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外科的切除された肝細胞癌89例を腫瘍径により4群にわけ,肝癌の進展について肉眼および組織学的検討を行なった.切除例では浸潤性発育を示す肝癌は少なく膨張性発育を示すものが83.2%と圧倒的に多い.肉眼的な被膜は,主結節では75.6%,肝内転移巣(径1cm以下)では5.3%に認められ,腫瘍径による検討から被膜は径1～2cmの段階で形成される可能性が高い,肝癌の進展に伴い,膨張型に浸潤性増殖が加わった混合型の占める割合が増加し,隔壁形成,娘結節も増加する.肝硬変非合併例は約40%を占めるが,その被膜形成率は63%である.組織学的に,肝癌切除例における基本的増殖様式は置換型であり,被膜は置換型増殖の進展とともに形成される.門脈腫瘍塞栓は57.3%で,肝癌の進展に伴い高率となる.

Adriamycin-Lipiodol emulsion (ADR-LIP) was injected, percutaneously via a 20 gauge needle with ultrasonographic guidance, as part of the treatment of 4 patients with relatively small hepatocellular carcinoma (HCC). Lymph vessels extending from the tumor nodule to the abdominal lymph nodes were imaged immediately after the injection in 3 patients. Subsequent plain films of the abdomen and abdominal computed tomography demonstrated stagnant collections of ADR-LIP in the abdominal lymph nodes. Histologic examination of lymph nodes removed during partial hepatectomy or at autopsy in these cases revealed many large and small fat droplets, thought to be Lipiodol, as well as macrophages containing phagocytized lipid. Although lymphatic metastasis occur in HCC, these findings suggest that lymphatics may exist in HCC tissue during the relatively early stages of tumor growth.

膵頭十二指腸切除術 (PD) 施行例, 205例中, 乳頭部癌76例, 中下部胆管癌55例, 膵頭部癌39例でこの三者で170例, 82.9%を占めていた. 直接成績では205例中直死例は9例4.4%で, 乳頭部癌3例, 下部胆管癌3例, 膵頭部癌2例, 胆嚢癌1例でいずれも悪性疾患であった. 合併症は膵が正常に近い例, 拡大した手術例にみられた. 遠隔成績では5生率は乳頭部癌54.1%, 中下部胆管癌24.4%, 膵頭部癌19.8%で, 乳頭部癌では十分なリンパ節郭清により著明な成績の向上をみた. 下部胆管癌の再発因子の検討から肝外胆管は全切除が必要である. 長期生存例の術後の病態はほぼ満足すべき結果であり, PD-I, PD-IIも良い消化管再建術式である.

肝切除に際して, 切除すべき脈管と残さなければならない脈管を十分に認識しつつ切除をすすめることは少なからず困難である.われわれは7×3mmの円錐型金属片を考案し, これに糸をつけ肝切除時ポイントとなる部位に, 超音波映像下に穿刺留置しておき, 金属片に向って糸に沿い肝切除をすすめるようになり, さらに安全かつ正確な肝切除が可能となった.肝細胞癌3例, 胆嚢癌1例, 肝門部胆管癌2例の計6例に使用したが極めて有用であった.なお, 金属片は超音波ではcomet signを伴なったstrong echoとしてとらえられ, 十分鑑別が可能であった.

当教室で施行した膵頭十二指腸切除術症例40例を対象として, 術後病態の検討を行った.特に問題となる残膵機能においては切除時断端膵の組織学的検索を行い, 線維化の程度と対比してみた.PS試験による外分泌機能の変動をみるに, 術後三因子共低下しており, 切除時膵の線維化の程度と相関する傾向を示したが, 消化吸収機能はPS試験による外分泌機能の低下にくらべ良好に保たれており, 膵の線維化とは必ずしも相関しなかった.内分泌機能は遠隔時, 血糖負荷試験により検索したが, 切除時膵の線維化の強いほど, また, 線維化の増強する因子 (例えば膵管閉塞など) があれば比較的早期に耐糖能障害が現われてくるものと思われた.

特異な原因で閉塞性黄疸を来たした2症例を報告する.本症例の閉塞性黄疸は,肝内胆管癌より産生されたムチンにもとづくものであり,拡張した肝内胆管から総胆管に到るまで,その内腔に粘調なムチンが充満していた.いずれも,組織学的には,乳頭状腺癌の像を呈するムチン産生肝内胆管癌であり,管内性発育を示し,他臓器への浸潤転多は認められなかった.ムチン産生肝内胆管癌は稀ではないとの報告があるが,本症例のような機転にもとつく閉塞性黄疸の症例は,内外を通じて数例に満たない.ムチン産生肝内胆管癌には,肝吸虫症の合併が高率であるとの報告があり,本症例も組織学的には,肝吸虫症の関与が示唆されるが,虫体は確認出来なかった.診断に関して,胆道造影で胆道内に異常陰影がみられた場合,稀ではあるが,本症例の様なムチンの存在の想定も必要と思われる.

肝細胞癌・胆管細胞癌の混合型(混合型肝癌)の1手術例を報告する.56歳,男性,腹部腫瘤触知を主訴として入院.画像診断上,通常の肝癌とは肝動脈造影,CTで異なる腫瘤を認め,摘出された.組織学的に,肝細胞癌と胆管細胞癌の性格を有する混合型肝癌であったが,両成分とも腫瘍間質結合織量が豊富であり,さらに,腫瘍内にグリソン鞘が多数認められ,興味ある組織像を呈していた.間質結合織が豊富なことと,グリソン鞘の存在が画像診断上の変化を来たしたものと考えられた.手術後約1年で再発がみられているが,3年4ヵ月後の現在経過観察中である.

