We studied abdominal aortic lesion anatomy for neural tissue preserving surgery in D3 dissection for advanced gastric cancer. Materials and methods: Paraaortic lesion, i.e., greater and lesser splanchnic nerves, celiac ganglia, and celiac plexus, were examined macroscopically in 31 cadavers. Using transverse sections of 14 cadavers, histology was also conducted focusing on the relationship of lymph nodes, neural tissue, and vessels. Results: The greater and lesser splanchnic nerves run across from both sides and merge into the celiac ganglion, which consists of only 1 ganglion (type I) or several ganglia (type II). Type I was frequently found on both left and right sides. The splanchnic nerve appears in the abdomen more caudal and lateral than that on the left. The average number of lymph nodes was 6.4 in No.16a2inter, 7.5 in No.16a2latero, 4.4 in No.16b1inter, and 5.2 in No.16b1latero. Lymph nodes of a2 and b1 in the lateral side of the aorta were larger in number than on the internal side. Lymph nodes were detected behind the celiac ganglia and splanchnic nerve in all cases, but not in the layer between arteries and the neural tissue. Conclusion: The nerve system and lymph node distribution around the aorta have several patterns, and anatomical studies, around the aorta provide useful information for effective, safe lymph node dissection.

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Purpose: To establish a rational surgical approach to gallbladder cancer which varies widely in dissemi-nation, we analyzed clinicopathologic features based on the depth of invasion.Method: Dissemination in 56gallbladder cancers and prognosis were clinicopathologically analyzed based on the depth of invasion.For ss (invade to the subserosal layer) gallbladder cancer we further classified subjects into three groups based on the grade of invasion in the subserosal layer of the gallbladder. Results: Five-year survival of the patients with m (invade to the mucosal layer) and mp (to the muscular layer) cancer was 100%. That of those with ss cancer was 80%, with se (expose to the serosa) cancer 34% and with si (invade to the neighbor organ) can-cer 13%.Gallbladder cancer with minimum invasion to the subserosal layer (ss min) had clinicopathologic fea-tures similar to mp cancer, but those with medium (ss med) or massive (ss mas) invasion to the subserosal layer or deeper (se, si) varied widely in dissemination and high-frequency metastasis.The prognosis of pa-tients with paraaortic lymph node metastasis did not differ either with or without pancreatoduodenectomy. Discussion: For cancers with mp and ss minimum invasion, cholecystectomy without hepatectomy should be sufficient but D2 lymph node dissection may be necessary. When invasion is greater than ss medium, he-patectomy of segments 4a and 5 or more extended hepatectomy together with cholecystectomy, extrahepatic bile duct resection, and D2 with paraaortic lymph node or D3 dissection is recommended. Pancreatoduodenec-tomy should be restricted to direct invasion to the duodenum without paraaortic lymph node metastasis. For cancers with liver metastasis, Hinf3 or Binf2, 3 radical surgery contributes in a few limited cases. Progress in preoperative refined assessment of invasion depth and establishment of the tailor-made multidisciplinary treatment should also be studied further.

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Aim: We evaluated a clinical pathway (CP) introduced in the management of pancreaticoduodenectomy, which has a high incidence of postoperative complications. Patients and Methods: Forty consecutive patients who underwent pancreaticoduodenectomy at our institute between October 2000 and August 2002 were included. Antibiotics and other perioperative medication were used based on current standards throughout the period. Physicians were asked to use the CP, which was created based on samples with the best clinical course among 14 patients before August 2001 (pre-CP), for the treatment of 26 patients thereafter (post-CP). Results: Among the 46% of patients completing the CP, the incidences of postoperative complications did not differ between pre- and post-CP. Postoperative hospital stay was reduced significantly after CP implementation (median 30 vs. 34 days, p=0.04), especially in on-path cases (24 vs. 30 days, p=0.01). Hospital charges were also significantly reduced (¥814, 640 vs.¥954, 960, p=0.02), thanks mainly to a drop in the cost of medication, postoperative surgical procedures, and laboratory tests. In on-path cases, hospital charges were significantly lower than those off-path (¥656, 780 vs.¥842, 160, p=0.005), and 73% of on-path patients were satisfied with the time and quality of treatment. Conclusions: The CP is feasible even in cases with a high rate of variances, as in pancreaticoduodenectomy. CP implementation primarily benefits on-path patients and helps to raise cost quality outcomes on the whole while maintaining the safety of surgical intervention and patient satisfaction.

