[Diaphragmatic hernia 3 years after the nephrectomy].

A 81-year-old man was referred to our department for the acute onset of dyspnea. Chest radiograph suggested a bowel shadow containing gases in the right chest. Computed tomography (CT) scan revealed the dislocation of the liver and the transverse colon in the right pleural cavity. Although the patient had no history of a blunt trauma, he had undergone the right nephrectomy for the renal cancer 3 years before. An emergency operation revealed the right lobe of the liver and the transverse colon profoundly entering into the right pleural cavity. The dislodged organs were gently restored through a dual approach, and the defect of the diaphragm was repaired with a prosthesis. The postoperative course was satisfactory. A diaphragmatic hernia sometimes occurs acutely and often shows life-threatening symptoms. The occurrence of the diaphragmatic hernia associated with previous surgery must be taken into account, when the procedure involved the diaphragm.

[Case of a giant pericardial cyst went under the thoracoscopic surgery using a double-balloon catheter].

A 45-year-old female was referred to our hospital due to right anterior chest pain. A chest X-ray and a computed tomographic examination showed a large cystic lesion in the right pleural cavity above the diaphragm. The internal surface of the cyst seemed to be smooth and the content was homogeneous suggesting clear liquid. Under the diagnosis of the benign pericardial cyst, a thoracoscopic surgery was performed using a double-balloon catheter. Aspiration of the cyst content by the double-balloon catheter minimized the spillage of the content into the thoracic cavity. Furthermore, the double-balloon catheter allowed the cyst wall to be more easily grasped and manipulated. We confirmed the usefulness of a double-balloon catheter for the thoracoscopic resection of giant cystic lesions.

Multidetector-row CT findings of colonic perforation: direct visualization of ruptured colonic wall.

BACKGROUND: We examined the findings of contrast-enhanced multidetector-row computed tomography (MD-CT) in patients with colonic perforation. METHODS: Abdominal contrast-enhanced MD-CT findings in six patients with colonic perforation were reviewed retrospectively. Patients (three men and three women) were 74 to 88 years old (mean age = 78 years). Colonic perforation was confirmed by surgery. CT findings were correlated with surgical and pathologic findings. RESULT: The site of colonic perforation was suggested by the following combination of CT findings: free air, dirty mass, dirty fat sign, extraluminal fluid collection, bowel wall thickening, and interruption of colonic wall. The ruptured colonic wall was directly visualized in four cases (67%). CONCLUSION: Abdominal contrast-enhanced MD-CT may improve the accuracy of diagnosis and localization of colonic perforation.

[Two delayed cases of traumatic diaphragmatic hernia].

This report concerns 2 cases with blunt traumatic hernia of the diaphragm. The diagnosis of these cases had been delayed by 1 month and 6 years, respectively. The former was a left sided case, which had suddenly suffered severe dyspnea. An emergency operation revealed the dislocated stomach into the left thoracic cavity. The latter was a right sided case, which was discovered by chance during the laparoscopic cholecystectomy. The right lobe of the liver dislocated into the right thoracic cavity. The delayed case of traumatic diaphragmatic hernia tends to be overlooked without suspicion. In all patients with thoracoabdominal blunt injury, a rupture of the diaphragm must be suspected.

Pulmonary carcinoid found in a patient who presented with initial symptoms of brain metastasis: report of a case.

Although atypical pulmonary carcinoids frequently metastasize to regional lymph nodes, they rarely metastasize to the brain. We describe herein an extremely unusual case of a 52-year-old woman who presented with the symptoms of brain metastasis as the initial manifestation of an atypical pulmonary carcinoid. After control of the multiple metastatic brain lesions had been achieved by tumorectomy and stereotactic radiosurgery, a middle lobectomy of the right lung was performed to completely resect the primary pulmonary carcinoid. This aggressive surgical approach was successful in that it prolonged the survival of the patient and enhanced her quality of life.

[An operative case of spontaneous rupture of the esophagus 10 days after the onset].

