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We report a rare case of carcinoma of the cystic duct (CCD) associated with pancreaticobiliary maljunction (PBM). A 63-year-old man had presented with relapsing cholecystitis of 4 months, duration. Computed tomography showed a distended gallbladder: however, small mass in the cystic duct was overlooked. Endoscopic retrograde cholangiopancreatography demonstrated a long common channel (20-mm-long) and fusiform dilatation of the common bile duct, findings, which were consistent with PBM. At laparotomy, we found a papillary tumor, 20 mm in diameter, that obstructed the cystic duct. The patient underwent resection of the gallbladder and the common bile duct, lymph node dissection in the hepatoduodenal ligament, and hepaticojejunostomy. Histologic study revealed a papillary adenocarcinoma confined within the subserosal space. There was no lymphatic or perineural invasion of cancer cells. The surrounding cystic ductal mucosa showed dysplasia and hyperplasia, and the gallbladder and common bile duct showed severe inflammation. The patient has been doing well for 16 months after surgery, without tumor recurrence. This case suggests a relationship between CCD and chronic biliary inflammation caused by PBM, as in cases of gallbladder carcinoma.

腸間膜癒着によるイレウスを伴った回腸アニサキス症を経験した.症例は,42歳男性.カツオの刺身摂取後,臍下部の腹痛が続くため,当科を受診した.腹部単純写真で小腸の拡張と鏡面像が認められた.イレウスを伴う急性腹症と診断し緊急手術を行った.回腸末端より約90cmの小腸が発赤し,約10cmにわたり腸間膜の浮腫を認め,内腔に弾性軟の隆起性病変を触知した.また,回腸末端より40cmの腸間膜に炎症性癒着を認め,癒着性腸閉塞をおこしていた.癒着剥離と小腸部分切除術を行った.切除標本では,粘膜壁が腫大し,陥凹病変の中心に粘膜に刺入する線虫を認め,回腸アニサキス症と診断した.アニサキスによるイレウス発生機序を文献から考察した.イレウスは,虫体の存在する部位の腸管浮腫および狭窄さらには腸間膜血流障害などから発生する事が多いと考えられた.

下血を主訴に来院した73歳,男性に対して上部消化管内視鏡検査を行ったところ, 十二指腸球部に有茎性広茎性隆起病変を認めた.内視鏡生検でgroup IVであり,胆嚢結石症を伴う早期十二指腸球部癌と診断した.球部の広茎性腫瘍であったため,内視鏡的切除は困難と判断し,幽門側胃切除および球部切除術,胆嚢摘出術を施行した.病理組織検査で,十二指腸球部の腺腫内癌 (carcinoma in adenoma) と診断された. 十二指腸球部の腺腫内癌症例は本症例を含め19例報告されている. m癌症例がほとんどであり,リンパ節転移を示したものはなかった.腺腫内癌症例は内視鏡生検で必ずしも確定診断できるとは限らないので,内視鏡的切除あるいは外科的切除が必要であると考えられた.

New techniques of CT-guided management were introduced to ablate ultrasonically invisible hepatocellular carcinomas. In six patients with HCC, a total of six nodules (8-30 mm in diameter) were treated under the guidance of CT. These lesions were not visualized by sonography but were visualized as Lipiodol spots on CT after chemoembolization. Tumor localization was successful in all patients without difficulty, using a thin needle or hookwire under the guidance of CT. Two patients underwent subsequent hepatic resection and/or microwave coagulation therapy (MCT) through a small incision after hookwire placement. Four patients received percutaneous MCT (n = 2) or ethanol injection (PEI) (n = 2) at the time of localization. The postoperative CT with contrast enhancement indicated that tumor ablation was complete in four of the five nodules treated with MCT or PEI. However, in one nodule (30 mm in diameter) treated with PEI, tumor ablation was not complete. There were no complications. There has been no local tumor recurrence 6-46 months after treatment in any of the patients. In conclusion, these CT-guided procedures were effective in treating ultrasonically invisible hepatocellular carcinomas that otherwise would have remained untreated.

To find out the appropriate dye laser output and frequency for each kind of stone experimentally, and to use flashlamp-excited dye laser for impacted biliary stones.Prospective study.University hospital, Japan.12 patients undergoing lithotripsy for both intrahepatic and extrahepatic impacted biliary stones.Appropriate dye laser output and frequency, histological changes in the bile duct wall, and outcome.Stones were pulverised, and required a median 155 pulses (range 80-205) at 40 mJ for bilirubin stones and 355 pulses (range 205-405) at 50 mJ for cholesterol stones. At the standard energies used, the laser caused only superficial damage to the serosa of the common bile duct. It was successful in fragmenting 133/135 stones (99%), and in addition pulverised 125/135 stones (93%). No patients complained of pain during laser lithotripsy even under local anaesthesia. All patients were discharged from the hospital after an uneventful recovery, and no recurrent stones have been found at outpatient follow-up ranging between 2 and 85 months.Flashlamp-excited dye laser with a small choledochoscope seems to be safe and painless way of treating biliary stones, even if they are impacted in the peripheral biliary tree and patients are at high risk.

