Sato Harunobu

We report a case of gastrointestinal pacemaker cell tumor (GIPACT) with special reference to the usefulness of multiplaner reconstruction (MPR) and three-dimensional imaging (3D) by multislice computed tomography (MSCT) for selecting the surgical procedure and approach. A 36-year-old man with constipation was admitted for further examination was found in diagnostic imaging studies to have a submucosal tumor in the lower rectum. MPR and 3D were used to select the tumor approach and surgical procedure, resulting in a successful ultralow anterior resection with transanal anastmosis. Histological examination of the resected specimen showed the tumor consisted of spindle-shaped cells. Immunohistochemical testing was negative for s-100 and muscle-actin, and positive for CD34 and c-kit and the tumor was diagnosed as GIPACT. The postoperative course was uneventful except for temporary urinary dysfunction.

Radiation therapy is one choice for malignant disease of the lower abdomen. However, radiation sometimes induces radiation colitis as a severe side effect. Radiation colitis sometimes causes severe bleeding, and it is often difficult to treat, A 66-year-old man received radiation therapy (external radiation with 65.2 Gy) for carcinoma of the bladder. Bleeding in the rectum occurred approximately 15 months after irradiation. Severe bleeding and anemia could not be controlled by Salazosulfapyridine and steroid enemas, and frequent blood transfusion was needed. Therefore, we gave ecabet sodium enemas to this patient, twice every day, for four weeks. Bleeding and anemia could be controlled by this treatment. It is suggested that ecabet sodium enema can be an available treatment for radiation colitis.

Sacrococcygeal teratoma is rare tumor in adults. It is usually diagnosed and resected in infancy. Only 29 cases have been reported in the Japanese literature.<BR>We report a rare case of an adult sacrococcygeal teratoma with usefulness of multi planer reconstruction (MPR) and three-dimensional imaging (3D) by Helical CT for selecting an operation method and position.<BR>A 52-year-old man visited our hospital with dull oppression in his buttocks. Barium enema and MRI revealed a sacroccygeal cystic tumor in the presacral space between the coccyx and the rectum. We studied the tumor by MPR and 3D, to select its operation method and position. We completely resected the tumor, including the coccyx and the 5th sacrum, through a trans-sacral approach with a jackknife position. The excised tumor was a benign mature teratoma, 13×12×8.5cm in size. The postoperative course was uneventful. He Is well, without defecatory or urination disturbance.

A rare case of ulcerative colitis with severe benign stricture in which abdominoperineal resection was performed is reported. A 60-year-old man with a 15-year-history of ulcerative colitis was examined for weight loss. The patient had been diagnosed with ulcerative colitis 15 years previously at another hospital. Barium enema, colonoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) revealed stricture in the rectum and the sigmoid colon. Abdominoperineal resection was performed because the stricture could not be discriminated from a malignancy. The resected specimen showed thickening of its wall and narrowing of its lumen. Pathological examination revealed that fibrosis in the submucosal layer and thickening of the muscle layer had caused the stricture and that there was no evidence of malignancy. Benign stricture in ulcerative colitis is rare, and only 13 cases have been reported in Japan. It is often difficult to diagnose benign stricture, and surgery is performed. It is hoped the research will clarify the cause of benign stricture in ulcerative colitis and that preventive treatment will be parformed in the early stage.

Rectocele is an anatomical disorder in which the rectal wall protrudes anteriorly and causes defecatory disorders. A rectocele with clinical symptoms, such as difficulty in defecation, sould be considered for treatment. Conservative treatment should be conducted initially for a symptomatic rectocele, and surgical treatment should follow if conservative treatment fails. Conventional surgical treatments, with excision or ligation of the rectum or vaginal wall, have sometimes failed to improve the defecatory disorders and anatomical disorders. These conventional treatments are not suitable for improving urinary or stool incontinence. Technique and results of anterior levatorplasty, to improve these combined disorders, are described herein.

