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This retrospective cohort study clarified associations between trajectories in palliative care and appetite loss among older patients with advanced unresectable pancreatic cancer and reviewed pancreatic cancer diagnosis among these populations in rural community hospitals. Patients aged >65 years and with pancreatic cancer in a rural community hospital were enrolled. The primary outcome was survival duration from the time of pancreatic cancer diagnosis. Participants were divided into those with and without appetite loss. Cumulative event-free survival rates were calculated using the Kaplan–Meier method, analyzed using the log-rank test, and stratified by factors with statistically significant between-group differences (serum albumin). The mean participant age was 84.14 (SD, 8.34) years; 31.4% were men. Significant between-group differences were noted in albumin concentration and survival duration. Kaplan–Meier curves showed a significant between-group difference in survival probability (p < 0.001). Survival duration significantly differed after stratification by albumin level (p < 0.001). Appetite loss may be a useful symptom for predicting mortality among older patients with unresectable pancreatic cancer, and hypoalbuminemia may accelerate deterioration in their conditions. Accordingly, subjective appetite loss observed by patients and families should be assessed to predict mortality, and it is advisable for physicians to promptly discuss relevant and advanced directives at appropriate timings.

Comprehensive care through family medicine can enhance the approach to multimorbidity, interprofessional collaboration, and community care, and make medical care more sustainable for older people. This study investigated the effect of implementing family medicine and the comprehensiveness of medical care in one of the most rural communities. This implementation research used medical care data from April 2015 to March 2020. Patients’ diagnoses were categorized according to the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). In 2016, family medicine was implemented in only one general hospital in Unnan. The comprehensiveness rate improved in all ICD-10 disease categories during the study period, especially in the following categories—infections, neoplasms, endocrine, nutritional, and metabolic diseases, mental disorders, nervous system, circulatory system, respiratory system, digestive system, skin and subcutaneous tissue, musculoskeletal system and connective tissue, and the genitourinary system. Implementing family medicine in rural Japanese communities can improve the comprehensiveness of medical care and resolve the issue of fragmentation of care by improving interprofessional collaboration and community care. It can be a solution for the aging of both patient and healthcare professionals. Future research can investigate the relationship between family medicine and patient health outcomes for improved healthcare sustainability.

Background and Objectives: In Japan, family medicine training is driven by community-based medical education (CBME) and is often provided in rural community hospitals and clinics. Although CBME’s positive relationship to family medicine in rural community hospitals is proven, the learning processes of medical students and residents in rural community hospitals needs investigating. The objective of this study was to reveal medical students’ and residents’ changing motivations and learning behaviors, as well as the factors underpinning their transition between medical schools or tertiary hospitals and rural community hospitals. Methods: Over 2 years, the researchers conducted one-on-one interviews with 50 medical students and 30 residents participating in family medicine training at a rural community hospital, and analyzed the difficulties the participants encountered and how they overcame them. The interviews were audio recorded and transcribed verbatim. We used grounded theory in the data analysis to clarify the findings. Results: Three key themes emerged: educational background, changing environment, and factors driving the learning cycle. Participants had difficulties in overcoming differences between their previous education and their CBME, particularly regarding expected roles and the variety of medical issues. They overcame their difficulties through cognitive apprenticeships and legitimate peripheral participation enhanced by daily reflection. Conclusions: In rural community hospitals, participants struggled to adapt to the wider practice range and the more interactive relationship with educators. Cognitive apprenticeships and legitimate peripheral participation, supported by constant reflection between learners and clinical teachers, can facilitate learning, leading to more effective learning and practice of family medicine in rural areas.

The aim of this retrospective observational study was to clarify the usefulness and safety of percutaneous sonographically assisted endoscopic gastrostomy or duodenostomy (PSEGD) using the introduction method.The information for the sequential 22 patients who could not undergo standard percutaneous endoscopic gastrostomy (PEG) and underwent PSEGD for 3 y was extracted and was reviewed. In standard PEG, we performed pushing out of the stomach from the mediastinum and full distention to adhere the gastric wall to the peritoneal wall without interposing of the intraperitoneal tissues by air inflation and a turning-over procedure of the endoscope, four-point square fixation of the stomach to the peritoneal wall by using a Funada-style gastric wall fixation kit under diaphanoscopy, extracorporeal thumb pushing, and in difficult cases extracorporeal ultrasound guidance, and if necessary confirmation of fixation of the gastric wall to the peritoneal wall and placement of the PEG tube without any interposed tissues by using ultrasound.Twenty-one patients (95.5%) successfully underwent PSEGD. Early complications (more than grade 2 in Clavien-Dindo classification) just after the procedure occurred in one case (active oozing). We did not encounter a case with mispuncture of the intraperitoneal organs and tissues. Delayed complications occurring within 1 mo were pneumonia in five patients, including death in three cases; bleeding from puncture site in two patients; and atrial fibrilation in one patient.PSEGD using the introduction method is a useful procedure for difficult patients in whom intraperitoneal organ or tissue is suspected to be interposed between the abdominal wall and stomach.

