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Malignancy and operation for it cause several alterations in immune function that are considered to be concerned with the development of infectious complications. Forty-three patients who underwent curative surgery for gastrointestinal malignancies were entered into this study and were divided into two groups, those with and those without postoperative infection. Changes in the proportion of Th1/Th2 subsets in CD4+ T cells and the expression of human leukocyte antigen (HLA)-DR and CD16a molecules on monocytes were measured by flow cytometry before and after surgery. We performed intracellular cytokine stainings to exactly detect Th1/Th2 subsets. The proportions of interferon-γ-producing CD4+ T (Th1) cells in the preoperative state were almost equal in the two groups, and the proportion decreased on postoperative day (POD) 1 in both groups. On POD 7, the proportion of Th1 cells recovered to the preoperative level in the noninfection group, while the suppression was further reinforced in the infection group (26.8% versus 18.3%, p < 0.005). In contrast, the proportion of interleukin-4-producing CD4+ T (Th2) cells in the infection group (11.3%) was already suppressed in the preoperative state when compared with the noninfection group (17.3%, p < 0.005). Changes in HLA-DR and CD16a expression on monocytes were similar to the changes in the proportion of Th1 cells. These results indicate that the suppression of Th1 cell and monocyte functions during the early phase of the postoperative course was directly related to the occurrence of infectious complications and that several immunological impairments have already occurred in the preoperative state in cancer patients.

We report a case of an abdominal aortic aneurysm which ruptured into the inferior vena cava indicated by CT and angiography in a patient that had been transferred to our hospital with a diagnosis of acute cardiac failure. The patient was a 73-year-old male who had been examined at another hospital for chest pain, hypotension, vomiting and vertigo and had been admitted to our hospital for examination of acute cardiac failure of unknown cause. A pulsating giant mass was palpable in the abdomen, and a continuous murmur was also audible in the abdomen. The patient showed no anemia or abdominal pain, but CT indicated the possibility of the rupture of an abdominal aortic aneurysm into the inferior vena cava. Emergency surgery was successfully performed following confirmation of the rupture by angiography. The results of this case indicate the need to consider a ruptured abdominal aortic aneurysm as a possible cause of symptoms resembling acute cardiac failure.

Background/Purpose: To provide a framework for clinicians to manage acute pancreatitis, evidence-based guidelines have been developed by the Japanese Society of Abdominal Emergency Medicine. Methods: Evidence was collected by a systematic search of MEDLINE and Japana Centra Revuo Medicina. A total of 1348 papers were reviewed and levels of evidence were assessed. Practical recommendations were also graded. Results: The present guidelines consist of introductions, a summary of recommendations, practice algorithms, definitions, epidemiology, diagnosis, severity assessment, and therapy. The main points of recommendation in these guidelines are: (1) measuring lipase for the diagnosis of acute pancreatitis (recommendation grade [RG], A). (2) The Severity of acute pancreatitis should be assessed using a scoring system, such as that of the Japanese Ministry of Health and Welfare or Acute Physiology and Chronic Health Evaluation (APACHE) II (RG, A). (3) Enhanced computed tomography (CT) should be used for assessment of degree of pancreatic necrosis and inflammation (RG, B). (4) Prophylactic antibiotic administration should be used for severe pancreatitis (RG, A), but not for mild to moderate pancreatitis (RG, D). (5) Gabexate mesilate should be used for severe pancreatitis (RG, B). (6) Enteral feeding should be used for all pancreatitis (RG, B). (7) Continuous hemodiafiltration and continuous arterial infusion of proteinase inhibitor and antibiotics may be of benefit (RG, C). (8) Fine-needle aspiration should be done for the diagnosis of infectious pancreatic necrosis, and if positive, necrosectomy is indicated (RG, A). Conclusions: These guidelines provide useful information for physicians to manage this troublesome disease.

