We analyzed the correlation between clinicopathological factors and int-2 and hst-1 gene amplification and RB-LOH in 17 patients with esophageal carcinoma who underwent surgery from 1989 to 1991. The rates of int-2 and hst-1 gene amplification were 59% and 53%, respectively. Int-2 and hst-1 amplification were not correlated with histological type or clinical stage, but were significantly correlated with sex, distant metastasis, venous invasion and lymphatic invasion. Patients with amplification of these genes especially with more than 4-fold amplification had poorer prognosis due to distant metastasis than those without amplification. The incidence of RB-LOH was 56%. RB-LOH was correlated with lymphnode metastasis, venous invasion and clinical stage, although RB-LOH showed no tendency in the analysis of survival. These results revealed that int-2 and hst-1 gene amplification is a useful biological indicator that is not related to histological malignancy.

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We have recently established three esophageal squamous cell carcinoma (SCC) cell lines, YES-1, YES-2, and YES-3, which can grow in a protein-free medium. A-431 cells have been maintained in the same medium. The growth of YES-3 and A-431 cells seemed to be independent of various factors in serum. The amount of EGF receptors on these cells was measured by binding as say of membrane preparation using ¹²⁵I-EGF. Of three SCC cell lines, YES-3 cells showed almost the same level of EGF receptors as A-431 cells, which contain a large amount of EGF receptors. But there was no relationship between the amount of EGF receptors and cell growth in the protein-free medium. Exogenous EGF inhibited the growth of A-431, YES-3 and YES-2 cells, but did not have any effect on YES-1 cells in that medium. Conditioned medium (CM) was obtained from the supernatants of culture at the subconfluent stage. EGF and TGFa were not detected in CM, and the growth of these cells was notaffected by CM. These observations suggest that the malignant potential of SCC with overexpression of EGFR did not result from tumor growth and EGF does not seem to act as an autocrine growth factor by means of extracellular secretion in these cells.

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The treatment of 19 patients of more than 80 years old with esophageal carcinoma, who had admitted to our two hospitals from 1980 to 1990, was analyzed. 1) Eighteen of the 19 patients had some impairment in circulatory, respiratory, liver, or renal function tests, with abnormalities of the former two being found in about half of the patients. 2) The prognosis of five patients who received radiotherapy alone was poor; two patients survived for 6 month, however, no patient survived over 1 year. 3) Twelve patients underwent surgical resection of the esophagus through right or left thoracotomy followed by single stage reconstruction of the alimentary tract. The hospital death rate of these patients was 41.7%, with a 1-year survival rate of 33.3%. 4) The most common cause of hospital death in surgical patients was postoperative pulmonary insufficiency, with the half being a part of multiple organ failure which seemed to be caused by inadequate circulation of the stomach or jejunum used for the reconstruction. 5) The prognosis was extremely poor if the patient had functional impairement in two or more organs, or underwent noncurative resection including the case of recurrence after radiotherapy. Therefore, surgery should not be attemped under these conditions.

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Rational lymph node dissection was studied in terms of the clinicopathological characteristics of 182 cases of upper third gastric cancer with esophageal invasion. Results were as follows: 1) The metastatic rate of mediastinal lymph node (MNL), which was correlated to the depth of invasion, was 9% in subserosal cancer and 39% in serosal invaded cancer. 2) The patients who did not need MLN dissection could not be determined from the length of esophageal invasion alone, whereas the metastasis of MLN was already found at a 1.0cm length of esophageal invasion. 3) Para-aortic lymph node (PLN), especially No.(16) a2 latero and No.(16) bl latero, was indicated to be the same grade as MLN from the similarity in metastatic rates. In conclusion, active dissection of not only MLN but also PLN with a choice of the appropriate mediastinal approach to relieve the operative load would be rational for the improvement of prognosis in advanced cases with esophageal invasion in whom curative resection can be expected.

