The results of treatment of superficial esophageal cancer in 25 patients receiving subtotal esophagectomy and in six patients receiving curative irradiation were evaluated. As a result, the following treatments are recommended for the various endoscopic types of superificial esophageal cancer. The endoscopic types of operated cases consisted of six cases of superficial and protruded type; two cases of superficial and depressed type; 14 cases of slightly depressed type and three cases of flat type. 1) Superficial and protruding type (type 0-I) and superficial and depressed type (type 0-III), as viewed from the recurrent types of postoperative recurrent cases, require subtotal esophagectomy with extensive lymph node dissection of upper mediastinal cervicalarea. 2) Slightly elevated type (type 0-IIa) and slightly depressed type (type 0-IIc), as viewed from postoperative complications and “quality of life” aspects, subtotal esophagectomy with standard lymph node dissection around the esophagus is recommended. 3) The flat type (type 0-IIb) were all intraepithelium carcinoma with no lymph node metastasis. Consequently, to eliminate operative invasion, extraction of the esophagus without thoracotomy is recommended. 4) From a separate viewpoint, for cases in which severe dysfunction of the organs exist, curative irradiation would be the favored choice.

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The authors attempted to determine whether preoperative nutritional support can reduce the incidence of postoperative pulmonary complications following esophagectomy for carcinoma of the esopagus in elderly patients. Preoperative nutritional parameters, muscle strength, and spirometric function were measured in 151 patients (group I: 45 patients, 70 years of age or older, group II: 106 patients, 33 to 69 years). These patients were followed for postoperative pulmonary complications. The relationship between response to preoperative nutritional support and postoperative pulmonary complications was also examined. There were significant differences in muscle mass, serum albumin level, muscle strength, and spirometric function between group I and group II preoperatively. The incidence of postoperative pulmonary complications in group I was greater than that in group II (p<0.05). Out of 10 patients in group I who received preoperative nutritional support, 7 exhibited weight gain and a decrease in serum albumin. Out of 19 who received nutritional support in group II, 12 exhibited this response. Of the group I patients, 57% (4 out of 7) who showed weight gain and a decrease in serum albumin developed pulmonary complications postoperatively. By contrast, none of the group II patients with this response developed pulmonary complications. On the basis of these results, it is concluded that more efficacious preoperative nutritional support is required for elderly patients with carcinoma of to esophagus to reduce postoperative pulmonary complications.

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The expression of epidermal growth factor (EGF) was studied immunohistochemically in a total of 37 esophageal carcinomas and compared with histological findings, prognosis, and DNA ploidy patterns which were measured by the cytophotometrical method. Histologically, the incidence of EFG immunoreactivity in welldifferentiated squamous cell carcinomas was higher than in poorly differentiated squamous cell carcinomas. A significant correlation was observed between the depth of tumor invasion, lymphatic invasion and EGF immunoreactivity (p<0.05). Furthermore a good correlation was demonstrated between lymphnode metastasis, DNA ploidy pattern and EGF immunoreactivity. The survical rate was worse for patients with EGF-positive tumor cells than for those with EGF-negative cells. These findings suggest that EGF stimulates proliferation and differentiation of esophageal carcinoma and influences its prognosis.

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To clarify the pattern of mediastinal lymphatic metastasis in cancer of the thoracic esophagus, the distribution of positive lymph nodes on CT was investigated in 50 patients whose tumors were clinically unresectable because of too advanced disease. Lymph nodes along the recurrent laryngeal nerves and subcarinal nodes were classified as the primary drainage nodes. It was suggested that the following lymphatic routes are involved in further lymphatic extension: from the right recurrent laryngeal nerve nodes to the right deep cervical nodes or right upper pretracheal nodes, from the right upper pretracheal nodes or subcarinal nodes to the right lower pretracheal nodes, and from the left tracheobronchial nodes to the subaortic nodes. When the left deep cervical nodes, lower pretracheal nodes, anterior mediastinal nodes, subaortic nodes or preaortic nodes were positive on CT, the disease was extremely advanced. However, in patients, presenting palpable right deep cervical involvement or right recurrent laryngeal nerve palsy, the cancer was occasionally not so extensive on CT as to be regarded as unresectable.

