The mortality of the patients who undergo hepatectomies for malignant tumors is quite high. To clarify the reasons of the high mortality of resected hepatocellular carcinomas, the patients who underwent hepatic resections for hepatocellular carcinomas were analyzed. One hundred and ninety three hepatectomies were performed for hepatocellular carcinomas in the Department of Surgery, University of Tokyo, between January, 1963 and June, 1990. One hundred and thirty five were minor hepatectomies and 58 were major ones. The operative blood loss is little in the patients of hepatocellular carcinomas who underwent hepatectomies after January, 1981, in comparison with those who were done hepatectomies before May, 1981. The difference was statistically significant (p<0.05). The 5 year survival rates of hepatocellular carcinomas resected before May, 1981 and after June, 1981 were 19.4% and 37.9%, respectively. The difference was statistically significant (p<0.05). This improvement of prognosis is mainly due to developments of operative procedures, medical equipments such as ultrasonography and computed tomography, and intense studies on liver failure. The main cause of death of resected hepatocellular carcinoma is the recurrence of tumor. Many attempts of therapies have been applied to prevent from and treat for recurrences. It must be emphasized that the re-resection is one of the best therapies for recurrent hepatocellular carcinomas.

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We report our investigation, using cardiac cancer models, into the route of metastases to the lymphnodes around the lower part of the mediastinum and the abdominal aorta, and the possibility of lymphagenous advance to the diaphragm. We produced cardiac cancer models by endoscopically transplanting VX₂ carcinoma into the lower esophagus (E<C), the esophago-gastric junction (C≥E), and into the upper stomach (C). We then followed the lymphatic flow using particulate active carbon (CH₄₄). An upward lymphatic flow ascending the paraesophageal route was found in 6 (40%) of the 15 models in the C≥E group, and in 6 (60%) of the 10 in the E<C group, but not found in the C group and not in the controls. A downward lymphatic flow towards the surroundings of the abdominal aorta was observed in 36 (80%) of the 45 models via the left gastric artery and in 12 (27%) of the 45 in the pathway through the inferior phrenic artery. A sideward lymphatic flow towards the diaphragm was observed under the serosa of the diaphragm in 3 (12%) of the 25 models in the C≥E and E<C groups. Notably the upward and sideward flows were considered to reveal the collateral pathways involved in the metastatic advance of the gastric carcinoma. It was further suggested that the region of the esophago-gastric junction and the lymphnodes around the aorta might be closely associated with the lymphatic metastatic flow.

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The accuracy of preoperative diagnosis using computed tomography with or without contrast enhancement in detecting the depth of tumor invasion in the gastric wall and the presence or absence of lymph node metastasis was compared based on histological findings in 94 gastric cancer patients who underwent gastrectomy. The diagnostic accuracy rate of plain CT for gastric wall invasion was less than dynamic CT. Particularly in the evaluation of invasion to another organ, the diagnostic accuracy of dynamic CT was higher (84%) than plain CT (56%). The diagnostic accuracy and sensitivity of dynamic CT for lymph node metastasis was significantly higher than that of plain CT. With respect to the detection of metastasis to group 2 lymph nodes (especially No.(7), (8), (9), (11)), the sensitivity of dynamic CT was higher than that of plain CT. We conclude that dynamic CT is an available preoperative diagnostic procedure for detecting lymph node metastasis and serosal invasion.

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The subjects were 300 patients with gastric cancer with peritoneal metastasis discovered at laparotomy. We investigated the effects of surgical treatment and chemotherapy on the outcome of these cases. The rates of resection in P₁, P₂ and P₃ cases were 83.5%, 83.1% and 38.1%, respectively, with a total rate of 64.3%. The survival rate decreased with advance in P-progress in overall P (+) cases. There were significant differences in survival rate between P₁ and P₃ (p<0.001), and P₂ and P₃ (p<0.05). In P (+) cases with gastrectomy, there was a significant difference in survival rate between P₁ and P₃ (p<0.05). No differences in survival rate were found in non-resected cases. As for the outcome of these cases according to the degree of lymph node dissection, R₂ was significantly better than R₀ in P₁ (p<0.05). Although we augmented the degree of lymph node dissection in P₂ and P₃ cases, no significant increase in the survival rate occurred. We studied the effect of chemotherapy. Concerning the outcome of non-resected cases, the cases with chemotherapy showed significantly better results than those without chemotherapy (p<0.001). The outcome of resected cases with chemotherapy was also better than that without chemotherapy. Treatment by sequential MTX-5FU was regarded as more effective in the present investigation than 5FU, MMC·5FU and ADM·5FU therapy. Consequently, we concluded that it is necessary to determine not only appropriate operative indications and lymph node dissection but also effective chemotherapy in P (+) cases.

