In order to determine the efficacy of total parenteral nutrition (TPN) as the postoperative nutritional mangement for thoracic esophageal cancer patients, we conducted a prospective randomized clinical trial, comparing enteral nutrition (EN) with and without TPN, EN alone and EN+TPN. Twenty-two patients who underwent total esophagectomy and reconstruction using a gastric tube with right thoracolaparotomic cervical manipulation were preoperatively randomized to either the EN alone group (n=10) or the EN+TPN group (n=12). In both groups, EN was started on the 3rd postoperative day (POD) at an initial dose of 5 kcal/kg/day (non-protein calories) and was gradually increased to a full strength of over 30 kcal/kg/day on POD 8 through jejunostomy. In the EN alone group, intravenous infusion of which the content was similar to that of extracellular fluid was administered peripherally. In the EN + TPN group, TPN was started at a dose of 20 kcal/kg/day on POD 1 and on the following days a total of over 30kcal/kg/day was maintained by TPN plus EN. Nitrogen balance, nutritional parameters, liver function, postoperative complications and medical expenses were evaluated. In the EN alone group, nitrogen balance became positive on POD 10. On the other hand, in the EN+TPN group, it was positive on 3rd and 9th POD, indicating a biphasic curve. In the changes in total protein, albumin, rapid turnover proteins and 3-methyl histidine, no statistically significant differences between the two groups were observed. However, the levels of blood urea nitrogen. GOT and triglyceride in the EN+TPN group were significantly higher than those in the EN alone group. Cost saving was achieved in the EN alone group. These results suggest that TPN is not absolutely necessary for the postoperative nutritional management of thoracic esophageal cancer patients, if EN can be started on the 3rd POD.

View full abstract

Reconstruction after proximal gastrectomy is still controversial. To compare the results of the two different reconstruction methods, 24 patients with relatively erly staged gastric cancer who underwent proximal gastrectomy were analyzed retrospectively. Ten patients received esophagogastrostomy (EG group) and 14 received single jejunal interposition (JI group). The mean operation time of the EG group was significantly shorter than that of the JIgroup. There was no significant difference in the bleeding volume and postoperative stay, but the EG group showed less blood loss and shorter hospital stay. Regarding anastomotic stenosis, one patient in the EG group had a symptom of dysphagia and 11 patients in the JI group had that. Eight of the 11 patients in the JI group received endoscopic dilatation ofthe anastomotic stenosis. However only one of the 10 patients in the EG group received such procedure. Concering reflux esophagitis, there were three patients in the EG group whichhave hearburn but seven in the JI group. Endoscopic findings of reflux esophagitis were present in four patients in the EG group, and none in the JI group. The nutritional status and the body weight change showed no difference between the two group. The fact that the JI group only showed the better result of endoscopic findings of reflux esophatitis but showed no better results concering postoperative symptoms than that of EG group, leads the conclusion of the necessity to improve the method of jejunal interposition after proximal gastrectomy.

View full abstract

The purpose of this study was to determine the prognostic significance of the number of dissected perigastric lymph nodes in gastric cancer. A total of 223 patients with nodal involvement who underwent a curative distal gastrectomy with D2 or D3 lymphadenectomy were included in this study, They were classified into three groups according to the total number of metastatic lymph nodes; 1-2, 3-6, 7 or more. In each group, survival rates were compared between patients with a total number of dissected perigastric nodes (#3, 4d, 5, and 6) of 20 or more and those with 19 or fewer. In patients with a number of metastatic lymph nodes of 1-2 and 7 or more, no significant difference in survival rate was observed between those with 19 or fewer perigastric nodes dissected and those with 20 or more. In patients with 3-6 positive nodes, however, those with 19 or fewer perigastric nodes dissected had a significantly lower survival rate than those with 20 or more. Five-year survival rate were75% and 92%, respectively (p<0.05). No differences exsisted between the two groups in clinicopathologic background, D-number, or a number of the second level lymph nodes dissected. Perigastric lymph nodes may act as a line of defense to prevent metastases to distant nodes in gastric cncer.

