兼田 裕司

Introduction Postoperative pancreatic fistula (POPF) is a critical complication occurring with a high incidence after distal pancreatectomy. To minimize the risk of POPF, we developed an innovative pancreas ligation device capable of closing the pancreatic stump without causing traumatic injury to the pancreatic duct and artery. We conducted an ex vivo follow-up study to compare the pressure resistance of the pancreas ligation device with that of a regular linear stapler. Materials and methods The pancreases were excised from 20 pigs and divided into two groups: ligation group (n = 10) and stapler group (n = 10). Distal pancreatectomy was performed, and the pancreatic stump was closed using either a pancreas ligation device or a regular linear stapler. The main pancreatic duct was cannulated with a 4-French catheter connected to a cannula and syringe filled with contrast medium. Using fluoroscopy detection, pressure resistance was defined as the maximum pressure without leakage from the pancreatic stump. Results No significant differences were found between the two groups regarding sex, age, body weight, or pancreatic thickness. In the ligation group, no leakage was observed at the stump in any pancreas. However, in the stapler group, six of 10 pancreases showed leakage at the staple line or into the parenchyma. Pressure resistance was significantly higher in the ligation group than in the stapler group (median: 42.8 vs. 34.3 mmHg, P = 0.023). Conclusions These findings suggest the effectiveness of a pancreas ligation device in reducing the incidence of POPF after distal pancreatectomy. Our ligation device is expected to be a useful alternative to a linear stapler for pancreatic stump closure.

PURPOSE: The aim of this study was to evaluate both the intestinal mucosa staple line integrity and anastomotic leak pressure after healing in a porcine survival model. METHODS: We used two suture models using two different size staples (incomplete mucosal closure model: group G [staple height 0.75 mm], complete mucosal closure model: group B [staple height 1.5 mm]) in the porcine ileum. Five staple lines were created in each group made in the ileum for each model, and the staple sites harvested on days 0, 2, and 7. The leak pressure at the staple site was measured at each time point. RESULTS: On day 0, the leak pressure for group G (79.5 mmHg) was significantly lower than that for group B (182.3 mmHg) (p < 0.01). On days 2 and 7, there was no significant difference between groups G and B (171 mmHg and 175.5 mmHg on day 2, 175.5 mmHg and 175.5 mmHg on day 7, p > 0.05). The histological findings in both groups showed similar healing at postoperative days 2 and 7. CONCLUSION: The integrity of the mucosal staple lines was associated with the postoperative leak pressure on day 0. However, there was no association with the leak pressure at two days or more postoperatively in a porcine model.

BACKGROUND: Pancreatojejunostomy (PJ) is one of the most difficult and challenging abdominal surgical procedures. There are no appropriate training systems available outside the operating room (OR). We developed a structured program for teaching PJ outside the OR. We describe its development and results of a pilot study. METHODS: We have created this structured program to help surgical residents and fellows acquire both didactic knowledge and technical skills to perform PJ. A manual was created to provide general knowledge about PJ and the specific PJ procedure used in our institution. Based on questionnaires completed by trainers and trainees, the procedure for PJ was divided into twelve steps and described in detail. After creating the manual, we developed organ models, needles and a frame box for simulation training. Three residents (PGY3-5) and three fellows (PGY6 or above) participated in a pilot study. Objective and subjective evaluations were performed. RESULTS: Trainees learn about PJ by reading the procedure manual, acquiring both general and specific knowledge. We conducted simulation training outside the OR using the training materials created for this system. They simulate the procedure with surgical instruments as both primary and assistant surgeon. In this pilot study, as objective assessments, the fellow-group took less time to complete one anastomosis (36 min vs 48 min) and had higher scores in the objective structured assessment of technical skill (average score: 4.1 vs 2.0) compared to the resident-group. As a subjective assessment, the confidence to perform a PJ anastomosis increased after simulation training (from 1.6 to 2.6). Participants considered that this structured teaching program is useful. CONCLUSION: We developed a structured program for teaching PJ. By implementing this program, learning opportunities for surgical residents and fellows can be increased as a complement to training in the OR.

Traumatic injury to the main pancreatic duct requires surgical treatment, but optimal management strategies have not been established. In patients with isolated pancreatic injury, the pancreatic parenchyma must be preserved to maintain long-term quality of life. We herein report a case of traumatic pancreatic injury with main pancreatic duct injury in the head of the pancreas. Two years later, the patient underwent a side-to-side anastomosis between the distal pancreatic duct and the jejunum. Eleven years later, he presented with abdominal pain and severe gastrointestinal bleeding from the Roux limb. Emergency surgery was performed with resection of the Roux limb along with central pancreatectomy. We attempted to preserve both portions of the remaining pancreas, including the injured pancreas head. We considered the pancreatic fluid outflow tract from the distal pancreatic head and performed primary reconstruction with a double pancreaticogastrostomy to avoid recurrent gastrointestinal bleeding. The double pancreaticogastrostomy allowed preservation of the injured pancreatic head considering the distal pancreatic fluid outflow from the pancreatic head and required no anastomoses to the small intestine.

