笹沼 英紀

Previous studies have demonstrated the safety of ABO-incompatible pediatric LDLT using preoperative plasmapheresis and rituximab; however, no reports have described the timing and dosage of rituximab administration for pediatric LDLT. This study aimed to describe a safe and effective dosage and timing of rituximab for patients undergoing pediatric ABO-incompatible LDLT based on the experience of our single center. A total of 192 LDLTs in 187 patients were examined. These cases included 29 ABO-incompatible LDLTs in 28 patients. Rituximab was used beginning in January 2004 in recipients older than two yr of age (first period: 375 mg/m(2) in two cases; second period: 50 mg/m(2) in two cases; and 200 mg/m(2) in eight cases). Two patients who received 375 mg/m(2) rituximab died of Pneumocystis carinii pneumonia and hemophagocytic syndrome. One patient who received 50 mg/m(2) rituximab required retransplantation as a consequence of antibody-mediated complications. All eight patients administered 200 mg/m(2) survived, and the mean CD20(+) lymphocyte count was 0.1% at the time of LDLT. In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200 mg/m(2) rituximab three wk prior to LDLT was safe and effective.

We report a rare case of immunoglobulin G4 (IgG4)-related sclerosing cholangitis without other organ involvement. A 69-year-old-man was referred for the evaluation of jaundice. Computed tomography revealed thickening of the bile duct wall, compressing the right portal vein. Endoscopic retrograde cholangiopancreatography showed a lesion extending from the proximal confluence of the common bile duct to the left and right hepatic ducts. Intraductal ultrasonography showed a bile duct mass invading the portal vein. Hilar bile duct cancer was initially diagnosed and percutaneous transhepatic portal vein embolization was performed, preceding a planned right hepatectomy. Strictures persisted despite steroid therapy. Therefore, partial resection of the common bile duct following choledochojejunostomy was performed. Histologic examination showed diffuse and severe lymphoplasmacytic infiltration, and abundant plasma cells, which stained positive for anti-IgG4 antibody. The final diagnosis was IgG4 sclerosing cholangitis. Types 3 and 4 IgG4 sclerosing cholangitis remains a challenge to differentiate from cholangiocarcinoma. A histopathologic diagnosis obtained with a less invasive approach avoided unnecessary hepatectomy.

In the field of pediatric living donor liver transplantation (LDLT), physicians sometimes must reduce the volume of left lateral segment (LLS) grafts to prevent large-for-size syndrome. There are 2 established methods for decreasing the size of an LLS graft: the use of a segment 2 (S2) monosegment graft and the use of a reduced LLS graft. However, no procedure for selecting the proper graft type has been established. In this study, we conducted a retrospective investigation of LDLT and examined the strategy of graft selection for patients weighing 6 kg. LDLT was conducted 225 times between May 2001 and December 2012, and 15 of the procedures were performed in patients weighing 6 kg. We selected S2 monosegment grafts and reduced LLS grafts if the preoperative computed tomography (CT)-volumetry value of the LLS graft was >5% and 4% to 5% of the graft/recipient weight ratio, respectively. We used LLS grafts in 7 recipients, S2 monosegment grafts in 4 recipients, reduced S2 monosegment grafts in 3 recipients, and a reduced LLS graft in 1 recipient. The reduction rate of S2 monosegment grafts for use as LLS grafts was 48.3%. The overall recipient and graft survival rates were both 93.3%, and 1 patient died of a brain hemorrhage. Major surgical complications included hepatic artery thrombosis in 2 recipients, bilioenteric anastomotic strictures in 2 recipients, and portal vein thrombosis in 1 recipient. In conclusion, our graft selection strategy based on preoperative CT-volumetry is highly useful in patients weighing 6 kg. S2 monosegment grafts are effective and safe in very small infants particularly neonates. Liver Transpl 21:233-238, 2015. (c) 2014 AASLD.

慢性膵炎の中には，膵癌と臨床上類似する症例が存在する．しかし，実際に鑑別困難例がどの程度の割合存在するか，またどのように鑑別が困難なのかについての詳細は明らかにされていない．今回，厚生労働省難治性疾患等克服研究事業難治性膵疾患に関する調査研究班における共同研究として「膵癌疑いで切除された慢性膵炎（非膵癌）症例プロファイル調査」を行った．2001～2011年において，鑑別困難例の症例数調査（1次調査）では，29施設から膵癌疑いで切除された非膵癌症例125例，非膵癌と考え経過観察した膵癌症例26例を集積した．2次調査として症例プロファイル調査を行い，23施設からそれぞれ78例，16例の症例報告を得た．EUS-FNAもしくは膵管擦過細胞診等でclass IV, Vを認めた症例が12例報告された．膵癌における細胞診偽陽性症例は少数であるが報告があり，その頻度や背景について今後の詳細な検討が必要である．

