell nuclear antigen (PCNA).
1) DNA aneuploidy pattern was found in 43 out of 55 materials (78%).
2) Heterogeneity on DNA histogram was observed in 8 cases (53%).
3) PCNA staining was positive in 53 materials (96%).
4) DNA ploidy pattern was revealed to correlate significantly to PI (p<0.05) and PCNA positive rate (p<0.005).
5) PI was revealed to correlate significantly (p<0.05, rS=0.345) to PCNA positive rate.
6) Fixation time did not effect in PCNA staining rate at least within 2 weeks.
7) No correlation of DNA ploidy pattern, PI, or PCNA positive rate to n-number (metastasis to distant lymph node) could be detected.
From these findings, no correlation between probable distant lymph node metastasis and the degree of malignanicy and proliferating activity due to these parameters were able to be proved. For this, possible participation of heterogeneity can be inferred.

View full abstract

Fifty-five resected cases of cancer of the remnant stomach were divided into those undergoing distal gastrectomy for benign gastroduodenal lesion (group I; n=23) and those for gastric cancer (group II; n=32), and compared with 190 resected cases of primary gastric cancer locating in the upper third of the organ (group III) for clinicopathological features, prognosis and recurrence pattern.
There was no significant difference in histological type, stage, depth of invasion and incidence of peritoneal or liver metastasis among three groups. But the rate of incidence of metastatic lymph node locating in the mesenterium of the jejunum was higher in remnant gastric cancers than in primary gastric cancers. On the contrary, rates of incidence of positive lymph nodes of No 1, 3 and 7 were lower in remnant gastric cancers than those in primary gastric cnacers.
No significant difference was found in prognosis by noncurative and curative resection among three groups. However to recurrent patterns after curative resection, patients with remnant gastric cancer commonly experienced liver and lung metastasis in a high rate of 80.0%, versus 40.0% for patients with primary gastric cancer. This indicates that we should follow up resected patients with cancer of the remnant stomach by entertaining a possible hematogenic recurrence.

View full abstract

In order to investigate the duodenal motor activity after subtotal gastrectomy (Billroth-I, R₂ lymph node dissection) for gastric cancer, migrating motor complex (MMC) of the duodenum was recorded using a micro-tip force transducer in 19 patients. At the same time serum levels of gastrointestinal hormone were measured. The following results were obtained.
1) MMC were observed in 12 patients, but not in the other 7 patients in whom only phase II was sustained.
2) It was suggested that the vagus nerve might not contribute to occurrence of MMC.
3) Possible participation of motilin and somatostatin as well as the necessity of their cooperation action in occurrence of MMC were also indicated.

View full abstract

Twenty patients with carcinoma of the papilla Vater experienced at the department in a past 17-year period were clinicopathologically studied in terms of the gross appearance of the tumor and prognosis. In the gross appearance of the tumor, nodular type was dominant in stage I and II, while ulcerative type was dominant in stage III and IV. Ulcerative type was not observed in the tumors involving only within the duodenal wall, but mainly observed in the tumors penetrating the duodenal wall or invading the pancreas. Lymph node metastasis was seen in 9 out of 18 patients (50%), mainly in the nodular type with exposure and the ulcerative type. Five year survival rate was 51.8% in the patients undergoing pancreatoduodenectomy, or 100% if limited to those without lymph node metastasis. Recurrence after curative resection was observed in the patients with lymph node metastasis and the type of recurrence was commonly hematogenous. In conclusion, it is important to consider the gross appearance of the tumor in the surgical management for carcinoma of the papilla Vater.

View full abstract

Five-hundred and thirty-one patients operated on for colorectal cancer at the department were subjected to a study that was designed to determine the influence of recent changes of operative procedure on the prognosis. The patients were allocated to three terms, namely, first term for 5 years from 1971 to 1975, middle term for 10 years 1976-1985, and latter term for 5 years 1986-1990, and the survival rate and recurrence pattern were compared.
In colon cancers, RI or R2 lymph node dissection was performed in more than half of patients with N0 or N1, with which radicality could be attained and the 5-year survival rate increased to 87%. For rectal cancers, low anterior resection and R3 lymph node dissection had been increasingly employed as time went by. An increase in 5-year survival rate was shown as demonstrated by 56% in the first, 71% in the middle, and 87% in the latter term.
Examination of the pattern of recurrence revealed a decreased number of local recurrence and an increased number of liver metastasis in both colon and rectal cancers.

View full abstract

We examined the significance of hepatic arterial infusion chemoterapy (HAIC) for synchronous liver metastases from colorectal cancer using an implantable reservoir. 29 patients operated on at the hospital from 1984 to 1991 were divided into two groups consisting of 14 patients with HAIC (intra-arterial infusion group: HAIC(+)), and 15 patients with general chemotherapy (non intra-arterial infusion group; HAIC(-)). The mean survival of HAIC(+) was 21.2 months, versus 9.7 months in HAIC(-). There was no statistically significant difference between the two groups. The cumulative survival rates of HAIC(+) and HAIC(-) were 77.9% and 42.9% for one year; and 39.6% and 7.1% for two years, respectively. These differences between both groups were statistically significant (p<0.05, p<0.01). When these results were reviewed in terms of natural history of colorectal liver metastases by CEA doubling time, a significant prolongation (p<0.01) of prognosis was found in three cases of HAIC(+).
In conclusion, hepatic arterial infusion chemotherapy for synchronous liver metastases was effective in the improvement of prognosis, however we could not have satisfactory experience with such effective cases. Further studies of this regimen including appropriate selection of medicines and method of administration, added by practicable hepatectomy would be necessary.

