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A case with an alpha-fetoprotein (AFP)-producing carcinoma originating from the rectum is described. A 71-year-old male patient, who underwent a rectectomy for rectal carcinoma, developed space occupying lesions in the liver and a remarkable AFP elevation (220,000 ng/ml) in the 6th month postoperatively, and then expired one year later. Histologically, the rectal carcinoma consisted of well-differentiated adenocarcinomas, and contiguous cancerous cells proliferating in either a medullary or trabecular pattern. In the "trabecular" areas, localization of AFP was confirmed immunohistochemically. Results of concanavalin A or lens culinaris agglutinin affinity chromatography demonstrated that it was between a hepatic type and a yolk sac type, and was considered to be an intestinal type. This could have been an AFP-producing rectal carcinoma, in which the patient experienced liver metastasis at a relatively early postoperative period and died. This shows that AFP-producing rectal carcinomas are highly malignant, biologically, similar to AFP-producing gastric cancers.

From 1976 to 1989, a total of 1303 patients with gastric cancers underwent gastrectomies in the First Department of Surgery, Kurume University Hospital. Of these, 358 (27.5%) were total gastrectomies, 84 (6.4%) were proximal gastrectomies and 825 (63.1%) were distal gastrectomies. The 5-year survival rate was 44.8% after the total gastrectomies, 38.9% after the proximal and 72.4% after the distal gastrectomies. The 5-year survival rate was 86.2% with the absolute curative resection, 36.3% with the relative curative resection, 29.3% with the relative non-curative resection and 9.4% with the absolute non-curative resection. Macroscopically, the 5-year survival rate was 95.1% for type 0 (early cancers), 61.3% for Borrmann type 1, 58.8% for Borrmann type 2, 37.5% for Borrmann type 3 and 16.5% for Borrmann type 4. According to the pathological cancer stage, the 5-year survival rate was 94.8% for stage I, 79.3% for stage II, 49.2% for stage III and only 11.3% for stage IV.

The deepest gastric cancer invasion into the tela subserosa is expressed as the ss-cancer. Subserosal gastric cancers (ss) can be divided into 4 subtypes; ss alpha, ss beta, (ss gamma) and ss gamma, pathologically. These four subtypes were compared to cancerous invasion into the muscularis propria (pm-cancer) and cancerous invasion with serosal exposure (se-cancer). During the 10 years from 1979 to 1988, a total of 938 cases with gastric cancer were resected in the First Department of Surgery, Kurume University Hospital. Of these, 104 (11.1%) cases were ss-cancers, consisting of 28 (27%) cases of ss alpha, 33 (32%) cases of ss beta, 4 (3%) cases of (ss gamma) and 39 (38%) cases of ss gamma. Pm-cancers and ss-cancers were most frequently observed in Borrmann type 2, macroscopically, and in the differentiated type, histologically. On the other hand, se-cancers were frequently observed in Borrmann type 3 and in an undifferentiated type. Positive lymph node metastases were found in 49.1% of pm-cancers, in 50.0% of ss-cancers and in 79.9% of se-cancers (p0.01), with no statistical difference in the positive lymph node metastasis rates for the subdivisions of ss-cancer. In ss-cancer, however, there was a statistical difference in prognosis according to the tumor size, and according to the degree of subserosal infiltration. The 5-year survival rate was 82.3% for pm-cancer, 75.0% for ss-cancer and 34.7% for se-cancer (p0.01).

Thirty-two cases of gastric cancer associated with hepatic cirrhosis were reviewed, retrospectively. These patients represented 1.3% of 2590 patients with gastric cancer who were treated over the 23 year period from 1966 to 1988. The male to female ratio was 9.7:1 for gastric cancer patients with hepatic cirrhosis (mean age, 63.2 years) and 2:1 for all patients with gastric cancer (mean age, 61.2 years). Among the 32 patients, one was inoperable, and 31 patients underwent surgical exploration. The gastric cancers were resected in 28 patients (90.3%), while the cancers in 3 patients (9.7%) were non-resectable. Twenty-two patients underwent curative resections with a five-year survival rate of 51%. Postoperative complications occurred in 6 patients (20%), but no anastomotic leakage occurred. There were no operative mortalities. On the basis of the present study, different surgical procedures are indicated depending on the preoperative hepatic conditions for patients with gastric cancer accompanied by hepatic cirrhosis.

