花井 恒一

＜文献概要＞ポイント ◆ロボット支援手術においては,体腔内外でのアームや鉗子同士の干渉を解消する工夫が必要である.◆ロボット操作のトレーニングにはシミュレーターやデュアルコンソールが有用と思われる.◆手術支援ロボットは内視鏡手術のツールの1つであり,腹腔鏡手術の概念を理解しておかなければならない.

OBJECTIVE: The treatment policy of colorectal cancer in elderly patients is controversial due to a lack of specific guidelines. To clarify the present management of colorectal cancer for aged patients, a questionnaire survey was conducted by the Japanese Society for Cancer of the Colon and Rectum. METHODS: Questionnaire forms were sent to the 430 member institutions of the Japanese Society for Cancer of the Colon and Rectum. RESULTS: The response rate of the surgical department to the questionnaire was 39%. Performance status was used for preoperative assessments, and electrocardiogram and ultrasonic cardiograms were conducted for cardiovascular evaluations in many institutions. The same extent of surgical procedures was often adopted for elderly and younger patients, and the frequency of a laparoscopic procedure was the same regardless of a patient's age. A simultaneous hepatectomy for hepatic metastasis was considered in one-third of institutions. In many institutions, intersphincteric resection for patients with possible sphincter-saving surgery was not considered for elderly patients with low rectal cancer. CONCLUSION: Japanese Society for Cancer of the Colon and Rectum member institutions often used the same surgical treatment strategies for both elderly and younger patients with the exception of performing intersphincteric resection.

Rectovaginal fistula caused by a tension-free vaginal mesh (TVM) is a rare condition. Moreover, a rectovaginal fistula is a challenging issue to address for surgeons regardless of causes. Due to a low rate of occurrence, treatment modality for a rectovaginal fistula caused by a TVM has previously received little attention. A successful surgery using several key techniques to address a rectovaginal fistula caused by a TVM is herein reported. A 78-year-old woman who underwent a TVM for a rectocele three months ago was referred to our hospital with a two-month history of anal bleeding. Mesh protruding into both the vagina and the rectum was confirmed. The patient was operated on under diagnosis of a rectovaginal fistula caused by TVM. TVM was removed by transvaginal dissection of the rectovaginal septum with division of both anterior and posterior arms of the TVM. Layer-to-layer sutures of rectal and vaginal walls were crossly performed with a drain placed in the rectovaginal septum after saline irrigation followed by a covering sigmoid colostomy. The wound healed without infection after surgery, and a water-soluble contrast enema demonstrated the healing of the rectovaginal fistula two months after surgery. No recurrent fistula was confirmed 15 months after stoma closure.

INTRODUCTION: Previous randomized controlled trials demonstrated similar oncological outcomes between laparoscopic and open colectomies, except for cases involving transverse colon and splenic flexure colon cancer. The objective of this study was to confirm the oncological safety and advantages of the short-term results of laparoscopic surgery for transverse and descending colon cancer in comparison with open surgery. METHODS: The study data were retrospectively collected from the databases of 45 hospitals. Patients with transverse or descending colon cancer who underwent laparoscopic or open R0 resection were registered. The primary end-points were the 3-year overall survival and relapse-free survival rates according to pathological stage. The secondary end-points were the short-term results, including blood loss, operative time, diet intake, hospital stay, and postoperative complications. RESULTS: Of the 1830 eligible patients, 872 underwent open colectomy and 958 underwent laparoscopic colectomy. The median follow-up period was 38.4 months. The conversion rate to open resection was 4.5%. The 3-year overall survival rate of the laparoscopic group was significantly higher than that of the open group for stage I patients (96.2% vs 99.2%; P = 0.04); it was also higher for stage II (94.0% vs 95.5%) and stage III (87.4% vs 90.2%) patients, but there were no significant differences. The 3-year relapse-free survival rate of the laparoscopic group was significantly higher than that of the open group for stage I patients; there were no differences between the open and laparoscopic groups among the stage II and III patients. In the multivariate analyses, laparoscopic resection was a significant factor in relapse-free survival. Laparoscopic patients had significantly lower blood loss and a significantly longer operative time than the open groups. Also, postoperative hospital stay was significantly shorter and postoperative morbidity was significantly lower in the laparoscopic group. CONCLUSION: Although this retrospective study has limitations, we can conclude that laparoscopic surgery for transverse and descending colon cancer is oncologically safe and yields better short-term results than open surgery.