View full abstract

We investigated postoperative complications including pneumonitis, pleural effusion, intraabdominal abscess, and bile leakage in 134 patients treated with hepatectomy with special references to the method of hepatic transection, the extent and the site of resection. Patients were categorized into three groups according to the methods used for hepatic transection: microwave tissue coagulator (MTC) group (n=25); cavitron ultrasonic surgical aspiration system (CUSA) group (n=52); and the other group (n=57). Comparisons were also made among patients having limited hepatic resection (_??_HrS:n=70), intermediate resection (Hr1:n=20), and extensive resection (Hr2_??_;n=44). Furthermore, the limited resections of S₇ and S₈ were distinguished from those of other sites. Each postoperative complication in the MTC group tended to be higher than those in the other two groups. The rate of pneumonitis reached to as high as 32% in the MTC group, which was significantly higher than that (5.8%) of the CUSA group (p<0.01). In the MTC group, the bile leakage occurred more frequently in patients treated with extensive resection (83.3%) as compared to that with limited resection (5.3%, p<0.01). In patients with limited resections, postoperative complications such as pleural effusion, pneumonitis, and intraabdominal abscess occurred more frequently in S₇ or S₈ resection. Therefore, it is concluded that adequate drainage is of particular importance in controlling infection and bile leakage of the transacted margin after hepatectomy using MTC and that of S₇ or S₈.

View full abstract

Formerly, it was believed that extra-adrenal pheochromocytomas were lacking in phenylethanolamine-N-methyltransferase (PNMT), and therefore did not secret adrenaline (Ad). Cases with high Ad levels, however, were sometimes encountered. To determine the reason for this apparent anomaly, immunohistochemical staining of resected tumor tissue was employed to study the localization of three types of catecholamine-synthesizing enzymes: primarily PNMT, but also tyrosine hydroxylase and dopamine-β-hydroxylase.
The subjects were twelve patients with extra-adrenal pheochcomocytoma who were trateted at the clinic. Two of them had high Ad content in preoperative urine test. Following surgery, urine Ad levels dropped to normal, indicating that the tumors had been the source of the excess Ad. Immunohistochemical study showed PNMT in eight of twelve cases, including the two already mentioned. The fact that PNMT is present in tumors of this sort helps to explain the high levels of Ad in patients with extra-adrenal pheochromocytoma.

View full abstract

We seldom encounter metastatic breast cancer from other internal organs. All patients were females, with a range of the age from 49 to 63.
Case 1: A 49-year-old woman had a left breast tumor. There was a previous history of undergoing operation for atypical carcinoid of the left lung. She was diagnosed as having metastatic breast cancer by aspiration biopsy cytology (ABC). Lumpectomy was performed 3 times, however, she died of dyspnea 4 years and 2 months after the metastasis. Case 2: A 54-year-old woman had a left breast tumor. There was a history of undergoing left nephrectomy for leiomyosarcoma of the left kidney. ABC indicated metastatic breast cancer. Operation was carried out, but she died of lung metastasis about 6 months later. Case 3: A 63-year-old woman had a left breast tumor and lung tumor. The tumors were excised on an one-step approach. A diagnosis of metastatic breast cancer from adenocarcinoma of the left lung was made. The patient received multi-agent chemotherapy, however, died of brain metastasis one year later.
It is difficult to discriminate on the basis of local and radiological findings whether a breast tumor is primary malignant or metastatic tumor. Careful evaluation of previous history as well as cytological and pathological findings of the tumor would greatly contribute to making diagnosis.

View full abstract

We experienced a case of idiopathic thrombosis of the inferior vena cava (IVC) which was incidentally detected by CT scan.
A 45-year-old man was admitted to the hospital for treatment of hepatitis C and was incidentally found having an asymptomatic thrombosis of IVC. No anomalies were found in other abdominal organs, and he had no previous history of injury. No abnormalities in the blood coagulation system were also shown. Local resection and plasty of IVC were performed to prevent pulmonary embolism. During surgery a belt-like thrombus about 10 cm in length was found at the dosal side of IVC beneath the renal vein. The resected specimen revealed a white thrombus alone without other findings including foreign body. It was concluded that the thrombosis in this case was idiopathic. In this paper briefly describes the case and presents some notes on the probable etiology of the thrombosis formation and treatment, as well as a review of the literature.

