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症例は76歳，男性．肝細胞癌と慢性肺気腫にて通院中であったところ，腹痛と嘔吐が出現したため受診した．腹部の膨満と左上腹部に筋性防御を認め，腹部造影CTで左側結腸の壁肥厚と浮腫，腹水を認めたため，汎発性腹膜炎と診断して緊急手術を施行した．壊死した左側結腸を切除し，口側結腸にて人工肛門造設術を行った．術後，人工呼吸器管理を要したが，第39病日に退院した．病理組織学的検査で，粘膜下層の小血管にCongo-red染色陽性を示すアミロイド蛋白の沈着を認め，免疫染色検査にてAAアミロイド蛋白と判明し，続発性アミロイドーシスと診断した．慢性関節リウマチや長期透析治療を背景に持たない消化管アミロイドーシスによる緊急手術例の報告は少なく，本症例は肝細胞癌か慢性閉塞性肺疾患がその原因になりうると考えられたが断定には至らなかった．

進行大腸癌に対して，緩和手術として人工肛門造設術が施行されるが，適応や成績，QOLへの寄与に関する報告はまれである．1999年から2007年までに人工肛門造設術を施行した切除不能進行大腸癌26例を対象に，患者背景因子，経口摂取期間，生存期間，予後因子（年齢，性別，BMI，PS，貧血，低栄養，腫瘍マーカー，腹膜播種，術後化学療法の有無）について検討した．平均年齢は72.9歳，男女比は19:7，切除不能因子はT因子が20例と最多であった．平均経口摂取開始日は4.9病日，50％経口摂取可能期間は160日，退院率は81％，術後在院のままでの死亡率は19％，50％生存期間は197日，最終入院時の平均入院期間は31.2日であった．術前PS低下と低栄養が有意な予後規定因子で，術後化学療法可能例は生存期間が長かった．切除不能進行大腸癌に対する人工肛門造設術は経口摂取と在宅療養の点でQOL向上に寄与していた．PS低下や低栄養を認める症例は適応を慎重に選ぶ必要がある．

目的:切除不能悪性腫瘍に伴う上部消化管狭窄に対する胃空腸バイパス手術の直接成績や予後に関する報告は少ない．当科におけるバイパス手術症例について検討したので報告する．方法:1999年1月から2007年12月までにバイパス手術を施行した33症例について，背景因子，術後経口摂取開始日および経口摂取期間，術後生存期間，術後生存期間に影響を及ぼす因子について検討を行った．結果:平均年齢は69歳，男女比は19:14，疾患は胃癌が16例で最多であった．平均術後経口摂取開始日は7.2病日，経口摂取期間中央値は127日間，32例で術後5分粥以上を摂取できた．退院率は93.9％，50％生存期間は149日であった．術後生存期間は，術前全身合併症，貧血，低栄養，術後化学療法未施行の群で有意に低下した．結語:バイパス手術は，術後早期の経口摂取が可能で，切除不能悪性腫瘍患者のQOLの改善に大きく貢献する．ただし，全身合併症，貧血や低栄養などがある場合には適応を慎重に決定する必要がある．

目的:外科重症患者の人工呼吸管理の現状や質を論じる報告は少ない．当科の人工呼吸管理症例を分析し，人工呼吸器関連肺炎（VAP）発生率を算出したので報告する．方法:対象は2004年11月から2007年7月までの全身麻酔手術症例1,393例のうち手術直後から人工呼吸管理を要した69例で，症例を待機手術群と緊急手術群に分け，人工呼吸器装着率，在院死亡率，気管切開率，離脱率，再装着率，人工呼吸期間に及ぼす因子，VAP発生率について検討した．結果:全例の人工呼吸器装着率は5.0％，人工呼吸期間は10日間，在院死亡率は10％，気管切開率は23％，術後早期に死亡した2例を除いた離脱率は100％，再装着率は16％であった．群間の比較では装着率でのみ有意差を認め，両群共に70歳以上，手術直後のPaO2/F1O2比が300以下で人工呼吸期間は長期化した．VAP発生率は4.3/1,000レスピレーター病日であった．結論:緊急手術で人工呼吸管理を要する頻度が高く，高齢者や術直後の酸素化低下例で人工呼吸管理期間が長期化した．VAP発生率や離脱率を併せると当科の人工呼吸管理は適切であると結論付けられた．

食道胃接合部（esophagogastric junction；以下，EGJ）は扁平円柱上皮境界を有するため重複癌が発生しやすいが，衝突癌の報告はまれである．今回，EGJに発生した食道扁平上皮癌と胃管状腺癌の衝突癌の1例を経験したので報告する．症例は85歳の男性で，嚥下困難を主訴に来院し，上部消化管内視鏡検査で下部食道から噴門部にかけて3型腫瘍を指摘された．当初は食道癌の噴門部浸潤を疑ったが，細胞診で扁平上皮癌と管状腺癌を認めた．噴門部重複癌の診断で下部食道切除，胃全摘，Roux-en Y再建を施行した．病理組織学的には，扁平上皮癌と管状腺癌が組織学的移行を伴わず，明瞭な境界を持って接しており衝突癌と考えられ，また一部のリンパ節には両成分の転移を認めた．衝突癌は病理組織学的検索なくして術前に診断することは困難であり，EGJに発生する悪性腫瘍では常に衝突癌を念頭に入れる必要があると考えられた．

