The efficacy of sequential methotrexate·5FU (MTX·5FU) treatment for Borrmann type 4 gastric cancer was evaluated. Of 279 Borrmann type 4 gastric cancer cases, 250 surgical cases were analyzed as subjects for the present study. Subjects were classified as follows: 54 unresectable cases (21.6%), 196 resectable cases (78.4%), including 81 curative cases, and 115 non-curative cases. Although in curative cases MTX·5FU treatment resulted in better prognosis than other treatments using adriamycin·5FU, mitomycin C·5FU, and pyrimidine fluoride, the differences were not significant. In contrast, in the non-curative cases, the MTX·5FU group showed a significantly better prognosis than the other chemotherapy groups (p<0.05). In the unresectable cases undergoing chemotherapy, the prognosis of the MTX·5FU group was significantly better than that of the other chemotherapy groups (p<0.01). Multidisciplinary therapy might be necessary for Borrmann type 4 gastric cancer, owing to the limitations of the surgical procedures. Therefore, sequential MTX·5FU treatment is considered to be a useful therapy for this type of gastric cancer.

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We analysed 454 gastric cancers treated in curative resection at the Department of Surgery, Kansai Medical University between 1980 and December 1990. In proxmal cancer, we found n2 (+) cases in advanced cancer, so we should perform cardiectomy only for gastric cancer. In advanced proxmal cancers, there are many cases (76%) which have the metastasis to the lymph node along the splenic artery. So, pancreato-splenectomy is indicated for the S (+) and N₂ (+) cases in proximal cancer. In middle cancer, lymph node metastasis was to under the group 2 nodes even in cancer which invaded into the proper muscle layer, we therefore should be lymphadenectomy of perigastric nodes and those located along left gastric, common hepatic arteries in early gastric cancer. But in advanced cancer we can often see cases of metastasis to the nodes along the splenic artery, so we need R3 lymphadenectmy with combine resection of pancreas tail and spleen for such cases. In distal cancer, lymph node metastasis extended to the lymph node in the hepatoduodenal ligament in advanced cancer, so we should remove all lymph nodes of group 1, 2 and the node in the hepatoduodenal ligament, even early gastric cancer. Concerning to the para-aortic nodes, the metastatic rate was 11.8%, and all the metastasized cancers were invaded beyond the serosal site. Therefore we should perform lymphadenectomy of para-artic nodes in the case of cancer which have serosal invasion, the metastatic cases were S (+) cancer.

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We infused physiological saline into the abdominal cavity and performed preoperative peritoneal cytology (PPC) and measurement of CA 125 in the recovered fluid in 54 patients with gastric cancer in whom no peritoneal tumor or ascites was observed by palpation, US, or CT. In the diagnosis of peritoneal dissemination, the sensitivity, specificity and accuracy of PPC were 60%, 95.5% and 88.9%, respectively. These figures were similar to those for peritoneal lavage cytology. The CA 125 level in the recovered fluid correlated well with the serum CA 125 level in P (+) patients. The CA 125 level in the serum did not differ significantly between ps (+) patients and ps (-) patients, but that in the recovered fluid was significantly higher in the ps (+) patients (10^1.61±0.46 U/ml) than in the ps (-) patients (10^1.33±0.25 U/ml). No complications of this examination were observed. These results suggest that PPC and measurement of CA 125 in recovered fluid are very useful for preoperatively diagnosing peritoneal dissemination.

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The records of 325 patients with early gastric cancer who had undergone curative resection during the previous 12 years were clinico-pathologically analyzed. Among them, 14 (4.3%) died of cancer recurrence. In the recurrent group, moderately differentiated tubular adenocarcionoma (tub₂) and poorly differentiated adenocarcinoma (por) were more common than the other histological types. The histological grade of malignancy was investigated histologically after these two histological types were divided into three subtypes: the so-called pure type of tub₂ (pure-tub₂), the pure type of por (pure-por) and a mixture of types tub₂ and por (tub₂-por). The incidence of lymph node metastasis in the tub₂-por type (28.6%) was statistically higher than that of the pure-tub₂ type (9.7%) and the pure-por type (12.8%). Furthermore the incidence of cancer recurrence of type tub₂-por (21.4%) was more frequent than that of type pure-tube₂ (2.8%) and type pure-por (2.1%). In conclusion, the mixture of types tub₂ and por, the socalled tub₂-por type was considered a higher grade of malignancy.

