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We report a male patient aged 45 years, who in 1993 had been diagnosed as having middle bile duct cancer and had received a pancreatoduodenectomy. Histopathology showed a nodular tumor with the main lesion in the middle bile duct and superficial spreading in both proximal and distal directions (which was not observed macroscopically), and residual tumor in the epithelium of the cut edge near the liver. The patient underwent follow-up without postoperative adjuvant therapy. In 2002, 9 years after the operation, the patient developed jaundice and was diagnosed with recurrence of bile duct cancer in the anastomotic site, based on cholangiographic results. He underwent resection of the right hepatic and caudate lobes and the anastomotic region of the bile duct and jejunum. Pathological findings showed an invasive tumor in the anastomotic region, with continuous intraepithelial spread in the direction of the bile duct, which suggested that the residual tumor in the epithelium had grown to become an invasive cancer. In this patient, the recurrence required 9 years after resection. This case provides evidence for the clinical course that might be anticipated for a patient with a residual tumor in the epithelium of the bile duct stump and subsequent superficial spreading bile duct cancer.

症例は75歳,男性.貧血の精査にて上部消化管内視鏡検査を施行され,体部大彎に径7.5cm大の3型腫瘍と幽門洞前壁に径3cm大の2型の重複胃腫瘍を認めた.入院時肝細胞癌,肝硬変などを認めなかったが, AFPが86ng/mlと高値であった.両病変を含む幽門側胃切除を施行したところ,術後AFPは9ng/mlと正常化した.摘出標本で体部の病変は核異型の強い管状腺癌でAFP染色陽性であったのに対し,幽門洞部の腫瘍では陰性であった. AFP産生胃癌と管状腺癌の重複は稀であり,文献的考察を加え報告する.

直腸に内分泌細胞癌,高分化型腺癌が重複した1例を経験した.症例は63歳,女性で,検診で便潜血を指摘され来院した.大腸内視鏡で歯状線から2cmのRbに1.5cm大の0-Is'病変と,その口側に近接する2cm大の2'型病変を認め,生検でそれぞれGroup3(管状腺腫), Group5(未分化癌)と診断された.遠隔転移の所見はなく,腹会陰式直腸切断術を施行した.切除標本で18×15mm大の0-Is型腫瘍と, 20×18mm大の2型腫瘍とが正常粘膜を介して隣接しており,組織学的には0-Is型腫瘍はsmに達する高分化型腺癌, ly1, v0, n(-)で, 2型腫瘍は内分泌細胞癌, a1, ly1, v1, n1(+)で,組織学的にも両腫瘍間に連続性はなかった.術後経過は良好で第24病日に退院したが,肝転移と腰椎転移をきたし,術後18カ月目に腫瘍死した.

原発性胆嚢管癌の4例を経験した. 症例1は70歳の男性で, 胆嚢結石症の診断で胆嚢摘出術を施行し, 切除標本で胆嚢管癌と診断され, 2期的に胆管切除, D2郭清を施行した. 組織学的にはpat C, tub1, fm, n1, 2(-)で, 術後9年目に他病死したが再発はなかった. 症例2は61歳の男性で, ERCPで中部胆管の狭窄を認め, 胆管癌の診断にて肝床, 胆嚢, 胆管切除 (D2)を施行. pat C Bm, tub1, ss, n2(+)であった. 術後9年4か月の経過で再発なく生存している. 症例3は54歳の男性で, 経皮経肝胆嚢造影で胆嚢管に不整な途絶を認め, 生検にて胆嚢管癌と診断され, 肝床, 胆嚢, 胆管切除(D2)を施行した. pat C Bm, tub2, ss, n1, 2(-)であったが, 術後16か月目に癌性胸膜炎のため死亡した.症例4は70歳の女性でCTにて胆嚢管腫瘍を認め, 生検で腺癌と診断され, 肝床, 胆嚢, 胆管切除 (D2)を施行した. pat C, pap, ss, n1, 2(-)で, 術後1年の経過で再発なく生存している.

