This study was designed to investigate the role of reflux of gastroduodenal juice in the genesis of esophageal carcinoma. Male Wistar rats, weighing approximately 200g, were subjected to one of the following three operative procedures: a reflux procedure through the stoma (Group 1, n=11) which allowed duodenal contents to flow into the forestomach and esophagus through the gastrojejunostoma, a reflux procedure through the glandular stomach (Group 2, n=18) which made duodenal contents flow backward into the forestomach and esophagus via the glandular stomach, and a sham operation (Group 3, n=22). The animals were given a standard maintenance diet and tap water without administration of a carcinogen, and were killed and examined 50 weeks after surgery. No pathological changes were detected in Group 3. On the other hand, squamous cell carcinoma was found in three animals (27%) in Group 1 and three animals (17%) in Group 2. The incidence in each group was significantly higher than that in Group 3 (p<0.025, p<0.05, respectively). Squamous cell carcinoma appeared in the esophagus in two rats and in the forestomach in one rat in Group 1, whereas it appeared in the forestomach in three rats in Group 2. Dysplasia, intramural cyst with hyperplasia, regenerative thickening and hyperplasia were also observed only in the two reflux groups. These lesions were regarded as paracancerous. In addition, columnar epithelial metaplasia (Barrett's esophagus) and mucinous adenocarcinoma were found in a rat in Group 1. These findings suggested that reflux esophagitis may be associated not only with the development of Barrett's esophagus and mucinous adenocarcinoma but also with the genesis of squamous cell carcinoma.

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The clinicopathological characteristics of 10 gastric cancer cases showing elevation of α-fetoprotein (AFP) in serum and AFP-producing cancer cells determined immunohistochemically in the primary lesion were studied. The proliferative activity of these cancers was detected by the immunohistochemical method using an anti-proliferating cell nuclear antigen (PCNA) monoclonal antibody. All the cases were of advanced gastric cancer with the gross appearance of Borrmann's type 2 or 3, and the majority of the cancers were located in the distal part of the stomach. The frequency of AFP-producing gastric cancer was 6.1% of the resected advanced gastric cancers. Histologically, the tumors were papillary, moderately differentiated and poorly differentiated adenocarcinomas, and many of the cases showed medullary growth in the stroma. In clinical findings, 7 patients had hepatic metastasis at the time of the operation, and 1 patient had it after the operation. The proliferative activity of AFP-producing gastric cancer was found to be higher than that of other advanced gastric cancers by the immunohistochemical method using an anti-PCNA antibody.

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Values of the ICG maximal removal rate (Rmax) of a total of 405 patients with chronic liver diseases during the 12 years from January 1976 through December 1987 were retrospectively analyzed and evaluated. In the early period before April 1983 when Rmax was obtained from ICG K_0.5, K_1.0 and K_3.0, the incidence of unevaluable Rmax, not provided by an inequality formula of ICG K₁>K₂>K₃, was 46% (92/201). In the current period since April 1983, when Rmax was obtained from ICG K_0.5, K_2.0 and K_4.0, the incidence fell to 14% (28/204). The evaluable Rmax values provided by the inequality formula remained within 5mg/kg/min without exception in both of the two periods so that Rmax exceeding 5mg/kg/min was considered an unevaluable value. The unevaluable Rmax values were frequently encountered in the patients with ICG K_0.5<0.05 or≥0.15, indicating that the patients with either extremely poor or very good hepatic reserve were not suitable candidates for Rmax estimation. In terms of clinical significance of evaluable Rmax as an index of hepatic reserve, Rmax correlated well with the histopathological severity as well as the morphometrically estimated collagen content. The patients with Rmax lower than 0.47 mg/kg/min without exception had an associated B type cirrhosis. Those, in whom Rmax values were relatively low for the ICG clearance rate had a higher degree of hepatic fibrosis and a higher incidence of esophageal varices as compared with Rmax corresponding to the ICG clearance rate.

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The records of 31 patients with gallbladder carcinoma with pathological evidence of subserosal invasion who underwent resectional surgery were analyzed to determine their clinicopathological characteristics and to investigate adequate surgical treatment. The mode of subserosal invasion was divided into three types: ssα (expanding type), ssβ (intermediate type), and ssγ (infiltrative type). In 22 patients with ssα, β, the positive rates of histopathological prognostic factors, lymph node metastasis (32%), venous invasion (18%) and perineural invasion (23%) were significantly lower than the 78%, 67% and 67% in 9 patients with ssγ. Consequently a sigificant difference in the 4-year survival rate was observed between the ssa, β (68%) and the ssγ (23%) patients. Four of the 22 patients with ssα, β and 3 of the 9 with ssγ received noncurative operations. Of 18 curatively operated on patients with ssα, β, 11 are alive, 3 died of local recurrence, and 4 died of unrelated disease. For the 11 surviving patients, cholecystectomy or partial hepatectomy (S5, S4 inferior) accompanied by lymph node dissection was performed. Resection of the extrahepatic bile duct was also performed in 3 and pancreatoduodenectomy for lymph node metastasis in 2, while recurrence was the cause of death of all 6 curatively operated on patients with ssγ. Local recurrence developed in all 6 and distant metastasis in 5 (liver metastasis in 2, brain metastasis in one and peritoneal dissemination in 2). In conclusion, an extended radical operation is needed to improve the surgical results for patients with gallbladder carcinoma with ssα, β invasion, and for patients with ssγ invasion, multidisciplinary therapy should be given after the extended radical operation.