症例は72歳，男性．平成19年3月27日，約4mの高さから転落して受傷．来院時CTにて左右胸腔にeffusionおよび肺挫傷を認めた．入院後ショック状態となり，左胸腔内にeffusionの増加を認めたため胸腔ドレナージを施行した．翌日には尿量減少し，採血にて腎機能低下，高カリウム血症，CKの増大が認められ，また尿検査にて濃縮尿・尿潜血（3+）であったため横紋筋融解による急性ミオグロビン尿症および急性腎不全と診断し，持続的血液濾過透析(CHDF)を導入した．後日報告のあった血中および尿中ミオグロビン値は異常高値を示していた．その後DICも併発したが，集中治療を行い全身状態は少しずつ改善し46病日に軽快退院した．横紋筋融解にはさまざまな原因があるが外因性のものとしては圧挫症候群が多く，一時的な外力の負荷にて横紋筋融解が起こるケースは稀である．著者の渉猟しえた範囲では外傷後早期に本症を発症した報告は認められなかった．本症例は比較的早期に横紋筋融解を疑い，CHDF等の適切な処置を施行し良好な経過が得られた．

症例は51歳，男性．狭心症にて当院内科通院中であったが胸やけを自覚し，貧血も認められたため上部消化管内視鏡施行し，胃噴門部に全周性の3型の腫瘍病変を認め下部食道（門歯35cm）まで浸潤しさらに門歯25cmに粘膜下腫瘤様隆起を2個認めた．いずれの箇所も生検にてGroupV，adenocarcinoma，tub2であり，胸部上部食道まで壁内転移した噴門部胃癌にてTS-1とCDDPによる化学療法を行った．化療後の上部消化管内視鏡では食道と胃の病変はPRと診断され，本人と相談のうえ平成18年3月手術（胃全摘・食道亜全摘・胸骨前結腸再建・腸瘻造設）施行．術後経過は概ね良好で20病日に退院．現在外来にて化学療法施行中である．噴門部胃癌の食道浸潤の多くは下部食道であり，本例のように上部食道にまで広範囲に浸潤した例はきわめて稀である．本症例は術前の画像診断で悪性度の高いことが予想され化学療法を行った後手術を行った．今後は化学療法を可及的に行いつつ注意深い経過の観察が必要である．

Background For thoracic esophageal cancer patients with a history of gastrectomy, esophageal reconstruction using segments of colon was often accomplished using the anterior mediastinal route to avoid fatal complications related to colon necrosis. Our aim was to review our experience with reconstruction by the posterior mediastinal route and assess the surgical outcomes. Methods Between 1989 and August 2006, 34 esophageal cancer patients at Akita University Hospital underwent esophageal reconstruction accomplished by colon interposition by the posterior mediastinal route. Data from these patients were reviewed. Results Colon conduits consisted of left colon segments in 4 patients and right colon segments in 30. The grafts were supplied with blood by the left colonic artery in 13 patients, the middle colonic artery in 20, and the right colonic artery in 1. The esophagocolic (pharyngocolic) anastomosis was located in the neck in 33 patients (97%) and in the thorax in 1. No patient died during the initial hospital stay. There were no instances of colon necrosis. An anastomotic fistula occurred in 3 patients (9%). Proximal anastomotic strictures occurred in 2 patients (6%). No late graft redundancies resulting in significant dysphagia occurred. Reductions in body weight did not differ from those seen when the gastric tube was used for reconstruction, and alimentary function was good after surgery. The 1-, 2-, 3-, and 5-year survival rates were 66%, 52%, 48%, and 48%, respectively. Conclusions Colon interposition by the posterior mediastinal route provides a good outcome and is considered the route of first choice.

症例は19歳の男性で左前頸部有痛性腫瘤, 発熱, 経口摂取不良を主訴に当院受診し頸部CT, 血液生化学検査より急性化膿性甲状腺炎, 下咽頭梨状窩瘻の疑いにて入院した. 絶飲食, 抗菌薬投与, 穿刺排膿にて炎症反応ならびに臨床症状は軽快した. 咽頭造影にて左梨状窩から瘻管を認め確定診断を得た. 術前に色素を内服, 気管内挿管後左梨状窩を直達喉頭鏡下で確認し瘻孔へ色素を注入後手術を施行した. 下咽頭収縮筋を貫通して甲状腺左葉内側に至る瘻管を同定し高位で結紮切離, 甲状腺左葉切除を施行した. 術後第7病日に経口摂取を開始し, 現在再発なく外来通院中である. 本症例はCT, エコー上特徴的な所見を示し当疾患を鑑別診断におくことができた. 色素にて瘻管を同定し確実に手術を遂行できた. 瘻管は重層扁平上皮で覆われており, カルシトニン抗体による免疫染色にて瘻管周囲の甲状腺にC細胞を認めなかったことより第4咽頭嚢由来と考えられた.

The aim of the present study was to assess the outcome of treatment for patients with recurrent mid- and lower-thoracic esophageal cancers in whom recurrence was localized to the lymph nodes of the neck, and to determine the best strategy for further treatment. Between 1989 and 2001, 270 patients with mid- and lower-thoracic esophageal cancer underwent curative esophagectomy; 90 of those patients had a cancer recurrence. Our focus was on lymph node recurrence, especially when the recurrent cancers were localized to the lymph nodes in the neck. The outcomes of those patients and the efficacy of the strategies used to treat the recurrent cancers were determined. In 43 patients (48%), recurrent cancer initially appeared in the lymph nodes. Among the 43 patients, 15 (35%) had localized neck recurrence. The time between tumor recurrence and death among the 15 patients with localized neck recurrence was significantly longer than among the 28 patients with other recurrence patterns. In addition, 15 patients underwent lymph node resection, while 28 patients were treated non-surgically. The time between tumor recurrence and death was significantly longer in patients treated surgically. Of the 15 patients in whom recurrence affected the neck lymph nodes only, 10 (67%) were treated surgically; their 2-year survival rate after recurrence was 45%. The outcomes of recurrent esophageal cancers localized to the lymph nodes of the neck were better than those seen with other recurrence patterns, and salvage resection followed by chemoradiation therapy would seem to be indicated for those patients.

