The effects of several different general anesthetics on routine liver function tests were evaluated in patients with abnormal liver function. A total of 128 cases of general anesthesia were divided into six groups, i, e., control, modified NLA, original NLA, GOE, Ketamin micro mini-drip method, and a group receiving blood transfusions.
A total of thirteen parameters including GOT, GPT, γ-GPT, LDH, ALP, LAP, ChE, TTT, ZTT, total cholesterol, cholesterol-ester ratio and T. P, were evaluated before, during, immediately after, 24 hours after and one week after surgery.
The adverse effects on liver function by various types of anesthesia can be summarized as follows: Ketamin micro mini-drip>original NLA>modified NLA>GOE where Ketamin micro mini-drip had the most adverse effect and GOE the least.

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Thirty patients with hepatocellular carcinoma (HCC) were treated with transcatheter arterial embolization therapy (TAE) and its therapeutic effects were evaluated mainly by follow-up angiography.
The tumorous shadows disappeared or the size of the tumors reduced in 24 of 30 cases (80%) on follow-up angiograms. In 5 cases the disappearance of the tumor stain was obtained and continued for more than 1 year. In 4 of these 5 cases, the tumors disappeared with the first TAE. In 3 cases, the tumor was solitary with the size of less than 3cm and located at peripheral parts of posterior, inferior subsegments of the liver.
These findings suggest that the effect of TAE depends on the number, the size and the location of the tumor in the liver. Patients with HCC having these conditions are considered to be good candidates for TAE.

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During the past 5 years from 1980 to 1985, abdominal angiography was performed in 221 cases of suspected hepatocellular carcinoma (HCC), and 139 cases (63%) were diagnosed as HCC. Seventy-three cases out of 139 HCC's were treated with transcatheter arterial embolization (TAE) using gelatin sponge and antineoplastic agents (mainly Adriamycin 40-60mg).
In 12 patients, tumor was resected following TAE. Recurrent tumors were treated with TAE after hepatectomy in two patients. For 59 unresectable HCC patients treated only with TAE, cumulative survival rate was 45% for one year, and 21% for two years.
Early deaths within one month after TAE were 6 cases (3 cases of hepatic failure, each one case of acute renal failure, gastroenteric bleeding, and brain stem hemorrhage, respectively) and there were 10 cases of poor prognosis group which died within 1-3 months.
In 12 cases of hepatectomy following TAE, 4 cases died within 6 months closely related to operation following TAE. Extending the indication of hepatectomy with TAE as an adjunctive therapy is difficult in HCC patients with liver cirrhosis.

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Roles of radiation therapy in the treatment of pancreatic cancer were studied by summarizing our 11 year's experiences at the National Medical Center Hospital.
Among 50 patients with unresectable advanced pancreatic cancer seen from Jan. 1975 through Dec. 1985, 29 patients were treated by intraoperative radiation therapy (TORT) and additional 5 patients were treated by external radiation therapy (XRT) alone. Seventeen patients of these 29 patients were treated by both TORT and XRT. The other 16 patients were treated by a combination of bypass operation and chemotherapy (n=6) or bypass operation alone (n =10).
Patients treated by radiation therapy (RT) were divided into three groups, i. e., metastatic, localized and infiltrative group, according to the presence of the metastases to the liver or the peritoneum and also according to the macroscopic growth pattern of the tumor.
Median survival time of 7.2 months of the localized group was significantly longer than those of infiltrating group (2.6 mo.) or metastatic group (3.9 mo.). Median survival time of TORT in combination with XRT was longer than TORT alone, but the difference was not statistically significant. Median survival time of RT was longer than those of bypass operation group with or without adjuvant chemotherapy, but again the differences were not significant. As for favourable effects of radiation therapy on the pancreatic cancer, 20 of 24 patients (83%) were relieved of the abdominal or back pains, and the reduction of the tumor size was observed in 15 of 29 patients (52%) after radiation therapy.
According to post-mortem examinations, however, 7 of 34 patients of RT (20.1%) developed bleeding from erosion or ulcer of gastrointestinal tract, whereas only one patient (6.3%) among non-radiation therapy group.
Higher incidence of the former was considered from possible adverse effect of radiation therapy.

