Nineteen patients with hypopharyngeal and cervical esophageal carcinoma underwent pharyngolaryngoesophagecotmy with free jejunal autograft reconstruction. Postoperative complications included anastomotic leakage in 1 patient (5.3%), wound infection in 3 patients (15.8%) and intussusception in 3 patients (15.8%). Postoperatively, all patients were able to maintain adequate nutrition by oral intake. Eight of 19 patients died of the carcinoma, local recurrence in 4 patients, pulmonary metastases in 2 patients and brain metastases in 2 patients. Five-year survival rate was 27.2%. No patient, in whom the intrathoracic and intraabdominal lymph node dissection was not done, experienced a recurrence. Pharyngolaryngoesophagectomy is acceptable treatment for carcinoma localized in the hypopharynx and/or cervical esophagus without detectable intrathoracic or intraabdominal lymph node involvement. Free jejunal autograft is an excellent technique for reconstruction in such patients.

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The difference between macroscopic and microscopic diagnoses of the lymph nodes of 46 patients with esophageal squamous cell carcinoma was assessed. The results obtained can be summarized as follows: (1) The accuracy of macroscopic diagnosis of lymph node metastasis of well, moderately, and poorly-differentiated sequmous cell carcinoma were 95.3%, 91.5% and 83.2%. That of poorly differentiated one was significantly lower than those of well or moderately one.(2) The specificity of macroscopic diagnosis was lower in lymph nodes in which the metastatic mode was micrometasis and in nodes whose diameter was less than 5 mm. The incidence of such lymph nodes was higher in cases of poorly differentiated squamous cell carcinoma.(3) Microscopically, all false positive lymph nodes were diagnosed as reactive lymphadenitis. The majority of of these lymph nodes were larger than 10 mm in diameter.

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The effect of two-thirds proximal small bowel resection (2/3 PSBR) on gastric secretion, plasma gastrin and histamine levels in the right gastroepiploic vein (RGEV), and antral G cell and parietal cell populations were studied by using a canine experimental model. Three or 4 weeks after 2/3 PSBR, the rates of increase in basal acid output (BAO), maximal acid output (MAO) and the parietal cell population were 48.5%, 282% and 16.4% and the rates of decrease in plasma gastrin and histamine levels and the antral G cell population were 57.8%, 32.2%% and 10.9%, respectively. Eleven or 12 weeks after 2/3 PSBR, BAO had decreased to almost the preoperative level but the MAO was still high. Plasma gastrin and histamine levels tended to increase to almost the preoperative levels and the parietal cell population had slightly decreased, but the antral G cell population had increased. These results suggest that the increase in the parietal cell population or the parietal cell response is directly associated with postoperative hyperacidity and thatthe change in plasma gastrin and histamine levels in the RGEV is influenced by the acid secretion feedback mechanism.

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Ninety-five cases of gastric malignant lymphoma were studied clinicopathologically. Malignant lymphoma which was confined to the stomach and regional lymph nodes was designated primary gastric malignant lymphoma. Among the 95 cases, 77 were found to be of primary gastric lymphoma, and 18 cases were systemic. The accuracy of preoperative diagnosis was 93.9% for the last 10 years. Macroscopically, the excavated type was the most frequent in both primary and systemic form. The superficial type was not found in systemic malignant lymphoma. The frequency of lymph node metastasis when the depth of invasion was sm (27.3%) was higher than that of gastric cancer (21.1%), but when the depth of invasion was pm or deeper, the frequency was lower than that of gastric cancer. The estimated 5-year survival rates were 87.4%, 50.0%, 21.4%, and 0%, respectively, for Ann Arbor Stages IE, IIE, III and IV. We believe complete resection of the primary lesion with dissection of the regional lymph nodes followed by adjuvant chemotherapy is important in the management of gastric malignant lymphoma.

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Fifty asymptomatic human subjects and 50 gastric cancer patients were analyzed by the BrdU-staining indirect enzyme method. In the asympotmatic subjects, the Labeling Index (LI) of histological types was 11.5±5.3% in atrophic gastritis, 7.2±3.1% in superficial gastritis, and 5.3±1.0% in normal gastric mucosa. In the gastric cancer group, the average LI was 17.8±5.8% for the gastric cancer lesions and 7.2±3.4% for the noncancerous mucosal lesions. LI correlations with cancer advancement stage, lymph node metastasis, lymphatic permeation and depth of invasion were revealed. In staining patterns of BrdU-positive cells, a significant difference was not seen in the asymptomatic group. On the other hand, in the gastric cancer group, Granular type (Type G) was 35.4%, Diffused type (Type D) was 41.2%, and marginal type (Type M) was 23.9%. A study of these types by advancement stage shows that in stage I all three types were distributed quite evenly. In contrast, the occurrence rate had increased in stage II, Type G, and in stage HI and IV, Type D. However, correlations with other factors were not found. These results suggest that the discrimination of the S phase from BrdU-staining patterns before surgery is an effective measure for greater accuracy in diagnosis in estimating the stage of advancement of gastric cancer and in determining operative procedures.

