It is still unclear whether n-6 polyunsaturated fatty acids enriched enteral nutrient (n-6PUFA-EN) or n-3 polyunsaturated fatty acids enriched enteral nutrient (n-3 PUFA-EN) is more effective in the protein synthesis, fat metabolism and mucosal integrity of the intestine in the nutritional management of pediatric patients with digestive disease. We aimed to investigate the efficacy of n-3 PUFA-EN in pediatric patients with digestive disease.
Patients and method: Eleven pediatric patients were studied after surgery for digestive disease. They were nutritionally treated with n-6 PUFA-EN and subsequently with n-3 PUFA-EN. Serum fatty acid analysis, total protein, albumin, rapid turnover proteins and plasma diamine oxidase activity (DAO) as a marker of mucosal integrity of the intestine were evaluated before and after administration of n-3 PUFA-EN. The ratio of n-6 to n-3 PUFA was decreased within the normal range during n-3 PUFA-EN administration. The ratio of eicosapentaenoic acid to arachidonic acid was 0.08 before and reached 0.20 after administration. The serum total lipid fatgram normalized. The prealbumin and the retinol-binding protein increased significantly. DAO (unit/l) was 4.21 before and reached 8.63 after administration.
Conclusion: These results suggest that the administration of n-3 PUFA-EN is effective to improve not only systemic metabolism but also intestinal integrity.

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We performed a stereotactic vacuum-assisted core needle biopsy (Mammotome) of 30 non-palpable breast lesions between March 2002 and March 2003. Mammography showed only microcalcifications in 26 lesions and only a mass shadow in the other 4 lesions. The lesions were classified into 5 categories based on mammography guidelines. Of the 26 cases with microcalcifications, we evaluated 3 as category 3, 12 as category 4, and 3 as category 5. Of the 4 cases with a tumor, we evaluated 2 as category 3, and 2 as category 4. Twelve (40%) of the 30 cases had malignant lesions. Three minor complications occurred in 30 patients: subcutaneous hematoma in one patient and mild malaise in two patients. We concluded that stereotactic vacuum-assisted core needle biopsy is a safe and useful diagnostic procedure associated with minimal invasion and a cosmetic benefit.

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Subcutanous mastectomy with immediate breast reconstruction by the surgeon using a saline-filled bag was conducted in 23 women with breast cancer. Six pectoral muscle-preserving mastectomies and one subcutaneous mastectomy with saline-filled tissue expander insertion during breast cancer surgery were done for secondary reconstruction by a plastic surgeon. Postoperative questionnaires showed satisfaction to be good. Three prosthesis-related infections occurred, with 2 cured by antibiotics and drainage. The benefit of the procedure is that it can be conducted during breast cancer surgery by a breast surgeon without special plastic surgery skill.

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We compared Billroth I with Roux-en-Y methods after distal gastrectomy in the early postoperative course for one year. Twenty-nine patients undergoing distal gastrectomy for gastric carcinoma were divided into two groups. Fifteen patients were reconstructed by Billroth I method after gastrectomy, and 14 patients by Roux-en-Y. Questionnaires were sent to all patients to ask their body weights, amount of oral intake, and subjective symptoms at the times of six month and one year after the surgery. Endoscopic study of the gastric semnant was performed at the same times. Endoscopic findings were scored based on the severity of gastritis. Complications after the surgery were also checked. There were no significant differences between two groups in terms of body weight, amount of oral intake, and subjective symptoms. Endoscopic findings of Roux-en-Y group, however, were better than those of Billroth I group at the time of six months after the surgery (11.8±0.7 vs 9.6±0.5, p<0.05). It is concluded that Roux-en-Y reconstruction after distal gastrectomy was not inferior to Billroth I method in the postoperative course and gastrointestinal complaints, and showed a significantly less degree of gastritis on endoscopic findings.

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[Aim] The purpose of this study was to evaluate our current performed for laparoscopic surgery for chronic pancreatitis and the surgical results. [Methods] Ten patients, 6 men and 4 women, with an average age of 53 years underwent laparoscopic pancreatic surgery for chronic pancreatitis. Distal pancreatectomy was performed for obstructive pancreatitis (n=2), localized pancreatolithiasis (n=2), and pseudocyst (n=1). Cystogastrostomy was performed for pseudocysts (n=5). In the cases treated by distal pancreatectomy, the lesion was located by intraoperative ultrasonography, and the parenchyma was transected with an endoscopic linear stapler. Cystogastrostomy was also performed with an endoscopic linear stapler. [Results] The mean operation time was 283±66 min for distal pancreatectomy and 204±50 min for cystogastrostomy, and mean blood loss was 248±263g and 38±48g, respectively. One of each procedure was converted to open surgery because of the presence of severe inflammation. There was no pancreatic leakage or other complications. [Conclusion] Laparoscopic pancreatic surgery is a safe and feasible treatment option for patients with chronic pancreatitis.

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We present a case of metastasis from gastric cancer to the thyroid gland.
A 67-year-old woman was admitted complaining of an abnormal mass in her neck. Computed tomography (CT) revealed a solid mass in the thyroid gland. A fine needle aspiration biopsy cytology was class V. We diagnosed undifferentiated thyroidal carcinoma, and a total thyroidectomy was performed. Histological examination of the resected specimen showed lymphatic invasion of poorly differentiated adenocarcinoma. Chemotherapy was started according to the aniti-cancer drug sensitivity test.
A gastroendoscopic study was performed because the patient complained of epigastric discomfort. A diffuse ulcerative lesion was observed in the middle part of the stomach, and it was microscopically diagnosed as poorly differentiated adenocarcinoma. The resected thyroid tumor was also diagnosed as a metastasis from the gastric carcinoma through immunohistochemical staining for thyroglobulin and cytokeratin.
According to the microscopic findings, this case was diagnosed as a metastasis from gastric cancer to the thyroid gland.
The patient died on the 57th postoperative day due to liver and lung metastasis and DIC.
When a patient has a history of carcinoma, a mass in the thyroid gland should be treated as not only as primary thyroid carcinoma, but also as a metastatic lesion until proved otherwise.

