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はじめに : 近年，画像診断の発達による軽症例や保存的治療施行症例の報告から，門脈ガス血症は必ずしも予後不良ではないといわれてきている．しかし救急医療の現場において，緊急開腹手術を行うか保存的治療を行うかの判断は容易ではない．今回門脈ガス血症の保存的治療の適応を血液生化学検査所見から検討した．方法 : 対象は当院にて経験した門脈ガス血症14例．手術・病理組織学的検査所見や治療経過から保存的治療不可能群（A群8例）と保存的治療可能群（B群6例）の2群に分けた．両群間で血液生化学検査所見を比較検討した．結果 : A群ではCRP値が有意に上昇，またBE値は有意に低下していた．BE -3.0以下またはCRP 15mg/dl以上の症例は全例保存的治療不可能群であった．結語 : 門脈ガス血症においてBE -3.0mmol/l以下またはCRP 15mg/dl以上の場合は腸管全層壊死の可能性があり保存的治療の適応外である．

大腸癌イレウスに消化管穿孔を続発し，急速な経過を辿った大腸未分化癌の1例を報告する．症例は90歳の女性．腹痛と嘔吐を認め近医を受診し，消化管穿孔が疑われ当科紹介となった．腹部CTにて多量の腹腔内遊離ガスと上行結腸に腫瘍性病変を認めた．緊急手術を施行したところ上行結腸に硬い腫瘤を触知し，同部より口側腸管はイレウスを呈していた．またTreitz靱帯から120cmの部位より回腸末端まで血流障害をきたしており，腫瘍より口側5cmの盲腸に径1cmの穿孔を認めた．血流障害をきたした小腸を含む右半結腸切除と洗浄ドレナージを行った．切除標本では上行結腸に4×6cm大，4型の全周性腫瘍を認め，病理所見では異型の強い腫瘍細胞が充実胞巣状に認められ，一部漿膜に露出し脈管侵襲が著明だった．組織学的には，腺管形成や粘液産生を認めず大腸未分化癌の像を示した．術後汎発性腹膜炎，敗血症を併発し多臓器不全にて死亡した．大腸未分化癌は極めて稀であり，文献的考察を加え報告する．

小腸原発肉腫様癌の1例を経験した．症例は74歳の男性で，近医にて貧血を指摘され当院を受診した．小腸造影検査にて下部小腸に陰影欠損，腹部CTにて小腸間膜内のリンパ節腫大を認め，小腸原発悪性腫瘍の診断で手術を行った．回盲弁より70cm口側の回腸に約4cm大の腫瘍性病変を認め，また同部を栄養する上腸間膜動脈周囲に腫大したリンパ節を伴っており，これらを一括して切除した．病理組織学的および免疫組織化学的検索にて腫瘍細胞はAE1/AE3，CAM5.2やEMAなどの上皮性マーカーに加え間葉系マーカーであるvimentinが陽性で，CEA，c-kit，CD34は陰性であり，小腸原発の肉腫様癌と診断した．術後は肝転移の急速な増悪を認め，術後40日目に死亡した．小腸原発の肉腫様癌は自験例を含めて22例の報告があるのみとまれであり，文献的検討を加えて報告する．

Keratinocyte growth factor (KGF) is involved in the development and regeneration of a variety of tissues. To clarify the role of KGF in cartilage wound healing, we examined the expression of KGF and its receptor (KGFR) immunohistochemically in the wound healing area of rat tracheal cartilage, and the direct effect of recombinant KGF on the proliferation and differentiation of primary cultures of rat chondrocytes. KGF was found in the cytoplasm of both chondrocytes and perichondrial cells. On the other hand, KGFR was detected only in the plasma membrane of chondrocytes. Although the expression of KGF was similar in the cartilage and perichondrial area before and after injury, KGFR expression was induced after injury and limited to proliferating chondrocytes. The staining pattern of KGF and KGFR was same in the mature and the immature rat tracheal cartilage. Moreover, in vitro experiments using primary cultured chondrocytes revealed that KGF at 200 ng/ml significantly increased the number of chondrocytes (~1.5-fold), and significantly reduced acid mucopolysaccharide production. These results indicate that KGF stimulates chondrocyte proliferation, suggesting that KGF could therapeutically modulate the wound healing process in the tracheal cartilage., Acta Histochemica et Cytochemica, 43(3), pp.89-98; 2010

Fournier壊疽は会陰部や陰嚢周囲に発症する壊疽性筋膜炎であり，死亡率が比較的に高く早期の診断と適切な治療を必要とする疾患である．今回，当科で経験したFournier壊疽3例について報告する．年齢は各々55歳，40歳，55歳で，全症例男性だった．基礎疾患として症例1で直腸癌，症例3で関節リウマチがあった．全症例とも病変部にCTにてガス像を認めた．検査所見では著明な白血球，CRPの上昇を認めた．起炎菌は多種多様であった．治療は全ての症例でドレナージおよび抗菌薬投与を行った．症例1，3は創部の安静のために人工肛門造設術を行った．全症例で救命可能であった．

