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Purpose The purpose of this study was to compare 27-gauge (27G) with 25-gauge (25G) microincision vitrectomy in patients with epiretinal membrane (ERM). Participants Seventy-four eyes of 66 patients undergoing 3-port pars plana vitrectomy using 27G or 25G instrumentation. Methods Seventy-four eyes of 66 patients with ERM, who underwent 27G or 25G microincision vitrectomy were prospectively evaluated. Results The mean operation time for vitrectomy was significantly longer in the 27G group than in the 25G group (9.9±3.5 vs 6.2±2.7 min, respectively, P

Aims: Invasive micropapillary carcinoma (IMPC) is associated with frequent lymph node metastasis and adverse clinical outcome. IMPC has been reported in breast, urinary bladder, ureter, lung and parotid gland but not in colon. We present the clinicopathological features of three cases of primary IMPC of the colon with a review of the literature. Methods and results: The patients (one man and two women) were 53, 67 and 68 years old, respectively. The size of the tumour ranged from 20 to 100 mm in diameter. Histologically, all cases were composed predominantly of papillary tumour cell clusters with spaces in a background of fine fibrocollagenous stroma. One of the tumours (case 1) was nearly completely composed of IMPC, but the other two were associated with foci of adenocarcinoma and concurrent mucinous carcinoma, respectively. MUC1 was positive in all cases, suggestive of reverse cell orientation which is responsible for its unique histological features. Conclusions: We report three cases of primary IMPC of the colon. Its clinical significance remains undetermined but the presence of this component may represent a poor prognostic factor.

There have been no reports that low serum cholesterol levels increase the risk of colorectal adenoma, although many studies have shown that they do increase the risk of colorectal cancer. Alcohol intake, which is associated with a risk of colorectal adenomas, and serum cholesterol levels are closely related. The purpose of this study was to evaluate the influence of alcohol consumption on the association between serum cholesterol levels and colorectal adenoma.The subjects were 1,349 male patients who underwent both barium enema examination and total colonoscopy. They answered a questionnaire regarding their alcohol consumption history, and their blood samples were analysed. The subjects were divided into three groups: those with no tumour (with neither adenoma nor adenocarcinoma), those with adenoma and those with adenocarcinoma. Among the groups, the serum total cholesterol and triglyceride levels were compared in all the patients, in the patients who did not drink daily and in the patients who did.In all the patients, the serum cholesterol and triglyceride levels did not differ between the patients with and those without adenoma. In the daily drinkers, the serum cholesterol and triglyceride levels were significantly lower in patients with adenoma than in those without.Significantly lower levels of serum cholesterol and triglycerides were found in daily drinkers with adenoma than in those without.

We studied benign and malignant hepatic tumors with color Doppler sonography and arteriography in order to correlate color Doppler flow characteristics with tumor hemodynamics (vascularity, arteriovenous shunting, and portal vein involvement) shown by arteriography. We also evaluated the usefulness of color Doppler flow characteristics in discriminating between tumor types.We performed color Doppler sonography and hepatic arteriography in 58 patients with 72 hepatic lesions larger than 2.0 cm in diameter. Differences in pulsatile flow (peritumoral or intratumoral) and the highest systolic peak flow velocities reached were evaluated on color Doppler sonograms and compared with arteriographic findings.Color flow sonograms were obtained in 43 of 45 hepatocellular carcinomas, 15 of 16 cholangiocellular carcinomas or hepatic metastases, and six of 11 hemangiomas. Mixed peritumoral and intratumoral pulsatile flow was shown by arteriography in highly vascular tumors. The mean peak systolic flow velocity seen in hepatocellular carcinomas (0.52 m/sec) significantly exceeded the velocity seen in hemangiomas (0.16 m/sec), but not the velocity seen in other malignant hepatic tumors (0.51 m/sec). Six hepatocellular carcinomas, one cholangiocellular carcinoma, and two hepatic metastases with peak systolic flow velocities greater than 0.80 m/sec were each proved arteriographically to have arteriovenous shunting or portal vein involvement.Color Doppler sonography was useful for evaluating hepatic tumor hemodynamics as seen at arteriography, and peak systolic velocity may be useful in differentiating malignant hepatic tumors from hemangiomas.

