Between 1978 and 1995, 67 patients of pancreas cancer underwent resection (respectability 50%). There were 42 males and 25 females. The mean age was 60±11. Of 67, 46 had combined resection of the portal vein. Which among T, N and M factors is indicative of resection was analyzed. Smaller tumors were seen in patients without resection of the portal vein while the rates of lymphnode metastasis were same in both groups. The patients with portal vein resection lived averagely for 17±4months notwithstanding the tumor size, which was grouped at 4 cm in a diameter. However, in the cases with combined resection of the portal vein, the patients with negative lymphnodes could survive significantly longer, for 34±8 months postoperatively, than with positive lymphnodes, for 10±1 months. It was suggested that the tumor size be not indicative of portal vein resection but lymphnode metastasis be indicative.

We reviewed our experience of surgical treatment for hepatobiliary and pancreatic carcinomas with reconstruction of portal vein (PV) in the period of the last 21 years. and evaluated the indications and the problem. From April, 1980 to May, 2000, 48 of 425 patients underwent PV reconstruction. Resection of PV tumor-thrombi and PV reconstruction were performed in 7 of 295 hepatectomies for hepatocellular carcinoma (HCC). Transcatheter arterial embolizadon (TAE) or re-resection for HCC in the remnant liver was added in 3 of the 7 patients. PV reconstruction included cholangiocellular carcinoma (CCC) in 8 of 28 cases (29%), biliary tract carcinoma in 16 of 68 cases (24%), and pancreatic carcinoma in 17 of 34 cases (50%). There were no significant differences in cumulative survival rates between the patients with and without PV reconstruction in resection of biliary tract and pancreatic carcinomas. Early PV stenosis occurred because of intra-abdominal infection in 3 of 48 cases, but there were no severe complications in them.

PV tumor thrombectomy and PV reconstruction were useful in patients with advanced HCC, and led to treat of HCC in the remnant liver and improve the prognosis. In the biliary tract and pancreatic carciomas, PV reconstruction is expected to increase the resection rates and curability and improve significantly prognosis of pv_0~1 patients.

In the last 12 years, 12 patients underwent caval reconstruction in our hospital. Reconstruction of superior vena cava (SVC), which included 4 SVC resection and brachiocephalic-right atrial appendage bypass, 1 SVC prosthetic replacement, 2 SVC partial resection, and 1 PALMAZ stent insertion, were performed for 3 mediastinal tumor, 3 lung cancer, 1 lymph node metastasis of esophagial cancer, and 1 lymph node metastasis of unknown origin. Reconstruction of inferior vena cava (IVC), which included 3 IVC prosthetic graft replacement and l endvenectomy with patch plasty, were performed for 2 renal cancer, 1 retroperitoneal tumor, and 1 Budd-Chiari syndrome There were 4 perioperative death and 3 late death of cancer. Five patients are alive 1 to 9 years postoperatively. SVC syndrome in 3 patients disappeared and the patient of Budd-Chiari syndrome got normalized liver function. Caval reconstruction allows complete resection of tumor and improvement of QOL, while indications should be carefully decided considering effects of the procedure and prognosis the primary disease.

(Objective) We report that we have experienced the latest treatment of leg telangiectasias using a long-pulse dye laser for the first time in Japan.

(Material and Methods) We studied 30 sites of leg telangiectasias (thigh: n=15, lower leg: n=11, foot: n=4) in 21 female volunteers. The maximum diameter of vessels was limited to slightly over 1 mm in red and blue telangiectasias. In most cases the set-up of long-pulse dye laser was wavelengths of 595 nm and fluences of 15J/cm³ (with a fixed pulse duration at 1.5 ms). Patients were comparatively studied at the average of 2.8 month interval after the laser treatment, using photography.

(Results) Excepting the sites of foot (n=4), ≧50% clearance was noted in 14/26 (54%) . While the ≧50% clearance of developed red telangiectasias was shown in 83% (10/12), that of complicated blue telangiectasias and reticular veins was seen in 38% (3/8) and 17% (1/6), respectively. As the side effects of laser treatment, hyperpigmentation (70%) and hypopigmentation (3%) were observed. Finally, we evaluated the treatment as effective (7%), fairly effective (33%), unchanged (40%) and worse (20%).

