The latissimus dorsi flap combined with a silicone implant has been a popular method of breast reconstruction since its description by Bostwick and his coworkers in 1978. The authors, who have avoided using silicone implants because of their disadvantages such as capsule contracture, have used the latissimus dorsi myocutaneous flap and additional fat over the iliac crest. The clinical experience with 174 patients who have undergone breast reconstruction with this extended latissimus dorsi flap between October of 1981 and January of 1997, the technical details, and long-term results are reported in this paper. There was no patient who experienced total flap necrosis and only four patients had recognized partial flap necrosis. The advantages of the extended latissimus dorsi flap are: (1) less complications due to stable circulation; (2) excellent restoration of the anterior of the axillary fold and infraclavicular area; (3) possible reconstruction of small and moderately sized breast and ptotic breast; and (4) simple technique and no nessecity of anastomosis of the vessels.
We strongly recommed this flap that demands no implant in almost patients.

View full abstract

We have made a study on perioperative management for open heart surgery in hemodialysis patients. Subjects were eight patients on hemodialysis for chronic renal failure who underwent open heart surgery at Nagasaki University Hospital between 1988 and 1996. Although there was no operative death among them, two hospital death occurred (each at 34 and 54 postoperative days) with various complications which were unrelated to either renal failure or hemodialysis trouble. As far as adequate hemodynamic state could be maintained, we tried to keep their water balance to dry side in the immediate preoperative period. In most instances, intraoperative hemodialysis could be avoided by correcting water and electrolyte balance properly by active hemodialysis, and by positive use of hemofiltration and removal enough of the infused cardioplegic solution during cardiopulmonary bypass. In the postoperative period, early introduction of continuous hemodiafiltration was useful for controlling water and electrolyte balance, and preventing metabolic acidosis and azotemia. Meticulous perioperative management under full understanding of peculiar pathophysiology of hemodialysis patients is essential to obtain satisfactory result of open heart surgery in these patients.

View full abstract

A series of 61 cases of achalasia of the esophagus underwent cardioplasty at the hospital from January 1985 to December 1996, and of these 61 cases, there were 11 cases of reoperation and 50 cases of initial operation. Reoperations were conducted by modified Jekler method in nine cases in which myotomy was possible, by fundic patch method advocated by Thal-Hatafuku and others in the remaining two cases in which myotomy was impposible. Esophageal inner pressure was measured before, during and after the operation to gain the lower esophageal sphincter pressure (LESP) and high pressure zone (HPZ). There was no remakable difference in LESP and HPZ among initial operation cases, whole reoperation cases, and reoperation cases by modified Jekler method. On the overall evaluation according to Payne' s criteria, however, all cases of initial operation were rated as excellent, but among reoperated cases two cases undergoing modified Jekler method and one cases undergoing fundic patch were rated as good and one case undergoing fundic patch was rated as fair due to regurgitant esophagitis. Compared with modified Jekler method, fundic patch tended to make severe degree of cicatrization that might cause the difference in surgical outcome. It is thought that the reoperation for esophageal alachasia may result in relatively favorable outcome by performing myotomy as possible as we can.

View full abstract

The usefulness of preoperative examinations with endoscopic ultrasonography (EUS) in determining operative procedure and ranges of lymph node dissection was examined in 135 patients with gastric cancer. The patients received EUS examinations in order to measure the depth of cancer invasion before undergoing gastrectomies. The EUS results were then compared with the findings of the histological examinations of the resected specimens; the depth of cancer invasion and the degree of lymph node metastasis.
The correct diagnosing rates of m-, sm-, mp-cancer groups and ss-cancer or deeper group were 68.1%, 42.4%, 50.0% and 93.3%, respectively, with an overall accuracy of 68.9%. In an analysis of misdiagnosed cases, there were more overdiagnosed cases than underdiagnosed ones. The cases diagnosed as M and SM by the EUS examination had low potential of lymphnode metastasis; and no cases were observed with n2 or more distant lymphnode metastasis.
It is suggested that positive adoption of conservative surgery with Dl-level lymph node dissection would be appropriate for patients with EUS diagnosis of M or SM.

View full abstract

To clarify the prediction of metachronous liver metastases on curatively resected colorectal cancers, tumor microvessel density was compared between 33 cases with postoperative liver metastases (meta-chronous group) and 66 cases without liver metastases (control group). Control group was frequency (1:2) matched with metachronous group for tumor location, depth of invasion, and histological type. Microvesels were immunohistochemically stained with anti-factor VIII monoclonal antibody and were counted in a×200 field. Microvessel density (MVD) of metachronous group was significantly higher than that of control group (36.1±5.21 vs. 31.9±5.62, p=0.0006). Receiver operating characteristic curve of MVD indicated that the most compatible cut-off value for liver metastases was 34. The positive predictive value of high MVD (_??_34) for metachronous liver metastases was 0.24. High MVD was significantly associated with lymph node metastases and histological stage. A significantly positive correlation was observed between MVD and PCNA LI. From the above results it is suggested that immunohistochemical study of MVD is useful for prediction of metachronous liver metastases on curatively resected colorectal cancers.

View full abstract

We retrospectively reviewed 29 cases of acute mesenteric ischemia (14 of acute mesenteric occlusion and 15 of non-occlusive mesenteric ischemia) with respect to underlying diseases, associated conditions and factors determining outcome. The majority of the patients had some underlying cardiovascular diseases. In 45% of the patients, this syndrome was developed postoperatively. At the initial diagnosis, 52% of the patients had failure of one or more organs and 55% of them were in a state of shock. Factors determining outcome between survivors and non-survivors were elevated hepatic enzymes, hypotension, combined intestinal infarction (both large and small intestinal infarction) and failures of two or more organs. DIC may play an important role in the development of liver and renal failure in the early phase of acute mesenteric ischemia. To further improve the therapeutic outcome of acute mesenteric ischemia, it is essential to make an early diagnosis. Therefore, physicians must have a high index of suspicion in high risk patients. If those patients have abdominal pain, mesenteric angiography should be performed. Based on the angiographic findings, appropriate intervention should be started as soon as possible.

