In early stage of breast cancer in which axillary lymph node dissection could be avoided we performed same day surgery with breast conserving operation following sentinel lymph node navigation biopsy under local anesthesia.
The meaning of preceding sentinel lymph node biopsy under local anesthesia is to avoid false negative sentinel lymph node metastasis.
Resected sentinel lymph nodes were examined on permanent sections and stained with hematoxylin-eosin and immunohistochemically studied (cytokeratin).
Furthermore to avoid radiation exposure of pathologists in intraoperative frozen section is important. Cost of day surgery on out-patient is half of the cost of surgery on in-patient, thus this policy is socially compatible with reduction of medical cost.

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In this study, we examined the validity and effectiveness of clinical pathway (CP) in conservative treatment for perforated duodenal ulcer (DU). We retrospectively analyzed 19 consecutive cases of perforated DU treated with conservative therapy from August 2001 to March 2003 in our institute. Based on these experiences, CP in conservative treatment for perforated DU was proposed and has been applied to 10 cases since April 2003. We made a comparative study on the patient's outcome between non CP group and CP group, and also investigated the causes of variances in CP group in detail. Although there was no significant difference between two groups, there was a tendency of shorter hospital stay and less medical expenses in CP group. There was no major complications, no conversion to operation and minimal variances in CP group. From the above-mentioned results, we conclude that our CP in conservative treatment for perforated DU is valid, which in turn would results in standardization, simplification and exhibition of perforated DU treatment.

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This study evaluated the safety of abdominal surgery in elderly patients over 90 years old. Between January 1993 and December 2004, 21 patients over 90 years old (18 females and 3 males, mean age; 92.4 years old, range 90 to 99) underwent laparotomy in our institution. Of those, 20 patients demonstrated preoperative morbidities and 14 had cardiovascular diseases. Of 8 patients with malignancies, radical surgery was performed in 3 patients and palliative surgery was performed in 5 patients. The rate of postoperative morbidity was as high as 95.2% (20/21), and there were many cases showing respiratory complication, delirium, and disuse atrophy. Although the surgical mortality rate was only 9.5% (2/21), the overall hospital-death rate was 42.9% (9/21). Of 12 patients discharged from hospital, 4 patients could not take meals or walk by themselves. In conclusion, it is difficult to say that abdominal surgery in the elderly patients over 90 years old has been performed safely, considering the poor prognosis shown by the overall hospital-death rate of over 40%. We should try to improve the prognosis and emphasize early discharge from hospital along with return to social life with a feeling of confidence.

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This study was made to investigate the efficacy of primary-lesion-opening surgery by the seton technique for high anal fistula. Subjects were ten patients with a high anal fistula, comprising seven with a fistula of the high trans-external anal sphincter muscle including three with horse-shoe type fistula and the remaining three with high inter-muscular fistula. They underwent surgery by the seton technique, i.e., incision and opening of the primary opening, primary track, internal anal sphincter muscle, primary focus, and subcutaneous external anal sphincter muscle.
Their postoperative courses were observed for at least one year, and complete cure of the high anal fistula was attained in eight patients. It took from 6 days to 38 weeks with an average of 17.9 weeks for the falling off of the “seton”. The time from the surgical treatment to healing ranged from 7 to 38 weeks with an average of 17.9 weeks. The remaining two patients whose treatments were unsuccessful had a fistula of the high trans-external anal sphincter muscle; one of them had the horse-shoe type. The postoperative anal function was favorable in the eight cured patients.

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This is a report of our experience in 46 cases of viper bites victims who were admitted in our hospital between 1998 and 2003. The feature and severity of clinical pictures of the victims in relation of the values of CPK and myoglobin were studied. Also the efficacy of the treatment with multiple skin incisions and cepharanthine use was investigated. The ratio of male to female was 27:19, and the sites of bites were either the tip of fingers or the toes in more than 90% of the cases. The peak of the incidents occurred between the month of July and September. No fetal cases were experienced. As the complica-tions one case of shoulder contracture and one case of finger contracture occurred. The value of CPK and serum myoglobin correlated to the severity of injuries. The treatment with multiple skin incisions and cephranthine administration did not prove to be effective in our experience. Some literatures in regard to the use of anti-serum, cepharanthine and multiple skin incisions were reviewed.

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We report a case of nonclostridial gas gangrene in a dentist caused by S. intermedius that was isolated from the oral cavity. A 42-year-old male dentist was admitted in April 2000, complaining of high fever and severe pain in the right axilla and chest. Pain and swelling started two weeks before without history of trauma and there was suppurative discharge five days before admission. The patient incised and drained his axilla and stitched the wound by himself using instruments in his dental office. On admission his axilla and front chest were swollen with palpable crepitations of the skin. He was diagnosed to have gas gangrene by X-ray, CT-scan and laboratory findings. He was treated with surgical debridement of necrotic tissue immediately. Antibiotics, that were negative on DLST (Drug Lymphocyte Stimulation Test) were administered intravenously. He also received hyperbaric oxygen therapy (2.5 ATA, 1 hr, 10 times). After a secondary closure of the wound was performed, the patient was discharged without any further complications 55 days after his initial operation. S. intermedius is one of the members of the Streptococcus milleri group. S. milleri group are indigenous bacteria separated from the oral cavity, intestine and vagina and are reported as a possible pathogen of the gas gangrene or myonecrosis. In this case, S. intermedius infection is recognized as an occupation related disorder.