We have established an orthotopic implantation model that is highly metastatic to the liver. A human gastric carcinoma cell line, AZ521, with low capacity for liver metastasis was implanted as a single-cell suspension in the stomach of nude mice. The tumor cells derived from a few liver metastatic foci were subsequently implanted orthotopically, and we established a cell line, AZH5G, by repeating the in vivo stepwise selection method. This metastasizing line (AZH5G) developed liver metastasis in seven of eight (87.5%) cases, whereas parental AZ521 developed in 3 of 20 (15.0%). The in vitro growth activities of AZH5G were lower than that of AZ521, although the in vivo tumorigenicity of AZH5G was clearly higher than that of AZ521. Motility assays demonstrated higher motility of AZH5G than of AZ521. Flow cytometric analysis demonstrated that the expression of alpha 6-integrin significantly decreased in AZH5G (4.9% +/- 4.1%) compared to in AZ521 (17.7% +/- 8.1%) (p < 0.05). The adhesive activity of AZH5G cells to laminin was lower than that of AZ521 cells. In contrast, the adhesive activity of AZH5G cells to fibronectin was clearly higher than that of AZ521 cells. These findings suggested that changes in the expression of integrins on the cell surface might play an important role in metastatic ability. This well characterized line and its in vivo experimental model should be useful to investigate the mechanisms of liver metastasis and to develop a new therapeutic approach for human gastric cancer.

The role of peritoneal lavage cytology (PLC) in surgery for gastric cancer was investigated in terms of the correlations between PLC and clinicopathological findings of advanced gastric cancers. Subjects were 49 patients who were diagnosed as having gastric cancer with the depth of tumor invasion of more than T_??_on imaging methods preoperatively and underwent peritoneal lavage at laparotomy. Positive carcinoma cells determined by PLC was found in 38.8% of the patients and the rate of positive cytology was significantly correlated with the following factors: macroscopic peritoneal dissemination; the depth of tumor invasion, especially serosal invasion; and the infiltrating growth pattern of the tumor. Among patients without macroscopic peritoneal dissemination, five were found as positive in PLC. None of these patients survived from peritoneal recurrence within 2 years after surgery. These results suggest that PLC are useful for predicting the peritoneal cancer dissemination. For future treatment of gastric cancer, patients with positive PLC are expected to be targeted for intensive adjuvant therapies during and/or after surgery.

The expression of α2β1 and α3β1 integrins was studied immunohistochemically in 110 resected human gastric carcinomas. Formalin-fixed and paraffin-embedded samples were serially sectioned and stained with monoclonal antibodies specifically against the α2 and α3 subunits of β1 integrins. Approximately 27% of the tumors expressed α3β1 integrin, and 20% expressed α3β1 integrin. The expression of α3β1 integrin was associated with lymph node and liver metastases (P

We present a case of a submucosal tumor in the stomach that was suspicious for malignancy on preoperative endosonography. The resected tumor was histologically diagnosed as a ductal adenocarcinoma that originated in ectopic pancreatic tissue in the gastric wall. Although malignant transformation in ectopic pancreas is extremely rare, it remains an important consideration in the differential diagnosis of gastric submucosal masses.

It has not been established that extended lymph node resection is necessary for ductal adenocarcinoma of the head of the pancreas. According to the general rules for the study of pancreatic cancer, a multiinstitutional, retrospective clinical study was undertaken to investigate the efficiency of extended lymph node dissection for this malignancy. Altogether 501 patients underwent resection of the pancreas between 1991 and 1994 at 77 medical facilities; the surgical procedures, staging, lymph node dissection, curability, and survival rate were analyzed retrospectively. Eighteen of the patients died within 30 postoperative days, leaving 483 patients to be studied. The resection was curative microscopically in 94 patients, resulting in a 3-year survival of 29%. Macroscopically curative resection resulted in a 3-year survival of 14%; noncurative resection produced a 3-year survival of 6%. Although extended lymph node dissection was performed on 38 patients in stage I, 42 patients in stage II, 206 patients in stage III, and 1 patient in stage IV, there was no improvement in survival when the results were compared to those seen after standard or palliative lymph node dissection. The extent of lymph node dissection has not affected the prognosis for ductal adenocarcinoma of the head of the pancreas at any stage of the course of the disease. Excessive lymph node dissection in advanced cases does not necessarily lead to a favorable prognosis. The patients who undergo a radical operation with an adequate lymph node dissection have longer survivals.

