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Heart rate variability (HRV), especially increased high frequency (HF), has been reported to provide clinically useful prognostic information regarding cardiovascular disease. Napping is an excellent sleep management strategy in older adults. This study was conducted to clarify the effect of napping on HRV in older adult patients with cardiovascular risk factors. The patients were divided into two groups: one group of 32 patients who reported napping (nap group) and another group of 45 patients who did not report napping (nonnap group). The HRV was calculated in terms of the HF component over 24 hr during wakefulness, sleep, and 1 hr after sleep onset. The HF in the nap group was significantly higher than that in the nonnap group during all times measured. In addition, napping was a significant predictor of increased HF. This study shows the effectiveness of napping in the daily lives of patients with cardiovascular risk factors.

This study evaluated the effect of increased physical activity on high-frequency (HF) heart rate variability (HRV) during the first hour after sleep onset in patients with hypertension and/or stable angina pectoris. Physical activity and HF were measured using activity monitors and 24-hour Holter monitors at baseline and 6 months later. The physical activity increased in 28 patients (increase group) and decreased in 20 patients (decrease group) after 6 months. In this study, after 6 months, compared to the decreased physical activity group, the increased physical activity group showed a significant increase in the HF index during the first hour after sleep onset. Therefore, the increase in the HF index may have been due to the increase in physical activity. An increase in physical activity suggests that the quality of sleep early in the sleep cycle may be improved, which may affect the patient’s prognosis.

AIMS AND OBJECTIVES The present study investigated whether morning or afternoon activity is more effective at increasing the high-frequency (HF) index, a parasympathetic index, in patients with cardiovascular risk factors. BACKGROUND A decreased HF index, a heart rate variability (HRV) parameter, is a well-established marker of poor cardiovascular prognosis. Because blood pressure and sympathetic tone are higher in the morning, physical activity and exercise in the afternoon has been recommended for patients with cardiovascular diseases. However, there have been no reports concerning the superior effects of afternoon exercise on parasympathetic activity and sleep. DESIGN This observational study was a post hoc comparison. METHODS Patients' physical activity was measured for 1 month to determine their habits. Patients' HF index was measured by 24-h Holter electrocardiography. The study enrolled 56 patients. Each patient's morning step count (before lunch) and afternoon step count (between lunch and dinner) were compared. We adhered to the STROBE guidelines in the present study. RESULTS Thirty-one patients took more steps in the morning, and 25 patients took more steps in the afternoon. The present study showed that those who took more steps in the afternoon had a significantly higher HF index during the first hour after sleep onset and during sleep than those who took more steps in the morning (p = .003, .047). CONCLUSIONS The present study showed that those who took more steps in the afternoon had a significantly higher HF index during the first hour after sleep onset and a higher HF index during sleep than those who took more steps in the morning. RELEVANCE TO CLINICAL PRACTICE Exercise in the afternoon may improve the prognosis in patients with cardiovascular disease by not only preventing excessive blood pressure, afterload, and sympathetic tone but also positively influencing the parasympathetic system and sleep.

Aim The purpose of the present study was to elucidate the relationship between high-frequency heart rate variability (HF HRV) and continuous daytime sitting time in patients with cardiovascular risk factors such as mild hypertension and/or stable angina pectoris. Background Decreased HF HRV precedes the progression and worsening of cardiovascular diseases. Continuous sitting behavior is a major risk factor for developing metabolic syndrome and is associated with cardiovascular disease, diabetes mellitus, renal failure, sarcopenia and osteoporosis. Risk factors for cardiovascular disease can be affected by continuous daytime sitting behaviors. Design The present study design was a post-hoc comparison. Methods Patients treated at two different primary care clinics from 2014 to 2018 were enrolled in this study (n = 53). We assessed HF HRV and continuous sitting time using 24-hour Holter electrocardiography and an activity meter at baseline and 6 months. HF HRV was calculated during sleep. Results Sitting time had decreased in 22 patients (decreased group) and increased in 31 patients (increased group) after 6 months. The mean patient ages were 73.1 and 72.0 years in the decreased and increased sitting time groups, respectively (p = 0.503). HF HRV during sleep had increased after 6 months in the decreased sitting time group. Compared with the increased group, the decreased group showed significantly higher HF HRV during sleep after 6 months by two-way repeated-measures ANOVA after adjustment for age, sex and change in activity (p = 0.045). Conclusion These results suggest that a decrease in sitting time might induce parasympathetic activity during sleep. Therefore, reducing continuous sitting time during the day might contribute, in part, to improving the prognosis of patients with cardiovascular risk factors not only by avoiding muscle loss but also by providing positive influences on parasympathetic tone during sleep.