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We report a case of meningeal carcinomatosis from breast cancer, which is rare in this country, without other metastasis, together with a review of 14 domestic cases until July 2004. The patient was a 40-year-old woman performed a modified radical mastectomy (Bt+Ax+Ic) for right breast cancer (T3 N2 M0 Stage IIIA) on January 18, 2002. Postoperative hormonal therapy (tamoxifen and LH-RH analog) and chemotherapy (6 courses of CAF and 5'-DFUR) were conducted. She presented with headache and posterior cervical pain on August 1, 2004, and was admitted to the hospital for close exploration. She was diagnosed as having meningeal carcinomatosis on magnetic resonance imaging and cytological examination of meningeal tap. There was no evident metastasis to the other organs. Intrathecal administration of methotrexate provided a temporary improvement, but she died 151 days after the onset of meningeal carsinomatosis. Excepting this case of meningeal carcinomatosis from breast cancer without other metastasis, so far only one case has been reported in Japan.

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We report a patient with hepatocellular carcinoma with hepatic cirrhosis who developed mycotic endophthalmitis after hepatectomy for which early administration of antimycotic drugs resulted in symptomatic remission.
A 68-year-old man was admitted to the hospital to undergo surgery for hepatocellular carcinoma. A central venous catheter was inserted and central venous nutrition was started on the 6^th day before surgery, a subsegmentectomy of the liver being performed. Central venous nutrition was maintained after the operation because he could not eat well. The patient had a high fever, 39.5°C, on the 21^st hospital day. Catheter fever was suspected and the catheter was removed. On the next day a decreasing tendency of fever was noted, but ocular symptoms such as dimming and ocular pain appeared. Mycotic endophthalmitis was suspected and intravenous administration of fluconazole 200mg was started on the same day. Ocular findings included bilateral conjunctival hyperemia, white exudative spots at the right fundus oculi, and deposits on the posterior aspect of the cornea, which suggested retinochorioditis but the vitreous bodies were normal. From these findings mycotic endophthalmitis was diagnosed. Continuous intravenous administration of fluconazole for 4 weeks resulted in improvement of both ophthalmic findings and subjective symptoms.

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We report a case of tubular adenoma of the breast, diagnosed as breast fibroadenoma preoperatively, in a 17-year-old woman.
The patient seen at our clinic because of a left breast tumor had a well movable tumor 20×20mm in diameter in the CD area of the left breast on palpation.
Results of ultrasonography and aspiration biopsy cytology suggested fibroadenoma. We excised the tumor under local anesthesia. The tumor was 22×20×18mm in dimension. The histopathological diagnosis was tubular adenoma of the breast.
Tubular adenoma of the breast is a rare benign epithelial tumor of the breast, and so far less than 50 cases have been reported in Japan. Only nine cases, including our case, involved juvenile women aged less than 20 years and accounted for about 23% of all cases. The preoperative diagnosis was fibroadenoma of the breast in most cases and no malignant diseases were suspected before surgery in all nine cases.

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We report a case of hemangioma of the breast with calcification on mammography. A 68-year old woman noticed a lump of her right breast in 1988. With examination, it was diagnosed as a benign tumor, and no treatment had been done. Nine years later, in 1997 we re-examined the tumor, but no definite diagnosis was made. As the mammography showed calcification in the lesion, we suspected possible breast cancer. So we resected the tumor and intraoperative frozen section examination was done. As the pathological diagnosis was hemangioma, additional procedure was not done. Six years and 11 months has passed since the operation, but no sign of recurrence is seen.

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A 63-year-old woman was admitted to the hospital because of two rapidly-grown lumps in her right breast. The lumps, 9cm and 5cm in diameter respectively, were both elastic soft with a well-defined margin, and were diagnosed as phyllodes tumor by imaging examinations. However, core needle biopsy suggested well differentiated carcinoma. We thus performed mastectomy with axillary dissection. Histological examination revealed that these tumors were both pure mucinous carcinoma with intratumoral hemorrhage. An anticoagulant which had been regularly administrated to the patient or compression to the tumor at the time of mammography were thought to be involved with the hemorrhage. This hemorrahge could be responsible for the low echoic areas mimicking a phyllodes tumor on ultrasonography. We must carefully deal with soft and especially large breast tumors such as mucinous carcinoma.

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A 64-year-old woman was admitted due to palpitation and shortness of breath on exertion. She was diagnosed as having ruptured aneurysm of sinus of Valsalva. An operation was performed with patch closure of ruptured aneurysm of sinus of Valsalva. She was admitted because of fever 13 months after the first operation. She was diagnosed as having bacterial endocarditis and aortic valve leaflet aneurysm. Aortic valve replacement was performed. Her postoperative course was uneventful. Aortic valve leaflet aneurysm is rare. According to the review of literatures, this case is the first case of aortic valve leaflet aneurysm developed after operation of ruptured aneurysm of sinus of Valsalva.

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Rupture into the duodenum is a very rare complication of abdominal aortic aneurysm. When such complication is to be surgically treated, surgeons will be challenged by the difficult problems related not only to aortic rupture but to possible vascular prosthesis infection and bowel reconstruction. We, herein, report a case who survived such unusual aortic rupture.
A 55-year-old male had rejected surgery when infrarenal aortic aneurysm was diagnosed one month before. On emergency, he was admitted to our hospital with severe lumbago accompanied with both hematemesis and melena. The emergency surgery revealed an inflammatory aneurysm penetrated into the third portion of the duodenum. To prevent possible vascular graft infection due to operative field contamination, aortic reconstruction in the abdomen was avoided . Infrarenal aorta was amputated to exclude the aneurysm, and the penetrated portion of the duodenum was repaired with direct closure. Lower limbs were revascularized with left-axillo-bifemoral bypass after the abdomen was closed. Postoperative course was uneventful, and he was discharged 17 days after surgery. Closure of the abdominal aorta combined with an extra-anatomic revascularisation is effective in the treatment of such complicated vascular rupture.