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In a total of 110 patients (67 male and 43 female) with pancreatic cancer; the ratios of associated diabetes mellitus, questionable diabetes and non-diabetic cases were 21.8, 29.1 and 49.1%, respectively on admission, and 37.3, 29.1 and 33.6%, respectively in the later stage. Primary diabetes which definitely preceded pancreatic cancer was thought to be found in 5.5% of the above cases.
Pancreatic diabetes occurred more often in cancer of the head of the pancreas than the body and tail. Furthermore, an elevation of serum and urinary amylase levels, dilatation of the main pancreatic duct, pancreatic atrophy and pancreatic fibrosis were also more often found in cancer of the head of the pancreas than that of the body and tail. These results strongly support the theory that diabetes mellitus following pancreatic cancer comes from associated obstructive pancreatitis rather than from the pancreatic cancer itself.
Incidence of diabetes increased among those who had an operation (pancreatectomy), radiotherapy and intravenous hyperalimentation. Food intake was low and unstable in most cases and insulin therapy was performed in 24.5% of the 110 cases. Diabetic microangiopathies were less but malnutrition was often recognized, in comparison with primary diabetes. From these observations, it is very important to keep blood glucose under excellent control by giving an appropriate dose of insulin matched with sufficient supply of calory.

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We have found that the maeasurement of serum pancreatic isoamylase (P-type amylase) in patients with digestive diseases helps us to diagnose pancreatic diseases. The isoamylase was assayed utilizing electrophoresis. The ratio of serum P-type amylase to serum total amylase was below 20 per cent in 20 of the 247 patients (8.196). These 20 consist of 10 patients with chronic pancreatitis (of these 10, seven patients also had pancreatolithiasis); 5 patients with pancreatic cancer involving 4 intra- and post-operative irradiated cases; one patient with malabsorption syndrome after Billoth II gastrectomy; plus 4 other cases.
Among 47 patients on whom the pancreozymin secretin test (exocrine pancreatic function test) was performed, the low levels of P-type amylase were found in all of 6 cases who showed both amylase output and maximum bicarbonate concentration, in 2 out of 5 cases who showed amylase output or maximum bicarbonate concentration and in none out of 36 cases who showed normal values in the pancreozymin secretin test. Thus, it is suggested that low levels of P-type amylase reflect a decrease of exocrine pancreatic function.
Of the above 20 patients with decreased serum P-type amylase, serum total amylase levels were not decreased in any of the 20 patients, serum elastase 1 levels were decreased in 9 of the 20 (45%), serum carotene levels were abnormally low in 12 out of 15 patients (80%), glucose intolerance was found in 12 of the 20 patients (60%), and insulin was given for the treatment of diabetes in 6 of the 20 patients (30%).

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Twelve patients with carcinoma of the ampulla of Vater were treated from January 1977 to April 1984. The mean age of the patients (5 males and 7 females) were 58.6 years, ranging from 31 to 72 years. Postoperative complications were encountered in 41.7% of the cases, of which 25% were pulmonary complications, and 16% were breakdown of the pancreaticojejunostomy. All of the patients who developed complications were conservatively treated with no operative mortality. Twelve operative procedures resulted in 36.6% five year survivals, which is similar to the data described by Honjo.
Based on the operative findings, 50% of the patients with papillary type of cancer, and 28, 6% of the patients with ulcerating type of cancer were alive after 5 years. Seventy-five percent of the patients in stages I and II, and 14% of the patients in stage III survived at the end of 5 years. Most of the patients showed duodenal invasion of the d₂ stage. Depending on the pancreatic invasion of the cancer, 100% of the patients with panc₀, 25% of the patients with panc₁, and 20% of the patients with panc₂ were alive for more than 5 years.
All of the patients without lymphnode metastasis were alive for 5 years, only 12.50 of the patients with lymphnode metastasis were alive for 5 years. The patients with panc₀ did not have lymphnode metastasis. Seventy-five percent of the patients with panci, and 83% of the patients with panc₂ had lymphnode metastasis.
It is reasonable to conclude that there is a strong relationship between prognosis of patients with carcinoma of the ampulla of Vater and operative histopathological invasion of the pancreas and lymphnodes.

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Chemotherapy of pancreatic carcinoma has not been established. In this paper, we reported two cases of pancreatic carcinoma who responded well to UFT or UFT-Mitomycin C combination (UFTM). UFT and UFTM chemotherapy have already been favorably applied to the treatment of advanced gastric cancer on the basis of therapeutic effect of UFT which has been confirmed by the pharmacokinetic study. Since UFT alone has minor side effects, it can be applied clinically for a longer period of time.
Further trials are needed to confirm the utility of UFT or UFTM therapy for the treatment of pancreatic carcinoma.