We report a case of CA19-9-producing transitional cell carcinoma of the renal pelvis. A 59-year-old male patient with left hydronephrosis was referred to us from a local physician. Retrograde pyelogram revealed irregular filling defects involving calices, pelvis and proximal ureter. The serum CA19-9 level was elevated. Under the diagnosis of renal pelvic tumor, we performed radical left nephroureterectomy. The tumor was histologically diagnosed as transitional cell carcinoma. The tumor cells showed positive immunostaining for CA19-9. The serum CA19-9 level was normalized after the operation. To our knowledge, this is the 28th case of a CA19-9-producing tumor in the Japanese literature.

A clinico-pathological study was performed retrospectively for 77 patients undergoing total cystectomy for primary transitional cell carcinoma of the urinary bladder between 1981 and 1995 to clarify the mode of recurrence, the risk factors which may affect recurrence following cystectomy and prognostic factors. Postoperative recurrence was recognized in 27 (35.1%) out of 77 patients and the one-, two- and three-year non-recurrent rates by the Kaplan-Meier method were 75.3, 64.9% and 63.3%, respectively. The duration from cystectomy to recurrence was 1 to 102 months with a mean of 12.1 months, and approximately 92.6% of recurrence occurred within two years. Among 27 patients with recurrence, pelvic recurrence, distant metastasis, both of them and urethral recurrence were recognized in 6 (22.2%), 18 (66.7%), 1 (3.7%) and 2 (7.4%), respectively as the first site of recurrence. The overall one-, three- and five-year cause-specific survival rates of the 77 patients were 84.7, 71.1% and 65.6%, respectively. Of the 27 patients with recurrence, 25 (92.6%) died of bladder cancer. Of the factors related to recurrence or prognosis, pathological stage, lymphatic invasion, venous invasion, type of infiltration and lymph node metastasis but not pathological grade or adjunctive chemotherapy were significant risk factors for recurrence and prognostic factors in univariate analysis. However, lymphatic invasion was the only significant risk factor for recurrence and prognosis in multivariate analysis using Cox's proportional hazard model.

We experienced a case of renal oncocytoma, in a 46-year-old woman. At a health examination, ultrasonography revealed a right renal tumor, and she was admitted to our hospital for evaluation. From the ultrasonogram, computerized tomography (CT) and angiography, we suspected a renal oncocytoma, but renal cell carcinoma was not completely ruled out. Since the location of the tumor seemed suitable for a local resection, we scheduled a surgical enucleation, but we intended to switch to a radical nephrectomy if examination of a frozen-section suggested renal cancer. Because the frozen findings were suggestive of an oncocytoma without malignancy, the surgical enucleation procedure was completed as scheduled. Pathological findings of the resected specimens were characterized by granular eosinophilic cytoplasm, and rounded nuclei without nuclear pleomorphism or mitotic figures. Electron microscopic studies revealed an increased number of mitochondria. The patient was accordingly diagnosed as having renal oncocytoma. We also reviewed the literature to elaborate procedures for a preoperative diagnosis and therapy for renal oncocytoma.

The relationship between bullous pemphigoid and malignancies of visceral organs is still controversial. A case of lung cancer associated with bullous pemphigoid is reported. A 63-year-old man admitted hospital because of multiple bullae of the whole body skin and continuous fever. The skin lesions were diagnosed as bullous pemphigoid by the skin biopsy. However, the chest x-ray on admission revealed a large tumor in the left upper lung field. The tumor was diagnosed as a lung cancer by trans-bronchial lung biopsy. The fever withdrew with the administration of prednisolone. The left upper lobectomy of the lung and mediastinal lymph node dissection were performed. The skin lesion disappeared 5 days after the surgery. This clinical course is thought to indicate the relationship of both diseases. Bullous pemphigoid is thought to have many problems during perioperative period, such as hypoproteinemia and delayed wound healing due to administration of the steroid, therefore intensive care is necessary in the perioperative care.

