A comparison of the diet intake state and survival period between patients receiving a bypass operation (group A; n=11) and esophageal prosthesis intubation (group B; n=8) for esophageal cancer was made and the usefulness of an esophageal prosthesis was investigated. The results were as follows, 1) In group A, 10 cases were highly advanced and the mean age was 65. In group B, 3 patients were intubated during the operation, 5 cases (2 with esophago-bronchial fistula) were diagnosed as A3 by preoperative examination and the mean age was 61. 2) Oral intake was possible in only 2 patients in group A, and intake of a regular diet or rice gruel was possible from several days after intubation in all patients in group B. 3) In group A, all except 1 patient could not be discharged because of nutritional management or postoperative complication and died in the hospital. The mean postoperative survival period was 62±74 days. In group B, 6 patients were dischaged from the hospital and 2 could resume work. The mean survival period was 118±57 days for 7 patients excluding 1 survivor, and the survival period was significantly longer than that in group A (p<0.05). Hematemsis and hemoptysis was observed as the cause of death, in 4 cases. 4) Intubation was performed at one time using an endoscope in all patients including those with a pinhole lumen. Complications such as bleeding and perforation were not observed. We conclude that esophageal intubation is useful for cases of unresectable esophageal cancer.

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We studied the main gastric lymphatics from the stomach to the abdominal para-aortic lymph nodes (No.16) by means of direct injection of the activated carbon particle (CH44) into the regional lymph nodes during surgery in 35 patients, and endoscopic injection of the CH44 into the gastric submucosal layer around the cancer lesion before surgery in 102 patients. We found 2 main lymphatic routes, subdivided into 3 routes as follows; (1) Left side routes were via the celiac artery, the splenic artery, and the left subphrenic artery, and (2) Right side routes were via the mesenteric vessels, the celiac artery, and retropancreatic route. The percentages of black stained No.16 nodes were high in “lateral a2” nodes of cardiac cancer (56.5%) and in “inter b1” nodes of antral cancer (60.0%). We also studied the frequency and prognosis associated with No.16 lymph node metastases in gastric cancer in 312 patients referred for surgical treatment between 1974 and 1988. The No.16 node metastatic rate was 25% (78/312), and it was high in lateral a, bl and inter bl nodes of cardiac cancers, and in inter bl and lateral bl nodes of antral cancers. No.16 nodes should be dissected for N3, or S2 and N2, or S3 cases except for absolute non-curative cases. The 5-year survival rate for P (-) and H (-) patients who underwent relative non-curative resection was 23.1%, and that for patients with one or two positive No.16 nodes was 23.3%, suggesting that dissection of No.16 nodes was significant for these cases.

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Cell kinetic analysis on gastrointestinal mucosa in Wistar male rats with ENNG-induced carcinoma was studied using anti-bromodeoxyuridine (BrdU) monoclonal antibody. The normal mucosa in rats without ENNG administration, the mucosa without tumor and carcinogenetic lesion in rats with ENNG administration were studied. The results were as follows: 1) It was found that the BrdU labeling index (L.I.) in the gastrointestinal mucosa was elevated and the number of S-phase cell was increased by the carcinogen ENNG according to the carcinogenetic process. 2) In the normal mucosa, the L.I. at small intestine was 8.7%, at antral portion of grandular stomach 6.6% and at fundic portion of grandular stomach 1.9%. Thus the L.I. in most carcinogenetic parts was relatively higher. 3) The L.I. in the carcinogenetic lesion (16.8-23.7%) was significantly higher than that in the normal mucosa or mucosa without carcinogenesis (p<0.001). 4) The histological types and differentiative grades of the carcinogenetic lesions were not correlated with the L.I. of those tissues. But the L.I. of the tumors with invasion to the proper muscle or deeper was slightly higher than those confined to the mucosal or submucosal layer. The present studies suggest that carcinogenesis was highly correlated with the changes in the rate of S-phase cells in the gastrointestinal mucosa.

