Papillary thyroid cancer frequently metastasizes to lymph nodes. Although ultrasound examination and computed tomography have been developed recently, it is still difficult to make a precise diagnosis of lymph node involvements preoperatively. The current study of the prospective evaluation of lymph node status in papillary thyroid cancer uses the cytologic morphometric parameter NACV, which represents the variation in size of the nuclei of cancer cells. Subjects were 50 patients with papillary thyroid cancer who did not have clinically proven metastasized lymph nodes. Using preoperatively aspirated materials, NACV was calculated with a microscope connected to a computerized system. All the patients then underwent thyroidectomies and neck dissections, and the lymph node status was also evaluated histopathologically. Of all 50 patients, 20 (40.0%) proved to have lymph node involvement. Of those cases with low NACV value, 21.4% had metastasized lymph nodes, compared to 63.6% of those with high NACV (p=0.0025).
The preoperative morphometric estimation of cancer cells using aspiration smears seems to be useful for predicting nodal metastases in papillary thyroid cancer. If correctly applied, this technique can provide a new information which will greatly assist in planning neck dissections.

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Closure of a patent duct arteriosus (PDA) during cardiopulmonary bypass was performed successfully in five cases by using a balloon catheter. All five patients had pulmonary hypertension, case No. 3 hadmitral valve disese, and case No. 4 had a recanalized PDA.
A Fogarty balloon catheter was used to control the return of blood from the aorta through the PDA before closure. The postoperative course was uneventful in every cased.

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The results of surgical treatment were analyzed in 275 primary lung cancer patients who underwent pulmonary resection between 1984 and 1997. The overall 5-and 10-year survival rates for patients with non-small cell lung cancer were 48.7% and 46.0%, respectively. According to pathological stage, 5-and 10-year survival was 100% and 100% in stage 0, 75.2% and 75.2% in stage I, 67.2% and 67.2% in stage II, 36.8% and 28.4% in stage IIIa, 0% and 0% in stage IIIb, and 10.2% and 0% in stage IV. Extended resection and adjuvant chemo-radiotherapy did not improve the 5-year survival rate of patients with stage IIIb cancers. According to the operative procedure, the 5-year survival rate was 100% (4-year) for extended radical segmentectomy, 56.0% for lobectomy, 13.0% for pneumonectomy, and 23.4% for partial or segmentectomy. The criteria for extended radical segmentectomy included a peripheral tumor less than 2cm in diameter on chest CT films. Nodes around the segmental and lobar bronchi should be examined during surgery by preparing frozen sections, and dissection or sampling of the mediastinal lymph nodes should be documented. All patients with N1 and N2 disease underwent lobectomy or some type of operation. The amount of lung tissues resected was actually more than one segment, because the resection lines entered the adjacent segment.
Extended radical segmentectomy is suitable for patients with small tumors less than 20mm in size and N0 disease.
According to detection methods, the 5-and 10-year survival rates were 64.2% and 60.2% for mass screening, 39.4% and 32.1% for consultation for another disease, and 32.4% and 32.4% for subjective manifestations, respectively.
Early detection of lung cancer by mass screening contributed to a better survival rate.

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In a recent 8-year period since January 1989, 29 patients with perforation of the colon were treated at the department. The leukocyte count, platelet count, and urea nitrogen concentration up to postoperative day 7 were compared according to systemic inflammatory response syndrome (SIRS) status. Group I (7 patients) was negative for SIRS. Group II (13 patients) was positive for SIRS and Group II patients were subdivided into group II-1, consisting of eight survivors and group II-2, consisting of five patients who died. Group III (9 patients) was positive for SIRS and underwent PMX. As compared with the
preoperative leukocyte counts in group I (7400 ± 4100/mm³) and group II (8800 ± 6600/mm³), the value in group II-1 (12900 ± 1600/mm³) was high and those in group II-2 (2400 ± 1600/mm³) and group III were very low (2500 ± 1200/mm³).
Postoperatively, however, the leukocyte count increased with time to 9800 ± 4300/mm³ on postperative day 7 in patients who underwent PMX, which was significantly higher than the value in group II-2. Similar trends were seen for the platelet count and urea nitrogen concentration. Our results suggest that PMX is effective for improving the status of patients who are positive for SIRS.

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Chronic dialysic patients usually have a high rate of surgical mortality and morbidity. Twenty-six dialysis patients were investigated to identify risk factors that the incidence of postoperative complications and death present before, during, and after the operation. Fifteen patients (57.7%) had postoperative complications and 3 (11.5%) patients died after the operation. Patients with a Prognostic Nutritional Index (PNI) value equal to or less than 40 had significantly more postoperative complications. Patients who had taken steroids before the operation and had serum a BUN level equal to or over 50 (mg/dl) one day before the operation, intraperitoneal infections, anastomotic leakages after the operation, serum BUN equal to or over 70 (mg/dl), and serum total protein equal to or under 4.0 (g/dl) one day after operation had significantly higher postoperative mortality. When these risk factors are present, reduction of the operation or selection of non-operative treatment should be considered.

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We have made a nonrandomaized study to compare operative procedure for groin hernias including open conventional, open mesh plug, and laparoscopic mesh hernia repair by types of hernias according to the Nyhus' classification. In type-I and II hernias, there were small difference in duration of postoperative hospital stay and frequency of narcotic analgesics among three procedures. In type-III, the conventional repair required longer postoperative hospital stay and more narcotic analgesics than the mesh plug or laparoscopic technique. Each procedure has both merits and demerits. We employ surgical procedure selected by the condition of hernia and the patient's quality of life. In type-I, the conventional technique is suitable for the patients who don't require repair with prosthetic material. In type-II, the conventional procedure without prosthesis may be the preferred repair in the young patient, while the tension free repair is proper for the hernia close to type-III. The mesh plug repair that turned out good results is indicated in type-III, but for large hernias, the laparoscopic technique that uses a large mesh offers an excellent repair. In type-IV, the laparoscopic repair is appropriate for recurrent hernias after anterior approach. This approach that operative procedure is selected by the Nyhus' classification has produced good postoperative results.

