This study was made to explore correlations of telomerase activity with a variety of biological factors in breast tumors. Telomerase activity was examined using the TRAP assay in 59 breast tumors including 45 breast cancers, eight fibroadenomas, four mastopathies and two phyllodes tumors which were surgically resected between 1996 and 1999. The correlations of telomerase activity with various biological factors such as DNA ploidy pattern and cell cycle phase were investigated. As far breast cancers, clinicopathological findings such as tumor diameter, axillary lymph nodes metastasis, clinical stage, histologic type, and hormone receptors were studied retrospectively in terms of correlation with telomerase. The telomerase activity was significantly higher in breast cancers than in benign tumors (P=0.0108), and correlated with Sphase of cell cycle phase. In breast cancers, the larger in size and the more advanced in clinical stage, telomerase activity was significantly higher, though there were no significant differences in histologic types. And in case of positive lymph nodes metastasis, telomerase activity tended to be higher. These results indicate a possibility that telomerase activity may be one of useful plognostic indicators.

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Of a series of resected primary lung cancer at the hospital in a recent 9-year period from January 1986 to December 1994, 90 patients with non-small cell lung cancer underwent “absolutely curative resection” and 72 non-small cell lung cancers underwent “relatively curative resection”. In order to elucidate the prognostic factors, these cancers were evaluated for age, sex, tumor size, pathologic T factor, pathologic N factor, histopathological features, and method of detection. Fifteen of the 90 (17%) patients developed recurrence which was examined for the presence of vessel invasion and involvement of visceral pleura. All of these 15 recurrent cases had evidence of lymphatic vessel invasion. Six of these 15 cases (40%) also had blood vessel ilmvasion. The mean size of the tumors was significantly larger in the recurrent cases after absolutely curative resection than that in all resected cases. However, there was no significant difference between the recurrent cases and all cases of curative resection in the presence or absence of involvement of visceral pleura. Multivariate analysis of all risk factors revealed that the T factor and the presence of vessel invasion are only independent risk factors for recurrence after curative resection. In conclusion, it is important for preventing recurrence after curative resection to detect the tumor in smaller size, to avoid the growth or invasion of the tumor due to delayed treatment, and to perform complete resection with mediastinal lymph node dissection as early as possible.

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Clinicopathological study was made on 111 thoracic esophageal cancers experienced in the 1^st department of Surgery of the Shiga University of Medical Science from 1979 to 1998. Cancers positioned in the middle part of the esophagus accounted for 68.2% of all cases. Stage 3 and 4 advanced cancers accounted for 61.7% of all lesions, and the frequency of early cancer was 22%. The lymph node metastasis to the upper mediastinum, especially along the recurrent nerves, was observed with a high frequency (60%) in the Ut cases. The lymph node metastasis in the neck was observed frequently in the Ut (20%) and Mt cases (19.4%), and the lymph node metastasis to the abdominal region was observed frequently in Lt cases (47.8%). In cases of superficial esophageal cancer, the lymph node metastasis was observed as a tumor invaded the depth of middle layer of submucosa (sm2). No cancer death occurred in cases of mucosal (m) and sml superficial cancer, however, the 5-year survival rates of sm2 and sm3 cases decreased remarkably. If the lymph node dissection along the recurrent nerves is reliable, significant difference in the survival rate was not recognized between the 2-field lymph node dissection and 3-field lymph node dissection.

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Since the cellular origin of gastrointestinal mesenchymal tumors (GIMT) is uncertain, the definite classification of them has not been established as yet. Recently it has been increasingly clarified that most of GIMTs may be gastrointestinal stromal tumors (GIST) derived from intestinal cells of Cajal (ICC) which reveal immunoreactivities to CD34 and membrane-bound tyrosine kinase receptor, Kit (CD117).
In this study a total of six patients with GIMT of the stomach treated in the hospital from 1994 to 1998 were reexamined clinicopathologically and immunohistochemically. Before entering the study, two cases were diagnosed as leiomyoma, two cases as leiomyosarcoma, and two cases as gastrointestinal autonomic tumor. In this reexamination, tissues from the six GIMTs were immunostaind for CD34, Kit, desmine (Des), alpha-smooth muscle actin (α-SMA) and S-100 protein (S100).
All the six GIMTs exhibited CD34(+), Kit(+), Des(-), α-SMA(-), S100(-) immunophenotype. After reexamination, all six GIMTs were diagnosed as GIST originated from ICC. No pure myoid nor schwannian (or neural) differentiation was seen in this series.
All tumors including one with liver metastasis were resectable. All the patients is still alive.
We need further accumulation of clinical cases to know malignancy and prognosis for GIST.

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Primary duodenal cancer is a rare disease that accounts for 0.8-2% of all gastrointestinal malignancies. Surgical resection is only the curative treatment, but optimal treatment opinion has not been established. We have experienced seven patients with primary advanced duodenal carcinoma so far, and successfully performed radical pancreatoduodenectomy for them. All tumors were at the second portion of the duodenum, and large over 50mm in maximum diameter. Tumors were resected safely in all patients, no local recurrences occurred after the operation. Pancreas invasion was seen in six patients, and lymph node metastasis was detected in three patients, however, the 5-year survival rate (66.7%) was excellent compared to prognoses of other periampullary tumors. Consequently, we should make an attempt to perform surgical treatment for primary duodenal cancer, if pancreas invasion or lymph node metastasis is suspected in preoperative examination.

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The usefulness of laparoscopic appendectomy (LA) was studied in terms of its need assessment based on exploratory therapeutic results and a questionnaire survey. Subjects were 62 cases undergone LA at the hospital from October 1997 to August 1999. Their ages ranged from 7 to 81 years. LA using three trocars was employed, and a 10/12mm trocar to the umbilical region, a 5/7mm trocar to the right flank, and a 5/7mm trocar to the superior extremity of the pubis were inserted. Mesentery and the root of the appendix were ligated in the body with 1-0 silk thread, and then the appendix was resected by mean of ultrasonic coagulotomy. As a result, the ratio of converting to laparotomy was 3.2%. Mean operating times were 98±38 min (n=15) in gangrenous appendicitis and 65±18 min (n=15) in non-gangrenous appendicitis (p<0.01). Complications included bleeding at the sites of inserting trocars in one case and intraabdominal abscess in one case in the early time of the study. A questionnaire survey revealed that 89.0% of the subjects answered preferably to select LA than laparotomic appendectomy.
It is concluded that LA is an established technique and is benificial in cosmetic merit as well as in the differential diagnosis of gynecological emergency disorders. In the explanation of operative procedures for appendectomy, we must explain LA to pay respect to the patient's right to choice the therapeutic method.