＜ポイント＞排便機能障害を呈する骨盤底臓器脱には、直腸脱、直腸重積、直腸瘤などがある。骨盤底臓器脱は骨盤底の支持組織の脆弱化によって引き起こされる。骨盤底臓器脱のうち、直腸瘤などの消化器系の臓器脱では排便困難や残便感、便秘、便失禁などの症状を呈する。骨盤底臓器脱は、泌尿器系、婦人科系の他の臓器脱を合併することが少なくない。骨盤底臓器脱の診察では肛門視・指診や画像診断を行う。骨盤底臓器脱ではまず保存的治療を行うが、外科的治療を要することが多い。(著者抄録)

＜ポイント＞直腸重積は排便障害の原因となる。直腸重積の病態は多彩な症状を呈する。直腸重積の診断には排便造影検査が必須である。直腸重積の治療では薬物療法や排便指導などの保存的治療が原則である。直腸重積に対する外科治療は完全直腸脱に対する術式が応用されている。(著者抄録)

＜POINT＞腹痛,嘔気,嘔吐,排便・排ガスの停止などのイレウス症状を呈する病態では,まずイレウスであることを診断する.イレウスと診断したら,機械的イレウスか機能的(麻痺性)イレウスであるかを診断する.機械的イレウスで絞扼性と診断すれば緊急手術を行い,単純性イレウスや機能的イレウスでは保存的治療を開始する.単純性イレウスでも,経過中に絞扼性イレウスに移行することがあるので,連日病態を注意深く観察する.(著者抄録)

PURPOSE: The aim of this questionnaire survey was to assess the change in treatment modality over time and the current status of clinical outcomes of local treatment in Japanese patients with pathological T1 (pT1) rectal tumors. METHODS: A questionnaire survey was conducted by the 81st Congress of the Japan Society for Cancer of the Colon and Rectum. Clinical and pathological outcomes of all eligible patients undergoing local treatment were retrospectively collected from the medical records of each participating hospital. RESULTS: A total of 1371 pT1 patients from January 2006 to December 2008 (Period A), and 659 patients in 2013 (Period B) were registered. Approximately 70 % of patients underwent radical surgery in both periods. The rate of patients undergoing laparoscopic surgery increased from 46.5 % in Period A to 84.7 % in Period B. The indications for local excision were comparable with those for endoscopic intervention in 78 % of institutions. The rate of endoscopic submucosal dissection (ESD) increased from 20.1 % in Period A to 37.9 % in Period B, whereas local excision decreased from 36.9 to 24.1 %. Few patients received adjuvant therapy, and approximately 40 % of patients underwent additional surgery in both periods. Local recurrence was observed in 9.2 % of patients in Period A, with the median follow-up period being 59 months. Eighty-two percent of patients with local recurrence underwent salvage surgery. CONCLUSIONS: Local treatment with various modalities was properly performed for early rectal cancer. The number of less invasive modalities, such as laparoscopic surgery and ESD, increased between study periods.

PURPOSES: This study prospectively assessed the sexual and urinary functions, as well as factors influencing these functions, in patients who underwent open or robotic surgery for rectal cancer. METHODS: Forty-five consecutive male patients who underwent rectal resection for rectal cancer were prospectively enrolled in this study. Their sexual and urinary functions were assessed through self-administered questionnaires comprising the International Index of Erectile Function (IIEF; sexual function) and the International Prostate Symptom Score (IPSS; urinary function) before and at 3, 6, and 12 months after surgery. RESULTS: Fifteen patients who underwent robotic surgery and 22 who underwent open surgery were finally analyzed in this study. The total IIEF score and the individual score items did not change at 3, 6 or, 12 months after open or robotic surgery compared with the preoperative values. However, a univariate analysis revealed that age affected the urinary function 12 months after surgery, while both univariate and multivariate analyses revealed that postoperative complications affected the sexual function 12 months after surgery. CONCLUSIONS: In this non-randomized comparison, the postoperative sexual and urinary functions were comparable between patients who underwent open rectal surgery and those who underwent robotic rectal surgery. Postoperative complications were a risk factor for sexual dysfunction, while age was a risk factor for urinary dysfunction.