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From October 1993 to March 1998, 2, 217 cases of various types of leg varicose veins in 1, 756 patients were treated by venous ligations, with or without sclerotherapy. Since November 1994, a duplex scanner has been employed not only to evaluate the competency of the sapheno-femoral junction but also to detect any incompetent perforator veins in the thighs and calves. An average of 500 cases were treated annually since 1994. The number of venous ligations per leg averaged 1.24 in 1993 and 4.32 in 1997. Sclerosing solution was injected on average 1.3 times per leg in 1993 and 1.6 times in 1997. The intermediate follow-up study showed that the present condition of over 95% of patients was satisfactory.
In conclusion, we advocate venous ligation with or without sclerotherapy, as an effective treatment for patients with leg varicose veins.

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A case of Warthin's tumor arising in an area except the parotid gland which is rare is reported.
A 66-year-old man was admitted to the hospital because of a tumor in the neck which had been felt since 2 years before admission. CT of the neck revealed a small hen's egg sized circular tumor showing isodensity in the right superior lateral side of the neck. With a diagnosis of benign cervical tumor, the tumor was enucleated. The tumor was present in the underside of the sternocleidomastoid muscle, and covered with thin fibrous capsula. It was easily freed and no communication with the parotid gland, submandibular gland, nerves, and vessels. The enucleated tumor was 4.5 × 2.7 × 1.7cm in size and elastic hard, and the section was solid with scattered small cysts. Histologically, epithelial cells with papillary growth formed cystadenoma and hyperplasia of lymphatic tissues with embryo center in stroma. The epithelial cells showed two layers, presenting typical pictures of Warthin's tumor.
An etiologic hypothesis has been widely accepted that Warthin's tumor originates from the ectopic salivary gland tissues in lymph nodes. It is thought that the tumor in this case might arise from lymph node, because no correlation with the parotid and submandibular glands were demonstrated during the operation.

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Tubular adenomas of the breast are rare benign tumors that commonly occur in younger women. The authers describe a case of rapidly enlarging tubular adenoma occurred in a pregnant woman. A 17-year-old woman was sent to the hospital because of a breast tumor. She had a baby girl 4 days before. The tumor had grown rapidly during pregnancy. The tumor, measuring 9.0 cm×8.0 cm was palpable in the CD area of the left breast.
Ultrasonography and mammography showed no apparent signs of malignancy. Under the diagnosis of fibroadenoma or phyllodes tumor, the tumor was extripated. Pathohistologically, the tumor was diagnosed as tubular adenoma. Tubular adenomas are so rare that only 32 cases have been reported in the Japanese literature. Among of them, this case is thought to be clinically rare in such a longer diameter of the tumor and a rapid growth during pregnancy.

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Medullary carcinoma of the breast is a rare specific type breast cancer. It has peculiar clinical features including favorable prognosis. In a series of 373 cases of breast cancer operated on at the hospital from 1990 to the end of 1997, eight (2.1%) cases were initially diagnosed as medullary carcinoma of the breast by postoperative pathological study. In this study, the specimens from the eight tumors were re-evaluated according to the pathological criteria given by Ridolfi and his coworkers. Five tumors were classified as typical medullary carcinoma (TMC), and three tumors as atypical medullary carcinoma (AMC). Ultrasonography images revealed well-circumscribed, hypoechoic nodules. On mammography the tumors were unclassified masses with indistinct or circumscribed borders. Enhanced magnetic resonance imaging revealed homogeneously enhancing masses with well-defined borders. Although AMC is similar to TMC in pathological findings, AMC lacks in clinical characters of medullary carcinoma, and hence it is important to distinguish TMC from AMC. Any diagnostic modalities could not reliably help to distinguish TMC from AMC.

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We describe a rare case of extraskeletal Ewing sarcoma of the chest wall. The patient, a 30-yaer-old woman, was seen at the hospital because of right back pain and an abnormal shadow in the right chest wall on X-ray, CT, and MRI films. CT and MRI revealed a solid tumor attached to the posteroinferior aspect of the intrathoracic chest wall. Angiography of intercostal arteries disclosed feeding arteries from the sixth and seventh intercostal arteies, and a tumor stain. We suspected a sarcoma, and surgically resected a tumor in the sixth intercostal space with the sixth and seventh ribs en bloc. The tumor measured 4.0×2.5cm. Histologically, there was a little involvement of the ribs. Individual tumor cells were small and round-shaped, with scanty, ill-defined, PAS positive material in the cytoplasma. With these results, we made a diagnosis of extraskeletal Ewing's sarcoma. Combination chemotherapy with ADR, CPM, ACT-D and VCR was administered after the operation. Tegafur and PSK were orally administered after discharge. There has been no evidence of recurrence after two and a half years of follow-up.

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A 57-year-old woman was referred to the hospital because of abnormal circular shadow in the right middle lung on a chest-ray film at another hospital in July, 1997. A possible malignancy could not be ruled out after close examinations, and an excision of the right middle lower lobe of the lung was carried out. Intraoperative frozen section diagnosis indicated adenocarcinoma, and mediastinal lymph node dissection was added. The definitive diagnosis of sclerosing hemangioma of the lung was made based on the permanent preparation. Immunohistologically, cuboidal cells were positive for surfactant apoprotein A that is an indicator of type II alveolar epithelial cell.
Although the true natures of the sclerosing hemangioma are still debatable, a recent view that regards the hemangioma as a benign tumor arising in alveolar epithelial cell has become the most convincing theory. And the immunohistological findings in this case also supported the theory.

