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症例は91歳，女性．突然の腹痛で当科へ入院した．腹部X線写真にて小腸と大腸の著明な拡張を認めた．腹部CTでは，肝内門脈に著明なガス像がみられ，卵巣嚢腫と推測される9.3×9.1cm大の嚢胞が，骨盤腔を占拠しており直腸を左方に圧排，その口側のS状結腸壁は肥厚し，壁内にガス像がみられた．腰椎左側に後腹膜腔気腫を伴っていた．骨盤腔内の嚢胞性病変による機械的イレウスが原因で生じた門脈ガス血症と診断し，イレウス解除を目的に緊急手術を行った．骨盤腔には，左卵巣嚢腫が時計方向に180度捻転し骨盤腔を占拠しており，卵管とともに摘出した．摘出した嚢腫はserous cystoadenomaと診断された．術中，腹腔内臓器を検索したが，壊死等の異常所見はみられなかった．術後16時間で施行したCTで門脈内のガスは消失していた．腹水培養，血液培養は陰性であった．術後に施行した上部内視鏡検査および下部内視鏡検査では，明らかな異常所見はみられなかった．術後経過は良好で21日目に退院した．

Many cases have been reported of disastrous port-site recurrence after laparoscopic cholecystectomy (LC) revealed unsuspected gallbladder carcinoma (GBC). Some investigators have reported that the prognosis of patients after LC showed unsuspected GBC is not worsened by laparoscopic procedures. We retrospectively reviewed our cases and the literature to reconfirm the intrinsic risks of LC for unsuspected GBC. Of 1663 patients who underwent LC from January 1991 to December 2003 in a single institution, 9 (0.54%) with unsuspected GBC were reviewed. These 9 patients consisted of 5 men and 4 women, whose ages ranged from 58 to 87 years, with a median age of 73 years. Two patients with a pT1a tumor (limited to mucosa) and 2 patients with a pT1b tumor (muscle layer) underwent no further operation. The remaining 5 patients with a pT2 tumor (subserosa) underwent further operations with lymph node dissection. Five patients (2 patients with pT1b and 3 patients with pT2) developed recurrence and all of them died within a median period of 19 months (range 14–37 months) after LC. The causes of death were bone metastases in 1 patient (pT2), local recurrence in 2 patients (pT1b and pT2), and peritoneal metastasis in 2 patients (one elderly patient with pT1b who underwent laparoscopic common bile duct exploration, and one patient with pT2 in whom the cystic duct was damaged during surgery). Four patients (2 with pT1 and 2 with pT2) have been doing well with a median follow-up of 39.5 months (range 12–99 months) after LC. Surgeons should always prevent bile spillage during LC and when removing the resected gallbladder. When laparoscopic common bile duct exploration is planned, especially for elderly women, surgeons should also bear in mind the increasing possibility of unsuspected GBC.

Hepatectomy with concomitant resection of the inferior vena cava (IVC) has become common for hepatic malignancies involving the IVC. However, diagnosing IVC invasion and the procedure of choice have yet to be standardized. Medical records of nine patients with liver cancer (five metastatic tumors from colorectal cancer and four intrahepatic cholangiocarcinomas) believed to have directly invaded the IVC wall were retrospectively abstracted for data on preoperative radiologic studies, surgical procedures, histology of the resected specimen, and treatment outcome. All nine patients underwent hepatectomy: Five did not undergo IVC resection because the IVC could be isolated from the tumor; the remaining four underwent combined IVC resection (wedge and segmental resections in two each). The segmentally resected IVC was reconstructed using an external iliac vein graft. Total hepatic vascular exclusion, venovenous bypass, and the ex vivo technique were not used. Interestingly, the tumor was smaller and the percentage of the IVC circumference in contact with tumor as seen on computed tomography (CT) was less in patients with IVC invasion than in those without it (40 +/- 11 vs. 134 +/- 61 mm, p0.05; 30% +/- 8% vs. 60% +/- 20%, p0.05). The length of the IVC compressed by tumor on cavography was similar in the two patient groups (47 +/- 9 vs. 55 +/- 8 mm). All patients were discharged from the hospital in good condition: Seven died of cancer recurrence, and the remaining two are currently alive and disease-free 15 and 73 months after surgery, respectively. In conclusion, imaging modalities demonstrating caval deformation, such as CT and cavography, are unreliable for diagnosing direct invasion of the IVC wall. Even when IVC invasion is strongly suggested by conventional radiologic studies, the surgeon should endeavor to peel the tumor from the IVC. This strategy is important to avoid unnecessary resection of the IVC, use of a prosthetic graft, or ex vivo hepatectomy.

