Sato Harunobu

50歳女.健診で便潜血反応陽性を指摘された.大腸内視鏡検査では肛門側より約6cmの直腸Rbに,約20mm大のIIc+IIa型早期直腸癌を認めた.注腸造影では直腸後壁側に腫瘍を認め,周囲の偽足様変形や中央にバリウムの溜まりのある透亮像を認めた.精査内視鏡では陥凹内隆起を認め,超音波内視鏡では概ねM癌で,陥凹内隆起部に一致してSM浸潤が疑われた.診断治療目的でminimally invasive transanal surgery(MITAS)を行い,病巣は完全に一括切除できた.病理組織学的には高分化腺癌で,粘膜筋板は保たれており,sm層への浸潤はみられなかった.壁深達度はm,ly0,v0,切除断端陰性であった.術後経過は良好であった.MITASは,早期直腸癌に対し正確な壁深達度診断と低侵襲治療を行うことのできる有用な術式であると思われた

Several researchers have reported the possible association between colorectal cancer and schistosomiasis japonica. However, it remains to be determined whether this association is significant. We report a case of sigmoid colon cancer associated with schistosomiasis japonica and discuss the relationship between schistosoma japonica and the development of colorectal cancer from a review of the Japanese literature. An 82-year-old man was referred to our hospital because of bloody stool. He had worked as a fisherman for 30 years in an endemic schistosomal area. A tumor was detected in the sigmoid colon without distant metastases. Sigmoidectomy with lymph node dissection was performed. A type-1 tumor measuring 2.5 × 2 × 1.5 cm was revealed in the resected specimen. Histological findings demonstrated well differentiated adenocarcinoma with muscular invasion, moderately lymphatic vessel invasion and lymph node metastases (n1). Many calci-fied eggs of schistosomiasis japonica were also seen in the colonic wall of both the tumor and normal tissue, mainly in the submucosal layer. The eggs were more often seen in the tumor than in the normal tissue. The patient also underwent transanal local excision for rectal adenoma 16 months later and survived for 50 months after the initial operation without recurrence.

Twenty-seven patients with ischemic colitis who were referred to Fujita Health University between 1988 and 2002 were studied to clarify the clinical features of ischemic colitis after colorectal surgery. The patients were divided into two groups : the patients undergoing colorectal surgery (POIC, 10 cases) and the patients without previous colorectal surgery (NOIC, 17 cases). Gangrenous colitis was seen in 1 of POIC and transient colitis was seen in 26. Among 10 patients of POIC, low anterior resection was performed in 8 patients, sigmoidectomy and right hemicolectomy in 1 patient each. The main feeding artery was divided at its root in every operative case. Predisposing factors of ischemic colitis were seen in 5 (63.6%) of POIC. They were more frequently seen in NOIC than in POIC with a significant difference. Abdominal pain appeared in 3 (33.3%) of POIC as the first symptom and in 4 (44.4%) of POIC during the course. It more frequently ap-peared in NOIC than in POIC as the first symptom and the symptom during the course, although there were no significant differences. Ischemic change occupying more than a half the circumference of intestinal wall was found in 2 (22.2 %) of POIC. Although transient ischemic colitis after colorectal surgery tended to occur without an underlying disease or conditions, severe symptoms rarely occur. However, if ischemic colitis occurs in a patient with severe underlying disease, it is important to remember that severe colitis such as gangrenous colitis could occur.

Ulcerative colitis generally occurs in young people under 30 years old ; the occurrence of ulcerative colitis in patients more than 70 years old is uncommon. We report a case of ulcerative colitis induced by barium enema study and colonoscopy at the age of 75 with a review of 29 cases with ulcerative colitis that occurred among those more than 70 years old reported in Japan. A 75-year-old man with paralysis of his left hand due to poliomyelitis was referred to Rokuwa hospital to check the large bowel because of constipation. Barium enema study and colonoscopy did not show any findings. However, he had bloody stool, abdominal pain and diarrhea 10 days after the barium enema study and 6 days after the colonoscopy. Colonoscopy was performed to check the origin and the findings were compatible with ulcerative colitis, but histopathological findings with a biopsy specimen did not support clinical diagnosis. He was treated for colitis by intravenous hyperalimentation, but symptoms did not improve much. Biopsy specimens taken 20 days after the onset of the colitis confirmed that his illness was ulcerative colitis. Mesalazine was administered and clinical symp-toms improved together with endoscopic remission. The patient has remained asymptomatic for 1 month after his discharge.

