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This report reveals that diffusion of hydrogen induces gradual degradation in InGaN-based laser diodes (LDs). The increase in nonradiative recombination centers (NRCs) in the LDs has been attributed to diffusion-related phenomena. Factors other than NRCs, such as the threshold carrier density Nth, can increase threshold current Ith. Those factors, however, were not fully investigated. Moreover, the diffusant responsible for the degradation of the LDs has not been univocally identified yet. To separately evaluate the roles of NRCs and Nth in increasing Ith, this report analyzes the stress-induced variation of nonradiative recombination lifetime τnr and lasing wavelength λl. It is revealed that the density of NRCs increases at the first stage of gradual degradation, followed by a rise in Nth. In addition, this report proposes a novel model for the time-variation of 1/τnr to investigate the diffusion-related degradation. By using this model, we extrapolate the value of the diffusion coefficient of diffusants involved in the degradation in InGaN-based LDs. The proposed analysis methods and obtained results are useful for understanding the physics of LD degradation.

Background The most significant prognostic factors for pancreatic head carcinoma (PHC) with pancreaticoduodenectomy (PD) are the resection margin and lymph node status. The curative surgical margin (R0) and complete clearance of regional lymph nodes contribute to the improvement of survival. To reduce microscopic residual tumor resection (R1) and achieve a complete lymphadenectomy around the superior mesenteric artery (SMA) when performing a PD for PHC, we propose a new concept of a total excision of the “meso-pancreatoduodenum.” which consists of a cluster of the soft connective tissue along the inferior pancreaticoduodenal artery and the first jejunal artery. Methods A total of 39 consecutive patients underwent a PD for PHC between May 2006 and August 2011 at Shimane University Hospital. Twenty-five patients received a standard PD (sPD), while 14 cases underwent a total meso-pancreatoduodenum excision (tMPDe) with PD. Results The tMPDe procedure was performed safely without any intraoperative complications. The total number of lymph nodes dissected was 18 (median, range: 5–40) in the sPD and 26 (median, range: 13–50) in the tMPDe ( p = 0.027). R0 resection was accomplished in 60% and 93% of patients with the sPD and tMPDe, respectively, resulting in a significant decrease in the R1 rate in the tMPDe (7%) compared to that in the sPD (40%) ( p = 0.019). No loco-regional recurrence was found around the SMA in the tMPDe patients. Conclusion Our surgical technique, tMPDe, is safe and more radical when performing a PD and should be adopted when performing pancreatic surgery as a pathological cure for pancreatic head carcinoma.

膵癌診断時に皮膚転移を認め，その後筋転移を来たした稀な一例を経験した．症例は74歳，男性．早期大腸癌にてEMR施行され，2年後の定期受診で，膵尾部腫瘍を指摘され，精査となった．腹部造影CTにて膵尾部に約5cm大の造影効果の乏しい腫瘍を認め，肝に多発する小さな低吸収結節影を認めた．EUS下針生検にて膵管癌と診断した．入院時，左腋窩に圧痛を伴う皮下腫瘤があり，切除生検にて膵癌皮膚転移と診断した．膵癌T4N1M1 Stage IVに対し，gemcitabineとS-1による化学療法を開始した．治療初期より左大腿外側の痛みがあり，画像検査にて膵癌筋転移が強く示唆された．化学療法への反応は悪く，腫瘍は進行し，治療開始200日後に永眠された．皮膚転移・筋転移が膵癌の発見契機となることもあり，皮下腫瘤や持続する原因不明の筋肉痛などは注意すべき所見と考えられた．

With this paper we propose a detailed study of the gradual degradation of InGaN-based laser diodes and Light-Emitting Diodes submitted to electro-thermal stress. The two device structures have been processed from the same epitaxial wafer. Our purpose is to compare the behavior of the two devices by means of electro-optical measurements, electroluminescence characterization, and near field emission measurements. We demonstrate that: (i) stress induces a decrease in the optical power and an increase in threshold current; (ii) the two failure modes are strictly linked each other, and correlated to the increase in defect-related current components, indicating a substantial increase in defect density during degradation; (iii) analysis of characteristic temperature and near-field emission measurements do not indicate any strong variation of injection efficiency nor current confinement of the devices.

目的・方法:POSSUMは1991年にイギリスで開発されたが（以下，original POSSUM），術後合併症の過剰予測で日本の実情に合わないとされ，2007年にHiroshima-POSSUM（以下，H-POSSUM）が開発された．島根県の多施設消化器手術データベースに集積された1,246例（2002年から2010年）の前半622症例からロジスティク回帰分析にてShimane-POSSUM（以下，S-POSSUM）を導き，後半624症例における有用性を観察された発生率の予測されたそれに対する比（以下，O/E比）の比較とROC解析を用いて，original POSSUM，H-POSSUMと比較した．結果:術後合併症率ではO/E比はoriginal POSSUM 0.52，H-POSSUM 0.70，S-POSSUM 0.86であり，手術直接死亡率でも各々0.09，0.25，0.46と，S-POSSUMが最も1に近かった．ROC解析では，術後合併症率ではAUCは各々0.666，0.672，0.672，手術直接死亡率では，0.817，0.829，0.836と3者同等であった．結論:当地域の消化器手術の合併症予測にはS-POSSUMが最も有用であった．

症例は84歳，女性．1年以上に渡って発熱・嘔吐による入院を繰り返していた．前医にて十二指腸傍乳頭憩室による再発性胆管炎（Lemmel症候群）と診断され，内視鏡的治療も試みられたが施行不能であった．8回の入院後も症状の改善なく，加療目的にて紹介となった．精査後，腹腔鏡下に総胆管十二指腸吻合を行った．術後は症状も軽快し，合併症無く退院となった．良性疾患であるLemmel症候群に対しては保存的加療が主となることが多く，再発を繰り返す症例は多い．難治例・重症例においては手術的加療が選択されるが，そのほとんどが開腹下による手術となり，高齢者においては侵襲も強く困難を伴う．現在までに本邦で当疾患に対して腹腔鏡下での総胆管十二指腸吻合を施行したという報告はない．若干の文献的考察を加えて報告する．