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Introduction: Antibiotic prophylaxis is an important measure for preventing postoperative surgical site infection (SSI) after colorectal operations. We attempted to confirm the optimal method of using prophylaxis for elective colorectal operations by performing a prospective study between January 1997 and August 2002. Methods: Mechanical preparation was used prior to operation in all cases. Preoperative chemical preparation was used for 0-2 days. Well-conditioned, non-contaminated primary resection cases were randomized into one of two groups in advance. In Arm A, antibiotics were given from just prior to the operation until one day after the operation. In Arm B, antibiotics were given from just prior to the operation until 3 days after the operation. The type of antibiotic was limited to PIPC, CEZ, CTM, or CMZ, administered intravenously. If the operation required more than 4 hours to perform, an additional dose of antibiotics was used. Results: In total, 521 cases were enrolled in the study. The rate of SSI was 5.7%(n=262) in arm A, and 5.4%(n=259) in arm B, and the rate of remote infection (RI) was 6.9% in arm A, and 5% in arm B. No relationship was observed between the duration of prophylaxis and the rate of SSI or RI. In Japan, many surgeons do not use preoperative chemical preparations to prevent superinfections, such as MRSA. However, the Centers for Disease Control and Prevention (CDC) recommends using a short period of chemical preparation before surgery. Unlike the results for colonic operation, the SSI controll level after performing a Miles'operation was poor when no chemical preparations were used. We believe that short period of chemical preparation is useful for preventing SSI after lower rectal operations. However, postoperative MRSA colitis or MRSA pneumonia occured only in the group where chemical preparations were given for 2 days. In these cases, an overdose of the chemical preparations may have induced antibiotic resistant bacteria to multiply. Conclusions: We recommend the following standard method of using antibiotic prophylaxis for colorectal operations. 1) The required duration of antibiotic prophylaxis for SSI and RI does not appear to differ according to the clinical stage or type of operation that is performed. 2) Using antibiotic prophylaxis from just before the operation to one day after the operation is sufficient to prevent SSI. 3) Short periods of administering chemical preparations are likely to be effective for preventing SSI after lower rectal operations.

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We present a case of ectopic gastric ulcer perforation of the esophagus. A 52-year-old man receiving medication for a duodenal ulcer experienced sudden epigastralgia and increased pain after serious vomiting. Based on highly suspicious for esophageal perforation, he was admitted. Barium study and computed tomography showed a perforation at the left side of the lower esophageal wall. Under a right thoracoabdominal approach, we conducted esophagectomy and esophagogastrostomy. Postoperatively, sepsis due to serious inflammation in the mediastinum occurred. He gradually recovered without anastomotic leakage or mediastinal abscess. In resected specimens, perforation of the ectopic gastric mucosa in the lower esophagus was found pathologically. No symptoms usually occur in ectopic gastric mucosa of the esophagus, and such lesions are found incidentally by endoscopy. We should thus be mindful of the risk of perforation and explain it to patients with such lesions.

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A 59-year-old woman, admitted our hospital for epigastralgia, was diagnosed as having acute cholecystitis and an abdominal cyst. She had been treated with medication at another hospital. We performed a cholecystectomy and then cut the border between the stomach and the abdominal cyst. We removed the cyst with a part of the gastric mucosa after separating the cyst from the muscle of stomach. The histological diagnosis was a bronchogenic cyst. The patient has remained in good health during the approximate 6.5 years since surgery. The bronchogenic cyst is a congenital cyst that arises from a developmental aberration of the primitive foregut. The bronchogenic cyst is benign, but surgery is indicated because preoperative diagnosis is very difficult and there is a possibility of complicating malignancy. A bronchogenic cyst in the abdomen is uncommon only 7 cases including ours have been reported in Japan.

