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ObjectivesAn extra-anatomic reconstruction would be beneficial in preventing recurrent malignant dysphagia. A long gastric tube that allowed a sufficient blood flow was necessary to perform the successful cervical anastomosis through the retrosternal route.MethodsThe gastric tube was created by means of separate division and closure of the seromuscular and submucosal-mucosal layers (stepwise group) in 15 consecutive patients and by means of full-thickness cutting of the stomach and closure of the seromuscular layer (standard group) in 22 patients. We compared these 2 types of gastroplasties in terms of total length of the tube, blood flow, and the incidence of anastomotic leakage. Blood flow was measured with a laser Doppler flowmeter during surgical intervention.ResultsThe gastric tube in the stepwise group was significantly longer than that in the standard group (P < .01, unpaired t test). Tissue blood flow at the site of anastomosis in the stepwise group was significantly greater than that in the standard group (P < .01, unpaired t test), and the rate of anastomotic leakage in the stepwise group was significantly lower than that in the standard group (P < .05, χ2 test).ConclusionWe consider this technique to be a useful procedure for retrosternal reconstruction after subtotal esophagectomy.

食道胃静脈瘤に対するHassab手術, 経腹的食道離断術および内視鏡的硬化療法 (EIS) 後の経過観察中に早期胃癌を認め, 幽門側胃切除術を施行しえた症例を経験した.症例は63歳の男性で, 1987年胃静脈瘤の診断でHassab手術および経腹的食道離断術, 1995年食道静脈瘤を認めEISを施行した. 1997年4月胃内視鏡検査で前庭部に早期胃癌を認め, 腹部血管造影X線検査ではHassab術後のため胃の栄養動脈は右胃・胃大網動脈であった. 同年5月19日胃癌に対して手術を施行した. 右胃・胃大網動脈および十二指腸を結紮・切離した後も胃の血行は良好であったため, 幽門側胃切除術を施行した. 病理組織診断は低分化型腺癌, 深達度sm, 術後経過は良好で第26病日に退院した. Hassab手術, 食道離断術およびEIS施行後ある程度の期間が経過した後には幽門側胃切除術は安全に行える可能性があると思われたので報告した.

Virchowならびに大動脈周囲リンパ節転移を有した進行S状結腸癌に対して根治度Bの切除術を施行し, 術後6年現在, 無再発生存が得られた症例を経験したので報告する.症例は48歳の女性で, 1991年9月左鎖骨上窩の腫瘍にて来院した. リンパ節生検および注腸検査よりVirchowリンパ節転移を伴った進行S状結腸癌と診断された. 11月8日S状結腸切除ならびにD4郭清を施行した. 病理組織診断は中分化型腺癌, ss, n4 (+), P0, H0, M (+), ow (-), aw (-), ly (3), v (3), stage IVであった. リンパ節転移 (合計16/48) を認め, 特に腹部大動脈周囲には多数の転移 (9/30) が認められた. 術後補助療法として, 5年間UFT600mgの内服を行ったが, 現在術後6年, 無再発生存中である.n4症例の予後は一般的に不良とされているが, 自験例のように積極的な手術および補助療法により予後が改善される症例も認められると思われたので報告した.

胃静脈瘤を合併した特発性門脈圧亢進症の手術前後に肝血行動態を検討し, 術後肝内門脈血流の改善が示唆された症例を経験した.症例は41歳の女性で, 特発性門脈圧亢進症・胃静脈瘤に対してHassab手術を施行した. 術前の血管造影X線検査では脾腫, 脾静脈から門脈本幹の拡張, 肝内末梢門脈の造影不良ならびに側副血行路である臍静脈の開存・拡張がみられたが, 術後は門脈本幹・臍静脈の径は軽減し, 肝内末梢門脈枝の描出が良好となった. 99mTc in-vivo標識赤血球肝動脈門脈血流シンチでの肝右葉/門脈臍部血流比は術前門脈臍部優位であったが, 術後肝右葉優位に逆転した. 術前の123I-IMP経直腸門脈シンチではほとんどの123I-IMPは門脈から大循環へshuntされていたが, 術後はshunt量が低下し, 肝内に集積された.以上よりHassab手術後門脈大循環shunt量の低下および肝内門脈血流の改善が示唆された特発性門脈圧亢進症の1例を経験したので報告する.

Giant cell arteritis (GCA), an inflammatory vasculopathy that preferentially affects medium-sized and large arteries, has diverse symptoms and varied clinical courses that can make the diagnosis difficult. We describe a 75-year-old woman in whom GCA presented as lack of a pulse in the right arm. Although steroid therapy is generally effective for treating GCA, surgical intervention provides a biopsy specimen for a definitive diagnostic study and restores blood flow in the affected limb. GCA should be considered along with atherosclerosis in cases of occlusive disease of the upper extremity, especially if the patient is an elderly woman.

More than 95% of patients with primary hyperparathyroidism have been treated with bilateral neck exploration by experienced surgeons. This procedure has been performed without employing preoperative localization tests or specialized techniques of intraoperative measurement. A renewed interest in unilateral neck exploration for primary hyperparathyroidism emerged (in three developments), in an attempt to maintain the excellent cure rate and to minimize the invasiveness of the procedure. The first development was the introduction of sestamibi scintigrams as a new preoperative localization technique and intraoperative nuclear mapping with a hand-held gamma probe. The localization of adenomas using this technique was much more accurate than that of previous localization studies, allowing unilateral procedures to become feasible. Sestamibi guidance enables parathyroidectomies to be performed much more rapidly through a significantly less invasive dissection. Secondly, the intraoperative quick parathyroid hormone assay allows the confirmation of removal of the parathyroid mass. The third development was endoscopic parathyroidectomy. Various approaches have been shown to be technically feasible, including endoscopic procedures that rely on CO 2 insufflation to create a working space or video-assisted procedures in which the working space is maintained through conventional external retraction. Given the safety and high success rate of the standard exploration, the potential advantages of these new strategies include decreased operating time, local or regional anaesthesia rather then general anaesthesia, and smaller incisions. ( Asian J Surg 2002;25(2):184-7)

Although thoracoscopic techniques have been introduced to esophageal surgery, the identification of the left recurrent laryngeal nerve and lymph node dissection along the nerve remain quite difficult. A mediastinoscopic technique via the neck enables an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve. Therefore, a thoracoscopic esophagectomy combined with this technique allows mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily and safely dissected.

Objectives: We sought to investigate the effect of tissue blood flow on the incidence of anastomotic leakage during esophagectomy. Methods: Reconstruction was done with a gastric tube, and all cases involved cervical anastomosis. Tissue blood flow of 43 patients was measured with a laser Doppler flowmeter before emplacement and after anastomosis during surgical intervention. The reconstruction route and tissue blood flow before emplacement and that after anastomosis were analyzed as possible factors influencing anastomotic leakage. Results: Tissue blood flow after anastomosis with leakage was 9.1 ± 2.0 mL/min per 100 g, and that without leakage was 13.7 ± 2.9 mL/min per 100 g. Tissue blood flow with leakage was significantly lower than that without leakage (P