Thirty-three patients who had transitional cell carcinoma of the bladder with stage PT1 and grade 3 components were treated between January 1980 and December 1992. Clinical study was done for these 33 patients on treatment modalities and it's problem, intravesical recurrence, disease progression and prognosis. Twenty-five of 33 patients underwent bladder-sparing surgeries and total cystectomy was performed for another 8 patients as initial treatment. Intravesical recurrence was observed in 18 (72%) of 25 patients who underwent initial bladder-sparing surgeries. Recurrence-free rate was 44% for 1 year and mean period to recurrence from initial therapy was 13.1 months. Although some adjuvant therapy after initial treatment was performed for 20 patients, it's efficacy in preventing intravesical recurrence could not be confirmed. Disease progression was recognized in 10 (40%) of 25 patients initially treated by bladder-sparing surgeries after median latent period of 33.7 months, whereas only one (12.5%) of another 8 patients who underwent total cystectomy showed progression, and 5-year progression-free rate after initial bladder-sparing surgeries was 55.6%. Three and five-year actural survival rate in all cases were 81.5% and 65.1%, respectively. According to initial treatment, 5-year survival rate was 62.2% for the patients treated by bladder-sparing surgeries, whereas it was 83.3% for the cases who underwent total cystectomy. However statistical significant difference was not recognized. In view of disease progression after initial bladder-sparing surgeries, patients with progression yealed a 45.7% 5-year survival rate compared to 81.5% for the patients without progression, and significant difference was demonstrated between them.(ABSTRACT TRUNCATED AT 250 WORDS)

A 61-year-old man received right middle and lower lobectomies for lung abscess caused by bronchiectasis in 1957. Since the right upper lobe was destroyed and multiple peripheral bronchopleural fistulae developed later, open thoracostomy was done in 1990. For this patient we performed transpericardial completion pneumonectomy with omental pedicle flap in 1993. He was complicated in a transient thoracic empyema. But he recovered by open drainage followed by surgical closure using Clagett's method and remains well 2 years after the radical operation. Transpericardial approach with omental pedicle flap though a median sternotomy seemed useful to prevent the postpneumonectomy bronchopleural fistula in this patient with thoracic empyema. But the primary closure of the empyema cavity should not be done, if dead space remains in the pleural cavity.

We report here two cases of priapism. One of these cases was suspected to be drug induced and high and low flow mixed type. The patient had taken the drugs, alpha-blocker for hypertension and dysuria by BPH for a long time. He was treated by a caveno-glandular shunt. After surgery, detumescence was obtained for some time, but erection appeared again soon. Transcatheter embolization of the internal pudendal arteries was then performed, and detumescence became permanent. The other case was an idiopathic and high flow type. Detumescence was achieved soon by transcatheter embolization of the internal pudendal arteries only, then he experienced morning erection imperfectly on the 9th day after this treatment. The management of priapism as reported to date is also reviewed.

The purpose of this study is to establish criteria of limited operation for bronchial carcinoid. Ten cases surgically treated in our hospital and 47 cases reported in Japan from 1981 to 1992 were examined. Thirty-nine cases had typical carcinoid tumor and 18 had atypical. Limited operation, such as pulmonary segmentectomy, wedge resection or partial resection, was performed in 12 cases. In these, all patients of typical type were alive except for a case died of other disease. However, two patients of atypical type died of distant metastasis of the tumor. No lymph node metastasis was revealed in all cases of typical type. On the contrary, in cases of atypical type, six had n1 and two had n2 disease. Moreover, two cases with n1 disease had pulmonary metastasis. Therefore, patients with typical bronchial carcinoid can be cured by limited operation, but radical operation should be indicated for atypical bronchial carcinoid.

