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Background Dietary fatty acids can affect chronic intestinal inflammation and have been reported to be associated with the development of ulcerative colitis (UC), mainly in Europe and the United States. The association of dietary intake of fatty acids and the risk for UC was investigated in Japan, where dietary habits lead to lower meat and higher fish consumption than in Western countries. Methods A multicenter case-control study of 83 newly diagnosed patients with UC and 128 age- and sex-matched control patients in the hospital was conducted from 2008 to 2014. Dietary fatty acid intake in the preceding 1 month and 1 year were examined using a self-administered diet history questionnaire that was developed for Japanese people. Results About 92% of patients had experienced the first symptoms of UC within the preceding 11 months. Regarding dietary habits in the preceding year, the risk for UC was significantly decreased in patients who consumed n-6/n-3 polyunsaturated fatty acids at a ratio of ≥5.2 (odds ratio [OR] = 0.26; 95% confidence interval [CI], 0.10-0.68). Conversely, an increased risk for UC was observed in the highest tertiles of consumption of docosahexaenoic acid (OR = 7.22; 95% CI, 2.09-24.95), eicosapentaenoic acid (OR = 6.91; 95% CI, 1.88-25.44), and docosapentaenoic acid (OR = 4.83; 95% CI, 1.56-14.95). Conclusions The ratio of n-6/n-3 polyunsaturated fatty acid intake was associated with a decreased risk for UC development. However, high intakes of docosahexaenoic acid, eicosapentaenoic acid, and docosapentaenoic acid may increase the risk for UC development.

The aim of this study was to assess the bowel function and quality of life (QOL) in patients with ulcerative colitis (UC) after total proctocolectomy with ileal pouch anal anastomosis (IPAA). Two questionnaires [“Questionnaire sheet on the bowel function” and “Inflammatory bowel disease questionnaire (Japanese IBDQ)”] were sent to 121 patients with UC who underwent IPAA at Tohoku University Hospital. Seventy-nine patients (65%) participated in the study. The median number of daily bowel movements was 6.5, which significantly decreased with postoperative time (≤ 1, 1–5, 5–15 years) and increased with age (

Although several complications capable of causing pouch failure may develop after restorative proctocolectomy (RPC) for ulcerative colitis (UC), the incidences and causes are conflicting and vary according to country, race and institution. To avoid pouch failure, this study aimed to evaluate the rate of pouch failure and its risk factors in UC patients over the past decade via a nationwide cohort study. We conducted a retrospective, observational, multicenter study that included 13 institutions in Japan. Patients who underwent RPC between January 2005 and December 2014 were included. The characteristics and backgrounds of the patients before and during surgery and their postoperative courses and complications were reviewed. A total of 2376 patients were evaluated over 6.7 ± 3.5 years of follow-up. Twenty-seven non-functional pouches were observed, and the functional pouch rate was 98.9% after RPC. Anastomotic leakage (odds ratio, 9.1) was selected as a risk factor for a non-functional pouch. The cumulative pouch failure rate was 4.2%/10 years. A change in diagnosis to Crohn’s disease/indeterminate colitis (hazard ratio, 13.2) was identified as an independent risk factor for pouch failure. The significant risk factor for a non-functional pouch was anastomotic leakage. The optimal staged surgical procedure should be selected according to a patient’s condition to avoid anastomotic failure during RPC. Changes in diagnosis after RPC confer a substantial risk of pouch failure. Additional cohort studies are needed to obtain an understanding of the long-standing clinical course of and proper treatment for pouch failure.

Cancer of the intestinal tract (small and large intestine) associated with Crohn's disease has a low incidence but can be fatal if it develops. Thus, the key question is how to deal with this type of cancer. The current study surveyed major medical facilities that treat inflammatory bowel disease (IBD) surgically in Japan in order to examine the clinical features of cancer of the intestinal tract associated with Crohn's disease and explore ways to deal with this cancer in the future.Sixteen major medical facilities that treat IBD surgically were surveyed regarding cancer of the intestinal tract associated with Crohn's disease. The medical facilities had treated 3,454 patients with Crohn's disease, 122 of whom had developed intestinal cancer. The medical facilities were surveyed regarding those 122 patients.The incidence of intestinal cancer associated with Crohn's disease has increased yearly. Cancer most often developed in the left side of the colon and, particularly, in the rectum and anal canal. Seventy-six percent of cases were diagnosed preoperatively, 4% were diagnosed intraoperatively, while the remaining 20% were diagnosed pathologically after surgery. The most prevalent histological type of cancer was mucinous carcinoma (50%). Forty-two percent of cancers were differentiated, with 4% being poorly differentiated. The surgical procedure performed most often (67%) was abdominoperineal resection. The 5-year survival rate by stage was 88% for Stage I, 68% for Stage II, 71% for Stage IIIa, 25% for Stage IIIb and 0% for Stage IV. Overall, the 5-year survival rate was 52%.Gastrointestinal (GI) cancer associated with Crohn's disease had an incidence of 3.5%, but also involved a poor prognosis with a 5-year survival rate of 52%. Early detection through surveillance is crucial to improving the prognosis for patients. However, surveillance of the intestinal tract with endoscopy or contrast studies is technically and diagnostically hampered by Crohn's disease and intestinal strictures. A biopsy of the anal canal, a common site of cancer, can readily be performed and constitutes the first step in surveillance.

