Fifteen cases diagnosed as follicular carcinoma of the thyroid at the department in a past 14-year period were reevaluated, and it was found that eleven cases out of them satisfied the diagnosis criteria for follicular carcinoma. Except for 2 cases associated with papillary carcinoma, follicular carcinoma of the thyroid represented 6.4% (9/141 cases) of all malignant tumors of the thyroid. In this study nine cases were clinicopathologically studied. Their ages ranged from 32 to 72 years old, with a mean of 52.1. There were one man and 8 women. Their clinical courses were observed during one years and 5 months to 11 years. In the same period distant metastasis was noted in only 2 cases which already had bone metastasis at the first visit to the hospital. Operative procedures included total thyroidectomy or subtotal thyroidectomy with modified neck dissection in 5 cases, lobectomy with lymph node dissection (I_??_IV) in one case, and lobectomy in one case. For the bone metastasis in the 2 cases excision of the 6th thoracic vertebral body or removal of the right pelvis was performed in each case, respectively. Bone metastasis cases had a tumor with diameter of 5.2cm in average versus 2.8cm in non-metastasis cases. Histopathologically vascular invasion was observed in 44.4%i (4/9 cases) and capsular invasion in 88.9% (8/9). All cases with metastatic lesion revealed significant vascular invasion and invasion into the thick capsule. There was no significant difference in histologic differentiation (well or poorly differentiated type) between patients groups with and without metastasis.

View full abstract

The regional lymph nodes of the breast are classified into class I and class II (according to Japanese Breast Cancer Society), and we studied the development pattern of lymph node metastasis in breast cancer and which is the prominent contributor for prognosis, the localization or number of metastatic lesions. Subjects were 1, 340 patients operated on for breast cancer at the hospital from 1975 to 1987. Of 1, 340 patients, 435 patients had metastasis only in the class I lymph nodes (group 1). 7 patients in the class II lymph nodes (group 2), and 124 patients in both the class I and II lymph nodes (group 3).
A relation that metastatic node in class II increased in proportion as metastatic node increased in class I was observed. The 10-year survival rates of group 1, 2 and 3 were compared in the specific subgroup for the number of metastatic nodes (1_??_n_??_3, 4_??_n_??_9, 10_??_n). There was no significant difference in three subgroups. In Cox's multivariate analysis, the number of metastatic node was more significant prognostic factor than the localization of metastatic node.
From the above results, we conclude that lymph node metastasis develops from class I to class II in principle, and the difference in the localization of metastatic node was not related to the survival but number of metastatic nodes.

View full abstract

Long-term results were studied on 64 patients who had had coronary artery bypass grafting (CABG) using auto-saphenous veins alone between 1977 and 1986. These patients were divided into two groups, that is, 24 patients undergoing re-catheterization early (one month) and late (more than 10 years) after CABG (Group I) and 40 patients early and late (between 5 and 10 years) after CABG (Group II). Overall graft patency rates at the late periods were 75.6% in Group I and 86.1% in Group II. Patency of the graft to the anterior descending coronary artery was definitely good, showing 86.4% in Group I and 92.5% in Group II. Significant progression of the coronary artery disease was found in 58.3% of Group I and 40% of Group II. Recurrence of angina observed in 37.5% of Group I and 27.5% of Group II was related to the progression of coronary artery disease in majority of these cases of both groups. Left ventricular function was significantly deteriorated in the group of patients with coronary artery disease progressed at the late period. It was concluded that recurrence of angina and left ventricular impairment at the late period was much more related to the progression of coronary artery disease than any graft disease.

View full abstract

To evaluate the usefulness of the retroperitoneal approach (RP) in comparison with that of the transperitoneal approach (TP) in elective aortic reconstruction, 50 consecutive cases of infrarenal abdominal aortic aneurysm were reviewed. The 50 patients were divided into three groups: Group I (n=14) underwent surgery through the TP, group II (n=21) through the RP and group III (n=15) operation through the RP using a Thompson retractor. The operation time in groups I and II (385±35 min, 395±42 min) was significantly longer than that in group III (265±61 min, p<0.05). Similarly, intraoperative blood loss was greater in groups I and II (1960±1340ml, 1794±896ml) than in group III (518±235ml, p<0.05). Nasogastric intubation and initiation of oral feeding was significantly prolonged in group I when compared with groups II and III (p<0.05). Postoperative hospital stay was also considerably prolonged in group I when compared with group III.
This experience demonstrates that the RP, especially using a Thompson retractor-which has been found to be very effective and can replace a second assistant for retracting the intraabdominal organs-is a preferable alterenative to the TP route in surgical treatment of abdominal aortic aneurysm.

View full abstract

One hundred and sixty-six cases of poorly differentiated gastric adenocarcinoma in Stage III were divided into medullary, intermediate, and scirrhous types according to the amount of interstitial connective tissue in the cancer tissue. In this study 19 cases of medullary and 49 cases of scirrhous type were compared for clinicopathological findings. The medullary type carcinomas showed more localized growth in the gross appearance, but revealed worse prognosis with higher ratio of hematogenous metastasis than that of scirrhous types. The AFP and/or CEA positive cancer was more frequently found in the medullary types than the others. In scirrhous types, lymph node metastasis and serosal invasion were underestimated in the operative findings, while no descrepancy was recognized between operative findings and pathological findings in the medullary types. Hematogenous metastatic pattern was observed in about two-thirds of medullary type carcinomas; while peritoneal metastatic pattern in about three-forth of scirrhous types. These results suggest that the typing is significant in therapeutic strategy and estimating prognosis.

