Purpose: The smaller degree of invasiveness and the radicality of laparotomic microwave coagulation ther-apy (LMCT) for hepatocellular carcinoma (HCC) were statistically evaluated compared with hepatectomy. Methods: Subjects were 72 patients with HCC undergoing LMCT or hepatectomy from 1997 to 1999. They were divided into patients receiving LMCT (M group, n=35) and patients receiving hepatectomy (R group, n=37). The background of the patients and tumors, staging, functional hepatic reserve, general liver functions, the factors of surgical stress, the time course of liver function, inflammatory markers before and after surgery, operative results, the survival rate, and the prognostic factors were evaluated statistically between the groups. Results: The diameter of tumor was greater and the rate of association with cirrhosis was significantly lower in the R group than in the M group. The levels of ICG R15, GSA LHL15, Alb, PT and T-Bil were significantly worth in the M group than in the R group. Operative bleeding in the factors of surgical stress were significantly lower in the M group than in the R group. The time course before and 2 weeks after surgery of the levels of AST and ALT was higher and the levels of CRP and IL-6 were significantly lower in the M group than in the R group. The inclinable correlation between the level of IL-6 on the first operative day and bloodloss during surgery, the level of IL-6 on the first operative day and relative hepatic resected volume, operative time and relative hepatic resected volume were significantly correlated. The operative results and the changes of the levels of AFP between the groups showed no significant difference. The rate of survival between the groups showed no significant difference. Conclusion: LMCT for the HCC patients with impaired liver function decreased the operative bleeding and surgical stress significantly without any sacrifices in the complication rate, local control of the tumor, or the survival rate. LMCT should be considered as a safe, less invasive, and more reliable local treatment for these patients, if the patient can not be received hepatic resection.

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Introduction: We evaluated the significance of surveillance for recurrence after operation with curative sur-gery intent in colorectal cancer patients. Patients and methods: Subjects were 126 patients with colorectal cancer who underwent curative resection from 1986 to 2001 at the Kanagawa Cancer Center recurred and suffered in a single organ. We divided them into 2 groups: group I (n=60) whose recurrence was detected by intensive follow-up by using CT every 4 months, and group C (n=66) whose recurrence detected by con-ventional follow-up CT once a year, we compared median survival time (MST), disease-free survival inter-val (DFI) and survival time after recurrence (SAR) retrospectively. Results: DFI was 690±63 days in group C, compared to 467±40 days in group I. SAR was 767±211 days in group C, compared to 943±89 days in group I. In lung recurrence (n=36), SAR was 925±333 days in group C, compared to 1, 296±461 days in group I. Elevation of tumor markers at recurrence was observed in 41 of 47 cases (89%) in liver recurrence. Symptoms at recurrence were observed in 12 of 14 cases (83%) in local recurrence. Conclusion: Intensive fol-low-up by using CT does not improve SAR, but in lung recurrence which is difficult to detect by tumor mark-ers or examination could improves SAR.

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A 49-year-old man who had a history of acute intermittent porphyria was diagnosed with thoracic esophageal cancer. Without the use of contraindicated drugs, and providing adequate infusion and glucose, we conducted esophagectomy with lymph node dissection. No porphyrial attack occurred and postoperative porphyrial metabolic products were not elevated. Only 7 acute intermittent porphyria patients have been operated in Japan according to our review of the literature. This is to our knowledge the first case of invasive surgery such as esophagectomy with acute intermittent porphyria. Our case shows that invasive surgery is safe in acute intermittent porphyria patients with adequate management.

