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Diffuse large B-cell lymphoma (DLBCL) with spindle cell components is extremely rare and often misdiagnosed as carcinoma or sarcoma. Here, we present a case of primary DLBCL with spindle cell components arising in the liver, for which a preoperative diagnosis by needle biopsies was unsuccessful. The patient was a 70-year-old man with a continuous cough. Thoracic computed tomography incidentally detected a mass of 5 cm in diameter in his liver. The initial and second needle biopsies from the liver mass were pathologically diagnosed as suspicious for sarcomatoid hepatocellular carcinoma. He underwent an extended left hepatectomy. Histological examination revealed a diffuse or epithelioid arrangement of round and polygonal cells, mixed with the fascicles of spindle-shaped cells. Immunohistochemically, all the morphological types of tumor cells showed positive reactions for a lymphocytic marker (CD45RB) and B-cell markers (CD20 and CD79a). Double-immunostaining revealed that the spindle-shaped tumor cells expressed CD20, but never expressed alpha-smooth muscle actin. Malignant lymphoma with a spindle cell morphology is quite uncommon, and this variant can be a diagnostic pitfall, especially in tiny biopsy specimens. We emphasize that pathologists should be reminded of lymphoma as a differential diagnosis of spindle cell tumors.

In 25 cancer patients treated with slow-release oral morphine (MS Contin® in 12 patients and Kadian® in 13 patients) and in 10 cancer patients treated with continuous infusion of morphine, plasma steady-state concentrations of morphine (M), morphine-3-glucuronide (M-3-G) and morphine-6-glucuronide (M-6-G) were determined by HPLC. Blood samples were withdrawn at 0 hr, 2 hr, 6 hr after oral administration in patients treated with slow-release oral morphine and once or twice a day in patients treated with continuous infusion of morphine. In 4 cancer patients treated with continuous infusion of morphine, in order to analyze chronopharmacokinetic variability, M-3-G/M ratio was observed at 12: 00 h and 24: 00 h.No significant changes were observed in M-3-G/M ratios and M-6-G/M ratios at 0, 2, and 6 hr after administration of oral morphine. There was no difference between Kadian® and MS Contin®.The M-3-G/M ratio (38.6±25.7) in the oral morphine group was significantly higher than that (15.3±12.9) of the continuous infusion group (p

This case report concerns a 62-year-old female who was known to have cirrhosis. An endoscopic examination showed no evidence of haemorrhaging due to either oesophageal or gastric varices. Angiographic studies demonstrated extravasation from the ileal varices. There was a prominent arterio-portal shunt in the liver, and the shunt was considered to be a contributing factor to induce portal hypertension and variceal bleeding in the ileum. Therefore, transcatheter arterial embolization was performed, but was unsuccessful. As a result, the patient underwent a laparotomy, and a dilatating ileocaecal vein and a communicating ovarian vein were selectively ligated. Following the procedure, the haemorrhaging stopped and she then recovered. The patient is doing well 21 months after surgery at the time of writing.

We report a case of gastric aberrant pancreas showed complicated histological findings combined with submucosal abscess formation and ulceration of gastric mucosa. A 47-year-old man was admitted to another hospital complaining of urticaria after drinking and eating. He was reffered to the hospital after a gastric lesion was detected by a gastrointestinal endoscopic examination. The findings of both upper gastrointestinal sereis and an endoscopic examination revealed a smoothly elevated lesion with enlarged folds and stiff wall located in the upper portion of the stomach. An abdominal magnetic resonance imaging showed a heterogeneous thickning of gastric wall, and no significant accumulation was detected in a gallium scintigram. These examination and intraoperative findings aroused a strong suspicion of a scirrhous gastric cancer. A total gastrectomy and regional lymph nodes dissection were thus performed. In the resected specimen, a submucosal tumor with ulceration of mucosa was found in the upper portion of the stomach. Pathologically, on a cut section, a light yellow tumor and fibrous tissue were found. A microscopic examination revealed an aberrant pancreas tissue with submucosal abscess formation and no evidence of malignancy.

