Kenya Chiba

Spontaneously Ruptured Giant Splenic Cyst with Elevated Serum Levels of CA 19-9, CA 125 and Carcinoembryonic Antigen.

Splenic cyst is a relatively rare disease; however, the occurrence of complications associated with its rupture is even more rare. A 20-year-old female patient who had severe abdominal and left shoulder pain was admitted to our hospital. The patient’s abdomen was hard and tender to the touch and she presented with a high fever. The patient’s serum levels of the tumor markers carbohydrate antigen 19-9, cancer antigen 125 and carcinoembryonic antigen were high. Ultrasonography and computed tomography of the abdomen showed an 11-cm multilocular cystic lesion in the spleen and the presence of free intraperitoneal fluid. Peritonitis with ruptured splenic cyst was diagnosed, and the patient underwent an emergency laparotomy. The abdominal cavity was filled with purulent fluid. The cyst was localized to the spleen and had already ruptured. Total splenectomy and cyst resection were performed. The postoperative course was uneventful. The patient was discharged on day 9 following surgery. The histological findings showed the lesion to be a benign epidermoid cyst completely lined with inner stratified squamous epithelium with a capsule of connective tissue. In the immunostaining analyses, the squamous epithelium was positive for carcinoembryonic antigen. A ruptured splenic cyst causes sudden onset of severe peritonitis and elevation of serous tumor markers. An emergency operation is indicated as the treatment for a ruptured splenic cyst with peritonitis, after which a favorable outcome can be expected.

Results of mobilization and drainage of the pancreas for acute pancreatitis

The surgical treatment of acute pancreatitis remains controversial. Since 1969, we treated 62 patients with acute pancreatitis. In 34 with severe acute pancreatitis who were not responding adequately to intensive medical care, surgical intervention was made by mobilization of the pancreas from retroperitoneal tissue and drainage of the pancreatic bed (M-D procedure). Thirty-four operative cases were classified into 7 edematous, 7 hemorrhagic, and 20 necrotizing. Macroscopic findings of the pancreas did not correlate either to the severity of the acute pancreatitis or to the mortality rate. Eight of 34 who underwent M-D procedure died (23 per cent), but the rate became 14.7 per cent after excluding 3 who died of unrelated causes. These data suggest that the M-D procedure is highly effective in the treatment of early cases of severe acute pancreatitis. There was an associated marked reduction in the mortality rate with the prophylatic use of broad spectrum antibiotics. With M-D procedure, there was a low incidence of late sequelae of pancreatic or peripancreatic abscess.

The surgical technique of retroperitoneal lavage for the treatment of extended necrotizing pancreatitis

For cases of extended necrotizing pancreatitis which involve the spread of infectious or hemorrhagic necrotic lesions to the retroperitoneal tissue, we recommend sequestrectomy and subsequent retroperitoneal lavage via the retroperitoneal access. For successful retroperitoneal lavage, as much liquefactive infectious necrotic tissue as possible should be removed from the retroperitoneal cavity during the operation. In addition, the necrotic cavity should be opened, adequately washed out, and catheters placed in the retroperitoneal cavity by retroperitoneal access. Although we have only applied this ideal technique in two patients so far, the details are presented herein. The significance of retroperitoneal lavage lies in the fact that it cleans the retroperitoneal foci of infection and necrosis, and that it eliminates the necrotic material, bacterial deposits, and biologically active substances produced after surgery. Ultimately, wound healing is markedly promoted, leading to improvement in the systemic condition.

Retroperitoneal Lavage in the Treatment of Infectious Necrotizing Pancreatitis. Report of a Case.

症例は50歳の男性で, 腹痛, 発熱を主訴として来院し, 諸検査の結果, 重症急性膵炎と診断され, ICU管理のもとで輸液, 薬剤, 高圧酸素療法を行う. その結果, 全身状態と臨床検査成績は急速に改善の方向に向かった. しかし, 入院3週目より, 再び腹痛, 高熱力が出現し, WBC15,500, CRP強陽性, computed tomographyによる画像所見の増悪傾向を示したので, 感染性膵壊死の診断で開腹した. 手術は後腹膜ルートで膵を含む後腹膜腔に存在する融解した感染壊死組織を用手的に除去し, 術後に持続的後腹膜灌流を行った. 後腹膜灌流期間は8週を要した. なお, 壊死巣よりStaphylococcus aureusを検出した. 本法は今までに例をみない新しい術式であり, その意義は後腹膜の感染壊死巣の浄化とともに, 術後に新しく産生される感染壊死物質や生物学的活性物質の排除であり, その結果, 創傷治癒が促進され, 全身状態が改善される.