Lateral node metastasis, recurrence, and outcome were investigated in rectal cancer with and without autonomic nerve-preserving operation to clarify the effect of autonomic nerve-preserving operation on lateral node dissection. All patients undergoing curative surgery for middle and lower rectal cancer were classified into the following three groups : a group that underwent autonomic nerve non-preserving operation from 1980 and 1987 (group A, n=109), a group that underwent the nerve-preserving operation between 1988 and 1993 (group B, n=71), and a group that underwent non-preserving operation between 1988 and 1993 (group C, n=12). Our indications for nerve preservation since 1988 have been the absence of evidence of direct invasion of the autonomic nerve macroscopically in frozen sections during surgery. The 5-year survival rate of all cases with and without node metastasis was 33.8% and 76.8% respectively. There were no statistically significant differences in the 5-year survival rate between groups A and B according to Duke's staging, staging by the General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus, and recurrence rate. However, the cumulative 5-year survival rate in group B was significantly better than in group A (P<0.05) in the lower rectum. There were no significant differences between group A and groups B and C in the 5-year survival rate. The 5-year survival rate in group B was significantly better than in group C (P<0.05). The autonomic nerve-preserving operation with lateral node dissection was concluded to provide as good an outcome as non-preserving operations with lateral node dissection within our indications.

著者等は,4例の十二指腸断端縫合不全症例に対してpercutaneous transhepatic biliary drainageの技術を応用してカテーテルを十二指腸内に留置し,胆管及び十二指腸内容のドレナージを行い,保存的に治癒せしめることに成功した.本法は再手術を施行せずに十二指腸内容のドレナージが行えるため,低侵襲で効果的である.又octreotide acetate(Sandostatin)を併用し,胆汁,膵液の分泌を抑制することによって治療効果の一層の向上が期待できる

従来の経肛門的局所切除術 (PAE) と新しく開発したE式およびF式開肛器と自動縫合器を用いた経肛門的局所切除術 (MITAS) について臨床的に比較検討した。対象は経肛門的局所切除術が施行された直腸腫瘍61例 (62病変) で, 術式はMITAS43例 (44病変), PAE18例であった。肛門縁から病変までの距離はPAEの4.9cmに比べてMITASでは9.3cmと有意に高位で, 腹膜反転部以上に局在する症例が有意に多かった。手術時間はMITASでは平均24.7分, PAEは40.9分で, 出血量はMITASでは平均19.6g, PAEは50.0gであった。術後経口摂取開始までの日数はPAEに比べてMITASは有意に短縮していた。MITASでは86.4%の病変で筋層以上の切除がなされていた。合併症はPAEで縫合不全を2例, MITASで後出血を1例に認めた。MITASはすべての部位の早期直腸癌の根治術として, また根治性確認の手段として有用なminimally invasiveな術式と考えられた。

Four cases of colorectal cancer with solitary adrenal grand tumor were retrospectively studied as to whether or not preoperative differential diagnosis between metastatic and benign condition is possible. The mean age of the patients was 54.8 years old, and the male to female ratio was 1 to 1. Three cases had rectal cancer and one sigmoid colon cancer. All adrenal tumors were found by computed tomography (CT) of the abdomen. One tumor was located in the left adrenal grand, and the others on the right side. Two tumors were found preoperatively, the others postoperatively. The maximum diameter of tumors were three to four centimeters. Magnetic resonance imaging (MRI) of the abdomen was performed in two cases, and angiography in one case. The level of serum CEA was within the normal range in all cases, but that of serum CA19-9 was out of the normal range in two cases. Endocrinary function test revealed that all tumor were nonfunctional. Adrenalectomy was performed in all eases in suspicious metastatic adrenal tumor. Histopathological examinations showed that three of the tumors were adenomas, and one metastatic adenocarcinoma. It was considered to be difficult to distinguish adenoma from metastatic tumor by preoperative findings.

Twenty-nine cases of mucinous carcinoma in the colorectum, except for multiple or fistulae cancer were clinicopathologically compared with 470 cases of well-and 162 cases of moderately-differentiated adenocarcinoma. The depth of invasion was se or more in 78.9% of mucinous carcinoma of colon, and all mucinous carcinoma of rectum invaded as a1. Node metastases up to the second grade were more often seen in mucinous carcinoma of the colon (44.4%) and the rectum (40.0%) than in the other histologic types. There was no significant difference in the incidence of distant metastasis and peritoneal dissemination between mucinous carcinoma and well-and moderately- differentiated adenocarcinoma. The five-year survival rate of mucinous carcinoma was 53.3% in the colon, and 64.9% in the rectum. Curative A resection rates were 77.8% in the colon, and 80.0% in the rectum. Curative resection was expected for mucinous carcinoma by wide resection and sufficient lymphadenectomy. There was no significant difference in the five- year survival rate between mucinous carcinoma and well-and moderately- differentiated adenocarcinoma. The adjuvant therapy for mucinous carcinoma with Dukes' C was recommended in the colon because the five-year survival rate of Dukes' C (37.5%) was worse in mucinous carcinoma of colon than in well-differentiated adenocarcinoma. More accurate method for diagnosis of mucinous carcinoma was needed because preoperative histological diagnosis was poor in the colon (45.0%) and the rectum (16.0%).