View full abstract

Pulmonary stenosis caused by calcium deposits on pulmonary valve is relatively rare. We experienced such as case in a 67-year-old man. In March 1992 the patient developed heart failure and internal treatment resulted in remission. Cardiac catheterization study and echocardiography showed a valvular PS. Chest CT and cineangiogram showed the calcified pulmonary valve and annulus.
In July pulmonary valve replacement with a bioprosthetic valve was performed under thoracotomy and ASD was closed by a patch. There were severe calcification of the pulmonary valve, adhered commissure and sclerotic valve ring.
Postoperative course was uneventful, however, the patient developed cardiac tamponade on the 12th day after the operation. Reoperation was carried out. No clear hemorrhage was found and only drainage was done. The patient gradually became worse to develop renal failure and DIC, and died of MOF on 34th postoperative day.

View full abstract

Morgangni's hernia represents around 3% of all diaphragmatic hernias. If the hernia content is the intestine, the preoperative correct diagnosis can be made in a high frequency. On the contrary, the correct diagnosing rate of Morgagni's hernia with only the omentum is as low as 20%. Recently we experienced a case of Morgagni's hernia containing the omentum alone, which was first diagnosed as the disease after operation under a preoperative diagnosis of lipoma of the anterior mediastinum. In this case we failed to make correct diagnosis preoperatively, however, CT appeares especially valuable in preoprative diagnosis.

View full abstract

A 39-year-old woman was admitted to the hospital because of a traffic accident. Since she had left hemothorax, drainage was performed. On the next day diaphragmatic herina associating with perforation of the stomach was found and thoracotomy was immediatedly carried out. Postoperative course was uneventful. We can infer that thoracentesis might cause the perforation of the stomach. In performing a drainage for traumatic hemothorax, we should pay careful attention to a possible association of diaphragmatic hernia.

View full abstract

A case of adult esophagobronchial fistula in a 53-year-old man who had been suffering from multiple brain absess is reported on. The patient was found to have an abnormal shadow in a chest X-ray film during the treatment of the brain absess. Until then, he had frequent episodes of coughing after drinking water. Upper gastrointestinal X-ray and endoscopic examination revealed an esophagobronchial fistula. The fistula and the S⁶ of the right lung were resected. Pathological examination showed that the wall of fistula was covered with two types of epithelium which were squamous cell and columner cell. And a transitional image of these two epithelia was recognized. Because of this pathological and clinical findings it was diagnosed with congenital esophagobronchial fistula (Braimbridge's type I). Adult esophagobronchial fistula is a rare disease and only 104 cases including the present case have been reported in Japan unitl 1992. According to Braimbridge's classification for congenital esophageal fistula in adults who proposed 4 types, these 104 cases can be classfied into type I for 42 cases; type II for 46cases; type III for 13 cases; type IV for 3 cases; and unclassified for one case. The opening sites of the fistule are frequently seen in the B⁶ of the right lung and the right lower lobe. In the definite diagnosis of this disease pathological finding of the fistula wall plays an important role. In tem of karasawa's proposal that the diagnosis is made for the case which has three components of both tracheal and esophageal mucosa and muscle layer or has a shift pattern of both tracheal and esophageal mucosa, only 44 (including this case) out of 104 cases can be considered those of this disease. The remaining 60 cases might have be reevaluated.

View full abstract

Two cases of spontaneous rupture of the esophagus, which were successfully treated by primary suture using the covering method, are reported.
Case 1 was a 41-year-old man admitted to the hospital because of chest pain after vomiting on a sight seeing bus. About 10 hours after admission, pleural effusion was noted by a chest x-p film. Esophagography revealed leakage in the lower portion of the esophagus. Emergency surgery was performed. After the esophageal rupture was sutured, the site was covered with a gastric fundic patch. He was discharged from the hospital on the 39th postoperative day.
Case 2 was a 26-year-old man referred to the hospital by a local practitioner. The patient complained of epigastralgia after vomiting in a ferry boat. Four hours after admission, a chest x-p film revealed pneumothorax and pneumomediastinum.A diagnosis of spontaneous esphageal rupture was made by esophagography. Emergency surgery was performed. After the ruptured was sutured, the site was covered with a pericardial pedicle flap. Although a minor suture failure occurred, conservative treatment was successful. He was discharged on the 77th postoperative day.
In early diagnosed cases of spontaneous esophageal rupture like these cases, a primary covered suture is useful.

View full abstract

A 52-year-old man visited a nearby hospital because of upper abdominal pain, and was pointed out having a submucosal tumor of the esophagus. The patient was referred to the hospital. A barium meal and endoscopic study revealed a sessile tumor with a longer diameter of 4cm in the lower thoracic esophagus. Computed tomography showed a low density mass like adipose tissue in the esophagus. Through a right thoracotomy, the tumor was enucleated without leaving any impairment to the esophageal mucosa by applying longitudinal excision. The tumor was 3.2×1.7×1.5cm in size, and was soft and yellowish like adipose tissue. The pathological diagnosis was benign lipoma. Esophageal lipoma is extremely rare. We have found only 21 reported cases in the Japanese literature. This paper presents a rare case of esophageal lipoma which was enucleated through thoracotomy, together with a review of the literature.

