We routinely perform screening annual mammography (MMG) for patients undergoing mastectomy or breast-conserving treatment (BCT) for primary breast cancer from April 2001. In this study we investigated whether screening annual MMG is beneficial for early detection of metachronous contralateral breast cancer (MCBC). Subjects were a series of 44 patients operated on at the hospital for MCBC from April 1997 through January 2004. We classified the patients into two groups; 21 patients treated from April 1997 to March 2001 were assigned to group A, and 23 patients treated from April 2001 to January 2004 were assigned to group B. The patients of group B received screening MMG annually. The mean time between the operation for the first breast cancer and the operation for MCBC was 121 months in group A versus 100 months in group B. There was, no significant difference between them (P=0.37), but early detection of MCBC predominated in group B. The mean diameters of the lumps were 2.5 cm in group A and 1.7 cm in group B. The mean diameter in group B was significantly smaller than that of group A (P<0.05). Seven patients (30%) from group B were detected to have MCBC by screening MMG after the operation for the first breast cancer, and all of them underwent BCT. This study indicates that screening annual MMG may contribute to early detection of MCBC.

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The major complications after breast surgery are hematoma, seroma, infection, necrosis of skin flap, pulmonary thromboembolism, and myocardial infarction. We reviewed the complications of 2023 cases (including four cases of male breast cancer) undergoing operation for breast cancer at National Cancer Center Hospital East from July 1992 to March 2004. In this study, age, body mass index, tumor size, tumor location, operative procedure, and blood loss for operation were analyzed with respect to the incidence of hematoma, seroma, infection, necrosis of skin flap, pulmonary thromboembolism, myocardial infarction, and Mallory-Weiss Syndrome. We experienced 44 (2%) cases of hematoma, 20 (1.0%) cases demanding hemostatic procedure for reopened surgical wound, 196 (10%) cases of seroma, 15 (0.7%) cases of infection, 24 (1%) cases of necrosis of skin flap, three (0.1%) cases of pulmonary thromboembolism, one (0.05%) case of myocardial infarction, and one case of Mallory-Weiss Syndrome. Seroma and necrosis of skin flap were associated with the body mass index (p<0.05). In order to prevent postoperative complications, preoperative evaluation of the patient's general condition, precise intraoperative procedures for hemostasis and careul perioperative management of fat patients are important.

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We investigated excision specimens from 21 cases of gastric malignant lymphoma undergoing gastric resection until 2001 based on the WHO organization classification, and elucidated clinicopathological features and the validity of surgical excision. There were seven cases of MALT lymphoma, 13 cases of diffuse large B-cell lymphoma (DLBCL), and one case of follicular lymphoma (FL). Patients with MALT lymphoma had good prognosis by surgical excision and postoperative chemotherapy, though one patient experienced securrence. On the other hand, six out of eight patients with DLBCL with Curability A experienced recurrence.
The 5-year-survival rates were 71.3% in all the patients, 100% in patients with MALT lymphoma and 52.7% in those with DLBCL, indicating that the WHO organization classification reflected the degree of clinical malignancy. Internal treatment is preferentially selected to avoid the degradation of the QOL by gastrectomy, however further studies to compare the both therapies may be required in terms of long-term prognosis.

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In order to elucidate the risk factors of clostridium difficile colitis, 149 patients undergoing cholecystectomy for benign disease and 371 patients undergoing digestive tract operation from January 1999 to December 2001 are enrolled in this study. We diagnosed the patients as having the disease when they presented with high fever followed by diarrhea after surgery and showed positive response with Clostridium toxin A detection kit. The incidence rate of this disease or diarrhea in the cholecystectomy group was significantly higher than that in the digestive tract operation group. In the cholecystectomy group, no significant differences in background factors such as operative procedure and age were noted between patients with and without symptoms of enteritis. However, a significantly higher incidence rate of the disease was noted in patients received examination or internal treatments including fasting and i. v. drip infusion of antibiotics and H2-blockers than that in preoperatively non-treated patients.
There is a recent tendency to select early operation for acute cholecystitis. We think that early operation is desirable in terms of an increasing tendency of risk of postoperative enteritis.

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We experienced a case of Graves' disease with an enomous goiter which rapidly enlarged in the recent one year against a 10-year administration of thiamazole for hyperthyroidism at another hospital.
A 33-year-old man with hyperthyroidism due to Graves' disease, who had received thiamazole, bisoprolol fumarate, Lugol's solution, prednisolone, and lithium carbonate to achieve a euthyroid state, was referred to the hospital because a rapidly enlarged goitor disturbed the internal treatment. When he was first seen, his neck was 50 cm round. Following 1200 ml of autologous blood donation was carried out for prospective massive bleeding, the patient underwent bilateral subtotal thyroidectomy, with the remnant thyroid of 3.2g. The dissected thyroid weight was 786g, the volume of blood loss was 1715g, and the operation time was 9 hours 54 minutes. Transitional thyroid crisis and hoarseness with left vocal cord paralysis occurred in postoperative period. Both complications were relieved immediately, but the patient remains under internal treatment for hypothyroidism as of 7 months after the operation. His neck was 38 cm round.
Surgical therapy for huge goiters that is usually very effective becomes difficult when the estimated weight of the goiter is over 200g. Consequently, if the goiter is judged to make resistance to internal and/or radiation therapies, these therapies must be converted to surgical operation as soon as possible before the goiter becomes large.

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A 48-year-old woman was seen at the hospital because of an anterior neck mass in April, 2000. She had progressive muscular dystrophy since the age of 20, and used a wheelchair in her life. The neck mass was diagnosed as a follicular tumor of the thyroid in the left lobe by US and fine needle aspiration cytology, then she was under observation at the outpatient unit. She had the sudden onset of massive anal bleeding in November, 2002, and was diagnosed as having rectal cancer with multiple metastases to the bilateral lungs. She was treated by partial resection of the rectum with artificial anus construction, and followed up with 150 mg of 5-FU oral administration.
In April, 2003, she was seen at the hospital again because of the growing neck tumor and a sense of compression. Although US and cytology showed no malignant findings, she was admitted to the hospital for her strong desire to relieve the serious compression sensation by removing the tumor. The tumor was a 6×5 cm, well defined and smooth surfaced mass in the left lobe of the thyroid, and it had a hard node (1.0×1.0 cm). Laboratory examinations showed normal thyroid function and a slight elevation in serum thyroglobulin, whereas remarkable elevations in serum CEA and CA19-9 levels suggested an advance of recurrence of the rectal cancer.
The thyroid tumor was excised by left thyroid lobectomy in May, 2003. The tumor was localized in the thyroid gland without either invasion to adjacent tissue or regional lymph nodes. Histological examination revealed that adenocarcinoma cells conformed of the tumor nest with necrosis inside the follicular tumor of thyroid. Metastasis of rectal cancer into the preexisted thyroid follicular tumor was thus diagnosed.
It is extremely rare that metastasis of other carcinoma occurs inside of a thyroid follicular tumor, then we present this interesting case together with some discussion based on the relating several previous reports.

