To investigate the early stage of peripheral circulatory disturbances, we measured systolic blood pressure (SBP) at arm and peak forward blood flow velocity (PFV) from radial artery (RA) and dorsalis pedis artery (DA) in senile patients (22 hypertension, 4 hyperlipidemia, 3 cerebral apoplexy and 7 others; 70-99 Years, n=36) and healthy volunteers (21-56 years, n=18) with ultrasonic Doppler velocity meter. Subgroup consisted of some senile patients' limbs whose PFV from an artery was 20% less or more less than the PFV from the contralateral artery. 58.3% of senile patients had those limbs of the subgroup. PFV (cm·sec^-1) from RA and DA of the subgroup (RA, 19.0±5.1; DA, 19.0±5.1) were lower than those in normal control group (RA, 23.0±4.2; DA, 25.8±7.9) (p<0.05). Conductance index (CoI =PFV/SBP, cm·sec^-1·mmHg^-1) from RA and DA of the subgroup (RA, 0.13±0.04; DA, 0.11±0.07) were lower than those in normal control group (RA, 0.19±0.03; DA, 0.21±0.07) (p<0.001). CoI from RA and DA of all senile patients (RA, 0.17±0.06; DA, 0.17±0.08) were also lower than those in normal control group (p<0.05). These results suggest that: (1) PFV and CoI are useful indices to evaluate disturbances of peripheral circulation, (2) Col is a more sensitive index to detect disturbances of peripheral circulation than PFV alone, (3) a relatively large number of senile patients had disturbances of peripheral circulation in upper limbs as well as in lower limbs.

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The relation between prognosis of bronchial asthma in children and other allergic complication, change of laboratory data were investigated in this study.
The following results were obtained.
1. There was a no correlation between allergic familliar history, age at onset and prognosis of bronchial asthma in children.
2. There was a definite correlation between severity of asthma at the initial visit to our hospital, other allergic complication, number of positive IgE RAST and prognosis of bronchial asthma in children.
3. The number of peripheral blood eosinophil counts decreased on remission groups after 10 years.
4. There was no significant changes of serum total IgE levels during over the 10 years on remission groups and unremission groups.
5. Respiratory threshold of acetylcholine (RT-Ach) in the remission groups after 10 years was increased than that in the unremission groups.
These results demonstrate that it is necessary to examine the number of peripheral blood eosinophils and RT-Ach on the evaluation of prognosis of bronchial asthma in children.

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From January 1982 to September 1993, 27 patients with hepatic metastases from colorectal carcinoma underwent hepatic resection at Nagasaki Chuo National Hospital.
Hepatic resection of these 27 patients consisted of 5 right hepatectomies, two left lobectomies, 4 left lateral segmentectomies, 4 mono- or di-segmentectomies, and twelve subsegmentectomies and/or partial resections. Hepatic metastases were H-1 in 19 patients and H-2, 3 in 8.
After hepatic resection, five-year survival rate of H-1 patients (30.5%) was siginificantly higher than that of H-2, 3 patients (0%) (p<0.05). There were no significant differences in site of colorectal carcinoma, size of largest tumor, temporal relation, histological type and DNA ploidy pattern of parimary and metastatic lesion in five-year survival rate. Of these 27 patients, 5 survived for more than 3 years. In these 5 patients, the metastases were metachronous in 2 and synchronous in 3, the primary lesions were located in sigmoid colon in 4 and rectum in 1, and the degree of metastases were H-1 in all 5. The DNA ploidy pattern of metastatic lesion was diploid pattern (D) in 3 and aneuplod pattern (A) in 2, and that of the primary lesion was D in 2 and A in 2. Two of the 5 patients received hepatic re-resection for re-recurrence. All patients who did not undergo hepatic resection for the metastatic lesions died within 3 years.
From these observations, the prognosis of hepatic resection for metastatic colorectal carcinoma with H-1 is considered to be favorable, and aggressive hepatic resection is recommended

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Laparoscopic cholecystectomy (LC) has become an accepted standard operation for gallstone in the world. On the other hand, complications accompanied by bile duct injuries were recently reported with extended indication of the LC. Intraoperative cholangiogram is essential for the safe LC to minimize the risk of bile duct injury. The disadvantages of intraoperative cholangiogram include increased operating time and the possibility of bile duct injury by its use, because of the difficulty of the maneuver.
We have achieved a method for real-time fluoroscopic cholangiogram by using a new instrument which was made by us. It is a kind of sheath by which firstly a round-tip stylet is inserted to coax gently through the spiral valves of the cystic duct. Secondly, this stylet is removed and the cholangiogram catheter is smoothly inserted. Digital Carm fluoroscopy provides “real-time” imaging of the biliary tree. As a result, we can now get a clear cholangiogram easily in a short time. In the first 86 patients, direct cholangiogram were attempted in 59 cases and were successfully completed in 55 cases (93.2%).
Now, we are able to cope with bile duct injuries and anomalies, and unsuspected bile duct stone, owing to our method of real-time fluoroscopic intraoperative direct cholangiogram.