View full abstract

To determine the clinical role of abnormality in the P53-dependent apoptosis pathway, immunohistochemical analysis was performed in patients with gastric carcinomas. The subjects of this study were 30 patients who were treated by preoperative chemotherapy for gastric carcinomas. 17 patients were medicated with 5'DFUR (p.o. group) and 13 patients were injected with CDDP (i.v. group). We choiced p53, Bax and Bc1-2 in the biopsy materials before chemotherapy for parameters. And we choiced histological evaluation, Ki-67 labeling index after chemotherapy and positive rate of Lewis Y antigen after chemotherapy for grades of chemotherapeutic effect. The positive rate of Lewis Y antigen after chemotherapy correlated with histological evaluation of chemotherapy both in p.o. group and in i.v. group (p<0.05). At i.v. group, the p53-positive group showed poor responses to chemotherapy both in histological evaluation and in positive rate of Lewis Y antigen after chemotherapy (p<0.05). At p.o. group, the P53-positive group showed poor response to chemotherapy in histological evaluation (p<0.05). These results indicate that, in gastric carcinomas, expressionof P53 in the biopsy materials before chemotherapy predicts a poor response to preoperative chemotherapy.

View full abstract

One hundred and fifteen patients have received autonomic nerve-and plexus-preserving paraaortic lymph node dissection for advanced gastric cancer (depth of tumor invasion to more than the muscle layer) during the last 5 years in our department. These patients were classified into four groups: 1) all nerves and plexuses preserved (bilateral major and minor splanchnic nerves, bilateral celiac plexuses and SMA plexus), n=61; 2) right side preserved, n=47; 3) left side preserved, n=4; and 4) all nerves and plexuses resected, n=3. The rate of paraaortic node involvement was more than 20% in the cases in which the depth of the tumor invasion was to more than the subserosal layer. It was not useful for the patients in whom the number of involved paraaortic nodes was more than 15 or in whom all sites of the paraaortic node area were involved. The 5-year survival rate for the patients with extended lymph node dissection (paraaortic node dissection, D4), whose tumors invaded to the serosal layer or other organs, was significantly better than those receiving conventional nodedissection (D2). Paraaortic node dissection preserving the splanchnic nerves, celiac plexus and SMA plexus (all preserved or right side preserved) was useful because the rate of occurrence of post-operative watery diaarhea was less than 4%, and there was no paraaortic node recurrence. However, male sexual function (ejaculation) was poor in the patients receiving paraaortic node dissection.

View full abstract

Cytological examintion of lavaged peritoneal fluid taken from 557 gastric cancer patients was performed to determine the relationship between positive cytology, reveral clinicopathologic parameters, and prognosis. The incidence of positive cytology was 13.6%, and no positive cytological findings were revealed in the groups in which tumor invasion was confined to the mucosa, submucosa, or the muscularis propria. The rates of positive cytology in patients in which depth of invasion was subserosa, serosaexposed, and serosainfiltrating were 11.8%, 29.8%, and 45.0%, respectively. The prognosis of the patients, having no peritoneal metastasis, but with positive cytology, was significantly poorer than that of the patients with grade P₁ dissemination (p=0.017). Prognostic factors were determined in 288 patients with advanced gastric cancer by multivariate analysis using Cox's proportional hazard mode. The tumor invasion was the strongest prognostic variable (p<0.001), and the peritoneal cytological examination (p=0.012). Peritoneal lavage cytology was judged to be an independent prognostic factor. The patients with positive lavage cytology had a significantly higher rate of recurrence in the peritoneum (p<0.001). The se results indicate that peritoneal lavage cytology may be a positive method in determining the potential of the recurrence in the peritoneum, or the prognosis of patients with gastric cancer.

