Search

A 71-year-old man was receiving follow-up examination because of a retention cyst in the pancreatic body that extended to the dorsal extrahepatic area, but presented to the Emergency Department at our hospital with dyspnea and cough. Chest X-ray showed a large amount of left-sided pleural effusion and abdominal computed tomography (CT) showed reduction in size of the cystic lesion. Biochemical testing of the pleural effusion revealed high levels of pancreatic enzymes. We, therefore, diagnosed rupture of the pancreatic cystic lesion into the chest cavity. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated stenosis of the pancreatic duct and leakage of contrast medium at the cystic lesion. CT after ERCP revealed leakage of contrast medium from the cystic lesion through the dorsal extrahepatic area into the chest cavity. Endoscopic naso-pancreatic drainage was performed, but the cystic lesion and pleural effusion remained unimproved. Distal pancreatectomy was, therefore, performed. Microscopic examination revealed eosinophilic infiltration of the pancreatic parenchyma, leading to a diagnosis of eosinophilic pancreatitis (EP). Pancreatic retention cyst secondary to chronic pancreatitis associated with eosinophilic infiltration was considered to have ruptured into the chest cavity. EP is a rare etiology of pancreatitis and few cases have been reported. This case was thus considered valuable.

Nodal metastasis is a leading attributable factor of poor survival in biliary tract cancer (BTC), and adjuvant chemotherapy targeting this high-risk feature has not been attempted to date. This study aimed to test the efficacy of adjuvant S − 1 for patients with node-positive BTC. This single-arm multicenter phase 2 trial enrolled patients who underwent resection for histologically proven node-positive BTC. In this trial, S − 1 was administered at a dose of 80–120 mg/day on 14 days of a tri-weekly cycle for 6 months. The primary end point of the trial was 3-year overall survival (OS), in which the result would be promising if the 90% confidence interval (CI) surpassed a threshold of 30% (alpha error, 0.1; beta error, 0.2). The secondary end points were relapse-free survival (RFS), feasibility, and toxicity. The trial included 50 patients with perihilar (n = 23) or distal (n = 20) cholangiocarcinoma, or gallbladder cancer (n = 7). The median numbers of positive lymph nodes and examined lymph nodes were respectively 2 and 15. The 3-year OS and RFS were respectively 50% (90% CI, 40.9–59.1%) and 32.0% (95% CI, 19.1–44.9%), with median survival times of 34.6 months (95% CI, 19.3–49.8 months) and 18.4 months (95% CI, 11.9–24.9 months). Although hematologic toxicity often occurred, grades 3 and 4 toxicity were rare. The completion rate of the test therapy was 64%, and the median relative dose intensity was 87.5% (interquartile range, 50–100%). Adjuvant chemotherapy with S − 1 may be promising for patients with node-positive BTC.

Purpose Since oncological outcomes of transanal colorectal tube (TCT) placement, an endoscopic treatment for colorectal cancer (CRC) with acute colorectal obstruction (ACO), remain unknown, this study analyzed long-term outcomes of TCT placement for stage II/III CRC with ACO. Materials and Methods Data were retrospectively reviewed from consecutive patients with distal stage II/III CRC who underwent surgery between January 2007 and December 2011 at two Japanese hospitals. One hospital conducted emergency surgery and the other performed TCT placement as the standard treatment for all CRCs with ACO. Propensity score (PS) matching was used to adjust baseline characteristics between two groups. Results Among 754 patients with distal stage II/III CRC, 680 did not have ACO (non-ACO group) and 74 had ACO (ACO group). The PS matching between both hospitals identified 234 pairs in the non-ACO group and 23 pairs in the ACO group. In the non-ACO group, the surgical quality was equivalent between the two institutions, with no significant differences in overall survival (OS) and disease-free survival (DFS). In the ACO group, the rate of primary resection/anastomosis was higher in the TCT group than in the surgery group (87.0% vs. 26.1%, p < 0.001). No significant differences were noted between the surgery and the TCT groups in OS (5-year OS, 61.9% vs. 51.5%; p=0.490) and DFS (5-year DFS, 45.9% vs. 38.3%; p=0.658). Conclusion TCT placement can achieve similar long-term outcomes to emergency surgery, with a high rate of primary resection/anastomosis for distal stage II/III colon cancer with ACO.

