The Japanese journal of surgery最新文献

A case of advanced gastric cancer associated with acute myelocytic leukemia (AML) is reported. Synchronous double malignancies of gastric cancer and AML are very rare. Combination chemotherapy (BHAC-DMP) was used as the method for induction and consolidation therapy for AML and a complete remission was obtained. However, it failed to show any therapeutic effect on the gastric cancer. A radical subtotal gastrectomy was performed with lymphadenectomy. During the postoperative course, both respiratory failure and severe thrombocytopenia progressed. Fortunately, the patient responded well to mechanical ventilation and the administration of heparin. She was discharged on day 52 after surgery, and no sign of recurrence of either gastric cancer or AML has been observed over the one-year period following the gastrectomy. In principle, in order to achieve a good prognosis, a radical resection should be carried out for gastric cancer associated with AML. However, chemotherapy for AML might make the patient vulnerable to surgical stress, although we could not demonstrate any concrete evidence which could prove the impairment of host immunity in this case. It is, therefore, possible that not only the relapse of AML but also the impairment of host immunity may cause some other difficulties during the post-gastrectomy course.

In order to further understand the natural history and timing of repair for subpulmonic (type I) ventricular septal defect (VSD), 70 patients who underwent radical surgery were reviewed. The patients with this type of VSD accounted for 30 per cent of a total 236 children with types I, II and III VSD who underwent repair between 1978 and 1989. The frequency of aortic regurgitation was 30 per cent, being higher in the group aged older than 10 years than in the younger group (p less than 0.05). The median ages of patients with normal, prolapsed and regurgitated valves were 5, 6.5, and 10 years, respectively, and each value exhibited significant differences (p less than 0.05). The left to right shunt ratio and systolic pulmonary artery pressure of the patients with normal valves were significantly higher than those of the patients with abnormal valves. The outcome of the patients with regurgitation varied according to Sellers grading with cases of grade two valvular deformities recovering well after the repair, while cases of grade three had deformities of grade one or two severity remaining. These results led us to establish the following strategy for patients with I-VSD: 1) a child should be regularly checked by USG; 2) a child noted as having a prolapsing valve is recommended to undergo repair by the age of 10 to 12 years; and 3) a child found to have regurgitation should undergo repair as soon as possible, unless the valve regurgitation does not become more severe than Sellers grade two.

We describe herein a clinical case in which a subcapsular splenic hematoma complicated chronic relapsing pancreatitis. A pathogenetic mechanism is postulated that explains the subacute insorgence of the liquid collection with the diffusion of proteolytic enzymes between the splenic capsule and parenchyma. Radical therapy, consisting of exeresis of the cystic formation, splenectomy and caudal pancreatectomy, is recommended for this extremely rare complication.

Agenesis of the gallbladder, which is an extremely rare anomaly, may present with biliary symptoms but is virtually impossible to diagnose by such conventional investigations as oral cholecystogram or ultrasonography. We report herein a case of a young man presenting with episodic epigastric pain on whom an ultrasonographic diagnosis of gallstones was made. A gallbladder was not visualized on oral cholecystogram, however, he was subsequently found to have agenesis of the gallbladder, the diagnosis of which was confirmed by intra-operative cholangiography and a postoperative N-2,6-dimethylphenylcarbamoyle methyl iminodiacetic acid scan (HIDA scan). His symptoms responded to antiulcer treatment with upper gastrointestinal endoscopic findings suggestive of oesophagitis and duodenitis.

All cases of primary adrenocortical tumors, including those found incidentally, recorded in the Pathological Autopsy Case Annuals of Japan during a 12 year period from 1973 to 1984 were surveyed. Age- and sex-specific incidences of lesions were estimated from the population, mortality and autopsy statistics for the same period. There were 101 adenomas, 77 of which were presumed to be non-functional, and 222 carcinomas. The age-specific distribution profiles of both the benign and malignant tumors showed single peaks in the sixties and could not be distinguished from one another. The estimated age-specific distribution of morbidity of the non-functional adenomas showed a peak at about 10 years younger than that found in the autopsy records, although it was again similar to that of carcinoma derived from various clinical reports. The morbidity of the non-functional adenomas per 100,000 population was almost equal to that of breast cancer in Japan, being highest in the fifties age group with more than 4,000 people a year being suggested to have adenoma in this age bracket.

