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症例は66歳の男性で，腹痛，嘔吐を主訴に平成18年1月前医を受診し，急性腹症の診断にて入院となった．腹部造影CTにて上腸間膜静脈の血栓および小腸壁の肥厚を認めた．凝固線溶系検査の結果，プロテインS欠乏症が明らかになり，プロテインS欠乏症による上腸間膜静脈血栓症と診断した．抗凝固療法を行い症状は改善したがイレウスを発症したため，当院に転院となった．イレウス管による保存的加療を行うが改善せず，開腹手術を施行した．狭窄部はTreitz靭帯より120 cmの部位1か所のみであったため，狭窄部を中心に10 cmの小腸を切除した．術後経過は良好であり，ワーファリンおよびバイアスピリンによる抗凝固・抗血小板療法を開始し，術後19日目に退院となった．プロテインS欠乏症による上腸間膜静脈血栓症の本邦報告例はこれまで12例しかなくまれである．文献的考察を加え報告する．

症例は56歳の男性で，1999年に腎細胞癌にて左腎部分切除術，2005年に肺転移に対し肺部分切除術を受けている．2006年6月上旬，上腹部痛を主訴に近医に入院した．入院後，急性心筋梗塞を発症し当院に紹介となる．血清アミラーゼの高値（1,883 IU/L）を呈し，腹部造影CT上，膵臓の腫大と網嚢腔および左腎周囲への液体貯留を認め，重症急性膵炎と診断した．ただちに，メシル酸ナファモスタットとイミペネムの動注を行った．症状が改善した後，精査を行ったところ腹部造影CTにて膵頭部に良好に造影される3 cm大の腫瘍を認めた．以上より，腎細胞癌膵転移を疑い，8月下旬，膵頭十二指腸切除術およびnecrosectomyを施行した．病理組織学的検査の結果，膵頭部腫瘍は腎細胞癌膵転移であった．術後2年が経過しているが，現在までのところ再発は認めていない．腎細胞癌の膵転移により重症急性膵炎を呈することは極めてまれである．文献的考察を加え報告する．

症例は生来健康な24歳の男性で, 急性腹症にて当院へ救急搬送となった. 初診時腹部CTにて肝外側より肝下面を中心に腹水貯留を認め, 腹部所見, 血液検査結果などを踏まえ, 同日緊急手術を施行した. 開腹時所見として, 胆汁性腹水の貯留を認め, Hartmann's pouch近傍の胆嚢体部に径約3mmの穿孔部を確認した. その他, 腹腔内臓器に明らかな異常所見は認めず, 胆嚢摘出および腹腔内洗浄ドレナージ術を施行した. 摘出胆嚢には胆石や慢性炎症所見などは認められず, 特発性胆嚢穿孔と考えられた. 病理組織学的に穿孔部近傍の微小血管に血栓を認めた. 術後経過は良好で第10病日に退院となった. 上腹部痛を主訴とし, free airを伴わない腹水貯留を認める急性汎発性腹膜炎症例では, 若年者においても本疾患を念頭におくべきであると考えられた.

The surgical anatomy of the hepatic hilar region is characterized by the three-dimensional formation of the branches of the bile duct, portal vein, and hepatic artery. The limit of ductal resection in hepatectomy for hilar cholangiocarcinoma is the most peripheral point where the hepatic ducts can be separated from the vasculature. The limit is different for each type of hepatectomy because the portal vein branches that should be preserved or divided vary with the extent of the hepatectomy, and therefore the limit of separation of the hepatic ducts differs. Surgeons are required to understand the surgical anatomy and to identify the precise area of cancer spread on a preoperative cholangiogram so as to choose the appropriate type of hepatectomy, and to ensure that the remnant ductal margin is cancer-negative.