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To evaluate the severity and predict postoperative infection for patients with peritonitis and abdominal trauma we determined the severity score according to our scoring system (modified acute physiologic and chronic health evaluation II [APACHEII]). The severity in 95 patients (74 with peritonitis, 21 with abdominal trauma) graded by this system. The scores ranged from 0 to 13. Seventy percent of the patients had a score of less than 3 and maximum number, 27, of the patients were distributed at 0 point. The average score in each disease was 0.7 (perforating appendicitis [n=19]), 1.9 (perforating upper gastrointestinal tract [n=26]), 4.1 (perforating lower intestinal tract [n=29]) and 4.4 (abdominal trauma [n=21]). Of the 95 patients, 35 had complicating with postoperative infections. Eight patients died of postoperative infections. The mean value of the severity score was 1.4 (no postoperative infections [n=60]), 4.9 (postoperative infections [n=27]) and 7.5 (non survivors [n=8]). The value for the each group was significantly different. Postoperative infections were observed in 80% of the patients with a score of 5 or more and in 24.5% less than 5. A score was closely correlated with the subsequent risk of postoperative infections. Mortality was 40% of all patients with a severity score greater than 8. The rate of the prediction of the fatal outcome was low. When an emergency abdominal operation is needed, we evaluate the severity and predict the postoperative infections using our scoring system. Consideration of the score leads to selection of the appropriate operation method and postoperative chemotherapy. This reasonable selection procedure gave us good results.

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One hundred forty-two patients (98 men and 44 women) with ileus were subjected to clinical study to establish a method of early diagnosis and treatment of strangulation ileus on the basis of serum creatine phosphokinase (CPK) levels during the 3 years between April 1987 and March 1990. The relation between findings at laparotomy and serum CPK levels was assessed. Serum CPK was 174.5±48.3 mu/ml in cases of strangulation ileus, 73.6±26.5 mu/ml in 23 cases of adhesive ileus and 54.1±7.5 mu/ml in 102 patients treated conservatively. A tendency toward correlation was observed between the serum CPK of the patients who underwent intestinal resection because of strangulation ileus and the severity of ischemic lesion of the intestinal tract. Thus it appeared that the level of serum CPK, which corresponded well with the results of diagnostic imaging and clinical findings, can be used as a parameter for early differential diagnosis.

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Five hundred seventy-six colorectal cancers were resected in our surgical department for the past 10 years, and 41 (7.1%) were diagnosed as poorly differentiated adenocarcinoma. The clinicopathological features of the 41 poorly differentiated adenocarcinoma cases were investigated and compared with those of the well and moderately differentiated cases. Poorly differentiated adenocarcinomas were more frequently found in the right sided colon and had more deeply invaded the wall than the well and moderately differentiated ones. Lymphnode metastasis and lymph vessel invasion of the poorly differentiated adenocarcinomas were found at the rate of 70.7% and 65.9% respectively and were significantly higher than those of the well and moderately differentiated ones. But in the rate of hepatic metastasis and peritoneal dissemination, no marked difference was found between the two groups. In cases other than stage I, there was no difference in the cumulative survival rates between the two groups.

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A case of esophageal hemangioma is described herein. The 52-year-old man had no symptoms. An esophageal tumor was found accidentally in a group examination. A hemangioma of the esophagus was revealed as a round defect by esophagography and a bluish soft tumor on the right wall of the cervical esophagus was also found by esophagoscopy. Through a left neck incision, the left normal esophageal wall on the side opposite the tumor was opened initially. Then, tumor on the right wall was resected completely by mucosectomy including normal esophageal mucosa. The microscopic section revealed a venous hemangioma. His postoperative course was completely uneventful. This method of resection is recommended for a benign tumor located in the submucosal layer as well as a hemangioma of the esophagus in view of its simplicity and safety.

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We presented a case of spindle cell carcinoma, a giant polypoid tumor resembling a pseudosarcoma but not combined with a squamous cell carcinoma. The tumor originated in the cervical esophagus and had grown up to 19.0×7.5cm, compressing the trachea and leading to severe dyspnea. An emergent operation was performed, and the giant tumor was resected by cervical approach without additional thoracotomy. A glandular pattern including mucin stained with PAS and Alcian blue was observed in the tumor tissue. Tumor cells were thus considered to have derived from the glandular epithelium. This appears to be the first case in Japanese medical literatures. There were two instances of recurrence and three operations were conducted over a period of 26 months. Following a successful hypopharyngolaryngectomy with reconstruction using a free graft from the small bowel, the patient has remained well without any signs of recurrence after 13 months.

