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Two cases of intractable massive ascites following radical gastrectmy for an early gastric cancer are reported. One case was a 79-year-old male and the other was a 57-year-old female. Both cases had been infected hepatitis C virus. Ascites was confirmed hepatic lymphorrhea, because it had appeared clearly yellowish fluid indicating high specific gravity and high protein density and containing much lymphocytes without chyle. Intraperitoneal infusion therapy with OK-432 was performed for both cases. Six times of the infusion procedure (total 75 KE) were done for the former case, and 3 times (total 25 KE) for the other case. After this therapy, ascites disappered. Both patients were discharged on the postoperative 89th and 75th day, respectively. In conclusion, we considered that the intraperiteal infusion regimen with OK-432 may be efficient therapy for intractable ascites due to postoperative hepatic lymphorrhea.

We occasionally encounter a case of gallbladder perforation secondary to severe cholecystitis with or without cholelithiasis. However, idiopathic perforation of the gallbladder is extremely rare and only 15 cases of the disorder have been reported in the Japanese literature. This paper describes a case of idiopathic perforation of the gallbladder with a review of the literature. An 84-year-old woman was admitted to the hospital because of abdominal pain. Abdominal ultrasonography and computed tomography revealed small amount of ascites in the abdominal cavity. Because of exacerbation of abdominal symptom, laparotomy was performed. Laparotomy showed serous bilous fluid in the peritoneal cavity, and the bile leak was found to from a perforation of the fundus of the gallbladder. Cholecystectomy, choledochotomy and T-tube insertion were performed. here was neither stones nor debris in the gallbladder, and bacterial culture of bile was negative. Histologically, localized necrosis associated with venous thrombosis was found, though cell infiltration was mild.

We experienced an adult case of Bochdalek hernia with generalized peritonitis due to incarcerated transverse colon 2 years and 7 months after radical operation for a gastric cancer. A 37-year-old male was admitted to the hospital because of a lower abdominal pain. There was a previous history of undergoing gastrectomy for a stomach cancer 2 years and 7 months before. Under a suspicion of intestinal obstruction conservative therapy was started, but generalized peritonitis due to intestinal perforation occurred. On Emergency celiotomy, we found a pin-hole perforation of the dilated transverse colon, the distal part of which was incarcerated into Bochdalek hernia. The patient was successfully treated by resection of the discolored segment with simple close of the hernia sac. Our experience suggests a possibility of Bochdalek hernia as the cause of incarcerated large bowel obstruction in the patient treated with gastrectomy. Furthermore, if the precise diagnosis and radical operation were able to be done on admission, association of generalized peritonitis should be avoidable.

To evaluate the tolerance of the cirrhotic liver to extended warm ischaemia, 47 patients with cirrhosis who underwent liver resection over a 4-year period were studied retrospectively. Three groups of patients were identified. In group 1 (14 patients) liver resection was performed under conditions of portal triad occlusion ranging from 50 to 75 (mean 57·1) min. Group 2 (12 patients) was treated with portal occlusion for a period ranging from 30 to 42 (mean 33·1) min. Group 3 comprised 21 patients who underwent hepatectomy using conventional techniques. Mean blood loss was significantly reduced by portal triad occlusion (819 ml in group 1, 523 ml in group 2) compared with the conventional technique (1652 ml in group 3) (P < 0·05, group 1 versus group 3; P < 0·01, group 2 versus group 3). Hospital death occurred in three of the 21 patients in group 3 but in no patient who underwent portal triad occlusion. The morbidity rate was lower in the two occlusion groups (four of 26 patients) than in group 3 (six of 21). Bilirubin metabolism was substantially better after surgery in the occlusion groups (P < 0·05, groups 1 and 2 versus group 3 at day 14). Although the serum levels of transaminases were significantly raised until day 3 in patients undergoing long-term occlusion, the cirrhotic liver withstood the ischaemia—reperfusion insult, as assessed by changes in hepatic microcirculation, lipid peroxidation and the morphology of hepatic sinusoids. It is concluded that prolonged ischaemia during liver resection can be sustained in patients with cirrhosis and without high-risk factors.

