笹沼 英紀

症例は70歳の男性で，塵肺（エリスロマイシン内服），慢性腎不全（血液透析中），ANCA関連血管炎（プレドニゾロン内服）の併存症があり，定期CT検査で肝腫瘤を認め当院を紹介受診した．CTで肝S3に単純で低吸収，動脈相で濃染，門脈相でwash outされる腫瘤を認めた．MRIではT1低信号・T2高信号，diffusionで拡散低下，肝細胞相でdefectを認め，エコーではhaloや後方エコーの増強を伴っていた．画像所見から肝細胞癌と術前診断し，腹腔鏡下肝S3部分切除術を施行した．腫瘍は大きさ40×37×33mmの被膜を有する壊死組織で，viableな細胞は認めなかった．中心壊死・硝子化線維性組織・弾性線維を特徴とする肝孤立性壊死性結節を鑑別としたが被膜に弾性線維がなく，肝細胞癌完全自然壊死を最終診断とした．自然壊死の機序として透析による血流障害，エリスロシンやステロイドの薬剤関与が考えられた．

症例1は30歳男性で、発熱と左腹部痛で来院した。CTで感染性Walled-off necrosis(WON)と診断し、保存的治療を行ったが、症状ならびに炎症所見の改善を認めず、インターベンション治療目的に当院転院となった。造影CT所見から壊死物質を主成分とした感染性WONと診断し、小切開Videoscope補助下に後腹膜経路でネクロセクトミーを行った。1回のネクロセクトミーで炎症所見とCT所見は速やかに改善し、追加の処置は不要となった。左後腹膜のドレーンは留置したまま入院40日目に退院した。症例2は34歳男性で、急性膵炎の診断で保存的治療が開始され、退院約2週間後に間歇的腹痛と発熱で来院し、炎症反応高値、CTで感染性WONと診断され再入院した。造影CT所見から膵体尾部の壊死物質を主成分とする左側感染性WONと診断し、腹腔経路で小切開Videoscope補助下にネクロセクトミーを行った。その後、右側WON増大による閉塞性黄疸が出現し、開腹ネクロセクトミーと胆道ドレナージが必要となった。症状出現から7ヵ月後、ERCPで左右肝管にERBD tubeを留置し退院した。

<p> 症例は64歳の女性．職域健診で便潜血が3年連続陽性だったが放置し，さらに，立ちくらみと排便時痛も出現したが放置していた．その後，貧血も指摘されて受診し，進行直腸がん，早期結腸がんと診断され，これらの治療前精査にて胆嚢がんも発見された．早期結腸がんに対して内視鏡的治療が予定されたが，その前処置で腸閉塞となった．人工肛門が造設され，その後，結腸がんに対する内視鏡的治療，胆嚢がんの手術が施行され，現在，直腸がんに対して化学療法が施行されている．</p><p> 近年，大腸がんは増加傾向にあるが，大腸がん検診の精検受診率は低い．また，地域検診に比し職域検診は精検受診率が低い．大腸がんの知識の啓発は受診意識の向上に繋がり，適切な受診勧奨と合わせて重要である．</p><p> 高齢化，画像診断の進歩に伴い，重複がんが増加傾向にある．大腸胆嚢重複がんは稀であるが，やはり増加傾向にある．がん検診でも，問診，理学・検査所見からがん好発・多発因子の有無を確認することが重要であり，健診医療従事者にも重複がんに関する知識は必要である．</p>

十二指腸乳頭部がんの外科治療において最も問題となるのは,深達度が乳頭部粘膜内にとどまる(T1a)か,Oddi筋に達する(T1b)かで,T1a以浅とT1b以深とでは治療の考え方が大きく異なる.Stage0〜IAの乳頭部がんの中には,内視鏡的,外科的乳頭切除術で治癒する症例は存在するが,『エビデンスに基づいた胆道癌診療ガイドライン改訂第2版』(2014年)で推奨される標準治療は,StageIB〜IIIと同様に,(幽門輪温存,亜全胃温存)膵頭十二指腸切除術である.(著者抄録)

