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脾静脈に発生した平滑筋腫の1例を経験したので腹部超音波検査（以下，US）像を中心に報告する．症例は61歳，男性．検診のUSで膵腫瘍を指摘され，精査を指示されて当院を紹介受診となった．USで膵体部相当部に40mm大の境界明瞭，内部に高エコー域を混ずる低エコー腫瘤を認めた．膵管の拡張は無く，脾静脈は圧排され，周囲に側副血行路の発達を認めた．開腹所見で，腫瘍は膵からは容易に剥離出来たが，脾静脈と融合しており，脾静脈合併腫瘍切除術が施行され，病理組織学的に脾静脈原発平滑筋腫と診断された．RetrospectiveにUS像を見直すと，脾静脈にbeak signが見られ，腫瘍の発生部位を特定する着眼点と考えられた．

症例は60歳の男性で，乳頭部癌に対し，膵頭十二指腸切除術を施行した．肝腸間膜動脈幹から分岐する総肝動脈が上腸間膜静脈の背側から膵鈎部頭側にいたり，膵頭部膵実質を貫通していたが，膵実質を剥離して総肝動脈を温存した．腹側膵，背側膵は総肝動脈の走行部に連続する疎性結合織で隔たれており，発生に伴う肝動脈走向異常の形成が想定された．病理組織学的に中分化管状腺癌で，進行度はpT1，pN0，P0，M−，fStageIであった．肝門部腫瘍により術後32か月目に死亡し，この際行った剖検の結果，組織学的には高分化管状腺癌を示したことから，異時性肝門部胆管癌と判定された．乳頭部癌手術においては，術前から肝動脈走行を十分に把握することが重要であり，肝動脈血流の維持や重複癌を発生した際の治療も考慮したうえで，非浸潤癌においては肝動脈を温存，浸潤癌においては切除，再建することが必要と考えられた．

Although the outcome of surgery for locally advanced pancreatic cancer remains poor, it is improving, with 5-year survival up to about 10% in Japan. The preliminary results of our multi-institutional randomized controlled trial revealed better survival after surgery than after radiochemotherapy. We report the final results of this study after 5 years of follow-up. Patients with preoperative findings of pancreatic cancer invading the pancreatic capsule without involvement of the superior mesenteric or common hepatic arteries, or distant metastasis, were included in this randomized controlled trial, with their consent. If the laparotomy findings were consistent with these criteria, the patient was randomized to a surgery group or a radiochemotherapy group (5-fluorouracil 200 mg/m2/day and 5040 Gy radiotherapy). We compared the mean survival time, 3-and 5-year survival rates, and hazard ratio. The surgery and radiochemotherapy groups comprised 20 and 22 patients, respectively. Patients were followed up for 5 years or longer, or until an event occurred to preclude this. The surgery group had significantly better survival than the radiochemotherapy group (P < 0.03). Surgery increased the survival time and 3-year survival rate by an average of 11.8 months and 20%, respectively, and it halved the instantaneous mortality (hazard) rate. Locally invasive pancreatic cancer without distant metastases or major arterial invasion is treated most effectively by surgical resection.

In 1991, we started a clinical prospective trial for operable esophageal carcinoma, foreseeing organ preservation, to assess the treatment results after definitive chemoradiotherapy (CRT) for clinical Stage I (T1N0M0) esophageal cancer.Between 1992 and 2003, 63 patients were enrolled in this study. Tumor depth was mucosal cancer (T1a) in 23 and submucosal cancer (T1b) in 40. CRT consisted of 55-66 Gy/50-60 fractions (median, 59.4 Gy); from 1 to 3 cycles (median, 2) of concurrent chemotherapy (Cisplatin and 5-fluorouracil), followed by high-dose-rate intraluminal brachytherapy 10-12 Gy/2-3 fractions.The 5-year overall and cause-specific and disease-free survival rates were 66.4%, 76.3%, and 63.7%, respectively. The 5-year cause-specific survival rates for T1a and T1b cancer patients were 85.2% and 70.0%, respectively (p = 0.06). The 5-year disease-free survival rates for T1a and T1b were 84.4% and 50.5%, respectively (p0.01). Esophageal fistula as a late toxicity occurred in 2 patients (G4: 1; G5: 1), and esophageal stricture requiring a liquid diet occurred in 2 patients. Pericardial effusion was observed in 3 patients.We confirmed that patients with T1N0M0 esophageal carcinoma had their esophagus preserved in 89.2% of cases after definitive CRT, and the survival rates were equivalent to those of previous reports of surgery.

