A series of 102 elderly patients over 80 years old undergoing gastroenterological surgery in our department in a recent 15-year period from January 1985 to December 1999 were subjected to a study surgical outcomes and problems. Underlying diseases including hypertension, previous myocardial infarction, previous cerebral infarction, arrhythmia, diabetes mellitus and bronchial asthma were recognized in 55 patients (53.9%). Postoperative complications inculuding delirium, pneumonia, heart failure and arrhythmia were recognized in 36 patients (35.3%). A comparison between 32 elderly patients with gastric cancer and 208 patients in their sixties showed no significant difference in underlying diseases, but significantly higher incidence of postoperative complications was noted in the elderly patients with gastric cancer. Some results were obtained in another comparison between 36 elderly patients with colon cancer and 107 patients in their sixties. Although postoperative complications occurred in the elderly patients in a high incidence, 93 (91.2%) out of 102 patients were able to leave the hospital without any decline of ADL. It is thought that even elderly patients who have some underlying disease can be discharged without any decline of ADL after gastroenterological surgery, if appropriate procedure is selected and strict postoperative management is perfomed.

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The purpose of this study was to evaluate factors which affected postoperative mortality in 43 cases of colonic perforation treated at Asahikawa Red Cross Hospital in a recent one decade. Factors relevant to immediate mortality were advanced age over 70 septic shock, and perforated diameter of over 1.5 centimeters; which were statistically significant.
On the other hand immediate mortality was high in cases with perforation in the left colon, free perforation, and/or intraperitoneal free gas, though there were no significant differences.
The appropriate technique of the operation should be chosen synthetically, making allowance for constitutional state, fundamental diseases, age, septic shock, perforated site, the level of peritonitis due to stool and period from the onset of the disease to operation. Saving the patient's life should be the first consideration in the case of perforation of the large intestine. Therefore colostomy would be the most desirable.

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In order to quantify risk factors for postoperative complications to serve better perioperative management, the usefulness of ‘physiological and operative severity score for the enUmeration of mortality and morbidity (POSSUM score)’ was investigated. 67 patients over 80 years old having a colorectal cancer were experienced at the hospital in a recent one decade, and 63 out of these 67 patients who had undergone operation were reviewed in this study. In these patients, physiological score (PS) was as high as 22.5±5.4, and 56 (88.9 %) patients were associated with other diseases. The frequency of postoperative complications was 46.0%. In patients who developed postoperative complications, PS was 24.5±1.1 and operative severity score (OSS) was 15.3±0.8. Morbidity rate calculated from these figures was 68.1±3.4 (cut-off value: 55%), that was significantly higher than that in patients group without postoperative complications (P<0.01). If mean bleeding volumes by degrees of lymph nodes dissection are added, the minimum OSS score in Stage III is inferred to be 13 points in colonic cancers or 19 points in rectal cancers, and to be within 55% of the morbidity rate, PS score is needed to be less than 22 points for colonic cancers or less than 15 points for rectal cancer. If PS score is within these good points, we guess that radical operation can be performed without any postoperative complications.

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Seventeen cases of abdominal aortic aneurysm associated with surgical digestive organ diseases experienced at the department were clinically evaluated. An average age was 68.6 years. All patients were male. There were six cases of cholecystolithiasis, seven cases of gastric cancer, three cases of colorectal cancer, two cases of hepatocellular carcinoma, and one case of pancreatic cancer. One-stage operation was carried out in six patients with cholecystolithiasis, two with gastric cancer, and one with colorectal cancer. Three patients with gastric cancer, one with colorectal cancer and one with pancreatic cancer underwent two-stage operation in which aneurysmectomy was preceded gastrointestinal surgery. Two patients with gastric cancer underwent a gastrectomy followed by an aneurysmectomy. Prior to AAA operation, transcathether arterial embolization was performed in two patients with hepatocellular carcinoma, and endoscopic mucosal resection was performed in one patient with colorectal cancer. We experienced no case of graft infection, but lost one case because of the postoperative complication. We conclude that in cases of concomitant surgical digestive organ disease and AAA, surgical strategy should be decided in consideration with the progression of the diseases and the condition of the patients.

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Granular cell tumors are thought to be derived from Schwann cells. Such tumors of the breast account for 4.6-14% of all granular cell tumors, and a total of 30 cases including our case have been reported in the Japanese literature. It is difficult to differentiate the tumor of the breast from breast cancer from the physical and imaging standpoint. Of these 30 reported cases, 73.3% were diagnosed as breast cancer preoperatively, including some cases which were clarified to be benign after radical mastectomy performed without any pathological exploration. We think that making the correct diagnosis by needle aspiration biopsy cytology or enucleation of the tumor is important.

