Mucosal tissue blood flow (TBF) of the cervical anastomotic portion after esophageal reconstruction was studied in humans to determine the relationship between mucosal TBF and benign anastomotic stricture. Two groups participated in the study. One was 24 healthy controls. The other was 14 patients who previously received both esophageal resection for esophageal cancer and reconstruction with a stomach roll, including both anastomotic stricture and non-stricture group. Mucosal TBF was measured by endoscopic laser-Doppler flowmetry. The control group had a TBF of more than 26ml/min/100g in all portions, and the TBF of the patient group was significantly lower. Furthermore, the anastomotic stricture group had asignificantly lower TBF in the anastomotic portion than the anastomotic non-stricture group. These results indicate that low mucosal TBF is strongly related to the occurrence of cervical anastomotic stricture in patients after esophageal reconstruction.

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A clinical evaluation of 72 patients with acute gastric mucosal lesion (AGML) seen at the Second Department of Surgery and the Department of Critical Care and Emergency Medicine from August 1979 to December 1991 was performed to establish prophylactic treatment and therapy. Clinical variables such as etiology, diagnosis, therapy and prognosis were analyzed statistically, dividing the cases into two time periods, the first 6 years and the last 6 years. Fifty-six patients (38 had undergone surgery, 18 had not) were included in the first time period and 16 (7 had undergone surgery, 9 had not) in the second. Mortality during the first time period was 43.1%; this decreased dramatically to 14.3% in the second time period. In both periods, AGML was likely to occur in complicated cases such as those with obstructive jaundice, renal failure or cerebrovascular disease in which the gastric mucosal bloodflow decreased. In addition to improved management of patients pre-and postoperatively, the widespread acceptance and use of H₂-receptor antagonists such as cimetidine has led to a gradual decrease in AGML, and the number of operations and the mortality rate have decreased dramatically. From these results, it was concluded that H₂-receptor antagonists or agents such as teprenone that increase defensive factors have clinical effectivenes as prophylaxis and therapy for AGML.

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This study was undertaken to investigate bone disorders and metabolism after gastrectomy in gastric cancer patients. Twelve patients in our out patient clinic who had no signs of clinical recurrence were evaluated. Their mean age was 64 years and their mean postoperative period was 33 months. The gastrectomy was partial in 7 cases and total in 5 cases. Symptoms of bone and joint disorders were noted in 6 cases and 3 cases of them developed that symptoms after gastrectomy. There were changes in roentgenograms of finger bones in the over-65-year-old group and the total gastrectomy group, but no differences were detected by the microdensitometry method. The over-65-year-old group showed increased levels of PTH-Intact and inorganic phosphrous, and decreased glomerular filtration rate (GFR) and serum calcium level. The total gastrectomy group showed higher levels of PTH-MID, osteocalcin and alkaline phosphatase (ALP) than the partial gastrectomy group. Furthermore, the level of osteocalcin correlated with the levels of PTH-MID and ALP. These results indicate that osteoporosis in the over-65-year-old group would increase following decreased GFR due to aging. We propose that bone metabolism in the total gastrectomy group would have a high turn-over rate in proportion to the increased synthesis of osteocalcin due to decreased calcium uptake.

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The role of active oxygen species in the process of organ failure was investigated and protective effects of antioxidants and protease inhibitors against endotoxin shock were experimentally studied in rats. Experimental shock was induced by a single intravenous injection of endotoxin at a dose of 4 mg/kg. After the injection, systolic blood pressure and hepatic tissue blood flow were reduced. Furthermore neutrophil-derived superoxide and lipoperoxide levels in the liver were markedly elevated. Severe destruction of the mitochondrial structure of hepatocytes was seen. Superoxide-induced chemiluminescence from in situ liver surface was increased after endotoxin injection. On the other hand, all these changes were prevented by pretreatment with superoxide dismutase and catalase, coenzyme Q₁₀, solcoseryl, nafamostat mesilate, and ulinastatin. These results indicate that active oxygen species, such as superoxide and hydrogen peroxide, are involved in the pathogenesis of organ failure following endotoxin shock, and suggest that antioxidants and protease inhibitors may exert some protective effects against organ failure in endotoxin shock.

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Dynamic changes in adenine and guanine nucleotide levels of rat liver during ischemia and reperfusion were investigated. The effects of thromboxane A₂ synthetase inhibitor (CV4151) and protease inhibitor (Ulinastatin) on the recovery of the liver energy status were also studied. Recovery of adenine nucleotide levels after 30-min reperfusion was markedly disturbed in the 30-min ischemia group compared with the 15-min ischemia group. Changes in guanine nucleotide levels were similar to those in adenine nucleotide levels. Increases in catabolites of the nucleotides, i.e. hypoxanthine and xanthine, were not marked even after 30-min ischemia. Recovery of liver tissue blood flow was more disturbed in the 30-min ischemia group than in the 15-min ishcemia group. CV4151 improved the recovery of liver tissue blood flow and liver energy level after reperfusion.Ulinastatin also improved the liver energy level, though it did not increase the blood flow. Ulinastatin has protective effects against free radicals, endotoxin and other of cytotoxic agents the effects of this drug migh be associated with its cytoprotective properties.