t2胆嚢癌切除症例を対象に漿膜下進展様式を中心に臨床病理学的所見を評価し,予後予知因子,再発様式を検討した.漿膜下進展様式は漿膜下腫瘍深達度(ss 1, 2, 3),腫瘍浸潤増殖様式(INFα, β, γ)およびこの2つの組み合わせ(ssINF-A, -B, -C)で評価した.結果,リンパ節転移(n), ss, INFはそれぞれ単独で予後予知因子となり得たがssINFはこれらよりさらに有効な予後予知因子であった.再発症例を検討した結果,拡大胆摘後に症例が肝転移再発死しており,肝床側にssINF-B, -Cに浸潤する症例ではS4, S5切除を含めた拡大胆摘術が必要であると考えられた.胆嚢頸部に腫瘍の進展を認めた症例のうち3症例に再発死亡を認めた.このうち肝門部胆管狭窄にて再発した2症例はssINF-A, -Bでリンパ節郭清時に胆管切除は行われていなかった.残る1症例は胆管切除を含めた拡大胆摘術が施行されており,肺転移再発した.これらの結果から胆嚢頸部に腫瘍が進展する症例に対してはリンパ節郭清時に胆管切除が必要であると考えられた.

We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.

Purpose: This retrospective study was designed to compare treatment results of the chemoradiation protocol with conventional surgery for thoracic T1-T2 esophageal squamous cell carcinoma. Methods and Materials: Sixty-six patients with esophageal carcinoma, clinically diagnosed as T1 (tumor invading lamina propria or submucosa) or T2 (tumor invading muscularis propria) were treated for 12 consecutive years, from July 1986 to January 1998. The conventional surgery group included 30 patients who underwent esophagectomy with regional lymph node dissection. Twenty-one of them received postoperative radiotherapy. Thirty-six patients were assigned to the chemoradiation protocol, consisting of neoadjuvant chemoradiotherapy (44 Gy; CDDP: 60 mg/m 2 , day 1, bolus; 5-FU: 400 mg/m 2 , day 1–4, continuous), followed by either definitive radiotherapy with high-dose-rate intraluminal brachytherapy (total 70 Gy) for responders or surgery for nonresponders as in the conventional surgery group. Surgical candidates in both groups received intraoperative radiotherapy for abdominal lymphatics since 1991. Results: In the protocol group, 4 patients underwent radical surgery after neoadjuvant chemoradiotherapy, and the remaining 32 underwent definitive chemoradiotherapy. Local control rates at 1 and 3 years were 85% and 70% in the T1/protocol group versus 91% and 80% in the T1/surgery group, and 83% and 83% in the T2/protocol group versus 94% and 80% in the T2/surgery group, respectively. There was no statistical significance. Overall 1- and 3-year survival rates were 100% and 83% in the T1/protocol group versus 82% and 72% in the T1/surgery group ( p = 0.36), and 100% and 51% in the T2/protocol group, versus 95% and 68% in the T2/surgery group ( p = 0.61), respectively. There was no treatment-related mortality in either group. The rates of esophageal conservation were 92% in the T1/protocol group and 58% in the T2/ protocol group. Conclusion: The chemoradiation protocol can result in comparable survival with conventional surgery for patients with T1-T2 esophageal carcinoma. A randomized trial between definitive chemoradiotherapy and surgery is required.