As a result of recent advances in diagnostic techniques and treatment modalities, the number of patients diagnosed with multiple primary malignancies has been increasing. We report the case of a 79-year-old male with multiple primary malignancies of three histological types in six different organs: Stomach, prostate, colon, urinary bladder, facial skin and pancreas, in chronological order. The first malignancy was upper gastric cancer diagnosed in 1998. The second and third malignancies were prostate cancer and ascending colon cancer, which were diagnosed in 2010. The fourth malignancy was bladder cancer diagnosed in 2011. The fifth and sixth malignancies were squamous cell skin cancer of the right cheek and intraductal papillary mucinous carcinoma (IPMC), respectively, diagnosed in 2014. The gastric cancer, colon cancer, bladder cancer, skin cancer and IPMC were surgically resected. The prostate cancer was treated by anti-androgen therapy. The patient died of local recurrence of IPMC in August 2016. Although multiple primary malignancies are not uncommon, diagnosis of six primary malignancies in a single patient, as reported in the present study, is extremely rare. It is important to understand the characteristics of multiple primary malignancies in order to administer suitable treatment and determine relevant follow-up plans for patients with cancer.

症例は60代女性。1991年他院で後腹膜脂肪肉腫に対して腫瘍摘出術および補助化学療法を施行された。1999年3月右腎臓下極近傍の再発に対して右腎摘出術を伴う再発腫瘍摘出術を当院で施行。その後、2006年1月肝臓尾側の再発、2008年6月腹部大動脈腹側の再発、2015年10月右側腹部の再発に対して各々、再発腫瘍摘出術を施行し、初回手術から25年の現在無再発生存中である。脂肪肉腫の予後は組織型に依存し、高分化型脂肪肉腫は予後良好である。高分化型脂肪肉腫においては外科的切除の可否が予後に反映し、再発を来しても、完全切除することで予後改善が期待できるため、術後の綿密な経過観察による早期再発診断、再発腫瘍摘出術の施行が重要である。(著者抄録)

症例は70代女性。上腹部痛と嘔吐を契機に胆嚢腫瘍を指摘された。膵胆管合流異常に合併した胆嚢癌の診断で胆嚢床切除術を施行。術後病理組織学的検査で胆嚢癌肉腫の診断となった。術後6ヵ月で肝転移再発を認めS-1療法、gemcitabine療法を施行。progressive diseaseであったが、他に新出病変を認めなかったため、肝切除を行った。術後gemcitabine療法施行し、初回手術後32ヵ月無再発生存中である。癌肉腫は上皮性悪性腫瘍の癌と非上皮性悪性腫瘍の肉腫が混在する腫瘍で、胆嚢原発の癌肉腫はまれな腫瘍である。本疾患は再発が多く予後不良であるが再発に対する有効な治療法は未だ確立されていない。今回、胆嚢癌肉腫の術後肝転移再発に対して、化学療法と肝切除を行い、病勢をコントロールしている1例を経験した。本症例は治癒切除が可能な胆嚢癌肉腫転移再発例に対する治療としての切除の有効性を示唆すると考えられた。(著者抄録)

Morphological response is considered an improved surrogate to the Response Evaluation Criteria in Solid Tumors (RECIST) model with regard to predicting the prognosis for patients with colorectal liver metastases. However, its use as a decision-making tool for surgical intervention has not been examined. The present study assessed the morphological response in 50 patients who underwent chemotherapy with or without bevacizumab for initially un-resectable colorectal liver metastases. Changes in tumor morphology between heterogeneous with uncertain borders and homogeneous with clear borders were defined as an optimal response (OR). Patients were also assessed as having an incomplete response (IR), and an absence of marked changes was assessed as no response (NR). No significant difference was observed in progression-free survival (PFS) between complete response/partial response (CR/PR) and stable disease/progressive disease (SD/PD), according to RECIST. By contrast, PFS for OR/IR patients was significantly improved compared with that for NR patients (13.2 vs. 8.7 months; P=0.0426). Exclusion of PD enhanced the difference in PFS between OR/IR and NR patients (15.1 vs. 9.3 months; P<0.0001), whereas no difference was observed between CR/PR and SD. The rate of OR and IR in patients treated with bevacizumab was 47.4% (9/19), but only 19.4% (6/31) for patients that were not administered bevacizumab. Comparison of the survival curves between OR/IR and NR patients revealed similar survival rates at 6 months after chemotherapy, but the groups exhibited different survival rates subsequent to this period of time. Patients showing OR/IR within 6 months appeared to be oncologically stable and could be considered as candidates for surgical intervention, including rescue liver resection. Comparing the pathological and morphological features of the tumor with representative optimal response, living tumor cells were revealed to be distributed within the area of vascular reconstruction induced by bevacizumab, resulting in a predictive value for prognosis in the patients treated with bevacizumab. The present findings provided the evidence for physicians to consider patients with previously un-resectable metastatic colorectal cancer as candidates for surgical treatment. Morphological response is a useful decision-making tool for evaluating these patients for rescue liver resection following chemotherapy.

