We have carried out endoscopic mucosal resection (EMR) for 10 patients with 12 lesions diagnosed as early esophageal squamous cell carcinomas or esophageal dysplasias by histological findings of their biopsy sections prior to surgery. In seven of the patients with eight cancer lesions, we investigated the indication for EMR of early esophageal cancer, particularly in the level of invasion. The number of lesions classified by depth of invasion was as follows: ep, 4; mm1, 2 and mm3, 2. Since one of the mm3 lesions was suspected to have invaded the lymph channels, we performed radiotherapy to the mediastinum from two weeks after EMR. While we have been following the patients for less than 33 months, we have seen no recurrence and all of the patients are alive. Presently, it is thought that early cancers, not deeper than mm2, are an absolute indication for EMR. But, it may be possible to completely treat mm3 lesions with invasion to the lymph therapy. We hope that the indication for EMR can be extended to mm3 early cancers.

View full abstract

To define the age of the elderly for surgery of esophageal carcinoma, a consecutive series of 517 patients who underwent esophagectomy by right thoracotomy and laparotomy from 1983 through 1992 was analyzed. They were classified into seven age groups (group I: 46 patients under 50 years; group II: 66 patients, 50 to 54 years; group III: 87 patients, 55 to 59 years; group IV: 107 patients, 60 to 64 years; group V: 90 patients, 65 to 69 years; group VI: 65 patients, 70 to 74 years, and group VII: 56 patients aged 75 years or older), in order to compare the pre-and postoperative function of vital organs and the incidence of complications and operative death. Postoperative periodic change in PaO₂ and the serum creatinine level significantly deteriorated in groups VI and VII. Postoperative pneumonia and delirium frequently occurred in group VII, and the rates of pneumonia and delirium were 28.6% (16/56) and 30.4% (17/56), respectively, significantly higher than those in other groups. The operative mortality for group VII was 17.9% (10/56), significantly higher than that for the groups under 70 years of age. The mortality for group VI was 12.3% (8/65). There was no significant difference in mortality in comparison with the groups under 70 years of age. We should manage patients aged over 75 years as the elderly in surgical treatment for esophageal carcinoma.

View full abstract

We have investigated safety and finding of direct effect of preoperative Cisplatin and 5-Fluorouracil combination therapy (in the following it is abbreviated to CDDP + 5FU therapy) in intensive treatment for esophageal carcinoma. Thirty-two patients were recieved CDDP+5FU therapy before operation were selected for this study from 85 patients with esophageal carcinoma who underwent surgery from September, 1991 to August, 1993. 80mg/m² (day 1) of Cisplatin and 800mg/m² (day 1-4) of 5-Fluorouracial were administered for 3 weeks as one course. Operation was performed to patients who showed no change or less and second course was treated to those who showed partial responce. Side effects were mild and did not affect operation schedule and postoperative progress. Partial responce in 11, no change in 17 and progresive disease in 4 were observed by image diagnosis. Histopathological diagnosis indicated slight effect or above in 18 (56%). Slight effect or above on lymph nodes were observed in 7 (28%). Preoperative CDDP + 5FU therapy had mild side effects and did not affect postoperative condition. Its effect on lymph node was also good.

View full abstract

The expression of factor VIII related antigen (FVIII-RAg) was investigated by immunohistochemical study of 124 gastric cancer patients to determine the correlation between the tumor's angiogenesis and the clinicopathological factors and the prognosis. The distribution of the microvessels was divided into the intratumoral type and the stromal type. Involvement of veins and liver metastasis were more often observed in patients with the intratumoral type. Patients with the intratumoral type tended to have a worse prognosis than patients with the stromal type. According to the site of recurrence, liver metastasis was significantly (p<0.01) more common in patients with the intratumoral type than those with the stromal type. Otherwise, patients with the stromal type tended to have the recurrence in the peritoneum. As a result of this study, we conclude that the intratumoral type is associated with blood-borne metastasis and that examination of the distribution of microvessels may be useful as a predictor of the site of recurrence.

