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A randomized study was performed in 35 centers in the Kinki area of Japan to determine the effectiveness of ftorafur (FT) plus tamoxifen (TAM) compared with FT monotherapy in postoperative adjuvant therapy for breast cancer. Patients were randomized by the envelope method to receive either FT 600 mg/day or FT 600 mg/day plus TAM 20 mg/day orally for 1 year, starting on day 7 after mastectomy. Between April 1982 and January 1985, 628 patients were assigned to treatment with FT alone and 626 to treatment with FT+TAM. Of these, 571 (90.9%) and 539 (86.1%) patients, respectively, met the eligibility requirements for this study. There were no significant differences in major background factors between the two groups of eligible patients. Five-year survival rates were 91.4% for FT alone and 91.1% for FT+TAM (not significantly different). Five-year disease-free survival rates showed a tendency towards a better prognosis (P=0.090) in the FT+TAM group, with observed rates of 83.0% for FT alone and 86.7% for FT+TAM. Stratified analysis showed that disease-free survival with FT+TAM is better than with FT alone for patients aged 50 years or more (P=0.048) and for patients with from one to three positive nodes (P=0.064).

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

A 45-year-old woman complained of a painless breast mass, sized 2.5cm in diameter. It was diagnosed as fibroadenoma of intracanalicular type or benign phyllodes tumor. About one month later, breast mass appeared again, which could not be disappeared by aspiration, and was diagnosed as late onset hematoma. Its wall was coagulated under general anesthesia. Microscopic findings of the hematoma wall showed fibrosarcoma partially including the proliferation of cartilage, and it was proved that the hematoma was malignant phyllodes tumor. She died elevent months later after mastectomy. Inappropriate high levels of serum ALP and RI accumulation (99mTcMDP) in the breast mass were present. This case suggests that ALP (isozyme 3) may be an useful marker of malignant phyllodes tumor with proliferation of cartilage.

We performed a controlled study to compare the response to cyclophosphamide (CPA), adriamycin (ADM), and fluorouracil (5-FU) (CAF therapy) with that to uracil-tegafur (UFT) plus tamoxifen (TAM) (UFT+TAM therapy), when given as postoperative adjuvant therapy to women with breast cancer. The patients were registered from September 1991 through February 1995 at 51 institutions in the Kinki district of Japan. All patients had stage I, II, or IIIa breast cancer with four or more lymph-node metastases and underwent mastectomy. CAF therapy and UFT+TAM therapy were started within 4 weeks after surgery. CAF therapy consisted of CPA (100 mg/day) on days 1 to 14, followed by 2 weeks of rest, plus ADM (20 mg/m(2)/day) on days 1 and 8 and 5-FU (300 mg/m(2)/day) on days 1 and 8. A total of 6 courses were delivered. UFT+TAM therapy consisted of 3 years of UFT (400 mg/day) plus TAM (20 mg/day), given daily. CAF therapy and UFT+TAM therapy were each assigned to 82 patients. The 5-year survival rate was significantly higher in the UFT+TAM group (82.1%) than in the CAF group (66.2%; p=0.04, logrank test). The 5-year relapse-free survival rate was higher in the UFT+TAM group (61.8%) than in the CAF group (46.3%; p=0.07, logrank test). As for adverse events, the rates of leukopenia, anorexia, nausea and vomiting, general malaise, and hair loss were lower in the UFT+TAM group than in the CAF group. These results suggest that long-term treatment with UFT+TAM may be a useful alternative adjuvant therapy for the management of breast cancer, especially in elderly patients.

Two-dimensional Eliashberg equations have been solved by use of a mixed interaction with $s$- and $d$-channels. It is discussed what kind of pairing symmetry of the superconducting state can be realized when the channel mixing parameters and the band-filling are varied. By changing the mixing parameters and varying the chemical potential $\mu$ between zero- and half-filling, the pairing symmetry is determined and summarized into a phase diagram of the symmetry. It is revealed that there is an effective threshold in $\mu$ for the appearance of the d-wave superconductivity regardless of the strength of the $d$-channel interaction. It is also shown that, although the s-wave superconductivity can occur for any value of $\mu$ if the $s$-channel interaction is mixed sufficiently, the d-wave superconductivity has the advantage of achieving a high $T_{c}$ over the s-wave one, once it occurs., Comment: 11 pages, LaTeX

