Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本腹部救急医学会  

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Ulcerative colitis-associated neoplasia (UCAN) harbors unique genetic alterations and mutational tendencies. The clinical application of gene panel testing enables precision medicine by tailoring treatment to individual gene alterations. We hypothesized that gene panel testing may detect clinically important genetic alterations in UCAN, with potential usefulness for the diagnosis and treatment of UCAN. In the present study, gene panel testing was used to identify genetic alterations in UCAN, and the possibility of clinical utility of gene panel testing in UCAN was investigated. The present study included 15 patients with UCAN, and gene panel testing was performed to identify genetic alterations associated with diagnosis and treatment. Genetic alterations of UCAN were compared with those of 203 patients with sporadic colorectal cancer (CRC). APC and PTEN mutations were less frequent, while RNF43 frameshift or nonsense mutations were more frequent in UCAN compared with sporadic CRC. TP53 mutations were identified in 13/15 patients (87%) with UCAN. Notably, 4/15 patients (27%) with UCAN had no genetic alterations other than TP53 mutation, while this occurred in 1/203 patients (0.5%) with sporadic CRC (P<0.001). Microsatellite instability-high was identified in 2/15 patients (13%) with UCAN. Mutational signature 3, which is associated with homologous recombination deficiency, was detected in 14/15 patients (93%) with UCAN, and enriched in UCAN compared with sporadic CRC (P=0.030). In conclusion, gene panel testing can detect important genetic alterations that can be useful for diagnosis and treatment in UCAN, and may provide clinicians with important information for tailored treatment strategies.

DOI： 10.3892/ol.2022.13562

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A woman in her 60s had been aware of perianal erosions for 1 month. Skin biopsy showed Paget's cells in the stratified squamous epithelium, and immunohistochemistry showed negative staining for CK7 and positive staining for CK20. Colonoscopy revealed well-differentiated adenocarcinoma in the anal canal. Computed tomography showed neither regional lymph node metastasis nor distant metastasis. Hence, she was diagnosed with anal canal carcinoma with pagetoid spread. We determined the extent of resection of the skin lesion preoperatively by mapping biopsy, and performed laparoscopic abdominoperineal resection. The pathological findings revealed adenocarcinoma(tub1, tub2), and the skin resection margin was negative. Immunohistochemistry for Paget's cells in the stratified squamous epithelium showed negative staining for GCDFP-15 and CK7, and positive staining for CK20. Twenty-four months after surgery, we detected right inguinal lymph node metastasis and performed right inguinal lymphadenectomy. As of 4 months after the lymphadenectomy, no local recurrence or distant metastasis has been detected during follow-up examinations.

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Language：Japanese   Publishing type：Research paper (scientific journal)  

The patient was a 71-year-old man with a diagnosis of duodenal carcinoma. Abdominal computed tomography(CT) showed no distant metastasis, and he underwent subtotal stomach-preserving pancreaticoduodenectomy. Postoperative adjuvant chemotherapy was not administered. A left supraclavicular lymph node recurrence was detected on CT 15 months after surgery. Capecitabine and oxaliplatin(CAPOX)therapy was administered and the metastatic lesion shrank. Positron emission tomography(PET)-CT showed no lesions at other sites and left cervical lymph node dissection was performed 5 months after the recurrence. Postoperative adjuvant therapy with S-1 was administered for 6 months. However, 2 years and 10 months after the first recurrence, CT showed recurrence in the left supraclavicular lymph node. CAPOX therapy was resumed, but due to an allergic reaction to oxaliplatin, the patient was treated with capecitabine alone. The recurrent lesion was gradually increased in size, and FOLFIRI therapy was introduced. One year and 5 months after secondary recurrence, PET-CT showed that the second recurrent lesion had grown but was confined to the left supraclavicular lymph node, so radiation therapy(60 Gy)to the left neck was performed. The disease was stable for about 10 months and chemotherapy could be discontinued. The lesion increased in size thereafter, and the patient died 7 years after initial surgery.

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A 71-year-old man with middle thoracic esophageal cancer was treated with neoadjuvant chemotherapy using docetaxel plus 5-FU plus cisplatin therapy and was also administered pegfilgrastim. Blood tests showed elevated white blood cell counts and C-reactive protein levels before the start of the third course. Contrast-enhanced computed tomography revealed wall thickening of the aortic arch. We diagnosed this as aortitis due to pegfilgrastim. Inflammation was improved with conservative treatment. We then performed video-assisted thoracoscopic esophagectomy. Drug-induced vasculitis should be included in the differential diagnosis of patients with elevated inflammation markers of unknown cause following the administration of granulocyte colony-stimulating factor preparations.

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：English   Publisher：(一社)日本癌治療学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Gastric cancer is a Lynch syndrome (LS)-associated tumor, with the cumulative lifetime risk in LS patients estimated to be 5.8-13%. Hence, surveillance for gastric cancer is important for LS patients, especially in those with a family history of gastric cancer or of Asian descent. We report a very rare case of a LS patient who showed gastric metastasis from jejunal adenocarcinoma curatively resected 8 years prior. A 79-year-old female was diagnosed with a synchronous gastric submucosal tumor (SMT) and right-sided colon cancer. She was referred to our hospital as she and her family had histories of LS-associated tumors. She underwent curative intent surgery for the tumors. Postoperative histopathological examination revealed the gastric SMT was an adenocarcinoma completely covered by non-neoplastic gastric mucosa. Immunohistochemical analyses showed the gastric SMT had the same expression pattern for CDX2, cytokeratins 7 and 20 as the jejunal adenocarcinoma. Thirty-four months after surgery the patient is alive without recurrence or any other LS-associated tumors. To the best of our knowledge, this is the first report of gastric metastasis from small bowel adenocarcinoma in a LS patient. Awareness of this case may be important for gastric cancer surveillance in LS patients.

DOI： 10.1007/s12328-022-01625-5

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Language：Japanese   Publisher：新潟医学会  

【目的】消化器外科術後に発症した播種性血管内凝固(disseminated intravascular coagulation;以下,DICと略記)に対する遺伝子組み換えトロンボモジュリン(recombinant human soluble thrombomodulin;以下,rTMと略記)の効果を検証し,治療成績改善に向けた方策を考察する.【方法】2016年1月から2021年5月に当科で消化器外科術後DICの改善を目的にrTMが投与された48例を対象とした.対象症例におけるDICの改善効果,および在院死亡の危険因子を検証した.DICの診断には,日本救急医学会の急性期DIC診断基準を使用した.患者背景および検査項目に関する2群間のカテゴリー変数の比較にはPearsonのχ2検定,Fisherの直接法を用いた.多変量解析はstepwise法によるロジスティック回帰分析を用いて行った.生存曲線はKaplan-Meier法で算出し,log rank検定で有意差検定を行った.有意水準5%(P<0.05)をもって有意差ありと判断した.【結果】年齢の中央値は76歳(59-91),男女比は21:27であった.原疾患は下部消化管穿孔が22例(45.8%),悪性腫瘍が11例(22.9%),消化管虚血が10例(20.8%),上部消化管穿孔が5例(10.4%)であった.DICを発症した原因は,急性汎発性腹膜炎が38例(79.2%),術後感染症が5例(10.4%),術後肝不全が4例(8.3%),術後出血が1例(2.1%)であった.rTM投与開始後7日目に28例(58.3%)で血小板数増加を認め,31例(64.6%)でDICスコアの改善を認めた.投与開始後28日の生存率は72.9%で,在院死亡率は41.7%であった.在院死亡群と生存群における比較では,在院死亡群において「悪性疾患あり」(P=0.034),「DICの原因が術後肝不全」(P=0.025),rTM投与開始時の「血小板数5万/μl未満」(P=0.009),「総ビリルビン2.0mg/dl以上」(P=0.002),rTM投与開始後7日目の「血小板数増加なし」(P=0.001),「DICスコア改善なし」(P=0.003)の占める割合が高かった.多変量解析ではrTM投与開始後7日目の「血小板数増加なし」(HR 5.076:95%CI 1.145-22.222:P=0.032)が独立した在院死亡の危険因子であった.【結語】消化器外科術後に発症するDICは極めて予後不良な病態であるが,rTM投与開始後早期に血小板数の増加を認めた場合,予後の改善を期待できる可能性がある.(著者抄録)

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Objectives: Diversion colitis (DC) is an inflammatory disorder caused by interruption of the fecal stream and subsequent nutrient deficiency from luminal bacteria. The utility of fecal microbiota transplantation (FMT) for DC was recently investigated; however, the precise pathogenesis of this condition remains unclear. This study aimed to evaluate the utility of autologous FMT in DC and to determine the related changes in the intestinal microbiota. Methods: Autologous FMT was performed to reestablish the intestinal microbiota in five patients (average age, 64.6 ± 8.3 years) with DC. They underwent double-ended colostomy. We assessed the diverted colon by endoscopy and evaluated the microbiota before and after FMT using the 16S rRNA gene sequencing method. Results: All five patients had mild inflammation (ulcerative colitis endoscopic index of severity [UCEIS] 2-3) in the diverted colon based on the colonoscopic findings. Three patients presented with symptoms, such as tenesmus, mucoid stool, and bloody stool. With FMT treatment, all patients achieved endoscopic remission (UCEIS score of 0 or 1) and symptomatic improvement. We observed a significantly decreased α-diversity in DC patients compared to healthy controls. The frequency of aerobic bacteria, such as Enterobacteriaceae, in the diverted colon decreased after autologous FMT. Conclusions: This study was the first to show that the microbiota in the diverted colon was significantly affected by autologous FMT. Since interruption of the fecal stream is central to the development of DC, FMT can be considered a promising treatment.

DOI： 10.1002/deo2.63

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DOI： 10.1007/s00595-022-02466-y

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 72-year-old man had a chief complaint of anal pain and difficulty in defecation. He was diagnosed with adenocarcinoma by biopsy from a tumor of the anal canal. A computed tomography scan revealed neither regional lymph node metastasis nor distant metastasis. Hence, he was diagnosed with cT3N0M0, cStage Ⅱa anal canal cancer. Preoperative capecitabine- based chemoradiotherapy(CRT)(50.4 Gy in 28 fractions of 1.8 Gy each)was implemented. Digital rectal examination and imaging evaluation 8 weeks after preoperative CRT revealed that the tumor had shrunk. Fifteen weeks after preoperative CRT, laparoscopic abdominoperineal resection was performed. The pathological findings showed mucinous adenocarcinoma associated with anal fistula. At present, 12 months after the operation, no local recurrence and distant metastasis has been detected under follow-up evaluations.

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は72歳、男性。肛門痛と排便困難を主訴に来院した。肛門管内に腫瘤を認め、生検で腺癌と診断された。胸腹骨盤部CT検査の結果、遠隔転移を認めず、肛門管癌、cT3N0M0、cStage IIaと診断された。術前化学放射線療法(chemoradiotherapy:CRT)(capecitabine併用、1.8Gy28回、50.4Gy)を施行した。術前CRT8週間後、骨盤部CT検査にて縮小率34%とPR判定であった。術前CRTから15週間後に腹腔鏡下腹会陰式直腸切断術を施行した。病理組織学的診断では、組織型はadenocarcinoma(muc、tub1)であり、肛門周囲皮膚と肛門管重層扁平上皮の境界相当部から直腸粘膜に連続する痔瘻様上皮嵌入部に癌の上皮内病変を認めた。周囲に粘液癌を主体とする浸潤癌を認め、痔瘻癌と診断された。術後12ヵ月となる現在まで無再発生存中である。(著者抄録)

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 62-year-old man was incidentally found to have a pancreatic tumor by CT. He was diagnosed with pancreatic cancer by EUS-FNAB. Gemcitabine(GEM)plus nab-paclitaxel(PTX)was started as neoadjuvant chemotherapy(NAC)for resectable pancreatic cancer. However, after the end of the second course, the tumor grew rapidly and invaded the stomach, so NAC was discontinued, and surgery was performed. The pathological diagnosis was anaplastic ductal carcinoma of the pleomorphic cell type, and the histological response was Grade 1a. Multiple liver metastases appeared during adjuvant chemotherapy with S-1, so GEM plus nab-PTX and modified FOLFIRINOX were administered, but the therapeutic response was poor, the patient died 9 months after surgery. Anaplastic carcinoma has a poor response to chemotherapy and may be included with cancers showing treatment resistance to NAC, as seen in our case. It is necessary to pay attention to anaplastic carcinoma during the course of NAC for pancreatic cancer.

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Language：Japanese   Publisher：(株)癌と化学療法社  

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BACKGROUND: Tumor mutational burden-high (TMB-H), which is detected with gene panel testing, is a promising biomarker for immune checkpoint inhibitors (ICIs) in colorectal cancer (CRC). However, in clinical practice, not every patient is tested for TMB-H using gene panel testing. We aimed to identify the histopathological characteristics of TMB-H CRC for efficient selection of patients who should undergo gene panel testing. Moreover, we attempted to develop a convolutional neural network (CNN)-based algorithm to predict TMB-H CRC directly from hematoxylin and eosin (H&E) slides. METHODS: We used two CRC cohorts tested for TMB-H, and whole-slide H&E digital images were obtained from the cohorts. The Japanese CRC (JP-CRC) cohort (N = 201) was evaluated to detect the histopathological characteristics of TMB-H using H&E slides. The JP-CRC cohort and The Cancer Genome Atlas (TCGA) CRC cohort (N = 77) were used to develop a CNN-based TMB-H prediction model from the H&E digital images. RESULTS: Tumor-infiltrating lymphocytes (TILs) were significantly associated with TMB-H CRC (P < 0.001). The area under the curve (AUC) for predicting TMB-H CRC was 0.910. We developed a CNN-based TMB-H prediction model. Validation tests were conducted 10 times using randomly selected slides, and the average AUC for predicting TMB-H slides was 0.934. CONCLUSIONS: TILs, a histopathological characteristic detected with H&E slides, are associated with TMB-H CRC. Our CNN-based model has the potential to predict TMB-H CRC directly from H&E slides, thereby reducing the burden on pathologists. These approaches will provide clinicians with important information about the applications of ICIs at low cost.

DOI： 10.1007/s00535-021-01789-w

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BACKGROUND: Mesenteric lymph node (MLN) involvement is often observed in ovarian cancer (OC) with rectosigmoid invasion. This study aimed to investigate the clinical significance of MLN involvement in the pattern of liver metastasis in patients with OC. METHODS: We included 85 stage II-IV OC patients who underwent primary or interval debulking surgery. Twenty-seven patients underwent rectosigmoid resection, whose status of MLN involvement was judged from hematoxylin and eosin (H&E) staining of resected specimens. The prognostic significance of clinicopathological characteristics, including MLN involvement, was evaluated using univariate and multivariate analyses. RESULTS: MLN involvement was detected in 14/85 patients with stage II-IV OC. Residual tumor status, cytology of ascites, and MLN involvement were independent prognostic factors for progression-free survival (PFS; p = 0.033, p = 0.014, and p = 0.008, respectively). When patients were classified into three groups (no MLN, one MLN, two or more MLNs), the number of MLNs involved corresponded to three distinct groups in PFS (p = 0.001). The 3-year cumulative incidence of liver metastasis of patients with MLN involvement was significantly higher than that of patients without MLN involvement (61.1% vs. 8.9%, p < 0.001). MLN involvement was significantly associated with liver metastasis of hematogenous origin (p < 0.001) compared with peritoneal disseminated origin. CONCLUSION: MLN involvement is an important prognostic factor in OC, predicting poor prognosis and liver metastasis of hematogenous origin.

DOI： 10.1245/s10434-021-09899-8

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DOI： 10.1111/1346-8138.15800

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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DOI： 10.1245/s10434-021-09919-7

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AIM: The role of preoperative frailty assessment in patients with gastrointestinal (GI) disease remains unclear. This study aimed to clarify the relationship between frailty and postoperative outcomes in patients with GI disease. METHODS: This study investigated 42 patients (aged ≥65 years) with GI disease who underwent abdominal surgery. The frailty status was analyzed using the Japanese version of the Cardiovascular Health Study criteria. We also investigated postoperative outcomes. RESULTS: Of the 42 patients, seven (16.7%) were robust, 24 (57.1%) were prefrail and 11 (26.2%) were frail. Postoperative complications were observed in 45.5% and 63.6% of prefrail and frail patients, respectively, whereas no complications were found in robust patients (P = 0.026). The median hospital stay was 15, 19.5 and 27 days in robust, prefrail and frail patients, respectively (P < 0.01). CONCLUSION: Preoperative frailty status based on the Japanese version of the Cardiovascular Health Study criteria is associated with postoperative complication incidence and hospital stay extension in patients with GI disease. Geriatr Gerontol Int 2021; ••: ••-••.

DOI： 10.1111/ggi.14134

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It is reported that an increase in aerobic bacteria, a lack of short-chain fatty acids (SCFAs), and immune disorders in the diverted colon are major causes of diversion colitis. However, the precise pathogenesis of this condition remains unclear. The aim of the present study was to examine the microbiota, intestinal SCFAs, and immunoglobulin A (IgA) in the diverted colon. Eight patients underwent operative procedures for colostomies. We assessed the diverted colon using endoscopy and obtained intestinal samples from the diverted colon and oral colon in these patients. We analyzed the microbiota and SCFAs of the intestinal samples. The bacterial communities were investigated using a 16S rRNA gene sequencing method. The microbiota demonstrated a change in the proportion of some species, especially Lactobacillus, which significantly decreased in the diverted colon at the genus level. We also showed that intestinal SCFA values were significantly decreased in the diverted colon. Furthermore, intestinal IgA levels were significantly increased in the diverted colon. This study was the first to show that intestinal SCFAs were significantly decreased and intestinal IgA was significantly increased in the diverted colon. Our data suggest that SCFAs affect the microbiota and may play an immunological role in diversion colitis.

DOI： 10.1016/j.bbrep.2020.100892

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Language：Japanese   Publisher：(一社)日本内視鏡外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 64-year-old man with liver dysfunction was given a diagnosis of perihilar cholangiocarcinoma(Bismuth type Ⅳ). The tumor was predominantly right-sided and invaded to the bifurcation of the right and left portal veins. After confirming sufficient liver functional reserve and future liver remnant, the patient underwent extended right hepatectomy, extrahepatic bile duct resection, and portal vein resection and reconstruction. Intraoperative examination of frozen sections revealed the presence of residual invasive carcinoma on both the hepatic and duodenal sides of the ductal resection margins. However, we did not perform pancreaticoduodenectomy or additional resection of the margin-positive proximal bile duct considering the curability and invasiveness of these procedures. He received postoperative chemotherapy with biweekly gemcitabine plus cisplatin for 1 year, followed by gemcitabine monotherapy for 1 year, and S-1 monotherapy has been performed since then. He remains alive and well with no evidence of disease 63 months after surgery.

