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【目的】胃原発広義GISTの手術適応におけるKITレセプターの臨床的意義を検討した.【対象】1987年～2001年に切除した胃原発広義GIST75例.【方法】LSAB法にてα-SMA, s-100蛋白, KITレセプターの免疫染色を行った.【結果】(1) Rosai分類いずれの群にも悪性例を認めた.(2)腫瘍径4 cm未満の症例に約40%の悪性例を含む.(3)全症例の76%がKITレセプター陽性.(4) KITレセプター陰性例に悪性例なく,陽性例中63%が悪性例.(5)再発8例全例にKITレセプター陽性.【結論】広義の胃GISTは腫瘍径で手術適応を判断してきたが, KITレセプター陰性症例に悪性例を認めない結果より生検可能であればKITレセプター染色性により手術適応を判断でき,特に腫瘍径の小さい粘膜下腫瘍の手術適応の判断に有用である.

症例は71歳,女性. 1994年右耳下腺癌(腺様嚢胞癌)の診断にて右耳下腺拡大全摘出術を受けた.局所再発を認めず経過したが1998年超音波検査にて肝右葉に10cm大の腫瘍を指摘された.超音波および腹部CT検査にて腫瘍中心部を走行する門脈枝を認め,ドップラー超音波検査にて車軸状血流を認めfocal nodular hyperplasia (以下FNH)が疑われた.腫瘍生検の結果耳下腺癌肝転移と診断され肝拡大右葉切除術が施行された.再発なく経過するも2003年12月超音波検査にて腹腔内腫瘍および肝転移を指摘された.耳下腺癌の化学療法の奏効率は低く切除を考えて開腹したが,腹膜播種の状態にて切除不能であった.本症例は原発巣術後4年で肝転移,さらに5年後に腹膜播種をきたした.長い経過で遠隔転移を呈する耳下腺癌の特徴を考慮し,長期間にわたる慎重な全身follow upの必要性が示唆された.

症例は65歳,男性.突然の下腹部痛を訴え救急車にて来院. 4年半前にC型慢性肝炎と巨大肝癌にて右三区域切除施行していた.病理所見は索状型中低分化型肝細胞癌, vp1 vv0 b0 tw0 im2で非癌肝は硬変肝であった.その後に残肝再発に対して1回の再切除と3回の焼灼療法を行っていた.来院時下腹部に圧痛と軽度の膨隆を認めたが反跳痛,筋性防御はなかった. CTにて小骨盤腔に造影効果のある腫瘤と大量の腹水を認めた.その直後出血性ショックとなり緊急手術となった.腹腔内には大量の凝血塊と小骨盤腔内右精嚢腺浸潤する直径3cm大,弾性軟の腫瘍からの出血があり腫瘍摘出術を施行した.術後13日目に軽快退院された.病理組織では好酸性異型細胞が索状に増生する中分化型肝細胞癌で, hepatocyte染色陽性であった.肝細胞癌術後の急激な下腹部痛,腹部膨満感では本症を疑い,適切かつ迅速な診断,治療が重要であると考えられた.

腎癌は転移しやすい癌であり,しかも10年以上の年月を経て転移巣が出現するなど,長期経過観察を要する疾患である.肝転移をきたした場合,ほとんどが多発で外科的切除は不能であるが,腎摘後11年を経て単発の肝転移をきたした症例に対し,肝切除術を施行し,術後4年間無再発生存をえた.病理組織学上も原発巣と同じ乳頭状腎細胞癌と診断された.乳頭状腎細胞癌は非乳頭状腎細胞癌に比べ予後良好な疾患であり,肝転移巣に対しても積極的な切除が有効と考えられた.

We experienced a case of solitary splenic metastasis after hepatectomy for hepatocelluler carcinoma. The case was a 69-years-old female without liver cirrhosis or hepatitis. She underwent “so called Right Liver Trisegmentectomy” for large hepatic tumor on November 16, 1993. Pathological findings revealed trabecular type moderately differentiated hepatocellular carcinoma. fc (+), fc-inf (+), Vp0, Vv0, b0, tw (-), im 1. Seven months later, we observed multiple liver metastasis and a low density splenic tumor of 2cm diameter by computed tomography. We perfomed Trans arterial embolization on the liver metastasis, but the splenic tumor had enlaged to 4cm diameter. We diagnosed the splenic tumor as metastasis of hepatocellular carcinoma. She underwent splenectomy on March 20, 1995. Before and during the operation, we found other evidence of metastatic tumors except for those detected in the liver and spleen. Immunological competence levels were within the normal range. There had been 8 cases of solitary splenic metastasis of hepatocellular carcinoma reported in Japan, and only 2 were resected.

