The relationship between blood transfusions and prognosis after surgery for gastric cancer was investigated. Patients who underwent curative resection for advanced gastric cancer were divided into three groups based on the volume of perioperative blood transfusions. The patients in the first group received no transfusion, the second group received a transfusion of less than 1000 ml, and the third group received 1000 ml of blood or more. The survival rate for the patients transfused with 1000 ml or more was significantly lower than that for the nontransfused patients (p<0.01). However, there was a difference in depth of cancer infiltration and lymph node involvement between these two groups, which might have been another factor causing the difference in the survival rate. In the patients with cancer infiltration beyond the proper muscle layer, there was a significantly better survival rate for the non-transfused patients than the patients transfused with 1000 ml or more (p<0.01), without any difference in depth of cancer infiltration and lymph node involvement between the two groups. In the patients with cancer infiltration beyond the proper muscle layer, the survival rate was analyzed further by Cox proportional hazard model, in which 11 clinical and pathological factors that could affect the postoperative outcome were chosen as covariates. The factors that were significantly correlated with survival were lymph node involvement, maximum diameter of the tumor, venous invasion, and perioperative blood transfusions. These results indicate that perioperative blood transfusions may have an adverse effect on the prognosis after curative resection for gastric cancer, especially in patients with cancer infiltration beyond the proper muscle layer.

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The tumor marker doubling time was calculated to evaluate the clinical significance of the predictedproliferation rate (S-phase fraction/DNA index) and the two indicators were compared them. Eighty seven patients with gastric cancer and eleven patients with colorectal cancer were studied. Tumor marker doubling time could be measured in 13.8% of gastric cancers and 45.5% of colorectal cancers. It tended to be short in the young patients and in poorly differentiated carcinomas. CEA doubling time was well correlated with the period from the operation to recurrence. CEA doubling time was significantly correlated with the predicted proliferation rate (r=0.65, p<0.05). Because the predicted proliferation rate can be determined from biopsied specimens, it is believed that the rate could be a useful indicator of malignancy not only in patients with negative tumor markers but also in patients with early gastric cancer.

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In recent years jejunal interposition has been used frequently as a more natural reconstructive method after total gastrectomy. Postoperative changes in biliary tract enzymes and results of ultrasound examination after reconstruction by jejunal interposition (group A, n=14) and the Roux-en Y procedure (group B, n=18) were evaluated and compared to determine the effect of the difference in reconstructive methods on the biliary system. The levels of biliary enzymes were significantly higher in group A than in group B one week and one month after surgery. The levels were within the normal range in all patients in group B throughout the observation period. Postoperative ultrasound examination revealed no gallstones in either group, and the common bile duct was not dilated in either group. This postoperative elevation of biliary enzyme levels in group A is thought to be related to a loss of coordination between the duodenum, the interposed jejunum, and the distal jejunum after reconstruction by jejunal interposition. Further study is necessary to determine the mechanism and the clinical significance of this phenomenon.

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We made a metastatic liver tumor model by injecting VX2 tumor cells into the portal vein of a rabbit. We then examined the suppressive effect of Adriamycin against liver metastasis, when administered through the portal vein in an adequate dose determined by a pharmacokinetic study. The minimum effective ADR concentration was determined in a sensitivity test using cultured VX2 tumor cells. And the pharmacokinetics of portal and systemic administration was analyzed with doses of 0.2, 0.4 and 0.8mg/kg of body weight. The liver extraction ratio was higher with the smaller doses, but satisfactory liver concentration over the minimum effective concentration was achieved with a dose of 0.4mg/kg. Complete suppression of liver metastasis was achieved by administering ADR 7 times at a dose of 0.4mg/kg.

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We analyzed cultures of bile juice taken from the gall bladder of 158 patients with cholelithiasis during surgery, and from the T-tube of 48 patients after surgery. The rate of isoration of Escherichia coli (18 patients), Klebsiella (12 patients) and Enterococcus faecalis (11 patients) from bile of the gall bladder during the operation were high. The rate of isolation of bacteria from bile taken during surgery was high in patients with a past history of some symptoms of cholelithiasis, aged over 60 years, and having an abnormality of liver function or having fever or leukocytosis during the week before the operation. With each day, the rates of isolation of E.coli and Klebsiella decreased but that of Enterococcus faecalis increased in cultures of bile from the T-tubes. E. coli (94.9%) and Klebsiella (81.9%) showed high sensitivity to antibiotics, but Enterococcus faecalis (53.3%) showed low sensitivity. That was one of the reasons the bacteria from the T-tubes changed. We experienced 18 cases of infectious complication after the operations of 158 patients, and the bacteria were the same as those from the bile juice taken from the gall bladder in 13 cases.

