堀江 久永

症例は69歳,男性.血便を主訴に近医を受診,直腸癌を疑われ当院紹介となった.下部消化管内視鏡検査では直腸Rasbに環周率90%の2型腫瘍を認め生検結果は高分化管状腺癌であった.CT・MRIで膀胱,精嚢への浸潤を認め,直腸傍・右側方リンパ節転移を疑った.他臓器浸潤直腸癌Rasb,2型,cSI,cN3,cH0,cP0,cM0,cStageIIIbと診断した.経過中に大腸イレウスを発症したため人工肛門を造設した.側方リンパ節転移と周囲臓器への高度な浸潤を認めていたため化学療法を先行した.mFOLFOX6を4コース施行し,その内bevacizumabを2回併用した.その後,原発巣は著明に縮小し部分奏効を得たため根治術を行った.手術では腫瘍は膀胱,精嚢,前立腺と一塊に存在し,腫瘍の残存を疑いこれらの臓器を含めた骨盤内臓全摘術を施行した.病理組織学的検査では,癌細胞は認めず組織学的完全奏効と判定した.(著者抄録)

Retinol-binding protein 4 (RBP4) is a recently identified adipokine that was involved in insulin resistance. RBP4 is predominantly expressed from the liver in normal metabolic state to transport retinoids throughout the body, but the exact physiological function and the regulatory mechanisms of adipocyte-derived RBP4 have not been revealed. We conducted the genetic analysis about metabolic parameters in Japanese and Mongolian; the minor allele carriers of regulatory single-nucleotide polymorphism (SNP -803G>A) showed significantly higher BMI in Japanese men (P = 0.009) and women (P = 0.017), and in Mongolian women (P = 0.009). Relative quantification of RBP4 transcripts in -803GA heterozygotes showed that the minor allele-linked haplotype-derived mRNA was significantly more abundant than the transcript from major allele. RBP4 promoter assay in 3T3L1 adipocytes revealed that the minor allele increased the promoter activity double to triple and the administration of 9-cis-retinoic acid (RA) and 8-bromo-cyclic adenosine monophosphate (8-Br-cAMP) enhanced the activity. Multiple alignment analysis of human, mouse, rat, and cattle RBP4 promoter suggested conserved seven transcription factor binding motifs. Electrophoretic mobility shift assay showed the -803G>A SNP modulate the affinity against unidentified DNA-binding factor, which was assumed to be a suppressive factor. These results collectively suggested that the minor allele of RBP4 regulatory SNP enhanced the expression in adipocytes, which may be associated with the adipogenesis.

画像強調内視鏡の1つであるFICE(flexible spectral imaging color enhancement)は,大腸腫瘍の拾い上げ診断・質的診断における有用性が既に報告されている.FICEは,遠景像が明るく,通常画像からFICE画像への切り替えが速い特長があり,拾い上げ診断における有用性が特に期待される.腫瘍と非腫瘍の鑑別は,病変表層の微小血管模様に注目することにより可能であり,その正診率はpit pattern診断に匹敵する.SM高度以深浸潤癌の診断では,腫瘍表面のpit様模様・無血管野の存在に着目することにより,筆者らの検討では高い正診が得られた.(著者抄録)

症例は53歳，男性．7カ月前より下血と肛門痛が出現し，当院を受診した．肛門後方に痔瘻を認め，肛門縁より5cmの直腸に腫瘤を触知した．大腸内視鏡検査で下部直腸に全周性2型腫瘍を認め，直腸腫瘍と痔瘻2次口から突出した硬結部の生検結果は，いずれも高分化型腺癌であった．直腸癌および転移性痔瘻癌と診断し，腹会陰式直腸切断術，D3郭清を施行した．直腸癌は中分化型腺癌で，直腸癌と離れた痔瘻1次口部，2次口部と括約筋間に中分化型腺癌を認めた．原発巣と組織が同一であることから，直腸癌からの管腔内転移を来たした転移性痔瘻癌と診断した．<br> 痔瘻は日常診療でしばしば遭遇する疾患であるが，大腸癌との合併例では転移性痔瘻癌も念頭に置き，通常の痔瘻と異なる所見に注意し，とくに瘻管内の硬結に対しては積極的な生検が必要と考えられる．反対に，痔瘻癌と診断された症例では，大腸の精査を必ずすべきである．<br>

