From 1983 to 1988, 31 cases of esophageal stomal strictures which had been dilated endoscopically were studied retrospectively and were divided into two groups. One group (26 patients) became free of stenotic symptoms after a few treatments by bougienage and the other group (5 patients) required more than 10 bougienage treatments or relapsed soon after bougienage. In estimating the prognosis of the esophageal stomal stricture, it was useful to compare the two groups in regard to the presence and the degree of anastomotic leakage, the ratio of the short diameter to the long diameter of the stoma endoscopically 1 or 2 weeks after bougienage and the length of the stenosis determined radiologically before bougienage. It is important to try to prevent recurrence of the cancer in patients for whom treatment is difficult and another treatment should be considered for a patient whose stenosis is too long.

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The effect of highly selective vagotomy on gastric intramural nerves in dogs was studied from 3 days to 12 months postoperatively by enzyme histochemical and electronmicroscopic methods. The most striking changes were seen in the early postoperative period in ganglion cells, enteroglia cells, and the neuropil of the myenteric ganglia and connecting strands. Those changes were limited to the fundic region. During the first postoperative week, the number of ganlion cells decreased in the denervated area and the remaining ganglion cells showed degeneration and decreased enzymatic activity as well. In the second week, amitotic cell division of ganglion cells and immature ganglion cells were observed, suggesting the regenerative process. From the second postoperative month, the number of ganglion cells recovered and hypertrophied ganglion cells with increased enzymatic activity were observed occasionally until the sixth month. Hyperinnervation of the muscularis propria was also observed during the same period. After sixth months, most of the ganglion cells became normal in appearance and enzymatic activity. By the twelfth month the intramural nerves had become entirely normal in appearance.

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To study the pathophysiology of the reconstructed intestinal movement after total gastrectomy, a dog was given a total gastrectomy and the reconstructed intestinal movement was recorded with a strain gage force transducer. Two reconstruction techniques were used, jejunal interposition and Roux-en Y anastomosis. Two weeks after the jejunal interposition, there was no spread of the interdigestive migrating contractions generated in the interposed jejunum to the anal side of the intestine. At about 5 weeks, however, spreading groups of contractions started to appear, and by 9 weeks almost all the contractions had spread. About 5 weeks after the Roux-en Y anastomosis, interdigestive migrating contractions appeared simultaneously in the duodenum and in the jejunal loop. These results demonstrated that the reconstructed intestinal movement after total gastrectomy with jejunal interposition approachs its physiological condition after 9 weeks. Great care should be taken with feeding until then. In addition, these chages seemed to involve the reconstruction of the intramural autonimic nerve plexus.

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Two hundreds and fourty-five patients who underwent pancreaticoduodenectomy for periampullary carcinoma were studied pathologically to determine the criteria for pylorus preserving pancreaticoduodenectomy. Among the 245 patients, carcinoma of the head of the pancreas was the indication for operation in 106, ampulla Vater in 54, middle and distal bile duct in 40, gallbladder in 38, and duodenum in 7. The patients were divided into different group with regard to positive lymph node metastasis in one of No group with regard to positive lymph node metastasis in one of No (3), (4), (5), (6), or (7) (N-meta factor) and direct tumor infiltration into the stomach or the first portion of the duodenum (D-inf factor). In patients with carcinoma of the ampulla Vater, percentage of the patients having positive N-meta factor was 0%, and percentage of the patients having positive N-meta factor was only 3.7%. In patients with carcinoma of the middle and distal bile duct, gallbladder, or duodenum, all patients with negative D-inf factor showed negative N-meta factor. In patients with carcinoma of to head of the pancreas, however, percentage with carcinoma of the head of the pancreas, however, percentage of the patients with negative D-inf factor and positive N-meta factor was 7.5%. 1. These results suggest that pylorus preserving pancreaticoduodenectomy is the choice of the operation in patients with carcinoma of the ampulla Vater. 2. This operation is also the choice of treatment in patients with carcinoma of the middle and distal bile duct, gallbladder, or duodenum, if those patients had negative D-inf factor. 3. Whipple's operation should be done for patients with carcinoma of the head of the pancreas as far as radical operation is concerned.