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We investigated whether the calmodulin antagonist, elziverine was effective in improving the survival rate after hepatic ischemia in normal and cirrhotic rats. We measured ATP in hepatocytes by HPLC and ³¹P-NMR to observe the effect of elziverine on the hepatic energy status during ischemia. ATP in hepatocytes of the elziverinetreated group disappeared more rapidly after hepatic ischemia than in those of the untreated group. Therefore, the potential of the hepatocytes was maintained, and the survival rate for normal and cirrhotic rats after hepatic ischemia was improved. Lactic acid in hepatic tissue increased before hepatic ischemia in the elziverine treated group, and elziverine inhibited elevation of phosphomonoester in hepatocytes during ischemia. It is possibly that elziverine promoted the system of glycolysis during hepatic ischemia. Elziverine was effective in improving the survival rate after hepatic ischemia, through promoting glycolysis and resolution of ATP in hepatocytes after hepatic ischemia.

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Clinicopathological analyses were performed on 13 cases of juvenile (less than 40 years old) hepatocellular carcinoma (HCC), which were 5.3% of all HCC patients treated in our clinic. Only 3 patients lacked positive HBsAg and a past history and family history of liver disease. Cirrhosis was present in 53.8% of the juvenile HCC patients, which was significantly lower than in nonjuvenile HCC patients. HBsAg was present in 66.7% of juvenile HCC patients, significantly higher than in those with nonjuvenile HCC patients. Three-fourths of the juvenile HCC patients had serum alphafetoprotein levels of more than 400 ng/ml, which was a significantly higher incidence than in nonjuvenile HCC patients. There was no difference in histopathological findings between juvenile and nonjuvenile HCC patients. Flow cytometry showed that 80% of the juvenile HCC patients were aneuploid in nuclearDNA content. Though juvenile HCC patients tended to be more advanced than nonjuvenile HCC patients, there was no statistical difference in outcome between the two groups. The outcome for patients with nonresected juvenile HCC patients was very poor, but some patients with resection achieved long survival. It is necessary forHB carriers to be followed up carefully for early diagnosis and treatment.

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The systemic and hepatic hemodynamics and oxygen metabolism in extrahepatic obstructive jaundice were studied experimentally. Twelve dogs with jaundice 2 weeks after ligating and cutting off the choledochus were compared with 6 normal dogs. The findings in the dogs with jaundice were as follows: (1) Although the mean arterial pressure (106±11 mmHg) was similar to the control value, the cardiac index (124±28 ml/min·kg) was increased and the total peripheral resistance (0.85±0.23 mmHg·Emin·kg/ml) was decreased, indicating a hyperdynamic state.(2) The hepatic arterial blood flow (9.07±1.30 ml/min·kg) and portal venous blood flow (30.4±4.7 ml/min·kg) were increased.(3) Although the oxygen delivery to the liver (6.55±0.93 ml/min·kg) and the oxygen consumption in the liver (0.95±0.50 ml/min·kg) were both increased, the oxygen extraction ratio in the liver (14.5±7.3%) was similar to the control value.(4) The ratios of the oxygen delivery (29.7±6.2%) and consumption (27.1±17.3%) in the liver to the systemic oxygen delivery and consumption, respectively, were increased. Thus, the oxygen demand in the liver was increased under the condition of obstructive jaundice, suggesting its close relation to the hyperdynamic state.

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Nineteen resected hilar cholangiocarcinomas were analyzed clinicopathologically to elucidate the surgical problems in curative resection for hilar cholangiocarcinoma. Histological lymph node metastases were within group 2 lymph nodes except for 1 patient. Cancer invasion to the portal vein was histologically positive in 4 of 7 patients with portal vein resection. Two of 3 other patients with negative invasion showed cancer invasion close to the wall of the portal vein. Quadrate lobe invasion was found in 6 of 10 patients (60.0%). Fourteen of 16 patients (87.5%) with histologically positive cancer invasion at the wedge of section were judged to be excisional wedge (ew) positive. Ten patients (55.6%) including 4 patients of portal vein resection were ew positive for large vessels in the hepatoduodenal ligament. Eight patients (44.4%) were ew positive at the hepatic side. Recurrent patterns were accompanied by local recurrence in all patients of primary death. The above results indicate that portal vein resection is thought to be necessary to obtain curative resection for hilar cholangiocarcinoma, but it is necessary to obtain an ew negative state for the hepatic artery from now on. Moreover, the pre and intraoperative closer examination in cancer invasion and quadrate lobe resection is suggested to be necessary to obtain an ew negative state at the hepatic side.