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To identify the problem of surgical treatment for the aged patients with gastric cancer, the clinico-pathological findings in 66 patients over 80 years of age (Group A) were compared with those in 4066 patients under 74 years of age (Group B). The conclusions were as follows: 1) There was no difference in resectability and rate of total gastrectomy. The operative mortality was 5.3% in group A and it was significantly higher than that in group B (p<0.05). The frequency of postoperative complications was high (22.8%) in group A. 2) Charactaristics of carcinoma in group A was clear differentiation of histology and tendency of high grade advancement in lymph node metastasis. 3) Except for other cause of death, the five-year survival rate with curative resection was satisfactory in group A (66.2%u). 4) A lowering preoperative %vc should be considered a risk factor for postoperative complications in group A. These results suggest that radical resection should be performed in aged patients over 80 years old if their general condition allows it. If not, rational surgical procedures are desirable.

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Patients were examined after total gastrectomy for bone metabolism, intestinal absorption, and anemia to determine pathology by comparison of long and short postoperative courses (group L and S respectively). The subjects, 31 patients in group L and 21 in group S, were classified into two categories according to surgical procedure: jejunal interposition (41 cases) and Roux-en-Y (11 cases). Incidence of bone metabolic disorders was 57.1% for group S and 42.9% for group L; the difference was not significant, nor did the incidence show any difference between the two groups when stratified by surgical procedure and age. Intestinal absorption of protein and fat was poorer in group L than in group S. In paticular, poor absorption was prevalent in cases of Roux-en-Y where the duodenum was bypassed. Anemia was noted in 44.4% of patients from group S and 55.6% from group L; iron deficiency anemia tended to occur during the early postoperated period, whereas erythroblastic anemia tended to develop during the extended postoperative period. These result indicate that periodic dietary guidance and checks for anemia are required during the extended post-operative period and that duodenal bypass should be avoided when possible.

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Selective proximal vagotomy with mucosal antrectomy (SPV + MA) is known to disturb the function of gastric evacuation due to the performance of an anastomosis near the pyloric ring. To prevent this problem, the antral mucosa should be preserved as much as possible. If too much antral mucosa is preserved, gastric acid output is not reduced. Dogs were used to investigate the interrelation between the preservation of the antral mucosa and gastric acid output, a 1-cm, 2-cm, or 3-cm band of antral mucosa was preserved, and gastric endo-exocrine function and gastric emptying were examined before and after MA as well as SPV + MA. Following SPV + MA with the 3-cm band of antral mucosa preserved from the pyloric ring, there was hypergastrinemia but a sufficient reduction of acid production was noted (MAO: 46.6%; IAO: 90.0%). Furthermore, the evacuation of both liquids and solids was observed to be satisfactory. Therefore, it was concluded that the antral mucosa can be preserved for up to extended 3 cm from the pyloric ring.

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To clarify the optimum extent of lymph node dissection in the surgical treatment of gastric cancer accompanied by liver cirrhosis, we recently analyzed the results of preoperative examinations, intraoperative findings and extent of lymph node dissection in relation to postoperative complications in 28 cases of cirrhosisaccompanied gastric cancer. The following results were obtained. 1. The incidence of postoperative complication was as high as 71% (28% for severe complications). 2. Factors associated with the high incidence of severe complications include Child C, preoperative serum GOT over 80 U/l, bilirubin over 1.1 mg/dl, albumin below 3.0 g/dl and ICG R15 over 35%. 3. The incidence of severe complications was high in cases where intraperitoneal venous dilation was found during the operation. 4. In cases accompanied by severe liver cirrhosis, complications occurred even when the extent of lymph node dissection was limited. 5. In cases showing intraperitoneal venous dilation, No.12 lymph node dissection increased the risk of severe complications and the mortality rate. 6. The five-year postoperative survival rates were 56% for early cancer and 14% for advanced cancer. Patients frequently died of hepatoma or liver failure. These results indicate that both the stage of gastric cancer and the status of liver cirrhosis should be considered in surgical treatment of cirrhosis-accompanied gastric cancer, and that lymph node dissection should be minimized in such cases.

