Collection of large numbers of cases of pancreaticobiliary maljunction (PBM) has shown that PBM without bile duct dilatation is frequently associated with gallbladder carcinoma. Surveys over the last decade, however, show that the incidence of bile duct cancer in PBM without dilatation is not as rare as that of choledochal cyst. The pathology in PBM is a result of reflux of pancreatic juice and stasis of the mixture in the biliary system. The bile acid fractions of bile are altered, and the presence of mutagens has been demonstrated. Dysplasia and hyperplasia are often found in the epithelia of PBM, and proliferative activity is increased, as evidenced by an increased PCNA labeling index and ODC labeling index. Furthermore, K-ras gene mutations, overexpression of p53 protein, p53 gene mutations and p53 LOH have been demonstrated even in nonneoplastic epithelia, especially of bile ducts without dilatation. Judging from the statistical data and the molecular biological data, total resection of an extrahepatic bile duct with gallbladder should be the treatment of choice for the prevention of carcinogenesis, regardless of whether dilatation is present or not. Hepaticoduodenostomy is preferable because it is a less invasive procedure and preserves natural bile flow into the intestinal tract. The incidence of postoperative complications, such as anastomotic stricture and or reflux cholangitis, is low even in cases without dilated bile ducts.

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We investigated 636 patients who underwent esophagectomy for thoracic esophageal cancer between 1984 and 1997 to clarify the influence of neoadjuvant therapy (NT) on postoperative morbidity and mortality. Among these 636 patients, neoadjuvant therapy was performed in 113. Of the 113 patients, 52 patients under went preoperative chemotherapy (CT), 53 underwent radiotherapy (RT), 8 chemoradiotherapy (CRT). The remaining 523 patients were treated with surgery alone (SA). Differences in serum albumin and body mass index before and after these treatments were not statistically significant, whereas differences in peripheral white blood cell and lymphocyte counts between SA and after RT or between SA and after CRT were statistically significant. Furthemore, there were statistical significances in the changes of peripheral white blood cell and lymphocyte counts before and after treatment in the RT and the CRT. The incidence of postoperative pneumonia and colitis in CRT were 37.5% and 37.5% respectively, which were significantly higher than the incidence in SA. There were no statistically significant differences in morbidity and mortality rates at 30 days after operation between the groups. The incidence of postoperative pneumonia between patients with and without CRT exhibited a statistically significant difference by univariate analysis. Additionally, logistic regression analysis revealed the CRT was one of the most important risk factors for postoperative pneumonia. Therefore, after neoadjuvant chemoradiotherapy patients should be considered as in an immunosupressive state prior to surgery which will require careful and special postoperative management.

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To investigate the usefulness of reconstructive procedures after proximal gastrectomy, we examined the extent of gastrectomy and the models of jejunal interposition. Assessment of the quality of life and a functional evaluation was examined in patients who had undergone 4 kinds of reconstructive procedures after proximal gastrectomies including total gastrectomy. At 1 year after the operation, the postoperative physical condition of the patients was evaluated by comparisons among 2/3 proximal gastrectomies reconstructed by the jejunal interposition group (2/3-PG group, n=5), 4/5 proximal gastrectomies reconstructed by the jejunal interposition group (4/5-PG group, n=7), 4/5 proximal gastrectomies reconstructed by the jejunal pouch in-terposition group (Pouch group, n=7), and total gastrectomies reconstructed by the jejunal interposition group (TG group, n=12). In the 2/3-PG and Pouch groups, the postoperative/preoperative ratios of meal intake were higher, and the changes in acetaminophen concentration, blood sugar and insulin levels were lower than those in the other groups. In particular, the postoperative/preoperative ratios of body weight were the highest in the 2/3 PG group than in the other grouos. In the Pouch group, the remnant stomach was observed by endoscopy in all cases, while 2 cases in the Pouch group showed finding of esophagitis. Postoperative QOL in the 4/5 PG and TG groups was inferior to that in the other two groups, and the results of functional evaluation in the 4/5 PG group resembled those in the TG group. In proximal gastrectomy, the extent of the distal stomach should be preserved, and when the remnant stomach is small, the reserve function should be increased with a jejunal pouch.