We examined the feasibility of umbilical diverting ileostomy for overweight and obese patients with rectal cancer undergoing laparoscopic surgery. Four patients who were overweight or obese (BMI > 27 kg/m2) were initially scheduled for the creation of a conventional loop ileostomy. Intraoperatively, however, this was considered too complicated because of thick subcutaneous fat, bulky mesentery, or both. Instead, patients received a diverting ileostomy with the placement of an umbilical stoma. All patients had protruding umbilical ileostomies. No severe stoma-related complications were encountered. One patient had minor skin dehiscence, and another had paralytic ileus but resumed oral intake after a short time. Performing a temporary loop ileostomy at the umbilicus was safe and feasible in this small group of overweight and obese patients. This stoma placement may avoid the problems inherent to conventional loop ileostomy in obese subjects.

Background Intrapericardial diaphragmatic hernia (IPDH), defined as prolapse of the abdominal viscera into the pericardium, is a rare clinical condition. This case illustrates the possibility of IPDH after esophagectomy with antethoracic alimentary reconstruction, although such hernias are extremely rare. IPDH often presents with symptoms of bowel obstruction such as abdominal discomfort or vomiting. If not properly treated, life-threatening necrosis and/or perforation of the herniated contents may occur. Case presentation A 68-year-old Japanese man underwent subtotal esophagectomy with three-field lymph node dissection for treatment of esophageal cancer. Completion gastrectomy with perigastric lymph node dissection was also performed because the patient had previously undergone distal partial gastrectomy for treatment of gastric cancer. The alimentary continuity was reconstructed using the pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. The patient was readmitted to our hospital because of abdominal discomfort and vomiting 6 months after the esophagectomy. A diagnosis of IPDH after esophagectomy was made. The patient was treated by primary closure of the diaphragmatic defect using vertical mattress sutures and additional reinforcement of the closing defect using a graft harvested from the rectus abdominis posterior sheath. The postoperative course was uneventful, and he was discharged on the seventh day after hernia repair. Conclusions This patient’s clinical course provides two important clinical suggestions. First, we must be aware of the possibility of iatrogenic IPHD after esophagectomy with antethoracic alimentary reconstruction. Second, a graft from the rectus abdominis posterior sheath is beneficial in the treatment of IPDH.

We examined the feasibility of umbilical diverting ileostomy for overweight and obese patients with rectal cancer undergoing laparoscopic surgery. Four patients who were overweight or obese (BMI 27 kg/m

Early colorectal cancers are defined as invasive tumors that are lim ited to the mucosal layer or submucosal layer (SM), regardless of the presence or absence of lymph node (LN) metastasis. The reported incidence of LN metastasis of SM1 colon cancers is 0 - 5.9%, but the incidence in SM2 and SM3 colon cancers could be as high as 11.3 - 25.0%, and risk factors for LN metastasis include depth of SM invasion, growth patterns (polypoid or non-polypoid), histological sub-classification (moderate or poor differentiation) and regional lymphatic and vascular invasion. Among colorectal cancers with non-polypoid growth, the malignant potential is higher for depressed, than polypoid types, even for small tumors. Herein, we describe a patient with small, depressed-type early colon cancer with extensive LN metastasis and superficial SM invasion (pSM 450 μm). Six courses of chemotherapy with mFOLFOX6 and bevacizumab reduced the size of the LN metastases, thus eliciting a partial response (PR) according to the response evaluation criteria in solid tumors (RECIST).

