This study was undertaken to investigate the relatinoship between peripheral granulocyte functions and levels of serum granulocyte colony-stimulating factor (G-CSF) after surgery for esophageal cancer with thoracotomy and laparotomy. Patients with esophageal cancer (group E, n=12) and patients with gastric cancer who underwent subtotal gastrectomy (group G, n=12, control group) were examined. The peripheral white blood cell count (WBC), granulocyte count (GC), granulocyte chemiluminescence (CL) and levels of serum G-CSF (G-CSF) were measurd before and after the operation. WBC and GC of group E were significantly lower at the 4th and 8th postoperative hours (POH) than those of group G (p<0.01), and CL of group E was significantly lower at the 4th, 8th and 24th POH than that of group G (p< 0.05). However, G-CSF of group E was significantly higher at the 4th and 8th POH than that of group G (p<0.01), and a significant negative correlation was found between PMN and G-CSF at the 4th POH (p<0.01). These results suggest that the peripheral granulocyte count and CL are decreased early after surgery for esophageal cancer because a lot of granulocytes, which are excessively stimulated by various cytokines including G-CSF, attach to and infiltrate into the tissues.

View full abstract

We performed a univariate and multivariate analysis of 682 patients with advanced gastric cancer and determined its prognostic factors. The univariate analysis showed that the 5-and l0-year survival rates were significantly different between each strata of the prognostic factors including tumors size, macroscopic pattern, serosal invasion, lymphatic invasion, vascular invasion, peritoneal dissemination, liver metastases, lymph node metastases, histologic stage and operative curability. Age, sex and histologic type did not change the survival rates significantly. Multivariate analysis using Cox proportional hazards model determined curability, serosal invasion, lymphatic invasion, lymph node metastases, vascular invasion and tumor size as the significant and independent prognostic factors affecting advanced gastric cancers. Hazard ratios (weights of prognostic factors) were estimated as follows: serosal invasion 1.67, curability 1.53, lymphatic invasion 1.33, lymph node metastases 1.1g, vascular invasion 1.16 and tumor size 1.04. These statistically estimated prognostic factors and weights are clinically acceptable and useful.

View full abstract

Pancreatic seretory trypsin inhibitor (PSTI) is an endogenous trypsin inhibitor and is also known as an acute phase reactant. However, its role and function has not been fully understood. Twenty-nine patients who underwent hepatic resections were divided into two groups. Group A: patients whose postoperative course were uneventful (n: 19). Group B: patients who developed postoperative complication after hepatectomies (n: 10). PSTI was measured with the radioiommunoassay before the operation and on the 2nd, 4th, 7th, 14th, 21st and 28th postoperative day. Postoperative patients were also evaluated by conventional liver function test (sGOT, sGPT etc.) PSTI was normal in all patients before the operation. We noticed the increase of PSTI in all patients who underwent hepatic resections and who developed postoperative complications after hepatectomies. There was a significant correlation between PSTI on the 4th postoperative day and the duration of the operation. PSTI is the index to evaluate degrees of surgical stress. And there was a significant correlation between the PSTI on the 4th postoperative day and both preoperative ICGRlS and preoperative hepaplastin test. Postoperative elevation of PSTI depends not only on the surgical stress but also on the hepatic function.

View full abstract

Hepatic hemodynamic changes after hepatectomy were analyzed with an ultrasonic transit time blood flow meter in patients with cirrhosis. Seven patients with cirrhosis had a hyperdynamic systemic circulation and a portal/systemic flow ratio before hepatectomy. Portal resistance increased significantly in cirrhotic patients after hepatectomy. In 7 patients without cirrhosis portal, systemic flow ratio decreased significantly according to increase of cardiac output after hepatectomy. In 10 patients received lobectomy, hepatic oxygen delivery decreased significantly. In conclusion, a hyperdynamic state compensates portal flow in cirrhotic patients whose portal resistanse is high. Since the portal resistance increases after hepatectomy, portal blood flow should be maintained.

