Purpose: Ischemia during hepatectomy, for example continuous clamping of hepatoduodenal ligament, is a cause of postoperative hepatic failure. To prevent ischemia, portal vein arterialization (PVA) is usually performed. We have reported that PVA producing a 25% total hepatic blood flow (THBF) rate was sufficient for hepatic energy metabolism and that carbon dioxide tension in the arterial blood influenced hepatic hemodynamics. Low flow PVA (LFPVA) unables portal vein cannulation and allows bleeding easy to be easily controlled. However, LFPVA may reduce hepatic energy metabolism. We decided to investigate whether the use of calcium antagonists could be used to improve hepatic hemodynamics. Material & Method: LFPVA and the administration of calcium antagonists (diltiazem: group D, nicardipine: group N, no administration: group C) was performed in 18 mongrel dogs to investigate the maintenance of hepatic energy metabolism. A LFPVA flow rate equal to 15% of the THBF was selected. LFPVA was performed from the right femoral artery to the portal vein trunk using a roller pump after ligating the hepatic arteries and clamping the portal vein using a portocaval shunt for 120 minutes. Calcium antagonists were continuously administered through the portal vein beginning 30 minutes before the initiation of LFPVA and throughout perfusion. Results: The mean aortic pressure (mAoP) decreased significantly after the LFPVA in all three groups. However, the mAoP decreased only slightly in the D group. Portal venous pressure did not changed in any of the groups. Portal venous resistance was lower in the N group than in the C group. No differences in oxygen delivery and consumption were observed among the three groups. ATP decreased in all 3 groups, but the changes were not significant. The AKBR of each group was low due to the LFPVA. However, the mean AKBR value of C group was lower than 0. 4. The AKBR in the D group was significantly higher than that of C group after 120 minutes of LFPVA. Histological examination showed hepatocellular damage in groups D and N to be sligh, and the functions of the sinusoidal endothelial cells were protected. Conclusions: The administration of calcium antagonists during LFPVA is effective for maintaining hepatic energy metabolism and hemodynamics. However, different calcium antagonists afforded different protective effects.

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Background: We studied the relationship between preoperative serum carbohydrate antigen 19-9 (CA19-9) and clinicopathological features and surgical outcomes. Methods: We analyzed preoperative serum CA 19-9 in 50 patients with mass-forming intrahepatic cholangiocarcinoma (m-ICC) who underwent hepatectomy. Results: Preoperative serum CA19-9 was elevated (exceeded 37U/ml) in 27 of 50 patients. No significant relationship was seen between serum CA19-9 levels and gender, age, type of hepatitis virus, liver cirrhosis, tumor size, or histopathologic differentiation. Tumors in patients with CA19-9 of 100U/ml or more showed significantly more vascular invasion. Tumors in patients with CA19-9 of 200U/ml or more showed significantly more lymph node metastasis. Tumors in patients with CA19-9 of 500U/ml or more showed significantly more intrahepatic metastasis. In univariate and multivariate analysis, the serum CA19-9 level was a significant prognostic factor in m-ICC (P=0. 0184, P=0. 0398). Conclusions: The preoperative serum CA19-9 level appears useful in judging the extent of m-ICC and predicting surgical outcome.

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Aims: We studied clinical pathophysiological characteristics and the tumorigenic and carcinogenic process from immunohistochemistry of β-catenin protein and p53 protein and microsatellite instability (MSI) analysis in 31 lesions in 31 patients of laterally spreading tumor (LST) of the large intestine. Results: LSTs were divided into three groups, of which Granular-Homogenous (G-H), Granular-Nodular mixed (G-N) and Non Granular (NG). The rate of involving cancer was significantly higher in group G-N and NG than in group G-H, particularly in group NG, in which all tumors with a diameter of less than 20 mm were cancerous. The incidence of p53 protein increased as heteromorphism advanced. The incidence of β-catenin protein was high in the nucleus and cytoplasm regardless of heteromorphism. We saw no MSI-H (igh) case. Conclusions: 1) group NG was high in biological malignancy. 2) β-catenin protein played a role in LST tumorigenesis. 3) The carcinogenic process was principally LOH. 4) LST was not one distinct concept-disease.