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A 45-year-old woman found to have a breast tumor at physical checkup and admitted to the hospital for close exploration and treatment underwent modified radical mastectomy and postoperative chemotherapy with CHOP, VP-16, etc. Immunohistological studies suggested non-Hodgkin lymphoma, diffuse medium T-cell type in LSG classification. Tests for antihuman T-lymphotropic virus I (HTLV-I) antibody were positive. The tumor was diagnosed as adult T-cell lymphoma of the breast. The patient underwent postoperative chemotherapy, but she died of multiple brain metastases 3 years after surgery.
Primary malignant lymphoma of the breast is rare, and may be difficult to diagnose preoperatively due to the lack of characteristic findings. Reports of the disease almost all involve non-Hodgkin lymphoma, diffuse large B-cell type in LSG classification.

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Most of adenomyoepithelioma are benign, but very rare malignant variants have been reported. In this paper, a case of adenomyoepithelioma with invasive ductal carcinoma of the breast is presented. A 52-year-old woman was seen at the hospital because of a left breast tumor. The tumor was clinically diagnosed as breast cancer, and a modified radical mastectomy with lymph node dissection was performed. Histologically, the tumor was composed partially of invasive ductal carcinoma and partially of adenomyoepithelioma, which involved proliferation of both epithelial and myoepithelial cell components. Estrogen and progesterone receptors were negative. There was no evidence of exillary lymph node metastasis. The patient is alive and well without any evidence of recurrence, as of 5 years after the operation.

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A 55-year-old postmenopausal woman admitted for cancer recurrence in the parasternal lymph node had undergone breast conservation for hormone-receptor-positive right breast cancer at age 51 followed by adjuvant chemotherapy with cyclophosphamide + methotrexate + 5FU and endocrine treatment with tamoxifen. Triweekly docetaxel therapy and toremifene administration were not effective for the recurrent lesion and were abandoned due to grade 4 granulopenia. The use of 1 mg daily of anastrozole, an aromatase inhibitor, successfully relieved anterior chest pain after 3 months and induced complete response in the recurrent lymph node after 6 months. No major adverse reaction to this therapy was observed. Complete response and good quality of life have been achieved in the 14 months of follow-up after anastrozole administration.
Our results suggest that postmenopausal women with hormone-receptor-positive advanced breast cancer who have undergone prior multiple cytotoxic and endocrine treatments could benefit from anastozole therapy.

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We report a rare accessory breast cencer arising in the left axilla.
A 50-year-old woman seen for a left axillary tumor was found in biopsy to have invasive ductal carcinoma, papillary tubular type, surrounded by normal ductal tissue. Accessory breast cancer was strongly suspected, but the possibility of communication with mammary tissue could not be ruled out. No tumor was palpable in the left breast nor were lymph nodes in the left axilla. We carducted local left axillary and lymph node dissection. Patholoically, the resected material showed no communication between the axillary tumor and mammary duct, yielding a definitive diagnosis of accessory breast cancer.
We also analyze 93 cases of the disease, including ours, in the Japanese literature.

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We report a case of right axillary accessory breast carcinoma together with some bibliographical comments. An 88-year-old woman was seen at the hospital because of a right axillary tumor. An elastic hard tumor, 2 cm in diameter, with reddened surface was found in her right axillary portion. Axillary lymphatitis was suspected, but neither leukocytosis nor elevation of serum CRP was noted by blood examinations.
Surgical biopsy was performed under local anesthesia and adenocarcinoma with mammary gland were found microscopically. Pathological diagnosis was axillary accessory breast carcinoma. Additional excision and axillary limph node dissection were performed under general anesthesia 1 month after the first operation, but no remnant carcinoma tissue or normal mammary gland was found microscopically. The patient has been followed in the outpatient clinic and no recurrence has occurred 18 months after the second operation. Accessory breast carcinoma is a rare disease. Only 100 cases have been reported in Japan until 2003. In the case of an axillary tumor, a possibility of a accessory breast cancer must be kept in mind and pathological examination of the whole tumor is required to determine appropriate operative procedure.

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We report a case of breast cancer with multiple brain and lung metastases that responded well to gamma knife radiosurgery. A 56-year-old woman with a tumor and an oppressive sensation in the right breast was clinically diagnosed with breast cancer with multiple brain and lung metastases. Gamma knife radiosurgery was done for the brain metastases 1 week after simple mastectomy. Chemotherapy with docetaxel was started for the lung metastases 2 weeks after surgery. Gamma knife radiosurgery was done twice more for new brain metastases. She enjoyed good quality of life 8 months after surgery. Treatment was interrupted by headache and nausea due to gamma knife use and to general fatigue due to chemotheraphy, however, and she died of brain and lung metastases 9 months after surgery. The gamma knife provides low invasive noss and high local control in brain metastasis treatment, making such radiosurgery the best therapy for breast cancer with brain metastasis if chemotherapy is effective against metastatic nonbrain lesions, and is expected to reduce mortality in brain metastasis.

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A 69-year-old man was accidentally found to have an abdominal aortic aneurysm (AAA) by screening CT scan during hospitalization in the department of neurosurgery in our hospital for cerebral infarction, and he was referred to the department. On abdominal CT scan, Mantle sign was not evident. Preoperative endoscopic examination demonstrated type II cancer of sigmoid colon. Staged approach was scheduled, and the patient underwent sigmoidectomy and D1 lymph node dissection at first. The histological diagnosis was moderately differentiated adenocarcinoma without invasion to the serosa or involvement of lymph node and diagnosed as in Stage II. Thirty-six days later, the AAA was repaired via a retroperitoneal approach. The aortic wall seemed white pottery and the histopathological diagnosis was inflammatory abdominal aortic aneurysm. This case of inflammatory abdominal aortic aneurysm with colonic carcinoma is reported because of the rarity, together with some review of literatures.