Objective. High-mobility group box 1, a ubiquitous nonhistone chromosomal protein, is passively released from necrotic cells and actively secreted by inflammatory cells. Extracellular high-mobility group box 1 has recently been recognized to be a mediator of hepatic ischemia-reperfusion injury; however, the kinetics of high-mobility group box 1 during hepatic ischemia-reperfusion and the role of high-mobility group box 1 in ischemia-reperfusion injury still remain poorly understood. This study was designed to assess the localization and the kinetics of high-mobility group box 1 during hepatic ischemia-reperfusion injury and the effects of high-mobility group box 1 adsorption column in hepatic ischemia-reperfusion injury. Design: A prospective, randomized animal study. Setting. University medical center research laboratory. Subjects: Male Sprague-Dawley rats. Investigation: The animals underwent 70% partial hepatic ischemia for 60 or 90 mins and were then reperfused. To investigate the high-mobility group box 1 levels in the serum and in the liver, the animals were killed at predetermined periods. As a lethal model, global hepatic ischemia-reperfusion was induced by portal triad cross-clamping for 30 mins. Hemoperfusion therapy using a cellulofine sulfate bead column (high-mobility group box 1 adsorption column) was performed during global hepatic ischemia. Measurements and Main Results; During 60 mins of 70% hepatic ischemia, nuclear high-mobility group box 1 was translocated to the cytoplasm in hepatocytes; however, serum high-mobility group box lwas not increased. Immediately after reperfusion, the serum high-mobility group box 1 was significantly increased (p < .05). High-mobility group box 1 mediated ischemia-reperfusion injury in not only liver but also the remote organ, lung. Removal of excess high-mobility group box 1 in blood using an adsorption column significantly improved animal survival (p < .03) and liver and lung injuries. Conclusions: High-mobility group box 1 plays an important role in the systemic as well as local pathogenesis of hepatic ischemia-reperfusion injury. The removal of excessive high-mobility group box 1 with adsorption column was beneficial and promising option in ischemia-related liver injuries.

症例は64歳の男性で，貧血精査の内視鏡検査で胸部下部食道に0-IIc病変を指摘され生検にて高分化扁平上皮癌と診断された．左声帯膜様部にも白板病変を認め，高分化扁平上皮癌と診断された．食道癌の深達度は超音波内視鏡検査にてsm1，CTにて気管分岐部のリンパ節腫大を認めるも生理的な腫大と判断した．胸腔鏡補助下食道亜全摘術（D3）および腹腔鏡補助下胃管による再建術を施行した．喉頭癌（T1N0M0，Stage I）には同時にレーザー切除が施行された．術中No. 109左リンパ節が食道外膜に浸潤する所見を認めた．術後の病理組織学的診断では，食道癌は高分化扁平上皮癌pT1aN0M0，Stage 0で郭清リンパ節59個中扁平上皮癌の転移はなかったが，No. 109左と107リンパ節はCD79aとL26が陽性でdiffuse large B cell lymphomaと診断された．術後R-CHOP療法3クール，放射線照射後外来通院となった．

With this paper we analyze the correlation between the degradation of InGaN-based laser diodes (LDs) and the increase in the non-radiative recombination rate in the active region. Several 405 nm MOCVD LDs have been submitted to CW stress, for 2000 h (stress current in the range 40-100 mA, case temperature = 75 °C). During stress, we extensively evaluated the optical characteristics of the LDs: a technique for the evaluation of the non-radiative recombination lifetime (τ nr ) in the active material was developed and used for the analysis of the stress effects. We demonstrate the following: (1) degradation determines the increase in LDs threshold current (I th ) and the decrease in the τ nr ; (2) degradation of I th and τ nr have similar kinetics; and (3) the degradation rate of the LDs is almost linearly related to the stress current level. The degradation process is therefore ascribed to the decrease of internal quantum efficiency caused by the increase of the non-radiative recombination rate in the active region.

A 73-year-old man was diagnosed with superficial esophageal cancer, and endoscopic mucosal resection was performed. Histologically, the lesion was found to be a squamous cell carcinoma invading the muscularis mucosae without vascular invasion. The patient was followed without being given adjuvant therapy, and lymph node recurrence along the lesser curvature of the stomach was found after 2.5 years. He underwent laparoscopic removal of the metastatic lymph node and cholecystectomy for cholecystolithiasis. He had two courses of adjuvant chemotherapy and showed no recurrence during 3 years of observation. Although the effectiveness of surgical resection for nodal recurrence of esophageal cancer remains controversial, this case highlights the possibility of salvage resection using minimally invasive surgery.

According to statistical documents regarding building construction floor space from the Ministry of Land, Infrastructure, Transport and Tourism, the construction floor space of all buildings was 115,490,000 m2, which was 26.6% less than the previous year and was the third year in a row for decline. Even for office space, there was a 20.0% decrease versus the previous year. In 2009, the rebuilding of historical buildings in major metropolitan areas continued, and efforts to reduce greenhouse gases also accelerated. The efficient use of office lighting was established through initial illuminance correction control using sensors, control for using daytime light, and control through motion sensors. Furthermore, in line with JIS standards revisions, lighting facilities that control discomfort glare have started to be implemented. Light emitting diode (LED) lighting is now being used in various types of facilities, including exhibition halls, multipurpose halls, conference rooms, and religious buildings. Even in art galleries, which demand high color rendering, LED lighting has started to be used for exhibits. In hospitals and retirement homes, there continues to be a strong consciousness of energy efficiency. The use of LEDs is increasing even for environmental lighting applications, and chandeliers and LED lightbulb downlights controlled by motion sensors have started to be employed. In 2009, the number of new theaters and halls constructed was very small. With a total number of six plus some small halls, it was the lowest number of new buildings in recent years. On the other hand, there is a feeling that all existing theaters and halls have gone ahead and performed renovations. Countrywide, forty-five facilities performed renovation work, which was a 50% increase over the previous year and was the highest number of renovations in recent years. In shops and business facilities, LED lighting has traditionally been often used as store fixture lighting and wall accent lighting. However, improvements in output and color rendering and the diversification of product types have progressed and full scale introduction into product presentation is now possible. In the accommodation, food and drink, and service industries, the use of LEDs as light sources is increasing in positions that require high color rendering, and renovations that emphasize energy efficiency are being introduced. Furthermore, LEDs are being employed for room lighting to provide modulated lighting that is suitable for when guests awaken. In the residential building industry, LED lighting fixtures are increasingly employed for high ceiling areas and underwater applications in order to utilize their greater control of the distribution of luminous intensity.