View full abstract

We have produced the sustained release type 5-Fluorouracil (5-Fu) for the purpose of the inhibition of liver metastasis of the gastrointestinal tract carcinomas and evaluated its hemodynamics.After 10mg/kg of sustained release type 5-Fu (Sustained release group) had been administered into the rabbit duodenum, the blood sample was taken from the portal vein with specific intervals.The concentration of 5-Fu reached the plateau three hourse after the administration and the high concentration higher than 700ng/ml was maintined.The concentration of the peripheral blood sample which was taken simultaneously was lower than 100ng/ml.On the other hand, the portal concentration of presently available 5-Fu (Control group, 10mg/kg) reached the maximum concentration of 2600mg/ml followed by the straight lined decrease.The mean retaining time (MRT) was 3.6 hours in sustaiend release group and 1.9 hours in control group.We conclude that our sustained release type 5-Fu maintain high portal concentration and the low peripheral concentration for the prolonged time.It is effective for the local treatment of liver metastasis which is targetting portal vein.

View full abstract

We experienced a case of tracheoesophageal fistula following blunt cervical trauma. A 57-year-old man was hit directly by falling cargo at work. His left temple, face and neck were injured. Confusion, dyspnea and hemoptysis occurred, but hemoptysis was immediately decreased by insertion of a tracheal tube. The tracheal tube was removed on day 5 after admission, then swallow-cough occurred. CT and esophagography revealed a tracheoesophageal fistula. An operation was carried out 11 months after the injury. The fistula was located in the 4th-6th cartilagines tracheales and it's major axis was 1.3cm. The fistula was divided, the trachea was closed with a single layer of 4-0 PDS II, and the esophagus was closed in two layers with 3-0 vicryl sutures. Though a muscle was not interposed between the trachea abd the esophagus, recanalization had not been seen up to now.

View full abstract

Carcinosarcoma is not very rare in the uterus, breast and esophagus, but is very rare in the stomach. We present a case of gastric carcinosarcoma in a 74-year-old woman. She complained of dysphagia. We found a tumor growing in the cardia and the lower esophagus. As the tumor was diagnosed as gastric cancer invading to the lower esophagus, total gastrectomy and lower esophagectomy was performed. The pathologic diagnosis was carcinosarcoma of the stomach. As the sarcomatous component was welldifferentiated to chondrosarcoma, we concluded that the tumor is a true carcinosarcoma. Most of the carcinosarcomas previously reported are “so-called carcinosarcoma” in which “sarcomatous component” is spindle cell sarcoma, not showing definite differentiation toward a specificorgan or tissue. There are only four reported cases of true carcinosarcomas in which the sarcomatous component was differentiated to the specific nonepithelial cell. In this case, we considered that the carcinoma cell acquired the ability to produce cartilaginous tissue histologically and immunologically.

View full abstract

A 70-year-old man was admitted to our hospital because his serum ALP, LDH and γ-GTP levels were elevated. Ultrasonography and computed tomography showed a 3×3 cm mass in the head of the pancreas. A pancreatic malignancy was strongly suspected from other extensive investigations with MRI, ERP, MR-cholangiography, and abdominal angiography. At laparotomy, a firm mass was found around the intrapancreatic bile duct, and it had invaded to the replaced right hepatic artery, therefore pan creaticoduodenectomy was performed. The final histological diagnosis was malignant lymphoma of the common bile duct, follicular, mixed cell type with B-cell nature. The patient was healthy with no evidence of recurrence for 3 years. Primary lymphoma of the common bile duct is extremely rate, and there have been only four detailed reports in the literature previously.

View full abstract

The acute superior mesenteric artery occlusion associated with hepatic portal venous gas (HPVG) has a grave prognosis, and only three survivous have been reported in Japan. Here we report one more survival. A 71-year-old man, who had a past history of atrial fibrillation, suddenly complained of severe upper abdominal pain. Abdominal computed tomography revealed HPVG, and an emergency laparotomy was performed about 32 hours after the onset. The operation revealed extensive necrosis of the bowel from the jejunum to the transvers colon. All of the necrotic bowel was resected and end-to-end jejunocolostomy was performed. The length of the intact small intestine was only 24cm. In the resected specimen, submucosal gas bubbles were observed, and this state was considered to be pneumatosis cystoides intestinalis. The postoperative course was uneventful. Because of the grave prognosis of bowel necrosis with HPVG, laparotomy should be performed as early as possible, if peritonitis with HPVG is suspected.

