The clinical features of esophageal achalasia are the abscence of peristalsis in the body of the esophagus and relaxation in the gastro-esophageal sphincter.
The pathogenesis of achalasia is still unknown. The treatment of choice for achalasia is also controversial. The mortality and the morbidity of the operation and the dilatation for achalasia are reviewed from literatures. The necessity of Heller's myotomy combined with or without anti-ref lux procedure is also discussed from a view point of post-operative reflux esophagitis.

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We investigated the prevalence of developmental disorders in very low birth weight infants, their risk factors during the neonatal period, and the correlation between their neurological symptoms and their MRI findings. Seventy-three infants, who were followed up for more than 5 years in the developmental clinic, were enrolled. The developmental disorders included 6 patients with CP (cerebral palsy) and 6 paietnts with MR (mental retardation). The types of CP were as follows: spastic diplegia (3), spastic quadriplegia (2), athetotic quadriplegia (1). IVH (intraventricular hemorrhage) and MV (mechanical ventilation) were significant risk factors for CP and MR and retinopathy was also a significant risk factor for MR. Periventicular areas of bright signal intensity on T2 (TR 2000 msec/TE 120 mse) weighted images, compatible with old, small white matter infarcts, gliosis or demyelination, were observed in only three of the seven patients. We measured the width of anterior horns, the maximum diameter of cerebrum, and the minimum thickness of white matter in occipital lobe on T1 (TR 500 msec/TE 20 msec) weighted transaxial images in eight patients (five patients with CP, three patients with MR).
The maximum diameters of cerebrums and the minimum thickness of white matters were significantly smaller in patients with CP or MR than those in controls, respectively. The DQ of patients significantly correlated with the maximum diameters of cerebrums and the minimum thickness of white matters in left occipital lobe significantly correlated with DQ.

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Although ventriculo-peritoneal shunt (V-P shunt) is a most common operative method for hydrocephalus, shunt malfunction due to obstruction of peritoneal tube are frequently experienced.
In this study, we conducted insertion of peritoneal tube into abdominal cavity under a guidance of the laparoscopy to evaluate its efficacy in 8 patients of hydrocephalus. Six of eight patients showed shunt malfunction of peritoneal tube in the abdominal cavity and have received repeated revision of peritoneal tube before this procedure.
Unlike the conventional method, our laparoscope-assisted method ensured tube insertion into the target site, minimized the abdominal wound, and reduced postoperative adhesion. This method also made it possible to differentiate shunt failure-induced abdominal pain from pains due to other diseases, including appendicitis, and easily to withdraw migrated peritoneal tube from abdominal cavity due to disconnection.
These results indicate that the new technique of V-P shunt under a guidance of laparoscopy is very useful and promising for a wide use, although the preoperative laparoscopic preparation is rather complicated.

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Evaluation of various factors affecting postoperative pyuria is based on 341 prostatectomies perfomed at Atami National Hospital during the five years between 1988 and 1992
The following ten factors were considered-surgical method, age of the patients, preoperative urinary tract infection, preoperative urinary condition, preoperative use of indwelling catheter, preoperative complications, weight of resected prostatic tissue, length of TUR-P, postoperative pyrexia and postoperative complications.
The average duration of postoperative pyuria was 84.2 days after open prostatectomy and 74.6 days after TUR-P.
Among the ten factors considered, age, preoperative urinary tract infection, weight of resected prostatic tissue, duration of TUR-P and postoperative complications influenced the normalization of postoperative pyuria.
As a result, it is necessary to prevent postoperative complications and important to administer appropriate antibiotics and maintain sterilized environments when using catheters.