Infectious epidermid cysts of the spleen with high serum levels of CA19-9 and CA125 are rare. We successfully performed a laparoscopic splenectomy for a 20-year-old woman who was diagnosed as having the disease. The patient was admitted to the hospital becuse of high fever and left hypochondralgia. After a workup of ultrasonography, CT and magnetic resonance imaging, she was diagnosed as having infectious splenic cyst. In addition, malignancy was suspected because serum levels of CA19-9 and CA125 were as high as 1.1×106U/ml and 1.8×104U/ml, respectively. Immunological stainings indicated that CA19-9 might escape from epithelium of the cystic wall to the blood. CA19-9 and CA125 decreased to 100U/ml and

An 81-year-old man with early gastric cancer chronic with renal failure was successfully treated by intragastric endoscopic surgery. He had early gastric cancer locating beyond the pyloric ring. After making a temporary gastrostomy under epidural anesthesia, a mucosal resection was performed using a Buess's endoscope. Operation time was 120 minutes. He was discharged from the hospital uneventfully. In conclusion, among minimally invasive surgeries for gastric cancer, this method seems to be advantagenus to lesions locating near the cardia and pylorus and can be recommeded for patients with risk factors such as elderly and same underlying diseases.

5-FUは数多くの悪性腫瘍に対して使用されているが,その副作用として心毒性はあまり指摘されていない.今回われわれは5-FU投与中に狭心症発作を頻発した症例を経験したので報告する.症例は74歳女性,心臓疾患の既往はなく,冠動脈危険因子も無い.平成10年1月膵頭体部癌に対し膵全摘術を施行し,術後22日目より化学療法(FP療法5-FU500mg/day, CDDP 6mg/day)を開始した.投与3日目に胸痛出現し心電図上虚血性変化を認めた. 5-FU中止,酸素投与,亜硝酸薬とCa拮抗薬の投与で消失した.自験例を含む報告例33例の集計では,冠動脈疾患の既往は9例,発作時に心電図上変化を認めなかった症例は11例,心原性酵素の上昇は7例に認め,投与総量と発作の相関関係は否定的であった.また,心停止も3例(うち1例死亡)も報告されており,心毒性を十分念頭においた投与の必要性が示唆された.

低左室機能を呈した虚血性心疾患と腹部大動脈瘤 (AAA) を合併した2例に対して冠状動脈バイパス術 (CABG) に続いて体外循環中にAAA手術も施行した. 症例は76歳と74歳の男性で, 左室駆出分画 (EF) は0.20と0.33, 冠状動脈は2枝と3枝病変を示していた. AAAは腎動脈下で1例は総腸骨動脈の閉塞を示し, 大きさは8cmと4.5cmであった. 低左室機能例では, CABGに続いて体外循環中にAAA手術を行う手技は有用な方法であると思われ報告した.

The principle of treatment of choledochal cysts is total cyst excision with hepaticojejunostomy because of the high rate of associated malignancy of the biliary system. The authors used a minimally invasive laparoscopic procedure to treat a patient with nonmalignant choledochal cyst. Although a large median laparotomy is usually used for cyst excision and hepaticoenterostomy, laparoscope-assisted total cystectomy and hepaticojejunostomy were performed with minimal skin incision. To avoid gas embolism during dissection around the hepatic hilus the surgical procedure was divided into two stages: CO2 insufflation and abdominal lifting without pneumoperitoneum. This combination of procedures was as safe and technically adequate as conventional surgery. No abnormalities were observed in liver function, and the patient could sit up in bed the first day postoperatively. Thirteen days after surgery, he was discharged from the hospital uneventfully.

Twenty-three cases of congenital biliary dilatation in children experienced at the hospital in a recent two decade were didided into two groups by type of the common bile duct, namely, cystic type dilatation (C-type; 12 cases) and fusiform type dilatation (F-type; 11 cases). There were five male and 18 female patients. Averaged age at operation was 2.8, ranging from 2 months to 10 years old. Items investigated included the age of onset of the disease, symptoms at the onset, blood biochemical data (white blood cell count, CRP, and total bilirubin), histopathologic types.The onset age was younger in C-type patients who manifested the disease less than one year of age. Higher total bilirubin level in serum noted in C-type cases than F-type cases. Elevated amylase level in the common bile duct was noted in F-type cases compared to the others.In C-type cases there were more pancreatico-choledochus types, and in C-type cases there were more choledoco-pancreas types in a type of pancreatico-biliary maljunction. Pathological sections of the common bile duct revealed severe chronic inflammation such as wall thickness and fibrosis in C-type cases.It is suggested that the age of onset, the presence of obstructive mechanism at the common bile duct, and type of pancreatico-biliary maljunction might be contributing factors to the type of dilatation.

