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In lung tumors, the p53 tumor suppressor gene is commonly mutated with a characteristic mutation spectrum. The amount of and alterations in plasma DNA, such as mutations in p53, were associated with several cancers. Few studies used quantitative methods of high sensitivity. Previously, we observed p53 mutations in the noncancerous tissue that differed from those in lung tumors using the highly sensitive p53 mutation load assay. Based on our observation of an increased p53 mutation load in nontumorous lung tissue in smokers, we hypothesized that plasma DNA may contain mutant p53 indicative of tobacco smoke exposure and will be an effective biomarker of lung cancer or smoking exposure. We modified the p53 mutation load assay to detect mutations at p53 codons 248 and 249, common mutations in lung cancer, in plasma DNA samples with a sensitivity of 1:5,000. The assay was applied to a set of lung cancer cases (n = 39), hospital controls (n = 21), and population controls (n = 20) from a larger study. Controls were selected to consist of equal numbers of both ever and never smokers. The p53 mutation load (mutated p53 copies per total number of p53 copies) was associated with smoking (P = 0.06), but not with lung cancer (P = 0.59). Most of the individuals with p53 mutations observed in plasma DNA were ever smokers and the p53 mutation load was higher in those who smoked for longer durations (P = 0.04). In summary, we were able to detect p53 mutations in plasma DNA from healthy individuals and our data suggest that p53 mutations in plasma DNA may be a marker of carcinogen exposure from tobacco smoke. (Cancer Res 2006; 66(16): 8309-17)

Supplementary Figure Legends from Quantitative Detection of p53 Mutations in Plasma DNA from Tobacco Smokers

Supplementary Figures 1-3 from Quantitative Detection of p53 Mutations in Plasma DNA from Tobacco Smokers

Supplementary Table 1 from Quantitative Detection of p53 Mutations in Plasma DNA from Tobacco Smokers

BackgroundRecently, transnasal endoscopy has become common in Japan. While transnasal endoscopy has many advantages, nasal pain and epistaxis are typical complaints. Consequently, we developed a new tube sheath system for transnasal endoscopy to reduce nasal pain and epistaxis. This new tube sheath system (outer sheath and inner tube) has been named Nasal Slider® and is produced by TOP Corporation, Japan.MethodsA tube sheath longer than the nasal concha is inserted to reduce pain along the nasal turbinate. Since the sheath is left in place, tubes can be passed through the nose multiple times without causing additional pain.A total of 34 consecutive patients (mean age 68.1 years, 22 males and 12 females) who had experienced transnasal endoscopy in the past, would undergo transnasal endoscopy with Nasal Slider® again. After the transnasal endoscopy was completed, patients who gave consent for use of the nasal slider® were interviewed using 3 questionnaires about nasal discomfort, nasal pain and epistaxis.ResultsSince the transnasal endoscope passes inside the sheath, epistaxis can be prevented. Thirty patients for whom trans nasal endoscopy using Nasal Slider® could be carried out. Twenty-seven and 28 patients of all patients used Nasal Slider® expressed feeling less nasal discomfort and pain compared to an examination without Nasal Slider®. No epistaxis was detected in all patients using Nasal Slider®.ConclusionsTo reduce nasal pain and epistaxis, Nasal Slider® for transnasal endoscopy was considerably available. It is currently in use at many hospitals in Japan.

The diverse treatments available for portal hypertension require specialized knowledge of hemodynamics and include endoscopic treatments, interventional radiology (IVR), and surgery. The Japan Society for Portal Hypertension has developed the skill qualification system (SQS) for portal hypertension and began examination in 2014. Here, the status and validity of the judgment of the SQS examination were evaluated.From 2014 to 2020, 79 applicants were evaluated by the SQS for portal hypertension. Each unedited video submitted as a candidate procedure was evaluated by two judges, and a grade of greater than 70% for the scoring items assessed by the judges was required to pass the examination. Inter-rater agreement of success/failure between the two judges was investigated by the ACThe results of two judges differed for 11 of the 79 videos (13.9%), and five applicants (6.3%) ultimately failed the examination. The percentages of total points received by the applicants with endoscopic treatments, IVR, and surgery were 87.3%, 79.4%, and 80.8%, respectively. There were significant differences in the percentages between endoscopic treatments and IVR (The SQS for portal hypertension of the Japan Society for Portal Hypertension showed high reliability for video assessments by the judges. This system may contribute to the spread and further development of safe and effective treatments for portal hypertension in Japan.

Various complications, such as esophagogastric varices, ectopic varices, ascites, and hepatic encephalopathy, can occur in portal hypertension. Bleeding from esophagogastric or ectopic varices is the most critical complication of portal hypertension. In 1980, general rules for recording endoscopic findings of esophageal varices were initially proposed in Japan. Revised rules were proposed as “General Rules for Recording Endoscopic Findings of Esophagogastric Varices (1991)” and “General Rules for Recording Endoscopic Findings of Esophagogastric Varices (2010).” The revised rules are simpler and more straightforward than the former rules. In 2013, “General Rules for Study of Portal Hypertension” was proposed by the Japan Society for Portal Hypertension. These rules have widely been used in Japan and other countries.

