We performed laparoscopic Nissen fundoplication on ten patients with reflux esophagitis, and investigated their short term results. Mean operative time, duration, of nasogastric tube insertion, diet start, and hospital length of stay after operation, were 196.0±55min, 1.2±0.4 days, 3.3±0.8 days, and 20.4±0.8 days, respectively. Mean follow-up period after operation was one year and three months (ranging from four months to three years and one month). During the follow-up period, esophagitis in all patients remained healed, and sliding hiatal hernia did not recur except in only one patient. Moreover, intraesophageal acid exposure time was markedly decreased, improving to within the normal range except in two patients. Preoperative symptoms were almost completely diminished after surgery. Prolonged dysphagia after operation was found in one patient whose procedure was not done with calibration at the gastroesophageal junction. This patient needed reoperation. Insummary, short-term results of laparosocopic Nissen fundoplication for reflux esophagitis were excellent, however, it was vey important to use an esophageal tube in making the fundic wrap.

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To determine the effectiveness of preoperative biliary drainage (BD) on major hepatectomy in rats with obstructive jaundice, liver chemistry, plasma endotoxin concentration, energy charge and mitotic index were studied initially in jaundiced rats with or without preoperative BD and sham-operated. At 48 hours after hepatectomy, the energy charge in the group without BD was significantly lower than in the sham-operated group. The mitotic index in the group without BD was significantly lower than in the sham-operated group, and it gradually increased in accordance with the duration of BD. However, bacterial infection appeared to be the problem in the group with BD. Then the effects of bile refeeding during BD on bile flow, mitotic index and bacterial infection before and after hepatectomy were studied. In the bile refed group, bile flow and biliary bilirubin excretion were significantly greater than in the saline fed group and the serum bilirubin concentration just before hepatectomy in the bile refed group was markedly decreased. The mitotic index in the bile refed group was greater than in the saline fed group and it was almost the same as in the sham-operated group. There were no differences in the positive bacterial culture rates in the bile and mesenteric lymph nodes between the bile- and saline-fed groups. These results suggest that preoperative biliary drainage is indispensable for major hepatectomy with obstructive jaundice. And bile refeeding during biliary drainage may play a role in preventing liver failure after hepatectomy with obstructive jaundice.

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Tumor angiogenesis is essential for growth and metastases of solid tumor. Vascular endothelial growth factor (VEGF) is a potent angiogenesis-promoting factor. It has been reported that VEGF expression is associated with hematogenous metastases. It has been hypothesized supposed that occult liver metastases already exist at the time of pancreatectomy. In order to explore the mechanism of liver metastases, we investigated VEGF expression in human pancreatic carcinoma immunohistochemically. We examined tumor specimens from 38 surgically resected pancreatic carcinoma by counting microves - sels and by staining for VEGF and factor VIII. Nine of thirty-eight cases (24%) were positive for VEGF. Microvessel counts varied from 0 to 122 counts/×200 field (mean±SD=17.47±3.85). Microvessel counts were significantly higher in VEGF positive tumors than those in VEGF negative ones. VEGF positivity was correlated with vessel involvement. 15 out of 38 patients experienced liver metastases. All of the patients with VEGF positive tumors had liver metastases. VEGF-related angiogenesis may play an important role in human pancreatic carcinoma. VEGF expression may be correlated with liver metastases.

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Sixty-four patients with intraoperative massive bleeding of more than 5, 000ml in gastroenterological surgery over the past 10 years were evaluated. These patients were divided into two groups according to the volume of intraoperative blood loss: a bleeding group (5, 000-10, 000ml, n=46) and an ultrableeding group (more than 10, 000ml, n=18). About 90 per cent of all patients in both groups had malignant diseases. The total transfusion volume almost corresponded to blood loss and half of it was composed of fresh frozen plasma. Only one patient was suspected of having post-transfusion hepatitis. A significant difference between the two groups was seen in the average speed of bleeding and was reflected in a difference in the drop in blood pressure and hemoglobin level. Although after the operation, a tendency of tachycardia, marked thrombocytopenia and liver dysfunction was seen in both groups, and a tendency of hepato-renal failure was observed particularly in the ultrableeding group, the patients recovered within a week. Grades of liver dysfunction were affected by the volume of blood loss. DIC was noticed among postoperative complications. All patients who received platelet transfusion were saved from DIC. This funding suggests that active platelet transfusion is necessary in intraoperative massive bleeding.

