A total of 111 gastric cancer patients with esophageal invasion who had undergone either laparosternophrenotomy or left thoraco-laparotomy were studied to evaluate the actual state of lower mediastinal lymph node metastasis and related clinicopathologic characteristics. The patients with positive lymph node metastasis (26 cases) in the lower mediastinal area had larger tumors, a higher rate of peritoneal dissemination (42%) (p<0.01), and were cases of type 3 and 4 than the negative lymph node metastasis group (85 cases). The former group also has more noncurative resections (77%) (p<0.01), a higher incidence of n₃ (+) and n₄ (+), more undifferentiated tumors (p<0.01), a significantly higher incidence (p<0.05) of ow (+) and significantly longer distance (p<0.05) of esophageal invasion. The rate of metastasis in the lower mediastnal lymph nodes were 22.5% for No.110, 13.4% for No.111, and 10.3% for No.112, or 23.4% overall. The rate of metastasis rose in proportion to increase in tumor diameter and length of esophageal invasion and was directly proportional to the extent of metastasis in the abdominal cavity and related depth of cancer. The positive group was characterized by a particularly high 16a-2 latero metastasis. The outcome was significantly worse in the patients with lower mediastinal metastasis than in those without it. Nonetheless, a relatively good prognosis even for positive metastatic cases may be achieved by systemic lymphadenectomy in the lower mediastinum and para-aortic extirpation along with ow (-), provided that the intra-abdominal procedure is curative.

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Results of treatment of malignant lymphoma have been improved by advances in research. Attempts to introduce new treatments of gastric malignant lymphoma, whose incidence has been increasing, have been made in recent years. In this study we investigated the superficial spreading type of gastric malignant lymphoma, about which new knowledge has been obtained. Of 102 patients who underwent gastric resection for gastric malignant lymphoma at gastric resection for gastric malignant lymphoma at Aichi Cancer Center between 1965 and 1990, 26 had the superficial spreading type of gastric malignant lymphoma. Of these 26 patients, 19 had submucosal invasion, 10 had tumors more than 20cm in maximum diameter, 11 had lymph node metastasis, 12 underwent R₂ lymph node dissection, and 19 underwent total gastrectomy. The 10-year survival rate was 86.8%, and only one patient died to recurrence. It is concluded that the prognosis of gastric malignant lymphoma is good in patients receiving proper gastrectomy with lymph node dissection. The histological classification of 24 cases was MALT lymphoma which is defined by Isaacson et al. RLH which is defined by Nakamura et al. has been considered identical to MALT lymphoma. In conclusion, recognition of the superficial spreading type of gastric malignant lymphoma is important for understanding the entity of gastric malignant lymphoma.

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The pattern of lymph node metastasis of 941 patients with gastric cancer who had undergo gastrectomy was analyzed. During the operation of 78 of these patients activated carbon particles (CH40) were injected the subserosa of the stomach and the pattern of lymph nodes which were blackened by CH40 was observed. Since the main lymphatic flow from the greater curvature of the upper third of the stomach drains through lymph nodes via the splenic artery and para-aortic nodes around the left renal vein, it is generally recommended that the entire stomach, distal pancreas, spleen and para-aortic lymph nodes be resected en bloc if this region is cancerous. With respect to cancers of the greater curvature of the middle third of the stomach, the main lymphatic flow is known to drain through the lymph nodes along the right and/or left gastroepiploic arteries. If this form of cancer shows metastasis within the lymph nodes along the right gastroepiploic artery, the pattern of the metastasis is similar to that observed in cancer of the greater curvature of the lower third of the stomach. Alternatively, if the cancer has metastasized to lymph nodes along the left gastroepiploic artery, the metastatic pattern appears to be similar to that of the upper third of the stomach. Since the main lymphatic flow from the greater curvature of the lower third of the stomach drains primarily into the infrapyloric lymph nodes, followed by drainage into lymph nodes along the common hepatic artery, and at the root of the superior mesenteric vein, as well as within the hepatoduodenal ligament and along the splenic artery, it is recommended that subtotal gastrectomy together with radical resection of all these lymph nodes be performed for cancer of this region.

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Survival rates for patients with esophageal varices treated by surgery were compared with those treated by embolization. There were 127 surgically treated patients and 85 patients treated by embolization. Ten patients could not be treated by either method. These 222 patients with esophageal varices were divided into two groups: Group I, elective treatment and Child's class A or B patients; Group II, emergency treatment or Child's C patients. These 222 patients were then divided into another two groups:-985, before the establishment of criteria for surgical indication; 1986-, after establishment of the criteria. 1) Before establishment of the criteria, in the Group II patients the 1-year, 3-year and 5-year survival rates were 46.7, 26.7 and 20.0%, respectively, in the surgery group and 65.9, 49.4 and 49.4%, respectively, in the embolization group. 2) In the surgery group, the 1-year, 3-year and 5-year survival rates were 71.5, 56.4 and 53.6%, respectively, before establishment of the criteria and the 1-year and 3-year survival rates were 91.2 and 82.9%, respectively, after establishment of the criteria. 3) In the Group II patients, the 1-year, 3-year and 5-year survival rates were 49.9, 32.6 and 28.8%, respectively, before establishment of the criteria and the 1-year and 3-year survival rates were 72.2 and 51.6%, respectively, after establishment of the criteria. Surgery gave poor results in the patients in Group II. Therefore these patients should be treated by embolization.

