Kazuo Kitabayashi

Perineal rectosigmoidectomy (Altemeier's procedure): a review of physiology, technique and outcome

Abstract. Perineal rectosigmoidectomy (Altemeiers procedure), as used for the surgical treatment of full-thickness rectal prolapse, has a long history. The physiological derangement in patients with rectal prolapse is complex, frequently showing impairment of the rectoanal inhibitory reflex, intermittent high-pressure rectal motor activity, disturbances in anorectal sampling and attendant pudendal neuropathy. There are currently few defined preoperative factors in patients presenting with rectal prolapse and fecal leakage which predict for the restoration of continence after surgery. This review describes our technique of Altemeyers procedure and analyzes the reported results of this operation, presenting those studies which assessed postoperative continence and prolapse recurrence in particular. The lack of prospective randomized data regarding this perineal approach makes clinical interpretation difficult at the present time.

A spontaneously ruptured gastric stromal tumor presenting as generalized peritonitis: report of a case.

Abstract Among the diverse clinical presentations of gastrointestinal stromal tumor (GIST), spontaneous rupture with peritonitis is extremely rare. We report herein the unusual case of a 75-year-old man found to have a spontaneously ruptured gastric stromal tumor after presenting with generalized peritonitis. The patient was brought to the emergency department of our hospital by ambulance, with generalized severe abdominal pain. On examination, his abdomen was extensively distended with generalized severe rebound tenderness. Abdominal computed tomography scan showed a giant mass arising from the anterior gastric wall with an irregular internal low-density area and a small amount of ascites. An emergency laparotomy revealed a ruptured gastric tumor with dissemination of its necrotic tissue throughout the peritoneal cavity. The tumor was excised together with normal gastric tissue around its base. The tumor, which was 15 × 11 × 4.4 cm in size, had a coarse laceration over its well-capsulated smooth serosal surface with massive necrosis and clotted blood inside. Immunohistochemical examination revealed positive reactivity to C-kit protein, which was consistent with the newly introduced diagnostic criteria of GIST. The patient had an uneventful postoperative course and remains well.

Primary Hepatic Non-Hodgkin's Lymphoma in a Patient with Chronic Hepatitis C : Report of a Case

We report a case of primary hepatic non-Hodgkin’s lymphoma in a 77-year-old man with chronic hepatitis C. Laboratory data revealed slightly elevated liver function parameters and positive antibody for hepatitis C virus (HCV). Abdominal ultrasonography showed a low-echogenic tumor, about 5 cm in diameter, in the left lateral segment. Abdominal computed tomography showed that the tumor was marginally enhanced in the early phase, but no enhancement was seen in the late phase. Magnetic resonance imaging showed that the tumor was hypointense in relation to the liver on T1-weighted images, but hyperintense on T2-weighted images. Hepatic angiography showed a homogeneously stained hypervascular tumor. Under the diagnosis of a liver tumor, thought to be a hepatocellular carcinoma, left lateral segmentectomy was performed. Histological examination confirmed a diagnosis of non-Hodgkin’s diffuse large B-cell lymphoma that was positive for L-26 and CD79Α, but negative for CD3 and UCHL-1. The surrounding liver tissue showed signs of chronic active hepatitis. Multiple recurrent lesions were found in the liver, spleen, and iliac bones 4 months postoperatively. However, complete remission was achieved after five courses of systemic chemotherapy using pirarubicin, cyclophosphamide, vincristine sulfate, and prednisolone. The patient has been carefully followed up for about 1 year since his operation, and has been doing well. We review the literature on primary non-Hodgkin’s lymphoma arising in the liver infected by HCV.

Gastric cancer occurring in a patient with Plummer-Vinson syndrome: Report of a case

We report herein the unusual case of a 59-year-old woman with Plummer-Vinson syndrome who developed gastric cancer. The patient had a longstanding history of dysphagia and iron deficiency anemia, for which she has sporadically taken iron deficiency anemia, for which she had sporadically taken iron supplements that improved the dysphagia to some extent, but not completely. Owing to her tolerance of the dysphagia, she had not been taking iron supplements for the past 17 years. On admission, she was in fair nutritional condition and not anemic. Blood chemistry results were all normal, including the serum iron level. Gastrointestinal radiographic series demonstrated cervical esophageal webs and advanced gastric cancer. Her dysphagia was successfully treated by endoscopic bougienage through the webs, and a distal partial gastrectomy with nodal dissection was performed. Histology of the resected stomach revealed atrophic mucosal change and, by chance, an adenomatous lesion in addition to adenocarcinoma. Her postoperative course was uneventful and she is now well, without any signs of recurrence. Although Plummer-Vinson syndrome is known to be associated with upper alimentary tract cancers, gastric cancer is extremely rare. A discussion on the etiology of Plummer-Vinson syndrome and its link with potential carcinogenesis follows this case report.