Experimental studies have revealed that duodenogastric reflux subsequent to gastrectomy was one of the most significant factors for the development of carcinoma in the remnant stomach. For this reason, the binding of carcinogenic agents to the nucleic acids in the gastric mucosa exposed to the duodenal contents were studied using an organ culture method. The intracellular DNA levels bound with carcinogenic agents were significantly increased in the mucosa of the remnant stomach, as compared to the parietal mucosa in the whole stomach. The remnant stomach may therefore provide an environment that enhances the development of cancer.

From 1978 to 1989, a total of 1272 patients with gastric cancer were admitted to Kurume University Hospital. Of these, 1184 (93%) underwent gastric resections. Of the resected cancers, 140 cases were gastric cancers invading the esophagus, as confirmed by postoperative pathological studies. For all 168 gastric cancers invading the esophagus, the resectability rate was 83% (140/168). These cancers were subdivided chronologically, with those during 1978-1983 included in Group 1 and those during 1984-1989 in Group 2. Group 2 patients were treated with a higher proportion of aggressive extended radical operations, such as combined resections of the diaphragm and lymph node dissections as far as the paraaortic lymph nodes (N4). The resectability rate was 76% in Group 1 and 93% in Group 2, due to the more aggressive operations. A lower esophagectomy with a total gastrectomy, mainly from a left thoracoabdominal approach, was performed for 71% of the patients in Group 1, and for 90% in Group 2. Lymph node metastasis was related to the extent of esophageal invasion and inversely related to the 5 year-survival rate. In all cases of esophgeal invasion of less than 1 cm, there were no mediastinal lymph node metastases, and the 5 year-survival rate was 76%. On the other hand, when esophageal invasion was more than 4cm, 50% had mediastinal lymph node metastases and the 5 year-survival rate was zero. The tumor size was also related to lymph node metastasis. When the maximal tumor length was less than 5cm, a negative lymph node metastasis was found in 78% of cases, and the 5 year-survival rate was 76%. On the other hand, when the tumor length was more than 10 cm, only 6% had a negative lymph node metastasis and the 5 year-survival rate was only 15%. The 5 year-survival rate with curative resection was 45% for Group 1, and 71% for Group 2. For those at stage III, 12% of Group 1 could be curatively resected with an extended radical operation, 46% of Group 2 (p

During the 14 years from 1976 to 1989, 1442 gastric cancers were resected in the Department of Surgery at Kurume University. 546 (37.9%) were primary early gastric cancers. One (0.2%) of these was associated with a synchronous liver metastasis. In the advanced gastric cancers, the rate of synchronous liver metastasis was 12.8%. However, synchronous liver metastasis with an early gastric cancer is quite rate. Only 19 cases have been reported in the Japanese literature. A case involving an early cancer, 10 mm in diameter, that was associated with liver metastasis is reported.

Two rare cases of a spontaneous portacaval shunt occurring in patients with gastric cancer and hepatic cirrhosis are retrospectively reviewed with special attention for the operative indications and techniques. One patient underwent proximal gastrectomy for a IIa cancer in the C region with splenectomy and closure of the splenorenal shunt, and died two years and 3 months later due to hepatic failure. The other patient underwent distal gastrectomy for IIa + IIc, IIc double cancers in the M and A regions with splenectomy through an upper transverse abdominal incision that ligated and divided the paraumbilico-caval shunt, and is alive and well 1 year and 2 months, postoperatively. The ICG-R15 was markedly decreased and the K-ICG and ICG-Rmax were improved following the operation in both cases. The preoperative chronic encephalopathy and hyperammonemia disappeared postoperatively in both cases.

