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Background: Esophageal injury following catheter ablation of atrial fibrillation (AF) is reported to occur in 35% of patients. Even with a low energy setting (20–25 W), lesions develop in 10% of patients. Body mass index (BMI) has been reported to be a predictor of esophageal injury, indicating that patients with a low BMI (39 °C, radiofrequency (RF) application was stopped immediately. RF application could be performed in a “point by point” manner for a maximum of 20 s. Endoscopy was performed 1–5 days after ablation. Results: Esophageal mucosal injury was not observed in any patient in the study. Conclusions: Catheter ablation using ETM reduced the incidence of esophageal injuries, even in patients with a low BMI.

症例は24歳男性,主訴は右腹部痛.20歳時より他院で全大腸炎型の潰瘍性大腸炎と診断され経過観察中であったが,肛門周囲膿瘍を合併し当科を受診した.大腸内視鏡検査でクローン病と診断し,サラゾスルファピリジン3g,プレドニゾロン5mg,経腸栄養剤(エレンタール〓600kcal/day)にて外来で薬物栄養療法を行っていたが,右腹部痛と発熱が出現したため当科入院となった.中心静脈栄養および薬物療法を行いながら精査したところ,消化管造影検査および内視鏡検査にて横行結腸・十二指腸瘻が認められた.腹部CTおよび腹部エコー検査では,上行結腸背側面に膿瘍形成を伴っていた.約1カ月間の保存的治療で症状の改善が得られず手術を施行した.クローン病に合併した横行結腸・十二指腸瘻の本邦報告例は8例のみと稀であり,本邦および欧米の報告例の検討を含めて報告する.

日本住血吸虫卵の介在と悪性腫瘍との因果関係については,とくに肝臓癌との間で報告されているが,大腸癌との関係は未だ不祥で,関係ありと報告するものが多い一方,消極的不支持報告例もみられる.今回,当科で68歳,男性の,直腸癌症例に日本住血吸虫卵の介在をみたので報告する.生活歴は20歳まで佐賀県鳥栖市に居住し,筑後川にたびたび素足ではいった経験をもつ.他院で貧血を指摘され,精査で直腸癌と診断され当科入院となった.術前に施行した大腸内視鏡検査の生検で日本住血吸虫卵の介在した高分化型腺癌と診断した.手術は低位前方直腸切除,S状結腸J型嚢再建を行い,RbRa, 2型, 4×4.5cm,全周, H0, P0, Se, N1, Stage IIIaであった.病理組織検査はwell differentiated adenocarcinoma, se, ly2, v1, n1であった.虫卵は腫瘍部中心に多数存在した.虫卵の介在と大腸癌発生機序について報告した.

皮膚筋炎に合併する悪性腫瘍としては比較的稀な舌癌と直腸癌の異時性重複癌の1例を経験した.症例は66歳男性で,55歳時に舌癌で手術され,58歳でヘリオトロープ皮疹などから皮膚筋炎と診断されステロイドが投与された.その後66歳時に便潜血反応陽性から直腸癌と診断され,低位前方切除術と肝部分切除が行われた.大腸癌取り扱い規約上はRa,2型,2.2×1.5cm,SS,H1,P0,N0,M0,Stage IVで,病理組織学的には高分化腺癌,ss,ly3,v1,n0,h1であった.術後2年で肺線維症に肺炎を併発し死亡した.皮膚筋炎に合併する悪性腫瘍では胃癌が多いが,自験例のようにに異時性重複癌の合併もみられることから厳重な経過観察が必要である.

多発性骨髄腫に合併した異時性多発性大腸癌の1例を経験したので報告する,症例は68歳,女性.60歳の時に右側多発性大腸癌で右半結腸切除.術後3年,6年後の大腸内視鏡検査では再発はなかった.67歳の時IgA 1600mg/dl,BenceJones蛋白陽性,頭部X線で骨打ち抜き像を認め,多発性骨髄腫と診断され,VCAPとINF療法を行った.術後8年目にHb 5.8g/dlと高度の貧血を示し,大腸内視鏡検査で吻合部に大腸癌がみつかり手術を行った.手術所見は,前回の吻合部に2型,全周,8×12cm,H0P0SENIで,組織学的にはwell differentiatedad enocarcinoma,ly3v1n1であった.多発性骨髄腫ではmonocl onalgammopathyを合併しやすく,また二次的な免疫不全状態や,抗癌剤投与が免疫抑制的に働き異時性発癌を誘発したと考えられた.

