With the object of avoiding infections, complications, and immunosuppresion associated with allogeneic blood transfusion, and reducing the incidence of transfusion-less surgery as well as the volume of allogeneic blood used in transfusion, we studied 55 patients who underwent surgery for esophageal cancer. These patients included 20 who received autologous blood, and 35 who did not receive autologous blood. The Hb level at hospitalization showed that anemia was not a common complication of esophageal cancer. Anemia and hypoproteinemia were not always found in advanced cases, and there was no correlation between tumor stage and Hb level at hospitalization, or between stage and T-P level. The mean intraoperative blood loss was 688ml, with the loss being than 1, 400ml in 92% of patients. In 70% of the autologous blood group, less than 2 units of autologous blood was transfused intraoperatively. Avoidance rate of allogeneic blood transfusion, including FFP, has increased dramatically with the introduction of autologous blood transfusion. The volume of autologous blood that should be banked for surgery of esophageal cancer is considered to be 800ml, but when perioperative complications occur, a risk of allogeneic transfusion rises sharply. Postoperative Hb levels were high in the non-allogeneic blood group, and T-Bil levels were constantly high in the allogeneic blood group. In conclusion, autologous blood transfusion seems to be useful for surgery of esophageal cancer.

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The purpose of this study is to clarify the clinical characteristics of breast cancers in younger patients aged under 35. Eight hundred and sixty-five patients with breast cancer undergoing mastectomy (Bt+Ax) at the hospital from June 1975 to December 1995 were divided into three groups based on age at diagnosis; 35 years of age or younger, between the ages of 36 and 49, and 50 years of age or older (older patients). Younger patients (46 women) were few and represented 5.3% of all patients, but women during pregnancy or lactation were significantly more than those in other age groups (p<0.01). Furthermore, younger patients were more likely to develop contralateral breast cancer than the others.
For an analysis of clinicopathological features and prognosis of younger patients, pregnant or lactating patients, patients with bilateral breast cancer, and those with breast cancer in stage IIIb or IV were excluded, and 660 patients with breast cancer were reviewed. Younger patients were more likely to have factors such as pathologically involved lymph nodes (p<0.05) and invasion beyond extraglandular fatty tissue (p<0.05) than older patients. Younger patients has a significantly lower disease free survival from older patients (p<0.05). Using Cox's proportional hazard model, n-classification was the most influential prognostic factor on disease free survival, and the age at diagnosis was also influential factor following n-classification, histologic type and tumor size. The clinical significance of the age at diagnosis as a prognostic factor has been demonstrated.

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Among 562 resected cases of colorectal carcinoma, carcinomas with mucinous compenent (MC) were classified into three groups; mucinous carcinoma (MC_??_50%), 25%<MC<50%, and MC_??_25% according to mucinous area ratio on largest cross-section of the tumor. Those three groups were clinicopathologically compared with differentiated type carcinomas without MC.
The ratio of threegroups were 4.8%, 5.0% and 4.4%. The incidence of lymph node metastasis and peritoneal dissemination in the mucinous carcinomas were higher than those in differentiated type and that of peritoneal dissemination in the group (25%<MC<50% was higher similarly.
The five-year survival rates of mucinous carcinoma (53.3%) and the group 25%<MC<50% (48.9%) after curative resection of the advanced carcinoma were relatively lower than that of differentiated type (68.2%).
The five-year survival rate (75.2%) in MC_??_25% group was almost equivalent to that of differentiated type.
As to mode of recurrenca, local or peritoneal recurrence was predominantly noted in mucinous carcinomas and 25%<MC<50% carcinomas.
It is throught that mucinous carcinomas tend to invade locally, and the same characteristic may be observed for colorecal carcinomas with mucinous component at moderate quantity.

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We investigated the correlation between the histopathologic findings in the submucosal invasive front of early colorectal carcinoma and the regional lymph node involvement. In 144 patients who underwent curative large bowel resection against early colorectal cancer eleven patients (7.6%) had regional lymph node involvement at the initial operation. We evaluated the relationship between lymph node involvement and following seven factors: budding, vessel permeation, INF, tumor differentiation in the invasive front, mucus collection, the depth of submucosal invasion and the shape of submucosal invasion. Twenty-one percent of budding (+) patients and 16% of ly (+) patients had regional lymph node involvement. In contrast, only 5% of budding (-) patients and 4% of ly (-) patients had it (p<0.05). The lymph node involvement was found in 33% of IFN-γ patients, but in none of INFα. The high rate of lymph node involvement was obtained on the poor tumor differentiation in the invasive front which did not occur in the dominant. The lymph node involvement was not found in all patient with inverted trapezium of the shape of submucosal invasion. In conclusion, the presence of “budding (+)”, “ly (+)”, “INF β or γ”, “moderate or poor tumor differentiation in the invasive front” appears to be a useful predictor for lymph node involvement.

