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

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Background:
Bilateral synchronous renal pelvic carcinomas are rare diseases. Complete urinary exenteration or kidney-preserving procedures are two different options that confer different benefits to the patient depending on the clinical situation.
Case Presentation:
A 69-year-old woman with bilateral synchronous renal pelvic carcinomas underwent laparoscopic complete urinary tract exenteration. Although dissection was difficult because of postoperative adhesions, the surgery was completed with minimal blood loss.
Conclusion:
Laparoscopic complete urinary tract exenteration allows minimally invasive surgery with minimal blood loss.

DOI： 10.1089/cren.2019.0045

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A 76-year-old male received concurrent chemoradiotherapy, at a dose of 60 Gy with low-dose 5-fluorouracil, for cT1bN0M0 squamous cell carcinoma of the mid-thoracic esophagus. Because his primary tumor relapsed with mediastinal and right supraclavicular node metastasis 4 months after completion of chemoradiotherapy, right transthoracic esophagectomy with mediastinal and right cervical lymphadenectomy was performed. However, metastatic tumors developed deep beneath the anterior border of the trapezius muscle 2 months after esophagectomy. En bloc dissection of the adipose tissue including the tumor and the transverse cervical artery was performed, followed by adjuvant radiotherapy of 50.4 Gy to the area of dissection. The patient died of pneumonia 11 months after metastasectomy, with locally recurrent disease. We have had three cases of this unusual lymph nodes metastasis from cancer of the thoracic esophagus to date and here present the characteristic imaging findings and the possible mechanism of this unusual lymph node metastasis.

DOI： 10.1093/jscr/rjy214

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DOI： 10.1016/j.eucr.2018.01.025

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A 75-year-old male received neoadjuvant chemotherapy for locally advanced squamous cell carcinoma of the mid-thoracic esophagus, followed by right transthoracic esophagectomy with extended mediastinal lymphadenectomy. Cardiac tamponade developed on postoperative Days 1 and 13, for which emergency ultrasound-guided drainage was required. Pericardial drainage fluid became chylous after administration of polymeric formula. A computed tomography scan demonstrated the presence of a retrocardiac fluid collection, encompassed by the left pulmonary vein and left atrium, descending aorta and vertebral column. Based on these findings, the diagnosis of chylopericardial tamponade communicating with a posterior mediastinal chylocele was made. The ligation of the thoracic duct was successfully performed via the left-sided thoracoscopic approach on postoperative Day 20 and the clinical course after the second operation was uneventful. The possible mechanisms of this exceptionally rare complication after esophagectomy were discussed.

DOI： 10.1093/jscr/rjx216

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

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 IHC 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 < .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.

DOI： 10.1016/j.humpath.2017.02.004

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

We report a case of advanced gastric cancer(AGC)that was resected for rebleeding after palliative radiotherapy for hemostasis. A 74-year-old man with Stage IV gastric cancer received chemotherapy and achieved stable disease. After 23 months, he experienced continuous bleeding from the tumor due to regrowth. Palliative radiotherapy was conducted to control the bleeding, and the tumor successfully achieved hemostasis. However, 6 weeks later, the patient experienced rebleeding and developed hemostatic shock. We then performed a successful emergency gastrectomy. Bleeding negatively affects quality of life in patients with AGC and is potentially lethal. Although palliative radiotherapy for bleeding of gastric cancer is a safe and useful treatment within a short time frame in cases of rebleeding, emergency gastrectomy may be necessary. Therefore, when we select this treatment, the possibility of subsequent surgical treatment must be considered.

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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：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：新潟医学会  

