Masanao Ito

Small Bowel Perforation Caused by Metastasis from an Extra-Abdominal Malignancy: Report of Three Cases

Abstract Small bowel perforation is rarely caused by metastasis from an extra-abdominal malignancy. This report describes three cases of small bowel perforation that occurred secondary to a metastatic tumor. The first case involved a 72-year-old man with malignant lymphoma of the larynx that had been treated with chemo- and radiation therapy; the second involved a 70-year-old man with rhabdomyosarcoma of the mediastinum that had been treated with radiation therapy; and the third involved a 41-year-old man with lung carcinoma that had been treated with surgery 10 months prior to perforation. Each patient presented with acute abdominal pain, had X-ray findings of free air in the abdomen, and underwent limited emergency surgery. Wedge resection and closure of the ileum was performed for the first patient and partial bowel resection with the creation of an intestinal stoma was performed for the second and third patients. In each case, the histologic findings of the resected specimens were consistent with the extra-abdominal primary tumors. Although the patients recovered sufficiently to begin eating and moving about, all three died of cancer or cancer-related complications within 45 days of surgery. We conclude that surgeons should be aware of the poor prognosis of such patients and perform only the minimal surgery required.

Pancytopenia associated with 5-aminosalicylic acid use in a patient with Crohn's disease

Abstract: We report a case of pancytopenia in a 23-year-old man with Crohns disease who was treated with 5-aminosalicylic acid (Pentasa; Nisshin, Tokyo, Japan) 3.0 g/day. He developed fever, nausea, diarrhea, and malaise and stopped taking on the third day after commencing Pentasa. Ten days after withdrawal of Pentasa, he was admitted to hospital because of worsening symptoms. Hematologic evaluation disclosed pancytopenia: red blood cells 283 × 104/mm3; white blood cells 700/mm3; and platelets 8000/mm.3 Other pertinent laboratory data, including liver and renal function tests results, serology for virus infection, and serum levels of vitamin B12 and folic acids, were normal. Bone marrow examination showed a generalized hypocellular picture, suggestive of drug-induced bone marrow suppression. He received blood transfusion and recombinant human granulocyte colong-stimulating factor (filgrastim). The leucopenia and thrombocytopenia resolved on the 7th and 13th days of hospitalization, respectively. The anemia continued because of bloody stool caused by Crohns disease. However, reticulocytes were markedly increased in number on the 13th day of hospitalization. He is well at 9 months follow-up. Excluding other causes, Pentasa-associated pancytopenia was considered. The increasing use of this agent is expected, because of the increasing number of patients with inflammatory bowel disease. Careful clinical and hematological monitoring should be performed, especially for the first 3 months, in patients beginning treatment with Pentasa. The drug should be withdrawn immediately if there is a suspicion of blood disorders.

Adenocarcinoma at the site of ileoanal anastomosis in Crohn's disease

PURPOSE: Proctocolectomy with ileoanal anastomosis has gained acceptance for the treatment of patients with ulcerative colitis. However, there are some patients with Crohns disease who received ileoanal anastomosis, because some Crohns colitis is difficult to differentiate from ulcerative colitis. The risk of cancer development at the site of ileoanal anastomosis has not been emphasized in Crohns disease. METHODS: A 12-year-old patient with Crohns disease was treated by proctocolectomy with straight ileoanal anastomosis. Twenty-five years after the operation, the patient noticed the tumor that developed at the site of ileoanal anastomosis. RESULTS: This article presents a patient with Crohns disease who developed invasive adenocarcinoma at the site of ileoanal anastomosis 25 years after proctocolectomy with ileoanal anastomosis. CONCLUSIONS: An ileoanal anastomosis does not eliminate the risk of cancer development, and surveillance after this operation seems advisable.

