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腹腔内出血をきたした胃原発の巨大なGISTの手術例を報告する.症例は61歳,男性. 10年以上前より腹部に腫瘤を自覚し,近日当院受診予定であった.平成16年11月,急な腹痛にて当院救急外来を受診し, CTにて多量の腹水貯留と原発不明の腫瘤を認めたことから消化管穿孔や腫瘍破裂を疑い緊急手術を施行した.腹腔内には約20cm大の嚢腫様病変が,頭側端を胃に癒着させ横行結腸間膜に載るようにして存在しており,腫瘍からは静脈性出血が続いていた.胃壁を一部合併切除して腫瘍を摘出した.摘出標本の免疫染色ではc-kit, CD34がともに陽性でGISTと診断した. GIST破裂による腹腔内出血は比較的稀な病態であり術前診断に難渋することが多い.文献的には(1) 原発不明の腹部腫瘤, (2) 急な腹痛, (3) 腹水貯留の三徴候を有する症例に対しては本疾患を視野に入れて開腹手術を検討すべきであると考えられた.

It is thought that cases of colonic cancer with multiple organ metastases including the spleen, liver, lung, and peritoneum are in the terminal stage. This time, we experienced a patient with splenic metastasis from colonic cancer who survives for 2.5 years with resection of the splenic metastasis and intensive therapy. A 56-year-old man underwent a curative right hemicolectomy for a cancer of the ascending colon with peritoneal dissemination. Nine months later, he experienced splenic, hepatic metastases. So a splenectomy and a hepatic resection with a cannulation into a proper hepatic artery were performed. Histologically, the splenic tumor revealed moderately differentiated adenocarcinoma and was diagnosed as metastasis of colonic cancer. Resection of peritoneal and lung metastases followed the splenectomy. Thereafter, intra-venous chemotherapy using -FU+Iow dose CDDP was performed for remnant multiple liver and lung metastases. Eleven months later, complete response was obtained. No evidence of recurrence has been found for two years and six months after the splenectomy. These results suggest that intensive resection and chemotherapy for distant meatstases including splenic lesion might lead to a long survival.

In 85 cases undergone total gastrectomy and 57 esophagectomy for esophageal carcinoma during the past 6 years, the corrected water-balance accumulation was calculated by determining the water intake and output for postoperative 5 days. Based on the oalculation, we intend to demonstrate a contribution of excessive fluid in the body to the development of postoperative pulmonary complications. Remarkable high levels in the correlected water-balance accumulation were noted in cases manifesting postoperative pulmonary complications. The value was also significantly higher in aged patients or a patient group who had impaired renal function preoperatively, indicating that their risks to provoke pulmonary complication might increase. Moreover, the corrected waterbalance accumulation had a closed corelation with FENa, particularly a case in which FENa was still maintained at 1% or more even after the 3rd postoperative day was supposed to be in overhydration. Another significant correlation between an increase in AaDO2 and FENa was found in patients after operation for esophageal carcinoma. To prevent postoperative pulmonary complication, the dry side control guided by FENa appears affective.