伊藤 誉

BACKGROUND: The aim of this study was to evaluate the effect of staple height and rectal wall thickness on the development of an anastomotic leak after laparoscopic low anterior resection performed with the double stapling technique. METHODS: One hundred ninety-nine patients treated from 2013 to 2021 were enrolled. Patients were divided into two groups: those who developed an anastomotic leak (AL (+)) and those who did not (AL (-)). Clinicopathological factors were compared between the groups. RESULTS: Anastomotic leaks were observed in 8/199 patients (4%). A 1.5 mm linear stapler was used for 35/199 patients (17%), 1.8 mm for 89 (45%), and 2 mm for 75 (38%). In the AL (+) group (n = 8), lower staple height (1.5 mm or 1.8 mm) was used more frequently than in the AL (-) group (n = 191). Rectal wall thickness and the rectal wall thickness to staple height ratio was significantly (p < .05) greater in the AL (+) group. However, rectal wall thickness was significantly (p < .05) greater in patients who received neoadjuvant treatment and those with advanced T stage (T3,4) lesions. CONCLUSION: Linear stapler staple height and rectal wall thickness are significantly associated with the development of an anastomotic leak after laparoscopic low anterior resection. Larger staples should be selected in patients with a thicker rectal wall due to neoadjuvant treatment or adjacent advanced rectal tumors.

Adenocarcinoma in a Meckel's diverticulum is rare and difficult to diagnose preoperatively. We report the first case of a metachronous Krukenberg tumor from adenocarcinoma in a Meckel's diverticulum. A 45-year-old woman was admitted for recurrent abdominal pain. Computed tomography scan showed a lesion with contrast enhancement, and a Meckel's diverticulum-associated tumor was suspected. Double-ballon enteroscopy revealed intestinal stenosis and biopsy showed adenocarcinoma. Operative findings showed a Meckel's diverticulum with tumor. Histopathological evaluation revealed well-differentiated adenocarcinoma, interrupted by ectopic gastric mucosa, diagnosed as adenocarcinoma in a Meckel's diverticulum. Two years postoperatively, a multi-cystic mass with contrast enhancement was observed in the pelvis on imaging evaluation and oophorectomy performed. Histological examination of the resected ovary showed proliferation of atypical glandular ducts, consistent with metastatic adenocarcinoma. This case demonstrates that adenocarcinoma in a Meckel's diverticulum may result in distant metastases and requires appropriate follow-up.

75歳以上の高齢者における腹腔鏡下大腸手術の治療成績を検討したので報告する。当院において2010年1月から2017年6月までの期間に大腸癌に対し腹腔鏡下大腸手術を施行した565例を対象とし、75歳未満の若年者群(474例)と75歳以上の高齢者群(91例)の2群間の短期成績を比較検討した。高齢者群において術前併存症が多くASA scoreは高値であった。また、高齢者群においてD3郭清の施行率が低く(高齢者群41.8%vs若年者群54.0%、p=0.04)、開腹移行率が高値であった(高齢者群4.4%vs若年者群1.1%、p=0.04)。しかし両群間において手術時間、術中出血量、術後在院日数、術後合併症発生率について有意差を認めなかった。以上より75歳以上高齢者においても75歳未満の若年者と同様に腹腔鏡下大腸手術を選択することが可能である。(著者抄録)

A 41-year-old woman presented with a positive fecal occult blood test. Colonoscopy showed a 20mm, elastic, hard lesion at the appendiceal orifice. Abdominal computed tomography revealed a protruding lesion in the intestine. Laparoscopic ileocecal resection was performed. Histological examination showed endometrial glands in the muscularis propria, consistent with appendiceal endometriosis. We report a patient with appendiceal endometriosis with intussusception.

