堀口 明彦

BACKGROUND: We present a case of pancreatic and splenic metastases following alveolar soft part sarcoma (ASPS), which was successfully treated by surgery. CASE PRESENTATION: A 41-year-old male was referred to our hospital in 2012. Computed tomography (CT) showed the presence of a pancreatic tumor. In 2002, the patient had undergone surgical resection of an ASPS of the anal region. In 2009, during follow-up, CT revealed lung metastases, which prompted surgical resection of the lung, followed by resection of the head skin in 2011. Abdominal ultrasonography (US) revealed the presence of isodense masses sized 34 mm in the pancreatic head and 60 mm within the spleen. The contrast-enhanced US revealed a solitary lesion with enhancement. Contrast-enhanced CT revealed solitary lesions with enhancement within the pancreatic head, spleen, and liver. The patient underwent metastasectomies from the pancreas, spleen, and liver. The patient was discharged on postoperative day 22 without recurrence for 18 months after metastasectomy. Twelve years after primary resection and 2 years after metastasectomy, the patient died as a consequence of multiple metastases. CONCLUSIONS: We have presented a rare case of pancreatic and spleen metastases from ASPS. Resection by radical metastasectomy was successful without morbidity. Thus, for improved survival of patients with multiple metastases from ASPS, metastasectomy may be indicated. If multiple metastases are resectable, surgical approaches may be the preferred treatment.

The National Clinical Database (NCD) of Japan grew rapidly, harvesting over 11 million cases of data between 2011 and 2018 from more than 5000 facilities. This is the Report of the NCD based upon gastrointestinal surgery information in 4 420 175 cases from 2011 to 2018. More than 70% of all gastrointestinal surgeries were performed at certified institutions, and the percentage of surgeries performed at certified institutions was particularly high for the esophagus (93.8% in 2018), liver (89.4%), pancreas (91.3%), and spleen (86.9%). Also, more than 70% of the surgeries were performed with the participation of the board-certified surgeon. As the patients have been getting older, the morbidities have been increasing. However, the mortalities have been kept at a low level. The rates of endoscopic surgery have been increasing year by year, especially high in low anterior resection (67.0%) and esophagectomy (61.0%). Nationwide, this database is surely expecting to ensure the quality of board certification system and surgical outcomes in gastroenterological surgery.

Hepatocellular adenoma (HCA) is a benign hepatocyte-derived epithelial tumor. HCA is associated with oral contraceptive use among Caucasian populations. We report a case of hepatocellular adenoma with a pedunculated protuberance and high protein induced by vitamin K absence or antagonist-II (PIVKA-II) levels, which made diagnosis challenging. The patient was a 22-year-old woman. In a medical check-up, a high γ-GTP level was detected and a 115-mm solid mass was found in her lower abdomen via abdominal ultrasonography. A blood test showed a high PIVKA-II level. Abdominal CT showed a tumor in the lower abdomen. Contrast-enhanced CT showed a blood vessel thought to be the left hepatic artery connecting to the mass, and a blood vessel thought to be the left hepatic vein returning from the mass to the inferior vena cava. In EOB-MRI, uneven enhancement was observed after contrast imaging, but washout in the equilibrium phase was unclear. Parenchymal hepatocyte phases showed a pale, non-uniform, high signal. These findings indicated that the tumor was derived from the left lobe of the liver and was suggestive of HCC. Surgical resection was then performed. A pathological examination led to a diagnosis of HCA, corresponding to unclassified HCA. The WHO classification of tumors of the digestive system based on an immunohistological examination includes HNF1α-inactivated HCA, β-catenin-activated HCA, inflammatory HCA, and unclassified HCA. In summary, our patient had a large HCA with pedunculated protrusion into the extrahepatic pelvic cavity. This case was challenging to diagnose because of abnormally high PIVKA-II levels, and it was resected laparoscopically.

＜文献概要＞ポイント ◆可能な限り,早い段階で脾動脈確保を安全に施行することが,出血コントロールで重要である.◆膵切離では,切離前に膵圧挫用クリップでしっかり圧挫し,自動縫合器にてゆっくり切離する.◆出血したら,まずガーゼ圧迫と脾動脈テープを牽引する.脾動脈の枝からの出血ならクリップ,脾動脈本幹からの出血なら縫合閉鎖する.