View full abstract

Forty-six adult patients with inguinal hernia except recurrent or incarcerated cases have been operated on under local anesthesia in the hospital. The operation under local anesthesia was possible in all cases. Compared to operations under lumbar anesthesia, operations under local anesthesia offered stable hemodynamics during surgery and no patients demanded any pressor agent. As to intraoperative pain, pains of 88.2% of those patients were rated as 1 or 2 according to Wong-Baker's face scale, and the operations were relatively easily performed. The frequencies of analgesics prescribed after the operation that would correlate with the strength of postoperative pain were 13% and 38.1% (p<0.01) on the day of operation and 37% and 4.8% (p<0.01) on the next day of operation in local and lumber anesthesia groups, respectively. In terms of postoperative complications and complaints, few patients complained of headache or constipation or needed urethral complaints, few patients complained of headache or constipation or needed urethral catheterization in the local anesthesia group, compared to the lumbar anesthesia group. Hospital stay came to 8.2days in the local anesthesia group or 9.2days in the lumbar anesthesia group, that was certainly accompanied with low cost for hospitalization. Local anesthesia had less anesthesia-relating affect to the patients, and hence it enables them to leave their beds early, shortens the duration of hospital stay together with leading to the cost benefit.
It is thought that the local anesthesia should be selected as standard anesthesia for adult patients with inguinal hernia in future.

View full abstract

We report a case of giant parathyroid adenoma in mediastium.
A 54-year-old female woman was admitted to the hospital because of hoarseness, lumbago and left patella fracture for which she was not able to walk. Blood Ca level was 17.4mg/ml and c-PTH was 46.96ng/ml. Blood ALP level and BGP were also high. X-ray film of the head showed salt and pepper appearance. CT and MRI films of the neck and chest showed a solid and smooth tumor located in the right upper mediastium to the neck. The patient was diagnosed as having primary hyperparathyroidism due to the parathyroid tumor. The tumor was excised from the neck wound without mediastinotomy. It was a parathyroid tumor, 32g in weight and 7.0×5.0×1.5cm in size, located in the site which coincided with the location shown in the CT and MRI films. Pathologically it was diagnosed as parathyroid adenoma. After the operation, hoarseness and lumbago disappeared and her general condition was getting better. Blood Ca level and PTH fell to the normal range. Blood ALP level and BGP level fell to the normal range. Therefore, she was able to walk after rihabilitation therapy.

View full abstract

We report a case of pulmonary large cell neuroendocrine carcinoma (LCNEC).
A 51-year-old man was admitted to the hospital for further evaluation of an abnormal shadow on a chest X-ray film which was detected at a health examination. Chest CT showed a nodular mass 3.0cm in diameter in the left upper lobe (S¹⁺²b). But no histological malignancy was revealed by a transbronchial tumor biopsy or cytology of brushing samples. Left upper lobectomy was performed because a possibility of malignant mass could not be ruled out. The case was pathologically confirmed as pulmonary LCNEC as proposed by Travis and coworkers in 1991. Pulmonary LCNEC is very rare and only seven cases including ours have been reported in the Japanese literature.

View full abstract

A 68-year-old man who had noticed a tumor in the left anterior thoracic region but let it alone for 7-8 years was admitted to the hospital because of a recent increasing tendency of the tumor (18×18cm in size). With chest CT scan, magnetic resonance imaging (MRI) and angiography, the tumor presented difficulty in differentiation from lipoma. Needle aspiration biopsy cytology offered a diagnosis of liposarcoma, and tumor was surgically extirpated. Histopathologically it was well differentiated liposarcoma, lipomalike type.
Few reports of liposarcoma arsen in the chest wall have been reported in Japan. Only 20 cases of the disease including our case are seen in the literature as far as we could review. Of most cases, the ailing periods ranged from one month to 4 years. There has been no such report as the liposarcoma of the chest wall had gradually grown for over 7-8 years.

View full abstract

Congenital cysts of the esophagus are relatively rare. We report two cases of congenital cyst arisen in the esophageal wall, together with a review of previous 97 cases in Japan in terms of the histopathological classification.
A 70-year-old man was admitted to the hospital because of tarry stool (Case 1). Chest roentgenogram revealed a tumor shadow in the right cardiophrenic angle. The cyst located in the esophageal muscle layer was removed. The cyst wall was lined with ciliated columnar epithelium, and had some cartilage and a well-developed smooth muscle layer. Another patient was a 46-year-old man who was admitted because of dysphagia and arrythmia (Case 2). The cystic was located in the same place as that of case 1. The removed cyst was lined with squamouse epithelium and had double layers of smooth muscle without cartilage. Based on Arbona's criteria, the cyst in case 1 was diagnosed as bronchogenic cyst, and the cyst in case 2 was diagnosed as duplication cyst.

View full abstract

Cinical cases of esophageal hiatus hernia with gastric cancer are rare and have numbered only ten in Japan so far. This paper presents our experience with two cases of the disease.
Case 1: A 74-year-old man was seen at the hospital because of epigastric pain. Upper gastrointestinal series revealed a sliding hiatus hernia of the esophagus, and an upper endoscopy showed a IIc leion at the herniated portion. Upper abdominal midline incision, proximal gastrectomy, D1 dissection, and jejunal interposition were performed. Histopathologically the lesion was differentiated tubular adenocarcinoma with invasion depth of m and without any lymph node metastasis. There have been no signs of recurrence, as of 5 years after the operation.
Case 2: an 83-year-old woman was seen at the hospital because of dysphagia. Upper gastrointestinal series and upper endoscopy revealed a mixed type of esophageal hiatus hernia and a Borrmann type 2 lesion at the cardiac part of the stomach. An open-heart surgery between 7th lib, proximal gastrectomy, D1 dissection, and esophagogastric anastomosis were performed. Histopathologically, it was poorly differentiated adenocarcinoma with the invasion depth of mp and without lymph node metastasis. As of one year after the operation, the patient is followed on an ambulant basis.

