林 秀樹

症例は73歳,女性。黒色便,腹部膨満感を主訴とした進行胃癌の診断で当院に紹介となった。精査の結果,幽門狭窄,多発リンパ節転移を伴う進行胃癌,cT4aN3M0,cStage IIIの診断となり,審査腹腔鏡,胃空腸バイパス術後の術前化学療法の方針とした。審査腹腔鏡ではsT4aN3M0P0CY0と診断した。胃空腸バイパス施行後,DS療法を2コース施行した。新規肝転移病変を認め,second-lineとしてXELOX療法を選択したが肝門部リンパ節腫大を認めた。MSI検査に提出しMSI-Highを確認した。third-lineとしてnivolumabを選択した。15コース後に新規肝転移巣が出現しfourth-lineとしてramucirumab(Ram)+nab-PTX療法を3コース施行するも骨髄抑制あり,その後はRam単剤とした。初回治療から2年4ヵ月でCRの判定となった。その後は薬剤性肝障害が出現しRamを中止した。その後1年間(初回治療から3年4ヵ月)抗癌剤投与なしでCRを維持している。本症例は胃癌MSI-High症例における分子生物学的背景に基づいた治療戦略を検討する上で示唆に富む症例であると考えられた。(著者抄録)

A 69-year-old man was referred for vomiting. CT and upper gastrointestinal endoscopy revealed a circumferential stenotic lesion in the third portion of the duodenum, and partial duodenectomy and lymph node dissection were performed for the diagnosis of duodenal adenocarcinoma. The histopathological diagnosis was pT3, pN0, pStage ⅡA(UICC 8th)well differentiated tubular adenocarcinoma. The patient was treated with FOLFOX as adjuvant chemotherapy and is alive 2 years and 4 months postoperatively without recurrence. Primary duodenal adenocarcinoma in the third portion is rare, and further case experience is required for selection of the operation and adjuvant therapy.

Soluble programmed death-ligand 1 (sPD-L1) levels can be used as a biomarker for gastric cancer (GC). However, comprehensive information regarding the sPD-L1 expression profiles and their association with cachexia in GC is lacking. Therefore, the present study evaluated the association between clinicopathological findings and sPD-L1 levels in patients with GC. Serum samples were collected from patients with GC during their first visit to Department of Esophageal-Gastro-Intestinal Surgery, Chiba University Hospital, Chiba, Japan (January 2012-December 2017; n=173), and sPD-L1 levels were measured using an enzyme-linked immunosorbent assay. Survival rates among 116 patients, excluding cases with preoperative chemotherapy or no radical procedures, were analyzed. sPD-L1 levels were associated with factors such as neutrophil-to-lymphocyte ratio, hemoglobin (Hb) and albumin (Alb) levels, total cholesterol and C-reactive protein (CRP) levels, and related to inflammation and nutrition in patients. Notably, the higher the number of applicable indicators related to cachexia (Hb <12 g/dl, Alb <3.2 g/dl, CRP >0.5 mg/dl and low body mass index) was, the higher the sPD-L1 value was. However, the pathological stage did not significantly differ between the groups. Clinicopathologically, there was no association with tumor depth, lymph node metastasis or vascular invasion; however, patients with the intestinal type had significantly higher sPD-L1 levels than patients with the diffuse type (P=0.032; Wilcoxon test). The overall survival did not significantly differ between the groups with low and high sPD-L1 levels; however, among patients who received radical treatment, the relapse-free survival was significantly worse in the high-sPD-L1-level group than in the low-sPD-L1-level group (P=0.025; log-rank test). Multivariate Cox regression analysis revealed that a high sPD-L1 concentration was a sign of poor prognosis, independent of pathological stage and cancer antigen CA19-9 (P=0.0029). Therefore, the present findings suggest that sPD-L1 can reflect cachexia status in patients with GC and may serve as a prognostic marker for relapse-free survival after radical GC surgery.

PURPOSE: In actual surgical research, case-matched studies are frequently conducted as an alternative to randomized controlled trials (RCTs). However, it is still unclear what differences there are between RCTs and case-matched studies in upper gastrointestinal surgery, and clarifying them is a very important clinical issue. Thus, the purpose of this study was to investigate estimated treatment effects between RCTs, case-matched studies, and cohort studies regarding laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC). METHODS: We searched the PubMed, Cochrane Central Register of Controlled Trials, and Web of Science databases for studies that compared LDG versus open distal gastrectomy for AGC published from the inception of the databases until July 2021. A meta-analysis was performed using the Review Manager version 5.3 software program from the Cochrane Collaboration, and six short-term outcomes and three long-term outcomes were assessed. RESULTS: Twenty-three studies with 13698 patients were included. There was no difference in estimated treatment effects between RCTs and case-matched studies for all outcomes except for the number of retrieved lymph nodes and postoperative complications. In terms of intraoperative blood loss, postoperative hospital stay, number of retrieved lymph nodes, and recurrence, observational studies tended to overestimate the treatment effects. CONCLUSION: The estimated treatment effects of LDG for AGC in the case-matched study were almost the same as in the RCTs. However, to assess the true magnitude of the treatment effect, the design and actual implementation of the analysis must be critically evaluated.

症例は77歳男性。1mのはしごより階段へ転落し左半身を強打,左胸痛が出現し救急搬送された。当院救急科で外傷性左血気胸,左肋骨骨折の診断で緊急入院,左胸腔ドレーンが挿入された。受傷後5日目の胸部X線で左肺透過性低下を認め,CTで左胸腔内に脂肪組織が脱出し,肺が圧排されていた。外傷性横隔膜ヘルニアの診断で同日腹腔鏡下手術を行った。腹腔内を観察すると,他臓器損傷を認めず,横隔膜損傷部位を経由し大網が胸腔内に脱出していた。癒着剥離を行い大網を腹腔内に還納した。ヘルニア門は40×40mmであり,非吸収糸でヘルニア門を水平マットレスで縫合閉鎖した。術後5日目のCTでヘルニアの再発所見なく,経過は良好であった。外傷性横隔膜ヘルニアに対するアプローチには経胸,経腹があり,腹腔鏡は経腹に含まれる。開腹における報告が散見されるなか,修復法とポート配置を意識して腹腔鏡下手術を行ったため,報告する。(著者抄録)

症例は46歳女性。2010年の検診で胃前庭部後壁に10mm大の粘膜下腫瘍を指摘されていた。2018年の上部消化管内視鏡検査で,同腫瘍は20mm大と増大傾向を認めたため当院紹介となった。造影CTでは動脈相で濃染し,門脈相で造影効果が遅延する血流豊富な内腔に突出する腫瘍を認めた。超音波内視鏡内視鏡では,固有筋層を主座とする境界明瞭,内部エコーは比較的均一な高エコー腫瘤を認め,穿刺吸引細胞診を施行し,胃glomus腫瘍の診断となった。腫瘍が幽門輪に比較的近いため,幽門輪を損傷しないように腹腔鏡・内視鏡合同胃局所切除術(LECS)を行った。切除標本の病理組織学的検査では核異型や核分裂像は乏しく,良性グロームス腫瘍の診断となった。術後経過は良好で術後7日目に退院し,術後8ヵ月経過したが再発・転移の徴候は認めていない。(著者抄録)