BACKGROUND: Pouchitis is the most common long-term complication after restorative total proctocolectomy and IPAA for ulcerative colitis. OBJECTIVE: We examined the incidence, clinical aspects, and long-term outcome of patients with idiopathic pouchitis. DESIGN: This study was a retrospective review of medical records. PATIENTS: Included in the study were 284 patients with ulcerative colitis who underwent a total proctocolectomy and IPAA. MAIN OUTCOME MEASURES: We evaluated the cumulative risk and long-term outcome of pouchitis including the duration of disease, pattern of relapse, and responsiveness to antibiotic therapy. RESULTS: Sixty-four patients developed idiopathic pouchitis. The cumulative risk was 10.7% at 1 year, 17.2% at 2 years, 24.0% at 5 years, and 38.2% at 10 years. At their first pouchitis episode, 45 patients had acute pouchitis, 19 patients had chronic pouchitis, and all patients received antibiotic therapy with oral ciprofloxacin and/or metronidazole. The efficacy of the therapy was 96.6% initially. Forty-five patients had antibiotic-responsive pouchitis, 17 patients had antibiotic-dependent pouchitis, and 2 patients had antibiotic-refractory pouchitis at their first episode. Whereas 20 of 45 patients (44.4%) with initially acute pouchitis experienced 2 or more relapses, 16 of 19 patients (84.2%) with initially chronic pouchitis had 2 or more relapses. After taking into account the relapses, the number of patients with antibiotic-responsive pouchitis decreased from 45 to 40, the number with antibiotic-dependent pouchitis increased from 17 to 20, and the number with antibiotic-refractory pouchitis increased from 2 to 4. Among the 4 patients with antibiotic-refractory pouchitis, 3 patients had Clostridium difficile-associated pouchitis. LIMITATIONS: This study was retrospective. CONCLUSION: The patients with chronic pouchitis at the first episode tend to have a higher incidence of relapse. In some patients, the responsiveness to antibiotic therapy changes during follow-up. When patients with pouchitis do not respond to standard antibiotic therapy, then the occurrence of C difficile infection should be considered.

57歳の男性で，直腸癌同時性多発肝転移の診断にて内肛門括約筋切除＋回腸人工肛門造設術を施行．肝両葉に計25個の肝転移を認め根治的肝切除は不可能な状態であった．術後mFOLFOX6を8コース施行し，その後のCT・MRI所見では25個の転移巣は5個まで減少した．当科での肝切除時にソナゾイドTMを用いた造影術中USを施行し腫瘍を検索したところ，24個の小腫瘍を同定した．肝右葉切除と左葉の部分切除で遺残腫瘍なく切除した．術後7か月を経過した時点で無再発生存中である．ソナゾイドTMは，術中USの造影剤として用いることでCT，MRIにてCRとなったものの癌細胞が遺残している肝転移病変を明瞭に描出できる極めて有用なmodalityであるといえる．大腸癌肝転移で化学療法が著効した症例においては，癌化学療法前における腫瘍の解剖学的位置とソナゾイドTM造影術中US所見の比較を行い，遺残腫瘍の見逃しに注意が必要である．

消化管ストーマ造設の標準化を進める上で，適切な分類法に基づいたストーマ合併症の評価が重要である．発症時期別分類としては早期と晩期に分けるのが一般的であるが，早期の定義に関して，過去の報告はストーマ造設術後30日（1カ月）以内とするものと術直後の入院期間中とするものに大別される．術後の入院期間が短縮しつつある昨今，退院直後にストーマ合併症が問題となる症例もみられるので，入院中に限らず術後30日以内を早期と定義するのが良いと考えられる．またストーマ合併症には処置不要なものから緊急手術を要するものまで様々な重症度があるが，重症度別の検討を行った論文は少ない．重症度分類としては有害事象共通用語基準（CTCAE）のストーマ合併症に関するGrade分類が利用可能と考えられるが，用語がストーマケアの現場で使いにくいという問題がある．そこで本稿では用語の修正と追加を行い，ストーマ合併症の重症度分類案として使用可能か検討を行った．