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Results of hepatectomy for 21 patients with small liver cancer and 41 patients with non-small liver cancer, excluding absolutely non-curative resections, were analyzed. The survival rates for small liver cancer and nonsmall liver cancer were as follows: 3-year survival, 95% and 44%, respectively; 5-year survival, 61% and 33%, respectively. The survival rate for small liver cancer was significantly higher than that for non-small liver cancer (p<0.01) and the mortality due to carcinoma of small liver cancer was significantly lower than that of non-small liver cancer (p<0.05). However the rate of recurrence in the two groups was not significantly different. The disease-free interval for small liver cancer was significantly longer than that for non-small liver cancer (p<0.05) and the rate of solitary intra-hepatic metastasis or a second primary lesion of small liver cancer was significantly higher than that of non-small liver cancer. The rate of re-operation for intrahepatic recurrence of small liver cancer was significantly higher than that for non-small liver cancer (p<0.05). It is concluded that long-term follow-up is necessary for small liver cancer after hepatectomy and that re-operation for a solitary recurrence is important for the long-term survival of patients with small liver cancer.

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Clinicopathological studies of 44 ductal carcinomas of the head of the pancreas revealed 39 cases of retroperitoneal invasion (rpe) and 40 cases of perineural invasion in the pancreas. In the 39 rpe cases, perineural invasion in the plexus was observed in 27 cases (69%). Neither perineural invasion in the pancreas nor that in the plexus bore any relationship to tumor size. There was no correlation between the degree of intrapancreatic perineural invasion and that of lymphatic invasion or lymph node involvement. However the degree of perineural invasion in the plexus had a statistically significant correlation with that of intrapancreatic perineural invasion. The cases of positive plexus invasion showed high frequency of lymph node involvement. in particular, the No.14 lymph node. In cases of absence of involvement of No.14 lymph node, 10 involved perineural invasion in the plexus, particularly in the second portion of the extrapancreatic plexus. These results indicate that perineural invasion is a different manner of invasion from that in lymph node metastasis. We concluded that complete dissection of the extrapancreatic plexus, including the lymph nodes and soft tissue around the pancreas is necessary in order eradicate ductal carcinoma of the pancreas.

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In 64 cases of colorectal cancer with synchronous liver metastasis, we assessed clinical and pathological findings and long-time results by surgical technique. 1) Evaluation of the degree of liver metastasis showed that there were 27 cases of H₁, 11 cases of H₂, and 26 cases of H₃, right lobe metastasis accounted for 88.9% of the H₁ cases. In cancer of the left large intestine where blood flows into the inferior mesenteric vein, the cancer tended to be metastasized not only to the right lobe but also to the left lobe. 2) In cases where the primary lesion was resected, comparison of prognosis by the degree of liver metastasis by the degree of liver metastasis showed that H₃ had extremely bad prognosis. 3) Prognoses were compared among a group of H₁ with hepatectomy (Group A), a group of H1 with colorectal resection (Group B), a group of H₂ with colorectal resection (Group C), a group of H₃ with colorectal resection (Group D), and a group without resection (Group E). The results indicated that Group A had a better post-operative short survival rate under a year than Group B. With comparison of Group B, C and D which underwent only resection of the primary lesion with Group E, extremely poor prognoses in Groups D and E were noted. 4) It was expected that at least in the H₁ cases, hepatectomy would produce an improvement in prognosis. However, primary lesion resection as reduction surgery in H₃ cases was not significant.

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Twenty-nine patients with hepatic metastasis from colorectal cancer were reviewed for their long-term surgical outcome after hepatic resection. The extent and the multiplicity of the hepatic metastasis was categorized as H₁, H₂, H₃ according to the general rules for clinical and pathological studies on cancer of colon, rectum and anus. This study found 3 year survival rates of 54%, 0%, 33% and 0% for patients with resected H₁, unresected H₁, resected H₂ and unresected H₂, respectively. The difference between the resected and unresected cases was statistically significant for both in H₁ and H₂ metastasis. In the 21 resected H₁ patients, the influence of several factors on survival rate was evaluated. The factors included age, sex, operative procedure, timing of operation, number and size of metastatic lesions and the effect of transcatheter arterial embolization (TAE). Maleness was the only variable that had a favorable influence on prognosis. In light of the fact that there was no significant difference in terms of prognosis between partial resection and anatomical segmental resection, partial resection was considered adequate for H₁ liver metastasis. The incidence of recurrence after the resection of H₁ liver metastasis was 52% (11cases), with the liver the most common site of recurrence (73%, 8 cases). Based on the above-mentioned findings, resection is recommended for hepatic metastasis from colorectal cancer, with partial resection used as a standard procedure, but recurrence in the residual liver is so frequent that measures should be taken to prevent it.