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We successfully treated two cases of bleeding due to portal hypertensive gastropathy after cardia resection and endoscopic injection sclerotherapy for esophageal varices.
A 63-year-old woman was admitted to our hospital because of hematemesis. She had previously been diagnosed with esophageal varices and cirrhosis and had undergone cardia resection and endoscopic injection sclerotherapy 7 years earlier. Another 60-year-old woman was admitted to our hospital because of melena. She had previously been diagnosed with esophageal varices and cirrhosis and had undergone cardia resection, splenectomy and endoscopic injection sclerotherapy 6 years earlier.
Endoscopy showed bleeding due to portal hypertensive gastropathy, but the esophageal varices were intact. Ethyl alcohol injection therapy was performed. Both two patients had good recovery after treatment, and bleeding has not recurred during follow-up.
A few studies have demonstrated that the deterioration of portal hypertensive gastropathy can increase after surgical treatment or endoscopic injection sclerotherapy. We think that long-term and careful follow up is very important in these cases.

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Two cases of gastric cancer associated with dermatomyositis are described.
Case 1: A 66-year-old man was admitted because of erythema and itching of the exposed parts of his body, muscle weakness of the lower extremities, and increased GOT, LDH, and CK. Dermatomyositis was diagnosed by skin biopsy. A search for malignancy revealed Borrmann type 3 gastric cancer, but only resection of the main tumor was performed because of peritoneal dissemination. After the operation, the symptoms of dermatomyositis remitted and never recurred. The patient died of peritonitis carcinomatosa and multiple liver metastases.
Case 2: A 50-year-old woman was admitted because of erythema. muscle weakness, swallowing difficulty, and increased GOT, LDH, and CK. Dermatomyositis was diagnosed by skin biopsy and electromyogram. A search for malignancy revealed Borrmann type 2 gastric cancer with metastasis to group 4 lymph nodes, and only resection of the main tumor was performed. After the operation, the symptoms of dermatomyositis remittel.
Both cases were characteristis because remission of the dermatomyositis was achieved only by resection of the main tumor.

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The patient was 67-year-old female. A diagnosis of ITP had been made 13 years ago previously, and her platelet count had been maintained well with small doses of steroids.
We performed distal gastrectomy to treat early gastric cancer, but preserved the spleen. After the operation, the platelet count gradually increased and steroid therapy was no longer required.
The results suggested that it is particularly important to select the most appropriate treatment according the stage of the cancer and ITP, instead of routinely performing splenectomy in the gastric cancer combined with ITP.

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A case of Cronkhite-Canada syndrome associated with a gastric cancer is reported with review of the literature.
A 50-year-old man was admitted to the hospital with a half year history of epigastralgia, hypogeusia, diarrhea and alopetia. Physical examination revealed hyperpigmentation, onychodystrophy, redness of tongue with atrophy of lingual papilla, and a hard tumor was palpated in the epigastrium. On gastroscopy, numerous small sessile polyps with reddish edematous mucosa were observed throughout the stomach and a Borrmann III type gastric cancer was detected in the antrum.
Under the diagnosis of Cronkhite-Canada syndrome associated with gastric cancer, the patient underwent a distal gastrectomy. Histological type of the cancer was that of well to moderately differentiated adenocarcinoma and the stage grouping was IIIb. Histological features of polyps were consistent with juvenile type polyps.
There have been 16 cases of the syndrome associated with a gastric cancer in Japan, including ours. Comparing to patients with the syndrome without gastric cancer, male patients were predominant in those with gastric cancer. Of associated gastric cancers, differentiated type early carcinomas were common. Patients with Cronkhite-Canada syndrome were associated with gastric cancer in a significantly higher incidence (6.4%) than that in the general population. Consequently close examination at the onset of the syndrome and strict observation of clinical course are recommended.

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A 46-year-old woman came to our hospital because of dyspnea. Cytology of the pleural effusion was positive for adenocarcinoma. The patient had an irregular tumor measuring 4cm in diameter in her left breast, and a needle biopsy revealed breast carcinoma. Gastrofiberscopy showed an elevated lesion with slight erosion in the body of the stomach along the greater curvature. The pathologic findings in the biopsy specimen were compatible with gastric metastasis from the breast cancer. Axillary lymph node metastasis and multiple bone metastasis were also present. Chemotherapy with cyclophosphmide, epirubicin, and 5-fluorouracil, was effective, and radical mastectomy was performed. The patient is well with slight elevation of tumor markers, 25 months after surgery, We report this case with a discussion of the 18 cases reported in the Japanese literature.

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A 14-year-old girl was admitted to the department of pediatrics in our hospital because of nausea and vomiting on February 23, 1996. She had been treated for macrohematuria with Nut craker phenomenon on an ambulant basis for one year. Upper gastrointestinal roentgenography showed a straight cut off sign in third portion of the duodenum. Abdominal magnetic resonance images showed a narrowing of the aorto-mesenteric angle (18 degrees) suggestive of superior mecenteric artery syndrome. The patient was treated conservatively initially, however, passage disturbance continuted persistently. Transposition of the doudenum was performed 10 days after admission. She was discharged from the hospital without sequela 28 days after the operation, though she had vomiting transiently from 11th postoperative day. We recommend the transposition of the duodenum, which provides physiologic passage, for cases of superior mesenteric artery syndrome which do not respond to any conservative therapies like this case and thereby demand some surgical therapy.