症例は66歳，女性．平成20年10月25日発熱と腰痛を主訴に受診．CT検査にて第3腰椎に腫瘤性病変を認めたため生検施行．病理組織検査にて悪性リンパ腫（diffuse large B-cell lymphoma）と診断された．11月5日THP-COP療法開始．12月17日CT検査にて腫瘍の縮小を認めたため3クール目開始．12月25日腹痛出現．CT検査にて消化管穿孔と診断され緊急開腹術施行．空腸に穿孔部を認め，穿孔部の小腸は後腹膜に強固に癒着していた．小腸部分切除術を施行した．病理組織所見では穿孔部の腸壁は壊死し周囲には好中球・慢性炎症細胞浸潤を伴う肉芽組織を認めた．周囲の漿膜下の動脈・静脈には器質化血栓による血管内腔の狭窄が見られ，血管障害による血流障害が穿孔の原因と考えられた．

A 73-year-old man underwent abdominoperineal resection for a rectal cancer. He developed a hip pain 3 years and 6 months after the surgery. A CT scan revealed a local recurrence in the perineum and multiple lung metastases in the bilateral lung. He received systemic chemotherapy consisting of XELOX with bevacizumab. Thereafter, the hip pain was slightly relieved. The hip pain worsened 1 year and 6 months after the recurrence. The border between the perineal tumor and skin was very narrow, and conventional radiation therapy could cause a perineal skin necrosis and subsequent poor wound healing. Therefore, we selected a Cyberknife treatment. The hip pain was relieved and a CT scan showed a reduction of the perineal tumor's size after the Cyberknife treatment. A Cyberknife treatment may be effective and promising as palliation for patients with local recurrence of rectal cancer.

A 76-year-old man presented with many bullous lesions and erythema over his whole body in August 2014. Blood examination showed an elevation of the anti-BP180 antibody (658 U/mL) and a biopsied specimen of the skin lesions showed subepidermal bulla. A diagnosis of bullous pemphigoid was made based on the clinical and histological findings. Although 20 mg/day of prednisolone was administered, there was a poor response and consequently the dose of steroid was increased to 70 mg/day after 2 weeks. Bullous pemphigoid related to a malignant tumor was suspected. Colonic endoscopic examination revealed a sigmoid colon cancer and he underwent a sigmoidectomy with lymphodenectomy. The histopathological findings revealed a moderately-differentiated adenocarcinoma, pT1b, pN1, pStage Ⅲa, and he received adjuvant chemotherapy(UFT/ LV). The dermatological findings were rapidly relieved after tumor resection and anti-BP180 antibody was normalized. He has had no signs or symptoms of recurrence, both of the cancer and the bullous pemphigoid, for 9 months after the operation.

A 63-year-old man who had a history of rectal cancer and was treated with low anterior resection in February 2006, presented with liver metastases in September 2007 and underwent right anterior sectionectomy of the liver. He developed a pelvic wall recurrence with buttock pain in September 2009. This was treated with conventional radiation therapy and Cyber- Knife. The buttock pain was relieved after CyberKnife treatment and the patient received systemic chemotherapy in the outpatient clinic. Subsequently, he developed a left sacral recurrence with buttock pain and gait disturbance in August 2013. Since the tumor was located close to the field previously subjected to radiotherapy, we opted for CyberKnife treatment again. Although the pain subsided, our patient died of lymphangitic carcinomatosis in April 2014, 7 years and 2 months after the surgery. In this case, CyberKnife was effective in treating pelvic recurrence with pain, and thus, may have a significant role to play in the multidisciplinary treatment of metastatic colorectal cancer.

Background In 100 consecutive patients with node-negative breast cancer who underwent curative surgery, we prospectively tested whether detection of circulating tumor cells in peripheral blood by means of reverse transcription-polymerase chain reaction for carcinoembryonic antigen (CEA) messenger RNA (mRNA) could predict patient outcomes. Methods We performed reverse transcription-polymerase chain reaction in blood samples taken before surgery and in repeat samples taken 2 to 3 weeks after surgery. Univariate and multivariate analyses of relapse-free survival were performed. Results Patients with CEA mRNA in preoperative samples had poorer survival rates than those who had no detectable CEA mRNA. The worst survival rate was seen in those with CEA mRNA in both pre- and postoperative samples. Stepwise multivariate analysis selected CEA mRNA expression pattern (P = .001; relative risk = 0.69) and histologic tumor grade (P = .002; relative risk = 1.35) as independent prognostic factors for disease-free survival. Conclusions Molecular detection of CEA mRNA in both pre- and postoperative blood samples is an independent, negative prognostic factor in patients with node-negative breast cancer undergoing curative surgery.

