The aim of this study was to investigate the influence of carbon dioxide pneumoperitoneum on cholelithiasis patients with liver cirrhosis. A total of 24 patients with symptomatic gallstones were scheduled for laparoscopic cholecystectomy. The patients were divided into two groups: an LC group (with liver cirrhosis, n=12) and a Control group (without liver cirrhosis, n=12). The cross sectional area of the portal vein trunk (S), the velocity of portal blood (V), and the mean portal blood flow (F) were measured and calculated by using a laparoscopic pulsed Doppler ultrasonic probe after insufflating the abdomen to an intra-abdominal pressure (IAP) of 4 to 15 mmHg. Subsequent laparoscopic cholecystectomy was performed successfully. Total bilirubin (T-Bil), AST, and ALT were measured on postoperative day 1 (POD 1). No significant differences were found in the background factors or postoperative course between the LC group and the Control group, except for the preoperative serum platelet level. The serum levels of T-Bil, AST, and ALT on POD 1 in the LC group were significantly higher than in the Control group (p<0.05). As IAP increased, the S, V and F values in the LC group significantly decreased (p<0.01). The F value at an IAP of 15 mmHg was significantly correlated with the ALT level on POD 1 in the LC group (R=-0.888, p=0.0002). In conclusion, the F values were shown to be a good parameter for intraoperative evaluation of liver function after laparoscopic surgery in patients with liver cirrhosis.

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Expression of p53 (to calculate the p53 labelling index: p53 LI) and CD34 (to calculate intratumoral microvessel density; IMD) was immunohistochemically investigated in 97 specimens of surgically resected tubular adenocarcinoma of the pancreas. And these parameters were analyzed together with patient outcome and the clinicopathological findings. Univariate analysis revealed eight significant factors: tumor site, tumor size (ts), venous invasion (v), intrapancreatic neural invasion (ne), pancreatic cut-end (pw), stage, p53 protein expression, and IMD, and a multivariate analysis yielded two independent prognostic indicators: pw and IMD (p<0.05). Comparison of hepatic recurrence and clinicopathological factors revealed that both IMD and p53 protein expression were significantly correlated with the frequency of hepatic recurrence and venous invasion (p<0.05). The data also showed a good correlation between p53 protein expression and IMD (p=0.0004). Thus, the probability was suggested that p53 abnormalites are likely to influence postoperative hepatic metastasis by facilitatng tumor angiogenesis and venous invasion.

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We report a case of recurrent spontaneous esophageal rupture in the right wall of the middle thoracic esophagus after following conservative treatment for spontaneous esophageal rupture in the left wall of the esophagus. A 74-year-old man admitted for acute onset of chest pain after swallowing was shown by chest X-ray to have mediastinal emphysema with an esophageal rupture about 2.5 cm long found esophagoscopy. The patient was treated conservatively with continuous drainage from a nasogastric tube inserted into the left mediastinal cavity. He recovered uneventfully and was discharged 19 days after admission. He began eating normally and was asymptomatic but was readmitted 5 days after discharg due to acute chest pain after vomiting. Computed tomography (CT) showed mediastinal emphysema on the right side of the esophagus, although chest X-ray showed no adnormal finding. The 0.5 cm esophageal rupture on the right wall of the middle esophagus was identified during esophagoscopy. Accurate diagnosis for both ruptures was made within 5 hours after onset aided particurally by CT. Spontaneous esophageal rupture in which mediastinal pleura is maintained is a good indication for conservative therapy, and transnasal continuous drainage proved to be effective. But careful attention should be paid to esophageal rupture recurrence after conservative therapy.