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The Clinicopathological features of colorectal carcinoma in young patients (under 30 years old) and older patients examined in our department were compared. There were 12 young patients, who accounted for 2.2% of a total of 534 patients with colorectal carcinoma. Three of the 12 patients had rectal cancer with abdominal pain as the chief complaint among clinical signs, and the incidence was higher than that in older patients. When examined according to histological type, there were only 2 cases of highly-differentiated adenocarcinoma, which was as low as that in the older patients. Thus most of the young patients showed poorer differentiation. Determination of the histological degree of invasion revealed a significantly large number of cases (55.6%) of infiltration to other organs. There was peritoneal dissemination in 3 cases (27.3%), and there were 4 stage V cases (44.4%). In most of the young patients the lesion progressed after surgery. These findings were considered to explain the low rate of resection and the poor end results after resection. However, the results after curative resection were satisfactory, suggesting that thorough examination is necessary for early diagnosis, taking into consideration the existence of colorectal carcinoma even in young people.

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Sexual function was evaluated after personal interview in 33 male patients and after examination of sexual function in 6 of these, in whom resection for carcinoma of the rectum with preservation of pelvic plexus nerves and/or hypogastric nerves was performed. From the results of questionnaire, total impotence was found to have occurred in 18.2%, and no inability to ejaculate in 66.7%. Sexual dysfunction occurred at high incidence in the group of patients who had undergone extensive lymph node dissection and abdominoperineal resection. In 14 patients in whom neither the hypogastric nerves nor the pelvic plexus nerves were injured, 7.1% total impotence, and 21.4% had ejaculatory inability. From the results of examination of sexual function, in 3 of 5 patients, the level of follicle-stimulating hormone was elevated. Penile blood pressure index was not decreased in 5 patients postoperatively. Semen was reduced in all patients. It is suggested that pelvic autonomic nerve-preserving operations should be undertaken only in cases preoperatively diagnosed as relatively early stage carcinoma of the rectum, and that examinations are useful for the evaluation of male sexual function.

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A fourteen-year-old girl with a corrosive stricture in the esophagus accompanied by an esophagotracheal fistula underwent esophagoplasty by introduction of a latissimus dorsi myocutaneous flap into the thoracic cavity. Leakage on the anastomotic line was evident three weeks after the operation, but was localized in the flap and healed spontaneously within three months. For corrosive stricture of the esophagus, a bypass operation using a gastric or colonic pedicle graft is commonly performed. However, we performed this operation for the perposes; first to undergo esophagoplasty using cutaneous one of myocutaneous flap and reinfoce the closure of the esophagotracheal fistula using muscle flap, and secondly to preserve the esophagus as much as we can. The other side, from our experience, as esophagoplasty using the latissimus dorsi myocutaneous flap, postoperative complications such as leakage or stenosis on the anastomotic line require careful attention.

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We have experienced three cases of primary malignant melanoma of the esophagus over the past ten years. All three patients complained of dysphagia. All the tumors were elavated or polypoid lesions located in the middle-lower portion of the esophagus, as is usual with esophageal melanoma. Case 1, a 69-year-old male. As the endoscopic biopsy specimen was diagnosed as anaplastic carcinoma, preoperative irradiation was carried out. Though the tumor size was definitely decreased four months after diagnosis, there were multiple metastases of the liver and lung at surgery. The patient died one month after the palliative resection. Case 2, a 60-year-old male. Multiple metastases were already apparent at the diagnosis. Chemo-endocrine therapy (DAV, OK432) was selected, but was not effective. The patient died six months after admission. Case 3, a 56-year-old female. Lower esophagectomy with total gastrectomy was performed one month after the diagnosis, and postoperative adjuvant chemotherapy (DAV) was added. This patient has survived for sixteen months with no evidence of recurrence. Early hematogenic or lymphogenic metastasis is common in the case of malignant melanoma of the esophagus. Our three cases suggest that early resection following diagnosis, associated with postoperative irradiation or chemo-endocrinetherapy, is the best choice for long-term survival of patients with malignant melanoma of the esophagus.