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We studied the results and complications of nonoperative treatment of 130 cases of hepatic injury during the past 14 years and 7 months.
According to our protocol, nonoperative treatment was used for hemodynamically stable patients after rapid drip infusion.
Of 130 hepatic injuries, an operation was performed in 14 cases, and nonoperative management was attempted in the remaining 116 cases, including 12 cases which received transcatheter embolization for the hemostat of active bleeding. Nine patients had complications: biloma, delayed rupture, and lung embolism. Nonoperative treatment should be combined with intensive care of the patient, and there should be no delay in shifting from nonoperative treatment to laparotomy when necessary.

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A series of 30 cases of femoral hernia which were operated on at the hospital in a recent 12-year period were clinically studied. There were 28 women and two men with a mean age of 73.2 years old. Swelling of the inguinal portion was the most common complain seen in 23 patients, followed by symptom of ileus in four patients and another symptoms in three patients. There were 18 patients with right femoral hernia, 10 patients with left femoral herunia and two patients with bilateral femoral hernia. All cases were diagnosed by physical examination. The diagnosis was made by palpation of the inguinal portion in the three patients with another symptoms and in the lateral lesion of two patients with bilateral femoral hernia. Incarceration occured in five patients (16.7%) who underwent an emergency operations. Of these five patients, two patients demanded resection of the intestine because of necrosis of the small intestine. Post operative complication occured in one out of the two resected patients whose wound healing delayed. Mean postoperative hospital stay in the incarcerated cases was longer than that in the non-incarcerated cases. We should make efforts to prevent the patients who are often elderly women from incarcerating of the hernia by careful routine medical examinations.

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Two-hundred and sixteen infants and children with foreign bodies being observed in the digestive tract have been experienced in our department for the last 34 years.
As our basic guidelines for treatment, esophageal foreign bodies are immediately removed from the esophagus, and foreign bodies from the stomach through the anus are observed as a rule, but button-shaped battery is removed by using a magnet catheter and dangerous sharp ones by endoscopy. Foley catheter is helpful, if magnetic catheter alone fails in removing. Operation in indicated for cases of perforation or intestinal obstruction. About 90% of observed foreign bodies are excreted spontaneously within 2 weeks. Relation between the size of foreign body and spontaneous excretion is obscure.
The coin was the most common foreign body, followed by button-shaped battery, nail, plastic, tack, and needle, which were swallowed by mistake. In 150 out of 216 cases, foreign bodies were excreted spontaneously, but four cases needed surgery. Two cases of an opened safety pin showed perforation in the stomach, and in the duodenum, respectively. Two cases of bezoar occupied the stomach cavity as alarge mass. Mediastinitis caused by foreign body in the esophagus in two cases were able to be conservatively treated.

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We report a 16-year-old famele who was found to have a non-recurrent inferior laryngeal nerve during surgery for papillary thyroid carcinoma complicating Graves' disease. The carcinoma was found in the right lobe of the thyroid during treatment of Graves' disease with antithyroid agents. Decreased T₃ and T₄ levels, increased TSH level, a positive thyroid rest, positive microsome test, and negativity for thyroglobulin antibody were observed. Computed tomography of the heck revealed a tumor in the upper right lobe of the thyroid and blood vessels around the trachea and posterior aspect of the esophagus. In addition, thyroid scintigraphy showed accumulation of ²⁰¹T1 and absence of ^99mTc in the superior portion of the right lobe of the thyroid. Fine-needle aspiration biopsy confirmed papillary carcinoma. Total thyroidectomy and modified neck dissection of the right side of the neck were performed because metastasis was found in the pretracheal lymph nodes. The left recurrent laryngeal nerve was located in its normal position, but the vagus nerve branched perpendicularly to give rise to the right recurrent as it coursed toward the larynx. The tumor (2.2×2.0×1.8cm in size) was found in a biopsy specimen obtained from the top of the right lobe. Iodine therapy (¹³¹I) was performed, and no relapse has been detected during close monitoring of the clinical course.

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A 54-year-old man was admitted to our hospital because of thyroid papillary carcinoma invading the upper mediastine. We performed an operation against local recurrence 3 times after the first operation for the primary lesion. Lung metastasis appeared about 6 years after the first operation, and we tried various kind of therapies, such as ¹³¹I therapy, external radiotherapy, chemotherapy, and immunotherapy, but none of them could control the metastatic lesions. Finally, hemoptysis from lung metastases occurred and it was controlled by BAE (bronchial artery embolization). The patient also had painful skin metastases, which were resected. We consider that the establishment of a new therapy for patients with thyroid papillary carcinoma which is effective and which supports QOL is very important.

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We report a case of early male breast cancer which localized in the superficial part of the nipple.
A 65-year-old man was seen at the hospital because of swelling and erosion of the right breast. Paratripsis cytology of the erosion resulted in Class V and Paget cells were also confirmed. No tumorous lesions were found in the mammary tissues. With a diagnosis of breast cancer localized in the nipple, a mastectomy with axilary lymph nodes dissection was performed. In the resected material, the lesion was localized at the depth of 4mm from the nipple erosion, and was 12×12×4mm in size. No cancer cells were present in mammary tissues. Histologically, it was solid adenotubular carcinoma, and Paget cells having clear cytoplasm were demonstrated in the stratum basale of epidermis.
This case on which no tumor was present in the breast and the lesion was localized in the nipple is considered to be classified into Paget cancer. However, infiltration besides ductal invasion was prominent that suggests a difference from ordinary Paget cancers. Further strict observation of the clinical course would be demanded in this case, because infiltration into the lymphatic vessels was also confirmed.

