Abstract
Introduction : For stable patients, we actively performed a reverse introduction into peripheral medical institutions, but “the interinstitutional relations in medical treatment which a hospital doctor hopes for” were not promoted or established.
Aim : Our primary aims were to understand “the interinstitutional relations in the field of medical treatment that outpatients demand” and to obtain materials to promote and establish such relations. Another major aim was to substantially investigate the backgrounds of the patients, the coordinated medical institutions, and general hospitals by using structural equation modeling, and to identify latent factors promoting interinstitutional relations in medical treatment.
Method : We enrolled 471 outpatients as subjects and conducted a questionnaire survey.
Results : Both the hopes and expectations of patients for coordinated medical institutions were related to a “strong connection with the general hospital and with the specialists”. On the other hand, the issuing of a “long-term prescription” with the purpose of reducing the burden on the outpatient department was a strong factor that disturbed such relations.
Conclusions : Our study suggested that the strong relationships that exist among these three elements--patients, peripheral medical institutions, and general hospitals--are latent factors that satisfy the medical demands of the patients and are promoted by smooth interinstitutional medical cooperation.

We report the efficacy of catheter-directed thrombolysis (CDT) for acute deep vein thrombosis. Between January 2003 and August 2004, 20 patients were treated with CDT for occlusive femoral, ilio-femoral and vena caval thrombosis, for less than 2 weeks from onset. Average age was 56.4 years (range 30-78 years), 11 patients were male, and the duration of leg symptoms was 4.4 days (range 1-12 days). Routine temporary inferior vena caval filters were used, and a multi-lumen catheter was inserted from the popliteal vein. Urokinase was used via the catheter by the combination drip infusion method and pulse-spray method. All patients received heparin and stasis of venous flow was prevented with intermittent pneumatic compression. If thrombus remained, mechanical thrombolysis was necessary. Metallic stents were implanted for iliac vein compression syndrome and organized thrombus. Venographic severity score (VS score) and extremity circumference were used to evaluate the effects of treatment. The duration of the treatment was 5.0±0.28 days (range 2-9 days) and the total dosage of urokinase was 1, 025, 000±57, 000 units (range 360, 000-1, 680, 000 unit). One (5%) iliac vein compression syndrome and two (10%) organized thrombi were treated by implanted metallic stents. Giant thrombi was captured by temporary inferior vena caval filters in two patients, but there was no pulmonary embolism. Two patients had thrombophilia, one was antiphospholipid syndrome and one was protein S deficiency. There was an early recurrence in one patient and re-CDT was needed. The VS score deteriorated to 6.2±2.5 (post CDT) significantly (p<0.0001) from 26.2±6.3 (pre CDT). CDT for acute deep vein thrombosis was effective and its early outcome was acceptable.

　　We describe a case of Inose-type hepatic encephalopathy due to congenital gastro-renal shunt that was effectively treated with balloon-occluded retrograde transvenous obliteration (B-RTO). An 80-year-old woman repeatedly experienced syncope. Her plasma concentration of NH₃ was elevated to 2363 level and syncope attacks improved after the gastro-renal shunt was closed by B-RTO. Although a congenital gastro-renal shunt is usually treated by surgical ligation, B-RTO is can be effective and less invasive treatment for such cases.

Enteral feeding is generally accepted in patients who cannot take nutrients orally. Percutaneous endoscopic gastrostomy (PEG) is a major enteral means for the introduction of nutritional solutions. However, jejunal feeding is sometimes employed instead of gastric feeding in cases of post-gastrectomy or repeated aspiration after PEG. The digestion and absorption of nutrients in trans-jejunal feeding might be different from those in trans-gastric feeding. In the present study, we measured the serum concentations of micronutrients and vitamins in the cases of direct percutaneous endoscopic jejunostomy (D-PEJ), compared to those of PEG. The enteral feeding has been continued for more than six months in all the cases. Serum copper and zinc concentration were significantly decreased in the D-PEJ group, whereas no significant difference in the concentrations of iron, selenium, vitamins A, B12 and E was ovserved between the two groups. Anemia and neutropenia were frequently observed in many patients with D-PEJ. These conditions were associated with copper deficiency. Much attention should be paid to copper and zinc deficiency in long-term trans-jejunal feeding.
Upper case dee ; Percutaneous endoscopic jejunostomy [PEJ] ; Percutaneous endoscopic gastrostomy ; Serum ; Feeding

A 57-year-old man was admitted to our hospital with adhesive bowel obstruction following pancreaticoduodenectomy performed for cholangiocarcinoma 4 months earlier. After admission, the patient remained nil per os and was closely observed. On the third day of admission, he developed worsening abdominal pain, and computed tomography revealed strangulation of the small intestinal mesentery dorsal to the superior mesenteric artery, with prolapse of the small intestine into the right upper quadrant to form a closed loop. Strangulated bowel obstruction secondary to internal hernia was diagnosed, and he underwent emergency surgery. Intraoperatively, we detected a hernia orifice formed by the mesentery and peritoneum at the site of the defect following resection of the ligament of Treitz, and we observed that approximately 2 m of the small intestine had prolapsed into the right upper quadrant. The herniated intestine was returned to the abdominal cavity, and the hernia orifice was sutured following hernia reduction. Few reports have described an internal hernia after pancreaticoduodenectomy; however, it has been reported that this operation can result in various types of internal hernia because of the complicated reconstructive procedure. Here we report our findings in this unique case together with a literature review.

We report a case of a 72-year-old woman with a tumor arising from a colostomy site that had been created 25 years earlier when rectal amputation was performed for perforated sigmoid cancer. She was referred to our hospital due to complaints of pain from the colostomy. The diagnosis was carcinoma arising at the colostomy site with lymph node metastasis. Laparoscopic surgery was performed by attaching an Applied Alexis® wound retractor to the incision site of the colostomy. Lymph node dissection was performed and the left hemicolon was resected. Carcinoma arising from a colostomy site is rare. Laparoscopic surgery was considered to be a useful procedure because it allows for lymph node dissection and intestinal mobilization with minimal invasiveness.

A chest X-ray taken during a medical checkup for a 75-year-old man revealed a nodular shadow in the right middle lung field. Chest computed tomography (CT) for further examination showed an intra-abdominal tumor as an additional finding, and the patient was referred to our department. Contrast-enhanced CT revealed a tumor (16×10×5 cm) in the left upper to middle abdomen. The tumor had a clear border and uniform fat density inside. It compressed the stomach to the ventral side, but the patient had no subjective symptoms. Magnetic resonance imaging also showed the tumor contained a uniform fatty component inside, as well as no obvious non-fatty components. An intra-abdominal lipoma was suspected, but the possibility of a welldifferentiated liposarcoma could not be ruled out due to its size. During curative surgery, intraoperative findings revealed a soft tumor, weighing 612 g, with a well-defined border in the mesentery of the transverse colon. Pathological findings showed proliferation of mature adipocytes without malignancy. We report here this case of mesenteric lipoma, a rare intraabdominal tumor, and review the relevant literature.