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Background: This study aims to identify which patients would benefit by surgery for pulmonary metastases from colorectal carcinoma. Methods: We retrospectively analyzed 30 patients with pulmonary resection for metastatic colorectal cancer at our hospital. The median disease-free interval, which was defined as the term that between the surgery of the primary tumor and the diagnosis of pulmonary metastasis, was 24 months. Nine cases had underwent surgery for extra pulmonary diseases as follows;8 hepatectomy, 1 brain metastectomy. Results: The 5-year survival was 34.5%. Age, gender, operative procedure, tumor size, histology, preoperative CEA, extra pulmonary disease, primary tumor site and stage were not found to be statistically significant prognostic factors in univariate analysis. The number and the site of pulmonary tumors and lymph node metastases were important prognostic factors by univariate analysis, but only the number was identified as an independent prognostic factor in multivariate analysis. The 5-year survival for the patients with a single metastasis was 59. 3%, as compared with 0% for those with multiple metastases. The 5-year survival was 49.1% for the patients without a lymph node metastasis, as compared with 20.8% for those with lymphnode metastases. Conculusions: The resection of pulmonary metastases from colorectal carcinoma benefit to small group of patients, even with extra pulmonary metastases. The number of metastases was a significant prognostic factor.

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A 59 year-old woman admitted to our hospital due to cough and sputum was diagnosed with pneumonia by X-ray. An upper gastrointestinal series (UGI) showed an esophagobronchial fistula in mass screening 18 months before admission. Minimal inflammatory change around the fistula was observed by computed tomography (CT). We evaluated the fistula as resectable thoracoscopically. Operative findings showed no severe adhesion, so we conducted diverticulectomy using endostapling. Microscopic findings of resected tissue revealed squamous epithelium covered with a muscle layer suggesting a congenital structure. The postoperative course was uneventful. This surgical procedure is thus recommended for patients with congenital esophagobronchial fistula with esophageal diverticulum.

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A symptom-free 47-year-old woman underwent UGI radiography and endoscopic examination of the stomach that showed an irregular polypoid lesion at the posterior wall of the middle gastric body. The polypoid lesion was diagnosed by biopsy as signet ring cell carcinoma (sig.), and distal gastrectomy was conducted. Pathologicaly, we diagnosed the lesion as undifferentiated (sig. and poorly differenciated adenocarcinoma (por.)) early gastric cancer presenting as Type I invading SM2. Generally, histological classification of elevated early gastric cancer is almost well or moderately differentiated adenocarcinoma. In many cases, undifferentiated histology such as por. or sig. exists almost exclusively as part of an elevated lesion or a restricted area of depressed components. Only 21 cases, including ours of this type of early cancer have been reported in the Japanese literature. Pathological findings indicated the involvement of collagen fiber, leiomyo fiber, and vessels forming the elevated leasion.

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A 78-year-old woman with chronic hepatitis type B who had often gone into a coma of unknown origin since August 1986 was examined in 1999 and found to have high blood NH₃->200μg/dl-and superior mesenteric varices with a diameter of 2 cm. Portal phase of mesenteric arteriography showed a massive portosystemic shunt from the ileocecal vein to the vena cava via the varices. She was diagnosed with Inose hepatic encephalopathy and underwent surgery to close the shunt. After confirming that portal venous pressure was less than 180 mmH₂O by test clamping of the shunt, varices were resected. Pulsed Doppler ultrasonography showed a significant increase in portal blood inflow to the liver and blood NH₃ decreased to 50μg/dl immediately after surgery. Her encephalopathy disappeared completely and she remains healthy with improved liver functional reserve to date.

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We report a case of intrahepatic cholangiocarcinoma associated with hepatolithiasis. A 73-year-old woman was admitted to our hospital for further examination of elevated serous alkaline phosphatase and γ-GTP. Abdominal ultrasonography and computed tomography showed dilation of the left intrahepatic bile ducts and common bile duct. Percutaneous transhepatic cholangiography showed a markedly dilated common bile duct, dilated left intrahepatic bile ducts, and a biliary stricture at the root of the left hepatic duct. Cytological examination of the bile specimen showed a cluster of adenocarcinoma cells. Under the diagnosis of intrahepatic cholangiocarcinoma associated with hepatolithiasis, we conducted left hepatic lobectomy with bile duct resection and right hepaticojejunostomy. Histological examination showed the tumor to be a papillary adenocarcinoma confined to the mucosa of intrahepatic bile ducts. The patient's postoperative course was uneventful with no evidence of recurrent disease during 1-year follow-up.