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We report a case of corrosive stricture of the esophagus (CSE) developing into esophageal cancer andinvestigate 21 reported cases of CSE including this case in Japan. The patient, a 54-year-old man who had ingested acid for processing papers at the age of 3 years, had felt a disturbance of passage of food or liquid in his throat. After 51 years, he suffered from difficulty in swallowing in his breast. Circulatory stricutres were detected in the upper part of the esophagus and the middle part of the esophagus (Im) by esophagography. Endoscopy showed esophageal cancer of the superficial and slightly depressed (0-IIc) type at the stricture of the Im and its oral area. Esophagectomy was performed. The resected specimen contained both stricutres and esophageal cancer of 0-IIc type in the Im. The pathological finding was moderately differentiated squamous cell carcinoma involving a part of the muscularis propria. He was discharged with no complications on the 36th postoperative day and is well after 12 months. The number of reported cases of CSE developing into esophageal cancer is 9 in males and 12 in females. These cases were compared with reported cases of achalasia developing into esophageal cancer. The mean interval from injury to cancer was 38 years or longer. The incidence of esophageal cancer which occupied the stricture and the oral area in contact with it was 68% or higher.

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The patient was a 64-year-old man who suffered from advanced esophageal cancer with extended mediastinal lymph node metastasis involving the bilateral main bronchi, left atrium and bilateral inferior pulmonary veins. He was treated by four cycles of continuous infusiona of a combination of cisplatin (75 mg/m²/day 1/q4w), mitomycin-C (10mg/m²/day 1/q8w) and 5-FU (600mg/m²/day 2-4/q4w). After chemotherapy, both of the primary and the metastatic lesions disappeared and a radical operation was successfully performed. Microscopically, the main lesion almost disappeared with only a small cancer nest remaining in the mucosa (Ef2), and lymph node metastasis completely disappeared (Ef3).

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Exulceratio simplex (Es) is a rare disease that is characterized by the rupture of comparatively thick arteries in the bottom of a gastric ulcer, resulting in massive hemorrhage. We encountered two cases of Es which developed after endoscopic sclerotherapy for esophageal varices. The etiology of Es is discussed with reference to the literatures. Case 1: A 63-year-old man. The chief complaint was hematemesis. He had experienced hemorrhage from esophageal varices, and it recurred after sclerotherapy. Observation revealed blood gushing from a ruptured artery in the posterior wall directly below the EC junction. Case 2: A 53-year-old man. The chief complaint was general fatigue. He had undergone sclerotherapy for ruptured esophageal varices, but then a site of hemorrhage was seen on the posterior wall directly below the EC junction. The etiology of Es following sclerotherapy is assumed to be as follows: a thrombus forms in the left gastric artery due to the development of an arteriovenous shunt as a result of liver cirrhosis, the thrombus, in turn, causes a circulatory disorder, which leads to degeneration of the arterial wall and ulcer formation in the gastric mucosa, then the internal pressure in the left gastric artery becomes elevated due to (1) the increased blood flow in the left gastric artery caused by liver cirrhosis and (2) the increased vascular resistance in the left gastric artery caused by the thrombus.

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Gastric lipoma is a rare benign tumor of the stomach. We experienced a case of gastric lipoma with gastric cancer and volvulus. A 78-year-old man, who was diagnosed by a neighborhood practitioner as having a gastric submucosal tumor by an upper gastrointestinal series and endoscopy because of his nausea and general fatigue, was admitted. Detailed examination revealed a submucosal tumor on the greater curvature side of the middle body of the stomach, and an advanced gastric cancer (Borrman 3 type) near the posterior wall of the lower body of the stomach on the greater curvature side. Furthermor, they were accompanied by gastric volvulus. CT showed that the lesion at the middle body of the stomach arose from adipose tissues. Subtotal gastrectomy (Billroth II method), and R₂ lymphadenectomy were performed. The pathohistological diagnosis was a lipoma in the subserosa and a poorly differentiated adenocarcinoma with subserosal invasion. Gastric lipoma accompanied by gastric cancer is rare; we found only 18 cases in the Japanese literature. Further, we found no report concerning a gastric lipoma with gastric cancer and volvulus.

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A 38-year-old man was admitted to Nipponkokan Hospital with a diagnosis of gastric cancer.At surgery we found a tumor thrombus extending from the superior mesenteric vein to the portal trunk along with gastric cancer. Metastatic lymph nodes in the subpyloric and prepancreatic area were adhering to the pancreas head.The mesocolon was also invaded by cancer.Therefore, pancreatoduodenectomy, resection of the transverse colon and resection of the portal vein were carried out.The resected portal vein was 8cm in length.End to end anastomosis of the stumps were performed without tension.The patient is alive without signs of recurrence 13 months after surgery.Thus far, 18 patients with gastric cancer with a tumor thrombus in the portal vein have been reported and 4 of them could undergo resection.With the development of imaging technics, this condition is likely to be diagnosed preoperatively.Surgeons should be aware of the possibility of treating such patients.