A simple experimental model of total hepatectomy, hepatic ischemia and extrahepatic portal obstruction in rats using splenic transposition

The objective of this study was to develop an easy and simple experimental rat model of total hepatectomy, hepatic ischemia and extrahepatic portal obstruction. The first operation involved transposing the spleen with its scarified capsule in a subcutaneous pouch to produce portasystemic anastomosis. Total hepatectomy was easily performed in a lobe-by-lobe fashion 2 weeks following the first stage operation. Anhepatic rats receiving a glucose infusion survived for about 10 hours and all died of acute hepatic failure. Hepatic support systems can be accurately evaluated in this anhepatic rat model because of its uniformity. Sixty minutes of hepatic ischemia was able to be performed in rats with a transposed spleen for a portasystemic shunt and no complicated or technically involved procedure was required for the ischemic model. No rats died due to technical difficulties, suggesting the reliability and reproducibility of this ischemic model. An animal model resembling extrahepatic portal vein obstruction was also obtained by ligation of the portal vein; a simple maneuver which was able to produce collateral veins to the liver and cavernous transformation, as similarly seen in clinical patients with extrahepatic portal obstruction. Because these 3 animal models were so easily achieved in the rat, and since the changes in hepatic function and formation of the collaterals to the liver after portal vein occlusion are still poorly understood, this model should prove valuable for future study.

Colon cancer in rectal bladder

A large number of patients have been reported with colon cancers following ureterosigmoidostomy, created after total cystectomy. However, there have been few reports of cancer in rectal bladder created instead of ureterosigmoidostomy to reduce the risk of cancer development. We report a case of colon cancer that developed in the rectal bladder 6 years after the operation. A 77-year-old man presented with blood in stools. Colonoscopy revealed a cancer adjacent to the urine inlet to the colonic lumen in rectal bladder. At laparotomy. the cancer was recognized in the rectal bladder. with invasion to the pubic bone. A palliative resection of the rectal bladder, and creation of sigmoid colostomy and ileal conduit were performed. Histologic examination confirmed moderately differentiated adenocarcinoma, which was considered to have originated from the colonic mucosa in the rectal bladder. Colonic mucosa has an increased risk of cancer development after continuous exposure to urine. It is important for gastroenterologists to perform surveillance colonoscopy in patients with urinary diversion into the colon.

Laparoscopically assisted resection of the lower rectum

We report a new laparoscopic approach to the resection of the lower rectum which has been successfully used in the treatment of a patient with a small rectal carcinoid tumor. Under general anesthesia a pneumo-peritoneum was established with CO2 gas insufflation and the rectum was mobilized from the sacrum including division of the lateral ligaments under the direct view of the laparoscope. The bowel was divided between the sigmoid colon and the rectum using an endoscopic linear stapler, and the rectum was everted through the anal canal. The lower rectum was transected extracorporeally using a linear stapler and the rectal stump was then returned to the anatomical position. An anvil of a circular stapling device into the oral colon stump through a small skin incision on the left lower abdomen was introduced and the shaft of the device through the rectal stump via anus was inserted. The device was then re-approximated under laparoscopic view and fired. Our procedure described here is applicable to the lower rectal lesion as a minimally invasive, safe, and useful therapeutic tool.

Macroscopic assessment of nodal metastasis is not reliable in colon cancer

BackgroundJapanese surgeons have to macroscopically assess nodal metastasis from colon cancer according to the general rules established in Japan. Adjuvant therapy is sometimes started after macroscopic assessment of nodal metastasis. Macroscopic assessment, however, is difficult in many cases.MethodsWe evaluated the reliability of macroscopic assessment of nodal metastasis in colon cancer by (1) comparing the number of nodes picked up macroscopically with that of nodes recognized microscopically, and (2) by comparing the number of metastatic nodes found between macroscopic and microscopic examination.ResultsThe number of nodes found during macroscopic examination was equal to that found in microscopic examination in only 52 of 206 cases (25%). Although 120 of 206 cases (58%) were judged macroscopically to have metastatic nodes, 61 had no metastatic nodes found microscopically. Sensitivity and specificity for the recognition of cases with nodal metastasis was 85.5% and 55.5%, respectively. The number of metastatic nodes in macroscopic examination was equal to that in microscopic examination in 90 cases (44%).ConclusionBecause macroscopic assessment of nodal metastasis is not reliable, physicians should not rely on macroscopic assessment to indicate the need for further therapy, such as adjuvant chemotherapy. The recommendation for macroscopic assessment of nodal metastasis should be eliminated from the general rules in Japan.