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We successfully removed recurrent papillary carcinoma of thyroid which firmly adhered to the common carotid artery (CCA) by resecting the CCA followed by revasculaization with a radial artery graft in two cases.
A 71- and a 67-year-old women developed recurrence of papillary carcinoma of thyroid at cervical lymph nodes. Preoperative ultrasonogram and computed tomogram revealed a suspicious invasion to the CCA. Brain spectogram (BSP) following balloon occlusion test (BOT) showed a>70% fall in the cerebral blood flow. Therefore the reconstruction of CCA was indicated in both cases.
At surgery, the metastatic lymph nodes were unable to be dissected from CCA because of their firm adhesion to the arterial wall. Thus, we bypassed CCA using a radial artery graft, and then removed the metastatic lymph nodes en bloc with CCA. The postoperative courses were uneventful in both cases. The pathological examination proved tight compression but no invasion of papillary carcinoma to the arterial wall. There was dense cicatricial tissue adjacent to CCA in both cases.
Removal of CCA is accompanied with cerebral ischemia and infarction. Hence, preoperative estimation of the risk of cerebral ischemia is imperative. BSP following BOT is useful for this aim.

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We report a case of stromal sarcoma of the left breast, which is the 101 st case in Japan.
A 54-year-old woman was seen at the hospital because of a tumor 1.5 cm in diameter in the AC region of the right breast, of which she had noticed about one month earlier. Palpation, mammography and breast ultrasound offered a suspicion of primary beast cancer. Aspiration biopsy cytology resulted in class IV and breast sarcoma was suspected. Right tumorectomy was performed, when intraoperative pathological examination demonstrated sarcoma of the breast. A breast-preserving wide local excision was thus performed without axillary dissection. Histological diagnosis was stromal sarcoma of the breast with chondrosarcoma differentiation. Adjuvant radiation therapy was performed for the right residual breast. No recurrence has occurred 14 months after the surgery. A review of previous 101 domestic cases for local control suggests that tumors less than 3 cm in diameter should be considered as candidates for breast-preserving wide local excision.

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Primary T-cell malignant lymphoma of the breast is rare, accounting for only 0.04%-0.5% of all malignant breast tumors. We report a case of primary T-cell malignant lymphoma of the breast, together with a review of the Japanese literature. A 49-year-old woman seen at the hospital because of a palpable left breast tumor was suspected to have breast cancer by clinical examinations before surgery. According to the LSG classification, the tumor was diagnosed as diffuse lymphoma derived from the large size cell type, and T cell type by immunohistochemical examination. Postoperatively, the patient received chemotherapy (VEPA). On the 8th month after the operation, she developed metastases to the tibial bone and axillary and cervical lymph nodes. After temporary symptomatic remission and a decrease of the lesion with additional chemotherapy (VEPA+VP16), she died of multiple bone metastasis 32 months after the diagnosis. T-cell lymphoma is often resistant to chemotherapy and the prognosis of this disease is poor.

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We report two patients with breast cancer who were performed breast-conserving surgery after successful 6-month neoadjuvant endocrine therapy. Patient 1, a 55-year-old postmenopausal woman with estrogen receptor (ER)-positive and Her-2/neu positive large (>3cm) operable breast cancer, was treated with anastrozole (1mg) as neoadjuvant therapy for 6 months. After achieving a partial response when the longer diameter of the tumor decreased to 2.5cm, the video-assisted breast-conserving surgery was performed. The histological findings showed a reduction of Her-2 expression and an increase of apoptoic index.
Patient 2, a 44-year-old premenopausal woman with ER positive and Her-2/neu negative breast cancer, was treated with tamoxifen (20mg) and goserelin (3.6mg) for 6 months. After the treatment, the tumor volume calculated using multi slice CT changed 70% decrease, and the video-assisted breast-conserving surgery was performed. The histological findings showed over-expression of Her-2/neu.
Neoadjuvant endocrine therapy may be effective for endocrine sensitive breast cancer selected by assessment of core-needle biopsy. The Hre-2/neu expression may be very important when we choose endocrine medicine.

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Blood cysts of the heart valves are commonly reported at postmortem examination of fetues and infants but are rarely seen in older children and adults. We report here a case of a blood cyst originating from the tricuspid valve.
A 67-year-old woman was admitted to the hospital after abnormalities of the tricuspid valve were identified on echocardiography. Preoperative CT and magnetic resenance imaging scans (MRI) showed a circular filling defect near the tricuspid valve, moving from the right atrium to the right ventricle, which was diagnosed as myxoma originating near the tricuspid valve. Intraoperatively, a blood cyst 3×3cm in diameter filled with dark red blood was found in the septal leaflet of the tricuspid valve, and was excised. Pathological examination identified the blood cyst to have originated from the tricuspid valve.
It is controversial whether surgical resection is necessary for the disease or not. We think that surgical resection should be carried out, because the possibility of malignancy as well as the risk of thromboembolism due to calcium stones or clots can not be completely ruled out.

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We encountered a case of rupture of the infrarenal abdominal aorta probably caused by penetrating atherosclerotic ulcer (PAU). A 68-year-old man admitted to the hospital because of severe abdominal pain went into shock when receiving CT examination. Abdominal CT with contrast medium revealed rupture of the aorta due to a break of the aortic wall and a large retroperitoneal hematoma. The aorta was of normal caliber adjacent to the site of rupture, and no evidence of aneurysmal formation was present. An emergency operation was performed with the diagnosis of aortic rupture. At operation, a 1.5cm hole was found in the left lateral aspect of the infrarenal aorta. Graft replacement for the infrarenal abdominal aorta was performed with a bifurcated graft. However, the patient could not recover and died of circulatory collapse on the second postoperative day. This case was diagnosed as ruptured infrarenal abdominal aorta probably due to PAU based on CT and intraoperative macroscopic fingings. This paper describes the case, together with a review of the relevant literatures on this topic.

