Cancer of the hypopharynx or the cervical esophagus often invades the adjacent larynx, so it has to be concomitantly resected for better prognosis. Loss of phonation in the laryngectomized patients needs to be corrected. A new voice apparatus, the tracheogastric shunt, has been studied experimentally and clinically. For better qualified phonation by shunt speech the stomach tube needs to be as narrow. However the narrower the stomach tube, the less blood flow there is in the gastric wall. Hence, we studied the need for adding vascular anastomoses between the gastric and cervical vessels. Blood flow in the gastric wall in mongrel dogs, measured by a hydrogen gas clearance method, was as follows, intact stomach, 110 ±0 ml/min/100 g; stomach tube 2 cm in width, 0.8±0.8; after venous anastomosis, 0.5±0.8; and after arterial anastomosis, 19.2±1.4. The results indicated that blood flow in the cervically elevated stomach tube was greatly impaired and was improved by adding arterial anastomoses, but not by venous anastomoses. In 5 patients with pharyngo-esophageal cnacer, the anastomoses between splenic and superior thyroideal vessels were used in this type of esophagus surgery. The anastomoses were possible without a microscopic apparatus. An anastomotic leak was found in the tracheogastric shunt in one case, but no other complications relevant to surgery was noted. Phonation by shunt sppeech as satisfactory in one of two cases to whom the shunt was made.

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One hundred cases of esophageal cancer were evaluated in regard to cervical and upper mediastinal lymph node metastasis by using conventional ultrasonography. The whole cervical area and the upper mediastinal region around the right brachiocephalic artery and the aortic arch could be examined. Sensitivity of the procedure was found to be 91%, specificity 95%, and over-all accuracy 94% for all lymph nodes of the cervical and upper mediastinal region. In particular, in the upper mediastinal area, the sensitivity was 91%, specificity 89%, and accuracy 90%. Therefore ultrasonographic examination of the cercical area is essential for the determination of preoperative staging for esophageal cancer.

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Clinical studies of liver metastasis of esophageal cancer were made in 94 patients in whom the outcome was clear. Liver metastases were found in 16 patients (17%) and these metastases were multiple and non-resectable. In 11 of the 16 patients (69%), the lesion was located in the lower thoracic esophagus. Of 12 patients with liver metastasis after complete resection, the incidences of lymph node metastasis and vascular invasion were high and 9 of the 12 patients (75%) had stag IV disease. Average survival of 9 patients given postoperative chemotherapy was longer than that of the 3 without chemotherapy (10.6 months vs. 5.3 months). Above all, hepatic arterial infusion chemotherapy was effective against liver metastasis of esophageal cancer. Of 4 patients with liver metastasis after incomplete resection, the outcome was very poor (mean survival 3.0 months).

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Between 1983 and 1987, postoperative bronchial aspiration was studied in 54 patients with intrathoracic esophageal cancer who underwent tumor resection by right thoracotomy. 1) Postoperative bronchial aspiration occured in 38.9%. 2) The age, gender of the patients, and the stage of the cancer were not significantly correlated with postoperative aspiration. 3) The frequency of postoperative aspiration increased from 11.5% in 1983 and 84 to 64.3% in 1985 through 87. During the same period, lymphnode dissection in the upper mediastinum became more aggressive; the average number of the resected nodes in the upper mediastinum per each patinet tripled. 4) Aspiration occurred most frequently in patients who received esophago-gastrostomy via the subcutaneous route followed by those via the retrosternal and posterior mediastinal routes. 5) There was a close correlation among lymphnode dissection in the upper mediastinum, recurrent nerve palsy, and postoperative aspiration, however postoperative adhesion and sensory disturbance of the pharynx may also promote the aspiration.

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We have treated 185 patients with esophageal cancer, 20 of them had undergone gastrectomy. Considerating the possible association between gastrectomy and esophageal cnacer, postgastrectomy changes in blood profiles and nutritional status, and postgastrectomy reflux esophatitis have been suggested as contributory factors. To clarify such associations, we analyzed these factors in 62 patients who had survived for a long period after gastrectomy for benign diseases. As a result, we found no evidence of any severe deterioration in blood profiles or nutritionaz status. We found evidence of endoscopic esophagitis in 15 (24%); the centers of the esophagitis were all located in the lower esophagus. Histologically, acute or chronic inflammation was present in 100%0 and 69%, respectively. Epithelial dysplasia of varying degrees of severity was detected in 26 patients (42%); there were more patients whose grade of dysplasia was most severe in the lower esophagus. These data suggest that postgastrectomy gastroesophageal reflux is more likely than postgastrectomy changes in nutritional status to be a possible contributory factor to the development of subsequent esophageal cancer.