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症例は64歳、男性。肝機能障害の精査で肝門部領域胆管癌と診断された。腫瘍は右側優位のBismuth分類IV型で、門脈右枝〜左右分枝への浸潤が認められた。肝予備能、残肝容積は十分であり、拡大肝右葉切除術+肝外胆管切除術+門脈合併切除術が実施された。術中迅速組織診断で十二指腸側・肝側胆管切離断端がともに浸潤癌陽性となったが、進行度や侵襲度を勘案し、膵頭十二指腸切除術の追加や左肝管断端の追加切除は行わなかった。最終的な進行度はpT4b、pN0、cM0、Stage IV A、pDMI(w)、pHM1(w)、pPV1(a)、R1であった。術後化学療法としてgemcitabine(GEM)+cisplatin療法を1年、GEM療法を1年実施した後、S-1療法を継続している。術後5年3ヵ月経過した現在、無再発生存中である。(著者抄録)

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症例は72歳、男性。下血を主訴に来院し、大腸内視鏡検査で肛門縁から5cmの直腸前壁に下縁を有する2型腫瘍を指摘された。生検で高分化管状腺癌であった。術前胸腹骨盤部CT検査の結果遠隔転移は認めず、下部直腸癌、cT3N0M0、cStage IIaと診断された。術前の全身検査で徐脈性心房細動および重症肺気腫を認め、全身麻酔のリスクが高い症例と判断された。ペースメーカー留置後、術前化学放射線療法(CRT)(capecitabine併用、1.8Gy28回、計50.4Gy)を開始した。術前CRT後4週間目の直腸診および画像評価では腫瘍は消失し、生検で悪性所見を認めなかった。十分なインフォームド・コンセントの下、全身麻酔のリスクを勘案し、"watch and wait治療"の方針とした。現在、術前CRT後15ヵ月経過し局所の再増大および遠隔転移を認めず、経過観察を行っている。(著者抄録)

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A 72-year-old man was referred to our hospital for treatment for rectal cancer. Digital rectal examination and colonoscopy revealed a 4 cm tumor located at the anterior rectal wall 5 cm away from the anal verge, and pathological examination confirmed that the tumor was adenocarcinoma. A computed tomography scan detected neither regional lymph node metastasis nor distant metastasis. Hence, he was diagnosed with cT3N0M0, cStage Ⅱa rectal cancer. The preoperative general examination revealed bradyarrhythmia and severe emphysema, and he was considered to be high risk for general anesthesia. After placement of a pacemaker, preoperative capecitabine-based chemoradiotherapy(CRT)(50.4 Gy in 28 fractions of 1.8 Gy each)was implemented. The digital rectal examination and imaging evaluation 4 weeks after preoperative CRT revealed that the tumor disappeared, and pathological examination showed no malignant findings. Considering the risks of general anesthesia, the"watch and wait therapy"approach was adopted with sufficient informed consent. At present, 15 months after preoperative CRT, no evidence of regrowth or distant metastasis has been detected under rigorous follow- up evaluations.

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PURPOSE: The 9th Japanese Classification of Colorectal Cancer (9th JSCCR) has two main differences from the TNM classification (8th AJCC): first, main or lateral lymph node metastasis is classified as jN3; second, tumor nodules (ND) are treated as lymph node metastasis. In this study, we verified the 9th JSCCR for rectal cancer, focusing on the differences with the 8th AJCC. METHODS: This retrospective analysis involved 212 patients with stage I-III rectal cancer. ND was evaluated using whole-mount sections. We evaluated the relapse-free survival of each staging system, and compared the prognostic significance of the different staging systems using the Akaike information criterion (AIC) and Harrell's concordance index (c-index). RESULTS: Main or lateral lymph node metastasis was detected in nine of 212 (4%) patients. ND was detected in 79 of 212 (37%) patients. The best risk stratification power was observed in the 9th JSCCR (AIC, 759; c-index, 0.708) compared with the 7th JSCCR (AIC, 771; c-index, 0.681), 8th JSCCR (AIC, 768; c-index, 0.696), and the 8th AJCC (AIC, 766; c-index, 0.691). CONCLUSIONS: The 9th JSCCR, which includes the concepts of jN3 and ND, is useful for the risk stratification of rectal cancer, and the contributes to precise decision-making for follow-up management and adjuvant therapy.

DOI： 10.1007/s00595-020-02024-4

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Language：Japanese   Publisher：日本消化器病学会-甲信越支部  

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Language：Japanese   Publisher：日本消化器病学会-甲信越支部  

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Language：Japanese   Publisher：日本消化器病学会-甲信越支部  

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Language：Japanese   Publisher：日本消化器病学会-甲信越支部  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publishing type：Research paper (scientific journal)  

Here, we report about a woman in her 30s who had peritoneal dissemination and multiple colon cancer with high-frequency microsatellite instability(MSI-H). Her father, paternal grandfather, and maternal grandmother had a history of colorectal cancer treatment. Thus, Lynch syndrome was suspected. We performed R0 resection for peritoneal dissemination and subsequent peritoneal dissemination. A 435-gene panel testing using a next-generation sequencer identified MSH2 and other mutations in the tumor. Hence, we speculated that she could have a germline mutation of MSH2, which causes Lynch syndrome. In the future, if she wishes to receive genetic counseling and undergo germline testing for variants to confirm the diagnosis of Lynch syndrome, we will perform them after receiving informed consent.

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PURPOSE: Treatment strategies of rectal cancer differ between tumors located above (RS/Ra) and below (Rb) the peritoneal reflection. Based on the extent of distal spread (DS), the Japanese Society for Cancer of Colon and Rectum proposed an optimal distal margin in RS/Ra and Rb tumors. In this study, we investigated the clinical significance of DS between RS/Ra and Rb tumors. METHODS: We analyzed 287 stage I-III rectal cancer patients who underwent curative intent resection without preoperative therapy. DS and other pathological factors were evaluated using whole-mount sections. To investigate the clinical significance of DS in RS/Ra and Rb tumors, clinicopathological variables, including DS, were analyzed for the survival outcome according to the tumor group. RESULTS: DS was detected in 20 out of 185 (11%) patients with RS/Ra tumors and 8 out of 102 (8%) patients with Rb tumors. DS was not significantly associated with the overall survival (OS) or relapse-free survival (RFS) in RS/Ra tumors, but was an independent prognostic factor for the OS and RFS in Rb tumors (P = 0.002 and 0.007, respectively). CONCLUSIONS: The clinical significance of DS differs between RS/Ra and Rb tumors. DS is associated with a worse survival in Rb tumors, but not in RS/Ra tumors.

DOI： 10.1007/s00595-019-01882-x

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Introduction: There are no specific standards for the timing of surgery to treat ulcerative colitis, so reaching a decision on timing is often difficult. Objective: The aim of this study was to evaluate the timing of surgery from the patients' perspective. Methods: From among 203 patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis to treat ulcerative colitis at our hospital from 1985 to 2013, we mailed a questionnaire to 101 of those who are currently attending periodic follow-up at our hospital. Results: We analyzed 72 valid responses (71.2%). Overall, 65 patients (90.3%) responded that they were happy that they underwent surgery, 38 patients (52.8%) responded that the timing of surgery was appropriate, and 32 patients (44.4%) responded that they would have preferred to have had surgery earlier. The group of patients who would have preferred to have had surgery earlier included 23 patients (71.9%) who had undergone emergency surgery; the incidence of emergency surgery was significantly higher than in the group of 13 patients (34.2%) who had responded that the timing of surgery was appropriate (p = 0.002). Scores on the Medical Outcomes Study 36-Item Short-Form Health Survey (SF36), which reflect postoperative quality of life, were maintained at the same level as the Japanese standard values in our Japanese patients. Conclusion: The degree of satisfaction of patients who underwent surgery for ulcerative colitis was favorable, although it is important to consider surgery at an earlier stage in patients who may need emergency surgery.

DOI： 10.1159/000504885

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Right-sided colorectal cancer (RCRC) demonstrates worse survival outcome compared with left-sided CRC (LCRC). Recently, the importance of RNF43 mutation and BRAF V600E mutation has been reported in the serrated neoplasia pathway, which is one of the precancerous lesions in RCRC. It was hypothesized that the clinical significance of RNF43 mutation differs according to primary tumor sidedness. To test this hypothesis, the clinicopathological characteristics and survival outcome of patients with RNF43 mutation in RCRC and LCRC were investigated. Stage I-IV CRC patients (n=201) were analyzed. Genetic alterations including RNF43 using a 415-gene panel were investigated. Clinicopathological characteristics between RNF43 wild-type and RNF43 mutant-type were analyzed. Moreover, RNF43 mutant-type was classified according to primary tumor sidedness, i.e., right-sided RNF43 mutant-type or left-sided RNF43 mutant-type, and the clinicopathological characteristics between the two groups were compared. RNF43 mutational prevalence, spectrum and frequency between our cohort and TCGA samples were compared. RNF43 mutation was observed in 27 out of 201 patients (13%). Multivariate analysis revealed that age (≥65), absence of venous invasion, and BRAF V600E mutation were independently associated with RNF43 mutation. Among the 27 patients with RNF43 mutation, 12 patients were right-sided RNF43 mutant-type and 15 left-sided RNF43 mutant-type. Right-sided RNF43 mutant-type was significantly associated with histopathological grade 3, presence of lymphatic invasion, APC wild, BRAF V600E mutation, microsatellite instability-high (MSI-H), and RNF43 nonsense/frameshift mutation compared with left-sided RNF43 mutant-type. Similarly, RNF43 nonsense/frameshift mutations were more frequently observed in RCRC compared with LCRC in the TCGA cohort (P=0.042). Right-sided RNF43 mutant-type exhibited significantly worse overall survival than RNF43 wild-type and left-sided RNF43 mutant-type (P=0.001 and P=0.023, respectively) in stage IV disease. RNF43 mutation may be a distinct molecular subtype which is associated with aggressive tumor biology along with BRAF V600E mutation in RCRC.

DOI： 10.3892/or.2020.7561

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Language：Japanese   Publisher：(一社)日本内視鏡外科学会  

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A 62-year-old man was admitted with complaints of bloody stool. Colonoscopy revealed a 5 cm diameter type 2 tumor in the lower rectum close to the anal canal. Tumor biopsy indicated a well-differentiated tubular adenocarcinoma. Computed tomography revealed locally advanced rectal cancer with mesorectal lymph node metastases(cT3N1P0M0, Stage Ⅲa, JSCCR 8th). The patient was treated with neoadjuvant chemotherapy(NAC)after transverse colostomy as an anus-preserving procedure. For the NAC, 12 courses of capecitabine plus oxaliplatin(CapeOX)and bevacizumab(BV)were administered. Colonoscopy after NAC revealed that the main tumor had considerably shrunk. No malignant tissues were found on biopsy. However, rectal wall thickness remained unchanged. Therefore, response evaluation for chemotherapy indicated partial response. Intersphincteric resection(ISR)with diverting loop ileostomy was performed as an anus-preserving surgical procedure. No remnant tumor in the rectum or lymph node metastases were found upon the pathological examination of resected specimens. Ileostomy closure was performed at 6 months post-ISR. At 12 months post-ISR, the patient was well and showed no signs of recurrence. This case demonstrated that NAC with CapeOX and BV can be a promising option for treating locally advanced lower rectal cancer and preserving the anus.

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A 65-year-old woman was referred for further examination following positive results on a fecal occult blood test. Colonoscopy revealed type 0-Ⅱa cancer, with a lesion measuring 2 cm in diameter in the rectosigmoid colon, and type 5 cancer, with a lesion measuring 6 cm in diameter in the upper rectum. Computed tomography(CT)and positron emission tomography (PET)-CT revealed mesorectal lymph node metastases. Therefore, she was diagnosed with rectosigmoid colon cancer(Stage Ⅰ)and upper rectal cancer(Stage Ⅲa). However, PET-CT also revealed slight fluorodeoxyglucose uptake in the paraaortic and lateral lymph node lesions; hence, the possibility ofmetastasis could not be ruled out. Given that chemotherapy was restricted due to renal dysfunction, low anterior resection was performed as the first choice. Analysis of intraoperative frozen sections showed paraaortic and lateral lymph node metastases; thus, we performed lymph node dissection of these lesions. Pathological examination ofthe resected lymph nodes revealed that 21 of 37 lesions were cancer metastases. S-1 was administered as adjuvant chemotherapy for 5 months. Mediastinal lymph node metastases was suspected on chest CT 5 months and 3 years post-surgery; thus, panitumumab was administrated. These lymph nodes decreased in size immediately. Six years after the first surgery, the patient was well without any signs of recurrence.

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 37-year-old man was admitted to our hospital for the treatment of familial adenomatous polyposis and rectal carcinoma. He underwent total colectomy with ileoanal anastomosis(pT3N1M0, pStage Ⅲa)followed by adjuvant therapy with S-1. Three months after primary surgery, CT and MRIrevealed liver metastases(S5, S6). Laparoscopic partial hepatectomy was performed. Two years after primary surgery, new liver metastases(S2, S8)were found and we performed open partial hepatectomy and administered mFOLFOX6. Three years and 5 months after primary surgery, right lung metastases(S6, S9) were detected and the patient underwent a thoracoscopic-assisted right lung wedge resection. Repeated resection of metastases might have contributed to the long-survival in our case.

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AIM: This study aimed to determine surgical outcomes in patients with gynecological cancers for whom surgery was performed by gynecologists and digestive surgeons. METHODS: Seventy-three patients who underwent surgery for a gynecological malignant tumor from January 2010 to December 2014 were included in this retrospective study. Data on the definitive diagnosis, operative procedures, postoperative complications, stoma settings, length of hospital stay, and prognosis was collected for each patient. RESULTS: The median age of this female-only cohort was 60 years. Emergency surgery was performed in 8(11.0%)patients. Ovarian cancer was diagnosed in 56(76.7%)patients, and among these patients, the clinical disease Stage was Ⅰ, Ⅱ, Ⅲ, and Ⅳ in 4, 4, 20, and 11 patients, respectively. Moreover, 17 patients had recurrent ovarian cancer. Intestinal resection with anastomosis was performed in 25(34.2%)patients. Stoma formation was performed in 22 (30.1%)patients, however no patient underwent stoma closure surgery in the current study. The median operative time was 252 minutes, and the median blood loss was 1,190 mL. Regarding postoperative complications, ileus, pelvic abscess, and anastomotic leakage developed in 6(8.2%), 4(5.5%), and 2(2.7%)patients, respectively. The postoperative median survival time in patients with ovarian cancer was 1,399 days. CONCLUSION: These results suggest that tumor debulking, including intestinal tract resection, may contribute to the prolonged prognosis of gynecological tumors, although stoma closure is difficult to perform.

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Study Design: Case-control study. Objectives: To determine the possible pathogenesis of ossification of the posterior longitudinal ligament (OPLL) in regard to the serum concentration of fibroblast growth factor 23 (FGF-23). Methods: The study included 95 patients with OPLL and a control group of 73 age- and sex-matched volunteers. The serum concentrations of FGF-23, creatinine (Cre), alkaline phosphatase, calcium (Ca), inorganic phosphate (Pi), and hypersensitive C-reactive protein (hs-CRP) were analyzed from blood samples, and Cre, Ca, Pi, and tubular reabsorption of phosphate were measured using urine samples. We evaluated the severity of ossified spinal lesions in patients with OPLL according to the ossification index (the OP index and the OS index). Data was compared between the OPLL and control group and between the OPLL progression and no progression group. Results: Serum FGF-23 and hs-CRP were higher, and serum Pi was lower in patients with OPLL than in the controls. There was a positive correlation between FGF-23 and hs-CRP and a negative correlation between serum Pi and the OS index; however, the correlations were very weak. Overall, 31.7% of patients had progression of OPLL during follow-up. FGF-23 and hs-CRP were higher in the progression group than in the no progression group. Conclusions: These results might indicate that FGF-23 and hs-CRP are positive markers for OPLL. Phosphate metabolism via FGF-23 might be a target for future study on the pathogenesis of OPLL.

DOI： 10.1177/2192568218801015

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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AIMS: SMAD4 acts as a tumour suppressor, and the loss of SMAD4 is associated with poor prognosis in colorectal cancer (CRC) patients. Although next-generation sequencing (NGS) enabled us to detect numerous genetic alterations in a single assay, the clinical significance of SMAD4 alteration detected with NGS has not been fully investigated. The aim of this study was to evaluate the clinicopathological characteristics and clinical significance of SMAD4 alteration detected with NGS in CRC. METHODS AND RESULTS: We retrospectively investigated 201 patients with stage I-IV CRC, by using a 415-gene panel. To analyse the relationship between SMAD4 alteration and other clinicopathological characteristics, we evaluated clinicopathological variables, including invasive-front pathological markers: tumour budding, poorly differentiated cluster, and Crohn-like lymphoid reaction. Fifty-six patients (28%) had SMAD4 alteration: 24 and 32 patients had SMAD4 mutation and deletion, respectively. SMAD4 alteration was significantly associated with T category (P = 0.027), N category (P = 0.037), M category (P = 0.028), and invasive-front pathological markers, such as poorly differentiated cluster grade 3 (P = 0.020) and absence of Crohn-like lymphoid reaction (P = 0.004). Immunohistochemistry revealed that SMAD4 alteration was significantly associated with loss of SMAD4 (P = 0.023). In 90 patients with stage I-III disease, SMAD4 alteration was significantly associated with poor prognosis for relapse-free and overall survival (P = 0.047; P = 0.022, respectively). Conversely, in 111 patients with stage IV disease, SMAD4 alteration was not significantly associated with overall survival. CONCLUSION: SMAD4 alteration is associated with invasive-front pathological markers and poor prognosis in stage I-III CRC patients.

DOI： 10.1111/his.13805

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Comprehensive genomic sequencing (CGS) enables us to detect numerous genetic alterations in a single assay. We aimed to identify molecular markers for predicting prognosis and conversion surgery in Stage IV colorectal cancer (CRC) using CGS. One-hundred eleven patients with Stage IV CRC who underwent primary tumor resection were analyzed. We retrospectively investigated genetic alterations using CGS of a 415-gene panel. Clinicopathological variables and genetic alterations were analyzed to identify independent prognostic factors of overall survival (OS). Forty-five of 111 patients had R0 resection; of these, 11 patients underwent conversion surgery. Univariate and multivariate analyses identified histopathological grade 3, R0 resection, BRAF V600E mutation, and SRC mutation as independent prognostic factors for OS (P = 0.041, P = 0.013, P = 0.005, and P = 0.023, respectively). BRAF V600E and SRC mutations were mutually exclusive, and SRC mutation was significantly associated with left-sided tumor and liver metastasis compared to BRAF V600E mutation (P = 0.016 and P = 0.025, respectively). Eleven of the 74 initially unresectable patients underwent conversion surgery for R0 resection, yet none harbored BRAF V600E or SRC mutations. BRAF V600E and SRC mutations are important molecular markers which can predict prognosis and conversion surgery in Stage IV CRC.

DOI： 10.1038/s41598-019-39328-6

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BACKGROUND: Neurofibromatosis type 1 (NF1) is an autosomal dominant disease of the skin and soft tissue. Aneurysms associated with NF1 can occur, but a secondary aneurysm rupture is very rare, with very few cases reported in literature. CASE PRESENTATION: We describe the case of a 67-year-old female with NF1 who underwent endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) rupture. She developed a type Ib endoleak requiring a redo-EVAR. Eighteen days after her primary operation, she was found to have two new left colic artery aneurysms. She required emergency surgery consisting of a left hemicolectomy and transverse colon colostomy. Pathology showed neurofibromatous changes to the peri-vasculature tissue, consistent with her underlying disease. CONCLUSIONS: Although rare, secondary aneurysms can occur following AAA repair. Patients with soft tissue connective tissue disorders, like NF1, may be at an increased risk for development of these secondary aneurysms. Endovascular repair appears to be a safe approach for NF1 patients with AAA, but endovascular management can be challenging in the setting of NF1. Surgeons should be ready to convert to open surgery if the patient displays persistent signs of bleeding or structural changes related to connective tissue disorders like NF1.