Purpose: A prospective clinical trial was undertaken to investigate the feasibility of concurrent chemoradiotherapy for esophageal carcinomas. Materials and Methods: Between June 1989 and May 1996, forty patients with operable squamous cell carcinoma of the thoracic esophagus (Stage 0 to III: UICC 1987), ages 45 to 78 years (mean: 64), were enrolled in a study of neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy (CRT group) or surgery (CRT-S group). Neoadjuvant chemoradiotherapy consisted of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 Fr/day) through 10-MVX rays, with 2 courses of cisplatin (80–100 mg/body, mean: 60 mg/m2, Day 1, bolus injection) and 5-fluorouracil (500–1000 mg/body/day, mean: 400 mg/m2, Days 1–4, continuous infusion). After completion of neoadjuvant chemoradiotherapy, an intermediate clinical response was assessed by barium swallow, esophagoscopy with/without biopsy, EUS in most cases, thoracic and upper abdominal CT scan, and cervical US. Definitive chemoradiotherapy was performed in patients when regression of more than 75% was evident (CRT Group), and esophageal resection was indicated in those who remained at less than 75% (CRT-S Group). In CRT Group, a cumulative dose of 60–70 Gy for Tis, T1 and 65–75 Gy for T2–T4 tumor with high-dose–rate intraluminal brachytherapy and a total of 3 courses of chemotherapy were planned. In CRT-S Group, intraoperative radiotherapy for abdominal lymphatic system and postoperative supraclavicular irradiation were added. Results: At the time of intermediate assessment, complete response (CR) was observed in 16 patients, a partial response (PR) in 22, and no change (NC) in 2. Thirty responding patients (CR, 16; PR, 14) entered the CRT Group, and 10 nonresponding patients (PR, 8; NC, 2) were followed by surgery (CRT-S Group). Radiotherapy was completed satisfactorily, but chemotherapy was suspended in 26 patients (65%) because of acute toxicity. Clinical CR rate at the completion of treatment showed 90% in CRT Group, and pathologic CR rate 10% in CRT-S Group. The overall median survival was 45 months, survival at 1, 2, and 3 years being 100%, 72%, and 56%, respectively. Local-regional failure was observed in 7 patients (all in CRT Group), distant failure in 6 (3 in CRT Group, 3 in CRT-S Group) and local-regional with distant failure in 1 (CRT Group). Four patients with local-regional recurrence in the CRT Group were salvaged by surgery. Overall survival at 2 and 3 years for CRT vs. CRT-S Group was 72%, 64% vs. 75%, 38%, respectively. No treatment-related mortality was observed. The rate of the ’esophagus conservation’ was 65% (Stage 0: 1 of 1, 100%; Stage I: 11 of 12, 92%; Stage II: 8 of 17, 47%; Stage III: 6 of 10, 60%). Conclusion: Our results demonstrated that almost all early disease (Stage 0–I) and about half of advanced disease (Stage II–III) could be conserved, their esophagus treated by the multidisciplinary approach centering on high-dose radiotherapy and concurrent chemotherapy.

We report herein the case of a women receiving tamoxifen therapy for breast cancer who developed vaginal bleeding, subsequently found to be caused by unusual endometrial polyps. Upon presentation, ultrasonography and magnetic resonance imaging (MRI) demonstrated a tumor within the uterus. A hysterectomy was performed, and macroscopic examination showed polyp-like lesions of the uterus. Histologically, these polyps demonstrated cystically dilated glands and stromal proliferation, and were diagnosed as endometrial polyps. Although tamoxifen has few side effects, any signs or symptoms of gynecological abnormalities should be carefully evaluated in patients on long-term tamoxifen therapy.

Twenty-eight patients with histologically proven pancreatic adenocarcinoma were investigated to evaluate the utility of serum CA19-9 levels as a prognostic indicator after pancreatic resection. Three patients were excluded from the study because their serum CA19-9 levels remained normal throughout the course of the disease. Of the remaining 25 patients, those with preoperative serum CA19-9 levels ≤200U/ml had a better prognosis than those with serum CA19-9 levels >200 U/ml; however, the difference between the two groups was not significant (P=0.13). Serum CA19-9 levels 30 days after pancreatic resection were normalized (≤37 U/ml) in 11 patients (group A), and the survival rate of this group was significantly higher than that of the group of patients with persistently elevated CA19-9 levels (>37 U/ml) (group B) (P