The usefulness of CAF [cyclophosphamide (CPA)/doxorubicin (ADR)/5-fluorouracil (5-FU)] + medroxyprogesterone acetate (MPA) therapy for advanced/recurrent breast cancer was studied in a randomised trial at 56 institutions. Patients received CAF therapy [CPA: 100 mg, orally, days 1-14; ADR: 30 mg/m2, intravenously (i.v.), days 1 and 8; 5-FU: 500 mg/m2, i.v., days 1 and 8) in arm I, or CAF + MPA therapy (CAF + MPA 1200 mg, daily) in arm II. The response rate was significantly higher (P = 0.041) in arm II (53.5%, 46/86) than arm I (36.6%, 30/82). The response rate by tumour site was significantly higher for lymph node and bone lesions in arm II. Partial response duration and overall response duration were significantly longer in arm II. Incidences of anorexia and nausea/vomiting were significantly higher in arm I but in arm II, moon face, oedema and vaginal bleeding were significantly higher. Many patients in arm II demonstrated improvement in performance status and weight loss, suggesting a beneficial effect of MPA. The chemoendocrine therapy with CAF + MPA appears to be more beneficial than CAF alone in the treatment of advanced/recurrent breast cancer.

We carried out percutaneous transhepatic portography (PTP) in 182 patients with liver, biliary tract, or pancreatic disease. With anterior and lateral views of selective portograms and stereoscopic x-rays, we investigated the ramifications of the intrahepatic portal vein. There were 3 patterns of branching of the portal trunk and of the left branch of the portal vein. There were 8 such patterns for the right anterior branch, with either 4 or 5 major branches arising from it. Branching of the right posterior branch was classified into 4 patterns; simple branching into 2 (one, the posterior superior branch, the other, the posterior inferior branch) was found in only 97 of the 164 cases inspected. These results suggested that the liver cannot necessarily be divided into 8 segments. Branching of the intrahepatic portal vein is very complex; therefore, the pattern of ramifications of the portal vein must be ascertained anew for every patient for whom systematic segmentectomy is contemplated.

肝切除33例と肝動脈結紮5例の門脈圧を術前後に測定し, その変動の背景因子を検討した.まず術直後の門脈圧が低下するか, またはその上昇率が10%未満のものをI型. 術直後10% 以上の上昇率を示し, 第5病日以降も低下しないものをIII型. その中間型をII型とした. その結果術後の門脈圧は肝硬変併存の有無よりも肝切除率によって大きく変化した. 術後の門脈圧と全身血行動態との間に明らかな関係がみられなかったが, 術後の総ビリルビン値はIII型で漸増し, 脾体積はII, III型で有意に増加していた. また予後不良例の門脈圧上昇率はきわめて高く, すべてIII型を呈した. したがって, 肝切除後の門脈圧測定は予後の予測にきわめて有用である.

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

患者は57歳,男.偶然AFP高値を指摘されて来院した.CT scan,超音波検査,及び動脈造影所見から肝右葉前区域の肝細胞癌と診断した.血液生化学検査上,肝硬変の所見はなく,経皮経肝門脈造影(PTP)施行時に測定された門脈圧も正常であったが,穿刺時の肝実質が極めて硬く,著明な線維化が示唆された.術前療法として,肝動脈塞栓術(TAE),経皮経肝門脈枝塞栓術(PTPE)を2週間隔で施した後,肝右葉前区域切除を施行した.切除標本上,腫瘍は単結節周囲増殖型,Edmondson II型,索状型の肝細胞癌であったが,非癌部の肝全体にはゴマ粒大の黄色斑が散在し,組織学的には,不規則に拡張した胆管様構造周囲に発達した線維組織がみられるmicrohamartomaであった.種々の肝・胆管系の先天性奇形は稀に胆管癌を合併するが,microhamartomaと肝細胞癌との合併報告は第1例目であるので,若干の文献的考察を加え報告した.

Submucosal esophagography is examined experimentally in rabbits and clinically to ascertain the cancer invasion to the adventitia of the esophagus before operation.

We have done a retrospective study of the clinical features, complications, surgical treatment, histological findings, and outcome of 27 adults with choledochal cyst (congenital biliary dilatation) whom we have encountered in the past 11 years. In 24 (88.9%) of them, an anomalous connection between the choledochus and the pancreatic duct was found by direct cholangiography, or during operation or autopsy; three also had carcinoma of the biliary tract. In congenital biliary dilatation, this anomalous connection seems to be a major factor in causing cholangitis and carcinoma of the biliary tract. For this reason, congenital biliary dilatation must be treated surgically. This involves resection of the dilated bile duct and the gallbladder to remove the place where bile stasis had been present, and reconstruction of the biliary tract to stop reflux of pancreatic juice in the bile duct.

