In 69 patients with thoracic esophageal cancer, we studied postoperative hemodynamics and/or respiratory changes by using the Swan-Ganz catheter from before the operation to the fifth postoperative day. Cardiac function and pulmonary circulation were depressed in patients more than 69 years old. Seventy-nine percent of the patients younger than 60 years old showed a normal hemodynamic pattern on the operative day. On the other hand, the hypovolemic type and the cardiac failure type were more numerous among patients 60 years old or older; only 38% were normal. According to the total infusion volume from the operation to the second postoperative day, the more infusion group (80 to 120ml/kg/day) showed a hyperdynamic state and respiratory index significantly lower than those of the less infusion group (less than 80ml/kg/day) in patients younger than 60 years old. In contrast, the more infusion group showed depressed cardiac function and a respiratory index higher than those of the less infusion group in patients 60 years old or more. We emphasize that the postoperative management of circulation and respiration after esophagectomy should be different according to whether the patients is younger than 60 or not.

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For the purpose of finding an appropriate treatment for mucosal carcinoma of the esophagus, we reviewed the macroscopic and microscopic findings of 17 cases (25 lesions) of mucosal cancer, 6 6cases of sml cancer and 8 cases of sm2 or sm3 cancer, of less than 2 cm in diameter. Mucosal cases had no lymph node metastasis, while 50% of sml cases had lymph node metastasis. In 7 cases of mm3, vascular invasion was found in two cases with a diameter of more than 2 cm. Macroscopically, all lesions of mucosal carcinoma consisted of the 0-II type. Although 0-IIa lesions showed invasion of more than mm2, the elevated area of mucosal lesions was smaller than 1.3 cm in size and lower than 1 mm in height. On the other hand, 5 of 6 sml cases had protruding lesions, the mean size of which was 2.7 cm. Moreover, of 8 cases that showed invasion of the sm2 or sm3 layer and diameter of less than 2 cm, 5 cases involved 0-I type lesions and 2 had 0-III type lesions, and these cases were easy to differentiate from mucosal lesions. Only one case of 0-II type seemed indistinguishable from mucosal lesions. This study demonstrated that endoscopic mucosal resection could be indicated in cases with flat and/or slightly depressed lesions and in cases (if they have protruding lesions) of less than 2 cm in diameter and less than 1 mm in height. Cases with other gross features were thought to require esophagectomy with lymph node dissection.

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The expression of tissue-type and urokinase-type plasminogen activators was examined in 102 cases of gastric carcinoma, using an immunohistochemical method with specific monoclonal antibodies. Urokinase-type plasminogen activator (u-PA) was detected in 58 cases (56.9%), whereas the expression of tissue-type plasminogen activator (t-PA) was seen in cancer cells of only 22 cases (21.6%). The positive rate for u-PA was significantly higher in patients with liver metastasis than in those without liver metastasis. On the other hand, t-PA positivity decreased as tumor invasion became deeper and the positive rate for t-PA also became lower as the histologic stage increased. In relation to prognosis, patients with u-PA positive or t-PA positive or t-PA negative tumors tended to have a worse prognosis than those with u-PA negative or t-PA positive tumors. Our findings suggest that the expression of plasminogen activators is associated with tumor progression and that u-PA may be a predictive indicators of malignant potential in gastric carcinoma.

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The purpose of this study was to investigate the effect of intravenous prostaglandin E₁ (PGE₁) administration on hepatic hemodynamics during cirrhotic liver resection. Twenty patients with hepatocellular carcinoma were divided into two groups consisting of 10 patients (group A) as controls, and 10 patients (group B) with PGE₁ infusion (0.03 μg/kg/min). Before and after hepatectomy, hepatic hemodynamics were examined with color Doppler ultrasonography. Arterial blood gases, mean arterial blood pressure (MAP), heart rate (HR), and arterial blood ketone body ratio (AKBR) were also determined. After hepatectomy, the portal flow rate fell to 56% from the preoperative value in group A, whereas in group B, PGE₁ produced increases of portal venous velocity and hepatic arterial diameter, which resulted in an increase of the portal flow rate to 162% and the arterial flow rate to 139%. MAP and HR were well maintained in group B. There were no differences between the two groups in pO₂, pCO₂, pH or base excess. Changes in AKBR values were 1.6±0.5 to 0.8±0.2 in group A, and 1.4±0.6 to 1.0±0.4 in group B. The decrease in AKBR was significantly suppressed in group B (p<0.01). These results suggest that PGE₁ has a preventive effect on postoperative hepatic damage through maintaining the hepatic energy charge levels achieved by increasing hepatic blood flow in hepatectomized patients with cirrhosis.

