Using Sprague-Dawley rats, the effect of trypsin and taurocholate on the electrophysiological characteristics of isolated esophageal mucosa was studied. After administration of trypsin, both the esophageal transepitherial potential difference (PD) and short circuit current (Isc) were increased and the esophageal transepitherial resistance (Rt) was significantly reduced. On the otherhand, there were no changes in these parameters after administration of taurocholate (TCA). Increased Isc after administration of trypsin was significantly reduced by amiloride administration. These results suggest that activeion transport in the esophageal mucosal cells is impaired by trypsin, but not bile acid in alkaline state. Compared to bile, pancreatic juice has more important role in the pathogenesis of reflux esophagitis after total gastrectomy.

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Clinicopathological studies of carcinoma of the esophagogastric junction were performed in comparison with 15 cases of squemous cell carcinoma and 36 cases of adenocarcinoma. Tumors of 7 patients with squamous cell carcinoma (46.7%) were located in the esophagus mainly located involving the esophagogastric junction (EC), and those of 25 patiens with adenocarcinoma (69.4%) were distributed in the stomach mainly located involving the esophagogastric junction (CE). The incidence of adenocarcinomas located in the CE was significantly higher than for that of squemous cell carcinomas (p<0.01). Patients with squamous ceII carcinoma had significantly longer esophageal distance of carcinoma than those with adenocarcinoma (p<0.01). In so patients receiving left thoracotomy the distance from the proximal edge of the carcinoma to the resected esophageal edge was significantly longer than that in those operated on by the trans-abominal approach (p<0.001), The majority of patients with tumors with characteristics intermediate between squamous cell carcinoma and adenocarcinoma had metastasis of the lower mediastinal and abdominal lymph nodes. The 5-yer survival rates for patients with squamous cell carcinoma and adenocarcinoma were 32.3% and 16.1%, respectively, and both had a poor prognosis. Therefore, it is important for patients with carcinoma of the esophagogastric junction involving the esophageal hiatus that lower esophagectomy and total gastrectetomy with left thoracotomy and laparatomy are preformed regardless of the histological type, along with intensive and reasonable lymph node dissection of lower mediastinal and abdominal lymph nodes.

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We have investigated whether some kinds of hepatocyte growth factor are induced in rats by inoculation with freeze-thawed hepatic tissue (FTHT). In the present study, its hepatocytotrophic effects for 30% partial hepatectomized rats and its protective effect against CCl₄-induced hepatic damage were examined. The following results were obtained. 1) When FTHT was inoculated before 30% partial hepatectomy, the liver wet weight, DNA synthesis and liver regeneration were significantly higher thanin the control rats without FTHT. 2) When FTHT was inoculated in rats with CCl₄- damaged livers, the levels of serum cytosolic enzyme activities (GOT, GPT, LDH) were significantly lower (p<0.01) than those in the control. 3) The mean serum HGF level was about 20 ng/ml two weeks after FTHT inoculation, and it was higher than that of the 30% partial hepatectomized rats (about 3 ng/ml). The above results suggest that inoculation of FTHT might induce some kinds of hepatocyte growth factor, and have protective activity against CCl₄-induced hepatic damage.

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To clarify the factors concerned with postoperative complications after hepatic resection by the right thoraco-abdominal approach (TAA), charts of 114 patients who had undergone hepatic resection for hepatocellular carcinoma between 1991 and 1995 were reviewed retrospectively. Among the patients, 45 received hepatic resection associated with right lobe by the abdominal approach (AA) and 32 by TAA, and various comparisons were made between AA and TAA. No difference was found in age, clinical stage, tumor size, morbidity and kinds of postoperative complications between the two approaches. But a number of patient in TAA had a resection of upper section (p<0.01). Then, risk factors concerned with major complications after TAA such as hyperbilirubinemia more than 10 mg/di and and/or disseminated intravascular coagulopathy were investigated. Elder age (p<0.01), bearing the tumor adjacent to the confluence of the hepatic vein (p<0.01), and liver transection without Pringle's maneuver (p<0.05) were risk factors of major complications after TAA. These results suggest that careful intraoperative hemostasis during hepatic resection is important to avoid the occurrence of major complications after TAA.

