The study subjects consisted of 42 patients who underwent hepatectomy and their serum HA levels were measured repeatedly in the perioperativeperiod. The serum HA levels were significantly correlated with the degrees of histological hepatic fibrosis, and were elevated in patients with poor liver function. In 15 out of 42 the patients, postoperative systemic inflammatory response syndrome (SIRS)(+) was observed. Be-tween the SIRS (+) and SIRS (-) cases, there were significant differences in the preoperative levels of PT, HPT, ChE and ICG R15 (p<0.05). As to the seru HA levels, the levels were significantly higher in SIRS (+) cases than in SIRS (-) cases in the perioperatie period of hepatectomy (p<0.05). In the 9 SIRS (+) cases with postoperative complications, the perioperative serum HA levels were significantly higher as compared to those in other cases (p<0.05). Thus the perioperative serum HA levels are considered as a useful maker for the predication of postoperative SIRS and complications during the perioperative period of hepatectomy.

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We treated 6 cases of extrahepatically growing hepatocellular carcinoma (EG-HCC) in the last 12 yearsout of 128 operative cases, and assessed their features and growth pattern to better evaluate HCC prolifera-tion and/or infiltration compared to 54 cases of intrahepatically growing HCC (IH-HCC). Results: Clinicopathologically, EG-HCC showd (1) significantly higher AFP (p<0.0001), (2) a significant larger tumor size (p<0.019), (3) a higher tendency of poorly differentiated histology and (4) a higher frequency of intrahepatic me-tastasis. Immunohistochemically, (5) the positive rate of p53 showed no significant difference, while EG-HCCwas tendency to show a higher labeling index (LI) of proliferating cell nuclear antigen (PCNA), Conclusion Our results suggest that extrahepatic growth may favor cell proliferation increasing tumor size and reflectingintrahepatic infiltration.

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Purpose: Improved prognosis of resected hepatocellular carcinoma (HCC) has led to an increase in thenumber of patients with distant metastasis (DM). To clarify the surgical indication and treatment of DM, weanalyzed 40 clinicopathologic variables related to survival after recurrence. Methods: Of 227 patients wholater developed recurrence after hepatic resection in the last 10 years, 166 suffered intrahepatic recurrenceand 61 DM. Results: The 1-year survival after recurrence in patients with hepatic recurrence alone was 77%, 3-year 48%, and 5-year 19%. That for patients with DM was 61% at 1 year, 31% at 3 years, and 15% at 5years of survival (p=.0042). DM sites included the bone (n=28), lung (n=20), lymph nodes (n=11), brain (n=7), adrenal gland (n=7), thoracic or abdominal wall (n=4), and peritoneum (n=3), while 43 of 61 suffered he-patic recurrence. Univariate analysis showed the positivity of alpha fetoprotein (AFP)(n=39), stage I-III (n=53) at initial hepatic resection, younger age (n=32), treatment for hepatic recurrence (n=34), and resectionfor DM (n=14) at recurrence were significant independent factors. The 3 variables were found to be independ-ent prognostic factors after recurrence by multivariate analysis were stage I-III, treatment for hepatic re-currence, and DM resection. Conclusions: To ensure better survival after DM recurrence, the resection of dis-tant metastatic lesions should be done whenever possible, in addition to treatment for intrahepatic recurrentlesions.

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Introduction: Transverse loop colostomy is conventionally used to defunction the distal colon and rectumfollowing certain surgical procedures. Loop ileostomy has recently become more widespread among colorectal surgeons. We compared these 2 procedures when used to defunction the distal colon and rectum. Methods: Subject were 43 patients undergoing closure of a diverting stoma between 1995 and 2000. They were divided into an ileostomy group (n=25; IS group) and a transverse colostomy group (n=18; CS group). Median follow-up was 41 months. Results: Age, gender and indication for surgery were similar in both groups.Between stoma construction and closure, no significant differences were observed except in the method of anastomosis. After stoma closure, significant differences were observed in the incidence of bowel obstruction (IS: 4.0%, CS: 33.3%; P=0.031) and length of postoperative hospital stay (IS: 7.6±2.5days, CS: 10.6±5.0days; P=0.017). No difference was seen in other complications. Conclusion: These results indicate that theloop ileostomy may be the procedure of choice when a diverting stoma is needed to defunction the distal colon and rectum.