We report herein surgical treatments for vaginal vault and complete genital prolapse with rectocele, peritoneocele, cystocele, and sphincter dysfunction.<BR>A 51-year-old woman, who had a 13-year history of vaginal vault and complete genital prolapse with urinary incontinence and dysfunction, constipation, and soiling of stool, was referred to our department for surgery. One-fourth of the anal sphincter was interrupted anteriorly by digital examination, and defecogra-phy revealed an enterocele. Anterior levatorplasty with sphincteroplasty was performed in addition to a transvaginal hysterectomy, anterior colporraphy. Partial excision and closure of the cul de sac of the perito-neum with pexy of the vaginal wall was added during surgery. The postoperative course was essentially uneventful without further recurrence or appearance of symptoms during a six-month follow-up.

進行大腸癌手術症例を対照群と化学療法群に無作為に分け,対照群では術前の化学療法を施行せず,加療群ではUFTを手術前日迄の14日間経口投与した.術前に化学療法を施行することによって起こる免疫抑制状態の有無を,血漿中と所属リンパ節細胞の培養上清中のTGF-β発現量を指標として検討した.その結果,腫瘍最大径と深達度において血漿TGF-β発現量との関連性が認められ,より進行した癌で免疫抑制状態が引き起こされていることが示唆された.術直前の方が術前14日前に比し血漿TGF-β発現量は対照群及び加療群共に増加傾向にあり,加療群では有意に増加していた.担癌宿主の免疫抑制状態は化学療法を行うことによって,より助長されると考えられた.以上より,術前化学療法は全身及び局所リンパ節における免疫機構を抑制する働きを有する可能性が示唆された

In order to clarify the significance of both chest X-ray and CT for postoperative lung metastasis from colorectal cancer, we studied 27 patients with lung metastasis detected by X-ray or CT among 543 patients after curative resection for colorectal cancer. Although there was no significant difference in the size of the lesions detected by X-ray or CT, only one of nine lesions (11.1%) detected by CT could be identified by X-ray when the lesions were 5 mm or smaller whereas five of six lesions (83.3%) could be detected when 6 mm or greater. The lesions could be identified by retrospective review of the chest X-ray in 12 of 27 patients (44.4%). The lesions overlapping on heart, aorta, pulmonary artery and bone shadow were often overlooked on chest X-ray. Detectable lesions on X-ray have been checked and overlooked by a single doctor in patients. Therefore, a double-checking system might help prevent delayed detection of metastatic lung lesions.

We report a case of ASPS with special reference to the usefulness of multi planer reconstruction (MPR) and 3D-angio by MSCT for selecting an operation method and approach. A 31-year-old man with anal pain and bleeding during defecation was admitted to our hospital for further examination. Diagnostic imaging studies revealed a suspectable sarcoma. MPR and 3D-angio were used to select the approach to the tumor and operation method. Tumorectomy, combined with partial resection of the anal sphincter, and puborectal and external sphincter muscle plication, were successfully performed. Histological findings of the resected specimen showed the tumor grown like an alveolar origined from the striate muscle. Immunohistochemical testing was negative for HMB-45 and positive for myoglobin, and the tumor was diagnosed as ASPS. The postoperative course was uneventful.

A 58-year-old female with anal bleeding. soiling and defecating disturbance was admitted to our hospital. She was diagnosed as rectal prolapse (Tuttle II type) with rectocele on defecography. Manometry revealed an obscure high-pressure zone, low maximum resting pressure and maximum squeezing pressure. She underwent laparoscopic rectopexy and anterior levatorplasty with sphincter plication. She had no significant complications postoperatively, and preoperative symptoms disappeared after the surgery.

We report a case of lipoma of the ileum with massive bleeding treated by laparoscopy-assisted partial resection of the ileum and review 49 cases of lipoma of the small intestine reported in Japan in the last 16 years. A 75-year-old woman with massive anal bleeding was admitted to the hospital. He had been examined for the same symptom 6 months earlier. Although colonoscopy suggested bleeding from the small intestine, we could not identify any lesions. We conducted laparoscopic surgery to identify the cause of the massive bloody stool. A tumor was detected in the ileum 90 cm proximal to Bauhin's valve, necessitating partial resection of the ileum. The resected specimen was a 2.5×2.1×3.5 cm submucosal tumor diagnosed histopathologically as lipoma. The patient has remained asymptomatic in the 4 years since surgery.

A novel transanal local excision, named minimally invasive transanal surgery (MITAS ; 89 cases), was retrospectively compared with conventional transanal excision (27cases) in perioperative outcome. MITAS includes usage of a new anal retractor and a stapler with several modified surgical techniques. Age, gender, tumor size, and complication rate were equivalent in both methods. Tumors were located higher up in MITAS than in the conventional method (p<0.01). Operative time, blood loss, and date of oral intake were less in MITAS (p<0.04). MITAS was considered to be a minimally invasive transanal local excision procedure, which is accessible to proximal tumors less invasively than conventional method for rectal tumors.