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The patients in our study consisted of 2 groups: Group A with 6 patients who had presented with benign disease and subsequently underwent partial gastrectomy (gastroduodenostomy in 3 and gastrojejunostomy in 3); and Group B with 8 patients who had presented with gastric cancer. Five of the 8 subsequently underwent gastroduodenostomy and 3 were subjected to gastrojejunostomy. The 14 patients presented later with remnant stomach gastric cancer. During the subsequent surgery we in vestigated the lymphatic flow in the remnant stomachs of 14 patients by endoscopically injecting activated carbon particles (CH40) into the lesser curvature and observing the carbon flow. In Group A, the main series of lymphatics was located along the left gastric artery, and the others ran along the splenic artery. In the patients in Group B who had undergone R₂ lymph node dissection, the main lymphatic stream coursed along the splenic artery and left subphrenic artery. In the patients who had undergone gastroduodenostomy, No 12 or No.13 lymph nodes were frequently stained. We therefore believe that new lymphatic pathways were formed. In the gastrodudenostomy cases who had undergone R₃ lymph node dissection, lymph flowed directly towards the stained para-aortic lymph nodes. In the gastrojejunostomy cases who had undergone R₃ lymph node dissection, the mesenteriolum lymph nodes were stained. In conclusion, we found that in patients who had undergone malignant disease surgery, collateral lymphatic flow in the remnant stomach was increased and new lymphatic pathways were found. In addition, the lymphatic flow in patients who had undergone R lymph node dissection was different from those who had undergone Rlymph node dissection.

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Fifteen patients with space occupying lesions detected by ultrasonography or computed tomography in the course of follow-up for liver cirrhosis underwent hepatic resection after computed tomography during angiography (angio-CT). Detectability and diagnostic value of angio-CT for intrahepatic tumor were evaluated in comparison with conventional imaging techniques including digital subtraction angiography (DSA), magnetic resonance imaging (MRI) and lipiodol CT (Lp-CT). Twenty-three lesions detected in 15 patients were as follows: 14 hepatocellular carcinoma (HCC), 3 adenomatous hyperplasia (AH), one early hepatocellular carcinoma (eHCC), one atypical adenomatous hyperplasia (AAH), one regenerative nodule, and 3 miscellaneous lesions. With regard to 8 patients with 2 lesions, there were 2 AHs in one patient and 4 patients with advanced HCC had small HCC, eHCC, AH and AAH, respectively. These findings are suggestive of the presence of multicentric carcinogenesis in cirrhosis. The detection rate for intrahepatic tumors was 86.9% with angio-CT, 56.5% with DSA, 71.4% with MRI and 50% with Lp-CT. The detection rate for eHCC, AH and AAH was 80% with angio-CT, and 20% with DSA, MRI and Lp-CT. Angio-CT visualized AH regarded as a precancerous lesion and eHCC more frequently than other imaging techniques. The above mentioned data suggested that there was such a frequent occurrence of multicentric carcinogenesis that recognition of precancerous lesion by angio-CT was important in surgical intervention for HCC with liver cirrhosis.

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We investigated the technical feasibility of anatomical hepatic resection (AHx) for hepatocellular carcinoma (HCC) with special reference to factors relating to tumor and vascular structure. According to the method of hepatectomy, patients were categorized into two groups: A, AHx, n=43; B, non-AHx (NAHx), n=35. With respect to tumor site, there was no significant difference between the two groups. However, among patients treated by limited hepatectomy of less than HrS, NAHx tended to be more frequently performed for s7 and s8 tumors. With respect to tumor location in each subsegment, centrally located tumors tended to be more frequent in group A than in group B, while marginally located tumors tended to be more frequent in group B than in group A. With HrS, these differences between the two groups became statistically significant (p<0.05). For intrahepatic metastases, extended resection was chosen in group A, whereas partial resection for each lesion was selected in group B due to impaired hepatic function. Patients with tumors located close to the deep vascular bifurcation were all treated by NAHx. In addition, patients with tumors having third-to fourth-order vascular pedicles from two or more adjacent subsegments and patients with non-standard bifurcation at the third order tended to be treated by NAHx. These results indicate that AHx can't always be applied for HCC due to factors relating to tumor and vascular structure. Therefore, the feasibility of AHx should be carefully determined with the aid of preoperative imaging techniques.

