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A 42‐year‐old man with schizophrenia was referred to our hospital after 2 weeks of worsening fatigue. His hemoglobin level was 2.8 g/dL owing to folic acid deficiency stemming from alcohol abuse and consumption of unbalanced meals. We induced behavioral changes in the patient by motivational interviewing. We had direct methodical conversations with medical staff involved with the patient as well as his family, and established new social support for him as well as public assistance. These have resulted in the patient maintaining a favorable lifestyle ever since.

The accuracy of measurements of the intima-media thickness (IMT) and flow-mediated dilatation (FMD) of the brachial artery made using a new semiautomated ultrasound system and the relationships among those parameters and the Framingham Risk Score (FRS) as a predictor of coronary heart disease (CHD) are unknown. We enrolled 70 subjects, including 47 patients with cardiovascular risk factors and 23 normal healthy volunteers. IMT and FMD were simultaneously measured using a new semiautomated ultrasound system, and the measurements were compared with those obtained manually as a reference standard (study 1). In addition, we enrolled 200 consecutive patients with risk factors but no CHD to examine the relationships among IMT, FMD and the FRS. The optimal cutoff values of FMD and IMT were determined in 200 patients without CHD, and the subjects were classified into four groups. The 10-year Framingham risks for each group were compared (study 2). FMD and IMT measurements made using the new semiautomated ultrasound system showed a good correlation with the measurements determined manually (study 1). Furthermore, FMD and IMT showed a significant correlation with the FRS. The 10-year Framingham risk was markedly higher in group D (FMD5.5% and IMT0.3 mm; 19.0±11.3%; study 2). In conclusion, the measurements made using a new semiautomated ultrasound system provided reliable and simultaneous evaluations of IMT and FMD. The combination of IMT and FMD measurements of the brachial artery may be beneficial for risk stratification of patients with cardiovascular risk factors but no CHD.

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To determine the predictive value of the preoperative serum concentration of type IV collagen 7s domain (7s collagen) for postoperative hepatic failure in patients undergoing liver resection for hepatocellular carcinoma.Clear and reliable criteria for predicting hepatic failure after liver resection are needed. The serum 7s collagen concentration correlates with the histologic degree of active hepatitis and hepatic fibrosis and may predict the regenerative potential of the liver.Potential risk factors for postoperative hepatic failure, including the serum 7s collagen concentration, were evaluated in 251 patients who underwent liver resection for hepatocellular carcinoma. Prognostic significance was determined by univariate and multivariate analyses.Hepatic failure developed postoperatively in 25 patients, 4 of whom died. The serum 7s collagen concentration correlated with the histologic degree of hepatitis activity and hepatic fibrosis. The serum 7s collagen concentration was a risk factor for postoperative hepatic failure by univariate analysis and was the only risk factor on multivariate analysis. No patient with a serum 7s collagen concentration12 ng/mL died of postoperative hepatic failure, and all 4 patients who died had a serum 7s collagen concentrationor=12 ng/mL.The preoperative serum 7s collagen concentration correlated independently with hepatic failure following liver resection for hepatocellular carcinoma. Patients whose serum 7s collagen isor=12 ng/mL are poor candidates for hepatic resection.

Background: Epigenetic alteration through methylation is one of the most important steps in carcinogenesis. However, the relation between hepatitis virus infection and epigenetic alterations is poorly understood. Methods: Sixteen patients without hepatitis B virus (HBV) and hepatitis C virus (HCV) and 35 patients with HBV or HCV who underwent liver resection for hepatocellular carcinoma (HCC) were studied. Mutation of p53 was detected by direct sequencing. Methylation status of p16 was evaluated in tumor and noncancerous liver tissues by methylation-specific polymerase chain reaction. Results: In HCC without HBV and HCV, p53 mutations were detected in 5 (31%) of 16 HCCs. Methylation of p16 promoter was detected in 2 (25%) of 8 moderately differentiated HCCs, 6 (75%) of 8 poorly differentiated HCCs, and none of 16 noncancerous tissue specimens. In HCC with HBV or HCV, p53 mutations were detected in 8 (23%) of 35 HCCs. Methylation of p16 promoter was detected in 2 (100%) of 2 well-differentiated HCCs, 13 (76%) of 17 moderately differentiated HCCs, 12 (75%) of 16 poorly differentiated HCCs, and 9 (26%) of 35 noncancerous liver tissue specimens. Conclusions: Our results suggest that hepatitis viruses might induce methylation of p16 promoter in liver with chronic inflammation, before appearance of HCC.

