Complications and/or sequelae following breast cancer surgery such as arm edema on the affected side have serious deleterious effects on QOL. Methods of therapy were classified into lumpectomy with or without axillary dissection and breast irradiation, lumpectomy+axillary dissection+breast irradiation, and modified mastectomy. A questionnaire survey was conducted on level of functional disorder of the arm. Results indicated that the present standard breast conservation therapy in which axillary dissection is followed by breast irradiation unfavorably affects QOL with respect to movement, numbness, pain and edema of the affected arm. Efforts should therefore be made after selection of indications to avoid either axillary dissection or breast irradiation.

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The aim of this study was to estimate the results of abdominal aortic aneurysm (AAA) repair with or without coronary artery disease (CAD), retospectively. We studied the incidence of associated CAD among 47 consecutive patients operated upon for AAA, excluding ruptured aneurysms. The screening of CAD was routinely performed by coronary angiography. More than 50% luminal stenosis of the major coronary artery was judged positive for CAD. Twenty-five of the 47 patients (53%) had CAD of 25 patients, 14 patients were subjected to pharmacotherapy, and 11 were indicated coronary revasculization. Nine of those patients underwent successful PTCA prior to surgery. The remaining two patients were considered to be unsuitable for PTCA and underwent coronary bypass grafting before AAA repair. There was no operative mortality or perioperative myocardiac infarction during and after the repair of AAA. This study seggests that AAA repair with CAD could be performed saflely by means of the detailed preoperative evalution and that PTCA or CABG should be approached aggressively in cases with CAD prior to AAA repair.

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We attempt to determine the ultrasonographic diagnostic criterion for choosing between operative and conservative therapy by the fuzzy theory.
1) 37 cases of acute appendicitis treated surgically after an ultrasonographic examination, were evalu-ated in regard to seven findings: margin, swelling, wall thickness, bending, foreign body, and peritoneal effusion, to determine the diagnostic criterion of the operative or conservative therapy. The accuracy rate of this criterion was 83%. and superior to leukocyte cell count and body temperature.
2) 16 patients who received conservative therapy were evaluated by this criterion. The patients who were successful in conservative therapy were diagnosed correctly by the ultrasonography, but 2 patients who received operation changed for operative indication by following ultrasonography.

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The purpose of this study was to determine the clinicopathological features of colorectal submucosal can-cers with lymph node metastasis and to investigate the principles of treatment for colorectal cancers with submucosal invasion. The subjects were 90 patients with primary colorectal submucosal cancer who underwent resection at our department between 1980 and 1997. Seven (7.8%) of 90 patients were histologically confirmed to have lymph node metastasis. According to the grouping of the regional lymph nodes proposed by the Japanese Research Society for Cancer of the Colon and Rectum, positive lymph nodes in the n 1 stations were observed in five patients. Two patients had positive nodes in the n 2 stations. None showed positive nodes in stations further than n 3. They were comprised of seven patients with lymph node metastasis (positive group) and 83 with no lymph node metastasis (negative group).
All of the patients with lymph node metastasis had sm 2 or sm 3 invasion, according to the criteria of submucosal invasion proposed by Kudo et al., and were positive for lymphatic invasion (ly (+) ). Concerning the macroscopic types, six (85.7%) patients in the positive group had the depressed element.
Accordingly, these results suggest that those 3 factors, namely cancer deeper the than sm 2. ly (+) and depressed factor, were likely high risk factors for lymph node metastasis of colorectal cancers with submucosal invasion.
Based on these results, resection of primary tumor with lymph node dissection of further than n 2 appears to be indicated for patients either with cancer invaded SM 2' or more at preoperative examination or with histological cancer invasion to sm 2 or more or ly (+) after polypectomy.

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Liver metastasis has the highest incidence of course of death in patients with early gastric carcinoma. We analyzed 14 patients with early gastric carcinoma and liver metastasis clincopathologically to ascertain the clinicopathologic features of the high risk group for liver metastasis in early gastric carcinoma. A series of 304 patients with early gastric carcinoma without liver metastasis were served as controls. The clinicopathologic features of early gastric carcinomas with liver metastasis are as follows; 1) tumor site in the lower part of the stomach; 2) macroscopic tumors of the mixed type (IIa+IIc); 3) submucosal tumors (sm 2sm 3); 4) histological tumor type of tubular or poorly differentiated adenocarcinoma, and cancer stroma of medullary type; 5) marked intestinal metaplasia of mucosa around tumors; 6) marked vessel invasion; and 7) high incidence of lymph node involvement. Patients with these features are defined as belonging to the high risk group for liver metastasis who would require some operation in proportion to advanced gastric carcinoma, strict observation of clinical course, and adjuvant chemotherapy.

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There is a decreasing tendency of hepatocellular carcinoma (HCC) associated with hepatitis B compared to HCC with hepatitis C. However, it occurs commonly in younger people at a steady rate, and is often detected in an advanced stage resulting in poor therapeutic result. In this study, we especially focused on patients less than 50 to review in our departments.
Fifty-six HCC patients with positive HBs antigen who underwent hepatectomy for HCC during 1980 and 1996 were divided into 2 groups: (Group A under 50 years and Group B over 50 years) and compared for clinicopathological features and operative results.
There were no significant difference between both groups in history of blood transfusion, alcohol intake, clinical stage, ALT level, TNM stage, tumor margin, histological type and grade, type of hepatectomy and curability. But, in addition to a tendency of male dominance, positive vascular invasion and positive intrahepatic metastasis, there were significant increase of AFP level and positive vp 2 vascular invasion in Group A than Group B. Cumurative survival rates after hepatectomy were similar in both groups. However, 10 year survival rates of stages I and II disease was 64% in Group A and 0% in Group B. Four of 5 patients of 10 years or more after hepatectomy entered into this group.
Though younger patients had tumors in more advanced stage than those in older patients, cumulative survival rates were similar and long term survival of former patients with early stage disease was excellent. These findings suggest that early detection of HCC among HBs antigen carriers seems to obtain long term postoperative survivals.

