Pancreatic cancer has an extremely poor prognosis. There are several reports on resectable cancer in the remnant pancreas after pancreatectomy; however, few have compared K-ras mutation patterns to clarify recurrent or second primary cancers. Here, we report on 2 cases of cancer in the remnant pancreas after total pancreatectomy for invasive ductal carcinoma. Case 1 is a 56-year-old man who underwent pancreaticoduodenectomy for cancer of the pancreatic head. However, serum carbohydrate antigen (CA19-9) was again elevated 23 months later. A tumor in the pancreatic tail was detected on abdominal computed tomography (CT), and total pancreatectomy was performed. Histologic examination of the tumors from both operations revealed moderately differentiated adenocarcinoma, and the surgical margins of both resected specimens were free of cancerous cells. The K-ras gene mutation was detected at codon 12V of exon 1 in both cancers. Case 2 is a 72-year-old woman who underwent distal pancreatectomy for cancer of the pancreatic body. However, serum CA19-9 was again elevated 4 years postoperatively. A tumor of the pancreatic head was detected on abdominal CT, and total pancreatectomy was performed. Histologic examination of the first and second tumors revealed poorly and moderately differentiated adenocarcinomas, respectively. The surgical margins of both resected specimens were free of cancerous cells. The K-ras gene mutation was detected at codon 12D of exon 1 in both cancers. These patients with rare pancreatic cancers both had metachronous carcinogenesis in the remnant pancreas.

Chronic peripheral neuropathy is a major adverse response to oxaliplatin-containing chemotherapy regimens, but there are no established risk factors pertaining to it. We investigated the efficacy of hyperacute peripheral neuropathy (HAPN) as a predictor of oxaliplatin-induced persistent peripheral neuropathy (PPN).

結腸癌術後補助化学療法である mFOLFOX6 療法においては初期の血液毒性が治療強度を低下させる要因となる．今回，mFOLFOX6 療法 6コースまでに血液毒性（好中球減少，血小板減少）で投与の延期または投与量が減量された 4例（Ａ群）とされなかった 7例（Ｂ群）を対象とし，血清アルブミン（ALB）値，Prognostic nutritional index（PNI）について比較検討した．Ａ群では relative dose intensity（RDI），PNI，ALB値が有意に低下していたが，両群間に体重減少や食事摂取量の低下の差はなかった．体重減少や食事摂取量の低下がないにも関わらず PNI値が低下した原因のひとつとして，5‐FUによる小腸粘膜傷害に起因する消化吸収障害が考えられた．PNIを測定することで初期の血液毒性の予測ができる可能性が示唆された．

症例は75歳，男性．両側鼠径ヘルニアを認め，左陰嚢内にはS状結腸が脱出し陰嚢内に硬い腫瘍を触知した．還納は困難であったが脱出による疼痛はなく，CTでの造影効果も良好で血流障害はないと診断し，待機にて腹腔鏡根治術を施行した．腹腔鏡下にリンパ節郭清，結腸間膜の処理，口側・肛門側の腸管の離断を行い，鼠径部に皮膚切開を行い，ヘルニア嚢に包んだ状態でS状結腸の摘出を行った．術後経過は良好で術後11日目に退院した．今回経験した症例はヘルニア嚢内腫瘍と分類され，S状結腸癌では左側に，盲腸癌では右側に多く報告されている．今回，術前にS状結腸癌によるヘルニア嚢内腫瘍と診断し，腹腔鏡下根治術を施行した症例を経験したので報告する．

This study evaluated a better treatment for patients with obstructive colorectal cancer (CRC) that have a poor prognosis.

