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Omentectomy is considered an essential part of curative gastrectomy for locally advanced gastric cancer (GC), albeit without solid evidence. We conducted a randomized phase II trial (the TOP-G trial) comparing omentectomy and omentum preservation for gastric cancer. This report describes the short-term findings regarding the trial’s secondary endpoints. The trial protocol was submitted to the University Hospital Medical Information Network Clinical Trials Registry ( http://www.umin.ac.jp/ctr/ : UMIN000005421). The key eligibility criteria were histologically confirmed cT2–4a and N0–2 gastric adenocarcinoma. Short-term surgical outcomes, including morbidity and mortality, were compared between the omentectomy group (group A, control arm) and the omentum-preserving surgery group (group B, test arm). All procedures were performed via an open approach. Based on a non-inferiority margin of 7%, statistical power of 0.7, and type I error of 0.2, the sample size was set to 250 patients. A total of 251 patients were eligible and randomized (group A: 125 patients, group B: 126 patients) between April 2011 and October 2018. After excluding patients who had peritoneal metastasis or laparotomy history, safety outcomes were analyzed for 247 patients. Group A had a significantly longer median operation time (225 min vs. 204 min, p = 0.022) and tended to have greater median blood loss (260 mL vs. 210 mL p = 0.073). The incidences of morbidity were similar and

BACKGROUND Standard treatment for stage II/III gastric cancer is curative resection followed by adjuvant chemotherapy. However, the five-year survival remains unsatisfactory. Inhibin βA (INHBA) has been reported to be associated with cancer cell proliferation and chemoresistance. PATIENTS AND METHODS We studied the clinical significance of INHBA gene expression in 134 patients with stage II/III gastric cancer who received adjuvant chemotherapy with S-1. INHBA expression of specimens of cancer tissue and adjacent normal mucosa was measured by quantitative real-time, reverse-transcription polymerase chain reaction (RT-PCR). RESULTS INHBA expression levels were significantly higher in cancer tissue than in adjacent normal mucosa. High INHBA expression was associated with significantly poorer 5-year survival than was low expression. On multivariate analysis, INHBA expression was an independent prognostic factor. CONCLUSION INHBA gene expression in gastric cancer tissue is considered a useful independent predictor of outcomes in patients with stage II/III gastric cancer who receive adjuvant chemotherapy with S-1.

Overall survival remains unsatisfactory in stage II/III gastric cancer, even after curative surgery and adjuvant chemotherapy. Platelet-derived growth factor receptor-β (PDGFR-β) is associated with the proliferation of cancer cells. The present study therefore investigated the association of PDGFR-β gene expression with patient outcome in 134 stage II/III gastric cancer patients who received adjuvant chemotherapy with S-1. Relative PDGFR-β gene expression was measured in surgical cancer tissue and adjacent normal mucosa specimens by reverse transcription-quantitative polymerase chain reaction. The PDGFR-β gene expression levels were found to be significantly higher in the cancer tissues compared with the adjacent normal mucosa. A high level of PDGFR-β gene expression was associated with a significantly poorer 5-year overall survival rate compared with a low level of PDGFR-β expression. Upon multivariate analysis, PDGFR-β gene expression was found to be an independent predictor of survival. Overall, the study indicates that PDGFR-β overexpression in gastric cancer tissues is a useful independent predictor of outcome in patients with stage II/III gastric cancer who receive adjuvant chemotherapy with S-1.

285 Background: A complete resection of the omentum has been believed as a standard procedure for advanced gastric cancer. However, there was no evidence for survival significance of omentectomy. Therefore, we conduct the Phase II trial (TOP-G trial) comparing gastrectomy with omentectomy and omentum preserving gastrectomy. Here, we present the short-term outcomes which was a secondary endpoint of TOP-G trial. Methods: Enrollment criteria included histologically confirmed cT2-4a and N0-2 gastric adenocarcinoma. The extent of nodal dissection was performed based on the Gastric Cancer Treatment Guidelines in Japan. All procedure was performed through laparotomy. Laparoscopic approach was not accepted. Surgical outcomes morbidity, and mortality were compared between gastrectomy with omentectomy group (group A) and omentum preserving gastrectomy group (group B). Postoperative complication was evaluated with Clavien-Dindo classification. Results: A total of 251 patients were randomly assigned to group A (n = 125) or group B (n = 126) between April 2011 and October 2018. After excluding patients who received bypass or no surgery, 246 patients were analyzed as actual treatment group. There was no difference between two groups in patient characteristics and pathological findings. There was no difference in operation time (median 244 vs 204 min, p = 0.156) and in blood loss (median 260 vs. 210 ml, p = 0.371). Median number of totally retrieved lymph nodes was similar (median 36 vs. 37, p = 0.758). There was no difference in the incidence of any postoperative complication (28.9% vs. 25.8%, p = 0.584). There was no mortality in both groups. Conclusions: Omentum preserving gastrectomy for advanced gastric cancer was similar short-term outcomes with gastrectomy with omentectomy. Clinical trial information: UMIN000005421.