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We report the results of repeated hepatic resections for 15 patients with hepatoma. These were 14% of hepatic resections performed for hepatoma, and 25% of intrahepatic recurrence. Fourteen of these patients had co-existing cirrhosis. All of the patients were followed up regularly by measurement of the α-fetoprotein (AFP) level once a month and by ultrasonograpny and/or CT scanning once every 3-4 months. Recurrence was detected in 7 patients with negative AFP level. Almost all of the patients had limited hepatic resection-partial resection. There was no operative mortality. The largest diameter of the tumor was less than 20mm in 7 patients. Except for 2 patients, resections were performed by using a micro-wave tissue coagulator and an ultrasonic surgical apparatus without vascular clamping at the hepatic hilum, Two patients underwent trans-thoracic and trans-diaphragmatic hepatic resections. The 1-year, 3-year and 5-year cumulative survival rates after repeated hepatic resection were 77%, 37% and 37%. The 1-year, 3-year, 5-year and 7-year cumulative survival rates after the first hepatic resection were 82%, 58%, 49% and 49%. The results show that careful follow-up study is needed for early detection of recurrence and that much effort for repeated hepatic resection leads to a good prognosis for intrahepatic recurrence.

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In order to evaluate the indocyanine green (ICG) test for patients with obstructive jaundice, 183 inpatients who had undergone an ICG test during the past 9 years were divided into 105 individuals with liver cirrhosis, 35 with jaundice and 43 without jaundice, and their data were compared. The disappearance rates (K_0.5, K_3.0) at ICG doses of 0.5 and 3.0mg/kg and the maximum removal rate (Rmax) were obtained, and the correlation between Rmax and each disappearance rate was examined. In the cirrhosis group, Rmax was strongly correlated with both K_0.5 and K_3.0, showing correlation co-efficients of 0.724 and 0.869, respectively. In contrast, in the jaundice and non-jaundice groups, Rmax was strongly correlated with K_3.0 (0.832, 0.791), but there was a wide variance in the values of K_0.5 (0.525, 0.524). In addition, the gradient of the regression line for the correlation with K_0.5 was moderate, 0.392, in the jaundice group, whereas it was 0.799 in the cirrhosis group. Of 26 patients who underwent resection of two or more hepatic segments, 11 had a total bilirubin level of 10mg/dl or higher during surgery. In these 11 patients, Rmax and K_3.0 were low before surgery, but the preoperative K_0.5 varied widely. Thus, Rmax proved to be a superior parameter of the preoperative ICG test for patients with obstructive jaundice. With regard to the disappearance rate, K_3.0under a greater load was found to reflect the degree of hepatic reserve more faithfully.

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The aim of this study was to clarify whether a close macroscopic examination can detect gallbladder carcinoma (GBC) in the resected specimen intraoperatively, and can contribute to improving prognosis. In our series of 318 GBC's, we found 63 GBC's at the time of operation in that way. Of these 63 patients, 18 had early GBC and 33 had advanced GBC showing subserosal invasion (GBC-ss). The factors that made the preoperative diagnosis difficult were inability to detect lesions by US or X-ray examination, coexistent acute cholecystitis, gallstones, and debris. Operative procedures included 30 simple cholecystectomies, 4 standard radical cholecystectomies (SRC), 15 modified SRC, and 2 other procedures. The 5-year postoperative survival rate for patients with early GBC was excellent. There was a significant difference in 5-year survival rate for the patients with GBC-ss between simple cholecystectomy (31%), and either modified SRC or SRC (88%). These results suggest that it is mandatory to examine the mucosa of the resected gallbladder and diagnose GBC at the time of operation, and that a radical operation or re-operation for GBCs after close pathological examination is indispensable for good prognosis.

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Fourteen patients after pancreatoduodenectomy (PD) and 14 patients after gastrectomy were assessed nutritionally and immunologically. For the nutritional assessment, the percent of the ideal body weight was at the lowest limit in both groups of patients. On the other hand, the percent of triceps skinfold was moderately or severely reducted in the patients after PD with only slight or moderate reduction after gastrectomy. The red blood cell count and percent of lymphocytes in the white blood count were significantly lower in the patients after PD than in those receiving gastrectomy. The total cholesterol levels in the patients after PD were below normal. The levels of serum retinol-binding protein were markedly low, and were significantly less after PD than after gastrectomy. For the plasma free amino acids, the total amino acid levels tended to return normal, but Fischer's ratio tended to decrease, 5 years postoperatively in the patients who received PD. There was a tendency for the levels of serum complement to decrease and the levels of serum immunoglobulin to increase in the patients after PD. About 29% of the patients after PD and about 36% of the patients after gastrectomy had a negative response to tuberculin purified protein derivative. In conclusion, the patients after PD and gastrectomy had marasmus type malnutrition, which was more severe in the patients receiving PD.

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To establish a procedure for duodenum-preserving total pancreatic head resection (DPTPH), we investigated vascular distribution patterns in the distal duodenum (DD). We performed superior mesenteric artery (SMA) angiography and selective inferior pancreaticoduodenal artery (IPD) angiography in 25 patients who had no pancreatic head disease. The DD was defined as that part of the duodenum extending from the right border of the superior mesenteric vein (SMV) to the nearest recurrent branch of the first jejunal artery (Jl). The duodenal branches (D-branch) to the DD were divided into three groups by their origin: A) 11 from the IPD and Jl. B) 6 from the anastomotic arcade (AA) between the IPD and Jl. C) 8 from the IPD only. Variations of the IPD were classified by whether a common trunk (C.T) with the J1 existed or not: I) 16 with a C.T. II) 9 without a C.T. On the assumption that DPTPH would be performed by resection along the SMA to remove the uncinate process, severe impairment of the blood supply to the DD could occur in following 6 (24% of all patients): an atypical Jl in 1 of group A, uneven D-branch origins in 1 of group B, and absence of a C.T in 4 of group C. Since DPTPH is chiefly used for benign lesions, a better approach for securing the blood to the DD may be resection along the right border of the SMV.