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Between September 1991 and April 1993, adverse effects were evaluated and treated in 7 patients with bone and soft tissue sarcoma (3 males and 4 females, 7 years through 29 years of age with an average age of 18.7, and performance status 1 or 2), who received a total of 95 cycles of chemotherapy mainly consisting of T-12, CESS 81, CESS 86 or MAID regimen. Leukopenia less than 2, 000/μ1 occurred in 56.9% of cycles and a relative correlation between the seventies of leukopenia and grades of fever was observed. Against this background, 2 septicemias were proven. Of 62 courses of rhG-CSF, 80.6% was effective in normalizing the recovery of WBC with mild and transient adverse effects. Anemia less than 8 g/dl in 4 cycles of chemotherapy and thrombocytopenia less than 7×10⁴/μ1 in 10 cycles were recognized. Further study of more effective ways to administer granisetron will be considered, since granisetron, having no major adverse effects, was not sufficiently protective against emesis considering that 22.1% of emesis required treatment. Mesna was very useful for protection against hemorrhagic cystitis, resulting in only 4 mild microscopic hematurias (40%), although glycosuria and ketonuria were detected after a combination of ifosfamide and other anticancer agents was administered with the concomitant use of Mesna. All transient symptoms of loss of consciousness with slow respiration (in one cycle), disturbance of speech (in 2), and irritation (in one) were regarded as induced either by the central neurotoxicity of ifosfamide or synergistic adverse effects of ifosfamide and metochropramide. Hypopotassemia (in 3 cycles), hypocalcemia (in one), elevated GOT and GPT levels (in 16), stomatitis (in 7), and diarrhea (in 8) were tolerable for all the patients, although adriamycin had to be discontinued at a total dose of 486 mg for one patient complaining of palpitation in 3 cycles. At a follow-up in April 1993, the status of 6 surviving patients was CDF in 3, NED in 1, and AWD in 2 and one had died of the disease. There were no deaths related to chemotherapy.

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Thirty-four patients (25 men and 9 women) with cancer were investigated to determine the relationship between a response to cancer treatment (CR, PR, NC and PD) and its prognostic indices (PNI: prognostic nutritional index, PS: performance status, body weight, serum protein levels, serum cholesterol levels and Hb values). The subjects included pancreatic cancer, hepatocellular carcinoma, gastric cancer, malignant lymphoma etc. Chemotherapy, radiotherapy, operation and IVH were performed in 91.2, 55.9. 26.5 and 47.1% of the patients, respectively, and resulted in CR in 2.9%, PR in 32.4%, NC in 32.4%, and PD in 32.4% of them.
Prognostic index such as PNI or PS gradually decreased after the treatment was started. There were few cases where the prognostic indices improved due to the treatment. However, the improvement of PNI was shown in 43.5% of the patients 6 months after the treatment compared to 3 months. The above 2 prognostic indices (PNI and PS) after 3 months and 6 months suggest a response to cancer treatment. The correlation between PS before the treatment and effects of the treatment was also significant. Among the above mentioned 6 prognostic indices, PS correlated most closely with a response to the treatment followed by Hb.

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Recently, local chemotherapy has been used as an useful treatment for carcinoma of the uterine cervix. We prepared vaginal and endocervical suppository for clinical use using cisplatin (CDDP) powder made from commercially-available CDDP solution by vacuum distillation method, and practiced local chemotherapy with CDDP suppository in patients with carcinoma of the uterine cervix. As to the pharmaceutical properties of each suppository, weight variation test showed 1316.3±20.1 mg in vaginal suppository and 236.1±1.9 mg in endocervical suppository, and content test by high performance liquid chromatography demonstrated 9.67±0.39 mg in vaginal suppository and 10.92±0.18 mg in endocervical suppository, respectively. Coefficient of variation was good enough in each test.
Investigation of content uniformity in three divied parts of vaginal suppository suggested the importance of controlling its good quality in preparation. Histological response of the tumor showed Grade 0-IIa in the squamous cell carcinoma of the uterine cervix. No major side effects were seen in this study, but redness or erosin of vaginal mucosa was the only side effect in most patients after the therapy.

