池田 太郎

Background/Aims: There are no reports about the relationship between soiling and other defecation states in patients with ulcerative colitis (UC) after ileal J pouch-anal anastomosis (IPAA). To assess the defecation states in patients with or without soiling at 5 years or more after IPAA for UC, we studied clinical findings in such patients. Methodology: Subjects with UC who had undergone IPAA [a 5-cm short cuff, anal canal mucosa including anal transitional zone (AZT) stripped from the level of dentate line (DL)] with ileostomy closure at least 60 to 132 months (mean; 103.6 months) previously, and who had no pre- or postoperative complications were recruited. They were 43 patients (28 men and 15 women aged 15 to 59 years, average 39.2 years) divided into 2 groups; group A n = 28; patients without soiling (18 men and 10 women aged 15 to 49 years, average 37.5 years) and group B n=15; patients with soiling (10 men and 5 women aged 24 to 59 years, average 42.1 years). Postoperative interviews concerning the defecation states (mean daily stool frequency, nocturnal stool frequency, ability to discriminate flatus from feces, feeling of stool remaining, consistence of stools, soiling, incontinence, and urgency) were conducted with patients after IPAA. Results: No cases in group A showed soiling. All cases in group B had some soiling, 6 cases; rare soiling (at diarrhea), 4 cases; occasional soiling (1 time per 2 or 3 days), 4 cases; frequent soiling (patients must use pad due to daily soiling, 2 cases had incontinence). There was a significant difference between groups A and B (P < 0.001). All cases in group A showed less than 6 times per day and all cases of group B showed 7 or more times per day. There-was a significant difference between groups A and B (P < 0.001). High nocturnal stool frequency was significantly more common in patients of group B than group A (P < 0.001). All cases in group A and 12 cases in group B could significantly discriminate flatus from feces (P < 0.05). Feeling of stool remaining was significantly more common in patients of group B than group A (P < 0.001). The stool consistency of group A was significantly harder than that of group B (P < 0.001). No cases in group A reported incontinence. Two cases in group B had incontinence. Urgency in group B was noted more than in group A. Regarding patient satisfaction (Peck's criteria), all cases in group B and no cases in group A reported "excellent". Ten cases in group B were "good". Three cases in group B were "fair". Two cases in group B showed failure. Patient satisfaction of group A was significantly higher than that of group B (P < 0.01). Conclusions: According to these interviews, no importance of preserving the AZT was recognized. The patients without soiling showed better defecation states than patients with soiling. The patients with soiling showed poor defecation status following IPAA.

Background: Recovery from esophageal atresia (EA) and tracheoesophageal fistula (TEF) has improved markedly over the years. But postoperative complications, however, have remained. This study evaluates recovery, preoperative, and postoperative status of patients with EA/TEF. Methods: A retrospective study review was undertaken in 24 patients with EA/TEF after primary anastomosis (January 1975 through September 2003). Results: There were no patients who had major cardiac anomalies or trisomy 18. In total, 17 of 24 (70.8%, group A) patients have survived and seven (29.2%, group B) have died. Birthweight and Apgar Scores in group A were significantly higher than in group B. The ratio of GAP (the distance of the location of the blind pouch from the ends of the upper and lower esophagus) to body length in group B was significantly higher than in group A. The birthweight and Apgar Scores in group A were significantly higher than in group B. When the authors compared their sample of cases by means of the Waterston classification, the Montreal classification and the Spitz classification, there were statistically significant differences between the results using the Waterston classification and the results using to the Spitz classification. Conclusions: For the cases of EA surgery that were examined, the authors concluded that bodyweight at birth and the existence of pre-surgery respiratory system complications have a significant effect on post-surgery recovery, and that results appear to indicate the importance of classification using the Waterston classification and Spitz classification as a means of assessing the degree of risk. Results also appeared to indicate that the control of Respiratory Distress Syndrome throughout both the pre-surgery and post-surgery periods is critical.