We performed lung volume reduction surgery (LVRS) in an experimental model using a simple stapling technique (SST) for pulmonary emphysema. The technique uses a stapler to isolate the affected lung from the remaining lung instead of removing it. We performed the present experiment using dogs to study the effects and safety of LVRS using the SST.Pulmonary emphysema was induced in 12 dogs with papain. They were divided into three groups: those operated on with SST composed the operation (Op) group; those receiving an experimental thoracotomy composed the sham-operation (Sham-op) group; and those not operated on composed the nonoperation (Non-op) group. Respiratory function was compared among the groups before induction of emphysema (baseline), after induction of emphysema (preoperation), and at 8 weeks after the operation (postoperation Op and Sham-op groups only). The lung was removed and histologically examined 8 weeks after the SST operation.In the Op group, alteration in forced expiratory volume (FEV) 0.5%, airway resistance (Raw) and specific airway conductance (sGaw) showed significantly favorable results. Histologically, the isolated area was widely replaced by fibrous tissue with numerous blood vessels in the circumference in the Op group; no signs of infection such as polykaryoleukocytes or microabscesses were observed in any of the samples.The LVRS for pulmonary emphysema using a simple stapling technique improved the expiratory flow and alleviated airway resistance. The isolated remaining lung was well organized without any infectious events or secondary adversity, thus demonstrating the safety of this technique. From these results, this technique is therefore suggested to be effective and applicable to clinical use.

症例は54歳の女性,右側腹部痛を主訴に来院.同部位に圧痛を認め,腹部超音波検査, CT, MRIにて腎静脈合流部上方の下大静脈を圧排する腫瘤を認めた.手術所見では腫瘍は下大静脈の腎静脈合流部前面に固定しており,下大静脈の一部を合併切除し腫瘍を摘出した.病理学的に平滑筋肉腫と診断され,腫瘍細胞の約5%でエストロゲンレセプターが確認された.術後約3年3カ月経過した現在も再発徴候を認めていない.

異所性膵は粘膜下腫瘤の形態をとることが多いが,壁外性に発育することは稀である.今回われわれは壁外性に発育した成人回腸異所性膵の1例を経験したので報告する.症例は59歳,男性.主訴は上腹部痛,嘔吐であった.腹部単純写真にて小腸ガスおよびニポーを認め,イレウスの診断で入院となった.保存的治療で軽快したが,原因検索を目的とした血管造影にて回腸末端枝の偏位を認め,腸捻転あるいは内ヘルニアによるイレウスの可能性が示唆された.試験開腹手術を施行したところ,回腸末端から150cm口側で回腸腸間膜対側に壁外性に突出する約2.5cmの腫瘤を認め,また,腫瘤口側の腸管拡張がみられた.同腫瘤を含む回腸部分切除,端々吻合術を施行した.病理組織所見にて腫瘤は粘膜下層に主座をおき,壁外性に発育した異所性膵 (Heinrich I型)と診断された.術後経過良好で,その後約1年経過し,再発徴候は認められていない.

今回われわれは,早期胃癌に併存した脾門部孤立性悪性リンパ腫の1例を経験したので報告する.症例は69歳女性,健診の胃バリウム検査にて体中部に隆起性病変を指摘され,平成14年12月17日,当院消化器内科紹介受診となった.上部消化管内視鏡検査にて胃体部後壁にO-I型の腫瘍を認め,生検にて高分化型腺癌の診断であった.一方,造影CTにて脾門部に造影効果を認めない約2 cmの腫瘤を認めた.以上より平成15年1月22日,幽門側胃切除術D2,脾門部腫瘤摘出術を施行した.胃は病理組織診断では乳頭腺癌, sm2, n1, stage IB,脾門部腫瘤はnon-Hodgkin, diffuse large, B-cell typeとされた.術後施行したガリウムシンチグラフィーにて異常集積を認めず,脾門部孤立性節性悪性リンパ腫と診断され,内科にて化学療法を施行し現在再発無く経過中である.

症例は8歳,男児.嘔気,上腹部痛を主訴に当院小児科受診した.受診時腹部触診にて右上腹部腫瘤を触知し腹部超音波検査にて胆嚢壁肥厚を認めたため,胆嚢炎疑いで入院.絶食,抗生剤投与にても軽快せず,磁気共鳴式胆道膵管造影(MRCP)施行された.胆嚢の内下方変位,胆嚢管の不明瞭化が観察されたため,胆嚢捻転症に伴う胆嚢壊死の診断で開腹手術施行した.手術所見では胆嚢は頸部を中心に反時計方向に約720度捻転し,壊死を呈していた.術後は合併症なく軽快退院した.小児発症の胆嚢捻転症は非常に稀であり, 10歳以下では本症例を含め22例が報告されているのみである.術前診断は従来困難であるとする報告が多かったが,近年は術前に診断可能例の報告が増加している.本症例でも術前に正診が得られ,腹部US, CTに加え, MRCP,カラードップラーエコーが診断に有用であった.