Forty-three patients with hyperparathyroidism (HPT), including 20 atomic bomb survivors (46.5 per cent) were treated surgically in our institute during the last 19 years. The mean age of the patients at the time of atomic bomb exposure (AB*E) was 17.6 +/- 1.5 years. The mean latent interval between atomic bomb exposure and detection of HPT was 39.1 +/- 1.1 years. We compared the 20 AB*E patients with 23 patients who had a history of neither atomic bomb exposure nor therapeutic irradiation to the neck region (non-AB*E patients). It was determined that females were more prominently affected by HPT than males among AB*E patients. The parathyroid lesions in AB*E patients consisted of adenoma in 16 patients and hyperplasia in 4. A similar proportion of pathological lesions was also observed in non-AB*E patients. Thyroid lesions accompanied by HPT, however, were more often revealed in AB*E patients than in non-AB*E patients. The two most common lesions in AB*E patients were papillary carcinoma in 3 patients (15 per cent) and adenoma in 3 (15 per cent). These findings suggest that atomic bomb survivors may be at a greater risk of developing HPT with a high incidence of accompanying thyroid disease.

Lysosomal protease was determined in the serum of patients with disseminated intravascular coagulation (DIC) to clarify whether the platelet count is an appropriate diagnostic index which allows the early initiation of treatment. The platelet count and the serum level of cathepsin D, a lysosomal protease, were determined in 60 patients diagnosed to have DIC. The cathepsin D activity could not be detected in the sera of healthy individuals with a platelet count of 100,000 or above, but was detectable in the serum of DIC patients with a platelet count of 100,000, and this activity increased as the platelet count decreased to 70,000 and 50,000, and was about 5 times higher at a platelet count of 30,000 than at 70,000. In DIC patients, the decrease in the platelet count was correlated with the increase in the serum lysosomal protease activity. The appearance of cathepsin D activity in the serum of DIC patients is considered to reflect the release of lysosomal enzyme activities from damaged organs, and the treatment for DIC must be initiated before the platelet count decrease below 100,000, and cathepsin D activity then appears in the serum. At a platelet count of 30,000 or less, DIC becomes established, and no therapeutic effects can be expected because of the associated multiple organ failure.

We encountered two cases of subphrenic abscesses around surgical sponges that had been left at cholecystectomy. These cases had been operated on either eight years or seven years earlier, respectively. These lesions resembled another diseases, especially, liver tumors. In order to make a differential diagnosis, various diagnostic procedures were carried out. Sonography showed a cystic mass with spongiform structures in one case. But in another case, no information of internal structures could be obtained because of the presence of a calcified wall. On CT, the lesions appeared as either round or elliptic masses that contained calcified foci in both cases. Angiography showed the extended and compressed branches of the hepatic artery. Spotty stains were also observed in one case. This appearance resembled a hepatic tumor. MR demonstrated both T1 and T2 elongated masses. The internal structures of the mass were clearly revealed by the improved version of the MR machine. MR proved to be extremely useful in making a differential diagnosis. It is, however, important to evaluate the findings of these imaging procedures synthetically and in association with a careful review of a patient's prior surgical history.

We report a 70-year-old woman with gastric varices due to splenic vein obstruction by a cystadenocarcinoma of the caudal pancreas. Most of the pancreatic cancer had already extensively progressed and was unresectable when an obstruction of the splenic vein was also discovered. Two contributing factors are thought to have enabled us to perform a curative resection in this case: (1) the gastric varices were detected by chance in a mass survey, (2) the cancer was not so advanced as to be unresectable.

Ex situ hepatic surgery, in which a diseased liver is resected from outside the body, was first reported in 1988. This study investigates the hemostatic changes occurring during such surgery in two cases. During the anhepatic period of more than 5 hours, veno-venous bypass without heparin was performed. The tests included platelet count, prothrombin activity (PT), partial thromboplastin time (PTT), fibrinogen (Fbg), factor II (F.II), factor V (F.V), and thromboelastography (TEG). Three to 4 hours after entering the anhepatic phase, marked fibrinolysis and a fall in the values of PT, Fbg and F.V. were observed. Every parameter temporarily deteriorated immediately after revascularization of the graft, however, all returned to almost normal values within 1-2 hours after hepatic reperfusion except for F.V and platelets. In conclusion, the coagulopathy during ex situ hepatic surgery is caused by the marked fibrinolysis and depletion of hemostatic factors which develop 3-4 hours after the onset of the anhepatic phase.