In Japan, nipple or breast conserving therapy is almost always applied to the node negative (i. e. early) breast cancers. And there is no report of the long term follow up results of conserving therapy for the node positive cases. In this report, 86 node positive cases undergoing nipple preserved mastectomy (Glt group) were compared to 123 node positive cases undergoing radical or modified radical mastectomy (Brt group) in point of survival, disease free survival and loco-regional disease free rates. There were 53 case of n1α, 21 of nlβ, and 12 of n2, 3 in Glt group, while 49, 44, and 30 in Brt group, respectively. Although surgical results of the Glt group were somewhat inferior to those of the Brt group in n2, 3 cases, there were no significant statistical differences between Glt group and Brt group in n1α, n1β and n2, 3 cases respectively. It is inferred that the somewhat inferiority in surgical results for n2, 3 cases (n=12) of the Glt group to others (n=30) may be attributed to few number of cases to be compared. In conclusion, nipple preserved mastectomy can be safely carried out for node positive breast cancers.

View full abstract

From January 1988 to June 1993, 295 cases of primary breast carcinoma underwent radical operation following complete resection of the main gross lesions at the department. Through the histological examination of the resected specimens, we tried to determine whether residual carcinoma was present following tumor extirpation and whether indications for breast preserving surgery can be better confirmed by the conduct of excisional operation.
It was confirmed that residual carcinoma was present in the periphery of the excisional operation wound in 58.3% of the cases, multifocal lesions in 10.7%, and lymph node metastasis in 29.6%. Inasmuch as the possibility of residual carcinoma is very high with lumpectomy, the standard operation method employed in this department for breast preserving surgery is comprised of quadrantectomy+Ax+plasty. However, the present study indicates that there is a possibility of residual carcinoma in 13.8% when the indication for our standard operative method is applied to cases with tumor diameter of less than 2.0cm, even if invasive lobular carcinoma, Paget's disease and E area cancers are excluded.
In view of possible candidates for the breast preserving surgery and its limits, we should not neglect to obtain the full informed consent from the patient preoperatively.

View full abstract

During a period from 1972 to 1991, 464 patients were treated surgically for peptic ulcer at the department. These cases were studied about the changes in operative indication and surgical treatment by dividing them into the first term (1972-1981) and the later term (1982-1991) bounded by the introduction of H2 receptor antagonist (H2RA). The number of operated cases remarkably decreased from 329 in the first term to 135 (41.0%) in the later term. The number of cases of intractable or stenosed ulcer in the later period significantly decreased to 21.2% or 20.0% of that in the first term, respectively. A slight decrease to 75.6% was noted in cases of hemorrhagic ulcer. On the contrary, perforated ulcers increased to 128.2% in the later period compared with that in the first term. In the terms of surgical procedure for gastric ulcer, stomach-preserving operations such as vagotomy and ulcerectomy were preferred instead of gastrectomy which had been widely used before introduction of H2RA. As for duodenal ulcer, vagotomy has been applied for the most cases regardless of H2AR introduction. But the recurrence rate following vagotomy was relatively high (9.9%), that may be a further theme for reevaluation.

View full abstract

To clarify the prognostic factors, clinicopathological findings were examined for 35 cases of carcinoma of the papilla of Vater and 16 cases of carcinoma of the lower bile duct resected during the past 21 years. For the long-time survival, panco_0.1a, n₀, d₀ for carcinomas of the papilla of Vater and panc₀, n₀ for carcinomas of the lower bile duct were important. In the past studies, panc had been the most valuable prognostic factor. In our study, cases with panc(+) had high positive rates of d, ly, v for carcinomas of the papilla of Vater and n, ly, v for carcinomas of the lower bile duct. Extended surgery or combination therapy should be into consideration for advanced carcinomas of the papilla of Vater with panc_{1b, 2, 3}, d(+), or n(+), and of the lower bile duct with panc(+) or d(+). When macroscopic and histological findings were compared for the stage, the most lowest consistent rate was noted in d of carcinomas of the papilla of Vater. As to panc, both carcinomas had the consistent rate of about 60%. Therefore, even if we can judge negative for the invasion into the pancreas, duodenum, and lymph nodes macroscopically, we should take a careful attitude to indicate more limited operation and actively employ intraoperative frozen section diagnosis and so on.

View full abstract

We have performed a clinicopathological assessment, in conformity to the rules for handling colonic carcinoma, in 37 cases of poorly differentiated adenocarcinoma, 21 cases of mucinous carcinoma, 9 cases of signet ring cell carcinoma and 3 cases of undifferentiated carcinoma, totaling 70, out of 1976 cases operated on for colonic carcinoma that underwent operation at the hospital and associated institutes from 1971 to 1991.
Poorly differentiated carcinoma (poorly differentiated adenocarcinoma, mucinous carcinoma, signet ring cell carcinoma and undifferentiated carcinoma) was slightly predominant in males (58.6%), and was more frequently found in the right side of the colon (60%). There was no case of early carcinoma. Quite a few patients with poorly differentiated carcinoma had more distant lymph node metastasis (40%) and peritoneal dissemination (27.5%). Hepatic metastases were more commonly observed with poorly differentiated adenocarcinomas in the left side of the colon. As to macroscopic types, there were many cases exhibiting an infiltrative type (42.9%), and it was characteristic that in particular 6 out of 9 cases of signet ring cell carcinoma were of type 4. The stage of progress was more than stage IV in many cases with an unfavorable prognosis, and the 2-year survival of signet ring cell carcinomas was only 11.4%. In contrast to this, some mucinous carcinomas had a more favorable prognosis, so we thought it was necessary to subdivide these types more finely.
In the treatment of poorly differentiated colorectal carcinomas, early detection and wide range of lymph node dissection are essential. Intra and postoperative chemotherapy is recommended considering the high incidence of peritoneal dissemination.

