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The most important factor influencing the long-term outcome after an initial repair of iatrogenic bile duct injury is late stricture at the repair site. We have encountered three cases of traumatic neuroma or a marked proliferation of nerve tissues (So-called traumatic neuroma) which were associated with obstructive jaundice following the repair of bile duct injury which occurred during a laparoscopic cholecystectomy. One patient underwent a simple suture repair for a laceration of bile duct while two patients underwent an end-to-end anastomosis for the transection of the bile duct at local hospitals. They were referred to our hospital because of obstructive jaundice due to a late stricture of the bile duct. A resection of the extrahepatic bile duct and hepaticoiemnostomy was performed. A histological examination of the resected specimens revealed traumatic neuroma with fibrous connective tissue. To our knowledge, there has been no documentation of a so-called traumatic neuroma associated with obstructive jaundice following the repair of bile duct injury which occurred during a laparoscopic cholecystectomy. The so-called traumatic neuroma may contribute to the late-onset stricture of the bile duct at the repair site. These cases may have important implications when considering the mechanism of stricture following a repair of the bile duct and when determining the appropriate management strategies to surgically treat bile duct injury during a laparoscopic cholecystectomy.

We herein present four cases of xanthogranulomatous cholecystitis (XGC) that involved the adjacent structures and clinically mimicked carcinoma of the gallbladder (diffuse-infiltrating type). The patients consisted of two males and two females, with a mean age of 64.5 years (range, 51 to 77 years). Three of them had an episode of acute cholecystitis one to five months before the operation. An elevation of CA19-9 and Span-1 was recognized in one case. Gallstones were present in all cases with a thickening of the gallbladder wall on either ultrasonography (US) or computed tomography (CT). Furthermore, three cases revealed either intramural hyperechoic spots or comet-like echoes on US. Three cases were erroneously diagnosed as carcinoma based on the operative findings and underwent a cholecystectomy with a partial hepatic resection of the gallbladder bed and/or a resection of the surrounding structures involved. In the remaining case, an intraoperative pathological study revealed chronic inflammation without malignancy and a cholecystectomy was thus performed. The resected gallbladders histologically revealed many granulomas (abundant pigment-laden foamy histiocytes, fibroblasts and inflammatory cells) which extended to the liver and/or colon. Therefore, in such a situation, an intraoperative pathological study is recommended in order to avoid any excessive and unnecessary surgery when determining the optimal method of treatment.

A case of apocrine carcinoma of thebreast in a 66-year-old Japanese woman is herein reported. The patient was admitted to our University Hospital for a palpable left breast mass on January 17, 2000. The tumor was mildly painful and waspalpated as a 2 × 3cm oval, hard mass with relatively well-circumscribed margins located in the outer upper quadrant of the left breast. The tumor markers (CEA, CA15-3, TPA, NCC-ST-439, BBC225) were all within the normal ranges. Mammography revealed a 2 cm-opaque mass with intratumoral scattered microcalcifications and relatively well-defined margins. MR images showed a 2 cm oval mass. The tumor showed a high intensity mass on the T1-weighted image and a low intensity masson the T2-weighted image. A needle biopsy revealed apocrine carcinoma. The patient underwent Auchincloss's operative procedure. The tumor measured 1.2 cm in the greatest dimension, and appeared to be solid, gray-whitish and well-defined. The tumor showed typical histologic features of apocrine carcinoma. Immunohistochemically, the tumor showed a positive expression for AR, PR, and GCDFP-15, but a negative expression for ER, bcl-2 and p53. The tumor was classified to be Stage I(T2, NO,MO).

We herein report a case of carcinosarcoma (sarcomatoid carcinoma) of the gallbladder with a cholecystocolic fistula and evidence of marked leukocytosis in a 77-year-old Japanese man. The patient presented with episodes of right upper quadrant pain and fever in April 2000. The physical examination revealed a painful, palpable mass in the right upper quadrant. Routine laboratory findings showed leukocytosis (18.000/mm^3). Abdominal sonography showed an echogenic mass occupying the entire gallbladder lumen. Abdominal CT demonstrated a solid mass lesion measuring 8×7 cm in size with a clear, hypodense asterisk configuration, suggesting a communication between the gallbladder and the gastrointestinal tract. At exploratory laparotomy, a large solid gallbladder tumor showed direct invasion into the transverse colon and regional lymph node metastasis. The tumor was evaluated to be Stage IV. With the intention of performing cytoreductive surgery, a cholecystectomy together with a partial transverse colectomy was thus performed. The gallbladder tumor showed penetration into the transverse colon, forming a cholecystocolic fistula. On a cut section analysis, the tumor occupied the entire gallbladder lumen and measured 7×5 cm in size. No gallstones were observed. The tumor was composed of two different histologic features: an adenocarcinomatous feature that was composed of moderately differentiated adenocarcinoma and a sarcomatous feature that consisted primarily of pleomorphic, spindle cells. Immunohistochemically, the adenocarcinoma cells were positive for keratin, EMA and CEA whereas the sacomatous spindle cells were positive for vimentin and CEA. However, both the carcinoma cells and sarcomatous cells were negative for G-CSF. Postoperatively, the patient's WBC counts increased from 26.9×10^3/mm^3 to 103.0×10^3/mm^3. Finally, the patient died with clinical manifestations of peritonitis carcinomatosa one month after surgery.

