Phyllodes tumors of the breast were detected in 37 of 8, 195 women, who visited the breast clinic of Nagano Cancer Center on an out-patients basis, were analyzed retrospectively, during the last 13 years and 3 months from October 1983 to December 1996.
All phyllodes tumors which were investigated by entire cut specimens pathohistologically, consisted of 30 (81.1%) benign lesions, five (13.5%) malignant lesions and two (5.4%) borderline lesions.
The ages of women with benign lesion ranged from 13 to 58 years, four of five women with malignant lesion were in their forties and the remaining one was 74 years old.
Over half of tumors occupied the outer over region, Twenty tumors were in the right breast and 17 in the left breast. Size of tumors distributed under 2.0cm to over 7.1cm. No difference in tumor size between benign and malignant lesions were seen. On palpation, half of benign lesions had been diagnosed as fibroadenoma, five cases as breast cancer and only five cases as phyllodes tumor, and four of five malignant lesions had been diagnosed as breast cancer.
The results of image diagnoses and aspiration biopsy cytologies were also analyzed. Phyllodes tumors presented difficulty in correct diagnosis without pathohistological examination. Especially, it was suggested that discrimination of benign from malignancy should not rely on aspiration biopsy cytology or frozen section, but on permanent section.

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Among 1160 patients with breast cancer who were treated at our hospital in an 11-year-period from 1986 to April 1997, 11 patients (13 breasts) on hemodialysis were subjected to a clinical study. A mean interval from induction of hemodialysis to the breast operation was 116 months. Two out of these eleven patients had a hemodialysis shunt in the upper limb on the affected side. All patients underwent radical operation. A mean operation time was 116 minutes and an average blood loss was 126ml. Neither blood trasnfusion nor emergency hemodialysis was required after the operation. Postoperative complications occurred in two cases, including hematoma under the skin flap and thrombus of dialysis shunt in each case. Two patients experienced recurrences and other two patients died of other disease. If the perioperative management is properly performed, patients with breast cancer on hemodialysis can be safely treated.

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This study was designed to clarify factors affecting hospital mortality and long-term prognosis after repair for abdominal aortic aneurysm (AAA). Subjects were 306 patients who underwent surgical repair for AAA from January 1987 through December 1996. There were 254 men and 52 women, aged between 44 and 86 years (an average of 70.3). A total of 65 patients required emergency repair for AAA, whereas 241 patients received elective repair. The hospital mortality rates were 2.1% in elective repairs and 36.9% in emergency repairs. The most influential factor associated with poor operative result in emergency repair was shock which represented about 50% of all death causes, followed by related acidosis. In a follow-up study of patients who survived operation, 5-year survival rates were 80.1% and 71.5% in elective and emergency repairs respectively. Both patients groups had favorable postopertive courses without significant difference as compared with those age and sex matched control. The risk factors for long-term prognosis included associated malignancy and thoracic aortic aneurysm in elective, and only renal dysfunction in emergency repairs. This study clarified that poor operative result was noted only after emergency repair for AAA in which shock was the determinant factor, and hence, to avoid shock would be of importance. But it is no doubt crucial to detect AAA early by screening and to perform elective surgery before rupture that causes a catastrophic condition.

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The clinicopathological features of 39 cases of mucinous carcinoma of the colon have been examined and compared with those of 370 well-differentiated adenocarcinomas and 146 moderately and poorly differentiated adenocarcinomas of the colon. Mucinous carcinoma had a greater likelihood of localization in the right colon. The mean size of the mucinous carcinomas was larger, and the macroscopic type of the mucinous carcinomas tended to be protruded, in contrast to adenocarcinoma. Mucinous carcinomas were deeper, the incidence of peritoneal dissemination of mucinous carcinoma was higher, and the rate of curative resection of a mucinous carcinomas was lower, than in well-differentiated adenocarcinoma. The incidences of lymph node metastasis and of severe venous invasion in mucinous carcinoma were lower than in moderately and in poorly-differentiated adenocarcinoma. The survival rate after resection of a mucinous carcinoma was less than after resection of well-differentiated adenocarcinomas, but there was no significant difference in survival rate between the mucinous carcinoma and either the moderately or poorly-differentiated adenocarcinoma. These findings suggested that early detection and wide dissection are of significant importance in improving in the prognosis after resection of a mucinous colon carcinoma.

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The clinicopathologic variables including mode of infiltrative growth were investigated by multivariate analysis using quantification theory II to evaluate multivariately their effects on the hepatic metastasis and to discriminate liver metastasis after curative resection for advanced colorectal cancer.
Subject were 194 patients with advanced colorectal who had hepatic metastasis (107 synchronous and 87 metachronous) and 261 patients with the disease who were free from any recurrence for more than 5 years.
The factor with the greatest influence was lymph node metastasis followed by the depth of invasion. Mode of infiltrative growth was though to be one of the useful indicators of hepatic metastasis after curative resection of colorectal cancer. Discrimination of hepatic metastasis was achieved with 75.2% success rate in the cases of Dukes B and Dukes C after curative resection. Discriminative analysis using quantification theory II was thought to be useful for the prediction of liver metastasis after curative resection for colorectal cancer.

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Twelve cases of bile duct and gallbladder stones were subjected to a study of clinically evaluating the usefulness for percutaneous papillary balloon dilation (PPBD) with laparoscopic cholecystectomy (LC). In conducting the PPBD, a gastointestinal ballon for dilation was inserted throught the percutaneous transhepatic bile duct (PTBD) route to dilate the papilla; and after the papilla was dilated, bile duct stones were pushed out to the duodenum by using a ballon catheter for angiography. LC was used in due form. The maximum horizontal diameter of the bile duct stones ranged from 7mm to 15mm (11 ± 3mm), and there were one to 25 stones. Ten patients had the stones in the common hepatic duct-common bile duct, and two patients in the left hepatic duct-common bile duct. Removal of stones were possible in all cases, but two patients who had stones with horizontal diameter of over 13mm necessitated lithotripsy with electric hydrostatic percussion waves (a success rate: 100%). It took 146 ± 26 minutes for LC operation. Hospital stay after LC was 9 ± 3 days. Indwelling time of PTBD was 23 ± 6 days and total mean hospital stay was 26 ± 3 days.
We think that PPBD can be used for cases of multiple bile duct stones, those of huge stones, and those in which the stones are escaped during operation. Further, the associated use of PPBD with LC may contribute to an increase in candidates who are omitted from laparotomy.

