Out of 38 patients who were underwent total thoracic esophagectomy under thoracolaparotomic cervical manipulation, 14 patients were assessed as to water and electrolyte metabolism and nutritional parameters, and all of them were studied about the postoperative complications under our postoperative infusion and nutritional management as follows: 1) In order to maintain stable circulation during the perioperative period, the infusion volume, whose contents were similar to extracellular fluid, was determined by the value of the preoperative cardiac index and end diastolic volume index 2) The nutrition was given by enteral feeding without TPN at the introducing dose of 5 kcal/kg/day from 3 postoperative day (POD) and gradually increased at a full dose of 30 kcal/kg/day. Total water and sodium intake on the operation day just after surgery were significantly higher than those on other postoperative days, 5.24ml/kg/hr and 0.56 mEq/kg/hr, respectively. Total calorie intake reached 30 kcal/kg/day on 9 POD. Nitrogen and potassium balances became positive on 10 and 4 POD, respectively. Total protein, albumin, prealbumin, transferrin, retinol binding protein and peripheral lymphocyte counts were the lowest on 3POD. 3-methylhistidine urinary excretion and C-reactive protein were the highest on 3POD. All these parameters returned to the preoperative values on 14 POD. The incidences of postoperative complications were 11% of primary pulmonary complication, 8% of arrhythmia, 11% of hyperbilirubinemia, 3% of minor leakage and 3% of ileus, respectively. These results suggest that our postoperative management is simple and safety mothod against thoracic esophageal cancer surgery.

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This study was designed to investigate the role of duodenal and gastric juice reflux in the genesis of esophageal carcinoma. Male Wistar rats, weighing approximately 250 g, underwent surgery that resulted in duodenogastroesophageal reflux (DGER), duodenoesophageal reflux (DER), gastroesophageal reflux (GER), or no reflux (RY). Twelve rats underwent a sham operation (SO). The animals were fed a standard maintenance diet and received no carcinogens. The rats were killed and examined 50 weeks after surgery. Esophageal carcinoma was identified in 23 lesions in 20 cases. The incidence of esophageal carcinoma was 83% in the DGER group (n=12), 77% in the DER group (n=13), 0% in the GER group (n=16), 0% in the RY group (n=11), and 0% in the SO group (n=12). The incidence rates of carcinoma in both the DER and DGER groups were significantly higher than in the other groups (p<0.001). Pathologically, 16 lesions were adenocarcinoma (ADC), three were squamous cell carcinoma (SCC), and four were adenosquamous carcinoma (ASC). Adenocarcinoma occurred near the anastomosis, whereas SCC and ASC occurred more proximally. Adenocarcinoma occurred within Barrertt's epithelium, whereas SCC and ASC occurred within squamous esophagitis. These findings suggest that duodenoesophageal reflux is associated with the development of Barrett's esophagus and adenocarcinoma and adenosquamous carcinoma and squamous cell carcinoma, while gastroesophageal reflux is not associated with the development of carcinoma.

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Mixing of food and bile after gastrectomy was examined among three groups: those who underwent total gastrectomy, distal gastrectomy and vagal nerve preserving distal gastrectomy, by dual scintigraphy of the gastrointestinal and hepatobiliary tract. Poor mixing depending on the delayed excretion of bile was frequently observed in those who underwent total gastrectomy. The results of hepatobiliary scintigraphy indicated that the excretion of bile to the duodenum was most delayed in the total gastrectomized group and the function of the hepatobiliary tract was better in those who underwent vagal nerve preserving distal gastrectomy than the other two groups. And by comparison of the results of six months and one year after gastrectomy, the function of the hepatogbiliary tract was relatively improved with time in two groups with vagal nerve dissection. As one factor in the poor mixing of food and bile after gastrectomy was the delayed excretion of bile, vagal nerve preservation in gastrectomy was useful for maintaining the hepatobiliary function after gastrectomy.

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To determine the effects of obstructive jaundice and biliary drainage on adaptive cytoprotection of the gastric mucosa, Sprague-Dawley rats were used and grouped as follows: 1) control group, 2) jaundiced group, 3) biliary drainage group. High and low doses of taurocholate were orally administered as an irritant and mild irritant, respectively. The ulcer index was significantly higher in the jaundiced group than in both the control and drainage groups. The mild irritant decreased the ulcer index in each group compared with the irritant groups. These phenomenon were eliminated by indomethacin. The mild irritant reduced the decrease in the hexosamine content of the gastric mucosa induced by the irritant, and enhanced recovery of the gastric potential difference level after administration of the irritant. We conclude that gastric mucosal adaptive cytoprotection occurs even in obstructive jaundice and biliary drainage. Prostaglandin may play an important role in these mechanisms.