右側肝円索は，胎生期における右側臍静脈遺残に起因するとされ，門脈右枝に臍部が存在し，同部に肝円索が付着する解剖学的変異と考えられている．今回，複雑な胆管分岐形態を示した右側肝円索を伴う肝門部胆管癌の切除例を経験した．症例は62歳の男性．皮膚黄染を主訴に当院を受診，造影CTで胆管壁の肥厚と肝内胆管の拡張を認め，さらに胆嚢が肝円索の左側に位置する右側肝円索を認めた．胆汁細胞診からはClass IVが検出され，右側肝円索を伴う肝門部胆管癌と診断した．門脈分岐形態を考慮し後区域枝のみ塞栓術を行い，手術は肝後区域切除・肝外胆管切除・胆管空腸吻合術を行った．本症例では胆管分岐においてB2から後区域枝が分岐する形態を示す他，その他の胆管分岐形態からも，右側肝円索における左右対称性の理論に合致するものと考えられた．右側肝円索には脈管の分岐異常を伴うことが多く，術前の詳細な画像検索と慎重な手術計画が重要と考える．

PURPOSE: Acoustic radiation force impulse (ARFI) has recently been used for tissue elasticity measurement and imaging. On the other hand, it is predicted that a rise in temperature occurs. In-situ measurement of temperature rise in animal experiments is important, yet measurement using thermocouples has some problems such as position mismatch of the temperature measuring junction of the thermocouple and the focal point of ultrasound. Therefore, an in-situ measurement system for solving the above problems was developed in this study. METHODS: The developed system is composed mainly of an ultrasound irradiation unit including a custom-made focused transducer with a through hole for inserting a thin-wire thermocouple, and a temperature measurement unit including the thermocouple. RESULTS: The feasibility of the developed system was evaluated by means of experiments using a tissue-mimicking material (TMM), a TMM containing a bone model or a chicken bone, and an extracted porcine liver. The similarity between the experimental results and the results of simulation using a finite element method (FEM) implied the reasonableness of in-situ temperature rise measured by the developed system. CONCLUSION: The developed system will become a useful tool for measuring in-situ temperature rise in animal experiments and obtaining findings with respect to the relationship between ultrasound irradiation conditions and in-situ temperature rise.

PURPOSE: Acoustic radiation force (ARF) impulse can be used to estimate the elasticity of cardiac muscle. The purpose of this study was to evaluate the effect of ARF on the heart with concomitant administration of the ultrasound contrast agent (UCA) perfluorobutane for recently developed elasticity imaging such as shear wave imaging. METHODS: Ultrasound with ARF was applied to the heart of Japanese white rabbit with or without UCA administration. During the exposure, electrocardiographs were recorded. RESULTS: Following the exposure of ultrasound with a duration of 10 ms and a mechanical index (MI) of 4.0 to the heart, extra waves (QRS complex) were observed only after UCA administration. Although life-threatening arrhythmia was not observed, a greater increase in the frequency of the extra waves was observed following a drip infusion compared with a single (bolus) UCA infusion. In addition, 16.3 % of extra waves were followed by arterial pressure pulse. CONCLUSIONS: Cardiac ultrasound with higher MI and longer duration should be carefully considered, particularly with the concomitant use of UCA and higher MI.

INTRODUCTION: We report a patient with a rapidly progressing recurrence of hepatocellular carcinoma (HCC) with a portal vein tumor thrombus after radiofrequency ablation of the original lesion, then treated with transcatheter arterial infusion. Radical hepatic resection demonstrated a complete pathological response.PRESENTATION OF CASE: A 60-year old male with alcoholic cirrhosis and gastric varices was diagnosed with HCC measuring 12 mm in segment 8. He underwent laparoscopic radiofrequency ablation, but recurred three months later. The lesion progressed rapidly and the right portal vein was occluded. He then underwent transcatheter arterial infusion with miriplatin and iodized oil, which was effective in reducing the size of the main lesion and portal vein tumor thrombus. Right anterior sectionectomy was then performed. Pathologically, there were no viable HCC cells in either the main lesion or the portal vein thrombus. He is alive two years and nine months after surgery without recurrence.DISCUSSION: A rapidly progressing HCC recurrence with portal vein tumor thrombus is usually associated with a poor prognosis. No effective treatments have been reported in this situation except hepatic resection. In this patient the tumor was effectively reduced after three courses of transarterial miriplatin and subsequent radical hepatic resection. This is the first report to achieve a complete pathological response for such an aggressive recurrence after initial radiofrequency ablation.CONCLUSION: This strategy may result in long-term survival of patients with rapidly progressing recurrent HCC with portal vein thrombus, and further study is warranted. (C) 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd.

