CEA antigen is a membrane-bound phosphatidylinositol anchor, and is released from cancer cells with phosphatidylinositol phospolipase c (PIPLC). By useing of this phenomenon, we produced a novel kit for peritoneal irrigation cytology. The peritoneal sediment obtained from peritoneal irrigation and filtered through a glass microfibre filter was fixed on a plate coated with anti-CEA antibody and 0.05 U of PIPLC was added. The reaction was considered positive if there was a color difference between the plates with PIPLC and without it after incubation for 60 minutes and colored by the sandwich method (PIPLC-kit). The PIPLC-kit and conventional irrigation cytology (cytology) were compared in 63 gastric cancer patients. All of the 16 patients showing a positive reaction by cytology were also all positive by the PIPLC-kit, while the 47 patients negative by cytology 5 patients were positive by the PIPLC-kit. Moreover, of the 52 patients without macroscopic peritoneal metastases 5 were positive by cytology and 10 by the PIPLC-kit. The above results suggest that the PIPLC-kit is a useful and simple assay system for the detection of early peritoneal dissemination.

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An immunohistochemical study was conducted by the ABC method for p53, c-erb B2, cyclin E and CD44 on formalin-fixed, paraffin-embedded slices obtained from 21 specimens of lymph node metastasis (n (+) group) from a total of 326 patients with early gastric cancer who underwent surgery between 1986 and 1995. The incidence of positive cases was compared with that in 40 controls (n (-) group). The incidence was significantly higher in the metastasis group than in the controls for p53, cyclin E and CD44. Thirty-three percent of the cases in the n (+) group and 8% of those in the n (-) group were positive for all three genes. All 7 of those who were strongly positive for cyclin E or CD44 were in the n (+) Group. Among the 29 patients who underwent surgery in 1996, four, including two with metastasis, were assessed as at high risk for lymph node metastasis based on the biopsy results. These findings indicate that consideration must be given to the fact that the risk of lymph node metastasis is extremely high in patients positive for p53, cyclin E and CD44, and that a judgement that can be used to assist in the selection of the most suitable therapy or surgery can be made prior to medical treatment at the time of biopy.

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To clarify the protective effect of induced heat shock protein (HSP) on hepatic ischemia-reperfusion injury, we determined the HSP 72 content and distribution after heat stress in normal and cirrhotic livers of rats by immunoblotting and immunostaining using anti-HSP 72 antibody, and then investigated DNA damage of the hepatocellular nuclei and measured the serum mitochondrial (m)-GOT value following inflow occlusion. The amount of HSP 72 was the highest 48 hours after the heat stress in both normal and cirrhotic livers, which was 3.9 times as high as in normal liver and 3.5 times as high in the cirrhotic liver as the pretreatment value. As for liver injury after inflow occlusion for 60min in normal livers, there were no statistical differences in DNA damage and m-GOT values between the control and the HSP 72-induced group at the end of inflow occlusion. However, one hour after reperfusion, those damages were significantly lower in the HSP 72-induced group than in the control. On the other hand, in cirrhotic livers, there were no significant differences between the control and the HSP 72-induced group either at the end of ischemia or one hour after reperfusion. Consequently, it was concluded that a hepatic ischemiareperfusion injury can be reduced by the preinduction of HSP 72 in normal livers but not in cirrhotic livers.

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Ninety-one patients with colorectal cancer with synchronous liver metastasis in the last 15 years, who underwent bowel resection with an adequate surgical margin, were selected for this study. The 5-year survival rate was 19.9%, and 8 of the patients survived for 5 years after the initial surgery. The 5-year survival rate for 40 patients who had undergone surgical resection of liver metastases was 29.1% and in 36 patients without resection it was 4.9%, demonstrating that the prognosis for the former was significantly better than for the latter. In this study the 5-year survival rate for patients according to the degree of liver metastasis were as follows: 31.1% vs 0% for H1 and 42.9% vs 0% for H3 (resection vs non-resection). In the case of liver resection, the numbers of liver metastases, size of the liver metastasis or extent of liver resection did not correlate with the prognosis. In view of the results, aggressive surgical resection may be an efficient treatment of multiple liver metastases.

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Two hundred fifty five patients were selected for this study to evaluate appropriate management for early cancer of the rectum. One hundred eighty two patients had mucosal cancer and 73 had submucosal cancer. No patients had lymph node metastasis with mucosal cancer or submucosal cancer limited in sm1, therefore endoscopic resection or local resection is feasible those patients. The deeper in submucosa the cancer invasion, the greater the incidence of vascular invasion and lymph node metastasis. But the incidence of lymph node metastasis was low (10%), therefore radical resection, such as abdominoperineal resection of the rectum (APR), should not be avoided. The depth of cancer invasion of patients with lymph node metastasis was deeper than sm2, and these patients had vascular invasion. Therefore the radical resection with lymph node dissection should be indicated only if the patients have both deeper than sm2 and vascular invasion which are confirmed by the specimen after endoscopic resection or local resection.