AIM: To assess the usefulness of en bloc right hemicolectomy with pancreaticoduodenectomy (RHCPD) for locally advanced right-sided colon cancer (LARCC). METHODS: We retrospectively reviewed the database of Saitama Medical Center, Jichi Medical University, between January 2009 and December 2016. During this time, 299 patients underwent radical right hemicolectomy for right-sided colon cancer. Among them, 5 underwent RHCPD for LARCC with tumor infiltration to adjacent organs. Preoperative computed tomography (CT) was routinely performed to evaluate local tumor infiltration into adjacent organs. During the operation, we evaluated the resectability and the amount of infiltration into the adjacent organs without dissecting the adherent organs from the cancer. When we confirmed that radical resection was feasible and could lead to R0 resection, we performed RHCPD. The clinical data were carefully reviewed, and the demographic variables, intraoperative data, and postoperative parameters were recorded. RESULTS: The median age of the 5 patients who underwent RHCPD for LARCC was 70 years. The tumors were located in the ascending colon (three patients) and transverse colon (two patients). Preoperative CT revealed infiltration of the tumor into the duodenum in all patients, the pancreas in four patients, the superior mesenteric vein (SMV) in two patients, and tumor thrombosis in the SMV in one patient. We performed RHCPD plus SMV resection in three patients. Major postoperative complications occurred in 3 patients (60%) as pancreatic fistula (grade B and grade C, according to International Study Group on Pancreatic Fistula Definition) and delayed gastric empty. None of the patients died during their hospital stay. A histological examination confirmed malignant infiltration into the duodenum and/or pancreas in 4 patients (80%), and no patients showed any malignant infiltration into the SMV. Two patients were histologically confirmed to have tumor thrombosis in the SMV. All of the tumors had clear resection margins (R0). The median follow-up time was 77 mo. During this period, two patients with tumor thrombosis died from liver metastasis. The overall survival rates were 80% at 1 year and 60% at 5 years. All patients with node-negative status (n = 2) survived for more than seven years. CONCLUSION: This study showed that the long-term survival is possible for patients with LARCC if RHCPD is performed successfully, particularly in those with node-negative status.

Previous studies have demonstrated the safety of ABO-incompatible pediatric LDLT using preoperative plasmapheresis and rituximab; however, no reports have described the timing and dosage of rituximab administration for pediatric LDLT. This study aimed to describe a safe and effective dosage and timing of rituximab for patients undergoing pediatric ABO-incompatible LDLT based on the experience of our single center. A total of 192 LDLTs in 187 patients were examined. These cases included 29 ABO-incompatible LDLTs in 28 patients. Rituximab was used beginning in January 2004 in recipients older than two yr of age (first period: 375 mg/m(2) in two cases; second period: 50 mg/m(2) in two cases; and 200 mg/m(2) in eight cases). Two patients who received 375 mg/m(2) rituximab died of Pneumocystis carinii pneumonia and hemophagocytic syndrome. One patient who received 50 mg/m(2) rituximab required retransplantation as a consequence of antibody-mediated complications. All eight patients administered 200 mg/m(2) survived, and the mean CD20(+) lymphocyte count was 0.1% at the time of LDLT. In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200 mg/m(2) rituximab three wk prior to LDLT was safe and effective.

The aim of the study was to investigate the relation between insulin resistance and risk of cerebral infarction in a Japanese general population. The subjects were 2610 men and women without past history of stroke or myocardial infarction and who were under treatment for diabetes. Subjects were divided into quartiles by the homeostasis model assessment of insulin resistance (HOMA-IR), and Cox’s proportional hazard model was used to calculate hazard ratios (HRs) for cerebral infarction. In men, the multivariate-adjusted HRs were 2.51 (95% confidence interval [CI] = 0.98-6.42) in quartile 1 (Q1), 1.43 (95% CI = 0.54-3.82) in Q2, and 2.13 (95% CI = 0.82-5.51) in Q4, using Q3 as the reference. In women, the multivariate-adjusted HRs were 2.12 (95% CI = 0.72-6.31) in Q1, 2.96 (95% CI = 1.06-8.26) in Q3, and 2.31 (95% CI = 0.80-6.69) in Q4, using Q2 as the reference. The association between risk of cerebral infarction and HOMA-IR was not dose dependent.