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In order to elucidate the cause of stomal ulcer, one of the complications associated with pancreatoduodenectomy, an investiagation was experimentally carried out to determine the relationship of exo-and endocrine gastric functions to the extent of preservation of the duodenal bulb after duodenectomy with preservation of the stomach and the duodenal bulb (preservative surgery). After the preservative surgery, the basal acid output, maximum acid output and insulin acid output were markedly increased, by 216.7%, 50.3% and 108.5%, respectively, when 1 cm of the duodenal bulb was preserved, while when 3 cm of the duodenal bulb was preserved, the changes were negligible, 5.5%, 3.0% and 1.9%, respectively, that is, as the extent of preservation of the duodenal bulb increased, the rate of increase in gastric acid secretion decreased. Secretin was present in a high concentration in the distal part 2 to 10 cm removed from the pyloric ring. These findings suggest that the postoperative increase in gastric acid secretion as due to the disruption of the duodenal brake. Further more, when 3 cm of the duodenal bulb was preserved, functions of physiological exo-and endocrine gastric secretion were retained. This finding indicates that the occurrence of postoperative stomal ulcers can be prevented by preserving the duodenal bulb to this extent.

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Our strategy for peritoneal dissemination (PD) in gastric cancer has been the elaborate resection of the tumors and continuous hyperthermic peritoneal perfusion (CHPP). In 58 patients (primary, n=40; recurrent, n=18) with gastric cancers with PD the cancers were grouped into tubercular (TB), nodular (ND), diffuse (DF), and unclassified type by gross findings. The predominant characteristics of the patients with PD were Borrmann types 3 and 4 (84%) in gross findings, poorly adenocarcinoma (71%) in histological finding, under ssγ(96%) in depth, scirrhous (71%) in stroma, INFγ(82%) in infiltrative growth, ly₂+ ly₂(70%) in lymphatic invasion, and v₀+ v₁(94%) in venous invasion. In the recurrence group there were more TB and DF types than in the primary group (p<0.05). There was no significant difference in survival times between the primary and the recurrence groups or between types of PD. The survival time of the resected group was significantly longer than that of the non-resected group (p<0.01). The survival time of the CHPP (+) group was significantly longer than that of CHPP (-) group (p<0.05). In the TB and ND types the outcome in the resected and CHPP (+) groups was better than in the non-resected and CHPP (-) groups. Resection of the tumor and CHPP have a chance of improving the patients with gastric cancer with PD, especially of the TB and ND types.

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In 149 cases of gastric cancer, 4 kinds of tumor markers, namely CEA, TPA, IAP and CA19-9 were simultaneously determined, followed up for changes, a nd examined before and after the operation. Recurrenceas noted in 10 of 99 cases of curative resection, 8 of which showed positivity for some these markers around the time of recurrence. It was suggested that follow-up by quadruple combination assay can contribute to the confirmation of recurrence. In particular, postoperative changes in preoperatively positive markers require much attention in view of their possible contribution to early confirmation of the recurrence. In terms of immunohistological stainability of CEA and CA19-9, the stromal type showed higher serum values than the other types, and some correlation between the modes of localization and serum value was suggested. In recurrent cases, CA19-9 staining-negative cases showed no increase in serum CA19-9, either before the operation or at the recurrence. These findings suggest that much attention should be paid to postoperative changes in staining-positive markers and a combination assay with some other marker is useful for early diagnosis of the recurrence in staining-negative cases.

