加藤 良一

When performing endovascular aortic repair (EVAR) procedures, clinicians sometimes encounter cases in which the indications for EVAR are beyond the instruction for use (IFU). In EVAR, proximal neck fixation is the most important factor. This report describes several techniques and tips for EVAR in cases presenting with a difficult short neck or angled neck, especially when using the Gore Excluder®. Endo-wedge techniques (EWT), including non-sheath-assisted EWT with sheath-assisted strategies, are presented. We describe the scrum technique, which is a special procedure that is only feasible when using the Gore Excluder®. In this technique, intentional wire bending around the proximal neck portion occurs by pushing from both sides of the guidewire. This technique is applicable in cases with a sharply angled neck. The scrum with EWT is a more precise strategy for cases with a short or angled neck. Other troublesome cases include limb occlusion caused by weak points in the Gore Excluder® body and legs. The very rare complication of stent-graft collapse is also reviewed. © Banno et al.

The purpose of this study was to assess the clinical features and characteristics of the blood flow in uterine vascular abnormalities using ultrasound and magnetic resonance imaging (MRI). A total of 17 women were diagnosed with uterine vascular abnormalities by ultrasound. The clinical characteristics of the patients and the distribution and waveform of the intrauterine vessels were examined using transvaginal gray-scale and Doppler ultrasonography, spin-echo MRI, and MR angiography. The average age of the 17 subjects was 44.3 years, and 5 were postmenopausal women. The number of pregnancies and deliveries was 2.0 and 1.7, respectively. Of the 17 subjects, 7 had a moderate or severe grade of dysmenorrhea and 7 had a history of vascular disease. In all subjects, vaginal ultrasound demonstrated tubular or numerous tortuous anechoic areas in the uterine wall, and Doppler ultrasound showed that the tubular or numerous dilated tortuous vessels had an atypical wave flow, unlike that of an artery or a vein. The distribution of displayed flow varied, and the waveforms of the Doppler ultrasound displayed three patterns. The averages of the pulse Doppler flow indices showed low impedance in the abnormal uterine vessel and the uterine artery, especially in cases of true arteriovenous malformations. MR angiography demonstrated distinct, tortuous, and coiled vascular channels in the pelvis during and just after the arterial phase. Characterization of the clinical features of uterine vascular abnormalities is considered to be valuable for obstetricians and gynecologists.

Although several murine mAbs that have been humanized became useful therapeutic agents against a few malignancies, therapeutic Abs are not yet available for the majority of the human cancers because of our lack of knowledge of which antigens (Ags) can become useful targets. In the present study we established a procedure for comprehensive identification of such Ags through the extensive isolation of human mAbs that may become therapeutic. Using the phage-display Ab library we isolated a large number of human mAbs that bind to the surface of tumor cells. They were individually screened by immunostaining, and clones that preferentially and strongly stained the malignant cells were chosen. The Ags recognized by those clones were isolated by immunoprecipitation and identified by MS. We isolated 2,114 mAbs with unique sequences and identified 21 distinct Ags highly expressed on several carcinomas. Of those 2,114 mAbs 356 bound specifically to one of the 21 Ags. After preparing complete IgG(1) Abs the in vitro assay for Ab-dependent cell-mediated cytotoxicity (ADCC) and the in vivo assay in cancer-bearing athymic mice were performed to examine antitumor activity. The mAbs converted to IgG1 revealed effective ADCC as well as antitumor activity in vivo. Because half of the 21 Ags showed distinct tumor-specific expression pattern and the mAbs isolated showed various characteristics with strong affinity to the Ag, it is likely that some of the Ags detected will become useful targets for the corresponding carcinoma therapy and that several mAbs will become therapeutic agents.