Crohn病に対する外科治療の原則は，健常部をできるだけ温存する病変部の切除である．また，線維性狭窄に対しては各種の狭窄形成術が行われ，病変に応じて消化管の可及的な温存が可能である．ストーマ造設はプアリスク症例や排便機能障害例において適応となる．術後の寛解維持療法については，6～12カ月ごとの内視鏡検査により軽度の病変では5-ASAを，中等度～高度病変に対しては免疫調節薬を加え，さらにInfliximabを用いるアルゴリズムが欧米では提唱されているが，本邦においては，これに成分栄養剤を加えたより丁寧な寛解維持療法が行われている．

PURPOSE: This study aimed to assess the feasibility and safety of undergoing emergency subtotal colectomy with hand-assisted laparoscopic surgery in patients with severe ulcerative colitis. METHODS: We reviewed the medical records of 60 patients who underwent emergency subtotal colectomy with hand-assisted laparoscopic technique (30 cases) or open technique (30 cases) for severe ulcerative colitis. RESULTS: No intraoperative complications occurred in either group. One patient in the laparoscopic group required conversion to open surgery. The median operative time was significantly longer in the laparoscopic group (242 vs. 191 minutes; P < 0.001). The rate of early postoperative complications in the laparoscopic group was significantly less than that in the open group (37 percent vs. 63 percent; P = 0.041). In the open group, four patients required relaparotomy because of peritoneal abscess or strangulation ileus, whereas no patient required relaparotomy in the laparoscopic group (P = 0.040). In the laparoscopic group, the median duration of postoperative food prohibition was significantly shorter (4.8 vs. 5.9 days; P = 0.007), and the median length of hospital stay was significantly shorter (23.0 vs. 33.0 days; P = 0.001). CONCLUSIONS: Although the operative time was elongated in the laparoscopic group, intraoperative safety and postoperative recovery were satisfactory. For severe ulcerative colitis, hand-assisted laparoscopic surgery can be an alternative to conventional open surgery.

A 75-year old woman was admitted to our hospital with right upper quadrant pain, vomiting, and jaundice. Laboratory findings showed elevated total bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, and C-reactive protein levels. Abdominal ultrasonography (US) and drip infusion cholangiographic computed tomography (DIC-CT) showed not only cholecystocholedocholithiasis, but a gallbladder located left of the round ligament and close to the lateral segments of the liver. We performed laparoscopic cholecystectomy (LC) with choledocholithotomy for suspected cholecystocholedocholithiasis with a left-sided gallbladder. Routine ports were inserted in the American configuration for LC. The gallbladder was normogradely separated from the gallbladder fossa, and the fundus of the gallbladder was lifted ventrally and toward to the patient's right shoulder. These procedures provided the usual view for laparoscopic choledochotomy. The patient recovered uneventfully and was discharged on postoperative day 10. To our knowledge, this is the first report of laparoscopic common bile exploration in a patient with a left-sided gallbladder.

To evaluate the efficacy of early diagnosis and early administration of corticosteroid for peristomal pyoderma gangrenosum, a prospective study was carried out.In April 1998, we began studying a new treatment regimen of peristomal pyoderma gangrenosum in which prednisone at a dose of 20 to 40 mg was administered systemically immediately after diagnosis. Early-stage peristomal pyoderma gangrenosum was treated concurrently with topical cadexomer iodine, and at the granulation stage, treatment with clobetasol ointment was started. Healing of peristomal pyoderma gangrenosum was determined by complete epithelialization of ulcer without pain or exudates. Patients were assigned to group A (n = 7) before April 1998 and group B (n = 10) after April 1998, and historical comparison was done between the 2 groups.In group A, all patients had ulcerative colitis, and in group B, 7 patients had ulcerative colitis, 2 had Crohn's disease, and one had indeterminate colitis. In group B, significantly earlier diagnosis (P = 0.0093), earlier start of treatment (P = 0.0057), higher initial dose of corticosteroid (P = 0.0052), and earlier healing of peristomal pyoderma gangrenosum (P = 0.0023) were observed.Early diagnosis and early corticosteroid administration appeared to be effective for promoting healing of peristomal pyoderma gangrenosum.

