Search

Highlights • We report a rare case of adenoma that developed after sigmoidocolocystoplasty. • There were 11 cases of oncogenesis after bladder augmentation in the literature, including our case. • We recommend routine surveillance cytoscopy and cytology for patients after bladder augmentation, although this remains controversial., Introduction We encountered a rare case of tubular adenoma developing after bladder augmentation. We here report our case as well as summarize reports in the literature on adenomas developing after bladder augmentation. Presentation of case A 23-year-old man came to our hospital for routine surveillance cystoscopy. He was born with a lipomyelomeningocele and neurogenic bladder with low bladder compliance, and hence his bladder was routinely emptied by clean intermittent catheterization. He was also treated with anticholinergic agents. However, because the patient’s neurogenic bladder was unstable, he underwent sigmoidocolocystoplasty when he was 8-years old. After the bladder augmentation, he was examined annually by surveillance cystoscopy. On cystoscopy, a 5-mm pedunculated polyp was found on the front side of the sigmoid colon cap. Therefore, we performed snare polypectomy together with electrocoagulation under cystoscopy. The patient’s final diagnosis was tubular adenoma (mild atypia) with no malignancy, as assessed by histopathology. There has been no evidence of recurrence after the polypectomy on routine surveillance cystoscopy. Discussion To the best of our knowledge, there have been 11 cases of adenoma occurring after bladder augmentation reported in the literature, including our present case. There are several carcinogenic pathways associated with colorectal oncogenesis. Adenomas that are larger than 1.0 cm in diameter with a marked villous component have a high risk of oncogenesis. Conclusion We believe that the early detection of carcinoma or adenoma and their treatment at an early stage is crucial. Therefore, we recommend routine surveillance cystoscopy for patients after bladder augmentation.

A boy with myelomeningocele who had sigmoidocolocystoplasty and ureteric reimplantation when 2-years old and normal annual cystoscopies, developed hematuria and abdominal pain with liver dysfunction 14 years postoperatively. Computed tomography showed a tumor on the left side of the augmented bladder, a large lymph node, and large multiple probable metastases in the liver. Cystoscopy 3 months earlier had been normal, but when repeated showed a tumor originating from the augmented sigmoid colon. Biopsy showed undifferentiated sarcoma. Despite chemotherapy, he died 3 months later. The diagnosis at autopsy was undifferentiated sarcoma originating from the sigmoid colon. We report the first case of undifferentiated sarcoma developing 14 years after sigmoidocolocystoplasty for meningomyelocele, and also review the 55 cases of post-bladder augmentation malignancy in the literature.

A 12-month-old boy presented with left scrotal swelling. The mass was irregular, soft, fleshy, and nontender. It adhered to the scrotal skin and gradually enlarged. Operative findings revealed a mass fixed to the scrotal fundus and diagnosed as angiomyolipoma. This is apparently the first report of scrotal angiomyolipoma in infancy.

Background/purpose We report the current status of patients who underwent augmentation cystoplasty (AC) at least 20 years previously. Methods Surgical history, incidence of urinary tract infection (UTI) and bladder stones, vesicoureteral reflux (VUR), urine cytology, renal function, a colon cancer tumor marker (carcinoembryonic antigen: CEA), and patient outcomes were assessed. Results Forty patients who underwent AC (mean age: 34.4 years; mean follow-up time: 24.3 years) were analyzed. Mean age at AC was 11 years. Incidence of bladder stones was 30%. There were no incidences of carcinoma after AC, and CEA levels were not increased. Ureteral reimplantation (URI) was performed in 21 patients. URI performed at the same time as AC was successful in 14 cases (93%) and unsuccessful in 1 (7%) because of persistent VUR. UTI developed after AC in only 1 patient (2.5%) with persistent VUR. This patient required unilateral nephrectomy 18 years after the AC because of repeated UTIs. Thirty-four patients (85%) were employed, and 4 (10%) were married. Two of the 19 female patients (11%) had experienced pregnancy and delivery. Five patients (13%) had mental disorders. Conclusion Ultra long-term follow-up suggests that AC is a safe procedure with manageable sequelae, although some mental health issues remain. Type of study Case series with no comparison group. Level of evidence Level IV.

症例は44歳の男性で, 1998年9月に左鼡径ヘルニアの疑いで当院に紹介された. 術前CT, 超音波検査で鼡径部に腫瘤が認められたため, 腫瘍切除術(精索合併切除)を施行した. 当初の病理診断ではmyofibroblastic sarcoma, low grade malignancyであった. 術後半年から約4年間, 自覚症状ないため受診されなかったが, 再受診時には左鼡径部に再発腫瘍を認めた. 手術所見では再発腫瘍は腹壁からS状結腸, 左尿管, 外腸骨動脈, 静脈, 膀胱壁への浸潤を認めた. 腫瘍摘出ならびに浸潤臓器の広範囲合併切除, F-F bypassによる血行再建ならびに腹壁再建を施行した. 再発腫瘍は脱分化型脂肪肉腫と診断, 初回病理標本も見直しにより同一腫瘍型であることを確認した. 術後は経過良好で現在3年経過したが再発はない. 本疾患は当初鼠径ヘルニアと診断されており, 診断, 臨床経過ならびに治療法において検討を要した症例であった.