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The aim of our study was to identify prognostic factors in advanced resectable gastric cancer patients. We investigated 50 advanced gastric cancer surgical specimens by immunohistochemical methods. Measurements of microvessel density, expression of urokinase-type plasminogen activator (u-PA), plasminogen activator inhibitor-1 (PAI-1), urokinase-type plasminogen activator receptor (u-PAR) and vascular endothelial growth factor (VEGF) were made by the streptoavidin-biotin complex staining method. We then compared these parameters with the survival, and clinicopathorogical factors. Microvessel density was between 19.7 and 72.7 (mean 42.7±12.9). Expression of u-PA, PAI-1, u-PAR, or VEGF in cancer cells was detected in 24 (48%), 29 (58%), 28 (56%), and 32 (64%), respectively. Monovariate analysis showed that u-PA expression and microvessel density had a significant influence on survival after surgery. The other two u-PA families had no impact on survival. Ten variables were entered into the Cox proportional hazard regression model to identify factors that independently influenced survival. Multi-variate analysis revealed that clinical stage and the expression of u-PA independently influenced survival in patients. In conclusion, it is suggested that the u-PA expression is useful as a new prognostic factor in advanced gastric cancer patients.

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We investigated the clinical course and the therapeutic outcomes for 11 patients with hepatocellular carcinoma (HCC) coexisting with bone metastasis after hepatectomy between 1989 and 1997. Bone metastasis of HCC very frequently occurred in the advanced stage, and intrahepatic recurrence was the main cause of death in most cases (72%). Cases of solitary bone metastasis were alive longer than 1 year after bone metastasis, and their prognoses were relatively good. Most therapies for bone metastasis were performed conservatively to reduce the pain The resection of the bone was performed in 3 patients. Though the bone metastases of these patients were progressive and finally changed to multiple foci, they had longer survivals than the other patients and took longer painless period. For HCC patients whose intrahepatic lesion is controllable and the metastatic bone lesion is solitary and easily resectable, resection of the lesions seemed to be effective as the intensive therapy for HCC with bone metastasis.

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The Epstein-Barr virus (EBV) DNA was detected with the polymerase chain reaction in the mucosal tissue of all resected gallbladders in patients with acute cholecystitis (n=17), which included two cases of acalculous acute cholecystitis. In 12 out of these 17 patients, EBV-DNA was detected in both the mucosal tissue and bile from the gallbladder. EBV-DNA was not detected in any gallbladder which was resected for gallstones without acute inflammation, and in normal gallbladders. Serum anti-viral capsid antigen (VCA)-IgM antibody was not detected in any of the investigated cases (n=38). Serum anti VCA-IgG antibody was detected in 37 cases except one case of chronic cholecystitis. These 37 cases had latent EBV infection. Latent EBV infection may be one of the etiologic factors for the development of acute cholecystitis.

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The Effectiveness of intraductal ultrasonography (IDUS) through the cystic duct during laparoscopic operation was evaluated in 11 patients with cholelithiasis. The IDUS probe (2mm diameter) was inserted easily through the cystic duct to the common bile duct in 10 of 11 patients. Residual common bile duct stones were detected by IDUS in 2 patients who had already performed endoscopic sphincterotomy (EST). In one patient, common bile duct stone was detected by IDUS, that was not detected by intraoperative cholangiography. In another patient only one common bile duct stone was demonstrated by intraoperative cholangiography, however, 2 stones were revealed by IDUS. We suggest that IDUS in useful for the detection of small stones that were difficult to demonstrate by intraoperative cholangiography, and effective to ascertain the presence of residual stones after endoscopic treatment for common bile duct stones.

