The Japanese Journal of Gastroenterological Surgery
Online ISSN : 1348-9372
Print ISSN : 0386-9768
ISSN-L : 0386-9768
Volume 30, Issue 10
Displaying 1-31 of 31 articles from this issue
  • Harufumi Makino
    1997 Volume 30 Issue 10 Pages 1973-1977
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We evaluated the utilityof gadolinium enhanced magnetic resonance imaging (Gd-MRI) in the diagnosis of lymph node metastasis of esophageal carcinoma. Gd-MRI was performed in 42 patients with esophageal carcinoma. The intensities of 50 lymph nodes in MR imaging were measured. No differences were observed in intensity between metastatic and non-metastatic nodes. However, intensity values did overlap. Thus, the auther devised a new method allowing comparison of metastatic and non-metastatic nodes on Gd-MRI utilizing an enhancement ratio (ER). ER higher than 45% reflected metastatic nodes.
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  • Toshitaka Fukumoto, Mario Shimada, Shouji Natsugoe, Shizuo Nakano, Hei ...
    1997 Volume 30 Issue 10 Pages 1978-1984
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    In our department, the esophageal carcinoma in situ (m1) and m2 which invades the proper mucosal layer are usually treated by endoscopic mucosal resection (EMR). From May 1992 to August 1996, a total of 30 patients (38 lesions) with early esophageal carcinoma underwent EMR in our department. In this series, we evaluated the indications of EMR for early esophageal carcinoma by clinical and pathological analysis of those cases, with the following results: 1) Endoscopic type 0-IIb or 0-IIc were found in 73.7% (28/38 lesions). 2) The maximum lengths of tumor were less than 2cm in 78.9% (30/38 lesions). 3) The depth of cancer invasion estimated by endoscopy was corresponded in 70.6% with histological depth of cancer invasion. 4) Five patients had bleeding which was successfully controlled by electric coagulation or balloon tamponade. 5) There were 3 cases of recurrence and one of metachronous multifocal cancers which could be resected endoscopically again, and no residual lesion were found. As a conclusion, EMR was evaluated as effective treatment for ml of m2 esophageal carcinoma, not occupied circumferentially, when properly indicated.
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  • Nobuo Omura, Hideyuki Kashiwagi, Teruaki Aoki, Yoshiyuki Furukawa
    1997 Volume 30 Issue 10 Pages 1985-1989
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We experienced a case of CREST syndrome complicated by reflex esophagitis of which the main complaint was dysphagia. In the roentgenographic examination of the upper digestive tract, the esophagus was dilated like achalasia and the lower part of the esophagus was narrowed. According to the classification of achalasia, the case was rated as Flask type of grade III. In the endoscopic examination, about 5 cm confluently circular the esophagitis rated as grade III of the Savary & Miller classification was observed. In the 24-hour continuous pH monitoring, gastroesophageal acid reflux was observed corresponding to only the postprandial period. The time spent lower than 4.0pH units was 9.8%, which was significantly prolonged. In order to relieve the difficulty of esophageal passage and to improve the function of preventing reflux, a laparoscopic Heller-Dor operation was conducted. After the operation symptoms including the main complaint of dysphagia disappeared and the narrowed esophagus was relieved. The esophagitis was ameliorated to a trace. The time spent lower than 4.0pH units was 0%. These results suggested that the present operation was effective as a surgical approach against symptoms accompanying the esophageal dysfunction of scleroderma.
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  • Yoshihiro Kinoshita, Masahiko Tsurumaru, Harushi Udagawa, Yoshiaki Kaj ...
    1997 Volume 30 Issue 10 Pages 1990-1994
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    It is generally believed that there is a close relationship between mortality after esophageal rupture and the time between the onset of symptoms and initial treatment. We recently encountered a 53-year-old man with rupture of the esophagus. A diagnosis of superficial esophageal cancer with possible invasion to the muscularis mucosa had been made, and the patient was scheduled for surgical resection. He developed severe epigastric and back pain after vomiting his first meal following fiberoptic esophagoscopy, and we diagnosed rupture of the esophagus based on the chest X-ray and computed tomography findings within 4 hours of the onset of symptoms. Superficial esophageal cancer that has invaded beyond the muscularis mucosa is said to require esophagectomy with lympn node dissection because of possible nodal metastasis. In this case, we thought that it would be very difficult to perform lymph node dissection as a second stage operation after esophagectomy because of severe adhesions. Accordingly, we resected the esophagus and performed lymph node dissection with simultaneous reconstruction and attributed the successful outcome to less extensive mediastinitis and the patient's stable general condition. The postoperative course was uneventful. Simultaneous esophagectomy plus lymph node dissection and reconstruction can be an option in the surgical management of esophageal perforation in patients with esophageal cancer.
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  • Takamasa Matsumoto, Nobutaka Murashima, Takuzo Fujiwara, Shigemichi Ih ...
