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Preoperative chemotherapy is efficacious in several cancers. However, it is not an established treatment for locally advanced colon cancer, particularly cases with microsatellite instability-high (MSI-H)/deficient mismatch repair. Herein, we report a case of pathological complete response of MSI-H clinical T4b ascending colon cancer to preoperative treatment with pembrolizumab. A 78-year-old man was diagnosed with ascending colon cancer that invaded into the iliacus muscle and enlarged regional lymph nodes. The tumor was classified as T4bN1bM0 stage IIIC according to the 8th Union for International Cancer Control guidelines, with MSI-H status. Based on our initial diagnosis, this tumor could not be resected completely. Thus, the patient underwent preoperative therapy with CAPOX (capecitabine and oxaliplatin combination) plus bevacizumab. After 4 cycles of preoperative CAPOX/bevacizumab, we observed tumor reduction corresponding to a partial response based on the Response Evaluation Criteria in Solid Tumors criteria. Nevertheless, tumor invasion of the iliacus muscle persisted. Since oxaliplatin-induced peripheral sensory neuropathy was observed, we discontinued treatment with oxaliplatin and changed the regimen to pembrolizumab in anticipation of the therapeutic effect of this immune checkpoint inhibitor against MSI-H tumors. After 2 cycles of therapy with pembrolizumab (200 mg/body on day 1 every 3 weeks), there was drastic tumor regression. In addition, computed tomography indicated that all lymph node metastases had disappeared. Therefore, the patient underwent laparoscopic right hemicolectomy with D3 lymph node dissection. Analysis of the resected specimen showed pathological complete response.

Background RAS/BRAFV600E mutations are the most remarkable oncogenic driver mutations in colorectal cancer (CRC) and play an important role in treatment selection. No data are available regarding the clinical and prognostic features of patients with detailed RAS/BRAFV600E-mutant metastatic CRC (mCRC) in Japan. Methods A total of 152 chemotherapy-naïve patients with mCRC were included in this study between August 2018 and July 2019. Tumor samples were collected, and RAS/BRAFV600E status was investigated. RAS/BRAFV600E status was examined using a MEBGEN RASKET-B kit and polymerase chain reaction reverse sequence-specific oligonucleotide method. Results RAS/BRAFV600E mutations were detected in 54% of cases (KRAS codon 12, 26%; KRAS codon 13, 17%; KRAS non-Exon2, 5%; NRAS, 5%; and BRAFV600E, 7%). BRAFV600E-mutant CRC mainly existed in the right colon, whereas KRAS non-Exon2 and NRAS-mutant CRC was predominantly present in the left colon. KRAS non-Exon2 and NRAS-mutant CRC were associated with shorter survival time than RAS wild-type CRC (hazard ratio [HR], 2.26; 95% confidence interval [CI], 0.64–8.03; p = 0.19; HR, 2.42; 95% CI, 0.68–8.61; p = 0.16) and significantly shorter overall survival than KRAS Exon2-mutant CRC (HR, 3.88; 95% CI, 0.92–16.3; p = 0.04; HR, 4.80; 95% CI, 1.14–20.2; p = 0.02). Conclusions In our multicenter study, the findings elucidated the clinical and prognostic features of patients with detailed RAS/BRAFV600E-mutant mCRC in Japan.

Summary A 54-year-old woman was referred to our hospital with a cervical tumor. CT revealed a cervical tumor extending to the upper mediastinum, tracheal deviation and tumor infiltration in the cervical vessels. She was followed-up because no diagnosis of malignancy was made by cytology. However, 2 months later, a CT scan showed enlargement of the tumor and tracheal stenosis, and a surgical biopsy was performed and she was diagnosed with anaplastic thyroid cancer (ATC). The tracheal tube with tracheal stenosis could not be removed due to the rapid growth of the tumor, necessitating management by mechanical ventilation. Due to the difficulty of surgical resection, she was treated with lenvatinib. A lenvatinib solution was made and administered via a nasogastric tube. After lenvatinib treatment, the tumor volume decreased and the tracheal stenosis improved. The tracheal tube was removed and oral intake became possible. She was discharged and received ambulatory lenvatinib therapy. The tumor was significantly reduced in size, but gradually grew and was exposed through the cervical wound 6 months later. Esophageal perforation occurred 10 months after the start of treatment. Lenvatinib was re-administered via a nasogastric tube. Eleven months later, the patient died of massive bleeding from the exposed cervical tumor. Patients with advanced ATC may require management with mechanical ventilation for airway stenosis or with a nasogastric tube for esophageal stenosis and perforation. We experienced a case in which lenvatinib was safely administered via a nasogastric tube while performing mechanical ventilation. Learning points: An anaplastic thyroid cancer patient under mechanical ventilator management was treated with lenvatinib via a nasogastric tube. The lenvatinib solution can easily be prepared and administered via a nasogastric tube. The lenvatinib solution was effective for a patient with difficulty in oral intake. Lenvatinib could also improve the prognosis of an anaplastic thyroid cancer patient with severe airway and esophageal trouble.