The effect of splenectomy on allograft survival was investigated using orthotopic liver transplantation in a rat experimental model (ACI rat liver grafted to LEW rat). Control rats without any immunosuppressive treatment died, on average, 10.4 +/- 1.4 days after operation. Splenectomy alone somewhat prolonged the survival (13.4 +/- 2.0 days), and low-dose FK506 therapy moderately prolonged it (22.7 +/- 7 days). The graft survival period was significantly prolonged (39.7 +/- 6.3 days) when them two treatments were combined. The elevation of cytotoxic antiallograft antibodies was suppressed by splenectomy but not by low-dose FK506 therapy. The development of jaundice was moderately suppressed by FK506 but not by splenectomy. There was no difference between the pattern of body weight decline in either of them two groups and that in control rats. When these two treatments were combined at the same time, the elevation of cytotoxic antibodies, development of jaundice and decline of body weight were suppressed. These data indicate that B cells play an important role in the acute rejection of the rat liver allograft at least partially via production of cytotoxic antiallograft antibody. Splenectomy or other immunosuppressive methods affecting B cells can be a supplement for immunosuppression when using reduced-dose FK506.

A 68-year-old man was seen at the hospital because of an epigastric pain. Close examination indicated a mild jaundice and endoscopy revealed a slight redness in the duodenal papilla. Endoscopic retrograde cholangiography (ERC) visualized an irregular wall of the papilla. With endoscopic biopsy of the papillary epithelium group III was detected. Since possibility of cancer not ruled out and no tumor formation made a discision-making for a range of resection difficult, pylorus preserving pancreatoduodenectomy (PPPD) was performed. In the resected specimen, a whole-circumferential flat IIb type lesion ranging 15 mm from the papillary portion of the bile duct to common channel was noted. Histologically it was early well differentiated adenocarcinoma invading the Oddi muscle. After the operation the patient is in a good nutrition. There has been no sign of recurrence as of 3 and 6 months. Such flat and invasive papillary carcinomas without tumor formation as our case are uncommon. We need to pay careful attention to possible existence of adenomatous tissue which is often associated with carcinomas of the duodenal papilla.

A 75-year-old man who was diagnosed as having mucin-producing pancreatic cystic lesion ofthe main pancreatic duct by duodenoscopic examination was reported. Because of the low malignant potential of such lesions, duodenum-preserving resection of the head of the pancreas was performed, and the intra-operative histological examination showed no malig-nancy of the resected pancreatic head and no other surgical procedures, such as lymph-adenectomy nor pancreato-duodenectomy were necessary. The significance of this case report lies in that a less invasive operation should be selected at first to diagnose whether the lesion is malignant or not, and als0 that the selected operation itself must be sufficient to resect an adequate part of the pancreatic tissue involving the cystic lesion, ifnot malignant. Here, we report the process to select the procedure and the surgical technique.

In this study, assessment by a flow cytometric method using dichlorhydroxy fluorescin diacetate (DCFADH) in vitro revealed that human peripheral blood inhibits the production of active oxygen species by human peripheral neutrophils. It was also revealed that among the blood components, the plasma fraction inhibits active oxygen production most strongly. This plasma inhibitory activity was dose-dependent. Human serum also exerted an inhibitory activity; however, its activity was only one-third that of plasma. Moreover, when HL-60 human promyelocytic leukemic cells, with or without differentiation into the neutrophils by culturing with dimethyl sulfoxide (DMSO), active oxygen, which was also inhibited by plasma, was produced. Heat inactivation of the plasma did not alter the inhibitory activity, and gel filtration analysis showed that the peak activity was associated with a molecular mass of 70,000. The results of this study indicate that human plasma contains one or more substances that inhibit the active oxygen production of neutrophils, which may play an important role in inhibiting unneeded neutrophil activation in the bloodstream.

Long-term results of hepatic resection for hepatolithiasis in 34 patients having intrahepatic biliary strictures were studied. The left lateral and the right posterior segmental ducts were commonly and often simultaneously involved. Fourteen patients had multiple segmental involvement. Hepatic resection included left sided resection (n = 27), right sided resection (n = 6), and repeated bilateral resection (n = 1). Seven patients had biliary tumors: 3 cholangiocarcinomas, 2 gall bladder cancers, 1 cystadenocarcinoma, and 1 dysplasia of intrahepatic ducts. Nineteen patients received bilioenteric anastomosis. Retained stones and recurrent stones developed in 3 and 4 patients, respectively. Twenty-six patients had no remaining symptoms; 2 died of operative complication or cholangiocarcinoma; 6 presented symptoms caused by retained stones (n = 2), recurrent stones (n = 2), bile stasis (n = 1), or neuralgia (n = 1). In 4 of the 6 patients, unrelieved posterior duct strictures caused the symptoms. With a mean follow-up period of 4.5 years, 30 patients are symptoms free, and 27 are stone free. In patients with right lobar or bilobar type, intra- and extrahepatic type, and confluence strictures, bilioenteric anastomosis is required. Hepatic resection is a rational treatment for hepatolithiasis, however, meticulous management of biliary tract abnormalities, particularly the posterior duct stricture, is mandatory.

