Management of superficial esophageal cancer was assessed by investigating clinico-pathological factors and the prognosis of 88 patients (ep 14, mm 12, sm 61). The five-year survival rate of the 14 patients with ep cancer was 100% in the absence of lymph node metastasis, vascular invasion and cancer recurrence. The five-year survival rate of the 13 patients with mm cancer was good at 83.3%. However, three patients with mm₃ cancer experienced lymph node metastasis and two of them suffered from postoperative cancer recurrence. The five-year survival rate (64.5%) of the 61 patients with sm cancer tended to be related to the degree of invasion to the submucosal layer and vascular invasion, although there was no difference in the prognosis of patients with sm cancer with regard to lymph node metastasis. Patients treated by T-shaped irradiation combined with chemotherapy or by aggressive chemotherapy tended to have better survival rates than those who received no adjuvant therapy or only T-shaped irradiation. Eight of the patients with sm cancer experienced postoperative cancer recurrence, and in five of the patients with sm_2-3 cancer located at Im, recurrence was recognized in cervical lymph nodes. Therefore, blunt dissection is efficactious in the patients with ep and mm_1-2 cancer, but mm₃ and sm cancers should be treated with lymph node dissection and sufficient postoperative adjuvant therapies. Particularly in cases of sm_2-3 cancers located at Iu or Im, cervical lymph node dissection is suggested.

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To study the longterm effect of total gastrectomy, nutritional parameters were studied in 16 patients 5.9±2.2 years after total gastrectomy for gastric carcinoma. A group of patients who underwent partial gastrectomy 6.1± 2.1 years ago served as a control group. Nutritional intake was assessed by taking dietary histories. The nutritional parameters included anthropometric parameters, serum trace elements (Fe, Zn, Cu, Mn, Cr) and serum vitamin concentrations (vitamin A, B₁, B₂, B₁₂, 25-0H-D₃, E, nicotinic acid, biotin, panthothenic acid, folic acid) Results: Energy intake in the totally gastrectomized patients was significantly greater than that of the control, being 38.6± 4.7 kcal/kg (170±44% of calculated basic metabolic rate). The anthropometric parameters of total gastrectomy group however, were low than those of the control group, suggesting that the patients were potentially in marasmus type malnutrition. The concentrations of all the fat soluble vitamins were decreased, B₁₂ and folic acid were also decreased, while biotin increased. Serum zinc decreased, and Mn and Cr showed higher concentrations. These results indicate that the diets taken by the patients after total gastrectomy are near the recommended daily allowanoes, but still, the patients are potentially deficient in all the fat soluble vitamins and some of the water soluble vitamins, and thus warrant daily supplements of vitamins and digestive enzyme preparations, on this patient population.

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Prognosis of early gastric cancer which has malignant disease arising from other organ, especially colorectal cancer, was evaluated. We analysed 747 patients of early gastric cancer surgically treated in the National Kyushu Cancer Center Hospital during the period between 1972 to 1989. Of these cases, multiple cancer was observed in 71 (9.5%), and found in organs next to the colorectum, lung, breast and liver. Early gastric cancer with colorectal cancer was found in 30 cases (42%) (Males numbered 25, and females 5; Synchronous or metachronous cancers numbered 10 and 12). Among these colorectal cancer, the sigmoid colon and rectal cancer were involved in 76.7%. The mean period between early gastric cancer and second colorectal cancer was 4 years and 11 months; that between colorectal cancer and second early gastric cancer was 6 years and 3 months. More than 30% of the death of these multiple cancer was due to colorectal cancer. Overall prognosis of the patients with these multiple cancer was depended on that of colorectal cancer. These data suggested that, in patients with early gastric cancer, it is important to examine the colorectum in 6 to 10 years after gastrectomy.

