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A 55-year-old woman underwent a laparotomy with a preoperative diagnosis of cholelithiasis. During operation, a mass occupying the cystic duct was found and intraoperative frozen section diagnosis was made with primary carcinoma of the cystic duct. Primary cystic duct carcinoma is rare. We found 15 cases of the disease in the Japanese literature, of which only four cases were diagnosed preoperatively. Of the methods currently used for diagnosis of this disease, endoscopic ultrasonography may be the most useful when the cystic duct is obstructed.

Cytokines and acute phase-proteins are important in infectious diseases and under surgical stress, especially in postoperative infections. To study the effects of antibiotics on changes in cytokines and acute-phase proteins after surgery, we measured serum levels of interleukin 6 (IL-6), elastase from granulocytes, pancreatic secretory trypsin inhibitor (PSTI), C-reactive protein (CRP), and fibrinogen after liver resection in 12 patients with hepatocellular carcinoma. In the six of the 12 patients (group A), flomoxef (FMOX, 4 g/day) was administered intravenously for 3 days after surgery. In six other patients (group B), imipenem-cilastatin (IPM/CS, 1g/day) was administered for the same period. Group A was comparable to group B in age distribution of patients, preoperative hepatic function, operating time, and intraoperative bleeding volume. No patients had postoperative complications. The mean changes in serum levels of IL-6 in group B were smaller than those in group A. The changes in serum levels of elastase, PSTI, CRP, and fibrinogen were also smaller than those in group A. These results suggest that IPM/CS suppressed the usual increases after major surgery in the levels of IL-6 and acute-phase proteins. This preparation may suppress the progress of hypercytokinemia in the systemic inflammatory response. The effects of antibiotics on cytokines and acute-phase proteins should be considered in the choice of antibiotics for severe infectious diseases.

A 44-year-old woman with known progressive systemic sclerosis was seen at the hospital because of anal discomfort and bloody stool. Digital examination revealed a grayish polypoid lesion in the posterior wall of the anal canal. With a preoperative diagnosis of internal hemorrhoid or anal polyp, the lesion was extirpated. Histopathologically the extripated tumor was malignant melanoma. So rectal amputation with lymph node dissection through abdomino-sacral approach was carried out. About one month later a metastasis to the inguinal lymph node developed. Malignant melanoma has a poor prognosis, because of delayed diagnosis, the high vascularity of the anal region, and high biological malignancy such as vascular and lymphatic spread. Though there was no statistical difference in the prognosis between local resection and rectal amputation, a few patients undergoing rectal amputation could live for more than 5 years. Rectal amputation of the abdomino-sacral method with lymph node dissection is recommended. The disease presents difficulty in diagnosis from macroscopic findings and absolutely demands intraoperative or emergent microscopic frozen section diagnosis.

We have treated a patient with polycystic kidney and liver disease with a coexisting cholangiocellular carcinoma surgically. Such treatment has not been reported in Japan so far, to the best of our knowledge. A 63-year-old man was admitted to the hospital because of obstructive jaundice. Imaging methods visualized a tumor of the porta hepatis and multiple cysts of the liver, kidney, and pancreas. The patient was diagnosed as having a cholangiocellular carcinoma with polycystic disease. Extended left lobectomy of the liver with reconstruction of the right hepatic artery and right hepaticojejunostomy was carried out. On and after 12th postoperative day, the patient had a fever and leukocytosis. A liver abscess was suspected, but we had difficulty in diagnosis, because the multiple liver cysts coexisted. Computed tomography done some days apart showed that the abscess changed while the cysts did not show any changes. If a patient with polycystic kidney and liver disease is treated by a surgical method that may increase a risk of liver abscesses, computed tomography should be done several times postoperatively to check the occurrence of this complication.

A 68-year-old man was admitted to the hospital because of a sensation of fullness in the abdomen and right hypochondralgia. A diagnosis of cystadenocarcinoma of the liver was made by analysis of various diagnosticimagings. Hemigastrectomy and left hepatic lobectomy were performed. Cystadenocarcinoma of the liver is a relatively rare disease, though the case report been increasingly seen in the recent years. As the method of the preoparative diagnosis of the cystadenocarcinoma has not been yet established, we cannot help relying on the comprehensive analysis of various diagnostic imagings. In this case, a preoperative histopathological diagnosis was not made but magnetic resonance imaging (MRI) could offer characteristics of the internal structure of cystadenocarcinoma. MRI can be recommended to qualitative diagnosis of the disease. The classification of cystadenocarcinomas of the liver has been proposed in terms of the pathogenesis. According to the classification, cystadenocarcinoma of the liver in this case is thought to have grown up as an adenocarcinoma from the onset, on the basis of a fact that mucinous cancer cells were noted in the surrounding wall of the cyst.