Background The prognosis of patients without nodal metastasis of oesophageal cancer is generally good, but recurrence develops in some cases. Methods Data on 88 consecutive patients with squamous oesophageal cancer who underwent three-field lymph node dissection from 1986 to September 1998 and who had no evidence of nodal disease were reviewed retrospectively. Disease status was based on histological examination of the section of each node with the largest surface area, stained with haematoxylin and eosin. Results The 3- and 5-year survival rates of patients without lymph node metastasis were 85 and 81 per cent respectively, better than in patients with metastasis. Twelve patients died from recurrence. Recurrence was haematogenous in nine patients and locoregional in three. Survival was worse in men, for patients with lesions located in the upper thoracic oesophagus, and in those with lymphatic or blood vessel invasion. Only the presence of lymphatic invasion correlated with survival on multivariate analysis (P = 0·04). Conclusion Although survival was generally good in patients without nodal metastasis from oesophageal cancer following three-field lymph node dissection, patients with lymphatic invasion remained at risk for haematogenous dissemination.

肝細胞癌(以下HCC)に対する前区域切除術13年後に根治切除した食道癌の稀な異時性重複癌を報告する.症例は71歳,男性.1987年, HCCに対し肝右葉前区域切除を施行した.術後13年間順調に経過したが, 2000年7月上旬より嚥下困難が出現し,胸部中部食道左側に4cm, 2型の中分化型扁平上皮癌を認めた.術前血液検査で肝機能の軽度低下を認め, CEAが7.5ng/ml, HCV(+)であった. 2000年8月30日,慢性C型肝炎を合併していたため,開腹先行にて開胸開腹食道亜全摘術,胸部,腹部の2領域D2リンパ節郭清と後縦隔経路全胃管再建を行った.病理診断は中分化型扁平上皮癌, pStage IVa,総合的根治度pBで,術後経過は良好である. HCCとの重複癌においてはHCCが予後規定因子となることが多いが, HCCが根治であれば第2癌に対しては,肝機能が許される範囲であれば重複癌に対して根治的な手術をすべきと考える.

Unlike normal liver with the sinusoids, hepatocellular carcinomas (HCCs) possess capillaries. Whether these capillaries derive from the sinusoids remains unclear in human HCCs. This study aimed to examine sinusoidal capillarization in human HCCs and its relationship to the tumor size, arterialization and dedifferentiation. Thirty-eight HCCs with a diameter of 10 - 140 mm were pathologically and angiographically examined. By electron microscopy, the microvasculature of tumors was classified into sinusoidal, intermediate and capillary types, which were all negative, partially positive and all positive, respectively, for four parameters, i.e., endothelial defenestration, continuous basement membrane, lack of Kupffer cells, and lack of lipid-containing hepatic stellate cells. Well-, moderately and poorly differentiated HCCs displayed sinusoidal / intermediate / capillary types, intermediate / capillary types and only capillary type, respectively, suggesting the transition from the sinusoids to capillaries in well-differentiated (and probably moderately differentiated) HCCs. Furthermore, well-differentiated HCCs with a diameter of less than 30 mm often received preferential portal venous blood, while moderately and poorly differentiated ones were all supplied with arterial blood, indicating a relationship between dedifferentiation and arterialization. In contrast, the microvascular type displayed no significant relationship with tumor size or arterialization in well-differentiated HCCs. The present study has demonstrated that sinusoidal capillarization occurs in human well-differentiated HCCs and seems to be related to dedifferentiation of parenchymal tumor cells, but not to tumor size or arterialization.