    1997 Volume 30 Issue 10 Pages 1995-1999
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We report a case of eosinophilic gastroenteritis diagnosed correctly after an emergency operation. A 17-year-old man came to our hospital on December 3, 1990, complaining of epigastric pain and right lower abdominal pain of about 2 weeks' duration. The following day ultrasonographic examination demonstrated massive ascitic fluid, and leukocytosis was noted. A diagnosis of peritonitis was made, laparotomy was performed, and 2.1 L of bloody ascitic fluid was found. The peritoneum was only slightly inflamed, and appendectomy was performed. Postoperatively, gastrointestinal symptoms, including nausea, vomiting, abdominal pain and diarrhea persisted, and peripheral eosinophilia and eosinophilic ascites were noted. After other systemic disorders associated with peripheral eosinophilia had been ruled out, pulse steroid therapy was performed, and the symptoms improved dramatically. Histological examination of the resected appendix and colonic biopsy specimens obtained during sigmoidfiberscopy showed massive eosinophilic infiltration leading to a definite diagnosis of eosinophilic gastroenteritis. The patient has been followed up in the outpatient department for 6 years as a very rare case in which relapses occurred every time steroids were stopped.
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  • Hideya Ohnishi, Masato Kato, Masaki Takashima, Shuji Saeki, Toru Yamas ...
    1997 Volume 30 Issue 10 Pages 2000-2003
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    Gastric duplication is a congenital anomaly, and it is one of the duplications of the alimentary tract. Only 74 cases including our case have been reported in the literature in Japan. Herein we report a case of gastric duplication with two cysts. A 40-year-old woman was found to have cystic masses at the left subdiaphragma and the back of the pancreas, respectively, by abdominal ultrasonography and computed tomography in December 1991. An operation was performed under the diagnosis of suspected pancreas cysts in April 1992. The cysts at the left subdiaphragma, 8cm in diameter, and at the back of the pancreas body and tail, 10cm in diameter, were separately and strongly continuous with the greater curvature of the upper body of the stomach. Histological findings show that the two cysts were similar to the structure of the alimentary tract, and that the proper muscle layer continued with that of the stomach. So we diagnosed the condition as gastric duplication. Gastric duplication is often discovered incidentally in adults because of its asymptomatic course. Barium meal roentgenography, computed tomography and endoscopic ultrasonography are useful for diagnosis. Because carcinoma arising from the duplicated stomach have been reported, we think surgical therapy should be the first choice. It is important to keep gastric duplication in mind for differential diagnosis from an abdominal cyst.
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  • Takayuki Aimoto, Hatsuo Yoshida, Nobuatsu Koyama, Mitsuhiro Nihei, Mit ...
    1997 Volume 30 Issue 10 Pages 2004-2008
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    A 55-year-old man was admitted to our bospital because of anorexia. Tbe laboratory data on admission sbowed marked leukocytosis (21200/mm3). Upper gastrointestinal X ray and endoscopic examination revealed a type 2 gastric cancer at tbe antrum of tbe stomacb. Tbe patient underwent distal gastrectomy witb D2 lympb node dissection on October 30, 1995. Surgical stage grouping was T2, N2, P0, H0, Stage IIIa. Tbe lesion, measuring 110×90mm, was type 5T2 according to macroscopic classification. Patbologic findings were pap, ss, ly3, v3 and n2. From tbe 3rd day after tbe operation to tbe 28tb day, tbe leukocyte count and tbe level of G-CSF in serum fell from 19200/mm3 to 7200/mm3 and 195pg/ml to 60 pg/ml, respectively. Tbe postoperative course was good. Tbe patient was discbarged from our bospital on February 20, 1996. Immunobistocbemical study sbowed positive staining for G-CSF witbin tbe cytoplasm of tbe tumor cells. A diagnosis of a G-CSF-producing gastric carcinoma was made from tbese findings. Tbere bave been only 7 cases of a G-CSF-producing gastric carcinoma in Japan, including ours.
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  • Ryoichi Kondo, Tadahiro Shimizu, Shigeyoshi Kumeda, Takehiko Iwasa, To ...
    1997 Volume 30 Issue 10 Pages 2009-2013
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    A case with multiple primary cancers of the stomach (4 primary cancers) and colorectum (3 primary cancers) is reported. A 66-year-old man who had undergone ileocecalectomy for cecal cancer at age 32 years, distal gastrectomy and partial resection of the liver for gastric cancer with liver invasion at age 55 years, low anterior resection of the rectum for rectal cancer at age 59 years, It hemicolectomy and resection of the efferent loop of gastric stump for transverse colon cancer at tage 62 years and subtotal resection of the gastric stump and partial resection of the transeverse colon and jejunum for gastric cancer at age 65 years, was admitted to our hospital because of anemia and occult fecal blood. Borrmann 2 like cancers in the lesser curvature and anterior wall of the gastric stump were indicated by gastrointestinal endoscopy. The patient underwent total gastrectomy and splenectomy. Recently, the number of multiple primary cancers has been increasing, but cases with six or more primary cancers are rare. Six of these seven primary malignant tumors were advanced. Therefore we reconsidered the methods of regular following and examination. The patient lived more than 34 years after the first operation due to the absence of liver metastases, peritoneal dissemination and lesser lymph node metastases.