There is a need to establish animal models which are suitable for investigation of human gastric cancer metastasis to the liver. To this end, a human gastric carcinoma line, AZ521 was injected into the spleens of nude mice. Cells from the few liver metastatic foci of injected AZ521 were expanded "in vitro" and subsequently injected into the spleens of nude mice. By repeating these procedures three times, we were able to obtain a cell line, designated as AZ-H3c, with high metastatic potential in nude mice. Liver metastasis developed in 15 of 21 (71%) animals injected with AZ-H3c, but only in 14% of those injected with parental AZ521. Further, AZ-H3c caused faster tumor development than did AZ521. However, the primary AZ-H3c tumors and liver metastatic AZ-H3c tumors showed essentially the same histological appearance. We also analyzed the cell surface expression of adhesion molecules. The data showed that the expression of VLA-1, VLA-2, VLA-3, VLA-4, VLA-5 was enhanced in AZ-H3c. In contrast, the expression of VLA-6, (alpha(v)beta3), E-cadherin, ICAM-1 and LFA-1 was reduced in this high-metastatic line. These results suggest that (beta1) integrins play an important role in the liver metastasis of human gastric carcinoma cells. Our high-metastatic line should be useful for studies aimed at the prevention of liver metastasis.

Liver actinomycoses are relatively rare. We report a case of liver actinomycosis with bronchohepatic fistula. A 56-year-old man was admitted to a local hospital for a subcutaneous abscess on his right chest wall in March 1993. Dissection and drainage were performed, but he suffered from relapse and fell into sepsis. He was admitted to our university hospital on April 22, 1994. Under a preoperative diagnosis of liver abscess with a bronchohepatic fistula, which was based on findings from CT scan, ultrasonography, and endoscopic retrograde cholangiopancreatography, we resected the right lobe of the liver, inferior lobe of the right lung and a part of the right diaphragm on May 18, 1994. On postoperative histological examination, there was a mycelium of actinomyces in the liver and lung tissue. After the operation, he was treated with potassium penicillin G, and miliary nodes of the bilateral lungs decreased remarkably. It is necessary to entertain actinomycosis as a probable diagnosis, for liver abscess in which any causative pathogen can not be identified.

胃上中郡および全領域の原発胃癌557例を対象に, 進行度に応じたNo.(10),(11) 郭清術式の選択について検討した.No.(10),(11) 転移率の高い因子としては腫瘍径8cm以上, 大彎・後壁に位置するもの, S2以上, N (+) 例などが挙げられ, 一方, 腫瘍径4cm未満, S1以下, N (-) 例などではNo.(10),(11) 転移率が低かった.No.(10),(11) のen bloc郭清は238例に行われ, 郭清術式の内訳は膵脾合併切除190例, 脾動静脈切除膵温存術48例であった.これらの根治切除例における5年生存率はそれぞれstage I: 96.3%, 100%, stage II: 64.0%, 79.6%, stage III: 39.8%, 35.6%, stage IV: 20.8%, 0%であった. stage I, IIではNo.(10),(11) 転移率が低く, 生存率にも差を認めないことから膵温存術の適応が合理的である. stage IIIでは郭清術式による生存率の差を認めないが, No.(10),(11) 転移率の高い症例が含まれるため, 完全郭清を目的とした膵脾合併切除を選択すべきと考える. stage IVでは根治切除可能であれば膵脾合併切除の絶対適応である.