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In an investigation of gastric carcinomas invading the Subserosa (ss cancers), 203 resected cases (ssα 39, ssβ 101 and ssγ 63) were studied to assess the appropriateness of ssγ as one of the main factors of histologic stage II. The survival curve for the patients with ss cancers was between the curves for the patients with pm cancers (invading the muscularis propria, 151 cases) and se cancers (invading the serosal surface, 551 cases). There were significant differences in the postoperative survival curves between pm and ss, ss and se cancers. However, there were no differences in the postoperative survival between ssγ and ssα or ssβ cancers. Prognostic backgrounds of the patients with ssα, β, γ showed no significant differences, and the curative resection rates for the three were similar (ssα 82%, ssβ 86%, ssγ 89%). This study indicates that ssα, β and γ cancers belong to the same rank of histologic stage (stage II) as ss cancers.

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To investigate the altered pancreatic endocrine function accompanying glucose intolerance and nutritional disturbance after total gastrectomy, intravenous glucose tolerance tests were performed in three groups: preoperative patients with gastric cancer (group A), total gastrectomy combined with pancreatectomy (group B), total gastrectomy with pancreatic preservation (group C). The mean level of K (mg/dl. min) is 1.27±0.19 in group A, 0.76±0.2 in group B and 0.71±0.28 in group C. The mean level of T.I.I (μIU. dl/ml. mg) is 0.18±0.1 in group A, 0.01±0.05 in group B and 0.04±0.01 in group C. Glucose intolerance and reduced insulin secretion were observed not only in group B but also in group C. However, there were no major differences between groups B and C in other tests, excluding HbAl and HbA1C, so the disadvantage of total gastrectomy combined with pancreatectomy was not clarified. HbA1 and HbA1C, as indices of postoperative glucose intolerance, BMI (body mass index, weight/height² ratio) and BWR% (body weight ratio, a comparison of pre-and postoperative weight), as indices of nutritional disturbance, are extremely useful indices. Moreover, these indices can be used as an index of the secretory capacity of insulin. In patients with diabetes mellitus, the grade of nutritional disturbance after total gastrectomy is more remarkable, and total gastrectomy with interposition reconstruction or with pancreatic preservation are recommended.

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In order to investigate the influence of the adjacent noncancerous liver cirrhosis on the intrahepatic extensive mode of hepatocellular carcinoma (HCC), we studied 243 surgically resected HCCs to compare the sizes and the grade of anaplasia of tumors and the incidence of intrahepatic extensive factors, i.e., capsular invasion, portal vein thrombosis, multiple nodule of cirrhotic patients with those of noncirrhotic patients. There were significantly larger number of HCCs smaller than 2.0 cm in diameter in the cirrhotic group than those in the noncirrhotic group (p<0.025). No significant difference of grade of anaplasia was found between the two groups. This result shows that HCC smaller than 2.0 cm in diameter in the cirrhotic group is likely to grow more slowly than that in noncirrhotic group, and adjacent noncancerous liver cirrhosis is likely to influence the growth of HCC arising in the cirrhotic group. As for the intrahepatic extensive factors, the incidence of capsular invasion and multiple nodules of the cirrhotic group with HCCs smaller than 2.0 cm in diameter, and the incidence of portal vein thrombosis and multiple nodules of the cirrhotic group with HCCs smaller than 5.0 cm and larger than 2.1 cm in diameter are significantly higher than those of the noncirrhotic group (p<0.05). These results suggest the possibility that HCC arising in a highly cirrhotic liver tends to grow infiltratively, invading the capsule and the portal vein, resulting in scattered intrahepatic metastases, instead of growing expansively.

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This study was conducted in male Donryu rats to investigate the role of portal vein chemotherapy for prevention of liver metastasis. Continuous mesenteric venous infusion of 5-Fu (20 mg/kg/day) resulted in a high portal vein level (5.3±1.3μg/ml) and a low caudal vein level (0.41±0.12 μg/ml) of 5-Fu, whereas a low portal vein level (0.62±0.23 μg/ml) and a high caudal vein level (0.91±0.31 μg/ml) were detected 6 hours after continuous femoral venous infusion. To evaluate the ability to prevent liver metastasis, Donryu rats (180-200 g) receiving intraportal inoculation of ascites hepatoma AH60C (4×10⁶ cells) were randomly assigned to 4 groups. Group A; continuous portal venous infusion of 5-Fu (20 mg/kg/day) + heparin (100 u/kg/day). Group B; continuous femoral venous infusion of 5-Fu+ heparin. Group C; continuous portal vein infusion of. heparin. Group D; Control. Infusion was started on the same day as tumor inoculation and maintained for 5 days. The volume of metastases on day 21 was calculated in each group. The tumor volume of Group A exclusively showed statistically significant reduction compared with that of the other groups. In conclusion, continuous portal venous infusion of 5-Fu was considered to be effective against liver metastasis by preventing the lodging of tumor cells in the intrahepatic portal system.

