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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.

We retrospectively reviewed postoperative complications in 105 patients with hilar cholangiocarcinoma who underwent hepatectomy at Nagoya University Hospital from January 1990 through March 1999. Of the 105 subjects, 97 (92.4%) underwent resection of two or more Healey's segments of the liver. Combined portal vein resection was performed in 33 (31.4%) patients and pancreatoduodenectomy in 10 (9.5%). Twenty (19.0%) patients had no postoperative complications, another 39 (37.1%) patients had minor complication(s) only, and the remaining 46 (43.8%) developed major complication(s). The morbidity rate reached as high as 81.0%. Major complications required relaparotomy in 11 (10.5%) patients. Of the 46 patients with major complication(s) 36 recovered; the remaining 10 patients died of liver failure with other organ failure(s) or of intraabdominal bleeding 12, 14, 18, 21, 57, 75, 75, 87, 93, or 134 days after surgery. Thus the 30-day mortality was 3.8% and the overall mortality 9.5%. Pleural effusion was the most frequent complication found in 66 (62.9%) patients, followed by wound sepsis in 39 (37.1%), and then liver failure in 29 (27.6%). Liver failure developed in 16.7% of 48 patients with less than 50% liver resection and in 36.8% of 57 patients with 50% or more resection (P < 0.05). Other organ failures, including renal, respiratory, gastrointestinal, and hematologic failures, developed as a sign of multiple organ failure following liver failure in most patients or preceding liver failure in a few patients. None of the six patients with four or more organ failures survived. Hepatectomy for hilar cholangiocarcinoma is risky owing to impaired hepatic functional reserve in jaundiced patients and the technical difficulty associated with hepatobiliary resection. Our goal is to reduce mortality to less than 5% while keeping a high resectability rate (above 80%).

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.

Combined resection of the celiac artery with a distal pancreatectomy (DP) increases the resectability and improves the overall prognosis of patients with locally advanced ductal cancer of the body and tail of the pancreas.Carcinoma of the body and tail of the pancreas is often unresectable because of invasion to adjacent organs. We evaluated a DP including an en bloc resection of the celiac artery ("extended"), for pancreatic cancer that had invaded the common hepatic and/or celiac arteries.Six cases of an "extended" DP were compared with 19 cases of a "standard" DP for pancreatic ductal carcinoma in terms of clinical and pathologic findings, perioperative course, and long-term outcome. We also compared the survival rate of these two groups with a third group consisting of 22 patients with unresectable pancreatic ductal carcinoma.The mean operative time, postoperative serum aspartate aminotransferase concentration, and length of hospital stay did not significantly differ between the "extended" and "standard" DP groups. The cumulative 1- and 3-yr accumulated survival rates for the "extended," "standard," and unresectable groups were 40.0, 33.3, and 5.4, and 20.0, 16.6, and 0%, respectively. Statistically significant differences (p0.01) existed between the "extended" and unresected groups.

Cholangiocarcinomas that produced clinically recognizable mucin (mucin-producing cholangiocarcinomas) were studied in ten patients. These ten represented 5.8% of all cholangiocarcinomas resected at our department. All tumors arose from the intrahepatic bile ducts. Macroscopically, the ten tumors were classified as: “ductectatic type” (n=3), in which papillary tumors developed in diffusely dilated intrahepatic bile ducts; “cystic type” (n=5), in which a large cystic tumor was present in the liver; and “intermediate type” (n=2), characterized by a large cystic lesion and a solid mass that infiltrated the liver parenchyma. Histologically, four tumors remained localized to the mucosal layer and six invaded the fibrous layer and the liver parenchyma. The invasion pattern of the six invasive cancers resembled that of the most common type of cholangiocarcinoma. Superficial spread of the cancer contiguous to the primary tumor was observed in four of the ten patients.