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Twenty-three cases of congenital biliary dilatation in children experienced at the hospital in a recent two decade were didided into two groups by type of the common bile duct, namely, cystic type dilatation (C-type; 12 cases) and fusiform type dilatation (F-type; 11 cases). There were five male and 18 female patients. Averaged age at operation was 2.8, ranging from 2 months to 10 years old. Items investigated included the age of onset of the disease, symptoms at the onset, blood biochemical data (white blood cell count, CRP, and total bilirubin), histopathologic types.
The onset age was younger in C-type patients who manifested the disease less than one year of age. Higher total bilirubin level in serum noted in C-type cases than F-type cases. Elevated amylase level in the common bile duct was noted in F-type cases compared to the others.
In C-type cases there were more pancreatico-choledochus types, and in C-type cases there were more choledoco-pancreas types in a type of pancreatico-biliary maljunction. Pathological sections of the common bile duct revealed severe chronic inflammation such as wall thickness and fibrosis in C-type cases.
It is suggested that the age of onset, the presence of obstructive mechanism at the common bile duct, and type of pancreatico-biliary maljunction might be contributing factors to the type of dilatation.

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Thrombocytopenia is a common clinical manifestation of HIV infection, and when it does not respond to medical therapy such as steroids and anti-HIV drugs, patients are eligible for splenectomy.
A HIV-positive 31-year-old man was admitted to the hospital because of diffuse purpura in the lower imbs. On admission, platelet count was 0.1×10⁴/mm³ and bone marrow examination showed increased numbers of megakaryocytes. Under the diagnosis of thrombocytopenia associated with HIV-Infection, the patient was placed on prednisolone, anti-HIV drugs, and γ-globulin, but did not respond. Laparoscopic splenectomy vas performed, resulting in marked improvement in both clinical symptoms and laboratory data soon after.
Considering the safety and effectiveness of the treatment, laparoscopic approach should be encouraged in candidates of splenectomy for thrombocytopenia with HIV infection.

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Carotid body tumors, which arise in the bifurcation of the common carotid arteries, are rare. Since these tumors generally adhere to the wall of the carotid artery and involve the internal and external arteries, it difficult to resect the tumors without injuring the carotid arterial wall. Therefore the tumors are often resected together with the carotid artery. We report a case of carotid body tumor, which was removed completely with CUSA. A 66-year-old woman was admitted because of a right neck mass. Ultrasonography revealed a tumor sitting in the bifurcation of the common carotid arteries. Carotid angiography showed widening of the branching angle of the carotid artery and the presence of a hypervascular tumor between the internal and external arteries on the carotid bifurcation. Resection of the tumor was performed without simultaneous excision of the carotid artery. The tumor was completely removed with CUSA. It was concluded that CUSA was a useful means to remove the carotid body tumor from the wall of the carotid artery.

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A case of angiosarcoma of the breast which is rare and carries the worst prognosis of any breast malig-nancies is presented. A 42-year-old housekeeper was admitted to the hospital because of a painful and elastic hard tumor with ill-defined margin and 5×5cm in diameter in her left breast. Incisional biopsy was per-formed and the tumor was diagnosed as a lymphangioma, so she was discharged. Two years later, she was admitted again with the same symptom as those in two years ago. The tumor size increased to 6×6cm in diameter and a color of the skin over the tumor is changed to dark purple tone. Aspiration biopsy from the tumor revealed class IV. Consequently a modified radical mastectomy and axillary dissection were performed with a suspicion of malignant breast tumor. Pathological findings revealed that the tumor was angiosarcoma of the breast. After the operation multi-disciplinary treatment including systemic administration of interleukin 2 was carried out, but in vain. She experienced metastasis 13 months after the operation and died from tumor metastasis. An autopsy disclosed metastasis to the liver, adrenal gland and bone.

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A case of invasive ductal carcinoma of the breast and localized in the right nipple is reported. The patient was a 65-year-old woman. Beginning in January 1997, she noticed gelosis surrounding the right nipple, but did nothing about it. During an examination in April of that year, she was persuaded to undergo additional tests, and was referred to this clinic. The right nipple measured 15×15mm, with a height of 10mm, and was slightly larger than the left nipple. Through palpation, a mass was found with indistinct, elastic boundaries directly under the nipple, but no bleeding or sores on the surface. Mammography confirmed the presence and shape of the mass, while ultrasonography showed a low-echo, uneven tumor area measuring 18×17×10mm with an irregular edge. Biopsy results suggested ductal carcinoma, with the possibility of an adenoid tumor; therefore, we elected to resect the nipple area. A pathological study showed the tumor to be an invasive type of ductal carcinoma, but there was no residual tumor at the resection site, and the remaining breast and axillary region were treated with radiotherapy. Discussion: Other diseases localized to the nipple include Paget's disease and adenoma of the nipple, so it is important to distinguish these from breast cancer. In particular, the latter type leads often to resection of the nipple. Most cases of cancer of the nipple are Paget's disease complicated by noninvasive ductal carcinoma, so it is unusual to find a case where the primary tumor in the nipple was an invasive tumor.

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A 47-year-old woman consulted us about a painless breast mass. It was 3.5×4.5cm in diameters, and lo-cated in the upper-outer quadrant of the right breast. It was elastic and hard and well movable. Axillary lymph nodes were not palpable. Mammography showed a dense mass.
Ultrasonography revealed a mass with an unclear contour. Halsted's mastectomy was performed immediately after an intraoperative diagnosis of carcinoma. Histopathological examination revealed a medullary carcinoma with abundant mucin production. Estrogen receptor or progesterone receptor were negative. No metastatic node was found. Carmofur was prescribed postoperatively. The patient is alive without recurrence at 4 years and 8 months after mastectomy. We report a case of medullary carcinoma with abundunt mucin production and its outcome.