近年、内視鏡的治療の進歩により、慢性膵炎およびその合併症(膵石症、膵仮性嚢胞、internal pancreatic fistula(IPF:膵性胸腹水)、胆道狭窄)に対して、膵管ステント留置、経胃的ドレナージなどの難易度の高い内視鏡手技が開発され、その低侵襲性から多くの病態では第一選択の治療となっている。しかし、すべての例で内視鏡的治療が実施できる訳ではなく、奏効率、長期成績では外科的治療に劣る部分もあり、どのようなタイミングで外科的治療を行うかを常に念頭に置いて治療計画を検討することが重要である。治療コンプライアンスの悪い症例などでは外科的治療を第一選択とすることも選択肢として、施設の熟達度を考慮し、十分なインフォームドコンセントを行ったうえで治療法を決定する必要がある。(著者抄録)

症例は35歳，女性．5年前，子宮頸癌に対し広汎子宮全摘術を施行し，術後放射線照射歴があった．突然発症の下腹部痛を主訴に救急搬送され，下腹部の反跳痛と炎症反応上昇，Cr値高値を認めた．CTでは左腎周囲と骨盤内に大量の腹水を認めた．病歴から，漏出尿による腹膜炎を疑い造影CT撮像30分後に単純CTを再検し，造影剤の腹腔内漏出を確認した．膀胱造影および膀胱鏡で膀胱自然破裂と確診し，腹腔内貯留尿のドレナージおよび膀胱カテーテル留置を行った．術後，症状は速やかに改善し，術後14日目に膀胱カテーテルを抜去し，術後19日目に退院となった．<BR>放射線照射後膀胱自然破裂の診断精度は低く，確定診断に至らないまま加療されている症例が少なくない．今回，CTを再検したことにより治療前に診断した膀胱自然破裂の1例を経験した．骨盤内放射線照射歴のある症例においては，漏出尿を原因とする腹膜炎の可能性があることを考慮して診療を行うことが重要である．

慢性膵炎の疼痛治療として、まず内科的治療が行われる。外科的治療は内科的治療無効例に対して適応が検討される。膵管拡張例には膵管ドレナージ術が適応になり、術式としては主にPartington手術とFrey手術が行われる。膵切除術は、膵管拡張がなく病変が頭部もしくは体尾部に限局した症例が適応になるが、術後の膵内分泌機能低下が必発であり、それを上回る利点があると判断された症例に実施すべきである。膵全摘術、腹腔神経叢ブロック、(胸腔鏡下)内臓神経切除術は限られた症例のみが適応となる。慢性膵炎の疼痛治療は、症例により所見、疼痛の状態はさまざまで、慢性膵炎が良性疾患であることも考慮して、治療方針を決定する必要がある。外科的治療の実施にあたっても、断酒・禁煙を中心とする生活指導は重要で、治療コンプライアンスの高い症例に対してのみ治療を行うことが推奨される。(著者抄録)

This is the first report of living donor liver transplantation (LDLT) for congenital hepatic fibrosis (CHF) using a mother's graft with von Meyenburg complex. A 6-year-old girl with CHF, who suffered from recurrent gastrointestinal bleeding, was referred to our hospital for liver transplantation. Her 38-year-old mother was investigated as a living donor and multiple biliary hamartoma were seen on her computed tomography and magnetic resonance imaging scan. The mother's liver function tests were normal and she did not have any organ abnormality, including polycystic kidney disease. LDLT using the left lateral segment (LLS) graft from the donor was performed. The donor LLS graft weighed 250 g; the graft recipient weight ratio was 1.19%. The operation and post-operative course of the donor were uneventful and she was discharged on post-operative day (POD) 8. The graft liver function was good, and the recipient was discharged on POD 31. LDLT using a graft with von Meyenburg complex is safe and useful. Long-term follow-up is needed with respect to graft liver function and screening malignant tumors.

