We started using autologous blood transfusion (AuBT) for esophageal carcinoma resection in May 1994. Indications for blood collection were defined according to the guidelines of the Japanese Society of Blood Transfusion. The AuBT group included 38 patients who underwent esophagectomy and three-field lymph node dissection. A total of 800ml of autologous blood was collected from each patient between January and December 1995. The historical control group consisted of 50 patients who received the same operations from January 1992 to April 1994 and who fulfilled the criteria for autologous blood collection. On the 1st, 3rd, and 7th postoperative days, hemoglobin (Hb) concentrations in the control group were respectively 11.8±1.1, 9.8±1.3, and 9.7±1.0g/dl while Hb concentrations in the AuBT group were 12.6±1.2, 10.2±1.4, and 10.4±1.1g/dl. Thus, after the operations, Hb levels were significantly higher in the AuBT group than in the control group. The percentage of patietns who did not receive an allogenic blood transfusion was significantly greater in the AuBT group (95%) than in the control group (68% p=0.002). In conclusion, autologous blood collection of 800ml for esophagectomy is useful for maintaining stable Hb levels after the operation and consequently aids in avoiding allogenic blood transfusion.

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For a clinicopathological study of superficial esophageal carcinomas from the standpoint of their growth pattern, 48 lesions of 44 patients were analyzed. The mean diameter of all carcinomas was 3.8cm. Submucosal tumors (4.1cm, p<0.01) and mucosal tumors (3.7cm, p<0.05) were significantly larger than intraepithelial tumors (1.7cm). Macroscopically 0-I and 0-III types of carcinoma were predominantly submucosal carcinomas (mostly sm₃), whereas the O-II type was dominant in the depth of invasion variants. Lymph nodal involvement, which was not found with mucosal tumors or with submucosal tumors less than 2.0cm, was more frequent when the tumor spread a distance equal to more than half of its circumference. There were two cases of multicentric-type superficial carcinoma. In one of them there were four cancerous lesions including one mucosal carcinoma and three intraepithelial carcinomas. Two cases of mucosal and five of submucosal superficial spreading-type carcinomas were experienced. In regard to the growth and progress of an extensively spreading type of superficial esophageal carcinoma, if the multiple cancerous lesions extend widely, they might yield a spreading-type carcinoma.

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A clinical study on the risk and the compatibility of operation by new surgeons in terms of the training in surgical techniques. We reviewed the 871 gastric cancer cases treated in the Fujisawa Municipal Hospital for the past 23 years. The operator and the elder surgeon of operator or assistant was divided into 4 groups according to the postgraduate year of the surgeon (group A;<5 years, group B; 5-9 years, group C; 10-19 years, group D; 20 years-). The surgical stress, postopereative course and the prognosis of the cases were examined respectively in the operator groups and in the elder surgeon groups.(1) Concerning to operative bleeding, duration of the operation, the interval of postoperative decompression with a nasogastric tube and postoperative fast, risk of postoperative complications, 5-year survival and the mode of recurrence, there was no difference among the operator groups at the curative cases of stage I, II and III. However, among the elder surgeon groups, there was significant difference (p=0.0481) in 5-year survival and that of group D was better, (2) concerning to the surgical stress, postopereative course and the prognosis of the cases, there was no difference among the operator groups and the elder surgeon groups at noncurative stage III and IV. In conclusion, under proper coaching there is no problem in operations by new surgeons concerning postoperative complications and long-term prognosis.

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Gastric cancers with mucinous adenocarcinoma had no liver metastases despite frequently having peritoneal and lymphatic metastases. To clarify the reason for gastric cancers with mucinous adenocarcinoma having no liver metastases, we investigated 28 gastric cancers with mucinous adenocarcinoma and 31 gastric cancers with liver metastasis clinicopathologically and studied the expressions of VEGF, MMP-9 and MMP-2 immunohistochemically. There was no differences, clinicopathologically, between the former and the latter except for V factor and H factor. The rates of VEGF and MMP-9 expressions were 21.4% and 28.6%, respectively, in the former and were significantly lower than those in the latter. On the other hand, the rate of MMP-2 expression in the former was 32.1%, and showed no significant difference with that in the latter. These results suggest that VEGF and MMP-9, produced in tumor cells, may play an important role in the development of liver metastasis in gastric cancer.