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The surgical treatment for renal cell carcinomas extending into the inferior vena cava was studied. Subjects were seven patients with renal cell carcinoma with tumor thrombus extending into the inferior vena cava or right atrium who underwent radical nephrectomy with removal of tumor thrombus at the hospital.
They were five men and two women, aged 47 to 73years (mean 62.1). The tumor involved the right kidney in five and left one in two patients. Leg edema suggesting the presence of inferior vena caval extention was encountered in only one patient.
For the diagnosis of the caval extention, magnetic resonance imaging (MRI) was useful in particular. All seven patients underwent radical nephrectomy with thrombectomy and lymph node dissection. In five of seven patients, a thrombectomy with partial caval resection was also performed. In three patients with suprahepatic caval extention, extracorporeal bypass was utilized. Three of seven patients are alive as of 9years and 3months, 1year and 9months and 7months after the surgery, respectively. The remaining four patients died of cancer. The 5-year survival rate was 21.4%. In conclusion, the aggressive surgical resection should be considered in patients with renal cell carcinoma with extension into the inferior vena cava, if feasible. Complete removal of the foci would promise a long-term survival after the operation.

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A case of ruptured infected thoracoabdominal aortic aneurysm (TAAA) was successfully managed with emergency resection with reconstruction in infected field.
A 76-year-old man was admitted to the hospital because of a painful pulsatile mass in the upper abdomen. A diganosis of ruptuted infected TAAA was made based on abdominal CT scanning, angiography and marked inflammation. An emergency operation was performed. A saccular aneurysm about 3cm in diameter was present and involved the orifices of the celiac axis. No gross accumlation of pus was found. The retroperitoneal phlegmon and aortic wall were debrided as extensive as possible. Since allowance was made for surgical stress and for the age of the patient, visceral artery replacement with prosthetic graft orthotopically and extraanatomic reconstruction of the aorta were performed. Staphylococus aureus was isolated from a culture of the aortic wall. Intensive antibiotic therapy was started postoperatively. The patient was discharged about three months afte the operation. There has been no sign of recurrent infection.

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Malignant phyllodes tumor is an unusual breast neoplasm. A 22-year-old woman was admitted to the hospital because of a small lump (3×3cm) in the area AC of the left breast. As the lump was extirpated and found to be malignant phyllodes tumor, a wide resection was performed. The most important therapy for malignant phyllodes tumors of the breast is surgical resection, and mastectomy with lymph node dissection has been principally employed in former times. The tumor, however, hematogenously metastasizes and recurs locally with unsatisfactory resection, and lymph node metastasis rarely occurs. Recently breast conservative surgical method tends to be indicated. In this case, the tumor was relatively small as the phyllodes tumor and the patient was unmarried young woman, and we chose a conservative surgical method. After the operation, a total cross section confirmed that surgical margin was free. Because no effective chemotherapy for malignant phyllodes tumor has been established as yet, adjuvant chemotherapy was not employed. The patient is now doing well with no evidence of recurrence, as of 20 months after the surgery. However, careful follow-up study of local recurrence and distant metastasis would be mandatory.

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We report a case of carcinoembryonic antigen (CEA) producing intracystic breast cancer. A 66-year-old woman was admitted to the hospital because of a palpable mass in her left anterior chest. Physical examination revealed a 2×2cm well-defined elastic soft and movable mass at 2cm distance from the nipple on CA area in her left mammary gland. Ultrasonographic examination revealed a cystic region and a nodular component with heterogeneous internal echo in the cyst. The CEA level in a fluid aspirated from the cyst was high, more 1000ng/ml. The mass was excised and diagnosed as papillotubular carcinoma histologically. Immunohistochemically the cytoplasm of carcinoma cells were stained with CEA-antiserum, and this demonstrated that the tumor was CEA producing breast cancer. Modified radical mastectomy was carried out and there has been no sign of recurrence as of 1 year after the operation.

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Apocrine carcinoma of the breast is a carcinoma in which cancer cells presenting apocrine meta-plasia hold a dominant position, and represents about 0.2-1.5% of all breast cancers. This time we experienced a very rare case of breast cancer which had to be diagnosed as “noninvasive” apocrine carcinoma because no invasive figure was confirmed. A 49-year-old woman was seen at the hospital because of a left breast tumor. Palpation revealed a vague, relatively hard mass 2.0×1.5cm in size in BDE area of the left breast. Both mammography and, ultrasonography did not show any mass.
Aspiration cytology diagnosis was class III, and an excisional biopsy was carried out. Almost of the tumor cells showed apocrine metaplasia without invasion into the stroma. And the tumor was diagnosed as noninvasive apocrine carcinoma. Modified radical mastectomy was performed due to intraductal spreading.
Apocrine carcinoma is histopathologically classified only into invasive carcinoma, and noninvasive apocrine carcinoma does not exist in the general rules for clinical and pathological recording of the breast cancer in Japan. However, seven cases of the disease have been already reported. We think that it may be necessary to reconsider the rules in the near future.

