升森 宏次

The aim of the present study was to classify the short-term outcomes of local correction of stoma prolapse with a stapler device. The medical records of 11 patients undergoing local correction of stoma prolapse using a stapler device were retrospectively reviewed. No mortality or morbidity was observed after the surgery. Median operative time was 35 min (range 15-75 min), and blood loss was minimal. Median duration of follow-up was 12 months (range 6-55 months). One of the 11 patients had a recurrent stoma prolapse. This technique can be a feasible, safe and minimally invasive correction procedure for stoma prolapse.

da Vinci Surgical System^®を使用したロボット手術の導入後3年半余りが経過し，これまで56例を経験した．ロボット手術の利点である高解像度3次元画像や多関節機能などは骨盤内の解剖を詳細に把握し，繊細な手術を行ううえで有用である．手術時間の延長や自費診療などの課題もあるが，今後本邦においても症例数の増加が推測される．これまでの経験から定型化されつつある直腸癌に対する手術手技を紹介し，43例の短期成績について報告する．また，欧米や韓国からの報告を踏まえて，ロボット手術の現状や今後の展望について述べる．

大腸癌穿孔の臨床病理学的特徴について非穿孔例と比較し，その治療方針を検討した。穿孔例（15例）は他臓器浸潤例，高度静脈侵襲（v3）例の割合が非穿孔例に比べて有意に高率で，stageIV症例が多い傾向にあった。穿孔部位は癌部7例，癌口側7例，肛門側1例であった。根治度A手術は9例で施行されたが（一期切除5例，二期切除4例），二期手術では一期切除に比べて手術時間は長く，出血量は多かった。stageIIの1例（25％）とIIIaの3例（100％）で再発を認め，穿孔に伴う腫瘍細胞の散布に関係する腹膜播種や皮下再発を4例に認めたが，根治度B手術後に再発した1例を含む4例で血行性またはリンパ行性の再発を認めた。根治度A症例のうち非再発例の郭清リンパ節数は平均19.8個で再発例の6.3個に比べて多い傾向にあり，全身状態が許す限り，積極的な一期的切除と十分なリンパ節郭清が血行性，リンパ行性再発を予防し，予後改善に寄与することが期待された。

進行大腸癌化学療法であるXELOX±BV療法の有効性・安全性を確認するための第II相臨床試験を計画した.[方法]主評価項目は奏効率,副次的評価項目は無増悪生存期間,安全性(手足症候群発生割合),治療成功期間とした.本試験では全例に対し医師,看護師,薬剤師によるチームで副作用対策に取り組んだ.この結果,副作用発現率の低下と相対的用量強度の維持に有効であったため報告する.国内I/II相試験であるJO19380試験での手足症候群(HFS)発現率はgrade2/3が17.2%/1.7%であったが当院では13.3%/0%と良好な結果であった.相対的用量強度は6コース時点でL-OHP 89.2%,Xeloda 91.0%で良好であった.またその効果はCR/PR/NC/PD割合がそれぞれ10%/56.7%/16.7%/3.3%で奏効率66.7%,病勢制御率96.7%と満足できる結果であった.[結語]今後も増加するであろう外来での抗癌剤治療では,自宅での管理がより一層重要となる.チームでの取り組みは今後更に必要になると考えられる.(著者抄録)

Laparoscopic gastrointestinal surgery with lymphadenectomy is rarely performed for multiple gastrointestinal cancers. We report four patients undergoing laparoscopic surgery for synchronous cancer of the stomach and colon. Resection of each organ with lymphadenectomy was performed by each specialist and the region of the lymphadenectomy was determined according to the lesion of cancer and its depth. The selection of gastric anastomosis, whether intracorporeal or extracorporeal, depended on the resecting areas of the large bowel to allow a small incision. All four cases were male with the median age of 69 (range 59-77) years. The median number of trocars used were 6 (range 5-8) and median length of incision was 4.5cm (range 4-4.5cm). The median operative time and blood loss were 495.5 minutes (range 390-605) and 88g (range 36-245), respectively. In all four cases, laparoscopic surgery with a lymphadenectomy on each region was successfully accomplished according to the respective progression stage. Anastomosis was completed with a small incision by using techniques and devices to provide a variation of anastomosis methods and incision positions. Laparoscopic surgery with lymphadenectomy was also undertaken for a patient with gastric remnant cancer and colorectal cancer. The median length of the postoperative hospital stay was 14.5 days (range 12-29). No complications were observed after the surgery. There was no case of recurrence during a median follow-up of 84.3 months (range 54.9-111.5). Laparoscopic surgery was feasible for patients with double cancer of the stomach and colon.