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We report a case of Morgagni's foramen hernia with gastric volvulus. A 68-year-old woman was referred with vomiting after meals and epigastric discomfort was found in chest X-ray to have an abnormal shadow in the right lung field. Barium enema demonstrated gastric volvulus and hernia of the transverse colon protruding into the right thoracic cavity. Sagittal MRI suggested a Morgagni's foramen hernia containing the transverse colon and greater omentum. A celiac surgical approach showed a Morgagni's foramen hernia with an orifice almost the same size as that estimated by MRI. After the sac was inverted and removed, the hernial opening was closed with interrupted non absorbable sutures. The postoperative course was uneventful. We suspected her symptom was due to gastric volvulus because of hernial contents retained in hernia. In diagnosis, MRI is valuable both with differential diagnosis, (e.g., mediastinal tumor), and hernia evaluation. A celiac surgical approach is recommended when the diagnosis is definitive.

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We report a case of esophageal hiatal hernia with incarcerated stomach and perforated transverse colon in the right pleural cavity. An 84-year-old woman admitted for sudden dyspnea was found in chest X-ray to have atelectasis of the right lower lung lobe caused by gastrointestinal gas pressure. An upper gastrointestinal series showed the stomach incarcerated in the right pleural cavity and the retention of contrast medium in the stomach caused by organoaxial gastric volvulus. Chest CT showed the stomach and intestine incarcerated in the right pleural cavity and atelectasis of the right lower lung lobe, yielding a diagnosis of esophageal hiatal hernia with incarceration of the entire stomach and intestine in the right pleural cavity.
The hernia port was closed suturing the hiatus. The perforated colon is excised, and transverse colostomy was made transverse colostomy. Despite temporary recovery, the woman died of DIC and MOF 45 days after surgery.

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We report a case of chyloperitoneum following resection of esophageal carcinoma in which somatostatin analogue might be effective.
A 57-year-old male patient with middle-upper intrathoracic esophageal carcinoma underwent esophagectomy by right thoracolaparotomy. Retrosternal reconstruction using gastric tube, cervical end-to-end anastomosis, and cervico-thoraco-abdominal lymph node dissection. His postoperative course was uneventful. On the 9^th postoperative day, he started to take oral ingestion. He became to have a sense of fullness from 14^th day. A large quantity of chylous fluid in the peritoneal cavity was recognized by intraperitoneal aspiration and the diagnosis of chyloperitoneum was comfirmed by lymphoscintigraphy. By a conservative treatment subjective symptoms were improved, then he restarted to take oral ingestion from 40^th day, but the subjective symptoms gradually got worse. He stopped to take oral ingestion on 50^th day, however, no symptomatic remission was attained. Finally administration of somatostatin analogue was started on 60^th day. After administration of somatostatin analogue, abdominal distention, enlarging girth and disproportionate weight gain gradually disappeared. He was discharged from the hospital on 103^rd day.
We conclude that somatostatin therapy should be attempted against intractable chylous effusion following operation before considering surgical intervention.

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A 71-year-old woman seen for dizziness having anemia was found on physical examination to have tenderness and rebound tenderness of the upper abdomen. Abdominal computed tomography showed a solid mass 10 cm in diameter in contact with the gastric wall, and hemoperitoneum. Emergency laparotomy showed 1200 ml of hemoperitoneum and a solid mass with a short stalk at the posterior stomach wall. The mass was resected with wedge-shaped resection of the gastric wall. The tumor was capsulated and filled with massive coagula. Histologically, the mass consisted of spindle-shaped cells and rare mitosis. Immunohistochemical staining showed positive c-kit, and partial positive α-SMA. We made a diagnosis of gastrointestinal stromal tumor (GIST) with differentiation to muscular tissue. Only 7 cases of hemoperitoneum caused by GIST, including our case, have been reported.

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A 76-year-old man with gastric cancer and the hiliar lymph node metastasis was scheduled for curative surgery. Before surgery 100 mg/day of TS-1 was orally administered for 2 weeks followed by 1 drug-free week. And 30 mg/day of CDDP was administered intravenously on days 1 and 8. The 2nd, 3rd, and 4th courses were administered on an outpatient basis. After the treatment, abdominal CT showed a reduction in hiliar lymph node metastasis and gastric cancer with no overt serious adverse reaction. On the 15th day after 4 courses of this chemotherapy, surgery was done. Histopathological study revealed no malignant cells, and the operation was thought to result in curative resection. The patient is now healthy and free of recurrent disease 9 months after surgery. Neoadjuvant chemotherapy (TS-1/CDDP) is thus useful for the treatment of advanced gastric cancer.

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A 63-year-old man was admitted to the hospital because of epigastralgia. Upper gastrointestinal endoscopic examination revealed a type 3 tumor in the lesser curvature of the upper corpus of the stomach, and microscopic study of the biopsy specimens led to an initial diagnosis of poorly differentiated adenocarcinoma. As no metastatic lesions were detected in any organ by preoperative abdominal CT scan, total gastrectomy with splenectomy and D2 lymph node dissection were performed. Histopathological examination revealed that the tumor was composed of dominant neuroendocrine carcinoma and well-differentiated tubular adenocarcinoma in the mucosa, and the both components were positive for chromogranin A on immunohistochemical study. Despite adjuvant chemotherapy with etoposide and cisplatin, the patient died of multiple liver metastases 6 months after the surgery. Neuroendocrine carcinoma of the stomach is a rare pathological type and has an extremely poor prognosis. This case is thought interesting from the standpoint of histogenesis of neuroendocrine carcinoma, because the coexisted well differentiated tubular adenocarcinoma also stained with chromogranin A.