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Seventy-three patients with stage III ovarian cancer (1968-1992) were studied with respect to operation, chemotherapy, histology and prognosis. First operation was performed for all cases. For the 26 cases (36.6%), complete tumor reduction was possible (group A-1). Incomplete operation was performed for 25 cases (residual tumor: 6 cases<2 cm, 19 cases>2cm) and probe laparotomy was applied for the other 22 cases (30.1% group B). After the first operation, for 66 cases (90.4%), following chemotherapy was performed. Except for the probe laparotomy cases, adjuvant chemotherapy with mainly FAMT or FAMX (majority was the patients before 1986) was applied. Among them, five-year survival of the group A-1 (with a complete tumor reduction by the first operation, followed by adjuvant chemotherapy) was 33.8%. On the other hand, for the 17 probe laparotomy cases of the group B, chemotherapy with CAP or CP as a neoadjuvant chemotherapy was applied (majority was patients after 1986). The other 5 cases of the probe laparotomy died soon after the first operation. As a result, for the 9 cases (40.9%) out of the 22, neoadjuvant chemotherapy was carried out. Five-year survival of the 9 cases was 88.9%. Histology of the 9 cases, 7 were serous cystadenocarcinoma and the other 2 were endmetrioid adenocarcinoma. Present data suggest that complete tumor resection was essential for the advanced ovarian cancer regardless of the first or second operation. For the cases of probe laparotomy with serous cystadenocarcinoma or endmetrioid adenocarcinoma, neoadjuvant chemotherapy should be tried expecting the second operation for complete tumor reduction.

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We modified the transseptal surgery and employed this method to the pituitary adenomas (10 cases), tumor on the posterior portion of the septum (1 case) and sphenoid sinuitis (1 case). Operative procedures were described as follows: a mucosal incision was made on the right side of the septum as posteriorly as possible and from there mucosal separations were performed along both sides of the septum and then speculum was introduced from the pyriform aperture in the right side. The advantages of the technique were easiness to perform, reduction of bleeding and shortening of the operating time owing to keeping the anterior portions of the septum intact. Insertion of the speculum from the unilateral pyriform aperture allowed opening of the speculum widely enough and midline access to the sphenoid sinus. Nasal complications were not noted. These procedures are useful for the extracranial approach to the pituitary gland and the microsurgery for the posterior portions of the septum, epipharynx and sphenoid sinus.

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Interventional radiology (IVR) is established treatment of choice for the management of patients with selected diseases by means of radiological procedures, which are less invasive to patients.
Various problems in clinical practice of IVR were enlightend in this symposium. Some of the important issues included the re-evaluation of palliative indication of IVR for oncology patients, the approach to improve curative rate by means of IVR, the concept and role of IVR in multidisciplinary treatment, the importance of communication and coordination with nurses and patients' family to maintain and improve quality of life of patients who are discharged but still need to keep a catheter placed after discharge, and the availability of catheters and supporting equipment in the hospital along with no or less restriction of purchase of the expensive catheter and equipment.
Then, each panelist focused on the details of IVR based on three anaatomical sites, including head and neck, thorax, and abdomen, respectively, with emphasis on the technical aspects and the patients care. In the abdominal session, non-vascular and vascular IVR were separately discussed.
Through this symposium, we are convinced of that IVR is of clinical and practical value for the delivery of the medical care.

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Twenty-seven patients diagnosed as atypical mycobacterial disease in our hospital were studied clinicaly. 1) There were 19 male (average age was 59.9 years) and 8 female (57.5 years) cases. 2) M. avium, M. intracellulare, M. kansasii, M. f ortuitum and M. chelonae was observed in 13, 4, 4, 3 and 3 patients respectively. 3) Cases with primary infection type were 9 and cases with secondary infection type were 18. Pulmonary tuber-culosis was most frequent in primary pulmonary disease of secondary infection type. 4) Cases with cavity were 17 and cases without cavity were 10 on roentgenogram. 5) M. kansasii was relatively well sensitive to anti-tuberculous agents, but other atypical myco-bacterias were completely or incompletely resistant. 5) M. kansasii showed high disap-perance rate of bacilli, but M. avium and M. intracellulare showed low disapperance rate.

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A case of anaerobic cellulitis accompanied by gas-containing abscess and complicated by rhabdomyolysis is reported. A 60-year old woman came to our hospital because of fever and pain and swelling of her right great toe of 3 days duration and was admitted for evaluation and treatment. A diagnosis of diabetes mellitus had been made 6 years be-fore, and the patient had been treated with insulin at a general practitioner's clinic. She had removed a corn from her right great toe 5 days before. On admission, she had a fever of 39C and her great toe was red and swollen. Leukocytosis and an elevated serum CRP level were noted. Intravenous antibiotics were started, however, her fever persisted, and the redness spread to her foot, and the swelling extended to her leg. An ulcer developed at the site of the corn, and purulent discharge was noted. On the 7th hospital day, increased serum levels of CPK and myoglobin were found. On the 10th hospital day, gas was observed on the X-ray films of her leg, and emergency surgery was performed. A large amount of gas-containing pus was drained from her leg. There was extensive necrosis of the subcutaneous tissue, but the muscle fascia seemed to be intact. Peptostreptococcus was cultured from the pus. Postoperatively the patient's fever resolved, and her elevated CPK and myoglobin levels became normal.