DOI： 10.1186/s40792-019-0570-4

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Language：Japanese   Publishing type：Research paper (scientific journal)  

We present a case of long-term survival in a patient with advanced ascending colon cancer and multiple liver metastases after receiving multimodality therapy, which included hepatic atrial infusion(HAI)and 4 hepatectomies. At diagnosis, the 65- year-old woman underwent right hemicolectomy for advanced ascending colon cancer with multiple liver metastases (T3N1M1[H2], Stage Ⅳ). The 11 liver metastatic lesions were treated by weekly HAI of 5-fluorouracil(5-FU). The lesions reduced in size(response rate 28.9%)immediately following treatment, and no new lesions were detected, but 10 months after treatment the size of the S2 tumor had increased. Systemic chemotherapy with irinotecan and S-1 was administered. Continued development of the S2 tumor in the liver prompted a radical lateral segment hepatectomy. Four months later, a computed tomography(CT)scan revealed a S6 tumor of the liver, for which a posterior segment hepatectomy was performed. A CT scan showing a S1 tumor in the liver 9 months later resulted in chemotherapeutic treatment with CapeOX, followed by mFOLFOX6. Despite treatment, the S1 tumor developed further, prompting a S1 partial hepatectomy. A further partial S8 hepatectomy was performed 7 years after surgery for the primary lesion following a CT scan that revealed a S8 tumor in the liver. There has been no recurrence of tumors in the 5 years and 5 months since this last hepatectomy.

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Language：Japanese   Publisher：(株)癌と化学療法社  

切除可能な遠隔転移を有する大腸癌は、原発巣に加えて遠隔転移巣に対するR0切除が推奨されている。症例は39歳、女性。血便を主訴に近医を受診した。大腸内視鏡検査を施行し、上部直腸癌と診断した。また、腹部MRI検査を施行し、肝S4およびS5/8に計2個の肝転移を認めた。二期的切除の方針とし、一期目の手術として腹腔鏡補助下低位前方切除術、横行結腸双孔式人工肛門造設術を施行した。肝転移に対する術前補助化学療法としてCapeOX療法を2コース施行した後に、二期目の手術として人工肛門閉鎖術と人工肛門閉鎖創を利用した用手補助腹腔鏡下肝部分切除術の同時手術を施行した。術後経過は良好で、二期目の手術から21日後にCapeOX療法を再開した。人工肛門閉鎖の創部を利用して用手補助用デバイスを装着し、安全かつ低侵襲に肝部分切除を施行できたと考える。(著者抄録)

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2018&ichushi_jid=J00296&link_issn=&doc_id=20190107600021&doc_link_id=%2Fab8gtkrc%2F2018%2F004513%2F021%2F1851-1853%26dl%3D0&url=http%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fab8gtkrc%2F2018%2F004513%2F021%2F1851-1853%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publishing type：Research paper (scientific journal)  

Here, we reported a case of a 39-year-old woman having rectal cancer with multiple liver metastases who underwent staged laparoscopic resection. She was diagnosed with low rectal cancer and multiple liver metastases; thus, she underwent low anterior resection and diverting colostomy. Following the neoadjuvant chemotherapy, she underwent colostomy closure and subsequent hand-assisted laparoscopic partial hepatectomy using the operative site during the colostomy closure. The postoperative course was uneventful, and adjuvant chemotherapy with CapeOX was performed 3 weeks post-surgery. Minimally invasive surgery was performed using hand-assisted laparoscopy.

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 78-year-old man was admitted with diarrhea. Colonoscopy and computed tomography(CT)revealed rectal cancer with multiple liver metastases. Low anterior resection was performed for local control. After the operation, 5 courses of mFOLFOX6 plus bevacizumab chemotherapy were administered as first-line systemic therapy, but CT showed progressive disease with liver metastases. After the first-line systemic therapy, 2 courses of FOLFIRI plus bevacizumab chemotherapy were performed as second-line systemic therapy, but CT also revealed progressive disease with liver metastases. We retrospectively performed comprehensive genomic sequencing with a 415-gene panel and found that the patient had a hypermutation subtype. Interestingly, the panel also revealed that he had mismatch-repair(MMR)deficiency with MSH2 mutation, which is reported as a possible cause of resistance to 5-fluorouracil in colorectal cancer.

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Language：Japanese   Publisher：(株)医学書院  

＜文献概要＞ポイント ◆内科,外科が緊密な連携をとり,ステロイド・免疫調節薬・生物学的製剤などの薬剤管理を行う.◆炎症性腸疾患に特徴的な,日和見感染,血栓症などの合併症も考慮に入れた適切な周術期管理が重要である.◆分割手術,ストーマ管理,合併症について,適切な対応と十分なインフォームド・コンセントが必要である.

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BACKGROUND: Inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn's disease (CD), is a chronic, idiopathic, repeated inflammatory disease. Colorectal cancer (CRC) that develops in patients with IBD is known as colitis-associated colorectal cancer (CAC), but the underlying carcinogenic mechanism remains unclear. Genomic analysis of sporadic CRC has been well described based on next-generation sequencing (NGS) data. Using NGS, we compared all exons of 415 cancer-associated genes in patients in Japan and the USA who had CRC and found similar genomic alteration patterns among the two populations. However, genomic analysis of CAC has not been thoroughly investigated. MAIN BODY: The molecular pathogenesis of CAC shares many features with sporadic CRC, but there are distinct variations in the time and frequency of some alterations. Gene alterations in CAC are gradually being elucidated using genomic sequencing analyses. Some studies have shown that gene alteration patterns differ between UC and CD. The carcinogenesis of CAC depends on unique environmental, genetic, and immunological factors. CONCLUSIONS: In this review, we have discussed the differences in genomic alterations between sporadic CRC and CAC. NGS in patients with IBD has the potential to detect early CAC and to suggest therapeutic targets.

DOI： 10.1186/s12957-018-1428-0

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Korean Society of Coloproctology  

Purpose: Small bowel obstruction (SBO) remains a common complication after pelvic or abdominal surgery. However, the risk factors for SBO in ulcerative colitis (UC) surgery are not well known. The aim of the present study was to clarify the risk factors associated with SBO after ileal pouch-anal anastomosis (IPAA) with a loop ileostomy for patients with UC. Methods: The medical records of 96 patients who underwent IPAA for UC between 1999 and 2011 were reviewed. SBO was confirmed based on the presence of clinical symptoms and radiographic findings. The patients were divided into 2 groups: the SBO group and the non-SBO group. We also analyzed the relationship between SBO and computed tomography (CT) scan image parameters. Results: The study included 49 male and 47 female patients. The median age was 35.5 years (range, 14-72 years). We performed a 2- or 3-stage procedure as a total proctocolectomy and IPAA for patients with UC. SBO in the pretakedown of the loop ileostomy after IPAA occurred in 22 patients (22.9%). Moreover, surgical intervention for SBO was required for 11 patients. In brief, closure of the loop ileostomy was performed earlier than expected. A multivariate logistic regression analysis revealed that the 2-stage procedure (odds ratio, 2.850
95% confidence interval, 1.009-8.044
P = 0.048) was a significant independent risk factor associated with SBO. CT scan image parameters were not significant risk factors of SBO. Conclusion: The present study suggests that a 2-stage procedure is a significant risk factor associated with SBO after IPAA in patients with UC.

DOI： 10.3393/ac.2017.06.14

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：English   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(株)篠原出版新社  

Stage IV大腸癌109例を対象とし、次世代シークエンサーを用いた癌遺伝子変異解析パネル(415遺伝子)で遺伝子変異を解析した。RAS変異群26例(23.9%)、RAS変異+PTEN欠失群16例(14.7%)、PTEN欠失+ERBB2増幅群16例(14.7%)、PTEN欠失+SRC増幅/欠失群8例(7.3%)、A11野生型群27例(24.8%)、BRAF変異+RNF43変異群9例(7.3%)、その他8例(7.3%)にカテゴリー分類された。実際に抗EGFR抗体薬を使用した40例の検討では、A11野生型群は、RASKETで判定できるKRAS/NRAS遺伝子以外の遺伝子に変異のある群に比べて、無増悪生存率(PFS)が有意に良好であった。

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BACKGROUND/OBJECTIVE: Restorative proctocolectomy (RP) may improve quality of life in patients with ulcerative colitis (UC)-associated lower rectal cancer to a greater extent than total proctocolectomy. However, patients with UC-associated cancer often have flat mucosal lesions that make it extremely difficult to endoscopically delineate the tumor margins. Therefore, there is a potential risk of residual tumor and local recurrence after RP in patients with UC-associated lower rectal cancer. The aim of this study was to assess the feasibility of RP in patients with UC-associated cancer of the lower rectum. METHODS: We retrospectively identified nine patients who had undergone RP for UC-associated lower rectal cancer at the Niigata University Medical and Dental Hospital between January 2000 and December 2016. The incidence of flat mucosal cancer, distal margin status, and oncologic outcomes were evaluated in the nine patients. RESULTS: Eight (89%) of the nine patients had flat mucosal cancer in the lower rectum. The median length of the distal margin was 22 mm (range 0-55 mm). No patient developed local or distant recurrence during follow-up. One patient had a positive distal margin. This patient underwent annual pouchoscopy, but had no local recurrence and died of pancreatic cancer 81 months after RP. The remaining eight patients were alive at the final observation. Five-year and 10-year overall survival rates in the nine patients were 100% and 66.7%, respectively. CONCLUSION: Patients with UC-associated lower rectal cancer often have lesions of the flat mucosal type. However, RP is feasible and not necessarily contraindicated in such patients.

DOI： 10.1016/j.asjsur.2018.01.003

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Language：Japanese   Publisher：医学書院  

DOI： 10.11477/mf.1407211906

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Language：Japanese   Publisher：(株)医学書院  

＜ポイント＞閉塞性大腸炎をきたす疾患として大腸癌が最も多いが,憩室炎,虚血性腸疾患,便秘なども原因となりうる.閉塞部から離れた口側腸管にびらん・潰瘍を認めることが多く,切除範囲の設定には注意を要する.ステント治療により,口側腸管の評価や減圧が可能となり,閉塞性大腸炎のマネジメントに変化がみられる.(著者抄録)

DOI： 10.11477/mf.1407211906

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は73歳、男性。下腹部痛を主訴に受診し、精査で上行結腸癌、多発肝転移と診断され、結腸右半切除を施行した。術後のKRAS遺伝子検査ではcodon 12の変異を認めた。CapeOX+bevacizumab(Bv)療法後に肝部分切除を施行したが、5ヵ月後に新規肝転移病変を認めた。FOLFIRI+Bv療法後に再度肝部分切除を施行し、8ヵ月後にダグラス窩と右横隔膜下の腹膜播種を認めたため、同病変に対して低位前方切除、腹膜播種切除を施行した。6ヵ月後に右横隔膜下の腹膜播種、肺転移、胸膜播種を認め、sLV5FU2(+Bv)療法を継続している。初回手術から5年9ヵ月、全身状態良好で通院中である。近年、抗酸化ストレス蛋白の一つであるNAD(P)H:quinone oxidoreductase-1(NQO1)の抗癌剤耐性に関する報告が散見される。本症例の原発巣切除標本の免疫組織化学染色ではNQO1発現が陰性であり、病勢制御や長期生存に関与している可能性が考えられる。(著者抄録)

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Language：Japanese   Publishing type：Research paper (scientific journal)  

Carcinoma with elevated SRC expression is associated with distant metastasis and drug resistance. We report 2 cases of SRC amplification observed after retrospective comprehensive genomic sequencing. Case 1 was a 62-year-old man who had RAS wild-type stage IV carcinoma of the sigmoid colon with multiple liver metastases in both lobes. He underwent low anterior resection and systemic chemotherapy was initiated to treat the unresectable multiple liver metastases. Case 2 was a 73-yearold man who had RAS wild-type stage IV carcinoma of the descending colon with metastasis in the lateral segment of the liver. He underwent left hemicolectomy and lateral segmentectomy. He subsequently underwent open radiofrequency ablation and systemic chemotherapy to treat a hepatic recurrence. Several previous studies have found that molecular targeted therapy with tyrosine kinase inhibitors is effective against colorectal cancer with elevated SRC expression. This suggests that the results of comprehensive genomic sequencing may support the implementation of new treatments.

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Language：Japanese   Publishing type：Research paper (scientific journal)  

The patient was a 73-year-old man with ascending colon cancer and synchronous liver metastases. A right hemicolectomy with a lymph node dissection was performed for the primary lesion. The resected specimen revealed a KRAS codon 12 mutation. After 6 courses of chemotherapy with capecitabine, oxaliplatin, and bevacizumab(Bv), we performed a partial hepatectomy and resection of the peritoneal dissemination. A computed tomography(CT)scan 5 months later revealed the recurrence of the liver metastases. After 8 courses of chemotherapy with 5-fluorouracil, Leucovorin, irinotecan, and Bv, we performed a partial hepatectomy. CT scan after 13 months revealed a recurrence in the peritoneal dissemination in the Douglas pouch and the right subphrenic space; therefore, we performed a low anterior resection and resection of the peritoneal dissemination with curative intent. CT scan after 19 months revealed a recurrence in the right subphrenic dissemination, a lung metastasis, and pleural dissemination. Chemotherapy with 5-fluorouracil, Leucovorin, and Bv was administered for 2 years and 5 months. After 5 years and 9 months of the primary operation, the patient is alive. Recently, we have focused on the mechanism of multidrug resistance through NAD(P)H: quinone oxidoreductase-1(NQO1)overexpression, which can be used to determine the role of an enzyme in sensitivity to toxicity and carcinogenesis. In this case, the pathological examination of the resected specimen revealed NQO1 negative expression. In conclusion, NQO1 may play a significant role in chemotherapy resistance in colorectal cancer patients.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：IMPACT JOURNALS LLC  

Objectives: Anti-epidermal growth factor receptor (EGFR) therapy has been found to be more effective against left-sided colorectal cancer (LCRC) than right-sided colorectal cancer (RCRC). We hypothesized that RCRC is more likely to harbor genetic alterations associated with resistance to anti-EGFR therapy and tested this using comprehensive genomic sequencing.
Materials and methods: A total of 201 patients with either primary RCRC or LCRC were analyzed. We investigated tumors for genetic alterations using a 415-gene panel, which included alterations associated with resistance to anti-EGFR therapy: TK receptors (ERBB2, MET, EGFR, FGFR1, and PDGFRA), RAS pathway (KRAS, NRAS, HRAS, BRAF, and MAPK2K1), and PI3K pathway (PTEN and PIK3CA). Patients whose tumors had no alterations in these 12 genes, theoretically considered to respond to anti-EGFR therapy, were defined as "all wild-type", while remaining patients were defined as "mutant-type".
Results: Fifty-six patients (28%) and 145 patients (72%) had RCRC and LCRC, respectively. Regarding genetic alterations associated with anti-EGFR therapy, only 6 of 56 patients (11%) with RCRC were "all wild-type" compared with 41 of 145 patients (28%) with LCRC (P = 0.009). Among the 49 patients who received anti-EGFR therapy, RCRC showed significantly worse progression-free survival (PFS) than LCRC (P = 0.022), and "mutant-type" RCRC showed significantly worse PFS compared with "all wild-type" LCRC (P = 0.004).
Conclusions: RCRC is more likely to harbor genetic alterations associated with resistance to anti-EGFR therapy compared with LCRC. Furthermore, our data shows primary tumor sidedness is a surrogate for the non-random distribution of genetic alterations in CRC.

DOI： 10.18632/oncotarget.20510

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Language：Japanese   Publishing type：Research paper (scientific journal)  

This study aimed to evaluate the health-related quality of life(QOL)using EQ-5D-5L scores for patients who underwent surgery for colorectal cancer. A total of 30 consecutive patients(14 men and 16 women; median age: 67.5 years)from the outpatient clinic of our institute in January 2017 were eligible for this study. The primary tumor was located in the colon(n= 18)or rectum/anu(s n=12). Twelve patient(s 40.0%)had cancer recurrence, and 3 patient(s 10.0%)had a stoma. In addition, 11 patients(36.7%)underwent chemotherapy. The median EQ-5D-5L score for all the patients was 0.867(range, 0.324- 1.000). The EQ-5D-5L score of patients with recurrence was significantly lower(0.820)than that of patients without recurrence( 0.948)(p=0.002). Furthermore, the EQ-5D-5L score of women(0.834)was significantly lower than that of men (0.942)(p=0.015). No significant difference was noted between the EQ-5D-5L score and other factors, such as age, cancer stage, location of primary tumor, absence/presence of chemotherapy, and absence/presence of stoma. In conclusion, using EQ-5D-5L scores, female gender and cancer recurrence were found to be associated with low QOL of patients after surgery for colorectal cancer.

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Language：Japanese   Publisher：(株)癌と化学療法社  

大腸癌術後患者の健康関連quality of life(QOL)を評価することを目的とした。QOL評価法として、EQ-5D-5Lを用いた。2017年1月に当科外来を受診した大腸癌術後患者30例を対象とした。年齢中央値は67.5歳、男性14例、女性16例であった。原発巣は結腸18例、直腸および肛門が12例であった。アンケート施行時に再発を有する症例が12例(40.0%)、化学療法中の症例は11例(36.7%)、ストーマ造設中の症例は3例(10.0%)であった。対象症例のEQ-5D-5Lスコア中央値は0.867(範囲:0.324〜1.000)であった。再発を有する症例のスコアは0.820であり、再発のない症例の0.948と比較して有意に低値であった(p=0.002)。女性のスコアは0.834であり、男性のスコア0.942と比較して有意に低値であった(p=0.015)。その他の因子ではスコアに差を認めなかった。EQ-5D-5Lスコアを用いた検討では、女性、再発を有することが大腸癌術後患者QOLの低下に関与していた。(著者抄録)

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SRC発現の亢進した癌は遠隔転移や薬剤耐性と関連があり、治療抵抗性とされている。今回、次世代シークエンサーによる415の癌関連遺伝子パネルを使用した後方視的な解析により、SRC増幅を認めた2例を報告する。症例1は62歳、男性。両葉多発肝転移を伴うRAS野生型cStage IVのS状結腸癌に対して、S状結腸切除を施行した。切除不能多発肝転移に対して、化学療法を行った。症例2は73歳、男性。肝外側区域に転移を伴うRAS野生型cStage IVの下行結腸癌に対して、左半結腸切除および外側区域切除を施行した。その後、肝再発に対して開腹ラジオ波焼灼術および化学療法を行った。SRC発現の亢進した大腸癌に対して、チロシンキナーゼ阻害薬による分子標的治療が有効であるという報告がある。包括的癌ゲノム検査により、新たな治療提案ができる可能性が示唆された。(著者抄録)

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Baishideng Publishing Group Co., Limited  

AIM: To assess the clinical significance of prophylactic lateral pelvic lymph node dissection (LPLND) in stage IV low rectal cancer. METHODS: We selected 71 consecutive stage IV low rectal cancer patients who underwent primary tumor resection, and enrolled 50 of these 71 patients without clinical LPLN metastasis. The patients had distant metastasis such as liver, lung, peritoneum, and paraaortic LN. Clinical LPLN metastasis was defined as LN with a maximum diameter of 10 mm or more on preoperative pelvic computed tomography scan. All patients underwent primary tumor resection, 27 patients underwent total mesorectal excision (TME) with LPLND (LPLND group), and 23 patients underwent only TME (TME group). Bilateral LPLND was performed simultaneously with primary tumor resection in LPLND group. R0 resection of both primary and metastatic sites was achieved in 20 of 50 patients. We evaluated possible prognostic factors for 5-year overall survival (OS), and compared 5-year cumulative local recurrence between the LPLND and TME groups. RESULTS: For OS, univariate analyses revealed no significant benefit in the LPLND compared with the TME group (28.7% vs 17.0%, P = 0.523)
multivariate analysis revealed that R0 resection was an independent prognostic factor. Regarding cumulative local recurrence, the LPLND group showed no significant benefit compared with TME group (21.4% vs 14.8%, P = 0.833). CONCLUSION: Prophylactic LPLND shows no oncological benefits in patients with Stage IV low rectal cancer without clinical LPLN metastasis.