BackgroundLentinan (LNT) is a purified β-1, 3-glucan that augments immune responses. The present study was conducted to assess the efficacy of LNT in combination with S-1 as a first-line treatment for unresectable or recurrent gastric cancer.Patients and methodsEligible patients were randomly assigned to receive S-1 alone or S-1 plus LNT. The primary end-point was overall survival (OS). Secondary end-points were time-to-treatment failure (TTF), overall response rate (ORR), safety, quality of life (QOL), and biomarker. The percentages of LNT-binding monocytes in peripheral blood prior to treatment were analysed for the biomarker assessment.ResultsOne hundred and fifty-four and 155 patients were randomly assigned to receive S-1 alone or S-1 plus LNT, respectively. The median OS was 13.8 and 9.9 months (P = 0.208), the median TTF was 4.3 and 2.6 months (P

Reaction rate and enantioselectivity of asymmetric hydrogenation of methyl acetoacetate were studied over Raney nickel catalysts modified with (R,R)-tartaric acid, malic acid, or succinic acid to r...

Aim: The Clinical Research Committee of the Japan Society for Portal Hypertension has conducted a nationwide questionnaire survey to clarify the current status of ectopic varices in Japan. Methods: A total of 173 cases of ectopic varices were collected. Results: Duodenal varices were found in 57 cases, and most of them were located in the descending to transverse parts. There were 11 cases of small intestinal varices and 6 cases of colonic varices, whereas 77 patients had rectal varices, accounting for the greatest proportion (44.5%). Other sites of varices were the biliary tract, anastomotic sites, the stoma, and the diaphragm. Liver cirrhosis was the most frequent diseases (80.3%) underlying ectopic varices. It was noted that patients with rectal varices frequently had a history of esophageal varices (94.8%) and received endoscopic treatment (87.0%). The treatments for ectopic varices were as an emergency in 46.5%, elective in 35.4% and prophylactic in 18.2%. In emergency cases, endoscopic therapy was most frequent (67.4%), followed by interventional radiology (IVR; 15.2%), and endoscopy-IVR combination (6.5%). Elective treatment was performed by endoscopy in 34.3%, IVR in 28.6%, combined endoscopy-IVR in 5.7%, and surgical operation in 25.7%. The prophylactic treatment was endoscopic in 50.0%, IVR in 33.3%, combined treatments in 11.1%, and prophylactic surgery in none. The change of ectopic varices after treatment was disappearance in 54.9%, remnant in 35.4% and recurrence in 9.7%. The rate of disappearance was significantly lower in rectal varices (40.8%) than in duodenal varices (73.4%). The patient outcome did not differ among the various sites of the lesion. Conslusions: Current status of ectopic varices in Japan has been clarified by a nationwide questionnaire survey. The authors expect that the pathophysiology of ectopic varices will be further elucidated, and that improved diagnostic modalities and treatment methods are established in the future.

Background: The aim of this study was to evaluate the effect of vagotomy on body weight changes after gastric banding. Methods: Rats were divided into a sham-operated group (n = 10), a vagotomy alone group (n = 10), a gastric banding alone group (n = 10) and a gastric banding + vagotomy group (n = 10). All groups were given a liquid diet for 5 days after surgery and then given free access to chow. Their body weight was measured through postoperative day (POD) 14, and caloric intake and nitrogen balance were measured until POD 7. Results: The increase in body weight in the banding + vagotomy group between POD 0 and POD 14 was not significant (12.5 ± 16.8 g; p = 0.48), and it was less than in the banding alone group (52.8 ± 3.8 g; p = 0.031). Cumulative caloric intake from POD 5 to POD 7 was less in the banding + vagotomy group than in the banding alone group (158.6 ± 26.3 vs. 223.9 ± 8.3 kcal; p = 0.030). Daily nitrogen balance from POD 5 to POD 7 in the banding + vagotomy group was less than in the banding group (337 ± 77 vs. 540 ± 42 mg; p = 0.033). Conclusions: Vagotomy suppressed body weight gain in the rat model of gastric banding.