In the field of pediatric living donor liver transplantation (LDLT), physicians sometimes must reduce the volume of left lateral segment (LLS) grafts to prevent large-for-size syndrome. There are 2 established methods for decreasing the size of an LLS graft: the use of a segment 2 (S2) monosegment graft and the use of a reduced LLS graft. However, no procedure for selecting the proper graft type has been established. In this study, we conducted a retrospective investigation of LDLT and examined the strategy of graft selection for patients weighing ≤6 kg. LDLT was conducted 225 times between May 2001 and December 2012, and 15 of the procedures were performed in patients weighing ≤6 kg. We selected S2 monosegment grafts and reduced LLS grafts if the preoperative computed tomography (CT)-volumetry value of the LLS graft was >5% and 4% to 5% of the graft/recipient weight ratio, respectively. We used LLS grafts in 7 recipients, S2 monosegment grafts in 4 recipients, reduced S2 monosegment grafts in 3 recipients, and a reduced LLS graft in 1 recipient. The reduction rate of S2 monosegment grafts for use as LLS grafts was 48.3%. The overall recipient and graft survival rates were both 93.3%, and 1 patient died of a brain hemorrhage. Major surgical complications included hepatic artery thrombosis in 2 recipients, bilioenteric anastomotic strictures in 2 recipients, and portal vein thrombosis in 1 recipient. In conclusion, our graft selection strategy based on preoperative CT-volumetry is highly useful in patients weighing ≤6 kg. S2 monosegment grafts are effective and safe in very small infants particularly neonates.

INTRODUCTION: Radical resection of bile duct carcinoma may require resection of hepatic arteries. Preoperative segmental embolization of the hepatic artery for resection of hilar cholangiocarcinoma has been reported. We report a patient with bile duct carcinoma infiltrating the proper hepatic artery. PRESENTATION OF CASE: A 66-year old male with jaundice was diagnosed with mid-distal bile duct carcinoma. A replaced left hepatic artery originated from the left gastric artery. Pylorus-preserving pancreaticoduodenectomy (PPPD) with combined resection of hepatic artery was planned. To promote the development of collateral blood flow after excision of the hepatic artery, preoperative segmental embolization of the proper hepatic artery was performed. The patient underwent PPPD with concurrent resection of the common hepatic, right hepatic, and middle hepatic arteries without arterial reconstruction. He received adjuvant chemotherapy with gemcitabine for six months and is alive three years after surgery without tumor recurrence. DISCUSSION: The growth of collateral vessels after selective embolization of the proper hepatic artery has been used for hilar lesions and bile duct lesions. Resection of the hepatic artery without the need for complex arterial reconstruction, allowing a radical resection, may have contributed to this patient's relatively unremarkable recovery and long-term survival. Retroperitoneal mobilization of the pancreatic head and duodenum must be limited as important collaterals may originate in that area. CONCLUSION: Preoperative segmental embolization of the hepatic artery before PPPD for a patient with a replaced left hepatic artery encouraged the growth of collateral blood supply, allowing radical resection including the vessels and obviated the need for arterial reconstruction.

The use of donors with coagulation FIX deficiency is controversial, and there are no current protocols for peri-transplant management. We herein describe the first reported case of a pediatric LDLT from an asymptomatic donor with mild coagulation FIX deficiency. A 32-yr-old female was evaluated as a donor for her 12-month-old daughter with biliary atresia. The donor's pretransplant coagulation tests revealed asymptomatic mild coagulation FIX deficiency (FIX activity 60.8%). Freeze-dried human blood coagulation FIX concentrate was administered before the dissection of the liver and 12 h afterwards by bolus infusion (40 U/kg) and was continued on POD 1. The bleeding volume at LDLT was 590 mL. On POD 1, 3, 5, and 13, the coagulation FIX activity of the donor was 121.3%, 130.6%, 114.6%, and 50.2%, respectively. The donor's post-transplant course was uneventful, and the recipient is currently doing well at 18 months after LDLT. The FIX activity of the donor and recipient at nine months after LDLT was 39.2% and 58.0%, respectively. LDLT from donors with mild coagulation FIX deficiency could be performed effectively and safely using peri-transplant short-term coagulation FIX replacement and long-term monitoring of the plasma FIX level in the donor.

