Atsushi Inayoshi

Inflammatory pseudotumor of the spleen: report of a case.

A case of a 45-year-old Japanese man with a splenic inflammatory pseudotumor is described. This benign lesion is rarely reported in the world literature. We preoperatively could not rule out the possibility of a malignant neoplasm, due to the fact that the tumor had grown in size after a 2-year observation. However, after performing a splenectomy, a histological examination of the mass revealed an inflammatory process. Inflammatory pseudotumors often pose diagnostic difficulties because the clinical and radiological findings tend to suggest a malignancy. The clinical and pathological features of such previously reported cases are also reviewed.

Trichoblastic carcinoma arising from colostomy

Trichoblastic carcinoma is a rare skin cancer originating from hair germ cells. We report a case of an 84-year-old man who presented with a tumor on the stoma of the descending colon, which was preoperatively diagnosed as colon cancer. He underwent colectomy with adjacent skin, and the tumor was diagnosed as trichoblastic carcinoma by postoperative pathological examination. We are not aware of any similar cases published in the English literature. Therefore, we report this case because it is quite a rare condition.

Acute afferent loop necrosis after Roux-en-Y cholangiojejunostomy

Afferent loop necrosis after Roux-en-Y cholangiojejunostomy biliary reconstruction is rare. We present the case of a 36-year-old woman with acute necrotic afferent loop obstruction. The peripheral area of the Roux-en-Y limb, including the cholangiojejunostomy portion, was twisted just proximal to the cholangiojejunostomy. Cholangiojejunostomy was completely separated due to necrosis of the Roux-en-Y jejunum. In addition to the case report, we discuss features of cholangiojejunostomy that require special attention.

The Transduodenal Endoscopic Treatment of Acute Cholangitis

Mortality due to acute cholangitis (AC) has been tremendously reduced by the advent of endoscopic sphincterotomy (EST). This study investigates whether EST is really a curative procedure for the treatment of AC, or not. Diagnosis of AC, in 159 out of 1,061 cases in which EST was performed, had been made by infected bile which was recognized as green or pyobile collected during ERCP. Emergency drainage by EST was performed immediately after AC was diagnosed. The causes of AC were attributable to benign diseases in 128 cases (80.5%) and malignant diseases in the remaining 31 cases. Clinical symptoms included abdominal pain, fever, and obstructive jaundice, but Charcots triad was noticed in 66 cases (43.3%) and Reynolds pentad in only 7 cases (4.6%). As to the relation between clinical symptoms and properties of bile, pyobile was more likely to be recognized in patients with severe symptoms.

TWO CASES OF NONPARASITIC HEPATIC CYST TREATED WITH ABSOLUTE ETHANOL INJECTION UNDER ULTRASONICALLY GUIDED PUNCTURE

Two patients with large nonparasitic cysts of the liver were treated with absolute ethanol injection under ultrasonically guided puncture. The first patient, a 63-year-old woman, was admitted to our hospital with the complaints of sense of fullness and epigastralgia. On the ultrasonogram, a cystic mass, 14×9cm in size, was seen in the left lateral segment of the liver. The second patient, a 56-year-old woman, was hospitalized with the complaints of general fatigue and anorexia. Ultrasonogram revealed a cystic mass, 12×9cm in size, in the right lobe of the liver. Neither, cyst showed malignant findings. Both patients were treated with absolute ethanol injection under ultrasonically guided puncture. After the treatment, no major complications were observed, and remarkable shrinkage of both cysts was seen on the ultrasongram. There was no recurrence over a period of two years. As this procedure was simple and harmless, this treatment for hepatic cysts may be considered as an alternative to surgery.