OBJECTIVES: The correlations of the ratio of long-/short-chain DNA fragments in blood with the existence of cancer and the clinicopathological features of colorectal cancer (CRC) were examined. The potential use of this ratio for diagnostic screening was evaluated. METHODS: DNA concentrations were amplified using Alu247 for long-chain DNA fragments and Alu115 for long- and short-chain DNA fragments. The Alu247/115 ratio was calculated for 60 patients with CRC and 24 healthy volunteers. The correlation of the Alu247/115 ratio with clinicopathological variables and the efficacy of this ratio as a tumor marker were examined. The Alu247/115 ratio cut-off value was set using a receiver operating characteristic (ROC) curve. RESULTS: The Alu247/115 ratio was significantly higher in patients with CRC than in healthy volunteers (P<0.001). The Alu247/115 ratio was also significantly higher in patients with Dukes stage A or B CRC than in healthy volunteers (P=0.034) as well as in patients with Dukes C or D CRC than in those with Dukes A or B CRC (P=0.016). Among patients with CRC, the Alu247/115 ratio was significantly higher in those with than without venous invasion (P=0.031). Using the cut-off value set from the ROC curve, the sensitivity of the Alu247/115 ratio was significantly higher than that of the carcinoembryonic antigen level (P=0.004) or the carbohydrate antigen 19-9 level (P<0.001). CONCLUSION: Our data suggest that the Alu247/115 ratio is a promising tool for highly sensitive and early detection of CRC.

＜文献概要＞早期胆嚢癌(early gallbladder cancer)の定義はたいへん難しい.なぜなら,何をもって早期とするのかは,個々人の感覚により左右されるからである.そこで,ここでは局所進展度(contiguous extent)がT1の胆嚢癌を早期と定義した.日本の胆道癌登録の成績ではT1aの5年生存率は92.5%,T1bは87.2%であった.T1でリンパ節転移のないStageIの5年生存率(5 year survivalrate)は91.1%であった.領域リンパ節(regional lymph node)に転移を認める症例は,5年生存率が28.5%であった.リンパ節転移がある症例を早期とするか否かは議論が残るところである.T1a胆嚢癌の治療法は,全層胆嚢摘出術(simplecholecystectomy)でコンセンサスがある.T1b胆嚢癌では,切除範囲やリンパ節郭清の有無につきコンセンサスがない.腹腔鏡下胆嚢摘出術(laparoscopic cholecystectomy)に関しては,大規模研究の結果が待たれる.今後,早期の定義については,専門家集団による議論が必要である.

上行結腸憩室出血に対して術中内視鏡を併施し腹腔鏡下手術を施行した2例を経験した。2例とも造影CT検査を行い、腸管内への造影剤の漏出が確認できた。症例1は一時緊急下部消化管内視鏡検査を行い止血したが、貧血進行し、造影CT検査で腸管内への造影剤の再漏出が確認され、下部消化管内視鏡検査を再度行うも憩室が多発しており出血部位の同定は困難であったため手術を施行した。症例2は造影CT検査で腸管内への造影剤の漏出が確認でき、IVRにより止血したが再出血のため手術を行った。術中内視鏡を併施することで残存予定腸管に出血点およびその原因となり得る病変がないことの確認ができ、切除範囲決定に有用であった。IVRが常時行えない施設では術中内視鏡を併施することで腹腔鏡下手術でも切除範囲を決定できる可能性があり、憩室出血に対して有効な治療法の1つになりうる。(著者抄録)

膵体尾部の病変に対する術式において注意すべき外科解剖につき概説した。膵体部は頭側が胃膵間膜、尾部が横行結腸間膜前葉に連続する膜に包まれた組織内に位置する。また、膵腹側は膵前筋膜、背側は膵後筋膜からなっている。膵後面と腎全面の膜はGerota筋膜と称され、膵後筋膜とこのGerota筋膜の間にはToldtの癒合筋膜(Toldt&#039;s fusion fascia)が存在する。MDCTによるDPAの分岐形態の検討では、脾動脈から分岐するタイプが40%、総肝動脈から分岐するタイプが25.7%、上腸間膜動脈から分岐するタイプが20.0%であった。膵体尾部の静脈は膵実質から脾静脈へ直接流入する数本の細い静脈とcentro-inferior pancreatic veinが重要である。centro-inferior pancreatic veinは膵体部下縁実質から脾静脈あるいは上腸間膜静脈へ流入する静脈であり、横行膵静脈と吻合枝を形成する症例もある。また、下腸間膜静脈が脾静脈へ流入する頻度は34%、脾静脈と上腸間膜静脈の合流部に流入する頻度は24%、上腸間膜静脈へ流入する頻度は42%と報告されている。(著者抄録)