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Cases of recurrent t1 cancer of the stomach were studied clinicopathologically with reference to the clinical course to evaluate the effect of fluoropyrimidine compound administration versus nonadministration. Thiryt-four of the 907 patients with t1 cancer of the stomach (3.7%) died of recurrence. Among them, five of 495 cases were characterized by invasion of the mucosal layer, while 29 of 412 showed invasion of the submucosal layer. Ten, ten, seven and seven cases were classified as stage 1, stage 2, stage 3 and stage 4, respectively. Five stage 1 cases manifested recurrence after 5 years while one curious case of recurrence occurred in the gastrectomized region 10 years later. All five cases of mucosal cancer of the protruding type developed recurrence. Five of the 63 cases of protruding submucosal cancer, and 12 of the 109 cases of mixed (elevated-depressed) type developed recurrence. Despite the low percentage of recurrence (1.3%) in node-negative disease, 24 of 73 cases of node-positive (32.9%) disease died of recurrence. Histologically, 14 of 29 patients with submucosal cancer (48%) showed well differentiated cancer, including 12 cases of papillary adenocarcinoma. No prognostic significance was associated with patients with node-negative and vascular or lymphatic invasion who received administration of anticancer drugs, compared with non-administered cases. In conclusion, gastrecotmy with careful attention to lymph node dissection is indicated for patients with t1 cancer of the stomach showing protruding or mixed type disease macroscopically or papillary adenocarcinoma histologically.

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The serum sialy Tn antigen (STN) level was measured in 97 patients with gastric cancer (cutoff value: 45 U/ml) before surgery. The overall positive rate was 37.1%, and it was elevated along with the histological stage of gastric cancer. In the patients with peritoneal dissemination, the postive rate was 72.7%, and the average serum STN level was significantly higher compared with patients in stage IVb without peritoneal dissemination. There were no significant differences in carcinoembryonic antigen (CEA), CA19-9 and tissue polypepide antigen (TPA) level whether or not the stage IVb patients had peritoneal dissemination. Liver metastasis had no differences on STN levels in stage IVb patients. In the resected cases, the STN-positive rate was significantly higher inthe patients with lymph node metastasis than in those without. The prognosis of patients in stage IV worsened, as the STN level became higher. These results indicate that measurement of the serum STN level is useful for the diagnosis of peritoneal dissemination before surgery, and that it can be a prognostic factor in gastric cancer.

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The purpose of this study was to determine the correlation between tissue fibrinolytic activity and recurrence in the liver after curative resection for gastric cancer. Among the patients who underwent curative resection for gastric cancer with subserosal invasion, 14 patients who showed recurrence in the liver (RL group) and 30 who survived for five years or longer without any recurrence (control group) were compared clinicopathologically. Paraffin-embedded tissue sections were stained immunohistochemically for urokinase-type plasminogen activator (u-PA) and its inhibitor (PAI-1) by the streptavidin-biotin method. The staining was judged as positive when 10% or more of the cancer cells were stained. Although higher incidences of metastatic involvement in distant nodes and that of moderate and severe lymphatic invasion were observed in the RL group than in the control group, there were no differences in the rate of proliferating cell nuclear antigen positive cells in the cancer and other pathological factors between the groups. The staining for u-PA was positive in 64.3% of the RL group and 40.0% of the control group. The PAI-1 staining was positive in 28.6% of the RL group and 36.7% of the control group. Positive staining for u-PA and negative staining for PAI-1 was observed in 35.7% of the RL group and 6.7% of the control group (p<0.05, chi-square test). Multivariate discriminant analysis revealed that the positive staining for u-PA and negative staining for PAI-1 were useful predictors for hepatic recurrence along with nodal involvement and age at operation. We believe the immunohistochemical staining for u-PA and PAI-1 is a useful predictor for recurrence in the liver after curative resections for gastric cancer.