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To investigate the most effective route of administration of prostaglandin E₁ (PGE₁) against warm ischemic liver damage, a model of 90-min warm ischemic liver was established in dogs. The dogs were divided into three groups: a PGE₁-untreated group (group A, n=10), an intravenous PGE₁-administered group (group B, n=10) and an intraportal PGE₁-administered group (group C, n=10). PGE₁ was continuously infused before and after the ischemia at a rate of 0.02 μg/kg/min. In groups A and B, all the dogs died within 24 h. However in group C, six of the 10 dogs survived and were sacrificed on the 4th day. Arterial ketone body ratio and the ratio of branched chain amino acids to aromatic amino acids in the hepatic vein were examined to observe oxidation-reduction ability and amino acid metabolism in hepatocytes, respectivley. These ratios were maintained in group C, but not in groups A and B. According to the value of serum lipid peroxide, it was considered that the hepatocellular membrane was protected from reperfusion injury in group C. On the other hand, in group C, serum platelet activating factor was sustained as a lower level than that of other groups, and endotoxin detoxication was maintained after ischemia. It was suggested that intraportal administration of PGE1 provides a more protective effect than intravenous administration against warm ischemic liver injury.

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This study was performed in order to investigate what kind of anastomosis, between pancreas and gastrointestinal tract, is ideal from the view of wound healing. Pancreaticogastrostomy, pancreaticojejunuostomy, and invagination of the pancreas into the stomach in 36 mongrel dogs were performed and wound healing was studied by microangiography and histopathology on the 3rd, 5th, 7th and 14th postoperative days. Avascular areas and neovascular vessels in microangiographic findings, and necrosis, bleeding, acute inflammatory cell infiltration and collagen in histopathological findings were evaluated. There is little difference between pancreaticogastrostomy and pancreaticojejunostomy in microangiography and histopathology. The avascular area of invagination of the pancreas into the stomach was smaller than that of the others. The patency of the pancreatic duct on the 14th postoperative days was examined, and histopathological findings of the pancreatic remnant were studied. One case of pancreaticogastrostomy and one of invagination of the pancreas into the stomach had stenotic pancreatic ducts, and the pancreas showed severe fibrosis. These results suggest that invagination of the pancreas into the stomach has less wound of the anastomotic site compared with the other procedures, but patency of the pancreatic ducts may be a problem.

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From 1974 to 1992, 11 cases of adult intussusception were encountered in our department. We performed a clinicopathological study of the sites of involvement of intussusception, and classified them into three types: 1) enteric (4 patients), 2) ileocecal (4 patients), which was subclassified into (1) ileo-colic type (1 patient) and (2) ceco-colic type (3 patients), and 3) colonic (3 patients). Average age was 31.0 years in the enteric type, 46.6 years in the ileocecal type and 69.3 years in the colonic type. Duration of symptoms was 59.3 weeks, 33.6 weeks and 1.1 weeks, respectively, the three types, and the rate of accuracy of preoperative diagnosis was 25%, 50% and 100%. Etiologically, the underlying pathologic process was identified in 10 patients (91.0%): all intussusceptions of the enteric type (4 patients) were caused by benign disease, 2 of 4 of the ileocecal type were caused by malignant disease and all of the colonic type (3 patients) were caused by malignant disease. In conclusion, intussusception in adults was classified into 3 types. It is necessary to take into consideration the type of intussusception for surgical treatment.

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The clinicopathological features of 29 mucinous carcinoma cases of the large intestine were compared with those of 61 cases of differentiated type adenocarcinoma. The incidence of mucinous carcinoma was relatively higher in the right colon than in the left colon and rectum. Mucinous carcinomas were more likely to invade the surrounding tissue. The mean tumor size (p<0.01), Dukes' classification (p<0.05) and lymph node involvement (p<0.05) were significantly different between mucinous carcinomas and differentiated type adenocarcinomas. The mucinous carcinomas were classified into two groups, papillotubular (PT) type and mucocellular (MC) type, according to their histological characteristics. Twenty two cases of the MC type were more common in younger patients, and it was characterized by deep invasion, lymph node metastasis and lymphatic vessel invasion. One-half of the PT type carcinomas were associated with adenomas, especially villous type adenomas. These results suggest that wide lymph node dissection and aggressive local resection for mucinous carcinomas, particularly of the MC type, are necessary, and that special attention should be paid to the histological subtype.