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The relationship between nutritional intervention and circulating thyroid hormones and rapid-turnover proteins was investigated in surgical patients with liver cirrhosis. Fourteen patients with well-comensated liver cirrhosis who were operated on esophageal varices or hepatoma were divided into two groups. The oral group was offered an oral diet containing 2.200 Kcal/day before the operation and conventional intravenous infusions of 5% glucose after the operation (500-600 Kcal/day). The supplementary parenteral nutrition (SPN) group was offered the same oral diet as the oral group, combined with intravenous 50% glucose, fat emulsion and branched-chain enriched amino acids solution, 600-1, 000 Kcal and 7.32g of nitrogen per day during the 10 days before operation, and 800-1, 800 Kcal and 7.32-9.76g of nitrogen per day during the first 2 postoperative weeks. The plasma triiodothyronine (T3) level was higher in the SPN group (1.26 ± 0.09 ng/ml) than in the oral group (0.91 ± 0.08) (p<0.001) and the reverse T3 (rT3) level was lower in the SPN group (297 ± 33 pg/ml) than in the oral group (351 ± 29) (p<0.01) on the day of surgery. In addition, SPN significantly attenuated the low T3 and high rT3 levels found in the oral group throughout the 2 postoperative weeks. Furthermore, attenuation of decreases in very shortturnover proteins was achieved in the SPN group. It is likely that SPN contributed to the partial correction of liver dysfunction and metabolic imbalance in traumatized cirrhotic patients.

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To examine the pathogenesis of liver ischemia more objectively, the change in liver lysosomal enzymes in a partial liver ischemic model in rats was studied. The free activity of the liver lysosomal enzyme and the lysosomal fragility index obtained from the ischemic lobe gradually increased after induction of ischemia and markedly increased after release of the clamp. There was a significant increase in free activity and fragility index of cathepsin D after two hours of reperfusion (0.52±0.05 units/mg protein and 41.2 ±3.7% respectively) compared to the preischemic values (0.27±0.4 units/mg protein and 28.5±2.5% respectively). In addition, serum lysosomal enzyme activity was markedly increased from 2.20±0.28 units/mg protein (preischemia) to 4.33±0.39 (after two hours of reperfusion). These results suggest that lysosomal labilization occurred in the ischemic lobe and that the lysosomal enzyme was released from the ischemic lobe into the serum. It is concluded that the lysosomal enzyme plays an important role in liver ischemic injury.

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Radioisotopic splenoportography was performed in 28 patients with moderate or huge size esophageal varices (Japanese research society for portal hyperension F₂, F₃ varices) before and after endoscopic injection sclerotherapy (EIS). Recurrence was judged endoscopically six months after EIS. In the successful EIS group (17 cases), radioisotopic images (RI-images) of ascending collaterals such as esophageal varices and the left gastric vein disappeared after EIS, but the images of the short gastric vein did not. In the successful EIS group, RI-images of descending collaterals such as the paraumbilical veins, splenorenal shunts and the images of the liver were enhanced after EIS. In the varices-relapsed group (11 cases), RI-images after EIS were almost the same as before EIS. Therefore the disappearance of the images of ascending collaterals excluding that of the short gastric vein, and the enhancement of images of descending collaterals and the liver by radioisotopic splenoportography are thought to be good indices for successful EIS. We think radioisotopic splenoportography is a safe and useful modality for therapeutic evaluation of EIS.

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Over the past 12 years, 108 cases of hepatocellular carcinoma were operated on. The factors that determined the course of the recurrence pattern after hepatic resection were studied. There were 23 recurrent cases, a rate of 60.5%. Recurrence patterns were divided into three types as follows: 1. recurrence in the cut surface, 2. solitary type, 3. multicentric type. Recurrence period of solitary and multicenric recurrence type were 1000±66.7 days and 566±511 days. And there was statistically no difference between them. However, the survival period for the solitary type of 472±237 days after confirmation of recurrence was statistically longer than for the multicentric type of 238±130 days. As hazardous factors of recurrence, the infiltration to the capsule of the hepatoma, the infiltration to the portal vein, tumor size, grade of liver cirrhosis, Edmondson's calassification and grade of stage could not predict the recurrence pattern. The factors for estimation of the multicentric recurrence pattern were presence of HBs antigen (38.5%), low rate of reduction of the alpha-fetoprotein (AFP) value (52.5%) after hepatic resection, and multiple tumors in the primary lesion. Preoperative multi-farious treatment could not control the recurrence pattern.