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von Recklinghausen's disease is often associated with neural malignant tumor, but the association of epithelial malignant tumor is rarely reported. This paper describes a case of breast cancer associated with von Recklinghausen's disease.
A 54-year-old woman was seen at the hospital becuse of a left breasttumor. Café au lait spots were noticed on the whole body skin. Fine needle aspiration cytology revealed breast cancer. Modified radical mastectomy (Br+Ic+Ax) was performed. Histopathologically, the breast tumor was papillo-tubular adenocarcinoma, and tnm clasification was t2n2m0 in stage III. Both estrogen and progesterone receptor were negative by EIA method. But immunohistochemically, positive reactions against anti-bodies of cerbB-2 and p53 protein were noted. We could not find any reports association of breast cancer and p53 protein in case of von Recklinghausen's disease, and thought that these findings were interesting. Adjuvant chemo-endocrine therapy was added, but 5 months after the operation recurrence was noticed. The patient died 3 years after the operation. Fifty-four cases of breast cancer with von Recklinghausen's disease have been reported in the Japanese literature. Most cases are in stage II or more advanced stage that might be derived from delayed diagnosis due to skin lesion. Careful observation is necessary for early detection of breast tumor in case of von Recklinghausen's disease.

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A rare case of carcinoma of accessory breast tissue is reported, which was suspected to be lymphoadenitis. A 44-year-old woman was admitted to our hospital because of a painful mass in the left axillary region. Physical examination revealed a mass 1.5cm in diameter, movable and with tenderness. Under the diagnosis of lymphoadenitis, an excisional biopsy was performed. Histological examination showed medullary carcinoma surrounded by normal mammary-gland tissue. So we performed a second operation. Wide resection of the left axillary region accompanied by resection of the biopsy scar, axillary tail of the left breast, and lymph-node dissection was done. No residual tumor was seen in the specimen, and the axillary tail was completely intact. A definite diagnosis of medullary carcinoma of accessory breast tissue with no lymph-node metastasis was made.
Following radiation therapy to the axillary region, this patient is being observed periodically.

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The patient was a 44-year-old woman, whose chief complaint was a mass in the right chest. Eight years previously, an approximately 8mm mass had been found at the right chest and left shoulder, for which excional biopsy was performed. The pathological diagnosis was steatocystoma multiplex. This time, the mass was found in the B-region of the right breast. The patient did not see a doctor at first because she thought it was the same as the previous mass, but when it increased in size rapidly, she came to our hospital. For a definite diagnosis, we performed excision biopsy. In the frozen-section diagnosis, we could tell that the specimen was mucinous carcinoma, though it was difficult to determine whether it was mucinous carcinoma of breast tissue origin or eccrine gland origin. Later, under a diagnosis of mucinous carcinoma of breast tissue origin, we performed the Auchincloss' operation. Mucinous carcinoma is a relatively rare form of the breast cancer. Most cases may be clearly diagnosed as being of breast tissue origin, but this case was very difficult to distinguish from mucinous eccrine carcinoma. From pathological data, we definitively diagnosed it was mucinous carcinoma from breast origin. When we encounter a subcutaneous mucinous tumor of the breast, we should consider not only skin origin but also breast origin.

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This paper presents a long-term survivor with three operations for pulmonary metastases following resection of colon cancer. The patient was a 68-year-old man. There was a previous history of undergoing a colostomy for ileus duo to cancer of the sigmoid colon, followed by sigmoidectomy on February 14, 1992. He had no liver metastasis, and pathologically it was moderately differentiated adenocarcinoma, without lymph node metastasis.
Sixteen months later after the sigmoidectomy, a CT scan showed a coin lesion, 30mm in diameter, in the S₄ area of the left lung, for which wedge resection was performed. Pathological findings showed metastatic adenocarcinoma from the colon cancer.
Eight months after the thoracotomy, metastases were found in the S₈ and S₄ areas of the right lung. They were resected by wedge/segmentectomy. The pathological findings again showed metastases from colon cancer.
Sixteen months after the second thoracotomy, a mass lesion was detected in the right lower lobe. A right middle and lower lobectomy and a resection of the part of the diaphragm were performed. The metastatic tumor of the middle lobe was 25mm in diameter, and that of the lower lobe was 70mm in diameter. Both were confirmed to be metastases from the colon cancer.
The patient is alive without any signs of recurrence, 7 years following the initial surgery. It is desirable to perform repeatal thoracotomies aggresively for repeatal pulmonary metastases of colorectal cancer, which might promise good outcomes. Some bibliographical comments are also presented.

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A 34-year-old man had had an episode of steering-trauma in a traffic accident when he was 25 years old. He visited a hospital with chief complaints of sudden chest pain and cold sweating. A chest x-ray revealed a slight elevation and an indistinct line in the right diaphragm. Just at that time, cardiac arrest caused by myocardial infarction occurred and cardiopulmonary resuscitation was performed. The patient was transferred to our hospital and his life was saved. A chest x-ray revealed the collapse of the right lung and intestinal gas shadow occupying the whole right pulmonary field. We speculated that this diaphragmatic hernia induced by cardiopulmonary resuscitation originating from an old diaphragmatic rupture. Findings of the emergency operation under thoracolaparotomy showed that the diaphragm was almost defective and the stomach, greater omentum and small and large intestines were translocated to the pleural cavity. An operation was performed in which the peritoneal organs were replaced and the right diaphragm was reconstructed.
Surgery is indicated for this condition immediately upon diagnosis. We need to bear this conditionin mind when listening to details past history, as one of several traumas and diseases with long latentperiods.