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A case of gastric cancer in a 29-year-old woman complaining of epigastric pain is reported. She had undergone gastrojejunostomy for congenital hypertrophic pyloric stenosis at the age of 3 months. The gastric cancer was identified as a Borrmann's type 3 tumor, located in the gastric body. The stomach was partially resected, but total remnant gastrectomy followed after a histological examination revealed the presence of remaining cancer cells at the cut end. Histological examination revealed a poorly differentiated adenocarcinoma; n (-), Po, Ho, se, stage III. Gastric cancer after gastrojejunostomy has been reported in 34 cases in the Japanese literature, and many of these were located in the anastomotic region. Therefore, duodenogastric reflux including bile seems to be an important factor in the mechanisms of development of gastric cancer after gastrojejunostomy.

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We report a case of alpha-fetoprotein-producing gastric cancer associated with aortic valvular disease. Computed tomography (CT), and ultrasonography for preoperative evaluation of gastric carcinoma revealed no liver metastasis. The patient, a 76-year-old man, underwent aortic valve replacement and gastrectomy in a twostage fashion. Twenty-eight days after the open heart surgery, gastrectomy was performed. Curative surgery for gastric cancer could not be performed, because of multiple liver metastases. After the gastrectomy, CT showed prominent growth of metastatic tumors of the liver and the patient died of hepatic failure 45 days after the gastrectomy.

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A one-stage radical operation was performed to treat a patient with multiple early gastric cancer and concurrent rectal cancer. The patient, a 56-year-old man, had had a chief complaint of abnormal defecation. A tumor was palpable on digital examination of th rectum, and colonoscopy revealed an advanced stage Borrmann I tumor. The biopsy diagnosis was moderately differentiated adenocarcinoma. In addition, multiple early gastric cancers were detected by preoperative gastroscopy. The patient, who was received total gastrectomy+ lymph node dissection and low anterior resection+ lymph node dissection, has remained well for 1 year after the operation. Double cancer consisting of gastric cancer and rectal cancer is not rare, but only a few cases of multiple early gastric cancer and rectal cancer have been reported.

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A malignant duodenal submucosal gastrinoma in a 37-year-old man is reported. Since 1981 he has had three times gastrectomies and one operation for lieus. In May 1989, hypergastrinemia (602 pg/dl) was noticed by a doctor and he was sent to our hospital. The diagnosis was Zollinger-Ellison syndrome because of a positive secretin test. We performed the selective arterial secretin injection test for locating gastrinomas. Increase of the hepatic venous IRGs 40 seconds after bolus injection of 30 units secretin into the gastroduodenal artery and superior mesenteric artery was 370 pg/dl and 150 pg/dl, respectively. But the increase was not meaningful after the injection of secretin into the splenic artery. Thus gastrinoma was diagnosed as being located in the pancreaticoduodenal region. At the operation, the tumor (8×9mm) was found in the submucosal layer of the descending duodenum, not in the pancreatic head, and was resected. An intraoperative secretin test by the rapid gastrin immunoassay method after the lymph node dissection around the pancreaticoduodenal region was negative, which led us to conclude that the operation was curative. The patient is alive with no recurrence 2 years and 10 months after the last operation.

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We performed intrahepatic combined immunochemotherapy (ACIT) after hepatic resection for patients with liver metastases from colorectal cancer to prevent recurrence in the liver. ACIT consists of 5 different agents, ie, recombinant interleukin-2 (IL-2), OK-432, adriamycin, cyclophosphamide and famotidine. The survival rate of patients with ACIT (40-month survival rate; 100%) was higher than that of 9 patients without intrahepatic therapy (40-month survival rate; 45%). Natural killer activity was augmented significantly after ACIT. Thus, intrahepatic combined immunochemotherapy after hepatic resection for liver metastases from colorectal cancer may be worth performing in further clinical trial.

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Hepatocellular carcinoma with a tumor thrombus was resected by the modified vascular exclusion method. The tumor thrombus in the vena cava extended from the right hepatic vein to part of the diaphragma. Thrombectomy with vascular exclusion on a veno-venous bypass was followed by right hepatic lobectomy without a venovenous bypass in order to saving the time of hepatic ischemia. Hepatic perfusion was not used because the time of vascular exclusion was as short as 27 minutes. The patient had no clinical problems during the postoperative period. This method is useful for resection of hepatocellular carcinoma with a tumor thrombus in the vena cava.

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An 84-year-old woman who had cholecystectomy, choledochotomy, lithotomy and T-tube drainage for cholecystocholedocholithiasis 5 years earlier, presented with upper abdominal pain and jaundice. She was hospitalized for recurrent choledocholithiasis. An emergency operation was performed and a heterotopic pancreas and a stone were found in the common bile duct. Heterotopic pancreas of the common bile duct is said to be very rare, only 7 cases having been reported. All of the patients were women and were found to have a dilated common bile duct. Biliary stasis by the tumor caused the choledocholithiasis, cholangitis and cholecystitis. Resection of the tumor is thought to be the only reasonable treatment.