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We reviewed angiograms and lymph node metastases of 20 patients with cancer of the remnant stomach. 17 whose angiograms revealed tumor vessels or tumor staining of cancer were divided into two groups according to the method of the previous operation. In 5 patients whose left gastric artery had been preserved in a previous operation, the remnant stomach tumor received its main blood supply from, and the lymph node metastases were found along, the left gastric artery. In 12 patients whose left gastric artery had been divided in a previous operation, the remnant stomach tumor received its main blood supply from the posterior gastric artery, the left gastroepiploic artery, or the short gastric artery, and the lymph node metastases were found along the splenic artery. When the left subphrenic artery was the main blood supply of the remnant stomach tumor, lymph node metastases were found in the left cardiac region, in the lower thoracic paraesophageal region or in the peri-diaphragmatic area. In patients who had their remnant stomach reconstructed by the Billroth U method, the remnant stomach cancer sometimes received a part of its blood supply from the jejunal artery. In these patients, lymph node metastases were found along the jejunal artery or the superior mesenteric artery.

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The effect of an artificial arterio-portal shunt (A-P shunt) for the dearterialized liver after a major hepatic resection was studied. Mongrel dogs were divided into 2 groups. The hepatic artery and collaterals to the liver were dissected after 40% hepatectomy in the control group. In the A-P shunt group the hepatic artery and collaterals to the liver were dissected and A-P shunt was made between the common hepatic artery and the gastroduodenal vein after 40% hepatectomy. Blood flow to the liver, pressure of the portal vein, O₂ partial pressure of liver tissue and hepatic enzymes were measured, and a hepaplastin test was carried out. Survival rates were also determined. The O₂ partial pressure of liver tissue and pressure of the portal vein were significantly elevated in A-P shunt group, and the group had better liver function and a better suvival rate. A-P shunt is a possible procedure for dearterialized liver after major hepatic resections.

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The present study was designed to evaluate the influence of obstructive jaundice on human natural killer (NK) cell activity and to elucidate the mechanism whereby this influence is exerted. In 7 clinical cases of jaundice the serum levels of 4 bile acids, i. e., glycocholic acid (GCA), taurocholic acid (TAC), glycochenodeoxycholic acid (GDCA) and taurochenodeoxycholic acid (TCDCA), were markedly elevated. NK activity in patients with obstructive jaundice (12.2±2.8%) was lower than normal (43.9±6.7%), but it returned to normal after biliary drainage. Seven-day incubation of lymphocytes from normal volunteers with sera from 6 patients with jaundice resulted invariably in strongly suppressed NK activity in vitro (4.9±5.6%). In a similar experiment, NK activity was entirely unaffected by 7-day incubation with conjugated bilirubin, TCA, TCDCA and GCA, whereas it was significantly inhibited by over 5-day incubation with GCDCA (5-day; 5.6±2.6%, 7-day; 4.3±3.5%, p<0.01). These data clearly indicate that sera from patients with obstructive jaundice suppress NK activity, suggesting that GCDCA is one of the important factors inhibiting NK activity.

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The present report is a retrospective analysis of the effect of intraoperative radiation therapy (IORT) for localized but unresectable pancreatic carcinoma. Thirteen of 30 patients treated by IORT in combination with external beam radiation therapy (EBRT) survived for more than one year. The longest survival period, attained by two patients, was 20 months. The 1, and 1.5-year survival rates were 46.5% and 20.8%, respectively, with a median survival of 11 months, whereas the 1-year survival rate was 0%, with a median survival of 6.2 months for the 16 patients treated by IORT alone (N=16). There was a statistically significant difference in survival rate between the two groups (p<0.01). Therefore, additional EBRT may be indispensable for prolongation of the survival period. Moreover, IORT conferred the palliative benefit of relief of pain in more than half of the patients with severe pain. In postmortem examination of seven patients who survived for more than one year, the tumors were replaced by fibrous and hyalinized tissue, as a result of the effect of IORT, and degeneration and necrosis of tumor cells were seen in the center of the tumor, while viable tumor cells remained in the periphery, spreading to the retroperitoneal tissues or neighborng organs. These histopathological findings are distinctive features of carcinoma of the pancreas treated by IORT.

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Leiomyosarcomas of the small intestine are rarely observed, selection of the operative procedure for this disease and its histological malignancy remain to be established. We evaluated 16 patients (11 males and 5 females) with leiomyosarcoma of the small intestine encountered in the Surgical Department of the Ogaki Municipal Hospital. Their mean age was 56. 1 years. Nonspecific symptoms and signs such as abdominal pain, a palpable abdominal mass, and decreased appetite were frequently observed, and a definite preoperative diagnosis was made in only 7. We classified lymph nodes of the small intestine according to the General Rules for the Clinical and Pathological Studies on Cancer of Large Intestine. R₀ (resection with no lymph node dissection) was performed in 6 patients, R₁ (resection with level 1 lymph node dissection) in 3, R₂ in 6 and R₃ in 1. Of the 7 patients who underwent R₂ or more, 2 showed metastasis to N₁ lymph node histologically. These results suggest that R₂ or more is recommended for leiomyosarcomas of the small intestine. As indices of tumor malignancy, mitotic figures and tumor diameter seemed important.

