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Background and aims. The mode and degree of tumor spread in gallbladder carcinoma is poorly documented. The present study classifies the patterns of dissemination of this tumor with a focus on surgical strategy. Patients and methods. Surgical specimens from 112 patients who underwent curative resection were reviewed. There were stage I, II, III, and IV in 9, 11, 14, and 78 patients, respectively. Results. Six types of spread were identified. In the hepatic bed type (n=20) a large mass in the fundus and body penetrated into the liver through the gallbladder bed with or without contiguous spread to the gastrointestinal tract. The extent of hepatectomy was individualized from wedge resection to extended right hepatectomy based on the clinical findings. In the hepatic hilum type (n=26) a relatively small tumor in the neck infiltrated the hepatic hilum causing obstructive jaundice. Extended right hepatectomy plus bile duct resection with or without portal vein resection was necessary for curative resection because the tumor had extended into the right portal pedicle, and postoperative hepatic failure was common. In the bed and hilum type (n=18) a huge mass occupying the entire gallbladder involved both the gallbladder bed and the hepatic hilum. Extended right hepatectomy with combined resection of contiguous spread was necessary for curative resection. In the lymph node type (n=15) enlarged metastatic lymph nodes were the most prominent feature, and the primary tumor remains limited to the gallbladder in most cases. Extended lymphadenectomy with combined individualized resection was performed. In the cystic duct type (n=9) a small mass arising from the cystic duct involved the common bile duct. This type presented at an earlier stage than the first four types. In the localized type (n=24) tumor spread is localized to the gallbladder and presented at the earliest stage of any type. Simple cholecystectomy with or without wedge hepatic resection and regional lymphadenectomy resulted in a satisfactory outcome. Prognosis depends on the stage rather than on the mode of tumor spread. Even in the advanced types favorable results may be obtained in selected patients undergoing radical resection for M0 tumors without portal vein invasion. Success also was achieved in the rare patients with para-aortic lymph node metastases that were not infiltrative. Conclusions. These six types of gallbladder cancer can be diagnosed preoperatively by clinical and radiological examination. This information should assist the surgeon in the choice of operation and predict outcome.

Background and aims. Septic complications after hepatectomy remain a difficult problem. Intra-abdominal sources of postoperative infections are well described in the literature. However, no studies have examined the cause and outcome of bacteremia after hepatectomy. This study evaluated the incidence and outcome of bloodstream infections, bacteremia, after hepatectomy and determined the risk factors associated with the development of this serious complication. Patients and methods. Records were retrospectively reviewed of 407 patients who underwent an elective first hepatectomy at Nagoya University Hospital between January 1990 and December 1999. The incidence, cause, outcome, and possible risk factors for bacteremia were examined. Results. A total of 403 blood cultures were performed after hepatectomy in 188 patients (46%), and bacteremia was confirmed in 46 (11%). The incidence was significantly different between patients with obstructive jaundice and those without (24% vs. 4%). Multivariate analysis identified four significant independent variables: operative time, age, obstructive jaundice, and large-scale hepatectomy. The most common bacteria isolated were Staphylococci, followed by Enterococci, Klebsiella pneumoniae, and Enterobacter. A probable source of bacteremia was identified in 21 (46%) of the 46 patients. Patients with bacteremia had higher morbidity and mortality rates than patients without bacteremia, and the incidence of organ failure was five to ten times that of patients without bacteremia; the mortality rate was 43% (20/46). Conclusions. Postoperative bacteremia is a common complication of hepatectomy to resect biliary tract carcinoma, especially in older patients with obstructive jaundice undergoing major hepatectomy. In addition, for more than half of patients with bacteremia, no clear source of the infection is identified. Thus blood cultures are mandatory in high-risk patients who spike a fever after hepatectomy to identify the correct pathogen and its antibiotic susceptibility.