View full abstract

A 66-year-old man complaining of dysphagia was admitted to the hospital because he was pointed out having a whole-circumferential stenosis of the middle thoracic esophagus on double contrast radiography at another hospital. Histologic examination of biopsy specimens suggested an undifferentiated carcinoma of the esophagus. Since computed tomography showed a direct invasion of the tumor to the descending aorta and left main bronchus, the patient was treated with CDDP and 5 FU for 4 weeks before surgery. After the chemotherapy when the reduction rate of the tumor was 65%, an esophagectomy under left thoracotomy with reconstruction was conducted. The resected tumor was 6 × 3 cm in size, covered with normal moucosa. Histologic findings showed that cancer nests were consisted of small round cells and expanded downward with peripheral palisading arrangement and a hyaline basement-like matrix. Thus the diagnosis was made as basaloid cell carcinoma of the esophagus, with a stage-grouping of a2, n4, M0, P0, stage IV. Despite postoperative chemotherapy, the patient died of lung, liver, and lymph node metastases 14 months after the surgery.

View full abstract

A rare case of adenoid cystic carcinoma of the esophagus is reported. A patient was a 48-year-old woman was admitted to the hospital because of dysphagea. Esophagography revealed a lesion at Ei, and an endoscopy demonstrated an uneven elevated lesion on the anterior wall of the esophagus 30-38cm from the incisors. An adenoid cystic carcinoma was diagnosed by a biopsy and a total thoracic esophagectomy was performed. The surgical material showed a 6.5×4.0cm 2type lesion with an ulcer in the center. The histopathological diagnosis of esophageal adenoid cystic carcinoma (mp, n2, stage III) was made. Immunohitological staining for actin was positive in the tumor. Electron micrograph showed microvilli. Esophageal adenoid cystic carcinoma is generally thought to be associated with a poor prognosis, but the patient has not developed recurrence and has been followed as an outpatient as of three years after surgery.

View full abstract

Papillary Adenoma of the ampulla of duodenum is a rare disease. There has been no consensus regarding carcinogenesis of the papilla and the biological malignancy. And the best operative procedure for this disease is debatable. Recent experience with a case of papillary adenoma of the ampulla of duodenum in a 69-year-old woman is presented here. For the patients total papillectomy was successfully performed on basis of preoperative pathohistological examination and a intraoperative frozen section diagnosis of the papillary adenoma.
We consider that total papillectomy should be the first choice of therapy for this disease because that, if it can be completely resected withiout any residual lesion by total papillectomy, no recurrence occurs.

View full abstract

A case of rupture of an aneurysm of the pancreaticoduodenal artery which occurred 2 years and 4 months after operation for a rectal cancer was successfully managed by transcatheter arterial embolization therapy.
A 62-year-old man who had no previous history of pancreatitis nor arteriosclerosis had an uneventful course after an operation for a rectal cancer. With a diagnosis of phlebothrombosis of the left lower limb, oral administration warfarin pottasium 3.0mg/day was started when it passed one year and 9months after the operation, and at the same time increases in CEA and CA19-9 were noted. Recurrence was suspected and oral administration of doxifluridine 1200mg/day was also started. Thereafter no particular problems arose, however, the patient was seen at the hospital in shock state because of abrupt massive anal bleeding. Emergency angiography offered a diagnosis of gastrointestinal bleeding due to rupture of an aneurysm of the inferior pancreaticodudenal artery. So an embolization via metal coil was conducted. The patient was able to relived from the shock state and anal bleeding disappeared thereafter. However, the patient died of local recurrence as of 6months after the embolization or 2years and 9months after the operation for the rectal cancer.

View full abstract

Multiple, primary non-specific ulcer of the small intestine is a relatively rare entity. We experienced a case of the disease causing perforation and mechanical ileus.
A 75-year-old woman was seen at the hospital because of abdominal pain and vomiting on June 8, 1995. An emergency operation was performed with a diagnosis of perforative peritonitis. Upon laparotomy, an about 1mm perforation in the ileum on the contralateral to the mesentery and 80cm oral side from the terminal ileum was noted. A wedge resection including the perforation was conducted. Histopathological diagnosis of primary non-specific ulcer of the small intestine was made. After the operation the patient developed intestinal obstruction that was cured by conservative treatment using an ileus tube. He was discharged from the hospital on the 53rd hospital day. Thereafter, the patient experienced two episodes of ileus that were conservatively treated by using an ileus tube. On October 4, 1995, the patient underwent an operation for ileus again that revealed a circular stricture of the ileum 80cm oral side from the terminal ileum where was the same location as the former lesion and was thought to be causative site. A partial resection of the ileum including the stricture was performed. The resected material disclosed that the lumen whole-circumferentially formed the bottom of ulcer. Histopathologically it was diagnosed as primary non-specific ulcer of the small intestine.

View full abstract

A 51-year-old woman on hemodialysis chronically after the age of 32 was admitted to the hospital because of hypotension, abdominal pain, and vomiting immediately after starting hemodialysis. Conservative treatment failed to improve the symptoms. On the 3rd hospital day, a laparotomy was conducted and the segmentally necrotizing jejunum ranging about 120cm in length was found. It is thought that hemodialysis patients are involved in a high risk group for ischemic inflammation of the intestine. Operated cases of the disease have been increasingly reported. These lesions are common in the SMA region, especially the ileocecal region. Our case in which the lesion was localized in the upper jejunm is thought very rare.

View full abstract

We report a case of inflammtory fibroid polyp (IFP) of the ileum which caused an intussusception.
A 41-year-old man was seen at the hospital because of right lower abdominal pain, vomiting and bloody stool. The abdominal pain lasted for about six months. Barium enema and abdominal CT indicated an intussusception in the ascending colon. Under a diagnosis of intussusception, an emergency laparotomy was performed. During surgery, the intussusception had been spontaneously released by that time and a tumor of the ileum located at 25cm oral from the terminal ileum was identified. A partial resection of the small intestine by 20cm including the tumor was performed. In the resected material, a 3.0×2.5×3.3cm polyp was confirmed which might cause the intussusception. This lesion was diagnosed as IFP histopathologically. IFP of the small intestine is rare. As far as we know, 68 cases including present one have been reported in Japan.
In conclusion, it is important to consider IFP as a probable underlying disease in case of adult intussusception.