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In 24 (6.7%) of 358 patients with primary colorectal cancer, multiple primary colorectal cancers were found. The male/female ratio was 16:8. The mean age was 56.8 years, and was 4.4 years younger than that of control group. In synchronous cases, 16 (70%) of 23 second lesions were less than 10cm from the first lesion, and almost all lesions that were more than 10cm from the first lesion was advanced cancers. The most frequent combination of lesions was advanced cancer-early cancer; however, in metachronous cases, all second lesions were advanced cancers. Patients with multiple primary colorectal cancers tended to have a family history of cancer and multiple cancers associated with other organs more frequently than patients without multiple primary colorectal cancers. The frequency of complication of benign neoplastic polyp of the colorectum in multiple colorectal cancers group was 83.3%, which was significantly higher than in the control group. In synchronous cases, multiple lesions could be diagnosed in 77.8% preoperatively and correctly, and the main reason why multiple lesions could not be diagnosed preoperatively was that the anal side lesion prevented the oral side lesion from being examined. At present, it is difficult to predict multiple primary colorectal cancers. Therefore, when colorectal cancer is found, careful preoperative examination, including other organs, and postoperative follow up are very important, bearing multiple primary cancers in mind.

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Thirty four patients with advanced rectal cancer treated by preoperative irradiation were examined endoscopically and histologically. On the bases of the histologic findings all the cases were classified into noneffective group (16 cases) and effective group (18 cases). We tried to establish criteria for endoscopic evaluation of radiation effect composed of the following 5 items; 1) flattening of the marginal wall, 2) smoothing of the crater, 3) removal of the dirty coat of the ulcer bottom, 4) improvement in ease of bleeding, 5) improvement of stenosis. According to each criterion, the radiation effect was evaluated as marked (2 points), moderate (1 point), and little (0point) change. The total score of each point was defined as endoscopic evaluation. Endoscopic evaluation was 5.4±1.8 in non-effective group and 8.1±1.6 in effective group (p<0.01). So the endoscopic evaluation was found to be correlated with the histologic evaluation. It was thought that the endoscopically revealed changes in the tumor shape could make us assume the histological radiation effect.

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Two cases of early gastric cancer with sarcoid reaction in the regional lymph nodes are reported. Case 1: A 54-year-old woman visited a practitioner with the complaint of epigastralgia and was referred to our hospital. A double contrast study revealed a IIc + III lesion on the lesser curvature of the middle body of the stomach and distal subtotal gastrectomy was carried out. Histologically, moderately differentiated tubular adenocarcinoma was found in the submucosal layer. Sarcoid reaction comprised of epithelioid cells and giant cells was seen in regional lymph nodes (15/21). Case 2: A 38-year-old woman with the complaint of fever visited our hospital for further examination. Endoscopy revealed a IIc lesion on the greater curvature of the middle body of the stomach and distal subtotal gastrectomy was carried out. Histologically, papillotubular adenocarcinoma was found in the submucosal layer. Sarcoid reaction was seen in regional lymph nodes (21/39). Only 12 cases of early gastric cancer with sarcoid reaction in the regional lymph nodes have been reported in our country, and we discussed their clinicopathological characteristics.

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A 62-year-old man visited the department of dermatology at our hospital because of itching in February 1991. On his second visit in the following May, small light to dark brown multiple papulae were observed over the back as well as the abdomen. Histopathological study of the skin yielded findings indicative of verruca senilis. With the proliferation of papula over a short period, a diagnosis of Leser-Trélat sign was made, followed by probing for any malignant tumor of the viscera, which disclosed a IIc + Ha-like lesion on the posterior wall of the gastric antrum. The condition was diagnosed as early gastric cancer, and subtotal gastrectomy with regional lymph node excision was performed. Histopathologically, the condition was classified as well differentiated tubular adenocarcinoma, m, n₀, stage I according to The General Rules for the Gastric Cancer Study by the Japanese Research Society for Gastric Cancer. Up to the present, no proliferation of verruca was observed. To date, no etiological association between Leser-Trélat sign and malignant tumors has been confirmed. The present case, however, could have a certain clinical significance from the aspect of early diagnosis and treatment of malignant tumors.

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We report a very rare case of an early histologic stage of asymptomatic primary biliary cirrhosis (PBC) with hepatocellular carcinoma (HCC), in which antimitochondrial antibody (AMA) was negative. A 71-year-old man was diagnosed as having HCC in another hospital and was sent to this hospital to have an operation for HCC. During the course of illness, he complained of no symptoms and there were neither icterus nor cutaneous signs of chronic liver disease. The abdomen was soft and no masses were palpable except for a palm-sized mass in the epigastric area. The laboratory data showed high elevation levels of serum ALP, γ-GTP and LAP. HBs Ag was negative and HCV Ab was positive. Serum alphafetoprotein and CA 19-9 were within normal limitis. Immunological examination showed slightly increased serum Ig M, but AMA, ANA and AS MA were negative. Abdominal ultrasonography, CT and angiography revealed a 70 cm mass in the lateral segment of the left hepatic lobe. He underwent laparotomy and lateral segmentectomy. Histologically, the tumor was a moderately well-differentiated HCC (Edmondson II). The non-neoplastic area around the tumor showed inflammatory changes consistent with precirrhotic PBC in stage 2. The patient had an uneventful postoperative course and was doing well 20 months after surgery.