Superoxide anion radical[formula]is one factor related to ischemia/reperfusion injury to the liver. The sites of[formula]production and injury have yet to be determined. Superoxide dismutase (SOD), a specific scavenger for[formula], has an inhibitory effect on injury caused by[formula]. SOD is of low molecular weight; hence, it has a short half-life in the circulating blood. Mannosylated SOD is taken up in sinusoidal endothelial cells of the liver by receptor-mediated endocytosis. In rats with an occluded inflow against 70% of the liver for 30 min followed by reperfusion there were elevations of serum aspartate aminotransferase and alanine aminotransferase, and lipid peroxide concentrations in liver tissue were significantly inhibited by intravenous administration of mannosylated SOD compared to treatment with normal saline. Electron microscopic examination showed that mannosylated SOD protected against damage to the sinusoidal endothelial cells caused by ischemia/reperfusion and that conventional SOD had no such protective effect. Thus,[formula]produced by ischemia/reperfusion apparently damages sinusoidal endothelial cells, and damage to hepatic parenchymal cells is secondary. Mannosylated SOD deserves further study for possible use in surgical resection of the liver and for liver transplantations.

Superoxide dismutase (SOD) 誘導体のmannosylated SODは肝非実質細胞に, galactosylatedSODは肝実質細胞に取り込まれ, 肝由来の活性酸素の効果的な消去を期待しうる.そこで, ラット肝移植実験でこれらの単糖類で修飾したSODを使用し再灌流障害に対する効果を検討した.通常のSODと修飾型SODを肝移植再灌流直前に投与し再灌流30分後に犠牲死させ, 血液および肝組織を採取して血液一般肝機能, 肝組織Na+, K+-ATPase活性, 組織過酸化脂質 (LPO), 組織SOD活性を測定した.移植再灌流によって血中逸脱酵素の上昇と肝組織Na+, K+-ATPase活性の有意の低下, LPOの増加とSOD活性の低下を認めた.これらの障害は通常のSODでは抑制されず, 単糖類で修飾したSOD, ことにgalactosylated SODによりNa+, K+-ATPase活性低下は抑制され, 組織LPO, SOD活性の改善が認められ, 再灌流時に発生する組織障害の防止に有効と考えられた.

消化器外科領域での好中球エラスターゼ (PMNE) の臨床的意義を明らかにする目的で, 膵頭十二指腸切除術, 胸部食道全摘術, 胃全摘術症例を対象に術前後の血漿中PMNE-α1プロテアーゼインヒビター複合体濃度 (PMNE-API), PMNEindexと術中術後の諸因子および術後合併症併発例との関係を統計学的に検討し次の結論を得た.(1) PMNEの過剰放出に起因したMOFに際し, PMNE-APIとPMNEindexはその臨床症状の出現に先行し異常高値を示した.(2) 縫合不全, 腹腔内膿瘍などの合併症併発時にPMNE-APIとPMNEindexは有意に上昇遷延したが, 適切な治療により正常値に復した.(3) 手術侵襲が大きい術式ほどPMNE-API, PMNEindexの上昇に個体差が認められた.これらの結果から, PMNE-APIとPMNEindexの術後の動態を把握することで, 個々における手術侵襲の程度や術後合併症の発症, 程度, 治療効果についての客観的情報を得ることが可能と考えられた.

A total of 97 patients with recurrent hepatocellular carcinoma (HCC) after hepatic resection in the 2nd Department of Surgery, Nagasaki University School of Medicine were reviewed to determine recurrent modes of HCC by tumor size and the location. The patients, comprising of 81 men and 16 women with an avarage age of 51.6 years, were divided into 3 groups according to tumor size, i.e., group A: 3cm or less in diameter, group B: between 3cm and 5cm, and group C: 5cm or more. In patients with intrahepatic recurrence, the bilateral lobes were most frequently involved in 3 groups and then, ipsilateral lobe was involved in group A. When the initial tumor locations were classified according to Couinaud's segment, the bilateral lobes of recurrence were more frequently involved in S7 or S8 than those in S5 or S6, and intervals between the first operation and recurrence in S7 or S8 were shorter than those in S5 or S6. These results suggest that large hepatic resection should be performed even in patients with small HCC, if they have well preserved hepatic function and surgical manipulation at operation may affect tumor recurrence.