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We report a case of malignant peritoneal mesothelioma with multiple early gastric cancers. A 70-year-old man admitted for a bleeding gastric ulcer had the gastric ulcer cured by suitable medication, but gastrointestinal fiber showed 3 early gastric cancers, necessitating distal gastrectomy with lymph node dissection. Intraoperative findings included thickened, hard, whitish, granulated lesions under the bilateral diaphragm, greater and lesser omentum, surface of the transverse colon, and mesenterium transversum. We suspected that lesions were dissemination of gastric cancer, although the cancer was thought to be in the early stage. We conducted peritoneal biopsy. Histopathologically, all 3 gastric lesions were early gastric cancer, but the peritoneal lesion suspected of dissemination was malignant peritoneal mesothelioma. Differential diagnosis between dissemination of gastrointestinal cancer with malignant peritoneal mesothelioma is very difficult. It is thus important to conduct peritoneal biopsy, even for lesions due to suspected to dissemination.

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We report a case of a 1.8 mm asymptomatic glucagonoma incidentally discovered without preoperative diagnosis in a resected specimen of a carcinoma of the ampulla of Vater. A 55-year-old woman hospitalized for icterus, brown urine and general fatigue was found to have obstructive jaundice due to carcinoma of the ampulla of Vater. No glucose intolerance, skin lesion, or tumor of the pancreas was identified preoperatively. She underwent pylorus-preserving pancreatoduodenectomy. A tumor 1.8 mm in size was found in the head of the pancreas and carcinoma of the ampulla of Vater. Immunohistologic labeling showed it to be glucagonoma. In recent years, reports of glucagonoma have increased in number as a result of progress in diagnostics. Glucagonoma, however, incidentally discovered in a resected specimen or as small as 1.8 mm is extremely rare.

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Type C liver cirrhosis is often associated with nephrotic syndrome secondary to membranoproliferative glomerulonephritis. Liver transplantation in such patients may worsen viremia and cause renal dysfunction due to the use of immunosuppressive drugs. We report a patient whose proteinuria decreased after liver transplantation. A 49-year-old man followed up for a diagnosis of chronic hepatitis C from 1984 was diagnosed in 1999 with nephrotic syndrome. We conducted a living related liver transplantation on August 21, 2001. Intraoperative renal biopsy showed the histology to be membranoproliferative glomerulonephritis. Preoperative proteinuria was 2-11 g/day, varied postoperatively from 6 to 10 g/day, gradually decreasing to 1-2 g/day. One cause of this reduction may be that membronoproliferative glomerulonephritis was alleviated by immunosuppression. Giver that renal function recovered after the recovery of liver function, hepatorenal syndrome alleviation is thought to have had a significant influence.

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A 61 year-old woman with abdominal fullness and jaundice due to polycystic liver disease was transferred to our hospital for liver transplantation. Blood examination was compatible with DIC, the liver was severely enlarged, and the cyst component was irregular due to bleeding. The diagnosis by radiology was compatible with liver cysts. After 14 days, she died and a liver cyst was diagnosed as angiosarcoma by autopsy. The diagnosis indicated contraindication of transplantation. Polycystic liver is benign disease and hepatic angiosarcoma is malignant disease without standard therapy. Although it is not difficult to differentiate polycystic liver disease from angiosarcoma, biopsy is needed to decide the diagnosis when the clinical course is unusual. Definite diagnosis is needed because the therapies are different between polycystic liver disease and hepatic angiosarcoma. If a patient's general condition is not satisfactory, radiological and clinical approaches are the only way to confirm the diagnosis.