The standard treatment for stage II/III gastric cancer is surgical resection followed by adjuvant chemotherapy with fluoropyrimidine anticancer agents, including S-1. The protein, secreted protein, acidic and cysteine-rich (SPARC), promotes angiogenesis, and the proliferation and migration of cancer cells. The present study evaluated the significance of expression of the SPARC gene in patients with stage II/III gastric cancer who had undergone surgical resection and adjuvant chemotherapy with S-1. In the present study, reverse transcription-quantitative polymerase chain reaction was performed in order to quantify mRNA expression levels of SPARC in cancer tissues and adjacent normal mucosa obtained from 134 patients with stage II/III gastric cancer who had undergone surgical resection followed by adjuvant chemotherapy with S-1. The mRNA expression level of SPARC was significantly higher in cancer tissues than in adjacent normal mucosa (P=0.0012). Additionally, the 5-year overall survival rate was significantly poorer in patients with high SPARC gene expression than in those with low expression (P

We report the case of a 69-year-old man diagnosed with gastric cancer.The patient underwent distal gastrectomy(D2) and Billroth I reconstruction in March, 2010. Postoperative histopathological examination indicated M, Ant, Type 5, 100×50 mm, pappor2sig, T4aN3M0, pStage III C.We performed S-1 therapy as adjuvant chemotherapy.Abdominal CT showed para-aortic lymph node recurrence in February, 2015. Since HER2 protein was overexpressed in primary tumor immunostaining, he was treated with capecitabine plus CDDP plus trastuzumab therapy.After the chemotherapy, CEA levels decreased to the normal range and the enlarged lymph node was remarkably decreased in size in May, 2015.T he patient is alive 24 months after the chemotherapy with no evidence of recurrence.

An 84-year-old man visited our hospital with epigastralgia.Levels of hepatic and biliary enzymes and CRP were elevated, as detected by a blood test.On a CT scan, a swollen gallbladder with stones was detected.The patient was admitted to the hospital with a diagnosis of Grade I acute cholecystitis.Conservative treatment was continued with antibiotic administration and the patient was discharged from the hospital with improvement on day 6 after admission.Three months later, the patient underwent laparoscopic cholecystectomy.In the gallbladder, a 45×45 mm tumor was found.Upon pathological examination, diffuse proliferation of lymphocyte-like heterotypic cells and subserosal invasion were observed.Immunohistochemistry results were negative for MUM1 and positive for CD10 and Bcl6 markers.A malignant diffuse large B-cell lymphoma was diagnosed.We experienced a case of malignant lymphoma of the gallbladder diagnosed after surgery for acute cholecystitis, which we herein report with literature consideration.

Curative resection and adjuvant chemotherapy is the standard treatment for Stage II/III gastric cancer, and S-1 is widely used for adjuvant chemotherapy. The type 1 insulin-like growth factor receptor (IGF1R) is involved in cell proliferation and prevention of apoptosis in many tumors. We evaluated the relative expression of the IGF1R gene to determine whether such expression correlates with outcomes in patients with Stage II/III gastric cancer. We measured the expression levels of the IGF1R gene in specimens of cancer and adjacent normal mucosa obtained from 134 patients with Stage II/III gastric cancer who received curative resection and adjuvant chemotherapy with S-1. We then evaluated whether the IGF1R gene expression levels correlate with clinicopathological characteristics and outcomes. IGF1R mRNA expression levels tended to be higher in cancer tissue than in the normal adjacent mucosa (P = 0.078). Multivariate analysis showed that high IGF1R gene expression was a significant independent predictor of poor survival in Stage II/III gastric cancer after curative resection and adjuvant chemotherapy with S-1 (HR 3.681, P = 0.007). The overall survival rate was significantly lower in patients with high IGF1R gene expression than in those with low expression (P = 0.012). IGF1R overexpression is considered a useful independent predictor of outcomes in Stage II/III gastric cancer after curative resection and adjuvant chemotherapy with S-1.

Background Overall survival remains unsatisfactory in stage II/III gastric cancer, even after curative resection and adjuvant chemotherapy. Tensin 4 (TNS4), a cell adhesion factor, is associated with cancer-cell motility and migration. Patients and methods We examined the clinical significance of TNS4 gene expression in 134 patients with stage II/III gastric cancer who underwent adjuvant chemotherapy with S-1. TNS4 gene expression in surgical specimens was measured by quantitative reverse-transcription polymerase chain reaction (RT-PCR). Results TNS4 gene expression levels were significantly higher in cancer tissue than in adjacent normal mucosa. High TNS4 gene expression was associated with significantly poorer 5-year overall survival than was low expression. On multivariate analysis, TNS4 gene expression was an independent prognostic factor. Conclusion Overexpression of the TNS4 gene is a useful independent predictor of outcomes in patients with stage II/III gastric cancer who undergo surgery and receive adjuvant chemotherapy with S-1.

Background: Standard treatment for stage II/III gastric cancer is curative resection followed by adjuvant chemotherapy. However, the five-year survival remains unsatisfactory. Inhibin βA (INHBA) has been reported to be associated with cancer cell proliferation and chemoresistance. Patients and Methods: We studied the clinical significance of INHBA gene expression in 134 patients with stage II/III gastric cancer who received adjuvant chemotherapy with S-1. INHBA expression of specimens of cancer tissue and adjacent normal mucosa was measured by quantitative real-time, reverse-transcription polymerase chain reaction (RT-PCR). Results: INHBA expression levels were significantly higher in cancer tissue than in adjacent normal mucosa. High INHBA expression was associated with significantly poorer 5-year survival than was low expression. On multivariate analysis, INHBA expression was an independent prognostic factor. Conclusion: INHBA gene expression in gastric cancer tissue is considered a useful independent predictor of outcomes in patients with stage II/III gastric cancer who receive adjuvant chemotherapy with S-1.

