In Japan, where the average age of the population is increasing rapidly, control of spiraling medical costs is considered to be a crucial issue, one that requires urgent attention. The recent introduction of the diagnosis-related-group/prospective-payment-system (DRG/PPS) has attracted attention as a promising means to this end. In order to examine the feasibility of introducing DRG/PPS in the field of gastroenterological surgery, the Group of Gastroenterological Surgery of the DRG Survey and Research Committee, directed by Prof. Yoshiki Hiki, investigated the medical costs involved in treating 539 patients with cholelithiasis who were hospitalized in 11 surgical facilities in Japan (nine university hospitals, one municipal hospital, and one private hospital). In the treatment of cholecystolithiasis, the cost of laparoscopic cholecystectomy was significantly less than that of both simple open surgery and surgery converted from laparoscopic cholecystectomy. The presence of postoperative complications after cholecystectomy resulted in a significant increase in the overall cost of hospitalization, because of the need for additional injections, examinations, treatments, and hospital care. The average cost of uneventful laparoscopic cholecystectomy in the 11 facilities ranged widely, from 530, 000 yen to 930, 000 yen, in accordance with the length of hospital stay. PPS may be applicable to the benign disease cholecystolithiasis if the treatment course is standardized.

View full abstract

Even in Japan, the number of HIV (Human Immunodeficiency Virus) infected patients is rapidly increasing. Thus, the opportunity for health care workers to come in contact with HIV infected patients will increases on a daily basis. This paper will mainly discusses the treatment for HIV infected patients and operative indications. A total of 10 operations were performed on 9 patients at the Tokyo Metropolitan Komagome Hospital (2 AIDS patients and 7 asymptomatic HIV infected patients). We performed lung lobectomies, biopsies of the tumor, permutations of artificial joints, adhesiolysis of an ileus, cannulation of the hepatic artery, colostomy, and skin transplantation in our study. All patients were known to be HIV seropositive prior to operations. No operative deaths occurred. No statistical relationships were observed between the immune conditions of the patients, operating times, volume of blood losses and the existence of complications in this study. The operative indication is usually determined according to the CD4+cell count. Although one case did not meet the operative indication on the CD4+cell count basis, we were able to get a good result. In considering the patient's quality of life, the operative indications should be more flexible.

View full abstract

The clinical efficacy of oral chemoendocrine combination therapy with cyclophosphamide, medroxyprogesterone acetate and doxifluridine (DMpC therapy), was evaluated on advanced and recurrent breast cancer. The response rate was 66.7% in 12 cases, including two complete responses and six partial responses. Restricted to recurrent breast cancer, the response rate was 66.7% that was the same rate of all cases. In terms of the efficacy classified by metastatic lesions, the effective rates were 75% in the skin, 62.5% in the bone, and 75% in the lung. The preoperative reduction therapy was also effective. Adverse side effect was leukopenia in 25% of them that was easily controlled. The response rate was almost the same as that of CAF therapy. On these findings, DMpC therapy is not only the effective therapy, but also the easy and safe oral therapy. In conclusion, DMpC therapy is considered to be one of the most useful treatment for advanced and recurrent breast cancer.

View full abstract

A clinical study was made 10 cases of cystic mediastinal tumor undergone thoracoscopic surgery at the hospital from August 1994 to March 1999. These patient's ages ranged from 16 to 70 years old with a mean of 43.8. There were five men and five women. The maximum diameters of tumors ranged from 2 to 9cm, with a mean of 5.3cm. These tumors were diagnosed as thymic cyst in three cases, pericardial cyst in three cases, bronchial cyst in two cases, esophageal cyst in one case, and cystic teratoma in one case. Intraoperative rupture of the cyst occurred in two cases of bronchial cyst and one case of cystic teratoma, a total of three cases. Postoperative complications included pneumonia and surgical wound infection in each one case which also developed rupture of the cyst. Duration of indwelling of a drain after the operation ranged from one to 7 days, with a mean of 2.6 days. The 7-day indwelling was needed for a plenty of discharge from the drain in one case of cystic rupture. Postoperative hospital stay came to 6-14 days, with a mean of 9.8 days.
Cystic mediastinal tumor is a good indication for thoracoscopic surgery. But, if bronchial cyst, esophageal cyst or cystic teratoma is suspected, it would be safe at present to use a minor thoracotomy concomitantly according to conditions, by entertaining a possibility of adhesion to the adjacent tissues and risk of rupture of the cyst.

View full abstract

We performed laparoscopic Nissen fundoplication on fifteen patients (age 72.3±9.5) with gastoesophageal reflux disease (GERD) and evaluated the results of the operation and short-term prognosis. Three patients had grade A (a case of type III hernia with gastric volvulus and two cases of stenosis at the hiatus were included), one patient had grade B, seven patients had grade C and four patients had grade D reflux esophagitis (according to Los Angeles classification). Our standard procedure is floppy Nissen fundoplication with 54 or 60 Fr bougie passing into the stomach. Mean operative time, loss of blood, diet start and length of hospital stay after operation were 128±43.3min, 74.0±93.0g, 1.1±0.3pod and 7.9±1.7days, respectively. In our short-term follow up (9.9±6.8months), eleven out of fifteen patients are asymptomatic and two have mild esophagitis which are well-controlable with H2 blocker (86.7% in efficacy). Reoperation was successfully performed on two patients with recurrent reflux esophagitis. In summary, laparoscopic Nissen fundoplication provides excellent surgical results in the point of effectiveness as well as less invasiveness.

View full abstract

We evaluated 16 resected cases of submucosal gastric tumor in which laparoscopic techniques were used. The tumors were located in the upper, middle, and lower third of the stomach in 9, 5, and 2 cases, respectively. Three tumors were located mainly on the anterior and 5 were on the posterior gastric wall, and 7 were on the lesser and 1 was on the greater curvature. The resected tumor sizes averaged 2.8×2.1cm. Twelve tumors were intraluminal and 4 were extraluminal type according to the classification of growth type. A histopathological examination identified 10 leiomyomas, 2 leiomyosarcomas and 4 smooth muscle tumors of indeterminate malignant potential.
An intraluminal tumor was found to be more complicated to resect laparoscopically without companion methods due to the difficulty in detection and resection from the serosal side compared with an extraluminal tumor (operating time: 225.5min vs 172.7min, respectively). Therefore, we attempted to resect an intraluminal tumor with ink-marking by intraoperative endoscopy and to resect as small a size as possible. These modifications were successful in reducing operating efforts.