症例は57歳の男性. 倦怠感を主訴に来院し, 貧血を指摘され入院となった. CT, MRIでは小腸壁が肥厚した腫瘤像を認め, 小腸造影では動脈瘤型の形態を呈し, 血管造影では回腸動脈末梢に淡いtumor stainを認め, 小腸悪性リンパ腫を疑ったが, 経過中に腹膜炎症状を呈したため, 緊急手術に踏み切った. 主腫瘍はトライツ靱帯から約90cmの部位に存在し, 穿破して腹膜炎をきたしており, 口側腸管には多発性の腫瘍性病変を認め, 小腸広範囲切除を施行した. 病理学的には腫瘍は未分化細胞からなり, 免疫染色ではCAM 5.2とVimentinが陽性で, 小腸原発未分化癌, 多発壁内転移と診断した. 術後は経口摂取可能となったが, その後全身状態が悪化し術後55日目に死亡した. 剖検では腹腔内に一塊となった遺残および再発腫瘍と, 左肺, 肝など広範に転移を認めた. 小腸原発の未分化癌はまれなことから, 文献的考察を加えて報告する.

近年, 我が国における結核患者数は増加傾向を示しており, それに伴い腸結核症に遭遇する機会も増加している. 今回, 我々は穿孔を来した腸結核症の1例を経験したので報告する. 症例は54歳の男性で, 腹痛を主訴に当院救急外来を受診した. るいそう著明で, 胸部単純X線にて両側上肺野に侵潤影および一部に空洞形成を認めた. また, 腹部は板状硬であり汎発性腹膜炎と診断し同日, 緊急手術を施行した. 小腸から大腸にかけて合計26か所の多発性輪状潰瘍を認め, うち1か所が穿孔していた.穿孔部腸管の切除を施行し全身管理を行ったが術翌日に突然の心停止を来たし死亡した. 部検の結果, 肺結核症, 腸結核, および粟粒性結核症が確診された.今後, 結核患者にあっては急性腹症の鑑別疾患として腸結核穿孔も念頭に置く必要があるものと考えられた.

症例は62歳の女性. 嘔気, 上腹部痛, 体重減少を主訴に当院受診. エコー, CT, MRI, 内視鏡検査などにて胃幽門側に内部不均一で周囲臓器との境界不明瞭なmassを認め, 進行性の胃原発悪性腫瘍の術前診断にて横行結腸合併切除を伴う幽門側胃切除術を施行した. 術後の病理組織学的検索にて悪性細胞は認められず胃放線菌症と診断された. 術後1週間の抗生剤投与を行ったのみで再発兆候なく術後1年9か月を経た現在, 経過観察中である. 本症は現在では比較的まれな疾患となり術前診断は必ずしも容易ではないが, 腹部腫瘤の鑑別診断の1つに考えることは重要であると考えられた.

下大静脈浸潤を伴う後腹膜平滑筋肉腫の症例を報告する. 54歳女性,右下腹部腫瘤を主訴に来院.右下腹部に可動性のない小児頭大,弾性硬の腫瘤を触知.腹部超音波検査, CT,血管造影にて後腹膜悪性腫瘍の診断を得て手術を施行した.右後腹膜に発生した大きさ約13×11×10cm大,重量1,110gの腫瘍を摘出した.術中,下大静脈浸潤を認めたため腫瘍摘出とともに下大静脈部分切除を施行した.病理診断は下大静脈浸潤を伴う平滑筋肉腫の診断であった. 本症例は,術後21カ月経過した現在も再発の兆候なく経過している. 本疾患の予後を左右するのは,根治的手術の可否である.下大静脈浸潤を伴う後腹膜平滑筋肉腫に対しても下大静脈合併切除による完全摘出を行うことが重要と考えられる.

