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Background Non-traumatic mesenteric hematomas are usually well controlled, with no resulting symptoms. Herein, we report a case in which collapse of a large mesenteric hematoma, after rupture of a right colic artery aneurysm, caused small bowel obstruction and rapid absorption of the hematoma contributed to cholestasis. Case presentation A-44-year-old man presented with a sudden onset of severe right lower abdominal pain. Computed tomography (CT) revealed rupture of a right colic artery aneurysm and intra-abdominal bleeding. After embolization of the right colic artery aneurysm, a large mesenteric hematoma remained. As the patient had no symptoms, we elected to pursue conservative treatment. However, on day 16 post-onset, he developed right lower abdominal pain. On CT imaging, partial collapse of the wall of the residual mesenteric hematoma was observed, with visible leakage from the hematoma into the abdominal cavity, resulting in small bowel obstruction and cholestasis. Symptoms did not improve with conservative treatment, and we proceeded to surgical treatment on day 32 after onset. Intra-operatively, adhesions between the small bowel and the abdominal wall were identified and caused the small bowel obstruction. We proceeded with removing these adhesions and as much of the hematoma as possible. Although the small bowel obstruction improved after surgery, cholecystitis developed, and percutaneous transhepatic gallbladder aspiration was performed on day 45. The patient was discharged on day 70. Conclusions Collapse of a mesenteric hematoma can cause small bowel obstruction. Rapid absorption of the hematoma due to the collapse might contribute to cholestasis. A large abdominal hematoma might be a risk factor for failure of conservative treatment, and surgery might be required due to abdominal complications.

BackgroundIntussusception occurs when a segment of the bowel (the intussusceptum) telescopes into an adjacent segment (the intussuscipiens). Adult intussusception occurs rarely and often requires surgical resection for its treatment. We describe the case of an adult patient with extremely rare cecorectal intussusception treated using a novel combined transabdominal and trans-anal approach, which has not yet been reported in the literature.Case presentationA 71-year-old woman was transferred to our hospital for the treatment of upper abdominal pain. Physical examination, laboratory tests, and imaging inspections showed strangulated bowel obstruction induced by intussusception associated with the intra-rectal mass. We performed an emergency operation and treated the intussusception using a combined transabdominal and trans-anal approach. The intraoperative findings revealed bloody ascites and a potentially malignant tumor that had moved toward the anal side from peritoneal reflection. The tumor served as the lead point in the cecum with mobile cecum. After reducing the intussusception using the combined procedure, we removed the ileocecal portion. The intraoperative and histopathological findings suggested that cecum cancer with mobile cecum had caused the cecorectal intussusception. The patient had an uneventful postoperative course, except for postoperative pulmonary pneumonia.ConclusionTo the best of our knowledge, this is the first reported case of adult cecorectal intussusception due to cecum cancer with mobile cecum successfully treated using the combined transabdominal and trans-anal approach. This combined procedure may be useful in treating the intussusception where the lead point is distal from the peritoneal reflection.

Few articles have reported cases of perianal abscess due to ingested foreign bodies. Herein, we report a case of perianal abscess due to a long fish bone. A 72-year-old man who was toothless and wore a denture had a chief complaint of anal pain. His left-side buttock had swelling and redness. Computed tomography revealed a perianal abscess on his left-side buttock and high-intensity linear structure in the abscess cavity. We made a diagnosis of perianal abscess due to a fish bone and performed an emergency operation. We opened the abscess cavity and removed the 5 cm fish bone from the cavity. After drainage of the abscess cavity and antibiotic administration, he was discharged from our hospital on day 8. A long fish bone could cause perianal abscesses. Rapid diagnosis and ensuring fish bone removal are important to prevent sepsis.