An asymptomatic 37-year-old man underwent gastroscopy for health screening, which revealed a protruded lesion at the upper part of the corpus on the lesser curvature of the stomach. He was referred to our hospital for close inspection. Computed tomography and endoscopic ultrasonography showed an extragastric and well-defined cystic lesion. We performed an operation with a presumed diagnosis of submucosal tumor of the stomach. At laparotomy a large mass on the anterior wall of cardia and a small mass on the anterior wall of the middle part of the corpus were found in the subserosal space, and both of them could be easily enucleated. Because histologic examination of the resected material revealed that they are composed of mucosal layer, proper muscle, subserosal layer, and the serosa, a diagnosis of duplication of the stomach was made. Gastric duplication cyst is a kind of gastrointestinal tract duplications, which are congenital anomalies and have been found in various organs from tongue to large intestine. Even though the duplication of the stomach is rare, we must keep this disease in mind on differential diagnosis of the submucosal tumor of the stomach, because its frequency will increase with recent advances in imaging modalities.

Background Transient gastric stasis immediately after pylorus-preserving pancreatoduodenectomy (PPPD) is a common complication, but the cause remains unknown. Changes in gastric emptying were investigated in patients undergoing PPPD for periampullary malignancy. Methods In 14 patients undergoing PPPD, liquid- and solid-phase gastric emptying were evaluated before and after operation (mean 38 (range 27–53) days after operation). Two pharmacological gastric-emptying tests were used: the acetaminophen test for liquid-phase emptying and the sulphamethizole capsule food test for solid-phase gastric emptying. Results All patients exhibited delayed solid emptying but fairly good liquid emptying. Conclusion Gastric function in the early postoperative period after PPPD is characterized by delayed solid-phase but good liquid-phase emptying.

Objective To clarify the importance of different patterns of infiltration at the proximal border of hilar bile duct carcinomas. Summary Background Data There are few detailed pathologic studies on the proximal resection margins in patients with hilar bile duct carcinoma. Methods Serial sections of 62 specimens of resected hilar bile duct carcinoma were examined histologically to determine the involved layers and routes of invasion at the proximal border. The degree of cancer extension was determined, and the relation between the length of the tumor-free resection margin and postoperative anastomotic recurrences was analyzed. Results Mucosal extension was predominant in papillary and nodular tumors, but submucosal extension was predominant in diffusely infiltrating and nodular-infiltrating tumors. Submucosal extension usually consisted of direct or lymphatic invasion. The mean length of submucosal extension was 6.0 mm. Superficial spread of cancer, defined as mucosal extension of more than 20 mm from the main lesion, was seen in 8 specimens. No patient had an anastomotic recurrence when the tumor-free resection margin was greater than 5 mm. Conclusions The pattern of infiltration at the proximal border of resected hilar bile duct carcinomas is closely related to the gross tumor type. The length of submucosal extension is usually less than 10 mm. Superficial spread of cancer is seen in more than 10% of cases. A tumor-free proximal resection margin of 5 mm appears to be adequate in hilar bile duct carcinoma.

A 68-year-old woman visited another hospital because of mucinous feces and vertigo, when laboratory data showed anemia and hyponatremia. She was referred to the hospital for surgery. A nodular surfaced tumor was palpable in the rectum just above the anal verge on digital examination. Endoscopy revealed a large tumor with a lot of mucus on the surface. Biopsy from the villous tumor offered a suspicion of adenocarcinoma. Abdominal CT showed two low attenuation areas in the liver and a large tumor occupied in the pelvis without invasion to the surrounding organs. Although a preoperative treatment did not improve her vertigo, an operation, which included abdominosacral excision of the rectum with partial resections of liver, was performed. The rectal tumor, 12cm in diameter, was located 15cm from the dentate-line actually. The cut surface of hepatic specimen was multilocular and cystic containing a lot of mucus. Histological findings of the rectal tumor revealed well differentiated adenocarcinoma mainly invading the subserosal layer, and villous adenoma or tublovillous adenoma partially. The hepatic lesions were metastases of the rectal carcinoma pathologically. After the operation the vertigo subsided gradually, and she could walk. Resected cases of hepatic metastases from villous tumor of the rectum are rare. The liver metastasis in this case was characteristic macroscopically.