Aim. 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 during rejection. Methods. Orthotopic small bowel transplantations (SBTs) were performed from BN to LEW rats. Isografted animals served as controls. Three groups of SBT animals were studied on days 3, 5, and 7 after operation: isograft, untreated allograft, allograft with FTY720. FTY720 was orally administered by gavage (1 mg/kg/d) to allograft recipients on 7 consecutive days. Cryostat sections were prepared from 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/Fas-L. Results. Graft survival was prolonged in the FTY720-treated group. The number of ISEL-positive enterocytes in the allografts increased significantly on days 3, 5, and 7 compared with the isograft group. In the FTY720-treated group, the number of ISEL-positive enterocytes in the allografts was down-regulated significantly on days 3, 5, and 7 compared with untreated allograft group. In the PPs, the number of ISEL-positive mononuclear cells increased significantly in the allografts compared with the isograft group. In the FTY720-treated groups, the number of ISEL-positive mononuclear cells were down-regulated significantly in the allografts compared with the untreated allograft group. The number of Fas/FasL-positive enterocytes were increased significantly in allografts compared with isograft group. In FTY720-treated groups, the number of Fas/FasL-positive enterocytes were down-regulated significantly on day 7 compared with the untreated allograft group. In the PPs, Fas/FasL-positive mononuclear cells also increased significantly on day 7 in the allografts compared with isografts. In the FTY720-treated groups, Fas/FasL-positive mononuclear cells were down-regulated significantly in the allografts compared with the untreated allograft group. Conclusions. The number of apoptotic enterocytes, lymphocytes, and Fas/FasL-positive lymphocytes increased during small bowel graft rejection. FIY720 prevented up-regulation of the number of apoptotic enterocytes, lymphocytes, and Fas/FasL-positive lymphocytes while also prolonging small bowel allograft survival.

Purpose. Pancreatitis has been reported long after total choledochal cyst excision. The aim of this study was to determine if the disease process of postoperative pancreatitis differs between a primary and secondary cyst excision in a long-term follow-up. Methods. Among 53 postoperative patients who underwent a total cyst excision and were followed up, 44 patients underwent a primary cyst excision (primary excision group), while 9 patients underwent a secondary cyst excision after a previous cyst-duodenostomy for internal drainage (secondary excision group). The long-term clinical course, including the pancreatographic findings after a total cyst excision, was compared. Results. In the primary excision group, six patients had mild pancreatitis. Endoscopic retrograde pancreatography demonstrated ductal dilatation that was limited to the common channel in two patients, concurrent with the ventral duct in three, and extended the duct of Santorini in three. Conservative treatments were carried out in three patients, and endoscopic irrigation in one patient with protein plugs in the ventral duct. A resection of the choledochal remnant in the pancreas was performed in two patients with choledochal remnant-associated pancreatitis. From the secondary excision group, 5 of the 9 patients had chronic pancreatitis. Endoscopic retrograde pancreatography showed entire pancreatic ductal dilatation. Two of these patients underwent duodenal papilloplasty at the same time as secondary surgery; however, the disease progressively worsened. Conclusion. In patients undergoing a secondary total excision after internal drainage, it is difficult to half the ongoing aggravating process in pancreatitis.

Background: We investigated the relationship between interdigestive migrating motor complex, phase III (IMMC-pIII) and postoperative quality of life (QOL) in pylorus-preserving gastrectomy (PPG) patients. Materials and Methods: A total of 40 patients (26 men and 14 women; average age 59.4 years) 5 to 7.5 years after PPG for early gastric cancer (Billroth I) (average 6 years and 3 months) were divided into two groups according to the occurrence of IMMC-pIII from the duodenum, and their postoperative quality of life (QOL) was compared. Results: As for appetite, "No change compared with before operation" was significantly more frequent in the IMMC-pIII positive group compared with the negative group (P = 0.0002). Food consumption per meal compared with normal; "80% or more" was significantly more frequent in the IMMC-pIII positive group than the negative group (P = 0.0002). Body weight loss during 5 years after surgery; "6 kg or more" was significantly more frequent in the IMMC-pIII negative group than the positive group (P = 0.0002). Early dumping symptoms did not occur in any patients of either group. Reflux esophagitis and nausea; no patients in the IMMC-pIII positive group experienced these symptoms, which was significantly different from the negative group (P = 0.0018). Abdominal pain occurred but was significantly less frequent in the IMMC-pIII positive group than in the negative group (P = 0.0023). Epigastric fullness occurred but was less frequent in the IMMC-pIII positive group compared with the negative group (P < 0.0001). Gastric stasis of the remnant stomach was significantly more frequent in the IMmC-pIII negative group than in the positive group (P < 0.0001). Gholelithiasis was significantly more frequent in the IMMC-pIII negative group than in the positive group (P = 0.0119). Conclusions: These results showed more satisfactory QOL in the IMMC-PIII positive group than in the negative group.