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Experiments were performed on adult beagle dogs to investigate the nutritional state and the release of gastrointestinal hormones after pancreatoduodenectomy. A new variation of reconstruction of the alimentary tract was devised and compared with the classical Child's method. In our method, the remaining stomach was anastomosed to the oral stump of the jejunum in end-to-end fashion. A short mid-intestinal segment was interposed between the pancreatic and bile ducts and the upper jejunum. During the observation period of six months after surgery, the loss of body weight was significantly lower after the new method, and the frequency of both morbidity and mortality was lower. A stomal ulcer was detectable in a dog receiving the Child's method, but not in any treated by our method. The integrated increase in plasma triglyceride in response to ingested butter was slightly greater after our method than Child's. Six weeks after surgery, plasma CCK and secretin levels, not only at fasting but after ingestion of butter, were augmented in both groups, particularly in the group receiving the new method. Six months after surgery, plasma levels of both CCK and secretin in the two groups tended to return to preoperative levels, though their integrated responses to butter were still higher after our method. Therefore, it is considered that retaining the remaining upper small intestine as the main food pathway is very effective for the digestion and absorption of nutrients and for the release of gastrointestinal hormones.

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Nuclear DNA content was determined in 143 cases of colorectal carcinoma by using flow cytometry, and relationship between DNA index (DI) and lymph node metastasis was studied. Moreover, we determined nuclear DNA content in 21 cases of metastatic lymph nodes and compared them with the primary tumor. With regard to the DNA ploidy pattern, there were 50 cases of DNA diploidy and 93 cases of DNA aneuploidy, so that the respective rates observed in lymph node metastasis were 30.0% (15/50) and 62.4% (58/93). Thus DNA aneuploidy was observed at a significantly higher rate. The lymph node metastatic rate tended to be DI=1.3 (75%), 1.5 (71.4%), 1.6 (100%), and 1.7 (70.0%). In addition, in 21 cases where the nuclear DNA content was determined in the metastatic lymph nodes, the DI between the primary tumor and the metastatic lymph node agreed in all cases.

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Synchronous serum specimens from the systemic and mesenteric circulation of 16 patients with colorectal cancer were assayed for the levels of carcinoembryonic antigen and CA19-9 and CA125 tumor-associated antigens. The hematocrit levels of draining vein were highly correlated with those of peripheral vein level (r²=0.90), and the dilution effect was noted (x-coef.=0.89). Draining vein levels of CEA, CA19.9, and CA125 were highly correlated with the peripheral vein levels (r²=0.91, 0.96, 0.81). These findings suggest that peripheral concentrations of these antigens are in equilibrium with shedding from tumors and that hepatic clearance of a single pass does not significantly alter the peripheral concentration.

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The clinicopathological features and treatment of flat elevation with central depression (IIa + IIc) type early colorectal cancer were studied. Three hundred and twenty four cases of early colorectal cancer were experienced in the past 7 years. There were 17 cases of IIa + IIc type early colorectal cancer comprising 5.2% of all early colorectal cancer cases. Seven of the 17 cancers were mucosal and 10 were submucosal. When the 17 cancers were examined macroscopically, they were found to be divided into U1 (+) type which had clear ulceration and U1 (-) type without it. Eight of the 17 cases were of the U1 (+) type. They were all submucosal cancer and the incidence of vessel invasion, lymphnode metastasis and liver metastasis was high. There were 9 cases of the U1 (-) type of which 7 were mucosal cancer and 2 submucosal cancer. One of the 17 patients underwent endoscopic polypectomy alone and 2 underwent curative trans-anal and trans-sacral resection respectively. This division of IIa + IIc type early colorectal cancer into U1 (+) and U1 (-) is clinically useful and for U1 (-) type at the lower rectum, local excision could be done at the first trial and the need for radical resection should be decided on the basis of the pathological findings.

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In order to determine preoperatively the presence of severe intestinal ischemia requiring resection, retrospective multiple regression analysis was conducted by various parameters in 65 surgical patients. The patients fell into two groups, an intestinal resection group (35 patients) and a non-resection group (30 patients). WBC, rate of left shift of granulocytes (RLS) and blood glucose levels (BG) were significantly higher in the resection group than in the non-resection group. On simple regression analysis, the length of the resected intestine was significantly correlated with body temperature (BT), WBC, RLS, CPK and BG. On multiple regression analysis, the length of the resection was also significantly correlated with WBC, RLS and serum level of CPK. The serum level of CPK was the most responsible in terms of standard partial regression coefficient. The linear discriminant function using BT, CPK and BG which we propose here revealed 90% accuracy of the true discriminant rate. In conclusion, with retrospective multivariate analysis, preoperative BT, WBC, RLS, CPK and BG proved to be responsible for the prediction of severe intestinal ischemia to be resected in 65 patients with strangulation ileus.

