<臨床>胃癌術後に肺転移巣を切除した2例

It is said that the prognosis is poor in cases with recurrent pulmonary metastasis after operation for gastric cancer. In this article, 2 cases with nodular type of pulmonary metastasis resected after operation for gastric cancer and surviving well are reported by the authors. Case 1: 57year-old female. The patient underwent a total gastrectomy for the 3'type of cardiac cancer. As the serum levels of tumor markers increased and the chest X-ray examination revealed a mass lesion in the right lung (S_10), the operation for the lesion under the diagnosis of metastatic lung cancer was performed 1 year and 2 months after gastrectomy. The patient died of pulmonal and pleural metastasis 4 years and 7 months after the first operation. Case 2: 65-year-old male. The patient underwent a subtotal gastrectomy for the 5'type of gastric cancer. Chest X-ray examination for follow-up study revealed a mass lesion in the left lung (S_5). The patient underwent a left pulmonary superior lobe resection 2 years and 9 months after gastrectomy. The patient is still alive 6 years after the first operation. Surgical treatment must be actively considered for nodular type of metastatic lung cancer after operation for gastric cancer.胃癌術後に肺転移をきたした症例の予後は不良とされている. 今回, 胃切除術後に結節型肺転移巣を切除し, 良好な結果を得た胃癌の2例を経験したので、報告する. 症例 1 は57歳, 女性. 噴門部 2'型胃癌の診断のもと, 胃全摘術を受けている. 腫瘍マーカーの上昇があり, 胸部X線写真で右肺 S_10 に腫瘤陰影を認めた. 胃癌術後1年2カ月目に肺部分切除術を施行した. 患者は胃癌切除後4年7カ月で肺転移および癌性胸膜炎のため死亡した. 症例2は65歳, 男性. 胃体部 5'型胃癌の診断のもと, 胃亜全摘を受けている. 術後経過観察中, 胸部X線写真で左肺 S_5 に腫瘤陰影を認め, 胃癌術後2年9カ月目に左肺上葉切除切除術を施行した. 患者は胃癌切除術後6年で健在である. 結節型の肺転移例に対しては積極的な外科手術を考慮すべきである

Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography ST segment elevation in lead aVR with less ST segment elevation in lead V1

AbstractOBJECTIVESWe sought to determine the electrocardiographic (ECG) features associated with acute left main coronary artery (LMCA) obstruction.BACKGROUNDPrediction of LMCA obstruction is important with regard to selecting the appropriate treatment strategy, because acute LMCA obstruction usually causes severe hemodynamic deterioration, resulting in a less favorable prognosis.METHODSWe studied the admission 12-lead ECGs in 16 consecutive patients with acute LMCA obstruction (LMCA group), 46 patients with acute left anterior descending coronary artery (LAD) obstruction (LAD group) and 24 patients with acute right coronary artery (RCA) obstruction (RCA group).RESULTSLead aVR ST segment elevation (>0.05 mV) occurred with a significantly higher incidence in the LMCA group (88% [14/16]) than in the LAD (43% [20/46]) or RCA (8% [2/24]) groups. Lead aVR ST segment elevation was significantly higher in the LMCA group (0.16 ± 0.13 mV) than in the LAD group (0.04 ± 0.10 mV). Lead V1ST segment elevation was lower in the LMCA group (0.00 ± 0.21 mV) than in the LAD group (0.14 ± 0.11 mV). The finding of lead aVR ST segment elevation greater than or equal to lead V1ST segment elevation distinguished the LMCA group from the LAD group, with 81% sensitivity, 80% specificity and 81% accuracy. A ST segment shift in lead aVR and the inferior leads distinguished the LMCA group from the RCA group. In acute LMCA obstruction, death occurred more frequently in patients with higher ST segment elevation in lead aVR than in those with less severe elevation.CONCLUSIONSLead aVR ST segment elevation with less ST segment elevation in lead V1is an important predictor of acute LMCA obstruction. In acute LMCA obstruction, lead aVR ST segment elevation also contributes to predicting a patient’s clinical outcome

<臨床>腹腔鏡下胆囊摘出術の合併症を予防するために

Laparoscopic cholecystectomy is now becoming a safe procedure for the benign cholecystic diseases. But the differences, for example in the method of access to peritoneal cavity, visual field, and tools, between laparoscopic surgery and open surgery results in different complications. The purpose of this paper is to discuss how to avoid complications during laparoscopic cholecystectomy. A hundred consecutive patients were expected to receive an elective laparoscopic cholecystectomy from April 1991 to November 1992 in our clinic. Two patients were converted to open cholecystectomy. The reasons for conversion were uncontrollable bleeding from cystic artery and common-bile duct injury. Two other patients were obliged to undergo laparotomy due to postoperative bile leakage. Arterial bleeding from abdominal wall caused by inserting trocar was experienced in one case. Improvement of the equipment and surgical technique have got rid of these complications. We think it is still necessary to do intra-operative examinations such as cholangiography or ultrasonography. The previous two cases with complication of biliary injury underwent laparoscopic cholecystectomy without intraoperative examinations. We could have avoided these complications if intraoperative examinations were used. To prevent the complication of bleeding from abdominal wall, we have been carrying out a unique method. After the introduction of these procedures, we have never experienced any of theses complications.腹腔鏡下胆嚢摘出術は良性胆嚢疾患に対し, 安全な治療法の1つとなりつつある. 開腹胆嚢摘出術と腹腔内操作は基本的に同じであるが, 腹腔鏡下胆嚢摘出術では術中の視野や処置具の違いから術中合併症が生じることがある. 教室でも, 開腹術に移行あるいは術後に再開腹を行った症例を経験している. これら術中合併症を生じた各々の症例につきその原因と予防策を検討し報告したい. 1991年4月から1992年11月までに教室で、腹腔鏡下胆嚢摘出術を受けた100症例のうち, 合併症のため開腹手術に移行した症例は2例, 術後再開腹を受けた症例は2例であった. また, 術中腹壁血管の損傷のため腹腔内に出血した症例を1例経験した. これら5症例は, いずれも初期の40症例までにみられ, 以後の60症例は開腹術移行例, 術後再開腹例, 腹壁血管損傷のいずれもみられていない. 開腹手術に移行した2症例は胆嚢動脈からの出血例と総胆管損傷であった術後再開腹となった2症例は十二指腸損傷と総胆管損傷であった. これらの症例以後, われわれは, ほぼ全例に術中検査として胆道造影と超音波検査を行い胆管の確認を行っている. また, 胆嚢壁の肥厚, 胆嚢管周囲の炎症がみられる症例に対しては CUSA を用いて剥離を行っている. 手術時聞は術中検査を行ったにもかかわらず後期の60症例の方が有意に短く, 手技の習熟も合併症を防ぐうえで重要な要素の1つであった. 以上のことから, 本術式で起り得る合併症を予防するためには, 1)充分な性能を有する器械を用いること, 2)処置具を安全に操作できるように手技を習熟すること, 3)できる限り術中検査を行い確実に胆道の解剖学的位置関係を把握することが重要であると考えられた