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Introduction Relebactam, a novel class A/C β-lactamase inhibitor developed as a fixed-dose combination with imipenem/cilastatin, restores imipenem activity against imipenem-nonsusceptible gram-negative pathogens. Methods This phase 3, multicenter, open-label, noncomparative study (NCT03293485) evaluated relebactam/imipenem/cilastatin (250 mg/500 mg/500 mg) dosed every 6 h for 5–14 days in Japanese patients with complicated intra-abdominal infections (cIAIs) or complicated urinary tract infections (cUTIs), including those with secondary sepsis. Sepsis was defined as an infection-induced systemic inflammatory response syndrome, with a documented positive blood culture; patients meeting these protocol-defined criteria were evaluated for efficacy against sepsis. Results Of 83 patients enrolled, 81 patients (cIAI, n = 37; cUTI, n = 44) received ≥1 dose of study treatment. Escherichia coli was the most common baseline pathogen isolated in both patients with cIAI and cUTI. Adverse events (AEs) were reported in 74.1% (n = 60/81) of patients, and drug-related AEs occurred in 18.5% (n = 15/81). The most common AEs were diarrhea and nausea (8.6%). Serious AEs occurred in nine patients, including one death, but none were considered treatment related. The primary efficacy endpoint for patients with cIAI was clinical response at end of treatment (EOT) in the microbiologically evaluable (ME) population, and for patients with cUTI was microbiological response at EOT in the ME population. The proportion of cIAI and cUTI patients achieving favorable responses were 85.7% (n = 24/28) and 100.0% (n = 39/39), respectively. All patients with sepsis (cIAI, n = 1; cUTI, n = 5) achieved a favorable composite clinical and microbiological response at EOT. Conclusions A favorable safety and efficacy profile for relebactam/imipenem/cilastatin was observed in Japanese patients with cIAI and cUTI.

A 66-year-old man was referred to our hospital after being diagnosed with a pelvic tumor. A subsequent transperineal biopsy revealed spindle cells with CD34·c-kit(+). An enhanced computed tomography scan showed a giant rectal-derived tumor in the pelvis. The tumor was pressing on the urinary bladder and the prostate, and appeared to invade the posterior wall ofthese organs. The patient was diagnosed with rectal GIST, and neoadjuvant therapy with 400mg/day imatinib was initiated. Three months later, the tumor reduction rate was at 33.6%, and surgery was performed. The operative method applied was pelvic exenteration and ileal conduit, for local R0 resection. The patient has remained recurrence free for 2.5 years since the surgery.

臍炎にて発症し炎症が軽快後，胆石症も同時に腹腔鏡下にて根治術を施行した高齢者の尿膜管遺残症を経験したので報告する．症例は78歳，男性．臍からの排膿を主訴に当院を受診した．血液検査所見で著明な炎症反応を認め，腹部CT検査にて臍部から膀胱頂部にかけて高濃度領域を認めたため尿膜管遺残膿瘍と診断し，抗菌剤とドレナージにより炎症の改善を待った．腹部CTで偶然胆嚢内に結石を認めたため，同時に腹腔鏡下にて手術を施行した．まず左前腋窩線上臍高部，右前腋窩線上臍高部，右季肋下，剣状突起下にトロッカーを挿入し，胆嚢摘出術を施行した．さらにMcBurney点の対側やや左外側に追加し，尿膜管を摘出した．術後経過は良好で，術後4日目に退院した．検索しえた限りでは，胆石症と同時手術した尿膜管遺残症の報告は本邦で初めてである．尿膜管遺残症は腹腔鏡下の適応であり，その症例に応じたトロカールの挿入位置を工夫することが大切であると思われた．

2000年12月から2006年9月までに魚骨による消化管穿孔を8例経験したので臨床的検討を加え報告する．年齢は59歳から89歳で男性7例，女性1例．穿孔部位は回腸4例，横行結腸2例，S状結腸2例であり，全症例に対して手術を行なった．慢性炎症型4症例のうち穿孔部不明症例が3例存在したが，魚骨の確実な摘出により治癒することが確認された．MDCT導入以前では術前に石灰化も含め病変を指摘できた症例は40％であったが，導入以降は魚骨同定率，術前診断率ともに100％でありその有用性が確認された．魚骨穿孔は，詳細な病歴聴取およびMDCTの施行により術前の確定診断が比較的容易となったが，魚骨遺残により再手術が必要となる症例もあり，急性腹症の鑑別診断として念頭におかなければならない疾患の一つであると考えられた．