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We evaluated the efficacy of magnetic resonance imaging (MRI) in assessing the therapeutic effects of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma. In the patients with excellent therapeutic effects, the signal intensities of the tumor were increased on Tl-weighted images and low-intensity tumors were encountered on T2-weighted images after TACE. The average tumor necrosis ratio after TACE was calculated as 86% on dynamic CT, 66% on dynamic MRI and 64% on DSA. The histological necrotic changes were correctly assessed with dynamic MRI, even in the are with good lipiodol accumulation. In addition, the tumor necrosis ratio in dynamic MRI was significantly correlated with the tumor regression ratio (r=0.47, p<0.05). In conclusion, wer recommend dynamic MRI as a modality for assessing the therapeutic effects of TACE using lipiodol.

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In order to determine the time to terminate or change administration of prophylactic antimicrobials in the perioperative period of pancreatoduodenectomy, the simplifed method to assess the postoperative status according to the criteria for SIRS was used. In 38 patients who received pancreatoduodenectomy during the past five years, a postoperative infectious complication occurred in 42%. Prophylactic antimicrobial administration failed in 16%, so that early infectious complication occurred. the pathogenic microorganisms were resistant to the drug administered, with an ineffective outcome. The positive rate according to the SIRS-based criteria on POD 3, 4 and 5 was 32, 18 and 23%, and 25, 60 and 63% of the patients had early infectious complications. The criteria-posivive status was the result of surgical stress or atelectasis in most patients on POD 3 or 4. In patients who were criteria-nagative status on POD 5, early infectious complications didn't occurred in 96%, the accuracy of the criteria was as high as 0.89. Therefore, if the result was negative on POD 5, an early infectious complication was considered to have been prevented, indicating that prophylactic antimicrobial administration should be terminated at this time. However, if the result remains positive, switching to another drug would be appropriate, assuming the occurrence of infection.

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Clinicopathological study was carried out in 239 patients with colorectal cancer who were treated inour hospital between 1993 and 1996. They were classified into two groups; FOB group (those who were asymptomatic and positive in fecal occult blood (FOB) test for the mass screening, n=33) and symptomatic group (n=206). There was no significant difference in the sex ratio, mean age, the location of tumor and histological types between the two groups. The incidence of early cancer, absence of lymph node involvement (n (-)) and Dukes A in FOB group was significantly higher than in symptomatic group. In the cancers of the right and left-side of the colon, the incidence of early cancer and Dukes A were significantly higher in FOB group, and all cases in the right-side colon were advanced more than Dukes B in symptomatic group. Therefore, cancer patients screened by FOB test seemed to have better prognosis, and FOB test could be useful in the early diagnosis of the colon cancer except rectum.

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The characteristics of clinicopathological findings of patients more than 90 years old presenting with colorectal cancer were investigated. The subjects were 20 patients (21 operations) who had undergone surgery during 1987-1997. These were compared with 103 controls aged 75-79, and also with 17 patients more than 90 years old in early period (1974-1986). In the subject group, the most common preoperative symptom was a sign of intestinal obstruction (38%), which occurred significantly more frequently than in the control group (p<0.05). The incidence of emergency surgery in patients 90 years and older was declined from 47%(in early period) to 33%(in late period), but was still in higher level than that of control group (p<0.05). The overall operative mortality rate in the subject group was 4.8%, which had been improved more than in early period, and was comparable to that of the control group (3.9%). During elective surgery, no patients in the subject group was lost perioperatively throughout both periods. The resection rate and the curative resection rate (95%, 90%) were similar to those of the control group (95%, 83.6%). There was no significant difference between the two groups with regard to preoperative coexisting disorders. Pathological findings demonstrated that Dukes B group was predominant in the subject group (p<0.05). It was concluded that surgery for patients over 90 years of age with colorectal cancer is warranted and diagnostic efforts should be made to avoid emergency surgery.

