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This study reports the treatment and local control of advanced breast cancer with a giant ulcer. A 53-year-old woman presented with a large left breast tumor and an associated giant ulcer, with massive exudates, bleeding, and an offensive odor. Histopathological examination revealed an invasive ductal carcinoma(Luminal B type). Computed tomography(CT) showed multiple metastases to the lymph nodes, lungs, liver and bones. The patient received chemotherapy with a combina- tion of paclitaxel(PTX 90mg/m / 2)and bevacizumab(BEV 10 mg/kg). After 4 courses of chemotherapy, there was a significant reduction in the tumor size, the discharge of exudates and bleeding as well as lumbago and femoral pain. High CEA and CA15-3 levels had been normalized and CT showed a remarkable decrease in metastases. Compared to the tumor itself, the ulcer associated with it had shown a smaller decrease in size, and there was the possibility of perforation in the thin chest wall. Suspecting these outcomes to the adverse events of BEV, its use was discontinued, and starting with course 5 of chemothera- py, we administrated only PTX(90mg/m2). Subsequently, the ulcer showed obvious granulation and was infected. CT of the chest prior to the second course of PTX revealed pleurisy, pneumonia and atelectasis. Following the administration of antibiotics, while infection in the ulcer had subsided, pleurisy and pneumonia continued, with increased right pleural effusion, which finally required drainage. We had to discontinue the administration of PTX. BEV, although effective as first-line therapy, has the adverse effect of slowing wound healing. Therefore, even though the combination therapy of BEV and PTX is markedly effective for systemic therapy, it should be altered for local wound healing as in this case.

進行癌に対する腹腔鏡下大腸切除術の短期および遠隔期手術成績を検討した．対象：腹腔鏡下切除術を施行した深達度pMP以深の進行大腸癌313例．開腹症例180例を対照とした．結果：腹腔鏡下手術群（LAC）の手術時間は209±70分，術中出血量120±219mlで，開腹術群（OC）と手術時間に有意差を認めず，出血量ではOCよりも有意に少なかった．検索リンパ節数はLAC 18.8±9.8個，OC 15.8±11.2個と有意差なし．術後合併症ではLACで縫合不全が多い傾向を認めたが統計学的な有意差を認めなかった．治癒切除症例295例中46例に再発を認めた（再発率15.6%）．再発型式は開腹例と有意差はなかった．LACの累積5年生存率は，Stage I 100%, Stage II 96.5%, Stage IIIa 85.1%, Stage IIIb 66.6%, Stage IV 49.3%（3年）でこれまでの当院の成績と同等と考えられた．まとめ：進行癌に対する腹腔鏡下手術の手術成績はこれまでの当院の成績と同等であり，腹腔鏡下手術導入による予後への悪影響は認められなかった．

肝細胞癌 (hepatocellular carcinoma ; 以下, HCC) の再発時に偶然発見された, HCCの転移性胃腫瘍の1切除例を報告する. 症例は70歳, 男性. 3年前のHCCの初発時に肝部分切除が行われた以降, 再発を繰り返していた. 平成16年11月にHCC再発と診断され, 貧血の原因精査のための上部消化管内視鏡検査にて胃体中部大彎に2型腫瘍を指摘された. 組織診断と免疫染色にてHCCの胃転移と診断され, 同年12月に胃局所切除およびラジオ波焼灼術が施行された. 胃漿膜面は平滑で可動性を有する隆起性の円形腫瘤を認めた. 術後組織診断上, 粘膜層から粘膜下層にかけ境界明瞭な充実性病変で, 静脈浸潤を認めた. HCCはEdmondson IV型であった. 以上からHCCの血行性胃転移と診断された. HCCの胃転移は稀で, 中でも血行性転移は本邦での報告は極めて稀である. 自験例に文献的考察を加えて報告する.

We report a 72-year-old man who was diagnosed by gastroscopy as having a type III poorly differentiated adenocarcinoma in the lesser curvature, with the longest diameter being 10 cm. An abdominal computed tomography (CT) scan revealed multiple liver metastases, thickening of the gastric wall, and an enlarged paraaortic lymph node. The serum carcinoembryonic antigen (CEA) level was 60 ng/ml and the carbohydrate antigen (CA) 19-9 level was 1355 U/ml. The patient received combined chemotherapy with doxifluridine (800 mg/body per day) and paclitaxel (one course comprised three weekly infusions at a dose of 70 mg/m(2) followed by 1-week rest). After the completion of three courses, the patient achieved a complete response (CR), with complete disappearance of the primary tumor, the metastatic foci in the liver, and the enlarged abdominal lymph nodes; as well, the tumor markers were normalized. Adverse effects included only mild anorexia that was limited to grade 1. He maintained a CR for 1 year and 2 months. Combination chemotherapy with paclitaxel and doxifluridine can be an effective treatment for unresectable advanced gastric carcinoma.

Transanal intersphincteric resection (ISR) was introduced and has been increasingly performed as an ultimate surgical treatment for extremely low rectal cancer. We considered that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined.Between December 2003 and June 2004, we performed laparoscope-assisted ISR for two patients with very low rectal cancer and total colectomy for two patients with ulcerative colitis complicated by colorectal cancer. In all patients, the transanal procedure was preceded by trans-abdominal laparoscopic rectal excision.Preceding transanal dissection facilitated muscle layer-oriented curative dissection, and more importantly, made subsequent laparoscopic rectal excision effortless as a result of penetrating to the dissected pelvic cavity. All patients showed favorable recovery including postoperative anal function with no complication or recurrent disease.This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease, while preserving anal function.