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Pyogenic granuloma arises from the connective tissue of the skin or mucous mem-branes. The oral mucosa is one of its most common sites.
We examined the clinical features of pyogenic granuloma of the oral cavity in 11 pa-tients in our department during the past 15 years.
Clinically, the patients ranged in age from 18 to 72 years, and the pyogenic granulo-ma was most frequent in patients from 50 to 69 years old. The lesion was slightly prevalent in males (54. 5%) than in females. The locations of the lesion were most fre-quent in tongue (36. 4%) and palate (27. 3%), and the remainder involved gingiva, lip, buccal mucosa. The duration from the first episode to the time of admission was from one week to five years, and was about 8.2 monfhs on the average.

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We discussed the long-term management of patients with Crohn's disease in childhood based on the clinical course of three patients treated with pharmacotherapy and elemen-tal diet.
In order to keep their quality of life (QOL) in higher level, early diagnosis and ear-ly treatment should be done as a part of pediatric primary care. Therefore, pediatricians have to rule out Crohn's disease on the clinical evaluation of patients with common symptoms, such as fever, abdominal pain and chronic diarrhea.

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Five patients of uterine cervical cancer (stage IIb) underwent intraarterial injection of combination drugs (CDDP 70-80mg, ADM or Epi-ADM 40-50mg, MMC 20mg, 5-FU 500mg) for two times before the operarion or the radiation therapy (as neoadjuvant chemotherapy).
Tumor size and cancer invasion were reduced, and also the value of abnormal tumor marker declined to normal level in all patients as a result.
These results suggest that intraarterial injection of the combination drugs as neoadjuvant chemotherapy may be able to make succeeding operation or radiation more curative and lead better prognosis.

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We report two cases with features of both myasthenia gravis (MG) and Lamhert-Eaton myasthenic syndrome (LEMS), and discuss pathogenesis of neuro-muscular junctions.
Results: (1) In both cases, an antiacetylcholine receptor antibody was positive and antivoltage-gated calcium channel antibody was negative. (2) Iu both cases, repetitive nerve stimulation test showed typical electrophysiological features of LEMS. (3) In case 1, ultrastructual study of motor-end plate revealed decrease of alpha-BTX binding site, widening of primary and secondary synaptic clefts and decrease of junctional folds. In case 2, ultrastructual study of motor-end plate revealed no changes. (4) In both cases, the efficacy of anticholinesterase inhibitors (A-ChE Is) was the same as that of 3, 4-di/4-aminopyridine. (5) In both cases, plasma exchange was effective. (6) Thymectomy was not effective in case 1, however the resection of mediastinal tumor resulted in favorable effects on the myasthenic symptoms in case 2.
Conclusions: Common pathogenesis between LEMS and MG is suggested by the effects of A-ChE Is, plasma exchange and resection of mediastinal tumor. Furthermore, in the neuro-muscular transmission abnormality in case 1, involvement of presynaptic acetylcholine receptors which regulats release of Ach is suggested by therapeutic results with A-ChE Is. In case 2, autoimmune LEMS is suggested by clinical features and the ultrastructual study of motor-end plate.

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Outpatient clinic program for the severely handicapped individuals living at home was started in April, 1991 at our hospital. Fourteen individuals, age between 2 and 24 years have continued to participate in this program. The purpose of this outpatient clinic program was to assess and accept ea h individual as they were, and their family dynamics. Furthermore, the main purpose was to encourage what each patient was able to do and enjoyed. This resulted in inducing more positive views and attitudes from the parents. The parents showed more interest to their handicapped children and more interactions between the parents and children were seen. The intervention of this outpatient clinic program was a success in this respect, but further follow-up is needed.

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We made the preoperative planning for pelvic osteotomy using stereolithography besides the 3-DCT. The subject cases were five, all women, of which one case has undergone Pemberton's operation, three rotational acetabular osteotomy, and one rotational acetabular osteotomy combined with advancement of greater trochanter.
The advantage of the simulation with 3-DCT was the possibility of processing the images in various ways and times. On the other hand, the stereolithography was incomparably good in its solid sense. The easiness to understand the anatomy and the sense of security during the operation were exceptional. The preoperative planning to combine 3-DCT with stereolithography has many cumbersome procedures, but we would like to emphasize that if it is used for a complementary, purpose, its merits can further be amplified and that though not a surgical simulation in the strict sense of the words, this method has reached a fully practical stage as a surgical navigation.

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