Background/Purpose. When a pancreatoduodenectomy is to be conducted, preoperative understanding of the vascular anatomy of the pancreatic head is important in order to reduce intraoperative bleeding. Using multislice computed tomography (MS-CT), we investigated the depiction rate and branching of the inferior pancreaticoduodenal artery (IPDA) and dorsal pancreatic artery (DPA), afferent arteries to the pancreatic head. Methods. In 109 patients (68 with pancreatic cancer, 21 with biliary tract cancer, 15 with intraductal papillary mucinous tumor of the pancreas, and 5 others), images were taken, using 64-row MS-CT, in the early and late arterial phases. Results. The depiction rates were 98.2% for the IPDA and 96.3% for the DPA. Branching of the IPDA was categorized into three types: a type in which the IPDA formed a common vessel with the first jejunal branch (72.0%), a type in which the IPDA branched directly from the superior mesenteric artery (18.7%), and a type in which the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) branched separately (9.3%). DPA branching was categorized into five types, in which the DPA branched from the splenic artery (40.0%), from the common hepatic artery (25.7%), from the superior mesenteric artery (20.0%), and from the celiac artery (8.6%), and a type in which the DPA branching did not follow any of the above patterns (5.7%). Conclusions. MS-CT images of vascular architecture enable evaluation from any angle, which is not possible with conventional angiography, making MS-CT a useful diagnostic imaging technique for understanding the vascular anatomy of the pancreatic head prior to conducting pancreatoduodenectomy for diseases of the pancreatic head region.

Background/Aims: We had previously reported that using CT during angiography as a preoperative evaluation improves the detecting rate of minute (less than 10mm) metastases and non-recurrent rate in the liver. We here evaluate the impact of CT during angiography on the survival after putative curative liver resection in our series. Methodology: During the period between 1990 and 2000, single detector helical CT was used for preoperative examination. There were 85 patients who underwent the examination before hepatectomy for colorectal metastases. Among them, there were 37 patients who underwent preoperative evaluating CT during angiography, and 48 who did not. The survival curves of the patient with/without CT during angiography, after the first hepatectomy, were calculated. Results: Although recurrences in the residual liver after hepatectomy were observed in 9 out of 37 patients with CT-during angiography and 19 out of 48 patients without, the actual 5-year survival rates of the patients with and without CT during angiography are 42.6 and 43.2%, respectively, after more than 5 years' follow-up period. There is no significant difference between them. Conclusions: The present data show that the benefits from the approach to improve the detection of minute liver metastases are limited for the survival of putative curative liver resection.

Humoral hypercalcemia of malignancy (HHM) is a rare complication of malignant pediatric tumors, specifically those that secrete humoral factor(s), such as parathyroid hormone-related peptide (PTHrP). The authors report a case of severe hypercalcemia associated with ovarian dysgerminoma in a 10-year-old girl. In this case, the humoral factor was considered to be 1,25-dihydroxyvitamin D. HHM is extremely resistant to medical therapy. Therefore, tumor resection or volume reduction is necessary to control serum calcium levels.

Background/Purpose. Pancreatoduodenectomy (PD) is one of the most difficult operations in gastrointestinal surgery. Standard PD ligates and cuts superior mesenteric vein (SMV) branches after the removal of the pancreas head, which leads to congestion and bleeding of these veins. Methods. In this study, we modified the standard PD and first ligated the efferent vessels ( arteries); namely, the gastroduodenal artery and inferior pancreatoduodenal artery (IPDA), before ligating and cutting the corresponding afferent vessels ( veins) of the pancreas head. By doing this, congestion of these veins was relieved and bleeding from the resected surface was substantially prevented. Thirty-six patients ( 18 underwent standard PD and 18 had modified PD) formed the study population. Results. The amount of bleeding in the modified PD group was significantly lower than that in the standard PD group. ( 678 +/- 329 g vs 1225 +/- 375 g, respectively; P < 0.05) However, no difference in operation time was found between the two groups. Conclusions. We believe this modified PD procedure is valuable to enable the safe performance of PD.

A unique case of hypervascular pseudotumor in the liver consisting of central angiodysplasia surrounded by atrophic liver tissue is described. A 45-year-old woman was referred for the incidentally found hepatic lesion. Computed tomography with contrast showed strong enhancement of the lesion in the arterial phase, and the effect persisted to the parenchymal phase. Doppler ultrasonography showed winding dilated blood flows into the lesion. Because the pathological examination of the biopsy specimen showed the possibility of a well-differentiated hepatocellular carcinoma, she underwent surgery. Final pathological findings showed that the lesion demonstrated atrophic change of the liver tissue with a cluster of abnormal vessels of various sizes in the center. Although there was no primary liver disease, multiple liver metastases from laryngeal carcinoma were found coincidentally The present lesion could represent a new entity or a variant (or an unknown stage of development) of focal nodular hyperplasia.