View full abstract

Among 402 patients with colorectal cancer treated surgically during the recent 6 years, 37 (9.2%) developed hepatic metastases were clinically studied. Twenty-nine patients had synchronous hepatic metastasis (7.2%), and 11 of them underwent hepatectomy. The 3-year survival rate for these 11 patients was 43%, which was higher than the rate (13%) for those who did not undergo hepatectomy. Eight patients had metachronous hepatic metastasis (2.0%), and 7 of them underwent hepatectomy. The 5-year survival rate for these 7 patients was 80%, which was higher than that (0%) for the non-receiver. In posthepatectomy patients with synchronous hepatic metastasis, recurrence in the remnant liver was as high as 75%, but no recurrence was found in 3 patients undergoing one-shot intraarterial chemotherapy postoperatively. Patients with hepatic metastasis from colorectal cancer receiving hepatectomy had better prognosis than that of non-receivers. From these findings hepatectomy should be recommended for the treatment of hepatic metastasis even in H₂ cases if complete resection of the metastatic lesion is possible. It is also indicated that one-shot intraarterial chemotherapy is useful in preventing recurrence in the remnant liver in cases of synchronous hepatic metastasis where the incidence of such recurrence is high.

View full abstract

Seventy-three cases of mucosal carcinoma and 46 cases of submucosal carcinoma of the rectum experienced at the department from 1978 to 1990 were subjected to a clinicopathological analysis to examine the indication of more limited operation. The submucosal carcinomas were subdivided into sml, sm2, and sm3 according to the depth of invasion. More than half of mucosal and submucosal carcinomas were located in the lower rectum. Macro-scopically, mucosal carcinomas were located in the lower rectum. Macroscopically, mucosal carcinomas were common (73.1%) in I type, but less in Ha type (19.2%). There was no mucosal carcinoma in IIa+IIc type. The rates of lymphatic vessel invasion in Ip and Isp types were 12.5% and 20.0%, respectively. And the rate of lymphatic vessel invasion of sml cancer was 16.7%. There was no lymph node metastasis among the cases in which local resection or intestinal resection was performed.
These results indicated that endoscopic polypectomy might have sufficient radicality for most Ip and Isp types of early rectal cancers. Carcinomas of IIa+IIc type mainly invaded sm2 and sm3, and might have a great possibility of lymph node metastasis. Therefore, in the case with IIa+IIc type among upper and middle rectal cancers, the nerve preserving low anterior resection should be chosen. In the case with lower rectal cancers, if no para-rectal lymph node swelling were observed, sphincter preserving operation including local excision should be considered for better quality of life after the operation.

View full abstract

Twenty-three cases of early carcinoma of the rectum, especially the lower rectum were clinicopathologically studied and the policy of the treatment was discussed.
Of all carcinomas of the rectum operated on, early carcinomas of the rectum represented 9.5%, of which 63.5% were early carcinoma of the lower rectum. As to the macroscopic and histological classification of the tumor, IIa (flat-elevated) type and IIa+IIc (flat-elevated with depression) type were frequently seen, and well differentiated adenocarcinoma occupied the majority of the cases (82.9%). Neither “m” cases in which cancer cells were limited within mucosal layer nor “sm” cases in which cancer cells were spreading into submucosal layer had lymph node metastasis. None of 12 “m” cases had venous invasion (v) and lymphatic vessel invasion (ly). In contrast, among 11 “sm” cases, three (27.3%) had ly invasion, four (36.4%) had v invasion, and the level of sm invasion of these cases were all deeper than sm_1c.
Early carcinoma of the lower rectum should be undertake polypectomy or local excision and the specimen should be examined histologically in detal. In case of “sm” carcinoma, level of sm-invasion seemed to be one of factors to determine indication for further radical operations.

View full abstract

To estimate the influence of surgical stress and safety of laparoscopic cholecystectomy (LC) on aged patients with cholecystlithiasis, consecutive 86 cases of LC treated at the institute during the past 16 months were devided into aged and younger groups and compared for clinical feature and operative outcomes. The aged group was comprized of 22 patients over 65 years old (aged LC group) and the younger group, of 64 patients under 64 (younger LC group). In addition both group were compared with 27 open cholecystectomized patients (aged OC group and younger OC group).
In the aged group there were many patients with previous history preoperative acute cholecystitis or with some underlying disease such as hypertension, chronic hepatitis or diabetes mellitus. Somewhat elongated operation time (155 minutes) was recorded in the aged LC group compared to that (140 minutes) in younger group. This elongation might be attributed to adhesions arround the gall bladder and wall thickness which were predominantly found in aged patients intraoperatively. The increase in blood pressure due to peritoneal insufflation was prominent in the aged LC group, and a transient decrease of urine output was also recognized.
Postoperative course was uneventful in all groups, and there were no remarkable differences between two LC groups in the number of febrile days, leucocytosis and elevation in C reactive protein value, time needed to change to the standard diet, which were significantly improved than those in OC groups.
These results suggest that LC on aged patients provides a better postoprative course under sufficient intraoperative management such as control of blood pressure and urine output, and that LC is less invasive procedure than OC.

View full abstract

Eight cases of acute cholecystitis following gastrectomy for gastric cancer were clinically investigated for the cause and characteristics. It was possible that the cause in early onset cases was related to circulatory disturbance. In late onset cases, the cause was relevant to additional infection after a preperatory stage by vagotomy or lymphadenectomy in hepatoduodenal ligament. On the other hand, there was no complication in 37 patients who were followed for more than one year after additional cholecystectomy with gastrectomy.
These results suggest that we should take an aggresive attitude for additional cholecystectomy in case with a possibility of postoperative cholecystitis.

