Makoto Nakamaru

One-stage Surgical Management of Concomitant Abdominal Aortic Aneurysm and Gastric or Colorectal Cancer

One-stage surgical management of concomitant abdominal aortic aneurysm (AAA) and gastric or colorectal cancer should provide certain benefits. We reviewed the records of 21 patients with both AAA and gastric or colorectal cancer who underwent one-stage surgical management. Four had distal gastrectomy, 2 had total gastrectomy, and 5 had abdominoperineal rectal resection transperitoneally; 3 had total gastrectomy transperitoneally and AAA repair extraperitoneally. Two underwent right hemicolectomy and thromboexclusion of the AAA. Two had creation of a temporary ileostomy and implantation of an interposition graft. Two underwent left hemicolectomy, creation of a temporary transversostomy, and implantation of an interposition graft. One had a Hartmann’s procedure and implantation of a bifurcated prosthetic interposition graft for AAA. There were no operative deaths or serious postoperative complications. One patient had colorectal ischemia that resolved with conservative treatment. Eighteen of the 21 patients (85.7%) were alive 10 months to 14 years postoperatively. In conclusion, one-stage surgical treatment of concomitant AAA and gastric or colorectal cancer is well tolerated and can avoid the time, financial costs, and patient anxiety involved in a second operation.

Surgical strategy for abdominal aortic aneurysm with concurrent symptomatic malignancy.

In an attempt to improve the guidelines for concurrent management of concomitant abdominal aortic aneurysm (AAA) and symptomatic malignancy, a retrospective study was undertaken. A total of 186 AAA repairs were performed electively, and 25 patients (13.4%) had concurrent symptomatic malignancy from April 1986 to March 1997. Fourteen patients underwent a one-stage operation, including five abdominoperineal rectal resections, four subtotal gastrectomies, three total gastrectomies, and two right hemicolectomies. Eleven others underwent a two-stage operation, including four with total gastrectomy and left hemicolectomy followed by AAA repair, as well as two with right hemicolectomy and one with left hemicolectomy prior to AAA repair. There were no operative deaths or severe postoperative complications. Of the 25 patients, 22 (88.0%) are still alive during follow-up ranging from 8 months to 11 years. Our surgical approach to both lesions is as follows: (1) Using the transperitoneal approach alone, subtotal gastrectomy and abdominoperineal rectal resection can be safely done simultaneously. (2) Although total gastrectomy can also be performed concurrently, the approach used for each lesion is separate. (3) Colorectal resection is generally done separately. However, a one-stage operation can be performed using the thromboexclusion procedure for AAA repair in patients with right-sided colonic cancer or a temporary transverse colostomy for left-sided colorectal cancer.

An Uncommon Case of Diabetic Mastopathy in Type II Non-Insulin Dependent Diabetes Mellitus

Diabetic mastopathy is an uncommon tumor-like proliferation of fibrous tissue of the breast that usually occurs in a patient who has suffered from type I diabetes mellitus of long duration. Here we report a rare case of diabetic mastopathy that occurred in type II non-insulin dependent diabetes mellitus. This patient was a 63-year-old postmenopausal woman. Mammography, ultrasonography and MR imaging could not distinguish it from breast cancer. Although the core needle biopsy specimen showed fibrosis without evidence of malignancy, excisional biopsy was performed. Histological findings demonstrated typical diabetic mastopathy with keloid-like fibrosis, perivascular lymphocytic infiltration, and lymphocytic lobulitis without evidence of malignancy. These lymphocytes were composed predominantly of B-cells. Five months after surgical biopsy, a nodular formation approximately 4 cm in diameter recurred adjacent to the resected end of the biopsy.

Celiomesenteric anomaly with concurrent aneurysm

We describe a rare case of a celiomesenteric anomaly with concurrent aneurysm. The patient, a 53-year-old man, had no abdominal pain or discomfort. The presence of a celiac artery aneurysm was suspected on the basis of the results of abdominal computerized tomographic scanning and echo ultrasound scanning performed because of proteinuria. Intra-arterial digital subtraction angiographic results showed the anomaly and aneurysm. Because of the risk of rupture of the aneurysm, the lesion was repaired surgically, with the placement of an interpositional prosthetic graft. We found no previous reports of celiomesenteric anomaly with concurrent aneurysm repaired with prosthetic graft.

Role of pararectal retroperitoneal approach in abdominal aortic aneurysm repair

To evaluate the appropriate use of the pararectal retroperitoneal approach (RPA) in abdominal aortic aneurysm (AAA) repair, we retrospectively compared the RPA with the transperitoneal approach (TPA). Fifty-four patients in whom the RPA was used and 92 who had the TPA were included in the study. The mean operating time was 286 minutes with the RPA and 252 minutes with the TPA. Intraoperative blood transfusions were necessary in 9.3% of patients who had the RPA and 16.2% who had the TPA. As assessed by computerized tomographic scanning, the mean size of the postoperative retroperitoneal hematoma was 440 mL in the RPA group and 180 mL in the TPA group. Ileus resolved a mean of 3 days postoperatively in the RPA group and 5 days postoperatively in the TPA group. The mean length of postoperative hospitalization was 21 days in the RPA group and 23 days in the TPA group. Prolonged postoperative ileus occurred in no patients in the RPA group and in three patients in the TPA group. None of the differences in outcomes between the groups were significant. Our findings indicate that, in carefully selected patients, the pararectal RPA is suitable for AAA repair.

Successful treatment of aortogastric fistula after esophagectomy

Aortogastric fistula is a rare and lethal complication after esophagectomy. We report a case of an aortogastric fistula due to a peptic ulcer after esophagectomy for esophageal carcinoma, in which treatment with surgery and endovascular stent graft repair was successful. A 67-year-old woman underwent esophagectomy for esophageal carcinoma and reconstruction with a gastric tube through the posterior mediastinal route. Eleven years later, she experienced massive hematemesis and severe shock due to an aortogastric fistula, although there was no evidence of cancer recurrence. The fistula was obliterated surgically and the perforated aorta was directly closed. However, a pseudoaneurysm located at the closure site on the aortic wall developed postoperatively. An endovascular thoracic aortic stent graft was placed successfully, and she was discharged after intensive care. Thus, we present the very rare case of an aortogastric fistula formed following esophagectomy that was successfully treated with surgery and endovascular stent graft repair.

Technique for iliac artery reconstruction in abdominal aortic aneurysm repair.

The aim of this retrospective study was to evaluate the technique for iliac artery reconstruction in abdominal aortic aneurysm repair, when external and internal iliac arteries were required to reconstruct individually. Among 203 elective infrarenal abdominal aortic aneurysm repairs,22.patients (10.8%) required individual reconstruction of bilateral or unilateral iliac arteries, including 56 external or internal iliac arteries. Mainly, three types of procedures were performed: (1) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner, and the internal iliac artery was attached to the side of the external iliac artery, (2) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner and the internal iliac artery was bypassed with the use of a straight prosthetic graft extending from the limb of the bifurcated graft, and (3) the internal iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end fashion, and the external iliac artey was sewn to the side of the graft limb. In these three types of procedures, the third technique was the easiest and simplest anatomically.