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A 69-year-old man was admitted to the hospital because he fell into a shock status due to anal bleeding. An upper gastrointestinal endoscopy showed massive bleeding at the duodenum.
Trans-superiormesenteric arterial portography revealed an enlarged and tortuous varices of the pancreaticoduodenal vein. He was diagnosed as having a rupture of the duodenal varices. We choiced less invasive treatment because he was also illed with acure myocardial infarction and nephrotic syndrome. We found a great deal of difficulty in the treatment using an upper gastrointestinal endoscopy due to massive bleeding. Therefore, trans-ileocolic vein obliteration under epidural anesthesia was employed for the ruptured varices, with a successful outcome. Rebleeding has not been recognized two years after the treatment. Trans-ileocolic vein obliteration is minimally invasive and can obliterate varices selectively. It is consequently an advantageous option for the patient with rupture duodenal varices who has a high risk and is unable to be treated by using an upper gastrointestinal endoscopy.

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Gastrointestinal bleeding from small intestinal varices with portal hypertension is quite rare, and accurate preoperative diagnosis is difficult. We report a case of ruptured jejunal varices diagnosed preoperatively by image analysis. A 25-year-old man who had previously undergone transabdominal esophageal transection for esophageal varices with portal hypertension was admitted to our hospital because of melena. Upper gastrointestinal endoscopy and colonoscopy failed to identify the site of bleeding. Helical CT during angiography, however, revealed that varices were present in the jejunum and continuous with collateral vessels in the abdominal wall. Jejunal varices were found at laparotomy and they were connected to the abdominal wall as demonstrated by helical CT. Partial resection of the jejunum was performed, and the postoperative course was uneventful. We therefore concluded that helical CT is very useful in diagnosing small intestinal varices. Ruptured small intestinal varices should also be considered in patients with gastrointestinal bleeding and portal hypertension, especially after a previous laparotomy.

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We present a rare case of ileal perforation by press-through package (PTP). An 83-year-old man was referred to the hospital because of vomiting and tachypnea. During the day, abdominal distention worsened and a diagnosis of ileus was made. By abdominal CT findings, a diagnosis of intraperitoneal abscess was made and drainage therapy was performed. The abscess was decreased, but a foreign body that had been suggested by CT remained. So he underwent an operation and was finally diagnosed as an ileal perforation by PTP. The perforation site was found at the 6cm oral side from the terminal ileum. There have been several cases of perforation of the small intestine by PTP in the Japanese literature. This condition was difficult to diagnose before operating because of the radiotransparency of PTP, but we were able to detect it as a foreign body by CT examination. We report a rare case of ileal perforation by PTP which was diagnosed by CT findings.

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Among various tumors of the small intestine which lack in specific clinical manifestations, myogenic tumors often present as melena and anemia as the chief complaints. In this paper, two cases of leiomyoma of small intestine in which angiography was useful for diagnosis are reported. These two patients were admitted to hospital because of anal bleeding. No lesions in the upper digestive tract and colon were revealed. To exlore the small intestine, angiography was carried out and valuable information about the location of the bleeding site was obtained in both cases. A close examination of the small intestine is needed for a patient with bleeding on the digestive tract from unknown lesion. Angiography is useful for diagnosis of myogenic tumors of the small intestine.

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A 66-year-old man was seen at the hospital because of abdominal pain and vomiting. On abdominal findings, distention localized from the upper abdomen to median subumbilical part was confirmed, and peritoneal signs were present. Abdominal simple x-ray examination revealed dilated colonic gas where coincided to the distended portion and a small quantity of gas in the small intestine continued from the right side and upper portion of the colonic gas. So, an emergency operation was performed with a diagnosis of strangulated ileus of the right side colon, especially under a strong suspicion of volvulus of the cecum. Upon laparotomy, the ileocecal region was twisted clockwise by 180 degree, and a dilatation and hemorrhagic necrosis extended from the ileal end to ascending colon were seen. A right hemicolectomy was performed.
This disease is relatively uncommon and often presents difficulty in preoperative diagnosis. If strangulated ileus is suspected, we must keep the possibility of the disease in mind and carefully consider abdominal simple x-ray films. This paper presents this case of cecal volvulus, with some bibliographical comments.

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A case of cecal volvulus in a patient of very advanced age is reported. An 85-year-old woman was admitted to our hospital because of abdominal distension. In a plain abdominal X-ray, a giant colonic gas shadow appeared as one kidney in the lower left quadrant. Abdominal computed tomography revealed an empty sigmoid colon beside the dilated large bowel, so a volvulus of the colon at the proximal side from the sigmoid colon was suspected.
On laparotomy, the cecum and the ascending colon were found to be unattached to the retroperitoneum and were rotated 360 degrees clockwise. There was no circulatory disturbance, so cecopexy was performed. A naso-intestinal tube was put into the cecum to aid decompression. The postoperative course was uneventful.
We think that decompression of the dilated intestine was necessary to perform cecopexy safely and to achieve good recovery after the operation. As more people live longer, these cases will undoubtedly increase.

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We describe a case of goblet cell carcinoid of the appendix with a review of the Japanese literature. A 48-year-old man was admitted to the hospital because of iliocecalgia. He diagnosed as having acute appendicitis, and an appendectomy was performed. In the resected material there were no tumor features in the macroscopic appearance which suggested a probable diagnosis of goblet cell carcinoid. Because histological examination revealed the goblet cell carcinoid in the resected appendix, a right hernicolectomy was added. Histologically, no neoplastic cells were detected in resected materal at the reoperation. Goblet cell cardinoid often presents difficulty in diagnosis preoperatively, and there have been no case diagnosed as the disease preoperatively in the Japanese literature. The difinitive diagnosis is made based on postoperative histopathologic study, and hence it would be important to explore resected appendix histologically even if it was done for appendicitis. It has been reported that malignant potential of these tumors appears to belong somewhere between those of cardinoids and adenocarcinomas of the appendix, but no guidelines for appropriate surgical approachs and indications of reoperation have been established as yet. Futher accumulation of clinical cases for discussion would be required.