1999年7月から2007年12月までに当院において施行した腹腔鏡下虫垂切除術267例について，2004年6月までの117例（前期群）と，2004年7月以降の150例（後期群）の2群にわけ，両群間で創感染および腹腔内膿瘍の発生率，術後在院日数を比較検討した．なお前期群ではドレーン留置に関しては主治医の判断に任せていたが，後期群では汚染の程度に関わらずドレーン留置を一切行わなかった．両群とも腹腔鏡手術は3ポートで施行し虫垂間膜は超音波凝固切開装置，虫垂根部は自動縫合器にて切離した．炎症が強い場合は生食にて十分に洗浄を行った．前期群では57例（48.7％）にペンローズドレーンが留置された．創感染は前期群7.7％に対し後期群1.3％と有意に発生率の減少を認めた．腹腔内膿瘍は前期群4.3％に対し後期群2.0％と両群間に差は認められなかった．今回のわれわれの検討では腹腔鏡下虫垂切除術においては炎症の程度に関わらずドレーンを留置する必要はないという結果を得た．

先天性胆道拡張症術後5年目に左肝管空腸吻合部の狭窄を来し肝左葉切除を行った症例を経験したので報告する．症例は16歳の女性で，11歳時に先天性胆道拡張症にて総胆管嚢腫切除術が行われた．その際，左肝管が拡張した嚢腫と交通していたため左右肝管空腸吻合術となった．術後4年頃より吻合部狭窄による化膿性胆管炎を繰り返すようになり今回手術となった．術前画像検査では左肝内胆管の拡張を認めるものの肝内結石は認めなかった．手術所見では左肝管はほぼ完全閉塞していた．組織学的には肝門部胆管は不規則に拡張・狭窄し，壁は強い線維化を伴って肥厚していた．術後の経過は良好で胆管炎の再発など認められない．

胃穿孔に対する治療法はいまだ一定のコンセンサスが得られていない. 今回当院にて経験した91例の胃穿孔症例から治療法の選択について検討を行った. 過去27年間に経験した非外傷性胃穿孔は91例であり79例が胃潰瘍穿孔, 12例が胃癌穿孔であった. 胃潰瘍穿孔79例中腹腔鏡下手術を10例に行い, 1例が開腹手術へ移行した. 保存療法は14例に行われ, 3例が経過中手術治療へ変更された. 胃癌穿孔12例において, 穿孔部閉鎖術または保存療法を行った6例中3例で2期的胃切除が行われた. 腹腔鏡下手術導入前の前期胃切除群と導入以後の後期胃温存群で比較すると, 死亡率は前期群17.9%, 後期群2.4%と後期では予後の改善が認められた. 胃穿孔においては潰瘍穿孔, 癌穿孔に関わらず初期治療として胃切除を行う必然性はない.

Objectives We evaluate the efficacy and safety of the modified intrapleural cisplatin treatment for lung cancer patients with positive pleural lavage cytology or malignant effusion. Methods The treatment was performed for seven patients with malignant effusion and 18 patents with positive pleural lavage cytology. After pulmonary resection, the pleural cavity was filled with cisplatin with a normal saline solution for 30 min. Complications and survival of the patients were evaluated. Results The chest tube duration were significantly prolonged in the treatment (CDDP) group (5.7 ± 3.6 vs. 2.8 ± 2.6 days). We had one operative death that developed a bronchial fistula; however, the other complications were not severe. The mortality rate was 4% and the morbidity rate was 60%. We experienced two carcinomatous pleuritis in the CDDP group. The median survival time of the CDDP group was 47.0 ± 11.1 months and the 3- and 5-year survival rate was 52.6% and 11.3%, respectively. Conclusions We were able to perform this treatment for these advanced lung cancer patients, which had the preventive effect of carcinomatous pleuritis. This therapy shows the possibility of a treatment that might lead to an improvement in the prognosis of these patients, without causing severe complications. J. Surg. Oncol. 2006;93: 323–329. © 2006 Wiley-Liss, Inc.