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Changes in hepatic reticuloendothelial function, Kupffer cell function, in moderately and massively hepatectomized male Wistar rats were studied by measuring the rates of hepatic uptake and degradation (metabolism) of ^99mTc-millimicrosphered albumin by computer-imaged liver scintigraphy. The two rates were obtained from the same liver scintigram by means of computer analysis of the time activity curve, and the degradation rate was evaluated as the rate of metabolism by Kupffer cells. Thirty and 70% hepatectomy were performed in rats and both uptake and degradation rates were measured before and on days 1, 3, 5 and 7 after the operation. After 30% hepatectomy, the degradation rate per liver weight was decreased on the first day after hepatectomy, although it was increased beyond normal on the firth day, which suggested hyperactiviyt of Kupffer cell caused by moderate hepatectomy. There was only a small change in uptake rate. After 70% hepatectomy, both uptake and degradation rates were markedly reduced and their recovery was prolonged beyound the fifth postoperative day. The rate of hepatic degradation of ^99mTc-millimicrosphered albumin can be a specific and sensitive indicator of hepatic reticuloendothelial function around hepatectomy.

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This study was focused on the changes in adenosine 5'-triphosphage (ATP) levelsand tissue blood flow in ischemia and reperfusion, in jaundiced rat liver. Bile ducts of male Wistar rats were ligated to induce jaundice. Rats were divided into five groups by the time (1, 2, 3 and 4 weeks) after bile duct ligation (BDL) (BDL-1W, 2W, 3W, 4W, respectively) and a control (no ligation). Ischemia was induced by clamping the portal vein and hepatic artery for 15 minutes and 60 minutes. The ATP level in BDL-2, 3, 4W (jaundiced) group was already lower than that in the control group before ischemia was induced and remained lower during reperfusion. No significant differences in the ATP level were found after 15 minutes of ischemia between the control and jaundiced groups. The rates of recovery of the ATP level after reperfusion preceded by 15 minutes of ischemia ranged from 70-100% among the variousgroups and no significant differences in the rates of recovery were seen between the control and jaundiced groups. The rates of recovery of tissue blood flow after reperfusion preceded by 15 minutes of ischemia ranged from 80-100%, and there were no significant differences in the rates of recovery between the control and jaundiced groups. The rate of recovery of the ATP level after reperfusion preceded by 60 minutes of ischemia in the BDL-4W group was significantly lower than that in the control. The rate of recovery of tissue blood flow 30 minutes after reperfusion preceded by 60 minutes of ischemia in the BDL-4W group was significantly lower than in the control. From these results, we concluded that there were no significant differences in therates of recovery of the ATP level and tissue blood flow after reperfusion preceded by 15 minutes of ischemia betweenthe control and jaundiced groups, but the rates of recovery of the ATP level and tissue blood flow after reperfusion preceded by 60 minutes of ischemia were significantly lower in the BDL-4W group than those in the control.

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To determine the characteristics of spread and the surgical treatment of gallbladder cancer, clinicopathologic findings of 84 patients were investigated in the past 16 years especially from the view point of depth of wall invasion. The rate of resection was 68.4% in the early period, and 97.8% in the late period. Simple cholecystectomy was performed for mucosal cancer and its outcome was better. On the other hand, lymph nodal involvement was shown in 71.0% of the patients with subserosal invasion (ss), and 78.3% of those with serosal invasion (se) and direct invasion to adjacent organs (si). Direct invasion to the liver was found in 31.3%of the patients with ss, 86.7% of those with se and si, and invasion to the hepatoduodenal ligament in 41.4% of thepatients with ss, and 89.5% of those with se and si. Thus, ss, se and si cancer displayed various and expansive modes of spread. Five patients with ss invasion survived for more than five years and the five-year survival rate was16.0% for ss patients, and 31.3% if limited to those with curative resection. But all patients with se and si died within 25 months. Patients with gallbladder cancer who survived for more than five years had received curative resection, had no lymph nodal involvement, or had lymph nodal involvement only in the first barrier along with ss invasion. Segmental hepatectomy and bile duct resection should be performed in addition to cholecystectomy associated with regional lymphadenectomy to obtain better prognosis for advanced gallbladder cancer.