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The effect of insulin-induced hypoglycemia on serum group I pepsinogen (PGI) levels, gastric H and pepsin sectetion was studied before and after selective proximal vagotomy (SPV) in 27 duodenal ulcer and gastric ulcer patients. The gastric H and depsin output decreased significantly after SPV, and it was more marked in duodenal ulcer patients than in gastric ulcer patients. The basal serum PGI levels in the patients with duodenal ulcers and gastric ulcers were 83.9 and 76.4 ng/ml, respectively, which were significantly higher than the control levels (48.5 g/ml). After SPV, the basal serum PGI level decreased significantly in duodenal ulcer patients, but it was unchanged in gastric ulcer patients. In duodenal ulcer patients, insulin-induced hypoglycemia caused a significant increase in the serum PGI level, but the increase did not occur after SPV. In gastric ulcer patients, no increase in serum PGI levels after insulin administration was observed before or after SPV. In peptic ulcer patients, the synthesis and transport of pepsinogen into the blood stream and gastric lumen is activated by vagal stimulation. The activity seems more pronounced in duodenal ulcer patients.

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The present study was conducted to determine the relationship between the gastric mucosal defense and acid secretion before and after biliary drainage in patients with obstructive jaundice. Studies were carried out on 16 patients with normal endoscopic findings of the gastric mucosa, 18 obstructive jaundice patients without biliary drainage and 11 patients with biliary drainage. Endoscopic investigation included gastric mucosal blood flow (GMBF), potential difference (PD), prostaglandin E₂, F₂a (PGE₂, F₂a) and pH of the mucus lake (pH). In the normal group, GMBF of the body of the stomach was about 1.3 times higher than that of the angle and antrum, but in patients with jaundice, the GMBF in the body tended to be lower. The PD of each region in patients with jaundice tended to be lower than in the normal group. After biliary drainage, a tendency towards improvement in GMBF and PD, and towards a decrease in PGE₂ was seen. In conclusion, it is suggested that a decrease in PD and PGE₂ p ays an important role in the occurrence of acute gastric mucosal lesion with obstructive jaundice.

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Forty-eight cases of cancer in upper stomach with esophageal invasion were classified as expansive type or infiltrative type from the histological form of the invasion, and studied according to each clinical feature. The macroscopic type of the main lesion in the expansive type was mostly Borrmann type 1 or 2, and in the infiltrative type, Borrmann type 3 or 4. The latter showed a statistically high non-curative resection rate (67.9%). The rate of metastasis to the mediastinal lymph node was 10.0% for the expansive type and 46.4% for the infiltrative type, while the rate of metastasis to the paraesophageal and diaphragmatic lymph node (No.110, 111) was very similar to that of the lymph nodes around the celiac artery (No.9) or the common hepatic artery (No.8). The outcome for the inifltrative type was poorer than that for the expansive type because of the lower curative resection rate, but in curative cases there was no significance between them. In conclusion, dissection of the mediastinal lymph node is not useful in non-curative cases of the infiltrative type because the cause of death is mainly carcinomatous peritonitis. However, in curative cases laparo-phreno-thoracotomy or laparo-phreno-sternotomy should be performed for cancer in upper stomach with esophageal invasion.