View full abstract

We have been employing our own guidelines for the treatment of inguinal hernia in infants that infants with an episode of incarceration or probable imminent incarceration are subjected to early surgery; and those without such risks are subjected to elective surgery until they reach one year of age and when the symptoms persist, by keeping periodical observations for that period. In this study a series of 302 consecutive infants was studied to assess the appropriate timing of elective surgery for inguinal hernia infants of less than one year of age.
In 12% of the infants who were kept in observation reached the age of one year, the groin swelling disappeared and spontaneous cure was expected without surgery. However, 15% of those who have their operations deferred, resulted in having episodes of incarceration. Incarceration was more frequent among those with earlier onset and episodes of incarceration were more frequent after the age of eight months.
This study suggests that an infant with inguinal hernia can be treated with least risk of incarceration, if he/she has a herniorrhaphy before the age of 8 months, while the fact that he/she still has some chance of cure without surgery should be taken into consideration.

View full abstract

Preanesthetic medication with an oral sedative has become routine in the pediatric field. However, due to the uncertainty of ingestion because of drug refusal or vomiting after oral administration, the drug in suppository has also been attemted.
In this study, bromazepam suppositories and diazepam syrup were used as preanesthetic medication in 100 ASA risk 1 children. The patients were randomly divided into three groups. Forty-three patients were given bromazepam suppositories; 36, diazepam syrup; and 21 were served as control. These three groups were compared for 4 parameters: the degree of sedation at the time of entry into the operating theatre; the smoothness of induction; the promptness of awakening; and the degree of sedation at the time of leaving the operating theatre.
The bromazepam suppository group showed greater sedation at the time of entry into the operating theatre than either the diazepam group or control group, and the smoothness of induction was significantly greater (p<0.05). No differences were detected among the 3 groups with regard to the promptness of awakening.
No severe complications were noted in the patients receiving bromazepam suppositories. Bromazepam in suppository can be recommended for pediatric preanesthetic medication.

View full abstract

A 33-year-old woman was seen at the hospital because of right hypochondralgia on September 2, 1991. On blood biochemical examination, the WBC count was 10, 200/mm³ and CRP was 4+, but no findings directly indicative of a diagnosis were obtained by ultrasound, CT, or gastroendoscopic examination. The patient developed an acute pain in the abdomen after endoscopy on September 4 and was admitted to the hospital. On September 8, genital bleeding was noted, and examination at the department of Obstetic and Gynecology disclosed right adenexitis due to Chlamydia infection. The antibiotic was changed to M1N0, and conservative therapy was sustained. However, right back pain and symptoms of peritonitis appeared, and imaging examination revealed intrapelvic abscesses and right hydronephrosis. Open abdominal drainage was carried out on September 13. The patient was diagnosed as Fitz-Hugh Curtis syndrome, because of anti-Chlamydia antibody level of 128 times, fibrous adhesion between the liver and the surrounding tissues, and the presence of right adenexitis. In this case, early diagnosis and administration of effective antibiotics are considered to have been needed. Fitz-Hugh Curtis syndrome should be included as a differential diagnosis of celiopathy in women complaining of right upper abdominal pain.

View full abstract

A case of Cushing' syndrome, primary hyperparathyroidism and adenomatous goitor which were diagnosed simultaneously in a 37-year-old woman is reported. Operative procedures included left adrenarectomy, parathy-roidectomy and partial thyroid resection. Histological diagnoses of these tumor or tumorous lesion were adrenal cortical anemoma, parathyroid adenoma and adenomatous goitor.
Postoperative course was uneventful, and plasma calcium level, PTH, and cortisol were all normalized.
For this patient there was no family history of endoclinological disease and the parathyroid gland was adenoma. It is difficult to determine whether the patient is classified into the category of MEN type I or not only based on these facts. When considered that explorated parathyroid gland was only one and the differentiation between adenoma and hyperplasia was very difficult, we should not neglect periodical observation of further change in plasma calcium level and scleening the members of the family to make the definite diagnosis.

View full abstract

This paper reports a case of multiple endocrine neoplasia (MEN) type 2B in a 41-year-old Japanese man. The patient had mucosal neuromas, bumpy lips, marfanoid habitus, megacolon, pheochromocytoma and medullary carcinoma of the thyroid. Plasma and urinary catecholamines increased, and plasma calcitonin (CT) and CEA increased to 12778pg/ml and 112ng/ml, respectively. The patient underwent total adrenectomy in August 1991, and total thyroidectomy with modified radical neck dissection in September 1992. Microscopically, bilateral adrenal tumors were benign pheochromocytoma, and the thyroid medullary carcinoma was associated with micro-invasion of neck connective tissue and no lymph node metastasis. Plasma CT and CEA levels still remained at 12600pg/ml and 95.4ng/ml respectively as of 6 month after the second operation, no metastatic lesion has not been detected. It is thought that the case seems to be of hereditarary spordic.

View full abstract

We experienced a case of reoperation for recurrent hyperthyroidism after surgical therapy for hyperthyroidism with favorable outcome. The case involved a 50-year-old man. There was a previous history of undergoing subtotal thyroidectomy for hyperthyroidism at the age of 17. The patient was well until the age of 35 when a tumor on the neck began to grow, and thyrotoxic symptom became evident since he was 38 years old. Oral anti-thyroid drug therapy was started under a diagnosis of recurrent hyperthyroidism and lasted for 12 years. However, no improvement of the thyroid function was obtained and the goiter became large and diffuse presenting with nodular lesion partially. Subtotal thyroidectomy was performed. The excised specimen weighed 72.5g and the residual mass, 5.2g. Postoperative course was uneventful and the patient was discharged from the hospital 10 days after the operation. TSH-receptor antibody level which is reportedly a good indicator for recurrence after treatment normalized from preoperative value of 53.8% to 17.8% two months after the operation.
In general, recurrent hyperthyroidism is not surgically treated because of difficulty in surgical technique and high frequency in postoperative complications. It is considered that recurrent hyperthyroidism with large goiter, long duration and resistance to drug therapy would be the indication of surgical treatment.

