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比較的稀な胃前庭部に発生した胃平滑筋腫に対して完全腹腔鏡下幽門側胃切除術を施行した1例を経験したので若干の文献的考察を加えて報告する.症例は26歳の女性.主訴は心窩部痛.上部消化管内視鏡検査にて胃前庭部後壁に径3.5cmのdelleを伴った粘膜下腫瘍を認めた.完全腹腔鏡下手術への希望が強いため,書面でのICをとった上で完全腹腔鏡下幽門側胃切除術を施行した.手術は気腹法で施行した.超音波凝固切開装置を用いて,胃大彎側および小彎側における胃壁周囲の血管処理と胃結腸間膜および小網の切離を行った.右胃大網動静脈の血管処理は,末梢にてクリップを使用した.十二指腸は,幽門輪から約2cm肛側,胃は胃角部にて切離した.再建はBillroth-I法とし,吻合は後壁の漿膜筋層を3針結紮縫合して胃と十二指腸を固定してから,後壁・前壁の順に全層連続縫合を施行した.腫瘍は3.5×3.5×1.8cmの大きさで,幽門輪までの距離が2cmであった.病理診断は平滑筋腫で術後経過は良好で術後17日目に退院した.幽門輪に近接した胃平滑筋に対し完全腹腔鏡下幽門側胃切除術は有効であると考えられた.

We present a patient with extragastric pedunculated gastric leiomyoma together with some bibliographical discussion. A 74-year-old woman had jaundice, with a lesion in the duodenal papilla. A gastric tumor was detected on abdominal computed tomography, but there were no abnormal findings in other examinations. Gastric submucosal tumor was diagnosed, and surgery was performed to remove this tumor and the duodenal papillary lesion. A tumor growing extramurally in a pedunculated manner was observed in the greater curvature-side on the anterior wall of the gastric antrum. Since this tumor was within the range covered by pancreaticoduo-denectomy for a duodenal papillary lesion, it was also removed in lump. The tumor was 3.0×2.5×1.5cm in size, lobular and tuberous, grayish black, elastic and soft, and fragile. Histopathologically, it was a myoepithe-lial tumor without malignant findings, and leiomyoma was diagnosed. The proper muscular tunic occupied by the tumor was growing in a pedunculated manner, and extragastric pedunculated gastric leiomyoma was sus-pected. This leiomyoma is extremely rare, and so far only 23 cases have been reported in Japan.

A 64-year-old woman was under observation for a submucosal tumor on the anterior wall of the stomach close to EC-junction which was detected 2 years before. The tumor rapidly enlarged in these several months. Upper gastrointestinal series and endoscopy revealed a submucosal tumor of Yamada's type II 2.5cm in longer diameter in the vicinity of the EC-junction with bridging fold. The tumor was shown as homogeneous mass connecting to the proper muscle layer in endoscopic ultrasonography. The patient underwent a laparoscopic wedge resection of the stomach after cutting of serosa surface on the tumor to prevent post-operative stenosis. The tumor was completely resected and histologically diagnosed as cellular leiomyoma. This procedure may be superior therapeutic method to the conventional laparotomy approach in the good curability, less post operative pain and excellent cosmetic benefit.

This paper describes a case of pedunculated gastric smooth muscle tumor. An asymptomatic 46-year-old man was pointed out to have a huge abdominal tumor in the left upper quadrant of the abdomen at an annual medical examination. The patient was admitted to the hospital for examination. Abdominal CT scan and MRI visualized a solid tumor with scattered small portions internally which seemed like hemorrhagic foci. The solid tumor, which was not demarcated from the spleen, was located in the left upper abdominal cavity. Abdominal ultrasonography revealed strong internal dot echoes, but ultrasonographic Doppler examination did not indicate rich blood supply in the tumor. Celiac angiogram showed a hypervascular huge tumor which was mainly fed by dilated splenic artery. Laparotomy proved that the tumor was well circumscibed and located between the stomach and spleen. The tumor, which was extirpated with small area of adherent gastric wall, was 15cm in maximum diameter with homogeneous yellowish solid section. There was no metastatic lesion. Histological examination revealed the tumor consisted with smooth muscle of spindle shaped cells with few mitosis. The tumor was determined to be originated in the gastric wall, because the tumor was continuous with muscle layer of the stomach wall by thin stalk (0.3cm).

Two rare cases of gastric leiomyoma with cyst formation are reported. Case 1: 74-year-old man visited the hospital because of an abdominal tumor. On admission an irregular surface mass (12×12 cm) was palpable at the epigastric region. Gastrofiberscopy and abdominal computed tomography revealed a submucosal tumor with multiple cyst formation. In May 1986, gastrectomy was performed and histological diagnosis was gastric leiomyoma. Case 2: A 60-year-old woman was hospitalized because of nausea and vomiting. Gastrofiberscopy, abdominal CT and ultrasonography revealed a submucosal tumor with cyst formation. In June 1990 partial gastrectomy including the tumor was performed. The histological diagnosis was gastric leiomyoma. Only one case of gastric leiomyoma with cyst formation has been in the Japanese literature. Because of a malignant potential, we should take surgical operation for the first choice.

