Kazuo Yamafuji

Direct Retroperitoneal Open Drainage via a Long Posterior Oblique Incision for Infected Necrotizing Pancreatitis: Report of Three Cases

Abstract.Although several surgical approaches have been advocated for patients with infected necrotizing pancreatitis, there is still a high incidence of morbidity and mortality. We used a new approach of direct retroperitoneal open drainage after various other treatments, for three patients with necrotizing pancreatitis and extended infection with multiple-organ failure. Long oblique incisions were made from the root of the 12th rib to the anterior superior spina iliaca on the left or right side of the back, or both, to approach the retroperitoneal area of infected necrosis. The necrotic tissue was removed bluntly and the wound was laid open. Lavage and debridement were done repeatedly after the operation. The patients recovered from multiple-organ failure within 2 weeks, and control of local infection was achieved within 3–4 weeks. All three patients were discharged and are now well. Therefore, we propose that this method is appropriate for patients with spreading infected necroses, who are in poor general condition.

A giant retention cyst of the pancreas (cystic dilatation of dorsal pancreatic duct) associated with pancreas divisum

We describe a rare case of pancreas divisum associated with a giant retention cyst (cystic dilatation of the dorsal pancreatic duct), presumably formed following obstruction of the minor papilla. The patient was treated by pancreatico(cysto)jejunostomy. A 50-year-old man was admitted with complaints of increasing upper abdominal distension and body weight loss. There was no previous history of pancreatitis, gallstones, drinking, or abdominal injury. An elastic-hard tumor-like resistance was palpable in the upper abdomen. Computed tomography and ultrasound (US) examinations revealed a giant cystic lesion expanding from the pancreas head to the tail. Endoscopic retrograde cholangiopancreatography findings showed a looping pancreatic duct which drained only the head and uncinate process of the pancreas to the main papilla. A US-guided puncture to the cystic lesion revealed that the lesion continued to the main pancreatic duct in the tail of pancreas. The lesion was connected to a small cystic lesion, which was located inside the minor papilla, and ended there. The amylase level in liquid aspirated from the cyst was 37 869 IU/l, and the result of cytological examination of the liquid showed class II. A pancreatico(cysto)jejunostomy was performed, with the diagnosis being pancreas divisum associated with a retention cyst following obstruction of the minor papilla. The histological findings of a specimen from the cyst wall revealed that the wall was a pancreatic duct covered with mildly inflammatory duct epithelium; there was no evidence of neoplasm. The patient is currently well, and a CT examination 2 years after the operation showed disappearance of the cyst and normal appearance of the whole pancreas.

Successful Treatment of Recurrent Liver Metastases from Gastric Cancer by Repeated Hepatic Resections : Report of a Case

Abstract We describe herein the case of a patient in whom recurrent liver metastases from gastric cancer were successfully treated by performing repeated hepatic resections. A 63-year-old man underwent a total gastrectomy with regional lymph node dissection for an advanced gastric cancer on November 17, 1992, the pathological findings of which confirmed a diagnosis of well-differentiated tubular adenocarcinoma, ss, INFα, ly1, v0, n1(+). Follow-up computer tomography (CT) and ultrasonography scans done 7 months after the gastrectomy revealed a metastasis in the liver S5, and a partial resection of S5 was performed on July 5, 1993. Subsequently, on November 17, 1994, an anterior segmentectomy of the liver was performed for a liver metastasis in the liver S8, then on August 11, 1998, a partial resection of the liver S6 was performed for a metastasis in the liver S6. The pathological findings of each liver specimen resected were compatible with metastatic adenocarcinoma from the primary gastric cancer. The liver tumors were expansive-growing tumors with capsules and massive necrosis. The patient is currently well with no evidence of recurrence on repeat CT scans, 6 years 6 months since-the initial gastrectomy, and 5 years 10 months since the first hepatic resection.

Simultaneously Diagnosed and Successfully Treated Rectovaginal and Vesicovaginal Fistulae after Low Anterior Resection with Concomitant Resection of Female Genitalia

Rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) are infrequent but distressing complications after pelvic surgery. However, their adequate treatment is not well described. Here, we simultaneously encountered and successfully treated RVF and VVF after radical surgery for rectal cancer. A 70-year-old woman underwent low anterior resection (LAR) combined with resection of the uterus, the bilateral adnexa, and the upper side of the vagina, as well as diverted ileostomy for rectal cancer. A month after the surgery, she developed urinary incontinence and underwent medical treatment, but her symptoms did not improve. Evaluation with contrast enema before stoma closure revealed the presence of RVF and VVF. We repaired the VVF and RVF via transabdominal and transperineal approaches. After 6 months, ileostomy was closed and the patient had no recurrence of cancer and fistula. In LAR with hysterectomy and resection of the vaginal wall, there is a risk of RVF and VVF. The excision and closure of the fistula tract and omental flap can be effective to treat both fistulae.