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We report a case of intrahepatic cholangiocarcinoma arising 26 years after excision of congenital biliary dilatation (CBD). A 46-year-old man with epigastralgia and back pain admitted for liver tumor and stenosis of the hilar bile duct had previously undergone reconstruction by Roux-en-Y hepaticojejunostomy for CBD in 1975. Computed tomography showed a liver tumor 30 mm in diameter on S4 and lymph node swelling surrounding the hepatoduodenal ligament. Endoscopic retrograde cholangiopancreatography visualized pancreaticobiliary maljunction and multiple stones in the residual intrapancreatic bile duct. Percutaneous transhepatic cholangiodrainage was initiated when jaundice progressed, and fistelography recognized bile duct stenosis of the anterior, posterior, and caudate branches. Angiography showed stenosis of the left hepatic artery and left branch of the portal vein. We diagnosed intrahepatic cholangiocarcinoma. Extended left lobectomy and caudate lobe resection were scheduled, but we undertook gastrojejunostomy due to liver metastasis and invasion of the hepatoduodenal ligament. The patient died of liver failure 1 month later.

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A 70-year-old man admitted for back pain and liver dysfunction in 1993 and having a history of choledococholecystolithiasis surgery in 1977 was diagnosed as having recurrent choledocolithiasis, necessitating percutaneous transhepatic cholangioscopy and lithotomy (PTCS-L). An extrahepatic bile duct stricture was detected and diagnosed as benign by cholangioscopy and biopsy. Although the stricture was successfully treated by expandable metallic stent (EMS) insertion, he suffered from recurrent choledocolithiasis twice until 1996, each time requiring PTCS-L. The last PTCS showed a bile duct tumor protruding through the EMS mesh confirmed pathologically to be adenocarcinoma. Surgery and histopathological findings showed moderate to poorly differentiated adenocarcinoma accompanied by adenoma and hyperplasia arising from the bile duct mucosa below the EMS. This suggests a possible relationship between EMS and bile duct carcinoma, indicating that EMS treatment for benign bile duct stricture should be undertaken only after extremely careful consideration.

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We report a rare case with double cystic duct of gallbladder in a 48-year-old man. The patient complained of vomiting and right hypochondrial pain. On admission, ultrasonography revealed wall thickness and several stones in the gallbladder. Preoperative endoscopic retrograde cholangiopancreatography showed 2 cystic ducts, 1 branching from the common bile duct and the other from the right hepatic duct. At laparotomy, the gallbladder and Calot's triangle were surrounded by thick multiple adhesions. With sharp and blunt dissection, the cystic duct branching from the common bile duct was first discovered. Subsequently, we discovered that there was another duct branching from the hepatic hilum. We performed intraoperative cholangiography by inserting the tube from the gallbladder neck, and were able to detect the double cystic duct and CBD stones. Following this procedure, we performed a cholecystectomy, choledocholithotomy and T-tube drainage. It was classified as an E type under Hisatsugu's classification. A double cystic ductis extremely rare. A search of the English literature showed only 12 previous reports. This case demonstrates the importance of being aware of the possibility of potential biliary variations to avoid biliary ductal injuries during surgery. We were able to perform open cholecystectomy safety. This case suggests that preoperative endoscopic retro-grade cholangiopancreatography and intraoperative cholangiography are required to avoid complications during open cholecystectomy.

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A 64-year-old woman with a history of diabetes and worsening weight loss was diagnosed with locally advanced pancreatic cancer based on radiological examinationincluding computed tomography (CT) and angiography. At surgery, we found that the common hepatic artery and portal vein had been invaded by a pancreatic-head tumor. She underwent a course of chemoradiotharapy with a total of 40 Gy directed to the tumor and continuous systemic infusion of 5-FU after palliative surgery. Intravenous administration of gemcitabine was instituted after chemoradiotherapy, and the tumor dramatically shrank, relieving major vessel stenosis. Serum CA19-9 also decreased. Pancreatoduodenectomy was successful, with no residual tumor and a high probability of cure 9 months after initial surgery, and the woman hasshown no sign of recurrence in 19 months. In conclusion, chemoradiotherapy with 5-FU followed by systemic administaration of gemcitabine is effective in down-staging for unresectable pancreatic cancer.

