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当院では1999年6月より食道癌術前から理学療法士が運動療法を含めた呼吸理学療法を開始した.術前から理学療法士が呼吸訓練を行った群(施行群n=40)と行わなかった群(非施行群n=14)の2群に分け,入院期間,合併症,入院医療費について後方視的に検討した.術後入院期間は施行群29.9日,非施行群67.9日で施行群が有意に短かった(p=0.020).呼吸器合併症は施行群28%,非施行群43%であった(p=0.287).呼吸器合併症との関係を以下の3群に分けて検討した.合併症非併発群(合併症なし群n=21)と呼吸器合併症のみ併発した13例中,術前理学療法施行群(施行群+呼合併群n=8)と非施行群(非施行群+呼合併群n=5)である.入院医療費は非施行群+呼合併群が施行群+呼合併群より高い傾向がみられた(p=0.248).術前呼吸理学療法と術後早期の訓練開始は,呼吸器合併症の予防に有用で,術後入院期間が短縮し,医療費の低減化に寄与したと考えられた.

症例は65歳,女性.右下腹部痛,右下肢浮腫および疼痛を主訴に内科入院.下大静脈閉塞症と診断され当科転科となる.右下腹部に腫瘤を触知し,皮下静脈の発達および右下肢浮腫を認めた. CT検査, MRI検査,血管造影検査等により,下大静脈および右卵巣静脈原発の平滑筋肉腫を疑い,手術を施行した.右側腹部,右卵巣静脈に一致して10×8cm大の腫瘤を認めた.また肝のS5に1cm大の腫瘤を認め,術中病理にて平滑筋肉腫と診断された.下大静脈前面を切開し,アンスロンチューブを挿入.部分体外循環とした後,下大静脈内部の腫瘍を摘出した.稀な右卵巣静脈原発の平滑筋肉腫により,下大静脈閉塞症となった症例と考えられた.本症例は稀であり,術式について術前より十分な検討が必要であると思われた.

症例は58歳の男性. 上腹部痛を主訴に近医を受診し, 腹部超音波検査, 腹部CTにより膵臓に腫瘍性病変を指摘され当院を紹介された. 初診時, CEA, CA19-9などの腫瘍マーカーは異常を認めなかったが, 好酸球増多を伴った白血球の増加とCRPも1.9mg/dlに上昇していた. 腹部超音波検査とEUSでは嚢胞成分を伴った膵頭部腫瘍を認め, 腹部CTと腹部血管撮影では上腸間膜静脈への腫瘍浸潤が疑われた. ERCPでは膵頭部領域において主膵管のびまん性狭窄を認めSantorini管も同様の狭窄像を呈していた. 膵頭十二指腸切除術を施行した. 病理組織検査により, 好酸球と好中球の浸潤の目立つ退形成性膵管癌 (巨細胞癌) と診断された. 術前認めた好酸球増多を伴った白血球の増加は術直後より正常化したが, 腫瘍の再発に伴い再増加した. 術後経過は良好であったが, 転帰はきわめて不良であった.

化膿性脊椎炎の中でも頸椎および頸椎椎間板での発症は多くはない.われわれは胃癌手術後にMRSAによる頸椎椎間板炎を合併した1例を経験した.症例は60歳男性,噴門部胃癌に対して噴門側胃切除空腸間置再建を施行したが,縫合不全による腹膜炎を併発し術後7日目に開腹ドレナージ術を施行した.術後MRSAによる肺炎と敗血症を合併したがその後軽快した.しかし初回手術後67日目に突然両側上下肢の知覚低下と脱力感が出現し頸椎MRIで第4, 5頸椎椎間板炎と診断した.麻痺の進行を認めたため71日目に病巣掻爬および前方固定術を施行した.掻爬された椎間板組織から起因菌としてMRSAが同定された.術後経過は良好で機能訓練の後,術後176日目に退院した.消化器癌術後などのcompromised hostが,頸部や腰背部の疼痛,感染症状を呈した場合,化膿性脊椎炎の可能性を考慮するべきである.

This article is based on our previously reported results of irregular bowel movement and disturbances of the intestinal microbiota/environment in gastrectomized patients. A placebo-controlled, double-blind comparative study was carried out to evaluate the effects of a fermented milk beverage containing Lactobacillus casei strain Shirota (LcS) in such patients. The major evaluated factors of this article were "bowel movement" and "quality of life." The secondary evaluated factors were "fecal microbiota" and "enteric environment."Of the 190 gastrectomized subjects who participated in our previously reported defecation survey, 134 subjects judged as having abnormal defecation gave consent to participate in this study. These subjects continuously ingested the test beverage containing 40 billion LcS or placebo (one bottle per day, 4 weeks).In the LcS-ingested group, among the 118 subjects who completed the tests, the assessments of the subjects were based on their division into groups based on their symptoms with our scoring system for constipation/diarrhea; although there was no significant ingestion effect in total, in the constipation group, LcS reduced the degree of constipation compared with that in the placebo group. In the diarrhea group, LcS ingestion improved diarrhea compared with that in the preingestion state. Fecal Staphylococcus level was decreased.The results suggest the possibility that the continuous consumption of LcS-fermented milk relieves irregular bowel movement in gastrectomized patients.

