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Liver resection is a widely preferred treatment modality for hepatocellular carcinomas (HCCs). This study aimed to compare the survival impact of anatomical resection with that of limited resection, in patients with single HCCs no larger than 5 cm in diameter.A cohort study was carried out on 209 consecutive patients who underwent hepatic resection for a single HCC no larger than 5 cm in diameter between January 1994 and March 2007 at Osaka City General Hospital.The cumulative 5-year overall survival and disease-free survival rates in the anatomical resection group (n = 111) were 71 and 40%, respectively, both of which were significantly better than the 48 and 25% seen in the limited resection group (n = 98) (P = 0.0043 and P = 0.0232, respectively). Better effects of the anatomical resection on both overall and disease-free survival were seen in patients having HCC larger than 2 cm in diameter and in patients with moderately or poorly differentiated HCC. But no significant difference in either overall or disease-free survival was seen between the groups in patients with a HCC 2 cm or less in diameter or in the patients with well-differentiated HCC. Using Cox's regression model, anatomical resection was confirmed to be an independent favorable factor for both overall and disease-free survival.Anatomical resection is therefore recommended for histologically advanced single HCCs ranging from 2 to 5 cm in diameter.

肝癌切除後の孤立性リンパ節転移を摘除することで, 術後2年6か月の現在, 無再発生存中の症例を経験したので報告する. 症例は58歳の男性で, C型慢性肝炎に伴う肝癌に対して肝切除術を2回施行されていた. 経過観察中のCT像上, 肝尾状葉に約4cm大の腫瘤性病変を認め, AFP, PIVKA-II値の著明な上昇がみられた. 腹部血管造影像では腫瘤は中肝動脈および左胃動脈より栄養される腫瘍濃染像として描出され, 肝癌の尾状葉再発と診断し開腹した. 腫瘍は肝尾状葉に接するように総肝動脈の腹側に存在していたが, 肝臓からは独立しており肝癌の総肝動脈幹リンパ節転移と考え摘除した. 病理組織学的検査では中分化型肝癌のリンパ節転移と診断された. AFP, PIVKA-IIは術後2か月目に標準値範囲内へ低下し, 以来, 再発徴候を認めていない. 原発巣がコントロールされた肝癌の孤立性リンパ節転移は摘除により良好な予後が得られる可能性が示唆された.

A spontaneous regression of hepatocellular carcinoma is an extremely rare phenomenon. A 69-year-old Japanese man with hepatitis C virus-related chronic hepatitis presented with a liver tumor. We diagnosed the tumor to be hepatocellular carcinoma in the course of spontaneous regression, by imaging studies and changes in the tumor markers. Because the possible presence of viable cancer cells could not be ruled out, we recommended surgery. He refused all treatments at first, but finally agreed to undergo surgery about 10 months after presentation. A hepatectomy was performed. Histologically, no viable tumor cells were found. In our case, the vascularity of the tumor according to the imaging findings was followed up during the clinical course. The patient is now doing well and without any evidence of recurrence at 37 months after surgery.

膵頭十二指腸切除後の膵腸吻合部縫合不全は,現在もなお発生頻度の高い合併症である.多くは保存的治療にて治癒するが,腸管との交通が消失した完全外膵液瘻は,難治性である.今回われわれは,膵頭十二指腸切除後の難治性膵液瘻に対して,超音波誘導下内瘻術を行い,治癒しえた2例を経験したので報告する.症例は,胆管癌にて膵頭十二指腸切除術を施行した78歳女性と62歳男性.再建はChild変法で,膵空腸吻合は,膵管挿入法にて行った. 2例とも膵管チューブ抜去後より,膵空腸吻合部ドレーンから膵液の漏出がみられ,瘻孔造影にて,完全外膵液瘻と診断した.保存的治療にて軽快せず,超音波誘導下にドレーン瘻孔より挙上腸管を穿刺し,腸管内にチューブを留置,内瘻術を行った.約3カ月後にチューブを抜去,膵液瘻は閉鎖した.膵頭十二指腸切除後の難治性膵液瘻に対して,超音波誘導下内瘻術は,低侵襲であり,有用な治療手段であると考えられた.

