Skin Tube Reconstruction for Esophageal Defects due to Postoperative Complications: Applying a skin flap in esophageal resection and reconstruction

Numerous improvements and advances in operational methods and techniques have occurred in the area of reconstruction for esophageal cancer. Patients with thoracic esophageal cancer who have previously had a gastrectomy usually undergo reconstruction using the colon and small intestine. The incidence of organ necrosis is not necessarily low after reconstruction with those organs. Generally, the main types of skin flaps and musculocutaneous flaps used for cervical and other esophageal reconstructions are deltopectoral (DP) flaps, pedicled musculocutaneous latissimus dorsi flaps and free anteriolateral thigh flaps. This kind of reconstruction is low invasive, relatively simple, and also causes very few fatal post-operative complications. Therefore, it is considered to be an effective reconstruction choice for the following types of patients: poor risk patients, patients whose gastrointestinal (GI) tract cannot be used for their reconstruction for some reason, and patients having a second reconstruction due to complications caused by organ necrosis after their first GI tract reconstruction

Amino acid signaling in the intestine : The roles of glutamine, leucine and arginine

Amino acids have an influence on the function of organs, glands, tendons and arteries. Some of them play crucial roles in the control of gene expression by controlling the initiation phase of mRNA translation. Furthermore, recent studies have revealed that some kinds of amino acids directly participate in important signal transduction in the immune system. Glutamine, leucine and arginine play crucial roles in intestinal growth, integrity, and function through cellular signaling mechanisms. In this paper, we review amino acid signal transduction in the intestinal function

A case report of isolated presacral squamous cell carcinoma developed four years after gastrectomy

Chemoradiation therapy and a transsacral resection were performed to treat isolated squamous cell carsinoma that occurred in presacral tissues in the pelvis four years after gastrectomy due to early gastric cancer, with the prognosis continuing to be favorable. The patient was a 57-year-old woman, who came to our hospital having symptoms of anemia four years after gastrectomy. After a rectal examination, a tumor mass the size of a sparrowegg was discovered on the left rectal wall. An abdominal CT showed a tumor, 3.7cm × 3.7cm in size, on the outer left wall of the upper rectum. After a CT-guided biopsy, squamous cell carcinoma was detected. Irradiation (total 40 Gy) and chemotherapy (MMC+5-FU) were performed, mass shrinkage was confirmed, and a transsacral tumor resection was performed. According to the histopathological examination, a very small but viable cancer was found to be remaining. 4 years after the tumor removal, no recurrence has been discovered. Squamous cell carcinoma in the pelvis often originates from the vagina. However, the patient didn\u27t have any malignant findings from a genital examination at the time the symptoms appeared, and this case was diagnosed as isolated squamous cell carcinoma. A transsacral approach to remove such a tumor is considered to be useful because it is relatively low invasion and preserves anal functions

A Case of Cholesterol Crystal Embolization with Hemorrhagic Intestinal Ulcer

Cholesterol crystal embolization (CCE) is a rare systemic embolism caused　by formation of cholesterol crystals from atherosclerotic plaques. CCE usually occurs during　vascular manipulation such as vascular surgery or endovascular catheter manipulation, or　due to anticoagulation or thrombolytic therapy. We report a rare case of localized intestinal　ulcer with active hemorrhage caused by spontaneous CCE. An 83-year-old man with a history　of hypertension and diabetes was treated with a percutaneous coronary intervention (PCI)　for myocardial infarction. Melena occurred eight days after PCI. An abdominal computed　tomography revealed small intestinal ulcer, extravasation of the gastrointestinal tract and　bleeding in the abdominal cavity. The patient was diagnosed as bleeding from the small　intestinal ulcer, so an emergency laparotomy was performed. Partial resection of the small　intestine was performed. A histopathological examination indicated that small intestine　obstruction was caused by CCE. A histopathological examination indicated that small intestinal　obstruction was caused by CCE. Therefore, in cases of intestinal obstruction after vascular　manipulation, CCE should also be considered

Evaluation of intra-ductal cancer spread using contrast superb micro-vascular imaging (SMI) : a case report

Currently, breast conserving surgery has been adopted to treat more than half of all breast cancer patients in Japan. When performing breast-conserving surgery, an appropriate margin needs to be determined for radical cure. The resection volume influences the esthetic outcome, but a cancer-positive resection stump is also important risk factor of local recurrence. Additionally, the degree of cancer progression influences the surgical method, so understanding the appropriate resection margin is necessary for the surgeons. We report here on a 50- year old patient whose intra-ductal cancer progression was shown, as predicted, by contrast SMI (superb micro-vascular imaging). A one-cm size tumor mass was palpable with a clear boundary. B-mode ultrasound confirmed the presence of a breast duct towards the nipple from the tumor mass. Using contrast SMI, an accelerated blood flow was detected around the duct, which suggested intra-ductal progression. The pathological results also showed intra-ductal progression to the nipple from the tumor. Around the progression area, a meandering vessel was found and the vessel was able to be visualized by contrast SMI