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A case of a foreign body-type giant cell granuloma suspected local recurrence of breast cancer after a breast conservative therapy is reported. A 70-year-old woman was admitted to the hospital because of an induration at the operative scar. The patient had undergone a breast conservative therapy for right stage II breast cancer (T2a, N0, M0) 2 years before admission, when the surgical stumps were negative and histologic type was solid ductal carcinoma, n0, f (+), ly (-), and v (-). Thereafter she was followed in the clinic and had not received any adjuvant therapies. A new lump was palpable just below the operative scar. An irregular mass was detected on ultrasonography. A spiculated mass with microcalcifications was seen on mammography. Local recurrence in the remnant breast was suspected. Fine needle aspiration cytology disclosed none of malignant cells. The mass was removed under local anesthesia in the outpatient clinic. Pathological findings showed a foreign body-type giant cell granuloma. There have been no findings of recurrent breast cancer at present.

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Solitary lung metastasis after radical operation for breast cancer often presents difficulty in diagnosis and treatment. This paper deals with four patients undergone lung operation who had a previous history of undergoing radical operation for breast cancer 2 or 4 years earlier. All four patients had solitary lesions 2.0 to 4.5cm in longer diameter in the peripheral lung field. Characteristics of imagings were suggestive of primary adenocarcinoma of the lung. One of the four patients was diagnosed by a biopsy under thoracotomy aiming at lobectomy because no diagnosis was made by a preoperative bronchoscopy. Another two patients who already had regional lymph node metastasis underwent a standard lobectomy of the lung as a primary lung cancer. We emphasize that lung metastasis from breast cancer sometimes mimics well differentiated adenocarcinoma of the lung on imaging findings. Thoracoscopic tumor biopsy would be recommended when preoperative diagnosis could not be made through bronchoscopy in order to reduce unnecessary surgical stress. However, most appropriate surgical option is still controversial whether partial resection or lobectomy is right.

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A 65-year-old man was referred to our department because of dysphagia. Diffusely infiltrating stenosis was detected from the middle thoracic esophagus to esophagogastric junction by an esophagogram and an endoscopic examination. A biopsy specimen indicated mucoepidermoid carcinoma. Systemic CT scan and a scintigram did not visualize aortic invasin and distant metastasis. Retrosternal gastric roll reconstruction followed by a subtotal esophagectomy under a right thoracotomy with lymph node dissection of the three fields was performed. The gross classification of the resected specimen was scirrhous type carcinoma 8cm in longer diameter. Pathologically, the carcinoma was composed of squamous call carcinoma and adenocarcinoma which had a PAS and alcian blue positive mucin. Therefore, the diagnosis of mucoepidermoid carcinoma of the esophagus was made. Histological progress of the lesion was rated pT3N2M0, and comprehensive curability was p A. EM of the surgical margins was less than 1mm. So, postoperative radiotherapy was added to the lower mediastinum; however, 2 months after the operation, multiple hepatic metastasis and metastasis to the fourth cervical verteblae occurred, and the patient died on the 128 postoperative day.

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We report a rare case of adenoid cystic carcinoma of the esophagus. A 71-year-old man was seen at the hospital because of chest pain when eating. Endoscopic findings revealed an elevated type tumor, 1.0cm in diagmeter, at anterior wall of the esophagus 37cm from the upper incisor dentition. The biopsy specimens showed squamous cell carcinoma. So a subtotal esophageal resection was performed. The histlogical diagnosis was adenoid cystic carcinoma (ACC), sm, n0, in stage0. The patient has now survived 41 months after the surgery. Since ACC of the esophagus, based on the submucosa, is often covered by normal esophageal mucosa, correct preoperative diagnosis is quite difficult. Moreover, since there are no effective therapies expect operation, the prognosis of ACC of the esophagus is very poor. But in a few cases, when being operated on at an early stage, the patients survived for a long time. Therefore, we must keep this rare esophageal tumor in mind as a probable diagnosis for esophageal tumors.

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Nutrition using a nasogastric tube has been conducted, but recently, the nutrition management by creating the convenient gastrostomy button under gastric endoscopy has come into wide use. The gastrostomy button is often used for patients in malnutrition, and hence, we feel misgivings about a possibility of injuring the gastrostomy at insertion of a button for exchange due to insufficient or fragile gastrostomy. This paper deals with three cases of cerebral infarction with panperitonitis after exchange of gastric button which demanded laparoscopic reconstruction of gastrostomy button. Gastrostomy button for exchange was installed one month after percutaneous endoscopic gastrostomy in three cases of cerebral infarction. When enteral alimentation was started after the exchange of the button, peritonitis symptoms developed. Emergency laparoscopic operation was carried out in all cases. Observation through a laparoscope disclosed that the gastrostomy button completely fell out of the stomach, a deficit portion of the gastrostomy was noted, and panperitonitis was evident. Laparoscopically the gastrostomy button was reconstructed and peritoneal drainage was safely carried out in all cases. Laparoscopic vision was good which had not been obtained by laparotomy and intraperitoneal lavage was able to be done satisfactorily. The procedure was less invasive with a small operative wound. It enabled us to restart the enteral alimentation in an early time after the operation. Three patients regained their health without any complications. Laparoscopic reconstruction of gastrostomy button is a valuable operative procedure.