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

Anastomotic stricture of the choledochojejunostomy is a common complication after living donor liver transplantation. Most anastomotic strictures can be treated by percutaneous transhepatic cholangiodrainage and/or double balloon endoscopy. However, in severe cases and/or in small infants, neither of these is possible. Our new technique, cholangiography accompanied by cholangioscopy, enabled successful guidewire placement and balloon dilatation in cases with severe anastomotic stricture.

Rational treatment for neoplasms of the duodenal papilla (NDPs) is still controversial, especially for early stage lesions. Total papillectomies are indicated in patients expected to have adenomas, adenocarcinoma in an adenoma, or mucosal adenocarcinomas with no lymph node metastases. However, the preoperative pathological evaluation of NDPs is still challenging and often inaccurate, mainly because of the complicated anatomical structures involved and the possibility of an adenocarcinoma in an adenoma. Herein, we introduce a new method of total papillectomy, the extraduodenal papillectomy (ExDP). In this method, papillectomy is undertaken from outside of the duodenum, instead of resection from the inside through a wide incision of the duodenal wall as is done in conventional transduodenal papillectomy (TDP). The advantages of ExDP are precise and deeper cutting of the sphincter and shorter exploration time of the tumor compared to conventional TDP. We demonstrate three representative patients, all of whom had an uneventful postoperative course. One of them subsequently underwent a pylorus preserving pancreatoduodenectomy after detailed postoperative pathological evaluation. Including that patient, no recurrence has occurred with 37-46 months of follow-up. In conclusion, ExDP is regarded as a "total biopsy" for early stage borderline lesions and a feasible, less demanding alternative method for the treatment of NDPs.

PURPOSE: This retrospective study evaluates the clinical course and outcomes of patients who underwent surgery for strangulated hernias. METHODS: Among 520 groin hernias from 2001 to 2012, 51 inguinal and 42 femoral hernias were strangulated and operated emergently at a tertiary referral center. Perioperative factors, patient profiles, and time interval to surgery (T total = time from onset to surgery, T 1 = time from onset to initial evaluation, T 2 = time from the first hospital to the tertiary center, T 3 = time from admission at the tertiary center to surgery, T total = T 1 + T 2 + T 3) were analyzed in patients with strangulation, then compared between two groups, the bowel resection (BR) group and the non-bowel resection (NBR) group. RESULTS: T 1, T 2 and T total in the bowel resection group were significantly longer than those in the non-bowel resection group (P < 0.05). Patients who presented initially to the tertiary center (T 2 = 0) had a significantly lower resection rate than patients transported from other hospitals (24 vs. 44 %, P = 0.048). There was no significant difference in morbidity between the BR and NBR groups (35 vs. 24 %, P = 0.231). CONCLUSIONS: The elapsed time from onset to surgery, especially T 1 and T 2, is the most important prognostic factor in patients with strangulated groin hernias. Early diagnosis and transportation are essential for good outcomes.

JMSコホート研究のデータを用いて、空腹時インスリン濃度(FI)、空腹時血糖(FG)と脳梗塞発症との関係について検討した。JMSコホート研究参加者の中で、FI、FGを測定しており、脳卒中、心筋梗塞の既往があるもの、糖尿病治療中のものを除外した2608例を対象とした。FI、FGをそれぞれ3分位に分け、FIが第1分位(T1)、FGがT1の群をGroup 1(G1)、FIがT2、FGがT1の群をG2、FIがT3、FGがT1の群をG3、FIがT1、FGがT2の群をG4、FIがT2、FGがT2の群をG5、FIがT3、FGがT2の群をG6、FIがT1、FGがT3の群をG7、FIがT2、FGがT3の群をG8、FIがT3、FGがT3の群をG9とした。統計学的手法としてCoxの比例ハザードモデルを用いた。G2を基準として脳梗塞発症のハザード比、95%信頼区間を計算したところ、G1、G3、G4、G5、G6、G7、G8、G9はそれぞれ3.93(1.13-13.72)、2.30(0.51-10.34)、2.19(0.58-8.19)、1.18(0.26-5.31)、2.96(0.81-10.88)、3.48(0.97-12.53)、2.39(0.66-8.62)、3.73(1.09-12.84)であった。脳梗塞発症とFIとの関係はFGの各レベルでU字型となっていた。(著者抄録)

BACKGROUND: The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis. METHODS: From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis. RESULTS: A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis. CONCLUSION: Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.