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Intramural metastasis of gastric cancer is very rare. We report herein a case of metastatic gastric carcinoma developed in the remnant stomach. A 63-year-old man seen at the hospital with the diagnosis of gastric cancer underwent distal gastrectomy in September, 2002. The histological diagnosis was papillary adenocarcinoma, ss, ly3, v3, n0. Three months later, serum CA19-9 level was elevated and an abdominal CT scan revealed multiple liver metastases. He received combination chemotherapy with TS-1 and taxol, but metastatic disease progressed. Three yamad III type tumors were visualized in the remnant stomach by endoscopic examination. With a suspicion of inframurol metastasis to the remnant stomach from gastric cancer, he was operated on in August, 2003. Total gastrectomy and hepatic arterial cannulation were performed. There were three tumors in the remnant stomach. Histological examination demonstrated papillary adenocarcinoma similar to that of gastric cancer one year before surgery-No postoperative complications occurred and he was discharged from the hospital on 19th postoperative day.

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A 58-year-old man undergone selective vagotomy with pyloroplasty (Finny method) for gastric ulcer at the age of 33, 25 years earlier, presented with anemia on a medical checkup. He was diagnosed as having gastric cancer after close exploration and was referred to the hospital. Advanced gastric cancer of type 3' was found on the lesser curvature of the antrum of the stomach and distal gastrectomy was performed. The excised material revealed that carcinoma had not reached to the pyloric ring and pyloroplasty part. The histopathological diagnosis was poorly differentiated adenocarcinoma with the depth of the tumor invasion of se, ly(0), v(0), and stage II.
Clinical reports on gastric cancer after vagotomy are few and so far 32 cases including this case have been seen in the Japanese literature. However, vagotomy had commonly been performed for benign gastric ulcer at one time and hence the disease can not be ignored as delayed complication of the procedure. It is inferred that gastric cancer after vagotomy might be similar in etiology to cancer of the gastric remnant and gastric cancer after gastrojejunostomy. From these points of view, we have analyzed cumulated domestic cases, and present this case together with some bibliographical comments.

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Case 1: An 8-year-old girl admitted for abdominal trauma due to a fall was found in abdominal CT on a second examination to have small amounts of intraabdominal free air. In emergency laparotomy under the suspicion of duodenal rupture due to abdominal trauma 11 hours after injury, we conducted duodenorrhaphy and gastrojejunostomy after finding a rupture 5.5 cm long from the bulb to second portion of the duodenum. Case 2: A 53-year-old woman admitted for abdominal trauma due to a traffic accident was found in abdominal CT scan on a second examination to have small amounts of retroper-itoneal free air. There was leakage from the site between the second and third portions of the duodenum in an upper GI series using amidotrizoic acid (gastrografin). In emergency laparotomy following diagnosis of the duodenal rupture due to abdominal trauma 10 hours after injury, we conducted duodenal end-to-end anastomosis after finding a transection between the second and third portions of the duodenum. Case 3: A 17-year-old boy admitted for abdominal trauma after hitting his abdomen on a platform was found in abdominal CT to have small amounts of intraabdominal free air. In emergency laparotomy under the suspicion of duodenal rupture due to abdominal trauma 3 hours after injury, we conducted duodenorrhaphy after finding a rupture 2.0 cm long at the bulb of the duodenum. In each case, the postoperative course showed no serious complications. In the early stage, findings in abdominal CT were unclear, so repeated abdominal CT is required.
Duodenorrhaphy or duodenal end-to-end anastomosis is considered safe in repairing of type II duodenal injury if laparotomy is undertaken within 24 hours after injury and the absence of blunt pancreatic injury.

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A 53-year-old man who underwent pylorus-preserving pancreatoduodenectomy (PPPD) under a diagnosis of duodenal leiomyosarcoma on December 7, 1993, was followed up and minor liver function impairment noted in October 2001. A cyst-shaped mass 7 cm in diameter of liver S4 was recognized in abdominal CT and the wall of the cyst was composed of tumor elements. Hepatic metastasis of duodenal leiomyosarcoma was strongly doubted and he underwent central bisegmentectomy of the liver on March 5, 2002. Histopathologically, findings were c-kit(+), CD34(-), SMA(-), desmin(-) and caldesmon(-), and the diagnosis was GIST. Because GIST may relapse 5 years or more after complete surgical resection such as in this case, long-term postoperative follow-up is a must.

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We encountered a patient with primary volvulus of the small intestine, which is an uncommon disease in Japan. We successfully treated this patient without enterectomy. The patient, an 85-year-old woman, had no past history of laparotomy. She visited our hospital because of abdominal pain and vomiting. She was diagnosed as having had ileus by abdominal roentgenography, and was admitted to our hospital. Computed tomography of the abdomen revealed an image of the dilated intestinal tract and marked ascites, and emergency surgery was undertaken. The small intestine was found to show three clockwise rotations of the small intestine in the vicinity of the root of the superior mesenteric artery. No anatomical abnormalities capable of inducing the rotations were found, and primary volvulus of the small intestine was diagnosed. There was no necrosis of the small intestine, and the operation involved only retention of the axis rotations. Oral ingestion was initiated 3 days after the operation, and her course was favorable. This disease is rarely diagnosed preoperatively, but it is likely to rapidly lead to necrosis of the small intestine after its occurrence. To avoid loss of the opportunity for laparotomy in terms of timing, much attention should be given to patients with this disease, particularly elderly patients in poor general condition.

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A 40-year-old woman was admitted to the hospital because of abdominal fullness and vomitting. Endoscopic study showed a severe stenosis in the transverse colon. Malignant disease was diagnosed and a laparotomy was performed. On exploration, multiple lesions with noted mesenteric nodal swelling were found in the right side colon and the terminal ileum. A right hemicolectomy with a resection of the terminal ileum by 70cm was performed.
There were multiple deep ulcers with inflammatory wall thickening in the resected material and histlogical examination revealed caseous necrosis and granuloma containing giant cells. Acid-fast bacilli were seen on a Ziehl-Neelsen stained specimen. We confirmed the diagnosis of primary intestinal tuberculosis.
Surgeons should be aware the presence of primary intestinal tuberculosis even in non-risk groups of patients.