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We found postoperative acute cholecystitis in eight (2.1%) of 380 patients who underwent abdominal surgery during 1989. All these patients had been operated on for gastric cancer (8.7% of 92 patients). The purpose of the present study was to analyze these patients from the aspects of diagnosis and treatment. The prognosis of postoperative acute cholecystitis is considered poor because of the difficulty of early diagnosis. Therefore, we tried to perform an ultrasonic examination for obtaining early diagnosis on the patients who developed high fever and right hypochondralgia after the operation. As a result, we were able to treat conservatively the patients who had acquired acute cholecystitis within 8 days after surgery without showing any other serious complication. On the other hand, in patients with a complication such as leakage, and in whom acute cholecystitis had occurred more than 10 days after the operation, percutaneous transhepatic gallbladder drainage, but not additional surgical treatment, was needed for cure. Early diagnosis by ultrasonic examiantion might improve the prognosis of postoperative acute cholecystitis.

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In order to investigate abnormalities of carbohydrate metabolism and pancreatic endocrine function in obstructive jaundice, the profile of changes in blood glucose, insulin and glucagon in response to DB-cAMP loading (group 1: 3 mg/kg one-shot injection in portal vein, group 2: 0.2 mg/kg/min 2-hour continuous infusion in portal vein) were monitored in dogs with obstructive jaundice. The results showed an increase in blood glucose in response to DB-cAMP loading, but after ligation of the common bile duct this blood glucose elevation lessened as jaundice progressed. DB-cAMP loading gave rise to an increase in both peripheral blood and portal vein immunoreactive insulin (IRI), however, this IRI elevation response lessened as jaundice progressed. The early IRI response to DB-cAMP loading was preserved even when jaundice was present. Pre-DB-cAMP loading immunoreactive glucagon (IRG) values were higher during jaundice than before jaundice was induced. There was hardly any change in the IRG response to DB-cAMP loading before jaundice in group 1, and there was a slight decrease in group 2. On the other hand, there was an IRG elevation response resembling the paradoxical IRG response during the oral glucose tolerance test in the presence of jaundice.

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Although determination of amylase activity in fluid from abdominal drains is available for the detection of anastomotic leakage and pancreatic fistula, the activity of pancreatic proteases such as trypsin which might play an important role in the cytolysis of surrounding tissues has not been well documented. In this study, we investigated the activities of both trypsin and amylase in the postoperative discharge from abdominal drains after gastrointestinal surgery, as well as in pure pancreatic juice and in fluid from pancreatic cyst complicating acute pancreatitis. Concerning amylase activity, 100 to around 100, 000 Somogyi U of activity per dl was seen in anastomotic leakage and pancreatic fistula following upper gastrointestinal surgery. With regard to trypsin activity determined by the method of Erlanger et al., pancreatic juice contaminated with intestinal fluid showed levels of 340-825 U/ml. Although pure pancreatic juice showed less than 10 U/ml of activity, pancreatic fistula ranged from 1.5-80 U/ml. Trypsin activity of less than 10 U/ml, concomitantly with amylase activity of no more than 100 Somogyi U per dl did not indicate the presence of pancreatic juice. Intravenous administration of aprotinin did not inhibit amylase activity but trypsin activity. These results indicate that simultaneous determination of trypsin and amylase activities in the discharge from abdominal drains can be useful in the postoperative management of gastrointestinal surgical patients.

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From 1976 through 1985, 404 patients with colorectal cancer underwent surgery in our department. Their background and clinicopathological findings were evaluated in relation to metachronous liver metastasis. In background, there were no significant differences between patients without liver metastasis and those with metachronous liver metastasis. Pathologically, neither patients with stage I nor those with Dukes' A had metachronous liver metastasis. The rate of vascular invasion was 87.5% in patients with synchronous liver metastasis (Group B), 16% in those with metachronous liver metastasis (Group A) and 8.8% in those without liver metastasis (Group C'). Lymph node metastasis was observed in 76% of Group A, 58.5% of Group B and 45.9% of Group C', patients. Lymph vessel invasion was observed in 53.8% of Group C', 80% of Group A and 85.4% of Group B patients. These results suggest that metachronous liver metastasis is closely related to lymph node metastasis and/or lymph vessel invasion as well as venous invasion. Careful follow up of the high risk group by way of carcinoembryonic antigen (CEA), computed tomography (CT) and ultrasonography may increase the chance of treatments such as hepatectomy or intra arterial infusion chemotherapy.