View full abstract

A case of necrotic Meckel's diverticulum due to torsion at its neck, resulting in peritonitis, is reported. A 35-year-old man was admitted with the complaint of severe lower abdominal pain. Emergency laparotomy was performed under the diagnosis of acute peritonitis. Meckel's diverticulum, 70× 40× 30 mm in size, was found on the ileum about 50cm proximal to Bauhin's valve. It was twisted about 360° counterclockwise at its neck and necrotized. The Meckel's diverticulum was resected. Torsion is a rare complication of Meckel's diverticulum, and we found reports of only 10 other cases in Japan. Those diverticula were also large, greater than 6cm in length, and had a narrow neck. It is reported that large size and a narrow neck of the diverticulum may be an anatomical factor in torsion of Meckel's diverticulum. In our case, we thought that the peritonitis was the result of torsion of Meckel's diverticulum with the same factor.

View full abstract

Case report of mesenteric fibromatosis is rare.Especially it without polyposis coli or surgical intervention is very rare.61-year-old man was admitted to the hospital complained of abdominal tumor. Abdominal ultrasonography, computed tomography, and magnetic resonance imaging revealed a tumor that may have developed from the large omentum or mesenterium.He underwent laparotomy.A tumor was found in the mesenterium of the ileum approximately 150cm from the ileocecal valve.The tumor, measuring 75×75×50nm in size had a solid and gray cut surface.The histological diagnosis was mesenteric fibromatosis. He is alive 1 andahalf year after the surgery and has no sign of recurrence.

View full abstract

Two cases of small intestinal malignant lymphoma with perforation are reported. The first case was a 37-yer-old woman who was admitted for right lower abdominal intensive pain. Emergency laparotomy was performed, and elastic hard tumors with perforation were found on the oralside of the ileocecal valve. Then ileocecal resection was performed. After the operation, which was not curative, the patient was diagnosed as having stage IV lymphoma. Chemotherapy had been expected to be effective, but it was not so effective. She died 11 months after the operation. The second case was a 71-year-old man who was admitted for lower abdominal intensive pain. He underwent on emergency operation with diagnosis of perforated peritonitis. By laparotomy an elastic hard tumor was found on the oralside of the ileocecal valve, and the ileum was partially resected. After the operation he was diagnosed as having stage III lymphoma. Postoperative chemotherapy was especially beneficial, and the patients is very well at the 10 th month after the operation. It is considered that staging and results of chemotherapy determine the prognosis.

View full abstract

Surgery should be a curative and minimally invasive treatment for early gastric cancer. Therefore we need to know the biology of malignancy of gastric carcinoma. We established a new cell line, AZ-H5c, which has a high potential of metastasis to the nude mice liver, from the human gastric carcinoma line AZ521. Experimental studies revealed that, compared with AZ521 cells. AZ-H5c cells moved more actively, had stronger enzymatic activity of MMP-9, and expressed higher levels of integrin alpha 1, alpha 2, alpha 3, slpha 4, alpha 5, integrin beta 1 and CD44v3. Based on the above information, we investigated the clinico-pathologic characteristics of patients with carcinoma of the stomach. There were significant correlations of integrin alpha 2 and lymph node metastasis and integrin alpha 3 and liver metastasis. There was no correlation of clinico-pathologic characteristics and the expression of MMP-9, nor was the MMP-9 staining pattern related to survival. To foster the development of more effective, minimally invasive surgery, we should continue to accumulate data on gastric carcinma so as to improve diagnostic accuracy regarding lymph node metastasis, the pattern of recurrence and other factors.

