We report a case of esophageal schwannoma in a 46-year-old woman who presented with rapidly progressive dyspnea and dysphagia. Chest computed tomography showed a large mediastinal mass, which was extrinsically compressing the trachea, widely adjacent to the upper thoracic esophagus. We performed an axillary right thoracotomy to enucleate the tumor, which was located in the esophageal muscle layer. A definite diagnosis of esophageal schwannoma was made from the pathologic findings, which included positive immunohistochemical staining for S-100 protein and negative staining for c-kit and CD34.

We encountered a patient with liver metastases from colorectal cancer in whom continuous hepatic arterial infusion brought complete remission. A 58-year-old man was admitted to our hospital for advanced rectal cancer with multiple liver metastases. He underwent a low anterior resection (D2). Continuous hepatic arterial infusion of 5-FU (250 mg/day) with a weekly arterial infusion of MMC (4 mg) was performed for 14 days. Six continuous hepatic arterial infusions resulted in a complete remission. The patient has been free from any sign of recurrence for 37 months after the operation. Continuous hepatic arterial infusion using 5-FU and MMC seems to be effective in the treatment of multiple liver metastases from colorectal cancer.

胆石症術前に偶然診断された原発性十二指腸球部進行癌の1例を経験した. 56歳,女性.胆嚢炎を併発した胆石症加療目的で当科に紹介された.術前スクリーニングの上部消化管内視鏡検査で原発性十二指腸球部癌と診断された.幽門側胃および十二指腸球部切除術, Billroth II法再建,リンパ節郭清と胆嚢摘出術を施行した.腫瘍は十二指腸球部上壁中心で3.2×2.5cmのBorrmann 1型様で,病理組織診断は低分化腺癌, ss, n (-)であった.十二指腸進行癌では通常膵頭十二指腸切除術が必要とされるが,本症例のような漿膜浸潤を認めない球部癌に対する術式に関しては議論の余地があると思われる.今回十二指腸球部癌の手術術式に関し主にリンパ節転移の面から文献的考察を試みた.

大腸脂肪腫は比較的稀な大腸良性腫瘍であり中高年者に多く女性にやや多い.今回われわれは肛門腫瘤を主訴としたS状結腸脂肪腫を経験したので報告する.症例は37歳,男性,主訴は肛門腫瘤である.排便時肛門からピンポン玉大の腫瘤が脱出した.出血はなく容易に還納された.大腸内視鏡検査では, S状結腸に約6 cmの有茎性の腫瘤を認め,注腸ではRs付近に約6 cmの腫瘤を認めた. CTでは直腸に脂肪組織と同レベルの低吸収域を示す腫瘤を認めた.手術所見ではS状結腸の可動性のある腫瘤で, S状結腸部分切除術を施行した.長さ6 cmの茎を有する14×8×7 cmの腫瘍で,病理診断は脂肪腫であった.われわれの症例は比較的低年齢の男性で,腫瘍径が大きく,肛門腫瘤を主訴とした点で珍しい.腫瘍が大きく,悪性腫瘍も否定できず開腹手術を施行したが,術前脂肪腫と確認できれば,腹腔鏡補助下手術の適応となりうると考えられた.

総胆管の拡張をきたした胆石症例(径10mm以上)に対し,術前にmagnetic reasonance cholangiography (MRC)検査を施行し,開腹所見をもとにその有用性と問題点について検討した.対象症例は1996年6月より当科にて手術を施行した総胆管の拡張を伴う胆石症例27例で,男13例,女14例,平均年齢は68.2±11.2歳である. 術前検査として,腹部超音波検査(US),腹部CR検査を全例に施行し,胆道系の評価としてintravenous cholangiography (IVC)・endoscopic retrograde cholangiopancreatography (ERCP)あるいはpercutaneous transhepatic cholangiography (PTC)を,また,禁忌症例を除く22例にMRC検査を施行した,総胆管の最大径は10～45mm (15.9±7.9mm)であった. 使用機種はShimazu Magnex α II (0.5-T)を用いfirst spin echo法によった.測定時体表コイルを併用し,息止め時間は10秒であり,測定回数は9回とした.造影剤は使用していない. 対象症例の手術内容は,総胆管切石術が20例,胆嚢摘出術6例,胆管空腸吻合術1例であり,総胆管結石を21例で認めた.胆摘術のみの症例は術中造影検査にて総胆管に結石のないことを確認している. 開腹所見と術前の画像検査所見を比較検討すると,US検査では総胆管内結石の有無を正診しえたのは27例中11例 (40,7%) であり,CT検査の正診率は62.9%であり,IVCでは68.4%であった. MRC検査の正診率は86.3%であり,開腹既往歴,造影剤アレルギー症例および黄疸症例においても胆道系ならびに結石像の鮮明な画像がえられ,また,3mm以下の微細結石症例の検索を可能であった.しかしながら,胆嚢内の結石嵌頓,すなわちnegative cholecystogram を示す症例においても胆嚢が過大に描出され,また傍乳頭部憩室の検索には限界がみられた.