Worldwide, patients with hepatitis B virus (HBV) number as many as 280 million. HBV infection is a risk factor for hepatocellular carcinoma (HCC), 1 most effectively treated by resection. Recent progress in the preoperative evaluation of liver function, surgical procedures, and perioperative management has improved the results of liver resection. 2,3 However, resection in patients with chronic liver disease still can lead to postoperative hepatic failure, resulting in decompensation and death. The Child-Pugh classification 4 has been used frequently to evaluate preoperative liver function. Risk factors for postoperative hepatic failure have been studied by many investigators, and various new methods have been proposed for evaluating preoperative liver function. 3,5–12 After undergoing liver resection for HBV-related HCC, some patients again develop hepatitis. Four years ago, we treated an HBV carrier and who underwent right lobectomy for HCC and 6 weeks later developed fatal acute hepatic failure with remarkably increased activities of alanine aminotransferase (ALT) and aspartate aminotransferase (≥3,000 IU/L). The patient had well-preserved liver function before surgery and was discharged from the hospital 4 weeks after surgery. Although acute hepatic failure has been reported to occur from reactivation of HBV replication after liver transplantation, 13 whether reactivation of HBV replication occurs after liver resection is not known, nor is the relation of such an event to postoperative hepatitis. In the present study, we retrospectively studied the incidence of postoperative hepatitis. Beginning in 1994, we also prospectively investigated reactivation of HBV replication after liver resection and factors that might be associated with reactivation.

22歳,男性.平成11年9月20日に交通事故のため,大阪府下の救命センターに搬送された. IIIB型肝外傷による腹腔内出血と診断され,肝動脈塞栓術が施行された.術後発熱が続くため胆嚢炎と診断,同月24日に胆摘術が施行された.しかし発熱は遷延し, 29日に発熱の原因と考えられたS5, S6の挫滅肝の非定型的部分切除が行われた.術後ドレーンより胆汁痩がみられ,保存治療で軽快せず,平成12年3月7日に当院転院となった. 瘻孔造影でS7肝内胆管が描出され,後枝の損傷による胆汁瘻と診断し, 4月5日に再々開腹した.肝門部で後枝胆管の肝側断端を確認しえたため胆道造影を施行し,肝管走行を確認した後に肝右葉切除を施行した.切除肝重量は425g. 術後経過は良好で,術3週後に軽快退院した. 肝外傷では胆管損傷を伴うことも多いため,胆道造影を行った後に,可能な限り定型的な肝切除を行うことが望ましいと思われた.

We studied the relationship between the findings of computed tomography during arteriography (CTA) and computed tomography during arterial portography (CTAP), and pathologic findings of 81 small nodular lesions (3 cm or less in diameter) in resected liver specimens. The 81 lesions consisted of 8 dysplastic nodule (DN) lesions, 23 well‐differentiated hepatocellular carcinomas (early HCCs) and 50 moderately or poorly differentiated HCCs (advanced HCCs). We also performed standard computed tomography (CT), digital subtraction angiography (DSA), magnetic resonance imaging (MRI), and ultrasonography, and compared sensitivities with CTA, CTAP, or combination of CTA and CTAP with other imaging methods. Forty‐four of the 50 advanced HCCs, 12 of the 23 early HCCs, and none of 8 DNs hyperattenuated with CTA and hypoattenuated with CTAP. The sensitivity for the early HCCs was significantly higher for CTA and CTAP in combination as compared with DSA or standard CT. The sensitivity for the advanced HCCs was significantly higher for CTA and CTAP in combination than with DSA. The sequential changes of the blood supply from the portal vein to the hepatic artery during the development of the HCCs were observed. Although CTA and CTAP in combination were useful for the distinction of advanced HCC from early HCC or DN, CTA and CTAP used in combination were not superior to CTA alone in the detection of such lesions.

われわれが切除した肝細胞癌562例のうち1998年7月までに臨床的に肺転移を来たした23例を肺転移巣切除8例 (肺切群) と非切除15例 (非肺切群) に分け各群の臨床像を比較した.肺転移時に残肝再発を併存した症例は肺切群, 非肺切群でそれぞれ5例, 10例であった. このうち非肺切群3例には追加治療を行いえなかった. 肺転移までの期間, 肺転移巣の局在に差はなかったが, その個数は肺切群では全例countableで, 非肺切群では3例がuncountableであった.肝切除後累積生存率および肺転移後累積生存率とも肺切群が良好であった (p=0.0447, p=0.0020).また, 非肺切群死亡11例中3例が肺転移に起因する癌死であったが, 肺切群死亡4例の死因は肺転移によるものでなかった.肺転移巣数がcountableで, 残肝再発の制御されている肝癌切除後肺転移例に対して肺切除を行うべきであると考える.