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Of the 1, 219 patients with colorectal cancer who underwent laparotomy at our facility during a 22-year period from May 1971 to December 1992, 76 (62%) had sm colorectal cancers that were surgically removed. Fifty-four patients were studied clinicopathologically for recurrence risk factors. Of the 54 patients, 11 (20.4%) had metastasis to lymph nodes, and all of them had a depth of invasion of sm₁c or more. Three (5.6%) developed postoperative recurrence: one at the sigmoid colon and two at the rectum (Ra: 1, Rb: 1). On macroscopic examination, there was one case, each of type 1, Ip, IIa and IIc with depth of invasion sm₂ or greater and metastasis to lymph nodes of ly₃ or more. Seventy-five percent of poorly differentiated adenocarcinomas had metastasis to lymph nodes, and 50% recurred. The results of this study suggest that the followings are risk factors for recurrence: 1) depth of invasion of sm₂ or greater, 2) a histological finding of poorly differentiated adenocarcinoma, 3) vessel invasion (especially ly₃ or more), and 4) metastasis to lymph nodes.

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One hundred thirty-seven patients underwent resection for colorectal cancer at our hospital during the recent 10 years. After dividing the patients into 3 groups according to their age, i.e., Group A (younger than 69 yrs), Group B (70-79 yrs), and Group C (older than 80 yrs), we compared the clinicopathological features and results of surgical treatment among the 3 groups. The distributions in tumor location, histological type and stage according to Dukes' classification did not differ among the groups. Preoperatively, patients of Groups B and C showed higher incidences of anemia and hypoproteinemia than those of Group A. R1 lymph node dissection was conducted in a large number of patients of Group C, reflecting the lower incidence of R2 dissection in patients of the group. Postoperative death within 3 months after operation showed a high incidence of 10.8% in patients of Group C, although the incidence was not significantly different from those in Groups A and B. The 3-year survival rate was significantly higher after curative resection than after non-curative resection in all 3 groups. However, the survival rates after curative and non-curative resection did not differ according to age group.

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Of 511 cases of resected colorectal cancer, extracolonic invasions were proved macroscopically in 68 cases (13.3%), though microscpic invasion were found in only 39 cases (7.6%). These 39 cases included 22 female cases and 27 cases with lymphatic spread. Extracolonic invasion frequently involved small intestine, urinary bladder and female genital organs, reflecting the anatomical relationship between the primary cancer and invaded organs. Combined resection of the invaded organs was performed in 26 cases (66.7%) and was curative in 23 cases (59.0%). In five-year survival rate, a statistically significant difference was found between curative cases (5yr. s.r.=57.1%) VS noncurative cases (5 yr. s.r.=0%). Compared with the cases of serosal invasion (170 cases), the cases with extracolonic invasions have following features; they frequently found in female and right colon; in curative cases, five-year survival rate of n (+) cases was significantly lower than that of n (-) cases (34.1% VS 75.0%). In conclusion, combined resection is expected to bring better prognosis and should be performed as possible to attain curative operation, especially in cases without lymphatic spread. After surgery, patients with lymphatic spread should be carefully observed because of the high frequency of recurrence, even if a curative operation was performed.

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A new irrigating proctoscope was invented to minimize implantation metastases by reducing exfoliated cororectal cancer cells in the distal rectum during anterior resection for rectal cancer. The proctoscope was used in 12 cases of rectal cancer following the clamping of the distal rectum prior to rectal dissection. Irrigation was performed with 2000 ml of saline after insertion of the proctoscope through the anus. Exfoliated cancer cells in the irrigation fluid were examined cytologically after every 500 ml of irrigation. Exfoliated cancer cells were demonstrated in the first sample of irrigation fluid in all cases, but few cancer cells were demonstrated at the end. The Irrigation time was 5 minutes and 29 seconds. More than 1000 ml of saline was considered to be needed to eliminate the exfoliated cancer cells for rectal cancer below the peritoneal reflection, and more than 2000 ml of saline for cancer above the peritoneal reflection. The new irrigating proctoscope was considered to be helpful in completing rapid, and effective irrigation without operating theater pollution.