This retrospective study evaluates the clinical course and outcomes of patients who underwent surgery for strangulated hernias. Among 520 groin hernias from 2001 to 2012, 51 inguinal and 42 femoral hernias were strangulated and operated emergently at a tertiary referral center. Perioperative factors, patient profiles, and time interval to surgery (T (total) = time from onset to surgery, T (1) = time from onset to initial evaluation, T (2) = time from the first hospital to the tertiary center, T (3) = time from admission at the tertiary center to surgery, T (total) = T (1) + T (2) + T (3)) were analyzed in patients with strangulation, then compared between two groups, the bowel resection (BR) group and the non-bowel resection (NBR) group. T (1), T (2) and T (total) in the bowel resection group were significantly longer than those in the non-bowel resection group (P < 0.05). Patients who presented initially to the tertiary center (T (2) = 0) had a significantly lower resection rate than patients transported from other hospitals (24 vs. 44 %, P = 0.048). There was no significant difference in morbidity between the BR and NBR groups (35 vs. 24 %, P = 0.231). The elapsed time from onset to surgery, especially T (1) and T (2), is the most important prognostic factor in patients with strangulated groin hernias. Early diagnosis and transportation are essential for good outcomes.

Purpose. Cytomegalovirus (CMV) infection is known to be the most frequently viral infection among patients after liver transplantation. This is especially true in pediatric living-donor liver transplantation because the recipients have often not been infected with CMV and postoperative primary infection with CMV frequently occurs. Patients and Methods. Of 93 patients who underwent pediatric liver transplantation at our department, 33 patients (36.3%) were diagnosed with CMV infection using the anti-genemia method (C7-HRP). Retrospective review and statistical analysis were conducted to confirm risk factors of post-transplantation CMV infection. Result. Positive lymphocytes were diagnosed between postoperative days 8 and 111 after transplantation. Ganciclovir or foscavir were administrated to 21 patients. The other 10 patients who had one positive lymphocyte were observed and the cell disappeared on follow-up examination. We did not observe any cases of positive lymphocytes with C7-HRP in patients who received a graft from a CMV antibody-negative donor. Independent predictors associated with CMV infection in the multivariable analysis were administration of OKT3 and grafts from CMV antibody-positive donors. Conclusion. In CMV infection after pediatric liver transplantation, cases with CMV antibody-positive donors and with OKT3 administration for acute rejection are considered high risk, and cases with CMV antibody-negative donors are considered low risk.

The use of donors with coagulation FIX deficiency is controversial, and there are no current protocols for peri-transplant management. We herein describe the first reported case of a pediatric LDLT from an asymptomatic donor with mild coagulation FIX deficiency. A 32-yr-old female was evaluated as a donor for her 12-month-old daughter with biliary atresia. The donor's pretransplant coagulation tests revealed asymptomatic mild coagulation FIX deficiency (FIX activity 60.8%). Freeze-dried human blood coagulation FIX concentrate was administered before the dissection of the liver and 12h afterwards by bolus infusion (40U/kg) and was continued on POD 1. The bleeding volume at LDLT was 590mL. On POD 1, 3, 5, and 13, the coagulation FIX activity of the donor was 121.3%, 130.6%, 114.6%, and 50.2%, respectively. The donor's post-transplant course was uneventful, and the recipient is currently doing well at 18months after LDLT. The FIX activity of the donor and recipient at ninemonths after LDLT was 39.2% and 58.0%, respectively. LDLT from donors with mild coagulation FIX deficiency could be performed effectively and safely using peri-transplant short-term coagulation FIX replacement and long-term monitoring of the plasma FIX level in the donor.

アルコール摂取(多飲)は急性膵炎、慢性膵炎の成因として最も頻度が高い。他の成因と異なり、アルコール性膵炎は断酒・禁煙で発症・進展の予防が可能で、生活指導が重要な疾患である。その一方で「アルコール性」を規定するエタノール摂取量の明確な基準はなく、その発症・進展の機序についても不明な点が多い。慢性膵炎臨床診断基準2009では慢性膵炎をアルコール性と非アルコール性に分類し、発症前、発症早期に治療介入ができるように慢性膵炎疑診、早期慢性膵炎の診断基準を設定した。急性膵炎でも高リスク群であるアルコール多飲者の実際の発症率は低率で、遺伝子異常(SPINK1、PRSS1など)など、他の要因が深く関与していることが想定されている。アルコール性急性膵炎、慢性膵炎の診断・治療は、他の成因によるものと大きく変わるところはなく、介入治療は改訂アトランタ分類2012による膵炎局所合併症の新分類に応じた適切な時期・手技で行うことが推奨される。(著者抄録)

胆道手術におけるドレーン挿入の功罪を臨床試験の結果から検討した.膿瘍・穿孔などの合併症がない胆嚢摘出術では,開腹・腹腔鏡下ともにドレーンの挿入は創感染,呼吸器感染といった術後の合併症を増やし,それに見合う利点がないとされる.胆道切開や胆管切除・吻合でも同様に,ドレーンの利点が乏しいという結果が得られている.ルーチンワークとして行われがちなドレーンの挿入であるが,evidence-based medicine(EBM)に基づき再考すべきである.(著者抄録)

