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Hepatobiliary and pancreatic surgery is recognized as technically demanding due to the complicated local anatomy and diverse anatomical variation that require precise techniques. Therefore, preoperative simulation to understand the detailed local anatomy and intraoperative navigation methods for surgical guidance are needed. Intraoperative navigation for anatomical hepatectomy originated with dye injection into the dominant portal pedicle under intraoperative ultrasound guidance to identify hepatic segments, which was reported by Makuuchi et al in 1985. In recent years, with advancing medical technology, newer medical devices that promote the safety and reliability of various surgical procedures have been developed. In this article, we will discuss the current state and future prospects of intraoperative navigation in hepatobiliary and pancreatic surgery.

A 56-year-old man with advanced esophageal carcinoma and lymph node swelling of abdomen (cStage III) underwent neoadjuvant chemotherapy (NAC) with 5-FU/CDDP. The side effect was stomatitis of grade 2. Primary tumor and lymph node swelling revealed remarkable effectiveness after 2 courses of NAC. Esophageal carcinoma was not found by endoscopy. Reduction of the lymph node was slight, however, radical resection of the esophageal carcinoma was performed. Pathologic examination of resected specimens revealed no malignant cells in the esophagus, and no metastasis of lymph node (Effect grade 3). Thus, we found NAC to be markedly effective for primary tumor and lymph nodes of esophageal carcinoma, and a radical operation was performed.

We experienced a case of primary gastric choriocarcinoma(PGC)treated by curative operation after neoadjuvant chemotherapy with S-1/CDDP. Gastric endoscopy was carried out on this 43-year-old woman with epigastric discomfort and revealed an ulcerative lesion in her stomach. Choriocarcinoma in the gastric lesion was pathologically shown by endoscopic biopsy, so we diagnosed the patient without another primary lesion as PGC. The patient was initially treated by five courses of neoadjuvant chemotherapy with S-1/CDDP due to the metastases of Virchow and intraabdominal lymph nodes, and then a curative operation could be performed because of disappearance of the lymph node metastases by neoadjuvant chemotherapy. The patient was continuously treated by S-1 after gastrectomy but was dead due to the multiple metastases of the liver and adrenals, and the multiple recurrences of lymph nodes four months after the surgery. Further therapeutic strategy by chemotherapies against PGC is needed to ameliorate the prognosis.

A rapid and precise determination residues of 4 tetracyclines (TCs) (oxytetracycline (OTC), tetracycline (TC), chlortetracycline (CTC) and doxycycline (DOXY)) in meat was developed by employing three analyses; a microbiological screening, HPLC and LC/MS/MS. TCs were extracted with pH 4.0 McIlvaine buffer containing 0.01 mol/L EDTA from a meat sample, and then purified using a mixed mode, reversed-phase and cation-exchange cartridge. The mean recoveries (n=5) of 0.2 microg/g OTC, TC and CTC, 0.05 microg/g DOXY spiked in meat samples were 76.6-99.0% (C.V. 1.6-5.4%). In 13 meat samples in which the microbiological screening indicated the presence of TCs, CTC (9 samples) and DOXY (4 samples) were identified with HPLC and LC/MS/MS.

The patient was a 61-year-old man who was referred to our hospital with a complaint of epigastric pain. Upper gastrointestinal endoscopy and X-ray examination of the stomach revealed type 3 cancer in the gastric antrum, extending to the middle body. It was about 9 cm in diameter, and the biopsy specimen revealed moderately differentiated tubular adenocarcinoma. Abdominal CT scan showed marked enlargement of No. 3 lymph nodes along the lesser curvature of the stomach. Examination of the blood showed a hemoglobin of 10.2 g/dl, CEA 5.8 ng/ml, CA19-9 330.5 U/ml. For this gastric cancer, clinical Stage IIIA (cT3N1HOPOMO), neoadjuvant chemotherapy with TS-1/CDDP was planned. TS-1 (120 mg/day) was orally administered for 3 weeks followed by a drug-free-2-week period as the first course, and 93 mg (60 mg/m2) of CDDP administered by intravenous drip on day 8. There were grade 2 nausea and grade 3 appetite loss by intravenous administration of CDDP in the second course. An upper GI series revealed 33% reduction of gastric cancer, and laboratory studies CEA and CA 19-9 showed normal values. One month after the second course of chemotherapy, total gastrectomy, splenectomy and lymph node dissection D2 were performed. The pathological specimens showed no cancer cells in the surgically obtained stomach and lymph nodes, so the histological effect was Grade 3. The postoperative course was satisfactory, and he now attends outpatient department without any findings of recurrence 12 months after the operation. TS-1/CDDP chemotherapy produced a high response in this case, and it may be useful as neoadjuvant chemotherapy for advanced gastric cancer.

