We have been investigating the histology of gastric ulcer, intestinal metaplasia and regenerated gastric mucosa in terms of the pathological background of carcinogenesis. Consequently, these three proved to interact with one another. In the process of regeneration of gastric mucosa, preintestinalization which proved to be related to carcinogenesis occurs at the early stage and then stable intestinal metaplasia takes the place of it. The experimental carcinogenesis using NMMG for chronic gastric ulcer or intestinal metaplasia and the pathological observation of healing process of human gastric ulcer, about 70% of which turns into intestinal metaplasia, can explain this interaction. Thus the regeneration of gastric mucosa-intestinalization system plays an important role not only as an initiator but also as a promoter of carcinogenesis. Another study we have concentrated on is a prospective randomized study to determine the clearance level of surgical operation for gastric cancer dependent on the pathological differentiation and the depth of cancer invasion. From the results so far, modified surgery proved to be effective for early cancers, but careful determination dependent on each grade of differentiation was suggested to be necessary for advanced cancers.
Concerning the pathological development of colon cancer, there are two theories dependent on the preceding status. “Adenoma-carcinoma sequence” which supports the presence of adenoma before cancer developes and “de novo carcinogenesis theory” which does not support it. According to our stepsectioning study of resected colon specimens of 38 colon cancer patients, 12 minute early cancers were discovered from macroscopically normal lesions. Six of them were cancers developed on adenoma and another six belonged to de novo cancers. There was a remarkable difference between cancer on adenoma and de novo cancer, the former one developed polyp like protruded lesion and invaded slowly. The latter one, appeared flat at the earliest stage, however, invaded vertically very fast. This fact is consistent with the results of another investigation into sm invasion rate of 32 early colon cancers less than 1 cm in diameter/ Only 7.1% (1/14) of the cancer developed after adenoma invaded into sm layer, versus 55.6% (19.18) of de novo cancers showed sm invasion. For the treatment of colon cancer, one of the most important things is to know the relationship between macroscopical or pathological findings and the degree of vertical invasion of early cancer. Since de novo cancer is invading very fast even if it's diameter is small, the majority of advanced cancers are supposed to develop from this type of early cancers. Thus, it's significant to search for de novo cancer histologically and flattyped colon cancer macroscopically. Another thing we have to stress on is that advanced colon cancers cannot be prevented just by polypectomy.

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The significance of para-aortic lymph node dissection and quality of life was studied from the viewpoint of clinicopathological findings. Para-aortic lymph nodes were dissected in 333 cases and metastasis was seen in 67 cases (20.1). The metastatic rate increased with the depth of cancer. High metastatic rates were seen in macroscopic type 3 and type 4 and in the histologically undifferentiated type. As lymphatic invasion advanced, the metastatic rate increased. Concerning the location of the cancer and the site of metastasis in the para-aortic lymph node, the metastatic rate was high on the left side of the aorta in cases of C area cancer, while metastasis was observed on both sides of the aorta in cases of M and A area cancer, the 33 cases in the n3 (-) group among 61 cases with n4 (+) showed a significantly better outcome than the 28 cases in the n3 (+) group (p<0.05). According to our results, this lymph node dissection should be performed in cases exceeding subserosal invasion and N2 (+). Concerning the relationship between para-aortic lymph node dissection and QOL, blood loss in the No.16 lymph node dissection group was greater and the length of surgery was longer than in the non-dissected group. Serum protein in the No.16 dissected group was signficantly decreased on the 7th postoperative day compared with the non-dissected group, and body weight in the dissected group decreased further than in the non-dissected group. Further studies should be done to determine the significance of para-aortic lymph node dissection and the effect of this procedure on QOL.