右腋窩,大胸筋に発生した筋肉内粘液腫の1例を経験したので報告する.症例は75歳,男性,主訴は右腋窩の腫瘤であった.初診時,右腋窩に弾性硬で周囲との境界明瞭な腫瘤を認めた.血液検査所見にて異常を認めず, CTにて脂肪より高CT値,筋より低CT値の腫瘤を右大胸筋外側に認め,浸潤傾向を認めなかった.手術は,腫瘤の辺縁を約5mmの切除marginをおき摘出した.大胸筋との間にstalkを認めたが,切離することにより摘出が可能であった.病理組織検査の結果,筋肉内粘液腫と診断した.術後10カ月の現在,再発はなく経過は良好である.

BACKGROUND The mechanism involved in the spontaneous acceptance of liver allografts in some rat strain combinations remains unclear. Immunoregulatory NKR-P1TCRalphabetaT (NKT) cells primarily produce IL-4 and IFN-gamma, and enhance the polarization of immune responses to Th2 and Th1, respectively. The aim of this study was to clarify the role of graft-derived NKT cells in inducing the spontaneous acceptance of rat orthotopic liver transplantation (OLTx) METHODS The experimental groups were divided as follows: Group 1, BN to LEW "low responder (acceptor)" combination; Group 2, DA to LEW "high responder (rejector)" combination; naive BN (Group 3) or LEW recipients (Group 4) with liver allografts from irradiated BN donors. The recipients had liver allografts from irradiated donors reconstituted from the following cell populations 24 hr before harvesting, spleen cells (SPCs, Group 5), IgSPCs (Group 6), IgNKR-P1SPCs (Group 7), and IgTCRabSPCs (Group 8) RESULTS In Group 1, the percent of graft-derived NKT cells harvested on day 7 posttransplant were significantly higher than in Group 2. In the case of BN liver allografts that had been irradiated and reconstituted with cell populations including NKT cells (Groups 5 and 6), the mean graft survival (MST) was extended to 39.2+/-5.7 and 38.8+/-8.0 days, respectively. In contrast, when NKT cells were excluded (Groups 7 and 8), the grafts were acutely rejected within MST of 17.8+/-4.0 and 18.8+/-7.7 days, respectively. The concentrations of IL-10 and TGF-beta, but not IL-4 in IgGICs culture supernatants were predominant in the acceptor, whereas those with IFN-gamma predominated in the rejector. CONCLUSIONS Graft-derived NKT cells might be responsible for spontaneous acceptance in the rat OLTx.

Pancreas transplantation (PTx) has evolved as a clinical therapy to achieve sustained euglycemia. However, it remains unclear if naive diseased islets of the pancreas benefit from the avoidance of glucose toxicity by PTx. In the present study, using an animal model of type 2 diabetes, the Spontaneously Diabetic Torii (SDT; RT1a) rat, we syngeneically transplanted nondiabetic 10-week-old pancreaticduodenal grafts into diabetic 25-week-old recipients. In the control SDT rats that received no treatment, hyperglycemia developed with a mean onset time of 25 +/- 3.9 weeks of age. Few normal islet cells were found from 25 weeks and none at 40 weeks. However, in the PTx rats, the onset age (graft age) of diabetes was significantly prolonged (47 +/- 18.2 weeks). Moreover, we found that the beta-cell mass was significantly increased in the naive pancreases of 40-week-old PTx recipients (PTx40-naive). Interestingly, islet-like cell clusters of varying size were found close to ductal structures of PTx40-naive pancreases, suggesting that these cells are derived from ductal cells. Furthermore, pancreatic and duodenal homeobox factor-1 (PDX-1) was more clearly expressed in the nuclei of PTx40-naive pancreatic islet-like cell clusters. Our results demonstrate the development of duct-derived beta cells in the pancreas of type 2 diabetic recipients after PTx.

Laparoscopic surgery has been applied to patients with primary Crohn's disease, and its beneficial outcomes have been already investigated. However, there is no systematic study of laparoscopic surgery for patients with recurrent diseases. We performed reoperation for 43 patients with recurrent Crohn's disease, including 23 patients who underwent laparoscope-assisted surgery. For all the patients, laparoscope-assisted surgery could be performed safely, even if the patients had been treated previously by open surgery or had undergone multiple abdominal procedures. Conversion to open or hand-assisted laparoscopic surgery was necessary for 16 patients (69.6%) because of dense adhesions (11 cases) or bulky tumor (5 cases). Importantly, even if the procedure was converted, the skin incision was significantly shorter than with open surgery, and postoperative recovery was faster, especially for the patients who underwent conversion to hand-assisted laparoscopic surgery. Laparoscope-assisted surgery is feasible and advantageous in reoperation for patients with recurrent Crohn's disease.