下部消化管領域の内視鏡外科手術は、大腸癌を中心に良性腸疾患から直腸機能障害まで広く普及してきている。大腸癌手術は、根治性の問題もあり、国内、海外で様々な大規模な臨床試験が行われ、短期成績では、患者に対するQuality of lifeの向上や整容性の面で評価され長期成績もほとんどの報告で差がないことが証明されてきている。内視鏡外科手術のデバイスの開発や拡大視効果などによりさらに適応拡大されつつあるが、直腸癌手術のように狭い術野での操作となる難度の高い手術においては、熟練した技術が必要となり、長期予後についてはまだ十分な評価がなされていないのが現状である。一方、内視鏡外科手術の新しい方向性として、整容性を求めた創を少なくする手術や、直腸癌手術のような難度の高い手術に対しても安定した術野で精緻な手術が可能とされるロボット支援手術が開発され期待されている。(著者抄録)

Robotic surgery offers advantages for operating in a narrow space such as inside the pelvis. We report on the technique of robotic-assisted laparoscopic total proctocolectomy with lymphadenectomy and ileal pouch-anal anastomosis for ulcerative colitis with transverse colitic cancer, using the single cart position. A 46-year-old female patient was diagnosed with colitic cancer of the transverse colon during the surveillance of ulcerative colitis. Six port sites were used. Mobilization of the left-sided colon through to the rectum and mobilization of the transverse colon with lymphadenectomy around the middle colic artery were performed using the robotic surgical system. After rectal mobilization was conducted near the anus, the right side of the colon was mobilized and the ileum resected laparoscopically. Thereafter, a mucosectomy of the proctorectum was carried out through a trans-anal approach, and a hand-sewn J-pouch was performed. Finally, a diverting ileostomy was constructed through the right lower abdomen. The operative time was 460 minutes, including the console time of 361 minutes. The amount of blood loss was 76 g. The patient was discharged on postoperative day nine. Pathological results demonstrated that the depth of the lesion was T3, and the positive lymph node was 1 of 115 retrieved lymph nodes. There were no complications or mortality. Robotic-assisted total proctocolectomy and lymphadenectomy with ileal pouch-anal anastomosis for transverse colitic cancer of ulcerative colitis was performed safely using the single cart position.

We report a case of gigantic cystic lymphangioma of the ascending colon excised through an open laparotomy. A 34-year-old woman consulted a gynecologist for treatment of infertility. Transvaginal ultrasonography revealed a cystic mass in the pelvis, and she was transferred to our hospital for further investigation. Abdominal enhanced computed tomography (CT) showed a bulky cystic mass, 25 cm or larger, in the abdominal and pelvic cavity. Colonoscopy revealed a cystic submucosal tumor with a cushion sign. Cystic lymphangioma was diagnosed and excised via open surgery as we could not exclude its malignant potential. Pathological examination confirmed lymphangioma. To our knowledge, this is the most gigantic lymphangioma of the colon documented in the literature. About 3 months after surgery, the patient discovered that she was pregnant and her first baby was delivered at term, uneventfully.