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To define the route by which carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) reach the peripheral blood, we conducted simultaneous intraoperative blood sampling from a peripheral vein, a tumor draining vein, and the portal vein for detection of these tumor-associated antigens. In addition, clinicopathological and immunohistochemical evaluations were performed of the primary tumors and involved lymph nodes. The results were as follows: 1) Higher CEA levels were found in the tumor draining vein and portal vein than in the periphersal vein. Significantly higher levels were found in the patients with liver metastasis. 2) CEA levels were related to venous invasion, and CA19-9 levels to lymphatic invasion and lymph node involvement. 3) In the patients with a localized pattern of primary lesions (Stromal type), higher CEA levels were obtained in the tumor draining vein and portal vein than in the peripheral vein. 4) On immunohistochemical lymph node staining, CA19-9 showed a higher positive rate than CEA. Additionally, peripheral venous CA19-9 showed a higher positive rate than CEA. Additionally, peripheral venous CA19-9 levels were significantly higher in the patients with positive lymph node staining than in those withosut it. These results may indicate that CEA drains from tumors via the portal vein, while CA19-9 drains via the lymphatics and the thoracic duct.

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We evaluated the prognosis of 14 patients with invasive gastric cancer who were possibly exposed to cancer cells because of additional intraoperative resection for histopathologicalevidence of cancer cells at the surgical margin (Group A). The control group consisted of 197 invasive gastric cancer patients, with or without additional resection and without cancer cells at the surgical margin (Group C). In group A, 4 patients without serosal invasion (PS negative) remained disease free during follow up. The five year survival rate and the five year disease free rate of 10 patients with serosal invasion (PS positive) was 33.3% and 13.0%. These rate were not statistically different from those of patients in group C (30.6 and 23.2%). Considering the degree of node metastasis, there is no significance between 2 groups. Compereing the survival rate and disease free rate divided into stage (The General Rules forthe Gastric Cancer study), there is no statistical significance in each stage between 2 groups. There is a possibility of exposure to cancer cells as a result of additional resectin, but the prognosis ofexposed patients was almost the same as those without exposure. We concluded that intraoperarive additional resection was avairable technique in terms of curability.

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In order to resolve major complaints after total gastric resection, e.g., heartburn, reduction of food capacity and body weight loss, we performed jejunal pouch-Y reconstruction with GIA in 12 patients with gastric carcinoma. We compared this pouch group with a ρ-Roux-Y reconstruction group as to body weight change, red blood cell count and concentrations of TP, ALB, CHO and TG. We also asked the patients about their postoperative symptoms and effects on nutrition. The patients in the pouch group had greater eating capacity, less heart burn and faster recovery of body weight than those of the Roux-Y group. There were no significant differences in red blood cell count, TP, ALB, CHO and TG. These results suggested that jejunal pouch-Y reconstruction after total gastric resection can be recommended from the standpoint of quality of life.

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We studied the indocyanine green (ICG) clearance curve measured with the finger-piece method in 30 patients (10 with normal liver, 10 with liver cirrhosis, 5 with obstructive jaundice and 5 hepatectomized for metastatic liver cancer). The initial peak value (a) expressed functional hepatic mass volume, and there was a significant correlation between (a) and both serum albumin (Alb) and cholinesterase (ChE) concentration (Alb: r=0.341, p<0.05, ChE: r=0.715, p<0.005) respectively. The secondary peak value (b) indicated the presence of portocaval shunt, and there was a significant correlation between (b) and serumγ-globulin level (r=0.413, p<0.025). The d/c value calculated from exponential curves in the ICG excretion phase expressed the plasma disappearance rate of ICG, and there was a significant correlation between (d/c) and the 15 min retention rate measured with the blood sampling method (r=0.378, p<0.025). A characteristic pattern (a≥4, b≥0.05, d/c≥0.5) of the ICG clearance curve was more frequently identified in patients with liver cirrhosis than in patients with other liver diseases (p<0.001). In summary, analysis of the ICG clearance curve measured with the finger-piece method is useful in assessing the various liver diseases.