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To investigate abuse of hypnotics and anxiolytics in Japan, we surveyed 938 cases of psychoactive substance abuse who were registered by 851 psychiatric institutes from August to September in 1991. Ninety cases (55 males, 35 females) of them suffered from abuse or dependence of hypnotics and/or anxiolytics. They were about 42 years old on average, older than abusers of meta-amphetamine or organic solvent. Many drugs were used for abuse, and the drug most frequently used for abuse was triazolam, secondarily Bromsoval (named bromvalerylurea in Japan), and thirdly diazepam. Abusers of these drugs used multiple drugs more frequently than single drug. So one-third of them abused single drug exclusively, but two-thirds abused multiple drugs. Seventy percent of the cases took drugs from the physician and 36% from the drug store. The most common motivation for abuse was medication of anxiety and/or insomnia, but sometimes recreation or stimulation to thier life. Three-quarters of them did not adjust in the social or family life. From these data presented, we conclude that it is neccesary to make the more appropriate and strict regulation of hypnotics and anxiolytics.

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In the last seven years, we observed six cases of hemolytic disease of the newborn (HDN), two of which were caused by anti-RhD (group RhD); three by anti-RhE and anti-Rhc; and one by anti-RhE. All six infants had hyperbilirubinemia that improved after a single exchange transfusion at zero to four days of age. However, there were a few differences between the infants with HDN induced by anti-RhE or anti-Rhc (group RhE/c) and group RhD. (1) A diagnosis was made later in group RhE/c than in group RhD (three to five days of age vs, zero days of age). (2) On admission, the red blood cell count of group RhE/c was lower than that of group RhD (332±98×10⁴/mm³ vs. 402±34×10/⁴/mm³), while total bilirubin was higher (22.7±2.0 mg/dl vs. 6.7±6.4 mg/dl). Since 1973, the incidence of HDN caused by anti-RhD has decreased because of the use of antiRhD immunoglobulin; however, the number of cases of HDN due to anti-RhE and/or antiRhc has increased. For the early diagnosis and early therapy of HDN caused by antiRh, we recommend performing an indirect Coombs test in all pregnant women.

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We report a case of non-Hodgkin lymphoma originated from retroperitoneum presented with hydronephrosis induced by bilateral urethal obstruction like retroperitoneal fibrosis. A 73 year old female with Sheehan syndrome treated with cortril was admitted to our hospital because of abdominal fullness and edema. CT and MRI showed large homogenous retroperitoneal mass. Her laboratory data showed renal failure (creatinine; 3.6 mg/dl), pancreatitis (amylase; 342IU/l) and elevated LDH levels (1922IU/l). She had no fever or superficial lymphadenopathy. There was no positive detection by Ga scintigraphy. CT-guided biopsy was done for the differential diagnosis of retroperitoneal tumor (malignant lymphoma) or retroperitoneal fibrosis, and then she was diagnosed as malignant lymphoma and treated by chemotherapy with multiple anticancer drugs. The tumor rapidly decreased and symptoms and laboratory data improved.

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We experienced a patient with ileovesical fistula due to Crohn's disease. A 25-year-old male was suffered from diarrhea, abdominal pain, fever and fecaluria. He was diagnosed as having Crohn's disease in other hospital in 1988. He was admitted on July 1, 1991 with the complaints as mentioned above. Laboratory finding showed hypoproteinemia and elevated CRP, and Citrobacter freundii was identified by the urinary and fecal examination. Intravenous pyelography, cystography, cystoscopy and CT-scan revealed an elevated lesion in the right posterior wall of the bladder. A barium enema study showed various abnormal findings of ileocecum, with many pseudopolyps with ascending colon and sigmoid colon, and linear ulcer at sigmoid colon. By fluoroscopic examination of the small intestine the bladder was visualized simultaneously. Accordingly an ileovesical fistula due to Crohn's disease was given. First, the patient was treated medically, but the fecaluria lesion was intractable to the treatment. Ileocecal resection and partial cystectomy were performed on September 24. Macroscopic examination of the terminal ileum showed an abscess associated with ileovesical fistula. After operation, he had an uneventful recovery and was discharged on January 13, 1992. At present, recurrence of fistula was not observed.