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This study was undertaken to determine the quality of life (QOL) after hepatectomy and its relationship to clinical factors and the change of liver function tests. Seventy-one patients who received hepatectomy between 1980 and 1993 at Kagoshima University Hospital and survived more than 3 months answered our original questionnaire including 16 items about the QOL. The results of principal factor analysis indicated the validity of our questionnaire. The QOL after hepatectomy was relatively satisfactory in physical condition and mental state, but not in social function and physical sensation. Age at hepatectomy, malignancy of the disease, time after hepatectomy, the occurrence of postoperative complications, and the deterioration of the hepaplastin test were significantly relevant to the QOL afterh epatectomy. In conclusion, it was suggested that preventing postoperative complications and the maintenance of protein synthesis are important to provide a satisfactory QOL after hepate ctomy.

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Reactive oxygen and oxygen radical scavenger superoxide dismutase(SOD)derivatives were examined in rat orthotopic liver transplantation. We used SOD derivatives modified with monosaccharides such as mannosylated SOD and galactosylated SOD which are rapidly eliminated from the blood circulation and taken up by parenchymal and nonparenchymal cells of the liver, respectively, after intravenous administration. And we determined the effect on reperfusion injury of liver grafts with or without these SOD derivatives. Orthotopic liver transplantation in Lewis male rats was performed under ethyl ether anesthesia. During the operation, native SOD and SOD derivatives were administered by intravenous injection before reperfusion of the graft. Animals were sacrificed 30 minutes after reperfusion, and then their blood samples and liver tissues were procured and analyzed for tissue Na⁺, K⁺-ATPase activities, lipid peroxides(LPO)and SOD activities, and serum biochemical tests were performed. After reperfusion, the levels of serum GOT and LDH were markedly increased and tissue Na⁺, K⁺-ATPase activities were decreased significantly, compared to those in the control rat livers. Tissue LPO were elevated and tissue SOD activities were decreased after reperfusion. The use of SOD derivatives, particularly galactosylated SOD, before reperfusion prevented the depression of tissue Na⁺, K⁺-ATPase activities and improved the levels of tissue LPO and SOD activities. In conclusion, reperfusion of the liver graft led to the production of oxygen free radicals and reperfusion injury was not prevented by native SOD, but SOD derivatives, particularly galactosylated SOD, had a significant effect on reperfusion injury of the liver graft.

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We evaluated the efficacy of intraperitoneal hyperthermic perfusion (IPHP) in regional hyperthermia of the liver. In beagles (n=6), an infusion catheter (14 F) and drainage catheters (12 F) were placed in the upper abdominal cavity and the Douglas pouch, respectively. Physiological saline (46-48°C) was infused into the abdominal cacity at a flow rate of 100-300ml/min through blood warmer coils in a water bath (47-52°C). The temperature was continuously monitored at seven measuring points including water bath, peritoneal inflow line, abdominal cavity, liver parencyma (5mm and 30mm in depth), portal vein and rectum. The mean temperature of the abdominal cavity reached 41.6°C20 minutes after the start of IPHP and was stabilized in a range of 42.6 to 42.7°C after 40 minutes. The temperatures of the portal venous blood and liver parencyma (30mm in depth) increased similarly and were kept in a range of 42 to 42.5°C after 45 minutes. On the other hand, the temperature of the rectum remained less than 40.4°C throughout the course. In conclusion, IPHP is a simple and effective method that permits optimum heating of the liver parenchyma in hyperthermia.

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The usefulness of hepatic resection by the trans-thoracic route for hepatocellular carcinoma with cirrhosis in the postero-superior subsegment (S7) was assessed. Twenty patients underwent hepatic resection by this procedure (Group A), and another 33 patients underwent resection by the transabdominal route (Group B) without thoracotomy. Thoracotomy was done in the 7th intercostal space. The volume of bleeding and transfusion during the operations was significantly less in group A than in group B (p<0.05). In case of partial resection or subsegmentectomy, the mean surgical margin of group A was 1.0 cm, significantly wider than that of group B, which was 0.4cm (p<0.05). No severe pulmonary complications occurred in either group. It was concluded that hepatic resection by the trans-thoracic route was very useful for hepatocellular carcinoma with cirrhosis in subsegment S7 of the liver.