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We performed chest wall reconstruction using an e-PTFE patch and a latissimus flap for lung cancer with chest wall invasion in an elderly patient.
An 81-year-old man was diagnosed as having squamous cell carcinoma in the S³ of the left lung with invasion to the adjacent chest wall. We performed the en-block resection of parts of the 3rd, 4th, and 5th ribs, serratus anterior muscle, and pectoralis minor muscle, with the left upper lobe. An e-PTFE patch was fixed to cover a 12×10cm deficit made in the chest wall, when a latissimus flap was placed to outside the e-PTFE patch to obtain sufficient stability. The muscle flap was fixed to the pectoralis major, teres major, and serratus anterior muscles. Paradoxical respiration did not occur and good QOL was obtained after the operation. The patient has been alive without relapse of cancer for four years following the operation.
Either alone an artificial material or a muscle flap would not be enough to obtain a satisfactory stability in chest wall reconstruction. For reconstruction of the lateral thin part of the chest wall, the above mentioned operative method seems to be useful.

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Morgagni foramen hernia is a relatively uncommon diaphragmatic hernia, and a variety of repairing procedures including those with laparoscopy have been described in the literature. Here we present a case of Morgagni foramen hernia that was laparoscopically successfully repaired. The hernia content, the omentum, was reduced to the abdomen, and the defect was closed by placing nonabsorbable sutures passing through the full thickness of the anterior abdominal wall and the posterior rim of the defect. The method reported already by La Greca and Azzie provides an easy and secure closure of the diaphragmatic defect in which the anterior rim is usually absent. It also gives an excellent cosmetic benefit as the sutures are tied in the subcutaneous tissue.

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We report herein a case of hemophagocytic syndrome after surgery for early thoracic esophageal cancer.
A 42-year-old woman, who underwent a subtotal esophagectomy and lymphadenectomy with retrosternal esophagogasrostomy for early thoracic esophageal cancer, revealed leukopenia (1.1×10³/μl) on the operative day and administration of G-CSF was started. General condition was stable and blood leukocyte count recovered gradually, but she suddenly went into shock with severe pancytopenia on the postoperative day (POD) 9. Opportunistic infection on the left lateral abdominal wall was revealed by CT scan on the POD 10, and bone marrow aspiration taken on the POD 11 showed macrophages which phagocytosed not only leukocytes, but also erythrocytes and platelets. Therefore, she was diagnosed as having hemophagocytic syndrome. Steroid pulse therapy was initiated, but she died of disseminated intravascular coagulation and multiple organ failure on the POD 24. Although surgery rarely provokes hemophagocytic syndrome, the disease must be added to a possible postoperative complication.

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A 43-year-old man, who was pointed out as having Becker muscular dystrophy on the basis of his family history and muscle biopsy at the age of 27, was seen at our hospital complaining of dysphagia, and was admitted with a diagnosis of gastric cancer. We performed total gastrectomy.
He presented with emaciation and serum CK levels were elevated, but he was not affected with remarkable muscle weakness or gait disorder. Genetic study showed deletions of the dystrophin gene, a finding specific to Becker muscular dystrophy. Patients with muscular dystrophy are generally short lived, and death is usually due to respiratory and/or heart failure. When operation is performed, it is necessary to avoid respiratory and circulatory complications.

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It is becoming clear that various cytokines, which are produced from cancer cells, are associated with not only spreading of tumor but also developing symptoms. A 55-year-old male underwent total gastrectomy due to gastric cancer in December 2001. Eleven months later, he developed high fever, elevation of CRP, CEA and CA19-9, and remarkable leucocytosis. He was readmitted to our hospital to examine and to rule out blood disorder or the recurrence, because of the increase of WBC counts over 50, 000/μl, which is defined as leukemoid reaction. A bone marrow examination showed normal findings except hypercellarity of bone marrow, so blood disorder was denied. Abdominal CT scan revealed an illdefined mass in the left abdominal cavity. A needle biopsy revealed adenocarcinoma which had the same histological findings of primary gastric cancer. Immunohistochemical study demonstrated that the cytoplasm of cancer cells was stained positive with anti G-CSF antibody and anti IL-6 antibody. Both cytokines produced from cancer cells reflected the increase of WBC counts. His condition was getting worse rapidly. and he died with peritonitis carcinomatosa in January 2003. It is highly suspected that gastric cancer producing G-CSF and IL-6 may have been involved with spreading of tumor and developing various symptoms.

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A 49-year-old male was admitted to our hospital with upper gastrointestinal bleeding.
Endoscopic examination revealed a depressed lesion with an exposed vessel on the upper body of the stomach. Our diagnosis was Dieulafoy's ulcer, and endoscopic hemostasis was successfully performed by clipping. About 50 days later, a follow-up endoscopy revealed abnormal mucous membrane with redness near the ulcer scar. Histological examination of the biopsy specimen showed moderately differentiated adenocarcinoma. Total gastrectomy was carried out. Macroscopically, a IIc lesion was noticed on the lesser curvature of upper gastric body, and its diameter was 65×45mm. Tumor cells were limited mainly in the mucosal layer. We were not able to find the ruptured vessel, but the internal mucosa was thickened, and a winding vessel was observed in the submucosal layer. Gastric cancer associated with Dieulafoy's vascular malformation is extremely rare, and only 16 cases, including ours, have been reported in Japan. Our case with early gastric carcinoma detected following a bleeding ulcer suggests the importance of careful endoscopic observation after hemostasis.