View full abstract

We experienced a case of hemoperitoneum due to a ruptured left gastorcepiploic artery aneurysm.
A 49-year-old man was transferred to the hospital because of severe abdominal pain which developed after recovering from loss of consciousness. On physical examination, there was a board-like rigidity in the entire abdomen. Ultrasonography revealed a collection of intraperitoneal fluid. Further exploration revealed a coagula of blood in the peritoneal cavity. However, the origin of the bleeding could not be found. Postoperative angiography of the abdomen demonstrated a left gastroepiploic artery aneurysm l cm in size without extravasation of contrast dye. On the sixteenth postoperative day, the patient again complained of similer abdominal pain. Emergency operation was performed and a small ballshaped hematoma oozing of blood was found in the greater omentum. Partial resection of the omentum including this hematoma was performed. The postoperative course was satisfactory. Only seven cases of gastrcepiploic artery aneurysm have been reported in Japan so far, and this is the first incidence of left gastrcepiploic artery aneurysm.

View full abstract

A 62-year-old woman was admitted to the hospital because of anemia and a tumor in the epigastrium. On admission both serum AFP and CA19-9 levels were as high as 243.2 ng/ml and 350 U/ml, respectively. Blood biological studies and imaging methods, however, revealed no abnormal findings in the liver, bile duct, and pancreas. A diagnosis of gastric cancer of Borrmann type 1 in the posterior wall of the pyloric antrum was made by gastric fluoroscopy and endoscopy. On laparotomy the tumor was macroscopically H₀P₀S₁N₀. Distal gastrectomy with lymph node dissection (R₂) was performed. Histopathologically the tumor was well differentiated tubular adenocarcinoma with the invasion depth of ssγ, n(-)in Stage II. Immunohistological study disclosed the localization of AFP and CA19-9 in the gastric cancer cells. After the operation serum AFP and CA19-9 were immediately normalized. The tumor was definitely diagnosed as AFP-and CA19-9-producing gastric cancer. In addition nuclear DAN ploidy pattern showed diploid type. There has been no recurrence, as of 3 years after the operation.
It is general that gastric cancers producing AFP and/or more than 2 kinds of tumor markers have poor prognosis. However, good prognosis can be expected for some gastric cancers like this, if these are of well differentiated histologic type and of diploid type in the nuclear DNA ploidy pattern.

View full abstract

In this paper, we report a case of bizarre leiomyoblastoma associated with early cancer of the stomach, together with a review of the literature. A 77-year-old male, who had the sensation of epigastrial fullness, visited the department with a diagnosis of IIc type early gastric cancer. On laparotomy, a 4.5×2.5×1.5cm mass was found on the anterior gastric serosa. The cancer, which was located in the posterior wall of the gastic antrum, and the mass were resected by subtotal gastrectomy. The lesions were histologically diagnosed as cancer limited mucosal layer and bizarre leiomyoblastoma of the stomach respectively.
As the bizarre leiomyoblastoma of the present case had no surrounding invasion and almost no nuclear mitosis, and the cancer penetration was limited to the mucosal layer, a favorable prognosis can be expected.

View full abstract

It is not uncommon with hepatic cancers to be associated with tumor embolus in the portal vein, but uncommon with gastric cancers. In this paper a case of advanced gastric cancer associating with tumor embolus in the portal vein is described.
A 61-year-old man visited a nearby hospital because of anemia and edema of the lower extremities. The patient was diagnosed as having a gastric cancer of Borrmann type 3 involving from the lower to upper part of the body of the stomach and was referred to the hospital. After the admission abdominal ultrasonography revealed a 2.5×4.5cm hyperrchoic mass in the portal vein and a metastatic lesion in the caudate lobe of the liver. Tumor embolus of the portal vein was suspected. Abdominal CT showed a tumor embolus in the main trunk of the portal vein and a hepatic metastasis. With abdominal angiography the main trunk of the portal vein was not visualized entirely and the vein along the common bile duct dilated like a varix as a collateral circulation. Operative procedures included total gastrectomy with excision of the pancreas and spleen and removal of the hepatic caudate lobe, followed by an attempt of enucleation of the embolus. The attempt, however, failed in complete enucleation.

View full abstract

Among 379 cases operated on for gastric cancer at the department in a past 8-year period, 8 cases (2.1%) had a perforated gastric cancer. In this paper these 8 cases were clinicopathologically studied.
Prceoperative diagnosis was able to be made in only 2 cases. As to operative findings, the perforated cancer was frequently found in region M (4 cases). These patients predominantly had an advanced cancer. namely, 2 patients had a Stage I cancer; one, Stage II cancer; 3 Stage III cancer; and 2, Stage IV cancer. Gastrectomy was carried out in 6 cases, which turned out curative resection in 2 cases. Invasion depth of the cancers was sm in 2 cases, ssβ in 3, ssγ in one, and se in 2. Perforation of early gastric cancer was noted in 2 cases. There were 2 operative deaths and one death during hospital stay, which occurred in aged patients over 80 years old. Two curative resection cases survive more than 5 years. According to Osawa's classification of perforated sites, direct perforation type might have poor prognosis compared to that of indirect perforation type. Even patients with perforated gastric cancer can expect good prognosis by radical operation on an one-step approach as far as conditions permit. For that, accurate diagnostic methods and appropriate lymph node dissection are important.