Background: Gastrointestinal stromal tumors occur frequently. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is performed commonly for diagnosis. However, the success rate of histological diagnosis is insufficient when the submucosal tumor (SMT) is small. Recently, another technique, mucosal cutting biopsy (MCB) has been reported. The aim of this study is to evaluate the efficacy and safety of MCB. Method: Between January 2012 and August 2018, MCB and EUS-FNA were performed 16 and 31 times for diagnosing gastric SMT. The diagnostic rate, the rate of successful immunohistochemistry, and the safety were reviewed. Difficult locations for EUS-FNA were also evaluated. Results: The mean SMT sizes measured on MCB and EUS-FNA were 21.2 and 36.2 mm. The diagnostic rates of MCB and EUS-FNA were almost the same (88 vs. 81%), but successful immunohistochemistry was significantly higher in the MCB group (93 vs. 59%, p = 0.03). In the subgroup of SMTs < 20 mm, the successful histological diagnosis rate from EUS-FNA was relatively low. There were no complications. Failures of EUS-FNA were more frequent in the middle third of the stomach. Conclusions: MCB was an effective procedure for diagnosing gastric SMT, especially in the case of small SMTs located at the middle third of the stomach.

BACKGROUND Expression of human equilibrative nucleoside transporter-1 (hENT1) is reported to predict survival of gemcitabine (GEM)-treated patients. However, predictive values of immunohistochemical hENT1 expression may differ according to the antibodies, 10D7G2 and SP120. AIM We aimed to investigate the concordance of immunohistochemical hENT1 expression between the two antibodies and prognosis. METHODS The subjects of this study were totally 332 whose formalin-fixed paraffin-embedded specimens and/or unstained sections were obtained. The individual H-scores and four classifications according to the staining intensity were applied for the evaluation of hENT1 expression by 10D7G2 and SP120, respectively. RESULTS The highest concordance rate (79.8%) was obtained when the cut-off between high and low hENT1 expression using SP120 was set between moderate and strong. There were no correlations of hENT1 mRNA level with H-score (p = .258). Although the hENT1 mRNA level was significantly different among four classifications using SP120 (p = .011), there was no linear relationship among them. Multivariate analyses showed that adjuvant GEM was a significant predictor of the patients with low hENT1 expression using either 10D7G2 (Hazard ratio [HR] 2.39, p = .001) or SP120 (HR 1.84, p

Background Malrotation is a congenital anomaly during the development of the embryonic intestine. Although it is generally considered a pediatric surgical condition, it can have significant implications for adult surgery in terms of reconstruction. Case presentation The patient was an 85-year-old man with pancreatic cancer and intestinal malrotation. He underwent pancreaticoduodenectomy with modified Child’s reconstruction. Because the ascending colon and efferent loop twisted easily, we fixed the ascending colon to the abdominal wall. Thereafter, right twist and stenosis of the efferent loop occurred. On the 22nd day after the initial surgery, detorsion and Braun anastomosis were performed for efferent loop fixation. Postoperative oral intake was good, and the patient was discharged from our hospital on the 24th day after the reoperation. Conclusions This is a rare case of pancreaticoduodenectomy with malrotation following reoperation due to a complication after Child’s reconstruction. In similar cases of intestinal malrotation, it is important to consider avoiding coaxial positioning of intestinal parts and an upper abdominal space while selecting a reconstruction method.