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Ninety-nine cases of adenosquamous carcinoma of the esophagus have so far been reported in Japan. A 60-year-old male was admitted with a history of dysphagia. Barium roentogenography and endoscopy revealed an erosive lesion in the middle portion of the esophagus, dignosed as a superficial esophageal carcinoma, and a large submucosal tumor in the cardial portion of the stomach. After subtotal resection of the thoracic esophagus and partial gastrectomy, an esophagogastrostomy was perfomed via the thoracic route. Histological examination of the resected specimen showed that the lesion in the middle portion of the esophagus was a moderately differentiated adenosquamous carcinoma invading into the submucosa. Histological examination of the tumor in the cardial portion of the esophagus, which measured 9.5×8.2×8.0cm in size, revealed that it was a poorly differentiated adenosquamous carcinoma representing metastasis of the esophageal carcinoma to the gastric wall. In all cases, excluding our present case, of intramural metastasis of esophageal carcinoma to the gastric wall, the primary lesion in the esophagus was a squamous cell carcinoma. Ours was a case of intramural metastasis of an esophageal adenosquamous carcinoma to the gastric wall.

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A rare case of cerebellar metastasis that was considered to be caused by gastri cancer was found 5 months after a total gastrectomy. The patient was a 72-year-old male who had undergone a total gastrectomy and splenectomy in September 1998 because of a Borrmann type 3 gastric cancer. After the operation, the patient received chemotherapy orally and by intravenous drip. The patient complained of mild nausea and lightheadedness 5 months after the operation. A cranial CT suggested a cerebellar hemorrhage, and the patient was admitted to this hospital. Further investigations, such as a cranial MRI and a scinitigram were performed, and the patient was diagnosed with multiple cerebellar metastases from the gastric cancer. No other metastases or local recurrences were found. The patient's family was informed of his condition, and the family decided not to pursue aggressive treatment, including operation and radiotherapy. Conservative therapy was performed, and the patient died in April 1999. Metastatic brain tumors from gastric cancer are rare, and the presence of cerebellar metastases without other metastases is very rare. In general, the prognosis of patients with metastatic brain tumors is very poor.

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We report a case with hepatocellular carcinoma (HCC) in association with autoimmune hepatitis (AIH). A-66-year-old woman, diagnosed as having AIH in April 1988, was under regular treatment with prednisolone. In January 1999, she was admitted to our hospital with elevation of the serum α-fetoprotein (AFP) level and a mass lesion in the S8 region of the liver detected by ultrasonography. She had no history of blood transfusion or drinking. Hepatitis B virus and hepatitis C virus markers were negative, and serum antinuclear antibody was positive. Imaging studies indicated that the mass lesion was a HCC, and in March 1999, hepatic subsegmentectomy (S8) was perfomed. The operation was a curative resection. The tumor, 3.3×3.0cm in diameter, was diagnosed histologically as a HCC of Edmondson type II>III. Reports of resection of HCC in cases with AIH have been rare, because of the advanced stage of the cancer at diagnosis. Hence, determination of the serum levels of tumor markers and imaging studies should be perfomed regularly in these patients.

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A 70-year-old female was admitted for right hypochondralgia. Blood biochemistry studies revealed evidence of inflammation, liver dysfunction, and jaundice. Abdominal ultrasonography (US) showed gallbladder wall thickening and common bile duct dilatation, suggesting acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) revealed clotted blood in the papillary region, and 3 filling dafects were detected in the common bile duct. An endoscopic nasobiliary drainage (ENBD) tube was inserted for drainage, and cholecystography was performed through the ENBD tube. The fundus of the gallbladder was not visualized, suggesting retention of blood clots in the gallbladder. Angiography revealed a tumor stain in the superficial cystic artery during the late phase. Therefore, a preoperative diagnosis of gallbladder cancer with hemorrhage was made, and hepatectomy (S4a+5+6a), bile duct resection, and lymph node dissection were performed. The resected specimens showed a papillary-infiltrating tumor measuring 30×20 mm with a newly clotted blood in the gallbladder fundus. The histological diagnosis was atypical well-differentiated ductal adenocarcinoma

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We treated a 59-year-old man for acute appendictis caused by a fish bone puncture. The man had reported pain in the right lower quadrant of the abdomen. Based on the abdominal finding and abdominal CT examination, we suspected acute appendicitis involving a fish bone and initiated surgery. We found a fish bone at the tip of appendix within the serosa associated with focal peritonitis. Few reports have reported caecal abscess associated with inflammatory granuloma due to appendix perforation. It is difficult, however, to determine how the fish bone came to cause the inflammation. Our case is of interest in the progression of initial pathological change in the appendix.