This paper presents a rare case of spontaneous rupture of the esophagus operated on 10 days subsequent to its onset. A 69-year-old male, who was diagnosed as acute pancreatitis, came to this department after 10 days of conservative therapy. Emergency examination including computed tomography, esophagoscopy and esophagography indicated spontaneous rupture of the esophagus. At operation, despite severe inflammation of the pleural cavity, a 2 cm horizontal tear at the left wall of the lower esophagus could be directly closed, and reinforced with fibrin glue. Postoperative decompression therapy prevented the rupture of the closure. The early symptoms resemble other emergency diseases, thus making correct diagnosis difficult. Early management is required for lifesaving, and preoperative aggressive exploration must thus be conducted. Postoperative management including through decompression of the gastrointestinal tract is also essential, regardless of the mode of operation.

Clinical abnormalities in adults with pancreaticobiliary maljunction with and without bile-duct dilatation.

OBJECTIVE: To study clinical diseases associated with pancreaticobiliary maljunction with or without bile-duct dilatation. DESIGN: A retrospective study over 16 years. SETTING: A single university surgical service in Japan. PATIENTS: Thirty-three patients with pancreaticobiliary maljunction. MAIN OUTCOME MEASURES: Gallstones and cancer in patients with and without bile-duct dilatation. RESULTS: Twenty-five patients had dilatation of the bile duct, 8 did not. Seven (28%) of the 25 patients with bile-duct dilatation had gallstones compared with 1 (12%) of the 8 patients with no dilatation. Seven (88%) of the 8 patients with no dilatation had carcinoma (all of the gallbladder), but only 3 (12%) of the 25 patients with bile-duct dilatation had carcinoma (1 of the gallbladder, 2 of the bile duct). CONCLUSION: Prophylactic cholecystectomy is recommended for patients with pancreaticobiliary maljunction and no dilatation of the bile duct because of the high incidence of gallbladder cancer.

Late massive hemorrhage following cystogastrostomy for pancreatic pseudocyst: report of a case.

We report the case of a man who developed life-threatening massive gastric hemorrhage 3 months after undergoing cystogastrostomy for a pancreatic pseudocyst. After cystogastrostomy, the pancreatic pseudocyst became remarkably reduced in size, having the appearance of a shallow ulcer by barium study. However, tarry stools and hematemesis developed 3 months later, 6 days after which sudden massive hematemesis and melena occurred with severe hypotension. At emergency operation, a large artery at the bottom of the reduced cyst wall was found to have ruptured and hemostasis was achieved by suture ligation. The splenic artery was suspected as the bleeding point because a 95% abrupt stenosis was seen on angiography-performed the next day. Thus, the risk of hemorrhage occurring after internal drainage of a pancreatic pseudocyst even in the late postoperative period should always be borne in mind.

[Multi-organ ischemia due to traumatic lesion of the descending thoracic aorta--a case-report].

This is a case of severe ischemic and reperfusion multi-organ failure due to descending thoracic aortic rupture. A 25 year-old man received a hard blow on his chest in a traffic accident. Chest X-ray, CT scans and aortogram elucidated descending thoracic aortic rupture. Emergency operation was performed 18 hours after the injury. The aortic rupture, 4/5 of the aortic circumference with intact adventitia was seen. The descending aorta 22 distal to the left subclavian artery was repaired under cardio-pulmonary bypass with selective cerebral perfusion. Ischemia due to aortic occlusion with thrombus and reperfusion injury after reconstruction of the aorta connected with rhabdmyolysis and severe multi-organ failure. Intestinal necrosis required laparotomy on the 9th and 15th post operative day. The patient died on 15th postoperative day of multi-organ failure.

[A case of free jejunal graft for anastomotic recurrence after subtotal esophagectomy].

A case of anastomotic recurrence after a radical operation for thoracic esophageal carcinoma is presented. A 68-year-old male was treated by subtotal esophagectomy and esophagogastrostomy through retrosternal route. One year after the operation he experienced dysphagia and anastomotic recurrence was detected by an upper gastrointestinal series and fiberscopy. He was admitted to our hospital for radiation therapy. The response was poor and dysphagia wasn't disappeared after radiation therapy at a dose of 10,200 rad. He was consulted to our surgical department for operative therapy. Cervical esophagectomy, partial resection of gastric tube and free jejunal transplantation for the reconstruction were performed. He had been eating anything of food after the operation.