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A 62-year-old man who had been administered proton pump inhibitor for gastroesophageal reflux disease (GERD) was admitted to the hospital because of heart burn with dysphasia constricts. On admission, he could take only liquid diet and sometimes complained of nausea and vomiting. The middle part of the esophagus was severely stenotic and the upper esopiagus was specially ballooning. The fiber scope couldnot pass through the stenotic region into the stomach. The results of 24 hours pH monitoring in the esophagus were: (1) there were 9 times of acid reflux for longer than 5 minutes (pH below 4.0); (2) incidence of pH below 4.0 was 26.3%; and pH above 7.0 amounted to 31.1%.
We treated this patient with modified Collis-Nissen procedure and thn evaluated the expandable metaric stent (EMS) into the esophageal stenotic portion. The postoperative course was uneventful. The patient could take common diet and the incidence of pH below 4.0 decreas 0.9%.
Sometimes, GERD induces esophageal stenosis regardless of medication of proton pump inhibitor or H2 receptor antagonists. So we should keep surgical tratment in mind before occurrence of the esophageal stenosis.

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This paper presents an interesting case of esophageal cancer with Barrett's esophagus in which mucinous carcinoma, adenocarcinoma and signet-ring cell carcinoma coexisted through the esophagus.
A 77-year-old man was admitted to the hospital because of dysphagia and cough. Examination revealed a stenosis over the entire circumference of the Iu-Ei regions and a hiatal hernia of the esophagus. Histological diagnosis of biopsied specimen was advanced esophageal cancer composed of mutinous carcinoma, tubular adenocarcinoma and signet-ring cell carcinoma concomitantly.
Subtotal esophagectomy, lymph nodes dissection of the thoracic and abdominal region, reconstruction using gastric tube through intrathoracic route, and a cholecystectomy were performed. Histologically, mucinous carcinoma was present in the Barrett's epithelium, with coexisting tubular adenocarcinoma and signet-ring cell carcinoma. The invasion depth of the tumor was adventitia of the esophagus. After the operation, a radiation therapy was added. The patient was discharged from the hospital on 107-hospital day. No evidence of recurrence has been observed, as of 9 months after the operation.
To our knowledge, there has been only one case of esophageal cancer composed of mucinous carcinoma, tubular adenocarcinoma, and signet-ring cell carcinoma, concomitantly. This extremely rare case is presented.

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A 42-year-old man was seen at the hospital because of severe abdominal pain. Panperitonitis due to perforation of the gastrointestinal tract with hepatic portal venous gas (HPVG) was diagnosed on radiological and physical examinations. He underwent on emergency subtotal gastrectomy. The postoperative course was uneventful and hepatic portal venous gas disappeared on the 5th postaperative day. He was discharged from the hospital on the 14th day after the operation.
HPVG is believed to be a sign of severe intestinal necrosis. With a recent widespread use of various imaging methods, even small quantity of gas can be visualized with a resultant increase in reports of HPVG which are of less clinical significance. However, we think that such cases of HPVG with good prognosis are few and HPVG is still an important sign suggestive of intraabdominal catastrophes, though it is rare. Once HPVG is noticed, careful and appropriate treatment would be mandatory.

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We recently experienced two patients with gastric metastasis from breast carcinoma.
Patients 1; a 45-year-old woman, who had a history of undergoing radical mastectomy for left breast cancer 3 years before, was seen at the hospital because of massive ascites. We found a submucosal tumor-like lesion in her stomach by an endoscopy. The pathologic findings of the biopsy specimens were compatible with gastric metastasis of invasive lobular carcinoma of the breast. Although chemotherapy was given, the patient died 5 years after the first operation. Patients, 2; a 58-year-old woman, was considered having gastric metastasis of invasive lobular carcinoma of the breast. The patient died of liver dysfunction 6 months after the radical mastectomy. We should pay careful attention to possible occurrence of metastatic involvement of the gastrointestinal tract in patients with advanced breast cancer or those having previous history of breast cancer.

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A 68-year-old man was admitted to our hospital with complaints of tremor and bilateral arm numbness. An MRI of the head showed multiple cerebral infarctions. Abdominal CT scanning detected a cystic tumor of the upper abdomen and angiography revealed that the tumor was fed by the splenic artery. Intraoperative findings determined that the tumor originated from the stomach with signs of dissemination. Total gastrectomy, distal pancreatectomy, splenectomy, and transverse colon resection were performed. The resected specimen was 30×23×10cm with signs of central necrosis. Histological and immunohistochemical studies of the specimen disclosed many mitosis, and that it was negative for vimentin, s-100, SMA, some areas were partially positive for NSE, and positive for CD34. This tumor was identified as a maligmant gastrointestinal stromal tumor, uncommitted type.

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We have sugically managed three cases of cancer arising in the reconstructed stomach tube following operation for esophageal caner.
Patient 1, a 63-year-old man who had undergone a subtotal esophagectomy with reconstruction by stomach tube via retrosternal route in 1973, was found to have type 3 advanced gastric cancer at the reconstructed stomach tube 9 year after the operation. The patient underwent a distal resection of the stomach tube, but died of local recurrence of stomach tube cancer 2 years and 2 months after second operation. Patient 2, a 62-year-old man who had undergone a subtotal esophagectomy with reconstruction by stomach tube via retrosternal route in 1977, was found to have a IIa+IIc type early gastric cancer at the reconstructed stomach tube 7 year after the operation. A distal resection of the stomach tube was carried out. The patient is still alive as of 4 years after the reoperation. Patient 3 was an 83-year-old woman who had undergone a subtotal esophagectomy with reconstruction by stomach tube via retrosternal route in 1972. Thirteen years later, type IIa early gastric cancer was detected in the reconstructed stomach tube and EMR was performed. The patient is still alive as of 2 years and 6 months after EMR. Two patients who were able to be detected having cancer by screening are living and well without any sign of recurrence. We think that long-term periodic endscopic examinations are mandatory for postoperative patients with esophageal cancer by entertaining the possible occurrence of the stomach tube.

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A case of superior mesenteric artery syndrome with gastric perforation in a 16-year-old woman is reported. The patient was admitted to the hospital because of abdominal pain and vomiting. Conservative therapy was started with a suspicion of superior mesenteric artery syndrome, but 2days later the abdominal pain was intensified. Emergency operation was performed with a diagnosis of generalized peritonitis. At laparotomy, gastric perforation associated with superior mesenteric syndrome was diagnosed. Partial gastrectomy and dissection of the Treitz' ligament were performed. The postoperative course was uneventful.
Dissection of the Treitz' ligament that is minimal invasive is thought to be an appropriate procedure for patients with the disease in poor general condition.