A microbiological method for screening of residual benzylpenicillin (PCG), oxytetracycline (OTC) and spiramycin (SPM) in meat using a single mixed mode, reversed-phase and cation-exchange cartridge was developed. A meat sample was extracted with 0.1 mol/mL pH 4.5 phosphate buffer and the extract was applied to a MCX cartridge. The cartridge was washed, and adsorbed antibiotic residues were eluted with acetonitrile for acidic fractions and acetonitrile containing 5% ammonia solution-0.1 mol/mL pH 4.5 phosphate buffer (9:1, v/v) for basic fractions. Each eluate was evaporated to dryness and the residue was dissolved in phosphate buffer to prepare test solutions for microbiological assay. When the diameter of the inhibition zone was more than 12 mm, the result was considered positive. In this method, the average recoveries of PCG at 0.05 microg/g, OTC at 0.1 microg/g and SPM at 0.2 microg/g were 70%, 92% and 84%, respectively. Tolerances of the three antibiotics were detected. All the results demonstrate that this method is simple, rapid and useful for screening of these three antibiotic residues in meat.

To clarify the genetic background of cancer patients, microsatellite instability (MSI) and mutations of transforming growth factor-beta type II receptor (RII), p53 and k-ras gene were investigated. MSI were detected in 33.3% of esophageal, 15.8% of gastric, 21.4% of colorectal, 4.5% of bile duct, 0% of gallbladder, 13.3% of pancreatic, 11.6% of breast and 10.5% of thyroid cancers. Mutations of RII gene were detected in only 2 of 9 MSI-positive colorectal cancers. k-ras gene mutations were investigated in colorectal, bile duct, gallbladder, breast and thyroid cancer and were detected in 11.9%, 36.4%, 64.3%, 0%, 0% of each. p53 gene mutations were investigated in colorectal and breast cancer and were detected in 9.5% and 9.3%, respectively. In addition, 4 colorectal cancer cases exhibited more than two kinds of genetic alteration, while breast cancer cases showed only single kind. From these findings, it is suggested that 1) the incidence of each genetic alteration differed among the cancers investigated and organ specificity may exist; 2) the genetic alterations investigated here contributed to a minor part of cancer development, which requires the identification of more unknown genes related to carcinogenesis; 3) to clarify the molecular mechanism of cancer development, the genetic alterations including genomic instability and mutations of several kinds of genes related to cancer development in each case should also be determined along with their genetic molecular profile.