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A 71-year-old female presented with vomiting. Laboratory tests on admission revealed leukocytosis, jaundice, and marked elevation of serum CA19-9 (89, 305 U/ml). An abdominal ultrasonogram, CT scan and PTC showed bile duct stones. No tumors were suspected. Serum CA19-9 gradually decreased to 145U/ml after biliary drainage. The patient was operated on for bile duct stones. The gallbladder exhibited wall thickening and had mixed stones in it. Pathology revealed no evidence of malignancy. Immunohistological staining for CA19-9 demonstrated it to be positive in the gallbladder wall.

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A 26-year-old woman complained of a tumor in the left hypochondrial region. The diagnosis of a splenic cyst was preoperatively made by CT, angiography and splenic scintigraphy. The spleen with its cyst was resected en bloc. The specimen weighed 1, 800g and measured 20×18×12cm. Histopathological examination revealed a true cyst, lined by a single layer of flattened cells. In order to determine the origin of the true splenic cyst we performed an immunohistochemical examination. Both keratin and vimentin as mesothelial markers and cancer antigen (CAl25) also showed positive staining. However neither epithelial membrane antigen (EMA) as an epithelial marker, nor factor-VIII-related antigen as an endothelial marker, was stained. From the above results this true sprenic cyst is considered to be of mesothelial origin.

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There are few case reports of a portocaval shunt with situs inversus. Here we report on a 71-year-old man with a splenorenal shunt and complete situs inversus. The patient had a gastrectomy for a benign gastric ulcer 6 years earlier. After gastrectomy, he was found to have developed liver dysfunction, and he received treatment for it. Recently he was admitted to our hospital because of hyperammonemia. His serum ammonia level rose to a maximum of 274 μg/dl. Although he had a tendency toward sleepness, there were no abnormal findings by EEG. Abdominal angiography and percutaneous transhepatic portography revealed a spontaneous giant splenorenal shunt (2.0cm in diameter). Neither abdominal CT nor ultrasonography showed the spleen. The histological findings of a liver needle biopsy showed fibrosis of the liver. On diagnosis of the splenorenal shunt without liver cirrosis, the shunt was ligated. At that time, three small spleens were found near the pancreas tail. The postoperative portal vein pressure did not show any appreciable increase compared with the preoperative level (110mmH₂O→125mmH₂O). The preoperative high level of serum ammonia decreased to the normal range after the operation.

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A 53-year-old woman was admitted because of a mass in the right lower abdomen with tenderness. Laparotomy revealed a mass in the ileocecal region, and a diagnosis of a malignant neoplasm involving the ileum, sigmoid colon, and the right ovarium was made. The tumor was removed with multiple organ resection, but a diagnosis of abdominal actinomycosis was established postoperatively by histopathological examination. A clinical problem with this disease is the difficulty in preoperative differentiation from malignant tumors. We reviewed the records of 121 patients (59 males and 55 females with a mean age of 48 years) who were operated on for abdominal actinomycosis between 1957 and 1991, and examined the clinical findings and image findings that may be useful for preoperative diagnosis of this disease. The tumor occurs commonly in the ileocecal region and the transeverse colon, and abdominal pain and an abdominal mass were common clinical complaints. Characteristic features of the tumor were hardness, tenderness, and poorly movablility. The white blood cell count was normal in about half the patients. Ultrasonography and computed tomography visualized the lesions as pooly defined and nonhomogeneous masses. Radiological findings of the absess cavity in the tumor, thickening of the intestinal wall around the mass, and an increase in the computed tomography value in the adipose tissue are considered to be useful for diagnosis. Balium enema findings varied from displacement to circumferential constriction of the intestinal wall, but relative intactness of the mucosa was a common feature.

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Retroperitoneal lipoma is a histologically benign tumor, and was comparatively rare tumor before the development of imaging methods (CT, US etc.). A total of 60 cases including the present one have been reported in Japan. A 71-year-old man complaining of abdominal fullness was admitted to our hospital. After examination, we made a diagnosis of lipoma, and removed it. The tumor weighed 7530 g. Parts of the tumor were examined, and the histological structure indicated well-differentiated lipoma. The lipoma recurred 3 and 6 years after the first operation, and was removed again. On histological examination malignant elements were not found, and we made a diagnosis of recurrence of lipoma. Our case is rare in view of the tumor size and recurrence.

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It has been generally pointed out that the levels of tumor markers in hepatic or pancreatic cystic fluids are elevated in patients with malignancies. However, there are yet no reports of the contents of mesenteric cysts. We encountered two cases of benign mesenteric cysts and measured tumor markers in cystic fluids after surgical excision. The patients were a 68-year-old man and a 46-year-old woman. The sites of development were the mesentery at the terminal end of the ileum in the first case and the jejunal mesentery, 110cm from Treitz's ligament, in the second case. Cytodiagnosis of cystic fluids after surgical removal was class I in both cases, the CEA levels were 1.7ng/ml and 150ng/ml, respectively, and levels of other tumor markers (CA19-9, CAl25, CA15-3 and SCC) were normal. The preoperative serum levels of the tumor markers were invariably within normal limits. Together with two cases reported previously in Japan, we investigated tumor markers in the contents of the mesenteric cysts. The CEA level in the cystic fluids is elevated in some patients with benign mesenteric cyst.

