Adjuvant chemotherapy with capecitabine is frequently not completed due to adverse events, including hand-foot syndrome. A higher completion rate of capecitabine by reduction of the side effects may improve disease-free survival and quality of life of affected patients. In the present study, colorectal cancer (CRC) patients were treated with capecitabine (2,500 mg/m(2)/day), which was taken for five days, followed by an interval of two days (5-days-on/2-days-off schedule). One course lasted three weeks, and eight courses (24 weeks) were administered. The median number of treatment courses was significantly higher in patients in the 5-days-on/2-days-off regimen group compared with that of patients in the retrospectively included conventional regimen group (P=0.0438). The frequency of completion of the scheduled treatment by patients in the 5-days-on/2-days-off regimen group was significantly higher (P=0.0389). The present phase II study suggests that toxicities associated with the 5-days-on/2-days-off regimen are lower compared with those of the conventional regimen, and that the occurrence of adverse events was higher, but less high-grade toxicities were reported. The time to treatment failure was also favorable in the new regimen and it demonstrated good feasibility. In conclusion, the present study demonstrated good feasibility with retained quality of life and acceptable adverse effects (mostly low-grade), and the 5-days-on/2-days-off regimen should be further evaluated in future randomized controlled trials. The present study was registered in the University Hospital Medical Information Network (UMIN) clinical trial registry (no. UMIN000012813).

Delayed intestinal stenosis after bowel-preserving reductions of incarcerated hernias have rarely been reported. Two patients who developed delayed bowel obstruction after bowel preservation during surgery for incarcerated femoral hernias are reported. Laparoscopic surgery was performed, and ischemic small bowel stenosis was diagnosed in both cases. In one patient after preservation of small bowel without any changes in color of the serosa, stenosis still developed later. In the other patient with linear color changes of the small bowel serosa, indocyanine green (ICG) fluorescence angiography showed enhancement of almost the entire bowel wall, but some areas of poor linear enhancement corresponding to the serosal changes were noted. Although bowel preservation was still considered safe, cicatricial changes causing stenosis later occurred in the areas of poor enhancement. The possibility of delayed ischemic small bowel stenosis after surgery for incarcerated hernias should always be kept in mind. Patients with even only slightly poor enhancement on ICG fluorescence angiography require careful follow-up, and surgery must be considered if any symptoms of intestinal obstruction develop.

横紋筋融解症を起こす原因に,様々な薬剤が報告されている.この度,大腸癌患者に対する化学療法が原因と考えられる薬剤性横紋筋融解症を経験したため報告する.症例は73歳の男性.横行結腸癌とS状結腸癌,また,その転移性肝癌に対し手術を施行した.術後補助化学療法としてcapeOX療法を施行したところ,Oxaliplatinの投与数時間後より四肢近位側に疼痛および倦怠感が出現し,採血検査にてCK 8,632U/lと高値を認めた.薬剤性横紋筋融解症の診断にて入院,点滴加療を開始した.筋崩壊に伴うADLの著明な低下や,嚥下機能障害,喉頭浮腫による呼吸障害をきたした.筋崩壊が終息するまでには発症後112日の期間を要し,大腸癌に対する治療は中止せざるを得ず,大腸癌の多発腹腔内再発により永眠された.Oxaliplatinによる横紋筋融解症の報告は,国内にて自験例を含め8例が報告されているのみであり,併せて報告する.

症例は80歳，女性．1カ月以上続く便柱狭細化と便秘を主訴に前医を受診し，下部消化管内視鏡検査（colonoscopy，以下CS）で直腸粘膜の全周性浮腫と狭窄を指摘された．以前よりCEA高値を指摘されており，精査目的で当院紹介．内視鏡下生検組織診断で悪性所見は認めなかったが，継続する全周性直腸狭窄とCEA高値より直腸癌を否定できず，開腹術を施行した．しかし，直腸および骨盤内に腫瘍を認めなかった．術中にCSをしたところ，直腸の狭窄は改善していたため直腸切除は行わず，保存的に経過をみることとした．一週間後に再びCSを行ったところ，軽度の直腸狭窄を認めたのみであり，直腸狭窄型虚血性大腸炎と診断した．直腸狭窄型虚血性大腸炎は比較的まれであり，さらにCEA高値を伴った症例はこれまでにほとんど報告がなく，若干の文献的考察を加えて報告する．