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We have experienced 25 cases of strangulated small bowel obstruction with bowel resection in the past 10 years. According to the histological findings in the resected bowel, these cases were divided into a necrotic group and a non-necrotic group. Preoperative findings on the clinical course and hematobiochemical examination in these two groups were compared, but no significant examination in these two groups were compared, but no significant differences were found. The results of enhanced CT scanning in these two groups were analyzed and some characteristic findings were seen in the necrotic group. Gasless small bowel, disappearance of the Kerckring's folds and increased mesenteric density were special features in the necrotic cases. Blurred enhancement of the small bowel wall and increased density of the bowel contents indicating bleeding were observed in the more severe cases. Enhanced CT scanning is very useful for diagnosing strangulated small bowel obstruction and should be used in cases of suspected necrotic bowel.

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Twenty male patients who underwent curative resection for rectal cancer were divided into 3 groups according to technical differences in preserving the autonomic nerves, i.e., bilateral-preserving, unilateral-preserving and bilateral resecting. The maximal urethral closure pressure (MUCP) was measured by the findings of the urethral closure pressure profile. MUCP decreased markedly in the bilateral-resecting group post-operatively. In the unilateral-preserving group, MUCP showed a significant decrease one month after the operation, but it recovered gradually thereafter, to 70 to 80% of normal levels. We applied the 3 operative procedures to dogs and measured MUCP in the same manner under electrical stimulation of a hypogastric nerve. In the bilateral-preserving group, MUCP showed values near the normal range through out the experimental period. MUCP in the unilateralpreserving group were decreased significantly one week after the operation, but recovered thereafter and maintained levels a little lower than those of the bilateral-preserving group. MUCP decreased significantly and did not recover in the bilateral-resecting group postoperatively. The results indicate that retrograde ejaculation may well be prevented by the unilateral autonomic nerve-preserving operation.

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The usefulness of recombinant human erythropoietin (r-HuEPO) to eliminate the need for perioperative blood transfusion was investigated in patients who mostly underwent digestive tract surgery. A dose of 200 IU of r-HuEPO per kg was given concomitantly with iron (40 mg) for 7 days before and for 14 days after surgery. Hemoglobin, hematocrit and red blood cell levels significantly increased following preoperative administration of r-HuEPO for 7 days. However, the increase in hemoglobin was only 0.3 g/dl on average. Therefore, further studies appear necessary to find a more effective method of administration, i.e. a more appropriate dosage and administration period. Postoperative anemia was improved from the 4th postoperative day (POD), a significantly better result than that seen in controls whose hematocrit continued to decrease up to the 10th POD. As side effects, a flu-like syndrome, hepatic function disorder, fever and rash were seen in one patient each. Two patients had abnormal laboratory findings. Of these, one showed a rise in GOT, GPT and Al-p and the other showed a rise in LDH. These side effects and abnormal laboratory findings were, however, not severe. Fever and the rise in LDH were judged to be related to r-HuEPO therapy. These results suggest that perioperative administration of r-HuEPO is safe and useful for eliminate, or reduce the volume of blood transfusion in general surgery.

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The patient was a 71-year-old man. Endoscopic exploration for epigastric pain revealed an elevated lesion 10 mm in size in the posterior wall 30 cm distal from the incisor. The surface of the tumor was slightly irregular and its edge was covered with normal esophageal epithelium; the tumor was regarded as a 0-1 type in the new endoscopic classification. The histological findings in the biopsy specimen showed poorly differentiated squamous cell carcinoma. The esophagus was resected. The histological findings of the tumor, measuring 13 by 10 mm, revealed basaloid carcinoma of which cancer nests expanded downward. Invasion was limited to the submucosal layer. Neither lymph node metastasis nor intraepithelial spread was demonstrated and no lymphatic or vessel involvement was found. The patient received postoperative chemotherapy and was alive without recurrence 8 months after the operation. This tumor was regarded as a typical type of an early stage of basaloid carcinoma of the esophagus. The prognosis for basaloid carcinoma in the early stage is likely to be better than that for the advanced stage, which has been considered to have a grave prognosis.