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A case of giant malignant solitary fibrous tumor (SFT) arising in the mediastinum is described. A 51-year-old woman complaining of coughing and dyspnea was operated on for a mediastinal malignant tumor occupying the entire left hemithorax. At operation the tumor was found to originate from the mediastinal subpleural region, extending over the left hemithorax and invading the diphragm. The tumor which was liable to bleed, combined with the invaded lesion, was successfully extirpated. The extirpated tumor was 27×21×17cm in size and 2100g in weight.
Histologically the tumor was composed of spindle cells in a storiform pattern with extensive collagen deposition and partially showed high cellularity and mitotic activity. Immunohistochemistry showed diffuse positive staining of tumor cells for CD34 and vimentin but negative staining for cytokeratin. The definitive diagnosis of giant malignant SFT was made. SFTs occur most commonly in the pleura, but can occur in various organs. SFTs of the mediastinum have been rarely reported in the world with a total of 26 cases so far. This is the third case in Japan.

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Intercostal hemangiomas are extremely rare and represent 1.2-1.4% of all hemangiomas of the skeletal muscle. This paper presents an operated case of intercostal hemangioma diagnosed preoperatively. A 41-year-old man had been pointed out an abnormal shadow by routine chest roentgenography was admitted to the hospital because of suspected chest wall tumor. Arteriograms were helpful for deter-mining the nature and localization of the tumor. The tumor was found to fed by right 9th intercostal artery. With a diagnosis of intercostal hemangioma, the tumor was extirpated undert the 8th intercostal thoracotomy. The tumor was 60×35×20mm in size and firmly adhered to the 9th, rib, and so the tumor with a part of the 9th rib was removed. Histologically it was hemangioma arised in inter costal muscle. The postoperative course was uneventful and he was discharged from the hospital as cured on 13th posyoperative day.

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A 69-year-old man who underwent coronary attery bypass grafting (CABG) for effort angina with an uneventful clinical course developed hemoptysis and fever on the 13th postoperative day. Chest X-ray showed interstitial pneumonia. the pneumonia spread quickly over the entire lung fields, and respiratory function worsened. The patient was diagnosed with having acute respiratory distress syndrome (ARDS). Steroid therapy was initiated and the patient responded very well. Remarkable remission in pneumonia and ARDS attained. General condition once improved, but 2weeks later, fever appeared again and reevalution revealed pancytopenia and lymphadenopathy. Bone marrow examination revealed hemophagocytosis by mature histiocytes, therefore he was diagnosed as virus associated hemophagocytic syndrome (VAHS). Steroid therapy was immediately started again, but the patient died of disseminated intravascular coagulation and multiple organ failure.
This is a very rare case of VAHS due to surgical stress. It is suggested that VAHS must be recognized as a probable postoperative complication.

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A 74-year-old man was performed a right lower lobectomy nd mediastinal lymph node dissection for a right lung cancer at the hospital. About 1 month after the operation, a chest X-ray film showed niveau on the right thorax. Computed tomography and bronchoscopy indicated development of a bronchopleural fistula and empyema cavity. About 2months after the initial operation, the fistula was closed with a pedicled gastric seromuscular flap based on the right gastroepiploic artery. The omental falp was brought up with the gastric seromuscular flap through the anterior diaphragm and filled the empyema cavity. Postoperative computed tomography showed successful closure of the fistula. This procedure provides a more air-tight closure of the fistula than that using omentum alone. He is doing well 6months following the second operation.

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A 68-year-old man who was pointed out a tumor shadow with cavities in the right upper lung field on a medical checkup was admitted to the hospital. On admission a chest X-ray film and CT visualized multiple nodulus in the right upper lobe. Although no definite diagnosis was achieved by various diagnostic methods including bronchoscopy, a lobectomy was performed because a possibility of lung cancer was not ruled out and the patient strongly wished. In the resected material, five nodulus were noted. Histopathologically, pulmonary infarction due to Dirofilaria immitis and its bodies were confirmed. The definite diagnosis of human pulmonary Dirofilaria immitis was made.
The disease appears solitary in most cases, and if it presents with multiple nodulus, the number of nodules have been counted up to two. This case with five nodulus is the first report in Japan. Immunological examination of serum of the patient collected preoperatively also confirmed the presence of antibody for Dirofilaria immitis. Consequently, it is possible to make the definite diagnosis of Dirofilaria immitis by immunological examination and the disease only forms infarct foci in the lung. It demands no paticular treatments and we are able to avoid unnecessary operations.