(Conclusion) These results suggest that the laser therapy may explore new treatment methods for leg telangiectasias in addition to the “gold standard” sclerotherapy.

Results of one thousand and three hundred ninety-one limbs in 968 patients of primary varicose veins. who had previously undergone high saphenous ligation and sclerotherapy, were studied. The strategy of our therapies is the investigation of minimary invasive technique of the preoperative examination and operative procedure. Our standard management of primary varicose veins of a combination of high saphenous ligation and sclerotherapy. Ascending venography was carried out in all patients in the first period (April 1991 to January 1996) and only physical examination and Hand-held Doppler ultrasonographic studies were carried out in all patients in the second period (February 1996 to September 1999). The purpose of this study was to assess the recurrence rate compared with the first period and the second period. The recurrence of varicose veins, defined as varicose veins requiring further treatment during 3 months after the initial treatment, occurred in 90 limbs (6.5%), and in details, 48 limbs (5.4%) in the first period and 42 limbs (8.2%) in the second period. The incompetent perforating veins were a common cause of recurrent varicose veins and recurrence rate was higher in the second period than in the first one. However, the recurrence rate is not so higher than that of previously reported, thus, these minimary invasive technique is the effective diagnostic measures for patients with primary varicose veins.

It has long been noted that incompetent perforating veins contribute to the development of chronic venous insufficiency and recurrent varicose veins that are complicated by skin ulcerations or liposcleroderma. For these conditions, severing of incompetent perforating veins is an effective surgical treatment. However, severing of incompetent perforating veins by a direct approach has become less commonly performed because of the excessive invasiveness of the procedure itself. We referred to 37 cases (44 legs) of varicose veins with or without active venous dermatitis, who underwent the two ports system endoscopic subfascial severing of incompetent perforating veins procedure we devised (hereafter referred to as TPS-ESSP). According to this method, incompetent perforating veins can be severed without surgical intervention in the lesion. One hundred forty one out of one hundred fifty two IPV s were processed.

The TPS-ESSP is relatively simple operation, but its skill is dependable and provides lower invasiveness. It is distinctive that the TPS-ESSP is advantageous for the cases with venous dermatitis. From now on, it is necessary to unify the authorized name of the endoscopic surgery of varicose veins and is also important to define the indication of this method for the primary varicose veins without stasisdermatitis. All of these problems, it is urgent that the operative method of TPS-ESSP will be certified by Japanese health insurance.

It is well known that the skin temperature of the lower limbs in patients with varicose veins is higher than that of normal limbs. This temperature increase is considered to be due to incompetent perforating veins and/or precapillary arterio-venous shunts. Several workers have shown that the temperature of venous blood in deep veins is higher than that in superficial veins. However, there are few reports on the difference of skin temperatures of the lower limbs in patients with varicose veins in the standing, supine or prone positions. The purpose of this study is to reveal these differences.

The subjects were 65 patients with unilateral or bilateral varicose veins associated with long saphenous vein incompetence detected by Doppler imaging. They consisted of 20 men and 45 women and their ages ranged from 35 to 81 years old, with a mean of 55.9 years old. Altogether, 92 affected limbs (16 right, 22 left and 27 bilateral) and 38 normal limbs were investigated The skin temperature of the healthy legs of patients were used for control. Skin temperatures were measured by thermography (NEC San-ei, TH3106ME). Patients were kept in a supine or prone position so that the most prominent varicossities were on the upper side in a quiet room at temperature of 23-25℃ for approximately 5 minutes. After these procedures patients were kept in a standing position for approximately 5 minutes and thermography was performed again. The histograms of the skin temperature of the lower limbs and the maximum temperature was calculated automatically. In the standing position the mean maximum skin temperatures (MMT) of the affected and normal limbs were 34.82±0.97℃ (n=91) and 33.92±1.05℃ (n=34), respectively. The former was statistically higher than the latter (p<0.001). In the lateral position MMT of the affected and normal limbs were 34.74±0.79℃ (n=48) and 33.96±0.79℃ (n=20), respectively. The former was statistically higher than the latter (p=0.004). MMT of normal limbs (n=20) showed no difference between the standing and lateral positions. MMT of the affected limbs (n=47) in the standing position was 0.12℃ higher than that in the lateral position, but there was no statistically significant difference. In both patients with (n=8) and without (n=39) congestive dermatitis, MMT in the standing position were 0.54℃ and 0.02℃, both higher than those in the lateral position but their differences were not statistically significant.