View full abstract

A 70-year-old woman was seen at the hospital because of an abdominal pain. After exploration, diagnoses of sigmoid colon cancer and cholelithiasis were made. Abdominal computed tomography demonstrated a solid intrapelvic tumor, but no preoperative definite diagnosis was made for appendiceal lesion. On laparotomy, the cystic tumor, which was found to be originating from the appendix had enlarged to 8.0×6.0cm in diameter, and mucous dissemination were seen. Appendectomy, resection of the sigmoid colon and cholecystectomy were performed. The resected specimen of the appendix was filled with gelatinous substance and pathologically diagnosed as mucinous cystadenoma. Such a case of appendiceal mucocele with synchronous colorectal cancer is rare, and only 11 cases have been reported in the Japanese literature. However, the disease is not so uncommon in foreign countries, and hence careful exploration of the entire colon for possible coexistence of primary cancer would have to be conducted if mucocele of the appendix is found out.

View full abstract

We report here two cases of Crohn's disease with diffuse peritonitis that demanded emergency operation. Case 1 involved at 42-year-old man diagnosed as having mechanical ileus due to stenotic lesion of Crohn's disease. Case 2 involved a 61-year-old woman diagnosed as having an intestinal perforation due to longitudinal ulcer of Crohn's disease. They were admitted to the hospital because of severe abdominal pain. And an emergency operation was performed with the diagnosis of diffuse peritonitis on the day of admission in them. In case 1, there were infant head sized dilatation and segmental stenosis in the terminal ileum. Partial resection of the ileum with end to end anastomosis was performed. Resected material revealed multiple ulceration in the mucosa and the diagnosis of Crohn's disease was made histopathologically. In case 2, an intestinal perforation 80cm oral from the Bauhin's valve, mesenteric site, and several ring-shaped stenosis in the anal side ranging about 60cm wre seen intraopertively. The operation was performed same as in case 1, and the diagnosis of Crohn's disease was made histopathologically. They are now in good health and have been free from abdominal pain without ileostomy.

View full abstract

A case of ruptured aneurysm of the middle colic artery is reported. A 44-year-old woman was admitted to the hospital because of severe upper abdominal pain. After a few minutes from arrival, she fell into a shock state.
Ultrasonotomography and computed tomography revealed intraabdominal hemorrhage. Angiography visualized a rupture of an aneurysm. Emergency operation was done and a large amount of blood with clot was present in the abdominal cavity. When the blood with clot was removed, a pulsatile bleeding site near the beginning of the middle colic artery was revealed. Since bleeding from the middle colic artery continued, the aneurysm was resected. The rupture of the aneurysm of the middle colic artery has been reported in only 14 cases in Japan. We find a great deal of difficulty in preopertive diagnosis, but the prognosis of the disease is good if early surgical hemostasis is successfully achieved. So the opportunity of the operation should not be missed.

View full abstract

A 78-year-old man visited another hospital because of epigastric discomfort. There was previous histories of pelvic peritonitis and diverticulitis of the colon. Abdominal ultrasonography revealed cholecystolitiasis. The patient was admitted to the hospital for operation. On admission, the abdomen was soft and flat, and no tumor was palpated on the abdomen. On laboratory examination no inflammatory reaction was noted, and the value of serum CEA (3.3ng/ml) was slightly high. Colonoscopy and Ba enema revealed stenosis in rectosigmoid colon, and a carcinoma of the rectosigmoid colon was susupected, but the definite diagnosis was not made by biopsy. The operative findings showed a granuloma due to a fish bone which stuck in the rectosigmoid diverticulum.
A considerable number of cases of perforation or penetration of the digestive tract due to a fish bone in the literature. This case is believed a rare report that the fish bone penetrated the rectosigmoid diverticulum.

View full abstract

An operated case of para-aortic lymph node recurrence after surgery for a cancer of the transverse colon is reported. A 64-year-old woman underwent an operation for cancer of the transverse colon on September 26, 1995. Six months after the operation, increases in serum CEA and CA19-9 level were found and further exermination revealed para-aortic lymph node swelling from the level of the It. renal vein to the bifurcation of the aorta. Para-aortic lymph node metastasis of the colonic cancer was suspected. There was no evidense of another metastasis in Ga scintigraphy. We judged that the patient was a candidate for operation and performed para-aortic lymphadenectomy. The patient has no sign of recurrence at present, 16 months after the operation. No case of para-aortic lymphadenectomy after operation for the colonic cancer has been reported to this time in Japan. It is suggested that this operation is beneficial for proloning the survival time in case of no evidence of another metastasis.

View full abstract

We report a case of recurrent colonic cancer that remains disease-free for nearly five years after the resection of metachronous metastases to the lung, liver, and peritoneum.
A 55-year-old man who underwent a potentially curative resection for cancer of the transverse colon at another hostpital was seen at the institution for the postoperative follow-up. He was found to have a solitaly pulmonary metastasis on a routine chest X-ray examination. A partial resection of the left lobe was performed. In a further follow-up period, an abdominal computerized tomography revealed a hepatic metastasis, which necessitated another surgery, Upon laparotomy, a solitary disseminated lesion was found at the pouch of Douglas. So a low anterior resection for the peritoneal lesion was performed in addition to a lateral segmentectomy of the liver. Thereafter hepatic arterial infusion chemotherapy was conducted as a prophylactic measure. The aptients remains disease-free for 56 months after the hepatectomy and 72 months following the initial surgery.

View full abstract

We report a case of nodal malignant lymphoma at a colostomy with lymph nodes dissection for a carcinoma of the descending colon which was thought very rare.
An 88-year-old man was admitted to the hospital for close exploration of a left lower abdominal pain. Except a mild hepatic impairment on biochemical examinations, no abnormalities including blood parameters were noted and tumor markers were in normal limits. Barium enema study revealed a whole-circumferential stricture in the descending colon, and a colonoscopic fiber visualized a type 2tumor. Biopsy revealed adenocarcinoma. We thought that the patient developed ileus like symptoms due to the carcinoma of the descending colon which caused the abdominal pain, and performed an operation. Upon laparotomy, no ascites, hepatic and lymph node metastases, nor peritoneal dissemination was present. Resection of the descending colon with regional lymph nodes dissection (D3) was performed. The resected material revealed that the tumor was 4×2cm in size, type 2, and moderately differentiated adenocarcinoma of ss, ly1, v1, ow-, and aw-. No regional lymph node mertastases were noted, but infiltrations of lymphoma cells to lymph nodes of #242 and #232 were confirmed. L-26, KP-1, BerH-2, and UCHL-1 stainings were done, resulting in a positive response to L-26. The diagnosis of B-cell type, diffuse, and large was achieved.