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We report a rare case of malrotation with gastric cancer presented with acute pancreatitis in an adult. A 62-year-old man was admitted to the hospital because of abdominal pain and was diagnosed as having acute pancreatitis. Symptomatic remission was attained by conservative therapy. Endoscopic examination revealed gastric cancer and on X-ray film revealed malrotation. So a proximal gastrectomy and a jejunal interposition were carried out. The findings of the bowel indicated a malrotation of nonrotation type. There were no Ladd ligament and any other structure, but the cecum and ascending colon did not fixed to the retroperitoneum. So we fixed the ascending colon to the descending colon for prevention against probable volvulus.
Malrotation in adults with gastric cancer is very rare. This case that is also interesting in terms of operative procedure is presented here.

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Gastrointestinal foreign bodies swallowed accidenntally are often extruded by themselves, and with a recent progression in the laparoscopic technique, those foreign bodies have become possible to be removed conservatively under laparoscopy. However, complications such as gastrointestinal bleeding, ileus, and abscess formation due to the foreign bodies can occur depending on the kind of foreign body and time of removal, that require laparotomy.
Recently we have experienced three cases of accidentally swallowed partial denture which required a laparotomy. In each patient, the denture was incarcerated in the gastric pylorus, jejunum, incision of the intestine and removal of them were performed. The remaining denture was incarcerated in a diverticulum of the sigmoid colon to form a mass adhered to the surrounding tissues, so that a sigmoidectomy was needed. In each case, a morphologically sharp part of the denture was present in the intestine with a risk of intestinal perforation, and we determined that early removal of the denture was necessary.

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Perforation of the small intestine due to foreign body is relatively rare and presents difficulty in preoperative diagnosis. In this paper, three cases of perforation of the small intestine due to a fish bone, a false tooth and a press through package (PTP) are presented. Patient 1 was admitted to the hospital because of right lower abdominal pain. Abdominal CT scan showed an edematous small intestine. Laparotomy was performed with a suspicion of acute appendicitis, when the jejunum was found to be perforated due to a fish bone. Direct suturing was done after removal of the fish bone. Patient 2 was diagnosed as having panperitonitis and an abdominal X-ray film and a CT scan showed a foreign body like a false tooth in the small intestine. Emergency operation revealed that the ileum was perforated due to a false tooth. A partial resection of the ileum with the false tooth was performed. Patient 3 was admitted to the hospital with a diagnosis of ileus. No peritoneal signs were presented. Abdominal CT scan showed an edematous small intestine and an intestinography showed stenosis of the ileum. Laparotomy was performed. During surgery, the ileum was perforated due to a PTP (1.5×1.5cm) and covered with the omentum. A partial resection of the ileum including the PTP was carried out.

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We report a case of tuberculosis of the small intestine in an elderly patient in whom resection of the intestinal foci under laparotomy brought about symptomatic remission. A 75-year-old woman was admitted to the hospital with a diagnosis of left venous thrombosis. Immediately after admission, she had chill and fever with tremor repeatedly. Urinary tract infection, was strongly suspected, but it was really difficult to specify the cause of this disease. During the process, she had painless ileus several times. CT and magnetic resonance imaging (MRI) revealed a thickening of the small intestinal wall. We performed a lapatomy. There were two spindly lesions in her ileum and we cut those off about eighty centimeters included the ileocecuon. Pathological diagnosis was small intestinal tuberculosis. After the operation, we enforced chemotherapy with antituberculotic agents and her condition improved. While she moved and was in another hospital to obeserve her health condition, suddenly there was right hemiplegia appeared. Brain enhanced CT scan and MRI visualized two edematous lesions on her left parietal lobe. After a craniotomy, she was pathologically diagnosed as having brain tuberculosis. After the operation, she maintained on the chemotherapy.

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A case of ileal carcinoid tumor presented with intussusception is reported. A 66-year-old man was admitted to the hospital because of ileus. Abdominal CT scan revealed an ileal tumor and ileus, and a barium enema study visualized the obstruction with a finding like a crab claw. Colonoscopy revealed the ileal tumor about 10cm from the Bauhin's valve which was dark red in color and had a smooth surface. Since no relief of intussusception was attained, a laparotomy was performed. During surgery, a submucosal tumor was present at the end of ileum, with its adhesion to its oral side to form a loop causing intussusception. A partial resection of the ileum including the submucosal tumor was performed.
Pathologically, the submucosal tumor was diagnosed as carcinoid tumor, with an invasion depth of ss, and regional lymph node metastasis was observed. Carcinoid tumor of the small intestine is rare in Japan. This case was thought valuable because the intussusception had occurred by mesentric retraction of the carcinoid tumor.