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To clarify the usefulness of two different reconstructive procedures after total gastrectomy for gastric cancer, we evaluated the clinical results and quality of life of 35 patients with no evidence of disease more than three years after operation. Roux-en-Y (RY group; n=15) reconstruction or jejunal interposition (IP group; n=20) reconstruction was performed. The body wieght ratio (RY group: 90.0%, IP group: 93.6%) and body mass index (RY group: 19.0 IP group: 19.6) were similar in both groups. Blood analysis and blood chemistry tests were almost within normal limits in both groups, and did not show statistically significant differences between the two groups. The pancreatic function diagnostic test did not show significant difference between the two groups. Blood glucose levels determined by the oral glucose tolerance test were similar in the two groups. Plasma insulin levels in the IP group at 60 and 120 minutes after the glucose load were significantly higher than those in the RY group. The patient's evaluation of treatment and postoperative life in the IP group was significantly better than that in the RY group. The quality of life evaluated by a questionnaire concerning postoperative or postpranidal symptoms was almost the same and good in both groups. In other clinical data and clinical symptoms except for a feeling of satisfaction, the two different reconstructive procedures following total gastrectomy showed few statistically significant differences and both procedures were acceptable.

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The influence of neutrophil elastase on ischemic reperfusion injury and the effect of an elastase inhibitor administered via the portal vein were investigated by using a rat experimental model. One hundred and twenty minutes after warm-ischemia, trans-portal injection of a neutrophil elastase inhibitor was followed by reperfusion for 30 minutes. The treated group showed increased seven-days survival rate and increased local hepatic blood flow than the untreated group. No significant destruction of the liver micro-circulation was detected by electron microscopy in the treated group. In the suprahepatic inferior vena cava, both the activity of neutrophil elastase and TNF were detected at lower levels in the treated group. The ketone body ratio, which shows hepatic viability, was found in the treated group. These results demonstrate the influence of neutrophil elastase on ischemic reperfusion injury and the possibility of improvement of ischemic reperfusion injury when a neutrophil elastase inhibitor is injected.

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We investigated the portal blood flow, paticularly intra-hepatic shunt, by measuring the level of ammonia in the portal vein (P) and hepatic vein (H), and the ammonia exclusion ratio (P-H) /P. Twentythree patients were evaluated, 14 had an extra-hepatic shunt, and the others had no shunt. As the liver function deteriorated becouse of fibrosis, the level of ammonia in the hepatic vein increased and the ammonia exclusion ratio decreased. In the patients with no extra-hepatic shunt, there was a highly negative correlation between the ammonia exclusion ratio and ICGR₁₅ (r=-0.85). In the patients with an extra-hepatic shunt, there was a highly negative correlation between the ammonia exclusion ratio and ICGR₁₅ after closing the shunt (r=-0.75). Consequently, the ammonia exclusion ratio reflected the degree of liver fibrosis and intra-hepatic shunt. The ammonia exclusion ratio is a useful method for determining the closing of the porto-systemic shunt.

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Significance of Sialyl Lewis X (SLe^x) expression on liver metastasis from colorectal cancer and residual liver recurrence was investigated with special attention to its expression in vascular permeating lesions surrounding the tumor. Using surgical specimens obtained from 78 patients with primary colorectal cancer and 22 patients with liver metastasis, who underwent curative resections, vascular permeating lesions around the tumors were examined immunohistochemically for SLe^x expression with SLe^x monoclonal antibody. Cumulative liver metastasis in SLe^x positive colorectal cancer was significantly higher than that in SLe^x negative colorectal cancer (p<0.01), and 3-year cumulative liver metastasis was 50.0% in positive groups and 35.0% in negative, respectively. Residual liver recurrence in patients underwent hepatectomy was not different between SLe^x positive and negative primary colorectal cancer groups, but it was significantly higher positive SLe^x in liver metastatic lesions than negative SLe^x (p<0.05). Those pathological results indicated that the examination for SLe^x expression in vascular permeating lesions outside of the tumor is useful in evaluating the malignant potential of colorectal cancers

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Perforation of the esophagus is an extremely rare but serious illness, which needs early diagnosis and appropriate treatment. We experienced a rare esophageal perforation into the right thorax with unique onset in a patient with an advanced esophageal cancer after a gastrectomy caused by vomiting. The problems of diagnosis and treatment, and the mode of its operation are reported. A 68-year-old man who was found to have a middle intra-thoracic esophageal cancer type 4+0-IIc+0-IIb after a wide gastrectomy was admitted to the hospital. Esophageal perforation into the right thorax occurred on vomiting aftre a meal. Therefore a total esophagectomy through a right thoraco-laparotomy with lymph node dissection RII, a cervical esophagostomy and a gastrostomy was carried out. The perforation site was the center of stenotic portion, was in the intraepithelial spread histopathologically. Because of an MRSA infection after the operation, complications like an abscess in the thoracotomy wound and osteochondritisdeveloped which were hard to cure. After improvement of the complication by evacuation of the abscess and chondrectomy, secondary reconstruction with a right colonic interposition between the cervical esophagus and the remnant stomach was carried out. We reported that second reconstruction was ableto be carried out to the case of esophageal perforation with esophageal carcinoma after the esophagectomy with lymph node dissection and appropriate drainage.

