Nutritional maintenance and postoperative pulmonary complications were retrospectively studied in 92 patients with advanced esophageal cancer who had received nutritional support during preoperative combined therapy. Hyperalimentation by either elemental diet or intravenous hyperalimentation to these patients resulted in generally good preoperative nutritional parameters, and the increase in rapid turnover serum proteins suggested improvement of preoperative nutrition. It was suggested on the basis of changes in body weight and serum protein that preoperative nutritional support should be at least 35 NPkcal/kg/day, a level that was also useful for recovery from the temporary immunosupression caused by irradiation. But serum albumin tended to decrease with any method or amount of nutritional support. Moreover, the serum albumin level of elderly patients over 70 years dropped lower than that of patients under 69 years. The incidence of postoperative pulmonary complications in the elderly patients was greater (p<0.05) than that in the younger patients if their final preoperative serum albumin level did not reach 3.5 g/dl. These results suggested that the nutritional management of elderly patients with advanced esophageal cancer should be examined more precisely to clarify more effective nutritional support.

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Histopathological status and preoperative assessment were evaluated for lymph node metastasis using conventional and/or endoscopic ultrasonography in 104 patients with thoracic esophageal cancer. Nodal clearance was carried out in three areas, i.e., cervical, mediastinal and abdominal, in all cases. Lymph node metastasis was found in 73 patients (70.2%) by histological examination of surgically removed nodes. The incidence of nodal involvement was 23.1% in the supraclavicular region, 31.7% in the thoracocervical transitional, 30.8% in the upper mediastinal, 22.1% in the middle mediastinal, 17.3% in the lower mediastinal, 38.5% in the perigastric, 19.2% in the celiac and 3.8% in the para-aortic region. Lymph nodes in the supraclavicular, transitional and upper mediastinal regions were more frequently involved in patients with cancer located in upper intrathoracic esophagus. On the other hand, perigastric nodes were frequently involved in those with lower intrathoracic esophageal cancer. The sensitivity of ultrasonography was 75.0% in the supraclavicular region, 60.6% in the transitional, 76.9% in the upper mediastinal, 71.4% in the middle mediastinal, 0% in the lower mediastinal, 67.5% in the perigastric, 65.0% in the celiac and 100% in the para-aortic region. Specificity was more than 80% in all the regions. Although conventionaland/or endoscopic ultrasonography is useful in screening esophageal cancer for lymph node metastasis, neither the surgical option nor the area to be dissected can be defined precisely by the measure itself.

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Ninety-seven patients with thoracic esophageal cancer underwent subtotal esophagectomy and lymph node dissection of three areas, i.e., cervical, mediastinal and abdominal. The operations were all judged curative resections. Recurrence occurred postoperatively in 43 patients (44.3%). The patients with recurrence were divided into two groups according to whether the number of metastatic lymph nodes was 5 or less (group 1) or 6 or more (group 2). Group 1 included 25 patients, and group 2, 18 patients. The time interval from operation to recurrence was shorter in group 2 than in group 1. Of all 43 patients with recurrence, lymph node recurrence occurred in 21 cases, visceral recurrence in 15 cases, and both lymph node and visceral recurrence in 3 cases; miscellaneous recurrence was observed in 4 cases. Upper mediastinal lymph node recurrence was found in a considerable number of cases, including 4 of 6 cases without lymph node metastasis at the time of operation. In 7 of 9 cases in group 2, lymph node recurrence occurred in the left upper mediastinum. Lymph node metastasis had been present in all cases. All the visceral recurrences occurred in cases with lymph node metastasis, which extended to more than two areas in 80% of the cases. The prognosis of patients with recurrence was poor, especially in those with both lymph node and visceral recurrences and with visceral recurrence in group 2. Four patients with lymph node recurrence have survived more than 4 years postoperatively. The indications for extended lymph node dissection and the option of combined therapy should be studied further, taking account of the number of metastatic lymph nodes.