BACKGROUND The effect of prior hepatitis B virus (HBV) infection on the clinicopathologic findings for patients with hepatitis C virus (HCV) RNA and hepatocellular carcinoma (HCC) is still unclear. METHODS Of 59 patients who underwent liver resection for HCV-related HCC (≤2.0 cm in greatest dimension) without metastases between 1990 and 1997, 38 patients had anti-HB core antibody (anti-HBc) and did not have HB surface antigen in their sera (Group 1). Their clinicopathologic findings and outcomes after surgery were compared with those of the remaining 22 patients without anti-HBc (Group 2). RESULTS The proportion of well-differentiated HCC was significantly lower in Group 1 than in Group 2 (P = 0.0214). The percentage of patients with cirrhosis was significantly lower in Group 1 than in Group 2 (P = 0.0228). The cumulative survival rate was significantly lower in Group 1 than in Group 2 (P = 0.0224). The risk ratio of anti-HBc for shorter survival time was 3.817. CONCLUSIONS HCC more often developed before cirrhosis in patients with HCV RNA and anti-HBc than in patients positive for HCV RNA alone. Prior HBV infection was a risk factor for poor outcome after liver resection for patients infected with HCV. [See editorial on pages 741–3, this issue.] Cancer 1999;86:793–8. © 1999 American Cancer Society.

The effect of persistent hepatitis C viremia on the outcome after resection of hepatocellular carcinoma (HCC) was investigated in 59 consecutive patients with a single small HCC (< or = 3.0 cm in diameter). The presence of serum hepatitis C virus (HCV) RNA was evaluated using a reverse transcription polymerase chain reaction method as well as a branched DNA probe method. Clinicopathologic findings were compared between patients with and without viremia and the risk factors for poor outcome were evaluated. Hepatitis C virus (HCV) RNA was not detected in the sera from 7 patients (group 1), but was detected in the sera from the other 52 patients (group 2). Alanine aminotransferase (ALT) activity was significantly higher in group 2 than in group 1. The proportion of patients with active hepatitis was significantly higher in group 2. In group 2, new HCC often developed after the operation and four patients died of liver dysfunction. HCV viremia, high ALT activity, high concentration of total bilirubin, and liver cirrhosis were related to recurrence after the operation. Multivariate analysis indicated that HCV viremia and high ALT activity were independent risk factors for recurrence of HCC. Continuous hepatitis with persistent HCV viremia worsened the outcome after the resection of HCC by causing new development of HCC and deterioration of liver function. In patients with HCV-related HCC, but without HCV viremia, satisfactory results can be expected after liver resection.

We treated 30 patients with hepatocellular carcinoma (HCC) by laparoscopic microwave coagulation therapy (LMCT) and 5 patients with hepatic tumors by laparoscopic hepatectomy (LH). LMCT : The HCC was between 10 and 35 mm in longest diameter. After observation of the surface of the liver during laparoscopy as usual, the lesions were punctured with a electrode needle, coagulated with 60 to 80 W for 45 seconds. The efficacy of LMCT was evaluated by dynamic CT or dynamic MRI. After LMCT, 3 lesions of 3 patients were thought to be coagulated insufficiently and additional therapy was needed. The lesions of the other patients seemed to be coagulated sufficiently. LH : We treated 5 patients by LH under general anesthesia. The longest diameters of tumors were between 13 mm and 45 mm. All tumors were located at the edge of the liver. We coagulated the surrounding tissues around the tumors with the above mentioned method and resected the coagulated lesions with Laparoscopic Coagulating Shears System. The bleeding were few and no serious complications were not found. Conclusions : Laparoscopic treatment for HCC was useful but the indication was restricted by location of HCC.