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We successfully saved a patient with pancreatoduodenal injury with situs inversus totalis by a pancreatoduodenectomy. A 46-year-old woman was brought to the hospital by ambulance because of a traffic injury. At the first medical examination, tenderness and muscular defense were noted in the left upper quadrant. X-ray films of the chest and abdomen showed dextrocardia and stomach bubble subphrenically on the right side. A CT scan of the abdomen revealed visceral inversion, enlargement of the pancreatic head, and a low-density area in the left anterior pararenal retroperitoneal space. We diagnosed the case as acute peritonitis due to traumatic injury of the pancreas, and performed an emergency laparotomy 3 hours after the injury. At laparotomy, there were about 500ml of bloody ascites and a fluid retention mixed with bile juice. And complete transections of the pancreatic head and descending part of the duodenum were revealed. Both lesions were resected.
All of the abdominal viscera showed right and left transposition. The visceral inversion did not constitute an intraoperative problem.

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There have been only 26 cases of gastroduodenal Crohn's disease with stenotic lesion reported in Japan. We report a case of resected duodenal Crohn's disease presented with duodenal stenosis in an elderly patient. A 66-year-old man had begun to suffer from nausea and vomiting ten years before. An endoscopic examination found a diffusely granular appearance in the bulbs, and the endoscope could not pass through the duodenum because of a stenosis. An upper GI series examination revealed a marked circular constriction about 3cm in length between the pyloric ring and the second portion of the duodenum. Partial resection of the stomach and duodenum was performed. The resected specimen showed a longitudinal ulceration and a cobblestone appearance in the duodenum. Histopathological examination showed the non-caseating granulomas scattered through the bowel. The patient is alive and well without any signs of recurrence one year after surgery.

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An 81-year-old woman was admitted to the hospital because of right upper abdominal pain and melena. Bleeding from the small intestine was suspected as a cause of melena, because we could not detect any bleeding lesion by gastrointestinal fiberscopy and total colonofiberscopy.
The patient appeared systemically well, and was treated conservatively. On the 47th day after the onset of symptoms, the patient exhibited symptom of ileus. Barium-meal studies revealed a long stricture about 30cm in length of the jejunum 25cm distal to the Treitz ligament, Angiography from the superior mesenteric artery (SMA) showed obstruction of major branches of SMA. Despite adequate hyperalimentation, the patient presented remarkable hypoalubuminemia. Extravasation was seen in the strictured jejunum by ⁹⁹mTc-labeled albumin scintigraphy. So, we diagnosed the case as ischemic stricture of the jejunum with protein-losing enteropathy.
A partial resection of small intestine was carried out on 99th day after the onset, the resected jejunnum showed firm tubular stricture 33cm in length, with ulceration (UL-II) and fibrosis. These features were strongly suggestive of an ischemic process.
It is rare that ischemic stricture of the jejunum causes protein-losing enteropathy. This rare case in which extravasation of protein was successfully demonstrated on imaging procedure is reporoted here.

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We report a case of small intestinal tumor diadnosed by ultrasonography-guided needle aspiration cytology. A 58-year-old woman was admitted to the hospital because of melena and severe anemia, Hb was 6.9g/dl and RBC was 249×10⁴/μl. Although both upper and lower digestive tracts were routinely examined, no abnormal findings were seen. Radiography of the small intestine revealed a type 2 tumor with deep ulceration in the jejunum at the site of 10cm to the Treitz's ligament. Endoscopic examination of the small intestine identified submucosal tumor with ulceration at the same part. Ultrasonic examination revealed a mass with the size of 2cm. An ultrasonography-guided needle aspiration cytology was performed. Obtained specimen showed spindle cells that were similar to myogenic cells. A partial jejunectomy was performed. Histology showed that the ressected tissue contained dysplastic cells with few mitotic cells in a high power view field. In conclusion, it was diagnosed as stromal tumor, smooth muscle type, borderline malignancy of the jejunum. This ultrasonography-guided needle aspiration cytology contributed to make qualitative diagnosis in this case.

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A 19-year-old woman was admitted to the hospital because of lower abdominal tumor with complaints of fever, nausea, and vomiting. Laboratory findings showed leukocytosis (13300/mm³) and CRP elevation (9.8mg/dl). Computed tomography and ultrasonography revealed an intraperitoneal tumor measuring approximately 14cm in diameter, in which air and fluid were found. At first, antibiotics were given to the patient for the treatment of intraperitoneal abscess. Although inferior mesenteric arteriography revealed tumor stains, colonofiberscopy showed no abnormal findings. At laparotomy on the twentythird day, a large tumor 13.0×15.5×5.5cm in size growing extramurally was found at the antimesenteric side of the jejunum, 15cm distal from Treitz's ligament, which was combined with an abscess caused by central necrosis of the tumor and fistula formation to the mucosa. Partial resection of the affected jejunum was performed. Histological findings showed leiomyosarcoma of the jejunum.

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A 77-year-old woman was admitted to the hospital because of right lower abdominal pain, and an emergency operation was performed. At laparotomy, the appendix swelled like a sausage 12×4cm in size and was twisted clockwise by 360 degree at the root of the appendix. An appendectomy was performed with a clinical diagnosis of torsion of appendiceal mucocele. Preoperative diagnosis was relatively difficult, because it presents clinical symptoms similar to appendicitis and is a rare entity. However, it may be possible by CT scan of the abdomen which shows a cystic mass in the right lower abdomen and a projection of a beak in shape toward the ileocecal region.
We present a case of torsion of appendiceal mucocele which is rare in the Japanese literature, with some bibliographical comments.