Background and Objectives Sushi repeat-containing protein X-linked 2 (SRPX2) was first described as a downstream target gene for E2A-HLA, which causes pro-B acute leukemia. SRPX2 is considered to promote cellular migration and adhesion in cancers. Our objective was to evaluate the relative expression of the SRPX2 gene and to determine whether such expression correlates with outcomes in patients with gastric cancer. Methods Surgical specimens of cancer tissue and adjacent normal mucosa obtained from 227 patients with previously untreated gastric cancer were examined. SRPX2 mRNA expression levels of cancer tissue and adjacent normal mucosa were measured by quantitative real-time polymerase chain reaction. We evaluated the clinicopathological significance of the relative expression of SRPX2 in patients with gastric cancer. Results SRPX2 expression was higher in cancer tissue than in adjacent normal mucosa (P

To clarify factors related to vitamin E malabsorption after gastric surgery, we evaluated serum vitamin E levels in patients who had undergone gastrectomy for gastric cancer. We studied 39 patients (26 men, 13 women; mean age, 61.7 years) who underwent gastrectomy for early gastric cancer. Surgical procedures included 24 subtotal gastrectomies and 15 total gastrectomies. We measured serum levels of vitamin E before and 3, 6, 9, and 12 months after gastrectomy. A level of less than 0.75 mg/dl was defined as a low vitamin E level. Serum vitamin E levels decreased to less than 0.75 mg/dl in 6 (15.4 %) of the 39 patients within 6 months after gastrectomy and in 7 (17.9 %) of the 39 patients within 1 year after gastrectomy. The proportion of patients with a low serum vitamin E level was significantly higher in the total gastrectomy group (p = 0.002). A low vitamin E level was significantly associated with a low total cholesterol level. Total cholesterol levels in low vitamin E levels patients were lower than normal vitamin E levels patients. None of the patients with a low vitamin E level had neuropathy. The type of operation performed (total vs. subtotal gastrectomy) may be the major cause of vitamin E malabsorption after gastrectomy for gastric cancer. Vitamin E deficiency probably begins within 6 months after gastrectomy for gastric cancer.

Background/Aims: Changes in estradiol that inhibits bone resorption were examined to investigate the in vivo defensive response to progression of bone disorder after gastric cancer surgery. Materials and Methods: Women who might show effects of menstruation were excluded because estradiol was examined. The subjects were 17 men with a mean age of 60.4 years who had undergone gastrectomy because of gastric cancer and were followed as outpatients. Microdensitometry was used to evaluate bone disorder. The duration after surgery until bone assessment was a mean of 3.5 years. The surgical procedure was total gastrectomy with Roux-Y reconstruction in 4 patients and subtotal gastrectomy with Billroth-I reconstruction in 9 patients and with Billroth-II reconstruction in 4 patients. Results: Bone disorder requiring treatment was observed in 6 out of the 17 patients (35.3%). Estradiol showed higher than normal values in 10 patients (58.8%). The incidence of bone disorder was high in patients with high estradiol levels, but the difference was not significant. Blood levels of estradiol in patients with bone disorder requiring treatment were high but again the difference was not significant (P = 0.119). Conclusions: Although the difference was not statistically significant, the increase in estradiol observed in patients with progressive bone disorder suggested to be caused by in vivo inhibition of enhanced bone metabolism after gastric cancer surgery.

Purpose Secreted protein acidic and rich in cysteine (SPARC) is one of the first known matricellular proteins that modulates interactions between cells and extracellular matrix. Recent studies investigated the clinical significance of SPARC gene expression in the development, progression, and metastasis of cancer. The present study examined the relations of the relative expression of the SPARC gene to clinicopathological factors and overall survival in patients with gastric cancer. Methods We studied surgical specimens of cancer tissue and adjacent normal mucosa obtained from 227 patients with previously untreated gastric cancer. The relative expression levels of SPARC mRNA in cancer tissue and in adjacent normal mucosa were measured by quantitative real-time, reverse-transcription polymerase chain reaction. Results The relative expression level of the SPARC gene was higher in cancer tissue than in adjacent normal mucosa. High expression levels of the SPARC gene were related to serosal invasion (P = 0.046). Overall survival at 5 years differed significantly between patients with high SPARC gene expression and those with low expression (P = 0.006). Conclusions Overexpression of the SPARC gene may be a useful independent predictor of outcomes in patients with gastric cancer. J. Surg. Oncol. 2013; 108:364–368. © 2013 Wiley Periodicals, Inc.