View full abstract

Operative procedure and clinicopathological features were studied in patients undergoing emergency operation for colorectal cancer. Subject were 29 patients with intestinal obstruction due to colorectal cancer and 10 patients with perforated colorectal cancer out of 290 patients operated on for colorectal cancer at the department from 1980 to 1991. In a comparison with patients undergoing elective operation, no significant difference was noted in age, sex, histological type, and macroscopic morphology, however, there was a tendency to have deeper invasion depth into the wall or to have other organ metastasis in emergency ones. Emergency operation cases were commonly in an advanced stage at the onset of the disease. That might be a probable reason for its lowered incidence of curative resection. However, if curative resection could be performed in emergency cases, the 5-year survival rate of them did not significantly differ from that of elective operation cases. The prognosis was not necessarily poor for even emergency operation cases. Some cases were capable of undergoing radical operation. Pre and intraoperative correct diagnosis and appropriate selection of operative procedure would promise some emergency cases a favorable prognosis of the same length as that of elective operation cases.

View full abstract

In the past eight years eighteen patients with large liver cyst underwent injection of absolute ethanol or carbon dioxide under ultrasonically guided percutaneous puncture and catheter drainage.
Sixteen of the 18 patients were treated with absolute ethanol injection and there was remarkable decrease in size of the cysts after this treatment in all of them. In patients followed up for over 5 years the decreased cysts did not expand again and no malignant change was observed. Some patients, however, had complications including serious ones such as hypotention, arhythmia and abscess formation in the liver which might be cause by regurgitation infection due to the indwelt catheter. It was thought that the cystic fluid in the large cysts over 10cm in diameter should be drained before absolute ethanol injection, but it should be withdrawn soon after injection because of probable risk of infection.
Two of the 18 patients were treated with carbon dioxide injection and both cysts decreased after the treatment. Injection of carbon dioxide under ultrasonographic guidance is simple and harmless method. This treatment for hepatic cysts may be considered as an alternative to absolute ethanol injection therapy.

View full abstract

In order to examine indications for laparoscopic cholecystectomy (LSC), 70 patients undergoing chole-cystectomy who have been treated after LSC was first introduced to this institution were subjected to a retrospective study. LSC was performed in all 70 cases. In 11 cases of them LSC was found to be inapplicable during surgery and was switched over to mini-laparotomy cholecystectomy. LSC could be performed in 9 out of 11 cases of acute cholecystitis, with the exception of 2 cases of acute gangrenous cholecystitis. LSC could be performed in 4 of 7 cases of choledocholith. LSC could be performed in 3 of 5 cases with a previous history of gastrectomy. In many cases in which preoperative cholecystographic findings were negative, LSC was successfully performed, while among the cases with hypertrophic cystic wall, there were a number of cases in which LSC could not be performed.
It is difficult to select a candidate for LSC preoperatively. We therefore recommend to try LSC for all cases which are indicated cholecystectomy.

View full abstract

Laparoscopic cholecystectomy was attempted in 100 patients from February 1991 to November 1992. Fifty-eight patients of them were performed at 15 associated hospitals as training procedures for 15 general surgeons. Seven patients required conversion to a conventional open cholecystectomy due to dense adhesions surrounding the gallbladder in three patients, fallen gall stones in the peritoneal cavity in two, hemorrhage from the cystic artery in one, and unsuspected gallbladder neoplasma in one. There were two major complications: clip ligation of the right hepatic artery in one patient with acute cholecystitis and moderate ascites accumulation in one patient with Child B class liver cirrhosis. Surgeons with general surgical experience of more than 10 years (average=14.0 years) at small and rural hospitals could perform safely laparoscopic cholecystectomy after more than three sessions (average=4.0 sessions) of training. There were two major complications associated with creation of the initial pneumoperitoneum. In order to prevent such complications, the open laparoscopy method should be recommended. As laparoscopic cholecystectomy appears to be a safe and effective treatment for selected patients with benign gallbladder diseases, as experienced general surgeon should make an attempt to learn this new technique.

View full abstract

Recently the extra-anatomic bypass operation has been increasingly performed for high risk cases having a chronic aortoiliac occlusive disease. In this study twenty-eight consecutive patients undergoing extra-anatomic bypass for chronic aortoiliac occlusive disease were reviewed.
Of the twenty-eight patients twelve underwent femorofemoral (F-F) bypass and sixteen underwent axillo-femoral (Ax-F) bypass. There were no perioperative deaths in either group. Overall, graft patency at 5th year after F-F bypass or Ax-F bypass was 71.1±18% and 85.9±9.3%, respectively. Five-year survival rate after F-F bypass or Ax-F bypass was 91.0±8.7% or 57.8±13.3%, respectively. Analysis of the early and late results of extra-anatomic bypass confirms the safety and effectiveness of this procedure, but further studies would be mandatory for its operative indication.

