Search

Aortogastric fistula is a rare and lethal complication after esophagectomy. We report a case of an aortogastric fistula due to a peptic ulcer after esophagectomy for esophageal carcinoma, in which treatment with surgery and endovascular stent graft repair was successful. A 67-year-old woman underwent esophagectomy for esophageal carcinoma and reconstruction with a gastric tube through the posterior mediastinal route. Eleven years later, she experienced massive hematemesis and severe shock due to an aortogastric fistula, although there was no evidence of cancer recurrence. The fistula was obliterated surgically and the perforated aorta was directly closed. However, a pseudoaneurysm located at the closure site on the aortic wall developed postoperatively. An endovascular thoracic aortic stent graft was placed successfully, and she was discharged after intensive care. Thus, we present the very rare case of an aortogastric fistula formed following esophagectomy that was successfully treated with surgery and endovascular stent graft repair.

術後の乳糜腹水に対してソマトスタチンアナログ（オクトレオチド）を使用し有効であった3例について報告する．症例1は61歳女性で悪性リンパ腫の疑いで腹腔鏡下傍大動脈リンパ節生検を施行した．術後第6病日よりドレーン排液が乳白色となり，排液の中性脂肪（以下TG）値は3,295mg/dlであった．乳糜漏の診断で，オクトレオチド300μg/日を開始したところ，2日後には排液量も減少し，TG値は218mg/dlまで改善した．症例2は83歳女性で食道胃接合部の穿孔による腹膜炎で緊急手術を行った．術後第6病日から乳糜腹水が出現し，TG値は399mg/dlであった．オクトレオチド200μ/日を開始したところ，TG値は72mg/dlまで改善した．症例3は53歳男性で膵頭部癌に対して全胃幽門輪温存膵頭十二指腸切除術を行った．術後第6病日に乳糜漏を認め，排液のTG値は399mg/dlでオクトレオチド開始後には72mg/dlに改善した．術後乳糜漏に対する早期のオクトレオチド使用は有効であると考えられた．

症例は64歳，女性．皮膚掻痒感，全身倦怠感を主訴に当院初診となった．T. Bil 15.1と高度の黄疸があり，腹部CT検査で肝内胆管の拡張と肝S4に8cm大の嚢胞を認めた．ERCP，PTCD造影では左右肝管から総胆管にかけてなだらかな圧排，狭窄像があり，血清CA19-9は20,600U/mlと著明な上昇を示したが，画像所見から良性の単純性肝嚢胞と診断した。嚢胞を穿刺しドレナージ後に，塩酸ミノサイクリンの注入療法を行ったところ，嚢胞は縮小し，黄疸も改善した．特に合併症や副作用はなく退院し，現在外来で経過観察中である．良性非寄生虫性巨大肝嚢胞が原因で閉塞性黄疸を呈することは極めて稀であり，今回われわれは，巨大肝嚢胞による閉塞性黄疸に対して，塩酸ミノサイクリンを注入し良好な結果を得た1例を経験したので報告する．

症例は51歳，女性．2006年の検診で脾臓に6cmの大腫瘤を指摘され，当院内科へ紹介となった．腹部CT検査で脾腫と内部に不均一な造影効果不良領域を認めたが，PET/CT検査ではFDGの集積増加は軽度のみで積極的に悪性を疑う所見ではなかった．その後，外来で経過観察とし，画像検査所見上大きな変化は認められなかったが，完全には悪性を否定できず，脾臓摘出術膵尾部合併切除術を施行した．腫瘍の大部分は血管腫の所見であったが，その一部に重層化傾向を示すやや小型の内皮細胞や不規則な配列を示す内皮細胞の増生が見られ，中間悪性である血管内皮腫と診断した．術後経過は良好で術後第10病日に退院し，現在外来経過観察中で術後8カ月の時点で再発の所見を認めない．原発性脾腫瘍は稀であり，なかでも血管内皮腫は本邦で2例の報告があるのみで，文献的考察を加えて報告する．

