For patients who experienced rebleeding and/or no variceal change after repeated sclerotherapy (14 cases) as well as for those who underwent emergency sclerotherapy (2 cases), we performed esophageal transection with devascularization along the distal esophagus and the proximal stomach. The patients underwent sclerotherapy using 5% ethanolamine oleate 1 to 9 (3.8 on average) times, and 7 days to 15 months (8 months on average) before transection. Transection modified by a fundic patch operation (15 cases) or transection using EEA with fundoplication (1 case) was performed. Multiple preoperative sclerotherapy resulted in thickening and indistensibility of the esophageal wall and its hard fibrous adhesion to surrounding organs, and it increased the operation time, the volume of intraoperative hemorrhage and the frequency of vagotomy. No postoperative suture insufficiency occurred. The cumulative rate of recurrence of varices and survival of the patients were almost the same as those for patients who underwent transection without preoperative sclerotherapy. We concluded that the method of transection by a fundic patch operation has an advantage in elective surgery for the patients who had previous multiple sclerotherapy or in emergency surgery immediately after sclerotherapy.

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Long-term results for 401 patients with esophageal carcinoma were reviewed according to the new TNM staging system (pTNM, 4th ed. 1987). The 5-year survival rates for patients with carcinoma classified as Stage 0, I, IIA, IIB, III and IV were 100%, 84%, 47%, 24%, 17% and 14%, respectively. Among the patients with early stages from 0 to IIA, stage grouping reflected survival rate well. However, among the patients with advanced stages from IIB to N, the correlation was not as good. The survival rate for patients with Stage IIB was more similar to that for patients with Stage III or N than was that for Stage IIA patients. Moreover, survival curves for patients with Stage III and IV overlapped and there was no difference between them. We propose the following revisions for this TNM staging system. Individualization should clarify two groups regarding lymph node involvement, one for patients with the involvement one for those without it; and similarly two groups for patients with and without a lesion invading adjacent structures, because statistically significant differences in survival rate were found between the pairs in both of these groups. Moreover, some metastases beyond regional nodes might be excluded from the M1 category falling under Stage N and included in the N2 category ranking above organ metastasis, since a better survival rate could be expected to some extent as a result of dissection of such lymph nodes.

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One hundred ninety-two cases of esophagogastric varices treated surgically during the past 20 years in our surgical department were divided into the following three groups: group I (esophageal varices alone) 111 cases; group II (esophageal and gastric varices) 72 cases and group III (gastric varices alone) 9 cases. The clinical findings and operative results in the three groups were compared. No significant difference was found in age, sex ratio, underlying liver disease and grade of liver dysfunction among the three groups. Of the angiographic collateral venous patterns, the left gastric venous dominant type was the most frequent pattern in group I and group II while it was the least frequent pattern in group III. Portal venous pressure was significantly low in group III (p<0.01). The grade of gastric varices was significantly more severe in group III than in group II (p<0.01), and the main location of gastric varices was the cardia in group II while it was the fundus in group III. The incidence of variceal hemorrhage was highest in group II, but an emergency operation was necessary most often in group III. Gastric varices were more frequently reduced (86.8%) than esophageal varices (74.2%) by any operative procedure (p<0.05).

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The significance of para-aortic lymph node dissection in gastric cancer was studied from the viewpoints of histological metastasis and the investigation of lymphatic flow by using activated carbon (CH40). Investigation of lymphatic flow in 66 cases of gastric cancer revealed a high staining rate in the para-aortic lymph nodesregardless of the carbon injection site in lymph nodes of the first group. However this finding did not completely conform to the actual state of lymph node metastasis according to the cancer location. Para-aortic lymph nodes were dissected in 257 clinical cases and metastases were seen in 59 cases (23.0%). The metastatic rate increased with depth of the cancer. High metastatic rates were obtained in macroscopic type 3, type 4 and histologically undifferentiated type. As the lymphatic invasion advanced the metastatic rate increased. Concerning the location of the cancer and the site of metastasis in the para-aortic lymph nodes, the metastatic rate was high on the left side of the aorta in cases of C area cancer, while metastasis was observed on both sides of the aorta in cases of M and A area cancer. Therefore, careful dissection of the para-aortic lymph nodes should be performed in M and A area cancer. Thirty cases in the n3 (-) group among 59 cases with n4 (+) showed a significantly better outcome than the 29 cases in the n3 (+) group (p<0.01). This finding shows the significance of dissection of the para-aortic lymph nodes. According to our results, this lymph node dissection should be performed in cases exceeding subserosal invasion (S1) and N2 (+).