Summary We report a case of rapid pleural effusion after discontinuation of lenvatinib. A 73-year-old woman was diagnosed with poorly differentiated thyroid cancer with right pleural metastasis. Weekly paclitaxel treatment was performed for 18 weeks, but it was not effective. Oral administration of lenvatinib, a multi-target tyrosine kinase inhibitor, reduced the size of cervical and thoracic tumors and lowered serum thyroglobulin levels. Lenvatinib was discontinued on day 28 because of Grade 2 thrombocytopenia and Grade 3 petechiae. Seven days after discontinuation of lenvatinib, the patient was hospitalized because of dyspnea and right pleural effusion. Pleural effusion rapidly improved with drainage and re-initiation of lenvatinib and did not recur. Anorexia caused by lenvatinib led to undernutrition, which resulted in death 13 months after initiation of lenvatinib. Autopsy revealed extensive necrosis with primary and metastatic lesions, suggesting that the patient responded to lenvatinib. Physicians should be aware of the possibility of flare-up in patients with thyroid cancer treated with lenvatinib. Learning points: Autopsy findings revealed that lenvatinib was efficacious in treating poorly differentiated thyroid cancer without primary lesion resection. Flare-up phenomenon may occur in thyroid cancer treated with lenvatinib. Attention should be paid to flare-up phenomenon within a few days of discontinuing lenvatinib.

今回われわれは極めて稀な男性副乳癌の1症例を経験したので報告する．症例は58歳，男性．2006年より右腋窩に母指頭大の腫瘤を自覚し，2008年初旬より増大傾向となった．同年9月に皮膚科を受診し，副乳癌が疑われ，当科に紹介された．CTでは右腋窩に内部が一部不均一に造影される5.5×3.5×4.0cmの腫瘍を認めた．FDG-PET/CTでも腫瘍のみに異常集積を認め，他部位からの悪性腫瘍のリンパ節・遠隔転移は否定的であった．生検ではER，PgR陽性の腺癌の像を認めた．手術は腋窩郭清を伴う腫瘤切除術を施行し，遺残なく切除可能で，周囲のリンパ節への転移は認めなかった．摘出標本では腫瘍周囲に固有乳腺と連続しない乳腺組織の存在を確認し，免疫組織化学染色ではER，PgR，gross cystic disease fluid protein-15（GCDFP-15）陽性，CK7，CK20，CEA，p63は陰性であり，副乳癌と診断した．術後補助療法としてTamoxifenを継続し，術後28カ月の現在，無再発生存中である．

It is widely accepted that antimicrobial prophylaxis is useful for the prevention of surgical wound infection, especially in colorectal surgery. While many reports support the finding that the first dose should be administered immediately before surgery, there is less evidence concerning the ideal timing for the second dose. The purpose of this study is to examine the significance of intraoperative repeated dosing. A surgical series of 131 patients with primary colorectal cancer was retrospectively analyzed for 14 parameters, including the protocols of antimicrobial administration to determine the clinical risk factors for surgical wound infection. The overall surgical wound infection rate of the 131 patients was 16.0% (21/131). When the operation finished within 4 h after the first dose (n = 29), wound infection was observed in only one patient (3.4%). In a prolonged operation exceeding 4 h after the first dose, the surgical wound infection rates were 8.5% and 26.5%, respectively, for those with (n = 47) and without (n = 49) intraoperative repeated dosing, which were significantly different based on both a univariate analysis (P = 0.031) and a multivariate analysis (P = 0.0079). Intraoperative repeated antimicrobial dosing is therefore recommended to prevent the surgical wound infection for prolonged colorectal surgery.