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The usefulness of OE-ERU in improving the preoperative diagnosis of perirectal lymph node metastasis from rectal cancer was evaluated in comparison with conventional ERU. With OE-ERU, the detection rate of perirectal lymph node and average number of perirectal lymph nodes detected per patient increased considerably, from 39% and 0.4/patient to 73% and 1.3/patient, respectively. Diagnostic accuracy and sensitivity with respect to lymph node metastasis also improved, from 70.4% and 59. 5% to 87.5% and 92.0% respectively. Out of 21 cases in which perirectal lymph nodes were detected by OE-ERU alone, lymph node metastasis was observed histologically in 10. It was concluded that OE-ERU appears to be useful in improving the preoperative diagnosis of perirectal lymph node metastasis.

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In a series of 50 colostomy closures, 17 patients (34%) had postoperative abdominal complications. There were 23 complications in the 50 patients, with an anastomotic stricture rate of 10%, a wound infection rate of 8%, a small bowel obstruction rate of 6%, a ventral hernia rate of 4%, an anastomotic leakage rate of 2% a stitch abscess rate of 16%. Five patients (10%) needed surgical therapy. Closure of a loop colostomy was associated with fewer complications. Factors that did not influence morbidity included the underlying disease, location of the colostomy, time interval between construction and closure of the colostomy, mechanical bowel preparation and method of closure. There have been much discussion concerning the optimal time for colostomyclosure. It appears that in some cases the colostomy may be safely closed within 3 months. Careful surgical technic seemed to be the most important factor in reducing complications.

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The patient was an 83-year-old male who had undergone left cervical lymphadenectomy at his age of 74. In January 1989 (at the age of 81) he underwent sigmoidectomy for malignant melanoma of the sigmoid colon and on that occasion it was confirmed that the left cervical lymphnodes resected previously had been affected with metastasizing malignant melanoma. In October 1989, exterpation of the lymphnode metastasis of the malignant melanoma and left hemithyroidectomy for medullary carcinoma of the thyroid were performed. In June 1990, the primary lesion of melanoma was found at the base of the palate and removal of the lesion was performed. Since then, the patient had been placed under medical surveillance on an ambulatory basis. No sign of a recurrence has been noted to date, indicating that the surgical treatment proved to be quite effective and beneficial. Since symptomatic improvement was achieved invariably in all 7 surgically treated cases with the same condition documented so far in Japan, operative treatment seems justifiable at least in malignant melanoma cases with a solitary metastatic lesion to the degestive tract.

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A 33-year-old man had recurrent thyroid cancer that was resected by total esophagectomy and reconstructed by pharyngogastrostomy. He received a left partial lobectomy because of thyroid cancer in 1985, and was admitted to our department with the chief complaint of a neck tumor. Neck ultrasonography, computed tomography and magnetic resonance imaging showed recurrent thyroidal papillary carcinoma with esophageal invasion. Since the thyroid cancer directedly invaded the cervical esophagus for 5 cm, subtotal thyroidectomy and resection of the cervical esophagus were performed. Reconstruction with a segmental free jejunum was impossible, because there were no anastomosed vessels. Therefore we performed total esophagectomy and pharyngogastrostomy. Though the prognosis of differentiated thyroid cancer is relatively good, in the case of invasion to the circumference, radical resection should be performed.

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A case which suspected of being recurrent carcinoma of the remnant esophagus six years and three months after a radical operation for thoracic esophageal carcinoma is presented. A 52-year-old man was treated by subtotal esophagectomy and esophago-gastrostomy by the antethoracic route. His follow-up course had been uneventful. Six years and three months after the operation he experienced dysphagia and visited a hospital, where stenosis of the anastomotic region was detected by a upper gastrointestinal series and gastrofiberscopy. He was admitted to our hospital for further examination. Carcinoma of the remnant esophagus was suspected from the histological findings of the resected specimen from the first operation. There were no signs of metastasis. Cervicalesophagectomy, partial resection of the gastric tube, and bilateral neck dissections were performed. Free jejunal transplantation by the microvascular technique was used for the reconstruction. He is getting along well without any recurrence four years after the second operation.

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A 54-year-old man had an abnormal finding of the esophagus detected during a medical examination in June 1990. An upper GI series revealed an elevated lesion, measuring 20×16×10 mm, arising from the anterior wall of the upper esophagus. The lesion, with a slight erosion on its surface, was diagnosed as an esophageal carcinoma in accord with a superficial elevated type of the endoscopic classification. The histological findings on the biopsied specimen taken from the surface of the lesion showed squamous cell carcinoma. Radiation therapy at a dose of 50 Gy was delivered in combination with 2 cycles of continuous IV infusion of 5-fluorouracil and cisplatin at doses of 1, 000 and 25 mg/m²/day respectively for 5 days. No reduction of the tumor mass was seen after the treatment. Resection was carried out on March 7, 1991. The histological findings on the resected specimen showed that the elevated lesion was composed of leiomyoma derived from the muscularis mucosa, and the epithelium on its surface contained no cancer cells. The carcinoma covering the surface of the coexisting leiomyoma had disappeared as a result of the radiochemotherapy and only the leiomyoma component remained unchanged.

