守瀬 善一

An 81-year-old woman visited our hospital due to abdominal pain. Abdominal computed tomography (CT) examination showed hepatic portal venous gas, intramural gas and dilation of the small intestine. Following intestinal decompression by nasogastric tube 1 day after admission, CT showed disappearance of hepatic portal venous gas and wall thickening of the small intestine. Endoscopic examination using the single balloon method showed circular stenosis and an ulcer in the ileum. Since the passage of the stenotic site on the ileum did not improve with non-surgical management, single-incision laparoscopic surgery was performed in order to diagnose and treat the stenosis. Resection of the small intestine followed by anastomosis and cholecystectomy for combined cholecystitis developed during non-surgical managements, was performed with a minimal umbilical incision. © 2012 The Japanese Society of Gastroenterological Surgery.

Morise Z, Sugioka A, Kawabe N, Umemoto S, Nagata H, Ohshima H, Kawase J, Arakawa S, Yoshida R, Asian journal of endoscopic surgery, 2011, vol. 4, no. 3, pp. 143-146, 2011

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Hepatic involvement was reported in about 11% of patients with sarcoidosis. However, cases of sarcoidosis in which the granuloma is solitary and limited in the liver are very rare. A 51-year-old woman with tumors in the liver underwent extended left lobectomy with caudate lobectomy and bile duct resection. The tumor was located between segment 4 and the hilar region. Some daughter nodules were found in the left lobe, which were regarded as intrahepatic metastasis. Our case displayed clinical and radiologically distinct findings, which are very similar to those of hilar cholangiocarcinoma restricted to the liver. This report demonstrates that sarcoidosis can show solitary hepatic involvement in the absence of thoracic lymphadenopathy. In such a case, it is difficult to distinguish the diagnosis from other malignant neoplasms. In conclusion, the diagnosis of hepatic sarcoidosis has to be made through prudent and comprehensive investigations that include a full clinical history of sarcoidosis in other organs. Despite utilizing several detailed diagnostic modalities, the definitive diagnosis of cases of solitary sarcoidosis may remain difficult. In these cases, surgical treatment including liver resection should be considered in order to avoid missing a suitable opportunity for treatment. © 2011 S. Karger AG, Basel.

従来教室では大腸癌の多発肝転移に対して積極的に肝動注療法を行ってきた。今回65例の多発肝転移に対する肝動注治療の成績を検討した。レジメンは5-FU 1,500mg/bodyあるいは5-FU(400mg/mm2)/l-LV(200mg/mm2)であり、RECISTによる多発肝転移動注症例の奏効率(PR+CR)は55%であった。肝機能障害により治療継続困難となった症例は2例のみでPS不良症例に対しても維持継続できた。肝動注治療の全生存期間の中央値は13.5ヵ月で5年生存率は8%と予後不良であったが、肝動注後に切除可能と判断された9例では5年生存率は21%と改善していた。同時性、異時性あるいは同時性肝切除後の再発例間では予後に差は認めなかった。肝動注療法は比較的忍容性が高く、肝切除可能となれば積極的に肝切除することにより、予後の改善に寄与する治療法と考えられた。(著者抄録)

We report what is, to our knowledge, only the third reported case of double hepatocellular carcinoma (HCC) and cholangiolocellular carcinoma (CoCC). A 64-year-old man with positive hepatitis B virus (HBV) liver cirrhosis hospitalized for hepatic lesions had elevated plasma AFP and PIVKA-II. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed hypervascular nodules at S8a and S8c, necessitating partial hepatic resections. Histologically, the S8a tumor was HCC and the S8c tumor CoCC. © 2010 The Japanese Society of Gastroenterological Surgery.

今回我々は、胆管癌と鑑別が困難であった原発性硬化性胆管炎の1例を経験したので報告する。症例は73歳の女性、高血圧症で通院中の医院で肝機能障害を指摘され、腹部超音波検査で肝内胆管拡張を認めたため当院に紹介となった。入院時には黄疸は認めなかったが、入院中にT-bil 8.8mg/dlと黄疸が出現したため内視鏡的逆行性胆道造影(endoscopic retrograde cholangiography:ERC)を施行した。ERCでは左右肝管から総肝管にかけて狭窄像を認めた。胆汁細胞診、ブラッシング細胞診では悪性所見はなかったが、経乳頭的胆管生検で高分化型腺癌を否定できない所見を認めたため経皮経肝門脈塞栓術を行った後、肝左3区域切除術+D2リンパ節郭清を施行した。術後病理診断は胆管周囲に炎症細胞の浸潤と線維化による壁肥厚を認め原発性硬化性胆管炎と診断された。(著者抄録)