View full abstract

An 80-year-old woman with loss of appetite was admitted to the hospital for evaluation and treatment of a tumor in the colon, which was found by barium enema examination. By colonofiberscopy, three flat elevated noudle-aggregating lesions were detected in the ascending colon, hepatic flexure of the transverse colon and descending colon. Further a type 2 tumor was detected in the hepatic flexure. Under the diagnosis of carcinoma in two lesions confirmed by histological examination, and taking a high incidence of malignant transformation of the adenoma into consideration, a right hemicolectomy and a partial resection of the descending colon were performed on May 15, 1997. In all of the noudle-aggregating lesions, well differentiated adenocarcinomas, limiting within the mucosa were confirmed by histological examination of the resectd spacimen. And these lesions were considered carcinoma in adenoma by the histological formation. The type 2 tumor was also confirmed as moderately differentiated adenocarcinoma, invading the proper muscle layer.

View full abstract

Out of a series of 45 cases undergone a curative low anterior resection for rectal carcinoma at the hospital from April 1990, to December 1994, four cases (8.9%) had local recurrences. In this clinicopathological study the four cases were examined the causes of the recurrences. In three cases implantation at the anastomosed site was the most probable cause and in the remaining case the recurrence might be caused by external surgical surface.
Up to 1994, the rectal stumps were autonomically anastomosed by using purse string instrument (PSI) at the hospital. After 1995, we have been using PSI as well as employing the following procedure in order to prevent implantation metastases of rectal carcinoma due to intraoperative technique: The rectal stump is irrigated with saline solution through a rectal catheter distally and opened to be treated with povidone iodine, then the stapler without the anvil is covered with the introducing cap prior to introduce it through the anus.

View full abstract

We report a case of multiple liver metastases from a colonic cancer which was completely cured by intra-hepatic arterial infusion chemotherapy. Preoperative diagnosis of a 58-year-old man was made as a cancer of the ascending colon with multiple liver metastases. Right hemicolectomy with lymph nodes dissection and insertion of an intrahepatic arterial catheter were carried out on Feburuary 8, 1990. On laparotomy seven metastatic liver tumors were observed in the both lobes. After the operation intrahepatic arterial infusion of chemotherapeutic agents (MMC 2mg, 5FU 500mg) was done five times. The biggest liver tumor which was 10×10cm decreased to 4.0×3.7cm (reduction rate: 85.2%), and the number of tumors decreased to three from seven. Liver resection was performed for all residual liver tumors on September 24, 1992. The histopathological findings revealed coagulation necrosis surrounded with fibrous tissue in the above masses. There was no living cancer cell in all slices of the liver specimens. The patient is identified to be alive for 96 months after the first admission. Intrahepatic arterial infusion chemotherapy for liver metastasis from colorectal cancer can produce an excellent effect by appropriate selection of chemotherapeutic agents, dosing method, and dosage like this case.

View full abstract

A 59-year-old man was admitted to the hospital because of recurrent severe hypoglycemia, who had undergone a total gastrectomy for a cancer of the cardiac part of stomach about one year before. During hypoglycemia the plasma level of immunoreactive insulin was under 2.5μU/ml. Adrenal and liver functions were normal. The serum level of IGF-I was 34ng/ml (normal range, 88_??_240), and IGF-II was 550ng/ml (374_??_804). So the ratio of IGF-II to IGF-I was higher than normal. Western immunoblot assay showed high-molecular-weight IGF-II in the serum. Abdominal CT visualized multiple heterogeneous tumors in both lobes of the liver. Percutaneous needle biopsy disclosed metastasis of adenocarcinoma, and immunohistochemical staining for IGF-II was positive in tumor cells in both the liver and stomach. We conclude that the most likely cause of this patients hypoglycemia was IGF-II produced by the metastatic liver tumor from the gastric cancer.

View full abstract

We experienced a case of hepatocellular carcinoma (HCC) with massive spontaneous necrosis.
A 53-year-old man was admitted to the hospital because he was pointed out an abnormal tumor at anterio-superior segment of the liver. Each examination showed atypical findings for HCC. Operation was performed through transdiaphragmatic approach because he had severe liver cirrhosis. The tumor had a thick capsula and fell into almost complete coagulation necrosis. Viable cancer cells were still alive at the diaphragamatic site of the tumor. It is supposed that the feeding artery of the tumor may be suddenly obstructed by thrombus to cause the massive necrosis, because the morphorogy of the spontaneous necrosis was simillar to that of necrosis after TAE. The massive necrotic HCC may be demonstrated as atypical findings as HCC in preoperative diagnostic images due to its variedtissue composition. It is necessary to consider the HCC with massive spontaneous nectrosis in diagnosis of atypical liver tumors. And it is assessed that transdiaphragmatic approach in hepatic resection that was employed in this case is useful for patients with poor hepatic function.

View full abstract

We report a case of cholecystolithiasis with a rare bile duct anomaly. A 50-year-old man with cholecystolitiasis which was diagnosed at another hospital in June was admitted to the department of medicine in our hospital because of attacks of abdominal colicky pain in September, 1994. Ultrasonogram revealed many stones in the gallbladder, and the patient was referred to the department for operation. Bile duct anomaly was suspected by ERCP. Helical CT following drip infusion cholangiography (DIC) confirmed the biliary distribution using 3-dimensional biliary images (3D-CT). Consequently it was revealed that the cystic duct showed an opening into an accessory bile duct which originated from the common bile duct to the right hepatic duct. Cholecystectomy with resection of the accessory bile duct was performed and a T-tube was placed after choledocholithotomy for a fallen stone in the common bile duct. This bilary anomaly did not belong to any sorts of previously reported classifications, It is important to confirm the biliary distribution to define possible bile duct anomalies to prevent intraoperative injury to the bile duct. Following DIC, helical 3D-CT along with ERCP is very useful for preoperative diagnosis.