Highlights • Significance of resection in patients with pancreatic metastasis from lung cancer. • A long-term survivor of pancreatic metastasis from lung cancer after pancreatectomy. • Consider resection if the disease is localized and the patient’s condition is good., Introduction Pancreatic metastasis from lung cancer is not an indication for surgical resection because patients with such a condition present with multiple-organ metastases. Therefore, the significance of resection in patients with pancreatic metastasis from lung cancer remains unclear. Here we report a case of a long-term survivor of pancreatic metastasis from lung cancer after pancreatectomy. Case presentation A 67-year-old woman presented with a pancreatic mass. She had undergone left lower lobectomy for stage IIIA lung adenocarcinoma 6 years prior to presentation. Following surgery, she received adjuvant treatment with gefitinib for 7 months. However, this treatment was discontinued due to its side effects. The patient received radiation therapy for mediastinal lymph node metastasis 2 years after resection and she became cancer-free. Six years after the initial pulmonary resection, the patient’s tumor marker level increased, and abdominal computed tomography (CT) revealed a 20-mm tumor in the pancreatic tail. Positron emission tomography–CT revealed an abnormal uptake in the pancreatic tail. However, no other abnormal lesions were observed. The diagnosis was primary pancreatic cancer or metastasis from lung cancer. Distal pancreatectomy with lymph node dissection was performed, and the pathological diagnosis was metastasis from lung cancer. The patient survived for more than 5 years without recurrence but she died of acute renal failure after acquiring pneumonia. Conclusion Surgical treatment should be considered for pancreatic metastasis from lung cancer if the disease is localized and the patient’s condition is good. Additionally, combined therapy, including surgical resection, may be effective for repeated recurrence.

Obstructive colorectal cancer (CRC) is an emergency situation with high morbidity and mortality, but long-term outcomes of stage II/III obstructive CRC remain unclear. The aim of this study was to evaluate prognostic factors, including colorectal obstruction. Data were retrospectively reviewed from consecutive patients with stage II/III CRC who underwent curative surgery between January 2007 and December 2011 at two Japanese institutions. We analyzed overall survival (OS) and relapse-free survival (RFS), according to various prognostic factors including colorectal obstruction. In total, 979 patients with stage II/III CRC were identified for this study. Among these 979 patients, 94 patients showed colorectal obstruction (9.6%). In both stage II and stage III CRCs, colorectal obstruction showed significantly poorer OS and RFS compared to non-obstruction (5-year OS, obstruction vs. non-obstruction, stage II: 65.9 vs. 86.5%, P = 0.002; stage III: 55.9 vs. 73.6%, P = 0.007) (5-year RFS, obstruction vs. non-obstruction, stage II: 59.2 vs. 77.8%, P = 0.008; stage III 31.3 vs. 56.3%, P = 0.001). Multivariate analysis demonstrated colorectal obstruction as a significant independent and poor prognostic factor in terms of both OS (hazard ratio (HR) 2.469; 95% CI 1.339–4.545; P = 0.004) and RFS (HR 1.992; 95% CI 1.160–3.425; P = 0.012) for stage II CRC, as well as pT4 stage. On multivariate analysis for stage III CRC, colorectal obstruction was a significant predictor of poor RFS (HR 1.626; 95% CI 1.070–2.469; P = 0.023), but not poor OS. Colorectal obstruction is an independent poor prognostic factor for stage II CRC. Adjuvant chemotherapy might be feasible for stage II CRC with colorectal obstruction.

The high expression of human equilibrative nucleoside transporter‐1 (hENT1) and the low expression of dihydropyrimidine dehydrogenase (DPD) are reported to predict a favorable prognosis in patients treated with gemcitabine (GEM) and 5‐fluorouracil (5FU) as the adjuvant setting, respectively. The expression of hENT1 and DPD were analyzed in patients registered in the JASPAC 01 trial, which showed a better survival of S‐1 over GEM as adjuvant chemotherapy after resection for pancreatic cancer, and their possible roles for predicting treatment outcomes and selecting a chemotherapeutic agent were investigated. Intensity of hENT1 and DPD expression was categorized into no, weak, moderate or strong by immunohistochemistry staining, and the patients were classified into high (strong/moderate) and low (no/weak) groups. Specimens were available for 326 of 377 (86.5%) patients. High expression of hENT1 and DPD was detected in 100 (30.7%) and 63 (19.3%) of 326 patients, respectively. In the S‐1 arm, the median overall survival (OS) with low hENT1, 58.0 months, was significantly better than that with high hENT1, 30.9 months (hazard ratio 1.75, P = 0.007). In contrast, there were no significant differences in OS between DPD low and high groups in the S‐1 arm and neither the expression levels of hENT1 nor DPD revealed a relationship with treatment outcomes in the GEM arm. The present study did not show that the DPD and hENT1 are useful biomarkers for choosing S‐1 or GEM as adjuvant chemotherapy. However, hENT1 expression is a significant prognostic factor for survival in the S‐1 arm., In the S‐1 arm, the median overall survival (OS) with low hENT1, 58.0 months, was significantly better than that with high hENT1, 30.9 months (hazard ratio 1.75, P = .007). In contrast, there were no significant differences in OS between DPD low and high groups in the S‐1 arm and neither the expression levels of hENT1 nor DPD revealed a relationship with treatment outcomes in the GEM arm.