Hepatic resection under the intermittent hepatic vascular exlusion technique (IHVE) was carried out on five patients with liver tumor involving major hepatic vessels which seemed otherwise difficult to resect, and its efficacy was evaluated. The total clamping time was 38 min for 3.8 clampings on average. Division of the right adrenal vein was necessary for a complete hemostasis during hepatic resection under IHVE, which was obtained in four patients. Maneuverability around major vessels was also improved due to IHVE, making the surgery less dangerous. General haemodynamic conditions during IHVE were stable, except for increased vena cava pressure and slightly decreased cardiac output. Postoperative course was uneventful except for pleural effusion in four patients. These results show that IHVE is a useful and safe procedure for hepatic resections, offering a bloodless operative field and improved the maneuverability around major hepatic vessels, in patients with liver cancer involving major hepatic vessels.

When familial adenomatous polyposis (FAP) is diagnosed in a patient, prophylactic surgery must be performed whether colorectal cancer is present or not. Operations for FAP have been performed through a large median abdominal incision or an additional perineal incision, depending on the coexistence of rectal cancer. Recently, we reported a technique of laparoscopic rectal amputation without abdominal skin incision for patients with rectal cancer to minimize postoperative cardiac and respiratory complications [6]. In this article, we report a case of laparoscopically assisted proctocolectomy with ileostomy through a minimal abdominal and perineal skin incision performed by a hand-assisted procedure. The purpose of combining the perineal and laparoscopic approaches is to minimize the skin incision, while retaining a rate of cure and safety equivalent to those of conventional rectal amputation, by using the advantages of laparoscopic procedures, and to facilitate postoperative recovery and improve the quality of life for relatively young patients with FAP.

Surgical outcomes of 151 abdominal operations in aged patients over 80 years old were studied in terms of life-saving significance, improved quality of life (QOL) and postoperative complications. In 102 elective operations, the operation was life-saving in 5, QOL improved in 58, and operative death occurred in 7 patients. In the remaining 49 emergency operations, surgery was lifesaving in 25, QOL improved in 33, and operative death occurred in 13 patients. Forty-one patients with benign disease necessitated emergency surgery, indicating a dominance of severe diseases. Curative resection of malignant tumors provided better QOL. Of the 20 postoperative deaths, 8 patients were caused by serious diseases (cancer in 4 and shock in 4); 6 by operative complications (anastomotic leakage in 4, pancreatitis and hepatic insufficiency in each one); and 6 by complicated diseases (pneumonia in two, cardiovascular disease in two, cerebral infarction in one and sudden death in another one). Though abdominal operation would carry a high risk to aged patients, about 60% of the patients in this series were able to have improved QOL after perioperative managenent could be cleared. It is concluded that opportune and correct operation, as well as cautious perioperative care, provide a better QOL for aged patients over 80 years old.

A case of hepatocellular carcinoma (HCC) in which the patient repeatedly underwent minimally invasive hepatic procedures is reported. The patient was a 71-year-old man who underwent transthoracic microwave coagulation therapy (MCT) for initial HCC nodules in segment VIII and subsequent laparoscopic MCT for small intrahepatic recurrent nodules in the left hepatic lobe. At this writing, the patient was alive and well without tumor recurrence 29 months after the initial surgery. Minimally invasive hepatic surgery alleviates perihepatic adhesion and allows subsequent laparoscopic surgery in the case of intrahepatic HCC recurrence.