症例は75歳女性。主訴は免疫学的便潜血反応陽性。大腸内視鏡でRaに15mmのIs型病変を認めた。FICE拡大観察で，病変の中央陥凹部に不整な血管構造と無血管領域を認め，SM高度浸潤癌と診断した。外科手術を施行した。病理学的に中分化腺癌，SMへの3mm浸潤，高度の簇出・リンパ管浸潤が見られ，リンパ節転移も存在した。FICE拡大観察がSM高度浸潤癌の診断に有用であった症例を経験したので報告した。

【目的】10mm以下の大腸SM深部浸潤癌が，内視鏡所見から診断できるか検討すること．【方法】当施設で大腸内視鏡検査が行われ，切除標本の病理組織検査で，腫瘍径10mm以下，SM深部浸潤（1,000μm以上）癌と診断された9病変を対象とし，その内視鏡写真を評価した．通常内視鏡所見では，明らかな陥凹，襞のひきつれ，表面凹凸不整，潰瘍・びらん，易出血性，緊満感の有無，拡大内視鏡所見ではピットパターンを評価項目とした．【結果】明らかな陥凹5例（56％），襞のひきつれ4例（44％），表面凹凸不整5例（56％），潰瘍・びらん2例（22％），易出血性3例（33％），緊満感3例（33％）を認めた．拡大観察では7例中4例（57％）にVN型ピットを認めた．9病変中8病変でいずれかの内視鏡所見が陽性であった．【結論】10mm以下のSM深部浸潤癌の多くは，通常内視鏡観察と拡大観察により診断可能と考えられた．

Evaluation of pathologic predictors of metastases in T1 stage colorectal cancer may be difficult with hematoxylin and eosin (HE) staining alone. The aim of this study was to clarify the role of pathologic predictors by using immunohistochemical staining, and Elastica van Gieson (EVG) staining. One hundred and twenty-four patients who underwent bowel resection for single T1 stage colorectal cancer from 1990 to 2004 in 1 institution were Studied. D2-40, EVG staining, and CAM5.2 were used to detect lymphatic invasion, venous invasion, and tumor budding, respectively. These 3 factors were separately evaluated based on HE staining. Histology was reviewed by 1 pathologist. Lymph node metastases in the surgical specimen were the standard reference, and distant metastases were identified by periodic computed tomography for 2 years or more after surgery. A logistic regression model was applied to analyze risk factors for lymph node metastases and a Cox regression model for distant metastases. In predicting lymph node metastases, univariate analysis demonstrated significance for all predictors except venous invasion by HE staining. Multivariate analysis showed that venous invasion by EVG and tumor budding by HE showed significance as predictors. In predicting distant metastases, univariate analysis showed significance for lymphatic invasion shown by D2-40, tumor budding shown by CAM5.2 and HE, and lymph node metastases. Multivariate analysis showed only venous invasion by EVG stain as being significantly associated with distant metastases (P = 0.001). In conclusion, venous invasion evaluated shown by EVG staining is a useful pathologic predictor for metastases in T1 stage colorectal cancer.