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A 33-year-old man was admitted to the hospital because of sudden epigastralgia. There was no muscle guarding on admission. Left pleural effusion appeared a day after admission. A computed tomography (CT) of the thorax revealed a perforation of the digestive tract and an abscess of the mediastinum. An emergency thoracotomy was carried out. The diagnosis of perforation of the gastric ulcer in a hiatus hernia into the medi-astinum was made during the operation. The primary suture was performed. On the 34th day after the opera-tion the patient was discharged.
It must be noted that the gastric ulcer in a hiatus hernia may perforate into the mediastinum, especially if pleural effusion is confirmed on simple x-ray films of the chest. In that case, early diagnosis with imagings including chest CT and emergency operation to save the patient's life are thought important.

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We have recently experienced a neurogenic tumor of the paravertebra in a 35-year-old man. The patient suffered from dull pain in the right side of the abdomen during previous three years. An abnormal mass shadow of the right lung had been detected on chest X-ray examinations at a medical checkup. CT findings indicated a tumor invasion between the thoracic vertebra 10^th and 11^th. Operation was performed with a Tshaped skin incision of the back and a resection of the posterior part of the 10^th and 11^th rib. The tumor was resected safely after partial resection of the ramina of 10^th thoracic vertebra. The tumor was neurinoma of the 10^th intercostal nerves. Paravertebral tumors sometimes grow in the intervertebral and take the form of the Dumbbell. An operation should be performed early in the course of treatment, because the growing tumor may appress the spinal cord to cause clinical symptoms.

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Patient 1, a 72-year-old woman was seen at the hospital because of an abnormal shadow on chest radio-graphs. CT revealed an irregularly shaped nodular shadow measuring 2cm in diameter in the right S 8 segment, and therefore, a partial lung resection was performed under thoracotomy. Histopathologic examination demonstrated a number of globular organisms positive to the PAS stain in a foreign body granuloma. Patient 2, a 38-year-old woman was seen at the hospital because chest radiographs revealed an abnormal shadow at a medical check up. CT showed a well-circumscribed nodular shadow measuring 1cm in diameter with a daughter nodule in the right S 6 segment. After a thoracoscopic partial lung resection, many globular organisms positive to the PAS and Grocott stain were noted in the tumor, which demonstrated coagulation necrosis. None of these patients had any underlying diseases except the pulmonary lesion, leading to a diagnosis of primary pulmonary cryptococcosis. Recurrences have not been encountered for postoperative 4 years in patient 1 and for 1 year and 6 months in patient 2.
This disease is a comparatively rare entity. It lacks distinctive clinical features or imaging findings, and presents difficulties in preoperative diagnosis in many cases. The lesion is liable to develop right under the pleura, and often imparts a solitary nodular shadow. It is considered to be a good indication for thoracoscopic surgery which is a less invasive approach.

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We report a case of esophageal hernia with severe dyspnea on effort.
An 80-year-old woman with kyphosis was seen at the hospital because of severe worsening dyspnea on effort with elongation of expiration. Preoperative lung function test showed mixed respiratory dysfunction with per-cent forced expiratory volume in one second (FEV 1.0%) 59.8%, and percent forced vital capacity (%VC) 49% but esophageal endoscopy showed no evidence of reflux esophagitis. Operative findings revealed enlarged hiatus and huge hernia sac as large as 7×10×6cm. Shrinked esophagus was dissected and pulled back into the abdominal cavity. The hiatus was directly closed with sutures and the stomach was fixed to the ligament.
Postoperative course was very smooth, and the dyspnea disappeared. We consider that the cardiopulmonary dysfunction due to the huge esophageeal hernia is a good indication for surgical repair.

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We experienced a case of advanced esophageal cancer complicated with hemophilia A. A 72-year-old man had been diagnosed as having hemophilia A at 40 years of age. At 44 years of age, when he underwent an appendectomy with a diagnosis of acute appendicitis, factor VIII concentrates were administered according to factor VIII activity levels measured daily. He was admitted to the hospital because of hematemesis and tarry stool, and an emergency endoscopic examination revealed an esophageal tumor with bleeding. A diagnosis of advanced esophageal cancer was made, and a subtotal esophagectomy with three-field lymph node dissection was carried out. Perioperative management was performed on the basis of the results obtained at appendectomy. For the purpose of maintaining factor VIII levels at over 60%, 2, 000 units per a day of factor VIII concentrate were administered from 1st preoperative day to 7th postoperative day, and no hemorrhagic compli-cations were observed. Appropriate replacement therapy by factor concentrates enables us to perform surgery with usual lymphadenectomy for the patient with cancer associated with hemophilia A.

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We present a case of giant leiomyoma with ulceration in the esophagogastric junction which is very rare together with some discussion in relation to the literature, An asymptomatic 31-year-old man been pointed out having ulcer in the esophagogastric junction in November, 1991. The patient was admitted to our department for the purpose of therapy because CT revealed a tumor developed into thracoabdominal space in February, 1997. Upper gastrointestinal series revealed a barium defect with regular margin from the lower esophagus to the upper gastric body and deep ulceration in the esophagogastric junction. An endoscopy revealed a submucosal tumor with the esophagogastric lesion. CT and magnetic resonance imaging demonstrated a well-demarcated homogeneous mass in the thracoabdominal space. Because this tumor was huge and presented with a deep ulcer, possible malignant submucosal tumor could not be completely ruled out. So a lower esophagectomy and a proximal gastrectomy were performed under the left thracoabdominal appoach. Reconstruction was performed by interposition of a jejunal pouch. The resected tumor was 12×8.5×6cm in size, and benign leiomyoma histopathologically. He has been well for 21 months with neither recurrence of tumor nor symptoms after the surgery.