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The factors related to residual liver recurrence following hepatectomy were investigated in 26 patients with hepatic metastsis from colorectal cancer. Although there is no significant difference between males and females, the frequency of residual liver recurrence was lower in patients over 61 years old than in younger patients. In rectal cancer, residual liver recurrence was higher than colon cancer recurrence but the size of the lesion, the number of foci and histological differentiation had no significant relationship with the recurrence. No marked difference was seen between synchronous and metachronous metastasis. The timing of the operation did not influence the prognosis and was the same for simultaneous and metachronous resection. Residual liver recurrence was seen in 4 of 7 patients (57.1%) who underwent partial resection but in 19 patients who underwent wide resection it was seen in only 4 (21.1%), which indicates that wide resection is important and should be the operation of choice in the case of metastatic liver cancer.

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Excretion of an antibiotic into human bile as well as various factors influencing the excretion were studied in 10 patients with obstructive jaundice. In this study the antibiotic cefpiramide (CPM) was used. When the bile duct was completely obstructed, CPM was never excreted. However, it was excreted relatively soon after release of the biliary obstruction. The rate of excretion of CPM in the presence of obstrucitve jaundice appeared to be strongly affected by the state of bile flow. After release of the biliary obstruction, a statistically significant negative relationship between the maximum CPM concentration in the bile and the total serum bilirubin level (p<0.05) was shown. Thus the excretion of CPM into the bile might decrease with advance in the severity of jaundice. Moreover, the possibility that fibrosis of Glisson's capsule and blood supply to the liver might affect the rate of excretion of the antibiotic into the bile is suggested, because the maximum biliary CPM concentration tended to correlate with the K value in the indocyanine green test.

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A clinicopathological study of adenoma and stage I carcinoma of the gallbladder, including a study of imaging diagnosis by ultrasonography (US) and computed tomography (CT), was performed to emphasize the characteristics of stage I carcinoma of the gallbladder. Differention of the US pattern between adenoma and stage I carcinoma of the gallbladder was difficult. The size of stage I carcinoma ranged from 6 mm to 50 mm. There were no death from recurrence of the protruded type of stage I carcinoma. The outcome of the protruded type of stage I carcinoma including tumors 30-50 mm in maximum diameter was better than that of the non-protruded type. The nonprotruded type which was composed of tubular adenocarcinoma, it was difficult to make a preoperative diagnosis of carcinoma of the gallbladder. The difficulity could lead to a poor prognosis of the non-protruded type of stage I carcinoma.

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Perineural invasion is one of the significant prognostic factors of pancreatic carcinoma. To clarify the relationship between the expression of neuro-endocrine (NE) markers and perineural invasion in human pancreatic carcinoma, tissue specimens from a series of 19 patients who were operated between January 1983 and August 1989 in our department were stained immunohistochemically with specific NE markers (i.e., NSE, Synaptophysin, Chromogranin, S-100 protein, Substance-P, Enkephaline) and with neural cell adhesion molecule (NCAM) MoAb. The staining method was immunoperoxidase staining with avidin-biotinylated peroxidase complexes. There were no carcinoma cells stained by NSE or Chromogranin in any specimens. Any specimens from 11 cases were positively stained by NCAM MoAb and at least one of 4 NE markers. On the other hand, 8 patients were negative for all of them. Specimens from 16 patients (84%) revealed perineural invasion when stained with hematoxylin and eosin. Perineural invasion of pancreatic carcinoma was significantly related to the expression of NCAM and 4 NE markers (p<0.01). In particulary, the expression rate was increased in carcinoma cells which invaded the perineural space. NCAM-positive patients showed much less a liver metastasis and had a better prognosis than NCAM negative patients. Our results indicate that NE differentiation may occur in some pancreatic carcinoma cells and especially that NCAM may be involved in perineural invasion through its neural affinity. Pancreatic carcinoma cells which express NCMA may have nerual affinity.