子宮留膿腫は高齢女性に多くみられる疾患で, まれに腹腔内に穿破し腹膜炎を起こすことがある. 今回, 我々は急性腹症により発症し, 保存的に改善した子宮留膿腫による直腸子宮瘻の1例を経験したので報告する. 症例は61歳の女性で, 2003年5月, 下腹部痛・嘔吐が出現した. 来院時は下腹部に筋性防御がみられ, CTでは直腸と子宮が交通している所見がみられた. 大腸内視鏡では直腸に径2cmの瘻孔を認め, 瘻孔からは子宮内腔が観察され, 子宮留膿腫の直腸穿破と診断した. 発症から約1か月後の大腸内視鏡・注腸検査で瘻孔は縮小傾向にあり, CTでは肥大した子宮の内腔にair densityと液体成分の貯留を認めた. 子宮頸管の癒着による閉鎖がみられたため, 頸管拡張術を施行し経過観察したところ, 症状の再燃はみられなかった. 子宮留膿腫による直腸子宮瘻は適切なドレナージで保存的に閉鎖が期待できるが, 慢性化する可能性もあり, 慎重な経過観察が必要である.

PURPOSE: CA19-9 is often used in combination with carcinoembryonic antigen to manage patients with colorectal cancer, even though there is insufficient evidence to support this use of CA19-9. Carcinoembryonic antigen, by contrast, has been regarded as a better indicator of poor prognosis and recurrence. The purpose of this study is to clarify whether CA19-9 is, in fact, a useful marker in the management of colorectal cancer patients by comparing it with carcinoembryonic antigen. METHODS: A retrospective investigation was done for a consecutive series of 155 patients with colorectal adenocarcinoma who underwent potentially curative surgery between 1995 and 1999. Excluded were patients with postoperative assays performed less than three times for either carcinoembryonic antigen or CA19-9 and those who had developed secondary cancers. Data from 118 patients were analyzed in terms of prediction of prognosis and detection of recurrences. RESULTS: The sensitivities of preoperative CA19-9 and carcinoembryonic antigen were 29.8 percent and 45.3 percent, respectively. In the univariate analysis of preoperative carcinoembryonic antigen and CA19-9 assays in 114 patients, high carcinoembryonic antigen level was significantly associated with poor prognosis (P = 0.0090 by log-rank test). We could not find a significant association between preoperative CA19-9 abnormality and survival (P = 0.12). Multivariate analysis of preoperative factors indicated significance in TNM stage (P = 0.0094) and tumor location (P = 0.036) but in neither carcinoembryonic antigen (P = 0.061) nor CA19-9 (P = 0.22). Among 40 patients with recurrences, postoperative elevations of tumor markers were seen in 19 cases for CA19-9 and in 37 for carcinoembryonic antigen throughout the follow-up periods. Sensitivity, specificity, positive predictive value, and negative predictive value were 0.48, 0.88, 0.68, and 0.77, respectively, for CA19-9, and 0.93, 0.88, 0.80, and 0.96, respectively, for carcinoembryonic antigen. In patients with recurrences, the initial postoperative elevation of tumor markers was seen earlier than the detection of recurrence in 68.4 percent of those with CA19-9 elevation and in 67.6 percent of those with carcinoembryonic antigen elevation. There was only one patient with recurrence who had CA19-9 elevation without carcinoembryonic antigen elevation, while 19 recurrent patients had carcinoembryonic antigen elevation without CA19-9 elevation. Multivariate analysis showed a significant risk of carcinoembryonic antigen elevation against recurrence with an odds ratio of 32.0 (P < 0.0001), in contrast to an insignificant association of CA19-9 elevation (P = 0.23). CONCLUSION: We could not find clinical significance to support the use of CA19-9 to predict the prognosis and detect recurrence of colorectal cancer. Because of this, we do not recommend routine use of CA19-9 in staging and surveillance of colorectal cancer patients.

進行胃癌を伴った食道破裂の1例を経験した.症例は57歳男性.昼食後に嘔吐し,急激に右胸部痛,上腹部痛が出現し,発症から約4時間後に当院救急外来を受診した.胸腹部所見,胸部単純レントゲン,胸腹部CT,食道造影により胸部下部食道破裂,幽門狭窄と診断し緊急手術となった.上腹部正中切開による経食道裂孔アプローチにて一期的単純縫合閉鎖術,有茎大網被覆術,縦隔ドレナージ術,胃空腸バイパス術を施行した.胃癌による幽門狭窄のうえ,出血が催吐因子となって発症した,と考えられた.胃癌に伴った食道破裂は自験例を含め本邦9例目であったが,同時に診断されたのは5例であった.また進行胃癌に伴ったものは4例であった.食道破裂は早期診断,治療をしないと死亡率が高く,併存疾患がある場合の診断はより困難である.まず食道破裂の存在を念頭におき,催吐因子として併存疾患の検索も重要であると考えられた.