症例は41歳女性,便潜血検査陽性のため行われた大腸内視鏡検査で,虫垂開口部に径20mmの正常粘膜に覆われた弾性,硬の隆起性病変を認めた.腹部CTでは腸管内腔に突出した隆起性病変として描出され,粘膜下腫瘍の術前診断で腹腔鏡下回盲部切除術を行った.術中観察では虫垂は盲腸内に反転しており虫垂重積を疑う所見であった.病理組織学的検査では,割面で虫垂粘膜の内反を認め,筋層内には円柱状の細胞からなる腺管が内膜様間質を伴って散見され,虫垂子宮内膜症に矛盾しない所見であった.虫垂子宮内膜症を原因とした虫垂重積症は稀であるが,特徴的な内視鏡所見を把握することで,盲腸切除などの縮小手術を施行できる可能性がある.(著者抄録)

Intestinal ischemia/reperfusion (I/R) injury is a life-threatening complication that leads to inflammation and remote organ damage. The NLRP3 inflammasome regulates the caspase-1-dependent release of IL-1 beta, an early mediator of inflammation after I/R injury. In this study, we investigated the role of the NLRP3 inflammasome in mice with intestinal I/R injury. Deficiency of NLRP3, ASC, caspase-1/11, or IL-1 beta prolonged survival after intestinal I/R injury, but neither NLRP3 nor caspase-1/11 deficiency affected intestinal inflammation. Intestinal I/R injury caused acute lung injury (ALI) characterized by inflammation, reactive oxygen species generation, and vascular permeability, which was markedly improved by NLRP3 deficiency. Bone marrow chimeric experiments showed that NLRP3 in non-bone marrow-derived cells was the main contributor to development of intestinal I/R-induced ALI. The NLRP3 inflammasome in lung vascular endothelial cells is thought to be important to lung vascular permeability. Using mass spectrometry, we identified intestinal I/R-derived lipid mediators that enhanced NLRP3 inflammasome activation in lung vascular endothelial cells. Finally, we confirmed that serum levels of these lipid mediators were elevated in patients with intestinal ischemia. To our knowledge, these findings provide new insights into the mechanism underlying intestinal I/R-induced ALI and suggest that endothelial NLRP3 inflammasome-driven IL-1 beta is a novel potential target for treating and preventing this disorder.

Hepatic ischemia-reperfusion (I/R) injury is a major problem in liver transplantation (LT). Although hepatocyte cell death is the initial event in hepatic I/R injury, the underlying mechanism remains unclear. In the present study, we retrospectively analyzed the clinical data of 202 pediatric living donor LT and found that a high serum ferritin level, a marker of iron overload, of the donor is an independent risk factor for liver damage after LT. Since ferroptosis has been recently discovered as an iron-dependent cell death that is triggered by a loss of cellular redox homeostasis, we investigated the role of ferroptosis in a murine model of hepatic I/R injury, and found that liver damage, lipid peroxidation, and upregulation of the ferroptosis marker Ptgs2 were induced by I/R, and all of these manifestations were markedly prevented by the ferroptosis-specific inhibitor ferrostatin-1 (Fer-1) or alpha-tocopherol. Fer-1 also inhibited hepatic I/R-induced inflammatory responses. Furthermore, hepatic I/R injury was attenuated by iron chelation by deferoxamine and exacerbated by iron overload with a high iron diet. These findings demonstrate that iron overload is a novel risk factor for hepatic I/R injury in LT, and ferroptosis contributes to the pathogenesis of hepatic I/R injury.

Pyroptosis is a form of regulated cell death that is characterized by gasdermin processing and increased membrane permeability. Caspase-1 and caspase-11 have been considered to be essential for gasdermin D processing associated with inflammasome activation. In the present study, we found that NLRP3 inflammasome activation induces delayed necrotic cell death via ASC in caspase-1/11-deficient macrophages. Furthermore, ASC-mediated caspase-8 activation and subsequent gasdermin E processing are necessary for caspase-1-independent necrotic cell death. We define this necrotic cell death as incomplete pyroptosis because IL-1β release, a key feature of pyroptosis, is absent, whereas IL-1α release is induced. Notably, unprocessed pro-IL-1β forms a molecular complex to be retained inside pyroptotic cells. Moreover, incomplete pyroptosis accompanied by IL-1α release is observed under the pharmacological inhibition of caspase-1 with VX765. These findings suggest that caspase-1 inhibition during NLRP3 inflammasome activation modulates forms of cell death and permits the release of IL-1α from dying cells.

