Fumihiko Yoneyama

Manometric Findings of the Upper Esophageal Sphincter in Esophageal Achalasia

Abstract. Pharyngeal and upper esophageal sphincter (UES) manometry was performed in 15 patients with esophageal achalasia and compared with that in 10 healthy controls. Neither the pharyngeal contraction pressure nor the UES resting pressure were significantly different between the two groups, although the UES residual pressure in patients with achalasia was significantly increased compared with that in controls. Pneumatic dilatation of the lower esophageal sphincter (LES) was performed in these patients. After successful LES dilatation, the increased UES residual pressure in patients with esophageal achalasia decreased significantly. Our results suggest that UES relaxation in patients with esophageal achalasia is incomplete compared with that in healthy adults. This UES abnormality is not a primary defect but a secondary phenomenon.

Primary lymphoma of the liver with bile duct invasion and tumoral occlusion of the portal vein: report of a case

A 55-year-old woman presented to hospital with epigastric pain and jaundice. Diagnostic imaging studies revealed a biliary stricture of the hepatic confluence and a hepatic tumour of the left and caudate lobes with a portal tumour thrombus, which occupied the main portal trunk, the umbilical portion of the left portal vein, and the right anterior and posterior portal branches. Left hepatic trisegmentectomy, caudate lobectomy, portal tumour thrombectomy, bile duct resection and bilioenteric anastomosis were performed. There were no other lesions, and so it was diagnosed as a primary lymphoma of the liver (B-cell, diffuse, large cell type). The patient underwent postoperative chemotherapy and has remained well for 4.5 years after surgery. Primary lymphoma of the liver is very rare, and this is the first case report with bile duct invasion and tumoral occlusion of the portal vein.

Aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization

We report a case of aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization. A 61-year-old man with a history of hypertension underwent surgery at our hospital in November 1995 for local peritonitis caused by perforation of the sigmoid colon secondary to cancer. On the 9th postoperative day, he developed shock, with complaints of epigastric and back pain. Abdominal computed tomography showed an enhanced mass, thought to be a peripancreatic aneurysm. Emergency angiography demonstrated an aneurysm arising from the arcade of the anterior pancreaticoduodenal artery. After diagnostic angiography, transcatheter arterial embolization was performed. With steel coils, the anterior superior pancreaticoduodenal artery and anterior inferior pancreaticoduodenal artery were embolized near the origin of the aneurysm. Angiography 7 weeks later revealed no recanalization of the aneurysm and the absence of anomalous collateral vessels. The patient has been well for 19 months without re-bleeding or recurrence of sigmoid colon cancer. Transcatheter arterial embolization is an effective therapeutic approach for aneurysm of the pancreaticoduodenal artery and is the preferred initial treatment.

Clinicopathological features of superficial spreading and nonspreading squamous cell carcinoma of the esophagus

OBJECTIVES:Superficially spreading carcinoma of the esophagus, consisting mainly of intraepithelial carcinoma, is not as rare as was previously thought. Despite the surgical significance of this entity, no general definition has been established, and the clinical features of this disease remain to be clarified.METHODS:A total of 54 patients with superficial carcinoma of the esophagus (defined as carcinoma limited to the epithelium or superficially invading the lamina propria or submucosa) were classified into two groups according to the longitudinal extent of the lesion. A total of 13 patients with superficially spreading carcinoma (defined as a superficial carcinoma measuring >5 cm and consisting mainly of intraepithelial carcinoma) were compared to 41 patients with nonspreading esophageal carcinoma.RESULTS:One patient with superficially spreading carcinoma had a positive resection margin because of multiple cancerous lesions. The only significant difference in the clinical and pathological features of the two groups was a higher prevalence of associated multiple cancerous lesions in patients with the superficially spreading type.CONCLUSIONS:Superficially spreading carcinoma of the esophagus is often associated with multiple cancerous lesions. For endoscopists and esophageal surgeons, it is important to define the proximal extent of intraepithelial cancer and the presence of multiple cancerous lesions to perform curative resection.

Massive mucinous carcinoma of the breast untreated for 6 years

Abstract. We report a patient with a massive mucinous carcinoma of the breast that had been untreated for 6 years. A 47-year-old premenopausal woman presented with a large right-breast mass. Although she had noticed a lump in the right breast 6 years previously, she had not sought treatment. The tumor had enlarged gradually and become ulcerated. With a diagnosis of advanced breast cancer with skin invasion, she underwent right mastectomy with a free skin graft. No lymph node metastases or distant metastases were detected. The histologic diagnosis of the tumor was pure mucinous carcinoma of the breast with no component of ordinary invasive ductal cancer. She has been well without evidence of tumor recurrence for 7 years after the surgery. The prognosis for mucinous carcinoma of the breast has been recognized as relatively good. The results in our patient are consistent with the biological behavior of this carcinoma.