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A 21-year-old man first presented in August, 1992 with dysphagia and hematemesis. The patient was hospitalized on January 8, 1993 due to severe dyspnea. endoscopy revealed a protruded lesion which was friable and bled easily. The biopsy specimen revealed necrotic tissue and fungus. Computed tomography of the chest showed a low density mass in the upper mediastinum. Because malignant smooth muscle tumor was strongly suspected from the open biopsy, transthoratic resection of the esophagus was performed on January 26, 1993. The postoperative diagnosis was A0, N (-), M₀, Pl₀. The surgical specimen revealed a submucosal pedunculated tumor measuring 13.0×7.5×3.2cm, histologjcally diagnosed as leiomyosarcoma.Widespread recurrences were noted in the right neck, right upper pleural cavity and mediastinum three months after the operation, and chemotherapy and radiation therapy were performed. Despite partial response he died six months after the operation due to respiratory distress. We report the youngest case of leiomyosarcoma of the esophagus, and reviewed 76 cases in the Japanese literature.

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Hemangiopericytoma was first reported by Stout et al. in 1942, as a neoplasm which originated from pericytes. A case of hemangiopericytoma originating from the stomach an extremely rare neoplasm, is reported. Only 16 cases, including this case, have been reported in Japan. A 74-year-old man was admitted to our hospital with a complaint of abdominal mass. A UGI series revealed a lesion like a submucosal tumor at the greater curvature of the stomach. Abdominal US and CT scan showed the tumor with a cyst in the left upper abdominal area. Angiography demonstrated that the tumor was supplied by the right gastric artery. Laparotomy was performed. The tumor was covered by the major omentum and continued from the gastric wall. There was no adhesion around the tumor and no invasion to other organs, the regional lymph nodes were not affected. The tumor was histologically diagnosed as hemangiopericytoma. Recurrence and metastasis have not been noted for 14 months.

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A 15-year-old boy who had been treated medically for multiple gastroduodenal ulcers and pyloric stenosis for 2 years was hospitalized because of vomiting and pain in the right lateral abdominal region. His parents and grandfather had also suffered from duodenal ulcers. He was diagnosed with acute appendicitis, and appendectomy was performed. Thereafter, he developed a high fever and pyloric obstruction. A second laparotomy was performed, and retroperitoneal abscess due to posterior perforation of the duodenal ulcer was found. Because of remarkable fibrotic change of the bulbus, distal gastrectomy without resection of the perforated duodenal ulcer, gastrojejunostomy (Billroth II), and abscess drainage were performed. Blood coagulation factor XIII-concentrate (Fibrogammin ^®) was administered in expectation of closing of the perforation. This case is rare, as only 17 similar cases (2 Japanese and 15 non-Japanese cases), including our case, have been reported in the literature during the past 30 years. In 7 cases (41.7%), a past history of peptic ulcer was recognized preoperatively, 3 cases (17.6%) were correctly diagnosed preoperatively, and approximately half the cases died from this event. Unlike other retroperitoneal abscesses, those from perforation of a duodenal ulcer have an influx of digestive fluid into the retroperitoneum, so that misdiagnosis or delayed therapy of this even can be fatal.