A 54-year-old man, with the chief complaints of hematuria, pollakisuria, and pneumaturia, was referred to our hospital, with a diagnosis of giant urinary bladder adenocarcinoma with massive invasion to the rectum. On the basis of the radiological diagnosis and findings of hematoxylin and eosin (H&E) of biopsy specimens, it was difficult to conclude whether the adenocarcinoma originated in the bladder or in the rectum. The immunohistochemical staining of the biopsy specimens showed cytokeratin 7 (CK7)(-) and CK20(+), which supported the notion that the adenocarcinoma possibly originated from the rectum. Although the prognosis of T4 bladder adenocarcinomas has been reported to be quite poor in comparison with that of transitional cell carcinomas, the postoperative prognosis of T4 rectal adenocarcinomas has been reported to be more favorable and such tumors are recommended to be surgically resected. Because no distant metastasis was detected, the patient underwent total pelvic exenteration with a reconstruction of the ileal conduit. Although the resected tumor measured 12 cm in diameter with n1 metastasis, the radial margin was cancer-negative, and the tumor was curatively resected. The immunohistochemical diagnosis of the resected tumor showed carcinoembryonic antigen(+), CK7(-), CK20(+), thrombomodulin(-), and uroplakin(-), which supported the rectal origin. At present the patient is undergoing postoperative adjuvant chemotherapy for rectal cancer.

潰瘍性大腸炎 (ulcerative colitis; 以下, UC) では小児期に手術を行うことが少なくないが, 学業への影響, 手術適応, 成長障害など小児特有の問題がある. 当科で1987～2004年の間に小児期 (15歳未満) に初回手術を施行したUC8例について検討した. 手術は全例2期あるいは3期分割で大腸全摘, 回腸肛門吻合 (ileo-anal anastomosis; 以下, IAA) 術を行った. 手術適応は重症4例, 難治3例, 出血1例で緊急手術となった例は5例であった. 術前平均総ステロイド投与量は9,855mgであった. 術後早期合併症は創感染3例のみで, 晩期合併症は腸閉塞2例, 重症pouchitis, 回腸瘻狭窄, 吻合部狭窄をそれぞれ1例ずつ (重複含む) 認めた. 重篤な合併症は認めなかった. 手術後の排便機能は良好であり, また成長障害は認めず, 現在頻回の通院を要している例は1例のみであり学業・就労への影響もほとんどないものと思われた. 小児UCに対するIAAは良好な結果であった.

"Pouchitis" is a term for nonspecific mucosal inflammation of the pouch after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. Pouchitis is the most frequent complication of the pelvic pouch at the late stage. To improve the accuracy of the pouchitis diagnosis, sets of clinical symptoms and endoscopic findings (with or without histology of biopsy samples) have previously been evaluated. Endoscopic findings are central to the diagnosis, and a universal consensus of various endoscopic findings must be the initial step toward an objective diagnosis of pouchitis. Since a proper signpost for the endoscopic evaluation of pouchitis has been absent, we developed this pouchitis atlas to minimize the diagnostic variation inherent among individual endoscopists. We also propose new criteria for the diagnosis of pouchitis: the Japanese criteria for diagnosis of pouchitis. These criteria are based on clinical symptoms and endoscopic findings that are clearly categorized in the atlas, and exclude infectious enteritis, anastomotic insufficiency, pelvic infection, anal dysfunction, and Crohn's disease. Advantages of the new criteria include ease of bedside diagnosis, without the calculation of points required by the other criteria for pouchitis. This pouchitis atlas, together with our new criteria, should contribute to the establishment of a clear-cut diagnosis for pouchitis and promote better evaluation and treatment of this novel intestinal inflammation.

We previously demonstrated the induction of the epithelial sodium channel, prostasin, and 11beta-hydroxysteroid dehydrogenase type 2 and activation of sodium transport mediated by those molecules in the remnant ileum after total proctocolectomy. The aims of the present study were to develop a new drug delivery system that targets ileal epithelial cells and to enhance local mineralocorticoid action without systemic effects. Orally administered D-aldosterone-containing D,L-lactide/glycolide acid copolymer microspheres are absorbed in the rat terminal ileum and released aldosterone. Blood and terminal ileal tissues were collected 2 weeks after the administration of the microspheres, and the aldosterone concentrations, mRNA, and protein expressions of the above molecules and sodium transport were evaluated. Significantly high levels of tissue aldosterone in the absence of elevated plasma levels were detected in the microspheres-treated rats. Epithelial mRNA and protein expression of the above molecules increased significantly in the microspheres-treated animals. Electrogenic sodium transport in the ileum was enhanced in the microspheres-treated rats. Aldosterone-containing microspheres successfully induced the expression of the above molecules and activated sodium transport in the ileal mucosa, both of which are essential for intestinal adaptation. Pre- and/or postoperative treatment with this drug may compensate for the excessive loss of sodium and water following proctocolectomy.

