We made a statistical study of 257 cases of obturator hernia reported in the Japanese literature in a recent six-year period including our four cases. The mean age of patients was 81.5 years, ranging from 56 to 99. There were 248 women and nine men, this disease being common in elderly women. Right obturator hernia was found in 149 cases, and left in 98 cases. Twenty-four percent of them had a history of abdominal surgery. The positive rate of Howship-Romberg sign was 62.1%. The preoperative correct diagnosing rate was 82.9%. The incidence of bowel resection was 49.8%. Some postoperative complications occurred in 11.6%. The mortality of this disease was 3.9%, and the operative mortality was 3.6%.
In our study pelvic CT scan is very useful for making diagnosis of the disease. Although the correct diagnosing rate before surgery and prognosis of the disease have recently improved, the incidence of bowel resection is still high. In order to avoid bowel resection as possible as we can, early diagnosis and early operation for the disease must be kept in mind.

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In regular physical checkups and surgery for thyroid cancer at Nagano Matsushiro General Hospital from April 1997 to March 2002, subjects numbered 25, 139 cases 17, 443 men and 7, 696 women with a mean age of 51. Of these, 58 (0.23%) 11 men and 47 women were found to have thyroid cancer.
Microthyroid cancer was found in 25 of 58 cases (43%). Histologically, 56 were papillary, 1 follicular, and 1 medullary. Lymph node metastasis was found in 47%. Surgery for all with thyroid cancers detected was completed without complications at our hospital.
The prognosis was very good and all remain disease-free, as of this writing. Regular physical checkups are thus useful in detecting and treating thyroid cancer, given the desired quality of life.

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This study was undertaken to determine the treatment of the recurrent laryngeal nerve (RLN) invaded by papillary carcinoma (PC) of the thyroid gland. A retrospective study was done with 27 patients whose RLN was invaded by PC at Tokushima Municipal Hopsital. In 9, RLN underwent resection and reconstruction (reconstructed group). Reconstruction involved direct anastomosis, vagus nerve to RLN, and ansa cervicalis to RLN in 3 patients each. In 13, RLN was resected but not reconstructed (resected group), and preserved in 5 (preserved group). Recovery in phonation was recognized in 7 in the reconstructed group. Their vocal cords did not move but were not atrophied and maintained good tension. No patients had local recurrence and distant metastasis in the reconstructed and preserved groups. These results suggested that RLN invaded by PC should be preserved, but if RLN resection is not avoided, reconstruction should be done for recovery in phonation.

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In order to know the long-term evaluation of the patients undergone Ravitch's operation, we sent questionnaires to 18 patients operated on for funnel chest in our hospital between 1981 and 1998. Eleven patients responded them after informed consent. The mean age of them at the operation was eight years old, ranging from three to 17, and the mean of 11 years, ranging from one to 17 years, had elapsed after operation. Although most patients were satisfied with the results of their operation, 81%of the responders voiced concern regarding their surgical scar, which resulted from the removal of the Kirschner's wire and the conventional median skin incision. Since 1980s, we have used “hammock support” method and small skin incision (about 5cm median skin incision) from a cosmetic point of view. Even these patients complained of dissatisfaction about their operative scars. In the future, we must adopt the techniques used in plastic surgery as well as the meticulous postoperative care for surgical wound.

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In this study, recurrent death rate, the time interval between operation and death, recurrent patterns, and risk factors for recurrent death were analyzed on patients with submucosal (n=137) and muscularis proprial (n=48) gastric cancer undergoing a curative resection. Six out of 137 (4.4%) patients with submucosal cancer and five out of 48 (10.4%) patients with muscularis proprial cancer died from recurrence. Hematogenous metastasis was the most common pattern of recurrence (54.5%). Eight out of 11 (72.7%) deaths occured within three years from the operation, while two out of 11 (18.2%) deaths occured five years after the operation. A multivariate analysis showed that lymph node metastasis was the only significant prognostic factor. Among patients with lymph node metastasis, patients with n_{2, 3} lymph node metastasis, according to Japanese Classification of Gastric Carcinoma (the 13th edition), showed the high rate (50%) of recurrent death. For patients with submucosal and muscularis proprial gastric cancer undergoing curative resection, close follow-up, anticipating hematogenious spread, should be made for lymph node-positive, especially n_{2, 3} according to Japanese Classification of Gastric Carcinoma (the 13th edition), cases.

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A 51-year-old woman seen September 19, 2001, with a 1-month history of right breast mass associated with marked pain had a hard, thumb-sized tumor in the right lower outer quadrant with retraction of the overlying skin. Soft mobile lymph nodes were palpable in bilateral axillae. Laboratory data showed mildly elevated serum C-reactive protein, but other parameters were within normal limits. Ultrasonography and computed tomography showed patterns suggestive of tumor malignancy, and cytological examination of a biopsy specimen showed Class II. We conducted excisional biopsy. The resected 20×18×18mm tumor was grayish-white inside and uniform. Pathological examination showed the tumor was nodular, microscopically consisting of spindle cells, diagnosed as nodular fasciitis of the breast.
Nodular fasciitis often appears in the extremities, and only 7 cases in the breast have been reported in Japan. The present case shows the diagnostic importance of differentiating this tumor from common breast cancer.