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The metastasis of breast cancer to the gastrointestinal tract is very rare. This paper describes a case of gastrectomy for a gastric metastasis from breast cancer diagnosed by gastric tissue at biopsy and past history. A 52-year-old woman developed epigastralgia and vomiting 3 years and 4 months after a modified radical mastectomy for a left breast cancer (t 3 n 1 m 0 stage III) . Radiological and endoscopic examination of the stomach showed a linitis plastica lesion. A specimen obtained from the lesion revealed metastasis from the breast cancer. Total gastrectomy was done to improve QOL. Diagnosis of the gastric metastasis from the breast cancer is difficult because the histological lesion is likely to be the primary gastric cancer. When a patient with a previous history of breast cancer has gastrointestinal symptoms, we should consider the possibility of gastrointestinal metastasis from breast cance and rule out primary gastric cancer.

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A patient with small cell carcinoma of the stomach who survived for 2 years and 7 months after resection of hepatic metastasis is reported. A 58-year-old man complaining of abdominal pain and diarrhea was referred to the hospital because a gastric radiography revealed a niche at the greater curvature of the middle body of the stomach at another hospital. After admission to the hospital, endoscopic examination of the stomach revealed a Borrmann type 2 tumor, and biopsy demonstrated poorly differentiated adenocarcinoma. A distal gastrectomy with D2 dissection was performed (T3, N1, H0, P0). An ulcerative tumor, 2×2cm in size, was composed of small atypical cells with chromatin-riched nucleus. Immunohistochemically, these small cells were stained positive for NSE and chromogranin A. Therefore, this tumor was diagnosed as small cell carcinoma of the stomach. Six months later, liver metastasis was found by CT scan examination, and a partial he-patectomy was performed. The CDDP and 5 FU therapy was regularly conducted. This patient died of multiple lung metastases and bone metastases 2 years and 7 months after the recection of the liver metastasis.

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A 55-year-old man was seen at the hospital because of sever epigastric pain. There was a previous history of undergoint a subtotal gastrectomy for duodenal ulcer 20 years before admission and he had been having anastomotic ulcer for these 6 years. On admission, an abdominal X-ray examination revealed free air at the subphrenic area. From the clinical course and findings, we diagnosed the lesion as perforative peritonitis caused by anastomotic ulcer. Upon laparotomy, perforated anastomotic ulcer as well as a Borrmann type 2 tu-mor in the remnant stomach was seen and a total gastrectomy and lymph node dissection were performed. The tumor was histologically diagnosed as endocrine cell carcinoma (ECC) . The tumor cells were positive for the Grimelius stain, and showed immuno expressions for NSE. Chromogranin-A stain and serotonin stain. He has been doing well without any recurrence as of 2 years after the operation. ECC is a relatively rare disease. The prognosis of this disease is very poor because of its rapid growth, metastasis and invasion in an early stage. Forty-two ECCs of the stomach including four cases arising in the remnant stomach have been reported in the Japanese literature.

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Aortoduodenal fistula is a rare and life-threatening cause of gastrointestinal hemorrhage. The patient was a 44-year-old woman who repeated intermittent hematemesis and melena after hysterectomy, para-aortic lymph node dissection, and subsequent radiotherapy. Angiography revealed no bleeding point. Upper gastrointestinal endoscopy showed an ulcer at the third portion of the duodenum. Emergency laparotomy revealed an aortoduodenal fistula which was inferred to be caused by radiotherapy because no recurrence of malignancy was detected. After the fistula was closed, the patient repeated hematemesis and anal bleeding. She died of acute hemorrhagic shock, in spite of three operations including axillo-femoral bypass. We propose that radiation might have played a role in the pathogenesis of the aortoduodenal fistula in our case. The new case of primary aortoduodenal fistula following radiotherapy is added to four cases previously reported in the literature. Six cases in which the lesion of the duodenum could be demonstrated by endoscopy, have been reported in Japan. Aortoduodenal fistula should be considered as a probable diagnosis in patients presenting massive gastrointestinal hemorrhage after radiotherapy. Rapid surgical treatments are needed, and operative procedures to be considered include resection of the aorta with aortic stump closure and axillo-femoral bypass.

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A very rare case of malignant lymphoma of the duodenum which presented with metastasis to the abdominal wall and progressed rapidly is reported. A 51-year-old man was seen at the hospital because he noticed of a tumor in the upper portion of the navel. Abdominal ultrasonography revealed a 3.0×3.0×2.0cm subcutaneous tumor. The tumor was enucleated under local anesthesia. Histopathologically it was malignant lymphoma of diffuse, B cell lymphoma, medium-sized type. The patient was followed on ambulant basis for treatment of the surgical wound, when he became to complain of epigastric discomfort. Close examination of the gastrointestinal tract revealed that the pylorus swelled like edema manifesting pyloric stenosis. Biopsy showed a malignant lymphoma of diffuse, B cell lymphoma, medium sized type arisen from the duodenum. The tumor of the abdominal wall was diagnosed as metastasis of malignant lymphoma of the duodenum based on clinical and imaging findings. Furthermore, abdominal CT and chest CT scan revealed hepatic and pulmonary metastases, and so one course of VEPA regimen was performed. The patient, however, developed MOF and died.