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The clnical presentation, clinical couse, and therapeutic result were studied in two patients with carcinosarcoma of the lung. From 1981 to 1995, a total of 408 patients with primary lung cancer were operated on at the hospital and these patients represented 0.5% of them. They were a 71- and an 81-year-old men and heavy smoker with smoking index of more than 700. Primary lesions were of peripheral type in both patients. Histological findings of carcinomatous lesions revealed squamous cell carcinoma in one patient (case 1) and a mixed cancer consisting of squamous cell carcinoma and adenocarcinoma in the other (case 2). As to sarcomatous lesions, scattered eosinophilic large cell which might arise from the striated muscle were seen in case 1 and a spesific differentiation to chondrosarcoma was confirmed in case 2. Immunohistochemical studies revealed that the sarcoma portion in the case 1 was myoglobin staining positive, and that in case 2 was S-100 protein positive. They were diagnosed with having true carcinosarcoma. The prognoses were very poor; one patient (case 1) died of recurrence to the chest wall 17 months after the operation and the other died of brain metastasis during hospital stay 3 months after the operation. Immunohistochemical stainings may be helpful in marginal cases in which there is doubt about the presence of heterologous stromal elements.

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A 56-year-old man who had been operated on for a cancer of the thoracic esophagus was admitted to the hospital with a suspicion of pleural recurrence on February 28, 1996. On March 14, dyspnea along with hallucination and disorientation appeared. Since severe impaired ventilation was noted, endotracheal intubation was emergently performed and the patient was entered the ICU. At that time, Ca level was 18.6mg/dl, showing significant hypercalcemia, and the white blood cell count increased to 18, 100/mm⁸. PTH-rP level in blood was as high as 260Pmol/ml. The elevated Ca level gradually decreased with a combinated use of elsitonine and bisphosphonate and his clinical condition became better, however, the Ca level converted to increase gradually since April 7, and appearance of arrhythmia and aggravation of ventilatory impairment were associated. On May 8, the patient died of abrupt cardiac arrest, when the white blood cell count was 21, 600/mm³ and Ca level was 14.8mg/dl.
It is thought that hypercalcemia in this case might be caused by pleural recurrence of the esophageal cancer based on an increase in PTH-rP, and the cause of his death might be due to hypercalcemia crisis because the increase in Ca level was correlated with the clinical symptoms.

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We experienced a case of malignant leiomyoblastoma which was incidentally detected when an emergency laparotomy was performed for hemorrhagic gastric ulcer. This paper presents the case with a review of the literature.
A 61-year-old man was admitted to the hospital because of hematemesis. Endoscopic examination of the stomach was emergently performed and hemorrhagic gastric ulcer was confirmed at the body near the lesser curvature. Endoscopic hemostasis was unsuccessful, and so an emergency laparotomy was conducted on the same day. During the operation, an extramurally growing segmented tumor about 13cm in longer diameter with smooth surface in the pyloric antrum was found out other than the ulcer lesion in the lesser curvature. A distal gastrectomy including the both lesions was carried out. Histopathological examination revealed that the tumor arised from proper muscular layer; it had eosinophilic oval-shaped cells and transparent band surrounding nuclei; and an average of 12/50 HPF was counted as to karyomitosis. Immunohistologically, the tumor exhibited vimetin (+), myosis (+), and α-smooth muscle actin (+), and was definitely diagnosed as malignant leiomyoblastoma of the stomach. The ulcer lesion was peptic ulcer of U1-4 and had no correlation with the tumor.

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A total of 47 cases of malignant schwannoma of the stomach appeared in the Japanese literature including seven operated cases in our clinic were clinically surveyed. Limited to our seven cases, gastric malignant schwannomas represented 0.3% of all gastric cancers and 8.5% of all gastric sarcomas in our clinic.
In the cumulative series, the male-to-female ratio was equal and the age at hospitalization was 56.1 in an average. In over half of these cases, the tumor occurred at upper 1/3 region of the stomach and the endogastric type was most common, reached 44% in a frequency. Deep ulceration with central necrosis in the tumor was seen in 56.4%. Both submucosal tumor without any further description and Leiomyosarcoma were main preoperative diagnosis, each occupied 36%. Acurate preoperative diagnosis as malignant shcwannoma was made in only 11.6%. Immunohistochemical staining for S-100 protein in biopsied or removed materials revealed positive in 87.1%, suggesting the usefulness of this examination. Metastasis on laparotomy was found in 23.8% in the liver, 9.5% in lymph nodes and 4.8% in the peritoneum.
Of the own seven patients, curative resection was feasible in four patients and the remaining three patients died of progression of the residual tumor within postoperative 2 years. Therefore, an effort for curative resection should be made at present and otherwise intra- or postoperative chemotherapy would be necessary in advanced cases.