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Vascular lesions of the colon were studied endoscopically in 75 patients with portal hypertension. The 3 characteristic findings of colonoscopy in these patients and their incidence rates were: (1) colonic varices · blue vein: 46.7% (varices: 16%, blue vein: 30.7%), (2) tree-like dilated vessels: 85.3%, (3) vascular spider-like vessels: 6.7%. Clinically, among these findings, colonic varices · blue vein was the most important and its relation to each clinical factors was also elucidated as follows: The colonic varices to occur in the rectum (39.7%, 25/63), sigmoid colon (25.4%, 16/63) and cecum (15.9%, 10/63); from the viewpoint of pathogenectic entity, there was a higher incidence in the patients with extrahepatic portal vein occlusion (83.3%, 5/6) than in those with liver cirrhosis (41.3%, 26/63). Moreover, among the patients with the colonic varices · blue vein complication, there was a tendency for it to occur in patients with advanced esophageal varices of F3 and Ls; and for limited occurrence in those with liver cirrhosis, the same tendency was also found in patients with Child B · C and those with ICG-R15 values beyond 30%. Furthermore, A-V fistula (3) and aneurysm (1) were also present in 4 of 6 patients (66.7%) who bled during mesenteric angiography.

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Seventeen patients with local recurrence who had received curative abdominoperineal resection for carcinoma of the rectum (lower rectum and upper rectum) were compared clinicopathologically with 62 patients with no recurrence after not less than two years. The rate of local recurrence was 16.7%, the average period until recurrence was 12.9 months, and the carcinoma recurred in 88.2% of the cases within two years. All the local recurrences were in the lower rectum (Rb), and they occurred at a significantly high rate in the following cases: Type 3 (infiltratingulcerating type) (70.6%; p<0.01); a2-ai depth of invasion (70.6%; p<0.05), especially ai (23.5%; p<0.01), n₂ (+) lymph node metastasis (64.7%; p<0.01) (including 41.2% lymph node metastasis in the internal and external iliac arterial system)(p<0.01); and carcinoma infiltration (ew) not more than 1 mm at the external surgical surface (52.9%; p<0.05). Three-and 5-year survival rates were 58.3% and 11.5% following curative resection, respectively, which was significantly lower (p<0.05; p<0.01) than that for the patients with no recurrence, and follow-up results were poor. These findings indicate that exhaustive dissection of lymph nodes associated with the internal and external iliac arterial system and extended preparation and resection of tumors including the surrounding tissues are important for abdominoperineal resection of carcinoma of the rectum, especially the lower rectum.

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Iliopelvic lymphadenectomy associated with low anterior resection or rectal amputation was performed on 171 patients with rectal cancer. Lymph node metastases were found in 26 of them (15.2%), and the metastatic lymph nodes were histologically well or moderately differentiated adenocarcinoma in 23 of the 26. In these 23 cases, the longest distance from dentate line to anal edge of the tumor was 6 cm in 3 patients with cancer invasion limited to the proper muscle layer, and 9 cm in 20 patients with invasion beyond the layer. The distance was as long as 12 cm in 3 patients with poorly differentiated adenocarcinoma. These results suggest that the indication for iliopelvic lymphadenectomy could be based on the histologic type, depth of cancer invasion and distance from dentate line to anal edge of the tumor. Furthermore, contralateral lymph node metastases were not found when the tumor was unilaterally or partially bilaterally confined to the right or left side of the rectal wall, occupying less than half of the circumference. A unilateral autonomic nerve-preserving operation dissecting only iliopelvic lymph nodes of the tumor side would be justified for these cases. However, metastases jumping to iliopelvic lymph nodes were demonstrated in 5 of the 26 cases, suggesting the necessity of wide lymph node dissection in some cases.

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Thirty-five cases of postoperative infection with MRSA treated at our department during the last 36 months were studied. When this period was divided into 6 stages, in stage I, MRSA infection were seen in 4.3% of cases, including 6 cases of infectious enterocolitis. In stage II, although severe MRSA infections decreased in number as a result of adequate use of third-generation cephems, the incidence increased to 6.6% because of infection in wounds and in the respiratory tract. During stage III, we made an attempt to isolate MRSA from floating bacteria in the air around patients, and had a suspicion of nosocomial infection originating from the recovery room. Therefore we undertook general management regimens against nosocomial infections, isolated patients infected with MRSA and at the same time, sterilized the recovery room. As a result, the incidence of MRSA infection was decreased to 0% in stage VI. There were no more MRSA carriers among medical staff or nosocomial infections in the recovery room. These results showed that the adequate use of antibiotics and some regimes against nosocomial infections, including the isolation of infected patients and sterilization of the recovery room, are very effective for the prevention of postoperative MRSA infection.

