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Falciform ligament herniation is a rare type of epigastric hernia. We report a case of a primary epigastric hernia containing a falciform ligament repaired using nonabsorbable barbed suture under laparoscopic surgery. A 74-year-old woman presented with discomfort in the upper abdomen. Physical examination revealed a 3-cm non-tender mass, and abdominal computed tomography revealed epigastric hernia with an incarcerated falciform ligament. By observation with a laparoscope, the fascial defect was single and 1.0 cm in diameter, thus sutured repair was selected. At 4 months follow-up, she had no complications or recurrence. The laparoscopic approach is useful for diagnosis and deciding a repair method of an epigastric hernia. The barbed suture closure system is convenient and effective for intracorporeal hernial defect closing. Both primary and incisional falciform ligament herniation have been reported in the past, and we reviewed six cases, including our case.

Background: /Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones. Methods: We retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis. Results: Preoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p

Background We evaluated the risk of acute cholangitis and cholecystitis while waiting for cholecystectomy for gallstones. Methods We retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after a waiting period and conservative therapy between April 2014 and March 2018 at our hospital. We compared the clinical data from 20 patients who developed acute cholangitis and cholecystitis while waiting for cholecystectomy (group A) with data from 148 patients who did not develop cholangitis and cholecystitis (group B). The risk factors for developing acute cholangitis and cholecystitis and all patients' surgical outcomes were investigated. Results Preoperatively, significant differences in age (68.6 years vs 60.7 years; p= 0.004) and the number of patients with a previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p< 0.001) and biliary drainage (20.0% vs 2.0%; p= 0.004) were observed between group A and group B, respectively. Preoperative white blood cell counts (13500/µL vs 8155/µL; p< 0.001) and serum C-reactive protein levels (12.6 mg/dL vs 5.1 mg/dL; p< 0.001) were significantly increased, and serum albumin levels (3.2 g/dL vs 4.0 g/dL; p< 0.001) were significantly decreased in group A vs group B, respectively. Gallbladder wall thickening (≥ 5 mm) (45.0% vs 18.9%; p= 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p= 0.005), and abscess around the gallbladder (20.0% vs 1.4%; p= 0.002) were seen significantly more frequently during imaging in group A vs group B, respectively. Furthermore, investigating patients' surgical outcomes revealed a higher conversion rate to open surgery (20.0% vs 2.0%; p= 0.004), longer operation time (137 min vs 102 min; p< 0.001), and a higher incidence of intraoperative complications (10.0% vs 0%; p= 0.014) in group A vs group B, respectively. Conclusions Our results suggest that a history of severe cholecystitis is a risk factor for developing acute cholangitis and cholecystitis in patients waiting for surgery, and a risk factor for increased surgical difficulty.

The patient was a 54-year-old woman diagnosed with adult Still’s disease, undergoing high-dose steroid and immunosuppressant therapy for 5 years, who was admitted to our hospital with abdominal pain. Computed tomography (CT) revealed pneumoperitoneum around the rectum and a large quantity of retroperitonal emphysema around the inferior vena cava, aorta and left kidney. An emergency laparotomy was performed. Intraoperative observation revealed a perforation on the mesenteric side of the rectum due to diverticulum, and Hartmann’s operation was performed. Deep tenderness and anemia were observed 4 days postoperatively. CT revealed extravasation in the left retroperitoneal space and a retroperitoneal hematoma, and emergency embolization of lumbar arteries was performed. Retroperitoneal bleeding associated with peritonitis after surgery is very rare. We surmised that higher-dose immunosuppressive therapy and gastrointestinal perforation with emphysema in the retroperitoneum induced lumbar artery bleeding. Clinicians should consider these factors as a potential cause of retroperitoneal hematoma.