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To reveal the pathophysiology after extended partial hepatectomy, we investigated serum endotoxin levels (Et), arterial ketone body ratio (AKBR) and DNA synthesis in the regenerating liver after 70% and 90% partial hepatectomy in rats. Survival rate was 55.5% at 72 hours after 90% partial hepatectomy (n=60), while all rats survived after 70% partial hepatectomy (n=34) (p<0.05). After 90% partial hepatectomy, serum GOT and total bilirubin concentrations were elevated remarkably (p<0.01) and AKBR was depressed significantly (p<0.05) through all postoperative times in comparison with 70% partial hepatectomy. Et after 90% partial hepatectomy showed transient increase at 24 hours postoperatively, while no significant change was observed after 70% partial hepatectomy (p<0.01). Hepatic DNA synthesis after 90% partial hepatectomy was significantly depressed at 24 hours postoperatively (p<0.01) but peaked 24 hours later than after 70% partial hepatectomy. Furthermore, its prolonged acceleration lasted at 72 hours postoperatively. It is concluded that both severe injury and depressed proliferation of hepatocyte were observed in the early stage after 90% partial hepatectomy in rats, and transient elevation of Et and hepatic energy crisis are suggested to relate to this depressed and delayed hepatic regeneration.

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To clarify the etiology of cholelithiasis following gastrectomy for gastric cancer, we examined bile flow by ^99mTC-N-pyridoxyl-5-methyltryptophan hepatobiliary scintigraph. Four parameters were obtained: peak time of the right lobe of the liver, peak time of the left lobe of the liver, peak time of the common bile duct, and time of RI appearance in the duodenum. These parameters were determined in 22 patients who had undergone gastrectomy with R2 lymph-node dissection and cholecystectomy as treatment for gastric cancer (gastrectomy group), and 28 control patients who had undergone cholecystectomy for cholecystolithiasis or cholesterol polyps of the gallbladder. Every parameter was higher in the gastrectomy group than in the cholecystectomy group. In the gastrectom group, the diameter of the common bile duct was correlated with the parameters obtained by hepatobiliary scintigraphy. These findings suggest that gastrectomy with lymph-node dissection causes delay of bile flow, contributing to the etiology of cholelithiasis following gastrectomy for gastric cancer. Moreover, the result that the diameter of the common bile duct was correlated with the delay of bile flow suggests that denervation due to lymph-node dissection might cause dysfunction of the sphincter of Oddi and the delay of bile flow.

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Lithogenic bile production and bile infection have been among the main theories of gallstone formation after curative gastrectomy for cancer. We collected gallbladder (GB) bile at the time of cholecystectomy from 7 patients gastrectomized for cancer who had developed GB stone. The bile was analyzed for its composition and was cultured for bacteriology. GB bile collected from 15 gastric cancer patients during gastrectomy was used as the control. The GB stones from the 7 patients were classified as 5 bilirubinate, 1 black and 1 mixed stones. Bile infection was seen 4 of the 5 patients with bilirubinate stone but in none of the control subjects. Chenodeoxycholic acid levels for the patients with GB stone (except those with percutaneous transhepatic gallbladder drainage) were significantly lower than those for the control subjects (p<0.039). Total bile acid, cholesterol, phospholipid, bilirubin and total calcium contents were also low for the patients with GB stone compared with those for the control subjects. Free bile acids were detected exclusively in 3 of the 5 patients with bilirubinate stone, which indicated the involvement bile infection in the formation of bilirubinate stone after curative gastrectomy for cancer. An explanation of the development of black stone after gastrectomy will require further investigation.

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Patients with obstructive jaundice often have complications such as postoperative hepatic insufficiency. In this regard, to ensure precise evaluation of preoperative liver function, we determined the level of bilirubin per day in drained bile (V.Bil) in 68 patients who underwent biliary drainage, and examined the usefulness of this parameter as an index of liver function. V.Bil was 279 ± 171mg/day on average, showing a close correlation with the serum bilirubin decreasing rate “b”, ICG disappearance rate and maximal removal rate (p<0.001). Eight patients underwent resection of two or more hepatic segments, and 2 of them died of postoperative hepatic insufficiency. In these 2 patients, V.Bil was distinctly different from those in patients surviving after surgery. Analysis of factors affecting V.Bil revealed that age, biliary infection and site of obstruction influenced V.Bil, regardless of the seurm bilirubin level prior to biliary drainage. Thus, V.Bil is useful for evaluation of liver function in patients with obstructive jaundice. Measurement of this parameter is advantageous in that it is simple and feasible at an early stage, that it allows the use of unilateral drainage, and that it is not affected by renal function.