View full abstract

A 68-year-old woman was admitted to the department of internal medicine in our hospital because of fever and vomiting. Since increases in biliary enzymes were noted and endoscopic retrograde cholangiopancreatography (ERCP) revealed multiple occupying lesions in the common bile duct, the patient was diagnosed as having multiple tumor in the common bile duct associating with cholangitis. The patient was referred to the department and operated on. Resected specimen revealed multiple cysts in the common bile duct, which were biliary microhamartoma histopathologically. This disease usually arises in the liver and most patients with the disease are asymptomatic. This case which presented cholangitis like symptoms and arised in the common bile duct appears to be rare. In addition, it is believed that the disease is associated with adult type multiple cystic kidney in a high rate, and this patient was also associated with the multiple cystic kidney. It is suggested that the multiple tumors in the common bile duct in this case might be a lesion of general multiple cystic disease.

View full abstract

We report a rare case of spontaneous biloma with a cancer of the common bile duct. A 71-year-old man was admitted to the hospital for further examination of fever up and obstructive jaundise. Abdominal computed tomography and ultrasonography revealed dilatated bile duct and ascites locarized in only left side of the abdomen which was from anterior wall of S3 area of the liver. Cholangiography at surgery showed complete obstruction at the lower common bile duct. Serum level of a tumor marker (CA19-9) was vary high. It was thought that the common bile duct cancer caused complete obstruction of the common bile duct to increase the pressure in the biliary tract which resulted in rupture and perforation of the intrahepatic bile duct causing spontaneous biloma. Drainage where PTCD tube was inserted into the perforated site and a T tube into the common bile duct was conducted.
In Japan, only 24 cases of biloma have been reported until 1996. Biloma with malignancy is very rare among of them.

View full abstract

A 39-year-old man was admitted to the hospital because of a sudden epigastralgia. He had been drinking sake of about 200ml per day for 20 years, and diagnosed as pancreatitis 5 years before. Extensive examinations revealed: stenosis of the duodenum, many pancreatic stones in the Santorini's duct, tubular narrowing of the common bile duct, and the pancreatic pseudocyst connecting with the main pancreatic duct. Judging from those findings, we planned to perform cystduodenostomy under the diagnosis of recrudescence of chronic pancreatitis with pseudocyst. Upon laparotomy, however, the pancreatic body and tail were almost normal and marked hyperplasia of the Brunner's glands was confirmed, which indicated groove pancreatitis. Therefore, a pancreatoduodenectomy was performed. During the operation changes in the shape of the cyst and an active ulcer in the duodenal bulb were also observed.
It is said that groove pancreatitis is caused by obstruction of the pancreatic juice out flow due to occlusion of the Santorini's duct. Thus, we can guess that the disease presents various clinical courses. In this case, hard drinking and the stones in the Santorini's duct might allow to cause the disease.

View full abstract

We have experienced a case of severe acute pancreatitis with a pancreatic cancer which was detecyted at autopsy.
A 67-year-old man developed severe acute pancreatitis after repeated attacks of acute pancreatitis. The clinical course after onset of severe acute pancreatitis was the same as usual severe acute pancreatitis, and despite laparotomic drainage the patient died of multiple organ failure. At autopsy, a pseudocyst of the pancreas 2cm in diameter was confirmed in the body of the pancreas which was associated with a tumor in the cyst that occluded the main pancreatic duct. And a caudal portion of the pancreatic duct from the cyst significantly dilated. Histologically the tumor was moderately differentiated adenocarcinoma. From these findings, it was thought that the occlusion of the pancreatic duct due to the pancreatic cancer caused severe acute pancreatitis.
We rarely encounter clinical cases of pancreatic cancer causing acute pancreatitis, especially those causing severe acute pancreatitis. Pancreatitis following pancreatic cancer generally manifests a form of chronic pancreatitis, but there are some cases presenting severe acute pancreatitis like this case. This possibility should be entertained in the treatment of severe acute pancreatitis.

View full abstract

Splenic cyst is still a rare disease, although clinical cases have been increasingly reported these day with a recent advance of various imaging diagnoses. Seven cases of splenic cysts experienced at our department over the last 13 years were examined for clinicopathological features. There were three men and four women, aged from 10 to 71 with a mean of 36.7. Five out of 7 patients had complained of abdominal pain, back pain, abdominal discomfort, vomiting and recognition of an abdominal mass. Six patient underwent surgery: Five splenectomy and one partial splenectomy (cyst enucleation). Morphologies of the resected cysts were mono in four, poly in one, and multiocular in one patient. Histologicaly there were two cases of epidermoid cyst, two cases of lymphangioma, and two cases of false cyst.
Splenic cyst has been generally treated by splenectomy, but recently partial splenectomy seems to be preferably employed for preserving the splenic function. Splenic cysts that maldistribute and grow extraparencymally appear to be candidates for the spleen preserving operation.

View full abstract

Myelolipomas of the adrenal gland are non-functioning benign tumors and are often detected incidentally because they lack in clinical findings. The tumor has been thought of rare entity. Recently, we have experienced a case of myelolipoma of the adrenal gland that was found out incidentally during close examination for cholelithiasis.
A 55-year-old man visited another hospital because of epigastric pain late in August 1994, and was referred to the hospital for operation with a diagnosis of cholelithiasis on March 1, 1995. The patient was under medical treatment for hypertension, angina pectoris and arrhythmia for these 2 years. After admission, preoperative close examinations including abominal ultrasonography, CT, magnetic resonance imaging (MRI), and ultrasonic endoscopy revealed a 50×45mm tumor upper the right kidney. With a diagnosis of right adrenal tumor and cholelithiasis, an extirpation of the right adrenal tumor and cholecystectomy were performed on March 13. Histopathological examination of the resected material revealed that yellowish portion of the adrenal tumor was composed of cortex and fatty tissue, and in the fatty tissue a small quantity of myeloid tissue including erythroblasts were confirmed. So the definitive diagnosis of myelolipoma of the adrenal gland was achieved.