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The purpose of this study was to review the pattern of recurrence of early gastric cancer and the actual state of death from other diseases and cancer of other organs affecting prognosis. The subjects were patients with early gastric cancer, 304 with mucosal cancer and 276 with submucosal cancer. Seventy-one died from the following diseases: recurrent gastric cancer (4 patients, 5.6%), cancer in the remnant stomach (3 patients, 4.2%), noncancerous diseases (41 patients, 57.7%), and cancer of other organs (23 patients, 32.4%). There were recurrences in one patients with mucosal cancer and three with submucosal cancer patients, and three patients had lymph node metastasis (n (-): 1 patients; n₂ (+): 2 patients; n₃ (+): 1 patients). Cancer recurred in the peritoneum, Virchow's node, the liver and lungs. The major causes of death other than cancer were cardiac disease (11 patients, 28.2%), cerebro-vascular diseases (7 patients, 17.9%), and respiratory disease (7 patients, 17.9%). The major causes of death due to cancer of other organs were colorectal cancer (6 patients, 26.1%) and lung cancer (6 patients, 26.1%), followed by hepatoma (4 patients, 17.4%) and pancreatic cancer (3 patients, 13.0%). In general, colorectal cancer was synchronous and lung and liver cancers heterochronous. Consequently, postoperative treatment of early gastric cancer patients demands periodic gastroscopy of the remnant stomach, complete examination to detect cancer in other organs, and preventing death from other diseases.

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Intraoperative peritoneal lavage cytology was performed in 682 patients with gastric cancer to determine the relationship between positive cytology, pathological findings of gastric cancer and prognostic value of positive cytology. The rate of occurrence of free cancer cells was 11.1% in the total 682 cases, 7.2% in resected cases and 2.7% in cases of curative resection. In terms of serosal invasion, the incidence of positive lavage cytology was 14.8% in S₂ and 28.8% in S₃. In terms of depth of wall invasion, it was null in m and sm, 0.9% in ps (-) and 15.2% in ps (+). By macroscopic type, types 3 and 4 of Borrmann's classification, the poorly differentiated type and INFγ showed intraperitoneal free cancer cells, and 22.5% in stage N showed a significantly higher rate. In cases of positive lavagecytology, even if cancer was resected curatively, all patients except one who survived more than 10 years had died as a result of peritoneal dissemination within 3 years after operation. The 2 year survival rate of 24.2% for these patients was not significantly difference from the 8.5% rate for those with peritoneal dissemination.

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To determine the clinicopathological significance of human chorionic gonadotropin α-subunit (HCG-α) in gastric adenocarcinoma, immunohistochemically 127 cases of gastric cancer were studied. HCG-α immunoreactive cancer cells were demonstrated in 10 (7.9%). There was no correlation between the appearance of HCG-α immunoreactivity and gross appearance, histological subtype, pathological stage or outcome. Furthermore HCG-α immunoreactive cells in the normal pyloric mucosa and gastric cancer were immunoreactive with chronogranin A, which is considered to be a useful marker of endocrine cells. Therefore, HCG-α cannot be regarded as a marker of malignancy in gastric adenocarcinoma. It should be regarded as one of the eutopic hormones expressed by endocrine differentiated gastric cancer cells.

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We developed a method of intraoperative peritoneal hyperthemia (IPH) along with cisplatin acompanied with adjuvant immuno-chemotherapy to prevent peritoneal recurrence and to improve the prognosis of gastric cancer with serosal invasion and used the treatment for 21 patients. As a result, although the period of observation is still short, at most one year and seven months, there have been no deaths from peritoneal recurrence of gastric cancer in the IPH-treatd group. The survival rate for the IPH-treated group was significantly higher than that for the control group (p<0.05). The nine-months survival rate for the IPH-treated group (n=19) was 88.0%, whereas that for the control group (n=82) was 66.1%. Moreover, for Borrmann 4 type gastric cancer the survival rate for the IPH-treated group was significantly higher than that for the control group at p<0.001. The one-year and seven-months survival rate for the IPH-treated group (n=6) was 100%, whereas for the control group (n=22) was 24.9%.These results suggested that IPH is an effective treatment for gastric cancer with serosal invasion to prevent peritoneal recurrence.