The purpose of this study was to determine the correlation between expression of ras oncoproteins and the tumor stage or outcome of patients with gastric carcinoma. After the specificity of each anti-ras monoclonal antibody was confirmed by protein immunoblot analysis, immunohistochemical assays for a common-ras antigen present in N-, Harvey- and Kirsten (K)-ras oncoproteins, as well as for K-ras specific antigen, were performed on paraffin-embedded carcinoma tissue from 110 patients who underwent curative resection. By Western blot analysis, there was more p21 in fresh cancer specimens than in normal specimens. K-ras expression distinguished advanced from early gastric carcinoma and correlated with depth of cancer invasion. Among the 110 patients, survival rates of those with carcinomas positive for the common-ras or K-ras antigens were significantly lower than of those with antigen-negative carcinomas (p < 0.05). In a multivariate analysis, nodal involvement (p = 0.002), serosal invasion (p = 0.012) and K-ras p21 expression (p = 0.044) were independently predictive of the recurrence. These results suggest that K-ras p21 is a useful marker of tumor progression and poor prognosis after curative resection.

A case of early gastric cancer with sarcoid reaction observed in the regional lymph nodes without metastasis and in the stomach wall around the carcinoma tissues is presented. A 64-year-old woman was diagnosed as flat type (IIb) early gastric cancer on anterior wall of the gastric angle by endoscopic examination and biopsies. In February 1991, distal gastrectomy with D2 lymph node dissection and sampling of No. 12 and 16 lymph nodes was performed in this patient. Regional lymph nodes including No. 7, 8, 9, 12 and 16 were enlarged consecutively. Postoperative pathological diagnosis was moderately differentiated tubular adenocarcinoma which was limited within mucosa. No metastasis but numerous epithelioid cell granulomas were observed in the dissected lymph nodes. No bilateral hilar lymphadenopathy in a chest X-ray film was found and no skin nor ocular lesions were seen in this patient. Serum level of angiotensin converting enzyme was within normal limit, 12.5 IU/L. This case was diagnosed as having an early gastric cancer with sarcoid reaction. She has been doing well without any evidence of recurrence of gastric cancer for 2 years and 7 months after the operation. Twelve cases of early gastric cancer with sarcoid reaction in the regional lymph nodes have been reported in the Japanese literature. Clinicopathological characteristics of this disease are discussed with these cases.

This study is designed to study the influence of splenomegaly on the risk and outcome following hepatectomy in 75 patients with hepatocellular carcinoma (HCC). Spleen volume was measured by preoperative CT findings and divided into 3 groups, i.e., group A: less than 120cm3, group B: between 120 and 300cm3 and group C: more than 300cm3. In order of group A, B, and C, the frequency of association of liver cirrhosis or esophageal varix increased, but the platelet count decreased. There was no significant difference among three groups in preoperative ICGR15 value. Intraoperative bleeding volume in group C tended to be larger than other two groups, without significant difference. There were no significant differences in mobidity rate among 3 groups, 52.0% in group A, 41.7% in group B and 57.0% in group C. The 5-year cumulative survival rates were 49%, 54%, and 68% in group A, B, and C, respectively. There was no significant difference among these rates, but it tended to increase with the volume of the spleen. It is thought that the influence of spleen volume on the morbidity rate and surgical outcome can be negligible in patients undergoing hepatectomy for HCC.

To assess the postoperative outcome of jaundiced patients and to select the optimal timing for surgical intervention, indocyanin green (ICG) concentrations in the bile were measured after biliary decompression in patients with obstructive jaundice. The maximal excretion rate of ICG in the bile was calculated as a function of time (ICG Bmax). Among 59 patients with positive ICG Bmax values, morbidity was 15.2% and postoperative hospital mortality was 3.3%. However, the morbidity and mortality in nine patients with values between -0.5 and 0 were 88.8 and 44.4%, respectively. The 13 patients with in ICG Bmax below -0.5 had a 76.9% morbidity and a 61.5% mortality. The patients with ICG Bmax values below 0 showed a significantly higher morbidity and mortality than positive ICG Bmax patients. In patients showing ICG Bmax values below -0.5, surgery is contraindicated despite intensive postoperative care. The ICG Bmax value improved according to the increasing effect of biliary decompression. The index is useful not only as a prognostic index in the early phase of biliary decompression but also as an index of bile secretory capacity at a given time. By means of time course measurement of this index, the suitable time for operation can be determined. The ICG Bmax is a useful and reliable indicator in the assessment of hepatobiliary functional reserve in jaundiced patients after biliary decompression and prior to further surgical intervention.