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Advances in imaging studies have made easier diagnosis of splenic cysts. We report a case of multiple splenic cysts with relapsing hemorrhage related to chemotherapy using anticancer drugs against right lung cancer and pleuritis carcinomatosa. A 58-year-old man reported left upper back pain during chemotherapy with anticancer drugs against right lung cancer and pleuritis carcinomatosa. He was found to be anemic in laboratory tests. Abdominal ultrasonography and computed tomography (CT) showed multiple splenic cysts, 1 of which had caused hemorrhaged. No cysts showed neoplastic lesions. He improved temporary with conservative therapy but after 14 days, symptoms curred and abdominal CT showed hemorrhage of another cyst. He was diagnosed with relapsing multiple hemorrhagic cysts, necessitating surgery. The pancreas, omentum, abdominal wall, and left diaphragm had adhered tightly to the spleen by fibrous connective tissue, so we conducted splenectomy with partial resection of these organs. The resected specimen showed 4 cysts up to 5 cm in diameter. All were monolocular and contained old blood. Cyst walls consisted of fibrous connective tissue with no lining cells, resulting in a diagnosis of pseudocysts. All cysts showed some stage of bleeding.

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We experienced a case with an intestinal perforation resulting from dialysisrelated amyloidosis. A fiftysixyear old women who had been receiving hemodialysis for twenty-three years underwent an operation for bilateral carpal tunnel syndrome and destructive spondyloarthropathy. She had experienced the onset of diarrhea four months earlier, and was operated on for perforative peritonitis. The middle part of the small intestine contained a 16×8mm hole. Partial resection of the small bowel and end-to-end anastomosis was performed. A pathological examination revealed an amyloid deposit in a perivascular area of the submucosal layer, and immunohistochemistry for β2-microglobulin was positive. She was diagnosed as having dialysisrelated amyloidosis. Anastomotic leakage occurred early during the post-operative day. She was died five months later because of a sepsis.

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We report 2 cases of necrotic Meckel's diverticulum due to torsion at the neck, resulting in peritonitis. Both were young men aged 25 (Case 1) and 24 (Case 2) admitted for severe lower abdominal pain and undergoing emergency laparotomy under the diagnosis of strangulated small bowel obstruction. Meckel's diverticulum, 90×40mm in Case 1 and 100×40mm in Case 2, was found on the ileum about 100 cm proximal to Bauhin's valve in Case 1 and 75cm proximal in Case 2. It was twisted about 360°counterclockwise at the neck in Case 1 and the same degree clockwise in Case 2 and necrotic. Torsion is a rare complication of Meckel's diverticulum, and we found reports of only 2 other cases in Japan. Our 2 cases were large size of the diverticulum with ampulla at the distal end. Size, distal ampulla, and mobility may thus be an anatomical factor in such torsion.

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A 60-year-old man suffering from vomiting and abdominal pain was diagnosed with ileus. Computed tomography showed a thrombus in the superior mesenteric and portal vein. Laboratory tests showed an elevated D-dimer of 10. 0 μg/ml. Protein S was markedly decreased in activity (<10%) and antigen (46%). The venous thrombus disappeared with anticoagulation therapy and symptoms were relieved. The patient was discharged 45 days after admission, but hospitalized about 5 months later due to ileus recurrence without thrombosis. A small intestine series showed localized stenosis in the ileum. Laparotomy showed ileal stenosis about 60 cm proximal to the ileocolic junction. We resected the lesion with end-to-end anastomosis. Histopathological findings showed a penetrating ulcer scar with acute inflammatory cell infiltration and organized mesenteric vein thrombi in the lesion. The patient had no underlying disease that would have caused thrombosis, and decreaed protein S activity was confirmed in his 2 daughters. We concluded that this was a rare case of superior mesenteric and portal vein thrombosis due to congenital protein S deficiency.

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Of 390 patients undergoing surgery for appendicitis from April 1995 to September 2000, 4 had had previous appendectomy. All reported right lower abdominal pain. At consultation, antibiotics were started without consideration of stump appendicitis due to previous appendectomy. Three days to 1 month after symptoms occured, surgery was done due to symptom persistence. Only 1 patient was diagnosed preoperatively with stump appendicitis and the other 3 were diagnosed as ileocecal abscess based on computed tomography. All underwent ileocecal resection and were diagnosed pathologically with stump appendicitis. In conclusion, any patient who has undergone appendectomy and presents symptoms similar to appendicitis should be evaluated for stump appendicitis.