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A 58-year-old woman was found to have an asymptomatic elevated lesion in the antrum of the stomach. Endoscopic examination revealed no elevated lesion in the stomach but rather an elevated mass in the second portion of the duodenum. Upper gastrointestinal series showed a smooth edged filling defect in the second portion of the duodenum. Abdominal CT, angiography and ERCP findings were negative. An endoscopic biopsy showed no malignancy. Under a possible diagnosis of carcinoid, pancreaticoduodenectomy was performed. The tumor was located in the papilla of Vater and measured 2cm in diameter. Histopathologically, epithelioid cells were arranged in nests and ganglion-like cells were scattered diffusely and surrounded by spindle cells. Immunohistochemical staining for neuron specific enolase, S-100 and pancreatic polypeptide showed positive results. Thus, the tumor was diagnosed as a gangliocytic paraganglioma. A case of gangliocytic paraganglioma has been presented and only 16 cases have been reported in Japan, including our case, to date.

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This paper describes a case of mucin-producing duodenal carcinoma arising from the aberrant pancreas. An 81-year-old woman was seen at a nearby hospital because of appetite loss as the chief complaint. She was found to have an ulcerative lesion in the wall of the duodenal bulb and was admitted to our department for close examiation. CT scanning showed a tumor (2cm in diameter) with a cystic change in the bulb. Gastrointestinal endoscopy revealed two depressed lesions on the greater wall of hte duodenal bulb. Biopsy revealed adenocarcinoma. Under a diagnosis of advanced cancer of the duodenal bulb, laparotomy was performed. Since peritoneal lavage cytology showed malignant cells, distal gas-trectomy was peformed. Histologically the tumor was a papillary and partially mucinous adenocarcinoma found mostly in the muscularis propria. The aberrant pancreas (Heinrich I type) with acinar cells, pancreatic ducts and Langerhans' islets bordered on the tumor. Adenocarcinoma arising from the aberrant pancreas was diagnosed from these findings. To our knowledge, this is the fourth case reported in the Japanese literature.

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A case of left-sided gallbladder combined with both an accessory bile duct and an anomaly of the intrahepatic portal vein, was confirmed accidentally by laparoscopic cholecystectomy was reported. A 41-year-old woman with cholelithiasis was admitted to our hospital and laparoscopic cholecystectomy was performed. The gallbladder was located in the left side of the round ligament, (left-sided gallbladder). It was also complicated with right round ligament and an accessory hepatic bile duct. There are only 50 reports of left-side gallbladder without situs inversus totalis in Japan, but in 9 of these cases the gallbldder misplacement was combined with a portal vein anomaly as in our case. For these cases, some authors advocate another possible mechanism: A left-sided gallbladder might arise when the right round ligament remains and the gallbladder develops at the left of this ligament. This could be added to Gross' theory.

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A 45-year-old woman underwent distal pancreatectomy for benign insulinomas of the pancreatic body and tail in 1987. In August 1994, she complained of nausea or palpitation after meals and her blood sugar on fasting was very low (51mg/dl). Ultrasonography revealed two tumors of the'residual pancreas with diameters of 15mm (body) and 5mm (head) Both tumors were enhanced by dynamic CT and were found to be hypervascular by angiography. IRI levels of the portal system in the pancreatic head and body were shown to be elevated by percutaneus transhepatic portal vein sampling. We enucleated three insulinomas of the residual pancreas (one was detected by intraoperative US) that occurred at different times. Intra operative Quick IRI monitoring was very useful for confirmation of tumor excision. All three tumors were diagnosed as insulinomas by pathological findings obtained by immunological staining. She has been followed up for 12 months without hypoglycemia.