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Cases of spontaneous rupture of the esophagus are relatively rare and those of esophageal cancer associated metachronously with spontaneous rupture of the esophagus extremely rare. We report a case of advanced esophageal cancer occurring at the site of an esophageal rupture 20 years postoperatively. A 60-year-old man diagnosed with spontaneous rupture of the esophagus and operated on 20 years earlier had an approximately 4cm vertical perforation in the left wall of the lower esophagus. The ruptured esophageal wall was directly closed layer to layer, but anastomotic leakage kept the patient hospitalized for 2 months. Twenty years after surgery, he was diagnosed with esophageal cancer fistulized to the left bronchus (B¹⁰), necessitating transthoracic esophagectomy by right thoracotomy and resection of the esophagobronchial fistula. The resected specimen was diagnosed histologically as well-differentiated squamous cell carcinoma but without cancer cells in regional lymph nodes or the fistula. Chronic continuous inflammation of the rupture site with leakage apparently induced malignant change in the esophageal mucosa. Spontaneous rupture of the esophagus must thus be considered a risk factor in esophageal cancer, necessitating long, meticulous postoperative follow-up after surgery for spontaneous rupture of the esophagus.

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A 52-year-old man had café au lait spots covering his body from infancy. His brother had undergone gastrectomy for gastric carcinoma and had von Recklinghausen's disease. In July 1992, gastroscopy showed an submucosal tumor near the duodenal papilla. In March 1998, SMT was redetected. He was examined further by abdominal computed tomography, abdominal ultrasonography, endoscopic retrograde cholangiopancreaticography, and angiography, but we could not determine whether SMT was malignant. Five years later, when he developed abdominal examination yieled a diagnosis of carcinoid tumor for SMT. We conducted pylorus-preserving pancreatoduodenectomy on December 11, 2003. The 25×25×23mm resected tumor was located near the papilla in the second part of the duodenum. He had lymph node metastases and the tumor showed mitotic figures with vascular invasion on microscopic examination, which suggested high-grade malignancy.

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We report a very rare case of carcinoma of the ampulla of Vater complicated by von Recklinghausen.s disease with hypoplasia of the pancreatic body and tail and an anomaly of the portal vein running on the ventral side of the common bile duct. Ours is the fourteenth case of carcinoma of the ampulla of Vater complicated by von Recklinghausen.s disease reported in Japan. No report has, to our knowledge, been made on cases of von Reck-linghausen.s disease complicated by hypoplasia of the pancreatic body and tail or an anomaly of anatomical vessels. The 57-year-old woman underwent pylorus-preserving pancreatoduodenectomty with D3 lymph node dissection for carcinoma of the papilla of Vater. The resected specimen showed a 3.0×8.0cm tumor. The pathological diagnosis of the resected specimen was moderately differentiated adenocarcinoma, stage III. To ensure better postoperative quality of life (QOL), we avoided total pancretectomy. Unexpectedly, part of the pancreas became ischemic, causing intractable leakage of pancreatic juice. The patient died of recurrence two years after surgery. Total pancreatectomy focusing on radical resection of advanced carcinoma of the ampulla of Vater accompanied by hypoplasia of the pancreatic body and tail would have prevented the postoperative leakage of pancreatic juice.

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A 62-year-old woman hospitalized for fever and systemic malaise and referred for a pancreatic tumorous le-sion detected by computed tomography (CT) and abdominal ultrasonography (US) was found in preoperative laboratory data to have leukocytosis (15, 700/mm³) and high serum CA19-9 (1, 342U/ml). CT showed an un-evenly enhanced mass in the pancreatic tail that invaded to the spleen. US showed a heterogenous hypoechoic mass in the pancreatic tail. Following distal pancreatectomy, pathological examination showed anaplastic duc-tal carcinoma, and immunohistochemical study showed positive staining for G-CSF in the tumor cell, leading to a diagnosis of G-CSF-producing tumor. After the surgery, the leukocyte count continued to increase and the patient died on postoperative day 38 due to cancer cachexia and disseminated intravascular coagulation. G-CSF-producing pancreatic cancer is very rare, with 8 cases, including ours, having been reported.

