回盲ヒダは虫垂間膜と回腸末端下縁との間に生じ，回腸末端下縁から虫垂間膜前面を通り盲腸または虫垂に至る構造物である．これまで，回盲ヒダを外科治療に応用した報告はない．今回，我々は盲腸穿孔と壊疽性虫垂炎に対して回盲ヒダで被覆した2例を経験したため，その手技と有用性を報告する．症例①は盲腸前壁のIsポリープに対してEMRを施行後，翌日に盲腸穿孔による急性汎発性腹膜炎を来し緊急手術を施行した．盲腸前壁に穿孔部を認め，穿孔部を単純閉鎖し回盲ヒダで被覆した．症例②は糞石を伴う壊疽性虫垂炎に対して緊急開腹虫垂切除術を施行した．虫垂は壊死し根部で断裂していた．虫垂根部を楔状切除した後，単純閉鎖し回盲ヒダで被覆した．盲腸穿孔での単純閉鎖症例や虫垂根部まで壊死した虫垂炎症例に対し，回盲ヒダ被覆術は有効な選択肢の一つとなりえると考える．

症例は74歳，男性．上部消化管内視鏡で胃体下部大彎に2型病変を認め，病変周囲は粘膜下が隆起し生検でtub1であった．CTでは胆嚢が壁肥厚を伴って腫大し連続して肝臍部から胃前庭部に低吸収域を認め，「胆嚢癌の胃浸潤」，「胃癌の周囲浸潤」，「胆嚢炎による胃壁膿瘍と胃癌の併存」との鑑別に迷った．抗菌薬治療を先行するとCTで胃の低吸収域は縮小，胃癌も粘膜下隆起が軽減し0-II c型となっていた．胆嚢炎による続発性胃壁膿瘍と胃癌併存と診断し，幽門側胃切除術+胆嚢摘出術を行った．病理所見は，T1bN0の胃癌と，近傍に漿膜～固有筋層まで膿瘍形成を認め，胆嚢は膿瘍を伴う急性胆嚢炎の所見で悪性所見を認めなかった．胆嚢炎による続発性胃壁膿瘍は稀な病態であり，さらに近傍に胃癌が併存するという稀少例を経験した．抗菌薬治療先行により胃癌の正確な術前診断も可能であった．

A 56-year-old woman was diagnosed with rectal cancer and liver metastases(Stage IV), and underwent low anterior resection and laparoscopic partial hepatectomy. The patient received adjuvant chemotherapy(mFOLFOX6 for 24 weeks), but developed multiple lung metastases 11 months later. Before undergoing a pulmonary resection, the patient presented with acute small bowel obstruction. Abdominal computed tomography showed small bowel stenosis due to a tumor, and we suspected peritoneal metastases from the rectal tumor. We performed partial resection of the small intestine, and histopathological examination revealed a primary small bowel tumor. The patient was discharged to her home without complications, and later underwent pulmonary resections for bilateral lung metastases. We usually suspect that small bowel obstruction is due to peritoneal metastases in patients with advanced colorectal tumors, but must consider the rare possibility of a separate primary small bowel tumor, especially in patients with a solitary lesion. We report a rare primary small bowel tumor after FOLFOX treatment in a patient with Stage IV rectal cancer.

A 46-year-old woman was referred to our hospital because of nausea. Endoscopy revealed scirrhous gastric cancer, and abdominalcomputed tomography revealed peritonealdissemination. She was diagnosed with Stage IV gastric cancer and treated with S-1 plus CDDP combination chemotherapy. After 4 courses of chemotherapy, the primary tumor and peritoneal dissemination were considered clinically stable, but the uterus grew rapidly. She was diagnosed as having uterine metastasis based on cervicaland endometrialsmear class V cytology. As the chemotherapy was not effective for the uterine lesions, totalhysterectomy and bilateralsal pingo-oophorectomy were performed. Histological findings showed a poorly differentiated cancer with vascular emboli. Uterine metastases are an important consideration in women with scirrhous gastric cancer, and we recommend palliative hysterectomy for chemotherapy-resistant metastases if the primary tumor and other metastases are controlled.