INTRODUCTION: Anastomotic surgical recurrence after bowel resection is a major problem in patients with Crohn's disease. The aim of this prospective observational study was to evaluate the efficacy of a novel technique for restoring bowel continuity after resection involving either the small or the large intestine. METHODS: The first case was instructed by Dr. Kono at Fujita Health University. The involved bowel segment was divided transversely with a linear stapler. The edges of two stapled lines are then connected to create a supporting column, which prevented surgical recurrence from anastomotic distortion due to mesenteric longitudinal ulcers. Thereafter, an antimesenteric longitudinal enterotomy was performed on each side to create a large-sized handsewn end-to-end anastomosis. RESULTS: Thirty consecutive patients underwent Kono-S anastomoses from December 2009 to August 2013. Neither anastomotic leakage nor surgical recurrence was observed during a median follow-up period of 35 months. Endoscopic surveillance was performed in 18 cases (69.2%) undergoing ileo-colonic or ileo-rectal anastomosis with an average Rutgeert's score of 0.78 (0-3) at a mean of 14.5 months postoperatively. CONCLUSION: The Kono-S anastomosis for Crohn's disease has been a safe and feasible technique. Long-term outcomes are required to confirm its advantage in preventing surgical recurrence at the anastomosis.

PURPOSES: To establish the efficiency of bowel ligatures in colon cancer surgery, focusing on the extent to which exfoliated cancer cells are shed in the colonic lumen during sigmoidectomy. METHODS: Twenty consecutive patients who underwent sigmoidectomy for sigmoid colon cancer were prospectively randomized into two groups: the "ligatures group", in which bowel ligatures were placed, 3, 5, 10 cm from the tumor proximally and distally before dissection; and the "no ligatures group", in which the corresponding sites were ligated only immediately before taking the specimen out. Each colonic segment ligated was irrigated with saline and samples were sent for blind cytological examination. RESULTS: Cancer cells were found in the colonic segment where the tumor was located, in 18 of 20 samples. The frequency of free cancer cells decreased from 50 to 0 % (p < 0.04) in the distal 3-5 cm colonic segment and from 80 to 20 % (p < 0.03) in the proximal colonic segment after performing bowel ligatures. Free cancer cells were confirmed in 1 of 10 samples at both colonic segments 5-10 cm from the tumor, even after bowel ligatures. CONCLUSIONS: Intraluminal exfoliated cancer cells could be eliminated by placing bowel ligatures during sigmoidectomy. Measures should be considered to eliminate exfoliated cancer cells during colectomy, even after placing bowel ligatures.

We evaluated the effect of hepatic arterial infusion(HAI)chemotherapy for liver metastases from colorectal cancer. A total of 65 patients received HAI chemotherapy. The chemotherapy regimen consisted of weekly 5-FU (1, 500 mg/body) or 5-FU (400 mg/mm2) and l-LV (200mg/mm2). The survival and response rates were assessed according to RECIST. Median survival time with HAI chemotherapy was 13. 5 months, 5-year survival rate 8% and response rates 55%. There was no evidence of myelosuppression, and HAI could be continued for a long time even for poor PS patients. There were no differences in survival time between synchronous, metachronous and postoperative metachronous liver metastases. In the patients who underwent curative hepatectomy after HAI chemotherapy, the 5-year survival rate was 21%, which was better than in patients with HAI chemotherapy alone. HAI chemotherapy could thus be an option for unresectable liver metastases, which could be well tolerated.

We reviewed clinical records of 10 cases with preoperative chemoradiotherapy to evaluate the clinical effectiveness of the chemoradiotherapy for T4 rectal cancer. The preoperative radiation therapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day for five days per week. A treatment of 5-fluorouracil (500 mg/body) per day intravenously, or oral UFT-E (300 mg/m2) with l-leucovorin (75 mg/body) per day, or oral S-1 (80 mg/m2) per day for five days per week, was given during radiotherapy. Grade 1 or 2 adverse effects occurred in 3 patients during chemoradiotherapy, but a completion of chemoradiotherpy was achieved in all of the 10 patients. Invasive findings to the adjacent organs identified by CT and MRI disappeared in 6 cases with complete or partial response 1 month after chemoradiotherapy. Although the adjacent organs were also removed during surgery in 7 patients, curative surgery was performed in 7 patients. There was no histological invasion to the adjacent organs in 4 patients, and one patient had a histological complete disappearance of tumor. Although complications after surgery were found in all of the patients, they were improved by conservative treatment. Two of 7 patients with curative surgery had recurrence, but the rest of them survived without recurrence. Preoperative chemoradiotherapy was expected to be a safe and effective treatment to improve the resection rate and prognosis for T4 rectal cancer.