Objective: Traumatic duodenal obstructions are rare, and most are caused by compression from intramural or retroperitoneal macroscopic hematomas. This report describes a very rare type of delayed traumatic duodenal obstruction without macroscopic intramural or extraluminal hematoma caused by traumatic fibrosis due to seromuscular and intramural injury and microscopic hemorrhage. Case presentation: A 31-year-old man was transferred to our center due to polytrauma with nausea and vomiting on day 53 after an accident. Gastrointestinal fiberscopy (GIF) on day 57 revealed an active stage small duodenal ulcer with patency of the pyloric ring. Although the patient underwent subdural drainage, the nausea and vomiting continued. A repeat GIF on day 91 revealed a duodenal ulcer with severe pyloric stenosis. GIF after nasogastric drainage on day 102 identified a severe pinhole stenosis. We performed surgery on day 106 and observed a constricted duodenal bulb due to a tumorous scar. We resected the stenotic section of the duodenal bulb including the pyloric ring. Conclusion: The histopathologic examination revealed constriction and fibrosis. Surgical options should be considered for patients with delayed duodenal obstruction without macroscopic hematoma around the duodenum after several months of hospitalization.

Both laparoscopic and endoscopic robotic surgery are widely accepted for many abdominal surgeries. However, the port site for the laparoscope cannot be easily sutured without defect, particularly in the cranial end; this can result in a port-site incisional hernia and trigger the progressive thinning and stretching of the linea alba, leading to epigastric hernia. In the present case, we encountered an epigastric hernia contiguous with an incisional scar at the port site from a previous endoscopic robotic total prostatectomy. Abdominal ultrasound and CT revealed that the width of the linea alba was 30-48 mm. Previous CT images prepared before endoscopic robotic prostatectomy had shown a thinning of the linea alba. We should be aware of the possibility of epigastric hernia after laparoscopic and endoscopic robotic surgery. In laparoscopic and endoscopic robotic surgery for a high-risk patient for epigastric hernia, we should consider additional sutures cranial to the port-site incision to prevent of an epigastric hernia.

Our unique rapid response system (RRS) includes a systematically organized structure by rapid response teams (RRT) and a nonorganized, nonsystematic structure for gathering hospital staffs in the scene. We examined the records of 54 patients described in this RRS. Our RRS is as follows; a medical/non-medical hospital staff who finds a victim, asks other staffs to activate the RRS by using inhospital whole paging system; predefined staffs bring predefined equipments; a standard educational course and e-learning system and a simple recording form. The mean interval between the event and the arrival of staff at the scene was 1.81 minutes. Hospital death rate per total discharged patients tended to decrease after RRS. Our unique RRS work well. The death rate among discharged patients decreased after this system was implemented.

After gastrectomy, the remnant stomach, a small stomach behind the lateral segment of the liver, is thought to be a relative contraindication to receiving a percutaneous endoscopy-guided gastrostomy (PEG). We successfully performed a percutaneous duodenostomy in a case with remnant stomach. We used a transhepatic pull method with computed tomography (CT) guidance and real-time visualization by using ultrasound (US) and an endoscopy. The procedure was as follows: 1. Full stretching of the remnant stomach; 2. Insertion of a fine injection needle into the duodenal lumen through the lateral segment of the liver without an intrahepatic vascular and biliary injury using real-time visualization through US; 3. Confirmation of the location of the fine needle using abdominal CT, which showed the fine needle penetrating through the lateral segment and the duodenal lumen; 4. Insertion of the thick needle of the PEG kit just laterally of the fine needle; 5. Confirmation of the location of the thick needle using a repeated CT; 6. Endoscopic confirmation of the location of the two needles; 7. Changing the direction of the thick needle using guidance with endoscopy, inserting the thick needle into the duodenal lumen, and removing the fine needle; 8. Insertion of the guide wire through the thick needle; and 9. Placement of the PEG tube using the pull method. Using a real-time US scan, we detected the puncture of the anterior wall of the duodenum or stomach and avoided intrahepatic major vascular and biliary injuries.

