[Adenocarcinoma in the Lung Detected Due to the Development of Perforative Peritonitis Caused by Small Intestinal Metastasis-A Case Report].

Previous studies have reported that perforations of the small intestine caused by metastatic tumors prior to the diagnosis of primary lung cancer are very rare. A 79-year-old man was admitted to our hospital with acute lower abdominal pain. Abdominal computed tomography revealed intraperitoneal free air around the bowel wall thickening in the small intestine. The patient was diagnosed with acute peritonitis caused by perforation of the small intestine, and an emergency operation was performed. Laparotomy revealed perforation in the jejunum without any palpable tumor in the abdomen. Partial resection of the jejunum revealed an ulcerating lesion at the perforation site. Histological examination indicated small intestinal metastasis secondary to lung adenocarcinoma. Positron emission tomography performed after discharge showed a small reticular opacity with intense accumulation of FDG in the left lung. The patient was diagnosed with perforation of the small intestine metastasis secondary to lung adenocarcinoma. The postoperative course was uneventful; the patient received chemotherapy, and is alive 6months after the operation.

[A Case of Trousseau Syndrome Complication during Chemotherapy for Advanced Gastric Cancer].

The pathological condition which causes cerebrovascular disease through hypercoagulability associated with malignant tumors is known as Trousseau syndrome. Here, we report the case of a patient with Trousseau syndrome which developed as a complication during chemotherapy for advanced gastric cancer. A 70-year-old woman with multiple lymph node metastases of gastric cancer underwent TS-1 plus CDDP chemotherapy before surgery. She had symptoms of left hemiparesis during the first course of chemotherapy. She was diagnosed with acute cerebralinfarction using brain MRI, and blood tests indicated hypercoagulability. Therefore, it was strongly suspected that she had Trousseau syndrome. A total of 2 courses of chemotherapy were administered, along with anticoagulation therapy with edoxaban. She exhibited improved paralysis and received a totalgastrectomy after chemotherapy. According to recent reports, more than 90% of patients with malignant tumors have hypercoagulability, and more than 50% of them have thromboembolisms. It is therefore essential to obtain early diagnosis and provide anticoagulation therapy for cerebral infarction, and to provide treatment against malignant diseases in patients with Trousseau syndrome.

[A Case That Was Complicated with Pulmonary Artery Thrombosis during Chemotherapy of the Regimen of CapeOX plus Bevacizumab against Recurrence of Colon Cancer].

An 80-year-old woman with peritoneal dissemination after laparoscopic right hemicolectomy for appendicular carcinoma (mucinous adenocarcinoma, pT4aN1M0, stage Ⅲa)underwent CapeOX plus bevacizumab chemotherapy. The patient achieved stable disease over 5 courses of the treatment. Subjective and objective symptoms were not observed; however, chest computed tomography findings revealed a thrombus in the pulmonary artery that was considered to be associated with bevacizumab. Chemotherapy was discontinued, and anticoagulation therapy was initiated with heparin and then switched to apixaban. The thrombus resolved with treatment, but the patient died following an increase in peritoneal dissemination. CapeOX plus bevacizumab is a recommended colon cancer treatment, and even though it is generally considered safe, the side effects of bevacizumab include relatively rare occurrences of gastrointestinal perforation or thrombosis. The frequency of pulmonary embolism associated with bevacizumab is approximately 0.1%, and fatalities have been reported. The possibility of asymptomatic thrombosis warrants regular monitoring of this serious side effect in patients receiving bevacizumab. Early detection and prompt antithrombotic treatment are necessary to ensure patient safety and continued disease management.

[A Case of Orange-Induced Small Bowel Diverticular Obstruction Treated with Laparoscopically-Assisted Surgery].

We report a case of orange-induced small bowel diverticular obstruction treated with laparoscopically-assisted surgery. A 64-year-old man was seen at the hospitalbecause of abdominalpain and vomiting after dinner. Abdominalcomputed tomography( CT)showed a small intestinal ileus. We performed laparoscopically-assisted surgery on the same day for definitive diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was orange-induced small boweldiverticul ar obstruction. Food-induced smallbowelobstruction is rare disease, but often requires surgery. Laparoscopic surgery is an effective option for surgery of food-induced smallbowel obstruction.

[A Case of a Laparoscopically Resected Gastrointestinal Stromal Tumor of the Stomach].

During treatment for sigmoid colon diverticulitis, a 72-year-old man underwent abdominal computed tomography, which revealed a gastric tumor that was approximately 40mm in diameter. He then underwent a detailed examination after the remission of diverticulitis. The gastric mucosa was found to be unremarkable on gastrointestinal endoscopy. On ultrasonic endoscopy, however, a hypoechoic mass of approximately 40mm in diameter was detected in the fourth layer of the gastric fornix and was believed to be a gastric submucosal tumor(SMT). The tumor was laparoscopically resected, and histological analysis of the tumor revealed a high-risk gastrointestinal stromal tumor(GIST, modified-Fletcher classification). In many cases, when subgastric SMTs are approximately 2-5 cm in diameter and are without obvious malignant findings on endoscopic or computed tomographic examinations, they are followed-up. However, some recent case reports describing treatments for high- or medium-risk groups of patients with small GISTs have been published. When a small submucosal gastric tumor is suspected to be GIST, we believe that laparoscopic surgery is a minimally invasive and effective method for the diagnosis and treatment of the tumor.