Background: The diagnostic accuracy of conventional endoscopy for small colonic polyps is not satisfactory Optimal band imaging (OBI) enhances the contrast of the mucosal surface without the use of dye. Objective: To evaluate the diagnostic accuracy for the differentiation of neoplastic and non-neoplastic colorectal polyps by using magnified OBI colonscopy. Design: An open prospective study. Setting: Jichi Medical University, Japan. Patients: A total of 133 colonoscopy cases. Main Outcome Measurement: A comparative study of the overall accuracy, sensitivity and specificity for the differentiation of neoplastic and non-neoplastic colorectal polyps &lt;= 5 mm in size by capillary-pattern diagnosis by using conventional colonoscopy, capillary-pattern diagnosis in OBI, and pit-pattern diagnosis in chromoendoscopy with low magnification. Results: A total of 107 polyps, composed of 80 neoplastic and 27 non-neoplastic polyps, were evaluated. 0131 clearly showed the capillary network of the Surface mucosa of neoplastic polyps at low magnification, whereas the surface mucosa of non-neoplastic polyps showed up as a pale lesion. The capillary pattern in conventional colonoscopy had 74% accuracy, 71% sensitivity, and 81% specificity for neoplastic polyps. The accuracy and sensitivity were significantly lower than those that used the capillary pattern in OBI (accuracy 87% and sensitivity 3%) and the pit pattern in chromoendoscopy (accuracy 86% and sensitivity 90%). There were no significant differences in specificity (OBI 70% and chromoendoscopy 74%). The kappa analysis indicated good agreement in both OBI and chromoendoscopy. Conclusions: Capillary-pattern diagnosis in 0131 is superior to that in conventional endoscopy and is not significantly different from pit-pattern diagnosis for predicting the histology of small colorectal polyps. (Gastrointest Endosc 2009;69:734-41.)

A 34-year-old woman was referred to our hospital with ileus. She had undergone surgical resection following chemotherapy for yolk sac tumor at the age of 12 years, and had received additional surgery and radiation therapy for a local recurrence at age 13. Following evaluation, a sigmoid colon tumor was detected and was surgically resected. Histology proved well differentiated adenocarcinoma with chronic irradiation colitis, suggesting that irradiation may have induced the colon cancer.

A 27-year-old woman seen for irregular menstruation, and found to have a right ovarian cyst became pregnant and underwent laparotomy during the 18th week of pregnancy. Instead of an ovarian cyst, she was found to have a 13cm spindle-shaped tumor of the appendix, necessitating appendectomy and partial ceacal resection to avoid possible perforation during pregnancy. The surgical specimen proved histologically to be an appendiceal mucinous cystoadenoma. The patient and fetus had an uneventful postoperative course followed by a natural childbirth. We review the literature on appendiceal mucocele in pregnant women and its features. © 2009 The Japanese Society of Gastroenterological Surgery.

PURPOSE: This study was designed to identify colonoscopic stigmata, indicating substantial invasion into the submucosa by T1 colorectal cancer with sessile morphology, including both flat and protruded types. METHODS: A total of 111 Tis or T1 colorectal cancers were studied retrospectively. The lesions were divided into two groups: Group A (n=83), Tis or T1 cancers with &lt; 1 mm submucosal invasion; and Group B (n=28), T1 cancers with a &gt;= 1 mm submucosal invasion. Printed photographs of the lesions were reviewed by five experienced colonoscopists who were blinded to histology. Deep depression, irregular surface, ulceration or erosion, fold convergence, and spontaneous bleeding were independently evaluated. Findings considered present by three or more reviewers were defined as positive. Kappa analysis was used to measure inter/intraobserver variability. RESULTS: Positive rates of four findings but not fold convergence were significantly higher in Group B than in Group A. Irregular surface and spontaneous bleeding were significant independent predictors of &gt;= 1 mm submucosal invasion, with diagnostic accuracies of 85.6 and 76.6 percent, respectively. Kappa analysis demonstrated fair-to-good inter/intraobserver agreement for spontaneous bleeding and fair-to-good intraobserver agreement for irregular surface. CONCLUSIONS: Irregular surface and spontaneous bleeding were colonoscopic stigmata, indicating &gt;= 1 mm submucosal invasion in T1 colorectal cancer.