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

Rational treatment for neoplasms of the duodenal papilla (NDPs) is still controversial, especially for early stage lesions. Total papillectomies are indicated in patients expected to have adenomas, adenocarcinoma in an adenoma, or mucosal adenocarcinomas with no lymph node metastases. However, the preoperative pathological evaluation of NDPs is still challenging and often inaccurate, mainly because of the complicated anatomical structures involved and the possibility of an adenocarcinoma in an adenoma. Herein, we introduce a new method of total papillectomy, the extraduodenal papillectomy (ExDP). In this method, papillectomy is undertaken from outside of the duodenum, instead of resection from the inside through a wide incision of the duodenal wall as is done in conventional transduodenal papillectomy (TDP). The advantages of ExDP are precise and deeper cutting of the sphincter and shorter exploration time of the tumor compared to conventional TDP. We demonstrate three representative patients, all of whom had an uneventful postoperative course. One of them subsequently underwent a pylorus preserving pancreatoduodenectomy after detailed postoperative pathological evaluation. Including that patient, no recurrence has occurred with 37-46 months of follow-up. In conclusion, ExDP is regarded as a "total biopsy" for early stage borderline lesions and a feasible, less demanding alternative method for the treatment of NDPs.

厚生労働省難治性疾患克服研究事業難治性肝・胆道疾患調査研究班参加施設を対象に，1990-2009年の肝内結石症合併肝内胆管癌のProfile調査を行った．調査期間の肝内結石症症例は696例，肝内胆管癌合併症例は37例（5.3%）であった．癌合併症例の肝内結石症罹患期間は，従来から特徴的とされる肝内結石症罹患歴10年以上の症例が37%と最多であったが，肝内結石とほぼ同時に癌が発見された肝内結石症罹患歴0-6カ月の症例が36%とほぼ同数認められ，その頻度は2000年以降増加していた．肝内結石症に合併する肝内胆管癌の65%が腫瘤指摘により診断され，その治療成績は極めて不良であった．肝内胆管癌の診断は従来の直接造影法もしくは胆管内内視鏡による細胞診・生検が主で，2000年以降臨床使用されているMRI-DWI, FDG-PETなどの新たな診断Modalityの実施頻度は低く，その評価は困難であった．今後さらに症例を集積し肝内胆管癌早期発見のための診断方法についての検討が必要である．

BACKGROUND: Sorafenib is a multikinase inhibitor with antiangiogenic and antiproliferative properties, approved for the treatment of hepatocellular carcinoma. The effect of Sorafenib on liver regeneration in healthy rats was investigated. METHODS: Sixty Wistar rats received either Sorafenib (group S; 15 mg/kg) or placebo for 14 days prior to resection and until sacrifice. After a 70% partial hepatectomy, the rats were euthanized on post-operative days (POD) 2, 4 or 8. Hepatocyte proliferation was estimated by immunohistochemistry for Ki-67 antigen using stereological methods on sections prepared by systematic uniform random sampling. RESULTS: Seven animals (12%) died after surgery. Death rates were similar in treated rats and controls. At hepatectomy, the body weight was significantly lower in group S rats. The liver weight and regeneration rates were lower in group S rats on PODs 2, 4 and 8. Hepatocyte proliferation was significantly lower in group S animals on PODs 2 and 4. Alanine aminotransferase ALAT was significantly higher in the Sorafenib-treated group on PODs 2, 4 and 8. Alkaline phosphatase ALP and bilirubin levels were similar in the two groups, although bilirubin was elevated in group S rats on POD 8. CONCLUSION: In this rat model, Sorafenib did not increase post-hepatectomy mortality, but was associated with a significant impaired liver weight gain, regeneration rates and hepatocyte proliferation.

肝内結石症の画像診断は、肝内胆管に結石が確実に存在するという存在診断と、肝内胆管全枝における結石の有無を見極める部位診断から成る。肝内結石症例の多くは胆管炎、肝内胆管癌の併存のため、正確な部位診断が困難である。厚生労働省難治性肝・胆道疾患に関する調査研究班により作成された「肝内結石症の診療ガイド」の肝内結石診断フローチャートでは、画像診断法をスクリーニングで肝内結石症の存在診断を行う1次検査法、詳細な部位診断、肝内胆管癌の有無、手術適応を判断する非侵襲的な2次検査法、治療を前提とした侵襲的3次検査法に分類している。今後肝内結石症に合併する肝内胆管癌の予後を改善するためにも、従来の超音波検査、CT、MRC(MRI)、ERC、PTCだけではなくFDG-PET、diffusion MRI、perfusion CTなど新たなmodalityを含む画像診断能の向上が望まれる。(著者抄録)

診断用超音波出力に関する安全基準はIspta≦720mW/cm2及びMI≦1.9である。米国を中心にこの基準を見直す動きがある。我々は、動物実験(ウサギ)を用いた超音波照射による組織損傷と温度上昇を検討するための実験システムを開発した。特に、照射中の生体内部での温度上昇を計測するために、振動子に貫通した孔をあけ、そこに熱電対を通して超音波の焦点領域における温度上昇を測定した。(著者抄録)