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Clinicopathological findings and outcome of 49 surgical cases of bile duct cancer in the middle (Bm) and distal (Bi) portions over a 16 year period were studied. The rate of resection was 91.8%. The 5-year survival rate was 31.2%and there were seven 5 year survivors (long term survivors). According to stage, Stage III, IV was in the majority and the survival rates decreased with advance in the stage. The rate of liver metastasis was 8.2%, peritoneal dissemination 4.1% and lymph node metastasis (n) 37.8%. The survival rate for patients with lymph node metastasis was significantly lower than for those without it. In both Bm and Bi cancers, invasion to the pancreas (panc) and duodenum (d) were frequently found, but the presence of invasion caused no difference in outcome. In pathological findings, lymphatic invasion (ly) and perineural invasion (pn) were frequently found. The outcome for patients without lymphatic and perineural invasion was better than for those with invasion. With special references to prognostic factors from the viewpoint of long term survivors, n, ly, and pn factors were important. Panc, d factors were not considered prognostic factor. We must reconsider the classification of stages in the general rules for clinical and pathological studies.

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The genesis and development of intestinal nerve plexus damage in ischemic and hypoxic states in the dog was investigated using immunohistochemical methods. The intestinal nerve plexuses were strongly stained by S-100 antibody in the control group, but no histological changes were observed in nerve fibers or neurocytes. The S-100 protein staining of intestinal nerve plexuses decreased from 30 minutes of ischemia, and degeneration features of neurocytes and nerve fibers appeared. After 150 minutes of ischemia, the S-100 protein staining of intestinal nerve plexuses almost disappeared, swelling of nerve fibers and necrosis of neurocytes could be clearly observed. Approximately the same degree of damage was found in the perfusion groups with hypoxic blood. On the other hand, ischemia-reperfusion tests were also conducted in mice. After 60 minutes of ischemia, mucosal damage was repaired after 3 days of reperfusion, whereas intestinal nerve plexus damage required 14 days to recover. After 90 minutes of ischemia, mucosal damage had returned to normal 14 days later, but clear repair did not appear in plexuses. In groups exposed to 120 minutes of ischemia, the damage was even more severe.

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Expedments were performed on dqgs to investigate the consequences of malnutrition after massive resection of the small intestine on the metabolism of vitamin D and bone.We further investigated the therapeutic effects of the administration of active vitamin D₃ (1α (OH) D₃) with or without ursodeoxycholic acid (UDCA).Nine adult beagle dogs underwent 75% resection of the distal small intestine, and were divided into three groups: Group A (n=3) received both 1α (OH) D₃ and UDCA, Group B (n=3) received 1α (OH) D3 alone, and Group C (n=3) did not receive eithe.During the observation period of six months after surgery, body weight decreased, watery diarrhea occurred, and transit time of the whole alimentary tract shortened.The administration of both lα (OH) D₃ and UDCA improved the maldigestive state.Plasma levels of vitamin D metabolites such as 25 (OH) D and 24·25 (OH) ₂D decreased after surgery, whereas 1α ·25 (OH) ₂D levels were barely kept within the preoperative range.Plasma levels of calcium, phosphorus, and protein remained unchanged for six months postoperatively.Histological study of the third lumbar spine did not show any findings of osteoporosis.Bone histomorphometry using a digitizing system showed no definite decrease in bone volume, but revealed a significant decrease in osteoid volume (OV), thickness (O.Th) and surface (OS), and bone formation rate (BFR). Mineralized surface (MS) and BFR were markedly reduced in Group C.These results suggest that insufficient matrix fomation caused by nutritional malabsorption is related with decreases in OV, 0.Th, OS and BFR, and will lead to osteopenia after a longer period. It is probable that administration of 1α (OH) D₃ tqgether with UDCA after massive small bowel resection is effective to lighten the disturbance of matrix fbrmation, although further studies are needed.

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The effects of surgery on five adolescent patients with ulcerative colitis complicated with growth retardation were evaluated. They consisted of 4 boys and one girl who ranged in age from 13 to 15 years (mean, 14 years) at the time of surgery. They comprised 2 with fulminating colitis and 3 with intractability. Three were treated with total colectomy and ileorectal anastomosis, two with proctocolectomy and ileoanal anastomosis. The average period from onset to surgery was 3.8 years (range, 4 months to 10 years and 2 months) and prednisolone was given at a total dose of 10066 mg (range, 1560 to 23375 mg). Their height and weight were assessed both pre-and postoperatively. The mean height of the patients was 1.6 SD preoperatively, and they recovered to an average of 0.8 SD at 3.8 years postoperatively (mean increment, +0.8 SD). Their mean weight was 1.8 SD preoperatively, and they recovered to an average of 0.9 SD at 3.8 years postoperatively (mean increment, +0.9 SD). Surgery should b considered for growth-retarded children with fulminating colitis or on long-term steroid therapy.