Studies on responses to surgical stress in blood coagulation and fibrinolysis, platelet counts and thromboxane B2 (TXB2) were carried out with 18 esophageal cancer patients who had undergone radical esophagectomy through right thoracotomy and reconstruction with gastric tube. Plasma levels were measured for the following for coagulation assessment: thrombin.antithrombin III complex (TAT), soluble fibrin monomer complex(SFMC), fibrinogen, antithrombin III, protein C and thrombomodulin. Selected fibrinolytic markers are: tissue plasminogen activator.plasminogen activator inhibitor 1 complex (tPA.PAI1C), plasminogen, alpha 2 plasmin inhibitor, plasmin. alpha 2 plasmin inhibitor complex(PIC), FDP and D-dimer. Peripheral venous blood samples were taken from the patients before the operation, immediately after the operation and on each of the first, second, third, seventh and fourteenth day after the operation. It was observed that TAT, SFMC, tPA.PAI-1C and TXB2 were remarkably altered immediately after the operation. This indicates that the major surgical stress significantly activated coagulation, fibrinolysis and platelets. Higher plasma levels of TAT compared to the pre-operation level was recorded for two weeks after the operation. Furthermore, in four cases, SFMC became positive during three to seven days after operation. These facts indicate that the activation of coagulation persisted during the days after operation. PIC began to increase from the 2nd to 3rd days after operation, reaching the maximum on the 7th day. Biphasic changes which peaked twice on the 1st and 7th days after operation were shown in plasma levels of FDP and D-dimer. These results indicate that the activation of fibrinolysis also persisted during the days after operation. The activation of coagulation and fibrinolysis may persist at least for two weeks after major surgical operation. Careful observation for the states of these systems was thought to be needed during the post-operative days, and the molecular markers could be useful to assess subclinical changes of these systems.

Imipenem/cilastatin sodium (IPM/CS) was administered to 102 patients with respiratory tract infections and lung cancer. Patients with other serious diseases were excluded and a total of 73 patients were enrolled. They were divided into 12 patients who underwent surgery (operated group) and 61 who did not (non-operated group); the latter group included 28 patients treated with anticancer agents or radiation therapy (treated group) and 33 untreated patients (untreated group). IPM/CS was effective in 75% of the patients, both with and without surgery. The drug was effective in 81% of the treated group, although many of the patients had Stage III or more advanced cancer, as well as bronchial occlusion. IPM/CS was also effective in 69% of the untreated group, although many of the patients have serious infections and a PS (Performance Status) of 3 or greater. Thus, IPM/CS treatment achieved good results. Bacteriological studies showed that 3 out of 4 strains in the operated group and 16 out of 18 in the non-operated group were eliminated. Safety was evaluated in all patients. Two patients (2%) experienced side effects and two others (2%) showed abnormal clinical findings, but the symptoms were mild and resolved after discontinuation or completion of therapy. In conclusion, IPM/CS was very effective for treating respiratory infections in patients with lung cancer.

Curatively resected specimens of 124 cases of colorectal carcinoma, and 6 cases of colorectal carcinoma showing hematogenous metastasis were used in this study. Each carcinoma was cut out in stepwise section through the entire tumor. DNA ploidy for each section was determined by flow cytometry, and the intratumor DNA ploidy distribution pattern was decided, and divided into 5 types (Type A-E). These 5 types were broadly divided into 2 types; predominantly diploidy type (Type A, C) and predominantly aneuploidy type (Type B, D, E). A statistically significant difference was seen in the 5-year survival between 25 cases of the predominantly diploidy type (100%) and 99 cases of the predominantly aneuploidy type (76.7%). However, there was no statistically significant difference in survival between these 2 types in any Dukes stage. The intratumor DNA ploidy distribution pattern in 6 cases of colorectal carcinoma showing hematogenous metastasis comprised 3 cases of Type E, 2 Type D and 1 Type B. And that of 8 cases of curatively resected colorectal carcinoma showing hematogenous metastasis postoperatively comprised 5 cases of Type D, 2 Type E and 1 Type B. Thus, a close correlation between the aneuploidy predominant type, especially Type D as well as Type E, and hematogenous metastasis, was suggested.

Surgically resected specimens of 139 cases of large-bowel carcinoma were analysed in this study. Each carcinoma was cut out in stepwise section through the whole tumor, and flow cytometric DNA measurement was performed for each section. The intratumor DNA ploidy distribution pattern decided in this way was classified into 5 types (Type A-E). The 139 cases of carcinoma comprised 19 cases of Type A, 27 Type B, 11 Type C, 37 Type D and 45 Type E. The intratumor DNA ploidy distribution pattern showed a statistically significant correlation to tumor size, gross type, depth of invasion, growth pattern at the tumor margin, venous permeation of visceral wall, DNA Index and Dukes stage. Among these 5 types of carcinoma, carcinoma showing Type E was seen most frequently, even in the earlier stage, and found most frequently among the cases showing invasive growth pattern at the tumor margin, positive venous permeation in the visceral wall and DNA Index of more than 1.7. Therefore, the intratumor DNA ploidy distribution pattern seemed to reflect the degree of tumor malignancy as well as that of tumor advancement. Moreover, Type E pattern of carcinoma appeared to reveal the highest grade of malignancy, and early detection of this type seemed to be necessary in order to improve survival after surgery.