膵・胆管合流異常の診断にMRCPが有用であった胆管非拡張型合流異常に合併した胆管癌の1例を経験したので報告する. 症例は70歳の女性. 一過性の右季肋部痛あり, その6か月後黄疸が出現した. 全身状態は暦年齢以上に不良であった. MRCPでは中部胆管に縦径2cmの腫瘍像, 胆管の完全閉塞がみられたが, 腫瘍より下流の胆管に拡張はなく, 共通管が1.5cmの胆管合流型の膵・胆管合流異常を認めた. 高齢で低栄養であるため, 胆管切除術を施行した. 手術診断はEM1, DM0, HM0, Surgical Stage I, Cur Bであったが, 病理組織学的所見は高分化型管状腺癌, hm2, em2, comprehensive stage II, cur Cであり癌の遺残を認めた. 本例は非拡張型合流異常における積極的分流手術の必要性を示唆する1例と考えられた.

A case of strangulated ileus caused by a knot in a Meckel's diverticulum is reported. A 75-year-old woman was admitted because of sudden diffuse abdominal pain. Her symptoms became worse despite conservative treatment, and she went into shock. Abdominal CT scan and clinical findings suggested strangulated ileus. There fore, an emergency operation was performed. At laparotomy. a large amount of bloody fluid and strangulation of the intestine caused by a knot in a Meckel's diverticulum without adhesions or bands was found. Resection of the necrotic intestine including the diverticulum was performed. Histopathological examination showed a diverticulum containing all layers of the ileum. Strangulation by a knot is a very rare complication of Meckel's diverticulum. Such a diverticulum characteristically has a long neck, an ampulla at its distal end, and is freely mobile.

Patients with "reflux" gastritis after gastrectomy suffer from a variety of symptoms, and this type of gastritis may sometimes compromise the quality of life of these patients. Since Helicobacter pylori is considered to be one of the most important pathogenetic factors in gastritis, the association between H. pylori and reflux gastritis was investigated in this study. A total of 145 patients with gastrectomy were entered into the study. Five biopsy specimens from the gastric remnant were taken at upper gastrointestinal endoscopy. One specimen was examined pathohistologically, and the remaining four were examined for H. pylori infection. Fifty-two patients (36%) demonstrated H. pylori infection. The prevalence of H. pylori was significantly higher in patients who had a partial gastrectomy, and it was significantly lower in patients who had undergone gastrectomy more than 4 years previously. The histologic gastritis score in patients with H. pylori infection was significantly higher. Furthermore, H. pylori was eradicated in patients with some symptoms of gastritis and no bile reflux to the residual stomach at endoscopy; in these patients the symptoms were relieved and the histologic gastritis score decreased significantly. In conclusion, possible involvement of H. pylori is suspected in the pathogenesis of "nonreflux" gastritis after gastrectomy.

症例は53歳の女性.1991年2月右下腹部痛を自覚して近医を受診し,注腸検査で回盲部に潰瘍性病変を認め,外来でfollow upしていたが,1993年3月中旬から右下腹部痛が増強するとともに腫瘤を触知するようになった.精査の結果,回盲弁に騎乗する下掘れ性の円形潰瘍を認め,CT・MRI検査では回盲部腸管がほぼ全周性に壁肥厚しており,血管造影検査では回結腸動脈領域の新生血管増生を認めたが広狭不整等の悪性所見は見られなかった.2年間の経過で回盲部の狭窄が著しく進行していたため手術適応ありと判断し,回盲部切除術を施行した.回盲部単純性潰瘍は比較的まれで,他の回盲部疾患との鑑別診断が重要であるが,とくに腸型べーチェット病との鑑別は困難で,内科的治療に抵抗し手術後の再発も高率で充分な経過観察が必要とされている.

