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Background: The feasibility and efficacy of adjuvant hepatic arterial infusion (HAI) in preventing the development of liver metastases in patients with advanced colon carcinoma have not been validated. The aim of this randomized controlled study was to compare the feasibility of HAI and the protective effect against liver metastasis after curative resection to those of systemic chemotherapy. Methods: Between July 2000 and June 2003, 91 patients were enrolled. Patients were randomly assigned to receive 5-fluorouracil (5-FU) via continuous venous infusion (CVI) or intra-hepatic arterial weekly high-dose 5-FU (WHF). The primary endpoint was overall survival (OS). Results: In the WHF group, the cumulative failure rate of hepatic arterial catheterization was 16.7% at 6 months. The occurrence of grade 3 adverse events was comparable between the groups. The 5-year OS rates were 59.0% in the CVI group and 34.9% in the WHF group (P = 0.164). CVI tended to show a protective effect against liver metastasis regarding the 5-year liver-specific cumulative recurrence rate: CVI, 45.0% vs. WHF, 68.3%; P = 0.037). Conclusion: HAI therapy has a certain protective effect against liver metastasis after curative resection in patients with colorectal cancer. However, this therapy did not contribute to any marked improvement in their overall survival.

Portal vein thrombosis (PVT) is a rare complication of liver transplantation which can lead to graft failure and patient death. Treatment can be difficult, especially in cases of PVT from the intrahepatic portal vein to the proximal jejunal veins. A 55-year-old woman had undergone living-donor liver transplantation with splenectomy for end-stage liver cirrhosis due to hepatitis C with hepatocellular carcinoma. Ten months after transplantation, massive ascites and slight abdominal pain developed, and computed tomography revealed a PVT between the intrahepatic portal vein and the superior mesenteric vein. Repeated interventional radiology procedures were used in combination with thrombolysis, thrombectomy, and metallic stent replacement to obtain favorable portal flow to the graft. Five years after being treated, the patient is well, with favorable portal flow having been confirmed. In conclusion, repeated and assiduous interventional radiological treatment combined with thrombolytic therapy, thrombectomy, and metallic stent replacement could be important for severe PVT.

We herein present a rare case of enterovesical fistula caused by ileal non-Hodgkin's lymphoma. A 75-year-old Japanese male presented with macrohematuria at Kosei General Hospital in December 2010. An egg-sized mass was palpable in his right lower abdominal region, and computed tomography (CT) revealed that the ileal tumor had invaded the right posterior wall of the urinary bladder (UB). A histopathological examination of a CT-guided needle biopsy specimen revealed diffuse large B-cell lymphoma involving the ileum and the UB. Thereafter, fecaluria appeared. A transurethral catheter was put in place, and there were no symptoms of cystitis. The patient received chemotherapy for the lymphoma, which produced a partial response. However, the fecaluria continued, and an examination of the small intestine with contrast revealed a thick and irregular wall of the ileum and a fistula between the ileum and UB. A partial resection of the ileum and a partial cystectomy were carried out in April 2011. The surgical specimen demonstrated two tumors 5 cm apart in the ileum, measuring 4.5 × 7 and 4 × 3 cm in size. The proximal tumor had directly invaded the UB and formed an ileovesical fistula. The patient made a good recovery and was doing well 5 months after the surgery without any evidence of recurrence.

Background: We compared two types of stents in patients who underwent surgery for hepatic hilar malignancies. Methods: Twenty-one patients with hepatic hilar malignancies who underwent hepatectomy were randomly assigned to one of two groups. A 5-Fr silicon drain with an internal lumen and side holes was used for the hepaticojejunostomy in one group (intraluminal stent group), and a 10-Fr silicon drain with channels along the sides was used in the other (channel stent group). Results: Leakage developed in four patients (36.4%) in the intraluminal stent group versus two (20.0%) in the channel stent group. Cholangitis developed in three patients with leakage (27.3%) in the intraluminal stent group versus no patient in the channel stent group. After operation, the times required for the serum alkaline phosphatase and total bilirubin levels to return to the normal range were significantly shorter in the channel stent group (5.3 ± 2.9, 3.8 ± 2.2 days) than in the intraluminal stent group (17.0 ± 5.8, 9.4 ± 5.7 days) (P

