池田 太郎

症例は,6か月乳児マススクリーニング(MS)にて陽性を指摘され,右副腎原発神経芽腫(38×21mm大,stage I)と診断された女児である.無治療経過観察を行ったが腫瘍マーカーは正常化せず,腫瘍増大を認めた.2歳10か月時に開腹腫瘍生検を行ったが,ganglioneuroma (GN),maturingの診断で,経過観察が継続された.しかし,その後も腫瘍は増大傾向にあり,3歳4か月時に腫瘍摘出術を施行した.摘出腫瘍は70×50×50mm大でありganglioneuroblastoma (GNB),intermixedの診断であった.腫瘍マーカー値は術後速やかに正常化した.本症例はMS発見神経芽腫無治療経過観察症例のうちでも,自然退縮には至らず全摘出を必要とした例であり,しかも2年9か月にわたる観察期間にGNへ完全には分化せず悪性の神経芽細胞の部分を残したまま増大傾向を維持していた.MS症例の自然経過を示す興味深い症例であると思われた.

【目的】小児腹部リンパ管腫は比較的稀な疾患で,真性の腫瘍ではなく,先天的なリンパ管原基の発生異常と考えられている.腹部リンパ管腫は,主に腸間膜や大網,後腹膜に存在するものに分けられている.本症の発症契機となる症状は多彩であり,治療についても様々な方法が報告されている.そこで今回我々は,当院で過去10年間に経験した本症について後方視的に検討したので報告する.【対象・方法】過去10年間に経験した本症は11例であり,これらについて発症年齢,症状,発生部位,術式,合併症などの検討を行った.【結果】発症年齢は0日〜13歳で,平均2歳7か月であった.男女比は10:1と男児に多く見られた.発生部位は腸間膜が6例,後腹膜が5例であった.症状として最も多かったのは鼠径ヘルニア関連疾患と診断されたのちに本症と診断されたものと腸閉塞症状で発症したもので各々3例に認められた.次いで胎児診断されたものが2例で,内1例は待機中に感染を併発した.また,他疾患検査中に偶発的に診断されたものを2例に認めた.感染で発症したものが胎児診断されたものを除き1例に認めた.治療は全例手術であり,腫瘤摘出が9例(内,腸管合併切除は3例)で,残る2例は嚢胞開窓術であった.腹腔鏡を併用したものは2例あった.術後合併症は,早期に創感染を認めたものが1例と遠隔期に腸閉塞を呈したものが1例に認められた.【結論】本症は比較的稀な疾患であるが,鼠径ヘルニア関連疾患として発症することもあり,日常診療においても注意を要する.治療に関しては様々な報告があり,基本的には切除で良いと考えるが,重要臓器を切除してまで完全切除するか否かは議論のあるところと思われる.

2007 年 1 月から 12 月までの 1 年間に日本大学医学部附属板橋病院で行われた消化器外科，心臓血管外科，乳腺内分泌外科，呼吸器外科，小児外科の手術統計をまとめた． 外科学系診療科の手術総数は増加がみられ，今後さらなる発展が期待される．

Objective. We investigated the extent of apoptosis in crypt cells and Peyer's patches (PPs) during small bowel allograft rejection in rats to examine the effect of FTY720 and ex vivo graft irradiation during rejection. Materials and Methods. Orthotopic small bowel transplantations (SBT) were performed from Brown Norway (BN) rats to Lewis (LEW) rats. Four groups of SBT animals were studied on days 3, 5, and 7 after operations: untreated allograft, allograft with FTY720, allograft with irradiation, and allograft with FTY720 + irradiation. Cryostat sections were prepared from the grafts, including PPs. An in situ end-labeling (ISEL) technique was used to detect apoptotic cells. Indirect immunoperoxidase staining was also performed using monoclonal antibodies against rat Fas/FasL. Results. The graft survival was prolonged in the FTY720-treated groups. In the FTY720-treated group, the number of ISEL-positive enterocytes was significantly down-regulated on days 3, 5, and 7 compared with the untreated allograft group. The number of ISEL-positive mononuclear cells was also significantly down-regulated compared with the untreated allograft group. The FTY720 the radiation and the FTY720 + irradiation treated groups showed significantly down-regulated numbers of Fas/FasL-positive enterocytes on day 7 compared with the untreated allograft group. Fas/FasL-positive mononuclear cells were also significantly down-regulated in the allograft compared with the untreated allograft group. Conclusions. FTY720 and ex vivo graft irradiation prevented up-regulation of the number of apoptotic enterocytes, lymphocytes, and Fas/FasL-positive lymphocytes, and also prolonged small bowel allograft survival. Combination FTY720 and ex vivo graft irradiation did not affect graft survival and apoptotic cell expression compared with the FTY720 only group. These findings suggest that FTY720 may prevent both rejection-associated and sepsis-induced apoptosis during the late phase of small bowel graft rejection.

To evaluate the efficacy of intraoperative radiation therapy (IORT) and the problem of securing the IORT field in advanced pediatric neuroblastoma. Between 1996 and 2005, 12 children received IORT for advanced pediatric neuroblastoma patients. Electron beam energies ranged from 10 to 12 MeV and median dose was 10 Gy (8 - 12 Gy). All of them had surgery with IORT against the primary tumor site and the abdominal aorta surroundings. A gross total resection (GTR) was achieved in 10 patients and subtotal resection (STR) was two patients. All of 12 patients were classified as high risk. Nine patients were alive 17-120 (mean 48 months) after diagnosis. Local tumor control was achieved in 100% of patients, of whom one experienced local recurrence outside the IORT field. At the operation, it was difficult to secure the IORT field because of the angle of the radiation cylinder in three patients. One of the three of these patients experienced local recurrence outside of the IORT field in the upper side of superior mesenteric artery and two of three patients had an external beam radiation after surgery, and there was no local recurrence. One patient had a postoperative ileus, and one patient had transient diarrhea and hydronephrosis. For advanced neuroblastoma patients, IORT produced excellent local control after surgery. However, there is a problem of securing the IORT field. For local control, it is necessary to add an external beam radiation after IORT when it is difficult to secure the IORT field.