The hepatic sinusoids are preferentially supplied with portal venous blood and equipped with fenestrated endothelial cells that are distinct from capillary endothelial cells. We previously observed in rats that sinusoidal capillarization proceeded concurrently with arterial blood supply during hepatocarcinogenesis. This study aimed to clarify the inducing role of arterialization in sinusoidal capillarization by investigating phenotypical, morphological and functional alterations to sinusoidal endothelial cells (SECs) in arterialized rat livers induced by portal branch ligation. At one week, after massive hepatic necrosis following ligation, the livers were restored to their normal architecture without causing post-necrotic fibrosis. At 12-21 weeks, they exhibited a normal histology except for mild pericellular fibrosis which developed along sinusoids or between adjacent hepatocytes. SECs expressed factor VIII-related antigen and showed a decrease in the number of fenestrae and porosity, still lacking any basement membrane but further retaining the functional capacity for carmine dye uptake. Stellate cells, while occasionally associated with large amounts of collagen bundles, contained many lipid droplets and expressed no alpha-smooth muscle actin, indicating a quiescent property. Kupffer cells were commonly found within the sinusoids. The present results indicate that arterialization of the liver induces a partial (but not complete) transition of SECs into capillary-type endothelial cells, suggesting that arterialization might be one of the factors which induce sinusoidal capillarization in the development of hepatocellular carcinoma.

1997年3月末までにCT during arterioportographyとCT during arteriography (CTA) を併用した血管造影下CT (angio-CT) を施行後に開腹した肝細胞癌 (肝癌) 103例中, angio-CT単独陽性結節は9例 (10結節, 9%) にみられた. 男女比は8: 1, 平均年齢は63歳. 8例にHCV抗体, 1例にHBs抗原を認めた. 臨床病期I期6例, II期3例で, 5例には肝硬変を認めた. 単独陽性結節径は平均1cm. 全例主病巣は別に存在し, CTAでhigh density areaを呈しangio-CT以外の画像診断法で描出されなかった. 術後平均観察期間は608日で, 5例に残肝再発がみられたが, angio-CT単独陽性結節からの残肝再発は肝深部に存在していた2結節 (20%) にみられた.angio-CT単独陽性結節のうち少なくとも20%は真の肝癌結節であるが, 肝辺縁部の結節は偽陽性結節の可能性が高い.

Tumor metastasis can be prevented by inhibiting angiogenesis. In the present study, we have demonstrated that the angiogenesis inhibitor TNP-470 also suppresses the development of primary hepatic nodules. Hepatocarcinogenesis was performed by the feeding of 2-acetylaminofluorene to hepatectomized rats during 8-14 weeks of age. Predominantly arterial-to-portal circulation and sinusoidal capillarization were determined by the staining of nodules with arterially infused ink and immunostaining for factor VIII-related antigen, respectively. Intraperitoneal administration of 30 mg/kg b.w. of TNP-470 twice a week significantly reduced the number of hepatic nodules. Among the nodules, hyperplastic nodules stained with ink, atypical hyperplastic nodules and hepatocellular carcinoma, all of which possess structurally altered sinusoidal endothelial cells or capillary-type endothelial cells, were dramatically decreased in number. Suppression was observed equally in nodules of all sizes. TNP-470 was more effective when administered during 8-20 weeks than during 14-26 weeks. In contrast, ink-non-stained hyperplastic nodules, which have normal sinusoidal endothelial cells, were not affected at all. The present results indicate that TNP-470 suppresses the development of primary hepatic nodules whose microvessels are capillaries or transitional forms from sinusoids to capillaries.

症例は52歳の男性. 1990年10月左腎癌の診断のもと左腎摘出術をうけ, 術後インターフェロンを投与された. 1996年10月検診の上部消化管造影検査にて異常陰影を指摘され, 精査の結果胃癌と診断された. 11月18日開腹すると胃角部に3×2cmのIII+IIc類似進行癌を認め, さらに空腸起始部に6×9cmの腫瘤を認めた. 胃癌に対し胃幽門側切除術, D2リンパ節郭清を, 小腸腫瘍に対し口側断端を十二指腸第4部とした小腸部分切除術を行った. 再建は空腸断端を十二指腸第2部に側側吻合したのち, BillothII法による胃空腸吻合を行った. 病理組織診断は胃癌は高分化型管状腺癌, 小腸腫瘍はmalignantlymphoma of mucosa-associated lymphoid tissueであった. 術後VEPA療法を施行し術1年7か月後の現在, 再発の徴候なく健在である.