当院で1974〜2005年に肝切除術を行った大腸癌肝転移196例の治療成績を単発転移群と多発転移群,同時性転移群と異時性転移群,大腸癌取扱い規約H分類別などに分けて比較検討した.全症例の初回肝切除後5年生存率は42.2%,10年生存率は33.4%であった.単発転移群は5年生存率54.7%,10年生存率46.9%,多発転移群はそれぞれ27.9%,18.8%で,多発転移群が有意に予後不良であった.同時性転移群は5年39.2%,10年28.2%,異時性群はそれぞれ44.9%,38.4%で,両群間に有意差は認められなかった.大腸癌取扱い規約(旧)H分類による比較ではH1群がH2・H3群に比べて有意に予後良好であった.残肝再発に対する再肝切除群,肺転移切除群,肝肺3回以上繰り返し切除群の再切除後5年生存率はそれぞれ31.1%,39.6%,22.5%であった.術前検査として血管造影下CTを施行された群と非施行群とで5年生存率を比較すると,それぞれ42.6%,43.2%で有意差は認められなかった

PURPOSE: The original double-stapling technique (DST) using a standard linear stapler horizontally can be difficult in patients with a narrow pelvis or an ultralow anastomosis. We review our experience of performing a modified DST (IO-DST) with vertical division of the rectum achieved using an endostapler. METHODS: We retrospectively studied the clinical outcomes of 90 patients who underwent low anterior resection (LAR) for lower rectal carcinoma. Low anterior resection was performed with IO-DST in 34 patients (IO-DST group), with the single-stapling technique (SST) in 47 (SST group), and with per anal anastomosis (PAA) in 9 (PAA group). RESULTS: The distances from the anal verge to the tumor and to the anastomosis were significantly shorter in the IO-DST group than in the SST group (5.8 cm, 4.0 cm vs 7.0 cm, 5.0 cm, respectively), whereas it was equivalent in the IO-DST and PAA groups (5.0 cm, 4.0 cm). Blood loss was less in the IO-DST group than in the SST and PAA groups (400 ml vs 578 ml and 950 ml, respectively). The operative time was shorter in the IO-DST group than in the PAA group (281 min vs 327 min, respectively). There were no significant differences in the length of the distal surgical margin among the three groups. The IO-DST group patients suffered less bowel frequency than the SST group patients 1 month after surgery (2.5 times/day vs 4.0 times/day, respectively) and less than the PAA group patients more than 1 year after surgery (2.0 times/day vs 3.5 times/day, respectively). There were no significant differences in the incidence of complications or local recurrence among the three groups. CONCLUSIONS: IO-DST is a feasible and safe procedure for performing low anastomosis, which results in less bowel frequency after LAR for lower rectal carcinoma.

Intra-arterial infusion chemotherapy via the internal iliac artery was performed in 5 patients with locally advanced rectal cancer or recurrent rectal cancer. Arterial infusion chemotherapy was conducted into the internal iliac artery via bilateral femoral artery following a blood flow change with a coil. 5 FU 500 mg and l-leucovorin 125 mg/m2 were injected weekly. An average time of injections or its duration was 40 (17-74) times or 12.8 (5-23) months, respectively. Disappearance or improvement of symptoms was observed in 4 cases. A decrease of tumor size observed by CT was in 2 cases and a decrease of blood CEA level was in 3 cases. As for the complication of arterial infusion chemotherapy, dermatopathy was found in all of the cases, and sensory disturbance of lower extremities was in 3 cases, infection was in 2 cases and catheter obstruction was in 2 cases. A decrease of dosage or abundance of continuation was done during the course due to complications. Two patients with primary cancer died 1-3 years after the treatment, and 2 patients with recurrence died 7 months to 1 year after the treatment. One patient with primary cancer is continuing the treatment for the last 2 years though multiple metastatic diseases have been confirmed.