BACKGROUND Recently, the usefulness of intratumoral microvessel density (IMD) and expression of several angiogenic factors as prognostic indicators have been demonstrated in several human solid tumors. METHODS One hundred four patients with pancreatic ductal adenocarcinoma were examined retrospectively. The investigated clinicopathologic and immunohistologic data included staining for vascular endothelial growth factor (VEGF), thymidine phosphorylase (TP), basic fibroblast growth factor (bFGF), CD34 (for calculating IMD), p53, and Ki-67. RESULTS Multivariate analysis for both overall and relapse-free survival revealed two independent variables, IMD and TP staining in stromal cells (TPs, P < 0.02). Whereas the frequency of hepatic metastasis was correlated significantly with cytoplasmic expression of TP or bFGF in tumor cells (TPc, bFGFc), IMD, and p53 status, local recurrence was significantly more common in patients with positive staining for TPs, bFGF in stromal cells (bFGFs), and for the pM category (P < 0.05). TPc, bFGFc, VEGF, and p53 expression correlated with IMD (P < 0.01), although TPs and bFGFs expression did not. VEGF and IMD status correlated with p53 expression (P < 0.001), although TP, bFGF, and Ki-67 status did not. CONCLUSIONS TPs expression and IMD were revealed to be valuable tools for predicting overall and relapse-free survival in patients with pancreatic adenocarcinoma. Whereas TPc and bFGFc are likely to participate in hepatic metastasis by means of their angiogenic properties, TPs and bFGFs may be related to local tumor progression. Angiogenesis in human pancreatic carcinoma may be dependent on VEGF, TP, and bFGF. p53 abnormality is likely to take part in VEGF-related angiogenesis. Cancer 2001;92:1788–97. © 2001 American Cancer Society.

良性胆管狭窄に対するメタリックステント(以下MS)留置の長期観察例を経験したので報告する.対象は7症例で,同時期に開腹下に胆管消化管バイパスをおいた7症例を対照群として成績を比較した.観察期間は8カ月から9年で原疾患は胆管空腸吻合後狭窄が3例,腫瘤形成性膵炎が2例,胆道結石術後が2例であった.留置前後のmortalityは0%, morbidityは14%であった.入院から治療完了までと入院期間は対照群に比べ有意に延長していた.再狭窄は1例に認め,開存率は1, 3, 5年それぞれ83.3%, 80.0%, 75%で,対照群は100%であった.外来では全例利胆薬と緩下剤にて胆汁の鬱滞を予防しており,胆汁の流出能の評価には胆道シンチグラフィーが有用であった.良性胆管狭窄に対するMS留置は論議の分かれるところであるが,われわれは2例の9年以上を含む経過良好な症例を経験し,注意深い術後の管理によって長期のpatencyを保ちうることが示唆された.

膵管状腺癌97例に対して, p53および腫瘍血管新生の評価としてCD34の免疫染色を行い, p53 labelling index とintratumoral microvessel density (IMD) を求め, 予後および臨床病理学的因子との関連, について検討した. 単変量解析では腫瘍部位, ts, v, ne, pw, stage, p53蛋白発現, IMDの8因子が有意で, 多変量解析ではpwとIMDの2因子が独立した予後因子であった (p

Congenital portosystemic venous shunt is a relatively rare disease. Recently, a 60-year-old woman was admitted to our hospital for hepatic encephalopathy caused by congenital extrahepatic portocaval shunt. She had been in good health until the onset of this event, with no liver damage and no experience of abdominal surgery or history of abdominal trauma. In May 1993, hepatic encephalopathy manifested suddenly, with the chief complaint of orthostatic disturbance. Although conservative treatment was administered during the subsequent 5 years, on admission, liver damage and slight splenomegaly were shown, for which complete resection of the shunt vessel and splenectomy were performed. Postoperatively, the patient's symptoms have been alleviated. Hepatic encephalopathy caused by congenital portosystemic venous shunt requires long-term conservative treatment, and the patient's quality of life is reduced. For this reason, surgical intervention or embolization with interventional radiology should be considered, and the maintenance of hepatic blood flow should also be considered.

