The treatment for portal hypertension have been developed as a surgery for portal system. Although portosystemic shunt was employed at the begining of the surgery, a high incidence (36.4%) of hepatic encephalopathy, so-called the Eck fistula syndrome, was observed in 110 patients who underwent this procedure. Afterwards, it was proved that this type of encephalopathy disappeared through the closure of theshunt. As a result, the closure of the shunt was actively performed. In view of poor quality of life, nonshunting operations, especially esophageal transection, came into prominence in place of shunting operation. In our department a total of 576 patients had a nonshunting operation for esophagogastric varices, including 413 cases of transthoracic esophageal transection with paraesophagogastric devascularization (Sugiura procedure), 40 cases of trans-abdominal esophageal transection and 123 cases of Hassab's procedure. We have obtained nearly satisfactory results showing 9.5% of cumulative recurrent rates at 10 years after surgery. Subsequently, the introduction and the spread of endoscopic injection sclerotherapy (EIS) have made dramatic changes in a treatment for esophagogastric varices. Nowadays it has been most popularized instead of surgical procedures because of less invasiveness. In addition, endoscopic variceal ligation (EVL), transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (B-RTO) as techniques of interventional radiology for portal hypertension have been recently applied. In consideration of incurable cases and a high incidence of recurrence under these non-surgical treatments, however, surgical treatments have still played an important part in the treatments for portal hypertension. In conclusion, it is considered that the cases which are expected to have a long-term prognosis, such as a case of idiopathic portal hypertension (IPH), extrahepatic portal obstruction (EHO) and liver cirrhosis of Child A group should be treated by surgical procedures.

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Leiomyoma is the most frequent submucosal benign tumor of the esophagus. Recently, most patients of leiomyoma of the esophagus have been asymptomatic at diagnosis and the tumor is often detected in a health examination for an examination of other disease. In this study, we examined 14 cases of recected esophageal leiomyoma clinicopathologically. In preoperative endoscopic ultrasonography, 15 lesions were detected in low echoic and homogenous submucosal tumors and two lesions were heterogenous. Endoscopic resection of leiomyoma was performed in three cases. These lesions were diagnosed as originating from muscularis mucosae by preoperative endoscopic ultrasonography. Esophagectomy was performed in two cases, because of suspected esophageal leiomyosarcoma in one case and complication with esophageal carcinoma at the covered mucosa of leiomyoma in the other. Enucleation of esophageal leiomyoma was performed in nine cases, four of them performed by the thoracoscopic procedure. The postoperative course after thoracoscopic enucleation was not different from that after conventional thoracotomy. We concluded that the thoracoscopic removal of esophageal leiomyoma is as effective and safe as enucleation by thoracotomy. And endoscopic ultrasonography is an effective diagnostic procedure for clinical management of leiomyoma of the esophagus.

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In a series of 359 patients with superficial squamous cell carcinoma of the esophagus treated at the National Cancer Center Hospital from 1962 to 1997, 140 (39%) had other primary malignancies involving various organs. Of the 140 patients, 70 had synchronous double cancers, 47 had metachronous double cancers and 23 had involvement of three or more organs. In patients with metachronous double cancers, the esophageal cancer was detected earlier than the other malignancies in 10 cases, while the associated cancer was detected before the esophageal cancer in the remaining 37. The most common site of the secondary cancer was the stomach (52 cases), followed by the pharynx (45 cases). The overall 5-year survival rate of patients with multiple primary malignancies was 67%, which is significantly worse than the 5-year survival rate of patients with solitary esophageal cancer, 77%. In dealing with patients with superficial squamous cell carcinoma of the esophagus associated with other primary cancers, early detection of both cancers is essential to improving their outcomes.

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The role of hepatic venous blood as oxygen carrier under hepatic ischemia was investigated in pigs. Thirteen pigs were exposed to inflow occlusion (IO) of the liver for 60 minutes under veno-venous bypass. Oxygen saturation of the hepatic vein (ShvO₂) and the hepatic tissue (ShtO₂) were significantly raised by the oxygenation of the hepatic venous blood with the use of prostaglandin (PG) E₁ during IO. Oxygenation of the hepatic venous blood significantly ameliorated serum GOT level and ICG clearance 120 minutes after reperfusion. Histological examination proved the protective effect of oxygenation of the hepatic venous blood, and sinusoidal endothelial cells were by electron microscopic observation to be preserved. In conclusion, hepatic venous blood has a potential to supply oxygen to the liver under IO, and such oxygen can be utilized in the hepatic tissue.

