Free papers (posters)-pt.3

307 AVol. 8, No.7S2004 FREE PAPERS (POSTER)

P-464Intraperitoneal Treatment with Dimethylthioampal(DIMATE) Associated to Surgical Debulking is Effective forExperimental Peritoneal Carcinomatosis in a Rat ModelOlivier Jean-Yves Monneuse1, Jean-Philippe Mestrallet2, GerryQuash3, Francois Noel Gilly4, Olivier Glehen4

1Surgery, Hospices Civils de Lyon, 2General Surgery, CHU deGrenoble, 3Laboratoire d’Immunochimie, Faculte de MedecineLyon, 4EA 3738, Faculte de Medecine Lyon, France

Aim:To evaluate the efficiency of intraperitoneal administration ofdimethylthioampal (DIMATE), a cellular apoptosis inducer, com-bined or not with a cytoreductive surgery on rats with colic perit-noneal carcinomatosis.Material and methods:Peritoneal carcinomatosis of rats was induced by intraperitonealinjection of adenocarcinoma cell line DHD/K12/pro B. Intraperi-toneal DIMATE was given at 17.3 mg/kg. Rats were randomizedinto 5 groups of 8 animals, regarding the day of treatment (2 daysor 20 days after peritoneal carcinomatosis induction) and the com-bination with cytoreductive surgery. All rats were sacrificed at 30days to evaluate the carcinomatosis extent (quantitative score) andthe volume of ascites. Results:The quantitative score of carcinomatosis was significantly reducedin the groups treated with DIMATE at day 2 (p=0.0052) and whenDIMATE was used with cytoreductive surgery at day 20 (p=0.009).Cytoreductive surgery or DIMATE used alone at day 20, were notefficient. The mean volume of ascites was significantly reduced inthe groups treated with DIMATE at day 2 (p<0.0001), and whenDIMATE was combined with cytoreductive surgery (p<0.0001).The haemorrhagic ascites was also reduced by cytoreductivesurgery made alone at J20 (p=0.0016). DIMATE administred aloneat day 20 was not efficient.Conclusion:Intraperitoneal DIMATE appeared to be an efficient drug in thetreatment of peritoneal carcinomatosis when combined withcytoreductive surgery or when given early before the developmentof macroscopic peritoneal carcinomatosis. It appears to be apromising therapeutic agent to be investigated in human phase-Itrial in peritoneal carcinomatosis.

P-465Minimally Invasive Diagnostic Procedure by Water EnemaComputed TomographyOlivier Jean-Yves Monneuse1, Frank Pilleul2, Aurelie Bansac-Lamblin2, Pierre-Jean Valette2

1Surgery, 2Radiology, Hospices Civils de Lyon, France

Study aims : The aim of this study was to assess the accuracy ofwater enema multi-row computed tomography for detecting clini-cally suspected colorectal tumor. Patients and methods : A waterenema multi-row computed tomography (WE-MR-CT) was per-formed in 128 consecutive patients (71 women and 57 men with amean age 67,7 years) referred for suspicion of colorectal cancer.We have defined at least one centimeter size of the lesion as thethreshold of detection. The results of WE-MR-CT were com-pared with the diagnosis obtained by colonoscopy, pathology orclinical follow-up. Sensitivity, specificity, positive and negative

predictive values were established with a 95% confidence intervals.Statistical analysis has been done with Microsoft Excel (Microsoft,Redmond, Wash). Results : Patients referred for suspicion of col-orectal cancer are defined as follow: intestinal bleeding (n=27),intestinal dysfunction (n=39), occlusive syndrom (n=5), atypicaldiverticulitis (n=17), incomplete colonoscopy (n=16) and suspectedlesion on abdominal ultrasonography (n=11). The overall sensitivi-ty and specificity of water enema multi-row CT in identifyingpatients with colorectal lesions was 95.5% and 93.5%, respectively.The negative predictive value 98.8% for a 10 mm threesholdlesion size. WE-MR-CT allowed to identify synchronous lesionsin three cases. Conclusions : WE-MR-CT performance comparedfavorably with reported performance of virtual colonoscopy withmore accessible technic. A prospective study evaluating the perfor-mance of this technique in a screening population is indicated.

P-466Jejuno-ovarian Fistula in Crohn’s Disease : MRI Can Diag-nose This Extremely Rare Complication before SurgeryOlivier Jean-Yves Monneuse1, Frank Pilleul2, Xavier Barth1, LaurentGruner1, Benoit Gignoux1, Patrice Mathevet3, Etienne Tissot1

1Surgery, 2Radiology, 3Gynecology, Hospices Civils de Lyon,France

Aim : Jejuno-ovarian Crohn’s fistulas are very rare in the literature.At the difference of colo-salpingo fistulas (much more frequent),or pelvic abcesses (extremely frequent), some articles describe itbut no real case is reported in these different articles. We report acase of a jejuno-ovarian fistula associated to a colo-jejunal fistuladetected by MRI exam. Material, methods : A 37 old woman, withmedical Crohn history consulted for abdominal pain with an aspe-cific abdominal exam. Ultrasonographic exam diagnosed a rightovarian cyst of 4 cm, irregular. An abdominal CT scan was done,without and with contrast injection, which suspected a digestivefistula because of the presence of gas in the cyst. MRI diagnosed afistula between the jejunum and the oocyst, and suspected a secondfistula between the small bowel and the sigmoid (witch explain thepresence of gas). Results : The patient has beneficiated of a com-bined surgery (gynaecologic and digestive surgery). The surgicaltreatment had consisted in a sigmoidectomy and a continuityreestablishment in the same time associated with a bowel fistularesection, and an ovarian resection.The surgical follow up was sim-ple. Conclusion : The diagnosis of an ovarian fistula is very rarebut must be done before the surgical procedure. To make thisdiagnosis, MRI has been effectiveness. Even if this exam cannot bedone for all women who present organic ovarian cyst, it could berealized when the patient has an association of an inflammatoryabdominal pathology with an ovarian organic cyst.

P-467Is Computed Tomography Provided Accurate Informationsin the Surgical Management of Gastro-Duodenal Ulcer Per-forations?Olivier Jean-Yves Monneuse1, Frank Pilleul2, Xavier Barth1, LaurentGruner1, Etienne Tissot1

1Surgery, 2Radiology, Hospices Civils de Lyon, France

AIM: To identify on computed tomography (CT) scan, predictivesigns of accurate management in patients with perforated gastro-duodenal (GD) ulcer. METHODOLOGY: Between 2000-2004,

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Gastrointestinal SurgeryAbstract of 19th WC-ISDS

we reviewed CT scans of 32 consecutive patients (14 women - 18men; mean age 60 years old), with perforated GD ulcer confirmedby surgery or endoscopy. Specific CT signs (location of air freefluid, ulcer localisation, presence of peritoneal fluid) were evaluat-ed. Pre operative abdomen plain film findings were compared toCT scan results for the diagnosis of perforated GD ulcer. Correla-tion was performed between CT scan and surgical or endoscopicresults. Surgical management were also studied. RESULTS: Airfree fluid was identified in 100% on CT scan vs 45.1% on plainfilm. 27 patients (87.1%) had abnormal fluid accumulation. Twen-ty seven (84,4%) patients had surgical treatment distributed as fol-low : 18 suture of the perforation, 6 suture associated with chole-cystectomy and transcystic biliary drainage, 2 ulcerectomy sutureand 1 partial gastrectomy. A peritoneal drainage was always done.The preoperative signs on CT scan were: diffuse peritoneal freefluid (n=10), diffuse abdominal pneumoperitoneum (n=13), correctlocalisation of the ulcer in 16 cases (59.3%).Five patients had nonoperative treatment. The preoperative signs on CT scan were: nodiffuse peritoneal free fluid, no diffuse abdominal pneumoperi-toneum, and correct localisation of the ulcer (n=4). CONCLU-SIONS: Helical CT was valuable in the diagnosis of perforatedpeptic ulcer, and it could be helpful for the surgeon in the thera-peutic management. Therefore, a prospective study should be nec-essary.

P-468Hepatic Oxidative Stress and Ischemia Reperfusion Injury inRat LiverEduardo Montalvo-Jave1, Arturo Ortega-Salgado2, Cesar Montalvo-Arenas3, Daniel Carrasco4, Enrique Pina-Garza5

1Department of Surgery and Biochemistry, School of Medicine,UNAM and General Hospital of Mexico, 2Department of Surgery,3Department of Cell Biology, 4Department of Pathology, 5Depart-ment of Biochemistry, School of Medicine, UNAM, Mexico

Introduction A period of ischemia is required for a number ofsurgical procedures on the liver, especially when dealing withresecting intrahepatic lesions or hepatic trauma, after the ischemictime, on restoring the blood supply, the liver is subjected to a fur-ther insult: The liver ischemia-reperfusion (LIR) injury. This phe-nomenon is associated with the liver transplantation (LT), theoxidative damage is considered to be the first event leading to graftdysfunction and after reperfusion the reactive oxygen species(ROS) causes cell damage and triggers further processes. The aimof the present study was to characterize the indirect effect of theORS measured by lipid peroxidation (LP), carbonyl reaction (CR)and liver enzymes during LIR in a rat model. Methods One hun-dred Wistar rats, divided in 10 groups of study, subjected to 30minutes of total warm ischemia and 30, 60, 90, 120 minutes and 4 ,12 and 24 hours of reperfusion was investigated. LP levels wasmeasured as thiobarbituric acid-reactive substances (MDA), CR byimmunochemical method with 2,4-Dinitrophenylhydrazine andthe blood samples were taken for measurement of LHD, AST,ALT and OTC. Results Significantly increased of MDA levelsand CR was found at 60,90 and 120 minutes. The serum levelsshowed that OTC, AST , ALT and LHD were increased dramati-cally in the reperfusion phase, specially during the period between60 and 120 minutes. Conclusions Our experiments suggest thatROS, although it is responsible, at least in part, for the enhancedLP and proteins CR during total LIR.

P-469Surgical Apporaches for Biliary Papilloma and PapillomatosisDeok-Bog Moon1, Deok-Bog Moon1, Sunggyu Lee1, Youngjoo Lee1,Kwangmin Park1, Shin Hwang1, Chulsoo Ahn1, Taeyong Ha2,Keonkuk Kim1

1General Surgery, Hepatobiliary and Liver Transplatnation, AsanMedical Center, 2Asan Medical Center, Korea

(purpose) Biliary papilloma and papillomatosis tend to occur inmultiplicity and along the biliary mucosa. They also have malig-nant transformation frequently. Furthermore there is difficult forus to perform curative surgery, and high recurrence. This studywas designed to find appropriate surgical approaches throughanalysis of the diseased patients. (method) We performed retro-spective review for 24 patients with papillary tumors of biliary sys-tem from September 1 1989 to December 31 2002. (results) Thesex of patients is 17 male and 7 female. The age is mean 58 year-old (range: 45-77). Most common symptoms were RUQ and epi-gastric pain (n=10). On ERCP, there are irregular bile duct walland multiple fillding defect (n=11), dilatation of bile duct andoccluding mass (n=8), mucus discharge form papilla of Vater (n=2).10 patients underwent PTCS. We could make a accurate localiza-tion and diagnosis grossly and histologically in all cases. Operationwere performed 21 cases. Histologic diagnosis were benign papil-lomatosis (n=4), papillomatosis with malignancy (n=7), papillaryadenocarcinoma (n=13). Curative and palliative surgery were 12cases respectively. Postoperative mean follow-up period was 27.4months, recurrence was 12 cases (50%) and takes 14.6 months. 3year survival was 56.7% and 3 year disease free survival was 40.5%.3 year survival between curative and palliative group were 83.3%and 34.3% each. (Conclusion) Papillary tumors have a characteris-tics that is difficult to be treated curatively. Therefore, we shouldperform PTCS preoperatively and minimize the possibility ofresidual lesions at operation.

P-470Surgical Resection of Liver Metastasis with Malignant Thy-momaMikito Mori, Hiroshi Yamamoto, Matsuo Nagata, NobuhiroTakiguchi, Osamu Kainuma, Hiroaki Souda, Kentarou Murakami,Toshihiko Fujimori, Takehide Asano, Kazuo WatanabeGastroenterological Surgery, Chiba Cancer Center, Japan

[Introduction] Thymomas are the most common neoplasm ofanterior mediastinum. Some thymomas tend to infiltrate adjacenttissues by direct extension, but there is the extremely rare inci-dence of extra thoracic metastasis. The most frequent metastasissites are the bones, lung, lymph nodes, and liver. It is supportedthat the treatment of choice for malignant thymoma is combina-tion of surgery, radiation, and chemotherapy. Recently, it has beenreported that preoperative chemotherapy helps to increase theoperability of the advanced cases. We describe a case of livermetastasis in a 33-year-old female with malignant thymoma whowas enable to undergo radical tumor resection and left hepaticresection. [Case Report] A patient, 33-year-old female, was diag-nosed as a malignant thymoma of Stage IVb. At first, combinationchemotherapy has been tried on this patient diagnosed as inopera-ble case. She was treated with 5 cycles of combination chemother-apy of PE (cisplatin 110 mg Day1, etoposide 140 mg Day1, 2, 3).After chemotherapy, she had a partial response and operability in


this disease. She received radical tumor resection, and left hepaticresection. After operation, she is well controlled medically andalive at present. [Conclusion] An extensive literature review hasrevealed a few record of surgical resection of liver metastasis withmalignant thymoma. Thus, we review a case with surgical resec-tion of local and liver metastasis in a patient with malignant thy-moma after neoadjuvant chemotherapy.

P-471Acid Secrection of the Gastric Tube as an Esophageal Substi-tute after Radical Esophagectomy for Thoracic EsophagealCancerNaoki Mori, Hiromasa Fujita, Susumu Sueyoshi, Toshiaki Tanaka,Yuichi Tanaka, Hideaki Yamana, Kazuo ShirouzuDepartment of Surgery, Kurume University School of Medicine,Japan

Purpose: Recently, a peptic ulcer was reported in a gastric tubeused in esophageal reconstruction after radical esophagectomy forthoracic esophageal cancer, which caused serious complicationsincluding hemorrhage, perforation, and penetration. In the presentstudy, we have examined the acidity using 24-hour pH monitoringto elucidate the acid secretion of the denervated gastric tube.Patients and methods: 24-hour pH monitoring was performedbefore surgery, one month and one year after surgery in 25patients who underwent esophagectomy for thoracic esophagealcancer. There were 23 men and 2 women, from 53 to 71 years old.The two sensors of the monitoring catheter were located at loweresophagus and upper stomach before surgery. They were locatedin the upper and lower portion of the gastric tube one month andone year after surgery. Results: The %time pH<4 (the ratio of theduration in which pH was below 4) was 70±26% in the upperstomach before surgery. This ratio fell to 40±33% in the upperportion of the gastric tube reconstructed esophagus, and to42±39% in the lower portion, at one month after surgery. Theratio recovered to 78±9% and 52±26%, respectively, at one yearafter surgery. Conclusion: Acid secretion in the gastric tube wasmarkedly decreased at one month after surgery, and may recoverby one year after surgery.

P-472A Case of Ulcerative Colitis with Massive Bleeding from theResidual Rectum after the Subtotal ColectomyRyutaro Mori1, Kazutaka Koganei1, Hiroshi Shimada2

1Chronic Intractable Disease Center, Yokohama City UniversiyMedical Center, 2Department of Gastroenterological Surgery,Yokohama City University, Graduate School of Medicine, Japan

We report a case of ulcerative colitis with massive bleeding fromthe residual rectum after subtotal colectomy. Fifty-one year-oldwoman was diagnosed as ulcerative colitis four years ago and hadbeen well controlled was referred to our department with recur-rence accompanied by rectal bleeding, diarrhea, abdominal painand tenesmus. As her treatment with predonisolone 30mg per daywas not effective, she admitted to our hospital and was placed onan intensive intravenous regimen of predonisolone in a dosage of50mg per day. Gastrographine enema showed there were deepulcers in her sigmoid colon and rectum. Ten days following thetherapy, she continued to have her symptoms without anyimprovement. Accordingly, the patient underwent subtotal colec-

tomy with ileostomy and suprapubic mucus fistula. On the sixthpostoperative day, she had massive bleeding from residual rectumwith hypovolemic shock. An urgent restorative proctocolectomywith ileal pouch anal canal anastomosis and covering ileostomy wasperformed. There were deep ulcers with much coagulation in herresected rectum. Total proctocolectomy with ileal pouch analcanal anastomosis and ileostomy might be a safe procedure, whenthe patients have continuous bleeding from deep ulcers on theirrectum.

P-473Middle Hepatic Vein Tributary Reconstruction Could NotAct as A Complete Substitute for An Entirely Preserved Mid-dle Hepatic VeinDaisuke Morioka, Hitoshi Sekido, Ken-Ichi Matsuo, Kazuhisa Take-da, Mitsutaka Sugita, Kaori Kubota, Kuniya Tanaka, Itaru Endo,Shinji Togo, Hiroshi ShimadaDepartment of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, Japan

Background/Aims The necessity of the middle hepatic vein for liv-ing donor liver transplantation using right lobe graft is still contro-versial. Methods We reviewed 7 long-term surviving right-loberecipients in whom middle hepatic vein tributaries were not recon-structed (group A, n=4) or were reconstructed (group B, n=3). Vol-ume regeneration of the right paramedian (segments V+VIII) andright lateral (segments VI+VII) sectors was assessed by computedtomography at 3, 6, 9, and 12 postoperative months. The rightparamedian sector was further subdivided into the ventral portionin relation to the anterior branch of the right portal vein and dor-sal portion. Results The volume regeneration ratio was significant-ly lower in group A than in group B persistently after 6 postopera-tive months in regard to the right paramedian sector, the dorsalportion, and especially the ventral portion (0.64+-0.19 vs. 1.22+-0.17, p=0.034, 12 postoperative months). However, volume regen-eration was impaired in the ventral portion as compared to otherareas in group B. Conclusion In conclusion, middle hepatic veintributary reconstruction improves the volume regeneration of theright paramedian sector in right lobe living donor liver transplan-tation. However, it could not act as a complete substitute for anentirely preserved middle hepatic vein.

P-474Remaining Caudate Lobe in the Right Lobe Graft in LivingDonor Liver Transplantation- A Blind Spot?Daisuke Morioka, Hitoshi Sekido, Kaori Kubota, Hideki Masunari,Ken-Ichi Matsuo, Mitsutaka Sugita, Yasuhiko Nagano, KuniyaTanaka, Itaru Endo, Shinji Togo, Hiroshi ShimadaDepartment of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, Japan

Right margin of the caudate lobe is obscure. Therefore, a part ofthe caudate lobe, namely a part of the right side of the paracavalportion, seems almost always to remain in the right lobe graft inthe standard harvesting procedure. We reviewed intraoperativefindings and postoperative courses in donors and recipients of 11consecutive living donor liver transplantations using right lobegrafts. We used computed tomography in recipients’ postoperativecourses to investigate whether the remaining caudate lobe was pre-sent in the right lobe graft and whether the remaining caudate lobe

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could cause serious complications if present. Intraoperative bileleak (IOBL) from a remaining part of the caudate lobe after thecompletion of biliary reconstruction was observed in 4 recipients.Most recipients with or without IOBL showed no postoperativebiliary complications, with the exception of one IOBL case, whichdeveloped repeated bile leakage from the same origin as IOBLduring the long-term postoperative course. However, this causedno serious difficulties and was cured conservatively on all occa-sions. Although the remaining caudate lobe was detectable bypostoperative computed tomography in all recipients, no seriouscomplications related to the existence of the remaining caudatelobe was observed in any recipients. In conclusion, a part of thecaudate lobe, namely a part of the right side of the paracaval por-tion, is almost always remaining in the right lobe graft in the stan-dard harvesting procedure. However, the implications of this phe-nomenon have not been clarified at this stage and may prove to bebenign.

P-475No Difference in the Safety Limit for the Extent of Hepatec-tomy between Rats with Normal Livers and Rats with Moder-ately Fatty LiversDaisuke Morioka, Kazuteru Watanabe, Hirochika Makino, ShujiSaito, Michio Ueda, Kaori Kubota, Hitoshi Sekido, Ken-Ichi Matsuo,Yasushi Ichikawa, Itaru Endo, Shinji Togo, Hiroshi ShimadaDepartment of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, Japan

Introduction The aim of this study was to determine if rats withmoderately fatty livers could withstand a 90% hepatectomy, whichrats with normal livers can survive.Material and methods Nine-week-old male Wistar rats were used.Normal rat chow was fed to the normal liver group, and fat-enriched rat chow was fed to the fatty liver group for 4 weeks toinduce a moderately fatty liver. We previously reported that thisfatty liver rat model can cause fatal liver dysfunction after reduced-size-liver transplantation. A 90% and 95% hepatectomy were per-formed using rats of both groups to evaluate post-hepatectomizedliver function.Results All rats undergoing a 90% hepatectomy were still alive 30days after the hepatectomy, but the rats who underwent a 95%hepatectomy were all dead within 4 days regardless of which groupthey belonged to. Increases in the remnant liver wet weight mea-sured until 7 postoperative days after 90% hepatectomy werealmost similar between the two groups. Alanin aminotransferasemeasured at 24, 48, 72, and 168 hours after a 90% hepatectomywere significantly higher in the fatty liver group than in the normalliver group. Similarly, at up to 72 postoperative hours, the serumhyarulonic acids were significantly higher in the fatty liver group. Conclusion A moderately fatty liver did not cause fatal liver dys-function in 90% hepatectomized rats. However, it caused a higherdegree of post-hepatectomized liver dysfunction.

P-476Do the Detection of Tiny Lesions and the Aggressive SurgeryImprove the Prognosis of the Colorectal Liver Metastases?Zenichi Morise, Atsushi Sugioka, Junko Fujita, Sojun Hoshimoto,Takazumi Kato, Akitake Hasumi, Akihiko Horiguchi, ShuichiMiyakawa, Kotaro MaedaDepartment of Surgery, Fujita Health University School of Medi-cine, Japan

207 hepatectomies for colorectal metastases were performed since1974. Preoperative CT-A,-AP was introduced at 1994. We evalu-ate the impact of detection of tiny lesions and aggressive surgery inour series.Overall survivals for 5, 10 years after the first hepatectomy are39.1%, 27.5%, respectively. Although the survival of multiplemetastases patients is significantly lower than that of solitarymetastasis patients, there are still 25.7%, 18.4% of 5-, 10-year sur-vivals, respectively. In patients with multiple metastases, there areno significant differences in survivals, according to the numbersand locations. Although 4 cases with >4 bilobar metastases survived5 years, 2 of them died of recurrence after then.Preoperative examination of CT-A,-AP improved the non-recur-rent rate in the liver. The difference was not evident in the sur-vival. 7 patients underwent repeat hepatectomy after CT-A,-APevaluation. 5 of them survive after the 56-month mean follow-upperiod. For selected patients, supposedly with lower risks of extra-hepatic metastases, the detection might work profitably.There are 27, 24 cases with repeat hepatectomy (rHx), pulmonaryresection for the metastases (Px), respectively. The survival of“rHx” after the second hepatectomy is 32.7% and that of “Px” is39.6% for 5 years. In regard to the survival after the first metasta-sectomy, “rHx” and “Px” have better prognosis than overallpatients (43.7, 36.4 %, 57.6, 32.9 % for 5, 10 years, respectively).Five among 10 5-year-survivors with multiple metastases hadundergone repeat surgery.Repeat surgery contributed to improving prognosis, adding the“piling up effect” to the survival.

P-477Gene Expression Analysis of Pancreaticobiliary MaljunctionsUsing cDNA MicroarrayTomoyuki Morita1, Ichikawa Yasushi1, Hitoshi Sekido1, Shinji Togo1,Kenichi Matsuo1, Takashi Ishikawa1, Yasushi Okazaki2, YoshihideHayashizaki3, Hiroshi Shimada1

1Department of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, 2Laboratory for GenomeResearch Group, RIKEN Genomic Science center (GSC), 3Group,RIKEN Genomic Science center (GSC), Japan

Purpose Pancreaticobiliary Maljunction (PBMJ) is recognized as aprecancerous state of biliary ductal system. Carcinogenesis ofPBMJ was reported to relate with abnormality of cancer relatedgenes, however the molecular etiology remains unclear.In these studies, to clarify carcinogenesis related genes of PBMJ,we analyzed gene expression of PBMJ cancerous and non-cancer-ous regions by cDNA microarray.Methods Clinical samples of gallbladder cancerous and non-can-cerous regions were obtained operatively from 6 patients of PBMJcases (2 cases with gallbladder cancer and 4 cases without cancer).As the reference, mixture of normal gallbladder mucosa was used.


Total RNA was extracted from each samples, and after amplifica-tion, mRNA was retrotranscripted and labeled with fluorescentdyes. Labeled cDNA was hybridized to RIKEN human 21Kmicroarrays, and gene expression profile of PBMJ compared withnormal gallbladder evaluated.Results Cluster analyses showed that gene expression at non-can-cerous regions of PBMJ were already closely resembled cancerousregions. Especially, growth factor such as VEGF, FGFR and c-met, and cyclins were up-regulated at cancerous and non-cancer-ous regions. Some onco-supressor genes, such as RB1, APC weredown-regulated at both cancerous and non-cancerous regions. Afew genes such as estrogen receptor and cadherin2, are up-regulat-ed in only PBMJ cases with cancer.Conclusions From the viewpoint of cancer malignancy relatedgene expression, non-cancerous mucosa of PBMJ with and withoutcancer cases, has already malignant potential and extracted clonesare associated with early event of carcinogenesis. A few genes suchas estrogen receptor are associated with progressive carcinogenesis.

P-478Usefulness of Trans-Abdominal-Mediastinal-Approach withDiaphragmatic Incision and Vagotomy for Esophageal Dis-ruption: Simple Closure and Fundic PatchYoshihiro Moriwaki, Mitsugi Sugiyama, Kenichi Yoshida, ShigeruYamagishi, Hiroshi Toyoda, Takayuki Kosuge, Koji Kanaya, KeijiUchidaCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

The prognosis of esophageal disruption long time after the onsetor with pleulitis is still poor. These cases often require aggressivesurgical therapeutic procedure such as continuous-laparotomy-left-anterolateralo-thoracotomy, often resulting in sever complica-tion or hospital death. Recently, we performed trans-abdominal-mediastinal-approach with diaphragmatic full incision, vagotomy,and fundic patch for two cases of esophageal disruption and coulddo all operative procedures easily under a good field of view. Wecould save both cases. In one case with anastomotic leakage, whohad liver cirrhosis and diabetes, continuous high pressure doubleluminal drainage is useful for healing from anastomotic leakageafter simple closure with fundic patch. We concluded that trans-abdominal-mediastinal-approach with diaphragmatic full incision,vagotomy, and fundic patch is useful therapeutic procedure foresophageal disruption long time after the onset or with pleulitis,and we have to prepare unnecessary leakage in cases with severecomplication disturbing wound healing and put proper drains inthe proper places.

P-479How Long Should We Wait for Operation in Patients withSever Acute Pancreatitis?: From the View Point of Retroperi-toneal PaniclitisYoshihiro Moriwaki, Mitsugi Sugiyama, Sinju Arata, Atsushi Hori,Hiroshi Toyoda, Koji Kanaya, Takayuki KosugeCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

OBJECTIVE: Standard treatment strategy for acute pancreatitishas been established in the guideline from some medical societiesin Japan. However, surgical strategy including indication, surgical

procedure, and the timing of the surgery is unclear. The aim ofthis study is to clarify the surgical treatment strategy for acute pan-creatitis, particularly the timing of the operation.PATIENTS AND METHODS: The clinical records of 4 patientswith severe acute pancreatitis who underwent operation were ret-rospectively examined. All cases were in SIRS condition.Intraoperative findings of patients (retroperitoneal inflammation,panicritis, retroperitonitis, and retroperitoneal abscess) were com-pared with the timing of operation (early operation, within 1month after onset of acute pancreatitis, n=2, and delayed operationafter 1 month, n=2).RESULTS: In early operation group, retroperitoneal panicritisand hematoma was necrotizing, melting (like a cream or mud),fragile, and easy bleeding. On the other hand, in delayed operationgroup, retroperitoneal panicritis was dry necrotic, fiblotic, and dis-sectable without bleeding, in spite of intestinal mucosal necrosis,shortening and sclerosis of intestine and mesentery. Operative pro-cedure was easier in delayed operation group than early operationgroup.CONCLUSION: We try to treat patients with severe acute pan-creatitis non-surgically as long as possible, and postpone the tim-ing of the operation as later as possible, at least 1 month after theonset for easy and safe operation.

P-480Two Cases of Lethal Obstructive ColitisYoshihiro Moriwaki, Mitsugi Sugiyama, Toshiro Yamamoto, TakayukiKosuge, Koji Kanaya, Hiroshi ToodaCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

Obstructive colitis is known as a rare complication of colonic can-cer. We recently encountered 2 cases of obstructive colitis withshock.Case 1: 80-year-old woman transferred to our center because ofcolonic obstructive cancer with shock. The patient underwentemergency operation (subtotal colectomy). However, the ileumbecame necrotic and the patient underwent emergency operationagain (subtotal resection of ileum and jejunum, resection of theremnant rectum). General condition of the patient was improved.Case 2: 57-year-old woman was transferred to our center becauseof acute abdomen with shock. Patient showed VT just after arrivalon our center and underwent emergency operation with csrdiopul-monary resuscitation (subtotal colectomy). However, general con-dition of the patient was not improved and the patient died inICU.DISCUSSION AND CONCLUSION:Stenosis due to colonic luminal occupying lesion often results inreversible simple intestinal obstruction, but more seldom results inlethal obstructive colitis. Primary lesion of obstructive colitis iscommon disease. However, obstructive colitis easily results in sep-tic shock. And if patients did not receive early appropriate treat-ment, they will rapidly be in the condition of cardiopulmonaryarrest. Early diagnosis and early aggressive surgery is essential forlethal obstructive colitis.

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P-481Severe Perianal Abscess with Septic ShockYoshihiro Moriwaki, Mitsugi Sugiyama, Toshiro Yamamoto, HiroshiToyoda, Takayuki Kosuge, Noriyuki SuzukiCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

Although perianal abscess is common disease, most of them are innot septic shock. Recently, we encountered patients with severperianal abscess with septic shock. In this report, we try to clarifythe pathophysiology and treatment strategy of this disease.MATERIALS AND METHODS:We examined the clinical records of 5 patients with sever perianalabscess with shock. Primary diseases of these patients were internalhemorrhoid (2), anal foreign body (1), rectal cancer (2). Four ofthem were suffered from diabetes mellitus (1), liver cirrhosis (1),atherosclerosis (1), and thyroidal crisis (1).RESULTS:Two of them, whose abscess derived from internal hemorrhoid,were died from septic shock within 3days after admission. Thesepatients underwent aggressive emergency operation (amputationof the rectum and perianal drainage) without full resuscitation forseptic shock under DIC condition, because we could not adequate-ly resuscitate these patients only by medical treatment. One of thepatients, whose abscess derived from perianal foreign body, under-went perianal drainage on admission, but resulting in retroperi-toneal necrotizing fascitis, and died from multiple organ dysfunc-tion syndrome at 16th postoperative day. Two of them, whoseabscess derived from rectal cancer, underwent resection afterresuscitation for septic shock. They could discharged from hospi-tal.DISCUSSION AND CONCLUSIONS:It is important to adequately resuscitate for septic shock in patientswith severe perianal abscess with septic shock before surgical treat-ment. If we cannot adequately resuscitate before surgical treat-ment, the survival rate is disappointing and life expectancy may bevery poor.

P-482Continuous High Pressure Aspiration with Double LuminalDraining Tube (DLD-CHPA) for Abdominal Abscess andGastrointestinal Anastomotic LeakageYoshihiro Moriwaki, Mitsugi Sugiyama, Kenici Yoshida, ShgigeruYamagishi, Goro Matsuda, Satoshi Hasegawa, Koji Kanaya, HiroshiToyoda, Kosuge Takayuki, Keiji UchidaCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

OBJECTIVE:In intraabdominal abscess and leakage of intestinal contents, onlyeffective drainage can prevent patients from MODS and abdomi-nal sepsis. We have preferred double luminal drain with continu-ous high pressure aspiration method (DLD-CHPA) in patientswith these conditions. The aim of this procedure is to clarify theboth effect of DLD-CHPA by clinical experience.MATERIALS AND METHODS:DLD-CHPA was performed in 27 patients. The effect of DLD-CHPA was examined before and after CHPA. The structure ofDLD is same as that of aspiration device used during surgerywhich consists of outer tube with multiple pore and inner tube

directly connected with high pressure aspirating central vacuumsystem.RESULTSMean grade of discharge soaking in gauze, a wash recovered inintermittent lavage, local inflammation of skin surrounding drain(DLD) improved after DLD-CHPA. Mean volume of dischargefrom wound and drain other than DLD was depressed after DLD-CHPA. The sum of volume of discharge and aspirated materialafter DLD-CHPA is smaller than before DLD-CHPA. The fre-quency of dressing change including daily routine procedure wasdecreased. In all cases, we could perform definitive surgery withoutworsening of local inflammation, especially inflammation of skinaround drain, even with continuous leakage of intestinal juice orbile. There was no complication with DLD-CHPACONCLUSION:DLD-CHPA is useful for managing abdominal sepsis by drainingmucinous purulent fluid effectively, which can prevent worseningof local condition of localized abscess and anastomotic leakageuntil definitive surgery with continuous leakage of intestinal juice.

P-483Seal and Continuous High Pressure Aspiration for OpenAbdomen with Intestinal Edema due to Sever Peritonitis andIntraperitoneal and Retroperitoneal Massive BleedingYoshihiro Moriwaki, Mitsugi Sugiyama, Hiroshi Toyoda, KojiKanaya, Takayuki Kosuge, Noriyuki SuzukiCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

OBJECTIVE:Abdominal Compartment Syndrome (ACS) is known as lethalcomplication with sever peritonitis or intra- and retro-peritonealmassive bleeding. In this condition, we cannot close abdominalwound (open abdomen) because of intestinal and retroperitonealbulky edema. Exudate and blood is too massive to be completelyabsorbed by dressing gauze. Spilled exudate and blood fromabdominal open wound and dressing gauze easily causes contami-nation for environment. We control these exudate and bleeding by“seal and continuous high pressure aspiration method (S-CHPA)”.The aim of this study is to clarify the usefulness of SCHPA.PATIENTS AND METHODS:Procedure of S-CHPA is following; sump tube wrapped in gauzewas inserted in abdominal open wound apart from the wound, andthe wound was sealed by surgical drape. We examined the volumeof exudate and bleeding from S-CHPA drain, the number of dress-ing change, and complication due to S-CHPA or open abdomen in7 patients with ACS.RESULTSThe volume of exudate and bleeding was completely aspirated byS-CHPA drain. We could accurately and easily measure the vol-ume of exudate and blood without contamination for environment.There was no complication.CONCLUSION:S-CHPA is useful procedure for open abdomen patients to preventcontamination for environment.


P-484Open Wound Drainage for Sever Peritonitis with Uncontrol-lable Gastrointestinal PerforationYoshihiro Moriwaki, Mitsugi Sugiyama, Hiroshi Toyoda, KojiKanaya, Takayuki Kosuge, Noriyuki SuzukiCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

OBJECTIVES:The aim of this study is to clarify the merit and demerit of openwound drainage (OWD) method for severe peritonitis with uncon-trollable gastrointestinal necrosis or perforation.PATIENTS AND METHODS:The clinical records of 4 patients of severe peritonitis with uncon-trollable gastrointestinal necrosis and perforation were retrospec-tively reviewed. Primary diseases of these patients were intraperi-toneal abscess in post-subtotal colectomy, severe acute pancreati-tis, non-occlusive mesenteric infarction, traumatic pancreatitis. Wecould not resect of necrotic or perforated segment of intestine, andwe could not exteriolization of necrotic or perforated intestine asenterostomy because of shortening and sclerosis of mesentery andintestine. We performed at first peritoneal lavage and drainagewithout primary closure of the abdominal wound, then intermit-tent peritoneal lavage and of gastrointestinal perforation repair ortubing as tube enterostomy 2 or 3 times a day in the ICU. Indelayed phase, we patched the abdominal wall to the perforatedportion and performed enterostomyRESULTS:One of these patients (NOMI) was died of multiple organ dysfunc-tion syndrome (MODS), and the other 3 patients was improved. Inthese 3 patients, leakage of intestinal juice and peritonitis could becontrolled, and open wound could be closed.DISCUSSION AND CONCLUSION:We think OWD is useful method for management of sever peri-tonitis with uncontrollable gastrointestinal necrosis or perforation.

P-485Importance of Duodenal Luminal Decompression in Trau-matic Duodenal InjuryYoshihiro Moriwaki, Mitsugi Sugiyama, Kenichi Yoshida, ShgigeruYamagishi, Koji Kanaya, Hiroshi Toyoda, Takayuki KosugeCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

In the surgery for traumatic duodenal injury distal to second por-tion, the luminal decompression is important. We demonstratedour method of duodenal luminal decompression drainage and itseffects.METHODSDuodenal luminal decompression tube (DDT) was normogradelyor directly inserted into the second portion. The double luminaldraining tube and high pressure aspiration system was performedfor the minor leakage. DDTs were inserted normogradely throughthe stomach and retrogradely through the jejunostomy and duode-nojejunostomy. Normograde insertion of DDT is thought trecom-mended, and the early correction of the location of DDT shouldbe avoided. The double luminal draining tube and high pressureaspiration system is suitable for the drainage of postoperative leak-age of duodenal juice.CONCLUSION:

It is important for preventing lethal complication of the traumaticduodenal injury to insert the DDT in aprepriate portion andthrough the apropriate route.

P-486Therapeutic Strategy for Misingestion of an Large Sized Arti-ficial ToothYoshihiro Moriwaki, Mitsugi Sugiyama, Satoshi Hasegawa, YoshidaKenichi, Shigeru Yamagishi, Koji Kanaya, Hiroshi Toyoda, TakayukiKosuge, Keiji UchidaCritical Care and Emergency Center, Yokohama City UniversityMedical Center, Japan

BACKGROUND:We often encounter cases with misingestion of large artificial teethwith sharp clasps, which often stick into the esophageal wall, andwe can hardly remove it. The aim of this study is to clarify thestrategy for removal of the large artificial teeth with clasps.METHODS:The clinical records of 5 patients with misingestion of the largeartificial teeth with clasps, which we could not remove by simpletraction, endoscope, balloon catheter, were reviewed. We exam-ined that 1) removing process in cases who did not underwentesophagectomy, 2) endoscopic findings after removal in thesecases, and 3) macroscopic findings of resected esophagus in caseswho underwent esophagectomy.PROCEDURE AND RESULTS: We removed them by directgrasp using esophagoscope under general anesthesia, by directgrasp using forceps under synchronous direct manipulation of theesophagus exposed by oblique cervical incision, by esopagotomy inthe neck, by esophagectomy under thoracotomy, and by gastroto-my after endoscopic pushing. In cases who did not underwent tho-racotomy and gastrotomy, the artificial teeth were removed afterhorizontal rotation, because these artificial teeth with sharp claspoften sticked into the esophageal wall. Endoscopic findings afterremoval and resected esophagus revealed ulceration or lasseration. CONCLUSIONS: The large artificial tooth with sharp clasp iseasily sticked into the esophagus. Rotation of the artificial teeth isuseful procedure for removing it. Traction and removing by forceeasily results in the esophageal rupture. After removing it, we mustevaluate the injury if esophageal mucosa by endoscope.

P-487The Efficacy of Protease Inhibitor(PI) in Patients WhoUnderwent R0 Resection of Gastric CancerHitoshi Murakami, Akira Tuburaya, Tomohiko Osaragi, TatsuyaYoshida, Takaki Yoshikawa, Osamu Kobayashi, Motonori Sairenji,Hisahiko MotohashiDepartment of Gastrointestinal Surgery, Kanagawa Cancer Cen-ter, Japan

Background: Among the metastases from gastric cancer, peri-toneum is the most frequent site of treatment failure. As manyproteases involove in the process of dissemination, proteaseinhibitors (PIs) were tested and their efficacy was confirmed in sev-eral animal models. We investigated the clinical effects of PIs inpatients who underwent R0 gastrectomy. Methods: From 1995 to1996 patients with T2 or greater and M0 gastric cancer were pre-operatively randomized to receive PIs (PIG) or not (CTR).Patients were stratified by the depth of the tumor and macroscopic

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type. Ulinastatin was administered d.i.v. 10,000U/hr intraopera-tively, 10,000U in the peritoneal cavity at closure, and100,000U/day postoperatively for 4 days, followed by p.o. camo-stat mesilate for 4 weeks. Morbidity and survival were comparedbetween the groups. Results: A total of 31 patients were enrolledin this study(16 CTR and 15 PIG). Between CTR and PIG, dura-tion of operation, blood loss, and hospital stay were not different.No hospital death and PI-related morbidity were observed. Patho-logical findings were not different between the groups except forthe depth of the tumor; more T3 tumor in CTR. Most frequentsite of the recurrence in CTR was peritoneum in 5 (36%) pts,while that in PIG was lung in 1 (8%) pt (p=0.1). Five-year survivalfor CTR and PIG were 56% and 71%, respectively (p=0.5). Con-clusions: Perioperative PI was administered safely, however sur-vival benefit was not apparent. Trend for less relapse at peri-toneum for PI treated group may prompt further investigation in alarge trial.

P-488Local Resection for Early Gastric Cancer with Sentinel NodeBiopsyHitoshi Murakami, Akira Tuburaya, Tomohiko Osaragi, TatsuyaYoshida, Takaki Yoshikawa, Osamu Kobayashi, Motonori Sairenji,Hisahiko MotohashiDepartment of Gastrointestinal Surgery, Kanagawa Cancer Cen-ter, Japan

Background: In breast cancer and melanoma, Sentinel NodeBiopsy (SNB) can alter the extent of surgery and may have a prog-nostic value. We analyzed solitary lymph node metastases in local-ized gastric cancer retrospectively, and showed that SNB could beapplicable for gastric cancer. Then, we tested SNB with 99m Tc-Tin colloid in gastrectomy cases, and defined application for localresection with SNB. This study evaluated the feasibility of localresection with SNB. Method: Eligibility criteria were as follows;adenocarcinoma, clinical T1N0 (CT and EUS were performed),less than 3cm in diameter, and written IC. One day before surgery,resection line was clipped around tumor and 99m Tc-Tin colloidwas injected to submucosa endoscopically. During the operation,after local resection of tumor with guide of the clips, SNs detectedby a gamma probe detector were picked up for pathologic exami-nation in frozen sections. Lymph node basin included SNs weredissected anatomically. If SNs were positive, conventional resec-tion was performed. Results: Local resection with SNB was per-formed in 48 pts. SNs were successfully detected in 47 pts (97.9%)with an average of 2.4 per pts. In 12pts (18.5%), SNs were locatedin N2 station. In 5pts operation was converted to gastrectomy dueto positive SNs (n=4), or T2 tumors (n=1). As adverse event, 2ptshad transient post-operative stasis. One pt had bleeding from rem-nant stomach 2years after the operation. Two pts developedchronological multiple cancer, and underwent curative total gas-trectomy. Conclusion: Local resection for early gastric cancermaybe feasible with an aid of SNB.

P-489Video-assisted Thoracoscopic Esophagectomy for AdvancedEsophageal CancerMasahiko Murakami, Kusano Mitsuo, Katoh Takashi, Otsuka Kouji,Gotoh SatoruGeneral & Gastroenterological Surgery, Showa University Schoolof Medicine, Japan

Objective: To evaluate short-term survival with thoracoscopicesophagectomy associated enlarged lymphadenectomy foradvanced esophageal cancer.Design: Case series involving 110 cases with follow-up of 6 monthsover.Patients: Between November 1997 and December 2003, 110patients underwent thoracoscopic esophagectomy associatedenlarged lymphadenectomy for advanced esophageal cancer.. 16patients had been previously submitted to irradiation (total 30gray) and neoajuvant chemotherapy (1 cycle of cisplatinum andfluorouracil. 4 patients had been neoajuvant chemotherapy afteroperation. Indications were squamous cell carcinoma in all.Technique: In a left lateral decubitus position, 5 thoraco-ports (15mm) were introduced. The 30-degree video scope was introduced.The azygous vein and right bronchial artery were divided in mostcases. The esophagus was mobilized down to the diaphragmaticreflection. Periesophageal lymph nodes and carinal and bronchiallymph nodes were removed. The esophageal reconstruction wasmade using gastric role through a retrosternal route.Outcome Measures: recurrence rate and survivalConclusions: Short-term survival was satisfied in this series.Because long-term survival was unknown yet, thoracoscopicesophagectomy may be a benefit procedure for esophageal cancerby skilled endoscopic surgeon.

P-490Levels of Serum Interleukin-12 in Patients with Gastric Can-cerSaburo Murakami, Yoshitaka Tsuji, Katsuhiko Okubo, Hideto Sakata,Taiju Hashimoto, Masataka Kikuchi, Takehiro Takahashi, SetsuoHamada, Renzo HirayamaDepartment of General Surgery, Saitama Medical School, Japan

(Purpose) The aim of the present study is to investigate the rela-tionships between serum levels of IL-12 and clinicopathologicalfactors in the patients with gastric cancer, for evaluating theimmunological status preoperatively. (Methods) One hundred andtwenty seven (82 men and 45 women) were included in this study.Levels of serum IL-12 were measured by a sandwich enzyme-linked immunosorbent assay (ELISA) using Human IL-12 +p40Immunoassay Kit. (Results) The levels of serum IL-12 in thepatients with gastric cancer were significantly higher than those ofnormal controls (p<0.05). In disease stage, and gross appearance,there were no significant differences among each group. Regardingtumor depth, the levels of serum IL-12 in patients of T4 were sig-nificantly lower than those in patients of T1, T2, and T3 (p<0.01).There were statistically no differences of serum IL-12 levelsbetween the patients who were positive or negative for lymphnode, liver, or peritoneal metastasis. On the other hand, The levelsof serum IL-12 in patients with distant metastasis were significant-ly lower than those in patients without distant metastasis (p<0.02).When the levels of serum IL-12 in patients with gastric cancer


were compared in each group classified by histopathological find-ings, there were no significant differences between each group.(Conclusions) The levels of serum IL-12 in far-advanced patientswith gastric cancer were significantly lower than those in the otherpatients. In these patients, their macrophages would be hectic andunable to produce the sufficient amount of IL-12.

P-491A Study on Cases of Bleeding Gastroduodenal Ulcer ThatUnderwent Surgery, Transferring from Endoscopic Hemo-stasisSaburo Murakami, Hideto Sakata, Yoshitaka Tsuji, Katsuhiko Okubo,Kennichi Suto, Yutaka Yoshida, Kairyu Kaai, Setsuo Hamada, RenzoHirayamaDepartment of General Surgery, Saitama Medical School, Japan

(Purpose) According to the progress of endoscopic procedures, thenumber of cases of bleeding gastroduodenal ulcer that need theoperation has been recently decreasing. Nevertheless, there arestill a few cases that are required for surgery. We investigated thecharacteristics of these cases and discussed the strategy. (Subjects)Fifty three cases, that were admitted to our department for bleed-ing gastroduodenal ulcer, are enrolled in this study. (Results) 38 of56 cases (67.9%) underwent the procedure of endoscopic hemosta-sis such as HSE or ethanol injection, clipping, and APC. 5 of these38 cases (13.2%) were needed for operations because of continu-ous bleeding from ulcer. These five patients consisted of 3 gastriculcer and 2 duodenal ulcer. Distal gastrectomy were performed for4 cases, and simple suture of bleeding points under gastrotomy 1case. The continuous lesions induced by too many repetitive endo-scopic procedures were recognized in two cases (wide submucosalhematoma in the stomach, and severe edema in the bulbus of duo-denum), resulting in perfomed distal gastrectomy instead of simpleclosure. (Conclusions) The surgical procedure for hemostasis isenough to bleeding gastroduodenal ulcer, as the surgical signifi-cance for peptic ulcer is almost none because of the progress of H2bockers and proton pump inhibitors. However, the continuoussome lesions by too many repetitive endoscopic procedure ofhemostasis sometimes disturb the simple closure, resulting in per-forming the gastrectomy. Under this concept, too many repetitiveendoscopic procedure of hemostasis should be avoided.

P-492Resection of Portal Vein During Pancreatoduodenectomy forCancer of the Head of the PancreasKatsutoshi Murase, Toyoo Nitta, Tetsuya Kondo, Takuya Sugimoto,Yutaka OzekiSurgery, Shizuoka Medical Center, Japan

Purpose: Cancer of the head of the pancreas (Phc) frequentlyinvades portal vein (PV), it becomes necessary that resection of PV(RPV) for curative resection of Phc. We evaluated the effect ofRPV during pancreatoduodenectomy (PD) for Phc.Methods: Weretrospectively reviewed the cases of 25 patients with Phc whounderwent PD. Fifteen patients were underwent PD with RPV(group A), and 10 patients were underwent PD without PVR(group B). We compared treatment outcome between two groups.Results: The operating time in group A was significantly longerthan that in group B (p=0.049). There were no significant differ-ences in bleeding, early complication, and post-operative hospital

stay. There was one case of in-hospital mortality in group A. Therates of curative resection in groups A and B were 67% and 80%,respectively, and there was no significant difference between twogroups. One-year survival rates in groups A and B were 42 and80%, respectively. And 2-years survival rates in groups A and Bwere 42 and 23%, respectively. There was no significant differencein survival rates between two groups. Median survival times ingroups A and B were 287 and 516 days, respectively.Conclusion: Treatment outcome of PD with RPV was equivalentof that of without RPV. There was no significant difference in sur-vival rates between PD with RPV and without RPV. These resultssuggest that RPV during PD for Phc improve prognosis of it.

P-493Screening of the New Sensibility and Resistant PredictionGene for 5FU Using Human Colorectal Cancer Cell LineYukio Murata1, Kenitch Shiiba1, Takayuki Mizoi1, Kou Miura1,Terutada Kobayashi1, Yasuhiro Hasegawa1, Nobuki Yazaki1, NaokiTanaka1, Shinobu Onuma1, Hiroyuki Sasaki1, Kazuhiro Takami1,Ieao Sasaki1, Wataru Fujibuchi2

1Gastroenterological Surgery, Tohoku University, Japan, 2NationalInstitute of Advanced Industrial Science and Technology/Compu-tational Biology Research Center, Japan

(background) 5FU taken in organism is modified by various fac-tors, Screening them; for elucidation of sensibility or resistancemechanism of anticancer drug, in its turn, it seems that an effectprediction or a side effect prediction can contribute to a tailormaid treatment.(aim) We were aimed at screening sensibility and resistant predic-tion gene for 5FU using human colorectal cancer cell line bycDNA microarray.(material and methods) We measured IC 50 for 5FU in MTTasseyabout 23 human colorectal cancer cell line. Next, we classed 23 celllines to three groups, high IC50, middle IC50 and low IC50. Fur-thermore, we performed cDNA microarray about a gene of 20Kusing CodeLink Expression Bioarray System in 23 cell lines. Inaddition, we obtained resistance cell of DLD1 and performedcDNA array likewise and compared a resistant cell with an old cell.(results and conclusions) We were able to extract the highexpressed gene in a group of high IC 50 as a natural resistancegene and the high expressed gene in a group of low IC 50 as a sen-sibility gene. In addition, we were able to identify the highexpressed gene in a resistant cell line as an acquired resistancegene. We were able to screen the new sensibility and resistant pre-diction gene for 5FU using human colorectal cancer cell line bycDNA microarray.

P-494Remnant Gastric Carcinoma after Proximal Gastrectomy: ACase Report and a Review of LiteratureKazuhito Nabeshima, Kyouji Ogoshi, Yuuichi Okamoto, Mari Morita,Kenji Nakamura, Toshihide Imaizumi, Hiroyasu MakuuchiDepartment of Surgery, Tokai University, Japan

Remnant gastric carcinoma after proximal gastrectomy is rare. Wehad performed proximal gastrectomy for upper and middle thirdgastric carcinoma.This report presents a case of carcinoma in the distal gastric rem-nant after proximal gastrectomy.