症例は69歳の男性で，主訴は右下腹部腫瘤．約2年前に，Kugel法による右鼠径ヘルニア手術を他院で受けていた．小児期の鼠径ヘルニア手術，急性虫垂炎手術の既往があった．CT，注腸検査で右側結腸憩室炎による膿瘍形成を疑い，手術を行った．回盲部が腹壁に強固に癒着しており，剥離するとメッシュが盲腸に癒着，穿通し一塊となり腫瘤を形成していた．メッシュを取り除き，回盲部切除術を行った．病理組織では膿瘍内に放線菌の菌塊を認めた．術後は麻痺性イレウス，surgical site infectionを起こしたが保存的に軽快した．過去に報告のない，Kugel法による鼠径ヘルニア手術後にメッシュが盲腸に穿通した症例を経験した．

腹腔内癌術後の腹腔内デスモイド腫瘍の診断は，癌再発との鑑別が困難である．症例は70歳の男性で，上行結腸癌（SE，N0，H0，M0，P0：Stage II）に対して腹腔鏡補助下結腸右半切除術を施行した．術後1年6か月目の画像検査で十二指腸腹側に径3 cmの腫瘤を認め，CT，MRIではリンパ節再発を疑う所見であったが，positron emission tomography（以下，PET）-CTではSUVの最大値は早期相1.95から後期相2.05と軽度上昇にとどまり，癌再発は否定的であった．手術は十二指腸壁と上腸間膜静脈壁の一部を合併切除する腫瘍摘出術を行った．病理組織学的検査では結腸腸間膜原発デスモイド腫瘍と診断され，PET-CTでの術前診断が癌再発との鑑別に有用であると判断された．家族性大腸腺腫症を伴わない腹腔内手術後の腹腔内デスモイド腫瘍発生はこれまで20例が報告されているが，本症例のごとく腹腔鏡手術後発生の報告はない．

General rules for recording endoscopic findings of esophageal varices were initially proposed in 1980 and revised in 1991. These rules have widely been used in Japan and other countries. Recently, portal hypertensive gastropathy has been recognized as a distinct histological and functional entity. Endoscopic ultrasonography can clearly depict vascular structures around the esophageal wall in patients with portal hypertension. Owing to progress in medicine, we have updated and slightly modified the former rules. The revised rules are simpler and more straightforward than the former rules and include newly recognized findings of portal hypertensive gastropathy and a new classification for endoscopic ultrasonographic findings.

Primary squamous cell carcinoma (SCC) of the colorectum is a rare malignancy of unknown etiology and pathogenesis. We report a case of primary SCC of the rectum. A 55-year-old man with a rectal tumor and human immunodeficiency virus (HIV) infection was referred to our hospital. Histopathology of biopsy specimens showed characteristics of SCC. We diagnosed the patient as having primary moderately differentiated SCC of the rectum according to the criteria proposed by Cooper. Human papillomavirus (HPV) DNA was amplified by polymerase chain reaction analysis of unfixed tumor biopsy specimens. In addition, no p53 overexpression or nuclear staining of retinoblastoma protein (Rb) was observed in neoplastic cells by immunohistochemical staining. We suggest from our case that HPV infection following the inactivation of the cellular tumor suppressor Rb and the immune suppression induced by HIV infection play an etiologic role in the pathogenesis of rectal SCC, consistent with the well-established concept of HPV-associated anal carcinogenesis.

We report a rare case of granulocyte-colony stimulating factor (G-CSF)-producing undifferentiated carcinoma of the ascending colon. A 52-year-old Japanese man presented with a rapidly growing, aggressive abdominal tumor, and severe leukocytosis (63 000/mm(3)). The serum level of G-CSF was remarkably elevated to 640 pg/ml (normal,18.1 pg/ml). The patient underwent palliative cytoreductive surgery for ascending colon carcinoma with lymph node and liver metastases. Histological examination revealed an undifferentiated carcinoma of the ascending colon. The tumor cells were positive for G-CSF on immunohistochemical staining. The leukocyte counts and G-CSF level decreased after surgery. Thus, we diagnosed G-CSF-producing colon carcinoma. His general condition deteriorated rapidly and he died of residual tumor growth on postoperative day 24.

A number of surgical procedures have been developed to manage esophageal varices. Broadly, these can be classified as shunting and non-shunting procedures. While total shunt effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. The distal splenorenal shunt (DSRS), a selective shunt, was developed by Warren in 1967 to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. The DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection (SPD, i.e. skeletonization of the splenic vein from the pancreas to its bifurcation at the splenic hilum) and gastric transection (GT, i.e. transection and anastomosis of the upper stomach with an autosuture instrument). An alternative to shunting was developed by Sugiura and Futagawa in 1973. Esophageal transection (ET) divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. DSRS was more effective than ET in preventing recurrence of esophageal varices, but was associated with a higher incidence of hyperammonemia. The incidence of hyperammonemia in patients who underwent DSRS with SPD plus GT was significantly lower than that in patients who underwent DSRS alone or those who underwent DSRS with SPD. In conclusion, there are various surgical treatments for esophagogastric varices. Distal splenorenal shunt with SPD plus GT is considered an adequate treatment for patients with esophagogastric varices.