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In the 14 years from 1980 to 1993, we experienced 171 patients with cura A lower advanced rectal cancer who had received D2 or D3 lateral dissection. Those patients were examined regarding rational lateral dissection for lower rectal advanced cancer. Stage II, IIIa and stage IIIb without lymph node metastasis to the 2nd lymph node group or more, accounted for about 90% of all cases, there was no significant difference in the accumulated survival rates between the D2 and D3 dissection groups. On the other hand, in the D3 dissection group with lateral lymph node metastasis to the 2nd lymph node group or more, the other 10% of all patients, half of them had nong-term survival, over 5 years. Therefore we should carry out lateral dissection along the surface of the internal iliac artery, so-called D2 dissection, for lower advanced rectal cancer, and D3 dissection should be carried out in the patients who were judged as positive for metastasis in the lateral 2nd or 3rd lymph node group for pathological assessment during surgery. As for the patients with extra capsular lesions, the lesions are not curable by surgery alone.

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We report a case of gastric necrosis caused by acute gastric dilatationafter an episode of bulimia. A 66-year-old man entered Mito National Hospital with complaints of progressive abdominal pain and distention.He had been in another hospital for treatment of a psychiatric disease.The gas within the gastric wall was observed as lines of bubbles on plain films.Bubbles within the gastric wall, gas within the portal vein in the Iiver and massive gastric dilatation were observed on CT scans.Although no episode of bulimia before the onset was known, the findings of x-ray and CT confirmed the bulimia and the diagnosis of gastric necrosis caused by gastric distention.An emergency laparotomy was performed. Much ingested food was in the stomach and almost the whole gastric mucosa was necrotic except part of the antrum.Total gastrectomy and Roux-Y esophagojejunostomy were performed.Patients suffering from psychiatric disease with severe abdominal pain and distension may suffer from gastric necrosis after bulimia, although it is definitely uncommon.For the diagnosis, x-ray and CT scanning are very valuable.

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A 68-year-old woman was found to have an abnormal shadow of the stomach by upper gastrointestinal series at an annual physical examination. She was diagnosed as having gastric cancer by upper endoscopy. Abdominal ultrasonograply and a CT scan also revealed a polyp in theneck of the gallbladder. She underwent gastrectomy and cholecystectomy. A lesion in the gallbladder, 5×5mm in diameter, was a subserous tumor. Pathohistological examination of the excised specimen revealed heterotopic pancreatic tissue of the Heinrich I type.

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A 65-year-old Japanese man presented with right hypochondrial pain. Ultrasonography detected a 5cm heterogeneous mass in the fundus of the expanded gallbladder. Abdominal computed tomography showed the mass infiltrating to the surrounding tissue and angiography demonstrated the mass as a hypervascular lesion. Endoscopic retrograde cholangiography showed complete occlusion of the cystic duct. Extended cholecystectomy was performed under the tentative diagnosis of gallbladder fundal carcinoma. Macroscopically, the resected specimen showed a mass in the fundus and an irregular small mass in the neck of the gallbladder. An intraoperative frozen section revealed that the fundic mass was xanthogranulomatous cholecystitis (XGC) and the tumor in the neck was well-differentiated adenocarcinoma. Extrahepatic bile duct resection was performed together with radical lymph node dissection. We report this case of gallbladder neck carcinoma presenting as xanthogranulomatous cholecystitis, briefly discussing the differential diagnosis between XGC and gallbladder carcinoma and the relationship of the two conditions.

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A 63-year-old woman with a history of severe acute pancreatitis was admitted to our hospital for the treatment for a gallbladder stone and a pseudocyst of the pancreas. Abdominal computed tomography and ultrasonography showed an elevated lesion in the fundus of the gallbladder with many gallstones. Endoscopic retrograde cholangiopancreatography revealed an anomalous pancreaticobiliary junction with about 4 cm of the common canal without dilatation of the common bile duct. Resection of the gallbladder and the common bile duct with Roux-en Y hepatidocho-jejunostomy were performed. In the gallbladder were 15 small gallstones and many elevated lesions, which were pathologically diagnosed as papillary adenocarcinoma of the gallbladder intraoperatively. Although severe acute pancreatitis with an anomalous pancreaticobiliary junction is rarely reported, some additional factors such as gallstones might have made the pancreatitis severe. Postoperative magnetic resonance cholangiopancreatography (MRCP) in this case clearly showed the anomalous junction, suggesting that noninvasive MRCP is very useful for the diagnosis of this anomaly especially when pancreatitis with it is associated.