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A case of gastric malignant lymphoma with gastric perforation is presented in this paper because of its rarity in the literature. A 45-year-old man was admitted to the hospital because of symptoms suggesting acute peritonitis due to gastrointestinal perforation. After gastric perforation was ensured by laparoscopy, the patient was converted to open surgery and a distal gastrectomy with peritoneal lavage was performed. A large ulcer, 8×9cm in size, was located at the body of stomach with a 7mm perforation. The diagnosis of diffuse medium-sized cell type malignant lymphoma was made by histological examination. Adjuvant chemotherapy was conducted after the surgery and the patient was discharged from the hospital on 71st postoperative day. The incidence of spontaneous perforation of gastric malignant lymphoma is rare. Only thirteen cases including ours have been reported in the literature for the past 16 years. It is emphasized that gastric perforation might occur in case of malignant gastric tumors.

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A rare case of so-called carcinosarcoma of the stomach is reported. A 74-year-old man was seen at the hospital because of anemia. Upper gastrointestinal examination revealed a 2' type tumor at antrum of the stomach. He was diagnosed as having a 2' type gastric carcinoma, and a distal gastrectomy was performed. Microscopic examination revealed that the tumor consisted of differentiated adenocarcinoma with pleomorphic cell with sarcomatous stroma. And because a transitional area between the two elements was recognized histopathologically, it was diagnosed as so-called carcinosarcoma. Postoperative course was uneventful and there has been no recurrence for seven years after the surgery.
Carcinosarcomas of the stomach are rare and there have been only 30 reported cases in Japan so far. In a review of these cases, so-called carcinosarcomas of the stomach frequently appeared as elevated lesion and were commonly detected in an advanced stage compared to the common gastric carcinomas. The prognosis of the disease was also poor, but operation was able to offer a good prognosis to some cases in an early stage. So we think that operation can cure the disease, if the lesion is found out in an early stage when no hepatic nor lymph nodes metastasis occurs.

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We experienced two cases of chilaiditi syndrome, in which the ileum was incarcerated beneath the right diaphragm and liver, presenting with acute abdomen.
A 61-year-old woman was seen at the hospital because of upper abdominal pain and vomiting. A simple abdominal X-ray film showed intestinal gas shadow beneath the right diaphragm. An emergency operation was performed with a diagnosis of strangulated ileus, and a funicular material was found between the diaphragm and liver, and a part of the ileum incarcerated to be strangluated.
A 67-year-old man was seen at the hospital because of upper abdominal pain and vomiting. Based on abdominal X-ray and CT findings, a part of intestinal tract was beneath the right diaphragm and acute cholecystitis was present. During the operation a part of the ileum was incarcerated between the diaphragm and liver, which covered the abscess of cholecystitis.
Chilaliditi syndrome has generally no paticular symptoms, but caution should be exercised in the small intestinal type that often associates with acute abdomen.

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A 55-year-old woman was admitted to the hospital because of recurrent massive melena with unknown bleeding site for two years. Blood pool scintigraphy revealed the active bleeding in the ileocecum. Abdominal angiography revealed the bleeding from arteriovenous malformation at the branch of the ileocolic artery. Immediately, the bleeding was successfully treated with intraarterial infusion of vasopressin, and thereafter an ileocecal resection was performed electively. In general, the patient with massive melena has a high risk for emergency operation. Therefore, the active bleeding from arteriovenous malformation revealed angiographically, should be first treated with intraarterial infusion of vasopressin like in this case. It is better to perform the operation after the general condition is improved.

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A case of preoperatively diagnosed early carcinoma of the appendix is reported.
A 78-year-old woman was admitted to the hospital complaining of lower abdominal pain. Barium enema revealed an elevated lesion of the cecum, and adenocarcinoma of the appendix was diagnosed by colon fiberscopy. Right hemicolectomy with D₃ lymph node disection was subsequently carried out. Pathological examination demonstrated intramucosal adenocarcinoma limited to the mucosa.
This case of early cancer of the appendix is the second case diagnosed preoperatively. We must be careful in treating appendicitis, taking the possibility of carcinoma into consideration.

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A case of mucinous cystadenocarcinoma of the appendix forming a giant appendix that presented difficulty in preoperative diagnosis is reported.
An 83-year-old woman was seen at the hospital because of right lower quadrant pain. On the first visit, a fist-sized tumor was palpated in the right lower abdomen. Abdominal CT revealed that an oval tumor existed on the right side in the pelvis, the wall was double-stuructured, and the content was almost water density. It was inferred that the tumor was adjacent to the uterus, bladder, and ileocecal region, but the primary site of the tumor could not be identified. A laparotomy was performed at the department of obstetrics&gynecology in our hospital with a suspicion of ovarian cystoma. During surgery, it was found that both the ovaries and uterus were normal and the tumor was connected to the appendix, when we (surgions) were consulted and confirmed that it was a giant appendix. An appendectomy was carried out. The resected specimen revealed the giant appendix with the whole length of 18cm and 465g in weight containing of jelly-like substance and mucus. Histopathologically, mucinous cystadenocarcinoma was observed at the tip of the appendix. Mucinous cystadenocarcinoma presenting giant appendix is extremely rare. This paper descibes such a rare case wih a review of the literature.