症例は64歳，男性．20歳代で肝機能異常・非A非B型慢性肝炎と診断された．胃穹窿部静脈瘤を指摘され，未出血例であるが，本人は積極的治療を希望した．血小板6.2万と低下しており，血小板増加が期待される胃上部血行郭清および脾摘（Hassab's手術）を施行した．術後，胃静脈瘤は消失，血小板は10万以上に増加し，HCVgenotype1b/高ウイルス量のC型慢性肝炎に対してコンセンサスIFNを開始した．7カ月目に全身倦怠感等のためnatural α IFNへ変更し，IFN開始から1年間継続して中止した．IFN中止後6カ月時もHCV-RNAの陰性を持続しており，著効と判定された．血小板減少を伴うC型慢性肝炎のIFN治療には，いくつかの方法が考えられるが，本例では胃静脈瘤を合併しており，一期的に胃静脈瘤の治療と血小板増多が期待できるHassab's手術を施行後にIFN導入し，ウイルス排除を達成した．その後2年間，静脈瘤，肝癌を認めず，良好に経過している．

胃癌の診断にて腹腔鏡補助下幽門側胃切除術を施行し, 切除標本から胃結核の合併を認めた1例を経験した. 症例は62歳の男性で, 主訴は食思不振. 来院1週間前から食思不振が出現し, 徐々に顔面蒼白となりタール便も見られるようになる. 来院時貧血を認め, 緊急内視鏡検査を施行したところ胃角部全体を覆う巨大潰瘍を認めた. 内科的治療を行ったが難治性であり, 経過観察中の生検にて胃癌の診断を得たため腹腔鏡補助下幽門側胃切除術を施行した. 術後は発熱が続き, 切除標本の病理組織学的検査結果より胃結核症の合併を認めた. 抗結核薬にて治療を行ったが, 全身状態は悪化し死亡退院となる. 原因は手術侵襲による免疫力低下による結核症の増悪と考えられた. 結核症は現在も散見され, 多彩な病像を呈することがあるため, 診断や治療に際しては慎重な対処が必要である.

目的: 手術のリスク評価の一つであるPhysiological and Operative Severity Score for the enUmeration of Mortality and morbidity(以下, POSSUM)の術後合併症発生率や死亡率は高く予測されるため, 多くの改良型が報告されてきた. 今回, 消化器外科全般で用いることのできるPOSSUMスコアを開発し, その精度を検証した. 対象・方法: 2002年1月から2005年12月までの4年間に施行した消化器手術1,573例を対象とした. 前半2年間(n=709)の成績より, 予測合併症発生率と予測死亡率の計算式の係数を変更しHiroshima POSSUM(以下, H-POSSUM)とした. 後半2年間の症例(n=864)において, 3種類のPOSSUMの精度を比較した. 精度は実際に観察された発生数を予測された発生数で除した比率 (以下, O/E ratio)で検討した. さらに, 6種類の症例構成を設定し, その有用性をO/E ratioで検討した.成績: 術後合併症発生率のO/E ratio はoriginal POSSUMでは0.78であり, H-POSSUMでは1.04であった. また, 死亡率のO/E ratio はoriginal POSSUMでは0.12, Portsmouth-POSSUMでは0.56, H-POSSUMでは0.94であり, H-POSSUMのO/E ratioが最も1.00に近似していた. 六つのシミュレーションにおいても, H-POSSUMの精度は他のPOSSUMより優れていた.考察: 新しく開発したH-POSSUMは消化器手術のリスク評価として有用である.

症例は55歳の男性で, 発熱, 右側腹部の発赤, 疼痛を訴え来院した. 来院時, WBC 13,900/μl, CRP 27.7mg/dlと炎症反応が上昇し, CTにて右側腹部に10×6×5cmの内部が不均一な嚢胞性病変を認め, 周囲脂肪織への炎症の波及が疑われ入院となった. 入院翌日には自潰し多量に排膿があったが, 抗生剤にて炎症反応は改善し, 8日後に排膿は消失し退院となった. しかし, 13日後再度自潰し, 瘻孔造影にて小腸が造影されたため手術を施行した. 腹腔内にφ2-3mmの白色小結節とムチン状腹水, 右側腹部に癒着を認めた. 診断不能のためムチン状粘液と小結節を採取したのみで閉腹した. 病理組織学的検査にて結核菌は認めないが, 一部壊死を伴った類上皮細胞からなる結節性病変を認め, 腸結核を疑い大腸内視鏡を施行した. 回盲部から類上皮細胞肉芽腫, ラングハンス型巨細胞を認めたため腸結核の診断にて治療開始し, 約2週間後に瘻孔は閉鎖した. 腸結核は多彩な病像を呈することがあり注意を要する.

42歳，男性の膵未分化癌の1例を経験した．主訴は左腰背部痛，腹部膨満感であった．血液学的検査ではDupan II, Span I, エラスターゼIが上昇していた．上腹部Computed Tomography（CT）像にて膵尾部に低吸収域な腫瘍を，上腹部エコーにて低エコー性腫瘍を認め，また内視鏡的逆行性胆道膵管造影（endoscopic retrograde cholangiopancreatography；ERCP）では膵管の狭窄，不整は認めず，腹部血管造影では腫瘍は脾動脈，中結腸動脈，下結腸動脈から栄養されていた．以上の画像診断，血液検査から通常の浸潤性膵管癌とは異なる疾患と推測された．手術時所見では胃背側部，横行結腸に浸潤する巨大腫瘍を認め，血性腹水を伴った腹膜播種が存在し切除不能であった． 術中に摘出した転移リンパ節の病理組織学的検査により膵由来の低分化型腺癌と診断し，また免疫組織化学的検索ではcytokeratin 7，20，epithelial membrane antigen（EMA），vimentin，M-actin，S-100は陽性であった．以上の所見より本腫瘍は膵原発未分化癌と診断した．なお自験例は術後化学療法を施行したが術後23日目に肝不全にて死亡した．本疾患は膵腫瘍の中では比較的稀であるが，腫瘍径が小さければ外科的切除を施行し，放射線療法，化学療法を積極的に行うべきである．今回のように巨大な腫瘍では切除不能例が多く，放射線治療，化学療法を含めた治療が必要と考えられた．