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Among 327 patients undergoing surgery for colorectal cancer in Hiratsuka City Hospital from 1970 through 1989, 53 patients whose cancer invasion was limited within the mucosa, submucosa and proper muscle (the pm group, which was defined by general rules for clinical and pathological studies on cancer of colon, rectum and anus) were selected and were compared with 212 patients whose cancer extended from the mucosa beyond the proper muscle and did not definitely infiltrate into other organs (the ss, s group, which was also defined by the rulesdescribed above) in respect to the clinicopathologic details and prognosis. The mean age in the pm group was 64.1 years, which is older than that in the ss, s group, but the difference was not significant. The frequency of rectal tumors in the pm group was 58.5% which was significantly higher than that in the ss, s group (p<0.01). The mean tumor size in the pm group was 4.2 cm, whereas that in the ss, s group was 5.5 cm and was significantly smaller than that in the ss, s group. There were no patients who showed distant metastasis in the pm group. The rate of regional lymph node metastasis in the pm group was 24.5%, whereas that in ss, s group was 47.6%. There was a significantly lower frequency of regional lymph node metastasis in the pm group (p<0.01). The cumulative five-and ten-years-survival rates for patients in the pm group were 83.9 and 74.0%, respectively which were significantly better than those for patients in the ss, s group. The cumulative five-and ten-years-survival rates for the ss, s group were 50.7 and 42.7%, resectively.

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Eighteen patients who had curatively resected rectal cancer have received intraoperative radiation therapy. The operations comprises 11 Miles' operations, 5 sphincter-saving operations and 2 pelvic exenterations. Lymphnode metastases were seen in 7 cases. Four cases showed direct invasion into the adjacent organs without lymphnode metastases. The radiation doses were 30-40 Gy with the energy of 6-18 MeV. Although the survival rate has not improved so far, the local recurrence rate has decreased. In regard to the safety of the operation, prolongation of operating time was apparent, though the total amount of blood lost and post operative changes in serum albumin levels and total lymphocyte counts were not different from those of control groups. There was a late complication, in one case: ureter stenosis, which could be dilated with a nephrostomy tube.

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A retrospective study of 44 patietns with rectal cancer who received preoperative radiation (42.6 Gy) combined with chemotherapy and 37 who received resection alone (control group) was undertaken to evaluate the effect of preoperative radiation therapy on local recurrence of rectal cancer. The rate of local recurrence in the radiation group was reduced to 4.5% compared with that in the controls (18.9%). From a pathological point of view, factors that have a close association with recurrence, such as depth of invasion, ew (defined as the distance between the external surgical surface and the deepest site of invasion) and lymph nodal involvement, have been successfully changed after radiation therapy. It was also evident that the rate of recurrence in irradiated patiens, depth of invasion of a₂ (defined as the invasion of cancer far beyond the muscle layer but without involvement of other organs) or ew less than 2 mm was significantly lower than in patients with the same pathological conditions in whom radiation was not used. However, especially in patients with remote lymph node metastasis, there was no difference in local recurrence rate between the two groups. From these findings, it was concluded that a careful follow up is necessary for patiens with remote lymph nodal involvement even after radiation therapy.

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We investigated the postoperative complications and factors affecting the outcome in 58 patients aged over 80 who underwent gastroenterological surgery under general anesthesia over the past 5 years. Patients aged more than 80 accounted for 5.7% of all cases, showing an increase compared with previous studies. Malignant diseases accounted for 69.0% of the operations, and emergency operations for 15.5%. Most emergency surgery was for complications of infections such as cholangitis and peritonitis. Postoperative complications occurred in 41.4% of the patients and 3 patients died after surgery because of serious complications, such as bleeding, sepsis, and anastomotic leakage. The presence of preoperative complications, results of preoperative general examinations, including hemoglobin and total protein determinations, and the operation time were not clearly related to the frequency of postoperative complications. Emergency surgery, and the volume of blood lost during the operation were related to the frequency of postoperative complications or the outcome. Therefore, it is important to attempt to decrease postoperative complications by choice of the correct operative procedure as well as careful supportive measures especially in emergency situations, although age itself must not become a reason to abandon surgery.

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In recent years, detection of esophagitis and esophageal ulcer has been developed with medical advancement, but middle intra-thoracic esophageal ulcer has rarely been reported. Herein we report a case of middle intra-thoracic esophageal ulcer. A 56 year-old male was transfered to this hospital because of fever and retrosternal pain, and there was no past history of caustine or medication. An esophageal roentgenogram and esophagoscopy revealed a large ulcer located at 26 cm from the incisors, and the biopsy specimen revealed no malignant cells. He was treated with antacids and TPN, but an emergency esophagectomy was necessary because of sudden massive hematemesis. Grossly, the lesion was located in the upper two-thirds of the esophagus with sharply demarcated margins. No ulcerations nor tumors were found in the lower third of the esophagus and stomach. Microscopic findings showed an active, well-developed, chronic ulceration.