DOI： 10.5306/wjco.v8.i5.412

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BACKGROUND: A prospective randomized study was performed to investigate the validity of intravenous carnitine administration during postoperative parenteral nutrition (PN) with lipid emulsion. METHODS: Patients undergoing surgery for gastric or colorectal cancer were enrolled in the study and were randomly divided into two groups (n = 8 in each group): 1) group L, who received a peripheral PN (PPN) solution of 7.5% glucose, 30% amino acid, and 20% lipid emulsion; and 2) group LC, who received the same PPN solution, as well as carnitine intravenously. PPN was performed from postoperative day (POD) 1 to POD4. Clinical and laboratory parameters were compared between the two groups; statistical significance was set at P < 0.05. RESULTS: Serum carnitine concentrations were significantly higher in group LC on POD3 (P < 0.01) and POD7 (P = 0.01). Postoperative changes in laboratory parameters and morbidity were comparable between the two groups. However, the decrease in C-reactive protein from POD3 to POD7 was significantly greater in group LC than in group L (P = 0.011). CONCLUSION: The results show that intravenous carnitine administration in addition to PN is safe and may be beneficial for recovery from postoperative inflammatory reactions.

DOI： 10.14740/jocmr3113w

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：W B SAUNDERS CO-ELSEVIER INC  

HER2-targeted therapy is considered effective for KRAS codon 12/13 wild-type, HER2-positive metastatic colorectal cancer (CRC). In general, HER2 status is determined by the use of immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH). Comprehensive genomic sequencing (CGS) enables the detection of gene mutations and copy number alterations including KRAS mutation and HER2 amplification; however, little is known about the utility of CGS for detecting HER2-positive CRC. To assess its utility, we retrospectively investigated 201 patients with stage I-IV CRC. The HER2 status of the primary site was assessed using IHC and FISH, and HER2 amplification of the primary site was also assessed using CGS, and the findings of these approaches were compared in each patient. CGS successfully detected alterations in 415 genes including KRAS codon 12/13 mutation and HER2 amplification. Fifty-nine (29%) patients had a KRAS codon 12/13 mutation. Ten (5%) patients were diagnosed as HER2 positive because of HER2 MC 3+, and the same 10 (5%) patients had HER2 amplification evaluated using CGS. The results of HER2 status and HER2 amplification were completely identical in all 201 patients (P &lt; .001). Nine of the 10 HER2-positive patients were KRAS 12/13 wild-type and were considered possible candidates for HER2-targeted therapy. CGS has the same utility as IHC and FISH for detecting HER2-positive patients who are candidates for HER2-targeted therapy, and facilitates precision medicine and tailor-made treatment. (C) 2017 The Authors. Published by Elsevier Inc.

DOI： 10.1016/j.humpath.2017.02.004

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Society of Gastroenterological Surgery  

We report the case of a 45-year-old man, who at the age of 24 had total proctocolectomy with ileal W-pouch anal anastomosis for familial adenomatous polyposis. A follow-up transanal endoscopy performed at the age of 38 revealed approximately 30 polyps in the ileal pouch, which were then confirmed by biopsy to be tubular adenomas. A transanal endoscopy performed at the age of 44 revealed an 8 mm 0-Is lesion located approximately 1 cm proximal to the ileal pouch-anal anastomosis, which was then removed by EMR. Histopathological analysis showed the presence of well-differentiated tubular adenocarcinoma in adenoma. To date, no recurrence of adenocarcinoma has been confirmed in follow-up transanal endoscopies. We have experienced treating a case of adenocarcinoma arising in the ileal pouch through the adenoma-carcinoma sequence after total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. For early diagnosis and prompt treatment, it is important to perform periodic surveillance of the ileal pouch and conduct aggressive endoscopic resection when a large adenoma exceeding 10 mm is found.

DOI： 10.5833/jjgs.2016.0055

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Language：Japanese   Publisher：日本臨床外科学会  

DOI： 10.3919/jjsa.78.399

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Society of Gastroenterological Surgery  

We report the case of a 45-year-old man, who at the age of 24 had total proctocolectomy with ileal W-pouch anal anastomosis for familial adenomatous polyposis. A follow-up transanal endoscopy performed at the age of 38 revealed approximately 30 polyps in the ileal pouch, which were then confirmed by biopsy to be tubular adenomas. A transanal endoscopy performed at the age of 44 revealed an 8 mm 0-Is lesion located approximately 1 cm proximal to the ileal pouch-anal anastomosis, which was then removed by EMR. Histopathological analysis showed the presence of well-differentiated tubular adenocarcinoma in adenoma. To date, no recurrence of adenocarcinoma has been confirmed in follow-up transanal endoscopies. We have experienced treating a case of adenocarcinoma arising in the ileal pouch through the adenoma-carcinoma sequence after total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. For early diagnosis and prompt treatment, it is important to perform periodic surveillance of the ileal pouch and conduct aggressive endoscopic resection when a large adenoma exceeding 10 mm is found.

DOI： 10.5833/jjgs.2016.0055

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：E-CENTURY PUBLISHING CORP  

NAD(P)H: quinone oxidoreductase-1 (NQO1) protects cells against redox cycling and oxidative stress; however, in cancer cells, NQO1 confers resistance against anticancer agents. The aim of this study was to evaluate the association between NQO1 expression and prognosis in patients with advanced (locally advanced or metastatic/recurrent) colorectal cancer (CRC). A retrospective analysis of 47 patients [28 male and 19 female; median age: 62 years (range, 17-78)] with advanced CRC was conducted. Immunohistochemical examination of tumor tissue specimens was performed using monoclonal anti-NQO1 antibody. The association of NQO1 expression with patient characteristics, chemotherapeutic response, and clinical prognosis was assessed. Therapeutic efficacy (complete response, partial response, stable disease, and progressive disease) was evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. We compared the therapeutic efficacy in KRAS wild and mutant CRC because epidermal growth factor receptor (EGFR)-signaling pathway plays a pivotal role in CRC. Of the 47 patients, 31 (66.0%) had KRAS wild CRC and 16 (34.0%) had KRAS mutant CRC. Moreover, 37 (78.7%) had NQO1-positive tumors and 10 (21.3%) had NQO1-negative tumors. Among the patients with KRAS wild CRC, NQO1-negative patients showed significantly better disease control rate (complete response + partial response + stable disease) than NQO1-positive patients (P = 0.028). Moreover, NQO1-negative patients had longer progression-free survival and overall survival than NQO1-positive patients (P = 0.041 and P = 0.043, respectively). NQO1 expression in the tumor may be a predictor of therapeutic efficacy and prognosis in patients with KRAS wild advanced CRC.

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Language：Japanese   Publisher：(一社)日本内視鏡外科学会  

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は58歳、男性。血便を主訴に受診した。肛門直腸診で下部直腸に腫瘤を触知し、下部消化管内視鏡検査およびCT検査で肝・肺転移を伴う進行直腸癌と診断された。XELOX+bevacizumab療法を3コース施行してPRとなった後、局所制御のため腹会陰式直腸切断術を施行した。原発巣のKRAS遺伝子は野生型であった。術後にXELOX療法を14コース施行したが、アレルギー反応により中止した。脳転移が出現した後に二次治療としてIRIS+panitumumab療法を3コース施行したが、肝・肺・脳のいずれの転移巣も増大した。次世代シーケンサーによる遺伝子解析パネル(CancerPlex)により癌関連遺伝子を解析し、原発巣にBRAF変異を認めた。RAS-RAF-MAPK経路においてBRAFはRASの下流に位置する。そのため、BRAFに変異を認める場合、本症例のように抗EGFR抗体薬の治療効果が期待できない可能性がある。網羅的遺伝子解析により、個々の症例に最適な化学療法を選択できる可能性がある。(著者抄録)

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Language：Japanese   Publishing type：Research paper (scientific journal)  

RAS mutation is an established predictive biomarker of resistance to anti-epidermal growth factor receptor(EGFR)therapy in metastatic colorectal cancer. In addition, previous studies identified mutations in ERBB2, FGFR1, PDGFRA, BRAF, MAP2K1, PTEN, and PIK3CA as potential mechanisms of resistance to anti-EGFR therapy. Testing for these mutations might be necessary to determine eligibility for anti-EGFR therapy in patients with metastatic colorectal cancer. CancerPlex®is a nextgeneration sequencer for 413 cancer genes. An analysis panel includes genes that may be associated with resistance to anti- EGFR therapy. A 65-year-old man with unresectable rectal cancer, multiple lung metastases, and a bulky liver metastasis was evaluated for expression of genes associated with resistance to anti-EGFR. The analysis found that all genes indicating resistance were wild-type genes. Cetuximab monotherapy was administered after rectal resection, with dramatic shrinkage of the metastatic tumors. A more accurate selection of patients according to tumor genetic status using CancerPlex®might improve the risk-benefit profile of anti-EGFR therapy.

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 58-year-old man was admitted with the complaint of bloody stools. Colonoscopy and computed tomography revealed a rectal cancer with a liver metastasis and multiple lung metastases. After administering a regimen comprising 3 courses of XELOX plus bevacizumab chemotherapy, the sizes of the primary and metastatic lesions decreased remarkably. Abdominoperineal resection was performed for local control of the cancer; the specimen from the initial tumor was found to be KRAS wild type. After 14 courses of XELOX chemotherapy, brain metastases were detected. Although 3 courses of IRIS plus panitumumab were administered, the liver, lung, and brain metastases spread rapidly. A comprehensive genomic analysis focused on cancer-related genes with CancerPlex®found a mutation of the BRAF gene(I326V). BRAF is a downstream molecule of KRAS in the RAS-RAF-MAPK pathway. Therefore, this mutation of the BRAF gene has the possibility of causing resistance against panitumumab that was found in this case. Furthermore, we expect that the systematic analysis of oncogene and suppressor oncogenes will enable us to choose the optimal regimen of chemotherapy or molecular targeting therapy for each patient with colorectal cancer.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BIOMED CENTRAL LTD  

Background: Meigs' syndrome is defined as the co-existence of benign ovarian fibroma or fibroma-like tumor, ascites, and pleural effusion. In contrast, pseudo-Meigs' syndrome is defined as the co-existence of other ovarian or pelvic tumors, ascites, and pleural effusion. In Meigs' and pseudo-Meigs' syndromes, ascites and pleural effusion resolve promptly after the complete resection of the ovarian or pelvic tumor(s). Secondary ovarian tumors from colorectal gastrointestinal metastases rarely cause pseudo-Meigs' syndrome; only 11 cases of pseudo-Meigs' syndrome secondary to colorectal cancers have been reported in the literature. Therefore, the prognosis and etiology of pseudo-Meigs' syndrome caused by ovarian metastasis from colorectal cancers remain unclear.
Case presentation: We report here a rare case of pseudo-Meigs' syndrome caused by ovarian metastases from sigmoid colon cancer with long-term survival. A 47-year-old woman presented with abdominal distention of 1month duration. She developed acute dyspnea 2 weeks after the initial presentation. Colonoscopy and computed tomography revealed sigmoid colon cancer with an ovarian metastasis, along with massive ascites and bilateral pleural effusion. Emergency operation, including bilateral oophorectomy and sigmoidectomy, was performed. Subsequently, ascites and bilateral pleural effusion resolved rapidly. Curative hepatic resection was performed for liver metastases 29 months after the first operation, and as of this writing, the patient is alive with no evidence of a disease 78 months after the first operation. In general, colorectal cancer with ovarian metastasis is hard to cure, and long-term survival in patients with colorectal cancer with pseudo-Meigs' syndrome is rare. Our experience suggests that curative resection for pseudo-Meigs' syndrome caused by ovarian metastasis from colorectal cancer may offer long-term survival.
Conclusions: Our experience suggests that pseudo-Meigs' syndrome can occur in a patient with colorectal cancer after metastasis to the ovaries, causing massive ascites and pleural effusion. Aggressive treatment, including R0 resection, for this disease if allowed by the patient's general condition may offer long-term survival.

DOI： 10.1186/s12957-016-1040-0

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Language：Japanese   Publishing type：Research paper (scientific journal)  

We report a case of panitumumab-resistant rectal cancer with HER2 gene amplification detected by CancerPlex®. A 51- year-old man was diagnosed with an obstructive rectal cancer having lung and adrenal metastases. He underwent the Hartmann 's operation, and KRAS mutations were not detected. After the surgery, 3 courses of CapeOx plus bevacizumab were administered as first-line chemotherapy; however, the lung and adrenal metastases progressed. Subsequently, 24 courses of IRIS/panitumumab was administered as second-line chemotherapy, and the metastases slowly progressed. Six courses of regorafenib were administered as third-line chemotherapy followed by a course of TAS-102 as fourth-line chemotherapy. Subsequently, a left femoral head metastasis and cerebellar metastases were detected. The patient received best supportive care including palliative femoral head replacement and stereotactic irradiation for the cerebellar metastases, and he died of cancer 3 years 5 months after the primary surgery. The comprehensive genomic analysis focusing on 413 cancer-related genes with CancerPlex®revealed that EGFR, BRAF, KRAS, NRAS, and HRAS had no mutations; however, ERBB2 amplification was detected. Furthermore, immunohistochemical staining revealed overexpression of HER2 protein in both the primary and bone metastatictumor. HER2 and EGFR independently promote the RAS-RAF-MAPK pathway. In the present case, the efficacy of anti-EGFR therapy may be attenuated because of ERBB2 amplification in the metastatic tumor.

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は51歳、男性。検診で便潜血陽性を指摘され、当院を受診した。精査の結果、左肺・左副腎への転移を伴う直腸癌と診断した。がん性腸閉塞に対してHartmann手術を施行した後、CapeOX+bevacizumab療法を3コース、IRIS+panitumumab療法を24コース、regorafenib療法を6コース、TAS-102療法を1コース施行した。その後、術後2年9ヵ月で左大腿骨頭転移、術後3年1ヵ月で小脳転移が出現した。左大腿骨頭置換術・小脳定位放射線照射療法を施行した後、best supportive careを行った。次世代シーケンサーによるがん遺伝子解析パネルであるCancerPlexを用いて、腫瘍組織におけるがん関連413遺伝子を網羅的に解析した。その結果、RAS遺伝子に変異を認めなかったが、HER2遺伝子の増幅を認めた。HER2受容体はEGFRと独立してMAPK経路を介して癌細胞増殖に関与するため、本症例では抗EGFR抗体薬が無効であった可能性がある。(著者抄録)

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抗EGFR抗体薬はEGFR以下のシグナル伝達を遮断することで、抗腫瘍効果を発揮する。RAS変異型では、RASより下流のシグナル伝達が恒常的に活性化されているため、抗EGFR抗体薬の効果が期待できない。しかし近年、RAS変異だけではなくERBB2やFGFR1などのチロシンキナーゼ受容体の変異もしくは過剰発現、BRAFやPIK3CAなどの遺伝子変異も、抗EGFR抗体薬の治療抵抗性にかかわると指摘されている。そのため、これらの遺伝子を解析することにより、抗EGFR抗体薬が奏効する症例を的確に抽出できる可能性がある。CancerPlexは、次世代シーケンサーによる413種類のがん遺伝子解析パネルである。今回われわれはCancerPlexを用いてがん遺伝子解析を行い、上記の抗EGFR抗体薬の治療抵抗性にかかわる遺伝子がすべて野生型であり、かつ抗EGFR抗体薬が奏効した1例を経験したので報告する。(著者抄録)

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

症例は59歳の男性で,心窩部不快感・食欲低下を主訴に来院した.腹部CTで十二指腸第4部に腫瘤性病変を認め,口側十二指腸および胃の拡張が認められた.上部消化管内視鏡検査で,第4部原発の十二指腸癌と診断し開腹手術を施行した.術中所見で横行結腸間膜に単発の腹膜播種を認めた.上腸間膜動脈リンパ節郭清を伴う十二指腸空腸部分切除術と腹膜播種巣を含めた横行結腸部分切除術を施行した.病理組織学的検査では,高分化型腺癌,pSS,ly0,v0であり,リンパ節転移は認めなかった.退院後は,S-1+CDDP療法を施行し,術後17ヵ月現在,再発なく外来通院中である.第4部原発の十二指腸癌の報告例は極めて少なく,その根治手術術式やリンパ節郭清範囲については確立されたものはない.十二指腸第4部に発生した原発性十二指腸癌の1例を経験したので,治療方針に関する考察を加え報告する.(著者抄録)

DOI： 10.3919/jjsa.77.833

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER  

Perineural invasion (PN) diagnosed by hematoxylin-eosin (HE) staining is an important prognostic factor after curative-intent surgery in patients with colorectal cancer. However, the clinical significance of PN diagnosed by immunohistochemistry (IHC) has not been investigated. The present study assessed the clinical significance of PN diagnosed by IHC with an anti-S100 antibody in patients with colorectal cancer.
We retrospectively enrolled 184 consecutive patients with stage I-III colorectal cancer who had undergone curative-intent surgery. We analyzed the absence/presence of PN diagnosed by HE staining (HE-PN) compared to that diagnosed by IHC with the anti-S100 antibody (S100-PN). Potential prognostic factors were identified by univariate and multivariate analyses of the overall and relapse-free survival. The statistics were used to assess the inter-observer reproducibility.
The incidence of HE-PN and S100-PN among the 184 patients was 60 patients (32.6 %) and 113 patients (61.4 %), respectively (P &lt; 0.001). A multivariate Cox proportional hazards regression model analysis indicated that S100-PN was an independent prognostic factor for both the overall and relapse-free survival. The value was 0.77 for S100-PN and 0.47 for HE-PN.
PN diagnosed by IHC is an important prognostic factor in patients with colorectal cancer. An inter-observer assessment showed superior judgment reproducibility for S100-PN compared with HE-PN.