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We have clinically studied eight cases (13 laterals) of sports hernia operated on at the department from July 1995 to January 1998. All patients were male soccer players aged from 16 to 29 years old. They were referred to the department by orthopedists (sports doctors) because of inguinal pain at exercise. The sites of pain were lateral in three cases and bilateral in five cases. The ailing times ranged from 2 months to 2 years. On physical examination, no inguinal elevations were seen in all cases even by addition of abdominal pressure, and almost cases complained of pain when the index finger was inserted into theinguinal canal. Operative findings included dilatation of the lateral inguinal ring, fissures and thinning of the external oblique abdominis aponeurosis, distention and weakening of the posterior wall of inguinal canal, but no hernia sac was confirmed. At operation, the posterior wall of inguinal canal was reinforced by an iliopubic tract repair. The pain at exercise disappeared in all cases in 6 to 9 weeks after the operation, and all patients recovered to the same sports level as before. We should deal with the sports hernia as a new concept of disease as a cause of chronic inguinal pain in sports players, and reinforcement of the posterior wall of inguinal canal at operation might be useful in the treatment.

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Angiosarcoma of the breast is a rare tumor which carries the worst prognosis of any breast malignancy. A 34-year-old woman was admitted because of a small tumor in her left breast. Incisional biopsy was performed and the tumor was diagnosed as an angiosarcoma. Left quadrantectomy and axillary dissection was performed and no metastasis was found in the lymph node. More than five years after operation, no symptom of metastasis or recurrence has been revealed.

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A 33-year-old unmarried woman was admitted to the hospital because of a left breast tumor. She was diagnosed as having a primary malignant lymphoma of the breast (B cell lymphoma; diffuse, large cell type) by clinical examinations. Breast conserving therapy was performed after obtaining informed consent. Radiation to the residual breast (50 Gy) and one course of CHOP therapy were added. The therapy and prognosis for malignant lymphomas of the breast are determined by histopathological classification and clinical stage. This case was classified into intermediate-grade by a Working Formulation, and clinical stage IA by the Ann Arbor's classification, thus candidate for a better prognosis. We regard this case as a good indication of the breast conserving therapy with radiation.

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Breast cancer after breast augmentation is uncommonly encountered. A case of breast cancer after breast augmentation with implant packed with saline is reported.
A 45-year-old woman undergone an augmentation mammoplasty with saline filled breast implants 2 years before, was seen at the hospital because of lumps in the left breast. Four tumors were palpable in the left breast. No tumors were revealed by mammography, but four tumors were detected by echogram. Excisional biopsies revealed that three out of four tumors were cancer, including one papillary ductal carcinoma and two non-invasive carcinomas in which wide-ranging intraductal extension was assumed. So a modified radical mastectomy was performed. Histopathologically extended intraductal component was revealed. There were 300-1200μm fibrous capsule around the prosthesis. It is considered that the prosthesis did not hide the breast cancer and there was no correlation between breast augmentation and breast cancer in this case.

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A 56-year-old woman was admitted to the hospital because of a tumor of 1.5cm in diameter in upper outer quadrant of the right breast in July 1994. A biopsy revealed cancer, and on September 7, she underwent a quadrantectomy with axillary dissection. Pathological examinations showed papillotubular carcinoma [nO, ly(-), v(-), ER(-), and PgR(-)]. Postoperative irradiation with 60 Gy and adjuvant chemoendocrine therapy were started. Thereafter, the patient experienced left axillary metastases in May, 1996, and was admitted to the hospital because of abruptly accumulated ascites in September. Echography and CT revealed no metastatic lesion in the liver. With puncture of ascites and systemic MF (mitomycin C and 5-FU) therapy, ascites disappeared almost completely. In October, however, left pleural effusion appeared that disappeared by intrathoracic drainage. Adenocarcinoma cells were found in both ascites and pleural effusion containing only CA15-3 in high levels. Thereafter, the patient was readmitted because of ascites with no metastasis in the liver in January 1997. She underwent puncture of ascites, followed by medication of CDDP^# intraperitoneally and systemic CAF plus MPA*. These treatments succeeded temporally in decreasing ascites. She was discharged from the hospital on April 12, 1997, when no liver metastasis was revealed on CT. But ascites became apparent and intestinal obstruction developed. The patient died on September 11.
It is assumed that lymphagenic metastases might occur in this case.
^#CDDP: cisplatin
*CAF: cyclophosphamide + adriamycin + 5-FU
MPA: medroxy progesterone acetate

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A 45-year-old woman was seen at the hospital because of an antetior neck nodule pointed out at a recent medical checkup. The nodule was diagnosed as intrathoracic goiter by neck CT and MRI. She was also pointed out an abnormal shadow on a chest X-ray film. Chest CT demonstrated a huge lipodensity mass pressing the right middle lobe of the lung in the anterioinferior mediastinum. The clinical diagnosis was lipoma or thymolipoma arising from the mediastinum. Right lobectomy including intrathoracic part of the thyroid and an extirpation of the huge mediastinal tumor were performed. Histologically, the specimen of anterior neck tumor (256g) was adenomatous goiter and the specimen of the huge tumor (2000g) of the mediastinum was thymolipoma. Thymolipoma associated with intrathoracic goiter is very rare and this is the first case report as far as we could review.