View full abstract

Metachronous double cancer of the stomach occurring in a 75-year-old man with dermatomyositis is presented here. There was a previous history of undergoing distal gastrectomy with Billroth I reconstruction for a Borrmann type 2 gastric cancer at elsewhere in 1977. In March 1991 the patient was admitted to the internal medicine of this hospital because of arthralgia and swelling in the area of the bilateral lower extrimities and hands. He was diagnosed as dermatomyositis by a muscle biopsy. During hospital stay the patient complained of anorexia and discomfort of the epigastrium. Upper gastrointestinal series revealed an advanced cancer of Borrmann type 3 in the lesser curvature of the remnant stomach. He was transferred to the department and underwent total gastrectomy, distal pancreatectomy and splenectomy, cholecystectomy with reconstruction by Roux-en Y anastomosis in June 1991. The serum level of CPK decreased to normal level and his symptoms of dermatomyositis disappeared after gastrectomy. He survived for 9 months after the second operation, but died of recurrence of gastric cancer in March 1992. Dermatomyositis is usually complicated with malignant disease in a high incidence, so careful follow-up is required for the second cancer even after the operation of the first cancer.

View full abstract

Primary adenocarcinoma of the duodenum is rare. It appears in a frequency of 0.8-2.9% of all gastrointestinal cancers. In a period from January 1976 to December 1990, 15 cases were diagnosed as having the carcinoma at the department, and 12 of them were resectable. These 12 resected cases were subjected to a clinicopathological study. The disease was predominant in women. Most patients were in their sixties, with an average age of 64 years old. Common complaints were abdominal pain and nausea/vomiting in 7 cases, which might be caused by stenosis and ulcer. Jaundice was also observed as the chief complaint. The duration of symptoms was mostly within 3 months, ranging from zero to 12 months. Eleven patients had a tubular adenocarcinoma and one had an anaplatic carcinoma. It would appear that fiberscopic endoscopy of the upper gastrointestinal tract should become the major diagnostic tool for this disease. The majority of tumors were located in the suprapapillary and gross appearance was almost ulcerative type. The resectability rate was 80%; pancreatoduodenectomy was performed in 8 cases segmental resection in 2 cases and distal gastrectomy in 2 cases. The prognosis of duodenal carcinoma is poor, and the patients often die of liver metastasis or peritonitis. Multidisciplinary therapy including radiotherapy and chemotherapy would be the only way to attain a higher percentage of cures.

View full abstract

Rare experience with a case of leiomyosarcoma of the jejunum associated with von Recklinghausen's disease is described with a review of the literature. A 48-year-old male was seen at hospital because of melena. Numerous cutaneous neurofibromas and café au lait spots all over the body were noted. Barium meal examination of the small intestine, CT and superior mesenteric agniography showed a myogenic tumor of the jejunum. During operation an extramulally growing tumor with the size of 6.O×5.2×5.5cm in the jejunum, at 2cm anal-side from Treitz ligament was found, and partial enterectomy was performed. Pathologically it was leiomyosarcoma. Postoperatively the patient was administered an antineoplastic agent adriamycin 60mg followed by tegafur 600mg/day orally. There has been no recurrence, as of 2 years after the operation. Leiomyosarcoma of the small intestine with von Recklinghausen's disease is so rare that only 8 cases have been seen in the Japanese literature.

View full abstract

Most leiomyosarcomas extratubally grow and have no specific symptoms. We often have difficulties in diagnosis. In this paper a case of ruptured leiomoysarcoma of the ileum in an 80-year-old man in whom preoperative ultrasonography was useful. The patient was seen at the hospital because of severe lower abdominal pain. Physical examination revealed an elastic hard, fist sized tumor in the lower abdomen and signs of panperitonitis. Ultrasonic examination showed a well defined, low echoic mass containing high echoic area in part. At emergency laparotomy, a10×7×6cm tumor was detected approximately 50cm oral from the ileocecal valve, showing outside growth of the intestinal wall. The ileum by 15cm including the tumor was resected. The cut surface of the mass was solid, partly showed necrotic change and rupture of the capsule. Histologically, the tumor was diagnosed as leiomyosarcoma arising from the proper muscle layer of the ileum. Postoperative course was uneventful. The patient has been asymptomatic and free from detectable lesion as of 3.5 years after the resection.

View full abstract

Obturator formen hernias are rare and account for only O.4% of all cases of mechanical small bowel. These hernias may be difficult to diagnose by physical examination and abdominal radiographys. The resultant delay in diagnosis contributes to a high mortality rate.
A 93-year-old woman was admitted to the hospital because of small bowel obstruction. Abdominal simple X-ray film confirmed complet small bowel obstruction, with distended intestinal loops seen in the pelvis.
A correct preoperative diagnosis of obturator formen hernia was made by Computed Tomography (CT) findings which recognized a loop of ileum protruding between the pectineus and external obturator muscles. On laparotomy, a Richter's herniation of the distal ileum into left obturator formen was found.
The ischemic ileum was resected and small bowel was reanastomosed. Obturator fromen hernia is commonly found in aged women and lacks in local symptoms.
So it presents difficulty in diagnosing preoperatively. In this case without specific symptoms the correct diagnosis could be made by CT.
CT can be a useful tool in the evaluation of small bowel obstruction and can lead to earlier diagnosis of obturator formen hernia.