症例は67歳の男性で, 突然の上腹部痛にて来院した. 緊急腹部CTでは, 肝尾状葉に原発した肝細胞癌とその破裂による腹腔内出血が疑われた. Vital signは安定していたため, 保存的治療を選択した. 他の画像検査で, 腫瘤はSpiegel's lobeと連続, 肝外性に発育し, 総肝動脈から固有肝動脈を巻き込み, 門脈を右方に圧排していた. Spiegel's lobe原発肝細胞癌の破裂と診断し待機手術を施行した. 開腹検査所見は術前診断と同様であり, 巻き込まれていた総肝動脈, 固有肝動脈を剥離し腫瘍を茎基部で切離して摘出した. 病理組織学的診断は, 8×5.5×4cm, 64g, 中分化型肝細胞癌で, 茎基部に出血巣を認めた. 肝尾状葉に原発した肝細胞癌破裂の本邦報告は12例と少なく, いずれもSpiegel's lobeであった. また, 肝外発育型肝細胞癌の茎基部が破綻し出血を来した報告もまれであった.

Background A superior mesenteric artery (SMA)-first approach has been considered to be an efficient technique in pancreaticoduodenectomy when the SMA is a factor of borderline resectable pancreatic head cancer (BRPHC). However, this excellent procedure has limitations in terms of tumor resection with an intact coverage including the pancreatic tumor and the tumor-draining lymphovascular systems and the ability to achieve a complete regional lymphadenectomy. Methods A modified mesenteric plane procedure has been developed that provides improved regional lymphadenectomy and permits adjustment of the surgical approach, which is based on the direction of the tumor infiltration. Results Of 55 patients taken to surgery, 19 had peritoneal dissemination and/or liver metastasis at staging laparoscopy, and the procedure revealed tumor infiltration to the SMA and/or hepatic artery (HA) in 4 patients. Finally, 32 patients with BRPHC have undergone the procedure between April 2009 and June 2015. Twenty-four of 32 patients (75.0%) had negative resection margins, and the median number of lymph nodes harvested was 34. Lymph nodes around the SMA tested positive for metastasis in 13 patients (40.6%), and those around the HA tested positive for metastasis in 7 patients (21.9%). Complications occurred in 14 patients (43.7%), with no perioperative mortality. Overall survival rates were 65.3% at 1 year and 35.2% at 3 years. Conclusions Short-term results with the procedure may encourage surgical management for BRPHC.

目的:脳卒中既往患者における開腹手術のリスク評価を検討した.方法: 2002年1月から3年間に脳卒中で入院歴を有し,開腹手術を行った77例を対象とした.手術のリスク評価のために術後合併症のあり群(n=33)となし群(n=44)に分けて,術前因子,血液検査,手術因子, POSSUMの比較を行った.結果:入院死亡は4例(5.2%)であった.術前因子,検査では年齢,脳出血後,呼吸器障害あり, performance status 2以上,アルブミン値,コリンエステラーゼ値の6項目で有意差が認められた.手術因子では緊急手術と出血量で, POSSUMでは3項目で有意差が認められた.結論:脳卒中既往症例の開腹手術における術前リスク評価の指標として, performance statusとPOSSUMは有用であった.

〔目的〕 膵頭十二指腸切除術 (PD) の術前リスク評価におけるPOSSUMの有用性について検討を加えた. 〔対象と方法〕 1996年5月より2004年4月まで施行した141例のPDを対象とした. 手術死亡は6例 (4.3%) であり, 術後合併症は43例 (30.5%) に認められた. 術後合併症の有無により, 2群に分けて術前因子, 手術因子, およびPOSSUMの比較を行った. 〔結果〕 術後合併症の有無による各因子別の結果, 術前13因子と術中4因子のいずれにおいても有意差は認められなかった. しかし, POSSUMのphysiological score, operative severity score, 予測死亡率, 予測合併症発生率, およびP-POSSUMの予測死亡率において, 術後合併症あり群となし群の間に有意差を認めた. 〔結語〕 PD症例におけるリスク判定法としてPOSSUMは有用である.

The mechanism for the onset of chronic alcoholic pancre-atitis(CAP) involves many unresolved questions. We (1,2) have succeeded in creating an animal model of CAPby inducing mild stenosis of the pancreatic duct in experi-mentalanimals given alcohol. The CAP seen in this modelis akin to that seen in humans. This means that pancreaticduct-related factors play an important role in the onset ofCAP.

Objectives There are many experimental models for chronic pancreatitis. However, it remains unclear which animal models of pancreatic fibrosis can be categorized as chronic pancreatitis models. We compared the histologic features of some animal models of pancreatic fibrosis/chronic pancreatitis and chronic pancreatitis in humans. Methods and results Human chronic pancreatitis due to chronic alcohol abuse and unknown etiology showed interlobular fibrosis and a cirrhosis-like appearance. Histopathologically, spontaneous pancreatitis models, WBN/Kob rats and OLETF rats, showed localized/nodular fibrotic lesions, which consisted of swollen, aggregated, atrophic islets of Langerhans; loss of the exocrine parenchyma and hemosiderin deposition that was seldom distributed in the interlobular area. On the other hand, fibrosis in the canine model, which was produced by combining alcohol administration with incomplete pancreatic duct obstruction, was characterized by interlobular fibrosis admixed with a cirrhosis-like appearance very similar to that in human chronic pancreatitis. Conclusion Most experimental models for chronic pancreatitis, except alcohol administration combined with other procedures such as incomplete pancreatic duct obstruction, are different from human chronic pancreatitis.