We reported a case with necrosis of the colon proximal to the anastomosis 3.5 years after low anterior resection. A 69-year-old woman with nausea and abdominal pain was admitted to our hospital. She had undergone a low anterior resection, with division of the inferior mesenteric artery at its root, for rectal cancer, 3.5 years previously. Emergency surgery was performed for increasing abdominal symptoms after conservative therapy. A laparotomy revealed necrosis of the colon proximal to the anastomosis after the low anterior resection. A colectomy with a colostomy in the transverse colon, and closure of the remnant rectum, were performed for the condition. She died eight months following the surgery, due to multiple organ failure.

直腸早期癌に対する局所切除術の適応と手技について述べた.術前検査所見でSM3の所見がなく,分化型の癌,もしくは壁深達度の所見に検査間で一致がみられない腫瘍の場合には局所切除の適応となり,これにより過大手術を回避できる.局所切除の術式として,低位の腫瘍には従来法による経肛門的切除を行い,高位の腫瘍にTEMやMITASなどによる低侵襲な経肛門的切除を行う.局所切除では,癌の組織学的な評価と治癒度が確認でき,少なくとも筋層が一部含まれる標本を採取すべきであり,これが可能な術式を選択する必要がある

A 42-year-old woman with anal bleeding at menstruation consulted a nearby clinic. She was diagnosed as having endometriosis, by biopsy under colonoscopy, and had been treated by endocrine hormone therapy for six months, without success. Colonoscopy and a barium emena study showed a stenosis with a mass in the sigmoid colon. Bilateral oophorectomy and partial resection of the sigmoid colon were performed under laparoscopy. Histopathological findings revealed endometriosis affecting the sigmoid colon, with fibrosis causini obstruction. The nostonerative course was uneventful.

Radiation therapy is one choice for malignant disease of the lower abdomen. However, radiation sometimes induces radiation colitis as a severe side effect. Radiation colitis sometimes causes severe bleeding, and it is often difficult to treat, A 66-year-old man received radiation therapy (external radiation with 65.2 Gy) for carcinoma of the bladder. Bleeding in the rectum occurred approximately 15 months after irradiation. Severe bleeding and anemia could not be controlled by Salazosulfapyridine and steroid enemas, and frequent blood transfusion was needed. Therefore, we gave ecabet sodium enemas to this patient, twice every day, for four weeks. Bleeding and anemia could be controlled by this treatment. It is suggested that ecabet sodium enema can be an available treatment for radiation colitis.

Sacrococcygeal teratoma is rare tumor in adults. It is usually diagnosed and resected in infancy. Only 29 cases have been reported in the Japanese literature.<BR>We report a rare case of an adult sacrococcygeal teratoma with usefulness of multi planer reconstruction (MPR) and three-dimensional imaging (3D) by Helical CT for selecting an operation method and position.<BR>A 52-year-old man visited our hospital with dull oppression in his buttocks. Barium enema and MRI revealed a sacroccygeal cystic tumor in the presacral space between the coccyx and the rectum. We studied the tumor by MPR and 3D, to select its operation method and position. We completely resected the tumor, including the coccyx and the 5th sacrum, through a trans-sacral approach with a jackknife position. The excised tumor was a benign mature teratoma, 13×12×8.5cm in size. The postoperative course was uneventful. He Is well, without defecatory or urination disturbance.

Rectocele is an anatomical disorder in which the rectal wall protrudes anteriorly and causes defecatory disorders. A rectocele with clinical symptoms, such as difficulty in defecation, sould be considered for treatment. Conservative treatment should be conducted initially for a symptomatic rectocele, and surgical treatment should follow if conservative treatment fails. Conventional surgical treatments, with excision or ligation of the rectum or vaginal wall, have sometimes failed to improve the defecatory disorders and anatomical disorders. These conventional treatments are not suitable for improving urinary or stool incontinence. Technique and results of anterior levatorplasty, to improve these combined disorders, are described herein.

Lateral node metastasis, recurrence, and outcome were investigated in rectal cancer with and without autonomic nerve-preserving operation to clarify the effect of autonomic nerve-preserving operation on lateral node dissection. All patients undergoing curative surgery for middle and lower rectal cancer were classified into the following three groups : a group that underwent autonomic nerve non-preserving operation from 1980 and 1987 (group A, n=109), a group that underwent the nerve-preserving operation between 1988 and 1993 (group B, n=71), and a group that underwent non-preserving operation between 1988 and 1993 (group C, n=12). Our indications for nerve preservation since 1988 have been the absence of evidence of direct invasion of the autonomic nerve macroscopically in frozen sections during surgery. The 5-year survival rate of all cases with and without node metastasis was 33.8% and 76.8% respectively. There were no statistically significant differences in the 5-year survival rate between groups A and B according to Duke's staging, staging by the General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus, and recurrence rate. However, the cumulative 5-year survival rate in group B was significantly better than in group A (P<0.05) in the lower rectum. There were no significant differences between group A and groups B and C in the 5-year survival rate. The 5-year survival rate in group B was significantly better than in group C (P<0.05). The autonomic nerve-preserving operation with lateral node dissection was concluded to provide as good an outcome as non-preserving operations with lateral node dissection within our indications.