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We report a case of familial adenomatous polyposis with an advanced cancer of the sigmoid colon which was treated with laparoscopic surgery.
A 36-year-old woman was pointed out to have a familial adenomatous polyposis with a signoid colon cancer by a barium contrast study of the colon. an operation was conducted through four 10-mm trocars. the total colon was laparoscopically dissected and mobilized from the abdominal wall and retroperitoneum. the root of the inferior mesenteric artery was exposed. The total colon was extracted through a 9cm lower abdominal midline incision. The gastrocolic ligament and right side of the mesocolon were incised. Lymph node dissection of the inferior mesenteric artery was perfromed through the incision. The lower recutm was dissectd through the incision. the total colon was removed through the incision after transcetion of the rectum and ileum. heal-reservoir (J-pouch9 and anal anastomosis were performed. The operation time was 6 hours and 34 minutes. Postoperative course was uneventful. As three months after the surgery, anal function has been good and the patients has bowel movements 3 or 4 times a day.

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It has been reported that malignant tumors during pregnancy are uncommon representing 0.1% of all malignant tumors, especially colorectal cancers, in a frequency of 0.002%. We report a rare case of colonic cancer in a 27-year-old woman during puerperium with a veview of the literature. The patient had anal bleeding and lower abdominal pain at defecation after delivery of her daughter, but she considered them as symptoms due to hemorroid or so and did not consult any practitioner. On 20th day after delivery, nausea and vomiting also occurred and she visited another hospital and was found to have an almost whole-ciucumferential elevated lesion in the sigmoid colon on colonoscopy. The patient was referred to the hospital. On admission she was diagnosed as having a sigmoid colon cancer with multiple liver metastases. At operation, multiple liver metastases and lymph nodes involvement were confirmed. Palliative resection of the sigmoid colon was performed. Resected specimen was histologically identified as well-differentiated adenocarcinoma. The patient died of liver failure 6months after the surgery. The diagnosis of the disease can be often delayed since pregnancy sometimes misleads the symptoms suggestive of colonic tumour.

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This paper presents a patient who was operated on for preoperative diagnosis of lymphangiosis type of primary diffusely infiltrating carcinoma of hte colon and rectum but experienced metastasis to the brain one month after the operation, with a fatal course. A 47-year-old man complaining of severe diarrhea was suspected of having inflammatory intestinal disease such as idiopathic ulcerative colitis, but was demonstrated having an denocarcinoma on biopsy at another hospital. The patient was referred to the center with a probable diagnosis of metastatic colorectal cancer. Barium enema examination demonstrated an irregularity of the intestinal wall, and difficulties of extension almost 30cm in length at the signoid portion and the rectum level. But no stenosis was found. Endoscopically, the mucosa was intact but edematous and rough. There was no luminal mass and only the small, shallow ulcerlation was observed. The patient underwent abdominoperineal resection of the tumor at the sigmoid colon and rectum, resulting in non-curative resection because of extensive abdominopelvic lymph nodes metastasis including involvement of the para-aortic lymph nodes. No evidence of tumor involvement in any other abdominal or pelvic organs was evident at the time of surgery. The surgical specimen revealed a diffusely thickened and irregular wall with a 2cm shallow mucosal ulcer. Histologically, the tumor was poorly differentiated adenocarcinoma except the small area of moderately differentiated adenocarcinoma under the ulcer. The patient received a course of chemotherapy (CPT-11) postoperatively, but after a week, the brain metastasis caused brain edema and his consciousness was getting down. The patient's clinical course continued to deteriorate due to the progression of the cancer, a nd he died two months after the operation.
Primary diffusely inflitrating carcinoma of the colon is a relatively rare primary colorectal malignancy. But the prognosis is poor and its clinical significance is large. The poor prognosis is likely related to the initial delay in its diagnosis especially in the lymphangiosis type, because its symptom is sometimes unclear and the lesion is often similar to inflammatory colonic lesions radiographically and microscopically.