Background Malignant peritoneal mesothelioma is a rare aggressive tumor of the peritoneum. We report a rare case of resection of multiple localized malignant peritoneal mesotheliomas. Case presentation A 55-year-old Japanese woman was admitted to our hospital because liver tumors were detected by abdominal ultrasonography during a screening examination. Blood examination findings, including tumor makers, were within normal ranges. She had no evidence of exposure to asbestos. Computed tomography showed four hypervascular, round liver tumors, one in the lateral liver segment adjacent to the hepatic hilus, and the other three on the liver surface. Computed tomography angiography revealed that the tumor in the lateral segment had strong enhancement and was fed from the left gastric artery. In contrast, the other tumors showed no enhancement, and were fed from the right inferior phrenic artery. Abnormal accumulation was identified in the four tumors only with 18F-fluorodeoxyglucose positron emission tomography. It was very difficult to obtain a definitive preoperative diagnosis, but surgical resection was performed because we considered potential malignancy. Laparotomy revealed the principal site of the tumor in the lateral segment was on the hepatoduodenal ligament, and all other tumors were on the diaphragm. A left lobectomy and partial diaphragmatic resection were performed. The final pathological diagnosis was multiple malignant epithelioid mesotheliomas. Our patient has had no recurrence for 20 months postoperatively. Conclusions In general, malignant peritoneal mesotheliomas are classified as diffuse tumors, which are often unresectable and have a poor prognosis. However, early diagnosis and treatment, particularly with the localized type, as in our patient, could lead to long-term survival of the patient. We recommend that multiple malignant epithelioid mesotheliomas be included in the differential diagnosis for patients with subcapsular hepatic tumors.

In traditional Japanese herbal (Kampo) medicine, daiobotanpito (DBT) or Da Huang Mu Dan Tang in Chinese has been used in medical treatment of acute diverticulitis for many years based on the experience. Our aim was to investigate whether the treatment of acute diverticulitis can be treated with intravenous antibiotics plus orally administrated DBT than intravenous antibiotics alone. A retrospective nonrandomized open-label trial was established to compare patients with acute diverticulitis who received oral DBT associated with intravenous antibiotics with those who received intravenous antibiotic alone. We included 34 patients, eleven patients in group 1 with DBT and 23 patients in group 2 without DBT. Both groups were comparable in patient demographics and clinical characteristics. There was a significantly better outcome in the group treated with DBT than in the group without DBT when comparing duration of fever, abdominal pain, and antibiotics administration. A trend toward a day shorter mean hospital stay and fasting was seen in group 1, although this did not reach statistical significance. In conclusion, most patients with acute diverticulitis can be managed safely with oral DBT. Although randomized, double-blind study must be done, we could show the possibility to use daiobotanpito as an additional option in treating acute diverticulitis.

症例は73歳男性．粘血便を主訴に来院し，精査にて直腸Raに径6.5cmの1型腫瘍を認め，腹腔鏡補助下低位前方切除術を施行した．病理組織学的には大部分は中等度から高度異型の管状絨毛腺腫であり，一部に高～中分化腺癌を認めた．癌の中央部分ではmicropapillary carcinoma（以下MPC）成分を認め，粘膜下層への浸潤をともなっていた．軽度のリンパ管侵襲を認めたが，リンパ節転移や他臓器転移は認めなかった．術後約2年目に単発性肺転移を認め，胸腔鏡補助下左肺上葉部分切除術を施行した．MPCはリンパ管様の空隙に囲まれた線維血管性間質を欠く微小乳頭状癌胞巣を組織学的特徴とする癌であり，再発や遠隔臓器への転移が高頻度で，悪性度の高い組織型であることが示唆されている．大腸癌での報告は少ないが，大腸癌においてもMPC成分を有する場合は，通常型の大腸癌に比較し，悪性度が高い可能性があり，厳重な経過観察が必要であると考えられた．