The side-to-side strictureplasty is a bowel-sparing alternative to resection in the treatment of stricturing Crohn’s disease. This study was initiated to review the adoption of the side-to-side strictureplasty as a new surgical technique and the relative outcomes a decade after its description. A total of 184 unique patients from six centers in the United States, Italy, and Japan served as the basis for this study. A questionnaire instrument was used to assemble prospectively acquired preoperative, intraoperative, perioperative, and postoperative data from each center into a computer-generated database. Average age at surgery for patients selected for a side-to-side strictureplasty varied significantly between centers (minimum, 31.0 years; maximum, 39.5 years, P < 0.006). Use of the side-to-side strictureplasty technique for primary Crohn’s disease vs. surgically recurrent disease also varied significantly by center (primary minimum, 16.7 percent; maximum, 68.6 percent, P < 0.03). Furthermore, length of diseased bowel selected for construction of a side-to-side strictureplasty was significantly different among centers (minimum, 20.8 ± 9.9 cm; maximum, 64.3 ± 29.3 cm, P < 0.001). Use of synchronous bowel resection away from the site of the side-to-side strictureplasty was relatively common (minimum, 21.1 percent; maximum, 66.7 percent) as it was with the use of additional synchronous strictureplasties (minimum, 41.9 percent; maximum, 83.3 percent). The six centers experienced a low number of complications (minimum, 5.7 percent; maximum, 20.8 percent). Forty-one of 184 total patients required surgery for recurrent disease, with an average time to recurrence of 35 months. The difference of reoperation-free five-year survival experienced by the patients in the six centers was not statistically significant, with a cumulative reoperation-free five-year survival of 77 percent across all centers. Worldwide implementation of the side-to-side strictureplasty technique and its variations has occurred. This procedure carries a very low mortality and morbidity rate, with acceptable recurrence rates.

Various intestinal conditions such as stricture, fistula, abscess, perforation, and hemorrhage are complications of Crohn's disease. Surgical intervention remains important, even in the era of biologic therapy. Limited surgical resection is essential to avoid short bowel syndrome after massive resection or multiple operations. Strictureplasty is effective for short, isolated stricture of the small intestine and provides good results equivalent to those of intestinal resection. Fecal diversion in the case of very complicated lesions not suitable for immediate resection can offer patients general and local improvement. Although bypass surgery is currently not performed because of the possibility of deterioration or carcinogenesis of the bypassed segment, bypass surgery is useful for avoiding stoma. Laparoscopic surgery is indicated for patients with nonperforating, localized ileocecal lesions, and for those presenting initially. The cumulative postoperative reoperation rate is about 50% to 60% at 10 years. The risk factors for early recurrence are smoking, perforating type, previous reoperation, and small intestinal disease. During postoperative follow-up and maintenance treatment, the importance of an algorithm comprising regular check-ups with ileocolonoscopy and the use of thioprines and biologics has been proposed.

The Inflammatory Bowel Disease Questionnaire (IBDQ) is the most widely used disease-specific health-related quality of life questionnaire for patients with inflammatory bowel disease. However, little has been reported about the validation of IBDQ for patients with ulcerative colitis after surgery. The aim of this study was to assess the validity and reliability of the Japanese version of IBDQ in patients with ulcerative colitis after total proctocolectomy and ileal pouch anal anastomosis (IPAA). The validity and reliability of the Japanese IBDQ were assessed in patients with ulcerative colitis who had received IPAA in our hospital. We mailed them the Japanese IBDQ and a supplemental questionnaire on bowel function, which was developed at our institution. Internal consistency, discriminative validity, and factor validity were assessed. Of the 121 patients to whom we sent the questionnaires, 64 patients (53%) participated in this study. The Japanese IBDQ scores correlated well with Cronbach’s alpha value (0.800 to 0.923) and daily life satisfaction score (Pearson’s r, 0.492 to 0.700). The total IBDQ score and two subscale scores of the IBDQ, “bowel symptoms” and “systemic symptoms,” correlated well with daily bowel-movement frequency (Pearson’s r, −0.256 to −0.329). Factor analysis revealed a four-factor structure, and all correlations among factors were moderately positive (0.337 to 0.465). Although the factor distribution was not clearly divided into the four IBDQ subscales, these four factors showed a marked tendency to represent the IBDQ subscales independently. The Japanese IBDQ is a valid and reliable instrument for the assessment of Japanese patients with ulcerative colitis after IPAA.