Background: Intestinal ischemia/reperfusion (I/R) injury is a life-threatening complication that leads to inflammation and remote organ damage. However, the underlying mechanism is not yet fully understood. Toll-like receptor 5 (TLR5) is highly expressed in mucosa and recognizes flagellin, the main component of the bacterial flagella. Here, we investigated the role of TLR5 in inflammation and tissue damage after intestinal I/R injury using TLR5-deficient mice.Methods and results: Intestinal levels of TLR5 mRNA and flagellin protein were elevated in wild-type mice subjected to intestinal I/R. Although TLR5 deficiency had no effect on intestinal flagellin levels, it significantly attenuated intestinal injury and inflammatory responses after intestinal I/R. TLR5 deficiency also markedly improved survival in mice after intestinal I/R injury. In wild-type mice, intestinal I/R injury induced remote organ damage, particularly in the lung, which was attenuated by TLR5 deficiency. Furthermore, TLR5 deficiency prevented lung inflammatory responses and vascular permeability after intestinal I/R injury.Conclusion: These findings demonstrate a novel role of TLR5 and provide new insights into the mechanism underlying inflammation and tissue damage after intestinal I/R injury. (C) 2019 Elsevier Inc. All rights reserved.

Long-term peritoneal dialysis (PD) therapy leads to peritoneal inflammation and fibrosis. However, the mechanism underlying PD-related peritoneal inflammation and fibrosis remains unclear. NLRP3 inflammasome regulates the caspase-1-dependent release of interleukin-1β and mediates inflammation in various diseases. Here, we investigated the role of NLRP3 inflammasome in a murine model of PD-related peritoneal fibrosis induced by methylglyoxal (MGO). Inflammasome-related proteins were upregulated in the peritoneum of MGO-treated mice. MGO induced parietal and visceral peritoneal fibrosis in wild-type mice, which was significantly reduced in mice deficient in NLRP3, ASC, and interleukin-1β (IL-1β). ASC deficiency reduced the expression of inflammatory cytokines and fibrotic factors, and the infiltration of macrophages. However, myeloid cell-specific ASC deficiency failed to inhibit MGO-induced peritoneal fibrosis. MGO caused hemorrhagic ascites, fibrin deposition, and plasminogen activator inhibitor-1 upregulation, but all of these manifestations were inhibited by ASC deficiency. Furthermore, in vitro experiments showed that MGO induced cell death via the generation of reactive oxygen species in vascular endothelial cells, which was inhibited by ASC deficiency. Our results showed that endothelial NLRP3 inflammasome contributes to PD-related peritoneal inflammation and fibrosis, and provide new insights into the mechanisms underlying the pathogenesis of this disorder.

IntroductionTransverse colon resection is one of the most difficult laparoscopic procedures because of anatomic hazards such as variations in the mesenteric vascular anatomy and the complex structure of organs and surrounding membranes.MethodsWe evaluated the short-term surgical outcomes of laparoscopic transverse colon resection using a creative approach. This approach included preoperative surgical simulation using virtual surgical anatomy by CT, a four-directional approach to the mesentery, and 3-D imaging during laparoscopic surgery.ResultsA total of 45 consecutive patients who underwent laparoscopic resection for transverse colon cancer from June 2013 to December 2017 were enrolled in this study. All procedures were completed safely, with minor postoperative complications, including two patients with anastomotic stenosis, two with intra-abdominal phlegmon, one with delayed gastric emptying, and one with pneumonia, all treated non-operatively. There were no conversions to open resection. Operation time was 203min (range, 125-322min), and the estimated blood loss during surgery was 5mL (range, 0-370mL). The mean postoperative hospital stay was 10days (range, 7-21days), and no patients required readmission.ConclusionShort-term surgical outcomes after laparoscopic transverse colon resection demonstrated that this creative approach was safe and feasible. The four-directional approach to the meso-transverse attachment combined with preoperative radiological simulation can facilitate laparoscopic transverse colon surgery.

右側結腸手術の周術期管理に、Enhanced Recovery After Surgeryプロトコル(ERAS)を導入したので短期成績を報告する。2014年6月から2017年10月に行われた右側結腸手術症例をERAS群、2010年1月から2014年5月の症例を従来群とし、後方視的に検討した。ERAS群では、機械的前処置の省略、術直後の胃管抜去、早期経口摂取開始を新たに採用した。ERAS群182例(腹腔鏡103例、開腹79例)、従来群202例(腹腔鏡84例、開腹118例)であった。腹腔鏡手術では、ERAS群と従来群で手術関連因子、術後合併症に差は認めなかった。開腹手術では、表層性の創部感染の発生率はERAS群で有意に高かった(ERAS群12.7%:従来群2.5%)が、Clavien-Dindo分類2以上の術後合併症はERAS群で有意に低かった(ERAS群3.8%:従来群18.6%)。右側結腸手術において当科のERASプロトコルは安全に導入可能である。(著者抄録)

