World Journal of Surgery

The morphologic anatomy of the liver is described as 2 main and 2 accessory lobes. The more recent functional anatomy of the liver is based on the distribution of the portal pedicles and the location of the hepatic veins. The liver is divided into 4 sectors, some of them composed of 2 segments. In all, there are 8 segments. According to the anatomy, typical hepatectomies (or “réglées”) are those which are performed along anatomical scissurae. The 2 main technical conceptions of typical hepatectomies are those with preliminary vascular control (Lortat‐Jacob's technique) and hepatectomies with primary parenchymatous transection (Ton That Tung's technique). A good knowledge of the anatomy of the liver is a prerequisite for anatomical surgery of this organ.

Radical surgery of gastric cancer has become more widely utilized in Japan. Topics explored in gastric cancer surgery include the extended lymph node dissection guided by the node staining method with India ink, left upper abdominal organs exenteration for advanced cancer of the upper stomach, and pancreaticoduodenectomy for advanced cancer of the lower stomach. Through the progress of surgical treatment as well as that of the early detection system, the treatment results have been improved. Using the data from nationwide registrations (5,706 and 11,845 cases) and those from the National Cancer Center Hospital (3,176 cases), the 5‐year survival rate of total primary resected cases was 44.3% in the first period (1963–1966), 56.3% in the second period (1969–1973), and 61.6% in the third period (1971–1985). Between the first and the third period, the 5‐year survival rate of patients with stage 2 cancer increased from 60.6% to 71.7%, and that of stage 3 increased from 32.7% to 44.3%; however, the limits of radical surgery were also clarified, especially in patients with peritoneal dissemination, liver metastasis, distant lymph node metastasis, and diffusely infiltrating carcinoma (Borrmann type 4). For such patients, chemotherapy, hormonal therapy, immunotherapy, radiotherapy, and hyperthermia should possibly be employed in hopes of improving treatment result.

As a countermeasure to portal tumor thrombi, which are a serious danger in liver cancer, we did portal vein embolization (PVE) during percutaneous transhepatic portography. Our 21 patients later underwent hepatic resection. After PVE, portal pressure increased and there was slight liver function damage, but this procedure was safer than transarterial embolization (TAE). We examined the pathologic specimens to view the state of occlusion achieved and also for histological findings, and found that Lipiodol ® mixed with fibrin was most effective. PVE done before hepatic resection strengthened the anticancer effect of TAE, prevented intrahepatic metastases, and caused permanent hypertrophy of the liver that may be useful as a kind of preparation for surgery.

Nonpolypoid colorectal neoplasms are grossly classified into three groups: slightly elevated (small flat adenomas), laterally spreading, and depressed. Flat adenomas are not invasive until they are rather large, whereas depressed lesions can invade the submucosa even when they are extremely small. Nonpolypoid lesions are difficult to detect and are often overlooked. Keys to detect them are their slight color change, interruption of the capillary network pattern, slight deformation of the colonic wall, spontaneously bleeding spots, shape change of the lesion with insufflation and deflation of air, and interruption of the innominate grooves. Spraying of indigo carmine dye helps to clarify the lesions. A pit pattern analysis with a zoom colonoscope is useful for the diagnosis and staging of early colorectal cancer. Small flat adenomas are thought to be precursors of protruded polyps and lateral spreading tumors, whereas depressed lesions are thought to grow endophytically and become advanced cancers. Small depressed lesions are treated with an endoscopic mucosal resection (EMR) technique; but when they massively invade the submucosa, surgical resection is indicated. Laterally spreading tumors are not as invasive despite their large size and therefore are good indications for the EMR or piecemeal EMR method. Small flat adenomas need not be treated urgently, as almost none is invasive. Accurate diagnosis with dye‐spraying and zoom colonoscopy is vital for deciding the treatment strategy.

This prospective study was performed to investigate epidemiological characteristics in terms of the age‐ and sex‐specific incidence in patients with perforated and nonperforated appendicitis. The study population comprised 1486 consecutive patients who underwent appendectomy for suspected acute appendicitis between 1989 and 1993. Two patient cohorts [n= 544 (37%)] were analyzed with regard to prehospitalization duration of symptoms and in‐hospital observation time. The crude incidence of acute appendicitis was 86 per 100,000 per year. Although the incidence of nonperforated appendicitis was highest among adolescents and young adults (13–40 years of age), perforated appendicitis occurred at almost the same incidence in all sex and age groups. The diagnostic accuracy was 76%. Perforated appendicitis occurred in 19%, with higher rates in small children and the elderly, irrespective of gender. A high diagnostic accuracy was not associated with an increased rate of perforation. In small children and the elderly, the diagnostic accuracy was low and the perforation rate high. Patients with perforation had a significantly longer duration of symptoms as well as in‐hospital observation time than did patients with nonperforated appendicitis. Perforated appendicitis showed a different incidence pattern than nonperforated appendicitis and was associated with a significantly longer duration of symptoms and in‐hospital observation time, probably due to patient‐related factors. We suggest this observation deserves attention regarding clinical diagnosis and treatment decision‐making for patients with suspected acute appendicitis.