Enterostomy is often undergone by patients with Crohn’s disease (CD) due to severe anorectal lesions such as rectovaginal fistula (RVF). Reports of successful pregnancy and delivery, which are important determinants of quality of life for female CD patients with stoma, are limited. Thus, we investigated problems associated with pregnancy and delivery in female CD patients at our hospital. Between 1985 and 2003, five female CD patients with enterostoma carried seven pregnancies and delivered eight babies in our hospital. For this study, we investigated CD activity, fetal growth, stoma complications, and the outcome of delivery in these seven pregnancies. Among the five patients, four underwent loop ileostomy and one loop sigmoidostomy for treatment of RVF or severe stricture of the rectum or sigmoid colon. Except for one case, no fertility treatment was done. During pregnancy, a flare-up was observed in one patient and was successfully treated with corticosteroids. Although home enteral or parenteral nutrition was required in two cases, fetal growth was within the normal range in all pregnancies. Preterm delivery occurred in one case with a twin pregnancy. The mean diameter of stoma increased during pregnancy (p

We hypothesized that epithelial cells of the remnant small intestine display "colonic" phenotype after total proctocolectomy. The aims of the present study were to identify preferentially expressed molecules in the colon or in the small intestine and to evaluate mRNA levels of those in the ileal pouch. Differential gene expression was investigated between the small intestine and the colon by using cDNA microarray and was confirmed by Northern blotting. Expression of three colonic mRNAs (3-hydroxy-3-methylglutaryl-coenzyme A synthase 2, deleted malignant brain tumors 1, carcinoembryonic antigen-related cell adhesion molecule 1) and one "small intestinal" (microsomal triglyceride transfer protein) mRNA were compared between the control and the ileal pouch mucosae by quantitative reverse transcriptase-polymerase chain reaction. Seventy-four clones were differentially expressed with more than a threefold difference. Differential expression was confirmed in all mRNAs examined, including 3-hydroxy-3-methylglutaryl-coenzyme A synthase 2 and microsomal triglyceride transfer protein. The mucosal expression of carcinoembryonic antigen-related cell adhesion molecule 1 mRNA in the ileal pouch was enhanced in humans. The remnant ileum develops some, but not all, colonic phenotype after total proctocolectomy. Comparative study of epithelial gene expression between the small intestine and the colon enables us to analyze mechanisms of intestinal adaptation after total proctocolectomy.

潰瘍性大腸炎(UC)とCrohn病(CD)の手術例における腸管外合併症の種類と頻度手術前後の経過について当科経験例を対象に検討を行った.UC233例中103例(44.2%),CD233例中99例(42.5%)に腸管外合併症が認められた.UC,CDともに胆石症が最多で,各々28例(12.0%),29例(12.4%)であった.その7割は術後に発症し,CDでは小腸型で有意に多かった.CDに特徴的な合併症としては微量元素・ビタミン欠乏症が20例(8.6%)に認められた.UCでは末梢関節炎,壊疽性膿皮症,ブドウ膜炎が各々20例(8.6%),16例(6.9%),7例(3%)に認められた.壊疽性膿皮症とブドウ膜炎は大腸全摘術後に改善することが多かったが,関節炎は逆に悪化または新たに発症することが多かった.UC,CDの外科治療では手術が各腸管外合併症に与える影響をよく理解することが重要である.

Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is now a common procedure for ulcerative colitis (UC). Moreover, it has been reported that fertility is preserved in women who undergo this procedure, many of whom can experience normal delivery.We assessed the perinatal outcomes and changes in anal function in four women, aged from 27 to 35 years, who gave birth after undergoing IPAA for UC. Pregnancies were confirmed 15-111 months after IPAA, three women had full-term pregnancies, and one gave birth after 31 weeks' gestation.Cephalic delivery with a vacuum extractor was used for one patient, and another underwent cesarean section. The other two patients experienced normal delivery. None of the patients needed artificial insemination and none had any symptoms of intestinal obstruction during their pregnancy. After delivery, two patients suffered a transient increase in bowel frequency and soiling, which gradually resolved.Although transient anal dysfunction occurred in the puerperal period, there were no changes in anal function during pregnancy. Therefore, there are no factors directly prohibiting pregnancy and vaginal delivery in women who undergo IPAA for UC.

在宅中心静脈栄養療法(HPN)施行中の症例の問題点を検討した.対象は当科で経験したHPN症例19例(男:女=13:6,HPN導入時平均年齢38歳,平均施行期間3.3年)であり,その原疾患はクローン病が15例,非特異性多発性小腸潰瘍症が2例,慢性特発性偽性腸閉塞症が2例であった.HPNの適応は短腸症候群,難治性の肛門病変,経腸栄養不耐などであった.HPNの合併症ではカテーテル感染が最も多く,2年で約6割の症例がカテーテルの交換を必要とした.また代謝合併症として微量元素の過剰と欠乏,肝機能障害,骨軟化症などを認めた,HPNはメリットも多いが重篤な合併症も数多くあり,その施行に際しての経過観察と管理は慎重に行うべきであると考えられた.