DOI： 10.1007/s00595-014-1096-9

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Language：Japanese   Publisher：新潟医学会  

症例は71歳男性。主訴は特になし。検診で便潜血陽性を指摘され精査を施行、肝両葉に計7個の多発肝転移を伴う進行S状結腸癌と診断された。原発巣切除(pT3N1M1(H2)pStage IV)を施行した後、Capecitabine+Oxaliplatin+Bevacizumabによる全身化学療法を計6コース施行した。有害事象は特に認めず、Response Evaluation Criteria in Solid Tumors v1.1判定では縮小率は38.7%でありPartial Responseであった。肝転移に対して切除可能と判断し、肝外側区域切除+6ヶ所の肝部分切除を行い、治癒切除となった。切除標本の病理組織結果では5病変に腺癌が認められ、S状結腸癌肝転移と診断された。残りの2病変には残存腫瘍を認めなかった。組織学的効果判定はGrade 2であった。術後にUFT/UZELによる化学療法を6ヵ月間行った。肝切除から1年6ヵ月後、肝S5に孤立性の肝転移を認めたため、肝S5の部分切除術を施行した。その後はUFT/UZELを継続し、外来通院中である。現在、初回手術から5年6ヵ月、無再発生存中である。切除不能・困難な肝転移を有する大腸癌に対して、Capecitabine+Oxaliplatin+Bevacizumabを用いた全身化学療法は有用である。(著者抄録)

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Other Link： http://hdl.handle.net/10191/44313

Language：Japanese   Publisher：新潟医学会  

症例は71歳男性. 主訴は特になし. 検診で便潜血陽性を指摘され精査を施行, 肝両葉に計7個の多発肝転移を伴う進行S状結腸癌と診断された. 原発巣切除(pT3N1M1 (H2) pStage IV)を施行した後, Capecitabine+Oxaliplatin+Bevacizumabによる全身化学療法を計6コース施行した. 有害事象は特に認めず, Response Evaluation Criteria in Solid Tumors v1.1判定では縮小率は38.7%でありPartial Responseであった. 肝転移に対して切除可能と判断し, 肝外側区域切除+6か所の肝部分切除を行い, 治癒切除となった. 切除標本の病理組織結果では5病変に腺癌が認められ, S状結腸癌肝転移と診断された. 残りの2病変には残存腫瘍を認めなかった. 組織学的効果判定はGrade 2であった. 術後にUFT/UZELによる化学療法を6か月間行った. 肝切除から1年6か月後, 肝S5に孤立性の肝転移を認めたため, 肝S5の部分切除術を施行した. その後はUFT/UZELを継続し, 外来通院中である. 現在, 初回手術から5年6か月, 無再発生存中である. 切除不能・困難な肝転移を有する大腸癌に対して, Capecitabine+Oxaliplatin+Bevacizumabを用いた全身化学療法は有用である.

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Language：Japanese   Publisher：(一社)日本内視鏡外科学会  

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 71-year-old woman diagnosed with Fournier's gangrene caused by penetration of a rectal carcinoma was referred to our hospital. Emergency drainage and sigmoid colostomy were performed. Pathological examination of a biopsy sample showed moderately differentiated tubular adenocarcinoma. Abdominoperineal resection with bilateral salpingo-oophorectomy and hysterectomy was performed with curative intent after 4 courses of chemotherapy with S-1 and oxaliplatin. The postoperative pathological diagnosis was StageⅡ (pT4bN0M0). The patient received tegafur/uracil and Leucovorin as adjuvant chemotherapy. Seven months after the curative operation, partial pneumonectomy was performed for the recurrence of the rectal carcinoma in the right lung. Eight months after pneumonectomy, recurrent tumors were observed in the right lung and subcutaneous fat layer of the right buttock along the drainage site. The tumor in the right buttock was excised along with part of the gluteus maximus, and partial pneumonectomy was then performed. Three years and 6 months after the emergency drainage, the patient is alive with no evidence of recurrence. After drainage for rectal carcinoma complicated by Fournier's gangrene, the possibility of recurrence around the drainage site should be considered.

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Case 1: A 61-year-old man who had a diagnosis of low rectal cancer with lateral pelvic lymph node (LPLN) metastasis and multiple liver metastases underwent low anterior resection with LPLN dissection. The initial surgery was followed by chemotherapy, and then an extended right hepatectomy with partial resection of the liver was performed. Subsequently, a lung metastasis was detected, and the lung was partially resected. The patient was alive 9 years and 6 months after the initial operation. Case 2: A 53-year-old man had a diagnosis of low rectal cancer. After 5 courses of mFOLFOX6 plus bevacizumab, he underwent low anterior resection with LPLN dissection and resection of the peritoneal metastasis. The patient was alive 6 years and 3 months after the surgery without any signs of recurrence. Case 3: A 48-year-old man had a diagnosis of low rectal cancer and multiple liver metastases. He underwent low anterior resection with LPLN dissection and right hepatic lobectomy. He subsequently showed liver and lung metastases. The patient received systemic chemotherapy, and is alive with recurrent disease. We report 3 cases of Stage Ⅳ low rectal cancer with LPLN metastasis, and propose that LPLN dissection is important as a part of R0 resection for Stage Ⅳ low rectal cancer.

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は58歳、女性。腹部膨満を主訴に近医を受診し、その後当院産婦人科へ紹介された。胸腹骨盤部CT検査では、右卵巣腫大、多発肺転移、多発肝転移、腹膜播種を指摘され、さらにダグラス窩の腹膜播種は直腸への浸潤が疑われた。卵巣癌Stage IVに対して術前化学療法(paclitaxel+carboplatin療法)を3コース行った。その後、腹腔内の腫瘍減量手術(子宮・両側付属器摘出、大網部分切除、腹膜播種切除、Hartmann手術)を施行した。直腸間膜内に多発するリンパ節腫大を認めたため、下腸間膜動脈根部までのリンパ節郭清を行った。術後の病理組織学的診断では、右卵巣漿液性腺癌の診断となった。また、傍直腸リンパ節にも卵巣癌の転移が認められた。術後は化学療法を再開し、現在加療中である。卵巣癌の直腸浸潤では、直腸切除と直腸所属リンパ節郭清を行うことで卵巣癌の腫瘍減量手術に寄与する可能性が示唆された。(著者抄録)

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症例は80歳女性. 前医で下部直腸癌に対し経肛門的局所切除術が施行された. 局所切除後2年1か月目に, 外陰部から肛門にかけて掻痒を伴う紅色扁平隆起性病変が明らかとなった. 生検でPaget細胞が認められた. 乳房外Paget病は, 皮膚原発の一次性乳房外Paget病と二次性乳房外Paget病に分類され, 鑑別診断には免疫組織化学染色が有用である. 本症例では, 免疫組織化学染色でGCDFP-15陰性, CK20陽性, CK7陰性であり, Pagetoid spreadを伴う直腸癌局所再発と診断した. CT検査で所属リンパ節および遠隔転移を認めなかった. 外陰部膣合併切除を伴う腹会陰式直腸切断術を行うことで, 治癒切除となった. 直腸癌局所切除後のPagetoid spreadを伴う再発形式は稀であるが, Paget細胞遺残の可能性を考慮し, 外来通院時の肛門皮膚観察に注意すべきである.

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は73歳、女性。2003年6月に盲腸癌に対して結腸右半切除、D3リンパ節郭清を施行した。術中所見で原発巣近傍に腹膜播種を認めたが、同部の合併切除を行うことでR0切除となった。術後補助化学療法は行わなかった。外来で経過観察していたが、2004年12月、左肺上葉単発の肺転移に対し左肺上葉部分切除を施行した。2007年6月、肝S3単発の肝転移に対し肝外側区域切除を施行した。原発巣切除後11年9ヵ月、肝外側区域切除後7年9ヵ月が経過し、現在無再発生存中である。複数臓器へ異時性に転移再発を来した場合でも、癌の遺残なく切除を行うことで長期生存が得られる場合がある。全身状態が良好でR0切除が可能であれば、積極的に転移巣切除を考慮すべきである。(著者抄録)

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症例は71歳、女性。肛門会陰部の硬結と疼痛を主訴に受診した。直腸癌穿通によるフルニエ壊疽と診断し、切開ドレナージおよびS状結腸人工肛門造設術を施行した。術中の生検で中分化管状腺癌と診断された。術後経過は良好で、S-1+oxaliplatin(SOX)療法を4コース施行後、両側付属器と子宮腟合併切除を伴う腹会陰式直腸切除術を施行した。最終診断はpT4b(腟)N0M0、Stage IIであり、術後補助化学療法としてUFT/Leucovorin療法を行った。根治術後7ヵ月目に右肺に再発を認め、右肺部分切除術を施行した。その8ヵ月後、右肺と右臀部皮下組織内に再発を認めた。臀部再発は切除可能と判断し、大臀筋の一部を含めた右臀部腫瘍摘出術を行った。腫瘍は切開排膿時のドレナージ創沿いの深部組織に局在していた。後日、右肺部分切除術を施行し、その後再発なく、初回の切開排膿時のドレナージ手術から3年6ヵ月生存中である。フルニエ壊疽合併直腸癌のドレナージ術後には、ドレナージ経路に再発を来す可能性を考慮する必要がある。(著者抄録)

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Language：Japanese   Publisher：(株)癌と化学療法社  

側方リンパ節転移陽性のStage IV下部直腸癌に対して側方リンパ節郭清を含む外科治療を行い、長期生存が得られている3例を報告する。症例1:61歳、男性。低位前方切除術、D3を施行した。5-FU肝動注療法・全身化学療法を行い、その後、肝転移に対して拡大肝右葉切除術・肝部分切除術を施行した。さらに肺転移再発に対して部分切除を行い、初回手術後9年6ヵ月経過し、無再発生存中である。症例2:53歳、男性。術前化学療法後に低位前方切除術、D3、腹膜播種切除を施行した。手術後6年3ヵ月経過し、無再発生存中である。症例3:48歳、男性。低位前方切除術、D3、肝右葉切除術、肝部分切除術を施行した。その後、肝転移・肺転移再発を来した。手術後4年経過し、現在、全身化学療法を継続中である。側方リンパ節転移陽性のStage IV下部直腸癌においても、R0切除の一環として側方リンパ節郭清は意義がある可能性が示唆された。(著者抄録)

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症例は80歳女性。前医で下部直腸癌に対し経肛門的局所切除術が施行された。局所切除後2年1ヵ月目に、外陰部から肛門にかけてそう痒を伴う紅色扁平隆起性病変が明らかとなった。生検でPaget細胞が認められた。乳房外Paget病は、皮膚原発の一次性乳房外Paget病と二次性乳房外Paget病に分類され、鑑別診断には免疫組織化学染色が有用である。本症例では、免疫組織化学染色でGCDFP-15陰性、CK20陽性、CK7陰性であり、Pagetoid spreadを伴う直腸癌局所再発と診断した。CT検査で所属リンパ節および遠隔転移を認めなかった。外陰部腟合併切除を伴う腹会陰式直腸切断術を行うことで、治癒切除となった。直腸癌局所切除後のPagetoid spreadを伴う再発形式は稀であるが、Paget細胞遺残の可能性を考慮し、外来通院時の肛門皮膚観察に注意すべきである。(著者抄録)

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A 58-year-old woman presenting with abdominal distension was diagnosed with a tumor in the right ovary. A chest-abdominal-pelvic computed tomography scan revealed multiple lung metastases, multiple liver metastases, and peritoneal dissemination. Invasion of the rectum by peritoneal dissemination of the Douglas' pouch was suspected. She was diagnosed with Stage Ⅳ right ovarian cancer and was treated with preoperative chemotherapy. After chemotherapy, debulking surgery of the abdominal cavity (total hysterectomy, bilateral salpingo-oophorectomy, partial omentectomy, and Hartmann's procedure) was performed. Because there was swelling observed in multiple mesorectal lymph nodes, lymph node dissection was performed based on methods used for rectal cancer surgery. Postoperative histopathological examination revealed multiple mesorectal lymph node metastases arising from ovarian cancer. We suggest that mesorectal lymph node dissection be considered a part of debulking surgery for ovarian cancers that have invaded the rectum.

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The patient was a 73-year-old woman. She underwent right hemicolectomy and D3 lymph node dissection for cecal cancer in June 2003. Although a peritoneal dissemination was intraoperatively noted around the primary tumor lesion, it was resected concurrently and thus R0 surgery was accomplished. Postoperative adjuvant chemotherapy was not performed. During the follow-up on an outpatient basis, a solitary left lung metastasis was found and partial left upper lobectomy of the lung was performed in December 2004. A solitary liver metastasis was identified in the liver (S3), and lateral segmentectomy of the liver was performed in June 2007. The patient was alive with no evidence of recurrence 11 years and 9 months after resection of the primary lesion and 7 years and 9 months after the hepatectomy. Long-term survival can be achieved by performing resection without residual cancer even in some cases with metachronous metastatic recurrences in multiple organs. Metastasectomy should be considered proactively when the patient is in a good general condition and R0 resection is possible.

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：新潟医学会  

症例は76歳の女性。主訴は右鼠径部腫瘤。肛門指診で、肛門縁から2.5cmに下縁を有する2cm大の隆起性病変、および主病巣より肛門側に0.5cm大の粘膜下腫瘤を触知した。大腸内視鏡検査で、下部直腸に主座を有し一部肛門管に進展する2cmの2型腫瘍を認め、生検で中分化型腺癌と診断された。胸腹骨盤部CT検査では、右閉鎖、右総腸骨、右鼠径リンパ節の腫大を認めた。下部直腸癌cStage IIIbの術前診断にて、腹会陰式直腸切断術D3郭清、右鼠径リンパ節郭清を施行した。術後の病理組織学的検査では、組織型は中分化〜低分化充実型腺癌、主病巣の深達度はMPで、ly2、v1と脈管侵襲を認めた。また、右閉鎖リンパ節に2個、右総腸骨リンパ節に1個、そして右鼠径リンパ節に3個それぞれ転移を認め、下部直腸癌pStage IIIbの診断となった。主病巣の肛門側に、主病巣と非連続性で低分化充実型腺癌の粘膜下腫瘍を認め、そのさらに肛門側にリンパ管侵襲を認めた。同粘膜下腫瘍は、主病巣と非連続性であること、および主病巣と類似した組織型であることから直腸癌の壁内転移と診断された。また、同粘膜下腫瘍は、周囲にリンパ管侵襲を認め、さらに鼠径リンパ節転移を認めたことから、直腸における下方向リンパ流を介した壁内転移と推定された。(著者抄録)

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症例は54歳, 女性. 26歳時に輸血によりC型肝炎に罹患し, 48歳時に慢性腎不全により透析導入となった. 2013年12月, 血液透析後に腹痛が出現し, 腹部CT検査で小腸腸間膜への穿通所見を認めたため緊急手術を行った. 回腸と周囲腸間膜の腫脹がみられ, 回腸部分切除術を施行した. 回腸粘膜に陥入したpress through package(PTP)を認め, PTPによる回腸穿通と診断した. 術前腹部CT検査を再検討するとPTPに特徴的な陰影が描出されていた. PTP誤飲は自覚していない場合が多く診断は困難であるが, 消化管穿通・穿孔の一因となることを念頭に置き, multi-detector CT検査による詳細な画像検討を行うことが重要である.

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症例は76歳の女性. 主訴は右鼠径部腫瘤. 肛門指診で, 肛門縁から2.5cmに下縁を有する2cm大の隆起性病変, および主病巣より肛門側に0.5cm大の粘膜下腫瘤を触知した. 大腸内視鏡検査で, 下部直腸に主座を有し一部肛門管に進展する2cmの2型腫瘍を認め, 生検で中分化型腺癌と診断された. 胸腹骨盤部CT検査では, 右閉鎖, 右総腸骨, 右鼠径リンパ節の腫大を認めた. 下部直腸癌cStage IIIbの術前診断にて, 腹会陰式直腸切断術D3郭清, 右鼠径リンパ節郭清を施行した. 術後の病理組織学的検査では, 組織型は中分化～低分化充実型腺癌, 主病巣の深達度はMPで, ly2, v1と脈管侵襲を認めた. また, 右閉鎖リンパ節に2個, 右総腸骨リンパ節に1個, そして右鼠径リンパ節に3個それぞれ転移を認め, 下部直腸癌pStage IIIbの診断となった. 主病巣の肛門側に, 主病巣と非連続性で低分化充実型腺癌の粘膜下腫瘍を認め, そのさらに肛門側にリンパ管侵襲を認めた. 同粘膜下腫瘍は, 主病巣と非連続性であること, および主病巣と類似した組織型であることから直腸癌の壁内転移と診断された. また, 同粘膜下腫瘍は, 周囲にリンパ管侵襲を認め, さらに鼠径リンパ節転移を認めたことから, 直腸における下方向リンパ流を介した壁内転移と推定された.

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症例は54歳、女性。26歳時に輸血によりC型肝炎に罹患し、48歳時に慢性腎不全により透析導入となった。2013年12月、血液透析後に腹痛が出現し、腹部CT検査で小腸腸間膜への穿通所見を認めたため緊急手術を行った。回腸と周囲腸間膜の腫脹がみられ、回腸部分切除術を施行した。回腸粘膜に陥入したpress through package(PTP)を認め、PTPによる回腸穿通と診断した。術前腹部CT検査を再検討するとPTPに特徴的な陰影が描出されていた。PTP誤飲は自覚していない場合が多く診断は困難であるが、消化管穿通・穿孔の一因となることを念頭に置き、multi-detector CT検査による詳細な画像検討を行うことが重要である。(著者抄録)

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Other Link： http://hdl.handle.net/10191/44121

Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：日本ストーマ・排泄リハビリテーション学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本腹部救急医学会  

症例は29歳,男性。車同士の交通外傷で受傷し当院へ救急搬送された。下腹部にシートベルト痕を認め,全身CTで下顎骨,右鎖骨,左第10肋骨,右腓骨の多発骨折および腹腔内出血を認めた。消化管穿孔は明らかではなかったが,確定診断のため腹腔鏡手術の適応とした。S状結腸腸間膜損傷IIa(S)およびS状結腸損傷cIa(S)の診断でS状結腸切除術を施行した。しかし,術後腸閉塞となったため初回手術後8日目に腹部CTを施行した。腹部正中臍下部で小腸が皮下に脱出しており外傷性腹壁ヘルニア嵌頓と診断した。再手術とし開腹すると,ポートサイトではなく弓状線尾側の下腹部で腹直筋鞘が断裂していた。小腸部分切除を施行し,腹直筋鞘を直接縫合した。今後,腹部鈍的外傷において,診断を兼ねた腹腔鏡手術例は増えてくると思われる。外傷性腹壁ヘルニアは,まれな病態ではあるが,腹腔鏡手術にて見落としがちな腹壁の損傷には注意すべきである。(著者抄録)

DOI： 10.11231/jaem.35.477

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Language：Japanese   Publisher：(株)日本臨床社  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：新潟医学会  

症例は79歳, 男性. 認知症治療のため当院に入院した. 軽度の貧血と体重減少を認めた. 精査のために施行した腹部CTで小腸内のPress Through Package(PTP)が確認された. 明らかな出血や腸閉塞症状が無く保存的に経過をみていたが, PTPはほとんど移動しなかった. 腸管浮腫, 腹痛も出現したため, 小腸内視鏡下でのPTPの摘出は行わず, 手術の方針とした. 単孔式腹腔鏡補助下にPTP摘出術を行った. 手術時間は80分で, 出血量は少量であった. 術後は特に問題なく経過した. 嚥下可能もしくは肛門より挿入可能な全てのものが消化管異物の原因となりうる. 高齢化社会に伴い, 今後このような症例は増加していくことが予想される. 単孔式腹腔鏡下手術は特に小腸良性疾患の手術に有用であると考える.