View full abstract

To investigate the role of collagens in gastric cancer tissues with regard to cancer invasion and metastasis. We homogenized cancer tissues and measured the collagenolytic activity against type I and IV collagens in tissue homogenates. We also studied the location of a tissue inhibitor of metalloproteinase- 1 (TIMP-1) in gastric cancer tissues by the immunoperoxidase staining procedure and measured the serum levels of TIMP-1 in patients before the operation for gastric cancer. We compared these results in scirrhous and non-scirrhous types of gastric cancer. Collagenolytic activities against both type I and IV collagens in the non-scirrhous type were significantly higher than those in the scirrhous type (p<0.01). TIMP-1 was stained on collagens in cancer tissues and therefore a large amount of TIMP-1 was present in the scirrhous type. The serum level of TIMP-1 in undifferentiated cancer was high (p<0.05), especially in the scirrhous type (p<0.025). These results suggest that gastric cancer cells forming the scirrhous typemight have the ability to accumulate collagens in cancer tissue and that cancer cells should use the dynamic biological activity of the extracellular matrix and then invade the stomach wall. Because the TIMP level in the scirrhous type was higher in cancer tissue snd serum of patients than in the nonscirrhous type, the mechanism of cancer cell metastasis in the scirrhous type characterizing lymph node metastasis and peritoneal dissemination might be different from those in the non-scirrhous type characterizing venous metastasis mainly.

View full abstract

The expression of vascular endothelial growth factor (VEFG), matrix metalloproteinase (MMP)-2, -9, and membrane type matrix metalloproteinase (MT1-MMP) in surgical specimens of 74 colorectal cancer patients were evaluated by Northern hybridization and immunohistochemistry, and the difference between primary tumors and metastatic tumors was investigated. The expression of mRNA of these 4 molecules in the primary tumors with liver metastasis tended to be higher in those without liver metastasis. But gene expression in metastatic tumors of the liver was not always higher than in the primary tumors. The VEGF gene expression in the primary tumors with lymph node metastasis tended to be higher than in those without lymph node metastasis. Both VEGF and MMP-9 mRNA expression in the metastatic lymph nodes tended to be higher than in the primary tumors. Immunohistochemical staining for metastatic liver tumors showed that the expression of VEFG or MMP-2 protein was not observed in the cancer cells but in hepatocytes neighboring the metastatic nodules. These results suggest that the expression of VEGF or MMPs may be changed by the circumstances of target organs, and that cancer metastasis may be brough into being through an interrelationship among cancer, cells, stromal cells and hepatocytes.

View full abstract

We have investigated the role of stromal cells in the invasion and metastasis of gastrointestinal tract carcinomas. The extracellular matrix is degraded by a carcinoma during its spread, which is known to be caused by matrix metalloproteinases (MMPs). We observed the gene expression of MMP-1 by in situ hybridization in gastric and colorectal carcinomas and found that MMP-1 mRNA was expressed in the stromal cells and some inflammatory cells. A human gastric carcinoma cell line, MKN74, was co-cultured with human fibroblasts, resulting greater MMP-1 production than in the simple culture. Another gastric carcinoma cell line, TMK-1, was injected intraperitoneally into BALB/c nu/nu mice along with the conditioned medium of a human fibroblast culture. Five weeks after the injection the mice were sacrificed and the nodules resulting from peritoneal dissemination were counted. The carcinoma cells with fibroblast-conditioned medium formed more nodules than the carcinoma cells without it (p<0.05). On the basis of these obervations, we can speculate that the stromal cells play important roles during invasion and metastasis and also that the stromal cells affect the degree of malignancy of the tumor.

