Sugical procedures for thoracic esophageal cancer were classified into two categories; the standard esophagecotmy with thoracotomy and reduced surgery, i.e. esophagectomy without thoracotomy, endoscopic mucosal resection and thoracoscopy-assisted esophagectomy. The standard esophagectomy included subtotal esophagectomy and extended lymph node dissection in the mediastinum, abdomen and neck. This was indicated for stage I (TIB), stage II and stage III. Lymph node metastasis was found in the upper mediastinum most frequently, followed by the middle mediastinum and upper abdomen. In particular, systematic lymph node dissection in the upper mediastinum was most important. Pathological results for 204 cases of T1 cancer resected in our department, have shown mucosal and submucosal cancer in 102 cases each. The incidence of lymph node metastases was 2% in mucosal cancer cases, and 38% in submucosal cancer cases. Lymph node metastasis was observed in mucosal cancer with gross invasin to the muscularis mucosae. The indications for endoscopic mucosal resection of esophageal cancer were stage I (T1A) less than 2×2cm or less than one third of the circumference of the esophagus apart from gross invasion to the muscularis mucosae, without nodal involvement. The indications for transhiatal esophagectomy were as follows: stage I (T1A) more than 4cm in size or more than two thirds of the circumference of the esophagus or multiple mucosal lesions throughout the esophagus. The indications of thoracoscopy assisted esophagectomy were T1 and T2 cancer without multiple nodal involvements.

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We performed factor VIII-related antigen staining of 37 resected superficial esophageal squamous cell carcinomas in order to determine the relationship between angiogenesis and clinicopathological factors. A computer image analysis system was used to measure microvessels inside the tumor (intratumor) and in the normal tissue around the tumor (extratumor) in 3 visual fields from each stained specimen. The mean number of blood vessels and mean blood vessel surface area (%) per visual field were calculated, and then compared with each of the clinicopathological factors. The mean intratumor blood vessel surface area (%) was significantly smaller in ml and m2 lesions than in the other lesions (m3-sm3). No differences in mean extratumor blood vessel surface area (%) were found in relation to depth of invasion. The mean number of extratumor blood vessels was significantly (p<0.01) lower than the mean number of intratumor blood vessels in m3 and sml patients without lymph node metastases (n) or vascular invasion (ly, v). Thus, intratumor angiogenesis appears to contribute to the process by which superficial esophageal cancer grows from m1/m2 to m3. These results also suggest that determining the mean number of intratumor and extratumor blood vessels may be useful when deciding on the suitability of endoscopic mucosal resection.

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Undifferentiated carcinoma of the esophagus is rare among esophageal malignancies and has a poor prognosis because of excessive lymphatic and hemogenous metastasis at the early stage. We present six cases of undifferentiated carcinoma of the esophagus, and compared them with 128 cases of squamous cell carcinoma of the esophagus clinicopathologically and immunohistochemically. The mean age of the patients (five male and one female) was 64 years. Five patients had intrathoracic esophagectomy with 3-field lymph node dissection and the other one patient had palliative esophagectomy because of tumor invasion into the left main bronchus. Histological examination revealed that the tumor in 4 patients were small cell type and in the other 2 patients were non small cell type. Lymph node metastasis was found histologically in all 5 patients who had lymphadenectomy. Twelve percent of the dissected lymph nodes had metastatic lesion in patients with undifferentiated carcinoma, which was higher than that in patients with squamous cell carcinoma (7%). Immunohistochemically, specimens of 5 patients stained for Neuron specific enolase. The specimen from one of the small cell type lesions stained for Epithelial membrane antigen as well. Carcinoembryonic antigen and keratin were not stained in these samples. In conclusion, the results suggest that the cells which composed undifferentiated carcinoma of the esophagus may have multipotential of differentiation.

