安井 稔博

An 11-year-old girl presented with recurrent right lower quadrant (RLQ) pain. There was no evidence of inflammation and appendiceal swelling except at the initial onset. The repeated presence of a small amount of ascites at the time of abdominal pain triggered the performance of exploratory laparoscopy. Intraoperative examination revealed a non-inflamed, unswollen appendix with a cord-like atretic segment at the middle part and an appendectomy was performed. At 46 months follow-up, she remained asymptomatic. In patients with recurrent RLQ pain of unknown cause, it is necessary to consider diagnostic laparoscopy while keeping appendiceal atresia in mind as a differential diagnosis.

PURPOSE: We previously reported that polyphyllin D, a main component of the traditional Chinese medicinal herb Paris polyphylla, exhibited anticancer effects in vitro against human neuroblastoma cells. The aims of this investigation was to examine the presence or absence of in vivo anti-metastasis effects of polyphyllin D were to establish a liver metastasis model of neuroblastoma and to evaluate the anti-metastasis effects of polyphyllin D. METHODS: Subcutaneous and intraperitoneal tumors, and metastasis models were established in immune-deficient BALB/c nude and BALB/c Rag-2/Jak3 double-deficient (BRJ) mice using the human neuroblastoma cell lines IMR-32, LA-N-2, or NB-69. For evaluating polyphyllin D activity, we used a mouse model of liver metastasis with the IMR-32 cells line injected through the tail vein. We analyzed the livers number and area of liver tumors in of the phosphate buffer solution- and polyphyllin D-treated groups. RESULTS: Liver metastasis and intraperitoneal dissemination models were successfully established in immune-deficient BRJ mice using the three human neuroblastoma cell lines. In the liver metastasis, the model of IMR-32 cells, we found that polyphyllin D suppressed both the number and total area of metastatic foci the average number of metastatic foci, average focus areas, and number of cleaved caspase-3-positive cells were significantly lower in the polyphyllin D group (p = 0.016, 0.020, 0.043, respectively). CONCLUSIONS: We developed a mouse models of neuroblastoma metastasis and demonstrated for the first time that polyphyllin D has an antitumor effect on neuroblastoma liver metastases.

<title>Abstract</title>We report a case of a 13-year<bold>-</bold>old boy with arginase 1 deficiency carrying a new variant in <italic>ARG1</italic>. Sanger sequencing identified the compound heterozygous variants: NM_000045.4: c.365G&gt;A (p.Trp122*)/c.820G&gt;A (p.Asp274Asn). Although not previously reported, the p.Asp274Asn variant is predicted to have strong pathogenicity because it is located in a highly conserved domain in the protein core and arginase activity in the patient was below measurement sensitivity.

<title>Abstract</title><sec> <title>Background</title> Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. </sec><sec> <title>Case presentation</title> We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). </sec><sec> <title>Conclusions</title> The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery. </sec>

<p>Objectives: Proximal stoma creation in neonates results in growth failure and distal intestinal atrophy. "Recycling stool" consists of stool injection from the proximal limb to the distal limb of a stoma. Because this method may prevent distal bowel atrophy and increase body weight, we investigated the effects of recycling stool upon distal intestinal mucosa by generating an ileostomy model in rats.</p><p>Methods: An ileostomy was created 5 cm proximal to the cecum in male Wistar/ST rats. Discharged stool or saline was injected into the distal limb, twice per day for 7 days. The intestinal adaptation was assessed by measuring the villus height and counting goblet cell number. Proliferation and apoptosis were analyzed by Ki67 and TUNEL immunostaining.</p><p>Results: The ratios of the height of the distal villi (D) to the that of proximal villi (P) were 0.97 (median [range] of D and P length: 421 [240–729] μm and 436 [294–638] μm, P<0.05) in the stool-injected group and 0.81 in the saline-injected group (442 [315–641] μm and 548 [236–776] μm, P<0.05). Compared with the saline-injected group, the stool-injected group showed elevated numbers of goblet cells (3.6 [2.0–7.6] vs. 4.9 [2.4–7.5] cells/100-μm villus length) and Ki67-positive cells (26.8% [13.8%–35.4%] vs. 40.1% [31.2%–45.7%]), along with a reduced number of apoptotic cells (5.0 [2.0–14.0] vs. 4.0 [1.0–9.0] cells/100-μm villus length).</p><p>Conclusions: Recycling stool prevented distal intestinal atrophy; this experimental design may facilitate further studies concerning alternative methods to prevent intestinal atrophy and growth failure.</p>