Background A few reports to date have described the effectiveness of surgical resection for recurrent intrahepatic cholangiocarcinoma (ICC). We report in this study a patient who achieved long-term survival after surgical resection for recurrent hepatic and pulmonary metastases of ICC. Case presentation A 62-year-old man was referred to our hospital for examination of a tumor in the left lobe of the liver. Computed tomography (CT) scans of the abdomen revealed a hypovascularized tumor, 30 mm in hepatic segment 2 (S2). The patient was diagnosed with a mass-forming type of ICC. A left lateral sectionectomy with regional lymph node dissection was performed. Histopathological examination showed moderately differentiated adenocarcinoma in the hepatic S2 with lymph node metastasis. There were two intrahepatic metastases around the main tumor. The pathological stage of the ICC was pT2pN1M0pStageIIIB. The patient did not receive adjuvant chemotherapy after surgery. Twelve months after surgery, liver lesions in S4/S8 and S7 were detected on CT scans. A partial hepatectomy was performed. The histopathological features were similar to those of the previous ICC. The patient did not receive adjuvant chemotherapy after the repeat hepatectomy. Four years and four months after this repeat hepatectomy, CT scans showed multiple nodes in S4 and S10 of the left lung and in S1 of the right lung. Wedge resection of the left upper lobe and sectionectomy in S10 of the left lung were performed. Histopathological findings of the resected lung nodules were compatible with metastatic ICC. The nodule in S1 of the right lung was too small to be diagnosed as metastasis; therefore, it was not resected. After pulmonary resection, the patient was treated with gemcitabine and cisplatin for 6 months. After chemotherapy, the size of the nodule in S1 increased gradually. One year and ten months after the pulmonary resection, we performed wedge resection of S1 of the right lung, and the histopathological findings were compatible with metastatic ICC. The patient is alive without evidence of disease 8 years after the initial surgery and 8 months after the last pulmonary resection. Conclusions ICC with poor prognostic factors can frequently recur; however, surgical resection for recurrent ICC might, for selected patients, enable long-term survival.

Colorectal cancer (CRC) with acute colorectal obstruction (ACO) is an emergency. Transanal colorectal tube (TCT) use can be a safe single-stage surgery with laparoscopy-assisted colectomy; it offers long-term outcomes equivalent to emergency surgery for stage-II/III CRC with ACO. Self-expanding metallic stent use, another alternative, may have detrimental pathological and molecular effects, whereas the pathological impact of TCT placement remains unclear. We hypothesized that TCT placement might exert little damage on primary tumor. Hence, the current study analyzed the pathological impact of TCT placement for CRC with ACO compared to emergency surgery. Data from consecutive patients with stage-II/III distal CRC with ACO who underwent surgery between January 2007 and December 2015 were retrospectively reviewed at two Japanese affiliate hospitals. Inflammatory and malignant potential-related parameters were analyzed by a single blinded pathologist. We extracted mRNA from tumor tissues to analyze inflammatory cytokines. Sixty-eight patients with stage-II/III distal CRC with ACO were identified (surgery: 25 patients; TCT: 43 patients). Baseline characteristics were well balanced between the two groups. TCT showed a significantly lower frequency of abscess (surgery vs TCT, 36.0% vs 11.6%; P = 0.017) and a lower tendency of pathological perforation (surgery vs TCT, 20.0% vs 4.7%, respectively; P = 0.091), compared to the surgery group. There were no significant intergroup differences in oncological factors, including perineural invasion (surgery vs TCT, 52.0% vs 62.8%; P = 0.383), microlymphatic involvement (surgery vs TCT, 52.0% vs 58.1%; P = 0.623), and microvascular involvement (surgery vs TCT, 32.0% vs 25.6%; P = 0.570). No significant intergroup differences were found in interleukin (IL)-6, IL-8, or IL-1β gene expression levels (P = 0.580, 0.250, 0.941). TCT placement had no pathologically detrimental effects on the tumor or surrounding tissues and might be an attractive non-invasive strategy for cases of curative distal CRC with ACO.