Multicentric occurrence is an important characteristic of hepatocellular carcinoma. We evaluated clinicopathological criteria for multicentric hepatocellular carcinoma and identified risk factors for such carcinogenesis. Subjects were 251 consecutive patients undergoing liver resection for hepatocellular carcinoma. One kind of multicentric hepatocellular carcinoma had at least one tumor consisting of well-differentiated hepatocellular carcinoma, together with moderately or poorly differentiated hepatocellular carcinoma located in a separate region. The other kind had an area of well-differentiated component around hepatocellular carcinoma with less differentiation in all occurrences. The outcome of patients with tumors classified in this way was studied. Univariate and multivariate analyses were done to identify risk factors for multicentric hepatocellular carcinoma. The cumulative survival rate was significantly higher in patients with multicentric hepatocellular carcinoma than in patients with hepatocellular carcinoma associated with intrahepatic metastasis. Analysis by Cox's proportional hazard model showed that multicentricity was not a factor in the outcome. The risk of multicentric occurrence increases with progression of chronic liver disease. Univariate analysis showed hepatitis C virus marker and hepatitis B core antibody to be risk factors. By multivariate analysis, the odds ratio for multicentric occurrence in patients infected with hepatitis C virus and with serum hepatitis B virus core antibody compared with patients without either hepatitis C virus or hepatitis B virus was 10.86. This ratio in patients with hepatitis C virus alone was 4.30. These criteria for multicentric hepatocellular carcinoma seem to be clinically useful. Hepatitis C virus infection with or without former infection by hepatitis B virus is a strong risk factor for multicentric hepatocarcinogenesis.

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.

1993年末までの主腫瘍径2cm以下の小肝細胞癌 (肝癌) 切除82例を対象に, 術式と肝機能評価法, 予後との関係を検討した. 施行術式はHr2: 8例, Hr1: 11例, HrS: 20例, Hr0: 43例であり, 広範囲切除例の肝機能は良好であったが, 術式決定には術中の肝肉眼所見が最も重視されていた. 82例中39例が残肝再発したが, Hr2の予後は他の肝切除術式より良好であった. そこでHr2可能条件をICGR1515%以下, CS1, Z1以下と仮定すると, Hr2未満切除74例中12例がHr2可能例であったが, 再発は2例にすぎなかった. 逆にHr2未満施行で再発をきたした37例のうちHr2を行えば切除領域に再発病巣が含まれた症例は7例であったが, Hr2可能例は1例に過ぎなかった. 小肝癌に対する切除術式は再発からみると, 術前の肝機能成績および術中所見を考慮した現行の基準が適切であると考えられた.

高齢者肝細胞癌に対する拡大肝切除の限界と対策を検討するため, 肝切除施行肝癌391例のうち70歳以上を高齢者 (34例), 75歳以上を超高齢者 (7例) と定義, これらを他の非高齢者 (357例) と対比した. 非高齢者群の術死, 在院死は13例4%であったが, 高齢者群では6例15%であった (p

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.

From October 1983 to January 1995, we performed microwave coagulo-necrotic therapy (MCN) in 21 patients in whom another cancer nodules were detected intraoperatively or liver resection was dangerous due to severe cirrhosis. Seven were treated with MCN alone, other 13 cases were treated with MCN combined with partial hepatic resection, and one case was done with portal vein ligation. Preoperative results of fifteen minutes retention rate of indocyanine green were 6.4 to 45.8 (mean ; 27.0) %. The needle-electrode was punctured into various site of the tumor one to fifty times, and coagulations with microwave energy of 80 watts for 30 seconds at 15 seconds intervals were done. The treated lesions changed to avascular areas on dynamic CT at 1 and 6 postoperative months, and these lesions were completely necrotic histologically. The postoperative courses of 7 patients who received MCN therapy alone were uncomplicated except for one patient with severe cirrhosis. Long term prognosis after MCN were almost the same as that after liver resection. MCN is useful for treatment of unresectable HCC with minimal invasiveness.