Acoustic radiation force (ARF) elastography has recently become available. The previous animal studies have revealed lung injuries induced by diagnostic ultrasound, but the effects on the lung resulting from exposure to ultrasound with ARF are unknown. This study aimed to assess the risk of lung injury associated with ultrasound with ARF.A focused 2.5-MHz transducer that emits ultrasound with ARF was used. A rabbit was anesthetized, and the transducer was placed in the right subcostal region. Exposure settings of mechanical index (MI) 0.80, pulse duration 10 ms, pulse repetition time 5 s, and exposure time 150 s were applied.One red spot (7 x 6 mm) was observed on the surface of the right lung corresponding to the area of exposure. Alveolar hemorrhage was observed microscopically. This lesion was visible across a range of 20-170 mu m in depth from the pleural surface.The first example of lung hemorrhage induced by ultrasound with ARF was observed in this study. This observation suggests the possibility of lung injury in humans when ARF elastography is applied with the transducer directed toward the lung. Further studies are needed to determine the safety of this modality.

Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial, and there are no pathological analyses of this procedure. Herein, we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation (LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins (HVs), which included the right HV (RHV; 15 mm) and the inferior RHV (IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor's opened round ligament (60 mm x 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs, but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology, there was adequate patency and continuity between the recipient's HV and the donor's opened round ligament. In addition, the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT, as observed on pathology.

We aimed to evaluate patients who had undergone pediatric LDLT with small-for-size graft (SFSG) and identify risk factors of graft failure to establish a preoperative graft selection strategy.The data was collected retrospectively. SFSG was used in 14LDLTs (5.7 %) of 245 LDLTs performed between May 2001 and March 2014. The mean patient age and body weight at LDLT were 12.6 +/- A 2.0 years and 40.5 +/- A 9.9 kg, respectively. The graft type was left lobe in six patients, left + caudate lobe in seven patients, and posterior segment in one patient.The graft survival rates in SFSG and non-SFSG groups were 78.9 and 93.1 %, respectively (p = 0.045). In the univariate analysis, bleeding volume during LDLT were an independent risk factors for graft failure (p = 0.011). Graft failure was caused by sepsis in all three patients and occurred at a median of 70 postoperative days 70 (range 14-88 days). Among them, two cases showed high preoperative PELD/MELD score (PELD; 19.4 and MELD; 22, respectively).Pediatric LDLT using SFSG had poor outcome and prognosis, especially when it accompanies the surgical infectious complications with preoperative high PELD/MELD scores.

Background In small infants, left lateral segment grafts are sometimes too large to overcome the problems of large-for-size grafts in the abdominal compartment. To address this problem, we have developed a safe living donor graftectomy for neonates, a so-called "S2 monosegment graft" to minimize graft thickness. We reviewed our single-center experience to evaluate the feasibility of this technique for reducing graft size. Methods Eleven living-donor liver transplants using S2 monosegment grafts were performed between October 2008 and September 2014 at our institution. Medical records of both donors and recipients were reviewed and data collected retrospectively. Results The mean age of recipients at the time of transplantation was 125.3 days, including 3 neonates. The average S2 monosegment graft weight was 127.4 g, and the graft-to-recipient body weight ratio was successfully reduced to 3.5%. The graft livers were reduced to 4.1 cm in thickness. Two recipients with grafts larger than 5 cm could not undergo primary abdominal closure. Portal vein stenosis and biliary stenosis was observed in 1 recipient, and hepatic artery complications were seen in 2 recipients the clinical course for all donors were uneventful. Liver regeneration was seen in every patient. The graft and patient 1-year survival rate was 100%. Conclusions Living-donor liver transplantation using S2 monosegment grafts offers a safe and useful option for treating smaller infants. Here, we introduce our method of S2 monosegment graft emphasizing the donor harvest and graft thickness.