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The significance of MMP-7 and type IV collagen expression in human colorectal cancer was investigated by immunohistochemical assay, and its correlation with liver metastasis was analyzed. In the synchronous metastasis group, 26 of 36 cases (72%) showed positive staining of MMP-7: 32 cases (89%) in the lymph channel, 28/32 (87%) in the vessel, and 19/32 (59%) a decreased rate of type IV collagen. In the metachronous metastasis group, 14 of 30 cases (47%) showed positive staining of MMP-7: 19 cases (63%) in the lymph channel, 13/19 (69%) in the vessel, and 10/19 (53%) a decreased rate of type IV collagen. In the control group, which is a 5-year disease-free group, in spite of no significant clinicopathological factors conpared with the other two groups, 17 of 37 cases (51%) showed positive staining of MMP-7: 12 cases (37%) in the lymph channel, 6/37 (18%) in the vessel, and 14/37 (38%) a decreased rate of type IV collagen. Thus the metastatic groups show significantly higher expression of MMP-7 in the lymph channel than the control group. The expression of MMP-7 in the lymph channel is the most useful paraneter to predict liver metastasis in colorectal cancer.

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A 62-year-old man was admitted to our hospital with a diagnosis of gastric tumor during a health screening X-ray examination. The submucosal tumor was detected with endoscopy, endoscopic ultrasonography and X-ray examination. The preoperative diagnosis was leiomyoma of the stomach because of the smooth and hypoechoic lesion seen during endoscopic ultrasonography. Laparoscopic partial resection of the stomach was performed. The histological examination revealed the tumor to be a glomus tumor. In Japan, a glomus tumor of the stomach was first reported in 1962 and only 69 cases have been reported in the Japanese literature up to now, of which only one case has been resected by laparoscopic surgery.

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An 82-year-old woman who was pointed out an abnormal shadow of the stomach by upper gastrointestinal series at a gastric cancer screening was diagnosed to have a submucosal tumor of the stomach and cholecystolithiasis. At surgery, a 11 cm tumor growing extraluminally from the anterior wall of the cardia and a hard right ovarian tumor with massive bloody ascites was observed. Total gastrectomy, cholecystectomy and right oophorectomy were performed. Immunohistochemical study showed that the gastric tumor was negative for myogenic and neurogenic markers, but was positive for CD34 and vimentin. From these observations, the gastric tumor was suspected to be gastrointestinal stromal tumor (GIST) with low malignant potential. The ovarian tumor was diagnosed as thecoma by Sudan stain and silver impregnation method. We suspected that the massive bloody ascites was due to thecoma and rupture of the GIST with bleeding. The postoperative course was uneventful and she had no sign of recurrence for three years.

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A 35-year-old woman was admitted with discomfort caused by a tumor mass in the lower abdomen, which was suspected to be an ovarian tumor. Bilateral oophorectomy was performed and the tumor was histopathologically classified as signet ring cell carcinoma. Postoperative gastrointestinal fiberscopy revealed an early gastric carcinoma of the IIc-type on the greater curvature of the middle potion of the gastric body. The biopsy specimens were diagnosed as signet ring cell carcinoma, and a total gastrectomy was carried out. Krukenberg's tumor is reported to be a kind of tumor cell dissemination, but our case did not show any peritoneal dissemination. Six cases of intramucosal gastric cancer with Krukenberg's tumor have been found in the Japanese literature.

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A case of gastric lymphoma of mucoa-associated lymphoid tissue (MALT) exhibiting marked plasma cell differentiation with idiopathic portal hypertension is reported. A 67-year-old woman was admitted to our hospital because of appetite loss and general fatigue. Upper gastrointestinal endoscopy revealed multiple stomach ulcers. Macroscopic examination revealed morphological similarities to the superficial type of malignant lymphoma. Abdominal CT and angiography showed splenomegaly and proliferation of the collateral vessels. Under the diagnosis of malingant lymphoma of the stomach and idiopathic portal hypertension, on the 29th of May, 1998. a total gastrectomy, lymphnode dissection (D2+α), splenectomy and liver biopsy was performed. The tumor was histopathologically classified as gastric lymphoma of MALT exhibiting marked plasma cell differentiation with monoclonality, the IgM-λ type. No abnormality of the liver was observed. The diagnosis was thus idiopathic portal hypertension. No case of gastric lymphoma of MALT exhibiting marked plasma cell differentiation with idiopathic portal hypertension has been reported and so this case is very important. Key words: gastric lymphoma of mucosa-associated lymphoid tissue, plasmacytoma of the stomach, idi-opathic portal hypertension