View full abstract

In surgical resection of gastric cancer, upper abdominal CT scan is usually performed, but the diagnosing method of the presence of abdominal lymph node metastasis has not been established as yet. The purpose of this study was to evaluate the accuracy of diagnosing criteria for the lymph nodes metastasis that was designed based on CT imagings of cases of gastric cancer. Subjects were 72 cases of advanced gastric cancer who underwent gastrectomy with lymph noede dissection at the hospital. In our criteria, lymph node with the diameter of 1cm or more and smooth circumference on CT imaging was designated positive lymph node. The dissected lymph nodes from the 72 cases were analyzed according to our criteria, and compared with histological findings for the accuracy of CT imaging diagnosis. The corect diagnosing rates by locations were as low as 56.5%, 47.8%, and 75.0% at the lesser curvature area, greater curvature area, and celiac artery area, respectively.
In conclusion, the diagnosing ability of metastasis of gastric cancer to lymph nodes by CT is poor at present, and examinations other than CT are required for more accurate assessment.

View full abstract

In order to determine a reasonable treatment for gastric mucosal cancer, the survival rates according to age and method of treatment were compared between 311 patients treated by surgical resection (SR) and 227 patients treated by endoscopical mucosal resection (EMR).
The results were as follows:
1. In the patients less than 70 years of age, the 5-year survival rate for SR (95.1%) was significantly better than that for EMR (88.2%, P<0.01). In contrast, there was no difference in the survival rate between SR and EMR in the patients more than 70 years of age.
2. The 5-year survival rate of the patients with distal gastrectomy (DG) and total gastrectomy (TG) were 92.5% and 81.1%, respectively. In patients more than 75 years of age, the 5-years survival rate of TG (16.7%) was significantly worse than that of DG (75.1%, P<0.05).
3. The incidence of lymph node metastasis in SR was 2.3% (7/311). And 21.5% of patients in SR, the depth of the tumor invasion was deeper than the submucosal layer before operation.
4. The cause of death between the SR and EMR was almost same
5. In patients more than 75 years of age, EMR may be the first choice of treatment for gastric mucosal cancer, if possible. SR should be performed according to the pathologic examination of the EMR specimen to avoid TG.

View full abstract

Small intestinal metastasis is very rare. We encountered a case of intestinal metastasis from maxilla cancer causing preoperative peritonitis. A 63-year-old man had under gone surgery for maxilla cancer in December of 1997 at another hospital. He was admitted to our hospital because of nausea, vomiting, and abdominal pain in March of 1999. Peritonitis was obvious and a CT scan revealed free air, so an emergency operation was performed. During surgery, about 1000ml of dirty ascites containing pus was noted in the abdominal cavity, and ring stenosis of the ileum was noted in the ileum about 20cm to the oral side from the ileocecal region. Perforation was found in the ring stenosis, and an ileocecal resection was performed. Histopathological studies of the tumor revealed poorly differentiated squamous-cell carcinoma, the same pathological type as the maxilla cancer which had been operated on before. The postoperative course was uneventful, but a CT scan of the chest revealed lung metastasis. As to the metastatic course of maxilla cancer, we consider that maxilla cancer metastasizes to the small intestine through the chest mediastinum by lymphatic flow or blood flow. We suggest that in this case metastasis by blood flow because lung metastasis had occurred previously.

View full abstract

We report here a case of Pancoast's syndrome that developed 15 years after a radical mastectomy for right breast cancer. The patient had undergone a radical mastectomy on February 1, 1979. Following surgery, numbness and pain persisted from the right shoulder to the right anterior chest region, and in 1993, the pain gradually became stronger. Right blepharoptosis occurred in 1994, and lymph node swelling in the supraclavicular region was noted in June of the same year. Aspiration biopsy was performed on the lymph nodes, and a cytological diagnosis of metastatic adenocarcinoma was made. Since the findings from a CT scan suggested Pancoast-type cancer, we performed a right upper lobectomy and dissection of the mediastinal lymph nodes, including the right supraclavicular lymph nodes. However, pulmonary and lymph node metastases were diagnosed 15 years after the breast cancer operation. The patient underwent chemo-endocrine therapy and irradiation after the operation and remains well at the present time, five years after this operation.

View full abstract

A case of bilateral breast cancer associated with von Rechlinghausen's disease is reported. [First cancer: left breast cancer] A 47-year-old woman was admitted to the hospital because of a left breast tumor with a gradual grouth for two years. The left breast tumor was measured 7.0cm in diameter and multiple neurofibromas and cafe'au lait spots were scattered on the entire skin surface. Modified radical mastectomy was performed under the diagnosis of breast cancer. Histologically, the tumor was papillotubular carcinoma without metastasis to the axillary lymph node. [Second cancer: right breast cancer] A right breast tumor 2.5cm in diameter was detected 3 years after the resection of the left breast cancer. Modified radical mastectomy was performed under the diagnosis of breast cancer. Histologically, the tumor was papillotubular carcinoma with intra-ductal component, and no metastasis to the axillary lymph node. was revealed. Clinically and histologically, metachronous bilatelal breast cancer was diagnosed.