Pancreas and islet transplantation is the only treatment that can cure type 1 diabetes mellitus (DM). With the recent advances of operative procedure and immunosuppression, pancreas graft survivals have become better than before, but some problems still remain. It is extremely difficult to establish tolerance and to reverse rejection once it has been initiated because the pancreas graft itself has a strong immunogenicity. It is also known that pancreatic graft failure is sometimes due to autoimmune recurrence. In the clinical situation, however, these immunologic events actually coexist within the pancreatic graft. Thus, it is rather difficult to analyze each of them independently, but possible to delineate each of these immunologic mechanisms with using animal models of type 1 DM such as BB (BioBreeding) rats or NOD (nonobese diabetic) mice. In the current study, we reviewed the immunological characteristics in pancreas transplantation (PTx) based on our experimental experiences together with that of others and investigated the possibility of tolerance induction in PTx.

Adenovirus-mediated CTLA4Ig gene transfer has been reported to enhance graft survival in several rodent transplantation models. In this study, we investigated the efficacy of ex vivo and systemic transfer of the CTLA4Ig gene by adenoviral vectors in pancreatic islet allo-transplantation. Islet grafts from BN rats were transplanted to chemically induced diabetic LEW rats. First, ex vivo CTLA4Ig gene transfer into isolated islets was performed prior to transplantation. Survival of transduced grafts under the kidney capsule was slightly prolonged (8.6+/-1.3 days) compared with survival of untransduced grafts (6.7+/-1.2 days); when combined with a short course of FK506, graft survival was further extended (32.6+/-10.7 days vs. 13.7+/-1.0 days with FK506 alone). Secondly, systemic gene transfer was accomplished by intravenous administration immediately after the transplantation procedure. In these animals, islet grafts under the kidney capsule survived longer (15.2+/-3.3 days) than in controls (6.7+/-1.2 days), and when FK506 was administered perioperatively, all the islet grafts survived for more than 100 days. In systemically transduced recipients, the survival of islet grafts transplanted into the liver was not significantly different from that of the grafts placed under the kidney capsule. In order to examine organ-specific immunogenicity, heterotopic BN cardiac grafts were transplanted to LEW rats intra-abdominally, with the virus transferred systemically as in the islet model. In contrast to the islet grafts, all the cardiac grafts were accepted for longer than 100 days, even without FK506 therapy. Finally, the LEW recipients with long-surviving islet or cardiac grafts were re-transplanted with islet grafts from the same donor strain (BN) on day 100. The second islet grafts survived longer than 100 days in half of the cardiac recipients, but consistently failed in the islet recipients. We conclude that in this transplant model, CTLA4Ig gene transfer and FK506 treatment synergistically improved islet graft survival, systemic transfer of the gene was more effective than ex vivo transfer to the islets, and donor-specific tolerance could not be achieved for islet transplantation but was achieved for cardiac transplantation.

症例は58歳女性で, 26年前,僧帽弁置換術が施行された. 8年前に慢性C型肝炎を指摘された.今回,人工弁機能不全にて,僧帽弁再置換術予定となるが,術前に肝硬変に起因した脾機能亢進による,二次性血小板減少症(血小板数3.4×104/mm3)を認めた.血小板輸血を行うが増加を認めず,開心術に先行して,血小板増加を目的に脾臓摘出術を施行した.その結果,血小板数は,翌日に16.0×104 mm3,脾摘後21日目の開心術時には20.5×104/mm3にまで増加し,血小板凝集能,粘着率もほぼ正常であった.僧帽弁再置換術は,止血に難渋することなく安全に施行しえた.開心術での大量出血,大量輸血は肝不全, MOFにつながり注意を要する.本例での脾摘後の血小板数増加は止血,特に術後早期の出血を抑制する点で有用であった.

BACKGROUND Many strategies of tolerance induction by intrathymic (IT) injection of donor alloantigens have been reported to date; however, the timing of IT injection is usually 1-3 weeks before transplantation. METHODS To apply IT injection to cadaveric organ transplantation, 1 x 10(8) fully allogeneic bone marrow cells (BMC) of Buffalo (BUF; RT1b) rats were intrathymically injected into Wistar Furth (WF; RT1u) rats at the time of BUF cardiac allografting with short-course therapy of antilymphocyte serum (ALS) and FK506 in our experimental model. RESULTS Allogeneic IT injection of BUF BMC with ALS and FK506 indefinitely prolonged graft survival (mean survival time > 210 days) in all WF rats. On day 130 after grafting, tolerant WF rats accepted donor BUF skin grafts (> 120 days) but not third-party Lewis skin grafts. In control groups, syngeneic IT injection of WF BMC or intravenous injection of donor BUF BMC in combination with ALS/FK506 therapy failed to induce tolerance. In vivo testing was performed during induction (1 month) or during maintenance (6 months of tolerance. In the mixed lymphocyte reaction (MLR), spleen T cells of tolerant rats at 1 month after grafting displayed hyporesponsiveness after stimulation with donor cells. The addition of interleukin (IL)-2 to MLR culture did not restore T-cell responsiveness. Tolerant rats had a significantly decreased frequency of T cytotoxic cell precursors (fTcp) of 1:4,926, and frequency of IL-2-producing T helper cell precursors (fThp) of 1:23,925, compared with naive rats (1: 2,158 and 1:4,266, respectively). By 6 months after grafting, however, the anti-donor MLR proliferative responses of tolerant rats had been restored to the levels of naive splenic T cells. These tolerant rats displayed restoration of the (fTcp) of 1:2,842 and of the (fThp) of 1:5,630, which were comparable frequencies of naive rats. Suppressor T cells did not contribute in this model. In cardiac grafts of tolerant rats induced by IT injection, expression of both Th1 (interferon-gamma and IL-2) and Th2 (IL-4 and IL-10) cytokines was detected in the early phase; thereafter, expression was completely inhibited, except for interferon-gamma in the chronic phase. CONCLUSIONS Perfect donor-specific tolerance was obtained by IT injection of donor BMC at the time of transplantation, while alloimmune responses were maintained at levels similar to those of naive rats.

