廣岡 芳樹

十二指腸乳頭部腫瘍に対する内視鏡的乳頭切除術はいまだ確立した治療手技ではないが、胆膵管内進展を伴わない腺腫または腺腫内癌を適応とすることでおおむね同意が得られている。切除に際しては、十二指腸スコープを用いた切開波による一括切除を基本とし、出血のコントロールと膵管ステントによる膵炎予防が術後処置として重要である。切除断端陰性が得られれば良好な長期予後が得られ、乳頭部腫瘍に対する根治術として評価できる。(著者抄録)

小腸内視鏡の分野は、2001年におけるダブルバルーン内視鏡(DBE)、カプセル内視鏡(VCE)の臨床導入により一気に飛躍した。それらは術後の消化管においても対応が可能である。特にDBEにおいては、blind loop挿入などによる術後腸管におけるtotal enteroscopyや、術後吻合部狭窄に対してのバルーン拡張術、術後出血の検索、内視鏡的止血術などの処置までカバーできるといった特徴を有する。一方、VCEは術後腸管への施行は躊躇される面もあるが、術後すぐの患者に対しても施行ができ、またDBEが癒着で深部挿入できなかった際に、補助的に用いるといった役割が担える。DBEとVCEはともに補足的な検査といわれるが、術後消化管においても同様であり、両者を上手に活用されると臨床効果は高い。(著者抄録)

Recently, decellularized tissue has been reported to have the potential to regenerate a variety of tissues. However, the optimal protocol for a decellularized esophagus has not been studied. Here, we investigated the effect of different decellularization protocols on the histology and biocompatibility of decellularized esophagi in view of future applications to tissue engineering. The esophageal mucosal epithelium (EP) from 4-week-old Wistar rats was enzymatically dissociated and cultured with growth-arrested feeder cells. Two methods for decellularization using deoxycholic acid (DEOX) or Triton X-100 (TRITON) were compared on esophagi from adult Wistar rats. Those treated with DEOX showed superior mechanical properties, maintenance of extracellular matrix, and lower DNA content than those treated with TRITON. To evaluate the biocompatibility of the scaffold, cultured (passage 3) esophageal epithelial cells were seeded inside the decellularized esophagus and cultured for 7 days. The cells seeded onto the decellularized esophagus were examined histologically and immunocytochemically. Esophageal epithelial cells were stratified into three to four cellular layers in vitro inside the decellularized esophagus, to show polarity. The results from immunocytochemistry indicated that the seeded epithelial cells expressed characteristic marker proteins for native esophageal EP. Decellularized esophagus showed suitable compatibility as a scaffold material for esophageal tissue engineering.

In local island (m/n = 1/1) divertor discharges in the large helical device a stable super dense core plasma develops when a series of pellets are injected. A core region with a density as high as 4.6 x 10(20) m(-3) and a temperature of 0.85 keV is maintained by an internal diffusion barrier with a very high density gradient. In a study of island dynamics, we find that an externally imposed large island (m/n = 1/1) as large as 15% of the minor radius is healed when beta at the island exceeds a critical value.

BACKGROUND AND AIMS: Infection with Helicobacter pylori (Hp) has been linked to atrophic gastritis, an inflammatory precursor of non-cardia gastric carcinoma. Mutations in the p53 gene are one of the most frequent genetic alterations in gastric carcinoma. In a subgroup of atrophic gastritis, antiparietal cell antibody (APCA) has been detected. This study was aimed to clarify the role of APCA in the progression of atrophic gastritis and gastric carcinogenesis, and to determine the relationship of the severity of atrophic gastritis to gastric carcinoma and to p53 mutations. METHODS: In 494 control subjects and 284 gastric carcinoma patients, serum APCA was evaluated and all subjects and patients were classified into four groups using serologic markers (anti-Hp IgG antibody and pepsinogen (PG) test: positive; PG I < 70 microg/L and PG I/II ratio < 3.0) as follows: A, HP- PG-; B, HP+ PG-; C, HP+ PG+ and D, HP- PG+. p53 mutations were analyzed in 174 of 284 patients. RESULTS: Antiparietal cell antibody seropositivity increased from group B to D, however, no difference in its positivity was found between controls and patients. The incidence of gastric carcinoma increased from A to D, especially the intestinal subtype. The frequency of p53 gene mutations was higher in PG+ than in PG- gastric carcinoma. CONCLUSIONS: Antiparietal cell antibody seropositivity is involved in the progression of a subgroup of atrophic gastritis, but not associated with gastric carcinogenesis. Severe atrophic gastritis is associated with susceptibility to gastric carcinoma, especially the intestinal subtype, and p53 mutations.