We report three cases of biliary obstruction caused by a juxtapapillary duodenal diverticulum that were treated by excision of the diverticulum. A 72-year-old man, a 77-year-old woman, and an 81-year-old woman each presented with recurrent obstructive jaundice. Diagnostic imaging revealed a juxtapapillary duodenal diverticulum compressing the common bile duct (CBD). Following cholecystectomy, the diverticulum between the intrapancreatic CBD and pancreatic parenchyma was isolated and excised successfully in each case. The patients have been followed up for 34, 31, and 22 months, respectively. In one patient, choledocholithiasis developed 33 months after the surgery, necessitating endoscopic sphincterotomy. Duodenal diverticulectomy is a useful procedure to relieve biliary obstruction caused by a juxtapapillary duodenal diverticulum. However, it remains unclear whether excision of the diverticulum is preferred to biliodigestive anastomosis from the point of view of long-term prognosis. Subsequent surveillance is necessary.

症例は73歳の女性で, 以前に腹部CTで膵体尾部実質の非描出およびERCP検査で短小な主膵管を認め, 膵体尾部欠損症の診断を受けていた. 今回は閉塞性黄疸のために入院し, 膵頭部癌と診断された. 膵体尾部欠損症に合併した膵頭部癌の診断で手術を行った. 手術所見では, 膵体尾部は分厚い脂肪組織に置換し, 膵実質を認めなかった. 亜全胃温存膵頭十二指腸切除を行い, 門脈左縁の脂肪置換部を膵切離ラインとし, 再建は行わなかった. 術後の内分泌機能は良好で, インスリンの使用は必要としなかった. 組織学的には, 脂肪置換部にラ氏島を散在性に認めた. 以上のように, 膵体尾部脂肪置換に合併した膵頭部癌に対して亜全胃温存膵頭十二指腸切除を行い, 術後経過の良好な症例を経験したので報告する.

症例は25歳,男性. 2000年5月28日,自殺企図にて薬剤服用.近医にて救命されたが,腐食性食道狭窄にて経口摂取不可能な状態で当院へ紹介となった.食道造影では頸胸境界部の一部を除いた食道ほぼ全長および下咽頭に狭窄像を認めた.内視鏡下のバルーン拡張術を試みたが,食道壁の穿孔を起こし内科的治療は無理と判断した.手術に際し喉頭を保存するため,下咽頭と頸部食道の狭窄は残す形での切除再建を行い,術後に狭窄部に対しバルーン拡張術を行う方針とした. 2001年2月28日,右開胸開腹食道亜全摘,胸腔内胃管再建,腸瘻造設術を施行した.術後に下咽頭狭窄部と食道胃管吻合部のバルーン拡張術を施行し,経口摂取可能な状態となった.腐食性食道炎,食道狭窄は多くが自殺企図による受傷であり,患者の精神状態に対する配慮の下に,狭窄の部位・程度・症状に合わせた治療方針決定が求められる.

主膵管, 総胆管に異常を来さなかったために, 術前診断に難渋した副膵管領域原発膵管癌の1例を経験したので報告する. 症例は69歳の男性で, 主訴は嘔気, 嘔吐. 上部消化管内視鏡検査で十二指腸下行脚が全周性狭窄を呈し, 粘膜に発赤, 浮腫などの変化を認め, UGIでは一部, 不整像, 硬化像を認めた. CTでは膵頭部領域腫瘤像が描出され, magnetic resonance cholan-giopancreatographyでは総胆管, 膵管には異常所見を認めなかった. 開腹すると十二指腸下行脚から膵頭部前面の漿膜のひきつれを認め, 迅速組織診で腺癌と診断されたために, 亜全胃温存膵頭十二指腸切除術を施行した. 腫瘍は十二指腸粘膜下から膵頭部にかけて存在し, 膵実質よりは十二指腸側への進展が優位であった. 病理組織学的には主膵管に異常なく, 副膵管に乳頭状に腺癌が存在し, 副膵管領域原発の高分化型管状腺癌と診断された.