Multicentric Occurrence of Esophageal Cancer After Gastrectomy: A Preliminary Report

Abstract The effect of gastrectomy on the subsequent development of esophageal cancer was investigated, focusing on its multicentric occurrence. We retrospectively evaluated 28 patients who underwent subtotal esophagectomy for intrathoracic esophageal cancer between 1985 and 1999. They were divided into two groups according to whether or not they had previously undergone a gastrectomy: group 1, comprising 7 patients who had undergone gastrectomy and group 2, comprising 21 patients who had not. Clinical profiles of the patients were obtained from the medical records and the whole resected esophagus was histopathologically examined. The interval between gastrectomy and esophagectomy in group 1 was significantly shorter in the patients who had undergone gastrectomy for gastric cancer than in those who had undergone gastrectomy for a peptic ulcer, and also in the patients for whom anastomosis had been performed by Billroth I compared with Billroth II. The patients in group 1 were significantly younger than those in group 2. The multiple occurrence of esophageal cancer was found in 4 of 5 patients (80%) in group 1, and in 2 of 18 patients (11%) in group 2, with significantly higher frequency being seen in group 1. More than two coexisting cancer lesions apart from the primary tumor were detected in all four patients. Histological examination of all the coexisting cancer lesions showed well-differentiated squamous cell carcinoma confined within the superficial mucosal layer. No significant differences were noted in the location of the coexisting lesions between the oral and anal side of the primary tumors. Squamous dysplasia was randomly observed, especially around the cancer lesions. These findings suggest that gastrectomy precipitated subsequent chronic gastroesophageal reflux which in turn induced the development of squamous dysplasia and carcinoma at multiple locations in the esophagus.

Anomalous junction of the pancreaticobiliary duct accompanied by gallbladder cancer and obstructive jaundice in a patient with high serum and bile cytokine levels.

Abstract: We report a case of anomalous junction of the pan creaticobiliary duct (AJPBD) associated with gallbladder cancer and obstructive jaundice in a patient with high serum and bile cytokine levels. The patient was a 63-year-old woman who complained of right hypochondralgia. Ultrasound, computed tomography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangio-pancreatatography revealed dilation of the bile ducts, an elevated lesion of the gallbladder, and AJPBD. She underwent percutaneous transhepatic cholangio-drainage (PTCD) for obstructive jaundice. However, the total bilirubin concentration remained high 7 days after PTCD. Her serum interleukin 6 level was 57 359 pg/ml before PTCD, and gradually decreased to 10 pg/ml after PTCD. Bile interleukin 6 level was 10 pg/ml before PTCD, 8997 pg/ml 3 h after PTCD and gradually decreased there after. Serum and bile levels of tumor necrosis factor α and hepatocyte growth factor were high before and after PTCD. The patient underwent an extended cholecystectomy and resection of the extrahepatic bile duct. The resected specimen showed two elevated lesions of the gallbladder which, microscopically, revealed moderately differentiated tubular adenocarcinoma. These findings suggest that pre-existing inconspicuous inflammation of the biliary tract due to reflux of pancreatic juice is involved in elevation of serum and bile cytokines, and that cytokines may participate in gallbladder carcinogenesis associated with AJPBD.

SOLITARY PEDUNCULATED GASTRIC GLAND HETEROTOPIA TREATED BY ENDOSCOPIC POLYPECTOMY: REPORT OF A CASE

The patient, a 68‐year‐old woman with a long‐standing history of schizophrenia, was admitted to our hospital complaining of vomiting which had lasted approximately 3 weeks. Endoscopic examination of the stomach revealed a solitary pedunculated submucosal tumor, of approximately 2 cm in diameter, on the anterior wall of the upper body, close to the greater curvature. The lesion was endoscopically excised using a polypectomy snare without any complication. Microscopic examination was compatible with the diagnosis of gastric gland heterotopia showing submucosal proliferation of pseudopyloric glands, fundic glands and foveolar epithelium with fibromuscular stromal framework. The proliferating foveolar epithelium and fibromuscular stroma were in continuity with the overlaying gastric mucosa and muscularis mucosae, respectively. The lesion was entirely covered by normal gastric epithelium. No atypical cells were revealed in the lesion. The clinical significance of gastric gland heterotopia is unclear because of its controversial histogenesis and carcinogenetic potential. We herein report a rare case of solitary pedunculated gastric gland heterotopia with some review of scientific reports.

TOW CASES OF TUBE FEEDING CERVICAL ESOPHAGOSTOMY

Tow cases were constructed a tube feeding cervical esophagostomy by an esophageal dilation technique, and elemental diet was controlled well for a long term. Esophageal dilation technique is as follows; at first balloon tube was inserted into the esophagus via the nasal cavity, and esophagus was dilated by the balloon filling with the contrast medium, then esophagostomy was performed by the double lumen needle which was inserted into the cervical esophagus under the fluoroscopy. This techniques is easy, and less painful for patient, and valuable for a long-term enteral hyperalimentation.

Preoperative Cytology and Measurement of Cancer Antigen 125 in Recovered Fluid from Saline Injected Peritoneal Cavity in Gastric Cancer.

触指診および超音波検査, CTで腹水, 腹膜腫瘤を認めなかった胃癌54例を対象として, 生理的食塩水を腹腔内に注入し, その回収液の細胞診 (以下, 術前腹腔細胞診) とCA125の測定を行った.腹膜播種診断における術前腹腔細胞診のsensitivityは60%, specificityは9515%, accuracyは88.9%であり, 術中腹腔洗浄細胞診と同等の成績であった.腹膜播種例における回収液CA125値は血清CA125値と高い相関を示した.また, 血清CAI25値は, 予後的漿膜面因子陽性 (以下, ps (+)) 例と同陰性 (以下, ps (-)) 例で差を認めなかったが, 回収液CA125値はps (+) 例: 101.61士0.46U/ml, ps (-) 例: 101.33±0.25U/mlで, ps (+) 例において有意に高値を示した.なお, この検査による合併症は全く認めなかった.以上より, 術前腹腔細胞診と回収液CA125の測定は腹膜播種の術前診断法として非常に有用であると考えられた.