View full abstract

A 54-year-old woman was seen at the hospital because of a left axillary tumor. With an excision biopsy, lymph node metastasis of adenocarcinoma was diagnosed. First, metastasis from the mammary gland was suspected, but no abnormallities were found clinically in the bilateral breasts. Based on facts that immunological staining of the axillary metastatic lesion was positive for lactalbumin and no other origins were detected, occult breast cancer was most probable. A left pectoral muscle-preserving mastectomy (lt-Bt+Ax+Ic) was performed. The rescted mammary gland was histologically and minutely explored, but no malignant lesions were demonstrated. Thereafter when about 2 years has past, metastatic foci appeared in the left internal thoracic lymph node. As a result of radiation therapy and chemotherapy, the patient has been doing well as of 3 years after the operation.
It is thought that immunological staining of the lymph node can offer efficient information in the diagnosis of occult breast cancer.

View full abstract

Patient, an 85-year-old woman, was seen at the hospital because of numbness and cold sensation of the left hand. Ratio against normal pressure was 0.5 on the left hand for that on the right hand. Angiography revealed a specific funnel like obstruction of the left axillary artery and proliferation of collateral circulation. Symptomatic remission was attained by revascularization. Pathological diagnosis was giant cell arteritis. The disease is granulomatous change including multinucleate giant cells, affects arteries from the aorta to middle-sized arteries, and commonly occurs in the temporal artery. It predominantly occurs in elderly people, and angiography visualizes characteristic tapering stenosis. It is important to differentiate it from aortitis syndrome.

View full abstract

A case of pryce type I sequestration of the lung with superficial esophageal cancer is reported.
A 76-year-old man was seen at the hospital because of pain at swallowing. With close examinations, superficially extending esophageal cancer of 0-IIa+IIc+IIb type with the invasion depth of sm1 of the middle intrathoracic esophagus was diagnosed. Preoperative chest x-ray film and chest CT scan revealed a tumor with calcification on the left side of the inferior mediastinum. It was diagnosed as lymph node swelling, because the patient nad a previous history of tuberculosis. Considering his advanced age and low activities, non-thoracotomic evulsion of the esophagus was performed. During operation, arterial bleeding from the tumor which was thought to be calcified lymph nodes occurred. We determined it to be abnormal vessel and sutured for hemostasis. Postoperative angiography, ventilation scan, and 3D-CT offered the definite diagnosis of Pryce I type sequestration of the lung.
Pryce type I sequestration of the lung is a rare entity and so far 32 cases have been reported in Japan. This case is thought interesting in that the disease had been silent until 76 years old, was associated with superficial esophageal cancer, and was found at manipulation of the mediastinum during operation.

View full abstract

A rare case of a fish bone penetration into the thyroid gland from the esophagus is reported. A 70-year-old woman visited a local practitioner because of cervical pain and low grade fever 5 days after she had swallowed a fish bone, and was referred to the hospital with a diagnosis of fish bone stuck in the esophagus. X ray examination of the neck revealed a lineal calcification in the cervical region, and a CT scan visualized a low density area including a lineal high density foreign body beneath the thyroid gland. Ultrasonography also detected a linear strong echo. Under a diagnosis of a fish bone stuck in the thyroid gland and a cervical abscess, an operation was started by a Kocher's incision. The fish bone was penetrated into the right lobe of the thyroid gland, and the esophagus was intact. A removal of the fish bone, a partial resection of the thyroid gland and suction drainage were performed. Postoperative course was uneventful and the patient was discharged from the hospital on the 21st postoperative day.
An endoscopic removal of the a fish bone stuck in the esophagus is often successful, however, there are a few cases in which perforation or penetration of the esophagus due to the fish bone will occur. CT and ultrasonography are useful for diagnosis and treatment of perforation or penetration of the esophagus due to fish bones.

View full abstract

A case of thoracoscopic resection of a esophageal duplication cyst is reported. An 18-year-old woman was seen at the hospital because of epigastralgia, Chest roentgenogram and CT scan revealed a mediastinal tumor. Chest CT showed a 3cm in diameter cystic tumor at the left side of the lower esophagus. Endoscopic ultrasonography was suggestive of esophageal cyst, therwfore, thoracoscopic resection of the tumor was performed. To prevent recurrence, the residual mucosa was cauterized as well. The tumor contained viscosous and mucinous mucus. The postoperative pathologic diagnosis was esophageal duplication cyst. Thoracoscopic resection is thought to be necessary for differential diagnosis of cysts of unknown origins, and that because the esophageal duplication cyst is a benign tumor, it is a good indication for thoracoscopic resection.

View full abstract

A case of lipomatosis with the extensive lesion covering from the duodenum to colon, which presented with intussusception, is reported. A 49-year-old man was admitted to the hospital because of lower abdominal pain. Abdominal CT scan revealed intussusception in which the small intestine prolapsed into the lumen of the ascending colon and circular low density masses which seemed like lipoma in the ascending and descending colons. Intussusception was diagnosed, and a resection of ileocecal region was performed. During operation, multiple tumors were found in the entire small intestine. Reexamination performed after the operation offered the diagnosis of intestinal lipomatosis extending from the duodenum to descending colon.
Intestinal lipoma is single in most cases, and multiple occurrence is extremely rare. There have been only 20 foreign cases and seven domestic cases of intestinal lipomatosis as far as we could review. This case appears to be the 8th case report. And only one case of intestinal lipoma extending from the duodenum to colon has been reported in foreign literature so far. This case is thought to be very rare.

View full abstract

Four cases of perforation of the small intestine caused by seat belt with three point supports are reported.
Patient 1, a 79-year-old woman, was revealed having a very small amount of intraabdominal free air on a CT scan. It was found that a perforation was present 220cm oral to the terminal ileum. Patient 2, a 55-year-old man, was revealed having intraabdominal fluid retention and intraabdominal free air on a CT scan. A small bowel perforation was located 160cm oral to the terminal ileum. Patient 3, a 22-year-old man, was revealed to have intraabdominal free air by a CT scan and thoracoabdominal simple x-ray film. A small bowel perforation was present 30cm anal to the Treitz' ligament. Patient 4, a 61-year-old man, was revealed to have fluid retention and intraabdominal free air on a CT scan, whose perforation was present 180cm anal to the Treitz' ligament. In all patients the perforated sites were sutured. Postoperative course was uneventful in all patients. In case of small bowel perforation, intraabdominal free air is minute in amount and helical CT is of great value to visualize it early. It is thought that the seal belt supported at three points can cause perforation of the small intestine, in that further consideration to device some seat belt with four or five point supports would be necessary.

