We have recently experienced two cases of traumatic diaphragmatic hernia which has been repaired by surgery. The first case was a 58-year-old man who had suffered left upper abdominal injury with a branch in his childhood. Although he had never symptoms, chest X-ray showed abnormal shadow in the left lower lung field. Radiologic studies indicated that the great omentum was escaped into the thoracic cavity. On patient request, we performed primary repair of the diaphragmatic hernia on thoracotomy. The second case was a 56-year-old woman who had undergone a left nephrectomy for the left renal abscess. Seven months after the operation, she began to feel nausea and vomiting, and the symptom aggravated with time. Chest X-ray showed air bubbles in the left lower lung field. It proved to be a projection of the stomach into the thoracic cavity through the iatrogenic diaphragmatic injury. We successfully performed a repairment of the diaphragm with a mesh.
Ninety-four patients with perforation of the alimentary canal who were treated in Saiseikai Shiga Hospital during the past five years were studied with regard to diagnosis, treatment and prognosis. Perforations of the stomach and duodenum were caused most frequently by peptic ulcer, while those of the small intestine and colon most commonly resulted from trauma. Perforations of the stomach and duodenum were diagnosed more easily than those of the small intestine and colon, by marked physical signs of peritonitis and a high rate of recognition of free intraperitoneal air. Extended gastrectomy was performed in almost all the cases of peptic ulcer. Selective proximal vagotomy with pyloroplasty was preferred for the other four cases. In all the three cases of gastric carcinoma, gastrectomy was performed. As operative procedures for patients with abdominal trauma, closure of perforated portions and resection of intestine were performed. Colostomy was undertaken in almost all the cases of perforation of the colon. The prognosis of patients with perforation of the alimental tract was good on the whole. Two patients with duodenal perforation died from hemorragic shock or septic shock, and three with colonic perforation died of endotoxin shock.
Small bowel obstruction by food impaction is relatively rarely encountered. In general, the impacted foods are fruits, konbu, Konnyaku, and tsukemono. A properative diagnosis is quite difficult to be established, because the symptoms are similar to the bowel obstruction by any other causes. On the other hand, the bowel obstruction by foodstuffs can be frequently seen postgastrectomy patients. A 54-year-old woman, having a previous history of undergoing subtotal gastrectomy for gastric ulcer with reconstruction by means of Billroth II method 22 years before, developed bowel obstruction due to “konnyaku”. On the morning following her taking “konnyaku”at dinner, she was seen at the hospital because of severe upper abdominal pain as well as nausea and vomiting. Abdominal X-ray film revealed small bowel gas accompanied by fluid level. A diagnosis of adhesive bowel obstruction was made. Laparotomy was performed and an impacted foodstuff was seen in the small bowel about 210cm from the end of ileum. After moving the impacted foodstuff from the jejunum to the ileum, it was removed from the ileum by ileotomy. It was found to be a mass of “konnyaku” taken at dinner. This case suggested that asking of the meals taken before played a great role in making the diagnosis of foodstuff bowel obstruction, especially for patients after gastrectomy.
A recent advance of ultrasonographic diagnosis leads to its increasing use for postoperative follow-up of patients with gastric cancer. However, we have often difficulties in early detection and diagnosis of the recurrence, especially that to the lymph nodes. In this paper, we assessed the ultrasonographic diagnosis and surgical treatment in three cases of recurred gastric cancer to the lymph node. Two of the 3 cases showed obstructive jaundice and it was difficult to resect the lesion, the bile drainage being done. In the remaining one case of early diagnosed, the recurrent lymph node was resected surgically. A better prognosis can be expected in patients having local recurrence of gastric cancer by strict postoperative observation due to ultrasonography, and by consequent early detection and resection of recurred lesions in the lymph nodes.
Among gastrointestinal tumors, small bowel tumors are found in a relatively low incidence. These tumors are hardly detected in an early stage because of lacked specific clinical manifestations, for that, the prognosis is poor. This paper describes a 59-year-old man with this disease presenting with nausea and vomiting. Abdominal simple X-ray film indicated an obstruction of the upper jejunum and barium meal method of the small intestine wascarried out. As a result, the obstruction due to a tumor was found in the jejunum about 25cm anal side from Treitz ligament. Laparotomy was performed under a diagnosis of small bowel tumor. During the operation, a hard mass about 5cm in diameter, in the jejunum and swollen regional lymph nodes were seen, and resection of the jejunum with lymph node dissection was performed. The tumor with ulcer formation occupying the whole-circumference of the tract was seen in the resected specimen. Histologically, it was moderately differentiated adenocarcinoma determined by HE staining. It is known that small bowel cancers can produce CEA. In this case elevated CEA level was shown preoperatively and it was detected by immunoperoxidase staining using anti-CEA antibody. Serum CEA level decreased after the operation. Based on this experience, when we encounter a patient who has some abdominal complaints but dose not show any abnormalities in upper and lower gastrointestinal series, a possible existence of small bowel tumor should be entertained.
Forty-four cases with childhood solid malignancy during the period from 1973 to 1982, were analysed. 11 cases underwent second-look operation, including 4 neuroblastomas, 4 hepatoblastomas, 1 malignant teratoma, 1 nephroblastoma, and 1 rhabdomyosarcoma. Two cases of hepatoblastoma in second-look operation are surviving over two years with no evidence of disease, and one case survived 5 years 8 months. For one patient of initially unresectable neuroblastoma, second-look operation was successfully performed by complete resection followed by paraortic-lymphonode dissection. In two cases of Wilms' tumor and malignant teratoma, second-look operations were performed for the purpose of treatment decision after radical operation. In the unresectable tumors or recurrent tumors or metastatic lesions, complete cure can be expected by aggressive surgical approach and combination chemotherapy followed by second-or third-look operation.