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We report a 42-year-old woman who was admitted for evaluation of an abnormal shadow on chest X-ray. Chest X-ray on admission showed a giant mass in the right middle and lower hemithorax. Chest CT showed a giant tumor in the right lower lung field. We suspected that the tumor was derived from mesothelium or lung. An operation was performed and the tumor was completely resected. The tumor was 22.3×16.3×13.6cm in size and weighted 2300g. The resected tumor was encapsulated, and its surface was smooth. From the microscopic findings and immunohistological stainings, the tumor was diagnosed as a solitary fibrous tumor of the pleura.
Since some solitary fibrous tumors of the pleura exhibit as malignant tumors, careful follow-up should be performed even after complete resection.

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A case of esophageal intramucosal carcinoma on the top of leiomyoma which is rare is reported. A 56-year-old woman complaining of epigastric discomfort was found to have a white, slightly elevated tumor in the upper intrathoracic esophagus by endoscopic examination. The biopsy specimen taken from the top of the tumor showed squamous cell carcinoma. Total thoracic esophagectomy was performed. The operative diagnosis was early esophageal cancer with the size of 2.2×1.2×0.2cm and in Stage I (A_o N_o Pl_o M_o). Histology of the resected material revealed a 20×14mm leiomyoma of the lamina muscularis mucosa coexistent with a 10×18mm intramucosal carcinoma on the top of the leiomyoma.
Only 20 cases of esophageal cancer which existed on the top of leiomyoma have been reported in Japan. We briefly reviewed these 20 cases in addition to this new case. The average age was 57.7 years, and the ratio of occurrence in males to females was 2 to 1.19 cases (90%) of them were of early carcinoma. We speculate that the underlying leiomyoma might prevent the cartinoma from infiltrating vertically.

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Carcinosarcomas of the esophagus are rare malignant esophageal tumors, and especially true carcinosarcoma has been scarecely reported.
A 70-year-old man received close examinations for fever as the chief complaint and was pointed out having an elevated tumor in the middle intrathoracic esophagus. Considering his advanced age and associated heart disease, a non-thoracotomic evulsion of the esophagus was conducted. Histologically, the tumor was composed of a part of squamous cell cacinoma and a sarcomatoid part of fusiform cells with a strong atypical tendency. No transitional area between the two components was seen. As of the sarcomatoid part, it was positive for nonepithelial antibody alone on immunohistochemical stainings; and an electron microscopy demonstrated myofilaments but no any parts suggestive of epithelial origin were noted. From these findings, the tumor was diagnosed as true carcinosarcoma. The patient has not have fever after the operation. It is thought that the fever might derived from the esophageal carcinosarcoma.

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We report a resected case of carcinoma developed in the reconstructed gastric tube 13 years after esophagectomy for a thoracic esophageal cancer. In February, 1984, he underwent a subtotal esophagectomy and an intrathoracic esophagostrostomy for an early carcinoma in the middle intra-thoracic esophagus (Im). The tumor was superficial and flat type, 2.0×1.5cm in size, and microscopically squamous cell carcinoma (sec) with m, n0, v0, ly0, and in stage 0. Since September, 1996 he had experienced chest discomfort and appetite loss. He visited the department of internal medicine in our hospital, and a pace maker was implanted for sick sinus syndrome in February, 1997. The symptom was not improved and an endoscopic examination showed a gastric carcinoma of type 5 in the lesser curvature of the antrum. So he was referred to the department in March, 1997. Preserving the right gastroepiploic artery and vein, a distal gastrectomy and a Roux-en-Y anastomosis for the remnant stomach and jejunum were performed. Histologically, the tumor was well-differentiated adenocarcinoma with tubl, ss, n(-), ly1, v1, in stage Ib. As of 12 months after the operation, the patient is disease-free without an signs of recurrence. Some bibliographical notes on 65 cases of carcinoma in the gastric tube reconstructed after esophagectomy in Japan are also presented.

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Among gastrointestinal injuries due to abdominal trauma, gastric injuries are rare, especially those of the stomach alone due to a blunt trauma. This time we have experienced a case of delayed stricture of the pyloric antrum after an abdominal blunt trauma.
A 22-year-old man was seen at the hospital because of upper abdominal pain after he got a bruise on the upper abdomen by a car handle at a traffic accident. No injuries of the parenchymatous abdominal organs were seen, but hematemesis occurred immediately after the accident. Gastric endoscopy performed on the 7th posttraumatic day revealed rupture of the membrane on the pyloric antrum. Some symptoms due to stricture became apparent from the 18th day and almost complete obstruction was established on the 30th day after the injury. So a gastrectomy was conducted. Gastric injury not extending tos the full thickness after a blunt trauma is so rare that no previous reports have been seen, and thereby spontaneous course after the trauma is still unknown. In this case, however, the clinical course from the trauma to the development of stricture of the pyloric antrum was observed. Some bibliographical comments about gastric injuries not extending to the full thickness are also presented.

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A 76-year-old man who developed an abdominal pain and nausea was referred to the hospital with a diagnosis of intestinal obstruction. A long tube was passed and progressed into the distal small intestine. The patient had a fever (38.0°C) and an abdominal pain on the 8th day after the placement of the long tube, on the 9th day symptom of panperitonitis due to perforation of the gastrointestinal tract appeared. Emergency operation revealed a cancer of the ascending colon which caused the bowel obstruction. During the surgery multiple perforated ulcers were found in the ileum, and abdominal drainage a partial excision of the ileum, and ileostomy were performed. The excised-ileum revealed multople ulcers ran in two lines, including three perforated ulcers. It is etiologically supposed that the progression of the long tube caused the small bowel to become telescoped over it, resulting in the formation of multiple pleats in the wall of small intestine. And it was considered that compression due to the long tube might cause multiple ulcer of the ileum.

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The clinical and pathologic features of two cases of intussusception of the appendix were reported. Case 1: A 42-year-old male was admitted to our hospital because of fecal occult blood. He had no complaint. A contrast enema and colonoscopic examination showed a type Ip polypoid lesion about 4cm long in the cecum. Because a neoplastic lesion could not be ruled out, we performed laparoscopy-assisted ileocecal resection. The appendix was found to be completely invaginated, and a diagnosis of the intussusception of the appendix (“inside-out type”). Case 2: A 57-year-old female was admitted to our hospital and examined because of anemia and fecal occult blood. She had no complaint. A contrast enema showed a polypoid lesion in the base of her cecum and about 3cm in diameter. The colonoscopic examination revealed intussusception of the appendix (Intussusception of the appendix, type 1).

