Nihon geka hokan. Archiv fur japanische Chirurgie最新文献

A 49-year-old woman with Recklinghausen's disease presented to our department for investigation of a left breast lump, measuring 60 mm x 50 mm, which she had first noticed 6 months earlier, but had disregarded, believing it to be another manifestation of her Recklinghausen's disease. The lump was suspected to be malignant based on physical examination and ultrasonography. Biopsy and frozen sections subsequently confirmed a diagnosis of scirrhous carcinoma. A standard radical mastectomy was performed, followed by postoperative chemoendocrine therapy. However, lungs, liver, and bone metastasis, as well as a contralateral breast tumor, developed and she died 4 months after surgery.

We describe our experience with a patient in whom a traumatic right diaphragmatic hernia developed 4 years after sustaining injury and review cases of delayed diaphragmatic injury reported in Japan. The patient was a 28-year-old man who sustained a severe contusion of the right epigastric region and fractured a right rib in a traffic accident in September 1992. In August 1996, the patient presented with shortness of breath on effort or after meals. A chest roentgenogram revealed intestinal gas in the right side of the thoracic cavity. A right diaphragmatic hernia was diagnosed on the basis of a gastrointestinal series, and the patient was operated on. The hernial orifice extended anteriorly from the central tendon in an 11:00 direction and measured 11 x 6 cm. The small intestine, right side of the colon, and liver were herniated. A total of 297 cases of blunt traumatic diaphragmatic hernia were reported in Japan between 1981 and 1996, including 47 cases (left side, 32 cases; right side, 15 cases) of delayed diaphragmatic hernia, defined as occurring one month or more after injury. Diaphragmatic hernia should be considered as a possible diagnosis in patients with abnormal shadows in the thoracic region who have recently sustained injury or who have a past history of injury.

Bouveret's syndrome involves gastric outlet obstruction by gallstone. Herein we describe an unusual case of duodenal bulb obstruction by gallstone. An 80-year-old woman was hospitalized with a fifteen-day history of vomiting. Computed tomography (CT) showed pneumobilia and a round calcified mass in the second portion of the duodenum. Upper gastrointestinal tract series demonstrated the same sized oval radiolucency between the bulbus and the second portion of the duodenum. Endoscopic examination revealed a round black mass in the second portion of the duodenum, totally occupying the lumen. Endoscopic removal and destruction of the gallstone was attempted using a dye-laser, but the stone was too hard to crush. Eventually surgical enterolithotomy was successfully performed without cholecystectomy or closure of the fistula. Improved preoperative systemic management and prompt examination allowed earlier surgical intervention and reduced the morbidity. Surgical approach whether fistula closure should be performed remains controversial.

An 83-year-old woman was seen at the First Department of Medicine Fukui Medical School because of upper abdominal pain. A simple chest film taken in the upright position revealed free air under the diaphragm. She was referred to the department and underwent a laparotomy with a diagnosis of acute panperitonitis due to a perforated gastric ulcer. At laparotomy, there was a perforation measuring 5 x 5 mm at the anterior gastric body of the lesser curvature, covered with abdominal wall. Billroth I gastrectomy was carried out with no lymph node dissection. The histological examination of the surgical specimen showed early gastric cancer of type IIc invading the submucosal layer around the ulcer in the gastric wall, composed of well differentiated adenocarcinoma. The perforated early gastric cancers often present difficulty in diagnosis pre or intra-operatively. So it is important to examine closely the resected specimen intra-operatively and perform frozen section diagnosis whenever possible. Forty-six cases of perforated early gastric cancer collected from the Japanese literature are also discussed.

Ultrasonography has recently been used for evaluation of various conditions in Orthopaedics. Ultrasonographic examination is a noninvasive screening test especially for soft tissue masses. Ultrasonography is also a useful and essential diagnostic tool in cardiovascular disorders because real-time images of heart and vessels can be obtained. However, there have been few reports which describe ultrasonographic evaluation of tumorous lesions in digital vessels. In this paper, such lesions in two cases were evaluated by ultrasonography. An aneurysm of the digital artery is one of the definite candidates for ultrasonographic evaluation.

Forty-three consecutive patients of venomous snakebite by the Japanese viper (Agkistrodon halys Blomhoffii, "Mamushi" in Japanese) were treated with an uniformly scheduled therapy from 1990 and 1994. The therapy was mainly composed of minimal dose of antivenin, methylprednisolon and cepharanthin. There were two clinical courses, i.e., the minimal envenomation course (Group A, n = 14) and the severe one (Group B, n = 29). Our treatment was so satisfactory that all patients of both groups fully recovered activities of daily living with neither organic disorders nor sequelae of the bitten extremities. The high appearance ratio of atypical lymphocytes (P < 0.05) and the increased ratio of lymphocyte count to White blood cell count (P < 0.02) could be indicators that predict which clinical courses the patients take.