Preoperative evaluation of cancer invasion into the trachea and bronchus is of vital importance in pa-tients with cancer in the upper thoracic esophagus. The usefulness of transtracheobronchial ulorasonography (TBUS) in diagnosing cancer invasion into the tracheobronchus was studied. Preliminary ultrasonic observa-tions of tracheal specimens revealed that the normal tracheal wall can be delineated as a structure composed of 5 layers. A total of 19 patients with esophageal cancer suspected to invade to the trachea and/or bronchus by CTwere examined. Informed consent was obtained from all patients. A 20-MHz sonoprobe (UM-3R, Olym-pus Optical Co. Ltd.), which was passed through the biopsy channel of a fibroptic bronchoscope (ST-30, Olym-pus Optical Co. Ltd.) was used. The balloon on the sonoprobe wasinflated with water to attach to the tra-cheobronchial mucosa in order to obtain an echo window. The tracheobronchial wall was delineated as 5 lay-ers. The esophageal lesion was detected as a low echoic area. The presence of tracheobronchial invasion was diagnosed by interruption in the most external high echoic layer of the tracheobronchus. Tracheobronchialin-vasion was not found surgically in the 6 patients diagnosed as having no invasion. In the 13 patients with the interruption, bronchial invasion was confirmed at operation in allof the 9 patients who had thoracotomy. There were no complications caused by TBUS. TBUS was useful in evaluating cancer invasion into the tra-cheobronchus because it is effective and safe, and is more accurate than CT for visualizing the layered struc-ture of the tracheobronchus.

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The purpose of this study was to evaluate ischemic injury of the liver by Pringle method during hepatec-tomy. Electrical impedance was used for instantaneous evaluation of the normothermic ischemic injury of the liver in Wistar rats, which had received a portal bypass by the subcutaneously transposed spleen. Four ischemic groups (15, 30, 60, and 120 minutes) were studied and then received a reperfusion. Conductance was measured with an LCR meter and then resistivity was calculated. Bile flow during experiments was meas-ured. The preischemic value of ρ at 1kHz was 1, 038±98 (mean±SD) ohm·cm. In the early phaseof ische-mia ρ increased and reached a peak (ρm). After the peak, ρ decreased to the point of reperfusion (ρr). The time from initiation of the ischemia to ρm was 35±5.9 minutes. Adenosine triphosphate (ATP) in the liver was measured by high performance liquid chromatography. The ATP level in the liver decreased with ischemic time, 40.5±2.9% at 20 minutes and 36±5.6% at the time of ρm. Microscopically, the ischemic damage of the liver was little up to 30 minutes and severe at 60 minutes of ischemia. Recovery of the bile flow one hour after reperfusion in each group was 98.2±6.2, 90.6±0.5, 23.9±15.6, and 6.96±4.2%.ρ has significant inverse correla-tionswith ATP in the early ischemic period to ρm and then a ρr/ρm has positive correlation with recovery of the bile flow one hour after reperfusion. These results suggests that electrical impedance is one of the indices for viability of ischemic injury of the liver in rats.

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Eighty-three patients with large hepatocellular carcinoma (>5cm), who underwent hepatic resections were analyzed for 30 clinicopathologic variables related to tumor-free survival after surgery. Univariate analysis showed that major hepatic resection (n=49), singlenodular case (n=41), no portal invasion (n=75), no intrahepatic metastasis (n=36), complete surgical margin (n=36) and curative operation (n=25) were significant independent factors for longer tumor-free survival. Using multivariate analysis, only no intrahepatic metastasis on its own found to be an independent factor. Although 16 of 49 patients with majorhepatic resec-tion underwent percutaneous transhepatic portal embolization before surgery, it was not an independent prognostic factor in tumor-free survival. In order to have a long tumor-free survival for large HCCs, curative major hepatic resection with a complete surgical margin seemed to be necessary. Percutaneous transhepatic portal embolization may contribute to extension of surgical indications for large HCCs.