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Venous invasion in cancer of the stomach was investigated in two series which were similar in several clinicopathological aspects, one (A) consisting of 235 surgical cases and the other (B) of 115 cases. For histological examination double staining with Victoria blue and hematoxylin-eosin was routinely used, supplemented with endothelial staining using factor VIII-related antigen and basement membrane staining using polyclonal antibody to laminin. The incidence of venous invasion was 37.0% in series A, while its incidence was 48.3% when the 55 cases in which invasion was confined to the mucosa were excluded. It was 56.0% in series B, though the average number of tissue sections examined in B was double that in series A. The incidence of venous invasion increased proportionately to the depth of penetration of the cancer, the degree of lymphatic invasion and lymph node metastasis, though no significant relationship was found between the incidence of venous invasion and the histologic type of cancer. Histological examination of tumor tissues which were obtained from both central and peripheral parts, totaling at least four pieces, were preferable for detection of venous invasion. Double staining with Victoria blue and hematoxylin-eosin proved to be useful for detecting venous invasion in carcinomatous tissue, though endothelial and basement membrane markers have great specifity.

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Biochemically modulated chemotherapy preceded by administration of methotrexate (MTX) and followed by 5-fluorouracil (5-FU) was given to 40 patients with advanced grastric cancer. The standard procedure was weekly intermediate-dose therapy consisting of MTX 100 mg/m² (i.v.) followed one hour later by 5-FU 800 mg/m² (i.v.) with leucovorin rescue in the following two days with concomitant OK-432 administration, but low-dose therapy of MTX 30 mg/m² and 5-FU 600 mg/m² was an alternative for 9 ambulatory patients. Of the 29 evaluable patients, 7 showed a partial response to the treatment (response rate 24%). Although none of the well differentiated group patients responded to this treatment, the response rate in the poorly differentiated group was as high as 35%. Seven responders and 5 other minorly improved patients showed the histological characteristics of poorly differentiated adenocarcinoma. In addition, effusion in the abdominal or pleural cavity caused by dissemination of the poorlydifferentiated adenocarcinoma was markedly improved in 8 of 12 patients by the treatment, retaining the relativelyhi gh serum MTX level after the intermediate-dose therapy. The rationale of this treatment for patients with poorly differentiated gastric cancer including those with malignant effusion in the pleural or abodminal ca vity was revealed here.

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87 cases of advanced gastric cancer were reviewed to find the answer to whether para-aortic lymph node dissection (R4-lymphadenectomy) improved the prognosis in patients with advanced gastric cancer and to determine the indications for R4-lymphadenectomy. 24 cases of the 87 cases were found to be n4. In 11 cases of n4 cases not judged N4, micrometastasis was found in the No.16 lymph node. In all 24 cases (n4 cases), metastasis was frequent in group 2 lymph nodes, especially Nos. 7, 9, 10, and 11. Furthermore, by measeuring the depth of cancerous invasion, the rate of positivity of prognostic serosal factor (ps (+)) in the n4 cases was found to be 79%, which was higher than that in non n4 cases (p<0.01). It is difficult to diagnose to be n4 during the operation, but it may be concluded that in cases of advanced gastric cancer diagnosed as ps (+) or with metasta sis to group 2 lymph nodes, R4-lymph-adenectomy should be performed to remove micrometastsis in No.16.

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Long-term results were studied in 141 patients who had undergone gastrectomies for gastric cancer invading up to the subserosal layer. The 5-year survival rate for the patients as a whole was 49.1%, while it was significantly lower in the patients who had undergone non-curative resections (15.8%), removal of lymph nodes R1 (18.8%) or R₃ (36.1%), those with cancer of macroscopic type 4 (6.5%), a cancer larger than 10 cm (31.2%), P (+) (18.2%) H (+) (20.0%), microscopically undifferentiated type (39.8%), lymph node metastasis of n₂ (29.0%) or n₃ (25.0%), stage III (29.5%) or IV (16.4%), lymph vessel invasion of ly₃ (28.2%), and a growth pattern of INF_γ (41.8%). The patients in whom the length of cancer infiltration in the subserosal layer was 5 cm or more showed a lower 5-year survival rate (19.8%) than those in whom the length was 4 cm or less (56.1%) (p<0.001). A significant difference was noted between these two groups regarding the 5-year survival rates after the curative resections, 24.8% and 64.1%, respectively (p<0.01). In regard to the mode of recurrence after the curative resections, hematogenous metastasis was characteristic (71.4%) of the latter group, while in the former group, peritoneal disseminating metastasis was the most frequent mode (71.4%) and it seemed to be the main cause of the poor outcome in this group.