Although adjuvant chemotherapy with gemcitabine is standard care for resected pancreatic cancer, S-1 has shown non-inferiority to gemcitabine for advanced disease. We aimed to investigate the non-inferiority of S-1 to gemcitabine as adjuvant chemotherapy for pancreatic cancer in terms of overall survival.We did a randomised, open-label, multicentre, non-inferiority phase 3 trial undertaken at 33 hospitals in Japan. Patients who had histologically proven invasive ductal carcinoma of the pancreas, pathologically documented stage I-III, and no local residual or microscopic residual tumour, and were aged 20 years or older were eligible. Patients with resected pancreatic cancer were randomly assigned (in a 1:1 ratio) to receive gemcitabine (1000 mg/m(2), intravenously administered on days 1, 8, and 15, every 4 weeks [one cycle], for up to six cycles) or S-1 (40 mg, 50 mg, or 60 mg according to body-surface area, orally administered twice a day for 28 days followed by a 14 day rest, every 6 weeks [one cycle], for up to four cycles) at the data centre by a modified minimisation method, balancing residual tumour status, nodal status, and institutions. The primary outcome was overall survival in the two treatment groups, assessed in the per-protocol population, excluding ineligible patients and those not receiving the allocated treatment. The protocol prespecified that the superiority of S-1 with respect to overall survival was also to be assessed in the per-protocol population by a log-rank test, if the non-inferiority of S-1 was verified. We estimated overall and relapse-free survival using the Kaplan-Meier methods, and assessed non-inferiority of S-1 to gemcitabine using the Cox proportional hazard model. The expected hazard ratio (HR) for mortality was 0.87 with a non-inferiority margin of 1.25 (power 80%; one-sided type I error 2.5%). This trial is registered at UMIN CTR (UMIN000000655).385 patients were randomly assigned to treatment between April 11, 2007, and June 29, 2010 (193 to the gemcitabine group and 192 to the S-1 group). Of these, three were exlcuded because of ineligibility and five did not receive chemotherapy. The per-protocol population therefore consisted of 190 patients in the gemcitabine group and 187 patients in the S-1 group. On Sept 15, 2012, following the recommendation from the independent data and safety monitoring committee, this study was discontinued because the prespecified criteria for early discontinuation were met at the interim analysis for efficacy, when all the protocol treatments had been finished. Analysis with the follow-up data on Jan 15, 2016, showed HR of mortality was 0.57 (95% CI 0.44-0.72, pnon-inferiority0.0001, p0.0001 for superiority), associated with 5-year overall survival of 24.4% (18.6-30.8) in the gemcitabine group and 44.1% (36.9-51.1) in the S-1 group. Grade 3 or 4 leucopenia, neutropenia, aspartate aminotransferase, and alanine aminotransferase were observed more frequently in the gemcitabine group, whereas stomatitis and diarrhoea were more frequently experienced in the S-1 group.Adjuvant chemotherapy with S-1 can be a new standard care for resected pancreatic cancer in Japanese patients. These results should be assessed in non-Asian patients.Pharma Valley Center, Shizuoka Industrial Foundation, Taiho Pharmaceutical.