Intrahepatic cholangiocarcinomas that secrete macroscopically excessive mucin into the biliary system are rare, and few of the previously reported cases have achieved a curative resection. We defined these tumors as "mucin-producing intrahepatic cholangiocarcinomas" and clarify the optimal preoperative and surgical management for them. Eleven patients with mucin-producing intrahepatic cholangiocarcinomas underwent surgical resection in our department. The clinical, radiologic, surgical, and pathologic findings were studied. The clinical presentation of the 11 patients included repeated abdominal pain, jaundice, and fever. Conventional cholangiographies, such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography, could not offer precise information about tumor location and extension because of abundant mucin in the biliary system. Using percutaneous transhepatic biliary drainage (PTBD) and percutaneous transhepatic cholangioscopy (PTCS), we were able to drain the mucin and determine precisely the cancer extension into intrahepatic segmental bile ducts. Based on these findings, various types of liver resection with or without extrahepatic bile duct resection were planned, and 10 patients obtained curative resection. The cumulative 5-year survival rate after curative resection was 78%. In patients with mucin-producing intrahepatic cholangiocarcinoma, PTBD and PTCS are important for evaluating the cancer extension. Rational surgery based on accurate preoperative diagnosis improved the prognosis of patients with this disease.

症例は47歳，女性．片頭痛，緊張型頭痛のためindomethacinを内服していた．腹痛と嘔気，嘔吐を主訴に受診．腹部単純X線と腹部CTで小腸閉塞と診断した．保存的治療にて症状改善しないため開腹手術を施行した．手術所見では回盲弁より20cm口側の回腸に硬結を触れ，その部位より口側の小腸は拡張していた．硬結部を含む小腸部分切除術を行った．切除標本では隔膜様の輪状狭窄と輪状潰瘍を認めた．病理組織所見では粘膜固有層から粘膜下層に達する潰瘍の形成を認め，潰瘍底では好中球浸潤を伴う肉芽織の形成を認めた．NSAIDの使用歴があり，NSAID起因性のdiaphragm diseaseと診断した．

A 55-year-old woman presented to hospital with epigastric pain and jaundice. Diagnostic imaging studies revealed a biliary stricture of the hepatic confluence and a hepatic tumour of the left and caudate lobes with a portal tumour thrombus, which occupied the main portal trunk, the umbilical portion of the left portal vein, and the right anterior and posterior portal branches. Left hepatic trisegmentectomy, caudate lobectomy, portal tumour thrombectomy, bile duct resection and bilioenteric anastomosis were performed. There were no other lesions, and so it was diagnosed as a primary lymphoma of the liver (B-cell, diffuse, large cell type). The patient underwent postoperative chemotherapy and has remained well for 4.5 years after surgery. Primary lymphoma of the liver is very rare, and this is the first case report with bile duct invasion and tumoral occlusion of the portal vein.

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.

Objective To clarify the importance of different patterns of infiltration at the proximal border of hilar bile duct carcinomas. Summary Background Data There are few detailed pathologic studies on the proximal resection margins in patients with hilar bile duct carcinoma. Methods Serial sections of 62 specimens of resected hilar bile duct carcinoma were examined histologically to determine the involved layers and routes of invasion at the proximal border. The degree of cancer extension was determined, and the relation between the length of the tumor-free resection margin and postoperative anastomotic recurrences was analyzed. Results Mucosal extension was predominant in papillary and nodular tumors, but submucosal extension was predominant in diffusely infiltrating and nodular-infiltrating tumors. Submucosal extension usually consisted of direct or lymphatic invasion. The mean length of submucosal extension was 6.0 mm. Superficial spread of cancer, defined as mucosal extension of more than 20 mm from the main lesion, was seen in 8 specimens. No patient had an anastomotic recurrence when the tumor-free resection margin was greater than 5 mm. Conclusions The pattern of infiltration at the proximal border of resected hilar bile duct carcinomas is closely related to the gross tumor type. The length of submucosal extension is usually less than 10 mm. Superficial spread of cancer is seen in more than 10% of cases. A tumor-free proximal resection margin of 5 mm appears to be adequate in hilar bile duct carcinoma.