We investigated the effects of ecabet sodium on experimentally induced reflux esophagitis in rats. Three groups of rats, i.e., a control group, esophagitis group, and an ecabet sodium group (25mg/kg given twice daily) were used. The number of animals which developed esophagitis, the extent of the lesions, and the esophagitis lesion index were assessed 3 weeks after the start of the experiment, and the lesions were evaluated histopathologically. All nine surviving rats in the esophagitis group developed esophagitis, and the esophagitis lesion index was 32.6 +/- 7.2 (mean +/- SE) per animal. Histopathologically, thickening of the epithelium, elongation of papillae of the lamina propria into the epithelium, and infiltration of the lamina propria by lymphocytes, eosinophils, plasmacytes, and neutrophils, were observed. Interruption of the lamina of the muscularis mucosae was also observed, and there was marked proliferation of collagen fibers in the submucosa and lamina propria. In the ecabet sodium group, esophagitis developed in five of the nine surviving animals (55.6%), but the esophagitis lesion index was 1.89 +/- 0.73 per animal, which was significantly lower than that in the esophagitis group. The histopathological changes in the rats which developed esophagitis were milder in the ecabet sodium group than in the esophagitis group. These results suggest that ecabet sodium could be useful for the prevention of reflux esophagitis.

The development of carcinoma in cases of gastric ulcer disease during long-term H(2)-blocker treatment is slowly increasing, and ulcers that require such treatment exhibit the characteristics of intractable conditions, including linear ulcers, simultaneous gastric and duodenal ulcers, immature intestinal metaplasia of the gastric epithelium, and atrophic gastritis accompanied with multiple ulcer cicatrices. The incomplete form of intestinal metaplasia resembling Filipe's type III lesions and showing structural atypia developed in the background gastric mucosa in such cases, and the characteristics of this metaplasia included structural atypia, a residuum of gastric-type mucous cells, rapid proliferative activity, and in some areas abnormal expression of P53 protein. In addition, in rat studies it was demonstrated that prolonged administration of H(2)-blockers while gastric ulcers were present accelerated cell proliferation in the background gastric mucosa in the long term. Accordingly, it was considered possible that the development of the incomplete form of intestinal metaplasia, which was strongly suggested to have some relation to the sites where intestinal-type gastric carcinoma appeared, was accelerated by mucosal injury due to chronic ulcers and by persistent elevation in intragastric pH. The results of the present study of gastric carcinoma as a complication of peptic ulcer disease indicated the possibility that Helicobacter pylori was a major contributory factor to the development of the incomplete form of intestinal metaplasia from damage to the background mucosa, but it was unclear whether H. pylori made any direct contribution to carcinogenesis.

We immunohistologically examined vascular endothelial growth factor (VEGF), thymidine phosphorylase (TP), and basic fibroblast growth factor (bFGF) on 61 patients with tubular adenocarcinoma of the pancreas which were resected, and studied their correlations with microvessel count (MVC), recurrent pattern, and prognosis. A univariate analysis revealed seven significant factors as tumor size (ts), pancreas cut end (pw), stage, curability, MVC, TP staining, and bFGF staining (P

症例は49歳女性,当院脳神経外科に入院中,平成9年12月2日の朝,薬を包装しているpress through pack (PTP)を誤飲した.翌日夜間より腹痛出現,外科転科となった.腹部CT検査で右下腹部に線状のhigh densityを示す異物を認め,本人の訴えなどからPTPと考えられた.腹部所見が増悪し板状硬となり, PTPによる穿孔性腹膜炎と診断し,緊急手術を施行した.回腸末端から25cmにPTPを触知し,同部が一部穿孔していた. PTP誤飲の中で小腸穿孔は稀であり,文献上本邦報告例は自験例を含め19例であった. PTP誤飲時にはまず上部消化管内視鏡検査を行い,早期に摘出すべきである.しかし小腸まで到達している場合には,十分な経過観察が必要で, PTPの存在部位の診断にはCT検査が有用と考えられた.

症例は52歳の男性. 下血を認めたため当院を受診した. 上部消化管内視鏡検査では, 十二指腸下行部の主乳頭対側に潰瘍をともなう粘膜下腫瘍が認められた. 腹部CTおよび低緊張性十二指腸造影X線検査において十二指腸下行部に腫瘤が指摘された. 超音波内視鏡検査では, この病変は十二指腸筋層から連続しており, 血管造影X線検査の所見も総合して十二指腸平滑筋肉腫と診断し, 手術を施行した. 腫瘍は十二指腸下行部から水平部にかけて管外性に発育しており, 腫瘍を含めた十二指腸部分切除術を行った. 切除標本上, 腫瘍は長径64mmで粘膜面に潰瘍形成がみられ, 内部は不均一で壊死による嚢胞性変化が認められた. 病理組織検査の結果, 平滑筋肉腫と診断された. 今回のように十二指腸の粘膜下腫瘍が認められた場合, 平滑筋肉腫を念頭においた種々の画像診断を行う必要があり, 特に超音波内視鏡検査が有用であると考えられた.