Highlights • Unclear pattern of recurrence and prognosis of IPNB. • IPNB with rapidly progressive recurrence in the remnant intrahepatic bile duct. • Consider multicentric recurrence and narrow examinations post curative resection., Introduction Knowledge on the pattern of recurrence and prognosis of intraductal papillary neoplasms of the bile duct (IPNB) is limited. Few studies have reported IPNB recurrence in the remnant intrahepatic bile duct, which is indicative of the true multicentricity of IPNB. Herein, we report a case of IPNB with rapidly progressive recurrence in the remnant intrahepatic bile duct and review the literature for discussing the prognosis of IPNB with multicentricity. Case presentation A 72-year-old male was diagnosed with IPNB in the hepatic duct of segment 3 that had spread to the left hepatic duct. The patient underwent left hepatectomy, total caudate lobectomy, and extra-hepatic bile duct resection with biliary reconstruction. Histologically, the tumor was IPNB with noninvasive adenocarcinoma with a negative surgical margin. Although dilatation of B8 and biliary enzyme elevation were observed beginning at 7–10 months postoperatively, there was no evidence of recurrence. At 17 months postoperatively, the recurrent tumor diffusely spread throughout the remnant intrahepatic bile duct. Internal drainage stents were placed within the intrahepatic bile ducts with relapsed IPNB to relieve jaundice, and a course of chemotherapy was considered. However, the patient did not receive any therapies up to his death at 21 months postoperatively because of rapid disease progression. Conclusion According to a literature review, some cases of multicentric IPNB have shown rapidly progressive recurrence and poor prognosis. We should consider multicentricity of IPNB even a few months after curative resection, and narrow examinations should also be considered.

Background Adjuvant chemotherapy with S-1 for resected pancreatic cancer demonstrated survival benefits compared with gemcitabine in the JASPAC 01 trial. We investigated the effect of these agents on health-related quality of life (HRQOL) of patients in the JASPAC 01 trial. Methods Patients with resected pancreatic cancer were randomly assigned to receive gemcitabine (1000 mg/m2 weekly for three of four weeks for up to six cycles) or S-1 (40, 50, or 60 mg twice daily for four of six weeks for up to four cycles). HRQOL was assessed using the EuroQol-5D-3L (EQ-5D) questionnaire at baseline, months three and six, and every 6 months thereafter. HRQOL end-points included change in EQ-5D index from baseline, responses to five items in the EQ-5D, and quality-adjusted life months up to 24 months. Results Of randomised 385 patients, 354 patients were included in HRQOL analysis. Mean change in the EQ-5D index was similar in the S-1 and gemcitabine groups within 6 months from treatment initiation (difference, 0.024; P = 0.112), whereas corresponding mean from 12 to 24 months was better in the S-1 group than in the gemcitabine group (difference, 0.071; P Conclusion Adjuvant chemotherapy with S-1 does not improve HRQOL within 6 months from treatment initiation but does improve HRQOL thereafter and quality-adjusted life months. Clinical trial registration number UMIN000000655 at UMIN CTR.

症例は68歳男性で，痔瘻を含め肛門疾患の既往はなかった．3か月前からの肛門部の排膿を主訴に近医を受診した．肛門周囲膿瘍の診断で切開排膿をうけたが治癒せず，当院に紹介された．肛門右側に約15cmの硬い腫瘤を認め，同部の生検は腺癌であった．CT所見では肛門右側の腫瘤と直腸S状部に壁肥厚を認めた．肛門部腫瘤の圧排のため大腸内視鏡の挿入は不可能であった．検索は不十分であったが肛門癌および直腸S状部癌の診断で腹会陰式直腸切断術を施行した．骨盤底形成には右腹直筋皮弁を用いた．肉眼的に直腸S状部に2型の腫瘍を認めた．肛門部の粘膜には肛門周囲腫瘤による圧排を認めるのみであった．直腸S状部癌は中分化型腺癌で肛門部腫瘍も同様の組織型であっため直腸癌および同時性肛門転移と診断した．自験例のように肛門疾患の既往のない症例の大腸癌肛門転移はまれと考えられた．

症例は6歳，男児．急性虫垂炎に伴う汎発性腹膜炎と診断して緊急手術を施行したところ，虫垂に炎症所見はなく，回腸末端から15mm口側で小腸の腸間膜付着部が穿孔しており，回盲部切除術を施行した．切除標本を検索すると回腸の腸間膜付着部に径10mm大の嚢胞状病変があり，これが穿孔していた．嚢胞状病変は径2mmの小孔を介して回腸と交通していた．病理組織学的検査所見では，嚢胞状病変の内面は小腸粘膜で覆われ，壁には平滑筋層が存在し，正常の回腸と同様の構造を呈していたため重複腸管症と診断した．重複腸管症は比較的稀な疾患であり，穿孔の本邦報告例は17例のみである．

