Sumio Mukaihara

Treatment of ruptured hepatocellular carcinoma.

AbstractBackground. The problem of whether surgical or conservative treatment is indicated for ruptured hepatocellular carcinoma (HCC) has not been analyzed from the viewpoint of long-term development of hepatitis viral infection from liver fibrosis to liver cirrhosis. Although transcatheter arterial embolization (TAE) for hemostasis followed by two-stage hepatectomy has been established as the best treatment for ruptured HCC, there still remain difficulties in the treatment of some patients. Methods. Twelve patients with ruptured HCC who were surgically or conservatively treated were retrospectively analyzed in terms of modality of treatment, liver function, extension of HCC, complications, survival rate, and cause of death. Results. Tumor rupture can occur either in the early phase or in the terminal phase during the development from liver fibrosis to liver cirrhosis, while tumor rupture occurs at the advanced stage in terms of HCC extension. TAE for emergent hemostasis or prevention of re-bleeding was performed in ten patients, while TAE was contraindicated in one patient and emergent laparotomy for hemostasis was performed in one patient. In four patients, elective extended surgical resection was performed, because liver function was evaluated as clinical stage 1 according to the General rules for the clinical and pathological study of primary liver cancer of the Liver Cancer Study Group of Japan. In seven patients, conservative or medical treat-ment was selected, because liver function was evaluated as poor. The surgically treated group, who could tolerate extensive operation, survived longer than the conservatively treated group. Conclusions. While TAE remains the best method to employ for hemostasis, it still has limitations. Hence, we should be mindful of other possible modalities for hemostasis and their outcomes. Rupture of HCC at an early phase in the development of liver fibrosis is a good indication for elective surgical treatment and should be distinguished from rupture in the terminal phase of liver cirrhosis, which should be treated conservatively. Although elective surgical treatment can be performed in selected patients, tumor size and location of HCC, in addition to liver function, should be taken into consideration.

Tumor thrombi in the portal vein system originating from gastrointestinal tract cancer

Intraluminal tumor thrombus in the portal vein (PV) system originating from gastrointestinal (GI) tract cancer is a rare condition. There are two types of such thrombi, one arising indirectly from metastatic liver cancer and the other directly from the primary lesion. We report here three patients with the direct type and two with the indirect type; i.e., a total of five patients with gastric or large intestinal cancer with PV tumor thrombus. In all patients, the primary lesion was surgically resected; in two patients, the tumor thrombus was easily extirpated by direct opening of the PV. It is noteworthy that a patient whose tumor thrombus could not be treated died of cancer with liver failure, caused by expansive growth of the PV tumor thrombus, 4 months after the finding of the PV thrombus. Because PV tumor thrombus may, possibly, determine the patients length of survival, in addition to causing cancer progression, surgical thrombectomy, combined with resection of the primary cancer and metastatic liver cancer, should be considered for prolongation of survival, if all macroscopic lesions can be controlled and if the tumor thrombus is a synchronous and recent one.

Presacral epidermal cyst found in an adult male with a high CEA content: Report of an unusual case

A 63-year-old Japanese man presented with constipation, having noticed flat stools for several years. Digital examination of the rectum, followed by barium enema, colonofiberscopy, computed tomography (CT), and magnetic resonance imaging (MRI) revealed an oval mass located between the retrorectal and presacral space without any mucosal lesion. This mass had narrowed the rectal lumen by compressing the rectum anteriorly. Although the plasma levels of the tumor markers were within the normal range, those of the tumor contents were elevated with a carcinoembryonic antigen (CEA) of 118 ng/mL, while the alpha-fetoprotein (AFP) value was 1 ng/mL. The tumor was completely extirpated through an abdominal incision, and there has been no evidence of recurrence thus far. Histological examination showed that the tumor wall was made of keratinized stratified squamous epithelium without any cutaneous adnexal structure, and hence it was diagnosed as an epidermal cyst. CEA was identified in these benign epithelial cells by immunoperoxidase staining using a monoclonal antibody. To the best of our knowledge, there have been only four other cases with a presacral epidermal cyst documented in the Japanese literature, all of whom were female. Our patient is the first reported case of an adult male with a presacral epidermal cyst.