Vagal nerve-preserving distal gastrectomy reconstructed by interposition of a jejunal J pouch with a jejunal conduit (hereinafter called DGP) is a function-preserving operation for early gastric cancer. However, some patients after DGP have suffered from postprandial stasis in the substitute stomach, and postprandial stasis leads to abdominal symptoms. To clarify the significance of mosapride citrate (MS) for prevention of food stasis in the substitute stomach for patients after DGP, we studied the effects of MS before and after administration of MS. In a total of 18 patients (10 men, 8 women; aged 34 to 70 years, average 63.1 years) during 5 years after DGP for early gastric cancer (Billroth I, D1 + alpha lymph node dissection, curability A), the relationship between their postoperative quality of life (QOL) and emptying function of the substitute stomach (EFS) was compared using a radioisotope method before MS therapy and after MS therapy at an oral dose of 15 mg/day for 3 months. (1) Interview. After MS therapy patients evidently had more appetite and ate more, with a slightly increase in body weight (0.5 similar to 2 kg) compared with patients before MS therapy. Before and after MS therapy no patients had early dumping symptoms, and after MS therapy all patients clearly had fewer symptoms such as reflux esophagitis, nausea, and abdominal pain compared with before MS therapy. After MS therapy they also had significantly decreased abdominal fullness compared with before MS therapy (P = 0.0026). Endoscopically, we found reflux esophagitis in 2 patients from the before MS therapy group but in no patients from the after MS therapy group. All patients in the before MS therapy group showed residual contents in the substitute stomach, and seven patients in the after MS therapy group showed residual contents in the substitute stomach (P < 0.0001). There was a significant difference between before and after MS therapy (P < 0.0001). (2) EFS; The time to 50% residual rate of the before MS therapy group (80.5 +/- 16.2 min) was significantly slower than that of the after MS therapy patients (65.6 +/- 9.4 min) (P = 0.0091). After MS therapy (28.4% +/- 5.2%), the residual rates at 120 minutes were significantly decreased compared with patients before MS therapy (38.2% +/- 5.7%) (P = 0.0372). Patients from the after MS therapy group clearly had improved gastric stasis compared with the before MS therapy group. These results showed more satisfactory QOL in patients after MS therapy. It is possible that MS therapy improves abdominal fullness due to the postprandial stasis in the substitute stomach, contributing to the improvement of QOL of patients after DGP.

Aim. Mucosal addressin cell adhesion molecule-1 (MAdCAM-1) mediates the homing of lymphocytes to gut-associated tissues (GALT). We performed a semiquantitative analysis of MAdCAM-1 expression during small bowel graft rejection in rat treated with FTY720. Methods. Orthotopic small bowel transplantations (SBT) were performed from BN rats to LEW rats. Isografted animals served as controls. Three groups of SBT animals were studied on days 3, 5, 7 after operations (Isograft, untreated allograft, allograft with FTY720). FTY720 was orally administered by gavage (1 mg/kg/d) to allograft models on 7 consecutive days. Cryostat sections were prepared from grafts, including Peyer's patches (PPs). Indirect immunoperoxidase staining was performed using mAbs against MAdCAM-1. The degree of vascular endothelial staining on high endothelial venules (HEV) in the PPs was graded from 1 (low levels) to 5 (high levels), and in the vessels of the lamina propia from 1 (faint), to 2 (low at the base of villi), 3 (low to the middle of villi), 4 (high to the middle of villi), to 5 (high to villi tip). Results. The graft survival was prolonged in the FTY720-treated group. MAdCAM-1 expression on HEVs in PPs was down-regulated during rejection. In contrast its expression on endothelial cells of vessels in the lamina propria was up-regulated during rejection. In the FTY720-treated groups, MAdCAM-1 expression on HEVs in PPs was up-regulated and its expression on endothelial cells of vessels in the lamina propria was down-regulated compared with untreated allograft group. Conclusions. Alteration in MAdCAM-1 expression may be associated with the development of SB graft rejection. The vessels at the base of villi, which are associated with lymphocyte recruitment, may become sites of intestine immune reactivity during the early phase of small bowel allograft rejection. FTY720 was found to prevent the down-regulation of MAdCAM-1 expression on HEVs in PPs and the up-regulation of its expression on endothelial cells of vessels in the lamina propria while also prolonging small bowel allograft survival.