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Over the last 18 years, patients with multiple gastric carcinoma were studied by using Moertel's principle. Of a total of 692 patients with gastric carcinoma, there were 24 (3.4%) with multiple gastric carcinoma, including 22 synchronous double lesions and 2 synchronous triple lesions. Seven patients had both primary and secondary lesions in the M-area. Secondary lesions were found to be in the early stages of cancer development. Only one case showed protrusion coupled with indentation. Histologically, 14 patients (58.3%) had double differentiated lesions.In 6 cases, secondary lesions in the C-area showed little histological differentiation. When we perform distal gastrectomy, it is important to refer to the C-area in detail before and during the operation.

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In this study we compared the general rules for the gastric cancer study in Japan with the new TNM staging of stomach cancer by UICC. Even though there are some delicate differences between the two rules, that have many similarities and it seemed rather easy to translate the former into the latter. Both of them seemed to be very useful for predicting the prognosis of gastric carcinoma. However, the new TNM staging does not include the evaluation of the factor of serosal invasion of cancer and some problems still remained to be solved. The new TNM staging is based on the survival rate which might be improved by the progress in treatment. The stage 4 cases according to the Japanese classification include many different prognostic groups and it seems necessary to divide tham into subgroups, which is still controversial. The new TNM staging takes this point into consideration and is thought to be better organized than the Japanese classification.

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Nuclear DNA content of paraffin-embedded specimens from 103 patients with carcinoma of the head of the pancreas was measured by flow cytometry. In order to determine the biological characteristics of pancreatic carcinoma from the viewpoint of nuclear DNA content, the relationship between nuclear DNA content and histopathological findings, prognosis, and recurrence was studied. No correlation between nuclear DNA content and histopathological findings was observed. There was no stastitically significant difference in cumulative survival rates between diploid and aneuploid tumors. On the other hand, five of six patients who survived more than 3 years had diploid tumors. In patients with aneuploid tumors, the survival rates for patients with a DNA index less than 1.5 tended to be higher than those for patients with a DNA index 1.5 or more. Intratumor variation in DNA index from different parts of the tumor was not observed. In patients who received curative resection, those with a DNA index 1.5 or more tended to have liver metastasis and none of the patients with a DNA index less than 1.5 had recurrence. Nuclear DNA content appears to be an important prognostic factor in pancreatic carcinoma, independent of histopathological findings.

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We evaluated perioperative changes in hepatic functional mass in patients who underwent hepatectomy using the galactose tolerance test, which specifically measures metabolism in liver cytosol. Preoperative T-1/2 values on the galactose tolerance test (GaTT-T/2) were significantly prolonged in various hepatobiliary diseases including primary liver cancer and liver cirrhosis (p<0.001), obstructive jaundice (p<0.01), secondary liver cancer and cholelithiasis (p<0.05) in comparison with control subjects. In hepatectomized patients, GaTT-T/2 was the most markedly prolonged at two to five weeks after surgery, but recovered to preoperative values six to eighteen weeks postoperatively. The GaTT-T/2 value at one week after hepatectomy was a good indicator of postoperative course. Furthermore, the ratio of GaTT-T/2 at one week after surgery to the preoperative value was positivery correlated with the parenchymal hepatic resection rate (r=0.799, p<0.001). The perioperative measurement of GaTT-T/2 could be a useful indicator of cytosolic functional mass of the liver in patients who undergo hepatectomy.