[Simultaneous operation for thoracic and abdominal lesions].

Successful simultaneous operation for thoracic and abdominal lesions was performed in three cases. A 70-year-old man with bronchogenic cyst and a 73-year-old woman with thymoma, who had also cholecystolithiasis respectively, underwent a cholecystectomy following resection of the intrathoracic tumors. A 69-year-old man with bronchogenic carcinoma and abdominal aortic aneurysm underwent a left upper lobectomy following aneurysmectomy and grafting using vascular prosthesis. Their postoperative courses were uneventful. One stage operation has the advantage of treating both lesions simultaneously and saving the patient from the physical and psychosomatic pain and the risk of a second procedure. If patients are properly selected, simultaneous operation for thoracic and abdominal lesions can be safely performed with a short hospitalization and less expense.

Extended central bisegmentectomy--an en bloc resection of hepatic segments 4, 5, 8 and 7: report of a case.

We herein present an example of an extended central bisegmentectomy in a patient with a large hepatocellular carcinoma. According to a magnetic resonance imaging study, the right hepatic vein was displaced and narrowed at its origin and a large inferior right hepatic vein was revealed. In this case, owing to the only slightly functional remaining hepatic reserve, an extended central bisegmentectomy was selected as the optimum treatment. The postoperative course was uneventful except for some bile leakage. Twelve months after operation, the patient is still alive and no sign of recurrence has been detected. The extended central bisegmentectomy is an en bloc resection of hepatic segments 4, 5, 7, and 8. When the large inferior right hepatic vein is present, segment 6 can be preserved even when the right hepatic vein is sacrificed at its origin.

[An operative case of empyema necessitatis].

A case of empyema necessitatis presenting a mass in the retroperitoneal space is reported. Computer tomography preoperatively revealed the transdiaphragmatic abscess with calcified capsule. The operation was performed by means of resection of the abscess together with overlying ribs. Dead space after resection of the lesion was filled up with intercostal muscles. Empyema necessitatis is rare after introduction of antituberculous drugs. However, recognition of this disease is necessary for an appropriate surgical management. Total resection of the abscess followed by filling of the dead space with the intercostal muscles should be considered as a useful alternative method.

Cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation.

The aim of this study was to delineate clinical features and prognosis of cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation, and to determine methods for managing the disease. A retrospective study of seven patients is presented. A further 27 cases from the Japanese literature were reviewed retrospectively with regard to method of treatment and prognosis. In 11 of 18 patients in whom staging was known the tumour was stage V, representing advanced disease. In seven of 34 cases curative operation was performed; only two patients survived for > 3 years. This poor outcome was due largely to delayed diagnosis of cancer of the gallbladder. Prophylactic cholecystectomy is recommended in patients with this anomalous junction without bile duct dilatation or a malignant lesion in the gallbladder, because of the high incidence of cancer of the biliary tract.

[Surgical repair of total anomalous pulmonary venous drainage--four adult cases of successful operation].

We have experienced four adult cases of total anomalous pulmonary venous drainage (TAPVD). They were three females and one male, age between 18-51 with a mean of 33.8. In Darling's classification, they constituted of three cases of type Ia and one type IV. Cardiac catheterization revealed 1.71-5.93 with a mean of 3.92 in Qp/Qs and 0.34-0.49 with a mean of 0.38 in Pp/Ps. The pulmonary to systemic resistance ratio (Rp/Rs) was then calculated as 0.02-0.15 with a mean of 0.09. All cases showed short route type of drainage vein in pulmonary arteriography. None of them had stenosis or obstruction in the drainage veins. The operation was composed of anastomosis between the left atrium and the common pulmonary vein, closure of the atrial septal defect (ASD), and ligation of the drainage vein. Gersony-Malm's method was adopted in two cases and the posterior approach in two cases in anastomoses between the left atrium and the common pulmonary vein. Intraatrial approach combined with posterior approach was tried in a case with small left atrium. The mean size of ASD was 43 mm (35-55 mm) in diameter. Patch closure was performed in three cases. Important factors in survival for adult TAPVD are large ASD and short route type drainage vein without stenosis. All of four cases had good results. The operation method is variable and an easier approach must be adopted.

