The clinical prognostic factors were analyzed in 47 patients who had undergone hepatic resection for liver metastases from colorectal cancers in order to determine the indication and procedure of he. patectomy and the usefulness of postoperative hepatic arterial infusion chemotherapy. A positive resection margin significantly shortened the disease-free survival (p<0.05), whereas a tumor size of less than 3 cm and curative hepatecomy improved overall survival (p<0.01, p<0.05, respectively). No other factors including synchronism, serum carcinoembryonic antigen level, distribution and number of liver tumors, operative method, blood transfusion and hepatic arterial infusion, influenced the survival. When the patients were limited to those with tumors greater than 3 cm in size, hepatic artery infusion chemotherapy significantly lowered the recurrence rate and prolonged the overall survival (p<0.05). We conclude that colorectal liver metastases, even when multiple or bilateral, are indications for hepatectomy as far as their absolute removal could be obtained. Postoperative arterial chemotherapy is strongly recommended for those with tumors larger than 3cm.

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We assessed the occurrence of apoptotic cell death in 24 colorectal adenomas, 69 colorectal carcinomas and 37 metastatic lesions, which included 21 of the liver and 16 of lymph nodes, in order to investigate the possible relation between apoptosis and clinicopathological features and to evaluate apoptosis as a possible prognostic factor. The apoptotic index (AI) was calculated by flowcytometry using terminal-deoxynucletidyl-transferase-mediated dUTP-biotin nick end labeling. The median values of AI were 27.0 in normal mucosas, 28.2 inadenomas and 15.2 in colorectal carcinomas. The AI was significantly lower in colorectal carcinomas than in normal mucosas and adenomas. Apoptosis of colorectal carcinomas was lessfrequently observed in tumors with higher malignant potential, such as tumors at advanced stages and with venous and lymphatic invasion. Moreover, the patients with a low AI had significantly poorer survival than those with a high AI. In comparing apoptosis between primary and metastatic lesions, AI was significantly lower in the latter. These results suggest that less apoptosis might result in greater progression of colorectal carcinomas and that the rate of apoptosis might be an indicator of the degeee of malignancy.

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one handred and ninety five patients have been received autonomic nerve-sparing operationsfor rectal cancer in our department since 1984. These patients were classified into two groups, those with preoperative irradiation (irradiated group) and those with surgery alone.The survival rates and the local recurrence rates for these patients were compared, and post-operative urinary and male sexual functions were discussed. The overall cumulative five-year and nine-year survival rates were 80.3% and 66.5%, whereas those in the irradiated group were 84.0% and 77.7%, and those in the surgery alone group were 74.6% and 62.9%. Local recurrence rates were 9.6% all, 5.6% in the irradiated groups, and 11.9% in the surgery alone group. Maintenance of urinary function was successful in almost all patients with bilateral and unilateral pelvic nerve plexus. But the sexual function in males especially ejaculation was preserved in only 54.5% of the patients with bilateral hypogastric nerve andpelvic plexus, and in only 14.3% of the patients with unilateral seving. There was no significant defference in the outcome of the two group, but there was a tendency to obtain thebetter survival and to decrease the local recurrence in the irradiated group. It was difficult to preserve the sexual function by the nerve-sparing operation with lymphadevectomy.

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Ninety-four of this author's patients with digestive cancer during the past 2 years and 10months were analyzed to clarify the present conditions and problems of notification of cancer based on question-naires. Notification of cancer was performed by mutual consent of the families. Sixty-three of the patientswere notified of cancer. The rate of notification of cancer was 88% in curability A group, 38% in B and 47% in C. Most of the patients and families were satisfied with notification. All of notified patients in curability B or C were performed adjuvant therapy or reoperation smoothly, but a few of unnotified patients were difficult to treat. Ninety-four percent of 54 alive notified patients desired to be notified of cancer, but only 41% desired to be given exact prognosis. Six percent of notifiedpatients did not desire to be notified and 39% of unnotified patients desired to be notified really. These results suggest that the notification of cancer is effective to psychology or treatment of the patients, but in case of notification of cancer, confirmation of thedesire of patients for notification in advance and an offer of information in line with the desire are necessary. But it is the future problem to offer all information to the patients with poor prognosis to their wish or not.