孤立性, 非寄生虫性肝嚢胞により閉塞性黄疸を来すことはまれで, 文献的に16例が報告されているに過ぎない.今回, 我々は閉塞性黄疸を来した孤立性肝嚢胞に対し腹腔鏡下dome resectionを行い, 良好な結果を得たので報告する.症例は75歳の男性で, 全身倦怠感を主訴に来院した.初診時, 黄疸および肝機能異常を認め, 諸検査にてS4, 5の径12cmの肝嚢胞による肝門部胆管圧迫が原因と診断した.治療は経皮経肝嚢胞ドレナージを行い, 減黄, 肝機能改善を得たのちに, 腹腔鏡下にdome resectionを行った.術後経過は良好で患者は術後7病日に退院した.腹腔鏡下dome resectionは低侵襲でかつ早期社会復帰が可能であり, エタノール注入療法に代わる第1選択の治療となると考えられた.

A simple surgical technique that facilitates circular-stapled Billroth I gastroduodenostomy in laparoscopic distal gastrectomy is described. After standard laparoscopic mobilization of the distal stomach, a small duodenotomy is made just distal to the pyloric ring. The anvil of a circular-stapling device, secured with a Vicryl suture, is introduced via the duodenotomy. The Vicryl suture is advanced anteriorly so that a center rod penetrates the anterior duodenal wall. The duodenum is staple-transected at this point, and the center rod is wrapped with the stapled duodenal stump by approximation of both edges using a suturing device. The circular-stapled gastroduodenostomy then is completed in a standard fashion. The authors have used this technique for three patients, and their early outcomes are promising.

Although the birth of homozygous α1, 3 galactosyltransferase gene-knockout pigs raised hopes for an imminent breakthrough in the prevention in the antibody-mediated rejection of pig to human discordant xenotransplants, human CD8+ cytotoxic T lymphocyte (CTL)–mediated killing may represent a new immunological barrier to long-term survival in xenograft recipients. In this study, we demonstrated that the cytotoxicity of human CD8+ CTL against swine endothelial cells (SEC) is highly detrimental and mediated at least in part by the Fas/FasL pathway. To prevent this CTL-mediated xenocytotoxicity, we overexpressed the human decoy Fas antigen, which does not contain a death domain in its cytoplasmic region, by means of binding competition with endogenous pig Fas antigen on SEC for the common ligand, human FasL. Furthermore, we generated a membrane-bound form of human FasL that cannot be cleaved by a putative metalloproteinase to produce a soluble form, which was assessed as an inhibitor of CTL cytotoxicity. Both human decoy Fas and membrane-bound FasL were effective to prevent CTL-mediated killing, suggesting that these novel molecules may represent a step forward toward preventing CD8+ CTL-mediated xenograft rejection. The combined expression of both molecules may be more beneficial to protect xenograft cells.

Diabetes-prone (DP) BB rats (RT1(u), RT6.1) spontaneously develop insulin-dependent diabetes mellitus (IDDM) and the disease manifestation resembles that in human IDDM. DP rats are immunodeficient with severe T lymphocytopenia due to the absence of T cells expressing the RT6 differential alloantigen, which have immunoregulatory functions. MHC- and non-MHC-compatible Wistar Furth (WF; RT1(u), RT6.2) pancreases were transplanted into DP rats. WF pancreas grafts were destroyed by IDDM recurrence (insulitis), but not by rejection, with a mean survival time of 65.3 +/- 21.7 days. To prevent the recurrence of IDDM in the grafts, monoclonal antibodies to intercellular adhesion molecule-1 and leukocyte function-associated antigen-1 were administered. WF pancreas grafts were indefinitely accepted (>108.0 +/- 26.8 days) in monoclonal antibody-treated DP recipients. The number of T cells was increased and cellular immune responses restored only in the DP rats that had accepted grafts. The increased number of T cells was due to the peripheral appearance of donor-type RT6.2+ T cells, which represented 34.3 +/- 7.0% of total splenic T cells. The cytotoxicity of splenic T cells to WF islet cells was suppressed in the presence of RT6+ T cells in vitro. These findings demonstrated that stable macrochimerism of donor-derived RT6+ T cells could restore the immune responses and prevent the recurrence of IDDM in the DP recipients.

The occurrence of Swan-Ganz (S-G) catheter-induced tricuspid regurgitation (TR) was investigated using transesophageal echocardiography in four patients who underwent laparoscopic cholecystectomy with 12-mmHg pneumoperitoneum. Before pneumoperitoneum, TR was not detected in any of the four patients, despite the presence of an inserted S-G catheter; however, it was detected after completion of 12-mmHg pneumoperitoneum in one of the four patients. This TR was diminished after depneumoperitoneum and the employment of a retraction method by which the intra-abdominal pressure became equal to the atmospheric pressure. This TR was not recognized after the removal of the S-G catheter during 12-mmHg pneumoperitoneum in the same patient. There is a possibility that the S-G catheter induces TR during 12-mmHg pneumoperitioneum.