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The role of glucagon as a blood-borne mediator of the gastric hyperdynamic circulation associated with liver cirrhosis was assessed by clinical and experimental studies. Clinical study: Both mucosal and submucosal blood flow in the gastric body was measured by the hydrogen gas clearance method through endoscopy in 42 patients including 30 cirrhotics and 12 non-cirrhotic controls. Furthermore, arterial glucagon concentration (IRG), left gastric venous blood pO₂(LGV-pO₂) and radial arterial blood pO₂(A-pO₂) were measured in the cirrhotics.(1) The patients with cirrhotic portal hypertension showed reduced blood flow in the gastric mucosal layer, but increased flow in the submucosal layer, as compared with the controls.(2) The gastric submucosal blood flow was significantly correlated with IRG (r=0.430, p<0.05).(3) There was a significant correlation between IRG and LGV-pO₂/A-pO₂(r=0.545, p<0.05). Experimental study: Hyperglucagonemia was produced in 10 hamsters by inoculation of the In-R1-G9 cell line. Blood flow of the stomach was measured by the laser-Doppler velocimetry method.(4) The gastric blood flow in the hyperglucagonemic hamsters was higher than in the normal controls [3.90±0.28 vs. 3.22±0.10 V (mean±SD), p<0.001)]. The results of these studies support the hypothesis that glucagon mediates a protion of the gastric hyperdynamic circulation associated with liver cirrhotic portal hypertension.

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Changes in the portal circulatory pattern and regional hepatic blood flow (rHBF) after surgical liver resection were studied by 133Xe-scintiphotosplenoportography (SSP). The visual patterns of pre-and postoperative portal circulation were compared. Different patterns were observed after the operation in five of 27 patients (portosystemic shunt formation 3, progression 1, regression 1). The patients with porto-systemic shunt showed postopertive complications (massive ascites, jaundice, cardiopulmonary failure) more frequently than those without it. The ratio of rHBF increase (post-/pre-operative rHBF) was 1.36±0.63 on average. The ratio was higher in patients with good liver function or without liver cirrhosis. The ratio also correlated with the weight of the liver resected. But operation time, blood loss or whether hepatic bloodsupply was clamped off during the operation did not affect the ratio. Resection in the right lobe, however, caused a greater rHBF increase in the residual liver than the same degree of resection in the left lobe. SSP could be a useful method for investigating the effect of hepatic resection on portal hemodynamics and it is suggested that existence of portosystemic shunt influences the postoperative course.

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We determined the effect of obstructive jaundice and its relief on liver regeneration after partial hepatectomy in rats. Rats received bile duct ligation, then 5, 10 or 14 days later choledocho-duodenostomy for its relief was performed. Partial (68%) hepatecotmy was performed at various intervals after the relief. We assessed the changes in: hepatic protein, DNA and RNA content after bile duct ligation, serum total bilirugin. GOT levels and hepatic DNA synthesis after partial hepatectomy. The hepatic protein content was significantly low after bile duct ligation compared with control rats and was restored gradually by drainage. There was no difference in hepatic protein content among the three different periodds of obstruction. The hepatic RNA content was unchanged, but the DNA content increased markedly in obstructive jaundiced rats without significant differences among the three periods. The rats with shorter periods of drainage showed higher levels of serum total bilirubin and GOT after partial hepatectomy. Hepatic DNA synthesis was significantly inhibited in obstructive jaundiced rats compared to pair-fed controls that received partial hepatectomy alone. Whle the inhibition disappeared after 5 days of drainage in the 5 day-obstructed group, the inhibition was detectable as late as 21 days after drainage in 10-and 14-day-obstructed groups, and the recovery of DNA synthesis occurred more than 30 days after the relief.

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Changes in hepatic secretion of primary bile acids (CA, CDCA) and bilirubin after oral administration of ursodeoxycholic acid (UDCA) (500 mg/body) were studied seven days after biliary decompression in 15 patients with malignant obstructive jaundice. Five patients with T-tube drainage after biliary tract lithotomy were used as the control. The results were as follows. 1) Bile flow was increased and reached a peak on 90 minutes after UDCA administration, then decreased gradually. 2) UDCA excretion was increased gradually in both the jaundice and the control group, but the rate of increase until 180 minutes was lower in the jaundice group than in the control group. 3) Before UDCA administration, CA secretion was 11.67 ± 6.5 mg/30 minutes in the jaundice group and 33.7 ± 7.0 mg/30 minutes in the control group. CA secretion was faster and in 60 minutes reached a peal that was approximately 50% higher than that before UDCA administration in both groups. Hoever, in a later stage CA secretion tended to remain at a high level in the jaundice group and diminished rapidaly in the control group. 4) Changes in CDCA secretion appeared to be similar to those in CA secretion. 5) After UDCA administration, bilirubin excretion was markedly increased in the patients who showed a prompt decrease in serum bilirubin. UDCA administration is thought to promote the synthesis of hepatic bile in patients with malignant obstructive jaundice after release of biliary obstruction.