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  • Tetsunori Yoshimura, Hitoshi Fujiwara, Yasuhiko Tanioka, Ken-ichro Ham ...
    1997 Volume 30 Issue 10 Pages 2014-2018
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    Two cases of ruptured hepatic artery aneurysm complicating hepatic artery infusion chemotherapy (HAIC) are reported. The first was a 57-year-old man, who had undergone resection of the posterior segment of the liver because of metastasis from rectal cancre. An intraarterial infusion catheter with a reservoir was placed in the common hepatic artery through the gastroduodenal artery. After two weeks of HAIC treatment, computed tomography and angiography revealed an aneurysm of the common hepatic artery. HAIC was interrupted, but while waiting for the scheduled operation the patient had massive hematemesis with bleeding which produced hypovolemic shock. Emergency laparotomy showed rupture of the aneurysm into the duodenum. The second case was an 89-year-old man, who had received HAIC for almost two years. He was admitted to the hospital because of right hypochondral pain and melena. ERCP showed hemobilia and computed tomography and angiography revealed an aneurysm of the hepatic artery. Transcatheter embolization was performed, but he died of sepsis associated with hepatic abscess. Hepatic artery aneurysm complicating HAIC is rare, but we consider this potentially serious complication to merit documentation.
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  • Masao Wakabayashi, Kazuhiro Hanazaki, Jun Igarashi, Harutsugu Sodeyama ...
    1997 Volume 30 Issue 10 Pages 2019-2023
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    A case of hepatoma with glycogen storage disease type I is described. A 40-year-old man was admitted to the hospital because of liver dysfunction. Imaging modalities using ultrasonography, computed tomography, (CT) and angiography revealed a liver tumor in the left lateral segment. Since examination of peripheral blood revealed a decrease in fasting blood sugar, and an increase in α-fetoprotein, and tissue biopsy of the liver showed a decrease in glucose-6-phosphatase, we diagnosed the tumor as hepatoma with glycogen storage disease type I. The patient underwent left lateral segmentectomy of the liver. Seven months later, we detected local recurrence by CT in the abdominal wall and the remnant liver in the right posterior segment. Eleven months after the initial hepatectomy, the patient underwent a repeated hepatectomy, and resection of the abdominal wall tumor, greater omentum, transverse colon and right adrenal gland. Histological findings of all resected specimens were hepatocellular carcinoma. The postoperative couse was uneventful and the patient was discharged one month after the second operation.
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  • Nagato Katsura, Kazunari Satomura, Syugaku Himukashi, Iwao Ikai, Masay ...
    1997 Volume 30 Issue 10 Pages 2024-2028
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We report a case of a spontaneous biloma associated with an incarcerated confluence stone. A 74-year-old man was admitted to our hospital because of upper abdominal pain, jaundice, and fever. Abdominal MRI performed in the morning of the admission day showed no specific findings. But, about 5 hours later on the same day, abdominal CT and ultrasonography revealed large cystic lesions located on the anterior and posterior surfaces of the left lobe of the liver. Since aspirated fluid revealed bile infected with Klebsiella pneumoniae, the lesions were diagnosed as bilomas with infection. We could not find any previous report on such a rapid-growing biloma following obstruction of the bile duct with a confluence stone. A biloma is usually slow-growing. Our rare case suggests that we should conduct CT or ultrasonography repeatedly to detect the possibility of bile duct obstruction when we find a rapidgrowing biloma.
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  • Hiroaki Tsumura, Takashi Kodama, Takashi Yokoyama, Yoshio Takesue, Yos ...
    1997 Volume 30 Issue 10 Pages 2029-2033
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    A case of renal cell carcinoma with metachronous multiple metastasis to the pancreas in a 57-yearold male is reported. He had received right partial nephrectomy 9 years earlier because of renal cell carcinoma, and multiple tumors of the pancreas were found by follow-up ultrasonography. Tumors with an unclear margin were detected in the whole pancreas by enhanced computed tomography. Tumors were detected iso intensity by Ti enhanced MRI study and heterogenous high intensity by T2 enhanced study. DSA study showed tumor stains and hypervascularity in the A-V shunt in the early period. ERP revealed multiple stenosis and occlusion of the main pancreatic duct. Tumor cells sampled by brushing of the main pancreatic duct were found to be class 2 by cytological diagnosis, and were dyed with p53. Consequently, endogenously derived tumors were neglected. Under the diagnosis of metastatic renal cell carcinoma to the pancreas, total pancreatectomy with D1 resection was performed. In this paper, we discuss about metastatic renal cell carcinoma to the pancreas reported in the literature.