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Whether or not a microscopically tumor-positive resection margin of the hepatic duct (hw (+)) affects the postresectional long-term prognosis was studied in 28 cases of middle and lower bile d uct cancer resected during the past 15 years (1978-1993). hw (+) was identified in 10 cases, or 36% of all cases. The pathological background was not different between hw (+) cases and those with a tumor-negative resection margin (hw (+)) except in d-factor. The five year survival rates of 30% in hw (+) and 43.8% inh w (+) were not significantly different. Intraoperative frozen section in 10 hw (+) cases was positive in 6, and negative in 4. Long-term survivors of more than 5 years numbered 6 in this series, and included 3h w (+) patients. Recurrence in long-term survivors, irrespective of hw positive or negative status, was characterized by anastomotic recurrence, while short-term survivors died exclusively of distant metastasesand peritonitis carcinomatosa. These results indicated that hw (+) is not a prognostic factor for the treatment of bile duct cancer. Since recurrence in short-term survivors seems not to be infl uenced byh w (+) as well, radical operation should be balanced with progression of the disease and curativity of the operation.

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The expression of nm23 gene products, that is, NDP kinase were investigated immunohistochemically in 54 resected cases using monoclonal antibodies for two types of isoform. The expression rate of nm23-H1 was 79.6% and that of nm23-H2 was 85.2%. The expression rate of nm23-H1 was significantly lower in the cases of duodenal invasion, but there were not significant relation between the expression of nm23 and depth of invasion lymph node metastasis and pancreatic invasion. There was no significant correlation between the expression of nm23-H1 and nm23-H2, and prognosis(p=0.79 and p=0.63, respectively).The expression rate of nm23 was not significantly different among patients with no recurrence over 3 years, those with no recurrence over 5 years and those who had liver metastasis after surgery. These results suggest that there is no significant correlation between the expression of nm23 and lymph node metastasis, prognosis and liver metastasis, and nm23 may lack value as an indicator of prognosis or metastasis in bile duct carcinoma.

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Estimation of the recurrent form is a significant determinant factor in the prognosis of a colorectal cancer. We examined the relationship between NCAM, concerning the neural invasiveness of rectal cancers, and the DCC gene which has high homology with NCAM. We examined the relationship between hepatic metastasis of a colorectal cancer and a soluble form of ICAM-1 in serum. NCAM expression was positive in 52 colorectal cancer cases (41%) out of a total of 128 cases, but this NCAM expression was found not to be related to the histological stage of a colorectal cancer. The neural invasiveness of rectal cancers is not related to the clinicopathological factors but is significantly related to NCAM expression. While NCAM expression is not significantly related to DCC gene expression, cases with hepatic metastases tended to be NCAM negative-DCC decreased and those with local recurrence tended to be NCAM strongly positive-DCC unchanged. The DCC gene mutation is significantly related to lymph node metastasis. Cases with hepatic metastases tended to be over 700ng/ml of a soluble form of ICAM-1 in sera. The investigation of NCAM expression in tissue and measurement of a soluble form of ICAM-1 in a colorectal cancer are suggested to be an important index for selecting appropriate postoperative therapy.

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We experienced a case of early basaloid carcinoma concomitant with early squamous cell carcinoma of the esophagus. Though the 54-year-old man was diagnosed as having an esophagealcarcinoma by endoscopic examination, he refused treatment. Three years and six months later, esophageal carcinoma was again detected. Previous endoscopic examination had revealed a superficially depressed lesion at 26 cm and a submucosal mass with an eroded surface at 30cm from the incisor level. The former was probably confined to the mucosal layer, the latter to the submucosal layer. Endoscopic examination at admission revealed that both tumors seemed to have enlarged slightly. Subtotal esophagectomy with regional lymph node disection was carried out under right thoracotomy and laparotomy. Histopathologic examination of the resected specimen revealed two mucosal cancers, one of which tumor was newly found by histologic examination, and a submucosal cancer without lymph node metastasis. Histologically, the mucosal tumors were well-differentiated squamous cell carcinoma and the submucosaltumor was basaloid carcinoma. Such multiple esophageal cancers followed for a long time retrospectively are very rare. Furthermore, this case is interesting for its histogenesis and the malignantbehavior of the eso-phageal carcinoma.