A case of adenocarcinoma of the small intestine in a young woman in described. A 24-year-old woman was referred to the hospital for further investigation and treatment of episodic abdominal pain. Abdominal ultrasonography demonstrated a low echoic mass adjacent to the right ovary, approximately 5×4cm in size. Small intestinal barium enema study showed a filling defect in the terminal ileum, and a colonoscopy confirmed a hemorrhagic tumor in the same region. Radical iliocecal recection with mesenteric lymph nodes dissection was performed. No tissue invasions or lymph nodes metastases were found in frozen sections intraop-eratively. The histopathological diagnosis was adenocarcinoma. The patient showed an uneventful recovery and has survived without any signs of recurrences or metastases. Malignant tumors of the small intestine are rare, especially in a young generation. In the treatment of the disease, surgical resection is mandatory, however, no definite criteria for regional lymph nodes dissection have been established as yet. We think that intraoperative frozen section diagnosis is very helpful to improve the radicality of surgery.

This paper describes a transumbilical resection and umbilical plasty for treatment of a patent omphalomesenteric duct (POMD). In a newborn infant with a POMD, a skin incision was made circumscribing the mucocutaneous junction of the protruded duct. The duct was completely extirpated with a wedge resection of the connection to the intestine and an umbilical plasty was performed. The postoperative appearance was excellent. It appears that transumbilical resection and umbilical plasty may be a satisfactory operation for POMD.

This paper describes a doughnut-like ultrasound (US) finding in pediatric intestinal Burkitt's lymphoma. A 9-year-old boy had a fist-sized, hard, non-movable mass in the lower abdomen. US showed a thickened, layered ring like a doughnut. The outer, low-level echoes seemed to be consistent with mucosa and muscle layers and the inner, high-level echoes seemed to be intraluminal air or mucus. The serum lactic dehydrogenase level was high. At surgery, a solid, hard tumor 15 x 10 cm in size was found in the jejunum. The intestinal wall was diffusely thickened with an intact mucosa. From this experience, the US doughnut sign may be a helpful diagnostic finding in pediatric intestinal Burkitt's lymphoma.

This paper reports a premature infant with a congenital diaphragmatic hernia (CDH) who underwent an abdominal wall plasty to enlarge the abdominal cavity, one of twin infants born at 32 weeks weighing 1,255 g. After stabilization, the herniated viscera were reduced from the pleural cavity and the abdominal wall muscle and skin layers were replaced by a Gore-tex patch without closure of the diaphragmatic defect. Respiratory and circulatory conditions were stable during the perioperative period. Postoperatively, a roentogenogram showed expansion of the lung. However, his condition deteriorated 24 h after surgery, triggered by intratracheal suction, and he died on the 4th day of life despite the use of high-frequency oscillation, catecholamines, and vasodilators. Postmortem examination showed severely hypoplastic lungs. Abdominal wall plasty may be a less invasive initial procedure, however, further studies, such as comparison with the standard method or conservative management, are needed using a large clinical group or animal models to justify the usefulness of this procedure.

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10 - 60 min under an insufflation pressure of 10 - 12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.

BACKGROUND:Recently, the retraction method has been used to reduce intraabdominal pressure (IAP) during laparoscopic surgery. The purpose of this study was to determine the serial changes in renal function during laparoscopic cholecystectomy (LC) using the retraction method.METHODS:Urine output, effective renal plasma flow (ERPF), and glomerular filtration rate (GFR) were measured serially in seven patients who underwent LC with 12 mmHg pneumoperitoneum (High-IAP group) and five who underwent LC using the retraction method with 4 mmHg pneumoperitoneum (Low-IAP group).RESULTS:Urine output, ERPF, and GFR were decreased during pneumoperitoneum in the High-IAP group, whereas no significant changes in any of these parameters were observed in the Low-IAP group.CONCLUSIONS:Our findings demonstrate that reduction of IAP to 4 mmHg using the retraction method prevents the transient renal dysfunction caused by prolonged 12 mmHg pneumoperitoneum during LC, suggesting that the retraction method reduces the risk of perioperative renal dysfunction during laparoscopic surgery.