症例は67歳，男性，右季肋部痛と発熱を主訴に来院した．腹部MRIで肝前区域を中心とする腫瘍を認め，肝亜区域切除・胆嚢摘出・十二指腸部分切除・横行結腸部分切除を施行，H.E.染色では低分化型胆管細胞癌であった．術後30病日ごろから口渇・多飲・多尿・全身倦怠感および見当識の低下を認めた．高血糖や骨転移は認めず，Ca と PTHrP の上昇（14.6mg/ml，7.0pmol/l）を認めた．ただちにcalcitoninおよびzoredronateを投与し，症状緩和は得られたが，まもなく播種性の再発が生じ，術後64病日に死亡した．免疫組織学的検討では，CEA，cytokeratin（CK）-7，CK-8，CK-19，PTHrPが陽性，AFP，hepatocyte specific antigen（HSA），CK-20，PTHが陰性であったことから，最終的にPTHrP産生胆管細胞癌と診断した．

症例は26歳，女性．S状結腸癌のため2009年7月，S状結腸切除を施行したのち，化学療法中であったが，手術から16カ月後に肺転移および右卵巣転移・腹水貯留が出現した．症状緩和目的に右卵巣腫瘍摘出したが，その2カ月後，突然一過性の視野欠損や構音障害・日々変化する上下肢の疼痛などの神経症状が出現した．頭蓋内圧亢進症状および髄膜刺激症状は認めず，gadopentetate dimeglumine造影MRI（以下Gd-MRI）では脳表・軟膜に沿ったびまん性の異常増強効果を認めた．髄膜癌腫症と診断し，dexamethasoneおよびcapecitabineを投与したところ，神経症状は消失した．その後患者は3カ月症状の再燃なく生存した．大腸癌による髄膜癌腫症はまれであり，文献的考察を加えて報告した．

胃未分化癌とは，「病巣のどの部分にも腺癌や扁平上皮癌への分化を示さない癌」と定義される．症例は55歳，男性，上腹部痛および膨満感を主訴に来院した．上部消化管内視鏡検査では幽門前庭部に3型の腫瘍を認め，同部からの生検では低分化型腺癌（por）を認めた．また，腹部CT検査では腹壁への浸潤と多発性肝転移を認めた．入院後直ちにS-1/CDDPによる化学療法を開始したが，腫瘍からの出血が増悪したため，やむなく幽門側胃切除術・肝外側区域切除・腹壁部分切除術を施行した．術後7病日から異型細胞を含む血性腹水が生じて増加し，術後39病日にDICおよび肝腎不全にて死亡した．免疫組織学的検討ではCytokeratinが陽性であったが，AFP・CEA・EMA・MUC2・MUC5AC・MUC6・CD56・Synaptophysin・Chromogranin Aが陰性であり，最終的に胃未分化癌と診断した．

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

デスモイドは腫瘍の発生および増大にエストロゲンが関与していることが報告されている．今回われわれは，産褥期に発見された腹直筋原発のデスモイドを経験したので文献的考察を加え報告する．症例は，32歳女性．出産後の1カ月検診で左鼠径部に圧痛を伴う8cm大の弾性硬の腫瘤を認め，当科紹介となった．CT検査および超音波検査で，血流に富む8×5cm大の左腹直筋と境界が不明瞭な腫瘍を認め，悪性腫瘍を疑い手術を施行した．腫瘍は左腹直筋より発生し，恥骨に癒着していた．腫瘍を含む左腹直筋とその前鞘を切除し，腹直筋欠損部はメッシュを用いて修復した．病理診断はデスモイドで，エストロゲンレセプターが陽性であった．術後経過良好で，1年の時点で明らかな再発は認めていない．

This report presents the rare case of a 75-year-old woman who developed a rectal obstruction caused by a pharmacobezoar, following the long-term ingestion of magnesium oxide cathartics for constipation. She was admitted to the hospital with lower abdominal pain and nausea. Abdominal computed tomography and magnetic resonance imaging showed that a huge calcified mass caused the rectal obstruction. A divided sigmoid colostomy was performed to relieve her symptoms, a colonoscopy from the distal stoma delineated a huge bezoar in the rectum, and thereafter she underwent an enterotomy. Magnesium oxide was detected in an analysis of a sample from this bezoar. Phamacobezoars resulting from laxatives or cathartics have rarely been reported. The current report showed a rectal obstruction caused by a pharmacobezoar composed primarily of magnesium oxide.

Background The lymph node ratio, defined as the ratio between the number of lymph node metastasis and the total number of lymph nodes examined, has been reported to be an important prognostic factor in other gastrointestinal carcinomas except middle and distal bile duct carcinomas. Methods Between 1991 and 2004, 62 consecutive patients who underwent surgery for middle and distal bile duct carcinoma were retrospectively analyzed concerning prognostic factors. Results The median number of lymph nodes examined was 12 (range 5 to 38). The overall 5-year survival rates of patients with lymph node ratio of 0, lymph node ratio of 0 to .2, and lymph node ratio >.2 were 62%, 41%, and 0%, respectively. A multivariate analysis revealed that a lymph node ratio >.2 and perineural invasion were independent predictive factors for survival. Conclusions Lymph node ratio >.2 is an important factor to predict survival after resected middle and distal bile duct carcinoma.