背景:まれな乳腺良性病変である乳腺過誤腫を経験したので, その細胞および組織所見を報告する.症例:30歳, 女性. 検診で右乳腺腫瘤を指摘され, 来院した. 右乳腺B領域に最大径2.5cmの腫瘍が認められ, 穿刺吸引細胞診と腫瘍切除術が施行された. 穿刺吸引細胞診では, 散在する裸核状細胞 (双極裸核) を背景に, 二相性の保たれた結合性の強い上皮細胞集団が散在していた. 大型の上皮集団は, 乳管・腺房からなる小葉単位に類似した構造をとっていた. いずれにも, 細胞異型はなかった. 脂肪細胞や平滑筋細胞は確認されなかった. 腫瘍切除標本では, 拡張した乳管と腺房からなる乳腺小葉が複数集簇した結節で, 小葉問には線維性組織が介在し, 一部で成熟脂肪細胞が少量混在していた. 腫瘤は, 境界明瞭で, 薄い線維性組織で覆われていた.結論:乳腺穿刺吸引細胞診にて, 乳腺過誤腫と診断することは困難であり, 最も鑑別を要する病変は線維腺腫である. 乳管・腺房からなる小葉単位に類似した上皮細胞集団の出現が, 線維腺腫と異なる重要な細胞診所見と考えられた.脂肪細胞は, 必ずしも採取されるとは限らず, 鑑別診断に常に有用な所見とはいえなかった.

症例は70歳の男性. 主訴は腹部膨満, 腹痛, 嘔吐. 2年前に右扁桃原発悪性リンパ腫 (stage I) にて治療を受け完全寛解をえた. 腹部単純X線で小腸ガスを認め, イレウス管を挿入し症状は消失したが, 造影にて空腸に境界が比較的明瞭な狭窄像を認め, 小腸悪性腫瘍を疑い手術を施行した. Treitz靭帯より150cmの空腸に, 肉眼的奬膜浸潤陽性の腫瘍を認め, リンパ節郭清を伴う小腸部分切除を行った.腫瘍は70×45mmのBorrmann 2型様で, 組織学的にdiffuse, medium-sized cell, B cell typeの悪性リンパ腫と診断された. 深達度はseで, リンパ節転移は認めなかった. 悪性リンパ腫がWaldeyer輪と消化管に重複発生することが知られているが, 自験例のごとき空腸病変の報告はこれまで認めていない. 小腸悪性リンパ腫とくに深達度seの予後は不良とされ, 術後6か月の現在, 化学療法を施行し厳重フォローアップ中である.

Some neurotrophic factors stimulate process outgrowth in peripheral and/or central nerve fibres. There is no published report that has focused on the expression of neurotrophic factors in human pancreatic cancer except basic fibroblast growth factor. This study was therefore designed to examine the mRNA and protein levels of neurotrophin-3 (NT-3), which is one of the representative neurotrophic factors. The mRNA level for NT-3 was first investigated in eight pancreatic cancers and two samples of normal pancreas, using reverse transcription-polymerase chain reaction (RT-PCR). NT-3 protein expression was then studied in 47 human pancreatic cancers, using a monoclonal antibody against human NT-3 protein. There was a notable difference in the level of NT-3 mRNA between normal and pancreatic carcinoma tissues, with no evident difference in the expression of the beta-actin gene. Immunohistochemically, 34 of 47 pancreatic cancers (72 per cent) were mildly to markedly immunoreactive for NT-3 in the cytoplasma. Immunoreactivity was usually more pronounced at the infiltrative margins of the tumours. These observations suggest that pancreatic carcinoma overexpresses NT-3.

BACKGROUND Lymph node status and neural plexus invasion are the most important prognostic factors that may be amenable to surgery for carcinoma of the body and tail of the pancreas. The pattern of lymphatic spread and neural plexus invasion were evaluated by analysis of various clinicopathologic factors. METHODS Twenty patients with carcinoma of the body and tail of the pancreas underwent pancreatectomy with systemic regional lymph node dissection at Kanazawa University Hospital. A precise evaluation of their lymph node involvement and neural plexus invasion was determined. RESULTS Sixteen of 20 patients (80%) had lymph node involvement. The lymph nodes with a high metastatic rate were those along the splenic artery (50%), the inferior body lymph nodes (35%), the lymph nodes around the common hepatic artery (25%), and the paraaortic lymph nodes (20%). There was no relationship between tumor size, histologic type, and lymph node involvement. Plexus invasion was observed in 14 patients (70%). The most frequent site was the splenic plexus, but between 15% and 20% of the patients had celiac or superior mesenteric plexus invasion. There was no relationship between tumor size, histologic type, and neural plexus invasion. CONCLUSIONS Based on these results, extended lymphadenectomy including the paraaortic lymph nodes, celiac lymph nodes, and superior mesenteric lymph nodes may improve the prognosis for patients with carcinoma of the body and tail of the pancreas. Extrapancreatic neural plexus dissection, especially of the celiac plexus and superior mesenteric plexus, also is necessary. Cancer 1996; 78:2485-91.