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A 61-year-old woman was admitted to the hospital because of abdominal pain. The pain had occurred after a meal of marine animals. There were tenderness and peritoneal sign over a wide area of the lower abdomen. A chest X-ray film revealed a significant sign of gastrointestinal perforation, and an abdominal X-ray film revealed shadow of a fish bone. An abdominal CT scan revealed panperitonitis due to perforation of the small intestine by a linear calcified foreign body. Emergency laparotomy was performed and the perforation in the ileum located 200cm oral from the terminal ileum was comfirmed. The foreign body was recognized in this perforated ileum and removed. It was a fish bone 44mm in length.
We can see a considerable number of cases of perforation or penetration of the digestive tract due to a fish bone in the Japanese literature. This case reported here demonstrates that detail collection of patient's history and abdominal CT scan are effective for the preoperative diagnosis.

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Leiomyoblastoma of the small intestine is a rare disease. We report a case of peritoneally disseminated recurrence occurred 2 years after an operation for a leiomyoblastoma of the jejunum.
A 70-year-old woman was admitted to the hospital because of other disease. Two years prior to this admission, she had undergone a partial jejunectomy due to leiomyoblastoma, when no lymph node metastasis nor invasion to other organs was revealed. Histologically, mitotic figures of the tumor were seen two or three per ten high-power fields. That was diagnosed as low grade malignancy. In this admission, she was detected the abdominal tumor on paltation. Bulky tumors were showed in the abdominal cavity on an abdominal CT scan. An exploratory laparotomy was performed. We judged that radical resection was impossible and removed those tumors as much as possible. These tumors were diagnosed histologically as peritoneally disseminated recurrence of the intestinal leomyoblastoma.
This paper also presents a review of 31 cases in the duodenum and 47 cases in the jejunum and ileum including this case which have been reported in Japan.

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A 78-year-old woman was admitted to the hospital because of abdominal pain and symptoms of small bowel obstruction. Since an enterography revealed a tumor shadow at the ileum, we performed an operation with diagnosis of tumor of the small intestine.
At laparotomy, Intussusception caused by the tumor at the ileum was observed. After manual restoration, a partial resection of the ileum and lymph nodes dissection were performed in consideration of possibility of malignancy.
Histological examination revealed well differentiaed adenocarcinoma of intramucosal infiltration and no involvement of regional lymph nodes.
In a review of the literature, 52 cases of adult intussusception due to some malignant tumor of the small intestine have been reported from 1981 to 1998 in Japan.
Preoperative accurate diagnosis of intussusception was made in 81% of these cases, and ultrasonography and CT scan were especially useful for the diagnosis of this condition.

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From 1978 to 1997 we have experienced four cases of primary carcinoma of the appendix, which ac-counted for 0.7% of all resected colorectal carcinomas in our hospital. Of the four cases, three cases were male and one case was female with the average age of 56.7 years ranged from 38 to 68. The chief complaints of them included lower abdominal pain in two cases, or palpable abdominal mass in one case and asymptomatic in one case. They were diagnosed preoperatively as acute appendicitis, sigmoid-colon carcinoma, ovarian tumor, and rectal carcinoma respectively. In the asymptomatic case the appendiceal carcinoma was detected during an operation for the rectal carcinoma. The preoperative diagnosis of the primary carcinoma of the appendix was very difficult as these cases had demonstrated. Operative findings showed pseudomyxoma peri-tonei in one case and severe involvement to other organs in two cases. Histological diagnosis was mucinous cystadenocarcinoma in all cases. Two patients died of carcinoma.
Our experience suggests that primary carcinoma of the appendix should be considered as a probable differential diagnosis for the patient having lower abdominal pain or an abdominal tumor.

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Inflammatory fibroid polyp (IFP) is an inflammatory tumor of unknown origin arising in the gastrointes-tinal tract. It commonly appears in the stomach and small intestine, and rarely in the large intestine. Only 19 cases of IFP arisen in the large intestine have been reported in the Japanese literature.
We report a case of IFP of the transverse colon with some bibliographical comment. A 69-year-old woman was admitted to the hospital because of positive response to the tests for fecal occult blood. Barium enema study and colonoscopic examination revealed a polyp in the transverse colon with the size of 3×3.5×7.0cm. A partial excision of the transverse colon was performed. Histological examination showed an enormous proliferation in the connective tissues and infiltration of eosinophilic leukocytes in the submucosa. There were thick-walled vessels surrounded by the proliferative fibromuscular fibers, resulting in an onion skin appearance. Pathologically, the lesion was diagnosed as IFP.

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A 44-year-old man was seen at the hospital because of diarrhea and weight loss. Colonoscopic fiber revealed cancer of the transverse colon. Barium enema study showed a leakage of contrast medium from the transverse colon to the duodenum and jejunum. Upper gastrointestinal series revealed no fistula and an extraluminal displacement of the greater curvature of the stomach was seen. A transverse colon cancer with fistulation to the duodenum and jejunum was diagnosed, and a left hemicolectomy, resection of the jejunum including the fistula, a partial gastrectomy, and associated resection of the body and tail of the pancreas and spleen were performed. Histopathologically, it was moderately differentiated adenocarcinoma in Stage III [si, n (-), H₀. P₀, M (-)]. There have been no signs of recurrence as of 12 months after the operation.
Jejunocolic fistulation due to colon cancer is a rare condition, and only 11 cases including this case have been reported in Japan so far. This disease invades the adjacent organs, but it scarcely causes liver metastasis, peritoneal dissemination, and lymph nodes metastasis. Curative resection can be expected by extended excision including the digestive organs where internal fistula is formed.

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A 69-year-old woman underwent hysterectomy with partial resection of left ureter for uterus cancer and ureterosigmoidostomy in 1960. She suffered remittent pyelonephritis in 1991, and her left kidney was removed for hydronephrosis the following year. She was admitted to our hospital for treatment of colon cancer in 1997. Colonoscopy and barium enema study showed a round tumor in the sigmoid colon, which was 4cm in diameter and almost occluded the lumen. Sigmoidectomy was performed. The tumor occupied the anal side of the ureterosigmoidostomy, which was well-differentiated adenocarcinoma limited to proper mucosa histologically. In conclusion, patients with ureterosigmoidostomy are a high-risk group for colon cancer, and need careful long-term follow-up with colonoscopy.