View full abstract

Changes in liver circulation and liver energy metabolism during acute reductionin portal venous blood flow were studied in dogs. Extracorporal circulation from the superior mesenteric vein to the portal vein during total clamping of the hepatoduodenal ligament was constructed to enable varying degrees of portal flow by a roller pump. Mongrel dogs were divided into three groups by the rate (100%, 50%, 25%) of portal perfusion (PP). 1) In the 100% flow group (n=6), oxygen delivery (OD) was reduced because of clamping the hepatic artery, but it was compensated by an increase in the oxygen extraction rate (OER). ATP in the liver was not changed significantly during PP. 2) In the 50% flow group (n=6), OD was reduced because of clamping the hepatic artery and portal venous flow reduction. OER was increased. ATP at 120 minutes' PP was signiicantly lower than the previous level. However, arterial ketone body ratio (AKBR) was more than 0.25 during PP. 3) In the 25% flow group (n=6), OER wassignificantly higher than that in the 100% flow group at 15 and 30 minutes. However, OER at 120 minutes' PP was signifiocantly lower than that at 60 minutes' PP. ATP at 60 minutes' PP was significantly lower than that in the 100% flow group. AKBR in 1/6 (at 60 minutes), 2/6 (at 90 minutes) and 4/6 (at 120 minutes) were less than 0.25. Portal vein resistance was significantly higher than that in the 100% and 50% flow group at 60, 90 and 120 minutes. These results suggested that normal metabolism could not be maintained in the 25% flow group after 60 minutes' PP, and become abnormal, as indicated by ATP and AKBR.

View full abstract

Significance of morphometric cytological study using computerized color image analyzer was attempted by comparing conventional liver function tests including indocyanine green clearance test (ICGR15). Multiple biopsies were taken from the noncancerous portion of the liver during hepatectomy in 16 cirrhotic patients with hepatocellular carcinoma. The morphological study of the liver, based on various parameters which are characteristic of liver cirrhosis, such as Ratio of hepatic parenchymal area and Hepatic cells per unit area including Hepatic volume, Hepatic parenchymal volume, Hepatic cell volume and Total hepatic cell volume, was performed. Hepatic volume was calculated by Ct scans of the liver. Total hepatic cells volume was calculated by multiplying these parameters. We compared these morphometric cytological parameters with the levels of ICGR15 and the liver function test (albumin, total bilirubin and prothrombin time). A significant correlation was found between ICGR15 and Ratio of hepatic parenchymal area (r=-0.506, p<0.01), Hepatic cells per unit area (r=-0.655, p<0.003) and Hepatic cells volume (r=-0.620, p<0.01). Total hepatic cells volume, which is the good index of the normal parenchymal cells volume in the liver, did not show a signficant correlationship with ICGR15 or liver function tests. Therefore, we though that the morphological changes of hepatic parenchyma by using computerized color image analyzer can be reflected in ICGR15 which is considered as one of the test for the function volume of the liver

View full abstract

A new approach for laparoscopic cholecystectomy (laparoscopic cholecystectomy from fundus downward: LCFD) was investigated. We performed twenty-eight laparoscopic cholecystectomies by the usual technique, and sixty-two were performed by LCFD. The median operating time was 100.7±50.9 min in the laparoscopic cholecystectomy (LC) group versus 77.8±33.0 min in the LCFD group (p<0.01). There was no signficant difference in the median operating time between the LC group and LCFD group of patients without cholecystitis. But in patients with acute cholecystitis, the median operating time was 129.6±25.0 min in the LC group versus 97.4±38.9 min in the LCFD group (p<0.05). Moreover, intraoperative and postoperative complications were fewer in the LCFD group than that in the LC group. LCFD appears to be a safe procedure and does not compromise retrograde laparoscopic cholecystectomy.