We conducted this study in order to determine how we should perform the surgical treatment for clinical stage I non-small cell lung cancer (NSCLC) in octogenarians. Thirty-three octogenarians with clinical stage I NSCLC participated in this study. They were retrospectively divided into two groups: one group of 11 patients who underwent a lymph node dissection (ND group), and one group of 22 patients who did not undergo this procedure (ND0 group). We analyzed the surgical invasiveness, morbidity, mortality, and survival in both groups. The morbidity rate in the ND group (45%) was higher than that in the ND0 group (23%); however, the difference was no statistically significant (P = 0.1805). There was no significant difference in the overall survival rates of the two groups (P = 0.1647), and the median survival time of the ND0 group (76 months) was slightly longer than that of the ND group (26 months). There was no significant difference in local recurrence rate between the two groups (9.1% vs 4.5%, P = 0.6059). We thus conclude that a limited operation without lymph node dissection might be the best surgical treatment for carefully selected octogenarians with clinical stage I NSCLC.

Keratinocyte growth factor (KGF)/fibroblast growth factor-7 (FGF-7), a mesenchymal cell-derived paracrine growth factor that specifically stimulates epithelial cell proliferation, has been implicated in the repair of lung tissue. The present study was designed to determine the expression and role of KGF and its receptor (KGFR) in human lung cancer tissues, particularly in relation to cancer cell kinetics and prognosis. Thirty-one adenocarcinomas and 30 squamous cell carcinomas, and ten normal lung tissues as a control, were examined. The expression of KGF and KGFR proteins was examined using rabbit polyclonal anti-human KGF and anti-human KGFR antisera raised in the authors' laboratories against synthetic peptides corresponding to parts of human KGF KGFR, respectively. Their specificity was confirmed in lung tumour tissues by western blotting various controls. Proliferative activity was assessed by determining the labelling index (LI) for Ki-67 antigen. Immunohistochemistry revealed that tissue co-expression of KGF KGFR correlated significantly with higher differentiation grades in squamous cell carcinoma. Conversely, in adenocarcinoma, co-expression correlated with lower differentiation grades high Ki-67 LI, was significantly associated with lymph node metastasis shorter 5-year survival. Therefore, the results indicate that co-expression of KGF KGFR correlates significantly with poor prognosis in adenocarcinoma, but not in squamous cell carcinoma, of the lung. Copyright © 2004 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

A 56-year-old man was performed a total gastrectomy with regional lymph node dissection for type 4 gastric cancer. On 60th postoperative day, massive hematemesis developed and a splenic artery pseudoaneurysm was found by angiography. We thought that the adventitia of arterial wall was damaged by an agressive dissection of lymph nodes, and postoperative infection around the drainage tube accelerated the formation of pseudoaneurysm. It seemed that the pseudoaneurysm penetrated the jejunal wall and hematemesis ap-peared.An emergency angiography was performed when the 2nd hematemesis appeared, and the bleeding was successfully stopped by transcatheter arterial embolization. On periodic observation by CT, almost no aneurysm has been revealed.When a sudden hematemesis appears during postoperative observation of cancer of the upper digestive tract, we consider the possible presence of pseudoaneurysm.

肺結核に対する人工気胸術後の慢性膿胸壁から発生した悪性リンパ腫の1例を経験した.症例は79歳男性, 腫瘍の大きさは8×5cmで第8から第10肋骨間に存在した.膿胸に対する剥皮術に加え, 第8, 9, 10の肋骨切除と腫瘍摘除術を行った.術後2年再発を認めていない.慢性膿胸に合併した悪性リンパ腫は切除可能例が少なく予後不良とされるが, 早期発見による完全切除により良好な予後が期待できる.

A 45-year-old female presented at our hospital with a one-day history of upper abdominal pain. Abdominal computed tomography (CT) revealed that the root of the celiac artery was obstructed and that a large hematoma was present in the retroperitoneum. The patient was diagnosed with retroperitoneal hemorrhage associated with the rupture of an inferior pancreaticoduodenal artery aneurysm, which was caused by increased blood flow in the pancreaticoduodenal arterial arcade. Because the patient's general condition was stable, she was managed conservatively and discharged on achieving remission after a month. Follow-up CT revealed spontaneous resolution of the celiac artery obstruction and aneurysm. The celiac artery obstruction in this case was assumed to be caused by segmental arterial mediolysis.

Nontuberculous mycobacterium infection is rarely accompanied by pleural involvement. We describe a very rare occurrence of Mycobacterium (M) avium pleuritis with pleural effusion in a non-compromised 73-year-old woman patient who had been treated for sick sinus syndrome. She was admitted to our hospital with general malaise and left pleural effusion. To establish a definitive diagnosis, a biopsy specimen was obtained from the left parietal pleura by video-assisted thoracoscopic surgery. The pleural biopsy specimen revealed only diffuse lymphoid cell infiltration and neoplastic or granulomatous lesions were absent. Culture of the pleural biopsy specimen revealed M. avium, indicating that the pleuritis was caused by this organism. A course of anti-tubercular agents (rifampin, ethambutol and streptomycin sulfate) and clarithromycin gradually resolved the pleural effusion., Internal Medicine, 47(19), pp.1727-1731; 2008

