鯉沼 広治

PURPOSE: The purpose of this study was to evaluate the clinical features, pathology, and etiology of adenocarcinoma in patients with anal fistulae. METHODS: We identified seven patients diagnosed with adenocarcinoma associated with anal fistulae from a retrospective chart review. RESULTS: Five patients were diagnosed with primary adenocarcinoma associated with anal fistulae. Two patients were diagnosed with secondary adenocarcinoma associated with anal fistulae originating from rectal cancer on the proximal side. The primary adenocarcinomas included cancers arising from long-standing anal fistulae fulfilling established diagnostic criteria in two patients, and cancer arising from short-duration anal fistulae in three patients. Excision of the fistula was performed based on the initial diagnosis of the anal fistula for all five patients. Increased suspicion of cancer was due to the existence of gelatinous material in the anal fistula in three patients and induration in the resected specimens in two patients. The etiologies of the secondary adenocarcinomas associated with anal fistulae included implantation in the anal fistula from rectal cancer and fistula formation originating due to the progression of rectal cancer. CONCLUSION: Anal fistulae are commonly seen in the coloproctology clinic, but special attention to similar conditions associated with malignant disease is needed.

A 41-year-old woman was admitted with upper abdominal pain, vomiting and fever. Abdominal CT scan showed a colo-duodenal fistula with inflammatory thickening of the transverse colon. The patient's general health was poor because of hypoalbuminemia and coagulopathy. Endoscopy showed a fistula at the lower duodenal angle and the stomach was filled with refluxed stool. Ileostomy and percutaneous endoscopic gastrostomy were performed at that time and a double lumen gastro-jejunostomy inserted through the gastrostomy to allow both gastric drainage and distal enteral feeding. Nutrition support was gradually converted from parenteral to enteral feeding. Colonoscopy showed stenosis of the transverse colon with a colo-colonic fistula near the stenosis. Two months later, right hemi-colectomy and closure of the colo-duodenal fistula were performed. The resected specimen showed stenosis and a fistula in the transverse colon due to Crohn's disease. The colo-colonic fistula was present and the colo-duodenal fistula had almost closed due to fibrosis. The postoperative course was uneventful and the patient was discharged after administration of infliximab. Use of a double lumen gastro-jejunostomy tube was effective in improving the patient's general condition. This therapeutic strategy allowed the safe conduct of major resection in a high-risk patient.

症例は66歳の女性で，嘔吐と体重減少を主訴に当院を受診した．腹部CTにて十二指腸周囲，肝十二指腸間膜，小網に至る気腫像，胃十二指腸下行脚部の著明な拡張，水平脚部のcaliber changeを認めた．さらに，多量の腹腔内free airと十二指腸周囲の後腹膜ガス像も認めたため，上腸間膜動脈症候群による腸管気腫症および上部消化管穿孔の診断で緊急手術を施行した．術中所見では胃十二指腸の拡張，および十二指腸気腫を認めたが穿孔所見や腹水は認めなかった．経胃腸瘻造設のみ行い，術後経過は良好であった．腸管気腫症の原因は多岐にわたり，時にfree airを伴い消化管穿孔との鑑別が困難なことがある．患者の臨床所見と腸管気腫症の成因を詳細に検討し治療方針を決定することが重要で，審査腹腔鏡も選択肢の一つと考えられた．

Retroperitoneal abscess after duodenal ulcer perforation is a rare condition. A 71-year-old woman was admitted with 1 month of appetite loss and back pain. Abdominal computed tomography scan showed a retroperitoneal mass behind the third and fourth portions of the duodenum. Single-balloon enteroscopy revealed erosion of the third portion of the duodenum with leakage of contrast agent into the retroperitoneal space. Based on a preoperative diagnosis of retroperitoneal abscess after duodenal perforation, laparotomy was performed. Partial duodenectomy with a duodeno-jejunal anastomosis was performed, and her postoperative course was uneventful. Pathology showed an ulcer with no specific findings.