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In 56 patients aged over 70 years with gastric carcinoma who were treated by total gastrectomy, we examined the relationship of the incidence of complications and hospital mortality rate to preoperative test results (the number of abnormal test items), the degree of cancer advance (stage, P factor, H factor) and surgical stress (R number, number of combined resections with other organs, thoracotomy, amount of blood loss, and time required for the operation). Of all patients, 23.2% developed complications and 17.9% died in the hospital. Major complications include anastomotic leakage, ileus and myocardial infarction. The major causes of death were respiratory and cardiac failure. Preoperative test results, cancer stage and surgical stress did not correlate with the incidence of complications. However, the incidence of complications was significantly higher in P (+) or H (+) cases than in Po or Ho cases. As a rule, elderly patients with gastric carcinoma should be treated with a curative operation by total gastrectomy accompanied by R2 or more extensive lymph node dissection (including dissection of the para-aortic lymph nodes) and excision of other affected organs. However, the results from this study indicate that total gastrectomy is not indicated in P (+) or H (+) cases.

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In the postoperative follow-up of gastric cancer patients, it is very important to examine the mucosal changes in the remnant stomach. For a pathological study of the mucosal changes following gastrectomy, 58 patients who had undergone distal gastrectomy for gastric cancer were divided into three groups according to the mucosal condition of the resected stomach at the time of surgery, as follows. Group A: the F-line was completely visible in the resected stomach, group B: the line of resection was located across the F-line, group C: the F-line was not detected in the resected stomach. Based on endoscopic biopsy tissue findings of the anastomotic regions and the corporeal regions of the remnant stomach, postoperative mucosal changes with time were studied in the three groups. The following results were obtained: 1) Hyperplastic changes in the foveolar epithelium (of the anastomotic regions) increased with time in group A. Such changes were marked in group C within 2 years of surgery, then gradually diminished, especially after 5 years. 2) The intestinal metaplasia tended to increase with time in both the anastomotic regions and the corporeal regions in all three groups. Patients who had no such metaplastic changes at the time of the operation were found to have developed intestinal metaplasia in the remnant stomach within 2 years of surgery, which spread progressively in periods of 2-5 years and more than 5 years. 3) Inflammatory cell infiltration was more marked in the anastomotic regions than in the corporeal regions, but these findings did not change with time.

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To clarify the characteristics of a cancer of the gastric remnant, clinicopathological findings were compared with those of a primary cancer located in the upper third of the stomach. Twenty-two patients had a laparotomy under a diagnosis of a newly appearing cancer of the gastric remnant 6 years and 6 months to 27 years after distal gastrectomy. The distal gastrectomies had been performed for cancer in 13 cases, for a peptic ulcer in 6 cases and for an other benign disease in 3 cases. A newly appearing cancer of the gastric remnant is defined as one in a patient who has survived for more than 10 years after the first distal gastrectomy or when the cancer is considered to have nothing to do with the first gastric lesion even if the second operation is performed within 10 years after the first operation. A lower resectability rate, a more advanced stage due to deeper serosal invasion and more frequent lymph node involvement especially in n3-4 and a poorer prognosis were indicated in patients with a newly appearing cancer of the gastric remnant than in 268 patients with a primary cancer located in the upper third of the stomach. In the histological classification, the differentiated type was more frequent in a newly appearing cancer of the gastric remnant than in the patients with primary cancer.

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Anti-tumor activities of peripheral blood lymphocytes (PBL) and regional lymph node lymphocytes (RLNL) in gastric cancer were studied. Natural killer (NK) and lymphokine-activated killer (LAK) activities of PBL were not affected in advanced cancer, but these activities of RLNL from proximal nodes were significantly depressed in stage IV cases, and in patients with organ metastases, moreover they were significantly suppressed in comparison with RLNL from distal nodes. NK activity of proximal nodes was decreased in patients with histologically welldifferentiated cancer. These results suggest that the depression of and-tumor activity of RLNL from proximal nodes is due to decreased NK cells and LAK precursor cells, which might be caused by some suppressive factors in advanced cancer.