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Forty-four frozen samples of surgically removed colorectal cancer were subjected to: (1) c-erbB-2 protein staining with a monoclonal antibody to c-erbB-2 protein and (2) analysis of nuclear DNA content by flow cytometry. The overall c-erbB-2 protein-positive rate was 25/44 (56.8%). There was no significant difference in the rate between well-differentiated adenocarcinoma (19/34), moderately differentiated adenocarcinoma (4/7). In relation to the depth of cancer, the incidence of c-erbB-2 protein was 0/1 in m cases, 1/2 in sm cases, 1/2 in pm cases, 6/10 i ss (a₁) cases, 15/23 in s (a₂) cases, and 2/6 in si (ai) cases. There was also no significant difference in the rate between patients without (16/26) and those with lymph node metastasis (9/18). The incidence tended to be higher in cases with lymphatic vessel invasion: 2/8 in lyo cases, 23/36 in ly1-3 cases. The incidence was 1/4 at stage I, 11/16 at stage II, 3/6 at stage III, 1/8 at stage IV and 9/10 at stage V. Aneuploidy was observed in 28/42 cases. The incidence of c-erbB-2 protein did not differ significantly in diploidy cases (11/14) from that in aneuploidy cases (14/28). These results suggest that the expression of c-erbB-2 protein in colorectal cancer is associated with distant metastasis, and that it serves as an index of the malignancy level of colorectal cancer independent of DNA ploidy patterns.

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Thirty-one cases of colorectal carcinoma were investigated for intratumor heterogeneity in DNA ploidy, DNA index, and S-phase fraction. DNA content of samples from the superficial layer and the deep layer in the same tumor was determined by flow cytometry. Heterogeneity of the DNA ploidy patternwas observed in 3 cases (9.7%). The DNA index was 2.18 and 2.11 and the S-phase fraction was 30.4% and 28.6% inthe superficial and deep layers, respectively. These data indicate a low degree of intratumoral heterogeneity of DNA content according to the depth of invasion in colorectal carcinoma.

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Two hundred ninety-seven patients who underwent rectal adenocarcinoma resection from 1978 to 1988 were studied retrospectively to evaluate the prognostic value of tumor budding. The surgical specimens were examined for histological evidence of budding, defined as small clusters of poorly differentiated or undifferentiated cancer cells ahead of the invasive front of the lesion. Patients were divided into two groups according to the degree of budding: none or mild (bd0, 1) and moderate or severe (bd2, 3). Of the 297 patients, bd0, 1 was seen in 181 patients (61%) and bd2, 3 in 116 (39%). Higher grade budding was associated with a significantly higher recurrence rate; 51% for bd2, 3 patients vs 19% for bd0, 1 for bd0, 1 patients. The five-year cumulative survival rate was worse in bd2, 3 than bd0, 1 (46% vs 79%, p<0.001), and the ten-year cumulative survival rate was also worse in bd2, 3 than bd0, 1 (38% vs 64%, p<0.05). As might be expected, the incidence of bd2, 3 rose according to Dukes's stage: namely, 8% in Dukes' A, 18% in Dukes' B and 57% in Dukes' C. There was no difference in recurrence rate or cumulative survival curve between bd0, 1 patients with Dukes' C and bd2, 3 patients with Dukes' B. The presence of higher grade budding appears to indicate vigorous biological activity in rectal cancer. Thus, regardless of the patient's Dukes' stage, meticulous postoperative follow-up and adjuvant chemotherapy may be beneficial for patients with marked budding.

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We analyzed 14 cases of anterior resection, one case of trans-sacral resection of the rectum and 11 cases of sigmoidectomy with partial resection of the rectum. They were performed between January 1983 and August 1990. The methods of anastomosis used in these operations were the double stapling technique (DST) in 15 patients, the single stapling technique in one and hand suture in 10. The sites of anastomosis were as follows; for DST, high in eight cases, low in five cases and super low in two cases; for hand sutute, high in six cases and low in four cases. In low and super low cases, the mean distance of the tumor from the anal verge was 11.7±5.4 cm for DST and 11.0±0.8 cm for hand suture. The mean distance of the anastomosis from the anal verge was 5.9±2.5 cm for DST and 8.7±0.7cm for hand suture (p<0.05). The mean operating time was 212.5±52.5minutes for DST and 296.0±42.5 minutes for hand suture (p<0.05). In all cases, complications from the operations were leakage in one patient and bleeding in another for DST and an abscess on the abdominal wall in two and mild stenosis in one patient for hand suture. We classified four types of anastomosis with DST. End to end type I and end to end type II are preferrable, because in these types the linear stapler is cut by the circular stapler at the adequate site. End to side type I has propensity for ischemia where two staplers meet and is not recommended. End to side type II was performed only in the secondary reconstruction with DST following Hartmann's operation. In Hartmann's operation, the distal rectum had been cut with a linear stapler, while in the secondary operation, a circular stapler served as a stent for the anal end of the rectum and made the operation easily. Reconstruction with DST could be applied to high anterior resection and sigmoidectomy with partial resection of the rectum. And it was effective for lower tumors, require shorter time for operation and produce fewer complications in low anterior resection of the rectum.