症例は63歳,女性.右乳頭血性分泌,右腋窩腫瘤を主訴に当院受診.生検にて乳腺扁平上皮癌の診断を得たため,胸筋温存乳房切除術を施行した.術後病理組織学的検索にてsquamous cell carcinomaの診断を得た.病理学的に腫瘍部と皮膚との交通を認めず術後の全身精査で他に原発巣を認めなかったため,乳腺原発と考えられた.エストロゲンレセプター,プロゲステロンレセプターは陰性であった.術後9カ月の現在再発を認めず経過観察中である.

A 69-year-old man was admitted to the hospital because of lower abdominal pain and constipation. Handgrip-sized mass was palpable at the left upper quadrant of the abdomen. CT scan of the abdomen revealed about 16×10cm solid tumor at the same region. After some other examinations small intestinal tumor derived from non-epithelial lesion was suspected. Upon laparotomy tumor grew extramurally from the third portion of duodenum and the peritoneum showed several disseminated nodules. A partial resection of the lesion with reconstruction by side to side anastomosis between the defect and jejunum was carried out. Postoperative histopathological findings on H-E staining revealed compact proliferation of round or spindle shaped cells with epitheloid arrangement. Immunohistochemiccal analysis showed positive staining for vimentin, and negative for smooth muscle actin, CD 34 antigen, S-100 protein. From these findings, this tumor was diagnosed as epitheloid leiomyosarcoma of the duodenum. This patient was predicted malignant because of tumor size and high miotic ratio (more than 1 mitose per one HPF). He died from the disease 18 months after the operation. Epidermoid leiomyosarcoma of the duodenum is so rare that only 17 cases including ours have been reported in the Japanese literature as far as we could review.

1962年から1993年までに教室で経験した縦隔腫瘍切除例220例中, 病理学的に嚢胞形態をとった83例 (34.3%) につき検討を行った.組織型では嚢胞性奇形腫, 先天性嚢腫, 胸腺嚢腫が多く, 全体の約80%を占めた.また, 組織学的に悪性であったものは後縦隔発生の嚢胞腺癌2例 (2.4%) のみであり, その他は全て良性であった.胸痛などの臨床症状を有した例は約30%であり, その他は全例胸部X線異常で発見されていた.また, 腫瘍径の大きな奇形腫, 間葉性腫瘍で症状発現率が高かった.嚢胞の正診率はMRIが90%と高く, CTの67.6%に比較し有用であった.嚢胞貯留液中腫瘍マーカーの測定では, いくつかの症例CEA, CA19-9などの非特異的な上昇を認め, 各組織型に特有のマーカーを見い出しえなかった.

In this study our cases of hepatoma which developed after the treatment for esophagogastric varices caused by liver cirrhosis or those diagnosed as having a hepatoma and the varices simulatneously were studied, and some discussion on the therapeutic guidelines was added. There were 25 cases of hepatoma following esophagogastric varices caused by liver cirrhosis. In 13 of the 25 cases, hepatoma was heterochronously found after the treatment of esophagogastric varices. Of the 13 cases, operation was performed in six cases as the treatment of the varices and EIS in another six cases. We were able to apply ourselves closely to treat the hepatoma in the six operated cases without worrying about bleeding from the varices. When compared for the prognosis, long-term survivors are noted in operated cases and there was no death due to hemorrhage. Operation is superior to the other in hemostasis. The remaining 12 cases were synchronuously diagnosed as having a hepatoma and varices. Of the 12 cases, two cases were operated on, in which we were able to concentrate on the treatment of hepatoma alone. It is concluded that aggresive attitude toward operation should be basically employed for the treatment of verices due to liver cirrhosis, if the hepatic functional reserve of the patient can permit it.