症例は53歳の男性.肝門部胆管閉塞にて経皮経肝胆道ドレナージを後区域枝, 前区域枝, 外側区域枝に行った.US・CTにて肝門部に腫瘤像を認めるとともに通常の門脈臍部は存在せず, 前区域門脈枝と内側区域枝によって右側門脈臍部 (right umbilical portion: RUP) を形成していることが判明した.経動脈性門脈造影でも直線的に左方へ伸びる外側区域門脈枝とRUPが確認できた.内側区域の動脈支配は前区域枝から分岐する枝 (RUPから左方へ伸びる) と中肝動脈があり, これに呼応するように内側区域胆管枝も2系統存在していた.自験例に対しRUPを温存した肝左葉切除・尾状葉切除・胆管空腸吻合術を施行した.RUPを伴った肝門部胆管細胞癌における胆管の合流形態と肝内脈管の分岐形態を中心に報告する.

We experienced a case of advanced gastric cancer with a tumor embolus in the portal vein. A 74-year-old man was seen at another hospital because of abdominal distention and poor appetite. He was diagnosed as having a gastric cancer and referred to the hospital. After admission ultrasonography and computed tomography revealed a gastric cancer with a tumor embolus in the portal vein. Operative procedures included a total gastrectomy with excision of the body and tail of the pancreas and the spleen, embolectomy in the portal vein and cholecystectomy. The postoperative course was good, and the patient was discharged from the hospital on the 30th postoperative day. Gastric cancer with a tumor embolus in the portal vein is rare. Only 29 such cases have been reported in Japan. With a recent progression of imaging diagnosis, cases of the disease have been increasingly seen in the literature, but the majority of them are in an advanced stage with a poor prognosis. However, there is one case that had surfived more than 5 years following resection of the portal vein containing a tumor embolus. The successs of this case as well as our own suggests that prompt and intensive surgery might improve the prognosis of such patients.

We experienced a case of amputation neuroma at the common bild duct where a T-tube was inserted when cholecysectomy and choledochotomy drainage were carried out 3 years before. A 51-year-old man was admitted to the hospital because of general fatigue. On admission jaundice and tenderness at the epigastric region were confirmed. Close examination revealed an annular stricture of the bile duct. After a relief of obstructive janudice with PTCD, biopsy under PTCS disclosed no malignancy. An operation was performed with a diagnosis of benign bile duct stricture. Operative procedures included an excision of hte bile duct and Roux-en Y anastomosis. Histopathological examination of the excised specimen indicated a diagnosis of amputation neuroma. Biliary amputation neiromas are rare and only 45 cases including this case have been reported in Japan. Bile duct stricture due to amputation neuroma presents difficulty in differential diagnosis from cancers only by imagings. Biopsy under PTCS appears useful. All cases reported were operated on, however, non-surgical procedures such as ballon dilatation method and fistulization using a stent should be considered.

We encountered a case of malignant fibrous histiocytoma (MFH) originating in the retroperitoneal region, in which the tumor was surgically resected but pancreatic and pulmonary metastases occurred two years after the first operation, and the metastatic foci were resected. The patient was a 56-year-old woman whose course after retroperitoneal MFH resection had been followed up at the outpatient clinic. The patient began to complain of epigastralgia two years after the operation. Pancreatic and pulmonary metastases were detected on detailed examination, and the metastatic foci were resected simultaneously. The tumor was histopathologically diagnosed as metastatic malignant fibous histiocytoma. MFH originating in the retroperitoneal region is rarely accompanied by subjective symptoms, and is often detected as a huge mass. Accordingly, the incidence of local recurrence and metastasis is higher than MFH originating in other regions, resulting in a worse prognosis. Preferential sites of metastatic foci include the lung, liver and bone. Pancreatic metastasis, as observed in our patient, is extremely rare. Accessory therapies such as radiotherapy and chemotherapy have been performed more frequently, but no established therapy is available. Effects for early detection of the recurrence should be made through careful postoperative follow-up, in order to resect the metastatic foci in the earliest stage possible.