The majority of cancer cells harbor homoplasmic somatic mutations in the mitochondrial genome. We show here that mutations in mitochondrial DNA (mtDNA) are responsible for anticancer drug tolerance. We constructed several trans-mitochondrial hybrids (cybrids) with mtDNA derived from human pancreas cancer cell lines CFPAC-1 and CAPAN-2 as well as from healthy individuals. These cybrids contained the different mitochondrial genomes with the common nuclear background. We compared the mutant and wild-type cybrids for resistance against an apoptosis-inducing reagent and anticancer drugs by exposing the cybrids to staurosporine, 5-fluorouracil, and cisplatin in vitro, and found that all mutant cybrids were more resistant to the apoptosis-inducing and anticancer drugs than wild-type cybrids. Next, we transplanted mutant and wild-type cybrids into nude mice to generate tumors. Tumors derived from mutant cybrids were more resistant than those from wild-type cybrids in suppressing tumor growth and inducing massive apoptosis when 5-fluorouracil and cisplatin were administered. To confirm the tolerance of mutant cybrids to anticancer drugs, we transplanted a mixture of mutant and wild-type cybrids at a 1:1 ratio into nude mice and examined the effect by the drugs on the drift of the ratio of mutant and wild-type mtDNA. The mutant mtDNA showed better survival, indicating that mutant cybrids were more resistant to the anticancer drugs. Thus, we propose that mutations in the mitochondrial genome are potential targets for prognosis in the administration of anticancer drugs to cancer patients.

Prevention of blood glucose elevation and insulin resistance could be more pronounced in patients undergoing laparoscopic rather than open gastrectomy.Fifty-seven patients underwent distal gastrectomy by either laparoscopy (n = 36) or an open approach (n = 21). Blood glucose, serum insulin, and the daily insulin secretion rate (urinary C-peptide) were measured. Insulin resistance was evaluated using an adapted homeostasis model assessment of insulin resistance (HOMA-R).Blood glucose levels were lower in the laparoscopy group than in the open group on the operative day and on postoperative days (POD) 1 and 3 (P.001, P = .001, and P = .024, respectively). Serum insulin levels were lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .045 and P = .027, respectively). HOMA-R was lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .024 and P = .009, respectively). Daily insulin secretion rates were lower in the laparoscopy group than in the open group on POD 1 (P = .023).Laparoscopic surgery prevents blood glucose elevation and improves insulin resistance compared with open surgery.

Background: We compared two types of stents in patients who underwent surgery for hepatic hilar malignancies. Methods: Twenty-one patients with hepatic hilar malignancies who underwent hepatectomy were randomly assigned to one of two groups. A 5-Fr silicon drain with an internal lumen and side holes was used for the hepaticojejunostomy in one group (intraluminal stent group), and a 10-Fr silicon drain with channels along the sides was used in the other (channel stent group). Results: Leakage developed in four patients (36.4%) in the intraluminal stent group versus two (20.0%) in the channel stent group. Cholangitis developed in three patients with leakage (27.3%) in the intraluminal stent group versus no patient in the channel stent group. After operation, the times required for the serum alkaline phosphatase and total bilirubin levels to return to the normal range were significantly shorter in the channel stent group (5.3 ± 2.9, 3.8 ± 2.2 days) than in the intraluminal stent group (17.0 ± 5.8, 9.4 ± 5.7 days) (P

Simple hepatic cysts are common benign lesions that are usually asymptomatic and require no treatment. However, complications can occur. This report describes a patient with an infected hepatic cyst treated with percutaneous transhepatic drainage. A 64-year-old woman presented at a nearby hospital because of acute right-upper-quadrant pain, mild left-lower-quadrant pain, diarrhea, and fever. She was admitted and received intravenous antibiotics for 1 week, but symptoms persisted. She was, therefore, referred to our hospital. On admission, ultrasonography demonstrated multiple hepatic cysts. One 13-cm lesion was hypoechoic, unlike the other simple cysts, which were anechoic. Computed tomography showed that the density of the hypoechoic cyst was slightly higher than that of the other cysts. The wall of the cyst was thickened and showed contrast enhancement. On initial laboratory tests the serum C-reactive protein concentration was 18.49 mg/dL, and the white-cell count was 13,300/microL. An infected hepatic cyst was suspected, and percutaneous transhepatic drainage of the cyst was performed. A catheter was inserted into the cyst, and dark red fluid was obtained. The right-upper-quadrant pain gradually resolved after drainage. An infected hepatic cyst was diagnosed, and system antibiotics were administered. However, the mild left-lower-quadrant pain persisted. No pathogens were isolated from the drainage fluid. Minocycline hydrochloride (200 mg) was injected, and the catheter was clamped for 30 minutes, once daily for 3 days. The serum C-reactive protein concentration was 1.78 mg/dL, and the white-cell count was 5,700/microL. The left-lower-quadrant pain resolved, and colonoscopic examination revealed multiple diverticula of the sigmoid colon. Infection has not recurred, and the hepatic cyst has not become larger.