240例のCrohn病手術例のうち,狭窄形成術は計151例に対して行い,2回目手術以降は狭窄形成術施行例の比率が増加していた.施行部位は,回腸,大腸,回盲弁などに行われ,回腸がもっとも多い適応部位であったが,2回目以降の手術では前回吻合部,前回狭窄形成部に対しても狭窄形成術が行われた.施行術式は,Heineke-Mikulicz法が最も多いが,病変の長さ,固さに応じて他の術式も行われた.狭窄形成術の長期成績を累積再手術についてみると,手術施行部位では狭窄形成部と吻合部とで差はなく,症例毎でも狭窄形成術併用群と,腸切除単独例とでも差はなかった,また,狭窄形成術併用群と腸切除単独群との比較では,病変長が長いにもかかわらず切除腸管の長さ,残存小腸長に差はなく狭窄形成術による腸管温存効果が認められた.狭窄形成術は,腸管温存効果も見られ,繰り返す狭窄性小腸病変には良い適応で切除に匹敵する成績が得られた.

潰瘍性大腸炎では種々の合併症が報告されているが, 同じ炎症性腸疾患であるCrohn病と異なり瘻孔を形成することはまれであり, Crohn病との鑑別診断や, 治療上の問題となる. 今回, 我々は直腸肛門周囲に瘻孔を形成し, 外科治療を要した症例を3例経験したので報告する. 3症例はいずれも30～40 歳代の女性で, 病悩期間はそれぞれ約25年, 9年, 12年であった. 病型は症例1, 2が全大腸炎, 再燃緩解型, 症例3は左側大腸炎, 再燃緩解型であり, 重症例はなかった. 手術は症例1は全結腸直腸切除・回腸ストーマ造設術, 症例2は3期分割大腸全摘・回腸肛門吻合術, 症例3では直腸膣瘻修復・一時的回腸瘻造設術を行った. 3症例とも手術後1～3年経過しているが瘻孔の再発は認めず, 有効な術式であったと思われた.

The aim of the present paper was to study the effects of ileo-jejunal transposition (IJT) on ileal contractile activity in vitro in rats. Male Sprague-Dawley rats were divided into three groups: control, IJT, and sham. In rats with IJT, the distal ileum was interposed isoperistaltically into the proximal jejunum. The jejunoileum was transected and anastomosed at three sites in the sham group. Rats were sacrificed 17-20 weeks postoperatively and the ileal segment was removed. Isometric contractile activity of the isolated ileal longitudinal muscle was measured in tissue chambers. Spontaneous contractile activity was decreased in the IJT group (0.16 +/- 0.03 g/min per mg tissue) as compared with the control group (0.25 +/- 0.02 g/min per mg tissue, p < 0.05). The motor response to cholinergic agonist bethanechol in the IJT group was greater than in the control group above 10(-6) M dosage. The dose-response curves to adrenergic agonist norepinephrine did not differ between groups. A nitric oxide synthase inhibitor reversed electrical field stimulation-induced inhibition of spontaneous activity in all groups. These results indicate that the response to bethanechol in the IJT group was enhanced in rat ileal longitudinal smooth muscle and this may be an adaptive response to compensate for decreased spontaneous contractile activity.

Parallel induction of prostasin, a novel serine protease, together with epithelial sodium channel (ENaC) in the colon, may be essential for physiological response to increased circulating aldosterone. The aim of the present study was to investigate whether aldosterone induces prostasin mRNA in parallel with enhanced expression of ENaC in colonic epithelial cells.Sprague-Dawley rats were maintained on a sodium-depleted diet or subjected to continuous aldosterone infusion up to 4 weeks. Rats were necropsied at 1, 2, or 4 weeks after the beginning of each treatment. Blood was immediately collected and the large intestine was removed. Plasma aldosterone and arginine-vasopressin (AVP) levels were measured by radio-immunoassay. Epithelial cells were isolated from the right and left colon and RNA was extracted. Expression of prostasin and the alpha-, beta-, and gamma-subunits of ENaC was evaluated by quantitative RT-PCR or Northern blot analysis. In another series of experiments, T84 cells were stimulated with aldosterone, dexamethasone, and AVP alone or in combination, and prostasin mRNA was measured by quantitative RT-CPR.Treatment with sodium-depleted diet and aldosterone infusion resulted in an increase of plasma aldosterone and induction of prostasin mRNA in the left colon. Expression of three subunits of ENaC also increased in the left colon. Induction of prostasin mRNA was observed when T84 cells were stimulated with corticosteroids plus AVP in vitro.Aldosterone has a pivotal role for increasing expression of prostasin in epithelial cells of the left colon. AVP may have a synergistic effect on aldosterone-mediated prostasin induction.