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Clinical defecatory function, neorectoanal manometry and pouchography were assessed in 21 patients (18 with ulcerative colitis and three with familial polyposis coli) treated by restorative proctocolectomy with ileal W pouchanal anastomosis. The results are as follows: 1) The clinical score of neorectal function improved with time. 2) Daily stool frequency decreased with time and was 4.3 ± 1.2 at 6 months after ileostomy closure, 3.8 ± 1.2 at 12 months, and 3.3 ± 1.0 at 24 months. 3) There was an inverse linear relationship between daily stool frequency and maximal tolerated reservoir volume. 4) The horizontal diameter and dilatation ratio of the reservoir were significantly greater than those of the normal rectum. There were inverse linear relationships between daily stool frequency and horizontal diameter of the reservoir, and daily stool frequency and dilatation ratio of the reservoir. These results, show that maximal tolerated volume, horizontal diameter and dilatation ratio of the reservoir reflected neorectoanal function well, and we conclude that restorative proctocolectomy with ileal W puoch-anal anastomosis is a very effective operation for patients with ulcerative colitis and familial polyposis coli.

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We describe two patients with bleeding esophageal varices who underwent proximal gastrectomy and interposed esophagojejunostomy. The first patient is 63-year-old man who had those procedures because of a bleeding E-G junctional ulcer and had been given a blood transfusion 14 years earlier. The second patient is a 55-year-old woman with idiopathic portal hypertension who underwent the abovementioned procedure for remnant gastric carcinoid and recurrent esophageal varices 4 years earlier. These esophageal varices were eradicated by several sessions of endoscopic sclerotherpay. To date, no bleeding has reccured in 6 months. The abdominal angiographic studies in these two cases revealed, in the second case, some collaterals between the esophageal varices and the enlarged venous system of the interposed jejunum and, in the first case, there were no such collaterals only an enlarged marginal vein of the interposed jujunum. The regional hyperdynamic state in the interposed jejunum might have caused the esophageal varices in the first case.

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A case of T-cell primary gastric malignant lymphoma in a 61-year-old male is reported. The tumor occupied a large part of the body and antrum of the stomach with direct invasion into the pancreas and multiple lymph node metastases around the abdominal aorta and the roots of the celiac and superior mesenteric arteries. Immunohistochemical analysis of the membrane antigen of the tumor lymphocytes for subunit classification revealed phenotypical correspondence with helper/inducer T cells. Most primary gastric malignant lymphomas have been reported to be of B-cell origin, and according to the literature this will be the fifth case of such a lymphoma of T-cell origin ever reported in this country. Total gastrectomy was performed and was followed by chemotherapy with a combination of vincristin, cyclophosphamide, adriamycin and prednisolone, and this has been so effecitve that the residual intraabdominal mass disappeared from the CT-scan 10 months after the initiation of thepapy.

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A rare case of extragastric developing type carcinoma of the stomach with cyst formation is reported. A 74-year-old male complaining of dyspnea and general fatigue was admitted in May 1988. Upper gastrointestinal tract barium contrast study revealed a protruding lesion at the greater curvature of the antrum. This lesion looked like a submucosal tumor. The biopsy specimens revealed adenocarcinoma and subtotal gastrectomy was performed. Macroscopically, the serosal surface of the resected specimen showed an extragastric developing and round nodule measuring 7×5 cm. The cut surface revealed variously sized multiple cysts beneath the mucos-al layer up to the serosa. Microscopic examination revealed proliferation of cystic structures composed of collumar epithelium and, in some areas, tubular or papillary proliferation. The metastatic lymph node showed the same findings. It is suggested that this is a rare case of extragastric developing type carcinoma of the stomach with cyst formation.

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A case of advanced gastric cancer combined with idiopathic thrombocytopenia purpura (ITP) is reported. After the infusion of intact-globulin and transfusion of platelets, total gastrectomy and splenectomy were safely performed. A review of the literature revealed that ITP combined with solid cancer were dominant in males and the elderly than ITP alone.

