Acute acalculous cholecystitis (AAC) is said to occur in patients with severe illness under observation of the clinical course in a high incidence. However, the so-called de novo AAC has recently been increasing even in outpatients. We experienced two such cases of de novo AAC. Case 1: A 71-year-old male was seen at the hospital because of upper abdominal pain, fever and dyspnea. Abdominal ultrasonography revealed an enlarged gallbladder but no gallstones were found. A diagnosis of biliary peritonitis complicated by multiorgan failure was made. Cholecystectomy was performed, followed by T-tube drainage. Postoperating, transient hemodialysis was required. Case 2: A 58-year-old male with a history of heart disease was seen at the hospital because of lower right abdominal pain. With ultrasonography, thickening of the wall of the gallbladder and ascites were found. Cholecystectomy was performed. Both patients had biliary peritonitis. No gallstones or bile sludge were present in their gallbladders. Histologically, severe inflammation with partial necrosis was observed.
A 10-year-old boy sustained a blunt injury to the pancreatic neck with complete transection of the main pancreatic duct. Because endoscopic catheterization across the rupture site was not possible, an endoscopic nasopancreatic drain was inserted through the proximal pancreatic duct into the retroperitoneum. An emergency laparotomy was carried out, during which time the tube was used as a guide for identifying disrupted pancreatic ducts. Damaged tissue was removed, the proximal pancreatic duct was ligated, and a Roux-en-Y distal pancreaticojejunostomy was carried out.The patient was discharged 49 days after surgery.Preoperative catheterization of the transected pancreatic duct is an option for detecting a disrupted main pancreatic duct.
Clinical problems in the preoperative diagnosis of breast cancer were investigated in a total of 197 patients treated at our institute during a period from April 1987 through December 1989.The final diagnosis, by combination of clinical examination, mammography (MMG), ultrasonography (US) and aspiration biopsy cytology (ABC) resulted in malignant in 79%, suspicious in 20% and benign in 1.0%. Twenty of 62 cases (32%) in which clinical examination failed to diagnose as malignant were demonstrated as malignant by MMG, US and ABC, and the remained 42 cases were confirmed by open biopsy.Although mammographic visualization of breast masses was affected by the amount of each breast parenchyma and there were 29% of cases nonevaluative by MMG, MMG was found to provide the most accurate diagnosis of microcalcification. Ultrasonographic diagnosis was significantly affected by the degree of both obesity and histological vessel invasion of a tumor which influenced ultrasonographic diagnosis of marginal findings of the tumor. ABC contributed considerably to the diagnosis of breast masses alternative to open biopsy and also showed high accurate diagnostic rate for small breast masses in combination with US. Open biopsy was essential especially in the diagnosis of noninvasive breast cancer and it was useful to measure the level of CEA in nipple discharge when determining open biopsy (microdochectomy) for pathological diagnosis.
A 69-year-old man underwent a complete pancreatectomy in March 2002 because of cancer of the body of the pancreas. Two months after surgery, the patient had multiple metastases to the liver, abdominal recurrence, and an elevated cancer antigen (CA) 19-9 level. Combination chemotherapy with gemcitabine and UFT was administered on an outpatient basis. Chemotherapy consisted of biweekly gemcitabine (1,000 mg/m(2)) and daily UFT (300 mg). After 3 months of treatment, a computed tomographic scan of the liver showed marked shrinkage of metastatic lesions, accompanied by a decrease in the CA19-9 level. The patient spent most of his time at home and worked as usual; his quality of life was maintained. The only adverse event was transient leukopenia (grade 2). He died of peritoneal dissemination in August 2003 (15 months after recurrence). Our experience suggests that combination chemotherapy with gemcitabine and UFT may promote tumor dormancy and relieve symptoms in patients with liver metastasis after surgery for pancreatic cancer or with recurrence of metastasis.
An 8 1/2-year-old male is described with the rare triad of acquired adrenal insufficiency, esophageal dysfunction, and alacrima. In addition, he had velopharyngeal insufficiency, which is a previously unreported feature of this syndrome. Although the pathophysiology of this disorder remains to be demonstrated, a defect may be present, linking hormone-receptor cyclic AMP-mediated processes with abnormalities in parasympathetic and voluntary neuronal innervation or transmission.
This study was conducted to define the clinical significance of intraoperative determination of carcinoembryonic antigen levels in peritoneal washes from patients undergoing surgery for colorectal cancer.The correlation of carcinoembryonic antigen levels in peritoneal washes (pCEA) with several clinicopathological factors and the long-term surgical outcome in 54 patients with resectable colorectal cancer was determined retrospectively.Among several clinicopathological factors, the depth of tumor invasion significantly and independently correlated with pCEA levels as revealed by multivariate stepwise logistic regression analysis. A significant difference in overall survival rates was observed between pCEA-positive and pCEA-negative groups: five-year survival rates were 97.1% in pCEA-negative patients and 78.9% in pCEA-positive patients (p = 0.0274).Intraoperative determination of carcinoembryonic antigen levels in peritoneal washes could be a potentially predictive factor of a poor prognosis in patients with colorectal cancer.
The incidence of fibrous dysplasia (FD) is not frequent in the case of benign bone tumors of the chest wall, and differential diagnosis between FD and the malignancy on the basis of imaging findings is difficult. We report a case of a painful FD lesion (size, 9×8 cm) that originated from the 5th rib of a 52-year-old man and was surgically resected. His symptoms improved after the operation. Painful and large FD lesions should be resected because of a difficulty in differential diagnosis from malignant tumors.
Adrenal myelolipoma is a rare, nonfunctioning, and benign tumor composed of varying proportion of fat and bone marrow elements. A case is presented of a thirty-six-year-old woman in whom the diagnosis of adrenal myelolipoma was suspected preoperatively by ultrasonography, computed tomography, and magnetic resonance imaging (MRI). The patient cured by surgery. Histological examination showed mature adipose tissue and normal hemopoietic tissue. This is the first report which describes MRI of adrenal myelolipoma in Japan.
We studied the usefulness of three dimensional helical CT (3D-CT) combined with drip infusion cholanigoiography for determining the application of laparoscopic cholecystectomy (LC) and evaluating the cholecyst severity. The subjects were 56 patients who underwent LC with preoperative 3D-CT. Paticularly, in 42 patients undergoing endoscopic retrograde cholangiography (ERC) and 3D-CT simultaneously, the results with both methods were compared. The detection rates of the orginal site, forward and backward direction, and left and right direction in the confluence form of the cystic duct by means of 3D-CT versus ERC were 100% vs. 92.9% 92.9% vs. 71.4%, and 92.9% vs. 88.1%, respectively. Abnormal biliary distribution was visualized in 5 cases and all of them were depicted by 3D-CT. The 3D-CT was superior to ERC in terms of X-ray dose and cost. These results indicate the usefulness of 3D-CT as a LC preoperative examination.
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