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Leiomyosarcoma of the stomach are infrequently encountered tumors. They represent 1 to 3 percent of all gastric neoplasmas, and despite advances in endoscopy and computerized tomography, early diagnosis is rarely accomplished. A 38-year-old man presented with an upper abdominal tumor. Physical examination at admission showed that the tumor had a smooth surface and exhibited fluctuation. In upper gastrointestinal tract study (barium, endoscopy) revealed submucosal tumor with ulceration in the fundus. Computerized tomography and ultrasonography revealed a large cystic lesion with septums, compressing the stomach and pancreas. Left gastric angiography showed a moderate number of tumor vessels through out the lesion in the fundus. The serum ferritin level revealed 307 ng/ml, which is very high. When the abdominal cavity was opened cystic lesion measuring approximately 25 cm in diameter was seen to protrude from the submucosal tumor in the fundus. The pathological diagnosis was leiomyosarcoma of the stomach with giant cyst formation. The ferritin level of the fluid in the cyst was 22800 ng/ml.

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Although microscopic gastric cystic lesions are common in resected specimens, few cases are a problem surgically. We experienced a case of a giant gastric cyst in the cardia, with extremely high levels of elastase-1 in the serum and in the fluid aspirated from the cyst, in which the differential diagnosis from pancreatic cyst was difficult. An 82-year-old male, who admitted for treatment of inguinal hernia and in whom abdominal ultrasonography revealed a cystic tumor in the stomach, was readmitted because of gradual enlargement of the tumor. An upper GI series revealed a submucosal tumor in the stomach. Ultrasonography and CT scan revealed a gastric cyst, and laparotomy was performed because of the possibility of pancreatic cyst. Total gastrectomy was performed for gastric cyst, and the resected specimen was 90×80 mm in diameter, 64 mm in height Histologically, it was a giant gastric pseudocyst, in which heterotopic and lymphatic cysts were observed in the gastric submucosa. Although clinically malignant gastric cyst has a very low frequency, special attention should be paid to diagnosis and therapy in patients with a cyst in the stomach.

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A 60-year-old man underwent partial gastrectomy for Stage IV gastric cancer showed a Type 3 and S₂, N₃, P₀, H₃. Before closing the abdominal wall, we administered mitomycin C (MMC) and OK-432 into the peritoneal cavity. 3ostoperatively he received chemoimmunotherapy consisting of MMC (i.v.), OK-432 (i.d.) and Lentinan (d.i.v.). kfter these treatments, metastatic liver tumors were not detected by computed tomography (CT) in the fourth ostoperative month. The patient has been healthy for 2 years and 5 months with only Krestin prescribed. Now we annot find any sign of recurrence. According to our review of the Japanese literature, only 6 patients (H₃) who lived or more than 2 years have been reported. From our patient's postoperative course, we think the chemoimmunoherapy was very effective.

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A case of gastric cancer in a 37-year-old man with dyskeratosis congenita is reported. His chief complaints were anorexia and weight loss, and gastric cancer was detected by an upper gastrointestinal series and endoscopic examination. Laparotomy disclosed cancer occupying the body and antrum of the stomach and its liver infiltration and peritoneal dissemination. No leukoplakia was found in the resected gastric mucosa. Histological examination revealed adenocarcinoma. The patient died of a massive gastrointestinal hemorrhage following disseminated intravascular coagulation 90 days after surgery. We place particular emphasis on the development of adenocarcinoma of the gastrointestinal tract at an early age in patients with this disease, in addition to carcinoma arising from leukoplakia, based on our experience and a few reports in the literature.

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Cholecystolithiasis and hepatolithiasis were detected by abdominal ultrasonography in a 50-year-old man who complained of right hypochondralgia. Spindle-like dilatation of the bile duct without stenosis was visualized in the lateral segment of the liver by endoscopic retrograde cholangiopancreaticography. Cholecystectomy and lateral segmentectomy were performed. In the gallbladder, there were small black stones that were amorphous in section. No atrophy was seen in the resected liver and black muddy stones filled the dilated intrahepatic bile duct. Because the slight thickness of the dilated bile duct was seen only histopathologically, this appearance did not indicate chronic proliferative cholangitis. Chemical analysis of these stones revealed that the gallbladder stones were composed of calcium carbonate, calcium bilirubinate and calcium phosphate, and the intrahepatic stones were composed of pure cholesterol. The pathogenesis of both the stones were obscure. This is a very rare case and we could not find an identical case in the world literature.

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We performed a right hepatectomy and a tumor thrombectomy by partially resecting the inferior vena cava and the portal vein under extracorporeal circulation using the Bio-Pump on a patient with hepatocellular carcinoma, in whom there were tumor thrombi in the inferior vena cava and the portal vein. It might have been possible to operate by just clamping the inferior vena cava below the hepatic vein without extracorporeal circulation, as the tumor thrombus in the inferior vena cava was developed through a short hepatic vein. However, we decided to operate under extracorporeal circulation, because we thought it would be safer to take enough time to observe the extension of the vascular invasion of tumor closely, and to reconstruct the vein. Although the patient recovered without any problem after the operation, she died of recurrence of the carcinoma 4 months after surgery. On autopsy multiple recurrent tumors were found in the remnant liver, but there was no metastasis to other organs. In this kind of case of advanced hepatocellular carcinoma with tumor thrombi we think the patient should be protected by supplemental therapy such as transcatheteric hepatic arterial embolization or combination chemotherapy even in the early postoperative period.