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We report 2 patients who underwent total gastrectomy for gastric cancer, and then underwent resection for local recurrence. Case 1 (41-year-old woman): In the follow-up study after the first operation, upper gastrointestinal findings showed an irregular narrowing of the lifted jejunal loop, and computed tomography (CT) revealed a mass around the pancreatic tail. Invasion to celiac axis and common hepatic artery was not observed in celiac angiogram. We did not recognize obvious findings of peritoneal dissemination by using physical examination and imaging diagnosis. We underwent “en bloc” resection of multiple organs including the jejunum, part of the lateral segment of the liver, pancreatic body and tail, and transverese colon. Case 2 (53-year-old women): Barium enema showed an irregular narrowing of the splenic flexure of the colon 7 years after the first operation. Adenocarcinoma cells were proved by biopsy, and CT and angiography indicated a mass in the pancreatic tail. There were no obvious findings of peritoneal dissemination. The tumor mass, the pancreatic body and tail, the ρ-loop of the jejunum, the transverse colon and the left adrenal gland were resected “en bloc”. When local recurrence is found after total gastrectomy for gastric cancer, it is very difficult to determine whether or not peritoneal dissemination also coexist. However, it is recommended to make every effort to determine the extent of disease by using physical and imaging study, since operability depends upon such determinations.

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An 82-year-old woman was admitted to our hospital because of the cancer of the remnant stomach. Residual total gastrectomy, distal pancreatectomy and splenectomy were performed with dissection of the regional lymph nodes. On the first postoperative day, she was acutely ill and complained of abdominal pain. Then she manifested hypotension, subcutaneous hemorrhage and emphysema at the anterior chest wall. In spite of intensive therapy, she died about 36 hours after the operation. Aeromonas sobria was cultured from blood specimens. Any other previous case of postoperative infection due to Aeromonas sobria has been reported in the Japanese literature. As it takes rapidly progressive clinical course, we should pay attention to the diagnosis and chemotherapy.

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We report a case of massive hemorrhage from parapapillary diverticulum treated by TAE. An 82-year-old man was seen at our hospital with the chief complaints of hematemesis and blood bowel discharge. Laboratory tests showed RBC of 269×10⁴/mm³, Hb of 8.7g/ml and Ht of 24.5%, indicating anemia. Urgent gastrointestinal endoscopy did not reveal any source of hemorrhage. Abdominal US and CT showed a cyst at the body of the pancreas. At ERCP, parapapillary diverticulum was seen and it was covered with fresh blood. The pancreatic duct was not dilatated and there was no relation between the cyst and the pancreatic duct. Scintigram for gastrointestinal hemorrhage and abdominal angiography showed no bleeding focus. At the second endoscopic examination, the diverticulum was covered with fresh blood as before, so we diagnosed the hemorrhage from the diverticulum. TAE was performed for ASPD, PSPD and AIPD with gelfoam and microcoil. After this, the patient developed the complication of acute slight pancreatitis, but it remitted with conservative treatment. Re-bleeding was not seen. When vital signs are stable, TAE is valuable for stopping hemorrhage which is hard to control.

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A case of primary biliary cystadenocarcinomas is reported. Although its preoperative diagnosis is usually difficult. This case was correctly diagnosed before operation. In this case, simple resection of the cyst was considered to be sufficiently curative, since it was isolated from intrahepatic bile duct. A 66-year-old woman was introduced to our clinic for examination of liver dysfunction. Abdominal ultrasonography, computed tomography and magnetic resonance imaging demonstrated large, solitary, multilocular lesion in the liver, which was shown to be hypervascular in the marginal portion of the lesion by angiography. Laparoscopic aspiration biopsy did not show any malignant cells, but elevated CEA (135ng/ml) and CA19-9 (146U/ml) in the cyst fluid suggested that it was a primary biliary cystadenocarcinoma. Resection of the cyst was performed for therapy. Histological examination demonstrated that the cyst wall consisted of a mucin-producing papillary adenocarcinoma and the solid tumor consisted of poorly differentiated adenocarcinoma with partial necrosis. The prognosis of biliary cystadenocarcinoma after surgery is usually better than that of hepatocellular carcinoma or cholangiocarcinoma, and the surgical resection is the first choice for therapy.

