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症例は48歳の女性で，突然の右季肋部痛のため当院を受診した．CTにて肝S8に径6 cmの腫瘤を認め，腹腔内に中等量の液体貯留を来していたことより腹腔内出血を来していたと考えられた．腫瘍は造影CTで動脈性早期濃染を伴い，MRIではT1強調画像で低信号，脂肪抑制T2強調画像で高信号であり典型的ではないが肝癌と診断した．待期的に肝部分切除を行った．病理組織学的検査では類上皮細胞のみからなる充実性，類洞状増殖を認め肝細胞癌類似の所見であったが，HMB-45陽性であることから肝血管筋脂肪腫と診断された．肝血管筋脂肪腫は血管，平滑筋，脂肪の成分をさまざまな割合で含むまれな良性腫瘍である．その多様性のため，画像・病理の診断が困難なことがある．肝血管筋脂肪腫の破裂は極めてまれであるが，術前診断が困難であること，悪性化の可能性があることなどからも，病態によっては切除の適応とすべきである．

症例は60歳の男性で，乳頭部癌に対し，膵頭十二指腸切除術を施行した．肝腸間膜動脈幹から分岐する総肝動脈が上腸間膜静脈の背側から膵鈎部頭側にいたり，膵頭部膵実質を貫通していたが，膵実質を剥離して総肝動脈を温存した．腹側膵，背側膵は総肝動脈の走行部に連続する疎性結合織で隔たれており，発生に伴う肝動脈走向異常の形成が想定された．病理組織学的に中分化管状腺癌で，進行度はpT1，pN0，P0，M−，fStageIであった．肝門部腫瘍により術後32か月目に死亡し，この際行った剖検の結果，組織学的には高分化管状腺癌を示したことから，異時性肝門部胆管癌と判定された．乳頭部癌手術においては，術前から肝動脈走行を十分に把握することが重要であり，肝動脈血流の維持や重複癌を発生した際の治療も考慮したうえで，非浸潤癌においては肝動脈を温存，浸潤癌においては切除，再建することが必要と考えられた．

Although the outcome of surgery for locally advanced pancreatic cancer remains poor, it is improving, with 5-year survival up to about 10% in Japan. The preliminary results of our multi-institutional randomized controlled trial revealed better survival after surgery than after radiochemotherapy. We report the final results of this study after 5 years of follow-up. Patients with preoperative findings of pancreatic cancer invading the pancreatic capsule without involvement of the superior mesenteric or common hepatic arteries, or distant metastasis, were included in this randomized controlled trial, with their consent. If the laparotomy findings were consistent with these criteria, the patient was randomized to a surgery group or a radiochemotherapy group (5-fluorouracil 200 mg/m2/day and 5040 Gy radiotherapy). We compared the mean survival time, 3-and 5-year survival rates, and hazard ratio. The surgery and radiochemotherapy groups comprised 20 and 22 patients, respectively. Patients were followed up for 5 years or longer, or until an event occurred to preclude this. The surgery group had significantly better survival than the radiochemotherapy group (P < 0.03). Surgery increased the survival time and 3-year survival rate by an average of 11.8 months and 20%, respectively, and it halved the instantaneous mortality (hazard) rate. Locally invasive pancreatic cancer without distant metastases or major arterial invasion is treated most effectively by surgical resection.

はじめに: 術後合併症として肺血栓塞栓症は入院患者の予後に大きく影響する重要な懸案事項である. 方法: 2000年1月から2007年6月までに消化器外科術後に経験した急性肺血栓塞栓症19例を対象とし検討を行った. 結果: 発症率は同時期の全身麻酔下消化器外科手術の0.30%で, 平均年齢68.8±10.6歳, 平均BMI 24.0±2.5, 3例が男性, 16例が女性で, 15例が悪性疾患, 4例が胆石症であった. 術後早期の呼吸困難や胸部不快あるいは急性循環不全の症状に加え, 低O2・CO2血症, 心臓超音波検査による右心負荷所見が特徴的であった. 確定診断には簡便かつ低侵襲である胸部造影CTが有効であった. 肺血栓塞栓発症後は抗凝固単独あるいは血栓溶解併用療法が行われ, 死亡例はなくいずれも軽快退院した. 以後, ワーファリン内服による外来経過観察にて塞栓症の再発は認められていない. 考察: 過去の報告と比較し我々の検討結果における肺血栓塞栓症患者の予後が良好であった理由として, 肺血栓塞栓症予防ガイドライン施行後の器械的予防の徹底, 発生後の早期発見・早期治療開始などが挙げられる. 今後も肺血栓塞栓症の高危険群に対しては薬物的予防法も含めた十分な対策を行い, いかなる手術症例であっても術後肺血栓塞栓症は発症しうると考えられることから術後早期のバイタルサインの変化に対して常に本疾患を念頭においた早急な対応が望まれる.