View full abstract

We investigated hepatic functional reserve by using caffeine (CA), which is demethylated by centrilobularly distributed cytochrome P4501A2 in hepatic microsomes, in 32 patients with liver cirrhosis, 10 patients with cholecystolithiasis without liver cirrhosis and 5 healthy volunteers who served as controls. After an overnight fast, CA was administered orally at a dose of 2mg/kg body weight The serum concentration of CA decreased proportionately after oral administration of CA in volunteers. Among three primary metabolites of CA, the serum concentration of paraxanthine (PX) was higher than those of the other two metabolites, theobromine (TB) and theophylline (TP), Ninety percent of the metabolites of CA were PX. They reached maximum levels 4 to 6 hours after administration. Therefore was considered that this test should be performed 4 hours after the oral administration of CA to obtain the optimum ratio of PVCA. The serum PVCA ratio was significantly correlatd with CA clearance (CL) in all patients (r=0.75, p<0.0001). The PWCA ratio in patients with liver cirrhosis (0.17±;0.16) was significantly lower than that in patients with cholecystolithiasis (0.44±0.13). Furthermore, a significant correlation between the serum PVCA ratio and serum albumin, cholinesterase and IGCRlS was observed. The CA clearance test may be useful to estimate hepatic functional reserve and severity of liver disease

View full abstract

Portal angioechography, a method of enhancing ultrasonographic images by the injection of carbon dioxide gasinto a branch of the portal vein, was used in 31 cases of hepatocellular carcinoma to determine the location of tumors. A 2l-gauge needle for percutaneous transhepaticholangiography was inserted into an intrahepatic portal branch under ultrasonic guidance. Ultrasonography was performed after the injection of 10-15ml of CO₂ gas into the branch. Gas was injected into the anterior segmental branch in 26 cases and the posterior segnental branch in 5 cases. The respective areas supplied by these branches became hyperechoic, and borders between them and neighboring areas were clearly recognizd, indicating that they were intersegmental borders. In 17 of 18 patients in whom gas was injected into the tumor-bearing segment, the tumors were shown as negative enhancement. In all 31 cases, it was possible to determine whether the tumor was in the anterior segment, posterior segment, or left lobe. In addition, the distance between the tumor and the intersegmental plane was ascertained prior to surgery, which facilitated preoperative planning. The accuracy of these determinations was confirmed at operation. Portal angioechography allows reliable demarcation of hepatic segments and intersegmental planes, and precise location of hepatic tumors.

View full abstract

To evaluate the effect of hepatectomy on pancreaticojejunal anastomosis, we examined local hemodynamics in the anastomotic region in experimental models. Seventeen adult mongrel dogs were treated with 40% hepatectomy plus pancreaticojejunostomy (hepatectomy group) and eight were treated with pancreaticojejunostomy alone (nonhepatectomy group). Mortality was 55.8% in the hepatectomy group and 12.8% in the non-hepatectomy group (p<0.05). Macroscopically, more small abscesses were present (p<0.05), and histologically, changes tended to remain in the stage of hemorrhage and necrosis in the anastomotic region in the hepatectomy group. The pancreatic hydroxyproline level was more markedly elevated in the non-hepatectomy goup (p<0.05). Portal hemodynamics: pressure was elevated, while blood flow and PO₂ were reduced in the hepatectomy group (p<0.01). l, ocal hemodynamics in the anastomotic region: tissue blood flow and tissue PO₂, were reduced on the pancreatic side in the hepatectomy and non-hepatectomy groups. On the jejunal side, tissue blood flow and tissue PO₂ were as markedly reduced in the hepatectomy group (p<0.01). The above findings suggest that, if hepatectomy is combined with pancreaticojejunostomy, protracted portal stasis occurs to induce congestion and impairment of the microcirculation on the jejunal side of the anastomosis. This, together with circulatory disturbance on the pancreatic side, causes a delay in wound healing that can lead to suture failure at the site of anastomosis.

View full abstract

Thirty one patients with hepatocellular carcinoma (HCC) had selective segmental portal embolization (SSPE) combined with transcatheter arterial embolization (TAE) for improved results of the tumor necrosis and minimization of liver disfunction after surgery. Lipiodol + Ethanol was used as the embolic material. After SSPE, liver functional damage was not severe. Portal vein pressure was significantly elevated just after SSPE. Hepatectomy was performed in 7 with liver cirrhosis of these 31 patients. In comparison with 12 patients who underwent TAE alone, liver functional damage was slight, and the mean necrotic ratio of the tumor was significantly higher.

