This review describes our progress of surgical treatment in primary gastric cancer and indication of D4 dissection, which were based on our 6088 surgical experience from 1968 to 1993. Patient survival in later term was prolonged significantly than that of former term, which could be the result of increasing proportion of early cancer, surgical improvement of curability in advanced cancer, and extended lymphadenectomy. From the result of multivariant analysis between D2 and D4 dissection, D4 was considered to benefit against patient survival in mp or ss/n2, se/n1 and se/n2 case. We need further prospective study to establish a certain strategies for lymph node dissection in gastric cancer.

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Histological studies on hepatic necrosis and regeneration after transient ischemia of 70% of the liver by both inflow and outflow occlusion were carried out in rats. In the ischemic lobe massive hepatic necrosis was observed especially around the central vein just after ischemia, and the area was more, wide-spread with longer duration of hepatic ischemia. Even in the case of 120-min ischemia, the necrotic area disappeared by the 14th day after revascularization. The PCNA labeling index of hepatocytes showed the highest values on the 2nd day in both ischemic and non-ischemic lobes. With respect to survival, all rats with 90-min ischemia survived, while the survival rate of those with 120-min ischemia was 89%. In rats with of 90- and 120-min ischemia, with permanent inflow occlusion of the remnant lobe (30%) after transient ischemia of 70%, the survival rates decreased to 80% and 33%, respectively. Therefore, in case of more than 90-min ischemia of 70% of the liver, it is mandatory for the non-ischemic lobe to function properly during the period, so that the ischemic lobe recovers and the individual survives.

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A 51-year-old man had an esophageal cancer potentially invading the aorta in the middle third of the thoracic esophagus. On the 17th day of his chemoradiation therapy, he suddenly vomited blood and went into shock. A CT scan revealed a deep ulcerated tumor on the border of the penetration to the aorta. To prevent formation of an aortoesophageal fistula formation, a covered stent was inserted into the aorta. He died of pneumonia 111 days after stenting. The autopsy showed no fistula and that a tight fibrinous thrombus was formed between the cover of the stent and the aortic wall. We conclude that implantation of a covered stent may prevent aortoesophageal fistula formation in advanced esophageal cancer.

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We compared the portal hemodynamic changes in a patient with idiopathic portal hypertension (IPH) before and after operation. With a diagnosis of IPH with esophagogastric varices, a 41-year-old woman underwent Hassab's operation. The histological findings of the resected liver biopsy were consistent with IPH. The portal phase of celiac arteriography performed preoperatively revealed an unclear image of the peripheral portal branch. On the other hand, the peripheral portal branch was clearly imaged, postoperatively. ^99mTc-labelled in vivo blood cell scintography performed preoperatively showed that the radioactive counts from the regions of interest (ROI) over the right liver was less than those from the ROI over the trunks of the portal vein (PV) and the umbilical portion of the portal vein (UP). Postoperatively, however, the radioactive counts over the right liver increased and were greater than counts measured over the PV and UP region. Per-rectal portal scintography with Iodine-123-Iodoamphetamine performed preoperatively revealed early phase lung images, but no early phase liver images, thus suggesting that the radionuclide flowed into the inferior vena cava through a collateral vein. However, both the liver and lungs were clearly visualized in the early phase of scintography performed postoperatively, which meant the amount of blood flow via the porto-systemic shunt had decreased. In conclusion, these findings suggest that the portal hemodynamic state in a patient with IPH may change with apparently improved liver perfusion from portal flow following Hassab's operation.

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We experienced two cases of cholangiocellular carcinoma with intraductal extension into the extrahepatic bile duct. The first patient was a 46-year-old owman complaining of fatigability and appetite loss. Computed tomogram (CT) demonstrated a hepatic tumor in the medial segment with a mass in the common bile duct. Pericutaneous transhepatic cholangiogram revealed a filling defect in the common bile duct. Extended left hepatic lobectomy combined with bile duct resection was carried out. The resected specimen showed a nodular tumor arising from the medial segment of the liver with intraluminal extension into the common bile duct. Histologic section of the tumor showed mucin-producing cholangiocellular carcinoma. The second patient was a 62-year-old man. Ct showed a tumor in the lateral segment of the liver. Left hepatic lobectomy was performed. The resected specimen showed a nodular tumor with intraductal extension into the common hepatic duct. Histologic section of the tumor showed moderately differentiated cholangiocellular carcinoma. Intrahepatic cholangiocellular carcinoma with intraductal extension into the extrahepatic bile duct is uncmmon. In a review of literature, we could only one report that described a nodular tumor with intraluminal extension into the common bile duct.