Four cases of pancreatic cancer associated with pancreatic stones were investigated clinicopathologically. In Case 1, pancreatic cancer was diagnosed 2 yr 9 mo after the diagnosis of pancreatolithiasis. Numerous large stones were present throughout the pancreas, and stones in the resected specimen were embedded in the tumor. Chronic inflammation, including inflammatory infiltration and fibrosis, were found around the pancreatic duct where the stones were present, both within and adjacent to the tumor, suggesting that chronic pancreatitis had been present for a protracted period. In Cases 2-4, a few small free stones were found in the dilated pancreatic ducts and a cyst upstream from the tumor, but there were no stones noted within the tumor. Microscopically, mild atrophy of the pancreatic parenchyma and fibrosis were seen. In each of these three cases, it was considered that the pancreatic cancer was the primary event, with the pancreatic stones arising as a secondary process. The pancreatic cancers associated with pancreatic stones were classified into two groups, one with pancreatic stones preceding the pancreatic cancer and the other three cases in which the reverse occurred.

We measured the concentration of hepatocyte growth factor (HGF) in bile obtained from patients after hepatectomy. The HGF concentrations in the bile samples were quantified using an enzyme-linked immunosorbent assay (ELISA). By immunoblotting, using a monoclonal antibody raised against the HGF alpha-subunit, the bile HGF, which was purified on a Heparin-Sepharose column, showed a band of the same size as the recombinant HGF alpha-subunit (69 kd). Bile samples were obtained from 24 patients with biliary tract disease before and after hepatectomy by means of biliary drainage. Before surgery, the bile HGF concentrations were minimal (0.8 +/- 0.1 ng/mL); however, after hepatectomy on postoperative day 1 in patients without posthepatectomy liver failure (20 of 24), they increased severalfold (4.1 +/- 0.4 ng/mL, P < .05). The patients with posthepatectomy liver failure (4 of 24) showed no significant increase in bile HGF after hepatectomy (less than 2 ng/mL on postoperative day 1). The volume of the remnant liver correlated positively with the bile HGF concentration. The bile HGF concentration on postoperative day 1 exhibited a significant negative correlation with the maximum concentration of serum total bilirubin after hepatectomy. The concentration of bile HGF was generally higher than that in serum (2.1-fold). Thus, the bile HGF concentration after hepatectomy may be useful for the early assessment of posthepatectomy liver function.

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.

In this study, we investigated the expression of genes for inducible nitric oxide synthase (iNOS), tumor necrosis factor alpha (TNF-α), interleukin 1β (IL-1β), interleukin 6 (IL-6) of Kupffer cells in the presence of lipopolysaccharide (LPS), and the tissue expression of iNOS in a rat liver after LPS injection at various time intervals. The effects of L-NG-nitroarginine-methyl-esther HCI (L-NAMF), a NO inhibitor, also were examined. The mRNA transcripts of TNF-α IL-1β and IL-6 were rapidly detected no more than at 1 h after LPS stimulation, whereas the iNOS transcript was detectable from 3 h after LPS stimulation and maximally increased at 12 h. This fact suggested that these early induced cytokines were related to expression of iNOS. Using an anti-iNOS antiserum raised against recombinant iNOS protein, immunohistochemical analysis was made to reveal kinetics of NO producing cells. The cells immunoreactive for iNOS appeared at 6 h post-LPS injection in the sinusoids of the liver. By structural and immunohistochemical studies, almost all iNOS positive cells were identified as Kupffer cells and endothelial cells. The number of cells immunoreactive for iNOS increased until 12 h post-LPS injection. At 24 h after LPS injection, iNOS positive cells were restricted to the foci of spotty necrosis. Hepatic injury measured by released enzymes was increased by pretreatment of L-NAME before LPS injection. J. Cell. Biochem. 65:349–358. © 1997 Wiley-Liss, Inc.

The effects of hepatic denervation on liver blood flow and the influence of the denervation on the hemodynamic response to exogenously administered agents remain equivocal. This study examined the effects of the beta 2-adrenoceptor agonist, terbutaline, on liver blood flow and how these effects were influenced by surgical hepatic denervation in a conscious canine model. Two weeks after denervation, hepatic arterial flow, portal venous flow, and aortic blood flow were measured during intravenous infusion of terbutaline at 0.1, 0.2, 0.4, and 0.8 microgram/kg/min, and responses were compared between the hepatic denervated and sham-operated dogs. Implantable transit-time ultrasonic flowmeter and probes were used. Hepatic arterial flow increased dose-dependently in response to terbutaline in denervated dogs, while it remained unchanged in control dogs except at the highest dose of terbutaline. The increase in hepatic arterial flow of denervated dogs was significantly greater than that of controls at all doses of terbutaline. Aortic blood flow-indexed hepatic arterial flow in response to terbutaline also differed substantially between the two groups. Terbutaline produced a marked dose-dependent increase of portal venous flow similarly in both groups. These results suggest that the beta 2-adrenoceptor agonist terbutaline should be effective for increasing liver blood flow and could lessen postoperative liver ischemia. We speculate that hepatic denervation induces supersensitivity of the hepatic arterial system to intravenous terbutaline.