View full abstract

Twenty-nine cases of viper bites have been experienced in an 8-year period (from 1985 to 1992). Eighty-three percent of the patients were older than 50 years old. All snake bites occurred from April through September.
Antivanin was used for only serious patients whose skin tests were not sensitive. Twelve patients were treated with antivenin and 17 without antivenin, including 4 serious patients whose skin tests were sensitive. All 4 patients had systemic symptoms such as palpitation, nausea, and vomiting. There was an extending tendency in the swelled region in the antivenin administered group, but it might arise from a fact that antivenin was administered to severe cases. In one death case, administration of antivenin within 12 hours after envenomation was ineffective. No significant difference in duration of hospital stay was noted between both groups with or without antivenin. It is thought that withholding antivenin administration may be more dangerous than immediate administration for severe cases. For mild cases, however, careful attitude for antivenin regimen is recommended, because it can cause serum sickness. In addition, strict observation of the change in creatine phosphokinase (CPK) is mandatory, especially during 2 to 3 days after envenomation, because it is a good indicator for the severity.

View full abstract

A 69-year-old female developed graft-versus-host disease (GVHD) after the transfusion of unirradiated fresh blood donated by her family members when she underwent right hemicolectomy for ascending colon cancer and hepatic metastasis. Two units of blood was transfused during operation, 1 unit on 1st postoperative day (POD) and 1 unit on 4th POD. She developed diarrhea on 8th POD, and skin rash on 10th POD. Then liver dysfunction and pancytopenia rapidly progressed and she died of liver failure on 16th POD. In the findings of autopsy, toxic epidermal necrolysis, centrilobular hepatocytic necrosis, epitherial necrosis of the gastrointestinal tracts and hypoplasty of the bone marrow were revealed. In a retrospective study, the HLA haplotype of the patient was different from her own haplotype presumed by HLA study of her family. Fatal post transfusion GVHD can occur in non-immunosuppressed patient when the blood donor has homozygous HLA haplotype of a part of heterozygous HLA of the patient. Prevention is the first importance.

View full abstract

This paper presents a case of malignant lymphoma of the thyroid causing a dyspnea in a patient with schizophrenia. A 71-year-old male in a mental hospital developed a difficulty in breathing, and was referred to the hospital for a suspicion of thyroid cancer. Palpation of the neck revealed a large goiter and enlarged lymph node. He had a labored respiration and a stridor was audible. Malignant lymphoma of the thyroid was suspected, and the diagnosis was confirmed by an emergency aspiration biopsy cytology. The patient was admitted to the psychiatry ward. Immediately after the admission, a combination chemotherapy (CHOP) was started, followed by an incisional biopsy of the goiter. The tumors rapidly decreased in size, and the patient was relieved from the dyspnea. After two courses of CHOP regimen, a 41Gy of radiation therapy was given. The tumors showed a complete response to these therapies. He was given several courses of CHOP regimen in another mental hospital. At present there is no evidence of recurrence of the disease.
We emphasize the importance of rapid diagnosis and emergency chemotherapy in patients with thyroid malignant lymphoma causing a dyspnea.

View full abstract

A 31-year-old woman was seen at the hospital because of a left palpated breast mass in September 1989, which had been noticed about 5 months before, but she did not consult with any hospitals. On physical examination a 40×30mm tumor was palpated in the left upper lateral portion of the left breast and a 21×10mm lymph node was also palpated in the left axillary. Ultrasonography of the breast visualized an irregular shaped tumor in the same portion with calcification internally. Biopsy cytology indicated carcinoma of the breast. Radical mastectomy was carried out on September 21, followed by postoperative radiation and drug regimen with carmoful and tamoxifen. The patient still alive, as of 3 years and 5 months after the operation. Histological findings of the excised tumor suggested ring cell carcinoma of the breast. This disease is so rare that only 20 cases have been seen in the Japanese literature. This paper present such a rare case with a review of the literature.

View full abstract

Recent experience with a pediatric case of perforation of the cervical esophagus due to accidentaly ingested pool cleaner which caused mediastinitis is described here, with a review of the literature.
A 12-year-old girl who happened to ingest a pool cleaner tablet was referred to the hospital because of dyspnea. From an esophageal contrast examination, she was diagnosed as having a perforation of the cervical esophagus accompanied by mediastinitis. Primary closure of the perforation and left cervicomediastinal and paraesophageal drainage were carried out. After the operation right mediastinitis became worse. Seventeen days following the injury, the right cervicomediastinal and paraesophageal drainage was performed, but the inflammation advanced. Twenty-seven days after the injury, esophageal drainage with a T Tube, paraesophageal and right cervicomedias-tinal drainage with a Duple drain were performed. The inflammation gradually subsided as the paraesophageal and mediastinal continuous lavage with povidone iodine solution were applied.

View full abstract

A 58-year-old man was admitted to the hospital with a diagnosis of mediastinal tumor which was made by a nearby hospital based on chest CT and MRI, to where the patient visited for an abdominal mass on a chest X-ray film pointed out at a routine medical checkup. Myelography and myelography-CT showed a paravertebral growth of the hemispherical tumor on the border of the 10th and 11th thoratic vertebrae. The tumor was resected at the same time by Grillo's combined approach with laminectomy of the 10th vertebral lamina and partial resection of 10th and 11th ribs. The excised tumor was solid, 45×30×25mm in size; the surface was smooth and well-encapsulated; and there was partially necrotic tissue. Histopathologic findings indicated a benign nerve-sheath tumor. A rare case of dumbbell tumor of type IV according to the Eden's classification was experienced.

