BACKGROUND Stoma prolapse is the full-thickness protrusion of bowel through a stoma, which occurs in 2% to 26% of colostomies. However, stoma prolapse complicated by small bowel incarceration is very rare, reported in only 3 cases thus far. To our knowledge, the present case is the first reported case of surgical treatment after preoperative manual reduction for small bowel incarceration. CASE REPORT A 74-year-old male who had undergone sigmoid end colostomy in the right lower abdomen by Hartmann's operation for rectal cancer visited our emergency room complaining of severe stoma prolapse. The prolapse was about 20×15×15 cm in size and showed edematous change. Enhanced computed tomography revealed a loop of the small bowel incarcerated within the prolapsed colostomy. After the severe prolapse was reduced to 15×10×10 cm in size with manual compression for small bowel incarceration, an emergency laparotomy made via a circumferential incision revealed a partially necrotic prolapsed sigmoid colon and 15-cm-long reddish small bowel loop in the abdominal cavity that needed to be preserved. A new sigmoid end colostomy was constructed in the right lower abdomen at the same site as the preoperative stoma. CONCLUSIONS It is important to remember that small bowel can herniate into a stoma prolapse, and when encountering the acute presentation of a large stoma prolapse, manual reduction of the incarcerated small bowel may help in selecting elective versus emergency surgery.

Background: Inferior mesenteric arterioportal fistula (APF) is rare as only 35 case reports in the literature. We herein presented a case of simultaneously double cancer in the rectum and stomach with inferior mesenteric APF, which is the first case report by searching using PubMed. Combination of interventional embolization and surgical operation seemed to be optimal treatment for avoiding postoperative complications and the curability. Case presentation: A 66-year-old male with epigastric pain was admitted to a practitioner. He underwent a gastroscopy with biopsy, and cancer located in the lesser curvature of the gastric cardia was found. Enhanced CT did not reveal wall thickening of the stomach and distant metastases, but several swollen lymph nodes were observed in the right cardia. In the arterial phase, dilation of inferior mesenteric vein (IMV) and superior rectal artery (SRA) were noted, which raised suspicions of an arterioportal communication. Colonoscopy revealed a type 2 rectal tumor located 12 cm from the anal verge. The histological diagnosis of well-differentiated tubular adenocarcinoma was confirmed by biopsy. At a first step, we planned to perform a radiological embolization of inflow vessels to APFs except for SRA. Additionally, we determined the interval time of 1 month between the first low anterior rectal resection and the sequential gastrectomy for the purpose of decreasing portal pressure. The postoperative course was uneventful without hemorrhagic complications, and S-1 was taken internally 1 year as adjuvant chemotherapy for gastric cancer. The patient still lives without recurrence of this cancer with APF and portal vein thrombosis 2.5 years after the aforementioned surgeries. Conclusion; Inferior mesenteric APF and/or arteriovenous fistula (AVF) would be consisted of the several inflow arteries as superior rectal, internal iliac, and median sacral arteries, and outflow veins as inferior mesenteric, internal iliac, and median sacral veins. To determine the therapeutic strategy for left-sided colorectal cancers with abnormal vessel communications of the pelvis, it is significant to comprehend distribution and component vessels of APF and/or AVF.

肝外胆管原発の腺扁平上皮癌は，稀な疾患で通常の腺癌と比べ予後不良であると報告されている．症例は73歳の男性で，黄疸を主訴に近医を受診し，腹部CTで遠位肝外胆管に腫瘍を指摘された．精査加療目的で当科に紹介入院となった．腹部造影CTでは，遠位肝外胆管に造影効果のある約15mm大の腫瘍を認めた．ERCPを行い経乳頭的生検で腺癌と扁平上皮癌の両成分を認め，腺扁平上皮癌が疑われた．亜全胃温存膵頭十二指腸切除術およびD2リンパ節郭清術を施行した．病理組織学的に中分化型腺癌と高分化型扁平上皮癌が混在し腺扁平上皮癌と診断された．浸潤深部に扁平上皮癌成分を認めた．最終病期はT3a（panc），N0，M0，Stage IIAであった．術後3カ月目に肝転移を認め，術後6カ月目に誤嚥性肺炎による急性呼吸不全のため他病死された．