A 72-year-old man was admitted to the hospital because of abdominal pain and distention. Upper gastrointestinal barium study and gastroduodenoscopy revealed a submucosal tumor in the second portion of the duodenum. Angiography showed hypervascularity of the lesion. In the clinical course the patient suffered from obstructive jaundice due to stenosis of the middle portion of the common bile duct caused by the tumor. Pancreaticoduodenectomy was performed under a diagnosis of duodenal leiomyosarcoma. The histopathological diagnosis was duodenal leiomyoblastoma. He died of liver metastasis 11 months postoperatively. To our knowledge, this is the 20th case of duodenal leiomyoblastoma reported in the Japanese literatute.

This paper presents a satisfactory outcome with interventional radiology using an expandable metallic stent for portal stenosis and biliary obstruction caused by gallbladder carcinoma in a 66-year-old woman. The bile duct at the porta hepatis was completely occluded. After fistulization, three GianturcoRoesch Biliary Z-stents were placed at the stenotic site through PTCD tube. The portal vein was severely stenosed and one Z-stent was inserted percutaneously-transhepatically. At five months after the treatment biliary obstruction and portal stenosis were well-dilated and patent. No complication has been observed and she could live at home for about three months. Interventional radiology using expandable metallic stents may be recommended for patients who are not operative candidates and have a poor prognosis.

食道胃静脈瘤に対し, 内視鏡的硬化療法 (endoscopic injection sclerotherapy) を施行し, 経過観察中に食道癌を認めた症例につき術式上の工夫を加えたので報告する。症例は54歳の男性。1988年8月, 食道静脈嬉破裂に対しEISにて止血した後, 5か月にわたり頻回の追加治療を受けた。その後, 経過観察していたが, 1991年5月, 食道内祝鏡検査で下部食道 (Ei) に発赤を認め, 生検を行った結果, 扁平上皮癌 (深達度ep) の診断でレーザー治療を受けた。1992年1月, Elに再び癌を認めたため, 手術目的で入院となった。術前内視鏡では, 食道静脈嬉は改善されていたが, 胃静脈瘤を認めた。非開胸食道抜去, 胸壁前胃管再建に短胃静脈-外頭静脈吻合を加えた結果, 胃管鬱血, 静脈瘤の増悪に対処しえて良好な予後が得られた。

腎細胞癌は肺・肝・骨髄などに比較的高頻度に血行性転移をきたすが, 陣への転移は少ない.われわれは腎摘出後2年, 4年後にそれぞれ肺転移巣を摘出し, 6年後に再々度の肺転移および際転移を切除した1症例を経験した.腎細胞癌膵転移切除frlの報告は少なく, 自験例を含め22例にすぎない.これらの症例は何らかの臨床症状を契機に発見されたものが多く, 術後経過観察中の無症候性膵転移の発見切除例は自験例を含め3例のみである.進行期腫瘍術後の経過観察は局所のみならず全身臓器の精査が必要と思われた.腎細胞癌の転移巣に対しては化学療法あるいは放射線療法は効果が小さくその予後は一般に不良である.しかし自験例のように複数回の手術を受けながら比較的良好な予後が得られる症例もあることから, 他に有効な治療法のない現時点では腎細胞癌多発転移症例もまた外科治療の対象となりうると思われた.

In a 26-year period from 1965 to 1991, treatments for esophageal varices have been performed in 26 children. Its long-term clinical results were discussed in this paper. Causes of esophageal varices were congenital extrahepatic portal obstruction (EHPO) in 16, idiopathic portal hypertension in 4, liver cirrhosis or fibrosis in 3, chronic hepatitis in 1, and metabolic liver disease in 2 patients. The total number of treatments came to 45 times. Operative procedures included transabdominal esophageal or gastric transection with paraeso-phageal devascularization on 16, splenectomy on 10, shunt surgery on 15, and endoscopic injection sclerotherapy on 3 patients. Longterm results after treatments of esophageal varices, shunt surgery groups had lower rehemorrhagic rates than others. It may be a fear that hepatic impairment can occur in a longterm follow up after shunt surgery, but no severe impairment has been seen even 10 to 29 years the operation. We recommend that selective shunt surgery might be the procedure of choice for rehemorrhagic esophageal varices in children as well as adults.