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The patient was a 78-year-old man who underwent proximal gas-trectomy with jejunal pouch interposition reconstruction for a gas-tric carcinoma 6 years ago. In this time, histological findings werepT1 and moderately differentiated adenocarcinoma and both oraland anal surgical margin is free of the carcinoma. In July 2003,endoscopic examination revealed Type 1 carcinoma at the anasto-mosis of the remnant stomach. An endoscopic biopsy specimenwas histologically regarded as carcinoma. No distant metastasiswas detected. Then, partial gastrectomy was performed. Histologi-cal findings of resected material were moderately differentiatedtubular adenocarcinoma, which infiltrated submucosa(pT1, pN0).We report this case with references to the literature.

P-495Helicobacter Pylori Induces Mono-ADP-Ribosylation inHuman Gastric CarcinomaYoshihiro Nabeya1, Takashi Akai1, Kinnosuke Yahiro2, AkioSakamoto3, Naoko Morinaga1, Masahito Inoue1, Shin-Ichi Miyazaki1,Masatoshi Noda2, Takenori Ochiai1

1Department of Academic Surgery, 2Department of MolecularInfectiology, Chiba University Graduate School of Medicine,3Department of Surgery, Narutou General Hospital, Japan

Purpose: Adenosine 5’- diphosphate (ADP)-ribosylation, whichtransfers ADP-ribose from nicotinamide adenine dinucleotide(NAD) to an acceptor protein, is an important modification of cel-lular proteins. Several bacterial toxins have been known to possessmono-ADP-ribosyltransferase (mADPRT) activity to transfer onemoiety of ADP-ribose as a possible pathogenic factor. Alterationof mono-ADP-ribosylation in human gastric carcinoma and itsassociation with H. pylori infection is of interest, but has not yetbeen explored. The aim of this study was to examine whether H.pylori may induce mono-ADP-ribosylation in human gastricepithelial proteins. Methods: Specimens from gastric adenocarci-noma and adjacent non-tumorous mucosa were obtained from sur-gically removed stomachs of 5 patients with gastric adenocarcino-ma. Each tissue was homogenized and fractioned into cytosol andmembrane before subjecting to ADP-ribosylation assay with[adenylate-32P]NAD with or without H. pylori (OMH4) extract.Results: Incubation of membranous fractions from all 5 gastricadenocarcinomas with H. pylori extract in ADP-ribosylation assaycaused notable radiolabelings of 55-kDa and 45-kDa proteins,which were not found without H. pylori extract. However, theseradiolabelings induced by H. pylori extract were hardly found in themembranous fractions from the adjacent non-tumorous mucosae,and were not found in any cytosolic fraction examined. Inhibitionassays revealed that the radiolabelings were caused by enzymaticmono-ADP-ribosylation. Conclusions: We found that H. pylorihad the mADPRT activity to modify 55- and 45-kDa membranousproteins of human gastric adenocarcinoma, while its role on thecarcinogenesis or development of gastric carcinoma has yet to beelucidated.

P-496Long-Term Survival after Resection of Malignant Melanomaof the Esophagus: A Case ReportYoshihiro Nabeya, Inoue Masahito, Okazumi Shin-Ichi, MatsubaraHisahiro, Shimada Hideaki, Ochiai TakenoriDepartment of Academic Surgery, Chiba University GraduateSchool of Medicine, Japan

We report the case of a 62-year-old man who has survived foralmost 5 years after resection of malignant melanoma of theesophagus. The patient, without any complaint, was found to havea tumor in the lower esophagus by a follow-up endoscopy after theprevious polypectomy of gastric polyp, and he was admitted to ourDepartment in July 1999. The tumor, which top was black, wasdiagnosed as a submucosal tumor, and the biopsy was interpretedas malignant melanoma. However, neither any other melanomalesion nor metastasis was found. Subtotal esophagectomy with 3-field lymph node dissection was performed on August 11, 1999. Apathologic analysis demonstrated a proliferation of small spindle-shaped melanoma cells and melanocytosis in the tumor (40 x 20 x18 mm in size) limited to the submucosa, and no metastasis(pT1N0M0: pTNM stage I, ly1, v1). Based on the positivity oftumor for HMB-45 antimelanoma antibody as well as the micro-scopic findings, the esophageal tumor was finally diagnosed asmalignant melanoma. However, the primary nature could notdefinitively be confirmed, since the presence of either junctionalactivity or concomitant benign melanocytosis was unclear. Thepatient underwent postoperative chemotherapy with DTIC,CDDP, ACNU and TAM before discharge, and remains alivewithout recurrence as of June 2004. Although not pathologicallyconfirmed, the present case appears to be an uncommon primarymalignant melanoma of the esophagus because no other lesion hasbeen found so far. Surgery should be considered for the disease,while our patient may be a rare long-survivor.

P-497Beneficial Effect of Hyperbaric Oxygen Therapy on LiverRegeneration after 90% Hepatectomy in RatsKotaro Nagamine1, Toru Kubota1, Shinji Togo1, Youji Nagashima2,Motohiko Mori3, Hiroshi Shimada1

1Department of Gastroenterological Surgery, 2Department of Mol-ecular Pathology and Oncology, Yokohama City University Grad-uate School of Medicine, 3Japan Marine Science and TechnologyCenter, Japan

Background/Aims: Hyperbaric oxygen therapy ( HBOT ) hasbeen reported to augment oxygen delivery to ischemic tissues andimprove the liver dysfunction in clinical cases. HBOT was per-formed after 90% hepatectomy in rats to determine its effect onthe regeneration of remnant liver. Methods: After 90% hepatecto-my was performed in 8-week-old male Wistar rats, the animalswere subdivided into a HBOT (-2 atm abs., 80%O2, 1 hr/day, 3days- ) group and a non-HBOT group. Members of both groupswere sacrificed, usually every 4hrs until a maximum of 50hr afterhepatectomy, and the liver regeneration rate, the proportion ofPCNA positive cells and the ATP volume in the remnant tissueswere examined. Results: In the HBOT group, the liver regenera-tion rate at 36 hr and 50 hr after operation and the proportion ofPCNA positive cells at 8 hr was significantly increased comparedwith the non-HBOT group. The ATP volume in the remnant liv-


ers in the HBOT group was also significantly increased at 12 hr.Conclusion: HBOT augmented liver regeneration after hepatecto-my by stabilization of energy metabolism induced by oxygen deliv-ery in rats.

P-498Liver Surgery Followed by Intraarterial Infusion of 5-Fluo-rouracil and Subcutaneous Interferon-Alpha for AdvancedHepatocellular Carcinoma with Tumor Thrombi in theMajor Portal BranchesHiroaki Nagano, Masato Sakon, Motoi Kondo, Tameyoshi Yamamoto,Hideo Ota, Masato Nakamura, Hiroshi Wada, Shinichi Yoshioka,Bazarragcha Damdinsuren, Shigeru Marubashi, Atsushi Miyamoto,Keizo Dono, Koji Umeshita, Shoji Nakamori, Morito Monden Surgery and Clinical Oncology, Graduate School of Medicine,Osaka University, Japan

Background. The prognosis of hepatocellular carcinoma (HCC)invading the major branches of the portal vein (Vp3) is extremelypoor. Recently, we reported the efficacy of combination therapywith subcutaneous interferon (IFN)-alpha and intra-arterial 5-FUfor intractable HCC with Vp3. In this study, this therapy wasapplied for resectable advanced HCC (Vp3) as a postoperativeadjuvant. Methods. Patients with HCC and tumor thrombi eitherin the major or first branch of portal vein were included (n=30).Fifteen consecutive patients with HCC and Vp3 or Vp4 weretreated with at least 3 cycles of a combination therapy consisting ofcontinuous arterial infusion of 5-FU (300 mg/mm2/day, 5days/week, for the initial 2 weeks) and subcutaneous injection ofIFN (5 MIU, 3 times/week, 4 weeks) as a postoperative adjuvanttherapy following hepatic resection. Another 15 patients whounderwent hepatic resection with no IFN/5FU chemotherapyacted as controls. Results. The results were as follows in theIFN/5FU adjuvant treatment group; disease-free survival (n=12, 6-60 months), survival with recurrence (n=1, 55 months), cancerdeath (n=1, 18 months), death from other causes but no recurrence(n=1, 22 months). The 1-year survival rate was 100% in patientstreated with IFN/5-FU, and 41% in those without IFN/5-FU his-torical controls (n=15). There was a significant difference in dis-ease-free and overall survival rates between the two groups(p=0.0033 and 0.0031). Conclusions. Combination therapy withsubcutaneous IFN and intra-arterial perfusion of 5-FU seems to bea promising postoperative adjuvant treatment modality forresectable HCC with Vp3.

P-499Clinical Analysis of Esophageal Cancerassociated with OtherPrimary MalignanciesTakeshi Nagano, Susumu Sueyoshi, Toshiaki Tanaka, Yuichi Tanaka,Hideaki Yamana, Hiromasa Fujita, Kazuo ShirouzuSurgery, Kurume University School of Medicine, Japan

Background: The incidence of primary esophageal cancer compli-cated by malignancies in other organs has increased in Japan. Thisstudy aims to elucidate the incidence and the prognosis ofesophageal cancer patients with other primary malignancies.Methods: We analysis 241cases(23%) with synchronous ormetachronous other primary malignancies in 1,050 cases ofesophageal squamous cellcarcinoma treated at our institution from1982 to 2001. Results: The incidence of combined primary cancers

increased 12%, 19%, 26%, and 31% at 5-year intervals. The siteof combined malignancies was the head and neck in 40%, thestomach in 29%, the lung in 9%, the liver in 6%, the colon in 5%.The incidence of combined head and neck cancer from 1982 to1991 was 33% and that from 1992 to 2001 was increased 42%.The incidence of combined the gastric cancer(29%) remainedunchanged. The incidence of combined the other malignancieswas decreased. Death related to the other primary malignanciesoccurred in 5.5% of all patients. Death not related to theesophageal cancer was due to malignancies in the head andneck(40%), lung(17%), liver(16%), and stomach(9%). Althoughthe incidence of multiple primary cancer has increased, the inci-dence of death related to the other primary malignanciesdecreased each 5-year. This may be due to measures taken to findother primary malignancies in patients with esophageal cancer.Conclusions: It is important to follow up patients focusing on theincidence of synchronous or metechronous malignancies as well asrecurrence of esophageal cancer.

P-500Risk Factors and Management of Bile Leakage after HepaticResectionYasuhiko Nagano1, Shinji Togo2, Kenichi Matsuo1, Michio Ueda2,Kazuhisa Takeda2, Mitsutaka Sugita2, Kuniya Tanaka2, ToruKubota2, Itaru Endo2, Hitoshi Sekido2, Toshio Imada1, Hiroshi Shima-da2

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Yokohama City University Graduate School of Medicine,Gastroenterological Surgery, Japan

Objective: To identify the perioperative risk factors for postopera-tive bile leakage after hepatic resection, and to propose a treatmentstrategy for bile leakage. Patients and methods: Between 1992 and2000, 313 hepatic resections without choledocojejunal anastomosiswere performed at our institute. Risk factors related to bile leakagewere identified with univariate analysis, and strategies were evalu-ated in relation to the findings of postoperative fistulogram.Results: Postoperative bile leakage developed in 17 patients(5.4%). Univariate analysis identified high risk factors as advancedage, a wide surface area of incision (bile leakage group vs. non-bileleakage group: 102.1 cm2 vs. 66.4 cm2, p<0.05) and exposure ofGlisson’s sheath at the cut surface (ex. central bisegmentectomy,S4, S8 subsegmentectomy). Groupings of patients by postoperativefistulogram showed that those patients with involvement of theproximal bile duct were slower to heal than those with no demon-strable bile duct involvement. The one patient whose fistulogramdemonstrated peripheral bile duct involvement had uncontrollableleaking and required reoperation. Conclusions: Hepatectomieswith a wide surface area and/or those that expose the major Glis-son’s sheath present serious risk factors for bile leakage. When fis-tulogram shows proximal bile duct involvement, ENBD is neces-sary; when fistulogram shows peripheral bile duct involvement,reoperation is needed.

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P-501Local Ablation Therapy for Metastatic Liver Tumors fromColorectal CancersYasuhiko Nagano1, Togo Shinji2, Matsuo Kenichi1, Michio Uedo2,Kazuhisa Takeda2, Mitsutaka Sugita2, Tanaka Kuniya2, ToruKubota2, Itaru Endo2, Hitoshi Sekido2, Toshio Imada1, ShimadaHiroshi2

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Yokohama City University Graduate School of Medicine,Gastroenterological Surgery, Japan

Aim: The aim of this study was to evaluate the effectiveness oflocal ablation therapy for hepatic metastases from colorectal carci-nomaMethods: Fifteen patients with a total of 21 liver metastasesfrom colorectal carcinoma were treated with local ablation therapybetween January 1992 and March 2003 RFA was performed percu-taneously under ultrasound guidance using single 18-gauge inter-nally cooled electrodes. MCT was performed under laparotomyfor a period of 60 seconds at an output of 70 Watts per one ses-sion. The total session was 1-15 times. Results: The reason forablation therapy was as followa; nonresectable bilober multipletumor: 13 lesions, refuse resection:4 lesions, respiratory insuffi-ciency: 4 lesions. The mean age was 69 (range,48-83) years, themean observational duration was 8.33 (range, 0.93-18.5) months.The mean maximal diameter was 1.7( range 0.3-4.0) cm. MCT wasperformed in 16 lesions, and RFA was performed in 5lesions .Fourlesions (19 %) developed local recurrence, however the lesion lessthan 2cm in diameter did not appeared local recurrence. Majormorbidity occurred in 1 lesion (4.8%), hepatic abscess was found.Combination therapy of hepatectomy and ablation for bilobermultiple tumor were performed in 7 patients. Conclusion Localablation therapy is a safe and effective treatment for small metasta-tic liver tumor less than 2cm in diameter. When H3 liver metas-tases were not suitable for surgery alone, there were possibly treat-ed by a combination with resection of large tumors and ablation ofsmaller lesions in the opposite lobe.

P-502Right Hepatectomy or Posterior Sectionectomy with Belghi-ti’s Liver Hanging Maneuver -Anterior Approach withoutMobilizing the Right Liver-Ikuo Nagashima, Tadahiro Takada, Hideki Yasuda, Hodaka Amano,Fumihiko Miura, Takahiro Isaka, Naoyuki Toyota, Maki Sugimoto,Kenji Takagi, Kenichiro Kato, Kota OkinagaDepartment of Surgery, Teikyo University School of Medicine,Japan

We performed right hepatectomy as well as posterior sectionecto-my with Belghiti’s liver hanging maneuver and dissection of thewhole Glisson’s pedicle for hepatic malignancy, by anteriorapproach without mobilization of the right liver.·The abdomen was opened by J-shaped skin incision.·Belghiti’s liver hanging maneuver.·Taping of the whole right, anterior, and posterior Glisson’s pedi-cle at the hilus.·Dividing of the whole anterior and/or posterior Glisson’s pedi-cle(s). ·Transecting the liver along with the middle or posterior hepaticvein, until the anterior surface of the inferior vena cava.·Dividing of the some short hepatic veins and the right hepatic

vein at right side of the inferior vena cava.·The specimen was taken out after dissected from the diaphragm aswell as the right adrenal gland.This procedure dose not need the mobilization of the right liver,and seems to be useful in respect of avoiding of hepatic parenchy-mal damage and shortening of operating time.

P-503In Situ Cooling of Pancreata from Non-Heart-Beating DonorPrior to Procurement for Islet Isolation and TransplantationHideo Nagata1, Shinichi Matsumoto1, Teru Okitsu1, Yasuhiro Iwana-ga1, Hirofumi Noguchi1, Yukihide Yonekawa1, Syuichi Miyakawa2,Kiyotaka Hoshinaga2, Koichi Tanaka1

1Department of Transplantation and Immunology, Kyoto Univer-sity, 2Fujita Health University, Japan

For instance, most kidneys are transplanted from non-heart-beat-ing donors in Japan. These facts are particularly important forJapan in which country it is not allowed to isolate islets from heart-beating brain death donor pancreata. In such situations, warmischemia is critical. To shorten warm ischemic time, we have donein situ cooling of abdominal organs prior to donor pancreatecto-my. PATIENTS AND METHOD We procured three pancreatathrough Japan Organ Transplantation Network in Mid-Japanregion on January 17th, April 7th and April 17th in 2004. Afterconfirming brain death status, we inserted catheter for rapid cool-ing of pancreas. IN SITU COOLING To prevent warm ischemicdamage to donor pancreas, we used an in situ regional organ cool-ing system. Before cardiac arrest, a double balloon catheter wasplaced above the celiac axis and below the renal artery in the aortavia femoral artery, which was modified the time of nephrectomyfrom a non-heart-beating cadaveric donor. The venous catheterwas also placed in the vena cava through the femoral vein fordrainage of the perfusate. RESULTS We performed three humanislet isolations using non-heart beating donors with in situ coolingsystem. The islet yields were 324,575 IE, 354,384 IE and104,370IE. We transplanted the islets to a type 1 diabetic patientin one case for the first time in Japan. CONCLUSION In situcooling system enabled us to minimize warm ischemic period andperform islet transplantation for the treatment of type 1 diabetes inJapan for the first time.

P-504Effect of Gelatins on Secreation of Cytokines by MurineFibroblastsHiroshi Nagata1, Takashi Kojima2, Kazuyoshi Suzumura1, TatsuroKoide2, Yoshiaki Inamura3, Toshiaki Nonami1

1Department of Gastroenterological Surgery, Aichi Medical Uni-versity, 2Aichi-Gakuin University, 3Yamaguchi Hospital, Japan

PURPOSE: We have observed that bovine bone gelatin stimulatedmurine peritoneal macrophages to secrete various cytokines and β-chemokines in vitro, e.g., THF-α, IL-12 and IL-6 and KC, MCP-1, RANTES, MIP-1a and MIP-2 (in submission). In the presentstudy, it has been investigated whether the gelatin stimulatesmurine fibroblasts to secrete some cytokines in vitro. METHOD:Murine fibroblast cell lines, TIB-8o and L929 and a murine alveo-lar macrophage cell lline, AMJ2- C8 were incubated with or with-out 15 mg/ml of bovine bone gelatin or 500 ng/ml of LPS at 37°Cfor 24 hours. Supernatants were collected and examined in concen-


trations of various cytokines by means of ELISA kit (BioSourceInternational Inc., CA, USA) RESULT & CONCLUSION: Twomurine fibroblast cell lines (TIB-8o and L929) had common anddifferent characteristics as regards cytokines secretion. Cells ofboth cell lines secreted MCP-1 by themselves but L929 cellssecreted THF-α by itself. Bovine bone gelatin stimulated secre-tion of IL-6, MCP-1, M-CSF and THF-α from L929 cells. Actionon normal fibroblasts by the gelatin should be investigated.

P-505The Effect of Palliative Gastrectomy on QOL and SurvivalYasuhiro Nagata, Akihito Enjoji, Takashi KanematsuDepartment of Trasnplantation and Digestive Surgery, NagasakiUniversity, Japan,

Aim: Palliative surgery for advanced gastric cancer can be done toremove their major complaints, obstruction and/or hemorrhage.However, the significance of palliative gastrectomy remains con-troversial. The aim of this study is to evaluate the effect of pallia-tive gastrectomy on QOL and survival in the patients withadvanced gastric cancer. Methods: From June 1996 to May 2003,28 patients from 442 gastric cancers in our department were notcandidates for curative operations because of following factors, e.g.invasion of adjacent structure, lymphnodes metastasis, liver metas-tasis, distant metastasis, positive cytological study of peritonealwashings, or peritoneal dissemination. This study placed them intothree categories: 10 gastrectomies for reduction, 12 palliative gas-trectomies, and 6 patients without gastrectomy. Patients in eachcategory were evaluated in terms of palliative effects and survival.The survival rate was calculated by Kaplan-Meier method. Results:Among patients undergoing palliative gastrectomies, good controlof symptoms was only achieved in 7 of 12 (58%). However, theserious symptoms had still remained in 5 patients (42%) even afterpalliative surgery. The survival rate of patients with palliative gas-trectomy was significantly worse than other two groups. Conclu-sion: The palliative gastrectomy has less benefit for survival andeven palliative effect.

P-506Detection and Characterization of High Molecular WeightMmp in Urine of Esophageal Cancer PatientsShiro Nagatani, Go Watanabe, Itami Atsushi, Shimada YutakaSurgery and Surgical Basic Science, Kyoto University, Japan

Purpose Matrix metalloproteinases (MMPs) are proteolyticenzymes that play an important role in a variety of normal andpathological processes. Elevated levels of MMPs have been foundin serum or urine of several cancer patients. Recent studies haveshown that 125kDa high molecular weight MMP activities detect-ed in urine of variety cancers including prostate, renal, bladder,and breast cancer. The objective of this study is to identify and val-idate the urinary high molecular weight MMP in esophageal can-cer patients. Methods The urinary 125kDa high molecular weightMMP was detected by substrate gel electropholesis (geratinzymography) in 28 esophageal cancer patients and 20 healthy vol-unteer. Results The urinary 125kDa high molecular weight MMPwas detected in 71.4% of 28 esophageal cancer patients and 15%of 20 healthy volunteers (p=0.0001). The positive rates in 11patients with preoperative status were 54.5%. In addition, 8 of 9patients (88.9%) with esophageal cancer recurrence were detected

125kDa high molecular weight MMP in their urine. ConclusionDetection of the urinary 125kDa high molecular weight MMP,that is a simple and non-invasive method, might be useful in thedevelopment of diagnostic and prognostic cancer tests as well asbeing potential markers of therapeutic efficacy in esophageal can-cer patients.

P-507A Role of Measuring Thickness of the Skin to EvaluateLong Term Effect of Adrenocorticotropic Hormone Thera-py in Patients with Ulcerative ColitisHiroo Naito1, Yuji Funayama2, Kohei Fukushima2, Chikashi Shibata2,Tatsuya Ueno1, Akihiko Hashimoto2, Munenori Nagao2, ShoHaneda2, Kazuhiro Watanabe2, Iwao Saski2, Katsuko Kikuchi3

1Department of Surgery, South Miyagi Medical Center, 2Depart-ment of GI and Colorectal Surgery, 3Department of Dermatology,Tohoku University Hospital, Sendai, Japan

BACKGROUND: However, surgeons have noticed that patientswith ulcerative colitis (UC) treated by long term adrenocor-ticotropic hormone (ACH) had the thinner skin than the otherswithout ACH, no dermatologic parameters are available. AIM:The aim of this study is to elucidate the effect of long term ACHadministration on the thickness of the skin (TS). SUBJECTS: 5controls (NUCG) with colorectal cancer or familial adenomatouspolyposis, and 13 patients with UC (UCG) were studied. NUCGpatients who underwent colectomy had not taken ACH. UCGpatients who underwent subtotal colectomy or total proctocolecto-my had taken ACH compatible to 5.6g of predonisolone. METH-ODS: TS were measured preoperatively in the anterior arm andthe abdominal wall, using the high resolution ultrasound imagingsystem. In selected cases, these measurements were repeated post-operatively. RESULTS: 1) TS of the anterior arm in UCG(888±131µm) was significantly lower than NUCG(1194±188µm).Similar results were obtained in the TS of the abdominal wall.However, there were several cases excluded from this tendency. 2)In patients with high cumulative dose of ACH tended to showlower levels of TS. 3) In UCG, some patients demonstrated timedependent recovery of TS after discontinuing ACH, postopera-tively. CONCLUSION: Our results suggested that patients withUC administered by high cumulative doses of ACH have the thin-ner TS than patients without ACH. These results indicate the pos-sible use of TS as parameter for preoperative evaluation of ACHrelating complications in UC patients.

P-508Resection of Hepatocellular Carcinoma in a Patient withDubin-Johnson SyndromeAya Nakagawa, Kita Junji, Iwasaki Yoshimi, Rokkaku Kyu, NemotoTakehiko, Kubota KeiichiSecond Department of Surgery, Dokkyo University School ofMedicine, Japan

A 65-year-old woman had been followed up at nearby hospital forC-type hepatitis. Ultrasonography (US) demonstrated a tumor, 3cm in diameter, in segment 5 of the liver in March 2004. She wasadmitted to our hospital for further examination. She was pointedout to have Dubin-Johnson syndrome when she was 20-year-old.She was icteric and the blood laboratory data showed elevated lev-els of total bilirubin (T-Bil) (4.2mg/dl), serum AFP (14900ng/ml)

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and PIVKA-2 (623mAU/ml), while other data remained normalrange. US revealed a hypoechoic lesion, 3cm in diameter, in seg-ment 5 of the liver. Abdominal dynamic computed tomogramshowed an enhanced tumor in the early phase. Abdominalangiogram showed a hypervascular tumor 30mm in diameter at thesame portion. CTAP revealed a perfusion defect in segment 5.The tumor was diagnosed as hepatocellular carcinoma, and subse-quently she underwent systematic subsegmentectomy of Couin-aud’s 5 for HCC. She recovered uneventfully and was dischargedfrom hospital on the 15th postoperative day. Dubin-Johnson syn-drome is rare constitutional conjugated hyperbilirubinemia causedof mutant gene in multidrug resistance-associated protein 2(MRP2) and delayed discharge of conjugated bilirubin from hepa-tocyte to biliary canaliculus. This is the first case with Dubin-Johnson syndrome that underwent hepatectomy for HCC.

P-509Clinical Outcomes of Transhiatal Resection for Carcinoma ofthe Lower Thoracic EsophagusSatoru Nakagawa, Tatsuo Kanda, Masato Nakajima, Kaibe Tsutomu,Atsushi Matsuki, Manabu Ohashi, Katsuyoshi HatakeyamaThe Division of Digestive and General Surgery, Niigata GraduateSchool of Medical and Dental Sciences, Japan

Purpose: To evaluate the outcomes of transhiatal resection forpatients with carcinoma of the lower thoracic esophagus at a singleinstitution. Methods: From 1982 to 2003, 111 patients with carci-noma of the lower thoracic esophagus underwent esophagectomyat the Niigata University Hospital. The perioperative outcomesand survival of 54 patients who underwent transthoracicesophagectomy (TTE) with three-field lymphadenectomy (3FL)between 1982 and 1993 were compared with those of 22 patientswho underwent TTE with two-field lymphadenectomy (2FL) and35 patients who underwent transhiatal esophagectomy (THE)between 1994 and 2003. Results: There were significant differ-ences in the operating time, amount of blood loss, postoperativeventilatory requirements and morbidity between the TTE with3FL group and THE group (p<0.01). The 5-year overall survivalrates were 52%, 43 and 42%, respectively, for the TTE with 3FL,TTE with 2FL and THE groups (p = NS). The 5-year disease-freesurvival rates were 47%, 34% and 37%, respectively, for the TTEwith 3FL, TTE with 2FL and THE groups (p = NS). In the THEgroup, the 5-year overall and disease-free survival rates of patientswith pT1 and 2 with a diameter less than 5cm were 80% and 80%,respectively. Conclusions: Transhiatal resection can be considereda safe procedure than TTE with 3FL, but radicality and survivalresults were worse than those of TTE with 3FLwithout a signifi-cant difference. The patients with T1 and T2 with a diameter lessthan 5cm were considered acceptable candidates for transhiatalresection.

P-510Three Cases of Primary Adenocarcinoma of the AppendixSumiko Nakagawa, Masahiro Amano, Yutaka Itani, Hiroe Torii,Shigeo Matui, Toshiaki Takada, Masato Sakon, Susumu OoshimaSurgery, Nishinomiya Municipal Central Hospital, Japan

Primary adenocarcinoma of the appendix is rare, and frequentlyunresectable at the time of diagnosis. We experienced three casesof resectable appendiceal adenocarcinoma. Case 1: 77 year old

female complaining the right lower abdominal pain. Acute appen-dicitis was diagnosed by abdominal CT scan, which revealed theabscess-like mass in the ileo-cecal region. Upon laparotomy, foundwere an advanced carcinoma with regional lymph node involve-ment and its direct invasion to the abdominal wall. Right hemi-colectomy with resection of the adjacent abdominal wall was per-formed. Histopathological diagnosis is combined mucinous andsignet ring cell carcinoma. Case 2: 84 year old female with anabdominal mass and pain in the right lower quadrant abdomen.Since tumor markers were elevated (CEA: 5.1ng/ml and CA19-9:2133ng/ml), abdominal CT scan and colonoscopy were performed,by which appendiceal carcinoma was highly suspected. Mucinouscarcinoma associated with signet ring cell carcinoma was diag-nosed. Case 3: 59 year old male. Because of guiac positive stool oncheck-up, colonoscopy was performed, and a type I tumor wasfound at the orifice of the appendicitis. Ileo-cecal resection wasperformed. Well differentiated adenocarcinoma was confirmed byhistopathological examination.

P-511Enucleation for Solid Pseudopapillary Tumor of the PancreasToshio Nakagohri, Taira Kinoshita, Masaru Konishi, ShinichiroTakahashi, Naoto GotohdaDepartment of Surgery, National Cancer Center Hospital East,Japan

Background The clinicopathology and surgical outcome of solidpseudopapillary tumor of the pancreass are not fully understood,because this neoplasm is a rare pancreatic tumor. MethodsBetween June 1996 and February 2004, 8 patients with solidpseudopapillary tumor of the pancreas underwent surgical resec-tion at National Cancer Center Hospital East. In this single-insti-tution study, the short- and long-term results of surgical treatmentincluding enucleation are analyzed. Results Five patients with solidpseudopapillary tumor underwent enucleation. Subtotal stomach-preserving pancreatoduodenectomy, duodenum-preserving pan-creatic head resection, and distal pancreatectomy were performedfor the other three patients. Overall morbidity and mortality rateswere 38% and 0%, respectively. One patient developed cholecysti-tis and bile duct stricture after duodenum-preserving pancreatichead resection, 2 patients developed pancreatic fistula after enucle-ation. However, no patient needed postoperative surgical interven-tion. All patients are still alive without recurrent disease after amedian follow-up of 43 months. Conclusion Patients with solidpseudopapillary tumor of the pancreas had a favorable prognosisafter surgical treatment including enucleation.

P-512Indication and Problem of Laparoscopic Surgery for RectalCancerKoichi Nakajima, Hideo Yamada, Takahiro Kinoshita, MasahikoSato, Shigetaka Suzuki, Juri KondoLaparoscopic Surgery Center, Toho University Sakura Hospital,Japan

We treated 94 rectal cancer cases by laparoscopic surgery at Saku-ra National Hospital and Toho University Sakura Hospital from1994 to 2004. these cases were classified : DukesA,B(withoutinvading other organ) 57, DukesC 23, DukesD(accompanyingliver or lung metastasis)14. Operation methods were : anterior


resection 67, Miles’s operation 19, Hartmann’s operation 3,colostomy 5. We generally chose retroperitoneal approach to IMAand performed D3 lymph node dissection for advanced and cura-tive cases. The prognosis for these cases treated by laparoscopicsurgery is even or excellent compared with cases treated by opensurgery at every clinical stage. Therefore, we considere the indica-tions for laparoscopic surgery for rectal cancer can be from earlycancer to advanced cancer. But in 12 Rb cancer treated by laparo-scopic surgery, we experienced 5 suture failure cases(41.6%), thatwas the problem of disadvantage compared with open surgery.Against this problem, we have combined hand assisted techniqueor small laparotomy with laparoscopic surgery.

P-513Evaluation of the Perioperative Care for Pulmonary Compli-cations in Patients Undergoing Esophageal Cancer SurgeryMasaki Nakamura, Makoto Iwahashi, Yoshihiro Nakatani, MikihitoNakamori, Koichiro Ishida, Teiji Naka, Yoshinori Inada, KentaroUeda, Toshiyasu Ojima, Hiroki YamaueSecond Department of Surgery, Wakayama Medical University,School of Medicine, Japan

(Purpose) Esophageal resection is one of the most stressful proce-dures among all gastrointestinal operations. Pulmonary complica-tions are major components of morbidity and mortality afteresophageal resection. The purpose of this study was to evaluatethe perioperative cares for improving morbidity, especially pul-monary complications such as the respiratory rehabilitation andthe steroid therapy. (Methods) Fifty-three patients who under-went a right transthoracic subtotal esophagectomy for thoracicesophageal cancer between 2001 and 2003 were treated with peri-operative cares (perioperative care group; P-group). Fifty-fourpatients patients operated btween 1997 and 2000 were adopted as ahistorical control (control group; C-group). In the perioperativecares, 125 mg of methylprednisolone was administered intra-venously to each patient at start of thoracotomy, followed by 125mg at end of operation. Moreover, the respiratory rehabilitationwas carried out at preoperative and postoperative periods. Postop-erative clinical course, the duration of systemic inflammatoryresponse syndrome (SIRS), and morbidity were comparedbetween the two groups. (Results) The length until extubation,the length of stay in the Intensive Care Unit (ICU), hospital stayand the duration of SIRS were significantly shorter in P-groupcompared with C-group (p<0.05). The morbidity rate was signifi-cantly lower in P-group (28.3%) than in C-group (61.8%,p<0.001). Pulmonary complications also decreased in P-group(7.5%) than in C-group (35.3%, p<0.001). (Conclusions) Theperioperative cares of the respiratory rehabilitation and steroidtherapy reduced the surgical morbidity, especially the pulmonarycomplications, and those managements are very important for theesophageal resection, especially with three-field lymph node dis-section.

P-514Gemcitabine in Advanced Pancreatic and Bile Duct CancerNoriaki Nakamura, Takumi Irie, Daisuke Ban, Norio Noguchi,Atsushi Kudoh, Takahiro Sanada, Susumu Takamatsu, TohruKawamura, Kenichi Teramoto, Shigeki AriiHepato-Biliary Pancreatic Surgery, Tokyo Medical and DentalUniversity, Japan

Gemcitabine (GEM) remains standard treatment. Recently bileduct cancer also has been treated with GEM. Here we reviewed 29cases that were biliary or pancreas cancer and have been treatedwith GEM.Between January 2002 and February 2004, 29 patientswere treated with GEM that was administered intravenously aloneor combination GEM and radiation. Patients’ characteristicsincluded gender (M/F 21/8) and average age (66.3 years). Primarydiseases were 20 cases of pancreas cancer (include 5 recurrentcases) and 9 cases of biliary tract cancer (include 6 recurrent cases).In 15 cases of unresectable pancreas cancer, average administrationtimes was 9.2 times and average total amount was 14.2g. Theresponse rate in CT scan was 12.5% in case of GEM alone, 57.1%in combination of therapy. Also response rate in tumor marker(CA19-9) was 62.5% in single agent, 71.4% in combination thera-py. The most frequent toxicity was leucocytopenia in 40%. The50% over all survival time were 153 days. In 6 recurrent cases ofbile duct cancer patients, three were excluded because of few timesof administration. One was dead after 8 months and another wasstable disease for 8 months. In the other one, combination therapywas performed against recurrent sites that were liver and lymphnode, and effective clinically for more than one year. In three casesof unresectable bile duct cancer, 2 of 3 were partial response. Weconclude that the combination therapy is better than GEM aloneand GEM is also effective to the bile duct cancer.

P-515Effective Anticancer Drugs Will Improve Prognosis ofAdvanced Gastric Cancer PatientsRieko Nakamura, Yoshiro Saikawa, Teturo Kubota, Yukako Akatu,Tunehiro Takahashi, Masaru Yoshida, Yoshihide Ootani, KoichiroKumai, Masaki KitajimaSurgery, School of Medicine, Keio University, Japan

<Introduction> Recent development of novel anticancer drugs isimproving clinical outcome of gastric cancer (GC) patients. Wehave been reporting the usefulness of MTT chemosensitivity test,and also showing effectiveness of S-1. <Purpose> We are to eluci-date the clinical efficacy of S-1 or combination with S-1 againstStage III/IV GC, and evaluate survival benefit utilizing MTT assayin GC, in order to demonstrate that effective chemotherapy willsurely improve prognosis of such patients. <Patients> We evaluat-ed 62 patients histologically-diagnosed as stage III/IV GC, whounderwent resection of primary GC between January 1999 andDecember 2001. MTT assay were performed in all the patients.<Methods> Patients were divided into two groups consisting of S-1 administered group {S-1(+) n=18} and S-1 non-administeredgroup {S-1(-) n=44}. On the other hand, patients were also dividedthree groups consisting of “Adapted” group (n=22) treated with atleast an effective drug determined by MTT, “Non-adapted” group(n=14) with ineffective drug by MTT, and No chemotherapygroup (n=19). Survival rates were calculated by Kaplan-Meiermethod, analyzing statistically by log-rank test. <Results> There

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was no clinico-pathological bias between each group compared. Instage IV GC, S-1(+) showed better prognosis than S-1(-) with sig-nificant difference (P=0.019). There was no difference between S-1(+) and S-1(-) in all patients, however, median survival time was651 days of S-1(+) and 303 days of S-1(-). According to MTTassay, “Adapted” showed better prognosis than “Non-adapted”with significant difference. (Conclusion) Effective anticancer drugsincluding S-1 will improve prognosis of advanced GC patients.

P-516Complications of Retroperitoneal Reconstruction in Pancre-aticoduodenectomy for Advanced Periampullary TumorsTakayuki Nakamura1, Noriaki Kawano1, Masanobu Nakajima1,Nobukazu Hokamura1, Norihiro Haga1, Toshio Sawada1, TakahiroKojima2, Yoichi Kon3

1Surgery, Gunma Cancer Center, 2Shoda Hospital, 3HaramachiRed Cross Hospital, Japan

Pancreaticoduodenectomy is the standard procedure for resectableperiampullary tumors. There are mainly two jejunal routes for bil-iary and pancreatic reconstructions, namely retrocolic andretroperitoneal. We will report two cases as specific complicationsto retroperitoneal route for biliary and pancreatic anastomoses inpancreaticoduodenectomy for advanced periampullary cancers.Case 1 was 61-year-old male, who had had obstructive jaundicebecause of lower bile duct cancer. He had pylorus-preserving pan-creaticoduodenectomy with para-aortic lymph nodes dissection.On the 35th postoperative day, he complained of epigastralgia andfever. CT scan showed prominent distention of jejunal stump anddilatation of intraheparic bile ducts. Emergency laparotomydemonstrated that the expanded retroperitoneal seroma producedby para-aortic lymphorrhea compressed the jejunal loop. Thatfluid collection was incised and drained with Penrose. He was dis-charged home on the 35th postoperative day of the second opera-tion without recurrence. Case 2 was 44-year-old male, who hadhad obstructive jaundice and cholangitis duo to adenocarcinoma ofampulla of Vater. He had panceaticoduodenectomy with the stablepostoperative course. Multiple hepatic and mesenteric nodalmetastases were recognized on the fourth month follow-up. Hesuffered frequent cholangitis from the fifth month. CT scanshowed the mesenteric nodal swelling occluded the jejunal loopand made the dilatation of jejunal stump and bile ducts. So-calledesophageal stent was placed endoscopically in that stenotic intes-tine. He has never had cholagitis after that procedure. These twocases suggest that retroperitoneal route should not be chosen inthe operation for advanced periampullary tumor.

P-517The Relationship between Blood Polyamine Levels andImmune Function in Cancer PatientsTakeshi Nakamura, Kuniyasu Soda, Yoshihiko Kano, Fumio KonishiSurgery, Jichi Medical School Omiya Medical Center, Japan

Purpose: The underlying mechanisms by which cellular immunityin cancer patients are suppressed have not been fully elucidated.We have shown that changes in intracellular concentration andcomposition of polyamines in human peripheral blood mononu-clear cells decrease some of the cellular immunity without decreas-ing cell viabilities or activities in vitro. In this study, we examinedthe effects of blood polyamine levels on immune function in

patients with cancer in the gastrointestinal tract. Methods: Bloodsamples were obtained before and one month after surgery. Asblood levels of spermine in age-matched healthy volunteers werelower than 13 µM, the patients were divided into two groups:(1)Spermine low group - patients whose preoperative blood sper-mine levels were less than 13 µM ; (2)Spermine high group - sper-mine levels higher than 13 µM. Blood polyamine levels, theexpression of adhesion molecules, and lymphokine activated killercell (LAK) activities were compared among patients before andafter surgery. Results: In group(1), the blood concentrations ofspermine and spermidine increased after surgery, whereas LAKactivities decreased. In group(2), blood polyamine levels decreasedand LAK activities increased after surgery. The rates-of-changebetween blood polyamine levels and LAK activities after surgeryhad negative correlation (r=-0.631, p=0.005, n=17). The changes inmean fluorescent intensity of CD11a after surgery tended todecrease in group(1) and increase in group(2). Conclusions: Thisstudy suggests that increases in spermine and spermidine concen-trations in human peripheral blood mononuclear cells is one of thefactors that suppress cellular immunity in cancer patients.

P-518The Results of Microbiological Culture of the GastricMucosa Taken from the Patients after Distal Gastrectomy orPatients Underwent Living-Donor Liver TransplantationTetsuya Nakamura, Masashi Yoshida, Yukako Akatsu, HidekiIshikawa, Kouichirou Kumai, Yasuhide Morikawa, Tetsuro Kubota,Motohide Shimazu, Yoshihide Otani, Go Wakabayashi, Ken Hoshino,Minoru Tanabe, Toshiharu Furukawa, Yoshiro Saikawa, ShigeyukiKawachi, Masaki KitajimaDepertment of Surgery, School of Medicine, Keio University,Japan

[PURPOSE] It was speculated that duodeno-gastric reflux andlow-acid state in the patients after gastrectomy and immunosup-pressive agents after liver transplantation influence the flora of thestomach. [PATIENTS AND METNODS] General microbiologi-cal culture of the gastric mucosa was performed in 18 patients afterLDLT, 40 patients after distal gastrectomy and 30 patients fromcontrol patients. Culture of Helicobacter pylori (HP) was per-formed in 21 patients after living-donor liver transplantation(LDLT), 40 patients after distal gastrectomy (DG) and 30 controlpatients. [RESULTS] The number of the isolated bacteria wasincreased in the patients after DG, however, there was no differentbetween that in the patients after LDLT and the control patients.The HP positive rate of the patients after LDLT was only 4.8%(1/21). In the patients after DG, positive rate of Klebsiella sp. andPseudomonas sp. was 20% and 12.5% respectively. [CONCLU-SIONS] In the patients after LDLT, HP was isolated in only onepatient, and positive rate of other bacteria was not increased. Inthe patients after DG, the number of isolated bacteria wasincreased significantly.


P-519Surgical Outcome in Patients with Gastric Adenocarcinomain the Upper Third of the StomachMasayuki Nakashima1, Chikara Kunisaki2, Masato Nomura2, GoroMatsuda2, Yuichi Otsuka2, Hidetaka Ono2, Yasayuki Kojima2, Hiroto-shi Akiyama2, Hiroshi Shimada2

1Surgery, Yokohama Saiseikai Nanbu Hospital, 2Yokohama CityUnivercity, Department of Gastroenterological Surgery, Japan

Purpose: Therapeutic strategy for gastric adenocarcinoma in theupper third of the stomach is controversy. To clarify the optimaltherapeutic strategy, surgical outcomes were evaluated. Methods:A series of 191 patients with gastric adenocarcinoma mainly in theupper third of the stomach, who underwent potentially curativeresection, were enrolled in this study. The results of surgery, andefficacy of lymphadenectomy (the incidence of lymph node metas-tasis X 5-year survival rate) were evaluated. Furthermore, a nerindex (the incidence of lymph node metastasis X median survivalrate) was conducted. Result: Univariate analysis revealed thatesophageal invasion, macroscopic appearance, tumor diameter,histologic type, depth of invasion, lymph node metastasis wereindependent prognostic factors. Efficacy index of lymphadenecto-my was highest in lymph node along lesser curvature followed byright and left paracardial lymph nodes, along left gastric artery,and along pancreatic artery. In para-aortic lymph nodes, latero-aortic lymph node got fairly high index. Furthermore, in gastriccancer with esophageal invasion, the index in lower para-esophageal and supraphrenic lymph node were high. By the newindex, latero-aortic lymph node locating caudal side of the leftrenal vein also got high index. Conclusions:Latero-aortic lymphnodes for advanced gastric cancer in the upper third of the stom-ach, supradiaphragmatic and lower para-esophageal nodes fortumor extending to the esophagus should be candidate for lymphnode clearance based on our results.

P-520Identification of Genes Associated with Multiple Nodules inHepatocellular Carcinoma Using cDNA MicroarrayTakenari Nakata1, Shinichi Miyagawa1, Shiro Miwa1, AkiraKobayashi1, Kazuhiko Nomura1, Yoshinori Nimura2, Naohiko Seki2

1Department of Surgery, Shinshu University, School of Medicene,2Departments of Functional Genomics, Graduate School of Medi-cine, Chiba University, Japan

HCC patients have poor prognoses because of the occurrence ofeither intrahepatic metastasis (IM) or multicentric carcinogenesis(MC). We compared the effectiveness of microarray analysis inthe diagnosis of these two forms with that of conventionalhistopathological diagnosis and identfied IM- or MC-associatedgenes through delineation of the clonality of multinodular livercancer. The clonal relationship of 23 tumor foci obtained from 11surgically resected liver specimens was investigated by genome-wide expression profiling via an in-house cDNA microarray. Thegene expression signature of primary HCCs with IM was very sim-ilar to that of their corresponding IMs, implying that genes favor-ing progression of metastasis were initiated in the primary tumors.In comparison, different gene expression was observed in multi-centric HCCs. We also found that the adrenomedullin gene wasover-expressed in metastatic HCC. This was verified by RT-PCRand immunohistochemical analysis for adrenomedullin, proving

that over-expression of this gene is important in tumor growth andmetastasis in HCC. Over-expression of the adrenomedullin genehas to be reported as an indicator of poor prognosis in several can-cers. However, there are no currently available reports regardingthe expression of the adrenomedullin gene in human HCC.In con-clusion, Analysis of expression profiles by microarray could pro-vide a reliable method of delineating the clonal relationship ofmultiple nodules of liver cancer and identifying metastasis-associ-ated genes. Adrenomedullin is a factor associated with progressionof IM in human HCC.

P-521Postoperative Complications of Hepatectomy for Hepatocel-lular Carcinoma in Relation to Liver FibrosisHisashi Nakayama1, Tadatoshi Takayama1, Akihiro Hemmi2

1Division of Digestive Surgery, 2Department of Pathology, NihonUniversity School of Medicine, Japan

Background: Hepatectomy for hepatocellular carcinoma remainsassociated with significant morbidity and mortality, despiteimproved surgical techniques and perioperative management. Therelationship between the extent of liver fibrosis and postoperativecomplications is controversial. Methods: We studied 50 patientsin whom hepatectomy for Child-Pugh grade A or B had been indi-cated. Surgical procedures were determined by the indocyaninegreen retention rate after 15 minutes (ICGR15). The extent ofliver fibrosis was graded according to the Desmet classification.The frequency and grade of severity of postoperative complica-tions were evaluated. Results: Postoperative complicationsoccurred in 24 patients (48%), the frequency being significantlyhigher among those with liver cirrhosis. However, no significantdifference in the incidence of major complications was observedbetween cirrhotic and non-cirrhotic patients (p = 0.311). Therewas no association between grade of severity of postoperative com-plications and extent of fibrosis. Conclusions: When the surgicalindication and procedure were selected based on the Child-Pughclassification and ICGR15 value, respectively, the extent of liverfibrosis did not influence the incidence of major postoperativecomplications. In particular, there was no significant difference inthe incidence of life-threatening postoperative complicationsbetween cirrhotic and non-cirrhotic patients.

P-522Complications after Rectal Amputation, Especially PerinealWound FailureKazutaka Narui1, Ike Hideyuki1, Shuji Saito1, Kenji Tatsumi1, KaoriKubota2, Shoichi Fujii2, Yasuhiko Ichikawa2, Chikara Kunisaki1, Shi-geo Ooki2, Toshio Imada1, Hiroshi Shimada2

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Department of Gastroenterological Surgery, GraduateSchool of Medicine, Yokohama City Univercity, Japan

Purpose: To assess complications of rectal amputation with thegoal of improving surgical outcome. Methods: We reviewed themedical records of 56 patients who had undergone rectal amputa-tion between January 2000 and April 2004. The impact of compli-cations on length of postoperative hospital stay was analyzed, andthe effect of various clinical variables on postoperative complica-tions was also analyzed. Results: The incidence of complicationsafter rectal amputation was 62.5%. The complications consisted of

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wound failure (dehiscence or infection of abdominal or perinealwounds) in 32 cases (57.1%; abdominal wound failure in 16 andperineal wound failure in 25), ileus in 7 cases (12.5%) and urinarytract infection in 3 cases (5.4%). The postoperative hospital stay ofthe 32 patients with wound failure was longer than that of the 24patients without wound failure (35.0 days vs. 19.8 days, p=0.0006).The postoperative hospital stay of the 25 patients with perinealwound failure was significantly longer than that of the 31 patientswithout perineal wound failure (39.9 days vs. 19.3 days, p<0.0001).But according to the result of the univariate analysis, there were nostatistically significant correlations between the occurrence of per-ineal wound failure and patient background factors (age, gender,diabetes mellitus, preoperative anemia, nutrition status, history ofsmoking), ASA, low body temperature (<36°C) during the opera-tion, lateral lymph node dissection, combined resection of adjacentorgans, the type of administered antibiotics or duration of admin-istration, and clinical and pathological stages. Conclusion: Perinealwound failure prolonged the postoperative hospital stay after rectalamputation, but the risk factors for perineal wound failure are stillunknown.

P-523A Case of Gastric Cancer with Tumor Thrombi in the Portaland Splenic VeinsKazutaka Narui1, Mitsuyoshi Ota2, Hideyuki Takakura2, KotaroNagamine2, Takako Doi2, Junichi Wakasugi2, Kiyoshi Nishiyama2,Chikara Kunisaki1, Hideyuki Ike1, Hiroshi Shimada3

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Yokohama Medical Center, National Hospital, 3Depart-ment of Gastroenterological Surgery, Graduate School of Medi-cine, Yokohama City Univercity, Japan

A 48-year-old man was admitted to our hospital with epigastralgia.He was pointed out splenomegaly and dilatation of splenic vein byhis family doctor. Laboratory data showed progressive anemia andendoscopic examination of the stomach showed fresh blood spout-ing from varicose veins at posterior wall of the fornix. We couldstop bleeding by endoscopic injection of histoacryl to varicoseveins. Contrast enhanced computed tomography showed portalembolism and splenomegaly suggesting portal hypertension.Therefore, we thought that endoscopic hemostasis was not effec-tive and adopted operation. At this operation, we found multiplelymphadenopathy and tumor in the fornix of the stomach. Intraop-erative pathological diagnosis of lymph node revealed adenocarci-noma. Total gastrectomy combined with splenectomy was per-formed. Liver and peritoneal metastases were not detected.Macroscopically, a 7cm of ill-defined tumor was found in the pos-terior wall of fornix. Pathologically, it was poorly differentiatedadenocarcinoma, the depth of invasion was subserosa, lymphnodemetastasis was pN1 (3/22) and venous invasion was severe. Fur-thermore, metastasis to the spleen was also detected. Immunohis-tologically, alpha-fetoprotein was negative and carcinoembryonicantigen was positively stained. After the operation, hepatic arterialinfusion chemotherapy using 5-FU and systemic chemotherapyusing CDDP and TS-1 were administered to prevent liver metas-tasis. And now, he remains alive 9 months after the operation. Por-tal thrombi by gastric cancer were relatively rare. This case wasinteresting in point of its onset; rupture of varicose vein as a resultof portal hypertension caused by gastric cancer thrombi of portalvein.

P-524Hepatic Resection for Hepatocellular Carcinoma for Patientswith Poor Hepatic Function ReserveShunji Narumi, Kenichi Hakamada, Tung-Huei Chang, SyuichiYoshihara, Yoshikazu Toyoki, Mutsuo SasakiSurgery, Hirosaki University, School of Medicine, Japan

[Introduction] Even liver transplantation becomes a great optionfor treatment of HCCs, paucity of donors still limits hepatic trans-plantation. Hepatic resection and RFA/TAE remain major modali-ties for treatment of HCC. [Patients and methods] Hepatic resec-tions for patients with poor hepatic function reserve(ICGR15>30%) for last 15 years were retrospectively analyzed.Survival was compared with patients who underwent RFA whosenumbers of tumor were less than 3 and ICGR15 was less than50%. Data were expressed mean ± SEM. Kaplan-Meier, logrank,and Cox’s regression were used as indicated. [Results] Twenty outof 169 patients with poor hepatic function reserve (ICGR15>30%)underwent hepatic resection in Hirosaki University School ofMedicine for last 15 years. Average ICGR15 was 36.2%(30.1-46.7). Twelve patients were classified in Child A and 8 were inChild B. Average tumor size was 2.9 ± 0.3 cm in a diameter. Clini-cal stage was I in 4 cases and II in 16 cases. Operative time was 198± 13 minuets and blood loss was 1101 ± 123 ml. Distance fromtumor edge was 5.1 ± 1.4 mm. Total bilirubin transiently increasedby 1.2 (0-7.3) mg/dl postoperatively. No perioperative death wasobserved. Three-year survival was 73.7% while 63.8% in patientswho underwent RFA and disease-free survival was 41.4% and38.3% respectively (N.S). Cox’s regression and life model revealedan age, a tumor size, and child classification as risk factors for sur-vival time. Hepatic resection is safely indicated for patients withpoor liver function reserve, if they were carefully prepared andtreated.