In this study there were not significant differences of the skin temperature of the leg between the standing and the supine or prone positions, but there was a tendency for the skin temperature to increase in the standing position, especially in patients with congestive dermatitis. These findings suggest the possibility that not only incompetent perforating veins and/or precapillary AV shunts but also saphenous vein incompetence plays a role in the increase of skin temperature of the legs of patients with varicose veins.

We evaluated 51 lower extremities (5.4%) of 38 elderly patients over the age of 75 from a population of 670 patients (937 lower extremities) treated by an outpatient-based lower extremity varicose vein stripping procedure performed between September 1997 and July 2000. The mean age of the elderly patients evaluated was 78.4±2.8 years (mean±SD) (range: 75-85 yrs.), and the male/female ratio was 13: 25. The procedure was performed on the greater saphenous vein (GSV) in 41 legs and the lesser saphenous vein (LSV) in 10 legs. The procedural indications used for the elderly patients are both a diagnostic stage of American Society of Anesthesiologists class II or lower and the ability to walk unassisted. Thirty-two patients (84%) had complications of hypertension, ischemic heart disease, and/or a history of cancer. This outpatient-based stripping procedure selectively removes the reflux parts using concomitant administration of two local anesthetic agents and intravenous propofol. followed by complete high-position ligation. The average operation times were 43.7±10.2 minutes for GSV and 32.5±12.2 minutes for LSV. Though this is a day care surgery in principle, 14 patients (37%) were admitted for 3.8 days on the average for the reason such as their requests and so on. The only postoperative complications encountered were saphenous nerve injury and abnormal hypertension due to over-tonus in one patient, and there were no observable bleeding, wound infection, or anesthesia complications whatsoever. Further, none of the patients presented delirium, a symptom characteristically seen in the elderly. In the postoperative course. complete elimination of all symptoms was achieved in 32 legs (63%). remission was achieved in 15 legs (29%). and the condition remained unchanged in only 4 legs (7.8%), resulting in a very high degree of patient’s satisfaction.

We have treated 5 patients with inferior vena caval obstruction caused by invasion of malignant tumor over past 17years. They comprised 1 man and 4 women aged from 55 to 75 years (mean: 68 years). The causes of obstruction were spread of renal cell carcinoma to the inferior vena cava (IVC) in 4 patients and metastasis of breast cancer to the IVC in 1 patient. Obstruction was between the renal vein inflow and hepatic vein inflow in 3 patients, at the site of hepatic vein inflow in I patient. between the renal vein inflow and the right atrium in 1 patient. The operations were nephrectomy combined with tumor thrombectomy in 4 patients and IVC-right atrial bypass in 1 patient.

There were no postoperative complications and all the patients were discharged from hospital. However, the graft became occluded or the IVC became obstructed again from 1 month to 3 months postoperatively in 2 of 5 patients. Three of 5 patients died of cancer at 6~13 months postoperatively, while the others 2 patients have survived for 3 year and 5 months to 4 year and 3 months, respectively.

Obstruction of the IVC by malignancy should be treated surgically if there is no distant or lymphnode metastasis.

The purposes of this study were to visualize venous valve in proximal femoral vein and to assess valve function by high-resolution US. Ten extremities from 10 healthy volunteers and 9 from 5 patients with history of deep venous thrombosis and 6 from 3 patients with varicose vein were examined by US (HDI 3000 or 5000, ATL/Hitachi). All examinations were performed during normal breathing and an intentional cough was added for increasing peritoneal pressure. Following parameters were evaluated: visualization of the valve, shape of the valve, venous flow and valve movement during normal breathing, and changes of the venous flow and the cross-sectional area of the vein just peripheral to the valve when peritoneal pressure increased. Except 2 cases, in which the veins were occupied with old thrombi, all veins were satisfactorily visualized and valve function was easily assessed. In volunteer group, all valves had a complete shape, while in patient group, disappearance or shortening of the valves were consistently observed except 1 case (p<0.01). During normal breathing, the valve tended to open and close in the beginning of expiration and inspiration respectively in volunteer group. While such valve movements were not observed in patient group. When peritoneal pressure increased, no adverse-flow in the femoral vein was observed in volunteer group, while it was always observed in patient group (p<0.01). Increasing of the cross-sectional area of the vein of more than 10% was observed in l of 10 cases in volunteer group, 3 of 6 cases in patients with venous thrombosis (p=0.2), and 4 of 4 cases in patients with varicose vein (p=0.01). Visualization and analysis of venous valves in the femoral vein were satisfactorily achieved by US. Valve dysfunction may be strongly associated with venous diseases

