Precise assessment of morphological and functional pathologies of the liver is required during the perioperative period of hepatectomy, which results in massive liver mass reduction, and/or the period of any operative procedure in patients with advanced liver disease. For objective and quantitative assessments of the hepatic pathologies, 1) kinetic behavior of indocyanine green (ICG) injected into circulation, and 2) three dimensional images of the liver were analyzed. It was feasible to estimate the ICG excretion parameters including liver function and circulating blood volume. The three dimensional images led me to attain regional liver volume, localization of tumors, volumetric hepatic tumor ratio, posthepatectomy regeneration modes, and to help surgeons decide optimal resectional plane and procedure by computer simulation. Hepatic pathology should not be appreciated independently based on either morphologic or functional tests. Generalized comprehension of results obtained by both tests and computer simulation is imperative for objective assessment of hepatic pathology. It would be valuable for accurate estimation of the hepatic reserve in postoperative period of preplanned certain procedure.

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Clinical profiles and results of treatment for recurrence of thoracic esophageal carcinoma were analysed. The sites of recurrence were lymph nodes (73%), a distant organ (36%) and local (mediastinum) (17%). The median survival period was 7 months, mean survival period was 8.2 months and 1, 2 and 3-year survival rates were 21%, 10% and 5%, respectively. The outcome for the patients who underwent active therapy for recurrence was significantly better than for those who underwent only palliative therapy. The median survival period for patients who had been given irradiation was 9 months, which is significantly longer than that (6 months) for those who had been given chemotherapy. For the majority (73%) of the patients who had been given irradiation, the diagnosis was based on their clinical symptoms (mainly hoarseness). In these irradiated cases, the mean long diameter of the recurrent tumors was 4.4cm, the mean period between the onset of the symptoms and the beginning of treatment was 2.8 months and the effective rate was 39%. Resection at the site of recurrence was performed in 4 cases and the prognosis for these patients was relatively good; one patient died 17 months after re-resection and the other 3 patients were being treated as outpatients, whose survival period after re-resection was 6, 20 and 22 months, respectively. Interleukin-2 was administered for pleuritis carcinomatosa and pericarditis carcinomatosa with positive results.

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The clinical features including the distribution pattern of involved lymph nodes were investigated in 131 patients undergoing our standard systematic lymph node dissection (the cervico-abdomino-thoracal approach) and in 18 patients undergoing limited operation (less aggressive but including the cervical approach), to establish reasonable compromise dissection procedures for various poor risk patients. When the preoperative evaluation of the lymph node state was negative (preoperative No) and cancer did not penetrate the esophageal proper muscle (a₀ cancer), there was no nodal involvement in the middle and lower mediastinum (MLM).In a₀ or preoperative No cancer, MLM nodes were less frequently involved than nodes along the recurrent nerves (RN nodes) or nodes at the upper stomach (US nodes) including the celiac nodes. When neither RN nor US nodes were histologically positive, the incidence of MLM node involvement was low (0% in a₀ cancer). Cancer recurrencein the MLM was not found in a₀ cancer. Cancer did not recurred in the mediastinum in patients undergoing limited operations, except those with too extensive disease. These findings suggest that RN and US node dissections are substantial even in limited surgery. Less aggressive operations through left thoracotomy or without thoracotomy are a rational compromise for earlier stage cancer, especially a₀ or preoperative No cancer.

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On the basis of experimental studies showing that the excessive operative stressof thoracolaparotomyenhances tumor growth and metastasis, we chose transhiatal esophagectomy for all resectable carcinomas of thelower esophagus and carcinoma of the middle and upper thoracic esophagus in the early stage. The records of 33patients with carcinoma in the lower esophagus who received transhiatal esophagectomies were analyzed forcomplications, late results and sites of first recurrence. Pneumothorax occurred in 8 patients (24%), recurrent nerveparalysis in 4 (12%) and pneumonia in 3 (9%). Operative mortality within 30 days was 6% (2/33) dueto laceration ofthe azygos vein during the operation and mediastinitis. The survival rate for 31 patients (2 cases of operative deathwere excluded) was 24.8%. The sites of first recurrence in the 31 patients with carcinoma of the lower esophaguswere investigated. In 9 patients (29%) the site was parenchymatous organs, in4 patients (13%) it was lymph nodes (bifurcation, pulmonal hilar, posterior mediastinal and para-aortic lymph node, one each), in 2 patients (6%) recurrence wasdisseminated and in one patient the first recurrence was in the remnant esophagus.These resultsindicated that transhiatal esophagectomy causes minimal surgicalstress, and gives equivalent a survival rate tothat after thoracolaparotomy. Intensive multidisciplinary treatment using irradiation and immunochemotherapymay be required to improve the prognosis.