P-525Evaluation of S-1 and Cisplatin Combination Chemotherapyas Neoadjuvant Chemotherapy for Patients with AdvancedGastric CancerAtsushi Nashimoto, Hiroshi Yabusaki, Yasumasa Takii, YoshiakiTsuchiya, Otsuo TanakaSurgery, Niigata Cancer Center Hospital, Japan

This study aimed to evaluate the efficacy and feasibility of neoad-juvant chemotherapy (NAC) composed with S-1 (TS-1) and Cis-platin (CDDP) for advanced or unresectable gastric cancer anddisclosed its prognostic factor. Since October 2000, 67 patientswith advanced gastric cancer (AGC) were enrolled. Of them 49patients (73.1%) were resectable, but 18 patients were unresectableor inoperable. At the outpatient clinic, S-1 of 80 mg/m2 per daywas administered orally for 3 weeks and CDDP (50mg/m2) wasdrip infused at day 8. Results: A man/woman was 40/27, and amedian age was 60 y.o.(32-83). The curative resection rate was77.6%. The treatment related toxicity more than grade 3 was lowand there was no TRD. The drug administration periods were 2.9courses in average, and the home stay rate was 84.5%. The overallresponse rate was 68.7%. For site efficacy, the response rate was82.2% for the lymph node metastasis and 68.7% for the primarytumor. As for the histological effectiveness, 21 lesions were grade1a, 17 lesions were grade 1b and 11 lesions were grade2, respec-tively. The all over 3 year survival rate was 30.5% and 3 year sur-


vival rate of patients with resectable AGC was 53.0%. The univari-ate and muitivariate analysis revealed good prognostic factors suchas the female, responder, no liver metastasis, located in singleregion and curative resection. In conclusion, S-1/CDDP combina-tion therapy as NAC is safe and one of the best chemotherapy foradvanced or unresectable gastric caner patients who can take food.

P-526Prostaglandin E1 Protects Against Ischemia ReperfusionInjury of the Rat Liver by Inhibition of Neutrophil Adherenceto Endothelial CellsShiho Natori1, Yuichi Fujii2, Haruki Kurosawa1, Akira Nakano2,Hiroshi Shimada2

1Department of Surgery, Yokosuka Kyosai Hospital, 22nd Depart-ment of Surgery, Yokohama City University, Japan

Purpose. This study investigates the protective mechanism ofprostaglandin E1(PGE1) against hepatic ischemia-reperfusioninjury in vivo. Methods. We administered anti-intercellular adhe-sion molecule 1(ICAM-1) mAb, antiserum against rat polymor-phonuclear(PMN) leukocytes, or PGE1 to a rat model of left lobarischemia for 60 min followed by reperfusion. The retention rate offluorescence labeled hyaluronic acid was measured to investigatethe endothelial dysfunction. Leukocyte adherence was observed byintravital fluorescence microscopy. The effect of PGE1 on theexpression of adhesion molecules was analyzed by immunohisto-chemistry and flow cytometry. Results. 1) ALT was significantlydecreased in PGE1, anti ICAM-1, and anti PMN group. 2) IL-8was not influenced by administration of PGE1, anti-ICAM-1 anti-body, nor anti-PMN. 3) The retention rate of fluorescence labeledhyaluronic acid was significantly decreased in PGE1, ICAM-1group, and anti PMN group. 4) After reperfusion adherent leuko-cytes had progressively increased significantly in Control groupbut not in PGE1 group. 5) The expression of lymphocyte func-tion-associated antigen 1(LFA-1) and membrane attack complex1(Mac-1) was not affected by PGE1. However ICAM-1 onendothelium was suppressed by PGE1 administration. Conclu-sion. These data indicate that PGE1 protects the liver againstischemia-reperfusion injury by reducing leukocyte-endothelial celladhesion via down-modulation of ICAM-1 expression on theendothelium.

P-527Comparison of Radiofrequency Ablation and TransarterialChemoembolization for Unresectable Hepatocellular Carci-nomaKelvin Kwok-Chai Ng1, Ronnie Tung-Ping Poon1, Chi-Ming Lam1,Jimmy Yuen2, Wai-Kuen Tso2, Sheung-Tat Fan1

1Department of Surgery, Centre for the Study of Liver Disease,2Department of Radiology, Centre for the Study of Liver Disease,University of Hong Kong Medical Centre, Queen Mary Hospital,Hong Kong, China

Background: There is no single effective loco-regional therapy forunresectable hepatocellular carcinoma (HCC), for which bothradiofrequency ablation (RFA) and transarterial chemoemboliza-tion (TACE) have been adopted. Aim of Study: This study was tocompare the therapeutic effect of RFA and TACE for unresectableHCC. Patients and Methods: From April 2001 to December2002, 57 patients with unresectable hepatocellular carcinoma

received either RFA (n = 32) or TOCE (n = 25). The morbidity,mortality, tumor responses and patients’ survival were evaluated inboth RFA and TOCE groups. Results: There was no treatment-related death in all patients. There were no significant differencesbetween RFA and TOCE groups in major complication rate (23%vs. 13%; P = 0.717) and overall survival (1-year: 77% vs. 84%; 2-year: 61% vs. 56%; P = 0.61). For RFA group, the complete abla-tion rate was 96.8% after single session ablation and the localtumor recurrence was 12.5%. For TOCE group, there were 1complete response (4%), 1 partial response (4%), 9 static diseases(36%) and 14 disease progressions (56%). Conclusion: Both RFAand TOCE are safe for patients with unresectable HCC. RFAseems to have better local tumor control compared with TOCE.

P-528Experience with More Than 3500 Cases of Stapled Haemor-rhoidectomyKheng-Hong Ng, Kong-Weng Eu, Francis Seow-Choen, Choong-Leong Tang, Sieu-Min Heah, Boon-Swee OoiDepartment of Colorectal Surgery, Singapore General Hospital,Singapore

Introduction: Stapled haemorrhoidectomy was first undertaken bythe Department of Colorectal Surgery, Singapore General Hospi-tal, in October 1999. Since then, we had performed more than3500 cases. Methods: Data for all cases of stapled haemorrhoidec-tomy, between October 1999 and May 2004, were prospectivelycollected and analysed. Results: A total of 3610 cases were per-formed over a period of 56 months, with an average of 63 cases permonth. The average age of patients was 47.8 years old (range18-88). There were 1910 males and 1700 females. Of these, 3483cases were undertaken as an elective operation and 127 cases in anemergency setting. The indications for surgery were bleeding(80.7%) and third and fourth degree prolapse (59.6%). The meanduration of operation was 17.6 minutes (range 5-45). The overallcomplication rate during hospitalisation was 3.5%, includingbleeding, acute retention of urine and thrombosis of external piles.At 2 weeks after surgery 5.3% of the patients was admitted forbleeding. The stricture rate was 8.8%, requiring digital dilatationin the clinic. After 6 weeks, 1.7% of patients still complained ofincontinence to gas. Only one patient developed major complica-tion of retroperitoneal sepsis after surgery. Discussion: In ourexperience, stapled haemorrhodiectomy is a safe procedure, withcomplication rate comparable to conventional surgery.

P-529The Changes of the Portal Pressure and Flow Volume withthe Period of the Heart Beat, an Experimental Study in PigsYoshito Nihei, Yoshikazu Yasuda, Hideaki Sasanuma, Hideo Chiba,Keisuke Yamashita, Hideo NagaiDepartment of Surgery, Jichi Medical School, Japan

Purpose: The blood flow in the portal vein has been long consid-ered steady and layered. Recently, however, there have been anumber of studies showing that the portal blood flow is pulsatory.We have clinically noted a similarity between the wave patterns ofthe flow velocity in the intrahepatic portal vein and hepatic vein.However, it remains unclarified. In this study, we measured thepressure and flow volume in the extrahepatic portal vein, hepaticartery, and inferior vena cava of pigs at rest, and compared the

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wave patterns. Methods: The RR interval observed by ECG wasregarded as 100, and in the RR interval, the pressure wave patternsin the inferior vena cava (IVC), portal vein (PV) and hepatic artery(HA) and the timing of waves in the flow rate patterns were evalu-ated. Results: The portal pressure and flow volume were found tobe synchronized, and showed pulsatory changes with the period ofthe heart beat. Also, changes in the relationship between the pres-sure and flow volume in the PV more closely resembled those inthe HA than those in the IVC. Conclusions: Our findings sug-gested that pulsatory PV blood flow is affected by both inferiorvena caval pressure and the splanchnic arterial pressure.

P-530Hypogenesis of Left Lateral Segment of the LiverTakashi Niiya1, Ken Hayashi2, Hirohisa Kato1, Yuuta Enami2, YoshioDeguchi1, Takeshi Aoki2, Noriyuki Murai2, Junichi Tanaka1, MitsuoKusano2, Shinei Kudoh1

1Showa University NorthernYokohama Hospital, 2Showa Univer-sity, Japan

Purpose: To investigate the cause and incident of hypogenesis ofleft lateral segment of the liver accompanied with sigmoid volvu-lus. Methods: We analyzed the cases of sigmoid volvulus admittedto our institute from 1997 to 2004. Computed tomography (CT)volumetry was performed to evaluate the hypogenesis of left lateralsegment of the liver. On the other hand, dolichosigma was assesedin the patient, hypogenesis of left lateral segment of the liver wasappeared by chance. Results: We have experienced eleven cases ofsigmoid volvulus. CT was performed in eight cases and hypogene-sis of left lateral segment of the liver were revealed in seven cases.In the patient of hypogenesis of left lateral segment of the liver,dolichosigma is suspected by X-ray examination. Conclusion:Although the cause of hypogenesis of left lateral segment of theliver is not clear in this study, there are some relationships betweenthe hypogenesis of left lateral segment of the liver and sigmoidvolvulus (dolichosigma). These relationships gives us some sugges-tion to estimate the cause of hypogensis of the liver segment.

P-531Intraoperative Thermographic Assessment of Gastric TubeViability in Esophageal ReplacementKatsunori Nishikawa1, Mitsuo Yabe1, Hironori Ohdaira1, HidekiMatsudaira1, Hideyuki Suzuki1, Ryuuzo Murai1, Ryouji Mizuno1,Shuuichi Iwabuchi1, Yutaka Suzuki2, Nobuyoshi Hanyuu2, KatsuhikoYanaga2

1Surgery, Machida Municipal Hospital, 2Jikei University School ofMedicine Department of Surgery, Japan

PURPOSE: Gastric tube ischemia is serious complication afteresophagogastrostomy which is a major cause of anastomotic fail-ure. The purpose of this study is to examine the usefulness of ther-mal camera for intraoperative detection of gastric tube viability.METHODS: Thermograms of the gastric tube were obtainedbefore esophagogastrostomy in 6 patients with esophageal cancerundergoing esophagectomy. Anterior surface temperature of thegastric tube was measured, from the proximal end to the pyloruslongitudinally at 2cm interval on entire gastric tube. RESULTS:Gradual decline in the surface temperature of the gastric tube wasapparent by thermal imaging. The mean surface temperature atproximal region of the gastric tube was 26.9°C as compare to

31.6°C at distal region (p<0.00001). One patient who developedmajor anastomotic leakage by proximal gastric tube necrosisshowed significantly low anterior surface temperature for 14cmfrom the proximal end of the gastric tube. The mean temperatureof the surface region of the gastric tube 10cm distal to the proxi-mal end was 24.4°C in this patient, which was lower than 27.3°Camong patients without anastomotic leakage (p<0.00001). CON-CLUSION: Our preliminary results suggest that thermal camerais non-invasive and allows guide and reliable assessment of the gas-tric tube viability. Low surface temperature of the proximal regionof the gastric tube may be followed by gastric tube necrosis andanastomotic leakage.

P-532A Clinicopathologic Study of Mucinous Gastric CarcinomaNagi Nishikouri1, Chikara Kunisaki1, Shinsuke Hatori1, RoppeiYamada1, Sadatoshi Sugae1, Toshio Imada1, Hirotoshi Akiyama2,Masato Nomura2, Goro Matsuda2, Yuichi Otsuka2, Hidetaka Ono2,Hiroshi Shimada2

1Yokohama City University, Department of Surgery, Gastroen-terological Center, 2Department of Gastroenterological Surgery,Yokohama City University Graduate School of Medicine, Japan

Purpose: Mucinous gastric carcinoma (MGC) is a rare subtype ofgastric carcinoma. To clarify the clinicopathlogical characteristicson this type of carcinoma, we compared clinicopathological char-acteristics and surgical outcomes between 45 MGC and 1255 non-mucinous gastric carcinoma (NGC). Patients and Methods: Aseries of 1300 gastric cancer patients were included in this study.Of them, 1184 patients (early gastric cancer: 568, advanced gastriccancer: 616) were underwent potentially curative resection and 116palliative resection. Age, gender, location of the tumor, tumordiameter, macroscopic appearance, depth of invasion, lymph nodemetastasis, lymphatic invasion, and venous invasion wereemployed. Results: 1)Characteristics; In all registered patients, theMGC patients were found to have macroscopically ill-defined(p=0.0051), deeper invasion (p=0.0046), more lymph nodesinvolvement (p=0.0008), and advanced stage disease (p=0.0293).Furthermore, the MGC patients had tendency to have largertumor, and palliative resection. However, In curatively resectedpatients with advanced cancer, there was no significant differencebetween the both groups. In curatively resected patients with earlycancer, there were significant differences in depth of invasion(p=0.0060) and lymphatic invasion (p=0.0374). 2) Survival time; Inall registered patients, the survival time was worse in the MGCpatients (p=0.0489). However, there was no significant differencein survival in patients with curative resection. Conclusions: Thepoor prognosis in MGC patients was correlated with moreadvanced stage at the diagnosis. Earlier detection would improvethe survival for such type of cancer.


P-533Bilateral Major Splanchnicectomy for Patients with Intolera-ble Pain Due to Unresectable CarcinomaHidefumi Nishimori1, Yasutoshi Kimura1, Takayuki Nobuoka1,Masashi Imamura1, Yukio Nakamura1, Toshio Honma1, MitsuhiroMukaiya2, Koichi Hirata1

1Dept. of Surgery 1, Sapporo Medical University, 2Dept. ofSurgery, Hakodate Kyokai Hospital, Japan

To control the pain caused by far advanced carcinomas, we under-went bilateral major splanchnicectomy followed by the alimentarytract bypass operation. Five patients had suffered persistent, severeabdominal and/or back pain, and had diagnosed as the pancreaticcarcinoma with further advance. They were admitted large amountof dosage of morphine, opioid and NSAIDs and displayed poorface-score. After the operation, in all patients, less dosage of themorphine and NSAIDS were admitted than those needed preoper-atively, and the face-score improved. In this procedure, bilateralsplanchnic nerve was easily identified and was safely resected. Fur-thermore, no critical complications were observed intra- and post-operatively. The indications for this procedure were considered asfollows; 1) Patient carrying inoperable advanced cancer, and whoneeds such palliative operation as alimentary tract bypassing, 2)Persistent pain without our control is existing or nearly arise fromthe tumor progressing, 3) No evidence of invasion around cardiaof the stomach. We concluded this method as the most logicalapproach to the pain arisen from far advanced carcinoma becauseof its nature that the sensory neural tract was totally discontinued.

P-534Clinical Resistant to STI571 in Gastrointestinal StromalTumorsAkiko Nishitani, Toshirou Nishida, Toshinori Itou, Hikaru Matsuda,Seiichi HirotaDepartment of surgery (E1), Osaka University Graduate School ofMedicine, Japan

It has become a consensus approach to use STI571 (imatinib), fortreatment of the patients with unresectable or recurrent gastroin-testinal stromal tumors (GISTs). But there are some reports ofcases with resistant to imatinib. There seems to be some patternsof resistant cases, primary and late resistant. We report some ima-tinib-resistant cases of GIST patients and their clinical course.Case1: A 59-year-old man, who was diagnosed unresectable gastricGIST with peritoneal dissemination, was treated with 400mg/dayof imatinib. But the status of tumor was assessed as PD. His tumorhad a mutation of PDGFR-alpha, not KIT. Case2: A 74-year-oldman, who underwent partial gastrectomy for a gastric GIST,recurred of multiple liver metastasis. Imatinib treatment of400mg/day was started and after 2 months, liver tumors changedinto fluid density in CT scan. However, 11 months later, CT scanshowed solid part in the cystic lesion of the metastatic tumors.FDG-PET scan also showed uptakes so the lesion was assessed asviable caused by late resistant to imatinib. Then dose of imatinibwas increased to 600mg/day and 2 months later solid lesion wasreduced. Case3: A 33-year-old man, who underwent pancreato-duodenectomy for a duodenal GIST, recurred of liver metastasis.After one month of starting of 400mg/day of imatinib treatment,liver metastatic tumors changed into fluid level in CT scan. Sevenmonths later, CT scan showed solid part in the cystic lesion and

FDG-PET scan showed uptake. Increasing dose of imatinib up to800mg/day and 3 months later solid lesion was reduced.

P-535Lymphoepithelial Cyst of the Pancreas: Report of a CaseTkayuki Nobuoka1, Yasutoshi Kimura1, Hidefumi Nishimori1, Masafu-mi Imamura1, Yukio Nakamura1, Toru Mizuguchi1, Tadashi Kat-suramaki1, Fukui Rika1, Hideto Itou1, Mitsuhiro Mukaiya2, KoichiHirata1

1Department of Surgery, Section 1, Sapporo Medical University,Japan, 2Hakodate Kyokai Hospital, Japan

A lymphoepithelial cyst (LEC) of the pancreas is a rare lesion ofundetermined pathogenesis. A 60-year-old man complaining ofabdominal pain was found to have a pancreatic cystic tumor oncomputed tomography (CT). On admission, his serum carbohy-drate antigen (CA) 19-9 level was 652U/ml and CT scan revealed awell-circumscribed multilocular cystic tumor in the pancreaticbody. Magnetic resonance imaging, (MRI) showed a hypointensemass on T1-weighted imaging, and a hyperintense mass on T2-weighted imaging. Endoscopic retrograde cholangiopancreatogra-phy showed a normal duct system and no communication betweenthe pancreatic ducts and the tumor. Endoscopic ultrasound exami-nation revealed a low-density tissue mass on the surface of the pan-creas , less echogenic than the surrounding parenchyma. A spleen-preserving distal pancreatectomy (SPDP) was performed with asuspected diagnosis of epidermoid cyst of the pancreas. However,histological examination revealed that the cyst was lined by strati-fied squamous epithelium and surrounded by lymphoid tissue. Pre-operative diagnosis of LEC is quite difficult because it resemblesother cystic neoplasms of the pancreas in radiographic features andis frequently associated with an elevation of serum tumor markers.

P-536Clinical Evaluation of Chemosensitivity Testing in 485 Gas-tric Cancer Patients Using MTT AssayKohei Noguchi, Makoto Iwahashi, Masaki Nakamura, MikihitoNakamori, Yoshihiro Nakatani, Kentaro Ueda, Koichiro Ishida, TeijiNaka, Toshiyasu Ojima, Masaji Tani, Hiroki YamaueSecond Department of Surgery, Wakayama Medical University,School of Medicine, Japan

Purpose: We have evaluated the results of the chemosensitivitytesting for gastric cancer using MTT assay in terms of the correla-tion of chemosensitivities and clinicopathological findings in orderto establish reliable chemosensitivity test. Methods: We haveanalyzed 485 consecutive patients with gastric cancer treatedbetween January 1991 and January 2002. Highly purified freshhuman gastric cancer cells could be obtained from 415 primarytumors, 37 malignant ascites, 25 metastatic lymph nodes, 4metastatic liver tumors and 4 metastatic ovarian tumors. The drugswe analyzed were cisplatin (CDDP), mitomycin C (MMC), dox-orubicin (ADR), 5-fluorouracil (5-FU), etoposide (VP-16), irinote-can (CPT-11), and docetaxel (DOC). Chemosensitivity test wasperformed according to the SDI test using MTT assay. Results:CDDP and 5-FU were more potent drugs than MMC, ADR andVP-16. Chemosensitivities of metastatic tumors were lower thanthose of primary tumors. The chemosensitivity in differentiatedcancer was equivalent to that in undifferentiated cancer. Invasivetype cancer showed higher sensitivity for DOC and lower for

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CPT-11 and VP-16 than non-invasive type cancer although thedepth of invasion did not affect chemosensitivities for all drugsexcept VP-16. The chemosensitivities for 5-FU, VP-16 and DOCwere lower in stage IV gastric cancer than those of stage I, II, III.Conclusions: Our results suggest that individual chemosensitivitytesting is essential to individualized chemotherapy for gastric can-cer.

P-537Application of Clinical Pathway for the Patients Who Under-go Partial Hepatectomy: Its Efficacy and LimitationNorio Noguchi, Kenichi Teramoto, Daisuke Bann, Atsushi Kudou,Takahiro Sanada, Noriaki Nakamura, Susumu Takamatsu, TohruKawamura, Shigeki AriiHepatobiliarypancreatic Surgery, Tokyo Medical and Dental Uni-versity, Japan

Purpose:To investigate a clinical pathway (path) for patientsundergoing a partial hepatectomy in performing a standardizedand qualified medical treatment with less risk. Patients and Meth-ods:Based on data derived from the postoperative courses of 35consecutive patients who underwent a partial hepatectomy in2001(Group 1), a clinical path for the postoperative managementwas developed. Each time-related variables from early postopera-tive management to hospital discharge was made shorter than thecorresponding variables in Group 1 patients. According to thisclinical path 54 consecutive patients who underwent a hapatecto-my in 2002 (Group 2) were managed. The postoperative courses,including the postoperative complications and duration of hospitalstay were then compared between the two groups.Results:Approximately 70% of the Group 2 patients took unevent-ful postoperative courses under this clinical path. The disease, age,and extent of the hepatic resection did not affect the applicativeratio to the clinical path. The duration of the hospital stay in theGroup 2 patients was shorter than in the Group 1 patients, exceptfor patients with postoperative complications. Even in patientswith limited hepatic function in whom no complications occurred,the clinical path was completely applicable. The most influentialfactor in the application of the clinical path was the postoperativecomplications, mainly bile leakage and intraabdominal abscess.Conclusion:The clinical path shortened the hospital stay. Theclinical path was applicable to those patients without bile leakageand intraabdominal infection, even in patients with limited hepaticfunction and hepatic cirrhosis.

P-538A Case of Solitary Splenic Metastasis from Uterine CervicalCancerKazunori Nojiri1, Yasuhiko Nagano1, Keniti Matuo1, TikaraKunisaki1, Hideyuki Ike1, Toshio Imada1, Mario Ikeda2, Hiroshi Shi-mada3

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Department of Gynecology, Yokohama City UniversityMedical Center, 3Department of Gastroenterological Surgery,Yokohama City University, Graduate School of Medicine, Japan

A 54-year-old woman, had received a chemo-radiation therapy foran unresectable uterine cervical cancer in May 2003 and had com-plete response to this therapy. In February 2004, an abdominalultrasonography revealed a low echoic tumor in the spleen 6 cm in

diameter. Abdominal computed tomography scan revealed ahomogenous low density mass. Magnetic resonance imagingshowed a homogenous low intensity mass on T1 weighted imageand an heterogenous low intensity mass on T2 weighted image.Abdominal enhanced US revealed a splenic tumor with peripheralenhancement. Positron emission tomography (PET) with 2-deoxy-2-[18F]fluoro-D-glucose (FDG) revealed a focal area of increaseduptake of radioactivity in the splenic area,but there was no otherabnormal area of increased uptake in the whole body. On the basisof these findings,we diagnosed this tumor as a metastatic splenictumor. So we performed a splenectomy in April 2004.Thehistopathologic findings of the splenic tumor was squamous cellcarcinoma, which was compatible with a splenic metastasis. Shehas no findings of recurrence in not only adjacent organ but inother organ 1month after this surgery. A solitary splenic metasta-sis from uterine cervical cancer is considered to be very rare andonly 4 cases have been reported.

P-539Perioperative Treatment for Gastric Cancer According toBody Mass IndexMasato Nomura, Chikara Kunisaki, Hidetaka Ono, Yuichi Otsuka,Goro Matsuda, Akiyama Hirotoshi, Hiroshi ShimadaDepartment of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, Japan

Purpose; To clarify the attention points of perioperative treatmentfor gastric cancer, we analyzed clinicopathological factors from theviewpoint of body mass index (BMI). Patients and Method; Aseries of 305 advanced gastric cancer patients, who underwentpotentially curative gastrectomy, were involved in this study. Thepatients were classified according to BMI; lean (~19.7), moderate(19.8~24.1), excess (24.2~26.3), and obesity (26.4~). Preoperativerespiratory function, preoperative co-morbid disease, nutritionalassessment, operative bleeding, operation time and postoperativecomplications were compared between each group. Result; 1. Pre-operative respiratory function: The V25 in the lean group was sig-nificantly higher than those in the other groups. The V25 in theobesity group was lowest. 2. Preoperative nutritional assessment:There was significantly difference between the nutritional index inthe lean and those in the moderate and the excess group. 3. Preop-erative co-morbid disease: There was no significant correlationbetween BMI and the co-morbid diseases. 4. Operation time andbleeding: Operation time and amounts of bleeding in the obesitygroup was significantly longer and more than those in the othergroup. 5. Postoperative complications: Pulmonary complicationwas significantly frequent in the obesity group than in the other.Conclusion; In obese patients, longer operation time and muchamounts of bleeding frequently induced pulmonary complication.Therefore, it will be important to determine cautiously the indica-tion for operation and degree of lymph node dissection in obesepatients to avoid pulmonary complications.


P-540The Significance of Pylorus Preserving Gastrectomy for EarlyGastric Cancer Compared with Conventional GastrectomyMasato Nomura, Chikara Kunisaki, Hidetaka Ono, Yuichi Otsuka,Goro Matsuda, Hirotoshi Akiyama, Hiroshi ShimadaDepartment of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, Japan

Purpose; To clarify the significance of pylorus preserving gastrec-tomy(PPG) for early gastric cancer, postoperative procedure wascompared between conventional distal gastrectomy (DG) andPPG. Patients and Method; A total of 43 early gastric cancerpatients (20 PPG and 23 DG) were enrolled in this study. Clinicalsymptoms, body weight (BW), amounts of oral intake, and endo-scopic findings were estimated at one year after operation. Thecorrelation between the size of the remnant stomach after PPGand clinical symptoms was also evaluated. Results; 1. The inci-dence of persisting of heartburn was 5.0% in PPG group and17.4% of DG group. Difficulty of swallowing was observed in onlyPPG group (6.0%). There was no dumping syndrome in the bothgroups. 2. There was no significant difference in the mean ratio ofpost- to pre-operative BW (90.6% in PPG and 88.4% in DG). 3.There was no significance in the mean ratio of post- to pre-opera-tive amount of oral intake (71.2% in PPG and 69.5% in DG). 4.Endoscopic examination revealed that the remnant gastritis wasfrequent in DG than PPG. 5. The patients, who had smaller rem-nant stomach after PPG, complained difficulty of swallowing. Thepatients, who had smaller prepylorus portion preserved, could nothave sufficient oral intake and resulted in longer hospital stay.Conclusion; If we leave the prepylorus portion of the stomach 2cm or larger, PPG would have the advantages over DG in terms ofquality of life.

P-541Role of Bactibilia on the Development of Postoperative Sep-tic Complications in Patients with Malignant BiliaryObstructionTatsuya Nomura, Yoshio Shirai, Toshifumi Wakai, Naoyuki Yokoya-ma, Isao Kurosaki, Yoshinobu Sato, Katsuyoshi HatakeyamaDivision of Digestive and General Surgery, Niigata UniversityGraduate School of Medicine, Japan

Purpose: This study was intended to clarify the role of bile bacteriain the development of postoperative septic complications inpatients with malignant biliary obstruction. Methods: A total of116 patients with malignant biliary obstruction underwent surgicalintervention after biliary decompression. The relation betweencontaminated ductal bile and postoperative abdominal septic com-plications was analyzed retrospectively. Results: Such complica-tions developed in 49 patients (42%). Bile-contaminated opera-tions (n = 93) resulted in a higher incidence of septic complicationsthan non-bile-contaminated operations (n = 23; P = 0.009).Patients with pre-operative positive bile culture had a higher inci-dence of septic complications than those with negative bile culture(P = 0.06). There was a positive correlation between the presenceof pre-operative cholangitis and the occurrence of septic complica-tions (P = 0.007). Bacteria found in pre-operative ductal bile werealso detected in infected sites of 80% of patients with septic com-plications. Conclusions: Intra-operative contamination frominfected ductal bile plays a critical role in the development of post-

operative abdominal septic complications.

P-542Application of Dye-enhanced Laser Ablation in Liver SurgeryTomoaki Noritomi, Yuichi Yamashita, Koji Mikami, YasushiYamauchi, Seiichiro Hoshino, Tetuo Shinohara, Takahiro Maekawa,Takayuki ShirakusaThe Second Department of Surgery, Fukuoka University Schoolof Medicine, Japan

Purpose: Dye-enhanced laser ablation (DLA) using low powerdiode laser for indocyanine green (ICG) stained tissue has beenproven its effectiveness in dye-enhanced laser photocoagulation ofretinal vessels, or endoscopic surgical mucosectomy. The laserenergy in the stained tissue is enhanced because the wavelength ofdiode laser is same as the peak absorption wavelength of ICG. Werepot our experience of the use of DLA in liver surgery in compar-ison with Cavitron Ultrasonic Surgical Asprator (CUSA). Meth-ods: A diode laser (UDL-60 Laser unit, Olympus, Tokyo, Japan) at810±20 nm in wavelength was employed for this study. The ICG-dye (Diagnogreen, Daiichi Pharmaceutical Inc., Tokyo, Japan) at0.5 mg/ml in concentration with peak absorption wavelength at800 to 810 nm was topically injected into the resection plane of theliver. The liver tissue was divided by touching the tip of lowpower diode laser at 10 watts. Fourteen hepatectomy were per-formed by DLA, and 5 were performed with CUSA. Results: DLAdemonstrated satisfactory cutting and hemostasis. Among the casesby DLA, no postoperative hemorrhage and bile leakage was noted.The median postoperative hospital stay was 15 days in DLA, and21.5 days in CUSA (p=0.0045). The cut surface of the liver wassealed microscopically with a layer of protein coagulum. In con-trast, the fibrous exudates and the clotted red blood sells wereobserved in the liver cut surface in hepatectomy with CUSA.Conclusions: DLA using low power diode laser is effective for liverresection.

P-543A Case of Heterochronous Liver Metastases of Gastric Can-cer Favorably Responding to Trans-arterial Infusion of 5-FUYoshirou Obi, Tetsuya Takahashi, Atsushi Ishibe, Shun-Ichi Osada,Ken Yamanaka, Tetsuo AbeSurgery, Yokohama Red Cross Hospital, Japan

The patient is a 57-year-old man who underwent total gastrectomyin Aug. 2001. After the operation,he was treated for adjuvantchemotherapy with CDDP/TS-1 because of too advanced stage ofgastric cancer (H0P0T4 (SI;panc.) N2(+) M0Stage4). After 3courses of the chemotherapy were performed,heterochronous livermetastases were found at S7and S3-2, both 1 cm in diameter.InJan. 2002, the tumor of S7-8 was increasing to 3 cm in diameter,and new lesion of S8 was founded, 1 cm in diameter.After Feb.2002, new chemotherapy of 24 hours continuous trns-hepatic arte-rial catheterial infusion with 5-FU (1,500mg/day,weekly) was start-ed. Then the hepatic lesions were disappeared on CT. He ishealthy now and had no adverse reactions. This case suggests theusefulness of chemotherapy to hepatic metastases of gastric cancerusing TAI of 5-FU as 2nd line chemotherapy after TS-1.

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P-544Impact of Orotate Phosphoribosyl Transferase (OPRT) onSurvival and Relapse in Resectable Gastric Cancer PatientsTakumi Ochiai1, Takumi Ochiai2, Michiharu Sugitani1, KazuhikoNishimura1, Hajime Noguchi1, Tsuyoshi Okada1, Yuko Tsuruoka1,Yuka Takahashi1

1Surgery, Tobu Chiiki Hospital Tokyo Metropolitan Health andMedical Treatment Corporation, 2Tobu Chiiki Hospital TokyoMetropolitan Health and Medacal Treatment Corporation, Japan

Purpose: OPRT is the main enzyme that involves in the conver-sion of 5-FU to its active form, 5-fluorouridine monophosphate.The prognostic relevance of tumor tissue OPRT activity inresectable gastric cancer patients treated by 5-FU-based adjuvantchemotherapy was evaluated. Methods: Surgical specimen wasobtained from 61 resectable gastric cancer patients who were sub-sequently treated by 5-FU-based adjuvant chemotherapy (Medianfollow-up: 4.2 years). OPRT activity in the extract of tumor tissuewas measured enzymatically. Patients were divided into 2 groupsby the cut-off value of the enzymes determined by maximal χ2

method against DFS. Disease-free survival (DFS) and overall sur-vival (OS) was calculated using Kaplan-Meier estimate. Results:The cut-off value of OPRT activity against DFS was determinedto be 0.205 nmol/min/mg. There were significant differences inDFS and OS between 2 groups. 5-year DFS for high group (n=16)and low group (n=45) were 75.0% and 35.6% (p=0.01, log-ranktest) and OS were 81.3% and 34.0% (p=0.01), respectively. In mul-tivariate analysis between patient’s background factors, includingsex, age, nodal status and OPRT cut off, and overall survival, nodalstatus (HR: 2.64 [95%CI: 1.036-7.242], p= 0.04) and OPRT cut-off (HR: 0.302 [95%CI: 0.090-1.001], p=0.05) were selected. Con-clusions: OPRT activity in tumor tissue was one of relevant prog-nostic factor in resectable gastric cancer patients treated by 5-FU-based adjuvant chemotherapy.

P-545Hepatectomy in Cirrhotic Patients with Resectable SmallHepatocellular Carcinoma Who Met Milan CriteriaToshiya Ochiai, Teruhisa Sonoyama, Shojiro Kikuchi, DaisukeIchikawa, Hitoshi Fujiwara, Kazuma Okamoto, Chohei Sakakura,Yuji Ueda, Eigo Otsuji, Akeo Hagiwara, Hisakazu YamagishiSurgery, Kyoto Prefectural University of Medicine, Japan

Purpose: some patients with hepatocellular carcinoma (HCC) atan early stage cannot gain long-term survival after hepatectomy.The aim of the present study was to investigate the poor prognos-tic factors for hepatectomy in cirrhotic patients with resectablesmall HCC who met Milan criteria.Methods: We studied 95 cirrhotic patients with HCC, which wassolitary tumor 5 cm or smaller or two or three tumor nodules each3 cm or less; absence of extrahepatic metastasis; and absence ofradiological evidence of macroscopic portal vein or hepatic veininvasion. We used Cox's proportional hazard model to identifyrisk factors associated with prognosis to determine the contra-indi-cations for hepatectomy in patients with resectable small HCC. Results: Preoperative risk factors were (1) serum AFP concentra-tion of more than 400 ng/mL, (2) infiltrative-, massive-, or multin-odular-type (multiple) HCC, and (3) the presence of intrahepaticmetastasis. Patients who had had more than one of the three pre-operative risk factors were poor candidates for hepatic resection,

with a four-year survival of 16.3%.Conclusions: If patients with resectable small HCC are diagnosedas having more than one of three preoperative risk factors, theyshould not received hepatectomy or should be considered for pri-mary liver transplantation as a therapeutic option for HCC.

P-546Evaluations of Liver Metastases Treated with MicrowaveCoagulation TherapyKenji Ogata1, Kensei Maeshiro1, Yoshihiro Hamada2, Junya Yamamo-to2, Yoshifuku Nakayama2, Yohichi Yasunami1, Seiyo Ikeda1

1First Department of Surgery, 2Pathology, Fukuoka UniversitySchool of Medicine, Japan

Background: Clinical application of microwave coagulation thera-py (MCT) has been introduced as less invasive therapy for thetreatment of liver tumors. However, the indication for metastaticliver tumors remains controversial compared with HCC due to thelack of information regarding recurrence after MCT. In the pre-sent study, we evaluated the effect of the MCT on 12 metastaticliver tumors in 6 patients. Results: All of 12 nodules becamenecrotic by one month after open MCT (OMCT), revealed bydynamic CT scan. Two out of 12 nodules (17%) had recurrence inthe treated area at 9 and 16 months with expansion of the lesion onCT, and 2 did at 5 and 11 months with new lesions in periphery ofthe treated nodule. Thus, the two patterns of recurrence wereseen. The findings of CT scan were confirmed with histologicalexaminations of the resected specimen. Two patients treated withOMCT followed by hepatic resection survived more than 12months. Conclusion: Thus, the present study shows that there is ahigh rate of recurrence when MCT is applied to metastatic livertumors. Further studies are required for the improvements of theoutcome. At present, the application of MCT is to be limited tohigh-risk patients with liver metastasis.

P-547Treatment of Rectal Prolapse in Recurrent CasesShunji Ogata, Kazutaka Yamada, Yoriyuki Tsuji, Saburo Hisano,Michihisa Fuchimoto, Mitsuko Fukunaga, Syu Tanimura, YasumitsuSaiki, Eiji Nozato, Masahiro TakanoColoproctology Center, Takano Hospital, Japan

[Purpose] We preferably perform transanal surgery for high-riskcases as treatment of rectal prolapse in consideration of age, awhole body complication. We reviewed a treatment of rectal pro-lapse to focus on recurrence. [Methods] A total of 87 patients whounderwent surgery for rectal prolapse between 1991 and 2003were evaluated. We studied relation between the recurrence andother factors, treatment results and complications. [Results] SixThiersch procedure, 44 Gant-Miwa procedure, 30 vertical placa-tion and 7 abdominal rectopexy were performed, and there were29 recurrent cases. The senior patients had the tendency of recur-rence (p=0.018). The recurrence rate of operations with Thierschprocedure was lower than those without Thiersch procedure(p=0.025). Preoperative maximal resting pressure was low, howev-er, it had no relation to recurrence. Maximal squeeze pressure wasalso low, and those of recurrence cases were significantly lowerthan those of no-recurrence cases (p=0.016). Reoperations wereperformed in 29 recurrence cases. There were 10 re-recurrencecases. Among 9 cases which underwent (or added) Thiersch proce-


dure, there was only one re-recurrence case. Although 19 cases in87 cases had complications, there was no sever complication.[Conclusions] Although abdominal rectopexy is a suitable methodfor rectal prolapse from a respect of a recurrence, transanal surgeryis the first choice for high-risk cases. In case that transanal methodwas selected, it is necessary to add Thiersch procedure for theelderly patients with lower maximal resting pressure. In addition,radical cure is possible by the similar method even in a recurrence.

P-548Living Donor Liver Transplantation with Reduced Monoseg-ments for Neonates and Small InfantsKohei Ogawa, Mureo Kasahara, Yasuhiro Fujimoto, Yasuhiro Ogura,Kenji Uryuhara, Koichi Kozaki, Mikiko Ueda, Yasutsugu Takada,Hiroto Egawa, Koichi TanakaTransplantation and Immunology, Kyoto University, Japan

Background: In pediatric living donor liver transplantation, leftlateral segment graft (segment II and III) or monosegmental graft(segment III) is used to overcome size discrepancy between adultdonors and pediatric recipients. For neonates and extremely smallinfants, however, we sometimes encounter the problems related tolarge for size graft even when using these grafts mentioned above.We report 8 cases of transplantation using reduced monosegmentalgrafts (reduced segment III) from living donors for neonates andextremely small infants. Method: Of 575 children transplantedbetween June 1990 and April 2004, 8 patients, (median age 95days, median weight 4.2kg) received reduced monosegment livingdonor liver transplants. The indication for using this techniquewas infants with an estimated graft-to-recipient weight ratio(GRWR) of 4.0% or more when using left lateral segment.Results: Graft and patient survival is 75%. The GRWR wasreduced from 7.58 ± 2.89 to 3.41 ± 0.95% by this modification.Transaminase level for the first and second day after transplanta-tion was significantly higher in reduced monosegmental transplan-tation than monosegmental or left lateral segmental transplanta-tion. Hepatic artery thrombosis and portal vein thrombosis wasobserved in 1 case respectively. Conclusion: Reduced monosegen-tal living donor liver transplantation is a feasible option inneonates and extremely small infants with liver failure.

P-549Assessment of the Significance of Local Coagulation Therapyfor Colorectal Liver MetastasisShinpei Ogawa, Michio Itabashi, Shingo KameokaSurgery 2, Tokyo Women’s Medical University, Japan

PURPOSE: The purpose is to assess the significance of local coag-ulation therapy for colorectal liver metastasis. METHODS: Thesubjects consisted of 31 cases (56 tumors) of liver metastasis of col-orectal cancer that underwent MCT or RFA. Study was conductedon the significance of local coagulation therapy for colorectal livermetastasis by analyzing clinical pathological factors. RESULTS:Decreases in CEA values were observed in 29 of the 31 cases,thereby confirming effects in terms of mass reduction. Recurrenceat the treated site was observed in 22 tumors (45.8%). In contrastto the largest axis of the tumor measuring an average of 1.9 cm innon-recurrent tumors, this value was an average of 3.6 cm inrecurrent tumors. In contrast to recurrence being observed in 16of 21 tumors (76.2%) that approached a major vessel such as the

hepatic vein, recurrence occurred at a lower rate in only 5 of 27tumors (18.5%) that did not approach a major vessel. In addition,when examining only tumors measuring 3 cm or smaller which didnot approach a major vessel and which can be expected to be ade-quately cauterized, recurrent tumors were observed in only 4 of 20tumors (20.0%), and the 3 year disease-free survival rates of thesecases was comparatively favorable at 80.8%. CONCLUSIONS:Local coagulation therapy can be expected to demonstrate localcontrol effects comparable to partial liver resection by screeningapplicable cases based on such factors as tumor size and location.

P-550Analysis of the Knot Tying Force in Dog ModelsJunya Oguma, Soji Ozawa, Yasuhide Morikawa, ToshiharuFurukawa, Masaki KitajimaDepartment of Surgery, School of Medicine, Keio University,Japan

Purpose: From our experience of endoscopic surgery using thesurgical robot daVinci at our hospital, it has become clear that thelack of a sense of touch of the forceps makes meticulous operationsdifficult. For the development of a surgical robot that wouldimpart a sense of touch, we investigated the appropriate knot-tyingforce by determining the relation between this force and woundhealing in dog models. Methods: We cut and then sutured thejejnum of Beagle dogs, using a series of knot-tying forces (0.5-5.0N). The jejunum was then removed on the 4th ,7th ,11th and 14thpostoperative days, and the microvessel density and the expressionof bFGF for each force was measured to determine the appropriateknot-tying force for the jejunum. Results: The microvessel densityin the submucosa on the 7th and 11th postoperative days was sig-nificantly higher for theknot-tying force of 1.5 N than for otherforces used. The expression of bFGF in the mucosa on the 11thpostoperative days was significantly higher for theknot-tying forceof 1.5 N than for other forces used. Cicatrization of the wound hadadvanced and the microvessel density had begun to decrease bythe 14th postoperative day. Conclusions: Thus, the results of ourstudy suggested that a knot-tying force of 1.5 N was the mostappropriate force for suturing of wounds of the jejnum. We con-sider that this result would be useful for the development of a sur-gical robot that imparts a sense of touch to the surgeon’s hand.

P-551Surgical Treatment for Unilobar and a few Scattered BilobarHepatic Metastases from Gastric CancerManabu Ohashi, Tatsuo Kanda, Masato Nakajima, Tsutomu Kaibe,Atsushi Matsuki, Satoru Nakagawa, Katsuyoshi HatakeyamaDivision of Digestive and General Surgery, Niigata GraduateSchool of Medical and Dental Sciences, Japan

Aim: To clarify the benefit and limit of surgical treatment forunilobar and a few scattered bilobar hepatic metastases from gas-tric cancer. Materials and Methods: Between 1982 and 2004, 19patients underwent various types of hepatic resection and 23patients were treated by systemic 5-fluorouracile based protocolsor hepatic arterial infusion chemotherapy without hepatic resec-tion for unilobar and a few scattered bilobar hepatic metastases atthe Niigata University Hospital. The overall survival rates of thetwo groups were estimated and a multivariate stepwise analysis offactors related to outcome was performed using the Cox propor-

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tional hazard model. The sites of first recurrence and the diseasefree interval from hepatic resection were identified. Result: The 1-year and 3-year survival rates were 72 % and 27 % in the surgerygroup and 23 % and 0 % in the chemotherapy group. The survivalrate in the surgery group was significantly higher than thechemotherapy group. Multivariate analysis indicated that hepaticresection for metastases was an independent prognostic factor. In14 of 19 patients undergoing hepatic resection, residual hepaticrecurrence or the other types of metastasis developed 3 to 20months after surgical treatment. Conclusions: Surgical treatment isa beneficial option for unilobar and a few scattered bilobar hepaticmetastases. Various types of relapse including residual hepaticmetastases require careful follow-up and an adequate adjuvant pro-tocol.

P-552Gastrointestinal Cancer Discovered on Survey of LiverAbscess: Report of Two CasesHironori Ohdaira1, Ryuzo Murai1, Hideki Matsudaira1, Mitsuo Yabe1,Katsunori Nishikawa1, Hideyuki Suzuki1, Ryoji Mizuno1, SyuichiIwabuchi1, Mitsufumi Abe2, Katsuhiko Yanaga3

1Department of Surgery, 2Department of Pathology, MachidaMunicipal Hospital, 3Department of Surgery, Jikei UniversitySchool of Medicine, Japan

Gastrointestinal cancers rarely manifest clinically as pyogenic liverabscess unless concomitant liver metastases are present. Mostreports describe secondary infections of liver metastases only inpatients with a known malignancy. We herein present two suchpatients. Patient1: A 65-year-old man without past medical historypresented with fever. Abdominal US and CT revealed a solitaryliver abscess of 4×3 cm in size. A search for underlying disease ledto the discovery of sigmoid colon cancer. Under an appropriateantibiotic coverage, his clinical condition improved, and the size ofthe abscess reduced. Sigmoidectomy and liver biopsy was per-formed. Histologic examination ruled out liver metastasis. He hasbeen followed up every two months with CT. At 10 months afterthe operation, he remains well with no clinical evidence of recur-rence. Patient2: A healthy 72-year-old man was admitted with highfever. Abdominal US and CT revealed a solitary liver abscess of5×4cm in size. Gastric endoscopy revealed an ulcerative lesion inthe upper body of the stomach, and biopsy disclosed fragments ofadenocarcinoma. Percutaneous liver biopsy was negative for malin-gancy. Total gastrectomy was performed and histologic examina-tion revealed EBV-associated gastric carcinoma. At 8 months afterthe operation, he remains well with no clinical evidence of recur-rence. Based upon the experience with these two patients, pyo-genic liver abscess of unknown etiology should alert clinicians tosearch for occult gastrointestinal malignancy.

P-553Endoscopic Transanal Decompression with a Newly Devel-oped Drainage Tube for Obstructing Carcinoma of the LeftColon and the RectumSeiji Ohigashi, Ryou Hotta, Gen Shimada, Shintarou Sakurai, Take-ki NishioSurgery, St. Luke’s International Hospital, Japan

Purpose: This study was undertaken to evaluate the usefulness oftrasnanal decompression with a drainage tube for the treatment of

obstructive colorectal carcinoma. Patients and Method: Adrainage tube was introduced fluoroscopically. The bowel contentwas irrigated with saline two or three times a day until fecal mater-ial was disappeared. First, 38 patients who were intended to insertthe tube were examined about the successful ratio, complications,effectiveness of decompression and pathological features. Second,52 patients were divided into two groups of tube-placement(Group A; 34 patients) and non-placement (Group B; 18 patients),for comparison of surgical procedures, operation times, post-oper-ative complications and hospital stay. Results: 1) Placement of thetube could be successfully achieved in 34 of 38 patients with nocomplications excepting one perforated case. In 11 of 34 patients,ulcer formation was observed on proximal site of the tumor as aresult of pressure by the tube tip. 2) No statistical differences wereobserved about the clinical-pathological backgrounds. Single-stageanastomosis was performed in 25 of 36 cases in Group A, while 9of 18 cases in Group B(P=0.019). In patients who underwenttumor resection, there were no statistical differences in curability,numbers of dissected lymph nodes and operation time betweenGroup A and B. However, more frequent wound infection(P=0.011) and longer hospitalization (P=0.047) were noted inGroup B. Conclusion: Placing the trasanal drainage tube was rela-tively easy manipulation and allowed single-stage anastomosis safe-ly, while ulceration was considered to be a matter of careful atten-tion.

P-554Prevention of Postoperative Bowel Obstruction PuttingDenis Tube in the Small Bowel as an Intestinal Stent afterPelvic Exenteration for Rectal CancerShigeo Ohki, Shigeo Ohki, Hideyuki Ike, Yasushi Ichikawa, Syuji Saito,Syoichi Fujii, Shigeru Yamagishi, Syunichi Osada, Tetsuya Shimizu,Hiroshi ShimadaSurgery, Yokohama City University, Japan

Purpose: Bowel obstruction after pelvic exenteration gives patientssevere troubles and results in significant cost. In order to preventpostoperative obstruction, 14Fr. Denis tube (0.4cm in width and240cm in length) was put in the small intestine as an intestinalstent at the time of operation and the effectiveness of this trial wasstudied. Methods and Patients: 12 patients underwent total pelvicexenteratrion and 4 patients were put Denis tube in the smallbowel as an intestinal stent (Denis group), while the others werenot (control group). Between those groups, the amount of gastricjuice from nasogastirc tube, the average period to remove nasogas-tric tube, the average period to begin oral intake and the incidenceof bowel obstruction were compared. Results: At 4-th postopera-tive day, the average amount of gastric juice in Denis group was 0ml, while that in control group was 608ml (significant). The aver-age period to remove nasogastric tube in Denis group was 4.3±1.8days, while that in control group was 7.0±2.5 days (significant).The average period to begin oral intake in Denis group was7.0±2.4 days, while that in control group was 9.0±3.1 days. Theincidences of bowel obstruction in Denis group and control groupwere 0% and 37.5%, respectively. Conclusion: Putting Denis tubeas an intestinal stent after pelvic exenteration is helpful to preventbowel obstruction.


P-555Usefulness of Microwave Tissue Coagulation Therapy forMetastatic Liver TumorKoji Ohta1, Kazuhiro Yoshida1, Yoshiyuki Yamaguchi1, Tetsuya Toge1,Akihiro Sawamura2

1Surgical Oncology, Research Institute for Radiation Biology andMedicine, Hiroshima University, 2Shimura Hospital, Japan

The possible use of microwave tissue coagulation therapy(MCT)for metastatic liver tumor was studied.The subjects were 13patients with one or a few metastatic live tumors less than 4cm indiameter. All patients were received chemotherapy concurrent.Their primary lesions were 7 gastric, 2 mammary, 2 colorectal, and2 pancreatic cancers. The MCT was performed at the output of 30watt for 90 seconds under percutaneous route or 60 watt for 45seconds under laparotomy. We judged complete coagulation of thetumor using Enhanced CT one week later the irradiation.Notumor recurrence was recognized in the complete coagulated areaand median disease free interval was 10.8 months. Their survivalswere from 3 to 56 months and 50% mean survival time(MST) was15 months. The prognosis was especially poor in the patients withpancreatic cancer. Thus, these results suggest that MCT can be auseful tool as a local therapy in the multidisciplinary treatments forpatients with metastatic liver tumor.