肝内結石症に合併する肝内胆管癌は、重要な予後規定因子であるが、診断法の進歩した現在でも診断は困難で予後は不良である。2007年難治性疾患克服事業「肝内結石症に関する調査研究班」で第6次肝内結石症全国疫学調査および第5次全国疫学調査のコホート調査が行われ、「胆道再建の既往」、「肝萎縮」および「治療が切石のみ」が肝内胆管癌発症のリスク因子として抽出された。2009年「難治性の肝・胆道疾患に関する調査研究班」肝内結石分科会で行った「肝内結石症に合併する肝内胆管癌プロファイル調査」では、肝内胆管癌の発見動機は腫瘤形成が最も多かったが、腫瘤形成例では切除率が低く、予後も極めて不良であった。2000年以降は従来型の肝内結石長期罹患による発癌症例は減少しており、肝内結石症と同時に発見される肝内胆管癌症例が過半数を占めていた。肝内胆管癌早期発見のための画像診断法は確立されておらず、今後の重要な検討課題である。(著者抄録)

2001年〜2011年に施行した大腿ヘルニア手術症例52例を検討した。全例でCT施行し、大腿ヘルニアの術前診断は41例(CT正診率80%)だった。嵌頓群は37例(71%)で、イレウス症状は20例(嵌頓群の54%)で認め、全例緊急手術を要した。ヘルニア内容は小腸27例(73%)が最も多かった。腸切除は16例(43%)で施行した。発症から手術までの経過時間は、切除群と非切除群で平均値は同等で有意差を認めなかった(P=0.621)。後壁補強はMcVay法が37例(95%)で施行され、非嵌頓群では各種メッシュ法が53%で選択されていた。術後合併症は嵌頓群で有意に多かったが、腸切除の有無では有意差を認めなかった。腸切除を避けるためには、早期診断・治療が必要であり、発症からできるだけ早いタイミングでの介入が有効と考えられた。(著者抄録)

胆膵領域の診断に用いられる画像診断装置の進歩は著しい。これら画像診断装置から得られる高精細の情報を、系統的に活用する手法の開発が必要である。われわれは、画像情報を処理することによるvirtual 3D model(仮想三次元モデル)を作成した。さらに、産業界で用いられる3次元プリンタのrapid prototyping法によりreal 3D model(実体3次元モデル)を作成する手法を開発した。本手法により患者の個人情報を直接反映した臓器モデルが作成可能である。Virtual 3D modelは、コンピューター上での加工、処理が容易である。Real 3D modelは直接の大きさの把握や曲面の理解などに寄与する。デジタルとアナログの組み合わせにより、より詳細な理解や情報共有が得られる。今後は臨床のみならず、教育や患者コミュニケーションツールとしての活用も期待される。(著者抄録)

BACKGROUND: Rodent models have been used to evaluate aspects of liver regeneration. The aim of the present study was to investigate the natural history of liver regeneration in healthy rats. METHODS: A 70% partial hepatectomy was performed in 64 rats. The animals were randomised into 8 groups and evaluated on postoperative days one to eight. Hepatocyte proliferation was evaluated by immunohistochemistry using unbiased stereological principles. RESULTS: The mean rat body weight was 238 g (211-287). The mean weight of the resected liver was 6.3 g (5.2-7.3) and the estimated mean total liver weight was 8.9 g (7.4-10.4). Both liver weight analysis and regeneration rate showed an ascending curve, with a maximum slope on postoperative days 1-4, reaching a steady state on days 5-8. Hepatocyte proliferation (positive Ki-67 cell profiles pr. mm(2)) was high (250 cell profiles/mm(2)) on postoperative days 1-3 and tapered off on day 5. CONCLUSION: Seventy percent partial hepatectomy in healthy rats induces a rapid regenerative response and PODs 2, 4 and 8 seems optimal for assessing hepatic growth in future studies.