Introduction: Laparoscopic lateral pelvic lymph node dissection (LPLD) is technically challenging because of the complicated anatomy of the pelvic wall. To overcome this difficulty, we introduced preoperative 3-D simulation. The aim of the study is to investigate the usefulness of preoperative 3-D simulation for the safe conduct of laparoscopic LPLD for rectal cancer.Methods: After undergoing colonoscopy, patients were brought to the radiology suite where multi-detector row CT was performed. Three-dimensional images were constructed at a workstation and showed branches of the iliac artery and vein, ureter, urinary bladder, and enlarged lymph nodes. All members of the surgical team participated in preoperative simulation using the 3-D images.Results: A total of 10 patients with advanced lower rectal cancer and enlarged lateral pelvic lymph nodes underwent laparoscopic unilateral LPLD after total mesorectal excision, tumor-specific mesorectal excision, or total proctocolectomy. Four of the 10 patients (40%) had variations in pelvic vascular anatomy. The median operative time for unilateral LPLD was 91 min (range, 66-142 min) and gradually declined, suggesting a good learning curve. The median number of lateral pelvic lymph nodes harvested was nine (range, 3-16). The median estimated blood loss was 13 mL (range, 10-160 mL). No conversion to open surgery or intraoperative complications occurred. No patient had major postoperative complications.Conclusion: Preoperative 3-D simulation may be useful for the safe conduct of laparoscopic LPLD, especially for surgeons with limited prior experience.

We report three cases of colonoscope incarceration in a left inguinal hernia. In the first case, colonoscopy could be successfully performed with manual compression. The colonoscope could not be inserted in the other two cases. It is important to obtain a careful history and physical examination before colonoscopy. The scope must be carefully removed in patients with an inguinal hernia.

症例は30歳女性。突然の心窩部痛を主訴に救急外来を受診。来院時苦悶様顔貌で、右季肋部に圧痛を認めた。腹部CT検査で胆嚢腫大および粘膜の高吸収像、頸部の渦巻き像を認めたことから胆嚢捻転と診断し、緊急で腹腔鏡下胆嚢摘出術を施行した。腹腔内を観察すると、胆嚢は捻転解除後であったが、著明に腫大しており、漿膜面に虚血性変化を認めた。胆嚢は底部、体部が肝床部に固定されていない遊走胆嚢(Gross分類II型)であった。内腔は粘膜面の黒色調変化を来し、組織学的に壁全層の炎症細胞浸潤、うっ血、出血を認め、捻転に伴う変化として矛盾しない所見であった。胆嚢捻転はまれな疾患であり、先天的要因として遊走胆嚢、後天的要因として亀背、側彎、腹部打撲などが指摘されている。高齢女性に多いとされるが、小児や若年者の報告も散見され、原因不明の胆嚢腫大を認めた場合は、常に捻転の可能性を考慮すべきである。治療は腹腔鏡下胆嚢摘出術が適している。(著者抄録)

Metachronous solitary metacarpal bone metastasis from rectal cancer has not been reported previously. Here, we describe a 54-year-old woman who underwent abdominoperineal resection for rectal cancer following neoadjuvant chemoradiotherapy. The resected specimen contained adenocarcinoma with no lymph node metastases (Stage II, T3N0M0); no adjuvant chemotherapy was administered. Fifteen months after surgery, the patient presented with pain and swelling of the right thumb. Radiography revealed metacarpal bone destruction, and fluorine-18 fluorodeoxyglucose positron emission tomography showed uptake only in the metacarpal bone. Open biopsy revealed an adenocarcinoma, and a right thumb resection was performed. Histological examination indicated features of adenocarcinoma similar to the findings of a rectal lesion, leading to a diagnosis of metachronous solitary metacarpal bone metastasis from rectal cancer. The patient remains free of disease after 6 years of follow-up. Our findings suggest that surgical resection may lead to favorable outcomes in patients with resectable solitary bone metastases.