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Malignant lymphoma arising in the small intestine is a rare malignant tumor of the gastrointestinal tract. We report two patients with malignant lymphoma arising in the jejunum, whose cicatrical narrowing of the jejunum occurred after chemotherapy was resected.
Patient 1, a 74-year-old man, seen at the hospital because of appetite loss and an abdominal mass, was diagnosed as having malignant lymphoma of the jejunum on close exploration. Chemotherapy was started in May 2001. After completion of chemotherapy the patient developed narrowing of the jejunum and underwent a jejunectomy in October 2001. The patient was discharged from the hospital on the 17^th postoperative day, however, he died of recurrence of lymphoma 4 months after the operation.
Patient 2, a 74-year-old man, referred to the hospital because of upper abdominal pain and an abdominal mass, was diagnosed as having malignant lymphoma of the jejunum on close exploration. Chemotherapy started in December 2001. After completion of chemotherapy, narrowing of the jejunum developed and jejunectomy was performed in February 2002. There has been no apparent evidence of recurrence, as of about 16 months after the operation.
Sometimes malignant lymphoma of the small intestine develops intestinal narrowing after chemotherapy which is indicated surgery so that it must be kept in mind as an important complication in the treatment of the disease.

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Many malignant neoplasm are hypercoagulative, but this seldom causes arterial thrombosis. We report a patient who suffered two occurrences of acute arterial occlusion of different parts of the arteries during several series of chemotherapy. A 58-year-old woman who underwent ileocolectomy for malignant lymphoma of the cecum and T-COP chemotherapy three weeks later then suffered acute left iliac arterial occlusion. We conducted thrombolytic therapy associated with thrombectomy successfully. She then underwent three more series of chemotherapy and again suffered acute occlusion, this time of the right femoral artery. We conducted two thrombectomies on her right leg followed by thrombolitic therapy with tPA saving her right leg. We recommend that intensive therapy include complete resection of the neoplasm and thrombolitic therapy with thrombectomy in selected patients with acute arterial occlusion associated with paraneoplastic hypercoagulability.

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An 89-year-old female patient with gonarthrosis had been treated with non-steroidal anti-inflammatory drugs (NSAID) for pain due to the gonarthrosis at a nearby hospital for 6 years; the treatment included administration of indomethacin farnesil at a daily dose of 400mg and the on-demand use of 50mg indomethacin suppositories. In the mid-course of this treatment, indomethacin farnesil was changed to etodolac at a daily dose of 400mg. Since the patient had anorexia, nausea and diarrhea for 5 days, followed by hypogastric pain, she visited the hospital. She received conservative treatment with a diagnosis of enteritis, but her condition did not improve. Two days later peritoneal irritation signs initially appeared. Since intraperitoneal free air was observed on a plain x-ray film of the abdomen, the patient was referred to our department and examined. Emergency surgery was conducted with a diagnosis of diffuse peritonitis. Perforation was found at two sites of the cecum, and ileocecal resection was conducted. Serosal rubor and thickening of the wall were also observed in the center of the transverse colon. Histopathological examination revealed non-specific ulcers. After the operation, disseminated intravascular coagulation and intraperitoneal abscess developed, but the patient was cured of these complications. Colonofiberscopic examination conducted 49 days after the operation revealed a wide range of ulcerative scarring at the transverse colon. We report an uncommon case of NSAID-induced perforation of the large intestine, in which the patient's life was saved by surgery. The relevant literature is also discussed.

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A 50-year-old man admitted with lower abdominal pain and hematochezia was found to have an egg- sized tumor and tenderness in the left lower abdomen. Abdominal computed tomography showed intussusception of the sigmoid colon, in which an egg-sized elastic, hard, smooth tumor was found projecting into the colonic lumen by colonofiberscopy. Biopsy of the tumor showed Group 1 without carcinoma. Sigmoidectomy with D2 lymphnode dissection was done under preoperative diagnosis of sigmoid colon submucosal tumor combined with intussusception. Histopathologically, findings showed well-differentiated liposarcoma of the colon. The postoperative course was favorable and he discharged on postoperative day 23. Liposarcoma arising in the large intestine is rare, and this is only the fifth case of colon liposarcoma reported in Japan. We analyze these 5 reports, which suggest that well-differentiated liposarcoma may have a smooth surface and no metastasis. Pleomorphic liposarcoma may, however, have a polynodular irregular surface and invasive metastasis.

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A 41-year-old woman was admitted to the hospital for close exploration of a tumor prolapsed from the anus. Barium enema and colonoscopy revealed a submucosal tumor with the diameter of 5cm and smooth surface in the sigmoid colon. Abdominal CT scan showed a tumorous lesion containing honeycomb like aerogram at the left side of the pelvic space. Although the definite diagnosis was not made, laparoscopy assisted surgery was performed. At surgery, the soft and well-defined mass was present in the sigmoid colon at the mesocolon. Histopathological study showed the cystic lesion communicating with normal lumina via a small hole which contained stool. The cystic wall was lined with mucosa similar to the large intestine and smooth muscle layer. These findings indicated colonic duplication. Alimentary tract duplication in adult is rare, so that the correct preoperative diagnosis of the disease is not easily made. Laparoscopy assisted surgery, which has not seen attempted before this case, seems to be a useful treatment of colonic duplication.

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A 74-year-old woman was referred to the hospital because of fecal occult blood. Colonoscopic fiber visualized a cecal elevated lesion like a submucosal tumor. Barium enema study demonstrated an intracanalicular smooth elevation surrounded by a bridging fold in the cecum and compression in the terminal ileum. Ultrasonography, CT and magnetic resonance imaging scans of the abdominal and pelvic regions demonstrated a cystic appendiceal mass filled with mucus and an ovarian cyst measuring 6 cm in diameter. Mucinous cyst of the appendix with ovarian metastasis was suspected and rt-hemicolectomy (D3) and bilateral adnexectomies were performed. On histopathological study, mucinous cystadenoma was diagnosed for the appendicial mass, while struma for the ovarian cyst. Mucinous cyst of the appendix concomitant with struma ovarii is quite rare and there have been no previous case reports. Macroscopic differentiation of benignancy and malignancy is difficult for a mucinous cyst of the appendix. Therefore it is appropriate to tentatively diagnose it as malignancy and proceed with surgery if ovarian metastasis is suspected like in this case.