In 19 surgically treated patients with sleep-disordered breathing for whom electroencephalograms could be recorded before and after surgery, and in 10 patients who suffered from daytime lethargy as assessed using the Epworth Sleepiness Scale (ESS) score, correlations between the stages of sleep before surgery and the ESS score and apnea-hypopnea index (AHI) were evaluated, and changes in AHI and the stages of sleep after surgery were examined. Neither the preoperative severity of AHI nor the ESS score showed an association with the stages of sleep. The improvement in the quality of sleep tended to be greater as the percentage improvement in the ESS score increased.

Although general experience has suggested that the lateral sleeping position is the most effective for patients with sleep-related respiratory disorders, few studies have demonstrated this observation using controlled conditions and objective indicators. The aim of the present study was to investigate the sleeping position of 200 patients with sleep-related respiratory disorders, including some in whom obesity played a role. The apnea-hypopnea index (AHI) improved when patients moved from the supine to the lateral position, but the improvement was only slight in patients with a high AHI or a tendency to obesity. These findings suggest that advising patients to sleep in the lateral position will only be effective for those with a moderate to low AHI, or a minimal tendency to obesity.

OBJECTIVE: We assess the usefulness of microwave hepatic tumor coagulation therapy with balloon occlusion of segmental hepatic blood flow for eight recurrent metastatic hepatic tumors in seven patients. CONCLUSION: Limited early experience with microwave hepatic tumor coagulation therapy and segmental hepatic blood flow occlusion has been positive, suggesting that further clinical evaluation is warranted.

Two cases of obstructive sleep apnea (OSAS) caused by primary hypothyroidism are reported.The first patient was a 66-year-old man who complained of sleep apnea with an apnea/hypopnea index (AHI) of 50.8 per night as assessed by all night monitoring. Hypothyroidism was subsegently suspected when he showed delayed recovery from general anesthesia following surgery involving UPPP (uvulo-palato-pharyngoplasty). Hypothyroidism was diagnosed on the basis of blood tests. His snoring and apnea improved after 2 months of levothyroxine sodium administration and the AuI changed from 50.8 to 13.0.The second patient was a 73-year-old man with an AHI of 41.3 per night as assessed by all night monitoring. Hypothyroidism was diagnosed on the basis of blood tests and was suspected because of his slow speech. He was similarly treated with levothyroxine sodium. The AHI did not decrease after treatment for 4 months. His desaturation time (the rate of O2 saturation less than 90%) improved however, from 56.6 to 31.9, and the symptoms of hypothyroidism also recovered markedly. In both patients, elevated creatine phosphokinase (CPK), dull facial expression, peripheral edema, and slow speech were recognized and these were suggestive of hypothyroidism. The type of sleep apnea was mainly obstructive in both patients.

The following six parameters were studied in 119 patients who responded to a questionnairebased long-term survey of 208 adults who had undergone surgery for obstructive sleep apnea syndrome in the previous 8 years: 1) snoring, 2) sleep apnea, 3) daytime sleepiness, 4) nocturnal arousal, 5) malaise, and 6) quality of sleep.The patients were divided into a markedly or moderately improved group (group A) and a slightly improved or unchanged group (group B) based on improvement of the apnea-hypopnea index (AHI) after surgery.In group A, improvement of snoring, sleep apnea, daytime sleepiness, and quality of sleep tended to decrease over the long term.In group B, improvement of these four symptoms was more marked than improvement of the AHI in the early postoperative period (1 year after surgery), with a significant difference between the two. The same pattern was also apparent in the long-term results.There was no major difference between the improvement of nocturnal awakening or malaise and improvement of the AHI over either the short or long term in groups A or B.