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53-year-old woman was admitted with fever and epigastralgia. An abdominal enhanced CT scan and ultrasound examination revealed enlargement of the gallbladder and a cystic lesion below the left lobe of the liver, indicating probable cholecystitis and a biloma. Cholecystectomy with resection of the cyst was performed. The cyst contained turquoise-colored fibrin. Our case was classified as one of spontaneous biloma that had no evidence of trauma or iatrogenic injury. Twenty-two other cases of spontaneous biloma were previously reported in Japan. In our case, the biloma was thought to have been due to biliary leakage from the gallbladder with severe cholecystitis, in which obstruction of the cystic duct with infective hydrops had progressed. Thus, in case of severe cholecystitis with an intraabdominal cystic lesion, the presence of spontaneous biloma should be suspected in the differential diagnosis.

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Pancreatic arteriovenous malformation (AVM) is a very rare disease. A case of pancreatic AVM which could be treated by surgical resection is reported. A 49-year-old man was referred with epigastralgia and increasing back pain. Abdominal ultrasound examination revealed a low echoic lesion in the head of the pancreas with rapid blood flow dopplar signals. Stenosis of the distal end of the common bile duct and bleeding through the orifice of the Papilla of Vater, which could be identified also by magnetic resonance cholangiopancreatography, were shown by ERCP. Dynamic computed tomography demonstrated a hypervascular lesion of the pancreas head. Celiac and superior mesenteric angiography showed a typical racemose vascular network with early identification of the portal venous system. All of these findings confirmed the diagnosis of pancreatic AVM. As a radical treatment for this patient, pylorus preserving pancreatoduodenectomy was the choice for complete removal of the arteriovenous fistulous networks inside the pancreas head. Microscopic examination of the resected specimens revealed numerous dilated arteriovenous fistulous vessels within the pancreas parenchyma. The surgery resulted in complete disappearance of pain just after the operation. There has been no recurrence of symptoms or the imaging diagnostic signs.

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This paper describes a patient with a unique history of jejunal malignant lymphoma, multiple primary colorectal cancers, and mucin-producing pancreatic cancer. A 65-year-old man was admitted to our hospital because of vomiting. His medical history included partial jejunectomy for malignant lymphoma, right and left hemicolectomy including the recto-sigmoid region (preserved transverse seg-ment) for multiple synchronous colon cancers at age 49 years, and residual rectal resection for rectal cancer at age 55 years. Palliative operation was performed following an intraoperative diagnosis of duodenal cancer or papilla of Vater cancer. The patient died 20 months after the operation. Autopsy showed no evidence of recurrent malignant lymphoma or colorectal cancer, however, there was a large, mucin-producing tumor in the pancreatic head and the duodenal wall. Histologic examination revealed mucin-producing pancreatic cancer derived from the pancreatic duct, with invasion of the duodenum. The patient lived more than 16 years with an adequate QOL after the first operation. Furthermore, the residual short transverse colon had maintained its function.

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Ruptured splenic artery aneurysm is still a severe disease because of its mortality when treatment is not correctly timed. A 38-year-old man complaing of upper abdominal pain and vomiting was admitted to the hospital and diagnosed as having acute gastroenteritis. He went into preshock state during admission. Emergency CT scanning revealed high density mass suspected to be a hematoma in the Bursa. Emergency laparotomy was scheduled, but during waiting time, double rupture was occurred. He was rescued by emergency laparotomy performing splenectomy with aneurysm. Ruptured splenic artery aneurysm manifests with left upper abdominal pain. It sometimes ruptures in the peritoneal cavity after temporary hemostasis by coagula in the bursa. This case had double rupture phenomenon. Early diagnosis and operation before the second rupture are necessary.