Cholangiocarcinoma, arising from bile duct epithelium, is categorized into intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC), including hilarcholangiocarcinoma. Recently, there has been a worldwide increase in the incidence and mortality from ICC. Complete surgical resection is the only approach to cure the patients with ICC. However, locoregional extension of these tumors is usually advanced with intrahepatic and lymph-node metastases at the time of diagnosis. Resectability rates are quite low and variable (18%-70%). The five-year survival rate after surgical resection was reported to be 20%-40%. Median survival time after ICC resection was 12-37.4 mo. Only a small number of ICC cases, accompanied with ECC, gall bladder carcinoma, and ampullary carcinoma, have been reported in the studies of chemotherapy due to the rarity of the disease. However, in some reports, significant anti-cancer effects were achieved with a response rate of up to 40% and a median survival of one year. Although recurrence rate after hepatectomy is high for the patients with ICC, the residual liver and the lung are the main sites of recurrence after tentative curative surgical resection. Several patients in our study had a long-term survival with repeated surgery and chemotherapy. Repeated surgery, combined with new effective regimens of chemotherapy, could benefit the survival of ICC patients. © 2010 Baishideng.

Hoshimoto S, Morise Z, Takeura C, Ikeda M, Kagawa T, Tanahashi Y, Okabe Y, Mizoguchi Y, Sugioka A, Rare tumors, 2009, vol. 1, no. 2, pp. e27, 2009

Hoshimoto S, Morise Z, Takeura C, Ikeda M, Kagawa T, Tanahashi Y, Okabe Y, Mizoguchi Y, Sugioka A, Rare tumors, 2009, vol. 1, no. 1, pp. e23, 2009

Peliosis hepatis is a rare lesion histologically characterized by multiple cavities representing dilated sinusoids filled with blood in the liver. Although it has been observed in the liver parenchyma in association with several diseases and medications, there are few reports of nodules of hepatocellular carcinoma (HCC) showing extensive peliotic change. We describe a case of HCC showing extensive peliotic change in the cancer nodule. A 73-year-old man with a liver tumor was referred to our hospital for further investigation. Abdominal ultrasonography revealed an 8-cm hyperechoic lesion with a halo and mosaic pattern in segment 8 (S8) of the liver. Dynamic magnetic resonance imaging of the liver showed early irregular enhancement of the peripheral part of the lesion, and the effect persisted into the late phase, spreading into the central part of the nodule. Hepatic arteriography showed the "cotton-wool" sign, usually observed in cavernous hemangiomas. Fine-needle aspiration biopsy revealed the diagnosis of HCC. Anterior sectionectomy of the liver was conducted. Histological examination of the resected specimen showed that the tumor was a well-differentiated HCC with extensive dilated sinusoid-like structures in the main portion of the nodule, suggestive of peliotic change.

Background: The results of 12 consecutive patients with unresectable advanced biliary tract carcinoma treated with first line chemotherapy of S1/cisplatin, combined surgical resection and second line chemotherapy of gemcitabine are evaluated. Patients and Methods: Eight patients with intrahepatic cholangiocarcinoma, 1 with extrahepatic cholangiocarcinoma and 3 with gallbladder carcinoma were included in the study. All patients were treated with S1/cisplatin. Two of the patients underwent combined surgical resection before and 2 after therapy. Second line chemotherapy of gemcitabine was administerd in 6 patients. Results: MST of the patients was 14.9 months. With S1/cisplatin therapy, 6 patients had PR and 4 had SD. Two patients with surgical resection after the therapy survived more than 3 years. Second line chemotherapy of gemcitabine with moderate effects and mild adverse effects was well tolerable. Conclusion: S1/cisplatin showed considerable anti-cancerous effects. Employing surgical resection for patients with good response may lead to the chance of long-term survival.

Stepwise carcinogenesis of hepatocellular carcinoma (HCC) in the cirrhotic liver has been well described pathologically and radiologically.(1,2) It is accompanied by sequential hemodynamic changes in the nodules.(3,4) The dysplastic nodule (DN, adenomatous hyperplasia) and early HCC frequently include portal tract structures without arterial neovascularization. In contrast, advanced HCC is characterized by abundant arterial neovascularization. Therefore, late-stage hepatic nodules are enhanced at the arterial phase of various imagings and early-stage nodules are not. We describe a unique case in which we could observe stepwise carcinogenesis of HCC in a nodule surrounded with hyperplastic and hypervascular liver tissue.

