症例は54歳,女性,右下腹部痛と腰背部痛を主訴に近医を受診し,超音波検査にて下大静脈腫瘍を疑われ紹介となった.腹部CT, MRI, 下大静脈造影にて,最大径約5cmの下大静脈腫瘍が認められた.手術は左腎静脈を含む下大静脈左側壁を約5cm切除して腫瘍を摘出し, 20mmリング付きePTFEグラフト5cmを用いて下大静脈をパッチ形成した.病理組織検査にて平滑筋肉腫と診断された.術後4カ月目のCTで4cm大の局所再発を認め,放射線化学療法を施行したが,術後225日目に死亡した.下大静脈原発平滑筋肉腫は,放射線化学療法に抵抗性を示し再発率も高いため外科的治療が第一選択であるが,切除不能例や再発例に対する新たな治療方法が望まれる.

Hypercholesterolemia is a major risk factor involved in abnormal cardiovascular events. Rho-kinase-mediated Ca(2+) sensitization of vascular smooth muscle (VSM) plays a critical role in vasospasm and hypertension. We recently identified sphingosylphosphorylcholine (SPC) and Src family tyrosine kinase (Src-TK) as upstream mediators for the Rho-kinase-mediated Ca(2+) sensitization. Here we report the strong linkage between cholesterol and the Ca(2+) sensitization of VSM mediated by a novel SPC/Src-TK/Rho-kinase pathway in both humans and rabbits. The extent of the sensitization correlated well with the total cholesterol or low-density lipoprotein cholesterol levels in serum. However, an inverse correlation with the serum level of high-density lipoprotein cholesterol was observed, and a correlation with other cardiovascular risk factors was nil. When cholesterol-lowering therapy was given to patients and rabbits with hypercholesterolemia, the SPC-induced contractions diminished. Depletion of VSM cholesterol by beta-cyclodextrin resulted in a loss of membrane caveolin-1, a marker of cholesterol-enriched lipid raft, and inhibited the SPC-induced Ca(2+) sensitization and translocation of Rho-kinase from cytosol to the cell membrane. Vasocontractions induced by membrane depolarization and by an adrenergic agonist were cholesterol-independent. Our data support the previously unreported concept that cholesterol potentiates the Ca(2+) sensitization of VSM mediated by a SPC/Src-TK/Rho-kinase pathway, and are also compatible with a role for cholesterol-enriched membrane microdomain, a lipid raft. This process may play an important role in the development of abnormal vascular contractions in patients with hypercholesterolemia.

A 36-year-old woman with a history of left nephrectomy for renovascular hypertension secondary to arterial occlusive lesion of Takayasu's arteritis was re-admitted to our hospital with complaints of postprandial abdominal pain in the sixth post-operative month. On the 14th hospital day, the developing abdominal distension and generalized tenderness suggested a mesenteric vascular occlusion. Following abdominal aortography, emergency surgery was performed. The entire small bowel was edematous and markedly cyanotic with spotted, dark colored areas and the mesentery was pulseless. The patient was sucessfully treated by thromboendarterectomy at the origin of the celiac and superior mesenteric arteries and the necrotic loop of intestine was then resected 7 days later. Takayasu's arteritis was diagnosed by histological examination of the resected specimens. Although the occurrence of mesenteric infarction secondary to Takayasu's arteritis is rare, the possibility of mesenteric vascular occlusion should be given consideration in the follow-up of patients with Takayasu's arteritis.

再手術時における到達法では正中切開がもっとも頻用されるが,種々の合併症があることも周知の事実である.とくに弁膜症の再手術に関しては,心拡大による癒着のため,心損傷などの合併症が起こりやすい.正中切開以外の到達法として,右前側方開胸がある.われわれの経験では右前側方開胸は術野が深く手術操作が困難であった.このため,right parasternal vertical incision (PVI)を採用した.症例は50歳,女性.主訴は労作時呼吸困難.患者は4度目の開心術であり,過去に僧帽弁置換術,三尖弁置換術を受けている.経過観察中に,三尖弁機能不全を認め,当科紹介となった.CTにて胸骨と右室の癒着が示唆された.手術はPVIにてアプローチした.この右開胸の利点は癒着剥離がほとんど不要なことである.前側方開胸に比較してPVIの利点は,1)術野が浅いこと,2)仰臥位で行えることの2点があげられる.PVIは再手術において有用な到達法であると考えられた.

