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54歳女性，腹部膨満感を主訴に当院内科を受診．大腸内視鏡検査で，S状結腸に約半周性の2型病変（生検:高分化型腺癌）を認め，数日後に自覚症状が強くなり緊急入院となった．入院後の腹部造影CTで，S状結腸の壁肥厚像，長径約10cm大の多房性嚢胞性腫瘤と多量の腹水を認めた．腹水細胞診はclassIIで，貧血もなく，左卵巣癌の疑いで精査を進めたが，急な腹痛と腹水の増加を認め緊急開腹手術を施行した．開腹時に濃厚な血性腹水を認め，左卵巣腫瘤の破裂による出血と判明した．腹水の迅速細胞診で腺癌細胞を認め，S状結腸癌同時性卵巣転移の破裂と診断，高位前方切除術+左卵巣摘出術を施行した．病理組織診断および免疫組織診断により左卵巣腫瘍はS状結腸癌の卵巣転移と診断された．術後は補助化学療法を施行し，術後4年現在，無再発生存中である．

症例は64歳,男性. 37歳時に十二指腸潰瘍のため幽門側胃切除術の既往を有していた.食物つかえ感,心窩部痛のため上部消化管造影,胃内視鏡検査を施行したところ胃噴門部にほぼ全周性のBorrmann III型腫瘍を認めた.生検でgroup Vと診断され,手術を施行した.総肝動脈,膵頭領域,大動脈周囲のリンパ節が一塊となり,著明に腫大していたため,根治術は不可能と判断し,姑息的な残胃全摘術を施行した.病理組織検査では細胞質に乏しい,小型から中型の核を有する異型細胞が索状,充実性に増殖しており,著明な核分裂像,脈管侵襲像を認めた.腫瘍細胞は好銀顆粒を有し,酵素抗体法でsynaptophisin, chromogranin, gastrinが陽性なことから,内分泌細胞癌と診断された.術後4カ月に多発肝転移を生じ1年で癌死した.胃内分泌細胞癌は稀な疾患であるが,残胃に発生したとする報告は少なく,極めて稀な症例と考えられた.

最大腫瘍径3cm以下, 3病巣以下の肝細胞癌(HCC)切除49例, 56結節を対象に,腫瘍および腫瘍周囲の病理組織像を腫瘍径別(径15mm以下; 12結節, 16-20mm; 20結節, 21-25mm; 16結節, 26-30; 8結節)に検討し,選択すべき治療法を考察した.腫瘍径15mm以下のHCCでは,腫瘍周囲進展像(被膜外浸潤・脈管侵襲・肝内転移)陽性が1結節(8.3%)のみであったため,経皮的エタノール注入療法(PEIT)が第一選択と考えられた.しかし,中・低分化型が6結節(50%)に混在していたこと,被膜形成陰性が5結節(41.7%)にみられたことは, PEIT後の局所再発へのrisk factorとして留意すべきと思われた.腫瘍径16mm以上のHCCでは被膜浸潤が59.1%, 腫瘍から1cm以内の腫瘍周囲進展像が45.5%と高率にみられ,またPEIT施行後肝切除例の4結節中の1例(腫瘍径22mm)に肝内転移の組織学的遺残がみられたことから,腫瘍周囲を含めた確実な局所コントロールが可能な治療法,すなわち肝切除術やマイクロ波凝固壊死療法が第一選択となると考えられた.

閉鎖孔ヘルニアは高齢者の女性に好発する比較的稀な疾患で,穿孔例の報告は少ない.今回,閉鎖孔に嵌頓した象徴が穿孔し,大腿部に巨大な膿瘍をきたした1例を経験したので報告する.症例は82歳女性で,腹痛,嘔吐,左大腿部痛のため,近医を受診.同医でイレウスと診断され保存的治療が行われるも改善せず,左大腿部の腫脹が出現した.画像上,大腿部にガス像を認めたことよりガス壊疸の疑いで当科に紹介された. CTでは,左大腿部に膿瘍を認め,その上方は左閉鎖孔に近接していた.また前医で挿入されたイレウス管の先端は左閉鎖孔付近で停止していた.膿瘍穿刺液にenterococcusが検出されたことより,閉鎖孔ヘルニア嵌頓による小腸穿孔と診断した.術中所見では回盲部より75cm口側の小腸が左閉鎖孔に嵌頓・穿孔し,大腿側に穿破していた.小腸部分切除とヘルニア門の修復を行い軽快退院した

A 50-year-old man who had been operated on for fibrosarcoma of the right upper arm, was admitted to the hospital because of a right adrenal tumor. Abdominal ultrasonography and computed tomography disclosed an abnormal tumor in the right adrenal gland. Bone scintigraphy showed metastatic bone tumor. The adrenal tumor was enlarging quickly, and so we considered that operation was indispensable. Under a suspicion of adrenal metastatic tumor, a right adrenalectomy was performed. Resected specimen showed a 5.4×4.4cm tumor, contained coagulating tissue. Histological findings were the same as those of fibrosarcoma of the right arm. Adrenal metastasis of fibrosarcoma was diagnosed. The metastatic adrenal tumor is rare, especially that of fibrosarcoma. Although the prognosis of metastatic adrenal tumor is usually poor, a better prognosis can be expected by positive excision of the tumor, if the original foci is well controlled and no other prominent metastasis is present.

Insulinomas are comparatively rare. We successfully operated on a cases of insulinoma of which localization was revealed by preoperative as well as intraoperative examinations. A 20-year-old man was admitted because of an unconsciousness attack. By magnetic resonance imaging and ultrasonography, a tumor with the size of 2cm in diameter was found in the tail of the pancreas. We performed percutaneous transhepatic portal catheterization (PTPC) and selective arterial calcium injection (SACI), in which the localization of the tumor was diagnosed by observing the marked increase in the insulin concentration of the portal venous blood sampled near the tumor site. Partial resection of the tail of the pancreas without splenectomy was performed. In our case, hypoglycemic attacks did not occur any more after the operation. Because the surgical resection is the primary choice for the treatment of insulinoma it is necessary to diagnose the localization of the tumor preoperatively and intraoperatively for a successful resection. It is though that PTPC and SACI were useful examinations for insulinoma.

Recently, transjugular intrahepatic portosystemic shunt (TIPS) has been proposed to produce portal decompression in patients who have gastroesophageal varices and intractable ascites. We experienced a case of death due to liver failure after TIPS. A 70-year-old male undergoing a partial resection of the liver developed intractable ascites following this operation. TIPS was performed about one year after the operation because of the failure of other treatments. The right hepatic vein was selectively catheterized with a sheath via a right internal jugular approach. The shunt was created between the hepatic and portal veins by using a 10mm diameter balloon catheter and 10mm diameter wallstents. The procedure was successful, and the portal pressure decreased from 27.5cmH2 O to 23.5cmH2O after TIPS. Portal blood flows in the right and left branches were not detected by portography or doppler echography. Ascites decreased gradually, and disappeared on day 7 after TIPS. However, the patient died on day 22 after TIPS due to hepatic encephalopathy progressing to hepatic failure. It was suggested that excessive shunt-flow deteriorated the liver function. TIPS should be considered with caution in the indication and the optimization of the shunt-flow.