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A 47-year-old woman was admitted to our hospital because of abnormal findings in a gastrointestinal series, without any symptoms. An elevated lesion, Yamada type II, was found in the gastric body upon examination by a gastrointestinal series and gastroendoscopy. Endoscopic ultrasonography revealed an abnormal heteroechoic mass with almost clear margins in the fourth layer of the stomach, wall. The diagnosis was a submucosal tumor originating from smooth muscle tissue. Exploratory laparotomy revealed a thumb headsized mass without apparent metastasis or direct invasion into the surrounding organs, and local excision was performed. Histological examination of the specimen showed leiomyoblastoma, with oval-shaped cells each containing a clear space near the nucleus, and medullary growth. Thus, endoscopic ultrasonography was shown to be useful for imaging details of the tumor, suggesting the possibility of diagnosis before surgery.

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Recently, we encountered a case of simultaneous occurrence of early gastric cancer in twins. This is the third case report of gastric carcinoma in identical twins in Japan. Case 1: A 38-year-old housewife visited Juntendo University, School of Medicine, Urayasu Hospital in Chiba Prefecture. An upper gastrointestinal barium X-ray and gastrofiberscopy revealed early gastric cancer at the anterior wall of the stomach angle. Biopsy materials showed signet-ring cell carcinoma. On march 25 1987, Billroth I subtotal gastrectomy was performed at Juntendo University, School of Medicine, Urayasu Hospital, Department of Surgery. Case 2: A 38-year-old housewife was asked to undergo evaluation of her stomach because her twin sister had had gastric surgery for early gastric cancer that month. An upper gastrointestinal barium X-ray showed only mild gastritis. Due to the fact that her twin sister had early gastric cancer, the patient persisted to have further gastric examination. Subsequently, gastrofiberscopy was performed and biopsy materials revealed signet-ring cell carcinoma of the stomach angle. On May, 1987, we performed Billroth I distal gastrectomy. Postoperatively, we examined the HLA type and blood groups of the twins. Typing for HLA and blood groups of the twins showed no difference. These results confirmed that the twins were truly monozygotic twins. The genetic factor in gastric carcinoma is of considerable importance for oncogenic research.

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Two large cysts in a 69-year-old woman with multiple hepatic cysts were successfully treated by absolute ethanol injection after continuous drainage. Cystic fluid tumor marker levels, CEA (536.1 ng/ml) and TPA (4615IU/ml), were extremely high. CEA and CA19-9 were localized immunohistochemically in the epithelium of liver cysts. It is speculated that the secretion of tumor markers is increased by liver cyst inflammation. We conclude that high levels of tumor markers do not necessarily indicate malignant change.

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To perform radical resection of a subsegment, staining of the subsegment is indispensable. The demarcation area on the surface of the liver is obtained by the conventional technique introduced by Makuuchi and colleagues, but the intersegmental or subsegmental plane in the liver is not recognized by this method. To identify the subsegment in the liver, we have developed a new method that retains the stain in the portal unit parenchyma until the division of the liver is accomplished. The portal venous branch is clamped with a Surgiclip^® under ultrasonic guidance and the subsegment is stained clearly by injection of a sufficient amount of dye into the portal venous branch. In five cases of hepatocellular carcinoma, the subsegment containing the tumor was successfully stained and complete removal of the subsegment was achieved.

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A case of porto-umbilical vein anastomosis for portal vein injury during surgery is reported. A 65-year-old man was admitted to our hospital because of a tumor of the liver. The tumor was diagnosed as hepatocellular carcinoma in the posterior segment of the right lobe of the liver, measuring 11 cm. On the portography, the posterior branch was ramified independently, then the anterior and left branches were bifurcated. Since the liver function was good, right hepatectomy was performed. During the operation, the portal trunk was mistaken as a posterior branch and divided. Portal blood flow was preserved only in the left caudate branch. Because direct anastomosis of the divided portal vein was impossible, the portal trunk and the recanalized umbilical vein were anastomosed. Postoperative angiography revealed patency of the porto-umbilical anastomosis. Porto-umbilical anastomosis for portal vein injury is an alternative when direct anastomosis of the divided portal vein is impossible.

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A 45-year-old man was admitted to our hospital because of an abdominal injury. An abdominal tumor was found between the right lobe posterior segment of the liver and the right kidney. Angiography revealed the hypervascularity of the tumor. The extrahepatic portion was fed mainly by the right middle adrenal artery. The tumor was considered to be an extrahepatically growing hepatocellular carcinoma because of the high serum level of α-fetoprotein and positive HBs antigen. A right hepatic lobectomy was performed and the patient has been healthy for the more than 2 years since the operation. It is difficult to determine the origin of a tumor by the feeding artery only. In this case, the problem was differentiation from a nonfunctional adrenal medullary tumor. T2-weighted magnetic resonance imaging was useful in the differentiation. Sixty-seven cases of extrahepatically growing hepatocellular carcinoma have been repored in the Japanese literature. In Japanese and English literature this is considered to be the first case of the extrahepatically growing hepatocellular carcinoma fed by the right middle adrenal artery.