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Peripheral blood lymphocytes (PBL number), T cell subsets (percentage), PHA-and Con A-induced lymphoblastogenesis and PPD, SU-PS skin tests were measured pre-and postoperatively in 51 patients with gastric cancer and were analyzed in 4 curative surgical groups divided according to the histological stages of cancer and the kind of operative procedure. On the basis of correlations among these parameters, the influence of surgical stress on immunological activity was determined. In many cases, PBL, PHA, Con A, PPD and SU-PS were depressed at PO2W and recovered at PO3M, and a decrease in OKT4 and a reduction in the OKT4/OKT8 ratio were also observed until PO3M, but these recoveries were delayed in the larger surgical groups and advanced stage groups (compared with those of the other groups). On the other hand, in the measurement of the T cell subset using two-color flow cytometry at the same time and during the operation in another 23 patients with gastric cancer, an increase in suppressor T cells (CD11 (+) ·CD8 (+)), and decrease in helper T cells (CD4 (+) ·E2H4 (-)) and cytotoxic T cells (CD11 (-) ·CD8 (+)) were already demonstrated about 2 hours after the beginning of the operation. Recently, we tried pre-operative immunotherapy using only OK432 in 48 patient with gastric cancer, in an attempt to obtain early recovery. But the planning of the treatment was inadequate to give a clear effect, and especially, in the more advanced cancer groups, the drug did not block the immunosuppression due to the operation. Therefore, more effective pre-operative immunotherapy is nessessary for advanced gastric cancer and the large surgical stress groups.

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To reveal the cell-biological character of carcinoma of the papilla of Vater, localization and distribution of carcinoembryonic antigen (CEA) and 5 cancer-associated carbohydrate antigens (CA19-9, CA50, Sialyl Le^x-i, Le^x, and Le^y) were studied in 16 carcinomas, 9 adenomas, and 4 specimens of normal tissue by the avidin-biotin-complex (ABC) immunohistochemical technique. CEA was present in 93.8% and CA50 in 81.3% of the carcinomas CEA, CA50 and the other antigens were mostly located in the cytoplasm as well as on the apical membrane of the cancer cells. CEA was present in 100% and CA50 in 77.8% of the specimens of adenoma in carcinoma tissue. In adenoma cells, CEA was located in the upper half of the cytoplasm as well as on the apical and basolateral surfaces (77.8%), whereas CA50, Le^x and Le^y were predominant on the apical surfaces alone (77.8%). These findings suggest that adenoma arises from the normal mucosa of the papilla of Vater, but that it might be different from cancer in terms of the intensity and the grade of each antigen.

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Bypass circulation for maintaining proper hepatic circulation during total clamping of the hepatoduodenal ligament was studied in mongrel dogs. Three experimental groups were prepared: a group with no hepatic inflow under total clamping of the hepatoduodenal ligament, accompanied by portal vein-inferior vena cava (IVC) bypass to portal congestion; a group with double bypass which consisted of both iliac artery-proximal portal vein and distal portal vein-NC; and a group with a single portal vein-portal vein bypass. Total clamping of the hepatoduodenal ligament immediately decreased the levels of ATP and energy charge in the liver. In the double bypass group, the hepatic blood inflow, hepatic tissue blood flow, tissue oxygen pressure, and the levels of both ATP and energy charge in the liver were maintained at normal levels, with no significant systemic circulatory dynamic or histologic changes. In the single bypass group, hepatic blood inflow, hepatic tissue blood flow and tissue oxygen pressure were decreased, although normal ATP and energy charge levels were maintained. The double catheter bypass method proved to be exellent for maintaining hepatic function and portal congestion during temporary clamping of the hepatoduodenal ligament. The single catheter bypass method was not satisfactory for maintaining hepatic circulation.

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Hepatic oxidative damage can be detected after ischemia-reperfusion and abnormal endotoxin levels. We have investigated the effects of the Pringle maneuver (temporal occlusion of the hepatic blood inflow) on normal dogs, dogs with obstructive jaundice and dogs with hyperbilirubinemia without obstructive cholestasis which was induced by cholangio-caval shunt. The Pringle maneuver only transiently altered the hepatic energy charge and increased lipid peroxide was not found in all three groups of dogs. After the maneuver endotoxemia was not detected in normal dogs and the delayed onset of slightly increased endotoxin level was found in dogs with cholangio-caval shunt. Hepatic total glutathione and α-tocopherol concentrations in both groups of dogs were within control ranges. However, in dogs with obstructive jaundice, this maneuver produced increased systemic and portal endotoxin levels with a decrease in hepatic total glutathione and α-tocopherol content. In conclusion, the Pringle maneuver in dogs with obstructive jaundice appears to trigger the liberation of free radicals by means of an increased absorption of enteric endotoxins. However, oxidative damage, measured as an increment in the content of lipid peroxides, was not detected.