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We report a radically operated case of early recurrent stromal sarcoma of the breast, which is a rare entity, after surgery for the primary lesion. A 50-year-old woman was referred to a hospital because of agradually enlarging mass of the right breast. The mass with llcm in diameter was diagnosed as phyllodes tumor or stromal sarcoma by an incisional biopsy. Radical mastectomy was performed. Pathological examination revealed stromal sarcoma of the breast with osseal invasion and positive surgical stumps. Three weeks after the primary surgery, local recurrence in the chest wall was detected. Radiation therapy (a total of 20 Gy) was ineffective and bleeding from the chest wall tumor occurred. The patient was admitted to the hospital. A curative resection of the chest wall including the tumor with arectus abdominus musclocutaneous flap transplantaion was performed.
There have been no signs of recurrence for 20 months without adjuvant chemotherapy.

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We report a case of intracystic male breast carcinoma. A 71-year-old man seen for a left breast mass was found in ultrasonography (US) to have a cystic tumor with a solid component measured 5cm in diameter. Fluid aspirated from the cyst was bloody and diagnosed cytologically as invasive ductal carcinoma, necessitating modified radical mastectomy with regional lymph node dissection. Histologically, papillo-tubular invasive ductal carcinoma was observed without lymph node metastasis. The patient's postoperative course was uneventful and he remains recurrence-free 9 months after surgery.

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A 58-year-old man diagnosed with an abdominal aortic aneurysm and left renal tumor on screening ultrasonography was found in computed tomography (CT) to have an infrarenal aortic aneurysm 4.0cm in diameter and a solid mass of the lower pole of the left kidney 2.5cm in diameter, suggesting renal cell carcinoma. Simultaneous partial nephrectomy and repair of the abdominal aortic aneurysm were done via retroperitoneal approach through a left pararectal incision. The postoperative course was uneventful and no graft infection occurred. A combined approach to abdominal aortic aneurysm and renal neoplasm is still controversial in poor-risk patients, but in good-risk patients, simultaneous operativ therapy is safe and appropriate without evidence of increased mortality or morbidity.

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A 69-year-old woman with a history of mitral stenosis was admitted with pain and numbness of the right lower limb. Complete occlusion of the aortic bifurcation was found in arteriography via a left brachial approach. When the guide wire penetration test was positive, catheter-directed thrombolysis (CDT) was done. Initial infusion with 480, 000 units (u) of urokinase (UK) in 25 minutes resulted in partial clot lysis and reduction in symptoms. Subsequent to initial recanalization, 20, 000 u/hour of UK were infused for 24 hours. Due to pericatheter hematoma, the dose was decreased to 8, 000 u/hour of UK for 48 hours. Arteriography at 72 hours showed persistent clots in the abdominal aorta, the right external iliac artery, and the left common femoral artery. Bilateral transfemoral embolectomy was done under local anesthesia and old, firm, organized clots obtained. The postoperative course was uneventful.
CDT promptly induced partial recanalization and reduced the need for emergency surgery. Slow, low-pressure reperfusion prevented revascularization injury. CDT may thus be considered an initial treatment of choice in aortic saddle embolus.

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We report a rare case of Swyer-James syndrome with hemoptysis submitted to a left lower lobectomy of the lung.
A 70-year-old woman was admitted to the hospital because of hemoptysis. An elevated lesion like a blood blister was seen at the bronchial mucosa of the left basal bronchus by a fiberoptic bronchoscopy. A computed tomographic scan showed unilateral hyperlucency of the left lung with decreased vascular marking. A pulmonary arteriography showed the diminished left pulmonary artery and narrowed artery of left upper lobe. The left bronchial artery was dilated and meandered by a bronchial arteriography. A pulmonary scintigram showed a perfusion defect in the left lung. From these findings, we diagnosed this case as Swyer-James syndrome and a left lower lobectomy was performed to prevent hemoptysis. The pathological findings included stricture of the pulmonary artery due to its thickened internal membrane.

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The problem of recurrence arises from video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. A 30-year-old man was admitted to the hospital because of cough and dyspnea. There were previous histories of undergoing an operation for bilateral heterothronous pneumothrax at the age of 15 and undergoing a VATS for recurred spontaneous sneumothorax at the age of 26. A chest X-ray film, a chest CT scan, and a pleurography film showed left pneumotorax with a large bulla. At the second operation, regrowth of bullae were found at the edge of all-length of staple-line. Since 1991, we have performed 204 thoracoscopic surgeries for spontaneous pneumothorax. However, we have not experienced relapse like in this case. We suspected that the regrowth of bulla was caused by hypertonus of the lung at the periphery of the site where an endoscopic stapler was used (Hypertonus which include the power from the edge of surface will breake the pleura of the lung). After the experience of this case, we have used polyglycolic acid (PGA) sheet for covering the staple-line.

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We report a rare case of paraduodenal hernia showing typical findings in abdominal computed tomography (CT). A 14-year-old boy with abdominal pain treated by nasointestinal intubation underwent diagnostic laparoscopy due to repeated abdominal pain. Laparoscopy showed the small intestine covered by a hernia-like sac in the left upper abdominal cavity, necessitating a change to laparotomy for further examination. We found the small intestine herniated into the left side retro abdominal cavity through the paraduodenal fossa, diagnosed as paraduodenal hernia. We returned the small intestine to the normal position and closed the orifice with simple sutures. Although computed tomography (CT) showed typical findings with anterior dislocation of the inferior mesenteric vein, paraduodenal hernia was not diagnosed preoperatively. Paraduodenal hernia should thus be considered as leading to repeated intestinal obstruction in yound patients without a medical history of abdominal surgery. Abdominal CT may therefore provide useful information in disease diagnosis.