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This paper presents a rare case of vesicorectal fistula which presented with hematurea and anal bleeding and might be caused by prostatitis.
A 75-year-old man was referred to the department because of anal bleeding occurred during treatment for chronic prostatitis at the department of urology in our hospital on an ambulant basis. By digital examination, a hard mass was palpated at the anterior lower rectum. Prostatitis with abscess formation and vesicorectal fistula were diagnosed and medical therapy and follow-up were performed. One year later, surgical maneuver was needed because pyelonephritis was caused by vesicorectal fistula. At laparotomy, there was no ascites but severe pelvic inflammation was found, and a sigmoid loop colostomy was performed. Thereafter the abscess disappeared, and he has a good quality of life (QOL) and no urological problems at present. In the treatment of vesicorectal fistula due to benign disease, we must think that the patient's QOL is important and thereby select therapies according to the pathological condition.

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A 49-year-old man was admitted to the hospital with a chief complaint of abdominal pain. Niveau was observed on an abdominal X-ray. An edematous bowel in the ileocecal region was revealed by an abdominal CT examination. The patient complained of increasing abdominal fullness after a long intestinal tube was inserted. Under a diagnosis of ileocecal tumor and ileus, an operation was performed. During the operation, a region of the small intestine located 80 cm anal to the Treitz ligament was found to have strictly adhered to a swollen appendix fixed in the retroperitoneal space. A right hemicolectomy and resection of the adhered bowel was performed because a malignant tumor of the appendix was thought to have caused the ileus. A goblet cell carcinoid was diagnosed after a postoperative histological exmination using PAS, Glimelius and chromogranin staining. An accurate diagnosis of goblet cell carcinoid is hardly ever made preoperatively. An extensive ileocecal resection should be performed when swelling of the ileocecal lymph node and a swollen appendix fixed to the retropeitoneal space and bowel is seen.

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We report a patient with megacolon with severe respiratory failure, whose life was saved by emergency total proctocolectomy.
A 71-year-old woman was admitted to the hospital because of the sudden onset of unconsciousness state during treatment of schizophrenia at a mental hospital. On admission, physical examination disclosed severe abdominal distention, no abdominal tenderness and loss of bowel sounds. Conservative therapy was started, but she developed deep coma, hypotension, ventricular tachycardia and respiratory arrest. Emergency operation including total proctocolectomy and ileostomy was performed, because the sigmoid colon was necrotic with ischemic change and the total colon was significantly distended. On the 1st postoperative day (POD), she recovered from respiratory and circulatory failure and was discharged on the 70th POD. If the patients develop severe respiratory failure due to megacolon like in this case, emergency laparotomy including total colectomy may provide the reduction of intraabdominal pressure, sesulting in the improvement of respiratory-circulatory failure.

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An 80-year-old woman hospitalized for dizziness underwent pelvic CT scan, because bloody mucinous attachment was recognized on her under wear. Pelvic CT showed multi concentric ring sign around a mass at the lower rectum. We suspected that the mass might cause intussusception. The irregular tumor was palpable at the 3cm oral side from the anal verge. Barium enema visualized the tumor as hay-fork sign at first, but the appearance changed into apple core sign as the tumor was elevated and intussusception was reduced by inflation. Colonofiberscopy visualized the type 2 tumor near the anal verge, and it moved to the 7cm oral side from the anal verge by inflating the rectum. Biopsy revealed group V (well differentiated adenocarcinoma). Low anterior resection was performed under a diagnosis of rectal cancer with intussusception. Upon laparotomy, we saw that intussusception had been reduced.
Intussusception caused by rectal cancer is very rare. We reviewed seven cases of adult intussusception or rectal prolapse caused by rectal cancer previously reported in the Japanese literature, with some bibliographical comments.

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A 45-year-old woman with bloody stool was found to have a type 2 tumor 6 cm in diameter in the rectum 4 cm proximal to the anal verge in colonoscopic examinations. Biopsy specimens of the tumor showed poorly differentiated adenocarcinoma. Pelvic magnetic resonance imaging scan demonstrated a tumor infiltrating to the mesorectal fat tissue. Under the diagnosis of advanced rectal cancer with poor differentiation, preoperative chemoradiotherapy was performed. By irradiation to the whole pelvis at a total dose of 40 Gy combined with systemic chemotherapy using 5FU, LV and CDDP, the size and spread of the tumor were extremely decreased. Abdominoperineal resection with lateral lymph node dissection was performed three weeks after the termination of the chemoradiation. Pathological examinations of the resected specimens revealed that the tumor was completely replaced by scar tissue with no viable cancer cells, showing that the preoperative chemoradiation resulted in complete response. The patient has survived without recurrence for 46 months after the operation. Preoperative chemoradiation may be an effective adjuvant therapy for advanced poorly differentiated adenocarcinomas of the rectum that are prone to recur locally and have poor prognosis.

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This report is about three cases of digestive cancer with psoriasis vulgaris. The first patient, a 71-year-old man, had psoriasis vulgaris associated with rectal cancer. After a successful resection of rectal cancer, his rash was reduced. The second patient, a 63-year-old man, had psoriasis associated with synchronous double cancer of the stomach and rectum. After a simultaneous radical resection, his rash was improved, probably due to a successful treatment with topical steroid ointment prior to the surgery. The third patient, a 52-year-old man, had psoriasis associated with gastric cancer. His rash was not reduced after a radical surgery, and did not become worse on recurrence of the cancer. Eighteen cases of internal malignancies with psoriasis vulgaris have been reported in Japan. Regarding our experience and investigated references on this matter, we believe that visceral malignancies might induce or worsen psoriasis vulgaris.