View full abstract

A 79-year-old woman was admitted to the department of internal medicine in our hospital because of fever and difficulty in oral intake. The patinet had paresis for polio and cerebral infarction and was staying at a nurising home. After admission a symptomatic remission was temporarily attained by medical treatment including antibiotics, but these symptoms recurred, accompanied by vomiting and abdominal pain. With close examination, the patient was diagnosed as having generalized peritonitis with pyometra and referred to the department. At the time of arrival, the patient showed poor respiratory and circulatory conditions and was in shock state. On the same day an emergency laparotomy was carried out and a perforated pyometra was found out. Since a significant decrease in blood pressure was noted at time of anesthesia induction, peritoneal lavage and peritoneal and trans-peritoneal uterine drainage were conducted. Postoperative course was uneventful. After trans-vaginal uterine drainage were conducted. Postoperative course was uneventful. After trans-vaginal uterine drainage the patient was discharged from the hospital and there has no been no sign of recurrence.
Perforation of pyometra is relatively rare, with 54cases reported in Japan so far. It is common in aged people and so it is often detected after the disease progresses. It has been believed that trans-vaginal uterine drainage is recommended for non-perforated cases and total hysterectomy for perforated cases. But in severe cases like this case, the drainage procedure added by trans-vaginal drainage might be also useful.

View full abstract

We experienced a case of broad ligament hernia which is considered to be a rare condition in the literature.
A 52-year-old woman without any previous surgical history was admitted to the institution because of acute onset of lower abdominal pain. A plain abdominal radiogram and abdominal CT demonstrated several air-fluid levels of the small bowel and the uterus deviated upward due to the distended small intestine occupying the small pelvic cavity respectively. Then her illness was diagnosed as small bowel obstruction probably caused by internal hernia related to the uterus, and an emergency operation was performed. On entering the peritoneal cavity, the distal ileum, approximately 15cm in length and 50cm proximal to the ileocecal vavlve, was noted to pass through a defect of the left broad ligament of the uterus into Douglas pouch and to be incarcerated. Following reduction of incarceration, the hernia orifice was closed. Intestinal resection was not carried out.
Broad ligament hernia has been known as a rare disease, that presents difficulty in diagnosis preoperatively. Because of its specific feature on CT, however, it can be a helpful diagnostic modality.

View full abstract

A case of mesenteric panniculitis in a 79-year-old man is reported. The patient was admitted to the hospital because of abdominal pain. Physical examination revealed a hard fist-sized mass with tenderness in his left lower abdomen. Barium enema study demonstrated a narrowing extended from the descending to sigmoid colon with a saw-tooth-like appearance. CT scan and US revealed a remarkable thickening of the wall of the descending and sigmoid colon.
He was treated conservatively under a diagnosis of intestinal obstruction due to ischemic colitis, but no symptomatic remission was attained. So we performed an operation. At laparotomy, the wall extending from the descending to sigmoid colon was remarkably thick and firm. He underwent left colectomy and transverse colostomy. Histologically, degeneration and necrosis of fat cells were seen and mesenteric panniculitis was confirmed. After the operation, ileus symptoms improved and be he is doing well.
Mesenteric panniculitis is a rare disease characterized by unspecific inflammation of the mesenterium. In our country, only 52cases of the disease of the colon have been reported so far. A total of 53cases including this case are presented and discussed here.

View full abstract

A 54-year-old man was seen at the hospital because of lower abdominal dull pain lasting for about one month. On physical examination a tumor about 5cm in diameter was palpated in the right lower abdomen where he complaind of the pain. Barium enema study and colonoscopic fiber revealed remarkable thickening of mucosa. CT visualized a tumor with malignant suspicion in the ileocecal region. The patient was operated on with a strong suspicion of malignant tumor of the ileocecal region. It was found that the appendix firmly adhered to the surrounding organs and the ileocecal region formed a mass. The top of the apendix dissolved due to inflammation and a fish bone about 3cm in length was confirmed in the same portion. The fish bone was easily removed. No tumor was found in the ileocecal region and an appendectomy was performed.
This case of localized peritonitis with a long course is rare. It is thought that the aberrated fish bone to the appendix caused appendicitis with perforation, but the inflammation was localized by the firm adhesions of the surrounding organs including the intestine and retoperitoneum because of dosal dislocation of the appendix, leading to the course of such a long duration.

View full abstract

A case of primary choriocarcinoma of the retroperitoneum is reported. A 32-year-old man was admitted to the hospital because of epigastralgia and vomiting. On physical examination bilateral gynecomastiae were noted and a 12 × 9 cm elastic soft tumor with tenderless smooth surface was palpated in the right hypochondrium. A chest X-ray film revealed multiple round metastases in both lung fields. Abdominal ultrasonography and CT showed a tumor with central necrosis and multiple metastases in the liver. The patient underwent an operation diagnosed as malignant lymphoma of the retroperitoneum but it was unresectable. Finally gastrojejunostomy and needle biopsy were performed, and it was diagnosed as choriocarcinoma. Chemotherapy commenced but he died of hematemesis on 16th day after the surgery. Primary choriocarcinoma of the retroperitoneum is extremely rare. Only 20 cases have been reported in the literature in Japan. Unfortunately any hopeful prognosis can not be expected due to difficulties involved in preoperative diagnosis. We have reviewed the literature and reported that primary choriocarcinoma of the retroperitoneum can be diagnosed by measuring HCG if the patient is a young man, and has a retoroperitoneal tumor, distant metastasis, and a high level of LDH.

View full abstract

This case report describes isolated aneurysm of the left internal iliac artery with neurofibroma.
A 72-year-old man was seen at the hospital because of a left inguinal mass, and was found to have a strangulated hernia and an isolated aneurysm of the left internal iliac artery. The patient was admitted to the hospital for treatment. At operation, the inguinal tumor so strongly adhered to the surrounding tissue that we were obliged to select resection of the ilioinguinal nerve, testicular artery, and vein in order to remove the tumor. Intraoperative frozen section diagnosis of the tumor was neurofibroma, and so the tumor was left intact. Then the left internal iliac artery was freed, its central side was ligated to its peripheral side, and the aneurysm was removed. This case of isolated internal iliac aneurysm coexisted with neurofibroma is relatively rare. The anatomical location of the aneurysm make the early detection difficult, and it is often found after rupture has occurred.
We could resect the aneurysm before rupture. This patient has been in good condition for postoperative 12 months.