View full abstract

A 56-year-old man was admitted to Itsukaichi Memorial Hospital because of syncopal attack. Monitoring ECG revealed that the attack was ventricular fibrillation (Vf). DC shock was applied immediately and he was referred to the hospital for further examination. There was a familiar history that his father and older sister died of cardiac sudden death. His ECG showed normal sinus rhythm, no QT elongation and any other abnormality except bradycardia. Also coronary arteriography and cardiac echo study showed no abnormal findings. Electrophysio-logical study showed normal sinus function and a dual pathway at the atrio-ventricular node. Vf was induced easily with serial stimulation given on the right ventricular outflow tract. The diagnosis was idiopathic Vf, and AICD implantation was indicated.
With median sternotomy two patch electrodes and two rate sensing leads were fixed. The generator was inserted under the left abdominal rectal muscle. Postoperative course was uneventful. The patient is followed with medication of procaineamide 1000mg daily and mexiletine 300mg daily.

View full abstract

Extra-abdominal desmoid tumors of the chest wall are rare and only 16 cases have been reported in Japan. We present a case of extra-abdominal desmoid tumor with a review of the literature in Japan. A 30-year-old woman was seen at the hospital because of a tumor in the left chest wall and numness of the left forearm. The tumor was located in the left sternocostoclavicular area. Incisional biopsy of the tumor histologically showed growing lesions of no atypical spindle-shaped fibroblasts with abundant collagen. The tumor including the first and second ribs which was 8.0×6.0×2.5cm in size was resected en bloc. The defect of the chest wall was reconstructed with an artificial dura (Liodura_??_). Histologically, the tumor infiltrated into the muscles and ribs. There has been evidence of recurrence, as of 16 months after the surgery.

View full abstract

A 77-year-old man was admitted to the hospital because of hematemesis which followed epigastric discomfort on the day before (March 30 1992). There was a history of undergoing gastrectomy with B-II reconstruction for gastroduodenal ulcer at the age of 40. On admission emergency endoscopy of the stomach revealed a giant submucosal tumor occupying almost entire the lumen of the remnant stomach, however, no bleeding source was detected. Blood transfusion was started, but the patient was transferred to the department of surgery of Showa University on April 19, because his blood showed irregular antibody positive and transfusional blood supply was difficult. Leiomyosarcoma of the remnant stomach was suspected and laparotomy was carried out on April 15, when a 15cm submucosal tumor with an ulcer on the top was found. Total excision of the remnant stomach was performed. Histopathologically it was diagnosed as leiomyosarcoma.
This paper presents a rare case of giant leiomyosarcoma of the remnant stomach of lumen type.

View full abstract

Transcatheter arterial embolization (TAE) was carried out in three patients with massive intra-abdominal bleeding caused by pancreatic fistula after radical operation for an advanced gastric cancer. Three cases had the following common features: 1) after extended lymphadenectomy, 2) with pancreatic fistula following acute pancreatitis or suture insufficiency, and 3) with bacterial infection around pancreatic fistula. Under these conditions, main arteries surrounding the stomach were exposed by activated pancreatic juice and pseudo-aneurysms developed. Postoperative sudden and massive arterial bleeding might be caused by rupture of these pseudoaneurysms. It is important that TAE should be the first choice for treatment of this complication rather than the ligation or suture of the ruptured artery, and the drainage and lavage of pancreatic fistula should be done enough to remove the infection.

View full abstract

A 91-year-old woman was seen at the hospital 3 hours after the onset of epigastric pain. On admission, there was tenderness in the right hypogastric lesion. The WBC count slightly increased to 9100/mm³, but no other abnormalities were found. Abdominal plain roentgenography suggested the presence of free air on the inferior plane of the liver. CT presented the free air in the region extending from the anterior plane of the right kidney to inferior vena cava. Fluoroscopy of the upper digestive tract, using Gastrografin, did not reveal any perforation. However, based on CT revealing free air in the retroperitoneal cavity, the patient was preoperatively diagnosed as having duodenal perforation and underwent emergency surgery 5 hours after the onset of the symptoms. During surgery, a diverticulum (4×3cm), filled with stone, was detected on the medial portion of 2nd portion of the duodenum. An intraoperative diagnosis of perforated duodenal diverticulum was made and the patient underwent diverti-culectomy. The postoperative course was uneventful. The patient recovered completely and was discharged 44 days after surgery.
In this paper the usefulness of CT in the preoperative diagnosis of perforated duodenal diverticulum is reported on, together with a review of 8 cases including this case seen in the Japanese literature so far.

View full abstract

As 60-year-old man who had been bed-ridden for about 15 years because of diplegia had repeated frequent vomiting for these 7 years. Upper gastrointestinal series showed a perpendicular obstruction at the third portion of the duodenum. Abdominal echograpy showed that a divergent of the superior mesenteric artery from the aorta at an angle of 15 degrees. He was diagnosed as superior mesenteric artery syndrome and underwent “anterior transposition of the duodenum”. The postoperative course was uneventful, and his subjective symptom was disappeared. Postoperative upper gastrointestinal series showed smooth barium flow into the jejunum. We conclude that aggresive surgical treatments should be indicated for patients who have been suffering from superior mesenteric artery syndrome for a long time like this case, and among others, anterior transposition of the duodenum is a superior radical procedure.