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To determine the most important prognostic factors for patients with gastric cancer, 23 factors were evaluated by uni-and multivariate analyses. A total 6, 540 patients with primary gastric cancer treated in the National Cancer Center, Tokyo, between 1962 and 1991 were studied. In 22 factors (excluding sex), a significant difference was seen in cumulative survival rate (univariate analysis), and they seemed to be the important prognostic factors. However, 11 factors were excluded after checking for independence (by Spearman's correlation) and checking for multivariate analysis (by the stepwise method), and the remaining 12 factors were finally studied by Cox's proportional hazard model (multivariate analysis); i.e. age, sex, depth of invasion, lymph node metastasis, liver/peritonal metastasis, maximal tumor diameter, location, infiltrative growth, lymphatic invasion, venous invasion, lymph node dissection, and resection margins. The most important prognostic factor was depth of invasion (hazard ratio: 4.62), followed by lymph node metastsis (3.63), age (2.07), liver/peritoneal metastasis (1.91), and lymph node dissection (1.58). The important prognostic factors changed in rank in the 30-year period. Depth of invasion and lymph node metastasis kept their first and second position during the whole period. Liver/peritoneal metastasis dropped in rank from the third to the fourth place. Age rose in rank from the fourth to the third place, and lymph node dissection also increased in prognostic significance, rising in rank from the seventh to the fifth place.

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Electrical properties of the liver, especially when they are measured at various frequencies, reflect its structural and physiological changes. This study was designed to examine viability during preservation of the liver by measurement of electrical impedance. The liver was preserved by simple storage in saline. Livers were divided into three groups according to the preserving temperature: Group I, 4°C (n=6); Group II, 15°C (n=6) and Group III, 25°C (n=6). They were examined for morphorogical changes by electron microscopy during the preservation. Two hundred and forty minutes in Group I, 120 minutes in Group II, 60 minutes in Group III were the times for a mitochondrial score below 3. Adenine nucleotide (ATP) levels of the preserved liver were measured by high pressur liquid chromatography. Percent ATP decreased 18-21% of the preischemia level at the same times described above in each group. Permittivity and conductivity in measurement of electrical impedance were measured at 39 frequency points in the 20 Hz-1 MHz range with an LCR meter system. Then tan δ was calculated from the permittivity and conductivity, as a function of frequency. Percent tan δ decreased immediately after ischemic injury and changed between 0.033-0.086%/min at the time for a mitochondrial score below 3. Significant correlation between percent ATP and percent tan δ was found in all groups. These results suggest that measurement of electrical impedance could be an index of the viability of the preserved liver.

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Forty-nine patients with cystic disease of the liver were reviewed. Three simple liver cysts were diagnosed as cystadenocarcinoma of the liver based on the findings of X-ray-CT or ultrasonography. One cystadenocarcinoma of the liver seemed to be a simple cyst before being diagnosed by histological examination. The levels of CA19-9 and CEA in the cystic fluid of benign liver cysts were much higher than the upper normal limit for serum but within normal limits in the corresponding serum. Examination of cystic fluid of the liver does not appear to be an aid in the diagnosis since the levels of the tumor markers were high not only in malignancy but in benign diseases. In epithelial cells of the wall of benign liver cysts, there was positive immunohistochemical staining for CEA in a non-polar pattern. It seems that immunohistochemical examination is an useful means to predict the outcome of cysts and cystadenomas of the liver.

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Serum interleukin-6 (IL-6) levels of 16 patients who underwent hepatic resection were measured during the perioperative period.Sixteen patients with non-cirrhotic livers were divided into two groups. The steroid group (S-group: n=7) received preoperative administration of methylpredonisolone (250 mg/ body) was compared with a control group (C-group: n=9) as to the levels of IL-6 and other factors in order to determine the effect of steroids.There was no difference of preoperative background between two groups.The postoperative levels of IL-6 of S-group were suppressed in comparison with C-group.The peak levels of IL-6 of S-group were significantly lower than those of C-group.Two out of the 7 patients in S-group (28.6%) had some complications after the operation, whereas 6/9 (66.7%) patients in C-group had complications.S-group showed a tendency of not only keeping a good level of respiratory function but also inhibition of liver damage after the operation.These results suggest that preoperative administration of a steroid could control the excessive reactions after hepatic surgery.

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Forty-three patients with hepatic metastasis from colorectal carcinoma were studied. The secondary intrahepatic spreading in the resected specimen was microscopically examined. The specimens were double stained with hematoxylin-eosine and Victoriablue, then four intrahepatic spreading modes were examined; liver parenchyma invasion, portal area invasion, hepatic vein involvement and satellite nodule. Thirty-one patients (72%) showed expansive growth, and of these patients 14 had capsule formation. Six of 12 patients with infiltrative growth had secondary liver parenchyma invasion through the portal area invasion. Thirty-eight patients (88.4%) had portal area invasion. In these patients, portal vein involvement was found in 31 and bile duct involvement in 17. Hepatic vein involvement was observed in 10 patients and satellite nodules were found in 28. Twenty-two satellite nodules were in the portal area and 6 were in the liver parechyma surrounding the main tumor. It was shown that 24 of the 28 satellite nodules (85.7%) were located within 1.5 cm distant from the main metastatic tumors. Furthermore, as the size of the main metastatic tumors increased, the distance and the incidence of satellite nodules tended to increase. All of the tumors less than 2cm (7 cases) had portal area invasion. Metastatic hepatic carcinoma showed secondary intrahepatic spreading and the main invading pattern was portal area invasion. It is considered that anatomically systematized hepatic resection should be recommended as a surgical procedure not only for primary hepatic carcinoma but also for metastatic hepatic carcinoma.