View full abstract

We experienced a case of lactating adenoma with a rapid enlargement. A 28-year-old woman at 12 weeks' pregnancy was seen at the hospital because of a rapidly growing mass in the right breast with skin pigmentation. Physical examinations, mammography, ultrasonography, thermography, and aspiration biopsy cytology could not rule out malignancy. The patient herself requested a resection of the tumor and was operated on. The specimen showed a 14×9cm capsulated tumor. Pathologically it was lactating adenoma.

View full abstract

A 63-year-old woman was admitted to a neighborhood hospital because of difficulty in holding her head up in December, 1988. Medical therapy for myasthenia gravis was started. A simple X-ray film and CT of the chest revealed a mediastinal tumor. An enlargement of the tumor and severe anemia developed, then pure red cell aplasia was diagnosed in April, 1992. The patient was admitted to the hospital for a surgery of the mediastinal tumor. On admission, the classification of her myasthenia gravis was Osserman II a type. The activity was eased with an anti Ch-E drug. CT revealed that the mediastinal tumor was egg-sized and located in the fore-mediastinum with internal calcification, and its invasion into the left lung was lightly suspected. At the time of the operation a thymoma located in the lower left lobe of the thymus invading the left pleura and left lung was observed, so that the extended thymectomy including this site was performed. Histological diagnosis of the tumor revealed malignant invasive thymoma. After the operation, radiotherapy was added. We here report this rare case of autoimmune disease with a malignant thymoma, and survey of the literature on this subject is added.

View full abstract

A 37-year-old woman, presenting with dry cough and fever, was pointed out an abnormal shadow in the left lower lobe. Angiography revealed an abnormal artery which branched from the aorta on a level of the 10th thoracic vertebra and was distributed over the left basal segment was observed, but the pulmonary artery at the same region was absent. Bronchography did not reveal branching abnormality.
We understand that pulmonary sequestration is a mobit state in which pulmonary tissues separated from the normal ones receive the blood flow from an artery of the systemic circulation. Here the present case is described not to be categorized into the pulmonary sequestration and the so-called Pryce classification is discussed. In addition some consideration on the increased CEA level in this case is presented, together with a review of the literature.

View full abstract

A 71-year-old woman progressively developed esophageal stricture during a follow-up observation of reflux esophagitis after operation for duodenal ulcer-induced perforative peritonitis. The patient was treated first by baloon dilatation, but, as perforation of the esophagus developed, another operation by the procedure used for achalasia was performed after closing the perforated site of the esophagus. She is recovering favorably under good condition of oral feeding. This case suggests that esophageal stricture associated with reflux esophagitis may be induced not only by dysfunction of protective factors such as esophagus, lower esophageal sphincter, but by excess of attacking factors. Also suggested by this case is that fundoplication applied to achalasia is useful in some cases of reflux esophagitis complicated with esophageal stricture but without hiatal hernia.

View full abstract

This paper describes a case of glomus tumor in a hemodialysis patient. A 59-year-old man receiving hemodialysis for chronic renal failure on an ambulant basis developed right hypochondralgia. Gastroduodenal fluoroscopy and gastroendoscopy revealed a submucosal tumor on the anterior wall of the gastric antrum. Biopsy indicated carcinoid of the stomach. Distal gastrectomy with regional lymphadenectomy was performed. The resected stomach had a spherical tumor on the anterior wall of the autrum. The tumor was 3×2×2.5cm in size and had superificial ulceration in the center. The pathologic findings were glomus tumor located from the submucosa through the muscularis and appended on the serosa. He had received hemodyalysis since postoperative day (POD) 2 and was dicharged from the hospital on POD 25.

View full abstract

A 65-year-old woman was pointed out having a large elevated lesion of the stomach at a medial checkup. She visited a nearby hospital and was referred to the hospital because of severe anemia on blood analysis. Gastric endoscopy revealed a giant gastric adenoma. Pyrolus preserving gastrectomy (PPG) was performed. The excised tumor was 9.0×7.5 cm pedanculate tumor with a surface presenting a variety of papillary growth. Histologically there was a tubular or papillary growth of the epitherium, but no clear cancer change was detected. The patient was diagnosed as tubular villous adenoma among gastric adenomas of large intestinal type.
Gastric adenoma of large intestinal type is relatively rare and its cancer change can occur in a high frequency. Once the lesion grows more than 2 cm in diameter, cancer change is increasingly seen and the tumor tends to show characteristic features of precancer. This case was rare in that even the tumor of enough size for cancer change revealed no malignancy.

View full abstract

A 57-year-old man was admitted to the hospital because of epigastric dullache in July 1989. Upper GI series showed a large tumor on the posterior wall of the antrum of the stomach. Endoscopic biopsy of the tumor revealed adenocarcinoma. At laparotomy, a large tumor, measuring 7×4cm, was revealed at the antrum of the stomach. Moreover, numerous enlarged lymph nodes were detected. This gastric cancer was in stage IV (S2POHON4) and a distal gastrectomy was performed. Histopathology showed that this tumor consisted of two components, adenocarcinoma and choricarcinoma. Though potent postoperative chemotherapy was carried out, he died of multiple distant metastasis 5 months after the surgery. Autopsy disclosed that almost all metastatic lesions of the liver, lymph nodes, and peritoneum were histologically choriocarcinoma.
An analysis of nuclear DNA by flow cytometry revealed the difference in DNA index between the adenocarcinomatous part and the choriocarcinomatous part.