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To clarify the factors affecting to the abdominal physical examinations in patients with blunt pancreatic injury, we reviewed 59 patients whom we experienced during the past 12 years and 10 months. Abdominal pain was obvious in 56 (94.9%) of 59 patients, 20 (90.9%) of 22 and 36 (97.3%) of 37 in those with isolated pancreatic injury (Isolated group) and those with intraabdominal associated injuries (Complicated group), respectively. Pain was located within the epigastric area in 33 (58.9%) of 56 whose abdominal pain was obvious. This tendency was significantly higher in the Isolated group than the Complicated group. Peritoneal irritation was obvious in 33 (55.9%) of 59 patients, and this frequency in patients with type 1 injury (contusion) was signficantly lower than that in patients with type 2 injury (laceration) and type 3 injury (ductal injury). The frequency of the peritoneal irritation in type 1 patients in the Isolated group was significantly lower than that in type 3 patients in the Isolated group and type 1 patients in the Complicated group. In conclusion, the potential location of abdominal pain was within the epigastric area in patients with blunt pancreatic injury, but intraabdominal associated injuries altered the location of pain. Postive signs of peritoneal irritation were a high index of pancreatic ductal injuries or intraabdominal associated injuries.

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Fifty-seven patients with advanced colorectal carcinoma who had undergone curative resection during the previous 20 years were clinico-pathologically studied. Among them, 25 cases showed hematogenous recurrence after surgery (Group A), and 32 cases remained disease free for at least 10 years after surgery (Group B). The histological grade of malignancy was investigated with regrad to histological subtype as follows: (1) histological change (changes in the histological grade of differentiation as tumor invasion); (2) por component (tumor with single cells like those of poorly differentiated adenocarcinoma at the invading margin); (3) mucinous component (tumor with mucinous component). The incidence of histological change in group A (64.0%) was significantly higher than that in group B (25.0%). The incidence of por component in group A (84.0%) was also significantly higher than that in group B (40.0%), whereas the incidence of mucinous component in group A (28.0%) was almost the same that in group B (34.4%). Furthermore, the incidence of lymph node metastasis in the cases with por component (64.7%) was significantly higher than that in the cases without por compoment. In conclusion, colorectal carcinoma with por component at the invading margin of the tumor was considered a high risk factor for hematogenous recurrence.

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We classified 46 patients with local recurrence following resection of rectal cancer into three groups according to pelvic invasive pattern: lateral invasive type (29 cases; 63%), sacral invasive type (8 cases; 17%) and localized type (9 cases; 20%). Clinicopathological findings at the initial operation and period until recurrence were not significantly different between the types. The serum CEA value of all patients with the lateral and sacral invasive types was more than 2.5 ng/dl; however, 38% of patients with the localized type had that CEA level. Recurrent lesions in the loealized type were diagnosed by symptoms of organ invasion in 7 patients and found by periodic image diagnosis in 2 asymptomatic patients. Rates of radical resection per number of cases were 0% in the lateral invasive type, 50%in the sacral invasive type and 100% in the localized type; these rates were significantly different. Survival after recurrence of the localized type was significantly longer than that of the other types. Moreover, survival of 13 patients with radical resection for local reccurrent tumor was significantly longer than that of 13 patients with non-radical resection. These results suggested that the mode of local recurrence influenced prognosis. In particular, the resection for recurrence of the lateral invasive type did not contribute to survival.