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A gastrointestinal stromal tumor (GIST) of the duodenum in a 51-year-old male is reported. The patient presented with a history of repeated tarry stools and was admitted to our hospital. An elevated lesion with ulceration was found in the third portion of duodenum as a result of various types of examinations. Biopsy revealed a GIST originating in the duodenum, and partial duodenectomy was performed. The surgical specimen was a submucosal tumor, 38×37×30 mm in size, with a clear border and central necrosis. Pathological examination revealed dense fascicular proliferation of spindleshaped tumor cells in a bundle and 2-4 nuclear divisions in 10 HPFs. Since immunohistochemical studies revealed tumor cells with a positive pattern for vimentin and CD34, and negative pattern for desmin, α-smooth muscle actin, HHF-35, and S-100 protein, we made a diagnosis of malignant gastrointestinal stromal tumor, uncommitted type. GISTs originating in the duodenum are rare and more malignant than GISTs originating at other sites in the digestive tract, and therefore careful follow-up may be required.

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A 71-year-old man with no complaint was referred to tur hospital because of a subpedunculated tumor at the opposite side of Vater's papilla, which was detected by upper gastrointestinal endoscopy during screening. Hypotonic duodenography revealed a subpedunculated tumor, and was diagnosed as a benign tumor of the duodenum. Incision of the duodenal wall and resection of the tumor were performed. Histological examination revealled slightly enlarged tumor cells located on the submucosal layer and proliferating in a papillary pattern, which suggested they had originated from Brunner's glands and also showed few cellular and structual atypia, which indicated adenoma. However, destruction of the muscularis mucosae and invasion to the propria mucosae, therefore, we concluded that the tumor was carcinoma arising in Brunner's glands. This case presented cancer in adenoma, so these findings seemed to propose an interesting problem in the development of carcinoma arising in Brunner's glands.

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We reported a case of carcinoid tumor of the Vater's papilla, accompanied by liver metastases and lymph node metastases. The patient was a 37-year-old women, who was admitted to our hospital for control of diabetes mellitus. As she had complained of some liver disfunction, several examinations were performed. By endoscopical and radiological investigations, a tumor approximately 4cm in diameters was found at the Vater's papilla. The biopsied specimen demonstrated a positive reaction to chromogranin A stain and Grimerius stain. This case was thus diagnosed as a carcinoid tumor of the Vater's papilla.
At operation, although there were two liver metastases at the surface of the liver S⁴ and regional lymph node metastases, we selected pancreatoduodenectomy with D₂ lymph node dissection and enucleation of the liver metastases.
This patient is doing well without recurrence 2years 1month postoperatively. Key words: carcinoid tumor of the Vater's papilla, liver metastasis of carcinoid tumor, pancreatoduodenec-tomy

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We experienced a rare case of choledocholithiasis caused by metal clips which were engaged at the site of a previous laparoscopic cholecystectomy (Lap. C) performed nine months before. The patient was a 53 year-old-woman with cholecystolithiasis, who underwent the Lap. C in another hospital in April, 1995. The operation was converted to an open cholecystectomy to stop bleeding from the liver bed at the time of surgery. During the follow-up period, the patient suffered from intermittent high fever and abdominal pain. In January, 1996, endoscopic retrograde cholangiography revealed a stone shadow with metal clips in the common bile duct (CBD), and a stenotic lesion in the middle portion of the CBD. Surgery was subsequently performed on March 8, 1996 (11months after the initial operation). The CBD was explored and the stone was removed. The stone appeared to be a pigmented gall stone with a nidus comprised of the metal clips used in the Lap. C.We performed a hepaticoduodenostomy, and the patient had an uneventful recovery, and maintained good bile flow. Surgical clips have previously been reported to form choledochal stones. In this case, the clips were located at the end of the cystic duct near the juncture with the CBD. Surgeons must exercise caution in the use of metal clips and electric cauterization to avoid damage to the CBD, which can result in local inflammation around the CBD.