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To see the effect of choledochotomy and papillary bougienage on bile duct pressure, the pressure and the volume of drained bile during 7 postoperative days were compared between the bougienage group (n=9) and a group with cholecystectomy and biliary drainage via the cystic duct (n=9). Among 14 background factors, the caliber of the common bile duct was significantly different and subserved as a variable in the regression analysis of the biliary pressure and bile output. These two variable in each group underwent a second degree polynomial regression. The bougienage group showed higher daily slopes of the pressure with marginal significance and demonstrated the following regression equation: Pressure=-0.047 (Date-7.5) ²+ 10.4 (cmBile). The slope of bile output was significantly increased in the bougienage group. Thus the postoperative pressure of the bile duct increased more in the bougienage group and culminated on the seventh day. The results suggested reconsideration on the biliary drainage after choledochotomy and papillary bougienage.

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Tumor-forming pancreatitis (TFP) was compared with chronic pancreatitis with respect to histological findings and the expression of tumor markers. In serological examinations, serum levels of type I carbohydrate antigens were prone to be high in chronic pancreatitis and TFP. The histological findings of TFP were almost the same as those of chronic pancreatitis. It is suggested that tumor-formation in TFP is due to a relatively wellmaintained lobular structure and intense interlobular fibrinization. In immunohistochemical studies, sialyl SSEA-1 (SLX) was not detected in normal pancreatitis. Carbohydrate antigen 19-9 (CA 19-9) was expressed principally in the apical membrane of the intralobular pancreatic duct and SPan-1 antigen was found in the centroacinar cells and the apical membrane of the pancreatic duct. Chronic pancreatitis showed no expression of SLX and the increase of CA 19-9 and SPan-1 antigen expression. The expression of tumor markers in TFP was the same as that in chronic pancreatitis. It was suggested that TFP is belong to chronic pancreatitis but not an individual disease, and the reason for the high serum levels of tumor markers in chronic pancreatitis is the congestion of pancreatic juice with deviation to blood vessel.

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We studied immunohistochemically the expression of aldolase C in 12 endocrine tumors (5 functioning and 7 nonfunctioning tumors) and 15 ductal adenocarcinomas of the pancreas as well as normal pancreatic and duodenal tissues, using monospesific antibodies against human aldolase C. The degree of staining was categorized into four grades, 0 to 3. In normal pancreatic tissues, islet cells and nerve fibers were positive for aldolase C. All endocrine tumors demonstrated diffuse immunostaining of aldolase C, with an average grade of 2.8±0.4 (M±SE). The expression of aldolase C in ductal carcinomas was significantly lower than that in endocrine tumors, and the average grade was 0.7±1.0. Aldolase C would be useful in differentiating endocrine tumors from pancreatic exocrine cancers, and it is considered to be an excellent biomarker for islet cells and tumors derived from these cells.

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Of 206 patients with acute appendicitis who visited our hospital during the last 3 years and 9 months, 65 patients did not undergo immediate surgery: 50 were successfully treated conservatively (group A), and 15 underwent surgery after conservative treatment (group B). We compared group A with group B as to clinical course and examined the criteria how to foreknow the result of conservative therapy. On ultrasonographic examination, the cases whose ultrasonographic diagnosis was positive were 18.8% in group A, 86.7% in group B. On clinical course in group A, WBC had decreased to 60% on day 1, 50% on day 2 incomparison with the WBC at admmition. C-reactive protein was less than 3 plus (3.2-5.9mg/dl) at admission and on day 1, and had decreased after day 2 or day 3. Body temperature was less than 37.0°C on day 1 and had decreased after day 2. There was not this tendency in group B. These results were usefull in how to foreknow the result of conservative therapy in acute appendicitis.