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We report a case of primary gastric small cell carcinoma presented a specific morphology.
A 74-year-old man, who had intermittent abdominal pain starting in about November 2003 and was found having an upper abdominal tumor at another hospital on January 8 2004, was referred to the hospital for further examinations. Gastrointestinal endoscopy, upper gastrointestinal series and computed tomography (CT) showed a huge pedunculated tumor in the greater curvature of the body of the stomach. Distal gastrectomy with D2 lymphadenectomy and cholesystectomy were performed under a diagnosis of advanced gastric adenocarcinoma with a peduncle. Pathologic examination of the resected specimen showed coexistence of adenocarcinoma and small cell carcinoma with a high N/C ratio. Immunohistochemically, these small cells were stained positive for synaptophysin. The final pathological diagnosis was small cell carcinoma of the stomach with severe lymphatic invasion. We orally administered S-1 as adjuvant chemotherapy for 4 courses, starting on postoperative day 19. Seven months after the operation lymph node metastasis in the vicinity of the pancreas head was detected by abdominal CT scan, but the metastasis was well controlled by sustained chemotherapy with S-1 and paclitaxel. There has been no increasing tendency in size of the metastatic lesion and the patient has been on chemotherapy on an ambulant basis, as of one year after the operation. The patient's good QOL has been kept.
Since this case of small cell carcinoma of the stomach is rare in that a huge mass was formed and the patient has been alive without declining QOL one year after the operation, we report it here, together with a review of the literature. On postoperative 1 year, abdominal CT showed the lymph node metastasis by pancreas was exactly the same as before. Patients with small cell carcinoma of the stomach are reported to have very poor prognosis, however, this patient lives 1 year after the first operation without reduction in the quality of life.

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An 81-year-old woman was admitted to the hospital because of a large mass palpated in the right middle-lower abdomen. Right hemicolectomy was performed with a diagnosis of ascending colon cancer. When two and a half months elapsed after the operation, bilious vomitting appeared, and she was admitted again. Upper GI series revealed a duodenal stenosis at the end of descending portion, lack of the Treitz ligament, and connecting to the jejunum in the right abdomen. She was operated on with a diagnosis of duodenal stenosis due to torsion of the intestine with intestinal abnormal rotation. During the operation, lysis of intestinal adhesions to the right upper abdominal posterior wall disclosed that the duodenojejunal junction was unclear, small mesentery was not fixed to the retroperitoneum entirely, and the upper jejunum was rotated clockwise by 180 degree to the normal position. We repositioned the upper jejunum and fixed it for preventing volvulus. As the case is considered to be rare, we reported it here.

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Although it is necessary to wear seat belt to decrease serious head and chest injuries caused by motor vehicle accidents, seat belt injuries such as intestinal injuries are increasing instead. From January 2001 to December 2003, we had experience in treating four cases of small intestinal injuries related to seat belts. All of the patients were drivers. There were diagnostic delay in three patients because the signs of peritonitis were obscure and neither radiographic examination nor laboratory data showed abnormal findings on admission. But abdominal pain continued and free air and fluid were seen in abdominal cavity on CT after admission to our hospital, surgery was done under a diagnosis of peritonitis due to perforated viscus. Small intestinal perforations were found and partial resection or simple closure of small intestine were performed. When we see the patients with motor vehicle accidents with marks of seat belt, careful clinical examination and observation are needed not to miss the signs of peritonitis due to intestinal perforation.

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On September 18, 2003, a 68-year-old female was hospitalized because of abdominal pain occurring during steroid treatment for rheumatoid arthritis. She was diagnosed as having perforation of gastro-intestinal tract based on CT findings. Emergency surgery was performed. During surgery, a perforation was found in the ileum about 30cm proximal to Bauchin's valve and segmental resection of ileum was performed. The lesion was histologically diagnosed as two ulcer scaused by candida infection and that one of the two ulcers had perforated. There was no report of ileal perforation caused by candida infection in recent 10 years. Severe candida infections in compromised hosts have often been observed. It is important to be aware that ulcer and perforation of the gastro-intestinal tract may be caused by candida infection.

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A 48-year-old woman admitted to the hospital because of persisting diarrhea was found to have a mesenteric mass 6cm in size and more than 50 liver tumors 3-15mm in longer diameter by abdominal CT scan. Puncture of the liver tumors provided the histopathological diagnosis of carcinoid tumor. Laparotomy disclosed numerous peritoneal disseminations. The mesenteric tumor 6cm in diameter was seen, which retracted its mesenterium. An ileocecal resection was performed because the mesenterium was retracted widely. The primary tumor was present in the ileum which was 8×8mm in diameter and like Ila type and was diagnosed as carcinoid tumor with the invasion depth of mp pathologically. The mesenteric tumor was metastatic lymph node associated with fibrosis around it.
In Japan carcinoid tumors of the small intestine are rare, but they metastasize in a high frequency. This case of small intestinal carcinoid tumor, which had large metastatic lymph node, multiple metastatic liver tumors, and peritoneal dissemination despite the small primary lesion 8mm in diameter, is very rare. Multidisciplinary treatment is expected to be established for such cases in future.

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We report a case of angiolipoma of the ileum causing intussusception.
A 53-year-old man was seen at the hospital because of the sudden onset of lower abdominal pain. Abdominal CT scan showed a multiple concentric ring sign from the terminal ileum to ascending colon and the presence of a low density mass 3cm in diameter in the transverse colon. The patient was diagnosed as having intussusception caused by an ileal lipoma, and an emergency operation was perfor-med. After successful reduction of the intussusception with Hutchingnson's maneuver, an ileoceal resection was performed. Resected material showed a 5.0×5.0cm polypoid tumor in the terminal ileum. Histological examination showed that the tumor was composed of mature adipose tissue and increased capillaries, and angiolipoma was definitely diagnosed.