View full abstract

In this study, two pancreatic cancer cell lines, SW1990 and PANC-1, were examined for the relationship between cellular motility and metastatic potential in the intrasplenic injection model, and the role of the motility factor released by SW1990 cells in invasion and metastasis was investigated. When the in vitro invasion and motility of SW1990 and PANC-1 cells were measured by the MTT method using a Trans well chamber, the percentages of cell invasion were 22.6% and 7.3% respectively, and those of motility were 33.3% and 13.6%. The high motility of SW1990 was correlated with its in vivo metastatic potential. As the motility of PANC-1 cells could be increased 2-3 times by treatment with SW1990 serum free spent medium in a dose dependent fashion, SW1990 cells may have the ability to produce motilityfactor. Incubation of PANC-1 cells with SW1990 medium resulted in the formation of thin processes and a fibroblast-like morphology, and also induced micro-metastasis in liver by splenic injection. These findings suggested that this motility factor may play an important role in panceratic cancer invasion and metastasis.

View full abstract

We elaborate the formula of operative risk probability in gastroenterlogic surgery to quantify operative risks. Subjects were 121 patients who underwent operations for gastroenterologic diseases. Background factors were American Society of Anesthesiologists' status [ASAS], age, sex, body weight, modified Oxford score, steroid administered, and respiratory index. Resultant factors were postoperative complications. Logistic regression analysis was used to induce the risk score (u) of significant factors, with which the probability of operative risk, P, was formulated: P=exp(u)/[1+ exp (u)]. The results yielded a linear combination for overall complications (n=46): u=0.8667x(ASAS) +0.0043x(operative time)+2.626x(wound)-8.950. P for patients with complications was 0.5±0.25 whereas P for those without (n=75) was 0.30±0.17. A cutpoint (P=0.62) best distinguished the presence or absence of complications. ASAS stood out as a significant factor common to various degreesof complications. The formula allows evaluation of the operative risks immediately after operations, thus providing means to facilitate postoperative management.

View full abstract

We report a case of severe hemorrhagic shock due to ulceration in the reconstructed gastric tube placed posterior to the mediastinum after radical resection for esophageal cancer. The patient is a 72-year-old man who underwent an operation for esophageal cancer on June 1, 1988. After the operation, he was irradiated prophylactically with a total dose of 80 Gy. He showed no sign of recurrence. Three years and seven months after the operation, he suddenly developed hematemesis with hemorrhagic shock. Endoscopy on admission revealed an ulcer with exposed vessels in the reconstructed gastric tube. Hemostasis using endoscopy and balloon tamponade could not control the bleeding. Emergency operations, gastrotomy and direct suture of the ulcer, were performed twice but were unsuccessful. At last the gastric tube was resected transthoracically and cervical esophagocutaneostomy and tube jejunostomy was performed on the third operation. After the operation, his shock improved dramatically. Reconstruction using pedicled colon was performed 6 months later. The pathogenesis of the ulcer was considered to be mucosal damage due to postoperative irradiation and the remaining acid secretion in the gastric tube.

View full abstract

Leiomyosarcoma of the stomach is reported to account for about 1% of the gastric malignancies. Cases of intraabdominal bleeding or hemoperitoneum are rare. We report a surgical case with massive ascites of about 10l. The patient was a 71-year-old man with abdominal mass in the epigastric region who was diagnosed with leiomyosarcoma of the stomach. He refused surgery, but after 20 months, massive abdominal distension appeared, and he was admitted to our hospital for tests. He was suspected of having a submucosal tumor of the stomach with massive ascites. At surgery, a 10cm tumor growing extraluminally from the anterior wall of the antrum was observed. Subtotal gastrectomy with partial lateral segmentectomy of the liver was performed. The histological diagnosis was leiomyosarcoma of the stomach. We suspected that the massive bloody ascites was due to increased vascular permeability of the peritoneum caused by rupture of the necrotic tissue of the tumor with bleeding.

View full abstract

Increasing levels of serum carcinoembryonic antigen (CEA) in a 66-year-old man led to examination of the systemic organs. Gastric endoscopy revealed a shallow, depressed lesion in the vicinity of the pylorus. The CEA level continued to increase, reaching 171 ng/ml preoperatively. The CEA level in gastricjuice was 249 ng/ml. The patient underwent partial gastrectomy. Microscopic examination showed the lesion to be well differentiated adenocarcinoma invading to the submucosal layer; the majority of the tumor cells were positive for CEA staining. Serum levels of CEA decreased postoperatively and fell within the normal range on the 80th postoperative day. Early gastric cancer rarely shows high levels of CEA. Increased CEA. Increased CEA levels in the gastric juice and serum dictate meticulous investigation of the stomach.