View full abstract

This paper describes successful application of mucosal jejunal patches to massive injury to the duodenum due to a blunt abdominal trauma in three patients.
The patients were 68-, 43- and 67-year-old men. All three patients had injuries accompanied by large defects in the descending, the third and postubulbar portion of the duodenum. A mucosal jejunal patch was produced by elevating the jejunum in Roux-en-Y fashion and creating side to side anastomosis. Subsequently, a 16 Fr. sump tube was inserted into the anastomosis for decompression. Whenever, there was a possibility of associated injury to the bile ducts, a cholangiogram was obtained, after which, a T-tube was inserted into the common bile duct for decompression.
Even if the injured area is large, a mucosal jejunal patch can be used for surgically repairing massive duodenal injury. Because it also serves to directly decompress the repaired area, it is less invasive than more risky surgical procedures like pancreatoduodenectomy.
The use of mucosal jejunal patches is a useful surgical technique in which serious postsurgical complications such as ruptured sutures do not occur, moreover, unlike more invasive surgical methods, pancreatic and digestive functions are much less likely to be impaired.

View full abstract

We experienced a case of adult intussusception caused by a lipoma of the small intestine. A 73-year-old female was admitted to the hospital because of sudden onset of lower abdominal pain, nausea and vomiting, with a suspecion of ileus. Abdominal plain X-rays showed a number of dilated loops of intestine and barium enema showed coiled spring sign in the terminal ileum. Abdominal computed tomography demonstrated target like appearance. Under a diagnosis of intussusception caused by a small-bowel tumor, an operation was performed. Although intussusception was not seen, a round tumor was palpated at 80cm proximal from the ileocecal valve. Subserosal bleeding and wall thickening were also recognized within 50cm distal of the tumor and there was no lymph node swelling. Partial resection of the ileum was performed. Histopathological findings of the specimen revealed typical feature of lipoma and we considered the tumor as the leading mass. Intussusception due to a tumor of the small intestine can often cause recurrent abdominal pain and intestinal obstruction for a long time. When we encounter a patient presenting such symptoms, a probable existence of small-bowel tumor should be always considered and further examination of the small intestine is recommended for the early diagnosis.

View full abstract

We experienced a child patient who was found having a large quantity of collection of chylous ascites during laparotomy for acute appendicitis and was diagnosed as nephrotic syndrome in the postoperative course.
A 10-year-old boy was seen at the hospital because of abdominal pain, diarrhea, and vomiting. He was diagnosed as acute appendicitis associating with ascites and laparotomy was carried out. There were about 300ml collection of chylous ascites and gangrenous appendicitis with milk-white change of the mesenterium and lymph node swelling. The ascites had the specific gravity of 1.008 and was a Ribaruta reaction negative transudate, which showed a high level of chylomicron, 490mg/dl. After the operation inflammatory findings disappeared and discharge of chylous ascites decreased, but hypoproteinemia, exudation of urinary protein, and mild hyperlipidemia were detected in the clinical course. The patient was diagnosed as having nephrotic syndrome.
Probable etiology of this association of acute appendicitis, chylous ascites, and nephrotic syndrome in the patient is presented here, together with a review of the literature.

View full abstract

A nine-year-old boy had abdominal pain, nausea and vomiting after being hit strongly the abdomen against a dodge ball. When he was seen at the hospital, slight tenderness in the right hypochondrial region was noted, and no mass was palpated. After that abdominal pain disappeared, but a mass developed in the region. Two days later, a palm-sized mass could be palpated. The mass had a smooth surface, was fluctuant, and could be moved slightly up and down. Blood biochemistry tests revealed positive C-reactive protein (CRP) and an increased sedimentation rate. An echogram and CT scan revealed a hemorrhaging multiocular cystoma that was inside or adjacent to the liver. A hepatic or mesenterial cyst was suspected. Because the mass was prone to enlargement and signs of peritoneal irritation emerged, laparotomy was performed. A 16×9×5cm multiocular capsular mass with cavernous hematoma was found in the mesentery of the transverse colon. Although the mass was attached to the transverse colon and duodenum, it could be removed. Pathohistological diangosis was multiocular lymphangioma with hematoma.

View full abstract

A case of mesenteric panniculitis of the transeverse colon mesenterium is described in this report. The patient was a 63-year-old male complaining of abdominal pain. Several tests and examinations demonstrated a tumor of the transverse colon mesenterium.
Laparotomy was performed. The tumor was a single mass extending from the antrum of the stomach to the middle of the transverse colon and a part of jejunum. No tumor tissue was found by rapid intraoperative pathological diagnosis of specimens collected from 3 locations. However, subtotal gastrectomy, extended left colectomy and partial resection of the jejunum were performed because a possibility of hidden malignancy could not be denied from the macroscopic findings and palpation of the tumor. It was diagnosed as mesenteric panniculitis histopathologically. Only 38 cases of mesenteric panniculitis including the present case have been reported in the Japanese literature, indicating that this is a rare disease.
Mesenteric panniculitis often mimicks other malignancies, and this case also presented difficulty in differential diagnosis and treatment.

