経皮経食道胃管挿入術 (percutaneous transesophageal gastrotubing : PTEG) 施行後のトラブルとしてチューブ事故抜去の頻度は高く、再挿入に難渋する場合がある。PTEGチューブ事故抜去後の再挿入時に、チューブを右胸腔内へ誤挿入した1例を経験した。症例は89歳、男性。当院でPTEGを造設後、療養型施設へ転院し栄養管理されていた。夜間にPTEGチューブが事故抜去されたため、再挿入したところ、翌日のCTにてチューブの右胸腔内への誤挿入、縦隔気腫、右気胸が確認された。誤挿入されたチューブの抜去と胸腔ドレナージによって改善を認めた。PTEGチューブ交換時に胸腔内へ誤挿入した報告例は認められず、稀な合併症の一つとして報告した。

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A 59-years-old man was referred to our hospital for treatment of gastric cancer. Esophagogastroduodenoscopy revealed that the lesion was depressed, 10 mm in diameter, and was located at the anterior wall of the lower gastric body. Signet-ring cell carcinoma was diagnosed using endoscopic biopsy. The lesion was diagnosed as the expanded indication lesion of endoscopic submucosal dissection (ESD) , and ESD was performed. The cancer invaded the submucosa to a depth of 1800 µm and vertical margins were negative ; however, the cancer cells were in close proximity to the vertical margins. The lesion was diagnosed as a non-curative resection. Additional gastrectomy was performed. The gastrectomy specimen revealed that residual cancer cells had invaded the muscularis propria. Since it was possible that the invasive cancer persisted in the deeper tissues of the submucosa, additional gastrectomy was suggested.

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We performed laparoscopic lower anterior resection using D3 lymph node dissection on a male patient in his 60s with rectal cancer. On the 25th day after surgery, abdominal distension occurred, and the abdominal CT revealed massive ascites. We speculated chylous ascites ; therefore, we changed his diet to a fat-restricted diet ; however the patient showed no improvement and his condition worsened. After performing CART, ascites markedly improved and the patient was discharged.
We conclude that CART is a useful and effective choice of treatment for postoperative refractory ascites.

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A 67-year-old woman was admitted to our hospital with constipation. Colonoscopy revealed a rectal tumor measuring 10 mm in diameter. Endoscopic mucosal resection of the lesion was performed. Histological examination revealed the diagnosis of rectal cancer invading the submucosa. Therefore, laparoscopic low anterior resection was performed. After the anastomosis, intraoperative endoscopy revealed leaking air bubbles from the site of the anastomosis, and we therefore clipped the anastomotic site with a metallic clip. After the surgery, the patient was discharged without any complications.

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PTEG用非破裂バルーン（RFB）の穿刺部を塞ぎ再穿刺を可能とする最適な素材について基礎的研究を行った。RFBの穿刺部にフィルムドレッシング、ハイドロコロイドドレッシング、セロハンテープをそれぞれ貼付し、RFBに造影剤希釈溶液10mlを注入し、溶液の漏出の有無を検証した。フィルムドレッシング、ハイドロコロイドドレッシングでは溶液が漏出したが、セロハンテープでは溶液の漏出は見られなかった。一度穿刺したRFBの穿刺部をセロハンテープで塞ぐことにより、RFBは虚脱せず再穿刺が可能であった。

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A 91-year-old woman was admitted for rehabilitation after undergoing right total knee arthroplasty. Her oral intake was poor after hospitalization, and she experienced vomiting on the 13^th day of the disease. Abdominal computed tomography showed mesenteroaxial gastric volvulus with a giant esophageal hiatal hernia, and she underwent endoscopic repair under X-ray fluoroscopic guidance. However, her oral intake did not improve following treatment secondary to gastric volvulus recurrence. She refused surgical intervention owing to her advanced age, and we performed percutaneous endoscopic gastropexy using a Funada-style loop gastropexy device. Her postoperative course was uneventful, and oral intake was gradually resumed without recurrence of gastric volvulus. Percutaneous endoscopic gastropexy may be a useful, less invasive treatment option in patients with gastric volvulus who are at high risk for surgery.

