Ryuhei Setoyama

APPENDICO-ILEO-VESICAL FISTULA

Abstract: Appendico-vesical fistula is a rare condition. In total, 109 cases, most secondary to appendicitis, have been reported in the English-language litera-ture. We report the first case, to our knowledge, of appendico-ileo-vesical fistula secondary to appendiceal diverticulitis. An enterovesical fistula was diagnosed by urine culture, cystoscopy, and computed tomography. The locations of enteric opening sites were demonstrated by barium enema and colonoscopy. Ileocecal resection and fistulectomy with primary reconstruction were performed. We believe that accurate pre- and intra-operative diagnosis is essential for cure. This case demonstrates the importance of barium enema and colonoscopic examinations in the diagnosis and treatment of complicated enterovesical fistula.

Malignant hemangiopericytoma of the liver: Report of a case

A 30 year old female was admitted with right upper abdominal pain and fever. Ultrasonography and computed tomography revealed a large cystic mass in the right lobe of the liver, and aspiration bacteriology was negative. A right hepatic lobectomy was performed for a suspected cystadenocarcinoma, however, the tumor was histologically diagnosed as a hemangiopericytoma with prominent venous invasion. The patient died within a short time of multiple pulmonary metastases. Primary hepatic hemangiopericytoma is extremely rare, and according to our research, this is only the 4th case reported in the literature.

Intracranial hemorrhage in patients treated with bevacizumab: Report of two cases

Treatment with bevacizumab, an antiangiogenic agent, in patients with metastatic or unresectable colorectal cancer was approved less than 4 years ago in Japan. Bevacizumab improves the survival of patients with metastatic colorectal cancer; however, it may lead to complications such as bleeding, which are sometimes fatal. Bevacizumab should be administered only after careful consideration because the potential risks of therapy outweigh its benefits. Therefore, pharmaceutical companies do not recommend bevacizumab therapy for patients with brain metastases. While some reports support the cautious use of bevacizumab, others report that it is not always necessary to prohibit its use in patients with metastases to the central nervous system (CNS), including the brain. Thus, bevacizumab therapy in colorectal cancer patients with brain metastases is controversial, and it is unclear whether brain metastases are a risk factor for intracranial hemorrhage during anti-vascular endothelial growth factor (VEGF) therapy. We report a 64-year-old man and a 65-year-old man with recurrent colorectal cancer without brain metastases; these patients developed multifocal and solitary intracranial hemorrhage, respectively, after the administration of bevacizumab. Our findings suggest that intracranial hemorrhage can occur even if the patient does not have brain metastases prior to bevacizumab treatment and also suggest that brain metastases are not a risk factor for intracranial hemorrhage with bevacizumab treatment. These findings also question the necessity of excluding patients with brain metastases from clinical trials on anti-VEGF therapy.

Esophageal small cell carcinoma effectively treated by cisplatin and irinotecan

Small cell carcinoma of the esophagus (SSCE) is regarded as a relatively uncommon neoplasm. Because of its aggressive characteristics with early systemic dissemination and widespread metastasis, SCCE is often associated with a poor prognosis. We report a case of carcinoembryonic antigen-positive SCCE coexistent with squamous cell carcinoma, which was successfully treated with cisplatin (CDDP) and irinotecan (CPT-11). The present case showed no evidence of distant metastasis at the time of preoperative examination. Therefore, the surgical resection was selected as a primary treatment followed by adjuvant therapy (CDDP and 5-flourouracil). However, multiple liver metastases appeared 8 months after the surgery. We changed the chemotherapy to CPT-11 and CDDP, because the regimen is effective for small cell carcinoma of the lung. After six courses of this regimen, the metastatic lesions had dramatically disappeared. These facts suggest that surgical intervention followed by a new regimen consisting of CDDP and CPT-11 is an effective treatment for SCCE.

Current Status of Patients with Arteriosclerosis Obliterans in Japan, with Special Reference to its Prognosis

過去20年間に東大第1外科を受診した慢性動脈閉塞は1339例であり, 閉塞性動脈硬化症 (以下ASO) 449例, いわゆる Buerger 病 (以下TAO) 890例である. 今回, アンケートを中心に遠隔成績追跡調査を行い, 主としてASOの予後についてTAOと対比して考察を行った.ASOは最近増加の傾向にあり, 男性に多くみられ, 51歳以上の発症が約80%に及んでいる. TAOが20～30歳代の男性に多くみられるのと対照的である. 冷感, 疼痛や間歇性破行を初発症状とするものが多く, 閉塞部位は末梢側にもみられるが, TAOと異なり中枢側の限局的な閉塞例が約30%にみられ, 血行再建術の適応例が増加しつつある.臨床検査所見, 合併症, 併存症そして死因等からみると, 本症は高血圧症や高コレステロール血症, 糖尿病, 臓器血管合併症と密接な関係を有しているといえる.本症の死亡率もTAOに比し極めて高く, 症状初発より死亡までの期間は3年以内14.1%, 5年以内28.7%, 10年以内33.9%, 10年以上40.2%に及んでいる. 死因別にみると81死亡例中, 心疾患50.6%, 脳血管障害16.1%, 腎不全4.9%と脳・冠・腎等の重要臓器血管障害が70%をも占めている.全身性の動脈硬化性病変に対する治療法が確立されていない今日, 生命の予後の面からは薬物療法, 運動療法, 食事療法, 禁煙, そして冠動脈バイパスや高コレステロール血症に対する腸管バイパス等の外科療法などを行い, 直接死因とつながる臓器血管合併症の出現もしくは進展を抑える努力が必要といえる.患肢の予後という観点からは可能なら血行再建術を行い, 手術適応がない場合でも対症療法と併せて患肢の保護が必要である.本症は生活様式や食餌の変化, 平均寿命の延長などに伴い更に増加すると思われ, 全身の動脈硬化性病変に対する治療法, 患肢に対する外科療法の進歩が今後の課題である.