During the 12 years from 1977 to 1988, a total of 425 cases of early gastric cancer (EGC) were treated by resection. Of these, 53 (13%) had lymph node metastases, occurring in 6 cases of mucosal cancer (m-cancer) and 47 cases of submucosal cancer (sm-cancer). Among the patients with positive lymph node metastases, 46 (87%) had metastases in the Group 1 perigastric regional nodes, and 8 (2%) had metastases in Group 2 lymph node. These data support the general view that lymph node metastasis occurs in only 2-5% of m-cancers and 15-20% of sm-cancers, and then mainly in Group 1 lymph nodes. A rare case of early cancer with Group 3 juxta regional lymph node metastasis (n3+) is described in this report with special attention to the surgical management and postoperative chemotherapy.

From 1979 to 1988, a total of 1265 cases of gastric cancer were admitted to our Institute. Of these, 80 cases (6.3%) involved hepatic metastasis. Thirty-eight cases (47.3%) underwent gastrectomy (24 distal, 2 proximal, 11 total and one partial). Of these 38 cases, 7 underwent a combined resection of a simultaneous metastatic hepatic tumor. A total of 19 (67.9%) of the 28 cases in H1, 6 (37.5 %) of the 16 cases in H2, and 13 (36.1%) of the 36 cases in H3 underwent gastrectomy. Hepatic metastasis occurred most frequently (18.2%) in Borrmann type 1, 5 % in type 2, 14.9% in type 3 and 8.7% in type 4. Of all 593 resected advanced cases, there were 283 differentiated type, with a hepatic metastasis rate of 14.5%, and 310 undifferentiated type with 7.1 % rate of hepatic metastasis. In H1 and H2, the prognosis after primary gastric cancer resection was better than for unresected cases. Moreover, there have been reports recently of long-term survival using continuous hepatic arterial infusion of anti-cancer durgs, and of combined resection of the metastatic hepatic tumor after curative gastrectomy. Therefore we should not give up these H1 and H2 patients.

We report 9 rare cases (7 males and 2 females) of early gastric cancer of the esophagogastric junction. From 1976 to 1988, 1308 cases of gastric cancer were resected in our Institute. Of these, 479 (36.6%) cases were early gastric cancer. Among all 479 early gastric cancers, 9 (1.9%) were located within 2 cm of the esophagogastric junction on the lesser curvature and/or posterior wall of the cardia. This represents 11.7% (9/77) of the cases of cancer at the esophagogastric junction. This incidence contrasts with the 39.5% of early cancers elsewhere in the stomach. Overall, 36.6% (479/1308) were early gastric cancer. Eight of these 9 patients were resected through the abdominal approach and one by the thoracoabdominal approach. Seven underwent proximal and 2 underwent total gastrectomy. On microscopic examination, one cancer was m-cancer, and 8 were sm-cancer. Lymphnode metastasis was found to be absent in all 9 cases. The prognosis of cancer of the cardia is generally poorer than that for adenocarcinoma in the corpus or distal stomach. However, cancer recurrence 22-91 months postoperatively was zero in these 9 cases of early gastric cancer at the esophagogastric junction.

The results of the surgical resection of the paraaortic lymph nodes metastases of the gastric cancer were evaluated in 116 cases. The frequency of the dissection of paraaortic lymph nodes (No. 16 lymph node) was 20%; the metastatic ratio was 24%. When classified by regions, the highest frequency of metastasis was observed in the cases of upper gastric cancer. The effect of the dissection of No. 16 was more conspicuous when No. 16 metastases were absent than when No. 16 metastases were present. Particularly, the prognosis was improved in the case of n1 and n2 population of the cases which were positive with respect to the proximal lymph node metastasis. It appears altogether that the dissection has considerable significance as prophylactic treatment.