In 1991, we started a clinical prospective trial for operable esophageal carcinoma, foreseeing organ preservation, to assess the treatment results after definitive chemoradiotherapy (CRT) for clinical Stage I (T1N0M0) esophageal cancer.Between 1992 and 2003, 63 patients were enrolled in this study. Tumor depth was mucosal cancer (T1a) in 23 and submucosal cancer (T1b) in 40. CRT consisted of 55-66 Gy/50-60 fractions (median, 59.4 Gy); from 1 to 3 cycles (median, 2) of concurrent chemotherapy (Cisplatin and 5-fluorouracil), followed by high-dose-rate intraluminal brachytherapy 10-12 Gy/2-3 fractions.The 5-year overall and cause-specific and disease-free survival rates were 66.4%, 76.3%, and 63.7%, respectively. The 5-year cause-specific survival rates for T1a and T1b cancer patients were 85.2% and 70.0%, respectively (p = 0.06). The 5-year disease-free survival rates for T1a and T1b were 84.4% and 50.5%, respectively (p0.01). Esophageal fistula as a late toxicity occurred in 2 patients (G4: 1; G5: 1), and esophageal stricture requiring a liquid diet occurred in 2 patients. Pericardial effusion was observed in 3 patients.We confirmed that patients with T1N0M0 esophageal carcinoma had their esophagus preserved in 89.2% of cases after definitive CRT, and the survival rates were equivalent to those of previous reports of surgery.

We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.

当科では外科卒後研修の到達目標として膵頭十二指腸切除術 (PD) の施行を必須としてきたが, その妥当性を検討した. 1975～1999年に対象者13人が最初に施行したPD患者の手術成績を指導医が施行し背景の一致した症例 (対照) と比較した. PD時の膵空腸吻合は同一術式 (Vertical mattress suture) で行った. 対象者がPD施行までに胃切除57例 (中央値), 胃全摘15, 結腸切除20, 直腸切除13, 胆摘52, 胆道再建15, 膵尾切除3を行い, 研修期間の中央値は40月であった. 手術時間 (521.1±122.5分, 対照414.6±74.6;p=0.01) 以外は出血量, 術後合併症, 膵空腸縫合不全, 術後在院日数で両群間で有意の差はなかった. 固定された研修プログラム上でのPD施行成績は上級医による手術と時間以外同等で, 研修の到達目標として妥当である. 研修には目標設定, 一定の指導方針が重要である.