The determinations of cardiac troponin T provide the highest diagnostic efficiency for the detection of myocardial cell necrosis. To assess perioperative myocardial infarction, serum levels of cardiac troponin T were determined in 14 patients undergoing coronary artery bypass grafting (CABG). The patients were divided into two groups: group I (n = 9), those whose troponin T was less than 1.00 ng/ml on the first postoperative day; group II (n = 5), those whose troponin T was more than 1.00 ng/ml on the first postoperative day. Troponin T levels in group II patients were significantly higher than in group I from the second to the seventh postoperative day. Two patients in group II had specific changes on the electrocardiogram detecting perioperative myocardial infarction as a new Q wave and R wave reduction. These results suggest that troponin T is a valuable marker of perioperative myocardial infarction following CABG.

A 62-year-old man who had undergone left lingual segmentectomy for pulmonary tuberculosis developed left chronic localized pleural empyema with multiple bronchial fistulae in the region of surgical gauze left in the thoracic cavity. We surgically removed the gauze and fenestrated the empyema. After disinfection of the region of suppuration, small fistulae which were less than 2 mm in diameter were closed by fibrin-glue-packing and consolidation of the orifices using 40% silver nitrate solution. Two and one-half months later a second operation was performed. Residual large fistulae were closed by fibrin-glue-packing and suturing of their orifices, and the empyema space was then obliterated by muscle flap plombage. The patient's postoperative course was good and the empyema was completely cured with this treatment.

In two patients who had developed aspiration due to left recurrent laryngeal nerve injury during radical resection for lung cancer, low power Nd:YAG laser irradiation of the paralyzed vocal cord was performed through a bronchofiberscope. With irradiation, the paralyzed vocal cords of both patients swelled and became fixed at the median portion of the glottis. Thereafter, aspiration disappeared. Thus, this new application of Nd:YAG laser irradiation is apparently quite useful in treating aspiration due to unilateral vocal cord paralysis immediately after pulmonary resection.

The clinical features of herpes simplex keratitis seen in 370 eyes of 356 patients (211 males and 145 females) in the outpatient clinic of the Yokohama City University hospital during the last 30 years (1963-1992) were statistically analyzed. The age of patients ranged from 1 to 75 years (mean 38.4 years). Bilateral herpetic keratitis was seen in 11 patients (10.4%) in the period of 1980-1992. Epithelial keratitis, stromal keratitis, and corneal endotheliitis were observed in 67 patients (57.3%), 46 patients (39.3%), and 4 patients (3.4%), respectively, in the period of 1980-1992. There was no significant change in the incidence of the types of corneal lesions during the last 13 years as compared with those in the previous 17 years (1963-1979). Life-table analysis revealed that 5-year recurrence rates were 17.5% in patients treated with acyclovir (ACV) and 52.9% in those treated with idoxuridine (IDU). The recurrence rate in ACV-treated patients was significantly lower than that in IDU-treated patients. Severe cases, such as those complicated by deep corneal ulcers with hypopyon, descemetoceles, or necrotizing keratitis, were decreased in number in ACV-treated patients, as compared with IDU-treated patients.

A 52-year-old man who had been pointed out cardiac tumor on echocardiography, CT, MRI and coronary angiography was admitted to our hospital. He was asymptomatic. The surgical excision of the tumor was performed under extracorporal circulation and the postoperative period was free of event. It was not certain whether it originated from interventricular septum or right ventricle. The histology was mixed hemangioma composed of capillary and cavernous type.

A case report on a 64-year-old male with pulmonary dirofilariasis cytologically mimicking lung cancer is presented. By transbronchial brushing cytology, several suspect cells with a papillary arrangement showing a high nuclear/cytoplasmic ratio, irregularity of nuclear shape, nuclear enlargement and a macronucleolus were obtained. These cells seemed to originate in the reparative process of the bronchiolar epithelium around the infarcted lesion containing Dirofilaria immitis.