固有肝動脈浸潤を伴った肝右葉および左葉切除術に関して、手技を中心に解説した。肝動脈合併切除再建を伴う肝切除は、手術関連死亡が多いうえに、予後が不良であったために、従来は手術適応外とされることが多かった。しかし、マイクロサージェリーの導入とともに肝動脈合併切除再建の報告例も増加しつつある。今後の消化器外科医の課題は、マイクロサージェリーの習得とともに、多様な肝動脈の変異と多彩な再建方法に精通して、術中所見に臨機応変に対応した再建術式を選択する能力を身につけることである。手技の確立とともに、有効な補助化学療法を併用することにより、肝動脈合併切除再建を伴った肝切除例の予後向上が期待できる。(著者抄録)

症例は51歳,女性.肝左葉の嚢胞性病変の精査目的に受診した.腹部CTで外側区域に嚢胞壁に造影効果を伴う多房性嚢胞性病変と内側区域側に連続する充実性部分を認めた.嚢胞性部分は胆管嚢胞腺癌で,周囲の充実性部分はその浸潤性変化と診断し,肝拡大左葉切除術を施行した.切除標本は外側区域を中心としたhoneycomb様を呈する多房性の嚢胞性部分とその周囲,特に内側区域側に拡がる充実性部分から成り,病理組織学的に広範な肝実質浸潤,胆管内進展,リンパ節転移および肝内転移を伴う胆管嚢胞腺癌と診断された.術後1年7ヵ月目に残肝再発をきたし再切除を施行.その後,多発肺転移,脳転移にて再々発したが,全身化学療法,ガンマナイフ治療を施行し,初回術後4年5ヵ月経過した現在,生存中である.(著者抄録)

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare malignancy arising from the biliary epithelium. Prognosis is typically poor. Currently, aggressive surgical resection is the only treatment modality that offers patients any chance of long-term survival. Here, we present the case of a 57-year-old woman in whom we diagnosed ICC, with the tumor occupying the entire left and caudate hepatic lobes and daughter nodules in the right lobe. She underwent hepatectomy of segments I to VI, combined with intraoperative microwave coagulation therapy for nodules in the residual liver. Three months after the surgical resection, she had recurrence of the disease. The patient subsequently received weekly intraarterial chemotherapy with irinotecan (CPT-11), and a partial response was observed which persisted for 18 months. Subsequent computed tomography revealed the regrowth of three tumors, and she therefore underwent a repeat resection 24 months after the first surgical operation. In postoperative-month (POM) 32, she received systemic chemotherapy with tegatur/gimeracil/oteracil potassium (S-1)/cisplatin for multiple small nodules in her lung. Following three cycles of chemotherapy with a stable disease response, partial resections of the lung were performed. Third and fourth hepatectomies were performed in POMs 46 and 59, respectively. Five years and 5 months after the first hepatectomy, she is alive with small lesions in her lung. This multimodal approach may be effective for ICC.

Background/Aims: Although the role of hepatectomy for patients with colorectal liver metastases is well established, few reports exist of hepatectomy for patients with metastases of gastric cancer origin. This study reviews cases of hepatectomy for metastatic gastric cancer at Fujita Health University Hospital. Methodology: Between 1.989 and 2004, 18 patients underwent hepatectomy for liver metastases from gastric cancer. The patients consisted of 16 men and 2 women and their ages ranged from 51-76 (median 64) years. Hepatic resection was indicated for patients with synchronous metastases who did not have peritoneal dissemination or any other distant metastases (11 patients), and patients with metachronous metastases who did not have any other recurrent lesions (7 patients). Results: Overall survival rate for 1, 2 3, and 5 years are 56.3, 36.52 27.3, and 27.3%, respectively. Although the 5-year survival rate was considerable, an early and rapid decrease of survival rate occurred in the first 1-2 years (compared with the colorectal patients). Univariate analysis showed serosal invasion and lymphatic invasion of the primary tumor as significant prognostic factors for survival. Conclusions: Surgical resection for liver metastases of gastric cancer is thought to be beneficial for small part of the patients. For other patients, the procedure may only provide the limited beneficial effects on survival.