Purpose. To clarify pathological predictor for lymph node metastasis in T1 colorectal cancer. Methods. One hundred and sixty-four patients who underwent surgery for single T1 colorectal cancer were reviewed. The pathological differentiations of non-well differentiation, invasion depth (&gt;= 2000 mu m), lymphatic channel involvement, venous invasion, and tumor budding were selected as candidate predictors. Tumor budding was estimated according to the definition proposed by Ueno et al. (Gastroenterology 2004; 127:385-394). The lymph node status was set for the endpoint. Logistic regression model was applied to analyze the predictors. Results. Lymph node involvement was observed in 9.8%. The positive rates were 13.4% for the pathological differentiations of non-well differentiation, 51.8% for invasion depth (&gt;= 2000 mu m), 6.1% for lymphatic channel involvement, 8.5% for venous invasion, and 14.6% for tumor budding. The pathological differentiations of non-well differentiation (P &lt; 0.001) and tumor budding (P = 0.002) were significantly associated with lymph node metastasis in multivariate analysis. When either two significant factors was adopted for the prediction of the lymph node metastasis, the sensitivity, specificity, positive predictive value, and negative predictive value were 94%, 82%, 36%, and 99%, respectively. Conclusion. The pathological differentiations of non-well differentiation and tumor budding are useful predictors for lymph node metastasis in T1 colorectal cancer.

Colorectal carcinoma (CRC) remains the major cause of cancer death in humans. Although chromosomal structural anomaly is presumed to play an important role in the carcinogenesis of CRC, chromosomal copy number alterations (CNA) and loss of heterozygosity (LOH) have not yet been analyzed extensively at high resolution in CRC. Here we aim to identify recurrent CNA and LOH in human CRC with the use of single nucleotide polymorphism-typing microarrays, and to reveal their relevance to clinical outcome. Surgically resected CRC specimens and paired normal mucosa were obtained from a consecutive series of 94 patients with CRC, and both of them were subjected to genotyping with Affymetrix Mapping 50K arrays. CNA and LOH were inferred computationally on every single nucleotide polymorphism site by integrating the array data for paired specimens. Our large dataset reveals recurrent CNA in CRC at chromosomes 7, 8, 13, 18, and 20, and recurrent LOH at chromosomes 1p, 4q, 5q, 8p, 11q, 14q, 15q, 17p, 18, and 22. Frequent uniparental disomy was also identified in chromosomes 8p, 17p, and 18q. Very common CNA and LOH were present at narrow loci of &lt; 1 Mbp containing only a few genes. In addition, we revealed a number of novel CNA and LOH that were linked statistically to the prognosis of the patients. The precise and large-scale measurement of CNA and LOH in the CRC genome is efficient for pinpointing prognosis-related genome regions as well as providing a list of unknown genes that are likely to be involved in CRC development.

Periostin is a unique extracellular matrix protein, deposition of which is enhanced by mechanical stress and the tissue repair process. Its significance in normal and neoplastic colon has not been fully clarified yet. Using immunohistochemistry and immuno-electron microscopy with a highly specific monoclonal antibody, periostin deposition was observed in close proximity to pericryptal fibroblasts of colonic crypts. The pericryptal pattern of periostin deposition was decreased in adenoma and adenocarcinoma, preceding the decrease of the number of pericryptal fibroblasts. Periostin immunoreactivity appeared again at the invasive front of the carcinoma and increased along the appearance of cancer-associated fibroblasts. ISH showed periostin signals in cancer-associated fibroblasts but not in cancer cells. Ki-67-positive epithelial cells were significantly decreased in the colonic crypts of periostin(-/-) mice (similar to 0.6-fold) compared with periostin(+/+) mice. In three-dimensional co-culture within type I collagen gel, both colony size and number of human colon cancer cell line HCT116 cells were significantly larger (similar to 1.5-fold) when cultured with fibroblasts derived from periostin(+/+) mice or periostin-transfected NIH3T3 cells than with those from periostin(-/-) mice or periostin-non-producing NIH3T3 cells, respectively. Periostin is secreted by pericryptal and cancer-associated fibroblasts in the colon, both of which support the growth of epithelial components.