View full abstract

We report here the case of an 81-year-old man referred to our hospital with spontaneous abdominal pain and persistent diarrhea after glycerin enema. Physical examination showed abdominal distension with no tenderness. The patient was been treated conservatively, but the abdominal pain increased and tenderness developed nine hours after the first examination. Abdominal computed tomography revealed gas in the hepatic portal venous system, and was considered to have a grave prognosis. Gas in the portal vein appeared with an increase of intrabowel gas within several hours. Superior mesenteric angiography revealed spasm of the peripheral vascular arcades and impaired filling of intramural vessels. A diagnosis of ischemic enteritis was determined, and emergency laparotomy was carried out. Resection of a 180cm long segment of ileum including an 80cm necrotic lesion was performed, but the patient was died of multiple organ failure within 48 hours. We retrospectively made the diagnosis of nonocclusive mesenteric ischemia from the angiographic findings. Nonocclusive mesenteric ischemia is caused by vasoconstriction following low flow syndrome of mesenteric circulation. Mesenteric angiography is still the only reliable diagnostic and therapeutic tool, and should be applied early in the diagnostic path.

View full abstract

We reported a recent case of ischemic stenosis of the small intestine. A 74-year-old man visited our hospital complaining of appetite loss and abdominal pain in September 1996. A diagnosis of ileus was determined and he underwent conservative therapy on admission. Although the ileus symptoms improved at once, his condition worsened with oral intake of food. Barium enema examination revealed complete obstruction of the cecum, so he was referred to the surgical department. At operation, severe stenosis of about 10cm in length was found at the terminal ileum. Intestinal tuberculosis was surmised, and ileocecal resection was performed because of his past history of lung tuberculosis. Histological examination showed Ul-II and Ul-III ulcer in the narrowed resected segment, with marked infiltration of inflammatory cells in the mucosa, hypervascularity, hyperemia and fibrosis in the submucosal layer, so a diagnosis of ischemic stenosis of the small intestine was determined. We considered arteriosclerosis, disturbance of venous blood flow and dehydration to be the ischemic factors in this case.

View full abstract

Malignant lymphomas of the small intestine commonly occur in the ileum and most of them are derived from B cells. Recently we experienced a case of T-cell lymphoma of the jejunum with perforation which demanded an emergency laparotomy.
A 73-year-old woman was admitted to another hospital because of abdominal pain, nausea and diarrhea. With close examination, the patient was diagnosed as having a tumor of the small intestine and elective surgery was scheduled, when severe upper abdominal pain occurred. Tenderness, Blumberg's sign and defense of muscle of upper abdomen were present. On abdominal CT scan, perforative peritonitis was diagnosed and the patient was referred to the hospital. Upon laparotomy, a tumor with small perforation was placed in the jejunum about 30cm distant from the Treitz ligament and a partial resection of the jejunum was carried out. Histological diagnosis was malignant lymphoma of the small intestine in stage III, intestine T-cell lymphoma. Postoperatively no lesion was detected in the other organs. Two months after the operation, a left axillary lymph node swelling was noticed and resected. Histological diagnosis showed that the lymph node swelling was the recurrence of malignant lymphoma. CHOP regimen was added in vain and the EHOC regimen and local injection of bleomycin were started. The lymph node swelling is decreased in size. Malignant lymphola is considered as a cause of the perforation of the small intestine.

View full abstract

A 27-year-old man was admitted to the hospital because of central abdominal pain. There was rebound tenderness around the umbilical region. Abdominal simple X-ray film demonstrated intestinal obstruction and abdominal CT showed thicking of the wall of the small intestine. The patient underwent an emergency laparotomy with a diagnosis of panperitonitis. Laparotomy showed a Meckel's diverticulurn at the ileum 40cm from the terminal ileum. Small bowell was obstructed at the diverticulum because of fibrous adhesion. The ileum was perforated at the oral side of the diverticulum. A partial resection of the small intestine was performed. Histopathological examination confirmed the diagnosis of Meckel's diverticulum with ectopic gastric mucosa and perforated ulcer. Meckel's diverticulum with perforated ulcer is rare, and so we report the case together with presenting some bibliographical comments.

View full abstract

A 59-year-old man was admitted to the hospital because of melena and dizziness. Barium X-ray study of the small intestine revealed a filling defect in the ileum. Partial resection of the ileum was performed with a diagnosis of ileal tumor. The tumor was 1.8×1.5×1.8cm in size, and located on a site, 60cm oral to the Bauhin's valve.
Histopathological diagnosis was leiomyoblastoma. Thereafter the patient had liver metastasis and peritoneal dissemination which were resected respectively, however, he died of metastases to the whole body 4 years and 2 months after the initial operation. Leiomyoblastoma of the small intestine is relatively rare and presents difficulty in diagnosis of the degree of malignancy of the tumor. Surgical resection of the tumor is said to carry a good prognosis. Nevertheless, some patients have a poor prognosis like this case and careful observation of clinical course would be mandatary.

View full abstract

A 72-year-old woman who had been staying at the department of respiratory surgery in our hospital for the treatment of lung cancer had vomiting, and a protrusion in the femoral area was confirmed. With a diagnosis of incarceration of femoral hernia, a radical operation was performed. On the next day, a right upper lobectomy was performed for lung cancer. Histopathologically, poorly differentiated adenocarcinoma with large cell carcinoma was demonstated. Postoperative course was uneventful. However, vomiting occurred again on the 8th day after the lobectomy. Abdominal x-ray film revealed air-fluid level and intestinal obstruction was diagnosed.
Fluoloscopy of the small intestine through an ileus tube revealed a stenosis 30cm distal to the Treitz' ligament. CT scan and echography showed layered intraperitoneal structure. From these findings, intussusception due to small bowel metastasis of the lung cancer was suspected, and a laparotomy was performed. At laparotomy, the jejunum developing intussusception 30cm distal to the Treitz' ligament which formed an infant's fist-sized tumor was confirmed. So a partial resection of the small intestine was performed. A 5.0×4.5cm tumor of the small intestine was noted. It was histopathologically metastasis to the small intestine from the lung cancer.