症例は61歳の女性で, 11年前より真性多血症 (polycythemia vera; 以下, PV) と診断され内科的治療を施されていた. また, IgA腎症による腎不全にて人工透析, ステロイド療法を施行されていた. 強い腹痛を主訴に外来受診. 大腸穿孔による汎発生腹膜炎と診断された. 緊急手術を施行し, 直腸S状結腸移行部に楕円形の穿孔を確認, S状結腸切除, 人工肛門造設術を施行した. 宿便性大腸穿孔と診断された. 術後集学的治療を行い術後40日目に軽快退院となった. PVを合併した患者の手術成績は不良で, 緊急手術例もまれである. 文献的考察とともに報告する.

症例は75歳の女性で. 上腹部膨満感で来院. 内視鏡および胃透視検査でcushion signを呈する十二指腸球部から胃前庭部にかけて巨大な粘膜下腫瘍が存在した. CTでは十二指腸球部に径67×66mmの脂肪濃度を呈する境界明瞭な腫瘍を認めた. 脂肪腫と診断し. 腹腔鏡補助下胃幽門側切除術を施行した. 切除標本では十二指腸球部から幽門輪を超え胃に進入する12×6.5×3.0cmの広基性巨大粘膜下腫瘍であった. 病理組織学的検査では粘膜下に発生した脂肪腫と診断した. 50mmを超える十二指腸巨大脂肪腫の報告は過去に本邦では5例. 外国では9例の報告があるのみで幽門輪をまたいで胃にかかるものの報告はない. また. 腹腔鏡補助下に切除したものの報告も過去に2例のみである. 今回. 腹腔鏡手術が有効であった十二指腸巨大脂肪腫の1例を経験したので報告する.

乳腺線維腫症(fibromatosis)は稀な良性の乳腺腫瘍であり,線維芽細胞と膠原線維が形成する浸潤性増殖病変である.転移を生じることはないとされているが,臨床的に乳癌との鑑別が問題となり,また,その浸潤増殖形態より切除を行ってもしばしば局所再発をきたすとされている.症例は74歳,女性.昭和63年他院で右乳癌(T4n0M0 Stage III B)にてハルステッド手術が施行されていた.以後,近医で経過観察されていたが,左乳腺の画像検査で異常を指摘され平成16年1月当院紹介となる.画像上,左乳腺C領域に12×11mm大の腫瘤が確認され,乳癌が疑われた.細胞診を施行するも,確定診断にいたらず,平成16年1月超音波ガイド下マンモトーム生検を施行した.生検組織の病理検査で,乳腺脂肪細胞の間に触手様に造成した線維組織がみられており,また,細胞の異型性などはなく,増生する成分からfibromatosisと診断された.その後,患者自身の希望もあり経過観察としているが,診断後2年経過した現在,腫大傾向なく経過観察中である.

肉芽腫性乳腺炎(granulomatous lobular mastitis)は,乳腺原発の肉芽腫性病変の一つで稀な疾患とされる.腫瘤を形成し,しばしば乳癌との鑑別が重要になることがある.症例1は41歳,女性.平成14年12月頃に左乳房腫瘤を自覚し,近医で精査施行されるも,確定診断に至らず,マンモトーム生検を希望して平成17年3月当院を受診した.左C領域に大きさ20×15mm大,連珠型の弾性硬の腫瘤として触知された.既往歴として不妊治療にて胎盤性性腺刺激ホルモン,下垂体性刺激ホルモン, Gn-RH誘導体等のホルモン療法薬を投与されていた.平成16年7月,超音波ガイド下マンモトーム生検を施行.組織は巨細胞と周囲の類上皮細胞を伴った肉芽形成がみられ肉芽腫性乳腺炎と診断された.診断後2年経過しているが,再発することなく現在経過観察中である.症例2は51歳,女性.平成18年2月乳癌検診にてマンモグラフィーで異常を指摘された.超音波,造影CT, 穿刺吸引細胞診を施行されるも確定診断が得られずマンモトーム生検を施行した.症例1と同様の組織結果であり肉芽腫性乳腺炎と診断された.

