Introduction: Many pancreatic cancers are detected only after they are far advanced, and thus show a poor prognosis. Methods: We evaluated the survival of patients with inoperable pancreatic carcinoma, and strategy treatment. Subjects were 72 persons with advanced inoperable pancreatic carcinoma selected from among 144 examined at our department from May 1992 to March 2001. Patient factors (age, gender, and nutrition), tumor factors (hepatic metastasis, peritoneal dissemination, and distant metastasis), and treatment (radiotherapy, systemic chemotherapy, and hepatic arterial infusion therapy (HAI)) were studied and survival evaluated statistically. Results: Overall mean survival was 175 days and the 1-year survival ratio was 13.5%. With multivariate analysis, prognostic factors were hepatic metastasis and radiotherapy. We therefore reevaluated 56 patients treated with radiotherapy. In the group with no hepatic metastasis whose mean survival was 247 days, the prognostic factor was systemic chemotherapy. In the group with hepatic metastasis, mean survival was 140 days and the prognostic factor was the prognostic nutritional index (PNI) on admission. HAI was also a significant factor, which prolonged survival time with univariate analysis. Conclusion: Radiotherapy will be conducted for all inoperable pancreatic carcinomas. For the group with no hepatic metastasis, systemic chemotherapy is effective and for the group with hepatic metastasis, HAI will be selected.

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Introduction: Intestinal content or purulent fluid continuously produced in the abdominal cavity must be aspirated to prevent abdominal sepsis. We discuss the usefulness of high pressure aspiration system (HPA) using overcoated double luminal draining tube.
1. Clinical investigation Methods: Fluid adhesion to gauze, discharge from the drain during lavage, and skin around the drain were compared in 14 subjects before and after HPA. The overcoated double luminal draining tube consisted of an outer and inner tubes. The end of the inner tube was 5 mm behind that of the outer tube and aspirated at the highest central vacuum pressure system, such as in suction used in surgery. Results: Fluid adhesion to gauze, discharge from the drain during lavage, and skin around the drain improved after HPA (P<0.0001), with 173.3 g of fluid aspirated a day and dressing changes decreased from 7.1 to 2.7 a day (P<0. 0001).
2. Experimental investigation Methods: Mucinous fluid in an irregularly hollowed sponge abscess model was continuously aspirated with a HPA model and low pressure with a sump tube. The ratio of residual to initial volume (aspiration ratio) and final residual volume (final aspiration rate) were studied. Results: Both the aspiration ratio and final aspiration rate were low in the high pressure model (P<0.0001, P<0.0001). Discussion and Conclusion: HPA is useful in removing intestinal and purulent fluid. Care must be taken, however, to avoid aspirating tissue due to dislocation of the end of inner tube and blockage due to the adhesion of dried matters making it important to change the inner tube as soon as convenient.

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Purpose: HGF which has both mitogenic and motogenic activity in cancer cells, is involved in tumor invasion and metastasis. We evaluated serum HGF related to the spreading of colorectal cancer, and clarified the clinical role of HGF to classify Dukes'classification. Patients and Methods: In 53 patients (Dukes'A;7, B;15, C;17, D;14) with colorectal cancer, we assessed the correlation of HGF with 1) clinicopathological features (lymphatic invasion (ly), venous invasion (v), lymph node metastasis (n), hepatic metastasis (H)), 2) HGF-related factors (IL-6, IL-1β, TNF-α, TGF-β1), 3) adhesion molecules (ELAM-1, ICAM-1, VCAM-1).And we evaluated these 8 factors (HGF, HGF-related factors, adhesion molecules) to classify 53 patients according to Dukes'classification. Results: 1) Significant relationships were seen between HGF and ly (p<0.05), n and H (p<0.01), 2) Significant relationships were seen between HGF and IL-6, TGF-β1, ELAM-1 (p<0.01), and VCAM-1 (p<0.05), 3) HGF and IL-6 values in Dukes'D cases were significantly higher than those in Dukes'A, B, and C cases (p<0.01), 4) HGF, IL-6, and ELAM-1 were strongly related to distinguishing the Dukes'A B group, Dukes'C group, and Dukes'D group. Conclusion: We suspect that HGF, which may be upregulated by IL-6 and TGF-β1 from colorectal cancer cells, is involved in the invasive phase during the development of lymph node and hepatic metastasis. And HGF, ELAM-1, and IL-6 had particular diagnostic significance (sensitivity 67.7%, specificity 86.4%), which were the same values as tumor markers (CEA, CA19-9) and imaging diagnosis (US, CT), for Dukes'C and/or D group.