Although there is a decreasing number of gastric cancer patients in Japan, the number of patients over 80 years of age is increasing. Forty patients over 80 years of age (from 80 to 88 years) with gastric cancer (Group 1) during the 10 years from 1980 to 1989 were retrospectively investigated and compared with those 70-79 years of age (Group 2). The resectability rate was 80% in Group 1 and 89% in Group 2. Early gastric cancer was observed at a rate of only 25% in Group 1 and 39% in Group 2. Pathologically, the differentiated type occurred in 78% of those in Group 1 and 68% of Group 2. Total gastrectomy was performed in only 6% of the resected cases in Group 1 and in 25% of Group 2. A combined resection including such operations as pancreatico-splenectomy or splenectomy (PS) was employed in none of the total gastrectomy cases in Group 1 and in 30% of Group 2. R3 gastrectomy was performed in none of the patients in Group 1 and in 21% of those in Group 2. Postoperative complications occurred in 25% of Group 1 patients and in 12% of Group 2 patients. Anastomotic leakage occurred in 3% of those in Group 1 and in 4% of those in Group 2. The 5-year survival rate was 47% for all the resected cases in Group 1 and 68% for Group 2. The 5-year survival rate was 61% for those who underwent a curative (radical) gastrectomy in Group 1, and 84% for those in Group 2.

A case of a massive advanced gastric cancer of the Borrmann type III in a patient with the rare blood group of negative Gregory antigen (Gregory (a-)) is reported. On admission, he was found to have a severe anemia (Hb 6.1 g/dl) requiring a direct blood infusion. He had never received a blood infusion, previously. In blood crossmatching tests, his blood was agglutinated by all the antisera for the common antigens, and he was discovered to have a rare blood type of Gregory (a-). There was no appropriate blood donor in his family. Before the operation, only 600 ml (6 i.u.) of frozen red blood cells could be found in storage from only 2 people with Gregory (a-), O blood type and Rh (+) in Japan. To increase the RBC, erythropoietin (3000 i.u.) was administered 6 times; and the Hb increased to 7.4 g/dl. However, the anemia remained and 200 ml (2 i.u.) Gregory (a-) blood was infused, preoperatively. The final preoperative Hb was 7.8 g/dl and the RBC was 283 x 10(4)/mm3. A massive gastric cancer directly infiltrated the pancreas, the transverse colon and the mesocolon. A palliative subtotal gastrectomy with combined resection of the transverse colon was performed. The intraoperative blood loss was 460 ml and the volume of blood infused was 400 ml (4 i.u.). The postoperative Hb was 7.9 g/dl, and more blood was needed. However, there was no more Gregory (a-) donor blood in storage in Japan.(ABSTRACT TRUNCATED AT 250 WORDS)

The best surgical procedure to treat a carcinoma in the gastric cardia remains a controversy because the carcinoma is often advanced and there are other unknown factors. In this article the incidence of invisible metastasis from cardia cancer to the diaphragm will be analyzed using an experimental cardia cancer model and clinical studies. An experimental cardia cancer was induced by an endoscopic injection of VX2 cancer cells into the submucosal layer of the esophago-gastric junction in rabbits using a 27G needle and an Olympus BF-4B2 bronchofiberscope. A total of 26 cardia cancer models for Borrmann type 2 or 3 were produced. Of these, six (23%) had visible cancer metastases in the diaphragm, including 4 cases with direct invasion and 2 cases with peritoneal dissemination on the surface of the diaphragm. Four (20%) of the remaining 20 were histologically found to have macroscopically-invisible cancer metastases mainly in the lymph vessels of the left hemidiaphragm. From 1985 to 1988, 22 clinical cases of cardia cancer were managed by a combined total gastrectomy with a partial diaphragm resection through a left thoracoabdominal approach. When widely resected, reconstruction was performed using a latissimus dorsi muscle flap. Six (27%) of these 22 were also histologically found to have macroscopically-invisible cancer metastases to the diaphragm, including 1 (11%) of the 9 well-differentiated type and 5 (39%) of 13 poorly-differentiated type adenocarcinomas. For patients with stage II, III or IV cardia cancers with no hepatic metastasis and no peritoneal dissemination, the 2-year survival rate was 64% for those who underwent a combined resection of the diaphragm and 42% for those who underwent a non-combined resection. The postoperative mortality in this series was zero. This is the first report of invisible cancer metastases from cardia cancer to the diaphragm.