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 recurrent tumor with intrabiliary ductal growth after hepatic resection for liver metastasis from rectal cancer is presented. The patient, a 55-year-old female, underwent subsegmentectomy of the anteroinferior and posteroinferior areas of the liver for metastatic liver cancer on August 29, 1988. Computed tomography in February 1990 showed dilatation of the intrahepatic bile duct in the right anterosuperior subsegment (B8), in which a filling defect was detected by cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter. Percutaneous transhepatic cholangioscopy (PTCS) revealed a protruding lesion without tumor vessels. Cholangioscopic biopsy revealed dysplasia, but not adenocarcinoma. However, recurrent tumor originating in the resected margin of the remnant liver was suspected, and resection of the right lobe of the liver and partial resection of the duodenum were therefore performed. The resected specimen showed a tumor, 4 cm in diameter, in the previous resected margin, forming a protruding lesion with a rough surface (measuring 10×20 mm) in the B8 bile duct. This case suggested the possibility of cancer recurrence in the resected margin of the liver after hepatectomy for metastatic colorectal cancer, with intrabiliary ductal tumor growth showing segmental biliary dilatation.

Background. Disseminated intravascular coagulation (DIC) after hepatectomy is not well understood. The objective of this retrospective study was to evaluate hemostatic changes after extensive liver resection and to elucidate the frequency of posthepatectomy DIC. Methods. In 100 patients without cirrhosis who underwent resection of two or more segments of the liver for biliary tract carcinoma, various hemostatic parameters were measured before and after resection, and the liver function of each patient was assessed. Results. In patients with posthepatectomy liver failure, platelet count, fibrinogen concentrations, and prothrombin time were significantly lower than in those without such failure. Serum levels of fibrin degradation product did not differ significantly between the two groups. The minimum platelet count was significantly negatively correlated with serum total bilirubin level. Posthepatectomy DIC occurred in 2.0% of the patients. Conclusions. After extensive liver resection patients exhibited a decreased platelet count with hepatic dysfunction. However, this condition rarely resulted in DIC, at least in patients without cirrhosis and serious postoperative complications.

Stepwise logistic and discriminant analyses were used to define the risk factors for hepatic failure after liver resection for carcinoma of the biliary tract and to predict this complication. The logistic analysis identified the linear pattern of oral glucose tolerance test, cholangitis, pancreatoduodenectomy, and indocyanine green disappearance rate as the factors most related to hepatic failure among 18 pre- and perioperative parameters of the past 84 hepatectomized cases (55 hilar bile duct carcinomas and 29 gallbladder carcinomas). Our discriminant formula using five variables, including the above-mentioned four plus the liver resection rate, could distinguish the patients with posthepatectomy liver failure (n = 25) from those without (n = 59) with 86.9% accuracy, 96.0% sensitivity, and 83.1% specificity. The cross-validation test has confirmed that this model was robust for discriminant analysis. The results of this study show that statistical multifactorial analysis makes possible the preoperative prediction of hepatic failure after liver resection for carcinoma of the biliary tract.

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.

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.

Interventional treatments such as transcatheter arterial embolization and placement of a biliary endoprosthesis have been carried out in cases of inoperable hepatobiliary malignancy. We report here a case of recurrent intrabiliary tumor thrombi due to hepatocellular carcinoma, successfully treated by cholangioscopic ethanol injection in which the intrabiliary tumor thrombi were completely eliminated.

OBJECTIVES: Superficially spreading carcinoma of the esophagus, consisting mainly of intraepithelial carcinoma, is not as rare as was previously thought. Despite the surgical significance of this entity, no general definition has been established, and the clinical features of this disease remain to be clarified. METHODS: A total of 54 patients with superficial carcinoma of the esophagus (defined as carcinoma limited to the epithelium or superficially invading the lamina propria or submucosa) were classified into two groups according to the longitudinal extent of the lesion. A total of 13 patients with superficially spreading carcinoma (defined as a superficial carcinoma measuring >5 cm and consisting mainly of intraepithelial carcinoma) were compared to 41 patients with nonspreading esophageal carcinoma. RESULTS: One patient with superficially spreading carcinoma had a positive resection margin because of multiple cancerous lesions. The only significant difference in the clinical and pathological features of the two groups was a higher prevalence of associated multiple cancerous lesions in patients with the superficially spreading type. CONCLUSIONS: Superficially spreading carcinoma of the esophagus is often associated with multiple cancerous lesions. For endoscopists and esophageal surgeons, it is important to define the proximal extent of intraepithelial cancer and the presence of multiple cancerous lesions to perform curative resection.