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A 74-year-old woman was admitted to the department of cardiology in our hospital because of sudden onset of abdominal pain. Abdominal ultrasonography (US) revealed gas running through the portal vein. Computed tomography (CT) of the abdomen showed massively edematous intestine and portal venous gas (PVG) in the liver. An emergency laparotomy was carried out because intestinal infarction was suspected. On operation, no necrotic bowel was found and a part of the jejunum between 40 and 80cm from the Treitz ligament showed marked edema and subserosal hemorrhage. The mesenteric vessels were completely patent. Intestinal resection was not indicated because the diseased jejunum was thought to be viable. Hepatic PVG disappeared on postoperative US and CT studies. Despite the improved abdominal condition, the patient went into severe renal and cardiac failure. During scrutiny, bone marrow aspiration revealed that she had multiple myeloma. Amyloidosis complicated with multiple myeloma might be a cause of organ failure. She died of cardiac failure on the 19th postoperative day. It is reported that gas of the bowel lumen escapes into the portal circulation through injured mucosa. Although the cause of PVG in this case is still unclear, underlying bowel amyloidosis might cause mucosal injury contributing to PVG. Hepatic PVG without bowel necrosis is rare. To our knowledge, no case of PVG complicated with multiple myeloma has been previously reported.

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A 93-year-old man was admitted with right hypochondralgia. The blood chemistry test and a CT scan indicated acute cholecystitis. On the 7^th hospital day, a CT scan revealed a large subcapsular cystic mass in right lobe. A thoracentesis under ultrasound guidance obtained bile-stained fluid. Contrast radiography revealed a fistula between the biloma and gallbladder. After conservative treatment, cholecystectomy was performed. This case demonstrated spontaneous biloma followed by acute cholecystitis. This disease is very rare, we report it with a review of the literature.

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A 53-year-old man, whose pancreatic extra-fistula complicated after undergoing necrosectomy for lately infected pancreatic necrosis had gradually healed by conservative treatment, was admitted to the hospital again because of fever, severe back pain and cough 6 months after discharge. Abdominal computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) showed severe stenosis of the main pancreatic duct and a rupture of the tail duct spreading to the mediastinum. It was suspected that high pressure in the pancreatic duct led to the rupture and caused the internal pancreatic fistula. CT also showed an obstruction of the portal vein and well-developed collateral vessels, which were successfully treated by side-to-end longitudinal pancreaticojejunostomy despite of the risk of massive bleeding. He was discharged from the hospital on the postoperative day 25, and the postoperative course was uneventful. We expected surgery would be difficult due to severe adhesions and bleeding from the collateral portal vein, but our approach was safe and useful in preserving the pancreatic function including pancreatic endocrine function.

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We experienced a case of mammary gland metastasis of pancreatic cancer.
A 72-year-old woman was seen at the hospital because of a right breast mass in February 2002. She had been suffering from epigastric discomfort and back pain since November 2001. On physical examination, an irregular shaped, clearly demarcated and elastic-hard mass with the diameter of 1.2cm was found in the upper outer quadrant of right breast. On mammography and ultrasonography, it was consistent with breast cancer. Fine needle aspiration biopsy cytology revealed adenocarcinoma. Preoperative abdominal ultrasonography and CT scan revealed a hepatic mass with the diameter of 4.5cm, a tumor of the pancreas body and tail with the diameter of 5cm and paraaortic lymph node metastasis. CA19-9 showed high score (2683U/ml). Therefore, pancreas cancer was considered to be the primary site for the breast tumor and chemotherapy was started for pancreatic cancer. However, upper gastrointestinal stenosis developed, and gastrojejunostomy was carried out. Concurrently, partial resection of the right breast was performed. The histological diagnosis was metastatic pancreatic cancer of the breast. Since metastasis to the mammary gland from other organ malignancy, especially from pancreatic carcinoma, is rare, this case is presented here.

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A 54-year-old woman was examined at a local clinic after complaining of a pain in her left hypochondrial region. While undergoing an abdominal ultrasound examination, the patients suddenly went into shock and was transported by ambulance to the emergency department of this hospital. A laparotomy was performed on the suspicion of abdominal bleeding based on the results of an abdominal CT examination. A large amount of blood was observed in the abdominal cavity during the laparotomy. A fist-sized ruptured tumor was discovered extending from the hilum of the spleen into the gastrosplenic ligament. Another tumor, measuring about 10cm in diameter, was observed in the lateral segment of the liver. A splenectomy and lateral segmentectomy of the liver were performed. The splenic lesion was a diffuse tumor occupying the entire spleen, while the hepatic lesion was a nodular tumor with a well-defined border. The tumors in the both the spleen and liver were diagnosed as hemangiosarcomas based on the results of histopathological examinations. Since the blood flow through the hilum of the spleen is hepatophilic, and no other lesions were observed outside of the liver and spleen, a primary splenic hemangiosarcoma with simultaneous liver metastasis was suspected. Although IL-2 was administered for postoperative immunotherapy, the treatment was ineffective and the patient died on postoperative day 80.

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Malignant tumors arising in the spleen are relatively rare. We report a case of malignant lymphoma of the spleen with direct invasion into the abdominal wall.
A 62-year-old woman who had felt left lateral abdominal pain and back pain and had had occasional episodes of the 37-degree of fever was referred to the hospital because of a splenic tumor. On admission no liver or spleen was palpable and there was muscle guarding in the left lateral abdomen. No superficial lymph nodes were palpable. On hematological study no abnormalities were noted except for LDH of 611U/l and CRP of 3.30mg/dl. On imaging findings an 8.5×5.0cm tumor was present in the upper pole of the spleen which continued with the abdominal wall on the left dorsal aspect and the left crus of the diaphragm. Ga-scintigram disclosed abnormal accumulation in the spleen and median dorsal aspect. Splenic malignant lymphoma with invasion into the abdominal wall was suspected, and a splenectomy was performed on June 2, 1998. Pathological diagnoses was malignant lymphoma, diffuse large, B cell type. Chemotherapy was started on the 22^nd postoperative day, but the patient died on the 231^st day after remission for a while.