View full abstract

Pancreatic cancer characteristically has a high incidence of neural invasion, leading to a pessimistic prognosis of a curative operation. We have recently examined the possibility that trophic action of GDNF (glial cell line-derived neurotrophic factor) induces the directed migration of human pancreatic tumor cells toward neural tissues, by using an in vitro invasion assay for assaying chemotaxis and chemokinesis. In the invasion assay, marked migration of pancreatic cancer cells was induced by cocultivation with human glioma cells capable of producing GDNF and its extracellular secretion. Anti-GDNF antibody suppressed a majority of the migratory activity in the conditioned medium of glioma cells. The results led us to postulate that human pancreatic tumor cells expressing a c-ret proto-oncogene invade human ganglions along a concentration of GDNF, produced by neural tissues.

View full abstract

We conducted an immunohistochemical study on expression of the extracellular basement membrane component laminin (LM), the extracellular basement membrane-degrading enzyme matrix metalloproteinase-3 (MMP-3), and the cell adhesion molecule CD44 in common bile duct cancer tissue and investigated their relationship with clinicopathologic factors for this form of cancer. There was a negative correlation between LM and MMP-3 expression. The relationship between clincopathologic factors and these molecules was as follows. There was a negative correlation between histologic invasion and LM or CD44 expression, a negative correlation between stage and LM or CD44 expression, a positive correlation between stage and MMP-3 expression, a positive correlation between perineural invasion and MMP-3 expression, and a negative correlation between lymph node metastasis and LM expression. The cumulative postoperative survival rate differed significantly depending on the presence or absence of LM expression. These results suggest that interations between the extracellular matrix and basement membrane-degrading enzyme and adhesion molecules may play a role in the invasion and progression of common bile duct cancer, as is the case with other gastrointestinal cancers.

View full abstract

In order to augment the inhibitory effect on tumor invasion and metastasis, we synthesized a new pseudo-peptide of RGD sequence (FC-336) and examined its inhibitory effect on tumor metastasis in vivo and on the adhesion, migration and invasion of tumor cells in vitro. FC-336 significantly inhibited experimental lung metastasis produced by i. v. co-injection with B16-BL6 melanoma in a dose-dependent manner. The intraportal injection of FC-336 with colon 26-L5 cells, a highly liver-metastatic cell line of colon 26 carcinoma, resulted in marked suppression of metastatic colonies in the liver and reduction of the liver weight, whereas the co-injection of tumor cells with a high dose of RGDS led to slight inhibition of liver metastasis. Multiple i. v. injections of FC-336 after tumor inoculation or the co-injection of FC-336 with tumor cells caused significant inhibition of experimental liver metastasis. FC-336 significantly increased the survival rate for mice compared to untreated controls when co-injected intraportally with tumor cells or intravenously administered after tumor inoculation. Furthermore, FC-336 inhibited the invasion, migration and adhesion of tumor cells in vitro, but it was not more inhibitory than RGDS peptide. Zymographic analysis revealed that FC-336 inhibited the degradation of a gelatin substrate by matrix metalloproteinases (MMPs) produced by tumor cells, while RGDS peptide did not affect the enzymatic degradation. These results indicate that the pseudo-peptides of RGD sequence, possessing the inhibitory property of degradation by MMPs differently from the original RGD-containing peptides, may provide an advantageous and useful basis for preventing tumor metastasis.

View full abstract

To investigate the feasibility of thoracoscopic esophagectomy for thoracic esophageal cancer, we evaluated the number of mediastinal lymph nodes harvested, a picture of the mediastinum after en bloc lymphadenectomy by means of thoracoscopy, postoperative pain, postoperative pulmonary function, requirement of ventilatory support and postoperative complications. From September 1994 to February 1997, 37 patients with thoracic esophageal cancer underwent total esophagectomy with en block mediastinal lymphadenectomy by means of thoracoscopy. We compared this series with patients receiving esophagectomy for thoracic esophageal cancer by conventional thoracotomy. All patients tolerated the procedure well, and the thoracoscopic esophagectomy was successfully completed in all of them. The operating time for thoracoscopy was 199±43 min and the estimated blood loss was 359±250 ml. The number of mediastinal lymph nodes harvested was 8-48 (mean 23.6). Postoperative pain in the thoracoscopic group was significantly less than in the thoracotomy group (p<0.05 by t test). Postoperative pulmonary function of the thoracoscopic group was better preserved than in the thoracotomy group. Requirement of ventilatory support and postoperative complications of the thoracoscopic group were, however, similar to those of thoracotomy group. Conclusions: The completeness of mediastinal lymph node dissection is equivalent to that of the conventional open technique. Though thoracoscopic esophagectomy is much less invasive than the open technique, we find it difficult to say that thoracoscopic esophagectomy is truly a minimally invasive operation.