P-556Hepatocellular Carcinoma with Severe Jaundice SuccessfullyTreated by Right Hepatic LobectomyTakehiro Ohta, Ryota Higuchi, Tatuo Araida, Masakazu Yamamoto,Ken TakasakiInstitute of Gastroenterology, Tokyo Womens Medical Universi-ty, Japan

The patient is a 53-year-old man. On February, 2004, he present-ed jaundice and was admitted to a local hospital. CT scan showed adiffuse tumor in the right hepatic lobe and tumor thrombus in theportal vein and the right and common bile duct. So he was referredto our institute. PTCD was performed through left hepatic lobe toreduce jaundice. Cholangiography showed a tumor thrombusextended from right hepatic duct to comon bile duct. Because ofhemobilia from tumor thrombus, jaundice was not improved, andthe total bilirubin finally increased to 25.9mg/dl. However, jaun-dice was reduced at time without hemobilia, and bilirubin dosageof bile from the left lobe was 96mg/day. Right hepatic lobectomy,extrahepatic bile duct resection, thrombectomy from the portalvein and the bileduct was performed. Jaundice was graduallyimproved during a postoperative course, and the total bilirubinvalue decreased to 2.3mg/dl two months later. It is considered thathepatectomy for a case of severe jaundice is high risk. However, Itis suggested that measurement of bilirubin dosage from retainedliver became an useful index for a patient with severe jaundice .

P-557Management and Outcome of Bile Duct InjuryTakehiro Ohta, Tatuo Araida, Masakazu Yamamoto, Ken TakasakiInstitute of Gastroenterology, Tokyo Womens Medical Universi-ty, Japan

PURPOSE:To estimate the current management and outcome forbile duct injury. PATIENT AND METHODS:From 1990 to

2003, 24 patients with bile duct injury ( 13 sustained injury inlaparoscopic cholecystectomy amd 11 in open cholecystectomy)were treated in our institute. We divided 24 patients into ninepatients damaged in our institute and 15 patients damaged in otherinstitute and reviewed each treatment and outcome. RESULTS:Asfor injury mode, six patients sustained partial injury, two sustainedcomplete transection and one sustained biliary ligation. Five of 6patients with partial injury underwent simple closure and remain-ing one underwent intereventional tretment.Two patients withcomplete transection and one with bile duct ligation underwentend-to-end choledochocholedochostomy. Except one missingpatient, the postoperative course of all patients was satisfactory,Asregards 15 patients who sustained injury in other institute,Twopatients underwent repair during an operation, but, as for 13remaining patients, injury was overlooked. They produced bileleak and obstructive jaundice postoperatively, and were referred toour institute. Surgical management was already done in otherinstitute with seven patients out of 15. Biliary reconstruction wasperformed in our institute by 11 patients out of 15. As for theremainder, two patients underwent surgical repair, and twopatients underwent interventional management.One patient withhepatic artery and portal simultaneous injury couldn,t do any sur-gical management and died one month later. The postoperativecourse of 14 remaining patients was satisfactory. CONCLU-SIONS:The appropriate surgical treatment for bile duct injuryproduced satisfactory results.

P-558Two Cases with Right-sided Round Ligament Associatedwith Abnormal Intrahepatic Portal Venous BranchingTakumi Ohta1, Akihiro Cho1, Shinichi Okazumi1, HarufumiMakino2, Ryoyu Mochizuki1, Kiyohiko Shuto1, Takayuki Tohma1, Kat-suhiko Matsubara1, Hisashi Gunji1, Koichi Hayano1, Takenori Ochiai1

1Department of Academic Surgery, Graduate School of Medicine,2Research Center for Frontier Medical Engineering, Chiba Uni-versity, Japan

Two cases of right round ligament We present two cases withright-sided round ligament associated with abnormal intrahepaticportal venous branching. Abdominal ultrasonography andenhanced computed tomography showed that the portal trunkgave off the right posterior portal vein, then bifurcated into theright anterior portal vein ( RAPV) and the left portal vein (LPV).LPV did not form the conventional umbilical portion but forkedoff P4, P3, and P2. In contrast, RAPV coursed ventrally, formingthe right umbilical portion. Moreover, both the ventral and dorsalbranches of the anterior segment arose from the cul-de sac of theright umbilical portion. In Case 2, 3D-portocholangiographyshowed that the intrahepatic portal and biliary system had thesame ramification. However, the extrahepatic system had the dif-ferent ramification, in which the right posterior bile duct joinedthe left hepatic duct. Previous reports have described that the rightand left branches arising from the right umbilical portion suppliedthe anterior and medial segments respectively. However, we sug-gest that these branches from the right umbilical portion suppliedthe dorsal and ventral areas of the anterior segment respectively. Inconclusion, this portal anomaly must be kept in mind at liverresection and liver transplantation.

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P-559Claudin-4 is Highly Expressed in Human Gastric CancerSatoshi Ohtani, Masanori Terashima, Michihiko Kogure, YutakaHoshino, Shinichi Matsuyama, Seigo Kashimura, Mika Hoshino,Nobutoshi Soeta, Mitsukazu GotohSurgery 1, Fukushima Medical University, Japan

Claudin is integral constituents of tight junctions. Claudin-4 is alsoknown as a receptor for the cytotoxic Clostridium perfringensenterotoxin (CPE). In order to clarify the function of claudin-4 ingastric cancer and evaluate the possibility of tumor targeted treat-ment for gastric cancer using CPE, we investigated the expressionof claudin-4 in human gastric cancer. Fifty-one gastric cancer tis-sues were obtained from a total of 51 patients who underwent gas-trectomy at Fukushima Medical University from 2000 to 2002.Expression of claudin-4 was investigated using immunohistochem-istry. Claudin-4 expression was observed in 49 of 51 tumor tissuesand all of metaplasitic epitheliums. On the contrary, claudin-4expression was observed in 9 of 51 normal mucosa. There was nosignificant correlation between claudin-4 expression and clinico-pathological features such as depth of tumor invasion, lymph nodemetastasis and prognosis, but strong expression of claudin-4 had atendency of favorable prognosis. Claudin-4 expression is strongerin differentiated adenocarcinoma than in undifferentiated adeno-carcinoma. There was significant difference in claudin-4 expres-sion between well differentiated tubular adenocarcinoma andsignet ring cell carcinoma. Claudin-4 was expressed in gastric can-cer, especially in differentiated adenocarcinoma. This result sug-gests the possibility of tumor targeted treatment for gastric cancerusing CPE. We will investigate the expression of adhesive mole-cule and protein components of the tight junctions such as cad-herin, occludin, and ZO-1 in same specimens and evaluate correla-tion between the expression of these proteins and claudin-4.

P-560Effect of Gastrointestinal Reconstruction on Early Postopera-tive Outcomes after PancreatoduodenectomyTakao Ohtsuka, Kenji Kitahara, Satoru Matsuyama, Tomonori Shi-monishi, Yuji Nakafusa, Kohji MiyazakiDepartment of Surgery, Saga Uniersity Faculty of Medicine, Japan

<Purpose> Several types of gastrointestinal reconstruction havebeen employed after pancreatoduodenectomy (PD), it has been,however, still controversial which type is beneficial. The aim ofthis study was to investigate the effect of gastrointestinal recon-struction on early postoperative outcomes after PD. <Methods>Medical records of 61 patients who underwent PD between 1994and 2003 were reviewed, retrospectively. There were 15 standardPD and 46 pylorus-preserving PD. They were divided into twogroups; Billroth-I (n=25) and -II (n=36) reconstruction. Postopera-tive events and nutritional status were compared between twogroups. <Results> Patients' age, gender, symptoms, diseases, andoperation profiles were same between two groups. Morbidity andmortality were not different between two groups; however, theprevalence of leakage of hepaticojejunostomy was higher in Bill-roth-II groups (0% vs. 22%, P=0.01). All of them were successfullytreated by conservative therapy. The day of resumption of oralintake and postoperative hospital stay were not different betweentwo groups. Both groups showed the similar postoperative nutri-tional status, assessed by body weight, serum albumin and choles-

terol concentrations, and number of lymphocytes, during onemonth after PD. <Conclusions> Bile leakage tends to occur in Bill-roth-II reconstruction after PD; however, this can be managedconservatively, and does not influence morbidity, resumption oforal intake, and hospital stay. Therefore, we cannot clearly deter-mine the advantage of one of the groups in terms of early postop-erative outcomes after PD. Further investigations from anotherpoint of view and long-term follow-up are necessary to clarify theeffect of gastrointestinal reconstruction after PD.

P-561A Highly-sensitive and Quantitative Telomerase ActivityAssay of Pancreatic Juice is Useful for Diagnosis of PancreaticCancer: Analysis of 100 Samples of Pancreatic Juice fromConsecutive PatientsKenoki Ohuchida1, Kazuhiro Mizumoto1, Nami Ishikawa1, NorihiroSato1, Eishi Nagai1, Koji Yamaguchi1, Hideki Takaishi2, ToshinoriIde2, Masao Tanaka1

1Department of Surgery and Oncology, Graduate School of Med-ical Sciences, Kyushu University, Fukuoka, Japan, 2Department ofCellular and Molecular Biology, Hiroshima University School ofMedicine, Hiroshima, Japan

Early detection of pancreatic cancer is difficult even with currentdiagnostic tools. Novel biomarkers and detection techniques areurgently needed. Telomerase activity is a promising diagnosticmarker; however, the conventional telomeric repeat amplificationprotocol (TRAP) assay is not suitable for clinical applicationbecause of its complexity, time-consuming nature and the effectsof PCR inhibitors in samples leading to difficulties in quantifica-tion. We used a hybridization protection assay in combinationwith TRAP (TRAP/HPA) to investigate the effects of PCRinhibitors in pancreatic juice on quantification of telomerase activi-ty and performed analysis of 117 consecutive samples of pancreaticjuice to determine the feasibility of TRAP/HPA for diagnosis ofpancreatic cancer. We found that TRAP/HPA was 1000-fold moresensitive than conventional TRAP, and the effects of PCRinhibitors could be avoided by diluting the samples. In large analy-sis of pancreatic juice with TRAP/HPA, 17 samples were excludedfrom the final analysis because of insufficient follow-up periods.Relative telomerase activities (RTA) in carcinoma samples weresignificantly higher than those in pancreatitis samples and 13(61.9%) of 21 carcinoma samples were over Grade 3, which wasconsidered as positive. Five samples (13.5%) of 37 IPMT werepositive for RTA, whereas high RTA was observed in only one(2.4%) of 42 non-malignant samples. TRAP/HPA can accuratelyevaluate weak telomerase activity in pancreatic juice without theproblem due to PCR inhibitors. This large analysis of non-selectedpancreatic juice samples suggests that TRAP/HPA is a promisingapproach for diagnosis of pancreatic cancer.


P-562Quantitative Assessment of Telomerase Activity Has MorePotential for Diagnosis of Pancreatic Cancer Using Pancreat-ic Juice Than That of H-tert mRNAKenoki Ohuchida, Kazuhiro Mizumoto, Nami Ishikawa, Eishi Nagai,Kouji Yamaguti, Masao TanakaDepartment of Surgery and Oncology, Graduate School of Med-ical Sciences, Kyushu University, Fukuoka, Japan

Measurement of telomerase activity is a potentially promisingdiagnostic tool for pancreatic cancer. Detection of human telom-erase reverse transcriptase (h-tert) mRNA, a catalytic subunit oftelomerase, is also a candidate for the diagnosis of pancreatic can-cer. In the present study, we developed TRAP assay with real timePCR (Real Time TRAP) and a protocol for quantification of h-tertcorrelated with real time PCR. To evaluate the feasibility of thesemethods for diagnosis of pancreatic cancer, we measured telom-erase activity and h-tert expression in a panel of pancreatic cancercell lines, pancreatic tissues, and pancreatic juice samples frompatients with different pancreatic diseases. There were significantcorrelations between telomerase activity and h-tert expression incell lines, tissues and juice samples. The levels of telomerase activi-ty and h-tert expression were significantly higher in tumor tissuesthan in non-tumoral tissues. In pancreatic juice, however, therewere no significant differences in h-tert expressions between thepatients with carcinoma and benign diseases although significantdifferences in telomerase activities were observed. Our presentresults suggest that h-tert is up-regulated in parallel with telom-erase activity in pancreatic cancer; however, quantitative assess-ment of telomerase activity with Real Time TRAP has a higherpotential of diagnosis for pancreatic cancer using pancreatic juicethan that of h-tert mRNA.

P-563Quantitative Assessments of MUCs Family and S100 Familywith Real Time PCR Are Useful for Diagnosis of PancreaticCancerKenoki Ohuchida, Kazuhiro Mizumoto, Nami Ishikawa, Eishi Nagai,Kouji Kamagucti, Masao TanakaDepartment of Surgery and Oncology, Graduate School of Med-ical Sciences, Kyushu University, Fukuoka, Japan

Recent global gene expression database using oligonucleotide andcDNA arrays suggests that MUCs and S100 families are noveldiagnostic markers for pancreatic cancer. In the present study, toinvestigate the feasibility of these candidates as diagnostic markersfor pancreatic cancer, we performed quantitative analysis of thesegenes in 50 resected pancreatic tumor or non-tumoral tissues withreal time PCR. We first designed primer sets for each MUC1, 4,5AC, 6 and S100P, A2, A3, A4, A5, A6, A11, A14 gene and exclud-ed the analysis of S100A3 and A5, since we could not obtain sensi-tive primers for real time PCR. In the analysis of resected tissues,we evaluated the expression of remnant 10 genes normalized by anamount of applied total RNA (absolute quantification) or theexpression of reference genes (relative quantification). In absolutequantification, all the genes showed significantly higher expres-sions in tumor than in non-tumoral tissues. In relative quantifica-tion, we used three major housekeeping genes, GAPDH, PBGDand beta-Actin. When referred to GAPDH, only MUC1 showedsignificant differences between tumor and non-tumoral tissues. In

contrast, when referred to PBGD or beta-Actin, MUC5AC,MUC1, S100P, and S100A6 showed significant differences. PBGDacts as a best reference gene to discriminate tumor from normaltissues; however, the expression of PBGD was undetectable in 55.6% of the small amount of RNA samples. These results suggest thatMUC5AC, MUC1, S100P, and S100A6 are promising diagnosticmakers and that absolute quantification is more useful for detec-tion of differences of target genes than relative quantification.

P-564Radiation to Stromal Fibroblasts Increases Invasiveness ofPancreatic Cancer Cells Through Tumor-Stromal Interac-tionsKenoki Ohuchida1, Kazuhiro Mizumoto1, Mitsuhiko Murakami1, Li-Wu Qian1, Norihiro Sato1, Eishi Nagai1, Kunio Matsumoto2,Toshikazu Nakamura2, Masao Tanaka1

1Department of Surgery and Oncology, Graduate School of Med-ical Sciences, Kyushu University, Fukuoka, Japan, 2Division ofMolecular Regenerative Medicine, Course of Advanced Medicine,Osaka University Graduate School of Medical Science, Suita,Osaka, Japan

Radiotherapy still represents a major treatment option for patientswith pancreatic cancer, but recent evidences suggest that radiationcan promote invasion and metastasis of cancer cells. Interactionsbetween cancer cells and surrounding stromal cells may play animportant role in aggressive tumor progression. In the presentstudy, we investigated the invasive phenotype of pancreatic cancercells in response to co-culture with irradiated fibroblasts. Using invitro invasion assay, we demonstrated that co-culture with non-irradiated fibroblasts significantly increased the invasive ability ofpancreatic cancer cells and, surprisingly, the increased invasivenesswas further accelerated when they were co-cultured with irradiatedfibroblasts. Secretion of the hepatocyte growth factor (HGF) fromfibroblasts remained unchanged after irradiation, whereas exposureof pancreatic cancer cells to supernatant from irradiated fibroblastsresulted in increased expression and phosphorylation of the HGFreceptor c-Met and increased mitogen activated protein kinase(MAPK) activity. We also demonstrated that scattering of pancre-atic cancer cells was accelerated by the supernatant from irradiatedfibroblasts. The enhanced invasiveness of pancreatic cancer cellsinduced by co-culture with irradiated fibroblasts was completelyblocked by NK4, a specific antagonist of HGF. These data suggestthat the invasive potential of certain pancreatic cancer cells isenhanced by soluble mediator(s) released from irradiated fibrob-lasts possibly through up-regulation of c-Met expression/phospho-rylation and MAPK activity in pancreatic cancer cells. Our presentfindings further support the potential use of NK4 during radio-therapy for patients with pancreatic cancer.

P-565Squamous Cell Carcinoma of the Pancreas : Case ReportShou Ohyama, Mitsunori Hoshino, Atsushi Ohta, Reiko Koike, Masa-ki Ohori, Tetsuji Enosawa, Mitsuo KusanoDepartment of Surgery, Showa University, School of Medicine,Japan

Squamous cell carcinoma of the pancreas is rare malignancy, witha reported incidence of 0.5~3.5% of all pancreatic neoplasms . Wereview the case report of a 73-year-old male. An abdominal com-

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puted tomography examination demonstrated a tumor in the tail ofthe pancreas ( 44mm ). A laparotomy was performed and thetumor was removed. The patient underwent complete surgicalresection. The microscopic diagnosis was squamous cell carcinomawith poorly differentiated carcinoma. During the subsequent 8-month follow-up, no local or systemic recurrence was observed.These tumors usually have a very poor prognosis. Nevertheless,favorable outcome seems possible, as exhibited in our patient.

P-566Undifferentiated Carcinoma of the Liver in a Patient withChronic Renal FailureKoichi Oishi, Toshiyuki Itamoto, Hideki Nakahara, Hideki Ohdan,Hirotaka Tashiro, Toshimasa AsaharaDepartment of Surgery, Division of Frontier Medical Science,Hiroshima University, Japan

Undifferentiated carcinoma of the liver is rare. We experienced apatient receiving hemodialysis who has survived for a long periodafter hepatectomy for undifferentiated carcinoma and moderatelydifferentiated hepatocellular carcinoma (HCC) of the liver. A 51-year-old man with chronic hepatitis C who had received hemodial-ysis for diabetic nephropathy was referred to our hospital withhepatic tumors in October 2000. Abdominal computed tomogra-phy (CT) revealed two nodules in the liver, one (55 mm in diame-ter) located in segment 5 and the other (58 mm in diameter) locat-ed in segment 3. Serum levels of alpha-fetoprotein and prothrom-bin induced by vitamin K absence or antagonist-II had markedlyincreased to 24159 ng/ml and 892 mAU/ml, respectively. He wasdiagnosed as having advanced HCCs and underwent subsegmen-tectomy (segment 5) and partial resection (segment 3) of the liver.At operation, macroscopic tumor thrombus was seen in the portalvein of segment 5. Macroscopic finding of the liver was macron-odular cirrhosis. Histopathological examination revealed undiffer-entiated carcinoma (spindle cell type) with portal vein infiltrationin segment 5 and moderately differentiated HCC in segment 3. Hewas discharged 30 days after surgery with no complications. Hehas been followed-up by measurements of levels of tumor markersevery month and by ultrasonography and CT every 3 months andevery 6 months, respectively. The patient is currently receivinghemodialysis and has had no HCC recurrence for 42 months sincehepatic resection. We report a hemodialysis patient with advancedundifferentiated HCC.

P-567Induction of CEA Specific Cytotoxic T Lymphocytes UsingDendritic Cells Adenovirally Transduced with CEA GeneToshiyasu Ojima, Makoto Iwahashi, Masaki Nakamura, Kenji Mat-suda, Teiji Naka, Mikihito Nakamori, Kentaro Ueda, Koichiro Ishi-da, Hiroki YamaueSecond Department of Surgery, Wakayama Medical University,School of Medicine, Japan

(Purpose) Genetically modified Dendritic cells (DCs), whichexpress tumor-associated antigen, can efficiently induce antitumorimmunity. Recently, several groups have identified that maturity ofthe applied DCs has a significantly impact on the outcome of thevaccination, and a streptococcal preparation OK-432 could be usedfor stimulating the maturation of human DCs. The purpose of thisstudy was to assess whether in vitro CTL induction using geneti-

cally engineered DCs expressing CEA resulted in generation of apotent CEA-specific immunity. Futhermore, we investigatedwhether OK-432 stimulation of DCs could elicit much morepotent immunity. (Methods) DCs (A24/02) were transfected withadenoviral vector AxCACEA expressing CEA, and then, were cul-tured in various conditions (TNF-α, LPS, OK-432). After 48h,DCs were used as stimulator cells, and autologous PBMCs wereused as responder cells. After 2 rounds of restimulation with genet-ically modified DCs, a cytotoxic assay was performed in a 51Cr-release assay. CEA cDNA-transfected autologous EBV-LCLs andHLA-A24 positive human cancer cell lines were used as targetcells. (Results) The cytotoxic activity induced by stimulation of allgroups/DC-AxCACEA showed killing activity against LCL-AxCACEA, although these CTLs did not recognize LCL-AxCALacZ (controls). OK-432-stimulated DCs induced the mostpotent cytotoxic activity against LCL-AxCACEA, and not againstcontrols, and also these CTLs showed cytotoxic activity onlyagainst MKN45 and HT29, which endogenously express CEA. Inconclusion, genetically engineered DCs to express CEA were veryusefull for the generation of a potent CEA-specific immunity.Moreover, the stimulation of DCs with OK-432 were suitable forthe maturation in this system.

P-568Oozing and Hemorrhagic Ulceration in an Interposed JejunalPouch: An Unusual Complication after Proximal Gastrectomy- Report of Three CasesYoshio Oka, Junichi Nishijima, Masaaki IzukuraSurgery, Higashiosaka City General Hospital, Japan

Proximal gastrectomy followed by interposition of a jejunal U-shaped pouch has recently been performed for early cancers of theupper portion of the stomach. We present here three cases withan unusual complication, bleeding in a jejunal pouch, after proxi-mal gastrectomy. Case 1 was a 53-year-old man who underwent aproximal gastrectomy and interposition of a jejunal pouch for gas-tric cancer. One month after the operation, he visited our hospitaldue to hematemesis. Emergent esophagogastroscopy revealedoozing from the side-to-side anastomosis of the pouch. Bleedingwas uncontrollable, and then emergent operation was required.Case 2 was a 70-year-old man who underwent a proximal gastrec-tomy and interposition of a jejunal pouch for gastric early cancer.Four months after the operation, he was referred to our hospitaldue to hematemesis. Emergent esophagogastroscopy revealed dif-fuse erosion and a hemorrhagic ulcer in a jejunal pouch near thejejunogastric anastomosis. Endoscopic clipping was successfullyperformed. Case 3 was a 69-year-old woman who underwent aproximal gastrectomy and interposition of a jejunal pouch for gas-tric cancer in other hospital. Four years and 6 months after theoperation, she complained of hematemesis and tarry stool. Emer-gent esophagogastroscopy revealed a hemorrhagic ulcer in a pouchwhich was located near the anastomosis with the remnant stomach.Endoscopic clipping was performed. The serum concentrations ofgastrin were elevated in all cases. Conclusion: After proximal gas-trectomy, serum gastrin may be secreted without negative feed-back. This may be implicated in the formation of hemorrhagiculcer and oozing in an interposed jejunal pouch.


P-569Apoptosis of Tumor-Infiltrating Lymphocytes (TIL) in Col-orectal Liver Metastasis and Possible Participation of Recur-rence in the Remnant LiverKazuya Okada1, Ko Komuta2, Sadayuki Okudaira2, Takashi Kanematsu2

1Department of Surgery II, Nagasaki University Graduate Schoolof Biomedical Sciences, 2Nagasaki University Graduate School ofBiomedical Sciences, Japan

[Purpose] Density of tumor-infiltrating lymphocytes (TIL) wasfound to correlate with survival in colorectal carcinoma patients.In addition, apoptotic depletion of TIL induced by Fas-FasLand/or RCAS1-RCAS1 receptor interaction may allow the tumorcells to escape from immunological surveillance. The presentstudy was carried out to determine whether frequency of apoptoticTIL in colorectal liver metastasis participate in recurrence afterhepatic resection and its prognosis. [Methods] A total of 58patients with isolated liver metastasis from colorectal carcinomaswere performed curative hepatic resections. Of these, 32 patientswith liver metastasis were investigated apoptotic cells of TIL usingnonradioactive in situ nick translation (ISNT) in paraffin-embed-ded sections. [Results] The ISNT labeling index (LI) determinedas the number of positive nuclei per 1000 nuclei of TIL in tissuesections ranged from 2-35, with a mean of 13 in all tumors. TheISNT LI of colorectal liver metastasis with recurrence after hepat-ic resection was higher than that of colorectal liver metastasis with-out recurrence. Patients with a high LI subgroup (>11) had a sig-nificantly poorer prognosis than those with a low LI subgroup.We also investigated RCAS1 expression by immunohistochemicalexamination using anti-RCAS1 22-1-1 antibody. The proportionof apoptotic TIL was higher in RCAS1-positive metastasis than inRCAS1-negative one. [Conclusions] Our results suggest that theapoptosis of TIL in colorectal liver metastasis induced byRCAS1/RCAS1 receptor system may affect the recurrence afterhepatic resection and its poorer prognosis.

P-570Laparoscopy Assisted Low Anterior Resection with Mini-Laparotomy for Rectal CancerMasaki Okada1, Masayuki Kojima1, Hisanaga Horie1, Fumio Konishi2,Hideo Nagai1

1Surgery, Jichi Medical School, 2Jichi Medical School, OmiyaMedical Center, Surgery, Japan

AIM: To introduce our method of laparoscopic operation forpatients with lower rectal cancer. The method consists of bothlaparoscopic technique and conventional operation under mini-laparotomy. METHOD: Firstly, we perform the laparoscopic pro-cedure through three or four ports: ligation of the inferior mesen-teric artery with lymph node dissection, and mobilization of thedescending and sigmoid colon. Secondly, we make an 8 cm inci-sion on the lower abdomen. Through the mini-laparotomy, weperform TME (total mesorectal excision) and fashion anastomosisin the same way as the conventional operation. The surgeon canobtain an appropriate view by moving the rectum with his or herhand. The assistant inserts a scope into the pelvic cavity to providelight for the surgeon and a view in the laparoscopic monitor.RESULTS: 36 patients underwent the operation. The sites of thelesion were 20 in the middle rectum and 16 in the lower rectum.

The methods of anastomosis were 31 in the double stapling, one inthe single stapling, 4 in the colonic J-pouch anal anastomosis viaanus. In 6 of 36 postoperative complications were occurred ; anas-tomotic leakage, anastomotic bleeding, drain infection, lymphor-rhoea. CONCLUSION: The most difficult point in the laparo-scopic low anterior resection for rectal cancer is generally thoughtto be obtaining an appropriate view of the pelvic cavity. Ourmethod can offer a good view and gentle manipulation of the rec-tum by hand. Furthermore, the laparoscopic technique can be con-verted to a conventional method whenever required.

P-571Hepatocellular Carcinoma (HCC) in a Patient with ChronicB-type Hepatitis Complicated by Autoimmune HemolyticAnemia (AIHA)Toshie Okada, Junji Kita, Yoshiaki Mihara, Masato Katoh, TakehikoNemoto, Keiichi KubotaDepartment of Gastroenterological Surgery, Dokkyo UniversitySchool of Medicine, Japan

A 57-year-old man was diagnosed as having B-type hepatitis at theage of 37 and had let the liver dysfunction untreated over 20 years.Since slight fever continued, he consulted a nearby hospital. Hewas diagnosed as having chronic B-type hepatitis, liver cancer, andmacrocytic anemia, and was referred to our hospital for furtherinvestigation. A HCC with maximum diameter of about 5cm wasdetected in the segment 8. Blood test showed as followings; serumtotal bilirubin ; 1.8mg/dl, indirect bilirubin ; 0.9mg/dl, haptogu-lobin ; less than 10mg/dl, hemoglobin ; 8.4g/dl, MCV ; 130fl,reticulocyte ; 14.5%. Bone marrow showed erythroid hyperplasia.Direct coombs test was positive. We diagnosed the anemia asAIHA, for which predonisolone could not be administered due tothe positive HBsAg and HBeAg. As preparing washed blood cells,he underwent systematic resection of segment 8. Pathologic diag-nosis was as follows; moderately differentiated HCC, single nodu-lar type, vp1, Stage three. On the 9th postoperative day, as histemperature rose up to 38°C, hemolysis proceeded; maximumvalue of total bilirubin was 5.8mg/dl and minimum of hemoglobinwas 4.6g/dl. He tolerated this period without blood transfusion.Now he is followed up at out-patient clinic, and there are no signsof recurrence of HCC and no symptoms of anemia. AIHA hasbeen described in only three cases in association with the infectionof HBV and our case is the first report in which the operation wasperformed for HCC complicated by AIHA.

P-572Nerve Growth Factor Enhances the Activity of MMP-2 andthe Expression of MT1-MMP in Human Pancreatic CancerCellsYuji Okada1, Yoichiro Matuo2, Hiroki Takahashi2, MinoruYamamoto2, Hitoshi Funahashi2, Tadao Manabe2

1Department of Gastrointestinal Surgery, 21st Department ofSurgery, Nagoya City University, Japan

Background: Pancreatic cancer (PaCa) shows a preference forinvading and migrating along perineural tissue and this has prog-nostic significance. However, the exact mechanisms underlyingthis phenomenon are unknown. We hypothesize that nerve growthfactor (NGF) released from neural tissue is critical for attractingPaCa cells. In a previous study, we have shown that the glial cell-

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derived neurotrophic factor is present in celiac ganglia and increas-es pancreatic cancer cell invasion. Aim: In this study, we sought toinvestigate the effect of the neurotrophic factor NGF on theexpression and activity of matrix metalloproteinases (MMP-2 andMT1-MMP) in human PaCa cells. Methods: RT-PCR was usedto detect NGF receptor mRNA in six human PaCa cell lines. Cellswere exposed to increasing concentrations of human NGF for 24hrs. Concentrated cell culture medium was subjected to Westernblot to determine the expression of MMP-2 protein. The activityof MMP-2 was analyzed by gelatin zymography. MT1-MMP pro-tein expression in total cell lysate was analyzed by Western blot.Results: NGF dose-dependently increased pro MMP-2 proteinexpression in the conditioned medium. Treatment with NGFdose-dependently increased both pro and active form of MT1-MMP protein in total cell lysate. Gelatin zymography revealedthat NGF enhanced MMP-2 activity in a dose dependent manner.Conclusion: NGF dose dependently stimulates MMP-2 andMT1-MMP protein expression and increases MMP-2 activity inhuman PaCa cells. These data suggest a proinvasive effect of NGFon PaCa cells.

P-573Surgical Treatment for Relief of Severe Pain Derived fromChronic PancreatitisYuji Okada1, Youichi Matsuo2, Hiroki Takahashi2, MinoruYamamoto2, Hitoshi Funahashi2, Hirozumi Sawai2, Tadao Manabe2

1Department of Gastrointestinal Surgery, 21st Department ofSurgery, Nagoya City University, Japan

Background: Chronic pancreatitis is characterized by progressiveand irreversible loss of structure and function. The major compli-cation of this disease is a continuous abdominal pain. Aim: Theaim of this study is to evaluate the effectiveness of surgical treat-ment aimed for the relief of severe pain derived from chronic pan-creatitis. Methods: Nineteen chronic pancreatits patients withsevere pain resistant to a previous conservative medical and/orinterventional treatment have taken surgical procedures in ourdepartment. We evaluated a difference regarding to the postopera-tive improvement of the symptoms between in patient with surgi-cal procedure including nerve plexus resection and non-resectiongroup. Results: The mean follow-up interval after surgery was59.7 months (range 3.0-187.3 months). Of 19 patients, 14 (73.7%)underwent nerve plexus resection. The relief of the symptoms wasobserved in 16 of 19 patients (84.2%). Fourteen of the 15 patients(93.3%) in the nerve plexus resection group were relieved fromtheir symptoms after surgical procedure, compared to only two offour (50%) patients in the nerve plexus non-resection group. Con-clusion: We conclude that the surgical procedures with nerveplexus resection for appropriately matched individual patients aresafe and could contribute to the improvement of the quality of lifefor chronic pancreatitis patients resistant to conservative treat-ments.

P-574A Case of Esophageal CarcinosarcomaYasushi Okazaki, Shinichi Miyazaki, Taito Aoki, Hideaki Shimada,Hisahiro Matsubara, Shinichi Okazumi, Tetsurou Urashima, AkiraShiratori, Kiyohiko Shutou, Takenori OchiaiDepartment of Academic Surgery, Graduate School of Medicine,Chiba University, Japan

Carcinosarcoma of the esophagus is comparatively rare malignanttumors composed of carcinoma and sarcomataous elements. Wereport a case of esophageal carcinosarcoma and reviewed some lit-erature. A 55-year-old man visited our hospital because of difficul-ty in swallowing since about four months ago. Barium swallowesophagogram showed a large polypoid lesion in the lower tho-racic esophagus. Endoscopy also demonstrated a bulky intralumi-nal polypoid tumor. Histological examination of the biopsy speci-men revealed carcinosarcoma. Thoracic esophagectomy with cer-vical, thoracic, abdominal lymph node dissection was performed.Pathological classification was pT3, pN1, pM0, stage III. Thispatient died about one year after the operation due to multipleliver and lung metastasis. Since 1965 there were 860 neoplasms ofthe esophagus, 7 (0.8%) carcinosarcoma, operated at our hospital.It was good prognosis for early cases without metastases to lymphnodes, but it caused local recurrence or distant metastasis in post-operative early period for advanced cases with metastases to lymphnodes like this case. As standard procedure, radical esophagectomywith lymph node dissection is necessary for carcinosarcoma of theesophagus.

P-575Survival after Curative Resection of Lymph Node NegativeT2-4 Colon CancerAtsushi Okita, Yoshiro Kubo, Akira Kurita, Naruto Taira, MinoruTanada, Shigemitsu TakashimaSurgery, Shikoku Cancer Center, Japan

Purpose: The aim of this study was to assess the risk factor ofrelapse and survival in patients with node-negative T2-4 coloncancer. Methods: Between 1995 and 2000, 219 patients underwentcurative resection and histologically diagnosed as node negativeT2-4 colon cancer. Analyses were carried out to evaluate theimpact of clinicopathological factors on disease-free survival andoverall survival. Factors were as follows; age, gender, tumor loca-tion, depth of tumor invasion and vessel involvement. The log-rank test and Cox regression analysis were performed and a p-value < 0.05 was considered significant. Results: There were 123men and 96 women, with a mean age of 66.3 years. There were 37patients of T2, 171 patients of T3 and 11 patients of T4. After amedian follow-up of 69.5 months, recurrences were occurred in 19patients, and 29 patients were died. In the univariate analysis, adepth of tumor invasion and lymphatic invasion were significantlyassociated with an increased risk of recurrence (p< 0.05). But therewere no significant prognostic factors according to overall survival.In multivariate analysis, there were no independent prognostic fac-tors of recurrence. Conclusion: This study did not identify a sig-nificant risk factor of recurrence in patients with node-negativeT2-4 colon cancer. Further challenge remains in discoveringmarkers reflecting accurate metastatic potential.


P-576Recombinant G-CSF Facilitates Upregulation of MMP-13Transcription in Adhesive Colon Tissue and ImprovesIntrabdominal Adhesion after SurgeryJiro Okiyama, Keisuke Hayamizu, Koichi Ohishi, Masanori Yosimitu,Xueheleti Aihaiti, Masazumi Okajima, Toshimasa AsaharaSurgery, Division of Frontier Medical Science, Programs for Bio-medical Research, Hiroshima University, Japan

‹Purpose›Postoperative intrabdominal adhesion is a major clinicalproblem, which could cause abdominal pain, bowel obstructionand infertility. Recent studies demonstrated that matrix metallo-protenases (MMPs) play a key role in regulating development ofthe adhesion. We evaluated preventive effects of treatment withrecombinant human granulocyte colony-stimulating factor (rhG-CSF) against intestinal adhesion after surgery since it is reportedthat rhG-CSF induces MMP-9 secretion by various cells. ‹Meth-ods›We established a Sprague-Dawley rat caecum adhesion modelby ablating 1 cm2 of serosa of the caecum and by fixing it to theperitoneum. On day 7, degree of adhesion was evaluated by mea-suring tension that is required for separating the caecum and theabdominal wall. Total RNA was extracted from the adhesive tissueand mRNA levels of MMPs and their inhibitors were quantified byRT-real-time PCR. ‹Results›The tension for separation was 179±13 gram-weight in control (n=6) and 123 ±17 gram-weight in ani-mals which had been treated with rhG-CSF (250 microg/day s.c.)on day -5 to 5 (P<0.05). Transcription levels of MMP-8, MMP-2or TIMP-2 were not significantly changed after surgery comparedto normal caecum tissue. On the other hand, mRNA levels ofMMP-9 and MMP-13 were upregulated and those of TIMP-1were downregulated significantly (P<0.05) after surgery. Notably,transcription levels of MMP-13 only were further elevated by therhG-CSF treatment (P<0.01) but TIMP-1 levels were unchanged.‹Conclusion› Treatment of hosts with rhG-CSF lessened intestinaladhesion in a rat model, which is associated especially with facilita-tion of MMP-13 transcription in the adhesion tissue.

P-577Minimally Invasive Methods in Diagnostics and Treatment ofPurulent CholangitisM. Okoemov, A. Mashinsky, A. Lotov, N. Kuzin, S. KharnasMoscow Medical Sechenov Academy, Russia

AIMS. To estimate the diagnostics and treatment results ofobstructive jaundice (OJ), complicated by purulent cholangitis(PC) using mini-invasive surgical technologies. PATIENTS ANDMETHODS: non-invasive diagnostic methods (US, CT, MRT,MRHPG) and mini-invasive surgical technologies used for 76patients with OJ of different genesis complicated by PC. OJ of 24patients (31%) was caused by malignant liver neoplasms, biliarytracts, pancreas; 52 patients had OJ of benign genesis. The patientswith cholangiolithiasis suffered from OJ and PC more often -73,2% (38) cases. RESULTS: The obstructive character of jaun-dice was diagnosed with all patients after US examination. Thecause of OJ was detected with 52 patients (68,4%), the block level-with 64 (84,2%). To verify the diagnosis and define further treat-ment the patients went under MRT in combination with MRholangiopancreaticography (MRHPG). MRT and MRHPG sensi-tivity of cholangitis was 100%, specificity-94,5%, total accuracy-96,2%, at strictures of biliary tracts: 98,6%, 96,2% respectively. At

pancreas head cancer sensitivity was 93,5%, specificity-95,5%,total accuracy-95,1%, metastatic liver affection-100%, 97,4%,97,5% respectively. Transhepatic cholangiography was used atupper blockage, proceeded by percutaneous transhepatic cholan-giography. At PC we give preference to external cholepoiesis bymini-invasive surgery at the first stage. That allows us to do sana-tion followed by radical treatment. CONCLUSIONS: The appli-cation of non-invasive diagnostics (US, CT, MRT, MRHPG)allows us to increase the diagnostic efficiency up to 97,8% andreduce the time of diagnostic search.

P-578Clinical Study of Colorectal Perforation Caused by Obstruc-tive Colorectal CancerKatsuhiko Okubo, Saburo Murakami, Yutaka Yoshida, Hideto Saka-ta, Toru Ishiguro, Masataka Kikuchi, Kennichi Suto, Taiju Hashimo-to, Yoshitaka Tsuji, Setsuo Hamada, Renzo HirayamaDepartment of Surgery, Saitama Medical School, Japan

(Purpose) We investigated the characteristics and strategy of col-orectal perforation caused by obstructive colorectal cancer. (Sub-jects) 546 cases had been admitted to our department with colorec-tal cancer for these eight years. 45 of these cases (8.2) had demon-strated the ileus sign by colorectal cancer. Among these cases, 10cases (male 7, female 3, average age 76 y.o.(67-84)), who had col-orectal perforation, are enrolled in this clinical study. (Results)Localization were 5 in sigmoid colon, 3 in ascending colon, and 2in rectum. The duration from the onset of the perforation to theoperation were 6-26 hours (average 11.9 h.). Surgical procedureshad been performed for all cases (Hartmann's operation 7, primaryanastomosis with oral artificial anus 2, and primary anastomosiswithout artificial anus 1). The operation times were 1.5-3.5 hours(average 2.6 h.). Macroscopic figures demonstrated that the lesionsof colorectal cancer were occupied as circle or near-circle andshowed type 2 or 3 in all cases. The postoperative mortality was30% (3/10). These three lethal cases were all high-aged (75-84y.o., average 79 y.o.) and had not undergone the dialysis of filtrat-ing for endotoxin. On the other hand, all 5 cases, who had beenperformed the dialysis of filtrating for endotoxin, were alive, andhad been discharged healthy. (Conclusions) The prognosis of col-orectal perforation caused by obstructive colorectal cancer is gen-erally poor. However, early diagnosis and surgical treatment withthe postoperative dialysis of filtrating for endotoxin are conceiv-able to be beneficial for the progress of the prognosis in thesepatients.

P-579Overexpression of Autocrine Motility Factor Receptor(AMFR) in NIH3T3 Fibroblasts Induces Cell TransformationYasuharu Onishi1, Avraham Raz2, Kenichi Tazawa1, TakuyaNagata1, Kotaro Sasahara1, Satochi Nozawa1, Tadashi Bando1, HidekiAbe1, Fuminori Yamagishi1, Shinichiro Hirokawa1, KazuhiroTsukada1

1Second Department of Surgery, Toyama Medical and Pharma-ceutical University, Japan, 2Karmanos Cancer Institute, USA

[Purpose]Despite the advances in diagnostic techniques for earlydetection of malignant tumor and the significant improvement intherapeutic procedures, the mortality rate of cancer has beenincreasing year after year, and the most frequent cause of death by

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cancer is metastasis. Therefore, elucidation of metastasis mecha-nism is one of principal subjects in cancer study and would lead todevelopment of new treatment method. Autocrine motility factorreceptor (AMFR) is a cell surface glycoprotein of molecular weight78000 (gp78), regulating cell motility signaling in vitro and metas-tasis in vivo. The purpose of this study is to test whether AMFRcould be a common mediator of transformation and oncogenicitself. [Methods and Results] We transfected NIH3T3 fibroblastcells with expression vectors carrying the full-length cDNA formouse AMFR and evaluated the effects of increased AMFR ontransforming potential. The cells stably expressing high levels ofAMFR as a result of transfecion displayed a complete morphologi-cal change and acquired the ability to grow in low serum. Further-more, they were anchorage-independent for growth in soft agarand more motile in phagokinetic track assay. Interestingly, theenhanced expression of AMFR produced tumors in nude mice.[Conclusion] Our findings provide a direct evidence that overex-pression of the AMFR is associated with the acquisition of a trans-formation phenotype.

P-580Imaging of Adenoviral Replication with a FluorescentReporter in the E3 Region without Hampering CytopathicEffectHidetaka Andrew Ono1, Long P. Le1, Julia G. Davydova1, ChikaraKunisaki2, Hiroshi Shimada2, David T. Curiel1, Masato Yamamoto1

1Division of Human Gene Therapy, Departments of Medicine,Pathology and Surgery, and the Gene Therapy, University ofAlabama at Birmingham, USA, 2Second Department of Surgery,Yokohama City University School of Medicine, Japan

Adenoviral vectors offer promise for gene therapy of various dis-eases. One recent development in this area is conditionally replica-tive adenoviruses (CRAds) which selectively kill cancer cellsthrough tumor-specific replication. To maintain safety and practi-cally apply these agents in a clinical context, a non-invasive detec-tion system of viral replication is required. Current adenovirusdetection methods are not suitable for monitoring dynamic eventsand isolated such as viral replication in clinical context. To addressthese issues, we hypothesized that expression of a reporter genefrom a replicative adenovirus would yield valuable information onviral replication noninvasively. We constructed Ad5∆E3ADPF bydeleting the E3 region but retaining the adenovirus death protein(ADP) since this viral product is required for efficient cell lysis andviral release. Using this construct, we generated six different vec-tors with EGFP in six different configurations (forward / reversedirections and three reading frames). Vectors with the EGFP cas-sette in the forward direction expressed EGFP in A549 (humanlung carcinoma cell line), not in BNL1NGA.2 (mouse hepatomacell line) in which human adenovirus can infect but not replicateproductively. These EGFP expressions were correlated with DNAcopy number of viral E4 DNA. In addition, this construct didn’thamper the viral cytopathic effect. In vivo experiment, signal ofEGFP was increased in A549 subcutaneous xenograft model. Ourdata suggest that our novel imaging system may provide a simpleand convenient way to monitor viral replication in preclinical andclinical settings without hampering the viral cytocidal effect.

P-581Enhanced IFN-gamma Production and Bacterial Clearance inthe Liver of Splenectomized Mice in the Models ofEscherichia Coli Injection or Intestinal ObstructionSatoshi Ono1, Shin-Ichi Ikuta1, Manabu Kinoshita2, Hironori Tsuji-moto1, Shuhji Seki3, Kazuhiko Fukatsu2, Hoshio Hiraide2, TakashiIchikura1, Hidetaka Mochizuki1

1Department of Surgery I, 2Division of Basic Traumatology,3Department of Microbiology, National Defense Medical College,Japan

Although several studies have reported that splenectomy increasessusceptibility to bacterial infections, it still seems to be controver-sial whether splenectomy itself induces an increased susceptibilityto bacterial infection. We therefore studied the effects of splenec-tomy on host defense against bacterial infection, focusing on thecytokine-related immune response, in the models of E.coli chal-lenge and intestinal obstruction. Methods: Using C57BL/6 miceat 4 weeks after splenectomy or a sham operation, either E.coli wasinjected or intestinal obstruction was made to examine the mortali-ty, serum cytokine levels, cytokine production of the livermononuclear cells (MNCs), and bacterial clearance in the liver.Result: No differences were observed in survival rates after E. colichallenge between the mice with and without splenectomy. How-ever, in a model of intestinal obstruction, splenectomized micesurvived significantly longer than the sham-operated mice. LiverMNCs from splenectomized mice produced a significantly largeramount of IFNgamma compared to those from sham-operatedmice. Furthermore, bacterial counts in the liver at 2 hrs after E.coli injection and at 24 hrs after intestinal obstruction were signifi-cantly decreased in splenectomized mice compared to sham-oper-ated mice. Conclusion: Splenectomy does not impair host defenseagainst bacteria infection provided that recovery is sufficient toallow compensatory processes in the liver to occur.

P-582Helicobacter Pylori Related Chronic Mucosal Inflammation inGastric Remnant after Distal Gastrectomy for Primary Gas-tric CancerNaoyoshi Onoda, Kei Katsuragi, Aya Mino, Kiyoshi Maeda, TetsujiSawada, Yoshito Yamashita, Nobuya Yamada, Masaichi Ohira, Tet-suro Ishikawa, Kosei HirakawaSurgical Oncology, Osaka City Univ. Graduate School of Medi-cine, Japan

Purpouse: The remnant stomach after surgery for gastric canceris at high risk for the development of second primary cancers. Weexamined H. pylori infection in gastric remnant after distal gastrec-tomy for primary gastric cancer and investigated the relationshipbetween H. pylori infection and chronic mucosal inflammation.Methods: One hundred-nine patients who had been performedgastrectomy were studied. Endoscopic findings and results fromurease test, bacteriologic assessment, serological test, histopatho-logical examination were analyzed. Twenty-seven H. pylori-positivepatients were treated with amixicillin 500 mg, clarithromycin 800mg and rabeprazole 20 mg daily for 7 days. Results: Seventy-onepatients (65.1%) were judged positive for H. pylori infection. Theprevalence of H. pylori infection was found to decrease significantlyin older cases, cases that passed long after operation, cases withsymptoms, or cases with severe reflux gastritis. On the other hand,


histologically chronic and acute gastritis correlated significantlywith H. pylori infection. H. pylori prevalence was the most frequentin the mild atrophic mucosa and was decreased along with thecompletion of atrophic change. Eradication was successful in 25cases (92.6%), and eradication therapy resulted in a significantdecrease in inflammatory cell infiltration of the mucosal layer.Conclusions: Persistence of H. pylori-related active gastritis aftergastric cancer surgery was suggested in the gastric remnant ofyoung patients with mild atrophic gastritis and without reflux gas-tritis. Eradication therapy was as effective and safe in the remnantstomach as in non-operated stomach to minimize the mucosalinflammation.

P-583Regulation of Perioperative Immunological Changes Follow-ing Laparotomy with Biological Response Modifier (BRM)Mitsuru Ooshiro, Yutaka Yoshida, Yu-I Sugishita, Hiroshi Tanaka,Kazuki Koide, Makoto Nagashima, Miyoji Wakabayashi, RyojiKatoh, Muneyuki YamaguchiDepartment of Surgery, Toho University Sakura Hospital, Japan

<Purpose> Immune responses have been reported to decline fol-lowing surgical stress, leading to the growth of tumors. In thisstudy, we report that preoperative treatment with Protein-boundpolysaccharide Kureha (PSK) can inhibit the decline of immuno-competence during the perioperative period. <Methods> BALB/cmice were laparotomized and the intestinal tracts were exposed toroom air for 1.5 hours. Six hours after the operation, the concen-trations of IL-6 in the serum and of IFN γ and IL-4 in the super-natant of splenocyte cultures were measured. <Results> The IL-6concentration was significantly elevated in the group with surgicalstress versus in the group that received surgical stress and the PSKtreatment. IFN γ was lower in the group with surgical stress thanin the control group. The IFNγ concentration in the group withsurgical stress plus PSK treatment was significantly higher than inthe group with surgical stress alone. The IL-4 concentration wassignificantly lower in the surgical stress group than in the controlgroup, however, the IL-4 concentration tended to be higher in thesurgical stress plus PSK treatment group than in the group withsurgical stress alone. The IFNγ/IL-4 ratio in the group with surgi-cal stress was lower than the ratio in the non-treated group. Theratio in the group with surgical stress plus PSK treatment was sig-nificantly higher than the ratio in the group with surgical stressalone. <Conclusion> These suggested that PSK restores theimmunological abnormality induced by surgical stress and correctsthe reduced Th1/Th2 to a normal level.

P-584Clinical Significances of Signal Transduction Related Proteinto Estimate the Features of Hepatocellular Carcinoma (HCC)Shinji Osada, Hisashi Imai, Nozomi Amaoka, Yasuyuki Sugiyama,Yosuke AdachiSurgical Oncology, Gifu University School of Medicine, Japan

Purpose: To estimate the feature of HCC, the clinical significancesof signal transduction related proteins, Hepatocyte Growth Factor,and its receptor (c-met), extracellular signal-regulated kinase(ERK) and cyclin D1 (CD), was studied. Methods: The resectedspecimens of 30 HCCs in recent 2 years were analyzed by westernblotting. Results: 1. The expression of ERK was higher in cancer

tissue, compared with non-tumor tissue, and in advanced caseswith vessel invasion, positive intrahepatic metastasis (IM), and his-tological types. The value of ERK was showed correlation with c-met level or tumor diameter and higher in over-expression cases ofHGF and c-met in cancer tissue. Over-expression of ERK wasrelated with histological types. 2. The detection of CD was simi-lar in both cancer and non-cancer tissue. It was higher inadvanced cases of positive IM and progressive histological types.The value of CD expression was higher in over-expression cases ofERK significantly. 3. The CD level in non-cancer tissue wasclearly higher in poor liver function cases. 4. The presence of IMwas found frequently in the cases of high ERK with high c-metexpression. The anatomical hepatectomy could suppress the earlyrecurrence of HCC even in the cases of high ERK with high c-metdetection. Conclusion: The study about signal transduction relat-ed proteins was useful to estimate the features of HCC and predictthe therapeutic effect.

P-585Significance of Perforin Positive Cell in Peripheral LiverMetastasis of Colon NeoplasmShunichi Osada, Shigeki Yamaguchi, Hirohumi Morita, MasayukiIshii, Mitsuyoshi OhtaColon and Rectal Surgery, Shizuoka Cancer Center Hospital,Japan

Purpose: It pays attention to perforin/granzyme-B as the routethat induces apoptosis through CTL and NK cell, the expressionof perforin in the liver excision specimen of synchronous livermetastasis of colon neoplasm is examined, and the relationshipbetween the number of perforin positive cells to short term recur-rence of the residual liver was examined. Object and method:Immunohistochemistry was performed liver normal tissue inperipheral liver metastasis of colon neoplasm with perforin anti-body. 14 examples of synchronous liver metastasis of colon neo-plasm was examined. The number of positive cells of high powerfield (HPF) was counted, each group was stratified by the numberof perforin positive cells into 2 subgroups Few (<1/HPF) and Nor-mal (>1/HPF). Preoperative WBC, ALP, GOT, the number ofliver metastasis, and short term recurrence of the residual liverafter the operation is examined in each group. Result: No signifi-cant difference was appeared in CEA, WBC, ALP, GOT, and thenumber of liver metastasis of each group. Short term recurrence ofthe residual liver were 4/5 (80%) in perforin-Few and 1/9 (11.1%)in perforin-Normal (p<0.05). Conclusion : The number of per-forin positive cell was few, the rate of short term recurrence ofresidual liver was higher. Perforin positive cell in peripheral livermetastasis was expected the predictor of short term recurrence ofthe residual liver.