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  • Suguru Sawada, Makoto Ishikawa, Masahiro Sekino
    1997 Volume 30 Issue 10 Pages 2034-2038
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    A 48-year-old woman was admitted to our hospital with the complaint of right lower abdominal pain. On admission, the physical examination revealed tenderness, muscle guarding and rebound tenderness in the right lower part of the quadrant. Although ultrasonography and computed tomography showed a right ovarian cyst, a diagnosis of panperitonitis due to appendicitis was made. An emergency operation was performed. At laparotomy, a great deal of ascitic fluid and a ruptured right ovarian cyst measuring about 5 cm in diameter were found. She was diagnosed as having panperitonitis due to a ruptured right ovarian cyst. Moreover, exploration of the cecum showed a tumor surrounded by a hard adhesion. The appendix could not be found. It was suspected that the tumor was a malignant neoplasm of the cecum and right hemicolectomy with right oophorocystectomy was performed. This case was diagnosed as appendiceal intussusception associated with endometriosis by pathological findings. The overall incidence of intussusception and endometriosis of the appendix is estimated as 0.01% and 0.05%, respectively. According to the literature, only 3 cases of appendiceal intussusception associated with endometriosis including ours have been reported in Japan. As histopathological diagnosis was difficult to obtain prior to the resection, meticulously planned treatment strategies are called.
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  • Yohei Hamaguchi, Yoshiro Obi, Johji Wada, Yoshiro Fujii, Yasuhiko Chib ...
    1997 Volume 30 Issue 10 Pages 2039-2043
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We report here two cases of inflammatory bowel diseases associated with gastrointestinal carcinoids. Case 1: A 36-year-old woman developed abdominal pain. She was diagnosed as having small and large bowel Crohn's disease, and an ileocecal resection was performed in October, 1988. Duodenal occlusion was found in June, 1993. Diagnosed with a carcinoid tumor by frozen section analysis during the operation, she underwent distal gastrectomy on August 11, 1994. She died of multiple metastases of the lungs and bones on March 4, 1995. Case 2: A 67-year-old woman presented with constipation. She had been treated with salazopyrin since she was diagnosed with ulcerative colitis (total colitis type) in July, 1990. She developed constipation in Januray, 1994, and was diagnosed as having a rectal carcinoid. Low anterior resection was performed on March 3. Laparotomy revealed that she had peritoneal and hepatic metastases, and she died on April 27, 1994. Including the cases described here, a total of 16 subjects have been reported with coexisting Crohn's disease and carcinoid tumors and 20 subjects with coexisting ulcerative colitis and carcinoid tumors. Most carcinoid tumors occur in bowel segments with inflammatory bowel diseases, and in the cases of ulcerative colitis in particular, patients predominantly endure ulcerative colitis for more than 10 years. It is suggested that inflammatory bowel disease may have playeda part in the pathogenesis of carcinoid tumors.
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  • Shoji Maruyama, Satoshi Okabe, Takehiro Arai, Munenari Lee, Naoya Mura ...
    1997 Volume 30 Issue 10 Pages 2044-2048
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We would report a case of small rectal carcinoid with lymph node metastasis. A 65-year-old woman was referred to us for rectal cancer. We performed a total colonoscopy, and found a submucosal tumor which was located 3cm above the rectal cancer. Anterior resection was performed for the advanced rectal cancer with lymph node dissection including the submucosal tumor. The submucosal tumor was diagnosed as a carcinoid tumor 5mm in diameter. Pathological examination revealed regional lymph node metastasis of revealed this carcinoid. We conclude that this is the smallest reported rectal carcinoid with lymph node metastasis.
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  • Osamu Ishikawa, Hiroaki Ohigashi, Hiroshi Nakano, Takushi Yasuda, Shoj ...
    1997 Volume 30 Issue 10 Pages 2049-2053
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We have improved the 5-year survival rate from 9% to 29% by extending the range of lymphatic and connective tissue clearance (D2a) in resection of pancreatic head cancer. When D2a was performed, the long-term survivors were obtained mainly from the groups in which the positive nodes were absent or limited in the pancreaticoduodenal regions. Among these two groups, 40% of patients had cancer extension at a microscopic levels (microinvasion), in the nerve plexi or connective tissues beyound the pancreatic confines. The 5-year survival rate was around 40% even in the patients who had microinvasion around the superior mesenteric artery, celiac artery and aorta. Whereas, the long-term survival would be scarecely expected when the patients had either positive nodes beyond the pancreaticoduodenal region or microinvasion around the hepatic artery or inferior pancreatic head. These data lead us to conclude that the D2a-procedure is recommended for the selected patients with pancreatic head cancer.
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  • Keiichiro Kanemitsu, Takehisa Hiraoka, Tastuya Tsuji, Tetsuro Morisaki ...