Mucin -p roduc ing i n t r a h e p a t i c bile duct c a r c i n o m a is a r a r e b i l i a ry t r a c t ma l ignancy . Desp i t e the develo p m e n t of m o d e r n d iagnos t ic technologies such as u l t r a s o n o g r a p h y , c o m p u t e d t o m o g r a p h y , a n d ang iography , the prec ise d e t e r m i n a t i o n of the ex ten t of th is t u m o r is difficult because of the a m b i g u i t y caused by the a b u n d a n t muc in sec re ted by the t u m o r and/or by the superf ic ia l mucosa l s p r e a d of the t u m o r a long the bile duct. 1-3 Given these problems, select ive p e r c u t a n e o u s t r a n s h e p a t i c b i l i a ry d r a i n a g e (PTBD) and p e r c u t a n e o u s t r a n s h e p a t i c cholangioscopy (PTCS) are i nd i spensab l e for the accu ra t e s t ag ing of th is cancer . 3-6 We repor t the case of a p a t i e n t who u n d e r w e n t the successful resec t ion of a m u c i n p r o d u c i n g bile duc t ca rc inoma. The c a r c i n o m a was d iagnosed p reope ra t ive ly as o r ig ina t ing in the left c a u d a t e lobe a f t e r P T B D and PTCS.

Glucose intolerance and impaired insulin secretion are often associated with obstructive jaundice. Our objective was to determine whether such abnormalities would be ameliorated after jaundice was relieved by biliary drainage.Twenty-four patients with hepatobiliary malignancy prospectively underwent intravenous glucose tolerance test with femoral and portal blood sampling, and the kinetics of insulin release were determined. Sixteen patients had obstructive jaundice (group A) that had been completely relieved by percutaneous transhepatic biliary drainage by the time of intravenous glucose tolerance testing, and eight patients exhibited no jaundice (group B).Integrated immunoreactive insulin (sigmaIRI, 10 muU min/ml; mean +/- SD) and integrated C-peptide (sigmaCPR, 10 ng min/ml) in the portal blood in group A were significantly lower than those values in group B (sigmaIRI: group A, 436.0 +/- 260.6; group B, 714.3 +/-287.2; p0.01; sigmaCPR; group A, 26 +/- 10.1; group B 49.5 +/- 18.8; p0.005). The hepatic insulin extraction ratio (portal-femoral difference of sigmaIRI divided by portal sigmaIRI) in group A was significantly higher than that in group B (group A, 0.75 +/- 0.06; group B, 0.55 +/- 0.05; p0.001), whereas the hepatic CPR extraction ratio did not differ significantly between the two groups (group A, 0.37 +/- 0.10; group B, 0.39 +/- 0.05).The impaired insulin secretion caused by obstructive jaundice is not fully reversed after percutaneous transhepatic biliary drainage. The high hepatic extraction ratio of insulin in patients who had been treated with percutaneous transhepatic biliary drainage may compensate for the impaired insulin secretion, although its mechanism is still unclear.

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.

当外科における1973年までの胃癌結腸合併切除例は394例で胃癌手術例の6.9%に相当する.これら結腸合併切除例に対し外科治療の立場から検討した.結腸および結腸間膜浸潤例は28.3%を占め予後的漿膜面因子PS (+) は66.3%で, 肉眼癌型では浸潤型が多かった.5生率は11.4%であり, PS (+) 例のそれは23.5%であり治癒切除例の5生率は32.9%であった.癒着か浸潤かは肉眼的には判別しがたい場合があり, 癒着と判定した中に9.8%は浸潤例があったために結腸癒着例または浸潤型の結腸間膜癒着例ならびに限局型でも癒着部分を切除後, 結腸への血行が保持できないような症例には積極的に合併切除すべきであると考える.