当科では1996 年以降, 腹壁瘢痕ヘルニア症例に対してメッシュによる腹壁修復術を導入し, 現在ではほぼ全例に対してメッシュを使用している. 1996年以前は, 主に単純閉鎖法を行っていたが, 1996年以降はMarlex meshを導入, 腹膜の修復が困難な症例に対しては癒着防止用のePTFE面を有するComposix meshの使用を開始した. また, ヘルニア門の小さい症例に対しては鼠径ヘルニアに使用されているProlene hernia system (以下, PHS と略記) による修復術を行ってきた. しかし, ヘルニア門が4cm 以上の2 症例にPHSを使用した際, 術後半年にメッシュが塊状となり突出が認められた. ヘルニア門が3cm以下の症例では異常がみられなかったことから, ヘルニア門が3cm 以上の症例にはPHSを使用しないことを基本とした. 現在までのところメッシュ使用症例に関しては感染, 再発はない. 今後, メッシュの使用方法を確立していけば腹壁癜痕ヘルニアに対するMesh repairは基本術式になりうると考える.

Purpose: The effects of liposome-infused doxorubicin on C-1300 murine neuroblastoma were studied. The liposome surface was covered with polyethylene glycol to avoid migration toward the reticuloendothelial system and to prolong its presence in the bloodstream. Liposome-infused doxorubicin hydrochloride (DXR), an anthracycline was used as an anticancer antibiotic substance. Methods: Each AJ mouse was transplanted with 1 × 10 5 C-1300 murine neuroblastoma cells subcutaneously in the thigh. The experiment was conducted when the maximum tumor dimension was 1 cm. The control group was given only physiological saline solutions, the second group was given DXR alone, and the third group received liposomeinfused DXR (Lip-DXR). The survival and doubling times were measured. One, 12, and 24 hours after the injection the DXR concentration in the cardiac tissues was measured for statistical comparison. Results: The survival time of the mice was found to be 27 ± 5.10 days in the control group, 31.40 ± 3.15 days in the DXR group, and 43.86 ± 2.13 days in the Lip-DXR group. The Lip-DXR group showed the longest survival time. The tumordoubling time was found to be 9.07 ± 2.30, 10.75 ± 3.49, and 19.80 ± 3.26 days, for each group, respectively. When comparing the DXR concentration in the heart tissues, the Lip-DXR-administered mice showed significantly lower DXR accumulation in the cardiac tissues after 1 and 12 hours than the DXR-administered mice. Conclusion: This study proved that liposome-infused DXR could be used effectively on murine neuroblastoma (C-1300 tumor cell model) and may reduce the incidence of cardiac toxicity as compared with DXR alone.

Two adult cases of sliding inguinal hernia are presented. Adult sliding inguinal hernia is an uncommon disease in Japan because many surgeons are unfamiliar with its anatomy and pathogenesis. Therefore, patients with this type of hernia would usually undergo an operation for an other inguinal hernia type. We could not obtain a correct diagnosis before surgery because this disease is difficult to diagnose. The key points in this operation is perfect closure of the internal ring and strict repair of posterior inguinal wall. We should choose an approciate procedure to prevent recurrent hernia as this type is known to have a high rate of recurrence.

The extravasation of liposomes of different sizes into solid tumors after i.v. injection was visualized by in vivo fluorescence microscopy in mouse neuroblastoma C-1300-bearing mice. Liposomes composed of distearoylphosphatidylcholine/cholesterol (1/1 molar ratio) and 6 mol% distearoylphosphatidylethanolamine derivative of polyethyleneglycol (PEG) were prepared. The PEG-coated liposomes were fluorescently labeled with 1,1′-dioctadecyl-3,3,3′,3′-tetramethylindocarbocyanine perchlorate (DiI) as a liposome marker or with doxorubicin (DXR) as an aqueous-phase marker. Liposomes with an average diameter of 100–200 nm showed the greatest tumor accumulation. With time after injection of DiI-labeled liposomes, the tumor interstitial fluorescence intensity increased. Most fluorescent spots were located outside and around the vessel wall, indicating extravasation of intact liposomes. The perivascular distribution was heterogeneous. We also obtained the same fluorescence localization pattern with DXR released from extravasated liposomes after injection of DXR-encapsulated liposomes. No fluorescence from extravasated liposomes was detected in normal s.c. tissue; the fluorescent spots were observed only in the vessel wall. Our results indicate that small-size long-circulating liposomes are able to traverse the endothelium of blood vessels in tumors and extravasate into interstitial spaces. Moreover, encapsulated drug was released from extravasated liposomes in the tumor.

One hundred and fourteen cases of hypertrophic pyloric stenosis (HPS) were operated on at the department from 1968 to 1988. These 114 patients were divided into 5 groups according to operated period and compared with clinical feature, intraoperative findings and measurements of resected muscularis. Patients operated on within 14 days of birth were allocated to group I; patients from 15 to 30 days of birth, group II; patients from 31 to 60 days, group III; patients from 61 to 90 days, group IV; and patients later than 91 days, group V. Group I and II, namely patients operated on in neonatal period, disclosed better preoperative conditions and postoperative clinical course than those of group IV and V, especially group V. Accordingly, more careful pre and postoperative management should be given to patients undergoing operation in a later period.