Stomal prolapse is one of the common complications in transverse colostomy and can be managed conservatively in most cases; however, laparotomy and reconstruction of the stoma may sometimes be required, especially in case of irreducible colostomy prolapse. We have reported a simple local repair with reconstruction of the loop colostomy. We herein report a new more simple technique to avoid laparotomy and allow excision of the irreducible colostomy prolapse and complete closure of the distal limb of loop colostomy when no decompression is required in the distal limb of the stoma. In this procedure, the number of stapler and the time with blood loss for the operation can be saved.

Stomal prolapse is one of the common complications in transverse colostomy and can be managed conservatively in most cases; however, laparotomy and reconstruction of the stoma may sometimes be required, especially in case of irreducible colostomy prolapse. We have reported a simple local repair with reconstruction of the loop colostomy. We herein report a new more simple technique to avoid laparotomy and allow excision of the irreducible colostomy prolapse and complete closure of the distal limb of loop colostomy when no decompression is required in the distal limb of the stoma. In this procedure, the number of stapler and the time with blood loss for the operation can be saved.

2009年9月に大腸癌に対するda Vinci Surgical Systemを用いたロボット手術を導入し,これまでに20例を経験した.今回は,そのなかで下部直腸癌3例に対して内括約筋切除術(ISR)を施行したので,その手技と手術成績を報告する.術前診断でcT1の2例と,経肛門的腫瘍切除(MITAS)術後の1例であり,いずれも側方郭清の必要のない症例を選択した.平均手術時間は512分,出血量は113gで,術後平均在院日数は9日であった.1例に骨盤内膿瘍を認めたが,保存的治療で軽快した.病理組織検査で,郭清リンパ節は平均17個であり,Surgical Marginも全例negativeであった.Learning curveによる手術時間の短縮とさらなる症例の蓄積によってfeasibilityと安全性を示す必要があると考えられた.(著者抄録)

Solitary fibrous tumors (SFTs) develop most commonly in the pleura, although they have occasionally been reported to arise in the pelvic cavity. We report a case of an SFT presenting as a painless nodule in the pelvis of a 56-year-old woman. Histologically, the tumor was composed of spindle-shaped cells arranged without pattern, with short and narrow fascicles and interspersed bundles of thick collagen, and numerous blood vessels with a focally hemangiopericytoma-like appearance. Immunohistochemically, the tumor cells strongly expressed vimentin, CD34, and bcl-2. The tumor was excised via a trans-sacral approach, without preoperative transcatheter embolization, and the patient remains well more than 2 years after her operation. To our knowledge, this is the first case of an SFT in the pelvis, which was excised completely via a trans-sacral approach.

Solitary fibrous tumors (SFTs) develop most commonly in the pleura, although they have occasionally been reported to arise in the pelvic cavity. We report a case of an SFT presenting as a painless nodule in the pelvis of a 56-year-old woman. Histologically, the tumor was composed of spindle-shaped cells arranged without pattern, with short and narrow fascicles and interspersed bundles of thick collagen, and numerous blood vessels with a focally hemangiopericytoma-like appearance. Immunohistochemically, the tumor cells strongly expressed vimentin, CD34, and bcl-2. The tumor was excised via a trans-sacral approach, without preoperative transcatheter embolization, and the patient remains well more than 2 years after her operation. To our knowledge, this is the first case of an SFT in the pelvis, which was excised completely via a trans-sacral approach.

[はじめに]直腸脱術後の直腸肛門機能に関する報告はほとんどない。本論文では直腸脱に対する腹腔鏡下直腸固定術前後の直腸肛門機能の変化を検討した。[対象および方法]1996〜2006年までに腹腔鏡下直腸固定術(Well's法)を施行した12例を対象とし、直腸肛門内圧測定はマイクロトランスデューサー法にて施行した。術後の臨床的排便機能評価にはWexner's scoreおよび患者アンケートを用いた。[結果]腹腔鏡下直腸固定術後には、肛門管最大静止圧が有意に(P=0.048)上昇した。その他の値は有意な変化を示さなかった。術後のWexner's scoreは有意に(P=0.037)改善し、患者の満足度も高かった。[結語]腹腔鏡下直腸固定術後には、肛門管最大静止圧が有意に上昇し、臨床的な排便機能にも改善がみられた。(著者抄録)