目的:再発鼠径ヘルニア症例に対する腹腔鏡下経腹的腹膜前メッシュ修復法（transabdominal preperitoneal mesh repair:TAPP）とopen mesh repair（OMR）の短期的な成績と有用性を検討した．対象と方法:1996年から2007年までの鼠径ヘルニア手術694例中再発は27例（4％）であり，その内メッシュを用いた修復は21例であった．TAPP（10例，61±4歳）とOMR（11例，62±2歳）を比較検討した．成績:手術時間は，TAPP 96±12分，OMR 108±11分と差はなかったが，術中出血量ではTAPP2±1mlに対しOMR 14±5mlと有意に高値であった．術後入院期間も，TAPP5±1日に対しOMR8±1日と有意に長かった．TAPPでは術後合併症を認めなかったが，OMRでは3例に皮下出血，1例に著しい疼痛を認めた．結論:再発鼠径ヘルニアにおけるTAPPはOMRより術後早期の愁訴が少なく早期に社会復帰可能な治療法として有用である．

Twenty years have passed since the first case of living donor liver transplantation (LDLT) in Japan. The recipients of LDLT have rapidly changed from children to adults through the use of right lobe grafts. The number of LDLTs in Japan has increased since January 2004 because of indication for LDLT changed widely in an insurance application. (UNCLEAR) A total of 4,292 LDLTs have been performed as of December 31, 2006, and 2,621 (61.1%) of these have been adult-to-adult LDLTs. Patients who have hepatocellular disease or hepatocellular carcinoma or both account for more than 50% of all recipients in Japan. The overall 3-, 5- and 10-year survival rates were 73.8%, 70.4%, and 66.3%, respectively. There were no significant differences in survival rates between LDLT in Japan and cadaveric transplantation in America or Europe. The survival rates will improve to clarify the timing and indications for LDLT and the optimal operative procedures. However, because of the number of patients requiring transplant will increase, it is important that cadaveric donor liver transplant is promoted in addition to LDLT in Japan.

We report a case of giant mucinous cystic neoplasm (MCN) of the pancreas that was successfully treated with laparoscopic surgery. A 29-year-old woman was admitted to our hospital for evaluation of an abdominal tumor that had been detected during a routine medical examination. The tumor was diagnosed as an MCN of the pancreas. We performed laparoscopic distal pancreatectomy and splenectomy. The patient could begin oral feeding 3 days after the operation. No complications occurred either during or after surgery. The outcome in this patient was excellent, with cosmetically acceptable small scars in the skin. Therefore, laparoscopic distal pancreatectomy may become a therapeutic option for patients with large MCNs of the pancreas.

We herein report on the successful surgical treatment of Crohn's disease with enteroliths formed in the ileum. A 58-year-old man presented with abdominal colicky pain, and long-standing constipation. He was diagnosed as ileus due to enteroliths and was initially managed conservatively, but improvement was not observed either clinically or on radio imaging. We, therefore, performed a laparotomy, which revealed Crohn's disease with enteroliths in the ileum. Because the enteroliths in the ileum were not mobile and could not be broken manually, we carried out a segmental bowel resection with the removal of the enteroliths. The pathology report revealed Crohn's disease with enteroliths. Intestinal obstruction caused by enteroliths associated with Crohn's disease occurs rarely, and is difficult to be diagnosed and managed.

Torsion of the gallbladder is a rare condition that most commonly affects the elderly. This condition is rarely diagnosed preoperatively despite advances in diagnostic imaging. We report a case of torsion of the gall bladder diagnosed preoperatively. An 81-year-old woman presented with right upper quadrant pain. Initial laboratory tests revealed elevation of the white blood cell count to 15,900/μL(normal, 4,000 to 8,000/μL) and mild liver dysfunction. Ultrasonography and computed tomography revealed swelling of the gall bladder with increased wall thickness, but neither examination showed any gallstones. Percutaneous transhepatic gall bladder drainage was performed, and bloody bile juice was obtained. Cholangiography via the drainage catheter of the gall bladder and endoscopic retrograde cholangiography revealed smooth tapering of the neck of the gall bladder. We diagnosed acute torsion of gallbladder and brought the patient to the operating theatre for laparoscopic cholecystectomy. Intraoperatively, we observed that the gallbladder had undergone complete torsion and appeared gangrenous. Routine cholecystectomy was then performed, and the patient recovered without incident.