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The authors investigated the factors associated with postoperative acquisition of MRSA in gastroenterological surgery. Surgical patients from whom MRSA was isolated had a longer hospital stay before the operation than the patients acquiring infections with other organisms. Although the underlying disease did not affect the acqusition of MRSA, a postoperative complication like suture insufficiency or blood sugar uncontrollability, or massive operative trauma caused MRSA infection. Regarding the number of invasive devices, there was a significant difference between the patients acquiring MRSA (3.1) and the patients acquiring other bacteria (2.2). Among the patients who acquired MRSA, a mean of 2.4 kinds of antibiotics were administered before isolation of the organism compared with 1.5 antibiotics among the patients with other bacteria. The duration of antimicrobial therapy before isolation was also significantly longer in the patients acquiring MRSA (9.7 days) than in the patients acquiring other bacteria (6.2 days).

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A 60-year-old man with a three-month history of vague symptoms of dysphagia was admitted to Urawa Municipal Hospital on April 8, 1992. Upper gastrointestinal barium examination revealed a bulky mass (13×7×6 cm) occupying the upper half of the stomach. Endoscopy revealed a large pedunculated tumor arising from the abdominal esophagus and suspended into the stomach. Lugol staining method disclosed multiple superficial lesions on the middle and lower third of the esophagus. Biopsied specimens revealed spindle-shaped sarcomatous cells in the bulky mass and multifocal squamous cell carcinoma in the esophagus. Thoracic esophagectomy with lymph node dissection and gastric tube reconstruction was performed. Based on immunohistochemical and electron microscopic findings, the tumor was diagnosed as spindle cell carcinoma (pseudosarcoma). The involvement of squamous cell carcinoma in pericardiac and celiac lymph nodes was observed. After postoperative adjuvant chemotherapy using cisplatin (125mg/body), the patient was discharged on 39th postoperative day. Fourteen months have passed without recurrence since the operation.

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A S4-year-old man with liver cirrhosis underwent endoscopic injection sclerotherapy (EIS) in October 1988. Thirty four months later, endoscopic examination showed an irregular red lesion in the thoracic esophagus (Ei). Biopsy revealed squamous cell carcinoma (depth: ep or mm). He had undergone laser coagulation, but he was pointed out recurrence in the same region of the esophagus (Ei) one year later. We performed esophagectomy without thoracotomy, and reconstructed using the gastric tube. As he had portal hypertension and the numerous gastric varices, we performed added operation, which was shunt procedure (short gastric vein-external jugular vein astomosis) to prevent congestion of the gastric tube and rupture of gastric varices in the future.

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Two cases of extremely rare villous-appearing early gastric cancer adjacent to advanced gastric cancer are reported. Case 1 was a man, aged 65 years, chiefly complaining of anorexia. Gastric cancer, Borrmann type 2, 5.0×5.0cm in size, was noted at the lesser curvature from the lower body to the antrum of the stomach, and there was a villous lesion, 2.0×2.0cm in size, in close proximity. Case 2 was a man, aged 78 years, chiefly complaining of hematemesis. Gastric cancer, Borrmann type 4, 5.0×5.0cm in size, was noted at posterior wall of the lower body of the stomach, and there was a villous lesion, 4.0×3.0cm in size, in close proximity. In both cases, the advanced gastric cancers were poorly differentiated adenocarcinoma of ssγ, and the villous lesions, macroscopically and histologically analogous to villous adenoma of the large intestine, were well differentiated adenocarcinoma of m. Case 1 was diagnosed as multiple cancer because histological continuity between the two lesions was not confirmed. Case 2 was diagnosed as collision cancer because the border between the two adjacent lesions was clear on histological investigation.