HOSHIMOTO, S, MORISE, Z, TANAHASHI, Y, KAGAWA, T, MIZOGUCHI, Y & SUGIOKA, A, 2008, 'A RESECTED CASE OF RUPTURED HEPATOCELLULAR CARCINOMA ORIGINATING IN THE SPIEGEL LOBE', <i>Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association)</i>, vol. 49, no. 9, pp. 1408-2082.

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.

Background/Aims: 5-FU plus Cisplatin combination therapy had been employed against primary liver carcinomas for years. S-1 is a fourth-generation oral fluoropyrimidine and attracts considerable interest for the activity against gastric cancer. We herein examined the effect and adverse effects of S-1 plus Cisplatin combination therapy for primary liver carcinomas. Methodology: 4 patients with hepatocellular carcinoma (HCC) and 3 with cholangiocellular carcinoma (CCC) were employed for this study. They all had far-advanced diseases in and/or out of the liver at the time of the therapy initiation. They were 4 men and 3 women. Their ages were in the range of 42-73 (58 +/- 9.73, mean +/- SD) years old. The protocol of the therapy is a 3-week period of S-1 (70-80mg/m(2)/day) oral administration combined with 2 intravenous administration of CDDP (20-35mg/m(2)) during the period. With two weeks of intermission, the therapy was repeatedly performed 2-11 times for each patient. Results: Three patients had PR and 2 had NC response with the therapy. Two patients with HCC and pre-treatment with 5-FU had PD response. Although the patients developed leukopenia and thrombocytopenia, the therapy was well tolerable also in the outpatient basis. Conclusions: S-1 plus Cisplatin combination therapy is a potential therapy for advanced primary liver carcinomas.

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.

59歳男性。患者は他院にて1994年に上行結腸癌に対する結腸右半切除術、2000年に異時性肝転移に対し肝右葉切除術を受けた。2004年8月に横隔膜、右腎に浸潤する肝断端再発を認め、著者らの施設で肝S4部分切除、横隔膜・右腎合併切除が行なわれたが、経過観察中の2006年5月に黄疸が出現し、消化器外科へ入院となった。腹部CT、胆道造影にて大腸癌肝転移術後の胆管内再発と疑い、肝S4部分切除・肝外胆管切除、左肝管空腸吻合が施行された。その結果、摘出標本では胆管内に腫瘍栓を認め、病理組織学的に結腸癌の胆管内転移と診断された。術後、肝管空腸吻合部の縫合不全を合併したが保存的に改善し、現在、7ヵ月経過で無再発生存中である。

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

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.

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

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

Hepatic resection for colorectal metastases was performed for 188 patients. Overall survival rates after the first hepatectomy are 41.4% and 32.7% for 5 and 10 years, respectively. The survival rate of 116 cases with unilobar hepatic metastases (H1) is significantly higher than those of 48 cases with two to four bilobar metastases (H2) and 24 cases with more than four (H3), respectively. However, the differences between the survival rates from H1 with multiple metastases, H2, and H3 are not significant, even though the H3 group has no 10-year survivors. The 5-year survival rates after the second hepatectomy (30 patients) and the resection of the lung (26 patients) are 30.3% and 35.2%, respectively, in this series. In those patients, the 5-year survival rates from the first metastasectomy are 43.4% and 50.3%, respectively. There are 14 5-year survivors with multiple metastases and 8 of those patients underwent multiple surgeries. There are 13 patients with three or more repeat resections of the liver and/or lung. The 5-year survival rates of the patients from the first and third metastasectomy are 53.9% and 22.5%, respectively. Repeat operations for the liver and the lung contribute to the improving prognosis.

Morise Z, Sugioka A, Mizoguchi Y, Fujita J, Hoshimoto S, Kato T, Hasumi A, Journal of gastroenterology and hepatology, 2005, vol. 20, no. 7, pp. 1136-1138, 2005

Background. In the orthotopic mouse liver transplantation model, allografts are accepted without immunosuppression, and donor-specific tolerance is induced upto 40 days. Although FK 506 is a well-known immunosuppressive agent, its influence on tolerance induction is not known. In this study, we examined the influence of FK 506 on tolerance induction in a mouse liver transplant model. Methods. Orthotopic liver transplantation was performed from B10.13R (H-2K) to B10.D2 (H-2D mice). In the experimental group, FK 506 (1 mg/kg/d) was given subcutaneously to the recipients from day 0 to day 21, whereas the control group received a placebo (1 mg/kg/d). On day 40, donor skin grafts were transplanted to the recipients to examine the survival times of the recipients and the skin grafts. On day 14, donor-type cells in recipient's blood, spleen, kidney, thymus, and lymph nodes were examined by RT-PCR using specific donor-type MHC class I and II primers. Results. All recipients survived for more than 100 days. The mean survival time of skin grafts in the experimental group was significantly reduced compared to that of controls. On day 14, either donor-type MHC class I- or class II-positive cells were detected in the control group, whereas donor-derived MHC class II-positive cells disappeared in the experimental group. Conclusions. In the early period after mouse liver transplantation, FK 506 inhibits tolerance induction paradoxically. Some donor-derived MHC class II-positive cells might play an important role in tolerance induction.