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Eighty-five cases of carcinoma of the gallbladder during the past 10 years were reviewed. The average age of the patients was 69 years, and the male to female ratio was 1: 1.8. The most common symptom of the disease was abdominal pain. CT, angiography, and ultrasonography were the useful diagnostic measures. Among the 79 patients whose stages were clarified, there were 5 in stage II, 6 in stage III, and 68 in stage IV. Therefore most patients were in the advanced stages. As for the treatments, there were 9 patients treated by curative resection, 14 by non-curative resection, 19 by non-resection, and 43 by non-operation. Serum CEA values correlated with the progression of cancer and the histologic grade of differentiation of carcinoma. The 5-year survival rate after curative resection was 38%. The histologic type in all three patients who survived more than 4 years without recurrence was well-differentiated adenocarcinoma. The common sites of recurrence were the hepatic hilus and the liver. Regional lymph-node dissection to R2 extent is definitely necessary since recurrence at the hepatic hilus frequently occurred in the patients with insufficient lymph-node dissection.

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Four patients with unresectable bile duct cancer and six patients with unresectable pancreatic cancer were treated by thermochemothrapy with a radiofrequency (RF) capacitive heating system, and we investigated the heating efficiency of RF heating and the antitumor effect of the treatment. Hyperthermic treatment was applied once every 1-2 weeks with an intratumor temperature of 42°C or more for 30 minutes. A strong positive correlation was observed between the maximum RF output power and the maximum temperature at the tumor center. RF output of more than 1000 W produced an effective intratumor temperature of 42°C or more. The antitumor effect of RF hyperthermia increased with increasing output of RF energy. Partial or minor responses of the tumor were observed in five patients, and improvement in performance status and reduction in serum levels of carcinoembryonic antigen or carbohydrate antigen 19-9 were observed in six patients. In three of five patients suffering abdominal pain due to pancreatic cancer, the pain was reduced. Three of the five patients in whom a tumor response was found survived more than one year; one of them has survived more than two years. In comparison with historical controls treated by conventional chemotherapy alone, the survival periods were prolonged in patients who underwent combined thermochemotherapy. Our clinical results indicate that thermochemotherapy using the RF capacitive heating system is of therapeutic benefit in the treatment of unresectable bile duct and pancreatic cancers.

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Patterns of recurrence were examined in 40 patients who had resected of hepatic metastases from colorectal cancer. Twenty-five patients (62.5%) of these patients have had recurrence and 42.5% percent have had recurrence in the liver after hepatectomy. The hepatic recurrence rates did not correlate with the lobar distribution of metastases, number of lesions or surgical methods. As the size of the largest, tumors of over 5 cm were at an increases risk of having a recurrence in the residual liver. Positive pathologic margins were related to hepatic recurrence. The hepatic recurrence rate of aneuploid tumor was significantly higher than rate for diploid tumors. Eight patients received chemotherapy intrahepatically via a hepatic arterial catheter in selecting drugs by SDI test. The hepatic recurrence rate of patients with hepatic infusion chemotherapy was 25 percent, which was lower than the rate of 46.9 percent for ones without hepatic chemotherapy. The use of the SDI test will aid in selecting drugs for the prevention of hepatic recurrence after hepatectomy.

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An almost equal and parallel correlation was noted between CEA doubling time and tumor (volume) doubling time among patients with hepatic metastasis from colorectal cancer. Based on these facts, a chronological study was made of 30 cases of hepatic metastasis from colorectal cancer, with the following results.(1) When the patients were left totally or virtually untreated, the metastatic tumor cells (MTC) doubled an average of 41.5 times.(2) MTC in the liver were believed to have started proliferation an average of 4 years and 7 months before surgical resection of the primary lesion.(3) MTC had presumably doubled an average of 32.6 times by the time the serum CEA level began to rise exponentially.(4) When a definite image diagnosis of hepatic metastasis could be made, MTC should have doubled an average of 35 times, and the metastatic tumor attained a diameter of 3.2 cm.(5) It is considered that in patients with hepatic metastasis the tumor has already gone through nearly three-fourths of its natural course (from the onset of the seeded hepatic tumor growth to the patient's death), before clinical manifestation of liver metastasis. Cognizance of these chronological features, therefore, is of great importance for the diagnosis and treatment of hepatic metastasis from colorectal cancer.