A 65-year-old man was diagnosed as having hepatocellular carcinoma (HCC) with liver cirrohosis classified clinical stage, which caused by hepatitis C virus. Abdominal contrast CT showed HCC in the diameter of 2 cm located Segment 4. Laparoscopic microwave coagulation therapy under hepatic blood flow occlusion using clamp was performed. We applied the coagulation time for 10 minutes with an output of 80 watts for 60 seconds at a time. After 2 months the hepatic tumor was completely enclosed within the coagulation area and no recurrence was showed for 14 months after procedure. We have reported that the coagulation areas with the hepatic blood flow occlusion was about twice as big as that without blocking the hepatic blood flow. This suggested that a 3 cm hepatic tumor can be controled by this method. We proposed that laparoscopic microwave coagulation therapy under hepatic blood flow occlusion should be selected for HCC of small size or middle-size hepatic tumor and high risk patients.

The possible use of percutaneous microwave tumor coagulator (PMCT) by using CT for local tumor recurrence of rectal cancer was studied in this paper. Preliminary study was performed using adult Landrace pig and we applied the coagulation time for 3 minutes. The CT guided PMCT was performed for patient with local abdomino-perineal excision. The tumor in the pelvic space were observed on CT images. With patient in the prone position on the CT table, a 14-gauge needle was used to penetrate the tumor under epidural and local anesthesia.PMCT was performed with an output of 60 watts for 60 seconds at a time. Effects of the PMCT were evaluated by CT images obtained three months after the therapy, there was no evidence of growth for the tumor on the CT images. Clinical symptoms disappered soon after the therapy, and no major complication was observed.Results of this study suggests that the CT guided PMCT therapy may be useful for local recurrence of rectal cancer.

Using the bovine liver and experimental deep electrodes, we investigated the coagulation effect in ischemic livers in an attempt to increase the range of coagulation of the deep electrodes. The hepatic blood flow was obstructed by blocking the hepatic artery (A), the portal vein (P), or both the hepatic artery and portal vein (AP), and for comparison, coagulation was performed without blocking the hepatic blood flow (C) in control animals. Two electrodes were used for microwave coagulation ; a 1.6-mm shell-type deep electrode (shell-type), and a 3-mm experimental electrode (30 NL). After coagulation, each sample was fixed in 10% formalin and sliced for histological examination. There was a brown boundary area between the coagulated and non-coagulated areas.When the hepatic blood flow was not blocked and coagulation was performed using the shell-type deep electrode at 60W for 2 minutes, a brown boundary area of 1 to 3 mm was seen. The internal diameter of the coagulated area was 23 × 11 mm, and its external diameter including the brown boundary area was 26 × 16 mm. When the hepatic artery or the portal vein was blocked to obstruct the hepatic blood flow, the internal diameter of the coagulated area was 51 × 20 mm, and its external diameter was 56 × 34 mm. Furthermore, on using the 30 NL electrode was used for coagulation at 60W for 2 minutes, the maximum internal and external diameters of the coagulated areas were 25 × 16 and 34 × 27 mm, respectively, when the hepatic blood flow was not blocked (C), 27 × 19 and 35 × 29 mm, respectively, when the hepatic artery was blocked (A), 24 × 21 and 35 × 34 mm, respectively, when the portal vein was blocked (P), and 27 × 26 and 68 × 50 mm, respectively, when the hepatic artery and portal vein were blocked (AP). This indicated that the brown boundary area increased when the portal vein was blocked, and when the hepatic artery and portal vein were blocked, the diameter of the coagulated areas was about twice as big as that without blocking the hepatic blood flow. HE-staining of the cross sections of boundary areas showed shrunken nuclei and intercellular hemorrhagic changes. This suggested that a 3-cm hepatic tumor can be controlled by a single microwave coagulation inserting the experimental electrode into the center of the tumor while blocking the hepatic blood flow.

Objective: 55 patients diagnosed as having obstructive sleep apnea syndrome (OSAS) underwent uvulopalatopharyngoplasty (UPPP). The effects of surgery were studied based on the findings of endoscopic examination under drug-induced sleep and AHI measurements performed before and after the operation. Changes in airway form during sleep were observed, and the usefulness of upper airway endoscopy in the diagnosis and surgical treatment of OSAS was studied.Methods: The site of airway obstruction during sleep induced by intravenous injection of 10mg of diazepam was classified into five types, and changes in AHI and the site of airway obstruction were compared before and after surgery.Results: The postoperative improvement rate was 73.5% in the soft palate type of obstruction, 75.6% in the tonsillar type, 52.3% in the full-circumference palatal type and 32.3% in the mixed type. Surgical treatment by UPPP had an excellent or good effect on the soft palate and tonsillar types. However, many patients with the ful1-circumference palatal type and the mixed type showed less improvement compared with the soft palate and tonsillar type.Conclusion: In the full-circumference palatal type and the mixed type, improvement can be expected following operations which include surgical treatment of the posterior pharyngeal wall or the lateral funiculus, or midline laser glossectomy.