食道癌はほとんどが扁平上皮癌であるが, 今回われわれは中部食道に原発した早期腺表皮癌の1例を経験したので, 文献的考察を加え報告する.症例は59歳の女性で, 嚥下障害を主訴として来院.食道透視でImに長径4.5cm, 鋸歯型の陰影欠損を認め, 内視鏡下生検で食道腺表皮癌と診断し, 30Gyの術前照射ののち胸部食道亜全摘術を施行した.切除標本では食道胃接合線より8cm口側に2.3×1.3cmのやや不整形の陥凹性病変を認めた.病理組織学的には腫瘍は潰瘍部分を中心に扁平上皮癌細胞の増生を認め, 一部に腺癌部分がみられ, 両構成成分の間の境界は明瞭であった.深達度は粘膜下層までで, 両者とも術前照射による変性を中程度伴っており, 放射線の効果判定はEf2であった.sm, n0, M0, Pl0, R-stage 0で, 原発性早期食道腺表皮癌と診断した.

膵頭部と体部に多発した漿液性膵嚢胞腺腫を経験したので文献的考察を加え報告する.症例は49歳の女性で, 腹部不快感を主訴として来院, 腹部超音波検査にて膵頭部に直径3cmの, 体部に直径1.5cmの多発性嚢胞像が認められ, 精査の結果多発性の漿液性膵嚢胞腺腫を疑い, 膵頭体部十二指腸切除術を施行した.切除標本を検索すると膵頭部の腫瘤は5×3×4cmで周囲の膵実質とは明瞭に区別されており, 漿液性の液を含む2～16mmの多数の嚢胞からなり, 主膵管は軽度狭窄が認められた.膵体部の腫瘤は直径1.5cmで1～6mmの多数の嚢胞から構成されていた.病理組織学的には膵頭部と体部に多発した漿液性膵嚢胞腺腫と診断した.膵頭部と体部に多発した漿液性嚢胞腺腫の1例を報告し, 病理所見と対比して画像診断上粘液性嚢胞腺腫との鑑別点について文献的に考察した.

75歳以上の高齢者大腸癌穿孔例の臨床・病理学的特徴を75歳未満の穿孔例と比較検討した.手術数に占める穿孔率は75歳未満3.0%に対して, 75歳以上では19.4%と高率であった.口側遊離穿孔の頻度は75歳未満では4例中1例 (25.0%) に対し, 75歳以上では6例中3例 (50.0%) であった.穿孔癌の占居部位は75歳未満では下部大腸に集中していたが, 高齢者では大腸に広く分布していた.癌の肉眼型はともに2型が75%以上を占め, 壁深達度は高齢者に浅い傾向をみた.ショック症状は75歳未満50.0%, 75歳以上33.3%であり, 直死4例中3例はショック症状を伴っていた.発症から手術までに24時間以上経過した症例は高齢者で66.6%と高率であったが, 経過時間と直死率に相関はなかった.術前併存疾患と術後合併症は高齢者で高率に発生し, これらの症例は高い直死率を示した.

膠原病に合併した腹部血管炎による腸管の壊死・穿孔の3例を経験したので報告する.症例1は52歳男性, 症例2は69歳女性, 症例3は46歳女性で原疾患はそれぞれperiarteritis nodosa, rheumatoid arthritis, systemic lupus erythematosusであった.全例激烈な腹痛で発症し, 壊死・穿孔部位は回腸を中心とし, 手術は病巣切除と吻合を行い, 症例1には横行結腸外瘻術も併施した.予後は症例1は縫合不全と壊死・穿孔の再発のため術後12日目に, 症例2は多臓器障害により術後2日目に死亡したが, 症例3は7か月後の現在も生存中である.膠原病に合併した腹部血管炎による消化管の壊死・穿孔は全身の血管炎の部分症状として出現したものであるため, 手術に際し腸管の切除範囲の決定が問題であり, 加えて術後intravenous hyperalimentation, steroid抗生物質などによる全身管理が必要である.