膵切除後に併発した膵液瘻に対し, ソマトスタチンアナログ (サンドスタチン ®) 投与が有効であった1例を経験した.症例は58歳の男性.9年前に皮膚筋炎と診断され, ステロイドによる治療が開始された.2年後に上部消化管内視鏡検査にて十二指腸乳頭部腫瘍の存在が指摘されたが, 組織診では腺腫と診断され経過観察となった.しかし, 今回施行した生検では腺癌と診断され, さらに, 便潜血陽性にて大腸内視鏡検査を施行したところ, 直腸癌の存在も認めた.皮膚筋炎に対してプレドニン内服中であったが, 膵頭十二指腸切除および直腸前方切除術を施行した.術後膵液瘻を併発し, 最高600ml/日に及ぶ排液を認めたが, サンドスタチン ® 100μg/回, 1日2回皮下注射にて, 約1週間で瘻孔の閉鎖をみた.本症例は, 術後膵液瘻の治療において, サンドスタチン ® 投与が有効であることを示唆する症例と考え報告する.

To develop a criterion to evaluate architectural changes of the subcutaneous tissue layer around the breast, 120 patients with histologically proven tumors were studied as to ultrasonographical delineation of the superficial layer (SL) of the superficial fascia. Breast ultrasonography was performed using an electronic-linear scanner with a 5.0 MHz probe. When SL was identified over the tumor, it was classified into 3 types: flat, disrupted, and convergent types. SL was identified in 106 patients (88%). Forty-six were evaluated to be flat type, and 41 (89%) of them had benign tumors. The remaining 60 were subdivided into either disrupted (n = 44) or convergent type (n = 16); 53 (88%) of these 60 cases had cancerous lesions. Histologically, inward retraction of SL was the most common pattern in breast cancer. Thus, the ultrasonographic pattern of SL reflects the histological findings and can be a useful clue to differentiate benign lesions from cancerous ones.

腸管膜動脈の循環障害に起因する小腸狭窄の1例を経験した.症例は61歳男, 腹部大動脈再建術後に下痢, 腹痛, 嘔吐を呈し, 腹腔内膿瘍と診断されて当科に入院した.排膿術を施行するも症状の改善を得ず, 腸閉塞症状が出現した.高カロリー輸液下に諸検査を行い, 血管造影で上腸管膜動脈根部の狭窄を認めた.虚血が関与する腸閉塞の診断で開腹すると, 回腸の一部が索状に狭窄し, これに沿う腸管膜は萎縮していた.狭窄部を切除し, 端々吻合して症状の消失をみた.病変部は肉眼的に瘢痕状で, 組織学的には腸管全層にわたる線維化と腸管膜動脈の閉塞性変化を認めた.本症は予後不良と言われるが, その改善のためには診断から治療にわたる栄養管理をはじめ, 適切な全身管理が肝要である.

Spontaneous rupture of the esophagus, Boerhaave’s syndrome, is a rare entity, and is often overlooked at ® rst. Its clinical and pathological features have frequently been described (1). Despite advances in supportive measures, delayed diagnosis and treatment still cause a high mortality rate (2). An early suture of the rupture, with adequate drainage of the mediastinum and pleural cavity, provides the best survival rates (3). Postoperative mediastinitis and empyema carry a grim prognosis. We report a case of Boerhaave’s syndrome, in which postoperative empyema was treated successfully by open chest drainage. The usefulness of open chest drainage is discussed here.

The methods and results of treatment for cancer of the cervical esophagus differ from those for cancer of the thoracic esophagus. Our objective was to retrospectively review the outcome for cervical esophageal cancer patients treated with radiotherapy. Twenty-seven patients with carcinoma of the cervical esophagus treated with definitive radiotherapy from 1988 to 2002 were enrolled in the study. Clinical stage (UICC 1997) was stage I in five, II in six, III in 12 and IV in four. Concurrent head and neck malignancy was found in six patients (22%). The mean radiation dose was 66 Gy. Concurrent chemotherapy (cisplatin and 5-fluorouracil) was performed in 23 patients. The actuarial overall survival rates at 1, 3 and 5 years were 55.6%, 37.9% and 37.9%, respectively, with a median survival of 13.9 months. In the patients with stage I, the 3-year and 5-year survival rates were 75% and 75%, respectively. With univariate analysis, only two of the possible prognostic factors were found to actually influence survival: performance status (p < 0.01) and tumor length (p < 0.01). The survival of patients with cervical esophageal cancer remains poor. It is thought that organ preservation is possible by definitive chemoradiation for early cancer.