症例は67歳の女性で, 1986年から肝右葉の肝嚢胞を指摘され, 1998年以降当院にてCT, 腹部超音波検査にて経過観察されていた.嚢胞は増大傾向を示し, 2002年7月より下腹部から右腎部の疼痛と食欲不振を自覚し入院となる.内部に腫瘤陰影を認め, 9月18日,肝悪性腫瘍の診断にて肝右葉切除術を施行した.病理組織検査にて嚢胞腺癌 (papillotubular, 肝臓浸潤(+)), EMA(+), CK7(+), CK20(+～-), AFP(-) であった.経過良好で,第19病日退院となったが, 12月に入り全身倦怠感などが出現. CTにて傍大動脈リンパ節腫大を認め, CEA, CA19-9も上昇し,再発と診断した.抗癌剤治療を行ったが全身状態は悪化し, 4月22日死亡された.肝嚢胞は多くの場合良性であるが,多房性で,壁の肥厚や不整を有する例では,悪性を念頭に入れた注意深い経過観察が必要である.

Background and Objectives A substantial body of evidence suggests that allogeneic blood transfusion increases the rate of recurrence of resected malignancies. The present study was conducted with the aim of understanding better the clinical characteristics of recurrent esophageal cancer and determining whether any survival advantage is conferred by transfusing autologous instead of allogeneic blood during the esophagectomy for the original malignancy. Methods We retrospectively analyzed 123 patients who received blood transfusion while undergoing esophagectomy for thoracic esophageal cancer between January 1991 and February 1998. We focused on those patients in whom the malignancy recurred. Of them, 23 patients received allogeneic blood and 18 received autologous blood. Compared were the clinico-pathological factors influencing prognosis as well as the disease-free survival periods and the period of survival after recurrence of the cancer. Results The clinico-pathological factors that influenced prognosis were similar in the two groups. There was also no significant difference in the rate at which the esophageal cancer recurred, or in survival time once it had recurred. On the other hand, disease-free survival prior to recurrence was significantly prolonged in the autologous blood transfusion group. Conclusion Use of autologous instead of allogeneic blood prolongs disease-free survival of esophageal cancer patients. J. Surg. Oncol. 2004;87:26–31. © 2004 Wiley-Liss, Inc.

The FasL-Fas system is one of the recognized apoptosis-inducing systems, and has been determined to have important functions in relation to homeostasis and biological defense mechanisms. In this study, we investigated the serum levels of soluble Fas (sFas), soluble FasL (sFasL) and tumor necrosis factor alpha (TNF-alpha) in patients with burns. The sFas levels were found to be significantly higher in the patients who eventually died as compared to those in the patients who survived (3.9+/-1.8ng/ml versus 2.6+/-1.0ng/ml). On the other hand, the sFasL levels were significantly higher in the patients who survived (61.5+/-29.9ng/ml versus 37.2+/-14.4ng/ml) than in those who eventually died. A positive correlation was noted between the TNF-alpha level and the sFas level, and a negative correlation was observed between the TNF-alpha level and the sFasL level. These findings suggest that worsening of the condition of a burns patient may be related to changes in the Fas-FasL system.

症例は74歳,女性.平成12年1月右鼠径部の腫瘤にて発症.生検にて悪性腫瘍由来と診断されたが,原発巣が同定されず経過観察となった.同年8月,直腸診で肛門管内に硬結を触知し再度精査,肛門周囲皮膚浸潤を伴う肛門管癌,肝転移と診断された.皮膚科にて肛門周囲皮膚生検を施行後,同年9月11日, Miles手術,肝部分切除を施行した.組織学的にはPagetoid spreadを伴う肛門腺より発生した肛門管腺癌であった.患者は術後1年9カ月後に再発,肝転移によって死亡した. Pagetoid spreadを伴う肛門管癌は稀であり,診断が困難なこと,予後不良であることから文献的考察を加え報告した.

症例は56歳,男性. 30年前の外傷による右腎摘出術を契機として後腹膜膿瘍,皮膚瘻を形成.受傷26年後上行結腸と膿瘍腔の間に瘻孔を形成,皮膚瘻から糞便の排泄がみられるようになり,結腸切除ならびにドレナージ術が施行された.結腸瘻は閉鎖されたが膿瘍腔は形成されたままであった. 2001年膿瘍腔が下肢方向へ伸展し右臀部に皮下膿瘍を形成,発熱,経口摂取不良を主訴として来院,入院となった.背側膿瘍腔を開放,皮下膿瘍をドレナージするも臀部からの膿汁排泄はおさまらず,ショック状態となった.後腹膜経路を通じて右化膿性股関節炎を発症していたためと判明,当院整形外科にて右大腿骨頭切除,抗生剤含有セメントビーズ留置を行った.その後の経過は順調で松葉杖での歩行が可能となり,入院147日目にリハビリ目的に転院となった.