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We report a case of goblet cell carcinoid of the appendix. A 54-year-old man was seen at the hospital because of melena and abdominal pain of the right lower quadrant. On physical examination, a hen-egg-sized tumor was palpated with tenderness and muscle rigidity. CT scan and US showed a round-shaped mass, measuring 5cm in diameter, in the right lower abdomen. When a laparotomy was performed under the diagnosis of acute appendicitis with abscess, there were a firm tumor invading the ileum and markedly enlarged lymph nodes suggestive of metastasis along the ileocolic artery. Appendiceal cancer was diagnosed intraoperatively and an ileocecal resection with lymph node dissection of the ileocolic artery region was performed.
Histopathological examination revealed that the tumor was goblet cell carcinoid. Postoperatively, the patient received 6 courses of chemotherapy (Leucovorin-5FU) and has been doing well without recurrence to date. To our knowledge, only 58 cases have been reported in Japan.

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An 81-year-old woman who was suffering from dementia since one year before was admitted to the hospital because of abdominal pain lasting for 10 days and increasing abdominal distension. The abdomen showed remarkable muscular defense. Plain abdominal X-ray film and abdominal CT scan showed intraabdominal free air. With a diagnosis of perforation of the digestive tract, and emergency laparotomy was performed. Turbid ascites was present in the abdominal cavity and foreign body caused multiple perforation from the descending to sigmoid colons. For these findings, left colectomy, lavage, drainage and transverse colostomy were carried out. It was found that vinyl cords filled the resected colon. Later it became clear that the patient had eaten Goza made of vinyl cords under the impression it was buckwheat noodles. Pica is a symptom of dementia. Therefore, it may be necessary to entertain the possible diagnosis of pica in the treatment for abdominal pain in demented senium.

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A 66-year-old woman was admitted to the hospital for low abdominal pain and vomiting in July 1998. She had undergone graft repair for abdominal aortic aneurysm in February 1997. Colonoscopy and a barium enema study revealed a whole circumferential stricture of the sigmoid colon. She was treated conservatively for two months, but her symptoms did not disappear. Therefore, low anterior resection was performed in September 1998. On histological examination, the specimen showed necrosis and fibrosis with ischemic colitis, but no malignant change. Thereafter, her right thigh was amputated for necrosis due to arteriosclerosis obliterans in December 1998, and she was discharged from the hospital subsequently. We report this case together with a review of the literature.

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Colonic stenosis associated with ulcerative colitis without malignant tumor is very rare with only eight cases reported in Japan. A case of total colonic type of ulcerative colitis with severe stenosis of the transverse colon is reported. A 37-year-old man had been complaining of abdominal pain and diarrhea, and diagnosed as having ulcerative colitis since 1979. In 1998, he was admitted to the department because of vomiting and abdominal pain. Barium enema and colonoscopy revealed stenosis around the entire circumference of the transverse colon measuring about 10cm in length. Right hemicolectomy was performed because possible association of malignant tumor could not be ruled out. Histopathologically, inflammatory cells like polymorphonuclear leukocytes which infiltrated into mucosa and submucosa, hypertrophy of muscle layer, and fibrosis covering from submucosa to subserosa were observed. No malignancy was seen.

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A 72-year-old man was admitted to the hospital because of pyrexia and dry cough. After admission, he complained of a severe leg pain. Angiography demonstrated an iliac arterial embolism, which was successfully removed. Gram-negative rods existed in the thrombus. Under the diaignosis of endocarditis associated with mitral valvular prolapse syndrome, the patient was placed on antibiotics.
During its course, pelvic MRI and angiography revealed a left iliac arterial aneurysm. Colonoscopy showed the transverse colon carcinoma incidentally. For treatment of the concomitant mycotic aneurysm and colon carcinoma, we selected simultaneous operation. The patient followed an uneventful postoperative course.
There has been no another case of simultaneous operation for mycotic aneurysm associated with colon carcinoma other than our case as far as we could review. This uncommon case together with some bibliographical comments is presented.

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Alpha-fetoprotein (AFP) is a reliable tumor marker for the diagnosis and monitoring of primary hepatoceller carcinoma and yolk sac tumors. Elevated serum AFP levels have also been frequentlly reported in patients with carcinoma of the stomach, pancreas, bile duct, duodenum, colon and rectum. Though most of these disease are of the fore-gut derivations, colorectal lesions are hind-gut derivations and AFP-producing carcinoma of a colorectal lesions are rare. We report one case of AFP producing carcinoma that originated in the transverse colon. The patient is a 73-year-old man with a chief complaint of general fatigue. CT scanning determined a diagnosis of transverse colon cancer, therefore transverse colon resection, partial gastrectomy and partial ileum resection were performed. Histologic examination of the transverse colon showed poorly differentiated adenocarcinoma and immunohistochemical staining detected AFP-producing cells. To our knowledge, AFP-producing colorectal carcinoma were reported in 38 cases in the Japanese literature.

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There have been only a few case reports demonstrating successful surgical treatment of intrapelvic recurrence from colon cancer. We report a patient who underwent a curative resection for recurrent colon cancer lesions in the pelvis and abdominal incision scar. A 38-year-old woman underwent a sigmoidectomy (D2) for advanced sigmoid colon cancer at another hospital. The resected tumor was well-differentiated adenocarcinoma invading the serosa, categorized in Dukes' B stage. Fifteen months postoperatively, she was found to develop a pelvic mass growing with an increase in serum carcinoembryonic antigen level. A combination chemotherapy with 5-fluorouracil and leucovorin was given, resulting in no response. She was admitted to the hospital for the additional treatment. Physical and radiographic examinations revealed a 7.0×5.0cm pelvic mass, and a 2.0×1.0cm mass, in the abdominal incision scar. There were no findings susceptible of malignancy other than these tumors. The patient was successfully operated on again 19months after the initial operation. Operative procedures included proctectomy with colostomy, hysterectomy, bilateral oophrectomy, and resection of the abdominal wound mass. Histological examination revealed that the masses in the pelvis and incision scar were compatible with recurrence of the sigmoid colon cancer. These have been no signs of recurrence as of 11 months after the third laparotomy.