症例は83歳，女性．腹部膨満感を主訴に来院．既往に55年前子宮外妊娠による手術歴があった．腹部膨満を認め左下腹部に腫瘤を触知した．腹部CTにてS状結腸に腸管壁の肥厚像を認めた．また左下腹部に5cm大の石灰化を伴う内部不均一な円形の腫瘤像を認めた．腹部MRIでは同部は造影効果が乏しくT1にて骨格筋とほぼ等信号，T2にて軽度高信号を示す腫瘤像であった．下部消化管内視鏡ではS状結腸に全周性の腫瘍による狭窄を認め，生検にて高分化型腺癌と診断された．以上よりS状結腸癌，腹腔内腫瘤の診断にてS状結腸切除，小腸部分切除および腫瘤摘出術を行った．腹腔内腫瘤は硬い被膜に覆われており内部にガーゼを認めた．組織学的にも細胞成分に乏しい硬化性被膜でありガーゼによる異物肉芽腫症と診断された．本症例は遺留より55年を経てガーゼによる異物肉芽腫症と診断された．診断まで50年以上を経た症例は文献的にも4例であり希少な症例と考えられた．

症例は63歳，男性．発熱と肛門痛を主訴に来院．直腸（Rb）に進行癌を認め，潰瘍底の穿通による骨盤内膿瘍を合併していた．fecal diversion目的で回腸人工肛門を造設し，炎症所見が改善した後，術前化学照射線療法（chemoradiation therapy:以下CRT）を行った（5-FU 500mg+CDDP 10mg/day，1-5days，照射線量は計40Gy）．有害事象および感染病巣の再燃はなかった．CRT終了から6週目に内括約筋切除を伴う肛門温存直腸切除術を施行した．病理所見はpA，pN1，M0，stageIIIa．腫瘍組織内に多くの壊死組織巣を認め，組織学的効果判定はGradeIbであった．術後1年を経過し再発の徴候は無い．穿通合併直腸癌は局所再発の危険性が高いので術前CRTの意義は大きい．CRTを行う上で，骨盤内の感染をコントロールしておく必要があり，回腸人工肛門造設が有効であった．

Few studies have compared laparoscopic distal pancreatectomy (Lap-DP) and open distal pancreatectomy (open-DP). The aim of this study was to evaluate the clinical outcome of Lap-DP and compare it to that of open-DP.A total of 37 patients who underwent distal pancreatectomy (Lap-DP, 21 patients; open-DP, 16 patients) between January 2000 and March 2007 were enrolled in this study. Prior to January 2004, open-DP was the standard procedure for patients with a lesion in the distal pancreas without invasive ductal cancer; thereafter, Lap-DP was also an approved procedure. All 16 open-DP procedures were performed prior to January 2004.The operating times for the Lap-DP and open-DP patients were 308.4 +/- 124.6 and 281.5 +/- 83.3 min, respectively, and these were not significantly different (P = 0.4635). Blood loss for the Lap-DP group (249.0 +/- 239.8 ml) was significantly smaller than that for the open-DP group (714.1 +/- 650.4 ml) (P = 0.0055), and none of the patients in the Lap-DP group received transfusions. The frequency of complications for the Lap-DP and open-DP groups was 0 and 18.8%, respectively, which is not significantly different (P = 0.0784). The average hospital stay for the Lap-DP group was significantly shorter than that for the open-DP group (10.0 +/- 2.6 vs. 25.8 +/- 8.8 days; P0.0001).In pancreatic diseases, other than invasive ductal cancer, arising in the distal pancreas, Lap-DP might be a more feasible and safer than open-DP.

A diverticulum in the lower third of the esophagus is rare. A 62-year-old woman presented with symptoms of dysphagia and regurgitation associated with recurrent aspiration. Endoscopic examination disclosed a large epiphrenic diverticulum, for which esophagoscopy-guided thoracoscopic surgery was performed. The postoperative course was uneventful. It is proposed that this method could be a possible alternative to the standard classical thoracotomy approach for a large epiphrenic diverticulum of the esophagus.

Background Our institute started laparoscopic simulator training for medical students in 2006. During the training, we observed considerable interindividual differences in laparoscopic skills among those students. This study aimed to investigate the predictive factors that affect laparoscopic skill by assessing the students' training results data. Methods Forty-three, fifth-year medical students were asked several questions and were divided into 2 groups depending on their answers. The participants performed an object-positioning module on a ProMIS simulator (Haptica, Inc., Dublin, Ireland). Execution time, instrument path length, and economy of movement for each trial were recorded on ProMIS. Comparisons of mean performance measures between the 2 groups were made using a Mann-Whitney U test. Results Interest about laparoscopic surgery and accomplishment in playing piano did not affect the skillfulness significantly. The students who had an interest in television (TV) games completed the task in less time (p = 0.046) and had a shorter left instrument path length (p = 0.012). The students who thought themselves manually dexterous completed the task in less time (p = 0.008). The students who were confident about driving completed the task in less time (p = 0.0247). Discussion In our interview, the factors that had a relationship to laparoscopic skills were favorableness to TV games, manual dexterity, and confidence about driving. These results were expected because TV games and driving a car require the same abilities as laparoscopic surgery. Psychomotor, perceptual, or visuospatial ability are essential for good performance. In conclusion, our study suggests that the interview can be an effective measure to examine the aptitude of medical students without the use of a simulator.

A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas.

