Severe Asherman's syndrome complicated with placenta increta conceived by intracytoplasmic sperm injection following hysteroscopic surgery.

Although severe Asherman's syndrome is a disease that may cause infertility, pregnancy and childbirth are possible by performing hysteroscopic surgery. However, the obstetrical outcome is not always satisfactory. We report a case where severe Asherman's syndrome occurred following a cesarean section. Hysteroscopic surgery was performed due to secondary infertility, and pregnancy was achieved through a subsequent intracytoplasmic sperm injection. At 23 weeks of gestation, the patient was hospitalized due to the threat of premature labor, and a cesarean section was performed at 29 weeks of gestation after pregnancy-induced hypertension occurred. It was determined to be abnormal adherent placentation such as placenta increta through intraoperative findings, and a cesarean hysterectomy was performed. The pathological diagnosis of the uterus was placenta increta. Due to the risk of complications from placenta increta in pregnancies following hysteroscopic surgery in patients with severe Asherman's syndrome, it is important to realize the high risk involved in such cases during the pregnancy course, and careful perinatal management should be required.

Microelectrode findings and topographic reorganisation of kinaesthetic cells after gamma knife thalamotomy.

A 64-year-old woman with Parkinson is disease had a severe resting tremor that was not completely relieved by right-sided gamma knife thalamotomy (GKT). We performed bilateral staged thalamic deep brain stimulation (DBS) and compared the right and left ventral intermediate nucleus (Vim) of the thalamus including the frequency of single units recorded with microelectrodes, and also the somatotopical distribution of kinaesthetic cells (Ki). The average frequency of units for the presumed left Vim exceeded that of the right (22.6 +/- 19.2 Hz vs. 14.3 +/- 8.8 Hz). Regarding the somatotopic distribution of Ki, the receptive field for the leg, which is usually situated in the dorsolateral Vim, was more widely scattered in the right Vim than the non-lesioned left side. Our findings raise the possibility that the specific properties of the neurons changed due to partial coagulation by GKT within both the coagulated and the surrounding thalamic lesions.

Frequent epigenetic inactivation of Wnt antagonist genes in breast cancer.

Although mutation of APC or CTNNB1 (beta-catenin) is rare in breast cancer, activation of Wnt signalling is nonetheless thought to play an important role in breast tumorigenesis, and epigenetic silencing of Wnt antagonist genes, including the secreted frizzled-related protein (SFRP) and Dickkopf (DKK) families, has been observed in various tumours. In breast cancer, frequent methylation and silencing of SFRP1 was recently documented; however, altered expression of other Wnt antagonist genes is largely unknown. In the present study, we found frequent methylation of SFRP family genes in breast cancer cell lines (SFRP1, 7 out of 11, 64%; SFRP2, 11 out of 11, 100%; SFRP5, 10 out of 11, 91%) and primary breast tumours (SFRP1, 31 out of 78, 40%; SFRP2, 60 out of 78, 77%; SFRP5, 55 out of 78, 71%). We also observed methylation of DKK1, although less frequently, in cell lines (3 out of 11, 27%) and primary tumours (15 out of 78, 19%). Breast cancer cell lines express various Wnt ligands, and overexpression of SFRPs inhibited cancer cell growth. In addition, overexpression of a beta-catenin mutant and depletion of SFRP1 using small interfering RNA synergistically upregulated transcriptional activity of T-cell factor/lymphocyte enhancer factor. Our results confirm the frequent methylation and silencing of Wnt antagonist genes in breast cancer, and suggest that their loss of function contributes to activation of Wnt signalling in breast carcinogenesis.

Frequent epigenetic inactivation of SFRP genes and constitutive activation of Wnt signaling in gastric cancer.