Recent experience with heterochronous double cancer of the rectum and stomach in a 67-year-old man, associating with superior mesenteric arterial embolism in the course of observation which could be successfully managed by extensive excision of the intestine, is described. the patient was admitted to the hospital because of severe abdominal pain. There were previous histories of having a rectal cancer which was treated by low anterior excision 5 years before and an early gastric cancer 3 years before, for which the patient denied to be treated. Laparotomy was carried out within 5 hours after the onset of the pain. During surgery, necrotizing lesions extending from the duodenal horizontal portion to entire the small intestine, and from the ileocecal region to remnant sigmoid colon were found. Partial excision of the duodenum, total excision of the small intestine, and extended excision of the colon were performed. Reconstruction was impossible and gastrostomy was made. Resected specimen showed a thrombolic embolism caused by a thrombus at the root of superior mesenteric artery. After surgery the patient was able to take fluids in the combinative use of IVH, but the impaired hepatic function and jaundice were aggravated. He died of MOF on the 42nd postoperative day. It is indicated that, if laparotomy can be performed in an early period after the onset of the disease, and if every effort is made to prevent shock and MOF after surgery, we can expect a long survival in these patients even though extended excision of the intestine can not be avoided.

For the treatment of hepatocellular carcinoma by intra-hepatic arterial injection, CDDP-Lipiodol emulsion (CPLEM) was prepared.CPLEM was in a water-in-oil state, and showed moderate retaining and releasing of CDDP.Clinically, 9 patients with advanced hepatocellular carcinoma underwent the transarterial chemo-embolization by CPLEM. Partial response was observed in 2 cases, and minor response 1 case. AFP decreased considerably, and side effects were slight.Serum platinum concentrations after administration were low. Deconvolution of the present data was demonstrated, and leakage of CDDP from liver was supposed to be gradual.In conclusion, CPLEM was considered to be useful for mild chemo-embolization in a treatment of hepatocellular carcinoma.

A case of small fibrolamellar hepatocellular carcinoma (HCC) coexistent with a HCC of common type is herein reported. A 56-year-old man was diagnosed as having multi-nodular type HCC with liver cirrhosis. The serum alpha-fetoprotein (AFP) level was slightly increased. The patient underwent a partial caudate lobectomy and lateral segmentectomy. Histologically, both resected tumors were small HCCs measuring less than 2 cm in diameter. One was a fibrolamellar type located in the caudate lobe, while the other was the common type in the lateral segment of the liver. Positive immunohistochemical staining for AFP was observed in the tumor cells of the HCC of common type but was not observed in the fibrolamellar HCC. We also reviewed previously reported cases of fibrolamellar HCC in Japan, and discussed the clinicopathologic implications of this disease.

The significance of 5-FU-Lipiodol emulsion as a tumor-targeting agent for primary hepatocellular carcinoma (H. C. C.) was experimentally and clinically investigated. Intrahepatic arterial infusion of 5-FU-LIP-E to rabbits bearing VX-2 tumor in the livers was compared with the infusion of 5-FU alone in relation to the tissue 5-FU level 30 minutes after administration. 5-FU-LIP-E had produced 36.9 times higher 5-FU level than that by 5-FU alone. Clinically, 20 patients with non-resectable primary H. C. C. underwent transarterial chemoembolization of 5-FU-LIP-E-Then tumor reduction rates were compared with those of other treatments (14 cases). Patients whose reduction rates in tumor size of over 50% came to three (15.8%) in the 5-FU-LIP-E group, and none in the other treatment group. Two patients (10.5%) with reduction rates between 25% and 50% were noted in the former group, and none in the latter group. Survival rate in the 5-FU-LIP-E group was significantly improved than that in the other treatment group, especially in patients whose tumors occupied below 40% of the liver in volume (p