The aim of the present study was to compare in a prospective, multicenter trial the results early and late after pylorus-preserving gastrectomy (PPG) versus conventional distal gastrectomy (CDG) with Billroth I anastomosis for early gastric cancer. Eighty-one patients with early gastric cancer were randomized and then underwent either PPG or CDG. Duration of operation, intraoperative blood loss, days until removal of the nasogastric tube, days until start of oral intake, and decrease in body weight were studied as parameters for outcomes early after the surgery. Late results were studied in patients followed for longer than 3 years. Change in body weight, status of oral intake, symptoms suggesting early dumping syndrome, and overall satisfaction were addressed in the questionnaire. The presence of gallstones was examined with ultrasonography. There were no differences in early results between PPG and CDG. The incidence of early dumping syndrome was lower in PPG (8%) than in CDG (33%). Other late results including the incidence of gallstones were not different between the 2 groups. These results indicate that PPG is as safe as CDG and has an advantage in terms of early dumping syndrome.

Although side-to-side isoperistaltic anastomosis is a useful strictureplasty technique when long segments of intestinal stenosis complicate Crohn's disease, concerns have been raised regarding disease recurrence adjacent to the anastomosis. We performed side-to-side isoperistaltic anastomosis without spatulated intestinal ends as a method of reconstruction after intestinal resection for Crohn's disease; both intestinal ends were transversely closed like a Heineke-Mikulicz-type strictureplasty. With this procedure, the luminal diameter proximal and distal to the anastomosis became wider than the original diameter of the intestine. This new procedure, which we refer to as the "modified side-to-side isoperistaltic anastomosis with double Heineke-Mikulicz procedure" could become an alternative operation after intestinal resection in persons with Crohn's disease, although long-term outcome analysis is necessary.

症例は23歳女性.5年前にスプレー缶の蓋を膣内に留置してしまったが医療機関を受診せず放置し,次第に月経周期に類似した下血と腰痛が出現したため近医を受診した.大腸内視鏡検査で膣内異物と直腸膣瘻を指摘され経肛門的に異物除去術が施行されたが,2カ月後も瘻孔が閉鎖しないため当科を紹介された.初診時2横指大の直腸膣瘻と膣狭窄を認めた.回腸にループ式人工肛門が増設されたが6カ月後も瘻孔は閉鎖せず,根治目的に手術が施行された.瘻孔周辺の直腸と膣は高度の線維化により強固に癒着しており直腸・膣の修復は不可能であったため,再手術により子宮摘出・直腸切除,結腸肛門吻合術が施行された.3年2カ月の間にこれらの手術を含む計6回の手術が行われ直腸膣瘻は根治した.膣内異物による直腸膣瘻はまれな病態であるが,治療に難渋した自験例を若干の文献的考察を加え報告する.

目的・方法:潰瘍性大腸炎術後のpouchitisについて,診断,治療上の問題点を検討した.Pouchitisの診断にはPouchitis Disease Activity Index (PDAI) scoreと厚生省診断基準案を併用した.厚生省診断基準案の内視鏡所見で中等度以上に該当した症例に対して抗生剤を投与し,前後の臨床症状,内視鏡所見について検討した.結果:PDAI scoreと厚生省診断基準案は同様の結果であり,組織所見なしでも診断,重症度判定は可能であった.Pouchitis症例では排便回数は内視鏡所見とよく相関し,治療後有意に減少した.

We report a patient with synchronous multiple liver metastases from rectal cancer associated with ulcerative colitis. Because the liver tumors were unresectable, we performed total proctocolectomy and hepatic intra-arterial cisplatin infusion with systemic oral administration of fluorouracil. A complete response was obtained. The patient is alive without sign of recurrence 5 years postoperatively. Hepatic intra-arterial administration of cisplatin should be considered in the treatment of unresectable liver metastases from colorectal cancer.

症例は29歳の男性で, 家族歴に特記事項はない. 平成11年11月に大腸型Crohn病の診断を受け, 以後近医にて経過観察されていた. 平成13年2月に腸閉塞を発症し, IVH管理となっていたが, 下行結腸にCrohn病による著明な狭窄を認め, 全身状態も不良であったため, 同4月に緊急手術にて回腸瘻造設術のみを施行し, 平成13年11月, 大腸亜全摘, 回腸直腸吻合, 回腸瘻閉鎖術を施行した. 病理組織学的には全層性の炎症像, 非乾酪性肉芽腫など, Crohn病としての典型的な像が見られたが, 病変部の中に深達度ssの高分化型腺癌の合併と周囲粘膜にp53陽性のdysplasiaが認められた. 術後第33病日より化学療法を施行し, 特に副作用なく退院となった. 現在, 癌の再発の徴候を認めず, 当科外来にて化学療法を継続中である. Crohn病においても常に癌合併の可能性を念頭におくべきであり, 今後は癌の早期発見のための手法の確立が必要と考えられた.