Colon cancer is one of the most commonly diagnosed cancers in the United States. Recombinant MDA-7/IL-24 has showed its selective cytotoxicity against cancer cells, and Ad-mda7 (INGN-241) is currently under clinical investigation for solid tumors. Here, we investigated the expression of MDA-7/IL-24 in colorectal cancer (CRC) tissues from 202 patients. Compared with the adjacent mucosa, CRC tissues displayed significantly lower MDA-7/IL-24 levels. The MDA-7/IL-24 levels in CRC were significantly associated with patients' survival rate in a 6-year period. These results indicate MDA-7/IL-24 level is both a diagnostic and prognostic biomarker for CRC, and support the role of MDA-7/IL-24 in the treatment of CRC. To elevate MDA-7/IL-24 level for colon cancer treatment, we successfully developed a small-molecule compound SC144 with the ability to up-regulate MDA-7/IL-24 expression via direct binding and stabilizing MDA-7/IL-24 in human colon cancer cells. Among the analogs tested, SC144 exhibited the highest cytotoxicity in a panel of colon cancer cell lines in a p53-independent manner, accompanied by cell cycle arrest in G0/G1 with downregulation of Cyclin D1 levels, and apoptosis induction with upregulation of cell surface-bound Fas/CD95. These results combined with our previous studies support the anticancer role of MDA-7/IL-24 as well as the clinical development of SC144 for colon cancer treatment.

To evaluate short-term outcomes of laparoscopy-assisted colectomy (LAC) in elderly patients with colorectal carcinoma.A total of 289 colorectal cancer patients underwent LAC between 2008 and 2013. They were divided into an elderly group (80 years of age, group E), and a younger group (80 years of age, group Y). The treatment results, including the surgery-related factors, the perioperative course, and the pre- and postoperative complications, were retrospectively analyzed.There were 49 patients in group E, and 240 patients in group Y. There was no significant difference between the 2 groups considering the operative time, blood loss, rate of transfusion, post-operative hospital stay, rate of conversion to open surgery, or rate of complications, except for the number of patients with an ASA classification of greater than Grade 2 and the degree of lymph node dissection.LAC in elderly patients was found to be relatively safe because it was associated with a reduction in damage to the abdominal wall, and with an early recovery from surgery. These results suggest that the indications of LAC could be expanded for elderly patients.

Aim: Obesity and visceral obesity are closely related to the development of colorectal cancer, as well as other metabolic complications. We investigated the prognostic significance of body mass index (BMI) and visceral obesity in 273 patients with resectable colorectal cancer. Methods: Visceral fat area (VFA) and subcutaneous fat area were measured on digital images of patients’ computed tomograms obtained before surgery. The patients were divided into two groups according to the cut-off levels of VFA proposed by Oka et al. Men with a VFA of ≥130 cm2 and women with a VFA of ≥90 cm2 were classified as obese (VFA-obese) and the others were classified as non-obese (VFA-non-obese). The patients were also divided into an overweight group and a normal range group, according to their preoperative BMI. Results: There was no significant difference in cumulative recurrence-free survival (RFS) or overall survival (OS) between the VFA-obese group and the VFA-non-obese group. In the subgroup of patients with Dukes’ C disease (n = 100) there was no statistically significant difference in RFS and OS between the VFA-obese group and the VFA-non-obese group. The results were similar when the patients were classified according to their BMI. Conclusion: Neither obesity nor increased visceral adiposity has any influence on outcomes in patients with resectable colorectal cancer.

Insulin-like growth factor-1 receptor (IGF-1R) and matrix metalloproteinase-7 (MMP-7) have been reported to be related to tumor invasion and metastasis in various malignancies. The aim of this study was to evaluate the expression levels of IGF-1R and MMP-7 in resected non-small cell lung cancer (NSCLC) and to examine the relationship of such levels to clinical characteristics and survival. Expression was measured immunohistochemically. The percentage of stained cells was multiplied by the staining intensity. The sample was classified as high when the score was equal or higher than the median value or was otherwise considered to be low. High IGF-1R expression was associated with nodal metastasis and recurrence (P=0.034 and 0.006, respectively). High IGF-1R expression was associated with significantly poorer overall survival than low IGF-1R expression (P=0.011). MMP-7 expression did not significantly correlate with any clinicopathological factor. There was a trend toward slightly, but not significantly poorer survival in patients with MMP-7-high tumors than in those with MMP-7-low tumors (P=0.220). There was no significant correlation between IGF-1R expression and MMP-7 expression (P=0.184). Upon multivariate analysis, IGF-1R expression was independently related to the outcomes of patients with NSCLC. Overexpression of IGF-1R may be a useful predictor of lymph node metastasis, recurrence and post-surgical outcomes in patients with NSCLC.

Background Regenerating islet-derived family members (Reg) are superfamily of calcium-dependant lectins that are expressed in the proximal gastrointestinal tract and ectopically at other sites in the setting of tissue injury. The regenerating islet-derived family member 4 (RegIV) gene has been reported in various cancers, associating with diverse functions. This study examined the relation of the relative expression of RegIV gene to clinicopathological factors and outcomes in patients with colorectal cancer (CRC). Methods We studied surgical specimens of cancer tissue and adjacent normal mucosa obtained from 202 patients with untreated CRC. The relative expression levels of RegIV mRNA in cancer and in normal adjacent mucosa were measured by quantitative real-time reverse-transcriptase polymerase chain reaction. Results RegIV gene expression was higher in cancer tissue than in adjacent normal mucosa. The multivariate analysis of clinicopathological factors for 5-year overall survival showed a higher level of RegIV gene expression was a significant independent predictor. Overall survival at 5 years differed significantly between patients with high RegIV gene expression and those with low expression. Conclusions Overexpression of the RegIV gene is considered a useful independent predictor of outcomes in patients with CRC. J. Surg. Oncol. 2011;104:205–209. © 2011 Wiley-Liss, Inc.