Background and aims. The mode and degree of tumor spread in gallbladder carcinoma is poorly documented. The present study classifies the patterns of dissemination of this tumor with a focus on surgical strategy. Patients and methods. Surgical specimens from 112 patients who underwent curative resection were reviewed. There were stage I, II, III, and IV in 9, 11, 14, and 78 patients, respectively. Results. Six types of spread were identified. In the hepatic bed type (n=20) a large mass in the fundus and body penetrated into the liver through the gallbladder bed with or without contiguous spread to the gastrointestinal tract. The extent of hepatectomy was individualized from wedge resection to extended right hepatectomy based on the clinical findings. In the hepatic hilum type (n=26) a relatively small tumor in the neck infiltrated the hepatic hilum causing obstructive jaundice. Extended right hepatectomy plus bile duct resection with or without portal vein resection was necessary for curative resection because the tumor had extended into the right portal pedicle, and postoperative hepatic failure was common. In the bed and hilum type (n=18) a huge mass occupying the entire gallbladder involved both the gallbladder bed and the hepatic hilum. Extended right hepatectomy with combined resection of contiguous spread was necessary for curative resection. In the lymph node type (n=15) enlarged metastatic lymph nodes were the most prominent feature, and the primary tumor remains limited to the gallbladder in most cases. Extended lymphadenectomy with combined individualized resection was performed. In the cystic duct type (n=9) a small mass arising from the cystic duct involved the common bile duct. This type presented at an earlier stage than the first four types. In the localized type (n=24) tumor spread is localized to the gallbladder and presented at the earliest stage of any type. Simple cholecystectomy with or without wedge hepatic resection and regional lymphadenectomy resulted in a satisfactory outcome. Prognosis depends on the stage rather than on the mode of tumor spread. Even in the advanced types favorable results may be obtained in selected patients undergoing radical resection for M0 tumors without portal vein invasion. Success also was achieved in the rare patients with para-aortic lymph node metastases that were not infiltrative. Conclusions. These six types of gallbladder cancer can be diagnosed preoperatively by clinical and radiological examination. This information should assist the surgeon in the choice of operation and predict outcome.

Background and aims. Septic complications after hepatectomy remain a difficult problem. Intra-abdominal sources of postoperative infections are well described in the literature. However, no studies have examined the cause and outcome of bacteremia after hepatectomy. This study evaluated the incidence and outcome of bloodstream infections, bacteremia, after hepatectomy and determined the risk factors associated with the development of this serious complication. Patients and methods. Records were retrospectively reviewed of 407 patients who underwent an elective first hepatectomy at Nagoya University Hospital between January 1990 and December 1999. The incidence, cause, outcome, and possible risk factors for bacteremia were examined. Results. A total of 403 blood cultures were performed after hepatectomy in 188 patients (46%), and bacteremia was confirmed in 46 (11%). The incidence was significantly different between patients with obstructive jaundice and those without (24% vs. 4%). Multivariate analysis identified four significant independent variables: operative time, age, obstructive jaundice, and large-scale hepatectomy. The most common bacteria isolated were Staphylococci, followed by Enterococci, Klebsiella pneumoniae, and Enterobacter. A probable source of bacteremia was identified in 21 (46%) of the 46 patients. Patients with bacteremia had higher morbidity and mortality rates than patients without bacteremia, and the incidence of organ failure was five to ten times that of patients without bacteremia; the mortality rate was 43% (20/46). Conclusions. Postoperative bacteremia is a common complication of hepatectomy to resect biliary tract carcinoma, especially in older patients with obstructive jaundice undergoing major hepatectomy. In addition, for more than half of patients with bacteremia, no clear source of the infection is identified. Thus blood cultures are mandatory in high-risk patients who spike a fever after hepatectomy to identify the correct pathogen and its antibiotic susceptibility.