We applied intraoperative radiotherapy (IORT) to the esophageal carcinoma in an attempt to prevent abdominal lymph node recurrence, and retrospectively studied patterns of failure and controllability of abdominal lymph nodes in patients treated with or without IORT. Between July 1986 and October 1997, 81 patients with radically resected esophageal carcinoma, aged 42-76 years (mean 61), were divided into two groups, the IORT group (39 patients) and the non-IORT group (42 patients). All patients except two, who received transhiatal esophagectomy for superficial carcinoma, underwent subtotal esophagectomy with thoracic and abdominal with/without cervical lymphadenectomy. Fourteen patients underwent only surgical resection, and the remaining 67 patients received radiotherapy to the mediastinum post-operatively (40-50 Gy/20-25 Fr/4-5 W) in 37 and preoperatively (44 Gy/40 Fr/4 W) in 30 patients. Preoperative irradiation was performed as a neoadjuvant chemoradiotherapy consisting of two courses of cisplatin (each patient received 80-100 mg, mean 60 mg m(-2), day 1, bolus injection) and 5-fluorouracil (each patient received 500-1000 mg day(-1), mean 400 mg m(-2), days 1-4, continuous infusion). The target volume of IORT encompassed the upper abdominal lymph node area including lymph node groups of right/left cardia, left gastric artery, celiac artery and abdominal para-aorta. A single dose of high-energy electrons (9-12 MeV) of 20-23 Gy, prescribed to the 90% isodose curve, was delivered. Treatment for the abdominal lymphatic system was classified into four categories: surgery alone in 30 patients, surgery with chemotherapy in 12, surgery with IORT in 15, surgery with chemotherapy and IORT in 24. There were no complications related to IORT. Forty patients (49%) had recurring carcinoma: in the lymph nodes (36%), in distant organs (27%) and locally (6%). The incidence of lymph node metastasis was 29% in the neck, 32% in the mediastinum, and 27% in the abdomen. Abdominal lymph node recurrence in the IORT group was less frequent than in the non-IORT group (p=0.048). In particular, 24 patients treated with a combination of surgery, chemotherapy and IORT had no recurrence in the abdominal lymphatic system. The overall median survival was 46 months, the survival at 1, 3, and 5 years being 85%, 52%, and 44% respectively. However, there was no difference in survival between the IORT group and the non-IORT group. The IORT for the abdominal lymphatic system was feasible for reduction of the rate of abdominal lymphatic recurrence without survival benefit in this study. This retrospective finding should be confirmed by a prospective randomized study.

Purpose: This retrospective study was designed to compare treatment results of the chemoradiation protocol with conventional surgery for thoracic T1-T2 esophageal squamous cell carcinoma. Methods and Materials: Sixty-six patients with esophageal carcinoma, clinically diagnosed as T1 (tumor invading lamina propria or submucosa) or T2 (tumor invading muscularis propria) were treated for 12 consecutive years, from July 1986 to January 1998. The conventional surgery group included 30 patients who underwent esophagectomy with regional lymph node dissection. Twenty-one of them received postoperative radiotherapy. Thirty-six patients were assigned to the chemoradiation protocol, consisting of neoadjuvant chemoradiotherapy (44 Gy; CDDP: 60 mg/m 2 , day 1, bolus; 5-FU: 400 mg/m 2 , day 1–4, continuous), followed by either definitive radiotherapy with high-dose-rate intraluminal brachytherapy (total 70 Gy) for responders or surgery for nonresponders as in the conventional surgery group. Surgical candidates in both groups received intraoperative radiotherapy for abdominal lymphatics since 1991. Results: In the protocol group, 4 patients underwent radical surgery after neoadjuvant chemoradiotherapy, and the remaining 32 underwent definitive chemoradiotherapy. Local control rates at 1 and 3 years were 85% and 70% in the T1/protocol group versus 91% and 80% in the T1/surgery group, and 83% and 83% in the T2/protocol group versus 94% and 80% in the T2/surgery group, respectively. There was no statistical significance. Overall 1- and 3-year survival rates were 100% and 83% in the T1/protocol group versus 82% and 72% in the T1/surgery group ( p = 0.36), and 100% and 51% in the T2/protocol group, versus 95% and 68% in the T2/surgery group ( p = 0.61), respectively. There was no treatment-related mortality in either group. The rates of esophageal conservation were 92% in the T1/protocol group and 58% in the T2/ protocol group. Conclusion: The chemoradiation protocol can result in comparable survival with conventional surgery for patients with T1-T2 esophageal carcinoma. A randomized trial between definitive chemoradiotherapy and surgery is required.