過去12年間に当科で手術した大腸癌272例のうち, 75歳以上の高齢者大腸癌47例の臨床病理学的特徴について75歳以下 (対照群) と比較検討し, 以下の結論を得た. (1) 最近6年間の高齢者大腸癌の手術率は22.8%と, それ以前の11.0%よりも上昇した (p 0.05), 肉眼型, 腫瘍径, 組織型, 壁深達度, Dukes 分類, リンパ転移率, 脈管浸襲率には対照群と差がなかった. (3) 切除率, 治癒切除率は両群間で差はなかったが, 高齢者の直死率は14.9%と対照群の4.0%より高率であった (P

In the recent years, Dieulafoy's ulcer is clinically noted, and this paper describes two cases of Dieulafoy's ulcer or its analogue. Both cases presented with sudden hematemesis and melena. As bleeding could not be stopped by conservative treatments including endoscopic hemostasis, emergency operations, proximal gastrectomy in one having an ulcer in the lesser curvature just below cardia and conventional partial gastrectomy in the other having an ulcer in lower body, were carried out. The ulcers were both of shallow, small and acute type with less than 10 mm in major axis and could be differentiated into U1II. Moreover, in submucosal layer of the ulcer bases, arteries with outer diameters of 750μm and 1000μm respectively were recognized. It is common that Dieulafoy's ulcer is operated on with proximal or conventional partial gastrectomy which is used to be applied to peptic ulcers, and we also adopted it. However, when the severe bleeding in Dieulafoy's ulcer comes from the existence of the abnormal arteries in submucosal layer, proximal or conventional partial gastrecotmy may not be necessarily required and ligature and suture hemostasis or local wedge resection may be satisfactory.

This paper describes our recent experience with a case of a retrograde intussusception due to a sigmoid polyp in light of the related literature. The patient was a 72-year-old woman who was admitted to our hospital because of abdominal pain and fullness. Abdominal X-ray showed the air-fluid level and a tumor-like mass in the gas contour of the intestine. Barium enema examination showed shortening of the sigmoid colon and tapering and obstruction of the descending colon. Judging from above information, we diagnosed mechanical obstruction of the descending colon due to malignant lesion, and laparotomy was immediately performed. The tumor was palpated in the splenic flexure of the descending colon, and it was clear that the sigmoid colon invatinated into the descending colon retrogradely. We could not rule out the existense of malignant tumor at the top of the intussusceptum, so the colon, from the splenic flexure of the descending colon to the upper half of the sigmoid colon, was resected with reginal lymphmodes. The resected specimen showed a large-sized polyp (10.0×5.5×1.0cm) at the top of the intussusceptum. Microscopic examination clarified that the polyp was a tubulovillous adenoma with malignant change. Because almost all intussusception in adults is due to organic lesions, the resection of intussuscepted lesions with lesional lymphmodes should be performed without reposition, if malignancy has not been ruled out.

急性虫垂炎症状をもって発症した患者に腹部超音波検査と注腸造影を施行し, 7カ月前に同様の症状発現時に他院で行った注腸造影の所見を踏まえて, 結果的に経過観察がなされた虫垂癌の1例を経験した.症例は50歳, 男性.超音波所見では虫垂は腫大し, 壁は不整で中心部は不均一であった.7カ月前の注腸造影所見では虫垂開口部の一部のみが造影され, その壁は硬化と伸展不良を示し, 虫垂開口部の盲腸粘膜は上方へ圧排されていた.当院での注腸造影では盲腸右側の陰影欠損があり, その壁は硬化, 不整を示していた.以上より, 虫垂癌を疑い計画的にリンパ節郭清を含めた回盲部切除を行った.病理組織所見は虫垂根部を中心とした結腸型の原発性虫垂癌であり, 大腸癌取扱い規約によると, V, 5型, pm, ly (-), v (-), n (-), P0, H0&, M (-), stage Iであった.虫垂癌の臨床病理学的特徴について検討を加えた.