Twenty years have passed since the first case of living donor liver transplantation (LDLT) in Japan. The recipients of LDLT have rapidly changed from children to adults through the use of right lobe grafts. The number of LDLTs in Japan has increased since January 2004 because of indication for LDLT changed widely in an insurance application. (UNCLEAR) A total of 4,292 LDLTs have been performed as of December 31, 2006, and 2,621 (61.1%) of these have been adult-to-adult LDLTs. Patients who have hepatocellular disease or hepatocellular carcinoma or both account for more than 50% of all recipients in Japan. The overall 3-, 5- and 10-year survival rates were 73.8%, 70.4%, and 66.3%, respectively. There were no significant differences in survival rates between LDLT in Japan and cadaveric transplantation in America or Europe. The survival rates will improve to clarify the timing and indications for LDLT and the optimal operative procedures. However, because of the number of patients requiring transplant will increase, it is important that cadaveric donor liver transplant is promoted in addition to LDLT in Japan.

Delayed gastric emptying (DGE) sometimes occurs after left hepatectomy with lymphadenectomy. We performed fixation of the greater omentum to the peritoneum to prevent DGE and other complications in patients undergoing left hepatectomy with lymphadenectomy for cholangiocarcinoma.Patients undergoing left hepatectomy with lymphadenectomy for cholangiocarcinoma were divided into a fixation group (n = 9) and a nonfixation group (n = 10). In the fixation group, the greater omentum was sutured to the peritoneum 3 cm from the greater curvature of the stomach to prevent contact between the stomach and the cut surface of the liver.Mean age, sex, disease, and hepatectomy procedures were similar in the two groups. DGE developed in six patients in the nonfixation group (60.0%) versus no patients in the fixation group (P = 0.011). The total number of complications was higher in the nonfixation group (16 complications) than in the fixation group (3 complications; P = 0.003). Overall morbidity was higher in the nonfixation group (60.0%) than in the fixation group (22.2%). Postoperative hospitalization was longer in the nonfixation group (67.4 days) than in the fixation group (20.2 days; P = 0.0041).Fixation of the greater omentum to the peritoneum decreases the occurrence of DGE and other complications after left hepatectomy with lymphadenectomy for cholangiocarcinoma.

We report a case of splenic abscess that was successfully treated with percutaneous ultrasound-guided drainage and without splenectomy. A 40-year-old woman was admitted to Nippon Medical School Hospital because of pyrexia and left upper quadrant pain, which had persisted despite antibiotic treatment. On admission, computed tomography demonstrated a low-density area in the spleen, which had been been seen on computed tomography 3 months earlier. Ultrasonography demonstrated a hypoechoic area in the spleen. Initial laboratory tests revealed a serum C-reactive protein concentration of 19.7 mg/dl and a white blood cell count of 15,800 /microl. The serum glucose concentration was 267 mg/dl, and the glycolated hemoglobin value was 7.7%. A splenic abscess was diagnosed and was treated with percutaneous drainage. Milky yellow fluid was obtained, and the patients left upper quadrant abdominal pain and pyrexia resolved. A culture of the drainage fluid yielded Escherichia coli. The drainage catheter was removed 12 days after insertion. The patient was discharged 6 days later. The splenic abscess has not recurred during 3 months of follow-up. Our results suggest that ultrasound-guided percutaneous drainage is a safe and effective alternative to surgery for the treatment of splenic abscess and allows preservation of the spleen.