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症例は79歳、男性。認知症治療のため当院に入院した。軽度の貧血と体重減少を認めた。精査のために施行した腹部CTで小腸内のPress Through Package(PTP)が確認された。明らかな出血や腸閉塞症状が無く保存的に経過をみていたが、PTPはほとんど移動しなかった。腸管浮腫、腹痛も出現したため、小腸内視鏡下でのPTPの摘出は行わず、手術の方針とした。単孔式腹腔鏡補助下にPTP摘出術を行った。手術時間は80分で、出血量は少量であった。術後は特に問題なく経過した。嚥下可能もしくは肛門より挿入可能な全てのものが消化管異物の原因となりうる。高齢化社会に伴い、今後このような症例は増加していくことが予想される。単孔式腹腔鏡下手術は特に小腸良性疾患の手術に有用であると考える。(著者抄録)

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Other Link： http://hdl.handle.net/10191/44039

Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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同一病巣内に神経内分泌腫瘍(neuroendocrine tumor;NET)と腺癌の成分を認める直腸腫瘍は非常に稀である.このような腫瘍の発生過程は,NETと腺癌の両者への分化傾向をもつ単一クローン由来,それぞれ別のクローンから発生した腫瘍の衝突の2つの可能性がある.症例は52歳,男性.便潜血陽性で下部消化管内視鏡検査を施行され,下部直腸に10mm大の粘膜下腫瘍様病変を指摘された.生検でNETの診断となり,同病巣に対し内視鏡的粘膜下層剥離術を施行した.病理診断では,病巣は径8mmで,病巣内にNETと腺癌の成分があり,両成分の粘膜下層までの浸潤を認めた.病巣構築より一方から他方が発生した経路を除外できること,明らかな組織移行像を認めないこと,および免疫組織化学の染色態度の相違から,NETと腺癌が別々のクローンから発生した衝突腫瘍であると診断した.追加腸切除の適応とされ,腹腔鏡補助下超低位前方切除術,D2郭清を施行し,現在まで再発を認めていない.(著者抄録)

DOI： 10.3862/jcoloproctology.68.55

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Language：Japanese   Publisher：新潟医学会  

【目的】虚血性小腸炎は, 動脈硬化などを背景とした血流障害により, 小腸に虚血性病変が発生する疾患の総称である. 虚血性病変の治癒過程で瘢痕狭窄をきたす場合があり, 外科的治療の対象となる. 今回我々は, 単孔式腹腔鏡補助下手術を施行し, 良好な経過をたどった狭窄型虚血性小腸炎の1例を経験したので報告する. 【症例】患者は60歳, 男性, 高血圧, 脂質異常症の既往を有していた. 腹痛を自覚し当院を受診し, 腹部CT検査および小腸内視鏡検査の所見から虚血性小腸炎と診断された. 保存的治療により症状は軽快したが, 約1か月後に再度腹痛を自覚した. 腸閉塞と診断され, 経鼻イレウス管による腸管減圧が行われた. イレウス管造影検査では, 回腸に約10cm長の狭窄像を指摘された. 虚血性小腸炎による瘢痕狭窄であり, 保存的治療による改善は困難と考えられ, 単孔式腹腔鏡補助下手術が施行された. 臍を3cm切開し, ラッププロテクターミニタイプ, E・Zアクセスを装着した. 鉗子2本を用いて, 小腸全体を手繰るように観察した. 回腸終末部より約80cm口側の回腸に, 発赤と壁の硬化を認めた. 同部が狭窄部位であると判断し, 回腸を約18cm部分切除した. 病理組織学的検査では, 特異性炎症や悪性所見は認められず, 虚血性変化として矛盾の無い所見が認められた. 術後経過は良好で, 術後12病日目に退院した. 【考察】虚血性腸炎は左側結腸に好発し, 小腸病変の発生頻度は比較的低いと報告されている. しかし, 虚血性小腸炎は狭窄による腸閉塞をきたしやすいため, 外科的治療を要する割合が高い. 小腸は後腹膜や他臓器に固定されておらず, 体腔外への導出が容易であることなどから, 一般的に小腸疾患は腹腔鏡下手術の良い適応とされている. しかし, 腸閉塞をきたしやすい本疾患に対して, 腹腔鏡下手術が施行された症例の報告は少ない. 本症例では, 術前にイレウス管を留置し腸管の減圧が得られたこと, 小腸内視鏡検査やイレウス管造影検査により, 病変の局在や範囲を把握できていたことなどから, 腹腔鏡下手術が施行可能であると判断した. より整容性に優れた術式として単孔式腹腔鏡補助下手術を選択し, 安全に施行し得た. 【結論】狭窄型虚血性小腸炎は腸閉塞を呈することが多いが, イレウス管により腸管減圧が得られ, 術前に病変の局在や範囲が確認された状態であれば, 単孔式腹腔鏡補助下手術は安全に施行可能である.

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Language：Japanese   Publisher：新潟医学会  

【目的】虚血性小腸炎は、動脈硬化などを背景とした血流障害により、小腸に虚血性病変が発生する疾患の総称である。虚血性病変の治癒過程で瘢痕狭窄をきたす場合があり、外科的治療の対象となる。今回我々は、単孔式腹腔鏡補助下手術を施行し、良好な経過をたどった狭窄型虚血性小腸炎の1例を経験したので報告する。【症例】患者は60歳、男性。高血圧、脂質異常症の既往を有していた。腹痛を自覚し当院を受診し、腹部CT検査および小腸内視鏡検査の所見から虚血性小腸炎と診断された。保存的治療により症状は軽快したが、約1ヵ月後に再度腹痛を自覚した。腸閉塞と診断され、経鼻イレウス管による腸管減圧が行われた。イレウス管造影検査では、回腸に約10cm長の狭窄像を指摘された。虚血性小腸炎による瘢痕狭窄であり、保存的治療による改善は困難と考えられ、単孔式腹腔鏡補助下手術が施行された。臍を3cm切開し、ラッププロテクターミニタイプ、E・Zアクセスを装着した。鉗子2本を用いて、小腸全体を手繰るように観察した。回腸終末部より約80cm口側の回腸に、発赤と壁の硬化を認めた。同部が狭窄部位であると判断し、回腸を約18cm部分切除した。病理組織学的検査では、特異性炎症や悪性所見は認められず、虚血性変化として矛盾の無い所見が認められた。術後経過は良好で、術後12病日目に退院した。【考察】虚血性腸炎は左側結腸に好発し、小腸病変の発生頻度は比較的低いと報告されている。しかし、虚血性小腸炎は狭窄による腸閉塞をきたしやすいため、外科的治療を要する割合が高い。小腸は後腹膜や他臓器に固定されておらず、体腔外への導出が容易であることなどから、一般的に小腸疾患は腹腔鏡下手術の良い適応とされている。しかし、腸閉塞をきたしやすい本疾患に対して、腹腔鏡下手術が施行された症例の報告は少ない。本症例では、術前にイレウス管を留置し腸管の減圧が得られたこと、小腸内視鏡検査やイレウス管造影検査により、病変の局在や範囲を把握できていたことなどから、腹腔鏡下手術が施行可能であると判断した。より整容性に優れた術式として単孔式腹腔鏡補助下手術を選択し、安全に施行し得た。【結論】狭窄型虚血性小腸炎は腸閉塞を呈することが多いが、イレウス管により腸管減圧が得られ、術前に病変の局在や範囲が確認された状態であれば、単孔式腹腔鏡補助下手術は安全に施行可能である。(著者抄録)

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Other Link： http://hdl.handle.net/10191/44019

Publishing type：Research paper (scientific journal)   Publisher：OMICS Publishing Group  

DOI： 10.4172/2165-7920.1000635

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

A 34-year-old woman presenting with bloody stools was diagnosed with a rectal tumor. Computed tomography (CT) revealed multiple liver masses in Couinaud segments IV, V, and VU. The lesions were diagnosed as multiple liver metastases from rectal cancer. Right trisegmentectomy of the liver was considered the optimal treatment option for curative resection
however, liver volumetric examination using CT estimated that the remnant liver volume after right trisegmentectomy would be only 24.6 % of the total liver volume. Therefore, she underwent resection of the primary lesion followed by systemic chemotherapy for multiple liver metastases. She showed a partial response, according to the Response Evaluation Criteria in Solid Tumors, after 5 courses of capecitabine/oxaliplatin plus bevacizumab. Embolization of the right branch of the portal vein was performed to increase liver volume. A subsequent liver volumetric examination with CT estimated that the remnant liver volume after right trisegmentectomy would be 38.4 % of the total liver volume. Therefore, she underwent right trisegmentectomy of the liver for curative resection of the liver metastases. She had had no signs of recurrence at 3 years and 6 months after initial surgery.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

A 69-year-old man with advanced rectal cancer and liver metastases was treated with 2 courses of chemotherapy with irinotecan and S-1 followed by low anterior resection and partial hepatectomy. Chemotherapy with S-1 was then administered for 22 months. However, lung metastases developed, for which partial pneumonectomy was performed. Seven months later, computed tomography (CT) revealed swelling of the left supraclavicular lymph node. Despite chemotherapy with 5-fluorouracil, Leucovorin, and oxaliplatin (mFOLFOX6)
5-fluorouracil, Leucovorin and irinotecan (FOLFIRI)
and capecitabine plus bevacizumab, the lung metastases recurred and Virchow lymph node swelling was noted again. Accordingly, palliative therapy was administered. The patient died 3 years 1 month after Virchow lymph node resection. Herein, we describe a case of advanced rectal cancer, in which lung and Virchow lymph node metastases developed after liver metastasis. Surgical excision of the metastases resulted in long-term survival of 6 years following the first operation.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

A 71-year-old man was referred to our hospital because of repeated bowel obstruction. He had previously undergone cystectomy with ileal conduit urinary diversion for the treatment of bladder cancer at the age of 28 years. Computed tomography revealed a mass in the ascending colon. Ileostomy was initially performed because of poor general condition that improved with postoperative nutrition management. Enema findings revealed ascending colon cancer and we therefore decided to perform curative surgery. Intraoperative findings revealed that the ascending colon cancer had invaded the ileal conduit. However, it was confirmed that the ureter-ileal conduit anastomosis and the mesentery of the ileal conduit could be preserved. We performed right colectomy and partial resection of the ileal conduit with curative intent. The pathological stage was pT4bpN0cM0, pStage II. There were no signs of recurrence 15 months after curative surgery.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

Purpose: In the present study, we aimed to describe the surgical results of single-port laparoscopic stoma creation in our institution. Methods: We examined the safety of the surgical procedure and short-term results in 10 consecutive patients who underwent single-port laparoscopic stoma creation at our hospital between April 2011 and July 2013. Results: The median age of the patients was 60.5 (range, 31-75) years. Five patients were men, and 5 were women. There were 5 cases of colorectal cancer, 2 each of extramammary Paget's disease and uterine cancer, and one of perineal neurofibroma. Eight surgeries were performed for bowel obstruction or stenosis, and two surgeries were performed for other reasons. The median operative time was 59.5 (range, 40-91) min, blood loss volume was 0 (range, 0-10) mL, postoperative duration before commencement of oral intake was 2.5 (range, 1-4) days, and duration of postoperative hospital stay was 11 (range, 5-19) days. No short-term complications were noted after the surgery. Conclusion: Single-port laparoscopic stoma creation appears to be feasible in terms of safety and short-term surgical results, and may improve the quality of life of patients requiring fecal diversion.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

A 70-year-old man was referred to our hospital with ascending colon cancer (cT3N1M0, Stage IIIa), which was found during examinations following a positive fecal occult blood test. The patient was also diagnosed with early gastric cancer (cT1a, NO, MO, Stage IA) during a preoperative gastroscopy examination. A laparoscopically assisted right colectomy and D3 lymphadenectomy was performed for the ascending colon cancer. The postoperative pathological diagnosis was Stage IIIb (pT3N2), he was administered in combination with capecitabine plus oxaliplatin (CapeOX) as adjuvant chemotherapy before the treatment for the colon cancer. After 6 months of adjuvant chemotherapy, we were unable to detect any gastric lesions at the same location using gastroscopy, and so diagnosed a clinical complete response. A follow-up gastroscopy 6 months later showed the same findings. The patient has had no recurrence of gastric cancer for 18 months after the initial operation. He will continue to be followed up closely using gastroscopy. In this case, CapeOX as adjuvant chemotherapy for advanced colon cancer was also effective for early gastric cancer.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

An 81-year-old man presented with chief complaints of abdominal pain and vomiting. Intestinal obstruction was found at the time of admission to a local hospital in October 2011. Conservative treatment provided symptomatic relief
however, he was readmitted with similar symptoms in December 2011. Small-intestinal wall thickening was detected by abdominal and pelvic computed tomography, and he was referred to our hospital. Small-bowel endoscopy revealed an elevated subcircumferential tumor in the jejunum. Biopsy revealed well to moderately differentiated adenocarcinoma diagnosed as jejunal cancer, which caused narrowing of the jejunum. Single-incision laparoscopy-assisted small-bowel resection was performed. The intraoperative findings were a tumor with inflammatory changes in the jejunum and enlarged surrounding lymph nodes. We performed regional lymph node dissection. Histopathological analysis showed moderately differentiated small-intestinal tubular adenocarcinoma and 2 of 5 lymph nodes positive for metastatic cancer cells. After an uneventful postoperative course, he was discharged on day 7. He preferred not to undergo postoperative adjuvant chemotherapy and quickly recovered his activities of daily living postoperatively. He stayed home until he developed abdominal distention resulting from peritoneal recurrence 1 year and 6 months postoperatively and died 1 month later.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Journal of Cancer and Chemotherapy Publishers Inc.  

A 57-year-old woman was referred to our hospital because of descending colon cancer with multiple liver metastases. Abdominal magnetic resonance imaging (MRI) revealed 13 liver metastases across the lobes. We started combination chemotherapy with capecitabine/oxaliplatin (CapeOX) and bevacizumab. After 9 courses of the treatment, the number and size of the liver metastases were remarkably reduced on MRI. Left colectomy and partial hepatectomy were performed. Histopathological examination revealed no residual cancer cells in the colon but revealed a few cancer cells in 4 of 7 resected liver specimens. At 11 postoperative months, 1 liver metastasis reappeared, for which we performed laparoscopy-assisted partial hepatectomy. At 21 months after the second operation, the patient was well without any signs of recurrence. Thus, the combination chemotherapy with CapeOX and bevacizumab allowed for the successful resection of the tumor and metastasis in our patient who initially had unresectable colon cancer and multiple liver metastases.

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症例は81歳、男性。主訴は腹痛、嘔吐で腸閉塞を生じ、近医で入院加療が行われた。保存的治療で症状は改善したが、2ヵ月後に同じ症状で再入院となった。腹部骨盤部CT検査で小腸壁の肥厚が指摘されたため、当院紹介となった。小腸内視鏡検査で空腸に亜全周性の隆起性腫瘍を認め、生検で高分化〜中分化腺癌と診断された。狭窄所見を伴う空腸癌と診断し、単孔式腹腔鏡補助下空腸部分切除術を行った。術中所見として、空腸に炎症性変化を伴う腫瘍が確認された。リンパ節の腫大を認めたため腸管周囲リンパ節の郭清を行った。病理組織結果は小腸中分化管状腺癌、リンパ節は2/5個で転移陽性であった。術後経過は良好で、7病日に退院となった。術後補助化学療法は希望されなかった。術後すぐに日常生活動作は回復し、自宅で生活されていた。術後1年6ヵ月ごろより腹膜再発による腹部膨満を生じ、1年7ヵ月で永眠された。(著者抄録)

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症例は70歳、男性。検診の便潜血陽性を主訴に近医にて下部消化管内視鏡検査が行われ、2型上行結腸癌と診断された。術前の上部消化管内視鏡検査で、体中部後壁大彎に12mm大の0-IIa病変(tub1)を指摘された。上行結腸癌(cT3N1M0、Stage IIIa)、胃癌[cT1a(M)、N0、M0、Stage IA]の診断で、上行結腸癌に対して手術を先行、その後内視鏡的胃粘膜下層剥離術を行う方針とした。腹腔鏡補助下結腸右半切除、D3郭清を施行。術後経過良好で12病日に退院した。病理組織診断はtub1、pT3N2(4/15)、Stage IIIbで、35病日から術後補助化学療法としてCapeOXを6ヵ月間施行した。その後、上部消化管内視鏡検査を施行したが病変は指摘できず、6ヵ月後の再検でも同様であった。補助化学療法開始後1年6ヵ月経過したが、胃癌は臨床的に完全奏効の状態である。(著者抄録)

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症例は34歳、女性。同時性多発肝転移を伴う直腸癌の診断で当院を紹介された。CT検査で肝S4、S5、S7に腫瘤を認め、治癒切除のためには右三区域切除が必要であった。CT volumetry検査では切除後の予測残肝容積率は24.6%であり、切除不能肝転移と判断した。下血の症状があることから原発巣切除を先行した。原発巣術後に、全身化学療法としてcapecitabine/oxaliplatin+bevacizumabを5コース施行した。新規病変はみられず、Response Evaluation Criteria in Solid Tumors判定でpartial responseであった。門脈右枝塞栓術を施行し、予測残肝容積率は38.4%まで増大した。切除可能と判断して肝右三区域切除を行い治癒切除となった。肝切除から3年6ヵ月経過し再発を認めていない。(著者抄録)

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症例は69歳、男性。主訴は肛門痛。肝転移、側方リンパ節転移を伴う直腸癌[Rb](cT3N3M1a)、S状結腸癌(cT1N0M0)、上行結腸癌(cTisN0M0)と診断された。全身化学療法としてirinotecan+S-1を施行後、腫瘍は著明に縮小し、低位前方切除、回盲部切除を行った。その後、肝転移巣に対し肝前区域切除、S2部分切除を行い、術後にS-1を22ヵ月服用した。さらにCT検査で右肺S2、S6に転移巣を指摘され、右肺部分切除を行った。7ヵ月後のCT検査で左鎖骨上リンパ節の腫大が指摘され、Virchowリンパ節の単独転移と判断し切除を行った。切除後3ヵ月後に肺転移が出現したため、mFOLFOX6、FOLFIRI、capecitabine+bevacizumabによる全身化学療法を施行した。その後、肺病変は増大、左鎖骨上リンパ節も再増大し、緩和治療に移行した。Virchowリンパ節切除後、3年1ヵ月で永眠された。肝転移、肺転移切除後に生じたVirchowリンパ節転移を切除し、初回手術から6年の長期生存を得た症例を経験したので報告する。(著者抄録)

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目的:当科における単孔式人工肛門造設術の手術成績を明らかにする。対象・方法:2011年4月〜2013年7月の間に当院で単孔式人工肛門造設術を施行した連続10症例において、安全性、短期的な手術成績を検討した。全例でストーマサイトを切開し、プラットフォームにEZアクセスを用いた。結果:年齢中央値(範囲)は60.5(31〜75)歳、男性5例、女性5例。原疾患は、直腸癌3例、S状結腸癌1例、子宮癌3例、乳房外パジェット病2例、会陰神経線維腫1例であった。手術時間の中央値(範囲)は59.5(40〜91)分、出血量0(0〜10)mL、術後経口摂取開始時期2.5(1〜4)病日、術後の在院日数は11(5〜19)日であった。術後短期の合併症はみられなかった。結論:単孔式人工肛門造設術は、安全性、術後の短期成績ともに良好で、QOL改善に寄与していると思われた。(著者抄録)