Child A・Bに属する肝機能良好例の食道静脈瘤に対する治療法として, 内視鏡的硬化療法 (以下EIS) 群84例とシャント手術群49例の治療成績を遠隔成績を中心に比較検討した.再発率はEIS群21.7%, シャント手術群2.1%, 再出血率はEIS群13.3%, シャント手術群2.1%であり, EIS群が有意に高かった.5年累積生存率はEIS群82%, シャント手術群88%と両群とも良好で有意差はなく, 遠隔期の社会復帰率もEIS群81.2%, シャント手術群74.2%であり, ともに良好であった.しかし, EIS群において初回入院時EIS施行回数が4回以上に及ぶ症例では, 3回以下の症例に比べて完全消失率が低く, 再発・再出血率が有意に高く入院期間も長期に及ぶことから, 早期に手術治療を考慮すべきと考えられた.シャント手術はEIS後も安全に施行でき, 再発・再出血率が極めて低いことから, 適応を選び積極的に施行されるべきである.

The preoperative diagnostic capability of CT and angiography for demonstrating extension of pancreatic cancer behind the pancreas was evaluated. Subjects were 19 patients out of 69 patients operated on for a pancreatic cancer at the department in a recent 11-year period (1980-1990), whose tissue infiltration behind the pancreas was examined in detail and preoperative extension of the cancer was pathologically diagnosed. As to V factor, the total accuracy was 84.2% by CT, that was superior to that (63.2%) by angiography. As to Rp factor, the total accuracy was 52.6% by CT and 68.4% by angiography. Among Rp (-) cases diagnosed by CT and angiography, histologic infiltration-positive ‹rp (+)› cases represented over 80%. Preoperative diagnostic ability of single use of CT or angiography was extremely low. However, when positive findings by either CT or angiography were noted, the correct diagnosing rate was about 80%. It is concluded that positive results accepted aggressively by CT and angiography was correlated with pathological findings. Preoperative CT or angiography was not effective for predicting PLX factor.

A case of bleeding jejunal varices after choledochojejunostomy is reported. Percutaneous transhepatic choledochoscopy was most effective for detecting the bleeding point before surgery. The patient underwent jejunocaval shunt, and there has been no recurrent bleeding, as of 13 months after the operation.

Bleeding from the small intestine rarely occurs and we have often difficulties in diagnosing causative disease and the site of bleeding. This paper presents 2 cases of massive bleeding from the small intestine. Case 1: A 55-year-old man, who was scheduled for undergoing hepatectomy for a hepatic hilar carcinoma, had massive melena preoperatively. Hemorrhagic scintigraphy revealed RI leakage suggesting intestinal bleeding. Emergency operation was performed. Intraoperative fiber-optic endoscopy demonstrated pulsatile arterial bleeding in the intestinalmucosa at the ileal end. The ileal end including the bleeding site was wedge-resected. Case 2: A 54-year-old man developed massive melena three weeks after hepatic resection for a hepatocellular carcinoma. Angiography revealed a leakage of medium at the end of ileocecal artery. The subtotal small intestine was resected, because there were multipleulcers in the ileum demonstrated by intraoperative fiberoptic endoscopy. In conclusion, it is important to localize the bleeding site exactly by hemorrhagic scintigraphy, and to perform operation as soon as possible, if it is necessary.

To prevent postoperative infection, intraoperative antibiotics therapy and washing of the operative wound is performing at the department. This paper discribes the evaluation of the prophylactic effect in 180 surgical cases not involving those with dirty procedures treated from January 1989 to January 1991. Of the 180 cases 84 were given antibiotics (antibiotics group) and 96 were not done (control group), and postoperative occurrence of wound infection and peritoneal infection were evaluated. Excepting cases complicated by anastomotic breakdown, postoperative wound infection was observed in 3 patients (3.6%) in the antibiotics group and in 5 (6.2%) in the control group; postoperative intraperitoneal infection was found in 7 (8.3%) in the antibiotics group and in 10 (11.1%) in the control group. Both wound and intraperitoneal infections were less frequent in the antibiotics group than in the control group, although the differences were not statistically significant. Postoperative bacterial positive ratio was not directly concerning to the ratio of infection growth.In conclusion, intraoperative antibiotics injection therapy is usefull for post operative infection. But its effects have some limitations. Other foctors such as patients themselves and the causative bacteria may play more important role in one onset of postoperative infection.