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A total pf 635 patients with primary colorectal carcinoma were treated surgically at our clinic from 1977 through 1988. Invasion to adjacent organs was noted in 51 of the patients (8.0%). Tumor invasion was recognized in the stomach, duodenum, small intestine, urinary bladder, ureter and female genital organs. Most of the tumors had entirely circumferential growth and were diagnosed as type 3 in macroscopic classification. Pathohistological findings of these tumors revealed moderately differentiated adenocarcinoma. The rate of curative resection was 50% for colonic carcinoma and 55.2% for rectal carcinoma, but the rate was low in the transverse colon and lower rectum compared with other regions. The 5-year survival rate for curative resection was 73% for the patients with colonic carcinoma and 19% for those with ractal carcinoma. In the patients undergoing curative resection, patient's life was obviously prolonged in comparison with those undergoing noncurative resection or with nonresectable carcinoma. Because distant lymph node metastasis and hematogenous matastasis were comparatively few in spite of tumor invasion to adjacent organs. Therefore, speedy procedure for exact diagnosis of malignancy and active planning for combined resection including pelvic exenteration are needed in order to obtain better results in the patients without distant metastasis.

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Radiolabeled monoclonal antibodies against a variety of cancer associated antigens have already been clinically used for tumor imaging, but reports of specific antibody uptake by tumors are still rare. Therefore tumor targeting and localization experiments were performed by intravenously injecting nude mice bearing LS-180 (colon carcinoma) with 1251-labeled antibody (anti-CEA; 1B2), along with defibrinating agents urokinase and low molecular weight dextran to improve the vascular permeability of the tumor. Tumor activity 72 hr after administration, expressed as counts per minutes per gram of tumor and the percentage of the injected dose per gram of tumor in animals given the defibrinating agents was significantly higher than in the control group. Accumulation of the antibody in the tumor after administration of the mixture of these two agents was 48.3% higher than the control level, and the higher the number of doses and the concentration of the mixture administered to tumor bearing mice, the higher was the specific uptake by the tumor. However nonspecific high accumulation in normal organs, such as the liver, kidneys and spleen, was not observed. Therefore the tumor/blood ratio and the tumor/liver ratio were increased. These results indicated that the mixture of urokinase and low molecular weight dextran could be a useful tool for radioimmunodetection by making the radioactivity of the transplanted tumors high enough to distinguish them from normal organs.

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Esophageal cyst is a rare disease. We found such a cyst in a 53 year old male. On a routine upper endoscopy as part of a physical examination, a submucosal tumor was found on the lower esophagus. Right thoracotomy was performed under the diagnosis of a mediastinal tumor or esophageal leiomyoma by barium meal study, plain chest X-ray and chest CT scan. The tumor was located in the wall of the esophagus and it was presumed to arise from the esophagus. This tumor, 2.8×2.2×2.2 cm in size, was a monolocular cyst and contained thick greenish brown material. Microscopic examination revealed a lining of ciliated columnar epithelium. The underlying stroma contained double thick layers of smooth muscle, mucous gland, and Auerbach's plexus but no cartilage. It is rather difficult to differentiate an esophageal cyst from a paraesophageal bronchogenic cyst because of their foregut cyst origin. In this case, the esophageal cyst was considered from the microscopic findings.

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A 65-year-old man came to our hospital with the complaints of pain in the left upper abdomen and an abdominal tumor. After admission, he was diagnosed as having a gastric leiomyosarcoma and a pancreato-total gastrectomy with lymphnode dissection was performed on June 29, 1988. However, a poor defined mass was pointed out in the left abdominal wall in October, 1988, and he was treated with two cycles of EAP (adriamycin 20 mg X2, iv: cis-platin 50 mg X2, div: Etoposide 100 mg X3, div). The response was remarkable, and the effect was judged as complete response by palpation and computed tomography. Now, he is leading a good life without recurrence. EAP therapy is a strong combination chemotherapy with which a high percentage of patients with inoperable advanced gastric cancer achieve complete or partial response. We applied this chemotherapy to the treatment of gastric leiomyosarcoma and obtained a good response. In general, it is rare that gastric leiomyosarcoma shows a good response to chemotherapy, so we report our case with the expectation of further examination. This therapy was accompanied by side effects such as severbone marrow suppression, nausea, vomiting and depilation, but these side effects were all reversible.

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A 25-year-old woman with complaints of sever abdominal pain and a temperature of 40°C was admitted to Hiroshima City Hospital, where an emergency laparotomy was performed. The surgical intervention alleviated the symptoms. T-tube drainage was performed and a diagnosis of Caroli's disease was made. Right hepatectomy was performed on the 47th day after the T-tube drainage. She has had no complaints whatsoever during the two years following the hepatectomy. In reviewing the 88 cases of Caroli's disease reported in the Japanese literature from 1983 to 1989, surgery was performed in 11 cases including ours. Both the right and left hepatic ducts were dilated in our case with saccular dilatation being more marked on the right side than on the left side. This is the first report of hepatectomy in Japan performed for Caroli's disease with dilatation of both hepatic ducts.