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We report a rare case of ileal mesenteric varices with Wilson's disease. A 28-year-old woman diagnosed as having Wilson's disease who had been treated by penicillamine and trientine for 10 years was admitted to the hospital because of recurrent melena. Abdominal angiography revealed ileal mesenteric varices shunting to the right ovarian vein. We partially resected the ileum including the varices without any additional decompression surgery. The portal vein pressure was 20cmH₂O. The patient showed no problems 15 months after the operation. We suspected that the pathogenesis of the mesenteric varices in this case was related to a previous appendectomy.

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A 52-year-old man visited our hospital in October 1996 because an abnormal shadow was found on gastrograms during a general health check up. Six years earlier, a left renal cancer had been treated by left nephrectomy and interferon had been injected postoperatively for 6 month. Gastric cancer was diagnosed by endoscopy. Upon laparotomy, tumors were found on the gastric wall and also in the beginning of the jejunum. Distal gastrectomy and lymph node dissection were performed for the gastric cancer and partial resection of the jejunum for the jejunal tumor. The jejunal stump was anastomosed to the second portion of the duodenum side-by-side, and then gastrojejunostomy was performed end-to-side. The jejunal tumor was 6×9cm in diameter and its microscopic findings revealed malignant lymphoma of mucosa-associated lymphoid tissue. After surgery, chemotherapy was administered for the lymphoma and the patient has been alive for 19 months without any sign of recurrence.

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Fitz-Hugh-Curtis symdrome (FHCS) is characterized by perihepatitis due to infection of Chlamydia or Gonococcus. We experienced an interesting case of FHCS which became ileus and required surgery. A 21-year-old woman was admitted to our hospital because of pain from the right epigastric resion to the umbilical resion, and vomiting. Clear intestinal dilatation and niveau formation were recognized on the abdominal X-ray, so she was diagnosed as having ileus. In spite of insertion of an ileus tube, the symptoms remained, so surgery was carried out. The laparoscope showed many violin-string type fibrous cords between the surface of the liver, the intestine, the omentumand the abdominal wall. This fibrous cord was wrapped around the ileum and hindered passage. The uterus and ovarium turned red. From the surgical findings and the presence of serous Chlamydia trachomatis antibody, she was diagnosed as having FHCS due to Chlamydia trachomatis infection, with ileus. Recently, Chlamydia infection as a venereal disease has been on the increase, and tests for FHCS should be administered to sexually active females who show right epigastralgia as in the above example.

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A case of Peutz-Jeghers type solitary hamartoma of the jejunum with bloody stool and intussusception is reported. The patient was a 47-year-old man. He was examined in our hospital because of a chief complaint of bloody stool on October 2, 1996. Contrast roentgenography of the small intestine revealed a tumor in the jejunum. One week later, abdominal ultrasonography and CT showed target-shaped thickening of the small intestine suggesting intussusception of the small intestine. However, there were no symptoms in the abdomen. Reexamination by contrast roentgenography of the small intestine showed good passage and no intussusception of the small intestine. He was diagnosed as having intussusception caused by a tumor in the jejunum and received an operation on November 26. Intussusception of the jejunum, 50 cm from the ligament of Treitz, was found. After manual repositioning, a 20-cm length of the jejunum including the tumor was resected. The resected specimen showed a pedunculated tumor with a lobulated head. The pathological diagnosis was Peutz-Jeghers type hamartoma. Our case showed a interesting course that an asymptomatic intussusception caused by hamartoma naturally improved. As hamartomas are benign, jejunotomy and polypectomy are considered to be better method than resection of the jejunum.

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We report a case of pseudocyst of the jejunal mesentery in an adult patient. A 34-year-old woman was admitted for a palpable abdominal mass of increasing size. The patient had a medical history of a indirect inguinal hernia and no injury. Abdominal ultrasonography and computed tomography revealed an apparent unilocular cyst about 7 cm in diameter. Abdominal magnetic resonance revealed that the superior component of the cyst was hyperintense on T2 images and even more so on T1 images, and the inferior component of the cyst was hyperintense on both T1 and T2 images. We made a preoperative diagnosis of a cyst of the jejunal mesentery. After laparotomy, the cystic mass, which indeed measured 7 cm in diameter, was found in the mesentery of the jejunum and was resected. The content of the cyst was pale yellow muddy fluid. Microscopically, its wall consisted of fibrous tissue without an epithelial lining, suggesting that it was a pseudocyst arising from the jejunal mesentery. Such pseudocysts of the mesentery are extremely rare, there are only nine cases including ours in the literature in Japan.