症例は56歳女性．33歳から全大腸型の潰瘍性大腸炎を指摘されていた．2005年9月，直腸癌RbP，type 3，cAI（vagina），cN2，pM1（両側鼡径リンパ節）に対し，腹仙腹式直腸切断術（D3 prxD2），大腸全摘術，回腸人工肛門造設術，および両鼡径リンパ節部分切除術を施行した．病理組織学的所見ではRbP，type 3，68×30mm，moderately differentiated adenocarcinoma（mod>por），pAI（vagina），pN2，ly2，v3，pM1（両側鼡径リンパ節），Cur C，f-stage IVであった．FOLFIRI療法10サイクルで両側鼡径リンパ節がCRとなりCEAも一旦正常化したが，2007年9月CEAが33.1ng/ml まで上昇し，PET検査で左大腿部に集積を認め，穿刺吸引細胞診で腺癌と診断された．同月，直腸癌左大腿転移の診断にて，左大腿腫瘍切除を行った．組織学的には低分化腺癌で，免疫染色の結果から直腸癌の転移と確認された．術後，CEAは正常化し，転移巣切除から27カ月経過した現在，無再発生存中である．大腸癌の骨格筋内転移症例は非常にまれであり若干の文献的考察を加えて報告した．

はじめに : 胃切除施行後患者における骨代謝障害は，以前より問題視されているが，明確な予防・治療指針が存在せず見逃されている症例も多い．近年骨代謝障害を改善するビスフォスフォネート製剤が登場したため，胃切除後骨代謝障害に対するアレンドロネートの効果を検討した．対象と方法 : 胃切除術施行後の男女で，腰椎骨密度が若年成人平均値の80%未満である骨量減少患者80名を対象とし，活性型ビタミンD3投与群（VD群），アレンドロネート投与群（ALN群），活性型ビタミンD3＋アレンドロネート併用投与群（併用群）に割付け，腰椎骨密度などの有効性，有害事象，骨折などの安全性を2年間観察した．結果 : 腰椎骨密度の増加率は24か月でVD群3.5%，ALN群9.3%，併用群7.7%で，ALN群，併用群で有意に増加した（P

In this report, we describe our traction suture technique of the pericardium for suspension of the heart without hemodynamic instability to obtain excellent exposure in the abdominal-transhiatal approach (TH). Our technique is an application of deep pericardium stitches for off-pump coronary artery bypass surgery. In detail, the left hepatic lobe is detached at its triangular ligament from the diaphragm and is deflected to the right. Then, the tendinous portion of the diaphragm arching over the esophagus is incised upward in the midline until the pericardium is exposed. Pericardial fatty tissue was dissected. Three U-shaped sutures reinforced with a felt pledget are placed on the posterior aspect of the pericardium and diaphragm. A 15 Fr. flexible catheter is placed over both ends of the suture to avoid damage of the adjacent organs. Finally, the sutures are fixed to the drape of anterior wall of the patient to maintain good exposure.

The role of gastric acid reflux is difficult to separate from that of pancreatic-biliary reflux in the pathogenesis of erosive esophagitis (EE) and Barrett's esophagus (BE). Gastric surgery patients provide a good model for both significant pancreatic-biliary reflux and marked gastric acid inhibition. We assessed the risk of EE and BE after distal gastrectomy in a case-controlled study.One hundred and sixty patients (121 men, 39 women; median age 68 years; range 32-86 years) with distal gastrectomies (Billroth-I) and 160 sex- and age-matched controls with intact stomachs were enrolled. The presence of EE and BE were diagnosed based on the Los Angeles Classification and the Prague CM Criteria, respectively. A conditional logistic regression model with adjustments for potential confounding factors was used to assess the associations.According to the multivariate analyses, patients with distal gastrectomies tended to have inverse associations with the risks of EE and BE, and the inverse association with the risk of BE reached a significant level.Distal gastrectomy is not a risk factor for the development of EE and BE. This lack of a positive association between distal gastrectomy and EE and BE may suggest that pancreatic-biliary reflux with a limited amount of acid is not sufficient to damage the esophageal mucosa.

症例は63歳，女性．2007年8月の検診にて左頸部腫瘤と右肺野異常影を指摘され当院受診した．精査にて転移性甲状腺癌，転移性肺癌と診断された．原発巣であるが病理組織形態や免疫染色の結果から大腸癌が疑われ，腸内視鏡検査を施行し上行結腸癌（病期IV）と診断された．治療は原発巣の狭窄が強いため2007年10月に結腸右半切除術を施行し，2007年11月よりmFOLFOX6を4コース施行した．2008年1月の効果判定ではNCであり他転移巣の出現もないことから，2008年2月に甲状腺左葉切除，右肺上葉切除を施行した．病理結果はmuc～mod SS N1 H0 M1 stage IVであった．術後経過は良好で，TS-1単剤にて術後化学療法を施行中である．また，術後1年3カ月になるが現在まで再発を認めていない．