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Four-cusped aortic valve occurs in an extremely low incidence and there are few surgical cases of aortic valve insufficiency. This paper deals with a case diagnosed as aortic valve insufficiency due to four-cusped aortic valve by echocardiography through the esophagus and chest wall preoperatively, and performed valve replacement.
A 37-year-old man was seen at the hospital because of abnormal sensation in the left chest. Echocardiography through the esophagus and wall revealed the diagnosis of aortic valve insufficiency due to four-cusped aortic valve. With cardiac catheterization, aortic regurgitation (AR) in grade III was diagnosed. The patient was referred to the department as a cancidate for operation. During operation, we saw that the aortic valve consisted of four leaflets, the right and left coronary cusps were same in size, and the non-coronary and excessive cusps which had same size were slightly smaller than the former two. Valve replacement using an artificial valve was performed, and the patient's postoperative course was uneventful.

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We report a case of pulmonary aspergillosis which had not preoperatively been diagnosed for nearly 2 years after the onset of symptom. A 51-year-old woman was seen at the hospital because of hemoptysis in July 2001, when chest x-ray showed infiltrative shadow in the right lower lung field, but no bleeding site was identified by bronchoscopy. In February 2002, bronchoscopy for second episode of hemoptysis also provided no helpful information on bleeding site. In April 2002, the patient developed third hemoptysis and was admitted to the hospital for close exploration and treatment.
Before operation, bronchial arteriography and pulmonary arteriography visualized bronchial arterypulmonary artery shunt. Hemoptysis caused by the bronchial artery-pulmonary artery shunt was diagnosed and a right basal segmentectomy was performed to control hemoptysis on June 3, 2002. Hemoptysis ceased thereafter.
Pathological diagnosis was pulmonary aspergillosis, which was thought to have been the direct cause of repeated hemoptysis.

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A 54-year-old man was brought into the emergency clinic in our hospital because of persisting back pain. Chest computed tomography (CT) revealed abnormal shadow in the mediastinum. He was admitted for close examination and treatment. In the next day the mediastinal abnormal shadow became larger and left pleural effusion occurred on chest CT. We diagnosed the case as mediastinal hematoma, but aortography and pulmonary aortography disclosed no apparent abnormal findings. Gastrointestinal endoscopy revealed a diverticlum like lesion at the lower esophagus on the 2nd hospital day. Spontaneous rupture of the esophagus was definitly diagnosed with esophagography. It had taken about 48 hours to make the definite diagnosis after the onset of symptoms because this case showed unusual pattern. No cases of spontaneous rupture of the esophagus first diagnosed to be mediastinal hematoma like this case have been reported. This case which is thought to be helpful information is presented together with some bibliographical comments.

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Spontaneous rupture of esophagus is often associated with mediastinal and intrathoracic contamination, and in such cases repair of the esophagus under thoracotomy and mediastinal and thoracic drainage are performed. This paper reports a case of spontaneous rupture of esophagus which needed a long time from the onset to diagnosis and was successfully treated by trans-abdominal repair under laparotomy for extended but localized inflammation in the mediastinum.
A 73-year-old man was diagnosed as having spontaneous rupture of esophagus 5 days after the onset of the disease and was admitted to the hospital. We selected conservative therapy, because he had localized inflammation in the mediastinum; his general condition was stable; and he might be intolerable with surgery due to significantly decreased cardiac function at that time when only one month had elapsed from percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction. Examinations conducted after one week revealed no improving tendency, and the patient was indicated surgery. Considering the invasiveness of the surgery, trans-abdominal repair of the esophagus was performed. During surgery we had no difficulties in surgical techniques and then added fundic patch method. No postoperative complications including suture failure occurred and the patient progressed satisfactorily. However, we are still apprehensive for anastomosed site and the route of mediastinal drainage that might be problems awaiting solution.

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We report two cases of vitamin B1 deficiency presented with peripheral neuropathy 6 months and one year 6 months after total gastrectomy with reconstruction with jejunal pouch interposition (JPI) for early gastric cancer.
Patient 1, a 36-year-old man, developed leg edema and gait disturbance 6 months after the surgery and was diagnosed as beriberi because of the low level of serum VB1, 13ng/ml. Patient 2, a 63-year-old man, developed bilateral knee numbness 18 months after the surgery, when his serum level of VB1 was 14ng/ml. Intravenous administration of VB1 at a dose of 100mg/day provided symptomatic remission within a week.
From our experience with these cases, we think that the possibility of VB1 deficiency should be cared in following postoperative patients with gastric cancer, especially in patients who underwent total gastrectomy with reconstruction with JPI.

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A 43-year-old man was admitted to another hospital because of tarry stool while traveling. An upper gastrointestinal endoscopic xamination demonstrated bleeding from a gastric submucosal tumor on the anterior wall of the upper body. After hemostasis was obtained, the patient was referred to the hospital for surgery. After 2 days, hematemesis occurred and emergency surgery was performed. During surgery, a gastric tumor showing extracanalicular entension measuring 6 cm in diameter was observed on the anterior wall of the upper body on the side of lesser curvature. The lymph node near the tumor showed swelling, so total gastrectomy (D1) was performed. Histopathological and immunohistological examinations demonstrated gastrointestinal stromal tumor (GIST), uncommitted type and metastasis to the lymph node No.1. Five years after the surgery, there has been no evidence of recurrence. GIST with lymph node metastasis is rare and in the opinion of some authors, lymph node dissection is not clinically significant. However, in a case showing tumor necrosis, greater diameter than 5 cm, or swollen lymph node, some degree of lymphadenectomy should be considered.

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We report a rare case of stomal recurrence of gastric cancer developed 13 years after total gastrectomy which was successfully resected.
The patient was a 67-year-old woman with a history of undergoing total gastrectomy for gastric cancer located at the gastric cardia in January, 1990. The histologic findings of the resected tumor showed that IIc-like advanced gastric cancer occupying the cardia of the stomach had invaded subserosa with positive lymphatic and venous invasion and no lymph node metastasis. The histologic diagnosis was signet ring cell carcinoma concomitant with poorly differentiated adenocarcinoma. Both the proximal and distal margins were negative for cancer. The operation was thought to be curative. The postoperative course had been uneventful until discomfort of upper abdomen appeared in January, 2003. Endoscopy revealed a recurred tumor at the site of anastomosis. An “en bloc” resection of multiple organs was carried out through the left thoraco-abdominal approach in March, 2003. The histologic type of the recurred tumor was similar to that of the initial tumor. Moreover, both cancers showed the same findings on immunohistochemical staining. Stomal recurrence of gastric cancer was diagnosed.
Resection is recommended to stomal recurrence even after total gastorectomy, because the reoperation may contribute to improve the quality of life of the patient including food ingestion.