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A case of neurilemmoma of the stomach is described. An abnormality of the stomach was detected in an asymptomatic 53-year-old female at a mass screening survey.
Upper GI series as minute examination revealed a submucosal tumor with a central ulceration of the gastric upper corpus measuring about 5×4 cm in diameter. The lesion was confirmed as group 1 by biopsy and we could not have a definitive diagnosis. We performed proximal gastrectomy with lymphnodes curettage because it was not completely ruled out that the lesion might be a malignant neoplasm. The resected specimen showed a submucosal tumor, 3.8×3.1 cm in size, at the anterior wall of the upper corpus. An ulceration was present at the top of the tumor.
Histopathological examination including hematoxylin-eosin staining (spindle shaped cells with a pattern of streaming in inconstant directions and lymphoid cuffs) and immunohistochemical staining (positive S-100 protein and negative desmin) led to the diagnosis of neurilemmoma.
Generally, it is very difficult to confirm a correct diagnosis of the submucosal tumor of the stomach preoperatively. It can not be said that the most appropriate surgical interventions have been adopted in accordance with malignant degrees of each case. We wish to emphasize that efforts must be made to accomplish a reliable and qualitative diagnostic method gaining an accurate histopathological diagnosis of the submucosal tumor of the stomach at the latest during operation. The efforts will lead to more satisfactory results in treating patients with submucosal tumor of the stomach.

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A case of tuberculous peritonitis showing increased levels of adenosine deaminase and CA-125 both in serum and ascitic fluid, with serial changes of these markers in serum during the course of treatment, is reported. A 26-year-old woman visited the Department of Obstetrics and Gynecology of our hospital because of amenorrhea of 8 weeks' duration, and was diagnosed as being pregnant. Then, she noticed abdominal distention and massive ascites was found on her second visit. She was admitted to the Department of Internal Medicine of our hospital for further evaluation. She had remittent fever, and increased serum levels of CRP and alpha 2 globulin were found. Her ascitic fluid was an exudate, cytology and bacterial cultures were negative, and about 80% of the cells were lymphocytes. Increased levels of adenosine deaminase and CA-125 both in serum and ascitic fluid were noted. Her pregnancy terminated in the 11th week due to spontaneous abortion. Diagnostic laparotomy was then performed. Her peritoneum was found to be thickened, and a large number of miliary-sized white nodules were scattered throughout the peritoneum, intestine, ovaries and tubes. Pathological examination of these nodules revealed epidermoid granuloma with Langhans' giant cells, caseous necrosis and ZiehlNeelsen stain positive rods. The diagnosis of tuberculous peritonitis was made and antituberculous therapy was started. Serum levels of adenosine deaminase and CA-125 decreased in accordance with the improvement of clinical symptoms and signs.

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We report serum levels of parathyroid hormone (PTH) and calcium during thyroid hormone replacement therapy in a case of primary hyperparathyroidism and primary hypothyroidism. A 40-year-old man was diagnosed as primary hyperparathyroidism (Ca=11.2 mg/dl, HS-PTH=1000 pg/ml, intact PTH=179 pg/ml) and primary hypothyroidism (TSH=147μU/ml, T4=5.1μg/dl, T3=0.88ng/ml). During replacement therapy with thyroid hormone, serum level of PTH decreased, though serum level of calcium didn't change. PTH value before treatment was 1000 pg/ml and that of after treatment was 760 pg/ml. As the sensitivity of target organ to PTH was recovered by thyroid hormone replacement therapy, the secretion of PTH from parathyroid adenoma might decrease.

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We report a male infant of Pena-Shokeir I syndrome, which was characterized by congenital multiple ankyloses, camptodactyly, facial anomalies, hypoplastic lungs, and normal chromosome. To our knowledge, there have been 12 cases of Pena-Shokeir I syndrome reported in Japan.

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Sixteen years have passed since the Emergency and Critical Care Unit of The Second Tokyo National Hospital was opened in 1997.
Therefore the authors report the results of performance and changes from 1997 until now.

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