Although massive cirrhotic ascites is generally considered a contraindication for the placement of percutaneous endoscopic gastrostomy (PEG), such patients are usually poorly nourished. Preceding paracentesis of ascites is one method for controlling ascites and allowing the safe placement of PEG, but it often results in overuse of albumin. Preceding peritoneal-venous (P-V) shunting can avoid excessive use of albumin, but this introduces the risk of infectious contamination. We encountered an 88-y-old woman with massive cirrhotic ascites, a giant esophageal hernia with dislocation of the proximal stomach into the mediastinum, hypertrophy of the lateral segment of the liver, and malnutrition who had suffered from appetite loss and a swallowing disorder for 4 mo. She underwent PEG using a staged sequential introduction method using a Funada-style gastric wall fixation kit as follows: 1) full stretching and pushing out of the stomach from the mediastinum into the peritoneal cavity by deep insertion and a turning-over procedure of the endoscope, 2) full distention by air to adhere the gastric wall to the peritoneal wall without migration of the colon, 3) four-point square fixation under gastroenterological endoscopy without migration of the visceral organ, and 4) puncture of the needle introducer of the PEG tube in the center of the fixations under repeated gastroenterological endoscopy 3 d after the fixation. She underwent P-V shunting under local anesthesia on the 28th day after placement of PEG and enteral nutrition. Her case shows that we can achieve proper enteral nutritional support even for patients with massive cirrhotic ascites.

Background: The aim of this study is to clarify the circumstances including the locations where critical events resulting in out-of-hospital cardiopulmonary arrest (OHCPA) occur. Materials and Methods: Subjects of this population-based observational case series study were the clinical records of patients with nontraumatic and nonneck-hanging OHCPA. Results: Of all 1546 cases, 10.3% occurred in a public place (shop, restaurant, workplace, stations, public house, sports venue, and bus), 8.3% on the street, 73.4% in a private location (victim's home, the homes of the victims' relatives or friends or cheap bedrooms, where poor homeless people live), and 4.1% in residential institutions. In OHCPA occurring in private locations, the frequency of asystole was higher and the outcome was poorer than in other locations. A total of 181 OHCPA cases (11.7%) took place in the lavatory and 166 (10.7%) in the bathroom; of these, only 7 (3.9% of OHCPA in the lavatory) and none in the bath room achieved good outcomes. The frequencies of shockable initial rhythm occurring in the lavatory and in bath room were 3.7% and 1.1% (lower than in other locations, P = 0.011 and 0.002), and cardiac etiology in OHCPA occurring in these locations were 46.7% and 78.4% (the latter higher than in other locations, P Conclusions: An unignorable population suffered from OHCPA in private locations, particularly in the lavatory and bathroom; their initial rhythm was usually asystole and their outcomes were poor, despite the high frequency of cardiac etiology in the bathroom. We should try to treat OHCPA victims and to prevent occurrence of OHCPA in these risky spaces by considering their specific conditions.

Background: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). Materials and Methods: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. Results: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. Conclusion: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.

Background: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. Materials and Methods: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients’ medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. Results: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. Conclusion: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

High-echoic objects in the hepatic vessels of patients with cardiopulmonary arrest (CPA) are frequently detected by ultrasonography.To demonstrate this phenomenon and clarify its clinical characteristics.In a tertiary care academic medical centre, 203 CPA patients were evaluated by ultrasonography. CT determined the origin and location of high-echoic objects detected in the liver. The frequency and characteristics of this phenomenon were investigated. The background, laboratory data and survival rate were compared between patients with and without high-echoic objects.High-echoic objects were seen in 73 (36.0%) patients and could clearly be detected in the hepatic veins of 41 (56.2%) patients. CT confirmed that these were gas in 27 of 53 patients, and were clearly visible in the hepatic veins in 12 (44.4%) patients. Hepatic portal venous gas was not identified. Compared to patients without high-echoic objects, witnessed arrest (p0.001), bystander cardiopulmonary resuscitation (p=0.005), ventricular fibrillation or pulseless electrical activity (p=0.012) and return of spontaneous circulation (p=0.018) were significantly less frequent in patients with high-echoic objects. These patients had a lower incidence of survival to discharge (1.4% vs 7.7%, p=0.100). Multivariate analysis showed that absence of high-echoic objects was a marginally significant factor in association with return of spontaneous circulation (p=0.052).High-echoic objects were often observed on ultrasonography in CPA patients; these objects were considered hepatic venous gas. The presence of high-echoic objects may be a poor prognostic sign in patients with CPA.

