High recurrence and rebleeding rates have been reported when endoscopic sclerotherapy has been performed on patients with esophageal varices. We studied the relationship between embolization range and recurrence rate in 26 patients in whom percutaneous transhepatic portography was carried out before and after sclerotherapy. Patients were divided into complete and incomplete embolization groups. The complete embolization group consisted of 16 patients whose esophageal varices had disappeared and in whom embolization of the feeders to the varices had occurred. The incomplete embolization group consisted of 10 patients whose esophageal varices had disappeared, but no embolization had occurred. Recurrence rates within 2 yr after the treatment were compared between complete and incomplete embolization groups. The recurrence rates in the respective groups were 6.7% (1 of 15) and 70.0% (7 of 10), indicating a significant difference between the two groups (p less than 0.05) and indicating that embolization of both esophageal varices and their feeders is essential to lower the recurrence rate after sclerotherapy.

From October 1976 to May, 1990, a total of 86 patients with stage IV (TNM) gallbladder cancer were treated at Tsukuba University Hospital. Twenty-seven of the 86 patients underwent tumor resection; 43 patients received palliative surgery. The remaining 16 were too advanced to have surgery. Of 27 patients who had tumor resection, 9 had resection alone, 17 had intraoperative radiation therapy (IORT) +/- postoperative external radiotherapy (ERT), and 1 had postoperative ERT. The procedures used were: extended right hepatic lobectomy plus hepaticobiliary resection (HBR) (n = 2), hepatic segmentectomy (SIVb, SV) plus HBR (n = 9), hepatic segmentectomy (SIV, V, VI) with HBR (n = 1), hepatic segmentectomy (SIV, V) plus HBR with pancreaticoduodenectomy (PD) (n = 3), PD plus HBR (n = 1), cholecystectomy with wedge resection of the gallbladder fossa plus HBR (n = 3), and cholecystectomy plus HBR (n = 3), and cholecystectomy (n = 4). Regional lymph node dissections were performed in every patient and 17 of 27 patients underwent additional resections of adjacent organs such as the stomach, duodenum, colon, and abdominal wall. A single dose of 20-30 Gy was delivered intraoperatively for 17 patients. A mean total dose of 36.4 Gy (1.8/fraction) was added to IORT for 10 patients. The three-year cumulative survival rate was 10.1% for resection plus IORT but 0% for resection alone. The longest survivor is alive and well at 3 years and 3 patients are alive 16, 13, and 4 months after tumor resection followed by IORT plus ERT.

Since October, 1976, we have treated a total of 81 patients with bile duct cancer. Fifty of these patients had cancer that originated at and/or infiltrated into the main hepatic ducts. Five patients had cancer on the upper to middle portion, 19 on the middle to intrapancreatic bile duct, and the remaining 7 had diffusely involved tumors. Fifty of the 81 patients underwent resections. Of the 50 patients, 33 received curative or noncurative resection alone, 14 were treated by resection plus intraoperative radiotherapy (IORT), and the remaining 3 received postoperative external irradiation. Thirty-one of the 81 patients did not undergo tumor resection. Of these, 6 had IORT and 4 underwent external radiotherapy after bile drainage. The remaining 21 underwent bile drainage alone. Curative resection achieved the best cumulative 5-year survival rate of 59.3%. IORT plus noncurative resection showed a superior 2-year survival rate of 17.1% compared to 9.0% after noncurative resection alone. Only 1 patient treated by IORT plus bile drainage survived more than 2 years and subsequently died at 34 months. In the earlier stage of the development of the combination therapy with resection and IORT, severe complications were experienced in 9 patients (so treated), including remarkable obstructive changes of the hepatic arteries. In the later stage, resection plus IORT with a reduced single dose (20 Gy), using a smaller field size (3.7 + 1.4 cm) and beam energy (7.3 _+ 3.0 MeV), did not result in complication and produced 2 long-term survivors among 5 patients. Fractionated external irradiation (30--40 Gy/4-5 weeks) has been added to the IORT recently. These results indicate that noncurative resection plus IORT in combination with external radiation would improve the prognosis of the patient with advanced bile duct cancer.