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To clarify the difference between multicentric occurrence (MC) and intrahepatic metastasis (IM), the ratio of the occupying area of histologic differentiation grades (HDG) and histological progression in 38 nod-ules of solitary hepatocellular carcinoma (HCC), and in the largest and in the next to largest nodule of 24 cases of multiple HCC, were investigated among surgical cases of small HCC in which the main tumor was smaller than 30mm in diameter. The next to largest nodules in multiple cases in which well-differentiated (-diff) HCC was found were classified as MC group (9 cases), in multiple cases in which well-diff HCC was absent were classified as IM group (15 cases). The area-ratio of HDG and the degree of the tumor histological progression of the largest nodules in MC group were similar to those of solitary HCC nodules. However, the largest nod-ules in IM group showed a high area-ratio of moderately-and poorly-diff HCC, and a high positive rate of fc-inf and vp. No difference was observed between the groups in location of nodules in the liver, or in the difference in diameter between the largest and the next to largest nodules, however the next to largest nodules in IM group showed a high positive rate of tumor staining on DSA angiography. It was concluded that in differenti-ating IM from MC for multiple small HCCs existence of well-diff carcinoma in the next to largest nodules should be examined.

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Thirty-one patients with bile duct carcinoma were studied. The specimens of carcinoma and of the hepatic surgical margin of bile duct carcinoma were stained with hematoxylin-eosin and examined Immunohistochemically using carbohydrate antigens (MUC1, MUC2, STn, SLx, SLa). The relationships between recurrence patterns and carbohydrate antigen expression were investigated. The rates of expression of MUC1, STn, and SLx in cancer were significantly higher than those in non-cancerous epithelium. Of 31 patients with hilar bile duct carcinoma, 19 had a negative hepatic surgical margin (hm0), 6 were positive at a distance of 5 mm from the hepatic surgical margin (hm1), and 6 had a positive hepatic surgical margin (hm2). MUC1 expression rates of hm0, hm1, and hm2 were 32%(6/19), 33%(2/6), and 67%(4/6), respectively. These 12 MUC1-positive margins histologically involved 4 carcinomas, and 4 dysplastic, 1 hyperplastic, and 3 normal epithelia. Local recurrences were observed at choledochojejunostomy in 4 (33%) of 12 patients with MUC1-positive margins, but in 0 (0%) of 19 patients with MUC1-negative margins. Therefore, expression of MUC1 may be useful for histological examination of the hepatic surgical margin of bile duct carcinoma.

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We treated and performed appendectomies on 9, 295 patients from 1973 to 1995. The ultrasonic findings of appendix from 627 of these patients were classified into the following 5 types: type I, unclear wall contrast and no swelling of the appendix; type II, clear wall contrast and no irregular appendix; type III, clear wall contrast and irregular appendix; type IV, unclear wall contrast and swelling of the appendix; type V, fluid collection in the periappendix. We evaluated the histological findings of appendicitis using these types. The relationship between ultrasonic and histological findings were as follows: type I, normal appendix; type II, catarrhal appendicitis; type III, phlegmonous appendicitis; type IV, gangrenous appendicitis; type V, abscess formation. The findings show that it is possible to make a diagnosis form the histological findings of appendicitis using ultrasonic findings of the appendix. We consider that type II is a relative indication for appendec tomy, and that types III, IV, and V are absolute indications for appendectomy.