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A very rare case of intractable ascites due to hepatic lymphorrhea following radical gastrectomy for gastric cancer is reported. A 70-year-old man had an operation for gastric cancer in another hospital. Massive ascites appeared soon after surgery. Diuretics and paracentesis failed to decrease the ascites. The quality of the ascites strongly suggested it was caused by lymphorrhea from injured hepatic lymph channels. Exploratory laparotomy was performed and the damaged lymph vessels in the hepatoduodenal ligament were ligated. He has had no more retention of ascitic fluid over one year after the operation. The hepatic lymphorrhea after abdominal surgery usually disappeared spontaneously in a short time. However in a case of intractable ascites following radical gastrectomy, which might be caused by hepatic lymphorrhea, surgical treatment should be considered before the patient gets worse.

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A 76-year-old man was admitted with abdominal distension and pain. A barium study of the small intestine revealed a narowing portion of the small bowel about 20cm from the ileum end. He underwent a resection of the ileum together with the right hemi-colon. The histopathological diagnosis of the tumor was well-differentiated squamous cell carcinoma. A series of post-operative examinations including chest and abdominal CT, gastrointestinal endoscopy and otolaryngeal study did not reveal any other malignant lesion. Thirteen months later, a tumor was found in the soft tissue of the left upper arm. Histopathological examination of the resected tumor again showed squamous cell carcinoma, suggesting metastasis from the intestinal tumor.During the following period cervical lymph node metastasis and a recurrent tumor in the left upper arm appeared. The patient died of abdominal recurrence 28months after the intestinal operation. Since no primary lesion of the intestine was detected during a follow-up period of over 2years, a diagnosis of primary squamous cell carcinoma of the ileum was made. Primary squamous cell carcinoma of the small intestine has rarely been reported to be located in the duodenum. As far as we investigated, only one case in the ileum has been reported in the last 50years.

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We have been involved in surgical treatment of 13 patients with psychosis for the last two years. There were six patients with schizophrenia, four with manic-depressive psychosis, and one each with a mental disorder due to epilepsy, alcoholic psychosis and paranoia. The mean duration of anti-psychotic therapy was 14 years. In cooperation with the psychiatrist and anesthesiologist, a great effort was made toprevent the onset of psychiatric symptoms and side effects of antipsychotics during the perioperative period.Psychiatric symptoms could be minimized by an adequate dose of antipsychiatric agents through an adequate route.However, suppressed respiration was noticed in one case, probably because of an overdose of antipsychotic drugs. Also side effect of antipsychotic agents, namely, postoperative paralytic ileus, hypotension and so on, were noticed. Therefore, we must take the influence of antipsychiatric agents into consideration during surgical treatment of psychotic patients as well as treatment of the psychosis itself.

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Ten of 68 patients with hilar bile duct cancer who underwent tumor resection (13 for curative and 55 for noncurative resection) survived more than 5years. The 68 patients were entered into a prognostic factor analysis using the log-rank test for Kaplan Meier's survival curves. The factors yielding significance after the log-rank test were examined to detect significant differences between the group surviving more than 5 years and the group surviving less than 5years using the Fisher exact probability test. These analyses indicated that a patient would have a possibility of surviving more than 5years provided that the patient underwent a curative resection (resection margins free from tumor microscopically) for papillary adenocarcinoma stage I or II (T1-2, N0, M0), i.e., a tumor which did not invade beyond perimuscular connective tissue, with no regionallymph node metastasis, located exactly at the major ductal confluence with minimum extension up to the right or left main hepatic duct, with no infiltration down to the middle common bile duct.

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Forty-five patients with far advanced (stage-IV) gallbladder carcinoma and 52 patients with carcinoma of the hepatic hilus who had undergone radical resection were studied. Various hepatic segmentectomies were used in 85 patients (87.6%). Furthermore pancreatoduodenectomy and/or portal vein resection were concomitantly performed in 19 patients (19.6%) and 24 patients (24.7%), respectively. In stage-IV gallbladder carcinoma, the survival time of the patients with peritoneal seeding, liver metastasis, or positive paraaortic nodes was extremely poor (3-year survival rate was 5.6%, 50% survival time was 9.8 months). By contrast, the survival of the patients without seeding, liver metastasis, or positive paraaortic nodes was unexpectedly better (5-year survival rate was 32.8%). In carcinoma of the hepatic hilus, the survival time of the patients with stage-I, -II, and-III was satisfactory (5-year survival rate 43.3%). Although the prognosis for the stage-IV patients was significantly worse (5-year survival rate was 21.5%), there were many long-term survivors among the patients with stage-IV with local staging factors such as hinf, ginf, or vs (+). In conclusion, we believe that aggressive surgery with more adequate indication and further improvement of operative techniques will give a better prognosis for patients with advanced carcinoma of the biliary tract.