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症例は57歳、女性。検診便潜血陽性の精査で、多発肝転移を伴う下行結腸癌(1/4周、低分化腺癌)と診断された。肝転移はMRI検査で両葉に13個認め、術前化学療法の方針となった。capecitabine/oxaliplatin(CapeOX)+bevacizumab(BV)療法を9コース施行したところ、原発巣は瘢痕化、肝転移は5個と減少し、partial response(PR)と判定し、左結腸切除術、肝部分切除術を施行した。術中超音波検査では肝臓に7病変を認め、すべて部分切除が可能でR0の手術となった。病理診断では原発巣は癌細胞を認めず、肝転移は切除した7病変のうち4病変にわずかに癌細胞の残存を認めるのみであった。術後11ヵ月目に肝S5に単発の肝転移を認め、腹腔鏡補助下肝部分切除術を施行した。現在、21ヵ月無再発生存中である。CapeOX+BV療法は切除不能肝転移大腸癌に対して、根治切除を可能とする有用な治療法と考えられた。(著者抄録)

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Language：Japanese  

症例は71歳、男性。28歳時、膀胱癌に対して膀胱全摘術、回腸導管による尿路変向術が施行されていた。腸閉塞症状を繰り返すため当院を受診した。腹部骨盤部CT検査で、上行結腸に腫瘤性病変を認めた。腫瘤による腸閉塞と診断し緊急手術の適応と判断したが、全身状態が不良であり小腸人工肛門造設を行った。術後の栄養管理により全身状態は改善した。術中所見、術後の注腸造影検査で上行結腸癌と診断、根治手術の方針とした。術中所見では回腸導管に浸潤する上行結腸癌を認めたが、尿管回腸導管吻合部、回腸導管腸間膜の温存は可能であると判断した。回腸導管の部分切除を含めた右側結腸切除を行い、治癒切除となった。病理結果はtype2、55×44mm、tub1、med、T4b(回腸導管)N0M0、pStage IIであった。術後15ヵ月経過し再発を認めていない。局所進行上行結腸癌に対して回腸導管部分切除を行うことで、治癒切除となった1例を経験したので報告する。(著者抄録)

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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＜Point＞▼創傷治癒にはエネルギーや栄養素が必要である▼創傷治癒形式には、一期治癒、二期治癒、三期治癒の形式がある▼周術期栄養管理は、創傷治癒を円滑にし、術後合併症を減らし術後回復を順調にすることである(著者抄録)

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japan Society of Coloproctology  

Metastasis of a carcinoma of the right-sided colon to the gastric regional lymph nodes is rare.<BR>Case 1: A 54-year-old male diagnosed with carcinoma of the ascending colon was admitted to our hospital for surgery. Intraoperative findings showed direct invasion to the omentum and transverse colon, and metastases to the omental and gastric regional lymph nodes (No. 4d) were suspected. Extended right hemicolectomy with dissection of the No. 4d lymph nodes was performed. Microscopic findings of the resected specimen revealed metastases of the omental and No. 4d lymph nodes.<BR>Case 2: A 59-year-old male diagnosed with carcinoma of the cecum was admitted to our hospital for surgery. Intraoperative findings revealed direct invasion to the omentum, and metastasis to the No. 4d lymph nodes was suspected; therefore, a right hemicolectomy with dissection of No. 4d lymph nodes was performed. Microscopic findings of the resected specimen revealed metastases to the omental and No. 4d lymph nodes. Postoperative adjuvant chemotherapy was administered in both cases. Both patients survived for over 10 years without recurrence. For cases of metastases to the gastric regional lymph nodes from a carcinoma of the right-sided colon, radical dissection may increase long-term survival.

DOI： 10.3862/jcoloproctology.67.173

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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A 60-year-old man who had received pylorus-preserving pancreatoduodenectomy for pancreatic head cancer 16 years previously underwent total gastrectomy, total pancreatectomy and splenectomy for cancer of the residual pancreatic body in October 2010. On post-operative day 3, he developed hepatorenal failure and disseminated intravascular coagulation and computed tomography revealed an alveolar internal structure in the left liver lobe, indicating a gas-forming liver abscess. Drainage was performed via a midline incision on post-operative day 7, and slight improvement in hepatorenal failure and disseminated intravascular coagulation was achieved. However, as inflammation and computed tomography findings remained unchanged, on post-operative day 15 the left liver lobe was resected to the extent possible and additional drainage was performed. The resected liver tissue exhibited sponge-like degeneration, all vascular tissue had disappeared and complete avascular necrosis had occurred. Based on these findings, gas gangrene of the liver was diagnosed. From post-operative day 40, the necrotized liver tissue naturally exfiltrated from the open midline incision and after 11 sharp surgical debridements, left liver lobe necrotic tissue was absent and inflammation had mostly resolved. Conventional drainage alone is insufficient to cure gas gangrene of the liver accompanying ischemia
removal of the necrotic tissue is required. © 2013 The Japanese Society of Gastroenterological Surgery.

DOI： 10.5833/jjgs.2012.0159

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We report a case of rectal cancer resulting in a pathologically complete response of the primary tumor by systemic chemotherapy with panitumumab, a new endothelial growth factor receptor (EGFR) antibody. A 56-year-old man was diagnosed as having unresectable Stage IV rectal cancer with local invasion and lung metastasis, and underwent systemic chemotherapy by FOLFOX, combined with panitumumab as a first-line therapy. After 3 courses of FOLFOX and 3 courses of FOLFOX with panitumumab, the treatment regimen was changed to FOLFIRI with panitumumab to prevent peripheral neuropathy. After 5 courses of FOLFIRI with panitumumab, pelvic computed tomography (CT) revealed that the primary tumor was markedly reduced, and the intrapelvic direct invasion was resolved. On the post-treatment chest CT, lung metastasis had disappeared. A low anterior resection preserving the automatic nerves, the colonic J-pouch and anal anastomosis, was performed 20 days after the last chemotherapy. Although the whole tumor-like lesion of the specimen was sectioned macroscopically at 5-mm intervals, no vivid tumor cells were detected at the pathological examination. The patient's postoperative course was uneventful, and no recurrence occurred 5 months after the operation. The EGFR receptor antibody is reported to have a significant anti-cancer effect for colorectal cancer without the KRAS gene mutation. In cases with relatively large tumors especially, EGFR antibody can be an effective first-line treatment.

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切除不能Stage IV直腸癌に対し、新規分子標的治療薬の抗上皮成長因子受容体(endothelial growth factor receptor:EGFR)薬であるpanitumumabを用いた化学療法を行い、病理学的完全寛解(complete response:CR)が得られた1例を報告する。症例は56歳、男性。局所浸潤と肺転移を伴う切除不能直腸癌に対して、一次治療としてFOLFOXとpanitumumabの併用化学療法を行った。FOLFOXを計6回(そのうちpanitumumabとの併用を3回)行った後、末梢神経障害の予防目的にFOLFIRIとpanitumambの併用治療に変更した。同治療を5回施行した後、CT検査で骨盤内の周囲直接浸潤所見は改善し、肺転移は消失した。最終化学療法から20日後に自律神経全温存の超低位前方切除および結腸嚢-肛門吻合術を施行した。肉眼的に腫瘍様にみえる部分を全割して病理学的検索を行ったが、大部分が肉芽組織に置換され、わずかに残る癌細胞もすべて変性・壊死しており、病理学的CRと診断した。術後経過は良好で、手術5ヵ月後の時点で再発を認めていない。抗EGFR薬はKRAS遺伝子に変異のない大腸癌に対して、良好な治療成績が報告され、特に腫瘍量の多い症例に対しては、一次治療として有効な選択肢の一つと考えられる。(著者抄録)

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巨大腹腔内膿瘍から肺炎・成人呼吸窮迫症候群(ARDS)をきたし、挿管・人工呼吸器管理と経皮的膿瘍ドレナージを施行したが、入院8日(全経過約3ヵ月)で死亡した20歳代男性例を経験した。剖検所見では、膿瘍壁の各所で胃腸管間質腫瘍(gastrointestinal stromal tumor、以下GIST)の所見が観察され、GISTの穿孔は認めず、腫瘍内部が嚢胞化し腸内細菌の感染が起こり膿瘍を呈したものと考えた。膿瘍壁と胃内腔との間には細い瘻孔が形成されており、胃や十二指腸にも膿瘍内と同様の膿が少量存在した。高度の肺炎とGIST内膿瘍による敗血症が死因と考えられた。GIST内嚢胞化・膿瘍化の機序を考察するために自験27例のGISTについて嚢胞の有無、背景病変の検討を行った。(著者抄録)

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腹腔鏡下胆嚢摘出術は近年、より低侵襲で整容性に優れた手技として単孔式腹腔鏡下手術が試みられており、その方法も様々である。今回我々はその一手法であるグローブ法を経験したので報告する。対象は3例(男性1名、女性2名)2例は胆石症、1例は胆嚢腺筋症であった。3例の平均手術時間は75分、術中出血は全例とも少量、トロッカーの追加挿入、開腹移行例も認めなかった。術後経過も通常の腹腔鏡下手術と同等であり、合併症もなく、臍部切開創の感染も認めなかった。平均在院期間は5日であった。グローブ法は、カメラと鉗子の干渉は存在するものの十分に実用的であり、従来の腹腔鏡下手術に代わるスタンダードとなり得ると思われた。(著者抄録)

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腹腔鏡下胆嚢摘出術は近年, より低侵襲で整容性に優れた手技として単孔式腹腔鏡下手術が試みられており, その方法も様々である. 今回我々はその一手法であるグローブ法を経験したので報告する. 対象は3例 (男性1名, 女性2名) 2例は胆石症, 1例は胆嚢腺筋症であった. 3例の平均手術時間は75分, 術中出血は全例とも少量, トロッカーの追加挿入, 開腹移行例も認めなかった. 術後経過も通常の腹腔鏡下手術と同等であり, 合併症もなく, 臍部切開創の感染も認めなかった. 平均在院期間は5日であった. グローブ法は, カメラと鉗子の干渉は存在するものの十分に実用的であり, 従来の腹腔鏡下手術に代わるスタンダードとなり得ると思われた.

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Language：Japanese   Publisher：Japanese Society for Abdominal Emergency Medicine  

Several methods of temporary abdominal closure (TAC), utilizing various materials, are employed during damage control surgery. We describe a case of TAC using a silo closure method that adopted a wound retractor (Applied AlexisTM). A 17-year-old man who was injured in a motorcycle traffic accident was brought to our hospital in an ambulance. He suffered from compound multiple pelvic fractures with broad genital laceration. He developed hemorrhagic shock due to massive bleeding from the laceration, so pelvic gauze packing was used to achieve hemostasis during laparotomy. Hemostasis was attained after the packing, but because of his serious injury, we determined that a planned reoperation was required. With the aim of accomplishing the TAC procedure, an extra-wound ring of Applied AlexisTM was applied and rotated to keep the peritoneal cavity airtight, and was then covered over with a sterilized drape. On the fourth day after the pelvic gauze packing, the gauze was removed, a sigmoid-colostomy was performed, and then the abdominal wall was closed. We successfully released the patient from the TAC and were able to do the second laparotomy rapidly and easily. No surgical site infection developed during the perioperative period. We suggest this unique technique preserves the viscera from physical injury and surgical site infection, and also reduces abdominal compartment syndrome, as well as enabling spontaneous silo closure for gastroschisis.

DOI： 10.11231/jaem.31.777

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Language：Japanese   Publisher：Japanese Society for Abdominal Emergency Medicine  

damage control surgeryにおいて創部保護リトラクターApplied Alexis(Alexis)を用いたsilo closure法で一時的閉腹を行った1例を報告する。症例は17歳男性。自動二輪運転中の事故で肛門近傍の陰部裂創とそれに連続する開放骨盤骨折を受傷し,当院へ搬送された。陰部裂創からの出血によりショックとなったが,体表からの止血は困難であったため,開腹し骨盤内ガーゼパッキングを行い止血した。後日にplanned reoperationを行う方針とし,術中使用したAlexisの創外リングを捻転してairtightとし,滅菌ドレープで被覆して一時的に閉腹した。第4病日にガーゼ抜去と人工肛門造設を行った。Alexisによる閉腹と再開腹は迅速かつ容易に行い得た。術後腹部手術部位感染を認めなかった。Alexisを用いたsilo closure法は,気密性の高い腹腔閉鎖を可能とし,臓器保護や感染に対して有効である。また,abdominal compartment syndromeへはAlexisによる吊り上げsiloでの対応を検討すべきである。(著者抄録)

DOI： 10.11231/jaem.31.777

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Language：Japanese   Publisher：The Japan Society of Coloproctology  

症例1は31歳女性.23歳時に全大腸炎型の潰瘍性大腸炎(UC)と診断され,ステロイド内服をしていた.腹部膨満感の精査で上行結腸から横行結腸にかけての腸管嚢腫様気腫症(PCI)を認めた.PCIの症状は保存的治療にて軽快したが,ステロイド依存性のUCのため,大腸全摘術を行った.病理組織検査では,盲腸から下行結腸にかけて粘膜下層に嚢胞を認めた.症例2は34歳男性.24歳時に左側結腸炎型のUCと診断され,ステロイドの内服を開始したが,ステロイド依存性のため手術の方針となった.術前の精査で上行結腸から肝彎曲部にかけてPCIを認めた.手術は大腸全摘術を行った.病理組織検査では盲腸から上行結腸にかけて粘膜下層に多発する嚢胞を認めた.UCの治療期間中にPCIを合併することは稀である.PCIを合併したUCの手術を2例経験したので報告する.(著者抄録)

DOI： 10.3862/jcoloproctology.64.433

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Language：Japanese   Publisher：新潟医学会  

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直腸脱は比較的稀な良性疾患であり、生命予後に直接影響を及ぼすことはないが、患者には身体的にも精神的にも大きな負担となり、生活の質は著しく低下する。現在まで直腸脱の手術は様々な術式が報告されている。経肛門的手術は、容易で手術時間も短く、手術侵襲や術後の合併症も少ないことが長所だが、再発率が高いという短所がある。経腹的手術は術後再発率が低いという長所があるが、全身麻酔が必要であること、手術時間が長く侵襲も大きくなることが短所である。直腸脱に対する腹腔鏡下直腸吊り上げ固定術は、従来の開腹手術では両立し難かった低侵襲、根治性を兼ね備えた有効な治療法として急速に普及しつつある。今回我々は腹腔鏡下直腸吊り上げ固定術による直腸脱の治療を経験したので報告する。症例は67歳、女性。気管支喘息、アレルギー性肉芽腫性血管炎、結節性多発性動脈炎の既往があり、ステロイド内服中であった。2年前から続く直腸脱に対し、腹腔鏡下でS状結腸間膜、直腸間膜を十分授動した後、ポリプロピレンメッシュを用いたWells法にて直腸を仙骨前面に吊り上げ固定した。その後、腹膜の閉鎖ならびにダグラス窩を浅く形成する目的でダグラス窩の挙上再建を行った。術後特に合併症なく経過し、現在まで再発を認めていない。腹腔鏡下直腸吊り上げ固定術は、腹腔鏡下直腸切除術を行っている施設であれば比較的安全に施行可能な術式であり、低侵襲性とその低い再発率を考慮すると、全身麻酔が可能な症例に対しては今後第一選択になりうる術式であると考えられる。(著者抄録)

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症例は64歳,男性.2009年1月,胸痛の精査をしたところ,Debakey IIIb型の大動脈解離と診断された.破裂の所見はなく,血圧コントロールを行いながら保存的治療の方針となった.2ヵ月後,右下腹部痛が出現した.下部内視鏡検査で上行結腸に限局性の狭窄が認められた.内視鏡的拡張術を行ったが拡張されなかった.症状が改善せず,狭窄も高度のため内科的治療の限界と考えた.手術適応と判断して腹腔鏡補助下回盲部切除を行った.病理組織学的標本では憩室や特異炎症はみられず,瘢痕組織による狭窄と診断された.術後の経過は良好で術後6病日に退院となった.退院後は腹痛などもみられず,外来経過観察中である.(著者抄録)

DOI： 10.11477/mf.1407103042

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Society of Gastroenterological Surgery  

Nonsteroidal antiinflammatory drugs (NSAIDs) negatively affects the upper and lower digestive tract. We report two cases of perforation of the lower digestive tract induced by NSAIDs. Case 1: A 75-year-old woman reporting back pain and malaise on day 1 from her first use of lornoxicam for tendovaginitis was found in abdominal computed tomography (CT) to have thickening of the descending colon and free air in the retroperitoneal space, necessitating surgery that showed one perforation of the transverse colon and two of the descending colon. We conducted left hemicolectomy and setting of the ascending colostomy. Case 2: A 72-year-old woman reporting abdominal pain on day 7 after her first use of sulpyrine for fever was found in abdominal CT to have thickening of the ileocecal region and free air around the liver, necessitating emergency surgery that showed two perforations-one in the terminal ileum and another in the transverse colon with serositis of the sigmoid colon. We conducted ileocecal resection and partial resection of the transverse and sigmoid colon, and setting of the ileostomy and mucous fistula In colon perforation induced by NSAIDs, several perforations and ulcers may occur separately, requiring extensive colon resection. © 2009 The Japanese Society of Gastroenterological Surgery.