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Duodenal perforation in the early infancy is an uncommon condition. We present a case of multiple duodenal perforations in a premature boy born with an extremely low body weight. The premature boy was born at the gestational age of 26 weeks by emergency cesarean section resulting from pelivic presentation, amniorrhexis, and intrauterine infection. His birth weight was 764g. The Apgar at 1 min was 3 and, at 5 min, it decreased to 2. He required intermittent mandatory ventilation for about one month after birth. Ninety eight day after birth, he developed abdominal distension. A supine radiograph of the abdomen revealed massive pneumoperitoneum. Exploratory laparotomy disclosed two perforations at the first portion of the duodenum. Direct closure and peritoneal drainage were carried out. On the postoperative day 1, he had central urorrhagia due to hematencephalon. Oral feeding was started on the postoperative day 34, and the boy is now staying in the hospital. Hematological studies after surgery showed that Helicobactor pylori IgG antibody was positive and blood gastrins level was high. Culture for Helicobactor pyroli in stools was positive. Although the cause of the perforations in this case, remained undetermined, duodenal ulcer was the most likely cause. Growth after surgery has been normal without recurrence of duodenal ulcer.

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A 48-year-old man who had been diagnosed as having von Recklinghausen's disease in 1995 was seen at the hospital because of abdominal pain and vomiting on March 27, 2003. Abdominal CT scan visualized bilateral adrenal tumors and a tumor of the pancreas tail. He was emergently admitted to the hospital. While receiving general examinations, he developed abdominal pain and vomiting again and was diagnosed as having intussusception by abdominal CT scan. Emergency operation was performed on the same day. At laparotomy an ileo-ileal intussusception was present at the ileum about 50 cm proximal to the ileocecal region which was led by a tumor about 3 cm in diameter. Partial excision of the ileum was performed including the necrotic intestine. Inside of the excised intestine eight mulberry and broad-based tumors with the maximum diameters of 7-40mm were identified. Histopathologically these tumors were composed of oval-shaped cells with high N/C ratio and spindle-shaped cells. On immunostainings, they were strongly positive for vimentin and S-100 protein, and malignant peripheral nerve sheath tumor was diagnosed.
Case reports on malignant neurogenic tumor of the small intestine associated with von Recklinghausen's disease, especially such cases presented with intussusception like in this case, are rare.

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A 71-year-old man complaining of epigastric pain and vomiting was treated conservatively under a diagnosis of ileus. Contrast radiography of the small intestine showed suspected stenosis of the ileum. Ileus improved temporally and alimentation was started, but he developed ileus again, necessitating laparotomy. An about 15 cm long ileal intussusception with a preceding tumor was present 30 cm proximal to the Bauhin's valve. Manual repositioning did not reduce intussusception, and we partially resected the ileum by about 25 cm including the tumor. Macroscopic findings showed a pedunculated tumor about 2.5 cm in diameter, yielding a histological diagnosis of Peutz-Jeghers hamartomatous polyp. This patient did not have typical mucocutaneous pigmentation or hereditary factors, so that we concluded that this patient had incomplete Peutz-Jeghers syndrome. Intussusception is rare in adults and several cases of adult intussusception due to Peutz-Jeghers hamartomatous polyp have been reported. We discuss this rare case and review the relevant literature.

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A 43-year-old woman was seen at the emergency clinic in our hospital on January 31 2001 because of abdominal pain, which first appeared in January 2000 and persisted with increasing intensity, and recently developed abdominal distention and nausea. Abdominal CT scan and other imaging methods offered a diagnosis of intestinal obstruction due to a tumorous lesion in the vicinity of the distal ileum, and the patient was admitted to the hospital. Since abdominal magnetic resonance imaging (MRI) scans for the tumor lesion showed high signal intensity on T1-weighted and fat-suppressed T1-weighted images and low signal intensity on T2-weighted images, a tumor with a hematoma was considered. The patient was operated on with a preoperative diagnosis of intestinal endometriosis.
There are many reports describing that intestinal endometriosis presented difficulty in preoperative diagnosis including differentiation from metastatic intestinal tumors. We think that preoperative inspection using MRI is helpful for making diagnosis of intestinal endometriosis.

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A 53-year-old woman, who complained of a mass in her right lower abdomen with tenderness, underwent laparotomy under a preoperative diagnosis of ileoceal malignant lymphoma. Histopathological examination revealed druse of actinomycosis and ileocecal actinomycosis was diagnosed. PEPC was orally administered at a dose of 2g/day for about 2 months to prevent recurrence.
Abdominal actinomycosis, which often forms an abdominal mass, is a chronic purulent granulomatous disease. To diagnose this disease is difficult and it is often diagnosed postoperatively by histopathological examination. We reviewed 170 reported cases of abdominal adinomycosis in Japan. The male-to-female ratio was 71:95, and a mean age of them was 51.8 years. The tumor occurs commonly in the ileocecal region, tansverse colon and pelvic cavity. The reasons why the diagnosis is so difficult are that the disease lacks specific symptom and imaging findings, and that we have often difficulty in biopsy. However, 77.8% (14 out of 18 cases) of the patients who were correctly diagnosed preoperatively were cured only by antibiotics. Patients can avoid invasive treatment if preoperative diagnosis can be made correctly. Actinomycosis should be included in the differential diagnoses for abdominal tumors.

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Meckel's diverticulum is after silent throughout the patient's life and is detected incidentally by a variety of symptoms associated with the diverticulum, or on laparotomy due to other diseases. We report a case of incompletely inverted Meckel's diverticulum with some bibliographical comments.
A 20-year-old man was seen at the hospital because of intermittent and movable abdominal pain in his right lower back, or in his right lower or left lower quadrant of abdomen. Meckel's diverticulitis was suspected under abdominal ultrasonography, CT, and magnetic resonance imaging (MRI). He was admitted for only overnight observation because no inflammatory findings were noted. On the next day the intermittent and movable abdominal pain still persisted. A multiple concentric ring sign on ultrasonography was found and an emergency operation was performed under diagnosis of intussusception. Incompletely inverted Meckel's diverticulum was disclosed at the time of laparotomy and a partial resection of the ileum including the Meckel's diverticulum was performed. Aberrant tissues of the gastric mucosa and pancreas were revealed at the bottom of the Meckel's diverticulum pathologically. On the 9th postoperative day he was discharged from the hospital without any complications.

