We measured the serum tissue polypeptide antigen (TPA) level in 148 patients with cancer of digestive organs, and in 174 patients with benign diseases of the same organs. The positive rate of TPA in patients with cancer was as follows: esophageal cancer 75.0% (6/8), gastric cancer 65.5% (38/58), colorectal cancer 76.5% (26/34), hepatocellular-carcinoma 80.0% (16/20), cancer of the biliary tract 81.8% (9/11), and pancreatic cancer 82.4% (14/17). The positive rate of TPA in each of these was higher than that of CEA and ferritin. The serum TPA levels increased in patients with liver metastasis from gastric cancer or colorectal cancer. The positive rate of TPA in patients with benign diseases of the digestive organs was as follows: gastroduodenal ulcer 46.7% (28/60), liver cirrhosis 50.0% (20/40), cholelithiasis 49.2% (31/63), and chronic pancreatitis 54.5% (6/11). AFP was found to be better than TPA in diagnosing hepatocellular carcinoma. Since the positive rate of TPA in patients with an elevated serum CEA level was high, combination assay using TPA and CEA was useful. The results confirm that although the specificity of TPA is low, it is useful for the diagnosis of cancer of the digestive organs except for hepatocellular carcinoma.

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Four cases of multiple primary carcinoma of the esophagus associated with dysplasia were found among seven patients with squamous cell carcinoma of the hypopharynx who received total esophagectomy with pharyngolaryngectomy at the Shikoku National Cancer Center Hospital. Two cases of minute carcinoma were observed in these cases. One of them appeared too small to detect clinically despite the application of esophagoscopy with the Lugol's solution spraying emthod. Since all four patients had a long history of smoking and drinking, smoking and drinking seemed to have very much to do with the carcinogenesis. These findings suggest that total esophagectomy is applicable to patients with hypopharyngeal cancer, particularly to those who continue to drink and smoke regularly.

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In 1951, Hunt devised a new method of reconstruction after total gastrectomy by combining Steinberg's pantaloon procedure with Roux-Y procedure. In this method, after the stomach is removed and the duodenal stump is closed, the jejunum is divided between clamps about 30 to 35 cm below the ligament of Treitz. The distal limb of the jejunum is brought up anterior to the colon, and the end is doubled back upon itself in a side-to-side manner for about 15cm. The sides of these loops are sutured together, an anastomosis with a full-length stoma is made, and the transacted end of the jejunum is incorporated in the anastomosis. This forms a large pouch, which is then anastomosed to the esophagus by interrupted suture.
After that, Kalemba, with his procedure modified by the introduction of the technique of fundoplication, obtained favorable results. We tried to perform Hunt's reconstruction in 34 patients, and conducted Kalemba's procedure in 17 patients.
The following operative results were obtained. There were no operative deaths, although three patients died during hospitalization (late death), postoperative complication included leakage of the anastomosis in four patients and intraperitoneal abscess in five patients, all of which, however, were cured by conservative treatment.
Reflux esophagitis occurred in two patients, one of whom required surgical procedure for stricture of the anastomosis. These two patients underwent the original procedure of Hunt. The modified Kalemba procedure did not induce reflex esophagitis.
The patients who lived for a longer period were relatively well nourished, but some of them developed vitamin B₁₂ deficiency within a long-term follow-up period. Therefore, it was necessary to give vitamin B₁₂ in these patients.
The overall cumulative 5-year-survival rate in the patients receiving the above procedures was 34.9 percent. Although this procedure of reconstruction needs complicated procedure, the application of an autosuture instrument solved the problem. Thus, this procedure is considered useful for such patients.

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It is very important to detect recurrent colorectal cancer after resection of the primary focus, since it has been reported that the survival rate of the recurrent cases increase with the appropriate treatment of recurrent tumor including surgical resection according to the extent of recurrence.
One hundred and thirty-one patients with previously untreated carcinoma of the large bowel were retrospectively evaluated about recurrences in order to find out the most appropriate follow-up schedule. The operations for these patients were curative or relatively non-curative and they were performed between 1982 and 1984. They were followed up carefully until the end of 1986. Twenty patients (15.3%) of these had recurrences and 85% of these recurrences occurred within the first 2 years after the primary resection. The sites of recurrences were liver in 40% of the cases, followed by lung in 30%, lymph node in 30% and local perineum in 20%. Fifty-five percent of the 20 recurrent patients was asymptomatic when the tumor was detected. Recurrent foci of the disease were found on routine chest x-ray examination and blood analysis as well as CEA level in serum.
Thus, we recommend the follow-up schedule as follows; Serial CEA determinations are recommended once a month for the first postoperative year and every 3 months after one year and every 6 months after 2 years, and chest x-ray and ultrasonic examinations should also be performed every 6 months. Whether specific symptoms may exist or not, these follow-up plans must be routinely executed.