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We reported a 62-year-old man who has survived 5.5 years after repeated resections for recurrent cholangiocellular carcinomas (CCC). Three years and nine months after a left hepatic lobectomv. a nartial hepatectmy for a recurrent tumornear the surgical margin was performed. Five months after the second operation tnree nodules on the rectum were resected by Hartmann's operation. For one year and five months no recurrent tumor has been seen. Histologic findings in all specimens were tubular adenocarcinoma with cytoplasmic inclusion bodies and the specimens were positive by CA19-9 immunohistochemical staining. The resected recurrent tumors were probably metastasized for the primary one. CCC is one of the cancers whose prognosis is poor. In our case the repeated resections might have been ettective in preventing the recurrence of CCC.

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A case of primary carcinoma of the cystic duct based on Farrar's criteria is reported. An 83-year-old woman complained of fever. Ultrasonography showed swelling of the gall bladder. Endoscopic retrograde cholangiopancreatography demonstrated that the cystic duct and gall bladder were not opacified. Tumor of the cystic duct could not be ruled out on MRI. Percutaneous transhepatic cholecystgram showed dilated gall bladder without gall stone and complete occlusion of the cystic duct. Laparoscopic cholecystectomy was performed under a preoperative diagnosis of cholecystitis because of complete occlusion of the cystic duct. Tumor measuring 17 × 15mm was detected in the cystic duct. Dissection of the regional lymph nodes was added because malignancy could not be ruled out. Histologically the tumor was a papillary adenocarcinoma. The depth of tumor invasion is limited to the subserosal layer. The resected specimen revealed no evidence of malignancy in the wall of the remnant cystic duct. As of 17 months after the operation, her clinical course is good and there has been no evidence of recurrence.

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We report a case thought to be a needle tract implantation after ultrasonically guided aspiration cytology for mucinous cystadenocarcinoma of the pancreas. A 68-year-old man was referred to our hospital because of a high serum amylase level detected in a mass examination. As abdominal US and CT revealed a small cystic lesion at the head of the pancreas, ultrasonically guided aspiration cytology was performed. The aspirates showed papillary adenocarcinoma cell clusters under the mucinous background. Thus we diagnosed mucinous cystadenocarcinoma of the pancreas. Pancreatoduodenectomy was performed. A year later abdominal US revealed hypoechoic mass in the abdominal wall at the epigastrium. About 2 years later, a thumb sized subcutaneous tumor was recognized at the epigastrium, the same site where the previous aspiration cytology was done. Aspiration cytology of this subcutaneous tumor disclosed adenocarcinoma cells with much mucin in the cytoplasma. We diagnosed the nodule as metastatic tumor of the abdominal wall. A second look operation was done. There were no signs of recurrence in the peritoneal cavity, and the metastatic tumor was excised. Histological examination of the tumor showed metastatic papillary adenocarcinoma similar to the previous pancreatic cancer. Therefore we considered this metastatic tumor of the abdominal wall a needle tract implantation after ultrasonically guided aspiration cytology for mucinous cystadenocarcinoma of the pancreas. We suggest that the occurrence of needle tract implantation should be expected in fine needle aspiration cytology. We should determine the indications for aspiration cytology of pancreatic cancers and follow them carefully.

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The total extraperitoneal preperitoneal approach (TPP) is a new method of “laparoscopic” herniorrhaphy in which the extraperitoneal space is dissected and a polypropylene mesh is placed in the preperitoneal layer to close the hernia ports of internal and external inguinal and femoral hernias. We have used TPP in treating 5 cases by the Preperitoneal Distention Balloon (PDB) System. All of them were primary cases. The patients' ages ranged from 26 to 79 years. The sex ratio (male: female) was 4: 1. Postoperative pain was minimal. None of them complained of postoperative inguinal tension. All of them were able to be discharged a few days postoperatively without complications. Dissection of the extraperitoneal space using the PDB System is easy. The disadvantages of TPP are: 1) it is difficult to ditermine the anatomy of the inguinal region and hernia port; 2) observation of the intraperitoneal organs is not possible; and 3) a more refined operative technique is necessary and therefore more time is needed for training. Since the operative field does not include the abdominal cavity, there is no need to open it. Therefore the advantages are: 1) intraabdominal adhesions from previous operations do not deter the surgeon; 2) adverse injury to intraabdominal organs is unlikely; and 3) postoperative intestinal adhesion or paresis is rare. Because of these advantages, we regard TPP as a promising main procedure for laparoscopic herniorrhaphy in the years to come.

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