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Perforation of carcinoid of the small intestine is rare. In this paper, we report a case of carcinoid of the ileum, which had a clinical episode of panperitonitis due to perforation of the tumor.
A 70-year-old man was admitted to the hospital because of incarceration of right inguinal hernia and ileus. There was a previous history of receiving conservative therapy for symptoms of peritonitis at another hospital one month before admission. Immediately after admission, a reduction of incarcerated hernia was done manually and a radical herniorraphy was performed on the fifth hospital day. Adhesion between the hernia sack and small intestine was recognized. At the seventh day after the operation, recidivation of the ileus occurred. He was diagnosed as having ischemic ileitis of stenotic type caused by incarcerated hernia on a contrast ileography, and underwent another operation on 17th day after the first operation. Diffuse adhesion of the intestine due to previous peritonitis existed. Stenosis of the ileum at about 3m anal side from the Treiz ligament was recognized. We considered it as cicatrical contraction after perforation, and performed a partial ileectomy. The resected specimen showed no obvious tumor but a histological examination revealed an island proliferation of small, homogenous tumor cells which were positive on immunohistochemical stainings such as Gromerius, Fontana-Mason and chromogranin stain. The difinite diagnosis of argentaffinity, insular type carcinoid of the ileum was made.

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Various complications with ventriculo-peritoneal shunt (VP shunt) have been reported. We encountered a rare case of ileo-rectal fistula and pelvic abscess due to a VP shunt tube. A 54-year-old woman received a VP shunt for normal pressure hydrocephalus following subarachnoidal hemorrhage. Thereafter she was doing well for eight years until she experienced a sign of intestinal obstruction. About nine years later, the tip of the peritoneal catheter was found to be protruding from the anus, but there had been no signs of peritonitis. So, she received continuously conservative therapy. Even after this event, she sometimes experienced some symptoms of intestinal obstruction. She was admitted to the previous hospital to examine the cause of intestinal obstruction. A gastrografin enema X-ray study revealed an ileo-rectal fistula. Pelvic CT scan revealed the large pelvic abscess from the pelvis to the right hip. She was referred to the hospital for abdominal operation. On the day before operation the abscess was drained from the back and defecation from the back was recognized. We performed an ileocecal resection including the ileo-rectal fistula, and the rectal wall was sutured.
In the early postoperative period, she was complicated by an intra-abdominal abscess and was reoperated on for abdominal drainage. The postoperative course was uneventful. The patient is strictly fallowed in the outpatient clinic.

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Pericecal hernia is a rare type of internal hernia, which occurs at one of the four principal fossae in the region of the cecum. Four cases of pericecal hernia which were treated surgically at the hospital between 1982 and 1998 are presented together with a review of the Japanese literature. Thirty-one cases have been previously reported in Japan. The disease more commonly occurred in men than in women (the male to-female ratio was 18:13). The ages ranged from 1 month to 86 years, with a mean of 46.9. Pericecal hernia can occur in any age groups. Pericecal hernia is a strangulated hernia, so that surgical treatment is mandatary because this condition can be fatal. However, the correct preoperative diagnosis of pericecal hernia is very difficult to make. The diagnosis can often be confirmed at laparotomy. Although only two deaths have been reported in Japan, a high mortality rate of 75% has been noted in a foreign report so far. The genesis of the disease is explained based on the minimal error in rotation with incarceration behind the cecum during the final phases of descent and fixation of the right colon or failure of cecal and retroperitoneal fixation.

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The primary malignant lymphomas of the large intestine account for about 10% of all malignant lymphomas of the gastrointestinal tract, and especially the perforated case is rare. This paper presents a case of perforated malignant lymphoma of the cecum. A 69-year-old man presented with lower abdominal pain. Abdominal X-ray films showed no free gas, but a gastrografin enema study showed whole circumferential stenosis at the cecum and extra-intestinal leakage of the contrast medium. Colonofiberscopy revealed a type 3 tumor at the cecum. Tissue biopsy revealed malignant lymphoma. We performed a right hemicolectomy with the diagnosis of perforated malignant lymphoma of the cecum.
The tumor was about 15cm in diameter. It was comparatively soft and type 3-like tumor with a large ulcer in the center. Histopathological examination revealed large, diffuse, B cell type malignant lymphoma. Post operative chemotherapy was not performed. During 99 days of follow-up observation after the operation, IL-2 receptor was useful as an indicator of recurrence.

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A 69-year-old man complaining of right hypochondralgia was referred to the hospital with a diagnosis of cholecystlithiasis based on an abdominal ultrasonography (US) at another hospital. Abdominal US performed in our department revealed a 6cm-sized tumor in the right flank abdomen as well as gallstones. Abdominal CT scan demonstrated a cystic tumor extending to the appendix area in the right abdomen, which invaded the peritoneum. Contents of the tumor were considered to be mucoid substance on an abdominal magnetic resonance imaging (MRI). Barium enema X-ray examination did not visualize the appendix but revealed an extramural shift of the ascending colon. On the basis of these findings, he was diagnosed as having cholecystolithiasis and mucinous cystadenocarcinoma arisen from the appendix, and a cholecystectomy and a right hemicolectomy were performed. Histopathological diagnosis was mucinous cystadenocarcinoma of the appendix associated with direct invasion to serosa of the ascending colon. Primary carcinoma of the appendix occurs rarely and the most common clinical finding is right lower abdominal pain which leads us to make the diagnosis of acute appendicitis preoperatively. This case is rare, in that a right hypochondralgia developed because the tumor extended from the appendix area to head side and it could be diagnosed preoperatively.