肝転移を伴う胆嚢腺内分泌細胞癌の一例

症例は50歳代,女性.20XX 年1月ごろより前屈での心窩部付近の疼痛と右季肋部違和感を認めていた.同年3月初旬に疼痛が増強したため近医を受診し,CTで胆嚢に造影効果のある腫瘤と肝内の腫瘤陰影が認められた.肝転移を伴う胆嚢癌が疑われ,精査加療目的に当院へ紹介された.当院での画像検査でも胆嚢底部から体部にかけて約4.5cm大の隆起性病変を認めた.胆嚢底部では漿膜面が腫瘤に引き込まれ陥入している像を認め,肝床と一部で接しており境界不明瞭ではあったが,肝実質内への浸潤像は認めなかった.肝S4に約2cm大のリング状に造影される腫瘤を認め,肝転移が疑われた.ERCPでは胆嚢頸部,胆嚢管,総胆管への浸潤は認めなかった.胆汁細胞診はClass Vであった.単発の肝転移以外には遠隔転移を認めず,主要血管への浸潤も認めないため肝S4a+5切除,胆嚢摘出術,リンパ節郭清を施行した.切除標本では,病変は約4.5cm大の乳頭・結節型であり漿膜外まで浸潤していた(T3).組織学的には腺管構造を呈する腺癌とシナプトフィジン,クロモグラニンAが陽性の内分泌細胞癌が混在していた.肝転移巣は約2cmの結節・浸潤型であり,組織学的には同様にCD56強陽性,シナプトフィジン,クロモグラニンA陽性となる内分泌細胞癌が認められた(M1).リンパ節転移は認めなかった(N0).病理診断は腺内分泌細胞癌,UICC Stage-IVBであった.本症例は孤立性の肝転移を伴った胆嚢癌であったが,肝転移がS4であり,通常の胆嚢癌手術の切除範囲内であり,大きなリスクもなかったため,切除手術を行った.術後,gemcitabineとcisplatinによる補助化学療法を行った.A 57 year-old-female was referred to our hospital, because of an epigastric pain and discomfort for 2 months. Contrast-enhanced CT showed the tumor in the gallbladder body with a liver tumor in S4. An ERCP and other examinations showed no evidence of invasion to bile duct, vessels and other distant metastasis. It was diagnosed as the gallbladder cancer with a solitary liver metastasis. Preoperatively, we assessed that the curative operation might be possible. Then, we performed subsegmentectomy of liver S4a+5, cholecystectomy, and lymphadenectomy. The gallbladder cancer invasion remained extra serosa and no direct invasion to the liver tissue. Immuno-histochemical examinations showed that the tumor contained tubular adenocarcinoma and endocrine cell carcinoma with synaptophysin and chromogranin A positive. Also, the metastasis in liver S4 showed almost same results in synaptophysin, chromogranin A and CD56 positive. According to those results, she was diagnosed as mixed adeno - neuroendocrine carcinoma and Stage-IVB. Although she recovered uneventfully, she developped other liver metastases, 4 months after surgery. The chemotherapy including gemcitabine and cisplatin was introduced. Clinical cases of mixed adenoneuroendocrine carcinoma of gallbladder have been rarely reported. We present this case with a review of literatures