The effects of convenient vagorrhaphy on the early recovery of gastric secretion and emptying: An experimental study on function-preserving gastric cancer surgery

An experimental study was conducted using a canine model to elucidate whether the once transected vagal nerve can be conveniently anastomosed, and to determine when and to what degree the vagorrhaphy retains its functions. In the vagorrhaphy group (n=5), the anterior and posterior vagal trunks were transected 1.5 cm above the diaphragma and the cut ends were anastomosed using two stitches of 8-0 nylon and fibrin glue adhesive without microsurgery. In the nonvagorrhaphy group (n=5), a 1-cm length of the nerve segment was resected to prevent reinnervation. A microscopic study of the anastomotic site performed on postoperative day (POD) 10 indicated the intervention of nerve fibers between the cut ends. No differences were found in the gastric secretory function, as assessed by the Hollander insulin test, or in the emptying function, as assessed by the acetaminophen test, between the vagorrhaphy group and the control preoperative values. However, both of these functions were superior in the vagorrhaphy group compared to the nonvagorrhaphy group. These results indicate that the technique of convenient vagal anastomosis could be put to practical use in gastric cancer operations to avoid postvagotomy syndrome.

Efficacy for Preoperative Screening of Liver Metastasis using Computed Tomography and Ultrasonography in Patients with Colon Cancer.

効率的な大腸癌肝転移の術前検査の確立を目的に, 進行大腸癌症例354例 (内, 肝転移例63例) を対象にして, CTとUSの感度や正診率, 肝転移発見の効率や費用を検討した. 肝転移の判定は術後5年の観察で判明したもので行った. 肝転移検出のsensitivity, specificity, accuracyは, CTで65%, 94%, 89%, USで57%, 97%, 91%と, 両者に有意差はなかった. また, CTとUSが共に施行された例では65%, 93%, 88%と, 単独検査に比べて双方を行うことによる診断能の有意な向上はなかった.肝転移例における肝内進展状況の診断能は十分ではなかった. 肝転移例1例発見に要した費用は単純CTで6,298点, 造影CTで20,169点, USで5,773点と, USが安価だった. 大腸癌肝転移の診断能は, CTとUSでほぼ同等であり相補する点も少ないことから双方の検査を行う必要性はなく, cost-benefitの点からUSを選択すべきである.

Metastasis of Nodes Along the Common Hepatic Artery and Significance of its Dissection in Gastric Cancer.

総肝動脈幹リンパ節 ((8)) の郭清が胃癌の治療成績向上にどの程度関与しているかを明らかにするため, 進行胃癌症例712例から,(8) 転移の臨床的特徴を求めた後,(8) 転移例の治癒切除率や再発率をretrospectiveに検討した.そして, 標準手術 (D2) に含まれる (8) 郭清の意義を考察した.(8) 転移例は100例 (14.0%) であった.(8) 転移例では (3) 転移や (6) 転移などを高率に合併するが,(3) 転移例や (6) 転移例が (8) 転移を合併する頻度は少なく,(8) 転移と他のリンパ節転移の関連はなかった.対象の大部分においては転移のない (8) の郭清であった.(8) 転移例のうち治癒切除例は52例であり, そのうち無再発5年生存例は13例であった.この (8) 郭清によって転移巣が摘除されて生存した13例が対象に占める割合は1.8%, 根治度AとBに限っても2.5%ときわめて少なく,(8) 郭清を標準手術としていることへの再検討が必要と考えられた.