View full abstract

Two rare cases of adenosquamous cell carcinoma of the sigmoid colon are described with a review of the literature. Case 1 was a 75-year-old man complaining of bloody stool. Barium enema revealed a whole-circumferential stenosis in the sigmoid colon. The patient was diagnosed as having a carcinoma of the sigmoid colon and underwent sigmoidectomy. The excised lesion of the colon was 130×90mm of type 2, the operation resulted in absolute non-curative resection. Case 2 was a 60-year-old man. Barium enema showed a type 2 carcinoma of the sigmoid colon and sigmoidectomy was carried out. The resected tumor was 44×42mm of type 2. Histopathological findings in both cases showed coexistence of cancerous lesions composed of adenomatous and squamous components. The expression of c-er-B-2 oncoprotein was immunohistologically investigated. The overexpression of c-erbB-2 has been reported in adenocarcinoma, but expression was seen in the components of adenocarcinoma and squamous cell carcinoma in case 2. This finding may suggest that adenocarcinoma cell can be transformed into squamous cell carcinoma.

View full abstract

Seven cases operated on for hepato-biliary-pancreatic malignancy in which the hepatic artery was accidentaly injured or intentionally resected at the operation, were studied. There were three cases of accidental injuries (one transection and two thrombus formation) and four intentional resections because of cancer invasion. The sites of occlusion were the proper hepatic artery in three cases and the right hepatic artery in four cases. The injured vessels were reconstructed in two and ligated in the others. Complications included bilioenteric anastomotic breakdown in three cases, liver abscess in one and hepatic infarction in one. Death attributable to hepatic artery occlusion occurred in only one.
It is concluded that reconstruction of the vessel is essential when the hepatic artery is interrupted at the level of the proper hepatic artery. When either the right or left branch is interrupted, the necessity of reconstruction depends on the extent of lymph node dissection of the hepatoduodenal ligament, the degree of back bleeding from the distal end, and the presence or absence of biliary tract reconstruction.

View full abstract

Hepatic angiomyolipoma is extremely rare among hepatic benign tumors, and only 40 cases have been reported. A preoperative diagnosis of angiomyolipoma was made merely in a few cases. Cases 1: A 33-year-old woman was examined with ultrasonography (US), which showed an abnormal shadow about 3cm in diameter at the posterior segment of the liver on a physical checkup, and the lesion was preoperatively diagnosed as hepatic angiomyolipoma by further examinations. As the tumor existed at the boundary of anterior and posterior segments, and as it was so close to the right hepatic vein, right hepatic lobectomy was performed. The pathological diagnosis was the same as above. Case 2: A 46-year-old man was examined with US, which revealed multiple abnormal shadows in the liver on a physical examination. By further examinations, a hepatic angiomyolipoma about 2cm in diameter and a hemangioma about 3cm in diameter at the lateral segment and a hemangioma about 5cm in diameter at the medial segment were detected. The partial resection of S₂ and enucleation of a tumor in S₃ were performed. The tumor in S₂ was pathologically diagnosed as hepatic angiomyolipoma. These two cases show that CT and echography, furthermore, MRI and angiography were profitable to get the qualitative diagnosis of the tumor before the operation.

View full abstract

A 54-year-old male with liver cirrhosis was transfered to the department for operation on early gastric cancer and cholelitiasis. After radical gastrectomy with lymph node dissection and cholecystectomy, a large amount of non-chylous high protein ascites appeared. Intravenous hyperalimentation, diuretics and reinfusion of the steralized cellfree and concentrated ascitic fluid were not effective. Four times intraperitoneal OK-432 were successfully administered.
It is difficult to ligate the lymphatic vessels in the second operation, and the possibility of conservative therapy for intractable hepatic lymphorrhea is described.

View full abstract

Ileus caused by impaction of gallstones is a rare disease. This paper describes our experience with seven cases of gallstone ileus from 1965 to 1992. A preponderance of gallstone ileus in the femal and aged patients is suggested. A suspicious history of biliary tract disease or diabetes was frequently noted. The site of obstruction included the smallintestine in all cases. The route of gallstone migration was a cholecystoduodenal fistula in 5 cases and unknown in 2. Resected stones were mixed stones in 3 cases and calcium bilirubinate stones in 4. Two cases were correctly diagnosed preoperatively, and in one of them the diagnosis was made by CT which demonstrated an obstruction of the small intestine and pneumoiblia. The necessity of CT should be emphasized in the diagnosis of gallstone ileus. Surgical procedures included enterolithotomy for 6 cases and cholecystectomy and repair of the fistula with enterotomy for only one. One of 6 cases without cholecystectomy had a gallblandder carcinoma 9 years after enteroli-thotomy. It is important that radical operation on an one-step approach is comploved as far as possible.