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A 29-year-old man admitted for abdominal pain was found to have, slight peritoneal irritation. Abdominal computed tomography (CT) showed a small bowel obstruction and whirl-like pattern. We diagnosed small bowel volvulus and conducted emergency surgery. We observed intraabdominal cavity via laparoscopy. The bowel was not necrotic and showed a caliber change at the anal side of the bowel about 1 meter from the ligament of Treiz. The rotated bowel was too long to rerotate laparoscopically, so we conducted a mini-laparotomy. The bowel from the caliber change to the ileumend showed counterclockwise rotation of about 360 degrees. The rotated bowel was returned its normal position and recovered color. Neither intraperitoneal abnormal findings nor anomalies predisposing to volvulus were noted, so we concluded with a diagnosis of primary small bowel volvulus. Only 40 cases of primary small bowel volvulus, including ours, have been reported in Japan. Abdominal CT is useful in early diagnosis and the laparoscopic technique may result in less invasive treatment of small bowel volvulus.

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A acute superior mesenteric artery occlusion associated with hepatic portal venous gas has a grave prognosis, but here we report one more survival with some bibliographical comments. A 77-year-old man with a past history of diabetes mellitus was admitted to the hospital because of sudden onset of abdominal pain. Computed tomography of the abdomen demonstrated hepatic portal venous gas and extensive pneumatosis cystoides intestinalis covering from the small intestine to ascending colon. An emergency laparotomy was performed 14 hours after the onset. At laparotomy, extensive necrosis of the bowel from the jejunum to transverse colon was disclosed. All of the necrotic bowel was resected and a jejunostomy was performed. The length of the intact small intestine was only 25cm. The postoperative course was comparatively uneventful. This disease cannot be saved by no treatments other than surgery, and diagnosis and laparotomy should be performed as early as possible.

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We present a case of superior mesenteric vein (SMV) thrombosis diagnosed by an abdominal CT scan, . in which the wide resection of the small bowel could be avoided by the thrombolytic treatment in an acute phase of the disease.
A 48-year-old man was seen at the hospital because of abdominal pain and nausea. Enhanced CT scan confirmed SMV thrombosis. Urokinase (240, 000 units) was administerd to the patient through a catheter inserted to the superior mesenteric artery for 7 days. Heparin sodium solution (10, 000 units) was also injected transvenously for 7 days. Symptomatic remission was gained and the patient started to eat.
Two months later, bowel obstractive ileus occurred following severe abdominal pain and nausea. Laparoscopic partial resection of the jenjunum was performed. Resected specimen showed severe stenosis 5cm in length with a ischemic change. He was doing well one year after the operation.

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We report a case of gastrointestinal stromal tumor (GIST) of the jejunum, observing its growth.
A 65-year-old man admitted for a solid mass in the left lower abdomen was found in abdominal computed tomography (CT) to have a solid 9.0cm tumor in the left lower abdomen. Since no mass was shown in the same CT slice taken 20 months ago, doubling time for this tumor appeared to be about 70 days. Under a diagnosis of a mesenchymal tumor of the small bowel, we conducted partial resection of the jejunum including of the tumor. H-E staining showed dense fasicular proliferation of spindle-shaped tumor cells in bundles and many nuclear divisions in a single field. Immunohistochemical studies showed that tumor cells were positive for c-KIT protein and CD34 but negative for other markers. This tumor was diagnosed as uncommitted malignant GIST considered high-grade malignancy with aggressive proliferation.
Surgical resection of the tumor is the principal treatment for GIST, but new drugs highly effective against GIST have been developed. To ensure appropriate surgical procedure and optimal indications of new drugs, we must understand the unique biology of GIST clarified by more clinicopathological studies.

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A 53-year-old woman with abdominal pain and bloody stool was found in barium enema studies to have a tumor in the cecum. Colonoscopy and abdominal computed tomography showed ileocolic intussusception resulting from cancer of the terminal ileum. At laparotomy, we conducted ileocecal and lymph node dissection after manually reducing the intussusception. The 8×4×1cm tumor was located in the ileum 12cm proximal to the ileocecal valve and showed laterally spreading growth. Pathological diagnosis was well differentiated adenocarcinoma infiltrating to the submucosal layer. We review 12 cases of early ileal cancer reported in Japan and analyze them together with our case.

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A 72-year-old man, who had undergone a gastrectomy for gastric cancer elsewhere, was seen at the emergency room because of severe lower abdominal pain. Abdominal X-ray film showed ileus. Abdominal CT scan revealed the spiral concentration of the mesenterium including air, and the dilataton of the sigmoid colon and small intestine. We suspected strangulated ileus, and performed an emergency operation. On laparotomy, he had been in ileosigmoid knot, and about 20cm of the sigmoid colon and about 250cm of the small intestine were necrotic. We resected the sigmoid colon and the necrotic small intestine. The postoperative clinical course was uneventful and he was discharged from the hospital on 19th hospital day.
Ileosigmoid knot is relatively rare disease, and is difficult to make the preoperative diagnosis. We consider that the spiral concentration of the mesenterium including air in our case revealed the knot of the strangulation by knotting. If the spiral concentration of the mesenterium including air appears between the dilated sigmoid colon and small intestine, we could diagnose ileosigmoid knot before operation on the basis of these findings.