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Recurrence of three hepatocellular carcinomas after primary liver resection was discovered in the bones by particular symptoms relating to their location. Case 1: a 58-year-old male, 2 years and 6 months after the operation, had sensory disturbance below C₄, paraplegy and vesicorectal disturbance, and signs of transection. MR imaging showed a metastatic lesion at the 4th cervical vertebra and a shirt of the spinal cord to the right. We diagnosed the condition as cervical vertebral metastasis of the hepatocellular carcinoma. Case 2: A 53-year-old male, 6 months after the operation, had sudden severe left chest pain and dyspnea. He received hemothorax and a computed tomogram showed a large mass protruding from the left 3rd rib in the left chest cavity. The pleural bleeding was diagnosed as being caused by rupture of the metastatic region at the rib. TAE was effective in stopping the bleeding. Case 3: A 61-year-old male, 6 months after the operation, had uncontrolled nasal bleeding. Biopsy revealed metastasis of hepatocellular carcinoma to the nasal bone and nasal mucosa. Ligation of the right external carotid artery was not able to stop the bleeding.

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We experienced a case of ectopic pancreas in the liver which is very rare and has not been reported in Japan. A 42-year-old man was admitted to the hospital with general fatigue and jaundice. Ultrasonography and computed tomography revealed severe dilatation of the common bile duct and the left branch of the intrahepatic bile duct. Endoscopic retrograde cholangiography revealed floating stones in the common bile duct. Cholecystectomy and choledocholithotomy were performed. Intraoperative cholangiography revealed dilatation of the left branch of the intrahepatic bile duct, so left lateral segmentectomy of the liver was performed. Macroscopically no tumor was seen in the resected liver, but histologic examination revealed ectopic pancreatic tissues, which were composed of acini, ducts and no islet cells, along the dilated intrahepatic bile ducts.

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A rare case of nonfunctioning islet cell tumor is reported with a view of the literatures. A 35-year-old woman was admitted because of epigastric discomfort. Laboratory data, ultrasonography, computed tomography, endooscopic retrograde pancreatography, and angiogram led to the diagnosis of the pancreas cancer located in the body. Distal pancreatectomy was carried out. A tumor measuring 4.5×4.5×4.0cm was located in the body of the pancreas. Histopathological findings revealed islet cell carcinoma.

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Two cases of so-called mucin producing pancreatic cancer are reported. Both of these tumors were histologically found to have extended in to the main pancreatic duct and its branches in the whole pancreas. Both patients were male, 74 and 46 years of age, respectively. They had epigastralgia in common as the chief complaint and, by several examinations, dilation of the main pancreatic duct and mucin pooling were observed. Total pancreatectomy was performed on both under the diagnosis of a mucin producing pancreatic tumor. In the first case, the main pancreatic duct was markedly dilated from the body through the tail and contained mucin, and an elevated lesion was noted at its tail. Histologically, the tumor was non-invasive adenocarcinoma and cancer cells spread in the fashion of intraductal growth continuously almost all the way to the peripheral branches. In the second case, mucus pooling as rather mild, and the main pancreatic duct and its branches were dilated owing to obstructive growth of the tumor which replaced almost all of the pancreas. Histologically, the tumor was noninvasive papillotubular adenocarcinoma. Only two cases of non-invasive ductal carcinoma with extension to the main pancreatic duct and its branches from head to the tail have been reported as mucin producing pancreatic cancer in Japan. In light of the pathological feature of mucin producing pancreatic cancer, this entity is considered to be an indication for total pancreatectomy.

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There are many clinical and histological problems in mucin producing pancreatic cancer (MPPC). We experienced a case of cystic adenocarcinoma of the pancreas in a 73 year-old woman, in whom the main pancreatic duct was dilated as in MPPC. Several examinations revealed that she had pancreatic cancer which was diagnosed as MPPC and we performed a pancreaticoduodectomy. We could not observe a tumor in the main pancreatic duct of the specimen, but we found a papillomatous tumor in a cystic dilatation of the pancreas head. It was it is unclear if these cystic dilatations were from a branch of the pancreatic duct or not. The histological diagnosis was cystadenocarcinoma. According to TNM Post Surgical Histopathological Classification, this cancer was pT2, pN0, pM0, stage I. It is difficult to decide whether this was a case of MPPC or cystadenocarcinoma of the pancreas communicating with the main pancreatic duct. But these two diseases could be categorized as mucinproducing pancreatic tumor.