Systemic and local immunological responses were studied in patients with or without preoperative administration of chemotherapeutic and/or immunotherapeutic drugs for colorectal cancer. The plasma TGFbeta and other cytokines such as IL-2, IL-4, IL-6, IL-10, IL-12, IFN-gamma in the supernatant fluid of culture of peripheral blood mononuclear cell (PBMC) and regional lymph node were measured by the ELISA method. A systemic response of cytokines was as follows: the production of plasma TGFbeta increased in many cases by chemotherapeutic drugs with a significant elevation of the mean production. Productions of IFN-gamma, IL-2, IL-12 in the supernatant fluid of culture of PBMC increased in many cases by immunotherapeutic drugs, and that of IL-4, IL-6 increased in many cases by chemotherapeutic drugs. A local response of cytokines was as follows: the production of IL-2 by immunotherapeutic drugs was greater than that without immunotherapeutic drugs whereas the production of IL-10 by immunotherapeutic drugs was smaller than that without immunotherapeutic drugs.

PURPOSE: Rectal stump washout has been recommended to prevent implantation of exfoliated malignant cells in the anastomosis after anterior resection for rectal cancer. The aim of this study was to investigate its efficacy, particularly the extent to which the volume of irrigation fluid might influence the efficacy of tumor cell elimination and whether tumor characteristics might influence the result. METHODS: The study comprised 30 consecutive patients operated on by anterior resection for rectal cancer. After cross-clamping the rectum below the tumor, a washout sample was collected for examination after every incremental 500 ml of saline irrigation up to 2 liters. The presence of shed cancer cells was correlated with the washout volume and tumor characteristics. RESULTS: Cancer cells were found in 29 of 30 patients (97 percent) in the first sample of irrigation fluid and decreased gradually in frequency and number with increasing irrigation volumes. No cancer cells were demonstrated after 1.5 liters of irrigation in patients with tumor below the peritoneal reflection, whereas cancer cells were still present in one-fourth of the patients with tumor located above the peritoneal reflection. Finally, only a small number of cancer cells was confirmed in one patient after 2 liters of irrigation. CONCLUSIONS: The irrigation volume determined the efficacy of rectal washout. With our method, 1 1/2 liters of saline irrigation appears to clear contents from cancer cells in patients with tumors below the peritoneal reflection whereas at least 2 liters is recommended for patients with tumor above the peritoneal reflection.

58歳女.直腸肛門視診にて直腸前壁に硬い腫瘤を触知し,注腸造影検査及び大腸内視鏡検査にて同部位にtype 2の腫瘍を認めた.大腸内視鏡下生検にて中分化腺癌と診断された.術前に,multi-slice CT(MSCT)を施行したところ左側方にリンパ節腫大を認め,転移が示唆され,また,radioisotope法を施行したところinjection pointのみのradioactivityを認め,周囲リンパ節へのRI集積は認めなかった.直腸Ra領域の直腸癌と診断し,手術を施行した.摘出標本により採取したリンパ節は合計67個であり,全てのリンパ節にHE染色を施行して病理組織学的検鏡を行った.転移陽性リンパ節数は12個で,いずれも好中球の浸潤を伴う高分化型腺癌であった.術前にMSCTによる転移陽性と診断した下腸間膜幹リンパ節には,病理組織学的転移が認められた.術中にSNと判定したセンチネルリンパ節には病理組織的転移を認めなかった