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We report a case of mucinous cystadenoma of appendix that mimicked perforated appendix. A 50-year-old woman was admitted to the hospital because of right lower abdominal pain. On admission, physical examination showed tenderness and muscle guarding in the right lower abdomen. Her axillary temperature was 38.1°C and rectal temperature was 38.5°C. Blood laboratory data revealed leukocytosis (10, 000/mm³), and CRP was negative.
Abdominal ultrasonography revealed slight ascites around the cecum. A diagnosis of acute appendicitis was made. Appendectomy and drainage and resection of the fat tissue around the appendix was performed. The appendix was perforated, and a ruptured mucinous appendiceal tumor was found. The histopathological diagnosis was mucinous cystadenoma of the appendix. There have been no signs of pseudomyxoma as of a year after the operation.

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This paper deals with a case of angiosarcoma of the colon which is very rare.
A 34-year-old man was admitted to the hospital because of left lower abdominal pain. Barium enema and colonoscopy revealed a polyp in the ascending colon. Prior to the scheduled operation the patient suffered from severe abdominal pain. Strangulation ileus or intussusception was suspected, and so an emergency operation was performed. A colo-colic intussusception extending to the midtransverse colon was found and a D2 right hemicolectomy was performed. A 6 (cm) × 4 (cm) × 4cm polyp and a 13.5 (cm) × 9 (cm) × 1.5cm submucosal tumor were detected. Histological examination showed that the polyp was lipoma and the submucosal tumor had irregular lobulated vascular channels which resembled hemangioendothelioma of infancy extending from submucosa to subserosa. Four of 13 regional lymph nodes also revealed the lesion which resembled hemangioendothelioma. Immunohistochemically the atypical cells expressed Factor VIII related antigen and UEA-I. The pathological diagnosis was low grade anigosarcoma of low grade of malignancy. As of six years after the operation, the patient is healthy without evidence of recurrence.

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A 58-year-old man was operated for a cancer of the ascending colon at the hospital. On the first day after the operation the patient's condition was well. But from the morning of the second day he felt an abdominal pain and abdominal fullness. Then anal bleeding occurred in the afternoon, leading to heart failure even though the bleeding was minimal. Eventually respiratory insufficiency progressed and he died of multiple organ failure on the third day after operation. Autopsy was conducted immediately and we found necrosis involving from the ileum to half of the jejunum. There was no anastomotic leakage at the ileo-colostomy nor intestinal obstruction. We could not find any occlusion and thrombosis in the superior mesenteric artery and vein. From these findings, the case was diagnosed as non-occlusive mesenteric infarction (NOMI).
The prognosis of NOMI is very poor, because it presents difficulty in early diagnosis. Although it is vey common for the patients after abdominal surgery to complain abdominal pain and fullness, we must keep this fatal NOMI in mind as a possible rare complication after abdominal surgery.

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We report a patient with stage IV mucinous carcinoma of the colon who is surviving for 7 years after the initial operation with resection of metastatic foci 4 times. The patient was a 47-year-old man. In October, 1990, he underwent a laparotomy for a cancer of the transverse colon adhered to the jejunum, when peritoneal dissemination was noted in the greater omentum and resections of the transverse colon, jejunum and omentum with colostomy were performed. Pathological report was mucinous carcinoma, H0, P1 and stage IV. Another peritoneal dissemination involved the descending colon and ileum appeared and was resected in November 1993. A recurrence of the abdominal wall incision appeared and was resected in February, 1996. Peritoneal dissemination involved the ileum and left ureter appeared which was resected in May, 1997 and metastasis to the left external iliac lymph node was resected in March, 1998. In spite of 4 times of operations for metastasis, the patient is doing well as of 7 years after the initial operation. It is thought that we were able to resect lesions because no synchronous multiple metastasis had occurred. The positive additional resection for metastasis is useful for long term survival if the lesion is solitary.

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A 72-year-old man was refferred to the departent because of an increase in birially enzyme in blood examination. There were previous histories of undergoing a partial gastrectomy (Billroth-II) 20 years before and cholecystectomy 12 years before. A foreign body in his right upper abdoen had been pointed out on an X-ray film after the cholecystectomy.
On an abdominal scout X-ray film, a bow shaped forign body was seen in the right upper quadrant of the abdomen. Urtlasonography demonstrated a dilated left intrahepatic duct with a stone. A PTC revealed that the foreign body existed in the left intrahepatic duct and surrounded by a filling defect. These findings suggested that the stone was caused by the foreign body. First we failed to remove the stone by PTCS. Therefore PTCS was performed again following ESWL procedure. With this procedure, we could successfully removed the stone and foreign body. The removed foreign body was a surgical needle. In this rare case, it was indicated that the surgical needle which remained in the abdominal cavity during the cholecystectomy transmigrated into the hepatic duct and became a nucleus of the gall stone. We conclude that for the removal of the stone and foreign body, PTCS in combination with ESWL is less invasive and effective.

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Our experience with a case of spontaneously ruptured hepatic cyst is presented. A 51-year-old man who had been pointed out having a giant hepatic cyst at the department of internal medicine in our hospital 2 years before admission was seen at the hospital because of severe abdominal pain which occurred during sleeping without no particular cause. The patient complained of severe pain entire the abdomen, and peritoneal signs such as muscular defense and rebound tenderness were present. Though no difinitive diagnosis was made, an emergency laparotomy was performed. Upon laparotomy, muddy ascites was noted and a perforated portion was found in the hepatic cyst. Intraoperative fluoroscopy of the bile duct visualized no clear communication between the hepatic cyst and biliary duct. So an extirpation of the hepatic cyst was conducted. Postoperative course was uneventful.