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A case of eary gastric cancer with sarcoid reaction observed in the regional lymph nodes is reported. A 53-year-old man was admitted to our hospital because of on abnormality in the upper gastrointenstinal tract. Endscopy revealed an irregular-shaped depression at the antrum endoscopic biopsy revealed an adenocartinoma. Abdominal CT examination revealed marked swelling of the common hepatic arterial lymph nodes. Laparotomy revealed swelling of the regional lymph nodes and subtotal gastrectomy with R₂ lymphadenectomy was carried out. Histological examination showed that the gastric cancer was a pooly differentiated adenocartinoma and that the cancer invaded the mucosal layer. Eighteen regional lymph nodes were resected and sarcoid nodules consisting of epitheloid cells and multinuclear giant cells were observed in 10 of them.

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We performed intraoperative peritoneal hyperthermia with concomitant use of cis-dichloro diammine platinum (CDDP) in six patients with serous-infiltration-positive gastric cancer. Side-effects connected with this therapy, pharmacokinetics and clinical efficiency were evaluated. Following IPH with concurrent use of CDDP 25 to 100 mg/m2, total blood concentrations of CDDP reached to 0.71 g/ml in average in 5 minutes after starting the therapy and a maximum of 1.5 g/ml in average. No serous complications were noted during and after the operation. Three patients including two with normal preoperative PSP levels who were loaded with more than 70 mg/m² of CDDP showed transient elevation of s-BUN and s-creatinin reaching a peak in postoperative one to two weeks. However, all the three cases recovered without developing renal failure. The dosage of CDDP which would not induce postoperative renal dysfunction was considered to be 70 mg/m². Five of the six patients excluding one who died from another disease are surviving without any recurrences of gastric cancer.

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We reported a patient who had peritonitis carcinomatosa because of gastric cancer and in whom aggravation of clinical symptoms and rapid growth of the tumor occurred together with an increase in immunologi cal suppression after intermittent intraperitonel administration of interleukin-2 (IL-2, 8×10⁵ JRU, twice a week). While highl ymphokine activated killer (LAK) activity was detected in peritoneal exudate cell (PEC) in this patient before IL-2 administration, the activity fell significantly after IL-2 administration, and the prostaglandin E₂ level in the ascitic fluid increased markedly. Analysis of the PEC subpopulation revealed that monocyte/macrophages were dominant and the CD3 and CD16 positive fractions were decreased in the PEC due to the IL-2 administration. Enlargement of a mass in the abdomen and increase in ascites occurred in this patient together with the marked reduction in immunological suppression. The patient expired on the 25th day of IL-2 administration. We examined the factors aggravating the clinical symptoms in this patient, though over our treatments and also discussed the criteria for administration of IL-2 to patients with peritonitis carcinomatosa.

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We report a relatively rare case of cystadenocarcinoma in the liver. Magnetic resonance imaging (MRI) showed characteristic findings and was useful for diagnosis. A 63-year-old female visited our hospital primarily due to general itching. A tumor was palpable in the upper abdominal region, and ultrasonography (US) of the abdomen, computed tomography (CT), and celiac arteriography demonstrated a cystic lesion in the left lobe of the liver. On T1-weighted images of MRI, high-intensity signals were observed in the area suggestive of fluid retention. On T2-weighted images a mixed pattern of high-and low-intensity signals was observed in the area suggestive of solid tissue. Cytological examination by US-guided puncture showed class II findings. These findings obtained by imaging techniques suggested cystadenocarcinoma of the liver, and left lobectomy was performed. The tumor (9×9×8cm) was cystic and multilocular and contained brownish mucinous fluid. Histopathological examination showed a cyst wall composed of thick fibrous connective tissue with papillary proliferation of an adenocarcinoma on its internal surface.