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We examined the retardation-factor influencing on the decrease of serum bilirubin after the alleviation of obstructive jaundice. In a clinical study 43 cases of malignant obstructive jaundice were divided into 3 groups on the basis of the bilirubin reduction rate “b” (good group, b<-0.09: fair group, -0.09≤b<-0.05: poor group, b≥-0.05) and some factors in the bilirubin reduction rate were examined. In an experimental study hepatic tissue flow, arterial ketone body ratio (AKBR) and endotoxin in the portal vein and systemic circulation were examined in a rat model of obstructive jaundice which was made by bile duct ligation. The clinical results were as follows: In the poor group, the incidence of a positive bacterial culture of the bile and that of leukocytosis were significantly higher than in the good group respectively (p<0.05, p<0.01). Endotoxemia was noted in 2 cases in the poor group. The experimental results were as follows: Endotoxin in the portal vein of the 7-day obstructed group was significantly higher than in the control group (p<0.001). Hepatic tissue flow and AKBR were significantly decreased in the 7-day obstructed group on the other hand (p<0.001). The above data suggested that infection derived not only from the bile duct but also from the portal vein retarded the bilirubin reduction rate in addition to liver dysfunction due to the decrease of the hepatic tissue flow and energy charge in obstructive jaundice.

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The outcome and prognostic factors of 114 cases of resected pancreatoduodenal cancers including 55 in the pancreas head, 34 in the papilla of Vater, and 25 in the lower bile duct from October 1969 through October 1990, were studied. The average ages of patients with carcinoma of the head of the pancreas, carcinoma of the papilla Vater, and carcinoma of the lower bile duct were 64.0±11.7, 59.3±12.3 and 62.1±11.5 respectively. The cumulative survival of patients with carcinoma of pancreas head was significantly shorter than those with carcinoma of the papilla of Vater or the lower bile duct (p<0.01). There were no significant differences in surviva curves between carcinoma of the papilla of Vater and the lower bile duct. One-year survival rates for carcinoma of the pancreas head, papilla of Vater, and lower bile duct were 40%, 64%, 72% respectively, and the 5-year survival rates were 8%, 31%, 44% respectively. However, in advanced cases, especially in stage IR, the cumulative survival curve for carcinoma of the papilla of Vater was almost the same as that for carcinoma of the pancreas head, and significantly worse than for carcinoma of the low bile duct. The most prognostic factor of carcinoma of the pancreas head was invasion to the retroperitoneal tissue (p<0.05). The most prognostic factor for carcinoma of the papilla of Vater was invasion to the pancreas (p<0.001), although the presence or absence of duodenal invasion (p<0.05) or lymph node metastasis (p<0.01) had significant influence on the outcodme. Carcinoma of the lower bile duct had the best outcome in this study, and there were no significant differences in cumulative survival curves in the presence or absence of each staging factor.

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Pancreaticoduodenal allotransplantation was performed to evaluate ciclosporin (CSA) and FK506 in dogs. Forty-two mongrel dogs were used for these experiments. There were three experimental groups, group 1 (n=5), controls, no immunosuppression was given. In group 2 (n=10), intramuscular injections of CSA 20 mg/kg/day were given initially, this was reduced to 10 mg/kg/day 3 weeks later. In group 3 (n=6), 0.1-0.3 mg/kg/day of FK506 was given intramuscularly. The conclusions of these experiments were following. 1) Significant prolongation of pancreaticoduodenal allograft survival was obtained with CSA and FK506 compared with control animals without immunosuppression. 2) Toxicity of FK506 was loss of appetite and weight loss. 3) In group 1 without immunosuppression, all dogs died of acute rejection. In group 2 with CSA, two dogs died of acute rejection, eight dogs died of chronic rejection. In group 3 with FK506, two dogs died of acute rejection, four dogs died of chronic rejection.

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A total of 107 patients with colorectal cancer underwent noncurative operations, including 17 relative noncurative resections, 80 absolute noncurative resections and 10 nonresections. There were 66 (62%) patients with a solitary noncurative factors and 41 (38%) with multiple noncurative factors. The 5-year survival rate was 10% for patients with a solitary noncurative factor and 0% for patients with multiple noncurative factors. The result difference was statistically significant. Among patients with a solitary noncurative factor, the 5-year survival rate was 15% for patients with peritoneal dissemination, 4% for patients with liver metastasis and 0% for patients with N4 lymphnode metastasis or invasion to an adjacent organ. These rates were not significantly different. Regarding the outcome according to the type of treatment, the 5-year survival rate was 29% for patients with relative noncurative resection and no patient with absolute noncurative resection or nonresection survived more than 5 years. There was a significant difference among these groups. Especially the 5-year survival rate for relative noncurative resection with P₁ and H₁ was good, 29% and 60% respectively. The 1-year survival rate was 53% for patients with absolute noncurative resection with multiple noncurative factors in which one of the factors was resected. This rate was better than that for absolute noncurative resection with multiple noncurative factors in which the factors were not resected, though the difference was not significant. These results suggest that resection of the primary lesions and noncurative factors improves the prognosis for patients with noncurative factors.

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Pelvic recurrence is an ominous event after curative resection of rectal cancer and is rarely amenable to curative re-resection by conventional method. The early diagnostic potential of the new follow up method to detect resectable local recurrence was assessed in 175 patients after curative resection of rectal cancer. The patients were divided into three groups-high, intermediate and low risk of recurrence-according to the clinicopathological factors, and followed by our new follow up regimen based on tumor markers and imaging by ultrasound, computed tomography and magnetic resonance imaging. Twenty-seven recurrences (15%) were detected, 20 of the 27 patients were in the high risk group. Of the 27 patients with local recurrence, 12 (45%) had undergone reoperative surgery curatively. In conclusion, even though these findings must be confirmed by larger studies and longer follow up, the new systematic followup appears to be an effective method for early detection of local recurrence suitable for “curative” surgery.