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Usually, we conduct total coloproctectomy for familial adenomatous polyposis (FAP) . However, a problem regarding quality of life (QOL) of patients includes high stool frequency. Also, total coloproctectomy is relatively highly invasive surgery. We performed laparoscopic subtotal colectomy with ileo-sigmoid anastomosis following postoperative intensive endoscopic polypectomy for minimally invasive treatment of FAP.
Case 1 ; A 39-year-old man. His stool frequency was about 4-5 times a day postoperatively. Colonoscopy was undergone every 3-6 months.
Case 2 ; A 35-year-old man with sigmoid colon cancer and FAP. His stool frequency was about 3 times a day postoperatively. No recurrence of cancer in 4 years follow up was observed.
Conclusion : Our procedures deliver high QOL for patients, and is relatively simple for surgeons and endoscopists to perform.

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　虫垂孔からの噴出性出血に対し止血クリップが有効であった症例を報告する。症例は50歳代女性。ビールを飲んだ後の突然の血便にて来院，緊急大腸内視鏡検査で虫垂孔からの活動性・噴出性の出血を認めた。虫垂開口部を金属性止血クリップ7個で閉鎖したところ止血された。止血後新たなる出血は認めず，止血後5日間にて退院。その後再出血予防のために2カ月後に虫垂切除術が施行された。検体では虫垂内に二カ所の出血点を認めた。

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Small bowel inflammatory fibroid polyp (IFP) is an idiopathic inflammatory polyp, which usually presents as intussusception and ileus requiring emergency laparotomy. In this study, we report a case of IFP associated with intussusception treated by single port laparoscopy. A woman in her 70’s was referred to our hospital due to ileus. Abdominal CT demonstrated a tumor at the terminal ileum. Initially an ileus tube was inserted to enable decompression. Colonoscopy of the ileum then identified the tumor at the distal end of the intussusception. Duly we elected to perform surgical intervention. In the first stage of surgery, a 3 cm umbilical incision was made and the abdomen insufflated. Using single port laparoscopy the site of intussusception was confirmed, and it was extracorporeally reduced by Hutchinson’s maneuver combined with partial small bowel resection. The patient’s prognosis was favorable and she was discharged on the fifth day postoperatively. Pathologically, the tumor was diagnosed as IFP based on the presence of granulation tissue by inflammatory cell infiltration and fibroblast growth. As the small intestine is not fixed usually, single port laparoscopy is considered to be both appropriate and achievable. Even in cases of ileus, use of laparoscopy is possible after the intestine is fully decompressed.

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　SILS^TM（Single lncision Laparoscopic Surgery）とは単孔式腹腔鏡下手術のことである。スコープや鉗子などを1カ所の創から挿入して行う腹腔鏡下手術であり整容上優れている。今回われわれはSILS^TMにて盲腸切除術を施行したので報告する。
　症例は40歳代女性，虫垂炎術後に病理検査にて虫垂カルチノイドと診断され，断端陽性が疑われたため追加切除目的にSILS^TMにて盲腸切除術を施行した。手術時間90分，出血量20mlであった。術後合併症もなく第5病日に退院となった。

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　症例は60歳代男性，下行結腸癌に対し腹腔鏡下左半結腸切除術を施行，術後11日目に間欠的腹痛，腹部膨満を訴え，大腸内視鏡検査を行いスコープが通過困難な吻合部狭窄を認めた。大腸内視鏡下にバルーン拡張を行うもイレウス解除せず，狭窄部に金属ステントの挿入を行い，良好な拡張が得られた。大腸金属ステントは基本的には悪性疾患のみに適応となるが，バルーン拡張が困難な良性狭窄に対しても有効な症例があると考えられた。

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　症例は60歳代女性，下部直腸に表面平滑な5cm大の粘膜下腫瘍を認め，当院紹介受診となった。腹部CTにて直腸右側に内腔を圧排する5cm大の嚢胞性腫瘍を認めた。右卵巣にも2cm大の充実性腫瘍を認め，卵巣腫瘍と直腸粘膜下腫瘍に対し開腹手術を行った。病理組織診断は卵巣癌と転移性直腸癌であった。腹膜反転部以下の下部直腸への転移，また粘膜下腫瘍の形態を呈する直腸転移は非常に稀である。

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