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目的:大腸癌待機手術における術前機械的腸管処置（MBP:mechanical bowel preparation）の有無による術後合併症の発生の検討を行い，その必要性を明らかにする．対象:2003年5月から2007年10月の間に当科で待機手術を行った，結腸癌切除症例および直腸癌前方切除症例467例を対象とした．方法:術前に，MBP施行群と非施行群に無作為に患者の割り付けを行った．MBPの有無と，主な術後合併症として，創感染，縫合不全，腸閉塞の発生との関連を検討した．また，手術時間，出血量との相関をみることにより，手術操作への影響を検討した．結果:全症例，結腸癌症例，直腸癌症例，腹腔鏡補助下手術症例のいずれの群においても，MBPの有無による術後合併症の発生および，手術時間，出血量に有意差はみられなかった．結論:大腸癌の待機手術症例では，MBPは必ずしも必要ではないことが示唆された．

大腸癌肝転移症例に対する治療成績を予後を中心に検討した.大腸癌肝転移症例99例を対象にし, I群 : 肝切除群16例, II群 : 肝切除+肝動注リザーバー群10例, III群 : 肝動注リザーバー群19例, IV群 : one shot肝動注あるいはTAE群14例, V群 : 抗癌剤全身投与群21例, VI群 : 非治療群19例の6群に分け, 予後について比較検討した.II群の肝切除+肝動注リザーバー群の予後が最も良好で, 1年, 3年生存率とも100%と, 他のいずれの治療群に対しても有意差を認めた.次にI群の肝切除群の予後が良好で, 累積生存率は1年75.0%, 3年39.3%, 5年29.5%であった.III群, IV群, V群, VI群の予後は非常に悪く, 1年生存率はそれぞれ, 44.2%, 28.6%, 38.1%, 26.3%であった.以上より, 肝切除後肝動注リザーバーによる反復動注が予後の延長に有用である可能性が示唆された.

大腸癌肝転移症例24例を対象として原発巣および肝転移巣でのSPan-1抗原およびCEAの発現を検討した.原発巣におけるSPan-1抗原,CEAの陽性率は,それぞれ87.5%,91.0%と高率であった.次に,原発巣および肝転移巣の組織発現の程度を比較検討したところ,SPan-1抗原は原発巣陽性例21例中10例の47.6%に肝転移巣における発現の増加を認め,総計学的に有意な差を認めた(p

家族性大腸腺腫症,大腸多発癌および大腸癌局所切除例を除き,大腸癌腹膜転移の有無が確定された985例を対象として,腹膜転移例の79例(P群)と腹膜転移のない906例(N群)を比較するとともに,P群を2年未満に死亡した群(Pa群;63例)と2年以上生存した群(Pb群;16例)に分けて比較検討した.N群とP群の性別には差はみられなかったが,年齢はP群では有意に低かった.右側結腸癌の腹膜転移率は17.5%と腹膜転移頻度は最も高かった.しかし,腹膜転移例の大腸癌切除率は右側結腸では74.2%と比較的良好な値を示した.肝,リンパ節転移はそれぞれN群では9.4%,46.4%,P群では46.8%,94.1%とP群はそれぞれ高率であった.P群のうち相対非治癒症例は11例あり,累積生存率は4年45.5%,5年で22.7%と比較的良好であった.以上より,腹膜転移陽性例では相対非治癒手術の可能な場合には,腹膜転移巣を含めた積極的な外科的切除が重要であると思われた.

絶対治癒切除大腸癌39例を対象として,核DNA ploidy patternとAgNORs数を測定し,これらと臨床病理学的所見および予後との関連について検討した.核DNA ploidy patternは臨床病理学的所見とは明らかな関連性はみられなかったが,予後の面ではdiplo1d型症例はaneuploid型症例に比べて有意に予後が良好であった.癌細胞核の平均AgNORs数は,そのcut off値を3.00とすると,臨床病理学的所見とは一定の関連性はみられなかったが,AgNORs数が低値の症例は高値の症例に比べて有意に予後が良好であった,aneuploid型症例においてもAgNORs数の低値群は高値群に比べて有意に予後が良好であった.以上の結果から,核DNA ploidy patternおよびAgNORs数は大腸癌の予後を反映する因子となると考えられ,核DNA ploidy patternとAgNORs数を組み合わせることにより,より鋭敏に予後を反映すると思われた.