Purpose: A prospective clinical trial was undertaken to investigate the feasibility of concurrent chemoradiotherapy for esophageal carcinomas. Materials and Methods: Between June 1989 and May 1996, forty patients with operable squamous cell carcinoma of the thoracic esophagus (Stage 0 to III: UICC 1987), ages 45 to 78 years (mean: 64), were enrolled in a study of neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy (CRT group) or surgery (CRT-S group). Neoadjuvant chemoradiotherapy consisted of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 Fr/day) through 10-MVX rays, with 2 courses of cisplatin (80–100 mg/body, mean: 60 mg/m2, Day 1, bolus injection) and 5-fluorouracil (500–1000 mg/body/day, mean: 400 mg/m2, Days 1–4, continuous infusion). After completion of neoadjuvant chemoradiotherapy, an intermediate clinical response was assessed by barium swallow, esophagoscopy with/without biopsy, EUS in most cases, thoracic and upper abdominal CT scan, and cervical US. Definitive chemoradiotherapy was performed in patients when regression of more than 75% was evident (CRT Group), and esophageal resection was indicated in those who remained at less than 75% (CRT-S Group). In CRT Group, a cumulative dose of 60–70 Gy for Tis, T1 and 65–75 Gy for T2–T4 tumor with high-dose–rate intraluminal brachytherapy and a total of 3 courses of chemotherapy were planned. In CRT-S Group, intraoperative radiotherapy for abdominal lymphatic system and postoperative supraclavicular irradiation were added. Results: At the time of intermediate assessment, complete response (CR) was observed in 16 patients, a partial response (PR) in 22, and no change (NC) in 2. Thirty responding patients (CR, 16; PR, 14) entered the CRT Group, and 10 nonresponding patients (PR, 8; NC, 2) were followed by surgery (CRT-S Group). Radiotherapy was completed satisfactorily, but chemotherapy was suspended in 26 patients (65%) because of acute toxicity. Clinical CR rate at the completion of treatment showed 90% in CRT Group, and pathologic CR rate 10% in CRT-S Group. The overall median survival was 45 months, survival at 1, 2, and 3 years being 100%, 72%, and 56%, respectively. Local-regional failure was observed in 7 patients (all in CRT Group), distant failure in 6 (3 in CRT Group, 3 in CRT-S Group) and local-regional with distant failure in 1 (CRT Group). Four patients with local-regional recurrence in the CRT Group were salvaged by surgery. Overall survival at 2 and 3 years for CRT vs. CRT-S Group was 72%, 64% vs. 75%, 38%, respectively. No treatment-related mortality was observed. The rate of the ’esophagus conservation’ was 65% (Stage 0: 1 of 1, 100%; Stage I: 11 of 12, 92%; Stage II: 8 of 17, 47%; Stage III: 6 of 10, 60%). Conclusion: Our results demonstrated that almost all early disease (Stage 0–I) and about half of advanced disease (Stage II–III) could be conserved, their esophagus treated by the multidisciplinary approach centering on high-dose radiotherapy and concurrent chemotherapy.

We report herein the case of a women receiving tamoxifen therapy for breast cancer who developed vaginal bleeding, subsequently found to be caused by unusual endometrial polyps. Upon presentation, ultrasonography and magnetic resonance imaging (MRI) demonstrated a tumor within the uterus. A hysterectomy was performed, and macroscopic examination showed polyp-like lesions of the uterus. Histologically, these polyps demonstrated cystically dilated glands and stromal proliferation, and were diagnosed as endometrial polyps. Although tamoxifen has few side effects, any signs or symptoms of gynecological abnormalities should be carefully evaluated in patients on long-term tamoxifen therapy.

Twenty-eight patients with histologically proven pancreatic adenocarcinoma were investigated to evaluate the utility of serum CA19-9 levels as a prognostic indicator after pancreatic resection. Three patients were excluded from the study because their serum CA19-9 levels remained normal throughout the course of the disease. Of the remaining 25 patients, those with preoperative serum CA19-9 levels ≤200U/ml had a better prognosis than those with serum CA19-9 levels >200 U/ml; however, the difference between the two groups was not significant (P=0.13). Serum CA19-9 levels 30 days after pancreatic resection were normalized (≤37 U/ml) in 11 patients (group A), and the survival rate of this group was significantly higher than that of the group of patients with persistently elevated CA19-9 levels (>37 U/ml) (group B) (P