Tracheobronchial injuries remain uncommon, but they are of great significance, because they can result in death or substantinal functional compromise. Such injuries are mostly from blunt trauma and motor vehicle accidents, but there also is an incidence of penetrating thoracic trauma inclunding iatrogenic accidents. Three cases of iatrogenic injury of tracheobronchial membranous wall were reported. Two cases were tear at the membraneous portion of the left main bronchus and trachea by forceful endotracheal intubation. Another case was tracheal membranous wall injury during operation at blunt dissection for esophageal carcinoma. We reported the emergent managements for iatrogenic injury of tracheobroncheal membranous wall in differents 3 ways. We should select the best treatment according to the condition of the patients and situation of the injury.

Two hundred and three patients with PHL were encountered for the last 10 years. In order to select treatment of PHL, we classified PHL on the basis of atrophy of hepatic parenchyma (AHP), existence of extrahepatic gallstone and dilatation of extrahepatic bile duct (DEBD). For the case with AHP hepatic resection must be performed, because there is often chronic proliferating cholangitis and improvement in hepatic function can not be expected in view of AHP. For the case with extrahepatic gallstone without AHP hepatic resection. For the case with DEBD and without AHP extrahepatic gallstone must be removed. For the patient with extrahepatic gallstone and DEBD without AHP, indication of the removal of stones, depends on the existence of symptoms. Twenty-two cases treated by biliary drainage procedure often had some complications in postoperative course, that is 5 patients had cholangitis and 7 patients liver abscess. It was suggested, therefore, that biliary drainage procedure was contraindicated in PHL.

The right gastroepiploic artery (GEA) was used as hepatic artery graft in 2 patients with advanced upper bile duct cancer. The pedicle, including the right GEA and surrounding tissues, was mobilized along greater curvature of the stomach. The GEA pedicle was raised up beyond the gastric pylorus and was anastomosed to the distal right hepatic artery by interrupted suture technique using 7-0 monofilament-nylon stitches. The patients recovered well without evidences of anastomotic dehiscence of hepatico-jejunostomy and prolonged liver dysfunction beyond three postoperative days. Angiograms at one week after operation showed good patency of the GEA graft. The method of hepatic artery grafting with the right GEA is very simple and useful for surgical treatment of upper bile duct cancer.

In March, 1988, a 65 year-old male underwent a total gastrectomy for a gastric cancer (Borrmann 3: a poorly differentiated adenocarcinoma; IIc: signet ring cell carcinoma). In October that year, however, an anastomotic recurrence of this tumor was found. Thus, from November, 1988 to January, 1989, to treat this recurrence, the patient received a course of radiation therapy frontally, towards the upper abdomen, with a total dose of 46.5 Gy (linac X-ray). His symptoms improved, and a CT, an upper gastrointestinal barium study, and an endoscopic examination indicated that the tumor had disappeared. No further recurrence was found until January, 1990, when the patient died of a metastasis that had spread throughout his body.