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The distance of discrepancy (DD) between macroscopic and histological measurement of the oral margin ingastric cancer was clinico-pathologicallly examined. The subjects were 248 patients with advanced gastric cancer, on whom a curative operation had been performed more than 5 years earlier. The DDs of these cases were comparedaccording to depth, histological type and macroscopic type of the main lesion. The results showed that misdiagnosiswas mostly related to the macroscopic type, and the DD of the infiltrative type was statistically larger than that ofthe localized type in underestimated cases (p<0.05). As for background, the ratesof stage 3, scirrhous growthpattern and INFγ were higher in the infiltrative type, whereas no difference was seen in the factors of lymphaticpermeation, venous invasion and tumor size. In contrast with a DD of less than 9mm in 93.3% of the cases of thelocalized type, a DD of 19 mm was required for the infiltrative typeto attain the same rate. In conclusion, more careshould be taken about the cutting line of gastrectomy in the infiltrative type of cancer.

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We studied the role of selective celiac angiography to predict the outcome of type 4 gastric cancer. Preoperativeselective celiac angiograms of 76 gastrectomized patients with type 4 gastric cancer were analyzed. Gross findingsof the resected stomachs were divided into two groups, a giant fold type including linitis plastica, and anulceroinfiltrative type. We selected two abnormal findings, irregular narrowing of gastric wall arteries in thearterial phase (A) and disappearance of gastric wall veins in the venous phase (V). According to A and V findings, anAV-negative (A and V negative) group and an AV-positive (A and/or V positive) group were defined. The outcome ofthe AV-negative group was significantly betterthan that of the AV-positive group, especially in the giant fold type.In curatively gastrectomized patients with the giant fold type, 50% survival times in the AV-negative and AV-positive groups were 24 and 9 months respectively, and the former survival curve was statistically better than thelatter. The outcome for theAV-positive patients was poorer than that for AV-negative patients, even if curativeoperations were performed. Histopathologically, severe lymph vessel invasionwas observed in AV-positive cases.Thickening of collagen bundles was frequently found in AV-negative cases. We believed that selective celiacangiography is useful to predict the outcome of type 4 gastric cancer before surgery.

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Lymph node metastasis is a very important issue when we perform endoscopic resection or a limited operationfor early gastric cancer. The clinicopathological characteristics of mucosal cancer with lymph node metastasiswere determined in 946 cases, in which the cancer had been resected in our hospital from 1966 to 1987. Ten of thepatients had lymph node metastases at a rate of 1.1% of all cases. Theclinicopathological characteristics of the highrisk group in terms of lymph nodemetastasis are as follows: 1. Tumor size more than 4 cm. 2. Depressed type. 3.The tumor has an ulcer or an ulcer scar more than UI-11.4. Undifferentiated type.In other words, conditions in thehigh risk group are idential with those of the so-called “superficial spreading type of carcinoma”. Therefore, as faras lymphnode dissection is concerned, almost all gastric mucosal cancers are supposed tobetreated by endoscopicresection or a limited operation. But now it is very difficult to make an accurate diagnosis of the depth “m”and “sm”beforesurgery, andits accurate diagnostic rate is still low. Therefbre we should select the cases strictly for this therapy, and in particular we should pay attention to the cases ofundiferentiated and depressed type with anulcer or an ulcer scar of early gastric cancer.

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From 1978 through 1990, 119 patients underwent selective proximal vagotomy for a duodenal ulcer (UD).Indications for surgery were: perforated UD, 86; non-perforated UD, 33. Basal acid output, tetragastrin-stimulatedgastric secretion (gastrin-MAO), insulin-stimulated gastric secretion (insulin-PAO), gastric emptying test, plasmagastrin levels in response to a test meal and insulin were measured before surgery in patients with non-perforated UD and 3 months to 5 years after surgery in patients with perforated and non-perforated UD. The cumulativerecurrence rates were calculated by the Kaplan-Meier method. Plasma gastrin levels after surgery in patients withnon-perforated UD were higher than the preoperative levels. Gastric acid secretion levels in patients withperforated UD 1 year after surgery were higher than the 3 months postoperative levels, but the levels over 1 yearafter surgery were not higher than those 1 year after surgery. Eight of the patients with perforated UD (9.3%) andnine of those with non-perforated UD (27.2%) developed recurrent ulcers and the 10-year cumulative recurrencerates were 26.6% and 31.6% respectively. Patients with a gastrin-MAO value 1 year after surgery of over 20 mEq/hor an insulin-PAO value 1 year after surgery of over 12 mEq/h had higher cumulative recurrence rates than thosewith a gastrin-MAO value of less than 20 mEq/h or an insulin-PAO value of less than 12 mEq/h. According to theseresults, patients with high gastrin-MAO and high insulin-PAO levels 1 year after surgery may develop recurrentulcers.