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A 70-year-old women complaining of diarrhea was admitted to our hospital. During the examination, computed tomography showed a mass in the cystic duct of the gallbladder. Subsequently, cholecystectomy and choledochectomy were performed. The histopathological diagnosis revealed that the resected tumor, 8×7mm in size on diameter was adenoendocrine cell carcinoma of the gallbladder. Adenocarcinoma in the mucosa showed gradual transition to endocrine cell carcinoma in the deeper tissues. Immunostaining disclosed a transitional form which was bonding between adenocarcinoma and endocrine cell carcinoma. Electron microscopy revealed that endocrinegranules detected even in adenocarcinoma cells were in transitional position. The granule was 0.3-0.4μm in diameter, roundelldptic in shape, and distributed mainly in the basal part of cancer cells from the transitional border. There was no finding of exocytosis. These granules may suggest a differentiation marker to transitional form of the endocrine cells from the adenocarcinoma cells, beecause both kinds of cells were detected in the identical tubule. Developement of adenoendocrine cells are thought to bo a clonal growth of endocrine cells in deeper tissues. We believe that the debree of biological malignancy was very high in this case, because of the rapid progressive, vascular invasion, metastasis in a lymph node, and multiple metastases in liver observed 10 months postoperation.

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Two cases of inflammatory pseudotumor of the spleen are reported. In the first case, a splenic mass was incidentally detected by abdominal ultrasonography in a 53-year-old man during follow up of the postoperative course of distal gastrectomy for gastric cancer. An abdominal CT scan revealed a wellencapsulated splenic mass, and only the capsule was enhanced. Solitary splenic metastasis of the gastric cancer and splenic hamartoma were considered in the differential diagnosis, and splenectomy was performed. In the second case, a 40-year-old woman who had undergone total hysterectomy six years before was also incidentally found to have a splenic mass by abdominal ultrasonography during observation of a gastric submucosal tumor. An abdominal CT scan revealed an isodensity mass in the spleen, and MRI showed a low intensity mass. The interior of the mass was slightly enhanced after Ga-DPTA administration. Based on our experience in the first case, we diagnosed the mass as an inflammatory pseudotumor of the spleen and performed splenectomy. Both tumors were histologically diagnosed as inflammatory pseudotumor of the spleen. Laparotomy had been performed previously in both cases, and this operative procedure appeared to be associated with the pathogenesis of the inflammatory pseudotumors.

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A 63-year old woman was admitted with severe abdominal pain of 9 hours duration. Past medical history included a polycytemia vera for two years. Laboratory measurements were as follows: white blood cell 47.6×10³/mm³, red blood cell 600×10⁴/mm³, hematocrit 44.0%, hemoglobin 14.2g/dl, platelet 100×10⁴/mm³. Abdominal X-ray CT scan showed a high density ascites. Intraoperatively, 2, 000 ml of intraabdominal haemorrhage and a massive hematoma in the free margin of the omentum were noted. Histological examination of the resected omentum revealed a ruptured mycotic aneurysm.