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A 15-year-old woman was seen at the hospital because of lower abdominal pain and slight melena. Although no abnormalities were detected by abdominal CT and ultrasoundgraphy, an Is type lesion 8mm in diameter located 5cm distant from the dentate line was incidentally detected. The lesion was resected by endoscopic procedure with clip gripped method after we got their informed consent. The pathological diagnosis was rectal carcinoid, and the surgical stump was negative. She has had no local recurrence or distant metastasis as of 9 months after the endoscopoic resection.
Rectal carcinoid lacks in manifestations and the endoscopy has been usually used in many institutions recently. Under these background factors, there is a tendency for rectal carcinoid to be detected incidentally by endoscopy in every age group. If tumor diameter is less than 10mm, lymph node metastasis rate has been reported to be 4.3%. So endoscopic complete resection of the tumor would be very useful for diagnosis and curability. And it is conceivable that the clip gripped method is very useful for resection of the smooth surface type IIa lesions or Is like lesions.

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Primary malignant melanoma of the anorectal region is a relatively rare entity and the prognosis is very poor. We experienced a case of malignant melanoma of the region. A 65-year-old man was seen at the hospital because of anal pain lasting for about one month and admitted with a diagnosis of the malignant melanoma. Preoperative imagings revealed no other lesions such as lymph nodes metastasis and no inguinal lymph node was palpated. So an abdomino-perineal resection with D 2 dissection was performed, followed by DAV (dacar-bazine, nimustatine, vincristine) therapy as adjuvant chemotherapy. The resected specimen revealed two black tumors with the sizes of 3.5×3.0cm and 1.7×1.1cm at the anorectal junction. At present, three months after the operation, no findings suggesting the recurrence have been observed and noticed. It is suggested that early discovery and establishment of the standard surgical therapy would promise good prognosis to this disease.

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We experienced a case of hepatocellular carcinoma with tumor recurrence in the right adrenal gland, who survived for a long period after a right adrenectomy. A 59-year-old man diagnosed as having a hepatocellular carcinoma with chronic hepatitis C underwent a partial hepatectomy (S7+S8) in 1988. PIVKA-II was markedly increased and tumor recurrence in the right adrenal gland was diagnosed. The right adrenectomy was performed in 1990 and no tumor reccurence was detected for about 7 years. Multiple intrahepatic recurrence was detected in November 1997 and died 6 months thereafter.
In autopsy cases of hepatocellular carcinoma, adrenal metastasis is frequent and its incidence has been reported to reach 13.1% However, reported clinical cases are quite rare. Fourteen cases including the present case have been reported so far. Surgical resection seems to be the best treatment for the patient with unilateral adrenal metastasis, unless other distant metastases or uncontrollable intrahepatic recurrences are detected.

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We report a case of multiple metastases of ampullary carcinoma, which completely responded to intrahepatic infusion of continuous 5-FU and low dose CDDP for about 4 months. A 61-year-old woman underwent a pylorus-preserving pancreatoduodenectomy for an ampullary carcinoma. One year after the operation, a single hepatic metastasis was found and enucleated. Thereafter a subcutaneous reserver for hepatic arterial infusion was placed and 2mg of MMC had injected three times. Eight months after the second operation, multiple liver metastases and swelling of lymph nodes were pointed out, with an increase in CEA and CA 19-9. Hepatic arterial infusion with 5-FU and CDDP at doses of 250mg/5h and 5mg/bolus respectively was per-formed 18 times every 3 days. Two months later, the multiple liver metastases completely disappeared with great decreases in tumor markers. Since the lymph nodes had increased in size, systemic chemotherapy was added. CR for liver metastases was obtained by this regimen and lasted for about 4 months, but recurrence of multiple hepatic metastases and poor patient's condition obliged us to finish the chemotherapy. The patient died 25 months after the initial operation.

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A 56-year-old man was performed a total gastrectomy with regional lymph node dissection for type 4 gastric cancer. On 60th postoperative day, massive hematemesis developed and a splenic artery pseudoaneurysm was found by angiography. We thought that the adventitia of arterial wall was damaged by an agressive dissection of lymph nodes, and postoperative infection around the drainage tube accelerated the formation of pseudoaneurysm. It seemed that the pseudoaneurysm penetrated the jejunal wall and hematemesis ap-peared.
An emergency angiography was performed when the 2nd hematemesis appeared, and the bleeding was successfully stopped by transcatheter arterial embolization. On periodic observation by CT, almost no aneurysm has been revealed.
When a sudden hematemesis appears during postoperative observation of cancer of the upper digestive tract, we consider the possible presence of pseudoaneurysm.

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Epidermoid cysts of the spleen are relatively rare, and most of them are found incidentally as an asymp-tomatic mass in the left upper quadrant. In this paper, an extremely rare case of epidermoid cyst of the spleen presented with a solitary splenic abscess is reported. A 26-year-old woman without previous medical history was admitted to the hospital because of high fever and left hypochondric pain. A infant'head-sized, elastic soft tumor was palpated in the upper quadrant. White blood cell count was 10, 700/mm and CRP was 15.0mg/dl. Computed tomography and ultranonography demonstrated a huge cystic mass in the left subphrenic space. The serum CA 19-9 levels were as high an 97U/ml and 122U/ml, respectively. Echo-guided needle aspiration of the cyst yielded a fluid that was positive for Staphylococcus aureus and the levels of CEA, CA 19-9, 194 CA 125 were extremely high, 76ng/ml, 20, 705U/ml, and 29, 400U/ml, respectively. Partial splenectomy was per-formed. Histologically, the inside of the cyst wall was mostly comprised of infiltrating cells and was partly cov-ered with a single layer of squamous cells. It was diagnosed as an epidermoid cyst of the spleen accompanied with splenic abscess. The postoperative course was uneventful.