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We experienced a crucially rare case of primary signet ring cell carcinoma of the vermiform processus.
A 32-year-old woman was admitted to the hospital because of right lower abdominal pain. Body temperature was 36.5°C. On physical examination, a tumor with tenderness was palpable in the right lower abdomen. Blood laboratory data revealed that there were signs of slightly inflammatory reaction (WBC: 11000/μl and CRP: 1.1mg/dl) and tumor markers showed high level (CEA: 11ng/ml and CA19-9: 2400U/ml). Abdominal ultrasonography and a CT scan demonstrated a heterogenous mass lesion 5×3cm in diameter with irregular border in the ileocecal region. Colonofiberscopy examination revealed a submucosal lesion 5cm in length to the anal side extending from the Bauhin valve to ascending colon. We performed an operation with a suspicion of malignant tumor of the ileocecum. Right hemicolectomy was carried out. Histopathological findings showed signet ring cell carcinoma of the vermiform processus, ss, ly₂, v₀, n₀, ow (-), aw (-), and ew (-). She received postoperative chemotherapy, but died 16 months after the operation.

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A 59-year-old man was seen at the hospital because his stool was positive for occult blood at a health examination. Colonofiberscopy revealed multiple inflammatory polyps in the right-sided colon, and early colonic cancer associated with an inflammatory polyp of the cecum. Right hemicolectomy was performed. Histopathological examination of the resected specimen revealed inflammatory polyps of unknown origin. No clear examination about the origin of the inflammatory polyps was gained histologically, but intestinal tuberculosis was strongly suspected from his clinical course, endoscopic findings and positive response to PPD skin test. From a morphological standpoint that cecal carcinoma had extended on the lateral wall of the inflammatory polyp, the cecal carcinoma was thought to have arisen in the inflammatory polyp.

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A 58-year-old man reporting lower abdominal pain was found by abdominal plain x-ray to have dilated colonic gas with air-fluid formation. Abdominal computed tomography (CT) showed a tumor of the sigmoid colon. Barium enema studies did not visualize the oral side from the sigmoid colon and intestinal obstruction due to sigmoid colon cancer was suspected. Attempts to decompress the intestine were unsuccessful and emergency surgery was conducted that day a tumor was found adhering to the surrounding sigmoid colon tissues. Sigmoidectomy was done based on a diagnosis of sigmoid colon cancer. The surgical specimen showed a long pedunculated polyp incarcerated in a narrow segment of the sigmoid colon, whose wall was thickened and completely obstructed. No tumorous lesion was found. Histopathological findings showed diverticulitis of the sigmoid colon and a mucosal tag. Intestinal obstruction was thus caused by the mucosal tag. In colorectal disease with obstruction in which the presence of the diverticulum can be confirmed, we must differentially diagnose the possible presence of an unclassifiable colonic polyp such as a mucosal tag.

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We experienced two cases of resectable giant hemangioma of the liver associated with hypochondralgia. Case 1: A 54-year-old woman was admitted to the hospital because of right hypochondralgia. She was diagnosed as having a liver hemangioma of the right hepatic lobe, 13cm in diameter based on an abdominal ultrasonography, a CT scan and an angiography. She underwent an extended subsegmentectomy. Case 2: A 68-year-old woman was admitted to the hospital because of the same complaint as in Case 1. Several examinations revealed two giant (10cm and 8cm) hemangiomas in S2+S3 and S4 of the liver. She then underwent a partial hepatectomy. In both Case 1 and Case 2, the right hypochondralgia disappeared after the surgery. According to the literature describing hemangioma of the liver, surgery might be indicated for patients having clinical symptoms, suspicion of malignancy, or complications of Kasabach-Merritt syndrome. It is still controversial as to whether or not the risk of spontaneous rupture should be considered a surgical indication.

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A 51-year-old woman, who consulted another hospital because of abnormal bile duct enzymes on a medical checkup in December 1997, was referred to the hospital for a tumor of the right posterior segment of liver on a CT scan in January 1998. Laboratory findings revealed a mild inflammatory reaction and elevations of bile duct enzymes, but no hepatitis virus was found and tumor markers were all in nomal limits. Because we had difficulties in making diagnosis on imaging studies such as US, CT, magnetic resonance imaging, and angiography, US guided needle biopsy was performed and the lesion was diagnosed as inflammatory pseudotumor (IPT). She had been treated for 6 months conservatively, but no reduction of the lesion nor improvement in laboratory findings were obtained. Posterior segmentectomy and a cholecystectomy were perfomed on September 9. IPT is an inflammatory disease of unknown origin and relatively rare. We report the case together with a review of 77 cases reported in Japan so far.

