Search

A case of adult Bochdalek hernia with gastric volvulus in a naturally healthy 54-year-old man is described. The patient was seen at the hospital because of epigastralgia, appetite loss and weight loss for 6 months. He was diagnosed as Bochdalek hernia with gastric volvulus by chest X-ray photographs, contrast radiography of the upper gastrointestine and thoracic CT scans. At laparotomy the stomach was rotated around its mesenteric axis and the antrum was dislocated into the thorax through the left posterior-lateral diaphragm defect. His symptoms disappeared after the operation. Adult Bochdalek hernia with gastric volvulus is very rare and only 5 cases including this case have been reported in this country. In the case of adult Bochdalek hernia with gastric volvulus, definitive operation should be selected even if the patients is asymptomatic.

For the better pathophysiological understanding of ischemic colitis, a clinical analysis of 24 cases of this disease in a 13-year period from 1979 to 1992 was conducted. The distribution of ages was 19-89 and there were 9 males and 15 females. As to disease type, transient type was noted in 15 cases, stricture type in 5 cases, and gangrenous type in 4 cases. Most of them had some underlying diseases. Eighteen patients had bowel diseases which increased the intraintestinal pressure, and 7 patients had cardiovascular diseases. These patients first manifested abdominal pain or melena in a relatively high frequency. The diagnosis was made mostly based on colonoscopic findings in transient type of patients; barium enema in stricture types; and operative findings in gangrenous types. Conservative treatment was performed in 17 patients, elective operation in 2 patients, and emergency operation in 5 patients. It has been emphasized that ischemic colitis has a close relation with cardiovascular diseases. However, our results suggest that ischemic colitis has a close relation with the increased intralumenal pressure of the bowel as well as cardiovascular disorders.

症例は53歳の女性.1991年2月右下腹部痛を自覚して近医を受診し,注腸検査で回盲部に潰瘍性病変を認め,外来でfollow upしていたが,1993年3月中旬から右下腹部痛が増強するとともに腫瘤を触知するようになった.精査の結果,回盲弁に騎乗する下掘れ性の円形潰瘍を認め,CT・MRI検査では回盲部腸管がほぼ全周性に壁肥厚しており,血管造影検査では回結腸動脈領域の新生血管増生を認めたが広狭不整等の悪性所見は見られなかった.2年間の経過で回盲部の狭窄が著しく進行していたため手術適応ありと判断し,回盲部切除術を施行した.回盲部単純性潰瘍は比較的まれで,他の回盲部疾患との鑑別診断が重要であるが,とくに腸型べーチェット病との鑑別は困難で,内科的治療に抵抗し手術後の再発も高率で充分な経過観察が必要とされている.

出血性胃十二指腸潰瘍75例の治療成績から予後に影響を及ぼす背景因子について検討を加えた. 潰瘍入院総数に対する出血率は22.4%で, 手術の内訳は緊急32例, 待期27例で, 死亡率は緊急21.9%, 待期3.7%と緊急の予後が著しく悪かった. また加齢につれて死亡率は上昇し70歳以上の高齢者では19例中6例 (31.6%) であった. 予後に影響を及ぼす重要な背景因子は年齢と併存症で, シメチジン出現以後, 年度別の出血例は減少したが, 入院数に占める出血率には変化なく, 緊急手術率は前期に比べて増加した.従って, 併存症を有する高齢者に対しては保存治療に固執することなく手術適応を考慮して手術時期を失しないよう迅速に対処することが必要である.

Clinical features and the results of treatment in 61 cases of ulcerative colitis (34 males and 27 females) were analyzed. In most of the cases (47 cases, or 77%), the age at which the disease occurred was estimated to be between 10 and 39 years. Early complaints were mucous bloody stools (seen in 77% of all cases), diarrhea (66%) and abdominal pain (23%). Fifty patients were treated medically and 11 were treated surgically (urgent or semi-urgent surgery in 4 cases and non-urgent surgery in 7 cases). Of the 4 patietns who underwent urgent or semi-urgent surgery, 2 had perforations and the other 2 had fulminant type ulcerative colitis. The fatality rate for these 4 patients was 50%. Of the 7 patients who underwent non-urgent surgery, 4 had been treated medically for less than 5 years; in these 4 cases, the active stage occupied more than 50% of the total observation period, and the average relapse frequency was over 1.3 times per year. The other two patients, who underwent non-urgent surgery, had been treated medically for more than 5 years; they had been treated with more than 10, 000 mg of Predonine (prednisolone acetate) and it was difficult to discontinue their steroid therapy. Carcinogenesis was seen in one patient who had a relapsing-remitting type of ulcerative colitis which affected the entire large intestine and which had initially occurred 24 years earlier (this gave an incidence of carcinogenesis of 1.6%). The results of this study suggest that patients with severe ulcerative colitis (including the fulminant type) should be surgically treated in time rather than adhering to conservative treatment, in order to reduce the current high mortality rate during or following urgent surgery.