Accumulating evidence suggests that IL-1 beta plays a pivotal role in the pathophysiology of hepatic ischemia-reperfusion (I/R) injury; however, the mechanism by which I/R triggers IL-1 beta production in the liver remains unclear. Recent data have shown that neutrophils contribute to hepatic I/R injury independently of the inflammasomes regulating IL-1 beta maturation. Thus, we investigated the role of neutrophils in IL-1 beta maturation and tissue injury in a murine model of hepatic I/R. IL-1 beta was released from the I/R liver and its deficiency reduced reactive oxygen species generation, apoptosis, and inflammatory responses, such as inflammatory cell infiltration and cytokine expression, thereby resulting in reduced tissue injury. Depletion of either macrophages or neutrophils also attenuated IL-1 beta release and hepatic I/R injury. In vitro experiments revealed that neutrophil-derived proteinases process pro-IL-1 beta derived from macrophages into its mature form independently of caspase-1. Furthermore, pharmacological inhibition of serine proteases attenuated IL-1 beta release and hepatic I/R injury in vivo. Taken together, the interaction between neutrophils and macrophages promotes IL-1 beta maturation and causes IL-1 beta-driven inflammation in the I/R liver. Both neutrophils and macrophages are indispensable in this process. These findings suggest that neutrophil-macrophage interaction is a therapeutic target for hepatic I/R injury and may also provide new insights into the inflammasome-independent mechanism of IL-1 beta maturation in the liver.

左側大腸癌イレウス治療における経肛門イレウス管の適応と限界について後方視的に検討した。2006〜2011年に当科で手術治療を施行した左側大腸癌イレウス59症例を経肛門イレウス管減圧群(DC群)と非減圧群(NDC群)の2群に分け治療成績を比較した。イレウス管留置成功率は89%であった。DC群25例中、一期的切除吻合術が施行できたのは13例(52%)のみであった。7例(28%)では減圧したにも関わらずストマ造設のみ施行されており、原因として減圧不良(4例)、血清アルブミン低値(3例)、骨盤内他臓器浸潤(2例)があげられた。一期的切除吻合を目的とした経肛門イレウス管挿入は遠隔転移や高度局所浸潤がなく栄養状態良好症例には良い適応と考えられた。一方、栄養状態不良症例には術前経口摂取が可能となるステント挿入を、遠隔転移や高度局所浸潤症例に対してはストマ造設を選択すべきと考えられた。(著者抄録)

クリニカルパスを用いて周術期管理を行った直腸癌前方切除症例94例を対象とし、以前のクリニカルパスで周術期管理を行った40例(男性21名、女性19名、65±10歳;5日目食事開始パス群)と経口摂取を早めたクリニカルパスで周術期管理を行った54例(男性33名、女性21名、61±12歳;2日目食事開始パス群)に分けた。手術に関しては、2日目食事開始パス群で腹腔鏡の手術の割合が増加した。入院中の経過は、術後在院日数は両群とも平均12日でパス通りであった。バリアンスでは2日目食事開始パス群において飲水や流動食開始遅延が有意に多く認められたが、退院が13日目以降に遅延した症例は2群間で有意差がなかった。ドレーン挿入留置期間も2群間で有意差を認めなかった。術後合併症は、SSIおよび縫合不全症例は2群間で有意差を認めなかった。一過性腸管麻痺を含めた術後イレウスが2日目食事開始パス群で有意に減少した。尿道カテーテル抜去後の尿閉の発症頻度は2日目食事開始パス群で少なかった。退院後の経過では2群とも再入院や再手術を要する症例は一例も認めなかった。

Metastatic squamous cell carcinoma (SCC) from an unknown primary site to the colon has not been reported previously. A 75-year-old woman presented with a mass in the left submandibular region. Biopsy revealed a Class V lesion, but the histologic type was undetermined. Surgical resection of the left submandibular gland with cervical lymph node dissection was performed. However, SCC was seen in the lymph nodes only, with no tumor in the submandibular gland. Three months after surgery, computed tomography revealed that the preoperatively diagnosed lesion in the transverse colon had grown considerably. A laparoscopic right hemicolectomy was performed. Histological examination showed features of SCC, similar to the findings in the cervical lymph nodes. We report a rare case of synchronous metastatic SCC to the colon and cervical lymph nodes from a carcinoma of unknown primary site.