Primary small cell carcinoma of the hepatobiliary tract is rare. Most cases occur in the gallbladder or in the ampulla of Vater, and such cases in the common bile duct (CBD) are extremely rare. We herein report a case of small cell carcinoma arising in the CBD. In this case, neoadjuvant chemotherapy followed by pylorus-preserving pancreaticoduodenectomy showed an excellent response. To our knowledge, this is the first reported case of small cell carcinoma of the CBD in which a radical resection was performed after successful neoadjuvant chemotherapy.

This report presents two cases of heterotopic gastric mucosa in the gallbladder. In case 1, the patient was a 43-year-old man who presented with diarrhea and fever. Abdominal ultrasonography showed a sessile polypoid lesion in the body of the gallbladder that grew over 2 months. Gallbladder carcinoma was suspected and a cholecystectomy was performed. Examination of an intraoperative frozen specimen of the elevated lesion in the body of the gallbladder suggested a gallbladder carcinoma invading the subserosal layer. A bile duct resection and regional lymph node dissection were performed. However, the postoperative permanent sections revealed heterotopic gastric mucosa in the gallbladder. Case 2 was an 80-year-old man. Screening abdominal ultrasonography revealed a sessile polypoid lesion in the gallbladder. This lesion was correctly diagnosed as heterotopic gastric mucosa in the gallbladder by the intraoperative frozen examination. The pertinent literature on this topic is reviewed.

Large-cell neuroendocrine carcinoma in the thymus is a rare cancer that is more aggressive and leads to a poorer prognosis than other thymic epithelial tumors. A 67-year-old woman presented with an anterior mediastinal mass in the thymus. Histological examination after thymectomy revealed large-cell neuroendocrine carcinoma in the thymus. Although the patient received postoperative chemotherapy and radiotherapy, a distant relapse was detected 6 months after the surgery. We reviewed nine cases of this rare cancer that have been reported in Japan. There is no evidence of to support postoperative therapy for large-cell neuroendocrine carcinoma in the thymus. However, it is essential to accumulate and study these cases to understand this disease and prolong patient survival.

Laparoscopic pancreatic surgery is rapidly evolving due to improving instrumentation and surgical techniques. The challenges confronting laparoscopic pancreaticoduodenectomy (LPD), however, are its technical difficulty and its appropriateness for oncologic treatment. This study sought to develop a novel technique for LPD in an acute porcine model and to evaluate the safety and feasibility of LPD before clinical trials are undertaken. The LPD procedure was performed in 10 pigs. Modified Child’s reconstruction was performed intracorporeally. After the animals were killed, anastomotic sites were investigated by laparotomy. All the animals underwent LPD. The median operation time was 5 h, with minimal blood loss. One choledochojejunostomy had a small leak. The study proved LPD to be technically safe and feasible in an acute porcine model. Further studies and technical advances are necessary for transition of this clinical application of LPD to humans.

To analyze the long-term results of distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body.Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis and is regarded as an unresectable disease. We previously reported the feasibility and safety of DP-CAR in 10 patients and 3 preliminary cases; however, the long-term results are unknown.Between May 1998 and September 2005, 23 patients underwent DP-CAR. No reconstruction of the arterial system was required because of early development of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery. We routinely used preoperative coil embolization of the common hepatic artery to enlarge the collateral pathways.The postoperative mortality rate was 0%, despite a high morbidity rate (48%). The chief postoperative complications were pancreatic fistula and ischemic gastropathy. Contrary to expectations, postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients (91%). The estimated overall 1- and 5-year survival rates were 71% and 42%, respectively, and the median survival was 21.0 months. The sites of recurrence were the liver in 6 patients and local recurrence in 2.DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The persisting early hepatic recurrence may indicate DP-CAR for the treatment of less advanced disease.