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Four cases of hepatolithiasis complicated by cholangiocarcinoma are reported. Three patients had preceding symptoms caused by hepatolithiasis, the average duration of which was 8.7 years. In 3 patients, the main part of the tumor and the stones were located in the same side of the liver. The gross appearance of the tumor were divided: massive type in 2 cases, diffuse type in 1 case and nodular type in 1 case. Regional invasion of the tumor were observed in 2 cases; hilar invasion in 3 cases; periductal invasion in 3 cases and lymph node metastasis in 2 cases. Two patients underwent hepatic resection, one of which was a curative one. One patient with cystadenocarcinoma is alive 4 years post-operatively. The prognosis of another 3 patients, who had extended tumors, was quite poor. Histologically these tumor were differenciated adenocarcinoma. Proliferative cholangitis and dysplasia of the epithelium were observed in the dilated intrahepatic bile ducts apart from the tumors; these may be malignant changes leading to the development of cholangiocarcinoma.

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A 35-year-old man was admitted to our hospital complaining of upper abdominal pain and nausea. His condition was diagnosed as congenital biliary dilatation (Alonso-Lej I type) associated with a common bile duct tumor and pancreatic stones, and pancreaticoduodenectomy was performed. The common bile duct showed cystic dilation (5.5 cm in diameter). A villous tumor (15×15×5 mm) in the dilated common bile duct, and 4 pancreatic stones in the main pancreatic duct were found. An anomalous arrangement of the pancreaticobiliary duct system was observed. Histological examination of the tumor revealed a papillary adenocarcinoma confined to the fibromuscular layer with no metastasis. Biliary carcinoma in congenital biliary dilatation is frequently detected only in the advanced stage, and its prognosis is poor. Many cases of early carcinoma such as this case should be studied to clarify the characteristics of carcinoma in congenital biliary dilatation.

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We report a case of carcinoma of the cystic duct which showed a very rare tumor growth. The patient is a 74-year-old female, who complained of upper abdominal pain. There was no jaundice, no palpable mass in the right upper quadrant. Ultrasonography showed a tumor mass in the dilated extrahepatic bile duct. Endoscopic retrograde cholangiography showed a filling defect in the common hepatic and the common bile ducts. Cholecystectomy and resection of the bile duct was performed with cleaning of the regional lymphnodes under the preoperative diagnosis of carcinoma of the bile duct. The tumor arose from the cystic duct and showed papillary growth into the common bile duct intraluminally through the bifurcation and the size was 26×7 mm.Histologically it was a papillary adenocarcinoma. Cancer invasion was limited to the fibromuscular layer and thetumor was recognized as an early carcinoma of the cystic duct. Sixteen cases of carcinoma of the cystic duct reported in the literature were discussed.

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This is a case report of fascioliasis in the pancreas definitively diagnosed by a resected specimen. Preoperatively the fascioliasis had been diagnosed by endoscopic retrograde pancreatography (ERP) as cystadenocarcinoma of the pancreas. A 72-year-old man was admitted with persistent upper abdominal pain.A bdominal ultrasonography and computed tomography (CT) scan showed a space-occupying lesion in the pancreatic body. ERP disclosed a cystic mass in the pancreatic body, which was tentatively diagnosed as cystadenocarcinoma of the pancreas. Resection of the pancreatic body and tail, and total gastrectomy were performed. The lesion was found by microscopic examination of the resected specimen to be inflammatory granuloma with many parasite eggs and infiltrated eosinophils and lymphocytes. The size and shape of parasite eggs identified them as those of Fasciola hepatica. Identified the eggs and a skin test with F. hepatica antigen positively, specific positive reaction of an Ouchterlony test and immunoelectrophoresis indicated the infection was F. hepaica. From these 5 findings, this case was definitely diagnosed as F. hepatica ectopic parasitism in the pancreas.

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Mucin-producing pancreatic cancer has been reported by many authors in recent years, but only a few cases of mucous occlusive jaundice have been described. We experienced mucin-producing pancreatic cancer from which mucin leaked through a fistula to the common bile duct and caused jaundice. The patient was a 73-year-old man, who visited our clinic with right hypochondralgia and jaundice. Abdominal ultrasonography and abdominal computed tomography showed prominent dilatation of the common bile duct and pancreatic duct with a protruded mass inside. Percutaneous transhepatic cholangiography revealed hypertransradiancy within the lower common bile duct, through which an outflow of bile with an admixture of a great deal of jelly-like material was found by drainage. The diagnosis of mucin-producing pancreatic cancer was thus established and total pancreatectomy was done. Microscopic examination showed papillary adenocarcinoma diffusely proliferated along the main pancreatic duct and the presence of a fistula between the main pancreatic duct and the common bile duct. We thought that the pressure inside the pancreatic duct by excessive mucin made the fistula to the common bile duct. Only 15 cases of mucin-producing pancreatic carcinoma presenting breakage into the common bile duct have so far been reported in Japan. We believe that this case is very suggestive in elucidating the developmental mechanism of mucin-producing pancreatic cancer.