Although intraarterial steroid infusion therapy has previously been shown to be effective for inflammatory bowel disease, it has not yet been applied for the treatment of hemorrhagic radiation gastritis. We report herein a case of hemorrhagic radiation gastritis of gastric tube that occurred after chemoradiation therapy for postoperative peritoneal lymph node metastasis in a patient with esophageal carcinoma who had a history of esophagectomy reconstructed with a gastric tube. The hemorrhagic gastritis that occurred in the gastric tube was successfully treated with repeated intraarterial steroid infusions through the regional vessels to the reconstructed gastric tube. A 70-year-old Japanese woman received chemoradiation therapy for metastatic lymph nodes of the celiac axis. Four weeks after completion of chemoradiation therapy, acute persistent bleeding occurred in the gastric mucosa of the reconstructed gastric tube in the irradiated area. Despite application of available therapeutic modalities, her persistent bleeding was intractable, and a total of 50 units of blood transfusion was required to improve progressive anemia. Finally, intraarterial steroid infusion therapy was applied through the right gastroepiploic artery supplying the main blood flow to the gastric tube. Three repeated intraarterial steroid infusions through the right gastroepiploic artery were effective, and hemostasis was finally completed soon after the last dose of intraarterial steroid was given. This case highlights the clinical importance and significance of hemorrhagic radiation gastritis of the reconstructed gastric tube with posterior mediastinal route occurring after chemoradiation therapy. Repeated intraarterial steroid infusion could be one option that appears clinically useful to treat intractable bleeding from radiation gastritis. © 2007 Japan Esophageal Society and Springer-Verlag.

症例は先天性門脈欠損症の3歳男児.高アンモニア血症と両葉の巨大肝腫瘍のため生体肝移植術を施行した.術前の空腹時血糖は正常であったが,食後は高値を示し,HbAlcは7.1%と耐糖能障害を認めていた.患児のHLAはA24, A33, B61, B44, DR9, DR13であった.術後の免疫抑制剤はタクロリムスとメチルプレドニゾロンにて開始した.術後肝機能は速やかに正常化したが,3週間後に糖尿病性ケトアシドーシスを発症した.自己インスリン分泌障害を認めたため15〜20単位/日のインスリン投与を開始した.タクロリムスをシクロスポリンに変更したところ,インスリン必要量は減量できたが,退院後もインスリン療法を継続している.本症例ではタクロリムスの副作用によりインスリン依存状態が完成したと考えられた.小児例といえども術前に耐糖能を十分評価し,その対策を行う必要がある.またHLA-A24, B61, DR9は糖尿病発症に関係するといわれ,その関係に対して今後検討を要する.

Backround. Dynamic three-dimensional computed tomography (D-3DCT: high-speed helical scanning during defecation) was used for morphological evaluation of intrapelvic structures in patients with rectal prolapse and rectocele. Methods. Twenty-five patients with rectal prolapse or rectocele diagnosed by conventional defecography (CD) or clinical findings were additionally investigated with D-3DCT. D-3DCT images were acquired using a multislice CT system with a 16-row detector during simulated defecation. Helical scanning was performed with a slice thickness of 1 mm, a helical pitch of 15 s/rotation, and a table movement speed of 35 mm/s. The contrast medium, 100 ml of iopamidol (370 mg/ml), was injected at a rate of 2.5 ml/s to enhance contrast with other structures, and scan start was triggered by using a function for automatically determining the optimal scan timing. Results. Among the eight patients with rectocele, additional intrapelvic disorders were diagnosed in five (enterocele, 4; cystocele, 1; and uterine prolapse, 1) with D-3DCT. In the 17 patients with rectal prolapse, concomitant intrapelvic disorders were found in six (intussusception, 3; cystocele, 2; uterine prolapse, 2; rectocele, 1; and vaginal prolapse, 1). Conclusions. D-3DCT can be a useful diagnostic tool for investigation of pelvic pathology in patients with rectocele and rectal prolapse.