    1997 Volume 30 Issue 10 Pages 2054-2058
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    Rational dissection of lymphatic and nervous tissue in curative resection for pancreatic cancer was studied on 46 patients with extended operation, containing 35 patients with IORT and 15 patients with ts1 tumor. Lymph node involvement and extrapancreatic nerve plexus invasion were found in 80% and 66.7% of patients with extended operation, respectively. Curative resection rate of these cases was 71%. Five year survival rates of 35 patients with IORT and patients with stage IVa tumor were 16.8% and 18.9%, respectively. Patients with stage IVb tumor or n2 lymph node involvement died within one year. At autopsy, control of local recurrence was improved in patients with IORT. Patients with small tumor within 1cm in diameter had good prognosis by standard operation. For tumor within 1cm, standard operation may be indicated. Extended operation with IORT should be performed for tumor over 1cm to stage IVa tumor and should not be done for tumor of stage IVb or with n2 lymph node involvement.
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  • Tomoo Kosuge, Kazuaki Shimada, Junji Yamamoto, Susumu Yamasaki
    1997 Volume 30 Issue 10 Pages 2059-2063
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    Improved postoperative survival was observed in patients with ductal pancreatic cancer treated with radical pancreatic resection including wide retroperitoneal dissection. Incidence of intractable diarrhea was suppressed by preservation of perivascular nerve plexus of the superior mesenteric artery. Survival merit was notable in patients either with less progressed stages or without nodal involvement. Laparotomy without resection was associated with high incidence of early postoperative death. Our results showed that certain part of ductal pancreatic cancer was curable with extended pancreatic resection. Diagnostic laparotomy should be avoided, and palliative surgery should be abstained if nonsurgical measure is available.
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  • Toshihide Imaizumi, Tatsuya Yoshikawa, Toshiaki Nakasako, Tatsuo Araid ...
    1997 Volume 30 Issue 10 Pages 2064-2068
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    In the present study, appropriate surgical margin of the tumor and adequate area forlymphadenectomy was evaluated in 527 patients with periampullary cancer who received radical operation. For the patients with invasive ductal adenocarcinoma of the pancreatic head, extended radical operation including extended lymphadenectomy, extrapancreatic nerve dissection and portal vein resection was thought to be necessary. Since the outcome of extended radical operation for patients with highly advanced cancer was extremely poor, extended operation should not be indicated for these patients. In order to improve the operative results, extended operation should be applied for patients with Clinical Stage III (RP2, PV2, A (-)) or below determined by using preoperative or intraoperative imaging techniques for tumor extent. For the patients with carcinoma of the duodenal papilla, dissection of lymph nodes along the superior mesenteric artery or vein (No.14) carried survival benefit, and for the patients with distal bile duct cancer, adequate resection of bile duct and dissection of retroperitoneal tissue contributed to the prognosis. Retrospective study on pancreaticoduodenectomy for periampullary cancer showed that if there are no findings of direct invasion to the duodenal bulb or the gastric antrum, lymph node metastasis surrounding stomach (No.3, 4, 5, 6, 7) is rare. Therefore pylorusf preserving pancreaticoduodenectomy can be indicated to more than 90% of the patients with periampullary cancer without reducing curability.
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  • Cholangiographic and Cholangioscopic Diagnosis of Cancer Extension
    Eiji Sakamoto, Yuji Nimura, Junichi Kamiya, Satoshi Kondo, Masato Nagi ...
    1997 Volume 30 Issue 10 Pages 2069-2073
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    One hundred and twenty-three patients underwent resection of hilar cholangiocarcinoma in our department during the last 18 years.The resected specimens and preoperative image diagnosis were compared in detail, and the accuracy of the preoperative estimation ofproximal cancer extension was examined.The accuracy was expressed as the percentage of the patientswhose cancer extension was correctly estimated within 5 mm.As for mucosal extension, the accuracy of cholangiographic estimation was 95% in cases without superifical spread of cancer.Howerver, in cases with superifical spread (n=12), it was impossible to estimate the mucosal extension without PTCS.The accuracy of cholangioscopic estimation of the superifical spread was 78%.On the other hand, the submucosal extension of the cancer was estimated by detecting biliary stiffness, tapering, and narrowing on hihg-quality selected cholangiograms achieved via PTBD in various positions.The accuracy of cholangiographic estimation of submucosal extension was 71%.
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  • Atsushi Takimoto, Itaru Endo, Shinji Togo, Hitoshi Sekido, Yasushi Ich ...
    1997 Volume 30 Issue 10 Pages 2074-2078
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    Macroscopically, hepatic bile duct carcinoma was divided into 3 types, papillary (P), nodular (N) and diffuse (D). P-type expressed cadherin and catenin mores trongly than N-and D-types. Expression of both cadherin and catenin was stronger in pap and tubl than tub 2.The nuclear area of the cancercell, which correlated with both the labeling index of Ki-67 and aberrant accumulation of p53, was significantly larger in the subserosal layer than in the mucosal layer. These findings may explain the differences in biological behavior between P-and N, D-types. P-type grows with in the mucosal layer, while N-and D-types are more in vasive, extending into the subserosal layer. Inreality, thepoorforN-, D-type of hepatic bile duct carcinoma after surgery is clinically observed. Therefore, for the treatment of N, D-type bile duct carcinoma, more extensive surgical intervention including resection of the liver and vessels is required.