We investigated whether the extent of graft ischemia reperfusion (I/R) injury can be evaluated by assessing the level of bile and serum endothelin-1 (ET-1). In groups 1 to 3 (n=5 in each group), the livers of male Wistar rats were surgically isolated from the surrounding attachments and then perfused in-situ with heparinized cold saline (4℃) under a port-systemic shunt. The livers were then reperfused after a pre-determined cold ischemia time (0, 30, and 60 min in groups 1, 2, and 3, respectively). The ET-1 levels in either the bile or the serum obtained from the suprahepatic vena cava (SHVC) and abdominal aorta, were assessed from -1 hour to +72 hours after reperfusion in each group. In group 3, the ET-1 level at the SHVC increased to $19.9 \pm 2.88$ and $19.43 \pm 3.14$ pg/ml at 1.5 and 2 hr after reperfusion, respectively, which were significantly higher than those of group 1 ($13.6 \pm 2.73$, $13.05 0.58\pm $, p

44-year-old male psychiatric patient (suffering from schizophrenia) with renal failure was referred to the University Hospital because of a massive rectal bleeding. A few days after undergoing retrograde irrigation enemas performed by the health care staff, the patient developed rectal bleeding. In his past medical history, the patient had been diagnosed to have schizophrenia at 14 years of age and renal failure (etiology unknown) requiring hemodialysis at 34 years of age. Colonoscopy revealed a large perforation occupying half of the luminal circumference of the sigmoid colon. Immediately after performing blood transfusion and hemodialysis, the patient underwent Hartman's procedure. The resected sigmoid colon revealed a large, longitudinal perforation measuring 4 cm in length on the mucosal surface and a ruptured configuration on the serosal surface. There were no diverticuli either at the site of or in the vicinity of the perforation. The perforated lesion showed mild inflammatory changes, a normal-appearing mucosa and tearing of the muscle fibers in the margins of the perforation. The patient recovered without any postoperative complications.

We investigated the effect of lidocaine on hepatic ischemia/reperfusion (I/R) injury in the rat both in vivo (ExperimentA, groups 1 to 3) and ex vivo (Experiment B, groups 4 to 7). In Experiment A, hepatic ischemia were performed for 60 min at room temperature. In groups 1 and 2, physiological saline (group 1, n=5) or 10 mg/kg of lidocaine (group 2, n=5) was injected through the peripheral vein, before the hepatic ischemia. In group 3 (n=5), 10 mg/kg of lidocaine was injected twice at reperfusion and before hepatic ischemia. The hepatic tissue blood flowingroup 1 was lower than in group 2 or 3 at 5 min to 90 min after reperfusion. Serum transaminase level was significantly lower in group 3 compared to that in group 1 at 2 hours after reperfusion. In Experiment B, livers were removed from the rat and preserved in saline at room temperature for 60 min, followed by 120 min of reperfusion with oxygenated perfusate at 37℃. The livers were perfused with Krebs-Henseleit solution (group 4, n=5). The perfusate was supplemented with lidocaine in group 5 (n=5), 3.5×10^6 of neutrophil in group 6 (n=5), and both lidocaine and neutrophils in group 7 (n=5). The levels of GOT, GPT and LDH were all significantly lower in group 7 than in group 6. These data thus suggest that lidocaine plays a protective role in hepatic I/R injury by stabilizing both the hepatocytes and the neutrophil membrane., 論文

The case of a large nonparasitic liver cyst with a 9-year history of cyst recurrence after undergoing aspiration therapy in a 78-year-old woman is herein reported. Nine years prior to this admission, she underwent an operation for a hernia of the lumbar intervertebral disc. At operation, a large liver cyst was incidentally detected, and the cyst was aspirated at that time to relieve her abdominal pain. Five years after the initial therapy, she developed abdominal distension and pain. The patient again underwent cyst aspiration. Thereafter, she experienced a 4-year symptom-free period after the second cyst aspiration. On admission, an abdominal CT scan revealed a large simple cyst measuring 17×12×17 cm in size which occupied most of the right liver lobe extending down to the right lower quadrant. At laparotomy, a large cyst showed entensive fibrous adhesions to the adjacent viscera. Following lysis of adhesions and the evacuation of the cyst fluid, the cyst, which was bulging into the abdominal cavity, was almost totally excised (unroofing). She remained asymptomatic 5 months after discharge. The standard treatment for nonparasitic liver cysts currently consists of cyst aspiration and alcohol sclerotherapy. However, the long-term follow-up of cysts after aspiration is unknown. Therefore, at present, cyst recurrence after aspiration may require either cyst unroofing or a partial excision., 論文