過去17年間に教室で治癒切除を施行した原発胃癌733例を対象に転移リンパ節個数, リンパ節転移度 (転移リンパ節個数/摘出リンパ節個数) の術後遠隔成績に及ぼす影響について臨床病理学的に検討した.その結果, これらのリンパ節因子が予後規定因子としての機能を発揮するのはn2例においてであり, n1, n3例では転移リンパ節の量的多寡による予後の差は明らかでなかった.転移個数については単純な総和値よりもn-numberを組み合わせた考え方が有用で, n2例における第2群リンパ節転移個数別の5生率は, 1～2個: 37.5%, 3～5個: 22.8%, 6個以上: 9.1%であった.リンパ節転移度 (F) 別のn2例の5生率は, F

A 77-year-old man underwent gastrointestinal endoscopy that revealed a small flat elevated lesion in the gastric antrum. Endoscopically, we assessed the tumor as intramucosal cancer or adenoma, and biopsy specimens were diagnosed as showing borderline malignancy. At the second examination, performed 6 months later, the elevated lesion had grown, showing remarkable changes in its appearance, and a diagnosis of adenocarcinoma was confirmed pathologically. The patient underwent distal gastrectomy about 8 months after the first examination, and the tumor in the resected specimens showed a moderately differentiated adenocarcinoma invading through the entire submucosal layer, with metastasis to a regional lymph node. Microsatellite analysis of this early gastric cancer disclosed mutations in all six markers examined, indicating high-level microsatellite instability (MSI-H). The tumor also showed frameshift mutations of TGFbetaRII and BAXgenes, as well as hypermethylation of the hMLH1promoter. These results suggest that a deficiency of the mismatch repair system played a critical role in the progression of this cancer.

Neuroleptic malignant syndrome (NMS) is often considered to be a precipitating factor for diabetic coma, such as a hyperosmolar hyperglycemic state (HHS). The combination of NMS and a systemic illness such as HHS can be difficult to diagnose because NMS may mask the coexisting condition. Although this coexistence is rare, it may be fatal if not detected early. We report a case of HHS in a 47-year-old male patient that developed after the distinguishing features of NMS had subsided. After the diagnosis of HHS, his recovery was a result of intravenous administration of soluble human insulin and fluid supplementation. Physicians caring for patients with diabetes who are also treated with neuroleptic agents should be aware that NMS may precipitate the development of secondary hyperglycemia despite a history of well-controlled blood glucose levels.

Pylephlebitis is extremely rare and associated with high mortality, even in this modern era. It usually occurs secondary to infection in the region drained by the portal systems or in the structure contiguous to the portal vein. We report a case of septic thrombophlebitis of the portal and superior mesenteric veins (SMV) with multiple liver abscesses caused by acute appendicitis with an abscess of the mesoappendix. We performed appendectomy and successfully removed the thrombi using a Fogarty catheter. Postoperative histopathological examination confirmed a diagnosis of appendicitis and septic thrombophlebitis of the portal vein and SMV. The patient recovered completely with appropriate medical and surgical treatment.

Reflux esophagitis, dumping syndrome and malnutrition are included in the postgastrectomy complications. To prevent or minimize such sequelae, proximal gastrectomy with an interposed jejunal pouch has been advocated as an organ-preserving surgical strategy to improve quality of life for the patients. Proximal gastrectomy was performed in 44 patients with tumors in the upper third of the stomach; 21 had reconstruction using jejunal pouch interposition between the esophagus and the remnant stomach (JP group), while 23 had reconstruction by esophagogastrostomy (EG group). Re-construction method was selected by each patient on the basis of the informed consent. Thirty-five patients had early gastric cancer. Postoperative courses of patients were reviewed in terms of symptoms, weight maintenance, nutritional status, blood chemistry values, endoscopic findings, and radiographic appearances after a barium meal. Concentrations of gastrointestinal hormones were measured in response to a test meal. The JP procedure permitted increased dietary volume. The JP group showed fewer severe postoperative symptoms than the EG group. After operation, all patients examined in both groups showed hypergastrinemia and all patients examined in the JP group showed hypersecretinemia. In proximal gastrectomy, the JP procedure improved patient's post-operative quality of life.