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This is a report on 57-year-old female patient in whom a tumor was found in the caudate lobe of the liver by the tests with ultrasonography and computed tomograpy during the accurate examinations for liver cirrhosis. The tumor was diagnosed as hepatocellular carcinoma (HCC) based on the findings of angiograpy. The image examination revealed the tumor localizing in the left lesion of the caudate lobe. Caudate lobectomy was indicated. The arterial branch to the left-side of caudate lobe, and the branch of the portal vein were ligated and cut at the portal hepatis. The short hepatic vein was ligated and cut. The lobectomy was made with Cavitron Ultrasonic Surgical Aspirator. The total blood loss during the operation was 880 ml. There have only been 6 cases in whom the resection was made for HCC developed in the caudate lobe. This is mainly accounted by the facts that the most of those patients have liver cirrhosis as a comlication, and/or there is a difficulty for the resection due to the anatomical features of the caudate lobe. The resection of the caudate lobe, however, may safely be made recently, as the anatomical vascular architecture of the caudate lobe has become elucidated clearly.

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We experienced 13 cases of extrahepatically growing hepatocellular carcinoma in our department and assessed the clinicopathological features and prognosis after surgical treatment. Compared with patients with intrahepatically growing hepatocelluler carcinoma, they showed a higher positive rate of hepatitis B surface antigen (5/12cases, 41.7%), a larger tumor size (7.2 cm in mean diameter), and a higher frequency of portal venous invasion and/or intrahepatic metastasis (9/13 cases, 69.2%). We performed systemic segmentectomy or lobectomy in nine of the 13 cases, and partial hepatectomy in the others. To date only four patients in the performed systemic hepatectomy group have been free from recurrence in the follow-up period of 10 to 57 months after the operation. All the patients in the performed partial hepatectomy group showed recurrence in the residual liver. In consideration of the prognosis and pathological characteristics, systemic segmentectomy or lobectomy should be performed for better prognosis for patients with extrahepatically growing hepatocellular carcinoma.

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In 108 patients with hepatocellular carcinoma (HCC), 8 (7.4%) had extrahepatic malignancies. Seven had synchronous multiple primary malignancies and one had a metachronous cancer. Gastric cancer was the most common malignancy combined with HCC. It was considered that the upper gastrointestinal series was necessary for the patient with HCC. The frequency of liver cirrhosis was 62.5% in the patients with multiple primary cancers (n=8) and 91% in those with non-multiple primary cancers (n=100) (p<0.05). Retention rate of indocyanine green was 13.9±6.6% and 22.9±13.0% respectively (p<0.05). The frequency of positive HBsAg was 0% and 29% respectively. It was suggested that factors different from those of the ordinary HCC participate in multiple primary cancers.

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Two cases of biliary cystadenocarcinoma, one from cystadenoma of the liver and the other from a simple cyst of the liver, are reported. Case 1: A 49-year-old male suffering from sudden-onset upper abdominal pain was admitted to our hospital. Further examination revealed a liver cyst in the left lobe with a papillary-growing tumor. Left lobectomy was performed and showed that the tumor had originated from a cystadenoma of the liver. Case 2: A 73-year-old female was followed up for a simple cyst of the liver in the left lobe for five years. Finally we detected a tumor in the cyst. She underwent left lobectomy and pathological findings indicated that the tumor originated from the simple cyst of the liver. A review of 106 Japanese cases of biliary cystadenocarcinoma of the liver revealed that 27 were from a simple cyst, 18 were from a cystadenoma and 24 occurred as biliary cystadenocarcinoma. We found only four cases in which a simple cyst of the liver was followed up until biliary cystadenocarcinoma finally developed as in case 2. Therefore even for a simple cyst of the liver, it is important to remember the possibility of cancer growing, and following up the cyst carefully is necessary.