A case of mediastinal teratoma in a 5-year-old girl is herein reported. She presented with chest pain and an abnormal shadow on the chest X-ray findings. CT and MRI demonstrated a right anterior mediastinal cystic tumor measuring 5cm in diameter with areas of calcification, solid lesions and fatty tissue, and right pleural effusion. Tumor markers such as AFP, h-CG, and urinary VMA and HVA were all within the normal limits. Tumor involvement to the adjacent organs was suspected based on the diagnostic imaging findings before operation. Subsequently, we performed a right thoracotomy with a possible diagnosis of potentially malignant teratoma. Fortunately, the tumor was localized with inflammatory adhesions to the lung, aorta, and pericardium. The tumor was completely resected. The tumor was oval shaped and measured 5cm in size. On cut section, the tumor contained a small amount of brown fluid. The tumor was cystic with intracystic polypoid projections. Histologically, the tumor was composed of pancreatic tissue, gastrointestinal tissue, bone tissue and fatty tissue. It was finally diagnosed to be a benign, mature teratoma. The patient showed an uneventful postoperative course and is presently doing well with no evidence of recurrence. This case and other similar reported cases suggest that it is difficult to differentiate inflammatory adhesions from tumor infiltration to adjacent organs based on the diagnostic imaging findings alone., 論文

We investigated the effects of Bcl-2 0verexpression on the morphological changes of the mitochondria (MC) in the regenerating rat liver after a 70% partial hepatectomy (PH). Bcl-2 or control marker (LacZ) gene transfection to the regenerating liver was performed immediately after PH by a systemical injection of 1X10^9 pfu/body of recombinant adenovirus, which encodes either human Bcl-2 protein (ACalbBcl2pLpA) in group 1 (n=39) or E.Coli $ \beta $-galactosidase (AxCALacZ) in group 2 (n=39). Ingroup3 (n=13), 1ml of normal saline was injected instead of the recombinant adenovirus. The rats were allowed to survive until the scheduled sacrifice at 0.5h, 2h, 4h, 12h, 24h, 2d, 3d, 5d, 7d, 9d, 11d, 14d, and 21d after PH (3 rats each). In the immunohistochemical analysis, the Bcl-2 protein expression showed a peak intensity at 12 to 72 hrs after PH in group 1, whereas it was delayed until 5 days after PH in groups 2 and 3 vMth a rather mild intensity, followed by a gradual decrease in all three groups. At its peak intensity, the Bel-2 protein expression was recognized over a wide range of the parenchymal area as well as in the penportal area. The $ \beta $-galactosidase activities in X-gal staining, showed apeak intensity at 48 hrs after PH followed by a gradual decrease until 21 days after PH in group 2. In the hepatocyte ultrastructure, MC shape was well preserved in group 1 until 7 days after PH with number of regular shaped mitochondria, well preserved cristae and dense matrix (RM) being $58 \pm 22$% at 12hrs and $60 \pm 21$% at 24 hrs, compared to groups 2 ($36 \pm 23$% at 12hrs and $40 \pm 15$% at 24hrs, p≦0.015 and ≦0.004 respectively) and 3 ($29 \pm 11$% at 12hrs and $35 \pm 12$% at 24 hrs, p≦0.0004 and ≦0.0015 respectively). In conclusion, Bcl-2 0verexpression in the regenerating liver was important in preserving mitochondrial shape in the early stage of liver regeneration, thus contributing to an accelerated liver regeneration., 論文

The case of a rare, peculiar tumor (sarcomatoid carcinoma, carcinosarcoma) in the gallbladder of an 82-year-old woman is herein described. The patient was admitted with right upper quadrant tenderness and mass. On admission, abdominal imaging modalities demonstrated a 10 cm-solid mass in the right upper quadrant with nonspecific features similar to those of carcinoma of the gallbladder. She was diagnosed to have carcinoma of the gallbladder, and thereafter underwent an extirpation of the tumor together with a cholecystectomy and partial transverse colectomy. The tumor was relatively circumscribed with invasion into the transverse mesocolon, and measured 12cm in greatest dimension. On bisection, the tumor showed a massive intraluminal polypoid and exophytic growth in the gallbladder with a solid, gray-color, and fibrous appearance. Histologically, the tumor was composed of three different tumor cell types (tubular adenocarcinoma, giant cell and spindle cell types). The giant cell-type cells occupied the largest part of the tumor and were infiltrated with lymphoid cells and leukocytes. Immunohistochemically, tubular adenocarcinoma was positive for cytokeratin while the remaining two components were negative for cytokeratin and vimentin. One month later, the patient developed local recurrence of the tumor at the primary site. The tumor grew rapidly and aggressively. As a result, she died 7 months after surgery., 論文