A total of 143 patients who underwent hepatic resection for hepatocellular carcinoma in our department were reviewed. The review was conducted for two periods: 1970-1982 (early period) and 1983-1990 (late period), that is, the periods before and after introduction of the hepatic surgical technique involving the use of a microwave tissue coagulator and ultrasonic dissector. One patient underwent extended lobectomy, 12 lobectomy, 9 segmentectomy, and 26 partial hepatectomy during the early period. Two patients underwent extended lobectomy, 7 lobectomy, 9 segmentectomy, 36 subsegmentectomy, and 41 partial hepatectomy during the late period. Operative mortality and hospital mortality were 16.7% and 22.9% during the early period and 1.1% and 8.4% during the late period, respectively. The overall mortality rate was significantly lower during the late period than during the early period. Postoperative complications developed in 62.5% of the patients with hepatic resection during the early period and in 48.4% of the patients during the late period. The size of tumors during the early period was significantly greater than that during the late period. Intraoperative blood loss during the late period was significantly lower than that during the early period. The survival curve was better among patients who underwent hepatic resection during the late period than among those during the early period. The satisfactory results during the late period are due to the introduction of intraoperative ultrasonography, microwave tissue coagulation, and ultrasonic dissection for hepatic surgery.

Five patients with peripancreatic abscesses associated with severe acute pancreatitis were treated by hyperbaric oxygen therapy (HBO). In 3 patients, the course after surgical mobilization of the pancreas and drainage of the pancreas bed was complicated by peripancreatic abscesses. HBO was conducted under a pressure of 2.8 atmospheres for two hours daily. Four of the 5 patients showed a progressive improvement in their condition. In one patient who failed to respond despite seven sessions of HBO, Pseudomonas aeruginosa was isolated from the discharge, and resection of necrotic tissue and drainage were performed. The main effects of HBO were the alleviation of high spiking fever, the improvement of white blood cell count and serum amylase levels, and the reduction of the abscess size. We recognized HBO to be a successful treatment for peripancreatic abscess associated with severe acute pancreatitis and better results were obtained than in cases that did not receive HBO.

To evaluate the incidence and period of gallstone formation after gastrectomy for a carcinoma, questionnaire survey has been conducted in 316 patients. Replies were obtained through 81% of the patients. Except for 48 unknown cases, 31 (15%) out of the 209 patients had gallstones. Additionally, 5 patients had gallbladder debris, 3 had cholesterol polyp, and one had acute cholecystitis. Overall 40 patients (19%) had some gallbladder disease. In 50 patients undergoing total gastrectomy, 13 (26%) had gallstones, and 17 (34%) had some gallbladder diseases. Gallstone was found within 5 years after gastrectomy in 14 cases, between 5 to 10 years in 12 cases, and after 10 years in 5 cases. In 26 cases (84%), gallstone was found within 10 years. Cholecystectomy was done in 13 patients, but 18 patients had no symptom and have been periodically checked at the outpatient clinic. In 13 cholecystectomised patients, 9 had black stone, and 2 had bilirubin stone. In the remaining 2 cases, nature of the stone was unclear. There was no cholesterol stone. In follow up of postgastrectomy patients with gastric cancer, special attention should be given to gallstone formation as well as recurrence. In such situation, the adequacy of prophylactic cholecystectomy would be a further problem to be solved.