Intrahepatic metastasis via the portal venous system and bloodborne distant metastasis are common in hepatocellular carcinoma. However, lymph node metastasis after resection of hepatocellularcarcinoma is rare. and recurrence of lymph node metastasis after surgical resection is also rare. On the other hand, detection of lymph node metastasis has been reported in about 30% of autopsy cases. We carried out this clinicopathological study to assess patients positive for lymph node metastasis among those who underwent surgical resection of hepatocellular carcinoma. A total of 951 patients underwent resection of HCC in our department during the period from 1983 to 1995, and 57 of them, the lymph nodes were dissected or the hepatoduodenal liga-ment and superior pancreatic rim alone were sampled intraoperatively because lymph node enlargement was noted during surgery. Histological examination showed lymph node metastasis in 7 patients. The carcinomas were larger than 4cm in diameter in all 7 patients and had invaded other organs in 3 of them. Many metastic lymph nodes were detected in cases 8 and 12. Lymph node metastasis was associated with cirrhosis in one of them. All 7 patients had poorly-differentiated HCC, with extensive interstitial invasion. We analyzed the correlation between lymph node metastasis and levels of carcinoembryonic antigen (CEA), tumor grade and liver tissue. There was a significant correlation between these facters and lymph node metastasis (p

A series of 61 cases of achalasia of the esophagus underwent cardioplasty at the hospital from January 1985 to December 1996, and of these 61 cases, there were 11 cases of reoperation and 50 cases of initial operation. Reoperations were conducted by modified Jekler method in nine cases in which myotomy was possible, by fundic patch method advocated by Thal-Hatafuku and others in the remaining two cases in which myotomy was impposible. Esophageal inner pressure was measured before, during and after the operation to gain the lower esophageal sphincter pressure (LESP) and high pressure zone (HPZ). There was no remakable difference in LESP and HPZ among initial operation cases, whole reoperation cases, and reoperation cases by modified Jekler method. On the overall evaluation according to Payne' s criteria, however, all cases of initial operation were rated as excellent, but among reoperated cases two cases undergoing modified Jekler method and one cases undergoing fundic patch were rated as good and one case undergoing fundic patch was rated as fair due to regurgitant esophagitis. Compared with modified Jekler method, fundic patch tended to make severe degree of cicatrization that might cause the difference in surgical outcome. It is thought that the reoperation for esophageal alachasia may result in relatively favorable outcome by performing myotomy as possible as we can.

We compared the antibacterial effect of a liquid hand-washing disinfectant containing aqua oxidation water with those of other liquid disinfectants, such as povidone-iodine and sterilized water. The bacteria count of the hands was chronologically measured before washing, after washing, and after surgical operations, and the measurements were compared between the subjected disinfectant and other conventional preparations. The antibacterial activity of the liquid disinfectant containing aqua oxidation water was comparable to that of povidone-iodine. These features of aqua oxidation water would make it a viable alternative to conventional liquid disinfectants used for hand washing before surgical operations.

Intra-abdominal infection following hepatectomy is a serious complication that prolongs postoperative course and develops into sepsis or hepatic failure in severe cases. We have recognized intra-abdominal infection in 108 of 439 patients who underwent hepatectomy throughout the past 6 years. The preoperative risk-factors for intraabdominal infection included diabetes mellitus, excessive alcohol consumption and liver cirrhosis. The infection occurred in such conditions with decreased immunological competence in a significantly high frequency. The risk factors included surgical procedures with a wide cut surface and a dead space, surgery with massive bleeding, incision of the liver by microwave tissue coagulator, and use of microcrystalline collagen. The postoperative risk factors included open drainage and the use of broad spectrum cephem antibiotics (Ishibashi's 5th group). Based on the above results, closed drainage method was used, then hepatic incision using a surgical ultrasonic aspirator with an electric coagulator was adopted, and the frequent use of wide spectrum cephem antibiotics was discontinued. Thus, the incidence of intra-abdominal infection and the frequency of the MRSA infection has greatly decreased year by year.

Recent experience with a case of pancreatic head preserving excision of the duodenal papilla under a diagnosis of carcinoma of the duodenal papilla is presented here. An 85-year-old man who pointed out abnormal levels of enzymes excreating to bile was diagnosed as having a carcinoma of the duodenal papilla by close examination. The lesion was confirmed as a tumor localizing from the duodenal papilla to near the confluence of the main pancreatic duct and common biliary duct. Intraoperative ultrasonography revealed no clear infiltration into the pancreas, but showed lymph node metastasis in the posterior portion of pancreatic head. When his risk factors including advanced age and impaired cardiac and renal function were considered, pancreatic head preserving excision of the duodenal papilla was selected for better postoperative quality of life. The freeing of the duodenum from pancreatic head was possible by resecting the rami duodenales branching from duodenal arcade. Postoperative course was uneventful and on the 5th week the patient was able to take foods orally and to have normal daily activities. There may be a great argument about the indication for the operative procedure, but it appears to be permitted as a more limited operation for carcinoma of the duodenal papilla.

In cases of massive bleeding from post-bulbar duodenal ulcer, pancreatoduodenectomy has sometimes been done to resect the bleeding portion. However, since this operation is performed at emergency, it is desirable to reduce its risk. We have devised a simplified operative procedure, pancreas-saving duodenectomy. In this operation, the feeding vessels of the duodenum are transected on the line of pancreato-duodenal fixation. There is no need to resect any part of the pancreas. We have experienced two cases of this operation with satisfactory results. In the first case, the duodanal papilla remained as a 3×3cm patch, and anastmosis to the jejunum was designed for reconstruction. In the second case, the duodenal papilla was also resected, and the pancreatic duce and bile duct, which were directly opened at the head of the pancreas, were anastomed to the jejunum.