Sixty patients undergoing hepatobiliary surgery were subjected to a bacteriological exploration in terms of postoperative infection and the significance of prophylactic administration of flomoxef (FMOX) was studied. Intravenous administration of FMOX 4g/day was started during surgery and lasted for 7 days. Bacteria in the bile, washing solution used during surgery, and fluid drained from the patients were cultured. Nine of the 60 patients developed infection (infection group). Five patients had intraabdominal infection and the other 4 patients had wound infection. The mean age of the group with infection was higher than that of the group without infection. The proportion of patients who underwent surgery likely to result in contamination by bile or gastrointestinal juice was greater in the infection group. The detection rate of bacteria in the bile from the infection group was higher than that in the other group. Enterococcus, pseudomonas spp., and Staphylococcus epidermidis were cultured from the bile, washing solution, and purulent dischage from patients with infection. In patients with fever (37°C or more) for one week after the operation, the same bacteria were cultured from the drained fluid. Most postoperative infections occurred because of intraoperative or postoperative contamination, and the causative bactaria were not sensitive to Flomoxef.

This paper presents a patient with mucinous cystadenocarcinoma of the bile duct, who was able to undergo radical operation after the extension of the cancer invasion was preoperatively diagnosed by percutaneous transhepatic cholangioscopy (PTCS), with a review of the literature. A 57-year-old woman was admitted to the hospital because of heart burn and general fatigue. On admission, alkaline phosphatase activity was 12.6 KAU, leucine aminopeptidase was 26mu/ml, carcinoembryonic antigen was 7.9ng/ml, and carbohydrate antigen CA19-9 was 71U/ml. Computed tomography and abdominal ultrasonography visualized dilation of the common bile duct and intrahepatic bile ducts. There was a honeycomb-like tumor stain in the area of cholangiectasis in the left lobe of the liver. The patient was treated by PTCD before cholangioscopy was done by the same route. These findings led us to the diagnosis of mucinous cystadenocarcinoam of the bile duct that had spread from the common bile duct to the intrahepatic bile ducts, as seen from the biopsy specimens. Extended lobectomy of the left lobe, resection of the extrahepatic bile ducts except for the right hepatic duct and common bile duct, and lymph node dissection were carried out. The adenocarcinoma was well differentiated and had not invaded the stroma of the liver or the perineural region.

We have treated a patient with adenosquamous cell carcinoma of the gallbladder. Most carcinomas of the gallbladder are adenocarcinomas, and few are adenosquamous cell carcinomas. The origins of squamous cell carcinomas in this location are not understood, because healthy mucosa of the gallbladder have no squamous cells. There are few reports of benign squamous metaplasia of the mucosa of the gallbladder in Japan. Benign squamous metaplasia and the interesting histology of the gallbladder in this case are discussed.

A 36-year-oid woman was hosptialized with the chief complaint of sudden episodes of unconsciousness. Endocrinological tests suggested the existence of insulinoma. Blood samples collected from the tail of the pancreas by percutaneous transhepatic portal vein catheterization (PTPC) had high levels of immunoreactive insulin (IRI) and C peptide, showing that the tumor was at the tail of the pancreas, which was confirmed by intraoperative sonography. The tumor was extirpated and the measurement of blood glucose and IRI levels during surgery disclosed that the removal was complete. Antibiotics, aprotinin, and hyperalimentation were used instead of surgical treatment for pancreatic juice leakage after surgery because the main pancreatic duct was not injured. The leakage ended 14 weeks after surgery. PTPC and intraoperative sonography are useful for identification of the location of insulinomas. Intraoperative measurements of blood glucose and IRI are useful for confirmation whether the removal of a tumor is complete or not. Postoperative pancreatic juice leakage can be treated conservatively if there is no injury in the main pancreatic duct and if satisfactory drainage for the leaking juice is available.

We treated a patient with hepatocellular carcinoma (HCC) in whom jaundice was caused by obstruction of the common hepatic duct because of compression by the tumor. A 71-year-old man was admitted to this hospital for jaundice. Laboratory examinations showed obstructive jaundice associated with increased levels of alkaline phosphatase and hyperbilirubinemia. The serum level of α-fetoprotein was 7, 580ng/ml. Abdominal ultrasonograms and computed tomographic scans showed a spaceoccupying lesion measuring about 4×4cm in the medial segment of the liver and dilatation of the intrahepatic bile ducts. A diagnosis of HCC with obstructive jaundice was made and percutaneous transhepatic cholangiodrainage was done. Transcatheter arterial embolization at the level of the proper hepatic artery was performed. At laparotomy, done after the jaundice had disappeared, the tumor could be seen in the visceral surface of the medial segment. The tumor had compressed both hepatic ducts, but there was no tumor invasion, and medial segmentectomy was done. Two years and 2 months after surgery, the patient is in good health. Jaundice in patients with HCC usually results from masive parenchymal damage arising from tumor infiltration into the hepatic parenchyma or cirrhosis of the liver. Patiens in whom obstructive jaundice is associated with HCC are rare. We found 68 such cases in Japan in a review of the literature.

A 62-year-old man who underwent medical treatment for cirrhosis of the liver was diagnosed as having hepatocellular carcinoma in the right anterosuperior subsegment of the liver. Right anterosuperior subsegmen-tectomy of the liver was performed. Bile leaked from the stump of an intrahepatic bile duct, but satisfactory drainage could be achieved and the leakage healed. About six months later, the patient coughed up yellowish sputum, and right subphrenic abscess was found after the patient was hospitalized. The abscess was drained and a communication with the right bronchus was detected. The fistula closed after two months drainage and the patient was discharged.Bronchial fistulas are a rare complication in patients who undergo hepatic resection.