Our hospital recently installed one of the newest types of extracorporeal shock wave lithotripters, a Dornier MFL 5000-(U). We conducted preliminary clinical trials with the apparatus from April to June 1991. In this report we discuss our experience with the first 40 patients (52 stones) treated in a total of 52 extracorporeal shock wave lithotripsy (ESWL) sessions. Follow up observation was conducted for three months. Except in one case, invasive anesthesia was not used. A double J-catheter was inserted in 13 cases, a ureteral catheter in 7 cases, and percutaneous nephrolithotripsy (PNL) was used after ESWL in one case. After one month of follow-up, 27 patients (67.5%) were completely free from stone fragments, while at 3 months after treatment, 34 patients (85.0%) were free from stone fragments. No serious complications were observed after ESWL. We concluded that the Dornier MFL-5000-(U) apparatus is effective for renal and ureteral stones and generates no serious complications.

Treatment of superior vena cava syndrome (SVCS) caused by advanced lung cancer is still controversial. We inserted Gianturco expandable metallic stents (GEMS) in 5 patients with SVCS due to the extension of lung cancer. GEMSs were introduced intravenously through the catheter after intraluminal balloon dilation of the stenotic sites. SVCS was successfully and easily relieved by this method without any significant complication. GEMS placement seems to be a useful alternative to bypass grafting procedure for the treatment of SVCS.

Treatment of postpneumonectomy pyothorax due to bronchopleural fistula (BPF) is troublesome, especially with methicillin-resistant staphylococcus aureus (MRSA) infection. Moreover, in a bypass-grafting case, the management becomes more complicated. We reported a successful treated case of MRSA pyothorax due to BPF after grafting and pneumonectomy. In a 48-year-old woman performed grafting and pneumonectomy for traumatic aneurysm of the thoracic aorta, MRSA pyothorax due to BPF occurred. BPF was successfully closed by fibrin-glueing under bronchofiberscopy. However pyothorax was not improved by thoracic irrigation for a month. Therefore, open pleural drainage underwent. At the same time, bronchial stump and graft surface was covered with the omental pedicle flap. The open wound had become sterile in two months, and the thoracic window was closed three months after the open drainage.

Postoperative pulmonary complications cause the decrease of the flow of remaining pulmonary circulation. We examined the effects of the difference of resected lobes on the postoperative course and remaining pulmonary circulation of the lobectomized lung cancer patients using a pulmonary digital subtraction angiography. In all cases with preoperative pulmonary complications, circulatory flow of the remaining lung on the operated side significantly decreased. In the cases without preoperative pulmonary complications, only the cases performed left upper lobectomy developed the decrease of the circulatory flow on the operated side. This seemed to be chiefly caused by a postoperative continual atelectasis of the remaining lower lobe due to kinking of the bronchus. On the other hand, the postoperative decrease of the residual pulmonary circulatory flow on the operated side was not developed in the cases undergoing a segmentectomy, even with pulmonary complications. Therefore, for any case requiring a left upper lobectomy or the case with an impaired lung requiring any type of lobectomy, contralateral pulmonary function should be exactly evaluated preoperatively.

Ten cases of central airway obstruction mainly caused by extrinsic compression due to the growth of extratracheal malignant tumors or longitudinal extension of tracheal adenoid cystic carcinomas, underwent palliative intubation subsequent to endoscopic Nd-YAG laser treatment. Mean length of the severe stenosis in these cases was 4.4 cm (3-7 cm). Sole application of endoscopic Nd-YAG laser to the stenosis failed relief of the symptom and an immediate palliative intubation was recommended. Mean time of the temporary intubation was 7 days (4-11 days). Airway was maintained by this intubation and also retained enough after extubation. Therefore, it seemed that, in a palliative treatment of the central airway severe stenosis, usefulness of the combination management of Nd-YAG laser with following temporary intubation was revealed. However, in order to maintain the airway for recurrence of the obstruction, use of indwelling airway stents seemed a better application. The longest period of follow-up in the cases treated by indwelling airway stents was 6 months and one of the cases is a now in comfortable state.