Although we have gained much knowledge about the signal transduction pathways at the molecular level in physiological and pathophysiological conditions in the last decades, it is still a major challenge to identify a molecular therapeutic target in a given disease. We describe a signaling pathway-oriented global transcriptional analysis, which identified JNK, a stress-activated protein kinase, as a proximal signaling molecule in the pathogenesis of abdominal aortic aneurysm (AAA). AAA is a common disease among elderly people that, when surgical treatment is inapplicable, results in progressive expansion and rupture of the aorta with high mortality. AAA has long been considered an irreversible destructive process and regression of AAA by non-surgical methods has not been expected. We show that JNK programs a gene expression pattern that cooperatively enhances the degradation of the extracellular matrix, while suppressing biosynthetic enzymes of the extracellular matrix. Selective inhibition of JNK in vivo not only prevented the development of AAA but also caused regression of established AAA in mice. These results revealed that JNK promotes abnormal ECM metabolism in AAA and represents a novel "druggable" therapeutic target for AAA.

Abdominal aortic aneurysm (AAA) is a common disease among elderly people that, when surgical treatment is inapplicable, results in progressive expansion and rupture of the aorta with high mortality. Although nonsurgical treatment for AAA is much awaited, few options are available because its molecular pathogenesis remains elusive. Here, we identify JNK as a proximal signaling molecule in the pathogenesis of AAA. Human AAA tissue showed a high level of phosphorylated JNK. We show that JNK programs a gene expression pattern in different cell types that cooperatively enhances the degradation of the extracellular matrix while suppressing biosynthetic enzymes of the extracellular matrix. Selective inhibition of JNK in vivo not only prevented the development of AAA but also caused regression of established AAA in two mouse models. Thus, JNK promotes abnormal extracellular matrix metabolism in the tissue of AAA and may represent a therapeutic target.

症例は50歳, 女性. 7年前に胸部X線写真および胸部CTで左肺門の3.5×3.5cm大の辺縁平滑な腫瘤を認めた. CTガイド下生検で過誤腫か軟骨腫と診断され経過観察となった. 今回, 腫瘤は7×6cm大と増大し, CTガイド下生検で軟骨性の過誤腫と診断した. 腫瘤が増大しているため手術を施行した. 手術は胸腔鏡補助下に腫瘤核出術を施行した. 本症は肺癌発生の可能性もあり, 厳重な経過観察が必要である.

全国5施設において,腎動脈下腹部大動脈瘤を対象に分岐型ステントグラフト(SG)であるPower WebTM system(Endologix社,USA)を用いて待機的治療を実施した.治療は適応判定委員会によって選択された症例につき,各施設のIRBが承認した説明と同意手順のもとに施行された.対象60例(うち男性53例)のSG運搬成功率は96.7%であった.術中にtype Iのエンドリーク(EL)を2例に認め,技術的成功率は93.3%であった.手術時間は193±55分,出血量は440±240gで,対照とした人工血管置換手術97例(うち男性83例)のおのおの303±88分,1,496±2,025gと比較し有意に短時間,少量であった.退院時または術後1ヵ月のCTで4例にEL(type I3例,type II1例)を確認した.Type IのELは,SG固定部が短く,かつ屈曲した症例にみられた.左腎動脈閉塞と,内腸骨動脈閉塞による一過性の臀筋痛を各1例に認めたが,入院死亡はなかった.術後6ヵ月では,他病死1例と追跡不能1例を除いた56例のうち1例にSGの脚閉塞を認めたが,ほかに新たなELや重篤な有害事象の発生はなかった.瘤径は縮小26例,不変30例で,拡大例はなかった.Power WebTM systemは腹部大動脈瘤に対する低侵襲治療として臨床使用可能なSGであり,今後の長期間にわたる成績が待たれる.

過去19年間に外科的治療を行った悪性腫瘍に起因したSVC症候群は6例であった．浸潤性胸腺腫3例中2例には血行再建を含めた腫瘍完全切除を行い，残りの1例には不完全切除兼バイパス術を行った．肺癌，食道癌各1例には切除不能のためバイパス術のみを行い，子宮癌1例にはステント留置術を行った．術後，SVC症候群は5例で改善し，残りの1例では術後早期のグラフト閉塞のため改善しなかった．血行再建を含む腫瘍完全切除術，ステント術の予後は良好であった．バイパス術はSVC症候群が改善されるものの予後不良で早期に癌死した．

症例は66歳,女性.心窩部痛を主訴に近医受診.超音波所見および白血球増多から急性胆嚢炎の診断で当院外科紹介となった.受診までの約6カ月間で10kgの体重減少を認めていた.その他生活歴・既往歴に特記すべきことなし.入院時右季肋部に圧痛を認めた.血液生化学検査では,白血球数, CRP,肝胆道系酵素の上昇を認めたが,腫瘍マーカー(CEA, CA19-9, DUPAN-2)の上昇は認められなかった.腹部超音波検査, CT検査にて胆嚢内に不均一に造影される腫瘤と肝十二指腸間膜内に著明に腫大したリンパ節を認めた. ERCPでは総胆管の拡張を伴う合流異常を認めた.リンパ節転移を伴う胆嚢癌の臨床診断にて,肝床切除を伴う胆嚢摘出術,膵頭十二指腸切除術を施行した(TNMstage III).病理組織学的検査では大細胞型の胆嚢未分化癌であった.