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Two hundred eighty-five patients who underwent curative resection of rectal carcinoma from 1978 to 1990 were studied retrospectively to evaluate the prognostic value of neural invasion (ni). First, patients were divided into three groups: ni (-) (71.9%), S-ni (+) (ni was seen only in the proper muscle layer, 8.1%) and D-ni (+) (ni was seen beyond the proper muscle layer, 20.0%). Since the S-ni (+) group's survival curve showed no significant difference from that of the ni (-) group, these two groups were considered to be one group {D-ni (+) group} in terms of the prognostic comparison. In comparison between the D-ni (+) and D-ni (-) groups, the former showed a significantly worse survival curve (p<0.001). The D-ni (+) group showed a significantly worse survival curve than the D-ni (-) group not only in the Dukes' B patients (p<0.05) but also in Dukes' C (p<0.001). D-ni (+) was associated with significantly higher recurrence rates. Overall recurrence rates were 56.1% for the D-ni (+) group and 14.9% for the D-ni (-) group (p<0.001). Local recurrence rates were 35.1% vs 8.3%, respectively (p<0.001). Among the D-ni (+) group, patients with bilateral lateral lymph node dissection and pelvic neural plexus resection showed apparently lower local recurrence rates than those without such lateral dissection and resection (18.8% vs 65.0%, p<0.01). Multivariate analysis revealed D-ni was an independent prognostic factor (p <0.02). From this study, it was suggested that D-ni might have a significant value as a prognostic factor. It was also suggested that for patients with D-ni, meticulous lateral lymph node dissection with pelvic neural resection seems to be indispensable.

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Eight cases in which acute pulmonary embolism (PE) developed during the past ten years following gastroenterological surgery were clinically reviewed. These cases represented 0.07% of all surgically treated patients for the same period. The average age of these patients was 65.5 years (55-73), including one man and seven women. There were seven cases of malignacy and one case of cholelithiasis. Acute PE is strongly suspected if symptoms of dyspnea, chest pain, chest discomfort and acute circulatory insufficiency are observed towards the end of the recuperative period and if right ventricular dilatation is demonstrated by subsequent echocardiogram. Pulmonary arteriography is the most reliable method of diagnosing PE, as thrombi were recognized in all of the five cases examined. Five of eight patients survived following thrombolytic and anticoagulant therapy, but three patients died. Two of those three patients died within a few hours following the onset, but the other patient survived for 11 days by means of thrombolytic and anticoagulant therapy combined with a cardiopulmonary partial bypass procedure. Thromblytic and anticoagulant therapy are recommended as initial treatment for acute PE in addition to controlling circulation by employing a partial cardiopulmonary bypass procedure as circumstances demand.

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A case of common bile duct (CBD) stone and intrahepatic, pure cholesterol stones localized in the caudate lobe of the liver with coexisting early gastric cancer is reported. A 65-year-old man had undergone percutaneous transhepatic drainage for liver abscess and cholecystectomy. The early gastric cancer and CBD stone were diagnosed before the operation, but the intrahepatic stone was diagnosed during the operation. Subsequently, the patient underwent subtotal gastrectomy, choledochotomy with T-tube drainage, and resection of the Spiegel lobe of the liver. It is difficult to screen the caudate lobe and detect pure cholesterol stones in the liver by ultrasonography (US) and computed tomography (CT). In our case, examinations of the biliary tract using US, CT, and drip infusion cholangiography (DIC) detected stones in the CBD but not in the liver before the operation. Both intraoperative cholangiography and intraoperative US revealed the stones in the liver. Intraoperative US is especially useful for screening the caudate lobe, because it can scan from any direction of the liver and can be used anytime during the operation.

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We present three cases of benign intrahepatic bile duct stricture which mimicked malignant stricture due to cholangiocellular carcinoma. Case 1 was a 61-year-old man with intrahepatic bile duct stricture in the right lobe coinciding with arterial involvement. Case 2 was a 58-year-old man with irregular biliary stenosis and a tumorous lesion on its proximal side in the lateral segment of the liver. Case 3 was a 45-year-old woman with complete obstruction of the bile duct in the lateral segment. In this case, tumorous lesions were demonstrated on intraoperative ultrasonography and proveed to be multiple abscess formation in the liver. For all the three cases we performed hepatic resection, and the histological examination revealed benign stricture. Since their operations, all patients are leading normal lives without any complaints or recurrence. The differential diagnosis is sometimes very difficult in such cases and the existence of bile duct stricture could cause cholangitis or cholangiocellular carcinoma, therefore, resection of the liver including abnormal biliary trees should be considered for the patients with undeniable malignancy and/or repeated cholangitis.