We report the first case of sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer. The patient is a 75-year-old man who presented with the sudden onset of severe abdominal pain. He had undergone laparoscopic sigmoidectomy for cancer 2 years before presentation. CT scan showed a distended sigmoid colon with a mesenteric twist, or "whirl sign." Colonoscopy showed a mucosal spiral and luminal stenosis with dilated sigmoid colon distally and ischemic mucosa. The diagnosis of ischemic colonic necrosis due to sigmoid volvulus was established. Resection of the necrotic sigmoid colon was performed and a descending colon stoma was created. A long remnant sigmoid colon and chronic constipation may contribute to the development of sigmoid volvulus after laparoscopic sigmoidectomy. Prompt diagnosis is essential for adequate treatment, and colonoscopy aids in the diagnosis of ischemic changes in patients without definitive findings of a gangrenous colon.

A 64-year-old man received mFOLFOX6+bevacizumab chemotherapy for metastatic lung cancer after rectal cancer resection( Stage IV). After 28 courses, he had an abdominal pain with fever, and computed tomography showed pelvic abscess with stercolith of appendix. He was diagnosed as acute appendicitis with intra-abdominal abscess, and emergency appendectomy with drainage was performed. Two days after the operation, he was suspected to have a sutural leakage as was suggested from the properties of his drainage, therefore re-operation was performed. A small hole of the ileum, about 2mm in diameter, was observed. The margin of the hole showed neither inflammatory nor neoplastic change, and a suturing closure of the hole was performed. The post-operative course was uneventful. Histopathological findings of the resected appendix suggested that the perforation was caused by necrosis of metastatic cancer cells penetrating the appendiceal wall. This is a case of a bevacizumab-related metachronous perforation that occurred in different gastrointestinal origins within a very short term.

BACKGROUND: Lynch syndrome, also referred to as hereditary nonpolyposis colorectal cancer, is the most common form of hereditary colorectal cancer, and is associated with a high incidence of multiple primary neoplasms in various organs. METHODS: A 79-year-old woman (patient 1) diagnosed with ascending colon cancer had a history of previous carcinomas of the uterus, stomach, uroepithelial tract, and colon. One year later, she developed a brain tumor (glioblastoma). A 54-year-old female (patient 2) was diagnosed with endometrial cancer and sigmoid colon cancer. Both patients underwent genetic evaluations independently. RESULTS: No mutations were found in an exon-by-exon analysis of genomic DNA by polymerase chain reaction (PCR) and reverse transcription (RT)-PCR. However, multiplex ligation-dependent probe amplification (MLPA) identified genomic duplication spanning from exon 7 to exon 14 of the MSH2 gene in both patients. Due to the presence of this characteristic gene duplication, their pedigrees were investigated further, and these showed that they are paternal half-sisters, consistent with paternal inheritance. CONCLUSION: Large genomic duplication from intron 6 through intron 14 in MSH2 is a very rare cause of Lynch syndrome and is difficult to identify with conventional methods. MLPA may be an alternative approach for detecting large-scale genomic rearrangements.

We report a rare case of acute mastitis caused by enteric organisms passing through a cystoperitoneal shunt catheter, which had penetrated into the colon. The patient is a 56-year-old woman who underwent shunt placement for cyst formation after surgery for meningioma at the age of 29. After 26 years, she suffered from a brain abscess and an attempt was made to surgically remove the indwelling catheter. Only part of the catheter could be removed, leaving a divided and ligated catheter in situ. A year later, she described right-breast pain. CT showed that the catheter had migrated into the colon, followed by colonoscopy confirming that the catheter had indeed penetrated the colon. The breast to the abdomen segment of the catheter was exteriorized through the right-anterior chest wall without laparotomy. A patient who presents with acute mastitis and has previously undergone shunt surgery should have a careful assessment of the entire catheter.

大腸癌の予後および治療法の選択は深達度と密接に関係している.CT colonographyでは,MDCTの技術革新に伴って,短時間で仮想内視鏡像や仮想注腸像,MPR像といった様々なpost processing imageの作成が可能となった.一方,大腸内視鏡や注腸造影検査においては,これまでに培われたそれぞれの診断基準が存在する.CT colonographyにおける大腸癌の深達度診断においては,得られた様々なpost processing imageに,従来のモダリティで培われた診断基準を用いて,総合的に診断することで的確な深達度診断が可能と考える.(著者抄録)