Yoriyuki Nakamura

A large inferior mesenteric-caval shunt via the internal iliac vein

SummaryA large portosystemic shunt between the inferior mesenteric vein and the right internal iliac vein in a 28-yr-old non-cirrhotic man is presented. This collateral was discovered by ultrasound done as a screening examination for gastrointestinal bleeding. The direct communication of the inferior mesenteric vein with the internal iliac vein was demonstrated by computed tomography and percutaneous transhepatic portography. Surgical ligation of the collateral, performed to prevent future portosystemic encephalopathy, resulted in reduction of serum ammonia level and cessation of long-standing hemorrhoidal bleeding.

A Case of Arborecent Liver Necrosis following Continuous Arterial Infusion Chemotherapy after Resection for Liver Metastases of Alpha-Fetoprotein-producing Gastric Cancer.

症例は61歳の男性. 1998年9月30日, 肝転移を伴うAFP産生胃癌のため, 幽門側胃切除術, 肝部分切除術 (S4c+S8) を施行した. 術前の血清AFP値は5715ng/mlであった. 術後, 右肝動脈内にカテーテルを留置し, 20PODに塩酸エピルビシン20mgを動注, 引き続きフルオロウラシル (以下, 5-FU) を250mg/日, 週5日, 3週間間欠動注した. その後, 近医にて5-FUを2,500mg/週, 16回 (総量;43,750mg) 間欠持続動注を受けた. 術後9か月のCTで肝右葉のグリソンに沿った樹枝状の不染域を認めた.画像上門脈内腫瘍栓を否定できず, 肝右葉切除術を施行した. 組織学的にグリソン周囲に漏出した胆汁を伴う肝壊死であった. 本症例では5-FUの肝動脈内動注化学療法のため胆管壁内動脈の障害から胆管壊死が生じ, 胆汁漏出によるグリソン鞘炎が原因で門脈閉塞と肝壊死が生じたと考えられた. 初回手術後2年7か月の現在再発兆候なく健在である.

A CASE OF MUCIN PRODUCING TUMOR OF THE PANCREAS IN WHICH INTRAOPERATIVE PANCREATOSCOPY WAS USEFUL

The existence diagnosis of mucin producing tumor of the pancreas is not so difficult because of its typical duodenoscopic findings and pancretographic finding. But the extent diagnosis often presents difficulty, because it mainly spreads along the mucosal layer histopathologically. This time we experienced a case of mucin producing tumor of the pancreas in which intraoperative pancreatoscopy was useful for the definite diagnosis of the mucosal spread. A 77-year-old female was seen at the hospital because of repeated epigastralgia, and was diagnosed as having a main duct type mucin producing tumor of the pancreas in the pancreatic head. Pyloruspreserved pancreatoduodenectomy was performed, and we observed the papillary tumor and irregular mucosa by intraoperative pancreatoscopy and could make the definite diagnosis of the mucosal spread. The pathological examination revealed intraductal papillary adenocarcinoma.

A CASE OF APOCRINE CARCINOMA OF THE BREAST

A 68-year-old female visited the hospital because of a left breast tumor and nipple discharge. Palpation of the breast revealed a tumor 5×4 cm in size in the upper outer quadrant of the left breast with a lot of purulent discharge from the left nipple. Mammography showed a mass with ill-defined margins and ultrasonography showed an irregular, heterogeneous low echoic area of about 4 cm in diameter in the upper outer quadrant of the left breast. Thermography showed that a mass was surrounded with irregular vascular hyperthermia in the left breast. A lactic cytological examination was false positive. Lactic CEA value was as low as 104 ng/ml. These finding indicates a breast cancer, and biopsy was performed. From pathological exploration the tumor was diagnosed as non-invasive apocrine carcinoma of the breast. Radical mastectomy was performed in addition.The apocrine carcinoma of the breast is pathologically classified into invasive carcinoma, a special type in the general rules for he breast cancer study, and non-invasive apocrine carcinoma of the breast pathologically can not exist in the rules. Here we describe a very rare case which can not but be diagnosed as non-invasive apocrine carcinoma of the breast, which reveals non-invasive ductal carcinoma with intensive apocrine metaplasia, with reference to the literature.

A CASE OF LIVER CANCER ASSOCIATED WITH CIRRHOSIS COMPLICATED BY A COEXISTING GIANT PORTACAVAL SHUNT

It is difficult to treat surgically hepatic encephalopathy of the Inose type that is causd by a portacaval shunt. The authors experienced a rare case of the disease accompanied by liver cancer, in which encephalopathy was improved by surgical closure of the shunt, and report diagnostic imaging and indications for surgical treatment of liver cancer complicated by hepatic encephalopacy of the Inose type, together with a review of the literature.A 59-year-old woman with the chief complaint of pain in the right hypochondrium was previously suspected by her physician to have liver dysfunction on the basis of biochemical examination of the blood, and liver cancer, cirrhosis and cholelithiasis on the basis of US and CT. After she was referred to our hospital, angiography and MRI revealed a coexisting portacaval shunt, and the patient developed mental symptoms. According to the diagnosis of liver cancer associated with cirrhosis with a coexisting giant portacaval shunt, partial resection of S8, cholecystectomy and closure of the shunt were performed. Portal pressure, which was 16.8 cmH2O, became 25.0 cm H2O after the closure. The patient showed improvement in encephalopathy after surgery, and was discharged from the hospital.