Pyloric stenosis due to Crohn's disease.

Gastroduodenal involvement by Crohn's disease is relatively rare and occasionally causes pyloric stenosis, for which medical therapy may be ineffective and surgery may be required. We report on a 44-year-old man patient in whom corticosteroids had a marked effect in reducing pyloric stenosis caused by Crohn's disease. A proton-pump inhibitor was not effective, and Helicobacter pylori was negative.

Laparoscopic repair for perforation of duodenal ulcer with omental patch: report of initial six cases.

We report our initial experience with perforated duodenal ulcer treated by laparoscopic repair with omental patch in six patients, and the results are compared with those of other procedures retrospectively. The average operative time was 85.0 min, and the estimated blood loss was 13.7 ml. The estimated blood loss of laparoscopic repair was significantly less than that of gastrectomy (p < 0.01). However, although all patients with gastrectomy or open omental patch needed administration of analgesia, only half of patients require analgesia in laparoscopic repair. No postoperative complication was encountered, and the recurrence of ulcer was not recognized in a mean follow-up of 10 months. We recognized this procedure to be safe and feasible. Although a larger number of patients with longer follow-up is needed, this procedure may become one of the treatments for perforated duodenal ulcer.

Intra-operative assessment of lymph node metastasis for colorectal carcinoma.

We have evaluated the reliability of intra-operative diagnosis for lymph node metastases and assessed the clinical features affecting accuracy of the intra-operative diagnosis based on a review of operative and pathological records in 218 patients treated by curative surgery for colorectal carcinoma. The sensitivity and specificity for diagnosis of lymph node metastases was 74.2% and 54.5%, respectively. The clinically positive but pathologically negative [cN(+),pN(-)] lymph nodes group differed significantly from the cN(-),pN(-) group with respect to tumor size, gross appearance and depth of tumor invasion. In the cN(+),pN(+) group, the tumor was larger and depth of tumor invasion was more extensive than in the cN(-),pN(+) group. The postoperative survival curves showed a statistically significant difference between cN(-),pN(-) and cN(+),pN(-) groups (P<0.05). Our data suggest less than satisfactory results for the intra-operative diagnosis of lymph node metastases. Macroscopically, tumor size and gross appearance were important clinical characteristics affecting accuracy in the macroscopic diagnosis of lymph node metastases. Therefore, prophylactic lymph node dissection is recommended, regardless of intra-operative assessment of lymph node metastases.

Strip biopsy to treat esophageal granular cell tumor.

Esophageal granular cell tumors are rare neoplasms. We successfully treated a 35-year-old Japanese man with an esophageal granular cell tumor without any complications using strip biopsy. Endoscopic ultrasonography revealed a hypoechoic tumor with a diameter of 8 mm that was confined to the submucosal layer. A strip biopsy done with a two-channel endoscope completely resected the tumor. Six months later, no abnormal findings were recognized in the resected area. Therefore we propose that strip biopsy be considered as a viable alternative treatment for esophageal granular cell tumor, depending on the histologic character, tumor size, and depth of tumor infiltration.

Synchronous multiple colorectal adenocarcinomas.

BACKGROUND: The object of the present work was to characterize clinical features and the quality of preoperative examinations in patients with synchronous colorectal carcinomas, and to compare the incidence of associated benign polyps with our findings in patients with a single malignant lesion. METHODS: A retrospective evaluation of 225 patients with primary colorectal carcinoma revealed 9 cases (4.0%) of synchronous colorectal carcinomas. RESULTS: The synchronous colorectal carcinomas were located in the same anatomical segment in 7 patients and were divided into different segments in 2 patients. The accuracy of preoperative diagnosis was 55.6% by endoscopy alone and 66.7% by double contrast barium enema (DCBE) alone, while the rate was 77.8% when colonoscopy and DCBE were combined. There was a higher incidence of associated benign polyps in the group with synchronous colorectal carcinomas (55.6%) versus 28.7% for a single carcinoma (P < 0.05). The main reason why multiple lesions could not be identified preoperatively was that the distal lesions prevented examination of the proximal lesions. CONCLUSIONS: At the time of surgical resection, it is important to ascertain preoperatively whether or not a second lesion exists. If synchronous polyps are present in patients with synchronous colorectal carcinomas, they should be ablated to reduce the risk of metachronous colorectal carcinoma.

Recurrent pattern of digestive tract carcinoma in the Japanese: comparison of gastric cancer to colon cancer.