入院経過中に肛門より脱出したS状結腸原発脂肪腫の1例を経験したので報告する.症例は63歳,女性.便秘,腹痛,下血を主訴に来院した.大腸内視鏡検査で肛門縁より18cmの部位に大腸内腔を占める粘膜下腫瘍を認め, CTでは骨盤内に約7cmのlow densityな腫瘍を認めた. MRIのT1強調像では同部位はhigh intensityであった.以上よりS状結腸原発脂肪腫と診断した.なお入院経過中に腫瘍が肛門より脱出したため用手的に還納した.小開腹にてS状結腸部分切除術を施行した.切除標本にてS状結腸に直径7cm大の亜有茎性の腫瘍で,粘膜下腫瘍の様相を呈していた.病理組織学的検査で,分化した異型のない脂肪細胞が分葉状に増殖する漿膜下脂肪腫と診断された.

肝内再発肝細胞癌が肝動脈塞栓療法(TAE)にてコントロール良好であったため,左副腎再発に対し副腎摘出術を施行し,良好な経過を得た1例を経験した.症例は62歳,男性. 1997年2月肝細胞癌に対し,肝左葉切除術を施行した.術後6カ月後血清alphafetoprotein (AFP)値の再上昇を契機に残肝再発(S6に単発)が発見されTAEを施行した. AFP値の上昇はTAEにてコントロール良好であったが, 2000年6月, 5回目のTAEでAFP値が低下しなかった. CTで左副腎再発と診断し,左副腎摘出術を施行した.術後1年5カ月,良好に経過している.肝細胞癌の治療成績の向上に伴い副腎転移が治療対象となる頻度が増加してきている.われわれは検索しえた肝細胞癌の副腎転移摘出術施行例に自験例を加えた29例を検討した.他に遠隔転移を認めず,肝病変がコントロール良好であれば副腎転移に対しては外科的切除が最も有効な治療法であると考えられた.

患者は51歳,男性で腹痛,嘔吐を主訴に入院した.右側腹部に圧痛を伴う腫瘤を触知し,腹部超音波所見, CT所見より腸重積症と診断し,緊急手術を施行した.開腹所見では上行結腸内に回腸が重積しており,用手的に重積を整復した.重積腸管の血行障害,壊死は認めなかった.整復後の回腸の触診で回腸末端より70cm口側に腫瘤を触知したため,腫瘤を含め回腸を2cm切除した.摘出標本の肉眼所見では,腫瘤は表面粗造な山田IV型のポリープで病理組織学的にPeutz-Jeghers型ポリープと診断された.本患者は,口唇,口腔粘膜,四肢末端部の色素斑を欠き,遺伝性も認められなかったことより,不完全型Peutz-Jeghers症候群と思われた.小腸過誤腫の過去10年間の本邦報告例は16例であり,そのうちPeutz-Jeghers型ポリープは8例でそのほとんどが腸重積で発症している.成人の腸重積症では本疾患も念頭に置くべきであると思われた.

食道癌術後に発生した食道胃管吻合部肺瘻を, 内視鏡的フィブリン糊注入により治癒せしめた症例を経験した. 症例は60歳の男性. 胸部中部食道癌に対し右開胸開腹, 胸部食道亜全摘, 胸腔内食道胃管吻合術を施行した. 術後経過は良好で術後8日目の上部消化管造影でも異常を認めず経口摂取を開始した. 左噴門リンパ節に転移を認めたため術後21日目から5日間化学療法を施行し, 34日目に退院した. 術後3か月目より発熱, 咳嗽が出現し, 肺炎, 肺膿瘍と診断された. 上部消化管造影で食道胃管吻合部から肺内へ瘻孔が造影されたため, 肺瘻と診断した. 絶飲食, 抗生剤投与により肺の炎症は消退したが瘻孔は閉鎖しなかったため, 内視鏡的にフィブリン糊を注入した. その後, 瘻孔は閉鎖し, 注入後6日目より経口摂取を開始し, 2年後も瘻孔の再発を認めない.