Esophageal intramural pseudodiverticulosis treated by balloon dilatation: report of a case.

A 72-year-old man presented with a 17-year history of dysphagia, which had gradually become worse in recent months. A barium esophagogram showed stenosis of the upper thoracic esophagus with multiple tiny flask-shaped outpouchings along the region of stenosis. Based on this characteristic appearance, we diagnosed esophageal intramural pseudodiverticulosis. He underwent successful balloon dilatation of the stenosis and his dysphagia resolved. Dynamic esophagography showed improved passage through the esophagus. He has been well and not suffering from dysphagia for 4 years since the balloon dilatation.

Vigorous achalasia with high-amplitude esophageal body contractions: a case report

A 25-year-old woman presented with dysphagia and chest pain in November 1999. Esophagography revealed esophageal stasis with spindle-shaped tapering at the cardia without dilatation of the lower esophagus. Manometry showed a hypertonic sphincter with incomplete relaxation on swallowing. Esophageal body contractions were simultaneous with an amplitude in excess of 200 mm Hg with tertiary contractions. These findings were not compatible with “classic” achalasia, but with vigorous achalasia. The patient underwent pneumatic dilatation with immediate relief of her symptoms. However, improvement in dysphagia and chest pain was temporary, necessitating four sessions of dilatation over three and a half years. The literature on this rare esophageal motility disorder is reviewed.

Mucosa-associated Lymphoid Tissue in Lymphoma of the Rectum.

症例は83歳の女性. 排便時出血で受診し, 直腸診で腫瘤を指摘され入院となった. 注腸造影X線検査では上部直腸から下部直腸にかけて半球状の腫瘤を認め, 大腸内視鏡検査では肛門縁から5cmに表面が平滑で中心に陥凹を伴う隆起性病変を認めた. 生検組織診断では上皮の異型はなかった. 以上より平滑筋肉腫を疑い, 低位前方切除術を施行した. 切除標本肉眼所見では3.5×3cmの中心に陥凹を伴う半球状の腫瘍を認め, 病理組織学的所見では腫瘍細胞は主に中型の異型リンパ球でcentrocyte-like cellの形態をとり固有筋層にまで浸潤し, 粘膜ではlymphoepithelial lesionを形成していたが, リンパ節転移はなかった. 以上よりlow grade MALTリンパ腫と診断した. 直腸MALT リンパ腫は自験例を含め本邦では14例しか報告がなく, その検討においても, 局所切除例では再発が50%に認められるため, 正確な診断に基づきリンパ節郭清を含めた根治的切除が必要と考えられた.

Hepatic Falciform Artery: Report of 3 Cases.

肝鎌状動脈を認めた3例を経験したので報告する. 頻度は腹部血管造影156例のうち1.9%であった. 肝動注化学療法を施行する際は本動脈の処理を行うべきである.症例1: 乳癌肝転移にて施行した血管造影で左肝動脈より分岐する肝鎌状動脈を認めた. 肝動脈CTで内側枝・外側前枝の分岐部から腹側に向かい, その後腹直筋直下を臍方向に走行する肝鎌状動脈が描出された.症例2: 小腸平滑筋肉腫の肝転移にて施行した血管造影で中肝動脈から臍方向に走行する肝鎌状動脈を認めた. 選択的造影では深下腹壁動脈との吻合が描出された. 肝動注化学療法の前に塞栓術を施行した.症例3: 胆嚢癌の診断で施行した血管造影で肝鎌状動脈が描出されたため, 手術時に肝鎌状間膜, 肝円索を採取した. 病理組織学的に外膜が肥厚した径1mmの動脈を認めた.

Intrahepatic stone in the caudate lobe treated by postoperative cholangioscopy: Report of a case

We report a 68-year-old female patient with intrahepatic stones in the right posterior inferior segment, the right anterior superior segment, and the caudate lobe. She had previously undergone distal gastrectomy, cholecystectomy, and choledochoduodenostomy. Advanced liver cirrhosis had been diagnosed at the previous laparotomy, and cholangioscopic lithotomy through a T-tube sinus tract was therefore performed. The stones in the right posterior inferior segment and the right anterior superior segment were easily extracted. However, removal of the stone in the caudate lobe was difficult and necessitated 11 sessions of cholangioscopy. Although reports of intrahepatic stones in the caudate lobe are unusual, modern diagnostic imaging modalities may identify more such cases.