Malignant rhabdoid tumor of the kidney (MRTK) is a rare but highly aggressive tumor in children, and knowledge about the molecular signature of this tumor is limited. We report the molecular genetic alterations and gene expression profile of an MRTK tumor that arose in a 4-month-old Japanese girl. Fluorescence in situ hybridization and Southern blot analyses revealed a homozygous deletion of an similar to 0.29-Mb genomic region bordered by the Rgr and DDT genes in these tumor cells. This deleted region encodes SMARCB1, a candidate tumor suppressor gene for MRTK. Using a high-density oligonucleotide DNA array, we found increased expression of 25 genes, including genes involved in the cell cycle (10 genes), DNA replication (3 genes), cell growth (5 genes), and cell proliferation (5 genes), in this MRTK tumor sample, compared with a noncancerous kidney (NK) sample. On the other hand, 64 genes, including 4 genes regulating apoptosis, were found to show decreased expression in this MRTK tumor sample, compared with the NK sample. Among these alterations, we found alterations of expression of some genes, such as IGF2, MDK, TP53, and TNFSF10, in this MRTK tumor, as described previously. The molecular genetic alterations and altered pattern of gene expression found in this case may have contributed to the biological characteristics of the MRTK tumor that arose in our patient. (c) 2005 Elsevier Inc. All rights reserved.

We describe here three cases of pancreatitis after congenital choledochal cyst excision. In these three cases, the choledochal remnant in the pancreas head was markedly dilated, probably because of an incomplete resection of the cyst at the primary operation, and an increase in intraluminal pressure of the pancreatic duct caused by a dynamic obstruction by a protein plug or a pancreatic calculus. Complete cyst excision, including the choledochal wall in the pancreas, is therefore strongly recomended.

Purpose. FTY720 is a novel immunosuppressive agent that is thought to reduce the number of peripheral blood lymphocytes (PBL) by directing them toward secondary lymphoid organs such as the lymph nodes and Peyer's patches. We studied the effects of FTY720 on aly/aly mice that do not have either lymph nodes or Peyer's patches, as well as on splenectomized aly/aly mice. Methods. FTY720 was orally administered by gavage (1 mg/kg) to aly/aly mice as well as to aly/+ mice with and without a splenectomy on 14 consecutive days. The number of lymphocytes was then counted using True Cell beads and flow cytometry. The number of B220-, CD3-, and CD4-positive cells was also determined. In addition, skin grafts from C3H donor mice were performed on these mice. Results. FTY720 was effective in significantly reducing the total lymphocyte count as well as the B220-, CD3-, and CD4-positive subtypes in the peripheral blood of aly/+ mice as well as in aly/aly mice with and without a splenectomy. While we did observe allograft skin graft rejection in both the aly/+ mice as well as the aly/aly mice recipients and splenectomized aly/aly mice, the graft survival was prolonged in all groups. The skin allografts treated by FTY720 thus demonstrated fewer lymphocytic cells and less infiltration of CD4-positive cells. Conclusions. The administration of FTY720 to mice without lymph nodes, Peyer's patches, or spleens still results in peripheral lymphopenia. In all groups, FTY720 was found to prevent the infiltration of CD4-positive cells in skin allografts while also prolonging skin allograft survival. The fate of these lymphocytes, however, is unclear.