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Two cases of resected double cancer of the liver and the colon are reported. In case 1, the patient was a 67-year-old woman with the chief complaint of loss of weight. The levels of carcinoembryonic antigen and α fetoprotein were high. Ultrasonography, computed tomography and arteriography revealed a hepatocellular carcinoma (HCC). A barium enema and fiberscopy revealed a cancer in the ascending colon. Right hemicolectomy and lateral segmentectomy of the liver were performed because she had cirrhosis of the liver. The patient died 1 year and 8 months after surgery because of recurrence of HCC. In case 2, the patient was a 54-year-old man who underwent sigmoidectomy for cancer of the sigmoid colon. A hepatic tumor was detected by sonography 3 years after the first operation. The patient was diagnosed as having HCC by angiography and aspiration biopsy. Tumor markers and sonography are useful for detecting double cancer of the liver and the colon. Angiography and biopsy are useful for diagnosing this disease. Whether or not surgery is indicated should be determined depending on both HCC and cirrhosis because the prognosis of this disease depends on the prognosis of HCC. The operation for both cancers at the same time can be done without complications.

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Biloma, a secondary cyst collecting bile in the subserosal space of the liver, is generally caused by injury to the liver and the bile duct due to trauma or surgery. However we have encountered 3 rare cases of biloma caused by acute cholecystitis. In one patient; the biloma disappeared spontaneously before conservative surgery was performed. In the second patient; the biloma was drained before surgery, but marked changes were not noted. In the third patient; the biloma disappeared after drainage of the gall bladder. The findings seen in these 3 cases suggest that the bile in biloma would spontaneously drain into the gall bladder if inflammation of the gall bladder was reduced by some sort of treatment. Therefore it is considered that removal or drainage of the diseased gall bladder causing the biloma is the most effective treatment of this entitiy.

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A 49-year-old woman with early cancer of the gallbladder, which had been diagnosed by preoperative ultrasonography-guided aspiration cytology, is reported. While being admitted for the purpose of controlling diabetes, the patient underwent an ultrasonographic examination which revealed a tumor of about 18 mm within the gallbladder. Therefore, ultrasonography-guided aspiration cytology was performed and established the diagnosis of adenocarcinoma. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed the presence of an anomalous junction of the pancreaticobiliary duct without dilatation of the common bile duct. The patient received cholecystectomy along with resection of the liver bed and removal of the regional lymph nodes. Histopathologically, the tumor was diagnosed as a papillary adenocarcinoma localized within the mucosal layer without evidence of lymph node metastasis.

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We have experienced a case of early bile duct cancer associated with congenital bile duct dilatation (CBD). The patient was a 57-year-old woman, who was admitted to our hospital with the chief complaint of epigastralgia. She was followed up for 10 years by our physicians after a diagnosis of CBD due to maljunction of the pancreaticobiliary system. Detection of a mass in the bile duct cyst by imaging devices prompted us to remove the choledochal cyst. We could not find a macroscopical tumor; however, pathological examination of the resected specimen revealed well-differentiated tubular adenocarcinoma invading the fibromuscular layer in the cyst wall in two places. The patient is alive and well 14 months after the operation. We have so far collected data on only 24 cases of early bile duct cancer associated with CBD in Japan. The option of the operative procedure in such a situation will be clarified after collection of long-term results in many cases.

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We encountered a patient in whom reoperation by means of total resection of the residual pancreas combined with splenectomy was possible 3 years after pancreatoduodenectomy (PD) for infiltrative cancer of the lower bile duct. The patient was a 60-year-old man diagnosed as having cancer of the lower bile duct and treated by PD who 3 years later developed generalized fatigue, weight loss, and was admitted. Thorough physical examination revealed recurrence of the patient's bile duct cancer, the lesion was judged operable on the basis of diagnostic imaging, and a combined reoperation consisting of resection of the residual pancreas and splenectomy was performed. On the basis of postoperative studies, it was concluded that the cancer recurred because of cancer cells, remaining in the pancreatic stump after the initial operation, formed a skip lesion via the pancreatic duct and grew 3 years later. The patient's postoperative course was favorable and his carcino-embryonic antigen level, which has been quite high preoperatively, fell to normal postoperatively. Nevertheless, local recurrence developed 6 months later, and the patient succumbed to carcinomatous peritonitis 7 months postoperatively.

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A case of reversed rotation of the midgut in an adult is reported. A 78-year-old man complaining of intermittent abdominal pain and bilious vomiting was admitted to our hospital. He had a similar episode in his adolescence, which improved spontaneously. A barium enema study demonstrated extrinsic obstruction of the transverse colon and a mobile cecum. An upper gastrointestinal tract series with Gastrografin revealed almost complete extrinsic obstruction of the duodenojejunal junction which deviated to the right of the vertebrae. A preoperative diagnosis of suspicion of reversed rotation of the midgut was made. At surgery the reversed rotation of the midgut was identified as of the retroarterial right-sided cecum type, according to the classification by Amir-Jahed, and volvulus was not present. Duodenal obstruction was caused by dense adhesions involving the duodenojejunal junction and mesentery. The adhesions were dissected and the entire intestines were placed in the position of nonrotation by 180° anticlockwise rotation. Ladd's procedure with appendectomy was performed. The patient had an uneventful course for a year after surgery. Reversed rotation is extremely rare, 35 cases having been reported in Japan from 1976 to 1990. Thirteen of the patients were adults. Only 7 of 31 surgical cases were diagnosed as reversed rotation preoperatively. Ladd's operation was the most common procedure in the recently reported cases. Although reversed rotation is a rare congenital anomaly, particularly in adults, its clinical course and the findings of barium enema study and upper gastrointestinal series are distinctive, and a thorough knowledge of embryology and anatomy will help us with preoperative diagnosis and proper treatment of this disorder.