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We report a rare case of vasitis nodosa presented with a painful mass in the right groin. A 56-year-old man was seen at the hospital because of a painful mass in the right groin. There was no history of previous surgery or trauma. Examination revealed a tender mass 3.0cm in diameter at the superficial inguinal ring. A diagnosis of irreducible right inguinal hernia was made, and an emergency operation was performed. At operation, a nodule 1.5cm in diameter was identified in the vas deferens. No hernia was present. A partial resection of the right vas deferens was done. Histological examination revealed granuloma formation with extravasated sperm and proliferation of eosinocytes. Pathological diagnosis was vasitis nodosa.

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A 39-year-old man was admitted to the hospital because of hypertension and obesity. On physical examination, he had a moon-shaped appearance and purple striae on the lower abdomen. Abdominal CT scan revealed situs inversus totalis and a right adrenal tumor. His plasma cortisol level was elevated without showing circadian rhythm and was not suppressed with dexamethasone suppression test. Plasma ACTH level was suppressed, below 5pg/ml (normal: 9-52pg/ml), and urinary level of 17-OHCS was elevated to 33.0mg/day (normal: 3.4-12.0mg/day). ¹³¹I adsterol scintigram showed hot nodule only at the right adrenal area. Under the diagnosis of Cushing syndrome due to the right adrenal tumor, the patient underwent right adrenalectomy. Cut surface of the tumor was tan in color, and the tumor was 40×30mm in diameter and 45g in weight. Histological examination showed benign adrenocortical adenoma. Cushing syndrome associated with situs inversus totalis is very rare, and to the best of our knowledge, this is the first case in the English and Japanese literature.

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Differing from Meigs syndrome originated from a benign solid tumor of the ovary, pseudo-Meigs syndrome is defined to originate from a malignant or benign tumor of the ovary or uterine tube and to be associated with ascites and pleural effusion in which removal of the tumor results in disappearance of ascites and pleural effusion. It is relatively rare that pseudo-Meigs syndome is caused by a metastatic ovarian tumor originating from gastric cancer. We report such a case of pseudo-Meigs syndrome originating from gastric cancer. A 76-year-old woman undergone a distal gastrectomy for adenocarcinoma of the stomach complained of cough 2 years after the operation. Ultrasonography and computed tomography showed a tumorous lesion in the right ovary and benign ascites and thoracic effusion. Surgical treatment was again performed and a right oophorectomy was done. Histopathological diagnosis was metastatic adenocarcinoma of the ovary, suggesting that a Krukenberg tumor originating from the gastric cancer presented pseudo-Meigs syndrome. The patient has been free from metastasis or recurrence of gastric cancer for 16 months and ascites and pleural effusion disappeared. But she died from peritonitis carcinomatosa at the 17^th month from the second operation. Pseudo-Meigs syndrome originated from metastatic gastrointestinal tumor is extremely rare and so far only six cases have been reported in the Japanese literature.

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A 44-year-old man found to have a giant liver tumor in abdominal ultrasonography and admitted for further examination was suspected of having a right adrenal tumor from CT and angiography. Endocrinological examination showed elevated urine 17-OHCS and 17-KS, so we made a diagnosis of adrenocortical carcinoma and conducted surgical resection. Histopathological diagnosis confirmed adrenocortical carcinoma based on nuclear grade IV, atypical mitosis, 5 or more mitotic figures per 50 high-power fields, etc. Metastases occurred to the liver in months 7, 14, and 31 since surgery. In the first 2 recurrences, tumors were resected but in the third, he underwent embolization for multiple metastases. He is current by under managed medical treatment. The prognosis of adrenocortical carcinoma is very poor because cure is almost impossible without surgical resection. Embolization was effective in this case but is not common for adrenocortical carcinoma. More effective adjuvant therapy or treatment are thus required as an alternative to.

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We report a case of retroperitoneal hematoma caused by arterial puncture in the insertion of a central venous catheter in the inguinal region. A woman in her seventy with anorexia and weight loss admitted to a previous hospital suffered from a punctured artery when a central venous catheter was inserted in the right inguinal region. That night, she reported right lower abdominal pain and anemia. On day 3 after the arterial puncture, anemia recurred. CT showed retroperitoneal hematoma. The patient was transferred to our hospital for surgery. Postoperatively, anemia did not recur. Retroperitoneal hematoma is a rare complication of catheterization. CT and abdominal echography are useful in making a diagnosis. A patient with retroperitoneal hematoma who suffers recurrent anemia requires surgical hemostasis.

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A 59-year-old woman with diarrhea in November 2001 was found to have an elastic, soft right lateral abdominal tumor. Abdominal computed tomography (CT) showed a low-density mass 12×7cm in diameter in the retroperitoneal space and barium enema examination showed the ascending colon deffected to the left. Extirpation was done under a diagnosis of serous cystic tumor. The tumor had a very thin cyst wall and was full of fluid. CA19-9 amounted to over 10, 000U/ml and CEA to 344.5 ng/ml, but cytology of the fluid was negative and no malignant sign was seen in the cyst wall.

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A 64-year-old man admitted for sudden-onset abdominal pain was found in computed tomography to have free air, a mass in the ascending colon, and edematous ileum. Under a diagnosed of perforative peritonitis due to colon cancer, we conducted emergency laparotomy. Colon cancer was found in the ascending colon, the ileum wall had segmentally diffuse necrosis, and the ceacum wall was perforated separately from the colon cancer site. The mesenteric arteries were patent. Under a diagnosis of nonocclusive mesenteric ischemia (NOMI). we widely resected the small intestine and conducted D2 ascending colon resection. The postoperative course was good and the patient was discharged 3 weeks after surgery.
NOMI causing gut perforation is rare, and few cases have been seen in the presence of colon cancer. We discuss this rare case together with a review of the literature.

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