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On the surgical treatment of cervical esophageal cancer, combined resection of surrounding organs has occasionally been performed. When total thyroidectomy is indicated, administration of thyroid hormone is indispensable during the postoperative fasting period. In these cases, however, administration of thyroid hormone has some problems because it is only prepared for oral use. We tried transrectal administration of thyroid hormone in the form of a suppository on a patient with total esophagectomy combined with total thyroidectomy to prevent a decline in serum levels of thyroid hormone. A 58-year-old man, complaining of dysphagia, was diagnosed as having cervical esophageal cancer. Total esophagectomy combined with resection of the bilateral thyroid and parathyroid, lower pharynx and larynx was performed because of tumor invasion into these organs. During 3 weeks after operation, suppository of thyroid hormone was used to prevent the decline of its serum levels. Trasrectal administration of thyroid hormone seems to be useful to treat fasting patients with cervical esophageal cancer after esophagectomy combined with thyroidectomy.

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We report a case of gastric anisakiasis with a very peculiar finding. A 66-year-old man complained of abdominal pain, vomiting and high fever on Aug. 27, 1989. The next day, he was admitted to another hospital with suspected acute abdomen. Gastrofiberscopy, transendoscopic biopsy and CT were performed and gastric cancer and peritonitis carcinomatosa were diagnosed. After transfer to our hospital gastrofiberscopy was performed, but this time the biopsy was negative. We carried out a laparotomy suspecting Borrmann type 4 gastric cancer. However, we could not find any cancer cells in the resected specimen. A perforation site was found at the greater curvature, and there was an inflammatory granuloma just outside the gastric wall. An ulcer scar was found at the lesser curvature with a foreign body in it, which was suspected to be an Anisakis larva. Perforation and ulceration of the stomach caused by anisakiasis is very rarely reported in Japan. Furthermore, we had diagnosed gasric cancer by the preoperative endoscopic biopsy, but no evidence of cancer cells was found in the resected specimen.

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A 70-year-old man was admitted to our hospital with the complaint of speech and dysarthric disturbance. He had a hematoma in the left lobe of the his brain. During conservative therapy, he had a sudden bleeding shock. Endoscopic examination showed a type IIc, early gastric cancer at the upper body of the stomach, but there was no evidence of bleeding. Abdominal CT and ultrasonography revealed an intra-abdominal hematoma under the liver, so abdominal angiography was performed. The findings revealed aneurysms of the left gastric artery. Total gastrectomy was performed under the diagnosis of a ruptured aneurysm of the left gastric artery with early gastric cancer and he recovered. Ten cases of this rare disease have been reported in the Japanese literature. In si patients, the aneurysms ruptured, and they were treated appropriately and recovered. As shown in these cases, the outcome of a ruptured aneurysm has improved recently, however, it is still difficult to diagnose. If you see a patient with abdominal pain of unknown origin and sudden shock, you should consider an aneurysm of the gastric artery.

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We report two cases of duplication of the alimentary tract lined with ciliated pseudostratified columnar epithelium. One patient is an asymptomatic 14-year-old male. Duplication of the stomach was incidentally found by computed tomography. On laparotomy, the duplication cyst, 7×4×4 cm in size, was found to be firmly attached to the posterior wall of the stomach, and in part shared a common muscular wall with the stomach. Histologically, the cyst was lined with ciliated pseudostratified columnar epithelium, and it's wall was composed of three welldeveloped muscular layers. The other patient is a 15-year-old male with complaints of abdominal pain and vomiting. Laparotomy was carried out because of ileus. A duplication cyst, 10×6.5×6.5 cm in size, was found on the ileum and was complicated by volvulus. Histologically, the cyst was lined with ciliated pseudostratified columnar epithelium, and there was a common muscular layer between the cyst and the ileum. Duplications of the alimentary tract are of various types, presumably because they arise from several types of developmental errors. As is often the case with duplication of the esophagus, in our cases the cysts were lined with ciliated columnar epithelium. Thus, based on anatomical and histopathological features, we favor a primitive foregut origin for our cases.