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A 64-year-old man presenting with lower abdominial pain and fever was referred to our hospital. A barium enema examination showed an irregular shaped wall and extravasation of barium of the sigmoid colon. Computed tomography showed a high density area coincident with the extravasated barium near the sigmoid colon and ileoceacal region, but no tumorous lesion was noted. The abdominal pain and fever improved after one and a half months of conservative therapy. Open laparotomy was subsequently performed, because a malignant disease could not be ruled out. Severe inflammatory changes were found in the appendix, of which the distal end adhered to the sigmoid colon. En bloc resection of the appendix and sigmoid colon was performed, and a fine fistula was found between them. Histopathological examination confirmed severe inflammatory changes in the appendix and that appendiceal-sigmoid fistula had been caused by appendicitis. In cases of appendiceal-sigmoid fistula, careful observation or low-invasive treatment such as laparoscopic surgery should be also considered in the future.

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We report a rare case of adult asymptomatic intussusception caused by transverse colon cancer and review the literature. A 74-year-old woman admitted to our hospital with edema of legs showed a tender hard mass in the right upper abdomen upon examination. Intussusception caused by transverse colon cancer was diagnosed based on barium enema, ultrasonography, computed tomography, and colonoscopy. She developed ileus during preoperative preparation of the colon and was managed conservatively. We conducted transeversecolectomy with D3 lymph node dissection. Upon laparotomy, the transverse colon was found to be normogradely invaginated with a tumor at the apex of the intussusception, with two lesions located closely side by side in the right side of the transverse colon. Histopathologically, one was poorly differentiated type 1 adenocarcinoma with n2 (+) and was 95 mm in diameter. The second lesion was moderately differentiated type 2 adenocarcinoma and 33 mm in diameter. Intussusception in adults is rarely caused by transverse colon cancer, with only 6 cases reported in Japan. All cases, including ours, involved elderly women and type 1 tumors. Five of 6 previously reported cases had ileus on admission. Precautions should thus be taken while preparing patients for investigations such as barium enema and for surgery to avoid iatrogenic ileus.

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A 85-year-old woman was admitted to our hospital because of gradually increasing abdominal pain after receiving a glycerin enema from her referring physician. Clinical deterioration, despite conservative therapy, manifested as a peritoneal irritation. An abdominal CT scan demonstrated hepatic portal venous gas, intraabdominal free air, ascites, and gas in the mesenterium of the descending colon. An emergency laparotomy was perfomed under a diagnosis of a perforated descending colon. Hartmann's procedure was performed, The postoperative course was uneventful except for blood coagulation abnormalities and a wound abscess. This case presents an interesting diagnosis of colon perforation. The CT findings were valuable in detecting the flow of gas from the etiologic location to the hepatic portal vein.

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A 69-year-old woman who had lost about 20kg of weight in a month and reported fecal discharge from the vagina was referred to us for further avaluation. Radiographic barium examination showed diverticula with stenosis of the sigmoid colon and a sigmoid-uterine fistula. Computed tomography suggested colonic tumor invading the bladder and the uterus, but colonoscopy and a saggital view in magnetic resonance imaging disclosed no evidence of sigmoid colon cancer. Sigmoidectomy with total hysterectomy was conducted successfully under a final diagnosis of colouterine fistula associated with diverticulitis. Macroscopic findings of the resected specimen showed multiple diverticula with 2 fistulas in the sigmoid colon and a fistula on the anterior wall of the uterine cervix. Histopathological examination showed abscess in the subserosal layer of pseudodiverticula. Sigmoid-uterine fistula remains rare, but colonic diverticulosis is gradually increasing. We review 8 cases previously reported in Japan.

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A 67-year-old woman underwent a lower anterior resection for rectal cancer in 1993 and subsequently received two hepatectomies and a partial lobectomy for metastases. In 2000, a computed tomography examination showed the dilatation of the main pancreatic duct and a 2 cm mass with enhanced heterogeneity in the pancreas head. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed stenosis of the main pancreatic duct in the head of the pancreas. A pancreatoduodenectomy was performed under a diagnosis of pancreatic metastasis of rectal cancer, based on a biopsy of the tumor. The microscopic appearance showed a well to moderately differentiated adenocarcinoma, similar to the primary tumor. Pancreatic metastasis of colorectal cancer is very rare. Some reported cases have survived for long periods of time, despite several operations for metastases in other organ. If radical operation is an option, surgical treatment is recommended.