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The purpose of this study was to investigate the minimum requirement of pelvic splanchnic nerve preservation for urinary function after a radical operation for rectal cancer, and a urodynamic study was conducted to determine whether restoration of urinary function can be predicted. Fifty-nine patients after rectal resection were divided into a non-preserving group (n=19) and a partial-preserving group (n=40). The minimum requirement for pelvic splanchnic nerve preservation was determined by scoring the preserved nerves (preserving score). The urodynamic study was performed in 16 patients in the partial-preserving group 1 month after the operation. Urinary function both of 3 months after and 6 months after the operation was better in the partial preserving group than the non-preserving group. Urinary function 3 months after operation was significantly better in the group with more than 2 points in preserving score than the group with 1 point (p=0.014). Those patients whose first desire to void (FDV) yieleded less than 200ml or whose maximal desire to void (MDV) yielded less than 400ml had the possibility of release from self-catheterization until 3 months after the operation. These results suggest that the minimum requirement for urinary function in 2 points in preserving score that means bilateral S4 or unilateral S3S4 preserving and the restoration of urinary function can be predicted by FDV and MDV one month after the operation.

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There have been few reports of patients with leiomyoblastoma of the stomach in association with other malignancies of the alimentary tract. Moreover, a collision tumor with a leiomyoblastoma and cancer in the stomach is very rare. An 80-year-old man presented with a expirational dyspnea and hematemesis. Blood laboratory examinations showed severe anemia and malnutrition. Upper gastrointestinal radiography and an endoscopic examination revealed a submucosal tumor on the gross curvature of the gastric body and Borrmann type4 gastric cancer in the antrum. Tissue from an endoscopic biopsy histologically revealed a poorly differentiated adenocarcinoma. A diagnosis of a Borrmann type4 gastric cancer with a submucosal tumor of the stomach was subsequently confirmed. A subtotal gastrectomy was performed, and the histological findings of the Borrmann type4 gastric tumor revealed a pooly differentiated adenocarcinoma and a submu cosal tumor leiomyoblastoma of clear cell type. In addition, the gastric tumor was located close to the capsule of the leiomyoblastoma but did not invade it. There was no admixture of the two cellular components, indicating that the tumors were of the collision type. The rarity of the collision phenomenon involving a gastric cancer and a leiomyoblastoma is apparent since there in only one documented case reported in the literature.

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We report a case of umbilical metastasis of the gastric cancer, known as Sister Mary Joseph's nodule, 4 months after a curative operation. A 65-year-old woman was seen at our hospital for an umbilical tumor. After the first operation intraoperative and histopathological findings of the gastric cancer were as follows: macroscopically type 3, P0, H0, M (-), mucinous carcinoma, se, ly3, v1, n (1+). A biopsy of the umbilical tumor was performed. The specimen was diagnosed as mucinous carcinoma metastasized from the gastric cancer. During the second operation, the abdominal wall with 1cm tumor-free margins was resected. No other evidence of metastasis was found. The tumor was surgically removed and histological examination revealed metastasis from gastric cancer. It was suggested that the implantation during the gastric surgery caused the umbilical metastasis.

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A 55-year-old man was admitted complaining of epigastralgia. An upper GI series and endoscoic examination revealed a Borrmann type3 lesion at the angle of the stomach. A CT scan and US showed a tumor shadow in the S4, 5 and S8 regions of the liver. The preoperative serum AFP level was high at 1, 600ng/ml. Distal gastrectomy and D1 removal of the rigional nodes were performed. After the operation, intrahepatic arterial infusion therapy using doxorubicin and lipiodol was performed and the AFP level gradually decreased. The liver was partially resected on the 42nd day after the first operation. Pathological findings of the specimens revealed that the lesion at the angle was poorly differentiated adenocarcinoma. It was also suggested that the liver might have metastasized from the lesion at the angle, because it had the histological features of the lesion. Moreover AFP-producing cells were demonstrated in both the primary lesions and the metastatic liver tumor by the PAP staining method. The serum AFP level returned to the normal range 3 months after the hepatectomy. As postoperative chemotherapy, sequential chemotherapy with methotrexate and 5-fluorouracil (MTX/5-FU) was undertaken. The procedure consisted of MTX 70mg/m² (iv) followed one hour later with 5-FU 500mg/m² (div). The patient was treated 140 times by MTX/5FU sequential therapy. No adverse drug reaction or clinical laboratory test abnormality due to chemotherapy was observed. The patient is alive without any sign of hepatic metastasis or recurrence, 5. 5 years after the hepatectomy.