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A case of medisastinal pancreatic pseudocyst in a 42-year-old man is reported. He had a history of reccurent abdominal pain after every time he drank, which was caused by relapsing pancreatitis. He was admitted to a hospital on March 17, 1994, complaining of epigastralgia. Computed tomography and magnetic resonance imaging revealed water density fluid collection in the posterior mediastinum. He was referred to Hakodate Municipal Hospital on June 27, 1994. After conservative treatment for pancreatitis, CT revealed that the mediastinal tumor had disappeared and a cystic tumor in the cavity of the bursaomentum had decreased. Endoscopic retrograde pancreatography showed that a pancreatic pseudocyst and an internal pancreatic fistula had developed from the pancreatic duct to the mediastinum. Distal pancreatectomy was performed on September 1, 1994. The postoperative course hasbeen uneventful during 16 months after discharge.

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A 64-year-old woman visited a medical clinic complaining of general fatigue, and was referred to our hospital because of an abdominal mass and anemia. Her serum CEA and CA19-9 levels were 21.7 ng/ml and 155.9 U/ml, respectively. An upper GI series revealed stenosis of the jejunum approximately 8 cm distal to Treitz's ligament, and a barium enema study showed a stenotic portion in the transverse colon. Under the tentative diagnosis of a jejunal tumor laparotomy was performed, and partial resection of the jejunum with lymph node dissection combined with right hemicolectomy was carried out. Macroscopically, the jejunal tumor had a small ulceration, forming an exrtaluminal mass about 8 cm in diameter, and involved the transverse colon. Histological examination revealed areas of adenocarcinoma forming moderately differentiated tumor glands, and areas of squamous cell carcinoma with mild keratinization showing sheet-like tumor growth. The patient died 32 months postoperatively, bearing liver metastases found in the 22nd postoperative month. Adeno-squamous cell carcinoma of the small bowel is very rare, and the present case appears to be the second reported from Japan.

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The patient was a 72-year-old man complaining of discomfort at defecation. Colography revealed an elevated lesion at the base of the appendix. Endoscopic view showed atumor at the orifice of the appendix with discharge of mucin. The biopsy specimen was diagnosed as tubulo-villous adenoma. Ileocecal resection was performed under the diagnosis of an appendicular tumor. The resected specimen showed a polypoid tumor, 25×11mm in size, at the base of the appendix with intussusception into the cecum. The tumor was histologically diagnosed as villous adenoma. Villous tumor of the appendix is uncommon with only ten reported cases including ours in Japan. Seven of the ten tumors were villous adenoma, and intussusception had ocurred in five of the ten patients.

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Endotoxin is an important pathogenetic factor in severe sepsis via the release of various mediators. We experienced two cases of severe sepsis treated effectively by surgery and endotoxin-eliminating therapy using a polymyxin B-immobilized fiber column. In case 1, the patient was a 62-year-old woman, who was suffering from complicating septic shock and failure of three organs due to rectal perforation. In case 2, thepatient was a 60-year-old woman, who was also suffering from complicating septic shock and from failure of six organs due to acute cholecystitis and acute obstructive suppurative cholangitis. Endotoxin-eliminating therapy was given twice to these patients postoperatively, resulting in improvement in the organs. The interleukin-6 and-8 concentrations in the plasma were decreased and the leukocyte count improved soon after endotoxin-eliminating therapy. We therefore concluded that when one performs endotoxin-eliminating therapy for severe sepsis, changes in the interleukin-6, -8 concentrations in the plasma and leukocyte count will furnish much information for the proper timing and number of endotoxin-eliminating treatments for severe sepsis.

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We report 2 patients who had an aberrant bile duct entering the cystic duct. Though in one of the two cases its existence was not confirmed before the operation, laparoscopic cholecystectomy was success fully performed without injury to the aberrant bile duct. In many hospitals, laparoscopic cholecystectomy involves initial dissection and transection of the cystic duct which is then divided from the gallbladder approaching from the corpus upward. As laparoscopic cholecystectomy has become widely practiced, it is important to perfrom the procedure with proper recognition of bile duct anomalies. We can not, however, consistently achieve this in all cases. We performlaparoscopic cholecystectomy by the pulling tape technique, such that we first bind the cystic duct with tape after having divided it from the corupus of gallbladder. It is important to maintain the structure without dissection or transection. Next, eperform cholecystectomy approaching from the fundus downward. Indeed, approaching from the fundus downward has the demerit of a less than optimal orientation of Calot's triagle as compared to approaching from the corpus upward, but our method facilitates obtaining a good view of Calot's tringle by pulling down the tape and the fundus of the gallbladder. We consider these two cases to have been done safely by this technique, performed with surgical expertise.

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