Purpose: There is evidence that blood transfusion is associated with an increased rate of tumor recurrence. This study was conducted to assess the survival advantage of giving autologous blood instead of allogeneic blood during surgery for esophageal cancer. Methods: We retrospectively analyzed 62 patients who underwent esophagectomy for thoracic esophageal cancer between January 1991 and February 1995 and received allogeneic blood transfusion, and 61 patients operated on between March 1995 and February 1998, who received autologous blood transfusion. The clinicopathological factors and survival rates were compared between the two groups. Results: The clinicopathological factors that influenced prognosis were similar in the two groups; however, a definite survival advantage was evident in the autologous blood transfusion group. According to multivariate analyses, the transfusion of allogeneic blood was an independent prognostic factor (P = 0.0222), as was the presence of metastatic lymph nodes. Patients who received allogeneic blood transfusions perioperatively had more than a twofold greater risk (Hazard ration 2.406) of death over patients who received autologous blood transfusions. Conclusion: Autologous blood transfusion appears to be an independent prognostic factor for the survival of patients with esophageal cancer.

症例は67歳の男性で, 糖尿病, 高血圧, 精神分裂病にて治療中であった. 嘔気, 食欲不振を主訴に来院. 著明な腹部膨満あり. WBC 8,300/μl, CRP 12mg/dl, Cr 2.4mg/dl, BS 324mg/dl. 単純X線では遊離ガス, niveauを伴う拡張した小腸を, CTでは遊離ガス, 腸管壁・腸間膜内ガスを認めた. 緊急手術施行し, 下部小腸に腸管壁・腸間膜内気腫を認めた. 原因は腸管内圧上昇と判断し, イレウスチューブ挿入, 腸内容排除後, 留置した. 術後経過良好で退院. 本症は腸管壁内に多数の嚢腫様気腫を形成するまれな疾患である. 原因は, 腸管内圧上昇, 腸管虚血, 慢性肺疾患, 薬剤性などと多彩である. 治療は保存的療法が原則であるが, 腸管虚血によるものなどは緊急手術が必要とされている. 本症例では炎症反応陽性で, Cr値の上昇を伴い, 糖尿病を合併しており腹部所見の信頼性が低いことを考慮し, 緊急手術を施行した.

下部直腸癌手術における輸血状況の把握と血液準備方針の確立を目的に検討を行った.対象は腹会陰式直腸切断術(以下Miles)26例,低位前方切除術(以下LAR) 20例.全体の輸血率は26%. 術中平均出血量はMilesで785ml, LARで345mlであり, 1,000mlを越えた症例はMilesで7例, LARで1例.同種血輸血例は12例(Miles 9例, LAR 3例).輸血例の平均輸血量はMilesで6.4単位(4～16単位), LARで2単位.術前治療,術前Hb値,手術時間,壁深達度, stageが輸血率と有意に相関.当院でのMilesでのmaximum surgical blood order scheduleは3単位.一方, LARでは輸血率は15%で, Type & Screen. 結論として,全体の輸血率は26%と少なく,ほぼ厚生労働省の指針に基づいた輸血が行われており,輸血準備に対する方針が確立された.

われわれは術前放射線治療を施行した成人肝芽腫の1例を経験したので報告する. 症例は60歳の男性, 1998年3月に検診で肝機能異常を指摘され来院した. エコーで肝右葉に径15cmの腫瘤を認めた. Alpha-fetoprotein (以下, AFPと略記) は11,932ng/mlと高値であり肝細胞癌と診断された. 放射線治療を40Gy施行した結果, CT上で最大径6.1cmと著明に縮小しAFPも42ng/mlと低下した. その後AFPが再上昇したため, 1999年6月に肝右葉切除ならびに横隔膜合併切除を施行した. 肉眼的には肝右葉に出血と壊死を伴う11×7.5×6cmの結節型の腫瘤を認めた. 組織学的に, 腫瘍は大部分が肝芽腫 (低分化型～未熟型) の像を示していたが一部に肝細胞癌の像も混在していた. 術後経過は良好で, 第22病日に退院したが, 左頸部と肺に腫瘍の転移が出現し術後2か月で死亡した.

This study investigates whether the pressure parameters obtained from the Swan-Ganz catheter (SGC) accurately reflect the circulating blood volume just after en bloc resection of the thoracic esophagus with regional lymph node dissection. It is well known that this operation induces severe hemodynamic changes and although the pressure parameters obtained from the SGC are an accepted means of monitoring circulating blood volume, we have often experienced a discrepancy between the SGC data and the clinical state. We examined the pressure parameters and diameter of the inferior vena cava (IVC) and left ventricle (LV), and the central venous compliance using SGC and echocardiography in ten patients who underwent esophagectomy for esophageal cancer. The central venous pressure, pulmonary arterial mean pressure, and pulmonary artery wedged pressure were significantly increased just after the operation compared with the preoperative levels, while the diameters of the IVC and LV decreased just after the operation. The compliances of the IVC decreased significantly just after the operation. The hemodynamic shift to the third space after esophagectomy induces decrement of the compliances of IVC. As the CVP does not always reflect the circulating blood volume, measuring the diameter of the IVC using echocardiography is extremely useful for monitoring circulating blood volume just after esophagectomy.

