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Hepatocellular carcinoma (HCC) with sarcomatoid change is a rare neoplasm of the liver, and recurrent therapies for HCC such as transcatheter arterial chemoembolization and percutaneous ablation therapy are presumed to promote sarcomatoid change. A 73-year-old man was admitted to our hospital diagnosed as having liver cancer originating from hepatitis C-related cirrhosis without any previous treatment for HCC. Ultrasonography showed that the tumor was hypoechoic, 3 cm in diameter, with unclear margins. Computed tomography demonstrated a low-density lesion with ring enhancement on delayed phase. Under a diagnosis of poorly differentiated HCC the patient underwent liver resection. Histologically, the tumor consisted of proliferation of spindle-shaped sarcomatoid carcinoma cells with unclear trabecular and pseudoglandular structures including a nodule of typical moderately differentiated HCC, which was observed to shift mutually in one region. Here, we report a case of sarcomatoid HCC with a review of the literature.

Background In liver resection, bile leakage remains the most common cause of operative morbidity. In order to predict the risk of this complication on the basis of various factors, we developed a clinical score system to predict the potential risk of bile leakage after liver resection. Methods We analyzed the postoperative course in 518 patients who underwent liver resection for malignancy to identify independent predictors of bile leakage, which was defined as “a drain fluid bilirubin concentration at least three times the serum bilirubin concentration on or after postoperative day 3,” as proposed by the International Study Group of Liver Surgery. To confirm the robustness of the risk score system for bile leakage, we analyzed the independent series of 289 patients undergoing liver resection for malignancy. Results Among 81 (15.6 %) patients with bile leakage, 76 had grade A bile leakage, and five had grade C leakage and underwent reoperation. The median postoperative hospital stay was significantly longer in patients with bile leakage (median, 14 days; range, 8 to 34) than in those without bile leakage (11 days; 5 to 62; P = 0.001). There was no hepatic insufficiency or in-hospital death. The risk score model was based on the four independent predictors of postoperative bile leakage: non-anatomical resection (odds ratio, 3.16; 95 % confidence interval [CI], 1.72 to 6.07; P

The aim of this study was to reveal the utility of alimentary reconstruction using staplers during pancreaticoduodenectomy (PD), focusing on the occurrence of delayed gastric emptying. Between 2003 and 2007, 72 PDs with alimentary reconstruction were performed by a single surgeon. Since August 2006, the new Roux-en-Y reconstruction methods using staplers were applied in 26 of the patients. We compared their clinical outcomes with those of the 46 patients who underwent PD using the conventional hand-sewn reconstruction methods. The results of upper gastrointestinal study showed improvement within 10 postoperative days (PODs; P = 0.03): the patients resumed eating their regular diet sooner (13 vs 6 days, P < 0.001), and both the incidence of delayed gastric emptying (43% vs 19%, P = 0.04) and the hospital stay (27 vs 21 days, P = 0.008) were reduced significantly in patients with stapled reconstruction. Despite the fact that operative costs were significantly higher for patients with stapled reconstruction (P = 0.009), hospital costs were significantly lower (P = 0.049) for those who underwent the conventional method. Our retrospective analysis shows that stapled reconstructions might reduce the incidence of delayed gastric emptying; however, further study will be necessary to evaluate the utility of this new method.

Adequate surgical procedure for gastrointestinal stromal tumors (GISTs) arising in the second portion of the duodenum remains controversial.Segmental resection of the second portion of the duodenum and Roux-en-Y reconstruction was performed in two patients with duodenal GISTs. In case 1, a huge tumor arising from the second portion of the duodenum occupied the right upper quadrant of the abdomen. Preoperative treatment using imatinib mesylate decreased the tumor size from 22 to 8 cm. In case 2, the tumor was located in the second portion of the duodenum longitudinally. In both of the cases, the major papilla was preserved.The postoperative course was uneventful, and they were discharged on day 11. Surgical margins were negative.The present simple segmental duodenectomy can be applied in the treatment of GISTs or other low-grade malignancies.