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A case of primary carcinoma of the cystic duct based on Farrar's criteria is reported. The patient, an 81-yearold woman, was admitted complaining of a mass in the right upper quadrant and diagnosed as having a tumor in the cystic duct. Cholecystecotmy was performed. A tumor measuring 1.3×0.7cm was detected in the cystic duct of the resected gall bladder, however malignancy was not revealed in a frozen section. The removal of regional lymph nodes (No.12) was added because a malignant tumor could not be completely denied. Microscopic examination showed a well-differentiated adenocarcinoma infiltrating the submucosa without metastasis to regional lymph nodes. The diagnostic and therapeutic problems with a tumor in the cystic duct are discussed on the basis of 16 cases reviewed.

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We found that Somatostatin Analogue (SMS 201-995) is very effective in reducing small bowel fistula output. A patient received pancreatoduodenectomy for cancer of the lower common bile ductand had a leak at the pancreatojejunostomy. He had been on conservative treatment with hyperalimentation (40 Kcal/kg) for 15 weeks, but had an enterocutaneous fistula with 400 ml output per day. Then we subcutaneously administered SMS 201-995 at a dose of 100μg/8 hours for 14 days. Within 24 hours of treatment, a 50% reduction of the fistula output was observed. Fistula output stopped on the 8th days after starting the treatment with SMS 201-995 and then the fistula closed spontaneously. Glucagon and C-peptide secretin were slightly inhibited, and secretin secretion was moderately inhibited, but glucose intolearance and inhibition of other intestinal secretions glutamic pyruvic transaminase levels increased to 125 lU/L and 110 IU/L respectively, but immediately returned to the normal range. No other side effects attribugtable to the drugs were observed. We found that SMS 201-995 could be safly and effectively used for pancrea to jejunal fistula.

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Two patients with giant spontaneous splenorenal shunts are presented. Case 1. A 34-year-old man spontaneously developed a giant splenorenal shunt. Small esophageal varices were present, and mentation was normal. Because the serum anmonia concentration was elvated, we constructed a selective splenorenal shunt with splenopancreatic and gastric disconnection to decrease shunt flow and prevent enlargement of the varices. Case 2. A 27-year-old man was noted to have small esophageal varices without any elevation of the serum anmonia concentration. We constructed a splenorenal shunt using a spontaneous splenorenal shunt with spleno-gastric disconnection to prevent subsequent development of hepatic encephalopathy. Patients with a giant spontaneous splenorenal shunt are at risk of progressive hepatic encephalopathy and liver dysfunction secondary to reduced portal vein flow. To prevent this, it is necessary to divert the shunt flow; a selective splenorenal shunt with pancreatic gastric disonnection should be constructed to prevent enlargement of esophageal varices.

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A 59-year-old man was admitted to our hospital with complaints of fever and suspected lung tuberculosis. He was diagnosed as having ileus three weeks after taking antituberculosis drugs. A barium enema and colonoscopy revealed stenosis of the cecum, inflammatory polyps and circular ulcers. A biopsy revealed Crohn's disease. Surgical findings showed a cecal mass and a little over 40 constrictions in the small intestine with wall thickening. It is rare to find an ileum with penetration into the rectum. The penetrating ulcer measured 3×3cm. Macroscopic examination of the resected specimen showed that there were several girdle ulcers in the cecum and many round to oval ulcers in the small intestine. All ulcers of the intestine were on the side opposite the mesentery. Histologically, there were multiple non-caseous granulomas throughout the resected intestine, but a few caseous granulomas were surrounded by Langhans' giant cells. Fibrous thickening of the submucosa in the ulcer regions was absent. Therefore this case was diagnosed as intestinal tuberculosis.

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We report a case of isolated eosinophilic colitis. A 74-year-old woman was admitted as an emergency right lower abdominal pain. There was no history of allergy. The peripheral eosinophil count was normal. A working diagnosis of acute appendicitis was made and laparotomy was performed. At the operation, an indurated mass at the hepatic flexure and a dilated proximal colon were noted; the appendix was normal. A right hemicolectomy was performed. Histological examination of the colonic mass showed a heavy eosinophilic infiltrate throughout all layers of the bowel associated with marked submucosal thickening. A diagnosis of eosinophilic colitis was made. Postoperatively, skin eruptions appeared when food intake was started, and the serum Ig G level was high. However no specific food was identified as an allergen. Twelve cases of eosinophilic colitis have now been reported in Japan. Laparotomy was performed in three cases, but there are no reports of this condition being treated surgically as an acute abdomen. Thus, this case seems to be extremely rare.