胆膵領域の診断に用いられる画像診断装置の進歩は著しい。これら画像診断装置から得られる高精細の情報を、系統的に活用する手法の開発が必要である。われわれは、画像情報を処理することによるvirtual 3D model(仮想三次元モデル)を作成した。さらに、産業界で用いられる3次元プリンタのrapid prototyping法によりreal 3D model(実体3次元モデル)を作成する手法を開発した。本手法により患者の個人情報を直接反映した臓器モデルが作成可能である。Virtual 3D modelは、コンピューター上での加工、処理が容易である。Real 3D modelは直接の大きさの把握や曲面の理解などに寄与する。デジタルとアナログの組み合わせにより、より詳細な理解や情報共有が得られる。今後は臨床のみならず、教育や患者コミュニケーションツールとしての活用も期待される。(著者抄録)

OBJECTIVE: The Lichtenstein inguinal hernia repair is commonly performed and suitable for teaching basic surgical skills. The objective of this study is to evaluate the feasibility of this procedure for surgical training, particularly in regard to patient outcomes.DESIGN: Retrospective case review after introduction of an integrated teaching program.SETTING: University teaching hospital.PARTICIPANTS: The Lichtenstein inguinal hernia repair is the standard procedure for adult primary unilateral inguinal hernia since 2003 at Jichi Medical University. We introduced an integrated teaching system of lectures, skill training, and videos to teach the skills for Lichtenstein inguinal hernia repair to residents and junior faculty in 2003. Cases were retrospectively divided into 4 groups. based on the experience of the operating surgeon; junior residents (PGY 1-2, group A), senior residents (PGY 3-5, group B), junior faculty (PGY 6-10, group C), and senior faculty (PGY 11 or more, group D). Background, perioperative factors, and outcomes were evaluated among the groups.RESULTS: A total of 246 elective inguinal hernia repairs (group A: 136, group B: 49, group C: 42, group D: 19) were performed. There was a significant difference in the frequeney of concomitant diseases (p = 0.012) and anticoagulant therapy (p = 0.031). Average operating time was 80.7 +/- 24.9, 72.6 +/- 20.8, 63.5 +/- 22.0, and 54.7 +/- 27.9 (min +/- SD) in groups A, B, C, and D, respectively, with a significant difference between groups A and D (p < 0.001). No significant differences were observed in estimated blood loss (p = 0.216) or morbidity (p = 0.294).CONCLUSIONS: The Lichtenstein inguinal hernia repair can be safely performed by residents and junior faculty with the appropriate supervision of senior faculty without any disadvantage to patients. This integrated teaching program for Lichtenstein inguinal hernia repair is effective and feasible for training residents and junior faculty. (J Surg 69:605-610. (C) 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

We report two cases of carcinoid tumor of the gallbladder. Case 1 was a 59-year-old woman who presented with epigastric pain. Abdominal ultrasonography and computed tomography (CT) revealed a 16 mm polypoid lesion in the neck of the gallbladder. Tumor markers were within normal limits. Open cholecystectomy was performed with a preoperative diagnosis of early cancer of the gallbladder. Case 2 was a 45-year-old man. A polyp in the gallbladder was incidentally detected on annual checkup. Ultrasound and CT showed an 18 mm protruding lesion in the neck of the gallbladder. Laparoscopic cholecystectomy was performed and the tumor diagnosed as a carcinoid tumor based on the findings of funicular and tubular cells in the lamina propria mucosa, homogeneous nuclei, basophilic cytoplasm, and positive staining with chromogranin A and synaptophysin. The postoperative course of both patients was uneventful, with no recurrence at 44 and 41 months after surgery. In this literature review of 39 cases, classical carcinoid of the gallbladder has a favorable postoperative outcome. Of cases reviewed, 60% are located in the neck of the gallbladder and 50% have a polypoid shape.

43歳男。発熱、呼吸促迫が出現し、胸部X線で右胸水貯留を指摘され紹介となった。胸腹部単純レントゲンで右胸水貯留、両側横隔膜挙上、小腸ガスの著明貯留を認め、腹部造影CTでは肝右葉に樹枝状門脈内ガス像を、小腸には壁内気腫像を認めた。腸管壁の造影効果は全長にわたって良好であった。画像所見に加え、血液生化学検査で炎症所見は強かったが、LDH、CPKの上昇はなく、腹膜刺激症状やアシドーシスも認めなかったことより、麻痺性イレウスによる腸管内圧亢進から生じた門脈内ガス血症と診断し、腸管壊死は否定的と考え保存的治療の方針とした。絶飲食、経鼻胃管挿入の上、輸液を行い抗生剤および免疫グロブリンを投与し、入院翌日のCTでは門脈内ガス像の消失を認めたが、腸管壁内気腫像は残存していた。全身状態が改善傾向にあったため保存的治療継続とし、第4病日に解熱して第8病日に炎症反応は沈静化した。第24病日のCTでは腸管壁内気腫も消失し、経鼻胃管からの排液も徐々に減少して胃管抜去に至り、第46病日より食事を開始し、第53病日に軽快退院した。