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A 35-year-old woman admitted to our hospital was suspected of having a submcosal tumor in the posterior wall of the cardia after upper gastrointestinal radiography in a medical checkup. Abdominal ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) showed a unilocular cyst 5 cm indiameter adjacent to the cardia. She was preoperatively diagnosed with gastric duplication bsaed on endoscopic ultrasonography and ^99mTc scintigraphy. Operative findings at laparotomy showed the tumor astrideboth the esophagus and stomach, sharing a common wall at 2×1.5cm. Tumor enuclation was conducted, based on a diagnosis of gastric duplication without malignancy in the rapid intraoperative frozen section diagnosis. The postoperative course was uneventful. CEA and CA19-9 in cyst fluid were quite high, but cytologyof the fluid was in Class I. Histopathologically, mimic mucosa to stomach, ciliated columnar epithelium, andsmooth musclar layer were observed in the inner wall of the cyst. These findings suggest the cyst arose fromthe primitive foregut.

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Among 373 patients with early gastric carcinoma invading the submucosal layer (SM carcinoma), we studied the clinicopathological findings of 3 patients with paraaortic lymph node metastasis (4.5% of SM car-cinoma with lymph node metastasis), that is, (1) macroscopic mimicking advanced gastric carcinoma, (2) larger tumor size, (3) marked lymphatic vessel invasion and poorly differentiated adenocarcinoma, (4) more metastasis to lymph nodes, and (5) smaller metastatic lymph nodes. It should be noted that it is difficult to evaluate lymph node metastasis by lymph node size. These cases died of liver or peritoneal metastasis in no more than 14 months after operation. It is difficult for these cases to treat curatively by means of extended lymph node dissection. An excessive lymphatic spread case is expected for effectiveness of chemotherapy. These cases require surgery and chemotherapy should be performed. In case of macroscopical SM carcinoma, it will not be necessary for paraaortic lymph node dissection.

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We treated two cases survived for long-term after resection of colon metastasis of gastric cancer. Two cases were diagnosed preoperatively as primary colon cancer, but they were colon metastasis of gastric cancer. Case 1 was a 70-year-old man and Case 2 a 75-year-old man. Both had recurrence 6 years after distal gastrectomy. All cases showed histology similar to the previous gastric cancers, and were diagnosed with recurrent gastric cancer after surgery. Case 1 underwent reresection 3 years and 8 months ago. And Case 2 2 years and 2 months ago. Neither has yet experienced recurrence. These 2 cases were isolated tumors on preoperative diagnosis imaging. Cases 1 and 2 also had single colon metastasis in operative views. Our cases are metastatic colon cancer. And it was thought that most of their origins are gastric cancer. However there was few of complete recover of cancer by means of reresection. Both remain alive, suggesting that some long-term survival may be provided by local resection.

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A 73-year-old man was admitted with right hypochondralgia. Computed tomography (CT), magnetic resonance imaging (MRI), and drip infusion cholangiography (DIC) demonstrated a gallbladder stone and marked dilation of the gallbladder fundus. Open laparotomy disclosed a dilated fundus involving the abdominal wall and a stenotic gallbladder body. Open cholecystectomy and conbined resection of the abdominal wall were conducted based on a diagnosis of chronic calculous cholecystitis. The fundus contained white serous fluid with low viscosity, in which bacillus tuberculosis was identified. Antituberculous agents were administrated for 1 year postoperatively, and the patient remains free of complications. The presented case indicated that gallbladder tuberculosis should be included in the differential diagnosis of chronic cholecystitis.

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We treated common bile duct carcinoma with sitsu inversus totalis in a 70-year-old man hospitalized due to icterus. Chest x-ray revealed dextrocardia. Abdominal ultrasonography showed situs inversus totalis and dilation of the intrahepatic and common bile duct. Magnetic resonance cholangiography and percutaneous transhepatic cholangiography showed an obstruction of the upper bile duct. We performed, based on a diagnosis of common bile duct carcinoma, the resection of the bile duct and right lobectomy because the tumor invased directly to the right hepatic artery and right hepatic duct. This is, to our knowladge, only the sixth case of common bile duct carcinoma with situs inversus viscerum reported in the Japanese literrature.

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We encountered a case of operation for recurrent occlusion of expandable mentallic stents (EMS) for postoperative benign stricture in a male 71-year-old patient who had previously undergone cholecystectomy and extrahepatic bile duct resection with bilateral hepaticojejunostomy for cholecystocholedocholithiasis in another in 1982. He was resently admitted to our service stenosis of the anastomosis and hepatolithiasis in 1990. After endoscopic lithotomy, EMS were placed in bilateral anastomoses. Although readmitted in December 1996 with cholangitis, he was promptly discharged with the EMS sufficiently intact. However, the patient developed fever and jaundice 3 weeks later, and severe setenosis of the left hepaticojejunostomy was confirmed on readmission. Attempts to relieve the stenosis by endoscopic treatment proved impractical, and peritoneotomy was performed. Because the EMS was firmly in cicatricial tissue partial surgical removal of the stent was required. The front of left hepaticojejunostomy was incised, and the incised jejunum was patched to the left hepatic duct. The outcome was excellent, and postoperative progress has been steady.

