Late results of treatment of esophageal varices were comparatively evaluated in 84 cases of endoscopic injection sclerotherapy (EIS) and 49 cases of shunt surgery for Child A and B patients. Recurrent and rehemorrhagic rates in the EIS group were 21.7 and 13.3%, respectively. The corresponding values in the shunt surgery group were 2.1 and 2.1%, respectively. The results indicated high incidence rates in the EIS group for both parameters. The cumulative five year survival rates in the EIS and shunt surgery groups were satisfactory, and 82 and 88%, respectively, with no significant difference between the two groups. The rehabilitation rates in the late period in the EIS and shunt surgery groups were 81.2 and 74.2%, respectively, with satisfactory results in both groups. In the EIS group, however, patients with four or more EIS in the initial hospitalization showed a lower complete disappearance rate than those with three or fewer EIS, and had significantly higher recurrence and re-hemorrhagic rates and longer hospital stays than the others. Thus early surgical intervention is recommended. Shunt surgery can be performed safely and with low recurrence and re-hemorrhagic rates even after EIS treatment and the recurrence and re-hemorrhagic rates are low. Aggressive shunt surgery is believed to be indicated.

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Five cadavers were anatomically evaluated for the possibility of clearing upper mediastinal lymph nodes through right thoracotomy and neck dissection for esophageal cancer. Furthermore, the status of lymph node metastasis in the area difficult to clear due to a limited view of the operative field was pathologically analyzed using 25 cadavers after lymph node dissection in three areas of the neck, thoracic cavity and abdomen. The anatomical study of 5 cadavers revealed that the left sides of the upper mediastinal lymph nodes were completely cleared up to the median sides of the brachiocephalic artery, left common carotid artery, left subclavian artery, and Botallo's ligament. However, clearing the lymph nodes located on the left sides of the aorta, Botallo's ligament and pulmonary artery was very difficult; remaining lymph nodes were found after clearing. In the analysis of the 15 of 25 cadavers that could be evaluated, no metastatic lymph nodes were seen in the left sides of the aortic arch and Botallo's ligament, and therefore clearing these regions was considered not so advantageous. It was concluded that clearing of the upper mediastinal lymph nodes was enough in view of the operative field through right thoracotomy and neck dissection for esophageal cancer.

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The influence of lymph node dissection on the survival rate of patients with Stage IV gastric cancer was evaluated. In 57 patients who underwent curative resection of N₃ lymph node metastasis, the three-year survival rate (3-YSR) was 63.2%. 3-YSR of patients with relative noncurative resection (rela-NCR) (n=85) and absolute noncurative resection (abso-NCR) (n=18) were 28.2% and 5.6% (p<0.001). In N₄, 3-YSR of rela-NCR (n=6) was 33.3% and that of abso-NCR was 9.5% (N. S.). In P₁, 3-YSR of P₁ alone (N≤R) (n=54) was 27.8% and those of P₁ plus N>R rela-NCR (n=24) and P₁ plus N>R also-NCR (n=17) were 12.5% and 0% (p<0.01). In P₂, 3-YSR of P₂ alone (n=22), P₂ plus rela-NCR (n=17) and P₂ plus abso-NCR (n=10) were 9.1%, 5.9% and 0% (p<0.05). All patients with P₃ factor (total n=28) died within three years after surgery, and no significant differenceswere observed among the three groups. The 3-YSR of patients with H₁ was 17.6% in the case of H₁ alone (n=17), 11.1% in the case of H₁ plus N>R rela-NCR (n=9) and 12.5% in the case of H₁ plus N>R abso-NCR (n=8) (N. S.). The patients with H₂ or H₃ factor (total n=16) died within two years after surgery (N. S.). The 3-YSR of patients with two or more than two factors of Stage IV was 25.0% in the case of N≤R (n=4) and 0% in the cases of two or more than twofactors plus N>R rela-NCR (n=5) or N>R abso-NCR (n=10) (N. S.). In patients with S₃ factor, 46 patients werecuratively operated and eleven patients were noncuratively operated. Of these eleven patients, seven were S₃ alone, two were S₃ plus N>R rela-NCR and two were S₃ plus N>R abso-NCR. 3-YSR of S₃ curatively resected was 50.0%, but S₃ was excluded from analysis because of the small number of N>R NCR patients. From these results, we considered that the dissection of metastatic lymph nodes was effective in improving the survival ratesof N₃, P₁ and P₂ patients, and might also be effective in N₄ and H₍₊₎ patients.