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A 69-year-old man was admitted to our hospital with dull upper abdominal pain and appetite loss. Ultrasonography and CT showed about a 7 cm hepatic tumor in the S5 area. Abdominal angiography showed that anterior inferior branch of the hepatic artery and portal vein was dislocated. Extended right lobectomy was performed. In pathologically, the tumor was diagnosed as a scirrhous type of hepatocellular carcinoma. Flow cytometric analysis showed the tumor had an aneuploid pattern. The patient died of bone metastasis on the 8th month after the operation. This case was considered to be highly malignant.

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We experienced a case of adenosquamous carcinoma of the liver with hepatolithiasis. The patient was a 74-year-old man having epigastralgia and pyrexia as chief complaint, who came to our hospital for suspected hepatolithiasis and choledocolithiasis. Various examinations suggested a complication of hepatolithiasis and hepatic abscess, for which a left lobectomy was performed. Pathohistologically, cholangiocarcinoma and squamous cell carcinoma were found adjacent to the left bile duct and in the lateral superior segment, respectively, leading to the diagnosis of hepatolithiasis complicated by adenosquamous carcinoma of the liver. Liver metastasis occurred 3 months postoperatively, resulting in death from hepatic insufficiency 9 months later. Adenosquamous carcinoma of the liver was reported for the first time by Pianzola et al. in 1971 and has been reported 21 times since then. Although an intrahepatic site of squamous cell carcinoma is still controversial, we believe in the present case that the squamous cell carcinoma originated in cholangiocarcinoma, and the possible involvement of hepatolithiasis in cholangiocarcinoma was also suggested.

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Hepatocellular carcinoma accompanied with tumor thrombus in the inferior vena cava was resected. Tumor thrombus extended from the right hepatic vein to just below the right atrium. Mobilization and resection of the liver, partial resection of the vena cava and removal of the tumor thrombus were performed on the in situ hypothermic perfusion of the liver under vascular isolation. Bio-Medicus pump was used for Veno-veno bypass. Although the total ischemic time of the liver was 70 minutes, the liver seemed to be well preserved. The maximum postoperative values of GOT and TB were 187 K.U. and 2.6 mg/dl, respectively. Now, 15 months after operation, there is no evidence of recurrence. This case shows the feasibility of resection therapy for hepatocellulacarcinoma severly invaded to the vena cava.

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A 52-year-old man with hypertension and chronic hepatitis was found SOL in the left lateral segment of the liver. Liver function tests gave no cirrhotic results on admission. Echogram showed central scar-like high echoic lesion in the eccentric part of low echoic mass. By fast scan of MRI the tumor showed lineal low signal intensity in a radiating fassion. CT and angiography gave no evidence of both HCC and FNHP athologically incomplete capsule, lack of bile ducts, and partial pseudograndular pattern suggested HCC, although lack of cholestasis and focal nodular growth suggested FNH. The scar-like lesion in echogram was recognized as a medular focallegion, and the stellate septum-like appearance in MRI was recognized to be blood vessels. These were consideredto be the causes of difficulty of pre-operative differentiation between HCC and FNH.

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Xanthogranulomatous cholecystitis (XGC) is a disease which is difficult to differentiate from gallbladder carcinoma. We report a case of XGC diagnosed preoperatively by imaging diangosis. The patient was a 54-year-old woman, who was referred to our hospital because of suspicion of a gallbladder tumor subsequent to right upper abdominal pain. Abdominal ultrasonography (US) showed a thickened gallbladder wall with a nodular hyperechoic lesion and a giant stone as much as 5 cm in the major axis. Contrast-enhanced computed tomography (CE-CT) revealed a low density area in the gallbladder wall. Angiographic findings revealed expansion and tortuosity of the cystic artery, but no encasement. Cholecystectomy was performed under the diagnosis of XGC. The resected specimen contained yellow nodules, distributed in agreement with the US and CT findings, in the gallbladder wall. Histological examination of the specimen revealed xanthoma cells, lymphocytes, and foreign body giant cells, leading to the diagnosis of XGC.