Background: No previous report has, to our knowledge, been made on anal mucosal electric sensation in postoperative patients with anorectal malformations (ARMs). We studied the anal mucosal electric sensory threshold (AMEST) in comparison with clinical manifestation. Methods: The study included 25 patients with ARMS who underwent anorectoplasty (ARMS group) and 10 subjects (control group). Based on the type of ARMS, patients were divided into 3 subgroups: high type, n = 14; intermediate type, n = 6; low type, n = 5. The AMEST was measured at 3 positions, at the anal skin margin and 1 and 2 cm from the anal skin margin. The AMEST was analyzed compared with the type of ARMS and clinical manifestation. Results: The AMEST clearly increased at the 3 sites in patients with ARMs, especially those with high and intermediate types, compared with control subjects. The sensitivity threshold in the lower anal canal in the low-type subgroup was about the same as that in the control group. An analysis of clinical manifestations showed significantly increased thresholds in the upper and middle anal canal in the group of patients with difficulty in discriminating between gas and defecation and with fecal incontinence (P <.01 and P <.05). Conclusions: The AMEST for the high-type and intermediate-type subgroups in the ARMS group was worse than that in the low-type subgroup and control group. The AMEST in the upper and middle anal canal was important for gas and defecation distinction and fecal maintenance. (c) 2005 Elsevier Inc. All rights reserved.

Background/Aims: The possibility that interleukin-1 beta (IL-1 beta) is a neuromodulator of the non-adrenergic non-cholinergic (NANC) inhibitory nerves which may be mediated by nitric oxide (NO) was recently reported from animal experiments. To clarify the physiological significance of the relationship between IL-1 beta and NO in the normal human-colon, enteric nervous responses to IL-1 beta in the normal colon muscle strips were investigated. Methodology: Normal colon muscle strips derived from patients who underwent colon resection for leftsided colon cancers (14 cases) were used. The subjects consisted of 8 men and 6 women, aged from 44 to 65 years with a mean age of 56.8 years. A mechanographic technique was used to evaluated in vitro-colon muscle responses to IL-1 beta of adrenergic and cholinergic nerves before and after treatment with various autonomic nerve blockers and N-G-nitro-L-arginine (L-NNA). Results: IL-1 beta concentration dependently caused a relaxation reaction before and after the blockade of the adrenergic and cholinergic nerves. The frequency of relaxation responses after blocking the adrenergic and cholinergic nerves was higher than that before blocking, but there was no significant difference between them. Both tetrodotoxin and L-NNA inhibited the relaxation reaction in response to IL-1 beta in the human colon. Conclusions: These findings suggest that IL-1 beta plays an important role in regulating relaxation of the normal human colon via nitregic nerves, and that NO plays a role as a neurotransmitter in the NANC inhibitory nerves.

Two cases of hepatoblastoma with unique karyotypic changes are described. One case was that of a 2-year-old boy with an unbalanced chromosomal translocation involving 4q35 as the sole chromosomal abnormality. The clonal karyotype of this tumor was 46,XY,add(4)(q35)[3]/46,XY[9]. In the other case, that of a 2-year-old boy, karyotypic analyses revealed the clonal karyotype as 57,XY,+del(1)(p22),+2,+5,+6,+7,+8,+del(12)(p12),+18,+19,+20,+22[4]/46,XY[12]. Review of these two cases, together with previous reports, underscored the significance of numerical and/or structural chromosomal abnormalities of 1q, 4q, 2, 8, and 20 in the development of hepatoblastoma. The present results show that imbalance of the terminal region of 4q could be the sole chromosomal abnormality in a hepatoblastoma. We also found that imbalance of chromosomal regions on chromosomes 1 and 12 may contribute to the development of hepatoblastoma. (C) 2005 Elsevier Inc. All rights reserved.