肝内結石症に対する肝外側区域切除術の10年後に胆管細胞癌と診断され, 特異な経過をたどった1例を報告する.症例は57歳の男性.47歳の時, 急性胆嚢炎の診断により胆嚢摘出術を施行されたが, その後も胆管炎症状が持続.精査の結果, 肝左葉の肝内結石の診断により同年, 肝外側区域切除を施行された.51歳の時, 総胆管結石の診断で内視鏡的乳頭切開術をうけた後は無症状にて経過していた.今回, 発熱および心窩部痛にて発症.心窩部には外胆汁瘻の形成を認めた.精査の結果, 肝断端付近に発生した腫瘍が腹壁, 横隔膜などに広範囲な浸潤をきたしていた.入院後, 腹腔内膿瘍が心嚢へ穿破し, 化膿性心外膜炎, 心タンポナーデを併発し, 入院後3か月で死亡した.肝内結石症の診療に際しては, 同時性および異時性の胆管癌合併を常に考える必要があり, 肝内胆石症に対する手術においては, 拡張胆管を含めた肝切除術が必要であると考えられた.

A 72-year-old man was admitted to our hospital because of upper abdominal pain and weight loss. Abdominal ultrasonography revealed a 4×4 cm hypoechoic tumor in the head of pancreas. Selective celiac angiography showed encasement of the posterior superior pancreatoduodenal artery. Pancreatoduodenectomy was carried out under a diagnosis of pancreatic cancer. The resected specimen showed that the tumor was stony-hard and 4 cm in diameter. Histological examination denied pancreatic cancer and demonstrated severe chronic pancreatitis. We report a case of so called “tumor forming pancreatitis” which is occasionally differentiate from pancreatic cancer.

245例の肝細胞癌 (HCC) 中40歳未満の若年者症例を13例 (5.3%) 認めたのでその特徴について検討した. 13例中肝疾患の既往, 家族歴, HBs抗原陽性の3因子をいずれも欠くのは3例のみであった. 非若年者に比べ若年者HCCでは肝硬変の合併率が53.8%と有意に低かったが, 逆にHBs抗原陽性率は66.7%と有意に高かった. 血清alpha-fetoprotein値400ng/ml以上の頻度が75%と有意に高く, 3分の1の症例で10,000ng/ml以上の異常高値を示した. 切除例の病理組織所見で両者に違いはなかったが, 若年者HCCの核DNA量はanueploidが80%を占めていた. 若年者HCCは非若年者に比べ進行例が多い傾向を示したが, その予後に有意な差はなかった. 非切除例の予後は不良であったが, 切除例では長期生存も得られており, 早期発見・早期治療が望まれた. そのためにはHBキャリアーの厳重な経過観察が重要であると考えられた.

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.

黄色肉芽腫性胆嚢炎 (xanthogranulomatous cholecystitis) は胆嚢癌との鑑別が困難とされているが, 超音波検査ならびにcomputed tomography (CT) 検査など画像診断にて鑑別が可能であった症例を経験したので報告する.症例は54歳女性.右季肋部痛の消腿後に, 胆嚢に腫瘍性病変を指摘されて来院した.超音波検査では胆嚢底部に全周性に壁肥厚を認め, 胆嚢内腔は狭小化していた.肥厚した胆嚢壁内には結節性にhyperechoic lesionを認め, 同部は造影CTでlow density areaとして描出された.また, 胆嚢頸部には最大径約5cmの結石を認めた.血管造影では胆嚢動脈は拡張し, 肥厚した胆嚢壁に沿って屈曲蛇行した細動脈の増生がみられたが, encasementは明らかでなかった.以上より, 胆嚢癌を否定し, XGCの診断のもとに胆嚢摘出術を施行した.切除標本の胆嚢壁内には黄色の結節を認め, 組織学的には同部にxanthoma cells, リンパ球および異物型巨細胞を認めた.

1969年10月より1990年10月までに経験した膵頭領域癌 (十二指腸癌, 原発不明癌を除く) 切除例114例の予後および予後に関与する因子について検討した.症例の内訳は膵頭部癌55例, 乳頭部癌34例, 下部胆管癌25例であり, 平均年齢はそれぞれ64.0±11.7歳, 59.3±12.3歳, 62.1±11.5歳であった.このうち膵頭部癌の予後が最も悪く (p