症例は42歳，男性．検診で肝機能障害を指摘され，当院を紹介受診し，腹部CT検査と腹部超音波検査で肝内側区域に腫瘤性病変を認め，精査加療目的で入院とした．腹部MRI検査で左肝内胆管の閉塞と右前後区域の分岐部にも胆管壁の不整像があり，腹部血管造影検査では左門脈枝の完全閉塞と門脈本管の左右分岐部付近での狭窄を認めた．以上より切除不能胆管癌と診断し，減黄後にGemcitabine 400mg/body/week投与と放射線照射（50.4Gy）を施行した．3カ月後の腹部MRI検査で腫瘤は縮小し，6カ月後には腫瘤を指摘できなかった．その後，治療開始から9カ月目に溶血性尿毒症症候群（以下HUS）を発症し，血漿交換などを施行したが2カ月後に死亡した．切除不能胆管癌は予後不良であり，今回われわれは化学放射線が奏効した後にGemcitabineによると思われる溶血性尿毒症症候群をきたした1例を経験したので，文献的考察を加えて報告する．

症例1は54歳，女性．下腹部痛を主訴に当院を受診した．急性虫垂炎および腹腔内膿瘍と診断し緊急手術とした．虫垂は骨盤内正中寄りに存在し，上行結腸は正中から左上腹部へ向かい，腸回転異常症を合併しており，虫垂切除術を施行した．症例2は24歳，男性．右上腹部痛を主訴に当院を受診した．腹部造影CT検査と小腸造影検査で腸回転異常症を併存した急性虫垂炎と診断し，腹腔鏡下虫垂切除術を施行した．腸回転異常症は，新生児期等に消化管閉塞で発症し，手術されることが多く，成人発症の報告は少ない．そのほとんどは他の疾患の開腹時に偶然発見され，術前に診断されることは少ない．腸回転異常症に急性虫垂炎を併存した場合，虫垂の位置異常があるために虫垂炎の診断に難渋し，さらに下腹部正中切開や術中に切開創を拡大するなど侵襲が大きくなる症例が多い．今回われわれは腸回転異常症を併存した急性虫垂炎を2例経験したので文献的考察を加えて報告する．

症例は75歳の男性. 平成17年4月排便時出血を主訴に当院を受診した. 大腸内視鏡検査で下部直腸にIIa型病変を認め, 6月9日内視鏡的粘膜切除術を施行した. 病理組織学的所見より中分化腺癌, SM (800μm), ly1, v0と診断されたため, 6月30日低位前方切除術を施行した. 病期はSM, N0 (0/8), H0, M0, P0, Stage Iであった. 退院後, 8月17日に突然の発熱, 意識障害で来院. 腹部CT検査では, 前回CTで血栓性動脈瘤と診断された下部尿管, 左内腸骨動脈近傍の腫瘤の増大を認めた. 腫瘤部より上流の尿管は著明に拡張しており, 尿管閉塞, 急性腎盂腎炎と診断した. 尿管をドレナージ後, 腫瘤精査のためFDG-PET検査, CTガイド下穿刺生検を施行した. 病理組織学的に直腸癌の閉鎖リンパ節転移と診断, その他に病変を認めず, 孤立性転移と考えられた. 化学放射線療法により腫瘍の増大はみられなかったが, 多発肺転移再発による呼吸不全のため平成18年6月16日に原病死した. 直腸SM癌が孤立性に主リンパ節へ転移をきたした例は極めて稀であった.

症例は61歳の男性.就寝中に突然の腹痛を自覚した.近医での腹部単純X線検査でイレウスと診断され,精査加療目的に当院紹介入院となった.開腹手術,外傷の既往はなし.腹部CT検査では小腸全体の著明な拡張像を認めた.イレウス管の挿入により症状は軽快したが,排液の減少はなく,イレウスは解除されなかった.イレウス管造影でも原因不明であり,腫瘍を含めた閉塞性病変の存在を疑い,発症後13日目に手術を施行した.開腹所見では, S状結腸間膜左葉の2cm大漿膜欠損孔に回腸末端部から約30cm口側回腸が嵌頓しており, S状結腸間膜内ヘルニアと診断した.嵌頓を解除し欠損孔を閉鎖,循環障害は軽度であったことより腸切除を施行せず,手術を終了した. S状結腸間膜内ヘルニアの本邦報告例は,本例を含めて27例であり,中でも左葉欠損例は8例のみと極めて稀であった.