症例は14歳,男性.腹部を打撲し当院受診.胸部X線写真およびCTで,胸腔内に腹腔内臓器の脱出を認め,横隔膜ヘルニアの診断で緊急手術を施行した.脱出臓器は大網および横行結腸であった.左横隔膜後外側に辺縁整な3×2 cm大のヘルニア門を認め,部位,形状より,外傷によるものよりもむしろ先天性のBochdalek孔ヘルニアであると判断した.脱出臓器を還納し,ヘルニア門を直接縫合閉鎖し手術を終了した.

巨大肝嚢胞により閉塞性黄疸をきたす症例は稀である.今回われわれは閉塞性黄疸をきたした巨大肝嚢胞に対して開窓術を行い,良好な経過を得たので報告する.症例は73歳,女性で,皮膚黄染,食思不振を訴えて来院した.初診時,黄疸・肝機能異常を認め,精査にて肝門部に径13×9cmの肝嚢胞を認めた.胆管は肝門部にて閉塞し,肝内胆管は両側とも著明に拡張していた.右肝内胆管に対しPTCD施行.その後良好に減黄,肝機能改善を認めた.しかし,左肝内胆管が完全閉塞状態であることに加え,閉塞性黄疸の原因として胆管癌の存在を完全に否定しえなかったため,手術を施行した.開腹術により胆管癌が否定されたため,開窓術を施行し,術後経過は良好であった.

大静脈の外科的治療を22例経験した．症例は男女共11例で，平均年齢は61歳であった．悪性疾患は上大静脈（SVC）では浸潤性胸腺腫4例，胸腺癌，肺癌，食道癌，子宮癌縦隔転移，各1例で5例にSVC症候群を認めた．下大静脈（IVC）では腎癌5例，乳癌腎転移1例でいずれも腫瘍栓によるIVC閉塞を認めた．良性疾患はSVCでは外傷1例，IVCでは血栓症4例，外傷2例，Budd-Chiari症候群1例であった．手術は悪性14例では腫瘍切除兼血行再建術10例，バイパス術3例，Stent留置術1例，良性8例ではパッチ形成術3例，バイパス術2例，IVC遮断術2例，直接縫合術1例であった．予後は，良性では問題なく，悪性では14例中5例が生存中であり，このうち4例は4年以上の長期生存が得られた．悪性腫瘍がたとえ大静脈に浸潤していても積極的に切除，再建を試みるべきである．

We report 2 cases in which the weekly administration of paclitaxel proved to be effective for patients with scirrhous gastric cancer who underwent a curability C operation. Weekly paclitaxel therapy was observed to effectively treat peritoneal and retroperitoneal dissemination. After this treatment the tumor markers decreased markedly. This weekly paclitaxel therapy was observed to cause no adverse effects, and thanks to the treatment the patients were able to consume normal meals. These patients could also be sufficiently treated as outpatients. Weekly paclitaxel therapy is thus considered to be effective for the treatment of advanced scirrhous gastric cancer with peritoneal and retroperitoneal dissemination.

PURPOSE:We investigated the efficiency of distal anastomosis with patch plasty (DAPP), both experimentally and clinically.METHODS:In our experimental study, dogs were divided into two groups: a control group in which anastomosis was performed without DAPP ( n = 7), and a DAPP group in which DAPP was performed at the distal anastomosis ( n = 7). In our clinical study, 169 femoropopliteal bypasses were divided into three groups and analyzed. In one group, the saphenous vein was used (SVG group, n = 65); in one group, an expanded polytetrafluoroethylene (ePTFE) graft was used without DAPP (ePTFE group, n = 64); and in one group, an ePTFE graft was used with DAPP (DAPP group, n = 40).RESULTS:In the experimental study, the ratio between the area of thrombus adherence and the entire area of the intraluminal surface of the graft, defined as the thrombus covering ratio, was 48.9% in the control group and 30.2% in the DAPP group. The ratio in the DAPP group was significantly lower than that in the control group. In the clinical study, although there were no significant differences among the three groups in cumulative patency rates of the femoral above-knee popliteal arterial bypasses, the patency in the DAPP group was excellent. The cumulative patency rates of the femoral below-knee popliteal arterial bypasses in the ePTFE group were significantly lower than those in the other two groups.CONCLUSION:There results suggest that the addition of DAPP may achieve excellent graft patency.