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Curative hepatic resections were performed in 263 patients with hepatocellular carcinoma (HCC) from 1981 to 1991. As of December 1991, there was recurrence in 142 cases (54%), and a second resection was performed in 20 cases (14%), which were analyzed clinicopathologically. The mean time from the first resection to detection of a recurrence in these 20 patients was 875 days. ICGR15 tended to increase by the time of second operation, and the amount liver resected tended to decrease. The total size of the tumors removed during the second resection was smaller (p<0.05) but the number of the tumors tended to increase. In eight cases, the recurrence was in another lobe of the liver. It was difficult to classify the 20 recurrences as involving intrahepatic metastasis or multicentric occurrence. In these 20 patients, a second resection was an effective treatment for recurrences of HCC, but for long-term survival, the mechanisms of recurrence must be identified.

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Liver regeneration after hepatic resection (the growth rate of the remnant liver) related to pathological findings of the resected liver were studied. Seventy cases of hepatic resection were used in the study. The growth rates of the remnant liver were calculated twice by computed tomography, once before and 3-4 weeks after hepatic resection. The degrees of fibrosis, inflammatory cell infiltration, and piecemeal necrosis were determined microscopically, and divided into four groups. In the cases without fibrosis or with mild fibrosis, the growth rate of the remnant liver increased exponentially in proportion to the rates of removal of the liver (p<0.001). The regression curves of the growth rate in the mild fibrosis group were significantly lower than in the group without fibrosis. In the groups with moderate or severe fibrosis also, no significant correlation was found between the growth rates and the removal rates. Less significant differences were found between the growth rates divided by the degrees of inflammatory cell infiltration or piecemeal necrosis than between those divided by the degree of fibrosis. We concluded that the degree of fibrosis regulates the regeneration of remnant liver.

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A controlled study of prophylaxis with Cefotaxime (CTX) was carried out in 58 patients undergoing cholecystectomy. The patients were randomyl divided into 3 treatment groups by the envelope method. All patients received intravenous drip infusion of 1g of CTX at one time. In group A it was given only when anesthesia was started (n=18). In group B it was given at the beginning of anesthesia and immediately after the operation and every 12 hours 3 days (n=20). In group C it was given at immediately after the operation and every 12 hours for 7 days (n=20). Postoperative infection related to the surgical field was noted in 10.3% of all patients, 27.8% in group A, 5% in group B and 0% in group C. The incidence of infection related to the surgical fields was greater in group A than in group B and C (p<0.05). Correlation between intraoperative bile contamination and postoperative infection rates was not demonstrated, but the organisms from contaminated bile often caused postoperative infection. Postoperative infection due to bacteria sensitive to CTX was not frequent, CTX was useful for postoperative antibiotic prophylaxis in cholecystectomy. A single infusion of 1 g of CTX was not enough for prophylaxis in cholecystectomy.

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Thirty-seven patients with advanced carcinoma of the gallbladder (14 in stage III and 23 in stage N according to the General Rules by JSBS) who received macroscopically curative tumor removal were analyzed retrospectively. Five types of hepatic resection combined with resection of adjacent organs were performed in 25 patients. Eight patients survived more than 3 years after the surgery. Three of the 8 patients had histologic tumor invasion to the adjacent organs (transverse colon, abdominal muscle and major omentum) (stage IV). In the other 5 patients the tumors had spread into the serosa of the gallbladder (stage III). Seven of the 8 patients had neither regional lymph node involvement nor tumor invasion to the hepatoduodenal ligament. There was no significant difference in survival rate between stage III and IV of JSBS. On the other hand, according to the TNM classification by AJCC, 15 of the 37 patients were in stage II, 18 were in stage III, and 4 were in stage N. There was a significant difference in survival rate between stage II and lII (p<0.01). Thus, in this series, the classification by AJCC seems to be reasonable because it sets a high value on regional lymph node involvement as a prognostic factor of carcinoma of the gallbladder.

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Blood concentrations of total bile acid (TBA), oxygen partial pressure (P0₂) and oxygen saturation (SO₂) in the portal (PV), splenic (SpV), and superior mesenteric veins (SMV) and the superior vena cava (SVC) were studied by percutaneous transhepatic catheterization in 24 patients with esophagogastric varices secondary to liver cirrhosis. TBA in the PV was significantly higher than that in the SVC (p<0.01). There was no significant difference in TBA between the SVC and the SpV. The SMV was the main transportation route of TBA. There was no significant difference in P0₂ between the PV and the SVC, but SO₂ in the PV was slightly higher than that in the SVC (p<0.05). P0₂ and SO₂ in the SpV were significantly higher than in the PV, SMV and SVC (p<0.01). Percutaneous transhepatic portography demonstrated that the SpV was the main blood supply route to the esophageal varices. The variceal blood during injection sclerotherapy appeared as red as arterial blood in all patients. Therefore, we conclude that the variceal blood approximates that of the SpV in which TBA is lower but P0₂ and SO₂ are higher than those of the PV and SMV.