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We experienced a case of coexistence of GIST and gastric and colon cancer. An 87-year-old man was diagnosed as having early gastric cancer in other hospital. Through the preoperative examinations in our hospital, a small intestinal tumor and colon tumor were discovered. After conservative therapy to DIC, only partial resection of jejunum and ileocecal resection were done without gastric resection to minimize the surgical stress. We planned to do gastric surgery later. The histrogical diagnosis of jejunal tumor was GIST on the basis of c-kit (+), CD34 (+) in immunofluorescent stain.
The coexistence of GIST and other tumor is rare, only fourteen cases having been previously reported in Japan. We believe that the coexistence of GIST and other tumor has good prognosis after radical resection.

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We experienced a case of perforated appendix by a fish bone that did not show obvious signs of inflammation. Patient was a 55-year-old male, who presented with a chief complaint of right lower quadrant abdominal pain. Physical examination suggested presence of appendicitis. The final diagnosis was made at the time of surgery as perforated appendix caused by a fish bone. It is quite rare to see a perforation of appendix by a fish bone swallowed by mistake. Eighteen such cases in including ours have been reported in Japan since 1989. Most of the cases were operated on with preoperative diagnosis of acute appendicitis of ileo-ceacal abscess with inflammatory signs, and only 3 cases had been correctly diagnosed preoperatively. In 2 cases blood study and image studies were normal. In this regard we believe careful physical examination of the patients are very important. A review of the literatures were done.

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We experienced a case of argyrophil carcinoid of the appendix in 36-year-old woman who was admitted to the hospital because of lower abdominal pain, nausea and vomitting. We performed appendectomy next day under the diagnosis of acute appendicitis. Resected appendix was whitish, hard and swollen, and histological examination revealed proliferation of tumor cells mainly in the submucosal layer of the appendix. The tumor cells were positive with Grimelius and chromogranin A stain, and negative with Fontana-Masson stain. Therefore, we diagnosed the case as argyrophil carcinoid of the appendix. Because of the positive surgical margin, ileocecal resection with lymphadenectomy was performed 55 days after the initial operation. There were no tumor cells microscopically in the resected specimen. There is no signs of recurrene in one year and 4 months since the operation. To our knowledge, argyrophil carcinoid of the appendix is very rare in Japan. Here, we report this case with a review of the literature.

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An ileocecal mass was detected in a 73-year-old woman who was admitted for close examination to lower abdominal pain, generalized edema, and positive signs of inflammation. Perforation of the digestive tract occurred during hospital stay, and an ileocecal resection was immediately carried out. On the resected material, the ilocecal region was hard and thickening and a round ulcer with perforation was noted on the oral side of the ileum. Tumor cells were detected from the distal end of the ileum toward the appendix, and invasion to the ileum of primary goblet cell carcinoid of the appendix was diagnosed. On cytokeratin staining, the tumor was CK20 positive that is a specific pattern of colon cancer. The results of cytokeratin staining in this case are of interest in evaluating the nature of goblet cell carcinoid which has a particularly poor prognosis among carcinoids.

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A 84-year-old female patient was admitted with a chief complaint of abdominal distension and diagnosis of ileus. Echographic and CT study of the abdomen revealed multiple masses in the liver and a mass in thee caecum. In order to relieve the bowel obstreection ileo-caecal resection was performed.
Pathological study of the resected specimen reavealed pleomorphism and active mitosis of cell nuclei with multangular neoplastic cells in cystic and solid arrangements with infiltration.
The grimelius staining and immunological staining with endocrine markers were positive and accordingly a diagnosis of caecal endocrine cell carcinoma was made. This type of carcinoma is highly malignant with rapid growth, vascular invasion and distant metastasis. The exact etiology and method of treatment have not been established yet.

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A 92-year-old man was admitted to the hospital because of bloody discharge from a fistula that was formed at the edge of incisional hernia in the right lower abdomen. Colonoscopy showed cecal cancer with the formation of a colocutaneous fistula. Ileocecal region with the fistula was resected. Pathological diagnoses were moderately differentiated adenocarcinoma in the colonic mucosa and mucinous carcinoma in the fistula, and the pathological staging was IIIa, si (skin), n0, H0, P0 and M(-). The postoperative course was uneventful. Thereafter no signs of recurrence have been seen 46 months after the operation until his death due to another illness.
Colonic cancer with colocutaneous fistula is comparatively rare, with only 25 domestic cases, including ours. It is etiologically thought in this case that the cecal tumor had invaded the abdominal wall because manifestation of symptoms were delayed due to its location in the cecum, and the infiltrating portion was mucinous carcinoma; and that colocutaneous fistula was formed because the tumor encountered adhesions and an incisional hernia on the way to invading.

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A 34-year-old man with a 2-year history of ulcerative colitis was admitted to a hospital because of severe total colitis. Despite IVH, administration of prednisone and mesalazine and granulocytapheresis (GCAP), bloody diarrhea persisted for about 2 months and he was referred to our hospital. He com-plained of dyspnea, fever up, hypoxicemia and chest x-ray remarkably showed bilateral interstitial pulmonary infiltrates. Pneumonitis due to pneumocystis carinii pneumoniae was diagnosed. He was medicated sulfamethoxazole trimethoprim with a succesful result. Subtotal colectomy, ileostomy and sigmoid-colostomy were made.
Steroids, immunosuppressive drugs and GCAP are often used in the treatment of ulcerative colitis that can cause immunodeficiency with opportunistic infection. It is important to decide to select a surgical treatment before development of the infection when limits of internal treatment are ascertained.