Laparoscopy-Assisted Distal Pancreatectomy

The advantage of laparoscopic surgery is obvious and has been extended to pancreatic and splenic operations. Since 1994, various laparoscopic pancreatectomy, including pancreatoduodenectomy (Gagner & Pomp, 1994), enucleation (Gagner et al., 1996; Dexter et al., 1999), and distal pancreatectomy (Gagner et al. 1996; Sussman et al., 1996), have been performed. As for laparoscopic splenectomy, nowadays it can be conducted safely even for splenomegaly due to portal hypertension (Hama et al., 2008). Open pancreatic surgery requires a relatively large incision for a small lesion, and therefore the potential benefits of the laparoscopic approach are substantial. The most common indications for laparoscopic pancreatic resection were presumed benign pancreatic diseases, such as insulinoma or localized neuroendocrine neoplasms and branch type intraductal papillary mucinous neoplasms. The most common indication for laparoscopic pancreatic resection appears to be enucleations and distal pancreatectomy. Laparoscopic pancreatectomy, however, is still technically rather difficult because of the retroperitoneal position of the pancreas and the complex anatomical relationship between the pancreas and surrounding vessels. Thus, hand-assisted laparoscopic pancreatectomy is gaining recognition as a new and feasible technique that introduces a surgeon’s hand into the abdominal cavity during laparoscopic surgery (Klingler et al., 1998; Shinchi et al., 2001; Kaneko et al., 2004). As a modification of hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is performed under direct vision extracorporeally (Hirota et al., 2009). Furthermore, laparoscopic assistance is also helpful in no-touch distal pancreatectomy for pancreatic cancer. For invasive pancreatic ductal cancers, the transection of the pancreas, splenic artery and vein, left gastroepiploic vessels, and short gastric vessels is performed at first to prevent the dissemination of cancer cells. Division of the pancreas, splenic artery, and splenic vein is done under direct vision through minilaparotomy at epigastrium. Division of the left gastroepiploic and short gastric vessels is done under laparoscope with left hand assistance. And then, retroperitoneal dissection is performed laparoscopically. In this way, the same no-touch distal pancreatectomy as open operation can be achieved.

EVALUATION OF PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHIC DRAINAGE UNDER ULTRASONOGRAPHY-GUIDED PUNCTURE USING THE NEW NEEDLE WITH CATHETER

We evaluated the indication and problems of percutaneous transhepatic cholangiographic drainage (PTCD) under ultrasonography-guided puncture using the 21G needle with catheter in order to decrease the X-ray radiation to the operators hands. The catheter of the 21G needle is flexible and we can performed cholangiography and insert guide wires and drainage tubes from outside of X-ray field. By this reason this method of PTCD can decrease X-ray radiation to the hands. These procedures of PTCD were performed in 214 times of 190 patients in our hospital. The punctures of the bile duct were successfully performed in all cases, but insertion of the drainage tube failed in 12 times because of insufficient dilatation under 5mm in diameter and hardness of the bile duct. As a result it is considered that this method is indicated for dilatation of the bile duct over 5mm in diameter and that the suitable angle of puncture and selection of an appropriate catheter are important. The complications in this series were bile duct bleeding in two cases, deviation of the catheter in four cases and serious shock in one case.

A case of hepatocellular carcinoma of pseudograndular type visualized as the hyperechoic pattern on ultrasonography.

偽腺管形成により,超音波像で高エコー型を示したと考えられる肝細胞癌の1例を報告した.症例は71歳の男性で右季肋部痛を主訴に来院した.超音波検査で,肝右葉後区域に高エコー型を呈する6.7×6.2cmの腫瘤エコーを検出した.肝右葉切除を施行し,切除標本の病理組織学的検索を行ったところ,肝には肝硬変の所見はなく,腫瘤はEdmondson II型の被包型肝細胞癌で,腫瘤内には,ほぼ全体的に偽腺管の増生を認めた.従来から,肝細胞癌の超音波像で高エコーを示す原因として,凝固壊死,脂肪浸潤,類洞の拡張によるものが報告されているが,本症例は偽腺管の増生によって高エコー型を示したと考えられ,まれな1例として報告した.