Neutrophil plays an important role in hepatic ischemia-reperfusion injury. We investigated neutrophil infiltration in liver tissue, Kupffer cells' role in neutrophil accumulation, and apoptosis and regeneration of hepatocytes in liver ischemia-reperfusion injury.Vascular microclamps were placed across the pedicles of the median and left lateral lobes for 90 minutes after 30% hepatectomy with the resection of caudate, right lateral and quadrate lobes and papillary process. Gadolinium chloride (GdCl(3)) was used to destroy Kupffer cells. Neutrophil activity was inhibited with Urge-8, a monoclonal antibody against neutrophil produced in our laboratory. GdCl(3) (10 mg/kg) and Urge-8 (50 mg/kg) were given intravenously in respective groups. Ischemia control, GdCl(3) and Urge-8 groups were compared.Following hepatic reperfusion, serum interleukin-8 (IL-8) levels and hepatic neutrophil counts peaked at 3 hours, and peak concentrations of alanine aminotransferase (ALT) occurred at 6 hours. Animals of the control group showed increases in neutrophil infiltration in liver tissue, liver enzyme levels, and apoptosis index of hepatocytes and decreases in overall survival rate and proliferating cell nuclear antigen (PCNA) expression of hepatocytes. The survival rates and PCNA proportion of hepatocytes were higher and the levels of hepatic neutrophil infiltration, liver enzymes, and hepatocyte apoptosis after reperfusion were lower in the GdCl(3) and Urge-8 groups than those in the ischemia control group.Blockades of Kupffer cells' activity and neutrophil infiltration by GdCl(3) and Urge-8 eliminate neutrophil-mediated hepatic injury and enhance subsequent hepatic regeneration during liver ischemia-reperfusion.

Duodenum-preserving resection of the pancreatic head is a risk factor for pancreatic fistula because of the wide surface of the transected pancreas. We report on a 72-year-old woman undergoing this procedure for cystadenoma in the pancreatic head using the ultrasonic coagulating shears. The soft pancreatic parenchyma was extensively transected around the cyst with the coagulating shears. Suture of the cut stump was not necessary due to absence of bleeding. The distal pancreatic duct was well preserved for pancreatojejunostomy. We oversewed the possible opening of the main pancreatic duct on the remaining pancreas attached to the duodenum after confirming the location by intrabiliary dye injection. The postoperative course was uneventful. The draining fluid amylase level was low and there were no viscous materials from the drains. We compared histologic changes of a porcine pancreas transected with the coagulating shears or electrocautery to evaluate the sealing effect of the transected surface. The cut stump was covered by a continuing layer of thick protein coagulum in cases of coagulating shears, but by a disrupted layer of coagulating necrosis with charring in cases of electrocautery. The coagulating shears are useful for pancreatic transection in duodenum-preserving resection of the pancreatic head to prevent bleeding and pancreatic fistula from the cut surface.

We report the case of 72-year-old man with recurrent gastric cancer who was successfully treated with TS-1. We performed only non-curative operation because the tumor had infiltrated the pancreas head and aspiration pneumonia complications developed under the anesthetic. Abdominal CT revealed local recurrence and metastasis of the paraaortic lymph node after 3 months, so we started TS-1 chemotherapy. One course consisted of daily oral administration of 100 mg TS-1 for 4 weeks and withdrawal for 2 weeks. The recurrent lesions disappeared completely after 1 course. Furthermore, this therapy was continued for 3 courses without any side effects.

Neutrophil activation initiates myocardial ischemia/reperfusion (I/R) injuries. The aim of this study is to evaluate the in vitro functions of an anti-neutrophil monoclonal antibody, Urge-8, and its therapeutic efficacy against myocardial ischemia (MI) in rats. We measured in vitro functions of rat neutrophils including chemotactic activity, superoxide production, phagocytic function, and neutrophil degranulation. MI was induced in Wistar rats by clamping the left coronary artery for 1 h. Rats received either isotype-negative control IgG1 (control group, n = 20), 250 µg/kg of Urge-8 before (pre-treatment group, n = 20) or after (post-treatment group, n = 20) MI. The three groups were compared during the first 24 h after reperfusion with respect to changes in mean arterial pressure, heart rate, body temperature, biochemistry, serum cytokines, myocardial neutrophil infiltration, survival rate, and size of MI. Urge-8 effectively suppressed in vitro functions of rat neutrophils including chemotactic activity, superoxide production, phagocytic function, and neutrophil degranulation. The Urge-8 treated groups showed higher levels of arterial pressure and survival rate, lower values of interleukin-6 and interleukin-8, lower grade of myocardial neutrophil infiltration, and smaller MI size as compared to the control group. In conclusion, Urge-8 is effective against myocardial I/R injury by suppressing certain functions and myocardial infiltration of neutrophils in rats.