穿孔性腹膜炎を契機に発見された小腸GIST破裂の1例

症例は57歳の男性で,近医より急性虫垂炎の疑いにて当院救急外来へ紹介初診の際の理学所見にて下腹部正中に圧痛を認め,血液生化学検査では炎症反応の上昇を伴っていた.腹部造影CT検査にて圧痛部位に一致して小腸と連続した直径13cm大の巨大腫瘍を認め,腫瘍内部及び周囲腹腔内に遊離ガスを認めた.小腸腫瘍破裂による穿孔性腹膜炎の診断にて緊急開腹手術を施行したところ,トライツ靭帯より約30cmの空腸に連続した直径13.5cm大の腫瘍を認め,空腸内腔との交通を有する粘膜下腫瘍の形態を示し,腫瘍表面が一部破綻して穿孔していた.腫瘍を含めて空腸を部分切除し,腹腔内洗浄ドレナージを行った.摘出組織を検索するに,空腸粘膜に5mm大の瘻孔口が開口し,瘻孔は腫瘍内部に通じていた.腫瘍表面には線維性被膜を有し,内容は白色充実性で出血や壊死巣が存在し,組織学的観察では紡錘形細胞が索状に錯綜しながら密に浸潤増殖していた.免疫組織学的検討において,腫瘍細胞はc-kit陽性,CD34は一部陽性で,空腸原発のGastrointestinal stromal tumor(GIST)と診断した.核分裂像は3/50HPF程度で,MIB-1は約19%の細胞で陽性であった.術中の肉眼的観察及び術後のFDG-PETにて腫瘍の残存は認めなかったものの,小腸原発,腫瘍径,腫瘍破裂を伴うことから高リスク症例に分類され,術後補助化学療法の適応症例であった.穿孔性腹膜炎を契機に発見されたGIST症例は比較的稀ではあるが,小腸GISTは無症候で巨大化した後に発見されることが多く,他部位原発のGISTと比し予後不良である.本症例のような破裂を伴って診断される症例においては,再発の高リスク群に該当することから,術後補助化学療法の適応であり,また厳重なフォローアップを要する.A 57-year old man, who had complained of lower abdominal pain since the previous evening, was referred to our hospital with suspected acute appendicitis. Enhanced computer tomography scanning revealed a giant tumor (approximately 13 cm in width) connected to the small intestine and intraperitoneal free air in and around the tumor. The patient was given an emergency open laparotomy, due to a diagnosis of perforated peritonitis caused by a ruptured intestinal tumor. The ruptured tumor was located on the jejunum at 30 cm from the ligament of Treiz and appeared to be a type of submucosal tumor with a connective route to the jejunal lumen. We removed the tumor with the responsible jejunum and the resected tissue was subjected to further pathological examination. The tumor contained histologically infiltrative spindle cells with a mitotic ability of 3/50HPF; immunohistochemical examinations revealed positive c-kit, partially positive CD34, and 19% positive staining of MIB-1 in tumor cells, leading to the final pathological diagnosis of gastrointestinal stromal tumor (GIST) originating in the jejunum. Since this case was classified as a high risk case by the Miettinen risk table, Imatinib administration was given to the patient though postoperative FDG-PET examination showed negative for the existence of residual or metastatic tumor. Intestine-origin GISTs can be found as a large mass without any symptoms and thus lead to a poor outcome compared to those of stomach-origin. Enlarged GISTs would increase the possibility of rupture before radiographic recognition. Since ruptured GISTs are known to have a high risk of recurrence, we should take a definitive surgical treatment promptly and should give subsequent adjuvant chemotherapy with Imatinib

Appendiceal mucinous neoplasm: a review of eleven surgical cases in our institution

