Search

‹目的›術後離開創に対する創傷被覆材の有用性を検討すること.‹方法›術後離開創に対し,生理食塩水による洗浄後,ハイドロファイバーを用いて被覆した群(アクアセル群) 11例とガーゼを用いて被覆したコントロール群(ガーゼ群) 17例とに無作為に振り分け,創部が上皮化した時点を治癒と判断しそれぞれの治癒期間を評価した.‹結果›両群間で背景因子,創の最大径や治癒日数に差はなかった.創1cmあたりの治癒日数を比較すると,アクアセル群ではガーゼ群と比較して有意に短縮していた.創培養陽性症例を抽出し両群間を比較したとき,背景因子,創の最大径,創1cmあたりの治癒日数に差は認めなかった.‹結論›臓器・腹腔内感染を伴わない術後離開創に対して,ハイドロファイバーを使用することにより創傷治癒日数が短縮する可能性が示唆された.

Introduction: Between April 1992 and December 2000, 167 patients with pancreatic carcinoma were evaluated and treated in our department. One hundred eight patients (64.7%) with pancreatic carcinoma underwent pancreatectomy. Of these patients, 94 had histologically proven ductal adenocarcinoma. The overall postoperative mortality rate was 3.2% (3 patients), and the morbidity rate was 35.1% (33 patients). The estimated 1- 2-, 3-. and 5-year survival rates were 43.6%. 28.7%, 21.8%, and 12.9% respectively. There were only six long-term survivors who survived >5 years after surgery. Methodology and Aims: Institutional experience with 94 consecutive patients with ductal adenocarcinoma who underwent pancreatectomy was reviewed to clarify the influence of 29 prognostic factors (5 host, 17 tumor, and 7 treatment factors). Special reference was made to determine whether these significant factors have an effect on long-term survival. Univariate and multivariate models were used to analyze the effect of prognostic factors on survival. Results: Univariate analysis indicated that blood loss, operative time, postoperative complications, histopathologic lymphatic and venous permeation, lymph node metastasis, conclusive stage, conclusive curability, resection margins, serosal invasion, size of tumor, retroperitoneal invasion, major arterial invasion, and mode of histologic infiltration were associated with significantly longer survival (p < 0.05). By Cox proportional hazards survival analysis, the most powerful predictors of outcome were venous permeation, lymph node metastasis, tumor diameter, and conclusive curability. The longest-term survivor had the most advanced stage (stage lV b ) of disease and curability C. No long-term survivors had all of the good prognostic factors (according to multi variate analysis). Conclusions: The prognosis after surgical resection of pancreatic carcinoma mostly depends on tumor factors. In this study, it was difficult to identify the determinants of long-term survival in patients with resectable tumors.

症例は82歳,男性.平成2年8月,右季肋部痛を自覚.精査の結果,胆嚢腫瘍および胆石を指摘.胆嚢癌の診断にて平成2年12月,胆嚢摘除・肝床切除・胃局所切除術を施行.病理所見は肝・胃への浸潤を伴う高分化型管状腺癌, t4 (si, hinf2, binf0, pv0, a0), n0, H0, P0, M(-), stage IVaと進行胆嚢癌であった.術後6年を経過した平成8年11月頃より黄疸・肝機能異常を認め,精査の結果,旧肝床部の腫瘤,肝門部・肝十二指腸間膜リンパ節の腫大,総胆管・肝内胆管の拡張を指摘.胆嚢癌の再発の診断にて平成8年12月, S4a・5肝部分切除・総胆管切除・十二指腸楔状切除・胆管空腸吻合術を施行.病理所見は旧肝床部の高分化型管状腺癌の再発による胆管・十二指腸浸潤であった.その後,肝転移,骨転移を認め,初回手術より9年4カ月後に死亡した.以上,非常に稀な長期生存stage IVa胆嚢癌を経験したので,文献的考察を加えて報告する.