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Eighty-eight patients who had undergone hepatic resection for hepatic metastases from colorectal cancer were reviewed. The cumulative 3-year recurence rate and the 3-year hepatic recurrence rate were 74.9% and 65.2%, respectively. The initial recurrence occurred in the liver in 73.3% and in the lung in 13.3% of the patients. Hepatic recurrence rates after hepatectomy were not influenced by distribution, number, or size of the metastases or the procedure of hepatectomy. However, the hepatic recurrence rate was significantly better in patients with a surgical margin more than 1cm than in those with a smaller surgical margin. Hepatic recurrence near the resecting plane (<4cm) was thought to be related to micrometastasis from macroscopic metastasis (daughter metastasis) and recurrence far from the resect ing plane (>4cm) was thought to be related to occult hepatic metastasis from the primary lesion. According to this theory, hepatic recurrence was caused by daughter metastasis in 29.3% and by occult metastasis in 70.7%. Accordingly, hepatic resection with an adequate surgical margin and postoperative intraarterial chemotherapy for daughter metastasis and occlut metastasis was thought to be indispensable, to prevent recurrence in the remnant liver.

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To determine the histological predictors of distant metastasis of advanced colorectal cancer that extends into only the muscularis propria, 119 patients wer examined clinically and histopathologically. Distant metastasis was found in 14 patients, and in 100 patients, there was no metastasis or local recurrence. Three patients with local recurrence, one patient with peritoneal dissemination and one patient with paraaortic lymph node metastasis were excluded from this study. Six clinicopathological charactaristics were identified as risk factors for distant metastasis: 1) tumor in proctos; 2) moderately differentiated adenocarcinoma; 3) invasion of the tumor into the outer longitudinal muscle; 4) prominent tumor budding (small clusters of undifferentiated cancer cells ahead of the invasive front); 5) vascular embolization by tumor cells in medium-sized vessels. 6) lymph node metastasis. In contrast, the cumulative survival rate for patients with no risk factor was 100%, and the survival rates for patients with one, two and more than three positive factors were 97.6%, 81.9%, 53.1% (p<0.05) respectively. To perform appropriate adjuvant chemotherapy in relatively early advanced colorectal cancer, it is useful to predict distant metastasis by histological examination.

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Large hospitals in Japan are plagued with methicilin-resistant Staphylococcus aureus (MRSA). Our ward has been undertaking basic measures against infection. We therefore analyzed a total of 1, 408 strains of bacteria isolated from gastroenterologic surgery patients from January 1994 to December 1995. Throughout the period patients were instructed to gargle an iodine disinfectant, which was also applied nasally, for one week preoperatively. The round proceeded from postoperative patients, to stable ones, to those isolated for being positive for MRSA. Statistically the piecewise linear regression was used for the numbers of patients with MRSA, Candida, Pseudomonas aeruginosa, and Enterococcus faecalis. The results showed that the incidence of Candida increased from January 1995 but the incidence of the remaining three microbes decreased. The incidence of MRSA had a rate of 6.1% (55/908 isolates) in 1994 but 0% (0/ 500 isolates) in 1995. The incidence of Candida was 5.0% (45 isolates) and 5.8% (29 isolates) respectively. The isolation of MRSA in our Department ceased due likely to basic measures against infection such as the preoperative treatment of the upper airway.