© 2018 Elsevier Inc. Introduction: Hepatocyte transplantation is a promising alternate for the treatment of hepatic diseases. Hypothermic preservation of isolated human hepatocytes is potentially a simple and convenient strategy to provide on-demand hepatocytes in the quantity sufficient and the quality required for biotherapy. Isolated fresh hepatocytes include damaged cells that are also early apoptotic cells, which is not ideal for hepatocyte transplantation. However, this does not reflect cell viability, although it is considered that it adversely affects cell survival after transplantation. We aimed to harvest these hepatocytes and filter the apoptotic cells using a magnetic method to provide a transplantation source. Materials and Methods: Rat hepatocytes were isolated from caudate lobes using manual enzymatic perfusion. The hepatocyte yield was 5.3 ± 0.66 × 109cells/g of liver tissue, with a viability of 82.3 ± 3.5%. Two samples of hepatocytes were freshly isolated, one using the magnetic method, and the other without. The magnetic method was performed using DynaMag-15 Magnet, and Annexin V Antibody was used on the early apoptotic cells. We evaluated the viability and plate efficiency of the cells after 24 hours at 37°C. Hepatocytes were isolated using cell separation method, and 30 × 106cells were mixed with 1.0 mL of Dulbecco&#039;s Modified Eagle&#039;s Medium (DMEM) and directly injected into the spleen of Lewis rats (150–250 g) using 24-gauge needles. Blood samples were collected on days 0, 3, 7, and 14, and the blood albumin level was measured using enzyme-linked immunosorbent assay (ELISA):G1, control (medium injection); G2, fresh hepatocyte transplant using the magnetic method; and G3, fresh hepatocyte transplant without the magnetic method. Results: The viability was 84.9 ± 2% for fresh hepatocytes and 80.7 ± 1.2% for hepatocytes isolated using the magnetic method. The magnetic method does not damage the cells (73.5 ± 2% vs 35.2 ± 2% after 24 hours), preserving hepatocyte. The albumin level accepted significantly increased in the magnet-treated group compared with the nonmagnet group. Simultaneously, the spleen in which these hepatocytes were transplanted could be used to observe the hepatocytes; the cells were transplanted 14 days later, and the magnet-treated group had significantly higher levels of hepatocytes than the nonmagnet group. Conclusion: We developed an effective technique for hepatocyte isolation for short-term preservation. As a result, we believe that transplantation not only improves the cell transplantation effect but also allows the cells to be stored efficiently using the magnetic method. These results demonstrate the usefulness of hepatocyte hypothermic preservation for cell transplantation.

症例は67歳、男性。嘔気、嘔吐にて当院を受診し、精査にて直腸癌による腸閉塞、多発肝転移と診断した。人工肛門造設術後に五次治療としてbevacizumab(Bmab)+TAS-102療法を行った。3ヵ月後のCT検査では13%の腫瘍縮小効果を認めた。Bmab+TAS-102療法中のGrade 3以上の有害事象は好中球減少のみであった。6ヵ月後のCT検査では肝転移の増大を認めたが、癌化学療法開始から40ヵ月生存中である。Bmab+TAS-102療法は標準治療抵抗性となった切除不能進行大腸癌に対する治療法として有効な選択肢となり得る。(著者抄録)

45歳の男性で,自ら肛門から大根を挿入したが抜けなくなり下血,下腹部痛出現したため救急搬送された.下腹部に限局した圧痛と筋性防御を認め,肛門からは動脈性の下血を認めた.腹部CTではRs直腸内に約74×58mmの異物を認めた.明らかな遊離ガスは認めなかった.全身麻酔下にて手術を行った.経肛門的に痔動静脈の損傷部位と直腸粘膜を修復した.腹腔鏡下にて腹腔内を観察すると,軽度濁った腹水を認めたが,明らかな穿孔部位は認めなかった.Rs直腸に異物を認めた.経肛門的に異物除去を試みるも困難であり,術者の左手を腹腔内に挿入して用手補助腹腔鏡下手術に移行し,用手的圧迫と経肛門的に異物を破砕しながら経肛門的に異物を除去した.経肛門的に摘出困難な直腸異物に対して,用手補助腹腔鏡下手術は腹腔内全体や腸管を観察することができ,用手的圧迫による異物誘導も可能であり,有用な治療のオプションになりえると考えられた.(著者抄録)