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The patient was a 27-year-old man with mental retardation due to cerabral paralysis. He had a habit of aerophagia since he was 17 years old. Megacolon had been seen on a plain abdominal radiograph and recurrent ileus had been treated concervatively since he was 21 years old. On October 23, 1999, he developed transverse colon volvulus. Reduction of the torsion was attempted using a colonoscopy, but in vain. An emergency operation was performed on the next day. At laparotomy, the transverse colon was ratated clockwise by 180° around the middle colic artery and ischemia of the transverse colon were revealed. Resection of the transverse colon was performed with an end to end anastomosis. A close watch needed by using mechanical ventilation and hyper alimentation therapy after the operation. Postoperative pneumonia due to MRSA infection and postoperative ileus were treated consevatively. Owing to meticulous postoperative treatments, he could start to eat on December 13, 1999. The case of megacolon due to aerophagia, which needs surgical treatment, is so rare that we could find only 2 reported cases during last 10 years in our country. And our case suggests that megacolon with recurrent ileus in severely disabled adults should be subjected to elective surgery.

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Recently, we encountered a case of ischemic sigmoid perforation caused by a giant residual barium stercoroma following imaging of the upper digestive tract. The patient, a 68-year-old woman, reported to our hospital with a chief complaint of pain in the lower abdomen. At admission, marked tenderness, muscular guarding of the abdomen and Blumberg's sign were noted. Hematological tests revealed a reduction in leukocyte count and an abnormal rise in the CRP level. Plain radiography and CT of the abdomen exhibited a large amount of residual barium and the presence of free air under the diaphragm. A diagnosis of panperitonitis caused by gastrointestinal perforation and septic shock was given and the patient was subjected to emergency surgery. Laparotomy revealed a perforation where the sigmoid mesentery was attached, probably due to compression necrosis by a giant barium stercoroma, for which partial resection of the sigmoid and a colostomy were conducted. The postoperative course was satisfactory and the patient was discharged on December 20, 2000. Ischemic sigmoid perforation caused by comp ression necrosis due to a giant barium stercoroma is very unusual. The case was introduced and the literature was reviewed.

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Nine adult cases of intussusception caused by colonic cancer resected in a recent 17-year period are reported. Their mean age was 65.4 years, and the male to female ratio was 4:5. Preoperative examinations led to a diagnosis of intussusception caused by colonic cancer in all the patients. Preoperative reduction of intussusception was successful in three cases. Intraoperative reduction was successful in five cases. The remaining patient underwent a colonoscopic reduction after a transanal resection of the prolapsing tumor. Two patients with cancer of the cecum and one patient with cancer of the transverse colon underwent a right hemicolectomy. One patient with cancer of the descending colon underwent a left hemicolectomy. Four patients with sigmoidal cancer underwent a sigmoidectomy, and one patient with prolapsing sigmoidal cancer from the anus underwent a tumor resection. Their postoperative courses were uneventful. Although it is recommended that resection without reduction is preferable for the treatment of adult intussusception by colonic cancer, in some cases with poor risks such as an advanced age, initial reduction seems useful so as to recover the patient's general condition and to minimize surgical intervention.

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A 65-year-old man with a history of anal fistula and bloody stool was found in physical examination to have a hard 1cm mass at the anus. Barium enema and colonoscopy showed a 9cm rectal tumor 9cm from the anal verge, diagnosed as type 3. Biopsy showed well differentiated adenocarcinoma. Operative findings were H₁, N₄, and P₀, followed by abdominoperitoneal resection. Pathological findings showed the rectal specimen was n₄, a₂, well, ly₃, and v₂ and metastatic carcinoma at an anal fistula, a rare condition generally caused by implantation. Our case, however, appeared to be metastasis from lymphatic drainage. In rectal cancer with an anal fistula, we must consider metastatic carcinoma at the anal fistula.

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We experienced a case of liver abscess due to hepatic actinomycosis following recurrent retrograde cholangitis.
A 61-year-old woman undergone a cholangiojejunostomy for tumor-forming pancreatitis in October 1990 had experienced recurrent cholangitis with fever and abdominal pain. Otherwise these symptoms, she developed chest pain and dyspnea on February 3, 2001 and was admitted to the hospital on February 19. Imagings visualized bilateral pleural effusion and pericardial fluid retention, as well as tumorous lesions in the liver S4 and S2. Hepatic abscess caused by recurrent retrograde cholangitis was diagnosed, and a left lobectomy of the liver and a Roux-Y type anastomosis between the bile duct and jejunum were performed. At that time, the elevated jejunal loop was prolonged from 15cm to 40cm in length. Histopathologically inflammatory features with necrosed material and actinomycetal druse were observed in the abscess cavity. Biliary fistula formed after the operation was consevatively treated. The patient was discharged on May 21 and thereafter she has been free from cholangitis and made a comeback to normal life.

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A 67-year-old man was admitted to the hospital because of ileus. Continuous fever, erythropenia and thrombocytopenia developed after conservative therapy for ileus. Physical examination revealed slight hepatomegaly. High level of CRP and abnormal coagulability, and hyperferritinemia were present. Bone marrow puncture showed increased mature histiocytosis with hemophagocytosis.
Abdominal CT scan revealed an abscess in S4 of the liver. Infection associated with hemophagocytic syndrome was diagnosed. He was treated with prednisolone plus antibiotics, and improved completely after the treatment. He was discharged 40 days after admission. Our case suggests that hemophagocytic syndrome must be considered as a possible diagnosis when bicytopenia with continuous fever is seen in patients with infectious disease, and that early diagnosis and treatment are important.