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A case of non-small cell undifferentiated carcinoma with lymphoid stroma of the esophagus in a 75-year-old woman is described. The chief presenting complaint was dysphagia. Biopsy revealed undiffer entiated carcinoma. Surgery was performed after chemotherapy with intravenous CDDP at 80 mg/m². In the surgical specimen, most of the tumor was covered with normal mucosa, as in submucosal tumors. Microscopic observation revealed proliferation of relatively large malignant cells with marked lymphoid infiltration, predominantly of T-cells. The pathological diagnosis of the tumor was made as undiffer entiated carcinoma since there was no finding of sequamous or glandular differentiation, histologic stage a2n4, stage IV. One year and 10 months later, a recurrent tumor in a cervical lymph node was resected. The prognosis of undifferentiated carcinoma of the esophagus is generally recognized as poor but some cases with lymphoid stroma have been reported to have a favorable prognosis. In this case, the prognosis was relatively favorable in spite of the advanced stage, and the patient is doing well 3 years and 5 months after esophagectomy. This is the 5th report in Japan of carcinoma of the esophagus with lymphoid stroma.

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The patient was a 45-year-old man with liver cirrhosis accompanied by B type hepatitis who had been diagnosed as having synchronous squamous cell carcinoma of the thoracic esophagus (SCC) and hepatocellular carcinoma (HCC). For 2 months after admission, lipiodolization and transarterial embolization (TAE) for HCC was performed, and for SCC, cisplatin was given intravenously in 4 sessions and UFT ^® was administered orally every day. As a result of these treatments, HCC was markedly curtailed without any tumor in the left lobe, but SCC was not abolished completely. Therefore, we performed stripping of the esophagus by blunt dissection and right hepatic lobectomy simultaneously. Histologically, SCC was diagnosed as moderately differentiated, invading the muscularis mucosa. As to the HCC, it was not possible to determine the type of differentiation, becuase most of the tumor tissues were necrotized due to the effect of previous TAE treatment. The patient tolerated the operation and the postoperative course was uneventful. After 9 months, three nodules of recurrent HCC were detected in the remnant liver. For these lesions percutaneous ethanol injection and TAE were performed and these streatments were effective in controling the growth of the lesions. The patient is now alive 22 months after the opeartion without further recurrence.

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A 59-year-old man who had a familial cancer accumulation (father, elder brother and younger brother with stomach cancer and elder sister with uterine cancer) underwent total pharyngo-laryngoesophagectomy, modified radical neck dissection, tracheostomy and a reconstructionwith the stomach tube through the posteriormediastinal route for hypopharyngeal cancer. One year later, a gastrointestinal endoscopic examination revealed an elevated lesion in the reconstructed stomach tube. The biopsy specimen showed well-differentiated adenocarcinoma. Segmental resection of the stomach tube preserving the right gastroepiploic vessels were performed with a reconstruction using the transverse colon, since he had severe renal dysfunction and the tumor was located on the counter side of the vessels. Pathologic examination showed well-differentiated adenocarcinoma, involving the submucosal layer without any lymph node metastasis. He is alive and well, as of 1 year after the second operation. This surgical procedure may be recommended especially for patients with a surgical risk of mortality and morbidity.

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We experienced a case of synchronous triple early cancers of the stomach, papilla of Vater and rectum. A 57-year-old man was admitted to the hospital because of detection of pancreatic cyst. Preoperative alimentary tract examination revealed a shallow depressed lesion of the stomach, a submucosal tumor-like bulge on the papilla of Vater and a protruding mass with a central ulceration in the upper rectum. Histopathologically each of the three lesions was identified as carcinoma. Total gastrectomy, pancreatoduodenectomy and low anterior resection were performed at the same time. The gastrointestinal tract was reconstructed with Roux Y, Child manner and direct end-to-end color-colostomy. The final pathological report indicated all three of the carcinomas were limited to the submucosa, and regional lymph nodes were negative for cancer. By immunohistochemical staining with anti-p53 monoclonal antibody, expression of p53 was detected in the rectal cancer lesion. The postoperative course was uneventful except for leakage of the pancreaticojejunostomy. The patient's condition is presently stable without signs of relapse. A case of simultaneously resected triple primary early cancer has rarely been reported, this is the second case reported in Japan.

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A 63-year-old man was admitted to a hospital with right hypochondralgia and jaundice. Preoperative imaging studies showed dilatation of the left intrahepatic duct and a filling defect in the common bile duct. Accordingly, a diagnosis of choledocholithiasis was made and he underwent laparatomy. At laparatomy, only clotted blood was found in the common bile duct. During operative cholangioscopy, anelevated lesion was observed on the left hepatic duct. The lesion showed malignant neoplasia histologically. The patient was referred to our hospital. Re-examination was performed after admission, but no space occupying lesion was revealed in the liver. Under a preoperative diagnosis of cancer of the left hepatic duct, he underwent left hepatic lobectomy with bile duct reconstruction. Macroscopically, a small tumor (1.0×0.5cm) was found in the liver along the left hepatic bile duct near the hepatic hilum. Histopathologically, it was diagnosed as a moderately differentiated hepatocellular carcinoma with tumor thrombus in the branches of the left intrahepatic bile duct. This is a rare case of a small hepatocellular carcinoma inducing obstructive jaundice with dilatation of the left intrahepatic bile duct.