Nutritional assessment was performed in 41 patients with squamous cell carcinoma of the esophagus to clarify factors associated with nutritional deficiency. Six parameters, i.e., body weight, triceps skin fold, arm muscle circumference, creatinine/height index, serum albumin and serum transferrin were measured on admission, after preoperative radiation therapy, and at four as well as eight weeks after surgery. The assessment indicated that, on admission, nutritional deficiency clearly existed in esophageal cancer patients. Out of factors including age, dysphagia, stage of cancer and cellular immunity in patients on admission, dysphagia and stage of cancer were associated with nutritional deficiency. The effect of treatments for cancer on nutritional status was also assessed. The parameters of nutrition were markedly depressed by the surgery with or without preoperative radiation therapy. These results indicate that treatments including surgery and radiation, dysphagia and stage of cancer, especially the former two, are critical factors associated with nutritional deficiency in esophageal cancer patients.

Two cases of oat cell carcinoma of the esophagus are reported together with a review of the related literature. Case No. 1, a 54-year-old-man with a 3-month history of dysphagia, was found to have a spiral-shaped lesion 16cm in length along the entire thoracic esophagus (In Im Ei). After preoperative irradiation at a dose of 40 Gy which was fairly effective, radical esophageal resection and reconstruction were performed. The patient was discharged and soon returned to work. Approximately 10 months after surgery, however, a recurrent tumor was found in the superior mediastinum. Irradiation at a dose of 60 Gy and immunochemotherapy with CDDP and OK-432 proved effective, and the patient has survived for approximately 29 months since the first operation, an extremely long period for a case of oat cell carcinoma. Case No. 2, a 59-year-old man with a 3-month history of dysphagia, was found to have not only a spiral-shaped lesion 10cm in length in the middle to lower esophagus (Im Ei), but also an early-stage cancer (IIa) in the anterior wall of the antrum of the stomach. Because of hepatic and pulmonary dysfunction, surgery was divided into 2 stages. In the early postoperative period after subtotal esophagectomy, however, the patient developed extensive metastasis in the superior mediastinal and abdominal lymph nodes and died of pneumonia caused by Pneumocystic carinii. Light microscopy revealed the cellular morphology in the esophageal lesions of both cases. Argyrophilic cytoplasm was not demonstrated by histochemistry, but electron microscopy revealed the presence of the neurosecretory granules in the two lesions. Therefore, the esophageal lesions in both cases were diagnosed as oat cell carcinoma.

食道噴門癌25症例に術前後の栄養管理として成分栄養法 (ED) を試みた. 術前は数経鼻的に胃・十二指腸にチューブを留置し, 術後は胃管に作成した胃瘻あるいは空腸瘻から術後の腸蠕動の回復をまつことなく, 術後第1日目から持続点滴法により24時間連続投与した. 術前ED施行例では入院時から手術までに平均3%の体重増加がみられた. 術後ED施行例の血清アルブミン値は術後普通経管栄養食投与群に比して術前値に対する減少率は軽度であった. またED施行群では術後6日目に窒素平衡が正に転じた. 術後縫合不全, 術後乳糜胸の症例にも有効であった.

A case of hepatic angiomyolipoma occurring in a 41-year-old woman, the eighteenth case in literature, is reported herein. The radiographic imagings of the tumor simulated those of focal nodular hyperplasia; namely, the tumor was hyperechoic on ultrasound, hypodense on computed tomography, hypervascular on angiography, and exhibited an uptake of technetium (Tc)-99m phytate. The diagnosis was established after successful removal of the huge tumor from the right hepatic lobe. Histologically, the tumor was angiomyolipoma which was made up of three components, blood vessels, smooth muscle and fatty tissue. Furthermore, extramedullary hematopoiesis, which is usually seen in this tumor was confirmed. The differentiation of hepatic angiomyolipoma from FNH is also discussed.

A case of a 66 year old woman with situs inversus totalis who developed hepatocellular carcinoma (HCC) as well as stomach cancer, is reported herein. The patient was successfully treated with a left hepatic lobectomy for the HCC and a B-I gastrectomy for the stomach cancer. Careful anatomical mapping made it possible to perform a combined resection of the liver and stomach in the presence of this congenital anomaly.