症例は62歳の男性. 検診の上部消化管造影検査の際胃の異常陰影を指摘され当院外来を受診した. 身体所見, 血液検査では異常所見は認められなかった. 上部消化管造影検査では幽門前庭部小彎に2.5cm大の立ち上がりなだらかで表面平滑な隆起性病変を認め, 超音波内視鏡検査 (EUS) では筋層内の均一な低エコーの腫瘍と描出され, 胃平滑筋腫の疑いと診断された. 生検ではGroup 1であった. 確定診断と治療を兼ね腹腔鏡下胃部分切除術を行った. 病理組織学的には腫瘍細胞は固有筋層内に存在し, 卵円形, 均一で広い胞体を有し胃glomus腫瘍と診断した.胃glomus腫瘍は1962年に本邦で初めて報告されて以来69例しか報告例のないまれな疾患である. 腹腔鏡下に切除した報告例は過去1例だけであるが, 良性腫瘍である胃glomus腫瘍に対する治療法としては腹腔鏡下胃部分切除が妥当であると考える.

A case of eosinophilic enteritis presented with intestinal obstruction in a 6-year-old boy is reported. The patient was seen at the hospital because of fever, abdominal pain, and vomiting. The abdomen was distended. There were tenderness and muscle guading over the abdomen. Simple abdominal x-ray film and abdominal CT scan revealed significant gaseous distention and niveau formation of the small intestine. With a suspicion of strangulated ileus, an emergency operation was performed. Upon surgery, an induration like lesion was found in the middle portion of the small intestine about 150cm oral side from the terminal ileum. The induration was diagnosed as a cause of intestinal obstruction, and a partial excision of the small intestine was performed. Histopathologically, infiltration on inflammatory cells mainly composed of eoshinophile was confirmed in the submucosal layer of the excised intetine. The diagnosis of eosinophilic enteritis was made. Postoperative course was uneventful and the patient was discharged from the hospital on 17th hospital day. It is though that we have great difficulty in discision making of preoperative diagnosis and indication of surgical therapy for the disease, especially for emergency cases.

A 44-year-old man, who had been pointed out having gallstones 10 years before and a polyp of the gallbladder 3 years before, was admitted to the hospital for the purpose of operation because an increase in size of gallbladder polyp (20mm) was noted at an abdominal ultrasonography. The polyp grew segmentally. With a diagnosis of gallbladder cancer, a laparotomy was performed when the liver was black in color. A cholecystectomy was performed and differentiated adenocarcinoma was diagnosed. So a resection of the liver bed and lymph nodes dissection were added, resulting in a radical operation. Postoperative course was uneventful, however, a mild increase in conjugated bilirubin lasted. From re-increase in BSP test and findings of the resected liver, this case was diagnosed as gallbladder cancer associated with Dubin-Johnson syndrome (DJS). This case is very rare in that gallbladder cancer and cholesterol stones were associated with DJS, and that a radical operation was successfully performed and only one case of radical operation has been reported as far as we could review. We present the case together with some bibliographical comments.

A 49-year-old man was seen at the hospital because he was pointed out having a gastric lesion at a physical examination. A submucosal tumor 1cm in diameter located paracardia was observed with endoscopy. There was no connection between the tumor and the proper muscle layer because the tumor had high mobility within the submucosal layer. We tried an endosopic resection for the gastric lesion 2 weeks later. After the tumor resection, the proper muscle layer was clearly observed in the resected surface, and no bleeding nor perforation was seen. And a pathological study documented us that the tumor was removed with wrapped capsule and without any proper muscle layer component. So we thought that the proper muscule layer had been slightly damaged by the endoscopic procedure. However, he was seen at the hospital again because of perforation of the stomach about 7 hours passed after the endoscope procedure. It is not able to rule out the possibility of delayed perforation of the stomach after the endoscopic procedure, nevertheless the damage of the proper muscle layer would be slight and no immediate perforation would be observed. It is very important to close a mucosal defect by endoscopic procedure with crips or any other goods.

Sweet disease is an inflammatory dermatologic disorder of unknown origin and is characterized by: 1) fever: 2) increase in neutrophile in peripheral blood; 3) painful elevated eruptions commonly occurred in the face, neck and extremities: and infiltration of neutrophile into the dermis. It is known that the disease can be associated with a variety of malignant tumors in a high frequency. Recently we experienced a case of Sweet disease with a cystadenoma of the pancreas. A 43-year-old woman who had been diagnosed as Sweet disease 5 years before and had gained a remission by administration of steroids developed fever and dermal symptoms in October, 1994, and was diagnosed as having a recurrence of Sweet disease. Abdominal CT revealed a cystic lesion in the body and tail of pancreas. A resection of the body and tail of pancreas was performed. Operative findings included multilocular cyst 9 cm in diameter and a collection of 120ml of mucous in the body and tail of pancreas. Histopathologically mucinous cystadenoma of the pancreas was considered. It is thought that, in making the definite diagnosis of Sweet disease, the exploration of possible tumorous lesions should not be lacked.