View full abstract

In 182 patients with hepatocellular carcinoma (HCC), 17 patients (9.3%) had 20 extrahepatic primary cancers. These were synchronous in 7 patients and metachronous in 10 patients. In 9 patients with metachronous multiple primary cancers (MPC), HCC was diagnosed after the treatment of extrahepatic primary cancers. The most common cancer associated with HCC was gastric cancer (52.9%). The average age in HCC with MPC was 65.0 years, and that in HCC without MPC was 61.0 years (p=0.082). The average age in metachronous MPC (68.1 yr) was significantly higher than that in synchronous MPC (60.6 yr, p>0.05). The frequency of a past history of blood transfusion in patients with metachronous MPC was 70.0%, and that in those with synchronous MPC was 28.6% (p=0.092). Of 17 patients with MPC, 11(64.7%) underwent radical resection for both cancers. The 5-year survival rate was 34.1% after radical resection for both cancers, no different from that of radical resection for primary HCC alone. It was thought that aggressive therapy should be performed even though the patient had MPC, if indicated for radical resection

View full abstract

Among 120 consecutive patients who underwent cholecystectomy at our institution in the past 26 months, 78 patients underwent laparoscopic cholecystectomy (LC group), and 42 open cholecystectomy (OC group). Clinical data, such as preoperative associated condition, operation time, intraoperative blood loss, and postoperative course and complications, were retrospectively compared in the two groups. Preoperatively, the rates of associated negative gall bladder on X-ray examination, previous abdominal operation and acute cholecystitis were similar in the two groups. Mean operation time was significantly longer in the LC group than in OC group (139vs 99min), whereas mean bld loss was less in the LC group (47ml vs 139g). Postoperatively, the number of febrile days, leucocytosis and elevation of C reactive protein value were significantly improved in the LC group. In addition, time needed to change to the standard diet and length of hospital stay were shorter in the LC group. There were no remarkable differences between the two groups, in the liver and renal function tests. There were no death or major complications after either procedure. These results demonstrated that LC is less surgically invasive and provides a better quality of life, and indicated that LC may be applicable as a standard procedure in cholecystectomy.

View full abstract

Clinicopathological features in 37 patients with obstructing carcinoma of the large bowel were compared with those in 487 patients with non-obstructing cases, and the timing of surgery and the surgical procedure for obstructing carcinoma of the large bowel were studied. Many patients with obstructing carcinoma were over 70 years of age, and the incidence was high in the transverse colon, particularly the left transverse colon. Marcoscopically, the incidence of type 3 cancer and of the circumferential type was higher than in the non-obstructing cases. Histologically, the incidence of poorly differentiated adenocarcinoma, of a lesion showing depth of invasion of ss or more and of a lesion of v (+) was higher than in non-obstructing cases. Thus, there were more cases of progressive cancer among the patients with obstruction. The rate of curative resection were low in the patients withobstruction, whereas the accumulated 5-year survival rate after curative resection for patients with stage III or IV cancer was not different from that for the patients without obstruction in the same stage. This finding suggests that as radical surgical treatment as possible should be selected for patients with obstruction. In the patients in whom primaryanastomosis was possible. dilatation of the intestinal tract on the oral side was 2 timesor less than that on the anal side. Therefore, we believe it is possible for the intestinal tract to be anastomosed if the diameter of the intestinal tract on the oral side is 2 timesor less than on the anal side.