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A 53-year-old woman was admitted to the hospital because of a right breast cancer. Preoperative ultrasonography revealed a hypoechoic nodule, 2.5 cm in diameter, in the anterioinferior segment of the liver. Abdominal angiograpy visualized a tortuous feeder and dense stain with centrifugal blood supply.Since a hepatic metastasis from the breast cancer could not be ruled out, a typical mastectomy and a partial hepatectomy were performed. A cut surface of the resected specimen revealed a yellow nodular mass without central scar and the histopathological diagnosis was focal nodular hyperplasia (FNH). We had difficulty in making the definitive diagnsis of FNH in this case because of absence of central scar which is characteristic of typical FNH. Among 76 resected cases of FNH in the Japanese literature so far, 25 cases (33%) had no central scar. It is emphasized that the central scar is not necessary to give a decisive clue in making the diagnosis of FNH.

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A case of hepatocellular carcinoma (HCC) with metastasis to the duodenum is very uncommon.
A 68-year-old man was admitted to the hospital because of epigastric pain. Ultrasonography (US) of the abdomen revealed a giant tumor 7cm in diameter in the medial segment of the liver, and an upper endoscopic examination revealed a submucosal tumor with a central ulcer at the posterior wall of the duodenal bulbi.
The histological diagnosis of an endoscopically biopsied specimen was suspected HCC. We diagnosed this case as having HCC with metastasis to the duodenum, and a left lobectomy of the liver, a distal gastrectomy and a lower extrahepatic bile btict resection were performed. With intraoperative US, tumor thrombi were seen in the left portal vein and left hepatic vein. A resected specimen revealed a trabecular type HCC. Unfortunately the patient died of cancer 101 days after the operation. It was considered that hematogenous metastasis via the portal vein occurred in this case, because no direct invasion into the duodenum was seen; there were tumor thrombin in the portal vein; and microscopically no metastasis to the lymph nodes were seen but submucosal venous infiltration was remarkable in the duodenal bulbi. So far 12 cases of HCC with duodenal metastasis have been reported in the world. This case is the fourth report as hematogeous metastasis, or the second case which was able to be diagnosed by biopsy. Some notes are also presented here.

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A case of hepatocellular carcinoma with situs inversus totalis is reported. A 63-year-old man was diagnosed with situs inversus totalis 41 years earlier during an attack of appendicitis. In April 1996, he was admitted to the hospital because of a hepatic tumor in the posterior segment recognized on echography. Based on the results of abdominal angiography, a surgery was performed under a diagnosis of primary liver cancer on June 13.
During the surgery, liver cirrhosis was found to be marked. After the location of the tumor was confirmed by the intraoperative echography, the patient underwent a lower posterior segmentectomy. However, the tumor recurred in the caudate lobe six months after the surgery. TAE (transcatheter arterial embolization) was performed. At present, the patient is followed on an ambulant basis once a month.
This case is the tenth report in the Japanese literature, and the hepatocellular carcinoma with situs inversus totalis is thought to be rare compared with other organ cancers as sociated with this condition.

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A case of acute emphysematous cholecystitis following gastrectomy for gastric carcinoma is reported. A 68-year-old man was diagnosed with gastric carcinoma, and total gastrectomy with dissection of lymph nodes combined with resection of the spleen and pancreatic body and tail was carried out. The patient began to complain of right hypochondralgia and fever 77 days after the operation. Abdominal X-ray films and a CT scan showed air around the gallbladder, and the patient was diagnosed as having acute emphysematous cholecystitis. Cholecystectomy and abdominal drainage were performed. Klebsiella pneumoniae was detected in a culture of bile juice collected during the operation. It is inferred that the mechanism of the onset of the disease may involve tissue necrosis based on ischemia due to circulatory failure in the gallbladder wall and consequent infection caused by the facultative anaerobe. We though that might have been caused the circulatory failure due to diabetes mellitus. According to the japanese literature on this disease following gastrectomy, and this case, we propose that the operation contributed to the mechanisms of the onset.

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Three patients with acute emphysematous cholecystitis are reported herein. The first patient was a 79-year-old woman who had diabetes mellitus and hypertension with the chief complaint of abdominal pain. The second patient was a 65-year-old man who had liver cirrhosis and hepatocellular carcinoma with the chief complaint of abdominal pain after TAE. The third patient was a 45-year-old man who had an abdominal pain and was in a pre-DIC condition with no remarkable history. Plain abdominal X-rays and CT scans for all three patients disclosed gas in the wall as well as in the lumen of the gallbladder. Since all patients had high risks, a percutaneous transhepatic gallbladder drainage (PTGBD) under US guidance was performed immediately, with successful outcomes. There has been no recurrence of cholecystitis in the first and second patient after PTGBD. The third patient underwent an elective cholecystectomy safely. PTGBD should be employed primarily in the treatment of acute emphysematous cholecystitis that previously has been considered to require operation in an early stage.

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A 73-year-old woman was admitted to the hospital because of tenderness in the right upper quadrant and a positive Murphy's sign. Her past history revealed hypertension, atrial fibrillation and sick sinus syndrome. Blood studies showed an evidence of severe inflammatory response without jaundice or liver injury. Abdominal pain film and CT scan showed gas in the gallbladder and intrahepatic bile duct. With a diagnosis of acute emphysematous cholecystitis, percutaneous transhepatic gallbladder drainage (PTGBD) was performed, but emergency laparotomy was not done so that the patient's heart disease could be evaluated preoperatively. Cholecystectomy and choledochotomy were performed 12 days after admission. Three black stones 2mm in size were present in the gallbladder, and histological examination of the gallbladder showed necrosis. The postoperative course was uneventful, and the patient was discharged 34 days after the operation.
We present a very rare case of emphysematous cholecystitis associated with pneumobilia, together with a review of 14 cases of this disease in the Japanese literature, including our own case. Whether air is present or not in the bile duct, it has a good prognosis if appropriate surgical treatment is performed immediately.