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We report a rare case of heterochronic development of extrahepatic bile duct carcinoma and cholangiocellular carcinoma. A 49-year-old woman was diagnosed with middle and lower bile duct carcinoma and pancreati-coduodenectomy and Whipple's reconstruction were conducted in June 1994. Four years later, the woman was admitted to our hospital suffering from diarrhea. Abdominal computed tomography (CT) and cholangiography revealed a liver tumor. We suspected recurrence of bile ductcarcinoma in the PTBD fistula in the liver, and conducted extended left and caudate lobectomy and resectioning of the choledochojejunostomy. Histopathologically, the tumor was diagnosed as cholangiocelluar carcinoma, and clarified to be heterochronic double cancer.

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We report a case of delayed splenic rupture 5 days after transcatheter arterial embolization (TAE). A 23-year-old woman came to our emergency center with traumato the left side of the abdomen. She was diagnosed with splenic injury type IIIcby abdominal computed tomography (CT). She was treated with selective TAE after angiography of the splenic artery showed extravasation. Following treatment, extravasation apparently disappeared. Five days after TAE, however, she reportedacute abdominal pain diagnosed as dalayed splenic rupture after abdominal CT showed extravasation and abdominal bleeding. Emergency surgery was conducted for continuing hypovolemic shock and the spleen partially resected because injury was limited to the upper spleen. Following the surgery, the patient recovered uneventfully and was discharged after 19 days. It is thus important to consider delayed splenic rupture in patients diagnosed with splenic injury, even if the patientis treated with TAE.

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Early diagnosis of superior mesenteric vein (SMV) thrombosis is difficult due to the lack of specific symptoms. Case studies have indicated surgical intervention to be the primary life-saving approach. We treated a 64-year-old man with appendicitis with SMV thrombosis using conservative therapy and followed up treatment with computed tomography (CT). The patient underwent conservative therapy upon diagnosis of acute appendicitis at a nearby hospital and experienced abdominal inflation with fever before being referred to us. On admission, he had leukocytosis and abnormal hepatic functions. Abdominal CT showed SMV thrombosis induced by appendicitis. Conservative therapy with antibiotics and continuous heparin administration was initiated, and abdominal findings thereafter indicated slight improvement, with the thrombus contracted within 1 week of treatment as seen in CT. Chemotherapy was then replaced by warfarin, and the patient was discharged when the third CT scan showed the thrombus had disappeared. Appendicitis recurring after discharge necessitated laparoscopic appendectomy. In the year since surgery, the man has experienced neither recurrence of thrombosis nor ileac signs.

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A 66-year-old man admitted to our hospital due to tarry stool was found in a lower intestinal examination to have rectal cancer. Preoperative abdominal angiography revealed the inferior mesenteric artery arose from the superior mesenteric artery. Between 1980 and 2000, 3, 182 abdominal angiographs were underwent to the intestinal cancer cases in our hospital. The variant of the inferior mesenteric artery was normal by originated from the aorta in 3, 177 (99.85%), a defect of the inferior mesenteric artery in 1 (0.03%), an abnormality of direction due to internal organ reversal in 2 (0.06%), and the inferior mesenteric artery arising from the superior mesenteric artery in 2 (0.06%).

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Tuberculosis is slowly being forgotten despite its recently increasing morbidity in Japan. A 54-year-old man reported abdominal pain that increased with muscular defense, but abdominal X-ray revealed free air. Chest X-ray showed infiltrative shadows in both lung fields. Abdominal computed tomography (CT) showed a concentric laminar structure in the cecum. He was deagnosed with perforation of the digestive tract and underwent emergency surgey. Surgical findings showed a cecal mass and more than 20 constrictions in the small intestine with wall thickening and intestinal perforarion due to mycobacterium tuberculosis. A jejunum perforation was resected and anastomosed. Pathological study showed characteristic tuberculous granuloma with caseation necrosis in the intestinal wall and in regional lymph nodes. Aftre surgery, triple therapy with INH, REP, and SM was started but the patient died on the post operative day 1. Autopsy findings showed intestinal tuberculosis with multiple ulcers, pulmonary tuberculosis, and miliary tuberculosis.