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A rare case of benign submucosal tumor of the esophagus is reported. A 57-year-old man was admitted to our clinic complaining of a superficial protruding tumor of the upper thoracic esophagus. On the basis of the results of barium X-ray, endoscopy and CT-scanning, the lesion was diagnosed as a benign submucosal tumor. The tumor was extirpated through the cervical route without thoracotomy. Macroscopic examination of the resected specimen revealed an elastic hard tumor without a capsule, measuring 2.8×1.5×1.5cm. Histopathological findings showed that the tumor was a very rare submucosal tumor of the esophagus arising from the mucosa-associated lymphoid tissue.

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A 78-year-old man had a history of acute nephritis at the age of 50 years. He was diagnosed as having esophageal carcinoma with he visited a nearby physician with the main complaint of precordial discomfort, and was transferred to our hospital. On preoperative abdominal CT, a massive lesion was detected in the uppermost site of the left kidney. Therefore surgery (esophagectomy without thoracotomy and transabdominal radical nephrectomy) was performed on the basis of a diagnosis of synchronous double cancer or isolated metastasis of esophageal carcinoma to the kidney. A surgical specimen of the esophagus revealed moderately-differentiated synchronous squamous cell carcinoma (SCC) with a depth of sm, and invasion of both ly and v. In the kidney, well-differentiated SCC proliferating into the parenchyma was observed. Although we had difficulty in identifying the renal tumor as an isolated renal metastasis of esophageal carcinoma or primary carcinoma, the tumor was defined as primary SCC of the renal pelvis because severe dysplasis was observed in the transitional epithelium in the vicinity of the tumor. Since squamous epithelial cells were observed in urinary sediment obtained before the operation, it was hypothesized that the transitional epithelium had squamous metaplasia, and then progressed to carcinoma. Although a patient with renal pelvic SCC should be carefully observed after surgery because this tumor sometimes occurs bilaterally, the patient had been in good condition for 2 years after the operation without evidence of recurrence.

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A case of hypertrophic gastritis with superficial multiple ulcers and mucosalbridges is reported. A 74-year-old woman was admitted to our hospital because of vomiting and malnutrition. Uppergastrointestinal X-ray study and gastric endoscopy revealed a thickened, irregular gastric wall and pooling of abarium meal which looked like a diverticulum. We could not rule out scirrhous cancer, and a total gastrectomywas performed. The resected specimen showed multiple ulcers and mucosal brides among giant rugae on thegreater curvature. Histologically, the mucosa of the bridge consisted of fundic glands, and the bottom mucosashowed scars or pyloric glands. It is likely that ulcers penetrating through the gastric mucosa caused mucosal bridgeformation. In the literature, the mucosal bridge of the stomach is reported less often than that of the largeintestine. Only 12 cases of gastric mucosal bridge have been reported in Japan.

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Ovarian metastases from gastric carcinoma are often encountered clinically, while those from “early cancer” of the stomach are seen rarely, only six cases having been reported so far in Japan. The present case was that of a 33-year-old woman admitted for ovarian tumors incidentally noted at a routine medical checkup. Hysterectomy and bilateral adnexectomy were performed. Frozen sections were immediately examined, pathologically, and the Kruckenberg type of metastases was indicated. Even careful inspection and palpation throughout the abdominal cavity failed to disclose the primary site of malignancy. A UGI series and endoscopy conducted following recovery revealed a small carcinoma on the posterior gastric wall and gastrectomy with regional nodal dissection was subsequently performed. Again, there was no indication of metastasis or retroperitoneal nodal swelling. Histological examination of the resected stomach showed the lesion to be a signetring cell carcinoma, invading mainly the mucosal layer and only slightly the submucosal layer. Lymph-canal invasion was quite conspicuous and regional nodal involvement was evident. Data on routes of metastasis from analysis of seven cases, including the six formerly reported, of early gastric carcinoma with ovarian metastases are presented. No vascular invasion or liver metastasis was reported in any of the documented cases. No reports of peritoneal dissemination were found in the literature. The present findings support the theory of lymphatic spread in Kruckenberg metastasis.