View full abstract

Gastric cancer associated with calcification is comparatively rare. A case of Borrmann 3 type gastric cancer showing calcification on a plain abdominal X-ray film is reported. The patient was a 36-year-old female with a chief complaint of epigastric discomfort. A diagnosis of Borrmann 3 type gastric cancer (signet-ring cell carcinoma) of the fundus was made on the basis of upper endoscopy. A plain abdominal X-ray, upper GI series, abdominal CT, and abdominal ultrasound examination demonstrated small stippled calcification in the gastric cancer. Total gastrectomy and pancreatico-splenectomy were performed with No.1, No.3 lymph node metastasis and serous invasion present (P₀H₀S₂N₁ Stage III R₂ Cur A). The resected specimen showed depth of invasion se, n₁ (+), and no invasion of the pancreas or spleen. Calcium phosphate and calcium carbonate were detected in the calcifications. The patient was followed postoperatively, but died of recurrence of her cancer 10 months later. The mechanism of calcification in gastric cancer is discussed with reference to the literature.

View full abstract

A 64-year-old woman underwent emergent operation for bleeding from duodenal ulcer, i.e., duodenonesidiectomy, for a tumor caput pancreatic forming duodenal fistula. The resected specimen indicated a 5×3cm tumor in the same region, the center of which showed hemorrhagic necrosis rupturing the duodenal wall. Pathohistological findings confirmed leiomyoma in continuation to the tunica muscularis propria duodenalis. The growth of duodenal leiomyoma within the parenchyma caput pancreatis is reported for the second time in this country, and its rare mode of growth was examined; the regio caput pancreatis has an area of union of the ventral pancreas and dorsal pancreas, which forms the so-called“weak spot”.The tumor developed pancreato-dorsally on the adoral side of the duodenal Vater papilla and was thought to develop intrapancreatically, slipping into the above“weak spot.”

View full abstract

Hepatic vascular exclusion with veno-venous by-pass and veno-portal by-pass using a Bio Pump was used in hepatectomy in four patients with giant hepatocellular carcinoma occupying the right lobe. Treatment was combined with in situ cold perfusion and surface cooling in three patients. Case 1 was a 46-year-old man whose tumor was resected by extended right lobectomy. Case 2 was a 45-year-old man whose tumor was resected by trisegmentectomy from the right. Case 3 was a 50-year-old woman whose tumor was resected by right lobectomy. Case 4, 58-year-old woman, underwent tumor resection by extended right lobectomy. The Bio Pump was used for 35, 117, 59 and 38 min, respectively. Total blood loss during surgery was 7555, 2155, 2310 and 1562 cc, respectively. Ascites was observed in 3 patients postoperatively, but all patients discharged in good condition. Hepatic vascular exclusion using a Bio Pump seemed to be used for cases of difficult resection or potential massive hemorrhage during operation.

View full abstract

We are reporting a case of diffuse thrombosis of the portal system, diagnosed preoperatively by means of CT scan. The patient was a 68-year-old man with no particular problems in his medical history. His chief complaints were abdominal fullness, epigastralgia and diarrhea. He was hospitalized 4 days after the onset. Physical examination revealed progressive abdominal distension with muscular defense. A plain CT scan disclosed occlusion of the splenoportal and superior mesenteric veins due to diffuse thrombus. Thrombus in the peripheral mesenteric veins and the thickened small intestine were also obserbed. Abdominal angiography demonstrated no visualization of the portal system. Surgery was performed on the same day. Bloody ascites and congestive necrosis of the small intestine were found, and venous thrombectomy and massive intestinal resection, 260 cm in length, were performed. Anticoagulant therapy was started during the operation. Postoperative angiography and CT scan clarified occlusion of the portal vein and the right portal branch, patency of the splenic vein and collateral circulation around the portal vein. The coagulation and fibrinolysis parameters of this patient were normal, and we considered this a case of primary thrombosis. In spite of the shortened bowel (40cm in length), he is being followed without any special nutritional support.