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Seventy-six patients with pathological metastasis to the lymph nodes at the splenic hylus (No.(10)) were divided into three groups: with splenectomy (S+) 38 cases, with pancreato-splenectomy (PS+) 21 cases, without PS (PS-) 17 cases. The 5-year survival rate of the S (+) group was 10.7%, and those of the PS (+) and PS (-) groups were 17.9% and 17.6%, respectively. There were no significant differences between the three groups. Eighty-two patients with pathological metastasis to the lymph nodes along the splenic artery (No.(11)) were divided into two groups: PS (+) 19 cases, PS (-) 63 cases. The 5-year survival rate of the PS (+) group was 10.5%, and that of the PS (-) group 12, 8%. There was no significant difference between the two groups. Residual lymph nodes were microscopically detected in the previously dissected pancreas specimen in three of nine cases and the splenic specimen in one of nine cases studied. These lymph nodes were few in number, small in size and all of them were cancer negative. From these results, we concluded that dissection of No.(10) and/or No (11) without PS might be a clinically satisfactory procedure against advanced gastric carcinoma.

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Ninety-four patients with ductal adenocarcinoma of the pancreatic head underwent pancreatoduodenectomy from January 1981 to December 1992, and among them, 40 patients underwent combined resection of the portal vein. This retrospective study attempted to evaluate portal vein resection in pancreatic head cancer by clinicopathological study. Macroscopic portal invasion did not always correspond with microscopic cancerous invasion to the portal vein. No cancerous invasion of the adventitia of the portal vein was shown histologically in 7 of 40 patients(17.5%). There was no relationship between the degree of histological cancer invasion into the portal vein and staging determinants such as tumor size(t), lymph node metastasis(n), serosal invasion (s), retroperitoneal invasion(rp), peritoneal dissemination(P) and liver metastasis(H). There was no relationship between the degree of portal vein invasion and lymph vessel invasion(ly) or venous invasion(v). The degree of portal vein invasion was not correlated with postoperative survival curves. The longest surviving patient who underwent extended radical pancreatoduodenectomy with combined portal vein resection is still alive after 10 years. Thus, although pancreatic head cancer is often considered unresectable because of portal vein invasion during surgery, we must aggresively attempt to resect the portal vein without abandoning hope.

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We report a case of epiphrenic esophageal diverticulum associated with esophageal dysmotilit. The patient, a 71-year-old woman, had the chief complaint of dysphagia. A diverticulum was detected in the lower part of the esophagus by radiography. Endoscopy showed diverticulitis. Nonperistaltic contractions between the upper esophageal sphincter and the diverticulum were found by manometry. Esophageal pH monitoring for 24-h showed acid reflux. Transthoracic diverticulectomy with Belsey Mark IV repair was performed. The pathological findings were of inflammatory changes and no malignancy. We suggest that esophageal diverticula be evaluated by manometry and 24-h pH monitoring, and that surgical treatment be not only diverticulectomy but also any treatment found to be needed by these methods.

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A case of early cancer and exogastric giant leiomyosarcoma coexisting independently in the same stomach is reported. A 70-year-old woman was admitted to our hospital because of painless tumor at the left upper abdomen. Upper gastrointestinal X-ray study revealed a large exogastric submucosal tumor at the major curvature of the cardia and a IIc lesion at the lesser curvature of the antrum. Biopsy specimens from the IIc lesion showed adenocracinoma. Subtotal gastrectomy with lymphnode cleaning (D₂) was performed. The resected tumor at the cardia was histopathologically diagnosed as leiomyosarcoma of 19×14×7 cm growing outside of the stomach wall. The IIc lesion was diagnosed as well differentiated adenocarcinoma invading within themucosal layer, that is, early cancer. In the diagnosing of the diagnosing of the leiomyosarcoma, more causion should be nessary, because of early gastric cancer, especially ivading in the mucosal layer is sometimes coexisting in the same stomach independently.