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Introduction: We evaluated the characterisitics and risk factors for recurrence and optimal follow-up for Dukes A colorectal cancer. Materials and Methods: Between 1965 and 1995, 372 patients were classified with Dukes A colorectal cancer among 2, 435 colorectal cancer patients undergoing surgical resection at our hospital. We evaluated the clinicopathological characteristics of the recurred cases, and those from rectal cancer were compared to the recurrence-free cases with the background factors. We also carried out multivariate analysis with the factors whose p value was under 0.1. Results: Of these, 16 (4.3%) showed recurrence, and 15 of the 16 cases were derived from rectum. Primary recurrence sites from rectal cancer were local (9), lung (4), liver (2) and bone (1). Eleven cases recurred within 2 years, and the rate of local recurrence was 72.7%. On the other hand, five cases recurred between 2 and 5 years, and the rate of far metastasis was 80.0%. Univariate analysis comparing to 194 recurrence-free cases showed histology to be an only significant risk factor for recurrence (p=0.003), and multivariate analysis with 3 factors also showed the identical result (p=0.005). Discussion: It is not so important to do follow-up for Dukes A colon cancer, but in case of Dukes A rectal cancer, we should do follow-up with attention to local recurrence within 2 years and to far metastasis between 2 and 5 years. Since cases whose histology are not differentiated type have very high risk for recurrence, intensive postoperative follow-up is necessary as far advanced cancer.

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A 47-year-old male man with hepatocellular carcinoma (HCC) underwent anterior segmentectomy of the liver in 1993 diagnosed by microscopy as moderately differentiated HCC. Following 1 year of observation, serum AFP rose, revealing intrahepatic metastasis. We implemented sequential transarterial embolization. Sudden massive hematemesis hospitalized him in March 1995, and a huge metastatic mediastinal lymph node was found, penetrating the midesophageal wall and causing a hemorrhagic esophageal ulcer. Radiation therapy to the mediastinum with a total dose of 59.4Gy lowered AFP to normal, but it rose again and a deep ulcer remained in the esophagus. Subtotal esophagectomy with lymph node dissection through a right thoracotomy, laparotomy, and neck incision was successful. The enlarged metastatic subcarinal lymph node involved the esophageal wall, pericardium, and thoracic duct, which proved to be HCC microscopically. In metastasis of HCC to the thorax, hematogenous metastasis to the lung occurs frequently but lymphatic metastasis to the mediastinal node is rare. This is, to our knowledge, the first report to demonstrate mediastinal lymph node metastasis from HCC causing esophageal penetration and being removed surgically. In our experience, radiation therapy is somewhat effective in reducing mediastinal lymph node metastasis and surgical resection including adjacent structures may be considered if locoregional cure or improved QOL is to be expected.

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A 57-year-old man visitted to our hospital because of tarry stool, nausea and epigastralgia. Emergency upper gastrointestinal endoscopic examination detected a submucosal tumor with a hemorrhagic ulcer at the third portion of the duodenum. Abdominal computed tomography showed that the tumor was 5 cm in diameter, solid with a well-delineated border. On abdominal angiography, the tumor had hypervascularity. Leiomyoma or leiomyosarcoma of the duodenum was suspected preoperatively, and a partial resection of the duodenum was performed. Histopathologically, the tumor was composed of proliferated spindle cells which had mitotic figures by 2-3/10 high power field. Immunohistological examination revealed that the tumor was positive for S-100 protein, CD34 and KIT, and partially positive for SMA. Therefore, this tumor was diagnosed as combined smooth muscle neural type of GIST, originated from interstitial cells of Cajal.

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We report difficult-to-diagnose a intramural hematoma of the duodenum and T1a carcinoma of the pancreatic head. A 66-year-old man with epigastric pain and vomiting was palpated with a fist-sized mass in the upper abdomen. Blood examination revealed high levels of pancreatic enzymes and tumor markers. Gastroendoscopy revealed no passage to the duodenum. Computed tomography (CT) of the abdomen disclosed a cystic mass, 8 cm at its greatest diameter containing an irregular solid lesion at the pancreatic head. From hospitalization day 10, the mass began to grow and its center became homogeneous in CT. After 1 month, drainage volume from the gastric tube remained unchanged. We conducted pancreatoduodenectomy due to elevated tumor marker levels, the results of cytological bile examination (class III), and suspected pancreatic head carcinoma. The mass was a hematoma situated in the muscle layer of the duodenum. In addition to the hematoma, a poorly differentiated tubular adenocarcinoma 1.5 cm in diameter was found near the main pancreatic duct at the pancreatic head.