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Adult intussusceptions are often caused by some tumorous lesion. This time we experienced a case of adult intussusception caused by intestinal tuberculosis.
A 60-year-old woman was seen at the hospital because of abdominal pain, vomiting and anal bleeding. Abdominal ultrasonography (US) revealed multiple concentric ring sign. Abdominal CT scan also revealed target sign which shows concentric laminar structure. The patient was operated on with a diagnosis of intussusception and was found having an ileo-colic type intussusception and swelling of mesenteric lymph nodes. As a possibility of malignant disease could not be ruled out, we did not release the intussusception but performed a partial ileocolectomy with D2 lymph node dissection. The resected material showed that the intussusception was headed by the ileum that involved a whole-circumferential mucosal hypertrophied lesion 7cm in longer diameter at the terminal ileum. Histologically, blastomas with Langhans giant cell and caseous necrosis were demonstrated, and no other lesions of tuberculosis were seen. So the case was diagnosed as primary intestinal tuberculosis.
It is relatively easy to make the diagnosis of intussusception by abdominal US and CT, but sometimes we find a great deal of difficulty in diagnosis of the causative disease. In order to select appropriate operative procedure, we should try to make the qualitative diagnosis of causative disease as possible as we can.

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A 57-year-old man on hemodialysis since 1993 was admitted to our hospital, because of shock status associated with abdominal pain and distention. Plain abdominal X-P and CT showed dilatation of intestine and colonoscopy revealed necrosis of the colonic mucosa. We therefore made a diagnosis of peritonitis secondary to necrotic ischemic enterocolitis and performed emergency surgery. Subtotal colectomy and resection of 10-cm of terminal ileum was performed because of the widespread necrosis of the colon and partial necrosis of the ileum discovered at laparotomy. After the operation the patient became being possible to oral taking with hyperbaric oxygen therapy (HBO), but he died of acute myocardial infarction 2 months after the operation. Although ischemic enterocolitis in hemodialysis patients almost always has a poor outcome, surgical tretment and HBO may be effective, as in our case.

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Hepatic portal venous gas is an ominous prognostic sign. We report a case of survival of necrotizing enteritis with hepatic portal venous gas and pneumatosis cystoides intestinalis. A 71-year-old man was admitted with a sudden onset of severe abdominal pain and vomiting. Hepatic portal venous gas was
detected by conventional radiography, ultrasonography, and computed tomography. In an emergency laparotomy, the necrotic bowel was resected, and the patient survived.
Hepatic portal venous gas suggests the presence of necrotic bowel, so it usually indicates the need for urgent surgical intervention.
Since hepatic portal venous gas is difficult to detect by conventional radiography, computed tomography is a more valuable method for this purpose.

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A case of intussusception caused by cancer of the cecum is reported with a review of the literature. A 90-year-old woman was admitted to because of right lower abdominal pain. There was tenderness in the right lower quadrant with a palpable mass. The patient was diagnosed as having intussusception caused by carcinoma of the cecum based on the results of ultrasonography, abdominal computed tomography, colonfibroscopy, and a gastrographin enema. Ilecolic type intussusception of the transverse colon was confirmed at laparotomy. Excision of the ileocecal region with lymph node dissection was performed. Microscopicaly, the tumor was a moderately differentiated adenocarcinoma, ss, n (-), ly0, v1, stage II. Intussusception is comparatively rare in adults as compared to children. Whether the intussusception is associated with cancer is important, and early definitive diagnosis is important. We reviewed the 18 cases of intussusception due to carcinoma of the cecum reported in Japan thus for, including the present case.

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Colitis cystica profunda is a rare benign disease of the colon and rectum, characterized by immigration of the mucosa into the submucosa and formation of the mucocele. We report a case of colitis cystica profunda. A 26-year-old man was seen at the hospital because of bloody stool passage. Total colonoscopy revealed a tender polypoid lesion with a central depression on the anterior rectal wall 5cm from the anal verge. The lesion was so tender that it was easily flattened by the air sent from a colonoscope. Histological features from the biopsy specimens could not rule out a possibility of well differentiated mucinous adenocarcinoma. The diagnosis of colitis cystica profunda was confirmed with intraoperative transanal resection of the whole lesion.

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Crohn's disease is treated by medication, operation, and alimentary therapy, and among of them the usefulness of enteral nutrition has been pointed out. Not only elemental diet (ED) but also low residue diets have been reported to be useful, however, there are few cases of long-term use of such digested diets. We have successfully managed a postoperative patient with Crohn's disease involving the small intestine and colon by enteral nutrition mainly with digested diets which are rich in lipids, especially medium-chain triglyceride (MCT) at home. The enteral nutrition was started in a remission period after operation for peritonitis due to perforation of the ileum. About three years have elapsed up to now, and normalization and maintenance of inflammatory reaction, disappearance of the subjective symptoms, maintenance of good nutritional status and weight gain were observed. The patient has recovered normal social activities without any recurrence.
Low molecular peptides and MCT in the digested diet are excellent in the digestion and absorption in the body. It is thought that this digested diet regimen involving such peptides and MCT might contribute to the good nutritional management in this case.