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The gastrointestinal hormones (gastrin, secretin, glucagon, insulin) and gastric juice (acidity, pH) were evaluated in 51 adult patients who received hepatectomy at the National Defense Medical College from April 1986 to April 1989. The patients were divided into the following four groups: 19 patients who received lobectomy or moreextended hepatectomy (major group), eight patients who received segmentectomy or more limited hepatectomy minor group), 11 patients with complicating cirrhosis (LC group), 18 patients who received both hepatectomy and pancreatoduodenectomy (HPD group). 1) Acidity of the LC group (pre-operation (pre-op) 58.0±5.0, post-operative day (POD) 1 40.5±33.2, 3POD 30.0±15.1, 5POD 39.0±12.1 mEq/1) was lower than that of the other three groups at POD1, 3, 5. 2) The pH of the LC group (pre-op 6.8±0.5, POD1 6.4±1.5, POD3 6.1±1.5, POD5 6.5±1.3) was higher than that of the other three groups at pre-op and POD1, 3, 5.3) The major, minor, and HPD group showed a post-operative decrease in the gastrin level, but the LC group (pre-op 30.0±3.0, PODI 25.7±10.7, POD3 39.0±9.5, POD5 31.7±15.6 pg/ml) showed a constant low level during the pre-and post-operative periods. 4) The secretin level increased similarly in each group with no significant difference between these groups, but the LC group showed the highest rate of increase of these four groups. 5) Glucagon showed a post-operative increase in all groups and the LC group (pre-op 210.3±150.5, POD1 372.5±326.3, POD3 325.0±163.0, POD5 400.0±293.0 pmol/ml) showed consistently higher glucagon levels than the other three groups during the pre-and post-operative periods. 6) The insulin level rose to its maximum point at POD1 in the minor, major, and HPD groups, but the major group reached its highest level at PODS or later. These results indicate that there was no hyperacidity or hypergastrinemia after hepatectomy, especially in liver-cirrhotic patients. To prevent a gastric hemorrhage after hepatectomy, we must pay more attention to improve the defense factors of the gastric mucosa than to suppress the secretion of gastric juice.

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Changes in immunological function were investigated after hepatectomy in 25 patients with malignant liver tumors by various parameters until 4th postoperative week. The patients were divided into two groups consisting of 15 patients associated with liver cirrhosis or active hepatitis (n=15, group A) and 10 patients with no other liver diseases (n=10, group B). The lymphocyte counts and Th/Ts ratio dropped to their minimum levels on the 3rd and 7th postoperative days, respectively. Both NK and LAK activities decreased significantly in the 2nd postoperative week (p<0.05), and showed virtual recovery in the 4th weeks. In group A, this decrease was particularly marked and recovery was delayed. No obvious changes were found in ADCC activity during the course of study. IgG, IgA and IgM levels were reduced on the 3rd postoperative day and recovered by the end of the first week, with group A showing significantly higher values throughout the monitoring period (p<0.05). Both C₃ and C₄ were significantly elevated at 1 week (p<0.05), and then normalized at 2 weeks. In conclusion, in patients undergoing hepatectomy, the suppression of immunological function persists until the 2nd postoperative week. This suppression was more pronounced and recovery was delayed longer in patients associated with combined liver disease.

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Forty of 49 patients with hepatocellular carcinoma (HCC) underwent hepatectomy, excluding 6 with noncurative resection and 3 with operative deaths, were reviewed. Overall one-, three-and five-year disease-free survival rates were 57, 42 and 26%, respectively. The factors significantly associated with recurrence were tumor size over 3 cm in diameter and positive portal vein involvement, but not macroscopic tumor invasion to the cut stump. In cases of tumors under 3 cm in diameter, a good outcome could be expected even if the treatment was limited hepatectomy. There were 25 recurrences in this series, and 22 of them were within 2 years after hepatectomy. One-, two-and three-year cumulative survival rates after recurrence were 63, 26 and 17%, respectively. It was suggested that therapy for the patients with confluent multinodular type and positive portal vein involvement should be developed, since in such cases early recurrence after hepatectomy and short survival after recurrence were observed.