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A 41-year-old woman with a chief complaint of a tumor of the umbilicus who had had right hypochondoraligia since her youth was diagnosed by ultrasonography, computed tomography and other examinations as having carcinoma of the gallbladder with umbilical metastasis. Cholecystectomy with partial hepatectomy, lymphnode dissection, partial resection of the transverse colon and resection of the umbilicus was performed. An anomalous arrangement of the pancreaticobiliary ductal system (AAPBDS) without dilatation of the biliary tract was revealed by intraoperative chorangiography. The disorders of liver function continued postoperatively dueto regurgitation of pancreatic juice into the biliary tract. This case was a typical case of AAPBDS with carcinoma of the gallbladder, but was a rare case as carcinoma of the gallbladder with hematogenous or lymphogenous metastasisto the umbilicus. In carcinoma of the biliary tract in younger patients or those with chronic cholecystitis without gall stones who have had right hypochondoralgia since their youth, we should attempt careful examination while always keeping AAPBDS in mind. And we should select the pancreaticobiliary ductal diversion evenfor AAPBDS without dilatation of the biliary tract after dissection of the peribiliary lymphnodes, to prevent regurgitation of pancreatic juice into the biliary tract.

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Most of the hilar carcinoma have been diagnosed when jaundice appeared. Non-icteric patients with hilar carcinoma were uncommonly diagnosed before surgical operation. We experienced two cases of non-icteric hilar carcinoma which were diagnosed by ultrasonography and ERCP on occasion to slight liver dysfunction. Case 1 is 68 year old male, with elevation of Transaminase and alkalinphosphatase. ERCP was performed, revealing hilar carcinoma. Curative operation was performed and histology revealed adenocarcinoma. Case 2 is 66 year old male, who was admitted to our hospital complaining of abdominal pain and slight liver dysfunction. ERCP revealed cancer of the common bile duct with infiltration into hilar region. At surgery, tumor was removed by hepatectomy. Histology revealed adenocarcinoma. We must pay attention to the patients with slight liver dysfunction, especially the elevation of alkalinphosphatase and γ-GTP, keeping in mind of cancer of the bile duct.

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Solid and cystic tumor of the pancreas is a rare low-grade malignant tumor occurring chiefly in young women. We report the case of a 49-year-old woman who received a pancreatoduodenectomy for a tumor in the uncal region of the pancreas. The tumor mass was 7×5×5 cm in diameter and well encapsulated. The cut surface showed extensive necrosis and hemorrhage except for some solid areas along the inside of the capsule. Histologically, sheets of tumor cells surrounding thin-walled vessels containing erythrocytes were predominant with some oval cells arranged about a fibrovascular stalk or a small blood vessel and focal invasions of the fibrous capsule. In addition, most tumor cells negative for Grimelius' stain were immunohistochemically positive for α₁-antitrypsin and showed no immunoreactivity with insulin, glucagon, estrogen receptor or progesterone receptor. These findings suggest that the tumor cells were capable of differentiation to acinar cells and had malignant potentiality.

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A case of a mucin producing cancer of the pancreas with a calcified metastatic lesion in a 76-year-old female is reported. Abdominal radiography showed calcification in the left upper quadrant. Ultrasonography and computed tomography revealed a calcified tumor in the tail of the pancreas and a tumor with calcification in the liver. The findings of endoscopic retrograde pancreatography corresponded to type 3 in our endoscopic retrogracde cholangiopancreatography classification of pancreatic cancer, that is, the condition was diagnosed as filling defects in the dilated main pancreatic duct. The preoperative diagnosis was a mucin producing cancer of the pancreas, liver metastasis and direct invasion of the transverse colon. Resection of the body and tail of the pancreas, splenectomy and partial resection of the transverse colon were performed. Microscopic examination indicated mucinous adenocarcinoma. The mechanism of calcium deposition in this case was believed to be dystrophic calcification. Five cases of mucin producing tumor of the pancreas with calcification were previously reported.

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A clinicopahtological evaluation of seven patients with nonfunctioning islet cell tumors of the pancreas was undertaken. All patients were women. Four of the tumors were diagnosed pathologically as malignant and the others were benign. All four tumors diagnosed as malignant were over 10 cm in diameter. None of the patients had any specific clinical symptoms or laboratory findings, but angiography was very useful for diagnosis. The tumors were most frequently located in the body and tail of the pancreas. All patients were surgically treated and macroscopically all tumors were curatively resected. The operative procedures were pancreaticoduodenectomy in two patients, distal pancreatectomy in three patients and extirpation of the tumor in two patients. As one of the patients has survived for more than 13 years after her tumor was diagnosed as malignant, prognosis of this disease seems to be relatively good. But the other patient whose tumor was extirpated died of recurrent hepatic metastasis and peritonitis carcinomatosa. After an adequate operative procedure, detailed examinations of the resected specimens and careful follow up are significant.