Solitary mediastinal lymph node metastasis of hepatocellular carcinoma (HCC) is rare. We report a case of metachronically solitary mediastinal metastases of HCC treated by video-assisted thoracic surgery (VATS) twice. A 66-year-old man underwent repeated laparoscopic radiofrequency ablation or trans-arterial catheter chemo-embolization against HCC for more than 10 years. The level of alpha fetoprotein protein was elevated, and radiological modalities including FDG-PET revealed solitary mediastinal tumor metachronically. VATS was performed bilaterally twice. The postoperative course was uneventful and there had no recurrence of extra-hepatic metastases and tumor markers are within normal limits at 18 months after second VATS. VATS is a minimally invasive and useful procedure for solitary mediastinal lymph node metastasis of HCC. If primary HCC was controlled and lymph node metastasis was solitary, mediastinum lymphadenectomy using VATS might give good short and long term results.

症例は76歳の女性で，発熱と腹痛，体重減少を主訴に当院を紹介受診した．腹部CT検査で骨盤腔に腸重積をきたした小腸腫瘍を認め，小腸部分切除術を施行した．周囲への浸潤や播種，腫大リンパ節は認めなかった．腫瘍は大きさ65×40×30mmの表面平滑な充実性腫瘤で，病理組織学的所見では核異型や異常核分裂像が著明な紡錘形細胞が錯綜増生しており，免疫染色検査ではKIT・CD34・S100が陰性，α-SMA・Desminが陽性であり，GIST診療ガイドラインとWHO Classification of Tumors of the Digestive Systemの定義に則り小腸平滑筋肉腫と診断した．さらに，DOG1免疫染色検査が陰性で，c-kit遺伝子とPDGFRA遺伝子検査の変異を認めずGISTは完全に否定された．小腸平滑筋肉腫は稀な疾患で，確定診断には免疫染色検査と遺伝子検査が重要である．

症例は48歳，男性．肝障害で受診し，精査の結果Mirizzi症候群と診断した．MRCPでは3cm大の胆嚢管結石が総胆管を圧排し狭窄しており胆管瘻が疑われ，ENBDチューブ留置で肝障害は改善した．手術所見では胆嚢周囲の炎症は高度で，胆嚢頸部を中心に肝十二指腸間膜・十二指腸が一塊となっていた．結石を除去するとENBDが確認でき，胆管瘻は直径1cm，胆嚢・胆管周囲組織は炎症性に肥厚・硬化していて単純縫合閉鎖や胆嚢パッチは困難であった．肝円索を瘻孔部に被覆・縫合し閉鎖，術中ENBD造影で造影剤漏出・狭窄がないことを確認し手術を終了した．術後経過良好で退院し，長期経過も良好である．胆嚢・胆管周囲組織の炎症が高度な場合，胆管瘻に対する肝円索被覆は有用な方法であると思われる．

AIM:Adipocyte lipolysis is mediated by a family of triglyceride (TG) lipases consisting of hormone-sensitive lipase (LIPE), adipose triglyceride lipase (PNPLA2) and carboxylesterase 1 (CES1); however, little is known about the relationship between the expression of each gene in different depots and TG lipase activity or obesity.METHOD:We measured both mRNA expression levels of the lipolytic enzymes (LIPE, PNPLA2 and CES1) and TG lipase activities of biopsy samples obtained from subcutaneous, omental and mesenteric adipose tissues of 34 patients who underwent abdominal surgery. The results were correlated with clinical parameters: adiposity measures, parameters for insulin resistance and plasma lipid levels.RESULTS:PNPLA2 mRNA levels were slightly higher in omental fat than subcutaneous fat. Cytosolic TG lipase activities were positively correlated with the mRNA levels of CES1 in subcutaneous fat and mesenteric fat, while they were correlated with those of PNPLA2 in omental fat. The mRNA levels of LIPE were negatively correlated with various measures of adiposity in subcutaneous fat. The mRNA levels of CES1 were positively correlated with various measures of adiposity, particularly those estimated by CT in the three depots; they were also positively correlated with plasma LDL-cholesterol levels in omental fat. In contrast, the mRNA levels of PNPLA2 were not significantly associated with adiposity.CONCLUSIONS:The positive correlations of the expression of CES1 with cytosolic TG lipase activities as well as with adiposity suggest that CES1 is involved in lipolysis, thereby contributing to the development of obesity-associated phenotypes. On the other hand, the expression of LIPE is negatively correlated with adiposity. These distinct regulatory patterns of lipolytic genes may underlie the complex phenotypes associated with human obesity.