[A Giant Malignant Lymphoma of the Ileocecum Treated with Laparoscopic Surgery].

We experienced a case ofa giant malignant lymphoma ofthe ileocecum treated with laparoscopic surgery. A 78-year-old man presented with right flank pain. Lower endoscopy and abdominal computed tomography revealed a giant tumor in ileocecum. Biopsy results suggested malignant lymphoma or adenocarcinoma. We performed a laparoscopic ileocecal resection for definite diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was malignant diffuse large B-cell lymphoma. The patient underwent chemotherapy and is being followed. Laparoscopic surgery can be considered useful to resect gastrointestinal malignant lymphoma.

[A Giant Appendiceal Mucinous Neoplasm Treated with Laparoscopic Surgery].

We encountered a case of giant appendiceal mucinous neoplasm that was treated with laparoscopic surgery. The patient was a 77-year-old man with constipation. Lower endoscopy demonstrated a giant SMT-like tumor in the cecum, and abdominal computed tomography revealed a giant appendiceal mucinous neoplasm and nearby lymph nodes swelling. Hematological examination showed an elevated serum CEA level. We performed laparoscopic ileocecal resection for a definite diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was low-grade appendicealmucinous neoplasm(LAMN). Laparoscopic surgery can be considered safe for the resection of appendicealmucinous neoplasm when it is performed with a carefulsurgicalapproach.

Endoscopic findings and lesion distribution in amebic colitis.

A retrospective cohort study was conducted in 55 symptomatic patients with amebic colitis that visited at St. Luke's International Hospital and Mie University Hospital from 1994 through 2013. To diagnose amebic colitis, 40 patients underwent total colonoscopy within 1 week after hospital visiting and before receiving any treatment. The percentage of characteristic endoscopic findings of amebic colitis including discrete ulcers or erosions with white or yellow exudates were 0% in terminal ileum, 93% in cecum, 28% in ascending, 25% in transverse, 15% in descending, 20% in sigmoid colon and 45% in rectum. The rectal lesions in 55% of patients with amebic colitis were nonspecific. The trophozoite identification rate by direct smear of intestinal tract washings performed during colonoscopy was 88%. The protozoan identification rate was 70% in biopsy specimens taken from the periphery of the characteristic discrete ulcers. Total colonoscopy should be considered for the diagnosis of amebic colitis.

Development of an automated synthesis system for preparation of glucuronides using a solid-phase extraction column loaded with microsomes.

An automated synthesis system using a solid-phase extraction (SPE) system and column packed with octadecylsilica (ODS), which was coated with phospholipid and loaded with dog liver microsomes, was developed for synthesis of glucuronides. Preparation of the microsome-immobilized SPE column, glucuronidation of drugs to synthesize the glucuronides and elution of the products were performed by an automated synthesis system. The phospholipid-coated SPE column and then the microsome-immobilized SPE column were readily prepared by allowing a solution containing L-alpha-dipalmitoylphosphatidylcholine to flow through the SPE column, and then by recycling a buffer solution containing dog liver microsomes through the resulting phospholipid-coated SPE column. The microsome-immobilized SPE column exhibiting the uridine diphosphate (UDP)-glucuronosyltransferase activity catalyzed the glucuronidation of mefenamic acid and estradiol to the corresponding glucuronides in the presence of UDP-glucuronic acid, and three glucuronides of mefenamic acid and estradiol were synthesized using the automated synthesis system, by simply recycling a buffer solution containing UDP-glucuronic acid through the microsome-immobilized SPE column loaded with the substrate. We used beta-cyclodextrin as a solubilizing agent for the synthesis of the glucuronides of estradiol that is practically insoluble in aqueous solutions. The productivity of these glucuronides using the microsome-immobilized SPE column was higher than that using the free microsomes (batch method). Furthermore, we developed a fully automated synthesis-isolation system by coupling the automated synthesis system to an automated preparative HPLC system. The automated synthesis system as well as the fully automated synthesis-isolation system should be very useful for synthesizing glucuronides for drug development.

Peripancreatic Tuberculous Lymphadenitis with Biliary Obstruction Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy.

A 57-year-old man with a history of tuberculosis (TB) was found to have a pancreatic head mass, accompanied by stenosis of the common bile duct. Due to the inherent difficulty in differentiating pancreatic carcinoma from an inflammatory mass, endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was thus performed. The pathological findings confirmed granuloma with caseous necrosis, and the results of the QuantiFERON TB2G test were positive. Accordingly, the patient was diagnosed with peripancreatic TB and thereafter was successfully treated with anti-TB therapy. Based on the findings of this case, we conclude that EUS-FNAB is a useful modality for the diagnosis of pancreatic TB.