OBJECTIVE: The Lichtenstein inguinal hernia repair is commonly performed and suitable for teaching basic surgical skills. The objective of this study is to evaluate the feasibility of this procedure for surgical training, particularly in regard to patient outcomes.DESIGN: Retrospective case review after introduction of an integrated teaching program.SETTING: University teaching hospital.PARTICIPANTS: The Lichtenstein inguinal hernia repair is the standard procedure for adult primary unilateral inguinal hernia since 2003 at Jichi Medical University. We introduced an integrated teaching system of lectures, skill training, and videos to teach the skills for Lichtenstein inguinal hernia repair to residents and junior faculty in 2003. Cases were retrospectively divided into 4 groups. based on the experience of the operating surgeon; junior residents (PGY 1-2, group A), senior residents (PGY 3-5, group B), junior faculty (PGY 6-10, group C), and senior faculty (PGY 11 or more, group D). Background, perioperative factors, and outcomes were evaluated among the groups.RESULTS: A total of 246 elective inguinal hernia repairs (group A: 136, group B: 49, group C: 42, group D: 19) were performed. There was a significant difference in the frequeney of concomitant diseases (p = 0.012) and anticoagulant therapy (p = 0.031). Average operating time was 80.7 +/- 24.9, 72.6 +/- 20.8, 63.5 +/- 22.0, and 54.7 +/- 27.9 (min +/- SD) in groups A, B, C, and D, respectively, with a significant difference between groups A and D (p < 0.001). No significant differences were observed in estimated blood loss (p = 0.216) or morbidity (p = 0.294).CONCLUSIONS: The Lichtenstein inguinal hernia repair can be safely performed by residents and junior faculty with the appropriate supervision of senior faculty without any disadvantage to patients. This integrated teaching program for Lichtenstein inguinal hernia repair is effective and feasible for training residents and junior faculty. (J Surg 69:605-610. (C) 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

ドレナージが必要な膵嚢胞は径の大きな有症状膵仮性嚢胞に限られる.急性膵炎後の膵仮性嚢胞に対する経皮的ドレナージは根治的治療とはなり難いが,全身状態不良例,嚢胞壁の脆弱例に対する感染コントロールのために行う適応はある.慢性膵炎の急性増悪による膵仮性嚢胞は内視鏡的ドレナージ,外科的内瘻造設術の良い適応であり,経皮的ドレナージの適応はごく限られる.経皮的ドレナージはUSガイド下,CTガイド下に行われ,もっとも問題となる合併症は難治性の膵液瘻形成で,追加治療の可能性を常に念頭におく必要がある.膵嚢胞に対する経皮的ドレナージの適応になる症例は限られているが,その手技について習熟することは重要である.(著者抄録)

2001年～2011年に施行した大腿ヘルニア手術症例52例を検討した。全例でCT 施行し，大腿ヘルニアの術前診断は41例（CT 正診率80％）だった。嵌頓群は37例（71％）で，イレウス症状は20例（嵌頓群の54％）で認め，全例緊急手術を要した。ヘルニア内容は小腸27例（73％）が最も多かった。腸切除は16例（43％）で施行した。発症から手術までの経過時間は，切除群と非切除群で平均値は同等で有意差を認めなかった（P=0.621）。後壁補強は McVay 法が37例（95％）で施行され，非嵌頓群では各種メッシュ法が53％で選択されていた。術後合併症は嵌頓群で有意に多かったが，腸切除の有無では有意差を認めなかった。腸切除を避けるためには，早期診断・治療が必要であり，発症からできるだけ早いタイミングでの介入が有効と考えられた。

症例は30歳，男性，日系ブラジル人．左季肋部鈍痛の精査で高度の血小板減少と脾腫を指摘された．腹部血管造影所見から特発性門脈圧亢進症と考えられ，最大径40 mmの多発脾動脈瘤を合併していた．肝容積を上回る著明な脾腫と瘤径の大きな多発脾動脈瘤に対して，2回のコイルによる脾動脈瘤塞栓術にて脾動脈本幹の血流を遮断し，待期的に脾摘術と脾動脈瘤切除術を施行した．術中超音波で肝外門脈に壁在血栓を認めた．脾重量は900 gで，肝生検の病理所見では特発性門脈圧亢進症による変化と診断された．術後は門脈血栓増悪を予防するためAT-III製剤，抗Xa活性阻害剤投与による抗凝固療法を行い，ワーファリン内服を開始した．経過良好で術後第11病日に退院した．外来経過観察中のCT検査で門脈血栓の増大が認められたが，ワーファリン内服の継続により消失した．門脈・脾静脈血栓発生の危険の大きい巨脾に多発脾動脈瘤を伴う特発性門脈圧亢進症の治療に対して，一連の治療戦略は安全に機能した．

Carcinoma of the minor duodenal papilla is extremely rare. We present the case of a 69-year-old man diagnosed with a tumor of the second portion of the duodenum by upper gastrointestinal endoscopy, which revealed a 1.5-cm elevated tumor with slight ulceration at the minor duodenal papilla. Biopsy revealed adenocarcinoma, and a computed tomography scan showed an enhanced tumor in the duodenum, with no abnormality in the pancreatic head. A pancreas-sparing segmental duodenectomy was performed, and the duodenum reconstructed with an end-to-end anastomosis. Microscopically, the tumor was a well-differentiated adenocarcinoma, with no infiltration at the cut end of the accessory pancreatic duct. The postoperative course was uneventful and the patient discharged on postoperative day 11. We reviewed previously reported cases of carcinoma of the minor duodenal papilla. Early and exact preoperative diagnosis of duodenal neoplasms makes it possible to select a less invasive treatment, which also maintains curability. © 2011 Springer.