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We report two cases of malignant lymphoma (ML) of the stomach which had an interesting clinical course. In case 1, the patient was a 68-year-old woman who had been followed for 2 years and 9 months under the diagnoses of multiple gastric ulcer and reactive lymphoreticular hyperplasia (RLH). Although the histological diagnosis by endoscopic biopsy was RLH, we clinically suspected ML, and she underwent total gastrectomy. This case shows the difficulty in making a differential diagnosis between ML and RLH even with biopsy examination and suggests the possibility of a change from RLH to ML. The patient in case 2 was a 71-year-old woman who had undergone subtotal gastorectomy 4 years earlier for ML of the stomach, which appeared to be Borrmann 2 type. As the present X-ray and endoscopic examination suggested recurrence of ML in the remnant stomach and this was confirmed by biopsy, total resection of the remnant stomach was carried out. This is the fifth case of the recurrent ML of the remnant stomach reported in Japan.

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Though the prognosis for patients with gastric cancer has been remarkably improved, there are still recurrence of early gastric cancer. In this study, we determined the clinicopathological features, nuclear DNA content and the location of CEA in tissue of recurrent cases with early gastric cancer. The records of 127 Japanese with early gastric cancer, who had been surgically treated in our department, were studied. The 10 year survival rates for the patients with mucosal (m) cancer and submucosal (sm) cancer was 100%, 92.8%, respectively. There were 2 cases of recurrece out of the 127 patients (1.6%). One recurrence was in a 71 year-old woman who died 5 years and 5 months after her curative operation. The other was in a 73 year-old man who died one year after his curative operation. Vessel invasion seemed to be one of the largest factors which affect the recurrence of the early gastric cancer.

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The patient is a 58-year-old man, who was diagnosed by a medical checkup as having gastric cancer and came to our hospital for surgery. Gastric X-P-endoscopy diagnosed the case as IIa + IIc type early gastric cancer on the posterior wall of the antrum. Except for a high 91.3 ng/ml serum a-fetoprotein (AFP) level, no abnormal findings were noted in blood biochemical tests, abdominal ultrasonography and computed tomography. While subtotal gastrectomy with R₂ dissection was carried out, a white tumor 2 mm in diameter was found on the surface of anterior segment of liver and was extirpated. Histological findings in the gastric cancer showed poorly differentiated adenocarcinoma (medullary type) infiltrating into the submucosal layer, without lymphnode metastasis and metastasis was noted in a small focus of the liver. Immunohistological examination revealed AFP in both the primary lesion and the metastatic hepatic lesion. The postoperative course was favorable, but in view of the high possibility of micrometastasis, we started administering UFT and performed two courses of hepatoarterial infusion with Cisplatin, Mitomycin C and Etoposide. Thanks to this chemotherapy, AFP, which increased again postoperatively, decreased to reach WNL.

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A patient who underwent a combined operation for splenic aneurysm, nonfunctioning adrenocortical adenoma, and gastric cancer is reported. A 74-year-old woman was diagnosed having early gastric cancer. A selective celiac angiogram and a computed tomogram showed a calcified splenic aneurysm at the splenic hilus and a left adrenal mass (incidentaloma). On March 17, 1986, the patient underwent total gastrectomy, aneurysmatectomy, splenectomy and adrenalectomy. The spleen was 10 mm in diameter and atherosclerotic. The adrenal mass was 16 mm in diameter and was diagnosed as nonfunctioning adrenocortical adenoma. At present she shows no sign of recurrence. It is generally said that splenic aneurysm with calcification and 10 mm in diameter has low frequency of rupture and nonfunctioning adenoma of 16 mm in diameter has a low possibility of malignancy. However, this patient underwent aneurysmatectomy and adrenalectomy at the operation for gastric cancer because a reoperation would have been somewhat difficult.