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A 78-year-old man had Crohn's disease complicated by peritonitis due to bowel perforation. He was admitted with the chief complaint of abdominal pain and subsequently developed fever and intraperitoneal free air, for which an emergency operation was carried out. A large volume of cloudy ascitic fluid was noted during the operation. No overt perforation site was found, but thickening of the ileum and its adhesion to the surrounding tissue were observed over about 20 cm of its length at a site about 80 cm from the ileocecal junction. A yellow fibrinous exudate was present over this lesion, indicating inflammtion. After intraperitoneal irrigation and drainage, part of the ileum was excised. The resected specimen showed many longitudinal ulcers, and Crohn's disease of the intestine was diagnosed histopathologically. Crohn's disease is infrequently seen in patients over 60 years old, and this case appears to be rare as the disease was accompanied by perforation. It is generally reported that elderly patients with Crohn's disease occurring only in the small intestine have a low risk of recurrence. The postoperative follow-up of this patient has continued for 2 years, and so far he has shown no signs of relapse.

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Obturator hernia is comparatively rare, and the preoperative diagnostic rate is low. This paper presents a case of obturator hernia diagnosed preoperatively by computed tomography (CT). An 80-year-old woman was admitted to the hospital complaining of abdominal pain, vomiting and pain in the right thigh. CT of the pelvis on suspicion of obturator hernia showed a mass in the region of the right obturator foramen. A definite diagnosis of obturator hernia was made and radical surgery performed. When this disease is suspected in an older patient with ileus of unknown origin, CT examination, which is very useful in making an early diagnosis, should be performed without hesitation.

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A 65-year-old woman was admitted with the chief complaint of bloody stool. Barium enema X-ray revealed ischemic colitis of the descending and sigmoid colon. After conservative therapy left hemicolectomy was performed, because the stenosis of the colon was not improved. Though the cytomegalic inclusion cells were found in and around the endothelium at the ischemic mucosa, the cytomegalic inclusion cells were few in comparison with the spread of the ischemic lesion. Therefore we considered that this cytomegalovirus infection was secondary to the lesion of ischemic colitis. Reports of 51 cases of cytomegalic inclusion disease of the alimentary tract in Japan revealed that most cases developed as a part of generalized cytomegalic inclusion disease and were associated with the immuno-suppressive condition. In our case the cytomegalic inclusion disease was localized, not associated with the immuno-suppressive condition. This is the first report of the disease complicated by ischemic colitis in Japan.

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The patient is a 90-year-old woman. The first cancer developed in the ascending colon and right hemicolectomy was performed in 1987. Its histological diagnosis was type 2, mucinous carcinoma. The 2nd cancer, which developed in the Rb portion of the rectum, was histologically well-differentiated adenocarcinoma of type 2. The 3rd cancer was observed in the R_S portion of the rectum. It was a carcinoma in adenoma of I_SP type. Low anterior resection of the rectum was performed on the 2nd and 3rd cancers in 1984. The 4th cancer was a II_C type early gastric cancer of well-differentiated tubular adenocarcinoma. The progress of the 4th cancer has been observed since 1986 up to May 1991 without an operation. The 5th cancer was detected in the transverse colon and partial resection of the transverse colon was performed in 1989. Its histological diagnosis was type 2, well-differentiated adenocarcinoma. The incidence of primary multiple cancers is on the increase with development of diagnostic techniques, improvement of therapeutic results and prolongation of the average life span. Recently we experienced a patient presently under observation for an early gastric cancer, who had heterochronous multiple cancers of the digestive tract for the past 16 years and received surgical treatment for cancers of the ascending colon, rectum and transverse colon. As reports of heterochronous multiple cancers including quadruple colon cancers and early gastric cancer are quite rare, our case will be presented and discussed with a literature review.

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In recent years, early esophageal cancer has become a target for endoscopic treatment, and resection of the cancer in aged patients is increasing. Under these circumstance, preoperative diagnosis is expected to be almost 100% accurate, especially in regard to the depth of cancer invasion and the extent of lymph node metastasis, in order to decide on the operative method. Diagnosis of the depth of cancer invasion has become 82.7% in accuracy by using a new endoscopic classification for superficial esophageal cancer. Endoscopic ultrasonography (EUS) is the best examination at present as to lymph node metastasis. According to the preoperative information from EUS, an endoscopic mucosectomy is performed for a small lesion of ep-mml cancer, and laser photodynamic therapy or surgical blunt descetion is selected for a spreading lesion. Esophagectomy by thoracotomy is required for mm2-sml cancers, and when blunt desection is selected radiotherapy must be added for a swelled lymph node detected preoperatively. For sm2-a2 cancers, usual thorachotomical esophagectomy and extended lymph node descetion should be performed. For a3 cancers, when invasion to the surrounding organs is limited esophagectomy should be tried as far as possible. However when the invaded area is relatively widespread a radical operation should be resingned and a by-pass operation should be conducted or an indwelling tube inserted to improve the quality of life for the patients.