Purpose: To describe 5-year survivors after radical surgery for stage IV gallbladder cancer and to determine the characteristics leading to potential long-term survival. Methods: Of 59 patients undergoing radical resection for stage IV disease between 1979 and 1994, 6 patients who have survived for more than 5 years were followed up. Results: Three patients had developed obstuctive jaundice due to involvement of the hepatic hilum, but the other three had not. The jaundiced patients had remarkable tumor spread over the bile duct and right hepatic artery within the hepatoduodenal ligament. However, the proper and left hepatic arteries and the portal trunk and its left branch were free from tumor involvement. The nonjaundiced patients had N1 or N2 lymph node metastasis. However, none underwent bile duct resection or pancreatoduodenectomy to establish radical lymphadenectomy. Conclusions: Selected patients with stage IV gallbladder cancer may be candidates for 5-year survival when the primary tumor is fairly localized even if it forms a large mass and involves neighboring organs including the hepatic duct, lymph node metastasis is limited to N1 and N2 except for the celiac and superior mesenteric nodes and is less infiltrative, and distant metastasis including that in the paraaortic area is absent.

We retrospectively reviewed postoperative complications in 105 patients with hilar cholangiocarcinoma who underwent hepatectomy at Nagoya University Hospital from January 1990 through March 1999. Of the 105 subjects, 97 (92.4%) underwent resection of two or more Healey's segments of the liver. Combined portal vein resection was performed in 33 (31.4%) patients and pancreatoduodenectomy in 10 (9.5%). Twenty (19.0%) patients had no postoperative complications, another 39 (37.1%) patients had minor complication(s) only, and the remaining 46 (43.8%) developed major complication(s). The morbidity rate reached as high as 81.0%. Major complications required relaparotomy in 11 (10.5%) patients. Of the 46 patients with major complication(s) 36 recovered; the remaining 10 patients died of liver failure with other organ failure(s) or of intraabdominal bleeding 12, 14, 18, 21, 57, 75, 75, 87, 93, or 134 days after surgery. Thus the 30-day mortality was 3.8% and the overall mortality 9.5%. Pleural effusion was the most frequent complication found in 66 (62.9%) patients, followed by wound sepsis in 39 (37.1%), and then liver failure in 29 (27.6%). Liver failure developed in 16.7% of 48 patients with less than 50% liver resection and in 36.8% of 57 patients with 50% or more resection (P < 0.05). Other organ failures, including renal, respiratory, gastrointestinal, and hematologic failures, developed as a sign of multiple organ failure following liver failure in most patients or preceding liver failure in a few patients. None of the six patients with four or more organ failures survived. Hepatectomy for hilar cholangiocarcinoma is risky owing to impaired hepatic functional reserve in jaundiced patients and the technical difficulty associated with hepatobiliary resection. Our goal is to reduce mortality to less than 5% while keeping a high resectability rate (above 80%).

An asymptomatic 37-year-old man underwent gastroscopy for health screening, which revealed a protruded lesion at the upper part of the corpus on the lesser curvature of the stomach. He was referred to our hospital for close inspection. Computed tomography and endoscopic ultrasonography showed an extragastric and well-defined cystic lesion. We performed an operation with a presumed diagnosis of submucosal tumor of the stomach. At laparotomy a large mass on the anterior wall of cardia and a small mass on the anterior wall of the middle part of the corpus were found in the subserosal space, and both of them could be easily enucleated. Because histologic examination of the resected material revealed that they are composed of mucosal layer, proper muscle, subserosal layer, and the serosa, a diagnosis of duplication of the stomach was made. Gastric duplication cyst is a kind of gastrointestinal tract duplications, which are congenital anomalies and have been found in various organs from tongue to large intestine. Even though the duplication of the stomach is rare, we must keep this disease in mind on differential diagnosis of the submucosal tumor of the stomach, because its frequency will increase with recent advances in imaging modalities.

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.