In a 56-year-old man under the treatment of gastric ulcer with anemia, a submucosal tumor in the posterior wall of the middle portion of gastric corpus was accidentally found by upper gastrointestinal series and gastroendoscopy. Abdominal CT and unltrasonography revealed a solid mass about 7 cm in diameter, locating in front of the pancreas and presenting as extragastrical growth. An extragastrically growing leiomyosarcoma was strongly suspected preoperatively. On laparotomy, an egg-size tumor was found to be arising from the posterior wall of the corpus of the stomach. The mass was pedunculated and encapsulated with no evidence of invasion into the surrounding organs. No hepatic metastasis nor peritoneal dissemination was found. Subtotal gastrectomy with dissection of regional lymphnodes (R1) was performed. The resected mass measured 7.5×6.2×4.2 cm in size and lobulated with partial cystic degeneration.Pedunculated gastric leiomyomas growing extragastrically behave specifically and differently from those presenting as other growth patterns. Here we describe a case and discuss its clinicopathological features and some problems in the surgical treatment.

DNA ploidy was studied with flow cytometry in 20 cases of smooth-muscle tumor of gastroduodenal origin. There were 13 leiomyomas and 7 leiomyosarcomas. Clinico-pathological parameters, mitotic index, cellularity and histological grade clearly differed between leiomyoma and leiomyosarcoma. Only one of 13 cases of gastric leiomyoma revealed aneuploidy and the rest of 12 cases did diploidy. Conversely, 4 of 5 cases of gastric leiomyosarcoma showed aneuploidy. Two cases of duodenal leiomyosarcoma showed diploidy. Repeated measurements of DNA ploidy did not always yield the same ploidy as seen in the previous measurement, in that unhomogenous presence of DNA was inferred. Occurrence of aneuploidy was significantly higher in the leiomyosarcomas, but the prognostic value is still unlear, because postoperative late death occurred only in one case in which complete resection of widespread invasion was unsuccessful. Long-term follow-up is needed to evaluate the usefulness of DNA ploidy analysis as a prognostic factor of gastroduodenal smooth-muscle tumors.

A case of calcified gastric leiomyoma is reported. A 76-year-old female complaining of upper abdominal pain was pointed out calcifications on an abdominal plain X-ray film, and an abdominal tumor touching to tail of the pancreas on CT. On laparotomy performed under a diagnosis of pseudo-pancreatic cyst, the tumor was found to be a gastric leiomyoma growing as extrastomach.To our knowledge, in Japan, 12 cases of calcified leiomyoma of the stomach have been reported. From a review of these literature, calcified leiomyomas, when compared to noncalcified leiomyoma, are characterized by 1) to be predominant in aged women; 2) to be frequently in the middle of the stomach, where the leiomyomas attend to show no manifestations; and grow extrastomachically. These characteristics and pathologic findings suggest that a possible inclusion of dystrophic calcification might contribute to the mechanism of the calcification. In addition it was extremely remarkable that all calcifications were massive type.

A 36-year-old man visited our hospital with a complaint of dysphoria of the epigastrium. A torous lesion was observed in the cardia by esophagogastric fluoroscopy. The patient was diagnosed as having submucosal tumor by endoscopic and biopsy examinations, and transgastric excision of the tumor nucleus was undertaken. The tumor was oval-shaped (ca. 5.5cm in a long diameter), white and solid. The histopathological findings indicated benign leiomyoma. The course was favorable two years after operation. Only 28 cases of leiomyoma in the esophagocardiac junction have been reported in Japan. Cases of leiomyoma in the esophagocardiac junction were compared with those in the esophagus and stomach. The most common age of occurrence for leiomyoma in the esophagocardiac junction was relatively young, 30s to 40s, similar to that of lesiomyoma in the esophagus. Chief complaints on admission to hospital also resembled those in esophageal leiomyoma: disturbed deglutition, epigastralgia and subclinical condition. These chief complaints were clearly different from those in gastric leiomyoma, i.e., hemorrhagic symptoms, unidentified clinical epigastric condition and abdominal mass. Leiomyoma in the esophagocardiac junction, esophageal leiomyoma and gastric leiomyoma showed different patterns of tumor development, and preoperative diagnosis is difficult in all cases. Unless specific circumstances (a markedly large tumor suspected of being malignant, full peripheral development of a tumor, or the presence of a serious complication) are present, excision of the tumor nucleus should be carried out as the first choice treatment.