View full abstract

An 11-year-old boy was admitted to the hospital because of recurrent nausea and vomiting after meals. In the newborn period, he had undergone a surgery for gastric outlet obstruction (complete prepylotic diaphragm). The surgical record had documented no abnormality at the bulb and descending portion of the duodenum. The upper gastrointestinal series, abdominal CT and ultrasound suggested superior mesenteric artery compression of the intestine involving an abnormally situated distal duodenum. Laparotomy revealed that the duodenum turned outward to the right at the end of the descending portion of the organ, ascending to enter the retroperitoneal space behind the pancreas. Intraoperative gastrointestinal endoscopy demonstrated a luminal stenosis just oral to the root of the mesentery, indicating a compression of the duodenum between the superior mesenteric artery and aorta. Intestinal passage was reconstructed by a side-to-side duodenojejunostomy and Roux-en-Y anstomosis. Postopera-tive course was uneventful and the patient has remained well.

View full abstract

A 70-year-old man was seen at the hospital because of epigastralgia. He was diagnosed as intestinal obstruction on his abdominal plain film and was admitted for further examination. A small elevated lesion on the anterior wall of the duodenal bulb was recognised by gastrointestinal endoscopic examination and the pathological specimen showed adenocarcinoma. Gastrectomy with partial resection of the duodenum was performed under a diagnosis of primary early duodenal bulb cancer. A 4.0×3.0mm elevated lesion with central depression was found at the anterior portion of the duodenal bulb on the macroscopical finding. Postoperative histopathological findings disclosed a well differentiated adenocarcinoma with submucosal invasion. This is the smallest case and fourth case showing an elevated lesion with central depression in the Japanese literature. An exact gastrointestinal endscopic examination is rutinely required for the finding of early duodenal bulb cancer.

View full abstract

We experienced a case of primary leiomyosarcoma originated from the jejunum. A 51-year-old male developed upper quadrant pain and melena since early in January, 1992, and was admitted to the hospital for examination on January 9. Jejunal X-ray series demonstrarated upper intestinal dilatation and a shadow defect of 3cm in diameter at the anal end. Abdominal CT scanning revealed a dilated bowel and a contrast-enhanced mass in the upper abdomen. Angiography of SMA showed a marked tumor staining at the peripheral part of the jejunal brunch. The tumor was located in the jejunum 50cm from the Treitz's ligament, and grew intraluminally and extraluminary, so that resection of the jujunum was performed along with dissection up to the regional radix of the jejunal artery. The gross appearance of the tumor included its having a maximum diameter of 3.8cm, whitish serous surface, elastic hardness, and encapsulation, with a delle being present on the intratu-bular surface at the center of the tumor. Histopathologically, the mass was leiomyosarcoma consisting of atypical smooth muscle cells with giant nuclei and mitosis (1-α/10×20 HPF) in the absence of nodal metastasis (0/15). The patient is now free of tumor recurrence as of one year and 2 months after the surgery.

View full abstract

An 82-year-old female was admitted to the hospital because of repeated tarry stool. A bleeding site could not be detected through examinations such as upper gastrointestinal series, barium enema, endoscopy, arteriography and radionuclide blood scintigraphy. An endoscopic examination of the stomach revealed an early cancer in the gastric corpus. At laparotomy, an intraoperative endoscopic examination and macroscopic findings using a transilumina-tion technique demonstrated the bleeding site of the ileum, which was partially resected. Both microangiographic and histological examinations showed the dilated arteries and veins, which were proliferated and convoluted ranging from the submucosal to the serosal layer of the intestinal wall. These findings were compatible with a congenital arteriovenous malformation. Gastrointestinal bleeding due to an intestinal arteriovenous malformation is uncommon with difficult diagnosis. To our knowledge, this patient is the eldest with a congenital arteriovenous malformation of the ileum.

View full abstract

The present paper describes 2 cases of mucocele of the appendix. Case 1: A 72-year-old female was admitted to the hospital because of right lower abdominal pain. Case 2: A 45-year-old male was admitted to the hospital because of lower abdominal pain. In both cases, Ba-enema examination revealed a filling defect with smooth surface in the cecum. CT and ultrasonography revealed a unilocular and internally homogenous cystic tumor with smooth surface which positioned the same area as the cecum exists. Both patients were diagnosed as having mucocele adenoma of the appendix and partial excision of the cecum was performed. Pathologically those were mucin-producing adenoma of the appendix. Mucocele of the appendix is a relatively rare disease and presents difficulties in the preoperative diagnosis. More than 420 cases have been reported in the Japanese literature so far, and only 53 cases could be diagnosed preoperatively. This time we experienced 2 cases of mucocele of the appendix, diagnosed correctly before operation by CT and ultrasonography. The importance of CT and ultrasonography should be emphasized if the disease is suspected preoperatively.