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A 47-year-old man with repeated epigastric discomfort admitted to treat a hepatic mass detected by ultrasonography(US)was found through laboratory data to have elevated serum AFP and CA 19-9, although hepatitis B surface antigen and anti-hepatitis C antibody assay were negative. Contrast-enhanced computed tomography(CT)and celiac angiography showed a slightly enhanced, heterogeneous mass 10 cm in diameter occupying hepaticmedial and anterior segments. We conducted right trisegmentectomy after transcatheter arterial chemoembolization and percutaneous transhepatic portal embolization to prevent postoperative hepatic failure. The tumor was diagnosed immunohistochemically as carcinoid of the liver. The man died in an accident 3 months after surgery with no evidence of recurrence. We reported a case of resected hepatic carcinoid tumor.

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A 59-year-old man diagnosed with hepatocellular carcinoma, lateral hepatectomy in July 1991 to excise a 4×3 cm nodular, found to be sclerosing hepatic carcinoma, EdI+II, IV, fc (-), sf (-), vp0, vv0, b1, tw (-), im1, z1. In ambulatory observation since 1996, his serum AFP was found to be elevated. Abdominal computed tomography (CT) in April 2000 showed a peritoneal lymphadenopathy and angiography showed dark tumor staining extending from the left gastric artery. The patient was free of recurrence from the residual liver or metastatic foci in other organs. Under a diagnosis of lymph node metastasis of liver cancer, the patient underwent surgery in July 2000. This case remonstrates hepatocellular carcinoma treated by hepatectomy with no recurrence in residual liver tissue but resulting in solitary lymphatic metastasis 9 years later that was excised. We also present a review of the literature.

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Primary leimyosarcoma of the gallbladder is an extremely rare neoplasm. To the best of our knowledge, this is the first case in the Japanese and English literature of synchronously concomitant primary leimyosarcoma of the gallbladder and adenocarcinoma of the stomach. A 80-year-old woman admitted for right upper quadrant pain was suspected of cancer of the gallbladder and early gastric cancer based on abdominal ultrasonography, CT, MRI, ERCP and gastrointestinal endoscopy. MRI appearance of the gallbladder tumor was intermediate intensity on T1 weighed images and slightly high intensity on T2 weighed images. We conducted extended cholecystectomy and distal gastrectomy. The resected specimen histologically proved to be leiomyosarcoma of the gallbladder and adenocarcinoma of the stomach. In 21-month follow-up, the patient was well with no reccurent evidence of either malignancies.

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A 55-year-old woman with jaundice sent to our department for consultation after percutaneous transhepatic cholangio drainages (PTCD) was suspected of catheter tract seeding. We conducted cholecystectomy, liver bed resection, extra hepatic bile duct resection and lymph node dissection for gallbladder carcinoma of comprehensive stage IVa. We added postoperative radiation therapy and adjuvant chemotherapy with CDDP and 5FU. About a month later, a metastatic subcutaneous catheter tract seeding tumor found at the bile duct drainage catheter tract was extirpated. It is thus important to consider the possibility of such recurrence, with positive early resection as the treatment of choice.

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Mucin-producing intrahepatic cholangiocarcinoma is an uncommon hepatic malignancy that macroscopically secretes mucin within biliary trees, generally resulting in obstructive jaundice and/or cholangitis. An asymptomatic 37-year-old man referred to us with intrahepatic bile duct dilation found in by ultrasonography (US) during a routine physical check up was diagnosed with mucin-producing intrahepatic cholangiocarcinoma based on radiological findings. We conducted extended left hemihepatectomy combined with extrahepatic bile duct resection and lymphadenectomy. Macroscopically, a polypoid lesion 1.8 cm in diameter was found in the dilated bile duct of Couinaud's segment III. Microscopically, the tumor was papillary adenocarcinoma confined within the fibromuscular layer without lymph node metastasis. No lymph node metastasis was seen in cases previously reported in Japan in which tumors remained localized to the mucosal or fibromuscular layer. This suggests the diagnosis of mural inbasion will be helpful in determining the extent of dissection in surgical treatment of this malignancy.