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A very rare case of volvulus of the transverse colon is reported. A 30 year old woman was admitted to our hospital complaining of abdominal distension. She was suffering from cerebral palsy, mental retardation, and chronic constipation. Abdominal X-ray films revealed marked gaseous dilation of the colon elevating the diaphragm. Suspecting volvulus of the sigmoid colon, we immediately performed a colonoscopy to determine the site of the volvulus. The colonoscope easiely passed through the sigmoid colon and torsion of the colon was found 90cm proximal from the anus. Detorsion was not successful. Considering volvulus of the transverse colon, laparotomy was performed. Because the transverse colon was necrotic even after attempted detorion, the transverse colon was resected. Reconstruction was by end to end anastomosis of the colon without colostomy. Chronic dysfunction of bowel movement predisposing to volvulus, colonic resection should be performed to reccurnce. Even if viable colon was found at detorsion.

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Reports of primary solid tumors of the mesentery are very rare in the literature and almost all reported malignant solid tumors of the mesentery are sarcomas and mesotheliomas. We experienced a case of papillary adenocarcinoma of the sigmoid mesocolon. A 42-year-old Japanese woman was admitted to this hospital because of a tender fist-sized tumor in the lower left quadrant of her abdomen. We performed a left hemicolectomy and a left salpingooophorectomy. Microscopically, the specimen was well-differentiated papillary adenocarcinoma mixed with undifferentiated carcinoma. By preoperative examinations and repeated intraoperative examination, except for this tumor in the mesocolon, we could not find any primary or metastatic foci of adenocarcinoma in her abdomen. The histological pattern of the adenocarcinoma is similar to that of germinal epithelial tumor of the ovary (serous papillary adenocarcinoma, partly with endometrioid adenocarcinoma). The patient is alive and doing well 3 years after this major operation and no signs of recurrence can be detected.

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As the gangrene type of ischemic colitis is often fatal, we should pay attention to the disease. Recently we experienced a patient with the disease who had received abdominoperineal excision of rectum (Mile's operation) 30 years earlier, and associated liver cirrhosis. A 78-year-old woman complained of sudden left lateral abdominal pain and watery diarrhea after constipation for 3 days. Soon she went into shock and was admitted to our hospital. Muscular rigidity, tenderness and Blumberg's sign were recognized over her entire abdomen. We performed an emergency operation under the diagnosis of “acute panperitonitis” 5 hours after onset. There was no perforation in the gastro-intestinal tract. The splenic flexus of the colon was necrotic for a length of 25 cm but the mesenteric vessels were intact. We diagnosed the condition as ischemic colitis, gangrene type, and resected the necrotic segment. The oral stump was used for a colostomy and the anal stump was closed. She recovered under strict post-operative care with a respirator and the like. The cause of this disease is not yet clear. In this case, ischemia of the colon produced by Miles's operation, congestion and coagulation disturbance caused by liver cirrhosis may have played important parts in causing the disease. Early laparotomy is the only life-saving therapy. We consider that resection of the injured segment and colostomy is a reasonable operative procedure.

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The effects of surgical stress and the nutritional management on the kinetics of protein and energy substrates were studied. The measurements of glycerol turnover rate, indirect calorimetry, plasma FFA and ketone body on 46 postoperative patients receiving gastric, colorectal and esophageal operations, and those of whole bdy protein turnover on 61 patients revealed the increased energy expenditure and the rates of fat and protein turnover in surgical stress. The increases were in proportionate with the stress level indicated by the excretion of urinary total catecholamines. The increase of protein dose from 1.0 to 1.5 or 2.0g/kg/d in 52 patients, the administration of 30% BCAA solution in 38 patients and the supplementation of human growth hormone (24IU/g) in 12 esophagectmized patients improved postoperative protein metabolism. The increased whole body protein synthesis, not the supression of breakdown, contributed to the improvement of protein metabolism.

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Portal and peripheral venous blood samples were obtained simultaneously from 43 patients who underwent abdominal surgery, about two hours after the beginning of the operation, and cytokine levels were measured. In addition to linear regression analysis of different cytokine levels, the relationships between cytokine levels and preor postoperative levels of acute phase protein were determined. No significant correlation was found between IL-1 and IL-6 levels is the peripheral venous blood, but the portal blood levels of IL-1 were positively correlated with the portal blood levels of IL-6 (r=0.31, p<0.05). The preoperative values of the third component of complement were positively correlated with the portal blood levels of IL-6 (r=0.64, p<0.001), as well as with the portal blood levels of IL-1 (r=0.35, p<0.05). Furthermore, serum CRP levels on the first postoperative day were positively correlated with the portal blood levels of IL-6 (r=0.47, p<0.01), as well as with the peripheral venous blood levels of IL-6 (r=0.41, p<0.02). These data suggest that the cytokine response to surgery is closely related to the preoperative nutritional status.

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We investigated the participation of cytokines in the hepatic response to injury. The animal study examined the effects of IL-1 and TNF on the carbohydrate and protein metabolism of the liver in chronically catheterized awake dogs. Both IL-1 and TNF enhanced the output of glucose and the uptake of alanine and lactabe by the liver. IL-1 also increased the hepatic output of C reactive protein (CRP). The clinical study examined the relationship between plasma levels of IL-6 and CRP in patients undergoing various operations. There was a positive correlation between plasma levels of IL-6 on postopersitive day 0 and levels of CRP on postoperative day 1 in patients without cirrhosis. However, there was a negative correlation between these two parameters in patients with cirrhosis. These results suggest that cytokines are mediators that orchastrate the hepatic response to injury and that the cytokine-mediated metabolic response depends on the function of the target organ.