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A 47-year-old woman was referred to our hospital with an elevated right hemidiaphragm on a chest X-ray. Preoperative angiography showed a huge tumor whth feeding arteries branching off the right and left hepatic and right subphrenic arteries, and surgery was performed whth a preoperative diagnosis of subdiaphragmatic liver tumor. The intraoperative diagnosis was diaphragmatic tumor with liver compression and right lung invasion, and complete extirpation of the tumor with partial resection of the right diaphragm and right lower lung was performed. The tumor was 14-10 cm in size and weighed 1, 300 g. Microscopically, fibroblastic tissue was tightly arranged with no evidence of dysplasia. Immunohistochemical staining showed keratin (-), epithelial membrane marker (-), S-100 (-), and vimentin (+), and the final pathological diagnosis was benign localized fibrous mesothelioma of the diaphragm. The patient's postoperative course has been good, with no evidence of recurrence after 12 months.

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We experienced a case of an advanced age patient with extended necrosis of the small intestine (220 cm) caused by strangulation a rare structure attributed as Meckel's diverticulum. A 76-year-old man came to the hospital with abdominal pain and vomiting as the chief complaints. He was hospitalized for adhesive ileus by signs and symptoms of scar and pain on pressure after extraction of the gallbladder and by stimulation of enterokinetic sounds. However, myogenic guarding and shock were observed on the following morning, and under a diagnosis of strangulated ileus peritoneotomy was performed. However, the intraoperative findings did not reveal adhesion of intestines, restiform substance and mesenteric deficiency, but rather a large volume of hemorrhagic ascites and extended intestine with multiple twists of dark-red color. We discharged the ileus by puncture aspiration at the midsectionof the sacculated mass, located at the opposite side of the mesentric attachment site at about 60 cm from the end of ileum. Histopathological diagnosed Meckel's diverticulum involving whole layers of intestine. Our own experimental case did not meet the criteria of intestinal obstruction classified by Rutherford et al. It was suggested that the neck of theMeckel's diverticulum had resulted from some unknown cause, and wrapped by the intestine in multiple twists had caused ischemia at the base of mesenterium.

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Gastrointestinal amyloidosis is a metabolic disease characterized by the deposition of amyloid proteins in the wall of the gastrointestinal tract, and causes symptoms such as abdominal pain, vomiting, and diarrhea. Surgical treatment is indicated for acute bowel obstruction, perforation and hemorrhage, and so on. This disease arises secondarily to chronic wasting diseases, such as rheumatoid arthritis (RA), renal failure, and so on. We recently encountered the case of a 62-year-old woman with gastrointestinal amyloidosis secondary to RA, in which diagnosis and treatment were difficult. Retrospectively, this case is now considered a typical gastrointestinal amyloidosis judging from clinical history and abdominal X-ray films showing many gaseous shadows, in which diagnosis was relatively easy and prompt treatment was desired. When we diagnose a patient who has acute abdomen or gastrointestinal symptoms with clinical histories of RA and/or hemodialysis, etc., we must consider secondary gastrointestinal amyloidosis, and if surgical treatment is not indicated, we must make a quick decision to refer the patient to a specialist for amyloidosis without delay.

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A 74-year-old woman was admitted complaining of a sudden onset of abdominal pain and vomiting. Physical examination showed a soft bulging of the abdomen and mild abdominal tenderness. A plain abdominal radiograph showed dilated loops of the small intestine. Abdominal computed tomography revealed ascites and gas in the hepatic portal venous system, the wallof the small intestine and the mesenteric vein. A diagnosis of bowel necrosis with hepaticportal venous gas was determined, and a laparotomy was performed. A 40-cm length of jejunum was found to be necrotic and an enterectomy was performed. The patient made an uneventful recovery. Hepatic portal venous gas is a rare condition, caused mostly by ischemic enteropathy. It should be considered an indication of sepsis, since bacteria from the intestine may infect the portal venous system from an ulcer in the intestine. Generally, cases of hepatic portal venous gas follow a serious clinical course including shock. We reviewed 94cases in the Japanese literature and found trend toward improving survival rate. The condition requires early diagnosis and surgical treatment.