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A 75-year-old man with dysphagia as the chief complaint was diagnosed as having esophageal Ieiomyosarcoma. He is the oldest patient with this disease reported in Japan. Esophagectomy was performed, and the patient has been fit and disease-free for nearly 3 years since the operation. Various surgical measures have been selected for this infrequent disease, since the precise preoperative diagnosis has not always been easily obtained, and decisionmaking during the operation based on the gross findings has often become necessary. Radical excision with extensive lymphadenectomy is not recognized as the standard treatment as in the case of esophageal carcinoma. Local recurrence, however, was observed in one of 29 patients who underwent partial esophagectomy, the treatmentmost frequently chosen for the 45 cases known, and for 3 out of the 10 patients who underwent simple excision of the tumor alone. No matter what measure is taken, long term follow up is mandatory for patients with this disease.

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A case of carcinoid tumor of the esophagus is reported. The patient was a 64 year-old man who came to our hospital because of pain on swallowing. Barium swallow and esophagoscopy revealed an elevated tumor in the middle third of the esophagus. The tumor had a shallow ulcer, the bottom of which was nodular and easy to bleed. Resection of the intrathoracic esophagus and retrosternal esophago-gastrostomy were performed. Pathological studies of the resected specimen revealed a carcinoid tumor invading the adventitia of the esophagus with metastases in the para-tracheal, pulmonary hilar, para-esophageal, and peri-gastric lymph nodes. Postoperative radiotherapy (50Gy) was given, and the patient survived for 12 months and died of pneumonia.

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A typical case of Barrett's esophagus complicated with a stricture and an ulcer of the upper thoracic esophagus is reported. The patient was a 58-year-old female with complaints of dysphasia and easy fatigability due to anemia: low hemoglobin concentration (2.7 mg/dl) on blood examination. Esophagography showed an annular stricture of the esophagus at the level of the aortic arch and sliding hiatal hernia. Esophagoscopy demonstrated an annular stricture and an ulcer at the level of 23 cm from the incisors. Biopsy specimens taken from the esophagus distal to the stricutre revealed columnar epithelium. Nissen fundoplication and dilatation of the stricutre were performed. The postoperative course was excellent and no complaints have developed. During the follow-up period of 7 years, no esophageal ulcer or stricutre has occurred; moreover neither aggression nor regression of Barrett's esophagus has been observed. Since Barrett's esophagus is considered a pre-cancerous lesion of adenocarcinoma of the esophagus, it should be carefully followed up even after a successful antireflux operation.

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A case of adenocarcinoma in Barrett-like esophagus after total resection of the gastric remnant is reported. A 52-year-old man underwent distal gastrectomy for gastric cancer at 33 years of age and total resection of the gastric remnant for cancer of the remnant at 35 age. Because of reflux esophagitis, endoscopy revealed Barrett-like esophagus in April 1983, when he was 45. Furthermore, superficial type esophageal carcinoma was detected in Barrett-like esophagus in December 1989. A subtotal esophagectomy was performed on January 19, 1990. A 7.4×3.2 cm lesion in the lower esophagus showed plateau elevation. The histological type was well differentiated adenocarcinoma and the invasion was limited to the muscularis mucosae. There were no metastases in the 44 dissected lymph nodes. Its mucin and clinicopathological features were similar to well-differentiated adenocarcinoma in the stomach.

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A case of cystic lymphangioma of the stomach is presented. The patient, a 61-year-old woman, was referred to the hospital because of epigastralgia. The pain seemed to be related to gastric submucosal tumor that was found when she was 58 years old. Gastrointestinal fiberscopy was performed, and needle aspiration biopsy was attempted but failed. At the operation a soft cystic mass on the anterior wall near the lesser curvature of the stomach was found and gastric resection of the distal part was performed. The diagnosis based on pathological examination was cystic lymphangioma. At the 4-year follow-up the patient was well, and free of the disease.

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A very rare case of leiomyosarcoma of the residual stomach associated with liver metastasis is reported. A 60-year-old man was admitted to our hospital complaining of epigastralgia. Upper gastrointestinal examination, gastrofiberscopic examination and ultrasonographic examination revealed a submucosal tumor of the residual stomach with liver metastasis. A total resection of the residual stomach, splenectomy, distal pancreatectomy with dissection of the regional lymph nodes and partial hepatectomy were performed. Histopathological examination revealed leiomyosarcoma of stomach with liver metastasis, but the regional lymph nodes were not involved.

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A 63 year-old woman with a hepatic foregut cyst forming a solid mass is reported. She had been followed up for liver cirrhosis and a small mass in S₄ of the liver was detected. U.trasonography revealed a 2.4-cm low echoic mass with an internal echo in S₄ of the liver. Computed tomography revealed a low density mass without enhancing effect. Angiography did not reveal any abnormality. In magnotic resonance imaging, the t1-weighted image revealed an iso-signal intensity tumor of the S₄ segment, the proton image revealed a slightly low signal intensity tumor and the t₂-weighted image revealed a slightly high signal intensity tumor. Enucleation was performed. The resected specimen was a cystic mass containing serous and hyperviscous uid. Histological examination showed that the wall of the cyst was covered by one layer of columnal cells with cilia. The pathological diagnosis was a ciliated hepatic foregut cyst.