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A 67-year-old man undergoing sigmoid colectomy for sigmoid colon cancer in February 1996 was found to have multiple metastases in February 1997. We instituted hepatic artery infusion (HAI) and metastases disappeared on computed tomography. Chemotherapy was continued until March 1998 (total dose: 43.75g). Liver metastasis after complete remission occurred in January 2001. We resected the lesion and the man remains alive as of January 2002.
HAI was effective for the first metastases but ineffective for the second. The patient has survived over 5 years since the first surgery, HAI for the first metastases and hepatic resection for the second.
Hepatic resection after HAI is thus effective as a strategy in treating liver metastases from colon cancer.

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We describe a long survival case of multiple liver metastases from colonic cancer completely cured by intra-hepatic arterial infusion chemotherapy. A 65-year-old man was seen at the hospital because of constipation. Barium enema examination and colonoscopic examination showed a 2'type tumor that was 50cm proximal from the anal verge, on the sigmoid colon. Abdominal CT and ultrasonograpy showed four metastatic liver tumors in the bilateral lobes. Sigmoidectomy with lymph nodes dissection was performed. At operation, four metastatic liver tumors could not be resected. After the operation, an intrahepatic arterial catheter was indwelt. On a weekly schedule, 1, 500mg of 5-FU was administered over 5 hours by hepatic arterial infusion. After 23 courses of the chemotherapy, four metastatic liver tumors vanished. A total of 43 courses of the chemotherapy with a total dose of 69.5g of 5-FU was given. There have been free from any signs of recurrence as of more than 5 years 8 months after the operation. Intrahepatic arterial infusion chemotherapy for liver metastasis from colon cancer can produce an excellent effect like as this case.

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A 57-year-old man diagnosed with rectal cancer with multiple liver metastases (H3) and stomach cancer underwent low anterior resection of the rectum, wedge resection of the stomach, and implantation of hepatic arterial infusion system. Subsequent pharmacokinetic modulating chemotherapy (PMC) consisting of continuous i. a. infusion of 5 FU over 48 hrs a week at 2000mg/body weight (BW) and an oral dose of UFT 450mg/day 5 days a week, repeated every week for about 6 months, with 1 shot of i. a. CDDP infusion 1 day a week at 5mg/BW dramatically reduced metastatic liver lesions and tumor markers to within normal limits over 6 months, enabling the man to undergo partial hepatectomy. No viable cells were found in resected hepatic lesions by pathological examination.

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We encountered a case of hepatocellular carcinoma invading the gall bladder. A 70-year-old man, who had been followed at another hospital due to type C chronic hepatitis, received examinations for hepatoma, because a tumor marker increased. He was found to have hepatocellular carcinoma with invasion to the gallbladder (S5) and another tumor (S7), and was referred to the hospital. Percutaneous trans-portal embolization to increase the volume of the left hepatic lobe was unsuccessful. Therefore, a partial hepatectomy including these tumors with the gallbladder was performed. Histopathological examination showed poorly differentiated hepatocellular carcinoma invading the mucosal layer of the gallbladder. The patient experienced multiple hepatic recurrence 3 months and died of rupture of esophageal varix 4 months after the operation. The characters of hepatocellular carcinoma with an invasive growth are reported with a review of the literature.

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Confluence stones are difficult to treat surgically due to local inflammation. With recent advances in laparoscopy, however, opinions have become divided on the suitability of laparoscopic surgery for this condition.
We conducted successful laparoscopic surgery on a patient with confluence stones and fair bile duct inflammation, removing the stones with an arcuate incision from the bile duct to cholecystic duct. Its widely incised orifice made stones extraction easy and we saw no stricture in the bile duct early postoperatively.
We describe laparoscopic surgical procedures due to their applicability to many cases of confluence stones.

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Patient 1: An 81-year-old woman admitted for a bile duct tumor was found in endoscopic retrograde cholangiopancreatography (ERCP) to have irregular stenosis of the lower bile duct. We conducted pancreaticoduodenectomy diagnosed as bile duct cancer. The 2.7×2.0cm tumor showed nodular invasion and histologically was composed mostly of squamous cell carcinoma components surrounded by adenocarcinoma components. She died of liver metastasis 1.5 years after surgery and aspiration cytology of the liver showed only squamous cell carcinoma. Patient 2: A 70-year-old man admitted for obstructive jaundice was found in percutaneous transhepatic cholangial drainage (PTCD) and cholangiography through the PTCD tube and simultaneous ERCP to have a polypoid defect of the lower bile duct. Cytology of bile juice showed adenocarcinoma necessitating pancreaticoduodenectomy. The 3.4×2.4cm tumor showed papillary invasion histologically composed of squamous cell carcinoma and adenocarcinoma in abundant stroma. Lymph node metastasis showed adenosquamous cell carcinoma.

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External intractable pancreatic fistula remains a serious complication following pancreaticoduodenectomy. We report such a fistula treated successfully by interventional internal drainage. A 54-year-old man undergoing pylorus-preserving pancreaticoduodenectomy for lower bile duct carcinoma experienced pancreatic juice discharge from the pancreatico-gastric anastomosis on postoperative day 7. Fistulography showed the main pancreatic duct but no communication between the main pancreatic duct and stomach. Percutaneous transgastric fistulodrainage was not possible because the pancreatic fistula could not be cannulated adequately. We placed a transjugular intrahepatic portosystemic shunt catheter through the pancreatic fistula into the stomach, putting a drainage tube in the shunt area between the pancreatic fistula and stomach. The course after internal drainage was good and the man was discharged 1 month thereafter.