膵切除後に併発した膵液瘻に対し, ソマトスタチンアナログ (サンドスタチン ®) 投与が有効であった1例を経験した.症例は58歳の男性.9年前に皮膚筋炎と診断され, ステロイドによる治療が開始された.2年後に上部消化管内視鏡検査にて十二指腸乳頭部腫瘍の存在が指摘されたが, 組織診では腺腫と診断され経過観察となった.しかし, 今回施行した生検では腺癌と診断され, さらに, 便潜血陽性にて大腸内視鏡検査を施行したところ, 直腸癌の存在も認めた.皮膚筋炎に対してプレドニン内服中であったが, 膵頭十二指腸切除および直腸前方切除術を施行した.術後膵液瘻を併発し, 最高600ml/日に及ぶ排液を認めたが, サンドスタチン ® 100μg/回, 1日2回皮下注射にて, 約1週間で瘻孔の閉鎖をみた.本症例は, 術後膵液瘻の治療において, サンドスタチン ® 投与が有効であることを示唆する症例と考え報告する.

腸管膜動脈の循環障害に起因する小腸狭窄の1例を経験した.症例は61歳男, 腹部大動脈再建術後に下痢, 腹痛, 嘔吐を呈し, 腹腔内膿瘍と診断されて当科に入院した.排膿術を施行するも症状の改善を得ず, 腸閉塞症状が出現した.高カロリー輸液下に諸検査を行い, 血管造影で上腸管膜動脈根部の狭窄を認めた.虚血が関与する腸閉塞の診断で開腹すると, 回腸の一部が索状に狭窄し, これに沿う腸管膜は萎縮していた.狭窄部を切除し, 端々吻合して症状の消失をみた.病変部は肉眼的に瘢痕状で, 組織学的には腸管全層にわたる線維化と腸管膜動脈の閉塞性変化を認めた.本症は予後不良と言われるが, その改善のためには診断から治療にわたる栄養管理をはじめ, 適切な全身管理が肝要である.

Anomalies of the biliary ductal system are not uncommon, and their clinical significance is variable. We present herein the case of a 70-year-old Japanese woman found to have an anomalous duplicated cystic duct, which is an extremely rare congenital anomaly. Intraoperative delineation of the anomaly by real-time cholangiograms assisted us in being able to subsequently perform a safe cholecystectomy. This case serves to demonstrate the importance of being aware of the possibility of potential biliary variations in order to avoid ductal injuries during biliary surgery.

Spontaneous rupture of the esophagus, Boerhaave’s syndrome, is a rare entity, and is often overlooked at ® rst. Its clinical and pathological features have frequently been described (1). Despite advances in supportive measures, delayed diagnosis and treatment still cause a high mortality rate (2). An early suture of the rupture, with adequate drainage of the mediastinum and pleural cavity, provides the best survival rates (3). Postoperative mediastinitis and empyema carry a grim prognosis. We report a case of Boerhaave’s syndrome, in which postoperative empyema was treated successfully by open chest drainage. The usefulness of open chest drainage is discussed here.

The methods and results of treatment for cancer of the cervical esophagus differ from those for cancer of the thoracic esophagus. Our objective was to retrospectively review the outcome for cervical esophageal cancer patients treated with radiotherapy. Twenty-seven patients with carcinoma of the cervical esophagus treated with definitive radiotherapy from 1988 to 2002 were enrolled in the study. Clinical stage (UICC 1997) was stage I in five, II in six, III in 12 and IV in four. Concurrent head and neck malignancy was found in six patients (22%). The mean radiation dose was 66 Gy. Concurrent chemotherapy (cisplatin and 5-fluorouracil) was performed in 23 patients. The actuarial overall survival rates at 1, 3 and 5 years were 55.6%, 37.9% and 37.9%, respectively, with a median survival of 13.9 months. In the patients with stage I, the 3-year and 5-year survival rates were 75% and 75%, respectively. With univariate analysis, only two of the possible prognostic factors were found to actually influence survival: performance status (p < 0.01) and tumor length (p < 0.01). The survival of patients with cervical esophageal cancer remains poor. It is thought that organ preservation is possible by definitive chemoradiation for early cancer.