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Renal cell carcinoma (RCC) easily metastasizes on blood. So, metastases from RCC to the lung, liver and bone are common, but the pancreas in a rare site. We report a resected case of multiple pancreatic and hepatic metastases of RCC occurred 8 years after operation in a 61-year-old man. The patient had undergone a right nephrectomy for a primary RCC 8 years before, and a sigmoidectomy for a metastatic tumor of the sigmoid colon 5 years before admission. And this time, abdominal CT and magnetic resonance imaging (MRI) demonstrated multiple tumors at the pancreatic head and tail and a solitary tumor at the posterior segment of the liver. A Pylorus-preserving pancreatoduodenectomy, a distal pancreatectomy, a partial resection of the pancretic body and a partial resection of the posterior segment of the liver were performed under the diagnosis of the multiple pancreatic and hepatic metastases of RCC. Histopathological findings of the resected material showed metastases of RCC to the pancreas and liver. There have been 57 resected cases of pancreatic metastasis of RCC in the Japanese literature. In about 78% of them, pancreatic metastasis occurred metachronously and after elasping for a relatively long time. Long-term follow up is necessary for the patient after nephrectomy for RCC.

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We conducted laparoscopic adhesiolysis in 20 cases: 6 gastrectomies, 3 large intestine resectios. 2 small intestine resections, 3 appendectomies, 3 gynecological surgeries, and 1 each cholecystectomy, laparoscopic herniorrhaphy, and ventriculoperitoneal shunt.
Laparoscopic adhesiolysis was successful in 19 cases. One mini-laparotomy was required in a case that had developed stenosis from firm adhesions of the small intestine, and which were resected after the minilapa-rotory. With laparoscopic surgery, it may be difficult to abrade intestinal adhesions. However, mini-laparotomy was used to deal with this situation. No complications resulting from the procedures were ob-served in any of the 20 cases. Laparoscopic adhesiolysis requires shorter postoperative hospitalization and produces fewer chances of postperative ileus.
Laparoscopic adhesiolysis for adhesive ileus and intestinal adhesion features less invasive surgery and in an effective treatment.

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This paper presents a case of large defect extending to the full-thickness of the abdominal wall infection which was reconstructed by pedicled rectus myocutaneous flap, with a good result. A 63-year-old obese man, who underwent a colectomy for cancer of the descending colon, had stomal leakage and infectious wound of the abdominal wall. Then, the full-thickness abdominal wall had opened due to MRSA infection of the wound (12×8cm). We were very worried about the treatment, because case reports or literature describing any strategies and treatments for such large abdominal wall defect with infection were very few. We found a great deal of difficulty in primarily closing the abdominal wound due to severe obesity and several adhesions in the peritoneal cavity. Then closure of the wound by means of artificial materials was thought to make infectious status worse. The defect of the abdominal wall was successfully reconstructed with the myocutaneous flap using the abdominal rectus muscle. Reconstruction with the myocutaneous flap appears to be an effective method for closing the full-thickness abdominal wall defect.

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A case of granular cell tumor (GCT) in the rectus abdominis muscle is reported. A 39-year-old woman was admitted to our hospital because of abdominal pain and left lower abdominal swelling. By clinical examination, the tumor was observed to be elastic and hard and 3×2cm in the left lower abdomen. CT scan re-vealed bilateral ovarian cysts and a low density area in the left rectus abdominis muscle about 2cm in diameter. We performed an operation under a diagnosis of ovarian cysts and rhabdmyoma. Wedge resection of the ovaries was done and the rectus abdominis muscle tumor was resected with a sufficient margin. The tumor was elastic hard and 2.8×2.0×1.5cm in diameter. Histologically, tumor cells were PAS-positive granular eosinophilic cyotoplasm and resistant to diastase digestion. They were also immunoreactive to S-100 protein. Thus, a histological diagnosis of GCT in rectus abdominis muscle was established. GCT is a relatively rare tumor observed in soft tissue, and its origin is still unclear. A total of 23 cases of GCT in skeletal muscle, including our case, have been reported in Japan. Preoperative diagnosis and outcome from histological findings is difficult in these cases, and is necessary long-term follow-up.

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Iatrogenic superior mesenteric arteriovenous fistulas (AVF) after gastrointestinal surgery are rare, especially in Japan, with only 28 cases being documented. We report a case of iatrogenic superior mesenteric AVF, which developed rapidly and detected at 26th day after a resection of small intestine for strangulated ileus. A 39-year-old man was emergently transfered to the hospital for strangulated ileus and underwent on excision of the necrosed small intestine. After the operation, abdominal pain and diarrhea persisted and a pul-sative tumor and continuous murmur in the middle abdominal part were confirmed on 26th postoperative day. Abdominal CT and angiography revealed a superior mesenteric AVF and a pseudoaneurysm. Successful resection of those were performed. The cause of AVF was considered to be related to the mass ligation of the mesenteric vessels in the primary operation. Postoperative course was uneventful.

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A case of mesenteric fibromatosis rapidly grown in a short duration is reported. A 70-year-old man was found to have a tumorous lesion about 11cm in maximal diameter in front of the left kidney by abdominal CT scan 77 months after a right hepatic lobectomy for hepatocellular carcinoma. We suspected that the tumor was originated from the mesentery of the small intestine with close examination. Upon laparotomy, the tumor was present in the mesentery of the ileum. A resection of the tumor including the ileum, about 60cm in length, was performed. On histopathological and immunohistochemical examinations, the tumor was diag-nosed as mesenteric fibromatosis (MF). No evidence of recurrence of the tumor has been found as of 24 months after the 2nd operation.
This case is a rare of in terms of the delayed occurrence of the tumor after a lapalotomy and rapid growth of the tumor for only 4 months.
Complete resection of the tumor is considered to be the treatment of choice for MF. If a complete resection is not performed, multidisciplinaly treatment including chemotherapy, irradiation therapy, and endocrine therapy should be added. Long-term follow-up would be mandatory because of its high rate of recurrence.