P-586Concurrent Preoperative Chemoradiotherapy for Stage III orIV Esophageal Squamous CarcinomaYoshiaki Osaka, Yu Takagi, Akihiko Tsuchida, Sumito Hoshino,Shingo Tachibana, Tatsuya AokiDepartment of Surgery III, Tokyo Medical University, Japan

The poor progress of advanced esophageal carcinoma cannot beexpected to be informed by surgical treatment alone. We retro-spectively examined the results of surgery alone (SA: 39 cases) and

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of concurrent preoperative chemoradiation therapy (PCRT: 51cases) for stage III or IV esophageal squamous carcinoma. In thePCRT group, the rate of pathological complete response was31.4% for the primary lesion and 31.1% for metastatic lymphnodes, which viable cancer cells were not recognized in eitherregion in 25.5% of all cases. Grade 2 or more toxicity was found in39 cases of leukopenia, 10 of anemia, 7 of thrombocytopenia, 11 ofesophagitis, 4 of stomatitis, 2 of nausea, 2 of diarrhea, 2 of liverdysfunction and 2 of infection. In 2 cases, PCRT was terminatedfor about 3 weeks because of thrombocytopenia. In 49 cases,PCRT was administered as scheduled. No statistically significantdifferences were noted between PCRT and SA in postoperativecomplications. There was postoperative recurrence in 16 cases inPCRT and 26 cases in the SA (p=0.008). In stage III, the 5-yearsurvival rate was 58.6% for PCRT and 17.2% for SA (p=0.022). Instage IV, the survival rate was 0% for SA and 16.7% for PCRT,showing better results in the latter, although there was no statisti-cally significant difference. Multivariate analysis of prognostic vari-ables revealed that therapeutic method (presence or absence ofPCRT) contributed the greatest to prognosis. These results indi-cate that PCRT is an effective adjuvant therapy for squamous cellcarcinoma.

P-587The Outcome and Indication of Laparoscopic Resection ofColorectal CancerMitsuyoshi Ota, Junichi Wakasugi, Kazutaka Narui, HidekiTakakura, Kotaro Nagamine, Takako Doi, Kiyoshi NishiyamaSurgery, National Yokohama Medical Center, Japan

PURPOSE: The aim of this study was to investigate the outcomeof fifty-four patients who underwent laparoscopic resection forcolorectal adenocarcinoma and to define the indication for laparo-scopic approach. METHODS: From January 1996 to December2001, 54 patients with colorectal cancer underwentlaparoscopicresection at our institution. The TNM stage distribution was 45patients in Stage I (83%), 3 in Stage II (5.6%) and 6 in Stage III(11.1%). RESULTS: All of the laparoscopic resection was com-pleted successfully and curatively. Average operating time was 103min. in D1, 225 min. in D2, and 213 min. in D3. The overall mor-bidity and mortality rates were 14.8% and 0%. One out of the 54patients developed anastomosis leakage and 5 developed woundinfection. Intestinal obstruction occurred in 2 patients. Median fol-low-up period was 40.3 months. The overall disease-free survivalrate was 90.6 %; Stage III disease free survival rate was 50.3%.Recurrence was seen in 3 patients. Two of the 6 Stage III patientsdeveloped recurrence in the liver and one of 45 Stage I patient inthe paraaortic lymph nodes. No local recurrence or port site recur-rence were seen. CONCLUSION: Operating time and early com-plication rate were within acceptable level in laparoscopicapproach. However, the Stage III recurrence rate was relativelyhigh. At present, the indication for laparoscopic approach shouldbe limited to Stage I and II patients at our institution.

P-588Laparoscopy-assisted Segmental Gastrectomy for Early Gas-tric CancerYoshihide Otani1, Toshiharu Furukawa1, Yuko Kitagawa1, MasashiYoshida1, Yoshiro Saikawa1, Koichiro Kumai2, Tetsuro Kubota1, MakioMukai3, Masaki Kitajima1

1Department of Surgery, Keio University School of Medicine,2Center for Diagnostic and Therapeutic Endoscopy, Keio Univer-sity Hospital, 3Department of Pathology, Keio University Schoolof Medicine, Japan

Laparoscopy-assisted vagus-sparing segmental gastrectomy(LAVSSG) is a new procedure that is expected to improve qualityof life in patients with early gastric cancer. Post-gastrectomy dis-turbances such as dumping syndrome, alkaline reflux esophago-gastritis, and reduced food intake due to small gastric volume areunpleasant sequelae in patients undergoing distal gastrectomy. Insegmental gastrectomy the stomach is transected at 2 to 3 cmintervals from the cancer edge, which reduces the loss of volume inthe remnant stomach and preserves the function of the pylorus.The quality of lymph node dissection for perigastric lymph nodeplus No. 7, 8a lymph nodes is confirmed by intraoperative radio-guided sentinel node analysis. Since 2003 we have treated sixpatients with this procedure and postoperative course of thesepatients was uneventful. Gastroscopy revealed less gastritis in rem-nant stomach of LAVSSG than in ordinary Billroth-I anastomosis.No patient with dumping syndrome was observed. This new pro-cedure for the treatment of early gastric cancer is a minimally inva-sive, curative and function-preserving method, which reduces theincidence of post-gastrectomy syndrome.

P-589Postoperative Morbidity Rate Predicted by Modified POS-SUM Scoring System for the Aged Patients Who Had Gas-trectomy for Gastric CancerYuichi Otsuka1, Chikara Kunisaki1, Hirotoshi Akiyama1, ShinsukeHatori2, Goro Matsuda1, Masato Nomura1, Hidetaka Ono1, ToshioImada2, Hiroshi Shimada1

1Gastroenterological Surgery, Yokohama City Unversity, 2Yoko-hama City University Medical Center, Japan

In order to predict postoperative morbidity after gastrectomy inaged patients, POSSUM scoring system was applied to agedpatients who had gastrectomies, evaluated its feasibility, found itspotential problems to apply and created original predictive equa-tion. A series of 123 patients who had gastrectomy for gastric can-cer at the age of 75 or older since 1994 to 2002 was enrolled in thisstudy. Postoperative morbidities and mortalities were documentedand POSSUM score was calculated in each case. Predicted mortal-ity and morbidity rates by POSSUM score in this series were47.9% and 14.1% respectively. Total actual morbidity and mortal-ity rates were 39.8% and 1.6% respectively. Two mortality caseswere documented. One case was caused by infectious endocarditisand the other was by aspiration pneumonia. These cases could notbe predicted highly for morbidity and mortality. According to theresults of these nine years period, we create new revised-POSSUMequation to predict morbidity. We applied this equation to 26cases who had gastrectomies during 2003 prospectively. Prospec-tively predicted morbidity and actual morbidity of this one yearseries were 37.3% and 38.5% respectively. In conclusion original


POSSUM score can not be applied to aged patients to predictpostoperative morbidity because of over-prediction but after creat-ing revised equation by analyzing cases retrospectively, revisedPOSSUM score can be applied precisely.

P-590A Case of Uncontrollable Bleeding from Gastric Ulcer inStomach Roll after Esophagectomy for Thoracic EsophagealCancer. Comprehensive Therapeutic Strategy Based on Etio-logical AspectsYuichi Otsuka1, Chikara Kunisaki1, Hidetaka Ono1, Goro Matsuda1,Masato Nomura1, Hirotoshi Akiyama1, Shinsuke Hatori2, ToshioImada2, Hiroshi Shimada1

1Gastroenterological Surgery, Yokohama City Unversity, 2Yoko-hama City University Medical Center, Japan

We experienced a case of uncontrollable bleeding from gastriculcer in stomach roll after esophagectomy for thoracic esophagealcancer. Fifty-six years old female who had past history of transtho-racic esophagectomy for thoracic esophageal cancer with stomachroll reconstruction was admitted for tarry stool. Emergent gas-trointestinal fiberscopy revealed actively bleeding gastric ulcer andmultiple active stage gastric ulcers in reconstructed stomach roll.Hemostasis was accomplished with clipping but rebleedingoccurred 8 hours later since clipping. Gastrointestinal fiberscopywas performed again but bleeding site was not detected because ofmassive hemorrhage. Transarterial embolizetion through rightgastroepiploic artery was also ineffective. Major bleeding ulcer wasthought to be located relatively distant, on the level of diaphragm,in this case. She was dead on the next day by hemorrhagic shock.Incidence of gastric ulcer in stomach roll is reported 3 to 13 %.Etiologies of this circumstance are discussed in aspects of route ofreconstruction, acid secretion, motion of stomach roll, compres-sive stimulation by the diaphragm, blood flow of stomach roll, pasthistory of gastric ulcer and association with H. Pylori. Because ofhigh mortality in uncontrollable cases, in follow up afteresophagectomy with stomach roll reconstruction, preventive thera-py based on etiologies is strongly emphasized. Furthermore, weshould not hesitate over aggressive surgical interventions, such asremoval of stomach roll or clamp of blood flow, in uncontrollablecases.

P-591Myelodysplastic Syndrome Followed after Esophageal CancerResection Occurred during Complete Remission from SmallCell Lung Cancer Treated with ChemoradiationYuichi Otsuka1, Toshiro Konishi2, Satoshi Nara2, Kaoru Furushima2,Kentaro Nakajima2, Chikara Kunisaki1, Hiroshi Shimada1

1Gastroenterological Surgery, Yokohama City Unversity, 2NTTEC Kanto Medical Center, Japan

We experienced a case of secondary myelodysplastic syndrome fol-lowed by complete remission of small cell lung cancer withchemoradiation therapy and thoracic esophageal cancer treatedwith esophagectomy accompanying with chemotherapy. Currentlychemoradiation therapy was thought to be one of highly effectivetherapeutic alternatives and many complete remission cases havebeen reported in small cell lung cancer or esophageal cancer. Inpost-therapeutic follow up of patients with such past therapeutichistories, we should be cautious about secondary hematological

malignancies even if primary malignant disease was evaluated ascomplete remission in long past history. Fifty years old man wasreferred to our department with esophageal cancer. He has pasthistory of small cell lung cancer treated with chemoradiation ther-apy consisted with 60 Gy of irradiation to the mediastinum andlung field accompanying with chemotherapy of etoposide, nimus-tine and cisplatin at the age of 39. This disease was evaluated ascomplete remission after chemoradiation therapy and no recur-rence had been observed since then. Esophagectomy with postop-erative chemotherapy was applied but he died of secondarymyelodysplastic syndrome with its acute myeloblastic transforma-tion. Literatual risk evaluation for MDS revealed relatively highincidence of esophageal cancer after radiation therapy and hemato-logical malignancies after chemoradiation therapy especially inusual regimen with topoisomerase inhibitor or alkyrating agents.

P-592Surgical Outcome for Early Gastric Cancer in the UpperThird of the StomachKyoko Otsuki, Chikara Kunisaki, Hirotoshi Akiyama, Masato Nomura,Goro Matsuda, Yuichi Otsuka, Hidetaka Ono, Hiroshi ShimadaDepartment of Gastroenterological Surgery, Yokohama City Uni-versity Graduate School of Medicine, Japan

Purpose: Although the outcome of surgery for advanced gastriccancer in the upper third of the stomach is said to be poorer, theoutcome of surgery for early gastric cancer in the upper third ofthe stomach has been less well studied. The aim of this study is toanalyze and establish a therapeutic strategy for early tumors in theupper third of the stomach. Patients and Methods: Patients(n=673; 79 patients were located in the upper third of the stomachand 594 in more distal sites) with early gastric cancer who under-went curative gastrectomy were included in this study. The clini-copathologic characteristics and the results of surgery for earlytumors were compared between the two groups. Prognostic factorswere evaluated evaluated with uni- and multi-variate analyses.RESULTS: Tumors in the upper third of the stomach were moreoften protruded, differentiated, submucosa invasive, and located atthe posterior wall, and more often involved venous invasion andadjacent metastatic lymph nodes. Lymph node metastasis, but nottumor location, was an independent prognostic factor in all regis-tered patients. The results of surgery had no difference betweenthe two groups. CONCLUSIONS: Early proximal tumors showdistinct features, but its prognosis after curative surgery is as goodas that of distal two-third tumors.

P-593Assessment of Hepatic Reserve Function Using SPECT Datafrom 99mTC-GSA ScintigraphyYoshihiro Owa, Takashi Arikawa, Katsuhiro Kotake, Hitoshi Inagaki,Tsuyoshi Kurokawa, Toshiaki NonamiDepartment of Gastroenterological Surgery, Aichi Medical Uni-versity, Japan

Purpose: We evaluated hepatic reserve function using 99mTC-GSAscintigraphy, which enables assessment of hepatic reserve functionsimultaneously with images. Subjects: The subjects were 332 liverdisease patients we encountered in our institution, and 176 whohad undergone hepatectomy. Methods: In assessing hepatic func-tion by scintigraphy, SPECT images are taken 15 minutes after

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the administration of 99mTC-GSA. The entire liver and area ofinterest in the residual liver are established in the images and mea-sured. The sum of the measured values is corrected by RI concen-tration and patient’s amount of circulating blood, and taken as theasialoglycoprotein receptor volume (AGRV), an indicator ofhepatic reserve function. Results: AGRV for the entire liver is19,000 in healthy livers, 15,000 in choronic hepatitis, and 12,000in liver cirrhosis; it thus decreases with advance of liver impair-ment. The conventional indicator of hepatic reserve function, theChild-Pugh score, has a high correlation with ICG test results.Liver failure was seen postoperative in 8 of 176 hepatectomypatients. The mean AGRV of the remnant liver was 6,600 in theliver failure patients, and less than 8,000 in 7 of the 8 patients.Summary: Assessment of hepatic reserve function using SPECTdata from 99mTC-GSA scintigraphy showed a high correlation withthe conventional method of assessing hepatic reserve function. Byobtaining simultaneous images it is possible to assess the reservefunction of the residual liver in hepatectomy, which will closelyreflect the postoperative course.

P-594Surveillance of Susceptibility of Clinical Isolates to Represen-tative Antibiotics between 1996 and 2003 in GastrointestinalDepartment of Kagoshima University HospitalTetsuhiro Owaki1, Heiji Yoshinaka1, Hiroaki Miyanohara1, Shoji Nat-sugoe2, Takashi Akiou2

1Surgical Center, Kagoshima University Hospital, 2Surgical Oncol-ogy and Digestive Surgery, Graduate School of Medical and Den-tal Sciences, Kagoshima University, Japan

The antibacterial activity of the parenteral antibiotics, amikacin(AMK), ceftazidime (CAZ), cefazolin (CEZ), cefmetazole (CMZ),cefotiam (CTM), imipenem/cilastatin (IPM/CS), piperacillin(PIPC), and vancomycin (VCM), against clinical isolates in gas-trointestinal department Kagoshima University Hospital was eval-uated every two years for eight years (first to fourth surveillance)from 1996 to 2003.In the first surveillance from 1996 to 1997,1341 isolates of 18 species were tested, 2950 from 1998 to 1999,2129 from 2000 to 2001, and 1073 isolates in the fourth surveil-lance from 2002 to 2003 were tested. AMK has not beenchanged in susceptibility against enterobacteriaceae andP.aeruginoza. Changes in percent resistance of P.aeruginoza toCAZ is 18.6--->23.6--->22.7--->29.8 %. CEZ, CMZ and CTM havenot been changed in susceptibility against Staphylococcus spp. andenterobacteriaceae except Serratia marcescens using CEZ (MIC of60 % in isolates was >64 ug/ml in the forth surveillance). IPM/CSexhibited no change against enterobacteriaceae and Staphylococ-cus spp., but MIC of 24 % in resistance P.aeruginoza was >16ug/ml in the forth surveillance. Also changes in percent resistanceof P.aeruginoza to PIPC is 0--->0--->0--->11.5 %. There was no resis-tance of MRSA to VCM in all surveillance, and the susceptibilityof Enterococcus spp. against VCM has been improved year byyear. conclusion: The susceptibility of P.aeruginoza and Serratiaspsp. to some antibiotics was getting increasingly worse year byyear. That of other clinical isolates against parenteral antibioticswere almost stationary level.

P-595Portal Shear Stress Promotes Liver Regeneration after LivingDonor Liver Transplantation Using a Small for Size GraftTakanori Oyama, Takahito Yagi, Hiromi Iwagaki, Hiroshi Sadamori,Hiroyoshi Matsukawa, Noriaki TanakaAbdominal Transplantation, Okayama University GraduateSchool of Medicine and Dentistry, Japan

Introduction In the living donor liver transplantation (LDLT),small for size syndrome (SFS) seriously affects on the prognosis.We reports whether graft size affects on portal shear stress, pro-duction of hepatrophic cytokines, symptom of SFS and hepaticregeneration. Methods In our 68 LDLTs, fulminant hepatic failurewere excluded because of normodynamic hepatic circulation.Recipients without rejection, infectious episodes and vascular com-plication within a month were studied and divided into 2 groups:Group L (n=8): Graft / body weight of recipient (G/R) ratio>=1.0,Group S (n=8): G/R ratio<1.0. We compared serum IL-6 andHGF as hepatrophic cytokines, the maximum portal velocity onDoppler US (Vpmax) as an index of shear stress, serial changes ofclinical parameters of SFS, and regeneration of the graft assessedby CT on POD 14. Results There were no significant differences inthe backgrounds including MELD score. Incidence of massiveascites, hyperbilirubinemia and thrombocytopenia were signifi-cantly higher in Group S. IL-6 and HGF were significantly higherin Group S. CRP production of Group S, representing proteinproduction, was delayed 2 weeks compared to Group L. TheVpmax was significantly higher during a first week in Group S.Indeed G/R ratio did not catch up, but hypertrophic ratio was sig-nificantly higher in Group S. Conclusion Heavier portal shear stressin Group S, a physical trigger of graft regeneration, promotesgreater hepatic regeneration with intervention of hepatrophiccytokines, however, symptoms of SFS remains by delay of proteinsynthesis and/or sustained portal hypertension in Group S.

P-596Synchronous Five Colorectal Cancers in a Patient withHNPCC : Case ReportChi Min Park, Hokyung Chun, Seong Hyeon Yun, Woo Yong Lee,Keuk Won ChungDepartment of Surgery, Samsung Medical Center, Korea

Reports on the frequency of multiple carcinomas of the colon andrectum have varied from 3-4% to more than 10% of all tumors ofthe large bowel. Especially, the frequency is higher in hereditarynon-polyposis colorectal cancer (HNPCC) patients. HNPCC iswell documented condition with defects in the DNA mismatchrepair genes. MSI is a useful test to guess the defects of DNA mis-match repair genes. Here we report the case of synchronous fivecancer arising from terminal ileum and colon with strong familialtendency of colon cancers. There is no reported case of simultane-ous five cancers in a patient at the same time. Patient was 43 yearsold female presented with intermittent abdominal pain and diar-rhea for one month. Colonoscopic examination revealed four ade-nocarcinoma at proximal ascending, proximal transverse, distaldescending, and sigmoid colon above anal verge 30cm. At opera-tion, except the lesion showed on colonoscopy, about 3cm sizedulcerative lesion was noted at terminal ileum. Total colectomyinvolving the lesion of terminal ileum and ileorectal anastomosiswas performed. Histologic evaluation revealed that all lesion were


adenocarcinoma invaded the pericolic fat and three out of 126lymph nodes were invaded by the cancer cells. It was a MSI-highcancer; 5 markers of MSI (BAT25, BAT26, D5S346, D17S250,and D2S123) were all unstable. We revealed point mutation of 67th

base (G to T) of 1st exon of hMLH1. The patient recovereduneventfully and the genetic test of her family is now under inves-tigation.

P-597Impact of External Beam Radiotherapy after Surgical Resec-tion for Hilar Bile Duct CarcinomaChung-Ho Park1, Ki Hoon Kim2, Chang Soo Choi2, Young Kil Choi2

1Department of Surgery, Busan Paik Hospital, 2Inje UniversityPaik Hospital, Busan, Korea

Purpose: For bile duct carcinomas local treatment including surgi-cal resection plays an important role. In the case of hilar bile ductcarcinoma, the rate of resection is low and local recurrences arefrequent even after radical resection. Radiotherapy, one of thelocal remedies, may influence the treatment result. The aims ofthis study were to determine the effect of radiotherapy after surgi-cal resection on the length of survival, as well as the radiation toxi-city, in patients with hilar bile duct carcinoma. Methods: Seventypatients with hilar bile duct carcinoma were included in this study;46 underwent surgical resection only while 24 additionallyreceived external beam radiotherapy after resection. Authors com-pared the survival rate between the two groups and investigatedthe complications following radiotherapy. Results: The overall 5-year survival rate after surgical resection was 28.3%; 20.1% and31.3% in patients with and without radiotherapy, respectively. Thedifference was not significant (p>0.10). In patients with positivesurgical margin, the 5-year survival rate for the radiation groupwas superior to that of the non-radiation group (21.8% vs. 10.1%),but again the difference was not statistically significant (p>0.10). Inpatients with lymph node metastasis the survival rates for radiationand non-radiation groups showed no significant difference(mediansurvival, 7 vs. 13 months) (p>0.10). Leukopenia (n=2) and digestivecomplications including gastroduodenal ulcers (n=2)! occurredafter radiotherapy. Conclusion: External beam radiotherapy afterradical resection had no significant effect on the length of survivalin patients with resectable hilar bile duct carcinomas.

P-598Two Cases of Benign Papillary Adenoma of Extrahepatic Bil-iary SystemIl-Young Park1, Tae-Hyung Kim1, Keun-Ho Lee2, Joon-Kyung Sung1,Woo-Bae Park3

1Surgery, Holy Family Hospital, 2Dept. of Surguery, Our LadyMercy Hospital, 3Dept. of Surgery, Saint Vincent Hospital,Catholic University of Korea, Korea

Benign neoplasms of the extrahepatic biliary system are rare, butdistinguishing between benign and malignant tumors is importantin the differential diagnosis of obstructive jaundice. There are sev-eral problems related to managing patients with benign tumors ofthe common bile duct, because the optimum treatment of suchlesions is uncertain, and predicting the presence of cancer preoper-atively is difficult. And also the natural history of the disease is notcompletely understood. Here we report two cases of papillary ade-noma of the extrahepatic biliary system. A 63-year-old female

patient was admitted because of high fever, epigastric pain andjaundice for 2 days .CT showed a mass in the common hepaticduct. She performed resection of common bile duct and Roux-en-Y hepaticojejunostomy. A 28-year-old man presented anorexia,fatigue and jaundice for 10 days. He underwent segmental resec-tion of common bile duct including cholecystectomy and Roux-en-Y choledochojejunostomy. Preoperative diagnosis was bile ductcancer. The lesion in the bile duct featured papillary proliferationof the epithelium with mild to moderate atypism and fibrous ele-ments with diffuse infiltration by inflammatory cells. Papillaryepithelium showed positive staining for Ki-67 but negative for p53.At diagnosis, differentiation between benign and malignancy isvery difficult. Complete excision is the goal of therapy because it isonly the tissue diagnosis that can confirm the presence of a benignversus malignant extrahepatic billiary tumors.

P-599A Case of Hepatic AngiolipomaIl-Young Park1, Yong-Sung Won2, Tae-Hyung Kim1, Hun Jung1,Joon-Ki Kim2

1Surgery, Holy Family Hospital, Catholic University of Korea,2Surgery, Saint Vincent Hospital, Catholic University of Korea,Korea

Angiomyolipoma is a rare tumor of harmatomatous lesion derivedfrom mesenchyme. The hepatic angiomyolipoma(HAML) wasdescribed by Ishak for the first time in 1976. HAML may be diffi-cult to differentiate from other liver neoplasms. A 67-year-oldfemale patient referred from local clinic for evaluation of hepaticmass in abdominal sonography and presented dyspepsia for 2months. CT scan showed 4.8 x 3.7cm sized heterogeneous low-density mass with peripheral rim enhancement at segment V. MRIshowed 4.8 x 3.7cm sized well-defined, high signal intensity hepat-ic mass and marked fat suppression on the fat suppressionsequence. Prominent tumor was enhanced during arterial phase,subtle remained enhancement on 10 min delayed image on thedynamic study. Intra-operative finding showed well-defined darkbrown-colored mass at segment IVb and V and no enlarged lymphnode. We performed segmentectomy IVb and V. Resection mar-gin was negative. The tumor was found to be an angiomyolipomacompose of lipid, vascular and smooth muscle cell. Immunohisto-chemical staining of specimen was resulted in Vimetin(+),Desmin(-), Actin(+) and HMB-45(+) and then we diagnosed asHAML. The patient discharged at 14 days after operation withoutother problems. She patient remains well 3 month after hepatecto-my. These immunohistochemical stainings are marker for patho-logic diagnosis of HAML and surgical resection is effective for thetreatment of HAML.

P-600Local Pelvic Recurrence after Curative Resection of the Rec-tal Cancer: Its Type and PrognosisJea Kun Park, Seung Hyuk Baik, Nam Kyu Kim, Kang Young Lee,Seung Kook Shon, Chang Hwan ChoSurgery, Yonsei University College of Medicine, Korea

Purpose: The management of locally recurrent rectal cancerremains difficult clinical problems to surgeons. This study was per-formed to analyze the outcomes of patients with local pelvic recur-rence according its recurrence type. Methods: A total 109 patients

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with local recurrence were evaluated. Among the 109 patients 62was local recurrence alone and 47 was both local and systemicrecurrence. The recurrence type was classified as Central, Anteri-or, Posterior, Lateral and Perineal recurrence according the rela-tion of the tumor location and either intra pelvic organ and/orfixed pelvic structure. Results: Mean follow up period was44.2±30.0 months and mean recurrence time between primaryoperation and recurrence was 26.0±22.7 months. Only 26 (23.9%)of the 109 patients had curative resection and the remaining 83(76.1%) patients has a palliative exploration or nonsurgical proce-dure. The resectability according to the recurrence type showedthat the Central and Anterior type was higher than other type ofrecurrences (p=0.001). When the primary operation wasAbdominoperineal Resection (APR), the resectability was poorerthan Low Anterior Resection (LAR) (p=0.0001). When comparingthe patients with local recurrence alone, the 5 year survival rateswere significantly higher with the curative resection(33%) thanpalliative or non-resection group(9.7%)(p=0.002). Conclusion:Resection for central type of the recurrent is potentially curative,however treatment failure was common when the recurrenceinvaded fixed pelvic structure. Results suggest that local pelvicrecurrence should be treated with radical resection as can as possi-ble.

P-601Inferior Lubar Hernia with Colonic IncarcerationSung Dae Park, Ok-Suk Bae, Tae Soon LeeDepartments of Surgery, School of Medicine, Keimyung Universi-ty/ Dongsan Medical Center, Korea

Lumbar hernia is a rare form of hernia which arises from the supe-rior or the inferior lumbar triangle. Inferior lumbar hernia is lesscommon than the superior lumbar hernia and bounded by lat-tisimus dorsi muscle, external oblique abdominis muscle, and iliaccrest. Here we report a patient with acquired traumatic inferiorlumbar hernia (with colonic incarceration) treated with meshherniorrhapy Case: The patient was a 72 year-old female withcomplaints of aggravating periumbilical pain for 2 weeks. For last 4years, she had suffered from intermittent , vague periumbilical painafter re-operation of spinal stenosis. She had a history of operationfor spinal stenosis with retroperitoneal approach 13 years ago. Onphysical examination, egg sized vague mass around previous opera-tion site on left flank was palpated. CT and Barium enema showedinferior lumbar hernia with colonic incarceration. Mesh hernior-rhapy was performed and hospital course was good with no mor-bidity.

P-602Prognostic Factors and Significance of Extended Lym-phadenectomy in Node-negative Gastric CancerSung-Soo Park1, Young-Jae Mok1, Chong-Suk Kim2, Seung-Joo Kim2

1Surgery, Korea University Guro Hospital, 2Dept. of Surgery,Korea University Ansan Hospital, Korea

Purpose: Lymph node status in gastric cancer is one of the mostimportant prognostic factors. In patients with node-negative gas-tric cancer, however, the variables affecting prognosis have notbeen well clarified. We retrospectively conducted this study toevaluate the influence of several clinicopathological variables onsurvival and to determine whether extended lymph node (D2) dis-

section is associated with a survival benefit. Methods: Between1993 and 2000, 506 patients without lymphatic metastases whounderwent a curative resection were enrolled. We analyzed clini-copathological factors for survival and evaluated whether D2 dis-section is associated with a survival benefit when stratified for Tstage by multivariate analyses using the Cox proportional hazardmodel. Results: The numbers of patients with stage T1, T2, T3and T4 were 347, 91, 67 and 1, retrospectively. Extended lym-phadenectomy (D2 or more) was performed in 474 patients and 32were received lesser lymphadenectomy. Multivariate analysis dis-closed age and T stage were significant factors. We revealed thesignificant variables for survival when stratifed for T stage. Ageand type of resection were significant in T1 staged patients. Ageand gross type were significant in T2 staged patients. Extendedlymphadenectomy was statistically significant only in T3 stagedpatients. Conclusions: T stage is most important prognostic factorin node-negative gastric cancer. When stratified for T stage, sig-nificant prognostic variables are age, type of resection, extent oflymphadenectomy. Extended lymphadenectomy is associated withsurvival benefit only in T3 staged node-negative patients.

P-603TP53 Mutation Still Is the Most Important Molecular Prog-nostic Factor in Adjuvantly Treated Patients with Stage IIIColon CancerJohn Plukker, Jantine Westra, Nanno Mulder, Charles Buys, RobertHofstraSurgical Oncology, University Hospital Groningen, The Nether-lands

Introduction: TP53 tumor-suppressor activity has a key functionin controlling growth of cancer. Other genetic factors, includingmicrosatellite instability (MSI), KRAS, thymidilate synthase (TS)and dihydropyrimidine dehydrogenase (DPD) have been reportedto be associated with the prognosis of colon cancer patients. Moststudies, however, included heterogeneous groups of patients withrespect to cancer stage. We determined the prognostic relevanceof MSI-H, TP53 mutations, KRAS mutations and the TS andDPD expression levels in patients with stage III colon cancer.Material and Methods: Tumor specimens of a well-defined groupof 391 resected stage III colon cancer, treated adjuvantly with 5-fluorouracil-based chemotherapy were analyzed. MSI analysis wasperformed in 273 specimens, TP53-mutation analysis in 220 andKRAS-mutation analysis in 205 specimens. TS and DPD expres-sion were determined by immunohistochemistry. Results: TP53mutation (116/220; 53%) was related to a shorter disease-free-sur-vival (DFS); p=0.018. In multivariate analyses, histology, invasionand grade of tumor were not associated with a better DFS. MSIstatus (MSI-H; 16%) had only an effect in univariate analysis.KRAS mutations (58/205; 28%) had no additional prognosticvalue. Furthermore, no association was found between DFS andexpression of TS or DPD, nor in the primary tumor, nor in nodalmetastases. TS combined with TP53 mutation status had no effectof TS on the DFS caused by TP53 mutation. Conclussion: In theDFS analysis, TP53 mutation showed to be a strong negativeprognostic factor. Expression of TS and DPD has no additionalprognostic value in the 5FU-treated patients.


P-604More Effective Method——-MLCPredrag Pocevski1, Marija Miodrag Pocevska2

1Primarius Dr Subspecialist of Abdominal Surgery, 1, 2Institucionof Pharmacy Vranje, Serbia and Montenegro

With this work I reveal my own experiance of MLC—-(Microla-paratomy Cholecystectomy). This term,method and division I wasinaugurated in 1996. after ten years hardly work.Finally, in1997.that method,division and term was indexed in Curent con-tents-ISI Philadelphia, USA. In 1882 Carl Langenbusch did thefirst classical cholecysectomy and in 1985 Erich Muhe inauguratedthe first laparascopic cholecystectomy.Now,the goal in this work isto present the comparative values of MLC- Microlaparatomycholecystectomy. Analysing different procedures (conventional,mini and MLC- microlaparatomy cholecystectomy) certain com-parative advantages of the above procedures are noticed in relationto the classical cholecystectomy. I present the followingdivision:the transrectal longitudinal section on the skin up to 4 cm-MLC-microlaparatomy cholecystectomy, from 4,1 to 6 cm miniand from 6,1 to 8 cm the conventional minilaparatomy cholecys-tectomy.The section on the skin over 8 cm belong classical chole-cystectomy. I present and analyse 1400 cases of cholecystectomy:The classical method was applied in 506 cases/36,14%/,the minila-paratomy in 323 cases/23,07%/, the microlaparatomy in 469cases/33,50%/ and laparascopy in 102 cases/7,29%/. Patients oper-ated by mini and microlaparatomy methods had no complicationsbecause they were selected before operations. The trend in surgerytoday is mini invasion surgery(MIS)-laparascopic and (MLC)-microlaparatomy cholecystectomy, because of,among all,minimaltrauma of abdominal walls, very good vision of peritoneal cavity,minimal pain after operation and very rapid recovery of patients.Ipoint out the advantage of microlaparatomy method as it requiresexstremly little financial assets. In the end, I accend , MLC- micro-laparatomy cholecystectomy have been done since 1986, for whicha special set of instruments is necessary, own light recourse,verycertain surgical exposition as well as a corresponding experience ofa surgeon.

P-605Choledochal Cysts: Diagnosis and Treatment in SevenPatientsRozalinda Popova JovanovskaGastroenterohepatology, Medical Faculty Skopje, Macedonia

Choledochal cysts are rare anomaly of the bile ducts. The aim ofthe study is to evaluate the different diagnostic procedures and thetherapeutic approach.Materials and methods: ultrasound (US), endoscopic retrogradecholangiopancreatography (ERCP), percutaneous transhepaticcholangiography (PTC), magnetic resonance cholangiography(MRC) were performed in seven cases with choledochal cysts aswell as cytological examination of the bile juice. All of the patientsunderwent surgical treatment.Results: Choledochal cysts were classified as type I (five cases), oneas type III and one as type IVa. The dominant symptoms werejaundice and recurrent abdominal pain. US, PTC, ERCP andMRC clearly define the cyst anatomy and site of biliary origin ofthe cyst. Cytological examination of the bile juice obtained duringthe PTC procedure showed malignant cells in one case although

tumor mass was not visualized. In this patient pancreaticoduo-denectomy was performed, because the cyst was located in the dis-tal portion of the common bile duct. Pathological examinationshowed adenocarcinoma limited to the mucosa inside the cyst.Four years after the operation patient was well and free from thedisease. US demonstrated cystic formation while PTC and MRCaccurately defined cysts. In five patient total cyst excision andRoux-en-Y hepaticojejunostomy was performed while in one par-tial cyst excision and cystojejunostomy.Conclusion: US, PTC, ERCP and mostly MRC are proved asvaluable diagnostic modalities. Cytological examination of the bilejuice is very important clue for diagnosis of malignancy. Total cystexcision is recommended.

P-606Comparison between Stapled and Conventional TransanalLocal Excision of Questionable Lesions in a Porcine ModelDrago Popovic1, Drago Popovic2, Federico Bilotti2, Jesse Kuhns3, San-dra Baark4, Joerg Holste5, Jadranko Kovjanic1

1Digestive Surgery, GH Sisak, Croatia, 2Via padre G.A. Filippini109, 3Viale Citta dEuropa 674, Roma Italy, 4In de Masch 14 Sch-enefeld, 5Steindamm 38, Norderstedt, Germany

AIM: Evaluation of a new method of transanal local excision(TLE) that meets today’s oncological standards for early rectalcancer, using the specifically modified circular stapler. Methods:This study was performed using porcine models. Artificial tumorswere placed 5 and 7 cm from the anal verge. Two different proce-dures were observed: stapled and conventional local excision. Thetumor margins were measured and pathologist analyzed tissuelayer. Results: We performed 11/38 conventional local excisions(CLE), and 27/38 stapled local excisions (SLE). Duration of theCLE group was 16.36 ± 3.38, and SLE was 11.07 ± 1.81. Marginsfor CLE were 8.14 ± 4.82 mm, with a minimal margin of 2.91 ±3.15 mm, for SLE were 12.01 ± 5.08 mm and 6.82 ± 3.85 mm,respectively. In CLE group 4/11 samples contained all layers withperirectal fat, 6/11 samples contained all layers, and 1/11 partialexcision. 5/11 samples had positive margins. In SLE group 22/27samples had all layers with perirectal fat, 4/27 samples had all lay-ers, and 1/27 partial excision. 3/27 had positive margins. Conclu-sion: SLE is superior compared to CLE. The SLE group had bet-ter tumor margins and minimal margins, full-thickness excisionwith perirectal tissues is better in the SLE group. The duration ofthe procedure is shorter in the SLE group not requiring the diffi-cult rectal wall defect closing. SLE is an effective tool, not only forbenign rectal tumor local excision, but also for early rectal cancerwith favorable characteristics.

P-607Sentinel Nodes Mapping in Gastric CancerIgor Rabin1, Bar Chikman1, Judith Sandbank2, Zvi Halpern1, IlanWassermann1, Ron Lavy1, Ariel Halevy1

1Division of Surgery, Assaf Harofeh Medical Center, 2Assaf Haro-feh Medical Center Institute of Pathology, Israel

Purpose: To evaluate sentinel nodes (SNs) mapping in patientswith gastric cancer. Methods: Thirty-three patients underwentSNs mapping during the operation. Subserosal injection of dyewas performed. Results: There were 13 females and 20 males, agerange: 33-88 years (mean - 66.8 years). Nineteen patients under-

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went distal subtotal gastrectomy, 8 patients - total gastrectomy and6 patients - proximal gastrectomy. The overall number of harvest-ed lymph nodes was 603 (mean - 18.3 nodes per patient). SNs werestained in 26 / 33 pts (79%), varying between 0 - 13 (mean - 2.32).In all patients (15/15) with T 1-2 tumors we could identify SNs ascompared to only 11 /18 (61.1%) of patients with T3 tumors.Patients with early stage cancer (T1-2) hada mean of 3.93 SNs perpatient as compared to 2.18 SNs in T3 tumors. Patients undergo-ing proximal and total gastrectomy (n=14) had a mean of 3.21 SNs,whereas patients undergoing distal subtotal gastrectomy (n=19)had a mean of 2 SNs. The number of SNs was independed to theoverall number of removed nodes: 17.7 vs. 18.7.Patients with T1-2tumors had 0.27 SNs with metastatic involvement per patient ascompared to1.73 positive SNs in T3 patients. In 24/26 patientswith SNs (92.3%) we could show a positive correlation to overallmetastatic pattern. Conclusions: 1. A good correlation was foundbetween SNs to metastatic pattern, tumor location and stage ofdisease. 2. The clinical implication of SNs mapping in gastric can-cer is still to be evaluated.

P-608Resection of the Superior Mesenteric Vein in the ExtensiveGastropancreatoduodenal ResectionRodion Ismagilovich RasulovSurgery, Regional Oncological Hospital, Russia

Method: During the period under study, 17 patients (M=14, F=3)were operated radically for periampular cancer. Adenocarcinomaof pancreas head was diagnosed in 11 patients, adenocarcinoma ofthe major duodenal papilla in 6 patients. Extensive gastropancre-atoduodenal resection by the Fortner-Ishikawa’s procedure withthe additional venous segment resection was performed in everypatient. The technique that we are suggesting includes the follow-ing stages. Prior to mobilization and removal of organocomplex,we performed the exposure of vena cava inferior (VCI) below therenal vessels, marginal pressing VCI out by vascular forceps. Theexposure of the superior mesenteric vein (SMV) distally from thelower pancreas margin, SMV clamping with vascular forceps andcrossing. End-to-side mesenteriocaval anastomosis (n=14). In largediastasis between VCI and SMV, the autovenous mesenteriocavalprosthetics was made (n=3). Subsequently, after the organocom-plex removal, the vascular stage of the operation was completedwith autovenous mesenteriocaval prosthetics in 10 cases. Results:The suggested technique allowed performing vascular proceduresat the beginning of the operation. The superior mesenteric veinclamping did not exceed 10 minutes. Complications and deathscaused by vein clamping were absent.

P-609Damage Large Abdominal VesselsRodion Ismagilovich Rasulov, Evgeny Georgievich GrigoryevSurgery, Regional Oncological Hospital, Russia

Objective: To study the ways of final hemostasis in perforatingwounds of vena cava inferior. Methods: During 1990-2002 yrs., 45patients (M=40, F=5) were admitted to the clinic with vena cavainferior injuries. Mean age was 35±1,8 yrs. Intraoperatively, it wasfound that vein wound was marginal in 23 cases, and perforating in22 cases. The most difficult for final bleeding arrest were perforat-ing wounds with the injuries of the anterior and posterior vein

walls. To achieve the final hemostasis in that trauma, we used thefollowing technique. In group A (controls, n=9), the wound of theposterior vein wall was sutured with the marginal suture with theprevious vein rotation axially (routine technical procedure). Ingroup B (main group, n=13), the wound of the posterior vein wallwas sutured via the vessel lumen with extralumunal placement ofthe knots (invention patent 2146891).Results: The retrospectiveanalysis showed that the mean intraoperative blood loss at hemo-stasis stage was 1711±61,1 ml in group A, and 347±34,5 ml ingroup B. Postoperative lethality made 77,7% (n=7) in group A,30,7% (n=4) in group B. Over-all postoperative mortality in venacava inferior wounds was 40% (n=18). Conclusion: Group B ischaracterized with significantly less intraoperative blood loss andpostoperative lethality (p<0,05) as compared to group A. Hence, inperforating wounds of vena cava inferior, transluminal suture is theoptimum way of the final hemostasis.

P-610Iatrogenic Injuries of Abdominal Vessels in OncologyRodion Ismagilovich RasulovSurgery, Regional Oncological Hospital, Russia

In the course of 2000-2002 yrs., 145 nephrectomies for renal carci-noma were performed in the regional oncologic dispensary. Themean age of the operated patients was 56,8±1,85 years. Males were87, females 58. Access to the kidney was made by the way of thora-cophrenolaparotomy in every case. Nephrectomy was obligatoryaccompanied by lymph dissection. Intraoperative injury of theabdominal vessels was observed in 11 cases. Among them, the cen-tral vein of the adrenal gland was injured in 4 patients, vena cavainferior in 3 patients, lumbar veins in 3 patients, and renal artery in1 patient. Intraoperative blood loss made 500,0±113,03 ml. Thefinal hemostasis was achieved by the vascular suture in 10 cases andby vessel ligation in 1 case. Retrospective analysis showed that intumor localized in the superior renal pole, the injury of centralvein of the adrenal gland and of vena cava inferior was present; intumor localized in the middle segment, the injury of vena cavainferior and of renal artery was observed; and in tumor localized inthe inferior renal pole, the injury of the lumbar veins was noted. Inevery case, the trauma of the abdominal vessels occurred duringthe manipulations for the right kidney. It should be noted thattumor sizes in that group of patients varied from 8×7 cm to 30×20cm. Furthermore, in every observation paracancrose infiltrateinvolved the renal crus and vena cava inferior.

P-611Vascular Suture in Abdominoanal Resection of the RectumRodion Ismagilovich Rasulov, Nikolay Igorevich Minakin, SergeyMichaylovich PlenkinSurgery, Regional Oncological Hospital, Russia

Method: In the course of January, 2002-April, 2003, we have per-formed 43 abdominoanal resections of the rectum. In 10 cases, thesigmoid colon was initially short, and the attempt of bringing itdownwards into the anal canal after the abdominoanal resectionrequired the additional mobilization of the left colon half withcrossing the great vessels. Due to the severity of patients’ state andconcomitant pathologies in group A (n=5), the operation was fin-ished with the end colostoma. In group B (n=5), to form the suffi-cient length of the intestine brought downwards, mobilization of


the left colon was performed, as well as crossing the inferiormesenteric artery at the site of its deviation from the abdominalaorta. Besides, in every patient in group B the obvious ischemia ofthe distal part (15-18 cm) of the intestine prepared for bringingdownwards was observed. In that group, the blood flow via thegreat vessels was restored by placing the inner ileo-inferiormesen-teric anastomosis. Subsequently, bringing the sigmoid colondownwards into the anal canal with the excess was performed.Results: Operation was completed with the end colostomy ingroup A. In group B, bringing the sigmoid colon downwards intothe anal canal was made in every case. In doing so, the adequateblood supply of the intestine brought down was achieved by apply-ing the inner ileo-inferiormesenteric anastomosis.Conclusions: Additional mobilization of the left colon parts andinner ileo-inferiormesenteric anastomosis allow formation of suffi-cient length of the intestine brought downwards with the adequateblood supply.

P-612Autovenous Prosthetics in Abdominoanal Resection of theRectumRodion Ismagilovich Rasulov, Sergey Michaylovich Plenkin, NikolayIgorevich Minakin, Oleg Petrovich IvanovSurgery, Regional Oncological Hospital, Russia

Methods: Beginning in 2002, we used two different approachesduring the routine mobilization of the rectum brought downwardsin the event of unconvincing signs of blood supply adequacy(n=14). In group A (controls, n=7), abdominoanal resection withthe standard mobilization of the rectum brought downwards wasperformed. In so doing, 4 procedures were ended with bringingthe sigmoid colon downwards into the anal canal with an excess. In3 cases, the operation was completed with the end colostomabecause of the obvious ischemia of the rectal distal part preparedfor bringing downwards. In group B (the main group, n=7), follow-ing the routine technique we performed the restoration of themain blood flow via the rectum brought downwards by the way ofautovenous inner iliosigmoid prosthetics. A part of the greatsaphenous femoral vein served as the autovenous prosthesis.Results: In group A, of 4 abdominoanal resections with bringingdownwards, 2 cases were characterized with the necrosis of therectal part brought downwards in the early postoperative period;the other 2 cases were characterized with paracolic fistula forma-tion in the delayed postoperative period. In group B, one compli-cation was observed in the early postoperative period - necrosis ofthe rectal part brought downwards. The necrosis was caused by theacute right occlusion of the inner iliac artery with the exfoliatedatherosclerotic plague followed by the thrombosis. The remotepostoperative complications in group B were not observed.

P-613Postoperative Adjuvant Arterial ChemoembolizationImproves Survival of Hepatocellular Carcinoma Patients withRisk Factors for Residual Tumor: A Retrospective ControlStudyZhenggang Ren, Zhiying Lin, Jinglin Xia, Shenglong Ye, QinghaiYe, Zengchen Ma, Jia Fan, Zhaoyou Tang, Zhiquan WuLiver Cancer Institute, Zhongshan Hospital, Fudan University,China

Purpose: To evaluate the effect of postoperative adjuvant tran-scatheter arterial chemoembolization (TACE) on the prognosis ofhepatocellular carcinoma (HCC) patients. METHODS: FromJanuary 1995 to December 1998, 549 consecutive HCC patientsundergoing surgical resection were included in this research.There were 185 patients who underwent surgical resection withadjuvant TACE and 364 patients who underwent surgical resec-tion only. Survival analysis was used to evaluate the prognostic sig-nificance of adjuvant TACE. RESULTS: In the patients withoutany risk factors for the residual tumor, There was no significantdifference in the survival between two groups (P=0.3956). Howev-er, in the patients with risk factors for residual tumor, postopera-tive adjuvant TACE significantly prolonged the patients’ survival.There was a statistically significant difference in survival betweentwo groups (P=0.0216). Cox proportional hazard model showedthat adjuvant TACE was not the independent prognostic factors inthe patients without risk factors for residual tumor. However, inthe patients with risk factors for residual tumor adjuvant TACE,and also tumor diameter, AFP level, vascular invasion was the sig-nificant independently factors. CONCLUSION: Postoperativeadjuvant TACE can prolong the survival of patients with risk fac-tors for residual tumor, but not in patients without risk factors forresidual tumor.

P-614Chronic Pain and Recurrence after Laparoscopic InguinalHerniorrhaphyJacob Rosenberg, Emilie Oberg, Bo JacobsenDepartment of Surgical Gastroenterology, Gentofte UniversityHospital, Denmark

Background: Chronic pain after open inguinal herniorrhaphy is acomplication with an incidence of 10-20% and recurrence may beseen in 2-5%. To discuss chronic pain and recurrence after laparo-scopic repair we present our experience with the laparoscopic tech-nique. Methods: A questionnaire was sent to patients who hadundergone laparoscopic inguinal herniorrhaphy (TAPP) at Gen-tofte University Hospital from 1995 to 2002. Patients were askedwhether they had chronic pain, recurrence of the hernia or otherdiscomforts after the procedure. Patients who reported any ofthese conditions were seen in the outpatient clinic for furtherexamination. Patients who had had open groin surgery previouslywere asked to compare the two procedures. Results: 161 patientsunderwent surgery during this period. 146 patients responded tothe questionnaire (91%). Median age was 63 years (range 22-90),the median observation time was 2,75 years (0.5-7) and 95 % weremale. Chronic pain related to the index operation was found in 6patients (4%), recurrence in 2 patients (1.4%) and other discom-forts in 7 patients (5%). 134 patients (92 %) had previously hadinguinal herniorrhaphy with an open procedure and of those, 105

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(78 %) preferred the laparoscopic procedure. Conclusion: Laparo-scopic inguinal herniorrhaphy led to a very low incidence ofchronic pain and recurrence compared with open surgery. Fur-thermore, it should be taken into consideration that the majorityof these patients were operated on for recurrent hernias. It istherefore reasonable to expect even lower incidences of chronicpain and recurrences in primary hernia repair.

P-615Primary Mesh in Permanent Stoma Formation is Not Associ-ated with Immediate ComplicationsJacob Rosenberg, Anders Fischer, Ismail Gogenur, Jacob RosenbergDepartment of Surgical Gastroenterology, Gentofte UniversityHospital, Denmark

Introduction: The frequency of parastomal hernia has been report-ed to be up to 58% after colostomies. With current surgical princi-ples there is high recurrence rates after parastomal hernia repairand it is a high morbidity procedure. Recent studies have suggest-ed that prophylaxis of hernia formation by insertion of a mesh dur-ing the primary operation may be beneficial. Some surgeons haveconcerns regarding immediate infectious complications and rejec-tion of the mesh. We conducted a pilot study to examine possibleimmediate complications to primary mesh insertion in patientsgetting a permanent colostomy. Methods: We have in our institu-tion included 9 patients scheduled for rectum resection, where anewly developed mesh (ColoMeshTM)was inserted during the pri-mary operation. The polypropylene mesh consists of a central ring(2 cm’s wide) with 6 “arms”. The mesh was fixated extrafasciallywith polypropylene sutures. No fixation in the centre of the ring tothe serosa of the colon was made. The six “arms” was pulledthrough radially through separate incisions and also placedextrafascially. Results: Patients were primarily observed for imme-diate complications to the placement of the mesh. Patients whereevaluated daily during the first postoperative week by the attend-ing surgeon and follow-up was made 4 weeks after surgery. Nopatients developed infectious complications, including phlegmoneformation, subcutaneous abscesses or stoma necrosis. No immedi-ate foreign body rejection reactions were observed. Conclusion:We conclude that primary mesh placement in colostomy forma-tion is a safe procedure. Further studies should clarify the risk oflong-term complications and risk of hernia formation.

P-616Laparoscopic Gastropexy a.m. Boerema as the Primary Treat-ment for Paraesophageal HerniaJacob Rosenberg, Bo Jacobsen, Anders FisherDepartment of Surgical Gastroenterology, Gentofte UniversityHospital, Denmark

Introduction: The operative procedure is normally the Nissen /Toupet fundoplication combined with closure of the hiatus. Wepresent the results of a less invasive procedure in this group ofpatients who are often old and fragile. Method: The position ofthe trocarts is similar to the Nissen procedure. The hernia sac istotally dissected and retracted from the intrathoracic cavity where-by the gastric herniation is pulled into the abdomen. We then per-formed a gastropexy a.m. Boerema by placing 4-5 sutures on thegastric corpus knotting the sutures transfacially through theabdominal wall. The hiatus was left open. The patients were

allowed to eat and drink immediately after the operation and witha planned hospital stay of 1-2 days. Results: We have performed 15laparoscopic Boerema procedures from 2002-2003. The meanoperation time has been 1 hour and all 15 operations were withoutmajor or minor complications. The mean postoperative hospitalstay was 2 days. Few patients had slight discomfort due to gastricdysfunction which tended to diminish over time and 14 of 15patients claimed great improvement after the operation. Until nowwe have seen no reherniation. Conclusion: Laparoscopic gas-tropexy a.m. Boerema is a safe operation for paraesophageal herniawith a short hospital stay and no complications. The clinical resultsare promising and we have so far seen no reherniations.