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A 66-year-old man without paticular complaints was referred to the department because of a colonic lesion revealed on a barium enema study for follow-up of a polyp of the colon.
Barium enema showed a protruding lesion near the splenic flexure of the transverse colon. Colonoscopic examination confirmed the potbellied protruding lesion covered with a smooth, white, normal mucous membrane.
A transverse colectomy was performed with a diagnosis of submucosal tumor of the transverse colon. The tumor was 2.0 × 1.8cm in size.
Histopathologically it was non-Hodgkin lymphoma, B-cell type and follicular medium cell existed from the submucosal layer to surface of mucous membrane. It was in Stage IIA.
The patient received several course of chemotherapy in another hospital after the operation, and has been followed on an ambulant basis. There have been no signs of recurrence.

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We herein present a resected case of nonspecific inflammatory stricture in the lower rectum. A 52-year-old man was admitted to the hospital because of diabetic coma on December 9, 1995. On physical examination, he was in poor general condition and his body temperature was 38.0°C. Abdominal palpation revealed no abnormal findngs. Diarrhea started on the 10th hospital day and thereafter insufficient evacuation appeared gradually. The cut-off index for antibody to Chlamidia trachomatis was positive. All other rectal cultures, stool cultures examined for any bacterias, ova and parasites and serum samples for shiphilis and others were negative. Barium enema study showed a whole-circumferential narrowing of the lower rectum. Colonoscopy showed a shallow ulcer and the granural mucosal change. Biopsy specimens showed nonspecific inflammatory findings and no evidence of neoplasm. Rectal resection including the stricture and ano-rectal anastomosis with covering colostomy were performed. There have been no symptoms of the disease as of 2 years after the operation.

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Undiferentiated carcinoma of the anal canal is rare. We report a case of extramucosal carcinoma of the anal canal in which pre-and post-operative diagnosis was difficult.
An 81-year-old male was admitted with a complaint of constipation. Digital examination of the anal canal and rectum reveaeld annular stricture 5cm above the anal verge caused by an immobile hard mass. Colonoscopy showed annular stenosis between 3 and 6cm above the anal verge but no mucosal abnormalities. Endoscopic mucosal resection and peranal needle biopsy did not allows pathological diagnosis. After obtaining the patient's informed consent, abdominoperianal rectal excision was performed on suspicion of extramucosal anal cancer or malignant submucosal tumor. Microscopic examination of the resected specimen showed that undifferentiated tumor cells had spread in an annular extraluminal fashion around the anal canal and the lower rectum and infiltrated the external sphincter muscle in the anal canal. The tumor cells were demonstrated to express cytokeratin and epithelial membrane antigen by immunohistochemical staining. Based on these findings, a diagnosis of extramucosal undifferentiated carcinoma of the anal canal was made.

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A 77-year-old woman was under follow-up for a cyst of 8cm in diameter in S8 of the liver with multiple small cysts all found incidentally by ultrasound in August 1997. She was admitted to our hospital complaining of fever and right hypochondralgia in November 1997. This was diagnosed as infection of the cyst in S8. The infected cyst was aspirated under sonographic guidance and drainage started. A catheter cystography performed after remission showed a peripheral bile duct communicating with the infected cyst. An operation was indicated since no further contraction of the cyst was obtained. The hepatic segment which included the infected cyst was excised by partial hepatectomy in December 1997. No recurrence has been encountered for the first four months postoperatively. Since an infected liver cyst communicating with the biliary tract is considered to have a possibility of recurrence, an operation such as hepatectomy is indicated early in the course of treatment.

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A 17-year-old girl had suffered jaundice at the age of six and her illness had been diagnosed as idiopathic portal hypertension with symptoms of liver dysfunction, splenomegaly, and esophageal varices. She was admitted to our hospital with left hypochondralgia on June 5, 1997. Endoscopic retrograde cholangiopancreaticography revealed pancreatico-biliary maljunction. Abdominal computed tomography showed splenomegaly and cavernous transformation in the hepatic hilus. Protography revealed extrahepatic portal stenosis. From these examinations, we diagnosed her illness as portal hypertension due to extrahepatic portal stenosis with pancreatico-biliary maljunction. Surgery was performed on September 24, 1997. After splenectomy, cholecystectomy, and resection of the extrahepatic bile duct, the portal vein was incised, and it was found that extrahepatic portal stenosis had been caused by a web of fibrous round membrane. The web was resected and patch angioplasty was performed using an autograft of the splenic vein, after which portal pressure decreased from 39cm H₂O to 19cm H₂O. The web was pathologically found to be of collagenous tissue with a one-way valvar lamina, which was recognized as a congenital anomaly.

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A 49-year-old woman, who had a pectoral muscle preserving mastectomy for a right breast cancer, revealed a swelling of supraclavicular lymph node and an increase in CEA level during clinical observation after the operation. Abdominal ultrasonography showed a mass with heterogenous echo level and 8cm in diameter at the hilum of spleen. So the patient was admitted to the hospital for close examination. Abdominal CT revealed a 14×10×8cm mass in the spleen, which was intensified but showed low density compared with that of parenchyma of the spleen. Abdominal magnetic resonance imaging (MRI) revealed iso-to mildly low signal on T1-weighted image and low signal with a high signal area on T2-weighted images. On Gd-DTPA T1-weighted image, it was a mass showing low signal in an arterial phase but slightly high signal in equilibrium phase. Angiography revealed a hypovascular tumor. Based on these imaging methods, a diagnosis of metastatic splenic tumor rather than primary tumor was made, and a splenectomy was conducted. On the resected material, the spleen was 580g in weight, 10×8×6cm in size, and yellowish white in colour which was sharply demarcated from the normal spleen.
Histopathologically, the mass was mainly composed of growth of collagen fiber with infiltration of plasmacytes and lymphocytes, and no angitis nor possible malignant cells were demonstrated. The definite diagnosis of inflammatory pseudotumor was made.