Surgical resection has been considered to be the only hope for the cure of biliary carcinoma. The prognosis of biliary carcinoma patients is still poor due to its location and complicated anatomic characteristics. Extensive surgery such as major hepatectomy in hilar cholangiocarcinoma and concomitant vascular resection in pancreatiticoduodenectomy seems to increase radicality and improve long-term results. On the other hand, this operative procedure is highly invasive and may result in postoperative morbidity and mortality. Therefore it is essential to acquire informed consent before such surgery. Preoperative informed consent should be based on an understanding of operative procedure including normal anatomy, other available therapy, expected postoperative complications, and course. There is no doubt that it contributes to establishing a desirable relationship between physicians and patients if opportunities for providing information are as frequent as possible.

Background Malignant pyloroduodenal obstruction by an unresectable cancer makes ingesting food or liquids impossible for patients. The patient’s quality of life deteriorates rapidly, leading to a dismal prognosis. The modified Devine exclusion (MDE) method of open laparotomy has been reported to be effective in such cases. Methods We performed laparoscopic MDE gastrojejunostomy in 8 cases. The patient data collected included surgical time, morbidity and mortality, length of stay, the state and duration of adequate oral ingestion, and outcome. Results The median surgical time was 191 minutes. There were no complications postoperatively. The median postoperative stay was 7 days. In that time, feeding conditions were restored to pre-illness levels. All patients were palliated successfully using this procedure. Conclusions Laparoscopic MDE gastrojejunostomy allows patients to regain their ability to eat, significantly improving their quality of life. This alternative laparoscopic procedure is effective for patients whose prognosis is poor as a result of unresectable cancer.

To determine whether fibril length is correlated with graft healing as well as cellular and capillary ingrowth in a canine carotid implantation model.Expanded polytetrafluoroethylene (ePTFE) vascular grafts with three different fibril lengths (30, 60, and 90 microm) were implanted into the carotid artery in dogs. They were retrieved 4 weeks later, and subjected to histomorphometric analysis.Endothelial healing was best in the 60-microm grafts. Not only cellular ingrowth but also capillary ingrowth was most evident in the 60-microm grafts, followed by the 90-microm grafts and then the 30-microm grafts.Better endothelial healing of ePTFE vascular grafts is correlated with more cellular and capillary ingrowth, but more cellular and capillary ingrowth is not correlated with longer fibril length or higher air porosity.

To evaluate the intermediate performance of small-caliber, long-fibril expanded polytetrafluoroethylene (ePTFE) vascular grafts pretreated with covalent bonding of fibronectin in dogs.Small-caliber (4 mm), long-fibril (60 microm), ePTFE vascular grafts, 10 cm in length, were pretreated by covalent bonding of fibronectin. Bilateral iliac grafting was done in dogs using a fibronectin-bonded graft on one side and a nonbonded control graft on the other side. The grafts were retrieved 12 weeks after implantation, and subjected to histomorphometric analysis.Although the patency rates of the fibronectin-bonded and control grafts were the same (3/7, 43%), the fibronectin-bonded grafts showed almost complete neointimal healing, whereas the nonbonded control grafts showed only partial neointimal healing, proximally and distally.Small-caliber, long-fibril ePTFE vascular grafts with covalent bonding of fibronectin achieved almost complete neointimal healing by the time of retrieval at 12 weeks. This indicates that, with further modifications, our new technique for covalent bonding of fibronectin has great potential in the development of small-caliber arterial prosthetic grafts.

IPMNが多中心性に発生することはすでに遺伝子学的に証明されているが, 現時点では病変それぞれの進展予測を行うことは不可能である.当科における単発IPMNの切除の対象は, Borderline (moderate dysplasia ; 境界病変) の段階で切除することである. 多発例の場合もこの規則にしたがい, 多発した病変の中でBorderline以上と判定できるものを切除の適応とし, それ以下の病変は切除せずに極力経過観察を行うべきであると考える.浸潤癌以外の多発病変では各種縮小手術が適応となりやすいが, 多発例でこれらを組み合わせて行う場合や切除範囲を通常より拡大して行う場合, 病変が遺残しないよう十分に注意すべきである. 膵全摘術ではインスリン注射の管理と術後のQOLが問題となるため適応は限られる.切除に際しては, 術前の詳細な情報と術中超音波検査所見を総合して病変の完全切除を達成すべきであり, 膵管再建においては再発時の精査を考慮して膵胃吻合を選択している.