As an esophageal substitute, a tubed gastric flap 2.5 cm in inner diameter and 38 cm in length, was constructed from the gastric wall along the greater curvature; a pedicle was attached to the gastric antrum, and its oral stump was brought up into the left supraclavicular fossa through a retrosternal tunnel to perform an esophagogastrostomy. Anastomotic breakdown occurred in only three of fifty cases in which this procedure was used.

We treated a patient with hepatocellular carcinoma in whom jaundice was caused by obstruction of the common hepatic duct because of compression by the tumor. Percutaneous transhepatic cholangiodrainage was performed preoperatively. The tumor was entirely in the medial segment of the liver, without invasion of the hepatic ducts, and medial segmentectomy was performed. As of the end of 1985, 58 cases of hepatocellular carcinoma complicated by extrahepatic obstructive jaundice have been reported in Japan. In only four was obstructive jaundice caused by extraluminal biliary compression. We review ten patients treated by liver resection.

A case of a rupture of splenic artery aneurysm, which is considered a rare condition, was successfully diagnosed preoperatively and treated. A review of the cases documented in Japan is also reported. A 60-year-old female was referred to us with complaints of sudden onset of epigastralgia and nausea. A child's fist sized, elastic hard mass with smooth surface in the left upper quadrant of the abdomen led the patient to receive CT scan and angiography, which revealed an aneurysm of 6.0×5.0cm in diameter at the root of the splenic artery. Severe anemia indicated an emergency laparotomy on the next day after admission. The aneurysm was found to be so close to the celiac axis that the abdominal aorta was clamped and the aneurysm was treated with aneurysmotomy and arteriorraphy, following splenectomy. The patient made an excellent recovery and was sent home on the 24th postoperative day. As far as we could find in documents, this case was the 31st one in Japan. Splenic artery aneurysms will be diagnosed more frequently because of further improvement of diagnostic techniques such as angiography.

肝切除施行small liver cancer (細小肝癌) 16例を検討した. 細小肝癌は無症状や不定愁訴の場合が多く, その発見にはhigh risk groupの設定とα-fetoprotein値の測定や超音波検査の施行が重要である. 腫瘍は全例結節型で, 被膜および被膜外浸潤はそれぞれ4例にみられたが, 脈管侵襲はみられなかった. 再発例を検討すると部分切除例, 被膜外浸潤例, TW (+) 例であり, 系統的肝区域切除術を行うべきである. 肝癌の占拠部位や肝機能によっては非切除療法を行わざるをえないが, 肝動脈塞栓術のみでは根治性は少なく, 経皮経肝門脈枝塞栓術などの併用が望ましい. 画像診断法の限界やその予後から, 細小肝癌は肝癌の早期癌に相当すると考えられた.

肝細胞癌の元凶ともいえる門脈内腫瘍栓の対策として経皮経肝門脈枝塞栓術 (percutaneous transhepatic portal veinembolization以下PTPE) を考案し, それを肝細胞癌17症例の術前に行ったのでその手技と成績を報告した.PTPE後門脈圧の亢進と多少の肝機能障害の出現をみたが, PTPEは動脈塞栓術 (transcatheter arterial embolization以下TAE) に比べ安全であった.また切除標本の塞栓状態と組織学的所見からみて塞栓物質としてリピオドール混入フィブリン糊が現在最も適していると考えられた.肝切除前に行われるPTPEはTAEの抗腫瘍効果を増強させ, 肝内転移の防止や肝切除後の肝再生ひいては手術適応の拡大にも有用であると考えられた.

患者は19歳の男性,生来健康で蛋白同化ホルモン剤等の服用歴はない.突然出現した右季肋部痛を主訴として東住吉森本病院に緊急入院した.症状は直ちに軽快したが,精査の結果肝腫瘍が疑われたため,当科へ紹介入院となった.入院時,理学的に異常所見を認めず血液検査上も異常を認めなかった.各種腫瘍マーカーは陰性であった.腹部超音波検査およびCT検査で肝右葉後区域に腫瘍性病変があり,腹部血管造影像上,右肝動脈は上腸間膜動脈より分岐しており,後上亜区域枝領域にhypovascular areaが認められた.リピオドール注入後のCT検査では,同病変にリピオドールの集積は認められなかった.肝生検で肝細胞腺腫と診断されたが,悪性腫瘍も否定し得ないため肝切除を施したところ,切除標本より肝細胞腺腫と確定診断された.術後約1年を経過した現在,再発はみられていない.