大腸癌による大腸イレウス11例に対して経肛門的にイレウス管を挿入後, 2例(18%)に穿孔をきたしたので報告する.症例1は74歳男性.直腸S状部の癌による大腸イレウスの診断で経肛門的にイレウス管を挿入した.翌日に腹膜刺激症状が出現したため手術を施行した.手術所見では直腸S状部に左尿管に浸潤する癌を認め,その2.5cm口側が穿孔していたため,ハルトマン手術を施行した.症例2は56歳男性.直腸S状部の全周性の3型の直腸癌に対して経肛門的イレウス管を挿入した.翌日より発熱が出現,挿入6日目に腹膜刺激症状が出現したため手術を施行した.手術所見では,直腸S状部に直腸癌を認め,その口側の腫瘍縁が穿孔していたためハルトマン手術を施行した.いずれの症例も,経肛門的イレウス管挿入が大腸穿孔の誘因と考えられた.

Patient 1, a 70-year-old man, was seen at the hospital because of blood stool and was found having rectal cancer at close examination. Preoperative contrast enhanced CT scan of the abdomen revealed left renal cancer. Low anterior resection of the rectum and a left nephrectomy were simultaneously performed. Patient 2, a 63-year-old woman, was seen at the hospital because of tarry stool. Close exploration revealed cancer of the ascending colon. Abdominal contrast enhanced CT scan before operation revealed a left renal cancer. Right hemicolectomy and a left nephrectomy were performed on an one-step approach. Patient 3, a 59-year-old woman, was seen at the hospital because a stool examination was positive to the guaiac test. Close exploration revealed cecal cancer. Abdominal contrast enhanced CT scan before surgery revealed right renal cancer. Right hemicolectomy and a right nephrectomy were performed on an one-step approach. We experienced three cases of synchronous colorectal cancer and renal cancer in which renal cancer was detected by preoperative contrast enhanced CT scan of the abdomen for the colorectal cancer and both cancers were successfully treated by simultaneous operation.

A 72-year-old woman who had been staying at the department of respiratory surgery in our hospital for the treatment of lung cancer had vomiting, and a protrusion in the femoral area was confirmed. With a diagnosis of incarceration of femoral hernia, a radical operation was performed. On the next day, a right upper lobectomy was performed for lung cancer. Histopathologically, poorly differentiated adenocarcinoma with large cell carcinoma was demonstated. Postoperative course was uneventful. However, vomiting occurred again on the 8th day after the lobectomy. Abdominal x-ray film revealed air-fluid level and intestinal obstruction was diagnosed. Fluoloscopy of the small intestine through an ileus tube revealed a stenosis 30cm distal to the Treitz' ligament. CT scan and echography showed layered intraperitoneal structure. From these findings, intussusception due to small bowel metastasis of the lung cancer was suspected, and a laparotomy was performed. At laparotomy, the jejunum developing intussusception 30cm distal to the Treitz' ligament which formed an infant's fist-sized tumor was confirmed. So a partial resection of the small intestine was performed. A 5.0×4.5cm tumor of the small intestine was noted. It was histopathologically metastasis to the small intestine from the lung cancer.

肝鎌状動脈を認めた3例を経験したので報告する. 頻度は腹部血管造影156例のうち1.9%であった. 肝動注化学療法を施行する際は本動脈の処理を行うべきである.症例1: 乳癌肝転移にて施行した血管造影で左肝動脈より分岐する肝鎌状動脈を認めた. 肝動脈CTで内側枝・外側前枝の分岐部から腹側に向かい, その後腹直筋直下を臍方向に走行する肝鎌状動脈が描出された.症例2: 小腸平滑筋肉腫の肝転移にて施行した血管造影で中肝動脈から臍方向に走行する肝鎌状動脈を認めた. 選択的造影では深下腹壁動脈との吻合が描出された. 肝動注化学療法の前に塞栓術を施行した.症例3: 胆嚢癌の診断で施行した血管造影で肝鎌状動脈が描出されたため, 手術時に肝鎌状間膜, 肝円索を採取した. 病理組織学的に外膜が肥厚した径1mmの動脈を認めた.