Multiple carcinoid tumors of the rectum is rare and the accumulated number of the cases in Japan is 13. Carcinoid tumors less than 10 mm in diameter have little metastasis. A case of multiple carcinoid tumors 9mm in maximal diameter with node metastasis was reported herein. A 64-year-old male with abdominal discomfort visited our hospital. Colonoscopic examination showed several carcinoid tumors of the middle rectum, and low anterior resection was carried out. The resected specimen demonstrated 9 separate carcinoid tumors from the mid-rectum to rectosigmoid colon. Three of 14 examined lymph nodes were found to be metastatic, and all tumors were less than 10 mm in diameter. The patient is doing well 12 months after surgery, without evidence of recurrent or metastatic disease.

A case of analgesia due to stretching a mucosal bridge between the anastomotic site and the anus following low anterior resection was presented. A 57-year-old male underwent low male anterior resection for rectal cancer in 1986, and a minor leakage of the anastomoitic site was treated conservatively. His analgesia started after discharge. Anastomotic stenosis was treated by bougie and strictureplasty in 1987 and 1989 respectively. Analgisia subsided transiently, but persisted. He consulted our clinic due to increasing anal pain on defecation. Digital examination revealed tenderness of the posterior wall of the rectum distal to the anastomotic site. Colonoscopic examination revealed a mucosal bridge between the anastomotic site and the anus, and pain was evoked by touching the mucosal bridge. Mucosal bridge was transected and resutured longitudinally. Analgesia disappeared postoperatively, and no pain has recurred 8 months after operation.

Minimally invasive transanal surgry (MITAS) was performed for early cancer without massive invasion into the submucosal layer in the upper rectum, which is not suitable for endoscopic or conventional transanal excision. Twenty-eight patients underwent MITAS for 29 rectal tumors (mucosal cancer 17, slight submucosal invasion 6, moderate submucosal invasion 5, massive submucosal invasion 1). The mean maximum diameter of the tumors was 26 mm, and the mean distance from the anal verge to the proximal margin of the tumor was 9.2 cm. Sixty-six percent of the tumors were located above the peritoneal reflection. Shortening and invagination of the rectum was initially performed using the E type anal retractor. The tumor was excised and simultanous anastomosis by a stapler following stiching under the tumor for pulling out the tumor. The mean operative time and blood loss were 23 minutes and 21 g respectively. There was no mortality or morbidity except one case of transient bleeding. Oral intake was started the day following the operation. The mean discharge day was about 5 days after the operation. The longest follow up was 3 years and 8 months. There was one recurrence, which was only surgical margin positive, and it was reexcised by MITAS. No further recurrent cases have been observed so far including the reexcised case. MITAS was considered to be a minimally invasive local excision procedure for cure and a better quality of life.

A rare case of undifferentiated carcinoma of the rectum in which the patient died shortly after resection of the primary lesion is reported. A review of undifferentiated carcinoma of the large intestine in Japanese literature is analyzed. The bloody stool of a 59 year-old male was diagnosed as rectal carcinoma without distant metastasis. Low anterior resection was performed. Type 2 tumor, 5.0 x 4.7 cm in size, was found in the resected rectum. Immunohistological studies concluded the diagnosis of undifferentiated carcinoma. The tumor invaded beyond the serosa (se), and lymph node metastasis was at the root of the inferior mesenteric artery (n3). The patient was doing well without any symptoms until discharged from the hospital. The patient was readmitted because of general fatigue, and died because of paraaortic lymph node metastasis 75 days after surgery. Undifferentiated carcinoma of the large interstine is a rare condition in Japaneses liteature. Only six cases have been reported so far. Most of the undifferentiated carcinoma had lymphatic and hematogenous metastasis, and the prognosis of these patients was extremely poor. It could be concluded that further efforts to improve prognosis of undifferentiated carcinoma of the large intestine should be focussed on adjuvant therapy instead of operation.