The purpose of this study was to evaluate the safety and value of laparoscopy-assisted distal gastrectomy (LADG) for early stage gastric cancer (stages IA, IB, and II).We retrospectively assessed 101 cases treated by LADG and compared to 49 contemporaneous cases treated by open distal gastrectomy (DG) between 2001 and 2006. Clinical variables, such as tumor diameter, operation time, blood loss, number of lymph nodes dissected, and length of stay were investigated.Tumor size (mm) was significantly smaller in the LADG group (p0.0001). Although operation time (min) in the two groups was similar (278 +/- 57 vs. 268 +/- 55), mean blood loss was significantly higher in the DG group (139 +/- 181 vs. 460 +/- 301, p0.0001). Fewer lymph nodes were harvested in the LADG group (27 +/- 14 vs. 34 +/- 19, p = 0.012). Hospital stay was longer in the DG group (13.3 +/- 8.5 vs. 16.7 +/- 10.5, p = 0.034). There was no mortality in either group. Postoperative surgical complications occurred in six (6%) of the LADG and four (8%) of the DG.The authors conclude that laparoscopy-assisted distal gastrectomy is a safe and useful operation for early-stage gastric cancers. If patients are selected properly, laparoscopy-assisted distal gastrectomy can be a curative and minimally invasive treatment for gastric cancer.

Tumour samples from 71 patients with stomach cancer, 41 patients with liver metastasis (group A) and 15 patients each in stages II–IV (group B) and stage I (group C) without liver metastasis were analysed. MAGE-A protein expression was evaluated by immunohistochemistry using a 6C1 monoclonal antibody and MAGE-A10 mRNA expression was detected by highly sensitive in situ hybridisation using a cRNA probe. Expressions of MAGE-A protein and MAGE-A10 mRNA in group A were detected in 65.9 and 80.5%, respectively. Both protein and gene showed significantly higher expression in group A than those in groups B (6.7, 26.7%) and C (0, 0%) (P=0.0003, P=

Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.

We describe an effective technique for the low-pressure continuous suction of bile and pancreatic juice from the hepatic duct and jejunal limb after major hepatectomy with pancreatoduodenectomy (PD). After hepatectomy and PD, reconstruction is performed by a modification of Child's method. A pancreaticojejunostomy is completed with interrupted sutures between the pancreatic duct and mucosa, without inserting a stent. During hepaticojejunostomy, a 10-F silicone drain with side channels (Blake Silicone Drain; Ethicon, Somerville, NJ, USA) is placed within the hepatic duct via the stump of the jejunal limb to drain bile and pancreatic juice. The drain is connected to a continuous suction device and low suction pressure is started. We found that the low-pressure continuous suction of bile and pancreatic juice from the hepatic duct and jejunal limb was very effective after major hepatectomy with PD.

A 53-year-old male presenting with anorexia, intermittent diplopia, general fatigue, headache and vertigo was admitted to our hospital. He was diagnosed as having gastric cancer by endoscopy of his upper gastrointestinal tract. Brain computed tomography (CT) showed no abnormalities, but magnetic resonance imaging (MRI) showed slight enhancement in the cerebellar sulcus. Cytological examination of cerebrospinal fluid revealed malignant cells. He became blind one week after hospitalization. We diagnosed his condition as meningeal carcinomatosis (MC) and started radiotherapy. His vision improved after four weeks of treatment, and then he became totally blind again. Since his general condition remained poor, we did not perform chemotherapy. He died on the 127th day of hospitalization. MC is a rare pathosis of gastric cancer in comparison with leukemia and malignant lymphoma. This disease does not often show characteristic pictorial images, and early diagnosis is difficult. Moreover, it usually manifests itself in its late stages after several months or more of treatment, and it is rare for MC to be present at the time of initial diagnosis. We present a case of gastric cancer with meningeal signs present when the primary tumors were diagnosed. Radiotherapy alleviated some of the symptoms, and the patient survived for as long as patients undergoing enforced chemotherapy.

Biliary cystadenocarcinomas are rare cystic tumors arising from the biliary epithelium. Symptoms vary and are sometimes absent. Most lesions are found incidentally during diagnostic radiologic procedures or surgical exploration for unrelated conditions. We describe an 80-year-old man with anemia due to intracystic bleeding. A computed tomographic scan showed a low-density hepatic lesion with thick, irregular walls and septa. Left lobectomy with cholecystectomy was performed. Histological examination revealed that the surgical specimen was a biliary cystadenocarcinoma. The concentrations of both carcinoembryonic antigen and CA19-9 were high in the cyst contents. The patient died of pneumonia 1 year 4 months after the operation, without the recurrence of cystadenocarcinoma.