View full abstract

A 44-year-old male was admitted to the hospital because of bloody stool lasting for several days. On admission, no anemia was found. Ultrasonography and CT revealed an abdominal mass with a small amount of interabdominal fluid. He suddenly developed abdominal pain with signs of shock and emergency laparotomy was done. Upon operation there were a large quantity of hemorrhage in the abdominal cavity, extensive hematoma in the transverse mesocolon, laceration of the posterior leaf of the transverse mesocolon, and a fist-sized clot in the same region. A definite bleeding source was not identified. The transverse colon including the hematoma was resected. Histopathologically, a ruptured aneurysm was seen in the mesocolon and crypt abscess was seen in the mucosa of transverse colon. Its submucosa was edematous. Aneurysms of the mesenteric artery are rare. Most of them undetected until some symptoms such as gastrointestinal bleeding or interabdominal hemorrhage occur. Gastrointestinal bleeding is usually caused by aneurysmal rupture into the gastrointestinal tract. This case is thought rare, because the bloody stool seen on admission might be caused not by rupture of the aneurysm into the transverse colon but by ischemia due to intermesenteric hematoma.

View full abstract

An 88-year-old man was urgently admitted to the hospital because of massive melena on September 27 1991. Emergency colonoscopy revealed a polyp of Yamada's type III in the sigmoid colon, but no definite bleeding site was determined. Ultrasonography and CT showed bilateral common iliac aneurysms which were not thought the bleeding source. Hemorrhagic scintigraphy for exploration of bleeding site led to a diagnosis that it was located in a portion of the sigmoid colon. On October 1 sigmoidectomy and colostomy were performed. A 10×8mm Yamada's type III polyp was found in the sigmoid colon and clots adhered to its surface. So it was determined that the bleeding stemmed from the polyp. Histopathologically the polyp was carcinoma in adenoma with invasion depth of m, with an artery locating in shallow layer of sm which appeared the bleeding vessel.
It is very rare that massive hemorrhage breaks out from a small carcinoma in adenoma with a diameter of less than one cm, and is also interesting that hemorrhagic scintigraphy greatly contrubutes to determine the bleeding site. This paper describes such a rare and interesting case with a review of the literature.

View full abstract

A case of synchronous double carcinoma, namely carcinoma of the transverse colon with obstructive colitis and an early gallbladder carcinoma, was experienced.
A 77-year-old man was admitted to the hospital because of bloody stool. The examination of barium enema and colonic fiberscopy revealed a transvese colon carcinoma, narrowing segment and cobblestone appearance about 25 cm long at the oral side of the transverse colon tumor. Ultrasonogram also indicated a gallbladder stone 2cm in diameter. Transversectomy with lymph node dissection and cholecystectomy were performed. Pathological diagnosis of the tumorous lesion of the colon was a well differentiated adenocarcinoma (se, ly₀, v₀, n₀), and that of the transverse ulcerative lesion at the oral side of the tumor was granuloma and inflammatory cell infiltration through the whole layer. This lesion was considered to be an obstructive colitis due to the tumor. Moreover, the resected gallbladder had a slightly protruded lesion, and was diagnosed as well differentiated adenocarcinoma (pm, hinf₀, binf₀). He has been doing well for 4 years and 4 months after the operation without reoperation for the gallbladder carcinoma in terms of his advanced age.

View full abstract

From the viewpoint of complete cure of symptomatic heptic cyst, conventional open fenestration is more preferable than percutaneous aspiration and/or ethanol injection with high recurrence rate. To obtain reliable effect with less invasion, laparoscopic fenestration (LF) was performed on 4 patients with symptomatic hepatic cyst. The mean age of these patients was 65 years, and there were 2 males and 2 females. Two of the 4 patients underwent simultaneous laparoscopic cholecystectomy for coexisted cholecystolithiasis. According to the technique of ordinary laparoscopic cholecystectomy, pneumoperitoneum by using carbon dioxide was carried out. Three or four trocars were inserted and the cyst was incised by using electrocautery hook dissector under laparoscopic view. All the patients received LF were released from preoperative symptoms and no recurrence was observed with postoperative follow-up for 2 to 6 months. It is though that LF which offers a reliable outcome with minimal invasion and simple procedure can be a standard operation for symptomatic hepatic cyst.

View full abstract

Xanthogranulomatous cholecystitis is a relatively rare disease and often presents difficulty in differential diagnosis from malignant tumors. This paper describes a case of this disease in which aspiration cytology was useful in the diagnosis, with a review of the literature.
A 63-year-old man was seen at the hospital because of abdominal pain. The patient presented paralytic ileus. Imaging methods revealed a tumor lesion in the fundus of the gallbladder, and a possible malignancy could not be denied. For this, aspiration cytology was performed. It disclosed large type of cells with cytoplasm presenting as bright and foamy appearance among the inflammatory cells. From these findings xanthogranulomatous cholecystitis was suspected and cholecystectomy was performed. Excised specimen revealed a yellowish white tumor in the Jundus of the gallbladder. Histologically no malignancy was found. The definite diagnosis of xanthogranulomatous cholecystitis was made.