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We report a case of a quadruple cancer (double early gastric cancers, early colonic cancer, small liver cancer) with a review of the literature. A 72-year-old man was admitted to our hospital under the diagnosis of liver cirrhosis, esophageal varices and early gastric cancer. On the secreening examination, a polyp in the sigmoid colon and a hepatic tumor in S₆ were detected. Polypectomy was performed and histological examination showed carcinoma in adenoma. Total gastrectomy (D₂), splenectomy and hepatic subsegmentectomy were performed. The histological examination showed two early gastric cancers (IIa, IIa + IIc; well-differentiated adenocarcinoma). The liver tumor was a well-differentiated hepatocellular carcinoma. There have been only 11 reports of patients with a quadruple cancer undergoing curative management for all cancers. Our case is the only one in which four cancers belonged to a category of early cancer. As the number of patients with multiple primary cancers is increasing, careful examination should be performed with consideration of the possibility of multiple cancers.

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Abdominal echography by a family physician of a 59-year-old male patient revealed a 3.5cm×2.5cm×2.0cm abnormal tumor in the medial segment of the liver. He was referred to our hospital and admitted on July 13, 1992. Our pre-operative survey included abdominal echography, magnetic resonance imaging, computed tomography, abdominal angiography, and cytology of the liver tumor, but it could not provide an accurate diagnosis. To eliminate the possibility of a malignancy a medial segmentectomy of the liver was performed on August 27. The final histopathological diagnosis of the tumor was of a ciliated hepatic foregut cyst.

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We report a case of ciliated hepatic foregut cyst showing echogenic mass in the lesion under ultrasonography. The patient was 57-year-old man who was admitted to our department because of IIc type early gastric carcinoma in the lesser curvature of the antrum. Abdominal US revealed a hypoechoic cystic lesion measuring 1.9×1.4cm in the left medial lobe of the liver (S4). An echogenic mass, simulating a solid tumor, was detected within the cystic lesion. Computerized tomography showed a well-demarcated low density area with homogenous inner struture. Based on these findings, cyst adenoma/adenocarcinoma was suspected. Therefore, resection of the cystic lesion was performed. The cyst was unilocular and contained viscous tan liquid, but no solid mass was observed in the cyst. Histopathological examination of the resected specimen provided a diagnosis of ciliated foregut cyst of the liver. In Japan, we found only 8 cases of ciliated hepatic foregut cyst including our case, and 4 of 5 cases in which US findings were mentioned showed high echogenicity or echogenic mass. It is important to role out these benign cysts from hepatic solid tumors.

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Combined hepatocellular and cholangiocellular carcinoma is rare. We reported such a case here. The two cancers occurred independently in separate segments of the liver. The patient was a 56-year-old man with the chief complaint of general malaise. Two liver masses, one in the right posteroinferior segment and one in the right anterosuperior segment, were detected by using ultrasonography, computed tomography and angiography, and a right lobectomy was performed. The mass in the posteroinferior segment was diagnosed histologically as hepatocellular carcinoma, and the mass in the anterosuperior segment was diagnosed as cholangiocellular carcinoma. Reports of the resection of combined hepatocellular and cholangiocellular carcinoma are rare. The clinical course of the disease in a patient study is of interest with respect to the diagnosis and histogenesis of primary liver cancers.

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A 74-year-old man who underwent sigmoidectomy and was followed by combined hepatic arterial and portal infusion chemotherapy for Stage V sigmoid colon cancer accompained with multiple liver metastases. For the infusion chemotherapy, we inserted a catheter in the gastroduodenal artery and another catheter in the inferior mesenteric vein, and the reservoirs connecting with catheters were placed in the abdominal subcutaneous space for postoperative use. Before closing the abdominal wall, 4 mg of mitomycin-C (MMC) was infused through both the reservoirs. Fifty milligram of cisplatin (CDDP) and 250 mg of 5-fluorouracil (5-FU) were infused through these reservoirs at 2, 5 and 9 weeks after the operation. After these treatments, metastatic liver tumors were not detected by computed tomography (CT) in the second postoperative month. The blood levels of carcinomebryonic antigen (CEA) and carbohydrate antigen (CA19.9) decreased markedly from 240 ng/ml and 450 U/ml to 16.5 ng/ml and 141 U/ml, respectively, and continued to decrease up to the 4th postoperative month. These findings suggest that combined hepatic artery and portal infusion chemotherapy may become an effective and useful modality in the treatment of multiple liver metastases of colon cancer.