症例: 66歳, 男性. 平成5年12月より糖尿病性腎症による慢性腎不全のため維持透析を受けていた. 平成14年3月21日, 夕食後約1時間より左臍周囲痛が出現し, 徐々に増悪したため, 翌22日に当院へ緊急入院となった. 以後, 同様の腹痛にて計5回の入退院を繰り返した. 血液データ上炎症反応を認めず, 腹部CTにて上腸間膜動脈 (SMA) および下腸間膜動脈 (IMA) の壁に石灰化がみられた. 血管造影では腹腔動脈 (CA) およびSMAの描出は良好なるも, IMA領域では, 本幹の狭窄像とその末梢動脈に内腔狭窄と考えられる造影不良領域を認めた. いずれの領域にも血栓形成はみられなかった. また, 胃カメラ, 注腸および大腸鏡では, 異常を認めなかった. 以上の臨床経過と検査所見より食事により誘発された腹部アンギーナと診断した. しかし, 血管造影で, IMA本幹の狭窄に加え, さらにその末梢動脈におけるびまん性の内腔狭窄が強く疑われたことから外科的治療の適応はないと判断された. 退院後は, 関連透析施設にてドライウェイトを甘めにするなどの管理にとどまっている. 主な3本の腹部臓器動脈である, 腹腔動脈, 上・下腸間膜動脈の間には豊富な側副血行路が発達しているため, 腹部アンギーナの出現に関する過去の報告例では, これら3本の主幹動脈のうち2本以上が関与する例が大多数を占めている. 本例は, IMA領域のみの慢性虚血が原因と考えられたまれな1例であった.

61歳, 男性. 1988年慢性糸球体腎炎を指摘されるも放置. 1991年9月慢性糸球体腎炎の増悪を認め透析導入となった. 2000年9月にたまたま施行したCTにて, 両側腎臓の萎縮性変化と多発性嚢胞および左腎の腫瘤を指摘され入院となった. 2001年1月10日根治的左腎摘除術を施行. 紡錘細胞癌 (肉腫様癌) と診断された. 補助療法を勧めるも患者が拒否したため断念. その後, 外来にて経過観察していた. 同年3月16日に左上下肢の麻痺を訴えたためCTを施行したところ, 脳転移が疑われ当院脳神経外科に入院となった. MRIでは右頭頂葉に腫瘤を認めた. 4月12日腫瘍摘出術を施行. 病理組織学的に腎細胞癌脳転移と診断された. その後, 頭部に50Gyの放射線照射を行ったが, 脳転移の再発をきたし, 9月28日死亡した.紡錘細胞癌 (肉腫様癌) は極めて予後の不良な腎細胞癌の一細胞型として知られている. しかし最近, 肉腫様変化は腎細胞癌の全ての細胞型から生じ得る, 異型度の高い表現型であると考えられるようになってきた. これまで透析腎癌の予後は良好とされてきたが, 透析患者に発生する腎細胞癌にも肉腫様変化が生じ得ることを認識すべきであると考えられた.

Introduction: Paraneoplastic syndromes are disorders associated with clinical signs and symptoms caused by substances produced by malignant disease and are not directly related to the physical effects of a primary or metastatic tumor. We describe a patient with gastrointestinal stromal tumor of the stomach accompanied by nephrotic syndrome as paraneoplastic syndrome in whom symptomatic treatment was ineffective. Nephrotic syndrome caused by gastrointestinal stromal tumors is quite rare, and to the best of our knowledge this is the first time that such a case has been documented. Case presentation: We describe a 69-year-old Asian woman with a gastrointestinal stromal tumor of the stomach accompanied by paraneoplastic syndrome. The patient had severe hypoalbuminemia and proteinuria, which were apparently attributed to a gastrointestinal stromal tumor. After preoperative treatment for hypoalbuminemia, the tumor was resected and nephrotic syndrome improved. Two years after her operation, she is still alive with neither tumor recurrence nor nephrotic syndrome. Conclusion: Patients with refractory nephrotic syndrome caused by a malignant tumor should be treated aggressively, even if they are in poor general condition. Otherwise, the opportunity for potentially curative surgery may be missed.

w t 1 p ( i a s ancreatic fistula is the most troublesome complication fter pancreaticoduodenectomy. A variety of pancreaticnteric anastomoses and other surgical techniques have een developed to prevent pancreatic fistulas, and the atest incidence of pancreatic fistula after pancreatioduodenectomy has been reported to be 9% to 17%. ut leakage of pancreatic juice from soft pancreatic issue cannot be eradicated, so prevention of lifehreatening complications associated with pancreatic fisula, such as delayed hemorrhage from major arteries, emains important. We recently developed a simple echnique in which the stump of the gastroduodenal rtery (GDA) is wrapped using the falciform ligament uring pancreaticoduodenectomy. This method may rotect the stump of the GDA from being exposed to ancreatic juice and prevent the development of seudoaneurysms or massive hemorrhaging.