肝細胞癌(hepatocellular carcinoma;以下HCCと略記)に対してTAEを施行後, bilomaを形成し,その後bilomaを含めて肝切除した2症例を報告する.症例1は67歳,男性.アルコール性慢性肝疾患を背景としたHCCに対してTAEを施行後, bilomaの診断をうけた.その後,当院での精査にて肝S8にHCCの再発が疑われた.症例2は65歳,女性. C型肝炎を背景としたHCCに対し, TAE施行約1.5カ月後に,多発するbilomaを認めた.その後,腫瘍マーカーが再上昇し,再発が疑われたが, HCCとbilomaの鑑別は画像上困難であった.Bilomaが保存的治療で軽快しない場合や,自験例の様にbilomaの遺残によりその後の癌治療に制約が大きい場合は,癌病巣も含めた外科的切除も考慮されるべきと考えた.

We investigated the rates of the treatments and their prognoses in 450 patients with hepatocellular carcinoma (HCC), in order to determine the usefulness of percutaneous microwave coagulation therapy (PMCT) given the present situation of treatment for HCC. Rates of initial treatments were hepatectomy in 31%, percutaneous ethanol injection therapy (PEIT) in 19%, transarterial embolization (TAE) and PEIT in 16%, TAE in 14%, hepatic arterial chemotherapy (HAC) in 7%, PMCT in 7% and others in 6% of cases. The prognosis of PMCT in patients with a single tumor 3 cm in size or less was comparable to that with hepatectomy. Recurrence was found in about 59% of 387 patients who underwent radical treatment initially, and about 96% of these were intrahepatic recurrences. Rates of treatment for intrahepatic recurrence were TAE in 59%, PEIT in 33%, HAC in 31%, PMCT in 24% and hepatectomy in 4% of cases. Indications for use of PMCT were more restricted than for PEIT for reasons of safety. Therefore, the rate of use of PMCT as initial treatment was lower than that of PEIT. On the other hand, the rate of use of PMCT in treatment of recurrence was similar to that of PEIT. PMCT should be used not only as initial treatment but also in the treatment of recurrence, in which HCC is often found at a size 3 cm or less, considering the high incidence of intrahepatic recurrence of HCC as well as reliability of the therapeutic effect and low invasiveness attached to PMCT.

We have performed percutaneous microwave coagulation therapy (PMCT) for hepatocellular carcinoma (HCC) of the size below 3 cm since 1994. In the present study, we examined the complication of 117 patients with HCC (including recurrent cases) having undergone PMCT. There was no severe complication with PMCT requiring a treatment except one patient with hemothorax (0.9%). Clinical results of the patients with single occurrence of HCC below 3 cm in size were examined by comparing the cumulative survival rate and cumulative nonrecurrent survival rate among the group of 16 patients having undergone PMCT as initial treatment, that of 38 patients given hepatectomy and that of 34 patients treated percutaneous ethanol injection therapy (PEIT) in the same period using Kaplan-Meier method. The 5-year cumulative survival rate was 93% in the group given PMCT, 72% in that given hepatectomy and 68% in that given PEIT, respectively. Similarly, the 4-year cumulative nonrecurrent survival rate was 29% in the group given PMCT, 38% in that given hepatectomy and 15% in that given PEIT, respectively. In conclusion, PMCT was a safe and less-invasive therapy similarly to PEIT. A therapeutic effect comparable to hepatectomy could be expected for PMCT in the patients with HCC below 3 cm in size.

今回われわれは, 胸部食道癌に対する高位胸腔内胃管吻合術後に, 右気管支動脈と奇静脈弓により胃管の絞扼壊死をきたした症例を経験したので報告した, 症例は59歳の男性, IuImの1pl+0-IIb型の高分化型扁平上皮癌に対して, 低容量しすぷらちんと5FUによる術前化学療法を2週間行った後, 胸部食道全摘・3領域りんぱ節郭清・全胃管高位胸腔内吻合術を施行した, 第4病日にショックとなりドレーンより消化液の流出を認めたため, 縫合不全による縦隔炎と診断した, 再開胸すると, 右気管支動脈と再縫合した奇静脈弓に挟まれた挙上胃管がその口側で壊死穿孔していたため, 壊死部胃管切除・頸部食道外瘻術を施行した, 術後はMOFに陥ったが集中治療にて回復し, 4か月後に左結腸による消化管再建術を施行し軽快退院した, 高位胸腔内での胃管再建は, 安全性が高く近年注目されているが, 右気管支動脈と奇静脈弓による絞扼壊死の報告は今回が初めてである, 右気管支動脈をその分枝近くの大動脈弓付近まで剥離する, あるいは奇静脈弓の再縫合をしない, またはゆるくするなどの工夫が必要と思われた.