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Postoperative sudden and massive arterial bleeding caused by pancreatic fistula or suture insufficiency after gastric surgery for cancer is one of the fatal complecation. We developped a new method against this condition-a continuous open peritoneal irrigation. After the ligation of the ruptured artery, an abdominal wound will be kept open for continuous irrigation. Under this condition, activated digestive juice is diluted and removed completely. By using this method recent four consecutive patients recovered from this serious condition. A continuous open peritoneal irrigation seems to be effective agaisnt massive arterial bleeding due to pancreatic fistula or suture insufficiency after surgery for gastric cancer.

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A case of adenocarcinoma derived from Meckel's diverticulum is reported. A 46-year-old male Caucation was admitted to the hospital with lower abdominal pain. From highly elevated serum CEA level (124 ng/ml), and small intestinal X-ray and selective angiographic findings, he was diagnosed as having ileal cancer. At laparotomy, a tumor (about 2 cm in diameter) was found 60 cm orally from the ileum end in an anti-mesentric portion. In addition, regional and para-aortic lymph nodes showed metastatic swelling. Partial resection of the ileum and partial dissection of the lymph nodes were carried out. Macroscopically, the tumor was covered with normal intestinal mucosa. Pathologic examination revealed a tubular adenocarcinoma producing mucous, infiltrating below the muscularis mucosae, and surrounded by a proper muscle layer, which confirmed that it originated from the diverticulum. After the operation, the patient was treated with chemo-immunotherapy based on an anticancer drug sensitivity assay. He has been alive for about one and a half years.

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The case of three young siblings with multiple colorectal carcinomas and multiple primary cancer sites are reported. Additionally, three other relatives were found with cancer in their history, and the family was thought to have cancer family syndrome, as proposed by Lynch et al. Their grandfather was known to have a rectal carcinoma. And their mother had malignant lymphoma, multiple colon cancer and uterine cancer, and died of malignancy. Also her sister had died of uterine cancer. Among three siblings in the third generation, a total 14 lesions of colorectal carcinomas, a uterine carcinoma and an ovarian carcinoma were already identified up to the present. We reviewed eighteen cancer family syndrome (CFS) families reported in Japan. The analysis showed that 74 patients of them had colorectal cancer. Among the patients with colorectal cancer, the ratio of men to women was 1: 0.9, and the onset of cancer was most frequent in the fourth decade of life. Proximal colon cancer in these patients occurred more frequently than in patients in the general population. Twenty-one of the 74 patients (28%) had multiple colorectal carcinomas, and 21 of the 74 patients (19%) had multiple primary cancer. Aside from endometrial cancer, which is one of the diagnostic criteria for CFS, gastric cancer was found most frequently in non-colorectal cancer patients.

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A 21-year-old Japanese man complained of chronic recurrent gastrointestinal bleeding. Superior mesenteric arteriography revealed an arterio-venous malformation in the ileocecum, and ileocecal resection was performed. Histologically, the lesion was ileocecal angiodysplasia mainly in the cecum. The area of angiodysplasia contained numerous dilated and tortuous thin-walled vessels, one of which was ruptured, in the mucosal and the submucosal areas. The predominant site of bleeding intestinal angiodysplasia is the cecum or ascending colon in elderly patients, for whom selective visceral angiography (SVA) and colonoscopy are commonly used for diagnosis. What makes this case noteworthy is that the patient was young and the presence of colonic angiodysplasia was revealed only after SVA identified the lesion.

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It is well known that the cancerous invasion into the perineural space is often observed in malignancies of the pancreaticobiliary system. As far as carcinomas of the digestive tract are concerned, however, there have been very few studied so far in Japan. Articles in several western journals have reported perineural invasion in 20 to 30% of whole rectal carcinomas, and that could be the cause of local recurrence and serious pain. In the case presented here the patient had intrapelvic recurrence of colonic carcinoma and developed acute and severe pain in the left thigh and buttock. The recurrent tumor was shown to grow mainly between the bladder and the rectum and to invade the left lateral pelvic wall. Pathological studies following resection showed marked perineural invasion at the periphery of the lesion. Microscopic study of serial sections of the specimen revealed that the distance of invasion into the perineural space reached 1.5 cm from the main tumor margin. This fact suggests that perineural invasion might be one of the major factors of local recurrence of colorectal carcinoma and the cause of pain when recurrence has developed. Careful attention should be paid to the lateral surgical margin at the time of resection and the indications for nerve-preserving surgery should be very strict.

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