A 58-year old man was referred to our hospital for treatment of an abdominal mass. As for him, tumor resection with right nephrectomy had been performed ten years ago for a giant well-differentiated perinephric liposarcoma. CT examination showed a huge tumor shadow in the abdominal cavity. Abdominal MRI examination showed a 15 × 8 cm tumor with almost high signal intensity on the T2 weighted images. At laparotomy, a large bulky retroperitoneal tumor pointed out before an operation was found. Surgical extirpation of the tumor was performed. Besides, several tumors of the thumb head size were detected into right retroperitoneal fatty tissue. The right side mesocolon and the tumors were not able to exfoliate, therefore right hemicolectomy was performed. Histological features showed dedifferentiated liposarcoma. The postoperative course was uneventful. But eight months after surgery, he was admitted again for treatment of a 4 × 3 cm retroperitoneal tumor. Extirpation of the tumor was performed. Histological finding of this tumor also showed dedifferentiated liposarcoma. Dedifferentiation, occurring in 15% of the well-differentiated liposarcomas, sometimes may develop later. Long-term detailed follow-up is necessary for well-differentiated liposarcoma.

A 74-years old man was referred to our hospital for treatment of a rectal mass. Colonoscopy revealed villous tumor covering all the lower rectal lumen. Biopsy yielded a diagnosis of adenoma. CT examination showed tumor shadows of the rectum and the liver. Pelvic MRI examination showed a 10.5×8×7 cm tumor with high signal intensity on the T2 weighted images in the rectum. Rectosigmoidectomy with lymph node dissection was performed with the diagnosis of rectal cancer that metastasized to the liver. Histological and immuno- histochemical features showed coexistent poorly-differentiated small cell neuroendocrine cell (NEC) carcinoma and non-invasive well-differentiated adenocarcinoma in tubulovillous adenoma. However the chemotherapy with FOLFOX and Bevacizumab was performed postoperatively, the patient died in cancer 3 months after surgery. Rectal poorly-differentiated NEC carcinomas are thought to be a tumor with a high malignant potential. Recently, the UICC TNM classifications of malignant tumors, 7th edition and the Guidelines for colorectal NEC tumors of European Neuroendocrine Tumor Society have been published. They would be evaluated, and effective multimodal therapy for NEC carcinomas should be established.

58歳女。膀胱炎で近医入院した際、膵の嚢胞性腫瘤病変を指摘され当院紹介された。腹部超音波で膵尾部に30×28mmのhypo echoic massを認め、境界明瞭、内部不均一であった。胸部CTで異常所見はなく、腹部CTでは膵腫瘤の内部に隔壁様構造を認めた。MRIでは腫瘤に造影効果は認めず、内部はT2WIで淡い高信号、DWIで高信号を呈した。膵嚢胞性腺癌を疑い手術を施行し、膵体部頭側前面に3cm大の腫瘤を認め、膵内への浸潤性発育が疑われた。9番リンパ節が腫脹して腫瘤と一体になっており、膵体尾部・脾合併切除を施行した。術中に腫瘤の内容物が一部流出し、内容物は粘性のある黄白色調の性状であった。病理組織所見では類上皮細胞から成る肉芽腫、多核巨細胞、乾酪壊死を認め、Ziehl-Neelsen染色で抗酸菌は認めなかった。術中に採取した嚢胞内容液のPCR検査では結核菌が陽性で、孤立性膵結核と診断された。術後経過は良好で、退院後抗結核剤を6ヵ月間内服し、再発はない。

79歳男。主訴は吐血、タール便で、上部消化管内視鏡にて十二指腸球部に1cmの半球状の隆起性病変を認め、その中心に5mm大の粘膜欠損があり、静脈性出血を認め、静脈瘤からの出血が疑われた。手術を施行し、術中超音波検査で腫瘤内の血流を認め、腹腔動脈又は上腸間膜動脈領域から発生した動脈瘤の十二指腸穿破と診断した。流入動脈の検索目的で術中血管造影を行い胃十二指腸動脈瘤と判明し、塞栓術を行なったが完全には塞栓できず、開腹術を施行した。術後消化管出血は止まり、術後1ヵ月の腹部CTで胃十二指腸動脈結紮部付近に仮性腸嚢胞を認めたが、瘤内への造影剤流入は認めなかった。仮性肺嚢胞は術後2ヵ月で自然消退し、術後2年現在、再発は認めない。