In the present study, we subjected 65 patients to overnight monitoring and continuous nocturnal blood pressure measurement in order to assess the influence of sleep apnea on the circulatory system. Thirty-one patients were compared before and after surgery. The severity of sleep apnea was classified by Apnea Hypopnea Index (AHI), the duration of exposure to low-level oxygen (calculated as the desaturation time: DT), and increment of blood pressure. Before surgery, a significant correlation was noted between the DT and blood pressure changes. Therefore, this index was considered useful for assessing the influence of sleep apnea on nocturnal blood pressure. After surgery, improvement of AHI was greater than 50% in 19/31 patients (61.3%), and this result was almost the same as described in the literature. The improvements in DT and BP change were greater than 50% in 21/31 (67.7%) and 14/31 (45.2%), respectively. With regard to severity before surgery, AHI was > or = 50 and DT was > or = 40% in 10 and 18 patients, respectively. Nineteen patients had BP changes > or = 40 mmHg. After surgery, 1,5, and 2, patients, respectively, still showed these values. Thus, a beneficial effect of surgery was demonstrated.

Obstructive Sleep Apnea Syndrome (OSAS) is children is commonly caused by upper airway obstruction, such as that caused by adeno-tonsillar hypertrophy. We report a rare case of SAS due to a nasopharyngeal tumor. The patient was a 10-year-old boy who complained of snoring and sleep apnea. The tumor was found in the nasopharynx and mesopharyngeal space. We diagnosed this case as OSAS by overnight sleep study (Apnea Hypopnea Index: AHI = 19.67). The tumor was removed under general anesthesia. Histopathology revealed features of nasopharyngeal angiofibroma. After removal of the tumor, his symptoms resolved completely. A follow-up overnight sleep study confirmed resolution of OSAS. At the last follow up, conducted 17 months after the operation there were no signs of tumor recurrence.

According to the obstructive site, the different types of obstructive-type sleep-disordered breathing are classified as the soft palate type, palatine tonsil type, soft palate and depressed lingual root type, depressed lingual root type and epiglottis type. In this study, we conducted dynamic MRI examinations of the oral, pharyngeal and lingual root sites in patients with obstructive sleep-disordered breathing, and studied the usefulness of MRI as a diagnostic tool for the examination of such obstructive sites.

We statistically investigated the total PTR resource record (RR) based DNS query request packet traffic from the Internet to the top domain DNS server in a university campus network through January 1st to December 31st, 2011. The obtained results are: (1) We found twelve host search (HS) attacks in the scores for detection method using the calculated Euclidean distances between the observed IP address and the last observed IP address in the DNS query keywords by employing both threshold ranges of 1.0-2.0 (consecutive) and 150.2-210.4 (random). However, we found nineteen HS attacks in the scores using the calculated cosine distance between the DNS query IP addresses (threshold ranges of 0.75-0.83 and 0.9-1.0). (3) In the newly found HS attacks, we observed that the source IP addresses of the HS attack DNS query packets are distributed. Therefore, it can be concluded that the cosine distance based detection technology has a possibility to detect the source IP address-distributed host search attack.

長期生存中の胃平滑筋肉腫肝転移の2例を経験した. 症例1は70歳の男性で, 噴門側胃切除後1年7か月目に肝転移を認め, 肝部分切除および門脈内注入化学療法を施行した. 肝切除後3年5か月無再発生存中である. 症例2は51歳の男性で, 術後の残胃に発生した平滑筋肉腫例である. 残胃全摘後2年8か月目に肝に転移を認めた. 肝動脈塞栓術を計3回施行し, 腫瘍の縮小は認めなかったものの, 肝転移の診断より4年10か月生存中である. 胃平滑筋肉腫の肝転移の予後は不良といわれているが, いずれの2症例も長期生存を得ている. また本邦における肝切除術16例の術後平均生存期間は19. 1か月であり, これらの中にも2年以上の長期生存例が5例認められた. 胃平滑筋肉腫の肝転移に対しては, 適応があれば肝切除術を施行し, 適応のないものに対しては肝動脈塞栓術を反復施行して延命効果を期待すべきであると思われた.