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Five patients (four with postoperative pancreatic fistulas and one receiving prophylactic treatment after post-pancreatoduodenectomy) were treated with a synthetic peptide (Sandostatin ^®) that mimics the action of somatostatin, a hormone which inhibits basal and stimulated pancreatic secretion. Two of the five patients developed fistulas after resection of the pancreatic head necessitated by periampullary malignancies, two others developed such fistulas after resection of the caudal pancreas for pancreatic or gastric cancer, whereas the remaining one was treated with Sandostatin ^® for prophylactic purposes. One hundred or 200μg of Sandostatin ^® was administered daily for 5 to 15 days. All fistulas closed 3 to 27 days after the treatment. By 3 days after initiation of therapy, the mean output of pancreatic juice of the three patients after pancreatoduodenectomy decreased to 44%, 48% and 68%. During treatment, transient hyperglycemia and a slight decrease in the serum amylase were observed, but plasma levels of gastrin, glucagon, insulin, lipase, GOT, GPT, AlP, LDH, Na, K, Cl, Ca and P were unchanged. Toxic reactions were limited to mild nausea and vomiting. These results revealed that somatostatin may be useful in the treatment of pancreatic fistulas and may be efficacious as a prophylactic agent for prevention of postoperative pancreatic fistula formation.

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Clinicopathological features of 28 cases of mucinous carcinomas of the large intestine were compared with those of 493 cases of well or moderately differentiated adenocarcinoma as a control. Mucinous carcinoma was more common in males and young people. Mucinous carcinoma had a greater likelihood of location in the right colon, deep invasion through the bowel wall, and lymph node metastasis than the control. Eleven cases of the floating type of mucinous carcinoma showed a greater likelihood of occurrence in young people, location in the rectum, invasive or special type, deep invasion, lymph node metastasis, venous invasion, peritoneal dissemination and poor prognosis than 14 cases of the fixed type. With the HID-AB staining method, 57.1% of the fixed type were the sulfomucinpredominant type and 85.7% of the floating type were the sialomucin-predominant type.

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The DNA ploidy was determined by flow cytometry in 62 smooth muscle tumors of the G.I.tract (26 leiomyomas, 3 leiomyoblastomas, 33 leiomyosarcomas). The study aimed to define the diagnostic and prognostic values of DNA ploidy for smooth muscle tumors of the G.I. tract. The DNA ploidy was aneuploid in six of the 26 leiomyomas, in one of the three leiomyoblastomas, and in 18 of the 33 leiomyosarcomas. DNA aneuploidy was found significantly more often in leiomyosarcomas than in leiomyomas and leiomyoblastomas (p<0.05), but no evidence of clinical malignant behavior was found in the six leiomyomas or one leiomyoblastoma with DNA aneuploidy. In patients with leiomyosarcomas, DNA aneuploidy and a higher tumor grade were associated with significantly poorer survival rates (p<0.05), but neither the tumor size nor the mitotic index correlated with survival of the patients. The DNA ploidy patterns had little diagnostic value for smooth muscle tumors of the G.I. tract, but had significant prognostic values for leiomyosarcomas of the G.I. tract.

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A 56-year-old man had received pancreaticoduodenectomy for a tumor at the pancreas head that was revealed at a mass screening examination. Histological examination, however, revealed metastatic undifferentiated carcinoma in the lymph node located in the parapancreatic head instead of pancreatic head cancer. Incidentally, IIc type early gastric carcinoma (signet ring cell type) was also found in the gastric antrum. The original site of the metastatic cancer was not found at that time. Nine months later, a submucosal tumor (SMT) like lesion of the esophagus was found. He underwent esophagectomy, and histological examination of the surgical specimen revealed large cell type undifferentiated carcinoma with lymphoid stroma in the SMT-like lesion and another moderately differentiated squamous cell carcinoma closely oral to the SMT-like lesion. This undifferentiated carcinoma of the esophagus was regarded as the primary lesion of the metastatic cancer in the lymph node behind the pancreatic head. Most of the reported undifferentiated carcinomas of the esophagus are small cell type and without lymphoid stroma. The present case showed two separate esophageal carcinomas of different histological types and a gastric carcinoma. Most of the cells composing the lymphoid stroma were T-cells. The patients doing well without recurrent disease 28 months after the esophagectomy.