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Carcinoma arising in the Meckel's diverticulum is rare, only 28 cases have been described in the literature. We report a case of carcinoma of Meckel's diverticulum, which appeared to derive from the vitello-intestinal duct remnant. A 43-year-old man complained of abdominal discomfort and a mass in the left lower abdomen and was admitted to our hospital. On admission an elastic hard and first-sized mass was palpated in his left lower abdomen. Serum CEA (4.3 ng/ml) and a-fetoprotein (36 ng/ml) levels were elevated. From the above findings in addition to the diagnostic imagings, he was suspected of having a malignant abdominal tumor. An exploratory operation revealed he had the Meckel's diverticulum, located at the ileum about 130 cm from coecum, to which a fist-sized tumor was connected and pushed towards the retroperitoneum through the mesocolon. Extirpation of the tumor including the Meckel's diverticulum together with segmental resection of the sigmoid colon was performed. Microscopic examination revealed that the tumor had arisen in the wall of Meckel's diverticulum with formation of multicystic spaces. Its histology was consistent with adenosquamous carcinoma. Recapitulation to the human vitelline ductlike structure was also present. It was therefore believed that the tumor originated in the vitelline duct remnant incipiently located in the wall of Meckel's diverticulum. The patient was well 7 months after the operation.

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A case of primary malignant lymphoma of the ascending colon is reported. The patient, an 18-year-old male, complaining of abdominal pain and high fever was found to have a right lower abdominal tumor. After a barium enema, abdominal ultrasonography and computed tomography, he was suspected as having a tumor in the right colon and operated on. Laparotomy was performed and wall thickening like a tumor from the ascending colon to the cecum, and mesenteric lymphnode swelling were seen. The tumor was diagnosed as malignant, so right hemicolectomy was performed. Pathologically, it was non-Hodgkin lymphoma, diffuse large cell type, according to the Lymphoma Study Group classification. It was positive for the cell surface markers anti B-cell antigen and IgG, λ type. After CHOP-Pepleomycin chemotherapy he is being followed up as an outpatient.

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Our experience with idiopathic intussusception (rectosigmoid intussusception) in a 90-year-old women is reported. The patient presented with the chief complaint of blood-stained mucous stools. On rectal examination through the anal canal, a reddish brown mass was found in the rectum with blood-stained mucous feces being evacuated from the center of the mass. A diagnosis of rectosigmoid intussusception was therefore made. Radiography, ultrasonography and computed tomographic scanning consistently revealed a concentric mass within the pelvic cavity, which was quite helpful in establishing the above diagnosis. At surgery, the sigmoid colon, together with the sigmoid mesocolon, was found to invaginate into the rectal lumen at 5 cm from the peritoneal reflection, and this confirming the diagnosis of rectosigmoid intussusception. The tip of the intussusceptum was swollen and edematous with partial necrosis but without any organic change such as tumor formation. In general, the majority of large bowel intussusceptions in adult occur as a result of organic diseases. The idiopathic rectosigmoid intussuception seen in our case is therefore an extremely rare example.

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A 67-year-old man was admitted to our department with the chief complaint of discomfort in the anus and tenesmus. Abdominoperineal resection of the rectum was performed, and a diagnosis of leiomyosarcoma was made preoperatively. The tumor was 12×6×6 cm in size, and its cross section showed a gray-white tumor with central necrosis. Microscopically, it consisted of spindle, oval-shaped cells in interlacing fascicles. The mitotic rate was 4.2 mitotic figures per 10 high power fields. In Japan, only 134 cases of leiomyosarcoma of the rectum had been reported up to 1989. Among these, only 43 (31.9%) were diagnosed preoperatively. Radical resection was performed in 102 (75.6%) cases and local resection in 25 (18.5%). Recently, it was stated that the prognosis of leiomyosarcoma is influenced by histopathological features and operative methods. In conclusion, it is important to diagnose this disease not only by microscopic examination of the biopsy specimen but also by medical imaging such as computed tomography, ultrasonography, and angiography. Radical resection should be performed, once the disease is diagnosed.

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