食道の異所性胃粘膜島は本邦では成人の3～10%に存在するといわれている.しかし,異所性胃粘膜島から発生した食道腺癌は極めて稀で,本邦では9例の報告例しかない.われわれは,異所性胃粘膜島から発生した頸胸境界部食道腺癌の1例を経験した.症例は51歳,男性で,嗄声を主訴に入院した.食道透視にて,頸胸境界部の食道左壁に腫瘤像を認めた.内視鏡検査にて隆起性病変を認め,生検にて異所性胃粘膜島から発生した中分化腺癌と診断した.平成11年2月17日に食道亜全摘術を施行した.病理標本上3.0×2.0cmの1型腫瘤を認めた.病理にて異所性胃粘膜島から発生した食道腺癌と診断した.統合失調症があり,術後補助療法は行わなかった.術後11カ月で再発のため他界された.

【目的】高齢者における消化器手術のリスク評価法としてPOSSUM scoreの有用性について検討した.【方法】1996年から2003年までに全麻下に手術を行った80歳以上の高齢者251例を対象とした.術後合併症のあり群(n=88)となし群(n=163)に分けて,術前因子,血液データ,手術因子, POSSUMの検討を行った.【結果】0.1%以下の有意差が認められた項目は白血球数,緊急手術,腹膜炎,およびPOSSUMのphysiological score (PS), operative severity score (OS), predicted mortality rate, predicted morbidity rateの7項目であった. PS 25点以上をhigh riskとすると,術後合併症発生率はhigh risk groupでは45/64 (70%)であり, low risk group (43/187, 23%)にくらべて有意に高率であった.【結論】高齢者における消化器手術のリスク評価の指標としてPOSSUM scoreは有用である.術前のPSにより術後合併症発生率のhigh risk groupを選定できる.

食道の癌肉腫は比較的稀な疾患であり,いわゆる癌肉腫・偽肉腫・真性癌肉腫の3つに分けられている.今回われわれは胸部中部食道より発生し,計5箇所の病変を有した,いわゆる癌肉腫を経験した.症例は60歳,男性で,嚥下困難を主訴に来院した.食道造影,食道内視鏡にて胸部中部食道に巨大な隆起性腫瘤を認めた.全身状態が不良であったため, 2期的に手術した.胸部食道全摘,胸部リンパ節郭清後,胃管を用いた食道再建術および腹部,頸部リンパ節郭清を行った.摘出標本では,胸部中部食道に13.5×5cmの巨大な腫瘤と2×2 cmの腫瘤が存在した.組織学的進行度はpT 3, pN 2 (+), M 0, PI 0, stage IIIであった.病理組織学的所見では, 2箇所の腫瘤部および粘膜内3箇所の病変部は,扁平上皮癌部分と紡錘型細胞よりなる肉腫部分からなり,その両者には移行部分がみられた.いわゆる癌肉腫と診断した.

局所進行大腸癌は解剖学的特性により,腹壁や小腸,膀胱,生殖器など近接他臓器にしばしば浸潤するが,腎に直接浸潤するものは比較的稀である.下行結腸癌が左腎に直接浸潤し,合併切除により治癒を得た.症例は51歳,女性.発熱を主訴に受診し,腹部超音波検査で左腎腫瘍を疑われた.精査にて下行結腸に全周性の進行癌を認め,結腸癌が腎に浸潤したものと考えられた.下行結腸癌は左腎に強固に癒着し,左腎合併切除を含む左半結腸切除(D3郭清)を施行した.病理組織所見では下行結腸癌および左腎腫瘤は共に中分化型腺癌であり,結腸癌の腎直接浸潤と診断した.結腸癌は他臓器浸潤例においても治癒切除例では良好な成績が報告されており,積極的な浸潤臓器の合併切除が予後を改善すると考える.

This letter describes an extensive analysis of the time- and field-dependent trapping processes that occur in GaN-based gate injection transistors exposed to high drain voltage levels. Results indicate that-even if the devices do not suffer from current collapse-continuous exposure to high drain voltages can induce a remarkable increase in the on-resistance (Ron). The increase in Ron can be recovered by leaving the device in rest conditions: Temperature-dependent analysis indicates that the activation energy of the detrapping process is equal to 0.47 eV. By time-resolved electroluminescence characterization, we show that this effect is related to the capture of electrons in the gate-drain access region. Finally, we show that charge emission can be significantly accelerated through the injection of holes from the gate.

ショック状態に至った大腸穿孔例は予後不良であるが,今回われわれは腎移植患者において1救命例を経験した.患者は52歳女性で, 1993年3月に生体腎移植を受けている. 1999年11月2日に急激な腹痛を生じ,約10時間後に当院を受診,血圧52/13mmHgで,腹部緊満著明であった.胸部単純X線で腹腔内遊離ガス像を認めたため,緊急開腹手術を行った.横行結腸脾彎曲部付近の腸間膜付着部反対側に直径約3cm大の穿孔を認め,同部および肛門側には,腫瘍を認めなかった.病変部横行結腸を局所切除・吻合し,口側横行結腸にストーマを設置した.術後にエンドトキシン吸着を2度行った. 術後graft lossに陥ることもなく,第131病日に退院した.病理組織学的所見上穿孔以外には明らかな所見はえられなかった.致死率の高い病態を腎移植患者に合併しながら救命し,さらにはグラフト機能を温存しえた症例であった.