Activation of Wnt signaling has been implicated in gastric tumorigenesis, although mutations in APC (adenomatous polyposis coli), CTNNB1 (beta-catenin) and AXIN are seen much less frequently in gastric cancer (GC) than in colorectal cancer. In the present study, we investigated the relationship between activation of Wnt signaling and changes in the expression of secreted frizzled-related protein (SFRP) family genes in GC. We frequently observed nuclear beta-catenin accumulation (13/15; 87%) and detected the active form of beta-catenin in most (12/16; 75%) GC cell lines. CpG methylation-dependent silencing of SFRP1, SFRP2 and SFRP5 was frequently seen among GC cell lines (SFRP1, 16/16, 100%; SFRP2, 16/16, 100%; SFRP5, 13/16, 81%) and primary GC specimens (SFRP1, 42/46, 91%; SFRP2, 44/46, 96%; SFRP5, 30/46, 65%), and treatment with the DNA methyltransferase inhibitor 5-aza-2'-deoxycytidine rapidly restored SFRP expression. Ectopic expression of SFRPs downregulated T-cell factor/lymphocyte enhancer factor transcriptional activity, suppressed cell growth and induced apoptosis in GC cells. Analysis of global expression revealed that overexpression of SFRP2 repressed Wnt target genes and induced changes in the expression of numerous genes related to proliferation, growth and apoptosis in GC cells. It thus appears that aberrant SFRP methylation is one of the major mechanisms by which Wnt signaling is activated in GC.

Epigenetic inactivation of TCF2 in ovarian cancer and various cancer cell lines.

Transcription factor 2 gene (TCF2) encodes hepatocyte nuclear factor 1beta (HNF1beta), a transcription factor associated with development and metabolism. Mutation of TCF2 has been observed in renal cell cancer, and by screening aberrantly methylated genes, we have now identified TCF2 as a target for epigenetic inactivation in ovarian cancer. TCF2 was methylated in 53% of ovarian cancer cell lines and 26% of primary ovarian cancers, resulting in loss of the gene's expression. TCF2 expression was restored by treating cells with a methyltransferase inhibitor, 5-aza-2'deoxycitidine (5-aza-dC). In addition, chromatin immunoprecipitation showed deacetylation of histone H3 in methylated cells and, when combined with 5-aza-dC, the histone deacetylase inhibitor trichostatin A synergistically induced TCF2 expression. Epigenetic inactivation of TCF2 was also seen in colorectal, gastric and pancreatic cell lines, suggesting general involvement of epigenetic inactivation of TCF2 in tumorigenesis. Restoration of TCF2 expression induced expression of HNF4alpha, a transcriptional target of HNF1beta, indicating that epigenetic silencing of TCF2 leads to alteration of the hepatocyte nuclear factor network in tumours. These results suggest that TCF2 is involved in the development of ovarian cancers and may represent a useful target for their detection and treatment.

Cyclooxygenase-2 is a possible target of treatment approach in conjunction with photodynamic therapy for various disorders in skin and oral cavity.

BACKGROUND: Anti-cancer effects of cyclooxygenase (COX)-2 inhibitors have been reported, but not fully investigated in skin and oral diseases. 5-aminolaevulinic acid (ALA)-based photodynamic therapy (PDT) for treating those patients with skin and oral lesions is a highly sophisticated procedure, but the incidence of disease recurrence after treatment is rather significant. OBJECTIVE: To confirm that COX-2 could be a molecular target in adjunctive therapy to ALA-based PDT, we investigated (i) COX-2 expression in various skin and oral diseases, and (ii) the inhibitory effects on cellular growth of COX-2 selective inhibitor (nimesulide), ALA-based PDT and their combination on human oral squamous cell carcinoma (SCC) cell lines. METHODS: A total of 129 biopsy samples from the skin and oral mucosal lesions were tested immunohistochemically for COX-2 expression. Then the in vitro effects of nimesulide, ALA-based PDT, and their combination were determined on two SCC cell lines, HSC-2 and HSC-4. Three different methods (MTT assay, double-staining for annexin V and propidium iodide, caspase-3/CPP32 fluorometric protease assay) were applied for evaluation of their inhibitory effects on these two cell lines. RESULTS: Among the skin diseases, a considerable number of COX-2 high expressers were found in actinic keratosis (15 of 25, 60%), Bowen's disease (13 of 17, 76%) and extramammary Paget's disease (15 of 15, 100%). In contrast, only one of 33 (3%) basal cell carcinoma tumours was a COX-2 high expresser. Among the oral mucosal biopsies, the proportion of COX-2 high expressers increased gradually from hyperplasia (one of six, 17%) through mild dysplasia (five of eight, 63%) and moderate dysplasia (20 of 23, 87%) to severe dysplasia (two of two, 100%). Nimesulide had an inhibitory effect in vitro on HSC-2 (proven to be a COX-2 high expresser), but not on HSC-4 (a COX-2 non-expresser). While ALA-based PDT showed an inhibitory effect on both HSC-2 and HSC-4, most importantly the combination of nimesulide and ALA-based PDT demonstrated a significant synergistic effect on the cellular growth inhibition of only HSC-2, but not of HSC-4. CONCLUSIONS: Our study strongly suggests that COX-2 can be one of the molecular targets in treating various skin and oral diseases. The results from our in vitro experiments also prompt us to develop a new protocol with a combination of COX-2 selective inhibitor and ALA-based PDT for more effective treatment of those diseases.

Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan.

We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma (n = 78), which was followed by olfactory neuroblastoma (n = 16) and adenoid cystic carcinoma (n = 16). The most frequent surgical approach was frontal craniotomy (n = 66), followed by front-temporal craniotomy (n = 54) and infratemporal fossa approach (n = 8). For repair of dura matter, fascia lata was used in 37 cases. galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan-Meier method of nose and paranasal sinus carcinoma (n = 119) was 48%. As for histological classification, the survival rates were both 65%) in adenoid cystic carcinoma (n = 12) and bone soft tissue malignancy (n = 10), 62% in olfactory neuroblastoma (n = 16), 46% in squamous cell carcinoma (n = 62) and 33% in adenocarcinoma (n = 11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases. liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment.

A comprehensive analysis of loss of heterozygosity caused by hemizygous deletions in renal cell carcinoma using a subtraction library.

Several new loci were identified by a comprehensive analysis of loss of heterozygosity (LOH) using a subtraction library between matched normal and renal cell carcinoma (RCC) tissues. A total of 187 clones from the library, with a complexity of 1x10(4), were mapped, and 44 clusters of the mapped loci were subjected to LOH analysis using microsatellite markers. A total of 27 loci, which exhibited frequencies of LOH of at least 10% among 44 tumors, mostly clear-cell RCC, included several loci that were reported previously, such as, the von Hippel-Lindau gene, adenomatous polyposis coli, and interferon regulatory factor-1, as well as new loci, at 5q32-q34, 6q21-q22, 8p12, and others. These loci exhibited LOH among 11.8-93.8% of tumors, and most, if not all, were derived from the sites of hemizygous deletions. The minimum regions of LOH of chromosomes 5, 6, and 8 were 9.0, 10.3, and 0.775 Mb, respectively. The average distance between the cloned fragments on the chromosomes was 2.2 Mb in 187 clones, indicating that the minimum LOH size expected from this subtraction analysis was roughly 50 kb. Therefore, the strategy described here provides comprehensive analysis of LOH sites, which were mostly caused by hemizygous deletions.

[A case of suspected pulmonary air embolism in endoscopic neurosurgery].

Sudden reduction in end-tidal PCO2 and SpO2 occurred during the endoscopic third ventriculostomy in a patient with hydrocephalus under general anesthesia. We suspect that it was caused by pulmonary air embolism. A 63-year-old female was scheduled for endoscopic third ventriculostomy under general anesthesia. Endoscopic manipulation caused hemorrhage from chorioid plexus 21 minutes after the procedure was begun, and intraventricular irrigation was performed to achieve hemostasis. In the subsequent 3 minutes, end-tidal PCO2 declined from 26 mmHg to 15 mmHg (PaCO2 39.6 mmHg), and SpO2 declined from 98% to 92% (PaO2 69.2 mmHg). Nitrous oxide was discontinued immediately because pulmonary air embolism was suspected and the oxygen concentration was increased to 100%. At the same time the surgical procedure was discontinued. After 15 minutes, end-tidal PCO2 recovered to 25 mmHg, and SpO2 recovered to 98% (PaO2 136.5 mmHg), and surgery was resumed. The patient recovered from anesthesia. The chest X-p at the end of operation, and pulmonary scintigraphy on the following day revealed no abnormal findings, but brain CT demonstrated a large quantity of air in both lateral ventricles.

Effect of carotid endarterectomy on chronic ocular ischemic syndrome due to internal carotid artery stenosis.