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To determine the role of cytokines in the host defense in surgical patients, we investigated the kinetics ofpost-operative elevation of cytokines and factors influencing the increase in serum IL-6 concentration in 38 patientswho underwent elective surgery. Serum IL-6 levels reached the maximum on the 1st post-operativeday in allpatients. Concentrations of IL-6 and IL-8 in the drain exudate were significantly higher than those in the peripheralblood. Strong expression of m RNAs of IL-6 and IL-8 was observed in the leukocytes in the exudate of the thorax andabdomen during the operative and 1st and 2nd post-operative days. On the otherhand, there was little expression ofthese mRNAs in the peripheral leukocytes. Significant correlations were observed between peak serum values of IL-6 and operation time or volume of blood loss during surgery. These results suggest that (1) cytokines are mainlyinduced and produced in the operative field and subsequently spill over into the blood, inducing hypercytokinemia, and (2) operation time and volume of blood loss during surgery are factors influencing the production ofcytokines.

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The efficacy of nonspecific immunotherapy for immunosuppression caused by surgical stress was studied. Asthe degree of surgical stress increased, both PHA-induced blastogenesis and natural killer (NK) activity ofperipheral blood mononuclearcells (PBMC) of tumor bearing rats were reduced, followed by facilitation of lungmetastasis. Administration of OK-432 prior to surgical stress, however, prevented the reduction of immunity of PBMC and the facilitation of lung metastasis. In gastric cancer patients, the values of PHA-induced blastogenesisand NK activity of PBMC 1-2 weeks after gastrectomy were significantly lower than those measuredbeforesurgery. Pre-and postoperative immunotherapy prevented the reduction of immunity of PBMC, while postopera-tive immunotherapy did not. Furthermore, to evaluate the efficacy of nonspecific immunotherapy, a total of 275gastric cancer patients were randomly divided into the following 3 groups; a pre-and postoperative immunotherapygroup, a postoperative immunotherapy group and a group without any immunotherapy. The patients whosecancers were histologically classified as stage I because of both m and n₀ were excepted from the study. When thepatients classified as having stage II cancer were statistically analyzed, the survival ofthe pre-and postoperativeimmunotherapy groups was significantly longer than thatof the postoperative immunotherapy group. The resultsindicate that nonspecific immunotherapy which is started prior to surgery should be effective against theimmunosuppression caused by surgical stress and should prolong survival.

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We studied the pathology of cellular immunosuppression, its underlying mechanismand the effect ofpreoperative administration of PSK on immunopotency, and obtained the following results. 1) Surgical stress led tocellular immunosuppression ingastro-intestinal cancer patients.2) The immunological pathology principallyinvolved reduced ratios of helperinducer T cells, cytotoxic T cells and NK cells, and an elevated ratio of suppressor T cells in peripheral lymphocytes.3) The underlying mechanism was tracted to the involvement of increasedendocrine hormones, such as catecholamine and cortisol, and increased acute phase reactants, such asIL-6 andIAP.4) It is important to prevent cellular immunosuppression during the phase between the pre-and post-operativeperiods. In this context, PSK, a BRM, isuseful, as it contributes to the maintenace of immunopotency whenadministered preoperatively.

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To investigate the influence of surgical reconstruction procedures after the resection of esophageal cancer onpostoperative quality of life, an interview was conducted and subjective and objective factors related to quality oflife were evaluated in 50 patients without recurrence of esophageal cancer. Among the 50 cases, reconstructionthrough the antethoracal route was performed in 9 (Group I) and through the retrosternal route in 24 (Group II), and intrathoracic anastomosis was done in 17 (Group III). Postoperative disturbance of the food passeage was seenin 22.0, 41.6 and 5.9% in Groups I, II and III, respectively. Dumping symptom was evident in 11.1, 12.5 and 11.8% ineach group. Heartburn was seen only in two cases in Group III. A body weight loss of more than 1.0kg from thepreoperative weight was seen in 33.3, 41.7 and 41.2% in Groups I, II and III, respectively. There was no difference inpostoperative performance status or laboratory data among the groups. Thus, although intrathoracic anastomosiswas favorable for postoperative food passage, there was no significant difference in any other quality-of-life factorsamong the routes of reconstruction in patients of reconstruction in patients without postoperative recurrence ofesophageal cancer.

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Cervical and extended upper mediastinal lymph node dissection was evaluated in relation to radicality andquality of life. Between 1987 and 1991, 170 thoracic esophageal carcinomas were resected in our department. Of thepatients, 42 satisfied out criteria regarding the local and general condition for cervical and extended uppermediastinal lymph node dissection. All of them received R-II or R-III lymph node dissection through rightthoracotomy. Extended lymphadenectomy (21 patients) were compared with the conventional lymphadenectomy (21 patients) in regard to the postoperative hemodynamic state, pulmonary function and the performance status.There was one direct operative death in the conventional lymphadenectomy group, while there were no directoperative deaths in the extended lymphadenectomygroup. There was no significant difference in postoperativehemodynmic state between the two groups. Damage to the cough reflex and the incidence of temporary recurrentlaryngeal nerve palsy were significantly higher in the extended lymphadenectomy group than in the conventionallymphadenectomy group. Moreover, the rate of tracheotomy was significantly higher in the extended lymph-adenectomy group. However, there was no significant difference in the incidence of pulmonary complicationbetween the two groups. Patients surviving more than six months after theoperation were asked about their lifestyle, via a questionnaire. There were no significant differences in performance status, complaints or the dietaryhabits between the two groups. Although extended lymphadenectomy causes great surgical stress in pulmonaryfunction, these results suggest that a high value should be placed on extended lymphadenectomy in relation to thequality of life.