We established a new cell line, AZ-P7a, with high peritoneal-metastatic potential in nude mice. AZ-P7a cells were derived from the human gastric carcinoma line AZ-521, which has low capacity for peritoneal dissemination. AZ-P7a cells developed peritoneal metastasis in 11 / 14 (78.6%) mice, whereas the parental AZ-521 cells developed metastasis in 2 / 6 (33.3%) mice. The metastatic foci in the peritoneum showed essentially the same histological appearance as those induced by parental cells. The tumorigenicity and the motile activity of AZ-P7a cells were stronger than those of the parental AZ-521 cells; in contrast, adhesion to the extracellular matrix and the production of vascular endothelial growth factor by AZ-P7a cells were decreased. In fluorescence-activated cell sorter (FACS) analysis, AZ-P7a cells expressed significantly greater levels of integrins alpha2, alpha3, alpha5, alpha6 and alphavbeta5, as compared with AZ-521 cells. However, alpha1, alpha4, alphavbeta3, hCD44H, hCD44v3, hCD44v6 and hCD44v10 were not expressed in either cell line. AZ-P7a cells developed no liver metastasis when administered by the intrasplenic injection method, though the highly liver metastatic cell line AZ-H5c showed the same rate of peritoneal dissemination as that exhibited by AZ-P7a cells after intraabdominal injection. These findings suggested that the mechanism of peritoneal dissemination differed from that of hematogenous metastasis. Moreover, the latter appears to be controlled by more complex mechanisms than the former. Thus, this cell line might be useful for investigating the mechanism of peritoneal dissemination of human gastric cancer.

To clarify the changes that occur in hepatic venous oxygen saturation (ShVO2) during hepatic ischemia/reperfusion (I/R) injury, we examined the relationship between ShVO2, hepatic tissue blood flow (HTBF), and portal vein pressure (PVP) in a warm I/R model using pig livers. Female pigs weighing 18-23 kg were subjected to warm I/R under extracorporeal circulation between the superior mesentric vein and the left jugular vein to avoid portal congestion. The warm ischemic times were 120 min (n = 4), 180 min (n = 14), and 240 min (n = 4). ShVO2, HTBF, and PVP were measured after reperfusion. The survival rates of the pigs 3 days after reperfusion were 100% in the 120-min group, 57% in the 180-min group, and 25% in the 240-min group. In the 180-min group, the ShVO2 was lower in the pigs that died than in those that survived. There was a significant correlation between ShVO2 and both PVP and HTBF after reperfusion. Histological examination revealed findings of severe I/R injury in pigs with a low ShVO2, and mild I/R injury in pigs with a stable ShVO2. These observations suggest that the changes in ShVO2 could reflect the degree of hepatic I/R injury, especially that related to microcirculatory disturbances occurring at the sinusoid levels.

To investigate of human pancreatic cancer metastasis to the liver, a pancreatic carcinoma line, HPC-3, was injected into the spleens of nude mice. The cells from a few liver metastatic foci of the mice injected with HPC-3 were expanded in vitro and subsequently injected into the spleens of nude mice. By repeating these procedures, we were able to obtain a cell line, designated HPC-3H4. The mice were observed to have liver metastasis in 6 of 6 (100%) cases injected with HPC-3H4, whereas the rate was 0% at 3 weeks after the intrasplenic injection of HPC-3. The tumorigenicity of HPC-3H4 was more rapid than that of HPC-3. The motile activity of HPC-3H4 was also stronger than that of HPC-3, and the adhesion to the extracellular matrix of HPC-3H4 was stronger than that of HPC-3. We also analyzed the cell surface expression of the metastasis-related adhesion molecules. As a result, no substantial changes were observed in the expression level of adhesion molecules. These results suggest that HPC-3H4 is useful for studies aimed at the prevention of liver metastasis.