View full abstract

A case of suppurative pylephlebitis of the portal vein following acute appendicitis is reported. A 52-year-old male with uncontrolled diabetes mellitus developed acute abdominal pain and high fever. Although physical findings and laboratory data were indicative of the pre DIC state accompanied by liver dysfunction secondary to panperitonitis, CT examination suggested obstruction of the portal vein and superior mesenteric vein. During surgery, the appendix showed acute inflammatory changes with localized peritoneal abscess, and the ileocolic, superior mesenteric and extra hepatic portal veins were confirmed completely obstructed with thrombi. Following appendectomy, peritoneal lavage and drainage, a polyethylene catheter was inserted into the ileocolic artery, through which antibiotics and urokinase were injected in addition to the systemic administration of antibiotics, y-globulin, heparin, antithrombin-HI, and gabexate mesilate. Angiography on the 38 postoperative day revealed cavernous transformation of the portal vein, with the main portal trunk being completely obstructed. Escherichia coli was isolated from culture of blood sample collected preoperatively and that of ascites or the thrombus obtained during surgery.
Suppurative pylephlebitis of the portal vein is a rare disease, but it can be associated with intraperitoneal infections including acute appendicitis, if the patient has some underlying disease such as diabetes mellitus. This case indicates that surgical removal of infected focus followed by conservative treatment is able to save the patient's life.

View full abstract

This paper describes a recent experience with duplication of ileo-caecal alimentary tract in a 37-year-old man.
The patient complained of persistent right lower abdominal pain even after appendectomy for acute appendicitis. Ultrasonography and CT scan revealed a cystic lesion which was about 5 cm in diameter on ileo-caecal location. Under a suspicion of duplication of alimentary tract, the patient was operated on. Cystic mass was adjacent to the ileum on the mesenteric side of ileum end. Ileo-caecal resection was done. Histological examination revealed that the cystic mass possessed the common proper muscle layer with ileum, and had ectopic gastric mucosa.
By definition, the duplication of alimentary tract means such conditions that is encapsulated with one or more smooth muscle layers; that the inside is covered with digestive epitherium; and that is adjacent to the original digestive organ and shares the common smooth muscle layer. About 400 cases of alimentary tract duplication have been reported in Japan so far. Two cases out of 9000 newborn and infant autopsies had alimentary tract duplication in the USA. This disease is seen in all ages, but about 70% of the cases are seen in infants.

View full abstract

Lipoma of the large intestine is a relatively rare disease and is characterized by an association of intussusception in a high frequency. This paper presents a case of lipoma of the large intestine with intussusception, together with a revies of the literature.
A 41-year-old man visited a nearby hospital because of abdominal pain and melena. With colonoscopy a tumor in the descending colon was found and the patient was referred to the hospital for close examination and treatment. Barium enema revealed a crab's claw-like shadow with a 5×4cm pedunculate tumor in the lead in the descending colon. Abdominal ultrasonography and CT visualized characteristic concentric cricles of multi-layered structure, from which a diagnosis of intussusception was easily made. In the meantime the diagnosis of lipoma could not be achieved by biosy cytology, however, CT value of -65 corresponded to the fat value. CT was useful for diagnosis of lipoma. From these findings the diagnosis of lipoma of the descending colon associating with intussusception was made. A partial excision of the descending colon was carried out.

View full abstract

We experienced a case of intussusception after operation for a cancer of the ileocecal region.
A 93-year-old woman was admitted to the hospital because of abdominal distention. Ileography and colonoscopy revealed a tumor of the cecum. Ileocecal resection with lymph node dissection was carried out. The resected tumor was an advanced cancer of the cecum. Postoperative course was uneventful, but abdominal distention and vomiting developed one month after the operation. Intestinal adhesion with obstruction was suspected. In spite of conservative therapy by inserting an ileus tube, her symptom was not improved. Abdominal CT scan and ileography showed ileo-colic intussusception. The intussusception was successfully reducted by both a high pressure enema and mannual method. The intussusception after ileo-colostomy is very rare and the possibility of this disease should be borne in mind. In addition, if the diagnosis of the disease is made, non-operative procedures should be tried first.

View full abstract

Obstructive colitis is found in about 6% of all colorectal cancers associating with obstruction. It presents difficulty in diagnosis and a few reports describing anastomotic leakage due to this disease can be seen. Here three cases of obstructive colitis are described.
All 3 cases presented with intestinal obstruction. One of the 3 cases was successfully diagnosed preoperatively, but the remaining 2 cases were diagnosed intraoperatively. During surgery, it was difficult to decide the extent and degree of the inflammation of the colon on the serosa side but only we can decide on the mucous side of the edge of the resection. So additional resection had to be performed in two cases.
In addition to the difficulty in diagnosis obstructive colitis offers a risk of anastomotic leakage, stenosis, or bleeding due to ulcerative lesion at the anastomosed site, if it is there. Then, we should examine the existence of the inflammation on the mucous edge of the resection to prevent post operative complication, and if it is found, additional resection for oral side colon should be carried out.

View full abstract

A case of gangrenous type ischemic colitis is described. The patient was a 48-year-old woman. There was a previous history of undergoing abdominal surgery three times. After the constipation for 5 days, abdominal pain with rebound tenderness, diarrhea and bloody stool was observed. CT scan revealed a remarkable thickening of the colon, and signs of in flammation continued. Left hemicolectomy was performed. Although the mortality of gangrenous type ischemic colotis is high, the immediate operation successfully saved the life of this patient. In case of gangrenous type of ischemic colitis, early diagnosis and immediate surgery should be performed.

View full abstract

Complete rectal prolapse was relatively uncommon disease, but a number of different methods of surgical treatment for prolapse of the rectum had been devised. There were transperineal, transabdominal and their combined method. The same surgical treatments of complete rectal prolapse were reported recurrence of the disease.
Here we report a case of complete rectal prolapse in a 77-year-old woman whose rectal wall was fixed with bilateral internal iliac artery branches, with good postoperative condition for one year and six months. New surgical method that we have devised was as follows:
1) Rectosigmoid and rectum are mobilized anterioly and posterioly
2) Suture of rectal wall with bilateral internal iliac artery branches
3) Incised peritoneum is sutured to the rectal wall
4) Rectosigmoidectomy, mattress placed to approximate walls of anal cuff and sigmoid.
This new devised procedure will promise to prevent recurrence as well as to keep healthy bowel movement after the operation, if it is indicated for selected candidates who are able to undergo laparotomy.