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For 37 days we collected pancreatic juice from an artificial external pancreatic fistula made in a 71-year-old man who had undergone pancreatoduodenectomy (the pancreatic function diagnostic test showed 59.20). Pancreatic juice was collected every 2 hours during the day (6 to 18 o'clock) and every 4 hours during the night (18 to 6 o'clock). In addition to the volume of pancreatic juice, the concentration of bicarbonate and the output of protein, amylase and lipase in the juice were also determined. The mean volumes(M± SE, n=7) were as follows: (1) without food: 57.3±1.92ml during the day and 33.0±1.10ml during the night (p<0.001); (2) with food: 93.8±5.32ml during the day and 42.9±4.16ml during the night (p<0.001). P-values between (1) and (2) were less than 0.001 during the day and less than 0.05 during the night. Peak values of the pancreatic flow rate were observed from 12 to 14 o'clock without food and from 6 to 10 o'clock with food. The pancreatic enzyme and protein secretion showed the same changes as the volume mentioned above; the bicarbonate concentration, however, did not show any significant changes.
In conclusion we found circadian rhythms in human exocrine pancreatic secretion.

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Although functioning islet cell tumors are well recognized for the characteristic clinical symptoms associated with hypersecretion of various hormones, non-functioning islet cell tumors have no obvious signs or symptoms and be found in the later course of the disease. In many cases it is difficult to diagnose preoperatively.
A 46-year-old female was admitted for evaluation of obstructive jaundice. There was no characteristic episode in her past history and family histories. CT and ultrasonography revealed a 5×5cm solid mass in the region of the head of the pancreas. Celiac angiography demonstrated hypervascularity, tumor staining and dislocation of the vessels in the same region. The level of Insulin, Glucagon, Gastrin, ACTH, Serotonin, Somatostatin and Calcitonin in the blood were examined and all of them were within the normal values.
Non-functioning islet cell tumor was considered and the operation was performed. A tumor was found in the region of the head of the pancreas sized 10×7×3.5cm. Liver metastasis and dissemination were not observed. A frozen section of the infra-pancreatic lymph-node revealed metastasis of the islet cell carcinoma, and pancreaticoduodenectomy (modified IMANAGA reconstruction) was carried out. Pathological diagnosis was islet cell carcinoma with a lymph-node metastasis (infra-pancreatic only). Immunohistochemical examination and measurement of every peptic hormones of the tumor were performed, but no siginif icant hyperproduction was observed. The patient remains well with no evidence of reccurrences 30 months after the operation.

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Injury to the inferior vena cava as a result of blunt trauma of the abdomen is one of the most intractable lesions. The mortality from this injury is reported to be as high as 80 to 90%. Injury to the retrohepatic inferior vena cava results in a more higher mortality. Only a few cases of survival from this injury have been reported in Japan. This report is a rare case of survival from the injury of the retrohepatic inferior vena cava accompanied by severe liver rupture.
A four-year-old girl was involved in a traffic accident and her abdomen was injured. She was admitted to our hospital in a state of shock about 1 hour after the injury. Severe anemia was present on admission, so that her blood pressure was hardly measurable. However, shock-alleviating therapy (such as blood transfusoon) could improve her general condition. A CT-scan on the abdomen revealed liver rupture resulting in intraperitoneal hemorrhage. The patient immediately underwent an operation. Pathological findings were crush and rupture in a wide range of the right hepatic lobe along the right hepatic vein and injury at 3 sites (5 to 10mm each) of the retrohepatic inferior vena cava. Since transient hemostasis in the inferior vena cava could be successfully achieved by the use of exclusion clamps, the right hepatic lobe was excised. After that, the inferior vena cava was completely blocked at the suprarenal and infrahepatic sites. The operation was finished with suture of the injury of the inferior vena cava. The patient recovered from the injury and discharged from the hospital on the 31st postoperative day.
Success in this treatment was attained under the following favorable conditions: (1) The patient was admitted to the hospital shortly after the injury. (2) The patient could transiently recover from shock after blood transfusion and other appropriate treatments. (3) The inferior vena cava could be easily reached with no need to excise and mobilize the liver due to severe liver rupture. (4) Transient hemostasis in the inferior vena cava was possible with the use of exclusion clamps. (5) No injury was present in any other organs except the liver. (6) The operation was easily performed because the patient was a child.