In the past 15 years, 101 cases of peptic ulcer in patients over 60 years of age were treated in our department. Of 101 patients, 76 had gastric ulcer, 16 had duodenal ulcer and 9 had combined gastric and duodenal ulcer. The number of peptic ulcers treated surgically has been decreasing recently, while the percentage of peptic ulcers in the aged has been increasing. Of these 101 cases, 52.4% of the patients had no past history of ulcer, and 49.3% had suffered from the disease for less than six months. In regard to symptoms, 71.3% of patients complained of abdominal pain, and 36.6% showed gastrointestinal hemorrhage. The indications for laparotomy were hemorrhage, perforation and stenosis in 48.6% and intractability in 47.2%. The rate of preoperative complications and the rate of emergency operations tended to increase with age. Although there was a complete absence of mortality in the patients without preoperative complications, that among patients with preoperative complications in emergency operations was a high 46.2%. How to avoid emergency operations in the aged remains a problem to be solved in the future.

Until now, 21 cases of Crohn's disease (78% of total cases of this disease) have been surgically treated at our department. Of thse cases, 14 received a curative surgery (complete resection of the lesion). We analyzed postoperative relapes of the disease in these 14 cases. Postoperative relapse was seen in 2 (50%) of the 4 patients with Crohn's disease of the small bowel and 3 (33%) of the 9 patients with Crohn's disease of the small and large bowels. Of these 5 cases of postoperative relapse, 4 had relapse at a site close to the anastomoses. The mean timespan from the surgery to the relapse was 3 years and 3 months in patients with Crohn's disease of the small bowel and 11 months in those with Crohn's disease of the small and large bowels. The relapse rate was 13% for the patients with a preoperative IOIBD (International Organization for the Study of Inflammatory Bowel Disease) score of 4 or less and 67% for those with a preoperative IOIBD score of 5 or more. Of the 9 cases in whom the unaffected intestine was resected for 10 cm more proximal (adoral) from the lesion, no one showed postoperative relaps. Of the 5 cases in whom the unaffected intestine was reseacted for less than 10 cm proximal from the lesion, all showed postoperative relapse. However, no correlation was found between the relapse rate and the length of the resected unaffected intestine distal (towards the anus) from the lesion. Reoperation was done in 2 cases because of fistulation.

This paper describes upper gastrointestinal hemorrhage after surgical treatment of primary colorectal cancer. During the past six years, operations have been carried out on 127 patients with primary colorectal cancer. Of these, 13 patients (10%) had postoperative bleeding from the upper gastrointestinal tract. This type of bleeding occurred in 5 (26%) of 19 patients undergoing urgent surgery. With regard to the operation methods, low anterior resection and colostomy frequently induced postoperative hemorrhage, in 3 of 11 cases (27%) and 4 of 15 cases (27%) respectively; however, abdomioperineal rectal amputation did not give rise to such bleeding in any of 23 cases. Gastrointestinal hemorrhage was also noted in 4 of 11 patients having diabetes mellitus as a preoperative complication; 2 of the 4 died. This arouses prognostic concern.Of the 13 cases with postoperative gastrointestinal hemorrhage, 10 were relieved with conservative hemostasis.Therefore, prophylactic administration of Cimetidine seems to be effective in the high-risk group for postoperative gastrointestinal hemorrhage.

慢性膵炎手術46例を対象として, 膵内外分泌能と酸分泌能を対比し, さらに潰瘍成因について防御因子の面より粘膜ウロン酸を測定した. 潰瘍合併率は30.6%と高率であったが, MAOは正酸から低酸を示すのがほとんどで, 潰瘍合併例のMAOは非合併例よりも低値を示す症例が多かった. P-S試験, OGTT insulinogenic indexを指標として, 膵内外分泌障害の程度とMAO, ガストリンを比較したが相関はなかった. 胃粘膜ウロン酸量は胃潰瘍例と似た値を示し, 防御能の低下が示唆された. 潰瘍合併例に対する術式は潰瘍を含む胃切除を基本とし, 迷切術の併用は胃防御能を低下することから好ましくないと思われた.