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A 70-year-old man with a past history of diabetes mellitus and hypertension was admitted to our hospital with a 2 day history of right hypochondralgia, nausea, vomiting and fever. Examination revealed tenderness and muscle guarding in the right upper quadrant of the abdomen. Plain abdominal X-ray showed an area of gas in the region of the gallbladder. Abdominal CT revealed gas in the wall of the gallbladder, and also in the pericholedocal and posterior pancreatic tissues. A diagnosis of acute emphysematous cholecystitis was made. The patient was treated with intravenous fluids and antibiotics. He improved after these treatments. Cholecystectomy was performed on the 11th hospital day. Pathologic examination of the surgical specimen revealed acute gangrenous cholecystitis. The postoperative course was uneventful. He was discharged on the 13th postoperative day. There has been no report of emphysematous cholecystitis with gas extension to the pericholedocal and other surrounding tissues in the Japanese literature.

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A surgically treated case of large neurilemmomas arising in the retroperitoneum and the mediastinum was reported. A 46-year-old man with no particular familial background had received operations for multiple neurilemmomas of the acoustic nerve and the spinal cord. Large mediastinal and retroperitoneal tumors were found at the time of previous neurosurgery. Because of the gigantic size of the tumors and a suspicion of malignancy, he was admitted for surgery in our department. Combined the 6th right intercostal thoracotomy and wide transverse laparotomy were employed for surgical resection. The resultant good surgical field guaranteed non-troubled resection of the large tumors. The total weight of these tumors was 1800 g and their histological diagnosis was neurilemmoma. Multiple neurilemmoma is rare and should be distinguished from von Recklinghausen's disease. Nevertheless, our case was diagnosed as multiple neurilemmoma because of the lack of cafe-au-lait-spots, skin tumors, and visceral organ involvement.

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A 69-year-old man was admitted with upper abdominal pain and vomiting. Contrast X-ray examination of the small intestine using an intestinal tube, and CT scan suggested the presence of intussusception on the upper jejunum. Emergency laparotomy was performed. On exploration of the peritoneal cavity, three hard masses were noted in the jejunum about 40 cm distal from the ligament of Treitz. The mesenteric lymph nodes were swollen. Multiple metastatic lesions were also noted on both lobes of the liver. One of thejejunal tumors was the cause of intussusception. The involved jejunum was resected along with the jejunal masses. Histopathologically, the tumor cells were of the undifferentiated type, growing mainly at the submucosal region of the jejunum. These findings characterized the metastatic nature of the tumors. Postoperative radiological examination of the chest revealed the pulmonary mass, 2 cm in diamter, in the right S6, with mediastinal lymph node involvement. Cytologic examination of sputum showed malignant cells. In view of these data, the lung cancer was considered to be primary, with the jejunal tumors with hepatic and mesenteric involvement being secondary.

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An extremely rare case of multiple ileal mucosal diaphragms in a 63-year-old man is reported. Previously hehad undergone surgery for rectal cancer in our hospital in March 1989. Prior to that, there was no past history ofintestinal obstruction. He was readmitted due to postoperative ileus in September 1989, and underwentrelaparotomy. During adhesiolysis, multiple mucosal diaphragms were incidentally found in the proximal ileum.Each diaphragm had one orifice whose diameter ranged from pin-hole like to 10 mm. The majority of thediaphragms were removed by resection of 50 cm of the ileum with end-to-end anastomosis. Using tubes ofjejunostomy and cecostomy, smooth passage through the lumen of the residual small intestine was confirmedbefore anastomosis. Histologically the mucosal diaphragm contained hypertrophied muscularis mucosae. Con-genital jejuno-ileal stenosis in anadult is extremely rare, and as far as we investigated, only six cases have beenreported in the world.