Vascular lesions of the duodenum, including hemangioma, are rare causes of gastrointestinal bleeding. We herein describe a 52-year-old woman with a solitary cavernous hemangioma of the duodenum that caused chronic gastrointestinal bleeding. Repeated upper gastrointestinal endoscopy and a barium meal study revealed a solitary vascular tumor in the fourth portion of the duodenum, although the initial investigations including selective angiography were unsuccessful. A wedge resection of the duodenum was performed and microscopical examination showed a cavernous hemangioma. Vascular lesions should therefore also be considered in the differential diagnosis of patients with gastrointestinal bleeding of unknown origin.

A 39-year-old woman came to us complaining of severe anemia (hemoglobin: 2.3 g/dl) and a painful right breast that was entirely occupied by an ulcerative, foul-smelling tumor approximately 20 cm in maximum dimension. The tumor, which was determined to be mucinous adenocarcinoma at biopsy, had invaded the chest wall with multiple lung metastases (T4cN2M1 stage IV). After a blood transfusion, the patient received the following multimodal treatment: concurrent chemoradiotherapy (50 Gy), intraarterial infusion chemotherapy consisting of doxorubicin 50 mg, mitomycin-C 10 mg, and cisplatin 50 mg, and skin graft surgery. After intraarterial infusion chemotherapy, the fungating tumor disappeared. The patient experienced a relapse of right pleural effusion 2 years later and received multimodal treatment. Now, March 30, 2000, the patient is doing well without local recurrence, 8 years after her first admission. The combination of intraarterial infusion chemotherapy and radiotherapy plays a role in successful treatment of extensive local disease of the breast.

We have been treating patients with operable thoracic esophageal cancer according to our own protocol. It includes the initial concurrent chemoradiotherapy (CRT) followed by continuous CRT or surgery. Patients with good response to initial chemoradiotherapy were allowed to continue chemoradiotherapy, whereas the others were treated with surgery. However, there were two cases which showed discrepancies in the clinicopathological response. Both patients received initial chemoradiotherapy, including two courses of cisplatin (100-120 mg), 5-fluorouracil (750-1000 mg for 4 days) and radiation (44-50 Gy). On completion of the initial chemoradiotherapy, all diagnostic imaging modalities including barium swallow, esophagoscopy, endoscopic ultrasonography and thoracic computed tomography strongly implicated residual tumor with a reduction rate of 40-50%. The patients underwent radical esophagectomy 15-20 days after initial chemoradiotherapy. Pathological specimens only revealed thickening of the esophageal wall due to inflammatory change without residual carcinoma. These facts suggest the current limitations of diagnostic images in evaluating the response to chemoradiotherapy.

We investigated results for thoracic T3-T4 esophageal squamous cell carcinoma in two strategies. The protocol group (46 patients) consisted of neoadjuvant chemoradiotherapy (44 Gy, CDDP, 5-FU), followed by either definitive radiotherapy (total 70 Gy) for responders or surgery for non-responders. The surgery group (26 patients) underwent esophagectomy with regional lymph node dissection. Nineteen of them received postoperative radiotherapy. Surgical candidates in both groups received intraoperative radiotherapy for abdominal lymphatics since 1991. In the protocol group, 23 patients underwent radical surgery after neoadjuvant chemoradiotherapy and the remaining 23 underwent definitive radiotherapy. The rates of recurrence were 64% in the protocol group, and 62% in the surgery group. Overall 3- and 5-year survival rates were 48% and 31% in the protocol group compared to those of 30% and 30% in the surgery group. The rate of theesophagus conservationwas 39% in the protocol group. There was no mortality in either group. Our protocol had at least comparable prognostic values with historical conventional surgery, and was excellent in having feasibility for organ preservation.