症例1:87歳，女性．糖尿病の既往がある．腹痛と嘔吐を主訴に受診．下腹部に圧痛を認め，軽度の反跳痛を伴っていた．腹部CT検査では門脈ガス血症と回腸から上行結腸の拡張，壁肥厚を認めた．緊急大腸内視鏡検査では回腸から上行結腸に全周性に粘膜の脱落とびらんを認めたが，明らかな腸管壊死の所見は認めず保存的治療を選択した．翌日より症状の改善を認め，その後軽快退院した．症例2:85歳，女性．皮膚筋炎にて15年間ブレドニゾロン（15mg/日）を内服中．右大腿骨頭壊死に対して人工骨頭置換術施行．第9病日より下痢，腹痛出現し，第14病日の腹部CT検査で門脈ガス血症と結腸全域に壁肥厚像を認めた．緊急大腸内視鏡検査では結腸全域に散在性に粘膜のびらんと浮腫を認めたが，明らかな腸管壊死の所見は認めず保存的治療を選択し軽快退院した．大腸内視鏡検査により保存的治療を選択し，軽快した門脈ガス血症を伴う腸炎の2例を経験したので，若干の文献的考察を加え報告する．

The surgical strategy for the treatment of colorectal cancer and synchronous liver metastases remains controversial. The aim of the present study was to investigate the effects of colonic resection on liver function and regeneration in a rat model.

症例は63歳, 男性で腹痛を主訴に当科受診した. 貧血を認め, 一時的な血圧低下も認めた. 下血は認めなかったが, CT上腹腔内に液体貯留を認め, 穿刺で血液と確認した. 右上腹部に動脈瘤様構造物を認めたが, 血管撮影では瘤や出血部位は描出されず, 5年前の腹部鈍的外傷以外に既往なく全身状態も安定していたので経過観察した. 2週後の血管撮影で中結腸動脈末梢に動脈瘤を認めた. 塞栓術では, 腸管壊死に陥る可能性が高いため, 開腹し動脈瘤を含む血腫と右結腸を切除した. 組織学的には腸間膜内に径3cm大の血腫形成を認め, 周辺の小動脈に部分的な中膜および内弾性板の欠損, fibro-cellular tissueへの置換を認めた. 他に明らかな原因を特定できず, 5年前の外傷による仮性動脈瘤の形成が疑われた. 上腸間膜動脈分枝の外傷性仮性動脈瘤の本邦論文報告は, 本編を含め4例のみであり, 本例のように5年間の長期経過後に破裂したと考えられる症例は, 本邦では初めてである.

Background: Colonoscopic assessment of the depth of invasion is an important factor determining the appropriate treatment for submucosal colorectal carcinoma: endoscopic or surgical resection. Magnifying chromoendoscopy using indigo carmine (IC) dye has been reported to facilitate meticulous observation. Acetic acid (AA), an inexpensive and safe agent which removes mucous on a lesion and simultaneously enables enhancement of the fine structure of the pits, could be an alternative to conventional dyes. The aim of this study was to assess the accuracy of AA-magnifying colonoscopy in terms of assessment of the depth of submucosal invasion. Patients and Methods: From November 2003 to October 2005, 133 patients with histologically confirmed colorectal carcinoma confined to the mucosal or submucosal layer were treated in our departments. In all cases, magnifying chromoendoscopy using 0.2% IC was performed, and in 66 cases 0.5% AA spray was added mainly because of indefinite chromoendoscopic findings, and these 66 cases were included in this study. The configuration of pits was classified by Kudo's classification and categorized into two categories: deep (massive invasion of the submucosal layer) and shallow (intramucosal or minimal invasion of the submucosal layer), according to the presence or absence of VN type pits, respectively. Histologically, if the depth of invasion was less than 1 mm, the lesion was defined as shallow, and if it was greater than or equal to 1 mm, the lesion was defined as deep. Results: There was no adverse event associated with AA spray. Histologically, there were 16 cases of intramucosal carcinoma, 14 cases of shallow submucosal carcinoma and 36 cases of deep submucosal carcinoma. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 61.1%, 93.3%, 91.7% and 66.7%, respectively. For the 18 ‘flat’ lesions, sensitivity, specificity, PPV and NPV were 83.3%, 100%, 100% and 92.3%, respectively. On the other hand, for the 48 protruding lesions, sensitivity, specificity, PPV and NPV were 56.7%, 88.9%, 89.5% and 55.2%, respectively. Conclusions: The results of magnifying colonoscopy combined with acetic acid spray were excellent, especially for ‘flat’ lesions, which are reported to have an aggressive nature. With its high PPV, this method is thought to contribute to clinical decision making for lesions with VN pits, which comprise about 60% of those with massive invasion. However, the relatively low accuracy for protruding lesions compared to ‘flat’ lesions might suggest a limitation of magnifying colonoscopy in assessing the histological characteristics in the submucosal layer.