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Two patients with hepatocellular carcinoma had received continuous infusion of recombinant interleukin 2 (r-IL2) and intermittent single injections of adriamycin (ADR) and lipiodol had maintained good performanse statuses despite increases in AFP until abrupt cessation of the r-IL2 administration. After that, rapid progression of lung metastatic lesions occurred. Before immunochemotherapy was started in Case 1, a main tumor, stage III, 9 cm in diameter, and its surrounding small tumors in the caudate lobe were resected by left lobectomy and caudate lobectomy. In Case 2 a tumor, 2.5 cm in diameter, in the posterior segment was not resected but only transcatheter arterial embolization was performed because of severe liver cirrhosis (clinical stage III). In both cases despite the absence of tumors detectable by CT, AFP levels continued to increase. After cessation of the treatment because of a common cold in Case 1 and rupture of esophageal varices in Case 2, lung metastatic lesions rapidly became larger within a week, and patients died of respiratory failure in the 3rd and 4th week, respectively after the treatment was stopped. Changes in NK and LAK activities and the presence of IL2 receptor positive subset in the peripheral lymphocytes led to the suspicion that a kind of rebound-like phenomenon occurred in the lung metastatic lesions after the discontinuance of the long term infusion of r-IL2.

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A case of cholangiocarcinoma acompanied with hepatolithiasis in a 44-year-old man is reported. This patient visited our hospital because of persisting dull pain in the left hypochondrium and fever over 39°C, and received a diagnosis of a tumor in the lateral segment and lithiasis in the medial segment of the left lobe, by ultrasonography, endoscopic retrograde cholangiography and computed tomography. A left hepatectomy was performed for the hepatolithiasis and cholangiocarcinoma was diagnosed by intraoperative pathological examination of frozen sections. The composition of bile acids in the intraductal bile around the tumor was analyzed by high performance liquid chromatography. The percentage of chenodeoxycholic acid, one of the primary bile acids, was 60%0, and that of cholic acid was 29.4%. On the other hand, the ratio of glycine to taurine-conjugated bile acids was 2.1. These results suggest a relationship between carcinogenesis in the bile duct and bile acids.

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A 72-year-old man who underwent surgery for a perforated duodenal ulcer 13 years earlier was admitted to our hospital with a main complaint of jaundice. While this patient manifested the pentalogy of Reynolds over a period of about 2 hours, emergency percutaneous transhepatic biliary drainage saved his life. After that, a linear scar of the duodenal ulcer and stenosis with a 5-mm internal diameter were detected in the superior duodenal angle by gastroscopy and hypotonic duodenography. On abdominal CT scanning, the head of the pancreas was found to be swollen, and the pancreatic duct was dilated from the head to the tail through the body. On angiography, a non-vascular lesion was seen in the head of the pancreas, and the artery distributing blood to this region showed smooth narrowing. On percutaneous transhepatic cholangiography, a sleeve obstruction with an irregular margin was observed in the center of the bile duct running in the pancreas. Based on these findings, we made the diagnosis of carcinoma of the head of the pancreas, and undertook pancreatoduodenectomy. The duodenal papilla could not be identified macroscopically because of the linear ulcer scar. Because growth of nerves and glands, but not tumorous lesions were histologically observed in the wall of the common bile duct, his obstructive jaundice was thought not to have been caused by carcinoma. It was very interesting that obstructive jaundice in this patient seemed to be caused by the scar of the duodenal ulcer.

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A case of solid and cystic tumor of the pancreas (SCT) is reported. The patient was a 39-year-old woman with a history of invasive lobular carcinoma of the breast, stage H (t₂, n_1β, M₀). Nine months after a standard radical mastectomy, distal pancreatectomy and bilateral oophorectomy were performed because of solid occupying lesions detected by an abdominal sonogram. Although metastases from the breast cancer were suspected, the histological findings revealed SCT and metastasis to the ovaries from signet ring cell carcinoma of the stomach. Therefore, 2 months after the second operation, it was necessary to perform a total gastrectomy for gastric cancer, stage IV (P₂, H₀, n _(-) , ssγ). At present, 2 years and 3 months after the third operation, recurrence cannot be observed and the patient is well. SCT is very rare, only 70 cases having been reported in Japan. Moreover, there was only one case of SCT with an other primary cancer, in addition to our case.