View full abstract

Endoscopic and histological effects and perianal dermal side effects after high-dose-rate intraluminal brachytherapy (HDRIBT) using ⁶⁰Co for preoperative irradiation were assessed in thirty-five patients with lowlying rectal cancers. In more than half of the patients irradiated with 30 Gy or more, marked effective change was observed under endoscopy. In the histological assessment, while the resected lesions irradiated with 16-20 Gy showed no effective change, 68.8%, 75.0%, and 76.9% respectively, of those in the groups given 30 Gy, 40-60 Gy, and 80 Gy showed marked destruction. While 23.1% of the patients irradiated with80 Gy developed severe perianal dermal lesions requiring surgical removal of the anus, 18.8% of the 30 Gy group and 25% of the 40-60 Gy group suffered dermal side effects which were mild and reversible. Consequently, it has been concluded that the proper regimen for preoperative HDRIBT for rectal cancer was 30 Gy followed by surgery within two weeks. During the follow up period from 35 to 70 months, one patient (2.9%) who received 16 Gy HDRIBT developed local recurrence within 3 years after resection, and the other one developed hepatic metastasis. The 3-year local recurrence rate after resection for lower rectal cancer in the previous series at our department was 19.6%. We, therefore, concluded that HDRIBT was a promising adjuvant therapy for rectal cancer.

View full abstract

We report a case of synchronous double cancers of the esophagus and stomach treated by pylorus preserving subtotal esophagogastrectomy with replacement of the right hemicolon. A 60-year-old man was admitted complaining of epigastralgia. Upper gastrointestinal series andendoscopy revealed synchronous double cancers of the esophagus (ulcerative and localized type carcinoma of the middle third of the esophagus) and stomach (Borrmann type 2 carcinomaof the anterior wall of the lower part of the gastric body; Borrmann type 3 carcinoma of the posterior wall of the lower part of the gastric body). Subtotal esophagectomy was performed, and subtotal gastrectomy was performed at a resection line 1.5cm from the pyloric ring. Reconstruction was made by using the right hemicolon, and cervical esophago-ileostomy and colo-residual gastrostomy with end-to-end anastomoses were performed. We consider thatthis operation has the following merits: it increases the capacity of the substitute stomach and prevents Damping's syndrome by preserving the pylorus, and is a physiological reconstruction that can provide good secretion of gastrointestinal hormone.

View full abstract

Appendiceal metastasis of gastric cancer is rare; only 13 cases have been reported in the Japanese literature. A 41-year-old woman underwent total gastrectomy for gastric cancer. Because she hoped to undergo appendectomy for intermittent right lower abdominal pain, we performed appendectomy after strict observation of the abdomen. Macroscopically, the gastric cancer showed P₀·H₀·N₁S₁, and was stage II. No inflammatory or maligant findings were observed in the appendix. However, the appendix showed the same poorly differentiated adenocarcinoma as the histological examination of the gastric cancer. Therefore, she was diagnosed as having an appendiceal metastasis from gastric cancer. The patient has survived without recurrence for two years after the operation. Appendiceal metastasis of gastric cancer has been reported in few cases, all of which were found in postoperation for secondary acute appendicitis. This case is extremely rare, considering the metastatic site and absence of the complication of secondary acute appendicitis.

View full abstract

We report the first Japanese case of the diverticular perforation of duodenum atthe third portion, diagnosed by retroperitoneal emphysema and abscess. A 39-year-old woman was admitted to our hospital under suspicion of small bowel obstruction. Supportive therapies were fairly effective. On the third hospital day, she had a body temperature of 38°C, WBC count of 15, 5000/mm³, and CRP of 27.3 mg/dl. Abdominal plain X-ray and enhanced CT revealed pneumoretroperitoneum, and gastrointestinal perforation was suspected. On laparotomy, retroperitoneal emphysema and edema were seen. The right colon was mobilized anteriorly. A smalldiverticulum in the third portion of the duodenum was perforated and surrounded by yellowish-white abscess. The diverticulum was inverted into the duodenal lumen and a z-stitch was placed. γ-Streptococci was cultured. The postoperative course was excellent. In Japan, 15 cases of diverticular perforation of the duodenum have been reported, all located in the second portion of the duodenum. This is the first report of diverticular perforation of the duodenum at the third portion in this country.