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Clinicopathological studies of 21 patients with polypoid lesions of the gallbladder (6 with adenocarcinoma (AC), 3 with adenoma, 5 with cholesterol polyp (CP), 4 with hyperplastic polyp, 2 with inflammatory polyp and 1 with ectopic gastric mucosa) which were resected in our department in the past five years are reported. Preoperatively, it was difficult to differentiate AC from other disease by ultrasonography (US). Only CP could be diagnosed by US. Most of the patients with AC were elderly and the muximum diameter of all of the polypoid lesions of AC was more than 10 mm. AC was divided into AC in adenoma whose lesions were pedunculated (P type) and advanced AC whose lesions were flat-elevated (F type). F type developed into advanced AC earlier when the maximum diameter of the polypoid lesion was small. All patients with AC are still alive without recurrence. An important factor for good prognosis of AC was that the DNA ploidy patterns of AC were all diploid. We suggest that the indications for surgical treatment of polypoid lesions of the gallbladder are a P type lesion of more than 10 mm and an F type lesion of more than 5 mm, and that total resection of the gallbladder, including lymphnode dissection, choledochectomy and hepatectomy according to the results of frozen sections, should be performed in these cases.

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It has been said that surgical intervention in patients with obstructive jaundice should be preceded by biliary decompression such as PTCD (percutaneous transhepatic cholangio-drainage) and ENBD (endoscopic nasogastric biliary drainage) to improve liver function. Some recent reports, however, have suggested that preoperative biliary drainage does not reduce operative morbidity or mortality. In an attempt to assess the efficacy of preoperative PTCD, the clinical records of 163 patients who had been subjected to pancreatoduodenectomy from January 1980 through December 1990 were divided into an icteric group (83 cases), with a preoperative serum bilirubin value greater than 3.0mg/dl, and a non-icteric group (80 cases), in which this value was below 3.0mg/dl. The icteric group was further divided into a PTCD group (65 cases) and a non-PTCD group (18 cases). There were no significant differences between the icteric group and the non-icteric group concerning operative time, operative blood loss, postoperative hospital stay, operative mortality or morbidity. Only the preoperative hospital stay in the PTCD group was significantly longer than that of the non-PTCD group. From these results and because of the recent advances in surgical techniques and perioperative patient care, we conclude that patients with obstructive jaundice can undergo a radical operation without preoperative PTCD.

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Thirty patients with Crohn's disease who were admitted to our department for surgical treatment were examined regarding gastric acid secretion stimulated by tetragastrin and release of gut hormones such as gastrin, GIP, and total-GLI after test meal loading. The mean MAO of these patients was significantly increased before the operation. MAO and PAO correlated with the length of the small intestinal lesions and the resected segment of the small intestine. Widespread lesions and resection of 100 or more centimeters of the small intestine were associated with increased acid output. Patients with Crohn's disease showed lower gastrin, GIP, and total-GLI levels in the fasting and postprandial state than the control. Immunohistochemical study with anti-glycentin antibody revealed a loss of positive cells in severe lesions of the ileum resected from Crohn's patients for surgical therapy. These results indicate that careful attention to gastric hypersecretion is necessary for the patients with Crohn's disease who have widespread lesions of the small intestine before and after surgery. We speculate that decrease of enterogastrone such as enteroglucagon may cause gastric acid hypersecretion in Crohn's patients.

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In 45 cases of colorectal carcinoma without hepatic metastasis, and 29 cases with synchronous and 16 cases with metachronous hepatic metastasis, the risk of hepatic metastasis from colorectal carcinoma was investigated by determining pathologic features, c-erbB-2 histochemical staining and nuclear DNA content. There was a correlation between synchronous hepatic metastasis and the depth of invasion, lymph node metastasis, involvement in small vessels (ly, v), histological stage, aneuploidy, and c-erbB-2 expression. There was a close correlation between metachronous hepatic metastasis and involvement in the small vessels and c-erbB-2 expression (p<0.01). These three factors appeared to be important predictors of hepatic metastasis after resection of colorectal carcinoma. On the other hand, there was no correlation between DNA ploidy pattern and involvement in small vessels, and because six of eleven cases with metachronous hepatic metastasis which did not have vascular invasion were aneuploidy. The findings suggests that the DNA ploidy pattern may develop the capacity to predict hepatic metastasis.