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The case of 4-month-old female with choledocholithiasis associated with bile duct perforation and biloma is reported. She was a premature infant weighing 1432 g at birth. She underwent an ultrasonographic examination because of fever and abdominal distension. It revealed an anechoic cyst, 5×5×4cm in size, which was localized in the right upper quadrant of the abdomen. A ^99mTC-PMT biliary scan demonstrated a cyst in communication with the bile duct. At laparotomy, a cyst was located in the area bounded by the duodenum, the gallbladder and the surface of the common bile duct. The cyst was opened and a small bile duct perforation through which bile was leaking was found at the bottom of the cyst, just below the entrance of the cystic duct. Intraoperative cholangiography showed no dilation of the common bile duct (4 mm in diameter) and free bile drainage into the duodenum. After incision of the bile duct, 2 small pigment stones were flushed out by irrigation with saline. From to the above, we considered the cyst a biloma caused by bile duct perforation. Retrograde transhepatic biliary drainage was perforation, followed by primary closure of the common bile duct. She has remained asymt omatic for 20 months after the operation.

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A 67-year-old man was admitted to our hospital because of jaundice. Percutaneous cholangiography showed an irregular obstruction of the common hepatic duct. Stenosis upstream from the obstruction was shown beyond the bifurcation of the anterior and posterior branches on the right side and that of the dorsolateral and ventrolateral branches on the left side. The rate of retention of indocyanine green in 15 minutes was 38.8-60.4% in spite of percutaneous biliary drainage. Under a diagnosis of cancer of the hepatic hilus, medial segmentectomy with caudate lobectomy was performed. The arterial branch of the ventrolateral segment (S3) entered into Glisson's capsule of the left hepatic duct and was ligated and divided. By histologic examination, a moderately differentiated tubular adenocarcinoma was demonstrated. On the 6th postoperative day (POD), glutamic pyruvic transaminase was elevated again and on the 10th POD, fever was encountered. On the 15th POD, contrast-enhanced computed tomography revealed a non-enhanced low density area consistent with the area of S3. Therefore, a diagnosis of liver infarction was made. On the 18th POD, an emergency operation was performed because of shock. Then, hepatic necrosis consistent with the area of S3 was recognized. The area of liver infarction was consistent with that of the blood supply of the ligated artery. The relationship between the ligation of the hepatic artery and the infarction of the liver was discussed.

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We encountered a case of advanced carcinoma of the duodenal bulb. The patient was a 68-year-old woman with epigastralgia and appetite loss as the chief complaints. An upper gastrointestinal series and endoscopic examination showed an ulcerative lesion in the anterior wall of the duodenal bulb. The biopsy specimen revealed adenocarcinoma. Under a diagnosis of advanced cancer of the duodenal bulb, subtotal gastrectomy and partial duodenectomy were performed with dissection of the regional lymph nodes. Macroscopically, the tumor had a Borrmann 2-like appearance and was 2.8×2.5cm in size. Microscopic diagnosis was moderately differentiated tubular adenocarcinoma with invasion of the serosa. Only 26 previous cases of advanced carcinoma of the duodenal bulb have been reported in the Japanese literature, and our knowledge of its clinical features is still deficient. Forty cases of advanced duodenal carcinoma in the Japanese literature were collected and discussed.

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A 64-year-old woman, who had been admitted to a nearby hospital because of unknown fever of one week's duration and had no history of traumas, increasing LDH, thrombopenia and splenomegaly, was admitted to our hospital on an emergency basis because of left hypochondrium pain, anemia, increasing splenomegaly and suspicion of hemoperitoneum. Abdominal CT scan showed massive hemoperitoneum and rupture of the spleen. Emergency laparotomy was performed. The operative findings included extensive coagulation, dark red giant splenomegaly and splenic rupture from serosa to parenchyma. Splenectomy was performed. The resected spleen was 19.5×13.0×5.0cm in size, 760g in weights and was infiltrated by malignant lymphoma (diffuse large cell type). Postoperative chemotherapy was performed, but she died four months later.