Spigelヘルニア部へ嵌頓した回腸の壊死によって生じた腸管皮膚瘻に対し，腹腔鏡補助下に治療しえた1例を経験したので報告する．症例は87歳の男性．2009年11月より原因不明の腹痛・下痢・嘔吐・食欲不振などの消化器症状を繰り返していた．2010年2月5日左下腹部に腫瘤を認め他医療機関を受診．腹壁筋層内の膿瘍と診断され，切開・排膿処置後当院へ紹介となった．創処置17病日に便臭を伴う排膿を認め，膿瘍腔造影検査を実施した．その結果，膿瘍腔と小腸との交通を確認した．1週間の絶食により膿瘍腔自体は縮小したが，その口側小腸の拡張が残存していたため，24病日に腹腔鏡補助下に手術を施行した．腹腔鏡ではSpigel腱膜に合致した左下腹壁へ強固に嵌頓・癒着した小腸を認めた．腹腔側よりこれを剥離し，瘻孔部を中心に小開腹下に嵌頓小腸の部分切除を行った．術後経過は良好で，術後11日に退院した．

症例は38歳,女性.虫垂切除術,子宮筋腫手術,および3回の帝王切開術の既往があった.下腹部痛があり,産婦人科で右付属器炎と診断,入院時腹部CT検査で小腸の拡張を認め,外科紹介となった.イレウス管を挿入し,症状は緩快したが,造影検査で骨盤内小腸に狭窄像を呈した. 5度の開腹既往のため今回の手術を拒んでいたが,腹腔鏡下手術を優先するとの方針に納得し,手術を行った.盲腸側より回腸を検索し,約20cmの部位が子宮右側の異常裂孔に嵌入しているのを確認した.腸管損傷なく整復でき,裂孔を縫合閉鎖した.本疾患は,先天異常,妊娠,手術などにより子宮広間膜に生じた異常裂孔をヘルニア門とした内ヘルニアである.近年,内ヘルニアに対する腹腔鏡下治療報告が増加しているが,腹腔鏡下手術は,本疾患を含めた内ヘルニアに対して有用な場合があり,考慮すべき治療法である.

Background/Aims: In spite of recent advances in liver surgery, biliary complications remain a common cause of major morbidity after hepatectomy.Methodology. We studied the postoperative evaluation of 28 hepatectomied patients with transcystic duct tube (C-tube) drainage (C-group), compared with 38 hepatectomied patients without C-tubes (NC-group), in terms of preoperative clinical profiles of patients, intraoperative findings and procedures, postoperative management and bile leakage, daily output of bile, liver function and postoperative infections.Results: There were no significant differences in the preoperative clinical profiles of patients and postoperative management between the two groups. In intraoperative findings and procedures, the tumor size, weight of the resected liver, operation time and operative blood loss were higher in the C-group than those in the NC-group. Therefore, the operative procedure was more serious in the C-group than that in the NC-group. However, bile leakage was observed in only one of 28 patients (3.6%) in the C-group and 10 of 38 patients (26.3%) in the NC-group, that is, bile leakage occurred less frequently in the C-group than in the NC-group. The daily output of bile in the C-group was thought to be enough to decompress the biliary tree. In liver function, aspartate aminotransferase and alanine aminotransferase had lower levels in the C-group than those in the NC-group with bile leakage. White blood cell count, C-reactive protein and body temperature were closer to the normal range in the C-group than those in the NC-group with bile leakage.Conclusions: C-tube drainage after hepatectomy is thought to be useful for decreasing postoperative complications, especially bile leakage.

Isolated bacteria from infections in general surgery during the period from April 2001 to March 2002 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, four hundred and twenty strains were isolated from 175 (79.2%) of 221 patients with surgical infections. One hundred and eighty-six strains were isolated from primary infections, and 234 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-positive bacteria were predominant, while from postoperative infections, aerobic Gram-positive bacteria were predominant. Among aerobic Gram-positive bacteria, although the isolation rate of Staphylococcus aureus was the highest, followed by that of Enterococcus faecalis from primary infections, the isolation rate of E. faecalis was the highest from postoperative infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa in this order, and from postoperative infections, P. aeruginosa was the most predominantly isolated, followed by Enterobacter spp., E. coli and Klebsiella spp. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both types of infections. The isolation rate of aerobic Gram-negative bacteria from primary infections and that of aerobic Gram-positive bacteria from postoperative infections were high in the last several years. We noticed no vancomycin-resistant Gram-positive cocci.

