花井 恒一

Systemic and local immunological responses were studied in patients with or without preoperative administration of chemotherapeutic and/or immunotherapeutic drugs for colorectal cancer. The plasma TGFbeta and other cytokines such as IL-2, IL-4, IL-6, IL-10, IL-12, IFN-gamma in the supernatant fluid of culture of peripheral blood mononuclear cell (PBMC) and regional lymph node were measured by the ELISA method. A systemic response of cytokines was as follows: the production of plasma TGFbeta increased in many cases by chemotherapeutic drugs with a significant elevation of the mean production. Productions of IFN-gamma, IL-2, IL-12 in the supernatant fluid of culture of PBMC increased in many cases by immunotherapeutic drugs, and that of IL-4, IL-6 increased in many cases by chemotherapeutic drugs. A local response of cytokines was as follows: the production of IL-2 by immunotherapeutic drugs was greater than that without immunotherapeutic drugs whereas the production of IL-10 by immunotherapeutic drugs was smaller than that without immunotherapeutic drugs.

PURPOSE: Rectal stump washout has been recommended to prevent implantation of exfoliated malignant cells in the anastomosis after anterior resection for rectal cancer. The aim of this study was to investigate its efficacy, particularly the extent to which the volume of irrigation fluid might influence the efficacy of tumor cell elimination and whether tumor characteristics might influence the result. METHODS: The study comprised 30 consecutive patients operated on by anterior resection for rectal cancer. After cross-clamping the rectum below the tumor, a washout sample was collected for examination after every incremental 500 ml of saline irrigation up to 2 liters. The presence of shed cancer cells was correlated with the washout volume and tumor characteristics. RESULTS: Cancer cells were found in 29 of 30 patients (97 percent) in the first sample of irrigation fluid and decreased gradually in frequency and number with increasing irrigation volumes. No cancer cells were demonstrated after 1.5 liters of irrigation in patients with tumor below the peritoneal reflection, whereas cancer cells were still present in one-fourth of the patients with tumor located above the peritoneal reflection. Finally, only a small number of cancer cells was confirmed in one patient after 2 liters of irrigation. CONCLUSIONS: The irrigation volume determined the efficacy of rectal washout. With our method, 1 1/2 liters of saline irrigation appears to clear contents from cancer cells in patients with tumors below the peritoneal reflection whereas at least 2 liters is recommended for patients with tumor above the peritoneal reflection.

58歳女.直腸肛門視診にて直腸前壁に硬い腫瘤を触知し,注腸造影検査及び大腸内視鏡検査にて同部位にtype 2の腫瘍を認めた.大腸内視鏡下生検にて中分化腺癌と診断された.術前に,multi-slice CT(MSCT)を施行したところ左側方にリンパ節腫大を認め,転移が示唆され,また,radioisotope法を施行したところinjection pointのみのradioactivityを認め,周囲リンパ節へのRI集積は認めなかった.直腸Ra領域の直腸癌と診断し,手術を施行した.摘出標本により採取したリンパ節は合計67個であり,全てのリンパ節にHE染色を施行して病理組織学的検鏡を行った.転移陽性リンパ節数は12個で,いずれも好中球の浸潤を伴う高分化型腺癌であった.術前にMSCTによる転移陽性と診断した下腸間膜幹リンパ節には,病理組織学的転移が認められた.術中にSNと判定したセンチネルリンパ節には病理組織的転移を認めなかった

BACKGROUND/AIMS: When an Appleby operation is performed for pancreatic body and tail carcinoma, it is necessary for prevention of hepatic ischemia to estimate accurately the hepatic circulation after resection of the celiac artery, the common hepatic artery and the portal vein. We studied the hepatic circulation by monitoring the ShvO2 (hepatic venous hemoglobin oxygen saturation) during an Appleby operation. METHODOLOGY: We performed an Appleby operation on 8 patients with pancreatic cancer. In 6 of 8 patients, a 7-Fr fiberoptic flow direct catheter was inserted in the right hepatic vein. The ShvO2 values were monitored continuously during surgery. RESULTS: The ShvO2 value was 76 +/- 3.5% just after laparotomy, and reduced to 61 +/- 13.2% after clamping the common hepatic artery. The values of the ShvO2 returned to 70.8 +/- 10.9% one hour after clamping. But, one patient underwent reconstruction of the common hepatic artery, because the ShvO2 value still stood at 50%. Combined resection of the portal vein was performed in 5 out of 8 patients. Two patients underwent resection of the portal vein without reconstruction due to the development of the collateral vein, one patients; resection of the portal vein with reconstruction, and two patients; wedge resection. In all 5 patients, the ShvO2 was stable during resection of the portal vein. CONCLUSIONS: Monitoring the ShvO2 is a useful method to evaluate at real time the hepatic circulation during the Appleby operation, and to decide if reconstruction of the common hepatic artery or the portal vein is needed or not.

症例は70歳,女性.食道透視により特発性食道破裂の診断,発症7時間後に緊急手術を施行した.横隔膜直上の食道の左側前壁側に破裂部を認め,同部を一期的に2層縫合し2本の胸腔ドレナージを施行した.術後,縫合不全,膿胸を認め持続洗浄,低圧持続吸引を行い膿瘍は瘻孔化し,縮小傾向を認めたが瘻孔気管支瘻も存在したため,消化液に加え唾液等の汚染のため治療に難渋した.この難治性瘻孔に対し内視鏡を用いて瘻孔内を観察後,2本のバルーンを用いて瘻孔内の汚染を予防しフィブリン糊製剤を瘻孔内に充満したところ,充満後比較的短期間で瘻孔閉鎖に成功した.