View full abstract

We report a relatively rare cecum cancer revealed by the formation of a colocutaneous fistula after gastrectomy for gastric cancer. The patient was an 80-year-old man, who was examined at our hospital with chief complaints of epigastralgia, nausea, and vomiting. A close examination gave a diagnosis of gastric cancer, and a distal partial gastrectomy was performed. From the 11th day after surgery, discharge of pus was noted from the scar of an appendectomy performed 40 years before and a fistula formed in that region. In a fistulograph, the contrast medium flowed out into the ascending colon, suggesting a colocutaneous fistula. Under colonoscopy, illumination of the ileocecum region was insufficient because of deformation due to adhesion. In spite of conservative therapy, convalescence and recurrence were repeated. Finally, exudate from the fistula was diagnosed as pathologically malignant in the 5th postoperative month. Thus, with the diagnosis of ileocecal cancer, ileocecal resection and curettage of the fistula were performed. The postoperative course was uneventful, and the patient was discharged on the 23rd day after this last surgery. It is necessary to consider not only an inflammatory disease, but also the possibility of colon cancer, when one comes across a case with a colocutaneous fistula.

View full abstract

Two cases of perforation of the colon caused by gastrointestinal amyloidosis are reported.
Patient 1 was a 49-year-old man who had a 21-year history of hemodialysis. He underwent an emergency operation with a diagnosis of perforating peritonitis while he was hospitalized for abdominal pain. At laparotomy, perforation about 10mm in diameter was present at the splenic flexure of the colon. A colectomy and a colostomy were performed. Patient 2 was a 55-year-old woman who had been treated for rheumatoid arthritis since the age of 38. She underwent an emergency operation with a diagnosis of perforating peritonitis while she was hospitalized in the depaprtment of internal medicine in our hospital because of intestinal obstruction. At operation, a pinhole like perforation was found in the midst of the transverse colon. The perforated portion with a margin was resected and sutured.
Histopathological studies of the resected materials from both cases revealed deposits of eosinophilic anhistic component to vascular walls and muscular layers in the vicinity of the perforation, which were Congo red-positive, indicating deposits of amyloid. Perforation of the colon caused by dialysis amyloidosis was diagnosed in the patient 1 and he is still alive at present. The patient 2 who was diagnosed as having colonic perforation due to amyloidosis secondary to rheumatoid arthritis died on the 7th postoperative day.

View full abstract

We report a case of obstructive colitis associated with rectal stenosis and adhesion due to irradiation. A 68-year-old woman who had been suffering from constipation after an episode of irradiation for cervical cancer of the uterus two years previously was admitted to our hospital complaining of the lower abdominal pain. After two days, an operation was performed under a diagnosis of panperitonitis. Stenosis and adhesion of the rectum and necrosis at the oral side of the adhesion was recognized. Histologically, necrosis of the rectum from mucosa to serosa was recognized, and no neoplastic change was seen at the stenotic portion. The most common cause of local stenosis of the colon leading to obstructive colitis is colon cancer. Obstructive colitis caused by a benign stenosis as reported here is rare.

View full abstract

Intramesenteric penetration is relatively uncommon. As far as we know, only 13 cases, including the present one, have been reported in the world.
A 75-year-old woman was seen at our hospital because of lower abdominal pain and nausea. She had been told that she had diverticulum of the sigmoid colon. After examination, she went home, but the next day she came again because her abdominal pain had not improved. When she was admitted, WBC was 24, 300/mm³ and CRP was 20.0mg/dl. An abdominal CT scan revealed a large tumor in the pelvic cavity which contained a good deal of air. A barium enema study showed that contrast medium had leaked out of the intestine and contrasted like a tumor. Suspecting penetration of the sigmoid colon by the diverticulitis, so we performed laparotomy. Much stool was contained in the sigmoid mesentry, so we resected the sigmoid colon and performed end-to-end anastomosis. Histological diagnosis of the resected specimen material was penetration by diverticulitis.

View full abstract

A 71-year-old man visited another hospital because of gradually intensifying abdominal pain on February 22 which appeared in the last evening. Abdominal ultrasonography on the next day revealed target sign at the right flank. The patient was referred to the medical center with a suspicion of intussusception. On the same day, a barium enema study revealed a filling defect like crab's claw and intussusception was diagnosed. Hydrostatic pressure reduction method was tried but failed in reduction, and an emergency operation was performed on the same day. At laparotomy, intussusception ranging about 3-4cm in the right side of the transerse colon was present. Manual reduction was impossible, and a resection of the colon about 20cm in length was performed because a possibility that the intussusception might be caused by some malignant tumor could not be ruled out. The resected material showed edema and reddening on the mucosa with the width of 35mm longitudinally and over the entire circumference of the colon. On close observation, worms which seemed to be anisakis were confirmed on the surface of mucosa where inflammatory tumor was formed.

View full abstract

We report a relatively rare case of adenocarcinoma of the colon with abdominal aortitis syndrome and nephrotic syndrome. A 72-year-old woman who had been medicated for nephrotic syndrome, hypertension, hyperlipidemia and iron deficiency anemia in our hospital since 1980 showed an exacerbation of anemia on blood examination in August, 1998.
Abdominal CT scan incidentally revealed stenosis of the abdominal aorta and atrophy of the left kidney. Abdominal aortitis syndrome was diagnosed. Preoperative intravenous digital subtraction angiography (IV-DSA) did not visualize the left renal artery and its periphery, but collateral artery to the femoral artery was revealed. Physical examination on admission showed hypotension of the legs. Blood examination showed iron deficiency anemia, and increase in carcinoembryonic antigen and carbohydrate antigen 19-9. Colonofiberscopy revealed colon cancer. With the diagnosis of colon cancer with abdominal aortitis syndrome, a right hemicolectomy with lymph nodes dissection (D2) and a biopsy of the right kidney were performed in October, 1998. The postoperative course was uneventful.