Sixteen long-term (more than 5 years) survivors after hepatic resection performed for hepatocellular carcinoma (HCC) from 1970 to 1988, were reviewed. The mean age of the patients was 51 years. There were 11 males and 5 females. HBs antigen was positive in 9 patients. Liver cirrhosis was associated with 11 patients but its severity was designated as Child's A in all patients except one. The mean tumour diameter was 2.8 cm and was relatively small. At the first operation, limited procedures (i.e. partial hepatectomy and subsegmentectomy) were employed in 87.5% of patients. A large percentage of tumours were located in S5 and S6 segments. A recurrence of HCC occurred in 9 patients after the first resection. A second resection was carried out in 7 patients, in 2 of which a third resection was done. Transcatheter arterial embolization (TAE) was performed on 4 patients. These results show that, in addition to detection of small tumours and early resection, repeated operation or TAE for treatment of recurrent HCC was important in achieving long-term survival after HCC resection.

Liver cirrhosis can cause specific circulatory dynamics such as hyperdynamic state, and a retension of Na or water, which easily result in irrerversible pathological changes. If perioperative management of hepatectomy for hepatocellular carcinoma associated with liver cirrhosis is performed without recognition of these circuratory states, sever postoaperative complications are often inevitable. Some reports had suggested the usefulness of limiting the fluid and sodium in postoperative management. Postoperative complications after hepatectomy in 40 cases of cirrhotic hepatoma in our department were studied to estimate the effects of fluid management. As a result, the cases infused with a less than 45ml of fluid/kg/day or less than 3mEq of sodium/kg/day had good prognoses. It is important for appropriate perioperative transfusional management of a patient with cirrhotic hepatoma to comprehend his or her hyperdynamic state.

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.

A patient with advanced rectal cancer was complicated by progressing proteinuria and hypoproteinemia. Low anterior resection was a procedure of choice. A surgical specimen obtained by intraoperative renal biopsy showed the findings of minimal change nephrotic syndrome. After surgery, nephropathy remitted promptly and completely. Her pre/postoperative serum level of vascular endothelial growth factor was 1,880/52.3 pg/ml, suggesting its elevation was associated with the nephropathy. Immunohistochemistry revealed strongly expressed tumor vascular endothelial cell growth factor. Minimal change nephrotic syndrome is a rare type of paraneoplastic nephropathy, and successful remission may require therapeutic resection of the underlying tumor, or administration of a vascular endothelial growth factor antagonist if the tumor is unresectable.

Mesenteric lymphangioma is one of the least frequently encountered types of benign tumor. This case report concerns a 31-year-old pregnant woman with a mesenteric cystic lymphangioma in the ileum. The multiloculated cystic mass was noted near the uterus by CT before the patient became pregnant. After becoming pregnant, she was followed without treatment for the asymptomatic mass. At 25 weeks' gestation, however, she underwent emergency surgical treatment for small bowel obstruction. Concomitant small bowel resection was performed to remove the cyst. Herein we review seven reported cases of mesenteric benign tumor in pregnancy and explore the clinical features.

Ileosigmoid knot is one of the causes of intestinal obstruction, but it is very difficult to make a correct preoperative diagnosis of the disease. This rare condition with high mortality is usually found in adult patients and has rarely been reported in children. We recently experienced two patients with ileosigmoid knot. One was a 4-year-old boy and the other a 60-year-old man. Both patients had suffered the sudden onset of abdominal pain. The boy was in a state of shock on admission. Abdominal computed tomography findings indicated intestinal obstruction. In laparotomy, intestinal resection and detorsion without resection were performed for the boy and adult patients, respectively. We herein report a case of ileosigmoid knot in which the patient was the youngest reported in the English literature, and showed that the computed tomography examination provided valuable information in both patients.

A 27-year-old man was admitted to Nagasaki University Hospital complaining of fever. Percutaneous trans-hepatic cholangiography revealed multiple cystic dilatations of the intrahepatic bile ducts of the right lobe, as well as three obvious cystic dilatations and several small dilatations of the intrahepatic bile ducts of the left lobe. An extended right lobectomy was performed. However, the patient later suffered from repeated cholangitis and required the administration of antibiotics as a result of remnant cystic dilatations and stricture of the extrahepatic bile duct following hepatectomy. A slight enlargement of the remnant cystic dilatations, but no new cystic dilatations, were also recognized in the regenerating liver. We reviewed nine cases of hepatectomy for Caroli's disease reported in the Japanese literature, as well as our own case. Among these, four of the seven patients subjected to hepatic resection involving unilateral lobe demonstrated a good recovery. On the other hand, it is difficult to successfully treat Caroli's disease involving both lobes of the liver by hepatic resection.