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A 73-year-old woman was admitted to our hospital with the chief complaint of epigastralgia. Ultrasonography, computed tomography and endoscopic retrograde cholangiopancreatography revealed hepatolithiasis in the left lobe, choledocholithiasis and cholelithiasis. At surgery, a solid tumor arising in the left lobe of the liver and invading the left diaphragma and posterior wall of the stomach was detected in addition to the stones. Resection of the left lateral segment, fundic gastrectomy with partial resection of the left diaphragma, cholecystectomy and choledochotomy with T-tube drainage were performed under the diagnosis of cholangiocarcinoma. The tumor was pathologically diagnosed as malignant fibrous histiocytoma originating from the liver on the basis of the findings of the storiform pleomorphic pattern, atypical giant cells and cells positive for a1-antitrypsin. She died 5.5 months after the operation because of recurrence in the residual liver. Malignant fibrous histiocytoma in the soft tissue is a common disease, but it rarely originates from the gastrointestinal tract and, very rarely arises in the liver. Our case is the 18th case in the literature.

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Omental cysts are relatively rare. We reported an incidentally detected giant cystic lymphangioma of the omentum. A 16-year-old boy visited our hospital because of common cold, and abdominal swelling and fluctuation were pointed out. Abdominal ultrasonograms and computed tomograms revealed a multiple cystic tumor. The resected tumor was 32×23×15cm in size and 7, 100 gin weight, the largest in the Japanese literature. The surface of the tumor was covered with omental tissues. The histological diagnosis was cystic lymphangioma.

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We present a very rare case of the emphysematous cholecystitis associated with pneumobilia. The patient was a 74-year-old man with chief complaints of right hypochondralgia, fever and jaundice. His past history revealed diabetes mallitus and hypertension. The laboratory examination on admission revealed mild leukopenia, increased CRP, jaundice and liver injury. Abdominal plain film and CT scan showed gas in the wall of the gallbladder and the intrahepatic bile duct. Percutaneous transhepatic gallbladder drainage (PTGBD) was immediately performed. Culture of the bile was positive for K. pneumoniae and Bacteriodies. A cholecystectomy was performed 8 days after admission. Sandlike stones and muddy material were present in the gallbladder. The histopathological findings of the gallbladder showed necrosis. The postoperative course was good. The patient was discharged 16 days after the operation.

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We report a case of signet-ring cell carcinoma of the gallbladder in a 67-year-old woman who was admitted with epigastric pain. Under the preoperative diagnosis of cholecystolithiasis with cholecystitis, which was based on findings of CT scan and ultrasonography, laparotomy was performed, revealing an expanding gallbladder with adhesion of the surrounding tissues. Cholecystectomy was performed. The resected gallbladder showed wall thickness at the neck, and had 42 calcium bilirubinate stones. The histological examination showed signet-ring cell carcinoma invading to the serosa in the neck of the gallbladder. The patient did not agree to undergo a second look operation for curative resection, and left the hospital. She died of the disease one year and 11 months after the operation. Signet-ring cell carcinoma of the gallbladder is very rare, and few cases have been reported. Because of the poor prognosis of signet-ring cell carcinoma of the gallbladder, we must be careful to consider inflammatory change of the gallbladder at surgery.

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The form of carcinoma overwhelming dominant among the cases of gallbladder carcinoma is adenocarcinoma. And adenosquamous carcinoma, in which case adenocarcinoma and squamaous cell carcinoma coexist in the same focus of carcinoma, is relatively rare. Durin the last 13 years of experience at our institution, we conducted dissection of gallbladder carcinoma on 33 patients (1.2%). Since we found 4 cases of adenosquamous carcinoma in total out of the 33 cases: 3 surgical operations and 1 dissection, we examined them in the light of histopathology. As a morphological feature of this disease, the image of transformational area was seen along the boundary dividing the two of the squamous cell carcinoma and the adenocarcinoma, which showed relatively clear distinction between the two. Regarding the growth of squamous cell carcinoma in glandular tissue, we think of the phenomenon that the squamous epithelial moiety is seen for the first time when tissue grows tumorigenic, considering the result that there was no squamous cell metaplasia seen beneath the gallbladder epithelium. In other words, squamous cell carcinoma is formed on the basis of adenocarcinoma. And we think it possible that some undifferentiated basal cells exist to act as intermediary in the process.