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The purpose of the current study is designed to determine whether it is possible to predict the incidence of postoperative infection. One hundred and eleven cases of gastric and colorectal operations, which were carried out between July 1995 and June 1997, were divided into two groups as follows. Thirteen cases suffered from postoperative infection (infection group), ninety-eight were infection free until the 10th postoperative day (POD10)(no infection group). We analyzed examinations of both groups on POD3 with univariate analysis. Lymphocyte counts (Ly), total cholesterol (TC), and total protein (TP) of the infection group were obviously lower than those of the no infection group. Body temperature, pulse and CRP were higher in the infection group than in no the infection group. Then, we utilized logistic regression analysis in multivariate analysis to evaluate which parameters (e.g. WBC, Ly, TC, triglyceride, TP, albumin, CRP) should be employed. Consequently, in gastric operations, 8 parameters were analyzed including TC, and in colon operations, 3 parameters were analyzed including TC, which produced the best overall percent correct and sensitivity between prediction and observation. The overall percent correct for analysis was 95.1% for gastric operations, and 95.4% for colon operations, and the sensitivity of analysis was 80.0% for both gastric and colon operations. However, in rectal operations, the overall percent correct was satisfactory, but the sensitivity was lower than that of gastric and colon operations. Taken together, we conclude that early diagnosis of postoperative infection is possible by utilizing logistic regression analysis of clinical data on POD3 including the serum total cholesterol level.

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This case report describes the use of distal gastrectomy to treat early stomach cancer in a patient who had previously undergone Hassab's operation, a transabdominal esophageal treansection and endoscopic injection therapy. A 63-year-old man, who had previously undergone Hassab's operation with transabdominal esophageal transection for gastric varices in 1987, and endoscopic injection therapy (EIS) for esophageal varices in 1995, was admitted to our hospital because early gastriccancer in the antrum had been incidentally detected by endoscopy during a follow-up examination in 1997. Preoperative angiogaphy revealed that the blood supply to the lesser and greater curvature of the stomach was through the right gastric and gastroepiploic arteries, respectively. Therefore, although the tumor was located in the antrum, the indicated procedure in this case of gastric cancer was a total gastrectomy with a Roux-en-Y anastomosis. However, since the patient had a past history of esophagealtransection and EIS, a total gastrectomy was ruled out because of the increased risk of anastomotic leakage. The procedure of choice was thus changed to a distal gastrectomy. We determined that the color of the serosal surface of the remaining stomach did not change after dividing the right gastric and gastroepiploic arteries, indicating that the blood supply was sufficient to perform an anastomosis between the remaining stomach and jejunum. Therefore, a distal gastrectomy was performed, and the patient successfully recovered without complications related to the operation.

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We encountered a rare case of primary sclerosing cholangitis (PSC) localized in the intrahepatic bile duct (IHBD)(B7). A 71-year-old man was fond to have an abnormal mucosa in the stomach at a medical examination visited our hospital and was diagnosed with gastric cancer by an upper GI seies. At the same time, ultrasonography and a CT scan revealed dilation of the IHBD (B7). Endoscopic retrograde cholangiography did not indicate IHBD (B7) and PTC revealed dilatation and stenosis of IHBD (B7). Distal partial gastrectomy and posterior segmentectomy of the liver were performed with the diagnosis of gastric cancer and a suspicion of hepatolithiasis or cholangiocelluler carcinoma. The surgical specimen showed dilatation and stenosis of IHBD (B7), and no tumor formation or stone. Histological examination revealed periductal fibrosis with infiltration of inflammatory cells. We made the final diagnosis of intrahepatic localized PSC. To the best of our knowledge, this is the first of an intrahepatic localized PSC in our country. Surgical resection should be performed for the localized type of PSC, because of progress of this disease and its rare combination with cholangiocellular carcinoma.

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A case of cholangiocellular carcinoma with tumor growth in the hepatic hilar bile duct is reported. A 72-year-old man was admitted with the complaint of obstructive jaundice. Abdominal computed tomography showed a low-density mass in the left lobe as well as within the hepatic hilar bile duct. A cholangiogram revealed a round filling defect at the hepatic hilus. A celiac arteriogram showed a hypervascular lesion fed by the middle hepatic artery. Therefore, under the diagnosis of cholangiocellular carcinoma with tumor growth in the hepatic hilar bile duct, an extended left lobectomy with caudate lobectomy and resection of the bile duct were performed. The specimen showed a whitish and firm tumor 5×4cm in diameter in the left lobe of the liver. Tumor growth extended into the hepatic hilar bile duct from the left hepatic duct. Histological examination showed that the tumor consisted of moderately differentiated tubular adenocarcinoma. The patient is alive without recurrence 13 months after the operation. A rare but significant extension of the tumor is on the view point of surgical management of cholangiocellular carcinoma.

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A case of primary follicular malignant lymphoma is reported. The patient was a 71-year-old woman who was found to have a splenic tumor by ultrasonography. Splenectomy with regional lymph-node dissection was performed. A hard irregular mass was palpable in the moderately enlarged spleen. The excised spleen measured 12 by 9 by 8 cm, weighted 390 grams and was partially replaced by a yellowishbrown tumor. Histological diagnosis was malignant lymphoma, follicular medium cell type. No adjuvant chemotherapy was performed because of the histological type and low stage (Stage 1 by Ahmann's classification). Six months later, malignant lymphoma recurred in the pleural cavity, and CHOP therapy was performed. She is alive 16 months after the operation. Primary follicular malignant lymphoma of the spleen is very rare, so we reported here.