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We report a case of early gastric cancer producing alpha-fetoprotein (AFP). A 59-year-old man was diagnosed by gastric X-ray and endoscopic ecamination as having IIc + IIa type early gastric cancer located in the anterior wall of the upper gastric body. The serum AFP level was elevated to 53.1ng/ml. Proximal gastrectomy with R₂ lymph node dissection was performed. The serum AFP level decreased to 8.4ng/ml after the operation. Histopathological study showed moderately differentiated adenocarcinoma limited to the submucosal layer, without lymph node metastasis. The localization of AFP was immunohistochemically demonstrated in thecytoplasm of gastric cancer cells. The patient is alive without recurrence, and the serum AFP level is not elevated 1 year and 4 months after the operation.

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Endocrine carcinoma of the stomach is a rare disease. A 57-year-old man was admitted to our hospital complaining of an epigastric discomfort. The upper gastrointestinal series and endoscopic examinations revealed a well-demarcated tumor with an undermining ulcer in the greater curvature of the gastric antrum (a Borrmann type 2 tumor). Subtotal gastrectomy was performed with the finidngs of 2T₃N₁ (+) P₀H₀M₀ in Stage IIIa. The tumor was diagnosed as an endocrine carcinoma and tumor cells were shown to have argyrophilic granules by the Grimelius stain. Furthermore, the tumor was immunohistochemically positive for chromogranin A. Postoperatively, chemotherapy using etoposide and cis-platinum was given. Endocrine carcinoma of the stomach belongs to a category different from so-called classical carcinoid, and shows a very aggressive clinical course. We suggest that patients with endocrine carcinoma of the stomach may benefit from anticancer chemotherapeutic regimens similar to those for patients with pulmonary small cell carcinoma.

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We report a patient with advanced gastric carcinoma associated with congenital factor χ deficiency, who underwent radical surgery with administration of Coagulation Factor Complex. A 71-year-old man, who had received a previous nasal operation during which massive bleeding was encountered, was referred to our hospital for closer examination of his bleeding tendency. The closer examination revealed a decreased level of factor χ (45%), which lead to a diagnosis of congenital factor χ deficiency. As the patient presented with epigastralgia, he received gastric fiberscopy, which detected a Type 2 gastric carcinoma of 6 cm in maximum diameter in the antrum. In order to determine an adequate dose of the combined Coagulation Factor Complex (PPSB-HT) for perioperative administration, we monitored the serum level of factor χ after injection of the coagulant. The operation was carried out with administration of PPSB-HT, performing total gastrectomy with combined resection of the spleen and the transverse colon, and D4 lymphadenectomy. During and after the operation, no abnormal hemorrhage was observed. Our experience may encourage radical resection of advanced malignancy in the GI tract despite association with coagulant factor deficiency as long as Coagulation Factor Complex is available and intensive hemostasis is performed.

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This study presents a case of carcinoma of Brunner's gland origin in a 71-year-old man. Roentgenography and endoscopy revealed a submucosal tumor with an ulcerated surface, in the second part of the duodenum. Biopsy disclosed a moderately differentiated adenocarcinoma, and pancreatoduodenectomy was performed. The lesion presented as a dome-shaped submucosal tumor 2.7×3.3 cm in size with a deep excavation on its surface. The tumor had no connection to Vater's papilla, the common bile duct, or the pancreatic duct. Following macroscopical, histological, and electron microscopical examinations, this case was diagnosed as carcinoma of Brunner's gland origin. Duodenal carcinoma originating from Brunner's gland was extremely rare, but recently some cases have been reported. We collected 21 similar cases reported in Japan to review the macroscopical and histological features.