Apoptosis was originally defined as shrinkage necrosis, as a distinct mode of cellular death from coagulative necrosis in the rat liver lobes after portal branch ligation. To reveal the functional role of the apoptosis of hepatocytes in the volume reduction and recovery of normal hepatic architecture in portal-deprived liver lobes, we ligated the portal vein branch supplying the left and median liver lobes in Wistar rats. The liver lobes were perfusion-fixed with glutaraldehyde solution via the proximal site of the ligated portion of the portal vein on Days 1, 2, 4, 7 and 14 after operation and examined light and electron microscopically. On Day 2 after ligation, massive necrosis of hepatocytes occurred in the central to intermediate zones of the liver lobule, and apoptotic hepatocytes were observed in the boundary region between necrotic and normal areas. Such necrotic area-associated apoptosis of hepatocytes was most frequent on Day 2, declining thereafter. The sequential changes of the cell organelles in apoptotic hepatocytes were distinct from those in necrotic hepatocytes. On Day 7, when necrotic areas had almost disappeared the apoptosis of hepatocytes occurred mostly between intact hepatocytes in the "combined hepatic cell cords" which included no obvious sinusoidal lumen between hepatic cell cords. Such necrotic area-nonassociated apoptosis began to increase in frequency on Day 4, reached a peak on Day 7 and was gone by Day 14, when normal hepatic architecture was recovered. The present study suggests that both necrotic area-associated and non-associated apoptosis of hepatocytes may be induced by mild ischemia and contribute in part to the volume reduction of ligated liver lobes. It further reveals that the necrotic area-non-associated apoptosis of hepatocytes plays a role in reconstructing the architecture of hepatic cell cords after necrotic hepatocytes have undergone dissolution in the liver lobule.

Although it is recognized that hepatobiliary scan is of value in assessing postoperative complications of biliary surgery or cadaveric whole liver transplantation, there have been few reports regarding its usefulness following living donor liver transplantation. We performed living donor liver transplantation in a patient with biliary cirrhosis due to hepatolithiasis, using a right lobe graft from her sister. On the 15th postoperative day, bile discharge appeared from the operative wound. The leakage point could not be identified by computed tomography and cholangiography from the biliary drainage catheter. Hepatobiliary scan with Tc-99m Sn-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) demonstrated biliary extravasation from the left side of the anastomosis of the hepatico-jejunostomy, indicating biliary leakage from the anastomosis. Conservative therapy was continued because the radioisotope flowed smoothly into the reconstructed jejunum and the biliary drainage catheter, and the leakage was stopped on the 63th postoperative day. Hepatobiliary scan is useful in determining the therapeutic plan as well as detection of bile leakage and identification of leakage points after living donor liver transplatation.

症例は胆嚢摘出術の既往を有する65歳の男性.肝膿瘍を繰り返すため胆道疾患の合併を疑い入院した.精査の結果, 総胆管結石症の他に早期胃癌を偶然発見し, 総胆管切開, 切石術と胃亜全摘術を施行した.その際尾状葉の肉眼所見, 術中胆道造影および超音波検査により尾状葉に限局する原発性肝内結石症を発見したため尾状葉切除術も追加した.結石成分は肝内・総胆管内ともコレステロール100%であった.尾状葉に限局する肝内結石症はまれな疾患であり, 術前診断は困難であったが, 尾状葉胆管の拡張と結石充満を反映する索状低吸収域を術前のCT像上看過していたことが判明した.一方, 術中超音波検査は簡便で結石の描出能に優れ, 部位診断にも有用であるため, 肝内病変の疑われる症例には励行されるべきである.

症例は57歳の女性,繰り返す上腹部痛の精査時,肝左葉を中心とする限局性肝内胆管拡張によりCaroli病(以下本症)と診断,尾状葉を含む肝左葉切除を施行した.肉眼的に悪性所見はなかったが,病理組織学的に拡張胆管の粘膜上皮内に限局する胆管細胞癌と診断された.諸家の報告では本症の約8%に胆管細胞癌を合併し,その要因として肝内結石による慢性刺激,長期間の胆汁鬱滞,繰り返す胆管炎さらには先天性の胆道奇形が考えられている.これらの発癌機序は総胆管拡張症や膵胆管合流異常症でも指摘されているが自験例は総胆管拡張や肝内結石を合併しない上皮内癌症例であった.また本例は拡張胆管上皮に著明な過形成や腸上皮化生がみられ,その部分に連続して癌化が認められ,発癌の背景を推測するには貴重な症例と考えられた.