われわれは肛門周囲Paget病変を伴った肛門腺由来と思われる肛門管癌を経験したので, 若干の文献的考察を加え報告する.症例は79歳の男性で, 肛門部腫瘤を主訴に来院した.肛門指診にて肛門管内に腫瘤性病変を認めるとともに肛門周囲に発赤・びらんを伴っていた.肛門粘膜生検にて印環細胞癌と診断されたため, 腹会陰式直腸切断術を施行した.術後病理診断では腫瘤は著明な粘液結節より成る粘液産生癌であり, また術前肛門周囲に認めたびらんはPaget病変であった.文献上, 肛囲Paget病の本邦報告例は本例を含め20例と少ないが, その大多数に癌の合併を認めることより注意を要する病態と思われる.

Total pelvic exenteration (TPE) is sometimes necessary for en-bloc resection of colorectal malignant tumors and adjacent organs which are invaded by tumors. We have applied TPE for 16 cases, and 11 cases out of 16 were for the primary site and the other 5 cases for recurrent site. As for the primary cases, more than 5 years survival is expected on condition that lymph node metastasis, invasion to the adjacent organs and remains of cancer are not recognaized histologically. As for the recurrent cases, although its prognosis is worse than the primary cases, relatively long survival is expected when recurrent site is detected more than 3 years after first operation. In the primary cases, distant metastasis often occurs after operation despite of low incidence of local recurrence. On the other hand not only distant metastasis but also local recurrence highly occurs in the recurrent cases.

最近10年間に経験した消化器外科手術後に発症した急性肺塞栓症例8例を臨床的に検討した.それらは同期間の手術例の0.07%に相当し, 平均年齢65, 5歳 (55～75), 1例が男性, 7例が女性, また7例が悪性疾患, 1例が胆石症であった.術後の安静解除の時期に呼吸困難, 胸痛, 胸部不快感あるいは急性循環不全の症状がみられ, 心エコーで右心の拡張が認められれば急性肺塞栓症が強く疑われる.肺動脈造影は診断のもっとも確実な方法であり, これを施行した5例全例で塞栓が証明された.8例中5例は線溶・抗凝固療法で軽快したが, 3例は死亡した.そのうち2例は発症後数時間で失ったが, 1例は補助循環下に線溶・抗凝固療法を行い11日間の生存が得られた.急性肺塞栓症に対しては, 必要なら補助循環を併施し, 強力な循環管理下に線溶・抗凝固療法をまず行うのがよいと思われる.

This paper reports a pediatric case of left sided gallbladder presented with acute acalculous cholecys-titis. The patient was a 11-year-old male complaining of right upper abdominal pain and fever. High values of white blood cell count and CRP were recognized and a mass was palpable on his right upper abdomen. Ultrasonography reveaeld the findings of acute acalculous cholecystitis, and immediately percutaneous transhepatic cholecystodrainage was performed. The common bile duct was imaged at the right side of the fundus of the gallbladder by a drainage tube cholangiography. No abnormalities were found in the common bile duct. The pancreatic duct and gallbladder were invisible by ERCP. Considering of his young age, conservative therapy was started. But as soon as the drainage tube was clamped, abdominal pain and fever occurred. So cholecystectomy was performed. The operative findings indicated gangrenous cholecystitis. The cystic duct was occluded. The liver bed was found in the left to Ligamentum teres hepatis and the gallbladder located on the lateral segment. Generally speaking, the most left sided gallbladders are incidentally found during the operation for another disease. As for this case, the left sided gallbladder itself probably caused the occlusion of the cystic duct because of its unnatural run.

We succeeded in surgically resecting a leiomyosarcoma of the inferior vena cava (IVC), which originated at the confluent portion of the right renal vein (RRV), together with the IVC and RRV, and also were able to preserve the right kidney by reconstructing the RRV with end-to-end anastomosis using the right gonadal vein. A good blood flow of the reconstructed RRV was thereafter confirmed by color Doppler ultrasonography, and the renal function was also satisfactory. This new procedure, a reconstruction of the RRV using the gonadal vein, has not been previously reported, but is considered to be an easy and effective method which enables the surgeon to preserve the normal right kidney.