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The clinicopathological characteristics of gastric cancers of the residual stomach and upper portion of the stomach were comparatively studied with special reference to background mucosal changes. In the gastric cancers of the residual stomach, undifferentiated types were predominant, whereas in the gastric cancers of the upper portion, differentiated types were predominant. Macroscopically, the early gastric cancers of the residual stomach tended to be of an elevated type. On the other hand, the early gastric cancers of the upper portion tended to be depressed type or mixed type. Histologically, intestinal metaplasia was seen in background gastric mucosa in 75% of the gastric cancers of the residual stomach, and gastritis cystica polyposa was seen in 50%, whereas in the gastric cancers of the upper portion, the former was seen in 65% and the latter in only 8%. From mucin-histochemistry, it was shown that about 67% of gastric cancers of the residual stomach were of a gastric type, whereas 72% of the gastric cancers of the upper portion were of an intestinal type. These findings may indicate that the mechanism of cancerization is somehow different between gastric cancers of the residual stomach and of the upper portion, although the regions bearing each cancer were originally the same from an anatomical point of view.

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In fifty-six hepatectomized patients with hepatocellular carcinoma, histopathological examination of hepatic parenchyma were performed along with trimethadione (TMO) tolerance test which is an estimation based on serum dimethadione (DMO) /TMO ratio and liver function tests (albumin, ALB; bilirubin, BIL; prothrombin time, PT) and indocyanine green clearance test (retention at 15 min, ICGR15). The correlation ratios were r=-0.495 or r=0.473 between DMO/TMO ratio and ICGR15 or PT, respectively. The DMO/TMO ratios were 0.28 in liver cirrhosis (LC), 0.37 in early LC (EC), 0.51 in liver fibrosis (FB) and chronic hepatitis (CH) and 0.52 in normal (NO). The DMO/TMO ratio showed significant differences between LC and EC, EC and, FB, CH and NO. But it did not show significant differences between Nagayo's type A cirrhosis and Nagayo's type B cirrhosis. We concluded that the TMO tolerance test can estimate the difference of degree in the formation of septal fibrosis from portal tract to the area of central vein in EC and LC, and that of the total amount of hepatocytes in LC and FB, CH.

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Retrograde transheptic biliary drainage (RTBD) and primary closure of the common bile duct (CBD), as a new method of treatment for choledocholithiasis, was compared retrospectively to conventional T-tube drainage as a control, in terms of postoperative major complications which necessitate laparotomy. We also evaluated radiographic diametric change in CBD at the site of primary closure and changes in liver function tests after this procedure. Between April 1986 and July 1991, a total 132 cases were managed by this procedure and compared with 199 cases of conventional T-tube drainage. In the RTBD group, only one (0.8%) postoperative major complication was seen due to incomplete fistula formation, while eight (4%) major complications were seen in the control group. Cholangiography via the RTBD tube revealed no severe stenosis at the site of primary closure. Liver function tests returned to normal levels immediately after the RTBD procedure. From these data we conclude that RTBD and primary closure of the CBD may be a clinically safe, alternative procedure for choledocholithiasis.

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Zenker's diverticulum is a relatively rare disease in Japan. We recently encountered a patient with this condition, which was treated surgically. A 59-year-ld woman consulted a local clinic with a chief complaint of pain in the left side of the neck. At that clinic, esophageal fluoroscopy revealed a pool of the contrast material, which was located on the left side of the pharyngeal segment of the esophagus and which was equivalent in size of the index finger. Based on this finding, she was diagnosed as having Zenker's diverticulum and referred to our department. In our department, esophageal endoscopy disclosed the entrance to the diverticulum about 17 cm distant from the incisors. Computed tomography revealed a mass in contact with the pharyngeal segment of the esophagus. We diagnosed this patient as having Zenker's diverticulum, accompanied by diverticulitis. The woman underwent diverticulectomy in our department, during surgery, the diverticulum was slightly edematous and was found to have been formed from the Lannier-Hackerman's spatium. Histopathological examination allowed a diagnosis of diverticulitis, accompanied by inflammatory cell infiltration. Postoperative esophageal fluoroscopy revealed good passage of the contrast material and the diverticulum has not recurred. The postoperative course was uneventful, and the patient was discharged on the 9th hospital day. Surgical results of Zenker's diverticulum are usually good. Therefore, in cases where this condition is accompanied by diverticulitis or symptoms, as seen in the present case, it is recommended that this disease be treated surgically.