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We report a case of splenic metastasis from colonic carcinoma without any other distant metastasis. The patient was a 60-year-old man. He was admitted to our hospital for diagnosis of ascending colon carcinoma accompanied by a splenic tumor. By various imaging examinations, it was difficult to tell whether the splenic tumor was primary or metastatic. On laparotomy, it was diagnosed as metastatic carcinoma by paraoperative histologic examination. A right hemicolectomy and splenectomy was performed. The serum CEA level again rose above the normal limit nine months after the operation, but no evidence of recurrence was clinically found about one year after surgery. Splenic metastasis from colorectal carcinoma is unusual, and there are only six cases of splenic metastasis without any other distant metastasis. The route of spread of carcinoma to the spleen is uncertain. The hematogenious route of splenic metastasis has been suggested, and it is possible that this was the route in our patient. Some studies reveal that a good outcome can be expected if the solitary splenic metastasis can be completely resected. Therefore, we consider important early diagnosis and resection.

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Esophageal dilation using a plastic bougie and a balloon dilator was performed in 91 patients with postoperative anastomotic stricutre from October 1982 to February 1991. Indications for and limitations of the dilation procedure were re-evaluated retrospectively. Dilation was successful in 80 of the 84 patients with benign strictures. The number of dilations was 3.7 on average. More frequent dilations were necessary for the patients with anastomotic leakage after esophageal resection. The only unsuccessful dilation for benign strictures was in a patient with an esophago-cutaneous fistula. In the three patients with a long narrow segment, dilation was difficult. Dilation was unsuccessful in two of seven patients with malignant strictures with cancer recurrence, and was difficult in four patients. One patient died soon after dilation because of cancer recurrence. Complications of the dilation procedure occurred in six patients, including two with bleeding which required blood transfusion, two with fever, one with cervical subcutaneous abscess, and one with perforation. Only one patient was operated on for complications, and no patient died because of the complication. The dilation method using a plastic bougie and a balloon dilator is a simple, safe, and useful treatment for benign esophageal anastomotic stricture.

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Indications for and limitations of endoscopic dilatation by incision and bougienage as treatment for anastomotic gastrointestinal stricutres were investigated. The subjects were 35 patients with of anastomotic strictures (26 with cicatrical strictures and 9 with cancerous strictures). For cicatrical strictures, the rates of strictures released according to the length of the stricture, were 14/15 (93.3%) for strictures shorter than 2 cm, 8/9 (88.9%) for those between 2 cm and 3 cm, and 0/2 (0%) for those longer than 3 cm. For cancerous strictures, the rate was 0/9 (0%), an unfavorable result. Ten cases showing unfavorable results excluding 3 cases of cancerous stricture (4 cases of cicatrical strictures and 6 cases of cancerous strictures) received some other treatment: Surgery was performed in 3 cases (1 case of cicatrical stricture and 2 cases of cancerous stricture) and intubation of a throughbougie esophageal prosthesis was performed in 7 cases (3 cases of cicatrical strictures and 4 cases of cancerous strictures). Of surgically treated patients, release from the stricture was achieved in only 1, and the others required an exploratory laparotomy or died from complications. Intubation of an esophageal prosthesis was able to release the stricture in all 7 patients, making discharge possible. In only 1 case of cicatrical stricture did the rolled skin flap form a skin fistula, which required an operation. Intubation of a through-bougie esophageal prosthesis was usefull as a non-invasive treatment for intractable anastomotic strictures.

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Superficial esophageal carcinomas, even mucosal carcinomas are increasing in number because of developments in endoscopic diagnosis and chromoendoscopy. In mucosal carcinomas, in which the muscularis mucosa is not invaded, both lymphnode metastasis and lymphatic and vessel invasion are extremely rare. Therefore, these superficial mucosal carcinomas could be treated by endoscopic mucosectomy. Instead, for lesions more than 3 cm in size or multiple lesions spreading widely throughout the esophagus, a blunt esophagectomy without thoracotomy should be performed. We have treated 19 mucosal carcinomas in 15 patients by endoscopic mucosectomy. The techniques of mucosectomy are as follows: (1) The extension of the lesion is determined by iodine staining.(2) The area to be resected is marked by high-frequency electric coagulation.(3) Approximately 5 to 10 ml of saline containing 80, 000-to 160, 000-fold diluted epinephrine and indigocarmine is injected into the submucosal layer of the lesion.(4) Endoscopic mucosectomy is performed, and the lesion is resected.(5) Mucosectomy is followed by iodine staining to assure the complete resection of the lesion. Up to now, no complications following mucosectomy have occurred except for one case of subcutaneous emphysema. This patient recovered in a few days with only antibiotic treatment.