肝細胞癌切除後, 肝尾状葉下大静脈部に再発した2例に尾状葉単独全切除を行い, 2年以上の無再発生存を得ている.手術は上腹部逆T字型切開による開腹のみのapproachで行い, 尾状葉下大静脈部右縁の同定は肝門approachによるグリソン一括処理法でグリソン後区域枝をclampして生じるdemarcation lineから同定した.短肝静脈を切離し肝を下大静脈から完全に剥離した後, 尾状葉右縁から肝切離を開始した.頭側は右肝静脈背側面, 中肝静脈背側面に沿って切離し, 尾側は肝門板から分枝する尾状葉グリソン枝をグリソン騰部背側端まで逐一切離し, 最後にArantius管を根部で切離した.いったん, 左側に術野を転じArantius管を中肝静脈流入部で切離した後, 中肝静脈背側縁に沿って肝切離を進め, 最後に両肝切離面を連続させて尾状葉単独全切除を完了した.最も切除困難といわれる尾状葉下大静脈部に再発した肝細胞癌といえども早期に発見すれば尾状葉単独全切除によって根治的切除も可能である.

We investigated morphological and functional changes after portal vein occlusion in rats. Portal branches for the median and left lateral lobes were ligated, after which the lobes were examined micromorphologically. After embolization of the same branches, regenerative capacity was evaluated in normal livers and in livers with CCl4-induced cirrhosis. Indocyanine green elimination, antithrombin III activity, and Kupffer cell density were also investigated. In another set of rats, the embolized lobes were resected 0, 2, 4, or 7 days after portal vein embolization (PVE), and endotoxin was injected intravenously 48h after each hepatectomy. In the ligated lobes, apoptotic hepatocytes were detected mainly around a widespread necrotic area on day 2, and among normal hepatocytes on day 7. In the nonembolized livers of control rats, increases were noted in liver weight, ornithine decarboxylase (ODC) activity, DNA synthesis, and mitosis of hepatocytes. In the cirrhotic livers, ODC activity was stimulated in a fashion similar to that seen in control liver, but DNA synthesis and weight change was delayed, although not significantly. On days 2, 4, 7, and 14 PVE, Kupffer cell density was about twice that seen in rats before PVE. Endotoxin-induced liver injury was slight if the rats had received PVE 4-7 days before the hepatectomy.

We report a case of retroperitoneal schwannoma which was difficult to diagnose preoperatively due to the cystic shape of the tumor. An abdominal tumor was pointed out in an asymptomatic 52-year-old man during a periodic health examination. Preoperative abdominal ultrasonography and an abdominal computed tomographic scan revealed a discrete, spheric shaped cystic tumor with a thin wall. It was found on the ventral side of the left kidney and to the left side of the aorta in the retroperitoneal space. The tumor was successfully extirpated. The extirpated tumor was 62×64×38mm in size, elastic hard and 153g in weight. The tumor had a solid wall, about 3mm in thickness, which enclosed 120ml of sero-bloody fluid. Histopathological examination showed that the tumor was schwannoma of mixed Antoni type A and B. Although cystic degeneration is common in and characteristic of retroperitoneal schwannomas, a cystic shape with a thin wall is rarely seen, and otherwise, malignant conversion, recurrence and metastasis of retroperitoneal schwannoma can occur. If a retroperitoneal tumor has a cystic shape with a thin wall like in this case, we should entertain retroperitoneal schwannoma as a probable diagnosis and the tumor should be extirpated completely.