View full abstract

We experienced a case of adenomyomatosis of the gallbladder with a CA19-9 producing ovarian dermoid cyst. A 59-year-old woman was incidentally diagnosed as having a polypoid lesion in the gallbladder by abdominal CT, which was performed to determine microscopic hematuria. Laboratory studies showed a markedly elevated serum CA19-9 level of 2150u/ml. The lesion in the gallbladder was small (8mm) and no malignancy was thought. As no other abnormalities were demonstrated in the alimentary tract, a cholecystectomy was performed. The lesion in the gallbladder was macroscopically adenomyomatosis. During surgery, a round tumor was found in the left ovary and resected simultaneously. The tumor was histophathologically diagnosed as an ovarian dermoid cyst and endothelial cells in the dermoid cyst showed positive reaction in CA19-9 production in the dermoid cyst.
CA19-9 is very useful in diagnosing or in monitoring therapeutic effect in a variety of malignancies. This case, however, calls attention to a fact that the evaluation of tumor markers including CA19-9 is necessary even for benign diseases.

View full abstract

A 67-year-old female presented with intermittent right upper quadrant pain. A gallstone was visualized on ultrasonography and CT. First, extracorporeal shock wave lithotripsy (ESWL) was attempted 4 times but abdominal discomfort prevented completion of the treatment. Laparoscopic cholecystecomy was then performed. The gallbladder was almost normal laparoscopically. Cannulation of the cystic duct for an intraoperative cholangiogram was unsuccessful and a drip intravenous cholangiogram (DIC) was performed. The cystic duct could not, however, be clearly visualized. The duct was divided after clipping. No biliary leakage was detectable at the end of the surgery. On the first postoperative day (POD), substantial biliary leakage from the abdominal drain occurred. Endoscopic retrograde cholangiography (ERC) was performed immediately and the contrast material was seen to be leaking from the remnant cystic duct. A naso-biliary drainage (ENBD) tube was then placed, producing a marked reduction in biliary leakage from the abdominal drain. The abdominal drain was removed on the 4th POD. A cholangiogram obtained on the 7th POD confirmed the cessation of leakage from the cystic duct, and the ENBD tube was extracted on the 14th POD. The patient was discharged from the hospital. We present herein the clinical course of a case in which biliary leakage, following laparoscopic cholecystectomy, was successfully managed with ENBD rather than surgery.

View full abstract

Volvulus of the gallblader is a rare disease and presents difficulty in preoperative diagnosis. Here recent two cases of the disease are described. Case 1 was diagnosed as volvulus of the gallbladder during surgery for suspected diagnosed of acute cholecystitis with severe inflammation. Case 2 was preoperatively diagnosed as gangrenous cholecystitis due to volvulus of the gallbladder by ultrasonography (US)-guided percutaneous transhepatic cholecystography. However, this patient died of multiple organ failure on the 4th postoperative day.
In a review of the literature 198 cases including these 2 cases were analyzed in terms of imaging findings for preoperative diagnosis. It can be concluded that abdominal US and US-guided percutaneous transhepatic cholecystography are useful for preoperative diagnosis.

View full abstract

Acute emphysematous cholecystitis is characterized by a specific gas image on plain abdominal X-ray films and detection of gas-producing organisms. This disease is a specific type of acute cholecystitis and shows a more serious course than other types. This paper describes a successfully treated case of acute emphysematous cholecystitis by surgical operation. A 55-year-old man was seen at the hospital because of right hypochondralgia. The WBC count was 13, 500/mm³, and CRP was 34.8mg/dl, suggesting marked inflammation. Plain abdominal X-ray examination showed a gas image corresponding to the outline of the gallbladder. Abdominal CT showed gas formation, with a mirror image appearance, in the swollen gallbladder. Based on these findings, a diagnosis of emphysematous cholecystitis was made, and operation was performed. The gallbladder was gangrenous, and abscesses were observed below the right diaphragm, around the gallbladder, and in the lesser omentum. Pathological examination showed necrosis of the gallbladder wall involving all layers, marked inflammatory cell infiltration, and many submucosal vacuoles that probably contained gas. Bile culture demonstrated Clostridium. It is thought that the pathologic characteristic of this disease lies in gangrenous cholecystitis, where surgical treatment in an early stage is necessary, if the general condition of the patient permits it.

View full abstract

Surgery was performed in the treatment of 46 cases of cancer of the gallbladder and 40 surgical specimens from 40 cases were available for histological examination. Seven lesions (17.5%) consisted of squamons cell carcinoma and adenosquamous cell carcinoma. These cancers had large masses and invaded the adjacent organs including the liver, duodenum and colon. Three patients were found to have liver metastases and all had lymph node metastases, but there was no instance of peritoneal metastasis. All lesions were evaluated as stage IV according to the General Rules for surgical Studies on Cancer of the biliary Tract. A considerable variety of proportions of squamous cell carcinoma and adenocarcinoma components was found. There was a case in which advanced squamous cell carcinoma and early adenocarcinoma coexisted in the same gallbladder.
This case was of interest with respect to the origin of squamous cell carcinoma. Both squamous cell carcinoma and adenocarcinoma have a poor prognosis. Six patients died within 6 months and one patient within one year after the operation.