View full abstract

Minimally invasive surgery (MIS) was used for early gastric cancer, and the long-term survival and quality of life (QOL) were evaluated according to the method of surgery. Mucosal gastric carcinoma (m-carcinoma) without an ulcer and/or scar was an indication for MIS, because our previous study showed that there was no lymph node metastasis of m-carcinoma less than 2.5cm in the cohort of the resected 1, 000 early gastric cancer cases. MISs included endoscopic mucosal resection (EMR), laparoscopic surgery (LAP) and modified radical gastrectomy (D1 + #7 operation). Differentiated adenocarcinoma less than 1cm was an indication for ERM, the elevated type less than 2.5cm and the depressed type less than 1.5cm were resected by LAP, and the other m-carcinomas without ulcer and/or scar were treated by the D1 + #7 operation. LAP consisted of the lesion-lifting method for the lesions in the anterior wall and intragastric mucosal resection for the lesions in the posterior wall. The postoperative survival of the treted patients was almost the same as that after the standard radical gastrectomy (D2 operation), and their postoperative QOL was found to be better than that after the D2 operation. These MISs were thought to be appropriate in improving the postopertive QOL without the loss of survival benefit.

View full abstract

In the four years from 1993, we have performed our original laparoscopic operation, namely, laparoscopic intra-gastric surgery (L.I.G.S.) on patients with early gastric cancer. The indications for L.I.G.S. have been generally limited to the early gastric cancer. Twenty-one patients with early gastric cancer, 15 with carcinoma limited in the mucosal layer (m-cancer) and six with carcinoma invaded to the submucosal layer (sm-cancer), were operated on by L.I.G.S. in this series. Two patients were converted to mini-open surgery because of the intra-operative complications, such as bleeding or minor perforation. No major postoperative complications were encountered in this series. In all 15 patients with m-cancer, no recurrence was observed. However, mucosal recurrence was found in two out of the six patients with sm-cancer, which has so far been well controlled by gastrofiberscopic laser and/or electrocautery. Therefore, the indications for this technique for the early gastric cancer might be extended to the patients with m-cancer of any age. We believe that L.I.G.S. will play an important role in the treatment of early gastric cancer which cannot be technically removed by endoscopic mucosal resection.

View full abstract

Laparoscopic surgery is now widely acceped because it has resulted in redused pain, early discharge, and good cosmesis. Thirty-six patients with early-stage gastric cancer were treated by laparoscopyassisted distal gastrectomy (LADG). To clarify the accuracy and problems of the present indications for LADG, we examined the reasons for select of LADG, the precision of the depth diagnosis before the operation, and of the histological depth examinations. Sixty-two percent of the LADGs were selected because the lesions were mucosal cancers with large size or ulceration. The accuracy of the preoperative depth diagnosis was 91% for mucosal carcinomas and 50% for submucosal carcinomas. Histological examination revealed that only 3 submucosal cancers had regional lymph node metastasis (n1). Because LADG dissected regional lymph nodes, all patients received the operation with high probability of a cure. These results show that for the present indications LADG is suitable and safe. We need more study of preoperative depth diagnosis of mucosal carcinomas with ulceration and submucosal carcinomas to expand the indications for LADG.