Gross E–type congenital esophageal atresia associated with congenital esophageal stenosis is extremely rare. In a male infant born at 36 weeks of gestation, bubbly vomiting was noted after birth. X-ray films of the chest and abdomen showed coil-up sign of the nasogastric tube and gas in the stomach and small intestines were recognized, so gross C–type esophageal atresia was suspected and surgery was performed on the first day of life. Surgery revealed the presence of a tracheoesophageal fistula in the upper esophagus and membranous stenosis on the distal side.

A 14-year-old boy was brought to our hospital with abdominal pain and nausea after suffering a blow to the abdomen. A mass was felt in the right hypogastrium, and the patient was hospitalized for possible hematoma resulting from the abdominal trauma. Initially, we treated him conservatively and observed his course, but on the 20th day after trauma, enhanced computed tomography showed that the area of strong enhancement in the tumor was unchanged. Superior mesenteric angiography showed findings indicative of a pseudoaneurysm caused by the trauma, and surgery was performed 26 days after the injury. Laparotomy revealed a tumor with a clear boundary, thought to originate in the mesoappendix, without any sign of pseudoaneurysm. Histopathological examination confirmed that the tumor was an omental-mesenteric myxoid hamartoma. The patient had an uneventful postoperative course and was discharged from hospital on the 12th day after surgery. More than 5 years have elapsed since the operation and no sign of recurrence or metastasis has been recognized.

Congenital biliary dilatation (CBD) is a relatively rare disease and highly associated with hepatobiliary malignancies due to pancreaticobiliary maljunction. For the treatment of CBD, the standard surgical method is the excision of the entire extrahepatic duct with a hepaticoenterostomy. However, in recent years, there has been an increase in reports of cancer developing in the biliary or pancreatic duct after hepaticoenterostomy. In this report, we describe the postoperative complications and carcinogenesis in 50 CBD patients according to the method of reconstruction of the bile duct. Hepaticojejunostomy (HJ) was performed in 34 patients and hepaticoduodenostomy (HD) in 16. In the HJ group, there were 7 cases of ascending cholangitis (20.6%), 3 cases of choledocholithiasis (8.8%), 4 cases of anastomotic stricture (11.8%) and 1 case of cholangiocarcinoma (2.9%). In the patient with cholangiocarcinoma, all complications including ascending cholangitis, choledocholithiasis, and anastomotic stricture were present. In the HD group, however, 2 cases of ascending cholangitis (5.9%) were recognized although choledocholithiasis, anastomotic stricture or cholangiocarcinoma were not observed. No significant differences were found in incidences of these complications between HJ and HD. It is unclear which method of reconstruction has a higher risk of carcinogenesis, however, it can be stated that hepaticoenterostomy itself is indeed one of the risk factors for biliary tract carcinoma. In any event, as several researchers have pointed out, since the incidence of bile duct carcinoma after the resection of the extrahepatic bile duct in CBD patients is very high compared to natural control, a long-term follow-up of the patient is necessary.

Purpose: For diagnosis of infantile hypertrophic pyloric stenosis (HPS), ultrasonography (US) is a useful and objective diagnostic method. In the current study, pyloric diameter, muscular thickness, and pyloric length were measured in normal infants (n = 26) and infants which is an adequate (n = 57). Each score was assigned to relevant measurements, and diagnostic criteria obtained with a scoring system were prepared using statistical skills by the probit analysis. Methods: For scoring, points were given to relevant measurements in conformity with the probit analysis. Zero points were given to patients with no possibility of HPS, 1 point to those with less than 25% probability, 2 points to those with 25% or more but less than 50% probability, and 3 points to patients with 50% or more probability. Points were totaled, and analysis was performed. Results: The composite score was evaluated by probit analysis, and cases with a composite score of 2 or less were all included in the normal group, whereas those with a composite score of 3 or more were all in the HPS group. Both groups could thereby be 100% identified. Conclusion: US was able to diagnose cases with overall score of 2 or less as normal and those with overall score of 3 or higher as having HPS. In addition, after the current diagnostic criteria were prepared, preoperative diagnoses were performed prospectively using them for vomiting neonates and infants, and all cases were correctly discriminated and diagnosed. These findings indicate our ultrasonographic diagnosis criteria are useful for diagnosing HPS. J Pediatr Surg 35:1714-1718. Copyright © 2000 by W.B. Saunders Company.

Traumatic rupture of choledochal cyst is an extremely rare disorder. The current patient is a 4-year-old boy who fell in a bathroom and suffered a blow to the abdomen. Percutaneous transhepatic cholangiography revealed pancreaticobiliary maljunction. Inflammation of the peritoneal cavity was moderate. At first look, the choledochal cyst was excised and hepaticojejunostomy was performed. At this time, a rupture approximately 2 mm in diameter was recognized at the rear surface of the inferior part of the common bile duct.