Hepatic blood flow is regulated by the autonomic nervous system; however, blood flow through the denervated liver has been controversial. The purpose of this study is to evaluate the changes in hepatic blood flow caused by experimental hepatic denervation during the intravenous infusions of catecholamines (dopamine or dobutamine) with or without prior administration of α-adrenoceptor antagonist (phenoxybenzamine) or β-adrenoceptor antagonist (propranolol). The liver blood flow was measured using transit time ultrasonic flow meter probes at the portal vein and hepatic artery in conscious dogs which (a) underwent hepatic denervation (denervation group, n = 9) and (b) were intact (control group, n = 10). Norepinephrine concentrations in the liver were determined to evaluate the effects of hepatic denervation and were decreased at 1 week and 4 weeks after hepatic denervation. In the control group, dopamine and dobutamine produced an increase of portal venous blood flow (PVF). Conversely, hepatic denervation reduced the increase in PVF by dopamine and dobutamine. Dopamine with prior administration of phenoxybenzamine produced a much larger increase in PVF in both groups. Pretreatment of propranolol in both groups abolished the increasing effects of dopamine and dobutamine in PVF. Dopamine reduced the hepatic arterial blood flow (HAF) regardless of hepatic denervation. During dobutamine infusion, HAF was decreased by hepatic denervation and prior administration of propranolol. These results suggest that hepatic denervation reduces the increasing effects of catecholamines on the hepatic blood flow through greater enhancement of α-adrenergic effects than of β-adrenergic effects in the hepatic vascular autonomic nerve response.

Background. Major hepatic resection for biliary tract carcinoma continues to be a risky operation. In this study we examined the influence of preoperative intrahepatic segmental cholangitis on posthepatectomy mortality. Methods. We analyzed retrospectively the clinical features of 118 patients who underwent liver resection including more than two segments for biliary tract carcinoma involving the hepatic hilus. Results. Intrahepatic segmental cholangitis was encountered before operation in 22 cases. The morbidity and mortality rates for these patients were significantly higher than those of patients without preoperative cholangitis. Selective percutaneous transhepatic biliary drainage was performed before operation in 11 patients for segmental cholangitis. The morbidity rate of patients after hepatectomy was significantly lower than that of patients treated without percutaneous transhepatic biliary drainage. Conclusions. The presence of preoperative intrahepatic segmental cholangitis is a major prognostic factor in the outcome of major hepatic resection for biliary carcinoma. Selective percutaneous transhepatic biliary drainage for preoperative intrahepatic segmental cholangitis plays an important role in reducing complications after major hepatic resection.

術後成人腸重積症の約9割は胃切除術後であり, 腸管に操作を加えない症例での発生はまれである.今回, 左腎腫瘍の診断で開腹による左腎摘出術後に発症した成人腸重積症を経験したので報告した.症例は59歳の女性で, 術後5日目よりイレウス症状が出現し, イレウス管による減圧で症状は軽快した.小腸造影では空腸に長い狭窄像と肛門側腸管内に腫瘤状陰影を認め, 腹部超音波検査ではmultipleconsentric ring signを認め, 腸重積症と診断し, 術後19日目に再手術を施行した.トライツ靱帯から約60cmの空腸に順行性五筒性腸重積を認めた.用手的に整復を行い, 先進部は約10cm程の強く癒着屈曲した空腸であった.この空腸の癒着剥離は困難であり, また腸間膜側に炎症性の硬結も認めたため, 同部位を切除した.切除腸管には腫瘍性病変を認めなかった.自験例は腎摘出術後の腸管癒着を起因として発症したまれな腸重積症であった.

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.