Background: A combined colorectal and hepatic resection is considered too risky by many surgeons owing to the high risk of postoperative septic complications. The aim of the present study was to investigate the effects of hepatic resection on the healing of left-sided colonic anastomoses in rats on postoperative day 7. Material and Methods: Fifty-four Sprague-Dawley rats were block-randomized into three groups. In each group, 1 cm of the left side of the colon was resected and anastomosed. Additionally, 40 or 70% of the liver was resected in group 2 and 3, respectively. Rats were killed on postoperative day 7. The abdominal cavity was inspected for the presence of complications. The bursting pressure and hydroxyproline content of the anastomoses were measured. Results: The total number of complications was significantly higher in group 3 than in group 2. Anastomotic bursting pressure and hydroxyproline content did not differ significantly among the groups. Conclusions: Increasing the extent of simultaneous hepatic resection did not significantly affect the healing of left-sided colonic anastomoses in rats on postoperative day 7, although there was a tendency towards lower bursting pressure paralleling the extent of liver resection. Excessive hepatic resection with colectomy may increase postoperative complications.

Purpose. A prospective study was conducted to ascertain the effects of preoperative enteral immunonutrition on a surgical site infection (SSI) in patients with colorectal cancer without malnutrition.Methods. Patients with colorectal cancer undergoing elective surgery without malnutrition, bowel obstruction, severe cardiopulmonary complications, diabetes, collagen disease, or renal failure were sequentially divided into an immunonutrition group (n = 33) and a control group (n = 34). In the immunonutrition group, an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids was administered for 5 days (750 ml/day) prior to surgery.Results. The mean age was slightly higher in the immunonutrition group (69 +/- 9 years) than in the control group (63 +/- 11 years; P < 0.05), but no significant differences between the groups were noted for the body mass index, total protein, albumin, hemoglobin, surgical methods, operation time, or volume of intraoperative bleeding. The frequencies of superficial incisional SSI, deep incisional SSI and organ/space SSI in the immunonutrition and control groups were 0% and 11.8% (4/34; P < 0.05), 0% and 0%, and 0% and 2.9% (1/34), respectively.Conclusion. Preoperative enteral immunonutrition appears to be effective for preventing SSI in patients with colorectal cancer without malnutrition.

Background: Previous studies have shown that deep invasion into the submucosal layer and lymphatic channel involvement are useful pathological predictors for lymph node (LN) metastasis in T1 colorectal cancer (CRC). Recently tumor budding (TB) has been reported to be a promising predictive marker for LN metastasis. The aim of this study was to clarify whether TB is a useful pathological predictor. Methods: Two hundred and twenty consecutive patients who underwent colectomy or colonoscopic resection for T1 CRC in 2 institutions from 1991 to 2001 were reviewed by 2 authors (HY, KT) blinded to histological lymph node status. TB as assessed by Ueno et al. 1, depth of submucosal invasion (DI), lymphatic channel involvement (LCI), and pathological differentiation (PD) were selected as candidate histological predictors for LN metastasis. Candidate positive predictors were defined as: Grade 2 (moderate) and Grade 3 (severe) for TB, ‘2000 μm or greater invasion’ for DI, not well differentiated for PD and the presence of LCI. LN status was judged from surgical specimens, and cases in which no recurrence occurred 4 years or longer after colonoscopic resection were assigned a status of “no LN metastasis”. LN status was the endpoint of the study. A logistic regression model was applied to analyze significant risk factors for LN metastasis. Results: The rate of LN metastasis was 7.3 percent (16 of 220 patients). Positive rates of the candidate pathological factors were 12% in TB, 48% in DI, 10% in PD and 5% in LCI. Univariate analysis showed significant differences in all 4 pathological factors examined. In multivariate analysis, TB (p = 0.001) and PD (p = 0.0001) were significantly associated with LN metastasis. When either TB or PD were adopted for the prediction of LN metastasis, sensitivity, specificity, positive predictive value, and negative predictive value were 94%, 86%, 34% and 99%, respectively. Conclusions: TB and PD are useful pathological predictors for LN metastasis in T1 CRC. 1. Gastroenterology 2004;127(2):385-94.