We reviewed the records of 64 patients with resected intrahepatic cholangiocarcinoma (ICC) according to the macroscopic classification proposed by the Liver Cancer Study Group of Japan, in which ICC is classified into three types based on the macroscopic appearance of the cut sur-face of the tumor: mass-forming, periductal-infiltrating, and intraductal growth types. There were 24 patients with the periductal-infiltrating type, 28 with the mass-forming type, and 12 with the intraductal growth type. The mass-forming type essentially showed expansive growth irrespective of hilar invasion. The periductal-infiltrating type of tumor exhibited diffuse infiltration along the portal pedicle, and preoperative planning of the resection procedure was similar to that for primary bile duct carcinoma of the hepatic confluence. Vascular resection and reconstruction was required in some patients with advanced disease. In the intraductal growth type of tumor, precise determination of tumor extent was difficult because of the ambiguity caused by abundant mucin secreted by the tumor and/or by the superficial mucosal spread of the tumor along the bile duct. Percutaneous transhepatic cholangioscopy provided the most reliable information for designing the operative procedure. The macroscopic classification is useful for preoperative diagnosis of tumor extent and for planning the surgical procedure.

A case of gallbladder carcinoma in a 75-year-old woman with familial hyperbilirubinemia and preoperative hepatic dysfunction is presented. Tube cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter demonstrated a stricture and the hepatic confluence without filling of the gallbladder and showed two bile duct branches arising from the left caudate lobe. Cholangiography also disclosed that the left dorsal branch, which joined the right hepatic bile duct, was involved with tumor, while the left ventral branch, which joined the left hepatic duct, was not. Extended right hepatic lobectomy with resection of the dorsal portion of the left caudate lobe, preserving the ventral portion of the left caudate lobe, was performed. Postoperative cholangiography showed that the ventral branch of the left caudate lobe bile duct was preserved. Precise preoperative anatomic diagnosis of the biliary system in patients with hepatobiliary cancer allows successful subsegmental resection of the caudate lobe.

We describe a case of mucosal bile duct carcinoma with superficial spread in a 69-year-old man with gallstone pancreatitis. The patient was seen at the hospital because of abdominal pain, fever, and jaundice. Endoscopic retrograde cholangiography (ERC) demonstrated a protruding lesion in the lower third of the common bile duct (CBD) showing wall irregularity suggestive of malignancy. Percutaneous transhepatic cholangioscopy (PTCS) disclosed a papillary tumor with granular mucosa extending continuously to the middle third of the CBD. Cholangioscopic biopsy specimens taken from both the papillary tumor and surrounding granular mucosa revealed papillary adenocarcinoma. After this assessment of extent of cancer by PTCS, we performed pancreatoduodenectomy with extrahepatic bile duct resection and regional lymph node dissection. Pathology examination revealed papillary adenocarcinoma limited to the mucosal layer. The resected margin of the bile duct was free of tumor. We also reviewed 25 cases of early mucosal bile duct carcinoma described in detail in the Japanese literature, and we discuss the diagnostic advantages of PTCS.

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.

A 68-year-old woman visited another hospital because of mucinous feces and vertigo, when laboratory data showed anemia and hyponatremia. She was referred to the hospital for surgery. A nodular surfaced tumor was palpable in the rectum just above the anal verge on digital examination. Endoscopy revealed a large tumor with a lot of mucus on the surface. Biopsy from the villous tumor offered a suspicion of adenocarcinoma. Abdominal CT showed two low attenuation areas in the liver and a large tumor occupied in the pelvis without invasion to the surrounding organs. Although a preoperative treatment did not improve her vertigo, an operation, which included abdominosacral excision of the rectum with partial resections of liver, was performed. The rectal tumor, 12cm in diameter, was located 15cm from the dentate-line actually. The cut surface of hepatic specimen was multilocular and cystic containing a lot of mucus. Histological findings of the rectal tumor revealed well differentiated adenocarcinoma mainly invading the subserosal layer, and villous adenoma or tublovillous adenoma partially. The hepatic lesions were metastases of the rectal carcinoma pathologically. After the operation the vertigo subsided gradually, and she could walk. Resected cases of hepatic metastases from villous tumor of the rectum are rare. The liver metastasis in this case was characteristic macroscopically.