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We developed an endoscopic mucosectomy technique for removal of the mucosa and the submucosa of the esophagus. Indications for endoscopic mucosectomy for treatment of superficial esophageal cancer were studied by clinical and pathological analysis of patients with superficial esophageal cancer who had undergone radical esophagectomy at our hospital. Results of endoscopic mucosectomy in mucosal cancer cases were studies, and conditions for endoscopic decision for radical treatment of mucosal cancer of the esophagus were discussed. Indications for endoscopic mucosectomy: The incidence of lymph node metastasis that determined the prognosis of superfical esophageal cancer showed a close relation to the depth of cancer invasion into the esophageal wall. Lymph node metastasis was found in only 5.5% of patients with intraepithelial and mucosal cancer and they had an excellent outcome (the 5-year-survival rate was 100%). On the other hand, patients with submucosal cancer showed frequent lymph node metastasis (49%) and recurrence (the 5-year-survival rate was 50%). It was suggested that patients with intraepithelial and most of them with mucosal cancer could be treated by endoscopic mucosectomy technique. It was suggested that patients with typical 0-II lesions probably have no lymph node metastasis, for almost 95% of their tumors were reported as intraepithelial or mucosal cancer of the esophagus. Results of endoscopic mucosectomy: Endoscopic mucosectomy was carried out on 12 patients with intraepithelial cancer (7cases), mucosal cancer (3) and severe atypical epithelial changes (2). Mode of resection: A single session could remove the whole lesion in 9 cases. Mucosectomy sessions were repeated in 3 cases. The largest dimension of removed specimen was 15 mm. Any mucosal lesion with dimensions over 10 mm was probably removed by dividing it into several pieces. Only one resection achieved complete removal of the lesion in 2 cases, several resections were required in 10 cases. Histological evaluation of resected specimens: All resected specimens contained the mucosa and submucosa. Histological studies revealed intraepithelial cancer in 7 cases, mucosal cancer in 3, atypical epithelium in 1 and only regenerative esophageal epithelial in 1 case although the biopsy specimen showed intraepithelial cancer before the endoscopic mucosectomy. Depth of removal was sufficient in all specimens. Histological evaluation of the margin of resection was difficult in cases in which the specimen was divided into several pieces. Complete removal by endoscopic mucosectomy: Complete removal of any mucosal lesion of the esophagus could be decided by endoscopic findings: The whole lesion should be removed in a single session. The margin of the resection should contain the normal mucosa. Iodine staining facilitates delineating the border of the lesion. No mucosal island should be left in the resection field. There was no relapse in patients with complete resection, but there was one relapse among three patients with incomplete resection. In one patient who underwent esophagectomy, histological studies revealed an intraepithelial cancer in the resected specimen. Complications of the mucosectomy: There were no major complications. In one patient there was a small amount of bleeding from the ulcer after the resection that could be controlled promptly by conservative treatment. Conclusions: Twelve patients with intraepithelial and mucosal cancer were treated by endoscopic mucosectomy. Relapse of the cancer was avoided by complete removal of the lesion. The whole lesion should be removed in one session and iodine staining facilitates this. Mucosal cancers with lymph node metastasis are rare, but their precise evaluation is not sufficient at present. Endoscopic mucosectomy for esophageal cancer is indicated for intraepithelial cancer and intraepithelial cancer with minimal invasion into the mucosa.

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To clarify the indications for and limitations of endoscopic surgery, particularly mucosal resection (EMR), for early gastric cancer, we reviewed 290 early cancer cases treated by operations and 65 treated by endoscopic surgery. We investigated lymph node metastasis and mode of invasion (continuous or incontinuous) in the former cases, and background factors and treatment results in the latter. EMR yielded the best results for curative endoscopic surgery for gastric cancer. All 122 resected gastric cancers that were confined to the mucosa were free of lymph node metastasis whereas 41 (24.4%) of 168 gastric cancers invading the submucosa metastasized to the lymph nodes, suggesting that surgical treatment is indicated when a specimen from EMR shows invasion of the submucosa. No lymph node metastasis occurred in cancers that were elevated grossly or well differentiated histologically and smaller than 2.0cm in size, and those that were depressed or poorly differentiated and smaller than 1.0cm. Among surgically resected cancers smaller than 2cm, 12 (92.3%) of 13 lesions that were elevated or well differentiated showed incontinuous invasions within 1mm, and 13 (92.9%) of 14 lesions that were depressed or poorly differentiated showed incontinuous invasion within 2mm, suggesting that endoscopic surgery requires 2mm of cancer clearance to cure the cancer. In conclusion, EMR is the best procedure for minute and small gastric cancers less than 1.0 cm, producing as good results as surgical treatment.

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Fifteen patients with inoperable gastric cancer underwent repeated intratumoral injection of OK-432. Seven showed a reddened tumor surface following the initial two or three injections. In most of these a marked change in configuration followed. Five of these patents showed a marked reduction of the tumor, while eight patients in whom no color change appeared initially later showed no or minor morphological changes, and the rate of effectiveness was estimated as 33.3%. There seemed to be no correlation between the effectivity and the patients' background factors. In ten patients for whom serial histological findings were obtained by biopsy, inflammatory cellular infiltration to the tumor parenchyma had increased. Among these, plasma cells were predominant in five patients, and the rate of effectiveness was the highest in these patients. The systemic immunological responses were determined, and did not show significant enhancement of the reactivity except in the case of the PPD skin test. In terms of the survival rate, there was no significant difference between these patients and patients who were treated in other ways. However, among the patients who received injections of OK-432, those with a good local response survived longer than those who had a poor or no response. Bleeding from the tumor surface was a complication that required much attention. One third of the patients were required to have a blood transfusion. Fever was a commonly seen side effect, however, it is noteworthy that the higher the body temperature, the better was the local response.