症例は33歳の女性.平成15年10月17日妊娠経過中に突然の右上腹部痛を自覚し,近医を受診した.腹部超音波検査で肝内胆管の拡張を指摘され,精査のため当院紹介入院となった.当院での腹部超音波検査で総胆管,肝内胆管の嚢胞状拡張と左肝内胆管内に約45mm大,境界明瞭な充実性腫瘤を認めた.さらにその他の諸検査より先天性胆道拡張症に合併した左肝門部胆管癌を疑い,出産後の平成16年2月4日肝左葉切除,肝外胆管切除術を施行した.切除検体では,拡張した左肝内胆管内に突出する弾性軟,割面は黄白色充実性の腫瘍を認め,病理組織学的所見より胆管原発小細胞癌と診断した.術後1年で腹部CT上肝断端に再発を指摘,現在,化学療法により経過観察中である.胆管原発小細胞癌は稀な疾患であり,これまでに自験例を含めて13例の報告があるが,肝内発生例は自験例のみであった.根治切除が得られても予後不良例が多く,術後に積極的な補助療法を考慮すべきであると考えられた.

食道憩室の多くは無症状であり,外科的治療の適応となることが少ない.検診にて発見され,経過中に増大傾向を示した巨大横隔膜上憩室に対し手術を施行した1例を経験したので文献的考察を加えて報告する.症例は45歳,女性.検診の上部消化管造影にて横隔膜上憩室を指摘されたが自覚症状を認めないため経過観察されていた.以後,憩室の増大傾向を認めたために当院受診となった.食道造影で胸部下部食道左側壁に7.5cm大の嚢状憩室を認め造影剤の排出は不良であった.上部消化管内視鏡検査では下部食道左壁に憩室開口部を認め,憩室の内腔に食物残渣が貯留していた.以上より横隔膜上憩室と診断した.増大傾向と憩室内容の排出不良を認める圧出性憩室であるため手術を施行した.圧出性憩室の発生機序を考慮し経腹的に憩室切除術,食道胃接合部中心に5cmの粘膜外筋層切除術,胃底部縫着術を施行し良好な経過を得た.

A 62-year-old male patient underwent endoscopic mucosal resection (EMR). Additional hybrid 2-port hand-assisted laparoscopic surgery (HALS) (Mukai's operation) was performed for early rectal cancer located at the distal border of the rectum/below the peritoneal reflection (Rb) region [SM massive invasion/ly+/vertical margin (VM)X] via a small transverse incision, approximately 55 mm long, at the superior border of the pubic bone. After the pelvic floor muscles were dissected by laparoscopy-assisted manipulation, transanal subtotal intersphincteric resection (ISR) was performed under direct vision, securing a margin of more than 15 mm distal to the EMR scar. Partial external sphincteric resection (ESR) was also performed to obtain an adequate VM at the posterior region of the EMR scar. After bowel reconstruction, the layers were sutured transanally and a temporary covering colostomy was created. The resected specimen contained no residual tumor cells without lymph node metastasis. At 3 months after the operation, digital examination revealed good tonus of the anal muscles without stricture. The patient is currently undergoing rehabilitation of his anal sphincter muscles in preparation for the colostomy closure. In conclusion, subtotal ISR combined with partial ESR may decrease the need to perform Miles' operation for T1/2 stage I rectal cancer located at the distal border of the Rb region.

The 5-year relapse-free survival rate (5Y-RFS) and the 5-year overall survival rate (5Y-OS) were calculated for 972 patients (stage I, 206 patients; stage II, 396 patients; stage III, 370 patients). We divided the stage III group into 259 patients with IIIa/N1 disease (≤3 positive nodes) and 111 patients with IIIb/N2 disease (≥4 positive nodes) according to the Japanese classification. The IIIa/N1 and IIIb/N2 categories were each subdivided into T1/2 (stage IIIa, 45 cases; IIIb, 9 cases) and ≥T3 (stage IIIa, 214 cases; IIIb, 102 cases) according to the TNM classification, and 5Y-RFS and 5Y-OS were compared between each subcategory and each group. The 5Y-RFS/5Y-OS values calculated for each stage were as follows: stage I, 94.0/90.7%; stage II, 80.5/81.1%; stage III, 63.5/65.7%. When stage IIIa was compared with IIIb, we obtained 67.9/72.0% for stage IIIa and 53.6% (p=0.001)/50.4% (p

