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小腸軸捻転症は比較的まれな疾患であり，今回，空腸憩室が原因と考えられた1例を経験した．症例は90歳，女性．上腹部痛を自覚し，数日後上腹部痛が増強したため来院した．腹部造影CTでは上腸間膜動脈を中心としたwhirl signを認め，小腸軸捻転症と診断し同日緊急手術を行った．手術所見では，小腸は全体が上腸間膜動脈を中心として反時計回りに720度捻転していた．腸管壊死はなく用手的に軸捻転を整復した．この際，Treitz靱帯より30cm肛門側の空腸の腸間膜対側に憩室を認め，その位置的関連から，軸捻転の原因と考えられた．このため憩室基部を楔形に切除し縫合閉鎖した．原因不明の腸閉塞症例では小腸軸捻転症も念頭に置き精査を行い，術中憩室を認めた場合には憩室の切除を行って，軸捻転の再発を防止すべきと考えられた．

症例は69歳の女性で, 高度の貧血で発症した. 上部消化管造影検査や内視鏡検査, 腹部CTで胃体上部大彎から胃内外に発育する腫瘍を認めた. 術前に確定診断が得られず, 広義の胃間葉系腫瘍として手術を施行した. 腫瘍は基部を有し, それから3方向に発育していた. 基部の胃壁を全層性に切除して標本を摘出した. 切除標本の病理検査では, 大部分は粘液性, 一部線維性の基質の中に紡錘形の異型細胞と多核巨細胞が存在する悪性線維性組織球腫様の所見であった. しかし, 腫瘍のごく一部に脂肪細胞と非定型的な脂肪芽細胞を認めたことから脱分化型脂肪肉腫と診断された. 胃原発の脂肪肉腫は, 本邦, 欧米合わせて31例の報告しかないが, 脱分化型の報告はない. 本例が胃に発生した脱分極型脂肪肉腫の初めての例と思われたので報告する.

乳癌による髄膜転移は非常に稀であり, 予後不良の疾患でもある. 今回われわれは, 左下肢麻痺で発症し, 急速に神経症状が進行した乳癌髄膜癌腫症の1例を経験した. 症例は67歳, 女性. 平成8年10月4日, 左乳癌 (T2 N0 M0 Stage II) に対して胸筋温存乳房切除術 (Bt+Ax+Ic) を施行した. 平成13年より胸骨傍リンパ節再発, 局所再発を繰り返し, 腫瘍切除, 放射線治療, 化学療法を施行されていた. 平成18年5月16日, 左下肢麻痺が出現, 脊髄MRIにて第7頸髄～第6胸髄に髄膜の肥厚を認めた. 髄液細胞診にて腺癌細胞が疑われたため, 髄膜癌腫症と診断した. 左下肢麻痺は脊髄圧迫によるものと考えられた. 治療としてMTX髄腔内投与, 脊髄外照射を施行した. 髄液所見, MRI所見は改善を認めたが, 下肢麻痺の改善は認めなかった. 髄膜癌腫症の予後は非常に不良であるが, 早期診断, 治療によりその後のQOLを改善できる可能性が考えられた.

An 81-year-old woman who was suffering from dementia since one year before was admitted to the hospital because of abdominal pain lasting for 10 days and increasing abdominal distension. The abdomen showed remarkable muscular defense. Plain abdominal X-ray film and abdominal CT scan showed intraabdominal free air. With a diagnosis of perforation of the digestive tract, and emergency laparotomy was performed. Turbid ascites was present in the abdominal cavity and foreign body caused multiple perforation from the descending to sigmoid colons. For these findings, left colectomy, lavage, drainage and transverse colostomy were carried out. It was found that vinyl cords filled the resected colon. Later it became clear that the patient had eaten Goza made of vinyl cords under the impression it was buckwheat noodles. Pica is a symptom of dementia. Therefore, it may be necessary to entertain the possible diagnosis of pica in the treatment for abdominal pain in demented senium.

We experienced a very rare case of leiomyoblstoma of the transverse mesocolon. A 44-year-old man was admitted to the hospital because of upper abdominal tumor which was found with abdominal ultrasound sonography at a physical checkup. Abdominal angiography showed tumor vessels and a tumor shadow fed by middle colic artery. Under a diagnosis of primary tumor arising in the transverse mesocolon, an operation was performed. During operation the tumor arising from the transverse mesocolon was found in the bursa omentalis. To remove the tumor, a partial resection of the transverse mesocolon and greater omentum was performed. The resected tumor was 7×6×6cm in size and 350g in weight. In the cross section, hemorrhagic necrosis was contained. Histological diagnosis was leiomyoblastoma of the transverse mesocolon. He has been doing well 10 months after the operation without any symptoms or signs of recurrence. We report this case with some additional discussion on the related literature.