PURPOSE: This study was designed to estimate the accuracy of CT colonography for the assessment of T stage in colorectal cancer. METHODS: CT colonograms obtained from 246 lesions were reviewed by 3 investigators. Intestinal wall deformity on shaded-surface display and rough appearance around the intestine were studied to assess their relations to T stage. Intestinal wall deformity was classified into arc type, trapezoid type, and apple-core type, defined as a trapezoidal wall deformity involving &gt;= N50 percent of the circumference of the lumen. RESULTS: As for intestinal wall deformity, the rate of arc type was higher in Tis/T1 than in T2 (74 percent: 17/23 vs. 24 percent: 8/34, P &lt; 0.0001); the rate of trapezoid type was 17 percent (4/23) in Tis/T1, 59 percent (20/34) in T2, and 15 percent (28/189) in T3/T4 (Tis/T1 vs.T2, P &lt; 0.0001; T2 vs. T3/T4, P &lt; 0.0001); and the rate of apple-core type was lower in T2 than in T3/T4 (18 percent: 6/34 vs. 81 percent: 154/189, P &lt; 0.0001). Arc type, trapezoid type, and apple-core type were primarily associated with T1, T2, and T3/T4, respectively. When these criteria were used, the overall accuracy for T stage was 79 percent. Rough appearance was specific for T3/T4, but insensitive. CONCLUSIONS: CT colonography can provide important information for the preoperative assessment of T stage in colorectal cancer.

PURPOSE: This study was designed to confirm the safety of not removing small adenoma in patients who undergo colorectal cancer surgery. METHODS: Patients who underwent surveillance colonoscopy after surgery were enrolled. The study was approved by our institutional review board. Colonoscopy was performed with magnification chromocolonoscopy. Benign adenomas of 6 mm or less in size, diagnosed based on both nonmagnified and magnified observation, were left unresected with a maximum of three polyps per patient. The sites of the polyps were marked by tattooing. Interval colonoscopy was performed predominantly yearly or biennially. Increase in size by 2 mm or larger was defined as significant. In follow-up, polyps were removed if they grew larger than 6 mm, were suspicious for high-grade dysplasia, or the patients requested to have polyps removal. RESULTS: Five hundred polyps in 284 patients met the above criteria and were not resected, and 412 polyps were followed by repeat colonoscopy. The mean observation period was 3.6 +/- 2.2 years and the mean number of repeat colonoscopy was 3.6 +/- 1.6. At the final colonoscopy, 71 percent of 412 polyps showed no change in size, 15 percent increased, 3 percent decreased, and 11 percent could not be identified. Eighty-eight polyps were resected endoscopically, and histology showed neither cancer nor adenomas with high-grade dysplasia. Two hundred fifty-five polyps detected in the same patient cohort during index/repeat colonoscopy were removed, including four adenomas with high-grade dysplasia and two T1 cancers. CONCLUSIONS: Leaving small polyps is safe even in patients who have undergone colorectal cancer surgery, provided that careful observation is guaranteed.

Purpose. Our purpose was to study the characteristics of colorectal neoplasms in patients with gastric cancer (GC). Methods. The study group comprised GC patients who underwent colonoscopy before resection of their GC. We examined the prevalence, site, and histology of colorectal neoplasms, as well as the clinicopathological features and treatment of the patients who had synchronous colorectal cancers (CRC). The logistic regression model was applied to investigate the features of the GC patients with concurrent CRC. Results. We studied 466 GC patients (mean age 64.5 years; 147 women, 319 men), 143 (31%) of whom had a family history of gastrointestinal cancer. Synchronous colorectal adenoma and cancer were detected in 182 (39%) and 18 (4%) patients, respectively. Among the 18 synchronous CRCs, 11 were in the early stages and 10 of these were resected endoscopically. The other eight required simultaneous open radical surgery. All the GC patients with synchronous CRC were older than 50 years. Statistical analysis did not show a significant difference between the features of the patients with and those without concurrent CRC. Conclusions. The possibility of synchronous colorectal neoplasms in GC patients cannot be disregarded in clinical practice; however, screening of the large bowel may not be necessary in GC patients younger than 50 years.

Based on colonoscopy findings, we made a preoperative diagnosis of primary mucinous cystadenocarcinoma of the appendix with features of a submucosal tumor (SMT) in the ascending colon. A 59-year-old woman who presented with right lower quadrant abdominal pain underwent colonoscopy, which revealed an SMT with three nodules covered with mucus in the ascending colon. Examination of colonoscopic biopsy specimens indicated '' very '' well-differentiated adenocarcinoma with mucus lakes. Abdominal computed tomography showed irregular wall thickness from the cecum to the ascending colon. The adjacent appendix had an enhanced wall and unclear border against the ascending colon. Thus, we performed right hemicolectomy, with good results. Histopathological examination revealed mucinous cystadenocarcinoma of the appendix, invading the ascending colon with fistula formation. Appendiceal tumors can manifest with a variety of colonoscopic features, and curative surgical resection should be attempted even if there is fistula formation.