Background and Aims: Prognosis after hepatectomy for hepatocellular carcinoma (HCC) has been improved by progress in the evaluation of hepatic functional reserve, surgical techniques and perioperative management. However, even when curative resection is performed at a relatively early stage, a considerable number of patients develop early intrahepatic and/or extrahepatic recurrence postoperatively. This study analyzed the clinicopathologic features of HCC with early recurrence. Methods: We reviewed records of 513 consecutive patients who had undergone liver resection for HCC. There were 48 deaths within a year after surgery from recurrence, including 21 patients with stage II or III HCC (group I). Clinicopathologic parameters of group I patients were compared with those of 188 patients (group II) who developed recurrence following resection of stage II or III HCC and died more than 1 year after surgery. Results: On univariate analysis, age, tumor diameter (Φ), α-fetoprotein (AFP):Φ and protein induced by vitamin K absence or antagonist II (PIVKA-II):Φ were significantly greater in group I than in group II. Macroscopic portal vein invasion, microscopic vascular invasion, intrahepatic metastasis, poor differentiation, pleomorphism, sarcomatous change, vascular lake, and angiographic condensed pooling were more frequently observed in group I than group II. Five independent determinants were selected by multivariate analysis: AFP:Φ, histologic pleomorphism, sarcomatous change, vascular lake and angiographic condensed pooling. Conclusions: Highly malignant HCC with extremely poor prognosis exhibits peculiar clinicopathologic characteristics, particularly histologic immaturity, and can be predicted by preoperative indicators such as markedly elevated tumor marker concentrations and condensed pooling on angiography.

This study was designed to clarify what differences the last 25 years have made in surgical results for patients with hepatocellular carcinoma (HCC). We examined results for 716 hepatectomized patients in four treatment eras: first era (1973–1980; n = 58), second era (1981–1985; n = 155), third era (1986–1990; n = 243), and fourth era (1991–1997; n = 260). Patient background, tumor characteristics, type of hepatectomy, treatment for intrahepatic recurrences, and surgical results in the four eras were compared by univariate analysis to clarify the factors that have contributed to or impeded progress in the surgical treatment of HCC. Although there were no significant chronological differences in liver pathology and surgical resectability, operative mortality was reduced to 2% in the fourth era, from 29% in the first era. With an increasing proportion of early-stage HCCs (TNM, stages I and II), the cumulative survival rate at 5 years improved in the course of the eras in our overall population of patients (12%, 31%, 38%, and 51%, respectively, for the first, second, third, and fourth eras) and in a subset of the population divided according to tumor stage. Also, we found a chronological improvement in the survival rate at 3 years after intrahepatic recurrence (10%, 28%, 36%, and 44%, respectively in the first second, third, and fourth eras). This improvement was associated with the establishment of an early detection program for intrahepatic recurrences. However, the recurrence rate was similar in any subset of the population through the four eras. Although this univariate study could not determine independent factors that contributed to the chronological progress in results for HCC surgery in the four eras, it is conceivable that the establishment of indication criteria for hepatectomy, an early detection program for primary and recurrent lesions, and the introduction of multimodal treatment for recurrence were contributory factors in this im-provement. A strategy for alleviating the frequent recurrences originating from posthepatectomy metachronous carcinogenesis remains to be established.

Little data are available regarding the effects of hepatitis virus serostatus and the severity of coexisting chronic inflammation on intrahepatic recurrence after hepatectomy for hepatocellular carcinoma (HCC). We investigated the extent to which these factors modified the prognosis of hepatectomized patients. A total of 274 patients treated in the period January 1981 to December 1996 were divided into three groups: antihepatitis C-positive (HCV; n = 144), hepatitis B surface antigen-positive and HCV antibody (Ab)-negative (HBsAg; n = 106), and HBsAg-negative and HCV Ab-negative (NBNC; n = 20). Positivity for HBV-related antibody in the HCV group was 76%. Histologic grading of inflammatory activity from coexisting hepatitis was determined according to Knodel's histological activity index (HAI) scoring system. Post-hepatectomy crude survival rates and disease-free survival (DFS) rates were compared, according to tumor characteristics, between the three groups. In the patients overall and also in the patients with a single nodular HCC, the HCV group had significantly higher HAI scores and preoperative serum aspartate aminotransaminase (AST) levels than the other two groups. When the patients were limited to those with a single nodular HCC, the crude survival was similar in the three groups with comparable tumor characteristics; however, the DFS was different (NBNCHBsAgHCV). When the patients were further limited to those with a single nodular HCC without microscopic extracapsular spread, in whom removal of the tumor was expected to be microscopically complete, the difference in the DFS became more marked. Irrespective of the viral serostatus, better crude and disease-free survivals were observed in the patients with lower AST levels (or =50 IU/ 1) than in those with higher AST levels (50IU/l). In contrast, there were no differences in survivals and HAI scores according to the presence or absence of HBV-related antibody in the HCV group. From our univariate analysis, we can conclude that the severity of virally induced inflammation, which was well correlated with viral serostatus, may be a factor that affects intrahepatic recurrence, which is more likely to originate from metachronous carcinogenesis. Prior co-infection of HBV in HCV patients may not be an adverse risk factor for intrahepatic recurrence.

Background. Urate underexcretion has been reported as the major cause of hyperuricemia in gouty patients. The four-component theory of urate transport in nephrons has been a valuable hypothesis for studying the mechanism of the urate underexcretion, but accurate quantitative analysis of urate transport in nephrons at different sites has not yet been carried out. To determine the amount of urate transport in nephrons more accurately, we applied mathematical calculations to urate transport in nephrons based on the four-component theory. Methods. In 20 gouty patients and 14 normal controls, 60-min urine fractions and blood samples taken at the midpoint of the urine collection period were collected before and after pyradinamide or benzbromarone administration, and urate clearance (Cua) was determined. Urate excretion (Uua) was defined as {Ccr(1-R1) + Cs} Sua(1-R2), where Ccr is creatinine clearance, R1 is the presecretory reabsorption rate, Cs (ml/min) is the secretion rate, Sua is serum urate level, and R2 is the postsecretory reabsorption rate. Results. In the gouty patients, urate glomerular filtration was significantly higher than in the normal controls, but approximately 96% of the filtered urate was reabsorbed. The urate secretion rate of gouty patients was markedly lower than that of the controls, but the amount of urate secretion was slightly and not significantly lower than that of the controls. Postsecretory reabsorption was proportional to intratubular urate concentration. Subsequent urinary excretion in gouty patients was significantly lower than that in the normal controls. Presecretory reabsorption, secretion, postsecretory reabsorption, and urinary excretion comprised 95.9%, 38.9% 38.6%, and 4.4% of urate glomerular filtration in gouty patients, and 96.2%, 52.2%, 49.6%, and 6.5% in normal controls, respectively. Conclusions. Urate secretion in the nephrons of gouty patients was significantly decreased compared with that in normal controls in terms of its rate and its proportion to urate glomerular filtration, which resulted in significant reduction of urinary urate excretion.