Out of 22 cases operated at the hospital for upper gastric cancer in a recent one decade, on 11 cases underwent proxymal gastrectomy and another 11 cases total gastrectomy. We studied the radicality of proxymal gastrectomy in terms of lymph node metastasis and prognosis and evaluated the quality of life of proxymal gasrectomy cases compared to total gastrectomy cases. In total gasrectomy caces, lymph nodes of No.4d, 5 and 6 that fell beyond the area of lymph node dissection for proxymal gastrectomy were free from metastasis. The survival rates between proxymal gastrectomy cases and total gastrectomy cases were not significantly different. In conclusion, the radicality of proxymal gastrectomy that was done in a early stage of gastric cancer was satisfactory. On the other hand in sm and poorly differentiated cases, lymph nodes metastasis of No 7 and 11 occurred. The d2 lymph node dissection was judged better for the cases. As to the quality of life of the patients, there was no significant difference between both groups in per os and body weight loss, laboratory data, and satisfaction after the operation. Further accumulation and analysis will be necessary to improve the quality of life of the patients undergoing proxymal gastrectomy

This paper presents a resected case of liver and lung synchronous metastases of colonic cancer, operated on 1 year after the primary operaton. The case was a 53-year-old man. An elevated tumor marker was detected in a follow-up period after the operation for the colonic cancer. Abdominal CT revealed a solitary liver metastasis in the anterior segment and a chest X-ray film showed a solitary lung metastasis in the right lower lobe. S5 hepatic segmentectomy and partial pulmonary lobectomy were carried out. As to statistics by Colonic Cancer Research in Japan, synchronous liver and lung metastasis represents 10% of all blood metastases of colorectal cancers. Nevertheless, articles and reports were few for the decidement and results of surgical treatment to the synchronous liver and lung metastases of colorectal cancer. Further accumulation and analysis for these synchronous liver and lung metastases of colonrectal cancer are expected.

Obturator hernia presenting in elderly women accompanies a high rate of bowel resection because of strangulation. Open laparotomy is usually indicated in general anesthesia. However, minimal invasive approaches would be advantageous unless resection is necessary. We aimed to determine clinical and radiological criteria for the selection of these patients.Preoperative clinical data from 23 cases and known signs of ischemia on CT examination were retrospectively compared to operative findings.Identification of patients having necrotic bowel was not possible by any clinical parameter or their combination. Patients with necrosis had longer history of symptoms, but acute onset less than 24 h does not exclude the need of resection (negative predictive value 83%). Impaired contrast enhancement was frequently seen on CTs independently from the onset of symptoms suggesting early vascular compromise (sensitivity 80%, specificity 22%), but not helping the differentiation. Signs of ischemia (bowel wall thickening and/or ascites) were present in every resected case while both were absent in 69% of patients having viable bowel.Absence of ischemic signs on nonenhanced CT may allow safe and more accurate selection of patients for minimal invasive surgery than any clinical or anamnestic parameter in obturator hernia.

A 62-year-old man reported to our hospital with serious complaints of abdominal pain, vomiting, and weight loss. An endoscopic examination detected a type 2 tumor of the descending limb of the duodenum. With a diagnosis of adenocarcinoma based on the biopsy finding, the patient was subjected to surgery. Laparotomy revealed the presence of a duodenal tumor disseminating to the omentum at the site where the transverse colon is attached. Pancreatoduodenectomy and partial resection of the transverse colon were carried out. CT conducted 6 months after surgery did not show any signs of tumor recurrence; but one year later, extensive tumor dissemination was noted on the hepatic surface. Upon consultation with the patient, a regimen of 80 mg/day of TS-1 given for 4 weeks followed by 2 weeks of a drug-free period was initiated. Six months later, the growth of tumor became arrested, improving his QOL. Nine months later, the tumor growth was progressive and the patient died two years after operation. The patient could gain long-term survival after operation. The TS-1 regimen applied in the present case may constitute a therapeutic strategy to be considered for similar conditions in future.