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A case of adenocarcinoma and leiomyosarcoma coexisting independently in the same stomach is reported. A 73-year-old man came to our hospital complaining of a floating feeling on walking. His hemoglobin level was 6.7 g/dl. X-ray and endoscopic examination of the stomach revealed a large submucosal tumor in the posterior wall of the fundus and a tumor like Borrmann 2 advanced cancer in the anterior wall of the corpus coexisting independently. Biopsy specimens from the tumor of the cardia revealed myogenic tumor, and those from the other tumor showed adenocarcinoma. Abdominal CT and ultrasonography revealed that the myogenic tumor grew inside and outside the stomach wall. Total gastrectomy with lymph node resection was performed. The resected tumor in the cardia was histopathologically diagnosed as leiomyosarcoma growing 10×6×5.5cm inside and 11×9×7.5cm outside the stomach wall. The cut surface showed necrosis and hemorrhage. The other tumor was diagnosed as moderately differentiated papillo-tubular adenocarcinoma invading within the submucosal layer, that is, early cancer. The Japanese literature contains reports of 28 cases of the independent coexsistence of carcinoma and leiomyosarcoma in the same stomach excluding carcinosarcoma. The literature is reviewed.

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We report a case of liver abscess associated with advanced carcinoma of the stomach. A 60-year-old man, who had received a cholecystectomy 21 years earlier, was admitted with high fever and abdominal pain. A abdominal computed tomography and an ultrasonography revealed a low density and low echoic multilocular cystic mass in the left lobe of the liver. Percutaneous drainage was performed and a roentgenogram after injection of contrast medium through a drainage tube revealed communication between the liver abscess and the stomach. Upper gastrointestinal barium contrast radiography and gastric fiberscopy revealed advanced gastric cancer. In order to rule out a hepatic malignant lesion, epatic angiography and endoscopic retrograde cholangiopancreatography were performed. There were no findings of malignant liver tumors. Total gastrectomy and left lateral segmentectomy of the liver were performed. Histological examination revealed direct invasion of the liver surface and no intrahepatic malignant lesion of the resected liver. The liver abscess might have been caused by direct invasion of the gastric cancer and an inflammatory process induced by penetration of the gastric wall.

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We experienced a case of hepatocellular carcinoma invading the duodenal bulb, which was diagnosed by endoscopic biopsy. A 47-year-old man was transferred to our hospital with the diagnosis of duodenal leiomyosarcoma with multiple liver metastasis by barium meal examination and abdominal CT. In addition to positive HBsAg, a high level of serum AFP and the angiography findings, endoscopic biopsy revealed Edmondson type 3 hepatocellular carcinoma. Laparotomy was performed because of duodenal bleeding. He died of hepatic failure 38 days after the operation. Autopsy revealed the primary lesion in the left lobe of the liver with multiple intrahepatic metastases. The tumor invaded the duodenal bulb directly through a fistula. We reviewed the 10 reported cases of hepatoma in Japan with invasion or metastasis to the duodenum.

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In recent years, internal treatment for peptic ulcer disease has made the remarkably progress. Therefore indication of surgical treatment for it has decreased because of its invasiveness. Aiming at less invasive surgery, we performed selective proximal vagotomy using a laparoscopic approach. The patient was 51-year-old man who had recurrent ulcer disease. Under general anesthesia, pneumoperitoneum was performed. Five trocars were inserted to allow the surgical procedure. Branches of the vagus were dissected and separated from the stomach and the abdominal esophagus, preserving the nerve of Laterjet to the antrum. Intra-and postoperative course were uneventful, the wound pain was minimal, and return to work was rapid. The patient underwent a gastric acid secretion test before and 1 month after the operation. The rates of reduction of the basal acid output and the maximal acid output were 70.9% and 42.7%, respectively, and the results of the post operative Hollander test were negative. This procedure was time-consuming and required skillful manipulation. It was considered that improvement in the instruments and the device for maneuvering would make this procedure acceptable.

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We report a case of lymphangioma of the lesser omentum with a review of the literature. The patient was a 37-year-old woman who visited the hospital with a complaint of abdominal fullness. Ultrasonography and computed tomography of the upper abdomen indicated a multilocular cyst extending from the left lobe of the liver. The patient was diagnosed as having a huge liver cyst, and laparotomy was performed. The operation disclosed a multilocular tumor which was not adherent to the liver but rather to the lesser curvature of the stomach. We considered that the tumor originated from the lesser omentum. The tumor was 19.5×13.5×10.0cm in size, 940 g in weight. Histopathological diagnosis revealed a lymphangioma. Lymphangioma of the lesser omentum is a relatively rare disease, and to date only 22 cases have been reported in the Japanese literature, including our case. There was only one case of lymphangioma diagnosed definitely before laparotomy, although typical findings are obtained from preoperative imaging diagnosis in most cases. Clinical aspects of these cases are also discussed in this paper.