View full abstract

An asymptomatic 58-year-old man was found to have a IIa+IIc type early colonic cancer by a nearby physician and was seen at the hospital for further examination. Colonoscopy showed a reddish depressed lesion with marginal elevation. Biopsy specimen showed a IIa+IIc type early colonic cancer. Histological diagnosis was well differentiated adenocarcinoma. A discending colectomy with lymph node dissection was performed following the resection line indicated by colonofiberscopy. The resected specimen disclosed IIa+IIc type early colonic cancer, measuring 3×4mm macroscopically. Histologically it was a well differenciated adenocarcinoma and mucosal cancer. It was positive in cancerous cells only with CEA staining. There was no lymph node nor liver metastasis. Adenoma was not detected at the resected specimen. indicating the de novo cancer. This case is valuable for the investigation of the early lesion and evolution of colonic cancer.

View full abstract

We recently encountered a patient having a small protuberant lesion in the rectum, who has been affected with ulcerative colitis of the total colitis type for 22 years. Early cancer was suspected, and surgery was performed. Pathologically, invasion to the wall was pm, and lymph node metastasis was positive. The patient developed metachronous multiple metastases in the liver eight months after the surgery.
The indication for surgery has been extended with the establishment of surgical therapy for ulcerative colitis. Even refractory case has recently tended to become a candidate for early surgery. Based on our experience with this case, earlier indication for operation should be considered because useless retardation can permit cancer change. The importance of surveillance of canceration for determining the timing of surgery is emphasized.

View full abstract

We experienced two cases of re-recurrent rectal carcinoma which was found after an operation for recurrence and were able to undergo curative resection.
Case 1: A 60-year-old woman. There were previous histories of undergoing low anterior resection for a rectal carcinoma of Ra 9 years before; and of undergoing Miles' ope for recurrence at the anastomosed site 7 years and 4 months before. Five years and 6 months after the second operation a recurrent lesion was found in a portion adjacent to the sacrum. Posterior resection with associated resection of the 3rd sacrum and the below was performed. Nine months later re-recurrence developed in the stumps of the sacrum. Resection of the remaining visceral organs with the 2nd sacrum was carried out. Postoperatively lung metastasis occurred, but there has been no local recurrence up to now.
Case 2: A 63-year-old man. There was a previous history of undergoing Miles' ope for a rectal carcinoma of Rb 3 years before. One year later recurrence was found in the posterior region of the prostate. Pelbic exenteration with combined resection of the 3rd sacrum and the below was carried out. Ten months after the second operation re-recurrence in the gluteal muscle was detected and the tumor was successfully excised. There has been no further recurrence as of 3 months after the 3rd operation and the patient is doing well.

View full abstract

A rare case of resected splenic metastasis from rectal cancer without any other distant metastases is reported here. The patient was a 65-year-old male. He had undergone an abdominoperineal resection for a rectal cancer in February 1987 (a₁n₁(+)P₀H₀M(-), stage III, muc). He was admitted to the hospital in May 1990 because a splenic tumor was recognized by an abdominal computed tomography during a follow-up study.
Abdominal computed tomographic examination showed a low density area with the size of 7cm in the upper pole of the spleen. Abdominal ultrasonographic examination showed a circular mosaic echoic area in the same portion. Abdominal angiographic examination revealed a hypovascular mass in the same portion. In these circumstances, a splenectomy was performed for suspecting either a splenic metastasis or primary splenic malignant lymphoma. Histophathological findings of the resected splenic tumor revealed the same histological type of rectal cancer. It was diagnosed as metastasis of the rectal cancer into the spleen without any other distant metastases.
According to the reported cases, the prognosis after splenectomy of the solitary splenic memasasis is comparatively good. This case is doing well 3 years and 5 month after splenectomy. For the early detect of this disease the importance of periodical examination by abdominal computed tomography and ultrasonography during a follow-up study is emphasized.

View full abstract

We experienced a case of anal canal cancer with periproctal Paget disease in which conservative treatment was effective.
An 86-year-old man complining of anal bleeding was diagnosed as having an anal canal cancer by elsewhere, and was referred to the hospital. This case is essentially a possible canditate for abdominoperineal rectal resection, but conservative therapy was employed because of his advanced age and association of dementia. The patient was administered doxifluridine 800 mg orally for consecutive 4 weeks, was applied 5-FU ointment locally, and received radiation at a dose of 2Gy a day 20 times, totally 40Gy. Consecuently the anal canal cancer and Paget disease completely disappeared 4 weeks and remission of erosion around the anus was attained 8 weeks after the therapy.
These findings indicate that we can choose more positively a combination of chemotherapy and radiation therapy which permits the anal function to be preserved in the treatment of anal canal cancer.

View full abstract

The authors present a case of complete remission of multiple liver metastases from gastric cancer as a result of intrahepatic infusion regimen with 5-FU after pancreaticoduodenectomy. A 65-year-old man was seen at the department because of epigastric pain. with endoscopic examination and CT, an advanced gastric cancer of Borrmann type 2 with multiple liver metastases was found. The patient underwent pancreaticoduodenectomy, because the extensive gastric cancer which was H3P0S3 (panc) N3 in Stage IV that directly invaded the head of the pancreas. An injection tube was inserted into the proper hepatic artery and 5-FU was consecutively given into the hepatic artery via the tube for 24 hours evely day (250mg/day). On CT taken at the first month after the operation decreases in both the number and size of metastasized lesions were observed. 'three months after the operation hepatic metastass disappeared in the imagings, and at the same time CEA level was normalized to 1.5ng/ml from 53ng/ml. The patient recovered his daily social activities.