We wanted to use the Ganz thermistor catheter, developed to measure blood flow in human coronary sinuses, to measure portal venous flow, which is greater. We prepared a model circuit with a high flow rate and studied the method for suitability and reproducibility of the measurements. Correlation was close between the measured and calculated flow rates when the thermal indicator was injected at the rate of 48 ml/min. Measurements were highly reproducible. The catheter was then tested clinically. It was inserted into the portal trunk during percutaneous transhepatic catheterization to measure the portal venous flow. Measurements in patients with cirrhosis of the liver were close to those reported by other workers, and were reproducible. The results suggest that this method will be useful for the continuous local measurement of portal venous flow that varies with time, and will provide information about portal circulation in hepatic disease.

The effect of splenectomy on hepatic ornithine decarboxylase (ODC) induction, DNA synthesis, and mitosis of hepatocytes was studied in rat liver after partial hepatectomy. ODC activity markedly increased in the early stages of liver regeneration, and the increase in the activity was significantly enhanced in splenectomized rats. Splenectomy specifically induced ODC since tyrosine aminotransferase and general protein synthesis were not affected. Splenectomy also enhanced increase in hepatic polyamines, DNA synthesis, and mitosis in regenerating liver. The results suggest that splenectomy affects liver regeneration after partial hepatectomy by enhancing induction of ODC activity, which is an important biochemical event in the early stage of liver regeneration.

In recent years, cases of cardiac disease concomitantly occuring with malignant tumor have been increasing, giving rise to a new problem regarding indications for surgery in these cases, since they are not simple cardiac diseases. Here we report 6 cases we have experienced (AS with hepatoma, ASD with gastric cancer, MSr with hepatoma, IHD with cholangioma, MS with rectal cancer, ASD with gastric cancer). Four of these patients underwent surgery for both cardiac disease and for malignant tumor. Surgery for malignant tumor only was done in one case, while no operation was performed in the remaining case. From our experience with these cases, it is considered that cardiac surgery must be done first in cases of malignant tumor due to the attndant cardiac risk, unless the malignant disease is beyond surgical intervention.

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

A 61-year-old woman with profound hypothyroidism underwent surgery for a ventricular septal perforation 15 days following an acute myocardial infarction, with no preoperative thyroid replacement. Her immediate postoperative course was complicated by a low cardiac output, respiratory suppression and high output renal failure, requiring prolonged hemodynamic and respiratory support. Thyroid replacement (50 micrograms of thyronine and 100 micrograms of thyroxine daily) was given in two installments on the 2nd day after the operation. The effect of the inotropic agents increased gradually and the patient was weaned off intra-aortic balloon pumping. A large quantity of diuretics, hydration and hyperalimentation also successfully reduced her elevated BUN and serum creatinine. After full thyroid replacement, she was discharged in good health on the 40th postoperative day.

The activity of ornithine decarboxylase and the intracellular concentrations of putrescine and spermidine in the non-ligated lobes of the liver increased after portal branch ligation. These changes were followed by increased [3H]thymidine uptake into the acid-insoluble fraction of the liver. The induction of ornithine decarboxylase and changes in intracellular polyamines are important biochemical events in liver regeneration, so our results suggest that portal branch ligation causes formation of some stimuli that trigger liver regeneration. Changes were less with ligation than with partial hepatectomy.

The development of diagnostic equipment for sonography has not only caused a marked improvement in the preoperative diagnostic rate of primary carcinoma of the liver, but also has enabled us to conduct sonography during operations. During the past 2 years, intraoperative sonography was used in 41 cases of primary carcinoma of the liver. The main tumor was detected in 39 patients (95.1%), and daughter tumors were detected in 14 (63.6%) out of the 22 who had them. Tumor thrombi in the portal vein were detected in 2 (50%) of the 4 patients in whom they occurred. Since intraoperative sonography can clearly demonstrate intrahepatic ductal structures, it is useful for identification of hepatic and portal veins and the subsegment containing tumors (by a sonographically guided puncture). Of the various kinds of medical imaging available to us, intraoperative sonography is the final diagnostic procedure used before the last details of the operation are decided.

We retrospectively classified patients with hepatocellular carcinoma by the results of tests of 15-minute indocyanine green retention (ICGR15). Of the 201 patients with hepatocellular carcinoma admitted to our department in the past 6 years, 36 patients were assigned to group 1 (ICGR15 less than 10.0%), 81 patients to group 2 (ICGR15 = 10.1-20.0%), and 84 patients to group 3 (ICGR15 greater than or equal to 20.1%). Of the total 201 patients, 72% underwent liver resection (78% of group 1 patients, 80% of group 2 patients, and 62% of group 3 patients). We regarded the cirrhosis of the patients in group 3 as severe and studied their survival rate classified by the treatment used. Of these 84 patients, 52 patients were treated by liver resection, about half of whom were treated preoperatively by transcatheter arterial embolization (TAE). Another 9 patients were treated preoperatively by both TAE and portal vein embolization (PVE). At 2 years, and again at 3 years, the survival rate was significantly higher when TAE was used preoperatively than with resection alone. We think that the possibility of performing needed liver resection will be enlarged by preoperative PVE and that liver resection can be done more safely after use of PVE in some patients.