脾腫にて発見された巨大脾腎静脈短絡2例の外科治療経験を報告する.症例1は34歳の男性で, 巨大脾腎静脈短絡を有する特発性門脈圧亢進症と診断された.食道静脈瘤は軽度で, 精神症状もなかったが, 経過観察中, アンモニアの上昇を認めたため短絡流量の軽減, 静脈瘤増悪防止のため短絡路の切除と胃壁の血行郭清を伴う選択的遠位脾腎静脈シャント術を施行した.症例2は27歳男性で, アンモニアの上昇はなく, 食道静脈瘤も軽微であったが, 将来的に予想される肝性脳症に対し, 短絡路を利用した選択的脾腎静脈シャントとし, さらに胃大小轡の血行郭清を加えた.巨大脾腎静脈短絡を合併した患者では門脈血流量減少に伴う肝機能低下, 肝性脳症の発症が予想される.したがって, 予防的に短絡路離断を行う必要があるが, その際, 静脈瘤増悪に対しては胃壁の血行郭清を行う選択的脾腎静脈シャント術が有効である

後腹膜海綿状リンパ管腫の1例を経験した.症例は40歳男性で, 腹部圧迫感を主訴として来院し, 超音波検査にて蜂巣状構造を呈する巨大な腹部腫瘤を認めた.Computed tomographyでは左横隔膜下から膵後方を通り左腎下極に及ぶ内部構造均一な嚢胞状腫瘤としてとらえられ, 血管造影では血管成分の乏しい腫瘤と考えられた.超音波ガイド下穿刺にて乳康を吸引した.上記より後腹膜腫瘍 (リンパ管腫を強く疑う) の診断にて摘出術を施行した.大動脈周囲にて強固に癒着し腫瘍の辺縁は不明瞭となっていた.切除された腫瘤はスポンジ様の構造・弾性を呈し, 病理組織学的にリンパ管腫と診断された.後腹膜リンパ管腫の本邦報告例は約100例で, そのうち海綿状リンパ管腫は7例とまれな疾患であり, また浸潤性の発育・悪性化の問題点もあり文献的考察を加え報告した.

A patient with cholangiocarcinoma appeared through a 45-year period after throtrust infusion could survive for a relatively long term with intraarterial infusion chemotherapy.A 67-year-old man received minute exploration for abnormal liver function that was pointed out at another hospital, and a tumor existing in the posterior segment of right lobe of the liver was found. There was a history of fluoroscopic examination of the liver using trotrust during the World War II. On admission abnormally high levels of CA19-9 and DUPAN2 were shown. From preoperative echo-guided puncture, a diagnosis of intrahepatic bile duct carcinoma was made. During operation it was found that the tumor directly invaded the inferior vena cava, right hepatic vein, middle hepatic vein, left hepatic artery, and diaphragm. This case was considered inoperable, and the operation was terminated after an intraarterial pump was inserted into the proper hepatic artery for intraarterial infusion of anticancer agents. Postoperatively intraarterial infusion chemotherapy was started. The patient survived for a relatively long period of one year and 8 months from the tumor confirmation by imagings to the death.There was no unified guideline for the treatment of the disease, however, aggressive intraartrial infusion chemotherapy appears one of the measures providing a life-prolongation effect even for inoperable cases.