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The preoperative assessment of the regional lymph nodes was correlated with the pathological findings and surgical results, in 198 patients with cancer of the thoracic esophagus undergoing esophagectomy. The nodal states were divided into 4 categories: (-), negative; (±), possible; (+), probable and (++), sure. 1. The sensitivity detecting positive nodes was limited because of frequent minute cancer deposite in lymph nodes. Involvement of lymph nodes along the recurrent nerves and perigastric lymph nodes was detected more sensitively than nodal involvement in the middle and lower mediastinum. Since the former lymph node groups are involved in earlier stages than the latter groups, limited resection without right thoracotomy can be regarded as a radical cure in poor risk cases which show no signs of cancer metastasis. 2. The specificity of nodal assessment was more than 95%, when (±) cases were regarded as negative. Such strict evaluation is useful for the selection of candidates for extended lymph node dissection. 3. The outcome after surgery was significantly less favorable when right recurrent nerve nodes or upper gastric nodes were (++). 4. The surgical outcome in cases which had lymph node involvement did not correlate with the preoperative evaluation, except for (++) cases.

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Preoperative angiography was performed for 735 patients with gastric cancer. The sensitivity and accuracy of diagnosis of peritoneal dissemination were 75.4% (86/114) and 93.2% (685/735) respectively. For liver metastasis, they were 80.6% (50/62) and 97.6% (717/735) respectively. The depth of gastric cancer invasion was histologically classified according to the following four groups: (1) mucosa (m) or submucosa (sm), (2) proper muscle layer (pm), (3) serosa (s) and (4) other organs (si). The accuracy of diagnosis of the depth of invasion was 80.2% (486/606). The diagnosis of the depth of invasion correlated well with lymph node metastasis (m-sm; n₀-n₂, pm; n₀-n₃, s-si; n₀-n₄). The patients who underwent radical gastrectomy were devided into four groups according to the feeding arteries. These four groups were compared with regard to the extent of lymph nodes metastasis.(1) The patients who had no identified feeding artery metastasis limited to the perigastric nodes.(2) The patients who had cancer fed by the left gastric, short gastric, left subphrenic and left gastroepiploic arteries had metastases limited to the attendant nodes of the celiac axis and its branches.(3) The patients who had cancer fed by the right gastric, pyloric and right gastroepiploic arteries had metastasis to the lymph nodes along the proper hepatic artery, behind the surface of the head of the pancreas or around the superior mesenteric vein.(4) The patients who had cancer fed by arteries of both groups (2) and (3) above, had para aortic lymph node metastasis.

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To allow a more rational selection of a surgical procedure for gastric cancer, taking into consideration the features of lymph node metastasis, we recently assessed the usefulness of imaging techniques in the preoperative diagnosis of lymph node metastasis. Lymph node metastasis of gastric cancer was divided into four types: micronodular, diffuse and micro-focal. By using this classification, a clinicopathological analysis was conducted on 515 patients who had undergone R₂ or more extensive lymph node dissection over the past 6 years. In 206 of these patients, the findings of ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) before the operation were compared. Of all cases of lymph node metastasis, 27.0% were of the macro-nodular type, 16.9% the micro-nodular type, 54.0% the diffuse type and 2.1% the micro-focal type. The largest diameter of the lymph nodes affected by macro-nodular type metastasis was significantly greater than that of the metastasis-free lymph nodes, while this parameter did not significantly differ between the lymph nodes showing the other types of metastasis and the metastasis-free lymph nodes. The rate of accurate diagnosis of lymph node metastasis was 55.6% with ultrasonography, 72.5% with CT and 68.6% with MM. The rate was particularly high for nodular type metastasis. For the diagnosis of metastasis to the lymph nodes of the abdominal para-aorta, MRI of the coronal sections was useful. These findings indicate that only the macro-nodular type lymph node metastasis can be accurately diagnosed by imaging before the operation, requiring the rout of cancer metastasis to be appropriately considered in selecting a surgical procedure for gastric cancer.

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Recently, surgery for rectal cancer has been concerned not only with radicality, but also with improving the quality of life by preserving defecatory, urinary and sexual functions. Consequently, various imaging techniques in addition to biopsy are used preoperatively to determine the best operative procedure. It is important to know (1) the location and size of the tumor, (2) the depth of invasion into the rectal wall and infiltration into another organ.(3) whether there is lymph node metastasis or not, (4) the length of distal invasion, and (5) whethere or not there are remote metastatic foci and peritoneal dissemination. The results of X-ray image accurately judgment the depth of invasion into the wall, while a transanal ultrasonic examination was effective for determining the depth of m, sm, or pm. MRI was useful for assessing the depth of a₂ or ai. Distal invasion and lymph node metastasis were effectively predicted by the degree of tissue differentiation from preoperative biopsy specimens. Lymphatic vessel invasion and budding (microtubular cancer nests and undifferentiated cancer cells) were indispensable to determine the AW distance for dicidig the surgical margin.