1972年から1995年までに教室で右葉切除以上の大量肝切除を行った胆道癌106例を対象として, 70歳以上の高齢者群 (n=22) の術後合併症, 術後在院死亡例を検討した. 高齢者群の切除率は69.8%, 肝切除施行率は56.1%, 肝切除例における右葉切除以上の大量肝切除施行率は, 53.7% (右3区域4例, 拡大右葉13例, 右葉4例, 左3区域1例) であった. これらの成績は, 非高齢者と同等であった.高齢者群では術後肝不全を54.5%, 呼吸不全を41.0%に認め, これが, 術後在院死亡 (10/22, 45.5%) の主因であった. これらは, 非高齢者と比較し有意に高率であった. 1990年以前における高齢者大量肝切除例の術後在院死亡率は58.3%であったが, 術前術後管理を改善した1991年以降は30%と半減した.術後呼吸不全と術後肝不全への対策が, 高齢者に対する大量肝切除の安全性向上のために不可欠である.

A case of esophageal leiomyoma with remarkable calcification is presented. A 65-year-old man was admitted to the hospital, because esophagography on a health screening demonstrated extraesophageal compression and deformity of the esophagus. Endoscopy showed a protruding lesion, 3cm in diameter, in the anterior wall of the esophagus under the bifurcation of the trachea. Esophagography and computed tomography showed a massive calcification in the lesion. With endoscopic ultrasonography a tumor originating from the proper muscular layer of the esophagus was suspected. Enucleation of the tumor was performed. The resected specimen was a hard and saddle-like tumor, 4×3×1.5cm in size. Histological findings revealed leiomyoma. Nine of 20 cases of calcified leiomyoma of the esophagus reported in Japan were characterized by the location in the anterior wall of the esophagus near the bifurcation of the trachea.

A 34-year-old woman was admitted to the hospital because of sudden onset of left flank pain. Ultrasonography and CT findings revealed a left giant renal tumor. The tumor was 13×11×20cm in size and composed of fatty tissue in the most part. A lesion which seemed to be hematoma surrounded the left kidney. She was diagnosed with retroperitoneal bleeding due to rupture of the renal tumor, and underwent abdominal angiography. It was revealed that the tumor was fed by three dilated and tortuous vessels of branches from the renal artery. A diagnosis of renal angiomyolipoma was made. These tumor vessels were embolized with 5ml of absolute ethanol superselectively. Post embolized course was uneventful and the tumor revealed a decrease in size on CT 9 days after TAE. She has been asymptomatic for 5 years. Transarterial embolization with absolute ethanol is first recommended for renal angiomyolipoma.

Zenker憩室は比較的まれな疾患でありその手術例の報告も少ない. われわれは甲状腺腺腫を伴ったZenker憩室の1例を経験したので報告する. 症例は73歳の男性. 5年前から嚥下障害があり, 1年前から前頸部の腫瘤に気づいていた. 頸部CT検査にて, 右葉の甲状腺腫とは別に, 左の頸部に特徴的な楕円形の含気を認めZenker憩室の合併を疑った. 食道造影と食道内視鏡検査にて嚢状のZenker憩室の存在を確認した. 手術は甲状腺右葉切除術とZenker憩室切除術を施行した. 甲状腺腫は大きさ90×70×35mmの濾胞状腺腫で, Zenker憩室の大きさは25×15mmで, 扁平上皮と薄い筋層から成る真性憩室であった. Zenker憩室は内圧性の憩室であり, 自験例では, 甲状腺腫瘍が偶然合併し気管や食道を圧排することにより, Zenker憩室の増大や嚥下障害の発生に間接的に関与したと考えられた.