A 27-year-old woman was seen at the department of obstetrics and gynecology in our hospital because of anal bleeding after a normal delivery, and referred to the department of surgery in a shock state due to massive anal bleeding. With various imaging methods and endoscopic studies, bleeding from the jejunum was identified and an excision of the small intestine was performed. Postoperative pathological study offered the definite diagnosis of choriocarcinoma. The patient was transferred to the gynecological department for chemotherapy. Thereafter the patient had metastases to the brain and lung. It has been said that choriocarcinoma which develops during pregnancy and puerperal period occurs at a frequency of about one to tens of thousands. Choriocarcinoma reveals a hematogenic metastatic pattern starting in an early phase from its biological characters. In particular, the metastasis to the digestive tract presents difficulty in diagnosis, is often associated with multiple metastatic lesions, and has a poor prognosis in most cases. Metastatic choriocarcinoma of the small intestine is a very rare entity and only eight cases have been seen in the Japanese literature. The disease during pregnancy and puerperal period is sometimes discovered from some symptoms due to its metastatic lesion. When abnormal genital bleeding, anal bleeding, respiratory symptoms, and neurological symptoms are seen in such patient, a possibility of the disease must be kept in mind, though it rarely occurs.

A 48-year-old man complaining of anemia, tarry stool, and upper abdominal distension was referred to the hospital from another hospital. On admisioon, he could not eat and marked anemia and a large upper abdominal tumor measuring 18cm were present. Leiomyosarcoma of the duodenum with liver metastasis was suspected preoperatively by abdominal CT, ultrasonograpgy (US) and angiography, Surgical findings revealed a tumor originating from second portion of the duodenum, growing mainly intraluminally but also invading the pancreas and liver. Pancreaticoduodenectomy and partial hepatectomy were performed to remove the tumor. Pathologically the tumor was comfirmed as primary leiomyosarcoma of the duodenum. Despite. of complete resection macroscopicaly, the patient died of liver failure due to multiple liver metastasis 20 months following the surgery. The importance of examination of the duodenum should be emphasized as this case has suggested.

これまでヒト大腸の運動機能を評価する際だって有用な方法はなかったが,今回著者らは大腸鏡を用いて大腸腸管内を生理的食塩水で満たし,その後体外式超音波検査を行いreal timeな画像として大腸の運動機能の評価を試みた(water sealed method).健常者では盲腸～下行結腸の半月ヒダは約2.5cm間隔に存在し,その位置は時間の経過とともには変化せず,一定の位置に存在していた.また積極的な蠕動運動は盲腸～上行結腸にだけ認められ,他の結腸では受動的に腸内容だけが移動していた.横行結腸～下行結腸の腸内容の移動は,半月ヒダとhaustraによって仕切られた2～3segmentを1単位とし肛側と口側を単振動しながら徐々に肛側に移動していった.一方,便秘症者では明瞭な半月ヒダおよびhaustraは観察されず,neostigmine負荷試験にも反応がみられなかった.よって腸内容の移動に半月ヒダおよびhaustraの緊張が強く関与しているものと考えられた.

A 78-year-old man was admitted to the hospital because of massive anal bleeding about 1l in volume during chemotherapy for malignant lymphoma at another hospital. Upper and lower abdominal endoscopy revealed no bleeding site. Hemorrhagic scintigraphy offered a suspicion of bleeding from the jejunum. Under laparotomy, a partial excision of the small intestine was performed, but unfortunately the patient died of multiorgan failure on the 4th postoperative day. Histopathologically, hemorrhage from lipoma of the jejunum was confirmed. Lipoma of the small intestine is very rare among all gastrointestinal tumors. And it can cause anal bleeding and bloody stools regardless of size of the tumor. It is thought for the case that pancytopenia and bleeding tendency due to chemotheray for the malignant lymphoma had caused massive anal bleeding. In the case of gastrointestinal bleeding during chemotherapy, we must entertain possible bleeding from benign tumor such as lipoma of the small intestine which has been silent until bleeding other than hemorrahge involved in the present disease in the diagnosis and treatment.