The causes of upper digestive tract bleeding after hepatic abscission were analyzed in this study by dividing subjects into 2 groups (cirrhosis and cirrhosis-free) and taking liver function, blood coagulation surgical stress, and the kinetics of gastric acid secretion into account. The results were as follows. Upper digestive tract bleeding occured in 1 case of 15 (6.7%) in the cirrhosis-free group and in 5 cases of 19 (26.3%) in the cirrhosis group. One case was fatal. Postoperative upper digestive tract bleeding was found to have no clear relationship to the extent of the hepatic abscission or to the volume of bleeding during surgery. When compared with the cirrhosis-free controls patients with cirrhosis showed significantly worse values of GPT, TTT, ICGK, ΔIRI/ΔBS, IRI max, and hepaplastin. In the cirrhosis group the preoperative MAO value was ortho-acid (5_??_20 mEq/h) in 10 cases and hypo-acid (below 5 mEq/h) in 8 cases. All of the 5 cases which developed bleeding after surgery were in the orthoacid condition. These results indicate that patients showing a preoperative MAO value of over 5 mEq/h need to be given cimetidine positively, starting immediately after surgery.

A retrospective study of patients with peptic ulcer admitted to the First Department of Surgery, School of Medicine, Kobe University, was made into the actual conditions of the surgical treatment of the ulcer after the introduction of cimetidine. The patients were divided into two groups, the first belonging to the period between 1976 and 1980 and the second belonging to that between 1981 and 1985 (July). A remarkable decrease was seen in the second group in the number of cases and operations. Especially noticeable was a decline in the number and rate due to intractability among such cases. But an increase was noted in the number of operations for complications of the ulcer (hemorrhage, perforation). There was a higher rate of complications in the second group in comparison with the first. There was no difference in the rate of occurrence of ulcers or shock. In cases of serious hemorrhage with duplicated complications, a barrier was observed in the efficacy of cimetidine, and the rate of cases requiring urgent surgery was still as high as 42.1%.

1973年より1984年6月末までに当教室へ入院した肝硬変201例中42例 (20.9%) に潰瘍合併を認めた. 潰瘍合併群の胃酸分泌は非合併群よりも有意な差を認めないものの高い傾向を示した. しかしグリシン負荷によるガストリン値, セクレチン値には非合併群と差はなかった. 食道胃静脈瘤陽性群の潰瘍合併率は26.7%と静脈瘤陰性群の14.6%よりも高率で, しかも静脈瘤のgradeの悪化に従って潰瘍合併率は上昇した. また静脈瘤の有無およびその程度と胃酸分泌, ガストリン値, セクレチン値には差を認めなかった.

Possible changes in surgical treatment of peptic ulcers at the Kobe University Hospital (First Dept. of Surgery) over the past ten years were explored, dividing the 10 years into the first (1978-1982) and second (1983-1987) periods. The number of hospitalized peptic ulcer cases and the number of surgically treated peptic ulcer cases fel by 50% from the first to the second period. The decrease was particularly marked in duodenal ulcer cases (in comparison with ulcers of the other sites) and intractable ulcer cases (in comparison with ulcers of the other features). The percentage of patients who underwent urgent operation was 37.3% in the first period, which fell to 28.6% in the second period. The number of surgically treated intractable ulcer cases showed a 69.2% reduction in the second period compared to the first period. However, the percentage of cases whose excised specimen was rated as representing giant ulcer, linear ulcer, or U1 IV was higher in the second period than in the first period. Stenosis was found in 7 cases in the first period and 3 cases in the second period. The percentage of hemorrhagic ulcer cases who received conservative treatment or pallilative operation became higher in the second period than in the first period, while the percentage of hemorrhagic ulcer cases who underwent urgent operation decreased from 65.2% in the first period to 33.3% in the second period. In hemorrhagic ulcer cases, the death rate during or after uregent operation rose from 28.7% (first period) to 40.0% (second period). Perforated ulcer was found in 7 cases in the first period and 1 case in the second period. Of these 8 cases, 4 died (3 in the first period and 1 in the second period). Death rate was particularly high in elderly patients who had no history of ulcer and in patients who received surgery 12 hours or more after perforation.