Morise, Z, Sugioka, A, Mizoguchi, Y, Fujita, J, Kato, T & Hasumi, A, 2004, 'CARCINOSARCOMA OF THE LIVER: A CASE REPORT WITH INTERESTING HISTOLOGIC AND IMMUNOHISTOCHEMICAL FEATURES', <i>Journal of Gastroenterology and Hepatology</i>, vol. 37, no. 8, pp. 1165-950.

We describe a solitary liver metastasis in the caudate lobe from a colon cancer treated with a hepatic resection following transarterial chemotherapy. A 73-year-old male was admitted with a complaint of melena. The findings from endoscopic examination of the colon showed a type 3 cancer at the hepatic flexure. Computed tomography revealed a metastatic lesion in the caudate lobe of the liver, which was three centimeters in diameter and located between the roots of the middle and the left hepatic vein. A right hemicolectomy was performed and the surgical findings revealed extended lymph node metastasis and the serosal exposure of the primary lesion. A transarterial catheterization to the liver for chemotherapy was placed instead of performing a hepatic resection. After six months of the transarterial chemotherapy, the metastatic tumor was decreased to less than one centimeter and no other new lesion was developed in and out of the liver. The patient underwent a resection of the Spiegel lobe 8 months after the first operation. There were small lesions of viable metastatic cells in the tumor histologically. The patient is currently well without any signs of recurrence 28 months after the first operation.

45歳女.S8の肝腫瘍であり,針生検で高分化肝細胞癌と診断された.また,舌根部に中咽頭腫瘍が発見され,生検で中分化扁平上皮癌,TN分類:T2N2c,病期IVAと診断された.肝癌と中咽頭癌の重複癌として同時に手術を行い,肝部分切除,リンパ節郭清術及び中咽頭・喉頭合併切除頸部郭清術を施行した.術後,胸膜及び腹膜播種が出現し,高度の胸腹水貯留がみられ,全経過約11ヵ月で死亡した.術前のangio-CTでは肝細胞癌或いは血管腫のいずれとしても非典型的であり,画像診断では確定が困難であった.術前生検で高分化肝細胞癌と診断したが,手術材料では主病変部において肉眼的に腫瘤や結節形成は不明瞭で,組織学的に動静脈奇形様異常血管周囲の虚血に伴う肝細胞の萎縮性変化が特徴的であった.その周囲には主病変として中咽頭癌の多発転移を認めた

Although hepatic resections for colorectal metastases have become established procedures, there is still only a small number of reports of hepatic resections for such metastases in the caudate lobe. From 1993 to 2001, seven patients underwent eight hepatic resections for colorectal metastases in the caudate lobe at our department. The patients were five men and two women, and their ages were from 53 to 73 years. The ratio of synchronous to metachronous liver metastases was 2:5. Solitary metastasis was observed in one patient. One patient with a metastasis in the Spiegel lobe and three patients with metastasis in the caudate process underwent partial resection of the site. The other patients underwent resection of the Spiegel lobe (two times), resection of the right-sided caudate lobe, and total caudate lobe resection. The mean ( SE) operative time was 31.5.9 +/- 30.6 min. Mean intraoperative blood loss was 1325.9 +/- 421.1 ml, and mean postoperative hospital stay was 21 +/- 3.7 days. One patient, who underwent sigmoidectomy and hepatectomy as an emergency operation due to ileus, experienced wound infection. No patient died within 12 months after the surgery. Five patients were alive at 24 months, and three at 36 months. The outcome of these patients encourages us to continue performing hepatic resection for colorectal metastases in the caudate lobe, as it is assumed to be a safe and effective procedure.