A 60-year-old woman with primary sclerosing cholangitis (PSC) and high levels of ALP, gamma-GTP, and DUPAN-2 was admitted to our institution for examination. The patient did not have ulcerative colitis or pancreatic intraductal papillary mucinous neoplasm. Imaging studies revealed atypical dilation of bile ducts in the left lobe of the liver. Repeated cytologic examinations of the bile showed atypical cells consistent with adenocarcinoma. The patient underwent extended resection of the left lobe of the liver and was found to have intraductal papillary carcinoma with associated mucin-producing bile duct carcinoma. This carcinoma fills dilated bile duct lumens with mucin. This tumor differs morphologically from typical cholangiocarcinoma, which is usually seen in the late stages of PSC. Just one case of mucin-producing bile duct carcinoma arising from PSC has been reported worldwide. The patient has had no signs of recurrence after 27 months. Patients with mucin-producing bile duct carcinoma, as in the case of its pancreatic counterpart, may have a better prognosis and a higher survival rate than patients with typical cholangiocarcinomas.

A 41-year-old male patient with aggravated epigastralgia and nausea was admitted to Central Aizu General Hospital in February 1997. His past history showed a colonic polyp and anemia in the fourth decade. The patient looked healthy, but showed abdominal distension and tenderness, and pigmented lips. A plain abdominal X-ray revealed a dilation of the small intestine with niveau. Computed tomography disclosed multiple target signs. An emergency laparotomy clarified four intussusceptions of the small intestine with numerous polyps. Three were successfully reduced, while one jejunal intussusception was resected. Due to a fear of recurrence, a total of over 290 polyps were removed. His illness was diagnosed to be Peutz-Jeghers syndrome with a histology of hamartomatous polyps. He thereafter did well for 6 years, when he underwent an ileal resection for another intussusception caused by a newly grown lipoma. He was able to retain his job, but anemia and hypoproteinemia due to the proliferation of polyps necessitated treatments at the outpatient clinic. In May 2005, he underwent a third emergency laparotomy for an intussusception, followed by a resection of the ileum and 54 polyps. Since then he has been able to lead a normal life.

We report a rare case of bleeding ileal varices successfully treated with emergency enterectomy. A 72-year old woman with hepatic cirrhosis due to hepatitis C was admitted to our hospital because of anemia and hematochezia. An endoscopic examination showed no evidence of bleeding in the upper and lower gastrointestinal tracts. Angiographic studies of portal hemodynamics revealed extravasation from the ileal varices and total occlusion of the portal vein due to portal thrombus. This made it difficult to remove the ileal varices using interventional radiology. Therefore, the patient underwent emergency enterectomy for the ileal varices. No further gastrointestinal bleeding occurred during the 1-year follow-up.

食道静脈瘤に対する内視鏡的静脈瘤結紮術（EVL）後に出現し，脳症治療に難渋した特異シャントを経験した．症例は40歳代女性，原因不明の肝硬変にて2001年から他院で経過観察されていた．他院にて食道静脈瘤に対し2度のEVL歴，肝性脳症にて2度の入院歴がある．Lg-cf（F2, RC（-））の胃静脈瘤に対し，精査加療目的にて当科紹介となった．血管造影にて，左胃静脈と傍臍静脈を介する門脈大循環シャントを認め，脳症に対する治療をおこなう方針となった．初めに門脈圧を下げる目的で部分的脾動脈塞栓術（PSE）施行し，左胃静脈は経皮経肝的シャント塞栓術（PTO），傍臍静脈は全身麻酔下に外科的結紮術を施行したが，術後早期に後胃静脈を介する新たなシャントを認め，アンモニア値の改善も得られなかった．肝性脳症を有する門脈大循環シャントに対しシャント閉塞術施行し著効を認めたとする報告は散見するものの，その治療適応に関しては明確な基準はなく，示唆に富む症例と考えられた．

症例は76歳男性. アルコール性肝硬変, 多発性肝細胞癌 (stage III) に対し動注リザーバーを留置し, CDDP静注併用5-FU持続動注化学療法 (CDDP 10 mg×2/week静注および5-FU 1000 mg/5 days動注, 4投1休を1クール) を施行した. 3クールで副作用にて投薬中止するも, AFPが160 ng/ml から9.4 ng/ml と著明な減少を認め, 画像上も多発性肝細胞癌の縮小, 一部消失し長期生存が得られている. CDDP静注併用5-FU持続動注化学療法が, 多発性肝細胞癌に対して有用であった1例を報告する.