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The prognosis of patients with colonic perforation is poor, because they often develop sepsis. We analysed seventeen cases of colonic perforation associated with sepsis and the following results were obtained.
1. Septic shock and multiple organ failure (MOF) followed by sepsis were the main causes of the death in the patients with colonic perforation.
2. The patients over 70 years of age more often developed sepsis and MOF, although a primary operation was successfully done immediately after the perforation.
3. Laboratory data at the early postoperative period already showed signs of multiple organ insufficiencies in the septic patients.
4. Leucopenia in the early postoperative period was an important sign of high mortality in the septic patients after the colonic perforation.
In conclusion, systemic care of the patients and aggressive antiseptic therapy are important as well as an early diagnosis of perforation and an adequate operation.

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Rectal carcinoid is a relatively rare disease. We report a case of rectal carcinoid in which two years' follow-up by colonofiberscopic examination (CF) was possible.
This 37-year-old female patient visited a clinic in Feb. '83 because of ileocecalgia. The CF in May '83 revealed an unclearly edged polyp in the rectum. The CF a year later (Apr. '84) showed the polyp with more clear edge. The edge of the polyp became demarcated on the findings of CF in Mar. '85 (two years later). The patient underwent a biopsy for the first time and it revealed a carcinoid disease. Although she was scheduled to have endoscopic polypectomy, she underwent a pen-anal extirpation of the tumor in May '85 because she developed a severe attack of gallstone disease and cholecystectomy was required. Her postoperative course was uneventful.
We report this case because we can not find a similar case of this disease with endoscopic follow-up of a rather longer period (two years).

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A low birth-weight infant who weighed 1, 300gm at birth (gestational age: 30w) was referred for severe abdominal distension. A radiograph of abdomen revealed massive free air in the abdominal cavity. Immediate laparotomy showed the inflamed terminal ileum with single perforation and multiple ballooning-out lesions. Exteriorization of perforated site and double barreled ileostomy were performed. Postoperatively she needed respiratory and nutritional support. Eighteen days later, closure of ileostoma was done successfully.
Several factors contributed to such good result in this case are discussed.

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A 13-year-old girl was admitted to our sanatorium with chief complaints of loss of appetite and emaciation. She had headache, abdominal pain, diarrhea and loss of appetite one month before her admission. But on her admission, diarrhea and abdominal pain had been already cured.
A tentative diagnosis of anorexia nervosa was made, because she had severe emaciation, refusal to eat, amenorrhea, and abnormal endocrinological findings.
Then, we started the behaviour therapy of anorexia nervosa. But several weeks later, she developed bloody stool and abdominal pain. Air contrast barium enema was done, the roentgenographic findings were minute ulcerations along the edge of the colon. Based on this, correct diagnosis of ulcerative colitis was made.
We think that ulcerative colitis is an important differential diagnosis, when we see clinical manifestations of anorexia nervosa such as loss of appetite or emaciation.

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From 1974 to 1985, 19 patients (10 families) with familial adenomatosis coli (FAC) were treated at Osaka National Hospital. At the time of initial diagnosis, 7/9 (78%) of the untreated patients with FAC already had cancer, but only 1/10(10%) of their relatives with FAC had cancer.
Ten patients not developing rectal cancer underwent subtotal colectomy and ileorectal anastomosis at a higher level. In these patients bowel movement was normal. But 2 patients without a careful follow-up developed cancer in the remained rectum.

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Small pieces of fish bones are usually digested and excreted without damaging gastrointestinal tract, but sometimes small bones will stick to the pharynx and the esophagus.
The authors report a case of perforative peritonitis due to a fish bone. A 72-year-old male with lower abdominal pain was referred to our surgical department. He underwent an emergency operation with a diagnosis of perforative peritonitis by physical examination, preoperative laboratory data and abdominal x-ray findings.
At operation the ileum was perforated by a curved fish bone which measured 4.5cm×0.4cm.