The clinicopathological studies on ovarian metastasis from the colorectal cancer were carried out. From 1972 to 1989, 385 female patients were managed by resection for primary colorectal cancer at our department. Six patients had ovarian metastasis from colorectal cancer (1.6%). The primary tumor was in the cecum in one case; in the ascending colon, two; in the sigmoid colon, two; and in the rectum, one. There was no relation between the location of the primary tumor and ovarian metastasis. An average age of six patients was 50.2 years, which was younger than that of female patients without ovarian metastasis. The primary lesions involved the serosa. Lymph node involvement and lymphatic invasion were present in all cases, and venous invasion and peritoneal disseminating metastasis were present in 4 and 3 of the 6 cases respectively. ER staining by immunohistological method was negative in all cases.

1973年から1988年までに経験した大腸早期癌73例, 79病変を対象に臨床病理学的検討を行った.壁深達度別では, m癌37病変, sm癌42病変, 治療法別では内視鏡的ポリペクトミーが14病変 (13例), 局所切除術が5病変 (5例), 腸管切除術によるものが60病変 (57例) であった.早期癌の全大腸癌に占める割合は, 全期間では8.5%, 最近の4年問では15.0%であった.占居部位では, 早期癌の91.1%がS状結腸以下にみられた.肉眼形態では, Ip型29病変, Is型22病変, IIa型20病変, IIa+IIc型8病変であり, IIa+IIc型の8病変中7病変がsm癌であった.リンパ節転移はsm癌37病変のうち5病変 (13.5%) にみられ, IIa型, IIa+IIc型, 中・低分化腺癌, ly (+) の病変にその陽性率は高かった。治療成績では, m癌, sm癌それぞれ1病変に局所再発がみられたが, いずれも根治的再手術を施行することができた.残りの病変では再発は認めなかった.

A total of 773 cases of colorectal carcinoma were surgically treated in our department for the past 18 years, and 196 of those cases were performed non-curative resection (relative non-curative in 52 and absolute non-curative resection in 144), and 63 tumors were not resected. As regards tumor locations, the frequencies of the non-curative resection were as high as more than 30% in the descending colon, cecum and transeverse colon. Histologically, non-curative resection cases became predominant in moderately differentiated adenocarcinomas, mucinous carcinomas and signet-ring cell carcinomas. Factors related to relative non-curative resection were lymph node metastasis (N) in 45 cases, liver metastasis (H) in 3, peritoneal dissemination (P) in 3, and H with P in one. Factors related to absolute non-curative resection were cancer infiltration on the resected wall edge in 48 cases, H in 45, P in 18, N in 10, distant metastasis in 2, and concomitant over 2 factors in 21. The five-year survival rates were 82.9% and 52.4% in absolute and relative curative resections versus 44.8% and 8.0% in relative and absolute non-curative resections, respectively.

Factors related to anastomotic leakage in colorectal surgery were studied in 190 patients with single colorectal cancer. The rate of anastomotic leakage was 5.8% (eleven cases) overall. The highest rate (18.4%) was observed in patients who received low anterior resection. Patients who had more advanced colon cancer tended to have a relatively high rate of anastomotic leakage. Also in the cancer patients with diabetes mellitus or liver cirrhosis there was a higher rate of anastomotic leakage than in patients without these preoperative complication. Preoperative serum cholinesterase and total cholesterol was at a low level in patients with anastomotic leakage. All cases had local peritonitis followed by anastomotic leakage, which closed within about 18 days on the average when treated by total parenteral nutrition (TPN) and complete fasting, except for one reoperated case. TPN maintained the nutritional state of patients with anastomotic leakage. Patients who received low anterior resection in EEA stapler showed no leakage after colorectal anastomosis. These result suggested that EEA stapler is useful for colorectal anastomosis and TPN is effective for anastomotic leakage.

大腸癌初回治療例109例を対象とし, 術前の同一検体を用い, CEA, CA19-9, SPan-1などの腫瘍マーカーを測定し, その臨床的意義について検討した.それぞれの腫瘍マーカーの陽性率は CEA 40.4%, CA19-9 23.9%, SPan-1 25.7%であった.組織学的進行程度別の各腫瘍マーカー陽性率をみると, CEA は stageII, III, IVでほぼ同程度の陽性率を示し, CA19-9は組織学的進行程度が進むにつれ陽性率は高くなる傾向がみられ, SPan-1は stage Iにおいて陽性率が25%とCEA, CA19-9にくらべ高く, stage IV, VはstageI, II, IIIに比べ高い陽性率を示した.CEA単独での陽性率が40.4%であるのに対し, combination assayでの陽性率は CEA と CA19-9では51.4%, CEA と SPan-1では55.6%であった.大腸癌の腫瘍マーカーとしては, CEAが最も鋭敏であり, またCA19-9, あるいはSPan-1を加えることは, 血清学的診断に有効と考えられた.