Background: We retrospectively identified the prognostic factors in cases of synchronous liver metastases from colorectal cancer and established a clinical strategy at our institution. Methods: One hundred eight patients with hepatic metastases from colorectal cancer underwent a first radical hepatic resection. Of these, 67 were diagnosed with hepatic synchronous metastases from colorectal primaries (S group) and 41 were diagnosed with metachronous metastases (M group). Hepatic lesions were diagnosed concurrently with the primary lesions in 45 of the 67 patients in the S group. Of these 45 patients, 37 underwent synchronous hepatectomy (SH group) and 8 underwent metachronous hepatectomy (MH group). Results: The overall 3-, 5- and 10-year survival rates were 51.4%, 41.6%, and 30.9%, respectively. There were no significant differences between the S and M groups in overall survival. Univariate analysis of the S group revealed significant differences in survival based on tumor factor, pathological lymph node metastases of the primary tumor, and the tumor-free margin. There were no significant differences between the SH and MH groups in overall survival. Conclusions: Patients with synchronous liver metastases from colorectal cancer should undergo radical resection of the primary lesion and simultaneous hepatectomy with an adequate tumor-free margin as a standard surgical course. (J Nippon Med Sch 2006; 73: 8288)

A 73‑year‑old male with C type liver cirrhosis and poor liver function reserve was diagnosed with hepatocellular carcinoma（HCC） （Segment V 2 × 2 cm in diameter）and underwent open microwave coagulation therapy（MCT） . Ten months later a movable hard mass about the size of a quail egg was palpable at the left supra‑clavicular lymph node（LN） （Virchow’ s LN）and blood tests revealed an elevated serum α‑fetoprotein（AFP）level of 26.7 ng dl . Abdominal and chest CT showed no evidence of recurrence in liver or lung and no metastases of abdominal LN. Barium and bone scintigraphy revealed no abnormal spots. The affected left supra‑clavicular LN was extirpated. The tumor was confirme dt o be an LN metastasis from HCC by histopathological examination. After the operation the patient developed uncontrollable pleural effusion and ascites and intrahepatic and abdominal LN metastases were visible on abdominal CT with great haste. He died 1.5 month sa fter the LN was extirpated. We herein report a case of HCC treated by MCT which later res ulted in a solitary Virchow’ s LN metastasis in the absence of any abdominal LN or recurrence in the liver or lung. （J Nippon Med Sch 2005; 72: 245―249）

We describe a patient with a ruptured and rapidly enlarging secondary tumor of the liver metastasized from an alpha-fetoprotein (AFP)-producing gastric cancer. The ruptured liver metastasis was successfully treated by transarterial embolization (TAE) followed by hepatic resection. A 65-year-old woman was admitted to our hospital with residual gastric cancer. No liver metastasis was detected by preoperative computed tomography (CT), or ultrasonography, and total gastrectomy was performed. Microscopically, the tumor was a poorly differentiated adenocarcinoma invading no deeper than the subserosa, with positive staining for AFP and positive staining for Ki67 in approximately 80% of the tumor cells. Severe venous and lymphatic involvements were evident. The serum AFP level was 100 ng/ml at 3 weeks after the total gastrectomy, but decreased to 16 ng/ml by the end of postoperative month 3. At 6 months, the patient was referred and readmitted to our hospital with sudden severe pain in the upper abdomen. She was admitted in a state of shock with laboratory findings of anemia. A liver tumor surrounded by effusion was detected in segment 8 and diagnosed as a ruptured liver metastasis. Emergency arteriography revealed a large hypervascular tumor, and a TAE performed promptly thereafter was successful in improving the blood pressure. A second TAE was performed 2 months after first TAE due to a dramatic elevation of serum AFP to 180,000 ng/ml. The second TAE decreased the patient's serum AFP to 2,200 ng/ml, but the level remained in the abnormal range. A right hepatectomy was performed after confirming the absence of other detectable metastatic tumors. The resected specimen contained a well-defined tumor, measuring 6 x 6 cm that appeared almost necrotic under microscope. Over the 6 years since the hepatectomy, no recurrence has appeared and serum AFP has remained within the normal range.