The present study has demonstrated for the first time that PVG.R1 (RT1.AaBcDcCc) pancreatic grafts are rejected by so-called "low"-responder PVG (RT1.AcBcDcCc) recipients with an isolated class I MHC disparity (mean survival time; MST: 21.4 +/- 1.8 days, n = 5), whereas PVG.R1 heart grafts are able to survive indefinitely (MST:100 days, n = 5). Splenic CD4+ T cells but not CD8+ T cells from the PVG recipients of PVG.R1 pancreatic grafts show a remarkable proliferative response against donor class I RT1.Aa alloantigens, while only a minimal proliferation is observed in the PVG recipients of PVG.R1 heart grafts or naive PVG rats. Naive PVG rats display an extremely low frequency of IL-2-producing helper T cell precursors (fThp) of 1/40,609 +/- 15,441 against class I RT1.Aa alloantigen. The PVG recipients of PVG.R1 heart grafts have a slightly greater fThp of 1/17,326 +/- 6822. On the other hand, the PVG recipients that rejected PVG.R1 pancreatic grafts show a significantly increased fThp of 1/5030 +/- 3396 compared with those of PVG.R1 heart grafts (P0.05) or naive PVG rats (P0.01). The frequency of cytotoxic T cell precursors (fTcp) increases slightly in the PVG recipients of PVG.R1 pancreatic grafts (1/1848 +/- 330) compared with those of PVG.R1 heart grafts (1/2215 +/- 2131) or naive PVG rats (1/2476 +/- 585). The size of cytotoxic T cell clones alone does not adequately account for a proliferation sufficient to complete the rejection of pancreatic grafts. The PVG recipients of PVG.R1 pancreatic grafts, but not heart grafts, demonstrate a strong cytotoxic alloantibody response to donor class I RT1.Aa alloantigens. In the study of alloantibodies, IgM is detected mainly in the early phase and IgG in the late phase during the course of pancreatic rejection. It is determined that in blocking studies by FACS analysis these antibodies target class I MHC antigens. These results suggest that cytotoxic T cells do not appear to be responsible for the rejection of PVG.R1 pancreatic grafts in PVG recipients. Rather, the rejection is mediated by CD4+ T cells and complement-fixing antibodies directed at class I MHC antigens.

A case of hamartoma in the ileocecal region associated with congenital absence of the vermiform appendix is reported. A 21-year-old man was admitted to the hospital because of intestinal obstruction. With barium enema, a tumor arising from the ileocecal region causing intestinal obstruction was revealed. Ileocecal resection was then performed. In the surgical specimen, a slender polyp of 7×1.5cm in size was present in the first part of colon and additional several small polyps were located in the terminal ileum. Vermiform appendix was not present. Pathological findings of these polyps were hamartomatous proliferation of submucosal smooth muscle. Only 23 cases of hamartoma in the small intestine have been reported so far in Japan. Those tumors generally consisted of smooth muscular and grandular components. In contrast, the specific finding of this case was that the tumors were made up with single smooth muscular component. The present case was also associated with rare congenital absence of vermiform appendix.

We present a case of giant mucinous cyst adenoma which occurred in the sacrococcygeal region and developed evacuational disturbance. A 41-year-old woman, who underwent sacral tumor resection on her birth, noticed a slowly growing mass in the perianal region and developed evacuational disturbance. She was referred to our hospital for the evaluation of tumor. Image studies suggested a recurred sacrococcygeal teratoma.The well-defined tumor was 1070 gm in weight and contained large amount of mucinous fluid. Histologically, it was mucinous cyst adenoma without any malignancy. There is no previous report of mucinous cyst adenoma occurred in the sacrococcygeal region, although it is common in the ovary and a few in the retroperitoneum. Histogenesis of sacrococcygeal cyst adenoma is unclear. We applied a technique of posterior gluteal thigh faciocutaneus flap because of a large amount of tissue and skin defect. This was proved to be useful from cosmetic and functional standpoint to cover the tissue defect as well as to reinforce the vulnerability of the pelvic floor after the resection of the tumor and some part of the levator ani muscle.

DNA ploidy was studied with flow cytometry in 20 cases of smooth-muscle tumor of gastroduodenal origin. There were 13 leiomyomas and 7 leiomyosarcomas. Clinico-pathological parameters, mitotic index, cellularity and histological grade clearly differed between leiomyoma and leiomyosarcoma. Only one of 13 cases of gastric leiomyoma revealed aneuploidy and the rest of 12 cases did diploidy. Conversely, 4 of 5 cases of gastric leiomyosarcoma showed aneuploidy. Two cases of duodenal leiomyosarcoma showed diploidy. Repeated measurements of DNA ploidy did not always yield the same ploidy as seen in the previous measurement, in that unhomogenous presence of DNA was inferred. Occurrence of aneuploidy was significantly higher in the leiomyosarcomas, but the prognostic value is still unlear, because postoperative late death occurred only in one case in which complete resection of widespread invasion was unsuccessful. Long-term follow-up is needed to evaluate the usefulness of DNA ploidy analysis as a prognostic factor of gastroduodenal smooth-muscle tumors.