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To determine the indications for and limitations of endoscopic surgery for colorectal diseases, our experience with 1927 polyps treated by endoscopic surgery and 259 early colorectal carcinomas is reviewed. Of these polyps, 67% were adenomas, 5% were mucosal carcinomas, 3% were Peutz-Jeghers polyps, 1% were juvenile polyps and 0.4% were benign submucosal tumors. Endoscopic surgery is recommended as adequate therapy for these colorectal diseases. The size limit for polyps treated by colonoscopic polypectomy was 45 mm in diameter. The complication rate after endoscopic surgery was 0.7%. There were no deaths in this series and endoscopic surgery was a safe procedure. The histopathological features of early colorectal carcinomas were analyzed. The results of this study indicate that endoscopic surgery for mucosal carcinomas could be acceptable as proper treatment, because preoperative estimation of lymph node metastasis of submucosal carcinomas could not be found. The patients with early carcinomas that are pedunculated (type Ip) regardless of size, sessile protruded (type Is) smaller than 20 mm and flat elevated (type 11a) smaller than 15 mm should undergo endoscopic surgery. The depressed type (IIa + IIc) of early colorectal carcinomas should be treated by surgery because of increased risk of submucosal invasion and lymphatic or venous invasion.

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We have been using cholangioscopic laser lithotripsy since 1980. From 1980 to 1990 we have treated with cholangioscopy 9 patients with cholecystolithiasis (1 recurrent case), 28 patients with choledocholithiasis and 68 patients with hepatolithiasis. Patients for whom we used percutaneous transhepatic cholangioscopic therapy for cholecystolithiasis and choledocholithiasis were those of polysurgery, aged patients and patients who had some complications. We established a treatment plan for hepatolithiasis; first, percutaneous transhepatic cholangioscopic lithotripsy was performed whenever possible. But if there was an atrophic lobe or stenotic bile duct making it impossible to removed the stones, liver resection or other operative procedures were performed. With this treatment we had only 2 cases (2.9%) in which were residual stones. From 1988 we used a flash lamp pumped dye laser for lithotripsy, this apparatus led to progress in the cholangioscopic treatment and shortened the treatment period.

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Seventy-two patients with cholecystolithiasis have been successfully treated by laparoscopic cholecystectomy using a flexible video laparoscop since July 1990. Intraoperative cholangiography confirmed the absence of residual bile duct stones and bile duct injury. All patients were free of complications postoperatively except for one umbilical wound infection, which was treated easily. They were discharged about 5 days after surgery. Our criteria of indication for this operation are 1) no history of upper abdominal surgery; 2) no acute cholecystitis; 3) no evidence of a common bile duct stone and positive cholecystogram by intravenous cholangiography. The advantages of this method over conventional cholecystectomy are 1) much less postoperative pain; 2) rapid recovery of abdominal transit; 3) rapid recovery of the patient, with complete return to normal activity; 4) small scar.

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During the 10 months from May 29, 1990 to the end of February 1991, 91 patients in the Department of Surgery, Teikyo University Hospital at Mizonokuchi required cholecystectomy, and 56 patients (61.5%) were considered to be candidates for laparoscopic cholecystectomy. In 52 of these 56 patients (92.9%) laparoscopic cholecystectomy was successfully completed. In the remaining 4 cases (7.1%) the operation was converted to open cholecystectomy. These 4 failures were attributed to acute cholecystitis in 1 case, inability of exposure of the cystic duct and the cystic artery at the Calot triangle in 1, and extensive omental adhesion around the gallbladder in 2. In the patients with acute cholecystitis whose treatments were converted to surgery, the cystic duct was easily desected with the clip applier unloaded. On the other hand, patients in whom laparoscopic cholecystectomy was not indicated included those with choledocholithiasis, acute cholecystitis, a previous history of upper abdominal surgery, cystic duct occlusion, Mirrizi syndrome, biliary tract anomalies, and bilio-enteric fistula. It is strongly advocated that surgeons who attempt to perform laparoscopic cholecystectomy should have a low threshold of conversion to open surgery whenever any difficult problems in management occur during laparoscopic surgery to prevent major complications.

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Two hundred fifty-five patients with chronic pancreatitis received surgical treatment at our institution between 1968 and 1990. Early and late postoperative results were compared between 157 patients who received pancreatic resection (8 total pancreatectomy, 104 pancreas head resection, and 45 distal pancreatectomy) and 56 patients receiving pancreaticojejunostomy. Two operative deaths (1.8%) occurred after pancreas head resection, and one (0.9%) occurred after pancreaticojejunostomy. The mean follow-up time was 4.1 years after total pancreatectomy, 42 years after pancreas head resection, 5.6 years after distal pancreatectomy, and 5.5 years after pancreaticojejunostomy. More than 90% of the patients with each operation were free of pain postoperatively. Postoperative diabetes was present in 100% after total pancreatectomy, 23% after pancreas head resection, 51% after distal pancreatectomy, and 44% after pancreaticojejunostomy. Five and 10-year survival rates were, respectively, 46% and 25% after total pancreatectomy, 82% and 72% after pancreas head resection, 92% and 66% after distal pancreatectomy, and 82% and 62% after pancreaticojejunostomy. Late deaths occurred in 5 patients (63%), 8 patients (7.7%), 4 patients (8.8%), and 4 patients (7.4%) after total pancreatectomy, pancreas head resection, distal pancreatectomy, and pancreaticojejunostomy, respectively. These data suggest that pancreatic resection can be done safely and provid good long-term results in patients with chronic pancreatitis.

