著者

小松原 正吉

出版者

Okayama Medical Association

雑誌

岡山医学会雑誌 (ISSN:00301558)

巻号頁・発行日

vol.90, no.1-2, pp.101-119, 1978-02-28 (Released:2009-03-30)

参考文献数

37

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A pertinent procedure for preserving postoperative urinary and sexual functions was searched in the radical surgery for rectal cancer, from a neuroanatomical point of view, and the clinical status about disturbances of these functions was analized in relation with a mode of preservation of the lower hypogastric and/or the pelvic nerve among the patinet undergone the surgery applied this procedure. The result of the operation was also evaluated as for the influence of this procedure on the curability of the cancer.Results obtained were as follows:1. In the anatomical study with 17 necropsy cases, it was found that the most preferable mean for identifying the lower hypogastric nerve, pelvic plexus and pelvic nerve was to begin with isolating the upper hypogastric nerve dividing the posterior peritoneum along the lower abdominal aorta, and to follow the bilateral lower hypogastric nerves on the inner surface of the pelvic cavity down to the pelvic plexus, from which the pelvic nerves were able to explore by the retrograde approach to the sacral foramina. Since this procedure was able to be progressed in accordance with that of the radical operation by Miles, technical troubles were of eliminable.2. Urinary functions were examined on 47 cases out of 60 patients received the surgery with the nerve-saving procedure above.a) The period before the spontaneous urination occurred after the surgery was prolonged significantly by the bilateral injury to the pelvic nerve and this was not observed in the patient whose pelvic nerve was unilaterally injured, as well as in the patient whose lower hypogastric nerve was uni- or bilaterally injured.b) The result of cystometry and catheterization study showed that cystic hypotonia and urinary retention prolonged as long as 40 days or more, and 23 days in average in the patient with injury to the bilateral pelvic nerves, as compared to 8 days in average in the patient with bilateral denervation of the lower hypogastric nerve and also in the patient with unilateral injury to the pelvic nerve. Duration of sensation as to urinary retention was quite accorded with these results.3. Sexual function was surveyed making inquiries by the letter to 48 subjects and was summarized on 43 including 19 female with satisfactorily recorded answers.a) Ability of the erection was preserved in about 60 to 70% of the patient regardless of presence or absence of the denervation of the lower hypogastric nerve. However, it was impaired in all patients with bilateral injury to the pelvic nerve, although even the unilateral preservation saved the ability in all.b) Ability of the ejaculation was satisfactorily kept only in the subjects whose lower hypogastric nerve was bilaterally saved. Among those who had injury to bilateral pelvic nerve, only the patient whose lower hypogastric nerve was bilaterally saved preserved the ability, suggesting a close participation of the hypogastric nerve to the ejaculation.4. The decrease in the curability of the cancer under this procedure was not observed, compared with that in patients undergone the surgery performed without the positive intention to save the nerve but with the aim to eradicate the cancer.

著者

田中 聰 佐藤 源 曽田 益弘 小松原 正吉 河本 知二

出版者

日本臨床外科学会

雑誌

日本臨床外科医学会雑誌 (ISSN:03869776)

巻号頁・発行日

vol.39, no.4, pp.521-527, 1978

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肝海綿状血管腫の3症例を経験し,それぞれ異なる摘除術式によって治癒せしめた.症例はすべて女性で,年齢は47歳, 47歳, 42歳であり,第1例は胆嚢水腫の診断のもとに手術されたが,第2例は腹腔鏡検査での腫瘤表面の性状から,第3例は肝動脈造影での造影剤のボタン雪状のpoolingから,術前に本症と診断されたものであった.その肉眼的増殖型はそれぞれ限局性被包型,多発性びまん型,部分的被包型で,第1例では腫瘤摘出術,第2例では左葉外側区域切除術,第3例では拡大右葉切除術(右葉および左葉内側区域切除術)をおこない, 270g, 890g, 3450gの腫瘤を摘除した.第1, 2例は腫瘤の圧迫によると思われる右季肋部痛,心窩部痛を主訴としたが,第3例の腫瘤は成熟胎児大であって.術前には下大静脈狭窄による両下肢浮腫,腹水の貯留,蛋白尿があり,ネフローゼとして加療されていた.また腫瘤内血液凝固に起因すると思われる血中FDP値の上昇があった.しかし腫瘤はほぼ被包化され,その約1/4周のみで肝実質に移行しており,結果的にはこの部での肝部分切除によって充分に摘除し得るものであった.肝海綿状血管腫は血管奇型とされているが,圧迫症状以外にも破裂による腹腔内出血, Kasabach-Merritt症候群,腫瘤内血液凝固にもとづくconsumption coagulopathy,貧血,うっ血性心不全,門脈圧亢進症状などを合併することが報告されているので,原則として外科的摘除を必要とするが,本症には有茎性肝外増殖型,限局被包型,不完全被包型,びまん性増殖型等,増殖形態に多様性があることが報告されている点を考慮し,必要最小限の侵襲にとどめるべく,術式の選択に慎重でなければならない.なお,ビリグラフィンによるcontrast enhancementを応用したCTスキャンは,肝嚢腫との鑑別上有用であった.