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Pyothorax associated with esophageal surgery is a disease that is hard to cure. Especially pyothorax with bronchopleural fistula is a more troublesome complication. For bronchopleural fistula, surgical treatments such as plombage with muscle and an omental pedicle flap have been common1ly used. However, these surgical methods cannot be chosen after esophageal surgery with stomach reconstruction. We report a case of bronchopleural fistula after esophageal surgery which was succesfully closed by using fibrin glue under bronchoscopic observation. A 61-year-old woman underwent subtotal esophagectomy with stomach reconstruction. Invasion of the main tumor to the carina and the left main bronchus precluded complete tumor resection. On the 12th postoperative day, pyothorax probably caused by the operation was detected. An air leakage continued despite drainage and frequent irrigation in the right pleural cavity. Bronchopleural fistula was diagnosed by the X-ray film in which the B6b bronchus was visualized by the contrast medium from the drainage tube. On the 43rd postoperative day, fibrin glue was bronchoscopically injected into the B6b bronchus distallyby means of a catheter with a balloon by which the orifice of the B6b was obstructed to avoid an back flow of the fibrin glue. The air leakage disappeared right after this treatment and the bronchopleural fistula was completely cured.

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A 78-year-old woman was admitted to our hospital because of abdominal fullness. A chest X-ray film showed several air-fluid levels in the mediastinum. An upper gastrointestinal series showed an“upsidedown-stomach”with a mixed esophageal hiatal hernia and was located inthe mediastinum. There was a filling defect on the middle gastric body. Gastrofiberscopy showed a deformed stomach with a type 3 lesion on the middle gastric body. Histological examination of the biopsy samples from the lesion revealed signet ring cell carcinoma. A total gastrectomy with D 1 lymph-node dissection and repair of the esophageal hiatus were performed. The resected specimen showed two elevated lesions, one on the middle gastric body and the other on the antrum of the stomach. Histologically, both tumors showed poorly differentiated adenocarcinoma infiltrating the subserosal layer and these tumors were connectedsubmucosally by cancer cells. There were metastases in the group 2 lymph nodes. The patient died of obstructive jaundice 17 months after the operation. The association between the gastric carcinogenesis and the hiatal hernia is controversial. This is the second case of resected gastric cancer within “upsidedown-stomach” in Japan.

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Most leiomyoblastomas originate in the stomach, and rarely in the duodenum. A case of leiomyoblastoma originated in the second portion of the duodenum of a 72-year-old woman is presented. 22 cases of the duodenal leiomyoblastomas have been reported in Japan. 4 cases of them showed malignant behavior and only one proved fatal. In our case, pancreatoduodenectomy was performed. No invasion and no metastasis of the lymph node were found on the macroscopic and the histologic examination. However, she was died with multiple metastasis of the liver and the retention of ascites 4 years later since the first surgery. The term “leiomyoblastoma”is commonly used for the epithelioid smooth muscle tumor. There are some cases in which it is to difficult to distinguish leiomyoblastoma from the neurogenic tumor in the ususal microscopic examinaton using hematoxylin and eosin staining. Immunohistological examination is indispensable for the differential diagnosis in our case. It must be proved that the tumor was smooth muscle origin on the diagnosis of leiomyoblastoma by the measns of various method, electron-microscopic or immunohistological examination, even though it showed typical findings on the usual microscopic examination.

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A 65-year-old man treated for hypertension was found to have a high serum level of AFP, and after several examinations he was diagnosed as having double cancers (IIc type gastric cancer in the antrum and hepatocellar carcinoma in the left lobe of the liver). On laparotomy, the left lobe of the liver showed natrophy but no tumor was detected in the liver. Theligamentum teres hepatis was enlarged and palpable as a hard mass which was 5 cm across indiameter. Left lobectomy of the liver including removal of the tumor of the ligamentum teres hepatis and distal gastrectomy were performed. Histopathological findings showed that the tumor had no connection with the liver itself and it was revealed to be hepatocelluar carcinoma originating from ectopic liver tissue exists in various organs such as gall bladder, suspensory ligaments of the liver, retroperitoneum, paccreas, spleen, omentum and intrathoracic space. However ectopic hepatocellar carcinoma is very rare; only four cases havebeen reported in Japan.