Objective: Since 1980, we have performed plasmapheresis before thymectomy for patients with generalized symptoms in order to protect against myasthenic crisis and to improve patient outcomes after thymectomy. The aim of this study was to evaluate an immediate and a long-term results of plasmapheresis before thymectomy for myasthenia gravis, retrospectively. Methods: Between January 1980 and December 1997, 51 patients with Osserman class IIA or IIB symptoms were treated with transsternal thymectomy. Nineteen patients (group 1) were treated with plasmapheresis before thymectomy and 32 patients (group 2) were treated with thymectomy alone. Results: In group 1, the time of plasmapheresis prior to thymectomy was 3.2±1.5. Nine (28.1%) patients in group 2 had crisis within 1 year after thymectomy as compared with only one (5.3%) patient in group 1 had crisis (p=0.049). There was no evidence of crisis within 30 days after thymectomy in group 1 and 5 (15.6%) patients in group 2 (p=0.0724). there was no postoperative death among patients in group 1. Responses to thymectomy in group 1 improved significantly, the improvement and pharmacologic remission rate had increased up to 100% and 79% at 5–7 years after operation, while the improvement and pharmacologic remission rate of group 2 had increased to 81.3% (p=0.0466 vs. group 1) and 50.0% at that time (p=0.0427 vs. group 1). Conclusions: The present study demonstrated that preoperative plasmapheresis may facilitate improved outcomes of patients with myasthenia gravis after thymectomy.

We report a case of traumatic hemopneumothorax caused by penetrating lung injury in a 26-year-old man. The patient underwent emergency thoractomy, which revealed hemorrhage in the lingular segment of the left lung. We found the bleeding point and controlled the hemorrhage using pulmonary tractotomy by inserting a linear stapler into the stab wound in the pulmonary parenchyma. The original technique of pulmonary tractotomy was performed for complete through-and-through injury by dividing the bridge of lung tissue between the aortic clamps. We were able to apply this procedure safely to stop bleeding from a stab wound that did not go through the lung. Thus, pulmonary tractotomy is an effective damage-control operation for the lung with obvious advantages over major lung resection.

There is no consensus as to the best treatment for Mallory-Weiss tears with severe bleeding. Endoscopic ligation is an inexpensive, readily available, and easily learned technique, in contrast to conventional thermocoagulation or hemoclipping. To evaluate the utility of endoscopic ligation, we performed this technique during emergency endoscopy to treat severe bleeding from Mallory-Weiss tears in four patients in our hospital with continuous active bleeding from Mallory-Weiss tears. The patients were all male with an average age of 40.5 years. Symptoms associated with increased intra-abdominal pressure, including retching and vomiting were reported by all patients. The bleeding points were aspirated and controlled by endoscopic ligation, and complete hemostasis was achieved in all cases. We conclude that endoscopic ligation is easy to perform and may provide an alternative treatment for severe bleeding from Mallory-Weiss tears.

OBJECTIVE: In rats pulmonary resection is followed by lung compensatory growth. However, the molecular mechanism underlying lung compensatory growth remains unclear. Keratinocyte growth factor is expressed in lung tissue and is considered a possible mitogen for lung epithelial cells. The objectives of this study were to define the role of keratinocyte growth factor and its receptor in rat lung compensatory growth after trilobectomy and the effect of exogenous keratinocyte growth factor gene transfection. METHODS: Adult Lewis rats were used. Right trilobectomy was performed in the operation group and sham thoracotomy in the sham group. In the operation group, keratinocyte growth factor-FLAG or FLAG expression vector was transfected directly into the lung by means of electroporation. Expression of keratinocyte growth factor and its receptor and alveolar cell proliferation index based on proliferating cell nuclear antigen levels were measured in the right lung at day 14 after the operation. RESULTS: Proliferating cell nuclear antigen, keratinocyte growth factor, and keratinocyte growth factor receptor expression in lung epithelial cells was significantly increased at day 4 after trilobectomy. Transfection of keratinocyte growth factor-FLAG expression vector resulted in further significant enhancement of proliferating cell nuclear antigen at day 4 after trilobectomy; however, the transfection of FLAG expression vector did not alter the enhancement of proliferating cell nuclear antigen. Exogenous expression of keratinocyte growth factor in the remaining lung by means of electroporation significantly augmented epithelial proliferation and decreased the average airspace distance (mean linear intercept). CONCLUSION: Our results implicate keratinocyte growth factor in the induction of alveolar epithelial cell proliferation for compensatory lung growth and indicate that overexpression of keratinocyte growth factor in the remaining lung by means of electroporation significantly augmented lung epithelial proliferation., The Journal of thoracic and cardiovascular surgery, 137(6), pp.1499-1507; 2009