View full abstract

We report a rare case of multiple colon cancer manifesting perforative peritonitis.
A 79-year-old woman was transferred to the hospital because of abrupt onset of severe lower abdominal pain. Abdominal radiography confirmed perforation of the intestine, and an emergency operation was conducted. During the operation, a perforation and multiple tumors in the sigmoid colon were observed and Hartmann's procedure was performed. Histological study of the resected specimen disclosed four lesions of colon cancer, one adenoma of the sigmoid colon, and perforation at the center of the advanced cancerous lesion.

View full abstract

A 63-year-old woman was admitted to the hospital because of massive anal bleeding. Emergency colonoscopy revealed pulsating bleeding from a polyp about 1cm in size in the sigmoid colon. Clliping of the polyp was carried out and the bleeding stopped. Endoscopic polypectomy was performed, but the pathological findings of the specimen showed moderately differentiated adenocarcinoma invaded the submucosa deeply. We thought that radical operation should be done. She underwent a sigmoidectomy. Histological findings demonstrated no residual tumor, but lymph node metastasis was showed. Early colorectal cancer presented with massive anal bleddding is rare. This rare case is reported together with a review of the literature.

View full abstract

We report a case of multiple pyogenic liver abscesses. The patient was a 47-year-old woman with liver abscesses secondary to sigmoid colon cancer. The liver abscesses disappeared after antimicrobial treatment and sigmoidectomy. Histological examination of the resected specimen disclosed circumferential colon cancer and inflammatory adhesion to the bladder and the ileum with formation of small abscesses around the tumor. No evidence of ascending biliary infection, sepsis, nor diverticular disease in the colon were observed. Detailed reports of coloreetal cancer presenting with liver abscesses in the absence of hepatic metastases are extremely rarc. Clinical findings of patients reported to date in the context of literature review are discussed.

View full abstract

Splenic metastasis is uncommon and usually occurs in a setting of widespred visceal metastases. A case of isolated intrasplenic metastasis from sigmoid colon cancer is reported.
A 77-year-old woman was admitted to the hospital because of pneumonia. During treatment, she complained of nausea and appetite loss. Barium-enema examination showed an apple core sign in the sigmoid colon and colonfiberscopy revealed irregulary mucosa, and adenocarcinoma was evidenced by punch biopsy. Computed tomography disclosed hypodense lesions in the spleen. Abdominal ultrasonography showed a hyper echoic area in the spleen. From these findings we diagnosed isolated intrasplenic metastasis from sigmoid colon cancer. Sigmoidectomy and splenectomy was performed. The histological diagnosis confirmed intrasplenic metastasis from sigmoid colon cancer.
In the literature, there are reports of good prognoses, following resection of the solitary splenic metastasis. Therefore, we recommend this procedure in case of solitary splenic metastasis.

View full abstract

Currarino syndrome is a disorder that has been first reported by Currarino and his coworkers in 1981 as a syndorome having three characteristics, namely, malfomation of the rectum, defect of the sacrum, and presacral tumor. Autosomal gene dominant inheritance is considered in the disorder and it has been reported that about the patients with the disease have family members with some malformation relating to the Currarino syndrome in family history. This paper deals with Currarino syndrome occurred in a father and his child. As to malformation of the rectum, stricture of the rectum is most common like in this father-and-child case. We must perform close examination by keeping the disease in mind as a probable diagnosis in the case of stricture of the rectum.

View full abstract

A 51-year-old man was admitted to the hospital because of perineal pain. There was previous history of undergoing abdominoperineal resection of the rectum for leiomyosarcoma of the rectum 6 years before admission. CT scan revealed local recurrence. Magnetic resonance imaging showed this tumor invading the prostate. So a total pelvic exenteration was performed. This tumor adhered to the prostate strongly, but did not invaded it. Pathological diagnosis was the rectal gastrointestinal stromal tumor (GIST) of uncommited type. Post operative couurse was uneventful and no evidence of recurrence has been found for 7 months.
We experienced three cases of local recurrence of the rectal GIST. More than 5 years had passed when recurrence occurred in two cases of them. These two patients are still alive now and pathological diagnosis was uncommitted type of the GIST in them. With further experience with many cases of GIST, we may be able to elucidate the correlations of immunophenotype with degree of malignancy, mode of recurrence and prognosis

View full abstract

A 50-year-old woman was admitted to the department because of intensifying abdominal pain with slight fever which started about one month before admission though the degree of he pain was slight. Abdominal simple x-ray film in the upright position visualized a cystic tumor in the lower abdomen and air fluid level in the tumor. Abdominal CT scan revealed a similar picture. Colonofiberscopy revealed a Borrmann type 2 tumor at the recto-sigmoid colon. Barium enema study showed leakage of contrast matrial from the vicinity of the tumor, and the inside of the cystic tumor which was revealed by the abdominal simple x-ray film and CT scan. Further the ascending colon was visualized through the fistula. Fistula formation of the ovarian cyst and ascending colon due to the cancer of the recto-sigmoid colon was diagnosed and the patient was operated on. Operative procedures included ‘en-bloc’ resection of the rectum, ovarian cyst, and ileocecal region which strongly adhered each other and simultaneus sutures between the ileum and ascending colon and between the descending colon and rectum. Postoperative course was uneventful.
This is an extremely rare case in which cancer of the recto-sigmoid colon perforated to the overian cyst to form a fistula in the midst of the adhesions which further perforated to the ascending colon.