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A case of esophageal granular cell tumor removed by endoscopic polypectomy is reported. A 78-year-old woman was admitted because of a tumor just under the esophagogastric junction. Histologically the tumor was diagnosed as an esophageal granular cell tumor by endoscopic biopsy. The tumor was completely resected by endoscopic polypectomy and no abnormal finding was found at the resected part two months later. In Japan 80 cases of esophageal granular cell tumor have been reported in detail. Follow up, endoscopic polypectomy and surgical resection were performed for these tumors. We confirm that endoscopic polypectomy is the first choice for an esophageal granular cell tumor, though we must consider its size and histological depth.

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A case of superficial esophageal cancer with a long stenotic lesion in which almost all depths of invasion were limited to the epithelial layer, is reported. The patient was a 49-year-old man with a chief complaint of dysphagia. An esophagogram and esophagoscopy showed a 10cm stenotic lesion without protrusion or depression in the Celu region. Endoscopic iodine staining revealed many spotted unstained lesions in the stenotic area, and a biopsy proved the lesions to be squamous cell carcinoma. Total thoracic esophagectomy with regional lymph node dissection under right thoracotomy and a gastric tube reconstruction in the posterior mediastinal route were performed. Histopathological results were sm, ie (+), n (-) (0/48), ly (-), v (-).The cancer cells stayed within the epithelium except in one 3 mm area that invaded the lamina muscularis mucosae. This case was thought to be a multicentric cancer spreading in the epithelial layer. The stenosis might be referred not only to the inflammatory change but also to the lymphocyte infiltration of the mucosal layer as an immunological reaction to cancer cells.

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A 67-year-old woman complained of increasing dysphagia after an operation for esophageal cancer. The symptom first appeared in the second postoperative month. Esophagoscopy disclosed scar formation on the jejunal loop, 7-8 cm distal to the anastomosis. Histological examination suggested a postischemic lesion and subsequent scar formation. Circulatory disturbance due to compression or overstretching that affected the mesenteric vessel was considered likely. Bougienage was not effective. Reoperation was abandoned because of the non-curative outcome of the initial operation, anticipation of a difficult reoperation and disapproval by the patient. An esophageal prosthesis was then selected to solve the problem. Her dysphagia was improved markedly. She is doing well with an almost normal diet four months after discharge. The esophageal prosthesis is a valuable tool for the patient with inoperable and/or unsuccessful bougienage stenosis. However further follow-up for a long period is required.

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A 64-year-old man underwent total thoracico-abdominal esophagectomy and lymph node dissection followed by reconstruction with a retrosternal gastric tube due to an esophageal cancer located in the middle and lower thoracic esophagus. Pathological diagnosis of the resected specimen was poorly differentiated squamous cell carcinoma, involving the epithelial layer, and without lymph mode metastasis. About 10 years later, he was admitted to a hospital because of nausea and vomiting. An upper gastrointestinal endoscopic examination revealed a protruded polyp (Yamada type III) in the reconstructed gastric tube. The biopsy specimen showed a moderately differentiated adenocarcinoma. Endoscopic ultrasonogram demonstrated the tumor was restricted to the mucosal layer, so endoscopic polypectomy was performed. Pathological diagnosis of the resected polyp was papillary adenocarcinoma, involving only the mucosal layer, and without invasion of the base of the polyp. Cases of early cancer of the reconstructed gastric tube after surgery for early esophageal cancer are rare, and only two cases have been reported. But according to our study of 46 cases of gastric cancer in the reconstructed gastric tube reported in Japan, follow-up on the reconstructed gastric tube is necessary for early detection.