症例は36歳，男性．腰痛を主訴に当科を紹介受診した．白血球，CRP上昇と炎症反応を認め，左側腰部後腹膜にCT，MRI検査で嚢胞性成分を伴う腫瘤として描出された．これらの結果，後腹膜の炎症性腫瘤と診断し，後腹膜アプローチでの鏡視下腫瘍摘出術を施行した．腫瘍は45×50×50mmで，病理組織学的に神経鞘腫と診断した．また，断端には既存の神経節細胞を認め，腫瘍は交感神経幹と連続していた．われわれはきわめて稀な腹部交感神経由来の後腹膜神経鞘腫の1例を経験した．後腹膜アプローチでの鏡視下手術は腸管損傷の危険性も少なく安全に行えるので，後腹膜神経鞘腫に対し有用と考えられる．

To determine the prognostic factors for patients with pathological T1 (pT1) carcinoma of the ampulla of Vater, 36 consecutive patients with carcinoma of the ampulla of Vater who underwent surgery were retrospectively analyzed in terms of clinicopathological features. The overall 5-year Kaplan-Meier survival in all patients was 50.2%, and the median survival of all patients was 64.0 months. Factors favorably influencing a long-term outcome were the absence of lymph node metastasis (P < 0.0001), the absence of ulcer formation of the tumor (P = 0.0062), and the absence of tumor invasion into the duodenum (P = 0.0025) and the pancreas (P = 0.0098). In a multivariate analysis, lymph node metastasis was the only predictor of survival (P = 0.0023). In the pT1 stage patients, 20% of the patients had lymph node metastasis, and their survival was statistically poor compared to the pT1 patients without lymph node metastasis (P = 0.017). As for survival after the operation, there was no significant difference between pancreatoduodenectomy and pylorus-preserving pancreatoduodenectomy.

BACKGROUND/AIMS:In order to predict liver failure which can lead to death after hepatectomy, a sensitive and specific indicator is needed for liver function. Transcystic duct tube (C-tube) drainage after hepatectomy is thought to be useful in decreasing postoperative complications.METHODOLOGY:Conventional serum liver function tests, and total bile acid (TBA) and total bilirubin (T.Bil) concentration levels of bile from a C-tube in 11 hepatectomized patients who underwent C-tube drainage were compared on postoperative day 2 (Day 2) and postoperative day 7 (Day 7).RESULTS:When serum liver function tests were improving between Day 2 and Day 7, the TBA concentration in bile was increasing in contrast to a decreasing T.Bil concentration. On Day 7, TBA concentrations in the bile in patients without liver cirrhosis or with low ICGR15 values were higher than those in patients with liver cirrhosis or with high ICGR15 values, whereas there were no significant differences between T.Bil bile concentrations in the two groups on Day 7, that is, the measurement of TBA bile concentration might be a faster and more accurate parameter for liver function than that of T.Bil bile concentration.CONCLUSIONS:TBA bile concentration obtained from C-tubes was a useful liver function indicator after hepatectomy.

Thymidine phosphorylase (TP) is considered to be a key enzyme affecting the prognosis of patients with advanced gastrointestinal cancer. We tried to demonstrate the correlation of TP expression in tumor tissue and adjacent normal tissue, that is, primary normal tissue. The present study was designed to quantify TP level by enzyme-linked immunosorbent assay (ELISA) in tumor tissue and adjacent normal tissue obtained from 42 hepato-gastrointestinal cancer patients including 15 with gastric, 19 with colorectal and 8 with hepatocellular carcinomas. TP levels in tumor tissues were higher than those in adjacent normal tissues (p<0.001). There was a significant correlation between the expression of TP in tumor tissue and adjacent normal tissue (R=0.711, p<0.001; y=23.420+1.534x). On the other hand, there was no significant correlation between the ratio of tumor to adjacent normal tissue levels of TP (TP T/N) and expression of TP in tumor tissue (R=0.250, p=0.110). Thus, TP expression in tumor tissue may be high in proportion to TP expression in primary tissue. Furthermore, in clinical care, not only TP level in tumor tissue but also TP T/N value should be considered when using anticancer agents that become effective after conversion by TP to the active drug 5-FU.

Thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) are considered to be key enzymes affecting the prognosis for patients with advanced gastrointestinal cancer. Preoperative examination of TP and DPD expression levels and assessment of these enzymes in inoperable cancer patients may contribute to successful treatment. We tried to prove the correlation of TP and DPD expression in preoperative specimens by endoscopy and in surgical specimens. The present study was designed to quantify TP and DPD levels by enzyme-linked immunosorbent assay (ELISA) in tumor tissue obtained from 30 gastrointestinal cancer patients by preoperative endoscopy and surgery, including 15 gastric and 15 colorectal cancers. Successful cases as those in which cancer cells were demonstrated histologically in preoperative specimens by endoscopy were 12 (success rate: 80%) in gastric cancer patients, and 15 (success rate: 100%) in colorectal cancer patients. In successful cases, there were almost significant correlations in all cases, gastric cancer, and colorectal cancer among the expression of TP, DPD, and TP/DPD ratio in each preoperative specimen by endoscopy and surgical specimen, respectively. On the other hand, in the gastric cancer group, 3 unsuccessful cases resulted in a significant departure from ideal equation compared with 12 successful cases. In actual clinical care, physicians should pay attention to and evaluate carefully the data from endoscopical biopsy specimens in which cancer cells may not be demonstrated histologically. Thus, endoscopic analysis of TP and DPD expression in preoperative or inoperable cancer patients may contribute to successful treatment.

Traumatic neuroma of the bile duct is not a true neoplasm, but a reactive proliferation of pericholangial nerve tissue induced by injury. A 60-year-old Japanese man was admitted to investigate obstructive jaundice. He had undergone cholecystectomy and common bile duct exploration 17 years previously. Ultrasonography and computed tomography showed a pneumobilia with dilatation of the intrahepatic biliary ducts. Endoscopic retrograde cholangiography and spiral-computed tomography cholangiography revealed biliary stenosis in the hepatic hilus with dilatation of the intrahepatic biliary ducts. Celiac angiography and arterial portography showed neither tumor stains nor signs of vessel invasion. At surgery, the confluent portion of the intrahepatic biliary ducts in the hepatic hilus was hardly palpable and deformed, but frozen-section microscopic examination confirmed that no malignant cells were present. Anastomosis of the right and left extrahepatic bile duct to the jejunum, reconstructed by Roux-en-Y hepaticojejunostomy, was performed. Histological examination revealed a nodule composed of a haphazard proliferation of nerve fascicles in the fibromuscular layer of the bile duct which were positively stained for S-100 protein. The pathological diagnosis was traumatic neuroma of the bile duct. Thus, the possibility of traumatic neuroma should be considered in the differential diagnosis of patients with late-onset jaundice after biliary tract surgery.

Thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) are considered to be key enzymes affecting the prognosis for patients with various cancers. We tried to prove the correlation of TP and DPD expression in hepatocellular carcinoma (HCC) and liver metastasis. We quantified TP and DPD levels by an enzyme-linked immunosorbent assay (ELISA) in the tumor (T) and adjacent normal tissue (N) obtained from 8 HCC patients, and 11 liver metastasis patients together with 9 of their primary cancers. TP levels were higher in the primary cancer, liver metastasis, and HCC compared with each adjacent tissue. TP levels were higher in HCC than in liver metastasis, and TP levels in the adjacent tissues of HCC were also higher than those in adjacent tissues of liver metastasis. TP levels were higher in liver metastasis than in primary cancer, and TP levels in adjacent tissues of liver metastasis were also higher than those in adjacent tissues of primary cancer. However, there were no differences in TP T/N ratio between HCC and liver metastasis, and between primary cancer and liver metastasis. DPD levels were lower in the liver metastasis compared with the adjacent liver tissues, and DPD levels in liver metastasis or its adjacent liver tissues were higher than those in primary cancer or its adjacent tissues. There were no differences in DPD T/N ratio between HCC and liver metastasis, and between primary cancer and liver metastasis. Thus, we demonstrated that TP was highly expressed in liver malignancy. We may be able to increase the success of anticancer chemotherapy for liver malignancy while decreasing the side effects by analysis of T/N ratios in TP, DPD, and TP/DPD in addition to TP expression.

An extrahepatic portosystemic shunt that has neither liver cirrhosis nor portal hypertension is rare. A 60-year-old Japanese woman who had been suffering chronic liver disease and anemia with mild disorientation was admitted to investigate general fatigue with dizziness and disorientation. The laboratory data revealed mild pancytopenia and liver dysfunction including hyperammoniemia, an increased Indocyanine Green 15-min retention rate, and a decreased Fischer's ratio. Color Doppler ultrasonography, computed tomography, and arterial portography revealed an extrahepatic portosystemic shunt that extended tortuously from the superior mesenteric vein into the inferior vena cava, and decreased blood flow in the main portal vein. Judging from intraoperative measurement of portal pressure and intraoperative portography, shunt ligations were performed at both the efferent portion of shunt from the superior mesenteric vein and the afferent portion of the shunt into the inferior vena cava, and resection of the spleen was also performed. On the postoperative laboratory data, pancytopenia disappeared, and liver function improved. Postoperative abdominal imaging showed increased blood flow in the main portal vein and disappearance of the shunt vessel. Moreover, symptoms present before surgery also disappeared. In conclusion, surgical treatment of extrahepatic portosystemic shunts may result in better postoperative quality of life if it is performed in carefully selected patients.