For borderline malignant diseases of the pancreas such as cystic adenoma, partial pancreatectomy or pancreatoduodenectomy including pylorus-preserving pancreaticoduodenectomy have been performed depending on tumor location under large median laparotomy. To investigate the feasibility of a technique with minimal skin incision, while retaining safety equivalent to conventional resection of the pancreatic tail, by making use of the advantages of laparoscopic procedure, we performed a minimally invasive laparoscopic resection of the pancreatic tail with preservation of the spleen. A 69-year-old woman underwent surgery for a diagnostic therapy for a cystic lesion of the pancreatic tail. The procedure was performed as follows: All procedures were performed completely laparoscopically under CO2 insufflation. After dissection of the omentum, laparoscopic ultrasound was performed to identify the location of the tumor and splenic vessels. The splenic hilus was dissected with preservation of the splenocolic ligament to maintain the lower blood supply to the spleen. The left gastroepiploic artery and the short gastric arteries and veins could be preserved. After division of the splenic hilus, the splenic artery and vein were identified from behind the pancreas by being held up and dissected individually by intracorporeal ligation by 3-0 Nylon. Then, pancreatic transection was performed 1 cm proximal to the tumor with the Endo-GIAII. The duration of operation was 4.5 hours. Intraoperative blood loss was under 50 mL. Histological examination revealed mucinous cytadenoma. She could walk the day after surgery and was discharged from the hospital uneventfully. CT prior to discharge from the hospital revealed sufficient blood flow in the spleen. Thus, it may be feasible to select laparoscopic spleen-preserving distal pancreatectomy as a first choice for diagnostic therapy for cystic lesions of the pancreatic tail.

Combined liver-intestine transplantation is an evolving procedure, and auxiliary liver transplantation has several advantages over standard orthotopic liver transplantation. We present a new model of combined intestine-auxiliary liver transplantation in rats. Total small bowel and 60% liver were harvested en bloc. An aortic segment that contained the celiac axis and superior mesenteric artery ensured blood supply to the graft. Venous drainage of the grafted intestine was achieved via the intact portal vein of the graft. The infrahepatic vena cava was cut at different levels during the modification period and at the oblique level of the left renal vein in consecutive series. Revascularization was accomplished by end-to-side anastomosis of the aorta and of the infrahepatic vena cava. The recipient small bowel was resected and the intestine continuity restored by anastomosis. Total operation time averaged 130 min. The overall survival rate of 3 months in the consecutive series was 80% (16/20). Exploratory laparatomy and histologic study in 3 rats on 90 days after transplantation revealed normal and viable grafts. Liver function was normal and both grafted liver and intestine showed normal histologic architectures in 5 rats observed for 12 months after transplantation. The present model is reproducible and allows preclinical research on several aspects of experimental combined intestine-auxiliary liver transplantation.

Objective: To assess the feasibility of cure of early gastric cancer by the endoscopic procedure done through a temporary gastrostomy and to use it to treat patients with various severe complications. Design: Prospective study. Setting: University hospital, Japan. Subjects: Four patients who required gastric mucosal resection for early gastric cancer. Main outcome measures: Ease of the procedure, cure rate, safety under epidural anaesthesia, and outcome. Results: All patients had the procedure under epidural anaesthesia without pain or complaints during operation. Mean operation time was 120 minutes (60-200). Histological examination showed that the surgical margin was free of tumour in 3 of the cases. One patient who had microscopic invasion of lymph nodes subsequently underwent second-look conventional gastrectomy with lymphadenectomy. Postoperative recovery was rapid, and all patients were discharged from the hospital uneventfully. Conclusion: This organ-preserving procedure enables good visualisation ...

Objectives: The number of patients with end-stage renal disease undergoing open heart surgery continues to grow. We evaluated continuous ambulatory peritoneal dialysis and the extracorporeal ultrafiltration method during cardiopulmonary bypass in the management of these difficult patients.Methods: These 2 methods were used in 4 patients with renal failure who underwent open heart surgery between July 1997 and March 1999. Preoperative continuous ambulatory peritoneal dialysis was conducted using standard protocols. Extracorporeal ultrafiltration method was used only during cardiopulmonary bypass. Continuous ambulatory peritoneal dialysis was initiated upon arrival at the intensive care unit. Mean follow-up was 12 months.Results: Postoperative blood urea nitrogen and creatinine concentrations were lower than preoperative concentrations. No patients required hemodialysis. All 4 patients were discharged to their homes. No deaths occurred.Conclusions: Continuous ambulatory peritoneal dialysis and extracorporeal ultrafiltration method are combined to treat patients with end-stage renal disease who require open heart surgery. This combination is simple, and does not require specialized personnel, and obviates the hemodynamic instability associated with hemodialysis.

The effects of phosphodiesterase III (PDE III) inhibitors administered after aortic declamping during cardiopulmonary bypass (CPB) for open heart surgery were investigated. Ten patients (group M) were administered milrinone (50 microg/kg) after aortic declamping during CPB, 10 patients were administered amrinone (1 mg/kg) at the same time during their surgery (group A), and 10 patients served as controls with no drug administered (group C). Soon after bolus infusion of the PDE III inhibitor, perfusion pressure dropped significantly in groups M and A. However, after release of CPB and at the end of surgery, there was no difference in aortic pressure between the 3 groups. There were also no differences between the groups in heart rate, pulmonary artery pressure, and pulmonary capillary wedge pressure. After weaning from CPB, the cardiac index was high and systemic vascular resistance index was low in groups M and A. There were no significant differences in the need for additional catecholamines and time for rewarming between groups. No adverse reactions were observed. A single administration of a PDE III inhibitor during CPB was useful for post-CPB management of patients undergoing open heart surgery. Amrinone reduced perfusion pressures more than milrinone, but cardiac indices and aortic pressures after weaning from CPB showed no differences between group M and group A patients.