OBJECTIVE: We evaluated the effect of carotid endarterectomy on chronic ocular ischemic syndrome due to internal carotid artery stenosis by use of data obtained from ophthalmic artery color Doppler flow imaging. METHODS: We examined 11 patients with ocular ischemic syndrome due to internal carotid artery stenosis (>70% stenosis) who were being treated by carotid endarterectomy. Ophthalmic artery color Doppler flow imaging indicated ophthalmic artery flow direction and peak systolic flow velocity and was performed before and at 1 week, 1 month, and 3 months after surgery. RESULTS: We assessed the ophthalmic arteries of 11 patients via color Doppler flow imaging. Before undergoing carotid endarterectomy, five patients showed reversed ophthalmic artery flow. In the other six patients who experienced antegrade ophthalmic artery flow, the average peak systolic flow velocity was 0.09 +/- 0.05 m/s (mean +/- standard deviation). Preoperative reversed flow resolved in each patient 1 week after undergoing surgery. All patients showed antegrade ophthalmic artery flow. The average peak systolic flow velocity in the patients who had preoperative antegrade flow rose significantly, to 0.21 +/- 0.14 m/s (P < 0.05). There was no significant change as compared with findings at 1 week after surgery. During the follow-up period (mean, 32.4 mo), no patients complained of recurrent visual symptoms. At the end of the study period, visual acuity had improved in five patients and had not worsened in the other six patients. CONCLUSION: Carotid endarterectomy was effective for improving or preventing the progress of chronic ocular ischemia caused by internal carotid artery stenosis.

E2F regulates growth-dependent transcription of genes encoding both catalytic and regulatory subunits of mouse primase.

DNA polymerase alpha-primase is one of the principal enzymes involved in eukaryotic chromosomal DNA replication. Mouse DNA polymerase alpha-primase consists of four subunits with molecular masses of 180, 68, 54 and 46 kDa. Protein and mRNA expression levels of the four subunits are up-regulated in a coordinated manner in response to growth stimulation. We have previously analysed the transcription of the 180 kDa (p180) and 68 kDa (p68) subunits, which form the DNA polymerase catalytic complex, and found that growth-dependent regulation of transcription of the mouse p180 and p68 genes is mediated by a common factor, E2F, while the basal transcription of the genes is regulated by different transcription factors. We characterized the transcriptional regulation of the 54 kDa (p54) and 46 kDa (p46) subunits, which form the DNA primase catalytic complex. We isolated genomic clones spanning the 5'-flanking regions of the p54 and p46 genes and showed, using transient expression and gel mobility shift assays, that the basal transcription of p54 is controlled by Sp1 and GA-binding protein, as is the basal transcription of the p180 gene. The basal transcription of p46 is controlled by unknown factor(s) which were bound to the upstream sequence. The variant E2F sites close to the transcription initiation sites of the p54 and p46 genes had no basal promoter activity, but were essential for the growth-dependent transcription of both genes. The promoter regions of the four subunits of mouse DNA polymerase d-primase complex share several common features. The coordinated transcription of all four subunits in response to growth stimulation appears to be controlled by E2F.

A case of successful fetal therapy for congenital chylothorax by intrapleural injection of OK-432.

A 38-year-old multiparous woman was referred at 19 weeks' gestation because of hydrops fetalis. Ultrasonic examination revealed severe pleural effusion, ascites and skin edema. Detailed examination of the amniotic fluid, fetal blood and intrathoracic fluid led to a diagnosis of congenital fetal chylothorax. Repeated thoracocenteses were not effective in improving the hydrops fetalis. We introduced fetal treatment for the pleural effusion by an intrapleural injection of OK-432 at 23, 24 and 25 weeks' gestation. The pleural effusion was reduced by adhesion of the intrathoracic space and resulted in the delivery of a neonate who was healthy except for right renal dysfunction. Pulmonary hypoplasia was successfully prevented by OK-432.

Transcription of the catalytic 180-kDa subunit gene of mouse DNA polymerase alpha is controlled by E2F, an Ets-related transcription factor, and Sp1.