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  • Shinichi Hayashi, Masaru Miyazaki, Masayuki Ohtsuka, Seiji Furuya, Hir ...
    1997 Volume 30 Issue 10 Pages 2079-2083
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    This study was aimed to clarify the surgical implication for hepatic resection for hepatic hilar ductal carcinoma and gallbladder carcinoma by clinicopathological examination of surgical specimens. Hepatic Hilar Ductal Carcinoma: Extramucosal extension toward the hepatic side was observed in 14 (78%) of 18 cases. The histological tumor margin was usually identified in the extramural layer, and the left dominant carcinomas had extended toward the left, whereas these right dominant ones had extended toward the right significantly (p<0.05). It was shown retrospectively that a histologically cancer-free surgical margin would be obtained in 89% of the cases if the proximal bile duct was cut at 15 mm proximally beyond carcinoma extension judged by the preoperative PTBD image, and in 72% of the cases if the proximal bile duct was cut at 15 mm proximally beyound mucosal carcinoma extension. Gallbladder Carcinoma: Of 19 cases of advanced gallbladder carcinoma which invaded into or beyound the subserosal layer, 11 hepatic metastases were histologically demonstrated in 6 cases (32%). These included 4 microscopic occult metastases (36%) smaller than 1 mm in diameter. It is suggested that appropriate hepatic resection such as segmentectomies of S4a and S5 and extended right lobectomy might be required in a patient with direct hepatic invasion. This study was aimed at clarifying the necessity for and good degree of hepatectomy of hepatic hilar ductal carcinoma and gallbladder carcinoma by full clinicopathological examination of surgical specimens obtained by hepatic resection.
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  • Kazuhiro Tsukada, Isao Kurosaki, Katsuyuki Uchida, Kazutoshi Date, Tos ...
    1997 Volume 30 Issue 10 Pages 2084-2087
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    To determine standard resection for advanced gallbladder carcinoma, surgical results of 96 patients were evaluated. All of the patients were classified according to the TNM category. The extended radical cholecystectomy with (standard procedure) or without bile duct resection was used for 60 patients and the extended operation (major hepatectomy and/or pancreatoduodenectomy) was performed in 36. For T3 or T4 tumors the extended procedure was used for 12 out of 26 patients (46%) or 18 of 22 patients (82%). However, the R1 resection was performed in 9 (35%) or 10 (45%) patients. One patient died within 30 days after the operation. The cumulative 5-year survival rates for patients with T2 (N=48), T3 (N=24), and T4 tumors (N=19) were 66%, 27%, and 15%, respectively. The survival curve for patients with T2 tumors was significantly better than those for patients with T3 or T4 tumors. The 5-year survival rate was 31% for patients with T3 or T4 tumors and RO resection. This was significantly better than that for patients after R1 resection (8%). The standard procedure is recommended for patients with T2 tumors. A more extended procedure is needed for performing RO resection for most patients with T3 or T4 tumors.
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  • Yoshio Koide, Shinichi Okazumi, Hisahiro Matsubara, Yukimasa Miyazawa, ...
    1997 Volume 30 Issue 10 Pages 2088-2092
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    In order to determine the optimal extent of resection for thoracic esophageal carcinoma, a retrospective study was carried out on 1, 023 patients receiving resection between 1959 and 1995. Partial resection of the esophagus followed by intrathoracic anastomosis resulted in a higher incidence of recurrence in the residual esophagus than total resection of the intrathoracic esophagus with cervical anastomosis. Because minute foci of intramural metastasis or lymphovascular infiltration cannot be determined by any equipment for image diagnosis at present, total resection of the intrathoracic esophagus should be performed. Cervical lymph node metastases were observed when cancer invasion reached the submucosa in cases of upper or middle third cancer, and the muscularis propria in cases of lower third cancer. So in these cases 3-field lymph node dissection is recommended in principle. On the other hand carcinoma in situ or cancer limited within the lamina propria mucosa showed no lymph node metastasis or lymphovascular infiltration, so endoscopic mucosal resection or transhiatal esophagectomy without thoracotomy can be performed. In p-T4 cases, combined resection of the esophagus and the lung resulted in a high mortality rate and very poor prognosis. Radical surgery for p-T4 cases should be limited toresponders to neoadjuvant chemoradiotherapy.
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  • Hiroyuki Kuwano, Hidetoshi Kawaguchi, Hiroshi Saeki, Kozo Sonoda, Take ...