ガラス片誤飲による咽頭喉頭頸部食道全層性損傷に対し，損傷部単純閉鎖，経頸部血管鞘的上縦隔ドレナージと傍正中アプローチによる気管切開により，頸部手術創と気管切開創との相互汚染を回避しえた症例を経験した．47歳，男性．統合失調症で入院中，ガラスビンの破片を誤飲し，呼吸循環動態は安定していたが，頸胸部CTで頸部食道にガラス片とこれから連続する深頸部気腫を認めた．手術時，ガラス片は胃内に落下しており，開腹下胃切開異物摘出，胃瘻造設，頸部食道損傷部縫合閉鎖，深頸部縦隔ドレナージ，傍正中気管切開を行った．胸鎖乳突筋前縁の斜切開から頸部食道に至りこれを反転し背側の損傷部を縫合閉鎖し，経頸部血管鞘的に持続吸引バッグ付きドレーンを留置した．気管切開の創は頸部手術創と反対側の傍正中とした．術後気管支鏡検査，CTでは，気管切開チューブは斜め方向から挿入されているのが観察されたが，気管切開チューブ交換は容易であった．

BACKGROUND: We retrospectively evaluated the predictive factors for lymph node metastasis in poorly differentiated early gastric cancer (poorly differentiated tubular adenocarcinoma, signet-ring cell carcinoma, mucinous adenocarcinoma) in order to examine the possibility of endoscopic resection for poorly differentiated early gastric cancer. METHODS: A total of 573 patients with histologically poorly differentiated type early gastric cancer (269 mucosal and 304 submucosal), who had undergone curative gastrectomy, were enrolled in this study. Risk factors for lymph node metastasis were evaluated by univariate and logistic regression analysis. RESULTS: Lymph node metastasis was observed in 74 patients (12.9 %) (6 with mucosal cancer and 68 with submucosal cancer). By univariate analysis risk factors for lymph node metastasis were lymphovascular invasion (LVI) (presence), depth of invasion (submucosa), and tumor diameter (> 20 mm), ulcer or ulcer scar (presence), and histological type (mucinous adenocarcinoma). By multivariate analysis, risk factors for lymph node metastasis were LVI, depth of invasion, and tumor diameter. In mucosal cancers, the incidence of lymph node metastasis was 0 % irrespective of LVI in tumors smaller than 20 mm, and 1.7 % in tumors 20 mm or larger without LVI. In submucosal cancers, the incidence of lymph node metastasis was 2.4 % in tumors smaller than 20 mm without LVI. CONCLUSIONS: A histologically poorly differentiated type mucosal gastric cancer measuring less than 20 mm and without LVI may be a candidate for endoscopic resection. This result should be confirmed in a larger study with many patients.

背景:致死的急速大量出血への未交差赤血球製剤（UCM-RCC）緊急輸血では不適合輸血が起きやすい．対象と方法:15例の消化管出血にUCM-RCC輸血（17回，80単位）を経験したので経過を検討した．UCM-RCC輸血の適応は，2,000mlの急速輸液でも循環不安定で交差適合試験（CMT）が待てない出血性ショック．結果:UCM-RCC輸血は1例に2～10単位，平均5.3単位実施，93％で6単位以下．血液型判定（BTT）未判定例へのO型UCM-RCC輸血は7例，1回のBTT後例へのO型UCM-RCC輸血は4例，1回のBTT後非O型症例への未確認同型UCM-RCC輸血は4例．輸血前の収縮期血圧，脈拍数，ショック指数（脈拍数/収縮期血圧），base excessの最低値は平均各，76.9mmHg，117.5回/分，1.69，-9.61mEq/l．意識障害は8例に認められた．死亡は2例（13％），ABO型不適合輸血，輸血関連急性期合併症はなかった．結論:消化管出血へのUCM-RCC輸血ではO型UCM-RCC輸血の迅速な決断が重要だが，初回請求量は6単位が妥当と思われた．