Introduction. Although hepatic vein stenosis after liver transplantation is a rare complication, the complication rate of 1% to 6% is higher in pediatric living-donor liver transplantation than that in other liver transplantation cases. Diagnosis is very important because this complication can cause hepatic congestion that develops to liver cirrhosis, graft loss, and patient loss. However, this is unlikely in cases where there are no ascites or hypo albuminemia. Objectives. Eleven of 167 patients who had undergone pediatric living-donor liver transplantation were identified in the outpatient clinic at Jichi Medical University as having suffered from hepatic vein stenosis, and were enrolled in the study. Methods. We conducted a retrospective study in which we reviewed historical patient records to investigate the parameters for diagnosis and examine treatment methods and outcomes. Results. The 11 patients were treated with 16 episodes of balloon dilatation. Three among these received retransplantation and another 2 cases required the placement of a metallic stent at the stenosis. Histological examination revealed severe fibrosis in four of nine patients who had a liver biopsy, with mild fibrosis revealed in the other five grafts. Furthermore, hepatomegaly and splenomegaly diagnosed by computed tomography, elevated levels of hyarulonic acid, and/or a decrease in calcineurin inhibitor clearance were found to be pathognomonic at diagnosis, and tended to improve after treatment. Conclusions. Diagnosis of hepatic vein stenosis after liver transplantation can be difficult, so careful observation is crucial to avoid the risk of acute liver dysfunction. Comprehensive assessment using volumetry of the liver and spleen and monitoring of hyarulonic acid levels and/or calcineurin inhibitor clearance, in addition to some form of imaging examination, is important for diagnosis and evaluation of the effectiveness of therapy.

膵切除術を行った浸潤性膵管癌74例(男性46例、女性28例、平均66.6歳)を対象に、標記について検討した。膵体尾部癌は31例、膵頭部癌は43例で、臨床病期はStage Iが2例、Stage IIが8例、Stage IIIが40例、Stage IVaが24例であった。術後補助化学療法は50例に施行した。R0群の3年生存率は60.1%、R1群では41.0%であったが有意差は認められなかった。癌組織型では有意差はなく、T因子についてはT1〜T2群に対しT3〜T4群は有意に予後良好であった。リンパ節転移なし群に対し、あり群は有意に予後不良であった。多変量解析では、リンパ節転移の有無のみが独立した予後規定因子であった。リンパ節転移の有無(N)と癌遺残度(R)の検討では、R0N-群の3年生存率は85.8%、R0N+群では40.3%、R1N-群は50.0%、R1N+群は41.7%と、R0N-群で有意に予後良好であった。

PURPOSE: Acoustic radiation force impulse (ARFI) is a modality for elasticity imaging of various organs using shear waves. In some situations, the heart is a candidate for elasticity evaluation with ARFI. Additionally, an ultrasound contrast agent (UCA) provides information on the blood flow conditions of the cardiac muscle. This study aimed to evaluate ARFI's effect on the heart concomitantly with UCA administration (i.e., perfluorobutane). METHODS: Ultrasound with ARFI was applied to the hearts of male Japanese white rabbits (n = 3) using a single-element focused transducer with or without UCA administration. They were exposed to ultrasound for 0.3 ms with a mechanical index (MI) of 1.8. UCA was administered in two ways: a single (bolus) injection or drip infusion. Electrocardiograms were recorded to identify arrhythmias during ultrasound exposure. RESULTS: Extrasystolic waves were observed following ultrasound exposure with drip infusion of UCA. Life-threatening arrhythmia was not observed. The frequency of the extra waves ranged from 4.2 to 59.6 %. With bolus infusion, extra waves were not observed. CONCLUSIONS: Arrhythmogenicity was observed during ultrasound (MI 1.8) with ARFI and concomitant administration of UCA in rabbits. Although the bolus administration of UCA was similar to its clinical use, which may not cause extra cardiac excitation, cardiac ultrasound examinations with ARFI should be carefully performed, particularly with concomitant use of UCA.