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A total 213 patients with colorectal cancer invading beyond the muscularis propria were classified into 3 groups according to presence of symptoms of bowel obstruction. Patients were classed as Ileus 0 group when they had no symptoms of obstruction, Ileus 2 groups when they clinically had Ileus, and Ileus 1 group if they had symptoms intermediate between those in Ileus 0 and Ileus 2. There were 58 patients (27.2%) in the Ileus 1 group and 29 patients (13.6%) in the Ileus 2 group. There were no significant differences among the three groups with respect to age, sex, gross tumor appearance, tumor diameter, and histological type. The Ileus 0 group had significantly fewer of the following features: degrees of constriction in the lesion, circumferential cancer invasion, vertical invasion of the bowel wall, and liver metastasis. The stage was earlier in the Ileus 0 group. The degrees of constriction and the extent of circumferential involvement in the Ileus 2 group were higher than in the Ileus 1 group. These results suggest that the symptoms of obstruction chiefly caused by constriction of the lesion, circumferential cancer invasion and vertical cancer invasion. Because the survival rate of patients after curative operation in the Ileus 2 group was as good as that in the Ileus 0 group, it is worth trying the curative operation also in the patient with severe bowel obstruction.

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A patient with colorectal cancer with bleeding may have a longer duration of bleeding if have been pointed out hemorrhoids, because he thinks that the source of the bleeding is a hemorrhoid. We compared symptom duration and survival rates of patients in whom hemorrhoidshad been pointed out with those of patients without hemorrhoids in patients with colorectal cancer with bleeding. The mean duration of bleeding in the patients with hemorrhoids (7.9 months) was longer than that in the patients without hemorrhoids (5.2 months). The duration of bleeding in 52.9% of the patients without hemorrhoids was less than three months and 29.6% of the patients with hemorrhoids has the symptom for less than three months. In patients with stage I and II cancer who complained of bleeding via the rectum, the three-year survival rate for patients who had had the symptom for less than three months (85.7%) was significantly better than that for the patients who had had the symptom for more than three months (49.8%). In patients with stage III, IV, V, the survival rate for patients who had had the symptom for less than three months (75.9%) was also significantly better than that for the patients who had had the symptom for more than three months (32.4%). Althoughprevious reports stated that the survival rate was not correlated with the duration of symptoms in colorectal cancer, our study demonstrats that in patients with colorectal cancer with bleeding the shorter clinical history could be associated with better survival rate.

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A mouse adenocarcinoma cell line that arose spontaneously in a nude mouse was established during the transplantation of a human colon cancer tumor line into the subcutaneous tissueof the nude mouse. Human colon cancer tumor line KUM·RK-4N was established in a nude mouse serially transplanted with human colon adenocarcinoma in October 1985. The cell line which we established was primary cultured from the KUM·RK-4N tumor in February 1990. Metastatic nodules were clearly produced in lung and liver after 3-4 weeks when the cells wereinjected into the tail vein and anterior mesenteric vein. The histological pattern of the subcutaneous tumor produced from the established cell line was a moderately differentiatedadenocarcinoma similar to the KUM·RK-4N cell line. Chromosomal analysis of this cell line revealed only murine chromosomes and isozymes analysis showed amurine pattern. Based on these results this cell line was named mouse adenocarcinoma cell line XK-4. Transplantation of XK-4 cells into thymus-intact littermates was rejected, suggesting that XK-4 cancer grew spontaneously in the nude mouse. In this study, a new adenocarcinoma cell line XK-4 was established and the metastatic potential to lung and liver was characterized.

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OK-432 was administered preoperatively into the peritumoral tissues of 23 patients with rectal cancer. Natural iller (NK) activity of lymphocytes was isolated from peripheral blood, portal vein blood, and tumorous lesions, andthe regional lymph nodes were measured by⁵¹Cr release assay. There was no effect on peripheral bloodlymphocytes (PBL) or lymph node lymphocytes (LNL) with the administration of OK432. NK activity of tumorinf iltrated lymphocytes (TIL) was increased in half the cases after the administration of OK-432. NK activity of portal vein blood lymphocytes (PVL) was higher than that of PBL following OK-432 administration. The cases which showed high NK activity on TIL also showed high activity on PVL. The above results suggested that peritumoral administration caused increases in both TIL and PVL activity. Therefore, the preoperative injection of OK-432 to the peritumoral region in rectal cancer patient could be effective as preoperative adjuvant therapy, particularly for the inhibition of liver metastasis.