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Of malignant tumors of the intestine, small intestinal malignant lymphoma is relatively rare and to make the diagnosis of the disease is difficult. In this paper we present a case of malignant lymphoma of the small intestine in which retrograde enterography was usuful. A 54-year-old man presented with mesogastralgia, melena and anemia. No bleeding site could be localized by either lower or upper gastrointestinal endoscopic studies. Intestinal fluoroscopy revealed mild stenosis of the distal ileum. Retrograde enterography revealed two sites of stenosis in the distal ileum. Partial resection of the ileum including the two lesions was performed. On the resected material, two tumors with ulcer were observed which might cause bleeding. These tumors were diagnosed as follicular lymphoma of B cell origin according to the LSG classification. We have renewed our understanding of the difficulty in making diagnosis of small intestinal tumors and of the importance of retrograde enterography which provide helpful information for diagnosis.

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We experienced a rare case of adult ileal duplication presented with acute appendicitis like symptoms.
A 77-year-old man was admitted to the hospital because of right lower abdominal pain, vomiting and fever. Abdominal CT scan showed slight swelling of the appendix, and he had peritoneal signs. Surgery was performed with the most likely diagnosis of acute peritonitis. At surgery, a cystic mass with inflammatory changes was present on the mesenteric side of the ileum and the mass was removed. Histological examination showed the cystic lesion was lined with mucosa similar to the small intestine, smooth muscle layer and ectopic gastric mucosa. These findings indicated ileal duplication. The patient's postoperative course was uneventful, and he was discharged from the hospital on the 21st postoperative day. Alimentary tract duplication is relatively rare in adults. Intestinal duplication presents with abdominal masses or ileus in many cases, but our patient presented with peritonitis. When other diseases are excluded in patients with acute abdomen, alimentary tract duplication must be kept in mind as a probable diagnosis and intra-operative exploration is required.

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A 69-year-old man under observation after surgery for ruptured gastrointestinal stromal tumor (GIST) of the small bowel in 1998 was pointed out to have several intra-abdominal masses by follow-up abdominal CT scan in 2003. The largest mass was 75mm in diameter and no recurrence site was found in other organs. Under a possible diagnosis of recurrence of GIST in the peritoneal cavity, removal of multiple tumors with partial resection of the small intestine was performed. The pathological diagnosis of the removed tumors was peritoneal recurrence of the small bowel GIST. His postoperative course was uneventful, and he was discharged on 13^th postoperative day. However, 5 months later, the liver metastasis was demonstrated by abdominal CT scan, and oral administration of a tyrosine kinase inhibitor STI571 was started. No signs of enlargement of the metastatic liver tumor were identified on abdominal CT conducted 9 months after initiation of STI571 regimen.

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Primary carcinoma, especially signet ring cell carcinoma, of the vermiform appendix is rare and to diagnose the disease is difficult preoperatively. We experienced two cases of primary signet ring cell carcinoma of the vermiform appendix which were diagnosed postoperatively. Patient 1, a 73-year-old man complaing of right lower abdominal pain, underwent appendectomy under a diagnosis of acute appendicitis. Postoperative histological examination revealed signet ring cell carcinoma of the vermiform appendix. We performed an ileocecal resection with lymph node dissection. No lymph node metastasis or peritorinal dissemination was recognized. He has been well without symptoms, as of 5 years after the operation. Patient 2 was a 72-year-old man undergone an appendectomy under a diagnosis of perforated acute appendicitis. Histological examination revealed signet ring cell carcinoma of the vermiform appendix. Instead of surgery chemotherapy was started, but the therapy could not be continued due to his physical condition. He has shown no signs of recurrence or metastasis for 18 months after the operation. To avoid overlooking appendiceal carcinomas, careful intraoperative observation and postoperative pathological examination are very important.

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We report a case of penetration of a plug to the large intestine after radical operation for inguinal hernia with mesh plug method in a 79-year-old woman.
The patient who had been given prednisolone orally for autoimmune hepatitis since 1995 underwent surgery for right internal inguinal hernia with mesh plug method in September 1996. The patient developed swelling in the right inguinal region in February 1998 and became felt tenderness at the site in December 2000. Then she underwent surgery. When the skin was incised, abscess was present there. Dissection of the mesh plug through a fistula on the aponeurosis disclosed that the plug projected into the abdominal cavity and adhered to the small intestine and cecum to form a fistula with the cecum. The cecum was partially excised and repaired with McVay's modified method.
In our experience, we can confirm that the indwelt plug has considerably projected into the abdominal cavity when laparotomy is performed for other diseases. Such projection of the plug might cause its intestinal penetration in the background that tissues became fragile due to long-term oral ingestion of the steroid in this case.

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Phlebosclerotic colitis is an ischemic colon disease caused by anomalous venous connection due to phlebosclerosis. It is a rare entity and there have been very few reports. We present a case of phlebosclerotic colitis with ileus of the colon.
A 66-year-old woman presented with abdominal pain and vomiting was referred to the hospital with a diagnosis of ileus. Abdominal plain X-ray and CT scan revealed calcified growths in the wall of the right colon and linear or nodular calcifications in the mesocolon, and phlebosclerotic colitis was diagnosed. Conservative therapy with a long tube led to her recovery and discharge. However, 2 months later she was re-admitted to the hospital because of recurrent ileus. She was again treated conservatively, and after obstruction of the colon had subsided, laparoscopic-assisted subtotal colectomy was performed. She has been healthy without signs of recurrence, as of 2 years after the operation.
As for the conservative therapy and postoperative course of phlebosclerotic colitis, there are still many unsolved problems, and much more experience is necessary to understand the etiology of phlebosclerotic colitis.