目的 : 回腸ストーマ閉鎖術における器械吻合と手縫い吻合の安全性と経済性についてprospective studyを施行した.<br>方法 : 器械吻合はfunctional end-to-end吻合, 手縫い吻合はlayer-to-layer吻合を行った. 器械吻合群は外科臨床経験2年以上の医師, 手縫い吻合群は4年以上で腸管の手縫い吻合の経験のある医師を術者とした.<br>結果 : 器械吻合群 (10例) と手縫い吻合群 (10例) の術者の平均臨床経験年数はそれぞれ3±1, 7±3年 (p<0.05) であった. 平均吻合時間は24±6, 58±16分 (p<0.05), 平均手術時間は96±21, 127±26分 (p<0.05) であった. 術後合併症は創感染が機械吻合群に1例, 手縫い吻合群に4例認められたのみで, 縫合不全やイレウスはなかった. 術後平均在院日数は10±3, 11±1日 (n.s.) であった. 手術材料費は器械吻合で32,000円, 手縫い吻合は24,827円であった.<br>結論 : 器械吻合は経験の少ない術者でも短時間で安全に施行可能で, コスト面でも手縫い吻合と大きな差は認められなかったため標準術式として妥当であると考えられた.

Purpose. A prospective study was conducted to ascertain the effects of preoperative enteral immunonutrition on a surgical site infection (SSI) in patients with colorectal cancer without malnutrition. Methods. Patients with colorectal cancer undergoing elective surgery without malnutrition, bowel obstruction, severe cardiopulmonary complications, diabetes, collagen disease, or renal failure were sequentially divided into an immunonutrition group (n = 33) and a control group (n = 34). In the immunonutrition group, an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids was administered for 5 days (750 ml/day) prior to surgery. Results. The mean age was slightly higher in the immunonutrition group (69 +/- 9 years) than in the control group (63 +/- 11 years; P &lt; 0.05), but no significant differences between the groups were noted for the body mass index, total protein, albumin, hemoglobin, surgical methods, operation time, or volume of intraoperative bleeding. The frequencies of superficial incisional SSI, deep incisional SSI and organ/space SSI in the immunonutrition and control groups were 0% and 11.8% (4/34; P &lt; 0.05), 0% and 0%, and 0% and 2.9% (1/34), respectively. Conclusion. Preoperative enteral immunonutrition appears to be effective for preventing SSI in patients with colorectal cancer without malnutrition.

今回我々は内視鏡所見を契機に診断した虫垂粘液囊腫の1例を経験したので報告する。症例は56歳男性。大腸内視鏡検査では虫垂開口部に硬い粘膜下腫瘍様隆起性病変を認めた。pit patternは正常，生検でgroup 1と診断され，CTでは腫大した虫垂の壁の厚さは一様であった。虫垂粘液囊腫の診断で盲腸部分切除術を施行した。摘出標本では腫大した虫垂が盲腸内に突出し，内腔は平坦で白色～透明の粘液が貯留していた。単層，一部が低乳頭状で粘液を含む異型の少ない上皮で，腺腫の診断であった。

直腸癌とS状結腸癌における下腸間膜動脈根リンパ節(253リンパ節)郭清の意義について検討した. 1980-1998年のD3郭清697例中253リンパ節転移陽性(253(+))症例は9例(1.29%)であり,この9例中8例に再発を認めた.再発は8例中6例で術後1年6カ月以内に認めた. 1990-1998年のD3郭清463例中253リンパ節転移陰性かつ中間リンパ節転移陽性(中間リンパ節(+))症例は24例(5.18%)であった.この24例中14例に再発を認めた(58.3%).再発は14例中12例で術後3年以内に認めた. 5年無再発生存率は253(+)症例が33.3%,中間リンパ節(+)症例が45.8%, 10年無再発生存率は253(+)症例が0.0%,中間リンパ節(+)症例が41.3%であった(p=0.045).以上より, 253(+)症例は少数かつ予後不良であり, 253(+)症例に対する253リンパ節郭清は予後を向上させないと考えられた.一方,中間リンパ節(+)症例では約半数は根治が得られ,中間リンパ節を郭清する意義は大きいと考えられた.