絞扼性イレウスにおける腸管循環障害の重症度と腸管切除の必要性を予測することは容易ではない.われわれは過去12年間に当院救急外科に来院した絞扼性イレウス65例を対象とし, 多変量解析を用いてその可能性を検討した.腸管切除群35例と腸管非切除群30例の2群に分け, 各術前因子を比較した.また, 各術前因子から腸管切除長, 腸管切除の必要性を解析した.結果: 体温, 白血球数, 核の左方移動率, Creatinine Phosphokinase値, 血糖値の5因子において, 腸管切除群は非切除群に比べ有意に高値を示した.重回帰分析では腸管切除長は白血球数, 核の左方移動率, CPK値と有意に重相関し, このうちCPK値が最も相関に寄与していた.また, 体温, CPK値, 血糖値の3因子からなる判別式が算出され, その正判別率は90.9%であった.これら術前5因子は絞扼性イレウスにおける腸管切除の必要性を判別し, 術前における腸管循環障害の重症度を推定する指標となることが示唆された.

A 58-year-old man who complained of an abdominal tumor was admitted to our hospital. Abdominal CT scan showed that a 15-cm tumor occupied the entire right upper abdomen and that there were ascites and liver metastases. A liver biopsy was performed. The liver biopsy showed a small cell carcinoma pattern, but no definitive origin of the tumor was determined. Considering the extensive peritoneal invasion and multiple liver metastases, he received 2 / courses of cisplatin/etoposide chemotherapy, but his tumor became larger with concomitant abdominal pain and nausea. The patient suddenly died due to multiple organ failure caused by tumor necrosis. The autopsy revealed a pathological diagnosis of primary small cell carcinoma of the pancreas.

We report a case of asymptomatic duodenal carcinoid in a 50-year-old male patient. A filling defect was detected on routine upper gastrointestinal X-ray examination, and serious and a sessile polyp of 5 mm in diameter was endoscopically observed. Biopsy revealed typical features of carcinoid. Partial resection of the duodenal was performed. The tumor was confirmed in the mucosa which was type B by Soga's classification. Immunohisto-chemically, numerous secretary granules of gastrin-positive and somatostatin-negative were observed. This patient is doing well with no signs of recurrence 12 months after surgery.

19歳男性に多発性大腸癌と胃癌の重複癌を認め, 幽門側胃切除術および回盲部より15cm肛門側の上行結腸から上部直腸までの大腸摘出術を行った. 再建はBillroth I法および結腸直腸吻合術を行った. 病理所見では胃体下部小彎に深達度ssの潰瘍浸潤型印環細胞癌を認めた. また直腸にはsmの有茎型中分化腺癌, ssの浸潤潰瘍型中分化型腺癌およびsmの陥凹型粘液癌を, またS状結腸から下行結腸にかけてmとsmの有茎型高分化型腺癌, smの陥凹型中分化型腺癌, pmの腫瘤型粘液癌2個と4個の腺腫を, さらに横行結腸に腺腫内癌を認めた. 術後2年1か月現在再発なく健在である. 本邦における20歳未満の若年者大腸癌は145例報告されている. このうち多発癌症例は本症例以外に6例で, 内訳は家族性ポリポージス症1例, Turcot症候群2例, 非家族性ポリポージス症1例, S状結腸多発癌1例, 横行結腸多発癌1例であった. Turcot症候群を除いた他臓器重複癌合併は本症例のみであった.

A 20-year-old male plating worker was accidentally immersed up to his lower thorax in a vat of hot chromic acid solution. The patient sustained third degree burns over 60% of the lower body surface area. Blood and urine concentrations of chromium were 740μg/dl and 1, 550μg/l, respectively. The initial course was characterized by hypotension, hypoglycemia, acute renal failure, hepatic damage, and thrombocytopenia. Continuous hemodiafiltration between Day 3 and Day 28 after the exposure resulted in recovery from renal failure. Although he underwent debridement and epidermization twice, candidiasis of the burned surface led to candidemia. After a second skin grafting on Day 50, his condition deteriorated, with azotemia again and hyperbilirubinemia. General convulsions occurred after Day 55, and he died on Day 66. The autopsy revealed tubular necrosis of the kidneys, a markedly enlarged liver (5, 700g), with severe fatty infiltration and a slightly atrophic brain without microscopical abnormality. The 21 cases of acute chromium intoxication previously reported are reviewed and recommendations for the management of such patients are presented.

The patient was a 72-year-old male diagnosed with type III poorly-differentiated adenocarcinoma in the lesser curvature by gastric fiberscopy. An abdominal computed tomography (CT) scan showed the thickness of the gastric wall and the enlarged lymph node around the stomach and laparoscopic examination revealed peritoneal dissemination. The patient received neoadjuvant combined chemotherapy with S-1 and CDDP. S-1 (100 mg/day) was orally administered for 3 weeks followed by 2 drug-free weeks as a course, and CDDP (100 mg/body) was administered by intravenous drip on day 8. After the third course, significant tumor reduction was obtained. Total gastrectomy, splenectomy and D2 nodal dissection were performed. Peritoneal dissemination disappeared, and the histological diagnosis revealed complete disappearance of cancer cells in the ascites and no metastasis in all lymph nodes. The patient has now been in good health with no recurrence for 22 months after surgery. The combined neoadjuvant chemotherapy with S-1 and CDDP can be an effective treatment of choice for advanced gastric carcinoma with peritoneal dissemination.