A 74-year-old man admitted to the hospital for close examination of an abdominal pain developed muscular defence, remarkable metabolic acidosis, coma and respiratory arrest immediately after a progressive distension of the abdomen. After resuscitation, an exploratory laparotomy was carried out. There were massive black ascites, gangrene spreading from the rectal colon over the end of the terminal ileum, and a carcinoma in the anal side rectum. All mesenteric vessels were pulsating normally. The whole necrotic lesion including the carcinoma was resected and a ileostomy was made. Sixty-five days later the patient died of multiple organ failure. This paper describes a rare case of severe obstructive necrotizing enterocolitis associated with carcinoma of the rectum, with a review of the literature.

We report herein the case of a premature infant with esophageal atresia (EA) and a tracheoesophageal fistula (TEF) associated with cardiac anomalies who was successfully treated by an early ligation of the TEF following gastrostomy, and delayed repair of the esophagus. A 1212-g male was born prematurely at 31 gestational weeks, at which time he was diagnosed as having EA with TEF and patent ductus arteriosus (PDA), ventricular septal defect (VSD), and atrial septal defect (ASD). A gastrostomy was initially performed but following extubation he gradually became tachypneic. A chest roentogenogram revealed atelectasis and ground-glass appearance, and reintubation was required. Ligation of the TEF was performed 53h after his birth. Following the improvement of his respiratory condition through ventilatory support and the intratracheal administration of pulmonary surfactant, he underwent repair of the esophagus on the 6th day of life. Postoperatively, he suffered from heart failure, but was treated with peritoneal dialysis and pharmacological closure of the PDA. Weaning the infant from the ventilator proved difficult, but it was finally achieved when he had reached a weight of 2268g at 3 months of age by enteral feeding. Our experience of this case demonstrates that early ligation of TEF should be performed for a premature infant with EA and TEF before respiratory distress syndrome (RDS) has developed. If a gastrostomy is required to prevent gastric distention, it should be followed by simultaneous or immediate ligation of the TEF.

Necrotizing enterocolitis (NEC) sometimes occurs in term infants with congenital heart disease. This article reports a rare case of a term infant with coarctation of the aorta complex who developed NEC on the 8th day after birth. Spontaneous closure of the ductus arteriosus in the 1st week of life may cause intestinal ischemia and hypoxia with resultant NEC.

腹部鈍的外傷の治療方針決定における全身麻酔下腹腔鏡検査 (以下, DL) の有用性について検討した. 1989年以降5年間に入院した腹部鈍的外傷81例に対して腹部X-P, 超音波検査を全例に, CT検査を68例に施行した. 手術適応に迷った17例にDLを施行し, 13例を手術適応とし, 4例を非手術適応と判断した. 手術適応例では, 進行性腹腔内出血, 極少量の腸液貯留, アミラーゼ高値の希血性腹水の所見を認めたが, これらのうち7例はBlumberg's sign陰性であった非手術適応例では, 後腹膜血腫 (骨盤骨折), 腹壁血腫を認めた. これらは全例Blumberg's signを認めており, 2例にCT上腹水の貯留を認めていたが, 保存的治療が奏効した. DLは損傷臓器を直視下に観察することができ, 臨床所見X-P, US, CTでは得られなかった質的診断が得られ, 手術適応の判断に有用であった.

We report herein the case of a 2080-g premature male infant born at 34 weeks' gestation with multiple intestinal atresia, for whom multiple anastomoses were successfully performed. A total of 11 atresias were found in the small bowel, and five anastomoses were performed to preserve 59cm of small bowel and the ileocecal valve. Postoperatively, he developed several episodes of sepsis caused by persistent enterostasis, but was able to be weaned from total parenteral nutrition (TPN) by postoperative day (POD) 106. Thus, multiple anastomoses may be the appropriate procedure to prevent short-gut syndrome for congenital multiple intestinal atresia, even in premature infants.