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When a case with far advanced liver metatases from breast cancer was treated by hepatic infusion chemotherapy (HIC), the masses diminished in size and number and resection was performed. A 61-year-old woman was admitted to our hospital because of a large mass in the left breast. Under a diagnosis of breast cancer, a mastectomy was performed. Eight months later, multiple liver metastases were detected. Intermittent HIC with 5-fluorouracil 500mg and carboplatin 100mg were administered every two weeks. The masses were gradually diminished and were limited to the right lobe of the liver. Thirteen months after the start of HIC, right hepatic lobectomy was performed. Histologic examination of the liver masses revealed no viable tumor cells and indicated a successful response to HIC. However, the metastases recurred in the lung and brain 5 months after the hepatectomy. Although irradiation therapy was perforemed, she died 15 months after the hepatectomy.

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We report rate case of primary hepatic actinomycosis. A 52-year-old man had undergone pancreatoduodenectomy for carcinoma of the ampulla of Vater 4 years earlier. He was admitted to our hospital for detailed examination of a small nodular lesion in the liver. Abdominal ultrasonography revealed a hypoechoic lesion, 2.0cm in diameter, in S6. A CT scan showed a low density area. T1 weighted MRI revealed a homogenous hypointense lesion. T2 weighted MRI revealed an isointense internal nodule surrounded by a hyperintense peripheral rim. A celiac arteriogram of the lesion showed no definite nodular staining. The posterior segment was partially resected under the suspicion of metastatic tumor. Histological findings revealed abscess-forming inflammation with fibrosis, in which radiating granules were found. There was no evidence of malignancy.

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A 39-year-old woman was admitted to our hospital because of repeated back pain. Abdominal ultrasonography(US) and computed tomography(CT) demonstrated a protruding lesion occupying the gallbladder. The lesion in the gallbladder and subsegments 4a and 5 of the liver were extensively stained during both contrast-enhanced CT and CT during arteriography. The operative cholangiogram and high bile amylase activity(160, 000IU/L) indicated the pancreaticobiliary maljunction. The retropancreatic portion of the common bile duct(CBD) was compressed by the right hepatic artery(RHA), which originated from the gastroduodenal artery and coursed immediately ventral to the CBD. Cholecystectomy, combined resection of subsegments 4a and 5 of the liver and extrahepatic bile duct, lymph node dissection, and hepaticojejunostomy were performed, on the basis of a diagnosis of gallbladder cancer. Histologically, the gallbladder lesion was diagnosed as papillary adenocarcinoma with minimal invasion(5mm) of the gallbladder fossa of the liver. The extensive staining in the liver on contrast CT was explained as an effect of abundant portal flow returning from the cystic vein. Generally, patients with pancreaticobiliary maljunction without choledoclocal cyst have few symptoms. However, compression of the CBD in the retropancreatic portion by the RHA seemed to be one of the causes of the cholangitis-like symptoms.

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We present a case of intrahepatic cholangiocarcinoma that gave rise to the formation of a huge livercyst mimicking the radiographic appearance of biliary cystoadenocarcinoma. A 81-year-old male was admitted on March 10 1997 because of a painful abdominal mass. Abdominal CT scan demonstrated a large lowattenuating mass in the left lobe of the liver. On a contrastenhanced CT, tha thick wall and papillary projection in the cystic lesion were poorly enhanced. We performed left hepatic lobectomy on the basis of a preoperative diagnosis of biliary cystoadenocarcinoma. The capsulated tumor, 82×78×72mm in size, was completely removed. Histological examination showed cholangiocarcinoma with a large cyst resulting from necrosis. Based on the radiographic findings and growth pattern, this case presents an unusual type of cholangiocarcinoma, resembling biliary cystoadenocarcinoma. It is nuclear whether suitable treatment and exact outcome in this case depended on the histological type and/or growth pattern. This question should be evaluated in the future.