Six hundred and two consecutive cases of gastric cancer and 204 of colorectal cancer in recent decades were investigated for recurrence. Recurrence occurred in 103 cases of gastric cancer and 31 cases of colorectal cancer. We classified three categories of recurrent patterns; A: local, B: peritoneal dissemination, and C: distant metastasis. In gastric cancer, 11 cases (11%) were grouped A, 50 (48%) were B, and 42 (41%) were C. Similarly, 12 (39%) were grouped A, 5 (16%) were B, and 14 (45%) were C in colorectal cancer. The incidence of local recurrence was more increased in colorectal cancer than in gastric cancer (p < 0.01). On the contrary, that of peritoneal dissemination was more increased in gastric cancer than in colorectal cancer (p < 0.01). In gastric cancer, 8 cases of 103 survived more than 5 years after operation, furthermore 7 cases obtained more than 5 years of tumor-free interval. At the time of diagnosis of recurrence, data of serum CEA was available in 77 for gastric cancer and 29 for colon cancer. CEA positive cases were revealed 32 (42%) for gastric cancer and 24 (83%) for colorectal cancer (p < 0.01). Our data clarified the different recurrence patterns between gastric cancer and colorectal cancer. And suggest that more than 5 years follow-up should be needed in patients with gastric cancer.

[A case of nonresectable esophageal cancer treated by the combination of cisplatin, 5-fluorouracil and THP-adriamycin].

An advanced esophageal cancer patient with multiple liver metastases was treated with a combination of CDDP, 5-FU and THP-ADM. Complete response was obtained against esophageal primary lesion endoscopically, and partial response was obtained against liver metastases observed by computed tomography. Bone marrow suppression of grade 3 was observed, but resolved within 2 weeks.

A 94 year old male stage IV breast cancer patient showing complete remission under tamoxifen treatment after operation.

A 94 year old man with an invasive ductal carcinoma of the breast (T4N2M1, stage IV), underwent a modified radical mastectomy to improve his quality of life. The estrogen receptor status of both the breast tumor and the metastatic axillar lymph nodes was high. Immunohistochemical staining for epidermal growth factor, epidermal growth factor receptor, or c-erbB-2 protein was negative. The patient received only tamoxifen continuously for 3 months, and later apparently showed a complete remission. Therefore, in advanced male breast cancer with a high estrogen receptor status, operation in conjunction with hormone therapy may lead to a favorable result in some cases.

Clinicopathological significance of c-erbB-2 protein expression in human gastric carcinoma.

One hundred seventy-nine primary human gastric tumors not associated with early cancer or noncurative resection were examined immunohistochemically for the expression of c-erbB-2 protein. Positive staining, regarded as an indication of gene amplification, was evident in 22(12%) of the tumors. Of various clinicopathological factors considered, a statistically significant difference in association with frequency of expression was noted only for histological differentiation, as follows: 39% positive staining in papillary, 17% in well differentiated, 5% in moderately differentiated, and 4% in undifferentiated adenocarcinomas (P greater than 0.01). The 5-year survival rates of patients with positive and negative c-erbB-2 staining were 57% and 59%, respectively. These findings indicate that, in the case of human gastric adenocarcinoma, expression of c-erbB-2 protein is correlated with tumor histological differentiation. Our results also suggest that the presence or absence of c-erbB-2 protein may not serve as a prognostic indicator, particularly in cases of adenocarcinoma of the stomach.

Recurrence in early gastric cancer.

In a retrospective study of 503 cases of early gastric cancer, 17 of the patients had died of a recurrence of the gastric cancer and 72 had died of unrelated causes. The cumulative recurrence mortality rates were 2.2% at 9 years for mucosal cancer and 8.4% at 8 years for submucosal cancer. The recurrence patterns of early gastric cancer were hematogenic metastasis to the liver, lung, or bone (nine cases), recurrence from lymph nodes (three cases), and recurrence in the residual stomach (five cases). Submucosal cancers with a macroscopically elevated appearance, lymph node metastasis, and evidence of vessel invasion were the high-risk cancers for hematogenic recurrence, and adjuvant chemotherapy should be prescribed. Two cases of lymph node recurrence were attributed to inadequacy of lymph node dissection. Because metastasis to the group 2 lymph nodes was noted in 1.5% of cases of early gastric cancer and a macroscopic diagnosis of nodal status was inaccurate, complete dissection should be performed regardless of identification of metastasis. Five cases of recurrence in the residual stomach were attributed to overlooked lesions of multiple carcinoma and were detected at an advanced stage. Careful and regular postoperative follow-up is required to detect these recurrences at an early stage.

Ruptured amebic liver abscess.

We treated two patients with a ruptured amebic liver abscess. The diagnosis was made at a relatively early stage and treatment was successful for one patient, but an accurate diagnosis of liver abscess was not made and invasive extraintestinal amebiasis led to multiple organ failure and to death for the other. Neither patient had been outside of Japan, and both were heterosexual. The origins of Entamoeba histolytica infection could not be determined. Though the mortality rate is high in cases of ruptured amebic liver abscess, appropriate management can lead to a good prognosis.