盲腸からS状結腸におよぶ広範囲の壊死型虚血性大腸炎を経験した.症例は59歳の女性で, 腹痛・嘔吐を主訴に入院した.翌日腹膜炎症状が出現し, 緊急開腹術を施行した.盲腸からS状結腸まで連続性壊死に陥っており, 壊死型虚血性大腸炎の診断のもと, 結腸亜全摘・回腸人工肛門およびS状結腸痩造設術を施行し, 救命しえた.本邦における壊死型虚血性大腸炎49例の集計では, 年齢34～90歳 (平均年齢70.2歳) で60歳代から80歳代に多く, 性差はほとんど認められなかった.好発部位は下行結腸・S状結腸であり, この範囲で半数以上を占める.予後不明11例を除く38例の死亡率は44.7%で, そのうち切除施行例36例においても死亡率は41.7%と予後不良である.唯一の治療法は病変部の切除であるが, この際切除断端粘膜面を観察しつつ十分広範囲に切除する必要がある.

We report a rare case of perforated leiomyosarcoma of the small intestine in a 79-year-old woman who was admitted with acute abdominal pain on October 12, 1990. Physical examination revealed signs of panperitonitis, and emergency exploratory laparotomy was performed. At laparotomy, a mass 4cm in diameter was detected approximately 150cm anal side from Treitz ligament. The tumor and adjacent intestine (25cm) were resected. Histologically, the tumor was diagnosed as leiomyosarcoma arising from the proper muscle layer. The postoperative course was uneventful, and the patient is asymptomatic and free of detectable lesion one year after resection. We also review 47 cases of perforation of leiomyosarcoma of the small intestine reported in Japan. Most tumors were detected during the sixth, seventh or eighth decade of life, and the duration of symptoms in most patients was short, i.e., within 10 days. More than 70% of leiomyosarcomas of the jejunum were located within 50cm from Treitz ligament. The cumulative 5-year survival rate of patients with perforated leiomyosarcoma was 46.0%.

We report 2 cases of synchronous metastases of colorectal carcinoma to the liver and lung in which the metastatic lesions could be radically resected. Case 1 A 59-year-old man underwent adominoperineal excision of rectum for lower rectal carcinoma (well-defferentiated adenocarcinoma in stage III; absolute curative resection). After 2 years and 3 months postoperatively, synchronous metastases to the liver and lung were found. Right lobectomy folloed by partial penumonectomy were carried out, each metastatic lesions being radically resected. As of 5 years and 3 months after the initial operation or one year and 11 months after resection of metastatic lesions, the patient is in health without recurrence. Case 2 A 57-year-old woman had a carcinoma of the ascending colon with synchronous metastatic lesions in the liver and lung. In the first step operation, right hemicolectomy (well-differentiated adenocarcinoma; absolute curative resection for the primary lesion) and catheter intubation into thehepatic artery were done, and postoperative chemotherapy by artrial injection was added. After 7 months, the metastasized lesions in the liver and lung were radically resected. At present as of 4 months after the resection no recurrence occurs. From these experiences, surgical appropriateness for synchronous metastases to the liver and lung was considered.

We herein report a rare case of portsite metastasis of gallbladder carcinoma which occurred after laparoscopic cholecystectomy. A 64-year-old man underwent laparoscopic cholecystectomy at another hospital for symptomatic cholecystolithiasis. The histological examination revealed an adenocarcinoma of the gallbladder infiltrating the entire wall. Despite the physician's advice the patient refused any additional treatment. Thirteen months after surgery he visited our hospital because of a palpable mass at the scar of the right trocar incision. The nodule was removed and histological examination confirmed metastasis from the gallbladder carcinoma.

We subjected 65 patients to overnight monitoring and continuous nocturnal blood pressure measurement in order to assess the influence of sleep apnea on the circulatory system. Thirty-one patients were compared before and after surgery. The severity of sleep apnea was classified by means of the apnea-hypopnea index (AHI), the duration of exposure to low-level oxygen [calculated as the desaturation time (DT)] and changes in blood pressure (BP). Before surgery, a significant correlation was noted between DT and changes in BP. Therefore, DT was considered useful for assessing the influence of sleep apnea on nocturnal BP. After surgery, an improvement in AHI of > 50% was noted in 19/31 patients (61.3%), a result comparable to that described in the literature. Improvements in DT and change in BP were > 50% in 21/31 (67.7%) and 14/ 31 (45.2%) patients, respectively. With regard to the severity of sleep apnea before surgery, AHI was > or = 50 and DT > or = 40% in 10 and 18 patients, respectively and 19 patients showed changes in BP of > or = 40 mmHg. After surgery, one, five and two patients, respectively, still showed these values. Thus, a beneficial effect of surgery was demonstrated.