Whether a laparoscopic approach is more effective for acute appendicitis than standard open appendectomy remains controversial.Clinical records of the 95 consecutive patients who underwent appendectomy for acute appendicitis between April 2002 and December 2005 were reviewed retrospectively. Laparoscopic appendectomy was performed for 62 patients (LA group), while 33 underwent open appendectomy (OA group). At our institution, LA is a standard operative procedure for acute appendicitis, and OA underwent because of social reasons. Characteristics, operative factors, and postoperative course were compared between groups.Age, gender, past appendicitis attacks managed conservatively, and preoperative white blood cell counts did not differ significantly. Pathologic severity of appendicitis was more advanced in the OA than LA group (gangrenous in 52% vs 21% respectively, p=0.009). Mean operative time was significantly longer in the LA than OA group (80 min vs 63 min respectively, p=0.012). Pre- and postoperative white blood cell counts did not differ between groups, but recovery from postoperative pain and fever was significantly earlier in the LA than OA group (p=0.0007 and 0.013, respectively). Postoperative wound infection was significantly less frequent in the LA (6%) than OA group (27%, p=0.01), while incidence of postoperative intraabdominal infection did not differ significantly. Two patients in the LA group had serious complications that required reoperation; postoperative bleeding from the coagulated mesoappendix in one, and perforation of the jejunum caused by electrocautery during trocar insertion in the other. Mean postoperative hospital stay was significantly shorter in the LA than OA group (6.7 and 14.4 days respectively, p=0.04). According to severity of appendicitis, LA had no advantages over OA for gangrenous appendicitis.Laparoscopic appendectomy has some disadvantages, such as long operative time and possible of serious complications, but generally accelerates postoperative early recovery to shorten hospitalization.

Background Small bowel obstruction (SBO) after abdominal surgery is usually treated successfully with intestinal decompression using a long nasointestinal tube (LT), but some cases fail to respond. Methods Clinical background and laboratory data on admission were evaluated retrospectively for 53 patients with adhesive SBO to determine predictive factors for failure of LT decompression, and the appropriate timing of laparotomy was investigated. Results Complete SBO (no evidence of air within the large bowel) and increased serum creatine phosphokinase (≥130 IU/L) were independent predictive factors for LT decompression failure. Laparotomy was indicated in 14 patients (9 and 5 with complete and partial SBO, respectively), whereas successful LT decompression occurred in 39 patients (9 and 30, respectively). Resolution of SBO took significantly longer for complete SBO (6.3 days) than for partial SBO (2.6 days). Conclusions Patients with complete SBO or high serum creatine phosphokinase (CPK) may not respond to LT decompression. Laparotomy is appropriate after non-response for 7 and 3 days for complete and partial SBO, respectively.

Acute cholecystitis associated with gallbladder carcinoma is very rare in young patients (younger than 30 years of age). Moreover, a definitive preoperative diagnosis is difficult. A 26-year-old man was referred to our hospital with a 5-day history of right upper quadrant pain. Computed tomography and ultrasonography demonstrated an enlarged gallbladder with a diffuse thick wall and a 2-cm gallstone obstructing the cystic duct. Magnetic resonance cholangiopancreatography showed no evidence of an anomalous pancreaticobiliary junction. The patient showed an elevation in the white blood cell count, serum C-reactive protein, and alkaline phosphate; however, total bilirubin, alanine aminotransferase, and tumor markers including carcinoembryonic antigen and carbohydrate antigen 19-9 were all within the normal ranges. The preoperative diagnosis of gallstone-induced acute cholecystitis was made and an open cholecystectomy was thus performed 2 days after admission. The macroscopic findings showed a necrotic enlarged gallbladder with a thick wall and a gallstone, but no intraluminal nodular lesion. Histologic examinations revealed well-differentiated focal adenocarcinoma in the gallbladder mucosa, but no venous, lymphatic, or perineural invasion. The postoperative course has been uneventful with no recurrence 18 months postoperatively.

The patient was a 16-year-old boy who had turned to the right rapidly as he fielded a baseball that had come to him quickly. Two days after this event, which occurred in July 2004, he was admitted to hospital with repeated vomiting and increasing right hypochondralgia. Laboratory examination on admission showed elevation of the white blood count and of serum C-reactive protein and total bilirubin. Computed tomography on admission demonstrated an enlarged gallbladder and a thickened wall without gallstones, and magnetic resonance imaging performed 1 day later showed air within the gallbladder wall. His symptoms worsened, with a positive Murphy's sign, and emergency laparotomy was performed, with a diagnosis of emphysematous cholecystitis. Intraoperatively, the gallbladder was dark red, necrotic, distended, and enlarged. The cystic duct was attached only to the mesentery, and the gallbladder was floating freely, with the neck of the gallbladder having rotated 180 degrees counterclockwise, leading to a definitive diagnosis of gallbladder torsion with emphysematous cholecystitis. Cholecystectomy was performed, and analysis of bile showed Escherichia coli to be the causative organism. Histopathologic examination revealed necrotized cholecystitis. The patient is doing well 25 months after surgery, with an uneventful postoperative course.