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The purpose of this study was to evaluate the relationship between DNA multiploidy and tumor charac-teristics of colorectal cancer. Flow cytometric quantification of nuclear DNA content was performed on freshly frozen tissue from 245 patients who underwent surgical resection from 1990 to 1996, at First Depart-ment of Surgery, Nagasaki University School of Medicine. The cases were classified into three groups accord-ing to DNA ploidy pattern as follows: 1) Dd group, 78 cases (31.8%) with DNA diploidy; 2) Dm group, 36 cases (14.7%) with DNA multiploidy; 3) Da group, 131 cases (53.5%) with DNA aneuploidy except for DNA multiploidy. The Dm group was associated with left colon (compared with Dd group, p=0.0069), absence of metastasis (compared with Da group, p=0.0095), and positive family history of extracolonic malignancy (com-pared with Dd and Da groups, p=0.031 and p=0.044, respectively).Of the 245 patients, 71 cases were ran-domly examined by fluorescence in situ hybridization for detection of numerical aberration of chromosome 17. The frequency of chromosomal aberration was lower in the Dm group than in the Da group (p=0.0068).

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To investigate the clinicopathological characteristics of various macroscopic morphological types of colorectal muscularis propria (mp) carcinoma, we studied 91 colorectal mp carcinomas resected surgically from 1979 to 1997. The 91 mp carcinomas were morphologically classified as: superficial and flat tumors with minimal elevation (type 0, N=4); protuberanttype (type 1, N=16);ulcerated type with clear margin (type 2, N=70); and ulcerated typewith infiltration (type 3, N=1). The 20 mp tumors of types 0 and 1 were considered as group A and the 71 mp tumors of types 2 and 3, as group B. Tumor histologies in group A were well and moderately differentiated adenocarcinomas. Howere, group B included not only welland moderately differentiated adenocarcinomas but also pooly differentiated and mucinous adenocarcinomas. Lymph node metastasis was present in 17 (18.7%) of the 91 cases of colorectal mp cancer. It was detected in 3 (14.3%) of the 21 cases in group A and in 14 (19.7%) of the 71 cases in group B. The incidence of lymph node metantasis was not signigicantly different between the 2 groups. Lymph node metastasis in group B, however, was found in moredistant regions than that in group A. The frequency of lymphatic invasion was 69.2%(63/91) of all mp carcinomas. Those in groups A and B were 65.0%(13/20) and 70.4%(50/71), respectively. Venous invasion was found in 40.7%(37/91) of all cases, 25.0%(5/20) in group A, and 45.1%(32/71) in B. Survival data indicated a more favorable prognosis in group A than B (p=0.08). These findings suggest that the mp carcinoma in group B with less differentiated histology and remote lymph node metastasis, as well as poorer prognosis, should betreated more intensely.

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The patient was an 82-year-old woman. Chest X-ray films obtained at a screening examination in August 1996 revealed cancer of the right lung accompanied by infiltration of the mediastinum. At the patient's re-quest, she was kept under observation without any active treatment. In March 1997, the patient developed dysphagia, and oral intake of food became impossible by the end of the same month. She was hospitalized and examinations revealed that mediastinal infiltration of the lung cancer had caused esophageal stenosis. An ex-pandable metallic stent (EMS) was inserted and improved oral intake of food, therefore, the patientwas dis-charged from the hospital. In May 1997, the patient developed dyspnea, and examination revealed tracheal stenosis. The patient's conditions suddenly worsened, so an EMS wasinserted into the trachea and improved the dyspnea. The patient was subsequently discharged from the hospital. In July 1997, the patient died of pneumonia. In patients with inoperable stenosis of the esophagus or of the trachea caused by cancer, an EMS may improve the patient's quality of life. However, caution should be exercised in patients with esophagealstenosis because placement of an EMS may accelerate the development of tracheal stenosis.

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For years, primary nonepithelial gastrointestinal tract tumor's origin was thought to be smooth muscle from microscopic findings. But many of these tumors have failed to show either muscle or neural differentia-tion by immunohistochemical study and by electroscopic findings, thus, they are now called gastrointestinal stromal tumors (GIST). A case of gastricstromal tumor is reported, which was thought to be a leiomyosar-coma before operation, however, determination of the tumor as smooth muscle, neural or fibrous tumor by mi-croscopicfinding only was difficult. Immunohistochemical study and electroscopy were used to diagnose a gastric stromal tumor. Immunohistochemical studies failed to show positivity in muscle or neural markers, and only vimentine and CD-34 were positive. Electroscopical study showed no findings to support the tumor's muscle, neural nor fibrous differentiation. Becauseimmunohistochemical and electroscopic study are com-monly used to diagnose gastrointestinal tract tumors nowadays, the number of GIST cases is increasing. There has been no parameter which clearly predicts the malignant potential of GISTs. Accumulation of GIST cases andtheir long-term follow-up is needed to clarify the biological mechanisms.