症例は45歳の女性. 腹部CT検査にて肝腫瘍を指摘された. 単純CT検査では低吸収域として認められ. CT値は+56HUであった. dynamic CT検査では造影剤静注10秒後に腫瘍はほぼ均一に濃染し, 60秒後にはwash outされた. 腹部超音波検査では肝右葉後区域に内部は不均一な卵円型の低エコー像を認めた. MRI検査のT1-強調像では低信号域, T2-強調像では高信号域として認められた血管造影検査ではhypervascularで動脈相から静脈相にかけて均一な卵円形の濃染像を認めた. 術前診断では肝focal nodular hyperplasiaを疑い, 肝右葉後区域部分切除術を施行した. 腫瘍の割面は暗赤色で境界明瞭な腫瘍で, 病理組織検査により肝血管筋脂肪腫と診断された. 自験例は脂肪成分の割合がきわめて少ない血管筋脂肪腫であり, 非特異的なhypervascularな腫瘍の様相を呈していたため, 術前診断に難渋したものと考えられた.

1979年から1990年までに肝門部胆管癌に対し合理的肝区域切除で根治手術を施行しえた56例を対象として, 根治性とquality of life (QOL) の両面から本手術法を評価した.詳細な術前進展度診断・肝門部立体解剖診断に基づいた合理的肝区域切除により, 肝門部胆管癌全例の67%に根治切除が可能であった.根治切除例の術後在院死亡率は11%で, 大部分は術後肝不全死であった.根治切除全56例の累積5年生存率は32%, 術後在院死・他病死を除く43例では43%と, 高度進行例が多いことも考慮すると良好な遠隔成績であった.根治切除後1年以上経過して現在無再発生存中の15例のQOLを調査したところ, performance status (PS) 0が14例, PS1が1例で, 復職率100%, 有症状率20% (軽度) と良好な社会生活を営んでいた.癌再発例でも肝門部局所再発は15%と少なく, QOLは比較的良好であった.以上より, 合理的肝区域切除は根治性と安全性・QOLを両立しうる手術法と考えられた.

Twenty-nine patients with advanced carcinoma of the bile duct or gallbladder underwent combined portal vein and liver resection. Segmental excision of the portal vein was performed in 16 cases and wedge resection of the vessel wall in 13. The operative mortality rate was 17 per cent. The median survival for the 24 patients who left hospital was 19·8 months. Actuarial survival rates at 1, 3 and 5 years for all 29 patients were 48 per cent, 29 per cent, and 6 per cent respectively, whereas the median survival for 46 patients with unresectable carcinoma was 3 months and the 1 and 3-year actuarial survival rates were 13 per cent and zero respectively. This difference in survival times between patients undergoing hepatectomy with portal vein resection and those with unresectable carcinoma were statistically significant (P

直腸癌に対する腹会陰式直腸切断術18か月後に膵頭部転移をきたした1例を報告した.症例は57歳男性.臨床的に膵の他に骨盤内に胡桃大の再発を認めたが, 肺, 肝, 骨には転移を認めなかった.膵頭部主膵管に狭窄があり, 内視鏡的膵管生検で直腸癌膵転移と術前診断でき, 膵頭十二指腸切除, 上腸間膜静脈合併切除を施行した.腫瘍は60×50mmの大きさで膵頭周囲リンパ節転移, 上腸間膜静脈腫瘍栓, 膵管内発育を伴っていた.骨盤内再発巣は高度の腹腔内癒着のため切除不能であり, 放射線療法, 抗癌剤動注化学療法を施行した.限局した転移巣であれば膵転移といえども切除の適応があると考えられた.

