Kanji Miyata

Treatment of spontaneous esophageal rupture with a covered self-expanding metal stent.

Spontaneous esophageal rupture is a life-threatening condition requiring immediate treatment. Surgical treatment usually is required, but conservative treatment can be pursued in selected cases.1,2 Covered self-expanding metal stents have proven useful in palliating malignant esophageal perforations and fistulas, but such implants seldom have been used in cases of benign esophageal rupture.3-5 We operated on a 56-year-old man with spontaneous esophageal rupture; when his general condition deteriorated after surgery, a covered self-expanding metal stent was placed to seal the persistent esophageal leak. After the procedure the patient’s vital signs stabilized, and the stent was removed safely by endoscopy 28 days later. Stent placement may be indicated in other similar cases.

True left-sided gallbladder with a portal anomaly: report of a case.

A 65-year-old female who presented with back pain was diagnosed to have the presence of biliary sludge in the gallbladder. Computed tomography showed that the round ligament connected to the left portal umbilical portion was in the normal anatomical position. However, the gallbladder was located to the left of the middle hepatic vein and the round ligament, attached to the left lateral segment of the liver. The right posterior portal vein diverged alone from the main portal vein, and there was a long stem from the right anterior and left portal veins. Laparoscopic cholecystectomy confirmed the abnormal location of the gallbladder. Most reported cases of left-sided gallbladder are caused by a right-sided round ligament, which is called a “false” left-sided gallbladder. A case of left-sided gallbladder with a normal left-sided round ligament, which is designated as a case of “true” left-sided gallbladder, is extremely rare.

Early carcinoma of the appendix vermiformis.

It is difficult to preoperatively diagnose early carcinoma of the vermiform appendix because of its rarity and few specific clinical features. In the present study, we report a preoperatively diagnosed mucosal carcinoma of the vermiform appendix.

Twisted cystic artery disclosed by 3-dimensional computed tomography angiography for torsion of the gallbladder

Torsion of the gallbladder is a rare condition that most commonly affects elderly women. The symptoms of torsion mimic acute cholecystitis, but several clinical features and imaging findings can be useful for distinguishing it from typical acute cholecystitis. However, preoperative identification remains difficult. Three-dimensional angiography reconstructed by preoperative multidetector row computed tomography is useful for definitive diagnosis of torsion of the gallbladder. Demonstration of a twisted cystic artery by 3-dimensional computed tomography angiography represents specific and direct evidence of this condition, which allows immediate diagnosis and treatment.

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.

Recurrent fibrolamellar hepatocellular carcinoma with biliary invasion: Successful resection

A jaundiced 17-year-old man was diagnosed as having a local recurrence of fibrolamellar hepatocellular carcinoma 2 years and 4 months after left hepatic trisegmentectomy with total caudate lobectomy had been performed. The patient had a tumor occupying the upper part of the extrahepatic and intrahepatic bile ducts. Complete resection of the recurrent tumor was carried out. The patient remains well 3 years after the second surgery. Fibrolamellar hepatocellular carcinoma, a rare type of liver cancer, is a well defined disease entity with distinct clinical and histopathological features and a favorable prognosis. The good prognosis seems to warrant aggressive surgical intervention in patients with recurrences. Therefore, additional surgery for tumor recurrence should be considered. To our knowledge, this is the first report of a case in which a recurrent tumor of fibrolamellar hepatocellular carcinoma invaded the entire bile duct wall was successfully resected.

Superficially Spreading Signet-Ring Cell Carcinoma Perpendicularly Colliding with Gastric Adenoma: a Rare Case Report

Nodular lesions within 0-IIc undifferentiated type of early gastric cancer are usually remnant normal mucosa, regenerated epithelia, or cancer growths [1]. Moreover, intestinal types of gastric adenomas generally originate from gastric mucosa with intestinal metaplasia [2]. Herein, we report a rare case of superficially spreading signet-ring cell carcinoma perpendicularly colliding with a gastric adenoma.

Massive pneumoperitoneum after esophagectomy

A 79-year-old man presented for routine follow-up computed tomography after esophagectomy (reconstruction had been done by intrathoracic esophagogastrostomy) had been performed 18 months earlier for thoracic esophageal cancer (pT2, pN1, M0, stage IIB according to International Union Against Cancer classification). Although he had no symptoms, plain abdominal radiography and computed tomography revealed massive pneumoperitoneum and a small right pneumothorax. On the day after admission, upper gastrointestinal endoscopy showed no ulcers or strictures of the remnant esophagus, gastric tube, and duodenum. Air was released by spontaneous rupture of blebs in the right lung, after which it passed through the esophageal hiatus, which had been opened at the time of esophagectomy, and accumulated in the abdominal cavity. The origin of the gas can be understood from the postoperative anatomic changes, as can the mechanism of air retention in the abdominal cavity. When a patient has a history of operation, accurate understanding of operative procedure and postoperative anatomic change may provide a clue to appropriate diagnosis.

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.