著者等は,4例の十二指腸断端縫合不全症例に対してpercutaneous transhepatic biliary drainageの技術を応用してカテーテルを十二指腸内に留置し,胆管及び十二指腸内容のドレナージを行い,保存的に治癒せしめることに成功した.本法は再手術を施行せずに十二指腸内容のドレナージが行えるため,低侵襲で効果的である.又octreotide acetate(Sandostatin)を併用し,胆汁,膵液の分泌を抑制することによって治療効果の一層の向上が期待できる

従来の経肛門的局所切除術 (PAE) と新しく開発したE式およびF式開肛器と自動縫合器を用いた経肛門的局所切除術 (MITAS) について臨床的に比較検討した。対象は経肛門的局所切除術が施行された直腸腫瘍61例 (62病変) で, 術式はMITAS43例 (44病変), PAE18例であった。肛門縁から病変までの距離はPAEの4.9cmに比べてMITASでは9.3cmと有意に高位で, 腹膜反転部以上に局在する症例が有意に多かった。手術時間はMITASでは平均24.7分, PAEは40.9分で, 出血量はMITASでは平均19.6g, PAEは50.0gであった。術後経口摂取開始までの日数はPAEに比べてMITASは有意に短縮していた。MITASでは86.4%の病変で筋層以上の切除がなされていた。合併症はPAEで縫合不全を2例, MITASで後出血を1例に認めた。MITASはすべての部位の早期直腸癌の根治術として, また根治性確認の手段として有用なminimally invasiveな術式と考えられた。

これまでの骨盤直腸窩痔瘻の治療の問題は, 術後の創治癒の遅延, 肛門機能の低下, 肛門や創の変形, 再発などであった。これらの問題を解決するために瘻孔造影で術前に瘻管の走行を確認し, 経仙骨的アプローチで全瘻管を確実に処理し, 半閉鎖する手術を施行した。症例は40歳の男性で, 肛門周囲痛で来院し, 肛門周囲膿瘍の切開排膿後痔瘻に移行した。肛門会陰部には10時の2次口と2次口周囲の皮膚の発赤, 直腸右壁の硬化を認めた。直腸肛門管造影を併用した瘻孔造影で骨盤+坐骨直腸窩痔瘻と診断し手術を施行した。2次口と皮下膿瘍を切除し瘻管をcoring out後, 経仙骨盤直腸窩の瘻管, 膿瘍を全て切除, 掻爬した。次に, 1次口の切除, coring outを行い1次口は半閉鎖した。2次口と仙骨切開創はドレーンを留置し閉鎖した。術後経過は良好で, 術後23日目に退院し, 術後6カ月現在再発もない。

The reported case was a 58-year-old male. The primary focus, rectal cancer was revealed to be type 2 macroscopically at 4.5cm abobe the anal verge. For rectal cancer, abdominoperineal resection was performed. The pathological findings were well differen-tiated adenocarcinoma, a2, ly2, v1, and n0, and surgery was completely curative. Followup of the patient was performed at the outpatient department after surgery. Fourteen months later, CT showed an abnomal shadow at the right adrenal gland. There was no metastasis except in the right adrenal gland. Right side adrenectomy was performed. The histology of the resected adrenal gland was the same as that of rectal carcinoma. The patient survived for 2 years and 7 months after adrenectomy, and died of pulmonary metastasis.

A case of traumatic diaphragmatic hernia by traffic accident is reported, together with a review of 267 other cases reported in Japan in a period from January 1981 to November 1990.<br> A 31-year-old man who sustained blunt traumas by traffic accident was seen at the hospital because of lumbago. On admission, chest X-P revealed an elevation of the left hemi-diaphragma. The patient was diagnosed as traumatic left diaphragmatic hernia by US and CT examination. Emergency laparotomy was carried out. The escaped organs, stomach and omentum, were returned into the abdominal cavity and ruptured diaphragma was closed directly. Postoperative course was uneventful and the patient was discharged from the hospital 39 days after the surgery.<br> We compared our review with the previous papers reported in 1980s. Though the lesions had been said to be located commonly in the left side of the diaphragma, those in the right side have been increasingly reported in these years. There is an increasing tendency to be caused by traffic accident as the causative trauma. In this review of 203 causes. 20 death causes (9.8%) are noted, and this percentage is comparable to that of previous reports by Kasahara.