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We have experienced two cases of bile duct stricture, which presented difficulty in differential diagnosis from malignant disease. A 40-year-old woman who was suffered steering wheel injury, developed obstructive jaundice one month after the trauma. Abdominal ultrasonography, computed tomography, endoscopic retrograde-cholangiopancreatography and cytology of bile juice were performed, but malignant disease could not be ruled out. Intraoperative frozen section diagnosis resulted in Group III and a pancreatoduodenectomy was performed. Histologically, the tumor was fibrosis. Another case, a 58-year-old man could not remember any accident of abdominal injury. Endoscopic retrograde-cholangiopancreatography revealed a complete obstruction of the common bile duct, and blood chemistry tests of tumor makers showed abnormal findings. At laparotomy, the tumor involved the right hepatic artery and portal vein, and a gastro-jejunostomy was carried out. Five years later, this patient was admitted to the hospital for anatomical stenosis and stone of the common bile duct. Upon laparotomy, he was diagnosed as having a bile duct stricture secondary to abdominal trauma. We have to employ drainage or operative method with less surgical stress. However, it present difficulty in differential diagnosis from malignancies, that demands us to take careful attitude to selection of operative indication.

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A 71-year-old woman with a history of cholecystectomy and T-tube drainage 24 years now complained of right hypochondralgia. At first examination, had been recognized that she had patent liver disfunction and an elevated level of cholangioenzyme were found. We determined that she had common bile duct dilatation and a space occupying lesion with an acoustic shadow by abdominal urtrasonography and computed tomography. Endoscopic retrograde chlangio pancreatography showed patent of the dilatation common bile duct and a filling defect of the middle region. We diagnosed choledocholithiasis, and choledochotomy with T-tube drainage was carried out. Surgical exploration revealed a silicon rubber tube coated by a thick precipitate of bilirubin-calcium crystals (27 × 12 mm). It was suggested that this foreign body was a T-tube remnant from the primary operation. We have rarely found a foreign body in the biliary duct, especially not a T-tube remnant of the common bile duct. Our case is the 10th reported in the world.

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We experienced a case of localized pancreatitis which presented difficulty in diagnosis because we had to treat primarily a stricture of the descending portion of the duodenum which provoked strong clinical findings.
A 57-year-old man was seen at the hospital because of epigastric pain. Endoscopic examination revealed a shallow ulcerative lesion with crater at the retrobulbar region. No malignant evidence was found on a biopsy and conservative therapy was started. But no remission was attained and the patient was admitted to the hospital. Hypotention duodenoscopy visualized a severe stricture in the descending portion of duodenum. Abdominal ultrasonography and CT revealed a tumorous lesion about 4cm in diameter at the head of pancreas and thickening of hte duodenal wall. No abnormality was noted on endoscopic retrograde cholangiopancreascopy (ERCP). Since we could not completely rule out a possibility of malignant disease and the stricture findings and abdominal signs were clinically strong, the patient was operated on. During operation a hard mass was palpated in the upper portion of the pancreatic head. Intraoperative frozen section diagnosis indicated no malignancy, but a pacreatoduodenectomy was performed. Pathological study revealed that the tumor was localized chronic pancreatitis with inflammatory infiltration into the duodenal wall.

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A case with a rapid clinical course of ruptured solitary splenic abscess on chronic hemodialysis is reported. A 76-year-old woman who had been on hemodialysis for the preceding 14 years due to chronic renal failure complained of appetite loss, nausea and diarrhea. Three days later, she felt a left upper abdominal pain and became febrile. On the next morning, she consulted with her general practitioner because of remarkable tenderness in the entire abdomen, and was immediately transferred to the hospital. On arrival, she had already been in a shock condition. With the diagnosis of panperitonitis, an emergency laparotomy was performed and generalized peritonitis due to rupture of splenic abscess was found out. Despite any treatments in the intensive care unit (ICU), she died one day after the operation. No case of splenic abscess with chronic hemodialysis has been reported in the literature as far as we could review. However, some complications associated with chronic hemodialysis appear to have correlation with etiologic factors of splenic abscess, and hence a future increase in splenic abscess is predictable. We should take the disease into consideration for chronic hemodialysis patients who complain general malaise, though it is relatively rare.

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We report a case of multiple splenic lymphangioma with scleroderma which was definitely diagnosed after a splenectomy for the splenic lymphangioma. A 49-year-old woman was admitted to the hospital because of abdominal pain and vomiting. Abdominal ultrasonography and CT revealed multiple cysts in the spleen. Angiography of the splenic artery showed swiss cheese appearance, a typical sign of splenic lymphangioma. As the patient was symptomatic, a splenectomy was performed. It was histologically confirmed to be the splenic lymphangioma. During the postoperative follow-up period, she was found to have scleroderma. Although she had already have symptoms of scleroderma 3 years before the operation, those symptoms have not become worse after the splenectomy. It is controversial to employ splenectomy to the lymphangioma as a therapeutic opinion. However, if malignancy can not be ruled out, if it is symptomatic, or if the tumor has a tendency to grow rapidly, splenectomy seems to be the first choice for the treatment of splenic lymphangioma. In this case, a carefull follow-up would be mandatory.

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We have experienced a case of solitary adrenal metastasis after a curative operation for a cancer of the descending colon. A 61-year-old man was underwent a curative operation for a cancer of the descending colon showed an incrase in serum level of carcinoembryonic antigen (CEA) 4 months after the operation. Abdominal ultrasnography and CT revealed a tumor of the right adrenal gland. It was thought to be a metastasis from the colonic cancer because no lesions had been detected by the preoperative examinations. We concluded that the patient was a possible candidate for surgical resection because neither local recurrence nor other metastases were seen. Right adrenalectomy including the tumor was performed. Histologically it was metastasis to the adrenal gland from the colonic cancer. The serum CEA decreased to a normal level and no recurrence has been detected for 3 years and 9 months since the adrenalectomy.
In some patients, solitary adrenal metastasis from colonic cancer apperas to be a good canditate for surgery in anticipation of a good prognosis.