BACKGROUND/AIMS In spite of many technical advances in liver surgery, optimal nutritional support after hepatectomy has not been established. METHODOLOGY We clarified the actual nutritional state in 16 patients with total parenteral nutrition (TPN group), and 16 patients without total parenteral nutrition (PPN group), after hepatectomy for hepatocellular carcinoma without biliary tract reconstruction, in terms of preoperative clinical data, intraoperative indexes, postoperative management and complications, liver function data, nutritional state, and changes in metabolic parameters. RESULTS There were no significant differences in any occurrences of postoperative complications, liver function data, or nutritional parameters between the two groups. On the other hand, the TPN group needed more doses of insulin than the PPN group. The beginning of each water and food intake was earlier in the PPN group than in the TPN group. The blood glucose level was higher in the TPN group than in the PPN group. The serum sodium and chloride levels were lower, but the serum potassium level was higher, in the TPN group compared to the PPN group. Thus, problems such as hyperglycemia and serum electrolyte abnormalities were more conspicuous in the TPN group than in the PPN group. CONCLUSIONS In the actual clinical care after hepatectomy for hepatocellular carcinoma without biliary tract reconstruction, in which oral feeding is started early, total parenteral nutrition is considered unnecessary.

Background/Aims: We studied the postoperative evaluation of transcystic duct tube drainage (C-tube), T-tube drainage (T-tube), and retrograde transhepatic biliary drainage after common bile duct exploration for patients with choledocholithiasis.Methodology: We analyzed the preoperative clinical features of patients, intraoperative findings, postoperative status and management, daily output of bile, liver function, postoperative infections, and postoperative complications for patients who. underwent common bile duct exploration including 16 C-tube, 17 T-tube, and 8 retrograde transhepatic biliary drainage cases.Results: There were no significant differences in the, preoperative clinical features, intraoperative findings, or the daily output of bile from the tube. The removal day of the biliary drainage tube and postoperative hospital stay were shorter in the C-tube group than in the T-tube and retrograde transhepatic biliary drainage groups. Aspartate aminotransferase level and body temperature in the C-tube group on day 7 were lower than those in the T-tube group, and the total bilirubin level in the C-tube group on day 14 was lower than in the T-tube and retrograde transhepatic biliary drainage groups. Moreover, postoperative complications occurred significantly less frequently in the C-tube group (25.0%) than in the T-tube group (76.5%).Conclusions: C-tube drainage is thought to be most useful after common bile duct exploration for patients with choledocholithiasis.

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in Japan since July 1982. In this paper, the results obtained in the academic year 1999 (from April 1999 to March 2000) have been summarized. Two hundred seven cases were investigated, and 411 strains were isolated from 169 cases (81.6%). Of those strains, 184 and 227 strains were from primary infections and postoperative infections, respectively. In primary infections, the isolation rates of anaerobes, Streptococcus spp., and Escherichia coli were higher than in postoperative infections, while in postoperative infections, those of Gram-positive aerobes were higher than in primary infections. Staphylococcus aureus were most frequently isolated among Gram-positive aerobes, Peptostreptococcus prevotii among Gram-positive anaerobes, E. coli among Gram-negative aerobes, and Bacteroides fragilis among Gram-negative anaerobes. In primary infections, the percentage of Gram-negative aerobes, which gradually increased by the year 1998, decreased in the year 1999. The percentage of Gram-negative anaerobes increased, while that of Gram-negative bacteria was equivalent to that in the last year. In postoperative infections, the percentage of Gram-negative anaerobes, which continuously increased after the year 1990, decreased, while that of Gram-positive aerobes, which decreased in the last year, increased. Methicillin-resistant S. aureus accounted for 70.7% of S. aureus (41 strains). Either the number of strain or the percentage of MRSA decreased. The susceptibilities of E. coli and Klebsiella pneumoniae decreased against third and forth generation cephems, oxacephems, and monobactams. The susceptibilities of P. aeruginosa to carbapenems tend to decrease after the year 1997. S. aureus showed good susceptibilities to the tested drugs including arbekacin, vancomycin, and teicoplanin.