The nuclear DNA content of parraffin-embedded materials was measured by cytofluorometry in 82 colorectal cancers, and the relationship between those histogram and clinicopathologic findings was investigated. The DNA histogram pattern was not related to clinicopathologic findings and stage. However, in absolutely and curatively resected cases, five year-survival rate of cases with diploid pattern was significantly higher than those with non-diploid pattern. Those observations suggest that the nuclear DNA histogram in colorectal cancer may be an important prognostic factor, being independent of pathologic stage.

A case of von Recklinghausen's disease (VRD) associated with rectal cancer is reported. A 58-year-old man was admitted to our hospital complaining of anal bleeding. He had VRD since his age of 20 or so, but there was no family history of VRD. Examinations revealed rectal cancer and low anterior resection was performed. No other abnormalities including neurofibroma were recognized. Tumors of neural crest origin are known to occur frequently in patients with VRD. But, on the other hand, the concurrence of intestinal cancer, as in our case, is relatively rare. An analytical study of 44 VRD cases documented so far in Japan, showed that the mean age of the patients was 54.2 years and no relation with family history was found. But cancers complicated were more commonly located at the Vater's papilla or pancreas (29%), and some cases had strongly suggested a possible relationship between VRD and intestinal cancer. This is an issue demanding further studies in a larger number of cases.

Charts of 570 patients with colorectal carcinoma surgically treated in one institution during a 13 year period were retrospectively reviewed to evaluate clinicopathologic patterns and surgical results of those 39 years of age or under. Of the 570 patients, 57 (10 percent) were 39 years of age or under, and this group included more female patients than the older control group. Mucinous carcinoma was frequently found on histologic examination, with significantly high incidences of lymph node involvement, peritoneal dissemination, and advanced tumor stages by Dukes' classification in the young patients. The overall cumulative 5 year survival rate in the younger group was significantly lower than that in the control group (41 percent and 55.9 percent, respectively), whereas the difference in rates among the two groups for curative resection was not statistically significant (71.6 percent and 76.3 percent, respectively). Early diagnosis and attempts at curative resection are of utmost importance in the treatment of young patients with colorectal carcinoma.

最近13年間の当科における大腸癌手術例570例のうち, イレウス症状を示した49例を中心に臨床ならびに病理組織学的にご検討した.大腸癌イレウスの発生頻度は全大腸癌の8.6%で, 部位別には盲腸・横行結腸での発生頻度が高かった.イレウス例では病期の進行した症例が多く, 切除率73.5%, 治癒切除率44.9%で直死率も6.1%であった.累積5生率はイレウス例の全例では33.2%, 治癒切除例では59.4%で, 非イレウス例の56.4%, 77.1%に比べて低率であった.大腸癌イレウスでは精力的な保存的療法を併用しつつ, 全身状態の回復をはかり, できれば待期的, 一期的治癒切除術を行うことが望ましいと考えられる.

Mucinous carcinoma of the colon and rectum comprised 35 (6.5%) of 540 cases of colorectal carcinoma. The clinical and pathological features of these mucinous carcinomas were compared with those of 478 well- and moderately differentiated adenocarcinomas. Mucinous carcinoma was more common in those under 39 years of age (p

当教室で最近13年間に経験した大腸単発癌手術施行例570例を対象とし, 39歳以下の若年者大腸癌の臨床病理学的所見ならびに手術成績について検討した.若年者大腸癌は570例中57例 (10.0%) であり, 女性が多かった.若年者大腸癌では, 組織型は粘液癌が多く, 壁深達度, リンパ節転移率, 腹膜播種, 組織学的進行程度において進行度の進んだ症例が有意に多かった.若年者の全手術例の累積5年率は41.0%と非若年者とくらべ有意に低率であったが, 治癒切除例の累積5年率は71.6%と非若年者の76.3%とくらべ有意差はなかった.若年者における大腸癌の早期診断ならびに治癒手術への努力が重要であると思われた.