DOI： 10.5833/jjgs.42.404

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Language：Japanese   Publisher：(一社)日本内視鏡外科学会  

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72歳女性。患者は2006年10月末に糖尿病性腎症による腎機能低下のため腹膜透析の適応となり、腹膜透析カテーテル挿入術が施行された。その後、順調に腹膜透析を行っていたが、2007年1月頃よりカテーテルの注・排液が不良となり、精査にてカテーテル位置異常を認めた。α整復術にて修復不可能であったため著者らの施設へ紹介となり、腹部単純X線で腹膜透析カテーテルの先端を右側腹部に認め、このカテーテル位置異常に対し、腹腔鏡下でカテーテル位置を整復し、PWATを用いてカテーテルを腹壁に固定した。その結果、術後は経過は良好で、術後3ヵ月経過、現在も位置異常は認めず、腹膜透析を継続中である。

DOI： 10.11477/mf.4426100209

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症例は55歳男性。会社の除雪作業中にスリップし転倒。スコップの柄で心窩部を強打し当科初診。受診時,症状ならびに腹部所見にとぼしく一旦帰宅したが,次第に腹痛が増強し入院。翌日の腹部CTにて十二指腸損傷,後腹膜穿孔を疑い緊急手術を施行した。十二指腸水平部の前壁と後壁の2ヶ所に穿孔部を認めた。穿孔部を単純閉鎖の後,十二指腸内腔の減圧が重要と判断し,胃空腸吻合,ブラウン吻合,胃管による十二指腸減圧,外胆汁瘻,さらに栄養空腸瘻を造設した。術後は腹腔内膿瘍,肝機能障害を認めたが,縫合不全なく軽快退院した。外傷性十二指腸損傷,後腹膜穿孔は縫合不全の併発が高率で予後不良とされているが,減圧術の組み合わせで良好な経過を得た。(著者抄録)

DOI： 10.11231/jaem.28.489

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Language：Japanese  

DOI： 10.11477/mf.1407102018

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症例は53歳女性で、検診にて異常を指摘され来院し、精検の上部消化管内視鏡で胃体中部前壁に0-IIc+IIa病変を認め、生検により印環細胞癌と診断され、手術目的で入院となった。手術では全身麻酔・硬膜麻酔下に幽門側胃切除術を施行、術中の心電図に異常所見は認めなかったが、麻酔覚醒時から背部痛を訴え、術後1日目の検査所見から心筋梗塞が疑われ緊急カテーテル検査が施行された。心エコー検査では心尖部を中心に壁運動の低下を認めたが、心駆出率は66%と正常範囲であり、心カテーテル検査では冠動脈の狭窄や閉塞は認めず、左室造影では心基部のみが収縮し心尖部は殆ど収縮せず、いわゆる「たこつぼ型」を呈していた。以上の所見から胃癌術後に発症したたこつぼ型心筋障害と診断、ジクロフェナクナトリウム坐薬とペンタゾシンによる除痛を行いつつ維持輸液による点滴で4日目には胸痛は消失した。術後3日後の心エコーでは心尖部に僅かな壁運動の低下を持続するものの、全体的に壁運動は良好であったが、5日目の心電図では発症直後に認められた異常Q波・陰性T波は持続していた。発症後2週間目に症状の再発を認めないことから退院となり、外来にて経過観察となったが、1ヵ月後の心エコーでは壁運動は正常に改善し、6ヵ月後の検査でも異常所見は認めなかった。発症から約22ヵ月を経過した現在、胸痛症状の再発は認めていない。

DOI： 10.11477/mf.1407102018

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We report on a single case of a 55-year-old man with a traumatic duodenal injury caused by a snow shovel. The patient complained of severe abdominal pain and so he was admitted for observation. Next day, abdominal computed tomography (CT) showed retroperitoneal rupture of Bthe duodenum and an emergency operation was performed. A laparotomy revealed double perforation, both anterior and posterior wall, of the duodenum in the third portion and retroperitoneal inflammation. All wounds were closed with Albert-Lembert sutures, and a gastrojejunostomy with Braun&#039;s anastomosis, catheter jejunostomy and external biliary drainage were performed for drainage of the duodenal contents. The postoperative course showed no serious complications, such as anastomotic leakage. We considered that the combination of some of the decompression treatments we performed was a simple and useful operation for duodenal rupture.

DOI： 10.11231/jaem.28.489

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Language：Japanese   Publisher：特定非営利活動法人 日本小児外科学会  

DOI： 10.11164/jjsps.44.7_991_4

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Language：Japanese   Publisher：Japan Surgical Association  

今回われわれは腸閉塞を伴う直腸癌の術前精査にて偶然発見された非常に稀とされる肝細胞癌と胆管細胞癌の重複癌を合併した同時性3重複癌の症例を経験した.症例は84歳,男性.以前よりHCV感染を指摘されていたが無治療であった.腹部膨満にて発症,精査にて直腸癌による腸閉塞と診断.また,術前の腹部超音波検査で肝のS5に3×2cm大,S7に2×2cm大の原発性肝細胞癌と考えられる腫瘤を認めた.手術は低位前方切除,肝S5,7の部分切除術を施行した.術後病理組織診断で肝S5の腫瘤を肝細胞癌,肝S7の腫瘤は胆管細胞癌と診断され,それぞれの腫瘤間に連続性のないことから重複癌と判断した.肝細胞癌と胆管細胞癌が同一の肝臓に異所性に発生する重複癌は極めて稀な疾患であり,その予後は肝細胞癌,胆管細胞癌いずれの単独例よりも悪いと報告されている.当症例では直腸癌に合併していたことで早期発見ができ,いずれも遺残なく摘出することができた.現在までの術後17ヵ月間再発なく生存している.(著者抄録)

DOI： 10.3919/jjsa.67.2232

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症例は77歳の女性.2002年夏より頸部腫瘤の増大を訴え,近医受診.精査にて甲状腺乳頭癌と診断された.当科での術前CT,MRIで甲状腺左葉に10×9.5×6.5cm大の腫瘍と左内頸静脈内に腫瘍塞栓を認めた.術中所見では5cm大の左内頸静脈内腫瘍塞栓を認め,甲状腺全摘術と左内頸静脈の合併切除を施行し,肉眼的には癌の遺残を認めなかった.甲状腺分化癌は一般的に予後良好な腫瘍であるが,局所浸潤をきたす症例は比較的予後不良であるとされる.内頸静脈浸潤を伴った甲状腺分化癌の外科的治療は,現在まで数症例でその有用性が報告されている.特に肉眼的に腫瘍を摘出しうることが重要であるとされる.本症例は肉眼的腫瘍の遺残なく,手術を施行し,術後TSH抑制療法にて経過観察中である.本人の希望により131I内照射療法は施行されていないが,術後現在まで28ヵ月間,再発を認めない(著者抄録)

DOI： 10.3919/jjsa.67.28

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A 77-year-old woman presented with an enlarged cervical mass for nine months. Fine needle aspiration cytology of the mass showed papillary carcinoma. Preoperative contrast enhanced computed tomogram and magnetic resonance imaging scan of the neck revealed a 10&amp;times;9.5&amp;times;6.5cm tumor with extensive tumor thrombi in the left internal jugular vein. A total thyroidectomy with modified radical neck dissection, combined with resection of the left internal jugular vein was performed and the entire tumor including tumor thrombi was removed macroscopically.&lt;br&gt; Patients with differentiated thyroid carcinoma, especially papillary carcinoma rarely develops macroscopic tumor thrombus. Only a few cases of differentiated thyroid carcinoma showing such invasive nature have been reported, but they generally had a poor prognosis and high mortality. This patient has been followed for 28 months after successful operation without recurrence.

DOI： 10.3919/jjsa.67.28

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Language：Japanese   Publisher：Niigata University  

全身性炎症反応(発熱,白血球数増多,血清CRP値上昇)は急性虫垂炎の診断に際して有用な所見とされている.今回,全身性炎症反応を欠く急性虫垂炎穿孔症例を経験したので文献的考察を加えて報告する.症例は57歳,女性.右下腹部痛を主訴に当院を受診した.右下腹部を中心に下腹部全体に圧痛,筋性防御を認めたが,発熱,白血球数増多,血清CRP値上昇等の全身性炎症反応は見られなかった.CT検査では,盲腸壁肥厚,少量の腹水,糞石を認めた.腹部所見,CT所見から穿孔性腹膜炎を合併する急性虫垂炎と診断し,虫垂切除術および腹腔ドレナージを施行した.臨床医は,急性虫垂炎が穿孔して腹膜炎を生じても全身性炎症反応を欠く症例があることを銘記すべきである(著者抄録)

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Society of Gastroenterological Surgery  

Extragonadal teratoma originating from the mesentery is extremely rare. A 45-year-old man was found in computed tomography and ultrasonography to have a round, well-encapsulated cystic mass with partial calcification in the right abdomen. Serum CEA was 138ng/ml and serum CA 19-9 53U/ml, suggesting potential malignancy. At laparotomy, the 9 × 5cm tumor was located in the mesentery of the ileocecal region. Because it was well encapsulated, we excised the tumor without bowel resection. The histopathological diagnosis of benign mature mesenteric teratoma was made postoperatively. Serum CEA and CA 19-9 normalized within 2 months of surgery. This is, to our knowledge, the first reported case of mesenteric teratoma with high serum CEA and CA 19-9. To diagnose mesenteric tumors, benign mesenteric teratoma should be considered. Because tumor resection is appropriate surgical management for mesenteric teratoma, bowel resection should be avoided to minimize surgical stress. ©2005 the Japanese Society of Gastroenterological Surgery.

DOI： 10.5833/jjgs.38.690

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Japanese Society of Gastroenterological Surgery  

Extragonadal teratoma originating from the mesentery is extremely rare. A 45-year-old man was found in computed tomography and ultrasonography to have a round, well-encapsulated cystic mass with partial calcification in the right abdomen. Serum CEA was 138ng/ml and serum CA 19-9 53U/ml, suggesting potential malignancy. At laparotomy, the 9 × 5cm tumor was located in the mesentery of the ileocecal region. Because it was well encapsulated, we excised the tumor without bowel resection. The histopathological diagnosis of benign mature mesenteric teratoma was made postoperatively. Serum CEA and CA 19-9 normalized within 2 months of surgery. This is, to our knowledge, the first reported case of mesenteric teratoma with high serum CEA and CA 19-9. To diagnose mesenteric tumors, benign mesenteric teratoma should be considered. Because tumor resection is appropriate surgical management for mesenteric teratoma, bowel resection should be avoided to minimize surgical stress. ©2005 the Japanese Society of Gastroenterological Surgery.

DOI： 10.5833/jjgs.38.690

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入院急性虫垂炎症例を,虫垂切除術24例(男13例・女11例,平均34.6歳:A群),虫垂切除術+腹腔ドレナージ術28例(男14例・女14例,平均48.3歳:B群),保存的治療73例(男44例・女29例,平均30.8歳:C群)に分類し検討した.C群に対しB群で有意に平均年齢が高く,C群で男女数の差を認めた.A群,C群に比べB群の平均入院期間は有意に長かった.経口摂取開始までの平均日数についてA群はB群に対し有意に短かく,抗生物質の平均使用期間についてC群はB群に対し有意に短かった.病理学的に保存的治療+カタル性78例(E群),蜂窩織炎性32例(F群),壊疽性15例(G群)に分類し検討したところ,Blumberg徴候,筋性防御の陽性率はE群に対しF群,G群で有意に高率であった.入院時の白血球数平均値はE群に対しF群で,CRPはE群に対しG群で有意に高値であった.腹部CT所見では,虫垂の腫大,糞石の陽性率はE群に対しF群,G群が有意に高く,腹水陽性率はG群が他群より有意に高率であった

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Publishing type：Research paper (scientific journal)   Publisher：Springer Science and Business Media LLC  

DOI： 10.1007/s10388-004-0020-6

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Other Link： http://link.springer.com/article/10.1007/s10388-004-0020-6/fulltext.html

Language：Japanese   Publisher：新潟医学会  

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は30歳代、女性。家族歴は父、父方祖父、母方祖母が大腸癌である。高頻度マイクロサテライト不安定性(high-frequency microsatellite instability:MSI-H)Stage II大腸癌の術後経過観察中に、腹膜播種再発および多発大腸癌を指摘された。現病歴および家族歴からリンチ症候群が疑われたため、当院を紹介された。当院では腹膜播種再発と、その後の腹膜播種再々発に対して2回のR0切除術を施行した。腹膜播種再発の癌組織を用いて、次世代シークエンサーを用いた遺伝子パネル検査を施行したところ、MSH2変異(c.A2211-2G)を認めた。本症例では、生殖細胞系列におけるMSH2変異がリンチ症候群の原因遺伝子変異となり、MSI-H大腸癌の発生に関与している可能性がある。今後は、必要に応じて遺伝カウンセリングや生殖細胞系列の遺伝子変異検査を実施する予定である。(著者抄録)

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

症例は68歳,男性.慢性腎不全による高カリウム血症に対しポリスチレンスルホン酸ナトリウムを内服中に急性心不全を発症し,弁置換術,弁形成術が施行された.術後9日目に腹痛と血便が出現した.上行結腸壊死による汎発性腹膜炎と診断し,結腸右半切除と二連銃式の人工肛門造設術を行った.術後半年後の人工肛門閉鎖の際に左側結腸に狭窄を認め,残存結腸全摘,直腸S状部切除を行った.下行結腸に著明な狭窄を伴う縦走潰瘍瘢痕を,S状結腸に潰瘍形成を認めた.病理組織検査では狭窄部,潰瘍部の腸管壁内に好塩基性結晶様異物を認め,異物反応を伴っていた.ポリスチレンスルホン酸塩が腸管壁内に取り込まれると排除困難で,慢性的な異物反応や炎症により組織障害が遷延する可能性がある.慢性腎不全患者の腸管壊死,穿孔,腸炎に対し手術を行う際には,ポリスチレンスルホン酸塩製剤の内服歴を確認し,腸切除範囲の決定や吻合の可否に注意する必要がある.(著者抄録)

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2020&ichushi_jid=J01146&link_issn=&doc_id=20200131180003&doc_link_id=10.3862%2Fjcoloproctology.73.64&url=https%3A%2F%2Fdoi.org%2F10.3862%2Fjcoloproctology.73.64&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Language：Japanese   Publisher：(一社)日本腹部救急医学会  

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Language：Japanese   Publisher：(株)癌と化学療法社  

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は37歳、男性。家族性大腸腺腫症および直腸癌、cT3N0M0、cStage IIの診断で、大腸全摘、回腸嚢肛門吻合、D3リンパ節郭清術を施行した。病理組織学的診断の結果は直腸癌、pT3N1M0、pStage IIIaであったため、術後補助化学療法としてS-1の内服を開始した。術後3ヵ月目に肝転移(S5、S6)を認め、腹腔鏡下肝部分切除術を施行した。術後24ヵ月後、肝転移再発(S2、S8)を認め、開腹肝部分切除術を施行した。術後41ヵ月後、右肺S6、S9に転移を認め、胸腔鏡補助下肺部分切除術(S6、S9)を行った。転移巣に対し外科的切除を行い、長期生存を得られている家族性大腸腺腫症に伴う直腸癌の1例を経験した。複数回の肝転移切除術、肺転移切除術の意義を示す症例として報告する。(著者抄録)

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2019&ichushi_jid=J00296&link_issn=&doc_id=20200117590106&doc_link_id=%2Fab8gtkrc%2F2019%2F004613%2F106%2F2228-2230%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fab8gtkrc%2F2019%2F004613%2F106%2F2228-2230%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(株)癌と化学療法社  

背景:婦人科悪性腫瘍に対して、婦人科医と消化器外科医による合同手術がしばしば行われているが、その術後成績については明らかでない。目的:婦人科悪性疾患手術時に消化器外科医が介入した症例について、術式、合併症、予後などの術後成績を明らかにすることを目的とした。対象と方法:2010年1月〜2014年12月までの5年間の73例を対象とした。疾患、術式、術後合併症、ストーマの有無、入院期間、予後などを検討した。結果:年齢中央値(範囲)は60(15〜78)歳、73例全例が女性であった。緊急手術が8例(11.0%)含まれていた。疾患は、卵巣癌が56例(76.7%)と最も多く、Stageの内訳はStage I/II/III/IV/再発:4/4/20/11/17例であった。25例(34.2%)で腸管切除吻合が行われていた。また、22例(30.1%)でストーマが造設されていたが、本検討ではストーマ閉鎖を行えた症例はなかった。手術時間(婦人科原発巣手術時間も含む)中央値(範囲)は252(37〜690)分であり、出血量は1,190(0〜11,210)mLであった。術後の合併症(Clavien-Dindo II以上)として、イレウス6例(8.2%)、腹骨盤内膿瘍4例(5.5%)、縫合不全2例(2.7%)などがみられた。Grade III以上の合併症としてはイレウス、縫合不全、腹水、膵液瘻がそれぞれ1例ずつ認められた。卵巣癌全症例の術後生存期間中央値は1,399日であった。結論:婦人科との合同手術のなかで、消化器外科医は進行卵巣癌の手術に携わることが多い。ストーマを造設した症例のストーマ閉鎖は困難であるが、消化管切除を含む腫瘍切除によって予後の延長に寄与することが期待される。(著者抄録)

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2019&ichushi_jid=J00296&link_issn=&doc_id=20200117590089&doc_link_id=%2Fab8gtkrc%2F2019%2F004613%2F089%2F2176-2178%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fab8gtkrc%2F2019%2F004613%2F089%2F2176-2178%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(株)癌と化学療法社  

症例は62歳、男性。主訴は血便。下部消化管内視鏡検査で、下部直腸に5cm大の直腸癌が指摘された。組織型は高分化管状腺癌であり、腫瘍下縁は肛門管近傍まで達していた。腹部骨盤部造影CT検査で直腸間膜リンパ節転移が指摘され、進行直腸癌(cT3N1P0M0、Stage IIIa、大腸癌取扱い規約第8版)と診断された。本人が肛門温存を希望したため、前医で術前化学療法の方針となった。化学療法としてcapecitabine、oxaliplatin(CapeOX)+bevacizumab(BV)療法が12コース施行された。化学療法後の下部消化管内視鏡検査で腫瘍は著明に縮小し、肉眼的には厚みのある瘢痕のみとなっていた。瘢痕からの生検では悪性所見を認めなかった。しかし画像検査で直腸壁の肥厚は残存していたため、化学療法の効果判定はpartial response(縮小率40%)、ycT3N0M0、ycStage IIと診断した。肛門温存手術が可能と判断して、括約筋間直腸切除術、一時的回腸人工肛門造設術を施行した。切除標本の組織診断では主病巣に悪性細胞を認めず、リンパ節転移も陰性であった。原発巣切除後6ヵ月目に小腸人工肛門閉鎖術を施行した。術後追加治療を行わずに外来で経過観察中であるが、再発の所見は認めていない。CapeOX+BV療法によって組織学的完全奏効が得られた進行下部直腸癌の1例を経験したので報告する。(著者抄録)

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Language：Japanese   Publisher：(株)癌と化学療法社  

症例は65歳、女性。便潜血陽性のため下部消化管内視鏡検査が施行され、直腸S状部に2cm大のtype 0-IIa病変(組織型はtub2、por)、上部直腸に6cm大の5型病変(組織型はmuc、sig、tub2)が指摘された。胸腹骨盤部CT検査、PET-CT検査で腸管傍リンパ節転移陽性と診断された。直腸間膜リンパ節、大動脈周囲リンパ節、側方リンパ節領域にも淡いfluorodeoxyglucose集積を認めた。転移の可能性も否定できなかったが、直腸S状部癌cT1bN0M0、Stage I、上部直腸癌cT3N1M0、Stage IIIa(大腸癌取扱い規約第8版)と診断した。腎機能障害により化学療法の選択に制限があったため手術先行の方針とし、低位前方切除術を施行した。術中、大動脈周囲リンパ節、左総腸骨動脈リンパ節を迅速診断に提出し、リンパ節転移陽性と診断された。リンパ節以外に遠隔転移を認めなかったことからR0切除が可能と判断し、転移陽性であった領域のリンパ節は可及的に切除した。切除標本の組織診断では、直腸S状部の病変は深達度T1b、上部直腸病変は深達度T3であった。切除リンパ節37個中21個で転移陽性であった。RAS遺伝子検査では野生型であった。補助化学療法としてS-1単剤療法を施行した。術後5ヵ月目と3年目に縦隔リンパ節転移が疑われたためpanitumumab単剤療法を行ったところ、リンパ節腫大は縮小した。現在、初回手術から6年が経過したが直腸癌再発は認めていない。長期生存が得られている大動脈周囲リンパ節、側方リンパ節への転移を伴った進行直腸癌の1例を経験したので報告する。(著者抄録)

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：English   Publisher：(一社)日本癌学会  

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Language：Japanese   Publisher：(一社)日本大腸肛門病学会  

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Language：Japanese   Publisher：(一社)日本産科婦人科内視鏡学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(株)癌と化学療法社  

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Language：Japanese   Publisher：日本消化器病学会-甲信越支部  

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Language：Japanese   Publisher：日本消化器病学会-甲信越支部  

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