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We report the case of a 69-year-old man with normal-type early carcinoma of the papilla of Vater. Upper GI and duodenofiberscopy showed redness and swelling of the papilla of Vater, and we suspected carcinoma. Repeated endoscopic biopsies of the papilla of Vater showed group IV, well differentiated adenocarcinoma. Radical pancreaticoduodenectomy was performed. The papilla of Vater was 7×7 mm in diameter, normal type. Histological findings showed early carcinoma of the papilla of Vater, special type, well differentiate dadenocarcinoma, m, panc₀, d₀, ly₀, v₀, ow (-), aw (-), but adenoma was not observed. It was suggested that this case was early carcinoma of the papilla of Vater originating from de novo cancer.

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A 45-year-old man was admitted to our hospital because of melena and severe anemia. Endoscopic findings showed gastric varices. Magnetic resonance imaging (MRI) clearly documented a pancreatic tail tumor. At laparotomy, a tumor, 3.0cm in diameter, was located in the pancreatic tail, infiltrating and completely obstructing the splenic vein at the splenic hilus. Distal pancreatectomy associated with splenectomy and lymph node dissection was carried out. The tumor was histologically adenosquamous cell carcinoma of the pancreas. The different carcinoma cells of adenocarcinoma and squamous cell carcinoma showed different modes of infiltration. The adenocarcinoma invaded the perineural space and the squamous cell carcinoma extended the splenic vein and made the tumor thrombus.

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A 57-year-old woman hospitalized for recurrent loss of consciousness. A giant splenorenal shunt was suspected from color doppler ultrasonography. Percutaneous transhepatic portography and selective injection of contrast medium into the shunt clearly visualized the whole aspect of the splenorenal shunt. When she lost consciousness, her blood ammonia level was 326μg/dl. The results of serum amino acid analysis revealed a high level of aromatic amino acids and a low Fisher's ratio. Indocyanine green (ICG) clearance from blood was very low. Perfect embolization of the giant splenorenal shunt was performed by ultrasound-guided interventional radiology, after which the blood levels of ammonia and aromatic amino acids normalized. Fisher's ratio and ICG clearance were improved ten months after this procedure, the patient is well and has not experienced any loss of consciousness. For the portosystemic encephalopathy accompanying severe liver damage, shunt embolization by interventional radiology was effective and less invasive than surgical operation.

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We report two patients with idiopathic thrombocytopenic purpura (ITP) who underwent laparoscopic splenectomy. The platelet count rose following the administration of an immunosuppressant agent or a high dose of gammaglobulin, and autologous blood was donated preoperatively. In the right oblique lateral position under general anesthesia, a total of 5 trochars were inserted. First the peritoneal reflexion on the left side of the spleen was incised. Next the splenocolic ligament was separated close to the spleen. The spleen was resected by serial dissection of the gastrosplenic ligament and pancreatosplenic ligament close to the spleen with Endo-clip, Endoscissors, and Endo-GIA. The spleen was packed in an Endo-pouch, crushed, and removed from the abdomen. The splenic bed was inspected for adequate hemostasis. The estimated blood loss was from 190ml to 200ml and mean operation time was 3 hours and 20 minutes. The postoperative course was uneventful in both cases. The advantages of this technique are rapid recovery, minimal incisional discomfort, brief hospitalization, and superior cosmetic results, especially in younger females. In cases of ITP, steroid therapy is considered first and splenectomy or immunosuppressant agents are favored in patients who do not respond to steroid therapy. However, steroid therapy has many side effects, such as peptic ulcers, infection, diabetes mellitus, and osteoporosis. Laparoscopic splenectomy may be the preferred treatment for ITP in the near future.

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We report a case of small bowel penetration due to lymphangioma of the jejunal mesenterium. The patient, a 1-month-old girl, was admitted with a complaint of vomiting and a palpable abdominal mass. Ultrasonography and computed tomography of the lower abdomen indicated an intraperitoneal cystic mass. The patient was diagnosed as having a mesenteric cyst, and surgery was performed. We found the tumor in the jejunal mesenterium and penetration of jejunum in the same region. The tumor was a multilocular cystic mass. Histopathological diagnosis revealed a cavernous lymphangioma. We considered the penetration of the jejunum probably to be due to the existence of subserosal lymphagioma. Lymphangioma of the small bowel is a relatively rare disease, and only 7 cases of lymphangioma of both the small bowel and its mesenterium have been reported in the Japanese literature. We discuss the clinical features of mesenteric lymphangioma.