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A 50-year-old man with a history of colon polyp was found to have a IIa like polyp at the transverse colon by surveillance. After marking clip was applied proximally to the polyp for scheduled EMR, he went home. Seven hours later, he had abdominal pain after supper and was admitted to the hospital on the next morning with the diagnosis of small bowel obstruction. Conservative therapy was unsuccessful. Six days after colonoscopy, a laparotomy was performed. At laparotomy the transverse colon adhered to the small bowel, because the marking clip held the ileum through the colon wall, and a loop of the ileum had trapped to be strangled there. A wedge shaped excision including the clip was performed for the colon and the small bowel wall was repaired by sero-muscular suture. Endoscopic clipping method is used widely for various purposes due to its usefulness and safety. Complications of this method are nevertheless reported. This paper deals with our experience with a rare complication of the method.

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We report a case of solitary liver abscess associated with transverse colon cancer.
A 70-year-old man admitted to the hospital because of low grade fever and general fatigue was found to have a solitary liver abscess with the diameter of 8cm in the right liver segment on abdominal computed tomography. Administration of antibiotics and percutaneous transhepatic abscess drainage (PTAD) were conducted. The patient responded well to the drainage. After PTAD, several gastrointestinal examinations were carried out to determine the cause of the liver abscess. Cytodiagnosis of the abscess revealed no malignant cells and no causative organisms were isolated by culture. No abnormalities were found by upper gastrointestinal endoscopy and 3D-DIC-CT, but a tumorous lesion of the transverse colon was detected by barium enema study. A type II tumorous lesion of the same site was identified by colonoscopy and a biopsy of the lesion resulted in group V. After the abscess subsided, a right side colectomy with D₃ lymph nodes dissection was performed. The resected specimen revealed H₀, P₀, N₀, MP in Stage I, mp, n₀, v₀, ly₀ microscopically. The patient has been free from liver metastasis and liver abscess 16 months after the operation. In conclusion, pyogenic liver abscess with unknown origin requires full gastrointestinal evaluation.

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We report a rare case of gastrointestinal stromal tumor (GIST) arising from the sigmoid colon.
A 69-year-old man under chemoradiation therapy for left lung cancer since June 6 2003 had currant jelly stool without any other abdominal symptoms. Colonoscopy revealed a spherical mass in the rectosigmoidal colon. Necrotic tissue was found in a biopsy of the tumor. Since there was the risk of intussusception, a sigmoidectomy was performed on August 22, 2003. At surgery, the sigmoid colon prolapsed into the lumen of the rectum Rs, showing intussusception like appearance. Two tumors were found in the resected specimen; a spherical tumor 7×6×5cm in dimension bulging into the lumen, and type 2 advanced cancer adjoined to its oral side. Microscopically the spherical tumor was composed of spindle shaped cells with interweaving bundle pattern and some mitosis. Immunohistochemically, the tumor cells were negative for c-kit, CD34, SMA and S100, and GIST was diagnosed in a broad sense. Colonic GIST has been reported in only 20 cases in Japan, and colonic GISTs presenting such macroscopic morphology of bulging into the lumen like in this case are quite rare. This rare case is presented here, together with an analysis of accumulated domestic cases.

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Trafermin (fibroblast spray) is principally composed of human basic fibroblast growth factor (bFGF) which is produced with human recombinant DNA technology. This drug, the world's first topical cytokine therapeutic drug, specifically binds to the FGF receptors existing on the vascular endothelial cells and cell membrane of the fibroblast and stimulates angiogenesis, accelerated granulation, and accellerated cutization.
A 62-year-old man was performed laparoscopically assisted low anterior resection of the rectum for rectal cancer. Intractable fecal fistula due to sutural insufficiency persisted for about three months after the operation. Treatment using fibrin glue was ineffective. Trafermin was injected into the fecal fistula, and about two weeks later, the fecal fistula was closed. Trafermin is expected to be an effective drug for intracrable fecal fistula.

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A 65-year-old man underwent a low anterior resection of the rectum for rectal cancer on May 13 1999, which was moderately differentiated adenocarcinoma, a2, nl(+), in stage IIIa. The operation resulted in curability A. Three months after the operation CEA level increased and CT scan visualized a recurrent tumor 8.5cm in diameter in the pelvis. Radiation therapy was given with a total pelvic dose of 50Gy together with oral administration of 5'-DFUR (800mg/day). Oral administration of 5'-DFUR (1200mg/day) was sustained for two months following radiation therapy. The recurrent tumor had disappeared on CT and endoscopic study of the lower gut 4 months after initiation of the chemoradiation therapy. Since the value of PyNPase/DPD was as high as 7.4 in this case, we tought that 5'-DFUR was effective. The patient has been disease-free for 5 years after the initial surgery. Chemoradiation is one of powerful treatment modalities for local recurrence of rectal cancers.

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A 54-year-old man was admitted to the hospital because of persisting colloidal discharge from the anus and perianal induration left after a radical aperation for anal fistula. He had been afflicted with fistula ani for 42 years. Cancer of the anal fistula was diagnosed preoperatively. A 3×2 cm tumor was present in the direction of six o'clock of the anus. Histological examination of the removed material from the fistula suggested adenocarcinoma. Preoperative colonofiberscopy showed a submucosal tumor 1 cm in diameter located oral to the primary opening.
The tumor was diagnosed as submucosal cyst (mucus lake) communicated with the anal fistula based on pathological exploration of the excised material. It was etiologically thought that the cyst was formed via fistulization extended from the primary opening to the oral side. Cancer arisen in an anal fistula is thought to show extraluminal spread, and there have been no cases of anal fistula cancer with intraluminal spread to form mucus lake in a form of a submucosal cyst like in this case. This case which showed a quite rare extension is presented here.

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A 70-year-old man was admitted to the hospital because of dyspnea on effort on December 9, 1997. Under a diagnosis of pulmonary embolism, thrombolytic therapy was administered. On follow-up CT scan, remission of embolism was confirmed, but a liver tumor was detected incidentally. CT scan showed a papillary projection in a cystic tumor occupied the periphery of the left lateral segment showing an extrahepatic growth. Abdominal magnetic resonance imaging (MRI) scan showed a well-circumscribed cystic tumor revealing low and high intensity on T₁-and T₂-weighted images, respectively. Abdominal angiography revealed a hypovascular tumor and no tumor stain was observed. No elevation of tumor markers was noted. A lateral segmentectomy was carried out with a diagnosis of cystadenoma of the liver. Histopathologically, the tumor was cystadenocarcinoma.
Since cystadenocarcinomas of the liver are relatively rare, we report on this case with some bibliographical comments.