心肺停止蘇生後に姑息的胃切除を行い神経学的異常を残さず救命しえた胃癌穿孔を経験した．81歳の男性で，食欲低下と体重減少，右側腹部痛，嘔気から経口摂取不能，意識障害となり緊急搬送された．病院到着12分後に心肺停止となり6分後に蘇生した．造影CTなどで腹腔内遊離ガス，胃幽門付近の壁不整像を認め消化管穿孔，腹膜炎，腹部コンパートメント症候群によるショックと判断した．初期輸液などの敗血症性ショックに対する治療と平行して，開腹減圧と感染源制御を目的に緊急手術とした．胃体下部前壁に胃癌漿膜浸潤と穿孔，腹膜全域に播種性小病変を認め，姑息的に幽門側胃切除，Roux-en-Y吻合を行った．腫瘍は，LCirc，type 3，pT3（SE），sN3，sH0，sP1，fStage IV，ly3，v2，INFβ，tub2＞por2であった．術後は比較的容易に敗血症性ショックから離脱でき，神経学的異常の遺残はなかった．術後8か月の造影CTで腹腔内リンパ節，肝臓，肺転移を認め，術後14か月（第407病日）で死亡した．

はじめに：肝，脾，腸間膜損傷で出血性ショック合併の腹部外傷では，蘇生的緊急開腹術など外科手技の適応と緊急輸血の適応判断を迫られる．異型輸血を含む危険を内在する未交差赤血球製剤（uncrossmatched-red cell concentrate；以下，UCM RCC）緊急輸血の安全性と問題点を考案する．方法：過去5年間で，O型Rh＋UCM RCCを含むUCM RCC緊急輸血を実施した腹部外傷を対象にUCM RCC輸血の実態と輸血関連インシデント・アクシデント回避の成否を検討した．結果：UCM RCC輸血は33例に54回，388単位実施され，準備UCM RCCは426単位で使用率は91.1％であった．出血源は肝臓13例，脾臓8例，腸間膜17例で，輸血前平均収縮期血圧は62.5 mmHg，脈拍数117回/分，ショック指数（脈拍数/収縮期血圧）1.97，base excessは−12.7 mEq/l，7日生存例は48.5％であった．血液型判定（blood typing test；以下，BTT）未判定でのO型UCM RCC輸血は17例（21回，168単位），うち非O型への輸血は11例（14回，120単位）であった．1回のBTT後のO型UCM RCC輸血は8例（12回，96単位），うち非O型への輸血は4例（7回，54単位）で，1回のBTTでの非O型症例への未確認同型UCM RCC輸血は15例（20回，120単位）であった．O型UCM RCC輸血全体に年度別増減はなかったが，1回のBTTでの非O型への未確認同型UCM RCC輸血は減少した．ABO型不適合輸血，輸血に関わるインシデントはなかった．考察：UCM RCC輸血では，院内マニュアルを整備したうえでのO型UCM RCCの使用は安全と考えられた．

鍼治療後の両側気胸症例を経験した。58歳の女性，体調不良に対し頸部から腰部にかけて約20箇所の鍼治療直後に胸部違和感，呼吸困難感自覚し，救急搬送された。意識清明，血圧200／110mmHg，脈拍数151回／分，呼吸数36回／分，苦悶様顔貌，発汗著明であったが，チアノーゼや気道狭窄音，呼吸音の左右差はなく，心臓超音波，心電図で異常なく，血液検査でも白血球上昇以外異常はなく，動脈血ガス分析（酸素10l／分）はpH7.215，Pao2118.7mmHg，Pco263.9mmHgであった。前医鍼灸院から情報を得て，胸部単純X線検査で両側気胸と診断，両側胸腔ドレナージを施行した。血液ガス分析はpH7.326，Pao2181.6mmHg，Pco242.8mmHgと改善，症状も消失し，第13病日退院となった。考察・結論：気胸など鍼治療の合併症が生じると鍼治療担当者とは別の医師が治療を行うことになるが，鍼治療合併症に対する対応体制は未発達である。今後は，鍼治療時のインフォームドコンセントの充実と合併症時の鍼灸治療者と救急医療機関との連携あるシステム構築が必要と思われた。