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Ninety-eight patients with chronic pancreatitis underwent surgery at our institutebetween 1970 and 1990. The mean age was 46.7 years and the male to female ratio was 79: 19. The etiology of the pancreatitis was alcohol in 59 cases, gallstones in 12, and idiopathic or other causes in 27. All of the alcoholic patients were male and 6 years younger, on average, than those with chronic pancreatitis due to gallstone. The reasons for surgery were intractable pain in 85% of the cases, cyst formation in 40%, and jaundice in 16% respectively. Others included gallstones, suspicion of cancer, and fistula formation. The surgical procedure was determined by considering the configuration of the main pancreatic duct, localization of the disease, presence or absence of cysts, and biliary tract findings, collectively. Thirty-two patients with irregular dilatation of the main pancreatic duct were treated with pancreaticojejunostomy, and 8 cases with cysts were treated with cystogastrostomy or cystojejunostomy as the final operation. In patients with suspicion of cancer or with a cyst in the tail and/or body, pancreatic resection was the treatment of choice. Others, especially those without dilatation of the pancreatic duct, were treated mainly with neurectomy. One patient died of hemorrhagic complications after pancreaticoduodenectomy. More than 80% of the patients were almost free of pain at follow up. Four patients died of complications of diabetes mellitus. Control of glucose intolerance is one of the most important postoperative problems facing patients with chronic pancreatitis.

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We analyzed the results of surgical treatment for 78 patients with chronic pancreatitis from January 1, 1971, to December 31, 1990. Eighty-one percent of the patients with longitudinal pancreaticojejunostomy (PJ), 100% of the patients with pancreatectomy, 91% of the patients with drainage of a pancreatic cyst, 100% of the patients with modified Warren's operation and 100% of the patient with surgery on the biliary tract experienced mitigation or disappearance of pain. Abnormal glucose tolerance after the operation was observed in 35% of the patients with pancreatectomy compared to 11% of those with PJ. In addition, concerning the quality of life, 35% of the patients with pancreatectomy became worse compared to 19% of the patients with PJ. As the main reason for surgical treatment of chronic pancreatitis is to lesson the pain, we recommend PJ for patients with dilation of the pancreatic duct and modified Warren's operation for patients with a nondilated pancreatic duct to preserve pancreatic function.

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From 1967 to 1989, 103 patients with chronic pancreatitis were treated surgically in our clinic. Of these, 43 underwent pancreatic duct drainage operation and 25 underwent pancreatic resection. Pain was relieved in 88.4% of the patients who had the drainage operation and in 84.0% of the patients who underwent pancreatic resection, there-fore pain relief was unrelated to therapy. All patients whose pain was not relieved had alcoholic pancreatitis and had continued to drink. With regard to ability to work and quality of life after surgery, there was no difference during a short follow-up period (shorter than two years) between the drainage operation and pancreatic resection but the number of patients with poor life quality increased during a long follow-up period (longer than two years) in the patients who underwent pancreatic resection. Diabetes and malnutrition had affected their social lives. Postoperative pancreatic function deteriorated in the patients who underwent pancreatic resection, though improvement of pancreatic function was observed in some patients who had a drainage operation. As recovery of pancreatic function is expected in the early stage of chronic pancreatitis treated by the drainage operation, maximum conservation of pancreatic tissue by avoiding resectional procedures is advisable.

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In 14 patients with chronic pancreatitis without dilatation of the main pancreatic duct, 7 had segmental lesions of the pancreas and 7 had diffuse lesions of the pancreas. All of the patients with the segmental lesion had relatively good pancreatic function and were relieved of pain by surgical treatment for only the segmental lesion. On the other hand, 6 of the 7 patients with the diffuse lesion had far advanced dysfunction of the pancreas. Two of the 7 patients were not freed from pain by drainage of the pancreatic duct and 2 other patients were relieved of pain by pancreatic resection but at the price of creating more severe insulin dependent diabetes. The remaining 3 patients underwent complete denervation of the pancreas and are still well more than 2 years after the operation. To control pain and to preserve pancreatic function as long as possible in such cases, this new surgical approach may offer a means of relieving pain with preservation of endocrine function in selected patients who have chronic pancreatitis without pancreatic duct dilation.