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We report a case of tumor-forming pancreatitis with abscess formation treated with pancreaticoduodenectomy and portal vein resection and its reconstruction with a left renal vein graft. A 57-year-old man admitted for right hypochondralgia. Computed tomography (CT) and ultrasonography (US) showed a multilobular cystic mass in the head of the pancreas. His serum CA19-9 was elevated to 380U/ml.
We undertook surgery to diagnose and treat his tumor properly. A hard tumor found to adhere to the portal vein was suspected of being malignant through intoraoperative pathological examination. We then conducted pancreaticoduodenectomy and portal vein resection and its reconstruction with a left renal vein graft. The resected mass was diagnosed pathologically as tumor-forming pancreatitis with abscess formation. The patency of both the reconstructed portal vein and collateral branches of the left renal vein was confirmed radiologically 4 days after surgery.

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A 54-year-old woman underwent distal pancreatectomy for insulinoma in 1986. In October 2000, she developed hypoglycemic shock and her blood suger was very low (42mg/dl). We found that the tumors could be well localized preoperatively by various diagnostic imaging technique such as computed tomography, magnetic resonanse imaging, endoscopic ultrasonography, angiography and percutaneous transhepatic portal vein sampling. She underwent a distal pancreatectomy and two tumors of remnant pancreas were detected by intraoperative ultrasonography. Histopathological examination of the resected specimen revealed many small nodules beside main tumor and all nodeles were diagnosed as insulinoma. She has been followed up for 12 months without hypoglycemia.

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A case of cancer of the remnant pancreas after a pylorus-preserving pancreatoduodenectomy in a 72-year-old man is reported. The patient underwent a pylorus-preserving pancreatoduodenectomy (PPPD) for tubulo-villous adenoma on the minor duodenal papilla and adenomatous prolifiration on the major duodenal papilla in March 1995. In December 1999, a low density area measuring 3.5×2.5cm in the remnant pancreas was found on an abdominal CT scan. Endoscopic retrograde pancreatography showed a stenosis of the main pancreatic duct, and an abdominal angiography revealed encasement of the splenic artery and an interruption of the splenic vein. From these findings, he was diagnosed as having cancer of the remnant pancreas. In February 2000, a total pancreatectomy combined with a splenectomy and a left adrenalectomy were performed. The lesion was a nodular tumor measuring 58×48×32mm in size. Histopathological examination demonstrated moderately differentiated tubular adenocarcinoma. Conclusive stage grouping was IVa (s3, rp1, pv sp3, a sp3, pl(+), ne2 mpd(+), scirrhous type) according to the general rules of the Japanese pancreatic cancer study. Although postoperative course was uneventful, multiple liver metastasis was detected in May 2000 and he died in November 2000.

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A 48-year-old woman was admitted to the hospital because of left upper abdominal pain and an abdominal ultrasonography revealed a tumor of the spleen. Colonofiberscope demonstrated a lesion like polyposis at the ileum end, in which malignant lymphoma was found by histological examination. The similar lesion was found in the entire of small intestine by an enteral rentgenoscopy. A preoperative diagnosis of primary splenic malignant lymphoma with metastasis to the small intestine was made by enhanced computed tomography, Garium scintigraphy, magnetic resonance imaging and angiography, and a laparotomy was performed. Exploration of the abdomen showed bloody ascites, a hard tumor in the spleen which appeared over the serosa and a small white nodule on the surface of the liver. Splenectomy, lymph nodes sampling and a patial resection of the liver were performed. Malignant lymphoma was found in all resected materials by histopathological studies. Adjuvant chemotherapy with THP-COP was conducted. There have been no signs of recurrence, and the patient is under clinical observation on an ambulant basis, as of 9 months after the operation.

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A 43-year-old woman with a right vulvar mass was found in computed tomography (CT) and magnetic resonance imaging (MRI) to have a tumor of the right vulva extending into the pelvis. This tumor was resected through separate abdominal and perineal incisions, with a histological diagnosis of aggressive angiomyxoma. This is extremely rare, with only 16, including our case, reported in Japan to date. The excised tumor was, at 30×22×8cm, the largest among those reported in Japan. This lesion usually occurs in the perineum or vulva of relatively young women. This case is reported along with a review of other cases reported in Japan and other literature.

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We report a case of primary omental torsion which is a relatively care entity, together with a review of 59 cases in Japanese literature. A 47-year-old woman was admitted to the hospital because of right lower abdominal pain. On physical examination, tenderness, Blumberg signs and muscular defence were noted in the right lower abdomen. On a blood analysis, the white blood cell count and CRP increased to 10, 000/ul and 5.0mg/dl, resectively. Emergency laparotomy was performed under a diagnosis of acute appendicitis. A moderate amount of serosanquinous ascites and torsion of the greater omentum were found in the abdominal cavity. The twisted omentum about three turns was resected. We reviewed 59 cases of primary omental torsion reported in Japan including this case. It is generally difficult to diagnose primary omental torsion preoperatively. When we encounter a patient manifesting similar symptoms to those of acute appendicitis without gastrointestinal symptoms, whose abdominal ultrasonography showed no prominent findings of appendicitis, abdominal CT must be conducted to confirm the presence of abnormalities in the mesentery and intraabdominal fatty tissues.