A 43-year-old man underwent subtotal pancreatectomy for chronic pancreatitis with subcutaneous and bone marrow fat necrosis. Postoperatively symptoms of chronic pancreatitis and subcutaneous necrosis resolved, but bone marrow fat necrosis became worse. The patient died of multiple organ failure 3 years and 5 months after the operation.Chiari first reported an association between subcutaneous fat necrosis and pancreatic disease in 1883 and subsequently several additional cases were reported in Europe and the United States of America. In Japan, few cases of fat necrosis have been reported, and this case is only the 11th. Seven cases were associated with acute or chronic pancreatitis and three cases were postoperative complications. If the release of pancreatic enzymes into the general circulation secondary to pancreatic inflammation is the primary etiologic factor in fat necrosis, then treatment by subtotal pancreatectomy is a reasonable approach. This case supports this hypothesis, at least in cases of subcutaneous fat necrosis.

慢性膵炎に対する外科治療には膵内外分泌機能を最大限に温存しえて, なお除痛効果に優れた術式の開発工夫が望まれる.1985年以後著者らは十二指腸温存膵頭部切除兼残膵神経叢切断術を30例の慢性膵炎患者に施行してきた.この手術は疼痛発現の最大要因と考えられる膵頭部を切除した上で膵体尾部遊離と神経叢切断を加えて膵臓のどの部位に由来する疼痛発現にも対処せんとするものである.2か月から6年に及ぶ観察期間中に生活状況に関する面談や内分泌機能検査を行って手術の効果を検討した.除痛効果としては85.7%に完全寛解が得られ75%が完全社会復帰を果たしていた.糖負荷試験にみる膵内分泌機能検査では約70%が術前値を維持するかそれより改善していた.高度胆管狭窄のため再建を要したのは7例であった.この術式は慢性膵炎のどのような病態にも対処でき, また本来の目的を達成しうる理想的な術式と考えられた.

Three cases of bleeding esophageal varices associated with arteriovenous malformation of the pancreas have been observed over the last 7 years. In 1 case, arteriovenous malformation (AVM) was the cause of the portal hypertension; thus, it was considered to be a "primary lesion." In the other cases, liver cirrhosis was the cause of the portal hypertension, and the AVM, which originally was a minor pathology, became significant as the portal hypertension progressed, thus making it a "secondary lesion." In the case of a "primary lesion," resection of the lesion is the preferred treatment for bleeding varices, but our case had multiple lesions, and excision was problematic. In the case of bleeding varices caused by liver cirrhosis, if liver function is normal, surgical treatment of both the varices and the AVM is recommended, while if the liver function is abnormal, repeated sclerotherapy is the best mode of therapy.

当科では従来より門脈圧亢進症に対し, 改良型選択的遠位脾腎静脈吻合術 (distal splenorenal shuntwith splenopancreatic disconnection; DSRS with SPD) を行ってきたが, さらにsplenopancreaticgastric disconnection (SPGD) へと改良を加えた.今回, 術後遠隔期に血管造影を施行し, 評価可能であった初期のSPGD不完全例6例とその後の完全施行例18例を対象にSPGDの意義を検索した.その結果, SPGDの不完全例ではportal perfusion grade (PPG) は維持されているものの, 完全例と比較すると術前後のPV/SMVの変化率は有意な低下を示し, 傍胃静脈などの側副血行路が描出されていた.これに対し, 現在恒常的に行っている完全例では門脈肝血流量の維持の上で満足すべき遠隔期所見が得られた.以上より, DSRSにSPGDを付加することは術後門脈血流の確保, シャント選択性の保持に不可欠であるものと考えられた.

We experienced a case of tumor-forming chronic pancreatitis with difficult defferential diagnosis from pancreatic cancer. A 73-year-old man was admitted to our hospital with a diagnosis of obstructive jaundice and performed transhepatic percutaneous drainage. Ultrasonography, computed tomography and transendoscopic ultrasonography revealed a tumor at the pancreatic head, but it could not be differed from malignant neoplasms. Aiming at complete biopsy, partial resection of the head of pancreas with resection of tissues including the tumor were performed. Intraoperative frozen section diagnosis and pathological diagnosis resulted in chronic pancreatitis, which showed a high degree of fibrosis in the pancreas.With a recent progression in graphic modalities, pancreatic cancer can be easily differentiated from chronic pancreatitis in most cases. However, we have often difficulties in differentiating tumor-forming pancreatitis from malignancies. Partial resection of the head of pancreas is useful for complete biopsy in such cases well as other cases presenting with stricture of the pancreatic duct or choledocheal duct.In this paper, we descrive the usefulness of this partial resection of the head of pancreas, protocol of diagnosis, and therapeutic guideline tumor-forming chronic pancreatitis.