From 1977 to 1988, 390 cases of lung cancer were resected in our hospital. In 12 patients (3.1%) a postoperative bronchopleural fistula developed. This complication occurred more commonly after right pulmonary resection than left and most common after right pneumonectomy. Moreover, that had occurred following right pneumonectomy was most fatal. After right middle and lower lobectomy, this complication occurred at the same rate as after pneumonectomy and also caused a fatal result. On the other hand, after the resection of single lobe, the rate of the occurrence of a bronchopleural fistula was lower. And, even if it had developed, the fistula sometimes could be healed by a conservative treatment only. In one of our cases the fistula was successfully treated by intra-bronchial gluing through a bronchofiberscope.

From 1977 to 1987, 27 cases of primary lung cancer were resected by the limited operation, 7 segmentectomy and 20 wedge resection. All cases of segmentectomy were considered to be potentially curative and 2 cases of them were X-ray negative early squamous cell carcinoma originated from the subsegmental bronchus. The mean tumor size of the other 5 peripheral cases performed segmentectomy was 37.6 mm in diameter. Two cases of segmentectomy died from cancer recurrence, but 2 cases are still alive more than 4.5 years after operation. All cases of wedge resection were originated peripherally, and 6 cases were thought to be potentially curative and the mean tumor size was 22.4 mm in diameter. Three cases of them died, 1 from the tumor metastasis and 2 from the other diseases than lung cancer, but the other cases undergone potentially curative wedge resection are alive without recurrence 1-3.6 years after operation. The limited operation should be indicated for the peripheral lung cancer without lymph node metastasis in the patients with marked cardiac and/or pulmonary impairment. The small nodule located in subpleural lung can be resected easily by the wedge resection, but the segmentectomy should be recommended for the tumor which is larger in size or located more deeply under the visceral pleura. Especially X-ray negative early squamous cell carcinoma of the bronchus can be curatively resected by the segmentectomy with lymph node dissection, if the tumor exists in the level of subsegmental bronchus or more peripherally. Palliative minimal resection for the advanced lung cancer seemed to be not effective of their long-surviving.

Preoperative examination using chest computed tomography (CT) of cases with pleural dissemination and no pleural effusion revealed small disseminated nodules of the visceral pleura. However, chest CT could not exactly diagnose those of the parietal pleura. The indications of operation, especially pan-pleuropneumonectomy, for cases with pleural dissemination should be limited to the following cases; those in which no pleural effusion and no metastasis to the mediastinal lymphnodes has been clinically proved and in which it is not necessary to perform extensive combined resection other than pan-pleurectomy and partial resection of the diaphragm and/or pericardium. Well differentiated histological types of lung cancer are better indications for surgical treatment.

Although the rupture of the esophagus is frequently a catastrophic event leading to lethal consequences, the mortality and morbidity rate can be significantly lessened by early diagnosis and nutritional management. Early recognition and intensive treatment of this condition are essential and life saving. Multiple techniques, often complex, are necessary to treat the disease, especially when the diagnosis is delayed. A 52-year-old women suffered from severe back pain after vomiting during breakfast, and was admitted to our hospital. Next morning bilateral massive pleural effusion was recognized, and chest drainage tubes were inserted into the bilateral pleural cavity. Three days after admission, drainage fluid changed to be mucous and dark green. Esophagography with Gastrografin demonstrated leakage from right wall of the lower esophagus. A right thoracotomy was performed 83 hours after the onset. In the lower esophagus, there was a longitudinal tear 3 cm in length and the mediastinum was significantly inflamed. So we decided to perform esophagectomy and esophagogastrostomy through ante-thoracic wall route. The right pleural cavity was debrided and thoroughly irrigated with saline. After chest drain removal, right hemothorax occurred in the postoperative period, but she had good recovery and was discharged from our hospital 2 months after the esophagectomy.