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We recentry encountered a case of a 50-year-old man who complained of an abdominal mass. Preoperatively diagnosed as having gastric sarcoma invading the left hepatic lobe, the patient underwent total gastrectomy and lateral segmentectomy of the left heaptic lobe. Histological examination of removal tissue revealed proliferation of spindle-shaped and circular tumor cells as well as focal proliferation of perinuclear vacuolated cells and epithelial cells with an eosinophilic cell body. Leiomyoblastoma is usually regarded as low grade malignancy. However, several cases of this tumor showing metastasis or invasion to the surrounding tissues, like the present case, have been reported. Until now, mitotic rate, tumor size, nuclear DNA content, duration of the illness, and other variables have been reported as useful indices of the malignant grade of this tumor. Of these indices, the mitotic rate is regarded as useless according to some investigators. It also seems unlikely that the malignancy grade could have been determined by the nuclear DNA content alone, in the present case. Therefore it seems necessary to assess the grade of malignancy on the basis of a general evaluation of multiple variables. We recommend that this tumor be treated by the surgical procedures used for gastric cancer.

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We report two cases of liver metastasis from gastric leiomyosarcoma with long-term survival. In case 1 the patient was a 70-year-old man who was diagnosed as having liver metastasis from gastric leiomyosarcoma 1 year and 7 months after proximal gastrectomy. Partial resection of liver metastases and adjuvant chemotherapy via the portal vein was performede. The patient had survived 3 years and 5 months after the liver resection without recurrence. In case 2 the patient was a 51-year-old man who was diagnosed as having liver metastasis from gastric leiomyosarcoma 2 years and 8 months after total residual gastrectomy. Transcatheter arterial embolization (TAE) was performed three times without reduction of the liver metastases. The patienthas survived 4 years and 10 months after diagnosis of liver metastasis. Although the prognosis for patients with liver metastasis from gastric leiomyosarcoma is poor, both of these patients have survived for a long time. The mean survival period for 16 patients in the Japanese literature after resection of liver metastases from gastric leiomyosarcoma is 19.1 months, and 5 patients survived over 2 years. We suggest that resection of liver metastases from gastric leiomyosarcoma be performed when it is indicated, and when it is not, that TAE be performed many times to achieve long survival.

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An 84-year-old man was diagnosed as having an alpha-fetoprotein (AFP)-producing cancer occupying the Cregion, and total gastrectomy was carried out. The preoperative serum level of AFP was abnormally high, 39.4ng/ml and AFP deposits were revealed by immunohistochemical study. When liver metastasis was found 10 months after the operation, serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) were high levels, although AFP was within normal limits. The same pattern was found in the ascitic uid and cystic fluid of liver metastasis. Generally, the serum AFP level increases with the advance in tumor growth and liver metastasis, and it may be useful for predicting the outcome of AFP-producing gastric cancer. This case is the opposite and it is assumed that the tumor cells have the ability to cause various forms of differentiation and proliferation. Therefore not only AFP but also various other tumor markers should be measured and followed even in an AFP-producing cancer.

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Case l is a 29-year-old woman who came to our hospital complaining of high grade fever. Blood chemistry showed markedly elevated biliary enzyme levels. Hypotonic duodenqgraphy and duodenoscopy revealed acircular stenosis in the second portion of the duodenum. A congenital duodenal membranous stenosis (web) was suspected and a laparotomy was performed. Intraoperative cholangiography showed that the caliber of the common bile duct was dilated and the wall was irregular.The papilla of Vater was located proximal to the web. She was diagnosed to have congenital duodenal membranous stenosis with cholangitis. The web was excised and Roux-en-Y choledochojelunostomy was performed. Case 2 is a 25-year-old woman (a younger sister of case 1) who came to a local hospital complaining of vomiting. Upper GI series and duodenoscopy revealed a circular stenosis in the second portion of the duodenum. She was suspected of having annular pancreas and a laparotomy was performed. However, stenosis in the second portion of the duodenum instead of annular pancreas was detected. GastrOjejunostomy was performed. These two sibling cases of congenital duodenal membranous stenosis in adolescence are the first reported in Japan. Moreover, case 2 is also important with respect to the fact that cholangitis is the presenting symptom.

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A 52-year-old woman had a huge cavernous hemangioma of the left hepatic lobe with Kasabach-Merritt syndrome treated urgently with ligation of the left hepatic artery, left portal branch and left hepatic vein, and gauze tamponade over the partially dissected liver surface. Ten weeks later she underwent left hepatectomy for the necrotized hemangioma. She remained well for five years, when recurrence of the hemangioma was noted in the anterior segment on CT. Seven years after the hepatectomy, because of the relatively well-localized but growing hemangioma in the anterior segment, with preservation of liver function by the remaining posterior segment, resection for the recurrence was performed successfully. This patient is now well eleven months postoperatively. Strategies for giant cavernous hemangioma of the liver with bleeding tendency and for recurrence encircling the IVC are discussed.