症例は50歳,女性. 10年前より肝嚢胞を指摘されたが放置していた.腹部圧迫感,嚢胞の増大傾向を認め当科紹介となった.右肋骨弓下に9横指,心窩部に7横指肝を触知し同部に圧痛を認めた.軽度の肝機能異常を認めた.腹部エコー・CTでは肝全体に大小の多発性嚢胞を認め,特に左葉では殆ど実質を認めなかった.血管造影検査で左肝動脈は狭小化し,総肝動脈,右肝動脈は外側方へ圧排されていた.門脈相では左枝は造影されず右枝の外側方への圧排を認めた.また脾静脈・左胃静脈は遠肝性に造影され,門脈圧亢進所見であった.肝左葉切除および右葉の嚢胞開窓術を施行した.病理組織ではvon Meyenburg complex様の所見も認め,嚢胞内腔は単層または扁平重層化した立方上皮に囲まれていた.術後,肝は右季肋下で5横指に縮小し,自覚症状も消失した.

Purpose. This study was conducted to accurately define the N status of non-small cell lung carcinoma (NSCLC). Methods. We retrospectively reviewed 147 patients with NSCLC and pathologically positive regional lymph nodes who underwent major pulmonary resections with complete mediastinal lymph node dissections. Results. The overall 5-year survival rate was 41% after a median follow-up period of 33 months. The survival rate of patients with hilar N1 disease (26%) was significantly lower ( P = 0.002) than that of those with interlobar and intrapulmonary N1 disease (60%). The survival rate of patients with hilar N1 disease (26%) was similar to that of those with N2 disease (33%; P = 0.56). Cox proportional hazards analysis with the covariates of age, sex, cell type, site of resection, pathological T factor, and pathological N factor revealed that pathological N factor indicated a relative risk for N2 disease of 1.76 ( P = 0.028). Grouping hilar N1 disease with N2 disease showed that the relative risk of this "new N2 disease" with the same covariates was 2.65 ( P = 0.002). Conclusion. According to our data, hilar N1 disease should be grouped with N2 disease because this combined category accurately reflects surgical outcome.

開心術における虚血/再灌流障害に好中球が関与しているか否かを知る目的で,大動脈遮断前後で冠循環での顆粒球エラスターゼおよびミエロパーオキシダーゼ産生量を測定した.再灌流後,冠循環での顆粒球エラスターゼおよびミエロパーオキシダーゼ産生量は有意に上昇した.さらに再灌流後の冠循環での顆粒球エラスターゼ,ミエロパーオキシダーゼ産生量は大動脈遮断時間と正の相関を示した.これらの結果から,開心術における心虚血/再灌流障害に好中球が関与していることが示唆された.

BACKGROUND:Peripheral leukocytes and platelets (LAPs) contain many kinds of cells with the ability to secrete several growth factors and cytokines. We attempted to induce therapeutic angiogenesis by injecting self-LAPs into a rat ischemic hindlimb model.MATERIALS AND METHODS:Supernatants from cultured LAPs were used for the endothelial cell (EC) proliferation assay, and LAPs were used in a cornea model to evaluate angiogenic potency. LAPs were injected directly into the male Dark Agouti rat ischemic hindlimb model, after which a microangiogram was done and the capillary/muscle fiber ratio was examined histologically. ELISA revealed the levels of contributing growth factors and cytokines present in the ischemic muscles.RESULTS:The EC proliferation assay showed that the supernatants of LAPs accelerated proliferation and that the LAPs induced angiogenesis in the cornea model. The microangiograms and histological evaluation revealed that angiogenesis was induced more effectively in the rats injected with LAPs (LAP group) than in the those injected with phosphate-buffered saline (PBS group). The levels of basic fibroblast growth factor (bFGF) in the ischemia, PBS, and LAP groups were significantly increased compared to those in the sham group. The level of interleukin-1beta (IL-1beta) in the LAP group was significantly more elevated than in the other groups.CONCLUSIONS:The injection of self-LAPs induced angiogenesis in a rat ischemic hindlimb model. Ischemia caused an elevation in the level of bFGF and also in IL-1beta derived from LAPs, which contributed to angiogenesis. This is a novel, yet simple and safe method of inducing therapeutic angiogenesis.

A 13-year-old boy [corrected] underwent heart transplantation for severe congestive heart failure due to dilated cardiomyopathy possibly caused by fulminant acute myocarditis. He suddenly suffered chest discomfort and loss of consciousness during running, and was referred to a hospital with cardiogenic shock. Electrocardiography showed ventricular tachycardia and echocardiography revealed severe hypokinesis in an extensive area of the left ventricular wall with markedly decreased left ventricular ejection fraction. Percutaneous cardiopulmonary support, intraaortic balloon pumping and artificial respiration were performed. He suffered from severe heart failure with septic shock and bleeding tendency. A left ventricular assist system was fitted at 73 days after onset, and he was transferred to the National Cardiovascular Center on the 119th hospital day. At 319 days after the left ventricular assist system operation, heart transplantation was performed. The etiology and treatment for severe heart failure, and several social problems which occurred during care for heart transplantation are discussed.