Patients with peptic ulcers admitted to the First Department of Surgery, Kobe University School of Medicine, during the past ten years were divided into a first half group and a second half group, corresponding to the development of cimetidine, and changes in the pattern of intractable ulcers were studied retrospectively.In the second half group, both the number of admissions and the number of operations decreased by 50%, but the rate of surgery, about 70%, was unchanged. In the second half, the rate of surgery for hemorrhage was reduced slightly, but the rate of surgery for intractability increased slightly.The backgrounds and morphological features of intractable ulcer patients were investigated, and the age, the rate of complications and gastric analysis were not different in the two groups but the percentage of women increased in the second half and the past history of ulcer dropped from 87% to 55%. Morphologically the rates of giant ulcers, 2 cm or larger, linear ulcers 3 cm or longer, and ulcers with deep UI IV increased, while multiple ulcers decreased from 57.5% to 25%.

血漿フィプロネクチン (pFN) と血液凝固第XIII因子 (XIII因子) が潰瘍性大腸炎 (UC) の病態の質やstageの指標になりうるか否かについて検討した.対象はUC32例で, 延べ46回 (活動期19例, 緩解期27例) 両指標と血小板数, フィブリノーゲン (Fbg) を測定した、pFNはパルチゲンプレート法で, XIII因子はモノダンシルカダベリン法にて測定した.活動期のpFN, XIII因子は緩解期に比べ低下し (P

Clinical features and the results of treatment in 61 cases of ulcerative colitis (34 males and 27 females) were analyzed. In most of the cases (47 cases, or 77%), the age at which the disease occurred was estimated to be between 10 and 39 years. Early complaints were mucous bloody stools (seen in 77% of all cases), diarrhea (66%) and abdominal pain (23%). Fifty patients were treated medically and 11 were treated surgically (urgent or semi-urgent surgery in 4 cases and non-urgent surgery in 7 cases). Of the 4 patietns who underwent urgent or semi-urgent surgery, 2 had perforations and the other 2 had fulminant type ulcerative colitis. The fatality rate for these 4 patients was 50%. Of the 7 patients who underwent non-urgent surgery, 4 had been treated medically for less than 5 years; in these 4 cases, the active stage occupied more than 50% of the total observation period, and the average relapse frequency was over 1.3 times per year. The other two patients, who underwent non-urgent surgery, had been treated medically for more than 5 years; they had been treated with more than 10, 000 mg of Predonine (prednisolone acetate) and it was difficult to discontinue their steroid therapy. Carcinogenesis was seen in one patient who had a relapsing-remitting type of ulcerative colitis which affected the entire large intestine and which had initially occurred 24 years earlier (this gave an incidence of carcinogenesis of 1.6%). The results of this study suggest that patients with severe ulcerative colitis (including the fulminant type) should be surgically treated in time rather than adhering to conservative treatment, in order to reduce the current high mortality rate during or following urgent surgery.

切除した小腸原発性悪性リンパ腫5例を対象に, 臨床病理学, 免疫組織学的検討を行った. 性別は4: 1, 手術時平均年齢は62.2歳, 病悩期間は平均3.3か月であった. 臨床症状は腹痛を全例に認めたが, 悪性リンパ腫に特異的な症状はなかった. 発生部位は空腸1例, 回腸4例, 肉眼型は潰瘍型3例, 動脈瘤型2例で, 腫瘍径は全例4cm以上 (平均8.0cm) と大きく, 多発症例は2例あった. 免疫組織学的検索では全例B細胞由来リンパ腫で, このうち, 2例に腫瘍細胞質内に免疫グロブリン局在を認め, 1例はIgGλ 型, 1例はIgMλ 型であった. 腫瘍径と予後の関連性は見出せなかったが, 深達度, リンパ節転移, 進行度との関連性は示唆できた.