View full abstract

A case of benign liver tumor in a 26-year-old Japanese woman who had taken oral contraceptive for about 5 years is reported. She had complained of low grade fever and right hypochondrial pain. Preoperative examination showed several hypoechoic tumors in the right posterior segment of the liver and a large hemorrhagic tumor in the medial segment. The latter was resected and the surgical specimen was examined pathologically. Macroscopically, the tumor was encapsulated by fibrous capsule, and occupied by hemorrhagic and necrotic mass. Histologic examination demonstrated remniscence of the trabecular pattern of tumor cells which resembled normal hepatic cord. No cellular atypism or capsular invasion was observed. Furthermore, portal triad was not recognized in the tumor. Both macroscopically and microscopically, cirrhotic or hepatitic change was absent in the non-tumorous part of the liver. These findings are compatible with those of hepatocellular adenoma. The postoperative course was uneventful, and the residual tumors in the right posterior segment have become reduced in both size and number, perhaps because of the withdrawal of oral contraceptive.

View full abstract

An extremely rare case of extrahepatically growing hepatocellular carcinoma presenting with gastrointestinal bleeding due to penetration into the gastric lumen by the tumor is reported. The patient was a 66-year-old man who was examined by a local doctor for the main complaints of hematemesis and melena. Upper gastrointestinal fluoroscopy and endoscopy revealed a huge elevated lesion extending from the fbmix to the posterior wall of the gastric corpus. The lesion, 13cm in diameter, touched the lower surface of the lateral segment of the liver in abdominal computed tomography. The diagnosis of bleeding from the gastric submucosal tumor was made, and the patient was hospitalized for the purpose of undergoing surgery. At the time of hospitalization, distinct anemia was presented, and therefore, an emergency operation was performed. Under laparotomy, the tumor was found between the lateral segment of the liver and the posterior wall of the gastric corpus. As the tumor appeared to invade the lower surface of the lateral segment of the liver, resection of the lateral segment of the liver was performed in addition to total gastorectomy and splenectomy. Histological examination demonstrated that the tumor was a hepatocellular carcinoma of Edmondson's grade III, with extrahepaticaly growth from the lateral segment of the liver causing penetration into the gastric lumen.

View full abstract

A case of biliary tract tuberculosis that was difficult to differentiate from solid and cystic tumor (SCT) of the pancreas was treated. The patient was a 25-year-old woman from Philippines. She was admitted to our hospital with complaints of dull continuous upper right quadrant pain. Laboratory findings showed no abnormality. Abdominal ultrasonography and computed tomography revealed a multi-lobular cystic mass with solid components. Celiac angiography showed dilation and displacement of the epitholedochal plexus. Portography showed stenosis and displacement of the main trunk of the portal vein. No significant findings of tumor stains or encasements were found. A solid and cystic tumor of the pancreas was our preoperative diagnosis. Laparotomy was performed and frozen pathological examination revealed no malignant cells, but Langhans' giant cells were found. The tumor was resected. The postoperative pathological diagnosis was tuberculous adenitis. The morphological features of tuberculous adenitis of the biriary tract are similar to SCT of the pancreas. Therefore, a means of differential diagnosis has to emerge.

View full abstract

We report three patients with Crohn's disease associated with gastric or duodenal enteric fistulas treated by surgery. Two patients had duodeno-colic fistulas, and another had a gastro-colic fistula. Preoperatively, all patients received total parenteral nutrition, and two of them were additionally treated with medical therapy, Although the nutdtional status of all patients improved remarkably, fistulae were not closed completely. After conservative therapy, all patients underwent colectomy and resection of the fistulae. They returned to work soon after the surgery and had a good QOL at fonow-up periods. Surgical treatment should be recomrnended in the management of intemal fistulas between upper and lower GI tract of Crohn's disease.

View full abstract

A case of rapidly growing leiomyosarcoma in the mesosigmoid is reported. A 73-year-old male was examined in another hospital by abdominal CT and echosonography 3 months previously under suspicion of metastatic brain tumor. No pathological findings were noted at the time. The patient was admitted to our hospital with a month's history of constipation and abdominal mass. The abdominal tumor, 20 cm in diameter, was diagnosed as sarcoma in the mesosigmoid by CT and angiography, and the operation was performed. The tumor, which was located mainly in the mesosigoid, invaded to the mesorectum, ileum and appendix. A part of the tumor ruptured, and 3000 ml of bloody ascites was observed. Low anterior resection with partial resection of the ileum and appendectomy was performed. The tumor was 22×17×8 cm in size and 1750 g in weight, and was diagnosed histopathologically as leiomyosarcoma in the mesosigmoid. The patient was discharged uneventfully on the 14th postoperative day. Liver metastases and intraabdominal recurrence were discovered 5 months after the initial operation. The patient died 10 months after the operation in spite of chemotherapy. Leiomyosarcoma in the mesentery is a disease with poor prognosis, but only surgical intervention is considered to be curative and improve the patient's quality of life. Anemia of moderate grade was suggested to be a characteristic finding of leiomyosarcoma from our analysis of literature.