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We present a case of gastrointestinal stromal tumor (GIST) of the rectum.
A 55-year-old man was admitted to the hospital because of a rectal tumor detected at a medical checkup in April 2003. Digital examination revealed an about 3-cm sized elastic-hard mass with a smooth surface, locating about 3cm oral from the anal verge. Colonoscopic examination showed a submucosal tumor encircling about 1/4 of the lumer in the lower rectum which had the smooth surface without ulcer. A transanal core needle biopsy was performed. HE staining showed a solid growth of spindle-shaped cells, and immunohistochemically the tumor cells were positive for CD34 but negative for SMA and S100. GIST was thus diagnosed. Considering that lymph node dissection was unnecessary and the anal function was able to be preserved, we performed a transsacral partial resection of the rectum. No local recurrence or distant metastasis has occurred, as of 20 months after the operation.

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A 56-year-old male visited the hospital complaining of perianal pain, swelling and redness. Under the diagnosis of an anal abscess, drainage was perfomed repeatedly. As the wound failed to heal and fistulae were detected, excision of entire tract of fistulae was perfomed. On histopathological examination of the resected fistulae, caseous necrosis, Langhans giant cells and epithelioid cell infiltration were found and diagnosed as anal tuberculosis. Chest X-ray showed infiltrative shadow in bilateral lower lobe without cavitary lesion. Acid-fast bacilli were positive in the sputum, and the diagnosis of pulmonary tuberculosis was confirmed. Anti-tuberculosis therapy was immediately started with good response to the treatment.
As tuberculosis of anal region is so rare recently and there is no characteristic clinical pictures, it is very difficult to diagnose it pre-operatively. In some cases such as ours, pulmonary tuberculosis is accompanied with anal tuberculosis. As anal tuberculosis is rarely diagnosed correctly before operation on the basis of the clinical pictures, the histopathological examination of the excised fistulae is mandatory for the correct diagnosis of anal tuberculosis.

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A 62-year-old woman was seen at the hospital for close exploration because her stool examination was positive at a medical checkup. Anoscope and digital examination revealed an elastic-hard and ill-movable submucosal tumor in the anus at the 3 o'clock direction. Contrast enhanced CT scan of the abdomen showed a tumor with enhancement. Since a possibility of malignant tumor could not be ruled out, the tumor was removed through the transanal approach. Histopathological studies of the removed material revealed tumor cells with granular or bright and broad cytoplasm and oval-shaped nuclei, which were S-100 protein positive immunohistochemically. The difinite diagnosis of granular cell tumor of the anus was made.
Granular cell tumors are benign neoplasms of Schwann cell derivation. These tumors develop in any parts of the body, but are most often seen in subcutoneous stractures of the chest wall, breast and neck. They rarely appear in the gastroinstestinal tract, especially in the anus. Since our experience with a case of granular cell tumor appeared as a submucosal tumor in the anus in thought to be of value, the case is presented here.

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A 64-year-old man diagnosed as having prostate cancer was referred to the hospital because of a liver tumor pointed out by screening abdominal CT scan. Although the tumor could not be detected by abdominal ultrasonography, it was showed as a low-density irregular mass in the segment 8 on plain abdominal CT scan. The tumor was enhanced slowly at the peripheral portion by contrast enhanced CT and angiography. Because a possibility of hepatic metastasis could not be ruled out, a right hemihe-patectomy was performed. The tumor was macroscopically a 5×3cm whitish mass with a very clear margin from the liver which was adjacent to the right hepatic vein. Histologically, the liver tumor was composed of dense collagenous tissue with marked hyalinization, but some vascular spaces were seen within the nodule. Consequently, the tumor was diagnosed as sclerosing hemangioma.
Because the radiological findings of this tumor were affected by the pathological features of collagenous tissue, it was difficult to differentiate it from malignant tumors composed of dense fibers. Sclerosing hemangioma should be included in the differential diagnoses as a rare variant of hepatic hemangiomas.

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A 61-year-old woman who had been followed for a hepatic cyst at another hospital since 1988 was seen at the department of internal medicine in our hospital on January 6, 2003, because a solid portion in the cyst was showed by abdominal ultrasonography at a clinical survey in the hospital in December. Abdominal CT and magnetic resonance imaging scans revealed a cystic lesion 9cm in longer diameter in the S6 of liver and an elevated lesion 2cm in size in the cyst. Cystic adenoma or adenocarsinoma of the liver was suspected and the patient was referred to the department. At surgery, the tumor was present on the surface of the liver S6 and showed an extrahepatic protrusion, but there were no adhesions between the tumor and surroundings. A right lobectomy of the liver was thus carried out. On the section the inner part of the cyst was filled with brown exudate and yellowish white spongiform material, and the elevated lesion 2cm in longer diameter was identified in the inside of the cyst. The pathological diagnosis of the solid portion was cavernous hemangioma and the spongiform material was clarified to be crystallized cholesterin. It is etiologically thought that, since the hepatic lesion had been observed as a cyst for a long time, an angioma existed in the cystic wall penetrated inside of the cyst and cholesterin in the blood crystallized.

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We report a case of postoperative liver metastasis from medullary carcinoma of thyroid treated with chemoembolization which resulted in stable values of tumor markers for 2 yeas after the treatment.
The female patient underwent total thyroidectomy and lymphadenectomy (D3a) for medullary carcinoma of thyroid (pT2bN1bM0) of the age of 14. The values of serum CEA and calcitonin gradually increased at the age of 17, but various imaging examinations showed no recurrence or metastatic lesions. Eight years after the operation when she was 22, enhanced computed tomographic scan showed multiple metastatic lesions with the diameter of less than 1.5cm, which were enhanced in the early phase, of the liver. The value of serum CEA was 852.9ng/ml, and calcitonin was 12100pg/ml. We performed chemoembolization 3 times for these lesions. Though 2 years have elapsed afterward, no changes in the size or shape of the hepatic masses have been observed and the values of serum CEA and calcitonin remains relatively low (CEA: 577.5ng/ml and calcitonin: 6400pg/ml).