Until now, 21 cases of Crohn's disease (78% of total cases of this disease) have been surgically treated at our department. Of thse cases, 14 received a curative surgery (complete resection of the lesion). We analyzed postoperative relapes of the disease in these 14 cases. Postoperative relapse was seen in 2 (50%) of the 4 patients with Crohn's disease of the small bowel and 3 (33%) of the 9 patients with Crohn's disease of the small and large bowels. Of these 5 cases of postoperative relapse, 4 had relapse at a site close to the anastomoses. The mean timespan from the surgery to the relapse was 3 years and 3 months in patients with Crohn's disease of the small bowel and 11 months in those with Crohn's disease of the small and large bowels. The relapse rate was 13% for the patients with a preoperative IOIBD (International Organization for the Study of Inflammatory Bowel Disease) score of 4 or less and 67% for those with a preoperative IOIBD score of 5 or more. Of the 9 cases in whom the unaffected intestine was resected for 10 cm more proximal (adoral) from the lesion, no one showed postoperative relaps. Of the 5 cases in whom the unaffected intestine was reseacted for less than 10 cm proximal from the lesion, all showed postoperative relapse. However, no correlation was found between the relapse rate and the length of the resected unaffected intestine distal (towards the anus) from the lesion. Reoperation was done in 2 cases because of fistulation.

A retrospective study of patients with peptic ulcer admitted to the First Department of Surgery, School of Medicine, Kobe University, was made into the actual conditions of the surgical treatment of the ulcer after the introduction of cimetidine. The patients were divided into two groups, the first belonging to the period between 1976 and 1980 and the second belonging to that between 1981 and 1985 (July). A remarkable decrease was seen in the second group in the number of cases and operations. Especially noticeable was a decline in the number and rate due to intractability among such cases. But an increase was noted in the number of operations for complications of the ulcer (hemorrhage, perforation). There was a higher rate of complications in the second group in comparison with the first. There was no difference in the rate of occurrence of ulcers or shock. In cases of serious hemorrhage with duplicated complications, a barrier was observed in the efficacy of cimetidine, and the rate of cases requiring urgent surgery was still as high as 42.1%.

Possible changes in surgical treatment of peptic ulcers at the Kobe University Hospital (First Dept. of Surgery) over the past ten years were explored, dividing the 10 years into the first (1978-1982) and second (1983-1987) periods. The number of hospitalized peptic ulcer cases and the number of surgically treated peptic ulcer cases fel by 50% from the first to the second period. The decrease was particularly marked in duodenal ulcer cases (in comparison with ulcers of the other sites) and intractable ulcer cases (in comparison with ulcers of the other features). The percentage of patients who underwent urgent operation was 37.3% in the first period, which fell to 28.6% in the second period. The number of surgically treated intractable ulcer cases showed a 69.2% reduction in the second period compared to the first period. However, the percentage of cases whose excised specimen was rated as representing giant ulcer, linear ulcer, or U1 IV was higher in the second period than in the first period. Stenosis was found in 7 cases in the first period and 3 cases in the second period. The percentage of hemorrhagic ulcer cases who received conservative treatment or pallilative operation became higher in the second period than in the first period, while the percentage of hemorrhagic ulcer cases who underwent urgent operation decreased from 65.2% in the first period to 33.3% in the second period. In hemorrhagic ulcer cases, the death rate during or after uregent operation rose from 28.7% (first period) to 40.0% (second period). Perforated ulcer was found in 7 cases in the first period and 1 case in the second period. Of these 8 cases, 4 died (3 in the first period and 1 in the second period). Death rate was particularly high in elderly patients who had no history of ulcer and in patients who received surgery 12 hours or more after perforation.

A study was performed on the clinical characteristics and prognosis of 27 patients aged 70 years and over who underwent surgery for peptic ulcer. Seventeen patients had gastric ulcers, six duodenal ulcers, and four gastric and duodenal ulcers. The male-to-female ratio was 2.4:1. Twenty patients (74.1%) had no past history of peptic ulcer before 70 years of age. Seventeen patients (63.0%) had epigastric pain, the commonest presenting symptom. Fourteen patients (51.9%) had suffered from the disease for less than six months, nine (33.3%) of these for less than one month. Bleeding (ten patients) and perforation (eight patients) accounted for 66.7% of indications for operation and 14 patients, six of those with bleeding and all of those with perforation, underwent emergency surgery. All patients with perforation developed peptic ulcers for the first time after 70 years of age and most of the perforating ulcers were located in the antrum of the stomach or the bulbus of the duodenum. Twenty-two patients (81.5%) had associated disease before surgery. The mortality of emergency surgery was 28.9%, and an extremely high mortality, 50.0%, was observed for perforation.