A 68-year-old man who had received resection for thoracic esophageal cancer 8 years ago, was operated on for the cancer of the reconstructed gastric tube. On the day of the operation, he accidentally swallowed gastric juice due to an obstruction in the reconstructed gastric tube. He suffered from acute hypoxic respiratory failure which could not be controlled with conventional therapy on postoperative day 1. Therefore, extracorporeal life support was employed at 3.0 L/min. extracorporeal flow for 11 days. Before extracorporeal life support data: PO2/FiO2 = 45, A-aDO2 = 600. During extracorporeal life support, the ventilator setting was pressure control (16 cmH2O) ventilation with a positive end expiratory pressure of 8 cmH2O, respiratory rate of 5 breaths/min., and FiO2 of 0.4. The patient was successfully weaned from extracorporeal life support and extubated on postoperative day 12. After extracorporeal life support data: PO2/FiO2 = 225, A-aDO2 = 465. We report on a successful weaning case from extracorporeal life support and discuss the efficacy these of regarding this patient.

It has been reported that reperfusion is the most important factor in ischemia-reperfusion (I/R) injury. However, causes of I/R injury in the lung are controversial, because oxygen is always supplied if ventilation continues. Therefore, we hypothesized that nonhypoxic ischemia without reperfusion is sufficient for lung injury. To test our hypothesis, we measured both hydrogen peroxide (H2O2) production in the pulmonary circulation, by digital imaging fluorescent dichlorofluorescein, and microvascular permeability (MVP), by the Evans blue extravasation technique in the nonhypoxic ischemia rat lung. We made a nonhypoxic ischemia rat lung by clamping the left pulmonary artery. Both H2O2 production and MVP increased in the nonhypoxic ischemia rat lung. We also determined the effect of oxygen removal by clamping the bronchus in advance of pulmonary artery occlusion, intercellular adhesion molecule-1 (ICAM-1) neutralization with monoclonal antibody 1A29, and platelet-activating factor (PAF) receptor antagonist CV6209 on H2O2 production and MVP. These treatments inhibited both H2O2 production and MVP increase. At high-power viewing of the fluorescent dichlorofluorescein image, H2O2 was detected in the leukocytes within pulmonary capillaries. These data indicate that the nonhypoxic ischemia without reperfusion alone causes radical production and increases MVP. Furthermore, PAF and ICAM-1 contribute to these reactions.

3領域リンパ節郭清や上縦隔の拡大リンパ節郭清が定着した現在, 手術直接死亡率が1%前後の施設が多く, 食道癌手術は安全なものとなった. しかし, 高齢者が多く, 各種既往歴を有し術前機能障害を合併する例が少なくないため, 食道癌手術の際は以前と変わりなく厳重な術後管理が要求される. 本稿では術後の病態, 標準的術後管理の実際, 術後合併症の管理を中心に述べた. 術後管理にあたっては, 1) 術前の十分な機能評価, 2) 術中所見, 操作の内容を術後管理に反映すること, 3) 術後の病態を十分理解し, 異常を早期にとらえ対処すること, 4) 呼吸, 輸液など術中管理が術後経過に及ぼす影響が大きいことから, 麻酔科医との綿密な連携などが重要なポイントと考えられる.

Patients who have undergone major surgery such as esophagectomy may develop peripheral edema in the immediate postoperative period, the cause of which is not fully understood. The purpose of this study was therefore to determine the mechanism of this phenomenon. Finger edema was measured as a marker for peripheral edema before and after esophagectomy in eight patients. Plasma interleukin-6 (IL-6) was also measured by an enzyme-linked immunosorbent assay. Finger edema markedly increased in the immediate postoperative period and remained significantly elevated until after postoperative day (POD) 3 compared to the preoperative value (P0.05). Plasma IL-6 also markedly increased in the immediate postoperative period and remained significantly elevated on POD 2 compared to the preoperative value (P0.05). The degree of finger edema highly correlated with the level of plasma IL-6 (r = 0.71, P = 0.0001). These findings indicate that peripheral edema after esophagectomy might be caused by a proinflammatory cytokine response.

We treated a case of paraesophageal hiatus hernia by laparoscopic repair. The procedure included a reduction of the gastric fundus and duodenal bulbus, closure of the diaphragmatic defect, mesh wrapping of the closure, gastropexy to the diaphragm, and a gastrostomy. Preoperative monitoring of the pH for 24 h showed no reflux. Intraoperative intraluminal manometry of the esophagus after hernia reduction showed the pressure of the lower esophageal sphincter to be normal, and thus an antireflux procedure was not deemed to be necessary. The patient was put on a soft diet from postoperative day 2. A postoperative upper gastrointestinal series showed no gastroesophageal reflux. No complications or recurrence of the hiatus hernia have been observed in the 12 months since the operation. Laparoscopic repair of a paraesophageal hiatus hernia with normal pressure of the lower esophageal sphincter, so that fundoplication is not needed, is thus considered to be possible.

食道癌術後早期には呼吸機能低下を認めるが, その原因については十分検討されていない. 今回, 我々は食道癌術後早期の呼吸機能低下を呼吸筋力の面から検討した. 1995年2月から9月の間に右開胸, 胸腹部食道全摘, 後縦隔経路頸部食道胃管吻合術を施行した食道癌患者13例を対象とした. 呼吸筋力の指標として最大吸気口腔内圧 (MIP) と最大呼気口腔内圧 (MEP), 骨格筋力の指標に握力を, 術前日, 第3, 4, 5, 6, 7, 14, 21病日に測定した. MIP, MEPは, それぞれ第3病日で術前の42-2%, 34.7%と有意な低下を認め, 21病日には87.2%, 86l4%に回復し, FVC, FEV1.0との間にそれぞれ有意な相関を認めた. 一方, 握力はMIP, MEPとの問に強い相関を認めなかった. 以上の結果から術後呼吸機能評価の指標としてMIP, MEPは有用と考えられ, 食道癌術後早期の呼吸機能低下には骨格筋力など全身的因子よりも呼吸筋障害, 肺・胸郭complianceの低下など局所的要因が強く影響していると推測された.