症例は77歳男性。大腸癌術後の大腸内視鏡検査で，下行結腸に径8mmのⅡc型病変が発見された。陥凹内隆起を認めたため粘膜下層深部浸潤癌が疑われたが，空気量の変化により形態変化することから粘膜内癌と診断し内視鏡的に切除した。組織学的には，粘膜内癌（高分化腺癌）で，隆起部分は表層へ固着した肉芽組織であった。IIc型大腸癌の陥凹内隆起は炎症性変化や癌の粘膜内増殖によって生ずる場合があるので注意が必要である。

今回我々は内視鏡所見を契機に診断した虫垂粘液囊腫の1例を経験したので報告する。症例は56歳男性。大腸内視鏡検査では虫垂開口部に硬い粘膜下腫瘍様隆起性病変を認めた。pit patternは正常，生検でgroup 1と診断され，CTでは腫大した虫垂の壁の厚さは一様であった。虫垂粘液囊腫の診断で盲腸部分切除術を施行した。摘出標本では腫大した虫垂が盲腸内に突出し，内腔は平坦で白色～透明の粘液が貯留していた。単層，一部が低乳頭状で粘液を含む異型の少ない上皮で，腺腫の診断であった。

A subset of colorectal carcinomas (CRCs) is associated with microsatellite instability (MSI) of the genome. Although extensive methylation of CpG islands within the promoter regions of DNA mismatch repair genes such as MLH1 is thought to play a central role in tumorigenesis for MSI-positive sporadic CRCs, it has been obscure whether such aberrant epigenetic regulation occurs more widely and affects other cancer-related genes in vivo. Here, by using methylated CpG island amplification coupled with representational difference analysis (MCA-RDA), we screened genomic fragments that are selectively methylated in CRCs positive for MLH1 methylation, resulting in the identification of hundreds of CpG islands containing genomic fragments. Methylation status of such CpG islands was verified for 28 genomic clones in 8 CRC specimens positive for MLH1 methylation and the corresponding paired normal colon tissue as well as in 8 CRC specimens negative for methylation. Many of the CpG islands were preferentially methylated in the MLH1 methylation-positive CRC specimens, although methylation of some of them was more widespread. These data provide insights into the complex regulation of the methylation status of CpG islands in CRCs positive for MSI and MLH1 methylation.

Alterations of the APC, K-ras, and β-catenin genes are defined as early events in colorectal tumorigenesis. These alterations are well-known as constitutents of Vogelstein's pathway, however, the relationship among them is unclear. For understanding colorectal tumorigenesis it is important to evaluate their relationship. We analyzed the relationship between β-catenin and K-ras gene mutations in clinical colorectal samples. Sixty-four cases of colorectal cancers (44 proximal, 20 distal) without a family history of colorectal cancer were used for this study. We purified genomic DNAs from fresh surgical samples and, thus, analyzed the mutations of β-catenin (exon 3) and K-ras (codons 12 and 13) by PCR direct sequencing method using Big Dye terminator cycle sequencing with AmpliTaq polymerase FS. We found 27% (17/64) K-ras mutations (proximal 25%, 11/44; distal 30%, 6/20). The frequency of β-catenin mutations was 11% (7/64; proximal 9%, 4/44; distal 15%, 3/20). All cases with β-catenin mutation had no mutation of K-ras. All sites of β-catenin mutation have been reported previously (codons 33, 34, 41, 45). In cell lines, it has been reported previously that β-catenin and K-ras play the same roles in activation of cyclin D1 transcription. Our results may support this report and suggest that some colorectal cancers with β-catenin mutation will progress without K-ras mutation. Further study may disclose a new pathway or new mechanism of colorectal tumorigenesis.