膵頭部領域癌133例 (膵頭部癌70例, 下部胆管癌31例, 乳頭部癌32例) の再発・浸潤様式を検索し, 上腸間膜動脈神経叢一部温存郭清の可能性について検討した. リンパ節転移は膵頭部癌の79%, 下部胆管癌の67%, 乳頭部癌の44%に, 神経叢浸潤はそれぞれ60%, 26%, 3%に認められた. 神経叢浸潤部位は膵頭部癌ではPL.phIIが, 下部胆管癌ではPL.phIが多かった. また, No.14リンパ節転移率はそれぞれ34%, 32%, 16%, No.16転移率はそれぞれ19%, 6%, 0%であった. 再発形式を膵頭部癌肉眼治癒再発確認40例でみると, リンパ節再発, 後腹膜局所再発が88%にみられた. 下部胆管癌治癒再発6例では全例に後腹膜再発がみられ, 膵臓浸潤の強いものが多かった. 以上より, 膵頭部癌では上腸間膜動脈神経叢とNo.14, No.16リンパ節郭清を行うことが重要であり, 膵臓浸潤をみない下部胆管癌や乳頭部癌では上腸間膜動脈神経叢を一部温存したNo.14リンパ節郭清が可能であると考えられた.

各種膵腸吻合法とその合併症ならびに腹腔内持続吸引ドレナージ法 (continuous intraabdominal suction drainage: CISD) の有用性について膵腸吻合143例 (膵頭部癌66例, 胆管癌40例, 乳頭部癌32例, 胆嚢癌5例) を対象に検討した. 膵嵌入 (I) 法が20例, 漿膜筋層切開膵管挿入 (II) 法が22例, 非切開膵管挿入 (III) 法が48例, 膵管空腸吻合 (IV) 法が53例であった. 膵液漏出はI, II, III, IV法でそれぞれ20%, 21%, 0%, 13%, 縫合不全は25%, 14%, 6%, 4%とIII, IV法の成績が良好であった. 膵液漏出は胆道癌で21%, 膵癌で6%, 縫合不全はそれぞれ14%, 5%と有意 (p

1981年1月から1992年12月までの12年間に経験した膵頭部癌切除症例は94例で, うち40例に門脈合併切除 (門脈合併切除率42.6%) が行われた.この門脈合併切除例を臨床病理学的に検索し, 門脈切除の意義について検討した.術中の肉眼的門脈浸潤度と組織学的門脈浸潤度は必ずしも一致せず, 肉眼的に癌浸潤陽性と判定しても, 7例 (17.5%) は組織学的に癌の浸潤が外膜にも及ぼないpv0であった.組織学的門脈浸潤度と他のstage決定因子 (t, n, s, rp, H, P) との間には相関はみられなかった.門脈浸潤度とリンパ管浸潤, 静脈浸潤の間にも相関はなかった.また門脈浸潤度と生存率にも差はみられなかった.したがって膵頭部癌における門脈浸潤 (pv) は独立した因子と考えられた.手術手技および患者管理の向上により, 門脈切除・再建は比較的安全に行えるので, 術中, 門脈浸潤が高度と判定しても, 積極的に合併切除すべきと考える.