[A retrospective study of ruptured abdominal aortic aneurysms--association with respiratory function and leukocytic granular elastase].

Fifty-two cases of abdominal aortic aneurysms including common iliac aneurysms operated on during July, 1981 and December, 1989 have been studied. They were divided into the following three of elective operation (n = 34), impending rupture (n = 5), and ruptured (n = 13) groups. Cases with abdominal operations without aneurysms were randomly selected as the control group (n = 12). Overall operative mortality was 9.6%, consisted of 30.8% of the ruptured, 20.0% of the impending rupture and 0% of the elective operation groups. Respiratory functions including FEV1.0%, V75, V50, V25 and V25/Ht were significantly lowered in the ruptured group. PaO2 of the ruptured group was also significantly lowered in comparison with both the control and the elective operation groups. Leukocytic granular elastase, playing a role of destruction of the elastin component in the pulmonary alveoli and the aortic media, was increased in the patients with ruptured aortic aneurysms, though the difference was not significant. The data suggested the possibility of aneurysm rupture in case with elevated leukocytic granular elastase. Surgery for abdominal aortic aneurysm, even in cases with decreased pulmonary function, should be considered aggressively to elimination of ominous result of aneurysm rupture.

[Congenital bicuspid aortic valve associated with aberrant coronary artery origin: a case report].

A 61-year-old man with congenital bicuspid aortic valve associated with aberrant coronary artery origin is presented. His aortic valve was severely stenotic with marked calcification. At the aortic valve replacement, it was found that the valve was markedly calcified and the bicuspid valve and both coronary ostia were very close to each other in a posteriorly positioned sinus of Valsalva. There have been a few reports concerning the combination of the bicuspid aortic valve and aberrant coronary artery origin, and it is well known that the bicuspid aortic valve more frequently accompanies short left main trunk or left coronary arterial dominance than a normal aortic valve. Some genetic mechanisms surrounding the coronary artery, aortic valve and aorta are suggested to occur with such anomalies.

[Pure aortic valve regurgitation due to congenital bicuspid valve--analysis of 7 cases and a report of 2 rare cases].

The congenital bicuspid aortic valves usually become stenotic with severe calcification or regurgitant due to infective endocarditis (IE). However, pure aortic valve regurgitation without calcification or IE may be occurred. We report seven these cases out of 30 bicuspid valved patients who underwent aortic valve replacements. Pathological findings of these resected valves revealed neither calcium deposit nor findings of infection, but commonly showed myxoid degeneration. They were operated on at the mean age of 39, while those with calcified bicuspid aortic valves had an average age of 56. Two rare cases in whom an anomalous fibrous band on the larger cusp attached to the aortic wall were also reported.

[A case report of abdominal aortic aneurysm complicated by left-sided inferior vena cava].

Left-sided inferior vena cava (IVC) was identified preoperatively in the case of abdominal aortic aneurysm. At operation, the left-sided IVC and bilateral common iliac veins were severely pressed by the huge aneurysm, and the walls of these vessels were thin and fragile at the site adhered to the aneurysm. Careful dissection around the common iliac arteries resulted in a successful operation. Without an awareness of such anomaly, accidental injury of IVC and the common iliac veins may occur. Preoperative diagnosis and accurate information from echography, CT scan, and venography of the vena cava are recommended in such rare cases.

[Membranous obliteration of the inferior vena cava in the hepatic portion--postmortem study of a rapidly deteriorated aged case].

A 67-year-old female of Budd-Chiari syndrome was rapidly deteriorated and died. Autopsy revealed membranous obliteration of the inferior vena cava in the hepatic portion with a small hole. The inferior vena cava and right hepatic vein contained fresh and organized thrombi. The left hepatic vein was patent and opened above the membrane. The onset and the clinical course of this case seem to be atypical, probably because of the patent left hepatic vein and a small hole of the membrane. We call attention such a rare case in managing Budd-Chiari syndrome.