Vascular lesions of the duodenum, including hemangioma, are rare causes of gastrointestinal bleeding. We herein describe a 52-year-old woman with a solitary cavernous hemangioma of the duodenum that caused chronic gastrointestinal bleeding. Repeated upper gastrointestinal endoscopy and a barium meal study revealed a solitary vascular tumor in the fourth portion of the duodenum, although the initial investigations including selective angiography were unsuccessful. A wedge resection of the duodenum was performed and microscopical examination showed a cavernous hemangioma. Vascular lesions should therefore also be considered in the differential diagnosis of patients with gastrointestinal bleeding of unknown origin.

A 39-year-old woman came to us complaining of severe anemia (hemoglobin: 2.3 g/dl) and a painful right breast that was entirely occupied by an ulcerative, foul-smelling tumor approximately 20 cm in maximum dimension. The tumor, which was determined to be mucinous adenocarcinoma at biopsy, had invaded the chest wall with multiple lung metastases (T4cN2M1 stage IV). After a blood transfusion, the patient received the following multimodal treatment: concurrent chemoradiotherapy (50 Gy), intraarterial infusion chemotherapy consisting of doxorubicin 50 mg, mitomycin-C 10 mg, and cisplatin 50 mg, and skin graft surgery. After intraarterial infusion chemotherapy, the fungating tumor disappeared. The patient experienced a relapse of right pleural effusion 2 years later and received multimodal treatment. Now, March 30, 2000, the patient is doing well without local recurrence, 8 years after her first admission. The combination of intraarterial infusion chemotherapy and radiotherapy plays a role in successful treatment of extensive local disease of the breast.

Mucinous carcinoma of the male breast is a rare histological type of cancer. We describe a 35-year-old male with mucinous carcinoma of the right breast. His breast mass enlarged subacutely, and became painful over a period of 2 months. Ultrasonography demonstrated echoes of a large multilocular cystic lesion with partially heterogenic internal echoes suggesting a phyllodes tumor. A modified radical mastectomy was performed, and histopathologic examination revealed mucin-producing solid or cribriform atypical cells with fibrous granulation tissue and hemosiderin deposition. The patient recovered uneventfully, and is still free of recurrence 30 months after his operation. The prognosis for male breast cancer can be improved by early diagnosis and appropriate multidisciplinary therapy.

We have been treating patients with operable thoracic esophageal cancer according to our own protocol. It includes the initial concurrent chemoradiotherapy (CRT) followed by continuous CRT or surgery. Patients with good response to initial chemoradiotherapy were allowed to continue chemoradiotherapy, whereas the others were treated with surgery. However, there were two cases which showed discrepancies in the clinicopathological response. Both patients received initial chemoradiotherapy, including two courses of cisplatin (100-120 mg), 5-fluorouracil (750-1000 mg for 4 days) and radiation (44-50 Gy). On completion of the initial chemoradiotherapy, all diagnostic imaging modalities including barium swallow, esophagoscopy, endoscopic ultrasonography and thoracic computed tomography strongly implicated residual tumor with a reduction rate of 40-50%. The patients underwent radical esophagectomy 15-20 days after initial chemoradiotherapy. Pathological specimens only revealed thickening of the esophageal wall due to inflammatory change without residual carcinoma. These facts suggest the current limitations of diagnostic images in evaluating the response to chemoradiotherapy.

We investigated results for thoracic T3-T4 esophageal squamous cell carcinoma in two strategies. The protocol group (46 patients) consisted of neoadjuvant chemoradiotherapy (44 Gy, CDDP, 5-FU), followed by either definitive radiotherapy (total 70 Gy) for responders or surgery for non-responders. The surgery group (26 patients) underwent esophagectomy with regional lymph node dissection. Nineteen of them received postoperative radiotherapy. Surgical candidates in both groups received intraoperative radiotherapy for abdominal lymphatics since 1991. In the protocol group, 23 patients underwent radical surgery after neoadjuvant chemoradiotherapy and the remaining 23 underwent definitive radiotherapy. The rates of recurrence were 64% in the protocol group, and 62% in the surgery group. Overall 3- and 5-year survival rates were 48% and 31% in the protocol group compared to those of 30% and 30% in the surgery group. The rate of theesophagus conservationwas 39% in the protocol group. There was no mortality in either group. Our protocol had at least comparable prognostic values with historical conventional surgery, and was excellent in having feasibility for organ preservation.