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A patient who suffered severe liver rupture accompanied by injuries of the retrohepatic inferior vena cava was successfully treated by right lobectomy and suturing of the injuries. The patient was a 20-year-old woman who was transported to us after a traffic accident. She went into shock 2 hours after the accident, and an emergency operation was carried out 6 hours after the injury. Rupture of the right hepatic lobe was observed. Since hemorrhage could be reduced by manual compression, the right lobe was resected after portal triad occlusion. The right hepatic vein was completely separated, and a wound about 1.5cm long was observed at 2 sites in the retrohepatic inferior vena cava. Each of these lesions was closed by continuous suture, and hemostasis was achieved. The operative field was filled with CO₂ to prevent air embolism. The survival rate after liver rupture with injury of the inferior vena cava is poor. However, temporary hemostasis by simulutaneus application of the Pringle maneuver and manual compression, followed by partial hepatectomy and suturing of vena caval injuries after restoration of the hemodynamics is considered to increase the chance of control of massive hemorrhage and survival of the patient. Filling the operative filed with CO₂ is effective for prevention of air embolism.

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Recently, we performed hepatectomies on three patients with hepatocellular carcinoma with a tumor thrombus in the portal trunk (Vp3 HCC patient) after radiation therapy (30.0-34.5Gy) which was aimed to minimize the portal tumor thrombus. Another aim of this therapy was to decrease postoperative recurrence in the residual liver due to dissemination via the portal vein. Pathological findings in the resected specimens revealed degenerative changes in the portal tumor thrombus including complete necrosis. The mean survival period and the mean disease-free interval were, respectively 13.3 and 5.3 months in patients with preoperative radiation and 7.5 and 1.7 months in those without radiation. These differences were statistically significant, and hepatic resection following radiation therapy was proved to be effective in Vp3 HCC patients.

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Two cases of biliary drainage by insertion of an expandable metallic stent after external or intraluminal irradiation are reported. In case 1 the patient was a 61-year-old man with obstructive jaundice due to extension of hepatic metastasis after total gastrectomy for gastric cancer. After 50 Gy of external irradiation, the bile duct was recanalized and an expandable metallic stent was inserted. In case 2 the patient was a 78-year-old man with obstructive jaundice due to cholangiocellular carcinoma. After 28 Gy of external irradiation, intraluminal irradiation by means of ⁶⁰Co remote afterloading system (RALS) was performed, and an expandable metallic stent was inserted. Both patients were discharged from the hospital without drainage tubes. For malignant obstructive jaundice with no indication for resection, the combination of radiotherapy and an expandable metallic endoprosthesis is useful for improving the quality of life of the patients.

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A case of solid and cystic tumor of the pancreas is reported. The patient was an 18-year-old woman with the chief complaints of epigastric and back pain. She was admitted to our hospital, because endoscopy revealed compression of the stomach. The results of laboratory tests were unremarkable. A solid cystic tumor of the pancreatic body was strongly suspected on the basis of ultrasonography, abdominal CT and MR imaging. At laparotomy, the tumor (9×7×7cm) was well encapsulated and arose from the body of the pancreas. Distal pancreatectomy was performed. Gross pathological examination showed that the tumor was circumscribed by a fibrous capsule and contained areas of severe hemorrhagic necrosis. Microscopically, the tumor cells showed solid proliferation in a pseudopapillary pattern. Collections of xanthoma cells and cholesterol granulomas were observed around it. Immunohistochemical examination for alpha-l-antitrypsin was positive, and electron microscopy revealed numerous zymogen-like granules in the pancreas. The patient has been followed up for 6 months with no evidence of recurrence.

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A case of serous cystadenoma of the pancreas with obstructive jaundice, which required concomitant segmental excision of the portal vein and the right hepatic artery (r.HA) is reported. The patient was a 59-year-old woman who visited our hospital with generalized itching and jaundice, and she had a hard tumor with slight tenderness in the epigastrium. Abdominal ultrasonography and computed tomography showed a multilocular tumor 6 cm in diameter in the head of the pancreas. A cytological diagnosis of class V was obtained from transhepatic biliary decompression through the gallbladder, and pancreatoduodenectomy was performed. Because of intense adhesion of the tumor to the portal vein and the involvement of the r.HA which originated from the superior mesenteric artery in the tumor, concomitant segmental excision and reconstruction of both vessels were performed. Reconstruction of the r.HA failed, and patency of the left HA was also lost postoperatively, because of manipulation along the course of dissection necessitated by the intense compression by the tumor mass. Fortunately, deterioration of hepatic function was transient. The postoperative course was uneventful thereafter. Histological examination led to a diagnosis of serous cystadenoma of the pancreas. Re-evaluation of the preoperative biliary cytology changed the diagnosis to class II. This case is interesting in the sense that this tumor showed expansive growth not only to the portal vein but also to the common bile duct and the main pancreatic duct, which was suspected of apparent invasion in spite of its benign nature.