Surgical treatment for abdominal aortic aneurysm in a patient with urinary diversion.

In two cases of abdominal aortic aneurysm (AAA) with urinary diversion after radical cystectomy, surgical aneurysm repair was successfully performed. Based on comprehensive preoperative examinations, the surgical strategy for aneurysm should be carefully planned so as not to injure diverted ureters.

Usefulness of Small Intestinal Endoscopy in a Case of Adult-onset Familial Mediterranean Fever Associated with Jejunoileitis.

A 66-year-old Japanese man consulted our institution due to paroxysmal and repetitive bouts of fever and abdominal pain that had persisted for more than one week. Capsule and double-balloon endoscopy (DBE) showed petal-shaped mucosal redness with white hemming in the jejunum and ileum, and histopathology of the biopsy specimens revealed villous atrophy and cryptitis with extensive severe neutrophil infiltration. A genetic examination disclosed compound heterozygous MEFV mutations (E84K, P369S), and familial Mediterranean fever was diagnosed. Treatment with colchicine and infliximab was very effective in inducing the complete disappearance of symptoms and normalization of the endoscopic findings. To the best of our knowledge, this is the first report to describe the findings of small intestinal endoscopic images obtained using capsule and DBE.

Pseudoaneurysms of peroneal artery: treatment with transcatheter platinum coil embolization.

This report describes two cases of pseudoaneurysms of the peroneal artery which were successfully treated by transluminal platinum coil embolization. A pseudoaneurysm developed following a penetrating wound of the calf, and another did following thromboembolectomy of the occluded femoropopliteal bypass with a Fogarty balloon catheter. The coils were guided and released into the proximal peroneal arteries via the placed catheters on the ipsilateral and contralateral femoral arteries, respectively. The pseudoaneurysms disappeared in both cases and the patients have been doing well until now.

Determination method for mono- and diethanolamine in workplace air by high-performance liquid chromatography.

OBJECTIVES: The purpose of this research was to develop a simultaneous determination method for monoethanol-amine (MEA) and diethanolamine (DEA) in workplace air for risk assessment. METHODS: The characteristics of the proposed method, such as recovery, quantitation limit, reproducibility and storage stability of the samples, were examined. RESULTS: An air sampling cassette containing two sulfuric acid-treated glass fiber filters was chosen as the sampler. The MEA and DEA were extracted from the sampler filters, derivatized with 9-fluorenylmethyloxycarbonyl chloride and then analyzed by a high-performance liquid Chromatograph equipped with a fluorescence detector or photo-diode array detector. The overall recoveries from spiked samplers were 86-99 and 88-99% for MEA and DEA, respectively. The recovery after 5 days of storage in a refrigerator exceeded 95%. The overall limits of quantitation were 0.750 and 0.100 jug/sample for MEA and DEA, respectively. The relative standard deviations, which represent the overall reproducibility defined as precision, were 0.3-1.6 and 0.4-5.7% for MEA and DEA, respectively. CONCLUSIONS: The proposed method enables 4-h personal exposure monitoring of MEA and DEA at concentrations equaling 1/3,000-2 times the threshold limit value-time-weighted average (TLV-TWA: 3 ppmfor MEA, 1 mg/m(3) for DEA) adopted by the American Conference of Governmental Industrial Hygienists and also by the Japan Society for Occupational Health. The method is useful for estimating worker exposure to MEA and DEA.

Extraanatomic bypass and coronary artery grafting for coral reef aorta.

A 63-year-old man complained of abdominal angina and intermittent claudication. Multidimensional angiography showed focal calcified obstruction of the suprarenal aorta, occlusion of the right external iliac artery, and instent restenosis in the right coronary artery. Extraanatomic bypass was performed from the ascending aorta to the left external iliac and right femoral arteries, using an 8-mm bifurcated graft, with concomitant off-pump coronary artery grafting. The patient's digestive symptoms and leg claudication disappeared.

Surgical removal of a tilted temporary inferior vena cava filter incorporated with a large thrombus: report of a case.

A 68-year-old woman was referred to our hospital with left leg edema and dull pain. Magnetic resonance imaging and enhanced computed tomography (CT) revealed a huge myoma uteri compressing the left common iliac vein, thus resulting in iliofemoral venous thrombosis. A total hysterectomy was uneventfully performed under the placement of a temporary inferior vena cava (IVC) filter. The postoperative enhanced CT-scan and cavography revealed the 90 degrees -tilted filter incorporated with a large thrombus. As an increased dose of heparin that was administered during the following week resulted in no reduction of the thrombus, a surgical removal was indicated. The infrarenal IVC was clamped proximal and distal to the filter, and the tilted filter with the large thrombus was removed through a longitudinal cavotomy. The postoperative course was uneventful, and she had no recurrence or residual symptoms for 6 months following the surgery.