The factors influencing the healing process of pancreaticojejunostomy (P-J) following pancreaticoduodenectomy (PD) are still ill defined, allowing the recommendation of various anastomotic methods. We conduced a prospective study to determine the risk factors influencing the protracted healing of P-J, examining 100 consecutive patients who underwent PD followed by P-J, performed as an end-to-side “mucosa-to-mucosa” anastomosis using vertical mattress sutures (VMS method). Protracted healing of P-J was classified as either peripancreatic sepsis (PPS), defined as prolonged suppurative discharge of less than 50 ml a day from the drain beneath the P-J for more than 1 week; or a pancreatic fistula (PF), defined as prolonged discharge of more than 50 ml a day with a high amylase content (>1000 IU) for more than 1 week. There were 80 patients with a malignant neoplasm, and 20 with benign disease. The overall incidence of healing problems following P-J was 9%, which included 6 patients (6%) with PPS and 3 (3%) with PF. Apart from an advanced age of more than 70 years, none of the patients' characteristics or postoperative complications influenced the healing of P-J. The type of reconstruction, an anastomotic stent, the duct size, and a “soft” pancreas were not risk factors either. In conclusion, no factors, apart from the age or any special problem of an individual patient, influenced the dehiscence of P-J when the VMS method was used after PD.

Extrathoracic invasions or metastases from thymomas are extremely rare. We describe herein the case of a patient with malignant thymoma which recurred three times during an 8-year period and invaded directly into the peritoneal cavity, involving the gastrointestinal tract. The huge thymoma was completely resected, along with the fornix of the stomach, the transverse colon, and the 8th, 9th, and 10th ribs. Careful observation and multidisciplinary treatment against recurrent thymoma will be requisite for this patient, even though the tumor has been completely resected.

This study was undertaken to determine whether short-term continuous epidural analgesia using morphine would relieve pain after laparoscopic cholecystectomy. The authors retrospectively reviewed the clinical data of 182 cases who had undergone a laparoscopic cholecystectomy. These cases were divided into four groups according to their anesthetic modes as follows: a control group with general anesthesia only (n = 37); group I, general anesthesia combined with one shot of epidural morphine (n = 78); and group II, general anesthesia combined with continuous epidural analgesia using morphine (IIa for 12 h (n = 33); IIb for 8 h (n = 34)). The pain score on a four-category verbal scale and the frequency of analgesic use were investigated. There were no differences in the background characteristics of the patients among the groups, except for the duration of surgery (I vs IIa; P = 0.006). The pain scores were significantly different between the control group and the other groups. The frequency of analgesic use in the control group was also significantly higher than in the other groups. A tendency toward a higher frequency of analgesic use in group I, compared with that in groups IIa and IIb, was observed. These findings thus suggest that short-term continuous epidural analgesia using morphine can effectively relieve postoperative pain after a laparoscopic cholecystectomy.

A prospective, randomized study was conducted to determine whether simultaneous infusion of lipid emulsion with an amino acid-dextrose-electrolyte solution would reduce the incidence of thrombophlebitis (TP) during postoperative peripheral parenteral nutrition (PPN). Thirty patients who had undergone gastric resection for adenocarcinoma were randomly divided into two groups according to whether they were infused with 10% lipid emulsion (group A) or 5% glucose solution (group B) simultaneously with the amino acid-glucose solutions. The total osmolarity of the infusion solutions in each group was 853 mOsm/l. The incidence of complications due to TP, namely, redness and/or edema beneath the cannula insertion site and/or pain, was investigated. There were no differences in the background characteristics of the patients in groups A and B, except regarding concurrent resection of other organs (P = 0.03). The incidence of edema in group A was significantly lower than in group B on postoperative days 2 and 4, although there was no difference in the incidence of redness and pain between the two groups. These findings suggest that the simultaneous infusion of lipid emulsion has a preventive effect against TP during postoperative PPN, and may be a practical means of providing PPN after gastrointestinal surgery.

TO THE EDITOR: Bezoars are large conglomerates or concretions of food or fiber in the alimentary tract, and infrequently cause intestinal obstruction. We describe here an unusual case of small bowel obstruction and concomitant perforated peritonitis caused by a "pseudo-phytobezoar" due to a seed from pickled plum.