当センターでこの12年間に経験したpositive selectionのCAPD症例59例中, 死亡15例, 血液透析 (HD) への移行23例の計38例 (64.4%) が, CAPD脱落症例であった.これらの脱落原因の50%がCAPDに関連したもので, 中でもHD移行の主な理由は, 限外濾過不全, 難治性・頻回のCAPD腹膜炎, 硬化性被嚢性腹膜炎 (SEP) であった. また, 開腹手術を要した6例中5例がHDへ移行した. 脱落関連因子として, CAPD施行期間の長さ, CAPD腹膜炎罹患が有意に相関があると考えられた.SEP症例は, 59例中3例, 5.1%であった. 限外濾過不全のためHD移行後, この前段階と考えられる著明な腹水貯留4症例に, 発症早期からのステロイド治療が有効であった.CAPD排液中のamylase値は, 平常時およびCAPD腹膜炎時には, それぞれ, 5.6±2.7, 19.3±22.6mU/mlで, 後者で有意に高値を呈した. 穿孔性腹膜炎2例 (S状結腸, 回腸) と急性膵炎1例に緊急開腹手術を施行したが, 術前のこれらの値はさらに著明な高値を示し, 一般のCAPD腹膜炎との鑑別に極めて有用であった. 回腸穿孔例では, 術後に縫合不全を合併し手術死亡となったが, このような後期の腹膜硬化症を呈する症例においては, 腸管吻合に重大な危険性が存在すると考えられた.脱落症例38例中16例に, カテーテル抜去時や開腹手術時に腹膜のサンプリングが行われ, 病理組織学的検索がなされた. CAPD施行期間が8-18か月の3例では, いずれも腹膜線維症の所見であった. しかし, 60か月以上の13例中12例, 92.3%では, 腹膜機能障害が非可逆性といわれる中期以後の腹膜硬化症の所見 (中期5例, 後期7例) が認められ, 極めて注目すべき結果が得られた. この事実は, かかる長期CAPD症例においては, SEPとの関連から, その中止時期も含めて, 注意深い経過観察が必要であると考えられた.

A 64-year-old woman underwent total gastrectomy, splenectomy, and lymph node dissection for a gastric leiomyosarcoma in November 1989. We found a liver tumor, 3cm in diameter, by abdominal ultrasonic study and CT in June 1994, but the patient refused surgical treatment. Hepatic arterial infusion was therefore performed, and the tumor subsequently gradually enlarged. We obtained the patient's consent to surgery and performed left lobectomy in March 1995. The histopathological diagnosis was metastatic liver tumor from gastric leiomyosarcoma. No recurrence or metastasis was detected during about 4-year follow up. Liver metastasis of leiomyosarcoma of the stomach is generally thought to occur in high grade malignancy, but a good outcome can be obtained by early detection of postoperative recurrence and repeated curative operations.

症例は60歳, 女性. 1986年12月9日慢性糸球体腎炎による慢性腎不全と診断され, 持続腹膜透析 (CAPD) 導入. その直後の1987年2月12日両側手根管症候群にて開放術施行. 以後9年間で腹膜炎を2回発症. 徐々に除水能の低下をきたし, 1995年12月より血液濾過透析に移行. 透析低血圧および, 凝固能異常の合併によると思われる内シャントの閉塞を反復した. 1996年11月より悪心, 嘔吐, 腹部膨満等の腸閉塞症状出現, 保存的療法にて-時軽快. 消化管透視腹部超音波検査, 腹部CT検査で, 腸管の拡張, 腸蠕動の著明な低下が認められ, 硬化性被嚢性腹膜炎と診断された. 同年12月再び腸閉塞出現, 保存的加療施行するも症状遷延. 内シャント再建術中, 突然ショック状態を呈し, 急性心不全状態持続したのち, 重篤な心筋伝導障害で12月16日死亡した. 病理剖検所見では, 化膿性腹膜炎および腹膜の線維性硬化像に加えて, 全身骨・関節, 消化管, 心, 肺, その他諸臓器にアミロイド沈着を認め, 硬化性被嚢性腹膜炎およびアミロイドーシスの合併が判明した. 本例のアミロイドは, β2-microglobulin由来であったが, AA抗体陽性, 過マンガン酸カリ抵抗性で, 従来の文献とは異なっていた.透析に伴う重篤な合併症を重複した, 貴重な剖検例を経験した. 透析療法の進歩で, 慢性腎不全患者の長期生存が可能となった現在, 同様の症例の出現が今後も予想され, 本例を長期透析患者の全身管理の指針について, 貴重な布石としたい.

症例は63歳の男性で, 主訴は下血. 血清CA19-9異常高値 (830U/ml), CT, Gaシンチなどから, 悪性腸間膜腫瘍を疑い開腹した. 回盲部より80cmの部位にMeckel憩室を認め, 同部に腫瘍および腸間膜リンパ節の腫脹を認めたため, リンパ節郭清を含めた回腸切除を行った. 病理組織学的にはMeckel憩室から発生した中分化型腺癌で, 憩室内には迷入組織を認めなかった. 術後血清CA19-9は速やかに低下し, また抗CA19-9抗体を用いた免疫染色で陽性であり, CA19-9産生腫瘍と診断した. Meckel憩室癌は本邦22例目と極めてまれである. 本症は予後不良であるが, 自験例は1年6か月経過した現在も再発の兆候を認めず, CA19-9の上昇も認めていない.