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A patient with huge HCC who underwent repair of diaphragm with a right external oblique muscle because of combined resection is reported. The postoperative course was uneventful, including respiratory function. Combined resection of the diaphragm is sometimes necessary for the resection of HCC. Most defects are closed primarily. However, in patients with a large defect, reconstruction is necessary. In such cases two types of material are available: artificial materials like Teflon and biomaterials (external oblique muscle, latissumus dorsi muscle, etc). Compared with artificial materials, bio-materials have decreased risks of infection, abscess at the liver stump and so on. Among several bio-materials we prefer to use the external obilique muscle, because of the ease of making a muscle flap and repairing the diaphragm in the same operation field used for resection. Considering these advantages, repair of the diaphragm with the external oblique muscle is a useful method of surgery for huge HCC invading the diaphragm.

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We experienced a patient with a giant inflammatory mass extending from the ileum to the transverse colon 11 years after the diagnosis of Crohn's disease, in whom abdominal pain did not improve, and surgery was performed under the diagnosis of peritonitis. The patient was a 39-year-old man who first presented to a local doctor with diarrhea and abdominal pain. Ilectomy was performed for ileus, and Crohn's disease was diagnosed. Temporary improvement was achieved by postoperative conservative treatment including an elemen-tal diet (ED), but after 5 years he was readmitted to the same hospital with nausea, vomiting, and fever. His symptoms were controlled by total perenteral nutrition (TPN) and ED, but remissions and exacerbations were repeated, and thegiant inflammatory mass formed. Right hemicolectomy and partial resection of the small intestine were performed afterhis admission to our department. Tumor size was 27.5 × 14.5 × 12 cm and the patient's postoperative recovery with conservative treatment was uneventfull.

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A case of Peutz-Jeghers syndrome associated with carcinoma of the small intestine is reported. The patient was a 25-year-old male, in whom Peutz-Jeghers syndrome was diagnosed at the age of 7 based on pigmented spots on the lips, hands and soles, and rectal polyps. At the age of 24, an episode of intestinal obstruction led to surgical resection of jejunal intussusception. During the operation, a massive group of jejunal and ileal polyps was found by palpation. At the age of 25, endoscopic polypectomy of the small intestine was performed under laparotomy. An enteroscope was introduced alternately through the openings in the small intestine, one 140 cm from the terminal ileum and the other 50 cm from Treitz ligament. In this way, 107 polyps (5 mm or over) were resected. On microscopic examination, although 105 polyps were described as having the typical Peutz-Jeghers pattern (hamartomatous), carcinomatous glands were found in parts of 2 polyps (26 mm and 7 mm in diameter). This suggests that polyps seen in Peutz-Jeghers syndrome should be considered potentialy malignant, and resected regardless of their size. Endoscopic polypectomy under laparotomy serves this purpose.

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We report an extremely rare case of invaginating neurofibroma of the colon that was not associated with von Recklinghausen's disease. The patient was an 80-year-old woman whose complaints were melena and intermittent abdominal pain. Barium enema study, endoscopic examination and CT scan showed that an intraluminal tumor of the ascending colon measuring over 5 cm invaginated the transverse colon, and indicated that the tumor was non-epithelial. Right hemi-colectomy was done. The postoperative histological findings showed that the tumor was a neurofibroma. Neurofibroma must be differentiated from other non-epithelial tumors. This histological classification can be achieved by hematoxillin-eosin staining and immunohistochemical study with anti-myoglobin antibody, anti-S-100 antibody and so on. This patient is the fifth such case reported in Japan.

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