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In order to study changes in complex carbohydrates of the large intestine, I used three kinds of lectins, peanut agg lutinin (PNA), Ulex aeropaeus agglutinin-1 (UEA-1), Glycine max (SBA). These lectin binding sites were examined in human normal mucosa, neoplasma, 1.2-dimethyl hydrazine (DMH) induced rat neoplasma and normal mucosa. The cell sarf ace staining increased in parallel with the grade of cellular dyspiasia in human PNA, UEA-1 and SBA and rat UEA-1, and SBA staining and the diffuse staining of cytoplasma increased in parallel with the grade of cellular dysplasia in PNA, UEA-1 and SBA staining of human and rat neoplasma. In the distal normal mucosa of rats, PNA, and UEA-1 binding sites were found by DMH inject. These results suggest that both adenoma in the human large instestine and rat dysplasia induced by DMH are precancerous lesion and that a chemical metabolic change may occur before histological malignant transformation and that the dysplasia developing from the high risk mucosa is the origin of the cancer.

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To elucidate the clinical characteristics of the so-called “string-stricture type” of obstructing carcinoma of the colon and rectum, which looks as if the bowel had been deeply constricted by a string tied tightly around it 22 cases of string-stricture carcinomas were clnico-pathologically compared with 19 cases of non-string-stricture type. String-stricture carcinomas demonstrated the following characteristic features: (1) short duration of symptoms.(2) high rate (63.6%) of emergency surgery.(3) high incidence in the left colon, especially the sigmoid colon (50.0%).(4) relatively short longitudinal diameter and growth to the transverse axis.(5) absence of histopathological features.(6) a high rate of Dukes' group C and D (68.2%), and nuclear DNA aneuploidy (78.6%).(7) poor prognosis (5-year suvival for the curative cases was 15.4%).

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To clarify the incidence and causal factors of catheter sepsis, we studied 715 patients who received total parenteral nutrition from 1986 to 1988 in the Surgical Department at Kansai Medical University. The incidence of catheter sepsis was 17.4% and the culture of the catheter tips was positive in 55 patients (36%). Candida was the most common organism in catheter sepsis (56%) and endogenous fungal endophthalmitis developed in four patients as a part of disseminated candidiasis. Apparently unrecognized systemic candida infection may be more frequent in patients receiving hyperalimentation than was previously suspected. Ophthalmoscopy should be routinely used to manage the patients with catheter sepsis. This should facilitate the early detection and diagnosis of endophthalmitis.

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A case of congenital esophago-bronchial fistula with an esophageal diverticulum in a 27-year-old female is presented. The patient, a pharmacist, was referred to the Yamaguchi Central Hospital in April 1988, complaining of paroxysmal coughing after liquid ingestion which she had suffered from for about 14 years. A barium swallow showed a fistulous tract between the esophagus and the right lower lobe bronchus (B7). Esophagoscopic examination revealed that a diverticulum with a round opening was present in the middle thoracic esophagus (25 cm from the incisors). Bronchial mucosa was seen through the opening. An endoscopic biopsy specimen from the fistula consisted of ciliated columnar epithelium. On May 20th, 1988, she was treated by right thoracotomy and complete removal of the fistulous tract and the diverticulum. The esophago-bronchial fistula was 3 cm in length and 1 cm in diameter, without adhesion to the surrounding structures. There was no lymph node swelling around the fistula. The resected specimen was free from inflammatory change such as lympocyte infiltration and fibrosis. A transitional zone from squamous epithelium to ciliated epithelium was not demonstrated microscopically, but mucosal transition was thought to be present from endoscopic examination and finding of biopsy. Hence, this case was categorized as Braimbridge type I esophago-bronchial fistula.

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To study the intratumoral regional differences in DNA ploidy and the expression of epidermal growth factor (EGF) of esophageal carcinoma, multipre samples from different sites of a tumor each of seven patients were subjected to DNA anlaysis and immunohistochemical examination for EGF. Every patient showed intratumoral regional differences in DNA index and a marked regional differences (0.4 or more) were found in three patients. Intratumoral regional differences in DNA ploidy were obseved in five patients. Regarding EGF expressions, six patients showed regionally different degrees and the degree of EGF expression as closely related to the histological differentiation of the carcinoma. However, there was no certain relationship between DNA ploidy and EGF expression. The results suggest that esophageal carcinoma may constitute a feature of intratumoral regional polymorphism.