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We report a case of metastatic pancreas and gallbladder carcinoid of the thymus. A 74-year old woman who had undergone thymectomy for a thymic carcinoid 4 years earlier was found by abdominal computed tomography to have a tumor at the pancreas head about 2 cm in diameter. Magnetic resonance cholangiopancreaticography (MRCP) confirmed the tumor and dilatation of the distal main pancreatic duct. Pyloruspreserving pancreaticoduodenectomy was conducted under a preoperative diagnosis of pancreatic head cancer. Specimens showed 3 brownish tumors with an unclear margin at the pancreatic head about 1 to 2 cm in diameter and a tumor at the neck of the gallbladder about 1 cm in diameter. Pathologic findings for these tumors showed a marked resemblance to the thymic carcinoid resected 4 years earlier, so we diagnosed these tumors as metastases from the thymic carcinoid. Metastatic pancreatic tumors are rare and the very few cases offer little advice in the choice of surgical treatment.

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A 72-year-old woman referred to us with an abnormal lesion in radiography showed a nodular shadow in the left lung, 2 tumors growing from the liver surface, and a cystic tumor in the pelvic catity in computed tomgraphy (CT). Colonic fiberscopy showed advanced cancer at the ascending colon. She underwent surgery under the diagnosis of ascending colon cancer, ovarian cancer, or both, with metastases to the lung and disseminations to the liver. Ascending colon carcinoma was not so invasive, but the ovarian tumor had invaded the urinary bladder, suggesting that disseminations and distant metastases were of ovarian origin. We conducted bilateral oehorectomies and iliocecum resection with lymph node resection. Microscopically, the tumor of the ascending colon, AFP-producing moderately differentiated adenocarcinoma, was found to be a primary lesion that had metasticised to the ovary and lung and disseminated to the liver and peritoneum. AFP immediately after operation was 69. 7ng/ml.

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A 94-year-old woman with a distentended abdomen and no histry of previous surgery was found on physical examination to have a distended, tympanic abdomen with tenderness in the right lower abdominal quadrant but without rebound tenderness or muscular guarding. No palpable masses were found. Elevated serum CEA (19.9 ng/ml, normal range: <6.0ng/ml) was found. Abdominal x-ray showed dilated loops of almost all of the small bowel suggestive of terminal ileum obstruction. Ultrasonograhy (US) showed a cystic mass with variable internal echogenicity and calcification wall in the right lower quadrant. Computed tomography (CT) showed a well-encapsulated cystic mass with cuvilinear calcification wall in the pericecal area compressing the terminal ileum. Small bowel obstruction due to appendiceal mucocele was diagnosed preoperatively. At emergency laparotomy, we found a mass full of mucoid material extending from the appendix, which compressed the terminal ileum, and conducted ileocecal resection. Pathologically we diagnosed appendiceal mucocele caused by mucinous cystadenocarcinoma in situ. The patient had a smooth postoperative course. US and CT were useful in diagnosing mucocele of the appendix and differentiating this from mimicking diseases. We review 66 patients with primary ealy carcionoma, which means the involvement of carcinoma in the mucosal or submucosal layers, of the appendix in the Japanese literature. Our case is the oldest in primary early carcinoma of the appendix, and is the first accompanied by small bowel obstruction.

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An 88-year-old woman with constipation was admitted to our hospital because of vomiting and lower abdominal pain. Physical examinations revealed rebound tenderness at the right lower quadrant and abdominal distension. Scout abdominal films showed dilatation of the small intestine and the colon. Gastrografin enema showed the elongated sigmoid colon filled with a large amount of stool, which descended into the pouch of Douglas. The contrast medium did not pass the sigmoid colon. Abdominal computed tomography (CT) showed the lowest portion of the sigmoid was at the coccygeal level. Laparotomy revealed that the long sigmoid loop having a larger diameter was incarcerated in the unusually deep cul-de-sac, causing bowel obstruction. She underwent the obliteration of the cul-de-sac preceded by disgorgement of the sigmoid colon. There are no signs of recurrence during the follow-up of 15 months. Sigmoidocele can cause the incarcerated internal hernia, although it is ordinarily thought to be a cause of evacuatory disorders.