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Cholesterosis of the common bile duct was observed in two patients under peroperative cholangioscopy. Case 1: a 53-year-old man was admitted to our hospital because of fever and jaundice. Endoscopic cholangiography showed a round filling defect in the gallbladder and a small and irregular one in the lower portion of the common bile duct of 10 mm in diameter. Peroperative cholangioscopy revealed yellowish-white multipolypoid cholesterosis in the common duct just above the papilla of Vater. The resected gallbladder had one pure cholesterol stone and cholesterosis in the mucosal membrane of the fundus. Case 2: A 73-year-old woman, diagnosed as having cholecystolithiasis, had been taking ursodeoxycholic acid (300 mg/day) for 4 months. She underwent cholecystectomy and choledochotomy with T-tube drainage. There were no stones in the gallbladder, but the organ showed diffuse cholesterosis. We considered that cholesterol gallstones which had been present in the gallbladder had been dissolved and disappeared during 4 months' administration of ursodeoxycholic acid. About 10 spots of polypoid cholesterosis were observed, by peroperative cholangioscopy, in the suprapapillary portion of the common duct which was dilated to 17 mm in diameter. Histological examination showed that there were many foam cells in the subepithelial layers of the common duct.

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We experienced a case of mucin-producing cholangiocarcinoma with cystic dilatation of the intrahepatic bile duct. A 68-year-old woman who complained of right back pain was diagnosed as having choledocholithiasis and underwent cholecystectomy and choledochotomy. Mucin flowed out from the choledochotomy. She discharged because outflow of mucin decreased and malignancy was not found. In the following examination, serum DU-PAN-2 was found to be abnormally increased and cystic lesion was found in the left hepatic lobe. On the second operation, cytological study of the aspirate from the cystic lesion showed malignancy. Left hepatic lobectomy was performed under the diagnosis of mucin-producing cholangiocarcinoma. In the Japanese literature, 33 cases of the disease have been described and it is relative rare. The prognosis is thought to be better than that for common cholangiocarcinoma. However the cases of metastasis and invasion suggest the need for close follow-up.

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We have decided on the line for the resecting pancreas because of intraductal spread of pancreatic cancer. For a pancreatic cancer with an irregular dilated main pancreatic duct (MPD) in its body or tail, we selecte the operative fashion by intraoperative pancreatography. A 50-year-old man visited Nagoya University Hospital because of malaise and jaundice. Ultrasonography and percutaneous transhepatic cholangiography revealed a pancreatic head mass and a dilated common bile duct. Endoscopic retrograde pancreatography showed an obstruction of the MPD at the pancreatic head. Abdominal computed tomography revealed the pancreatic head mass and irregular dilated MPD in the body and tail of the pancreas. Intraoperative pancreatography showed irregular dilatation of the MPD in the distal pancreas and a papillary tumor was seen inside. We diagnosed the condition as pancreatic head carcinoma with intraductal spread, and performed a total pancreatecotmy. Pathological findings indicated cancer extension in the MPD from head to tail into its branches with papillary multiplication. Intraoperative pancreatography is an effective method to detect the ductal spread of carcinoma of the pancreatic head and is use for decide the cutting margin of the pancreas remnant.

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Recently, case reports of mucin-producing pancreatic cancer have been increasing, but it is difficult to determine the spread of the tumor. We experienced two cases of mucin-producing pancreatic cancer with total pancreatectomy. In both cases, the pancreas was first cut at the body, but total pancreatectomy was performed later, because cancer cells were observed in the distal cut end of the pancreas. Both of these tumors were in the pancreas head and extended to the whole pancreas, with expansive growth in case 1 and with consecutive growth at the main pancreatic duct and its surrounding tissue in case 2. Therefore, we considered that intraoperative cytological examination of the pancreas cut end is useful for deciding the surgical margin in mucin-producing pancreatic cancer.

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Tumor-forming abdominal tuberculosis is rare disease that sometimes presents difficulties in diagnosis. This is a report of a patient with mesenteric tuberculosis that was difficult to differentiate from an abdominal tumor and was diagnosed by exploratory laparotomy. The patient, a 24-year-old Philippine woman, had a tender, egg-sized abdominal tumor slightly left of the umbilicus. She had no previous history of pulmonary tuberculosis, which was found in her parents' history. CT and ultrasonography revealed numerous widespread tumors 1-4 cm in diameter, presumably originating from the mesentery, while no abnormalities were detected by gastrointestinal tract study and abdominal angiography. An exploratory laparotomy, performed because no definitive diagnosis could be made, revealed minimal ascites and no adhesions in the abdominal cavity. There were numerous yellow markedly enlarged lymph nodes, irregular in size, throughout the mesentery of the small intestine. Because of evidence of tubercle bacillis in the biopsied lymph nodes, administration of anti-tuberculosis agents was started. It should be kept in mind that some patients with abdominal tuberculosis may present with markedly enlarged lymph nodes.