Background/Aims: When an Appleby operation is performed for pancreatic by and tail carcinoma, it is necessary for prevention of hepatic circulation after resection of the celiac artery, the common hepatic artery and the portal vein. We studied the hepatic circulation by monitoring the ShvO(2) (hepatic venous hemoglobin oxygen saturation) during an Appleby operation. Methodology: We performed an Appleby operation on 8 patients with pancreatic cancer. In 6 of 8 patients, a 7-Fr fiberoptic flow direct catheter was inserted in right hepatic vein. The ShvO(2) values were monitored continuously during surgery. Results: The ShvO(2) value was 76+/-3.5% just after laparotomy, and reduced to 61+/-13.2% after clamping the common hepatic artery. The values of the ShvO(2) returned to 70.8+/-10.9% one hour after clamping. But, one patient underwent reconstruction of the common hepatic artery, because the ShvO(2) value still stood at 50%. Combined resection of the portal vein was performed in 5 out of 8 patients. Two patients underwent resection of the portal vein without reconstruction due to the development of the collateral vein, one patient; resection of the portal vein with reconstruction, and two patients; wedge resection. In all 5 patients, the ShvO(2) was stable during resection of the portal; vein. Conclusions: Monitoring the ShvO(2) is a useful method top evaluate at real time the hepatic circulation during the Appleby operation, and to decide if reconstruction of the common hepatic artery or the portal vein is needed or not.

BACKGROUND/AIMS: The aim of this study was to determine whether Billroth I pancreaticogastrostomy (PG-I) or Billroth II pancreaticojejunostomy (PJ-II) after pylorus-preserving pancreatoduodenectomy is associated with better postoperative fat absorption, based on residual pancreatic exocrine function. Several reconstructive operations have been employed after pylorus-preserving pancreatoduodenectomy to maximize postoperative nutrition. However, no single-institution study has been published comparing the reconstructive procedures with respect to digestion and absorption of fat. METHODOLOGY: Fat absorption was studied using the C-13-trioctanoin breath test in patients who were grouped according to the degree of fibrosis of the pancreatic remnant, which was determined by histologic examination of the resection specimen. The fibrosis was graded: grade 0, &lt;10% fibrosis; grade 1, 10-30% fibrosis; and grade 2, &gt;30% fibrosis. There were 22 patients in the PG-I group and 22 patients in the PJ-II group. RESULTS: There were no significant differences between the PG-I and PJ-II groups in the cumulative excretion of labeled carbon dioxide in the patients with grade 0 pancreatic fibrosis. The cumulative excretion in the PG-I group was better than in the PJ-II group in the patients with grade 1 and grade 2 pancreatic fibrosis. CONCLUSIONS: Fat absorption after PG-I is superior to that; after PJ-II in patients with disordered exocrine function of the pancreatic remnant. Billroth I pancreaticogastrostomy allows more effective utilization of the exocrine enzymes of the pancreatic remnant due to elimination of the blind loop characteristic of the Billroth II pancreaticojejunostomy.

The practice of laparoscopic colorectal resection has become widespread,the D2 lymphadenectomy is necessary for early colorectal cancer. 20 patients have been performed laparoscopic asisted colectomy with D2 lymphadenectomy for the early colorectal canser at the Surgical Department in the period between July Ist 1996 and December 1997. The injected ink into the submucosa of colon on the preoperation could be identified easily a colic lymph nodes and lesion at the operation for all patients,The technique has been a index of surgical maneuver. The other technique was lifted the gastrocolic mentum to abdominal wall for the laparoscopic asisted transeverse colectomies(7patients)with D2lymphadectomy. As a result, the technique could decreased complications that traumatized the grasping intestine with intestinal forceps and we suggested that it will prevent implantation.

症例は70歳,女性.食道透視により特発性食道破裂の診断,発症7時間後に緊急手術を施行した.横隔膜直上の食道の左側前壁側に破裂部を認め,同部を一期的に2層縫合し2本の胸腔ドレナージを施行した.術後,縫合不全,膿胸を認め持続洗浄,低圧持続吸引を行い膿瘍は瘻孔化し,縮小傾向を認めたが瘻孔気管支瘻も存在したため,消化液に加え唾液等の汚染のため治療に難渋した.この難治性瘻孔に対し内視鏡を用いて瘻孔内を観察後,2本のバルーンを用いて瘻孔内の汚染を予防しフィブリン糊製剤を瘻孔内に充満したところ,充満後比較的短期間で瘻孔閉鎖に成功した.