A case of lipomatosis with the extensive lesion covering from the duodenum to colon, which presented with intussusception, is reported. A 49-year-old man was admitted to the hospital because of lower abdominal pain. Abdominal CT scan revealed intussusception in which the small intestine prolapsed into the lumen of the ascending colon and circular low density masses which seemed like lipoma in the ascending and descending colons. Intussusception was diagnosed, and a resection of ileocecal region was performed. During operation, multiple tumors were found in the entire small intestine. Reexamination performed after the operation offered the diagnosis of intestinal lipomatosis extending from the duodenum to descending colon. Intestinal lipoma is single in most cases, and multiple occurrence is extremely rare. There have been only 20 foreign cases and seven domestic cases of intestinal lipomatosis as far as we could review. This case appears to be the 8th case report. And only one case of intestinal lipoma extending from the duodenum to colon has been reported in foreign literature so far. This case is thought to be very rare.

Intestinal intussusption is primarily a disease of infants and occurs in adult in a relatively low frequency. Recently we experienced an adult case of idiopatic intussusption of the intestine. A 20-year-old man was seen at the hospital because of right lower quadlant pain. There was tenderness in the same region and a most probable diagnosis was appendicitis. With abdominal ultrasonography a diagnosis of iliocecal intussusption was made. During operation it was found that the cecum and terminal ileum was investigated into the ascending colon, but it was sponteniously released. We were not able to rule out a possible organic disease as a cause of the condition, and performed an ileocecal excision. No any lesion was detected in the excised intestine histopathologically. In a recent 11-year-old period a total of nine adult patient have been treated at the hospital, and two patients of them had an unknown cause. Eight out of nine patients underwent laparotomy, all of whom were definitely diagnosed as having an intestinal intussusption by preoperative abdominal ultrasonography. The importance of abdominal ultrasonography as a diagnotic tool should be emphasized.

The results of treating 12 consecutive patients with unresectable colorectal hepatic metastases with a hepatic arterial infusion of high-dose Adriamycin, 100–120 mg/m2, using hepatic venous isolation (HVI) and charcoal hemoperfusion (CHP) are reported herein. Adriamycin was administered over 5–15 min under extracorporeal drug elimination by HVI-CHP. HVI was percutaneously accomplished by either the double-balloon technique using a Fogarty occlusion catheter (8/22F) or a balloon-tipped catheter (16F). During the infusion, isolated hepatic venous blood was filtered by CHP and pumped into the left axillary vein. There were no lethal complications, and good hemodynamic tolerance to HVI-CHP was confirmed. Tumor liquefaction accompanied by a sharp decrease in serum carcinoembryonic antigen levels by more than 50% of pretreatment levels was observed in 6 of the 12 patients 1 month after treatment. Apart from chemical hepatitis, which developed in 11 (92%) of the patients, the Adriamycin toxicities were well controlled following the development of nausea and vomiting in 2 patients (17%), leukopenia

Background. We recently developed a novel system of direct hemoperfusion under hepatic venous isolation in an attempt to achieve high-dose intraarterial chemotherapy for patients with malignant liver tumors. We report here the results of treatment of these patients with advanced hepatocellular carcinoma. Methods. Adriamycin (100 to 150 mg/m2) was administered into the hepatic artery of 15 patients, under conditions of extracorporeal drug elimination by direct hemoperfusion under hepatic venous isolation. Hepatic venous isolation was accomplished mainly by the double-balloon technique with an occlusion catheter and a balloon catheter. The isolated hepatic venous blood was filtered by direct hemoperfusion and pumped to the left axillary vein. Results. During 5 minutes of adriamycin infusion, the mean drug extraction ratios of the direct hemoperfusion filters were 91%±9% (mean±SD). The amount of drug removed by the system was 26.4%±16.0% of the amount of drug administered. Two patients died, one of necrotizing pancreatitis and the other of hepatic arterial thrombosis. Both deaths were related directly to the hepatic arterial catheter. Other side effects included hemolysis related to the system of hemoperfusion (87%), chemical hepatitis (80%), leukopenia less than 3000/mm3 (67%), alopecia (33%), and nausea and vomiting (20%). Nine (64%) of 14 evaluable patients had objective tumor responses, with a median duration of response of 6.2 months. Conclusions. This approach offers an effective therapeutic option for patients with advanced hepatocellular carcinoma.