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The patient was a 79-year-old man who was hospitalized with a chief complaint of fever, vomiting, and upper abdominal pain. An abdominal tumor was palpated on the right side of the umbilicus. A plain film of the abdomen, abdominal ultrasonography, abdominal CT, colonoscopy, and a contrast enema led to a diagnosis of ileus secondary to herniation of a cecal cancer into an ascending colon-transverse colon intussusception. Emergency operation was performed. Laparotomy levealed a colon-colon type intussusception with the ascending colon as the leading end entering the right side of the transverse colon and a cecum-colon type intussusception with herniation of the cecum with containing a cecal cancer as the leading end. A mobile cecum was also found. Right hemicolectomy with the intussusception intact and D2 lymph node dissection were performed. The cecal cancer was type 2 and 5.5 cm × 5.0 cm in size. Histologically, it was a well differentiated adenocarcinoma, stage II. No organic change that might have caused the intussusception was found at the leading end of the ascending colon, and it was considered idiopathic. We reviewed the 27 cases of adult intussusception caused by cecal cancer reported in the Japanese literature in the past decade, including the present case.

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We report a case of ascending colon cancer with direct invasion to the liver causing a preoperative pyogenic liver abscess. A 69-year-old man presented with right flank pain and anemia. A barium enema study, ultrasonography, and computed tomography revealed an ascending colon mass with involvement of segment 6 of the liver. High fevers developed on the hospital day 7. Although imaging demonstrated a liver abscess in continuity with the tumor, intravenous antibiotics were administered without percutaneous transhepatic drainage for fear of cancer cell dissemination. Right hemicolectomy with partial resection of segment 5, 6 of the liver was performed. Postoperative recovery was uneventful. Inspection of the resected specimen revealed a fistula in the ulcerated cancer connecting to the liver parenchyma. Direct invasion to the liver by colon cancer has never been previously reported to cause a pyogenic liver abscess. Direct invasion to the liver and pyogenic hepatic abscess should be suspected in febrile patients with cancer of the ascending colon.

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A review of the literature would suggest that cancer rarely metastasize to the spleen except in terminal states. We report a case of solitary splenic metastasis of colon cancer, the 23rd report of splenic metastasis of colon cancer in the Japanese literature.
A 68-year-old man was admitted our hospital in August 1999 because of a high blood CEA level (585.7ng/ml) and splenic tumor. He had a history of partial sigmoidectomy for residual sigmoid colon carcinoma in April 1997.(He had undergone endoscopic tumor resection at another hospital.) An abdominal CT scan revealed two low-attenuating masses, and angiography demonstrated two avascular tumors in the speen. A GI series and other examinations showed no significant changes in any other organs. It was difficult to determine whether the splenic tumor was metastatic carcinoma or other disease preoperatively, and surgery was performed in September 1999. No liver metastase or peritoneal carcinosis was found at laparotomy, and splenectomy was performed. The pathohistological diagnosis of the splenic tumor was metastatic adenocarcinoma of the colon. At 9 months after the operation, the blood CEA level had decreased to 2.3ng/ml, and there were no signs of recurrence. Radical surgery is recommended for colorectal carcinoma patients who have a multiple splenic metastasis.

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A 69-year-old man underwent operations due to right lung cancer in 1980, rectal cancer in 1988, and left lung metastasis from rectal cancer in 1993, respectively. In 1996, the serum CEA level started to increase in January and rose to 58.0 ng/ml by December. Abdominal CT revealed a solid tumor 1.5 cm in diameter in the pancreas located between the body and tail. Because the tumor was brighter than surrounding normal pancreatic parenchima in the abdominal angiography, it was considered a metastatic tumor. Furthermore, an ascending colon tumor was found during total colonoscopy, and it was diagnosed pathologically as moderately differentiated adenocarcinoma from the biopsy specimen. Distal pancreatectomy combined with resection of spleen and right hemicolectomy were performed with a diagnosis of metastatic pancreatic tumor and ascending colon cancer. Histological examination revealed ascending colon cancer classified mp, ly₂, v₀, n₁ (+) and pancreatic tumor metastasis from colorectal cancer. This is the sixth reported case of resection due to pancreatic metastasis from colorectal cancer in Japan. The patient is doing well without any evidence of recurrence, as of 3 years and 5 months after the operation.