View full abstract

This paper describes a case of anomalous arrangement of pancreatobiliary duct which was detected in a patient with stoneless cholecystitis. The patient was a 40-year-old woman complaining of upper abdominal pain. Ultrasonography visualized hypertrophy of the gallbladder wall. Endoscopic retrograde cholangio-pancreatography revealed anomalois arrangement of pancreatobility duct. Cholecystectomy and excision of the extrahepatic bile duct were carried out. Pathologically the hypertrophy of the cystic wall and mild chronic inflammatory picture were confirmed, but no heteroplasia was observed. This patient appears to belong to a high risk group for gollbladder carcinoma, because she is relatively young, there was mild dilatation of extrahepatic bile duct, and she had anomalous arrangement of pancreatobiliary duct without stones.

View full abstract

A mesenteric chylous cyst is a rare disorder, and it is difficult to diagnose preoperatively because of lack of unique symptoms and definitive diagnostic test. In Japan 39 cases of mesenteric chylous cysts have been reported in the past. This paper presents a case of large mesenteric chylous cyst. An 18-year-old man visited his home doctor because of an abdominal fullness which gradually enlarged for several month. This patient was pointed out abdominal tumor and referred to the hospital. Abdominal ultrasonography, abdominal CT, magnetic resonance image, and abdominal angiography were conducted, and the tumor was diagnosed as mesenteric chylous cyst arising in an area from the ventral mesogastrium to parietal peritoneum. Laparotomy was performed. The cyst occupied entire the abdomen and strongly opressed the other organs, but there was no communication with the small intestine or lymph channel. It was able to be excised completely. There has been no sign of recurrence, as of about one year after the operation.

View full abstract

A 65-year-old female was admitted to the hospital because of right low back pain and jaundice. A tumor in the right upper abdomen was palpated. Abdominal ultrasonography and CT revealed gallstones and an 8×7×4cm tumor in the subhepatic space. Gastrointestinal series and endoscopy disclosed no any findings relating to the tumor. Angiography of the abdomen revealed the feeding vessels to the tumor origined from the gastro-duodenal artery.
Cholecystectomy was performed and the tumor in the greater omentum was excised. The tumor existing in the large omentum was solid and encapsulated, it being easily removed. Histopathologically the tumor was paraganglioma. Extra-adrenal-paraganglioma arising in the mediastinum or retroperitoneum can be infrequently seen in the literature. The paraganglioma arising in the greater omentum in this case appears the first report in Japan as far as we could review.

View full abstract

We experienced a case of perforative peritonitis caused by intestinal tuberculosis. A 76-year-old man was admitted to the hospital because of appetite loss. On the 11th hospital day abdominal pain developed and muscular defence was added on the 13th day. On the same day emergency operation was performed with a diagnosis of acute abdomen. There were a small quantity of pyoascites and a whole-circumferent ulcer at about 30cm oral-side from the ileocecal valve with a perforation at the ulcer. Diffused swellings of mesenteric lymph nodes and multiple nodule about 5mm in diameter in the peritoneum were confirmed. A diagnosis of diffuse peritonitis due to small bowel perforation was made, and excision of the perforated intestine was performed, followed by end-to-end anastomosis. The resected specimen had a thick intestinal wall and a deep ulcer perpendicular to the long axis of the intestine.
Histologic findings indicated tuberculos nodules comprising of Langhans giant cells, epitheloid granuloma, and lymphocytes. Bacteriological examination of the ascites confirmed the presence of tubercle bacillus. The patient developed pneumonia after the operation. On 3rd post operative day massive melena occurred, bleeding tendency being shown. The patient died on 12th POD.
Perforation of the intestinal tuberculosis is rare in recent years, but we should keep in mind as a possible cause of acute abdomen.

View full abstract

We experienced a rare case of retroperitoneal fibromatosis which occurred in an adult female.
A 51-year-old female was seen at the hospital because of a left lower abdominal tumor. Gastointestinal series, drip infusion pyelography (DIP), computed tomography (CT) and magnetic resonant imaging (MRI) revealed that the tumor was localized in the right anterior position of the left iliac muscle. The tumor had no relation to the gastrointestinal tract or urinary tract. An angiography did not reveal any tumor feeding artery or tumor stain. It was diagnosed as left retroperitoneal tumor, and therefore, the tumor was removed. The tumor was 10×9.5×5cm in size and 315g in weight. The histrogical diagnosis was fibromatosis.
This is a rare but not malignant tumor and it has a high recurrence rate. Recently it has been reported in relation to simian acquired immunodeficiency syndrome (SAIDS). Its etiology and treatment course are discussed in the paper.

View full abstract

We report a case of non-strangulated bilateral obturator hernias which was diagnosed preoperatively by herniography. A 75-year-old woman had been treated for bilateral thigh pain since three years before. Although no pain was complained of when she was referred to the surgical clinic, a Howship-Romberg sign was assumed on the basis of her medical history. Herniography demonstrated bilateral obturator hernias. She underwent surgery through a retropubic extraperitoneal approach under spinal anesthesia. Empty hernial sacs were identified in the bilateral obturator canals. Repair of both hernia porta was performed by approximating the pubic periosteum and obturator membrane. Herniography is mandatory in the preoperative diagnosis of non-incarcerated obturator hernia. Recently, reports on bilateral obturator hernias are increasing in number. We consider the retropubic extraperitoneal operative approach to be the most appropriate procedure, because bilateral obturator foramens can be identified through one common incision.

View full abstract