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A case of concomitant occurrence of early esophageal carcinoma and early gastric carcinoma is reported. A 46-year-old man was admitted to our hospital after the referring physician found a gastric abnormal shadow on his upper gastrointestinal X-ray film. Endoscopic examination revealed a lower esophageal early carcinoma as well as an early gastric carcinoma at the greater curvature of the lower middle stomach. A subtotal esophagus was stripped out with the whole stomach, and the esophagus was reconstructed with the tranverse colon. Microscopic inspection of the resected specimen revealed an intraepithelial squamous cell carcinoma (2.2×1.6 cm) at to lower esophagus and a poorly differentiated adenocarcinoma (1.2×1.5 cm) at the greater curvature of the lower middle stomach which was limited to the mucosal layer. There was no metastasis to the limphnodes. The occurrence of early esophageal carcinoma with early stomach carcinoma is rare. Only 24 cases have been reported in Japan. Among them only 3 patients had intraepithelial carcinoma.

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Ultrasonography occasionally revealed a tumor in the abdomen of a 76-year-old woman hospitalized for lumbago. The ultrasonography differentiated it from tumors of other organs, but not its primary origin, the same as with CT scanning. Angiography revealed a tumor in the upper body of the stomach, while gastric transillumination and a gastrocamera revealed no lesion in the gastric mucosa, so that a gastro-myogenic tumor was suspected in terms of its incidence. Laparotomy revealed a pedunculated myogenic tumor developing extragastrically from the posterior wall of the upper body of the stomach. It mesured 38×28×55 nm, weighted 35 g and its cross section showed white solid tumor with several parts of necrosis. The tumor showed neither metastasis norperitoneal dissemination and the patient received a local resection and an exploratory lymphadenectomy. Postoperative histopathological examination led to the diagnosis of gastric leiomyosarcoma without metastasis in the resected lymph node. Gastric leiomyosarcoma showing pedunculated extragastric development is very rare and that no report has previously been made of the disease diagnosed asymptomatically. Ultrasonography, which is noninvasive and enables us to obtain much information with ease, is considered a test worth trying for early detection of the disease in aged persons, in whom there are no symptoms but there is high prevalenece.

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A 57-year-old woman was admitted with complaints of epigastralgia and jaundice. A common bile duct stone was detected, and an upper GI series revealed a submucosal tumor in the stomach. Cardiectomy, cholecystectomy, and choledocholithotomy were carried out. The tumor was 4.5×4.0×2.2 cm in size and it had an ulceration at the top. Histological examination including hematoxilin-eosin staining, positive S-100 protein staining, and negative actin staining led to the diagnosis of malignant schwannoma of the stomach. Malignant schwannoma of the stomach is rare, and this is only the 11th report of it in Japan. Difficulty in differential diagnosis from a neurogenic or smooth muscle tumor, such as leiomyosarcoma, and the importance of immunohistochemical methods, such as S-100 protein staining, were emphasized. Because of poor prognosis due to hematogenous metastasis, early detection and treatment of the distant metastases are important.

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A 54-year-old male was admitted to receive hemodialysis for his severe renal failure. When he began to have hematemesis and bloody stools, panendoscopy detected considerable bleeding from a duodenal ulcer. As repeating hemostasis through the panendoscope was not effective, the patient was referred to us for surgery. Laparotomy revealed a very fresh perforation on the anterior wall of the duodenal bulb, and distal partial gastrectomy was carried out. Because histopathological findings led to a diagnosis of polyarteritis nodosa, steroid administration was initiated. The patient got through the risky postoperative period without serious complications. When arteritis affects the gastrointestinal region, ulceration, necrosis, and perforation are known to be its major complications. While arteritis is observed mostly in the jejunum or ileum, the duodenum is an occasional site of the disease.