Postoperative pancreatic fistula (POPF) is a most striking complication after pancreatic resection. The objective of this study is to reveal the risk factors for POPF defined by the international study group after pancreaticoduodenectomy in a Japanese high-volume center. During the recent 4 years, 220 patients underwent pancreaticoduodenectomies. In patients of obstructive jaundice, preoperative biliary drainage was performed by percutaneous (n = 71) and/or retrograde (n = 38) approach. Pancreaticojejunostomy was performed using either duct-to-mucosa anastomosis (n = 180) or dunking method (n = 40). Risk factors for POPF (grade B or grade C POPF by international definition) were evaluated using univariate and multivariate analyses. POPF was found in 109 (50%) patients; grade A in 45 (21%), grade B in 54 (25%), and grade C in 10 patients (5%). One patient died of intra-abdominal hemorrhage caused by POPF. Univariate and multivariate analyses revealed that independent risk factors for grade B or grade C POPF were the size of the main pancreatic duct (

透析患者の腎細胞癌に対するインターフェロンの投与方法について, IFN-α500万単位と250万単位を筋肉内投与した際の血中濃度を透析患者5名と非透析患者2名で比較検討した. 血中濃度の経時的変化は, 4-8時間で最高血中濃度に達し, 非透析患者と大差はなかった. 24時間後では, 透析患者5例中4例に血中濃度の蓄積傾向を認め, 500万単位投与群では, 7日目の平均血中濃度は89.3IU/mlと上昇し, 最高血中濃度が302IU/mlにまで上昇した症例もあった. 透析患者の血中-時間曲線下面積 (AUC) は, いずれも高値を示した. IFN投与時の副作用としては, 全例にGOTの上昇を認め2例投与中止となった. 透析患者の投与法としては, 非透析患者に比較して, 一律に投与するのではなく, 蓄積傾向なども考慮して副作用を抑え, 個々に工夫すべきものと考えられた.

The impact of pelvic lymph node dissection on the survival of patients with lymph node positive bladder cancer is controversial. We analyzed the records of the bladder cancer patients treated with radical cystectomy.Between 1976 and 1993, 84 patients with transitional cell carcinoma of the bladder were treated with radical cystectomy at Tokyo Metropolitan Komagome General Hospital. Sixteen patients (19.0%) had pathologically proved nodal metastases. These patients' records were reviewed with regard to pathological status, and the outcome compared with negative lymph node patients. The two patients with pN3, which we could not completely undergo lymph node dissection of, were excluded from the analyses for recurrence and survival.There were 10 males and 6 females, aged between 47 and 83 with a mean of 68.3 years. There were significant differences between the patients with positive lymph node and negative in the rate of grade 3 and the rate of infiltration of cancer to the vein and lymphatics of the bladder walls. The frequency of the patients of positive lymph node was 5.3% in pT1, 10.0% in pT2, 28.6% in pT3a, 32.0% in pT3b, 50.0% in pT4, and none in pTis, pTa and pT4is. The five-year survival rates estimated by the Kaplan-Meier method were 68.6% over all 82 patients, 75.7% for the patients with negative lymph node and 30.7% for positive. Of the patients with positive lymph node, two-year survival was 80.0% for pT2-3a, versus 0% for pT3b-4. This difference was highly significant (p0.01). But survival analysis for pT2-3a showed no significant difference between the lymph node negative patients and positive. The recurrence rate was 57.1% (8 of 14) in patients with positive lymph node and seven patients suffered from distant metastases. All the patients which had recurrent tumors died by bladder cancer.Radical cystectomy with lymph node dissection can provide favorable outcome in lymph node positive patients with low stage (pT2-3a). But the patients with high stage (or = pT3b) were poor prognosis. Most of the patients died by distant metastases.