Anal fistula in infants is a common disease. Although many are recovered by conventional treatment, there are some patients who are not repaired easily. We performed the seton method to an anal fistula and report the good result that we obtained. (c) 2007 Elsevier Inc. All rights reserved.

【目的】腸重積症はほとんどが特発性腸重積症であるが,器質的疾患を有する症例も含まれ,それぞれに適切な診療を行うことが重要である.当施設における腸重積症の臨床的特徴を明らかにする目的で症例の検討を行った.【方法】1995年1月から2006年2月の腸重積症自験例139例について調査し,臨床的特徴について検討した.さらに器質的疾患を有した症例については本邦報告例を集計し,その内容・頻度などについて検討を加えた.【結果】男女比1.54で男児に多く,年齢は1歳未満が51.7%で,月齢7か月にピークを示した.月別発生数については4月と9月にピークを示した.病型は68.2%が回盲部型であった.全症例の43.4%に前駆症状を認めた.159回行われた整復術のうち73.6%は非観血的整復術であった.回腸回腸結腸型に対する18回の整復術のうち66.7%が観血的整復術で,ほかの病型に比して観血的整復術の頻度が高かった.器質的疾患を有した症例は5例(3.6%;Meckel憩室2例,大腸若年性ポリープ2例,急性虫垂炎術後埋没断端1例)で年長児に多く,回盲部型は1例のみであった.3例(60.0%)に再発を認めた.本邦報告例では6,681例中183例(2.7%)に器質的疾患を認め,Meckel憩室30.0%,腸管重複症12.0%,異所性組織8.2%,若年性ポリープ5.5%,悪性リンパ腫5.5%の順で多かった.【結論】自験例でも多くが特発性で6か月前後の男児に多かった(男女比:1.54).一方器質的疾患によるものにおいて年長児や回盲部型以外の病型が多く,再発の頻度も高かった.原因疾患の多様性を念頭に入れた対応が必要であると思われた.

Background: To clarify the neurological function with respect to external anal sphincter (EAS) muscles in patients with or without soiling after low anterior resection (LAR) for lower rectal cancer, we examined the terminal motor latency in the pudendal motor nerves (PNTML). Materials and Methods: Thirty-eight patients after LAR for lower rectal cancer were studied electrophysiologically and compared with 30 healthy volunteers as controls (19 men and 11 women, aged 44 to 76 years of age, with a mean age of 65.5 years). Patients after LAR were divided into two groups [18 patients with soiling (12 men and 6 women, aged 51 to 77 years with a mean age of 64.8 years), 20 patients without soiling (13 men and 7 women, aged 47 to 75 years with a mean age of 62.1 years)]. The mean follow-up time from LAR was 67.2 months (range 60-84 months). Bilateral (left-sided and right-sided) PNTML tests were performed on all patients in order to measure the latency of the response in the bilateral EAS muscle following digitally directed transrectal pudendal nerve stimulation. Results: The distance from the anal verge to the level of anastomosis in patients with soiling (mean, 2.2 cm) was significantly shorter than that in patients without soiling (mean, 4.1 cm) (P < 0.05). Conduction delay of the bilateral PNTML in patients with soiling was longer than that in patients without soiling and normal subjects, significantly (P < 0.01, respectively). There was no significant difference between the right-sided and left-sided PNTML. Conclusions: These findings support the hypothesis that soiling after LAR may be partially caused by damage to the bilateral pudendal motor nerves.

Background:There are only a few reports discussing the characteristics of intussusception developing in school-age children. The characteristics of these cases are discussed, with reference to previous literature. Methods:The present study included eight cases of intussusception in school-age children among 143 intussusception patients treated on an inpatient basis at Nihon University Itabashi Hospital, during the 11 year period from 1993 to 2003. The remaining 135 patients were assigned to the infant group as controls. The clinical characteristics of intussusception in school-age children were compared with those of the condition developing in infants. Results:The eight children of school age with intussusception ranged in age from 8 to 15 years (mean, 11.6 years), and consisted of five boys and three girls. The major symptom was abdominal pain, occurring in 100% (8/8). Bloody stools and vomiting were reported in two patients each (25%) from this group. The triad of abdominal pain, bloody stools and vomiting was recognized in only one child (12.5%) of this group. Two children (25.0%) had a palpable abdominal mass, and one child (12.5%) complained of diarrhea. None of the school-age children with intussusception had any antecedent infection; five, two and one patients had the ileo-colic type, ileo-ileo-colic type and ileo-ileal type of intussusception, respectively. Four underwent enema reduction and four underwent surgical reduction. One of the eight children (12.5%) had underlying organic abnormality; in the remaining children the condition was labeled idiopathic. One child developed recurrences. Conclusions: In school-age children intussusception is generally believed to be commonly secondary to underlying organic abnormality, but in the present study only one of eight school-age children had underlying organic abnormality; in the remaining children, the condition was labeled idiopathic. The major symptom in school-age intussusception was abdominal pain. Therefore this may need to be differentiated from appendicitis in children of school age. It is considered that abdominal ultrasonography (USG) is a simple and useful method for making the diagnosis of intussusception, and that diagnostic USG should be conducted in all school-age children presenting with acute abdominal pain.