We have experienced a case of esophageal carcinoma asociated with hiatal hernia of which follow-up was prolonged because of difficulties in differencial diagnosis from esophagitis. A 59-year-old man visited our hospital with the chief complains of dysphagia and epigastric pain. Barium X-ray and esophagoscopy revealed a slight stenosis and shallow errosion in the lower esophagus. The differential diagnosis between superficial esophageal carcinoma and esophagitis was difficult, and the biopsy examination was group III, so he was followed up. Two years and two months later, his complaints became progressive and biopsy examination revealed squamous cell carcinoma, thus esophagogastrectomy was performed. The esophageal wall remarkably thickened ecause of muscular fibrosis whereas cancer cells remained within the muscle layer. A possibility that the cancer might exist at the first visit was considered, because histological feature of resected specimens was similar to that of the first biopsy specimens. Moreover the patient might have a longer history of esophagitis, under where esophageal cancer appeared to develop.

21年4か月間に教室で経験した大腸他臓器重複癌は21例で, 大腸癌手術例の5.5%であった.この21例 (重複癌群) を, 他臓器癌の合併のない大腸癌363例 (非重複癌群) と臨床的に比較検討した. 重複癌群は次のような特徴を有していた. 性比は3.2: 1と男に多く, 大腸癌手術時年齢の平均は61.7歳と非重複癌群よりも約4歳高かった. 大腸癌多発率が28.6%と高く (非重複癌群は5.2%), 大腸癌占居部位が右側結腸に占める率が非重複癌群に比べて高かった. 癌家族歴陽性率も55.6%と高かった. 他臓器癌は胃, 膀胱に多かった. 大腸他臓器重複癌の治療成績向上のためには, 他臓器癌診断後の大腸癌の早期発見の努力が必要であり, また大腸多発癌, 高齢, 癌家族歴陽性, 右側結腸癌患者は他臓器癌合併の危険群とみなして積極的に第2癌の発見に努めるべきである.

OBJECTIVE: This study was conducted to determine whether an immediate change occurs in the blood flow distribution in hepatic segments after segmental portal vein embolization. CONCLUSION: We found an immediate change in the distribution of blood flow in the liver after embolization; with portal vein embolization, we found an immediate increase in the hepatic artery blood flow in the affected segments.

Background The purpose of this study was to clarify the efficacy of, and define the indications for, extensive surgery for gallbladder carcinoma. Methods Between 1979 and 1994, 116 patients with gallbladder carcinoma underwent operation. Radical resection was performed in 80 patients. Results In 68 patients with stage III or IV disease, extensive resection including extended right hepatectomy (n = 40), pancreaticoduodenectomy (n = 23) and/or portal vein resection (n = 23) was employed to achieve complete tumour excision. The hospital mortality rate was 18 per cent. The postoperative 3- and 5-year survival rates were 44 and 33 per cent respectively in the patients with stage III disease (n = 9), and 24 and 17 per cent respectively in patients with stage IV (M0) disease (n = 29). In contrast, the postoperative survival rate for the 30 patients with stage IV (M1) disease (7 per cent at 3 years and 3 per cent at 5 years) was worse than that for patients with stage III and stage IV (M0) disease (P = 0·009 and P = 0·062 respectively). Conclusion Radical resection should be undertaken for stage III and stage IV (M0) gallbladder cancer. Although portal vein resection and/or pancreaticoduodenectomy did not contribute to long-term survival, better survival was obtained than that for the unresected patients.