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A 65-year-old female was diagnosed as having a tumor in the upper part of the stomach in 1989, however she had been refusing surgery for 7 years. In 1994 she was suddenly admitted with complaints of abdominal pain accompanied with nausea and vomiting. Ultrasonography showed that intussusception of a tumor arising from the upper part of the stomach had occurred into the duodenum. The tumor was resected with part of the gastric wall. The excised specimen was a smooth-faced oval tumor, 6. 5×7. 5 cm in size and weighing 120 g. Histologically, it was diagnosed as a leiomyosarcoma. This paper reported a very rare leiomyosarcoma arising from the upper part of the stomach which showed ball valve syndrome intussusception into the duodenum.

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A 67-year-old woman was admitted to our hospital in April 1997 with complaint of persistent epigastral-gia. On admission, physical examination showed tenderness and rebound tenderness in the upper abdominal region. Blood laboratory data revealed that the white blood cells count was 11, 130/mm³, and C-reactive pro-tein was 18.6 mg/dl. Peritoneal free air was not detectable on chest or abdominal roentgenograms. Abdominal ultrasonography revealed a low-echoic lesion with an internal high-echoic region in the upper abdomen. Ab-dominal CT revealed a low-density area with an internal slender high-density area. An operation was carried out under the tentative diagnosis of peritoneal abscess formation caused by perforation of the gastrointestinal tract. The gastric antrum was edematous and the abscess was found in the greater omentum, so distal gas-trectomy was carried out. A fish bone, 4.5 cm inlength was found in the omental abscess. Pathohistological ex-amination revealed a cuffed abscess between the submucosal layer and serosa of the gastric antrum to be the site wherethe fish bone penetrated, and infiltration of neutrophils under the serosa was considered.We re-port a case of omental abscess due to gastric penetration by a fish bone, although it is definitely uncommon.

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We sometimes encounter gastric cancer patients whose initial symptoms and signs are enlargement of the liver and liver dysfunction. We, therefore, studied these primary gastric cancer cases with clinical liver swelling and dysfunction that was due to extensive liver metastases.(MATERIALS AND METHODS) We defined this kind of gastric cancer as “Gastric cancer with extraordinary liver metastasis”, and found 5 of these cases out of 215 primary gastric cancer cases in a 5 year period (1. 9%).(RESULTS) The median age was 67 years and sex ratio (M/F) was 4/1. In these cases, the enlarged livers measured up to 3-5 f. w. under the costal margin. All cases showed high serum NSE (18-170 ng/ml), and 3 showedhigh serum AFP (250-27, 000 ng/ml). Histological examination of biopsied specimens from all cases revealed poorly differentiated adenocarcinoma with medullary growth pattern. Four cases underwent resection of the stomach. 2 of these showed histological differentiation towards neuroendocrine tumor, 2 towards hepatocelluar carcinoma. All cases were given intrahepatoarterial infusion or intravenous infusion of CDDP and 5FU, and showed high sen-sitivity to chemotherapy (PR). The volume of liver which had enlarged due to severe liver metastases re-duced to normal size. Liver volume reduction rate was 56%(43-67%). Three casesdied of cancer after 10, 13 and 18 months from initial chemotherapy treatment, and 2 casessurvived for 8 and 18 months.(CONCLU-SION) “Gastric cancer with extraordinary livermetastasis” showed neuroendocrine differentiation or hepato-cellular differentiation. Histological examination of biopsied specimen from original tumors revealed poorly differentiated adenocarcinoma with medullary growth pattern. NSE or AFP was the specific tumor marker for this type of gastric cancer. These tumors showed high chemosensitivity, which improved survival time. “Gastric carcinoma with extraordinary liver metastasis” exhibits unusual clinical and biological characteris-tics for a gastric cancer.

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A 56-year-old woman underwent a low-anterior resection of the rectum and partial hepatectomy for rectal carcinoma with liver metastasis. Remnant liver recurrence occurred three times during the 6 years after initial surgery. Hepatectomies were performed for each liver recurrence. At present, she has only the subsegment V and caudate lobe of the liver remaining, but is still alive and disease free. This is a rare case demonstratingthat long survival can be obtained by repeated hepatectomies.