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Amputation neuroma is not a true neoplasm but an overgrowth at transected stumps of the automonous nerve fibers. We have treated a patient with amputation neuroma which occurred in the common hepatic duct after cholecystectomy. A 63-year-old woman was hospitalized with complaints of epigastralgia and jaundice. She had undergone cholecystectomy eight years previously. Endoscopic retrograde cholangiopancreatography disclosed stenosis of the common hepatic duct with a smooth margin, and a common bile duct stone. On laparotomy, we found a tumor 7 mm in diameter covered with normal mucosa on the right wall of the common hepatic duct. Enucleation of the tumor and choledochotomy with T-tube insertion were carried out. Postoperatively the stenotic segment was dilated repeatedly with a balloon catheter, and improved. Histologic examination revealed that the submucosal tumor was an amputation neuroma due to the previous surgery. Amputation neuroma is one of the causes of obstructive jaundice after cholecystectomy, and awareness of this entity will lead to accurate diagnosis avoiding unneccessary extensive operations.

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A 65-year-old male underwent resection of an adrenal metastasis from hepatocellular carcinoma (HCC) in March 1989. The disease was diagnosed as HCC with multiple intrahepatic metastases in April 1986 and was treated three times by transcatheter arterial embolization (TAE). Follow-up computed tomography first revealed a 2.5 × 2.0 cm left adrenal metastasis in January 1987. The adrenal metastasis gradually became larger but the HCC itself was in good control with TAE. Therefore the adrenal metastasis was removed by surgery. The tumor was 12.5 × 8 cm in size and weighed 370 g. The histological findings of the tumor were the same as HCC. In this case, the combined therapy of TAE and surgery made it possible for the patient to live over 51 months since the tumor was first diagnosed.

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We experienced a case of extremely high level of serum carbohydrate antigen 19-9 (CA19-9) in a patient suffering from cholecystitis with a gall stone and liver abscess. The patient, a 53-year-old man, was admitted to the hospital with the chief complaint of epigastralgia. The clinical diagnosis on admission was cholecystitis and cholelithiasis. The echogram revealed that the stone was impacted at the neck, causing a marked distension of the gall bladder. An adjacent liver abscess was also suspected. Abnormal laboratory data included an extremely high CA19-9 serum titer (868, 094 U/ml), suggesting the presence of malignancy. At surgery, however, no malignant findings were observed and a simple cholecystecomy with drainage of the liver abscess was carried out. Pathologically, the gall bladder showed features of chronic cholecystitis with focally necrotic and granulomatous lesions. An immunohistochemical study using anti-CA19.9 antibody showed strong positivity in the epithelium of the gall bladder and intraluminal secretory substance. The CA19.9 serum titer was postoperatively decreased to the normal range in 6 months. Therefore it is possible that the cause of such a high preoperative CA19-9 serum level is related to the benign lesions of the gall bladder and liver. The present case indicates that an abnormally high CA19-9 serum titer per se does not necessarily mean the presence of malignancy.

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Rupture of the bile duct or bile duct stenosis is a rare complication of nonpenetrating trauma. A case of common bile duct stenosis after rupture of the bile due to nonpenetrating trauma is presented. A 47-year-old man was referred to our hospital with the complain of abdominal pain. He was involved in a motor accident and sustained severe trauma to the abdomen. Findings of abdominal computed tomography suggested liver injury and he was given conservative treatment. But he experienced high fever and the abdominal pain gradually increased. A laparototny was performed on the 32nd day after the injury. There was about 5200 ml of bile-stained fluid in the peritoneal cavity. Careful exploration revealed no obvious injury to the bile duct and he was treated only by inserion of serveral drains. He became jaundiced in the 4th month after the injury. Further examinations revealed complete obstruction of the lower bile duct. A balloon dilatation after percutaneous transhepatic biliary drainage was unsuccessful. A second operation, cholecystectomy and choledochoduodenostomy, was performed on the 235th day after the injury. The postoperative course was quite uneventful and the patient remains clinically well 11 months after the operation.

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Limy bile is a relatively rare disease, and only about 350 cases have been reported in Japan. However, limy bile associated with caricnoma of the gallbladder is extremely rare. We observed a case of limy bile associated with multiple carcinomas of the gallbladder. A 61-year-old woman had been diagnosed as having cholecystolithiasis combined with limy bile, for which cholecystectomy was performed. Intraoperative findings revealed a small elevated lesion located in the fundus of the gallbladder, the frozen section of which was diagnosed as adenocarcinoma. Resection of the liver bed with dissection of the regional lymph nodes was also performed. In the permanent sections, another early stage of carcinoma was found in the neck and body of the gallbladder. On the basis of the histopathologic findings, we believe that the operation was curative. She is getting along well without sings of recurrence 20 months after surgery.