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We have performed an operation for a stenosis of the sigmoid colon caused by ischemic colitis in a patient who had undergone an aortic reconstruction following ruptured abdominal aortic aneurysm. A 69-year-old man was admitted to another hospital because of a ruptured aortic aneurysm and an emergency aortic reconstruction was performed on December 29, 1995. On the fifth day after the surgery, diarrhea started and cord-like material was excreted in the feces on the 13th day. Lower abdominal pain and mild fever persisted for two months and intestinal obstruction developed. A barium enema and endoscopic examinations revealed friable mucosa with easy bleeding and almost complete obstruction of the sigmoid colon. At laparotomy there was no generalized peritonitis but the sigmoid colon had perforated with local abcess formation. Resection of the sigmoid colon and colostomy were performed. Post-operative course was uneventful.

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We present here a case of anal sphincteroplasty using the unilateral gluteus maximus transposition for traumatic anal incontinence. A 38-year-old man had a pelvic trauma with anorectal and urethral injuries and pelvic fractures, by a snowplow accident. Initial treatments at another hospital included double barrelled transversostomy, cystostomy and pelvic fixation. Six months later, the patient was admitted to the hospital when he had a very narrow and sclerotic anal canal which was only 18 French (6mm) in diameter, due to a stenotic scaring deformity and mucous soiling. After fistulotomy under spinal anethesia, the fistula had been dilated by finger bougienage and the patient had been exercised voluntary contraction of the residual sphincter muscles. Operation consisted of three procedures; (1) removal of the scar around the injured anal canal, (2) reconstruction of neoanal canal by rectocutaneostomy, and (3) sphincteroplasty by suture of the unilateral gluteus maximus and pubococcygeus muscle of the opposite site.
Minor local infection occurred after operation but functional results were satisfactory. Nine months later, the stoma was closed and the patient has been rehabilitated.

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A 67-year-old woman was referred to the hospital for admission because of prolapse of the intestine throught the anus. A tumor was found out at the top of prolapsed intestine and malignant cells were detected at a biopsy of the tumor. Pelvic computed tomography revealed that an intussusception headed by the cancer of the sigmoid colon had prolapsed through the anus. Upon laparotomy, the invaginated intestine was reduced as possible as we could, and then a sigmoidectomy was performed. Postoperative course was uneventful.
Intussusception in adults is relatively rare and is often caused by some organic disease. In paticular, intussusceptions in the large intestine are often headed by a malignant lesion, but the top of intussusception rarely prolapses through the anus. Our case of intussusception caused by a sigmoid colon cancer of which top prolapsed through the anus is presented, together with a review of the literature.

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We report two cases of cancer of the sigmoid colon with intussusception prolapsing through the anus. Case 1: A 77-year-old woman was seen at the hospital because of bloody stool and a prolapsing intestine. Manual reduction was tried, but in vain. Sigmoidectomy was performed without reducing the intussusception. Resected specimen was type 2 tumor (5.2×2.5cm) with n1. Case2: A 77-year-old woman had a prolapsing intestine with a protuberant tumor at its apex. Sigmoidectomy was performed after mannual reduction. The tumor was type I sp early cancer with n (-) and 3.0×2.5cm in size. We reviewed 23 cases of colorectal carcinoma with intussusception prolapsing through the anus in the Japanese literature. Depth of invasion was relatively shallow in those tumors and about half of the tumors were in an early stage. Many cases have no lymph node involvement. In treatment, it has been said that the resection should be carried out without reducing intussusception if malignant tumor is present. In case of intussusception prolapsing through the anus, under possible early reduction, an appropriate operation should be selected according to the accurate diagnosis.

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A 63-year-old woman was admitted to the hospital because of hematochezia. Severe anemia and thrombocytopenia were noted (red blood cell 248×10⁴/mm³, hemoglobin 5.8g/dl, hematocrit 19.6%, platelet count 0.8×10⁴/mm³). The patient was diagnosed as sigmoid colon cancer associating with idiopathic thrombocytopenic purpura (ITP). Transfusion of 25 units of platelet was performed and a large dose of globulin 20g/day for 5 days, methylprednisolon 500-1000mg/day, and prednisolone 50mg/day were administered. When the platelet count increased to 25.2×10⁴/mm³, splenectomy and sigmoidectomy with lymphnode dissection (D₂) were carried out. After the surgery, abnormal bleeding did not occur and the postoperative course was uneventful. After discharge, the patient has been followed at outpatient clinic as of 6 month after the operation, and the plateletcount is kept at good level of 25.2×10⁴/mm³ without taking predonisolone.
The large dose gulobulin regimen appears an extremely safe and useful method in preoperative management of surgical patients with ITP. It is possible to keep increased platelet level by splenectomy.