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We report a case of pancreatic head cancer with total obstruction of the common hepatic artery (CHA) by an aneurysm, in which we were able to perform pancreaticoduodenectomy including partial resection of the portal vein. A 70-year-old man complaining of jaundice was admitted and diagnosed as pancreatic head cancer on the basis of clinical findings including those of CT and MRI. Abdominal angiography did not reveal the CHA, but showed that the proper hepatic artery (PHA) was supplied with blood mainly via a pathway extending from the celiac artery to the gastric artery and from the dorsal pancreatic artery to the pancreaticoduodenal artery. An aneurysm of the CHA with total obstruction was detected intraoperatively. When blood flow in the gastroduodenal artery was momentarily interrupted, the PHA blood flow was unaffected and the color of the liver unchanged. We therefore proceeded with pancreaticoduodenectomy including partial resection of the portal vein, without revascularization, while maintaining collateral circulation. Because the patient showed good postoperative recovery and no complications, we concluded that collateral circulation was functioning well.

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A case of epiploic appendagitis is presented. A 39-year-old man was admitted to our hospital with complaint of abdominal pain associated with nausea. The right lower quadrant was tender to palpation with mild guarding and rebound tenderness. Routine laboratory findings showed no unusual trends. Exploration revealed a normal appendix vermiformis, but one of the epiploic appendages on the asending colon showed redness, swelling, petechiae, and necrosis, and the diagnosis of epiploic appendagitis was established. Because of the possibility of diverticulitis, a wedge shaped resection of the adjacent colon including the inflamed epiploic appendage was performed. Pathologic examination showed acute inflammation and hemorrhage. The inflammaion of the epiploic appendage appeared to be caused by torsion. The patient made an uneventful recovery and was discharged on the 11th postoperative day. In reviewing the 23 cases of epiloic appendagitis previously reported in the Japanese literature concerning the differential diagnosis from acute appendicitis, patients with epiploic appendagitis were less likely to have leucocytosis and fever simultaneously; however the number of the patients was too small for a conclusion.

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Delayed small bowel stenosis following abdominal blunt trauma is a very rare disease. The author experienced 2 cases of this disease, which are reported below. Case 1: A 15-year-old boy. The chief complaint was vomiting. He had been riding a bicycle and fell, striking the abdominal region. Because the vomiting persisted, the patient visited our hospital and was diagnosed as having small bowel stenosis following abdominal blunt trauma. An operation was performed on the 104th day after the accident. A portion of the jejunum about 5 cm from Treitz's ligament showed stenosis due to a fibrous adhesion, and thus this adhesion was detached. Case 2: A 52-year-old man. The chief complaint was postprandial abdominal pain. The patient was driving a car, which slid into a ditch and he received a blow to the upper abdominal region. Subsequently, he began to have postprandial abdominal pain and a feeling of gastric fullness, which did not improve. On the 41st day after the accident, an operation was performed under the diagnosis of small bowel stenosis following abdominal blunt trauma. The stenosis was found in the jejunum 3 cm anal from Treitz's ligament, and that region was removed and the two ends of the jejunum were anastomosed. The outcome of the surgical treatment in these two cases was good. For diagnosis of this disease, it is very important to suspect this disease and perform small intestinal radiography

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A 42-year-old woman had abdominal pain and abdominal fullness following improvement of the skin lesion of “toxic epidermal necrolysis (TEN)” caused by an antiinflammatory drug. The ileo-cecal region was resected under the diagnosis of mechanical ileus. The resected specimen had a reddish mucosa with multiple erosions and necrotic tissue. Histological examination revealed necrotic changes in the mucosal layer, but the layers below the mucosal muscle remained almost intact. These findings were similar to the pathological changes in the skin lesion of TEN. The intestinal lesion seems to be part of the systemic lesions of TEN.

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A case of double cancers in the rectum and anal fistula is described. The patient was a 59-year-old male who had been suffering from anal fistula for five years. He was admitted to our hospital with the complaint of anal bleeding and was diagnosed as having rectal cancer by barium meal enema. Low anterior resection was carried out for rectal cancer, and fistulectomy was done for anal fistula four weeks later. Histological examination of the fistulectomy specimen disclosed a focus of well-differentiated adenocarcinoma in the epithelium of the fistulous tract. The rectal cancer was located high in the upper rectum. The second cancer focus was very small, measuring 3 mm in size and situated locally in the inner surface of the fistulous tract with its internal opening in the anal crypt. Thus, the two malignant lesions were considered likely to be double cancers occurred that synchronously.