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A case of small carcinoma of the pancreatic body with obturator node metastasis is reported. A 60-year-old woman underwent an extended total hysterectomy for squamous cell carcinoma of the uterine cervix on April 17, 1987, and histological examination revealed adenocarcinoma in the small obturator node. Morphologic techniques for detection of the primary lesion revealed small carcinoma of the pancreatic body. Distal pancreatectomy was performed on June 5. No swelling of the parapancreatic or paraaortic nodes could be found macroscopically. Histological examination of the pancreatic tumor, which measured 1.8×1.7 cm, showed mainly moderately differentiated tubular adenocarcinoma and the same findings were observed in the obturator node. These facts demonstrate the difficulty of intraoperative evaluation of the stage of carcinoma of the pancreas and that even in small carcinoma there can be further lymph node metastasis even if extended resection is carried out. Therefore we believe that multi-disciplinary treatment such as intra-and postoperative chemo-and immunotherapy is necessary in addition to extended resection even in small carcinoma of the pancreas.

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Generally, it is difficult to make a correct preoperative diagnosis of small intestinal tumor, but in this case Computed Tomography, echography and angiography was diagnostic. We could not resect all tumors. Now we follow up the behavior of the tumors, because frequently histological examination cannot determine the grade of malignancy.

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A 26-year-old woman consulted a gynecologist because of lower abdominal pain and an abnormal uterine discharge, and was diagnosed as having an overian dermoid cyst. She was admitted to the gynecological department of our hospital. An over fist sized-tumor was palpable in touch with the uterus by the vaginal examination, and the ultrasonography and computed tomography of the abdomen revealed an abnormal and heterogenous mass, measuring 8×4 cm, of which the margins were not clear, in the lower abdominal cavity. Exploratory laparotomy revealed a diffuse and polycystic mass with chylous fluids in the ileum, 10 to 50cm distant from the anal end of the ileum, and also in the iliac mesentery. The ileectomy and an edge resection of the ovary was performed. Histological examination of the specimen showed cavernous lymphangioma. Lymphangioma is rarely encountered in the small intestine and is difficult to diagnose before surgery because of the anatomical features of the intestine. A case of lymphangioma of the ileum and its mesentery, suspected of an ovarial dermoid cyst was reported.

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A 56-year-old male was admitted to National Tohsei Hospital on November 14, 1989, complaining of lower abdominal pain and a mass. An ultrasonogram, a barium enema and rentogenography, a colonofiberscopic examination and an abdominal CT revealed a hard hen's egg sized tumor of the appendix. The tumor was diagnosed preoperatively and operated on as a primary cancer of the appendix, but the resected specimen was found to be a chronic inflammatory granuloma of the appendix due to fish bone perforation. This believed to be the first report of such a case in Japan.

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The patient was a 44-year-old female complaining of pain and a mass in the right lower quadrant. Physical examination and laboratory data suggested acute appendicitis. Findings by medical imaginings and fiberscopy also indicated acute appendicitis. Treatment with antibiotics improved her symptoms as well as physical signs. An appendectomy was performed. The appendix (5.5 cm) was swollen and hard, especially at the tip, and spiral-shaped. Microscopic sections showed endometrial glands, stroma and hemorrage in the subseromuscular layers. The mucous layer was grossly normal. A detailed history taken after surgery revealed that she felt right lower quadrant pain without periumbilical pain, nausea or vomiting and that the symptoms occurred just after menstruation. These findings are suggestive of appendiceal endometriosis. We have to bear appendiceal endometriosis in mind when diagnosis of acute appendicitis is made.

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Pneumatosis cystoides intestinalis is uncommon, but sometimes presents as free air in the abdominal cavity and may require an emergency operation. We report a patient treated for pneumatosis cystoides intestinalis in the jejunum, in hom gastro-intestinal perforation was suspected before surgery. The patient as a 35-year-old man. His chief complaint was abdominal distension gradually increasing during about 20 days before admission. He consulted our department on June 19, 1989. Marked abdominal distension and free air in the abdominal cavity were revealed by X-ray. From these findings, gastro-intestinal perforation was suspected and an emergency laparotomy was performed. The operative findings ere as follows: 1) 1600 ml of light yellow, clear serous ascitic fluid; 2) absence of perforation; 3) edematous thickening of the jejunal wall over 10 cm in length at approximately 50 cm from Treitz's ligament; 4) a number of vacuoles of various sizes in the subserosal layer of the jejunum and its mesentery. A diagnosis of pneumatosis cystoides intestinalis was made and the jejunum including the lesion was resected. The specimen showed a number of soft polypoid lesions about 5 mm in diameter in the mucosa. Histopathological examination revealed a number of cysts in the submucosal layer and these cysts were surrounded by granulomatous changes including polynuclear giant cells in the stroma. Moreover the inner surface of these cysts was covered by a lining of flat cells, and this was considered a case of “primary pneumatosis”.