【緒言】大腸癌化学療法の進歩は著しく、切除不能・再発大腸癌の生存期間は2年を超えている。大腸癌領域では、KRAS遺伝子測定が抗epidermal growth factor reseptor(EGFR)抗体薬の治療効果予測因子としてその地位を確立している。しかし、KRAS遺伝子野生型であっても奏効率の上乗せは10-30%にすぎず、KRAS遺伝子を介さない別経路の存在が注目されている。NAD(P)H:quinone oxidoreductase 1(NQO1)は、抗癌剤や放射線照射耐性に関与する抗酸化ストレス蛋白として知られているが、大腸癌におけるKRAS遺伝子変異、予後との関連は明らかになっていない。本研究の目的は、KRAS遺伝子野生型および変異型切除不能・再発大腸癌におけるNQO1発現が予後に関与するかを検証することである。【方法】2007年3月から2013年1月までに当科でKRAS遺伝子野生型および変異型切除不能・再発大腸癌に対して治療を行った51例を対象とした。対象症例の大腸癌原発巣標本において、NQO1モノクローナル抗体を用いた免疫組織化学検査を行い、NQO1の発現を解析した。NQO1の発現を陽性および陰性の2群に分類し、臨床病理学的特徴および予後を統計学的に検討した。【結果】男性29例、女性22例で年齢中央値は62歳(範囲:17-79歳)、KRAS遺伝子野生型は33例(64.7%)、変異型は18例(35.3%)であった。NQO1発現陽性群が40例(78.4%)、陰性群が11例(21.6%)であった。NQO1発現陽性群、陰性群の間で臨床病理学的因子に有意差はみられなかった。生存期間の検討では、NQO1発現陽性群と陰性群、KRAS遺伝子野生型と変異型の間で有意差は認められなかった。(P=0.453、P=0.089)。しかし、NQO1発現解析、KRAS遺伝子変異検査の両者を組み合わせることによって、生存期間が有意に層別化された(P=0.049)。KRAS野生型かつNQO1発現陰性群の生存期間中央値(MST)は46ヵ月であり、KRAS変異型かつNQO1発現陽性群の21ヵ月(P=0.042)、KRAS変異型かつNQO1発現陰性群の15ヵ月(P=0.007)と比較して有意に予後良好であった。KRAS遺伝子野生型に限ると、NQO1発現陰性群のMSTは46ヵ月、NQO1発現陽性群のMSTは26ヵ月であり、NQO1発現陰性群の予後が良好な傾向を示した(P=0.074)。【結論】NQO1発現解析とKRAS遺伝子変異検査の両者を行うことにより、切除不能・再発大腸癌の予後が有意に層別化される。(著者抄録)

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

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

gemcitabine(GEM)+テガフール・ギメラシル・オテラシルカリウム配合剤(S-1)療法が奏効し、多発肝転移を伴う膵癌が根治切除可能となった2例を報告する。症例1:40歳、男性。黄疸を契機に多発肝転移を伴う膵頭部癌を指摘された。根治切除不能と判断し、GEM(1,000mg/m2、day 1,8)+S-1(100mg/day 1〜14days)療法を施行した。7コース後、転移巣はCRとなった。腫瘍残存を考慮し、SSPPD-IIAを施行した。病理結果では原発巣に腫瘍残存がみられたが、R0切除であった。現在GEM+S-1療法を再開し、無再発である。症例2:65歳、男性。閉塞性黄疸にて多発肝転移を伴う膵頭部癌と診断された。根治切除不能と診断し、GEM+S-1療法を11コース施行。転移巣は1ヶ所のみとなり、根治切除可能と判断しPpPD-IIAを施行した。病理結果では原発巣およびNo.13aリンパ節に腫瘍残存がみられたが、肝の結節は線維化のみでありR0手術であった。現在GEM+S-1療法を再開し、無再発である。GEM+S-1療法はGEM単独療法より奏効率が高く、術前治療の有効な選択肢であると考える。(著者抄録)

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Language：Japanese   Publisher：新潟医学会  

【緒言】消化器外科領域では、術前・術後の栄養管理に加え、昨今では化学療法の重要性が急速に増してきており、CVカテーテルの必要性が増大している。体表解剖に基づいたランドマーク法による鎖骨下静脈(以下SCV)穿刺は、ブラインド穿刺のため、時に気胸・動脈穿刺など、種々の合併症を引き起こすことがある。リアルタイムエコーガイド下のSCV(USgSCV)穿刺で、これらの合併症が激減することが報告されているが、主に放射線科で実施されており、広く普及するには至っていない。そこで、我々は一般外科診療において、市中病院で容易に入手可能な材料を用いて、安全にSCVの穿刺を行える手技の工夫および検証を行ったため、報告する。【方法・結果】Sakamotoらの穿刺法に筆者の工夫を加え、7.5MHzの体表プローベを用いてSCVを長軸に描出し、エコー観察下にフリーハンドでSCV穿刺を行う手技を施行した。USgSCV穿刺施行例のうちCVポート増設を行ったものは3施設18例で、合併症の発生はみられなかった。平均手術時間は30分であり、経験症例数やBMIによって手術時間は影響を受けなかった。【結語】USgSCV穿刺法は、動脈・静脈の走行を直接確認しながら、合併症フリーでのSCV穿刺が可能であった。手術室のみならず、病棟での処置にも十分応用可能であり、エクストラコストを最小限に留めながら安全性のメリットを享受できうる方法であった。(著者抄録)