Dynamic Helical CT Mammography of Breast Cancer

PurposeThe purpose of this study was to determine whether dynamic helical computed tomography (CT)-mammography could assist in selecting the most appropriate surgical method in women with breast cancer.Materials and MethodsPreoperative contrast-enhanced helical CT scanning of the breast was performed on 133 female patients with suspicion of breast cancer at the same time as clinical, mammographic, and/or ultrasonographic examinations. The patients were scanned in the prone position with a specially designed CT-compatible device. A helical scan was made with rapid intravenous bolus injection (3 ml/s) of 100 ml of iodine contrast material. Three-dimensional maximum intensity projection (MIP) images were reconstructed, and CT findings were correlated with surgical and histopathological findings.ResultsHistopathological analysis revealed 84 malignant lesions and seven benign lesions. The sensitivity, specificity, and accuracy levels of the CT scanning were 94.6%, 58.6%, and 78.9%. Helical scanning alone revealed additional contralateral carcinomas in three of four patients and additional ipsilateral carcinomas in three of five patients. However, the technique gave false-positive readings in 24 patients. The preoperative CT-mammogram altered the surgical method in six patients.ConclusionDynamic helical CT-mammography in the prone position may be one of the choices of adjunct imaging in patients with suspected breast cancer scheduled for surgery.

Perioperative changes in carbonylhemoglobin and methemoglobin during abdominal surgery: Alteration in endogenous generation of carbon monoxide

Abstract Background: Carbon monoxide (CO), which is homologous to nitric oxide (NO) as a monoxide, has been recently studied as a novel gaseous mediator for the maintenance of circulatory homeostasis and as a regulator of organ functions. Abdominal surgery is supposed to modulate the gaseous mediator by the reduction of heme oxygenase (HO) activity or transcriptional regulation of inducible HO. Therefore, we investigated perioperative changes in CO generation during abdominal surgery.

A case of pediatric gastrointestinal stromal tumor of the stomach

A 16-year-old girl with an unremarkable past history presented with sudden dizziness. Patient height was 147 cm, and weight was 43 kg. White blood cell count, red blood cell count, Hgb, Hct, and Plt on blood count were 12600/ μ L, 168 × 10 4 / μ L, 5.3 g/dL, 15.6%, and 14.2 × 10 4 / μ L, respectively. The palpebral conjunctiva exhibited signs of anemia and the patient’s face was pale. Gastrointestinal bleeding was suggested and gastroendoscopic examination was performed. Numerous coagulations with acute bleeding were observed at the central concavity and a small ulcer was seen in the anterior wall of the lower stomach. There were no distinct gastroendoscopic characteristics when compared with other submucosal tumors. Moreover, whole body computed tomography (CT) and magnetic resonance imaging (MRI) showed a large mass in the stomach and revealed no apparent metastasis (Fig. 1). Preoperative differential diagnosis was leiomyosarcoma or malignant lymphoma. A malignant tumor was not considered because the neoplasm was nodular, the surface was smooth, and no typical ulcer formation was observed on gastroendoscopy. The tumor was removed by partial distal gastrectomy through minimal laparotomy and no liver or regional lymph node metastasis was noted. Postoperative course was uneventful, and radiotherapy and chemotherapy were not administered.

Surgical significance of dilatation of the common bile duct--with special reference to choledocholithiasis.

Diameter of the common bile duct was measured in 3,119 patients who underwent primary operation for gallstones, during the period from 1975 to 1978. Although dilatation of the common bile duct was most marked in patients with bilirubin stones in the bile duct alone, dilatation was also observed in patients with cholesterol stones in the gallbladder alone. Drip infusion cholangiograms of 84 healthy patients showed that the common bile duct dilated in parallel with aging. A review of patients with congenital choledochal cysts reported in the literature in Japan revealed that few had gallstones. Thus, it was difficult to determine whether common bile duct dilatation was the cause or result of gallstones, and it was suggested that the socalled drainage operation such as choledochoenterostomy should be done only under strict indications.

Etiology of cholesterol gallstones.

SummaryFormation of pure cholesterol stones is initiated by an excessive intake of highly purified carbohydrates, a large intake of animal fats and a restricted intake of vegetable fibers.When the protein content of the lithogenic diet was reduced, mixed or combined stones were formed in golden hamsters. These experimentally, dietarily produced gallstones had compositions and fine structures similar to those of human gallstones.Some mentions were made on black stones which were found in the aged golden hamsters fed with lithogenic diets.