Fifty patients with obstructive jaundice with biliary tract carcinoma who underwent percutaneous transhepatic portal vein embolization (PTPE) were studied to evaluate the clinical utility of PTPE in preparation for extensive liver resection. PTPE was performed 2–3 weeks before surgery, via the standard contralateral approach in the first seven patients and via the ipsilateral approach, devised by the authors, in the last 43 patients. The following portal branches in which embolization was planned were all successfully embolized: the right portal vein in 35 patients; the right portal vein plus the left medial portal branch in 6; the left portal vein and the right anterior portal branch in 3; the left portal vein in 2; the right anterior portal branch in 3; and the right posterior portal branch in 1. There were no procedure-related complications. Helical computed tomography demonstrated compensatory hypertrophy of the non-embolized segments. After PTPE, 35 of the 50 subjects underwent major hepatectomy with or without portal vein resection and/or pancreatoduodenectomy; the remaining 15 were found to have peritoneal dissemination or liver metastasis, and no resection was performed. Of the 35 hepatectomized patients, 3 died of posthepatectomy liver failure, and 1 patient died of pneumonia with pulmonary lymphangitis carcinomatosis; the other 31 patients were discharged in good condition. The hospital death rate was 11.8% (4/35), and mortality directly related to the surgery was 8.6% (3/35). PTPE appears to have the potential to increase the safety of extensive liver resection for patients with obstructive jaundice.

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.

A case of recurrent carcinoma of the cystic duct remnant invading the common bile duct and portal vein with subcutaneous implantation of the abdominal wall is presented. The patient was a 55-year-old woman with an abdominal wall tumor at the site of the surgical scar of a cholecystectomy, performed at a local hospital 5 years ago for symptomatic cholelithiasis. The diagnosis was made by incisional biopsy of the tumor, computed tomography, percutaneous transhepatic cholangiography, and angiography. She underwent extended right hepatic lobectomy with en bloc resection of the caudate lobe, extrahepatic bile duct, and portal vein. The abdominal wall tumor was resected concomitantly. Histological examination showed that both the recurrent carcinoma of the cystic duct remnant and the abdominal wall implantation were moderately differentiated adenocarcinoma. This recurrence probably could have been prevented if both the macroscopic and microscopic examinations of the resected specimen had been precisely carried out after the previous cholecystectomy and the primary carcinoma identified and treated at that time.

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.

A rare case of a huge carcinosarcoma of the gallbladder is presented. Despite a tumor thrombus in the portal vein, this tumor was resected successfully by extended right hepatic lobectomy with right caudate lobectomy and gastroduodenectomy. However, hepatic metastases developed rapidly, and the patient died only 3 months after surgery. Macroscopically, a whitish tumor filled the body and neck of the gallbladder and involved the right lobe and left medial segment of the liver, stomach, and duodenum. Microscopically, the neoplasm consisted of both carcinomatous and sarcomatous components. The former contained adenocarcinoma and squamous cell carcinoma, which were observed in the wall of the gallbladder. The latter comprised the bulk of the mass and contained malignant cartilage and osteoid. Immunohistochemically, the sarcomatous cells reacted to antibodies for epithelial membrane antigen and cytokeratin, but were negative for vimentin antibody, Although stromal differentiation into osteoid and cartilage was noted, the sarcomatous component was felt to be derived from mesenchymal metaplasia of the carcinomatous cells. Only 14 cases of carcinosarcoma of the gallbladder have been reported in the English language literature since 1967.

We have studied the surgical anatomy of the intrahepatic bile duct, hepatic hilus, and caudate lobe based on intraoperative findings and selective cholangiography of surgical patients and resected specimens, and have established the cholangiographic anatomy of the intrahepatic subsegmental bile duct. Thorough knowledge of the three-dimensional anatomy of the subsegmental bile duct, hepatic hilus, and caudate lobe is indispensable for curative surgery of hilar cholangiocarcinoma. We designed and actually performed 15 kinds of hepatic segmentectomies with caudate lobectomy and extrahepatic bile buct resection in 100 consecutive patients, with curative resection being possible in 82 patients. Postoperative survival after curative resection of hilar cholangiocarcinoma was better than expected, and the 5-year survival rates for all 82 patients with curative resection and for 55 patients with curative surgery without portal vein resection were 31% and 43%, respectively. Hepatic segmentectomy with caudate lobectomy and extrahepatic bile duct resection should be designed not only in accordance with the preoperative diagnosis of tumor extension into the intrahepatic bile ducts but also so that curative surgery for advanced hilar cholangiocarcinoma can be performed.

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.