View full abstract

Adenosquamous cell carcinoma is a relatively rare tumor in the bile duct. This is to report a case of adenosquamous cell carcinoma of the bile duct with an early gastric cancer. A 67-year-old woman visited a local physician because of epigastric pain. Gastric endoscopy revealed an early gastric cancer, type Ila on the posterior wall of the middle stomach. After that the patient developed jaundice and was referred to the hospital. On admission, remarkable jaundice was noted. An egg-sized swollen gallbladder with tenderness was palpated. Abdominal CT and ultrasonography visualized significantly swollen gallbladder and intrahepatic bile duct, and PTGBD was performed. A papillary tumor was found in the middle portion of the bile duct. The patient was diagnosed as having a carcinoma of the common bile duct and early gastric cancer. Total gestrectomy and pancreaticoduodenectomy were performed. In the excised bile duct specimen, the coexistence of adenocarcinoma of every variety of differentiation and squamous cell carcinoma with keratinization was confirmed. So it was diagnosed as adenosquamous cell carcinoma. Partial bone and cartilatenous metaplasia was also recognized within carcinoma. The gastric lesion was histologically well differentiated adenocarcinoma. Flow cytometric analysis of DNA ploidy of adenosquamous cell carcinoma exhibited diploid pattern. As of 20 months after the operation the patient has hepatic metastasis, but she is still alive by trans-arterial embolization.

View full abstract

A 62-year-old man was seen at the medical center because of epigasric disfassion. An abdominal ultra-sonography showed multiple cystic lesions in the spleen and hypoechoic mass including small cystic lesions in the pancreas tail. After surgery, cystic lesions in the spleen were diagnosed as metastatic tumors from the pancreas cancer. Metastasis to the spleen from a pancreas cancer is very rare, and only four cases including this case have been reported in Japan. The spleen is a central immune system and it is hard for cancer cells to implant to the spleen. A route of metastasis of the cancer cells to the spleen is unclear, but in the present case cancer cells in the pancreas went to the spleen via the splenic artery.

View full abstract

A case of presacral neurofibroma is described. A 23-year-old woman who had been suffering from numbness and pain in the inside of the right foot in the night since 1991 visited a nearby practitioner because of eczema in the pudental region in January 1993. Vaginal examination disclosed a tumor in the pelvis. The patient was seen at the hospital for further examiantion. CT and MRI demonstrated a mass extending into the right side of the presacral space from the sacral cavity. The tumor was diagnosed as neurogenic presacral tumor, and the operation was performed on 13th April, 1993. The tumor was originated in S₂ nerve, so the proximal and distal S₂ nerve were divided and the tumor was excised. Histopathological finding disclosed a growth of tumor cells with spindle-shaped nucleus and wavy acidophilic cytoplasm, accompanying by myxoid framework. It was definitely diagnosed as presacral neurofibroma.

View full abstract

We experienced a patient with malignant hemangiopricytoma in the pelvic cavity who was able to survive for 7 years and 6 months after initiation of the treatment.
A 70-year-old woman was seen at the hospital because of severe pain extending from the left gluteal region to left lower extremity in June 1984. A 9×7cm hard tumor was palpated in the left gluteal region. Computed tomography identified a homogeneous tumor mass protruding into the peritoneal cavity and destruction of the pelvis. Angiography showed a hypervascular tumor with internal illiac artery as dominant artery. With biopsy a diagnosis of malignant hemangiopericytoma was made. Bone scintigraphy revealed a hot spot on the right seventh rib. Since radical excision was apparently impossible from these findings, trans arterial embolization of the left internal illiac artery was performed. Two months later, the size of the mass was reduced by 50%. Then chemotherapy with ADM via the left illiac artery using an implanted reservoir was done. The size of the tumor was reduced by 60% at maximum and intratumoral necrosis was recognized. Radiotherapy using ⁶⁰Co facilitated the intratumoral calcification. No increase in size of the tumor was noted until she died of symptosis after fracture of the right thigh 7 years and 6 months after the initiation of the treatment. In this case multimodal therapy comprizing of trans-arterial embolization of the dominant artery of malignant hemangiopricytoma, intraarterial chemotherapy, and radiotherapy was very effective.

View full abstract

Though venous ulcer was caused by venous hypertention of lower limb deep vein thrombosis, the risk facter of the primary lower limb varicose vein associated with lower limb stasis syndrome is still unknown in recent years.
Of 268 cases (336 legs) of primary lower limb varicose vein, 104 cases (128 legs) were operated on for clinical complication or associated diseases.
Twenty-five cases (26 legs) out of the 104 surgical cases were associated with venous ulcer, the rate of association being 24.0%.
Lower limb stasis syndrome associating with stasis ulcer tended to occur in the left lower limb.
In the surgical treatment of lower limb primary varicose vein with stasis ulcer, sure subcutaneous stripping techniques for the primary varices including subfascial ligation of a perforating vein and ligation of uncom-municating vein is necessary.

View full abstract

A case of heterochronous triple cancer in a 75-year-old man is described. He underwent prostatectomy and castration for prostatic cancer at the hospital in 1986. The histopathological diagnosis was adenocarcinoma. In 1988 the patient was readmitted to the hospital because of a 8×8mm rectal polyp, 5cm far from the anal verge. The polyp was resected by transanal approach. Histopathologically it was well differentiated adenocarcinoma. Two years and two months after the second operation, he returned to the hospital because of a 6×5cm tumor on the right axillar. The tumor was surgically resected. Histopathological examination of the resected specimen revealed Hodgkin's disease. All three lesions were found in an early stage and were successufully resected.

View full abstract