A 55-year-old woman presented to hospital with epigastric pain and jaundice. Diagnostic imaging studies revealed a biliary stricture of the hepatic confluence and a hepatic tumour of the left and caudate lobes with a portal tumour thrombus, which occupied the main portal trunk, the umbilical portion of the left portal vein, and the right anterior and posterior portal branches. Left hepatic trisegmentectomy, caudate lobectomy, portal tumour thrombectomy, bile duct resection and bilioenteric anastomosis were performed. There were no other lesions, and so it was diagnosed as a primary lymphoma of the liver (B-cell, diffuse, large cell type). The patient underwent postoperative chemotherapy and has remained well for 4.5 years after surgery. Primary lymphoma of the liver is very rare, and this is the first case report with bile duct invasion and tumoral occlusion of the portal vein.

We report a case of aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization. A 61-year-old man with a history of hypertension underwent surgery at our hospital in November 1995 for local peritonitis caused by perforation of the sigmoid colon secondary to cancer. On the 9th postoperative day, he developed shock, with complaints of epigastric and back pain. Abdominal computed tomography showed an enhanced mass, thought to be a peripancreatic aneurysm. Emergency angiography demonstrated an aneurysm arising from the arcade of the anterior pancreaticoduodenal artery. After diagnostic angiography, transcatheter arterial embolization was performed. With steel coils, the anterior superior pancreaticoduodenal artery and anterior inferior pancreaticoduodenal artery were embolized near the origin of the aneurysm. Angiography 7 weeks later revealed no recanalization of the aneurysm and the absence of anomalous collateral vessels. The patient has been well for 19 months without re-bleeding or recurrence of sigmoid colon cancer. Transcatheter arterial embolization is an effective therapeutic approach for aneurysm of the pancreaticoduodenal artery and is the preferred initial treatment.

We experienced a case of unilateral multiple breast cancer in which two primary tumors arising in the right breast had each lymph node metastasis in accordance with each histologic type of the tumors. An 85-year-old woman was seen at the hospital because of a right breast tumor. There were two palpable tumors comprising of a tumor 4cm in diameter in the EBD area and another tumor 2cm in diameter in the C area of the right breast. Ultrasonography of the right breast visualized the both lesions as hypoechoic and internally heterogenous tumor. The tumor in the C area was poorly demarcated. On mammography spicula were noted in the C area tumor. With needle aspiration cytology a diagnosis of adenocarcinoma was made. A modified radical mastectomy was carried out on December 18, 1995. Histopathologically the tumor in the EBD area was solid ductal carcinoma and another tumor was scirrhous cancer. Lymph node metastases were confirmed in area 1a and 1b; the lymph node metastasis in the 1a area revealed histologic feature of solid ductal carcinoma and that of 1b area histologic feature of scirrhous cancer.

A 25-year-old woman presented with dysphagia and chest pain in November 1999. Esophagography revealed esophageal stasis with spindle-shaped tapering at the cardia without dilatation of the lower esophagus. Manometry showed a hypertonic sphincter with incomplete relaxation on swallowing. Esophageal body contractions were simultaneous with an amplitude in excess of 200 mm Hg with tertiary contractions. These findings were not compatible with “classic” achalasia, but with vigorous achalasia. The patient underwent pneumatic dilatation with immediate relief of her symptoms. However, improvement in dysphagia and chest pain was temporary, necessitating four sessions of dilatation over three and a half years. The literature on this rare esophageal motility disorder is reviewed.

We report a 68-year-old female patient with intrahepatic stones in the right posterior inferior segment, the right anterior superior segment, and the caudate lobe. She had previously undergone distal gastrectomy, cholecystectomy, and choledochoduodenostomy. Advanced liver cirrhosis had been diagnosed at the previous laparotomy, and cholangioscopic lithotomy through a T-tube sinus tract was therefore performed. The stones in the right posterior inferior segment and the right anterior superior segment were easily extracted. However, removal of the stone in the caudate lobe was difficult and necessitated 11 sessions of cholangioscopy. Although reports of intrahepatic stones in the caudate lobe are unusual, modern diagnostic imaging modalities may identify more such cases.

A 72-year-old female visited our hospital, because an abdominal mass was pointed out by medical examination. The mass was palpable at the right upper abdomen, which was movable and as large as an infant's head. On diagnostic imaging methods, the surrounding organs were found to be compressed by the tumor. Abdominal angiography revealed the feeding artery and faint hypervascularity of the tumor. Mesenteric tumor was suspected and laparotomy was performed. The tumor was connected with only the lesser omentum and developed in the bursa omentalis, being excised easily. Other abdominal organs were normal and there were neither lymph node swelling nor peritoneal dissemination. The excised tumor was 17×12×11 cm in size, and 1110 g in weight. Histologically, it was diagnosed as leiomyosarcoma. The postoperative course was uneventful and the patient is alive and well without any recurrence at present. Primary leiomyosarcomas of the lesser omentum are rare and only 13 cases have been reported in Japan. Further discussion is made by reviewing the literature.