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The most important complication of portal hypertension is ruptured variceal bleeding, which usually occurs in esophagogastric varices. However, hemoperitoneum can occur as a result of variceal bleeding. We recently experienced a case of hemoperitoneum caused by ruptured variceal bleeding under a portosystemic shunt. The patient was a 65-year-old woman, in whom hemoperitoneum occurred on the tenth day after a pancreaticoduodenectomy. A reoperation was performed immediately, because of ectopic variceal bleeding, and the ruptured varices were ligated and a splenorenal shunt was made. In case of hemoperitoneum, we should consider ectopic varical bleeding too, and immediately ligate the ruptured varices.

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Ileus due to intestinal incarceration of a postoperatively formed gastric bezoar is a very rare disease. We encountered two cases of ileus due to gastric bezoars formed after selective vagotomy and plyoroplasty (SV+P). Patient No.1 was a 57-year-old mart, who underwent SV + P for a duodenal ulcer 9 years earlier. In November of 1981, the patient experienced upper abdominal pain, nausea and vomiting and was hospitalized under a diagnosis of ileus. On Day 3 of hospitalization, an emergency operation was performed, and a goose-egg sized mass of foreign matter was found in the jejunum, and excized. Patient No.2 was a 54-year-old man who underwent SV + P for a duodenal ulcer 16 years earlier. In November of 1989, with the main complaint of abdominal pain, the patient was hospitalized under a diagnosis of ileus. By intestinal radioscopy, the disease was diagnosed as ileus due to intestinal foreign matter, and he was operated on Day 21 of hospitalization. A hen-egg sized mass of foreign matter was found in the ileum, and excised. In both cases, the foreign matter was believed to be a diospyrobezoar on the basis of constituent analysis.

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Solitary ulcer syndrome of the rectum presenting with full-circumferential elevation is relatively rare in Japan. We recently encountered one such case. The patient was a 48-year-old male who visited our clinic with the chief complaint of mucous stool. Because a full-circumferential elastic-firm mass was palpable just above the anus, barium study and rectal endoscopy were performed and revealed a lesion, resembling a rectal carcinoma type 2' lesion, about 4 cm proximal from the anal verge. The affected area was poorly demarcated, and a white coat was observed on the mass surface. Based on characteristic histological findings of fibromuscular obliteration, the condition was diagnosed as solitary ulcer syndrome of the rectum and the patient was conservatively treated because he refused an operation because of diverse features, there has been confusion as to the concept and the information about this disease entity. For physicians with sufficient knowledge of this condition, its diagnosis is easy. It is a benign disease, so not to perform over surgery should kept in mind.

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Seventeen cases of rectal carcinoid which were experienced in our hospital were examined and discussed their surgical treatment. The sex ratio was 1: 1 and the mean age was 51.9 years. Carcinoids were located mainly in the range from 5 to 8 cm from the anal verge. Eight of them were 9 mm or less in size, 5 were 10-19 mm and 4 were 20 mm or more. All tumors smaller than 19 mm were sessile in shape and located in the submuscular layer (sm). Polypectomy was performed in 5 cases, local resection in 5 cases, and a radical operation with lymphadenectomy in 7 cases. Five patients with carcinoids smaller than 9 mm underwent polypectomy. 5 with tumors 10-19 mm underwent local resection, and all patients with tumors larger than 20 mm underwent radical surgery. Only 2 patients, with tumors of 50 mm with lymphnode metastasis, died of recurrence. The treatment of a rectal carcinoid must be selected according to its size as follows: polypectomy or local resection for tumors smaller than 9 mm and radical surgery with lymphadenectomy for those larger than 20 mm are recommended. In the case of tumors of 10-19 mm, radical surgery must be decided according to the depth of the carcinoid and invasion to vessels after local resection.

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Anal carcinoma associated with a perianal pagetoid lesion is extremely rare, and only nine cases including ours have been reported in Japan. On October 8, 1989, a 74-year-old man was hospitalized in Gunma University Hospital with chief complaints of anal pain and tumor. Biopsy of the perianal skin revealed a pagetoid lesion and the left inguinal lymph nodes showed metastases. The patient was operated on November 29. Abdominoperineal excision of the rectum and dissection on part of the inguinal lymph nodes were performed. In addition to the operation, the patient was treated by postoperative radiotherapy. Histological diagnosis of the lesion was adenocarcinoma with pagetoid phenomenon originating in the sweat gland of the skin. Histochemically the cancer cells were PAS-and Alcian blue-positive.

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