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Primary malignant lymphoma of the stomach is relatively uncommon. We recently experienced two cases of malignant lymphoma in which a giant filling defect was found by x-ray examination of the stomach. The preoperative diagnosis by x-ray and endoscopic findings was gastric cancer, but no tumor cells were found by biopsy. Total gastrectomy was then performed in two cases. Pathological examination of the excised specimens revealed malignant lymphoma. Case 1 died 5 months after operation and case 2 has been alive for 4 years on cancer chemotherapy.

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We encountered a case of gastrointestinal malignant lymphoma with obstructive jaundice as an initial sign. At first, we diagnosed this case as a malignant lymphoma of duodenal papillary region. But at laparotomy, multiple malignant lymphomas were seen not only in the duodenum but also in the stomach, jejunum and ileum. By palliative operation, subjective symptoms were improved for a while. In spite of chemotherapy, multiple malignant lymphomas developed in oral cavity and subcutaneous tissue. This patient died about six months after the appearance of the initial symptom.

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Adjuvant cancer chemotherapy after gastric surgery is a routine therapeutic modality in recent years. However, postoperative bolus injections of a large amount of anticancer drugs sometimes bring severe side effects.
In this paper, two cases are presented who died of severe myelotoxity of Mitomycin-C (MMC) used as a postoperative adjuvant chemotherapy.
Case I … A 68-year-old male visited our hospital with a large Borrmann type III cancer in the cardiac region of the stomach. As a postoperative adjuvant chemotherapy, a bolus injection of MMC 14mg was performed on the day of the operation and on the 28th postoperative day. Oral administration of Tegafur 600mg/day was also started on the 14th postoperative day. The patient was discharged on the 28th postoperative day in good condition. However, on the 11th days after the discharge, he was readmitted with general malaises and severe dehydration. Despite the intensive care, he died within only three days from the readmission. Findings of severe myelotoxities were observed on the laboratory data at that time.
Case II … A 66-year-old male was admitted with a Borrmann type-III carcinoma in the antral region of the stomach. After the distal partial gastrectomy, a bolus injection of MMC 10mg and subcutaneous injection of OK 432 (0.5 KE every other day, total dose 3.0 KE) were performed as an adjuvant immunochemotherapy. The postoperative course was uneventful, but on the 14th postoperative day, the patient suddenly developed high fever, exanthemas of extremities and bleeding tendencies. Despite the intensive care, the bleeding tendency progressed and multiple organ failures (MOF) occurred. The patient died on the 22nd postoperative day. A postmortem examination reveald marked hypoplastic bone marrows and an increase in histiocytes with phagocytosed red blood cells. Concerning to the clinical course and the findings of postmortem examination, a virus-associated hemophagocytic syndrome which followed the myelotoxity of MMC, has been most considerable as the direct cause of the death.
The postoperative adjuvant cancer chemotherapy is well known as an effective therapeutic method for gastric cancer but clinicians should be aware of its side effects and a careful attention is most recommended.

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Cure of esophageal carcinoma by irradiation is difficult and long-term survival rates are not yet satisfactory. A total of 119 patients with esophageal carcinoma were treated by external radiotherapy at Kumamoto National Hospital from 1968 to 1985.
Forty-eight patients (40%) were irradiated curatively with doses of more than 50 Gy and 40 patients (34%) were irradiated palliatively. Thirty-one patients (26%) were treated with irradiation and surgery; 16 patients of them were treated by pre- and post-operative irradiation, 13 of them were treated by preoperative irradiation only and 2 of them were treated by postoperative irradiation. Double primary malignancy were observed in 7 cases (6%) during the course.
Cumulative survival rate of curatively irradiated patients were 27% for 1 year, 6% for 2 years, and 6% for 5 years. Cumulativesurvival rate of combined treatment with surgery were 52% for 1 year, 14% for 2 years, 7% for 3 years, and 7% for 5 years. Fifty percent survival period in curatively irradiated patients was 7 months, but it was 13 months when the length of tumor was less than 5cm. In our series, there were no differences in long-term survival between curatively irradiated patients and combined treatment with surgery.
In the area of radiotherapy, an effort to improve irradiation method has been remarkable, but the importance of combined treatment of surgery, chemotherapy, and irradiation should be emphasized for esophageal carcinoma.