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The results of a radical operation for carcinoma of the gallbladder were reviewed. The standard procedure consists of a cholecystectomy accompanied by adequate resection of the adjacent liver tissue, en bloc dissection of the regional lymphatics and resection of the extrahepatic bile duct. Between July 1981 and October 1991, 87 patients underwent radical operations. Sixty-one patients underwent standard operations or modified standard operations. The remaining 25 patients underwent extended operations (major hepatectomy in 6, pancreatoduodenectomy in 17 and major hepatectomy and pancreatoduodenectomy in 2). One patient died within 30 days after surgery. The cumulative 5 year survival rates for the patients in stages I, II, and III were 87.1% (n=11), 66.7% (n=19) and 31.2% (n=16), respectively. The longest survivor in stage IV (n=25) is still alive 51 months after surgery. The 5 year survival rate for the patients with no residual tumors (n=71) was 62.8%. We conclude that a radical operation based on the standard procedure according to the extent of carcinoma of the gallbladder can be performed.

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Two hundred eighty-four patients who had extended radical operation for ductal adenocarcinoma of the pancreas were studied to evaluate the effectiveness of the extended radical operation. They were divided into two groups, with or without an extended radical operation. Morbidity after the extended radical operation in the patients with carcinoma of the head and the body of the pancreas were 19% and 29%, respectively. Mortality after extended radical operations was 4% and 0%, respectively. Thus the extended radical operation was performed safely. Curability in the patients with carcinoma of the head and the body of the pancreas was 49% and 71%, respectively. Nine patients who had the extended radical operation for the carcinoma of the head of the pancreas survived longer than 5 years postoperatively. The mean survival time was prolonged in the patients who had the extended radical operation for carcinoma of the body of the pancreas. No histological difference was noted between the two groups. Stage III or IV tumors in the patients who had the extended radical operation for carcinoma of the head and the body of the pancreas were found in 85% and 95% or more, respectively. As the majority of the patients with pancreatic carcinoma showed serious invasion, retroperitoneal invasion and lymphnode involvement, the extended radical operation is indicated. And however, as curability was 0% and the survival rate was 8% at 1 year and 0% at 2 years in the patients who had clinical stage IV tumors, in those patients an extended radical operation is not be indicated. Retroperitoneal recurrence and liver metastasis occurred at a high incidence even after extended radical operations. Multidisciplinary therapy is indicated for those patients.

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Ninety-two patients with carcinoma of the pancreas hed lesion who had undergone macroscopically curative resections were analyzed regarding the mode of recurrence. Retroperitoneal local recurrence including neural, lymphatic invasion, and/or para-aortic nodal involvement was the most frequent. Postoperative radiographic examinations revealed hepatic metastasis in 2 patients, retroperitoneal recurrence in 12, and both in 10. The frequency of recurrence in patients with Stage I, II was statistically lower than that in Stage III, IV patients. Recurrence in the patients with distal bile duct cancer was seen when carcinoma cells invaded the pancreas tissue. The main sites of recurrence for those patients were hepatojejunostomy, or the para-aortic region. In patients with carcinoma of the papilla of Vater, hepatic metastasis and local recurrence were equally observed. These results indicate that local recurrence was one of the most important problems and radical dissection including para-aortic lymph nodes and extrapancreatic plexus was necessary for carcinoma of the head of the pancreas. It is important to perform the pancreatectomy with nodal resection around the superior mesenteric artery for the patients with distal bile duct cancer and carcinoma of the papilla of Vater.

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The relationship between the cause of postoperative major organ dysfunction and sepsis or endotoxemia was determined following hepatic surgery in 147 cirrhotic patients. Postoperative endogenous or exogenous endotoxemia induced high morbidity and mortality after surgery. The fact that postoperative endotoxemia was caused by long-term fasting suggested the presence of bacterial translocation. In experimental studies, metabolic alteration in the liver, skeletal muscle and gut was evaluated during sepsis which was induced by cecal ligation and puncture (CLP) in rats with thioacetamide-induced cirrhosis. The protein synthesis rate in vivo was measured by the flooding dose technique utilizing ¹⁴C-leucine. In particular, the protein synthesis rate in isolated enterocytes was determined by measuring incorporation of amino acid into protein during incubation for 30 min with ³Hphenylalanine in vitro. In cirrhotic rats, the protein synthesis rates and protein content of the liver, skeletal muscle and gut were lower than those in normal rats during sepsis. In addition, the mortality rate for cirrhotic rats was higher than for normal rats 24 hours after CLP. As nutritional supports, enteral nutrition (EN), pareteral nutrition (PN) or non-therapy (Non) were carried out following surgery. When EN was given during sepsis in cirrhotic rats, protein synthesis rate in the liver and gut was 89±6, 83±9%/day, respectively, which was significantly higher than in animals given PN or Non with improvement in the amino acid clearance rates: glutamine in the gut and alanine in the liver. Moreover, EN increased protein synthesis including secreted protein production in isolated enterocytes, and also inhibited the decrease in the number of enterocytes and protein content of the gut during sepsis, thus decreasing the mortality rate.