A rare case of nonfunctioning islet cell carcinoma associated with tumor thrombi in both the portal and splenic veins is reported. The patient, a 49-year-old male, had a 2-year history of occasional abdominal pain. Computed tomography (CT) disclosed a huge mass in the body of the pancreas, and celiac arteriogram showed a tumor stain in the body and tail of the pancreas. Percutaneous transhepatic portography (PTP) demonstrated an irregular filling defect, indicating intraportal tumor growth. Curative surgery, which included total pancreatectomy with combined resection (50 mm in length) and reconstruction of the portal vein, distal gastrectomy, and partial resection of the transverse colon, was performed. Histological examination of the surgical specimen led to a diagnosis of nonfunctioning islet cell carcinoma with a negative immunohistochemical stain for insulin, glucagon, somatostatin, and adrenocorticotropic hormone. The patient has been well for 38 months to date without any sign of tumor recurrence. Our experience with this case has introduced a radical resection for islet cell tumor of the pancreas, even if the tumor has extended into the portal vein.

Background. Percutaneous transhepatic embolization of the right portal vein plus the left medial portal branch (R3-PE) and the left portal vein plus the right anterior portal branch (L3-PE) is not well described. Methods. Four patients with far advanced carcinoma of the hepatic hilus underwent R3-PE (n=1) or L3-PE (n=3) as preoperative management for right hepatic trisegmentectomy or left hepatic trisegmentectomy. The portal vein embolization was performed with the ipsilateral approach through the right anterior portal branch. Results. In all patients the embolizations were successful without complications. Volumetric study with computed tomography showed sufficient hypertrophy of the nonembolized hepatic segments. Three of the four patients eventually underwent trisegmentectomy. The postoperative courses in two of the patients were uneventful. The remaining patient suffered from posthepatectomy liver failure but recovered. Conclusions. R3-PE or L3-PE is advisable as preoperative management for trisegmentectomy and appears effective for increasing the safety of the operation. This embolization is achievable only through the ipsilateral approach.

A case of recurrent tumor with intrabiliary ductal growth after hepatic resection for liver metastasis from rectal cancer is presented. The patient, a 55-year-old female, underwent subsegmentectomy of the anteroinferior and posteroinferior areas of the liver for metastatic liver cancer on August 29, 1988. Computed tomography in February 1990 showed dilatation of the intrahepatic bile duct in the right anterosuperior subsegment (B8), in which a filling defect was detected by cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter. Percutaneous transhepatic cholangioscopy (PTCS) revealed a protruding lesion without tumor vessels. Cholangioscopic biopsy revealed dysplasia, but not adenocarcinoma. However, recurrent tumor originating in the resected margin of the remnant liver was suspected, and resection of the right lobe of the liver and partial resection of the duodenum were therefore performed. The resected specimen showed a tumor, 4 cm in diameter, in the previous resected margin, forming a protruding lesion with a rough surface (measuring 10×20 mm) in the B8 bile duct. This case suggested the possibility of cancer recurrence in the resected margin of the liver after hepatectomy for metastatic colorectal cancer, with intrabiliary ductal tumor growth showing segmental biliary dilatation.

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.

A case of carcinoma of the pancreatic head associated with situs inversus (SI) and polycystic liver (PCL) is presented. The patient was a 71-year-old male with complaints of jaundice and general fatigue. Percutaneous transhepatic biliary drainage (PTBD) revealed complete obstruction of the lower end of the common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis of the main pancreatic duct (MPD) in the head of the pancreas. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated multiple cysts in the liver as well as SI. Pylorus-preserving-pancreatoduodenectomy (PPPD) was performed by an operator who took his usual position on the patient's right side. We had no particular difficulty during surgery, although we had to charge several procedures. We consider it reliable to take the usual positions during surgery, even in cases of SI.

We describe herein the successful treatment of four patients with ischemic ulcers or gangrene of the fingers due to Buerger's disease by thoracoscopic sympathectomy, a new method of surgery which eliminates the difficulties associated with the traditional "open" approaches to the thoracic sympathetic chain, such as poor exposure, risk of damage to the adjacent structures, and postoperative pain. After the patients were placed in the lateral decubitus position with unilateral pulmonary ventilation, the thoracic sympathetic ganglia (T) from the lower third of T1 to T3 were resected endoscopically. The operative results were excellent, with improvement or complete resolution of the ulcer being achieved in all four patients. All of the patients were satisfied with the results in terms of ulcer healing, postoperative pain, and cosmetic appearance. Although a postoperative air leakage developed in one patient with a history of pulmonary tuberculosis, it was successfully treated with an adhesive agent. None of the patients developed Horner's syndrome. Thus, because thoracoscopic sympathectomy is easier to perform with a lower risk of complications than conventional thoracic sympathectomy, we recommend this operative approach as the procedure of choice for surgical thoracic sympathectomy.