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We reported a case of pancreatic head cancer showing a very rare pattern of recurrence. A 67-year-old patient was admitted to our hospital with the chief complaint of jaundice. As a past history, he had underwent partial gastrectomy and establishment of a catheter duodenostomy for duodenal ulcer at another hospital one month before this admission. He was diagnosed with pancreatic head cancer by PTC and CT, etc and underwent pancreaticoduodenectomy with R1 lymphadenectomy for stage 4 pancreatic head cancer. However, subcutaneous recurrence was detected on the upper abdominal wall coinciding with the scar of the catheter duodenostomy at three months after the operation. But he gradually deteriorated and died at one year after the first operation. In this case, cancer cells were suspected to be implanted via the catheter duodenostomy as well as the cases of chest wall metastasis implanted along the the fistula of pericutaneous transhepatic biliary drainage.

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We experienced two cases of surgical treatment of left adrenal metastasis from hepatocellular carcinoma (HCC) after hepatectomy. The first patient was a 65-year-old man who underwent hepatectomy for advanced HCC.Recurrent foci in the residual liver were controlled by transcatheter arterial chemoembolization(TAE) therapy. As left adrenal metastasis was found by computed tomography (CT) 20 months after hepatectomy, left adrenalectomy was performed. This patient died of gastrointestinal bleeding without recurrence 13 months after adrenalectomy.The second patient was a 64-year-old man who underwent hepatectomy for HCC and partial resection of the right lung for metastatic foci. Because left adrenal metastasis was detected by CT and ahigh level of serum alpha fetoprotein was found, left adrenalectomy was performed. This patient survived for 7 months after adrenalectomy with no sign of recurrent HCC, but he died of recurrence in the residual lung 15 months after adrenalectomy. From our cases and other reports, it is suggested that the surgical extirpation of metastatic adrenal tumor from HCC can be effective, when the primary lesion is well-controlled and no other metastatic foci were detected.

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A 24-year-old woman was placed on oral bile salt maintenance therapy due to cholecystolithiasis at another hospital because of right hypochondralgia and back pain in April 1992. However, the pain did not disappear, and she was admitted to our hospital on April 12, 1993. Many strong echoes with acoustic shadows and comet signs were observed on abdominal ultrasonography. Drip infusion cholangiogram (DIC) showed many small stones and the wall thickness of the gallbladder, but the cystic and common bile duct were not identified. Three dimensional reconstruction with spiral CT scanning after DIC indicated the cystic duct opening into an accessory hepatic duct.Laparoscopic cholecystectomy was done, and the confluence pattern was confirmed with intraoperative cholangiography.Spiral CT scanning was useful for preoperative examination, and intraoperative cholangiography was also helpful for avoiding damage to the bile duct.

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A 68-year-old woman underwent cholecystectomy for gallstone. An anomalous arrangement of the pancreaticobiliary ductal system was suspected postoperatively from T-tube cholangiography, and was confirmed by endoscopic retrograde cholangiopancreatography. The length of the common duct was approximately 15mm. The common bile duct was not dilated but had two small diverticula. The amylase level in bile was measured before and after eating. The level rose remarkably after eating, indicating reflux of the pancreatic juice into the bile duct. Endoscopic sphincteropapillotomy (EST) was performed. The amylase level then remained in the normal range even after eating. It is suggested that EST could be one of the therapeutic modalities for anomalous arrangement of the pancreaticobiliary ductal system.

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An 83-year-old man was referred to the hospital because of general fatigue. Laboratory studies revealed some hepatic dysfunctions and the total bilirubin was 2.2 mg per dl. Abdominal ultrasound demonstrated a gallbladder tumor which surrounded the neck and corpus of the gallbladder. Endoscopic retrograde cholangiogram revealed a dilated common bile duct containing a radiolucent filling defect. The papilla of Vater was swollen and the mucinous secretion could be seen originating from it. Percutaneous transhepatic cholecystgraphy showed irregular filling defect that surrounded the neck and corpus of the gallbladder. Cholecystectomy was performed under suspicion of a mucus-producing gallbladder tumor. There was thick adhesive mucus on the neck and corpus of the gallbladder. On the histologic sections of the surgical specimen, hyperplastic mucinous cells with focal adenomatous proliferation formed microcysts and papillae. Pathological diagnosis was mucinous cystadenoma. The localization of the tumor corresponded to that of the mucinous substance. The postoperative course was uneventful. We believe this lesion represents the first reported case of gallbladder mucinous cystadenoma that showed mucinous biliary obstruction.