View full abstract

Minimally invasive transanal surgry (MITAS) was performed for early cancer without massive invasion into the submucosal layer in the upper rectum, which is not suitable for endoscopic or conventional transanal excision. Twenty-eight patients underwent MITAS for 29 rectal tumors (mucosal cancer 17, slight submucosal invasion 6, moderate submucosal invasion 5, massive submucosal invasion 1). The mean maximum diameter of the tumors was 26mm, and the mean distance from the anal verge to the proximal margin of the tumor was 9.2cm. Sixty-six percent of the tumors were located above the peritoneal reflection. Shortening and invagination of the rectum was initially performed using the E type anal retractor. The tumor was excised and simultanous anastomosis by a stapler following stiching under the tumor for pulling out the tumor. The mean operative time and blood Ioss were 23 minutes and21g respectively. There was no mortality or morbidity except one case of transient bleeding. Oral intake was started the day following the operation. The mean discharge day was about 5 days after the operation. The longest follow up was 3 years and 8 months. There was one recurrence, which was only surgicalmargin positive, and it was reexcised by MITAS. No further recurrent cases have been observed so far including the reexcised case. MITAS was considered to be a minimally invasive local excision procedure for cure and a better quality of life.

View full abstract

In our department, 71 laparoscopic operations for colorectal cancer have been performed and followed up for 6-51 months. Two patients underwent wedge resection of the cecum, and 69 underwent laparoscopic-assisted resection with lymph-adenectomy. There were 29 cases of early cancer and 42 cases advanced cancer. Accurate dissection of colon cancer was possible. In nine cases, lymph node metastasis was histologically positive and in three cases, metastasis was identified by laparoscopic ultrasonography before dissection. There was no cancer recurrence. The mean period from hospital discharge to starting work or sport was significantly shorter in the laparoscopic-assisted resection group in the open resection group (13 days vs 31 days; p<0.0001). Laparoscopic-assisted resection for colorectal cancer was acceptable for minimally invasive surgery.

View full abstract

Laparoscopic surgery for colorectal carcinoma has been employed in many institutes in our country. However, the indications and techniques are not standardized yet. The aim of this study was to determine the indications and limitation of laparoscopic surgery for colorectal carcinoma. Laparoscopic colorectal surgery has been performed on 105 patients in our department. Eighty-one cases of them (77.1%) had been malignant tumors. The location of the tumor was the cecum in 5 cases, ascending colon in 5, transverse colon in 10, descending colon in 4, sigmoid colon in 39 nd rectum in 18. The root of the inferior mesenteric artery can esily be dissected intracorporeally in cases of left side colorectal carcinoma, but intracorporeal dissection of the root of the middle colic artery was not indicated in the first 3 cases and it was dissected extracorporeally with 5 cm laparotomy. No statistical difference was noted in the number of lymph nodes resected by laparoscopic surgery and conventional surgery. Recovery after the operation was faster in the laparoscopic surgery group than in the conventional surgery group. Perioperative complications were seen in 2 cases, but they improved with conservative therapy. The cancer recurred in 1 case 1 year after the operation. Port site recurrence has not been encountered in any cases. We believe that systematic lymph adenectomy can be performed in laparoscopic surgery if the lesions are not located in the lower rectum.

View full abstract

The aim of this study was to investigate whether microwave coagulation therapy (MCT) could be adopted as a treatment option with minimal invasiveness for hepatocellular carcinoma (HCC). Thirty-two patients had undergone endoscopic or open MCT for HCC from June 1992 to June 1997. Preoperative liver function, postoperative complications and prognosis of MCT patients were compared with those of 34 patients who underwent wedge resection. Postoperative mortality was seen in one case in each groups. Incidence of postoperative complication of MCT was less than that of wedge resection. The actual and disease-free 5-year survival rates were identical in the patients who received MCT and those who had wedge resection. MCT is a possible choice of treatment for HCC with severe liver cirrhosis. However, local recurrence due to incomplete coagulation occurred in 2 patients after endoscopic MCT. During the coagulation procedure, the coagulated area rapidly becomes indistinct due to generation of micro bubbles. Accurate mapping of coagulation guided by intraoperative ultrasonography before coagulation is the most important point for MCT.

View full abstract