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Primary carcinoma of the vermiform appendix is uncommon, and cases of double cancer of the vermiform appendix and other organs are rare. In this paper two cases of vermiform appendix, including one case of double cancer of vermiform appendix and caecum, are reported together with some discussion of the literature. Case 1 was a 70-year-old woman with the chief complaint of right lower abdominal pain. A small mass with a smooth and elastic hard surface was palpated in this region. Perityphilitic abscess caused by acute appendicitis was suspected. Appendectomy and partial resection of the greater omentum were performed. Histopathological examinations indicated a diagnosis of mucinous cystadenocarcinoma with invasion to the greater omentum, so right hemicolectomy was then performed. Case 2 was a 79-year-old woman who was admitted to the hospital to determine the cause of occult blood in stool. Barium enema studies and colon fiber studies indicated caecal cancer and caecal submucosal tumor. Right hemicolectomy was performed. The mass preoperatively diagnosed as caecal submucosal tumor was proved to be appendicular tumor. The histopathological diagnoses were moderately differentiated adenocarcinoma for the caecal tumor and well differentiated mucinous cystadenocarcinoma for the appendicular tumor.

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Laparoscopic surgery has been introduced for the treatment of perforated duodenal ulcer and early gastric cancer in our department. Five patients with perforated duodenal ulcers have been successfully treated by the laparoscopic omental patch method. Peritoneal irrigation with 5-10 L of warmed saline was carried out, and an omental patch was applied by laparoscopic continuous suture. The postoperative courses were uneventful and the ulcers has been well controlled by an H₂ blocker. For early gastric cancer, two different types of laparoscopic surgery have been performed. If the lesion is located at the anterior wal or the greater curvature of the stomach, laparoscoic wedge resection of the stomach by the lesion lifting method is applied. If the lesion is located at the posterior wall, the lesser curvature of the stomach, or near the cardia or pylorus, laparoscopic intragastric mucosal resection by Ohashi's method is applied. Ten patients with early gastric cancer which were preoperatively diagnosed as mucosal cancer have been successfully treated by these laparoscopic surgical methods. Postoperative courses were all uneventful, and histological examination revealed that the cancerous infiltration was within the mucosal layer, and that there was a sufficient surgical margin.

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In the surgical treatment of a diseased gallbladder, laparoscopic cholecystectomy has gained a world-wide popularity since 1989, with the advantages of less pain, good cosmesis, short hospital stay and early ecovery. Since 1990, 564 laparoscopic cholecystectomies have been carried out in our institution. The rate of convertion to open surgery is about 3.5% and the postoperative complications occurred in 3 of the patients; a bleeding from the mesenteric vessel, CBD injury and a bleeding from the cirrhotic liver bed. The more complicated procedures have been done in some of the selected institutions. In case of CBD exploration, we used a C-tube to be inserted into the cystic duct following primary closure of the CBD, instead of a T-tube.

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To evaluate complications of laparoscopic cholecystectomy, the complications reported to eight Japanese medical societies by 53 hospitals including ours were analyzed. Bile duct, vascular, bowel and diaphragm injuries occurred in 1.09, 0.18, 0.10 and 0.12% of 6, 800 laparoscopic cholecystectomies, respectively. The common bile duct was the site of bile duct injury in 69% of the cases. Most of the bile duct injuries (77%) were due to disorientation of the anatomy or an electric burn, while most of the vascular injuries (91%) were due to puncture by the first trocar, and all of the diaphragm injuries were due to an electric burn. To prevent these complications, it seems important to start dissection of the cyscic duct after skeletonizing the neck of the gallbladder and to avoid use of electrocautery near the bile duct and diaphragm. Furthermore, it is recommended to perform intraoperative cholangiography and to adopt open laparoscopy.

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