We have isolated a genomic DNA fragment spanning the 5'-end of the gene encoding the catalytic subunit of mouse DNA polymerase alpha. The nucleotide sequence of the upstream region was G/C-rich and lacked a TATA box. Transient expression assays in cycling NIH 3T3 cells demonstrated that the GC box of 20 bp (at nucleotides -112/-93 with respect to the transcription initiation site) and the palindromic sequence of 14 bp (at nucleotides -71/-58) were essential for basal promoter activity. Electrophoretic mobility shift assays showed that Sp1 binds to the GC box. We also purified a protein capable of binding to the palindrome and identified it as GA-binding protein (GABP), an Ets- and Notch-related transcription factor. Transient expression assays in synchronized NIH 3T3 cells revealed that three variant E2F sites near the transcription initiation site (at nucleotides -23/-16, -1/+7 and +17/+29) had no basal promoter activity by themselves, but were essential for growth-dependent stimulation of the gene expression. These data indicate that E2F, GABP and Sp1 regulate the gene expression of this principal replication enzyme.

[Sitting position in the neurosurgery: the results of a questionnaire sent to neurosurgeons of medical colleges].

We analyzed questionnaire on the sitting position among neurosurgeons. We sent questionnaire to 80 medical colleges in Japan and obtained response from 61 universities (76.3%). The sitting position surgery was performed in 7 institutions (11.5%) and was not in other 54 (88.5%). The first reason for not adopting the sitting position was "other position was good enough to perform the surgery" (44 institutions, 81%). This reason exceeded "objection from the anesthesiologist" (17 institutions, 31%). Twenty institutions (33%) adopted or wished to perform the surgery in sitting position, indicating that neurosurgeons still are interest in performing the sitting position surgery. But 6 institutions adopting the sitting position predicted that the sitting position would diminish in the future, and the sitting position surgery would decrease in number in Japan.

Cloning and characterization of the 5'-upstream sequence governing the cell cycle-dependent transcription of mouse DNA polymerase alpha 68 kDa subunit gene.

We have isolated the genomic DNA fragment spanning the 5-end and the first four exons encoding the 68 kDa subunit (p68) of the mouse DNA polymerase alpha-primase complex [corrected]. The p68 promoter region lacks TATA and CAAT boxes, but contains a GC-rich sequence, two palindrome sequences and two putative E2F-binding sites [corrected]. A series of transient expression assays using a luciferase reporter gene indicated that a region from nucleotide position -89 to -30 (-89/-30) with respect to the transcription initiation site is crucial for basal transcription of the p68 gene in proliferating NIH 3T3 cells. In particular, part of the GC-rich sequence (-57/-46) and the palindrome (-81/-62) elements were necessary for promoter activity, both of which share homology with the E-box sequence. Gel mobility shift assays using NIH 3T3 nuclear extracts revealed that the upstream stimulatory factor, known as an E-box-binding protein, binds to these sites. Moreover, we observed binding of E2F to two sites near the transcription initiation site (-11/-3 and +9/+16). A transient luciferase expression assay using synchronized NIH 3T3 cells in G(0)phase revealed that these E2F sites are essential for transcription induction of the p68 gene after serum stimulation, but are dispensable for basal transcription. These results indicate that growth-dependent regulation of transcription of the mouse p68 and p180 genes is mediated by a common factor, E2F; however, basal transcription of the genes, interestingly, is regulated by different transcription factors.

Use of the abdominal wall fat index determined ultrasonographically for assessing the risk of post-operative pulmonary embolism.

OBJECTIVE: To assess the usefulness of the abdominal wall fat index (AFI) for predicting pulmonary embolism (PE) after gynecologic surgery. METHOD: The subjects were 115 female patients who underwent laparotomy for gynecologic disease. They were divided into low-dose heparin therapy (n=28) and control, without heparin (n=87) groups. The AFI ratio of the maximum preperitoneal fat thickness to the minimum subcutaneous fat thickness was determined using ultrasonography. RESULT: Post-operative PE occurred in four control patients. If the cut-off value of the AFI for predicting PE development was set at more than or equal to 0.85, the sensitivity was 1.00 and the specificity was 0.60 (P=0.03). If we restricted the criteria, and set the cut-off value of the AFI to more than or equal to 0.85 in patients with hypertension [systolic blood pressure (BP)>/=140 mmHg, diastolic BP>/=90 mmHg or patients were taking antihypertensive medication], the sensitivity and specificity were 0. 75 and 0.92, respectively (P=0.001). CONCLUSION: Visceral fat obesity is a risk factor for PE after gynecologic surgery, and the AFI is useful for predicting PE and for whom post-operative low-dose heparin therapy may be indicated.