A 72-year old women underwent total laryngectomy and left radical neck dissection combined with left internal jugular vein (IJV) resection for laryngeal cancer in November 1997. In May 1999, she was readmitted to our hospital because of right cervical lymph node recurrence which probably invaded the right IJV. Tumor invasion to the right IJV was confirmed during resection of recurrent cancer performed on June 14. After systemic heparinization, an internal venous shunt was temporarily made. The right IJV was then venous shunt was temporarily made. The right IJV was then reconstructed using a spiral graft of the great saphenous vein. Cervical ultrasonography confirmed patency of the graft 3 months after surgery. A spiral graft of the great saphenous vein is useful for reconstruction of the IJV after resection for malignancies in the neck.

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA). We report a patient with the aid of left femoral vein flow pattern analysis by Doppler sonography. A 73-year old man was transferred from another hospital with history of lower back pain, marked left lower edema, and dyspnea. Therefore, diuretics and catecholamine were given under a provisional diagnosis of primary heart failure. Pulmonary artery flow directed catheter study demonstrated a cardiac output of 11. 5l/min.. We thought that he had a state of high cardiac output failure. The ultrasonography performed for diagnosing a deep vein thrombosis of left femoral vein. A ultrasonography revealed a dilatation of left femoral vein, but thrombus did not present. A pulse Doppler detected arterial blood flow signal during early systolic phase, confirming the suspicion of an arterio venous fistula in abdominal cavity near this location. A computered tomographic (CT) scan revealed a infrarenal AAA. 4.7x5.7 cm in diameter and bilateral common iliac aneurysms. A compressed inferior vena cava rightward by the AAA and a compressed left iliac vein by the left common iliac aneurysm was also confirmed by the CT scan. Digital subtraction angiography revealed an ACF caused by rupture of an AAA. An operation was performed. The fistula was closed and abdominal aorta was replaced with Y-graft. Doppler velocity signal analysis was helpful in confirming the venous disease, too.

A 71 year-old man transferred to our hospital because of acute respiratory dysfunction, hypotension and cyanosis. Several days before admission, he had suffered from frequent diarrhea. On admission, atrial fibrillation and hypoxia were noted and he was unconscious. He was immediately incubated and ventilated by a respiratory machine. And then he received transfusion therapy. Soon his general condition became stable, and we clinically considered that he had acute pulmonary thrombo embolism (PTE). Anticoagulant therapy was started but no thrombolytic therapy. He received an infusion of the Macroaggregates of ^99mTC Albumin (^99mTC-MAA) for a diagnosis of PTE. The lung scinti scan revealed no pulmonary blood flow in his left lung. To confirm thromboembolism, we scheduled a pulmonary arteriography for the next day. The pulmonary arteriogram showed that the left pulmonary artery was occluded only in A8 and A9. We expected improvement in the left pulmonary blood flow, but the second (on the 6th day after the first scinti scan) lung scinti scan revealed only slight recovery of the pulmonary blood flow. We wondered if the lung scinti scan by ^99mTC-MAA could detect the pulmonary vascular lesions. In this paper, we considered that the different results of two examinations depended on the difference between the mechanisms of the two examinations.

Catheter-directed thrombolysis is a new attractive therapeutic option for acute deep vein thrombosis. The recent literatures on catheter-directed thrombolysis for deep vein thrombosis (especially obstructive type) indicate that the procedure is a safer and more effective method for restoring the patency of the venous system and for relieving acute symptoms than systemic thrombolytic therapy by which it is difficult to penetrate the thrombus.

We review the indication, technique and procedure of catheter directed thrombolysis, thrombolytic agent and dose. short-term efficacy of catheter-directed thrombolysis and the incidence of acute complications associated with the procedure.