The new bifunctional ligands Ph(2)PCH[double bond]CPh[OP(O)(OR)(2)] (1) (1a, R = Et; 1b, R = Ph) represent the first examples of P,O derivatives resulting from the association of a phosphine moiety and an enolphosphate group. The Z stereochemistry about the double bond provides a favorable situation for these ligands to act as P,O-chelates. Neutral and cationic Pd(II) complexes have been synthesized and characterized, in which 1a or 1b acts either as a P-monodentate ligand or a P,O-chelate, via coordination of the oxygen atom of the P[double bond]O group. In the latter case, it has been observed that phosphines 1a and 1b can display a hemilabile behavior, owing to successive dissociation and recoordination of the O atom. Competition experiments revealed that phosphine 1a presents a higher chelating ability than 1b, a feature ascribed to the more electrodonating properties of the ethoxy groups in 1a compared to the phenoxy groups in 1b. P,O-Chelation affords seven-membered metallocycles, which is unusual for P,O-chelates. Complexes trans-[PdCl(2)[Ph(2)PCH[double bond]C(Ph)OP(O)(OPh)(2)](2)] (2b), [PdCl[Ph(2)PCHdouble bond]C(Ph)OP(O)(OEt)(2)](mu-Cl)](2) (3a), [complex--see text] (8a'), and [complex--see text] (10a) have been structurally characterized. Interestingly, the seven-membered rings in 8a' and 10a adopt a sofa conformation with the double bond lying almost perpendicular to the plane containing the Pd, the two P, and the two O atoms.

胆嚢癌の唯一の根治的治療は外科的切除であるが,深達度ss以深のいわゆる進行胆嚢癌では,超拡大切除を要する症例が多いにも拘わらず切除後の予後は不良である.進行胆嚢癌の外科治療においては,正確な質的診断と進展度診断により手術適応を決定すると共に過不足のない術式を選択し,手術の根治性と安全性を両立させることが肝要である.現時点で胆嚢癌診療において外科が直面している問題点は,即ち,1)胆嚢良性疾患と胆嚢癌との鑑別,2)進行胆嚢癌の正確な進展度診断,3)胆嚢癌の生物学的悪性度の把握,である

Fibrolamellar carcinomaは,肝硬変のない若年成人に好発する肝細胞癌の特殊型である.黄白色調充実性の腫瘍で,好酸性顆粒状の豊富な胞体を持つ癌細胞がシート状に配列し,その間に層状構造を示す線維性結合織の増生を見ることが特徴とされる.画像診断上は,中心性瘢痕を有することが多く,同様の所見を有するfocal nodular hyperplasia及び硬化型肝細胞癌との鑑別が問題となる.造影CT,MRI,シンチグラフィーなどの検査により診断が可能であるが,硬化型肝細胞癌を含めた線維成分の豊富な悪性腫瘍と,典型的な所見が少ない場合のFLCの鑑別が問題となると思われる

Although several surgical approaches have been advocated for patients with infected necrotizing pancreatitis, there is still a high incidence of morbidity and mortality. We used a new approach of direct retroperitoneal open drainage after various other treatments, for three patients with necrotizing pancreatitis and extended infection with multiple-organ failure. Long oblique incisions were made from the root of the 12th rib to the anterior superior spina iliaca on the left or right side of the back, or both, to approach the retroperitoneal area of infected necrosis. The necrotic tissue was removed bluntly and the wound was laid open. Lavage and debridement were done repeatedly after the operation. The patients recovered from multiple-organ failure within 2 weeks, and control of local infection was achieved within 3-4 weeks. All three patients were discharged and are now well. Therefore, we propose that this method is appropriate for patients with spreading infected necroses, who are in poor general condition.

Pulmonary injury with leukocyte infiltration is a frequent occurrence in obstructive cholangitis patients. We wished to evaluate the roles of reactive oxygen species and vascular cell adhesion molecule-1 (VCAM-1) in this distant organ failure. Wild type (WT) and transgenic (SODtg) mice overexpressing superoxide dismutase underwent bile duct ligation and transection (BDL). VCAM-1 expression was quantified, and histopathology was assessed for the liver and lung. BDL resulted in increased leukocyte infiltration to the lung at five days in WT mice. VCAM-1 expression significantly increased in WT mouse liver at three days and WT mouse lung at five days. When these same experiments were performed in SODtg mice, these increases in leukocyte infiltration and VCAM-1 expression in lung were significantly attenuated. These data suo, est that reactive oxygen species produced in response to BDL may up-regulate VCAM-1 expression in the lung and play an important role in the pathophysiology of this pulmonary injury.