51歳女性。20歳頃に出現した左大腿部の紅色隆起性腫瘤を当院形成外科で切除したところ, 悪性黒色腫と診断され当科を受診した。当科で拡大切除術+リンパ節郭清術を施行し, 化学療法 (DAV-Feron 2クール+D-Feron3クール) を施行した。拡大切除術施行9ヵ月後に肝転移巣と皮膚転移巣を認めたため, 肝転移巣に対してCDDP動注, 皮膚転移に対してINF-βの約4ヵ月間の静注に引き続き約3ヵ月間の局注を行った。CDDP 70mg/m²/M動注時は肝転移巣, 皮膚転移巣共に縮小傾向を認めたが, 治療の有害反応が強く, CDDP投与量を7mg/m²/2wに減量したところ皮膚転移巣は再び増大した。その後, 腹膜播腫によるイレウスが併発したため動注療法は中断し, 平成17年5月DICと脳転移により死亡した。本例では肝動脈塞栓療法は併用しなかったが, CDDP動注療法により一時転移巣が縮小したことから, 転移性肝腫瘍に対してCDDP動注療法は有効と考えた。

高度進行肝癌症例に対してスフェレックス(DSM),イリノテカン(CPT-11),マイトマイシンC(MMC)を用いた経動脈化学塞栓療法(DSM-CPT療法)を施行した.大腸癌肝転移症例5例,胃癌肝転移症例2例,肝細胞癌症例2例,胆管細胞癌症例1例を対象とした.大腸癌肝転移症例では5例全例にPRが得られ,胃癌肝転移症例2例はいずれもPD,胆管細胞癌症例および肝細胞癌症例のうち1例にlong NCが,肝細胞癌症例の他の1例にPRが得られた.効果が最も高いと思われた大腸癌肝転移症例5例に関して検討を行った.全例で2ヵ月以上持続するPRが得られ,腫瘍マーカー値は,CEAおよびCA19-9が,それぞれ治療前値の16.1%,19.3%に減少した.dose設定を適切に行えば,DSM-CPT療法は外来での反復投与も可能であった

Degradable starch microspheres (DSMs) provide transient occlusion of small arteries and are thought to improve the therapeutic effect of anticancer drugs. Irinotecan (CPT-11) is one of the most effective anticancer agents. We herein report cases with liver metastases treated with transarterial chemoembolizition with DSM, CPT-11, and mitomycin-C (DSM-CPT therapy). Five patients underwent DSM-CPT therapy for liver metastases that originated from colorectal cancer for four and gastric cancer for one. They all lack indication for surgery. They were all male with an age range of 42-78 years (mean, 55.2 years). Three of them had pretreatment histories with 5-fluorouracil or related agents, and four of them had combined systemic or local chemotherapy at the period. Required doses for stasis of whole blood flow of hepatic artery of DSMs were used with CPT-11 and mitomycin-C. After one to six injections, four patients had a partial response and the disease progressed in one patient with gastric cancer origin. Two of the partial response patients underwent surgery after 2 months of the partial response period. Carcinoembryonic antigen and CA19-9 levels in partial response patients decreased to 16.1% and 19.3% of the level before treatment, respectively. DSM-CPT therapy can be a potential therapy for liver metastases.

Enterocele is often associated with other pelvic floor disorders but it is not always possible to detect by clinical examination. Defecography with peritoneography and/or barium meal intake has recently been developed as a new method to identify enterocele, but this method is an invasive procedure. Multislice computed tomography was performed at rest and during simulated defecation to evaluate an 80-year-old female patient who had a defecation disorder and was diagnosed as having rectocele based on results from defecography and clinical findings. Multiplanar reconstruction images were generated for image evaluation. Using this novel method of dynamic pelvic computed tomography, a third-degree enterocele was clearly demonstrated in this case.