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A 67-year-old woman was admitted to the hospital because of worsening right hypochondralgia and fever lasting since March 14, 2000. Imaging procedures disclosed multiple cysts in the liver, and especially a cyst in the posterior segment was 12cm in longer diameter and contained debris in it. So infectious hepatic cyst was diagnosed. No communication with the bile duct was seen. Percutaneous drainage (causative organism was Staphylococcus aureus) provided a transient symptomatic remission, but the symptoms recurred. We determined that the case was resistant to conservative therapy and performed a laparotomy. It revealed that the cystic lesion did not expose on the hepatic surface and fenestration was impossible, so that a partial hepatectomy (S67) was performed.
Hepatic cyst is an everyday disease and is scarcely subjected to therapy. In instance in which infection is associated, however, conservative therapies including percutaneous drainage are carried out. When those therapies are unsuccessful, fenestration procedure is selected. In this case we were able to conduct a partial hepatectomy with a good outcome, because the cystic wall had not exposed on the surface of the liver.

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We uncommonly encounter clinical cases of gallbladder cancer associated with solitary hepatic abscess which has no connection with the gallbladder in the literature. This paper presents recent two cases of gallbladder cancer associated with solitary hepatic abscess.
Patient 1, a 78-year-old man, was seen at the hospital because of right hypochondralgia. With a diagnosis of chronic cholangitis and solitary multiple hepatic abscess, an open drainage for the hepatic abscess and a cholecystectomy were performed. Histologic study of the resected gallbladder disclosed gallbladder cancer localized in the subserosa.
Patient 2, a 70-year-old woman, was seen at the hospital because of epigastric pain. Acute cholecystitis and solitary hepatic abscess associated with choledocholithiasis were diagnosed, and an open drainage for the hepatic abscess, a choledocholithotomy, and a cholecystectomy were performed. Histologic study revealed early gallbladder cancer.
In review of six cases including our two cases seen in the Japanese literature, only two cases had been diagnosed as gallbladder cancer before surgery. Considering that operative procedure is determined according to progression pattern of gallbladder cancer, we must be cautious in the treatment of bacterial hepatic abscess with suppurative cholangitis by keeping the possible association of gallbladder cancer in mind.

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A case of hepatocellular carcinoma with extensive peliotic change is reported. The patient was a 73-year-old man with a diagnosis of hepatic tumor as the probable cause of his right hypochondralgia. The most of the tumor showed a slight ring enhancement and a small part disclosed early enhancement on dynamic CT and angiography, which highly suggested a combined type of cholangiocellular carcinoma. Therefore, a partial hepatectomy was carried out. Histologically, the tumor was diagnosed as HCC with a remarkable dilated sinusoid-like structure simulating peliosis hepatis, (peliotic change). Generally peliotic changes in HCC show vascular pooling on dynamic CT and angiography, but in this case, the greater part of the peliotic change was organized and exhibited a hypovascular appearance, and resulted in misdiagnosis.

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A rare case of hapatocellular carcinoma with solitary axillary lymph node recurrence after liver resection is reported and discussed. The patient was a 68-year-old mam. There were previous histories of undergoing a left lobectomy of the liver for hepatocellular carcinoma and a sigmoid colon resection for sigmoid colon carcinoma in 1989 and undergoing a partial hapatic resection (S6, S8) for recurrence in the residual liver in 1997. In 1999, a right axillary tumor suggestive of metastasis of hepatocellular carcinoma was pointed out by an aspiration biopsy cytology. A resection of the right axillary tumor was performed, which was diagnosed as solitary recurrence of hepatocellular carcinoma to the right axillary lymph node by a pathological examination. No metastasis to other lymph nodes was detected. Lymph node metastasis of hepatocellular carcinoma is not uncommon that is obvious from its incidence of around 30% of all autopsy case in the Japanese literature. But it is as rare as 2.2% that the metastasis is found in hepatectomy case. Moreover, solitary lymph node metastasis of hepatocellular carcinoma has been found commonly in the abdominal cavity, but rarely in the distant lymph nodes. This rare case is presented.

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We report a case of cholecystolithiasis with a rare biliary anomaly. A 68-year-old woman complaining of right upper abdominal pain was admitted to the hospital with a diagnosis of cholecystoldithiasis. ERC revealed a bile duct anomaly.
The cystic duct seemed to join the right hepatic duct. Considered probable unnatural run of the bile duct, a laparotomy was performed on June 23, 1999. Intraoperative cholangiography demonstrated that the cystic duct joined an accessory bile duct connecting the right hepatic duct and common hepatic duct.
To the best of information, this anomaly in our case has been reported in four cases before, but is not included in any published classification system advocated by Hisatsugu or Saito. It is important to demonstrate the biliary anatomy by preoperative biliary examinations to prevent intraoperative bile duct injury.