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A 58-year-old man was admitted to the hospital because a huge abdominal tumor was found on ultrasonography (US) at a medical checkup. On physical examination, a movable, elastic soft mass with smooth surface was palpable on the left upper abdomen. The results of biochemical examination and the tumor markers, including CEA and CA 19-9, were nomal. Computed tomography (CT) and magnetic resonance imaging (MRI) disclosed a large cystic mass, measuring 9.0×13.0cm in size, which was located in posterior-lower portion of the stomach. Preoperative diagnosis was submucosal tumor of the stomach or a tumor arising from the greater omentum invading the gastric wall. A tatal extirpation of the tumor in combination with a partial resection of the involved gastric wall was performed. The extirpated tumor was 12.0×11.0×10.0cm in size, was entirely encapsulated, and composed of cystic and solid portions concomitantly.
Histologically, it was leiomyoma originating in the omentum.
Most of the tumors arising from the omentum have been proved malignant, such as leiomyosarcoma or leiomyoblastoma. Leiomyoma of the omentum is extremely rare, there have been only four cases including ours in the Japanese literature. Although, due to the absence of characteristic symptoms, it is difficult to make the preoperative diagnosis, US, CT and MRI are useful for the diagnosis.

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Two cases of retroperitoneal leiomyosarcoma are reported. Patient 1, a 68-year-old man, was admitted to the hospital because of a left upper abdominal mass.
Abdominal echo and CT scan showed giant masshaving necrotic change. The tumor 16×15×19cm in size and developing in the retroperitoneum was removed with the body and tail of pancreas, and spleen tran-speritoneally.
Patient 2, a 65-year-old man, was admitted to the hospital because of tarry stool and fatigability.
Abdominal echo and CT scan showed a well demarcated large abdominal mass accompanying with colonic gas. Intraoperative findings showed that the tumor invaded the second portion of duodenum and pancreas head. The tumor 13×7×6cm in size, was removed by partial resection of the duodenum and pancreas tran-speritoneally.
The pathological diagnoses of case 1 and 2 were retroperitoneal leiomyosarcoma.
Postoperative courses of both patients were uneventful.
Histological grading is the Determinant prognostic factor for retroperitoneal sarcomas.
We would emphasize the importance of early detection and if necessary, radical resection as much as possible which is the most effective and available treatment.

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Inflammatory aneurysms are common in the abdominal aorta, but uncommon in the thoracic aorta and iliac artery. Recently we experienced a rare case of inflammatory aneurysms of the bilateral iliac arteries which was diagnosed by a histopathological study. A 70-year-old man was admitted to the hospital with a 10-year history of a pulsatile mass at the right lower abdomen. Contrast enhanced CT scan of the abdomen demonstrated aneurysms of the bilateral common iliac arteries associated with a periaortic thin layer enhanced by contrast dye, and hydronephrosis of the right kidney. The aneurysms and right ureter were extremely difficult to dissect not capable of being dissected due to retroperitoneal fibrosis, even though the gross appearance of the aneurysms was not identical with that of the classical inflammatory aneurysm. Then graft replacement of the abdominal aorta to bilateral common iliac arteries was performed by using a Gelseal knitted Dacron Y graft.
Pathohistological study of the aortic wall revealed heavy infiltration of lymphocytes and plasma cells in the thickened adventitial and medial layers, being compatible with an inflammatory aneurysm. This case appears to be in an extremely early stage in the spectrum of clinical pregress.

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This paper presents a case of congenital factor XI deficiency which was clarified by prominent prolongation of APTT in preoperative examination for acute appendicitis, as well as a study of the patient's family.
A 48-year-old man after diagnosed as having appendicitis was referred to the hospital by a small island clinic. Preoperative evaluation showed marked prolongation of APTT (127.0 second with a standard of 29.6 sec.). When using a 1:1 mixture of the patient and normal plasma, the prolongation of APTT was normalized. An appendectomy was successfully performed. Any transfusion of fresh frozen plasma was not required. The patient revealed no bleeding tendency during hospitalization, but postoperative evaluation indicated that his factor XI was less than 3%.
Several months later, his son, who also underwent an appendectomy for appendicitis, was found to have a prolonged APTT of 38.3 sec. (31.0 sec.), and a factor XI of 36%. His daughter, who had undergone a cervical spine surgery for Morquio's disease, had a prolonged APTT of 35.8 sec. (30.4 sec.) and a factor XI of 35%. His wife had normal coagulation tests.
These facts suggest that the patient has homozygous and his children heterozygous factor XI deficiency.

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A 66-year-old man visited our hospital because of vertigo and vomitting. Endoscopically, an elevated lesion with delle was revealed at the antrum of the stomach. Abdominal CT and MRI revealed a right renal hypoplasia and left renal tumor, subsequently, distal gastrectomy and partial resection for the left renal tumor was performed. The final histological diagnosis was small-cell carcinoma of the stomach with findings of INFα, medullary, sm, ly1, v1, n0, stage Ia and renal cell carcinoma papillary type, granular cell subtype. Forty months after operation, a left pulmonary nodule was detected and resected under thoracoscopic surgery. Histologically, the nodule was diagnosed as metastatic renal cell carcinoma and treated with interferon. Patients with gastric small-cell carcinoma are reported to have very poor prognosis, however, this patient in alive 5 years after the first operation, and is without renal failure.

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