症例は67歳の女性で，慢性関節リウマチで通院中に血液生化学検査で閉塞性黄疸を指摘された．腹部dynamic CTで膵頭部に3.5 cmの低吸収域を認め，また上腸間膜動脈根部に4 cm長の著明な狭窄と胃十二指腸動脈からの膵頭動脈アーケードの代償性拡張を認めた．開腹生検で腺癌の確診を得た後，膵頭十二指腸切除術（pancreaticoduodenectomy；以下，PD）の方針となった．まず，上腸間膜動脈根部および各分岐のテーピングを行い，ドップラー血流計にて血流を測定した．下膵十二指腸動脈，第一空腸動脈をクランプしても上腸間膜動脈末消の血流低下を認めず，これらを結紮切離した後にPDを施行した．切除後は中結腸動脈から逆行性の血流供給を認めた．術後経過は良好で，第20病日に軽快退院した．本症例はPD後の腸管虚血が懸念されたが，上腸間膜動脈分枝の先行処理により血流が保たれることを確認したうえで安全に切除することが可能であった．先行処理は有用な手法であると考えられた．

大腸癌根治切除例のうち，粘液癌を分化型腺癌と比較し臨床病理学検討を行うとともに，粘液癌を組織学的特徴により2群に分類し，臨床病理学的な検討と予後因子の検討を行った．粘液癌の発生頻度は5.1%で，高·中分化型腺癌と比較して，右側の発症率，腫瘍径の大きい症例，深達度T3以深の症例が有意に多かった．粘液癌の5年生存率は68.8%と高·中分化型腺癌と比較し有意に低かった．粘液癌の予後因子の検討では，由来組織，リンパ管侵襲，リンパ節転移が予後規定因子として有意差をもって選択され,因子の数が多い症例ほど5年生存率は有意に低かった．また，粘液癌をその由来組織により高分化型と低分化型に分類し検討すると，低分化型では5年生存率が40%と有意に低かった．粘液癌の中でもこれらの予後不良因子を有する症例の場合には高リスク大腸粘液癌として，高·中分化型腺癌とは異なる治療方針を考慮する必要性があると考えられた．

Objective We previously reported on vitamin E malabsorption after gastrectomy. In this study, we focused on neurological dysfunction due to serum vitamin E decrease during the postgastrectomy period in lager number of patients. Methods We examined the type of gastrectomy, type of reconstruction, serum vitamin E level, and neurological status for 96 gastrectomy patients. Results Low serum vitamin E levels were observed in 20 patients, and 10 of those patients suffered some neurological symptoms, i.e., peripheral neuropathy, limb or truncal ataxia. Vitamin E levels tended to decrease with time after gastrectomy, and the number of patients with low serum vitamin E levels increased at about 50 months after gastrectomy. This relationship was stronger in total gastrectomy patients than in subtotal gastrectomy patients. Ten patients were given oral vitamin E, and serum vitamin E levels normalized in 9 of the patients and neurological abnormalities improved in 8 patients. An oral intake of 300 mg or more of vitamin E was necessary for normalization of vitamin E levels. Conclusions Gastrectomy should be considered a risk for vitamin E deficiency and neurological disturbance over the long-term clinical course. An oral vitamin E supply can improve serum vitamin E levels and neurological symptoms.

目的：下部直腸癌患者の低位前方切除術の際にdiverting stomaとしてileostomyを造設後にイレウスを発症した症例を分析し，イレウス発症の危険因子を明らかとする．対象·方法：下部直腸癌手術の際に同時にileostomyを造設した23人を対象とした．イレウス発症群，イレウス非発症群の2群に分け，術前因子，手術因子の各項目について比較検討した．結果：イレウス発症群は10例で，イレウス非発症群は13例であった．単変量解析では男性および腹直筋の厚さ≥10mmが危険因子として選択された（p＜0.05）．多変量解析では腹直筋の厚さ≥10mmが危険因子として選択された（p＜0.05）．考察：腹直筋の厚さ≥10mmの危険因子を有する症例に対しては，diverting stomaとして腹直筋以外の回腸挙上経路あるいは横行結腸人工肛門の造設なども考慮して手術を施行する必要があると考えられる．

目的：下部直腸癌に対する側方リンパ節郭清の適応の指標とする目的で，Air注腸CTでの下部直腸癌の深達度T3以深を示す所見を明らかとし，診断精度を評価した．対象・方法：当科での下部直腸癌167例中，術前にAir注腸CTを施行した113例を対象．病理学的深達度がT3以深とT2以浅の2群に分け，CT画像における，（1）腸管壁の辺縁凹凸不整，（2）腸管壁の肥厚，（3）ケバ立ち，（4）鋸歯状変化，（5）腫瘍径，（6）環周率の6項目を比較検討した．結果：病理学的深達度がT3以深63例，T2以浅50例であった．単変量および多変量解析では，（1）腸管壁の辺縁凹凸不整，（3）ケバ立ちの2項目が深達度T3以深を示す因子として選択された（p＜0.05）．（1），（3）の所見を有する症例のAir注腸CTにおける深達度T3以深の正診率は，87.6%，89.4%であった．結論：Air注腸CTは下部直腸癌の術前深達度診断に有用であることが示唆された．