これまでの骨盤直腸窩痔瘻の治療の問題は, 術後の創治癒の遅延, 肛門機能の低下, 肛門や創の変形, 再発などであった。これらの問題を解決するために瘻孔造影で術前に瘻管の走行を確認し, 経仙骨的アプローチで全瘻管を確実に処理し, 半閉鎖する手術を施行した。症例は40歳の男性で, 肛門周囲痛で来院し, 肛門周囲膿瘍の切開排膿後痔瘻に移行した。肛門会陰部には10時の2次口と2次口周囲の皮膚の発赤, 直腸右壁の硬化を認めた。直腸肛門管造影を併用した瘻孔造影で骨盤+坐骨直腸窩痔瘻と診断し手術を施行した。2次口と皮下膿瘍を切除し瘻管をcoring out後, 経仙骨盤直腸窩の瘻管, 膿瘍を全て切除, 掻爬した。次に, 1次口の切除, coring outを行い1次口は半閉鎖した。2次口と仙骨切開創はドレーンを留置し閉鎖した。術後経過は良好で, 術後23日目に退院し, 術後6カ月現在再発もない。

A case of local recurrent cancer in the sigmoid colon with submucosal spread 4 year and 8 months following endoscopic polypectomy was reported. A 64 year old male underwent endoscopic polypectomy for semipedunculated polyp of 15 mm in diameter. Histological examination disclosed the polyp was cancer in adenoma with penetration into the muscularis mucosa. Surveillance colonoscopy was done 2 weeks, 15 months, and 3 years and 1 month after polypectomy, but did not show any pathological findings at the polypectomy site. Surveillance barium enema study did not indicate any recerrent lesion except indentation of the polypectomy site 3 months after polypectomy. Elevated lesion with ulcer was found in the sigmoid colon by surveillance colonoscopy 4 years and 8 months after polypectomy. Barium enema study showed a severe indentation with ulcer. Laparotomy revealed cancer in the sigmoid colon with node metastases. Sigmoidectomy with lymph adenectomy was performed. Resected specimen showed a tumor, growing mainly in the intramural and pericolic fat layer, of 3 cm in diameter with ulceration of 0.8 cm in diameter. Most of the tumor was covered with the normal mucosa except an ulceration. Histological examination revealed well differentiated adenocarcinoma with node metastases (ss, ly2, v0, n2). Re-examination of the polypectomy specimen revealed well differentiated adenocarcinoma with moderate invasion into the submucosal layer and lymph vessel invasion. Recurrent cancer was considered to have originated from residual cancer cells.

Exfoliated cancer cells in the rectum were studied to clarity the possibility of implantation methastasis in early rectal cancer. Twelve patients with rectal cancers and one with sigmoid colon cancer at an early stage who underwent transanal local excision were entred in the study. Cells were collected from three different areas of the mucosa around the tumor (right, left and anal side), and from the center of the tumor before excision. Exfoliated cancer cells were examined cytologically. Scratch cytology was performed from the tumor in 11 of the 13 patients following excision. Exfoliated cancer cells were confirmed in one of 39 specimens collected from the mucosa (2.6 %). Cancer cells were identified in 9 of the 13 patients (69.2 %) by contact cytology. Scratch cytology revealed cancer cells in 10 of the 11 patients (90.9 %). It was considered that intraoperative preparation like rectal washout is not necessary because the possibility of exfoliated cancer cells in the mucosa of the rectum was very low.

The significance of preoperative serum CEA levels for predicting clinical stage, prognosis and recurrence of colorectal cancer was investigated to obtain a source for informed consent in patients with colorectal cancer. Three hundred twenty nine patients who underwent surgery in our department was analyzed by the medical records from 1986 to 1990. 55.3% of these patients had normal CEA levels before surgery. All cases with preoperative serum CEA levels over 5.1 ng/ml had more advanced cancer. 77.0% of patients with preoperative serum CEA levels over 10.1 ng/ml had lymph node metastasis. Furthermore, 50.0% of patients with preoperative serum CEA levels over 20.0ng/ml had hepatic metastasis. Patients with elevated preoperative serum CEA levels had higher rates of recurrence and poor prognosis than those with normal serum CEA levels. CEA levels were elevated at recurrence in 75.0% of cases with elevated serum CEA levels before surgery. But CEA levels were within normal limit even at recurrence in 62.5% of cases with normal serum CEA levels before surgery. Thus, measuring serum CEA levels was not helpful for predicting recurrence of colorectal cancer in cases with normal serum CEA levels before surgery, but surveillance with diagnostic imaging was useful to detect recurrence in these cases.