Successful Resection of Isolated Para-Aortic Lymph Node Recurrence from Advanced Sigmoid Colon Cancer following 156 Courses of FOLFIRI Regimen

Isolated para-aortic lymph node (PLN) recurrence from colorectal cancer (CRC) is rare, with no currently validated treatments. Few reports have described the successful resection of isolated PLN involvement from CRC following chemotherapy. We report the case of a 63-year-old man who underwent sigmoidectomy for sigmoid colon cancer at our hospital. Pathological examination demonstrated advanced sigmoid colon cancer with metastatic involvement in both of the tested PLNs. Palliative chemotherapy was initiated four weeks after surgical resection, with administration of the FOLFIRI regimen. Four years after the operation, computed tomography (CT) revealed an enlarged PLN below the left renal vein. As PLN enlarged to 15 mm in the minor axis on a CT scan in 2014 after receiving a total of 156 courses of the FOLFIRI regimen, we considered the enlarged PLN to represent an isolated metastasis. Accordingly, lymph node resection was performed with microscopically negative margins. The patient maintained a good quality of life without any side effects throughout the whole course of his treatment and remains disease-free at 24 months without chemotherapy after resection of the isolated PLN. Curative resection following chemotherapy may improve survival of carefully selected advanced CRC patients with locoregional recurrence, such as isolated PLN involvement.

A case report: Asymptomatic pulmonary embolism diagnosed before sigmoid colon cancer operaion

症例は73歳の男性で, S状結腸癌と診断され精査・手術目的にて入院した. 術前の胸部CTにて, 右肺動脈本幹および左肺底動脈に浮遊血栓を認め, 肺血流シンチおよび下肢静脈造影検査にて下肢深部静脈血栓症および無症候性肺塞栓症と診断し, ヘパリンによる抗凝固療法を開始した. ヘパリン投与開始14日目に施行した肺動脈造影検査にて左右肺動脈内に血栓を認めなかったため, 術前日に下大静脈フィルターを留置し手術を施行した. 術式はS状結腸切除術で, 術中はヘパリン低用量投与 (200単位/時間) および弾性ストッキングを使用した. 術後2日目よりヘパリンを400単位/時間にて投与しワーファリンを術後8日目より開始しINRが2.0を超えた時点でヘパリンを中止し維持療法を続行した. 消化器外科領域では手術を必要とする患者は肺塞栓症の高リスク群であり無症候性肺塞栓症の可能性も念頭にいれ周術期の管理を行うことが求められる.

A Case of Extended Necrotizing Pancreatitis Treated Successfully by Direct Retroperitoneal Open-Drainage Method.

重症壊死性膵炎に対して, 経後腹膜経路アプローチによるオープンドレナージ法をもちいて救命しえた症例を得たので, その術式とともに報告する.症例は69歳の女性で, 心窩部痛, 背部痛を主訴として来院した.急性膵炎の診断で治療を行ったが, ショック状態に陥り手術を行った.CTで, 膵床より両側腎周囲, 左側は結腸背側を経て骨盤部後腹膜に至る感染壊死巣を認めた.左第12肋骨根部より上前腸骨棘に至る斜切開にて腎周囲に直接到達し, 脾臓背側から仙骨前面までの後腹膜壊死巣の用手的除去後, 開放創とした.右側にも同様の切開を置き, 1日2回の洗浄・壊死組織除去を行い, 感染は約1か月で制御された.感染性壊死性膵炎に対しては開腹下に腹側より行われる手術法が多いが, 後腹膜全体広がった感染壊死巣の除去は不完全となりやすい.経後腹膜経路オープンドレナージ法は, 後腹膜全体に広がった感染壊死巣に軽度の侵襲で十分な効果を挙げる術式である.

A Case of Pedunculated Pseudosarcoma Arising from the Abdominal Esophagus Concomitant with Multifocal Superficial Cancer of the Esophagus.

多発粘膜内癌を伴う腹部食道原発の有茎性偽肉腫を経験したので報告する.症例は60歳の男性.主訴は嚥下障害.近医にて上部消化管造影X線検査で胃の巨大腫瘤を指摘され, 当科紹介受診となる.内視鏡検査にて腹部食道を基部とする手拳大の有茎性腫瘤 (13×7×6cm) の胃内への脱出を認め, ルゴール染色所見では切歯列28cmから腫瘤茎部まで斑状の不染帯が多発していた.生検では同不染帯に扁平上皮癌, 腫瘤には異型性を伴う紡錐形細胞を認めた.手術は右開胸開腹胸部食道全摘 (R2), 胸骨後胃管再建術を施行した.扁平上皮癌の深達度は大部分が上皮内 (ep), 一部粘膜筋板 (mm) で第2群リンパ節に転移を認めた.腫瘤には扁平上皮癌からの移行像は認められず, 免疫染色, 電顕所見から偽肉腫と診断された.多中心性の扁平上皮癌と偽肉腫の併存はまれであり, 多発する上皮内癌の一部からの刺激で間質細胞が異常増殖したものと考えられた.