Despite progress in therapy for hepatocellular carcinoma, management of extrahepatic metastatic lesions remains problematic. A 73-year-old man who underwent transcatheter arterial embolization for hepatocellular carcinoma presented bilateral adrenal metastases. Ten months after transcatheter arterial embolization, computed tomography detected huge tumors in both adrenal glands. Simultaneous resection of both adrenal lesions was performed under hydrocortisone replacement therapy. These tumors were confirmed histopathologically to represent adrenal metastatic lesions of hepatocellular carcinoma. The patient died of respiratory failure due to lung metastasis 9 months after adrenalectomy, although intrahepatic tumor was controlled by transcatheter arterial embolization. It is necessary to clarify the therapeutic effectiveness and the indication of adrenalectomy for patients with adrenal metastasis.

A 75-year-old man underwent distal gastrectomy for advanced gastric cancer with liver and lymph node metastases and synchronous hepatocellular carcinoma in April 2004. HAI with low-dose CDDP/TS-1 combination therapy was initiated after gastrectomy. Liver and lymph node metastases decreased significantly, with achievement of a partial response (PR) and a complete response (CR), respectively, and the hepatocellular carcinoma was reduced to 54.1% of its initial size after 3 sessions of this chemotherapy. These results suggested that combined chemotherapy with TS-1 and HAI with low-dose CDDP was not only useful for liver and lymph node metastases from gastric cancer, but for hepatocellular carcinoma as well.

We examineded the clinical effects of serum hepatitis B e antigen (HBeAg) positivity on clinicopathologic findings and prognosis after liver resection for hepatocellular carcinoma (HCC) in patients with chronic hepatitis B. A series of 56 patients who underwent curative resection were divided into two groups: 25 HBeAg-positive patients (group 1) and 31 HBeAg-negative patients (group 2). The mean age was significantly lower in group 1 than in group 2 (p = 0.0021), and the proportion of patients with symptoms was significantly higher in group 1 than in group 2 (p = 0.037). There were no significant differences in other clinical findings between the two groups, including laboratory test results, coexisting medical conditions, and operative methods. Although tumor size, degree of differentiation of the main tumor, and the prevalence of vascular invasion did not differ between the groups, the prevalence of intrahepatic metastasis and the proportion of patients with active hepatitis were significantly higher in group 1 than in group 2 (p = 0.009 and p = 0.043, respectively). Tumor-free and cumulative survival rates were significantly lower in group 1 than in group 2 (p = 0.022 and p = 0.0001, respectively). Multivariate analysis of various possible risk factors demonstrated serum HBeAg positivity to be an independent risk factor for recurrence [risk ratio (RR) 2.49; 95% confidence interval (CI) 1.12-5.49; p = 0.032] and an independent unfavorable factor for the survival time (RR 7.58; 95% CI 2.10-27.8; p = 0.0020). We concluded that the prognosis after liver resection for HCC is worse for HBeAg-positive patients than for HBeAg-negative patients.

A case of erythrocytosis caused by a hepatocellular carcinoma (HCC) that produced erythropoietin (Epo) is described. A 64-year-old man, with a huge HCC tumor in the right lobe of the liver, showed a high concentration of hemoglobin and increased levels of serum Epo, alpha-fetoprotein (AFP), and protein induced by vitamin K absence II (PIVKA-II). Right lobectomy of the liver was performed. Histological findings of the specimen showed a moderately differentiated HCC. The existence of Epo was confirmed immunohistochemically only in the tumor tissue and not in the normal liver tissue. Erythrocytosis disappeared and the serum levels of Epo, AFP, and PIVKA-II returned to the normal range after the operation. Within 2 months after the operation, recurrent tumors appeared in the remnant liver, and the patient died 13 months after the operation.

We describe herein the case of a hepatic abscess that developed secondary to fish bone penetration which was successfully treated without laparotomy. A 61-year-old man was admitted to our hospital with a high fever that had persisted for 2 weeks in spite of medication. Abdominal ultrasonography (AUS) and computed tomography (CT) of the abdomen revealed a hepatic abscess with a linear calcified foreign body and gas. Percutaneous abscess drainage was performed under ultrasonographic guidance. After drainage, the patient became afebrile, and AUS and CT findings demonstrated that the abscess cavity had decreased in size, but still contained the foreign body. Under ultrasonographic guidance and fluoroscopy, we inserted endoscopic forceps into the sinus tract and succeeded in removing the foreign body from the liver. It was found to be a fish bone that was 2.8 cm long and 0.3 cm wide.