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A therapeutic strategy for early cancer of the gallbladder was investigated on the basis of itszpathological characteristics. Ninety-five patients who had carcinomas confined to the mucosa or proper muscle layer of the gallbladder were studied. About 60% of the early cancers showed superficial elevated or flat type lesions and only 7.2% (11.1% in IIa and 3.6% in IIb) of these lesions were detected preoperatively. The importance of intraoperative macroscopic examination of the specimen during cholecystectomy was confirmed. Radical cholecystectomy was performed in 27 patients and simple cholecystectomy in the remaining 68 patients. However, there were no deaths from recurrence within 5 years. Only two patients, who had positive margins of the cystic duct, died of recurrence more than 5 years postoperatively. All lymph nodes removed from the 27 patients who underwent radical cholecystectomy were examinded histologically. No lymph node involvement was observed. It is difficult to differenciate early from advanced cancer. Therefore, even when a cancer is suspected to be in the early stage from preoperative or intraoperative examination, it is recommended that radical cholecystectomy be performed. In the case of pedunculated polypoid carcinoma, cholecystectomy with resection of first-station lymph nodes is indicated. When early cancer is diagnosed by histological examination, a second look operation is not necessary in the case of mucosal cancer, if the cut margin is negative. A second look operation is recommended for cancer extending to the proper muscle layer.

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Advanced carcinoma of the gallbladder can be classified by mode of infiltration into four types: Adjacent organs are involved by localized carcinoma of the liver bed type, whereas the hilar type is diffusely infiltrating carcinoma involving the liver along the bile duct at the hepatic hilus. The liver bed and hilar type of carcinoma shows a large mass involving the liver, hepatic hilus, adjacent organs and regional lymph nodes. The lymph node metastatic type has a rather small primary lesion with extended metastatic nodes involving the pancreas, duodenum and/or portal vein. Intrahepatic extension and lymph node metastasis are shown by ultrasonography and computed tomography. Duodenal involvement is demonstrated by hypotonic duodenography and endoscopic ultrasonography. Extension of cancer invasion to the bile duct can be diagnosed by selective cholangiography through transhepatic biliary drainage and percutaneous transhepatic cholangioscopy. Selective hepatic arteriography and percutaneous transhepatic portography are helpful for diagnosing the vessel involvement. Standard operations are hepatic segmentectomy for the liver bed type of carcinoma and extended right hepatic lobectomy with caudate lobe resection for the hepatic hilar type. Hepatopancreatoduodenectomy is indicated for extremely advanced carcinoma of the liver bed and hilar type which also involves the pancreas and duodenum, forming a large mass. The lymph node metastatic type of carcinoma requires liver bed resection for the primary lesion and extended lymphadenectomy combined with aggressive resection of the adjacent organs. Resection combined with that of the surrounding organs should be chosen not only to minimize the operative hazards but also to improve the curability.

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The modes of tumor spread and results of surgery in 164 patients with advanced gallbladder cancer resected between 1968 and 1990 were evaluated retrospectively. All of the gallbladder cancers located in the fundus or body with direct invasion through the liver bed (liver bed type) were localized tumors apread in the liver parenchyma, whereas 80% of the tumors located in the neck (hilus type) were invasive tumors spread in the liver along Glisson's sheath of the hilus of the liver. Lymphatic spread, vascular spread, and neural spread in the hepatoduodenal ligament accounted for 84%, 71%, and 75%, respectively. Positive lymph node metastasis was related to the depth of cancer invasion in the gallbladder wall. The incidence of positive lymph node metastasis, in ss cancer which extended over one area, either fundus or body, or in ss cancer which was located in the area of neck, or in the se or more serious cancer, were in the range of 55% to 86%. Positive lymph node metastasis surrounding the head of the pancreas was found in half of the patients with these cancers. The curability in this series was 41%. The most important factor which prevented curative resection was positive surgical margin in the hepatoduodenal ligament in the patients with ae or more serious cancer. Hospital deaths occurred in half of the patients who underwent right hepatectomy with pancreatoduodenectomy (rHPD) or hepatoligamentopancreatoduodenectomy (HLPD). In the patients with se or more serious cancer with positive n2 or more distant lymph node metastasis, the survival rate for the patients who underwent hepatopancreatoduodenectomy (HPD) was significantly better than than that for the patients who underwent non-HPD therapy. We conclude that patients with advanced gallbladder cancer should undergo HPD, and we especially advocate rHPD for patients with hilus type cancer and HLPD for patients with positive surgical margin in hepatoduodenal ligament. However, there still remains the problem of the significant risk of operative death following these extended procedures. Post operative liver failure is the most important problem to be solved.

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