The data on 272 patients with esophageal cancer who underwent resection in our department between 1984 and 1994, were reviewed to assess the postoperative infection caused by MRSA, MRSA were isolated from 48 (17.6%) patients, and in the latest 3 years MRSA were isolated from 4 or 5 patients every year. The incidence of patients who had clinical symptons of the infection was 62.5%, and pneumonia, pyothorax and wound infection were common. MRSA were isolated within 5 postoperative days in many patients, and the number of symptomatic patients was high (73.3%) in these patients. In patients with postoperative complications (bleeding, anastomosis insufficiency), MRSA were isolated much more frequently than in patietns without postoperative complications (25.2% v.s. 12.7%). Other pathogens were isolated with MRSA in 64.3% of patients, and the incidence of symptomatic patients was higher in cases with polymicrobial infections than in cases with infectins caused by MRSA alone (68.5% v.s. 43.3%). The most common pathogens isolated with MRSA were gram-negative rods (62.3%). Pseudomonous aeruginosa isolated with MRSA has gradually become resistant to antibiotics. In conclusion, these data indicate that the strict prevention of hospital acquired infections in the early postoperative period and the avoidance of postoperative complications by adequate selection of operation methods and skilled technics are necessary to prevent postoperative infections caused by MRSA in patients with esophageal cancer. The next problem is to come up with a strategy against the polymicrobial infection caused by MRSA and pseudomonous aeruginosa, which is resistant to antibiotics.

This study was conducted to examine the long-term outcome of 500 patients who underwent surgery for cancer of the thoracic esophagus during the past 20 years. Favorable results were obtained with postoperative adjuvant radiation and chemotherapy and there were no surgical deaths in the last 5 years. The mortality rate decreased from 17% prior to 1980 to 5% between 1981 and 1993, this being most probably attributable to the decreased incidence of suture leakage. With respect to changes in surgical techniques, during the initial years we performed intrathoracic anastomosis, after which sternal manubrium resection with anterior mediastinal esophagogastrostomy was carried out. Subsequently, we invented a technique for performing esophagogastrostomy via the posterior mediastinum. The posterior mediastinum was selected as the most physiologic route, based on measurement of tissue oxygen tension. Using blood flow determinations obtained by laser-Doppler velocimetry, we concluded that the effectiveness of thicker gastric tubes was superior to that of thin tubes. Esophagogastrostomy was performed in a shallow field in the cervical region, with the anastomosis ultimately positioned in the superior mediastinum and covered with mediastinal pleura.

Although the importance of free oxygen radical has been reported in acute lung injury, the direct evidence in vivo model was lacking. We report a new method, which for the first time allows direct detection of hydrogen peroxide in the intact rat pulmonary microcirculation. We used the computer image-analyzing system and 2',7'-dichlorofluorescin diacetate for the marker of hydrogen peroxide production in vivo. A rat sepsis model was produced by continuous infusion of endotoxin for 30, 60, and 120 min. Hydrogen peroxide production in the pulmonary microcirculation of the sepsis rat was higher than in the control rat at each time point (p < 0.01) and increased time-dependently (p < 0.01). Catalase (5,000 U/kg) almost completely inhibited the hydrogen peroxide production in the sepsis rat (p < 0.01). In high-power view, hydrogen peroxide was detected in granulocytes that adhered to the capillaries and endothelial cells that were adjoining adherent granulocytes. These observations suggest that hydrogen peroxide in the endothelium was diffused from granulocytes. In this study, we demonstrated direct evidence of hydrogen peroxide production from adherent granulocytes in intact rat lung treated with endotoxin. We conclude that endotoxin causes the granulocyte adhesion and oxidative stress to the endothelium due to adherent granulocytes within 30 min in the pulmonary microcirculation.

We evaluated the inhibitory effect of pretreatment of a mouse antiendotoxin monoclonal antibody (E5) on hypotension and oxygen radical production in the intact pulmonary microcirculation, using our original method which allows us to visualize the hydrogen peroxide production of white blood cells in vivo.The rat sepsis model was developed by continuous infusion of endotoxin (5 mg/kg/hour) . Blood pressure was recorded by left femoral arterial intubation. After 2 hours, we visualized the hydrogen peroxide production by intravenous administration of 2', 7'-dichlorofluorescin diacetate, and observed the pulmonary microcirculation, using a fluorescence microscope, a SIT TV camera, and a videotape recorder. We calculated the hydrogen peroxide production by image analysis after the experiment. E5 (6 mg/kg), which was injected 1 hour before, significantly prevented the hypotension induced by the endotoxin. We found that the amount of fluorescence significantly decreased in the E5 pretreatment group compared with the endotoxin group.In conclusion, E5 pretreatment inhibits hypotension and hydrogen peroxide production in the intact pulmonary microcirculation associated with endotoxin in a rat sepsis model.