Case 1 (a 53-year-old man, postoperative status for hepatocellular carcinoma, follow-up of 1.5 years) developed anal pain on defecation. A barium enema showed a segmental stricture. Colonoscopy revealed a multinodular mass with no obvious ulcer 4 cm from the anal verge. Endoscopic ultrasonography showed a mucosal mass with a preserved layer structure of the rectal wall. A biopsy of the lesion showed the characteristic features of fibromuscular proliferation in the lamina propria. He underwent a colostomy because of rectal stricture. He remained asymptomatic after the colostomy. Case 2 (a 54-year-old man, postgastrectomy status for gastric carcinoma, follow-up of 10 months) presented with thin stool and rectal pain on defecation. A barium enema revealed a segmental stricutre. Colonoscopy showed a multipolypoid mass with no ulceration 5 cm from the anus. A pelvic CT scan showed a mucosal mass with a normal layer structure of the rectal wall. The bioptic findings were identical to those of Case 1. He also underwent a colostomy and showed a good recovery. The two above described patients were both misdiagnosed to have rectal carcinoma, especially linitis plastica on the colonoscopic appearances. A biopsy of the lesion may lead to an accurate diagnosis of mucosal prolapse syndrome. A colostomy is thus considered to be a useful alternative treatment as a temporary strategy for such patients., 論文

We report a case of metastasis-induced acute pancreatitis (MIAP) that we successfully treated by chemotherapy based on a cytodiagnosis. A 62-year-old man was diagnosed to have localized small cell lung carcinoma (T1, N3, MO; stage IIIb) and thereafter underwent four courses of chemotherapy accompanied by radiotherapy as follows: 120mg of cisplatinum (CDDP) on Day l,150mg of etoposide (VP-16) on Days 1 through 3, and 1.5 Gy X2/day of radiotherapy on Days 5 through 9. The carcinoma went into complete remission (CR), and the patient was then followed up on an outpatient basis. Two years later, the patient was readmitted for left upper abdominal and lumbar pain, and was diagnosed to have mild acute pancreatitis accompanied by neoplastic lesions in the pancreas. Since primary pancreatic carcinoma could not be ruled out by diagnostic imaging, an exploratory laparotomy was performed. An intraoperative cytologic examination confirmed small cell carcinoma. Therefore, four courses of intra-artenal chemotherapy were chosen. The pancreatic tumor disappeared and a cystic lesion remained after completing chemotherapeutic regimen, and a favorable quality of life was thus maintained for nine months. Although unnecessary surgical procedures should be avoided for patients with small cell carcinoma, an exploratory laparotomy for an intraoperative rapid and accurate cytodiagnosis should be performed for the differential diagnosis and thereafter the most appropriate therapeutic modality should be chosen., 論文

A case of Krukenberg tumor in a 30-year-old woman with transverse colon cancer is reported herein. The patient was found to have bilateral ovarian tumors and abnormal elevation of serum CEA at a community hospital. Subsequently, she was referred to the University Hospital for further work. Diagnostic examinations including US, CT and colonoscopy demonstrated transverse colon cancer and bilateral ovarian tumors. Exploratory laparotomy showed the growth of transverse colon cancer over the peritoneal cavity to the ovaries. She underwent partial colectomy for colon cancer, bilateral oophorectomy for ovarian tumors and sigmoid colostomy for pelvic carcinomatosis. Her colon cancer showed mucinous adenocarcinoma at stage IV. She is well 5 months after surgery. Krukenberg tumor has been considered as a metastatic tumor from gastric cancer, but recent reports have shown an increasing frequency of colon cancer metastatic to the ovaries. Therefore, metastatic ovarian tumors should be included in differential diagnosis.

A case of Krukenberg tumor in a 30-year-old woman with transverse colon cancer is reported herein. The patient was found to have bilateral ovarian tumors and abnormal elevation of serum CEA at a community hospital. Subsequently, she was referred to the University Hospital for further work. Diagnostic examinations including US, CT and colonoscopy demonstrated transverse colon cancer and bilateral ovarian tumors. Exploratory laparotomy showed the growth of transverse colon cancer over the peritoneal cavity to the ovaries. She underwent partial colectomy for colon cancer, bilateral oophorectomy for ovarian tumors and sigmoid colostomy for pelvic carcinomatosis. Her colon cancer showed mucinous adenocarcinoma at stage IV. She is well 5 months after surgery. Krukenberg tumor has been considered as a metastatic tumor from gastric cancer, but recent reports have shown an increasing frequency of colon cancer metastatic to the ovaries. Therefore, metastatic ovarian tumors should be included in differential diagnosis., 論文