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The metabolic response to stress results in proteolysis, increased gluconeogenesis, and negative nigrogen balance. The branched chain amino acid (BCAA) has been shown to decrease protein degradation and to stimulate protein synthesis in liver and muscle in the stressed state. However, controversy still remains as whether BCAA has any beneficial effects on nutritional support after surgical stress. Cytokines play an important role in the regulation of hepatic and muscle protein metabolism during stress. Therefore, the present study was undertaken to investigate the effect of BCAA solution as a component of parenteral nutrition in patients undergoing total gastrectomy. Urinary excretion of norepinephrine and serum levels of IL-1 and IL-6 were measured as markers of surgical stress. There were no significant differences in the severity of surgical stress among these subjects. Infusion of BCAA decreased the urinary excretion of 3-methylhistidine as a marker of muscular protein degradation. Such infusion may modify the response of patients to surgical stress.

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For the postoperative nutritional management, enteral nutrition (EN) was performed for 13 patients who received hepatectomy (segmentectomy or lobectomy), 9 with esophageal varices who received Hassab's operation with or without esophageal transsection under laparotomy, 12 who received pancreato-duodenectomy and 24 with esophageal cancer who received subtotal esophagectomy under thoracolaparotomy. Constant and continuous infusion of enteral nutrient was performed at 20 kcal/20ml/hr (480 kcal/day) from the third day after the operationvia the enteral feeding tube, then the dose was increased by 20 kcal/20ml/hr daily, and from the fifth post-operative day, 80 kcal/80ml/hr (1920 kcal/day) was given. For the pancreato-duodenectomy patients, EN was applied in combination with intravenous hyperalimentation (IVH), and to the other patients without IVH. All patients were examined for changes in various nutritional parameters. Branched-chain amino acids (BCAA)-enriched enteral nutrient (BCAA-EN) containing 32.6% BCAA was administered to 6 patients with esophageal carcinoma to determine the nutritional effects. In every patient, nitrogen balance became positive within a week, and an inverse correlation with 3-methylhistidine urinary excretion was observed. Rapid turn-over proteins such as retinolbinding protein, prealbumin and transferrin recovered rapidly except for liver cirrhosis cases, which showed a slight delay. BCAA-EN was suggested to be effective clinically in esophageal cancer patients who received subtotal esophagectomy under thoraco-laparotomy.

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We investigated the effects of intravenous infusion of alanylglutamine (Ala-Gln) on the amino acid and protein metabolism in animal models with surgical stress. One-hour Ala-Gln infusion increased hepatic uptake of glutamine (Gln) and alanine (Ala), gut uptake of Gln and lung uptake of Gln and Aln in conscious dogs receiving interleukin-1. Ala-Gln also inhibited release of lactate by muscle in this model. Five-day Ala-Gln supplemented total parenteral nutrition in rat peritonitis model increased the protein synthesis rate of the liver and the muscle more than parenteral nutrition with a standard amino acid solution. In addition, Ala-Gln-supplemented nutrition enhanced the whole-body protein turnover and protein synthesis rate of the intestine more than branched-chain amino acid-enriched nutrition. Moreover, height of the small intestinal mucosa was maintained with Ala-Gln supplementation. These results suggest that Ala-Gln infusion may be beneficial in severe surgical stress.

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The present study was undertaken to investigate the metabolic changes in the patients with multiple organ failure (MOF) receiving gastroenterological surgery and to establish better nutritional support based on the observed metabolic changes for those patients. The useful parameters for the evaluation of metabolic changes were energy expenditure, respiratory quotient, and percent fat measured by indirect calorimetry, arterial ketone body ratio along with ketone body volume, and blood lactate level as an index of tissue oxygen metabolism. Those patients were hypermetabolic, expending 140-150% of the basal energy expenditure. The MOF patients with complicating acute hepatic failure (AHF) could utilize only a limited energy substrate and showed depressed protein metabolism. All the patients were nutritionally supported with total parenteral nutrition. It was difficult to administer the amount of energy compatible with the measured energy expenditure, especially among the patients with complicating AHF and/or acute renal failure (ARF). The adjunctive administration of ATP-Mg and concurrent plasma exchange for the MOF patients with complicating AHF, and simultaneous continuous hemofiltration and continuous hemodiafiltration for the MOF patients with complicating ARF were effective for administering the necessary energy with the total parenteral nutrition. Branched-chain amino acid-enriched amino acids solution was effective in the nutritional support for those patients. These results suggest that the precise evaluation of metabolic changes is of utmost importance for better nutritional support for the patients with MOF, especially for the MOF patients with complicating AHF and ARF.

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