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A 72-year-old man was admitted to our hospital with loss of appetite and anemia. Gastroscopy showed a Borrmann I type tumor in the antrum. Leiomyosarcoma was suggested from the biopsy specimens of the lesion. After admission, an emergency gastrectomy was performed because of massive gastric bleeding. Histological examination revealed carcinosarcoma of the stomach. Adenocarcinoma cells and undifferentiated tumor cells, which were not clearly determined as epithelial or non-epithelial, were found in the metastatic lymph node. Five months postoperatively the patient died of liver failure due to liver metastasis. Only adenocarcinoma was found in the metastatic lesion of the liver. Immunoperoxidase studies showed that the adenocarcinoma cells were strongly positive for CEA and EMA and were negative for desmin, vimentin and s-100 protein. In contrast, the cells in the sarcomatous portion were positive for desmin and vimentin and were negative for the epithelial marker. Only 20 cases of carcinosarcoma of the stomach (excluding collision tumor) have been reported in Japan.

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Two successfully treated patients with ruptured duodenal varices are described. Case 1 was a 50-year-old man admitted to our hospital with a complaint of massive melena. Upper gastrointestinal examination revealed a lesion showing meandering prominence on the anterior wall of the first portion of the duodenum. Angiographic study demonstrated an obstruction of the portal vein and dilated tortuous veins along the duodenum. From these findings, the lesion was diagnosed as duodenal varices, and suture-ligation of the varices was performed under laparotomy. Case 2 was a 69-year-old woman after suffering from liver disease for a long time, she presented with hematemesis and melena. Endoscopic examination revealed an actively bleeding lesion showing a meandering prominence at the second portion of the duodenum. The diagnosis was ruptured duodenal varices, and endoscopic sclerotherapy was conducted. As the procedure produce hemostasis, devascularization of the duodenum was surgically performed. The postoperative course of the 2 patients was uneventful, and no serious events have occurred in the two years or more since surgery.

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A 57-year-old man involved in an automobile accident sustained a steering wheel injury to the upper abdomen. The preoperative diagnosis was intraabdominal hemorrhage and hepatic blunt injury. Opening the abdomen, we found that the hepatic artery was injured at two sites, and these were surgically repaired. The common bile duct was found to have been exposed by trauma. However, no leakage was noticed by cholangiography. The postoperative course was uneventful, even though angiography on the 17th postoperative day suggested that the gastroduodenal artery and right gastric artery had been separated from the common hepatic artery and proper hepatic artery. However, two months later, he developed hyperpyrexia and his liver enzyme level increased. He was rehospitalized. Middle common bile duct stenosis was diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) and hepatobiliary scintigraphy. He was treated conservatively and recovered. However, following his discharge, jaundice had appeared and he underwent choledochoduodenostomy seven months after the first operation. He has remained well since his discharge.

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A 25-year-old man complained of right upper quadrant pain and shortness of breath only on effort over a two-year period. On physical examination the patient appeared healthy. Neither ascites, leg edema nor dilated abdominal veins was noticed. Ultrasonic examination revealed communicating vessels between hepatic veins, enlarged inferior right hepatic vein and reversed blood flow in the hepatic vein, leading us to the diagnosis of Budd-Chiari syndrome. The diagnosis was confirmed by inferior vena cavography. Percutaneous transluminal angioplasty was performed easily and successfully by using an Inoue balloon catheter. The symptoms disappeared completely and immediately after treatment. The diagnosis of this condition could be made by ultrasonic examination easily, and transluminal angioplasty by Inoue catheter was effective and safe for the treatment of Budd-Chiari syndrome.

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A relationship between schistosomiasis japonica and hepatocellular carcinoma has been reported. However, there have been no reports of hemangioma of the liver associated with schistosomiasis japonica. A 64-year-old man was diagnosed as having hepatocellular carcinoma by CT, echo, MRI and angiography. It was localized to the posterior segment of the liver, and he was subjected to posterior segmentectomy. Histological examination of the resected specimen showed calcified ova in the portal area, and the tumor consisted of a venous hemangioma. It was difficult to diagnose as a hemangioma because of the peripheral, small-type and long-term accumulation of lipiodol in the tumor. It appeared that a type of portal hypertension caused by the calcified ova of Schistosoma japonicum in the portal area made it impossible to wash out the lipiodol.