Two rare cases involving distal gastrectomies for gastric cancer after an earlier gastrojejunostomies without gastrectomy for duodenal or gastric stricture due to a duodenal or pre-pyloric ulcer are reported. The time interval between the initial gastrojejunostomy and the resection of the distal stomach with gastrojejunal stoma were 17 and 36 years. One patient underwent reconstruction by Billroth II and the other by Roux-en-Y end-to-side gastrojejunostomies, both retrocolically without any peri or postoperative complications. The histological classification was confirmed for both as type IIc mucosal early gastric cancer. Only 6 other primary early gastric cancers following gastrojejunostomies without gastrectomy have been reported in the Japanese literature.

From 1979 to 1988, a total of 1083 patients with gastric cancer underwent resection at Kurume University Hospital. Among these cancers, 183 (16.8%) were located in the upper third of the stomach. Of these, 56 (5.2%) were adenocarcinomas in the esophagogastric (E-G) junction. Cancer in this area was designated as cardia cancer when the focus of the cancer was macroscopically located within 2 cm of the E-G junction line and the tumor was less than 8 cm in diameter. The incidence of early gastric cancer in the cardia was only 13%, while the incidence for stage III advanced cancer was high at 46%, and the positive lymph node metastasis rate was 59%. Thirty-nine (70%) were cured by resection with a 5-year-survival rate of 64%, while for non-curative resection, this was only 10%. Twenty-two cases of either advanced cardia or advanced CE cancer underwent combined resection of the diaphragm. The rate of invisible metastasis to the diaphragm was 20% in our experimental study. The two year-survival rate for a combined resection of the diaphragm was 64%, while the rate for those who did not undergo a required combined resection was 42%.

Twenty-four cases of resected remnant cancers following partial gastrectomy were retrospectively investigated for benign gastroduodenal disease. The time interval between the initial gastrectomy and the remnant gastrectomy was more than 10 years in 19 (79%) patients and less than 10 years in 5 (21%) patients. There were 2 cases with remnant cancer at stage I, 1 at stage II, 3 at stage III and 13 at stage IV for the all cases with a time interval of more than 10 years. Early-type remnant gastric cancer has a frequency of only 5%. The proportion of positive lymph node metastases was high, in 84%.

From 1985 to 1989, a total of 598 gastric cancer patients underwent gastrectomies in the First Department of Surgery at Kurume University School of Medicine. Of these, 24 patients (4.0%) incurred a subphrenic abscess, postoperatively. Subphrenic abscesses occurred most frequently after total gastrectomies at a rate of 17 of 197 (8.8%) cases. Leaking gastrointestinal anastomoses were responsible for 12 of the 17 (70.5%) abscesses. In 384 cases of distal gastrectomy, only 6 (1.6%) cases with a subphrenic abscess occurred, and only 3 were due to anastomotic leakage. Among the total of 24 cases with subphrenic abscesses, 16 (67%) were related to an anastomotic leakage including a pancreatic fistula, while the other 8 (33%) showed no leakage by contrast roentgenography. When chest roentgenography shows a pleural effusion and an elevation of the diaphragm, then a subphrenic abscess must be suspected. The majority of patients were treated by replacing the intraabdominal drainage catheter inserted during the gastrectomy with a larger catheter. The overall operative mortality rate was 4.1% due to a death in only one (MOF) patient.