Lymph nodes from patients with colorectal cancer were immunohistochemically stained for cytokeratin in order to investigate the relationship between the presence of occult neoplastic cells (ONCs) and recurrence/metastasis. A total of 78 patients with stage II/Dukes' B colorectal cancer were divided into two groups. The first group consisted of 18 patients who had developed recurrence/metastasis (recurrence group) and the other one of 60 patients who had survived without recurrence (non-recurrence group). The presence of ONCs was compared between the two groups with respect to i) single cells (≥3 floating ONCs), ii) clusters of cells (≥1 floating aggregates of 2-20 ONCs), and iii) single cells + clusters. When single cells were detected, the sensitivity for recurrence was 55.6% (10/18), the positive predictive value (PPV) was 30.3% (10/33), the specificity was 61.7% (37/60, p=0.195), and the negative predictive value (NPV) was 82.2%(37/45). For the clusters, the sensitivity was 55.6% (10/18), PPV was 37% (10/27), specificity was 71.7% (43/60, p=0.033), and NPV was 84.3% (43/51). With single cells + clusters, the values were 55.6% (10/18), 43.5% (10/23), 78.3% (47/60, p=0.006), and 85.5% (47/55), respectively. These results suggest that the detection of single cells + clusters has a high specificity and NPV, and indicates a low risk of recurrence/metastasis in patients with stage II colorectal cancer.

Lymph nodes from patients with colorectal cancer were immunohistochemically stained for cytokeratin in order to investigate the relationship between the presence of occult neoplastic cells (ONCs) and recurrence/metastasis. A total of 78 patients with stage II/Dukes' B colorectal cancer were divided into two groups. The first group consisted of 18 patients who had developed recurrence/metastasis (recurrence group) and the other one of 60 patients who had survived without recurrence (non-recurrence group). The presence of ONCs was compared between the two groups with respect to i) single cells (≥3 floating ONCs), ii) clusters of cells (≥1 floating aggregates of 2-20 ONCs), and iii) single cells + clusters. When single cells were detected, the sensitivity for recurrence was 55.6% (10/18), the positive predictive value (PPV) was 30.3% (10/33), the specificity was 61.7% (37/60, p=0.195), and the negative predictive value (NPV) was 82.2%(37/45). For the clusters, the sensitivity was 55.6% (10/18), PPV was 37% (10/27), specificity was 71.7% (43/60, p=0.033), and NPV was 84.3% (43/51). With single cells + clusters, the values were 55.6% (10/18), 43.5% (10/23), 78.3% (47/60, p=0.006), and 85.5% (47/55), respectively. These results suggest that the detection of single cells + clusters has a high specificity and NPV, and indicates a low risk of recurrence/metastasis in patients with stage II colorectal cancer.

During the initial emergency operation, a temporary loop colostomy (TLC) was constructed at the oral border of the region for subsequent radical resection. Then, radical surgery was performed by hybrid 2-port HALS (Mukai's operation) using the TLC as the hand access site. Left hemicolectomy was done in three patients, sigmoidectomy in two cases, low anterior resection in one case, and Hartmann's operation in one case. Radical surgery was not done in one patient with multiple distant metastases. The mean operating time was 3 h and 7 min (ranging from 1 h and 55 min to 3 h and 47 min), the mean blood loss was 146.4 ml (7-354 ml), the mean duration from TLC to HALS was 11.3 days (8-16 days), and the mean hospital stay after HALS was 13.9 days (9-20 days). Mild wound infection occurred postoperatively in 2/7 patients and ileus occurred in one patient. However, there was no anastomotic leakage/stricture or conversion to conventional laparotomy. These results suggest that 2-stage treatment (Mukai's method with Mukai's operation) is also applicable to large obstructing left colon or rectal cancers. This method is safe, less invasive, and achieves excellent results, including a good cosmetic outcome.