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Transomental hernia often develops into strangulated ileus, but is difficult to diagnose preoperatively due to a lack of specific symptoms. We report a patient with strangulated ileus due to transomental hernia, diagnosed via laparoscopy. A26-year-old man admitted for epigastralgia was referred the next day to the department of surgery because of progressive abdominal pain and muscle defense. Abdominal CT showed dislocation of the small intestine into the omental bursa. We diagnosed strangulated ileus due to an internal hernia and conducted emergency surgery. When the laparoscopic view showed a necrotic intestine, we immediately conducted a laparotomy. The ileum had herniated through an abnormal omental hiatus to the omental bursa and was strangulated by minor omental hiatus. About 60 cm of the ileum was resected and the hiatus was closed by direct suture. In this case, laparotomy was followed by a diagnosis of necrotic intestine, suggesting the utility of laparoscopy in diagnosis or repositioning when internal hernia is suspected.

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A 25-year-old woman with typical itch-free red papulae from August 1999 was diagnosed with Degos dis-ease.She took oral aspirin from then on, but reported abdominal discomfort in April 2001.We undertook lapa-rotomy based on suspected diffuse peritonitis due to gastrointestinal perforation.Serobloody, purulent mas-sive ascites had accumulated in the peritoneal cavity, and inflammation was observed along the entire small intestine.Despite marked dilation, no macroscopic perforation was seen in the small intestine.We conducted construction of a loop ileostomy for intestinal decompression, but she died of sepsis on postoperative day 91. Multiple inflammatory lesions were observed in the small intestine at autopsy, but no perforation was appar-ent macroscopically.

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Adult intussusception in the large intestine is often headed by a malignant lesion, but the intussusception prolapsing through the anus with sigmoid cancer is rare, only 27 cases have been reported in Japan. In this paper, we present 2 cases of this desease. Case 1 was a 90-year-old woman with dyschezia and lower abdominal pain. The prolapsed colon with a tumor located at the apex through the anuswas seen during defecation. Preoperative examinations including colonoscopy and a gastrografin enema study were done. Case 2 was an 84-year-old woman with lowerabdominal pain and a prolapsed colon through the anus. Pre-operative examinations including pelvic computed tomography (CT) were done. In both cases, sigmoidectomy with lymph node dissection (D2) was performed after manual reduction of the intussusception. It is controvertial wheather preoperative manual reduction of the intussusception should be performed or not. But in our cases, preoperative manual reduction of the intussusception seemed to be plactical. On the other hand, it should be considered to select less invasive transanal colorectomy for an oldperson with some complication.

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We report a case of duodenal injury with pancreatic and superior mesenteric venous injury following blunt trauma treated surgically by temporal pyloric occlusion. A 40-year-old man struck on the abdomen in a traffic accident was found in post computed tomography (CT) to have extravasation from the superior mesenteric vein (SMV) and intraabdominal hemorrhage. Laparotomy showed massive hemorrhage and injuries to the SMV, third portion of duodenum, pancreas head and colon were found. SMV hemostasis was conducted, then coagulopathy was revealed, therefore rapid closure of abdominal wall was immediately performed by gauze packing for theprevention of contamination. After the coagulopathy was improved at ICU, and a second laparotomy was done. The hemorrhage was almost controlled with gauze packing. The injured duodenum was treated by temporal pyloric occlusion without gastrojejunostomy. The pylorus was reopened with gastroendoscopy on postoperative day (POD) 17. The patient was discharged on POD 42 with an uneventful recovery. We found temporal pyloric occlusion is effective in treating severe duodenal injury.

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