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We experienced a rare case of transepiploic hernia that was diagnosed preoperatively. A 43-year-old woman was admitted to the hospital because of abdominal pain and vomiting. A computed tomographic (CT) scan showed the presence of the small intestine behind the stomach and liver and ascites. A diagnosis of strangulated ileus by transepiploic hernia was made and an emergency operation was performed. A great deal of the small intestine entered to the omental sac, and through a hiatus of the lesser omentum about 2cm in diameter, about 170cm of the small intestine prolapsed, twisted by 270 °and necrosed. A portion of the invaginated small intertine prolaspsed outside the omental sac through the foramen of lesser omentum. A resection of the necrosed small intestine and closure of the hiatus were performed. The postoperative course was uneventful. This is a rare case of transepiploic hernia with a specific invaginating morphology. Internal hernia such as transepiploic hernia must be kept in mind as a probable cause of ileus symptomatic in patients without history of undergoing laparotomy.

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We treated a case of strangulated obstruction of the small intestine caused by trans-omental herniation, which presented with uncharacteristic abdominal findings. A 78-year-old man was seenfor unremitting abdominal pain. He had no history of surgery. He also had abdominal distension which persisted even when there was some relief, occasionally, from the pain. Blood gas analysis revealed metabolic acidosis with a base excess (BE) of-8.3. Plain X-ray of the abdomen revealed the presence of small intestinal gas, only on the right side. Abdominal ultrasonography and computed tomography (CT) showed marked dilatation of the intestine on the left side, with ascites. A diagnosis of strangulated obstruction of the upper small intestine was made, and emergency surgery was performed. Intraoperatively, incarcerated herniation of the small intestine through the abdominal hiatus of the greater omentum was noted, at a site 60cm from Treitz's ligament, with the herniated intestinal segment showing some ischemic change. A diagnosis of strangulated obstruction of the small intestine caused by transomental herniation was made. The strangulated intestinal loop was released from the hiatus and partial intestinal resection was performed. The postoperative course was favorable and the patient was discharged on hospital day 20. This case emphasizes the importance of internal hernia being borne in mind as a cause of intestinal obstruction in patients with no history of surgery. As this case of strangulated obstruction presented with uncharacteristic abdominal findings, investigations should also be considered for early diagnosis, and no time should be lost in performing emergency surgery.

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We report a case of giant retroperitoneal lipoma. A 50-year-old woman admitted for years-long abdominal distension was found in computed tomography (CT) to have a giant homogeneous, welldefined tumor with the density of adipose tissue at the retroperitoneum. The tumor showed high intensity in T2-weighted magnetic resonance imaging (MRI). Laparotomy was conducted under the diagnosis of retroperitoneal lipoma. The tumor at the retroperitoneal space, compressed intraabdominal organs to the left. The right ovarian artery was found as a feeding artery and the tumor was considered to originate in right perirenal fatty tissue. The 6.1kg tumor was thinly encapsulated and easily extirpated. Macroscopically, it was yellow and its surface was smooth with a thin capsule. Histopathological diagnosis was lipoma of mature lipocytse. Tumors in the retroperitoneal space is rare and lipoma is extremely rare. The average weight of retroperitoneal lipomas was 3.7kg in 95 cases in Japanese literature, including ours.

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We report a case of idiopathic retroperitoneal fibrosis mimicking malignant lymphoma, which was successfully treated with prednisolone. A 65-year-old man was seen at the hospital because of a swelling of the left lower extremity. A venography of the left lower extremity venography disclosed no abnormalities around the iliac vein from the femoral vein. Pelvic enhanced computed tomography (CT) demonstrated a tumor in the front of the sacrum, which penetrated by some blood vessels. Gallium scintigraphy demonstrated abnormal accumulation in the same region. The level of serum soluble IL-2 receptor was high. Therefore, a laparotomy was performed to biopsy the tumor on suspicion of malignant lymphoma. But the pathological diagnosis was idiopathic retroperitoneal fibrosis because fibrous connective tissue increased diffusely with inflammatory cellular infiltration. We began steroid therapy with prednisolone, and it was very effective for the idiopathic retroperitoneal fibrosis. The patient is strictly followed in the out patient clinic and no signs of recurrence have been observed. It is necessary to consider idiopathic retroperitoneal fibrosis in case of a localized retroperitoneal mass.

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A 29-year-old man with a right lower abdominal tumor was found in preoperative abdominal computed tomography (CT) to have a 10cm retroperitoneal tumor with cystic components excluding the external iliac artery. Abdominal angiography showed that the tumor fed on a branch of external iliac artery. Only AFP was elevated. We diagnosed this case as yolk sac tumor, conducting retroperitoneal tumor resection. Microscopically, spindle-shaped tumor cells were tightly arranged. Immunohistochemistry showed the tumor to be positive for AFP, placental alkaline phosphatase (PLAP), and human chorionic gonadotropin (hCG). The final pathological diagnosis was retroperitoneal yolk sac tumor. After surgery, a right testicular tumor became obvious, which we resected. We also conducted combined PBSCT and salvage high dose chemotherapy against the remnant tumor. The patient had no evidence of recurrence or metastasis in the 13 months after chemotherapy. Tumor markers may thus be effective in qualitatively diagnosing of retroperitoneal tumor, and multidisciplinary therapy is important.