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A case of Cowden' s disease is reported. A 59-year-old man sought medical treatment for diarrhea andanal bleeding. A series of endoscopic examinations showed multiple Yamada type 2 esophageal, gastricand colonic polyps, as well as type 3 rectal cancer. A careful orocutaneous examination with biopsy revealed acral and postauricular keratotic papules, cutaneous hemangioma on the lower right side of the abdomen and a papilloma of the right tonsilar area. These findings were sufficient to diagnose as Cowden' s disease. On abdominal CT scan, we also found a hepatic tumor in the lateral segment. Miles' operation and partial resection of liver were performed. Histological findings showed that all the polyps were of hyperplastic types, and the liver tumor was a cavernous hemangioma (hamartoma), and the rectal cancer was a moderately differentiated adenocarcinoma. In addition, human papillomavirus was detected at both of the sites of rectal cancer and liver hamartoma. There are many problems needed to be solved in the pathogenesis of Cowden' s disease. That may be helped by the accumulation of more detailed genetic studies.

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A 68-year-old woman complained of upper right abdominal pain during follow-up after radical resection of the ascending colon cancer 6 years ago. Imaging study reveaeld a thick wall of the gallbladder with irregular elevated lesions, anomalous arrangement of the pancreaticobiliary system and no gallstones. Abdominal ultrasonography showed a low echoic area in the liver bed and abdominal computed tomography showed a high density area with ataining in the same area. At the operation, dissemination, invasion to the serosa or subserosa or direct invasion to the liver bed was denied, and cholecystectomy and lymph node dissection was performed. Microscopic findings revealed multinodular undifferentiated carcinoma with well differentiated tubular adenocarcinoma in situ. Immunohistochemical study showed that the tumor was endocrine cell carcinoma. Carcinoma partially invaded to the serosa, but was not exposed on the surface of the liver bed. The imaging findings of the liver bed probably resulted from increased cystic venous drainage. The patient was died 3 months after surgery. Autopsy showed multiple metastases. We reported a case of endocrine cell carcinoma of the gallbladder that was thought to be relatively rare and the interesting findings of the image.

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Case 1 was a 75-year-old man who admitted to a hospital because of diarrhea and melena. The patients was diagnosed ulcerative colitis and underwent Ba-enema and colonoscopy. Because of colon is perforation he underwent anemergency operation. Entamoeba histolytica was identified histologically and he addmitted our hospital. Case 2 was a 28-year-old man who consulted a hospital and was diagnosed ulcerative colitis but anal bleeding did not disappear. He admitted our hospital because entamoeba histolytica was identified histologically. During the subsequent 2 days abdominal pain rapidly increased and he underwent anemergency operation. Recently amoebiasis has been increasing gradually in Japan, especially as a sexally transmitted disease in homosexual. Once perforation occurred, itsmortality rate is very high. We keep flaminant course of amebic colitis in mind, and early diagnosis is paramount when paforation occurs.

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Twenty-four lesions of rectal carcinoids with a diameter of 15 mm or less were retrospectively clinically analyzed. Invasion was limited to the submucosal layer (sm) in 21 lesions, and spread to the proper muscle layer (mp) in the other 3 lesions. For sm lesions, endoscopic polypectomy was performed first in 12 lesions followed by trans-anal local resection (TAR) in 7 of them because of a positive tumor cut end {ce (+)}. TAR was performed first in 8 cases and low anterior resection (LAR) in another case. All surgically resected specimens showed ce (-). For mp lesions, no operation was performed on one patient with multiple liver metastases. Miles' operation was performed on another one, and another, who was found to have lymph node metastasis received LAR. Two (25%) of 8 patients with lesions more than 10 mm in diameter had metastases and 3 (37.5%) had mp invasion. It was suggested that local resection is indicated for carcinoid tumors with a diameter of 10 mm or less. For tumors with a diamteter of 11 mm or more, radical resection is indicated first for those with mp invasion or deeper, whereas local resection is recommended for those with sm invasion. Trans-anal local resection is the most proper procedure for local resection.

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