View full abstract

Chemotherapy with combined administration of UFT and oral leucovorin has been reported to be effective for advanced colorectal cancer. We adopted this regimen for two cases of far advanced colorectal cancer and its efficacy was confirmed by diagnostic images and pathohistology. As to chemotherapy protocol, UFT (300mg/m²) and LV (100mg) were administered daily for consecutive 28 days as one course. Case 1: A 50-year-old man with a huge rectal cancer involving the urinary bladder was treated with oral UFT/LV for one course. After the chemotherapy, CT and magnetic resonance imaging (MRI) revealed a remarkably reduced tumor which allowed us to remove completely by a total pelvic exenteration. Histological evaluation of effect of the chemotherapy resulted in Grade Ib. Case 2: A 55-year-old man had an advanced cancer of the colon perforating into the abdominal space with hepatic metastasis. He was rescued by an emergency operation consisting of an partial resection of the transverse and descending colon and abscess drainage. Postoperative oral UFT/LV was induced for two courses. After the chemotherapy a significant reduction of the hepatic metastasis and an apparent decrease in CEA were observed. No adverse side effects other than mild diarrhea in case 2 were found. Therefore, oral UFT/LV can be a promising adjuvant chemotherapy before or after operation for far advanced colorectal cancer.

View full abstract

We report two cases of rectal carcinoma presented with perianal abscess. Although perianal abscess is not uncommon, rectal carcinoma is rarely associated with the disease in a frequency of about 1%. In our series of 144 cases of lower rectal carcinoma, two (1.4%) cases were presented with perianal abscess. It has been reported that rectal cancer with perianal abscess has a high risk of local recurrence after curative operation, but in these cases there have been no signs of recurrence.
In both cases, we performed abscess drainage and lavage to control local inflammation prior to curative operation. Abdominosacral excision of the rectum was carried out and the tumor was resected with abscess cavity and abscess wall to prevent local recurrence. In one case, musculocutaneous flap reconstruction was performed secondarily to fill up the dead space in the pelvic cavity and gluteal region. One patient died of pulmonary metastasis two year and three months after the operation, but there was no sign of local recurrence. Other patient has been free from recurrence as of three year and 10 months after the operation.

View full abstract

A 74-year-old woman underwent pancreatoduodenectomy for a carcinoma of the common bile duct. On the 7th postoperative day, there was sudden onset of bleeding through the drain. At the emergent laparotomy, a large thrombotic mass was found in the upper abdomen but there was no active bleeding.
On the 14th postoperative day, similar bleeding occurred again. As angiographic examination revealed a pseudoaneurysm of the right hepatic artery which ruptured toward the choledochojejunostomy, she underwent transarterial embolization. Four weeks after the first operation, she suffered from frequent hematoemesis. Radiologic examination revealed that the pseudoaneurysm was still viable. Re-embolization was abandoned because it was supplied not only from the recanalized right hepatic artery but also from the left hepatic artery. The aneurysm was ligated proximally and distally and resected, and the broken choledochojejunostomy was repaired.

View full abstract

Although massive hepatic infarction after abdominal surgery is uncommon, the prognosis is poor. Here we report a case of massive hepatic infarction following total gastrectomy. A 67-year-old woman presenting with vomiting and upper abdominal disturbance was admitted. She had a history of distal partial gastrectomy 19 years previously because of gastric cancer. A series of examinations revealed advanced cancer at the pregastroduodenal anastomosis site. She underwent surgery on October 23, 1998. Because of cancer invasion to adjacent organs, total gastrectomy combined with caudal pancreatectomy and splenectomy, partial hepatectomy and partial resection of jejunum were performed. Bile leakage was observed through the drain placed in the abdominal cavity on the 1st day after the operation. Serum transaminase levels increased remarkably, and CT scan revealed a massive hepatic infarction in the left lobe, S5 and the surrounding area of the right portal vein. Transaminase levels normalized two weeks after the operation. Abdominal angiography demonstrated obstruction of the proper hepatic artery and left branch of the portal vein. The area of hepatic infarction decreased in size gradually thought bile leakage persisted. The patient was discharged on July 11, 1999.

View full abstract

An 84-year-old woman was seen at the hospital because of a subcutaneous abscess and was admitted for treatment and close examination. Because of senile dementia, she hardly complained of subjective symptoms such as pain. On physical examination, there was a subcutaneous abscess with reddening and edema in the right anterior thoracic region. With an incision of the abscess, discharge of pus was observed. Pus discharge occurred from subcutaneous space between the right 10th and 11th ribs to form a fistula. A fistulography visualized the gallbladder and subsequently the colon. There were stones in the gallbladder. Cholelithiasis associated with an external fistula of the gallbladder and a fistula between the gallbladder and colon was diagnosed. A cholecystectomy and a partial excision of the transverse colon were performed.

View full abstract

An 83-year-old man was admitted to the hospital because of lt-hypochondralgia and epigastralgia. There were previous histories of under going rt-nephrectomy at the age of 67 and being diagnosed as having multiple lung metastasis at the age of 80. Laboratory examination revealed anemia and an abdominal US showed a tumor 7cm in diameter at the pancreatic tail. It was suspected that the pancreatic tumor was metastasis from renal cell carcinoma and its spontaneous rupture with intraperitoneal bleeding occurred. Distal pancreatectomy with splenectomy was performed. The tumor was covered with pancreatic capsule but separated from pancreatic tissure by thin connective tissue. On an analysis of 33 cases of pancreatic metastasis after nephrectomy in the Japanese literature including our case, a mean period untill appearance of pancreatic metastasis was 9.1 years. The long term postoperative follow-up would be mandatory for renal cell carcinoma because of its character of having a long term interval for the reccurence. Operation for pancreatic metastasis is indicated not only for solitary case but also for multiple organ matastatic case if it is slow growing type.