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A 74-year-old man was admitted to the hospital because of epigastric pain. Ultrasound revealed an elevated lesion and stones on the fundus of gallbladder. Laparoscopic cholecystectomy was scheduled and initiated, when gallbladder cancer was suspected by laparoscopic findings. So we decided to suspend the operation and a two-step approach was employed. Abdominal CT scan and magnetic resonance imaging revealed thickening of the gallbladder wall and an elevated lesion protruding to the lumen. With a diagnosis of nodular invasive gallbladder cancer, a cholecystectomy, segmentectomies for S4a and S5, a resection of extrahepatic bile duct and lymph nodes disection (D2) were carried out. Resected material disclosed that the gallbladder wall thickened at the fundus and the stones strongly adhered to the wall. Histopathologically, xanthogranulomatous cholangitis (XGC) was revealed, and the stones connected with the gallbladder wall via necrosed tissue of ulcer and granulation tissue.
In a clinical study of our cases involving previous three cases, all cases had been diagnosed as gallbladder cancer preoperatively and underwent an extended surgery. The disease presents difficulty in differential diagnosis from gallbladder cancer on imagings, and there are cases of both diseases simultaneously. Accordingly, in instances in which gallbladder cancer is suspected, we must bear a possibility of the disease in mind and select carefully operative procedure.

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A 77-year-old woman was admitted to the hospital because of upper abdominal pain. On admission, she had no jaundice. Abdominal ultrasound showed a hyperechoic mass in the hepatic hilus. Tube cholangiography revealed a polypoid tumor with a shaggy surface growing in the hepatic confluence. Cholangioscopic biopsy showed adenocarcinoma. Extended left hepatic lobectomy with caudate lobe resection, extrahepatic bile duct resection, and regional lymph node dissection were performed. Macroscopically, besides the main polypoid tumor that originated from the left hepatic duct and measured 2.5×2.5cm, another polypoid tumor, 0.6×0.5cm in size, was located in the common hepatic duct. histologically, two tumors were papillary adenocarcinoma within the mucosa and this case was classified to stage I.
Reports of non-icteric early bile duct carcinoma confined to the mucosa like this case are very few. Those carcinomas are macroscopically characterized by to have polypoid appearance in many cases and to have intraepithelial spreading and multiple cancerous lesions in some cases. Care must be taken of these characteristics, in treating cases of early bile duct carcinoma.

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A variety of therapies have been attempted for incurable pancreatic fistula so far. This paper deals with a case of intractable pancreatic fistula treated by anastomosis between the fistula and jejunum, with a good outcome. A 76-year-old man was referred to the hospital because he was associated with pancreatic fistula after an incision of a pancreatic cyst and an operation for external fistula. Complete obstruction at the downstream of the injured main pancreatic duct was confirmed. We determined that the condition might be incurable by conservative therapy and performed an operation. At the operation, the fistula which was dilated to 18F preoperatively to make an anastomosis easy and the jejunum were anastomosed by two layers suture. An then, a splint tube was inserted into the anastomosed site, the jejunum and abdominal wall were sutured for fixation, and drainage was made externally via the splint tube.
In the treatment of incurable pancreatic fistula, it is important to diagnose the condition of fistula correctly by endoscopic retrograde cholangio-pancreatography and fistulography and to select therapeutic method.

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A case of Fournier's gangrene secondary to pelvic abscerss after surgery for rectal cancer with diabetes mellitus is reported. A 50-year-old man was diagnosed as having advanced rectal cancer located in Rb, and an abdominoperitoneal excision was carried out. After the operation, abscess was formed in the pelvic cavity and about 2 months later, redness and swelling covering from the perianal area and right thigh to the body appeared. Computed tomography (CT) revealed abnormal gas image in the soft tissue, and wide incision with debridement was performed. But the patient couldn't be saved because of sepsis and consequent multiple organ failure (MOF). There have been only four domestic cases in which Fournies's gangrene was associated with rectal cancer. This disease often has a fatal course. It's important to diagnose before it spreads to the body, incision with drainage, debridement of necrosed tissue, and irrigation with general care in an early stage are necessary.

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This paper deals with a female infant with meconium peritonitis caused by intestinal duplication-induced ileal volvulus. At 35 weeks gestation, the patient was detected to have an intra-abdominal cystic mass by an ultrasonography. At 37 weeks gestation, massive ascites was detected, and she was delivered by a cesarean section. At the birth, her abdomen was severely distended. Because paracentesis revealed meconium-colored ascites and the abdominal distension was aggravated, an emergency operation was performed with a diagnosis of meconium peritonitis on the same day. The abdominal cavity was full of turbid ascites and meconium. Ileal volvulus, which seemed necrotic, was observed. In addition, there was a 2.5cm cystic tumor in the mesentery of the necrotic ileum. A localized perforation was observed 3cm to the oral side of the cyst. The necrotic ileum including the duplication cyst was excised. An end-to-end anastomosis was performed. Pathologic examination showed duplication of the ileum, which was lined with necrotic mucosa. No communication to the ileal lumen was found. Her subsequent postoperative course was uncomplicated. She was discharged from the hospital at 24 days of age. To our knowledge, no report has been published describing meconium peritonitis caused by intestinal duplication-induced ileal volvulus.