今回，われわれは比較的稀な魚骨による肉芽腫性回盲部炎の1例を経験したので報告する．症例は56歳の女性で，平成19年5月腹痛精査目的に下部消化管内視鏡検査を施行し，盲腸に浮腫状粘膜に覆われた隆起と腸管拡張不良を指摘された．生検の結果は慢性炎症所見のみだった．注腸造影X線検査で回腸末端部から盲腸に狭窄を，CTで同部位に壁肥厚を認めた．Positron emission tomography（以下PET）で回盲部に2-fluoro-2-deoxy-D-glucose集積を認めた為，肉眼型4型の盲腸癌を疑い開腹回盲部切除術を施行した．切除標本では回盲部に著しい壁肥厚を認めた．組織学的検索では小型の多核巨細胞を含む，乾酪壊死のない，多数のepithelioid granulomaを認めた．また，同部位に魚骨と考えられる異物を認め，異物による肉芽腫性回盲部炎と診断した．術前PETで陽性となった比較的稀な肉芽腫性回盲部炎を経験したので，若干の文献的考察を加えて報告する．

目的:高齢者術後せん妄発生予測因子を明らかにする．方法:2006年1月からの2年間に当院で手術をした胃癌と大腸癌の症例で，改訂長谷川式簡易知能評価スケール（以下HDS-R）による評価を術前行った70歳以上の高齢者121例を対象とし，術前因子（年齢，性別，既往歴，ASA分類，PNI，PS，術前在院期間，HDS-R）と手術因子（病変部位，手術時間，出血量，アプローチ，手術難易度，ICU入室，白血球数，CRP，術後合併症，食事開始時期）を検討した1)．結果:術後せん妄発生率は19.0％（23/121）だった．単変量解析では，術後せん妄発生とPNI（p=0.007），HDS-R（p=0.001），CRP（p

症例は59歳，男性．2004年10月 右季肋部痛を主訴に当院を受診した．同部位に著明な圧痛，反跳痛を認め，また，腹部CTでは回腸周囲のfat densityの上昇および右側腹直筋の肥厚を認め大腸憩室炎と診断された．入院後絶飲食，抗生剤投与を行い症状は一時改善したが，経口摂取開始後再び発熱と上腹部痛を認め開腹手術を施行した．圧痛部位の直下に手拳大の腫瘤を認め，空腸，横行結腸が巻き込まれていたため，腫瘤を含め小腸部分切除及び横行結腸部分切除術を施行した．腫瘤内部は膿瘍を形成しており，内部に小腸と交通する爪楊枝を認め，爪楊枝による消化管穿孔と診断した．爪楊枝による消化管穿孔は稀で，病歴から誤飲の有無を聞き出せないことも多く，診断に難渋する．本症例は，急性腹症の鑑別診断のひとつとして重要な症例と考え報告した．

We previously reported that the administration of 1alpha hydroxy vitamin D3 was effective for treating post-gastrectomy bone disorders. Accordingly, we performed the present study to obtain evidence supporting the effectiveness of 1alpha hydroxy vitamin D3 in post-gastrectomy patients.The study involved 22 outpatients who had undergone gastrectomy for gastric cancer and had not been treated with 1alpha hydroxy vitamin D3 or calcium. They comprised 17 men and 5 women, with a mean age of 61.9 years. Laboratory tests were performed to examine the following parameters: 1,25(OH)(2) vitamin D3; 25(OH) vitamin D3; 24,25(OH)(2) vitamin D3; ionized calcium; calcium; phosphorus; alkaline phosphatase; N-parathyroid hormone; and osteocalcin.The level of 1,25(OH)(2) vitamin D3, the most active of the vitamin D metabolites, was found to be normal in all of the patients. In contrast, the level of 25(OH) vitamin D3, which shows weak activity, was below the normal range in 7 of the 22 patients (31.8%). The mean serum level of 25(OH) vitamin D3 was significantly lower in patients at 1 year or more postoperatively than the level in those at less than 1 year postoperatively (P = 0.041), as well as being significantly lower in patients who had received total gastrectomy than in patients who underwent other gastrectomy procedures. The level of 24,25(OH)(2) vitamin D3, a metabolite of 25(OH) vitamin D3 that shows weak activity, was below the normal range in 19 of the 22 patients (86.4%). On multivariate analyses, factors associated with the change in vitamin D metabolites did not remain.The patients showed a decrease of 25(OH) vitamin D3 and 24,25(OH)(2) vitamin D3, which are metabolites that show weak activity. This suggests that a homeostatic response maintains the normal level of 1,25(OH)(2) vitamin D3, which is important for calcium regulation. Thus, it was suggested that gastrectomy had a moderate influence on the metabolism of vitamin D. However we could not detect any factor associated with the decrease of 25(OH) vitamin D3 and 24,25(OH)(2) vitamin D3.