60歳男性.患者は下血および腹痛を主訴に,近医で貧血を指摘され,著者らの施設へ紹介となった.入院時,腹部CTでは肝左葉辺縁部に門脈内ガスを認め,腸管壊死は否定的で,保存的治療にて門脈内ガスの軽減を認めたが,大量消化管出血によるショックを呈し,緊急開腹術を施行した.手術所見では回腸末端10cmから30cmにわたる浮腫状の腸管を40cm切除し,端々吻合を行った.術後,貧血は改善したが,再度下血し,出血性ショックとなり,再手術を施行した.病理組織学的に1回目の切除標本で不整型多発性の潰瘍性病変を認め,非特異性多発性小腸潰瘍症と診断した.再手術後5日目に縫合不全を発症し,小腸瘻を造設したが,経過良好で小腸瘻閉鎖術後に退院した.退院後1年経過した現在,小腸潰瘍の再発なみられない

管腔内超音波検査(intraductal ultrasonography;以下,IDUS),経口胆道鏡(peroral cholangioscopy;以下,POCS)が術前診断ならびに術式選択に有用であった粘液産生胆管癌の1例を経験したので報告する.症例は75歳の女性で,腹痛を主訴に近医を受診し,閉塞性黄疸の診断で当科紹介となり入院した.ERCPで主乳頭開口部の開大,粘液の排出を認め,総胆管内に粘液による陰影欠損を認めた.IDUSで前区域枝分岐部に粘膜の不整,肥厚をみとめ,深達度mと診断した.POCSで腫瘍の存在部位の確認,表層進展度の評価を行い,擦過細胞診で腺癌と診断された.以上の結果から,前区域枝分岐部に限局した深達度mの粘液産生胆管癌と診断し,肝外胆管切除術,肝管空腸吻合術を施行した.病理組織検査では大きさ1.5×1.0 cm,深達度mの乳頭腺癌で,手術根治度はAであった.術後1年2ヵ月が経過した現在,明らかな再発は認めず生存中である(著者抄録)

65歳男.食欲不振を認め,上部消化管造影検査にて幽門狭窄を指摘された.入院時,右上腹部に鶏卵大の硬い腫瘤を触知した以外に異常はなく,CTにて前庭部胃壁の肥厚を認めたのみであった.入院3日目突然上腹部の激痛が出現し,筋性防御と腹部CTにて腹腔内遊離ガス像を認めたため消化管穿孔と診断して緊急手術を施行した.胃L領域に存在する腫瘤の前壁穿孔を確認,肉眼所見で胃癌と診断し,幽門側胃切除,D2郭清,胃空腸吻合を行った.摘出標本では2型腫瘤の前壁に穿孔があり,病理組織学的には低分化型腺癌が漿膜下層まで浸潤し,総合的にT2,N1,H0,P0,M0,StageIIIa,根治度Aであった.術後,MTX-5FU療法とUFT内服を行い,術後6年経過した現在も再発所見はない.進行性胃癌穿孔では予後不良例が多いが,長期生存を得るにはできる限り根治度B以上の一期的手術を行う必要があると思われた

49歳男.膵体尾部腫瘤を主訴とした.人間ドックで膵体尾部腫瘤を指摘されたが腹痛等の症状はなかった.画像診断から膵体尾部の嚢胞腺腫あるいは同部周辺のリンパ管腫を疑った.経過観察中に腫瘤の増大傾向を認めたため,malignant potentialを有する膵嚢胞性腫瘍も否定できず,腹腔鏡下腫瘍摘出術を施行した.摘出された腫瘤は7.0×5.5×3.0cmの,結合織で囲まれた多房性腫瘍であった.悪性所見は認めず,膵海綿状リンパ管腫と診断された.術後経過は良好で,術後4年の現在,再発なく無症状で経過している.膵海綿状リンパ管腫は極めて稀な膵非上皮性腫瘍であり,検索し得た限り自験例を含め15例の報告があるのみであった

17歳女.嘔吐,摂食不良を主訴とした.乳児期から嘔吐の頻度が多かった.上部消化管透視,造影後腹部X線検査,腹部造影CT検査,腹部3D-CT検査の所見と経過から,長期にわたる極端な内臓下垂を伴った上腸間膜動脈性十二指腸閉塞症(SMA症候群)と診断した.手術適応と考えられ,腹腔鏡下に十二指腸第3部と空腸を経横行結腸間膜的に側々に吻合した.術後経過良好で,術後第5週の透視においても通過は良好であった.本症には術式も簡単で手術侵襲が少なく美容的にも優れている,経横行結腸間膜的腹腔鏡下十二指腸空腸吻合術がより適応と考えられた