View full abstract

This paper presents a successful treatment of a 99% stenosis of the portal vein due to invasion of cholangiocellular carcinoma in a 72-year-old woman, with intraoperative radiation and dilatation of the protal vein by an expandable metallic stent (EMS) with partial excision of the colon. Monitoring by imaging method, a Gianturco-Roesch biliary Z-stent with a diameter of 10mm was embeded at the stenosed site, and 20 Gy radiation was given to the porta hepatis intraoperatively. The stenosis was as narrow as the guide wire barely passed through, but the stent was able to dilate. Postoperative course was uneventful. The portal vein was dilated to 7mm in diameter (70% stenosis). The significance of this case lies in the use of a metallic stent to dilate the malignant stenosis of the portal vein. We recommend the use of this metallic stent for the patients who are not possible candiates for operation and have a very poor prognosis.

View full abstract

Case 1: A 65-year-old man was admitted to the department after he underwent PTCD to the bilaterla intrahepatic bile ducts for obstructive jaundice. The patient was diagnosed as having a cholangiocarcinoma at the porta hepatis by various imaging methods and bile cytology. It was unresectable because of advanced local invasion. The bile duce at the porta hepatis was completely occluded which did not respond to the treatment by the stent. Through a PTCD tube 5-FU 250mg/day was administered. The tube was clamped for 30 minutes after the 5-FU regimen. On the 17th day after the regimen noninvasive reopening of the bilateral intrahepatic bile ducts was successfully performed by using a fistulization tube.
Case 2: A 83-year-old woman developed obstructive jaundice due to a cholangiocarcinoma at the porta hepatis about 3.6cm in diameter. In preoperative evaluation the patient was considered not to be a candidate for operation because of extended local invasion, advanced age, and undernutrition. Like Case 1, a 25-day regimen with 5-FU into the bile ducts followed by reopening of the ducts was successfully performed.

View full abstract

Recent experience with three successfully resected cases of insulinoma, a relatively rare pancreatic endocrine tumor, is presented here. Cases 1 and 2 were adults. Tumors in these cases were localized by percutaneous transhepatic portal catheterization (PTPC). Post-surgical histological examination of the specimens from Case 2 revealed the presence of multiple microlesions around the main lesion, which suggested that the excision not only of the apparent tumor but of a certain amount of pancreatic tissue might also be necessary in some cases. Because the treatment of choice for insulinoma is adequate resection, localization is important. In pediatric cases such as Case 3, preoperative medical management for the regulation of blood sugar, preceding localization, is necessary and not less important.

View full abstract

Forty-six cases of acute pancreatitis associating with hyperlipidemia have been seen in the Japanese literature, which included only four cases in youngs under 20 years of age. Here recent experience with 2 such juvenile patients is described.
Twelve-and 17-year-old girls were seen at the hospital because of severe upper abdominal pain and vomiting. Both patients were diagnosed as acute pancreatitis and were admitted. On admission their serum presented strong chyle and lipoprotein fractionating test revealed a remarkable increase in pre-β lipoprotein in both cases. These findings indicated hyperlipidemia of type IV. No causative relation between hyperlipidemia and pancreatitis has been established as yet, and the condition is considered by classifying into the following three occasions: that hyperlipidemia may cause pancreatitis; hyperlipidemia may occur secondary to pancreatitis; and pancreatitis and hyperlipidemia may occur independently with each own cause. However, the causative correlation is hardly determined when the onset of pancreatitis gives a chance to diagnose hyperlipidemia. In this paper we discussed the association of hyperlipidemia with pancreatitis in a review of the literature.

View full abstract

A 34-year-old female patient was seen at the hospital because of right flank pain, back pain, and anemia. Abdominal ultrasonography demonstrated a round 10×10cm cystic retroperitoneal mass just behind the right lobe of the liver, superior to the right kidney and to the right of the vena cava. Abdominal CT and MRI confirmed these findings. Cavogram revealed compression of vena cava by the tumor. Right renal angiogram revealed feeding arteries from the adrenal arteries to the tumor. Three dimentional CT image visualized the accurate anatomical relationship between the tumor and surrounding vascular structures. A preoperative diagnosis of adrenal pseudocyst was made, and the lesion was removed surgically on July 21, 1992. The three dimentional anatomical relationship between the tumor and surrounding vascular structure was the same as preoperative determination by 3D-volume CT. Histopathologically the tumor was adrenal pseudocyst. The patient was discharged in a good clinical condition on August 5, 1992. Three dimentional CT imaging was very useful to image anatomical relationship between the tumor and surrounding vascular structure preoperatively.