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症例は58歳,男性.32歳時に先天性胆道拡張症に対して肝外胆管切除・肝管空腸吻合術の既往あり.食思不振を主訴に他院受診し,膵頭部腫瘤を指摘され当院紹介.CTで膵頭部に拡張した総胆管および同部に接する40mm大の腫瘤性病変あり.MRCPでは腫瘍近傍に拡張膵内胆管が描出された.先天性胆道拡張症術後の残存膵内胆管癌と診断し,亜全胃温存膵頭十二指腸切除術を施行した.病理検査結果では,No.16リンパ節に転移を伴う進行下部胆管癌であった.現在補助化学療法中であり,術後5ヵ月現在再発はみられていない.本邦の先天性胆道拡張症の術後発癌報告を検討すると,戸谷分類I型の発癌例では残存膵内胆管からの発癌例が4例中3例を占めていた.初回手術時の残存膵内胆管長を短くすることで発癌抑制できると考えられるため,膵管直上での胆管切除の順守が重要である.(著者抄録)

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This is the first successful report of a laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation (LDLT). A 35-year-old man underwent LDLT using a right lobe graft as an aid for primary sclerosing cholangitis (PSC) in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2]; gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Preoperative Child-Pugh was grade B and score was 9. Because these esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab's operation. Operative time was 464 minutes. Blood loss was 1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested that portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed improvement in the esophagogastric varices (esophageal varices [EV]: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], gastric varices [GV]: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) at 6 months after the operation. We also confirmed the improvement of esophagogastric varices by serial examinations of CT.

DOI： 10.1016/j.transproceed.2013.10.047

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This report presents the case of a two-step laparoscopic resection and reconstruction for obstructive colitis accompanied by advanced sigmoid colon cancer. An 81-year-old woman was admitted with a diagnosis of ileus. Computed tomography revealed a circumferential tumor in the sigmoid colon and a diffuse dilated large intestine on the oral side of the tumor. On the 7th day after admission, her temperature was 38.8°C, she had increased white blood cell count (24 610 cells/mm(3)), and suffered persistent severe abdominal pain. An emergency laparoscopy-assisted Hartmann procedure was performed, based on a tentative diagnosis of obstructive colitis due to sigmoid colon cancer. The descending colon and residual rectum were anastomosed laparoscopically by double-stapling technique 6 months after the initial surgery. Her postoperative course was uneventful for both procedures and she was discharged after 10 and 18 postoperative days, respectively. This case demonstrates that an initial laparoscopic emergency excision followed by a later reconstruction might be a safe and simple surgical technique for patients with obstructive colitis accompanied by left-sided colon carcinoma.

DOI： 10.1007/s00595-009-4189-0

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

腸重積を併発した腸管原発脂肪腫2例に対して鏡視下切除を行ったので報告する.症例1;87歳,女性.急性腹症で発症し,右側腹部に手拳大の腫瘤を触知した.腹部骨盤部CTでは内部にfat densityを伴う腫瘍を認め,周囲がリング状に造影されるいわゆるtarget signを認めた.大腸内視鏡では上行結腸に黄色調の粘膜下腫瘍を認めた.腸重積を併発した上行結腸脂肪腫と診断し,腹腔鏡補助下回盲部切除術を行った.症例2;58歳,女性.乳癌術後の経過観察CTで,上行結腸にtarget signを伴う腹腔内腫瘤を認めた.大腸内視鏡では終末回腸に可動性良好,鶏卵大の粘膜下腫瘍を認めた.無症候性の腸重積を伴う回腸脂肪腫の診断で,腹腔鏡補助下回盲部切除術を行った.両症例とも術後経過順調で,術後10日および8日目に退院した.鏡視下手術の持つ低侵襲性や美容面の利点は,悪性疾患のみならず良性疾患にこそその真価が発揮されるものと考えた.(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：一般社団法人日本消化器外科学会  

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Language：Japanese   Publisher：新潟医学会  

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