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To determine the risk factors in abdominal surgery for patients with collagen disease, the records of 21 patients operated on were analyzed for their clinical features and surgical results. Fourteen patients (66.7%) showeddysfunction of the vital organs due to involvement by collagen disease and 14 patients had been treated withsteroids. The patients with a poor outcome (hospital death) had a higher percentage of emergency operations (p<0.05) and operations for collagen disease-related problems, including intestinal perforation and acutepancreatitis (p<0.01) than those with favorable postoperative course. On the other hand, 17 patients with electivesurgery for non collagen disease-related lesions, such as gastric cancer and cholelithiasis, had a favorable outcome.We conclude that elective abdominal surgery is generally well tolerated in patients with collagen disease and thatearly and adequate surgical treatment is especially important in patients exhibiting the symptoms of acuteabdomen.

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A 55-year-old woman was admitted to the hospital because of abdominal distension. We made a diagnosis of Borrmann 4 type advanced gastric cancer with peritoneal dissemination by computed tomography and uppergastrointestinal series, and decided that it was inoperable. Although the white blood cell count was down to 2400/mm³ at admission, she was given a combination of oral administration of 5-FU, 200 mg/day, andintraperitoneal administration of cisplatin, 100mg, followed by another combination therapy regimen consisting ofintravenous administration of cisplatin, 100mg, etoposide, 225mg and 5-FU, 2250mg. After this treatment, themassive ascites disappeared and the gastric lesion was improved with a slight decrease in white blood cell count.Total gastrecotmy was performed after improvement of the her general condition, and histopathological findings ofthe resected specimen revealed that our pre-operative chemotherapy was effective.

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A case of resected minute hepatocellular carcinoma detected by laparoscopy is reported. A 62-year-old man withchronic hepatitis was found to have a small nodule on the surface of the left lobe of the liver under laparoscopy. Nomass was detected by various imaging methods including echogram, computed tomography, and hepaticarteriography. Tumor markers were within normal range. Partial resection of the liver was performed. The tumorwas 1.1 cm in diameter and had two daughter nodules. Histological examination of the specimen revealedhepatocellular carcinoma. This case showed that laparoscopy is very helpful for the detection and diagnosis ofminute hepatocellular carcinoma at the surface of the liver.

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In recent years the incidence of typhoid fever has markedly decreased. However biliary carriers are the main sources of infection. We performed cholecystectomy and transduodenal-sphincteroplasty for a typhoid carrier. The patient was a 70-year-old man who was admitted to our hospital for the treatment of incidentally detected Salmonella typhi in the feces and bile. Abdominal CT scan revealed multiple gall stones. Following administration of 4 g of Ampicillin per day for 5 days preoperatively, he underwent cholecystectomy and transduodenalsphincteroplasty. Cefazolin was used to prevent postoperative infection, because specific antibiotics are not always necessary. Salmonella typhi has been absent from the feces and bile since then, for about 1 year.

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We experienced an asymptomatic microglucagonoma which had been reported only twice in Japan. A 74-yearold woman was diagnosed as having advanced gastric cancer with cholelithiasis and was admitted to our hospital. There were no clinical features which suggested glucagonoma except for diabetes mellitus and no pancreatic tumor was found by CT scanning. The resected specimens after total gastrectomy, distal pancreatectomy with splenectomy and cholecystectomy revealed no pancreatic tumors. But many tumor granules smaller than 5 mm in diameter were found histopathologically and they were thought to be malignant. The tumors were diagnosedimmunocytochemically as glucagonomas. Six months after the operation, the patient died from peritonitis carcinomatosa of gastric cancer. At autopsy, we found many microglucagonomas smaller than 5 mm in diameter only in the pancreas. Including this case, 52 cases of glucagonoma have been reported in Japan. This case revealed for the first time that some microglucagonomas are malignant and the need for therapy of the microglucagonomas like those in this case is suggested.

