Total gastrectomy with distal pancreatectomy and splenectomy for advanced gastric cancer.

BACKGROUND: Pancreaticosplenectomy (PS) is often performed simultaneously with total gastrectomy (TG) to facilitate dissection of the lymph nodes around the splenic artery and splenic hilus. To evaluate the effects of PS on survival, a retrospective study was performed. METHODS: Various clinicopathological factors influencing lymph node metastasis around the splenic hilus (No. 10) and the splenic artery (No. 11) were studied retrospectively in the upper or middle third of advanced gastric cancer patients who underwent TG with PS. The postoperative morbidity, mortality, and survival rate of patients who underwent TG with PS (the TG with PS group) were compared with those of patients who underwent TG alone (the TG-alone group). RESULTS: Tumor size larger than 41 mm and lymph node No. 2 metastasis were independently correlated with lymph node No. 10 and No. 11 metastasis. The mortality rate was similar, but the morbidity rate was significantly higher in the TG with PS group. In the patients with stage I and III, there was no significant difference between the two groups, but in the patients with stage II, the TG-alone group was significantly better than the TG with PS group (P = 0.0400). CONCLUSIONS: Combined PS with TG should never be performed as the standard surgical procedure for every stage of gastric cancer, especially stage II.

Clinical characteristics of acute hemorrhagic rectal ulcer.

BACKGROUND: Acute hemorrhagic rectal ulcer (AHRU) occurs suddenly with painless, massive, fresh rectal bleeding in elderly, bed-ridden patients who have a serious primary disease. There have been several reports on AHRU in Japan, but in Western countries, there have been none. We examined the clinical characteristics of four cases, and we report on AHRU in Western countries. STUDY: The medical records and endoscopic findings in four patients with AHRU seen during a 3-year period were reviewed. The diagnosis of AHRU was established by clinical symptoms, endoscopic examination, and other methods. RESULTS: All of the patients were elderly and bed-ridden and all had sudden onset of massive, fresh rectal bleeding without pain. Sigmoidoscopic examination of all patients showed a shallow or irregular bleeding ulcer in the lower rectum. In three cases, the clinical course was uneventful. In the other case, massive, fresh rectal bleeding recurred but transanal ligation was effective. CONCLUSIONS: When painless, massive, fresh rectal bleeding occurs in elderly and bed-ridden patients, it is important to carefully examine the lower rectum, as there is a strong possibility of AHRU.

Clinical studies of enteritis caused by methicillin-resistant Staphylococcus aureus.

OBJECTIVE: To study the clinical features of methicillin-resistant Staphylococcus aureus (MRSA) enteritis in our surgical ward. DESIGN: Retrospective study. SETTING: Teaching hospital, Japan. SUBJECTS: 16 men and 1 woman who developed MRSA enteritis from January 1995 to October 1999. MAIN OUTCOME MEASURES: Causes and treatments. RESULTS: The underlying diseases were as follows: gastric cancer (n = 13), colorectal cancer (n = 2), recurrent cancer (n = 1) and bowel obstruction following gastrectomy (n = 1). 16 patients were operated on. Two cases were treated with histamine H2 receptor blockers. The mean age of patients was 65 years (range 50-80). In 13 cases MRSA enteritis developed within 6 days of operation. 10 strains of MRSA were isolated from stools, 8 from gastric juice, and 3 from intra-abdominal exudate. 10 patients were treated with vancomycin given through a nasogastric tube and 2 through a nasogastric tube and by drip intravenous infusion. 15 patients survived and 2 died. CONCLUSIONS: Patients who are given broad-spectrum antibiotics and whose gastric secretion is reduced are at high risk of MRSA enteritis. In the surgical ward, early diagnosis, treatment, and isolation are essential for patients with MRSA enteritis.

Malignant proliferating trichilemmal tumor in the skin over the breast: a case report.

A proliferating trichilemmal tumor is relatively uncommon. It is composed of multiple cysts consisting of squamous epithelium with trichilemmal keratinization without granular layer interposition. This lesion usually occurs in the scalp of elderly women. We describe a 67-year-old woman with a malignant proliferating trichilemmal tumor in the skin over the breast. We first misdiagnosed the disease as a primary squamous cell carcinoma of the breast with a metastatic lymph node in the axilla because of the disease site and our unfamiliarity with the disease. The patient underwent radical mastectomy with axillary dissection. Eight months postoperatively, a tumor appeared in her right axilla and progressively enlarged. We subsequently excised the tumor. She is healthy as of 8 months postoperatively. To the best of our knowledge, only one case of a proliferating trichilemmal tumor occurring in the skin over the breast has been reported.

Sonographic features of acute colonic diverticulitis: the "dome sign".

PURPOSE: This study was performed to clarify the sonographic features of acute colonic diverticulitis to enable its differentiation from appendicitis. METHODS: Of 119 patients who were referred to our hospitals for lower abdominal pain between June 1997 and December 1998 and underwent sonography, 12 patients had a definitive diagnosis of acute colonic diverticulitis and 4 patients a tentative diagnosis. Seventy-eight patients were diagnosed as having acute appendicitis, confirmed by appendectomy. In the 16 patients with diagnoses of diverticulitis, the sonographic and clinical features of acute colonic diverticulitis were studied. RESULTS: Among the 12 patients with definitive diagnoses of acute colonic diverticulitis, sonographic findings included localized thickening of the colonic wall (100%) and a hemispheric mass (the "dome sign") protruding at the thickened colonic wall (100%) and consisting of a hypoechoic wall (100%) and a central echogenic area (66%). The presence of diverticula was confirmed by barium-enema x-ray study in all 12 patients. The 4 patients with tentative diagnoses of acute colonic diverticulitis all had colonic wall thickening but no dome sign. Colonoscopy revealed colitis in 3 of these patients. All 16 patients recovered with conservative treatment, without laparotomy. CONCLUSIONS: Sonography was useful for differentiating acute colonic diverticulitis from appendicitis. The sonographic finding of the dome sign seems to be specific for acute colonic diverticulitis.

[A case of recurrent breast cancer responding to long-term treatment with 5'-DFUR combined with MPA].

A 55-year-old woman with recurrent breast cancer treated with sequential mastectomies, chemo-and hormonal therapy of UFT, CPM and TAM, achieved remission. Six months later she was admitted with a diagnosis of carcinomatous pleurisy. A large pleural effusion was drained followed by administration of ADM, which improved her effusion and accompanying dyspnea. The effusion recurred but the patient desired outpatient treatment. Thus, we prescribed oral 5'-DFUR and MPA. One month later, her cough had improved and her sputum cytology was negative, while on chest radiograph the pleural effusion had decreased and the patch-like shadows in her right lung field had disappeared. She was considered as a case of PR. At one year and 3 months after starting concomitant 5'-DFUR and MPA the pleural effusion disappeared. The patient has received this outpatient treatment for 2 years without adverse reactions.