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Hamartoma of the spleen is a rare disease. There have been only 56 reported cases in Japan. Nearly all were solitary, only 4 reports described multiple tumors. We recently treated a patient with multiple splenic hamartoma. A 19-year-old female visited the hospital because of left hypochondrium pain. She was diagnosed as having a splenic tumor. The tumor was detected as a hyperchoic mass projecting from the hilus of the spleen on ultrasonography and as a low density area with an enhancement effect on computed tomography. Angiography revealed a tumor stain at the hilus of the spleen, and also mutiple nodular stains at surface and inner part of the spleen. Because it was difficult to make the final diagnosis and to exclude a malignant tumor, we performed splecectomy. In the resected specimen there were 7 yellowish nodules. The histological diagnosis was mixed splenic hamartoma. It is diffcult to make a preoperative diagnosis of splenic hamartoma, but conservative therapy should be considered in such a case showing solitary and typical image findings.

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We experienced a case of spontaneous mesenteric fibromatosis without Gardner's syndrome or previous abdominal surgery. A 69-year-old man presented with a hard movable mass, about 4 cm in diameter, in the umbilical region. Barium enema and colonoscopy showed a submucosal tumor of the transverse colon and an operation was performed. The tumor, 45×40×30 mm in size, elastic hard in consistency, arising from mesenterium of the small intestine and firmly attached to the transverse colon, was excised with a segment of the transverse colon and the jejunum. The pathological diagnosis of the tumor was mesenteric fibromatosis. It is rare for this tumor, only 14 cases have been described in the Japanse literature, with mesenteric fibromatosis to occur in a patient without Gardner's syndrome or an episode of previous abdominal surgery. It is well known that mesenteric fibromatosis often develops into a local necurrence especially in patients with Gardner's syndrome whereas it is reported that the recurrence rate of spontaneous mesenteric fibromatosis is reportedly low. Our patients is still alive and has been recurrence free for more than a year.

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A 60-year-old male was admitted with complaints of abdominal fullness and left lower abdominal pain. He had neither a past history of surgery nor injury. An abdominal X-ray showed niveau. The diagnosis of intestinal ileus was made. The patient showed no response to conservative therapy with an ileus-tube. Combined intestinal contrast study with enema using diatrizoate meglumine revealed occlusion of the ileum in the loop of the sigmoid colon. Abdominal CT showed the stenotic portion of the ileum in the sigmoid mesocolon. Diagnosis of internal hernias of the sigmoid mesocolon was made and an operation was carried out. There was incarceration of a part of the ileum in the right mesenteric round defect of the sigmoid colon, of which diameter was 7.5 cm. We easily reduced the incarcerated ileum manually and the hernia orifice was closed with sutures. The occurrence of internal hernia involving the sigmoid mesocolon is not common and only 22 cases have been reported in Japan. Among them, only 10 had intersigmoid hernia and ours is the first case diagnosed preoperatively.

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An 82-year-old man underwent bypss graft replacement with an artificial bifurcated graft for a pseudoaneurysm-rectum fistula. He was admitted to our hospital on June 24, 1996, because of diarrhea for 4 days. He complained of melena 2 days after admission and a diagnosis of a right common iliac artery pseudo-aneurysm-rectum perforation was made by CT scan. An emergency operation was performed. A femoral-femoral artery byapss was performed before laparotomy. An aneurysm was detected of the Y Graft right limb of the anastomosis. The fistula was closed after partial resection of graft right limb and pseudoaneurysm. He recovered completely colostomy after the operation and was discharged on December 12 1996. Pseudoaneurysm-rectum perforation is associated with a high rate of death due to infection and bleeding, but it is very rare. A rare case of a Y-graft bypass for a right iliac pseudoaneurysm-rectum perforation was reported 13 years ago.

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A 71-year-old man, who had a history of cholangioma and left-sided lobectomy of the liver, presented with vomiting of blood. Upper abdominal computed tomography nd ultrasonography showed recurrent tumor the liver, and barium examination of the upper gastro-intestinal tract revealed an approximately 8cm long high-grade stenosis of the antrum of the stomach and the first portions of the duodenum due to direct invasion of the recurrent tumor. Owing to the patient's advanced dissase and poor general condition, we decided that further surgery procedure would not be successful. Therefore we dilated the stenotic portion with baloon catheter and put a polyurethane-coated self-expandable nitinol stent in it, using endoscopic procedure, as palliative therapy. He was then able to ingest a solid diet, and his quality of life was much improved.

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