Blue rubber bleb nevus syndrome is characterized by gastrointestinal and cutaneous hemangiomas and gastrointestinal bleeding causing anemia. We report a unique case of this syndrome in an adult woman. It was associated with congenital heart disease, for which the patient underwent surgery at 12 months of age, and cutaneous hemangiomas, for which surgery was performed later in childhood. Gastrointestinal bleeding was diagnosed and treated when she was 21 years of age after a workup for iron deficiency anemia. Successful total resection of all gastrointestinal hemangiomas was performed by minimally invasive surgery with gastric, small intestinal, and colonic fiberscopy and laparoscopy. The postoperative course was uneventful. The patient could walk the day after surgery, and she was discharged from the hospital 14 days after surgery. Our experience and findings given in other reports suggest that total resection of hemangiomas should be the final goal and that minimal skin incision is preferable for this benign disease, with multiendoscope-assisted treatment to ensure that any hemangiomas remaining in the gastrointestinal tract are not overlooked.

This perfusion model enables a pharmacokinetic study of enteral absorption and hepatic metabolic rate simultaneously. FK 506 is absorbed mainly via the proximal small intestine and metabolized rapidly by the liver during single passage. These results may lead to further analyses of absorption and metabolism of FK 506 under various conditions.

We report herein the first known case of early gastric cancer with synchronous liver metastasis forming a portal tumorous embolism. A 62-year-old man was found to have multiple liver tumors and a portal tumorous embolism by ultrasonography. A gastroscopy subsequently showed Borrmann type III-like gastric cancer in the antrum. His carbohydrate antigen (CA) 19-9 level was elevated to 8280 U/ml, but the alpha-fetoprotein level was within normal limits. A laparotomy revealed multiple liver metastasis and subpyrolic lymph-node enlargement; a distal partial gastrectomy with group 1 lymph-node dissection for the gastric cancer in the antrum, and cannulation of the proper hepatic artery for postoperative chemotherapy were performed. Histopathologically, the cancer was found to be a medullary type well-differentiated adenocarcinoma. Subpyrolic lymph node metastasis was noted, but cancer invasion was localized to only the mucosal and submucosal layers of the stomach. Thus, the patient was diagnosed as having early gastric cancer. Adjuvant chemotherapy given through the cannula suppressed further elevation of CA19-9 levels, and a total of 26 Gy irradiation to a liver tumor, which had caused ascites by pressing on the inferior vena cava, diminished the ascites. The patient was able to remain at home with treatment for 7 months after radiation therapy, but finally died of cancer with jaundice 13 months after his operation. Therefore, although adjuvant chemotherapy and radiation therapy contributed to improving his quality of life, it could not prolong survival.

Background: Percutaneous microwave coagulation therapy (PMCT) is effective for small liver tumors. To enhance the radicality of PMCT, we developed a sequential coagulation technique. Methods: After inserting the first guide-needle under sonography, multiple needles were placed through a disk-type introducer that was devised to guide needle puncture at regular intervals, and microwaves were irradiated. Six patients, including 4 with hepatocellular carcinoma and 2 with liver metastasis, underwent this technique for tumors of 15 to 80 mm in diameter. Results: This technique can coagulate an area up to 60 mm in diameter in one session. Insertion of multiple needles, ranging from 2 to 11, was successful without complications. Three patients undergoing curative PMCT developed no tumor recurrence. The other 3 received incomplete PMCT due to the large size and location of the tumor. Conclusions: This preliminary study indicates the efficacy of this technique to facilitate and secure PMCT in selected patients with liver tumors.

For the purpose of prophylactic treatment of splenic aneurysms, both examinations and treatments should be minimally invasive. Here, we report a case of a patient who underwent three-dimensional arterial computed tomography (CT) and laparoscope-assisted splenectomy with aneurysm resection as a combination of minimally invasive examination and treatment.

The effects of low dose FK506 therapy (0.1 mg/ kg/day x 1 day) on graft survivals were analyzed, and the feasibility of splenectomy was assessed. ACI strain liver grafts were orthotopically implanted into LEW male rat recipients. In the control group, the survival period was 10.4 +/- 1.4 days. In the group treated with splenectomy, the survival period was 13.4 +/- 2.0 days. In the groups with low dose FK506 therapy, the survival periods were 22.7 +/- 6.7 and 39.7 +/- 6.3 days with or without splenectomy, respectively. Rats in the group with average dose FK506 (1.0 mg/kg/day x 7 days) survived more than 100 days. In summary, the effect of low dose FK506 therapy was relatively limited. Splenectomy by itself was marginally effective; however, this effect was enhanced when combined with low dose FK506 therapy.