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Two patients receiving hepatectomy for a metastatic liver tumor with portal vein tumor thrombus are reported. In case 1 a 28-year-old woman multiple metastases in the hepatic right lobe after oophorectomy for embryonal carcinoma of the ovary. A tumor thrombus involved the right portal vein down to its first branch. Extended right hepatic lobectomy was carried out, but she died of hepatic insufficiency due to a recurrent tumor inthe residual liver two months after the operation. In cases 2 a 61-year-old man had a sigmoid colon carcinoma and a solitary metastatic deposit in the hepatic left lobe. A tumor trombus involved the left portal vein down to its first branch. Left hepatic lobectomy was carried out, but after 11 months he died of hepatic insufficiency due to massive metastases in the residual liver. Thus the prognosis for patients is poor despite hepatectomy including the tumorinvolved portal vein. More intensive therapeutic strategies are required to control cases of metastatic liver tumor with portal vein tumor thrombus.

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We had one cholecystectomied case of Dubin Johnson syndrome (D-J syndrome) complicated with gallstones, a 35 year old man with jaundice and right hypochondralgia. His common bile duct and gallbladder were visualized by Drip Infusion Cholecystocholangiography (DIC), but no gallstones appeared. Ultrasonography showed a strong echo with acoustic shadow in the gallbladder, which on cholecystectomy contained 327 cholesterol gallstones. They consisted of more than 98% cholesterol. His postoperative liver function was almost the same as the preoperative one. On the 3rd postoperative day his maximum level of serum total bilirubin and direct bilirubin were 5.6 mg/dl, 4.0 mg/dl respectively. His postoperative course was uneventful. A total of 24 such cases are reported in Japan to 1988, including our case. In these cases, younger generation from 10 to 29 years old is more frequently complicated with gallstones, compared with the same generation of operated gallstone cases without D-J syndrome. When patients with D-J syndrome complain of abdominal pain, it is important to check for gallstones by ultrasonography at first too.

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A 72-year-old man was admitted because of right hypochondralgia. Urtrasonography and computed tomography failed to detect a gallbladder. The gallbladder and the cystic duct were not visualized by drip infusion cholangiography or endoscopic retrograde cholangiography. These findings of graphic studies suggest the possibility of congenital absence of the gallbladder and cystic duct. At laparotomy, the abdomen was carefully explored. The liver was normal, but the gallbladder and cystic duct were congenitally absent. The common bile duct was slightly dilated. No other abnormalities were found. He had slight right hypochondralgia after the operation. Now he is being followed up carefully.

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A case of mesenteric panniculitis is presented. Mesenteric panniculitis is an uncommon inflammatory disease. An 11-year-old boy was referred to our hospital because of abdominal pain and muscular defense in the whole abdomen. His white blood cell count was 17, 000/mm³. After examination by abdominal ultrasonography, he was operated on for acute abdomen. Laparotomy revealed suppurative ascites and cystic lesions in the transverse mesentery. Some cysts were infected. Tumor resection and drainage were performed. The histopathological diagnosis was mesenteic panniculitis. Acute onset and cystic lesions in mesenteic panniculitis have not been reported previously. This case shows an acute presentation of mesenteric panniculitis.

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Benign rectal ulcer has been said to be a rare disease. Recently, however, the number of cases of this disease has been on the increase. We have encountered 3 cases of benign rectal ulcer which started with a large volume of bloody stools, presented characteristic clinical pictures and were healed in a short period of time. In two patients, both of whom had cerebrovascular disease as an underlying disease, a mass with ulcer was formed in the lower rectum and healed in a relatively short period of time. Therefore, acute hemorrhagic ulcer of the rectum were highly suspected. The remaining patient with a pacemaker implanted was admitted to the hospital because of pelvic fracture. Multiple aphtoid ulcers developed in the upper rectum and also healed in a short period. The cause was not specified. For bloody stools, endoscopic examination should be performed in order to clarify the site and etiology of the lesion. Also it is important to perform biopsies repeatedly even when cancer is suspected macroscopically from endoscopic examination.