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A 17-year-old woman presented to our hospital with a complaint of pain around the anus and was admitted on suspicion of perianal cystoma. The cystoma was found to be a parenchymal tumor, and examination of a biopsy specimen revealed cystic rhabdomyosarcoma that appeared to have arisen in the anal sphincter. Abdominoperineal resection of the rectum was performed and followed by adjuvant chemotherapy (VAC therapy) and radiation therapy. The patient remains free of relapse as of 6 years 9 months after treatment. The other patient was a 21-year-old woman who presented with swelling of the left inguinal lymph nodes and perianal pain. Colostomy was performed to relieve anal obstruction caused by a perianal tumor. Biopsy revealed cystic rhabdomyosarcoma. The patient had bone metastasis and lymph node metastasis and died 3 months after the operation. Twenty-five cases of perianal rhabdomyosarcoma have been reported in Japan. A review of the literature suggests that although recent advances in chemotherapy have contributed to improving the survival rate, it appeares necessary to completely resect the tumor, and follow it by appropriate adjuvant chemotherapy.

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A 37-year-old woman was seen at the our hospital because of a cystic lesion in theliver detected at a medical checkup in June, 1998. CT scan and ultrasonography revealed a multilobular cystic tumor 6cm in size in the posterior segment of the liver. The cystic wall was smooth and thin with thickened septem partially, indicating tumorous change. Under a guide of ultrasonography, the tumor was punctured to aspirate a liquid in it. The retained fluid was serous and revealed CEA level of 2, 210ng/ml and CA 19-9 of 120, 000U/ml. Hepatic cystadenoma was suspected, but a possibility of cystic adenocarcinoma could not be ruled out. So the tumor was removed and the definite diagnosis of hepatic cystadenoma was made. So far, 34 cases of hepatic cystadenoma have been reported in Japanese literature. Hepatic cystadenoma and hepatic cystadenocarcinoma were difficult to distinguish before resection. Additionally, hepatic cystadenocarcinoma arising from hepatic cystadenoma have been reported in Japan. Since hepatic cystadenoma has malignant potential, its early resection is recommended.

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Typical pathological type of carcinomas in the biliary tract is adenocarcinoma. In rare occasions, partial squamous cell carcinoma components can be found in these cancer tissues, although pure squamous cell carcinoma is hardly encountered. We herein report a case of a 63-year-old man with the complaint of jaundice, whose tumor was successfully resected by a pancreatoduodenectomy. A pathological study revealed pure squamous cell carcinoma originating from the lower common bile duct. Previously published articles have inferred cancer change subsepuent to squamous metaplasia or metaplastic change of adenocarcinoma as the origin. However, the etiology of this rare tumor has not been elucidated as yet. Further investigations are essential for understanding of the tumor.

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A 71-year-old woman was admitted to the hospital because of obstructive jaundice in June 1998. There were previous histories of undergoing a rihgt colectomy for ascending colon cancer on May 18, 1993 and an extended left lobectomy of the liver for hepatic metastasis on July 31 1997. After admission an abdominal CT showed a 2.5cm diameter solid tumor at the retropancreatic head region. We diagnosed the mass as retropancreatic lymph node involvement from metastatic lesion of the liver. We performed pancreatoduodenectomy because there was no evidence of other metastasis. The patient has no signs of recurrence one year after the operation. It is suggested that resection for the lymph nede involvement from hepatic metasitasis which is derived from colorectal cancer is beneficial to prolong the survival time, if no other metastic foci are present.

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Conservative treatment is rarely successful for patients with delayed rupture of the spleen. We report a case with successful transcatheter arterial embolization (TAE) of the splenic artery for rebleeding of delayed splenic rupture.
A 64-year-old man fell down the stairs. Three days later, he came to our hospital because of persistent severe pain in his left chest. CT and X-ray revealed a fracture of spinous process of the 7th cervical spine and fractures of the right 2nd and left lst, 2nd, 8th and 9th ribs. He was admitted to the hospital, but he fell into hemorrhagic shock suddenly on his 7th hospital day. An abdominal CT demonstrated an intraparenchymal hematoma of the spleen with fluid retention in the peritoneal cavity. We diagnosed a delayed rupture of the spleen and placed the patient under conservative management. Two days later, he fell into hemorrhagic shock again, and an abdominal CT disclosed rebleeding from the spleen. Though no bleeding point could be detected by emergentcy angiography of the splenic artery, hemostasis was completed by TAE. Thereafter, he was discharged uneventfully on the 65th day. Non-surgical management for delayed splenic rupture is acceptable, and TAE is the method of choice in high-risk cases, including patients with liver cirrhosis.

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We report a case of splenic abscess ruptured into the peritoneal cavity. A 71-year-old man was admitted to Suwa Central Hospital because of abdominal pain and vomiting. He had severe tenderness with muscle guarding in the entire abdomen showing generalized peritonitis. The blood examination revealed left shift of leukocyte-neuclei and high serum level of C-reactive protein. Ultrasonogram and computed tomogram of the abdomen showed mild splenomegaly, a space-occupying lesion and acites. From these findings generalized peritonitis due to ruptured splenic abscess was suspected. Splenectomy and drainage were performed on the sameday. However, he died of seplicemia and multiple organ failure on 50th postoperative day. Although the mortality of patients with splenic abscess has been gradually improved, ruptured cases such as this patient shows a high mortality. We consider that early diagnosis and prompt treatment of this disease, and prevention of postoperative complications are important to save patients with ruptured splenic abscess.

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A 48-year-old man with chronic renal failure underwent placement of a continuous ambulatory peritoneal dialysis (CAPD) eatheter using a microlaparoscopical surgical technique. He had previously undergone appendectomy due to appendicitis with panperitonitis and left nephrectomy due to hydronephrosis of unknown origin. Under general anethesia, the patient was placed in a supine position. The 2mm Minisitegold was inserted through a 2mm introducer placed in the left paraumbilical area. Multiple adhesions between the bowel or emontum and the peritoneal surface of the anterior abdominal wall were detected. Adhesiolysis was perfomed with a Microscissors, then a 10mm port was placed in another site. A CAPD catheter was inserted through this second port, and the distal end of the catheter was guided into the pelvic cavity under direct visualization. To prevent leakage, the peritoneum around the catheter was closed by Endoclose and 1-0 Vycryl. This technique proved to be safe, effective and non-invasive.