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A 66 year-old man was admitted complaining of abdominal pain and fever. According to the examinations (ultrasonography, CT scan, percutaneous transhepatic cholangiography, percutaneous transhepatic cholagioscopic biopsy), firstly gallbladder carcinoma invading the common hepatic duct with cholecysto-hepatidochal fistula, and secondary bile duct carcinoma invading the gallbladder were suspected. Cholecystectomy, choledochectomy and hepaticoduodenostomy were performed. Mixed type stones were found in the common bile duct, the common hepatic duct and the gallbladder. A large fistula between the gallbladder and the common hepatic duct was noted, and a large pedunculated polypoid tumor originated from the neck of the gallbladder grew into the common hepatic duct through the cholecysto-hepatidochal fistula, which seemed to be formed secondary to cholecystolithiasis. Pathological diagnosis was papillary adenocarcinoma. The regional lymph nodes were not involved. At 1 year after surgery the patient had no signs of recurrence.

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A case of idiopathic portal hypertension, in which diffuse portal thrombosis developed after splenectomy is reported. A 35 year old woman was referred to Nagasaki University Hospital becauseof pancytopenia and esophageal varices. Splenectomy and transection of the esophagus were performed. Postoperative portal thrombosis was detected by ultrasonography three days after surgery and thrombus was observed as an isohyperrechoic mass in the portal vein and decrease in flow volume and flow speed in the portal vein was also detected by the ultrasoic doppler method. Intravenous infusion of Urokinase, 240, 000 units/day was effective in decreasing the thrombus. In these cases ultrasonography with doppler examination was useful for early diagnosis and follow-up portal thrombosis.

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A relatively rare case of ischemic jejunitis with stenosis is reported. A 69-year-old man was referred to our hospital with epigastric pain and vomiting. Laboratory data showed a high level of serum amylase. His condition improved with conservative therapy. But 8 weeks after his remission, he complained of vomiting. A small intestinal roentgenogram showed stenosis of the jejunum, but superior mesenterial arteriography revealed neither stenosis nor obstruction. Laparotomy revealed jejunal stenosis of about 40 cm on the anal side, about 60 cm distant from Treitz's ligament. Histopathological findings indicated ischemic enteritis. The stenosis was considered to be caused by impaired microcirculation of the jujunum due to diabetes mellitus and atrial fibrillation.

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Non-specific ulcers and necroses in the oral side of the intestinal tract found in cases with occlusive lesions from carcinoma of the colon are known as obstructive colitis and necrotic enteritis. Their generating mechanism, howerver, has not yet been fully explained. In this case, common factors contributing to generation of necrotic enteritis were considered to relate with multiple ulcerative lesions found in the ileum, although decompression with the ileus tube applied to the barium ileus might have produced a special situation in this case. Further, fewer caseswith necrotic enteritis in the small intestine have been reported. It was shown that the ileus tube therapy was effective in a case with defective obstruction of the ileocecal valve and could prevent perforation. However, possible risk of generating ileum ulcer in this therapy was also suggesed as it took about three weeks to eliminate barium administered.

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An 11 year old boy was admitted to Nippon Medical School Tamanagayama Hospital with acute abdomen. An emergency laparotomy was performed immediatly after admission because there was peritoneal irritation in his abdomen and he went into mild shock. The laparotomy revealed that there was widespread necrosis in the small intestine which was due to strangulation obstruction caused by a transmesentric hernia. The defect of the ileal mesentery measured 4.0 × 3.0 cm and was located 50 cm from the terminal ileum. More than half of the small intestine with necrosis and the defect was resected, and an end to end anastomosis was performed. The postoperative course was uneventful and the patient has been in good health since his recovery.

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Although amyloidosis of the digestive tract is relatively common, few patients develop perforating peritonitis.An 82-year-old woman consulted us with abdominal pain and bloody stool. An X-ray showed free gas, and laparotomy, performed under a diagnosis of perforating peritonitis, revealed perforation at 3 sites of the ileum. Thehi stopathological diagnosis was AL-type amyloidosis. Postoperative general examinations suggested secondary amyloidosis. The perforation is believed to have been caused by some stimulation such as amyloid deposition in small vessels of the intestinal wall, inducing regional ischemic changes and increase in vascular vulnerability.

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