P-617Splenosis Mimicking a Metastatic Lymph Node in AdvancedGastric CancerSeung-Wan Ryu, Soo Sang Sohn, In Ho Kim, Chang Wook JungGastrointestinal Surgery, Keimyung University School of Medi-cine, Korea

Splenosis is the autotransplantation of fragmented splenic tissue,occurring as a result of traumatic splenic rupture or routinesplenectomy. Generally, the splenic implants are numerous and arelocated within the peritoneal cavity; peritoneum, omentum,abdominal viscera, and occasionally extra-abdominal surfaces. Thesplenic implants are rarely clinically significant and are incidentalfindings at abdominal operation, but it occasionally mimics prima-ry and metastatic tumors seen on radiologic studies. We describe apatient in whom multiple abdominal masses were identified radi-ographically and a diagnosis of metastatic tumor implants was ini-tially entertained.

P-618Mutation Analysis of Genes Related to Gastrointestinal Stro-mal TumorsSeung-Wan Ryu1, In Ho Kim1, Soo Sang Sohn1, Dae Kwang Kim2

1Gastrointestinal Surgery, 2Anatomy, Keimyung University Schoolof Medicine, Korea

Gastrointestinal stromal tumors are the most common mesenchy-mal tumor of the gastrointestinal tract. In this study, KIT,PDGFRA, NF2 and GPHN mutations were examined by PCR-SSCP and DNA sequencing. Mutation in exon 11 of KIT wasidentified in 6 of 11 GISTs, but mutations in exon 9, 13, and 17 ofKIT were not detected. Three cases lacking KIT mutationsshowed PDGFRA mutations. No NF2 mutation was detected.GPHN gene mutation in exon 1 was identified in one case whichshowed a simple point mutation in exon 11 of KIT. In correlationbetween mutation types and risk of aggressive behavior, fourtumors involving multiple (>2 codons) KIT mutations and oneshowing a point mutation of KIT plus a GPHN mutation were ofhigh risk, one tumor with a point mutation of KIT showed lowrisk. Three tumors having PDGFRA mutation were of intermedi-ate or very low risk. In conclusion, this study suggest that themutation at exon 9, 13, or 17 of KIT and NF2 mutation are con-sidered to be rare in sporadic GIST. KIT and PDGFRA mutationsappeared to be alterative. GPHN mutation occurred with KITmutation may be a secondary change in the pathogenesis of GIST,because of the KIT mutation is a major event in GIST. KITmutant GIST may have more poor prognosis than PDGFRA


mutant GIST.

P-619Therapeutic Fistuloscopy for the Management of ProlongedPostoperative Intra-abdominal Abscess Caused by SmallIntestinal “Pinhole” PerforationYoshihisa Saida, Yoshinobu Sumiyama, Jiro Nagao, Yasushi Nakamu-ra, Yoichi Nakamura, Miwa Katagiri, Manabu Watanabe, ShinyaKusachiThird Department of Surgery, Toho University, Japan

Fistuloscopy is an effective treatment for intractable fistula, asometimes difficult to manage postoperative intra-abdominal com-plication. A case of 69-year-old male with an abdominal abscessafter underwent right hemi-colectomy for cecum cancer with inva-sions into the ileum and sigmoid colon is reported. A re-operationfor lavage and drainage was performed, 2 weeks after surgery.However, no obvious origin for the pus was located. Though phys-iological saline lavage was repeatedly performed, the effusion ofpus persisted in the drain at the midline incision, about 7 monthsafter surgery. Then, fistuloscopy with an upper gastrointestinalendoscope was performed through the hole of the tube. A pinholethat produced a bubble just below the midline incision wasobserved. Then, an ERCP tube was inserted to obtain images ofthe small intestine by fluorography that findings suggested a diag-nosis of perforation of the small intestine, which appeared toexplain why resolution of the abscess was prolonged. After directdrainage to the small intestine with a 40-cm-long 7Fr. PTCD bal-loon catheter, pus from the tube notably decreased. After confirm-ing that the abscess cavity had disappeared by abdominal CATscan, the PTCD catheter was extracted, about 8 months after pri-mary surgery. Since then, no recurrence of cancer or abscess hasbeen observed. In cases of intractable postoperative intra-abdomi-nal abscess, fistuloscopy utilizing smaller diameter gastrointestinalendoscopy appears to be a valuable diagnostic tool.

P-620Hepato-pancreatico-biliary Surgery in Elderly Patients: IsThere a Difference in Outcome?Reza F. Saidi1, Reza F. Saidi2, Vijay K. Mittal2, Stephen G. Remine2,Michael J Jacobs1

1Surgery, Providence Hospital and Medical Centers, 2ProvidenceHospital, USA

Background: Early and long-term outcomes of hepato-pancreati-co-biliary (HPB) surgery in elderly adults have been controver-sial.Patients and Methods: Clinical information was reviewedfrom patients undergoing HPB surgery for HPB malignancies dur-ing a 14-year period (1990-2003). Patient demographics, tumorcharacteristics, operative mortality and morbidity, survival, andlength of hospitalization were reviewed. Statistical analyses wereperformed.Results: Eighty-five (85) patients underwent HPBsurgery; 50 (58.8%) had pancreatectomy and 35 (48.1%) had liverresections. Forty-six (54.1%) were older than 70-years of age(Group 1) and 39 (45.9%) were under 70-years (Group 2). Hepaticresections were primarily performed for metastatic colorectal can-cer (45.7%), hepatocellular carcinoma (17.1%), and cholangiocar-cinoma (11.4%). Pancreatic resection was mainly performed forpancreatic carcinoma.There was no significant difference betweenGroups 1 and 2 for: Tumor size; stage of disease; comorbidities;

intraoperative blood loss; length of hospital stay (11.3 vs. 11.0days); or readmission (32.6% vs. 28.2%). The overall mortality andmorbidity of HPB surgery was 3.5% and 25.6%, respectively. Themortality and morbidity in Group 1 was 4.3% and 28.2%,whereasthe mortality and morbidity in Group 2 was 5.2%, 23.6%. Thesefindings were not statistically significant. The mean survival inGroups 1 and 2 were 20- vs. 22-months; however, this was not sta-tistically significant.Conclusion: This study suggests that HPBsurgery can be carried out safely in elderly patients. The early andlong-term outcomes in elderly patients (older than 70-years) arecomparable to younger patients (less than 70-years). Age aloneshould not preclude HPB surgery in elderly patients.

P-621Prognostic Significance of Serum Granulysin Level inPatients with Gastric CarcinomaSusumu Saigusa1, Takashi Ichikura1, Takashi Majima1, ManabuKinoshita2, Kentaro Chochi1, Satoshi Ono1, Hidekazu Sugasawa1,Hoshio Hiraide2, Shuji Seki2, Hidetaka Mochizuki1

1Surgery 1, National Deffense Medical College, 2Division of BasicTraumatology, National Defense Medical College Research Insti-tute, Japan

BACKGROUND: Granulysin is a cytolytic granule proteinsecreted by natural killer cells and cytotoxic T lymphocytes with abroad range of antimicrobial and tumoricidal activity. The purposeof this study was to determine the clinical significance of serumgranulysin levels in patients with gastric carcinoma. METHODS:Peripheral blood samples were obtained from 80 patients with gas-tric carcinoma who underwent curative surgery and from 63healthy volunteers. The serum granulysin levels were determinedwith an ELISA. The relationship between serum granulysin leveland clinicopathologic factors and its prognostic impact were ana-lyzed. RESULTS: The mean serum granulysin levels in patientswith gastric carcinoma of stage I, II. II, and IV and in healthy vol-unteers were 2.01±0.22, 3.92±0.94, 2.73±0.69, 2.73±0.25, and1.7±0.07, respectively. The serum granulysin levels in patients withstage II and III were significantly higher than in healthy volunteers(P<0.05). No significant relationship was observed between serumgranulysin levels and other clinicopathologic factors. Patients withserum granulysin levels≥1.7ng/ml (the mean value in healthy vol-unteers) showed a significantly higher survival rate compared withpatients with serum granulysin levels <1.7ng/ml (P<0.05). Multi-variate survival analysis using a Cox’s proportional hazard modelrevealed that the serum granulysin level was an independent prog-nostic factor (hazard ratio, 4.27; P<0.01). CONCLUSIONS: Theserum granulysin levels in patients with stage II and III gastric car-cinoma were significantly higher than that in healthy volunteers.The preoperative serum granulysin level was a significant prognos-tic determinant after curative gastrectomy.

P-622Allelotype Analysis of Gallbladder Carcinoma Associated withAnomalous Junction of Pancreaticobiliary DuctMasaru Saito, Yuji Takebayashi, Tomoyuki Momma, Atuko Kanzaki,Masashi Higashimoto, Seiichi TakenoshitaDepartment of Surgery 2, Fukushima Medical University, Schoolof Medicine, Japan

<PURPOSE>Anomalous junction of pancreaticobiliary duct

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(AJPBD) patients has an increased risk of gallbladder and bile ductcarcinomas. However, the relevance of carcinoma with AJPBD isnot fully clarified. <METHODS>We performed analysis of loss ofheterozygosity (LOH) at p53 locus and immunohistochemistry ofp53 and K-ras gene mutation in five cases of gallbladder carcinomaassociated with AJPBD. <RESULT>LOH of p53 locus and over-expression of p53 were detected in two out of five (40%) and fiveout of five (100%), respectively, in the present study. K-ras genemutation at codon 12 and 13 was not detected (0%, 0/5). Theseresults suggest that aberrations of p53 are involved in carcinogene-sis of gallbladder carcinoma associated with AJPBD. Next, in orderto find the genetic events besides K-ras mutation and overexpres-sion of mutant p53 in this disease, LOH analysis was performedusing 72 microsatellite markers. High frequency of allelic loss (>50%) was found on 2p (81.8%), 4p (50%), 4q (50%), 8q (60%), 9q(50%), 10p (50%), 14p (60%), 14q (50%), 16p (60%), 19p (50%),21p (50%) and Xp (66.6%). The highest deletion regions on chro-mosome 2p24 (3/3, 100%), 14q22 (3/4, 75%) and 21q22 (3/4,75%) were found. <CONCLUSIONS>The present study suggeststhat gallbladder carcinoma associated with AJPBD has high fre-quent allelic loss and has two new regions which may harbor puta-tive tumor suppressor genes.

P-623Expression of Phospholipase D2 in Human Colorectal Carci-nomaMasaru Saito, Atuko Kanzaki, Tomoyuki Momma, MasashiHigashimoto, Yuji Takebayashi, Seiichi TakenoshitaDepartment of Surgery 2, Fukushima Medical University, Schoolof Medicine, Japan

<PURPUSE>Phospholipase D (PLD) catalyzes the hydrolysis ofphosphatidylcholine (PC) to generate phosphatidic acid (PA) andcholine. PA acts as a second messenger in cell proliferation, there-fore PLD is believed to play an important role in tumorgenesis.Recently, PLD activity has been reported to be elevated in humanbreast carcinoma, gastric carcinoma, renal cancer, colorectal carci-noma tissues compared with normal tissues. Moreover the activitywas correlated with nuclear grade in breast cancer, tumor size ingastric carcinoma, nodal involvement and deeper invasion in col-orectal carcinoma. Aim of this study is to determine the expressionof PLD2 and its association with clinicopathological findings andits prognosis values in human colorectal carcinoma tissues. <Mate-rials>Tissues were obtained from the tumors of 89 patients whosecolorectal carcinomas were completely removed by surgery.Expression of PLD2 assessed by Real Time PCR. <Results>Therewere differences in PLD2 expression in human colorectal carcino-mas. The expression levels of PLD2 were associated with tumorsize, however was not associated with lymph node metastasis,extent of invasion, pathological classification, distant metastasis.<Conclusion>These findings suggest that higher levels of PLD2expression in human colorectal carcinoma are associated withtumor growth. Further, the inhibitor against PLD2 might be use-ful in clinic.

P-624Serum Laminin Level is a Predictive Marker of High RiskGroup in Colorectal CancerNoboru Saito, Shingo KameokaDepartment of Surgery II, Tokyo Women’s Medical University,Japan

Purpose: We investigated laminin, an important extracellularmatrix component, to elucidate mechanisms of invasion and metas-tasis in colorectal cancer, and whether preoperative serum lamininis a predictive marker of high risk groups. Methods: We measuredpreoperative serum laminin levels using a 2 step sandwich EIAmethod in 205 subjects with colorectal cancer, 109 with colon can-cer and 96 with rectal cancer, 52 with hepatic metastases, and 153with no hepatic metastases. Results: Mean serum laminin in sub-jects with colon cancer was 606.3±260.2 ng/ml, significantly higherthan that of 258.0±92.0 ng/ml in normal controls (P<0.0001). Thepositive rate was higher at 89.3% for laminin vs 38.0% for CEAand 19.5% for CA19-9. Mean serum laminin in subjects withhepatic metastases was 668.0±274.7 ng/ml, significantly higherthan that of 585.2±252.5 ng/ml in subjects without hepatic metas-tases (P=0.0472). Survival rates were significantly lower in the high(>520 ng/ml) than in the low laminin group (<350 ng/ml)(P=0.0451). Univariate and multivariate analysis, using Cox’s pro-portional hazard regression model, showed serum laminin is anindependent prognostic factor in colorectal cancer, along withhepatic, pulmonary and peritoneal metastases. Conclusion: Preop-erative serum laminin levels are a useful predictive marker of highrisk groups in colorectal cancer.

P-625Preoperative Simulation Using Novel Three-DimensionalImage Analysis for Systematic Liver ResectionShinichi Saito, Junichi Yamanaka, Yuji Iimuro, Nobukazu Kuroda,Tadamichi Hirano, Toshihiro Okada, Takaaki Sugimoto, Jiro Fuji-motoFirst Dept. of Surgery, Hyogo College of Medicine, Japan

[Purpose]Majority of hepatocellular carcinoma (HCC) are associ-ated with chronic liver disease and cause intrahepaticmetastasis.Therefore, preoperative assessment of liver resectionvolume, and surgical margin(SM) is important to perform safe andsystematic liver resection.The aim of this study was to analyzeaccuracy of liver resection volume and SM using novel three-dimensional(3-D) image processing software. [Materials and meth-ods]Between May 2001 and June 2004, 70 patients underwent pre-operative simulation for liver resection.The entire liver wasscanned using helical CT during the hepatic artery, portal, andhepatic venous phases. The 3-D images of portal vein, hepaticvein, tumor, and hepatic parenchyma were reconstructed and over-lapped to make fusion image.Based on direction and diameter ofportal branch, its perfusion area was calculated as predicted livervolume. Surgical margin was also estimated. Then correlations ofliver resection volume and SM were analyzed between predictedand actual values at true operation. Total liver volume was alsocompared between simulation and historical controls using con-ventional electronic planimeter. [Results]Difference in liver resec-tion volume between simulation and true operation was 6.1 ±52cm3 (r=0.92, p<0.01). Difference in SM was 1.4 ± 2.8mm(r=0.84, p<0.05). Difference in total liver volume between


planimetry and simulation was 30 ± 136cm3 (r=0.89 ,p<0.01).[Conclusion]Preoperative simulation based on portal anatomyenabled accurate assessment of liver resection volume and SM,which are both important to perform safe and systematic liverresection.

P-626Liver Regeneration after Repeat Hepatectomy in RatsShuji Saito1, Shinji Togo2, Kuniya Tanaka2, Kenichi Matsuo1, DaisukeMorioka2, Noboru Yoshimoto2, Yasuhiko Nagano1, Haruki Kurosawa2,Toru Kubota2, Chikara Kunisaki1, Hitoshi Sekido2, Hideyuki Ike1,Yoji Nagashima3, Hiroshi Shimada2

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Department of Gastroenterological Surgery, YokohamaCity University Graduate School of Medicine, 3Department ofPathology, Yokohama City University Graduate School of Medi-cine, Japan

Background/Aims: Repeat hepatectomy is performed for multi-recurrent liver tumours. Liver regeneration after the first hepatec-tomy is well documented; however little is known of activity afterthe second hepatectomy. We thus investigated liver regenerationin a two-staged hepatectomy model in rats. Methods: Seven-week-old male Wistar rats underwent a first hepatectomy; 70% of theliver was excised. Seven days later, 70% of the regenerated rem-nant liver was excised. Rats were sacrificed at several time points. Aliver regeneration ratio was quantified from remnant liver weightand total hepatocyte cell number. Cell populations of the remnantlivers were assessed by DNA histogram and Ki-67 immunostain-ing.Results: The liver regeneration ratio by weight peaked at 80%72h after first hepatectomy, then plateaued. It reached 98% 168hafter the second hepatectomy, but total cell number recovered toonly 65% of the original, as opposed to complete recovery 72hafter first hepatectomy. The fraction of hepatic cells in S phase wassignificantly higher in the second hepatectomy group at 168h afterhepatectomy. Fewer nuclei positive for Ki-67 were seen in the firstgroup.Conclusions: Regeneration of hepatocytes is almost com-plete 168h after first hepatectomy, but takes longer following sec-ond. Liver regeneration following second hepatectomy was thusdisadvantaged.

P-627Significance of FDG-PET for Diagnosing Metastasis ofColon CancerShuji Saito1, Hideyuki Ike1, Shoichi Fujii2, Kenji Tatsumi1, KazutakaNarui1, Kaori Kubota2, Shigeru Yamagishi1, Yasushi Ichikawa2,Chikara Kunisaki1, Shigeo Ooki2, Takashi Oka3, Nobukazu Taka-hashi3, Tomio Inoue3, Toshio Imada1, Hiroshi Shimada2

1Gastroenterological Center, Yokohama City University MedicalCenter, 2Department of Gastroenterological Surgery, YokohamaCity University Graduate School of Medicine, 3Department ofRadiology, Yokohama City University Graduate School of Medi-cine, Japan

We investigated FDG-PET diagnosis of colon cancermetastasis/recurrence. Eighty-two colon cancer patients under-went FDG-PET at Yokohama City University Hospital from April2001 to July 2003 for suspected metastasis or postoperative recur-rence of colon cancer. Diagnosis was based on FDG accumula-tion, the maximum SUV (standardized uptake value) at lesion sites,

and CT/MRI. FDG-PET accuracy was calculated according tometastatic site. Recurrence occurred in 57 of 82 subjects in liver(33), lungs (12), peritoneum (12), lymph nodes (12), or locally (13).For liver metastasis, the sensitivity, specificity, and accuracy ofFDG-PET were 97%, 100%, and 99%. Sensitivity, specificity andaccuracy were between 83% and 100% for lung, peritoneal andlymph node metastasis, and local recurrence. One false negative inliver was due to a high SUV in peripheral organs. Two lung falsepositives were complicated with atypical mycobacteriosis, suggest-ing FDG accumulation in inflammatory lesions. In one lymphnode we could not determine FDG accumulation in the tumorbecause it was continuous with a ureter. FDG-PET is consideredhighly accurate compared with other diagnostic tests for peritonealmetastasis. However, no FDG was seen in peritoneal cases below4mm. Few liver/lung metastatic lesions below 10mm were detect-ed; the smallest detected was a 9mm liver metastasis site. FDG-PET of metastasis of colon cancer is useful in diagnosing whetherdifficult biopsy sites are malignant. However, false positive read-ings occur from inflammatory lesions, and small lesions may givefalse negative readings. In the pelvis, which is close to physiologi-cally accumulated sites, diagnosis of local recurrence is difficult.

P-628Effect of Transarterial Immunoembolization Using OK432for Hepatocellular Carcinoma Evaluated by Infiltration ofDendritic CellsTakuro Saito1, Takuro Saito2, Takao Tsuchiya1, Yoshihiro Satoh1,Akira Kenjo1, Takashi Kimura1, Takayuki Anazawa1, MikaHoshino1, Norio Kanzaki1, Masanori Terashima1, Mitsukazu Gotoh1

1Surgery, Fukushima Medical University, 2Fukushima MedicalUniversity, Japan

Transarterial immunoembolization (TIE) using streptococcalpreparation OK432, an immunomodulatory agent, and fibrinogenwas reported to have tumoricidal effect for hepatocellular carcino-ma (HCC). In this study, we applied TIE preoperatively againstHCC to clarify its effectiveness in combination with surgery.Methodology: Eighteen patients underwent hepatic resection forHCC in our institution. Patients were divided into 2 groups, 8patients who had TIE preoperatively, and 10 patients who hadundergone hepatic resection without TIE. Disease free survival,changes of cytokines, and histological findings includingimmunoperoxidase technique using dendritic cell (DC) markerswere compared between these 2 groups. Results: TNF-α, IL-6,IL-10 and IL-12 were significantly elevated after TIE peaking at 3and 6 hours following TIE. INF-γ was significantly elevated at 24hours after TIE. Histological findings of the resected specimenafter TIE showed lytic necrosis of tumor cells at embolized areawith infiltration of inflammatory cells, and some of these wereanti-S-100 positive DCs. These DCs included anti-CD1a positiveimmature- and anti-Fascin positive mature-DCs. Number of infil-trating DCs were significantly high in TIE group as comparedwith control group. Only 1 of 8 patients with TIE developedextra-hepatic tumor recurrence, in contrast, 7 of 10 patients with-out TIE developed intra-hepatic recurrence during the follow upperiod. Conclusion: Preoperative treatment of TIE with OK432and fibrinogen induce transient elevation of the Th-1 dominantcytokines with accumulation of lymphocyte and dendritic cells tothe embolized lesion. These dendritic cells might play an impor-tant role to suppress intrahepatic tumor recurrence.

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P-629Surgical Therapy for Cystic Duct Carcinoma of the Gallblad-der from View Point of Resected CasesKatsu Sakabe1, Taichi Shuto1, Takatsugu Yamamoto2, Takahiro Uen-ishi1, Shogo Tanaka1, Seikan Hai1, Satoshi Yamamoto1, TsuyoshiIchikawa1, Shintaro Kodai1, Shigekazu Takemura1, Hiromu Tanaka1,Shoji Kubo1, Kazuhiro Hirohashi1

1Hepato-Biliary-Pancreatic Surgery, Osaka City Uiniversity Grad-uate School of Medicine, 2Surgery, Ishikiri Seiki Hospital, Japan

Purpose: Primary cystic duct carcinoma of the gallbladder is classi-fied as a gallbladder carcinoma, but its details are not obvious.Here in we report on the pathological findings, particularly infil-trative direction, and surgical therapy for cystic duct carcinoma.Patients and Methods: We resected cystic duct carcinoma in 4patients before 2001 at our hospital. In this study we investigatedthe clinicopathological findings for these cases and their surgicaltherapies. Results: The average patient age was 65 years old.They included one man and three women. Their complaints wereabdominal pain in one case, obstructive jaundice in two cases, andthe other case was unexpectedly, detected cystic duct carcinomaduring an operation for cholecystolithiasis. All cases had gallstones. The preoperative diagnosis was extrahepatic bile duct car-cinoma in case 1, hilar bile duct carcinoma in case 2, gallbladderpolyp in case 3 and cholecystolithiasis in case 4. Pathologically,infiltration of cystic duct carcinoma was observed toward theextrahepatic bile duct through interstitial invasion. Two cases hadlymph node metastasis but direct liver invasion and liver metastasiswere not observed. Conclusions: Infiltration into the extrahepaticbile duct through interstitial invasion was a common feature.Therefore, we suggest that the appropriate surgical therapy forcystic duct carcinoma is that commonly performed for extrahepaticbile duct carcinoma rather than gallbladder carcinoma.

P-630Differential Gene Expression Profiles of Gastric Cancer CellsEstablished from Primary Tumor and Malignant AscitesChouhei Sakakura1, Koji Miyagawa1, Ken-Ichiro Fukuda1, YuenKakase1, Susumu Nakashima1, Shuichi Kin1, Tetsuji Yoshikawa1,Yoshiaki Ito2, Kazuma Okamoto1, Eigo Otsuji1, Akeo Hagiwara1,Hisakazu Yamagishi1

1Digestive Srgery, Kyoto Prefectural University of Medicine,Japan, 2National University of Singapore, Singapore

Mechanisms involved in gastric cancer metastasis have not beenfully clarified because metastasis involves multiple steps andrequires a combination of altered expressions of many differentgenes. In this study, we performed a global analysis of the differen-tial gene expression of a gastric cancer cell line established from aprimary main tumor (SNU-1) and of other cell lines establishedfrom the metastasis to the peritoneal cavity (SNU-5, SNU-16,SNU-620, KATO-III and GT3TKB). The application of a high-density cDNA microarray method made it possible to analyze theexpression of approximately 21,168 genes. Our examinations ofSNU-5, SNU-16, SNU-620, KATO-III and GT3TKB showedthat 24 genes were up-regulated and 17 genes down-regulatedbesides expression sequence tags (ESTs). The analysis revealed thefollowing altered expression such as: (a) up-regulation of CD44(cell adhesion), keratin 7, 8, and 14 (epitherial marker), aldehydedehydrogenase (drug metabolism), CD9 and IP3 receptor type3

(signal transduction); (b) down-regulation of IL2 receptor g, IL4-Stat (immune response), p27 (cell cycle) and integrin b4 (adhesion)in gastric cancer cells from malignant ascites. RT-PCR confirmedthat several genes selected by DNA microarray were also overex-pressed in clinical samples of malignant ascites. It is therefore con-sidered that these genes may be related to the peritoneal dissemi-nation of gastric cancers. The results of this global gene expressionanalysis of gastric cancer cells with peritoneal dissemination,promise to provide a new insight into the study of human gastriccancer peritoneal dissemination.

P-631Significance of the Preoperative Serum Interleukin-18 Levelin Patients with Esophageal Squamous Cell CarcinomaKazuhiko Sakamoto, Toshihiro Abe, Shigehumi Yoshino, Akira Tan-guku, Masaaki OkaDepartment of Surgery II, Yamaguchi University School of Medi-cine, Japan

(Purpose) Patients with advanced cancer reportedly have a highserum interleukin (IL)-18 level. The purpose of this study was todetermine the relation between the serum IL-18 level and clinicalfactors in patients with esophageal squamous cell carcinoma(ESCC). (Method) In 71 patients with ESCC scheduled to under-go curative resection and 23 volunteers without malignant disease,serum IL-18 levels were measured by enzyme-linked immunosor-bent assay. (Result) The serum IL-18 level did not differ betweenESCC patients and control subjects or between patients withESCC at different stages. The disease-free survival rate of patientswith an IL-18 level > 306 pg/ml (n = 17) was significantly lowerthan that of patients with an IL-18 level < 306 pg/ml (n = 54) (P =0.011). Lymph node metastasis and serum IL-18 level were shownto be independent prognostic factors by multivariate analysis. Theserum IL-18 level was an independent prognostic factor even inpatients with lymph node metastasis. (Conclusion) The preopera-tive serum IL-18 level may be useful as a prognostic indicator inESCC patients.

P-632A Case of Anaplastic Carcinoma of the RectumShuichi Sakamoto1, Yuichi Tomiki1, Yoshiro Ishibiki1, Tomoo Watan-abe1, Shinji Kasamaki1, Takashi Matsuoka1, Masayuki Kitajima1,Tsutomu Maeda1, Kazuhiro Sakamoto1, Toshiki Kamano1, ToshioKumasaka2, Koichi Suda2

1Coloproctological Surgery, 2Department of Pathology(1), Junten-do University School of Medicin, Japan

A 59-year-old woman was admitted to our hospital because oflower abdominal pain and pain on defecation. Abdominal comput-ed tomography and magnetic resonance imaging scans showed apelvic tumor, 6 x 5 cm in sized. Barium enema and colonoscopyrevealed stenosis of the rectum and sigmoid colon. Although noneoplasmic cells were identified in colonic and endometrial biopsy,the preoperative diagnosis was the tumor of uterus, invading to therectum and sigmoid colon. Abdominal total hysterectomy, bilateraloophorectomy, and low anterior rectal resection were performed.Macroscopic findings of the resected materials revealed the tumor,7 x 7 x 5 cm in sized, with ulcer penetrating to the uterus at therectal resion. The tumor showed diffuse proliferation of polygonaland / or giant cells with large cytoplasm and bazarre nuclei without


characteristic structures, similar to rhabdomyosarcoma. Immuno-histochemical examination revealed that cytokeratin was positivebut myogenic markers were negative. Finally the diagnosis wasanaplastic carcinoma of the rectum. Anaplastic carcinoma of theintestine is very rare and its diagnosis may be difficult before oper-ation. So we report anaplastic carcinoma of the rectum characteris-tic of penetrating to the uterus.

P-633A Case of Nonocclusive Mesenteric Ischemia, NOMI, withSurvival Following Emergency Surgery, with an Overview of50 Reports in JapanWataru Sakamoto1, Koji Sekikawa2, Hiroshi Sakuma2, Shinji Ohki2,Kenichi Takita2, Yuichi Hatakeyama2, Yoshihisa Koyama2, NorioInoue2, Seiichi Takenoshita2

1Surgery, Ohara Medical Center, 22nd Dept. of Surgery, Fukushi-ma Medical University, Japan

Non-occlusive mesenteric ischemia (NOMI) accounts for 20% ofacute mesenteric ischemia. It is difficult to diagnose. Mortality is60% to 100%. Therefore, NOMI should be considered during dif-ferential diagnosis of acute abdomen. Moreover, treatment mustbe rapid to secure survival. We saved life through emergencysurgery for NOMI. A 77-year-old man was brought to this hospi-tal by ambulance complaining of sudden abdominal pain. Rectalexamination showed marked swelling of the abdomen and a largeamount of bloody stool. Colonoscopy showed mucosal necrosisand erosion in the left hemicolon, sigmoid colon, and rectum. Forthat reason, IMA thrombus / embolism was doubted because thepatient had diabetes mellitus and a history of hypertension. Bloodflow of IMA was shown by CE-CT. Peritoneal irritation devel-oped, necessitating emergency surgery. The IMA pulsation waspalpable. Doppler echo showed the IMA flow, but mucosal necro-sis advanced with perioperative autoscope. Consequently, we extir-pated the transverse colon left 2/3 to the rectum, which had anecrotic color, and constructed an artificial anus. The patient’spostoperative course was good. He was discharged 3 weeks aftersurgery.

P-634Clinical Significance of Lymph Node Micrometastasis inAmpullary CarcinomaEiko Inomata Sakata, Yoshio Shirai, Naoyuki Yokoyama, ToshihumiWakai, Tatsuya Nomura, Chie Kitami, Ryo Kurosaki, Isao Kurosaki,Katsuyosi HatakeyamaDivision of Digestive and General Surgery, Niigata UniversityGraduate school of Medical and Dental Sciences, Japan

Purpose: The purpose of this study was to clarify the sensitivityand clinical implications of lymph node micrometastasis inampullary carcinoma. Methods: A total 1115 lymph nodes fromsurgical specimens of 45 consecutive patients who had undergone aradical resection were examined histologically. Micrometastasiswas defined as a metastasis missed on routine histologic examina-tion with hematoxylin-and-eosin but detected by immunohisto-chemical examination with an antibody against cytokeratines 8 and18. The results were examined for relationships with clinical andpathologic features and patient survival. Results: Immunohisto-chemical examination revealed micrometastasis in 21 (1.8%) of1115 lymph nodes and in 11 (24%) of the 45 patients examined.

Nodal micrometastasis was significantly associated with lymphnode overt metastasis (P = .017) and pancreatic invasion (P = .026).Nodal micrometastasis correlated significantly with tumor relapse(P = .009). Cumulative 5-year survival of the patients with nodalmicrometastasis was significantly worse (20%, median ; 18 month )than that of the patients without nodal micrometastasis (76%,median ; not reached) (P = .0018). Multivariate analysis revealedthat lymphatic vessel invasion (P=0.010), vascular invasion(P=0.016), nodal micrometastasis (P=0.029) were independent andsignificant factors. Conclusions: Lymph node micrometastasis isthe strong independent prognostic predictor of worse survival con-founding the overt nodal status and may indicate aggressive biolo-gy among patients undergone radical resection for ampullary carci-noma.

P-635A Case of Medial Pancreatectomy for Serous Cystadenomaand Localized Stenosis of the Main Pancreatic DuctHaruhito Sakata1, Takeshi Uematsu2, Masanori Ichinose2, KimiakiFukasawa2, Kazuaki Okuyama2, Hisahiro Matsubara1, YukimasaMiyazawa1, Kazuyuki Matsushita1, Tetsurou Urashima1, RyousukeMochizuki1, Taichi Kawashima1, Yasunori Akutsu1, Takanori Nishi-mori1, Isamu Hoshino1, Yasuo Yoneyama1, Takenori Ochiai1

1Academic Surgery, Chiba University, 2Shioya General Hospital,Japan

We report here a case of medial pancreatectomy for serous cys-tadenoma and rarely combined localized stenosis of the main pan-creatic duct. A case of 51 year-old woman referred with complain-ing sever epigastralgia was administered. Ultrasonography revealedmulti cystic and high echoic lesion at the body of the pancreas. CTscan disclosed isodensity mass lesion and all of the pancreas wasdemonstrated low density. Magnetic resonance cholangio-pancre-atography revealed high signal intensity mass and dilatation of thedistal part of the main pancreatic duct on T2-weighted imaging.ERCP disclosed localized stenosis of the main pancreatic duct. Weperformed medial pancreatectomy after the diagnosis of serouscystadenoma combined with chronic pancreatitis or serous cys-tadenocarcinoma with fat degeneration of the pancreas. Cut sur-face were examined intraoperative frozen section resulted freefrom malignancy. Histopathorogical examination of the specimenshowed serous cystadenoma at the body of the pancreas and steno-sis of the pnacreatic duct was beside itself. Pancreas parenchymecertificated fat degeneration that expected from radiological find-ings remained with islets of Langerhans. Pre and postoperativeexocrine function examined by PFD test were 17.7% and 8.5%respectively. The patient had discharged 35 days after operationwith no complication and doing well three years after the opera-tion. The management of these tumor is sometimes waver in ourjudgment whether pancreatico-duodenectomy or distal pancreate-ctomy. We selected a medial pancreatectomy and preserves pan-creatic function.

P-636Serum Soluble Interleukin-2 Receptor and Immunohisto-chemical Staining of IL-2R/Tac Antigen in Colorectal CancerHideto Sakata, Saburo Murakami, Renzo HirayamaDepartment of General Surgery, Saitama Medical School, Japan

[Purpose] We investigated the significance of serum soluble IL-2R

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as a tumor marker, and examined the existence and localization ofthe positive cells for IL-2R/ Tac antigen in colorectal cancer tis-sues and its regional lymph nodes. [Subjects and Methods] 155patients with colorectal cancer were included. Levels of serum sol-uble IL-2R were measured by an ELISA assay. In the tissuesobtained from 18 cases, immunohistochemical staining was per-formed with the use of avidin-biotin-peroxidase complex tech-nique, in which mouse anti-human interleukin-2 receptor antibodywas used. [Results] The preoperative levels of serum soluble IL-2Rin patients with colorectal cancer were significantly higher thanthose of normal controls. The levels of serum soluble IL-2R incases with metastatic lymph nodes were also significantly higherthan those without metastatic lymph nodes. Concerning the tumormarkers, there were significant differences of serum soluble IL-2Rlevels between the two groups who were positive and negative forCEA and IAP. In the immunohistochemical staining of IL-2R, six-teen of 18 cases (88.8%) showed the IL-2R positive cells in thecolorectal cancer tissues. In regard to the metastatic lymph nodes,all of 5 cases (100%) showed the IL-2R positive cells. On the otherhand, the IL-2R positive cells were not recognized in normal col-orectal tissues and non-metastatic lymph nodes. [Conclusions]These results may suggest that activated T-lymphocytes infiltrat-ing into the cancer tissues to play an antitumor role release a largeamount ofα-chain of IL-2R, resulting in the high levels of serumsoluble IL-2R in patients with colorectal cancer.

P-637Tumor Seeding in Jaundiced Patients with ExtrahepaticCholangiocarcinoma Undergoing Percutaneous TranshepaticBiliary DrainageJun Sakata, Toshihumi Wakai, Yishio Shirai, Pauldion Cruz, EikoSakata, Naoyuki Yokoyama, Katuyoshi HatakeyamaDivision of Digestive and General Surgery, Niigata UniversityGraduate School of Medical and Dental Sciences, Japan

Backgrounds: Although percutaneous transhepatic biliary drainage(PTBD) has been used as a biliary decompression procedure inpatients with malignant biliary obstruction, tumor seeding alongthe catheter tract may occur following PTBD. The incidence oftumor seeding associated with PTBD remains unknown. The aimof this study was to delineate the risk of tumor seeding in patientsundergoing PTBD. Methods: A retrospective analysis was con-ducted of 67 patients with extrahepatic cholangiocarcinoma whounderwent radical resection after prior PTBD. The median fol-low-up period was 105 months. Tumor seeding along the cathetertract was defined as subcutaneous implantation metastasis at thepuncture site following PTBD procedure. Results: The puncturesites of PTBD were left side in 43 patients, right side in 11patients, and bilateral side in 13 patients. The incidence of tumorseeding along the catheter tract was 5% (3/67 patients). Thecumulative probability of tumor seeding was 6% at 2 years afterresection. The average duration of maintaining the catheter beforeoperation was 52 days (range, 28 to 67 days). In the 3 patients whohad tumor seeding, excision of puncture sites at the time of radicalresection was not performed. The initial site of relapse was thepuncture site and 3 patients with tumor seeding died of relapse at10, 28, and 33 months after resection. Conclusions: Tumor seed-ing along the catheter tract is not a rare complication in patientswith extrahepatic cholangiocarcinoma undergoing PTBD. Clini-cians should note the risk of tumor seeding when performingPTBD for malignant biliary obstruction.

P-638Clinical Application of the Tactile Sensor for Estimation ofLiver CirrosisHiroshi Sakuma1, Hatakeyama Yuichi1, Suzuki Satoshi1, ShinnjiOoki1, Naoki Sato1, Koyama Yoshihisa1, Norio Inoue1, SeiichiTakenoshita1, Sadao Omata2

1Surgery 2, Fukushima Medical University,school of medicine,2Department of Electrical and Electnic Engineering, College ofEngineering, Nihon University, Japan

We studied significance of quantifying liver hardness using ratswith liver cirrhosis and the tactile sensor. In that study, it was use-ful for estimation of liver fibrosis and liver regeneration activity. Inthis study, we applied the tactile sensor to clinical cases and studiedsignificance of quantifying liver hardness. Seventeen patients ( 8with primary liver cancer, 4 with metastatic liver cancer, and 5with other cancers) in our department from May, 1997 throughApril, 2004. Blood examination and ICG test were performedbefore each operation. Besides Conventional blood tests, procolla-gen III peptide (PIIIP), type IV collage 7S, and hyaluronic acidvalues were evaluated as preoperative blood examination. Further-more, ICG R15 values and K ICG values were obtained at ICGtest. Liver hardness was quantified as tactile values by using thetactile sensor after lapatotomy . Hepatic fibrosis index (HFI) wasobtained from each intraoperative biopsy specimen for estimationof liver fibrosis. Moreover, the area ratio of type III, and VI colla-gen stained with immunostaining was estimated in 8 patients bycomputed color image analysis. Results 1 The tactile sensor wasuseful to quantify liver hardness in clinical cases rapidly and safely.2 The tactile sensor was useful to evaluate hepatic fiblosis index. 3Liver hardness depended on type IV collagen content of the cir-rhotic liver. 4 Considering the result of animal experiment, itwas suggested the quantification of liver hardness could be clini-cally useful for estimation of liver regeneration activity.

P-639Methods and Results of Laparoscopic Surgery for GIST ofthe StomachShinichi Sakuramoto, Shiro Kikuchi, Kuroyama Shinichi, FutawatariNobue, Katada Nastuya, Kobayashi Nobuyuki, Watanabe MasahikoSurgery, Kitasato University School of Medicine, Japan

(Purpose) We have performed laparoscopic local resection of thestomach for 18 patients with GIST since April 1998 to date. Itssurgical technique and results are examined. (Indication) GISTwith the size 5 cm or smaller which does not hang over the EGjunction or pyloric ring. (Methods) We insert the camera portfrom the infraumbilical part, and then insert two 5 mm-trocars andone 12 mm-trocar. Then, insert the gastric camera and confirmthe lesion site using concurrently both the gastric camera and thelaparoscope. Hold the line to be resected using the bowel forcepsand the Babcock forceps, and confirm that the lesion is completelywithin the line to be resected using the gastric camera. Then, putthe linear staple on the same site, resect it under observationthrough the laparoscope and the gastric camera. Put the resectedspecimens into the surgical bag and remove it from the body byextending the incision for the camera port to the size of the tumor.(Results) The mean operation time was 101minutes and maximaldiameter of the tumor mean 3.8cm. Pathological diagnosis was


GIST in all the patients including low grade in 11, high grade in 7and surgical margin was negative. Oral ingestion was started at 1.9days after surgery and mean hospital days after surgery were 7.3.Postoperative complications were not observed in any of thepatients. Currently no recurrence is observed. (Conclusion)Laparoscopic surgery for GIST of the stomach was low invasiveand postoperative QOL was excellent.

P-640S-Nitrosothiols and their Increased Formation FollowingLiver Ischemia-reperfusion InjuryHenryk J. Salacinski1, Georgios K. Glantzounis2, Sophie A. Rocks3,Hemant Sheth2, Brian R Davidson2, Paul G. Winyard4, Alexander M.Seifalian1

1Hepatic Hemodynamic Unit, University Dept of Surgery, RoyalFree & University College Medical School, University CollegeLondon, 2Hepatic Hemodynamic Unit, University Dept ofSurgery and Liver Transplantation Unit, Royal Free & UniversityCollege Medical School, University College London and theRoyal Free Hospital, 3Bone and Joint Research Unit, Barts and theLondon, Queen Mary’s School of Medicine, 4Institute of Biomed-ical Science, Peninsula Medical School, Universities of Exeter andPlymouth, UK

Introduction: Plasma S-nitrosothiols (RSNOs) are a circulatingform of nitric oxide (NO) that potentiates both vascular functionand platelet aggregation. Their role in liver ischemia/reperfusion(I/R) injury is still unclear. In the current study the changes inplasma RSNOs were investigated in the rabbit lobar I/R model.Methods and Materials: Two groups of animals were used: I/Rgroup (n=6) where lobar liver ischemia was induced for 60 min,followed by 7 hrs of reperfusion and sham (n=6) that underwentlaparotomy but no liver ischemia. Serial RSNOs levels were mea-sured in plasma by electron paramagnetic resonance (EPR) spec-trometry, nitrite/nitrate plasma levels by electrophoresis, hepaticmicrocirculation by Laser Doppler Flowmetry and tissuecytochrome oxidase by near infrared spectroscopy. As reactivenitrogen species (RNS) can mediate the formation of RSNOs invivo the oxidation of dihydrorhodamine to rhodamine was mea-sured by fluorescence to act as an independent marker of RNSproduction. Results were considered significant when p<0.05.Results: There was a significant increase in plasma RSNOs levels 5hrs post-reperfusion in the I/R group when compared to baseline.At the exact, same time points there was a significant decrease inmicrocirculation coupled with those of cytochrome oxidase. Theincreased plasma RSNOs concentration correlated significantlywith the changes in the microcirculation. Plasma nitrite/nitrateconcentration decreased during reperfusion period. There was sig-nificant production of rhodamine at the end of the experiment inthe I/R group. Conclusion: The results show that there was amarked up-regulation of NO synthesis during I/R injury, whilstmicrocirculation and intracellular oxygenation decreased. In addi-tion significant oxidation of DHR to RH took place. Since nitriteand nitrate levels did not show this change it is concluded thatplasma RSNOs levels as determined by EPR are a better marker ofNO activity and can be used as a quantitative indicator ofnitrosative stress.

P-641Evaluation and Treatment of Colorectal Cancer in ShahidRahnemoon and Afshar Hospitals Yazd-IranAli Akbar Salari1, Ali Akbar Salari2

1Surgery, Yazd University, 2Yazd Univercity, Iran

Purpose : Cancer of colorectal is the most common cancer of ali-mentary system. In the women is the second cause of mortalityafter cancer of breast and in the men is the third cause of deathafter carcinoma of the lung and prostat. Methods: This study istype of retrospective by method of cross - sectional descriptive fileof 191 patients in Shahid Rahnemoon and Afshar hospitalsfrom1992-1999. The aim of evaluation of abundance distributionof colorectal cancer for staging, age, sex, job, place of living andclinical signs and method of treatment. Results: From 191 patientswith cancer of colorectal 186 Adenecarcinoma and 5 were lym-phoma. Prevalence in the men was more than women majority inthe age of 28-94 years. 127 patients were in age group of 60-69and 70-100years, and least prevaleace in age 20-39 years. Surgicaltreatment A.P.R. in 55 patet (A.R)Resection and anastomosis 40patients Rt & Lt hemicolectomy 25 and rectosigmoidectomy,anastomosis in 18 patients.Result of treatment 177 patiets withproportional recovery and 5 with their satisfication dischargedfrom Hospital 3 has died and 6 with poor condition after laparato-my discharged. Conclusion: The most patients with colorectalcancer referred were with rectorrhagi and mainly type of adeno-carcinoma and most surgical procedure was (A.P.R) with attentionto results of study etiology of colorectal cancer and more researchin fields of search for patients, diagnosis, treatment and prognosisof These patients can help in the treatment of them.

P-642Safe Access to the Peritoneal Cavity after Multiple PreviousSurgeriesPierre F. Saldinger, Fatejeet Sandhu, Keith ZuccalaSurgery, Danbury Hospital, USA

Access to the abdominal cavity after numerous previous surgeriescan be a daunting task. Multiple adhesions from previous can leadto injuries to small and large bowel prior to entering the abdomen.We describe a combined interventional radiology / laparoscopicmethod providing safe access to the peritoneal cavity. This methodallows for laparoscopic visualization of adhesions prior to enteringthe abdomen.

P-643Minimally Invasive / Transitercostal Placement of HepaticArterial Infusion PumpPierre F. Saldinger, Fatejeet SandhuSurgery, Danbury Hospital, USA

Hepatic Arterial Infusion (HAI) chemotherpy of metastatic col-orectal cancer to the liver is a well established modality. Placementof those pumps requires a laparotomy with its associated morbidi-ty. We describe a method whereby a HAI is placed via cannulationof an intercostal artery.

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P-644Radiofrequency Ablation for Metastatic Liver TumorHironori Samura, Masayoshi Nagahama, Masayuki Shiraishi, Hiro-humi Tomori, Takashi Ohshiro, Tadashi NishimakiFirst Depertment of Surgery, University of Ryukyus, Faculty ofMedicine, Japan

[Purpose] The aim of this study was to evaluate the safety and effi-cacy of radiofrequency [Purpose] The aim of this study was toevaluate the safety and efficacy of radiofrequency ablation(RFA)for unresectable metastatic liver tumors, in comparison to RFA forprimary liver tumors. [Patients and Method] Between May 2000 toDecember 2002, 13 patients underwent Radiofrequencyablation(RFA) for unresectable liver tumors. Four patients of thosehad metastatic liver tumors.Primary lesions of those metastatictumors were colorectal cancer in two patients, duodenalleiomyosarcoma in 1, and unknown in 1. Morbodity , mortality,serum level of liver enzymes and tumor makers after RFA wereevaluated. [Result] The liver enzymes were elevated maximally oneor two days after RFA.AST and ALT elevated 104 to 1171 IU/L,86 to 1091 IU/L, respectively. The liver enzymes had returnedinto normal range in a week in all case. In two case, serum level ofCEA was reduced after the procedure of RFA. There was no avail-able tumor maker in other two cases. One patient had infected bilecollection at the site of ablation was done. Others had no gravecomplication associate with RFA. The patients were observed 6 to12 months, and three patients had recurrent disease and died.[Conclusions] We treated over 4-cm metastatic liver tumor withRFA and had no grave complication after the procedure. But 3 of 4patients had recurrence and died. Local control of metastaticlesion and survival benefit were controversial.

P-645Defining the Risks of Complications of Subclavian VeinCatheterizationKinya Sando, Haruki Ide, Toshikazu Ito, Hitoshi Mizuno, TsunekazuMizushima, Kentaro Nonaka, Yoshihito Souma, Kazuhiro IwaseSurgery, Rinku General Medical Center Izumisano MunicipalHospital, Japan

PURPOSE: A high frequency (6.2-10.7%) of mechanical compli-cations according to the subclavian vein catheterization has beenreported. To determine the rate of mechanical and infectious com-plications of subclavian vein catheterization and to define the risksof complications. METHODS: A prospective clinical trial wasconducted between September 2002 and January 2004 in a surgicaldepartment of Rinku general medical center Izumisano municipalhospital. One hundred and two adult patients were enrolled toreceive subclavian vein catheterization in non-emergency condi-tions under the supervision of another doctor. The time of proce-dure (insertion time) was measured and the number of times of the“finding” and “introducing” punctures and the number of attend-ing doctors and their clinical experience year (CEY) were record-ed. The rate of mechanical complications (pneumothorax , hemo-thorax, arterial puncture, hematoma, arrhythmia, and misplace-ment) and infectious complications within one week after insertionwere determined. RESULTS: The complications occurred in 12patients (arterial puncture 9, infection 2, pneumothorax 1). In nocomplication patients insertion time was significantly shorter(13’59” vs 22’30”) and “finding” and “introducing” puncture time

were significantly smaller (1.29 vs 3.73, 1.95 vs 3.40). The compli-cation rate was significantly lower in over 5CEY doctors (2.9 vs13.5%) and in patients whom punctured once or twice (“finding”:8.3 vs 46.7%, “introducin”: 4.6 vs 50.0%) and in patients whoseinsertion time was less 22minnute(10.7 vs 50.0%). CONCLU-SIONS: Over three times “finding” or “introducing” puncture andover 22minute insertion time were associated with a high risk ofcomplications of subclavian vein catheterization.

P-646Gastrocolic Fistula - Our ExperienceAbhijit SarmaDept of Surgery, Gauhati Medical College, India

Introduction :GJcolic fistula is a rare but serious complication fol-lowing surgery for peptic ulcer. Aim : We did a retrospectiveanalysis of all the cases we saw in our institute for a period of 10yrs. Material & Methods: The total no of cases were 15. The mostcommon age group was between 30 to 40 yrs. Male: Female ratiowas 13:2. For all the cases we did a complete haemogram withLiver function tests & renal profile. Endoscopy was done in 10cases. Barium meal follow-through was done in 4 cases & Bariumenema in 9 cases.They were further evaluated & then taken up forsurgery. A total of 14 cases underwent surgery. Single stage tripleresection was done in 12 cases, oesophagojejunostomy was done in1 case & Colostomy was done in 1 case. I patient refused surgery.The operative findings were an intact vagus in 8 cases & fistulademonstrated in 13 cases. To conclude. 1.GJcolic fistula thoughuncommon, still encountered in the present day 2.IncompleteVagotomy is the commonest cause 3.Barium enema is the investi-gation of choice. 4.Single stage triple resection is the procedure ofchoice. 5.Incomplete Vagotomy should be avoided.

P-647Immunohistochemically Demonstrated Lymph NodeMicrometastasis in Gallbladder CarcinomaEiji Sasaki, Masato Nagino, Tomoki Ebata, Uichirou Tojima, JunichiKamiya, Norihiro Yuasa, Koji Oda, Toshiyuki Arai, Hideki Nishio,Yuji NimuraDivision of Surgical Oncology, Department of Surgery, NagoyaUniversity Graduate School of Medicine, Japan

Purpose: To evaluate whether immunohistochemically demon-strated lymph node micrometastasis has prognositic impact inpatients with gallbladder carcinoma. Method: A total of 1612lymph nodes from 77 patients with gallbladder carcinoma whounderwent macroscopically curative resection were immunostainedusing monoclonal antibody, against cytokeratin 8 and 18. “Overtmetastasis(Ov)” was defined as the metastasis which was detectedby conventional pathological examination with hematoxylin andeosin slides. “Micrometastasis(Mi)” was defined as the immunohis-tochemically demonstrated metastasisless than 0.5mm. Correlationbetween nodal status and clinicopathological features wasreviewed. Results: Ov were detected in 27 (35.1%) of the 77patients, being found in 47 (2.9%) of 1612 lymph nodes examined.Mi were detected in 25 (32.5%) of the 77 patients, being found in40 (2.5%) of 1612 lymph nodes. Five-year survival for patientswith Mi(-) and Mi(+) was 63.7% and 35.2% respectively (p=0.022).Five-year survival for patients with Ov(-) and Ov(+) 67.2% and31.7%, respectively (p=0.0006). Five-year survival for patients with


Mi(-)/Ov(-), Mi(+)/Ov(-), Mi(-)/Ov(+) were 73.7%, 50.0%, and41.7%, respectively. There was no 5-year survivor in the patientswith Mi(+)/Ov(+). There was a significant difference between Mi(-)/Ov(-) and Mi(+)/Ov(-) (p=0.0065). However, no significant dif-ference between Mi(-)/Ov(+) and Mi(+)/Ov(+) (p=0.07). Multivari-tate analysis revealed only microscopic venous invasion and per-ineural invasion as independent prognostic factors. Conlcusion:Lymph node micrometastasis might worsen survival for patientswith gallbladder cancer; however, it is not an independent prog-nostic factor.