We investigated the antitumor effects of adriamycin (ADM) encapsulated in 3 types of liposomes using rat hepatom cells (AH66) in vitro and in vivo. Liposomes were coated with cholesterol pullulan (CHP) and 1-aminolactose conjugated to CHP (lactose CHP) as a molecular recognition site for cancer cells. Antitumor activity of ADM encapsulated in lactose CHP was the most effective compared to that of liposomes alone or CHP on AH66 cells assyed by MTT test in vitro. Furthermore, growth of the tumor (AH66 cells) implanted into BALB/c mice was markedly inhibited by the treatment with ADM in lactose CHP-coated liposomes. Thus, lactose CHP-coated liposomes are an effective drug carrier for active targeting chemotherapy on cancer cells.

Two cases of intrahepatic gallstones with stenosis of the common hepatic duct caused by overriding of the right hepatic artery are described. The probable diagnosis of the compression of the bile duct by the artery was obtained by superimposing a direct cholangiogram on an angiogram. The final diagnosis was made at operation. The first patient was successfully treated by resection of the compressed common hepatic duct with Roux-en-Y hepaticojejunostomy anterior to the right hepatic artery. In the second patient, lateral segmentectomy and cholangiojejunostomy were performed.

肝細胞癌に対する術前肝動脈塞栓術施行例25例と非施行例23例の病理学的検索を行った.スポンゼル単独使用群8例と, 抗癌剤併用群17例とは壊死率に差はなく, 手術を前提として肝動脈塞栓術を行う場合塞栓物質のみにて肝動脈塞栓術を行い早期に腫瘍を含む硬塞病変の切除を行うべきものと考えられた.壊死組織の診断には鍍銀染色が有用であり, 完全壊死例を含め肝細胞癌として特徴を示すものが多く診断価値があるものと考えられた, また肝動脈塞栓術から手術までの期間による組織修復過程は, 形態学的に経時的なパターンを示さなかった.これは結節の大きいものは修復過程の遅延が起るものと考えられた.

To determine problems involved in the treatment and diagnosis of pancreatic cancer, a collective study of small carcinoma of the pancreas (2 cm or less in diameter) was performed. One hundred six cases were collected and analyzed. The results were as follows: In small carcinoma of the pancreas, the resectability rate was 99.0% and the operative mortality rate was 4%. Only 44% of the patients belonged to Stage I, and 14% belonged to Stage III or IV. Lymph node involvement, capsular invasion, retroperitoneal invasion, and vascular invasion were found in 30, 20, 12, and 9% of the patients, respectively. The postoperative cumulative 5-year survival rate was 30.3%, and that of Stage I was 37.0%. A small-sized tumor of the pancreas is not always an early carcinoma, but a tumor in Stage I may be regarded as an early carcinoma. Percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography were the main diagnostic indicators in cases with and without jaundice, respectively. There was no specific single serum test for detecting small pancreatic cancer.

過去4年間に経験した胃癌および大腸癌の肝転移症例 (胃癌10例, 大腸癌14例) について, 転移巣ultrasonography (US) 像を比較検討した. 腫瘍の大きさは大腸癌 (4.6±1.3cm) の方が胃癌 (3.3±1.4cm) より有意に大きかった. 形状は両者ともに大きくなるにつれ球形からヤツガシラ形となる傾向を認めた (p

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.

A male patient with an arterio-portal fistula resulting from a mesenteric arteriovenous malformation, who developed portal hypertension and liver cirrhosis, is presented herein. The malformation was considered to be congenital in origin and its location made any ablative surgical procedure impossible. Such alternative treatments as ligation of the afferent arteries, followed by transarterial embolization were therefore given, but both were unsuccessful. We also present a review of the literatures of mesenteric arteriovenous fistula. Radical surgical approach for this rare entity is proposed. The case reported here as related to mesenteric arteriovenous communications of congenital origin is the seventh such case published, and the first which was ever found to be located in the trunk of the superior mesenteric artery.