Background: The current study presents the long-term results of multiple minocycline hydrochloride (MINO) injections for the treatment of symptomatic solitary hepatic cyst. Methods: From 1989 to 1998, nine patients were referred for the treatment of a symptomatic solitary hepatic cyst, comprising two males and seven females aged between 41–72 years (mean 58.2 years). The chief complaint in all cases was upper abdominal discomfort or pain. Mean cyst diameter was 14.1 ± 2.3 cm. After insertion of an 8 or 9-French catheter into the cyst, 200 mg of MINO in 10 mL saline was injected and the catheter was flushed with 10 mL saline, for a total of 20 mL saline. The catheter was then clamped for 30 min. MINO injection was performed daily for 7–8 days, after which time the catheter was removed. Results: One patient complained of moderate right subscapular pain immediately after the injection, and one patient complained of pain at the site of catheter insertion. Patients were followed for 42–153 months (mean 85 months). Cyst regression without recurrence was documented in all patients. Conclusions: Multiple injections of MINO are safe, definitive treatments for symptomatic solitary hepatic cyst. © 2003 Blackwell Publishing Asia Pty Ltd

We report herein the case of a 67-year-old man who was admitted to our hospital with a 3-month history of hoarseness, a cervical mass, and weak muscles of the extremities 6 years after undergoing a right colectomy for carcinoma. Physical and imaging examinations disclosed a nodule in the thyroid with swollen cervical lymph nodes, multiple pulmonary lesions with pleural effusion, and a cerebral mass. Fine-needle aspiration cytology of the thyroid nodule and brush cytology of the lung mass revealed adenocarcinoma, which was consistent with a diagnosis of metastases from the primary colon adenocarcinoma to the thyroid, brain, and lung. The patient eventually died from the malignancy, although he survived for 4 months after the disclosure of the metastases. The rarity, diagnosis, and prognosis of thyroid metastasis from colon carcinoma are discussed.

Routine transplant aspiration cytology (TAC) after liver transplantation gives detailed information that concerns immunologic events in the graft. TAC can be helpful for diagnosis of acute rejection, but it also detects morphological signs of rejection without clinical correlate ("subclinical rejection"). The aim of this study was to systematically evaluate factors that influence the development of early clinical and subclinical rejection and to analyze the relevance of these early immunologic processes for the long-term course. The study includes the course of 340 patients after liver transplantation between 1988 and 1995 in whom TAC was performed routinely and who were followed for a minimum of 3 years. TAC findings were correlated with the following various clinical parameters: (1) Overall early clinical rejection occurred in 17.4%, subclinical rejection in 59.1%, and no immune activation was seen in 23.5% of patients. (2) Incidence of early clinical and subclinical rejection was markedly influenced by type of immunosuppression. (3) Basic disease and extent of preservation injury had only a minor influence; there was a trend towards lower early rejection associated with more severe preservation damage, increased patient age, and early retransplantation. (4) Presence of early clinical or subclinical rejection was not associated with a higher incidence of chronic dysfunction. (5) Falsely indicated antirejection treatment was associated with inferior graft survival. Subclinical rejection is very frequent early after liver transplantation, requires no treatment, and has no long-term adverse effect. Incidence of early clinical rejection is mainly determined by initial immunosuppression; its occurrence has no negative long-term effects and may even be associated with a lower risk for later immunological complications. Thus, the incidence of early acute rejection is no adequate parameter for evaluating the quality of an immunosuppressive treatment protocol.