We present herein the first reported case of a deep ulceration developing in the pouch of a jejunal side-to-side anastomosis following the interposition of a jejunal U-shaped pouch (jejunal pouch), performed as reconstruction. A 47-year-old woman underwent a proximal gastrectomy and interposition of a jejunal pouch for early gastric cancer, 4 mouths after which she began to develop a fever. Esophagogastroscopy revealed a deep ulceration in the side-to-side anastomosis of the jejunal pouch. Her serum gastrin level was much higher than the normal range, and 24-h monitoring of the intraremnant stomach pH revealed that it was below 7.0 at night. A peptic ulcer was thought to be one of the causes of the pouchitis. Due to the drug-resistant ulceration and fever, a reoperation was performed, in which the jejunal pouch and remnant stomach were removed and Roux-en-Y reconstruction was done. There were no postoperative complications, and the fever resolved after surgery. Reconstruction of the jejunal pouch after proximal gastrectomy is recommended from the standpoint of quality of life (QOL); however, further studies on the size of the remnant stomach and the length of the interposed jejunal pouch are necessary.

Expression of sialyl-Lewisx (sLex) antigen was studied immunohistochemically in 110 resected human gastric carcinomas using an anti-sLex monoclonal antibody. Lymph node, liver, and peritoneal metastases were clearly more prevalent in tumors expressing high levels of sLex than in those with no or low-level sLex expression. No correlation was found between sLex expression and histologic grade or histologic type of the Lauren classification. Among the tumors with lymph node metastasis, 44% expressed high levels of sLex in both the primary tumor and involved lymph nodes, and 14% of the metastatic lesions demonstrated increased sLex expression. The 5-year survival rate of the patients undergoing complete (R0) gastric resections was 60% in the sLex high-expression group, which was significantly lower than that of the sLex low-expression group (81%) and of the no-expression group (87%) (p0.05). These results suggest that high-level sLex expression is related to both an increased risk of metastasis and poor prognosis in gastric cancer patients.

We present a case of perforation of the sigmoid colon due to blunt abdominal trauma. Computed tomography showed nominal free air in the inguinal fossa. The distribution of free air may be a clue to the site of an injured intestine. Early detection of intestinal injury is difficult, but repeated computed tomography after several hours may reveal increased free air.

The correlation between nm23 protein (nm23) expression and the expression of several cell adhesion molecules was studied immunohistochemically in 110 resected gastric carcinomas. Formalin-fixed and paraffin-embedded samples were serially sectioned and stained with antibodies against nm23, integrin beta1 subfamily members (alpha2beta1, alpha3beta1 and alpha4beta1), LFA-1, ICAM-1, sialyl Lewis(x) (sLex) and CD44H, -V3, and -V6. Primary carcinomas presenting with either lymph node involvement or liver metastasis expressed significantly reduced levels of nm23 compared to tumors without metastasis. The percent of tumors expressing each adhesion molecule was as follows: alpha2beta1, 27.3%; alpha3beta1, 20.0%; alpha4beta1, 14.5%; LFA-1, 14.5%; ICAM-1, 12.7%; sLex, 67.3%; CD44H, 55.5%; CD44V3, 20.0%; and CD44V6, 4.5%. Expression of alpha2beta1 integrin and high levels of sLex were significantly correlated with lymph node metastasis, and expression of alpha3beta1 integrin and high levels of sLex were correlated with liver metastasis. Expression of ICAM-1 was inversely correlated with liver metastasis. Comparing the expression of each cell adhesion molecule with nm23 immunoreactivity, expression of sLex was significantly associated with nm23 expression. Of tumors expressing high levels of sLex, 75% showed reduced nm23 expression, compared to 52% of tumors with weak or no sLex expression (P < 0.05). A similar tendency was also observed in the metastasized secondary tumors. These results suggest that reduced nm23 expression may promote the metastatic properties of cancer cells in concert with increased sLex expression.