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A 59-year-old woman was admitted to the hospital because of jaundice. Magnetic resonance cholangiopancreatography revealed dilation of the intrahepatic bile duct and obstruction at the bifurcation of the left and right hepatic bile ducts. An extended right lobectomy was performed under a suspected diagnosis of hilar cholangiocarcinoma. Histological diagnosis was sclerosing cholangitis characterized by periductal fibrosis with severe infiltration of chronic inflammatory cells. On hematological studies after the operation, antinuclear antibody test was positive and the serum IgG4 was elevated. Endoscopic retrograde pancreatography disclosed diffuse narrowing of the main pancreatic duct, and autoimmune pancreatitis was diagnosed. The patient's postoperative course was uneventful. We have to keep sclerosing cholangitis associated with autoimmune pancreatitis in mind as a differential dignosis of hilar cholangiocarcinoma.

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A 64-year-old woman presented with pain in the right hypochondrium since around June, 2003. She was admitted to our hospital. CT showed swelling of the gallbladder and dilation of intrahepatic bile duct down to superior bile duct. In addition, the body and tail of pancreas was replaced with fat. MRCP and ERCP showed the tubercle-shaped filling defect in the common bile duct and dilation of the superior bile duct in fusiform with a diameter of 2cm. In addition, there was pancreaticobiliary duct maljunction. She underwent surgery with the diagnosis of bile duct cancer associated with pancreaticobiliary duct maljunction with fatty replacement of pancreatic body and tail. Histopathologically, the tumor was papillary adenocarcinoma, invasion depth ss, no metastases to lymph nodes. Postoperative course was uneventful, and she is alive 16 months after the operation.

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Undifferentiated carcinoma of the gallbladder is comparatively rare and has a poorest prognosis. In this paper we present a case of undifferentiated gallbladder carcinoma.
A 51-year-old woman, admitted to the hospital because of a high fever and right hypochondralgia on March 31, 2004, was found to have a 4-cm sized, well-defined tumor with clear border by imaging examinations. Conservative therapy was started with a diagnosis of gallbladder carcinoma with cholan-gitis, but no symptomatic remission was attained. The patient gradually developed anemia and impaired hepatic function. On May 15 a cholecystectomy associated with the transmural resection and lymph node dissection of group I was carried out. The tumor had invaded up to the lower layer of serosa but no lymphatic and vascular metastases were identified. Pathologically the tumor was composed of spindle-shaped cells and had the center necrosis. Since the tumor was cytokeratin positive and vimentin negative, undifferentiated carcinoma of the gallbladder was diagnosed. Without performing another surgery after the operation, we treated the patient with anti-cancer drugs. There have been no signs of recurrence, as of 17 months after the operation.

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We report a case of bile duct cystadenocarcinoma.
A 69-year-old woman who had been observed for a hepatic cyst for about 5 years received close exploration because a papillary prominence in the hepatic cyst and debris like echo were revealed by abdominal ultrasonography in July 2002. On imaging methods, an about 8-cm sized cystic lesion mainly in the medial segment of the liver and an about 6-mm sized ridge on the cystic wall were visualized. Tumorous cyst or a cyst communicated with the bile duct was suspected and a puncture examination of the hepatic cyst was conducted. The content of the cyst was white translucent mucus and its cytological diagnosis resulted in class II. An extended left lobectomy was performed with a diagnosis of cystic hepatic tumor. The excised material revealed an about 8-cm sized monolocular cyst mainly locating in the medial segment of the liver with mucus in it. The cystic wall was smooth except a part at where the 6-mm sized palillary prominence was identified. Pathologically the cystic wall except the papillary prominence was covered with high columnar atypical epithelium, and was diagnosed as bile duct cystadenoma. Atypical cells predominated in the papillary prominence, where was diagnosed as cystadenocarcinoma. It is etiologically thought that cancer change had occurred in a part of the adenoma.

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A case of lymphoepithelial cyst (LEC) of the pancreas is reported.
A 60-year-old man who had been pointed out a cystic lesion near the pancreas about 44 months earlier was admitted to the hospital, because serum CA19-9 level elevated and the lesion enlarged. He was asymptomatic. On blood chemistry, no abnormal findings were noted except increased CA19-9 and CEA to 83U/ml and 6.5U/ml, respectively. Abdominal CT scan demonstrated a well-circumscribed cystic lesion measuring approximately 4.5cm in diameter, located in the cranial side of the body of the pancreas, and the continuity to the body of the pancreas was suspected. The lesion had increased the mass by 1.5 times compared with that detected about 44 months before admission. Cystic tumor of the pancreas or lymph node swelling was diagnosed and he was operated on. Upon laparotomy, an elastic-soft mass connected with the body of the pancreas was seen. The resected mass had multilocular cystic structure with capsule and was filled with cream like material. Histopathologically, the cyst wall was lined by mature, squamous epithelium and surrounded by lymphoid tissue. It was diagnosed as LEC of the pancreas. LEC of the pancreas is a rare benign lesion of the pancreas and so far cases of the disease resected after clinical follow-up have rarely been reported.