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We treated 5 cases of primary carcinoma of the vermiform appendix. The incidence of appendectomy was 5/247 (2.02%) and colorectal cancer resection 5/361 (1.39%) from July 1986 to March 2000 at our hos- pital. The mean male age (3 cases) and female (2 cases) patients was 59.2 years. Four cases were prediagnosed as acute appendicitis and one as mucocele. Pathological examination showed 3 were well differentiated adeno- carcinomas, 1 was cystoadenocarcinoma, and 1 was mucinous carcinoma. Ileocecal resection was conducted in 3 cases and right hemicolectomy in 2. Three cases were treated by additional surgery after appendectomy. Primary carcinoma of the vermiform appendix is rare and preperative diagnosis difficult, so it is important to conduct preoperative X-ray examination, careful intrapoerative inspection, and postoperative pathological ex- amination. Although radical surgery involving lymph node dissection in advanced cancer and appendectomy as routine in early cancers with undefined preoperative diagnosis are common, additional surgery in early cancer should follow procedures designed for advanced cancer if the tumor has invaded the submucosa. Ap- pendectomy is adequate if the tumor has not invaded the marginal layer, and closure of the stump is possoble if tumors are limited to mucosa. With data on these issues not yet available, cases and follow-up sutdies should be collected to detemine appropriate operative procedures in each case.

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The incidence of intussusception and endometriosis of the appendix is estimated as 0.01%and 0.05%, respectively. But few cases have been reported in Japan. According to literature, only 5 cases of appendiceal in-tussusception associated with endometriosis, including our case, have been reported. Here we report the case of a 34-year-old female. She visited our hospital presenting with bloody stool and abdominal pain. She was diagnosed as having a submucosal tumor or a tumor of the appendix using colonofiberscopy. abdominal ultrasonography and computed tomography. At operation, intussusception of the appendix into the cecum was observed, and appendicecal resection was done. Histologically, appendiceal endometriosis and aappendiceal mucocele were diagnosed. Primary appendiceal intussusception by obstructing endometriosis may have led to secondary appendiceal mucocele.

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Intramesosigmoid hernia is a rare type of internal hernia difficult to correctly diagnose preoperatively. A 65-year-old man admitted with nausea, vomiting, and lower abdominal pain had no history of surgery nor injury. Abdominal X-ray revealed air fluid levels. The patient underwent conservative therapy using a longtube. Intestinal contrast sutdy through the long-tube showed obstruction of the small intestine at the lower abdomen. Abdominal computed tomography revealed obstruction of the small intestine. Surgery was undertaken the 11th day after symptom onset. Incarceration of the small intestine was seen 60 cm proximal from the terminal ileum into a mesenteric defect on the right side of the sigmoid colon, and the proximal small intestine was dilated. The incarcerated ileum reverted easily by manipulation and the hernia orifice, 3.0 cm in deameter, was closed with sutures. The postoperative course was uneventful and the man discharged on postoperative day 14. The occurrence of intenal hernia involving the sigmoid mesocolon is rare, with only 15 cases, including ours, involving intramesosigmoid hernia reported in Japan.

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We report a case of advanced colon cancer with osteogenisis imperfecta. A 49-year-old woman admitted to our hospital with complaints of abdominal pain and an abdominal mass. Her height was 110 cm, and her weight was 26 kg. Endoscopic and histological examination of colon, and computed tomography revealed sigmiod colon cancer invading the bladder. We performed sigmoidectomy and partial resection of the bladder. Anesthesia was satisfactory, and no transfusions were necessary. The postoperative course was good except for atelectasis on the 2nd day after the operation. Because severe 5-fluorouracil toxicity has reported in a patient with osteogenesis imperfecta, we comfirmed that the patient had normal dehydropyrimidine dehydrogenase (DPD) activity before starting 5-FU 100mg/day orally. The patient was discharged on the 39th day after the operation, but died 19months later of liver metastasis and local recurrence in the remnant bladder. This is the first report of intestinal cancer associated with osteogenesis imperfecta.

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It is difficult to diagnose concealed prolapse which is often misdiagnosed as constipation. We diagnose a case concealed prolapse by dynamic defecography. A 53-year-old womanwas admitted reporting constipation with abdominal pain, abdominal distension and a sense of retention after defecation. She had reported these symptoms 5 times in 10 years without proper diagnosis. Dynamic defecography showed intussusception of the rectum diagnosed as concealed prolapse. She underwent laparoscopic rectopexy and had a good course. She is alive and recurrence-free 2 years after surgery.

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Wound infection is a common complication in colorectal surgery. In functional end-to end anastomosis common in colon surgery, the linear cutter must be inserted into the intestine. Postoperative wound infection may increase due to repeated linear cutter use. We disinfected the cutter using 0.5% chlorohexidine for 30 seconds before using a second cartridge. This reduced the number of microbes on the linear cutter from 79% to 16%(p<0.01). In 46 consecutive colon cancer operations, the cutter was not disinfected in 22 patients and disinfected in 24 patients. Wound infection occurred in eight (33%) in the nondisinfection control group and 2 (9%) in the disinfection sterile group (p<0.01). These results indicate that linear cutter disinfection using 0.5% chlorohexidine is useful in reducing surgical site infection.

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