View full abstract

A 78-year-old man was seen at the department of medicine in the hospital because of heartburn in June 1991. Close examination revealed a gastric cancer of Borrmann type 2 in the lesser curvature under the cardiac part of the stomach. Total gastrectomy was carried out on August 6, 1991. Histopathologically it was poorly differentiated adenocarcinoma of ssβ, INFβ, ly0, v1, and n2. The patient was discharged from the hospital and followed on an ambulant basis. In February 1992 he was pointed out having a tumor in the left adrenal gland by CT, and its enlargement was confirmed by CT in June of this year. Under a suspicion of adrenal metastasis of gastric cancer, left adrenalectomy was performed on July 15 1992. Excised specimen was 60×44×30mm in size and 55 g in weight. The cross section was comprized of yellowish white segments with remnant normal adrenal tissue partially. Histopathologically the tumor was diagnosed as adrenal matastasis of gastric cancer. Postoperative course was uneventful. The patient was discharged from the hospital, and is followed on an ambulant basis. There has been no recurrence, as of 18 months after the first operation.
Resected adrenal matastasis of gastric cancer after gastrectomy is very rare. Only 3 cases including this case have been seen in the literature as far as we could review.

View full abstract

This paper presents a case of immature teratoma with gliomatosis peritonei (GP) in a child with a discussion on the necessity of postoperative chemotherapy.
A 14-year-old female was admitted to the hospital because of abdominal fullness lasting for 2 years. A tumor mass occupying entire the abdomen with smooth surface and slight movability from side to side was palpated. Serum levels of tumor markers, CA19-9 and α-fetoprotein were as high as 224U/ml and 22.9ng/ml, respectively, Increased serum levels of CA125 and α-fetoprotein were noted. A plain abdominal X-ray film revealed a huge mass with calcification in whole peritoneal cavity. Abdominal ultrasonography and CT visualized a well-defined tumor shadow with calcified, solid and cystic lesions. These findings suggested an ovarial teratoma. In the operation, the tumor was the left ovarial tumor, and there was many nodules in the peritoneum and serosa of the duodenum. Pathologically, the tumor was immature teratoma (grade 1), and the nodule was mature glial cell (grade 0). Chemotherapy was not performed. The elevated CA125 and a-fetoprotein levels were normalized rapidly postoperatively. These have been no signs of the recurrence, as of 14 months after the operation, and she is enjoying school-life.

View full abstract

We report a case of Fournier's syndrome which formed a periproctal abscess widely spreading to the supraumbilical abdominal wall. A 30-year-old man was seen at the hospital because of high fever and periproctal pain. He had an underlying disease of diabetes mellitus and spent seven days after the symptom appeared. An incisional drainage was performed, but inflammatory changes progressed. Computed tomography (CT) and ultrasonography (US) revealed a wide abscess cavity spreading to the scrotum and supraumbilical abdominal wall. A wide drainage made a remission. In the treatment of periproctal abscess, the evaluation of the abscess cavity with CT and US is essential for early sufficient drainage, by entertaining a possible existence of Fournier's syndrome which can rapidly and progressively spread.

View full abstract

A 33-year-old woman was seen in Yachiyo Hospital because of continued abdominal pain around the umbilicus, which intermittently lasted for 17 years. The abdomen was flat and soft. She was good in the general condition, but amoveable eggsized mass was palpated on the left side of the umbilicus. It was elastic soft but not tender, and had a smooth surface.
Ultrasonography, CT, MRI, angiography, and gastrointestinal series revealed a cystic lesion in the mesentenum.
The mesenteric cyst was enucleated. The removed cyst 4×4×2.5cm contained clear serous fluid. Histopathologically it was diagnosed as benign cystic mesotherioma. There has been no recurrence, as of one year and 4 months after the operation.
Mesenteric cysts due to mesotherioma are so rare that only 9 cases, including 7 cases collected by Ishizuka, one case reported by Tanaka and this case, have been seen in the Japanese literature in a recent 20-year period. No case has been diagnosed preoperatively, but recent progression in imaging methods will enable us to make the definite diagnosis preoperatively.

View full abstract

Case 1: A 44-year-old man was admitted to the hospital because of fever, jaundice and abdominal pain. Abdominal ultrasonography showed swelled peripancreatic lymph nodes and dilatation of the biliary tract. Lymph node metastasis of pancreatic cancer or malignant lymphoma was suspected and a laparotomy was performed. Bulky peripancreatic mass formed by hardened lymph nodes was detected and the intraoperative histopathology of the mass revealed tuberculous lymphadenitis.
Case 2: A 20-year-old female was admitted to the hospital because of swelled lymph nodes on the left side of the neck. CT scan showed swelled peripancreatic lymph nodes and huge left psoas abscess. PPD was strongly positive. Biopsy of the left cervical lymph node and aspiration cytology of the left psoas abscess confirmed the presence of tuberculosis. Tuberculosis markedly decreased due to the progress of antituberculous chemotherapy. Recently this disease, however, has been gradually increasing again. These two cases remind us of the importance to entertain the presence of tuberculosis as a possible differential diagnosis, when a patient having a swelling of peripancreatic lymph node is encountered.

View full abstract