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A 54-year-old man was admitted with a 3-year history of anal bleeding on defecation and perianal pain. Physical examination showed redness, swelling, tenderness, and some disintegrated and defective regions of skin in the broad area of the buttocks and perineum. At surgical drainage, biopsy of the perianal mass showed well differentiated adenocarcinoma. He was first given an artifical stoma, followed by chemoradiotherapy. Two months later, the tumor was no longer detectabe in palpation, computed tomograhy, or magnetic resonance imaging. Miles operation with lymph node dissection was conducted, including superficial inguinal lymph nodes. Macroscopically no tumor mass was seen in the resected specimen and, histologically, only a few residual cancer regions. Tumor markers were normalized by the chemoradiotherapy. We thus consider chemoradiotherapy useful both in neoajuvat and radical treatment for selected cases.

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A 75-year-old woman was admitted to our hospital for sudden right upper abdominal pain. Ultrasonography and computer tomography (CT) showed an abdominal tumor 5 cm in diameter. Aspiration biopsy showed squamous cell carcinoma. Blood chemistry examination showed marked elevation of squamous cell carcinoma (SCC) antigen and carcinoembryonic antigen (CEA). The esophagus, skin, lungs, and uterus showed no abnormalities. We completely resected the egg-sized tumor and part of the tenth rib, abdominal wall, and right lobe of the liver, which the tumor had invaded. We diagnosed primary squamous cell carcinoma arising from the right abdominal wall. Microscopic examination showed the tumor to be well-differentiated squamous cell carcinoma invading the liver. We found no such case in a 15-year review of the Japanese literature. The woman has had no recurrence in the 10 months since surgery. Serum SCC decreased to normal immediately after surgery, and continues to be normal.

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Laparoscopic splenectomy (LS) is being accepted as an effective alternative to open splenectomy (OS) in treating idiopathic thrombocytopenic purpura (ITP). The objective of our retrospective study is to compare the outcome of LS and OS and to evaluate their safety and efficacy. We compared 14 LS patients who underwent treatment from February 1998 to April 2001 to a control group of 7 patients who underwent OS. All LSs were successful. The mean operative time was 185 minutes (range: 143-260) for LS and 116 minutes (range: 78-140) for OS (p<0. 01) with a similar amount of blood loss of 87. 7ml for LS and 101. 7ml for OS. Postoperative use of analgesics was lower for LS patients (p<0. 01), and LS patients tolerated oral intake and mobilization earlier than OS patients (p<0. 01). The median length of postoperative stay was 10. 9 days for LS and 15. 7days for OS (p<0. 01). Complications occurred in 14% of LS patients and 28% of OS patients. Compared to OS, LS requires more operative time but is associated with less pain, a more rapid return of gastrointestinal function, and a shorter hospital stay. With respect to ITP treatment, LS appears to be an effective alternative to OS.

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We studied the impact of variance analysis on the clinical path (CP) in laparoscopic cholecystectomy. Implementing the CP enabled us to shorten hospital stay and increase hospital income. We found 18 variations in 17 CPs, 72.2% of which occurred in the first 6 CPs. We categorited reasons for the 18 variations as follows: patient-related, 8; staff-related, 10; hospital-related, 0 ; and social factors, 0. Patient-related variances in 6 cases were due to physical problems. Two others were related to patient mental health. The remaining 10 variations were staff-related all due to unnecessary orders by individual doctors. The frequency of variations decreased with doctors'experience and understanding of the CP. These doctors evaluated their treatment strategy compared to the CP, and the CP and its outcome should continue to be evaluated and discussed.

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The completion of the sequencing of the human genome has provided us with a powerful tool for unlocking the secrets of our genetic heritage. The Frontier Research Center, of the National Institute of Radiological Sciences, has recently launched the Rad Genomics Project, the aim of which is individualized radiotherapy based on genetic factors. The protocol and informed consent guidelines of this project were submitted to a specially appointed ethical review committee in the National Institute of Radiological Sciences. One of the most important issues is the proper balance between privacy concerns and fair use of genetic information. Growth in the number of genetic tests available and the frequency with which they are used raises the possibility of discrimination due to inappropriate access to, and use of, private genetic information. In this paper, we discuss the key issues and problems concerning informed consent. The topics covered include the dignity of human subjects, freedom to perform genetic studies, advantages and disadvantages for subjects, disclosure of results of genetic analysis, and intellectual property.

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