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Among 75 severe handicapped children, 14 cases were diagnosed to have occult blood in their stools. These 14 cases were examined by barium esophagogram. Four of the 14 cases had hiatal hernia, 3 had gastroesophageal reflux (GER), 2 had both hiatal hernia and GER, and 5 had no particular findings. Among these 14 cases only one case was able to sit down while the rest were just lying on the beds. In 5 of 6 cases who had hiatal hernia were accompanied by scoliosis.
Three cases of hiatal hernia, 2 of hiatal hernia and GER (group C), 4 of severely handicapped children without hiatal hernia or GER (group B) and 5 healthy adults (group A), were given test meal to stimulate gastrin secretion. Venous blood was taken for measuring serum gastrin value 15 minutes before ingestion of the test meal, and thereafter, serum was taken every 15 minutes for one hour. The gastrin value before ingestion of the test meal were 106pg/ml in, group A 87 in, B and 89 in C. There were no significant differences among three groups. Integrated gastrin responses were 6.7±4.9min, pg/ml (mean±SD) in A, 6.0±5.2 in B, and 2.6±2.1 in C. Relatively low values were obtained in patients with hiatal hernia. We thought that hiatal hernia in severely handicapped childen was caused mainly by distortion of esophago-gastric junction by scoliosis. The cause of low integrated gastrin response in patients with hiatal hernia was unclear. However it might be an etiological factor of hiatal hernia or a result of hiatal hernia.

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Spontaneous bacterial peritonitis is not a rare complicaton in cirrhotic patients with ascites. The condition carries a high mortality. This is a report of spontaneous bacterial peritonitis because of nephrotic syndrome in a compensated cirrhotic patient. A percutaneous renal biopsy specimen obtained in April 1983 consisted of hepatic glomerular sclerosis.
A 56-year-old man was admitted to our hospital on December 15 1984 complaining of severe edema. Laboratory data on admission revealed severe nephrotic syndrome, renal insufficiency and liver dysfunction. On the 3rd hospital day, the patient suddenly, developed a high fever with chills and abdomen was protuberant with diffuse tenderness. Abdominal paracentesis showed transdative ascites which contained many neutrophils, culture of ascites fluid grew Pneumococcus. The patient was treated with a large dose of Ampicillin and peritonitis was improved rapidly. Despite apparent clearing of peritonitis, the patient developed incresing renal failure and regular hemodialysis was started. The pathological features of renal biopsy and review of the literature are also discussed.

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A 48-year-old male was admitted to our hospital in July 1983 for hematemesis and melena. At the time of his hospitalization, anemia, ascites and jaundice were found. Emergency endoscopy revealed esophageal varices (Lm C_B F₃ RC (++)) without any active bleeding. Because of his decompensated liver cirrhosis (Child C), elective endoscopic injection sclerotherapy (EIS) for esophageal varices was indicated and performed on October 4 1983, by intravariceal injection method utilizing 50% glucose, bovine thrombin and 1% Aethoxysclerol. Additional treatment of EIS was performed on December 7, 1983 and February 9, 1984. When bovine thrombin was injected at the 3rd EIS, he develeoped shock with TIA-like symptoms. Soon after, he recovered, but mild dysarthria remained and left truncal ataxia appeared in the next morning. Brain CT scans indicated the existence of isodensity mass and peritumoral low density area in the left cerebellar hemisphere. Cerebral angiography revealed avascular mass in the left cerebellar hemisphere. Because of intracranial hypertension, left suboccipital osteoclastic craniectomy, partial resection of the mass and external decompression were performed on February 29, 1984. Histological diagnosis was cerebellar hemorrhagic infarction. On the other hand, his esophageal varices disappeared and no Red-Colour sign was seen after the 3rd EIS. Now, 2 years and 5 months have passed since the 3rd EIS, and no evidences of recurrence of esophageal varices and Red-Colour sign have been noted throughout his course. Furthermore, post-EIS improvement of liver function tests was found in this case. EIS is a very effective treatment for esophageal varices, however, the best precaution should be taken to avoid hazardous complications such as cerebellar infarction.

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