The factors influencing the healing process of pancreaticojejunostomy (P-J) following pancreaticoduodenectomy (PD) are still ill defined, allowing the recommendation of various anastomotic methods. We conduced a prospective study to determine the risk factors influencing the protracted healing of P-J, examining 100 consecutive patients who underwent PD followed by P-J, performed as an end-to-side “mucosa-to-mucosa” anastomosis using vertical mattress sutures (VMS method). Protracted healing of P-J was classified as either peripancreatic sepsis (PPS), defined as prolonged suppurative discharge of less than 50 ml a day from the drain beneath the P-J for more than 1 week; or a pancreatic fistula (PF), defined as prolonged discharge of more than 50 ml a day with a high amylase content (>1000 IU) for more than 1 week. There were 80 patients with a malignant neoplasm, and 20 with benign disease. The overall incidence of healing problems following P-J was 9%, which included 6 patients (6%) with PPS and 3 (3%) with PF. Apart from an advanced age of more than 70 years, none of the patients' characteristics or postoperative complications influenced the healing of P-J. The type of reconstruction, an anastomotic stent, the duct size, and a “soft” pancreas were not risk factors either. In conclusion, no factors, apart from the age or any special problem of an individual patient, influenced the dehiscence of P-J when the VMS method was used after PD.

Extrathoracic invasions or metastases from thymomas are extremely rare. We describe herein the case of a patient with malignant thymoma which recurred three times during an 8-year period and invaded directly into the peritoneal cavity, involving the gastrointestinal tract. The huge thymoma was completely resected, along with the fornix of the stomach, the transverse colon, and the 8th, 9th, and 10th ribs. Careful observation and multidisciplinary treatment against recurrent thymoma will be requisite for this patient, even though the tumor has been completely resected.

A prospective, randomized study was conducted to determine whether simultaneous infusion of lipid emulsion with an amino acid-dextrose-electrolyte solution would reduce the incidence of thrombophlebitis (TP) during postoperative peripheral parenteral nutrition (PPN). Thirty patients who had undergone gastric resection for adenocarcinoma were randomly divided into two groups according to whether they were infused with 10% lipid emulsion (group A) or 5% glucose solution (group B) simultaneously with the amino acid-glucose solutions. The total osmolarity of the infusion solutions in each group was 853 mOsm/l. The incidence of complications due to TP, namely, redness and/or edema beneath the cannula insertion site and/or pain, was investigated. There were no differences in the background characteristics of the patients in groups A and B, except regarding concurrent resection of other organs (P = 0.03). The incidence of edema in group A was significantly lower than in group B on postoperative days 2 and 4, although there was no difference in the incidence of redness and pain between the two groups. These findings suggest that the simultaneous infusion of lipid emulsion has a preventive effect against TP during postoperative PPN, and may be a practical means of providing PPN after gastrointestinal surgery.

Role of magnetic resonance cholangiopancreatography in diagnosing pancreatic cancer originating from the peripheral duct

TO THE EDITOR: Bezoars are large conglomerates or concretions of food or fiber in the alimentary tract, and infrequently cause intestinal obstruction. We describe here an unusual case of small bowel obstruction and concomitant perforated peritonitis caused by a "pseudo-phytobezoar" due to a seed from pickled plum.