著者らは1993年以降早期乳頭部癌に対するIDUSによる診断体系の確立とともに,内視鏡的治療の確立をめざして取り組んできた.本稿では自験例67例(男女比45:22,平均年齢66.8歳)の切除成績を示して,十二指腸乳頭部癌の早期診断における内視鏡的乳頭切除術の意義について言及する.まず早期合併症および後期合併症の検討から安全な術式であることを確認し,診断的意義を論じるに値する術式であることを評価した.次に術前の生検病理診断と内視鏡的切除術後の最終病理診断の比較検討から,その一致率は86.6%(58/67)で,13.4%(9/67)の例で診断が異なっていた.特に術前の過小評価例9.0%(6/67)において本術式の診断的意義は大きく評価されると考えられた.内視鏡的乳頭切除術は前癌病変や早期癌の治療法として位置づけるべきであるが,そこには当然,診断的意義も有しているものと考えられる(著者抄録)

筆者らは、基本的に胆膵管内進展を伴わない腺腫または早期癌を適応として78例に内視鏡的十二指腸乳頭切除術を施行した。おもな早期合併症は、出血26.9%、膵炎7.7%、胆管炎3.8%で、後期合併症は、胆管炎3.9%、総胆管結石2.6%と、重篤な合併症は認めなかった。腫瘍性病変74例中50例(67.6%)で完全切除しえ、完全切除不能例(術前に胆膵管内進展陽性と診断)を除く実質の完全切除率は83.3%(50/60)であった。内視鏡的乳頭切除術は安全な治療法であり、手技の工夫によりさらに治療成績は向上する。(著者抄録)

Host genetic susceptibility may influence gastric carcinogenesis caused by Helicobacter pylori infection. We aimed to clarify the relationship of interleukin (IL)-8 polymorphism with the risk of atrophic gastritis and gastric cancer. We examined IL-8 -251 T > A, IL-1B -511 C > T, and IL-1RN intron 2 polymorphisms in 252 healthy controls, 215 individuals with atrophic gastritis, and 396 patients with gastric cancer. We also investigated the effect of the IL-8 polymorphism on IL-8 production and histologic degree of gastritis in noncancerous gastric mucosa. Although no correlation was found in the analysis of the IL-1B and IL-1RN polymorphisms, IL-8 -251 A/A genotype held a higher risk of atrophic gastritis [odds ratio (OR), 2.35; 95% confidence interval (CI), 1.12-4.94] and gastric cancer (OR, 2.22; 95% CI, 1.08-4.56) compared with the T/T genotype. We also found that the A/A genotype increased the risk of upper-third location (OR, 3.66; 95% CI, 1.46-9.17), diffuse (OR, 2.79; 95% CI, 1.21-6.39), poorly differentiated (OR, 2.70; 95% CI, 1.14-6.38), lymph node (OR, 2.50; 95% CI, 1.01-6.20), and liver metastasis (OR, 5.63; 95% CI, 1.06-30.04), and p53-mutated (OR, 1.91; 95% CI, 1.13-3.26) subtypes of gastric cancer. The A/A and A/T genotypes were significantly associated with higher levels of IL-8 protein compared with the T/T genotype. Neutrophil infiltration score was significantly higher in the A/A genotype than in the T/T genotype. In conclusion, we showed that the IL-8 -251 T > A polymorphism is associated with higher expression of IL-8 protein, more severe neutrophil infiltration, and increased risk of atrophic gastritis and gastric cancer.

著者等が行った超音波大腸内視鏡下穿刺について概説した.具体的な対象は粘膜下腫瘍(GIST,腸管子宮内膜症など),粘膜下を中心に発育した癌(カルチノイド腫瘍や4型の大腸癌など),直腸癌や結腸癌術後の再発,他の悪性腫瘍による消化管近傍の腫瘤,直腸或いは下部消化管周囲の膿瘍であった.スライディングチューブやガイドワイヤーを用いることにより,深部結腸への挿入も可能であった.EUS-FNABを行った大腸疾患22例中,95.5%で組織診断が可能であった.EUS-FNAB施行後に治療方針が変更となった症例も多く認めた.以上,本法の開発で悪性腫瘍との鑑別が必要な消化管及びその周囲の腫瘤に対して下部消化管からもアプローチが可能となった