View full abstract

A 48-year-old woman underwent hysterectomy and left oophorectomy under a diagnosis of hysteromyoma and endometriosis in March 1994. Although the left ovary was normal-sized, poorly differentiated adenocarcinoma was detected pathologically. The serum level of CA125 started to increase in July 1996. Abdominal MRI and CT revealed a tumorous lesion in the spleen. An operation was performed under a diagnosis of solitary metastasis to the spleen from the ovarian cancer in June 1997. The tumor was found in the hilum of the spleen, but there was no recurrent finding of the ovarian cancer, and so splenectomy was performed. The pathological diagnosis of the tumor was poorly differentiated adenocarcinoma as a metastasis from the ovarian cancer.
Solitary splenic metastasis from a malignant tumor is rare only 64 cases of solitary splenic metastasis have been reported in Japan. This paper reports the first case of solitary splenic metastasis from a normal-sized ovary carcinoma. In some cases of solitary splenic metastasis from ovarian cancer, good prognosis were obtained by chemotherapy following splenectomy. Therefore, splenectomy should be indicated to treat patients with solitary splenic metastasis from ovarian cancer.

View full abstract

We experienced a case of left adrenal ganglioneuroma after operation for breast cancer. A 51-year-old woman, who had undergone a modified radical mastectomy for left breast cancer, was admitted to the hospital because of an adrenal tumor. The tumor was found incidentally on ultrasonography during a routine examination. The mass was located between the spleen and left kidney. No abnormal findings were revealed on laboratory and endocrinological studies. Under a preoperative diagnosis of nonfunctioning adrenal tumor, the tumor was removed. The resected material was 320g in weight and 10×10×5cm in size, with capsule.
It communicated with the adrenal gland. The section had homogenous inner part and was solid and grayish white in color. Histological diagnosis was adrenal ganglioneuroma.
Ganglioneuroma originating from the adrenal gland is relatively rare. The patient has been free from recurrence as of 2 years and 10 months after the operation. Adrenal tumor in this case was thought a candidate for operation because it was incidentally found by a routine medical examination after breast cancer and had a large diameter, and a possibility of metastatic tumor could not be ruled out. A review of clinical cases of ganglioneuroma is also presented.

View full abstract

The Urachal cyst which is supposed to be relatively rare has increased with the progress of imaging diagnosis. We experienced a case of infected urachal cyst. A 22-year-old man was seen at the hospital because of lower abdominal pain and high fever. A lower abdominal mass was palpated and CT scan and ultrasonography suggested an infected urachal cyst. Injection of antibiotics for seven days was ineffective and a drainage was performed. His symptoms and the inflammation dramatically improved. In this case, the cyst was not communicated with the nabel nor with the bladder, and a culture of the fluid in the cyst was negative.

View full abstract

We experienced a case of lymphangioma of the lesser omentum associated with gastric cancer. A 76-year-old man was seen at the hospital because of upper abdominal pain. The patient was diagnosed as having gastric cancer on upper GI endoscopy. Computed tomography revealed a cystic tumor, 5.0cm in size, which was located between the stomach and pancreas. Under a diagnosis of gastric cancer and pancreas cyst, a laparotomy was performed, The 7×5cm tumor was located in the lesser omentum and was not connected with other organs. The patient underwent a distal partial gastrectomy with regional lymph nodes dissection and an extraction of lesser omental cyst. The omental tumor was multi-cystic with pale bloody fluid and 7×5×4cm in size. The histopathological diagnose of gastric cancer and lesser omental cyst were well differentiated adenocarcinoma and lymphangioma, respectively. Lymphangioma of the lesser omentum is rare and, to our knowledge, only 34 Japanese cases have been reported. This is the third case in which malignant tumor was associated with the disease. Lymphangioma of the lesser omentum has no specific clinical symptoms and presents difficulty in preoperative diagnosis. Removal of the tumor becomes the primary treatment and the prognosis is good. This rare case of lymphangioma of the lesser omentum with gastric cancer is presented with a review of the Japanese literature.

View full abstract

Torsion of the greater omentum is a relatively rare entity in which the greater omentum twists with ischemic change of its periphery. Two cases of primary torsion of the greater omentum which were preoperativly diagnosed as acute appendicitis are reported. The patient 1 was a 40-year-old man complaining of right lower abdominal pain. With a preoperative diagnosis of acute appendicitis, a laparotomy was perfomed. At laparotomy, it was found that the greater omentum was twisted clockwise by 5 terns with serous bloody ascites. The definitive diagnosis was made as primary torsion of the greater omentum, and the patient underwent a resection of the necrosed part of the omentum and an appendectomy. The patient 2 was a 70-year-old woman complaining of right lower abdominal pain after taking a laxative for her constipation. With a preoperative diagnosis of acute appendicitis, and operation was perfomed. At laparotomy, it was found that the greater omentum was twistwd clockwise by 3 terns without ascites. She underwent a resection of the necrosed part of the omentum and an appendectomy.
Their postoperative courses were uneventful. It is etiologically thought that abrupt change in patient's posture might cause the torsion, because the patient 1 was apt to twist the body on busines; and in patient 2, accelration of bowel movement due to taken laxative for constipation might cause the condition. The disease presents difficulty in differential diagnosis from acute appendicitis, but we must consider the disease in the case of acute abdomen complaiing of right lower abdominal pain.
Pathogenesis of the disease is discussed with a brief survey of the literatures.

View full abstract

Two cases of perforating peritonitis due to metastasis of lung cancer to the small intestine which were surgically treated are reported. Case 1: A 63-year-old man was pointed our abnormal chest shadow at a medical checkup, and was diagnosed as having cancer of the right upper lobe of the lung with infiltration into the trachea and esophagus and metastases to the adrenal gland and brain. While he was followed up without any treatments in the outpatient clinic, abdominal pain abruptly occurred 3 months after the first visit. Emergency operation was performed with a diagnosis of perforating peritonitis. The patient was discharged from the hospital on the 25th day, but died on the 35th day after the operation. Case 2: A 73-year-old man was diagnosed as having right lung cancer, pleural effusion, and brain metastasis. While he received radiation therapy for the brain metastasis, abdominal pain abruptly occurred one month after admission and an emergency operation was performed. He was able to eat after the operation, however, he died of cancer on the 25th hospital day. Perforation due to metastasis of lung cancer to the small intestine has poor prognosis because it often occurs in the course of terminal stage. We think that surgical treatment should be performed by considering the patient's general condition, because it can offer an improvement in the QOL for the patient even though it is temporal.

View full abstract