A 38-year-old man with Crohn’s disease had been receiving total parenteral nutrition for 16 years, from the age of 22 years. At the age of 28 years, he had rapidly developing heart failure and ventricular premature beats associated with selenium (Se) deficiency. Laboratory data included a serum Se concentration of 62 μg/L (normal value, 80 to 230 μg/L), an erythrocyte Se concentration of 93 μg/L (normal value, 100 to 194 μg/L), and an erythrocyte glutathione peroxidase activity of 5.4 U/g hemoglobin (normal value, 25.3 to 45.3 …

In the period from January 1985 to May 1987, 68 patients with palpable breast cancers were studied to compare the size on ultrasonography with the size of the cut-surface of the resected specimen. Both the width (mediolateral size) and height (size in depth) were delineated as smaller on ultrasonography than on the cut-surface of resected specimens. The difference in size between ultrasonography and resected specimen was greater for the width than for the height. These results can explain why breast cancer has a greater ratio of height to width on ultrasonography. The ratio of the width on palpation to that on ultrasonography was also evaluated. These ratios proved to be useful in differentiating breast cancer from benign lesions.

A multivariate probit analysis was used to develop a prognostic scoring system known as the Prognostic Index (PI), which consisted of age, pulse rate, blood urea nitrogen, serum albumin, serum cholesterol and serum potassium. This PI accurately predicted the severity and mortality of 83 surgical patients with septic shock caused by gastrointestinal diseases, who were admitted to Tenri Hospital, Nara, Japan from 1975 to 1981 (internal check), and also that of 25 other patients, examined from 1982 to 1983 (external check). As the prognostic predictive model provides a prompt and easy prediction of how severe the patients' state is, it has proved to be very useful to our surgical staff for managing critically ill patients.

Ninety-seven histologically proven benign tumors and 96 breast cancers were studied to determine the relationship between the diameter measured by palpation and that by ultrasonography. A scatter diagram of the two variables provided a correlation coefficient of 0.95 in the benign group and 0.94 in the malignant group. The ratio of the diameter in palpation to that in the ultrasonogram (ratio of P/U) was 2.00±0.79 in breast cancers and 1.14±0.26 in benign tumors (p

Eight patients at school-age, from 12 to 17 years old, were surgically treated for Crohn's disease at Tenri Hospital, Nara, Japan. The relationship between operative results and their school lives were evaluated. Primary symptomes of the small intestinal type (6 cases) included abdominal pain (5), melena (1), and abscess formation in Douglas' pouch (1), and that of the colonic type (2 cases) mucinous-bloody stool (2) and anal fistula (1). Mean preoperative duration from the onset of the disease, except for 2 emergent cases, was 21.8 (ranged 8-46) months with mean cumulative hospitalizing duration of 8.6 (1-21) months. Four patients had recurrence, and in all 13 operations of 8 cases intestinal resections limited to macroscipical lesions. Mean postoperative disease-free term was 40.7 (ranged 5-168) months, during which all patients have completely finished curricula in schools. As now there is no effective treatment of Crohn's disease, physician should take school-aged patients back to the schools in disease-free state obtained by operations. An early return to the school might be important for mental or psychiatric development of the patient of this age.

We report a case of biotin deficiency developed in a 25-yr-old man with Crohn's disease who had been on total parenteral nutrition for more than 9 months. His cutaneous, ophthalmic, and neurologic manifestations were characteristic of this disease entity described in literature. In particular, the appearance of his face deserves to be called "biotin deficiency facies." After administration of biotin the low plasma nonesterified fatty acid level promptly returned to normal. This phenomenon may prove to serve as a convenient means for the purpose of detecting biotin deficiency. (Journal of Parenteral and Enteral Nutrition9:760-763, 1985)

Three cases of obstruction of the afferent loop following a Billroth II type gastrectomy were preoperatively detected by ultrasonography. The obstructions in the 3 patients were caused by volvulus, internal herniation and recurrence of gastric cancer, respectively. The important US findings which helped diagnose this condition were a dilated intestinal loop without gas echo in the upper abdominal cavity and echo lucent swelling of the pancreas. Ultrasonography is very useful for the early and easy detection of this life-threatening condition which requires immediate surgery.

Total pancreatectomy was performed for carcinoma of the head of the pancreas associated with multiple anomalies in the peripancreatic region and of the pancreas. The anomalies were preduodenal portal vein, annular pancreas with agenesis of the dorsal pancreas, left-sided gallbladder, polysplenia and high mobile right colon. The surgical implications of pancreatectomy for such anatomical abnormalities, especially preduodenal portal vein, and the usefulness of ultrasonography for the preoperative evaluation are given attention.