Background: Reconstruction of the portal vein with autologous veins requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of portal vein reconstruction using the peritoneum. Methods: A 2.5 × 2.5 cm piece of the peritoneum was resected from Landrace pigs weighing 30 to 40 kg and was dipped in 100% alcohol for 10 minutes. The anterior wall of the portal vein measuring 1.2 × 0.6 cm was resected. The peritoneal patch-graft fitting the defect of the portal vein was used to repair it. Results: All 7 pigs survived the surgery, and were killed at 2, 7, 7, 14, 21, 35 and 49 days, respectively, after surgery. There was no evidence of thrombosis or obstruction of the reconstructed portal vein or any other complications. Complete endothelialization of the patches were noted at day 14. Conclusions: Our patch-graft technique using the peritoneum is considered to be a good and safe alternative for reconstruction after partial resection of the portal vein in clinical surgery.

肝細胞癌(hepatocellular carcinoma;以下, HCCと略記)の治癒切除施行49例を対象に術前の肝動脈塞栓術(transcatheter arterial embolization;以下, TAEと略記)施行例をA群(24例),非施行例B群(25例)の2群に分類し術前TAEの有用性を再発および長期予後に及ぼす効果から検討した.患者背景因子では,臨床病期ではA群においてII期のものが有意に多かった.病理学的因子では両群に有意差はなかった. 1年無再発生存率はA群76.3%, B群69.7%, 2年無再発生存率はそれぞれ31.8%, 41.3%, 3年ではそれぞれ34.4%, 25.4%で有意差なく,生存率でも, 1年累積生存率がA群91.1%, B群86.3%, 3年累積生存率はそれぞれ63.9%, 68.0%, 5年ではそれぞれ47.3%, 46.6%と両群間に有意差は認められなかった.以上から,術前TAEは治癒切除可能なHCCに対しては,再発,長期予後の点から有用性は低く,ルーチン化すべきでないと考えられた.

Background: Reconstruction of the vena cava with an autologous vein requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of vena cava reconstruction using the peritoneum. Methods: A 2.5 × 2.5 cm piece of peritoneum was resected from 7 pigs weighing 30 to 40 kg. An oval window (long axis: 1.5 cm) was made in the infrarenal vena cava. This was repaired with the peritoneal patch fixed in alcohol. Results: In 2 animals sacrificed at 5 hours, there was no evidence of thrombosis, but there was fibrin clot on the patches. Two animals sacrificed on day 8 exhibited excellent patency of the vena cava. Complete endothelialization of the patch was noted at day 15. At 6 weeks, the vena cava was healed. No infections or other problems were noted. Conclusions: The peritoneum is an accessible and safe substitute for reconstruction of the vena cava.

At our institute, laparoscopic hepatectomy for hepatocellular carcinoma has been successfully performed in two cases. Each tumor was located solitarily, one in segment IV of the liver and another in the segment VI. Introducing a minimum of four trocars, the exact location of the tumor and the distance from main vessels to the tumor were determined by laparoscopic intraoperative ultrasonography. Hepatic parenchymal resection was carried out using a laparoscopic coagulating shears in combination with a microwave tissue coagulator to minimize the blood loss. After the operation, these patients made a rapid recovery. Although this technique has been available for good quality of life to the patient, a longer time for observation of the clinical course will be necessary to determine the long-term effectiveness.

A very rare case of adenomyoma of the common hepatic duct is described. A 54-year-old woman was admitted with impending obstructive jaundice secondary to adenomyoma of the common hepatic duct. Our impression, formulated from her clinical presentation, endoscopic investigations, and biochemical and radiological findings, was a cancer of the proximal common hepatic duct. The patient was treated successfully by combination surgical resection and hepaticojejunostomy. Despite our obtaining an intraoperative frozen section, final histological examination was required to confirm the diagnosis. The patient remains well 16 months postoperatively. A survey of the world literature revealed that this is the second report of adenomyoma occurring in the common hepatic duct.