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A case of retroperitoneal venous hemangioma is reported. A 37-year-old woman was seen at the hospital for close examination of left flank pain. Abdominal ultrasonogram and a computed tomogram showed a multilobular cystic tumor behind the pancreas. Magnetic resonance imaging revealed a retroperitoneal cystic tumor with high signal intensity on both the T1-weighted and T2-weighted images. Laparotomy revealed a retroperitoneal cystic tumor adhered tightly to the left adrenal gland and the left side of the abdominal aorta. The tumor was completely resected with a part of the left adrenal gland to which it was invasively adherent. The resected specimen was multilobulated, 650g in weight, 21×10×8cm in size, and filled with 350ml, brown, and turbulent fluid. Histopathologically, the tumor was venous hemangioma.

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A 62-year-old woman complaining of abdominal pain was admitted to the hospital with a diagnosis of intestinal obstraction. On the next day, she developed shock and underwent an abdominal drainage and a sigmoidostomy for diffuse peritonitis due to perforation of diverticulum of the sigmoid colon. Intensive care including CHDF (continuous hemodiafiltration) improved her general condition. However, about one month after the abdominal surgery, she developed neck, back, and knee pain. Orthopedists observed no abnormal signs, and a compress and tranquilizers were prescribed. Further one month later, swelling of both knees and paralytic symptoms of both arms developed. Purulent discharge from the knee and a MRI study of the cervical vertebrae led us to diagnose arthritis of both knees and pyogenic spondylitis. She underwent anterior spinal fusion and drainage of both knee joints on POD 63. MRSA was detected from all sites. Ten days later, paralytic symptoms developed in both legs and were treated conservatively with vancomycin. On POD 177, she was discharged from the hospital on foot. We conclude that infectious disease in the orthopedic field needs to be considered when patients complain of pain of the trunk and limbs following surgery for colon perforation.

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An obstructed inguinal hernia associated with Hirschsprung's disease in a child is herein reported.
A newborn male was transferred to the hospital becaus of congenital ichtyosis and low birth weight. Since the age of 4 days, he had abdominal distension, and it continued. He was diagnosed as having Hirschsprung's disease. At 20 days after birth, bilateral inguinal hernias were noted. At the age of 9 months, he was readmitted because of severe constipation and swelling of the bilateral scrota. A contrast material enema revealed that the left scrotum contained the sigmoid colon with a considerable hard stool. Trying to reduction failed, because the stool inside the sigmoid colon was so hard that he complained of pain during the procedure. Therefore, he was diagnosed as having obstructed hernia. During a herniorrhaphy, the hard stool in the sigmoid colon was broken down into smaller parts and reduced into the connecting abdominal colon.
At the age of 22 months, a modified Duhamel procedure was carried out for Hirschsprung's disease. At the age of 29 months, he died of unknown cause in his own home. An autopsy was not permitted.

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Spigelian hernia is a nearly aquaired and extremely rare hernia. We report a first case of muliple Spigelian hernias causing ileus in Japan. An 82-year-old obese woman who had had an asymptomatic abdomial wall hernia, was admitted to the hospital because of abdominal pain and vomiting. On an abdominal CT scan and a small intestinal series, there were two Spigelian hernias, the smaller one of them had irreversed ileum and caused ileus. Considering of the poor general condition with multiple complications, she received conservative therapy, but in vain. We decided to perform surgical treatment on the smaller one alone. Uppon laparotomy, there was a hernia sac protruded from the Spigelian fascia. The hernia sac contained the incarcerated ileum and greater omentum with little ischemic change which were reducted. We resected the hernia sac and closed the orifice of the hernia with interrupted sutures. She was soonly recovered and discharged.

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A 62-year-old woman was seen at the hospital, because of epigastric pain in May 1997. These were previous histories of undergoing a distal gastrectomy for peptic ulcer at the age of 19 and caesarian section at the age of 36. A round-shaped mass, 5cm in size, was palpated in the left lower abdomen on a physical examination. She was admitted for further evaluation of the lesion. Abdominal ultrasonography (US) showed linear high-echoes in a low-echoic mass, whose border was clear. CT scan revealed a well-encapsulated low density mass. Upon laparotomy, the lesion was located in the mesentery of the small bowel and firmly adhered to it. A partial resection of the small bowel including the tumor was performed. Pathological examination finally demonstrated a granulomatous mass with chronically inflammatory changes caused by a retained surgical gauze. The accurate pre-operative diagnosis is considered to be difficult in such cases even by making the most use of imagings. However, both unusual US and/or CT findings of the lesion wlth previous surgical history help us to suspect the diagnosis of retained surgical materials.

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