Nitric oxide (·NO) is known to influence circulatory, neural, immunologic, and metabolic alterations. To evaluate the clinical significance of ·NO production under surgical stress, serial measurements of plasma nitrite plus nitrate levels were performed in 45 surgical patients. Group A included 19 patients who underwent major surgery with uneventful postoperative courses. Group B included 18 patients who underwent laparoscopic cholecystectomy. Group C included 8 patients whose surgery was complicated by intra-abdominal abscesses. Eight healthy volunteers served as controls. Plasma nitrate levels were determined with a redox chemiluminescence ·NO analyzer and coincided with measurements made by high-performance liquid chromatography (r = 0.868, p < 0.0001, 58 samples). During laparotomy, arterial nitrate levels correlated well with peripheral, portal, and hepatic venous nitrate levels (r = 0.966, 0.938, and 0.949, respectively; p < 0.0001). A significant decrease in nitrate from preoperative levels in groups A (postoperative day (POD) 1 and 3; p < 0.0005) and B (POD 1, p < 0.0001) was observed; nitrate levels in group C did not decrease for 14 days after surgery. Plasma nitrate levels in groups A and B were significantly different (POD 1 through 6, p < 0.05) and at POD 3 were significantly lower in group A (p < 0.005). Plasma nitrate levels measured before and after fasting or food intake were not significantly different. These results suggest that surgical stress leads to a decrease in the end product of ·NO in the whole body, and that the greater the surgical stress the longer the duration of decreased ·NO production.

Intestinal obstruction is a rare complication during pregnancy, and almost all causes are considered to be secondary adhesions in a patient with a surgical history. During pregnancy, there have been only a few reported cases of internal hernia. An internal hernia is formed by the protrusion of a viscus through a peritoneal fossae or anomalous opening in the mesentery leading to its encapsulation within a compartment of the abdominal cavity. The difficulty of diagnosis of the disease associated with pregnancy which limits diagnostic investigation also brings a dangerous combination of bowel obstruction. We present a case of internal hernia caused by anomalous opening in the falciform ligament in a pregnant woman of the 37th week of gestation. She underwent a cesarean section, followed by lapalotomy which revealed intestinal obstruction through the opening in the ligament falciform. The ligament was divided and 40cm of the small intestine was resected. In patients with symptoms suggestive of bowel obstruction during pregnancy, internal hernia must be included in the probable differential diagnoses.

Objective : To evaluate conditions similar to those of carcinogenesis of the gallbladder between the gallbladder with a low junction of the cystic duct (LJCD) and an anomalous pancreaticobiliary junction (APBJ). Design : Retrospective and clinicopathological analysis of patients with gallbladder carcinoma. Setting : First Department of Surgery, Kansai Medical University. Patients : Examination of 47 patients (7 men and 40 women ; average age : 67.8 years) with gallbladder carcinoma revealed 7 patients (14.9% ; 1 man and 6 women ; average age : 67.8 years) with LJCD and 6 patients (12.8% ; 6 women ; average age : 60.3 years) with APBJ. Methods : Clinical findings in both groups were compared with those of the 34 patients who remained after exclusion of the data of the above 7 patients with LJCD and 6 patients with APBJ. The data of the three groups were examined by the χ 2 test at the 5% level of significance. Results : Most of the gallbladder cancer patients with LJCD or APBJ had gallstones. The biliary amylase levels determined in the gallbladder of patients with LJCD or APBJ were remarkably high. Conclusion : The results indicate that patients with LJCD or APBJ are more likely to develop carcinoma of the gallbladder. The factors responsible for carcinogenesis may be alteration of the bile content due to reflux of pancreatic enzymes through the LJCD or APBJ, and mechanical irritation due to gallstones. Therefore, these pathological conditions in patients with LJCD are similar to those experienced in patients with APBJ.

Fifty cases of colorectal adenocarcinoma were immunohistochemically examined for the relationship between distribution of plasminogen activators (PAs) and the degree of differentiation of cancer cells as reflected by carcinoembryonic antigen (CEA) expression as well as tumor cell kinetics. The A chain of urokinase-type PA (u-PA-A) was mainly observed in the apical portions of highly differentiated cancer cells. Increased expression and change in localization to the cytoplasm were found with progressive dedifferentiation. The numbers of DNA polymerase alpha (pol. alpha) positive cancer cells also increased in line with u-PA-A expression. The B chain of u-PA (u-PA-B), and the A and B chains of tissue-type PA (t-PA-A and -B) did not show similar alteration. The present findings suggest that the distribution of u-PA-A in colorectal carcinoma tissues, the degree of tumor differentiation, and the proliferation kinetics of cancer cells are closely related.