我々は稀な肝未分化肉腫を2例経験したので報告する.症例1は11歳女児.発熱,腹痛で発症し,CTで肝右葉に巨大腫瘍,PET-CTでは腫瘍辺縁に強く集積を認めた.血液検査所見ではLDHとCA125が高値を示し,生検にて肝未分化肉腫と診断した.VAC療法(ビンクリスチン,アクチノマイシンD,シクロフォスファミド)(5クール)後に腫瘍核出術を施行した.術後VAC療法(8クール)を行い治療終了後5年2ヶ月経過し再発なく生存中である.症例2は12歳男児.右上腹部膨隆と腹痛で発症し,CTで肝右葉に腫瘍,PET-CTで腫瘍辺縁に集積を認めた.血液検査所見ではLDHとCA125が高値を示し,肝未分化肉腫と術前診断し右3区域切除術を行った.摘出腫瘍は肝未分化肉腫の病理診断であった.術後VAC療法(5クール)行い治療終了後1年4ヶ月経過し無病生存中である.年長児で特異的腫瘍マーカーの上昇が伴わない肝腫瘍においては,本疾患を想起することが肝要である.(著者抄録)

Pectus excavatum has been performed using techniques such as sternum elevation and sternum reversal however, the Nuss method is now widely used. The Nuss method is considered less invasive, but it requires a plate. We have performed open-repair surgery that can be completed at once without using a plate as a standard procedure. Conversely, the usefulness of the internal thoracic artery (ITA) in coronary artery bypass surgery and breast reconstruction has increased in recent years. Therefore, since 2017, we changed the surgical procedure to preserve the ITA here, we mainly report on the surgical procedure. Five patients, four boys and one girl, were examined for in Haller index, operation time, blood loss, postoperative complications, and postoperative hospital stay. Among the five cases, before the change of surgical procedure, the operation time, blood loss, and hospitalization period postoperatively were not significantly different from those before the change. Bilateral ITA could be preserved except in one patient in whom one side was damaged and ligated during the operation. No postoperative complications were observed in all cases. It is possible to preserve the ITA, and we intend to perform additional studies to evaluate its long-term effectiveness.

【目的】胆道閉鎖症(以下、BA)スクリーニングのために便色カラーカードが2012年に母子健康手帳へ導入され5年が経過した。しかしながら未だに3ヵ月を越えて紹介されてくる患児も多く、便カラーカードの意義や本症に対して医療従事者らがBAおよびカードをどのように認識しているかを評価し、知識を深めることを目的にアンケート調査と啓蒙活動を行った。【方法】当院に勤務する小児科医、産婦人科医、小児もしくは産科病棟の看護師および准看護師、助産師ら172名を対象に便色カードに関するアンケートテストと本症に関するプレゼンテーションを行い、結果と効果を確認する。【結果】109名(63.3%)の回答を得られた。カラーカードを知らないと回答したのは13名(11.9%)であった。カラーカードを用いずに便色を判定していただき39名(35.7%)がわからないと回答した。一方でBAを知っていると回答したのは105名(96.3%)で、59名(54.1%)が生後1ヵ月以内で発見されると回答した。BAが完治すると回答したのは45名(41.2%)であった。BAに関するプレゼンテーションについて「ものすごく勉強になった」と回答したのは92名(84.4%)であった。【結論】今回のアンケートから、小児外科医以外の医師や看護師のBAに対する認識は低いものと考えられた。カラーカードは導入されたが、その意義やBAに対する認識を患者両親に正しく伝えるためにも、今後さらなる啓蒙活動の推進が必要である。(著者抄録)

【目的】胆道閉鎖症(以下、BA)スクリーニングのために便色カラーカードが2012年に母子健康手帳へ導入され5年が経過した。しかしながら未だに3ヵ月を越えて紹介されてくる患児も多く、便カラーカードの意義や本症に対して医療従事者らがBAおよびカードをどのように認識しているかを評価し、知識を深めることを目的にアンケート調査と啓蒙活動を行った。【方法】当院に勤務する小児科医、産婦人科医、小児もしくは産科病棟の看護師および准看護師、助産師ら172名を対象に便色カードに関するアンケートテストと本症に関するプレゼンテーションを行い、結果と効果を確認する。【結果】109名(63.3%)の回答を得られた。カラーカードを知らないと回答したのは13名(11.9%)であった。カラーカードを用いずに便色を判定していただき39名(35.7%)がわからないと回答した。一方でBAを知っていると回答したのは105名(96.3%)で、59名(54.1%)が生後1ヵ月以内で発見されると回答した。BAが完治すると回答したのは45名(41.2%)であった。BAに関するプレゼンテーションについて「ものすごく勉強になった」と回答したのは92名(84.4%)であった。【結論】今回のアンケートから、小児外科医以外の医師や看護師のBAに対する認識は低いものと考えられた。カラーカードは導入されたが、その意義やBAに対する認識を患者両親に正しく伝えるためにも、今後さらなる啓蒙活動の推進が必要である。(著者抄録)