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A 41-year-old man was admitted because of hematemesis. He previously underwent enterectomy secondary to thrombosis of the superior mesenteric vein at the age of 25 years. His father had venous varices of the lower limbs and his brother was diagnosed as having superior mesenteric venous thrombosis. Antithrombin III (AT III) activity and antigen levels in the patient, his sister and his daughter were decreased. In the patient, endoscopy showed esophagogastric varices. Adominal angiography revealed complete occlusion and cavernous transformation of the portal vein. From these findings, he was diagnosed as having portal hypertension secondary to congenital AT III deficiency. Splenectomy and cardial resection were performed without thrombotic complication. AT III concentrate was infused from the day before the operation through the 8th day after the operation to maintain AT III level at 100-120%. Warfarin potassium and ticlopilidine hydrochloride were given to prevent from thrombotic attacks. We reviewed 38 families with congenital AT III deficiency reported in Japan and discussed the perioperative management of AT III levels in patients withcongenital AT III deficiency to prevent potential risk of thrombotic formation. Surgery was performed only in 3 cases diagnosed as congenital AT III deficiency.

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We report an unusual case of portal hypertension complicated by repeated major gastrointestinal hemorrhage following bile duct cancer surgery, in which it was difficult to identify the source of the bleeding. The patient was a 59-year-old man with central bile duct cancer who underwent bile duct resection plus hepatojejunostomy (Roux-en-Y). Angiography was ultimately performed after difficulty in identifying the source of the frequent major gastrointestinal hemorrhages which began approximately 1 year and 6 months postoperatively. A diagnosis was made of portal hypertension due to extrahepatic portal occlusion secondary to cancer recurrence, and hemorrhage from hepatopetal varices arising in the portal area of the anastomosed jejunum. Treatment consisted of H-shunting from the dilated jejunal vein to the inferior vena cava plus banding of the dilated jejunal vein. Although there were no subsequent recurrences of gastrointestinal hemorrhage, the patient developed lung metastasis from his recurrent cancer and died 11 months later. porto-jejunal varices were confirmed at autopsy. This is the first report of hemorrhage from ectopic varices in the anastomosed jejunum following bile ductcancer surgery, and we consider it a very interesting case.

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The patency of the paraumbilical vein (PUV) may contribute to hepatic encephalopathy as a portosystemic shunt in patients with liver cirrhosis. Accordingly, ligation and embolization of the PVU is thought to affect hepatic encephalopathy. So we have performed ligation of the PUV in 2 patients and embolization in one patient. After the treatments, symptoms of encephalopathy were absent, and the blood ammonia level was improved in all cases. Although portal vein pressure increased, esophago-gastric varices were not affected. In case 3, subsequent splenic artery embolization decreased the portal vein pressure.

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We report a giant hemangioma of the liver with an excised specimen weighing of 4.3kg, the second largest in Japan in the past 10 years, which meaning not clear Kasabach-Merritt syndrome. A 43-year-old woman, who complained of abdominal fullness and an elevated right diaphragm that was found in a periodic checkup, was admitted to our hospital for a detailed examination. Findings by percussion examination indicated that the lungliver border was elevated to the third intercosta. The tumor, which had a smooth surface and elastic hard consistency, was palpable 2 finger-breadths below the umbilical portion. Laboratory data suggested coagulative and fibrinolytic disorders (platelet count 13×104/mm3, prothrombin time 53%, thrombin time 33%, fibrinogen 112 mg/dl, fibrin degradation products 40μg/ml), but other laboratotry data were within normal limits. Findings by medical imagings and hepatic arterial angiography also indicated a giant hemangioma of the liver. Extended right lobectomy of the liver was performed. The operative findings showed that the tumor occupied all of the right lobe and the quadrate lobe of the liver. The resected specimen weighed 4.3kg and histological findings revealed a cavernous hemangioma with hemangioendothelioma.

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A 59-year-old man with a diagnosis of hepatocellular carcinoma, in whom preoperative hepatic function tests did not disclose liver cirrhosis, developed liver failure after right hepatic lobectomy. Examination of the resected specimen revealed chronic active hepatitis (CAH). It is difficult to determine if chronic hepatitis is active or inactive by using only a routine liver function test. To estimated the activity of chronic hepatitis, the following methods are necessary: needle biopsy guided by echo or by laparoscopy and intraoperative liver wedge biopsy. This case suggests that resection of the liver with severe CAH could precipitate hepatic failure. Sometimes, in spite of the administration of hepatoprotector agents, activity of CAH does not decrease. In these cases, it is recommended to reduce the extent of the resection or to use non-surgical therapeutic modalities that do not worsen the already altered hepatic function, such as TAE (transcatheter arterial embolization) or PEIT (percutaneous ethanol injection therapy).