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From 1977 to 1990, 233 patients received distal pancreatectomy (DP) and 137 received a pancreas-preserving operation with removal of the splenic artery (PP) for advanced gastric cancer without leaving a tumor mass, at the National Cancer Center Hospital. The 5-year survival rate for the DP group (33.9%) was significantly lower than the 58.1% for the PP group. Concerning the cancer stage, the 5-year survival ratefor the PP group was better than for the DP group in stage I, II and III. The 5-year survival rates for the patients with one or more positive lymphnodes around the splenic artery were 10.1% for the DP group (n=59) and 16.8%for the PP group (n=14). The incidence of hospital death and complications was higher in the DP group than in the PP group. Results of the oral glucose tolerance test revealed better glucose tolerance in the PP group than in the DP group. Thirteen patients in the DP group (5.6%) but none in the PP group required further treatment for diabetes mellitus. These data suggest that the pancreaspreserving operation is effective for selected patients who needprophylactic lymph node dissection around the splenic artery, and gives the patients better quality of life than distal pancreatectomy.

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A good quality of life (QOL) after curative resection for patients with gastric cancer is important, but no method of evaluation has been established. One hundred twenty-one outpatients who had undergone curative resection of stomach cancer were assessed by interview concerning factors influencing QOL. Only 14% of the patients were informed that they had cancer. During the first year after gastrectomy, surgery itself was the influencing factor. Factors influencing QOL were quality changes in diet, abnormal bowel movements and complaints during or after treatment. In the second investigation of 80 patients, changes in dietary content, such as intolerance of fatty foods, meat or milk, were significant. There was no significant difference between R₂ standard lymph node dissection and R₁ reduction of surgery in terms of the patient's evaluation.

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Low anterior resection (LAR, 67 cases) or rectal amputation (APR, 106 cases) was performed on 173 patients with rectal cancer. The postoperative 5-year cumulative survival rates were 63.2% for LAR and 70.1% for APR for stage I-III cancer, but 28.6% for LAR and 50.4% for APR for stage N cancer. Thus, APR was superior to LAR in curativity of advanced rectal cancer. Postoperative urinary dysfunction occurred in 30.0% of the LAR cases and in 52.6% of the APR cases. Erection and ejaculation dysfunctions occurred in 30.8% and 46.2% of the LAR cases, and in 77.5% and 79.5% of the APR cases, respectively. The incidence of these dysfunctions was increased by dissecting intrapelvic lateral lymph nodes in both groups. These results reveal that the postoperative quality of life is influenced by different operative methods and the extent of lymph-adenectomy. Preoperatively, we analyzed the nuclear DNA contents of rectal cancer by flow cytometry and the depth of cancerous invasion in the rectal wall by endoscopic ultrasonography. Preoperative staging for rectal cancer was useful for the determination of a limited operation for early cancer and the improvement of the quality of life. We should choose a curative operation with extended lymphadenectomy for advanced cancer.

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To improve the surgical rate and the quality of life (QOL) for patients with advanced low rectal carcinoma, we investigated whether preoperative treatments (irradiation and hyperthermia and 5-FU suppository, irradiation and hyperthermia, irradiation and 5-FU suppository, irradiation alone and 5-FU suppository alone) were useful. The tumor shrinkage rate after preoperative treatments was highest in the irradiation, hyperthermia and 5-FU suppository group. Pathologically complete regression was observed in the 2 of 18 cases (12%). According to our criteria of histological changes, the irradiation, hyperthermia and 5-FU suppository group showed the greatest effectiveness. The 4 year postoperative survival rate and the 4 year local recurrence rate were 100% and 8% in the irradiation, hyperthermia and 5-FU suppository group and the data suggest that these results were the best of the 5 treatments. After the carcinoma was shrunk after irradiation, hyperthermia and 5-FU suppository, the patients could receive curratively a shincter-savingt operation (super-low anterior resection and transanal rectal resection). The fecal continence of 7 patients after sphincer-saving operatins was increased as good by manometric study, defecography and clinical evaluation. In conclusion, our data suggest that the preoperative combined teratment of irradiation, hyperthermia and 5-FU suppository prevents local recurrence and increases the possibility of a sphincter-saving operation for advanced low rectal carcinoma.

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Partial resection and systematic resection for hepatocellular carcinoma combined with liver cirrhosis were evaluated according to postoperative metachronous multicentric carcinogenesis and postoperative quality of life (QOL). The 5-year survival rate was 45.0% after partial resection and 42.9% aftersystematic resection; there was no significant difference between the rates. According to the comparison of histologic grade of the resected tumor and recurrence of the tumor in 24 patients, in 14 patients (58.3%) recurrence was due to postoperative metachronous multicentric carcinogenesis and in 9 patients (37.5%) it was due to metastasis. In7 of these 9 patients, the site of the recurrent tumor was a different segment from that of the resected tumor, even though the recurrence was due to metastasis. The length of hospitalization for resection and the total postoperative hospitalization was investigated and the hospitalization tended to be longer in patients who received systematic resection or who also had severe liver cirrhosis. These results indicate that systematic resection, such as subsegmentectomy or segmentectomy, should not be performed only to prolong life but also to improve the QOL. However, there was no correlation of QOL scores from our assessment with the resection method nor the degree of liver cirrhosis. The difficulty of an objective evaluation of QOL in patients with hepatocallualr carcinoma combined with liver cirrhosis is empahasized.