症例は69歳，男性．CT，MRIで肝右葉に早期濃染される最大径15 cmの巨大腫瘍と外側区域と尾状葉に数個の小腫瘍を認め，PIVKAIIの高値と画像所見から肝細胞癌と診断した．総コレステロール855 mg/dl ，トリグリセリド753 mg/dl と著明な高脂血症も認めた．2年前の総コレステロールは250 mg/dl であった．胆汁うっ滞所見がなく，高脂血症の家族歴もなく，急激な上昇を認めていることから腫瘍随伴症候群による高脂血症と考えられた．右肝の主腫瘍切除後，総コレステロール・トリグリセリド値は急速に改善したが，術後早期に肝内再発をきたし，肝動脈化学塞栓療法を行うも著効なく，骨転移により急速な転帰をたどった．<br>

Context: Although surgical resection is the only curative therapeutic option for recurrent or metachronous pancreatic carcinomas, most such cancers are beyond surgical curability. We herein report on two rare cases of remnant pancreatectomy used to treat recurrent or metachronous pancreatic carcinomas. Case reports: Case#1 A 65-year-old male developed weight loss and diabetes mellitus 83 months after a pylorus-preserving pancreaticoduodenectomy followed by two years of adjuvant chemotherapy (5-fluorouracil plus leucovorin plus mitomycin C) for a pancreatic carcinoma in the head of the pancreas (stage IA). An abdominal CT scan revealed a 3 cm tumor in the remnant pancreas which appeared as a 'hot' nodule on FDG-PET. A remnant distal pancreatectomy was performed and a pancreatic carcinoma similar in profile to the primary lesion (stage IIB) was confirmed pathologically. Case#2 A 67-year-old male showed increased CA 19-9 levels 25 months after a distal pancreatectomy for a pancreatic carcinoma in the body of the pancreas (stage IA). An abdominal CT scan revealed a cystic lesion in the cut end of the pancreas which appeared as a 'hot' nodule on FDG-PET. A remnant proximal pancreatectomy with duodenectomy was performed and a metachronous pancreatic carcinoma (stage III) was confirmed pathologically. Conclusion: Remnant pancreatectomy can be considered a treatment option for recurrent or metachronous pancreatic carcinomas. FDG-PET can play a key role in detecting remnant pancreatic carcinomas.

Background: The surgical strategy for the treatment of colorectal cancer and synchronous liver metastases remains controversial. The aim of the present study was to investigate the effects of colonic resection on liver function and regeneration in a rat model.Methods: Ninety-six Sprague-Dawley rats were block-randomized into six groups: Group I had a laparotomy performed. Group II had 1 cm colon resected and anastomosed. Group III and V had 40% or 70% of the liver resected, respectively. Additionally Group IV and VI had 1 cm colon resected and anastomosed, respectively. Body weight was recorded on postoperative day 0, 3, 5 and 7. Rats were sacrificed on postoperative day 7 by rapid collection of blood from the inferior vena cava, and endotoxin levels were measured. Remnant liver function was evaluated by means of branched amino acids to tyrosine ratio. Liver regeneration was calculated by (liver weight per 100 g of the body weight at sacrifice/preoperative projected liver weight per 100 g of the body weight) × 100.Results: The total number of complications was significantly higher in Group VI than Group I, III, IV, and V. Body weight and branched amino acids to tyrosine ratio were both significantly lower in rats that had simultaneous colonic and liver resection performed. Hepatic regeneration rate was significantly higher in the simultaneous colectomy group. Systemic endotoxin levels were unaffected by simultaneous colectomy on postoperative day 7.Conclusions: In our model morbidity seems to be related to the extent of hepatic resection. In rats undergoing liver resection, simultaneous colectomy induced a higher degree of hepatic regeneration rate. Body weight changes and branched amino acids to tyrosine ratio were negatively affected by simultaneous colectomy. © 2009 Sasanuma et al licensee BioMed Central Ltd.

今回われわれは，甲状腺濾胞腺腫術後8年に高サイログロブリン血症を契機に発見された甲状腺濾胞癌異時性多発骨転移の症例を経験したので報告する．症例は43歳，女性．1998年7月，左甲状腺腫瘍に対して左葉切除術を施行．病理は，異型腺腫であった．2006年8月，血清サイログロブリン値（以下，血清Tg値）が7,867ng/mlと著明に上昇していたため，精査を行ったが，局所再発や遠隔転移の所見は得られず，原因は明らかにされなかった．2007年4月には血清Tg値が12,000ng/mlまで上昇したため，さらに精査をすすめたところ，多発骨転移が発見され，骨生検で濾胞癌と診断された．2007年7月，残存甲状腺を全摘し，術後34日からI-131内用療法を行った．現在，血清Tg値は低下傾向にある．甲状腺濾胞性腫瘍は良悪性の診断が難しく，良性と診断されても，遠隔転移の可能性を念頭におき，定期的，かつ慎重な術後管理を長期間行う必要がある．