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A case of cholelithiasis with elevated serum CA19-9 and DUPAN-levels, which were normalized after improvement of obstructive jaundice, was reported. A 66-year-old man complained of jaundice, abdominal pain and fever. Ultrasonography, computed tomography and endoscopic retrograde cholangiography revealed a choledocholithiasis. Endoscopic lithotomy was performed for improvement of obstructive jaundice due to common bile duct stone. Preoperative serum levels of CA19-9 and DUPAN-2 were 9300 U/ml and 826 U/ml, and both postoperative serum levels were normalized. Immunohistochemical staining of CA19-9 and DUPAN-2 revealed positive reaction on the epithelium of gallbladder. It is suggested that CA19-9 and DUPAN-2 are secreted from bile duct epithelium and flows back into blood in situation of cholecystitis or obstruction of bile duct. It is necessary to recognize such as this case in cholelithiasis.

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A case of pleomorphic carcinoma of the pancreas associated with gallbladder carcinoma is reported. A 64-yearold man complaining of epigastralgia, tarry stools and weight loss was admitted to our hospital. Barium swallow revealed a Borrmann type 1 elevated lesion at the greater curvature of the gastric corpus. Endoscopic biopsy revealed undifferentiated carcinoma of the stomach. Abdominal CT scanning and sonography showed thickness and irregularity of the gallbladder wall. We performed laparotomy under the diagnosis of double carcinoma of the stomach and gallbladder. At the operation, tumors in the pancreatic head and duodenum were discovered. Pancreaticoduodenectomy and extended cholecystectomy were performed. Histologically, the pancreatic tumor was a pleomorphic carcinoma and the lesions of the stomach and duodenum were metastases. The gallbladder carcinoma was a highly differentiated adenocarcinoma and was diagnosed as synchronous double carcinoma.

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A case of primary sclerosing cholangitis (PSC) complicating cholangiocarcinoma is reported. The patient, a 32-year-old female, was admitted to the hospital with obstructive jaundice. Cholangiographical evaluation revealed localized obstruction of the common bile duct. Although she was suspected of unremovable cholangiocarcinoma at laparotomy, the obstructed part of the common bile duct was not malignant histopathologically. After indwelling an internal drainage tube the patient was observed as PSC for 3 years and 5 months. Since the tube was obstructed repeatedly during the period, operation was indicated. Since atrophy was observed in the left lobe of the liver, the left lobe and common bile duct were removed and hepatocholangiojejunostomy was performed. On histopathological examination there were no malignant findings in the obstructed part of the common bile duct, but the development of cholangiocarcinoma was observed in the part of the left lobe of the liver. Only 2 cases of PSC complicating cholangiocarcinoma have been reported in Japan. We must pay attention to the possibility of the occurrence of cholangiocarcinoma in the treatment of PSC.

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We report a case of leiomyoblastoma of the duodenum which rarely originates in the extragastric alimentary tract. A 60-year-old woman suffering from hypoplastic anemia had noticed a right lower abdominal tumor in 1986, but she had not consulted a doctor because she had no abdominal symptoms. In February 1989 she was admitted to our hospital for an operation for a left external inguineal hernia and then complained of the abdominal tumor. Ultrasonography and computed tomography revealed a cystic mass in the right lower abdomen and surgery was performed for both the inguinal hernia and the abdominal tumor. On laparotomy, neither peritoneal dissemination, nor liver nor lymph node metastasis was observed. The tumor originated in the anterior wall of the second portion of the duodenum and was resected with the muscular layer of the duodenum. The tumor, 10.0×9.5×9.0 cm in size, 550g in weight, was a thin-walled cystoma containing dark reddish serous fluid and a massive amount of white yellowish debris. No connection with the duodenal lumen was noticed. Histologic examination revealed hemorrhage and necrosis in the cyst wall and two cell components, spindle-shaped cells and large round or polygonal eosinophilic clear cells. The histopathologic diagnosis was leiomyoblastoma (epithelioid leiomyoma) without malignant findings. The patient has been well for about 3 years and 5 months after surgery, without any signs of recurrence.

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Duodenal leiomyoblastoma is an exceedingly rare disease and 14 cases includingours have been reported in Japan. This is the first case of the leiomyoblastoma combined with von Recklinghausen's disease. The patient was a 56-year-old man who had a past history and family history of von Recklinghausen'sdisease. He was admitted with the complaint of a right hypochondrial tumor. Under the diagnosis of a smoothmuscle tumor located in the 1st portion of the duodenum and a gastric ulcer, tumor resection and totalgastrectomy (Roux-Y) was performed. The histological diagnosis was leiomyoblastoma and from its size, the evidence ofinfiltration and pleomorphism it was thought to be malignant though there was no metastasis to regional lymph nodes.Twenty months after the operation the patient is still alive without evidence of recurrence. He should becarefully followed up because the biological behavior of leiomyoblastoma is still controversial.