　虫垂原発粘液産生腫瘍は WHO 分類に基づき低異型度虫垂粘液性腫瘍（Low-grade appendiceal mucinous neoplasm，以下 LAMN）と粘液癌に分類される．当科にて2010年４月〜2018年11月までに外科的切除された11症例を集積検討した．　11症例の内訳は年齢が27～88歳（中央値61歳）で男女比は男７人，女４人であった．主訴は腹痛が６人で無症状が５人であった．病理診断での腫瘍最大径は３〜12 cm（平均5.9 cm）であった．術前より LAMN と疑われた症例は７例で，虫垂腺癌の術前診断に至った症例は１例であった．虫垂腫瘍との術前診断に至らなかった３症例のうち，虫垂炎の術前診断で虫垂切除術施行後に病理診断で判明したものが２例，十二指腸潰瘍穿孔で緊急手術を行った際に合併切除した虫垂組織より偶然発見されたものが１例であった．術式は虫垂切除のみが３例，回盲部切除が５例，右半結腸切除が３例であった．予定手術は６例で緊急手術が５例であった．最終病理診断（大腸癌取り扱い規約第９版に準拠）は LAMN が７例で虫垂腺癌が２例，粘液嚢胞が２例であった．術後入院期間は2〜47日（中央値12日）で，虫垂腫瘍切除に関連する術後合併症はなかった．LAMN は比較的稀な疾患であるが，腫瘍破裂により粘液が漏出することで腹膜偽粘液腫をきたす可能性がある．そのため，再発を引き起こさないためには①画像検査などでの術前診断（術中診断を含む），②術中に粘液漏出させない術式選択，③術後病理診断で判明した場合の追加治療の適否，についてその都度慎重に判断する必要がある．　LAMN は低悪性度腫瘍にも関わらず再発の危険性があるため，画像検査で疑った場合は再発防止を念頭においた術前評価と治療方針の策定が必要であり，切除後の厳重フォローも重要である．　Appendiceal mucinous neoplasm (AMN) is composed of mucinous adenocarcinoma and low-grade appendiceal mucinous neoplasm (LAMN) according to the fifth edition World Health Organization classification. Although AMN is relatively rare in clinical practice, we had eleven surgical cases of AMN from April 2010 to November 2018 and retrospectively review them in this report. The eleven cases consisted of seven men and four women, ages 27 - 88 years old (average: 65.5 y.o.). Six patients had abdominal pain upon their initial visit. Preoperative examinations made a presumptive diagnosis of LAMN in 7 cases and cancer of the appendix in 2 cases. In the other two cases, one was diagnosed after surgery for acute appendicitis, and the other was coincidently found in the appendiceal tissue that was resected during an emergent laparotomy for a perforated duodenal ulcer. Emergency operations were performed for 5 cases, whereas laparoscopic surgery was done in 4 of the cases. The following operative procedures were performed; 5 ileocecal resections, 3 right hemicolectomies, and 3 simple appendectomies. Pathological examinations concluded that 7 cases were LAMN, 2 were appendiceal adenocarcinoma, and the remaining 2 were hyperplastic mucocele. The length of hospital stay after surgery varied from 2 to 47 days (median: 12 days), with no apparent complications related to surgery in any cases. The most critical features of AMN are the potential to recur as pseudomyxoma peritonei, when the tumor is ruptured during surgery, or in case of tumor cells remaining at the resection stump. Since LAMN is specifically recognized to be low-grade malignant, several steps should be taken to minimize recurrence in addition to the standard postoperative follow-up on regular basis. These steps include assessing each preoperative state of disease adequately, selecting the most suitable procedure to reduce the risk of mucus leakage, and cautiously reviewing the necessity of additional resection based upon pathological determinations

Degos 病の関与が疑われた腸管気腫症の一例

症例は70歳代男性．既往に脳梗塞，パーキンソン病があり抗凝固薬を内服していた．デイサービス利用中に倦怠感および血圧低下を認め近医を受診し入院加療となった．入院２日目に40℃の熱発があり，腹部造影CT を施行したところfree air を認め外科的治療目的に当院へ救急搬送された．造影CT では肝彎曲部から脾彎曲部にかけての横行結腸に腸間膜気腫および腸管壁内ガスを認めた．明らかな腸間膜虚血および壊死を示唆する所見はなかった．消化管穿孔または腸管気腫症が考えられ緊急手術が検討されたが，腹部症状に乏しく液体成分など腸管内容の流出を示唆する所見がないことから一旦保存的加療を行った．また，体幹部を中心に小豆大までの皮膚潰瘍が多発していた．皮膚病理所見，既往および今回の病態からDegos 病と診断された．入院６日目に注腸造影および腹部CT を施行したところ，free air はほぼ消失しており，造影剤の腸管外漏出は認めず８日目に退院となった．Degos 病は皮膚の萎縮性丘疹を呈し，消化管の多発性潰瘍や穿孔，中枢神経系の出血や梗塞を特徴とし，病態としては末梢の血栓性血管炎が主体と考えられている．今回我々は，Degos病の関連が疑われた腸管気腫症の一例を経験したので文献的考察を加えて報告する．The patient was a 70 year-old-male. His past medical history was significant for cerebral infarction and Parkinson’s disease. He presented with malaise and hypotension and had been admitted to a local hospital three days ago. After admission，he had a fever of 40℃ and a computed tomography (CT) showed free air in the upper abdomen，he was referred to our hospital for an operation. A contrast-enhanced computed tomography also showed free air and pneumatosis intestinalis in transverse colon, with no evidence of mesenteric ischemia such as superior mesenteric artery occlusion (SMA) or non-occulusive mesenteric ischemia. Due to no abdominal pain and intraperitoneal fluid, we assessed that pneumatosis cystoides intestinalis was more probable than intestinal perforation. It was observed that the patient had many skin ulcers the size of red beans which were located around the chest and abdomen. A skin biopsy was performed，indicating Degos’ disease by a pathological exam. On day 6 of admission，we performed a barium enema exam and plain abdomen computed tomography (CT), it was seen that the free air almost disappeared and there was no leakage of the contrast medium. He was discharged on day 8. Patients with Degos’ disease present atrophic papula with perforation of intestinal or cerebral vascular accidents such as hemorrhage or infarction. This is considered a cause for bythrombotic angiitis of the peripheral vessels. We present a report with reference to the relevant literature