From both the therapeutic and diagnostic viewpoints, percutaneous transhepatic biliary drainage (PTBD) is crucial for the preoperative management of hilar cholangiocarcinoma. The direct anterior approach under fluoroscopic guidance is the most advantageous form of PTBD. Despite some advantages, endoscopic retrograde biliary drainage is contraindicated for preoperative biliary decompression. Pertinent multiple catheterizations using PTBD result in an accurate diagnosis of cancer extent, and produce effective relief of jaundice, as well as preventing the development of cholangitis. This, in turn, permits a rational surgical strategy and improved postoperative recovery. Preoperative staging of hilar cholangiocarcinoma is achieved by tube cholangiography through the PTBD catheter and by percutaneous transhepatic cholangioscopy. Angiography and percutaneous transhepatic portography are also recommended to diagneous extramural invasion of cancer. Prevention of posthepatectomy liver failure is the greatest challenge in the treatment of this disease. A multifactorial approach that combines several elements may provide sufficient data for determing the safe limits of surgery and for predicting posthepatectomy liver failure. Preoperative percutaneous transhepatic portal vein embolization (PTPE) is an effective method for preventing this intractable complication.

Metastases to the regional lymph nodes of the stomach were studied in patients in whom carcinoma of the head of the pancreas had been resected (51 standard pancreatoduodenectomy and 26 total pancreatectomy). Involvement of gastric lymph nodes was rare (1.3%–3.9%), except of the subpyloric lymph nodes (9.1%). Carcinoma in the five patients with positive gastric lymph nodes, with the exception of the subpyloric nodes, was clinically far advanced: four of the five had liver metastasis or peritoneal dissemination. This suggests that, in terms of preservation of the regional gastric lymph nodes, only subpyloric node involvement has any significance with respect to surgical treatment of carcinoma of the head of the pancreas. There was no significant difference in survival rates after curative resection between standard pancreatoduodenectomy (n=44) and pylorus-preserving pancreatoduodenectomy (n=17). In the patients who underwent the pylorus-preserving pancreatoduodenectomy for various kinds of periampullary diseases (n=47), postoperative recovery of gastric and small bowel function was temporarily prolonged compared to that after shandard pancreatoduodenectomy (n=44). However, the former group were able to take significantly more calories 6 weeks after the operation. Our study indicates that the pylorus-preserving pancreatoduodenectomy with subpyloric lymph node dissection is applicable to the treatment of patients with carcinoma of the head of the pancreas from the viewpoints of both extent of operation and quality of life.

We report a 68-year-old female patient with intrahepatic stones in the right posterior inferior segment, the right anterior superior segment, and the caudate lobe. She had previously undergone distal gastrectomy, cholecystectomy, and choledochoduodenostomy. Advanced liver cirrhosis had been diagnosed at the previous laparotomy, and cholangioscopic lithotomy through a T-tube sinus tract was therefore performed. The stones in the right posterior inferior segment and the right anterior superior segment were easily extracted. However, removal of the stone in the caudate lobe was difficult and necessitated 11 sessions of cholangioscopy. Although reports of intrahepatic stones in the caudate lobe are unusual, modern diagnostic imaging modalities may identify more such cases.

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.

Clarification of risk factors for surgical site infection (SSI) after hepatectomy for hepatocellular carcinoma (HCC) is important for improvement of surgical outcome.The incidences of SSI under various states were evaluated in 171 patients who underwent hepatectomy for HCC. Univariate and logistic regression analysis were performed to identify risk factors for SSI. The relation between postoperative hepatic failure and SSI was also evaluated. Data were analyzed using Stat View 5.0.SSI occurred in 36 patients (21%). Of the 36 patients with SSI, organ/space SSI occurred in 27. Bile leakage occurred in 22 patients, of which 18 patients had accompanying organ/space SSI. Postoperative hepatic failure occurred in 6 patients, and 5 of these 6 patients also had organ/ space SSI. The postoperative mortality rate was significantly higher in the patients with organ/space SSI (3 of 27 patients, 11%) than in those without organ/space SSI (1 of 144 patients, 0.7%). Logistic regression analysis revealed bile leakage and blood loss to be independent right factors for occurrence of organ/space SSI.Bile leakage frequently causes organ/space SSI after hepatectomy. Organ/space SSI is closely related to postoperative hepatic failure and death. Prevention of bile leakage is important to improve the surgical outcome of hepatectomy for HCC.