P-648Surgical Management of Extensive Corrosive Injuries of Ali-mentary Tract; Use of the “Supercharge Technique” toColonic Graft: A Case ReportKazunori Sasaki, Koji Yamaguchi, Nobuyuki Matsumura, HitoshiZenbutsu, Rika Fukui, Fumitake Hata, Hidefumi Nishimori, WataruSuga, Yasutoshi Kimura, Tadashi Katsuramaki, Koichi Hirata1st Department of Surgery, Sapporo Medical University, Japan

A 68-year-old woman, attempted suicide by ingesting about 500mlof alkaline bleach, was sent to our hospital one hour later. Obvi-ously, endoscopic examination showed severe corrosive injuriesand it seemed to be infiltrated into the deep layer of esophagus,stomach and duodenum. Furthermore, analysis of blood chemistryshowed the progress of metabolic acidosis and tissue necrosis, weenforced the emergency operation; blunt dissection of the esopha-gus, total gastrectomy, pancreaticoduodenectomy, and partialresection of the proximal jejunum. As a result of this operation, shewas rescued. After nutrition management by enteral diet alone wasattained, she left the hospital temporarily.32 months later she hos-pitalized again. Embolisms of superior rectal artery and 1st branchof sigmoid colon was formed by interventional radiology (so-called“supercharge technique”) in order to improve arterial inflow andvenous drainage of the graft. It was performed 47 days precedentto re-operation - esophageal replacement with descending colonicgraft. In addition to, we reconstructed the marginal vessels of thecolonic graft, using transverse cervical artery and internal jugularvein, to maintain microvascular blood flow. This re-operation wassuccessful and complications were hardly observed. She was muchsatisfied and left hospital 41days after the re-operation. Diagnosisand surgical management of corrosive injuries is still controversial,but our experience showed emergency operation might be themost effective treatment in terms of prevention against perforativecomplications - to save the patients’ life. And we could emphasizethe “supercharge technique”, pre-operative vessel preparation, wasuseful for esophageal replacement by colonic interposition.

P-649A Case of Advanced Gastric Cancer with Multiple Liver andParaaortic Lymph Node Metastases Successfully Treatedwith Salvage Operation Following Biweekly Paclitaxel and S-1Ken Sasaki1, Sumiya Ishigami2, Shuichi Hokita2, Akihiro Nakajo2,Shoji Natsugoe2, Takashi Aikou2

1Surigical Oncology, Digestive Surgery, Kagoshima University,2Kagoshima University, Japan

We experienced a case of 67-year-old male having advanced gas-tric cancer, who had a complete response of multiple liver andparaaortic lymph node metastases by combination chemotherapy

with paclitaxel and S-1. After the chemotherapy, the patientunderwent total gastrectomy with D3 lymph node dissection forcurative intent. Macroscopically the tumor was curatively resectedincluding distant metastases. Biopsy of the liver was negative forcarcinoma. Pathological report suggested that the lymph nodemetastases were completely disappeared and minute cancerouslesion was identified in the gastric mucosa. Therefore, histologicalefficacy was evaluated as Grade 2. He is fine without sign ofrelapse of gastric cancer nine months after the operation. Salvageoperation following paclitaxel and S-1 chemotherapy may be use-ful for advanced gastric cancer patients associated with distantmetastases.

P-650The Differences of Long-Term Prognosis after HepaticResection between Patients with HBV- and HCV-RelatedHepatocellular CarcinomaYo Sasaki, Terumasa Yamada, Hidetoshi Eguchi, Hiroaki Ohigashi,Shingo Noura, Ko Takachi, Isao Miyashiro, Kohei Murata, YuichiroDoki, Osamu Ishikawa, Shingi ImaokaGastro-Intestinal and Hepato-Biliary-Pancreratic Surgery, OsaskaMedical Center for Cancer and Cardiovascular Diseases, Japan

(Background)Characteristic differences of some etiologic or clini-cal factors are pointed out between HBV-, and HCV-related hepa-tocellular carcinoma (HCC). However, it is not elucidated of thedifferences of long-term prognosis after hepatic resectionsbetween both the two types of virus-originated HCC. (Patientsand Methods) From the beginning of January 1989 to the end ofDecember 1999, 469 patients underwent curative hepatic resec-tion. The HCC patients with positive HBs-Ag and negative HCV-Ab were regard to HBV-related HCC (HBV-group, n=66), andthose with negative HBs-Ag and positive HCV-Ab were regard toHCV-related HCC (HCV-group, n=351). The clinicopathologicalfindings and a long-term surgical results were compared betweenHBV-group and HCV-group. (Results) The 3-, 5- and 10-yearDFS rates of HCV-group, 42%, 25%, and 12%, respectively,were significantly worse than those of HBV-group, 56%, 51%,and 36%, respectively,(p=0,0047). Multivariate analysis was per-formed for DFS using the variables of which the p values were lessthan 0.05 in univariate analysis. Viral hepatitis was one of the inde-pendent prognostic factors for DFS (p=0.0085) together withtumor size, surgical margin, and Edmondson grade. The risk ofrecurrence from HCC increased to 1.97 times greater in HCCpatients with C type hepatitis than in those with B type hepatitisby the adjustment. (Conclusion) DFS of HCV-related HCCpatients was significanly worse than that of HBV-related HCCpatients. Viral hepatitis was one of the independent prognostic fac-tors for DFS. We shuould change the strategy for the treatment inaccordance with the difference of hepatitis.

P-651Cellular and Hormonal Immune Response to Recurrent Col-orectal Cancer by Peptide Vaccination with ChemotherapyTeruo Sasatomi1, Masataka Fukumitsu1, Keiko Matono1, YutakaOgata1, Kyogo Itoh2, Hideaki Yamana3, Kazuo Shirouzu1

1Dept. of Surgery, 2Dept. of Immunology, 3Multi-diciplin, CenterKurume University School of Medicine, Japan

PURPOSE: Colorectal cancer accounts for 10-15% of deaths from

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cancer in industrial nations. Especially recurrent colorectal cancerafter surgery were challenging disease and difficult for cure. Wetried a new immunochemotherapy for these patients. METH-ODS: We had been identified new 26 cancer vaccines by geneexpression method (6 new genes). HLA-A24 or HLA-A2 positive17 patients with recurrent colorectal cancers (metastasis to liver orlungs) were simultaneously accepted cancer vaccine therapy. Andall the patients was ineffective at chemotherapy and progressivediseases. First, we had checked skin test and CTL precursor fre-quency of each patient for our cancer peptide vaccines. Then, 3mgof three or four most frequent cancer vaccines were injected intra-dermaly three times bi-weekly, and at the fourth trial, at 14 of 17patients, cancer peptide vaccines and intravenous 5FU (750mg)and Leucovorin (250mg) combined therapy had been started everyother weeks. We have been investigated CTL precursor frequencyall the period. RESULTS: CTL precursor frequencies wereincreased in all the patients. At seven of ten patients, Ig G antibod-ies for cancer peptide vaccines were increased. And there were nosevere adverse effects. At three of eight patients who had beenaccepted cancer peptide vaccines with 5FU and Leucovorin com-bined therapy, tumor markers (CEA) and tumor sizes weredecreased and alive more than nine months. CONCLUSIONS:We think our combined cancer vaccine and chemotherapy, intra-venous 5FU (750mg) and Leucovorin (250mg), may be effectivefor patients with recurrent colorectal cancers after surgery.

P-652Clinical Significance of Core2 GlcNAc Transferase Expres-sion in Colorectal CancerMotoki Sassa1, Kensuke Kumamoto1, Masami Hoshino2, KojiSekikawa1, Seiichi Takenoshita1

1Second Department of Surgery, Fukushima Medical University,2Department of Surgery, Ohara General Hospital, Japan

(Purpose) The carbohydrate determinants, sialyl Lewis A/X, areinvolved in the adhesion of cancer cells to vascular endotheliumand thus contribute to hematogenous metastasis of cancer. Core 2beta-1,6-N-acetylglucosaminyltransferase (C2GnT) is a glycosyl-transferase that is responsible for the core 2 branch, which is criti-cal for biosynthesis of sialyl Lewis A/X in O-glycans. To determinewhether tumor cells express increased level of C2GnT, we exam-ined the expression of C2GnT in colorectal cancer. (Methods)C2GnT expression was detected by immunohistochemical stainingin colorectal cancer tissues from 80 cases received surgery for pri-mary colorectal cancer. We investigated the correlation with theexpression of sialyl Lewis X (NCC-ST-439) and p53. We analyzedthe result between C2GnT expression and the clinicopathologicalfindings and prognosis. (Result) C2GnT positive expression wasdetected in 48 cases (60%) of the colon cancer patients. There wassignificant correlation between the expression of C2GnT andNCC-ST -439 in the same case. Statistical analysis between theC2GnT expressed in colon cancer tissues and clinicopathologicalvariables revealed that the expression of C2GnT was significantlycorrelated with vessel invasion (P<0.005) and depth of invasion(P<0.05). Regarding the effects of C2GnT expression on the prog-nosis, the C2GnT with positive patients had no significantly poor-er prognosis than those with negative. (Conclusion) The presentstudy indicated that C2GnT is expressed in colon cancer tissues.We have demonstrated that C2GnT expression is closely correlat-ed with the expression of sialyl Lewis X and vessel invasion.

P-653The Effect of Lateral Node Dissection for Dukes C RectalCarcinoma below the Peritoneal ReflectionHarunobu Sato, Koutarou Maeda, Tunekazu Hanai, KoujiMasumori, Yoshikazu Koide, Masahisa Matsumoto, Hiroyuki Aoya-ma, Hiroshi Matsuoka, Hidetoshi Katsuno, Tarou Ishikawa, Funa-hashi Masuo, Toshiaki KamanoSurgery, Fujita Health University, Japan

Purpose: This study was performed to identify patients who mighthave benefit from lateral lymph node dissection (LND) for DukesC low rectal carcinoma. Patients and methods: The study com-prised 91 patients with Dukes C low rectal carcinoma who under-went total mesorectal excision and LND. The patients were retro-spectively divided into two groups; patients with or without lateralspread (Group A). Patients with lateral spread were subdividedinto two groups; Group B (patients with nodal involvementbetween inferior hypogastric nerve and internal iliac artery) andGroup C (patients with nodal involvement within the obturatorspace). Group C was subdivided into C1 (patients with less than 4nodal involvement within the obturator space) and C2 (patientswith equal to or more than 4 nodal involvement within the obtura-tor space). Clinical outcomes were studied in terms of survival rateand recurrence. Results: Local recurrence and overall 5-year sur-vival rate were 6.8 and 64.1per cent in Group A, and 21.4 and 58.4per cent in Group B, and 30.3 and 23.9 per cent in Group Crespectively. There was no significant difference between Group Aand B in 5-year survival and local recurrence rate. Overall 5-yearsurvival rate was lower and local recurrence rate was significantlyhigher in Group C than in Group A. Overall 5-year survival ratewas significantly higher in C1 (29.4%) than in C2 (0%). Conclu-sion: LND for low rectal carcinoma was effective in Group B toimprove prognosis. However, LND for C2 gave no survival bene-fit.

P-654A Case of Esophagectomy with a Nonrecurrent InferiorLaryngeal NerveHiroshi Sato, Yasuhiro Tsubosa, Masayuki Nemoto, Toru UgumoriEsophageal Surgery, Shizuoka Cancer Center, Japan

In rare cases, the inferior laryngeal nerve branches directly fromthe vagus trunk. Most reported cases of this anatomical abnormali-ty were related to cervicotomies for thyroid and parathyroid exci-sion. Few reports have described the preoperative recognition ofthis nerve in esophagectomy. A 58-year-old man with carcinoma ofthe thoracic esophagus underwent esophagectomy with three-fieldlymph node dissection. This anomaly was detected preoperativelyby computed tomography. In this case, the cervical and abdominalprocedures, including the anastomosis in the neck, were performedbefore the thoracic procedure. Recognition of the right inferiorlaryngeal nerve before upper mediastinal lymph node dissectionwas thought to be important for avoiding unexpected nerveinjuries, since the range of right upper mediastinal lymph nodedissection in our thoracic procedure often reaches the level of theright lower pole of the thyroid. And in this case, left vocal cordpalsy occurred due to unexpected injury of the left recurrent laryn-geal nerve. This anomaly disturbed lymph node dissection alongthe left recurrent laryngeal nerve, which usually runs between thetrachea and vertebra. In this case, however, an aberrant right sub-


clavian artery located in front of the vertebrae narrowed this space.In conclusion, for a successful esophagectomy with three-fieldlymph node dissection in patients with esophageal carcinoma asso-ciated with an aberrant right subclavian artery with branching ofthe aortic arch, a cervico-abdominal procedure followed by a tho-racic procedure, which is opposite the usual process, could be use-ful for a safe operation.

P-655Curability and Functional Results after IntersphinctericResection in Very Low Rectal CancerKaznori Sato, Norio Saito, Masanori Sugito, Masaaki Ito, AkihiroKobayashi, Takanori Suzuki, Toshiyuki Tanaka, Yusuke Nisizawa,Masahito Kotaka, Youiti KarakiSurgery, Ntional Cancer Center Hospital East, Japan

(Purpose) AS compared with abdominoperineal resection (APR),the most important concepts of intersphincteric resection (ISR) areto preserve the balance of local control and sphincter function.The aim of this study was to evaluate oncologic and functionalresults of ISR with direct coloanal anastomosis (CAA) for very lowrectal cancer patients. (Methods) Between 1999 and 2004, 57patients underwent ISR . 21 patients underwent a partial resectionof internal sphincter, and CAA was situated above the dentate line.In 22 patients a subtotal or a total resection of internal sphincterwas performed, and the anastomosis was situated below the dentateline. 14 patients were performed additional partial external sphinc-ter resection. Preoperative the mean distances between the tumorand the dentate line was 1.7 (range,0-3) cm. All tumors were ade-nocarcinoma. A diverting transverse colostomy (40) or ileostomy(17) was established in all cases. Preoperative chemoradiotheraphywas performed in 33 patients. (Results) Pathologic TNM classifi-cations for the 57 patients has been revealed that T0 (4) who had apathologic complete response by preoperative chemoradiothera-phy, T1 (6), T2 (15), T3 (29), T4 (3). The median follow up was22 months.There was no perioperative mortality. Serious compli-cations occurred in 4 patients (7 percent) of whom 2 underwentpermanent colostomy included perinanastmotic abscess and post-operative bleeding. In early results, local recurrence rate was 9 per-cent (5). The rate maight be allowed us to be acceptable for thisresection. According to the Kirwan scale, the functional resultsafter stoma closure (6 month), continence and flatus discriminationimproved monthly. (conclusions) Thease early results suggest thatISR can be alternative to APR for selected rectal cancer situatedbelow 3cm from the dentate line.

P-656Appropriate Selection of Anticancer Drug by Assessing Sev-eral Molecular MarkersKen Sato, Yoshihiko Kitajima, Atsushi Miyoshi, Yasuo Koga, KohjiMiyazakiSurgery, Saga University Faculty of Medicine, Japan

(Background) In cancer chemotherapy, identification of molecularmarker to predict drug effect is important. We have reported thatgallbladder (GB) cancer cell lines which lacked DNA-repairenzyme 06-methylguanine methyltransferase (MGMT) showedhigher sensitivity to alkylating agents such as MNU and ACNU.(Purpose) In present study, we assessed (1) whether DPD and TSactivity or mismatch repair gene hMLH1 could be sensitive mark-

er for 5-FU, CPT-11(SN-38), respectively. (Material and Method)(1) In 5 gallbladder cancer cell lines (KMG-C, G-415, GBK-1,GB-d1,TGBC-2TKB, HBDC), DPD or TS gene expression wereassessed in RT-PCR, The enzyme activity of TS, DPD were ana-lyzed in ELISA. MTT assay was performed for 5-FU sensitivityagainst these cancer cell lines. IC50 was calculated and comparedwith DPD and TS activity. (2) Western blot analysis was per-formed to assess hMLH1 expression in 5 gallbladder cancer celllines and SW48 (colon cancer cell line). The sensitivity for SN-38was analyzed in MTT assay. (Result) (1) DPD or TS activity werecorrelated with IC50 of 5-FU (R=0.623(DPD), R=0.643(TS) (2)SW48 was defined as negative for hMLH1 expression. The IC50of SN-38 was 31.1nM, which was the lowest among these celllines, indicating that SW-48 was most sensitive for SN-38. (Con-clusion) We confirmed DPD or TS activity and hMLH1 expres-sion might predict the sensitivity for 5-FU, CPT-11(SN-38),respectively. These results indicated that suitable selection of anti-cancer drug could be determined by assessing several molecularmarkers.

P-657Studies on Multiple Colorectal CancerMikinori Sato, Hiromitsu Takeyama, Yoshimi Akamo, Yuji Okada,Hitoshi Funahashi, Minoru Yamamoto, Takehiro Wakasugi, YouichiMatsuo, Hiroki Takahashi, Masaki Sakamoto, Tadao ManabeDepartment of Gastroenteological Surgery, Nagoya City Univer-sity Graduate School of Medical Sciences, Japan

Recently multiple colorectal cancer has been reported increasingly.Thirty nine cases (29 synchronous, 6 metachronous, and 4 syn-chronous and metachronous) of multiple colorectal cansers werechrinicopathologically studied and compared with the 490 cases ofsolitary colorectal cancer. Twenty one cases (53.8%) were asociat-ed with adenomatous polyps. Sixty one lesions (65.6%) were locat-ed in the sigmoid colon and rectum. The main/first lesions invad-ed beyond the serosa mostly whoreas the secondary/second lesionswere mostly comfined to the submucosa (64.9%). Histologicalexamination revealed most of the lesions to be well-differentiatedadenocarcinomas. The cumulative 5-year survival rate was 79.4%in the multiple carcinoma group and 67.7% in the solitary carcino-ma group. All 10 cases of metachronous cases, had the secondlesion resected after a mean of 66 months from the firs operation,and all of then are 5-years survival cases. When a patient is diag-nosed to have colorectal cancer, careful pre- and intra-operativeexamination and surveillance follow-up are essential, bearing mul-tiple cancers in mind.

P-658The Patterns of Recurrence Following Hepatectomy forLiver Metastases from ColorectumNaoki Sato, Akihiro Yamaguchi, Masatoshi Isogai, Toru Harada, YujiKaneoka, Junji Washizu, Kiyoshi AikawaDepartment of Surgery, Ogaki Municipal Hospital, Japan

(Purpose)To know the patterns of recurrence and outcome follow-ing hepatectomy for liver metastases from colorectum and clarifythe optimal strategy for bilober liver metastases. (Patients andMethods)Between July 1980 and June 2003, 181 patients receivedhepatectomy against liver metastases from colorectum. The meanage of the patients was 61 years (range: 29-84), and male/female

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ratio was 118:63. The subjects were divided into three groups, sin-gle metastasis (S): 100 patients, multiple metastases to unilobe(Mu): 33 patients, and both lobe (Mb): 48 patients. The recurrencerate and the patterns of recurrence of remnant liver and prognosiswere compared among the groups. (Results)1) The recurrencerate: S; 40, Mu; 42, Mb; 58%. No statistical differences were seen.According to number of metastatic nodules, 2 or 3; 39, >=4; 73%,and there was a statistical difference (p=0.003). 2) Rate of multi-ple recurrences to the remnant liver: S; 65, Mu; 50, Mb; 88%. Mbwas higher than the others (p=0.038). 3) Prognosis (3- and 5-yearssurvival): S; 53, 34, Mu; 57, 48, Mb; 60, 53%. No statistical differ-ences were seen. Survival rates according to number (3- and 5-years survival), 2 or 3; 60, 56, >=4; 49, 36%. No statistical differ-ences were seen. (Conclusions)The bilober multiple liver metas-tases should be resected as possible. The patients of bilober multi-ple liver metastases demonstrated the multiple relapse in the rem-nant liver and number of nodule >=4 brought high hepatic recur-rence rate.

P-659Liver Transplantation from Live Donors Over 65 Years: AReport of Two CasesToshiyuki Sato, Kenichi Hakamada, Shunji Narumi, Yoshikazu Toyo-ki, Hajime Morohashi, Mutsuo SasakiDepartment of Surgery, Hirosaki University School of Medicine,Japan

The shortage of organs has led centers to expand their criteria forthe acceptance of older live donors. However, the use of such amarginal donor has to be balanced with the risk of donor hepatec-tomy and the recipient's outcome. We present two cases of livertransplantation from donors over 65 years. [Case 1] A 39-year-oldwoman with late onset hepatic failure underwent living donor livertransplantation (LDLT) by using a left liver graft from her fatheraged 69 years and 9 months. The graft weight was 320 g, whichwas estimated to be 30% of her standard liver volume. Theamount of blood loss in the donor hepatectomy was 341 ml andthe postoperative course of the donor was not remarkable. Thegrafted liver functioned slowly and she received plasma exchangefor 8 times for her persistent hyperbilirubinemia. She was dis-charged at POD 90. [Case 2] A 12-year-old girl with fulminantWilson's disease received a liver graft of 356 g from her grandfa-ther aged 68 years and 1 month. The donor's postoperative coursewas uneventful. The recipient experienced transient hyperbiliru-binemia but she did not require any additional therapy. She wasdischarged at POD 39. In our cases, the donors tolerated their lefthepatectomy well and the recipients could survive by receivingelderly liver grafts with relatively smaller volume. Because donorscan be evaluated preoperatively on their conditions in LDLT, theupper limit of donor age might be expanded older than that ofcadaveric liver transplantation.

P-660Significance of MIB-1 and AgNOR as Prognostic Factorsafter Resection of Cholangiocellular Carcinoma withoutLymphnode MetastasisTsutomu Sato, Ouki Yasui, Toshiaki Kurokawa, Go Watanabe,Takeshi Kato, Tomoyuki Kusano, Satoshi Shibata, Makoto Kume,Yuzo YamamotoDepartment of Gastroenterology, Akita University School of Med-icine, Japan

[Purpose] Outcome after resection of mass-forming type cholan-giocellular carcinoma remains poor, particularly in patients withlymphnode metastasis. Five-year survival rate was 18% with LNmetastasis and 43% without LN metastasis by the nation-wide sur-vey in Japan. However, these figures indicate that more than halfcannot live long even without LN metastasis. Purpose of the studywas to clarify prognostic factor influencing the outcome of CCCwithout LN metastasis with special reference to cell kinetics.[Methods] Twenty CCC patients underwent hepatectomy at AkitaUniversity Hospital from 1987 to 2003 and 16 of them, negativefor LN metastasis, were allocated to the study. Profiles; Age, 58-80y.o.; tumor size; 5.5±3.1cm, operative procedures;2 segmentecto-my, 2 trisegmentectomy, 12 bisegmentectomy, 3 combined portalvein resection. In addition to routine histological examination,MIB-1 labeling index was calculated after immunostain and argy-rophilic nucleolar organizer regions (AgNOR) score was counted.[Results] Ten patients died of recurrence, one is alive with intra-hepatic recurrence, and remaining 5 are well without recurrence.Using univariate analysis, tumor differentiation, presence orabsence in venous and/or lymphatic infiltration and perineuralinvasion were significant prognostic factors. In addition, MIB-1and AgNOR were both most powerful in predicting outcomes; 3-year survival rate in patients having MIB-1 LI no less than 20 was20% whereas it was 100% of MIB-1 less than 20. Similarly, 3-yearsurvival rate having AgNORs no less than 2.5 was 28% whereas itwas 100% of AgNORs less than 2.5. [Conclusion] MIB-1 andAgNORs were useful to predict prognosis of CCC after resectioneven when lymphnode metastasis was absent.

P-661Treatment and Prognosis of Biliary Injuries during Laparo-scopic CholecystectomyYoshihiro Sato, Takuro Saito, Takao Tsuchiya, Akira Kenjo, TakashiKimura, Mika Hoshino, Takayuki Anazawa, Mitsukazu GotohDepartment of Surgery I, Fukushima Medical University, Schoolof Medicine, Japan

Biliary injury is one of the critical complications in laparoscopiccholecystectomy (LC). Twenty-five cases of biliary injuries among4482 cases undergoing LC in our institution and 27 affiliated hos-pitals from 1991 to 2003 were analyzed for characteristics ofinjuries, treatments and its outcome. Results: The injuries weredetected during (18 cases) or after surgery (7 cases). Sites of theinjury were common bile duct (CBD) (17 cases), right hepatic duct(2 cases), common hepatic duct (2 cases), cystic duct (3 cases), andliver bed (1 case). Twenty cases had single injury and 5 cases hadmultiple injuries. Nine cases of incomplete cutoff of CBD whichwere found during (5 cases) or after surgery (4 cases) underwentdirect closure of the injury site followed by T-tube or RTBdrainage, and no complication was found later on except one case


who needed transient bougienage. Sixteen cases of complete cut-off of CBD or clipping of common hepatic duct which were foundduring (13 cases) or after surgery (3 cases) underwent end-to-endanastomosis of bile duct (9 cases), choledocho-jejunostomy (4cases), choledocho-duodenostomy (2 cases), hepatico-jejunostomy(1 case). End-to-end anastomosis of CBD for complete cutoffcases which had multiple injuries or were found after surgeryresulted in severe biliary strictures leading to liver failure (1 case)or necessitating another biliary diversion (2 cases). Conclusions:Simple biliary injury can be treated with direct closure. In contrast,complete cutoff of bile duct needs special surgical interventionsincluding intestinal diversion when injuries were multiple or foundafter operation.

P-662A Case of Hemorrhagic Duodenal Diverticulum Successfullyby Endoscopic ClippingYoshiki Satoh, Noriyuki Kamiya, Norihumi KumamotoDepartment of Surgery, Ito City Hospital, Japan

A 79-year-old female visited at our hospital with the chief com-plaint of tarry stool. On admission, laboratory tests showed8.7g/dl of Hb. Therefore, an emergent upper gastrointestinalendoscopy revealed spurting hemorrhage in a large diverticulum inthe second portion of the duodenum. Endoscopic direct clippingof the artery was successful. Although hemorrhagic duodenaldiverticulae are rare, their hemostasis are difficult and surgeryshould be often applied. In Japan, endoscopic therapy of hemor-rhagic duodenal was reported for the first time in the year 1992.In this case, endoscopic clipping must be an effective procedure forhemorrhagic duodenal diverticulum.

P-663Preoperative Evaluation of Pancreatic Cancer by Multidetec-tor-row CT (MDCT) -Comparison with Catheter Angiogra-phy-Sohei Satoi1, Soichiro Takai1, Hiroaki Yanagimoto1, AtsushiKomemushi2, Noboru Tanigawa2, Morihiko Ishizaki1, Ryuji Iwaki1,Atsuko Fukuyasu1, A-Hon Kwon1, Satoshi Sawada2, YasuoKamiyama1

1Department of Surgery, 2Dept. of Radiology, Kansai MedicalUniversity, Japan

(Background) The use of multiple detector rows in CT scan allowsfaster scanning and thinner collimation, which may result in truevolume acquisitions and accurate diagnoses. This study was per-formed to determine the diagnostic value of preoperative MDCTon liver metastasis and tumor extension of the pancreatic cancer.(Patients and Methods) Thirty-seven patients with pancreatic can-cer were evaluated with MDCT between September 2002 andDecember 2003. Fifteen patients who had locally advancedtumors, underwent pancreatectomies and 22 patients had metastat-ic liver tumors. CE-CT, CT angiogram, MRI, and catheterangiography were performed. Findings of liver metastasis andtumor extension were compared with MDCT. Furthermore,MDCT findings were compared with intraoperative findings.(Results) On the diagnosis of liver metastasis, MDCT had a sensi-tivity of 95%(21/22), and CT angiogram had a sensitivity of73%(16/22). Five patients who were diagnosed with liver metasta-sis with MDCT only had small liver tumors (around 10mm in

diameter) on the surface of the liver, which were confirmed duringsurgery. On the compatibility of MDCT findings with the opera-tive findings (n=15), MDCT made more accurate diagnoses oftumor extension than catheter angiography, CECT, and MRI.Especially, MDCT clearly detected the extent of vascular invasioninto the portal vein and artery. (Conclusion) MDCT providesvaluable preoperative information on the therapeutic strategy ofpancreatic cancer and can be used as a noninvasive alternative tocatheter angiography before oncologic pancreatic surgery.

P-664The Changes of Tumor Microcirculation and AntitumorEffect by StrangulationSuguru SawadaSurgery, Yokohama General Hospital, Japan

The purpose of this study was to examine the antitumor effect ofstrangulation to cease blood flow on tumor tissue. AH130 cellswere implanted in the mesentery near the ileocecal portion of rats10 days previously. A recovery rate of blood flow was observed inthe tumor tissue and normal tissue (cecal wall) after reperfusionwith a charge-coupled device microscope (CCD). Five days afterreperfusion, the tumor volume ratio was measured. On the deathor sacrifice of the animals, the tumor necrotic area ratio was exam-ined. The vascular morphology and the changes of a recovery rateof blood flow after reperfusion differed from the tumor tissue andthe normal tissue by CCD observation. In the 15-min and 30-mingroups, the tumor vessels underwent little or no destruction, withonly a few showing a cessation of blood flow. However, the 60-min and 90-min groups showed a cessation of blood flow and hem-orrhage due to vascular destruction in many vessels, and few ves-sels showed intact blood flow. In 60 and 90-minutes strangulatedgroups, a recovery rate of blood flow after 60 minutes was lower intumor tissue than in the normal tissue. The tumor volume ratiodecreased more in the 60 and 90-minutes strangulated groups thanin the non-strangulated group and the tumor necrotic areaincreased more in all strangulated groups than in the non-strangu-lated group. These findings suggest that strangulation for ischemiafor 60-90 minutes injures the tumor tissue and shows the antitu-mor effect.

P-665Laparoscopy-assisted Gastric Segmentectomy with SentinelNode Navigation for Early Gastric CancerTetsuji Sawada, Masakazu Yashiro, Toru Inoue, Tamahiro Nishi-hara, Yoshito Yamashita, Nobuya Yamada, Kiyoshi Maeda, NaoyoshiOnoda, Masaichi Ohira, Tetsuro Ishikawa, Kosei HirakawaSurgical Oncology, Osaka City University, Graduate School ofMedicine, Japan

<purpose> We analyzed the application of sentinel node (SN) nav-igation for early gastric cancer and tried a navigation surgery basedon the SN concept. <method> For 52 patients with M, L T1 gas-tric cancer, we injected blue dye (Lymphazurin) into the submu-cosal layer surround tumor, and identified blue-dyed node (BN)after laparotomy. We also investigated a micrometastasis by CEAor cytokeratin mRNA with RT-PCR in 36 patients. <results> TheBN detection rate 100% (mean number: 2.6), and all BNs were inblue dyed lymphatic basin, but more than in two basins. All 4 caseswith pN+ had histological metastasis only in BNs, therefore the

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accuracy was 100%. The micrometastases were positively detected5/36 (4 in only BN and one in BN+ non-dyed node) and no casewhich had BN negative and non-BN positive was observed.According to these results suggesting the acceptance of SN naviga-tion by this method, we tried gastric segmentectomy+Lymphaticbasin dissection by laparoscopy assist with SN navigation in 20patients with M, L N0 gastric cancers (localized in M or under SMinvasion with differentiated type less than 3 cm). BN could bedetected in 19 patients (mean number was 2.2), except for oneobesty patient who had switchover to open laparotomy, and nohistological metastasis was detected in all frozen section of BNs.All procedures can be done without any complication and func-tional disorder. <conclusion> The present procedure may havehigh clinical application by its curability, low invasiveness, functionpreservation and handiness of maneuver.

P-666German Artificial Sphincter System Gass Technical Revolu-tion of a Novel Sphincter Prosthesis for Therapy of MajorFecal IncontinenceHans Juergen Schrag1, Federico Padilla Fragoza1, Frank Goldschmidt-boeing2, Alexander Doll2, Peter Woias2, Ullrich Theodor Hopt1

1General and Visceral Surgery, 2IMTEK University of Freiburg,Germany

Purpose. No highly integrated sphincter prosthesis (SP) for thera-py of major fecal incontinence exists. Therefore, this trial was per-formed to develope a SP which includes all functional components:the fluid reservoir (FR), the occlusive cuff (OC) and an intercon-nected bidirectional micropump (MP), based on piezotechnology,voluntarily controlled through an subcutaneus generator. Meth-ods. The GASS be made of polyurethane, consists of a MP inter-connected with an OC and FR, fixed on the inner, respectivelyouter diameter of a support ring (SR). The integrated MP mea-sures only 15x20x1 mm in thickness and is structured of bondedsilicon wafers. GASS was evaluated around the external sphincterof isolated porcine anal canals (n=6). Following parameters wereanalyzed: the intraanal pressure (panal) and the pressure in theocclusive cuff (pCint). The threshold of continence were definedas the inflating volume wich water ceased to leak through the areaoccluded by the device under an induced rectal pressure of 150 cmH

2O (diarrhea simulation). Result. Filling volumes between 15cc

to 21cc maintained continence for liquids under diarrhea simula-tion. The median panal in the area occluded by the device, rises upto 67 mm Hg only (median pCint 182 mm Hg). The time of infla-tion/deflation of OC and FR takes an average of 7 minutes. Con-clusion. We designed a highly integrated SP. The special occlu-sive cuff guarantees an effective continence with small filling vol-umes. A low intraanal resting pressure indicates a little risk ofischemic injury of the anal canal in vivo.

P-667Pylephlebitis- A Case Report and Cases ReviewJu Yaw See, Chin Tat Lim, Ju-Yaw See, Ravishankar K Diddapur,John Richard IsaacGeneral Surgery, National University Hospital, Singapore

Introduction: Pylephlebitis is defined as the infected thrombosis ofthe portal vein. It can complicate any intraabdominal or pelvicinfection that occurs in the region drained by the portal venous

system, especially diverticulitis and appendicitis. We report a rarecase of cholangitis complicated by pyelephlebitis. Case Report: 70year old Chinese woman presented with obstructive cholangitis;intravenous meropenem was started. Blood culture on grew Enter-obacter cloacae. On day 2, ultrasound hepatobiliary system showedshrunken gallbladder with multiple stones with a 2cm stone in thedistal CBD. PTC was performed as ERCP failed to cannulate theduct. Subsequent CT revealed thrombosis of the main portal veinand its branches. She was started on intravenous heparin. Even-though the patient subsequently developed Ranson’s 8 pancreatitis,secondary to venous congestion of the splenic veins, the patientresponded well to maximal supportive therapy. Discussion: Thediagnosis of pylephlebitis was made from both the demonstrationof portal vein thrombosis using CT and bacteremia status of thepatient. Cholangitis has been a rare cause of pyelephlebitis. Areview of the English literature only revealed 1 other case ofcholangitis. Conclusion: As a result of the low incidence of pyele-phlebitis, there has been a lack of controlled randomized trials.This limits most of the literature to case reports and case reviews.

P-668Emphysematous Gastritis; A Case Report and a Review ofLiteratureJu Yaw See1, Tsuan-Hao Loi2, Ju-Yaw See1, Ravishankar K Didda-pur1, John Richard Isaac1

1General Surgery, National University Hospital, 2Division ofHepato-Pancreatico-Biliary Surgery, Singapore

Introduction: Emphysematous gastritis is a severe, rare and unusu-al form of gastritis caused by infection of stomach wall with gasproducing organisms. Predisposing factors are diabetes, alco-holism, corrosive ingestion and in immuno-compromised individ-uals. We report a case of emphysematous gastritis in a post hepate-ctomy patient, who responded to conservative management. CaseReport: A 45 years old Chinese lady, known hepatitis B carrier,with Child’s A cirrhosis and a hepatocellular carcinoma in theright lobe was referred to our unit. She subsequently underwent aright hepatectomy. On POD 11, she became increasingly septic,jaundiced and encephalopathic. A CT of her abdomen showed thestomach wall to be oedematous, with air pockets within the thick-ened stomach wall. Cultures from the abdominal drain showedmulti-resistant Pseudomonas and Acinetobacter sensitive tomeropenem. She was treated conservatively with intravenousmeropenem.Patient responded to conservative management andwas discharged after 7 weeks. Discussion: Emphysematous gastritiswas first described by Frankel in 1889, about 15% of cases are inrecent post abdominal surgery period. Diagnosis is usually basedon the circumstances, clinical presentation and imaging investiga-tions of CT/MRI. Reported mortality is in about 60%, thoughsome authors have reported 100% mortality in patients withoutsurgical intervention. Associated perforation is an indication forsurgery. Our patient settled on conservative management. Conclu-sion: Though there are many advocates for immediate surgery, ofrecent, there has been a trend towards conservative management.


P-669Necrotizing Pancreatitis Management in Concordance withIAP GuidelineJu Yaw See, Chin Tat Lim, Ju-Yaw See, Ravishankar K Diddapur,John Richard IsaacGeneral Surgery, National University Hospital, Singapore

Introduction: We report a case of acute necrotising pancreatitiswith a Ranson’s score of 7 and a CT severity index of 9. Thispatient has a morbidity and mortality rate of as high as 100%. CaseReport: 68 year old Chinese lady presented with gallstone pancre-atitis of 1 day duration. She was strated on intravenous meropen-em. By day 5 she developed SIRS. CT demonstrated near totalnecrosis of pancreas. She became septic by day 12. Computedtomography on day 16 showed a large infected pseudocyst. Pan-creatic debridement and necrosectomy, cholecystectomy andinsertion of feeding jejunostomy, were performed on day 20. Dis-cussion: Patient had 1 day of ICU stay post operatively. Post oper-atively patient had a gradual and unremarkable recovery. Our teammanaged this case in concordance with most of the recommenda-tions. We feel that following IAP guidelines helped in the success-ful outcome for our patient, who had high predicted rate of mor-bidity and mortality. Conclusion: IAP guidelines are useful andhelpful in the management of most patients with severe acute pan-creatitis, though individual variations in patient circumstances haveto be borne in mind, and treatment modified as appropriate. Imag-ing, clinical status and clear demarcation of the necrotic pancreatictissues are better predictors for the need for surgery as also theclinical status of the patient.

P-670Laparoscopic Left Hepatectomy: Case Report and Review ofLiteratureJu Yaw See1, Jyh Kuen Siak1, Ju-Yaw See1, Ravishankar KDiddapur1, John Richard Isaac1, Rick O’ Rourke2

1General Surgery, National University Hospital, Singapore, 2RoyalBrisbane Hospital, Australia

Introduction: Laparoscopic surgery has seen major advancement intechniques and refinement in the instruments used, making it nowmore feasible to explore the place of laparoscopic resection of theliver. We here report a case of a patient with multiple liver adeno-matosis in segments 3 and 4, who underwent a successful laparo-scopic left hepatectomy for dominant nodule in segment 4. CaseReport: A 50 year old Chinese male presented with left lower limbswelling. Biopsy of lesions suggested high grade sarcoma. StagingCT revealed several lesions in segment 3 and 4 of liver. CT guidedbiopsy of liver tissue revealed adenoma. He underwent laparoscop-ic left hepatectomy followed by left below knee amputation. Dis-cussion: Patient had an rapid post-operative recovery. He wasambulatory with assistance on POD 1. On POD 4, he was dis-charged home. Conclusion: Laparoscopic hepatectomy is a safeand feasible operation with careful patient selection. Besides areduced postoperative analgesic requirement, shorter time intervalto oral intake and reduced hospital stay, there is a faster improve-ment in the serum transaminase levels post operatively. Localisa-tion of the lesions is of crucial importance and peripheral lesions insegment II-IV are more feasible for laparoscopic approach forresection. With experience more cases and more complex lesionscan be offered laparoscopic hepatectomy.

P-671Pancreatic Anaplastic Cancer with Splenic Involvement Caus-ing Splenic Infarct: A Case Report and DiscussionJu Yaw See, Ming Hai Eric Wong, Ju Yaw See, Ravishankar K Did-dapur, John Richard IsaacGeneral Surgery, National University Hospital, Singapore

Introduction: Pancreatic cancer has the lowest five-year survivalrate of any cancer. Pancreatic body & tail cancer are notorious fordelayed presentation as they are asymptomatic till the spreadbeyond the organ itself. We are reporting a case of pancreatic can-cer with local invasion into spleen causing splenic infarct. CaseReport: Our patient was admitted complaining of severe lefthypochondrial pain of 1 day duration. History and clinical exami-nation was suggestive of possible septic foci in the left upper quad-rant. Inflammatory markers were elevated with normal tumormarkers. CT abdomen and ultrasound revealed large hetrogenousmass in region of splenic hilum with invasion into spleen causingsplenic infarct. OGD showed extrinsic compression. Patient wasvaccinated against pneumococcus, meningococcus and H influen-zae. Distal pancreatectomy with splenectomy and partial adrena-lectomy was performed for patient on 19/5/04. Intra-operativefindings were of tumour involving distal pancreas, spleen andadrenal gland with infarction of spleen and metastasis in segments2, 4 and 7 of liver. Post operatively patient had uneventful recoveryand was discharged on 8th day. Histology report was of poorly dif-ferentiated ductal adenocarcinoma of pancreas involving thesplenic substance. Areas of necrosis are found within splenicparenchyma along with tumor cells. Omentum and adjacent lym-phnodes were not invoved Discussion: Pancreatic tail and bodycancers though are known and discussed in literature. It is veryunusual for them to cause splenic infarcts and virtually unheard ofwith adenocarcinomas of pancreas. Our literature search did notyield any results for associated splenic infarcts.

P-672Fine-needle Aspiration Cytology of Metastatic CarcinoidTumor: Report of a Case and Review of the LiteratureJu Yaw See, Ju Yaw See, Ravishankar K Diddapur, John RichardIsaacGeneral Surgery, National University Hospital, Singapore

Introduction: While carcinoid tumor is a relatively common neo-plasm in surgical pathology, FNAC as a method of primary diag-nosis has only been reported in the literature a few times. CaseReport: A 66-yr-old Indian female presents with epigastric pain forinvestigation. Initial work-up included a FBC, LFT and OGD wasnormal. She subsequently underwent an ultra-sound of her hepa-to-biliary system which showed two intra-abdominal masses in theepigastrium. CT and MRI were performed to further evaluate themasses which found them to be within the omentum, not attachedto surrounding viscera. FNA was performed, and was diagnosed ascarcinoid tumor. Her urine 5HIAA and capsule endoscopy of hersmall bowel were normal. She underwent laparotomy and excisionof her 2 carcinoid tumours. Discussion: While FNA biopsy is acommon procedure, the primary diagnosis of metastatic carcinoidtumor by FNA biopsy has only been reported in 7 case reports inthe literature to our knowledge. The metastatic sites were widelyvaried. In our patient, the tumor did not cause her any significant

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symptoms after her initial admission. If tumors are not causing sig-nificant symptoms and a lesion is accessible to FNA biopsy, thismay be the preferred method of diagnosis. Pretreatment of apatient with known carcinoid syndrome with antiserotonin and/orantihistamine medications may be advisable before performingFNA biopsy. Conclusion: Fine-needle aspiration cytology can be auseful and safe tool in the diagnosis of carcinoid tumors, perhaps attimes avoiding the need for surgery.

P-673High versus Low Ligation of the Inferior Mesenteric Arteryin Rectosigmoid Colon CancerKazuhiro Seike1, Keiji Koda2, Chihiro Kosugi1, Kimio Shimizu1,Masaki Nishimura1, Tooru Tonooka1, Masanobu Shioiri1, ShigetsuguTakano1, Masaru Miyazaki1

1General Surgery, 2Department of Academic Surgery, GraduateSchool of Medicine, Chiba University, Japan

Purpose: The most significant early complication after anteriorresection for rectosigmoid colon cancer is anastomotic leakage.Although high ligation of the inferior mesenteric artery (IMA)allows more radical lymphatic drainage which should improveprognosis, it can jeopardize the blood supply to the proximal sideof an anastomosis. The aim of present study is to evaluate theinfluence of ligation of IMA on postoperative complications andsurgical curability. Patients and Methods: Rectosigmoid colon can-cer patients who underwent curative anterior resection were evalu-ated. 1. Blood flow at the proximal colon adjacent to the anasto-mosis was measured before and after IMA clamping using laserDoppler flowmetry in 77 patients. 2. ParaIMA fat tissue was col-lected from surgical specimen and cancer infiltration was examinedin 23 patients. 3. Endoscopic and histological ischemic change atthe anastomosis were assessed in 71 postoperative patients. Results:1. Anastomotic blood flow was reduced by 38.9% with the IMAligation. In 36 patients who underwent high ligation of the IMA, 2patients with massive blood flow decrease were suffered fromischemic anastomosis complications. 2. One patient had cancerinfiltration to the paraIMA tissue, but paraaortic lymph nodesmetastasis was postoperatively disclosed. 3. No significant differ-ence in endoscopic and histological findings between high and lowligation groups was observed. Conclusions: No statistically differ-ences in surgical morbidity and curability between high and lowligation of IMA were observed, however, some patients with highligation of IMA were suffered from anastomosis complicationscaused by severe ischemic necrosis.

P-674Usefulness of Predeposit Autologous Blood ComponentTransfusion for Donor Safety in Living Donor Liver Trans-plantationHitoshi Sekido1, Kenichi Matsuo2, Kazuhisa Takeda2, Michio Ueda2,Mitsutaka Sugita2, Daisuke Morioka2, Yasuhiko Nagano2, Toru Kub-ota2, Kuniya Tanaka2, Itaru Endo2, Shinji Togo2, Hiroshi Shimada2

1Hepato-Biliary-Pancreatic Surgery and Liver TransplantationDivision, Department of Gastroenterologi, Yokohama City Uni-versity, Graduate School of Medicine, 2Department of Gastroen-terological Surgery, Yokohama City University, Graduate Schoolof Medicine, Japan

Background: Donor safety is focused in the era of right liver

grafting for adult-to-adult living donor liver transplantation(LDLTx). Aim: This study is to determine whether the usefulnessof predeposit autologous blood component transfusion for donorsafety. Patients and Methods: Thirteen consecutive right liverdonors for LDLTx were enrolled in this study. The patients weredivided into three groups; group A (n=4, whole blood was prede-posited, mean 2.8U (1U=200cc)), group B (n=3, predeposited withcell separation into fresh frozen plasma (FFP) 3.3U and concen-trated red cell (CRC) 3.3U), group C (n=6, FFP 8.3U, CRC4.0U). In those three groups, postoperative course, blood coagula-tion and liver function tests were evaluated. Results: (1) Postoper-ative course: postoperative stay in group A, B and C were 17 days,12 and 13, respectively. No serious complication occurred.Homologous FFP transfusions were needed in two cases of groupA. (2) Blood coagulation: prothrombin (PT) (INR) was deteriorat-ed postoperatively. Its ratios between postoperative day (POD) 1and before operation in group A, B and C were 1.62, 1.36 and1.24, respectively. These values in group C were significantlylower than those in group A. Activated partial thromboplastintime (APTT) was shorter in group C than in group A. Plateletscounts was higher in group B than in group A. (3) Liver functiontests: maximum levels of alanine aminotransferase (ALT) were 446U/L, 316 and 327, respectively. Conclusion: Predepositautolougous blood component donation deposited 6U or more ofFFP was useful for right liver donor safety.

P-675Drug Induced Liver Injury after Liver Transplantation: TheDrug Used before Transplantation is not Always Safe afterthe TransplantationHitoshi Sekido, Kenichi Matsuo, Kazuhisa Takeda, Michio Ueda,Mitsutaka Sugita, Daisuke Morioka, Yasuhiko Nagano, Toru Kubo-ta, Kuniya Tanaka, Itaru Endo, Shinji Togo, Hiroshi ShimadaHepato-Biliary-Pancreatic Surgery and Liver TransplantationDivision, Department of Gastroenterologi, Yokohama City Uni-versity, Graduate School of Medicine, Japan

Introduction: We have encountered post-transplant liver injuryinduced by the drug used uneventfully before liver transplantation.Case: A 53-year-old woman visited our hospital to undergo livertransplantation for her end-stage liver disease associated withhepatitis B virus. Living donor liver transplantation was success-fully performed. Although early postoperative course wasuneventful without any serious complications, her liver functiontests (LFT) were gradually deteriorated from one week after theliver transplantation. Histology of the liver biopsy specimen sug-gested drug induced liver injury. After several drugs were ceasedand steroid pulse therapy for acute cellular rejection (ACR) wasperformed, the LFT was gradually improved. Lamivudine admin-istered again from postoperative day (POD) 20 to prevent hepatitisB virus replication. Histologic findings of liver biopsy specimenson POD 23 and 29 showed ballooning of the hepatocytes in zone 2and remission of ACR. Lamivudine ceased on POD 30 because ofthe histologic suggestion of drug induced liver injury. Liver biop-sy on POD 38 was performed and histology showed mild ACR,viral hepatitis and drug induced liver injury. LFT was stablethereafter and she was discharged from our hospital. She ishealthy with normal LFT on 7 months after the liver transplanta-tion. According to the “International Consensus Criteria” ofcausality assessment of adverse drug reactions, the score was calcu-lated at 8 and the degree of the relationship was classified to


“probable”. Conclusion: Clinicians should pay attention to suchdrug induced liver injury as occurs after liver transplantation eventhough uneventfully used before the transplantation.

P-676Postoperative Intraperitoneal Chemotherapy with Irinotecan(Metastatic Liver Colorectal Cancer)Aleksei N. Severtsev1, Viktor A. Stupin2, Serguei A. Privezentsev1,Dimitry B. Tchudaev1, Lali M. Kogonia1, Telman N. Mejgih1, MarinaV. Kosjutcenko1, Eduard M. Nikolaenko1

1Dept. of the Hepato-Pancreato-biliary Surgery, The CentralClinical Hospital of the MPS (Russian Railways), 2Moscow StateMedical University, Moscow, Russia

The basic goal of all regional chemotherapy is to increase the totalamount of drug delivered to the tumor while decreasing theamount of drug reaching the systemic circulation. An importantroute of clearance from the peritoneal cavity is by portal circula-tion. Some drugs are then metabolized into nontoxic forms duringthe first pass through the liver. Most patients with colorectal can-cer on the time of diagnosis had liver metastases (MTS). NowIrinotecan is one the most prospective drugs for the treatment col-orectal cancer. The purpose of this study was to assess the clinicalresults of intraperitoneal chemotherapy with Irinotecan for MTSliver colorectal cancer. From Dec., 2001 till Feb., 2004 9 patientswith MTS liver colorectal cancer had the postoperative intraperi-toneal chemotherapy with Irinotecan at the Dept. of the HPBSurgery. Male/female ratio: 9/0. Mean age of patients was 65years. The main site of cancer was resected. All patients hadcolostomy and non resectable bilobar liver MTS. Intraperitonealcatheter with subcutaneous port were inserted during the mainsurgery or just after the surgery. 3 weeks after surgery patients hadintraperitoneal chemotherapy: Irinotecan (Campto) 400 mg/m2.Number of courses was up to 11. All patients are alive. Liver nod-ules are disappeared or their size are significantly reduced. 3patients had colostomy closure. The intraperitoneal chemotherapywith Irinotecan could be good challenge for the patients withadvanced colorectal cancer even if liver nodules are not resected.