天理よろづ現談所病院で過去12年間に経験した, 悪性腫瘍による閉塞性黄疸 (悪性閉塞性黄疸) は, 114例である.この症例を手術死亡群17例と耐術群に分け, 術前の各検査データー, 病歴などに統計的解析 (2群間のStandardized Distance, Probit解析) を行い, 本症を有する患者の手術のRisk予測を試みた.黄疸が強く, 高齢で, BUNが高く, 黄疸の進行度が大きい膵癌の患者の手術死亡率が高くなる傾向を見いだした.しかし, 厳密な意味でのCritical pointの設定までには至らず, 新たな症例の予測を行うには, 解析に用いた症例数が少なすぎる点は向後の検討を要す.悪性閉塞性黄疸の治療方針 (一期手術か, 二期的手術かPTCDを行うか否か等) を決定するための判定基準の設定が必要なことを強調し, その1つの試みを提案する.

A multivariate probit analysis was used to develop a prognostic scoring system known as the Prognostic Index (PI), which consisted of age, pulse rate, blood urea nitrogen, serum albumin, serum cholesterol and serum potassium. This PI accurately predicted the severity and mortality of 83 surgical patients with septic shock caused by gastrointestinal diseases, who were admitted to Tenri Hospital, Nara, Japan from 1975 to 1981 (internal check), and also that of 25 other patients, examined from 1982 to 1983 (external check). As the prognostic predictive model provides a prompt and easy prediction of how severe the patients' state is, it has proved to be very useful to our surgical staff for managing critically ill patients.

過去13年間で40例の膵頭十二指腸切除術が施行され, 手術後入院中死亡率は17.5%で黄疸例29例の死亡率は20.7%であった. 死亡率は黄疸の強弱, 一期的手術, 二期的手術には無関係であった. 当院独自のVertical mattress sutureによる膵管空腸吻合術 (本法) が15例に行われ, 他の吻合法が25例に行われた.膵空腸吻合縫合不全は膵管径の小さいほど高率となり, 本法で1例, 他では8例に起こっており, 本法が優れていた. 長期生存例での検討で下痢の発生が本法ではなかったが, 他の吻合法による12例中3例に起っている. 本法は縫合不全の低率さに加えて, その特徴から長期にわたる膵管の開存が得られる可能性が多い.

Eight patients at school-age, from 12 to 17 years old, were surgically treated for Crohn's disease at Tenri Hospital, Nara, Japan. The relationship between operative results and their school lives were evaluated. Primary symptomes of the small intestinal type (6 cases) included abdominal pain (5), melena (1), and abscess formation in Douglas' pouch (1), and that of the colonic type (2 cases) mucinous-bloody stool (2) and anal fistula (1). Mean preoperative duration from the onset of the disease, except for 2 emergent cases, was 21.8 (ranged 8-46) months with mean cumulative hospitalizing duration of 8.6 (1-21) months. Four patients had recurrence, and in all 13 operations of 8 cases intestinal resections limited to macroscipical lesions. Mean postoperative disease-free term was 40.7 (ranged 5-168) months, during which all patients have completely finished curricula in schools. As now there is no effective treatment of Crohn's disease, physician should take school-aged patients back to the schools in disease-free state obtained by operations. An early return to the school might be important for mental or psychiatric development of the patient of this age.

Three cases of obstruction of the afferent loop following a Billroth II type gastrectomy were preoperatively detected by ultrasonography. The obstructions in the 3 patients were caused by volvulus, internal herniation and recurrence of gastric cancer, respectively. The important US findings which helped diagnose this condition were a dilated intestinal loop without gas echo in the upper abdominal cavity and echo lucent swelling of the pancreas. Ultrasonography is very useful for the early and easy detection of this life-threatening condition which requires immediate surgery.

Total pancreatectomy was performed for carcinoma of the head of the pancreas associated with multiple anomalies in the peripancreatic region and of the pancreas. The anomalies were preduodenal portal vein, annular pancreas with agenesis of the dorsal pancreas, left-sided gallbladder, polysplenia and high mobile right colon. The surgical implications of pancreatectomy for such anatomical abnormalities, especially preduodenal portal vein, and the usefulness of ultrasonography for the preoperative evaluation are given attention.