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Primary low grade malignant histiocytoma of the spleen is extremely rare. We report here a case a of 29-yearold man admitted with the complaint of abdominal discomfort. Blood tests revealed anemia, thrombocytopenia, hypoproteinemia and hypoglobulinemia. With a diagnosis of primary malignant lymphoma, a splenectomy was performed and the peritoneum was partially resected because the tumor was adherent to it. The histological diangosis was primary low grade malignant histiocytoma of the spleen. Soon after splenectomy, the anemia, thrombocytopenia, hypoproteinemia and hypoglobulinemia had improved, and the patient is alive and doing well one year after the operation with no signs of recurrence.

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A rare case of primary malignant lymphoma of the large bowel with myelodysplastic syndrome is presented. A 57-year-old man who was treated in the outpatient clinic for myelodysplastic syndrome complained of abdominal pain. A mass of 10×10 cm in the right lower abdomen was evident at palpation. A malignant lymphoma of the cecum extending to the ascending colon was suspected as a result of examinations (barium enema, colonoscopy, computed tomography etc.). At surgery, a huge mass, 13.5×8.5×5.5 cm in size, was found on the cecum and adjoining the ascending colon. No ascites or mesenteric lymph node swelling was evident. Right hemicolectomy with lymph node dissection (R₃) was performed. Histological examination of the mass revealed a malignant lymphoma of diffuse medium cell type according to the Lymphoma Study Group classification. Local radiotherapy was done postoperatively. The patient is well without any sign of recurrence 10 months after surgery.

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Two of five patients, in the First Department of Surgery, Nagasaki University Hospital, who had colonic lipomas had associated colonic carcinomas. We report a rare case of a 73-year-old man who had two submucosal lipomas, three early carcinomas, multiple adenomas in the right-sided colon and limy bile with gallstones. In the Japanese literature, the characteristic features in the 21 reported cases of colonic lipoma associated with colorectal carcinoma were as follows: (1) These lipomas most frequently occurred in elderly women and appeared as small tumors in the right-sided colon. Intussusception occurred as a complication at a low incidence.(2) Colorectal carcinomas that are close to lipomas are simultaneously diagnosed in the right-sided colon. These data suggest that colorectal carcinoma seems unlikely to be causally related to colonic lipoma.

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We experienced a case of diffusely infiltrating transverse colon carcinoma with direct invasion to the skin as an initial symptom. A 79-year-old woman was admitted complaining of left lower abdominal tumor. A cauliflower-like tumor developed from the skin after admission. The patient was diagnosed as having diffusely infiltrating transverse colon cancer with direct invasion to the skin and the sigmoid colon. Left hemicolectomy with radical excision of the abdominal wall was performed as a curative operation. The wide defect in the abdominal wall was reconstructed using an extended musculo-cutaneous flap formed by the dominant pedicle of the inferior epigastric and superficial epigastric vessels. Diffusely infiltrating colon carcinoma was far advanced generally, and metastases sometimes manifested initial symptoms. This is the first case in Japan of diffusely infiltrating colon cancer with direct invasion to the skin as an initial symptom. Pathologically this case was classified as lymphangiosis type. The tumor was well or moderately differentiated adenocarcinoma originally, and it was considered to grow relatively expansively. Reconstruction by musculo-cutaneous flap was useful for the wide defect of the abdominal wall.

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A 30-year-old man, diagnosed as having total ulcerative colitis 11 years earlier, complained of abdominal fullness and anal bleeding from February 1991. He was admitted for treatment of an acute attack of ulcerative colitis. Roentgenological examination revealed complete obstruction of the sigmoid colon, however no elevated lesion had been detected by a barium enema eight month prior to this admission. After 5 days of intensive intravenous steroid therapy, and bleeding had improved, but the sigmoid colonic obstruction was unchanged. Laparotomy revealed sigmoid colonic cancer which was unresectable because of direct invasion to other sites of the large bowel and ileum and peritoneal dissemination (H₀N₃P₃S_i). He died of acute respiratory failure on the 47th postoperative day. A routine cancer surveillance program seemed to be of little benefit in this case from the retrospective view. Also some colonic cancers associated with ulcerative colitis may have a tendency to more rapid progression than the ordinary colonic cancer.

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A case of leiomyoma of the rectum is reported. A 66-year-old woman was admitted to our hospital with the chief complaints of anal discomfort and bleeding. Barium enema, rectoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a submucosal tumor in the rectum, and surgery was carried out under a diagnosis of suspected leiomyoma. Transsacral resection of the tumor was performed under general anesthesia. The tumor was 4.0×4.0×5.2 cm in size with a daughter nodule (2.0×3.0×3.0 cm). The cut surface of the solid tumor was white. The histological diagnosis was leiomyoma. As distinction between benignancy and malignancy is often difficult in this disease and cases of recurrence, metastasis and malignant transformation have been reported, and therefore more adequate follow-up studies are needed.

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