A 48-year-old man underwent laparoscopic sigmoid colon resection for cancer and surveillance colonoscopy was performed annually thereafter. Five years after the resection, a submucosal mass was found at the anastomotic staple line, 15 cm from the anal verge. Computed tomography scan and endoscopic ultrasound were not consistent with tumor recurrence. Endoscopic mucosa biopsy was performed to obtain a definitive diagnosis. Mucosal incision over the lesion with the cutting needle knife technique revealed a creamy white material, which was completely removed. Histologic examination showed fibrotic tissue without caseous necrosis or tumor cells. No bacteria, including mycobacterium, were found on culture. The patient remains free of recurrence at five years since the resection. Endoscopic biopsy with a cutting mucosal incision is an important technique for evaluation of submucosal lesions after rectal resection. (C) The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.

Purpose Endocrine cell carcinoma, according to the Japanese classification criteria for colorectal cancer, corresponds to neuroendocrine carcinoma (NEC) and mixed adenoneuroendocrine carcinoma (MANEC), as defined in the 2010 World Health Organization (WHO) classification. We retrospectively reviewed the clinical features of patients with these tumors diagnosed and treated at our institution.Methods The clinicopathological features of endocrine cell carcinomas of the colon and rectum diagnosed by neuroendocrine markers from January 2000 to December 2012 were retrospectively evaluated in 12 patients.Results Surgical specimens were obtained from eight of the 12 patients. MANEC was diagnosed in six patients and NEC in one. One tumor was unclassifiable. The tumors were not resected in four patients, and all died within 3 months. Of the eight patients who underwent resection, four received an R0 resection, two of whom underwent adjuvant chemotherapy and survived more than 5 years. One patient who underwent an R2 resection and continuous chemotherapy survived for 53 months. One patient with NEC underwent surgery and radiotherapy, and died 17 months later.Conclusion Most endocrine cell carcinomas of the colon and rectum reviewed were MANECs. Though their prognosis was generally poor, chemotherapy may be effective in some patients.

We hypothesized that a reduction in the size of the lymph nodes after neoadjuvant therapy for locally advanced rectal carcinoma would be associated with decreased lymph node metastases and/or a better prognosis.Between March 2006 and April 2012, 71 patients with primary rectal cancer received neoadjuvant chemoradiation therapy (CRT). For all lymph nodes 5 mm or larger in size, the major and minor axes were measured on CT scan images, and the product was calculated. The lymph node size was determined before and after CRT. The patients were divided into three groups based on the lymph node size before and after treatment. Group A exhibited a reduction in size of 60 % or more, Group B a reduction of less than 60 % and Group C had no lymph node enlargement before treatment.The incidence of lymph node metastases on pathological examination was 15 % in Group A and 50 % in Group B (p = 0.006). The five-year disease-free survival in Group A was 84 % compared with 78 % in Group B (log rank p = 0.34). The five-year overall survival in Group A was 92 % compared with 74 % in Group B (log rank p = 0.088).A reduction in the size of enlarged lymph nodes after neoadjuvant therapy may be a useful prognostic factor for recurrence and survival.

Recently, bevacizumab has become a key drug for treatment of metastatic colorectal cancer. Molecularly targeted agents such as bevacizumab can cause life-threatening adverse effects, though they are generally considered less toxic than cytotoxic drugs. Here, we review the case of a 76-year-old male rectal cancer patient with liver metastasis who suffered extensive bowel necrosis after administration of 5-fluorouracil-based chemotherapy with bevacizumab, and required a subtotal colectomy and end-ileostomy. Microscopic findings revealed extensive mucosal necrosis in the resected colon specimen and necrosis at the muscularis propria of the descending colon. Pathological findings suggested that the mucosal damage induced by chemotherapy may be exacerbated by treatment with bevacizumab, resulting in extensive necrosis.

要旨：77 歳男性．急性A 型大動脈解離を認め，術前心タンポナーデに伴うショック状態であった．造影CT では，偽腔開存の大動脈解離を認め腹部分枝まで解離が及んでいた．緊急上行大動脈置換術を施行し，術中腸管虚血を疑う所見なく手術を終了した．術後10 時間で下血を認め緊急試験開腹手術を施行した．小腸に虚血を認めず，S 状結腸壊死を認め結腸切除を施行した．帰室後よりアシドーシスの進行と膀胱内圧軽度高値を認め，再度腸管虚血を疑い，2 回目の緊急試験開腹術を施行した．広範な小腸虚血を認めたが，切除範囲が広く切除を断念した．しかし保存的治療で腸管虚血・全身状態の改善を認め退院となった．可逆的な腸管虚血の診断は難しいが，広範な虚血のため虚血部腸管が切除できない症例でもその後虚血が回復することがあり，腸管虚血に対し試験開腹による腹腔内圧の減圧効果が治療に奏功した可能性がある．