A 49-year-old woman was admitted to the hospital with a palpable mass in the right hypochondrium. A laparotomy was performed under the clinical diagnosis of a solitary cyst of the liver. The cystic lesion of the liver was removed. Although the histological finding of the cyst wall showed a similarity to hepatocellular carcinoma of trabecular pattern, the tumor cells with uniform nuclei and little mitotic figure were positive for both argyrophil and argentaffin reaction. The pathological diagnosis was metastatic carcinoid tumor of the liver. There was no carcinoid syndrome nor the other clinical symptoms after the operation and various postoperative examination could not reveal a primary site of the carcinoid tumor. The cystic lesion of the liver recurred ten months after the first operation and a second laparotomy was performed to reveal the primary site in the ileum: three submucosal tumors, 0.8, 0.7, and 0.3 cm. in diameter, two of them, however, extended into the muscle wall or subserosa and conclusively, the small lesion of the ileum metastasized into the liver as a large pseudocystic lesion.

肝癌4例に対しADR-Lipを直接穿刺注入したところ,3例に腫瘍から腹腔内リンパ節に向かうリンパ管が造影され,腹部単純,CTにて確認された.3例中2例は剖検および手術時にリンパ節を採取して検索し,lipiodolと考えられる大小種々の脂肪滴をとり込んだ異物巨細胞を多数認めた.また,Adriamycinは通常投与量の3～5倍を使用し,明らかな腫瘍の壊死,縮小とAFPの平衝ないし減少を認め,TAEが困難となった例に対する一つの治療法となり得る可能性が示唆された.

A 78-year-old man with giant abdominal aortic aneurysm complicated with serious cardiac disease, ventricular septal defect, aortic stenosis and regurgitation, and mitral regurgitation was managed by a woven bifurcated graft under temporary axillo-femoral bypass (Temporary Ax-FB).He suffered left hydronephrosis at admission because the aneurysm, which extended from the abdominal to bilateral common iliac arteris, compressed the left ureter. Future rupture was likely becasuse dilatation was 8 cm in width.At operation we used the Temporary Ax-FB with the intention of decompressing the heart tolerance at aortic cross clamping and declamping.Blood pressure increased transiently by 40 mmHg at aortic cross clamping, but decreased 40 mmHg after 10 minutes, and did not change at aortic cross declamping.We achieved satisfactory results with this method and confirmed the usefulness of Temporary Ax-FB in a patient with extensive abdominal aortic aneurysm complicated with other cardiac disorders.

過去8年間の胆石症手術例663例中19例 (2.9%) の副肝管症例を経験し, この中の2例を損傷したので, その臨床的意義について検討した.術前診断率は10/19 (53%) と比較的に高率であったが, これは内視鏡的逆行性胆道造影 (endoscopic retrograde cholangiography: ERC) を積極的に施行した結果によるものと思われた.2例の術中損傷例はいずれも副肝管が胆嚢管にご合流する型式であり, 逆行性胆摘術中に損傷した, 1例は修復術を行ったが, 他の1例はこれを結紮した.予後は, いずれも良好であった.このような型式の副肝管の診断は, 術中造影でも不可能なこともあり, 術前のERCの意義が確認された.副肝管損傷の予防には, 術前の積極的ERCの施行と, さらに手術は順行性胆摘術が安全である.

A two-step procedure for percutaneous transhepatic drainage (PTD) of the biliary tract is described. This technique was applied on a total of 105 cases of obstructive jaundice, 84 with malignant and 21 with benign lesions, and was successful in 104. Decompression effect was adequate and reduction in serum bilirubin level was quick. Operative mortality, which used to be high in jaundiced patients with serum bilirubin levels above 10 mg per dl, has been significantly reduced with this procedure employed as the first step in a two-stage operation for malignant biliary obstruction. PTD proved to be very useful in the management of acute obstructive suppurative cholangitis and ensuing liver abscesses. Continuous drainage was also achieved by PTD in inoperable cases, and 1 patient with a hilar carcinoma was kept alive for 2 years and 1 month by PTD alone. With the improvement in the diagnosis of biliary tract disease this procedure will assume an important position in the management of obstructive jaundice.

Hepatic angiograms of 114 patients with hepatocellular carcinoma (HCC) were studied, particularly changes in the portal vein branches. Arterio-portal shunts of varying sizes, evidenced by opacification of intrahepatic portal branches, were seen in 72 cases (63.2%), with retrograde opacification of the portal vein trunk in 29 (25.4%). At least four types of shunts were found: (a) through a tumor thrombus in the portal branch, (b) in a retrograde direction via a peripheral tumor nodule, (c) through a small tumor invading or amputating an artery, and (d) through a tumor located near a major portal vein branch and supplied by a large, coiling artery. Postmortem angiography of the liver in 50 patients with HCC suggests that arterio-portal shunts are the result of the special vasculature in HCC and are highly diagnostic when accompanied by other angiographic changes.

Angiographic studies were carried out on 49 cases of liver cirrhosis and 47 cases of primary liver cell carcinoma.An unequivocal retrograde portal blood flow was demonstrated in 1 cirrhotic patient. The portal vein was visualized during celiac arteriography in 5 patients with hepatoma, In 1, the portal flow was to- and-from, the direction depending upon the force of the contrast medium injection. In 4 hepatoma patients in whom retrograde portal flow was seen, there were tumor thrombi in the portal vein, and in 1 patient, in the collateral veins.Thus, retrograde portal flow does occur in cirrhosis of the liver, but very rarely, and it occurs more often in primary liver cell carcinoma, probably due to arterial neovascularization and arteriovenous communications.