To improve surgical results of duodenal ulcer, transgastric myotomy (TGM) was added to the traditional selective proximal vagotomy (SPV) and its efficacy was evaluated clinically in 40 patients. 35 men and 5 women were involved, with a mean age of 33.07 +/- 14.25 years. Pyloroplasty was added in 12 operations for stenosis and perforation. 28 patients in this series underwent TGM with SPV without drainage. In the 36 patients, basal and maximal acid output (BAO and MAO) was compared preoperatively and at 6 months postoperatively. A satisfactory reduction of acid output was achieved, with a mean reduction rate of 71.4% in BAO and of 79.9% in MAO. All 40 patients were negative in Hollander's insulin stimulation test at 6 months postoperatively. The gastric mucosa was injured during myotomy in 2 of the patients (5.0%), and was simply sutured using 3-0 Dexon, without causing any problems. No other early or late postoperative complication was present. In addition, no peptic ulcer recurrence has been noted over a maximal follow-up of 8 years. The present results suggest the completeness of gastric denervation by TGM+SPV, and establish the efficacy of TGM with SPV, and therefore this method is recommended in the surgical treatment of duodenal ulcer.

From 1966 to 1985, 2130 patients with gastric cancer were admitted to our surgical department. Among these cancers, gastric cancer following partial gastrectomy for benign gastroduodenal lesion were present in 22 (1%) patients. The original pathology was gastric ulcers in 64% (14 patients), duodenal ulcers in 23% (5 patients), combined gastric and duodenal ulcers in 9% (2 patients), and leiomyoma of the gastric cardia in 4% (1 patient). Fourteen patients were reconstructed by Billroth II, 7 by Billroth I, and one had an esophagogastrostomy after a proximal gastrectomy. The cancer in 19 (86%) patients was resected and 3 (14%) could not be resected. Only 2 (9%) were early cancer, 20 (89%) were advanced cancer including 11 (50%) with Borrmann type 3. A higher proportion of positive lymphnode metastasis was observed for residual gastric cancer (84%) than for primary gastric cancer (49%). The overall 5-year survival rate was 32%, with a 5-year survival rate of 45% for those who underwent curative resection.

Three patients with hepatic cirrhosis who had undergone gastric operations following endoscopic sclerotherapy were retrospectively reviewed. One patient had undergone total gastrectomy for gastric cancer and two had Hassab and Tanner operations for gastric and esophageal varices. All patients were recovering with no complications related to the operations and were free of disease for 2 years, postoperatively. When esophageal varices are found in combination with an upper gastric cancer that requires total gastrectomy, endoscopic sclerotherapy for esophageal varices is contraindicated because severe esophageal injuries may be induced by the sclerosing agent. The Hassab and Tanner method is useful for esophageal and gastric varices after sclerotherapy. A repeat endoscopic sclerotherapy should be performed after this operation.

From 1975 to 1984, 894 patients with gastric cancer were operated on in the Department of Surgery at Kurume University School of Medicine. Of these, 86 (10%) had upper gastric cancer invading the esophagus. The 86 resected tumors were divided into two groups according to the surgical approach, thoraco-abdominal or abdominal. Twenty-three (27%) were resected through the abdominal approach and 63 (73%) were resected by the thoraco-abdominal approach. The overall positive mediastinal lymphnode metastasis rates for the 55 patients who underwent mediastinal lymphnode dissection by the thoraco-abdominal approach were 22% for differentiated type and 37% for undifferentiated type. The positive mediastinal lymphnode metastasis and the correlation to the extent of esophageal cancer invasion were observed at a minimal 7 mm distance from the esophago-gastric (E-G) junction for the undifferentiated type, and 2.2 cm for the differentiated type. Sixteen patients with cancer invading the esophagus were radically resected by the abdominal approach with an overall survival rate of 39%, while 48 were resected by the thoraco-abdominal approach with a 5 year survival rate of 40%. The 86 resected tumors were further subdivided into two groups according to the year of surgery. From 1975 to 1979, the abdominal approach was employed in 36% and the thoraco-abdominal approach in 64% of the surgeries, with an overall curative resection rate of 47%. However, from 1980 to 1984, the abdominal approach was employed in only 17% and the thoraco-abdominal approach in 83% of the surgeries and the curative resection rate increased to 59%.(ABSTRACT TRUNCATED AT 250 WORDS)