We report a case of liposarcoma of the spermatic cord associated with rectum cancer. A 78-year-old man visited our hospital with a complaint of painless left inguinal mass. He also showed constipation and bloody bowel discharge, rectum cancer was diagnosed by further evaluation. Ultrasonography, computed tomography and magnetic resonance imaging revealed a 2 x 4 x 6 cm mass in the left spermatic cord. Left high orchiectomy for the left inguinal tumor and Hartmann's procedure for rectum cancer was performed. Histologically, the mass in the left spermatic cord was well differentiated liposarcoma and rectum cancer was poorly differentiated adenocarcinoma. He died from rectum cancer with no evidence of recurrence of liposarcoma of the left spermatic cord after follow up for 6 months.

A 72-year-old male with advanced gastric cancer (cT3N2M0H0P0CY1, cStage IV) was treated with TS-1/CDDP as neoadjuvant chemotherapy. TS-1 (60 mg/m(2)/day) was orally administered for 3 weeks followed by 2 drug free weeks as a course, and CDDP (60 mg/m(2)) was administered by intravenous drip on day 8. After the fourth course,a significant tumor reduction was obtained. Total gastrectomy, splenectomy, and D 2 type nodal dissection were performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and all of the lymph nodes, which is a so-called pathological complete response. The patient has now been in good health without a recurrence for 24 months after surgery. This case suggests that neoadjuvant chemotherapy with TS-1/CDDP is a potential regimen for advanced gastric cancer.

We conducted combined therapy of weekly paclitaxel and doxifluridine (5'-DFUR) for 23 cases of advanced and recurrent gastric carcinomas to investigate their efficacy and safety. Subjects included 7 unresectable cases, 5 noncurative resection cases, and 11 recurrent cases. Twenty of the 23 subjects had a history of prior treatment with another anticancer drug. The treatment regime consisted of one course comprising 70 mg/m(2)of paclitaxel weekly for three consecutive weeks followed by one week rest, combined with 800 mg/day of 5'-DFUR orally. Results revealed a response rate of 17.6% (3/17), with 2 cases of CR, 1 case of PR, 10 cases of NC, and 4 cases of PD. One of the CR cases was an unresectable case involving a primary tumor, liver metastasis, and abdominal lymph node metastasis, while the other was a recurrent case involving abdominal lymph node metastasis. The median survival period was 387 days. The one-and two-year survival rates were 52% and 24%, respectively. In terms of adverse effects, there were only single cases of grade 3 leukopenia and grade 3 neutropenia, with no cases of grade 4 hemotoxicity. Both patients could be treated as outpatients. Combination therapy of weekly paclitaxel and 5'-DFUR can be an effective and safe therapy for advanced and recurrent gastric carcinomas.

Aims. Type 2 diabetes is characterized by a combination of insulin resistance and pancreatic beta-cell dysfunction. Although pancreas transplantation (PTx) is mainly performed in patients with type 1 disease, both clinical and experimental data have demonstrated that PTx improves insulin sensitivity in type 2 diabetic recipients. However, it remains unclear whether PTx has the potential to induce islet neogenesis in a recipient's native pancreas. Methods. Nondiabetic 10-week-old and diabetic (defined as blood glucose level >250 mg/dL) 25-week-old (average onset age of diabetes) male spontaneously diabetic Torii (SDT; RT1 a ) rats served as donors and recipients, respectively. Results. In nontreated control SDT rats, beta-cell mass gradually decreased and blood glucose levels progressively increased (>600 mg/dL after 40 weeks of age). In PTx rats, however, the onset of diabetes was significantly delayed (>47.5 ′ 18.2 [graft age] versus 25.2 ′ 3.9 weeks in control rats). On immunohistochemical staining, insulin-secreting islets were observed in the naive pancreata of 40-week-old recipients with PTx (PTx40w), whereas no islets were found in 40-week-old control SDT rats. Moreover, the islets in the native pancreata of PTx40w recipients were located close to ductal structures, and PDX-1 (pancreatic duodenal homeobox-1)-positive cells were more clearly visible. These results indicate the possibility of beta-cell regeneration in the recipient native pancreas by avoiding glucose toxicity under normoglycemic condition achieved by PTx. Conclusions. Pancreas transplantation has beneficial effects on impaired islet, inducing regeneration in the spontaneously diabetic Torii rat.

BACKGROUND: CTLA4Ig gene transfer directly to graft tissue might have the potential to avoid the need for systemic immunosuppression. In our previous studies of bio-breeding (BB) rats, local adenovirus-mediated CTLA4Ig gene transfer protected the pancreas from autoimmune and alloimmune responses. This study investigated the potency of local CD28/B7 costimulatory blockade for induction of donor-specific tolerance and further examined the existing mechanisms. METHODS: Brown Norway (BN; RT1)-pancreaticoduodenal grafts transfected with Ad.CTLA4Ig via intraarterial ex vivo perfusion were transplanted into streptozotocin-induced diabetic Lewis (LEW; RT1) rats. RESULTS: Ad.CTLA4Ig transduced grafts combined with a short course of FK506 resulted in indefinitely prolonged survival (>156 days vs. 19.5 days with FK506 alone). CTLA4Ig was predominantly expressed in grafts on day 4. The expression was gradually diminished and was only slightly detectable at day >100. The proliferative responses against BN antigen were remarkably enhanced among recipients with rejected grafts, but the T-cells from tolerant recipients (>100 days) showed poor cytotoxic responses. On adoptive transfer assay, the splenic T-cells of tolerant recipients were able to suppress the rejection of BN, but not third-party Wistar Furth (WF; RT1) hearts in irradiated (480 cGy) LEW recipients. The percentage of CD4CD25 splenic T-cells was significantly increased in tolerant recipients (13.53 +/- 4.06% vs. 6.06 +/- 0.56% in naive rats). CONCLUSION: CTLA4Ig gene transfer to the pancreaticoduodenal allograft combined with a short course of FK506 induces donor-specific tolerance. The mechanism of maintaining tolerance could be explained by development of splenic T suppressor cells.