View full abstract

A 68-year-old woman was admitted with the complaint of tumor in the upper abdomen. Abdominal ultrasonography and computed tomography showed a solid, partially cystic mass, 10×8 cm in diameter, in the pancreas body. The magnetic resonance image showed high intensity of the wall and a part of content in the lesion on Tl-weighted images and high intensity on T2-weighted images. The superior mesenteric vein and portal vein were deviated to the right side. The lesion was fed by a posterior pancreatic artery. The portal vein was not invaded. Blood insulin and blood gastrin were increased without peptic ulcer or symptom of hypoglycemia. Laparotomy was carried out on 26 August 1992. The pancreas body and tail with spleen was resected with the lesion. The resected pancreatic tumor measured about 10cm in diameter and has a cystic cavity showing irregular tubers. The histopathological diagnosis was islet cell carcinoma. The immunopathological stains of insulin, gastrin, cromogranin A, pro GRP and GRP were positive. From the above findings, the lesion was concluded to be cystic asymptomatic functioning islet cell carcinoma.

View full abstract

An extremely rare case of chronic pancreatitis with hemosuccus pancreaticus and left-sided portalhypertension is reported. A 45-year-old man was medicated for chronic pancreatitis and gastroduodenal ulcer. He was admitted to our institute because of massive duodenal bleeding and underwent emergent distal gastrectomy. After discharge, he had epigastric pain and was admitted again under a diagnosis of chronic pancreatitis and pancreatic pseudocyst. His blood count showed pancytopenia. Abdominal CT revealed splenomegaly and a low density mass in the pancreatic tail. Angiogram revealed aneurysmal change of the distal splenic artery, and stenosis of the splenic vein and collateral circulation on the venous phase. Distal pancreatectomy with splenectomy was performed. On the resected specimen, there was a pseudocyst filled with blood clot in the pancreatic tial, and it communicated with the main pancreatic duct. In addition, the splenic artery had ruptured into the pseudocyst. The stenosis of the splenic vein was due to fibrosis of the surrounding tissue.

View full abstract

Isolated splenic abscess is relatively uncommon since the development of antibiotic therapy. However, multiple splenic abscess is increasing with the progress of anti-cancer chemotherapy and medical imaging techniques. An 18-year-old female patient was admitted to our hospital with high fever and left hypochondric pain. Computed tomography and ultrasonography demonstrated a huge cystic mass in the left subphrenic space. After making the diagnosis of splenic abscess by echo-guided needle aspiration, we introduced a drainage tube into the abscess vavity. She recovered 24 days later. In the Japanese literature since 1948, we collected 31 cases of isolated splenic abscess. Only 4 of them were successfully treated with echo-guided percutaneous drainage. As in our case, percutaneous drainage under echo guidance seems to be a safe and effective treatment for isolated splenic abscess.

View full abstract

We encountered two cases of gastrointestinal tract perforation due to amyloidosis. The first patient was a 56-year-old man who had been treated by hemodialysis three times a week for 19 years for chronic renal failure. An emergency laparotomy, performed under a diagnosis of perforating peritonitis, revealed perforation of about 1cm in the sigmoid colon. The sigmoid colon including the perforated site was resected. Histopathological examination showed severe deposition of β2-microglobuoin as amyloid protein in the tunica muscularis and vessel walls of the submucosa. This amyloid protein deposition may be caused by long-term insufficient hemodialysis. The second patient was a 68-year-old man who was diagnosed with perforating peritonitis 6 days after nephrectomy because of a right small renal cell carcinoma. An emergency operation revealed a spontaneous perforation of about 5 mm in the jejunum. Histopathological examination showed deposition of the light chain of immunoglobulin as amyloid protein in the perivascular tissue of the kidney and the jejunum. A post operative general examination suggested primary amyloidosis.