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The patient, a 34-year-old woman, was emergently admitted on May 21st, 1996, because of acute severe pain in the upper abdomen with repeated vomitting. Abdominal X-ray films showedseveral air-fluid levels in the upper abdominal area and abdominal CT scans showed a strangulated ileum located in the ventral space of the lateral segment of the left hepatic lobe. Under a diagnosis of incarcerated hernia, emergency laparatomy was performed. The operative diagnosis was incarcerated internal hernia through a small defect in the falciform ligament. The patient, in whom the strangulated ileum was resected and the small defect in the ligament repaired, was discharged from our hospital in good condition 20 days later. Only eight such cases have been reported, over the last half century, in the international literature. This very rare case is considered to be the fourth of its kind to be reported inJapan.

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A 53-year-old man underwent percutaneous transhepatic biliary drainage involving the rightanterior, posterior and left lateral hepatic ducts because of obstructive jaundice due to a cholangiocellular carcinoma at the hepatic hilus. From the findings of ultrasonography and CT, a mass was located at the hepatic hilus, and the right anterior and medial segmental portal branches originating from the right unbilical portion (RUP). Transarterial portography confirmed this anomaly and the left lateral segmental portal vein coursed solely to the left. The medial segmental arteries ramified from the anterior hepatic artery and middle hepatic artery. The medial segmental hepatic ducts also had two ramifications similar to those of the artery. Left hepatectomy with the caudate lobectomy was performed with preservation of the RUP. Separate hepatico-jejunostomies were constructed on the right anterior and posterior segmental bile ducts. We discuss the intrahepatic biliary confluent with the ramification of intrahepatic vessel regarding to association of the RUP and cholangiocellular carcinoma at the hepatic hilus.

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We describe herein a 60-year-old female with an operative wound-scar recurrence 19 months after curative resection for sigmoid colon cancer. She has been well, to date, with no evidence of recurrence for more than six years since the second operation. At the first surgery, intraoperative and histopathological findings of the sigmoid colon cancer were as follows: macroscopically type2, 6×4cm in diameter, SE PO HO M (-) D3, se, ly0, v0, n (-). Nineteen months after the operation, a tumor (3×3cm) appeared in the median incisional scar near the umbilicus. Subsequently, an other operation was performed. The abdominal wall, with 2cm disease-free margins, and the part of the small intestine adhering to the tumor were resected. Marlex mesh was used to close the abdominal wall defect. No other recurrent lesion was found and the resected tumor was diagnosed as moderately differentiated adenocarcinoma, a metastasi from the colon cancer. It was suggested that the implantation during colon surgery caused the operative scar recurrence.

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Pulmonary embolism (PE) is a rare but extremely important postoperative complication because it is often lethal when it does occur. Therefore, prophylaxis for PE such as low doseheparin (LDH), low molecular weight heparin (LMWH) and intermittent sequential pneumatic compression (ISPC) has been generally carried out in the West. Fully realizing the importance and ncesssity ofprophylaxis for PE in Japan, we have adopted ISPC for 56 surgical patients with gastroenteological diseases (ISPC group), who are supposed to belong to a high risk group for deep vein thrombosis (DVT) and PE.We compared them with 126 patients withoutISPC (non-ISPC group) in frequency of DVT or PE. ISPC isa device to massage the lower limbs mechanically with pneumatic boots and prevent the formation of a deep vein thrombus. Each one patient suffered from DVT in the ISPC group (1.8%) as well as the non-ISPC group (0.8%). No PE occurred in the ISPC group, while two patients were attacked with PE in the non-ISPC group (1.6%). Although this showed no statistically significant difference in frequency of DVT and PE, ISPC can be an effective prophylactic device for both DVT and PE as well as a safe and convenientone.

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