A case of esophageal leiomyoma with remarkable calcification is presented. A 65-year-old man was admitted to the hospital, because esophagography on a health screening demonstrated extraesophageal compression and deformity of the esophagus. Endoscopy showed a protruding lesion, 3cm in diameter, in the anterior wall of the esophagus under the bifurcation of the trachea. Esophagography and computed tomography showed a massive calcification in the lesion. With endoscopic ultrasonography a tumor originating from the proper muscular layer of the esophagus was suspected. Enucleation of the tumor was performed. The resected specimen was a hard and saddle-like tumor, 4×3×1.5cm in size. Histological findings revealed leiomyoma. Nine of 20 cases of calcified leiomyoma of the esophagus reported in Japan were characterized by the location in the anterior wall of the esophagus near the bifurcation of the trachea.

A 34-year-old woman was admitted to the hospital because of sudden onset of left flank pain. Ultrasonography and CT findings revealed a left giant renal tumor. The tumor was 13×11×20cm in size and composed of fatty tissue in the most part. A lesion which seemed to be hematoma surrounded the left kidney. She was diagnosed with retroperitoneal bleeding due to rupture of the renal tumor, and underwent abdominal angiography. It was revealed that the tumor was fed by three dilated and tortuous vessels of branches from the renal artery. A diagnosis of renal angiomyolipoma was made. These tumor vessels were embolized with 5ml of absolute ethanol superselectively. Post embolized course was uneventful and the tumor revealed a decrease in size on CT 9 days after TAE. She has been asymptomatic for 5 years. Transarterial embolization with absolute ethanol is first recommended for renal angiomyolipoma.

Laparoscopic cholecystectomy (LC) in patients with a previous history of upper abdominal surgery is a difficult procedure with a high conversion rate.Forty-two patients with a previous history of gastrectomy (gastrectomy group) were compared to patients without previous abdominal surgery (no surgery group, n=1375). Patients in the gastrectomy group were divided into two groups for comparison: first, an umbilicus-group (n=12, at the umbilicus) and a side-group (n=23, right of the umbilicus) by the location of the primary port insertion, second, a benign group (n=31) and a malignant group (n=11).Patients in the gastrectomy group had similar operative morbidity but a significantly higher conversion rate and a longer postoperative hospital stay than patients in the no-surgery group. Conversion was performed in four patients in the gastrectomy group (9.5%): 3 in the umbilicus-group and one in a side-group. Two patients in the umbilicus-group had adhesion only just around the primary port site. Patients in the malignant group had similar postoperative hospital stay and morbidity but a significantly longer operating time than patients in the benign group.Previous gastrectomy for benign or malignant diseases is no longer considered a relative contraindication for performance of safe LC.

The biliary branches of the caudate lobe (B1) join the right hepatic duct, the left hepatic duct, the confluence of these ducts, and/or the right posterior segmental bile duct. Therefore, in the preoperative staging of biliary tract carcinoma it is important to delineate the anatomy of B1 and the extent of cancer spread into B1. Tube cholangiography through percutaneous transhepatic biliary drainage or selective cholangiography by percutaneous transhepatic cholangioscopy enables us to obtain fine images of B1. We have developed cholangiography in the cephalad anterior oblique position to visualize B1 more clearly and distinctly. Four separate types of biliary branches are identified in the caudate lobe: (1) A duct running from the cranial portion of the right caudate lobe along the inferior vena cava to the hepatic hilus (B1r); (2) a duct from the cranial portion of the left caudate lobe to the hepatic hilus (B1ls); (3) a duct from the left lateral part of the left caudate lobe to the hepatic hilus (B1li); and (4) a duct from the caudate process to the hepatic hilus (B1c). The findings of the root of B1 in resected patients with biliary tract carcinoma were classified into four groups: not stenotic, short segmental stenosis, long segmental stenosis, and poorly imaged. A study of 64 branches of B1 in 42 resected patients with biliary tract cancer revealed carcinoma invasion in or near the root of B1 in all patients with poorly imaged or long segmental stenosis of B1, and in 33% of those with short segmental stenosis of B1.