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A 53-year-old man was admitted to the hospital because of left flank dull pain. Abdominal US revealed a dilatation of the pelvis of the left kidney. DIP showed left non-function kidney and CT combined DIP revealed air density in the dilated pelvis. When percutaneous pelvic drainage was conducted, pus discharge was observed, and a catheterography performed at that time visualized that a contrast material entered the descending colon. We diagnosed the case as renocolic fistula. Pus discharge and high grade fever persisted and so a lapalotomy was performed 5 days after drainage. Left nephrectomy and partial resection of the colon were performed. A histological study revealed squamous cell carcinoma, grade 1, INFα, pT (colon), pR₀, pL₀, pV₀. It has been reported that squamous cell carcinoma of the renal pelvis grows invasively. This case in which the carenoma directly invaded the colon to form fistula is very rare.

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Testicular feminization syndrome (TFS) is a rare disease, but it is seen with a considerably greater frequency from puberty onward. We report a case diagnosed as TFS during surgery for inguinal hernia, and discuss it with reference to the literature. The patient was officially registered as a 15-year-old girl. Inguinal masses were found bilaterally on examination by a local physician, and were diagnosed as hernias, and so the patient was referred to this department for surgery. The patient's phenotypes, such as the physique and external genitalia, were those of a girl, and breast development was good, but a soft mass was palpable on each side in the inguinal region. During surgery, masses resembling testes accompanied by atrophied epididymides were found in the vicinity of the two external inguinal rings. An interview with the parents revealed that she suffered from primary amenorrhea, and TFS was diagnosed. Bilateral gonadectomy was performed and the hernias were reduced by repairing the iliopubic tract. In performing surgery for inguinal hernia in a female patient, it is important both to bear in mind the possibility of TFS and to check for primary amenorrhea by asking the patient. In addition, the timing of gonadectomy would require our understanding and consideration the patient's condition and prognosis.

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A 53-year-old man was seen at the our hospital because of intermittent claudication and impotence. With close examination, he was diagnosed as having the Leriche syndrome with arterial impotence and underwent an aorto-biexternal iliac artery bypass, with satisfactory results.
The patients having symptoms of arteriosclerosis obliterans such as intermittent claudication seldom complain of impotence. In this respect, it should be always checked by surgeons and appropriate therapy should be selected according to anatomical lesions. Surgical treatment is the option for some patients who need blood supply to the internal iliac arteries instead of endovascular treatment.

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A case of spontaneous rectus sheath hematoma caused by cough is reported. A 72-year-old woman was admitted to the hospital because of right abdominal pain and nausea immediately after cough. Tenderness and peritoneal irritable sign were recognized on the entire right abdomen, but no sign was recognized on the left side. Since abdominal CT showed an iso and high density lens shaped mass like lesion in the right rectus sheath, it was diagnosed as right rectus sheath hematoma. She recovered by conservative therapy within 40 days. We discussed the characters of this disease in Japanese 37 cases reported in a recent one decade. Spontaneous rectus sheath hematoma is relatively rare, a mean age is 58.6 years old and 78.4% of all cases are women. This disease has often peritoneal irritable sign, but conservative therapy is effective fundamentally. In the diagnosis, if spontaneous rectus sheath hematoma is not considered, unnecessary laparotomy would be sometimes performed, and abdominal ultrasonography, CT and magnetic resonance imaging are so useful for diagnosis of this disease. We were able to avoid unnecessary laparotomy in this case.

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We report a case of epithelioid leiomyoma of transverse mesocolon. A 72-year-old man was admitted to the hospital because of an abdominal distention. Abdominal CT showed a cystic tumor in the upper abdominal cavity. Percutaneus drainage and ethanol injection therapy was not effective and an operation was performed. The tumor was found in the transverse mesocolon and no invasion into the surrounding tissue was seen. It was removed with a partial resection. Histopathological findings of the tumor indicated epithelioid leiomyoma.

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Mesenteric panniculitis is a rare disease characterized by nonspecific inflammation of the mesenterium. We report a case of mesenteric panniculitis with intestinal obstruction after an operation for rectal cancer. A 60-year-old man with rectal cancer underwent Miles' operation. He complained of a full sensation in the abdomen and.vomiting from the fourth postoperative day, and was treated conservatively as a case of postoperative adhesive ileus. However, his complaints did not improve and another operation was performed on the 16th postoperative day. A length of jejunum about 70cm long forming an adhesive mass at 20cm anal to Treitz' ligament toward the retroperitoneum was resected. It was found that the mesenterium had become markedly thick and sclerous. In spite of operative treatment, the intestinal stenosis continued and steroid hormone medication was prescribed. In this case of marked intestinal stenosis, it was necessary to perform intestinal resection to shorten the hospitalization, but basically mesenteric panniculitis is benign and should be treated conservatively.

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A 45-year-old woman with systemic lupus erythematosus (SLE) that began at the age of 28 was admitted to the hospital because of acute lower abdominal pain and high fever. On admission, body temperature was 39.7°C. The laboratory findings showed that WBC was 11700/mm³, CRP was 17.7mg/dl, and serum anti-nuclear antibody was positive to a dilution of 1:20 with speckled pattern. The levels of C3, C4, CH50 and immunoglobulin were within normal limits. Neither pleural nor pericardial effusion was detected on chest X-ray films. An abdominal X-ray film showed a lot of small intestinal gas. Little peritoneal effusion was detected by pelvic CT. We suspected more acute bacterial peritonitis than lupus peritonitis with SLE. Laparotomy was carried out under a diagnosis of acute peritonitis. There was serous ascites, but no definitive findings of intestinal perforation, appendicitis or ischemic enteritis were found. A diagnosis of lupus peritonitis was made. Prednisolone was administered following the laparotomy. But the patient died of heart and lung failure on postoperative day 4. In this case, no immunological study of the ascites nor histologic exploration of the peritoneum was conducted, but we diagnosed with acute lupus peritonitis associated with recurrence of SLE based on her clinical course and intraoperative findings.