Patients with hepatocellular carcinoma (HCC) in stage III to IV-A were allocated to those receiving TAE (TAE group) and those receiving regional chemotherapy using subcutaneous reservoir (reservoir group), and the survival rate was statistically compared between them. Of 18 patients in stage III, median survivals were 21 months (the longest: 72 months) for the TAE group (n=14) and 17 months (the longest: 33 months) for the reservoir group (n=4). Comparative study of one year survival between the two groups revealed no significant difference (63% vs 50%), as the same as for two year survival (52% vs 25%), although the former group seemed to be higher than the latter. Of 51 patients in stage IV-A median survivals of 9 months (the longest: 38 months) and 12 months (the longest: 36 months) were noted for the TAE group (n=34) and the reservoir group (n=17), respectively. Comparison for one year survival between the two groups revealed no significant difference (33% vs 41%), as the same as for two year survival (15% vs 21%), although the reservoir group seemed to be higher than the TAE group. There were 15 death cases due to early liver failure or gastrointestinal bleeding after TAE. For proper treatment of unresectable HCC, meticulous evaluation of the liver is mandatory before performing TAE whether it can tolerate the treatment or not, then if not or the TAE was ineffective once the regional chemotherapy is a better choice.

Neuroblastic tumor cases in our departments were evaluated in terms of the stage of the tumor, N-myc amplification, urinary vanillylamndelic acid (VMA)/homovanillic acid (HVA) and survival rate. Two asymptomatic cases, diagnosed when under a year old by mass screening, had no amplifications of N-myc but showed more than one value of urinary VMA/HVA ratio. The patients are now doing well eight years after complete excision of the neuroblastoma which had originated in the sympathetic ganglion. On the other hand, two other symptomatic cases, operated on at the ages of 3 and 5 years, showed remarkable amplifications with less than one value of urinary VMA/HVA, and died from the tumor soon after partial resection of the neuroblastoma and ganglioneuroblastoma which had originated in the adrenal gland and the sympathetic ganglion, respectively. The present monograph reports our cases and discusses prognostic factors.

A 67-year-old male complaining of constipation with a change in stool caliber for several months visited our hospital in June 1999. A positive test for occult blood in the feces led to the disclosure of a type II carcinoma of the sigmoid colon with multiple liver metastases. A lymph node dissection with a sigmoidectomy disclosed no metastases histologically, so a left hepatectomy and enucleations of the metastases were performed. In addition, the invaded middle hepatic vein (MHV) was resected and repaired using a peritoneal patch. The patient's postoperative course was uneventful until July 2000, when computed tomography of the liver showed a single nodule measuring 3 cm in diameter in segment 6. The metastasis was excised in August. Since then, the patient has shown normal tumor marker values. The MHV has remained patent for 24 months after its reconstruction. A resection of the liver metastases including venous reconstruction is beneficial for patients since it results in a longer survival and allows for venous drainage of the residual liver. The peritoneum is also accessible, enabling the fitting of a patch graft for hepatic vein repair.

One hundred laparoscopic cholecystectomies were performed since April 1991. Eleven patients were treated with a new technique without CO2 insufflation, using a traction device to elevate the right upper quadrant wall. Two Kirschner wires were introduced subcutaneously to permit the abdominal wall to be lifted for satisfactory laparoscopic view, as the gas insufflation technique yields. Preoperative evacuation of the intestines and intraoperative muscle relaxation are necessary for easy and successful cholecystectomy. Three cases were converted to laparotomy because of remarkably distended intestine due to incorrect endotracheal intubations. No complications related to subcutaneous wire traction technique were noted in this series. Subcutaneous wire traction technique provides a simpler, and possibly safer alternative to the gas insufflation technique.

A case of malignant small cell tumor of the thoraco-pulmonary region, so called Askin tumor, in a three year-old female complaining fever is described.In the chest plain roentrenogram and pulmonary CT scan, a spindle shaped chest wall mass situated on the right 5th rib was disclosed. The rib destructed. Ewing sarcoma or osteosarcoma was suspected. The chest wall resection with the 5th to 7th ribs, and the partial resection of the pulmonary segment 4 were performed. The tumor was elastic soft and 80×30×25 mm in size, a grayish-white appearance. The ribs, lung, and pleura were involved. Pathologically, the tumor was diagnosed as Askin tumor.Askin tumor is uncommon in infants and the prognosis is generally so dismal. Here the important of multidisplinary treatments as well as early diagnosis and operation is emphasized.