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Three cases of foreign bodies in the gastrointestinal tract of the patients with psychosis are reported. Case 1: A 46-year-old female schizophrenic who swallowed 12 small batteries for a suicidal purpose was admitted. Case 2: A 34-year-old woman with epilepsy and mental retardation who swallowed a hair pin and a needle for a suicidal purpose was admitted. Case 3: A 36-year-old man with epilepsy and mental retardation who was admitted for abdominal fullness and pain, and was operated on for small intestinal obstruction due to swallowing a rubber globe and vinyl sheet was diagnosed as having pica from his past history. All three patients have been discharged with no problems. A patient such a psychostic background often shows vague clinical symptoms and is considered to need close examination and contact by the family when an operation is indicated.

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Endometriosis of the appendix has rarely been reported in Japan, as has spontaneous appendicoduodenal fistula. This is a case report of endometriosis of the appendix accompanied by a fistula of the duodenum. The patient, aged 68 years, was admitted to our department mainly for cancer of the ascending colon. From photographic examination we preoperatively diagnosed appendicoduodenal fistula, right ovarian cyst, and ascending colon cancer, and performed an operation. The appendix, rising along the mesenteric side of the ascending colon, flexed and fibrously adhered to the right lower part of the third portion of the duodenum, making a fistula. We detached the adhesion and closed the fistula by direct suturing. Pathohistologicaly we found a glandular structure in the subserosal layer of the appendix and the cilia at the inner side of it, but no interstitial component or bleeding focus. Our case was asymptomatic and endometriosis of the appendix, which was accompanied by right ovarian endometriosis, was accidentally detected by postoperative pathological study. Endometriosis of the appendix is likely to be accompanied by that of intrapelvic organs, so we must pay attention to endometriosis of other organs before and during surgery, and perform an adequate operation.

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A case of intussusception caused by an inverted Meckel's diverticulum is reported. The patient was a 51-yearold-man who complained of abdominal pain, an abdominal tumor and diarrhea. Physical examination, ultrasonography and CT were helpful in diagnosing intussusception. He was operated on under the diagnosis of intussusception. Laparotomy revealed that an inverted Meckel's diverticulum leading to intussuception. The ileum was partially resected with end-to-end anastmosis. The histology of the resected specimen revealed that the Meckel's diverticulum contained heterotopic pancreatic tissue. Thirty cases of intussusception caused by Meckel's diverticulum were reported in Japan during the past 10 years. In all but one of the cases which were described in detail, the diverticulum was inverted, leading to intussusception.

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A case of chronic intestinal pseudo-obstruction with megacolon due to segmental colonic oligoganglionosis is reported. A 57-year-old woman with no known history of difficulty in defecation in her childhood was admitted to our hospital complaining of severe abdominal distension and periodic abdominal pain. Plain abdominal X-ray film showed marked dilatation of the ascending and transverese colon with fluid. Barium enema examination revealed the descending colon to be poorly distended with marked dilatation proximal to it. As ileus was not relieved by conservative therapy, transverse colostomy was performed, and a secondary, narrow part of the colon was resected. Histological examination revealed a marked decrease in the number of normal ganglion cells in both Auerbach's plexus and Meissner's plexus in the affected part of the resected specimen. At 10 months after surgery, her clinical course is good and she is alive.

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A 47-year-old male was referred to our hospital for evaluation of occult bleeding in the stool. Pigment spots were known to have been present on the lips since early childhood. At the age of 25, ilectomy was performed for intussusception due to intestinal polyps, and a diagnosis of Peutz-Jeghers (P-J) syndrome was made. Investigation of the family revealed similar mucocutaneous pigmentation and intestinal polyps in his mother, two brothers and a nephew. Fiberoptic colonoscopy revealed many polyps in the colon and advanced carcinoma of the sigmoid colon. The patient was treated by sigmoidectomy and R₃ lymphoidectomy. During the same operation, several colonic and rectal polyps were removed by colotomy and polypectomy. Histologically, the tumor in the sigmoid colon was mucinous carcinoma (n₁, ss, stage III), and most resected polyps were hamartoma. Adenomatous epithelium, however, was identified in three hamartomatous polyps: in the ascending colon, transverse colon and rectum. This paper reports the occurrence, in a patient with P J syndrome, of advanced carcinoma and of adenomas arising in hamartomatous polyps. The literature on the occurrence of neoplastic changes in hamartomatous polyps of the P J syndrome is reviewed.

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