View full abstract

We experienced a case of transepiploic hernia. A 47-year-old man was seen at the hospital because of epigastric pain and vomiting. An abdominal X-ray showed an enlarged intestinal gas shadow and the patient was admitted for bowel obstruction. He was observed conservatively with a short tube inserted, but no remission in clinical findings was noted. Due to an air-fluid level appearing on the abdominal X-ray, a long tube was inserted. As a loop formation of the small intestine was detected on an ileus tube enterogram, a laparotomy was carried out with a diagnosis of adhesive ileus. The jejunum was herniated through abnormal omental hiatus to the omental bursa and adhered to the lesser omentum. About 10cm of the jejunum was resected and the hiatus was sutured.
Transomental hernia is a rare disease and only 77 cases have been reported in Japan. The disease presents difficulty in preoperatively diagnosis because it is so uncommon and lacks specific findings in clinical and X-ray examinations. But it may be possible to make preoperative diagnosis in cases presenting omental bursa hernia like this case by confirming the air-fluid level locating in the gastric lesser curvature side on abdominal simple X-ray examination and the presence of the intestine in the omental bursa on abdominal CT.

View full abstract

Pyoderma gangrenosum is an ulcerative dermal disorder of unknown origin that occurs in patients with inflammatory diseases of the intestine in a low frequency. This time we experienced a case of metachronous and ectopic occurrence of pyoderma gangrenosum in a patient under medical observation for Crohn's disease.
A 22-year-old man who was staying at the internal medicine in our hospital for the purpose of controlling aggravated Crohn's disease was found having an ulcerative dermal lesion in the left anterior tibial region. In spite of incision for drainage, administration of antibiotics, and debridement, the lesion became worse so that the patient was transferred to the department. Based on negative results in biological culture of pus and macroscopic findings, the diagnosis of pyoderma gangrenosum was made. External and internal uses of steroids were started. Remarkable remissions in inflammatory findings and dermal lesion were obtained and the patient was discharged from the hospital about 2 months after the treatment. Thereafter, a recurrence to the temporal region occurred, but it was relieved by increasing the dose of steroids.
It is inferred that pyoderma gangrenosum will increase with a recent increase in Crohn's disease. When we encounter intractable dermal ulcerative lesion, a possibility of the disease must be kept usually in mind, and medical treatment including steroids should be preceded to surgery to minimize the surgical stress.

View full abstract

A case of gunshot wound due to a shotgun causing multiple wounds is reported.
A 63-year-old man was accidentally shot by a shotgun at close quarters. A total of 23shots were noted in the head, chest, abdomen, and right thigh. Chest CT scan confirmed that some shots were present in the right lung and right ventricle. Under local anesthesia, one shot on the surface of the abdominal wall was extirpated. And others were removed using fluoroscopy under general anesthesia after his general condition was improved. Shots in the right lower extremety were present in the wall of superficial femoral artery, and the artery was reconstructed after removal of the shots. Shots in the right lung were spontaneously evacuated with sputa. The ramaining five shots in the mandibula, superior mediastinum, and right venticular wall were under clinical observation without removal. In order to remove shots, fuluoroscopy is useful and angiography to grasp the anatomical correlation between the shots and vessels is important to select appropriate therapy. Further, shots in portions where we have difficulty in removing them would often present no paticular problems, and saturmism is hardly induced by remained shots beneath the skin or in the muscule. However, saturnism has been reportedly caused by shots which remained in the body for more than 10 years, and hence, a careful long-term observation would be demanded.

View full abstract

Recently, case reports of double primary cancer have been increasing, but the case of double malignancy of the large intestine and kidney is rare. Of 2353 patients with colorectal cancer from 1980 to 1996, six patients had also malignant tumor of the kidney detected before or after the operation for colorectal cancer. Since all of these cases were diagnosed after 1987, an increasing in the incidence appears to be due to routine use of ultrasonography and CT-scan for the staging of the colorectal cancer. The therapeutic result is satisfactory if these double primary malignant tumors are treated in an early stage. We must be careful not to overlook the presence of hematuria in urinalysis as well as abnormal renal image in ultrasonography and CT-scan in the preoperative examination of the colorectal cancer.

View full abstract

Sweet syndrome is acute eruption of tender, dull red plaques and nodules accompanied by which is common in the face, neck, and extremities. It is characterized histologically by intense focal infiltration of the dermis by polymorphonuclear leukocytes. It has been recently reported that the disease is associated with malignant tumors, and the disease as a skin marker of malignant tumor is acquiring increasing interest. A 58-year-old man was admitted to the hospital because of an early gastric cancer which was detected at a medical checkup. The patient had been noticed of a swelling of the left thumb and erythemas on the back of the neck. A pylorus preserving gastrectomy was conducted for the 2c lesion on the angular notch. No lymph nodes metastasis were noted. After the operation, erythemas on the back neck, face, anterior chest and thumb appeared, become worse, and then revealed Sweet syndrome. Steroid therapy was choiced but the effect remained to be fair, and no complete remission was achieved. Thereafter a thyroid cancer was revealed and a subtotal thyroidectomy was performed 9 months after the operation. Skin eruptions which were once aggravated after the thyroidectomy improved slightly that persist up to now. The patient should be carefully followed by paying attention to possible occurrence of blood dyscrasias. Sweet syndrome associated with malignancy has been hardly studied in a large series, especially association with solid tumor. This case of the disease combined with two solid malignant tumors is the first report in the Japanese literature.

View full abstract

We experienced a rare case of multiple cancer of the stomach, gallbladder, and kidney. An 84-year-old woman with a past history of undergoing a distal gastrectomy for a gastric cancer at the age of 77, was admitted to the hospital because of general fatigue in June, 1994. Abdominal ultrasonography and CT revealed a polypoid lesion in the gallbladder and a tumor in the left kidney. Resection of the gallbladder and left kidney was performed. Histophathologically, the tumor of the gallbladder was well differentiated adenocarcinoma and that of the kidney was clear cell type of renal carcinoma. Definitive diagnosis of synchronous double cancer of the gallbladder and left kidney or heterochronous triple cancer of the stomach, gallbladder and left kidney was made. It is thought that the curative surgery of the first cancer and the advances in imaging techniques may contribute to the occurrence and diagnosis of this synchronous double cancer.

View full abstract