Purpose. The correlation between age and the outcome following an operation for colorectal cancer (CRC) has not yet been determined. We studied the appropriate operation for elderly CRC patients based upon the assessment of preoperative risk factors. Methods. Seventy patients with Dukes' stages B or C CRC (more than 80 years old: aged group) and 66 stage-matched patients (50-69 years old: control group) were studied. The preoperative condition, the grade of surgical intervention, the perioperative activities of daily life (ADL), and the survival rate were compared between the two groups. Results. The preoperative conditions were significantly worse and the frequencies of patients with a deterioration in ADL during the perioperative period were significantly higher in the aged group. In the aged group, the peripheral lymphocyte count was significantly lower in patients with major postoperative complications, and the 1.0% forced expiratory volume (FEV1.0%) was significantly lower in patients with a deterioration in ADL. The low grade of surgical intervention tended to be related to a poor prognosis in rectal cancer of the aged group. Conclusion. The indications for operation in elderly CRC patients should be determined based upon an appropriate assessment of preoperative conditions, such as the lymphocyte count and FEV1.0%.

This case report describes a 68-year-old man who presented with bronchiolitis obliterans organizing pneumonia (BOOP) and gastric carcinoma. During evaluation, including a colonoscopy, he was found to have distal colitis and a giant polypoid lesion in the cecum that was diagnosed as localized giant inflammatory polyposis (LGIP) by magnifying colonoscopy. The patient was treated over a period of 3 years without surgery, and the LGIP was reduced in size during the follow-up period. Magnifying observation was useful to distinguish LGIP from a neoplastic lesion.

症例は68歳,男性. 2002年1月5日発熱にて発症した.近医にて抗生物質を投与されるも解熱せず,黄疸を呈してきたため急性肝炎を疑われ入院加療を受けた.しかし状態は改善せず,上腸間膜静脈血栓が認められたため, 1月21日当院消化器内科へ転院した.腹部は平坦,軟で,腹膜刺激症状は認められなかった.血液検査では,白血球, CRP,総ビリルビンの上昇を認めた.腹部USおよびCT検査で肝腫大,脾腫,上腸間膜静脈血栓が認められ,虫垂近傍に径5 cmの膿瘍が描出された.静脈血培養ではグラム陰性桿菌が検出された.以上より本病態の原因は虫垂炎によるものと診断され1月23日当科紹介となり同日虫垂切除術およびドレナージ術が施行された.虫垂は後腹膜に穿孔し膿瘍を形成していた.腹膜刺激症状を呈さずに,敗血症,上腸間膜静脈血栓症および高ビリルビン血症を呈するに至った虫垂炎の貴重な症例と考え,文献的考察を加え報告する.

内視鏡切除の対象となる大腸sm癌は,明らかな脈管浸潤がないこと,癌先進部も含めて低分化腺癌でないこと,1,000μmを越える癌浸潤がないこと,のすべてを満たす必要がある.大腸sm癌の内視鏡切除後における追加腸管切除の適応基準としては,癌浸潤距離を1,000μm程度まで引き上げることが可能と考えられ,リンパ管侵襲の判定基準を厳格にすることによっても追加腸管切除例を安全に減らすことも可能と考えられた.従来は内視鏡切除の対象とは考えられなかったsm癌に対する適応拡大を図るためには,リンパ節転移のない大腸sm癌を的確に診断することが必要で,明らかな脈管侵襲や癌先進部の低分化腺癌は内視鏡切除前に診断することは困難であるため,1,000μm以下の癌浸潤を示すsm癌を鑑別する内視鏡診断学の確立が急務である.著者の検討では,表面凹凸不整像や出血の内視鏡所見から鑑別可能であった.