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A 68-year-old woman was admitted with massive melena. There were no palpable abdominal masses, and her abdomen was not distended. Repeated gastrointentinal fiberscopy and total colonoscopy to the cecum yeilded normal findings. A barium meal study of the small intestine revealed only irregular external compression in the terminal ileum. Enhanced CT of the pelvis, however, showed a low density mass measuring 8 cm in diameter. Superior mesenteric arteriography showed stretching of the artery in the arterial phane, and pooling of the contrast medium at the end of the artery in the venous phase. In the pelvis, radionuclide scintigraphy with ^99mTc-HSA showed persistent increased uptake on delayed scans. We diagnosed the patient as having mesenteric tumor of the small intestine and performed partial resection of the small intestine. The tumor was approximately 8 cm in diameter and was located 80 cm proximal to the end of the ileum. Pathological examination showed the tumor to be a cavernous hemangioma. Mesenteric herangioma of the small intestine is extremely rare, with only 15 cases ever reported in Japan. Massive bleeding has never been reported as a main symptom. We have reported a woman with mesenteric hemangioma of the small intestine who presented with melena.

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A 57-year-old woman was admitted to our hospital because of a palpable mass in the right lowerquadurant of the abdomen. Abdominal ultrasonography (US) and computed tomography (CT) showed atarget-like appearance on right lower abdomen. Barium enema showed a crab-finger finding the cecum with nonfilling of the appendix. Endocopic examination of her colon showed polypoid mass, foreskin and glans-like in the cecum. After cannulation dimple and injection of contrast medium, the lumen was appeared. A diagnosis of primary appendiceal intussusception was determined. However appendiceal intussusception was not inproved by laparotomy, so ilececal resection was carried out. Sugical specimen shoewd the appendix invagnated into the cecal lumen, mesuring 5×2cm in size.

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An 83-year-old woman was presented to our hospital because of complaining of anal bleeding. Physical examination disclosed a tumor with a hard consistency on the posterior aspect of the rectum, 5 cm beyond the anal verge. A barium enema examination showed the tumor to have a hemispheric contour with a central depression and was located on the posterior wallof the Ra and Rb areas. Endoscopic examination revealed an elevated lesion with a smooth surface covered with slightly erythematous mucosa, 5 cm beyond the anal verge. Examination of a biopsy specimen near from the surface of the mass revealed no evidence of malignancy. Low-anterior resection with a regional lymph node dissection was performed for as a preoperative diagnosis of leiomyosarcoma. The resected specimen confirmed features which was seen in barium and endoscopic studies. The tumor was measured 35×30mm. Histopathologic examination demonstrated that the tumor was composed of centrocyte-like lymphoid cells invading the muscular layer, and that lympho-epithelial lesions were present at the epithelial surface. No evidence of lymph node involvement was present. We also discussed the features of the 14 cases including present case in MALT lymphoma of the rectum previously reported in the Japanese literature. As the recurrence rate in cases of local excision was 50%, it is necessary to perform the radical resection with lymph node dissection on the basis of precise diagnosis.

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We experienced a case of advanced esophago-gastric double cancer with reconstruction after jejunal pull up after Roux en Y with microvascular anastomosis to inernal mammary vessels-supercharge-. A -58-year old man was diagnosed as both advanced esophageal cancer and gastric cancer. The operative procedure was consisted of subtotal esophagectomy and total gastrectomy, and reconstruction was performed jejunal pull up through anterior chest wall after Roux et Y anastomosis. To overcome vascular insufficiency of the pull-up jejunum, the authors have performed microvascular anastomosis between jejunal vessels and left internal mammary vessels. Subcutaneous dissection of the anterior chest wall and the second and third costal cartilages were resected at the left border of the sterunum, and a pedicle of internal thoracic artery and vein was dissected. End-to-end anastomosis of both the arteries and veins between jejunal vessels and left internal mammary vessels was performed. It is conceivable that the addition of supercharge to jejunal reconstruction for esophageal replacement is a good substitute for the thoracic esophagus, especially in cases where the stomach is unavailable for use.