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On May 12 in 1990, a 66-year-old farmer was admitted because of sudden onset of severe left lower abdominalpain while he was mowing grass. At the emergency operation after the diagnosis of acute abdomen, the ileum wasfound to be twisted 180° with clockwise rotation. Because there were no abnormal organic findings nor congenitalanomaly, the diagnosis of primary small bowel volvulus was made. As the blood flow recovered quickly after thedetorsion, intestinal resection was not performed. After an asymptomatic period, in the afternoon of January 1 in1993, he complained of sudden onset of abdominal pain at his home. After conservative management he wasreferred to our clinic because symptom did not improve. On admission, he was alert and afebrile. The bloodpressure was 160/90, and the heart rate was 66. Tachypnea or dyspnea was not seen. Physical examinationrevealed abdominal distension, intestinal contour, tenderness in the left lower quadrant and no bowel sound, but nomuscle guarding. A plain roentgenogram showed fluid level and dilated loops of small intestine. An emergencyoperation was performed upon the diagnosis of recurrence of volvulus of the small intestine. Abdominal explorationrevealed a gangrenous small bowel twisted by 360° counter-clockwise rotation around the mesenterium with noadhesion. The distal parts of the ileum adhered to each other, which suggested the site of the previous volvulus.Detorsion and intestinal resection of about 140 cm were performed. The postoperative course was uneventful, andhe was discharged on the 43rd POD.

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A case of primary appendiceal intussusception, complete type, is reported. A 22-year-old man was admitted toour hospital because of recurrent right lower abdominal pain. He also complained of occasional diarrhea containingold blood. Barium enema and endoscopic examination of his colon showed polypoid mass of the cecum. The grossappearance and histology of the biopsy specimen from the mass were resembled to hyperplastic polyp of the colon.After laparotomy, the mass was diagnosed as completely intussuscepted appendix vermiformis, and was treated byileocecal resection. Retrospectively, preoperative ultrasound images of the mass showed the typical appearance ofappendiceal intussusception. Although primary appendiceal intussusception is a rare condition, we consider that iscan be diagnosed by careful abdominal ultrasound imaging.

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Recently we experienced a case of desmoid tumor which had grown in the mesentery of the transverse colon.The patient was 38 years old, and with the chief complaint of an intra abdominal mass. The solid tumor wasrecognized beside of the transverse colon by computed tomography and echo gram, and laparotomy was performed.The tumor was in the mesentery of the transverse colon, and invaded the ileo-colic artery, the right colic artery, andhe right branch of the middle colic artery. Right hemicolectomy was performed, and the tumor was completelyeliminated with those arteries. The tumor was histologically diagnosed intra-abdominal desmoid tumor. Intra-abdominal desmoid tumor was known to be rare. We examined the clinical details of 31 cases which had beenreported in Japan since 1970. There reported only 5 cases with intra-abdominal desmoid tumor which had nocomplication of Adenomatosis Coli nor laparotomy in ananmnesis. In this case tumor was considered to be derivedfrom the mesentery of the transverse colon, whereas in other 4 cases, they were from the mesentery of smallintestine. It appeared to be the first case in Japanese medical literature.

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A 70-year-old woman was admitted to our hospital with complaints of bloody stool, diarrhea, and weight loss.Digital examination of the rectum, barium enema, endoscopy, and computed tomography revealed a huge rectaltumor with invasion to the uterus and vagina, and a pancreatic tumor and multiple liver tumors. Rectal amputationwith resection of neighboring organs, distal pancreatectomy with splenectomy, needle biopsy of one of the livertumors, and cannulation into the proper hepatic artery for postoperative chemotherapy were performed. Resectedtumors of the rectum, pancreas, and liver showed similar findings immunohistochemically and electronmicroscopically, and were diagnosed as rectal carcinoid tumor with metastasis to the liver and pancreas.

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