View full abstract

We report a case of goblet cell carcinoid of the appendix with a review of the literature. A 62-year-old man was diagnosed as having acute appendicitis, and an appendectomy was performed. Because the histological diagnosis was considered to be mucinous carcinoma, an additional right hemicolectomy was performed. Histological reexamination revealed a goblet cell carcinoid of the appendix. The patient has been well for 5 years after surgery, without any signs of recurrence. From the clinical viewpoint, this tumor often develops the sign of acute appendicitis. Histological features are important to distinguish the tumor from a mucin-producing adenocarcinoma. Therefore, we must pay careful attention to the histological examination of the resected appendix.

View full abstract

Ten cases of deep fungus infection after gastroenterological surgery were analyzed in terms of infectious risk index and serological examination for candidemia, namely, CAND-TEC. The infectious risk index, calculated using numbers of neutrophilis, lymphocytes and leukocytes, was as high as 54 in one case, but lower than 20 in the other 9 cases. In leukemia and malignant lymphoma patients, impaired cellular immunity is reportedly an important contributing factor for the establishment of opportunistic fungus infections because of the high infectious risk index. However, in patients who undergo gastroenterological surgery, the increased opportunity for fungal infection due to operative insult on the intestine and tissues is the main causative factor in combination with the change in microflora caused by the administration of multiple antibiotics. In all cases, Candida antigen titer was positive at a level of 1: 2 or greater titer. It became negative in the 7 survivors, but was unchanged or increased in 3 dead cases. CAND-TEC is useful for the diagnosis of candidemia and judgement of the efficacy of antifungal treatment.

View full abstract

The patient was a 65-year-old woman with chief complaints of abdominal pain and diarrhea. Three years earlier, in 1987, she had undergone abdomino-perineal resection of the rectum for rectal cancer. Abdominal ultrasonography and computed tomography revealed a tumor developed from the mesenterium. The operation was performed on August 20, 1990. A tumor was found in the mesenterium between Treitz's ligament and the left common iliac artery. We performed tumor extirpation with resection of the small intestine near Treitz's ligament. The resected elastic hard tumor, measuring 10×8×5cm, showed a smooth surface, whitish and solid cut surface, and was histologically diangosed as intra-abdominal desmoid tumor of the mesenterium invading into the muscular layer of the duodenum. This is a very rare case of intra-abdominal desmoid tumor without polyposis coli. Since 1981, only 27 such cases have been reported in the Japanese literature.

View full abstract

We reported the rare case of a 67-year-old woman with metachronous quadraple cancer including carcinoma of the pharynx, stomach, breast and esophagus during 12-year period. These four cancers had quite different histological features. The patient was successfully treated and is well without any evidence of recurrence. Impaired cellular immunity was observed in this case suggesting that it might be the possible pathogenesis of the multiple cancers.

View full abstract

A case of quadruple cancer including breast, uterine, colon and gastric cancer during a period of 16 years is reported. The 64-year-old woman patient had a family history in which all but one brother had suffered from cancer. She had undergone mastectomy at age 48 due to breast cancer, and total hysterectomy at age 54 due to uterine cancer. She complained of epigastral discomfort, and visited our hospital, where she received a curative operation for colon and gastric cancer (synchronous double cancer). We review a total of 16 cases of quadruple cancer in Japan, 7 (43.8%) of which could be resected. The most common sites were the stomach and colon. The first cancer tended to have a favorable prognosis. It is important to provide follow-up, taking care not only of recurrence but of additional carcinoma.

View full abstract