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We performed the transportal ultrasonography (TPUS) using a micro-probe (2.4mm in outer diameter, radial scanning system, 15MHz), which was inserted intra-operatively into the jejunal vein and led to the portal vein.TPUS revealed an intraportal tumor in a patient with choledocal carcinoma which formed a huge tumor behind the hepatoduodenal ligament. TPUS images demonstrated the intraportal tumor continuing with a low echoic mass, showing portal invasion of the choledocal carcinoma, that could not be diagnosed preoperatively by angiography.The other patient with pancreatic carcinoma had portal invasion of the carcinoma. TPUS images demonstrated the high echoic wall thickness of the affected portal vein. We conclude that TPUS can provide new information on the invasion of pancreato-biliary tract malignancies.

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A male case of solid and cystic tumor of the pancreas was experienced. The patient was 67 years old. Tumor was detected incidentally on abdominal computed tomography (CT) for further examination of prostatic hypertrophy. Abdominal ultrasonogram and CT showed cystic tumor in the head of the pancreas. Endoscopic retrograde cholangiopancreatography showed complete stenosis of the main pancreatic duct. Pancreatoduodenectomy was performed. On the cut surface, the tumor was composed of solid and cystic lesions, with necrotic and hemorrhagic materials. Microscopically, the tumor cells had small and oval nuclei, and showed sheet-like proliferation. Immunocytochemical staining (PAP-method) for α1-antitrypsin was positive. From these findings the diagnosis of solid and cystic tumor of the pancreas was made. A total of 126 cases, including this case, in the Japanese literature were reviewed to compare clinical differences between males and females.

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We report two resected cases of small intestinal metastasis from lung cancer. The first case was a 58-year-old man who had squamous cell carcinoma of B¹_a of the right lung. Because of thoracic wall invasion and mediastinal lymph node metastasis, he underwent radiation and chemotherapy. Small intestinal metastatic tumor was detected by examination for anemia and bloody stool. Accompanied with lymph node swelling of the mesentery, a fist-sized tumor was found at the jejunum 220cm distal from Treiz's ligament. Partial resection of the jejunum was performed. In spite of radiation and chemotherapy, he died of the brain, adrenal and liver metastases 11 months after the operation. The second case was a 69-year-old man who had adenocarcinoma of B³ of the right lung with lymph node metastasis at the right neck and axillary region and right pleural effusion. From acute abdominal pain and hyperpyrexia occurred during the radiation and chemotherapy, he was diagnosed as diffuse peritonitis. He underwent partial resection of the jejunum including the metastatic lesion with perforated carcinomatous ulcer at 170 cm distal from Treiz's ligament. He died 49 days after operation in spite of chemotherapy.

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A case of adult malrotation (right paraduodenal hernia) associated with intestinal necrosis is reported. A 32-year-old woman with progressive epigastralgia and vomiting was diagnosed as having diffuse peritonitis. An emergency operation was performed. The operative finding was right paraduodenal hernia associated with massive intestinal necrosis. In Japan, only 16 patients who underwent surgery due to malrotation have been reported, but paraduodenal hernia has not been reported.

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A case of peritonitis chronica fibrosa incapsulata presenting as ileus after irradiation is reported. A 62-year-old women who had a past history of radical hysterectomy and irradiation after surgery due to uterine cancer visited our hospital complaining of abdominal distention and nausea. We diagnosed adhesional ileus due to radiation enteritis, and performed laparotomy. Operative findings revealed terminal ileum resembling a lump of 10.8×7.6×7.4cm, and covered with a white capsule 1mm thick. She was diagnosed with peritonitis chronica fibrosa incapsulata. The Japanese literature contains reports of only 23 cases of this disease since 1970. This is the first report of this disease caused by irradiation. Preoperative diagnosis of this disease is considered very difficult. In this case, abdominal CT could retrospectively demonstrate characteristic findings of incapsulated intestine.

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