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原発性肝細胞癌切除例のうち術前リピナドール (Lp) 併用肝動脈塞栓術 (Lp-TAE) 施行後にcomputed tomography (Lp-CT) を行った30例について検討した.男性27例, 女性3例であり, 平均年齢は59.5歳であった.肝硬変の併存は24例 (80%) に認めた.Lp-CTにて腫瘍内のLp集積像は4型に分類できた.I型: びまん性集積型 (16例), II型: 斑状集積型 (7例), III型: 点状集積型 (4例), IV型: 微少集積型 (3例).I型は小結節に, IV型は大結節に多い傾向であった, Lp-TAE前後での50%以上の血清alphafetoprotein減少率の頻度はI型80%, II型50%, III型80%, IV型50%であった.平均腫瘍壊死率はI型79.6%, II型52.1%, III型13.8%, IV型63.3%であったが, I型にのみ100%の完全壊死を7例に認め腫瘍壊死効果が良好であった.腫瘍の組織型では索状型の場合腫瘍壊死効果が良好で, 充実型, 偽腺管型では不良となる傾向であった.Lp-TAE後のLp-CT像からLp-TAEの効果判定がある程度可能であると考えられた.

Point mutations at codons 12 and 13 of c-Ki-ras gene were analyzed in human pancreatic cancer. DNAs obtained from sample tissues were amplified by means of polymerase chain reaction and were analyzed by dot blot hybridization assays with oligonucleotide probes appropriate for detecting mutations at these codons. Out of 38 evaluated cases, point mutations at codon 12 were found in 35 cases; these mutations resulted in changes of the coded amino acid to aspartic acid in 24 cases, to valine in 9 cases, to arginine in 2 cases and to cysteine in one case. In one case, a glycine-to-aspartic acid mutation was found at codon 13. In two cases, two distinct mutations were simultaneously present. The frequency pattern of mutations at codon 12 was somewhat different from those given in two previous reports on the similar analysis of pancreatic cancers in European countries. This may indicate the presence of possible genetic or non-genetic factors in determining preferential mutational patterns at these particular codons.

A total of 103 patients with unresectable hepatocellular carcinoma (HCC) treated in the Second Department of Surgery, Nagasaki University Hospital from September 1969 to December 1987 were reviewed. Unilateral ligation of the hepatic artery was done on 9 patients, unilateral ligation of the portal vein branch on 3, catheterization into the hepatic artery for infusion of anticancer drugs on 16, transcatheter arterial embolization (TAE) on 23 and other treatment with or without systemic chemotherapy on 52. The one, two or three year cumulative survival rate of the total cases was 14%, 9% or 4% respectively. The outcome of the 23 patients treated with TAE was better than that of the other patients. Macroscopic stage classification and clinical stage classification reflected the prognosis of the disease. However, the factors with or without hepatitis B-antigen, liver cirrhosis or high levels of serum AFP before the treatment did not influence the prognosis. Recently, we have done a combination therapy with TAE, tumor reduction surgery and infusion therapy via both hepatic artery and portal vein on 4 patients with unresectable HCC. The average survival period of these patients were better than that of other patients, but not significantly.

手術後に発生した広範囲肝梗塞の2例を経験したので報告した.症例1は62歳男性で肝門部胆管癌に対する門脈合併切除を伴う肝左葉兼尾状葉切除後にS8領域に発生した肝梗塞であり, 症例2は46歳男性で胃癌再発例に対する門脈, 肝動脈合併切除兼再建を伴う膵頭十三指腸切除後に発生したものである.前者は術後1か月目に肝不全にて失ったが後者は救命しえた.また肝梗塞の発生機序として, 症例1は剖検により門脈再建部は良好に開存しているのが確認されたが, 右肝動脈前枝が腫瘍に巻き込まれていたため結紮切除しており, その支配領域 (S8) が広範囲に肝梗塞に陥っていた.症例2は胆管空腸吻合部の減圧目的として挿入したretrograde transhepatic biliary drainage tubeで肝内血管を損傷し, その肝内血管支配領域に肝梗塞が発生したと考えられた.これら肝梗塞の診断, および反省点について考察を加え報告した.

This study attempts to define early carcinoma of the extrahepatic bile duct through a study of 11 patients whose carcinomatous invasion did not extend to the outer layer of the bile duct. The patients were divided into the following 3 groups, namely; a mucosa group comprised of 3 patients, a fibromuscular layer group comprised of 5 patients, and an adventitia group comprised of 3 patients. None of the patients had any lymphnode metastases. Histological characteristics were determined according to infiltrative growth (INF alpha, beta, gamma), lymphatic invasion (ly), venous invasion (v) and perineural invasion (pn). In the mucosa group, INF alpha was observed in 2 patients, while ly, v, and pn factors were all negative. In the fibromuscular layer group, INF beta was seen in 3 patients, ly was positive in 2 patients, while v, and pn factors were negative in all patients. In the adventitia group, INF gamma was found in 2 patients, and ly, v, and pn factors were positive in all patients except for 1 in whom v was negative. Death from recurrence occurred in all the adventitia group patients and in 1 other patient. Early carcinoma of the extrahepatic bile duct could therefore be defined at present, as being carcinoma confined to within the mucosa and fibromuscular layer.

The surgical treatment of acute pancreatitis remains controversial. Since 1969, we treated 60 patients with acute pancreatitis. In 34 with severe acute pancreatitis who were not responding adequately to intensive medical care, surgical intervention was made by mobilization of the pancreas from retroperitoneal tissue and drainage of the pancreatic bed (M-D procedure). Thirty-four operative cases were classified into 7 edematous, 7 hemorrhagic, and 20 necrotizing. Macroscopic findings of the pancreas did not correlate either to the severity of the acute pancreatitis or to the mortality rate. Eight of 34 who underwent M-D procedure died (23 per cent), but the rate became 14.7 per cent after excluding 3 who died of unrelated causes. These data suggest that the M-D procedure is highly effective in the treatment of early cases of severe acute pancreatitis. There was an associated marked reduction in the mortality rate with the prophylactic use of broad spectrum antibiotics. With M-D procedure, there was a low incidence of late sequelae of pancreatic or peripancreatic abscess.

Eighty-seven patients with carcinoma of the gallbladder treated in our hospital over a 15-year period were reviewed. Macroscopic curative resection was performed in 30 cases, 6 of which received second-look operations, and their cumulative five-year survival rate was 42.6 per cent. Histological and clinical analysis of our cases initially diagnosed by postoperative histologic examination revealed that the depth of carcinomatous invasion was the most important criterion for the indication of second-look operation, and that the second-look operation is mandatory for the inapparent carcinoma limited to the muscularis or subserosa. The surgical procedures of the second-look operation were: resection of the anterior inferior and medial inferior areas of the liver and dissection of the regional lymph-nodes. The presence of invasion of carcinoma to the cut end of the cystic duct or severe carcinomatous invasion to the lymphatic vessels were also important histopathologic findings for a second-look operation. Cases in which lymphatic invasions are remarkably observed, should receive an en bloc hepato-cholecystectomy plus a resection of the extrahepatic bile duct with neural tissues and soft fatty tissues in the hepatoduodenal ligament in a two-stage operation.