食道癌患者の退院後の栄養状態の改善を目的として1989年より導入した在宅経腸栄養補助 (home enteral nutritional support: HENS) の意義について, 根治術を受けた51例を対象とし検討した. HENSは42例 (82%) に平均486kca1で5.4か月間投与されていた. 結果: 体重は退院時のレベルで推移した. 理想体重比 (%IBW, 入院時90%, 退院時87%), 健常時体重比 (%UBW, 入院時97%, 退院時93%) も退院時のレベルを維持できた. 血清総蛋白 (TP), アルブミン値 (Alb), 総コレステロール値の回復も良好であった. 一方, 上腕三頭筋部皮下脂肪厚 (%TSF) は約70%の例が中-高度の低下を呈した. 上腕筋囲 (%AMC) の低下は軽度であった. 結論: 退院後の体重減少が防止でき, 血液検査成績も良好であったことからHENSは有用であった. TP, Alb, %AMCに比較して%TSFの低下は著しく, 体脂肪を消費し体蛋白や内臓蛋白を維持するのが, 食道癌患者の退院後の栄養状態の本態と考えられる. %TSFの低下を防止すべく, %IBWや%UBWを目安とする入院直後からのより積極的な栄養管理が今後の課題である.

肺癌切除56例の治療成績を郭清リンパ節個数, 転移リンパ節個数の面から検討した.結果 : R2a+2b例の平均郭清リンパ節個数は右37, 左28と右が多かった.転移リンパ節でみると個数0;34例, 1～3;10例, 4～6;9例, 7以上;3例であった.腺癌では平均2.8個であり, 扁平上皮癌では平均1.0個と前者が多かった.全症例の5生率は66%であった.病理病期別5生率は, stageI;89%, II;83%, IIIA;47%, IV;0%であり, 転移リンパ節個数別では0;72%, 1～3;60%, 4～6;61%, 7以上;0%であった.再発は15例あり, 遠隔臓器が12例と優位でリンパ節は2例と少なかった.結論 : 左の郭清リンパ節個数は右に比べ少ないが, 再発形式に差はなかった.リンパ節転移個数が6個までは良好な予後が期待できると考えられた.また, リンパ節転移個数よりもstageの方が, よく予後を反映していた.

胸部食道癌術後, 後縦隔経路再建胃管-右主気管支痩が発生した症例に対し, 有茎大胸筋弁による痩孔閉鎖術を施行し治癒しえた症例を報告する. 患者は63歳の男性, 胸部中部食道癌に対し1993年7月14日, 胸腹部食道全摘, 3領域リンパ節郭清, 後縦隔経路食道胃管吻合術を施行した-第13病日, 術後透視にて異常なく経口摂取開始となったが, 咳嗽が激しく経口摂取困難, また誤嚥性肺炎を合併. その後, 絶食, 中心静脈栄養, 経腸栄養を実施していたが, 第120病日, 食道造影にて胃管気管支痩を確認, 12月21日, 有茎第3肋間筋弁を用いた痩孔閉鎖術を施行したが, 術後膿胸を合併, 第40病日に胃管気管支痩の再発を確認. 当科に転院後, 1994年3月14日, 有茎大胸筋弁による痩孔再閉鎖術を施行. 術後経過良好, 気管支内視鏡, 食道内視鏡にて治癒を確認, 現在外来加療中である. 本症では, 術後経過, 内視鏡所見, 術中所見より胃管自動縫合器縫合線部循環障害が痩孔形成の原因と考えられた.

1976年から1993年までの間に当科で手術施行した肺アスペルギルス症3例において, 診断と治療, 術後合併症につき検討した.菌球型が2例, 限局型ではあるが肺炎様浸潤影を伴った例が1例である, 菌球型1例のみ菌糸を証明できず術前確診がつかなかったものの, その術前胸部X線上air meniscussignが明らかであることから画像診断上肺アスペルギルス症が最も考えられた.菌球型2例では, 術後合併症もなく経過良好であった.もう1例は術後気管支胸膜瘻を発生し保存的治療で軽快したが19ヵ月後アスペルギルス症の再発をきたした.また, 菌球型の場合, 組織学的検討の結果, 肺機能が許せば区域切除よりも葉切除の方が根治性を考えると合理的術式と考えられた.

食道癌術後の後縦隔経路再建胃管に発生した潰瘍より大量出血を来し, ショック状態に陥った患者に対し胃管切除術を施行することにより救命しえた症例を報告する. 患者は72歳の男性で1988年6月1日, 食道癌根治術を施行され, 術後に計80Gyの頸部, 縦隔T字照射を受けている. 再発の兆候も見られず順調に経過していたが, 術後3年7か月後に突然下血, 吐血し, ショック状態となったため, 緊急入院し内視鏡を施行, 再建胃管に発生した潰瘍からの出血と判明し内視鏡的止血およびバルーンによる圧迫止血を試みるも止血できず胃管切開直視下縫合による止血術を2回施行するも再出血を来したため3回目の手術で開胸下に胃管切除術, 頸部食道皮膚瘻, 空腸瘻造設術を施行しようやく止血しえた. 患者は6か月後に有茎結腸による胸壁前食道再建術を受け現在経口摂取訓練中である. 本症例では術後の照射および酸分泌能の残存が潰瘍形成に関与していたものと考えられる.

われわれは両側深部大腿動脈瘤の1例を経験し,両側深部大腿動脈結紮術を施行し,良好な結果が得られた.本症例は末梢動脈瘤の中でも極めて稀な深部大腿動脈瘤が両側に存在した1例である.本症はその解剖学的位置および構造から,診断および治療に関していくつか注意すべき点があるので若干の文献的考察を加えて報告する.