Sixty patients diagnosed with obstructive sleep apnea syndrome (OSAS) underwent uvulopalatopharyngoplasty (UPPP). The effects of surgery were studied based on endoscopic findings during drug-induced sleep and determination of the apnea-hypopnea index (AHI) before and after the operation. Changes in the form of the airway during sleep in the recumbent position were observed, and the role of upper airway endoscopy in the diagnosis and surgical treatment of OSAS was determined. The site of airway obstruction during sleep induced by i.v. injection of 10 mg of diazepam was classified into five types, and changes in AHI and the site of airway obstruction were compared before and after surgery. Changes in airway morphology during sleep in the supine and recumbent positions were also compared before surgery. The postoperative improvement rate was 74.4% for the soft palatal type of obstruction, 76.2% for the tonsillar type, 53.3% for the circumferential palatal type and 34.0% for the mixed type. Treatment produced excellent or good effects for the soft palatal and tonsillar types of obstruction. However, many patients with the circumferential palatal and mixed types of obstruction showed only some improvement or no change. Good airway morphology was maintained in the recumbent position by patients with the soft palatal type of obstruction. With the circumferential palatal and mixed types of obstruction, improvement can be expected from operations which include surgical treatment of the posterior pharyngeal wall or lateral funiculus, or with midline laser glossectomy. A good operative outcome can be predicted in patients showing improvement of apnea in the recumbent position preoperatively.

Uvulopalatopharyngoplasty (UPPP) and nasal CPAP are used for the treatment of obstructive sleep apnea syndrome (OSAS) in different institutions. Although OSAS results from an abnormality in the soft-palate, almost no reports have been made on the selection of UPPP or nasal CPAP procedures according to the type of abnormality. The most probable reason for this is that a comparison of treatment methods in individuals cases is difficult. We performed CPAP titration before and after operations, and compared the treatment methods, and evaluated the medical therapy.A sleep polygraph was performed on the first night, and cases diagnosed as OSAS received CPAP titration on the second night. The blocked region was identified by endoscopic examination. The results of the operation were evaluated after 1-2 months, and apnea hypopnea index (AHI) improvements of less than 50% received a second CPAP titration.The operation results were poor for cases where endoscopic examination showed full-circumference palatal type, and good for soft palate and tonsillar type abnormalities. When endoscopic examinations were performed in conjunction with nasal CPAP, the treatment was observed to act on the soft palate and expand the air way in all cases. Nasal CPAP was effective in cases with full-circumference palatal abnormalities because in these cases, the pressure was caused by inflamma. Combined medical treatments were effective in cases where CPAP alone was ineffective because the pressure was too high.

A case of esophageal ulceration caused by the antiphlogistic agent dicrophenac natrium was reported.A 77-year-old man suffered from a sensation of obstruction of the esophagus after taking a dicrophenac natrium tablet.Examination of the gastrointestinal tract 4 days later led to a suspicion of esophageal cancer.After 2 weeks, he came to this hospital because of the onset of hematemesis and tarry stools.An emergent esophagoscopy revealed multiple esophageal ulcers and a remnant of the drug in the upper portion of the intrathoracic esophagus.He was treated with antacids and a bland diet and improved rapidly.

先天性総胆管拡張症に膵管の拡張と膵石を合併した1例を報告する.いままでの先天性総胆管拡張症に関する報告のほとんどは, 肝内・肝外胆管および膵管胆管合流部についてのものに限られている.この症例は, 29歳, 女性, 主訴は右季肋部痛であった.胆道造影にて診断を下し, 逆行性膵胆管造影では膵石と境界明瞭な膵管の拡張がみられた.PPSテストでは膵外分泌機能正常であった.術式は嚢胞切除・肝管空腸吻合術に拠った.術中膵胆管造影では乳頭部に狭窄はなかった.この膵管の拡張には先天的な因子とともに, 後天的な因子の関与が考えられる.