逆流性食道炎9症例に対して腹腔鏡下Toupet噴門形成術を施行し, 逆流防止効果と愁訴に関して検討した. 症例の平均観察期間は6か月 (2か月～11か月) であった. 術前, 全症例で滑脱型食道裂孔ヘルニアを認めたが, 術後には修復された. また, 食道炎も全例で治癒し, 瘢痕となった. 術前の食道内酸曝露時間 (pH

We studied the effect of pirenzepine on gastric secretion kinetics in rats in a hypochlorhydric state induced by lansoprazole, a proton pump inhibitor. Pirenzepine was administered intramuscularly at a dosage of 20 mg/kg twice daily; and lansorprazole, subcutaneously at 50 mg/kg once daily, both every day for 4 weeks. After the 4-week treatment, serum gastrin and plasma somatostatin levels were determined by radioimmunoassay. In addition, gastrin cells, somatostatin cells, and enterochromaffin-like cells were immunostained and counted. Serum gastrin levels were elevated, and gastrin and enterochromaffin-like cell numbers increased in the group on lansoprazole alone, compared with these values in the control group (which received distilled water). In the group on the lansoprazole and pirenzepine combination, serum gastrin levels decreased, and gastrin and enterochromaffin-like cell numbers were significantly decreased, compared with the respective variables in the group on lansoprazole alone, while the number of somatostatin cells increased in the group on the combination. Plasma somatostatin levels did not vary significantly in any group. It was thus demonstrated that pirenzepine corrects the abnormal gastric secretion kinetics resulting from treatment with lansoprazole alone, such as hypergastrinemia and gastrin and enterochromaffin-like cell hyperplasia.

遺伝性非ポリポーシス大腸癌 (以下, HNPCCと略記) は, 患者のほとんどが大腸癌に限られるLynch症候群 (以下, Lynchと略記) Iと, 大腸以外の他臓器にも悪性腫瘍を併発するLynch IIに亜分類される. 今回HNPCC術後に発生した原発性小腸癌 (Lynch II) の1例を経験したので報告する. 症例は53歳, 男性 (長男). 既往歴: 1990年 (45歳時) に上行結腸の多発癌 (低分化腺癌ss, 中分化腺癌ss) で右半結腸切除術, 1996年 (52歳時) に直腸癌 (m) を内視鏡的切除術. 家族歴: 母方祖父および母が直腸癌 (死亡), 三男が小腸癌と大腸癌 (生存), 五男が肝臓癌 (死亡). 現病歴: 健診で便潜血陽性と貧血を指摘され受診. 小腸造影X線検査でTreitz靱帯の肛門側に隆起性病変が疑われ, 小腸鏡で確認し, 生検で高分化型腺癌と判明した. 空腸部分切除術を施行し, 術後17日目に軽快退院となった. Lynch IIで小腸癌の報告はなく自験例が最初の報告例であった.

再発および根治的切除不能胃癌症例に対して腹腔内投与用tube (右横隔膜下3例, 左横隔膜下3例, ダグラス窩3例) を留置し, 99mTc-TSA-Dを1ml (740MBq) 投与しその後のリンパ流の動態を検索した. 横隔膜下投与群では, 左右どちらの横隔膜下に投与しても縦隔リンパ系の描出程度に差は認められなかった. 横隔膜下投与群とダグラス窩投与群を比較すると, 横隔膜下投与群は投与後速やかに縦隔リンパ系が描出されるが, ダグラス窩投与群では横隔膜にHSA-Dが達するまで縦隔リンパ系は描出されなかった. また, 末梢血中HSA-D countを比較すると, ダグラス窩投与群は経時的増加を認めたが, 横隔膜下投与群は低値が維持された. よって, 腹腔内リンパ系と縦隔リンパ系の主な交通経路は横隔膜リンパ系であると考えられ, 抗癌剤の腹腔内投与は腹腔内リンパ系だけでなく縦隔リンパ系に対しても効果を有する可能性があり, 特に横隔膜下投与は末梢血中濃度を低値に保て有用である.

逆流性食道炎10症例に対して, 腹腔鏡下Nissen噴門形成術を施行し, その短期治療成績を検討した. 手術時間は196.0±55分, 経鼻胃管挿入日数は1.2±0.4日, 食事開始時期は3.3±0.8日, 術後在院日数は20.4±0.8日であり, 術後観察期間は平均1年3か月 (4か月-3年1か月) であった. 食道炎は全例で治癒し, 1例を除き滑脱型食道裂孔ヘルニアも完全に修復された. また食道内酸曝露時間も著明に短縮し, 2例を除き正常となった. 術前の胸やけを中心とする症状は1例を除きすべて消失した. 術後の嚥下障害は噴門部のcalibrationを施行しなかった1例で認められ, 再手術を必要とした. 以上より, 逆流性食道炎に対する腹腔鏡下Nissen噴門形成術の短期治療成績は良好であったが, 手術手技として食道ブジーを使用するfloppy Nissen法にすることが術後の愁訴をもたらさないためにも重要であると考えられた.