再発食道癌の予後の向上を目的として, 当科の治療成績を分析した.全症例の50%生存月数は7か月であった.再発癌に対する積極的治療施行例では非施行例に比べ予後が有意に良好であった.治療法別にみると, 放射線療法施行例は化学療法施行例よりも予後が有意に良好であった.放射線療法施行例では嗄声を中心とする臨床症状により発見される例が73%を占め, 腫瘤の長径は平均4.4cmで, 臨床症状発現から治療開始までは平均2.8か月を要していた.直接効果では39%が有効と判定された.定期検査で発見された例では腫瘤も小さく, 有効率も高く, 予後も良好であった.手術的療法施行例は4例あり, 1例は17か月後に死亡したが, 他の3例はそれぞれ6, 20, 22か月を経た現在も生存中であり, 予後は比較的良好であった.Interleukin-2の腔内投与は優れた局所制御効果を示した.以上より再発食道癌の予後向上のためには, 早期診断と再発形式にあわせた積極的な治療が重要と考えられた.

症例は44歳の女性, 3年前から胸部X線上右下肺野の異常陰影を指摘されていたが, 精査にて悪性腫瘍否定できず手術目的にて当科紹介となった.気管支鏡検査では右 B8aの内腔に突出する表面平滑な腫瘤が認められた.右下葉切除を施行.腫瘍はS8領域にあり, 被膜を有する径2.5cmの弾性硬の球形で, 正常な肺実質におおわれていた.組織学的には星芒状の未分化な問葉細胞からなる間質の中に中小の為重層性の導管構造が散在し, 間質細胞の一部は粘液性, 軟骨性変化を示しており, 気管支腺由来の多形性腺腫と診断された.また浸潤像, リンパ節転移は認めなかった.肺原発多形性腺腫は過去22例の報告があるのみであり, 文献的考察を加え報告する.

症例は59歳の男性で, 2度にわたり肺炎を繰り返し当院を受診した.胸部X線写真では右上肺野に無気肺を認め, 胸部CT検査及び気管支鏡検査にて右上葉支分岐部にポリープ様の腫瘍が認められた。長期間の無気肺と肺炎のため右上葉は機能廃絶していると考えられ, 手術は右上葉切除術を施行し, 病理組織学的検索で軟骨性過誤腫の診断を得た.術後経過は良好で23病日に退院となった.

A rare case of esophageal schwannoma is presented. A 63-year-old woman was admitted to our hospital with a 5-year history of dysphagia. The barium esophagogram showed a protrusive smooth tumor in the upper thoracic esophagus. The tumor was removed through right thoracotomy. There was no anatomical relationship between the tumor and vagal nerve trunk. From pathologic findings and positive immunohistochemical staining for S-100 protein, the diagnosis of esophageal schwannoma was made.

胸痛で発症した右第5肋骨原発の骨好酸球性肉芽腫の1手術症例を経験したので若干の文献的考察を加え報告する.症例は24歳, 男性.胸痛を主訴に平成元年10月, 近医受診, 胸部X線写真上右第5肋骨に一致する異常陰影を指摘され精査の結果原発性肋骨腫瘍の診断で当院に紹介.平成元年12月6日, 第4, 5, 6肋骨, 第4, 5肋間筋を含めた右胸壁切除術を施行した.切除標本は肉眼的には黄色調, 弾性軟で6.5×1.5×1.0cmの大きさであり, 病理組織学的には好酸球浸潤を伴う組織球の増生を認めることより, 骨好酸球性肉芽腫の診断であった.

Background Recent advances in the treatment of thoracic esophageal cancer have afforded it a better prognosis. As a consequence, increasing attention is being paid to the outcomes with postoperative monitoring for second primary malignancies after esophagectomy, but no recent study has focused on the longterm followup and outcomes in these patients. Study design In 1989, we began intensive prospective screening and surveillance designed to detect cancers of the head and neck, lung, stomach, residual esophagus, and colon/rectum after esophagectomy. Between 1989 and 2001, 365 patients underwent esophagectomy for thoracic squamous cell esophageal carcinoma in our department. Of those, 200 were followed up as part of this program. Excluded were patients in whom esophageal cancer recurred, patients with other prior or simultaneous malignancies, and patients who died within a year of operation. Clinicopathologic profiles and treatment outcomes were determined for 33 patients who developed a second primary malignancy after esophagectomy. Results The interval between the primary esophageal cancer and the secondary carcinoma was 49 ± 40 months (median, 48 months). The second primary malignancies were located in the stomach (30%), head and neck (24%), lung (24%), colon/rectum (9%), liver (6%), pancreas (3%), and blood (6%). Twenty-one patients (64%) were classified as stage 0, I, or II; 10 (30%) were stage III or IV. Overall, the 2-year, 3-year, and 5-year survival rates following diagnosis of a second primary malignancy were 58.0%, 58.0%, and 48.6%, respectively. Of the 19 patients (58%) in whom second primary malignancies were detected before symptoms developed, the 5-year survival rate was 70.7%, which was significantly greater than that among patients whose secondary malignancies were discovered after symptoms developed (17.1%). Conclusions Good outcomes in the treatment of second primary malignancies after esophagectomy for thoracic squamous cell esophageal carcinoma can be obtained with longterm, intensive followup and active surgical intervention for detected malignancies.

We report a case of gastrobronchial fistula that developed after esophagectomy for esophageal cancer. The fistula was repaired successfully by transposing a pectoralis major muscle flap. Complete healing was confirmed histologically by epithelialization of the fistula site and at autopsy 12 months after surgery. Muscle flap transposition effectively repairs gastrobronchial fistula.