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A rare case of adenosquamous carcinoma of the liver is reported. A 48-year-old woman presented with epigastralgia and back pain. Various examinations judged the case to be cholangiocarcinoma of the liver. extended right hepatectomy was performed under extracorporeal circulation with a bio-pump, but liver metastasis occurred 3 months postoperatively, resulting in death one month thereafter. Histologically, the tumor was located in the right anterior lobe of the liver and demonstrated both malignant squamous and glandular components as well as foci of transition between the two. Adenosquamous carcinoma of the liver is an extremely rare primary hepatic neoplasm that was first reported by Pianzola et al. in 1971. A review of the literature revealed 24 previously reported cases. Although the intrahepatic site of occurrence of squamous cell carcinoma is still controversial, it is generally accepted that the pathogenesis of adenosquamous carcinoma is the squamous metaplasia of cancer cells. In the present case, we considered squamous cell carcinoma to have originated from cholangiocarcinoma.

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We report a case of undifferentiated carcinoma of the gallbladder in a 68-year-old woman who was admitted to our department with an abdominal tumor and obstructive jaundice. Under the preoperative diagnosis of gallbladder tumor, based on imaging findings and elevated levels of NSE, CEA, PIVKA-II and CA19-9, laparatomy was performed, revealing a primary tumor of the gallbladder invading the liver parencyma, common bile duct, hepatoduodenal ligament and transverse colon, which were resected “en bloc” with the tumor. The resected specimen weighted 2, 105 g, and the histological examination showed that most areas consisted of undifferentiated small cells. There were also focal areas showing epithelial connection of the tumor cells, where they stained for CA19-9 and cytokeratin. Because of the very poor prognosis of undifferentiated carcinoma of the gallbladder and its early remote lymphnode metastasis, early diagnosis and surgical treatment must be achieved.

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A 66-year-old man who had bee exposed to the atomic bomb explosion underwent surgery for the adhesive ileus. Borrmann type 2-like advanced cancer and two IIc-like dysplasias of the jejunum were found. Postoperative examination showed multiple IIc-like lesions of the duodenum and jejunum. Reoperation was performed, and the anal half of the duodenum and jejunum were resected. The resected specimen showed a IIa + IIc-like carcinoma at the third portion of the duodenum and 25 IIc-like dysplasias at the duodenum and jejunum. The DNA ploidy pattern of the cancer of the jejunum and duodenum was aneuploidy and the normal duodenal mucosa and most of the IIc-like dysplasias also showed aneuploidy.These findings suggested the atomic bomb explosion as apossible cause of the lesions.

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We report a case of gangrenous-type ischemic colitis involving the bowel from thececum to the sigmoid colon. The patient, a 59-year-old woman, was admitted to our hospital complaining of abdominal pain and vomiting. The next day, rebound tenderness appeared on abdominal examination, and an emergency laparotomy was carried out. consecutive necrosis of the bowel from the cecum to the sigmoid colon was discovered. Under the diagnosis of gangrenous-type ischemic colitis, subtotal colectomy and exteriorization of both ends were performed resulting in her survival. In 49 cases of gangrenous-type ischemic colitis in the Japanese literature, the patients' ages ranged from 34 to 90 years (mean 70.2) with the majority in the seventh, eighth and ninth decades. There were 21 males and 22 females (6 unknown). The descending and sigmoid colon were most frequentlyinvolved. The mortality of 38 cases (11 unknown) was 44.7%, and in 36 resected cases, the mortality was 41.7%. This indicates poor prognosis of gangrenous-type ischemic colitis. The only therapy for survival is resection of the gangrenous area, and wide excision should be performed with observation of the intestinal mucosa of both ends.

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Hemolytic uremic syndrome (HUS) is characterized by a triad of features: acute renal failure, thrombocytopenia and microangiopathic hemolytic anemia. A 4-year-old girl presented with hemolytic uremic syndrome following a prodrome of bloody diarrhea. No organism was cultured from the patient's stool at admission. However, because of the high titer of anti-Verocytotoxin 2 and anti-E. coli serotype 0157 in the patient's serum, we diagnosed this case as HUS induced by infection of Verocytotoxin-producing E. coli. The patient developed severe renal failure. Bloody ascites and necrosis of colon were found a laparotomy performed to implant a continuous ambulatory peritoneal dialysis (CAPD) catheter. Partial resection of the transverse colon and colostomy were performed. Microscopic examination revealed embolisation of small vessels in the submucosal region. We successfully performed colostomy closure 16 months after she recovered from the first operation.