症例は79歳，女性．右下腹部から鼠径部の発赤，浮腫で近医に入院し，右下腹部ガス壊疽の疑いで当センターへ転院となった．意識清明，血圧100/60mmHg，心拍数75/分，末梢冷感なし．腹部に圧痛，筋性防御はなかったが，右腋窩から右鼠径にかけての気腫と右鼠径部発赤，腫脹，熱感，圧痛を認めた．肛門周囲に異常はなく，血液検査では炎症所見，血小板数軽度低下，凝固異常を認めた．壊死性筋膜炎のドレナージを目的に病変部を局所切開したところ便汁が排出し腸管の大腿ヘルニア嵌頓絞扼壊死穿孔と診断した．開腹すると回腸がヘルニア門に癒着しRichter型嵌頓ヘルニアを形成し，ヘルニア内容と腹腔内とは隔離されていた．回腸部分切除と右下腹部皮膚切開，部分的デブリドマンを行った．術後は陰圧持続洗浄吸引ドレッシングとし，間歇的洗浄，デブリドマンを繰り返し，創面が肉芽で覆われるのを待って第19，33病日に植皮術を施行し第41病日に転院としえた．

症例は56歳, 男性. 前医の単純X線とCT検査で腹腔内遊離ガス像を認め, 発症後2日経過した消化管穿孔腹膜炎の診断で転送されてきた. BUN, クレアチニンの上昇があったが腎機能障害の合併と考えていた. 手術時に腹腔内膀胱遊離破裂と判明した. 術後情報を再確認し, 前医で単純X線撮影前に膀胱留置カテーテルから空気を注入したこと, 患者は発症当日大量飲酒後に下腹部を打撲していたことが判明し, 膀胱充満状態での下腹部強打による膀胱腹腔内遊離破裂, 偽腎不全, 医原性腹腔内遊離ガスという典型的病態であったことが判明した. 適切な手術の準備などのためにも, 病院間高次転送時には, 正確な情報伝達と情報確認に努め, 情報に対する先入観や思いこみを排除し, 前医からの情報のみに基づく緊急手術の適応だけの判断で手術を行うのではなく, 症例の緊急性に応じて自施設でも責任を持って術前診断を確実に行うことが重要と思われた.

The aim of this study was to clarify the lymph node status in patients with submucosal gastric cancer. Between April 1994 and December 1999, 615 patients with histologically proven submucosal gastric cancer who underwent curative resection were included in this study. The results of the surgery and predictive factors for lymph node metastasis were evaluated by univariate and multivariate analyses. The accuracy of the predictive factors was assessed in a second population of a further 186 patients. Lymph node metastasis was observed in 119 patients (19.3%). Multivariate analysis showed that pathologic tumor diameter (≥20 mm) and lymphatic invasion were independent predictive factors for lymph node metastasis. The incidence of lymph node metastasis without these 2 predictive factors was 1.8% (2 of 113), and it was 51.2% (85 of 166) with the 2 predictive factors, 9.5% (14 of 148) in tumors

54歳,男性の胸腹移行部刺創による腹腔内多臓器損傷(右横隔膜,小腸,肝,胆嚢,右腎)症例で,術中に腎周囲・後腹膜血腫の急速な増大を認め, lethal triadに向かいつつある状態と判断し, damage control (DC)に治療戦略を修正し,肝・胆嚢縫合止血,肝・腎周囲ガーゼ圧迫留置,引き続き腎動脈の経カテーテル的動脈塞栓術(TAE)を行い,一時止血に成功し,第2病日に予定再手術でガーゼ除去,胆嚢摘出術を施行し救命しえた症例を経験した. DCは通常の治療戦略とは概念を異にする一時回避的戦略であるが,大量出血やseptic shockで致命的代謝失調状態にある症例に対しては,救命のための有用な手段である.重症緊急症例では治療戦略に関して事前検討もできず,その場に居合わせた者だけでの即座の判断が要求されるが,本法の適応判断や実践は,緊急事態への対応能力の一つとして重要と思われた.