View full abstract

Diverticulosis of the vermiform appendix is relatively rare. We experienced two cases of diverticulum of the vermiform appendix. The first patient was an 85-year-old man who was admitted to our hospital with the complaint of right lower quadrant pain. Appendectomy was performed under the diagnosis of acute appendicitis. A perforated diverticulum was found at the base of the appendix. The diverticulum was acquired type. The second patient was a 60-year-old man who visited our hospital for a health care examination. A barium enema revealed numerous diverticula in the whole colon and 14 diverticula in the appendix. A diverticulum of the vermiform appendix has a frequent risk of perforation. Therefore, appendectomy is recommended to the patient with a symptomatic or asymptomatic diverticulum of the vermiform appendix to prevent panperitonitis.

View full abstract

Internal herniation is relatively rare. Internal herniation through the broad ligament is extremely rare, and only 13 cases have been reported in Japan. We report here a case with strangulating obstruction of the small intestine, and the cases reported in the literature. The patient was a 68-year-old woman, admitted because of periodic abdominal pain and vomiting. She was followed conservatively. Three days later, the patient again complained of severe abdominal pain, and physical examination disclosed defense in the whole abdomen. She developed shock, and emergency laparotomy was performed. Surigical exploration showed moderate ascites, pale red and serose. There was a mass the size of an infant's head covering the left broad ligament, 5 cm in diameter, with approximately 2 m of small intestine herniated through this hiatus from the posterior direction. Part of the herniated bowel, 70 cm, was strangulated due to torsion of the small intestine. We diagnosed this case as internal herniation through an abnormal defect in the broad ligament, pouch type. Resection of the herniated bowel by left adnexectomy was performed. The patient recovered and was discharged on the 27th postoperative day.

View full abstract

A 27-year-old woman was admitted to our hospital with anal bleeding and abdominal pain. Cutaneous pigmentation was found her lips and the fingers of both hands. The patient's daughter, aged 2, also had pigmentation on her lips. Small intestinal X-ray examination revealed various sized polyps in the jejunum and ileum. Barium enema demonstrated many small polyps in the left side of the colon, and one large one each in the distal descending colon and sigmoid colon. Gastroduodenoscopy showed numerous minute polyps in the stomach and several various sized polyps in the duodenum. Left hemicolectomy and partial resction were performed, and polyps of the duodenum and jejunum were removed by enterotomy. Fifteen polyps in the small intestine and 15 in the large intestine were removed. All polyps were histologically hamartoma. One each of the polyps of the jujunum and the sigmoid colon included focal cancer and adenoma along with hamartoma. This finding implies a malignant change of Peutz-Jeghers' polyps.

View full abstract

We have experienced a case of colonic Crohn's disease, presenting massive bleeding preoperatively. The patient was a 15-year-old male who was admitted to our hospital with chief complaints of fever, watery diarrhea and bloody stool. Barium-enema demonstrated the absence of haustra, and a cobblestonelike appearance at the transverse colon. Biopsy specimens showed multiple crypt abscesses, but no granuloma. In spite of intensive care with intravenous hyperalimentation and administration of salazosulfapyridine and predonisolone, his general condition became worse, and there was further shock due to massive bleeding from the colonic lesion. Subsequently, he underwent resection of the transverse colon with an end-to-end anastomosis. The lesion, located in the transverse colon, had a cobblestone appearance and was covered with a large amount of coagula, but had a clear margin. Microscopically, epitheloid granulomas were observed together with multinuclear giant cells in addition to crypt abscesses, leading to the final diagnosis of colonic Crohn's disease.

View full abstract

We studied a case of giant neurinoma of the intrapelvic retroperitoneum. The patient was a 60-year-old man who complained of dyschezia. Computed tomography and magnetic resonance imaging revealed a global mass occupying almost the entire pelvic cavity extraperitoneally. The tumor was diagnosed as a neurogenic pelvic tumor, and an operation was performed on January 17, 1994. The tumor originated in the S2 nerve, so the proximal and distal S2 nerve were divided, and the tumor was excised. The excised specimen was 610 g in weight and 13.0 by 11.0 by 6.5 cm in size. Histopathological diagnosis was benign schwannoma of two different types, Antoni A and B, and was specifically identified as neurinoma at the intrepelvic retroperitoneum.

View full abstract