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The anal function is controlled by the smooth and striated sphincter muscles which are innervated with the autonomic and somatic nerves respectively. Anatomically, the anorectal angle which is formed by an adequate forward pull of the puborectalis muscle is most important. In manometric study, resting pressure is a function mainly of the internal anal sphincter, and squeeze pressure is a function of the external anal sphincter. In electromyographical study, the external anal sphincter reveals cotinuous or basal electrical potentials in the resting state which is an unusual phenomenon for skeletal muscle. This feature means the anal canal can maintaine in continuous tonic state all the time without fatigue. The same feature is provided as the type 1 fiber predominance by the histochemical staining of the external anal shincter muscle. An assessment employing basic anatomical and physiological features of the anal canal may supply valuable information directly affecting diagnosis and treatment for various anal deseases.

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We, in 1967, introduced a new technique of abdominoperineal anorectoplesty (Nichidai Method) for high type of imperforate anus in which a blind rectal pouch is pulled through the puborectalis muscle under direct vision from the abdomen. In this paper, the essence of the technique and its postoperative functional results were presented. In clinical evaluations of anorectal function of 35 patients who became more than 5 years old (mean age; 15.0±4.8), 40% of them were determined as good, 46%, as fair and 14%, as poor. Further, in these patients, the anorecal function was objectively evaluated by using anorectal manometry, rediography, and pudenal nerve stimulation technique.

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Soiling was noted in 25% of patients after hemorrhoidectomy and in 40% after fistulectomy by questionnaire for patients. Submucosal hemorrhoidectomy in ligature-excision mothod and core-out method without sphincterotomy in fistulectomy were recommended. Mucosal prolapse and anal stricture were common caused by Whitehead's operation and injection necrotherapy, so that these treatments must be refused. Sphincter repair operation was selected for the patient of postoperative sphincter defect within a half circumferential and sphincter replacement operation was performed in the patient of those over a half. But sphincter replacement operation has not resulted the perfect fecal continence.

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Anal function after low anterior resection was studied by means of a questionnaire and colorectal manometry in 103 patients who had been operated on for rectal cancer for more than 1 year. The patients were categorized into two groups: Rb group (48 patients) where the colorectal anastomosis was found 6 cm or less from the anal verge and Rs·Ra group (55 patients) where the anastomosis situated more than 6 cm above the anal verge. More of the Rb patients complained of frequent defecation, loose stool or soiling than those of the Rs·Rb patients. Generally, these complaints were closely correlated, especially in the Rb group, to deranagements (abnormalities) of resting canal pressure and/or amplitude and frequency of bowel contractions registered above the anastomosis. However, some patients were desperately discontented with their new bowel habit despite of their excellent manometric results. For these patients, a special counceling based on their individual circumstances (age, personality, family, profession, social status and so on) seemed to be mandatory to improve their complaints. As a whole, very few of either Rb or Rs·Ra patients had significant problems with regard to daily life.

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As a practical and universal criteria for clinical bowel functional assessment after ileoanal anastomosis, we deviced the “continence disturbance grade (CDG)” which is classified into five categories as follows. CO-1: normal continence, CO-2: nearly normal continence, DC-1: mild dyscontinence, DC-2: moderate dyscontinence and IC: incontinence. They are proportionally correlated with the other parameters such as daily bowel frequency, soiling pattern, noctural defecation, and perianal soreness, use of pad, use of drug, discrimination, and restriction of social ability. In our series of 56 patients including 28 colitis and 28 polyposis who passed 6 months or more after ileoanal anastomosis, 44.6% were CO-1, 25% CO-2, 14% DC-1, 8.7% DC-2 and 7.1% IC. The adverse factors affecting on the continence rate was pelvic sepsis, too short rectal cuff, high age and colitis.

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