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A 68-year-old man visted our hospital because of abdominal distention. Laboratory data on admission showed anemia and positive occult blood. Upper gastrointestinal fluoroscopy and endoscopic examination revealed an extramurally growing tumor in the second portion of the duodenum. These findigns suggested cancer of the duodenum, and carcinoma cells were confirmed in the biopsied specimens. The patient underwent pancreatoduodenectomy and partial hepatectomy along with regional lymph nodes dissection. Microscopically, the tumor was found to be choriocarcinoma. Immunohistochemical studies revealed that human chorionic gonadotropin (HCG) was localized in the syncytiotrophoblasts with a more intense staining reaction. Choriocarcinoma of the duodenum is extremely rare. To the best of our knowledge, only one case has been reported to date in the literature.

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An 85-year-old woman who had cholecystolithiasis was admitted to our hospital because of sudden onset of vomiting. She complained of upper abdominal fullness and right hypochondralgia but had no anemia, icterus or pyrexia. Endoscopic examination of the upper gastrointestinal tract showed pyloric stenosis due to the impacted stone. Abdominal ultrasonography revealed gallbladder wall thickening and pneumobilia. Abdominal CT revealed a 4-cm gallstone at the duodenal bulb. The gallbladder and duodenal bulb could not be separated as distinct structtures on CT. An upper gastrointestinal tract series demonstrated partial obstruction by the radiolucent gallstone in the duodenal bulb with reflux of balium into the gallbladder. Laparotomy was performed under a diagnosis of pyloric obstruction due to the impacted stone, namely Bouveret's syndrome. After the severely atrophic gallbladder and duodenal bulb was separated, a 4×3×3-cm gallstone was extracted from a dilated fistula of the duodenal bulb. We performed pyloroplasty by the Heineke-Mikulicz method, and no biliary radical operation was carried out. The patient had acute heart failure during the postoperative course but soon she recovered and was discharged on postoperative day 17. Duodenal bulb obstruction by a gallstone is an uncommon cause of gallstone ileus that is a rare complication of cholelithiasis. This paper describes a case of Bouveret's syndrome with a review of 12 cases in the Japanese literature over the last 21 years.

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A 67-year-old man was admitted to our hospital because of liver dysfunction. We diagnosed his condition as HCV antibody-positive liver cirrhosis. Ultrasonography revealed an oval shape, isohypoechoic nodular mass measuring 20mm in the right posterior segment of the liver. A plain CT scan revealed a low density area. This tumor was homogeneously enhanced with an irregular border. Celiac arteriography revealed a tumor stain in the posterior-superior segment in the arterial phase. By ultrasound-guided fine-needle biopsy, we obtained a histological specimen of cholangiocellular carcinoma (CCC). Partial hepatectomy of S6 was performed. The cut surface of the resected tumor showed a milk-whitish nodular type tumor 15×20mm in size. The histopathological diagnosis was a moderatly differentiated tubular adenocarcinoma. The liver except for the tumor showed liver cirrhosis. His postoperative course has been good without recurrence for 16 months after discharge. It is difficult to find a CCC in the early stage because it has no typical symptoms or specific sings earlier. Only 16 cases of minute peripheral CCC have been reported in the Japanese literure up to now. There were no previous reports of minute peripheral CCC associated with HCV antibody-positive liver cirrhosis.

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A case of cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct is reported. A 65-year-old woman presenting with obstructive jaundice was hospitalized and underwent percutaneous transhepatic biliary drainage (PTBD). Cholangiography through the PTBD catheter revealed a filling defect at the hepatic hilus. The right hepatic duct and the right caudate branch were not visible. Abdominal CT showed a mass about 3cm in diameter in the right caudate lobe and a low-density mass in the bile duct at the hepatic hilus. Percutaneous transhepatic cholangioscopy (PTCS) demonstrated a pinkish tumor with a nodular surface in the bile duct. Cholangioscopic biopsy revealed adenocarcinoma. Right hepatic lobectomy and caudate lobectomy with bile duct resection were performed. Cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct is extremely rare and only a few cases have been reported. Endoscopic findings and biopsy under PTCS proved very useful for differential diagnosis between hepatocellular carcinoma and cholangiocellular carcinoma. To identify the location, the range, and the type of the main tumor and the intraluminal tumor is important for deciding on the operative procedure.