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A case of erythropoietin producing hepatocellular carcinoma is presented. A 64-year-old man was referred to the hospital because of a hepatic tumor and erythrocytosis. CT showed a large hepatic tumor in the right lobe and ultrasonography demonstrated tumor thrombus in the inferior vena cava. His serous erythropoietin level was elevated to 1, 510 mU/ml. Trans arterial chemotherapy was not effective and the patient died of the tumor on the 61st hospital day. Necropsy of the hepatic tumor revealed hepatocellular carcinoma of a trabecular type and immunohistochemistory for erythropoietin was strongly positive. Eight cases of hepatocellular carcinoma with erythrocytosis in the Japanese literature are reveiwed.

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A 70-year-old man was referred to our hospital because of an increase of the AFP level in a blood test. Abdominal CT film showed situs inversus totalis and a tumor lesion about 2 cm in diameter in the lateral segment of the liver. Angiography of the superior mesenteric artery revealed the variant common hepatic artery rising from the superior mesenteric artery to supply the liver.
Partial hepatectomy was performed. Herein we reported the sixth case of hepatocellular carcinoma with situs inversus totalis in Japan.

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After microwave coagulation therapy (MCT) for a recurrent metastatic liver tumor, a biloma and biliobronchial fistula were encountered. A 61-year-old man underwent sigmoidectomy and extended right hepatic lobectomy for sigmoid colon cancer concomitant with multiple liver metastases in September of 1996. He also underwent microwave coagulation therapy for a recurrent metastatic liver tumor in May of 1997. Two months later, he was admitted to our hospital because of jaundice. Under a diagnosis of biloma, percutaneous drainage of the biloma and bile duct were performed. Cholangiography revealed bile leakage from the left intrahepatic bile duct. To correct stenosis of the left hepatic duct, a metallic stent was placed. In May of 1998, he had biloptysis and a biliobronchial fistula was demonstrated by fistulography from the right subphrenic drainage. The fistula was closed once but soon recurred. Therefore, medial segmentectomy and hepaticojejunostomy were performed in August. His postoperative course was uneventful. The biliobronchial fistula is a complication of MCT which should be kept in mind.

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We report a case of chronic pancreatitis with pseudocyst rupture into the common bile duct (CBD).
A 60-year-old man was admitted to our hospital because of chronic pancreatitis complicated with a pancreatic cyst. Abdominal CT scan showed the homogeneous cystic lesion with a smooth wall located at the pancreatic head. Endoscopic retrograde pancreatography demonstrated a pancreatic cyst which communicated with the pancreatic duct and ruptured into the CBD. Thus, the diagnosis of chronic pancreatitis with pancreatic cyst was made. Because the cyst ruptured into the CBD, we could not exclude malignant neoplasm. Pylorus-preserving pancreatoduodenectomy with D2 lymphnode dissection was perfomed. Pathological diagnosis of the lesion was chronic pancreatitis with pseudocyst. It should be noted that various complications can be associated with chronic pancreatitis.

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Although small-bowel metastasis of lung cancer is unusual, the number of such reports is increasing. In this report, we intend to clarify clinicopathological features of lung cancer metastasis to the small intestine and to determine the indication for surgical treatment. Small-bowel metastases were present in 4 of 877 patients with primary lung cancer during the recent 11-year period at Toranomon Hospital. All 4 patients underwent surgical resection after acute abdominal symptoms. Three of the 4 had other organ metastasis and died within 3 weeks because of postoperative complications and one without other organ metastasis survived7.5 months postoperatively. Although the prognosis of lung cancer metastasis to the small bowel is poor, surgery is still indicated for palliation in otherwise fatal circumstances.

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A case of allergic granulomatous angiitis (AGA) complicated with multiple perforation of the ileum is described. A 40-year-old woman had suffered from bronchial asthma for ten years, and had been treated for 2 years with steroid hormones under a diagnosis of AGA. She was admitted to our hospital complaining of right lower abdominal pain. Laboratory tests highlighted an increase in WBC (9, 600/mm³) and CRP (11.3ng/dl), but eosinophil count (0.0%) and IgE (240U/ml) were at normal levels. She was diagnosed as having gastrointestinal perforation by abdominal physical findings and underwent an emergency operation. Three ileal perforations, which located 30, 33, and 60 cm from terminal ileum, were found intraoperatively and an ileotomy was carried out. Only 19 cases of AGA complicated with the intestinal perforations have ever been reported in Japan. Almost all cases were in the active stage on laboratory data at perforation. However, this is a rare case, because it perforated at the non-active stage.