Sacrococcygeal chordoma is one of the retrorectal tumors. Relative rarity and anatomical location of this may lead to difficulty in diagnosis and surgical treatment. We report a case of sacrococcygeal chordoma successfully treated by high sacral resection by a posterior approach, in which the co-operative efforts of gastroenterological surgeons and an orthopedic surgeon were employed. A 64-year-old man with a long term continued vague anal pain was referred to our hospital. Digital rectal examination revealed an elastic hard mass presacrally. Plain sagittal radiograph, CT, barium enema showed a retrorectal mass and sacral destruction. Diagnosis was confirmed histologically by the specimen taken by open biopsy. Surgical resection was carried out in prone position with the buttocks elevated. The skin incision was upward arched transverse. The lower sacral vertebrae, including S3, were removed en block with the tumor. Bilateral S3 sacral nerve roots were preserved. Postoperative disturbances of the urination and defecation were not seen. High dose radiation therapy, 80 Gray, was done after surgery. Radiation ulcer of the skin was treated by free skin graft, but radiation proctocolitis was not seen. Now he is free from the disease.

We report a case of surgically resected adrenal myelolipoma. Myelolipoma of the adrenal gland is a rare, benign and nonfunctioning tumor. The present patient represents the 57th reported clinical case of this tumor. It consists of fatty and hematopoietic tissue. It is asymptomatic and usually found only at autopsy incidentally. Ultrasonography, computed tomography and fine needle biopsy help in the preoperative diagnosis of adrenal myelolipoma. Especially fine needle biopsy is recommended when the diagnosis is doubtful.

In order to clarify the cause of the atrophy of the pectoral muscles after modified radical mastectomy, twenty patients who had had the operation at Nagasaki Chuo National Hospital 40 days to 2 years prior to this study, were investigated by electromyography. Of 20 subjects, 11 had the operation to preserve the pectoralis major muscle and 9 had the operation to preserve both the pectoralis major and minor muscles. The results were as follows: 1) Electromyography revealed some damages to the pectoral nerves in 16 cases of 20 (80%). In 12 cases, development of fibrillation potentials was observed at rest, while motor unit potentials disappeared during voluntary contraction. These findings suggest the damage to the nerves including neutrotomy. 2) The regions with macroscopic muscular atrophy remarkably coincided with those with neurogenic changes on electromyography. This suggests that the atrophy of the pectoralis major after modified radical mastectomy might be mainly caused by the damage to the pectoral nerves. 3) The mastectomy preserving only the pectoralis major tends to cause damage to nerves innervating the sternocostal part of the pectoralis major more frequently than the mastectomy preserving both the pectoralis major and minor muscles. The abdominal part was frequently damaged irrespective of the types of the operation.

Ultrasound examination is a useful diagnostic procedure in mass screening for thyroid tumors. Between September 1983 and September 1985, we found many cases of nodular lesions in the thyroid, in which we frequently detected small carcinomas by echo-guided aspiration cytology. Nineteen thousand eight hundred twenty-four samples were examined, and echo-guided aspiration cytology was carried out in 1,169 persons, from which 115 positive cases were obtained. Seventy-four patients were operated upon, and 71 of them (96%) were found to have carcinomas, including 40 cases of small papillary carcinomas less than 10 mm in largest diameter. These small carcinomas were classified into four types histologically. Echogram patterns were different from each other and corresponded to histological types. Cytological figures of the small papillary carcinomas were also varied.

A 42-year-old female visited our hospital because of left breast tumor and left arm swelling with severe pain. She had had right radical mastectomy and bilateral oophorectomy at 27 and 29 years of age, respectively. On admission, she had a hard mass, which seemed to be a severe invasion of the chest wall, on her left breast with a severe nipple ulcer. We inserted a catheter operatively through the thyrocervical truncus to the subclavian artery for the arterial infusion therapy. She was administered 250 mg of 5-FU daily, and 10 mg of ADM, 10 mg of CDDP, 10 KE of OK-432, every other week. During 70 days, 10,000 mg of 5-FU, 50 mg of ADM, 50 mg of CDDP and 50 KE of OK-432 were administered. As soon as the breast tumor became smaller, showed some mobility and the nipple ulcer healed, we carried out left mastectomy and axillary lymph node dissection. Pathological findings showed severe degeneration and necrosis of cancer cells. Lymphocytes surrounded necrotic tissue, and there was a follicular pattern of invasion. This phenomenon was considered to result from the promotion of cellular immunological reaction by OK-432.