The ileosigmoid knot (ISK) is a rare cause of intestinal obstruction. ISK is a condition in which the ileum wraps around the base of the sigmoid colon and forms a knot, leading to high mortality with rapid progression to bowel gangrene. We herein report a rare case of ISK at week 13 of pregnancy. The ISK was diagnosed by computed tomography, and the patient underwent emergency surgery for acute abdomen. Laparotomy showed segmental gangrenous change in the sigmoid colon, which was twisted around the distal ileal loop. The gangrenous bowel was resected, and primary anastomosis was performed. To our knowledge, the present case involves the first and earliest pregnancy in which a preoperative diagnosis of ISK was made and successful treatment was performed with surgery. A radiologic approach should be undertaken for prompt diagnosis and optimal management, even in early pregnancy.

35歳男。慢性的に腹痛が出現し、検診で便鮮血を指摘された。下部内視鏡検査を施行され、回腸末端に潰瘍性病変を指摘された。経肛門的ダブルバルーン内視鏡(DBE)を施行した。回盲弁は破壊され、回腸末端から5cm程の長さで、不整形の潰瘍を認めた。腹部造影CTでは、盲腸から回腸末端にかけて壁肥厚、造影効果を認め周囲脂肪織の索状影や濃度の上昇を認めた。回腸末端に深い潰瘍、狭窄を認め、腹痛も改善傾向ないため診断、治療目的に腹腔鏡下補助下回盲部切除術を行う方針とした。口腔内アフタ、ブドウ膜炎、外陰部潰瘍などの既往なく、Behcet病の診断基準を満たさないため単純性潰瘍と診断した。合併症の発症なく、術後9日目に退院となった。

Dilatation and curettage (D&C) sometimes causes uterine perforation, which usually does not cause a serious problem. Here, we report uterine perforation caused by D&C, in which the small intestine prolapsed from the uterus, requiring intestinal resection. D&C was performed for missed abortion at 9 weeks. After dilating the cervix, forceps grasped tissue that, upon being pulled, resulted in the intestine being prolapsed into the vagina. Laparotomy revealed a perforation at the low anterior uterine wall, through which the ileum had prolapsed. The mesentery of the prolapsed ileum was completely detached and the ileum was necrotic, which was resected. The uterus and the intestine were reconstructed. Although intestinal prolapse is considered to be caused by "unsafe" D&C performed by inexperienced persons or even by nonphysicians in developing countries, this occurred in a tertiary center of a developed country. We must be aware that adverse events such as uterine perforation with intestinal prolapse can occur even during routine D&C.

80歳代男。食欲不振を主訴とした。血液検査で閉塞性黄疸と肝胆道系酵素、腫瘍マーカーの上昇を認め、腹部造影CTでは胆嚢癌の胆嚢床浸潤による肝門部胆管・十二指腸球部・横行結腸への浸潤と、播種・リンパ節転移が疑われた。胆嚢癌Stage IVbの臨床診断で、入院5〜16日目に内視鏡的逆行性胆管膵管造影・下部消化管内視鏡・上部消化管内視鏡によりそれぞれ胆管・十二指腸および横行結腸の狭窄に対して3期的にstentを内挿し、入院19日目に経口摂取を開始した。黄疸・便秘は改善し、入院44日目に退院した。退院後4ヵ月経過してステントの狭窄は認めていない。

Metastatic pancreatic cancer is rare, accounting for approximately 2% of all pancreatic malignancies, and most cases arise from renal cell carcinoma. We report the case of a 63-year-old woman, who presented with a pancreatic tumor detected during her annual health examination. She had undergone left nephrectomy 13 years previously for renal cell carcinoma. Computed tomography (CT) revealed two tumors in the head and body of the pancreas, a hypervascular tumor and a hypovascular tumor with an enhanced rim, respectively. She underwent pylorus-preserving pancreaticoduodenectomy, and metastatic pancreatic tumors arising from the kidney with clustered clear cell carcinoma immunohistochemically positive for CD10 were diagnosed. This report presents the different enhancement features of different lesions on CT scans. Because the enhancement features of lesions have been reported to vary according to the size of the metastatic tumor, a knowledge of the history of renal cell carcinoma is crucial for diagnosis.