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We report two cases of delayed rupture of the spleen which is relatively rare. A 21-year-old man was seen at the hospital because of acute diffuse abdominal pain which occurred on the 27th day after an abdominal trauma. Since his vital signs were stable, he was treated conservatively and remained uneventful. He was discharged on the 16th hospital day. Another patient, a 29-year-old man who was receiving a conservative therapy for acute splenic and left renal injuries suddenly felt an abdominal pain on the seventh hospital day. CT scan revealed a fluid collection in the intraabdominal space. With a diagnosis of delayed rupture of the spleen, a conservative therapy was started, but further increase in volume of ascites was noted 5.5 hours after the therapy. So an emergency splenectomy was conducted when a deep injured portion was found in the inferior pole of spleen. He followed an uneventful postoperative course and was discharged 21 days after the operation.
The patients with delayed rupture of the spleen are operated on frequently, because the association of trauma is not obvious. Although conservative therapy for delayed rupture of the spleen has been increasingly employed like for acute splenic rupture, the indication of conservative therapy should be restricted.

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A very rare case of partial strangulated necrosis of the tubal fimbriae is reported. A 13-year-old girl was admitted to the hospital because of right lower abdominal pain. She was afebrile and white blood cell count was 6700. No abnormal findings were found by gynecological examination. Since intolerable right lower abdominal pain gradually increased, a laparotomy was performed. The appendix was normal and isolated strangulated necrosis of three fragments of the right tubal fimbria was observed. One fragment of the fimbriae was adhesive with a distal tube, formed a ring and near three fragments went into the ring, resulting in strangulation. To our knowledge, there has been no report with such a case. The cause of the adhesion was unknown. The preoperative diagnosis of this disease is very difficult, but it is important to examine the adnex at the question of a young girl with lower abdominal pain and without leucocvtosis.

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A rare case of adrenocortical carcinoma in an adult with vilirism is reported. A 25-year-old woman, with hirsutism, acne, and amenorrhea was diagnosed as having an androgen producing tumor of the right adrenal gland by abdominal computed tomography, ultrasonography and endocrinal examinations. We resected the tumor and performed lymph node dissection. The tumor had a smooth surface and a cystic region, but was not invasive. Histopathological study revealed adrenocortical carcinoma.
Adrenocortical carcinoma with vilirism in adults is very rare, and have been only 14 cases reported in Japan previously. The prognosis of adrenocortical carcinoma is very poor, and additional follow up should be performed.

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We encountered a case of pheochromocytoma as a complication of total heterotaxia in a 49-year-old female. The patient was hospitalized because of a chief complaint of nausea and headache. Significant fluctuations in blood pressure were observed. A chest x-ray revealed dextrocardia. Abdominal ultrasonography and computed tomography showed total heterotaxia and a right adrenal tumor about 6cm in size. MIBG scintigraphy revealed abdominal acumulation was observed in the region that coincided with the right adrenal gland, and urinary catecholamine levels were high. Based on the above findings, the case was diagnosed as right adrenal pheochromocytoma and total heterotaxia, and the right adrenal gland was excised. The surgical findings revealed that the intra-abdominal organs were a mirror-image of the normal arrangement because of the total heterotaxia. A tumor 6cm in size was observed in the right adrenal grand, and the excised specimen weighed 116.45g. As there have been no reports of cases of pheochromocytoma with total heterotaxia, and our case is the first one of this type, we report the case.

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Six cases of vesicoenteric fistula which had been operated in a recent 13-year period are reported. Their mean age was 62.7 years, and male-to-female ratio was 4:2. Five patients had fecaluria, and another patient had hematuria. Barium enemas revealed vesicoenteric fistula in two patients. All patients underwent cystoscopy and fecaluria were see. However, feces were seen to enter the bladder from a fistula in only one patient. Computed tomography showed air in the bladder in all patients. From these studies, the diagnosis of vesicoenteric fistula was made in all patients. Their primary diseases causing vesicoenteric fistula were rectal cancer in three patients, sigmoid diverticulitis in two patients and radiotherapy in one patient. Of three patients with rectal cancer, two patients underwent total pelvic exenteration, and the remaining patient underwent proctosigmoidectomy with partial cystectomy. Two patients with diverticulitis underwent sigmoidectomy with partial cystectomy. The patient with rectovesical fistula secondary to radiotherapy was treated by sigmoid colostomy because reversal was difficult due to pelvic adhesion. All fistulas successfully healed except one who had a sigmoid colostomy.

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We experienced an extremely rare case of pleomorphic liposarcoma of the greater omentum. A 62-year-old man was seen at the hospital recently because of abdominal discomfort lasting for over the past 5 years. A tumor which was movable from side to side and infant's head-sized was palpable in the upper abdomen.
Ultrasonography of the abdomen revealed a hyper echoic mass, about 11cm in diameter, showing an irregular pattern.
An abdominal computed tomography (CT) scan presented an iso-density area with a clear boundary, and heterogeneous enhancement. These results were suggested that the tumor was a sarcoma arising from the mesentery. Laparotomy with an excision of the tumor which was 15×10cm in size situated in the greater omentum, an omentectomy and a partial gastrectomy was performed.
The histopathological diagnosis was pleomorphic liposarcoma of the greater omentum.

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We report a case of generalized peritonitis by perforated pyometra. A 72-year-old woman developed lower abdominal pain during hospitalization for polymyalgia rheumatica. The muscle guarding was present in the area centering the lower abdomen, and an emergency operation was performed under a diagnosis of generalized peritonitis by perforation of lower intestinal tract. On laparotomy, the intestinal tract was intact but a perforation in the fundus of the uterus was found and pus flowed out. A diagnosis of generalized peritonitis by perforated pyometora was made, and total histerectomy and peritoneal drainage were carried out. Histological examination of the uterus revealed out. Histological examination of the uterus revealed no evidence of malignancy. In case of the elderly women with generalized peritonitis, especially those with poor activity in daily living a perforated pyometra must be considered in the differential diagnosis.