The efficacy of the femoro-hepatic arterial heated bypass in liver hyperthermia was evaluated using mongrel dogs (n = 4). Extracorporeal circuit contains a centrifugal pump and a heat exchanger consisting of warmer coils and a water bath kept at a temperature of 47C. Mean hepatic parenchymal temperature showed rapid and isolated elevation up to 42.8°C, while the mean rectal temperature remained less than 39.3°C. Therefore, we conclude that this method is simple and highly effective to perform regional liver hyperthermia.

A new simple technique consisting of direct hemoperfusion under infrahepatic inferior vena caval isolation for intraarterial chemotherapy of pelvic tumors is herein described. The inferior vena cava is occluded at the infrahepatic level by means of balloon inflation using a balloon-tipped catheter (16F), which is placed through the right greater saphenous vein. The isolated infrahepatic vena caval blood is withdrawn by a centrifugal pump through a catheter (16F) in the contralateral greater saphenous vein and is filtered by direct hemoperfusion during intraarterial infusion of anticancer drugs. Venous reentry is provided by the central lumen of the balloon-tipped catheter. This procedure was used sequentially on two different occasions to treat a patient with an extensive pelvic tumor. Good hemodynamic stability and a reduction of the systemic drug toxicities were confirmed in both trials. Therefore, we believe that this technique is technically feasible and highly effective in reducing systemic toxicities during high-dose intraarterial chemotherapy for pelvic tumors.

Xanthogranulomatous Cholecystitis is a chronic inflammatory disease of the gallbladder, a variant of the chronic cholecystitis. As xanthogranulomatous cholecystitis is occasionally seen with carcinoma of the gallbladder, the association with cancer is a controversial issue. A focal type of xanthogranulomatous cholecystitis is found simultaneously with gastric cancer diagnosed preoperatively. The resected specimen was genetically studied. Polymerase chain reaction amplification, single-strand conformational polymorphism analysis for mutation of p53 showed no abnormality indicating that less association with cancer in which the mutation of p53 is often seen. Etiopathologic factors of xanthogranulomatous cholecystitis might have relation with cancer, but xanthogranulomatous cholecystitis itself may not be the direct cause for cancer.

We investigated the effect of oxygen supply on hepatic cellular viability during cold perfusion storage of rat livers. A perfluoro-N-methyldecahydroisoquinoline (FMIQ) emulsion is used as an oxygen carrier. The composition of the perfusate containing 20 w/v% FMIQ is essentially the same as the University of Wisconsin (UW) solution except for the exclusion of hydroxyethyl starch. Rat livers were perfused at 4 degrees C for up to 24 h with either UW solution (group I, oxygenated; group II, unoxygenated) or FMIQ solution (group III, oxygenated; group IV, unoxygenated). After perfusion storage, the livers were reperfused with warm (37 degrees C) oxygenated or cold (4 degrees C) unoxygenated Krebs-Henseleit bicarbonate buffer, and nuclear trypan blue uptake was measured as the index of cell death. With warm oxygenated reperfusion, there remained less than 2% noviable parenchymal cells up to 24 h, regardless of perfusate or oxygenation. In UW-perfused livers, the proportion of nonviable nonprenchymal cells (NPC) increased progressively regardless of oxygenation, the values in groups I and II in the periportal field at 24 h being 39.9 +/- 4.7% (mean +/- SD) and 36.5 +/- 4.2%, respectively. By contrast, in FMIQ-perfused livers, dye uptake by NPC was significantly reduced with oxygenation (16.9 +/- 5.7% and 39.4% +/- 9.1% at 24 h in groups III and IV; P < 0.001). With cold unoxygenated reperfusion, livers in groups I, II, and IV showed a significant decrease of nonviable NPC, while those in group III showed no significant changes. These data indicate that oxygen supply during perfusion storage of the liver may ameliorate lethal injury to NPC precipitated during reperfusion.