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We report a lipoma of the transverse colon which is rarely encountered. A 61-year-old woman complained of abdominal pain. A barium enema showed a smooth tumor in the transverse colon. Colonofiberscopic findings revealed a submucosal tumor which was elastic-soft with erosion. The CT value of the tumor was-80 Hounsfield unit, identical with that of adipose tissue. From these findings, we diagnosed the tumor as a lipoma of the transverse colon. A partial colectomy was performed and the resected tumor was 3 × 3 × 7 cm in size. The histopathological diagnosis was a typical submucosal lipoma.

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Hemorrhage from colonic diverticula is self-limiting in the majority of cases; therefore a conservative attitude to therapy has been recommended. We experienced a case of massive bleeding of a colonic diverticulum, which required resection of the colon. A 76-year-old man with a history of alcoholism was admitted to our hospital for acute pancreatitis (serum amylase 2, 056 u/l, urinary amylase 21, 850 u/l) and was treated by conservative therapy. Bleeding began and stopped spontaneously. A barium enema showed two diverticula in the ascending segment and many in the sigmoid segment, which were suspected as the source of bleeding. A second massive hemorrhage occurred, and was uncontrollable. Then right hemicolectomy was undertaken after selective mesenteric arteriography revealed the diverticular bleeding in the ascending colon. He died of pneumonia and multiple organ failure following pancreatitis. Arteriography accurately located the site of hemorrhage, and effective surgical therapy was possible.

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A case of multiple lymphangioma of the colon, a very rare disease, is reported. A 62-year-old woman consulted her home doctor with complaints of recurrent diarrhea and tenesmus, and multiple polypoid lesions were found in the ascending to transverse colon after barium enema. A colonofiberscope revealed a smooth surfaced and pale-blue soft submucosal tumor, which was revealed by colonofiberscopic ultrasonography as a cystic lesion having some septums. The Diagnosis of a lymphatic cyst of the colon was made and a right hemicolectomy was performed. Histologically, any tumor was diagnosed as cystic lymphangioma. Agha reported 22 cases of colonic lymphangioma abroad and this is the 50th case reported in Japan. According to the Japanese literature, the average age of the patients is 53.1 yr and this disease is found more often in males than females with a ratio of 3 to 2. The lesion is present more often in the right-sided colon. It is said that the differential diagnosis of colonic submucosal tumor is difficult. But the ultrasonic colonofiberscope is an efficient apparatus with which one can determine the location and characteristics of the lesion, and it is possible that it will be an useful means of differential diagnosis.

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We report two cases of renal cellcarcinoma meatastasized to the pancreas and to the gallbladder. Case 1: A 65-year-old female patient, who underwent radical right nephrectomy for renal cellcarcinoma 7 years ago, was admitted to our hospital suffering from back pain. On physical and laboratory examination, there were no significant findings except for a diabetic pattern in the glucose tolerance test. Enhanced CT and angiography revealed a relatively well-defined mass at the tail and body of pancreas. Sixty of pancreatectomy with splenectomy was performed. Histological examination revealed pancreatic recurrence of clear cell type renal cell carcinoma. Case 2: A 61-year-old male patient was admitted with the complaint of constipation. There were no abnormal physiological findings, Blood chemistry on admission showed a slight increase in total bilirubin (1.2 mg/dl). Endoscopic retrograde cholangiopancreatography revealed a tumor at the fundus of the gallbladder. Angiogram revealed a hypervascular tumor at the fundus of the gallbladder and the upper pole of the right kidney. Right radical nephrectomy and extended cholecystectomy were performed. Histological examination revealed renal cell carcinoma of the right kidney with a metastatic tumor of the gallbladder.

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