1980年-1993年の14年間に当教室で経験した下部直腸進行癌根治度A症例で側方リンパ節郭清がD2郭清とD3郭清が施行された171例を対象とし, 至適側方リンパ節郭清の程度について検討した. stage II, IIIa, およびstage IIIbの側方第2群以上にリンパ節転移をみない症例, つまり全対象症例の約90%の症例では側方D2郭清群とD3郭清群に累積生存率で有意差は認められなかった. 一方, 全対象症例の約10%であるD3郭清を施行した側方第2群以上のリンパ節転移例では, その約半数に5年以上の長期生存をみた. よって下部直腸進行癌に対する側方リンパ節郭清は, まず内腸骨動脈の前面に沿ったいわゆるD2郭清を行い, 術中迅速診断で側方第2, 3群リンパ節転移陽性と判断された場合にD3郭清を行うべきである. またリンパ節被膜外病変を伴う症例は単なる外科的治療だけでは十分な根治性が得難いと考えられた.

Testicular feminization syndrome (TFS) is a rare disease, but it is seen with a considerably greater frequency from puberty onward. We report a case diagnosed as TFS during surgery for inguinal hernia, and discuss it with reference to the literature. The patient was officially registered as a 15-year-old girl. Inguinal masses were found bilaterally on examination by a local physician, and were diagnosed as hernias, and so the patient was referred to this department for surgery. The patient's phenotypes, such as the physique and external genitalia, were those of a girl, and breast development was good, but a soft mass was palpable on each side in the inguinal region. During surgery, masses resembling testes accompanied by atrophied epididymides were found in the vicinity of the two external inguinal rings. An interview with the parents revealed that she suffered from primary amenorrhea, and TFS was diagnosed. Bilateral gonadectomy was performed and the hernias were reduced by repairing the iliopubic tract. In performing surgery for inguinal hernia in a female patient, it is important both to bear in mind the possibility of TFS and to check for primary amenorrhea by asking the patient. In addition, the timing of gonadectomy would require our understanding and consideration the patient's condition and prognosis.

We investigated changes in the secretory kinetics of gastric endocrine cells related to the administration of lansoprazole, and the effects of enprostil on these altered kinetics. Male Wistar-derived 8-week-old rats were allotted to a control group, a lansoprazole administration group, an enprostil administration group, and a lansoprazole + enprostil administration group. Lansoprazole (30 mg/kg once a day for 4 weeks) and enprostil (10 micrograms/kg twice a day for 4 weeks) were administered into the gastric lumen with a gastric tube. At this time, blood was collected and immunohistological staining of gastric endocrine cells was conducted to investigate the secretory kinetics. Lansoprazole administration induced hypergastrinemia, increase of gastrin cells, and increase of enterochromaffin-like cells. Enprostil administration induced increase of somatostatin cells. The group administered lansoprazole + enprostil exhibited significant decreases in serum gastrin level, total gastrin cell count, and total enterochromaffin-like cell count, compared with the group administered lansoprazole alone. These findings suggest that enprostil may ameliorate the alteration in gastric endocrine secretion produced by the chronic administration of lansoprazole.

Using adult mongrel dogs, we experimentally investigated the gallbladder emptying after total gastrectomy from the relation ship between the endogenous cholecystokinin (CCK) secretion kinetics and the blind-loop duodenal motility.Postprandial gallbladder emptying was about 60% by 60 minutes in the totally gastrectomized dogs, the same as in the control dogs, then the volume increased. Serum CCK secretion in the totally gastrectomized dogs rapidly increased until 50 minutes after the meal in accordance with the gallbladder emptying compared with the control dogs. On the other hand, during fasting the gallbladder underwent partial refilling synchronous with phase I in the blind-loop duodenum and emptying throuth phase II into the latter half of phase II, but the volume of the gallbladder was greater than that in the control dogs. Moreover, the cycle of gallbladder partial emptying and refilling was prolonged with prolongation of the phase III appearance cycle. Variation of serum CCK secretion during fasting was not observed.From the above redults, it is suggested that the abnormality of gallbladder emptying after total gastrectomy mainly depends on the change in the endogenous CCK secretion kinetics in the digestive state and, on the other hand, in the interdigestive state it is correlated with the change in the blind-loop duodenal motility pattern.

It is said that malignant pheochromocytomas represent about 10% of all pheochromocytomas, and no effective treatment has been established for malignant pheochromocytoma if it is associated with multiple organ metastases before surgery. We experienced a rare case of giant malignant pheochromocytoma with coexistence of poorly differentiated neuroendocrine tumor and its hepatic metastasis. A 37-year-old man was seen at the hospital because of left lateroabdominal pain. At initial visit, a giant tumor 17cm in diameter was noted in the retroperitoneum. The patient also had attacks of hypertension. With close examination, the tumor was diagnosed as pheochromocytoma. Besides the tumor, scattered tumors were observed in the liver, indicating malignant pheochromocytoma. The tumor was extirpated. Histopathologic examination of the specimen revealed malignant pheochromocytoma with coexistence of poorly differentiated neuroendocrine tumors. Only poorly differentiated neuroendocrine tumors occurred in the hepatic metastatic foci. Although the origin of pheochromocytoma is still obscure, here we report this valuable case of malignant pheochromocytoma with neuroendocrine tumors which may be involved in the genesis of the disease.