One-hundred and ten cases of mediastinal tumors treated in our department during a past one decade were subjected to a clinical assessment of surgical outcomes and prognosis by types of tumors. Seventy-one point two per cent of the patients manifesting some symptoms had malignant tumors. This suggested that mediastinal tumors having symptoms predominantly comprised malignant tumors. The frequencies of the medistinal tumors by histologic types were: 28.2% for thymoma, 19.1% for germ cell tumor, 16.4% for neurogenic tumor, 11.8% for bronchogenic cyst, 5.5% for thymic cyst, 3.6% for lymphoma, and 7.3% for miscellaneous tumor. Malignant tumors accounted for 35.5% (39/110) of all mediastinal tumors. As high as 90.3% and 75.0% of thymoma and lymphoma were malignant respectively. Five cases necessitated reconstruction or bypass operation for SVC syndrome with the advanced invasive thymoma. The longest survival period of 3 years and 5 months was recorded. We believe that surgical therapy followed by postoperative adjuvant therapies such as radiation and chemotherapy may promise sumptomatic remission and better prognosis for this patients.

Since Gauderer and others performed simple percutaneous endoscopic gastrostomy (PEG) which does not require laparotomy or systemic anesthesia, its modified techniques in several kinds have been made public up to now. This time we tried PEG according to the method by Russell and others on a total of 8 cases in a period from July 1989 to October 1990. Of the 8 cases, 5 had swallowing difficulty due to cerebrovascular disturbance, 2 would not take food due to demential symptom, and one was of hypoxic encephalopathy. As a result, we could successfully perform the method on 6 cases under local anesthesia.As complications, we have experienced intraperitoneal deviation of a guide wire midoperatively in one case, and rubor and infection in one at the site where a tube for gastrostomy was inserted. The longest of 14 months has elapsed postoperatively, and PEG not only played the role of nutritional supply but exhibited secondary effects such as improvement of aspiration pneumonia in 3 out of 4 cases and improvement of neurotic symptom and decompression of gastric dilation due to duodenal stenosis in one case.It is presumed that the indications for this technique will be expanded, and applicable cases will be increased owing to the fact that this method can be manipulated easily and safely.

Dihydropyrimidine dehydrogenase is the initial and rate-limiting enzyme in the catabolism of 5-fluorouracil. The aim of this study was to determine the levels of messenger RNA for 5-fluorouracil-related metabolic enzymes in cirrhotic liver and to assess the correlation between these mRNA levels and clinicopathological features.The study material consisted of 33 liver samples. The levels of mRNA for the 5- fluorouracil-related metabolic enzymes were quantified by real-time reverse transcription polymerase chain reaction combined with laser-captured microdissection.The Dihydropyrimidine dehydrogenase mRNA level in patients with grade B liver damage was significantly lower than that in patients with grade A liver damage (p=0.009). The Dihydropyrimidine dehydrogenase and orotate phosphoribosyl transferase mRNA level in al samples was higher than that in a2 and a3 samples (p= 0.01 and 0.013, respectively). Statistically significant correlations were found between the hyaluronic acid and the thymidylate phosphorylase mRNA level (p= 0.0001), and the T-BIL and the dihydropyrimidine dehydrogenase mRNA level (p=0.01).The level of Dihydropyrimidine dehydrogenase mRNA may be affected by the clinicopathological status of patients with cirrhosis.

Background: Refractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE. Patients: Four patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE. Surgical Procedure: Partial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery. Result: The mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 ± 56.4 μg/dL, mean ± SD) than after surgery (41.8 ± 20.2 μg/dL; p=0.0299). No patient had symptoms of HE. Conclusion: Ligation of the patent PUV is an effective treatment for patients with refractory HE.