虚血性僧帽弁閉鎖不全症 (IMR) のメカニズムとして, 左室形態, 局所壁運動が注目されているが, これらが外科治療後にいかなる影響を及ぼすかは明らかでない. IMRに対して外科治療を施行した30例について血行動態, 左室局所壁運動, 左室形態, 遠隔期成績を検討した. 左室形態の評価は左室造影より長軸短軸比を求め, その拡張末期の値をDR, 収縮末期の値をSRとした. また, 球形度 (左室容積/長軸を直径とする球容積) を求め, 拡張期をDSI, 収縮期をSSIとした. 5年生存率は10.5%で, 術後心臓死症例と生存例では術前のIABP使用, 術前よりのICU滞在, 複数回の心筋梗塞の既往, DR, DSI, SSIにおいて有意差を認めた. 多変量解析で心臓死の単独危険因子はDRの低値, 前基部および心尖部の左室壁運動の低下であった. 左室が球形に近い症例ではIMRに対する外科治療成績は不良で, そのさいには左室形態をも考慮に入れた左室形成術を含む新たな手術法の開発が必要と考えられた.

We experienced a case of secondary amyloidosis causing intestinal obstruction. An 81-year-old woman, having an underlying disease of rheumatoid arthritis, was admitted to the hospiatal because of bloody diarrhea, vomiting, abdominal pain and fever elevation. An emergency laparotomy was carried out under a diagnosis of intestinal obstruction due to ischemic enteritis, and extended dilatation and multiple ulcers of the ileum were found. Partial resection of the ileum was performed. Histopathological examination revealed AA amyloidosis. Emergency surgery for amyloidosis of the gastrointestinal tract is rare, with only 18 reported cases in Japan so far. At operation, most patients with amyloidosis already have deposited amyloid proteins to multiple organs, so that their prognoses are very poor.

A rare case of idiopathic benign biliary stricture is reported. A 50-year-old man with liver dysfunction underwent ultrasonography, which revealed dilation of the intrahepatic bile ducts, and endoscopic retrograde cholangiopancreatography, which revealed a short, ring-like stenosis at the junction of the left and right hepatic ducts. Although a benign stricture was suspected, radiologic tests alone were insufficient to make a firm diagnosis. Therefore, a cholecystectomy and resection of the extrahepatic biliary tract were performed. Microscopic examination of the resected specimen demonstrated no evidence of malignancy. The final diagnosis was mild, localized, chronic cholangitis. The patient had not had previous biliary tract surgery, choledocholithiasis, nor did he have a congenital abnormality of the biliary tract, bile duct carcinoma, or pancreatic disease. Since there was no evidence of primary sclerosing cholangitis, the stricture was considered to be idiopathic.

The application of a robot to rehabilitation has become a matter of great concern. This paper deals with functional recovery therapy, one important aspect of physical rehabilitation. Single-joint therapy machines have already been achieved. However, for more efficient therapy, multjoint robots are necessary to achieve more realistic motion patterns. This kind of robot must have a high level of safety for humans. A pneumatic actuator may be available for such a robot, because of the compliance of compressed air. A pneumatic rubber artificial muscle manipulator has been applied to construct a therapy robot with two degrees of freedom (DOF). Also, an impedance control strategy is employed to realize various motion modes for the physical therapy modes. Further, for efficient rehabilitation, it is desirable to comprehend the physical condition of the patient. Thus, the mechanical impedance of the human arm is used as an objective evaluation of recovery, and an estimation method is proposed. Experiments show the suitability of the proposed rehabilitation robot system

This report describes a new unroofing technique to secure an effective microwave coagulation therapy (MCT) for a case of hepatocellular carcinoma, which was deeply located in segment 5 adjacent to the confluence of right anterior and posterior portal pedicles. A 62 year-old man developed HCC in the context of liver cirrhosis caused by hepatitis C virus. Transcatheter arterial embolization was attempted initially because of the tumor location and poor hepatic functional reserve, but failed to achieve satisfactory remission. On laparotomy, hepatic parenchyma was superficially resected to uncover the ventral surface of deeply located HCC adjacent to major hepatic vessels, enabling an accurate as well as effective MCT. The patient has been alive and well without recurrence for five months following the surgery.

We report the cases with local recurrence or peritoneal dissemination after microwave coagulation therapy (MCT) for hepatocellular carcinoma (HCC).(Case 1) The patient was a 63-year old woman. Laparoscopic MCT (L-MCT) was performed for HCC. Local recurrence occurred 2 years after L-MCT, and considered to be caused by incomplete coagulation. When laparotomy was performed, peritoneal dissemination was found, and tumors were resected as many as possible.(Case 2) The patient was a 74-year old woman. Open MCT (O-MCT) was performed for HCC. One year after O-MCT, recurrent tumor was found adjacent to the liver. We performed resection of this tumor. Ethiology of this tumor was considered also peritoneal dissemination.Local recurrence due to incomplete coagulation is well-known as pattern of after MCT. During coagulation procedure, coagulated area becomes indistinct rapidly due to generation of micro bubbles. Accurate mapping of coagulation area guided by intraoperative ultrasonography before coagulation is the most important point before MCT. It is unknown if MCT typically causes peritoneal dissemination. In these cases with peritoneal dissemination. there was no extrahepatic metastasis apart from peritoneal dissemination, which is rare in HCCs. Thus, there is a possibility that peritoneal dissemination is characteristic pattern of recurrence after MCT.

我々は,検診にてCA19-9の軽度上昇を指摘され,超音波にて偶然発見された成人の肝間葉性過誤腫を経験したので報告する.症例は47歳の女性である.超音波やCTにて肝のS6より肝外性に発育する大きさ7cmの腫瘍を認め,腫瘍は充実性の部分と嚢胞性の部分にて構成されていた.血管造影では腫瘍全体に濃染像が見られた,良性腫瘍を最も疑ったが,悪性腫瘍も否定できず手術を施行した.切除標本では大きさ7.5cm×7.5cmの境界明瞭で光沢のある充実性腫瘍で,内部に大小の嚢胞を認めた.組織像では主に豊富な線維結合織よりなり,その間に大小の血管あるいはリンパ管や,小胆管の増生を認めた.現在,術後3年であるが,再発兆候はない.肝間葉性過誤腫の本邦報告例は64例であり,このうち15歳以下の小児例が52例と大部分を占め,成人例はわずか12例に過ぎない.小児例では腫瘍の発育速度は早く,成人例では発育速度は緩慢であるも悪性腫瘍との鑑別も困難で,共に切除が第一選択の治療である.悪性化や転移例はなく予後良好であるが,3例の再発例があり注意を要する.