2度の再発に対し外科的切除を行い長期生存が得られているSiewert type II食道胃接合部腺癌の1例を経験した．症例は67歳の男性で，胃癌取扱い規約第13版に準じ，UE+，Type 2，cT2，cN0，cH0，cP0，cM0，cStage IBの術前診断で2008年7月に胃全摘術，D2リンパ節郭清術を施行した．組織型は中～低分化型腺癌，進行度はpT2，pN2，cH0，sP0，pCY0，cM（–），fStage IIIAで根治度Aであった．UFTによる術後補助療法を行った．3年後に肝転移に対し肝部分切除を，1年5か月後に脾動脈幹遠位部リンパ節転移に対し膵体尾部・脾摘出術を行った．その後2年間S-1による術後補助療法を行っており，初回手術後6年6か月，最終手術後2年経過し現在無再発生存中である．再発に対する積極的な外科的切除が予後の向上に寄与する可能性が示唆された．

症例は63歳の男性で，右季肋部痛，黄疸を主訴に来院した．血清総ビリルビン値は9.8mg/dlと上昇，画像検査で胆嚢と胆管内に石灰化物質を認め胆嚢総胆管結石と診断した．内視鏡的経鼻胆道ドレナージにて減黄を行った後に胆嚢摘出術および経胆嚢管的結石除去術を施行した．摘出標本では胆嚢内に泥状の石灰乳胆汁を認め，頸部には1cm大のビリルビンカルシウム結石が嵌頓していた．総胆管内から除去した物質も化学分析で石灰乳胆汁であり，これが閉塞性黄疸の原因と考えた．石灰乳胆汁は胆嚢管の閉塞で生成されるが，この閉塞の原因がビリルビンカルシウム石で，かつ胆管内の石灰乳胆汁による閉塞性黄疸を合併していた報告は，我々の渉猟しえたかぎりではなかった．本症例ではビリルビンカルシウム結石が胆嚢頸部に嵌頓し胆嚢内に石灰乳胆汁が発生，その後に頸部の結石の嵌頓が解除され石灰乳胆汁が一部総胆管内に移行し，閉塞性黄疸を来したと思われた．

症例は83歳の女性で, 前医でイレウスと診断されイレウス管を挿入されたが症状改善なく, イレウス管造影で小腸の完全閉塞を認めたため, 当院に転院となった. 腹部CTで骨盤外に脱出する小腸を認め, 骨盤底ヘルニアによるイレウスと診断し緊急手術を施行した. 右坐骨孔に回腸がRichter型に嵌頓しており, これを解除. 腸管は壊死に陥っておらず腸切除は行わなかった. ヘルニア門は卵管間膜を縫着して閉鎖した. 術後経過はおおむね良好で術後第23病日に軽快, 前医に転院した. 坐骨ヘルニアは非常にまれな疾患であり, 文献検索にて世界で77例の報告しかみない. 今回, 我々の経験した症例を提示し, 文献的考察を加えた.

Mitochondrial sterol 27-hydroxylase (EC 1.14.13.15) is an important enzyme, not only in the formation of bile acids from cholesterol intermediates in the liver but also in the removal of cholesterol by side chain hydroxylation in extrahepatic tissues. The enzyme has been assayed by complicated methods using radiolabeled substrates or deuterium-labeled tracers. These methods may be inaccurate for measuring enzyme activity, because the amount of electron-transferring proteins may be insufficient for maximal velocity. To solve this problem, after solubilization of the enzyme from rat liver mitochondria with n-octyl-β-d-glucopyranoside (OGP), we measured the enzyme activity by incubating the solubilized enzyme with saturated amounts of electron-transferring proteins. In our assay system, using 7α-hydroxy-4-cholesten-3-one (HCO) as a substrate, we could easily measure the product, 7α,27-dihydroxy-4-cholesten-3-one, with HPLC monitoring absorbance at 240 nm. The product formation was proportionate to the time up to 5 min and the protein concentration up to 0.5 mg of protein/ml. The maximal velocity of the enzyme was 1.1 nmol/min/mg of protein, which was 4- to 16-fold higher than previously reported values. A simple and accurate assay method for sterol 27-hydroxylase in rat liver mitochondria is herein described.