The reported case was a 58-year-old male. The primary focus, rectal cancer was revealed to be type 2 macroscopically at 4.5cm abobe the anal verge. For rectal cancer, abdominoperineal resection was performed. The pathological findings were well differen-tiated adenocarcinoma, a2, ly2, v1, and n0, and surgery was completely curative. Followup of the patient was performed at the outpatient department after surgery. Fourteen months later, CT showed an abnomal shadow at the right adrenal gland. There was no metastasis except in the right adrenal gland. Right side adrenectomy was performed. The histology of the resected adrenal gland was the same as that of rectal carcinoma. The patient survived for 2 years and 7 months after adrenectomy, and died of pulmonary metastasis.

A case of traumatic diaphragmatic hernia by traffic accident is reported, together with a review of 267 other cases reported in Japan in a period from January 1981 to November 1990.<br> A 31-year-old man who sustained blunt traumas by traffic accident was seen at the hospital because of lumbago. On admission, chest X-P revealed an elevation of the left hemi-diaphragma. The patient was diagnosed as traumatic left diaphragmatic hernia by US and CT examination. Emergency laparotomy was carried out. The escaped organs, stomach and omentum, were returned into the abdominal cavity and ruptured diaphragma was closed directly. Postoperative course was uneventful and the patient was discharged from the hospital 39 days after the surgery.<br> We compared our review with the previous papers reported in 1980s. Though the lesions had been said to be located commonly in the left side of the diaphragma, those in the right side have been increasingly reported in these years. There is an increasing tendency to be caused by traffic accident as the causative trauma. In this review of 203 causes. 20 death causes (9.8%) are noted, and this percentage is comparable to that of previous reports by Kasahara.

The surgeon or physician investigates how good the anorectum is at preserving continence or facilitating defecation and what component of the mechanism is faulty. Anorectal manometry is one of the physiological tests to assess the anorectal function. There fore manometric study was carried out on patients with lower rectal cancer who underwent very low anterior resection and with ulcerative colitis who underwent J-pauch anal anastomosis, with traumatic anal injury (obstetric injury and anorectal surgery), with complete rectal prolapse and with pelvic floor outlet obstruction. As a result, anorectal manometry was appropriate as a screening test for anorectal disorders and very useful for the evaluation of the anal function after treatment, but did not indicate the aetiology. Therefore, more complex neurophysiological tests may be necessary.

Goblet cell carcinoid of the appendix is a relatively rare neoplasma that has histologic features of both carcinoid and adenocarcinoma. We experienced a case with goblet cell carcinoid, in the appendix of the specimen that had ileocecal resection, diagnosed as mutinous cystadenoma of the cecum. The total number of the cases of goblet cell carcinoid of the appendix which had been reported in Japan was 26. In this report, we describe a woman with goblet cell carcinoid of the appendix. A 65-year-old female was admitted complaining of positive occult blood in stool, which was diagnosed as cystadenoma of the cecum. I leocecal resection was carried out. We found the goblet cell carcinoid in the appendix. In most of the 26 cases in Japan, appendectomy was performed under a diagnosis of acute appendicitis, and goblet cell carcinoid was found in the resected appendices after surgery. In five of the 26 cases in Japan, metastasis was found during surgery or recurrence was noticed after surgery and it was shown that goblet cell carcinoid of the appendix was potentially malignant. In our case, there were no symptoms before surgery, no metastasis of the liver and lymph node during surgey, and no recurrence 2 years and 7 months after surgery. It is interesting that goblet cell carcinoid in the head of the appendix produced much mucin and mutinous cystadenoma in the neck of the appendix was found discontinuously.

Histological and histochemical comparison was performed between normal human and rat external anal sphincters.<BR>Human external anal sphincters had 85.02 % of type 1, 6.64 % of type 2A, 8.28 of type 2B and 0.06 % of type 2C fibers. Type 1 fiber predominance was seen in all human external anal sphincters.<BR>In contrast, rat external anal sphincters had only 0.90 % of type 1 and the percentage of type 2A fibers was 98.51 %. Type 2B fibers were not seen in rat external anal sphincters.<BR>The mean diameter of type 1 fibers of the human external anal sphincter was 28.2± 9.1 μm, which was significantly smaller than that of other types (p<0.01). There were no differences of the mean diameter among each type of rat external anal shincters.<BR>Ragged-red fibers were found in human external anal sphincters, but they were not found in rats.<BR>Human external anal sphincters generate resting potentials and are always keeping tonus, but rat external anal sphincters don't, which were thougt to be one of the causes of these differences.