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There have been no case reports in which liver resection was performed for pyogenic liver abscess.
We performed right hepatectomy for liver abscess in a 79-year-old patient.
The reason why we performed right hepatectomy for this case in spite of diagnosing as the liver abscess, was that we could not exclude completely the possibility of liver cancer considering the consolidated tumor image on liver echogram and progressively increasing anemia.
The pattern of pyogenic liver abscess has been changing recently as follows: (1) the older age cases are increasing, (2) liver abscesses originating from the portal system are decreasing, (3) liver abscesses accompanying the obstructive disease of the biliary tract are increasing, (4) liver abscesses in which the causative bacteria are antibiotics resistant gram-negative organisms are increasing.
Considering these changes in disease patterns and the safety of hepatectomy, it is suggested that hepatectomy will be performed more frequently for the pyogenic liver abscess from now on.

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We succeeded in radical resection of hepatic hilar cancer by using the method of a sagittal incision on the medial segment of the left lobe of the liver, which allowed us to leave his whole liver intact. This patient was 78 years old suffering from emphysema.
This surgical method has the following three advantages.
1. Feasibility of having wider operative area and of easy anastomosis without encroaching on liver resection can be accomplished.
2. Judgement as to the extent of tumor invasion, the necessity of lobectomy, and, most importantly, the radicality of the tumor resection can be easily done.
3. And, additionally, this sagittal incision is relatively easy and is accompanied by less bleeding using an ultrasonically-guided method.
Now, we intend to adopt this surgical method for hepatic hilar cancer with no caudate lobe invasion.

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Gallstone attacks accompanied by severe liver dysfunction with an elevation of serum transaminase levels above 400 IU/l were studied in this paper. Of patients with gallstone attacks admitted to our department during the past 4 years, 137 cases without complications of hepatic or cardiac diseases were analyzed. They consisted of 88 patients with cholelithiasis, 24 with choledocholithiasis and 25 with both of these lesions. Severe liver dysfunction was found in 10 (7.3%) of the total 137 cases, namely, 6 cases (6.8%) of cholelithiasis, 1 (4.2%) of choledocholithiasis and 3 (120%) of combined lithiasis. Investigation of the time course of total bilirubin, GOT, GPT, LDH and biliary tract enzymes such as LAP in these 10 cases revealed maximum elevation of GOT, GPT and LDH immediately after attack, which was followed by rapid return to normal approximately 10 days later. Biliary tract enzymes, following the course of bilirubin, frequently showed a delayed elevation to the highest level a few days later than transaminase and delayed return to normal. The ERCP and operative findings in the cholelithiasis group were featured by the presence of multiple small stones below 5mm in diameter in 4 of the 6 cases with severe liver dysfunction. The etiology of liver dysfunction in gallstone attacks has not so far been fully elucidated. We consider that the onset of liver dysfunction in cholelithiasis is triggered by an elevation of the intrabiliary pressure due to the blockage of the Ampulla, which is caused by an overflowing of small stones in the gallbladder into the common bile duct. This spontaneous migration of stones to the duodenum was presumed to contribute to a rapid normalization of the transaminase level.

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We report a case of ascariasis invading into the bile duct. The removal of the worm was done by a basket catheter. We also reviewed some additional literatures.
On March 28, 1984, a 33-year-old woman was admitted to our hospital because of epigastralgia and back pain. She underwent cholecystectomy due to cholelithiasis when she was 21 years old. She used to wash vegetables by salt.
Laboratory examinations at the time of her hospitalization revealed eosinophillia and increasing urinary amylase.
Endoscopic retrograde cholangio-pancreatography (ERCP) demonstrated the Ascaris reaching right hepatic bile duct from the end of common bile duct.
Though the ascarid migrated entirely into the bile tract, we tried endoscopic therapy to make use of basket catheter and succeeded to remove a male ascarid, a length of 16cm.
At the present time maintaining high level of sanitary conditions, we seldom observe a case of ascariasis invasion of the bile duct. However, we should bear in mind of occurrence of such a rare case. Furthermore, as the method of endoscopic therapy is very useful, it is suggested that the above method be tried with first priority.

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A case of the autoimmune hepatitis which developed four months after the renal tubular acidosis was reported. The autoimmune mechanism was considered to be the common cause of both disorders.
A 32-year-old woman was admitted to our hospital because of hypovolemic shock, hypokalemia and hyperchloremic acidosis, and the tentative diagnosis of renal tubular acidosis of unknown cause was made. She improved with oral administration of Indomethacin.
Three months after discharge, she developed autoimmune hepatitis, and improved with plasma exchange and steroid therapy.
The clinical course of this case was defferent from usual autoimmune hepatitis with renal tubular acidosis because autoimmune hepatitis developed four months after the renal tubular acidosis.

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