Background. In terms of the temporal relationship between pancreas transplantation (PTx) and reversal of diabetic ocular complications, it has been difficult but important to determine a point of no return. Thus, it is of great clinical interest to evaluate the efficacy of PTx on diabetic ocular complications. Methods. A spontaneous type 2 diabetic model of Spontaneously Diabetic Torii (SDT; RT1 a ) rats was used in the present study, and syngeneic PTx was performed. Results. In the control SDT rats that received no treatment, hyperglycemia (>250 mg/dL) was developed from 25.2±3.9 weeks of age. Lens opacity was observed in all rats at 15 weeks after the onset of diabetes. Fluorescein angiography and immunohistochemistry detected the nonperfusion area and neovascularization in the retina at 5 weeks of diabetes. Daily insulin treatment could not prevent or reverse the ocular changes in our experiment. Fluorescein filling defect of the retinal vessels was observed at 10 weeks of diabetes. However, in the PTx rats, normoglycemia was achieved at all experimental time points. Diabetic cataract and retinopathy could have been prevented and improved if PTx had been performed at 5 weeks, but not at 10 weeks after the onset of diabetes. With PTx treatment, an inhibition of angiogenesis in the retina at 5 weeks after the onset of diabetes was demonstrated by immunohistochemistry. Conclusions. Our results indicate that the potential use of the SDT rat for diabetes study and the positive effect of PTx performed before the point of no return could prevent and cure diabetic ocular complications.

Since the establishment of laparoscopic cholecystectomy (LC) for benign gallbladder lesions, the four-trocar method has been the standard procedure. However, the fourth trocar generally is used just for fundic retraction of the gallbladder. We have developed a three-trocar method for LC and performed it in 132 patients.After the creation of the pneumoperitoneum, the first 10-mm trocar sheath was inserted in the subumbilicus for the endoscope, the second 5-mm trocar in the epigastric paramedian point for the working port, and the third 5-mm trocar in the subcostal area for grasping forceps. Monofilament nylon with a straight needle was inserted through the right 7th intercostal space in the anterior axillary line, and the seromuscular layer of the gallbladder fundus was punctured and retracted toward the anterior abdominal wall. After that, usual cholecystectomy was performed.Among the 132 patients who underwent the three-trocar method, 10 cases (8%) needed a fourth trocar. No patient was converted to open cholecystectomy. There were no significant differences in the operating time, the length of hospital stay after the operation, or the use of analgesics between the three-trocar and the four-trocar methods. No major complication was recognized.This method also has cosmetic advantages. Therefore, we believe this method might be recommended for LC.

Alterations of the left atrial/right atrial pressure gradient were determined using a Swan-Ganz thermodilution catheter in 20 patients who underwent laparoscopic cholecystectomy with 12 mmHg pneumoperitoneum (LAP) and 13 patients who underwent minilaparotomy cholecystectomy (MINI). Right and left atrial pressures were both elevated by pneumoperitoneum. A diminished or reversed left/right interatrial pressure gradient was recognized during pneumoperitoneum in 4 of the 20 patients (20%) in the LAP group, whereas it was not recognized during operation in any of the 13 patients in the MINI group. Evaluation of the elevation of intrathoracic pressure during pneumoperitoneum using peak inspiratory airway pressure or pulmonary arterial pressure could not predict the occurrence of this paradoxical interatrial pressure gradient.

In clinical pancreas transplantation, no reliable marker for the early diagnosis of acute rejection has been reported. This is one reason why the graft survival rate of pancreas transplantation alone is much lower than that of other organs, such as hearts, livers, and kidneys. We designed an experiment to investigate acute rejection of pancreas allografts in hyperglycemic rats by measurement of blood glucose levels and nitric oxide (NO) products (nitrite plus nitrate, and nitrosyl hemoglobin). As recipients, Lewis rats were rendered hyperglycemic by intravenous injection of streptozotocin before transplantation. F344 rats were used as donors of pancreas allografts. Lewis rats were also used as donors of syngeneic pancreas grafts. After transplantation, the blood glucose level returned to a normal level and rejection was defined as the recurrence of hyperglycemia. The mean survival time of pancreas allografts was 14 +/- 0.7 days. The plasma level of nitrite plus nitrate in allografted rats peaked on postoperative day 7. Electron spin resonance spectra of NO bound to hemoglobin were detected in the blood from allografted rats with a peak on postoperative day 7, whereas NO bound to hemoglobin was not detected in the blood from recipients of syngeneic grafts at any sampling time. The results show that NO was synthesized in the earlier period than the elevation of the blood glucose level during rejection after pancreas transplantation in rats.