To determine whether p53 alterations, which are frequent in human breast cancers, are also common in rat mammary tumors, we examined 40 tumors from 24 rats treated with 7,12-dimethylbenz[a]anthracene (DMBA) and 34 tumors from 14 rats treated with N-nitroso-N-methylurea (NMU) (an N-nitroso compound). DMBA and NMU are known genotoxic mutagens. The entire coding regions of the p53 and Ha-ras genes were examined for mutations by polymerase chain reaction single-strand conformational polymorphism analysis and by direct sequencing. One of the 40 DMBA-induced mammary tumors had a p53 mutation, a single-base substitution (???AGC???GGC) at codon 307, resulting in an amino-acid change from Ser to Gly. No mutations were found in NMU-induced tumors. The incidence of Ha-ras gene mutation was 79% (27 of 34) at codon 12 in the NMU group and 23% (nine of 40) at codon 61 in the DMBA group. Thus, p53 mutation, in contrast to Ha-ras mutation, did not seem to be a prerequisite for carcinogenesis in chemically induced rat mammary tumors. © 1996 Wiley-Liss, Inc.

Laparoscopic cholecystectomy (LC) has become one of the options for the treatment of acute cholecystitis as surgeons gain facility with this procedure. However, acute suppurative cholecystitis is still a severe condition, because a high mortality rate still exists. In the early years (1991 to 1992), 4 patients were operated on without a preceding percutaneous transhepatic gallbladder drainage (PTGBD) at our hospital, however, one patient died of septic shock after a laparoscopic cholecystectomy. Conversion to open surgery was performed on two patients. However, in later years (1992 to 1995), 14 patients were operated on with preceding PTGBDs safely. Here, we report the safeness and significance of the combination therapy of PTGBD and LC for patients with severe acute suppurative cholecystitis.

In spite of the development of techniques for liver resection, preoperative evaluation of hepatic functional reserve and some other therapeutic options such as transcatheter arterial embolization (TAE) and percutaneous ethanol injection therapy (PEIT), liver failure after surgery is sometimes observed. Some patients, who have small liver cancers (under 2 cm in diameter) are diagnosed by various tests, but hepatic resection is not an option for the subset who have lowered hepatic functional reserve. Conventionally, such cases have been treated by TAE and/or PEIT. For the tumors in segments 7 or 8, as termed by Couinaud, which are located just beneath the diaphragm and are difficult to investigate by ultrasonography (US), or to perform PEIT, we have recently applied laparoscopic microwave coagulo-necrotic therapy (LMCNT) with the guidance of US and in some cases, thoracoscopic MCNT (TMCNT), which is performed across the diaphragm to necrotize the tumor, again with the help of US. Here, we report some cases treated by this technique, and the intraoperative color doppler US, which helps evaluate the effectiveness of MCNT.

Acute pancreatitis sometimes leads to pancreatic abscess with a high mortality rate when appropriate drainage is not applied. Pancreatic pseudocysts are also major complications of pancreatitis, which usually need to be treated only when they are symptomatic; they sometimes lead to disseminated intravascular coagulopathy or intraabdominal bleeding if they maturate. Conventional pancreatic drainage operations have sometimes been so invasive that they cannot be applied for severe cases with renal failure and disseminated intravascular coagulopathy. To avoid the risks of conventional drainage operations for pancreatic abscesses, a low invasive and effective percutaneous drainage technique guided by a laparoscope was developed and employed to a high-risk patient with post-pancreatitic pancreatic abscess. After the operation, leukocytosis and high fever improved dramatically. One year after discharge from the hospital, no recurrence of abscesses or leukocytosis have been found. Thus, this technique should be considered as a first option for the pancreatic drainage operation.

Ex situ hepatic surgery, in which a diseased liver is resected from outside the body, was first reported in 1988. This study investigates the hemostatic changes occurring during such surgery in two cases. During the anhepatic period of more than 5 hours, veno-venous bypass without heparin was performed. The tests included platelet count, prothrombin activity (PT), partial thromboplastin time (PTT), fibrinogen (Fbg), factor II (F.II), factor V (F.V), and thromboelastography (TEG). Three to 4 hours after entering the anhepatic phase, marked fibrinolysis and a fall in the values of PT, Fbg and F.V. were observed. Every parameter temporarily deteriorated immediately after revascularization of the graft, however, all returned to almost normal values within 1-2 hours after hepatic reperfusion except for F.V and platelets. In conclusion, the coagulopathy during ex situ hepatic surgery is caused by the marked fibrinolysis and depletion of hemostatic factors which develop 3-4 hours after the onset of the anhepatic phase.