    1997 Volume 30 Issue 10 Pages 2093-2097
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    The safe proximal resection margin in esophagectomy for esophageal squamous cell carcinoma was etermined on the basis of the extent of epithelial and subepithelial accessory lesions from the main lesions of esophageal cancer. One hundred and twenty-two specimens of whole resected esophagus were examined histopathologically and the proximal spreading patterns were classified into six types, these aze (1) direct margin, (2) intraepithelial spread, (3) multiple cancer, (4) subepithelial direct spread, (5) vascular invasion and (6) intramural metastasis. Among the 122 cases, the direct margin type was seen in 44 (36%), intraepithelial spread in 50 (40%), multiple cancer in 7 (6%), subepithelial direct spread in 13 (11%), vascular invasion in 5 (4%) and of intramural metastasis in 3 (2%). There were no differences in the incidence of the proximal spreading types according to the histologic types of squamous cell carcinoma of the main lesions. On the other hand, there were tendencies that the intraepithelial spread type occurred in 18 (64%) from 28 sites of main lesions restricted to the mucosa, and that subepithelial spreading types, such as subepithelial direct spread, vascular invasion and intramural metastasis occurred from 12 (33%) of 39 sites of main lesions invading the adventitia. For the detection of epithelial accessory lesions, careful endoscopic examination throughout the entire esophagus is necessary. On the other hand, especially for advanced cancer, the resection margin should be determined done in consideration of subepithelial spread of the lesions.
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  • Tsutomu Kaetsu, Masatoshi Kawamura, Hiroyuki Nagayama, Koichi Takamura ...
    1997 Volume 30 Issue 10 Pages 2098-2102
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    We investigated the indications for proximal gastrectomy for gastric cancer in the upper third of the stomach. Three hundred eighteen resected stomachs (C, CM, CE) were evaluated. The percentage of lym h node metastasis at each depth of tumor invasion was as follows: m 0% (0/23), sm 6.1% (2/33), mp 25% (4/16), ss 74.1% (43/58), se 81.3% (104/128), and si 91.7% (55/60). In the patients with early gastric cancer, lymph node metastases were found in station numbers 1 and 7. Lymph node metastases in the patients with mp invasion were found in stations 1, 2, 3 and 11, but not in numbers 4d, 5, 6 and 10. As regards the recurrence, there was no lymph node recurrence of proximal gastric cancer which did not extend beyond mp after curative resection. In respect of prognosis, the 5-year survival rates for the patients with proximal and total gastrectomy were 86.7% and 74%, respectively. There was no difference in the cumulative survival rates between the two groups. In conclusion, D1+No7 dissection should be performed for early gastric cancer. D1+No 7, 11 dissection is necessary for patients with mp cancer. Thus it is possible to perform proximal gastrectomy for proximal gastric cancer that was not beyond the layer of mp. However, the percentasge of metastasis to lymph node groups 2, 3 and 4 has increased according to the depth of invasion. Therefore, extended surgery should be performed for gastric cancer that is deeper than mp.
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  • Keiichiro Ohta, Mitsumasa Nishi, Shigekazu Ohyama, Takashi Takahashi, ...
    1997 Volume 30 Issue 10 Pages 2103-2106
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    Appropriate indications for proximal gastrectomy in cases with cancer in the upper third of the stomach and pylorus preserving gastrectomy (PPG) for those with middle third gastric cancer, i.e. without compromising curability, were examined. Study materials included 341 upper third and 1258 middle third gastric cancers less than 4 cm in size which were surgically resected at our hospital between 1946 and 1994. Localized, superficial lesions less than 30 mm in size, and other macroscopic types including differentiated and undifferentiated lesions with neither lymph node metastasis nor serosal involvement are indications for proximal gastrectomy provided that the lesion is less than 4cm in size and is an upper third gastric cancer. Polypoid, protruded, ulcerated and depressed types, less than 20mm in size, and differentiated types less than 18mm in size or undifferentiated types without serosal involvement, are indications for PPG if the lesion is less than 4cm in size and is a middle third gastric cancer.
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  • Zenro Nihei, Wataru Ichikawa, Masashi Ito, Toshiki Yamashita, Hiroyuki ...
    1997 Volume 30 Issue 10 Pages 2107-2111
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    One hundered cases of synchronous multiple gastric cancer, specimens of which were obtained at our department and affiliated hospital during a 15-year period, were analyzed to determine whether local excision is applicable for those cases. Accessory lesions were diagnosed by preoperative examination in 45.4% of the cases. Grossly flat lesions and small lesions tended to be missed preoperatively. In cases in which the main lesion was in the early stage, lymph node metastasis was identified in only one case in which the main lesion was infiltrating to the submucosal layer. Among 32 cases in which the accessory lesions were identified before surgery, local excision could be performed for 37.5% of the main lesions and 53.1% of the accessory lesions. Finally, 40.6% of the cases of preoperatively identified multiple early gastric cancer required gastrectomy and could not be treated by local excision, but 37.5% of the cases might be treated by endoscopic mucosal resection and/or laparoscopic local excision without performing gastrectomy. Postgastrectomy problems could be avoided even in multiple gastric cancer and the quality of life after treatment would be better. The mucosal layer in which metachronous cancer can develop will remain after local excision. Careful follow-up examination is indispensable after treatment of the lesions in multiple gastric cancers by local excision.