A 65-year-old man with the chief complaint of tarry stool and abnormal shadow on chest roentogenogram was admitted to our hospital and was diagnosed as having a thoracic aortic aneurysm and duodenal cancer with liver metastasis. Alpha fetoprotein (AFP) level of 491.2 ng/ml was revealed on admission. First of all, we performed distal gastrectomy including the first portion of the duodenum in order to prevent massive bleeding. Tumor's type was Borrmann III and clinical stage was stage IV. Histological examinations revealed that the tumor was consistent with hepatoid adenocarcinoma. Production of AFP in the tumor was demonstarated by immunohistochemical technique (abidin-biotin peroxidase complex method). On the other hand, aneurymsmectomy and patch angioplasty were carried out for the thoracic aortic aneurysm. Finally, transarterial embolization was performed to the liver metastsis.AFP is a typical carcinoembryonic protein, but positive AFP values are very rarely reported in duodenal cancer. Here we describe a case of duodenal cancer, which showed a markedly elevated serum AFP and existence of AFP positive tumor cells evidenced by a use of immunohistochemical staining.

There is much controversy concerning the mode of therapy for patients in whom Zollinger-Ellison syndrome is strongly suspected but a tumor can not be located. We recently experienced a patient with Zollinger-Ellison syndrome presenting with melena in whom an attempt to stop the bleeding by H-2 antagonists failed and an emergency operation had to be carried out. At laparotomy, no tumor was found in the pancreas, duodenum or stomach wall and there was no specific swelling in any of the lymph nodes. A total gastrectomy was thus done with lymphadenectomy and a histopathological examination revealed two gastrinomas in the lymph nodes of the gastrinoma triangle. Postoperative secretin tests with 2 u/kg of secretin have been negative even 6.5 years later, and the patient is now well and working as a full time teacher. In this case, an emergency total gastrectomy was performed for uncontrolled bleeding, but we want to stress the importance of lymphadenectomy based on the findings of the frozen section and changes in gastrin levels.

A 34 year old male was hospitalized because of severe abdominal pain and diarrhea. An abdominal X-ray revealed multiple calculi in the head of pancreas and blood tests showed his serum calcium level to be high. He underwent surgery of the parathyroid gland and a parathyroid tumor was removed. Two months later, resection of the head of the pancreas was also performed. Eighteen months after his operation there has been no recurrence of abdominal pain or diarrhea and his serum calcium level is within the normal range. We report this case herein and also discuss the possible cause and effect relationship between primary hyperparathyroidism and pancreatitis, and the appropriate management, in relation to a review of the literature.

膵部分切除後の残存膵に対する体外分割照射が内分泌機能に与える影響を知る目的で, 雑種成犬を用いて60%膵切除を行い, 術後3週間を経た時点で臨床効果30GYおよび60GY相当の体外分割照射を行って切除単独群と比較検討した. 3ヵ月時の耐糖能は血糖消失率K値で切除単独群1.32±0.33, 30GY群1.07±0.58, 60GY群1.03±0.55といずれも境界型を示した. しかし照射の有無および量による影響はなかった. 電顕像の計量組織学的検索では実験群でInsulin穎粒の増加と同顆粒のVolumeDensityの増加 (正常対照10.6, 切除単独群14.1, 30GY群26.9, 60GY群22.4) がみられた. 60%膵切除・照射後3ヵ月時にみる限り, 照射による内分泌機能への影響は認められなかった. 耐糖能保時の因子としてラ島機能の亢進が考えられた.