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A 34-year-old man who has a history of conservative treatment of acute pancreatitis with huge pancreatic pseudocyst and small pancreatic tail pseudocyst about 2 years ago was admitted to our hospital for hematemesis with left upper abdominal pain on 21 September 1997. Emergency endoscopic examination was performed and active bleeding from submucosal tumor like lesion of the stomach at the upper-posterior-body near the greater curvature was detected. Color doppler ultrasonography and abdominal dynamic CT demonstrated a 3×3-cm mass in the tail of the pancreas. Splenic angiography revealed a tumor of the same size stain So we made a diagnosis of a splenic pseudoaneurysm with fenestration into the stomach. Distal pancreatectomy, splenectomy and partial gastrectomy were performed. Histological examination revealed that a false splenic aneurysm caused the hemorrhagic pancreatic pseudocyst. Fenestration into the digestive tract of a hemorrhagic pancreatic pseudocyst is very rare. Only 7 cases have been reported in Japan since 1972. Because of it's severe symptoms and high mortality, color doppler ultrasonography, dynamic CT and angiography should be used for a timely detection of the pancreatic pseudocyst.

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The patient was a 59-year-old woman in whom an asymptomatic pancreatic tumor was detected by ultrasonography. Dynamic CT revealed a hypervascular tumor in the body of the pancreas. We suspected it to be an islet cell tumor, but serum hormonal levels were within normal limits. The tumor was encapsulated and measured 1×1×1cm. It was extirpated in July, 1992, and histological examination revealed as islet cell tumor with evident trabecular and ribbon-like structures. No malignant cells were seen. Immunohistochemical studies showed that the tumor cells were positive for glucagon. Thus, it was diagnosed as an asymptomatic glucagon-producing tumor. No recurrence has been detected in the 6 years since the operation. We compared the clinical pathology of asymptomatic glucagon-producing tumors (group A) with symptomatic tumors (group S). The group A tumors were smaller and the patients had lower serum glucagon levels when compared with the group S. The group A also contained a higher proportion of benign tumors than the group S. We consider the prognosis of the former would be better than that of the latter.

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We experienced a case of thromboembolism after laparoscopy-assisted colectomy. A 67-year-old man underwent laparoscopy-assisted descending colon resection with lymph node dissection for early colon cancer. During the laparoscopic procedures, the intraabdominal pressure was set at 10 to 12 mmHg by peritoneal insufflation of CO₂ while the patient kept a slight head-up tilt position, and the operative time was 270 minutes. The postoperative course was uneventful until the 7th postoperative day. Suddenly he complained of a chest pain when he was getting out of bed. A pulmonary perfusion sintigram revealed a segmental perfusion defect of the left S5 area. He was diagnosed as having a pulmonary thromboembolism, and anticoagulant therapy with heparin was initiated. After the therapy, his condition improved. Only 6 cases of pulmonary thromboembolism after laparoscopic gastroenterological surgery have been reported in the Japanese literature up to now, and there have been only 2 cases after laparoscopic colectomy. This case represents 0.11% of 880 laparoscopic surgically treated patients in our institute. Although pulmonary thromboembolism is very rare, it should be considered as one of the most critical complication after laparoscopic surgery, and we have to use careful control during and after surgery.

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A 46-year-old man with a history of four episodes of perforation of the sigmoid colon during the previous 20 years was admitted to our hospital because of abdominal pain. Emergency operation with a preoperative diagnosis of intestinal perforation was performed. The resected specimen revealed punched-out perforation, and histological examination of the site of the perforation revealed only non-specific inflammation. Both the macroscopic and histological findings in this case were similar to those of the specimens obtained at the 2nd, 3rd, and 4th operations. We made the diagnosis of simple ulcer of the sigmoid colon based on the following findings:(1) the 1st punched-out perforation occurred at the age of 26 years;(2) the patient had never been constipated;(3) recurrent punched-out perforation occurred 5 times near the anastomotic site in the sigmoid colon in the absence of a diverticulum;(4) no granuloma formation was observed histologically;(5) no signs of Behcet's disease were observed; and (6) colonfiberscopic examination revealed an ulcer scar near the anastomotic site 10 months after the 5th operation. Although the incidence of postoperative recurrence is high, simple ulcers may heal naturally, and medical therapy for early lesions, such as small and shallow ulcers, is effective. Since it is possible for simple ulcers which have never been treated by some therapy to cause recurrent perforations, we have to emphasize the importance of detecting early lesions and treating them at the early stage of recurrence.