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Malignant lymphoma rarely occurs in the colon, especially in the sigmoid colon. The concept of mucosa associated lymphoid tissue (MALT) lymphoma is not widely accepted among pathologists. We report here the first case of MALT lymphoma in the sigmoid colon. The patient was a 54-year-old man who complained of fever. He was treated under the diagnosis of prostitis and Crohn's disease. However, his clinical condition did not improve. Barium enema study showed two skip lesions with irregular surface in the sigmoid colon. These changed from concave to elevated in the endoscopic findings. Thus, the patient, suspected of having malignant lymphoma rather than Crohn's disease, underwent sigmoidectomy. The surgical specimen was diagnosed as MALT lymphoma. We should observe clinical changes carefully to differentiate malignant lymphoma from inflammatory bowel diseases.

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Endoscopic sphincterotomy (EST) is a safe and effective alternative to surgery for the treatment of common bile duct stones. It is extremely useful especially for patients with acute obstructive suppurative cholangitis (AOSC) or gallstone pancreatitis, and high-risk patients with serious complications. We have performed EST in 1, 080 patients with choledocholithiasis since October 1974. The success rates for EST and stone removal were very high, 98.9% and 93.1%, respectively. Immediate complications occurred in 82 patients (7.6%). One patient died of AOSC and another of acute pancreatitis in the early phase of our experience, yielding a mortality rate of 0.2%. The long-tipped sphincterotome allows easy control of incision, contributing to zero incidence of duodenal perforation. As precutting may increase the risk of acute pancreatitis, selective bile duct cannulation should be first attempted with the use of a guide wire. Long-term follow-up was completed in 140 of 141 patients with common bile duct stones more than 10 years after sphincterotomy. Recurrent stones developed in 18 patients (12.9%). Recurrence of common bile duct stones has a tendency to increase with time.

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Although the advantages of laparoscopic cholecystectomy over open cholecystectomy in terms of less postoperative pain, shorter hospitalization and earlier resumption of activity, in addition to better cosmetics, are apparent, it has been documented that complications such as bile duct injury occur more frequently during laparoscopic surgery than open surgery. Moreover, the risk of intraoperative injury to bowel or major blood vessels which are unique to laparoscopic surgery have been reported. On the other hand, the management of choledocholithiasis by laparoscopy has been also attemted in many institutions and favorable results have been reported in the literatures. An additional concerns arised here is the risk of retained stones. In this paper, fundamental techniques to prevent these complications and make laparoscopic surgery a standard procedure for the management of cholecysto-and choledocholithiasis are detailed and the need to place a T-tube for the management of possible retained stones is also advocated based on the limitations of EST and laparoscopic intraoperative examinations. Moreover, it is emphasized that surgeons who attempt to do laparoscopic surgery must be; 1. competent for the special techniques required by laparoscopic surgery, 2. competent for the techniques of general surgery, and 3. competent for the management of difficulties frequently encountered during surgery and predictive postoperative complications.

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The author discusses the basic procedures of cholecystectomy and choledochotomy under laparotomy as well as the problems associated with these procedures. At the time of cholecystectomy, cholecystectomy from the fundus should be selected in the first place. In cholecystectomy after the course of acute cholecystitis, it is not necessary to stick with typical surgical procedures, but it is important to incise the gallbladder first and to carry out the procedure while making sure of the anatomical relationships with the surrounding organs. The author emphasizes that preventive drainage after cholecystectomy may be withdrawn the next day if there are no accidents or problems. Choledochotomy is applicable to choledocholithiasis, and in addition to cases of cholecystolithiasis where previous jaundice suggesting biliary infection and choledochal dilatation are recognized. In cases in which a number of small calculi are seen in the gallbladder, cystic duct dilatation and a contracted gallbladder without calculus suggest escape of a gallstone into the choledochus. Therefore, detailed inspection is required during surgery. Choledochal drainage using a T-tube subsequent to choledochotomy should be carried out in cases where complications of biliary infection, choledochal dilatation, and copious biliary sand and mud are recognized in the choledochus.

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