To assess the status of the regional and paraaortic lymph nodes in hilar cholangiocarcinoma and to clarify the efficacy of systematic extended lymphadenectomy.There have been no studies in which regional and paraaortic lymphadenectomies for hilar cholangiocarcinoma have been routinely performed. Therefore, the metastasis rates to the regional and paraaortic nodes, the mode of lymphatic spread, and the effect of extended lymph node dissection on survival remain unknown.This study involved 110 patients who underwent surgical resection for hilar cholangiocarcinoma with lymph node dissection including both the regional and paraaortic nodes. A total of 2,652 nodes retrieved from the surgical specimens were examined microscopically.Of the 110 patients, 52 (47.3%) had no involved nodes, 39 (35.5%) had regional lymph node metastases, and 19 (17.3%) had regional and paraaortic node metastases. The incidence of positive nodes was significantly higher in the patients with pT3 disease than in those with pT2 disease. The pericholedochal nodes were most commonly involved (42.7%), followed by the periportal nodes (30.9%), the common hepatic nodes (27.3%), and the posterior pancreaticoduodenal nodes (14.5%). The celiac and superior mesenteric nodes were rarely involved. The 3-year and 5-year survival rates were 55.4% and 30.5% for the 52 patients without involved nodes, 31.8% and 14.7% for the 39 patients with regional node metastases, and 12.3% and 12.3% for the 19 patients with paraaortic node metastases, respectively. Of the 19 patients with positive paraaortic nodes, 7 had no macroscopic evidence of paraaortic disease on intraoperative inspection. The survival in this group was significantly better than in the remaining 12 patients.The paraaortic nodes and the regional nodes are frequently involved in advanced hilar cholangiocarcinoma. Whether extended lymph node dissection provides a survival benefit requires further study. However, the fact that long-term survival is possible despite pN2 or pM1 disease encourages the authors to perform an aggressive surgical procedure with extended lymph node dissection in selected patients with hilar cholangiocarcinoma.

Hilar cholangiocarcinoma has remained a challenge to surgeons because of its propensity for local invasion and its proximity to the portal vein, hepatic arteries, and liver parenchyma. Locally advanced disease at diagnosis and surgical inaccessibility have resulted in low resectability and poor survival. Recent advances in interventional radiology and endoscopy have made possible nonsurgical palliation of this disease. Consequently, some clinicians recommend that palliative biliary stenting supplant surgical resection as the standard treatment for patients with hilar cholangiocarcinoma. Although some patients with advanced disease or prohibitive surgical risk factors are best served by nonoperative biliary stenting, we believe most should be evaluated for surgical resection. Recently, many institutions with expertise in the management of patients with hilar cholangiocarcinoma have reported higher resectability rates without increased surgical death rates. 1–12 Japanese surgeons 13–16 have reported resectability rates as high as 80% in patients treated by combined bile duct and liver resection with caudate lobectomy. Although surgical resection has gained acceptance during the past decade as the mainstay of therapy for hilar cholangiocarcinoma, the acceptance of combined liver resection with caudate lobectomy has been slow, especially by American surgeons. Moreover, the higher resectability and survival rates in Japanese reports have stirred debates as to whether the tumors in Japanese patients are of a more favorable histopathologic type or are detected at an earlier stage. The surgeons at Lahey Clinic and Nagoya University have a long shared an interest in the management of biliary malignancies and have gained from each other’s experience through the exchange of visiting surgeons. This study was prompted by one of these exchange visits. The aim of this study is to identify factors in our management approaches to hilar cholangiocarcinoma that might explain the reported differences in resectability and overall survival between American and Japanese patients.

Background There have been no reports on the routine use of regional and para-aortic lymphadenectomy for gallbladder cancer. The aim of this study was to elucidate nodal status, its prognostic influence and the efficacy of lymphadenectomy. Methods A retrospective analysis was made of 60 patients who underwent radical resection and routine regional and para-aortic lymphadenectomy. Results Of the 60 patients, 73 per cent had node-positive disease and 38 per cent had positive para-aortic nodes. Postoperative survival was extremely poor in patients with minimal distant metastasis, and similarly in patients with para-aortic disease. The survival of patients with metastasis limited to the regional nodes was significantly better than that of those with distant metastasis (P = 0·029) or para-aortic disease (P = 0·017) and was not significantly different from that of patients with no metastasis (P = 0·82). Conclusion Regional and para-aortic lymphadenectomy provides no survival benefit for patients with para-aortic disease, which has an influence on poor prognosis equivalent to that of distant metastasis. It has the potential to bring survival benefit only in selected patients with metastasis limited to the regional nodes. A sampling biopsy of the para-aortic nodes before starting radical surgery is recommended because they are involved more frequently than expected.