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A 23-year-old man complaining of persisting epigastralgia was referred to the hospital because he was pointed out impaired liver function and dilatation of the intrahepatic bile duct on ultrasonography at another hospital. After admission, percutaneous transhepatic cholangiography (PTC) showed cystic dilatation of the extrahepatic bile duct with the maximum diameter of 80mm and bilateral intrahepatic bule ducts with the maximum diameter of 40mm; and relative stenoses in the junction of B2·B3, the bifurcation of right hepatic duct and hilar bile duct. Endoscopic retrograde cholangiopancreaticography (ERCP) detected pancreaticobiliary maljunction with common channnel measuring 10mm long. Cystic dilated lower common bile duct led to a short narrow segment and subsequently joined in the main pancreatic duct. With a series of examinations, Todani's type IV-A congenital biliary dilatation was diagnosed. During surgery, we incised the septi of the hilar bile duct and bifurcation of right hepatic duct to relieve the stenoses, so that dimension of the anastomosis was broad thoroughly. The biliary duct was reconstructed by hepaticojejunostomy. Because relative stenoses was severest in the junction of B2·B3, lateral segmentectomy was performed. Postoperative course has been uneventful, as of 1.5 years after the operation.

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Squamous cell carcinoma of the gallbladder is rare, and curative resection of it is hardly achieved because it is huge and extends to adjacent organs at diagnosis. We herein report a case of the disease treated curatively by extended resection, with resultant favorable outcome.
A 61-year-old woman, who was discharged from another hospital because there were no available surgical therapies for her advanced gallbladder carcinoma, was admitted to the hospital because of fever and general fatigue which made her life unbearable. The tumor of the gallbladder was evaluated as Hinf3, S2, and N2(+) on admission, but no ascites nor hepatic metastasis was identified. After admission jaundice rapidly progressed. A cytodiagnosis of bile after percutaneous transhepatic biliary drainage revealed squamous cell carcinoma. For major liver resection, embolization of the right branch of the portal vein was percutaneously performed. Although the portal vein and pancreas became invaded by enlarged lymph nodes, a tumor resection was completed with resection of the pancreas head, duodenum, segmental portal vein, extended right lobectomy of the liver and regional lymph nodes dissection without major postoperative complications. Histopathological diagnosis was poorly differentiated squamous cell carcinoma of the gallbladder with metastasis to the second station of lymph nodes, which meant histologically no residual cancer. The patient was discharged from the hospital on the 42nd postoperative day, and is still healthy without any recurrence 36 months after the surgery.

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A 65-year-old woman was referred to the hospital for management of bloody stool and a protruded lesion of the descending colon. Preoperative abdominal computed tomography showed remarkable dilatation of the pancreatic duct and a cystic tumor with hetelogeneous contents which was 7cm in diameter in the pancreas tail. Colonoscopy revealed a man's fist-sized type 1 tumor in the splenic flexure of the decending colon. Endoscopic retrograde pancreatography demonstrated the wide orifice of the papilla Vater draining clear mucin and the remarkable dilatation of the main pancreatic duct with saturation of mucin. The preoperative diagnosis was mucin producing carcinoma which owed its origin to intraductal papillary mucinous tumor (IPMT) with direct invasion to the stomach and colon. We performed a combined resection of the pancreas body, tail and spleen with lymphadenectomy and a partial resection of the colon and stomach. Histopathological diagnosis was invasive ductal carcinom, mucinous carcinoma (colloid carcinoma), and the clinical diagnosis was mucin producing carcinoma of the pancreas originating from IPMT. Mucin producing carcinoma originating from IPMT has a more favorable prognosis than other pancreatic ductal tumors. However, the present case with invasion and/or perforation to adjacent organs suggests that the early diagnosis and appropriate surgical therapy for the disease are significantly important.

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We report a case of splenic sarcoidosis which is comparatively rare. An 81-year-old asymptomatic woman was admitted to the hospital with suspected malignant lymphoma of the spleen because of high value of interleukin-2 receptor (1, 020U/ml) and three low density areas in the spleen on abdominal CT scans. Serum β2 microgroblin level was also high, 3.8ng/l. Abdominal ultrasonography showed three hypoechoic tumors with clear border in the spleen. We performed splenectomy with a diagnosis of malignant lymphoma of the spleen. In the removed spleen four cream-colored tumors were present. The maximum tumor was 2 cm in diameter. Histopathological examinations demonstrated splenic sarcoidosis through confirmation of epithelioid granuloma with numerous Langhans type giant cells, while diagnoses of tuberclosis and Hodgkin's disease were excluded.

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We report a case of Still's disease in an adult who presented with fever of unknown origin persisting after laparoscopic cholecystectomy, together with a review of the literature.
A 28-year-old woman was admitted to the hospital because of gallbladder stone and choledocholith, and underwent laparoscopic cholecystectomy after endoscopic choledocholithotomy. A high fever over 39°C persisted after the operation and the cause was explored. There were no abdominal findings, and no postoperative complications includig cholangitis and intraabdominal abscess were disclosed on CT and hematological examinations. The patient developed pharyngalgia from the postoperative day 3, rosepink eruption in the extremities from the p. o. d. 4, and polyarthritis on the p. o. d 6. According to the criteria for diagnosis, Still's disease in an adult was diagnosed. Thereafter the disease was relieved by administration of non-steroidal anti-inflammatory drug.
Since this case of maturity-onset Still's disease after surgery is very rare and presented difficulties in differentiation from postoperative complications, we present this case.

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We successfully diagnosed a case of splenic metastasis and multiple bone metastases by splenectomy in a 53-year-old man with a previous history of undergoing resection of pulmonary carcinoid 8 years earlier.
The patient underwent a right middle lower lobectomy for pulmonary carcinoid in July 1993, when it was pathologically evaluated pT2N0M0 in Stage I. The patient was followed thereafter. In November 2001, he was found to have the enlarged spleen at a medical check-up and was referred to the hospital. Abdominal CT scan revealed a tumor 9×9×7cm in dimension, and bone scintigraphy showed multiple bone metastases. In order to diagnose and treat, a splenectomy was performed. The removed specimen was neuron-specific enolase (NSE) and chromogranin A positive, so that splenic metastasis of carcinoid was diagnosed. The patient's postoperative course was uneventful, and chemotherapy with cisplatin and irinotecan was added.
Since splenic and bone metastases of carcinoid rarely occur, this case is presented with a review of the literature.