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We report a case of retroperitoneal malignant hemangiopericytoma together with some bibliographical comments. A 70-year-old woman admitted computed tomography for right breast cancer was found in abdominal enhanced computed tomography (CT) to have a giantic wellenhanced tumor of the left abdomen. She had neither abdominal pain nor other digestive tract symptoms. She underwent right modified radical mastectomy and the tumor was excised abdominally on postoperative day 28. Neovascularization was found between the mass and retroperitoneum, and total bleeding volume during surgery reached 4, 000ml. From pathological findings, the tumor was diagnosed as retroperitoneal malignant heamangiopericytoma. At 24 months after surgery, the patient is doing well with no evidence of recurrence.
Enhanced CT and angiography are very useful for diagnosing malignant hemangiopericytoma, so we must keep this disease in mind when characteristics in these examinations are confirmed.

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We report a rare complication of pyogenic discitis after sigmoidectomy. A 56-year-old woman with melena undergoing sigmoidectomy due to sigmoid colon cancer developed continuous fever exceeding 38°C on postoperative day (POD) 4. On POD 12, she suffered severe low back pain with sensory paralysis of the lower extremititis and gait apraxia. Plain X-ray, computed tomography (CT), and other examinations did not detect the fever focus. On POD 20, magnetic resonance imaging (MRI) examination showed an abnormal deformity of an intervertebral disk lesion between L5 and S1. Bone scintigraphy and SPECT showed a hot spot at the same site as in MRI. She was diagnosed with the pyogenic discitis and discharged after conservative treatment. Plain X-ray on POD 60 showed narrowing and an uneven lesion of the intervertebral disc. Although pyogenic discitis after such surgery is not common, this complication requires a definitive diagnosis with MRI to detect the original course.

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We have experienced a case of incarcerated umbilical hernia in an adult. A 44-year-old woman was referred to the hospital because of a painful umbilical tumor, with the size of ping-pong ball which appeared 4 years before admission, but was let alone. The tumor in the umbilical region was painful and red. Abdominal computed tomography showed a bowel mass in the fat of the abdominal wall. The leukocyte count was elevated. A diagnosis of incarcerated umbilical hernia was made, and an emergency surgery was performed. The incarcerated small intestine about 5cm in lenght did not require resection and it was reduced because this operation was done several hours after the onset of incarceration. The postoperative course was uneventful and she was discharged very much improved 9 days afer the operation. In a review of the literature, incarcerated umbilical hernia in adults is rare and 27 cases including our case have been reported in Japan in the recent 10 years.

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We report a case of incarcerated inguinal hernia of the appendix. A 77-year-old man who noticed a bulging of the right inguinal region from a week earlier was seen at a hospital because the bulging became increase and painful. He was referred to the hospital with a suspicion of right incarcerated inguinal hernia. After admission, the contents of the hernia could not be determined, but an emergency operation was performed with a strong suspicion of right incarcerated inguinal hernia. At laparotomy, the appendix incarcerated into the right inguinal hernia, the head of appendix became necrotic, and retention of purulent discharge was present in the hernia sac. On the same surgical wound, a radical operation for hernia and an appendectomy were performed; a drain was indwelt in the remnant peripheral hernia sac and the wound was closed.
Although it is very rare that incarcerated inguinal hernia contains the appendix, the disease can be suspected in instances in which ileus symptoms are lacked and lamellar structure is visualized on an inguinal ultrasonography.

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We report a case of obturator hernia diagnosed early after the onset of the disease and treated by a repair under ultrasonic guidance followed by an elective surgery.
A 40-year-old woman was seen at the hospital because of left inguinal pain. CT scan visualized a circular tumor between the left pectineal and external obturator muscles, and obturator hernia was diagnosed. After the impacted intestine was reduced by using an ultrasonic probe, a radical operation with inguinal procedure was electively performed.
Although many cases of obturator hernia are reported, this case was characterized by juvenile occurrence and early clinical manifestations with obscure hernia sac. With a recent progression in imaging diagnoses including CT, the disease has been diagnosed before surgery in most cases. Although emergency laparotomy is still performed in many cases, elective surgery with less invasive approach can be considered, if impacted intestine is successfully reduced early after the onset of the disease.

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A 41-year-old man with untreated type 2 diabetes mellitus was admitted to the hospital because of pain and swelling in the left precordia and left lumbar region. A CT scan showed a low density area at the same lumbar region. Under a diagnosis of pyomyositis, incision and drainage were performed. As a high fever persisted in spite of insulin-and antibiotics-therapy, a CT scan was done again. It demonstrated low density regions of the right abdominal wall and right lower extremity. Re-incision and drainage improved the patient's symptoms significantly. It is said that pyomyositis occurs more frequently in immunocompromised patients. Therefore pyomyositis should be taken into consideration when a diabetic patient complains of pain and swelling of muscles, and general examination should be done as soon as possible to investigate whether another abscess exists.

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We report a case of synchronous gastric lymphoma of mucosa-associated lymphoid tissue (MALT) and sigmoid colon cancer. A 72-year-old woman was referred to the hospital with a diagnosis of gastric malignant lymphoma and sigmoid colon cancer. There was a previous history of undergoing surgery for right breast cancer at the age of 50. Gastrointestinal endoscopic examination revealed erosive gastric lesions. Histological findings of a biopsy from the stomach suggested gastric malignant lymphoma or MALT lymphoma. At the same time, she was diagnosed as having sigmoid colon cancer. We performed a sigmoidectomy and a total gastrectomy. Histological examination of the resected specimens showed low-grade gastric MALT lymphoma and moderately differentiated adenocarcinoma of the sigmoid colon. This is a unique case of gastric MALT lymphoma that synchronously occurred with other cancer except gastric cancer in Japan.

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