This study aimed to analyse whether age, metastasis, extrathyroidal invasion and size (AMES) risk definition is valuable for Japanese patients with differentiated thyroid carcinoma (DTC). Methods: Two hundred and fifteen Japanese DTC patients (43 men, 172 women; mean age, 51.0 years; mean follow-up, 102 months) treated surgically at our institutions between 1981 and 2001 were retrospectively analysed. Clinicopathological features were compared between high-risk and low-risk patients by AMES criteria. Various risk factors were also evaluated for each group of patients. Results: There were 57 high-risk and 158 low-risk patients. Recurrence and mortality rates were 43.9% and 24.6% in high-risk patients and 7.6% and 0.6% in low-risk patients, respectively (p < 0.0001). Disease-specific survival rates at 5, 10 and 15 years were 84.3%, 74.0% and 63.5% in high-risk patients and 100%, 100% and 98.3% in low-risk patients, respectively (p < 0.0001). Univariate analysis revealed that curative resection, local recurrence and distant metastasis were risk factors for mortality in the high-risk group. Multivariate analysis revealed that curative resection (hazard ratio [HR], 4.68; 95% confidence interval [CI], 1.23-17.83; p = 0.024) and distant metastasis (HR, 4.79; 95% CI, 1.24-18.40; p = 0.023) were significantly related to mortality in high-risk patients. Conclusion: AMES can identify high-risk and low-risk Japanese patients. Distant metastasis and curative resection are prognostic factors for disease-specific death.

The aim of this study was to evaluate microscopic nodal status in papillary thyroid carcinoma (PTC) with and without lymphadenopathy and its relation to outcomes.We retrospectively analyzed 134 patients with PTC who underwent initial thyroidectomy. Forty-two patients with lymphadenopathy underwent therapeutic modified neck dissection (MND) and 92 without lymphadenopathy underwent prophylactic MND. The frequencies, numbers, and percentages of lymph node metastasis (LNM) were determined to evaluate nodal status; then, whether each nodal status influence to outcomes was analyzed. Disease-free survival (DFS) and disease-specific survival (DSS) were assessed (Kaplan-Meier method and log-rank test).Lymphadenopathy was significantly related to local recurrence and DFS, but not DSS. The frequency (100 vs 67.4%), number (15.8 vs 2.7), and percentage (49.7 vs 17.8%) were significantly higher in patients with lymphadenopathy than in those without lymphadenopathy (p0.0001). Similarly, these were significantly higher in patients who developed recurrence than in those who did not. Recurrence was frequent in older patients with lymphadenopathy. The frequency, number, and percentage were also higher in older patients who developed local recurrence.Lymphadenopathy and microscopic nodal status are significantly related to recurrence. Only a few nodes seem to be involved pathologically when no lymphadenopathy.

Tissue inhibitor of metalloproteinase-1 (TIMP-1) not only inhibits matrix metalloproteinases but also stimulates tumor growth. In this study, long-term follow-up results were analyzed to clarify the prognostic value of plasma TIMP-1. Preoperative plasma TIMP-1 was measured from peripheral blood samples of 87 Japanese patients with colorectal carcinoma. All the patients underwent surgical resection and were followed for 5 years prospectively. The median follow-up period was 70 months (60–79 months). The cutoff value of plasma TIMP-1 was set at 170 ng/ml based on the ROC curve. Sensitivity and specificity to predict 5-year survival was 66.7 and 55.0% with this cutoff value. In univariate analyses for overall survival, lymph node metastasis, serosal invasion, peritoneal metastasis, liver metastasis, metastasis to other distant organs and TIMP-1 were significant. In multivariate analyses, lymph node and liver metastases, metastasis to other distant organs and plasma TIMP-1 were independent prognosticators, but p values of TIMP-1 did not reach statistical significance. Our results suggested that the preoperative plasma TIMP-1 concentration could be a useful prognosticator of long-term survival in patients with colorectal carcinoma.

症例は63歳の男性. 25年来の痔瘻を有し, 2004年6月痔瘻根治術目的に近医受診. 術前の大腸内視鏡検査で下行結腸, S状結腸, 直腸に腫瘍を認め生検の結果中分化腺癌と判明. 同年8月3日結腸左半切除, 直腸部分切除術を施行した. 術後外来経過観察中肛門部の硬結が増大したため痔瘻部の穿刺吸引細胞診を施行したところadenocarcinoma group Vと診断された. 手術は画像上明らかな側方・鼠径リンパ節転移を認めなかったことおよび患者が直腸切断術を拒否したため, 肛門部腫瘍の局所切除術を施行した. 病理組織学的には中分化腺癌であり結腸癌の管腔内転移による転移性痔瘻癌と診断した. 大腸癌患者に痔瘻を有する場合には, 転移性痔瘻癌の発生も考慮に入れた経過観察が必要である.

症例は53歳, 女性. 7歳時より肺炎を繰り返していた. 近医通院していたが, 2001年12月上部消化管造影検査にて食道気管支瘻を疑われ, 当院紹介受診. 2002年5月手術目的で入院. 食道造影検査では胸部上部食道の拡張, 右気管支への造影剤の流出および右下葉末梢気管支の拡張があった. さらに上部消化管内視鏡および気管支鏡検査で瘻口が確認された. 経静脈下肺血管造影検査では右肺下葉の荒蕪肺に伴った右肺動脈の中葉前方枝, 下葉枝の閉塞が認められた. 食道気管支瘻および右肺下葉荒蕪肺の診断にて2002年5月右開胸で瘻管切除, 右肺下葉切除術を行った. 術後の食道造影検査にて瘻管切除部からの造影剤の流出はなく, 第12病日軽快退院した.