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A determination of the surgical procedure for hepatocellular carcinoma (HCC) takes into consideration the functional and anatomical condition of the patient. Function of the liver should take precedence over the anatomical stage of the cancer. The functional condition usually is suggested by biochemical examination; however, that does not always correspond to the pathological status of the liver parenchyma. Final decision should be made after the macroscopic and/or histological observation at laparotomy. Preoperative imagings, although there has been remarkable progress in recent years, cannot given sufficient information about the anatomical status of the cancer. Intraoperative examinations by ultrasound and/or biopsy at laparotomy give us important information for the final decision. We use a “Risk Score” which is composed of 5 items in biochemical examination, but that is only part of the information needed for decision of the surgical procedure. Considering the frequency of intrahepatic metastasis of HCC through the portal vein. Theoritically wider resection is expected to give a better outcome. However the results which have been achieved do not support that expectation.

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The present study was carried out to determine the limitations of diagnosis by currently available hepatic imagings in terms of extension of primary hepatocellular carcinoma. Diagnosis by hepatic imagings was compared with that by pathological findings in resected specimens from 112 patients with hepatocellular carcinoma who had undergone hepatic resection. The agreement between hepatic imagings and pathological examination was 70%. The false negative and false positive rates were 16% and 14%, respectively. In patients with a “false negative” diagnosis, intrahepatic metastasis was the most frequent cause. Half of these error were noticed during the operation, by naked eye, palpation or ultrasonic examination. However, the remaining errors were detected by pathological examination. In patients with a “false positive” diagnosis, angiographic study was the most common cause. In 195 patients undergoing hepatic resection with a tentative diagnosis of hepatocellular carcinoma, 9 (4.6%) of the tumors were histologically proved to be non-malignant.

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We reviewed the records of 85 patients who underwent tumor resection for cancer of the bile duct and analyzed the selection of operative procedures according to the preoperative diagnosis of the cancer's spread. As the mode of spread of cancer of the lower bile duct, spreading along the bile duct to the hepatic duct was observed in some cases and microscopic examination revealed cancer cells in the plexus around the superior mesenteric artery in no cases. The outcome after pancreatoduodenectomy (PD) combined with intraoperative radiotherapy (IOR) was better than after PD alone. As the mode of spread of cancer of the middle bile duct, the portal vein was likely to be invaded anatomically. Spreading also occurred along the bile duct to the hepatic side and/or to the duodenal side. The rate of radical resection in the bile duct resection group was about 20% and the outcome was very bad. The rate of radical resection in PD was 67%, but the outcome was not very good. Therefore PD combined with portal vein resection and/or IOR, including resection of the right and left hepatic duct separately, should be selected for cancer of the middle bile duct. Major liver resection combined with caudate lobectomy was better than bile duct resection in view of the longer survival of patients with cancer of the proximal bile duct. Right-sided resection of the liver was the procedure performed most often (about 67%). This was because the right hepatic duct is short and the tumor is more likely to invade the right hepatic artery than the left. Major hepatic resection combined with caudate lobectomy should be performed for cancer of the proximal bile duct.

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In order to perform a curative operation for pancreatic cancer, an accurate diagnosis of retroperitoneal invasion and vessel involvement is necessary. CT scanning and selective angiography are very helpful to assess the operability of the cancer. If no major arteries are involved, it may be possible to perform curative pancreatectomy by extended pancreatectomy with sufficient lymph node clearance and excision of the connective tissue around the pancreas. When involvement of the portal system is suspected, resection of the portal system combined with pancreatectomy should be performed. The resection of the connective tissue should be accomplished by the skeletonization of the superior mesenteric artery and paraaortic regions. Furthermore, combined modality treatment using radiotherapy and chemotherapy should be employed to prevent microscopic lesions and distant metastasis.

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The aim of this study was to establish appropriate indications for extended radical pancreatecotmy in patients with carcinoma of the head of the pancreas on the basis of a preoperative diagnosis of tumor extension and the curability rate. Seventy-five patients with ductal adenocarcinoma of the head of the pancreas in whom CT scan and abdominal angiography were performed preoperatively were selected for this study. The accuracy of preoperative diagnosis of arterial invasion (A) by CT scan and angiography was 92.0%, and it was 49.4%, 62.7%, 58.7%, and 61.3% of portal (PV), retroperitoneal (Rp), plexuses (Plx), and serosal invasion (S), respectively. Preoperative diagnosis was more difficult in patients who had mildly extended tumors than in patients who had no tumor extension or severely extended tumor. Curability was 65.1% in patients with A₀, 46.4-86.4% in PV_0-2, 50.0-100% in Rp_0-2, whereas it was 0-16.7% in A₃, PV₃, or Rp₃. The curability rate was so low in patients with severe extension of the tumor that extended radical pancreatectomy was not considered the treatment of choice. Although preoperative diagnosis was not easy in patients with mildly extended tumor, extended radical surgery is indicated to obtain a curative operation.

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