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We report a case of superior mesenteric vein (SMV) and portal vein (PV) thrombosis. A 47-year-old man re-ferred for upper abdominal pain suspected of being strangulation ileus underwent emergency laparotomy. In-traoperating findings showed congestive necrosis of the jejunum approximately 100 cm long located 10 cm from the Treitz ligament and due to thrombosis of the SMV and PV. Following bowel resection with primary anastomosis, SMV and PV thrombectomy was done using a Fogarty catheter. Urokinase and heparin were ad-ministered immediately postoperatively into the PV. Despite perioperative shock status, the man's condition gradually improved postoperatively. The right portal vein was recanalized from collateral vessels around the hepatoduodenal ligament. In this case, adding to bowel resection, thrombectomy and postoperative direct thrombolysis and anticoagulant therapy to the PV is thought to have been effective.

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Upper and lower gastrointestinal tract endoscopy failed to find the bleeding sit e in a 57-year-old man with he-matochezia. Abdominal angiography and CT during arteriography to assess suspected small intestinal bleeding showed intra intestinal tumor staining from the periphery of the first jejunal artery. This was diagnosed preoperatively as an intestinal tumor and laparotomy was conducted placing a micro catheter in the artery that supplied the tumor for angiography. The serous membrane at the tumor growth was identified by infusion of dyes through the catheter. Histopathological examination showed low-grade malignant gastrointestinal stromal tumor (GIST). This is, to our knowledge, the first and only case in Japan of GIST manifested with melena and intra intestinal development. This case also indicates that intraoperative infusion of dyes through a catheter during angiography is helpful in determining the anatomic region of the tumor and contributes to prompt diagnosis and treatment, even in an emergency.

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We report a case in which a 46-year-old man with gastrinoma underwent emergency surgery for jejunal ulcer and perforation. Surgery had been conducted for duodenal ulcer and perforation 8 years earlier and for a parathyroid tumor 7 years earlier. The patient was taking oral drugs for duodenal ulcer and underwent emergency surgery for gastrointestinal perforation on June 4, 2003, after the perforation was found in a lesion of the jejunal ulcer. After symptoms were relieved, the patient was diagnosed with gastrinoma, based on the results of a secretin test, abdominal angiography, a selective arterial secretin injection (SASI) test, and serum gastrin (6, 514pg/ml). On August 19, 2003, he underwent pancreatoduodenectomy. Based on the result of a postoperative histological test, the patient was diagnosed with malignant gastrinoma. This case provides a relatively rare example of primary jejunal ulcer and perforation caused by gastrinoma. We re-recognized that it is necessary for patients who are resistant to the anti-ulcer drugs to measure serum gastrin.

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A 34-year-old man seen for recurrent abdominal pain. He was found in colonoscopy and barium enema to have a 6 cm tumor of the ascending colon. Pathological diagnosis was not possible because the biopsy specimen was rather necrotic. Abdominal computed tomography (CT) showed a tumor of the terminal ileum causing intus-susception of the ascending colon. After right hemicolectomy, immunohistological labeling showed the tumor to be extramedullary plasmacytoma of the ileum. The man remains well without evidence of recurrence in the 7 months since surgery. Extramedullary plasmacytoma of the ileum is rare, with only 9 cases, including ours, reported in Japan. Extramedullary plasmacytoma is radio- and chemo-sensitive. Ten-year survival is 61-67%. At present, therapy involves complete tumor resection, radiotherapy added in incomplete resection. Chemoradiotherapy should be used in unresectable or recurrent cases.

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A 59-year-old man with a history of systemic malignant lymphoma was undergoing a second cycle of CHOP therapy for malignant lymphoma. He reported increasing abdominal pain 1 day before consultation. Plain abdominal CT before consultation showed a pin-point lucency in the hepatic margin and we suspected hepatic portal venous gas (HPVG). Because no other intraabdominal lesion was found in plain CT, CT with contrast enhancement was done, showing dendritic HPVG in the hepatic margin and thickening of the dilated ileal wall. Under a diagnosis of ilealnecrosis with HPVG, we conducted surgery resecting a necrotic ileum between 120 and 220cm from Treizs' ligament. The post operative course was uneventful, and CT on day 7 showed disappearance of the HPVG. The prognosis of HPVG due to intestinal necrosis is poor. In this case, we detected early HPVG which helped make a quick decision to emergency surgery and an uneventful recovery.