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  • The Study of the Bowel Habits after the Right Hemicolectomy and the Low Anterior Resection
    Masamichi Yasuno, Takeo Mori, Keiichi Takahashi
    1997 Volume 30 Issue 10 Pages 2112-2116
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    This study was designed to determine the reasonable length of the colon to be resected for right side colon and rectal cancers from the viewpoint of radicality and postoperative function. After right hemicolectomy or ileocecal resection, patients had frequent stools, 11% took antidiarrhoeal drugs, and 18% complained of abdominal symptoms. These complications could be caused by resection of the ileocecal junction. Our findings on lymph-node metastasis of right side colon cancer were as follows. Lymph-node spread along the bowel was not above 5 cm from the tumor. Intermedite nodal metastasis was to either between the right branch of the middle colic artery and the right colic artery, or between the right colic artery and the ileocolic artery. Retrograde metastasis were very rare in the principal nodes. Therefore, preserving the ileocecal junction may be feasible in radicality and valuable for function, in cancer near the hepatic flexure. And we obtained good results by ileocecal junction-preserving right hemicolectomy. We performed a barium enema study of the neoreclum after low anterior resection. Patients with a straight type neorectum had very frequent stools while those with a winding type neorectum like a physiological rectum had good postoperative function. As far as possible the sigmoid colon should be preserved for a neorectum with good function. Our data show that lymphnodal oral side cancer that spread more than 10 cm along the rectum wall accounted for 0.5% of advanced lower rectal cancers. Reconstruction of the neorectum using a long sigmoid colon may be possible for curability and give good postoperative function. We achieved good practical results in low anterior resection by preserving the sigmoid colon.
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  • Atsushi Ihara, Yoshimasa Otani, Shigeki Aihara, Tadashi Nozawa, Yukihi ...
    1997 Volume 30 Issue 10 Pages 2117-2121
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    The subjects were 79 (7.5%) patients who had undergone resection of transverse colon cancer among 1060 patients with colorectal cancer which had been resected in our hospital during the 11 years from April 1986, when the hospital was founded, to March 1996. In those 79 patients grades of lymph node metastasis wree distributed as follows: n0, 45 (57.0%); nl, 14 (17.7%); n2, 7 (8.9%); n3, 3 (3.8%); and n4 (SMA+, hereinafter), 10 (12.7%) patients. Of these patients with lymph node metastatis, a clinical problem exists in patients with SMA + (10 cases in the present study) which likely results in insufficient dissection of the lesions by transverse colectomy together with lymph node dissection (D3). Therefore in the present study, we investigated the prognosis for such the SMA+ patients and also risk factors for the cases. The results, regarding optimal ranges for the lymph node dissection in cancer of the transverse colon and other findings, include the following. First, patients with cancer of the transverse colon showing intramural extension of mp or less do not show lymph node metastasis indicating eligibility for resection of the transverse colon. Second, risk factors for lymph node metastasis along the SMA are: 1) intramural extension, ss or more; 2) histological types, poorly differentiated and undifferentiated carcinoma; 3) intravascular invasions ly2/v2 or more; 4) infiltration (INF) modes, INFβ and INFγ; 5) tumor diameter, 3cm or more. And finally, results in the present study suggest that extended right hemicolectomy meaning not clear dissection of the surgical trunk should be performed for patients who show advanced transverse colon cancer with intramural extension of ss or more and with any one of the characteristics described in 2-5) of item 2 above.
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  • Jin-ichi Hida, Takamasa Maruyama, Kiyoshige Fujimoto
    1997 Volume 30 Issue 10 Pages 2122-2126
    Published: 1997
    Released on J-STAGE: August 23, 2011
    JOURNAL FREE ACCESS
    The optimal extent of intestinal resection was investigated for cancer control. Node metastases were examined by the clearing method in 164 patients with colon cancer and 198 patients with rectal cancer. For pericolic spread of colon cancer, the distance from the primary tumor to a metastatic node was within 7cm. For central spread of colon cancer, the rate of metastatis to main nodes was 11.6%. For rectal cancer, the rate of distal intramural spread was 10.6% and the maximum distal spread was 2cm. The metastatic rate in the distal mesorectum was 20.2% and the longest distal spread from the primary tumor to the metastatic node was 4cm. The rate of metastasis to pericolic nodes that lie along the last sigmoid artery was only 1.0%. In T1 colon cancer, central node dissection is not required, but 3-cm proximal and distal margins of resection are required. In T2, central node dissection that includes the intermediate node should be performed, and 5-cm proximal and distal margins of resection are required. In T3 and T4, central node dissection that includes the main node should be performed, and 7-cm proximal and distal margins of resection are required. A 3-cm distal mural resection is required for rectosigmoid and upper rectal cancer, a 2-cm distal mural resection for lower rectal cancr, and a 1-cm distal mural resection for T1 and T2. Total mesorectal excision is required for T3 and T4 in the lower rectum, and excision of all mesorectal tissue down to at least 5cm below the tumor is required for T3 and T4 in the upper rectum. A J-pouch can be constructed by using the sigmoid colon.
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