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We report a rare case of traumatic abdominal wall hernia. The case was a 72-year-old female. 17 years ago she underwent conservative treatment for a fracture of the pelvis following the traffic accident. Physical examination was hindered by obesity, but the abdominal wall was tender in the right lower quadrant. Abdominal CT and barium enema revealed that the ascending colon was apparent in the hernia. She was diagnosed as having a lumber hernia, and operated on. Interaoperative findings failed to reveal any evidence of a lumbar hernia, but found instead a 4-cm disruption of the external oblique muscle. The defect in the abdominal wall was repaired in layers. She was diagnosed as having delayed traumatic abdominal wall hernia that occurred 17 years after the traffic accident. This diagnosis is usually made at the time of injury, and repair is undertaken at that time. Our delayed traumatic abdominal wall hernia was rare. The diagnosis had been on the basis of careful history and clinical examination. A computed tomographic scan and barium enema were particularly useful for diagnosis of our case.

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A case of idiopathic perforation of the sigmoid colon with a fecal mass formation in the mesocolon due to penetration into the mesocolon is reported. A 76-year-old woman was hospitalized with the sudden lower abdominal pain, which was not very severe, and melena. She was referred to the surgery department because of the manifestation of the peritoneal sign during further examinations. An emergency operation was performed with the diagnosis of colonic perforation, because the abdominal CT showed gas at the retroperitoneal space and a low density area with air bubbles in front of the sacrum. Perforation was present in the mesenteric side of the sigmoid colon, and a fecal mass was formed as a result of penetration into the mesocolon. Hartmann's operation was performed with resection of the fecal mass and the retroperitoneal space with emphysema was opened for drainage. Her clinical course after the operation was uneventful. Idiopathic perforation of the colon with penetration into the mesocolon is rare. It is believed that a prognosis of colonic perforation without fecal peritonitis is good, as in our case.

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A 62-years-old woman visited our hospital with sudden lower abdominal pain. On admission, pelvic CT showed a large retro-rectal mass and Ba-enema and colonoscopy showed a compression of the rectum without irregularity of the mucosa. We suspected a malignant gastrointestinal stromal tumor and Mile's operation was performed. Histopathological examination of the resected specimen failed to reveal a neoplasm but only a hematoma in the rass. Because of no etiologic factors like abdominal trauma and anticoagulant therapy, we diagnosed spontaneous intramural hematoma of the rectum. Intramural hematoma of the colon is a rare disease and the operative indication and therapy have not been established

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Recurrence in the abdominal wall is rare after resection for rectal cancer. Here we report two such recurrence cases. Case 1: A 72-year-old man underwent Hartmann's procedure for rectal cancer. The histological findings of the tumor showed moderately differentiated adenocarcinoma (se, n1, ly3, v1, P0, H0, M (-), stage IIIa). Nineteen months after resection, recurrence in the operative wound scar and lung metastasis (solitary) were found. Recurrence in the abdominal wall and lnug metastasis were resected. Case 2: A 53-year-old man unederwent resection of the rectum for rectal cancer. The histopathological findings of the tumor showed moderately differentiated adenocarcinoma (a1, n1, ly2, v0, P0, H0, M (-), stage IIIa). Fifty-two months after resection, recurrence in the operative wound scar was found, and resections of the abdominal wall and part of the bladder wall were carried out. We thought the recurrences were caused by implantations of the cancer cells when the operative woudns were closed. These two cases are the first evidence of recurrent rectal cancer in operative wound scars.

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Leakage of the duodenal stump after total gastrectomy with Roux-en-Y anastomosis and distal gastrectomy of the Billroth II type are refractory. Conservative treatment or reoperations to drain the duodenal contents are carried out. But healing takes time and sometimes sepsis or intra-abdominal hemorrhage can complicate the healing process and even cause death. In this study we applied the technic of percutaneous transhepatic biliary drainage (PTBD) for treatment of the duodenal stump leakage in four patients. The PTBD catheter was placed into the duodenum through the liver and common bile duct to drain the duodenal contents. Octreotide acetate (Sandostatin ^®) was administered in three patients in order to improve treatment outcome. This method is considered a conservative treatment of the duodenal stump leakage because it is minimally invasive and makes reoperation unnecessary. Therefore, we recommended PTBD for the treatment of duodenal stump leakage after gastrectomy. Furthermore, we think that administration of Sandostatin ^® makes this treatment more effective.

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