1980年～1991年に当教室で施行されたstage II～IIIb下部直腸癌症例においてD3郭清と不完全なD2 (inD2) 郭清が施行され, 術後遠隔転移再発が認められない65例を対象として側方リンパ節郭清の意義について検討した. inD2郭清とは内腸骨動脈の前面に沿った郭清で, 内腸骨動脈を全周性には郭清していないものである. stage IIにおいてinD2郭清施行群とD3郭清施行群で累積生存率に有意差は認められなかった. よって壁深達度が固有筋層を越えている症例でリンパ節転移が認められなければ, inD2郭清で十分な根治性が得られるものと考えられた. stage IIIa, bではD3郭清施行群のほうがinD2郭清施行群より5生率で有意 (p

A 48-year-old woman was admitted to the hospital because of intestinal obstruction. A long intestinal tube was inserted for aspiration therapy. Symptomatic remission was attained temporarily, but on the fourth day after the insertion the patient had a pain in the left upper abdomen and a tumor was palpated in the same region. Emergency abdominal ultrasonography and CT revealed invagination of the intestine at where the tube was induwelled. Emergecy operation was performed. At about 70cm from the ligament of the Treitz, the jejunum on the anal side. Invagination was reduced and the necrosed intestine was resected. Simultaneously, a cancer was observed in the splenic flexure of the trnsverse colon, and a exision of the colon was performed. In this paper a case of invagination probably caused by a long intestinal tube is reported.

大腸原発, 特にS状結腸原発悪性リンパ腫はまれな疾患である.なかでもT細胞性リンパ腫は極めてまれである.今回われわれは, 術前に悪性リンパ腫が強く疑われたS状結腸穿孔例を経験したので報告する.症例は72歳の男性, 左下腹部痛を主訴に他院受診の後, 当院紹介入院となった.術前超音波および注腸にてS状結腸悪性リンパ腫を疑い, 同部に穿孔を認めたため, S状結腸切除およびドレナージ術を施行した.術後病理学的に多発性の高悪性度群, 多形細胞大細胞型T細胞性悪性リンパ腫と診断された.悪性リンパ腫と, 炎症性腸疾患, 癌との鑑別診断に腹部超音波検査と注腸は有用であった.術後下行結腸残存悪性リンパ腫に化学療法を施行するもほとんど効果なく, 再度腫瘍部穿孔による腹膜炎となり左半結腸切除およびドレナージ術を施行した.T細胞性リンパ腫はB細胞性リンパ腫に比べて予後不良であり, 少なくとも所属リンパ節を含めた原発巣の手術的切除が必要である.

We experienced a case of malignant phyllodes tumor requiring an emergency operation for bleeding. A 44-year-old woman was referred to the hospital because of a recently enlarging tumor of the left breast. There was a previous history of undergoing an excisional biopsy for a left breast tumor existing at the same area which was diagnosed as benign phyllodes tumor at another hospital 4 years and 7 months before. After admission, a 12×9cm soft tumor of the left breast was palpated. Numerous hematomas were noted on ultrasonography, which were drained from an incision of the tumor, yielding approximately 100ml of bloody fluid. After 7 days, the tumor appeared to be infected and the patients' anemia was worsening. An emergency simple mastectomy was performed. Histologically the resected specimen showed a malignant phyllodes tumor. In this case, it appeared that the remnant of benign phyllodes tumor became malignant and developed intratumorous hemorrhage. Wide excision of a tumor including surrounding tissues and close follow up may therefore be indicated for cases diagnosed as benign phyllodes tumor.

大建中湯の消化管運動に対する作用およびイレウス治療に対する有用性について検討した. 方法: 意識下の雑種成犬4頭を用いて, 大建中湯投与前後の消化管運動をstrain gauge transducer法により測定した. さらに, xylocaineにより胃粘膜を麻酔した後に同量の大建中湯を投与した. 臨床的検討として, イレウスにて入院となった患者の在院日数を大建中湯投与群と非投与群で比較検討した. 結果: 大建中湯の投与後, 胃, 十二指腸, 空腸および回腸の運動亢進が観察された. 胃粘膜麻酔後には, これらの消化管運動亢進作用はまったく認められなかった. 臨床的検討では, 大建中湯投与群の在院日数は21.8±2.4日で非投与群は, 27.7±2.9日で両群間に有意の差を認めた. 結論: 大建中湯は, 粘膜刺激を介して, 強い上部消化管運動亢進作用を有する. この大建中湯の薬理作用および作用機序は, 臨床的にイレウス治療に対して十分応用価値があるものと考えられた.