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Esophagobronchial fistulas have been treated conservatively, endoscopically, or surgically. We report a case of endoscopic closure of a fistula using ethyl-2-cyanoacrylate (ECA) which is a bioadhesive prodruct, obtaining good result.
A 73-year-old man suffered from chest disconfort in early June 1997. On June 6, endscopic examaination revealed a diverticululm 32-cm away from the superior incisor teeth at the 3 o'clock position associated with a 2-mm fistula in it. On July 2, radiographic examination of the fistula disclosed leakage of contrast medium from the right B6. On July 10, 1ml of ECA was applied with a spraying tube, followed by contrast studies to confirm the closure of the fistula. Contrast study 4 days after the spraying showed minor leakage of contrast material, so application of 1ml ECA was repeated. The next day the patient started ingesting food and was discharged from the hospital with an uneventful course. Endoscopic closure of a fistula is thought to be an effective treatment for patients before consideration of surgery and those with a poor general condition due to its relativesimplicity and safe repeatability.

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We performed laparoscopic Toupet partial fundoplication on nine patients with reflux esophagitis, and investigated their short-term results in terms of anti-reflux effects and symptoms. The mean follow-up period was six months (ranging from two months to eleven months). Each patient had a sliding hiatal hernia before operation, which did not recur. Esophagitis in all patients remained healed after operation. The preoperative mean duration of intraesophageal acid-exposure (the value of pH<4 holding time) was 27.1±25.0%(5.8%-84.1%), and decreased to 1.8± 2.7%(0%-7.9%) postoperatively. Preoperative complaints due to gastroesophageal reflux were almost completely diminished after surgery. Moreover, postoperative dysphagia and chest discomfort were improved within one month. In conclusion, short-term results of laparoscopic Toupet partial fundoplication for reflux esophagitis were excellent in terms of anti-reflux effects and symptoms improvement.

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We present three cases treated with hyperbaric oxygenation therapy (HBO) for prolonged jaundice after hepatectomy. Case 1: A 65-year-old man underwent right lobectomy for cancer of the gallbladder. After the operation, jaundice was prolonged and his total bilirubin rose to 18.1mg/dl. HBO was performed thirteen times, and his total bilirubin decreased to 5.4mg/dl. Case 2: A 69-year-old man underwent right lobectomy bile duct cancer. His total bilirubin increased to 19.3mg/dl. HBO was performed sixteen times and his total bilirubin decreased to 3.3mg/dl. Case 3: A 64-year-old man underwent electrohydraulic lithotripsy for his remnant intrahepatic stone after hepatectomy of his cirrhotic liver. His total bilirubin increased with each lithotripsy treatment. HBO was commenced and his total bilirubin temporarily decreased to 11.5mg/dl from 21.1mg/dl, but finally increased again due to severe cholangitis, which caused fatal liver failure. Therefore HBO was not effective for jaundice in the patient with a cirrhotic liver and without a functional reserve. However, prolonged jaundice after hepatectomy of a non-cirrhotic liver was successfully treated with HBO.

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Spiral computed tomography combined with drip infusion cholangiography (DIC-SCT) has come into widespread use as a new method for examinating patients with biliary diseases. The aim of this study was to determine the usefulness of DIC-SCT during the postoperative period in patients with congenital biliary dilatation. DIC-SCT was performed on 7 patients who had undergone excision of a cyst with hepaticoenterostomy for congenital biliary dilatation. Their age at surgery ranged from 4 months to 40 years. The follow-up period after surgery ranged from 10 to 127 months. In all cases, the first branch of the intrahepatic bile duct, the anastomotic site and intestine were recognized by DIC-SCT. The size of the anastomosis ranged from 4 to 25mm in transverse diameter and from 3 to 20 mm in occipitofrontal diameter. In one type IV-A case, dilatation of the right intrahepatic bile duct and obstruction of the left intrahepatic bile duct were revealed. This study demonstrates that DIC-CT is suitable for postoperative examination of the anastomotic site and monitoring for cholestasis in patients with congenital biliary dilatation.

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