[Anesthetic management of two patients with polymyositis].

We report anesthetic experience of two patients suffering from polymyositis. The first case is a 56 year old woman who underwent tympanoplasty for cholesteatoma of the middle ear. Anesthesia was induced with thiopental and deepened with oxygen-nitrous oxide and sevoflurane. No muscle relaxant was used for endotracheal intubation and for maintaining anesthesia. Another is a 61 year old man who underwent open reduction and internal fixation for condyle fracture of the tibia. Epidural catheter was inserted at L 3-L 4. Epidural blockade was established with 2% mepivacaine, and sedation was achieved by intravenous midazolam. Concerning the anesthetic management of a patient with polymyositis, there are some informations on the appropriate use of muscle relaxants. It is generally believed that the patient is sensitive to nondepolarizing muscle relaxants and the use of antagonist drug (reversal) may cause muscle weakness, severe dysrhythmia, et al. Therefore we think it is appropriate to manage such a patient without muscle relaxants.

Comparison of predictive value for colorectal cancer in subjects with and without rectal bleeding.

BACKGROUND/AIMS: To clarify the association between a sign of rectal bleeding and colorectal cancer, and to reveal the relationship of rectal bleeding to the results of an immunochemical fecal occult blood test. METHODOLOGY: In a population-based cross sectional study, 30,138 subjects who received immunochemical fecal occult blood screening with a 2-day method were divided into two groups, according to the results of a questionnaire on a sign of rectal bleeding, and the positivity rate of an immunochemical occult blood test as well as the predictive value for colorectal cancer were compared in the two groups. RESULTS: The fecal occult blood test was positive in 8.8% of subjects with rectal bleeding and in 6.0% of subjects without rectal bleeding, and the predictive value was 6.4% and 3.3% in subjects with and without rectal bleeding, respectively, showing a significant difference in the positivity rate (p<0.001) as well as the predictive value (p<0.05) between these two groups. CONCLUSIONS: These findings indicate that there are positive relations between the subjects with rectal bleeding presentation and colorectal cancer, and a sign of rectal bleeding and the results of an immunochemical fecal occult blood test.

[Anesthetic management of a patient with Osler-Weber-Randu disease].

Osler-Weber-Randu disease (Osler disease) is an autosomal dominant disease, sometimes known as hereditary hemorrhagic telangiectasia with its family history. It is not a popular disease and approximately seventy families are known as inheritance lineage in Japan. We experienced anesthetic management of a 49-yr-old woman with Osler disease. She was diagnosed to have the brain abscess following fever and clouding of consciousness for several days and was scheduled for the removal of the abscess. A chest X-ray revealed pulmonary arteriovenous fistula in the right middle lung field. The patient had had life threatening frequent massive bleeding from her nose and/or stomach for the past several years. Her brother and children also had the same symptoms. In addition to Osler disease, the patient had the prolonged coagulation time that was supposed to the due to chronic liver disease. Therefore, fresh frozen plasma (5 units) and platelet concentrates (10 units) were infused during the surgery. Intraoperative blood loss was about 700 grams. We had no difficulties in management of bleeding and respiratory controls during anesthesia.

[The effect of epidural anesthesia on reducing blood loss during upper abdominal surgery].

We examined the advantage of the combined epidural anesthesia with general anesthesia for the upper abdominal surgery One hundred and thirty-five gastric cancer patients were subjected to the study. They were divided into four groups. Group A (n = 46) and B (n = 44) received distal gastrectomy, and group C (n = 27) and D (n = 18) received total gastrectomy. In group A and C, anesthesia was maintained with combined epidural and general anesthesia. In group B and D, only general anesthesia was administered. We compared group A versus B and groups C versus D. The parameters for the comparisons were intraoperative blood loss, averaged mean blood pressure, surgical operation time, etc. The patient background was not different between group A and B, and also between group C and D. The blood loss and mean blood pressure were significantly lower in groups A and C than in groups B and D. But there was no correlation between the blood loss and mean blood pressure. The results suggest that the fall of the mean blood pressure is one of the causes of reduced blood loss, but the causes may include other complicated parameters. We conclude that the combined use of epidural anesthesia with general anesthesia is useful for reducing the amount of blood loss for upper abdominal surgery.