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A 32-year-old man was referred to our hospital because of left abdominal pain. Under the diagnosis of acute peritonitis by palpation and CT findings, emergency laparotomy was performed. Operative findings revealed superior mesenteric venous thrombosis with local eruption in the ileum. The ileal lesion was resected with end to end anastomosis. Three days after the operation, he complained of severe abdominal pain and CT showed edema of the small intestine and ascites. A reoperation revealed recurrence of the thrombosis, and the same procedure as the first operation was performed. Immediately after the operation, anti-coagulation therapy was in. He had no particular past history, but his father and brother had suffered from superior mesenteric venous thrombosis. Coagulation study showed lower levels of protein S antigen and activity. This is thought to be a case of superior mesenteric venous thrombosis due to protein S deficiency.

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We encountered a case of external intestinal fistula that developed after resection of the colon and had been left untreated for 44 years. This report describes the functional and histological changes of the long-diverted large intestine and anus, detected during the treatment. The patient was a 69-year-old man who consulted our hospital with the chief complaint of dermatitis around the intestinal fistula. Only the sigmoid colon and rectum of the large intestine remained, and there was a subcutaneous anastomosis with the ileum, forming an external intestinal fistula. In the rectal biopsy specimen, mucosal chronic inflammatory infiltration, crypt distortion and atrophy, and surface erosions were detected histologically. We resected the intestinal segment containing the fistula and performed an ileoproctostomy. For two months postoperatively, aqueous soft stools were seen. This was presumably caused by dysfunction of water absorption due to disuse. Rectal biopsy performed three months later revealed that the inflammatory findings had disappeared. Though maximum resting pressure of the anal canal was as low as 40 cmH₂O before surgery, it had recovered to 80 cmH₂O three months postoperatively. It was thought that the decreased sphincteral function recovered as a result of reuse of the anus.

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Crohn's disease confined to the appendix is rare and we found reports of only 10 other cases in Japan. We present a case of Crohn's disease of the appendix in a 20-year-old man. He was admitted to our hospital with complaints of pain in the right lower quadrant. Physical examination at that time had revealed rebound tenderness and muscle guarding of the right lower quadrant of the abdomen. Abdominal ultrasonography and an abdominal CT scan revealed a swollen tumor shadow in the ileocecal region. The preoperative impression was appendicitis. A laparotomy was performed and the appendix was found to be inflamed, and markedly enlarged (35× 30mm). An appendiceal tumor could not be excluded and ileocolectomy with D2 lymphnode clearing was performed. Histologically, the specimen had a fullthickness appendiceal wall showing inflammation with lymphoid aggregation, a fissuring ulcer and non-caseating small granuloma. As a result of histologically findings, we diagnosed this as a case of Crohn's disease of the appendix. He has had no sign of recurrence of the disease for a 2-year follow-up period.

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The patient was a 68-year-old man with rectal carcinoma admitted to our service because of hepatic coma. On admission, the blood ammonia level was 191μg/dl. The venous phase of a superior mesenteric and celiac angiogram showed a dilated, tortuous collateral vein, 2cm in diameter, extending from the superior mesenteric vein to the inferior vena cava, with the contrast medium draining into the inferior vena cava through it. The portal vein was not visualized. After occlusion of the collateral vein by a balloon, the contrast medium drained to the liver through the portal vein and the wedge pressure of the hepatic vein rose from 17 mmHg to 20 mmHg. Ligation of the collateral vein and abdominoperineal resection was performed with a diagnosis of rectal carcinoma with portosystemic encephalopathy. Intraoperative manometry of the portal vein showed a 33% rise in pressure after ligation of the collateral vein. Postoperatively, the encephalopathy resolved without varix formation in the esophagus or stomach during the year of follow-up to date. The blood ammonia level has decreased, and liver function has improved. Because it is capable of both improving the portosystemic encephalopathy and improving liver function, obliteration of the portosystemic shunt appeared to be a meaningful method of treatment that should be aggressive performed.

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Papillary dilatation using a balloon-tipped bilary catheter positioned across the papilla through the common bile duct, was performed for the treatment of 10 cases with bile duct stones. The balloon catheter was inserted into the common bile duct through the fistula of the percutaneous transhepatic biliary drainage in 4 cases, via the cystic duct during laparoscopic cholecystectomy in 5 cases, and through the fistula of the trans-cystic duct drainage tube after laparoscopic cholecystectomy in 1 case. Before the balloon dilatation of the papilla, precutaneous transhepatic cholangioscopy with pulsed dye laser lithotripsy was performed in 4 cases, in which the bile duct stones were over 10 mm in diameter. In 9 cases, balloon dilatation of the papilla was successful in removing the bile duct stones, but endoscopic sphincterotomy was required after the procedure to remove the residual stones completely in 1 case. After the procedure, the serum amylase level was elevated in 2 cases, but acute pancreatitis did not occur. Cholangitis was observed in 1 case. There has been no mortality to date. Recurrent stones were experienced in only 1 case. This technique was useful to remove bile duct stones safely and easily.

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