Search

回腸-結腸型腸重積症を呈した重積内腸管に単純性小腸潰瘍が存在し,穿通・瘻孔を形成したため腸閉塞の腸管内減圧が得られ,閉塞症状の改善をきたしたと推察される1例を経験した.症例は59歳女性で,腹痛,食思低下の初発症状より約1カ月間自宅にて放置され,嘔吐,全身浮腫,意識レベルの低下をきたし当院へ搬送された.全身管理のもと諸検査施行し成人腸重積症の診断下に外科的手術を行った.術後摘出標本所見,病理組織学的所見および臨床経過より単純性小腸潰瘍および瘻孔の存在する腸重積症と診断した.腸重積症と小腸潰瘍との合併例,また腸重積腸管内での穿通,瘻孔形成をきたした報告例はわれわれの検索しえた限りではなく,極めて稀な症例と思われるので報告した.

A 72-year-old female was admitted to the hospital because of upper abdominal pain and vomiting. A chest plain film demonstrated dextrocardia and bowel gas at the left phrenic o-costal angle. An upper GI barium series and barium enema revealed that the antrum portion of the stomach and transverse colon were incarcerated in the left thoracic cavity. Surgery was carried out using the trans abdominal approach. The operative findings included that the hernia sac contained the greater omentun, stomach and transverse colon; and that the liver and gallbladder were found in the left side of the abdominal cavity, the spleen was in the right side of it. Moregagni hernia has been reported in around 3% of all diaphrag-matic hernias, but we could not find any literature concerning this disease associated with situs inversus. The most valuable diagnostic approaches were chest X-ray, CT, or MRI scan and barium GI series. She was discharged in satisfactory condition on the 14th postoperative day uneventfully.

It has increased that we encounter reports concerning a malignant lymphoma which appeared in the chest wall several decades after tuberculous empyemathorax or tuberculous pleuritis. A 54-year-old male, with asymptomatic chronic empyema thorax was admitted to the hospital because of pain from a huge chest tumor. The chest CT and MRI studies revealed that the tumor of the chest wall invaded the ribs, and it seems to arise from the chest wall which adjoined to the peel of the parietal pleura with severe carcifications of the empyemathorax. Biopsy of the tumor revealed a non-epitherial malignant tumor but correct diagnosis of a malignant lymphoma could not be attained. The tumor of the chest wall was widely resected and a radical surgery was also performed for chronic empyemathorax. The resected specimens were pathologically diagnosed as non-Hodgikin's malignant lymphoma which was of B cell lymphocyte origin, diffuse type and medium sized cell type by LSG classification. Two courses of chemotherapy with ACOP were administered after the surgery. There has been no sign of local recurrences and metastasis up to now. We discussed and reviewed this unusual cases which have been previously published in the Japanese literature.

Seventy-six lesions of 38 cases of multiple early gastric cancer were clinicopathologically studied, and the localization of CEA and CA19-9 in the lesions was also investigated using enzyme antibody method. Multiple early gastric cancer (double cancer) accounted for 5.5% of all resected gastric cancers, and was predominant in elderly men, and in region A and M. Macroscopically, the major lesions predominantly compresied torus type, while the minor lesions, concave type. Histologically well differentiated tubular adenoma was predominant in both lesions. Twelve of 38 (31.6%) minor lesions occupied oral-side regions from the major lesions, and 11 minor lesions were comparised of minimal size of cancers. The importance of appropriate decision of the resection area should be emphasized not to leave the minor lesions in the residual stomach. As for tumor markers, both CEA and CA19-9 were positive in all lesions of poorly differentiated cancers. On the other hand, CEA positive rates in well defferentiated cancers were 80.6% in the major and 56.3% in the minor lesions, and CA19-9 positive rates, 64.5% and 50.0% respectively. Both tumor markers showed higher positive rates in major lesions rather than those in the others, which might reflect a fact that, with the lapse of time, the cancers gradually proliferated, differentiated, and produced the tumor markers.

Since 1985, we have been performing an extensive combined resection of the unilateral diaphragm under left thoracotomy in cases of gastric cancer with esophageal invasion, involving invasion to the serosa without distant or disseminated metastasis. From 1976 to 1988, the resection was performed in 111 cases of upper gastric cancer with esophageal invasion. When classified by the approach route, there were 77 cases of left thoracoabdominal approach and mediastinal incision, and 34 of abdominal approach alone. Of the 77 cases of left thoracoabdominal approach, combined resection of the diaphragm was performed in 22, and the surgical results were evaluated form 17, after excluding 3 of only partial resection of the diaphragm, one of remnant gastric cancer and one of multiple cancer. The 2 year survival rates all ps (+) cases were 64% for combined resection and 41.8% for non-combined resection. When classified by stage, the survival rates in stage IV cases were 55.6% for combined resection, and 12.5% for non-combined resection, showing a significant different.

We experienced a case of early gastric carcinoma of type IIc occurred 36 years after gastrojejunostomy in the pyloric stenosis due to gastric ulcer.This case is a 56-year-old man. A concave lesion and concentrated pattern of mucous membrane connecting to the gastrojejunostomy regions of the greater curvature of corpus ventriculi were noted. The patient was diagnosed as having a signet-ring cell carcinoma by endoscopic biopsy. Gastrectomy of the pyloric side including anastomotic regions was carried out, and reconstructed by Roux-en-Y method. The macroscopic type of the extirpated sample was early gastric cancinoma of type IIc and histologically it was in H0P0n0 m: stage I. The tissue type was signet-ring cell carcinoma. With regard to the developmental mechanisms of gastric carcinoma after gastrojejunostomy, a chemical factor due to stimulus of duodenal juice is the most important. Endoscopy is useful for the diagnosis of the disease, especially, changes of surroundings of the anastomotic region should be marked in the follow up of stomach performed gastrojejunostomy.

A retrospective study has been made on resected 541 cases of early and primary gastric cancer for past 22 years, to know characteristics of early gastric cancer detedted by mass screening. The cases were divided into screening group (n=86) and non-screening group (n=455). 1) In both groups tumors commonly occurred in M-region and lesser curvature site. A greater number of sinking type macroscopically or differenciated type histologically was observed. 2) A lower occurrence in the anterior wall and higher occurrence in the posterior wall were noted in the screening group. 3) The most commonly detected tumors were 1.1 to 2.0cm in longer diameter in both groups. In the screening group no case of minute carcinoma was detected, while minimal for large mass 5cm or more. 4) In the screening cases m cancer was more commonly found than sm cancer, showing lower anginal invasive rate and metastasis rate to the lymph nodes. Accordingly, mass screening can not be expected to detect minute carcinoma because of its essential objective of screening. However, it is advantagous to detecting a large number of early gastric cancers less than 5cm in diameter, accompaning neither vascular invasion nor lymph node metastasis. Further spreded use of mass screening is desired.