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A 35-year-old man was admitted because of severe abdominal pain. He had been treated with medication for Crohn's disease for 10 years. 5-aminosalicil acid and an elemental diet were started 8 months prior to admission. Seven days before admission, the patient took a nonsteroidal antiinflammatory drug for abdominal pain. His abdomen was rigid, and pan-peritonitis was suspected. An abdominal X-ray showed free air under the right leaf of the diaphragm. At laparotomy, the entire small bowel was diffusely erythematous and edematous, and both the mesentery and the bowel wall on the mesentric side were very thick. Perforation of the ileum was observed 230cm distal to the ligament of Treizt. A 20-cm segment of the ileum, including the perforation site, was resected, and an ileostomy was constructed. The ileostomy was successfully closed 5 months later. The postoperatiVe courese was satisfactory, although most of the affected bowel was left in situ.

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We report a case of giant retroperitoneal teratoma in an infant. A two-months-old infantile girl was admitted to the hospital on emergency because of a severe abdominal distension. She was suffered from malnutrition and pneumonia because she could not have orally taken milk enough and often vomited by the tumor oppression of stomach. Abdominal CT and magnetic resonance imaging revealed a tumor with cystic components, calcification, and fat tissues, and the tumor was diagnosed with retroperitoneal teratoma. the intensive cares such as the administration of proper antibiotics for pneumonia, blood transfusion, and continuous milk infusion via a nasogastric tube were tried and the patient underwent a successful operative resection of the tumor on the 17th hospital day. The tumor was pathologically diagnosed as immature teratoma. retroperitoneal teratoma is often recognized as giant tumor, and it can cause a variety of complications due to abdominal distention and its resultant poor general condition. For that, we should attempt to improve the general condition and to cunduct operative therapy as soon as possible. And the disease demands careful anesthetic management during surgery when we would find a great deal of difficulty for unstable respiratory condition. These bibliografical comments about per and perioperative treatments are also presented.

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A case of retroperitoneal xanthogranuloma is reported. A 41-year-old woman underwent total hysterectomy by the trans-vaginal approach for uterine myoma. She was readmitted because of a high fever. CT scan revealed an abdominal abscess, and trans-vaginal Douglas' drainage was performed. Repeated CT scans showed a solid tumor in the retroperitoneal space connected to a cystic mass in the left lower abdominal cavity.
Total resection of both tumors was performed. Histopathologically, the solid tumor, measuring 23×13×6cm in diameter, was diagnosed as a xanthogranuloma, and the cystic mass, 10cm in diameter, as a simple cyst. The patient is alive two years after the operation without any sign of recurrence.

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The number of the cases of multiple primary cancer has been increasing. The authers report two cases of synchronous double cancer of the kidney and stomach. In each case, renal cell carcinoma was incidentally diagnosed by abdominal ultrasonography (US) and computed tomography (CT) prior to a gastric operation. Both cancers were resected simultaneously.
Case 1: A 70-year-old man was admitted to the hospital because of an epigastric pain. Endoscopic studies and US revealed a gastric cancer in the upper third and multiple renal cell carcinomas in both kidneys. Wedge resection of the stomach and three partial nephrectomies were simultanously performed. Case 2: A 69-year-old woman was admitted for a resection of a gastric cancer in the antrum. CT and US revealed a renal cell carcinoma in the left kidney. Distal gastrectomy, D₂ and a radical nephrectomy were simultanously performed. Both patients are disease-free for 5 years without any signs of recurrence.
Renal cell carcinomas are often silent especially in an early phase. In evaluating the CT and US findings before and after gastrectomy, the kidney should be examined, by entertaining a possible double cancer of it.

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A 63-year-old man was admitted to the hospital as pointed out a type 2 moderately differentiated adenocarcinoma at the rectosigmoid by the colonoscopy in 1992. Abdominal ultrasonography and abdominal CT revealed 4 centimeters SOL in segment 8 of the liver. Serum level of CEA was 39ng/ml, AFP was within nomal range, and hepatitis viruses were all negative. Therefore we made a diagnosis of colonic cancer with liver metastasis, and performed a high anterior resection of the rectum and a partial resection of the liver. After the operation, a diagnosis of simultaneous double cancer of the colon and liver was established histopathologically.
No evidence of recurrence has been seen as of 5 years after the operation. If there are liver lesion and malignant tumor of the digestive tract concomitantly allowances must be made for a possibility of primary hepatocellular carcinoma in the diagnosis and treatment.

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A 44-year-old man was admitted because of a mass on his left anterior chest wall. Palpation of the mass revealed a smooth, elastic-hard nodule measuring 1.5cm in diameter that was not fixed to the skin or underlying tissue and could be moved readily. Tumor excision was performed under local anesthesia. Histological examination revealed a foreign body granuloma with some degenerated nematode parasites. The worms measured 87.5×295μm-143×345μm in diameter, and had a 15-20μm thick cuticle with 3-4 distinct layers without external longitudinal ridges. They had well-developed lateral chords with distinct internal longitudinal ridges. The hypodermis, muscle layer, digestive tract, and reproductive organs of the worms could not be differentiated due to severe degenerative changes. The worms were thus diagnosed as immature Dirofilaria immitis based on their morphological features, size, and the site of parasite infection. This is the fourteenth human subcutaneous dirofilariasis case, and is the first case of extra-pulmonary dirofilariasis reported in Akita prefecture.

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