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A 64-year-old man admitted for abdominal pain had ileus symptoms due to intestinal obstruction and was found in colonoscopy to have an upheaval tumor with rand wall in the terminal ileum. Histological biopsy of the tumor showed adenocarcinoma. Abdominal CT showed a round 80×60mm tumor with a clear border in the right hepatic lobe together with several swollen lymph nodes around the aorta, which we diagnosed as primary cancer of the ileum and liver and lymph nodes metastasis, necessitating ileocecal resection and right hepatic lobectomy. Pathologically, the tumor consisted of moderately differentiated adenocarinoma invading the serosa. The solitary hepatic tumor consisted of metastatic adenocarcinoma. Lymph nodes around the aorta were reduced after chemotherapy. Subsequent bilateral lung metastasis disappeared after another cycle of chemotherapy, as did spine metastasis after radiation. The man is doing well two years and six months after surgery. Carcinoma of the small intestine usually has a poor prognosis. Multisciplinary treatment with surgery may improve prognosis, so we recommend proactive treatment.

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Splenic metastasis of malignant tumors is relatively rare, and metastasis of colon carcinoma is extremely rarely. We report a case of transverse colon carcinoma with concurrent solitary metastasis to the spleen. A 58-year-old woman found to have fecal occult blood was further found in colonoscopy to have a type2 lesion at the left transverse colon leading to a diagnosis of adenocarcinoma based on a biopsy. Abdominal CT showed a low-density 35×32mm tumor in the spleen. Ultrasonography showed a similar solitary high-echoic area, the subsequent solitary metastasis of the spleen was treated by simultaneous colectomy and splenectomy. Histopathological diagnosis confirmed intrasplenic metastasis from transverse colon carcinoma. The postoperative progress was favorable and she has no sign of recurrence at present, 14 months after surgery. There are reports of good prognosis following resection of solitary splenic metastasis, so we recommended radical surgery for patients who have colorectal carcinoma with solitary splenic metastasis.

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A 76-year-old woman admitted for appetite loss and a fever. A catheter was inserted via the left femoral vein. Abdominal CT showed an abscess in the right hepatic lobe. Percutaneous drainage of the liver abscess was done and contrast material via a drainage tube showed a radiolucent mass in the common bile duct, necessi-tating duodenal sphincterectomy by endoscopy. After this, the patient suffered abdominal ileus. Colonoscopy showed a type 2 tumor in the sigmoid colon. As the left limb swelled, becoming discolored and painful, the catheter was removed. And CT detected deep venous thrombosis in the bilateral femoral vein. Before sur-gery, we implanted a vena cava filter to prevent pulmonary embolism. Hartmann's procedure was done 85 days after admission. The patient's recovery was uneventful. Implantation of a vena cava filter for preventing pulmonary embolism, especially in a patient who had colorectal cancer complicated by deep venous thrombo-sis, thus appears beneficial. We review the Japanese cases of vena cava filter for colon cancer.

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A 64-year-old man undergoing Miles'operation for rectal cancer with multiple liver metastasis (a2, ly2, v3, n1, H3, P0, M0) in August 2001 underwent postoperative hepatic artery infusion (HAI) at 5 FU (1, 500mg/body/5 hr) weekly as an outpatient. HAI was done 46 times, with total 5 FU administered of 64g. Metastatic tumors at S3, S4 and S6 disappeared but those at S5, 8 remained. The left hepatic artery narrowed and he hoped for hepatectomy. Neither distant metastasis nor local recurrence was detected, so he enderwent hepatectomy in July 2003. He continues to undergo HAI of 5 FU once a month as an outpatient. Hepatic resection after HAI chemotherapy is thus effective as a strategy in treating multiple liver metastasis from rectal cancer.

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