Our institution introduced laparoscopic surgery for esophageal achalasia in 2001. The present report summarizes 15 cases of achalasia treated with laparoscopic Heller myotomy and anterior fundoplication according to the method of Dor, and we have investigated the therapeutic effects on specific symptoms such as dysphagia, reflux, and chest pain. From February 2001 through January 2007, the laparoscopic Heller-Dor operation was performed in 15 patients, including 7 men and 8 women. Achalasia was classified morphologically on esophagography as spindle type in 11 cases, flask type in 3 cases and sigmoid type in 1 case. The degree of esophageal dilatation was classified as grade I in 8 cases, grade II in 6 cases, and grade III in 1 case. Dysphagia was the main symptom and was present in all cases. The mean disease duration was 4.3 years (range, 5 months to 20 years), and the mean weight loss was 4.2 kg. All patients underwent endoscopic dilatation preoperatively. Intraoperative blood loss ranged from 0 to 100 mL (mean, 21 mL). Adequate Heller myotomy was considered more than 6 cm and more than 3 cm in the esophagus and the stomach, respectively. Injury to the esophageal mucosa occurred during the myotomy in 3 cases but could be repaired in all cases during the laparoscopic procedure. All patients reported an excellent level of satisfaction postoperatively. In conclusion, the laparoscopic Heller-Dor operation for esophageal achalasia is a useful procedure because the postoperative satisfaction level of patients is excellent. Despite the risk of mucosal injury, adequate Heller myotomy should be achieved to obtain a good prognosis. It is, therefore, of utmost importance to obtain mastery over the surgical technique to repair any mucosal injury that might occur.

A 41-year-old man was referred to our hospital for treatment of a large pancreatic pseudocyst. On admission an abdominal computed tomography scan showed an 8-cm pseudocyst in the tail of the pancreas. On the 28th hospital day hypotension suddenly developed, and the patient became unconscious. An enhanced computed tomography scan showed hemorrhage in the pseudocyst. Celiac angiography confirmed bleeding from the splenic artery to the cyst. Transcatheter arterial emobilization was performed. We inserted a catheter in the splenic artery, which was then packed with metallic coils. The hemorrhage of the pseudocyst was stopped, but the pseudocyst did not decrease in size during the next 6 weeks. Therefore, we considered the presence of a communication between the cysts and the main pancreatic duct. A pancreatic duct stent was then placed via the papilla of Vater, and the pancreatic pseudocyst was eliminated.

A 70-year-old man was admitted to our hospital for evaluation of multiple pancreatic tumors. Twelve years earlier he had undergone left radical nephrectomy for renal cell carcinoma (RCC). Computed tomography revealed two well-defined mass lesions in the head and tail of the pancreas, with strong contrast enhancement in the arterial phase. Fluorine-18 fluorodeoxyglucose positron emission tomography detected an elevated uptake within the lesions but no extrapancreatic uptake. The preoperative diagnosis was isolated multifocal metastatic pancreatic tumors from RCC. The patient underwent total pancreatectomy with splenectomy. Both of the tumors were well-demarcated, gray-white, and firm on gross observation. Microscopic examination, meanwhile, revealed solid tumors consisting of clear oval cells with severe nuclear atypia. These pathologic findings were consistent with the preoperative diagnosis of pancreatic metastasis from RCC. Radical resection improves the long-term survival of patients, and total pancreatectomy may be an appropriate procedure.

Bile duct invasion is rare in patients with hepatocellular carcinoma (HCC). We show the usefulness of selective transcatheter hepatic arterial embolization (TAE) followed by microwave coagulation therapy (MCT) in a case of HCC with portal and biliary tumor thrombi that ruptured into the biliary system. A 70-year-old man with HCC was admitted because of melena and postprandial abdominal pain. Four years earlier, he had undergone posterior segmentectomy of the liver for HCC. Portal venous thrombus was detected on computed tomography (CT) 3 months earlier. On admission laboratory tests revealed the following values: serum alkaline phosphatase, 760 IU/L; total serum bilirubin, 11.9 mg/dL; direct bilirubin, 9.8 mg/dL; serum hemoglobin, 7.7 g/dL; alpha-fetoprotein 103.9 ng/mL; and PIVKA-2, 52,655 mAU/mL. Serum examinations were positive for anti-hepatitis C virus antibody but negative for hepatitis B surface antigens. Ultrasonography revealed a hypoechoic mass in the right branch of the bile duct at the hepatic hilum. Doppler ultrasonography showed blood flow in the mass. CT showed diffuse tumor involvement throughout the liver parenchyma and the presence of a high-density substance in the right intrahepatic bile duct. The diagnosis was hemobilia secondary to HCC in the right hepatic lobe. The symptoms recurred, and emergency TAE was performed 5 days after the onset of hemobilia. The symptoms subsided, and liver function improved. Endoscopic retrograde cholangiography revealed obstruction of the right intrahepatic bile duct. Surgery was performed 15 days after TAE, and MCT of the right hepatic hilum was performed. After MCT, CT revealed necrosis of the right hepatic hilum. Seven months after TAE, the patient died of liver failure with no recurrence of hemobilia.