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A 77-year-old man complaining of bilateral leg edema was referred to the hospital, because his blood examination at another hospital revealed severe thorombocytopenia, low proteinemia, and anemia. On admission, his total protein, hemoglobin, and platelet were 3.5g/dl, 9.8g/dl, and 1.8×10⁴/μl, respectively. Abdominal CT scan revealed the swollen spleen with splenic tumors and more than one tumor in the liver as well. Because no definite diagnosis was made preoperatively and the recovery of platelet count could be expected, a splenectomy was performed. The spleen was 12×9.5×6cm in dimension, and contained multiple hemorrhagic and slightly ill-defined tumors. Immunohistochemical staining showed that the splenic tumors were positive for CD31, KP1 (CD68), S-100, and Vimentin and negative for CD1a and CD21. Accordingly, these tumors were diagnosed as angiosarcoma. After the splenectomy, the platelet count did not recover and remained low. No adjuvant treatment was conducted. On September 18 2003, the patient was brought into the emergency room because of general fatigue and dyspnea. When he arrived, he was already in cardiopulmonary arrest condition and could not be rescued in spite of resuscitation.

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We report a successful case of surgery for splenic sarcoidosis presenting with giant splenomegaly and hypersplenism. A 21-year-old male suffering from high grade fever and fatigue revealed pancytopenia on haematological examination on April 1992. Trans-hepatic catheter examination proved that the portal pressure was normal. He underwent splenectomy for primary hypersplenism on June 16^th 1992, following catheter embolizations of the splenic artery with metalic coils. The size of the resected spleen was 23×14×7cm and the weight was 1500g. The pathological diagnosis was splenic sarcoidosis. Post splenectomy, the patient had a complete resolusion of his symptoms and haematological disorders. In patients with splenic sarcoidosis giant splenomegaly is rare and one presenting with pancytopenia is very rare. In some cases, splenectomy was effective for the improvement of clinical and haematological disorders, but the long-term results remain to be unknown. We report a case with good result in the long-term postoperative follow up of over 10 years.

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A 58-year-old man was seen at our hospital because of rectal pain and difficulty in urinating. On digital examination, a hard indurated mass was palpable. CT revealed a mass which involved rectum, prostate and bladder. Colonoscopy showed annular stricture of rectum near dentate line. Rectal biopsy was found to be inconclusive. We could not discriminate between primary rectal carcinoma and prostate carcinoma locally invasive to the rectum. Total pelvic exenteration was performed. Immunohistochemical staining for protate specific antigen (PSA) led to the diagnosis that the origin of the tumor was poorly differentiated adenocarcinoma of the prostate. Denonvilliers' fascia serves as an effective barrier to the posterior extension of carcinoma of the prostate. Therefore, rectal involvement secondary to prostate cancer is rare. The importance of distinguishing a prostatic neoploasm from other type of neoplasm in the rectum needs emphasis because of distinct differences in the treatment and prognosis. We consider that immunohistochemical examination of rectal biopsy may be necessary to differentiate adenocarcinomas of the prostate from those of the rectum when we encounter an annular stricture of rectum.

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A 77-year-old man with the history of alcoholic hepatic insufficiency, diabetes and hypertension was admitted to the hospital because of appetite loss and abdominal pain. The patient went into shock a day after admission, then the erosion of his scrotum was found. He was diagnosed as Fournier's gangrene and had emergency debridement of necrotic tissue. The necrosis extended to scrotum, perineum, anal sphincter, levator muscle, and lower part of rectum. He recovered from shock after endotoxin removal. To prevent contamination by stools due to deterioration of anal function, we made a permanent colostomy on thirteenth day after the first operation. The patient was discharged 23 weeks and 3 days after the first operation as the wound had almost healed. Fournier's gangrene is a necrotizing fasciitis of the perineal and genital legion. It spreads rapidly and mortality rate is still high. The most common underlying disorders are diabetes and alcoholism. Thus possibility of Fournier's gangrene should be considered in patients who have such disorders. The choice of treatment in Fournier's gangrene is debridement of necrotic tissue in early stage. Additionally it may be an effective treatment to remove endotoxin by apheresis.

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An 81-year-old woman was seen at our hospital because of abdominal pain. On palpation, there was an elastic, hard and fixed mass with tenderness in the right lower abdominal region. An operated scar of previous appendectomy performed 62-years-ago was seen on the skin of medial edge of the mass. Abdominal CT scan revealed a defect of abdominal wall in the same region, and the prolapse of the intestine and adipose tissue from there. Form these findings, incarceration of the incisional hernia was diagnosed. Emergent operation was performed after a trial of repair with manual manipulation. The components of hernia were Meckel's diverticulum and greater omentum adhered to the hernia sac.
Meckel's diverticulum was removed with wedge resection using a linear stapler, and the incisional hernia was repaired with the use of PROLENE^® Hernia System (PHS) simultaneously.

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An 85 year-old female underwent pancreato-duodenectomy (PD) for intraperitoneal lymphnode metastasis of unknown primary cancer which was undistinguishable from the pancreatic head tumor. Her symptoms were appetite loss and weight loss. Abdominal CT and US examinations revealed a solid tumor of 4.2×3.6cm in size in the pacreatic head, which showed hyper-vascular stain on angiography. US-guided aspiration cytology revealed cancer cells. Under the preoperative diagnosis of islet cell tumors based on its hyper-vascularity, she underwent laparotomy. PD was performed because of the operative finding that a solid tumor of 5×3cm in size expanded from the pancreatic head, involving the common hepatic artery. The pathological diagnosis was lymph node metastasis of adenocarcinoma which was clearly different from the pancreatic cells and no primary site was found in the resected specimen. We believe that this operation enhanced the curability of this patient in spite of the fact that the primary site was not ascertained.

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