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We report a case of jejunal fistula due to late-appearing intraabdominal abscesses following ulcerative colitis (UC) surgery. A 52-year-old man who underwent total colectomy and ileal pouch anal canal anastomosis after perforation of the descending colon and panperitonitis during steroid treatment for ulcerative colitis. Histological examination of the resected specimen showed acute fulminating type of UC. He was admitted due to fever 6 months after surgery. Ultrasonography (US) and computed tomography (CT) showed an intraabdominal abscess in the upper left quadrant. X-ray examination with contrast medium showed an abscess cavity and 2 fistulas between the abscess cavity and jejnum, necessitating partial resection of the jejunam and drainage of the abscess cavity. Resected specimens did not show ulcerative colitis or Crohn's disease. After discharge, he was readmitted for fever and leukocytosis. X-ray examination with contrast medium showed the abscess cavity and an other fistula between the abscess cavity and jejnum. We conducted further partial resection of the jejunum and drainage after abscess curettage. The resected specimen did not show ulcerative colitis or Crohn's disease. The man has had no recurrence of symptoms or diagnostic imaging signs since discharge.

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A 52-year-old man admitted for palpitation and exertional dyspnea was found by our internal medicine department to have anemia and sigmoid colon carcinoma. The patient had situs inversus (Kartagener syndrome), and preoperative diagnosis of complicated anomalies were right-sided heart, two-lobe lung, multiple spleens, IVC defect and intestinal malrotation. Surgical findings were left-sided liver, right-sided stomach, total situs inversus, and nonrotational intestinal malrotation in which the cecum was on the median. Since sigmoid colon carcinoma inveded the cecum we conducted sigmoidectomy with ileocecal resection. The man was discharged on postoperative day 18. Situs inversus is a rare congenital disease and often has several complicated anomalies. Although this case involved sigmoid colon carcinoma with some complicated anomalies, no severe problems occurred during surgery.

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Spinal epidural abscess is a complication of continuous epidural block, and its incidence has increased to 1.96 cases per 10, 000 hospital admissions. We report and epidural abscess occurring soon after rectal cancer surgery treated to full recovery with intravenous antibiotic therapy alone. A 70-year-old woman with rectal cancer underwent low anterior resection, with an epidural catheter inserted via the L1-L2 interspace for epidural anesthesia in the operating room. On postoperative day (POD 5), she reported back pain and the catheter insertion site showed a subcutaneous abscess. We immediately removed the epidural catheter, punctured the subcutaneous abscess, and started an intravenous antibiotic therapy. The next day, she suffered a severe headache and her temperature rose to 39.4°C. Magnetic resonance imaging (MRI) of the spine on POD 8 with gadoliniumenhanced MR imaging showed a small, 2cm long enhanced area in the posterior epidural space at L1-2 compressing the spinal cord, which we diagnosed as an epidural abscess. Since Methicillin resistant Staphylococcus aureus (MRSA) was isolated from the skin abscess, we changed antibiotics to Vancomycin (VCM) and continued intravenous antibiotic therapy. She recovered from the abscess without neurological deficit under antibiotics alone. Staphylococcus aureus is the most common causative bacterium of spinal epidural abscess and MRSA has recently become the major species. Epidural abscess management consists of early diagnosis and therapy. Early checkup and treatment should be started for patients undergoing continuous epidural block who demonstrate high fever complicated by headache.

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An 81-year-old man was diagnosed with an esophageal cancer in the middle thoracic esophagus. A CT scan and a bronchofiberscopic examination suggested that the cancer might not have invaded the left main bronchus. Following a right lateral thoracotomy without cutting the right latissimus dorsi muscle, a radical esophagectomy was performed, and the membranous wall of the left main bronchus was partially resected because the tumor could not be isolated from the membranous wall. A latissimus dorsi muscle flap with the subcutaneous fat tissue on the distal part was created, and the bronchial defect was covered by the inner side of the muscle flap. No air leakage was noted during positive pressure ventilation or coughing, and the postoperative course was uneventful. We conclude that coverage of the latissimus dorsi muscle flap with subcutaneous fat tissue is a useful technique that can be used to prevent postoperative complications in patients requiring a combined resection of the membranous wall for the treatment of esophageal cancer.

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To determine the usefulness of transcystic drainage tube (C-tube), we compared the duration of biliary drainage and complications with those of the T-tube. The study included a series of 110 patients with choledocholithiasis-55 cases of T-tube drainage and 55 of C-tube drainage. The frequency of localized peritonitis after drainage tube removal was significantly lower in the C-tube group (p<0.01). Biliary drainage in the C-tube group lasted 6.2 days versus 24.2 days in the T-tube group, significantly shorter (p<0.01). Residual stones were seen in 2 patients in the T-tube group and endoscopically treated, but none in the C-tube group. We conluded that C-tube drainage is more useful in choledocholithiasis surgery because it is safer and shortens tube indwelling time.

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