We report a patient with a massive mucinous carcinoma of the breast that had been untreated for 6 years. A 47-year-old premenopausal woman presented with a large right-breast mass. Although she had noticed a lump in the right breast 6 years previously, she had not sought treatment. The tumor had enlarged gradually and become ulcerated. With a diagnosis of advanced breast cancer with skin invasion, she underwent right mastectomy with a free skin graft. No lymph node metastases or distant metastases were detected. The histologic diagnosis of the tumor was pure mucinous carcinoma of the breast with no component of ordinary invasive ductal cancer. She has been well without evidence of tumor recurrence for 7 years after the surgery. The prognosis for mucinous carcinoma of the breast has been recognized as relatively good. The results in our patient are consistent with the biological behavior of this carcinoma.

A 67-year-old male with jaundice was found to have hepatocellular carcinoma in the right hepatic lobe and tumor thrombi in the common hepatic duct. Physicians initially considered the tumor unresectable, and treated the patient with transcatheter arterial infusion chemotherapy and biliary endoprosthesis. The patient developed a liver abscess after the second transcatheter arterial infusion, and the physicians consulted our department for another form of therapy. Percutaneous transhepatic biliary drainage was performed to relieve revived obstructive jaundice. Cholangiography revealed tumor thrombi extending through the right posterior segmental bile duct into the common hepatic duct. Most biliary branches of the caudate lobe joined with the left lateral posterior segmental branch. Arterial and portal venous branches of the caudate lobe were not involved. Right hepatic lobectomy and extrahepatic bile duct resection were performed 1 year after initial diagnosis. On histologic examination, the epithelium of the right posterior segmental bile duct, which was filled with the tumor thrombi, was not detected. The patient is alive without recurrence 24 months after surgery. Careful investigation of biliary branches of the caudate lobe on cholangiography is essential to determine the necessity of caudate lobectomy in patients with hepatocellular carcinoma and tumor thrombi filling the right posterior segmental bile duct.

OBJECTIVES: Superficially spreading carcinoma of the esophagus, consisting mainly of intraepithelial carcinoma, is not as rare as was previously thought. Despite the surgical significance of this entity, no general definition has been established, and the clinical features of this disease remain to be clarified. METHODS: A total of 54 patients with superficial carcinoma of the esophagus (defined as carcinoma limited to the epithelium or superficially invading the lamina propria or submucosa) were classified into two groups according to the longitudinal extent of the lesion. A total of 13 patients with superficially spreading carcinoma (defined as a superficial carcinoma measuring >5 cm and consisting mainly of intraepithelial carcinoma) were compared to 41 patients with nonspreading esophageal carcinoma. RESULTS: One patient with superficially spreading carcinoma had a positive resection margin because of multiple cancerous lesions. The only significant difference in the clinical and pathological features of the two groups was a higher prevalence of associated multiple cancerous lesions in patients with the superficially spreading type. CONCLUSIONS: Superficially spreading carcinoma of the esophagus is often associated with multiple cancerous lesions. For endoscopists and esophageal surgeons, it is important to define the proximal extent of intraepithelial cancer and the presence of multiple cancerous lesions to perform curative resection.

Pharyngeal and upper esophageal sphincter (UES) manometry was performed in 15 patients with esophageal achalasia and compared with that in 10 healthy controls. Neither the pharyngeal contraction pressure nor the UES resting pressure were significantly different between the two groups, although the UES residual pressure in patients with achalasia was significantly increased compared with that in controls. Pneumatic dilatation of the lower esophageal sphincter (LES) was performed in these patients. After successful LES dilatation, the increased UES residual pressure in patients with esophageal achalasia decreased significantly. Our results suggest that UES relaxation in patients with esophageal achalasia is incomplete compared with that in healthy adults. This UES abnormality is not a primary defect but a secondary phenomenon.