We are reporting on a comparison of serum concentrations of cefotaxime during and after surgery and on its passage to the wound fluid after surgery. Five patients undergoing mastectomy and dissection of the axillary lymph nodes for breast cancer were studied. Serum concentrations were compared after 2 g of cefotaxime dissolved in 20 ml of saline had been administered by i.v. bolus injection intraoperatively during general anaesthesia and six to eight days postoperatively in a conscious state. After intraoperative administration under general anaesthesia, cefotaxime serum concentrations were 157.3 mg/l at 15 min, 87.5 mg/l at 30 min, 43.08 mg/l at 1 h, 15.54 mg/l at 2 h and 9.56 mg/l at 3 h. In a conscious state, cefotaxime serum concentrations were 122.0 mg/l at 15 min, 84.35 mg/l at 30 min, 47.63 mg/l at 1 h, 18.2 mg/l at 2 h and 9.63 mg/l at 3 h, comparable to the time course under general anaesthesia. The half-life of cefotaxime was 0.86 h under general anaesthesia and 0.92 h in a conscious state. Urinary recovery of cefotaxime (0 to 3 h) under anaesthesia and in a conscious state was 53.8% and 56.3%, respectively (as reported previously for a non-surgical state). Samples of wound fluid were taken at the completion of surgery from the drain inserted subcutaneously into the wound or by means of a tracheal aspirator kit attached to a portable aspirator. Cefotaxime concentrations were determined postoperatively on days six to eight, when the wound fluid became no longer serous. The mean wound fluid concentration of cefotaxime was 5.53 mg/l after 2 h, 16.7 mg/l (peak) after 3 h, 14.65 mg/l after 4 h, 12.25 mg/l after 5 h and 7.9 mg/l after 6 h. Similar studies with other cephalosporins will also be mentioned for comparison.

A total of 325 patients with gastric cancer were subjected to total gastrectomy and proximal gastrectomy at our clinic during the 20-years period from 1965 to 1984. The incidence of postoperative esophagitis was as high as 24% in the 106 cases treated during the first 9 years. In 1974, therefore, we started to employ the following reconstructive procedures for the prevention of this complication: (1) procedures following total gastrectomy: (a) Roux-en Y, in which a distance of 40 cm was taken between anastomoses (esophagus-jejunojejunostomy) and (b) jejunal interposition between the esophagus and duodenum, in which a jejunal segment 40 cm long was used; and (2) procedure following proximal gastrectomy: jejunal interposition between the esophagus and stomach, in which a jejunal segment of appropriate length was used so that the distance between anastomoses came to 40 cm. As a consequence, the incidence of postoperative endoscopic esophagitis was reduced to 3.7%. However, 13% of the patients who received total gastrectomy and 18% of those who received proximal gastrectomy still complained of reflux symptoms. These incidences were higher than that determined after subtotal gastrectomy.

During the last 8 years, the authors had experience with 10 cases of carcinoma of the gallbladder with an anomalous connection between the choledochus and the pancreatic duct. These cases were studied in reference to age, sex, frequency of gallstones and dilatation of the bile duct, amylase levels in bile, direct cholangiograms, histologic findings, methods of treatment, and prognosis. Histologically, intestinal metaplasia was noticed in cancerous areas and also in noncancerous areas of differentiated adenocarcinomas. These facts suggest that in carcinoma of the gallbladder with this anomaly, reflux and stasis of pancreatic juice in the gallbladder may induce chronic cholecystitis which leads to mucosal metaplasia and, eventually, to differentiated adenocarcinoma.

An anomalous connection between the choledochus and the pancreatic duct may be associated etiologically or pathogenetically with congenital biliary dilation and carcinoma of the dilated bile duct. During the past 10 years, a total of 14 cases of carcinoma of the gallbladder with an anomalous connection between the choledochus and the pancreatic duct were encountered. These cases were studied in reference to their clinical features and histological findings. An experimental model of pancreatic juice inflow into the gallbladder of mongrel dogs was produced and the histological changes of the mucosa of that organ was observed. The intent was to elucidate the relationship between carcinoma of the gallbladder and this anomaly. The results of this clinical and experimental study suggest that reflux and stasis of pancreatic juice in the gallbladder induce chronic cholecystitis with intestinal metaplasia. This may be important in the pathogenesis of well-differentiated carcinoma of the gallbladder.