Kallikrein activity in human stomach tissue was measured and found to be about threefold higher in cancer tissue than in normal tissue. To clarify the physiological role of this tissue kallikrein, we investigated its effects on the spontaneous metastasis and tumor growth of Lewis tumors (3LL). Antiprotease, aprotinin, and gabexate mesilate (FOY) inhibited spontaneous metastasis but did not inhibit tumor growth, while tissue kallikrein and plasmin enhanced the spontaneous metastasis of 3LL. The results suggest that the inhibitory effects of aprotinin and FOY on metastasis are not only due to an inhibition of tumor cells released by tissue kallikrein, but that tissue kallikrein, a protease, also participates in metastasis. We thus conclude that aprotinin or FOY should be administered either before or immediately after operation to inhibit spontaneous metastasis.

Plasminogen activator activity was investigated in extracts of 42 surgically removed gastric carcinomas. The mean levels of total plasminogen activator (total-PA) and urokinase-type plasminogen activator (u-PA) activities in the gastric carcinomas were significantly higher than those in the background normal tissues (p less than 0.001). On electrophoresis, gastric cancers were found to contain u-PA as the predominant PA, this being confirmed using zymography by direct inhibition with anti-urokinase antibody. Assessment of the relationship between PA activity and biological behavior of gastric cancer revealed total-PA and u-PA levels to be significantly higher in differentiated than in undifferentiated tumors (p less than 0.001), and in aneuploid than in diploid ones (p less than 0.01). Immunohistochemical staining showed that the proportion of u-PA-positive cancer cells in the carcinoma tissues also correlated with activity as measured by the azocaseinolytic method. These findings suggest that the study of PA contents in gastric cancer, combined with a nuclear DNA ploidy and immunohistochemical analysis, might be useful for understanding the biological characteristics of the tumor.

14029 Background: A phase I clinical study was performed to determine safety and immunogenicity of personalized peptide vaccination with gemcitabine (GEM) in advanced pancreatic cancer patients (APC). Methods: Thirteen human histocompatibility leukocyte antigen (HLA)-A24+ or A2+ patients with unresectable (n=10) or recurrent (n=3) pancreatic cancer were treated with GEM plus up to four peptides that were positive for pre-vaccination measurement of peptide-specific IgG antibodies and/or cytotoxic T lymphocyte (CTL) precursors in the circulation (personalized peptide vaccine). GEM was administered at 1000mg/m2 as a 30-min intravenous infusion once a week for three week, followed by 1 week of rest. All patients were treated on outpatient basis. The cycle was repeated every 8 weeks. Results: Peptide doses of vaccination per week were planned as follows: level 1, 1mg; level 2, 2mg; and level 3, 3mg. The main grade 3 toxicities observed during the first cycle in each level were neutropenia (15%), anemia (23%) and thrombocytopenia (15%). No significant differences in the toxicities were found between each level. There was no dose limiting toxicity (DLT) observed in each level. Augmentation of peptide-specific CTL responses in the post-vaccination peripheral blood mononuclear cells was observed in each level, while increased titer of peptide-specific IgG antibodies was observed in the post-vaccination plasma in level 2 and level 3. Applicable responses were no complete response, two partial responses (15%), and 7 stable diseases (55%). Nevertheless 7 patients of them (54%) were under the second-line chemotherapy, disease control rate was 70%, the median TTP (time to progression) was 18.5 weeks and the MST (median survival time) was 7.6 months in this study. Conclusions: The combination therapy of personalized peptide vaccination with GEM for APC patients is feasible and safe. Because of positive immune responses under a full dose of GEM, the peptide vaccination of 3 mg is recommended. No significant financial relationships to disclose.

4097 Background.Pancreatic cancer is one of the cancers with very poor prognosis that might be associated with impaired host immune function. The aim of study is to determine whether circulating de...