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We report a rare case of internal supravesical hernia.The case was a 73-year-old male with no past history of abdominal surgery.He had been admitted three times because of intestinal obstruction that improved with conservative management.This time, he was admitted again because of intestinal obstruction with complaints of frequent vomiting and lower abdominal pain. As there was complete obstruction of the ileum on a small-intestine series, we diagnosed either invagination by an ileal tumor or internal hernia.Therefore, he underwent surgery for intestinal obstruction. We operatively established the diagnosis of intestinal obstruction due to incarceration of the ileum in a right internal supravesical hernia.Then, the patient received partial resection of the is chemic ileum and hernioplasty. In the classification of supravesical hernia that has a hernia orifice between the medial and lateral umbilical ligament, internal supravesical hernia in which the sac lies in the retropubic space of Retzius is very rare. Although there has been no case in which a final diagnosis was achieved preoperatively, in elderly cases with intestinal obstruction but no abdominal operation, we should consider the existence of supravesical hernia.

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The operative procedure of resection of thoracic esophageal cancer with combined resection and reconstruction of the left main bronchus is described. The patient was a 76-year-old man who had an advanced esophageal cancer in the middle third of the thoracic esophagus. Bronchofiberscopic examination revealed cancer involvement of the left main bronchus. A radical esophagectomy was carried out through a right thoracotomy, and approximately 3cm of the left bronchus was resected en bloc with the tumor. During the resection and reconstruction of the bronchus, mechanical ventilation was interrupted to obtain a good operative field but only high-frequency jet ventilation was provided for the right lung. The alimentary tract was reconstructed with cervical anastomosis using the gastric tube through the posterior mediastinum. The posterior mediastinum was filled with omental adipose tissue to suppor the bronchial anastomosis. The postoperative course was uneventful and no complication caused by bronchial reconstruction was noted. These results suggest that the operative procedure described here is a safe and simple method for the surgical treatment of avanced esophageal cancer involving the bronchus.

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This report is about clinical experience of two surgical cases of recurrent hepatocellular carcinoma (HCC) in the paracaval portion (PCP) of the caudate lobe. These two patients received isolatd entire caudate lobectomy (IECL) and are fine without any recurrence more than 2 years. We performed IECL by upper abdominal “reverse T shaped” skin incision. We identified the right margin of the PCP from the demarcation line appearing on the liver surface by clamping the portal triad of the posterior segment. After the liver was isolated from the inferior vena cava by dividing all short hepatic veins, we started dissection on the demarcation line. As the cranial margin of the caudate lobe, we dissected along the caudal surface of the right hepatic vein and the middle hepatic vein. As the caudal margin of the caudate lobe, we divided the portal triads of the caudate lobe along the hilar plate. After we divided the root of Arantius duct at the dorsal end of the umbilical portion from right side approach, we divided Arantius duct at the confluence of the middle hepatic vein from left side approach. Thereafter we continued to dissect hepatic parenchyma along the middle hepatic vein from left side approach and combined both dissection planes together. Therefore we accomplished IECL. Even if HCC recurs after hepatectomy in the PCP, which is the most difficult part for liver surgery, being in the early stage, it is possible for us to perform curative resection by IECL safely.

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Although laparoscopic cholecystectomy (LC) has become a standard treatment for a variety of benign gallbladder diseases, many LC-related complications have been reported, the msot serious being accidental injury to the bile ducts. In order to prevent such complications, it is important to clarify the anatomy of the biliary system during LC. The purpose of this study was to assess the usefulness of intraopertive laparoscopic ultrasonography (LUS) for clarifying the anatomy during LC. Materials & Methods: Since 1992, 117 LCs have been performed in our institution; of these, 69 which included LUS during LC were studied. We performed LUS to visualize the biliary system before and after exposure of the cystic duct. LUS was performed by the water soakage or balloon method. Results: The gallbladder, cystic dust and common hepatic duct were successfully visualized in all cases. The cystic duct-common hepatic duct junction was visualized in 47% of the cases prior to exposure of the cystic duct. This junction was visualized with difficulty and unclearly before exposure of the cystic duct, but after exposure it was easily and clearly visualized in all but one case. After determining the precise location of the cystic ductcommon hepatic duct junction by LUS, we were able to safely clip and divide the cystic duct without complications during LC. Clear pictures were obtained more easily with the balloon method than with the water soakage method. Conclusion: LUS is useful for clarifying the anatomy of the biliary system to prevent accidental injury to the bile duct during LC.

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