Background Although nifekalant is a class III antiarrhythmic agent without negative inotropic activity, its effect in patients with shock-refractory ventricular fibrillation remains unclear. Methods and Results Patients who had an out-of-hospital cardiac arrest with ventricular fibrillation that persisted after 3 shocks from an external defibrillator, intravenous epinephrine, and another shock were retrospectively studied. The patients received lidocaine from January 1997 through June 2001 and nifekalant from July 2001 through December 2004. Short-term survival rates (survival to hospital admission and 24-h survival) were compared between the groups. The study group comprised 120 patients (mean age: 62±16 years): 55 received nifekalant and 65 received lidocaine. Age, sex, history of ischemic heart disease, whether arrest was witnessed or not and time to arrival at the hospital did not differ significantly between the groups. As compared with lidocaine, nifekalant was associated with significantly higher rates of survival to hospital admission (67% vs 37%, p

大量の肝内門脈ガス像を呈した広範小腸壊死1例を報告する.82歳,女性.既往歴は,高血圧,胆石,逆流性食道炎と20年前に帝王切開。平成15年12月5:30,全身倦怠感,水様性下痢,嘔吐を主訴に他院受診.腹部造影CTで肝左葉の門脈内に樹枝状に広がる空気像,腹部大動脈周囲後腹膜に空気像を認め,当院へ転送された.意識レベルはJCS-1,収縮期血圧42mmHg,脈拍数146,呼吸数32,直腸温36.9℃,腹部は板状硬で圧痛を認めた.白血球数は9,270/mm^3,CRPは16.4mg/dlと上昇しており,血小板は4.1万/mm^3,PTは45%などDIC状態だった.アルブミン1.5g/dlと低栄養,BE-10.8mEq/lとアシドーシスを認めた.造影CTで上腸間膜動脈内の血栓は明らかではなかった.開腹すると,腐敗臭を伴う腹水を認め,E.coliが同定された.小腸は,Treitz靱帯より約1mから境界明瞭に壊死状態,肛門側は横行結腸中央部付近まで全層性壊死,下行結腸とS状結腸は虚血状態であった.穿孔は認められなかった.全身状態が劣悪であったため,小腸広範囲切除,結腸亜全摘,上位空腸痩造設,S状結腸断端の腹壁開腹創への固定しか施行しなかった.切除標本の病理では腸管の末梢動脈攣縮像が認められた.術後,サイトカイン吸着術,大量輸血,CHDFを含む集中治療を行ったが翌日多臓器不全で死亡した., This is a case report of grossly necrotic bowel with hepatic-portal venous gas. An 82-year-old woman with a history of hypertension, gallstone, reflux esophagitis and caesarian section, was brought to a hospital because of general fatigue, watery diarrhea, and vomiting. She was transferred to our center because abdominal contrast enhanced computed tomography (CE-CT) scan showed arborescent dialation of the hepatic-portal venous gas and air around the abdominal aorta. Her conscious level was JCS-1, systolic blood pressure 42mmHg, pulse rate 146, respiration rate 32, and her body temperature 39.6℃. She had abdominal tenderness and muscle guarding. CE-CT did not reveal any thrombus in the superior mesenteric artery. An emergency operation was performed and we found transmural bowel necrosis from 1 m distal to the Treitz ligament to the middle transverse colon and ischemic and cyanotic change of the descending and sigmoid colon. There was no perforation. We resected the necrotic bowel. Pathological examination showed small arterial spasms in the involved bowels. Although intensive care, including cytokine absorption therapy, blood transfusion, and continuous hemofiltration dialysis (CHDF) was given, she died the following day of multiple organ dysfunction syndrome (MODS).

A 51-year-old man was admitted to our hospital with a tumor in the right anterior region of his neck. Aspiration biopsy revealed squamous cell carcinoma (SCC). Further investigations, including upper gastro-intestinal series and endoscopy, showed two flush lesions in the middle and lower thoracic esophagus. An endoscopic biopsy was done and the pathological findings indicated poorly differentiated SCC. He underwent esophagectomy with three-field lymph node dissection, including the neck tumor. Histological findings revealed that the tumor in the middle thoracic esophagus was moderately differentiated SCC, and that the other tumor below it was basaloid cell carcinoma (BCC). The depths of invasion were to the lamina propria mucosae for the former and to the submucosal layer for the latter. There was no lymphatic invasion, venous invasion, or lymph node metastasis. A diagnosis of poorly differentiated SCC of unknown origin was made for the neck tumor. Postoperative recombinant chemotherapy with cisplatin and 5-fluorouracil was given for the unknown primary site, which we still have not identified. No recurrence of the esophageal cancer has been detected.