症例は34歳，男性．某年12月に腹痛を主訴に前医を受診した．CT検査等で，上腹部から骨盤腔内まで占める腹腔内多房性嚢胞を指摘され，膵仮性嚢胞の診断にて経皮的ドレナージを施行し症状は軽快した．4年後4月に再び腹痛が出現．再度経皮的ドレナージを施行したが症状の改善は認めず当院へ紹介となった．CT，MRIにて胃小彎に接した多房性の巨大な腫瘍を認め，膵外病変と考えられた．小網原発のリンパ管腫と診断し手術を施行した．開腹時，小網を主座とする巨大な多房性嚢胞性腫瘍を認めた．膵・胃などと癒着していたが他臓器への浸潤はなく，腫瘍摘出術を施行した．切除標本で腫瘍は16×12×9cm，800gで病理組織学的にcystic lymphangiomaと診断された．術後の経過は良好で14日目に退院となり症状も軽快した．

症例は34歳，男性．某年12月に腹痛を主訴に前医を受診した．CT検査等で，上腹部から骨盤腔内まで占める腹腔内多房性嚢胞を指摘され，膵仮性嚢胞の診断にて経皮的ドレナージを施行し症状は軽快した．4年後4月に再び腹痛が出現．再度経皮的ドレナージを施行したが症状の改善は認めず当院へ紹介となった．CT，MRIにて胃小彎に接した多房性の巨大な腫瘍を認め，膵外病変と考えられた．小網原発のリンパ管腫と診断し手術を施行した．開腹時，小網を主座とする巨大な多房性嚢胞性腫瘍を認めた．膵・胃などと癒着していたが他臓器への浸潤はなく，腫瘍摘出術を施行した．切除標本で腫瘍は16×12×9cm，800gで病理組織学的にcystic lymphangiomaと診断された．術後の経過は良好で14日目に退院となり症状も軽快した．

膵温存十二指腸切除術には多彩な術式があり,十二指腸早期癌,十二指腸腺腫症,GIST(gastrointestinal stromal tumor)などの低悪性度腫瘍,他臓器からの癌浸潤,外傷などが適応となる.膵温存十二指腸第2・3部切除術では主乳頭・副乳頭の処理の有無や切除範囲によりその再建方法は異なり,多くの例で空腸空置が必要になる.合併症としては,吻合部狭窄(胃内容停滞),膵瘻,膵炎など膵に起因する病態に注意する必要がある.本術式は十二指腸,膵臓,胆管およびこれらの支配血管系の解剖を熟知すれば安全に施行できる手技であるが,根治性を損なわないことが重要で,症例選定のため十分な術前検討を行う必要がある.(著者抄録)

Background: A combined colorectal and hepatic resection is considered too risky by many surgeons owing to the high risk of postoperative septic complications. The aim of the present study was to investigate the effects of hepatic resection on the healing of left-sided colonic anastomoses in rats on postoperative day 7. Material and Methods: Fifty-four Sprague-Dawley rats were block-randomized into three groups. In each group, 1 cm of the left side of the colon was resected and anastomosed. Additionally, 40 or 70% of the liver was resected in group 2 and 3, respectively. Rats were killed on postoperative day 7. The abdominal cavity was inspected for the presence of complications. The bursting pressure and hydroxyproline content of the anastomoses were measured. Results: The total number of complications was significantly higher in group 3 than in group 2. Anastomotic bursting pressure and hydroxyproline content did not differ significantly among the groups. Conclusions: Increasing the extent of simultaneous hepatic resection did not significantly affect the healing of left-sided colonic anastomoses in rats on postoperative day 7, although there was a tendency towards lower bursting pressure paralleling the extent of liver resection. Excessive hepatic resection with colectomy may increase postoperative complications. Copyright (c) 2007 S. Karger AG, Basel.

Background: The surgical strategy for the treatment of colorectal cancer and synchronous hepatic metastases remains controversial. Many surgeons fear anastomotic leakage and intraperitoneal abscesses when performing a one-step procedure. They prefer a two-step procedure with a liver resection 2 to 3 months after resection of the colorectal primary lesion. Subjects and Methods: We analysed medical records from April 1994 to April 2002 for a total of 42 patients with colorectal cancer and synchronous liver metastases who underwent simultaneous liver and colorectal resections with a primary anastomosis. Special attention was paid to data on surgical procedures, postoperative morbidity, and mortality. Results: Forty-two patients, 24 men and 18 women, were studied. Median operating time was 6.50 hours (3.75-11.0 hours), and median blood loss was 1522 ml (range 288 to 5650 ml). Postoperative complications included pleural effusion in 4 patients, ileus in 3, anastomotic leakage in 2, intraperitoneal pelvic abscesses in 1. pneumonia in 1, bile leakage in 1, atelectasis in 1, and wound infection in 1. There was no perioperative mortality. Conclusion: Simultaneous colorectal resection with a primary anastomosis and hepatectomy for synchronous liver metastases is considered a safe procedure.