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We report a 53-year-old woman with internal hernia through a defect in the broad ligament of the uterus who reguied emergency operation for intestinal obstruction. She was admitted to the hospital because of lower abdominal pain and vomiting. Tenderness and muscle defense were present in the lower abdomen. We made a diagnosis of strangulated ileus due to internal hernia by CT findings of the dilated small intestine and ascites. A 30cm long segment of the ileum approximately 150cm proximal to the ileocecal valve was herniated through an abnormal defect in the left broad ligament. After the herniated ileum was reduced, necrotized segment of the ileum was resected, and the defect of the ligament was sutured. Internal hernia through a defect in the broad ligament of the uterus is extremely rare and CT scan is useful in preoperative diagnosis. It is worth to keep in mind this entity for the preoperative correct diagnosis.

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We report a case of incarceration of the small bowel through a defect of the left broad ligament of the uterus, diagnosed and treated with laparoscopy-assisted surgery. A 23-year-old woman was admitted to the hospital because of abdominal pain and continuous vomiting. She had been in good health until this admission. She was not pregnant and had no history of undergoing operation. A plain abdominal X-ray film showed air-fluid levels of the small bowel in the mid abdomen. Abdominal CT scan demonstrated a dilated edematous loop of the small bowel and a transitional zone between the dilated small bowel and collapsed bowel posterior to the uterus and anterior to the rectum. A week later, symptomatic remission was attained after decompression by a long intestinal tube. A contrast medium study showed a partial stenosis of the ileum in the pelvic cavity. A lapaloscopy-assisted surgical exploration was performed. The small intestine 40cm apart from the terminal ileum had been herniated into a defect of the left broad ligament of the uterus. The obstruction was released without bowel resection because the incarcerated bowel was intact. The defect of the broad ligament, 2.5cm in diameter, was closed. The patient had an uneventful postoperative course and was discharged on the eleventh postoperative day. The possibility of this diseased should be kept in mind when a woman with no previous abdominal surgery presents with intestinal obstruction. And in the treatment of this disease which is often difficult to make preoperative diagnosis, laparoscopic procedure appears to be an effective and minimally invasive method for both diagnosis and treatment.

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Metastatic adrenal tumors are found frequently at autopsy, but are rarely resectable clinically. An elderly long-term survivor after adrenalectomy for metastasis of lung cancer is reported. An 81-year-old man underwent a resection of the right lower lobe of the lung for lung cancer. Histopathologically, it was reported as poorly differentiated squamous cell carcinoma (t2n2stage3b). Three months after the operation, in November 2001, an abdominal CT scan revealed a left adrenal tumor. Work-up revealed no other metastasis. Solitary adrenal metastasis of the lung cancer or a primary adrenal tumor was suspected. A left adrenalectomy was performed in spite of his great age. Histopathological diagnosis was adrenal metastasis of the lung cancer. Two years three months after the surgery the patient is alive without further recurrence. Solitary metastasis of lung cancer to the adrenal gland can be resected with an intention for cure, even if the patient is old, as far as he or she is able to tolerate the surgery.

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A 58-year-old woman who noticed an abdominal tumor in October 2002 was seen at the hospital because she was diagnosed as having an intraabdominal tumor on CT at another hospital in December 2002. On physical examination a fist-sized, well movable, and elastic hard tumor was palpable in the lower abdomen. CT and magnetic resonance imaging scans showed a tumor with heterogeneous internal structure. From angiographic findings, a tumor of the small intestinal mesentery fed by the 4^th and 5^th jejunal branches from the superior mesenteric artery was suspected, and on February 10, 2003, the patient was operated on. Upon laparotomy, a 12-cm sized tumor with nodal protrusions was present in the small intestinal mesentery of the jejunum where was apart from the Treitz' ligament by 50cm. A partial excision of the small intestine was carried out. Histopathological study revealed dense fascicular growth of spindle-shaped atypical cells. On immunostaining examinations the tumor showed α SMA (+), desmin (+), CD34 (-), c-kit (-) and s100 (-). Accordingly the tumor was thought to be leiomyosarcoma arisen from the small intestinal mesentery. The patient's postoperative course was uneventful and she has been free from recurrence.

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A 68-year-old woman seen at another hospital because of abdominal distension in May 2000 was found having an elastic-hard tumor with the size of infant's head in the right abdomen. Ultrasonography and CT showed a multilocular cystic lesion, 20 cm in diameter, with a part of parenchymatous component, and another tumor 5 cm in diameter in the pelvis. Angiography showed only an expansively growing tumor and could not indicate growth of tumor vessels and accumulation of contrast material. The patient was operated on for treatment and diagnosis of the abdominal tumor. During surgery a soft tumor which was 25 cm in diameter and white in color and had smooth surface was identified in the mesentery of the transverse colon. And a solid tumor which was 5 cm in diameter and grayish white in color was present on the retroperitoneum in the pelvis. These tumors were removed. On histopathological and immunohistological studies, they were positive for c-kit, α-SMA, and desmin. Gastrointestinal stromal tumor (GIST) arisen in the mesentery of the transverse colon was diagnosed.
GIST arising in the extra-intestinal tissue is rare and is sometimes called EGIST. In this paper we present an analysis of accumulated cases from recent Japanese literature, together with some bibliographical consideration.

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Liposarcoma commonly occurs in the lower extremities and retroperitoneum, and rarely in the mesentery. This time we experienced a case of liposarcoma arisen in the mesentery.
A 42-year-old man was seen at the hospital because of abnormal defecation and abdominal distension. On physical examinations, an elastic-hard, movable and infant's head-sized tumor with tenderness was palpated in the lower abdomen. Abdominal ultrasonography showed a 14×11×7cm cystic tumor with septum and a solid part in the pelvis. Angiography visualized development and expansion of the superior mesenteric artery and vein, but no accumulation of contrast material was seen. After admission abdominal pain occurred and abdominal CT scan revealed an enlargement of the tumor and an area of hyper absorption. Intracystic bleeding was diagnosed and an emergency operation was performed. The tumor which was reddish brown in color and was filled with clots was present in the ileocolic msentery, mainly involving the ileocecum. The tumor was well movable and was easily dissected from the retroperitoneum. An excision of the tumor and an ileocolic resection were carried out, resulting in complete removal of the tumor. Histopathological diagnosis was highly malignant and dedifferentiated liposarcoma with a part showing differentiation to fibroblast. The patient has been well without recurrence, as of 1 year 9 months after the operation.

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