2010年に十二指腸ステントが保険収載されて以来、幽門狭窄や十二指腸狭窄に対してステントの挿入が行われるようになってきている。当院では2010年4月から2012年10月までの間、悪性腫瘍にて幽門や十二指腸の通過障害を生じた症例のうち、バイパス手術を選択しなかった22例に対して十二指腸ステントの挿入を試み、19例に留置した。男女比は15:4で男性が多く、平均年齢は73.7歳。平均狭窄長は39.95mm(最短20mm、最長100mm)であった。食事再開までの平均日数は2.25日であり、挿入完遂率は86%(19/22)。全粥摂取可能となったのは84%(16/19)。重篤な合併症は消化管穿孔が1例であった。また、生存日数は平均166.7日であり、最短は1日。最長で807日(現在生存中)であった。十二指腸ステントは幽門や十二指腸狭窄を伴う高度進行癌に対して有効な治療法の1つであると考えられた。(著者抄録)

当院では2011年4月よりラジアル型超音波内視鏡検査を導入し、2012年7月までの1年3ヵ月に膵管内乳頭粘液性腫瘍(膵IPMN)22例に対しEUS検査を行った。対象は男女比13:9で41歳から80歳の22症例であった。主膵管型、分枝膵管型、混合型の比率は2:16:4で、壁在結節は22例中9例に認めた。EUS検査を行った22例中10例は手術適応と判断し、うち6名は切除術を施行した[膵管内乳頭粘液性腺癌(膵IPMC)5例、膵管内乳頭粘液性腺腫(膵IPMA)1例]。EUSにて壁在結節を確認できた9症例において、CTやMRI検査にて壁在結節が確認できなかった症例は7例あった。過去の文献においても壁在結節の描出率は78%と報告されており(体外式US35%、MRI19%、CT24%)、膵IPMNの悪性度診断における高危険因子である壁在結節の診断においてEUSは非常に有意な検査と考えられる。2012年度版IPMN国際診療ガイドラインにおいてworrisome featureを呈する症例(嚢胞径30mm以上、主膵管径5〜9mmなど)にEUS検査が推奨され、経過観察方法についても20mm以上の嚢胞径の症例についてEUSが推奨されている。自験例においてはworrisome featureを呈さない嚢胞径15mmの症例でもEUSにて壁在結節を認め、病理組織学的に悪性所見を認めた症例もあり、膵IPMNにおいて初回診断時に可及的全例にEUS検査を行うべきと考える。約1年3ヵ月の期間にてEUSを行った膵IPMN症例22例について検査所見、経過、病理組織検査結果などについて報告する。(著者抄録)

59歳男性。検診の上部消化管内視鏡検査にて食道異常所見を指摘され、著者らの施設へ受診となった。所見では上部消化管造影および胸部CT、MRI検査では胸部下部〜中部食道に粘膜下腫瘍が認められた。また、FDG-PETでは食道病変に一致して異常集積を示し、超音波内視鏡では腫瘍は低エコーを呈していた。以後、EUS-FNABの結果、本症例は食道GISTと診断され、リスク分類で中間リスク以上と考え、右開胸開腹中下部食道切除ならびに胸腔内胃管再建術が行われた。その結果、術後の経過は良好で、患者は第26病日目に軽快退院となった。

70歳代女。40年前に胃潰瘍穿孔に対して広範囲胃切除術、Billroth II法再建を施行された。心窩部不快感が出現し、上部消化管内視鏡検査(EGD)を施行し、吻合部に小彎を中心とする2/3周性の1型腫瘍を認め、生検ではadenocarcinomaと診断した。残胃吻合部癌の診断で手術を施行したが、腹膜播種および膵浸潤を認め試験開腹術となった。化学療法を施行するも奏効せず、繰り返す嘔吐を認め、経口摂取不良となった。EGDではBillroth II法吻合部に易出血性の隆起性腫瘍を認め、内腔は狭小化し、スコープは通過困難であった。悪性腫瘍に伴う吻合部狭窄と診断し、SEMS挿入を行う方針となった。翌日から経口摂取可能となり退院となった。外来化学療法を施行したが、SEMS挿入3ヵ月後に全身状態が悪化し死亡した。経口摂取は直前まで保たれていた。