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A 57-year-old woman presented with a 7×6×3 cm tumor in the posterior segment of the liver. It was diagnosed as carcinoid by needle biopsy but had no endocrine symptoms. Preoperative examination revealed no lesions in other organs. The posterior segment was resected and exploration and pathological examination revealed two additional small carcinoid lesions in the liver. Eight months after liver surgery, a rectal carcinoid tumor was found and resected endoscopically. It was only 5 mm in diameter and was located within the submucosal layer of the rectum. Two years later another carcinoid tumor was found in the liver and removed. The patient currently has multiple tumors in the liver, but has survived for more than 6 years after the first liver resection. Although rectal carcinoids smaller than 10 mm in diameter rarely metastasize, the liver carcinoid tumors in our case were thought to be metastases of the small rectal carcinoid. Only 15 cases of rectal carcinoid tumors under 10 mm that caused hepatic metastases have been reported in the Japanese literature.

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A 71-year-old woman treated by hemodialysis for 22 years occasionally suffered from abdominal pain, especially in the left lower abdomen. She was examined for diverticula of sigmoid colon and ischemic colitis. In 1997, endoscopic biopsy of the rectal mucosa revealed intestinal amyloidosis. Last January, she was admitted as an emergency case due to lower abdominal pain. The next day, she was diagnosed with bowel perforation and underwent emergency surgery. The posterior wall of the upper rectum had a perforation 1 cm in diameter accompanied by a hard 3 cm stool mass. we conducted partial rectosigmoidectomy including the perforation site and a colostomy. Anti-β₂-microglobulin antibody-positive amyloid deposits were diffusely recognized on the submucosal small vascular walls, among other sites. Ischemia of the rectal wall following amyloidosis appeared to have initiated the perforation, in addition to diverticulitis and mechanical compression by the hard stool. Dialysis-related amyloidosis should thus be recognized as a risk factor in bowel perforation in long-term hemodialysis patients.

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The breast metastasis of colorectal carcinoma to the breast is rare, and radical surgery for this disease rarely improves a patient's prognosis due to the frequency of multiple metastasis. A 52-year-old man under-went low anterior resection for rectal carcinoma in March 1994 and partial hepatectomy for solitary metachronous hepatic metastasis 1 year after resection of the primary lesion. The patient underwent excision 2 more times for painless flat tumors of the right breast in May and October 1995, both tumors being histologically moderately differentiated adenocarcinoma compatible with rectal carcinoma. Since the right axillary lymphnodes became gradually swollen and no other metastatic lesions were identified, we conducted radical mastectomy (Br+Ax+Mn) in December 1995. Histological examination showed 5 further axillary lymph node metastases. The man remains disease-free 53 months after the radical mastectomy. No report has been made, to our knowledge, of such a long-surviving case following breast resection from colorectal carcinoma.

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Eight patients with a total of 11 insulinomas were examined by ultrasonography (US), computed tomography (CT), angiography, and percutaneous transhepatic portal vein sampling (PTPVS) preoperatively. We discussed preoperative diagnostic accuracy and intraoperative localization. Tumor localization was achieved by US in 55.5%, CT in 55.5%, and angiography in 65%. Three patients underwent tumor extirpation, and 4 distal pancreatectomy. One patient received extirpation and distal pancreatectomy. The surgical strategy for insulinoma is complete resection of the tumor, so not only exact pre- and intra- operative localization but also certification of comlete removal of the tumor are important. After excision of the insulinoma most patients exhibited a definite early hyperglycemic rebound but intraoperative IRI monitoring of the portal vein was ueful for confirmation of tumor excision. All the patients were alive without hypoglycemia or tumor recurrence. The incidence of patients with multiple tumors and malignancy was 25%(2/8) and 12.5%(1/8) respectively.

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