Changes in lobar volume of the liver and in total hepatic function were studied in 19 patients with biliary tract cancer who underwent right portal vein embolization as preoperative management for extensive liver resection. Computed tomography (CT) was performed to estimate liver volume before and approximately 11 days after embolization. An indocyanine green (ICG) test was performed before and 11 to 13 days after embolization. The calculated volume of the right lobe decreased from 761 +/- 181 cm3 to 625 +/- 110 cm3 11 days after embolization (P.0001), whereas the volume of the left lobe increased from 420 +/- 94 cm3 to 555 +/- 110 cm3 (P.0001). Thus, portal embolization produced a gain in left lobe volume of 136 +/- 62 cm3 and an almost equivalent loss in right lobe volume. The hypertrophy ratio of the left lobe, expressed as percentage of postembolization volume of the left lobe to preembolization size, of the 5 patients with diabetes mellitus (DM) was lower than that of the 14 patients without diabetes (116.7 +/- 6.3% vs. 140.4 +/- 18.4%; P.005). The ICG disappearance rate in 16 patients improved from 0.163 +/- 0.034 to 0.177 +/- 0.027 (P.05). The improvement was especially evident in 9 of 14 post-jaundice patients, although the rate decreased slightly in 2 patients without jaundice. We conclude that right portal vein embolization can produce a compensatory hypertrophy of the left lobe within 11 days without seriously affecting hepatic function. In diabetic patients, however, a longer interval between embolization and operation may be needed to achieve sufficient hypertrophy of the left lobe.

Using preoperative and postoperative arteriography, angiographic changes in the hepatic artery were studied after skeletonization of the hepatoduodenal ligament and hepatic resection for biliary tract carcinoma. Of 52 patients evaluated (32 with carcinoma of the bile duct, 20 with gallbladder cancer), no angiographic changes were apparent after operation in 30 (58 per cent) and there were pathological findings in 22 (42 per cent; smooth stenosis in five patients, irregular stenosis in seven, a beaded appearance in four, dilatation in two, obstruction in four). Based on angiographic findings, patients were classified into three subgroups (no change, 30 patients; irregular form, 18; obstructed, four). Postoperative liver function was also evaluated. No definite correlation was evident between angiographic findings and the incidence of hepatic failure or liver dysfunction in the first month after operation. Given that connective tissue and lymph node dissection in the hepatoduodenal ligament is essential for curative resection of biliary tract carcinoma, these findings suggest that skeletonization is an acceptable operative procedure.

To elucidate the clinical significance of perineural invasion on bile duct cancer, a clinicopathologic study was performed on 70 resected patients with bile duct carcinoma. The overall incidence of perineural invasion in the resected specimen was 81.4%. There seemed to be no correlation between perineural invasion and site, size of the tumor, and lymph node metastasis. A significant correlation was observed, however, between macroscopic type, microscopic type, depth of invasion, and perineural invasion. Perineural invasion index (PNI) was defined as the ratio between the number of nerve fibers invaded by cancer and the total number of nerve fibers with and without cancer invasion. Perineural invasion index was significantly higher at the center compared with the proximal and distal part of the tumor (p less than 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower (p less than 0.05) than that for those without perineural invasion (67% versus 32%).

上腹部の自律神経叢切離およびリンパ流障害が血糖値とinsulin分泌に与える影響について検討した.麻酔下で対照群 (C群), 迷走神経幹切離群 (V群), 上腹部の自律神経叢切離とリンパ管閉塞群 (D群), 上腹部の自律神経叢切離とリンパ漏群 (DL群) の4群をイヌで作製し, 十二指腸内ブドウ糖負荷試験を行った.血糖およびinsulin基礎値は4群とも100mg/ml, 25μu/ml前後であった-糖負荷後60分で血糖 (C群: 165±13, V群: 167±20, D群: 212±18, DL群: 136±20mg/dl) およびinsulin (C群: 74±9, V群: 63±14, D群: 386±35, DL群: 276±66μu/ml) は頂値に達した. 上腹部の自律神経叢切離はinsulin分泌を促進することが示唆された.