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A 63-year-old man underwent a pancreatoduodenectomy for pancreatic tumor. On the 52nd postoperative day, platelet counts and hemoglobin concentration rapidly declined. The next day the patient suddenly went into a convulsion and coma followed by left hemiplegia, and he had a sudden onset of fever. The initial diagnosis was cerebral infarction and DIC due to sepsis, but treatment for cerebral infarction and sepsis was not effective. Thrombocytopenia, hemolytic anemia with fragmented red blood cells, unexplained encephalopathy, and fever indicated a diagnosis of thrombotic thrombocytopenic purpura (TTP). The patient received plasma exchange with fresh frozen plasma and showed marked improvement. He achieved complete remission after five plasma exchanges. This was a case of postoperative TTP and the cause is unknown. After discharge, no relapse has occurred for 6 months. An accurate diagnosis and early treatment of TTP are essential to patient survival.

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A 52-year-old man was admitted to our hospital because of proteinuria. On admission, his urine albumin level was high (5.92g/day) and his serum albumin level was low (1.9g/dl).He was diagnosed as having nephrotic syndrome. Abdominal US and CT showed a mass in the pancreas, suggesting a malignant tumor. Additionally, a barium enema study and fiberoptic colonoscopy were performed because of occult blood in the stool, and sigmoid colon carcinoma was diagnosed. We were concerned that simultaneous pancreatoduodenectomy and sigmoidectomy would cause too much damage and have a high risk of post-operative complications, so we performed subtotal distal pancreatectomy and sigmoidectomy and an operative left renal biopsy. Histologicaly, the pancreatic tumor was diagnosed as acinar cell carcinoma and sigmoid colon was diagnosed as early colon carcinoma invading the submucosa without lymph node metastasis. Postoperatively, the patient was followed without any sign of recurrence, but nephrotic syndrome did not dissapear. Nephrotic syndrome combined with a malignant tumor is well known, but our case is rare because no case of combined pancreatic carcinoma and double cancer has been reported up to now.

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A case of carcinoma of the small intestine after right hemicolectomy for hereditary non-polyposis colorectal cancer (HNPCC) is reported. A 53-year-old man had had 2 colon and 1 rectal cancer lesions, including synchronous and metachronous cancers, since he was 45 years old. His grandfather on the mother's side and his mother had rectal cancer. His 3rd brother had jejunal and colon cancer and his 5 th brother had hepatocellar cancer. He visited our hospital with occult blood in the feces and anemia. An elevated lesion was detected in the jejunum about 5 cm distal to the ligament of Treitz by small bowel radiography and endoscopy. Endoscopic biopsy allowed a histological diagnosis of well-differentiated adenocarcinoma of the jejunum. After admission, partial resection of the jejunum and intraoperative endoscopy of the whole small intestine were performed. Histological examination showed welldifferentiated adenocarcinoma of the small intestine. The patient's clinical course was satisfactory and he was discharged on the 17th postoperative day. The HNPCC syndrome includes hereditary site-specific colon cancer (Lynch I) and the cancer family syndrome (Lynch II). This case was classified as Lynch II. Lynch II usually includes carcinomas of the stomach, uterus, and ureter. However, carcinoma of the small intestine had not been reported until our investigation.

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We reported two cases of non-rotation of the intestine following rectal carcinoma. Case 1: A 57-year-old woman with anal pain and bleeding consulted a doctor. Rectal tumor was diagnosed by digital examination and she was admitted to our hospital. A barium enema revealed a type 2 rectal carcinoma with non-rotation of the intestine. At laparotomy, the small intestine found to be located on the right side and the large intestine on the left, yielding a diagnosis of non-rotation. She underwent rectal amputation by the abdominoperineal approach with D₃ lymphadenectomy. The tumor was a 6.2×3.8cm type 2 rectal carcinoma, and was diagnosed as adenosquamous carcinoma of stage I. She has been healthy for the 9 years since the operation. Case 2: A 62-year-old woman with bloody stools consulted our hospital. After a diagnosis of rectal carcinoma at the Ra portion and non-rotation of the intestine, she underwent low anterior resection with D₃ lymphadenectomy. The resected specimen revealed a 52×47mm semicircular type 2 rectal carcinoma which was histologically diagnosed as moderately differentiated adenocarcinoma of stage IIIa. Both patients underwent prophylactic appendectomy. Intestinal malrotation has the possibility to make diagnosis and treatment of the following diseases difficult, so we must always take into account this condition.

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