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We report a case of a pancreatic mucin-producing cystic tumor with carcinoma in situ of the dilated main pancreatic duct detected by immunohistological staining. The patient, a 76-year-old man, was admitted for enlargement of pancreatic cysts and elevation of CEA and CA19-9, although small cysts of the tail of the pancreas were found 5 years earlier. Distal pancreatectomy was performed because of a strong suspicion of malignancy. Macroscopically, multiple cysts were located in the whole pancreas and communicated with the main pancreatic duct. By histological examination of the whole specimen cut into 1.5 mm sections, the only lesion of dilated main pancreatic duct was diagnosed as carcinoma in situ because of swelling of the nuclei, increase in chromatin, distinct nucleoli and disappearance of cell polarity. The lesion was strongly stained immunohistologically in the apical portion and cytoplasm of cells by CEA.

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A 9-year-old child was admitted to our hospital for left upper abdominal fullness. Ultrasonqgraphy and computerized tomography revealed a large cystic tumor in the hilus of the spleen. Sonographically a preoperative guided aspiration biopsy of the tumor was performed. Cytological examination revealed contaiminating squamous epithehal cens. Splenectomy was performed under the diagnosis of a splenic epidemoid cyst. The inner surface of the cyst was lined by squamous epitheiium and reacted positively to CA19-9 and CEA immunohistochemical staining.Laboratory studies showed moderately elevated serum CA19-9 1evel (860u/ml) preoperatively but its level had decreased to the normal range one month after splenectomy. Splenic epidermal cyst associated with a moderately elevated CA19-9 level is rare, and to our knowiedge this is the third case of its kind reported in the literature.Our findings suggest that measurement of CA19-9 in the serum and cystic fluid may be useful as a supplementary diagnostic procedure in this disease on a case by case basis.

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Mesenteric fibromatosis is well known as a complication of familial colonic polyposis coli or Gardner's syndrome but occurs very rarely in the abdominal cavity alone. We experienced a case of mesenteric fibromatosis with a giant abdominal tumor weighing over7kg and originating in the mesenterium. This lesion is a benign tumor characterized by growth and infiltration of fibrous tissue without metastasis. Therefore complete removal of the total tumor is relatively easy and definitive surgical treatment should be performed in spite of suspicion of malignancy in the clinical findings.

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We experienced a case of small bowel perforation due to lung cancer metastasis. A 73-year-old man was transferred to our hospital with the diagnosis of acute abdomen. An abdominal X-ray demonstrated free air in the abdominal cavity. The case was diagnosed panperitonitis due to intestinal perforation. Emergency laparotomy was performed and the perforated jejunum was resected. Histological examination revealed malignant cells, but the histological type could not be determined. A chest X-ray showed a coin lesion in the lower lung field of the left lung, from which the lung cancer was suspected. Segmentectomy of the left lung was performed and histological findings revealed a poorly differentiated adenocarcinoma, which was the same finding as in the perforated jejunum. After chemotherapy, another perforation occurred and the perforated ileum was resected. We could not find the cancer cells in the perforated site. Chemotherapy and radiotherapy were performed for bone metastasis and mediastinal lymph node metastasis. The prognosis for a patient with perforation of the small intestine due to lung cancer metastasis is poor. Our patient died 2 years and 10 months after the first operation.

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Two cases of gangrenous-type ischemic colitis are described. The patient in case 1 was a 64-year-old man and the patient in case 2 was a 60-year-old woman. Rebound tednerness was elicited in their abdomens. He had liver-cirrhosis and she had chronic renal failure as an associated medical problem. Gangrenous-type ischemic colitis was diagnosed by Barium enema, ultrasonography and computed tomography (CT). Righthemicolectomy was performed for him and left hemicolectomy with transverse colostomy was performed for her. His surgical specimens revealed mucosal necrosis and inflammatory infiltration. Her surgical specimens revealed necrosis of the total layer. The first patient was discharged, whereas in case 2 the patient had a complicating peritonitis caused by stomal necrosis and died of pneumonia. In gangrenous-type ischemic colitis it is important that early diagnosis and immediate surgery be performed and attention must be paid to postoperative management.

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A case of intramesocolic abscess caused by penetration of a sigmoid diverticulum is reported. A 52-year-old man was hospitalized with signs of lower abdominal pain and anal bleeding, Exploratorylaparotomy was performed because signs of peritonitis appeared. It revealed an abscess 8.0×6.2×2.0 cmin the sigmoid mesentery. It was thought that the sigmoid diverticulum had ruptured between the leaves of the mesentery. The sigmoid colon with the intramesocolic abscess was resected. The cavity of the abscess contained 50 mlof pus. The postoperative course was not complicated. Intramesocolic abscesses are rare. Most reported cases were complicated because of the difficulty of diagnosing the intramesocolic abscess. Early surgical treatment should be performed to avoid a complicated postoperative course.

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