In this study, a total of 108 patients with primary colorectal cancer who underwent hybrid 2-port hand-assisted laparoscopic surgery (HALS) were classified as 58 patients with colon cancer and 50 patients with rectal cancer. The mean operating time, mean blood loss, postoperative complications, and mean postoperative hospital stay were compared between the two groups. In patients who underwent colon cancer surgery, the mean operating time was 2 h and 26 min, the mean blood loss was 166.3 ml, and the postoperative complications were wound infection in 5/58 patients (8.6%), postoperative ileus in 3 patients (5.2%), and anastomotic stricture in 1 patient (1.7%). There was no anastomotic leakage and no conversion to conventional open laparotomy. The mean postoperative hospital stay was 12.6 days. In patients who underwent rectal cancer surgery, the mean operating time was 3 h and 38 min, the mean blood loss was 238.8 ml, and the postoperative complications consisted of wound infection in 6/50 patients (12.0%), anastomotic leakage in 3/35 patients (8.6%), anastomotic stricture in 3/47 patients (6.4%), postoperative ileus in 3/50 patients (6.0%), and conversion to conventional open laparotomy in 1/50 patients (2.0%). A covering stoma was constructed during surgery in 12/47 patients (25.5%). The mean postoperative hospital stay was 19.1 days. These results suggest that hybrid 2-port HALS (Mukai's operation) could become a standard method for the treatment of colorectal cancer, and that the long-term outcome should be compared in detail with that of standard laparotomy in the future.

The aim of this study was to retrospectively evaluate the effect of adding CPT-11 to postoperative chemotherapy for stage III colorectal cancer. The subjects were 94 patients, including 60 in stage IIIa (or=3 positive nodes) and 34 in stage IIIb (or=4 positive nodes), who underwent curative resection. The clinical outcome was compared between patients receiving 5-FU/LV plus CPT-11 (FLC group) and patients receiving 5-FU/LV alone (FL group). The FLC group (54 patients) had a 3-year relapse-free survival (3Y-RFS) of 68.7%, a 5Y-RFS of 68.7% and a 5Y-OS of 67.1%, while the FL group (40 patients) had a 3Y-RFS of 67.5% (n.s.), a 5Y-RFS of 64.9% (n.s.), and a 5Y-OS of 77.3% (n.s.). There were no significant differences of these parameters between the two groups. For stage IIIa patients, the corresponding survival rates were 92.4, 92.4 and 90.9% in the FLC group (29 patients) vs. 64.5% (p=0.024), 61.1% (p=0.018), and 77.1% (n.s.) in the FL group (31 patients). For stage IIIb patients, the rates were 36.6, 36.6 and 24.8% in the FLC group (25 patients) vs. 77.8% (n.s.), 77.8% (n.s.), and 77.8% (n.s.) in the FL group (9 patients). These results suggest that the 3Y-RFS and 5Y-RFS of patients with stage IIIa colorectal cancer were significantly improved by adjuvant chemotherapy with 5-FU/LV plus CPT-11.

Inflammatory pseudotumor (IPT) is a benign tumorous lesion of unknown cause, which is composed of fibrous tissue with infiltration of plasma cells and lymphocytes. A 57-year-old male with gastritis was indicated to have hepatic dysfunction during observation of the course of gastritis at a nearby hospital. He was referred to our facility to undergo detailed examinations. When he visited our hospital for the initial examination, he had no subjective symptoms. His past medical history was unremarkable. There were no distinct abnormalities on the medical examination. Blood tests revealed a white blood cell count of 10400 / L, CRP of 0.29 mg/dl, AST of 31 IU/L, ALT of 46 IU/L, ALP of 583 IU/L and -GTP of 408 IU/L, showing a mild inflammatory reaction and elevated hepatobiliary enzymes. Abdominal ultrasonographic examination revealed a tumor mass approximately 4 cm in diameter in a lateral hepatic segment. The margin and center of the mass were hypoechoic and iso- to hyperechoic, respectively, and the inside of the mass was non-homogeneous. Needle biopsy revealed only inflammatory findings with no indications of malignancy. Since computed tomography (CT) of the abdomen, done 4 months after detection of the tumor mass, revealed the mass to have increased to approximately 6 cm in diameter, excision biopsy was considered. The CT taken 2 months later revealed the mass to have regressed to approximately 2 cm in diameter, but excision of the lateral hepatic segment was undertaken at the patient's request. As a result, the diagnosis of IPT of the liver was confirmed. Imaging findings of hepatic IPT are variable and specific findings are lacking. Since the rate of correct diagnosis with needle biopsy is also low, IPT of the liver is often very difficult to differentiate from malignant tumors. On the other hand, since it may show spontaneous regression, indications for surgery must be assessed very carefully.