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Endometriosis is a disease in which endometrial tissues grow in locations outside the uterus. Of such ectopic sites, the intestine has been increasing recently. In this paper, we present a case of endometriosis of the ileum presented with intestinal obstraction which is relatively rare, together with a review of 23 domestic cases.
A 25-year-old woman was seen at the hospital because of right lower abdominal pain. Acute appendicitis or localized peritonitis was suspected from abdominal findings. An emergency operation was performed, when the appendix vermiformis and ovary were normal grossly and a ring like stenosis was confirmed at the terminal ileum. A biopsy of the wall of the small intestine and a plasty for the stricture were performed. Pathological diagnosis was endometriosis of the ileum. No remission of the intestinal obstruction could not be attained after the operation, and an excision of the ileocecum was carried out.
Since endometriosis of the intestine presents difficulty in diagnosis, it must be kept in mind as a probable cause of intestinal obstructiton.

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A 31-year-old female had been diagnosed with endometriosis in 1996 and received hormone therapy for endometriosis, which was effective, but she began to notice pain on defecation and left back pain during menstruation in 1997. In December 1998, she entered our hospital and laparoscopic ovarian cyst excision was performed. The rectum, sigmoid colon, and left ovary were densely adherent and also strongly stuck to the Douglas pouch. After the operation, endometriosis of the rectum was diagnosed by colonoscopy and barium enema. Another operation was thought to be required because rectal stenosis was severe, but an operation at this point was predicted to be difficult, so preoperative hormone therapy with LH-RH analog (leuprorelin acetate, 3.75mg/month) was given for 5 months first. After hormone therapy, the patient did not complain of pain on defecation, but there was still a possibility of recurrence. On July 1, 1999, low anterior resection with partial left uretectomy was performed. Exploration of the peritoneal cavity showed improvement of pelvic adhesion that demonstrated a significant effect of preoperative hormone therapy.

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We herein report two patients with endometrial carcinoma who were under medication with tamoxifen as adjuvant therapy for breast cancer. A 70-year-old woman presented with vaginal bleeding who had been given tamoxifen 20mg daily for 8 years prior to admission. Curettage biopsy of the uterine endometrium confirmed the diagnosis of endometrial carcinoma. After receiving a cycle of preoperative chemotherapy with CDDP, CPM and EPI (CEP), she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histologically, it was well differentiated adenocarcinoma in Stage Ib (G2). There is no evidence of malignancy 37 months later. Another patient, a 66-year-old woman, had been receiving tamoxifen 20mg daily for 5 months after surgery. Endometrial carcinoma was diagnosed after repeated cytology. She was treated by total abdominal hysterectomy with bilateral salpingo-oophorectomy. Histologically, it was adenosquamous carcinoma in Stage Ib (G1). Postoperatively, she received two cycles of CEP. There has been no evidence of malignancy 44 months after the operation. Since most tumors reported in patients treated with tamoxifen in the Western randomized studies are early good-grade endometrial carcinoma, it is speculated that periodic detection strategy of endometrial changes of the uterine corpus is not strictly recommended. However, the patients should be followed up immediately with gynecologic examinations if spotting or bleeding occurs like in our patients.

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A case of infected ruptured aneurysm of the superior mesenteric artery (SMA) is described. A 46-year-old man was referred to our hospital because of infective endocarditis (IE) involving the mitral valve. Because treatment with antibiotics was infective, and despite being in the active phase of infection associated with brain abscess, mitral valve replacement was performed successfully. One month later, the patient was found unconscious with massive hematemesis and melena. An abdominal CT scan showed a ruptured aneurysm of the SMA penetrating into the terminal duodenum. Direct suture of the SMA and combined resection of the aneurysm and the terminal duodenum seved the patient. However, recurrent bleeding from the involved artery obliged us to do additional repeat laparotomies and a transarterial embolization of the SMA. The clinical course and pathological findings which showed and inflammatory change of the aneurysm wall without atherosclerosis, suggested that the aneurysm was caused by vegetation derived from IE. Although ruptured aneurysm of the SMA associated with infection is rarely seen cafeful follow-up is necessary for the management of patients with IE.

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Mesenteric hiatal hernia, an internal hernia, is a relatively rare herniation of bowel through an unusual hiatus in the mesentery. We report a unique case of hiatal hernia of the ascending mesocolon. A 91-year-old female consulted a nearby hospital complaining of subumbilical pain. A diagnosis of ileus was made, and she was referred to our hospital. When the symptom was not alleviated by conservative treatment with a long tube, surgery was performed 12 days after the onset of symptoms. Laparotomy revealed an unusual hiatus (about 4cm in size) in the ascending mesocolon, which was incompletely attached to the retroperitoneum. A protrusion of small intestine (about 70cm through the hiatus into the dorsal side) was located about 100cm distal to the ligament of Treitz. No impairment of blood flow to the bowel was noted. The patient's postoperative course following repair of the herniation and closure of the hiatus was good, and she was discharged from the hospital 21 days after the operation.

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Primary torsion of the greater omentum which presents with acute abdomen is a relatively rare entity. There have been only 47 cases in the domestic literature so far. In this paper case of the disease is reported with some bibliographical comments.
A 69-year-old man was referred to the hospital with a suspicion of acute appendicitis for right lower abdominal pain. On admission, the body temperature was 37.6°C. There were tenderness, muscular defense, and Blumberg's sign in the right lower abdomen. On a blood analysis, the white blood cell count and CRP increased to 12, 000/μl and 13.6mg/dl, respectively.
Abdominal ultrasonography (US) visualize no mass, but ascites in the right ileocecal region. CT Scan showed the mass with mixture of the high and low-density areas. Emergency laparotomy was performed under a diagnosis of perforative appendicitis. At laparotomy, a fistic size of dark red, edematous omental mass was found associated with moderate bloody ascites. It was a part of the greater omentum, which twisted conuter-clockwise by two turns. Excision of the omentum at the second postoperative day, but improved on the next day. He was discharged from the hospital on the 9th postoperative day.
It may be a rare disease, but we have to entertain the existence of the disease as a probable diagnosis for patients with acute abdomen. US or CT would be useful when we have difficulty in differentiation from appendicitis. Forty-eight cases including our case in the Japanese literature are reviewed.

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