P-677The Use of Octreotid for the Treatment of Chronic Abdomi-nal Pain after Liver ResectionAleksei N. Severtsev1, Viktor A. Stupin2, Dimitry B. Tchudaev1, Tel-man N. Mejgih1, Marina V. Kosjutcenko1, Eduard M. Nikolaenko1,Mikhail V. Remizov1, Igor V. Leonenko1

1Dept. of the Hepato-Pancreato-biliary Surgery, The CentralClinical Hospital of the MPS (Russian Railways), 2Moscow StateMedical University, Moscow, Russia

One of the causes of the chronic abdominal pain after abdominalsurgery is the development of abdominal adhesions. There aresome publications about the prevention and treatment role ofoctreotid (OC) in case of the development of adhesions. Accordingto data the liver resection is the ideal clinical model which givesthe maximal development of abdominal adhesions. The purpose ofthis clinical study is to assess the use of OC for abdominal adhe-sion prevention and the treatment of chronic abdominal pain. 135patients with liver tumors were surgically treated. There were themain (31) and the control (44) groups which were compared forthe use of OC. The mean age of patients in groups was 57 and 55

years and male/female ratio was 14/17 and 17/27, respectively.The mean OC (Sandostatin) dose was 0,1 mkg per day subcuta-neously 3 days before surgery and 14 days after. The criteria ofOC effectiveness were the absence of intestine obstruction, thepresence of chronical abdominal pain which demands the use ofnon- opiod analgetics. All general criteria were the same for bothgroups. Adhesive intestinal obstruction was developed in 7 patientsin the control group and in no patients in the main one. Laparoto-my was used in 5 patients.Postoperative pain was developed in 14patients in the control group and 1 in the main. Octreotid couldbe used for the treatment and prevention of abdominal adhesionformation after liver resections and the subsequent treatment ofchronic abdominal pain after such kind of surgery.

P-678Duodenogastric Reflux in “Sub-Groups” of GallstonePatients before and after CholecystectomyWalaa Ibrahim Shehab1, Zaki Ahmed Azzam2, Nadia AhmedBarghash3, Kamel Atef Marzouk2

1Department of Surgery, Alexandria Faculty of Medicine, 2Surgery,Alexandria Faculty of Medicine, 3Alexandria Faculty of Medicine,Medical Biochemistry, Egypt

Purpose: Gall bladder and gastric motility showed dysmotility incirrhotic wthe portal hypertension. However, this issue was con-ducted to assess gastric and gall bladder motility in Schitosomalpatient before and after gastro-esophageal devascularization proce-dure (GEDP) describe by Hassab. Methods: Thirty Schitosomalpatients with bleeding varices, who underwent GEDP, were sub-jected to gastric and gall bladder motility assessment, using ultra-sonography, before and after surgery. Gastric emptying for liquidswas assessed by measuring the post-prandial changes in the gastricantral area (AA), while gall bladder emptying was assessed by mea-suring its ejection fraction (EF). The results were compared to thatof fifteen matching controls. Both patients and controls underwentsymptomatic score, essentially for gastric stasis and reflux gastritis.Results: Schitosomal patient had significantly impaired gastricemptying for liquids compared to controls ,as gastric emptying (%)at 30 minute, 64.67± 12.98 Vs 74.89± 12.78, P=0.016). Gall blad-der emptying, assessed by EF (%), were significantly lower thancontrols (44.47± 10.57 Vs 52.98± 8.945, P=0.011). Postoperativelygastric emptying (%) was significantly delayed than preoperativevalues (54.29± 14.449 Vs 64.67± 12.98, P=0.004) Gall bladderemptying show same postoperative changes (38.95± 9.469 Vs44.47± 10.57, P=0.007). Symptomatic score showed that tendencyof the cirrhotic to gastric stasis and reflux gastritis, which wasaggravate by surgery (p.0003) Conclusion: There data suggestingthat Schitosomal patient had impaired gastric and galls bladderemptying which became worth after GEDP, and associated withimpaired symptomatic outcome.

P-679Long Term Results of Truncal Vagotomy and “Uncut” RouxGastrojejunostomy for Management of Chronic DuodenalUlcer with Reference to Gastric EmptyingWalaa Ibrahim Shehab1, Ahmed Mohamed Mohalell2

1Department of Surgery, 2Department of Diagnostic RadiologyAlexandria Faculty of Medicine, Egypt

Purpose: In the previous reports, we described the technique of

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truncal vagotomy and “uncut” Roux gastrojejunostomy(TV+UCRGJ) in management of chronic duodenal ulcer (CDU).Also, we demonstrated that the technique is not associated withsignificant increase in postoperative entergastric reflux (EGR).This work represents the long term results of TV+UCRGJ, withassessment of gastric emptying following the procedure.Methods: 52 patients (mean age 47.21±12.89 years) with CDUwere managed by TV+UCRGJ and followed-up for a mean of64.71±9.21 months, for symptomatic outcome. Gastric emptyingfor liquids was assessed by measuring the post-prandial changes inthe gastric antral area (AA) in 15 patients, 24-58 after surgery. Theresults were compared to 15 matching controlsResults: Excellent or satisfactory symptomatic outcome wasdescribed by 49 patients (94.2%). Two patients had symptomaticalkaline reflux gastritis, with anastomotic erosions in one, whichneeded redo gastric surgery. One patient had symptomatic gastricstasis. Patients with TV+UCRGJ showed insignificant change inthe gastric emptying for liquids compared to controls, as measuredby the gastric emptying (%) at 30 minutes (74.96±14.09 vs.77.35±10.07) (F=0.286, p=0.597).Conclusion: Truncal vagotomy “Uncut” Roux gastrojejunostomy,is associated with a good long term symptomatic outcome, and isassociated with normal gastric emptying. So, it can be included inthe surgical options for management of chronic duodenal ulcer.

P-680Colo-rectal Cancer in a Random Sample of the Egyptian Pop-ulation: A Different Disease EntityWalaa Ibrahim Shehab1, Emad El-Nashaar2

1Department of Surgery, 2Oncology Departement, Alexandria Fac-ulty of Medicine, Egypt

Purpose: Colo-rectal cancer (CRC) is not uncommon in Egypt.This retrospective study was conducted to identify the pattern,outcome and prognostic factors of CEC.Methods: Patients with CRC retrospectively collected over fiveyears, starting from the year 1997 to 2002. Data were collectedfrom the registry of the Departments of Surgery and Oncology,Alexandria Main University Hospital. Five percent was the level ofstatistical significance.Results: 363 cases (male to female: 185/178) were collected. TheMean age was 46.05±14.33 years (15-86 yeas). Forty percent ofpatients were < 40 year. Adenomas were present in only 5.5%. Themean duration of symptoms was 32.6 ±20.03 weeks. Duke’s stagesB2 and C were the commonest stages (32.5% and 39.7% respec-tively). Mucoid adenocarcinoma constituted 29.5% of tumors. Dis-ease Free Survival (DFS) was 22.38±19.19 months (0-72). OverallSurvival (OS) was 32.38 ±17.32 months. Local recurrence (LR)developed in 39.9%, within a mean duration of 20.12±9.09months. Systemic recurrence (SR) developed in 40.2% within amean duration of 19.28 ±8.92 months. Univariate analysis revealedthat radical surgery and duke’s stage were the main prognostic fac-tors. Multivariate analysis revealed that radical surgery was inde-pendent predictor for LR, while LR was an independent predictorfor SR. Radical surgery, Duke’s stage and LR were independentpredicators for DFS. While LR, SR and DFS were independentpredicators for OS. Conclusion: CRC in Egypt seems to carry different epidemiologi-cal, demographic and prognostic factors compared to the West. Afurther larger multicenteric study is recommended to confirm andexplain these discrepancies.

P-681Intraoperative Frozen Section of the Proximal Margin for aResection of Gastric Adenocarcinoma of the CardiaJianguo Shen, Jae Ho Cheong, Woo Jin Hyung, Junuk Kim, SeungHo Choi, Sung Hoon NohDepartment of Surgery, Yonsei University College of Medicine,Korea

PURPOSE: The significance of margin evaluation using intraop-erative frozen section during gastric cancer surgery is controver-sial, and little has been done to determine the appropriate indica-tions for this technique. The aim of this study was to evaluate therole of intraoperative frozen section for proximal margin in gastricadenocarcinoma of the cardia, and to determine the risk factors ofthe cancer positive resection margin on frozen section. METH-ODS: From August 1995 to June 2000, 66 patients with cardiacadenocarcinoma who underwent an intraoperative frozen sectionof the proximal resection margin were reviewed. The frozen sec-tion results were compared with those of the permanent sections.The clinicopathological features that were predictive of a positiveresection margin on the frozen section were examined by univari-ate and multivariate analysis. RESULTS: The overall accuracy,specificity and sensitivity of a frozen section in a margin evaluationcompared with a permanent section, was 97%, 77.8% (7/9), and100% (57/57), respectively. Two (28.6%) of the seven patientswho had undergone a re-excision according to the positive frozensection margin had a positive re-excisional margin. The positivemargin on the frozen section was associated with a deeper tumorinvasion and late-stage diseases. However, multivariate analysisshowed that the depth of the tumor invasion was the only indepen-dent factor predictive of a positive margin on a frozen section.CONCLUSIONS: Intraoperative frozen sections may not need tobe routinely used to evaluate the proximal margin during cardiacgastric cancer surgery. This technique is recommended in patientswith T3 or T4 lesions.

P-682Lipid Absorption and Metabolism after Pancreatic ResectionSatoshi Shibata, Tsutomu Sato, Masanao Ito, Makoto Kume, HideakiMiyazawa, Masatake Iida, Tomoyuki Kusano, Masatake Iida, MasatoYoshioka, Yuzo YamamotoAkita University, Japan

[Background] In general, disorders of lipid metabolism coexistwith “primary” diabetes mellitus, resulted in hyperlipidemia. Inpatients who underwent pancreatecctomy, glucose metabolismdeteriorated in proportion to the extent of removed pancreas as wedescribed previously (Dig Surg 2004;21:48). The lipid absorptionand metabolism after pancreatectomy has not been analyzed well.The aim of this study was to investigate the change of lipid absorp-tion and metabolism after pancreatectomy.[Methods] Seventeen patients who underwent distal pancreatecto-my or segmental pancreatectomy were studied. Serum triglyceride(TG) and total cholesterol (Tcho) were determined for the markerof lipid absorption and metabolism. The relations between thelength of removed pancreas and TG or Tcho were analyzed.[Results] The level of TG and Tcho were elevated in proportionwith the length of removed pancreas, when the length of removedpancreas was shorter than 10cm, showing significant correlations


(TG, Tcho vs. Length r=0.75, p=0.02). The level of serum lipid,however, turned down when the length of removed pancreas was10cm or greater, resulted in hypolipidemia.[Conclusions] The hyperlipidemia due to dysfunction of lipidmetabolism was mainly seen if the length of removed pancreas wasshorter than 10cm. The hypolipidemia due to dysfunction of lipidabsorption was observed if the length of resected pancreas was10cm or greater. The management for the disorder of lipidabsorption and metabolism after pancreatectomy should be differ-ent according to the extent of the removed pancreas.

P-683Sulfo-glycolipid, β-SQAG9 which was Derived from SeaUrchin Intestines, Attenuates Rat Hepatic Ischemia-Reperfu-sion (I/R) InjuryHiroaki Shima1, Hiroaki Shima2, Tetsuhiro Tsuruma2, HiroekiSahara3, Mika Takenouchi3, Atsuhito Yagihashi4, Noriyuki Sato3,Koichi Hirata2

1First Dept. of Surgery, 2Department of Surgery, 3Department ofPathology, 4Department of Laboratory Diagnosis, Sapporo Med-ical University, Japan

(Purpose) In hepatic surgery and liver transplantation, I/R is anunavoidable process and a major unresolved problem. So variouspharmacologic approaches to prevent hepatic I/R injury are cur-rently under trial. We previously reported that sulfo-glycolipid, β-SQAG9 which was derived from sea urchin, possessed immuno-suppressive effects on human mixed lymphocyte reaction (MLR)and skin in rat skin transplantation. However the other effects ofβ-SQAG9 had been unclear. So, we investigated whether β-SQAG9 could attenuate hepatic I/R injury. (Methods) Male LEWrats weighing approximately 250-300g were used throughout thisstudy. The rats were pre-treated intravenously either with β-SQAG9 (group 1) or with the PBS alone (group 2). 70% warmhepatic ischemia was subjected by occluding the blood vessels witha microvascular clamp. After induction of ischemia (60 minutes),the clamp was carefully removed allowing hepatic reperfusion. Forexamination of hepatic function, serum levels of established mark-ers of hepatic injury; aspartate aminotransferase (AST), alaninetransaminase (ALT) and lactate dehydrogenase (LDH) were mea-sured 6 hours after reperfusion. In addition, histological examina-tion was also assessed. (Results) The level of AST, ALT and LDHwas significantly decreased in group 1 compared with that in group2. In histologic examination 6 hours after reperfusion, the degreeof polymorphonuclear leukocytes (PMNs) infiltration accompa-nied by hepatocyte necrosis were markedly attenuated in the group1 compared with group 2. (Conclusions) Our data demonstratedthat βSQAG-9 might attenuate the warm hepatic I/R injury.

P-684The Characteristics of Small Dukes B and C Colorectal Can-cerKeita Shimada, Tatsusi Inoue, Aida Sadatsugu, Noboru Yokoyama,Kouki Masuo, Koji Shimizu, Kazuhide KumagaiSurgery, Showa University Toyosu Hospital, Japan

(purpose) to investigate the characteristics of small advanced col-orectal cancers defined as less than 20mm in diameter and classi-fied as Dukes B and C(methods) 78 cases of colorectal cancers, which were all resected

laparoscopically, were less than 20mm in diameter. These 78 caseswere surveyed in terms of their preoperative diagnosis, pathologi-cal findings and the outcomes.(results) 2 cases were classified as Dukes B and 8 cases were classi-fied as Dukes C out of 78 cases. The diameter was from 13mm to20mm. As preoperative diagnostic procedures, colonoscopy andcontrast study were performed in all cases. Endoscopic ultrasonog-raphy was performed in 2 cases of Dukes C. The depth of invasionwas in advance evaluated to be submucosa (SM) in 7 cases out ofthe 10 cases and to be muscularis propria (MP) in other cases,however, it turned out that the depth of invasion was further. Itwas muscularis propria (mp) in 4 cases, subserosa (ss) in 5 cases andextended through serosa (se) in one case. Liver metastasis and localrecurrence were found in one case respectively and both cases wereoperated. No cancer-related death was seen among them. ( obser-vational period : 1 year to 9 years)(conclusion) Small Dukes B and C colorectal cancers tented to beevaluated as less advanced compared to their histopathologicalfindings.

P-685Greater Splanchnicectomy for the Relief of IntractableabdominalKen Shimada, Tsuyoshi Takahashi, Hiroki Hoshino, MasamichiKatori, Kazunori Furuta, Muneki Yoshida, Koshi Satoh, MasahikoWatanabeSurgery, Kitasato Univ., Japan

[Aims]To relieve intractable abdominal pain in patients with unresectablepancreatic cancer, we have applied greater splanchnicectomy tosuch patients.[Rationale]The ganglionic nerve fibers originating from the 5th through 10ththoracic sympathetic ganglions get together in the trunk of the leftor right greater splanchnic nerve (GSN) at the level above the aor-tic hiatus. Therefore, it is considered most effective in relievingab-dominal pain mediated through the GSN to cut off the trunk(s) ator below the aortic hiatus.[Patients & Methods]During the past 10 years, 28 patients with unresectable pancreascancer underwent either left only (n=18) or bilateral (10) greatersplanchnicectomy, by either transthoracic (thoracoscopy) or tran-shiatal (laparotomy) approach. The effectiveness of these proce-dures in relieving upper abdominal pain was evaluated postopera-tively.[Results]Both transthoracic and transhiatal procedures were completed in27 patients without difficulty. The pain disappeared completely in14 of 18 patients who underwent thoracoscopic left greatersplanchnicectomy, and reduced in degree in 3. Among 9 patientsundergoing transhiatal greater splanchnicectomy, abdominal paindisappeared in 3, reduced in degree in 4. Eight patients neverrequired any pain-killing agents postoperatively until their deaths.[Discussion]Greater splanchnicectomy may contribute greatly to improvingthe QOL of end-stage pancreatic cancer patients by effectivelyrelieving intractable abdominal pain.

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P-686Initial Experience with 26 Cases of Laparoscopic AssistedColectomy for Colon CancersMasashi Shimada1, Yutaro Takeshita1, Masaki Kawahara2, KojiNozaki1, Keisuke Kubota1, Kazuhiro Imamura1, Naoki Hiki1,Hirokazu Yamaguchi1, Shouji Shimoyama1, Kenichi Mafune1, MichioKaminishi1

1Gastrointestinal Surgery, Tokyo University Hospital, Japan,2Showa Public Hospital, Japan

[Purpose] Laparoscopic-assisted colectomy (LAC) has emerged asthe preferred minimally invasive surgical treatment for diseases ofthe colon. While a definite statement regarding its use in colorec-tal cancers can not be ascertained. We report our initial experiencewith 26 LACs for early colon cancer between 1997 and 2002.[Methods] Our indication of LAC for colon cancer was submucos-al (SM, 24 cases) and mucosal (M, 2 cases) which could not becompletely resected by endoscopic procedure. We analyzed themconcerning on operation time, blood loss, hospital stay, post oper-ative complications and prognosis, retrospectively. [Results] Twen-ty-five LACs were completed out of 26 attempts (96 %), one casewas converted to open surgery due to advanced stage cancer foundby laparoscopic observation because of the advanced cancer withserosal invasion. In the LAC group the mean of operative time waslonger (251 vs 218 minutes, p<0.05) but blood loss was less (93 vs209 g, p<0.05) than in the open group. No significant differencewas found in the hospital stay between both two groups. Therewere 3 minor complications, one wound infection and two bowelobstruction. There were no wound or trocar implants. All patientsare alive, and no recurrence has been found so far, mean follow uptime is 56 months. [Conclusions] This review provides that LAC issafe and technically feasible for early colon cancers. After this, weexpect that our indications of LAC extend to colorectal cancerswith proper muscle invasion.

P-687Expression of HER2 in Esophageal CarcinomaTakeshi Shimakawa1, Yoshikiko Naritaka1, Yoshihisa Wagatuma1,Kanako Hamaguchi1, Souichi Konno1, Takao Katube1, Kengi Ogawa1,Motohiko Aiba2

1Surgery, 2Surgical Pathology, Tokyo Women's Medical Universi-ty Daini Hospital, Japan

Objective: The expression of human epidermal growth factorreceptor 2 (HER2) in esophageal squamous cell carcinoma hasbeen very controversial. Therefore, we investigated the level ofexpression of HER2 in patients with esophageal squamous cell car-cinomas resected at our department, and examined the relationshipbetween the HER2 expression and clinicopathological factors, orthe efficacy of chemotherapy, or the outcome, or the expression ofp53. Subjects: Forty patients with radically resected esophagealcarcinoma were investigated. Methods: Tissue-block specimenswere fixed in formalin, embedded in paraffin, and subjected toimmunohistological staining by Hercep Test. The results of stain-ing were classified into four degrees. Using the same tissue-blockspecimens, immunohistological staining for p53 was performed.Results: The results of the Hercep Test were evaluated: the scorewas 3+ in 3 (7.5%), of which excessive expression of HER2 (3+)was infrequent . Excessive expression of HER2 revealed no rela-tionship with clinicopathological factors, or the efficacy of

chemotherapy. There was no difference in outcomes betweenpatients who showed excessive expression of HER2 and patientswithout excessive expression. Eighteen (45%) patients were posi-tive for p53, but there was no relationship between the expressionof p53 and the excessive expression of HER2. Conclusion: In theesophageal carcinoma, HER2 was expressed at a low level and hadno relationship with clinicopathological factors, or the efficacy ofchemotherapy or the outcome and the expression of p53.

P-688Postoperative Adjuvant Gemcitabine (GEM) Therapy inAdvanced Pancreatic Head CarcinomaTsuyoshi Shimamoto, Katsuyoshi Murase, Toyoo Nitta, Kondo Tet-suya, Takuya Sugimoto, Naomasa Yoshida, Hiroyasu Sumi, YutakaOzekiDepartment of Surgery, Shizuoka Medical Center, Japan

Purpose: The effect of adjuvant chemotherapy in pancreatic canceris unclear. We evaluated the feasibility of postoperative adminis-tration of GEM after surgical resection of pancreatic head carcino-ma. Methods and materials: Between June 1995 and June 2003, 22patients with pancreatic head carcinoma after operation were treat-ed at our institution. We classified two groups: GEM group (n=8)who had been treated with GEM 1000mg/m2 biweekly and Ngroup (n=14) who had not been treated GEM after surgical resec-tion. Results: PPPD with portal resection were performed 5patients (5/8) in GEM group. PPPD (10/14) or PD (4/14) withportal resection had been performed 8 patients (8/14) in N group.Blood loss, operation time, and surgical, pathological findings (T,N, PL, M) were not significant in two groups. WHO grade 3/4toxicities in GEM group included: nausea / vomiting 12.5%. Oneyear survival rate was 50% for GEM group as compared with42.8% for N group (P=0.5). Median survival time was 17.2 monthsfor GEM group as compared with 13.2 months for N group(P=0.7, log-rank test) . There were 50% (4/8) survival for GEMgroup and the mortality of GEM group were two liver metastasisand one peritoneal dissemination. Conclusion: One year survivalrate and median survival time for GEM group were longer thanthose for N group, but not significant. WHO grade 3/4 toxicitieswere very rare and all patients except for one patient could go tothe hospital twice a week .

P-689Effects of Denervated Neorectum after Anterior Resectionfor Rectal CancerKimio Shimizu, Keiji Koda, Isamu Iizuka, Kazuhiro Seike, ChihiroKosugi, Masaki Nishimura, Toru Tonooka, Masaru MiyazakiDepartment of General Surgery, Graduate School of Medicine,Chiba University, Japan

PURPOSE: In a curative resection for advanced rectal cancer, theneorectum is generally constructed with denervated sigmoid colonbecause extrinsic autonomic nerves are sacrificed in a variousdegree. At the current study, we evaluated the motor activity ofneorectum after anterior resection for rectal cancer. METHODS:Sixty patients who underwent anterior resection for rectal cancerwere examined. The motility of the neorectum was examined with4-sensors intraluminal pressure transducer during follow-upcolonoscopic examination, and the segmental colonic transit timewas determined with radiopaque markers. Patients were inter-


viewed regarding their recent defecatory status at each examina-tion. In addition, changes in colonic motility after extrinsic auto-nomic denervation at distal colon were studied in rats using straingauge force transducers. RESULTS: 32 patients experiencedpropagated contraction waves down to the neorectum. In no prop-agated cases, the mean colonic segmental transit time through theneorectum significantly prolonged in comparison with the propa-gated cases. Minor spastic waves at the neorectum were observedin many patients who did not show propagated waves, which close-ly correlated with the transaction of inferior mesenteric plexus andthe degree of patients' satisfaction regarding their defecations. Inrats undergoing autonomic denervation, motility index, averageamplitude and number of cycle at distal colon were significantlyincreased in early phase of postoperative period. CONCLU-SIONS: The motor activity of the neorectum, especially with theexistence of minor spastic waves, is an important factor and a pos-sible mechanism for postoperative defecatory disorders followinganterior resection for rectal cancer.

P-690Gene Expression of Liver Regeneration after Partial Hepatec-tomy in Mice Lacking Type1 Tumor Necrosis Factor Recep-torTetsuya Shimizu1, Shinji Togo1, Makino Hirochika1, Tanaka Kuniya1,Kubota Toru1, Nagasima Youji2, Hiroshi Shimada1

1Department of Gastroenterological Surgery, 2Department of Mol-ecular Pathology and Oncology, Yokohama City University, Japan

aim: To investigate whether TNF-α is necessary for hepatocyteproliferation, we study liver regeneration after partial hepatectomyin mice lacking TNF receptor-1. Methods: TNF receptor type-1 knockout mice and wild type micewere subjected to two-thirds partial hepatectomy (PHx). Liverregeneration was evaluated by assessing liver weights and Ki67immunohistochemistry. Riken cDNA microarray analysis was per-formed on liver samples from mice undergoing PHx to compareclearly differentiated mouse PHx models (TNFR-1 knockoutmice-K group, and wild type mice-W group). Results: The cumulative survival after PHx in K group was lowerthan in W group. The mortality rate in K group during the first 3days after PHx was higher (33%)than in W group. The time toregain the liver weight in K group was 14days and 7days in Wgroup. The plasma IL-6 levels in K type at 3 hr was significantlyhigher than in W group. The Ki67 expression in K group at 4 dayswas lower than in W group. LPS, Toll like receptor 4 precursorand MAPK 8 interacting protein in K group was higher than in Wgroup. For cell cycle-regulated genes, cyclin D1, NFκB light chainand TNF receptor super family membrane 1a in K group waslower than in W group.Conclusions: Lack of TNF-α signaling through TNFR-1 delaysthe initiation liver regeneration after partial hepatectomy. It is sug-gested that hepatocyte proliferation can be induced by a LPS-JNKpathway instead of TNF-α and IL-6 .

P-691A Case of Transverse Colon Low Differentiated Adenocarci-noma Invaded the Liver and DuodenumTetsuya Shimizu, Hiroshi Shimada, Kaori Kubota, Shoichi Fujii,Toru Kubota, Yasuyuki Ichikawa, Shigeo OokiDepartment of Gastroenterological Surgery, Yokohama City Uni-versity, Japan

As for the case of colon low differentiated adenocarcinoma, thereare much examples of advanced cancer compared with well ormoderately differentiated adenocarcinoma. It is said with poorprognosis. We report a case of transverse colon low differentiatedadenocarcinoma invaded the liver and duodenum. A 73-year-oldman who had epigastralgia was diagnosed with transverse coloncancer invaded duodenum and liver in colon fiber scopy andabdominal CT at the hospital. He was referred to our hospital inMarch, 2004. Right hemicolectomy with D3 lymph node dissec-tion and hepato-pancreaticodeuodenectomy was performed. Atransverse colon tumor of 9.5×9.5cm was found in an extractionspecimen. The circumferencial rate of tumor was 100% anddescending leg lumen in the duodenum included an exposure oftumor of 4.5cm×2.7cm from sphere. The histopathological diag-nosis was poorly differentiated adenocarcinoma with the depth ofthe tumor invasion of si, ly(0), v(1), n0(0/47) and stageIIIa.According to the 5year survival rate of 60 examples of ai and siadenocarcinoma for 11 years well differentiated adenocarcinomawas 78.6%, mod was 54.4%, por was 8.33%. The hepatic metasta-sis as the cause of death were eight examples (22.9%), peritonealdissemination were eight examples (22.9%), the local recurrencewere four examples(11.5%).The control of local recurrence waspossible with colon right hemicolectomy and hepato-pancreati-codeuodenectomy for transverse colon low differentiated adeno-carcinoma invaded the liver and duodenum. Chemotherapy is nec-essary for the recurrence prevention.

P-692A Case of Duodenal GIST with Hepatic Metastasis andLymph Node MetastasisTetsuya Shimizu1, Hiroshi Shimada1, Youichi Iemoto2, AkiraNakano2, Shunsuke Kobayashi2, Shinji Togo1

1Department of Gastroenterological Surgery, Yokohama City Uni-versity, Japan, 2Fujisawa City Hospital, Japan

I report a case of duodenal GIST with hepatic metastasis andlymph node metastasis. A 78-year-old woman who had anemia wasreferred to our hospital for surgical treatment. Upper gastroin-testinal endoscopic examination revealed a type 2 tumor withulcer, the circumferential rate was 50%. Pathological examinationof our endoscopic biopsy specimen indicated a diagnosis of GIST.Duodenography showed that tumor was detected in the firstpor-tion of the duodenum. Abdominal computed tomography showedthat an irregular duodenum obstacle was detected. Hypervascularnodule was detected by angiography. Hyperplasia of the wallextended over 3.5cm to a duodenum in second portion. In October2001, pancreatoduodenectomy with D2 lymph node dissection wasperformed. Histopathologically, the mass consisted of spindle-shaped cells and mitosis, findings were c-kit(+), CD34(+), desmin(-), SMA(-), s-100(-) and the diagnosis was uncommitted type ofGIST with hepatic metastasis and lymph node metastasis. I investi-gated 79 examples of duodenum GIST added this case. We experi-

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enced a rare case of duodenum GIST with liver metastasis andlymph node metastasis. We significantly recognized metastasis in a high-risk-group inGIST of the duodenum. However, our case recognized metastasisin spite of a low-risk-group. We thought that it was difficult topredict prognosis of duodenum GIST only by this risk classifica-tion.

P-693Pathological Examination in the Hepatoduodenal LigamentInvasion by Locally Advanced Gallbladder CarcinomaYasuhito Shimizu, Masayuki Ohtsuka, Hiroshi Ito, Fumio Kimura,Hiroaki Shimizu, Satoshi Ambiru, Akira Togawa, HiroyukiYoshidome, Atsushi Kato, Hideyuki Yoshitomi, Shigeaki Sawada,Masaru MiyazakiGenaral Surgery, Graduate School of Medicine, Chiba University,Japan

Purpose: Resection of the extrahepatic bile duct is commonly per-formed as a part of radical surgery for advanced gallbladder carci-noma. However, it is unclear whether such a procedure should beperformed when apparent cancer involvement into the extrahepat-ic bile duct is absent. The purpose of this study was to elucidatethe incidence and mode of spread of gallbladder carcinoma intothe hepatoduodenal ligament.Methods: Between 1985 and 2002, 50 consecutive patients withgallbladder carcinoma extending into the subserosa or beyondunderwent radical surgery including extrahepatic bile duct resec-tion. Serial sections of specimens of the resected extrahepatic bileduct were examined histologically to determine the incidence andpattern of invasion of the hepatoduodenal ligament.Results: Invasion of the hepatoduodenal ligament was present in30 specimens. Of these, 9 showed direct extramural spread (type I),4 showed continuous intramural spread (type II), 5 showed distantspread separated from the primary tumor (type III), and 4 showedpermeation of cancer cells from metastatic lymph nodes (type IV).The remaining 8 patients had more than one type: 1, types I + III;3, types I + III+ IV; 4, types III + IV. Invasion of the hepatoduode-nal ligament was present in 24 of 44 patients without preoperativeobstructive jaundice and in 2 of 13 patients with stage IB disease.Conclusions: Locally advanced gallbladder carcinoma invades intothe hepatoduodenal ligament with relatively high frequency, pre-operative diagnosis of this invasion is difficult, and therefore thethreshold for resection of the extrahepatic bile ducts should below.

P-694Protective Effect of Ischemic Preconditioning againstIschemia-Reperfusion Injury after Major Hepatectomy UsingIntermittent Pringle’s Maneuver in SwineMitsugi Shimoda, Yoshimi Iwasaki, Tokihiko Sawada, Toshie Okada,Makoto Furihata, Keiichi KubotaGastroenterological Surgery, Dokkyo University School of Medi-cine, Japan

[Purpose] Although protective effect of ischemicpreconditioning(IPC) after hepatectomy using continuousPringle’s maneuver has been reported in clinical setting, that afterhepatectomy using intermittent Pringle’s maneuver(IPM) has notbeen clarified yet. [Methods] In all male white swine, a shunt

between splenic vein and internal jugular vein was created undergeneral anesthesia. Left hepatectomy was performed underIPM(repeated 15 min-clamping and 5 min- reperfusion). All swinewere divided into IPC(10-min ischemia and 10-min reperfusion)group or non-IPC group. Liver damage after hepatectomy wasevaluated among two groups by monitoring hemodynamics andbiochemical examination. [Results] 10 swine were divided into twogroups. There were no significant differences in body weight,blood loss, hemodynamics, Pringle’s maneuver time and resectedliver weight among the two groups. In biochemical examination,although there were no significant differences in the value of AST,ALT, LDH, lactic acid and hyaluronic acid after hepatectomy,serum levels of LDH in IPC group were elevated less than those innon-IPC group (IPC vs non-IPC, Immediately after hepatectomy:803±30.9 vs 1109±312.2, 1 hr after hepatectomy 850±40.9 vs1106±236.2, 3 hr after hepatectomy 964±62.9 vs 1215±206.5 IU/l).The values of lactic acid in IPC group were elevated more thanthose in non-IPC group (IPC vs non-IPC, Immediately after hepa-tectomy: 64.5±13.3 vs 47.4±5.5, 1 hr after hepatectomy 71±14.1 vs32.4±5.1, 2 hr after hepatectomy: 74.7±20.0 vs 28.6±7.1, 3 hr afterhepatectomy: 94.2±33.7 vs 29.3±9.0 mg/dl). [Conclusions]Although IPC had no protective effect in hemodynamics and bio-chemical examination after hepatectomy using IPM, IPC tended tobe better in LDH. Further investigation is required.

P-695A Phase I Study of S-1 and Low Dose Cisplatin for Patientswith Recurrent or Advanced Gastric CancerShouji Shimoyama, Kazuhiro Imamura, Naoki Hiki, NobuyukiShimizu, Hirokazu Yamaguchi, Ken-Ichi Mafune, Michio KaminishiGastrointestinal Surgery, Tokyo University, Japan

Purpose: To identify the dose limiting toxicity (DLTs) and recom-mendedn dose (RD) of S-1 in combination with low dose cisplatinon an outpatient setting for advanced or recurrent gastric cancer.Methods: Eligible patients had measurable metastatic lesions ofhistologically confirmed gastric adenocarcinoma, ECOG PS 0-2,age between 20 and 75, without serious comorbidity, and fullyinformed. Escalating dosages of cisplatin (15, 20, and 25mg/m

2as

levels 1, 2, and 3, respectively) were administered over 2 hours ondays 1, 8, and 15 with a fixed dose of S-1 for three consecutiveweeks (days 1~21), repeated every five weeks. Adverse events wereevaluated at the end of the first cycle and DLTs were determinedas grade 3 or more hematological and/or nonhematological toxici-ties. Results: Nine patients (male:female 5:4, mean age 68 yearsold) were enrolled. Six had undergone gastrectomy and three hadunresectable diseases. Three patients were chemonaive, and theremainders received prior FU based regimen. All patients weretreated on an outpatient setting. At the end of the first cycle, noneexperienced DLTs nor required hospitalization. Grades 1 or 2hematological toxicities were common while mostly transient dur-ing a total of 43 cycles. Mean dose intensities for S-1 and cisplatinwere respectively 90% and 91%. There were no treatment relateddeaths. The preliminary response rate was 44%. Conclusions: Weconclude 25mg/m

2of cisplatin as a RD in combination with S-1

for further studies. They appear to be a well-tolerated, active, andoutpatient regimen for advanced gastric cancer.


P-696Micrometastasis in Node Negative Colorectal Carcinoma byImmunohistochemical Diagnosis with CK20Seiichi Shinji1, Noritake Tanaka1, Kiyonori Furukawa1, HideakiTakasaki1, Hideyuki Suzuki1, Tomoko Seya1, Hayato Kan1, HiroyukiTsuruta1, Akihisa Matsuda1, Miwako Katsuta1, Nobuhisa Teranishi1,Takashi Tajiri1, Toshiyuki Ishiwata2, Munehiro Yokoyama2, ZenyaNaito2

1Surgery for Organ and Biological Regulation (Department ofSurgery I), Graduate School of Medicine, Nippon Medical School,2Department of Pathology II, Nippon Medical School, Japan

Purpose: The purpose of this study is to clarify the clinical signifi-cance of micrometastasis in regional lymph nodes that could notbe identified by routine pathological examination. Methods:Forty-two cases of stage I and II of colorectal cancer (withoutlymph node metastasis) who underwent operation from January1999 to December 1999 at the Nippon Medical School Hospitalwere enrolled in this study. Five hundred and twenty five lymphnodes were examined by immunohistochemistry using cytokeratin(CK) 20 antibody. The paraffin-embedded sections were slicedinto 1 piece of 3 µm for hematoxylin and eosin (H&E) stain and 5pieces of 6 µm for immunohistochemistry. All of slices were pre-pared serial sections. Results: CK 20 positive cells were observedin the subcapsular and paracortical sinuses of 20 nodes (8 of 42patients). No micrometastasis was detected in the lymph nodes ofsubmucosal colorectal cancer patients. In comparison between thepatients with and without micrometastasis, the patients withmicrometastasis had significantly poorer disease free survival ratethan those without micrometastasis (log-rank test, p = 0.0093).However, over all survival and clinicopathological factors did notshow significant differences in two groups. Conclusion: The pre-sent study suggest that micrometastasis detected by CK 20 is a pre-dictive indicator for recurrence in node negative colorectal cancer.

P-697Incorporating IL-1 Receptor Antagonist Secreting Hepato-cytes in a Bioartificial Liver Device for the Treatment of Ful-minant Hepatic FailureMasahiro Shinoda1, Arno W. Tilles1, Go Wakabayashi2, NaoyaKobayashi3, Atsushi Takayanagi4, Hirohisa Harada2, Hideaki Obara2,Toshinori Totsugawa3, Francois Berthiaume1, Motohide Shimazu2,Nobuyoshi Shimizu4, Noriaki Tanaka3, Masaki Kitajima2, Ronald G.Tompkins1, Mehmet Toner1, Martin L. Yarmush1

1Surgery, Massachusetts General Hospital, USA, 2Surgery, KeioUniversity, 3Surgery, Okayama University, 4Molecular Biology,Keio University, Japan

An optimally functioning bioartificial liver (BAL) device has thepotential to provide critical hepatic support to the patient with ful-minant hepatic failure (FHF). In an effort to develop hepatocyteswith additional functions for use in our BAL, we focused on IL-1blockade. We injected an adenoviral vector encoding human IL-1receptor antagonist (Ad-IL-1Ra) into the liver of D-galactosamineintoxicated rats via the portal vein. We also transfected primary rathepatocytes and reversibly immortalized human hepatocytes withAd-IL-1Ra. We then incorporated these transfected hepatocytesinto our flat-plate BAL device and evaluated their efficacy in ourD-galactosamine induced rat FHF model after 10 hours extracor-poreal perfusion. Rats injected with Ad-IL-1Ra showed significant

reductions in the plasma levels of hepatic enzymes (p<0.05, vs.control virus group), suggesting that IL-1 receptor antagonist (IL-1Ra) is beneficial for the treatment of FHF. Primary rat hepato-cytes transfected with Ad-IL-1Ra secreted IL-1Ra without losingtheir original synthetic function. Incorporating these cells into theBAL device and testing in the rat FHF model resulted in signifi-cant reductions in plasma levels of AST and IL-6 (p<0.05) and sig-nificantly improved animal survival (p<0.05, 86% vs. 21% in con-trol group). When incorporated in the BAL device and tested inthe rat FHF model, immortalized human hepatocytes transfectedwith Ad-IL-1Ra also significantly improved plasma levels of ASTand IL-6 (p<0.05), and a trend toward improved survival (56% vs.21% in control group) was seen. In conclusion, hepatocytes thatsecrete IL-1Ra are a promising cell source for BAL devices in thetreatment of FHF.

P-698A Study of the Risks of Colorectal Cancer Surgery in theElderly (80 Years or Older) Evaluation of the PerioperativeRisks Using the POSSUM ScoreTakeshi Shioya1, Masanori Watanabe2, Tetsuo Shibuya2, Akira Toku-naga2

1Gastrointestinal Disease Center, Nippon Medical School, Japan,2Nippon Medical School 2nd Hospital Gastrointestinal DiseaseCenter, Japan

[Objectives] With the aging of society in the present time, the fre-quency of abdominal surgery in the elderly is increasing. Undersuch circumstances, treatment and postoperative managementoften pose difficulties. We conducted a retrospective study of theperioperative risks of surgery for colorectal cancer in elderlypatients who were 80 years or older, using the POSSUM score.[Subjects and methods] The subjects were 46 patients who were 80years of age or older, who underwent surgery for colorectal cancer(elective surgery, 35 patients; emergency surgery, 11 patients). Thefrequency of preoperative comorbidities, POSSUM score (PS,OSS values, prediction ratio for postoperative complications andprediction ratio for mortality), postoperative complications andprognosis were examined. [Results] Thirty-two patients (69.6%)had preoperative comorbidities, 28 patients (60.9%) had postoper-ative complications. The overall prediction ratio for the incidenceof complications calculated on the basis of the POSSUM score was61.8%, and that for mortality was 22.1%. The PS, OSS values,prediction ratio for postoperative complications and predictionratio for mortality were significantly higher in the emergencysurgery group than in the elective surgery group. The number ofthe patients who died in the hospital was also larger in this group(4 patients: 36.4%). [Conclusion] The POSSUM score is an easy-to-evaluate and useful indicator for predicting the occurrence ofcomplications and prognosis after colorectal surgery in the elderly.

374 AJournal of


P-699Clinicopathological Feature of Skip Metastases in ColorectalCancerManabu Shiozawa1, Makoto Akaike1, Ten-i Godai1, NaotoYamamoto1, Yukio Sugimasa1, Shouji Takemiya1, Toshio Imada2

1Gastrointestinal Surgery, Kanagawa Cancer Center, Japan, 2Gas-troenterological Center, Yokohama City University Medical Cen-ter, Japan

Porpose: The status of lymph node metastases was divided intothree groups according to their locations from the main tumor inJapanese General Rules. According this rules, we often found thecases with skip metastases, in which distant nodes were positive formetastases but lymph nodes close to the tumor were negative. Sowe evaluate the skip n2 (Japanese rules) metastases in clinicopatho-logically. Method: The 323 Dukes C patients were subclassifiedaccording to location of positive nodes. skip n2 defined lymphnodes which were positive for metastases in N2 area but negativefor in N1 and N3 area. Results: The 211 patients were in the n1group and 91 patients were in the n2 group. skip n2 group con-tained 21 patients. Pathological study showed that skip n2 was fewnumber of lymph nodes metastases compared with n1 and n2groups but it situated between n1 and n2 group in the degree oflymphatic invasion. Cumulative survival of the patients in skip n2group was significantly poorer (p=0.039, Log Rank test) than in n2group. And there was no difference in survival between skip n2group and n1 group. Conclusion: The results was suggested thatlymph nodes of skip n2 metastases were sentinel nodes from themain tumor. Therefore, the cases of skip n2 were better prognosisthan n2 cases, and similar to n1 cases.

P-700Sentinel Lymph Node Biopsy in Rectal CancerManabu Shiozawa1, Makoto Akaike1, Ten-i Godai1, NaotoYamamoto1, Yukio Sugimasa1, Shouji Takemiya1, Toshio Imada2

1Gastrointestinal Surgery, Kanagawa Cancer Center, Japan, 2Gas-troenterological Center, Yokohama City University Medical Cen-ter, Japan

Purpose: To evaluate the feasibility and utility of radiocolloid lym-phatic mapping in patients with rectal cancer. Methods: Sixteenpatients with rectal cancer were investigated. An endoscopic injec-tion of 1.2mL technetium 99m-sulfur-colloid into the peritumoralsubmucosa was performed before surgery. Ex vivo identification ofthe nuclide-enriched lymph node (Sentinel node) was performedusing a hand-held gammma probe. We were conducted to evaluatecomparison Sentinel node metastases as assessed by HE stain andcomparison non-sentinel node metastases as assessed by HE stain.Results: One or more sentinel nodes were found in 13 of the 16patients. The sentinel lymph node detection rate was 81.2%. Themean number of sentinel nodes was three per patient. Seven of the16 patients had lymph node metastases. In four of the 7 patients,the sentinel nodes correctly represented the nodal status. In 3 ofthe 7 patients, the sentinel nodes were negative for metastases butnon-sentinel nodes were positive for metastases. In addition, sen-tinel nodes of this 3 cases were investigated micrometastases byreal time PCR and all of them had micrometases. Conclusion:Sentinel lymph node biopsy using the radiocolloid technique withexvivo lymph node identification shows a high detection. But thestatus of the sentinel node metastases by HE stain showed poor

diagnosis of the all lymph node metastatic status of the tumor. Itwas nessessary to evaluate sentinel nodes as assessed by real timePCR (micrometastases).

P-701Useful Predictive Factors of Common Bile Duct Stones Priorto Laparoscopic Cholecystectomy for GallstonesShunichi Shiozawa, Akira Tsuchiya, Dal Ho Kim, Takebumi Usui,Toshio Masuda, Kouichi Kubota, Toshihiko Hosokawa, Toshinori Oishi,Yoshihiko Naritaka, Kenji Ogawa Department of Surgery, Tokyo Women’s Medical UniversityDaini Hospital, Japan

Purpose: In the present study, endoscopic retrograde cholan-giopancreatography (ERCP) was performed in all patients withcholelithiasis scheduled for laparoscopic cholecystectomy (LC)with a view to seeking case profiles adequate for an efficient dis-covery of common bile duct stones (CBDs) by ERCP.Methods: A total of 510 patients underwent ERCP prior to LC.Also reviewed in each were clinical data, laboratory data, and ultra-sonographic findings. Data were evaluated by uni-and multivariateanalysis to determine which of useful predictive factors thus farreported might be in the concurrence of CBDs.Results: Univariate analysis identified jaundice, pancreatitis, ALT,total bilirubin, alkaline phosphatase, amylase, and CBD dilatationat ultrasonography as predictors. Multivariate analysis subsequent-ly identified alkaline phosphatase (p<0.0001), total bilirubin (p =0.0008), amylase (p = 0.0009), and CBD dilatation at ultrasonogra-phy (p = 0.0012) as independent predictive factors of CBDs. Theestimates for the detection of CBDs, when the indication of ERCPis determined on the basis of the four predictive factors, werefound to be as follows: sensitivity 97.6%, positive predictive value78.6%, and positive accuracy 95.3%.Conclusions: It is advisable to ascertain by preoperative ERCPwhether there might be any CBDs in patients to undergo an LCfor treatment of cholelithiasis insofar as the patient has one ormore of these factors. It is concluded that an LC may be per-formed by omitting the prior ERCP, conversely, on patientsdevoid of all of these factors.

P-702Liver Transplantation or Resection for the Treatment of Car-oli’s Disease? A Case of Twin Sisters Treated with Two Dif-ferent ApproachesMasayuki Shiraishi, Akira Toyoda, Hiroki Sunagawa, ShimojiHideaki, Tadashi NishimakiSurgery I, University of the Ryukyus, Japan

[Aims] Both the liver resection (LR) and liver transplantation(LTx) are now used for the treatment of Caroli’s disease. To eluci-date the role of these treatments, we herein present a case of twinsisters with Caroli’s disease.[Case Reports] First patient started to develop repeated high feverdue to cholangitis at 36 years old. A diagnosis of Caroli’s diseasewas made by diagnostic imaging, showing segmental dilatation ofthe intra-hepatic bile ducts mainly in the right lobe. She was livertransplanted at Kyoto University to replace the diseased liver, at 1-year after onset. In the resected specimen, cholangiocellular carci-noma (CCC) was detected. Second patient was also diagnosed tohave Caroli’s disease at 38 years old, with the same segmental


dilatation of the intra-hepatic bile ducts mainly in the right lobe.She had high levels of serum ALP and CA19-9, which continuous-ly increased thereafter without any tumor image detected. Sinceher twin sister developed CCC in a short period, right hepaticlobectomy of the liver was performed at 4 years after initial diag-nosis. Those serum levels of ALP and CA19-9 were normalizedrapidly after lobectomy. Both patients returned to their normal lifewithout any clinical symptom.[Conclusion] Once the patients with Caroli’s disease start to expe-rience recurrent cholangitis, they are also at great risk to developCCC and hepatic failure. In these patients with localized intra-hepatic bile duct’s involvement of Calori’s disease, hepatic resec-tion as a preventive therapy might thus be justified at an early stageof the disease.

P-703The Role of Radio Frequency Ablation (RFA) under SurgicalApproach in Treating Advanced Hepatocellular Carcinoma(HCC)Masayuki Shiraishi, Hirofumi Tomori, Hideaki Shimoji, TadashiNishimakiSurgery I, University of the Ryukyus, Japan

[Aims] Advanced HCC is often diagnosed to be untreatable, due toits size, location, and hepatic function. In treating such advancedHCC, we used RFA under surgical approaches, combined withpre- and postoperative trans-arterial chemo-embolization(TACE). [Methods] Between 2001 and 2003, 18 cases of advanced HCC(Stage III:n=5, Stage IVa:n=13) were treated with RFA under 20surgical approaches (laparotomy n=13, thoracotomy n=3, laparo-scopic n=4), and trans-arterial chemo-embolization (TACE) wasperformed before and/ or after RFA. Maximum tumor diameterwas larger than 5 cm in 6 patients, and 11 had more than 4 tumors.Five to 15 sessions of RFA were performed in each surgery. Con-trast-enhanced computed tomography and power doppler echog-raphy were used to evaluate the viability of the tumor at 1 monthafter treatment.[Results] Sixteen patients showed no residual viable lesion at 1month after treatment, and 2 patients with residual lesion weretreated with the second TACE+ RFA+ TACE. Five multi-centricrecurrences were observed in 3 patients at 10 to 15 months aftertreatment. Twelve patients showed elevated serum tumor markers(AFP 80-830 ng/ml or PIVKA-II 115-4500 mAU/ml) before treat-ments, which normalized within 1 month after treatments in allthe cases. Two patients died of unrelated causes, at 2 and 16months after RFA.[Conclusion] RFA under surgical approaches combined withTACE was thought to be safe and effective in establishing excel-lent local control of the advanced HCC.

P-704Short and Long-term Results of Laparoscopic Surgery forColorectal CancerAkio Shiromizu, Yoko Hata, Yoko Matsui, Yoshitake Ueda, ManabuTojigamori, Koichi Izumi, Tsuyoshi Etoh, Koichi Ishikawa, MasafumiInomata, Norio Shiraishi, Seigo KitanoSurgery I, Oita University Faculty of Medicine, Japan

Background/Purpose: Although laparoscopic colectomy has been

widely accepted, little is known about the subjective clinical results.The aim of this study was to evaluate the short and long-term out-come of patients who underwent laparoscopic surgery for colorec-tal cancer.Method: The study included 73 patients with laparoscopic and 112with open surgery for the colon and upper rectal cancer withoutserosal invasion between 1993 to 2003 in Oita University. As theshort-term results, operation time, blood loss, the day of first fla-tus, serum C-reactive protein and albumin level, lymphocytecount, nutrition index, and postoperative complications were com-pared between two groups. Also, the long-term results were com-pared between two groups.Results: Laparoscopic surgery was significantly different fromopen surgery with regard to the blood loss (103 vs. 318 ml,p<0.01), the day of the first flatus (3.5 vs. 4.2, p<0.05), hospital stay(16.4 vs. 24.6 days, p<0.01) and C-reactive protein level (6.3 vs.11.2 mg/dl, p<0.05) on postoperative day 1, lymphocyte count(1354 vs. 995 /mm3, p<0.05) on postoperative day 7, and nutritionindex (43.2 vs. 38.5, p<0.05). There were no differences of morbid-ity, mortality, and 5-years survival rate between two groups.Conclusions: Laparoscopic surgery for colorectal cancer is safe,less invasive, and not reducing in curability during a long-term fol-low-up period, when compared with conventional open surgery.

P-705Eicosapentaenoic Acid Inhibits Cell Growth and Invasion ofHuman Pancreatic Cancer CellTetsuya Shirota, Seiji Haji, Mitsuo Yamasaki, Takuya Iwasaki,Toshiharu Hidaka, Yoshifumi Takeyama, Hitoshi Shiozaki, Haru-masa OhyanagiDepartment of Surgery, Kinki University School of Medicine,Japan

Purpose: Clinical studies have revealed that administration ofeicosapentaenoic acid (EPA) to the patients with unresectable pan-creatic cancer induces marked attenuation of cachexia. However,the exact mechanisms by which EPA influence pancreatic cancerare not known. The purpose of this study was to examine the effectof EPA on pancreatic cancer cell proliferation, apoptosis, invasivecapacity and the mechanisms in vitro. Methods: The Human pan-creatic cancer cell line SW1990 was treated with different doses ofEPA. Proliferation of the cells was measured by MTT assay.Induction of apoptosis and active caspase-3 were assessed by flowcytometry. The effect of EPA on the cells was also examined inelectron microscopy. The effect of EPA on the cells invasivenessand cyclooxygenase-2 (COX-2) expression was determined.Results: EPA inhibited significantly proliferation of the cells. Asignificant increase in the number of apoptotic cells and the activecaspase-3 was observed by EPA treatment. Electron microscopicevaluation of the cells treated with EPA revealed the presence ofmorphological characteristics consistent with apoptosis. Preincu-bation with EPA suppressed invasive activities. The expression ofCOX-2 was down-regulated significantly in the cells treated withEPA. Conclusions: In this study, we demonstrate that EPA inhibithuman pancreatic cancer cell proliferation by mechanisms thatinduce apoptosis and active caspase-3 is involved in the apoptosisof the cells. We also provide treatment with EPA decreased theinvasive capacity and the expression of COX-2. EPA may be apotent biologic modulator of human pancreatic cancer, reducingtheir proliferative and invasive activities.

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