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In 30 patients with severe chronic pancreatitis, duodenum-preserving resection of the head of the pancreas with denervation of the left pancreas was performed. The objective of this surgical therapy is excision of the inflammatory tumor in the region of the head of the pancreas and cutting off of all nerve fibers of the body and tail of the pancreas. Reconstruction with drainage of the pancreatic secretion from the left pancreas into the upper intestinal tract takes place through end-to-side or side-to-side jejunal loop anastomosis. The limited operative intervention at the head of the pancreas and the preservation of the duodenum explain the preservation of the endocrine and exocrine function of the pancreas. As a result of the operation 85.7% of the patients were completely free of abdominal pain and 75% returned to their former occupation. During the late follow-up period, glucose metabolism was unchanged or improved in 70% of the patients. In 7 patients, there was stenosis with wall rigidity in the common bile duct. In these patients, common bile duct-duodenal anastomosis was carried out. In 3 patients a Partington modification was performed between the left pancreas and the jejunal interponate.

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Pylorus-preserving pancreaticoduodenectomy with minimized resection of the duodenum, followed by the Billroth I type of reconstruction was performed in 9 patients with chronic pancreatitis who had an inflammatory tumor including a cyst and/or stone in the head of the pancreas. Anal to duodenoduodenostomy (end-to-end), three types of pancreatobiliary anastomoses were made, taking account of the pathophysiological state of the diseased pancreas. Type A with pancreatojejunostomy (end-to-side) and choledochojejunostomy (end-to-side) was performed in 2 cases; type B with choledochojejunostomy (end-to-side) and pancreatojejunostomy (end-to-side) in 3 cases; and type C with choledochojejunostomy (end-to-side) and pancreaticojejunostomy (side-to-side) in 4 cases. Types A and B were used mainly for patients with a nondilated pancreatic duct. Type C was used for patients having a dilated pancreatic duct with hard pancreas tissue in order to decompress the duct and to removed stones within the remnant pancreas. Pain relief was obtained in 7 of 8 patients (88%). All the patients were discharged without serious postoperative complications. We conclude that our type C reconstruction is a rational modified procedure for chronic pancreatitis with stones and hard pancreatic tissues in regard to postoperative digestion as well as absorption.

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In surgical treatment for chronic pancreatitis, it is important not only to obtain a pain-free effect but to preserve the pancreatic function. Focal pancreatic resection was performed in patients with diffuse calcification, and pancreatectomy was carried out in patients with cystic formation or those without dilatation of the main pancreatic duct. In these patients, four who had received nearly subtotal removal of the distal portion of the pancreas underwent autotransplantation of the resected pancreas. The splenic artery and vein of a segment of the body and tail of the pancreas were transplanted to the iliac vessels heterotopically to avoid reinnervation that would cause pain in the pancreas. The transplanted pancreas was anastomosed to the jejunum. All of the autotransplanted pancreases have survived, and almost all of the endocrine and exocrine functions of the pancreas are preserved. Every patient has completely recovered from the severe pain, and has returned to a normal social life.

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Choice of operative procedures for chronic pancreatitis and results of long term follow-up were studied in the 52 patients who underwent pancreatic duct drainage or pancreatectomy among 60 surgical patients. In the group of 28 patients with a dilated main pancreatic duct, longitudinal pancreaticojejunostomy was performed in 22 with multiple duct stenosis. Sphincteroplasty with pancreatic duct plasty was performed in 4 patients who had pancreatic duct stenosis near the papilla of Vater. Of 2 patients who had ductal stenosis in the pancreatic head, one had pancreaticoduodenectomy and the other had double pancreaticojejunostomies with local resection of the pancreatic head. In the group of 24 patients without a dilated main pancreatic duct, total pancreatectomy was performed in 1 patient with diffuse pancreatic parenchymal lesions. Of 3 patients who had pancreatic lesions located in the pancreatic head, pancreaticoduodenectomy was selected for 2 and cystojejunostomy for 1. Of 20 patients who had pancreatic lesions located in the pancreatic tail, distal pancreatectomy was selected for 18 and cystojejunostomy for 2. In the late postoperative period of more than 1 year, the incidence of complete relief of pain was 84.2% for pancreatectomy and 81.5% for pancreatic duct drainage. Pancreatic endocrine and exocrine functions, however, had been maintained or recovered more completely after pancreatic drainage. Operative procedures should be selected for the individual patient by considering the degree of pancreatic duct dilatation and location of the pancreatic lesions as well as the effect of pain relief and maintenance of pancreatic function.

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During the last 30 years, 174 patients with chronic pancreatitis were treated surgically in our clinic. Operative procedures included side-to-side pancreaticojejunostomy in 64 patients, other pancreatic duct drainage procedures in 12, caudal pancreatectomy in 33, pancreaticoduodenectomy in 24, and others. A beneficial effect of the operation on abdominal pain was noted in 96% of the patients. There was no significant difference in the effect on pain among the types of surgery. The study of follow-up results showed an operative benefit in 85% of the patients. But in 15% of the patients (20 patients including 19 with alcoholic pancreatitis) poor results were obtained because of severe diabetes mellitus, alcohol abuse, analgetic addiction, and inappropriate surgery. There was no significant difference in the cumulative survival rate among the types of surgery and etiology of pancreatitis. Patients with diabetes mellitus at the time of the operation had 77% 5-year, 68% 10-year and 48% 15-year survival rates compared with an over 80% 20-year survival rate for patients with normal and impaired glucose tlerance. The difference between diabetes and either normal or impaired glucose tolerance is statistically significant. Diabetes mellitus is an important factor for long-term survival of surgically treated patients with chronic pancreatitis.

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