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From 1979 to 1990, 56 patients with bile duct carcinoma of the hepatic hilus underwent curative operation, that is, various hepatic segmentectomies based on a thorough understanding of the anatomical features of the hepatic hilus and precise preoperative diagnosis of mode and extent of cancer involvement. The rationale for our surgical procedures was assessed retrospectively from the viewpoint of surgical curability and postoperative quality of life (QOL).Postoperative hospital mortality, because of hepatic failure, was 11%.Five-year survival rates for all 56 patients and 43 patients excluding those who died of causes other than recurrent cancer were 32% and 43%, respectively. The long-term results are good, even though the majority of our cases were in the advanced stage.QOL in 15 patients surviving more than 1 year without cancer recurrence has been evaluated.Performance status (PS) was 0 in 14 patients and 1 in only one.All 10 patients who had jobs before surgery could return to their original occupations.Only 3 patients (20%) have shown some mild symptoms of transient cholangitis.We emphasize that our rationale for hepatic segmentectomy provides not only surgical cure but also satisfactory QOL after surgery.

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Home-life survival rates for 60 hilar (H) and 73 gall bladder (GB) carcinoma cases in our department since 1981 were retrospectively analyzed according to stage, curability and operative procedures. One-year home-life survival rates decrease with an advance in stage, to 7% for GB carcinoma and 4% H carcinoma of stage 4. Curability also directly influence the 1-year home-life survival rate as follows; 0% and 4% for H and GB carcinomas with an absolute non-curative operation. However, the low survival rates was improved to about 30% for H carcinoma and 8% for GB carcinoma by resection and to around 65% for GB carcinoma by a curative operation, The 1-year home-life survival rates after no resection and minor and major operations for advanced H and GB carcinoma of stages 3 and 4 were 0, 25 and 22% respectively for H and 4, 42 and 22% for GB carcinomas. Thus, resection of the tumor results in better quality of life than no resection, but a major operation does not necessarily improve life quality.

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To evaluate the total benefit of the multidisciplinary treatment for TNM Stage III (N=58) and Stage IV (N=94) pancreatic cancers who underwent laparotomy in Aichi Cancer Center from 1975 through 1990, the overall survival time was divided into 1) period of postoperative hospitalization (POH), 2) hospital-free survival (HFS) and 3) hospitalization period after systemic relapse (REL) were analysed. POH and REL were adjusted by coefficients of utility in quality of life relatives to HFS and the results were calculated to give a period of quality adjusted survival time relatives to HFS (Q-HFS). From the questionnaires given to pancreatic cancer patients and to the attendants of the 9th meeting of the society for survival time studies on cancer patients, utility coefficients for POH and REL were detemined as-0.5 and Orespectively, rdadve to +1.0 for HFS. Benefits measured by Q-HFS significantly favored pancreatectomy in Stage III patients. However, no difference in Q-HFS was observed between patients with and without pancreatectomy in Stage IV patients although there was a significant difference in overall survival according to the generalized Wilcoxon test (p=0.039).From these results, we postulate that quality-adjusted survival analysis might be useful in assessing the advantages and disadvantages of extensive surgery as well as of toxica djuvant therapy.

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This retrospective study attempted to determine the operative curability and postoperative quality of life in the patients who had received an extended pancreatectomy for carcinoma of the pancreas. Among 102 patients who tolerated pancreatectomies, lymph-adenectomy was limited to the area immediately adjacent to the cancer lesion in 39 patients (R1), while it was extended to the n2-area (in the classification of the Japanese Pancreas Society) together with the neighboring connective tissue in the other 63 patients (R2α). Though there was no significant difference in the background factors between the two groups, the 3-year survival rates were 10% and 35%, respectively (p<0.05). The R2α-group, but not the R1-group, had 3-year survivors even among the patients with nodal involvement, retroperitoneal invasion or portal vein-invasion. However, there were few 3-year survivors among the patients whose cancers were more than 4cm in diameter, metastasized to the n2-area, or widely invaded the portal vein. In the 3-year survivors of the R2α-group, neither both body weight nor performance status had been recovered by one year after surgery. On the other hand, the mean survival period was 13 months in the patients who died of cancer recurrence. Therefore, The R2a-procedure is recommended for the less advanced cases, with very careful management.

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We performed extended radical operations for carcinomas of the pancreatic head region. These included extended paraaortic lymph node dissection, portal vein resection and complete dissection of connective tissues surrounding the superior mesenteric artery, (SMA). We studied the efficacy of a complete dissection surrounding the SMA. We looked at curability and postoperative quality of life. Frequently the carcinomas of the pancreatic head region invaded the plexus and metastasized to the lymph nodes surrounding the SMA. In particular, in the cases of pancreatic cancer, the incidence of invasion to plexus was 68.9% and that of metastasis to the lymph nodes was 36.1%. We investigated the postoperative quality of life of the 112 patients who received pancreatoduodenectomy or total pancreatectomy. The patients who received an extended radical operation remained hospitalized for a long time after the operation. Also they frequently had diabetes, incurable diarrhea and fatty liver. In conclusion, the results of our therapy suggest that complete dissection surrounding the SMA for a patient with carcinoma of the pancreatic head region is necessary. Intensive postoperative care is also very important in that it will improve the patient's quality of life.

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