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Ten cases of living related liver transplantation (LRLT) were carried out by cooperative surgery between two separate institutions, from January 1995 to December 1998. In this report, the postoperative course and the safety of donor hepatectomy were evaluated, and also, the psychological state of the donors were investigated by a questionnaire. The donors were 8 mothers and 2 fathers, their age ranged from 25 to 46 years. All were completely healthy with no hematological or biochemical abnormalities. Four lateral segmentectomies, 3 extended lateral segmentectomies and 3 left lobectomies were carried out. The mean intraoperative blood loss was 687g, and the mean operative time was 7 hour 33 minutes. Eight cases required autologous blood transfusion. Two cases of postoperative complications were observed; bile leakage from the cut edge in 1 and transient elevation of transaminase in 1, which required only conservative treatment. The mean postoperative hospital stay was 17.6 days. The mean graft-transport time between the two institutions was 15.2minutes. Eight recipients are alive with normal liver function, and two recipients had functional grafts but died of complications. The questionnaire presented several concerns of donors before LRLT. The present results demonstrate the safety of donor hepatectomy of LRLT carried out by cooperative surgery between two separate institutions. Graft transportation did not affect graft viability. The separation of institutions seemed to be only a minor demerit in the estimation of the donors. However, psychological support and care for the donors before and after LRLT should be recommended.

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Eight laparoscopic hepatectomies were performed in patients with hepatocellular carcinoma. Surgical procedure: A microwave tissue coagulator was used in combination with an ultrasonic surgical aspirator or laparoscopic coagulating shears to divide hepatic parenchyma by using the abdominal wall lift without pneumoperitoneum to avoid the risk of CO₂ embolism. Branched vessels and ducts were clipped and transected. An endoscopic linear stapler was used to transect the Glisson's pedicle and left hepatic vein. Hemostasis of thetransection plane was secured by using an argon beam coagulator and fibrin starch. The indication for hepatectomy was hepatocellular carcinoma in 9 cases (Clinical Stage I: 5 cases, II: 3 cases, III: 1 case). Seven patients underwent partial hepatectomy and 2 patients underwent left lateral segmentectomy. The 8 hepatectomies were performed safely with no operative complication. There were notable differences in operation time and blood loss compared with open hepatectomy. The postoperative recovery was faster and pain was minimal. The preoperative assessment of liver function for laparoscopic and open hepatectomy is the same. Important considerations for the indication of laparoscopic hepatectomy are the size, type, and location of the tumor. Tumors smaller than 5 cm, and nodular types, especially extrahepatic growth types. are the best candidates for laparoscopic resection. Concerning location, tumors in the lower segment and left lateral segment were good indications. Laparoscopic hepatectomy in a patient with hepatocellular carcinoma appears to be a viable surgical alternative in selected cases.

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The purpose of this study was to assess the utility of dynamic MR cholangiopancreatography (MRCP) in evaluation of pancreatic exocrine function after pancreatogastrostomy. The cases of two patients who under-went pylorus-preserving pancreatoduodenectomy reconstructed by pancreatogastrostomy with the help of a tube pancreatostomy were analyzed. Abdominal CT disclosed no particular change in the remnant pancreas, and endoscopy detected no orifice of the residual pancreatic duct. On the other hand, dynamic MRCP using secretin stimulation revealed secretion of pancreatic fluid. Moreover, the mean pixel value and the total inten-sity value that were caluculated by tracing the image of pancreatic fluid were useful in objectively estimating the changes in pancreatic fluid. Pancreatogastrostomy is easy and safe to perform, yet the likelihood of dys-function of the pancreas due to pancreatic duct obstruction has been pointed out. Also, appropriate evaluation of the pancreatic exocrine function has often been difficult by conventional modalities. Using dynamic MRCP, however, made it possible not only to observe the image of pancreatic fluid clearly but to estimate objectively the kinetics of pancreatic fluid. Thus, this study demonstrated that dynamic MRCP after secretin stimulation was significantly useful in evaluating the residual pancreatic exocrine function after resection of the pancreas.

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