Background: It is established that substance P (SP) is released by stimulation of nonadrenergic noncholinergic (NANC) excitatory nerves and vasoactive intestinal peptide (VIP) by stimulation of NANC inhibitory nerves. To evaluate the function of peptidergic nerves such as SP and VIP in small-bowel isografts, we examined the enteric nerve responses to SP and VIP in the isografted rat jejunum, using the normal rat jejunum as a control. Methods: Orthotopic entire small bowel transplantation (SBT) with portocaval drainage was performed from Lewis rats to Lewis rats. Grafted tissue specimens were obtained 130 days after SBT (n = 9). As controls, normal segments of the jejunum were obtained from untransplanted Lewis rats (n = 22). A mechanograph was used to evaluate in vitro jejunal responses to electrical field stimulation of the enteric nervous system before and after treatments with various autonomic nerve blockers and neuropeptides (SP and VIP). Results: SP concentration-dependently mediated the contraction reaction of NANC excitatory nerve in the isografted jejunum and to a lesser extent in the normal jejunum. In addition, there were significant diferences in the percentages showing contraction at 1 x 10(-8) and 1 x 10(-6) g/mL SP between the normal and isografted jejunal muscle strips (P < .05, respectively). VIP concentration dependently mediated the relaxation reaction of NANC inhibitory nerve in the normal jejunum and to a lesser extent in the isografted jejunum. In addition, there was a significant difference between the relaxation frequencies of the normal and those of isografted jejunal muscle strips at 1 x 10(-6) g/mL SP (P < .01). Conclusions: Contraction reactions of SP were observed in both the normal and isografted jejunum but were increased in the isografted jejunum. Relaxation reactions of VIP were also observed in both the normal and isografted jejunum but were decreased in the isografted jejunum. The increase of the effects of SP via NANC excitatory nerves and the decrease of the effects of VIP in mediating NANC inhibitory nerves may be largely related to the peristaltic abnormalities seen in the isografted LEW rat jejunum. (C) 2005 Excerpta Medica Inc. All rights reserved.

先天性胆道拡張症(CBD)分流手術後膵炎の経過観察上の問題点を検討した.対象は,CBD65例中術後に膵炎の徴候を呈した8例で,術後の臨床経過と膵管造影所見を検討した.手術は初回に肝外胆道切徐,肝管空腸Roux-Y吻合術(標準手術群)が6例(女性5例,男性1例),初回に内瘻手術後標準手術(内瘻手術群)が2例(女性)であった.標準手術群では術後平均7.5年で全例とも腹痛発作で発症し,内視鏡的逆行性膵管造影(ERP)で共通管の拡張5例,腹側膵管の拡張4例,S管の拡張3例を認め,膵管拡張のない症例はなかったが,拡張が体部膵管,尾部膵管に及ぶ重症例はなかった.内瘻手術群では術後1年,2年で繰り返す腹痛が出現し,ともに術後8年のERP,術中造影で全膵管系の著明な拡張を認め,標準手術に加え乳頭形成術を施行したが,膵管の拡張は増大し膵病変は進行性で,慢性膵炎と診断された

【目的】肥厚性幽門狭窄症における外科的治療において,臍部切開法での創外幽門筋切開と創内幽門筋切開の有用性について検討した.【対象】1999年12月から2003年8月まで日本大学板橋病院小児外科において肥厚性幽門狭窄症の診断で手術を施行した26例を対象とした.【方法】創外幽門筋切開症例20例と創内幽門筋切開症例6例について手術時間,出血量,術後経口摂取までの時間,術後入院期間について比較検討した.統計学的検討には,Mann-Whitney U検定を用い,p<0.05をもって有意とした.【結果】全症例とも術中合併症は認めなかったが,術後に肝機能障害を2例に認めた.手術時間や出血量に関しては,両者に有意差を認めなかった.術後経口摂取までの時間,術後入院期間については,有意に創内幽門筋切開症例が短かった.【結論】肥厚性幽門狭窄症に対する外科治療法はRamstedt手術が基本であるが,幽門筋に対する到達法によりいくつかに分けられる.その中でも臍部切開法は美容的にも有用とされている.本検討では,臍部切開法においては臍外法よりも臍内法が術後経過からみると有用と思われた.