Since April 1990, we have been aggressively performing immediate breast reconstruction using the rectus abdominis myocutaneous flap mainly. Patients undergoing breast reconstruction and those without reconstruction in the same period were subjected to a questionnaire survey to investigate the merits and demenrits of this procedure. In the 3-year period after 1990, 184 patients with breast cancer received mastectomy and 126 out of the 184 patients underwent immediate breast reconstruction, the reconstruc-tion rate being 68.5%. Questionnaire from was mailed to 180 patients and the form filled but unsigned was sent back from 144 (80%) patients. Patients who replied that it was nice to receive reconstruction represented 71% of all responders; and 88% of them were almost satisfied with their reconstruction. In particular, patients with reconstruction appreciated the procedure in that they could wear clothes as usual as they did before mastectomy and they could behave without an inferiority complex as a woman in most times. However, there was no significant difference between patient groups with and without reconstruc-tion in social positiveness. And 74% of patients with reconstruction replied that they bothered about surgical wound in the abdomen; that would be a problem in future. It can be concludedthat immediate breast reconstruction is vey helpful to improve the quality of life for breast cancer patients.

Bafilomycin A1, a specific inhibitor of vacuolar type H(+)-ATPase, can inhibit the growth of a variety of cultured cells in a dose-dependent manner, but its mechanism is unclear. The aim of this study was to examine whether bafilomycin A1 inhibits the growth of Capan-1 human pancreatic cancer cells through apoptosis. The effect of bafilomycin A1 on tumour growth in vitro and in vivo was examined using an MTT assay and an in vivo tumour model. The presence or absence of apoptosis was determined by morphology and DNA analysis of tumour cells. The concentration of bafilomycin A1 for 50 per cent inhibition of cell viability during 72 h by the MTT assay was 5 nm. In DNA analysis, a ladder of fragmented DNA was detected in Capan-1 cells treated with bafilomycin A1 at concentrations greater than 10 nm for 24 h. Nude mice bearing a xenografted Capan-1 cell line tumour received 4 weeks of bafilomycin A1 (1.0 mg/kg per day). This treatment significantly inhibited tumour growth compared with controls after 21 days (P < 0.05). Histopathological examination of tumour cells in the treated group demonstrated signs of apoptosis with chromatin condensation and cell shrinkage. These observations suggest that bafilomycin A1 inhibits the growth of Capan-1 human pancreatic cancer cells through apoptosis.

We examined the inhibitory effect of a serine protease inhibitor, FOY-305, on the invasion and metastasis of human pancreatic cancers. The in vitro matrigel invasion assay showed that the invasiveness of Capan-1 human pancreatic cancer cells was inhibited by FOY-305 treatment in a dose-dependent manner at concentrations greater than 100 nM. Intrasplenic injection of Capan-1 cells in nude mice resulted in frequent metastases to liver, however, its incidence was significantly decreased by FOY-305 treatment. These findings suggest that a serine protease inhibitor, FOY-305 can inhibit tumor invasion and metastasis by blocking the serine protease-mediated activation cascade.

Recent studies have shown that bafilomycin A1-sensitive vacuolar-type H(+)-ATPase (V-ATPase) plays important roles in cell growth and differentiation. However, there is no published study that has focused on the expression of V-ATPase in human tumour tissues. This study was designed to examine the mRNA and protein levels for the 16 kilodalton (kDa) proteolipid of V-ATPase in human pancreatic carcinoma tissues. We first investigated the mRNA level for V-ATPase in six cases of invasive pancreatic cancers and two normal pancreases, using reverse transcription-polymerase chain reaction technique. Then, we examined immunohistochemically the level of V-ATPase protein in 49 pancreatic cancers and ten benign cystic neoplasms of the pancreas, using antisera raised against the 16 kDa proteolipid. There was a notable difference in the level of V-ATPase mRNA between normal and pancreatic carcinoma tissues, with no evident difference in the expression of the beta-actin gene. Immunohistochemically, 42 out of 46 invasive ductal cancers (92%) displayed a mild to marked immunoreactivity for V-ATPase in the cytoplasm, whereas neither non-invasive ductal cancers nor benign cystic neoplasms expressed detectable immunoreactive proteins. These findings suggest that the overexpression of V-ATPase protein is characteristic of invasive pancreatic tumours. V-ATPase may play some crucial roles in tumour progression. Images Figure 2 Figure 4 Figure 3