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We experienced a case of retroperitoneal cystic lymphangioma presenting with acute abdomen.
A 24-year-old man was admitted to the hospital because of abdominal pain and distention. Physical examination of the abdomen revealed tenderness, and distention. Abdominal plain roentgenogram showed a shift of the transverse and sigmoid colon to the right upper abdomen. Abdominal ultrasonography revealed a multilocular tumor showing a cystic echo pattern. Abdominal computed tomography scan showed the same tumor. An emergency operation was performed with a diagnosis of acute abdomen with a retroperitoneal cyst. A 30 × 14cm tumor with smooth surface arising in the retroperitoneum was found. The tumor partially involved mesentery, superior mesentric vein and pancreas, so it was partially excised. The inner portion of the tumor was multilocular and filled with yellow serous material. Histopathologically the cystic tumor was lymphangioma.

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We report a case of retroperitoneal ganglioneuroma arising in the bilateral adrenal glands. A 29-year-old man was admitted because of abdominal pain. CT and magnetic resonance imaging revealed a retroperitoneal tumor 18cm in size in the right adrenal gland. The tumor surrounded the celiac artery and the superior mesenteric artery, and there was another similar tumor in the left adrenal gland. Needle biopsy specimens revealed ganglioneuroma. Partial resection of the tumor was performed and the left adrenal gland was preserved to keep the adrenal function.
Although ganglioneuroma is a benign tumor, sometime we have difficulty to resect completely because it can grow involving major blood vessels.
Close postoperative follow up is necessary.

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A 58-year-old man underwent a low anterior resection with drainage for a rectal cancer. A drain was subperitoneally inserted and placed to dorsal side of the anastomosis from the left lower abdomen. The drain was removed on the 8th postoperative day. Two days later, the patient noticed a change in his voice.
On palpation subcutaneous emphysema of the neck was noted. Laboratory data showed leucocytosis and hyperamylasemia. A plain chest X-ray film revealed extensive cervical subcutaneous emphysema and pneumomediastinum. Computed tomography showed that gas had spread widely to the mediastinum and neck from the low retroperitoneal space. There were no signs of anastomotic leakage and an inflow of gas from the drain openning was thought. We performed continuous suction with the splitted drain at 40cm H₂O for three days. The air in the cervical subcutaneous tissue and the mediastinum as well as in the retroperitoneal space decreased markedly by the 4th day after the suction was started.
The patient made a good recovery and was discharged from the hospital. We reported that the continuous suction using a splitted drain which is effective for subcutaneous emphysema is also effective for retroperitoneal emphysema.

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A 66-year-old man was admitted to the hospital because of vomiting, abdominal distension, and a swelling of the left scrotum which lasted for three days. Physically there were abdominal distension, flare and swelling of skin covering from the left flank to the inguinal region and scrotum. On blood chemistry, a remarkable increase in white blood cells, high level of CRP, and renal impairment were noted. Abdominal X-ray film revealed intestinal obstraction. CT visualized a wide range of retroperitoneal abscess extending from the left perirenal retroperitoneum to inguinal region and a swelling of the left spermatic cord. With a diagnosis of intestinal obstruction due to perforation of incarcerated inguinal hernia and retroperitoneal abscess, an emergency operation was performed. Upon laparotomy, no inguinl hernia was present and a defect on mesentery in the vicinity of the root of sigmoid mesentery was found. And the ileum perforated and incarcerated into the defect in the manner of Richter type, forming the retroperitoneal abscess. A diagnosis of intermesosigmoid hernia was made, and the perforated site of the ileum and the mesentery defect were closed by sutures, and abscess drainage was performed. The patient's life was successfully saved. There have been only 38 cases of the hernia involving the sigmoid mesocolon in the Japanese literature so far. Especially, this case is very rare that caused perforation of the incarcerated intestinal hernia forming retroperitnoneal abscess.

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We report a case of primary actinomycosis of the liver presented with liver abscess and a case of actinomycosis of the cecum which was operated on with a diagnosis of malignant tumor of the colon.
Case 1 involved a 39-year-old man who was seen at the hospital because of right hypochondralgia and a slight fever. Increases in white blood cell count and level of CRP were noted. CT offered a suspicion of liver abscess, and a hepatic segmentectomy (S5) was performed. Case 2 involved a 43-year-old woman who was seen at the hospital because of right lower abdominal pain. On physical examination, a 10 × 7cm painful tumor was palpated in the ileocecal region. Increases in white blood cell count and CRP level were noted. With colonoscopic fiber, a submucosal tumor of the cecum (malignant lymphoma) was suspected and a right hemicolectomy was performed. Histological studies of the resected materials from both patients revealed specific club formation surrounding the grain. The definitive diagnosis of actinomycosis was made in them.
In recent years, abdominal actinomycoses are relatively rare, and among of them primary actinomycosis of the liver is especially so rare that only nine cases have been reported in Japan in the last one decade. It can be said that the case is extremely rare. Although it is rare, we must keep the disease in mind in differential diagnosis of tumorous hepatic lesions including malignant tumors.

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A 70-year-old man indicated anemia by a medical examination was seen at the hospital. As a result of further examinations, the patient was diagnosed as having an adenocarcinoma at the colostomy site and an adenocarcinoma of the transverse colon, and a submucosal tumor of the stomach. An operation was performed.
Operative procedures included a left hemicolectomy including abdominal wall at the colostomy site and a partial gastrectomy.
Pathologically, the invasion until the subserosal layer was observed in both the carcinomas at the colostomy site and transverse colon. The submucosal tumor of the stomach was extra-luminally growing leiomyosarcoma. So far 34 cases of adenocarcinoma at the colostomy have been reported, and almost of them have some underlying disease with malignant potential. This patient also had a hereditary non polyposis colorectal cancer, Lynch type 2 according to the Japanese clinical criteria.

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