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A 58-year-old man was admitted to the hospital because of progressive muscle weakness and pain of the extremities. Past history and familial history are unremarkable. In October 1996, he began to feel muscle pain. The pain disappeared gradually after one week, but he began to feel muscle weakness of the extremities. The serum GOT, GPT and LDH levels on admission were high, and especially the CPK level was 17330 IU/l. The diagnosis of polymyositis was made by examination of muscle biopsy. Steroid therapy was performed for three days from October 16. The CPK decreased to 6222 IU/l after the treatment, but muscle strength did not improve. The CPK rose again to 11440 IU/l on October 30, and he felt difficulty in swallowing. He passed bloody stool, and a colonoscopy revealed a rectal cancer at Rb of the rectum, and a biopsy showed malignant cells. A diagnosis of rectal cancer associated with polymyositis was made, and a rectal amputation was performed on November 12. He was able to walk 2months after surgical treatment of the cancer. The CPK level was normalized and muscle strength improved completely 4 months later. He has had no recurrent sign of the cancer, nor relapse of Polymyositis as of 6 months after the operation.

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A case of rectal cancer with Leriche syndrome which was successfully operated on by considering the operative procedure in terms of both blood flows to the lower extremities and to the intestine. A 68-year-old man was seen at the hospital because of intermittent claudication and the painful left first toe. Aortography revealed that the abdominal aorta had tapered from just below the furcation of renal artery and occluded at the furcation of the inferior mesenteric artery. During a period of waiting operation, the patient developed intestinal obstruction. Close examination disclosed a rectal cancer (Borrmann type 2, Rs) and a 1.8×1.7cm solitary nodular shadow in the left upper lobe of the lung which was thought metastatic lung cancer.
A colostomy and a right axillo-bilateral femoral artery bypass were performed as the first operation. Two weeks later a low anterior resection for rectal cancer with closure of the colostomy and a resection of the lung metastasis under video assisted thoracoscopic surgery were performed. The patient has an uneventful course after the operation. In the treatment of this kind of case, it is essential to establish a blood flow to the intestines distal to the anastomosis through the internal iliac arteries.

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A 68-year-old man who had been suffening from anal fistula with purulent discharge for more than 10 years was seen at the hospital because of bloody discharge from an 8×4cm perineal mass. We suspected a carcinoma associated with anal fistula, but he refused surgery. Eight months later when he was seen at the hospital again the mass enlarged and bloody discharge persisted. We recommended admission for surgry. Preoperative histological examination following a partial resection of the mass revealed mucinous adenocarcinoma, and an operation was performed three days later. We created a double-barrel stoma using sigmoid colon in the left lower quadrant of the abdomen with the patient in the supine position, and then the perineal tumor was removed en bloc with the anal fistula and with half of the external sphincter muscle with the patient in the jack-knife position. The large defect in the perianal skin and the pelvic cavity required a repair and plasty using a left posterior thigh flap. Since the inguinal lymph nodes were bilaterally not palpable, postoperative radiation therapy was performed instead of lymphadenectomy. The postoperative course was uneventful, and he was discharged on the 35th postoperative day. There have been no signs or symptoms of local recurrence or metastasis. In conclusion, a posterior thigh flap was useful for reconstructing the large skin defect in the perineal region in this patient.

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A 63-year-old woman was seen at the hospital because of right upper quadrant pain. An abdominal X-ray film in the standing position showed a calcified shadow producing a fluid level in the right upper quadrant. Abdominal CT revealed calcified material concomitant with small calcified stones in the gallbladder. Oral and intravenous cholangiography failed to visualize the gallbladder or cytic duct. With a diagnosis of cholecystolithiasis with limy bile, a laparoscopic cholecystectomy was performed. Intraoperative cholangiography failed because of obstruction of the cystic duct, and laparotomy was performed. Limy bile was noted and a calcified stone was impacted in the cystic duct. A small area of induration was noted at the confluence, which was resected and choledochotomy with T-tube drainage was performed. Histological examination of the induration showed adenocarcinoma, and a re-operation for resection of the extrahepatic bile duct with lymph node dissection was performed. The histological findings indicated early bile duct carcinoma without lymph node metastasis, and an absolutely curative operation had been performed.
Few cases of limy bile associated with cancer of the biliary system have been reported in Japan thus far. We could not find obvious relationship between limy bile and the carcinoma in a review of the Japanese literature.

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Bile duct papilloma is an extremely rare entity. Note has been increasingly made of the disease because it has a variety of clinicopathological characteristics and its cancer change has been sometimes reported.
A 68-year-old man complaining of jaundice had been diagnosed as having bile duct papilloma at another hospital, and had been followed up after endoscopic fistulization. Two years and 5months later, the patient was admitted to the hospital for operation because of repeated cholangitis. Histopthological study of the resected specimen revealed cholangiocarcinoma with multiple papillary projections covering the entire extrahepatic bile duct. It was inferred to be cancer change of bile duct papilloma.
There have been eight cases of the disease in Japan in a recent one decade. Most lesions in these cases were located in the intrahepatic bile duct or extrahepatic to intrahepatic bie duct, and were characterized by mucin-production or cancer change. This case had almost similar characteristics, but the lesion was localized in the extrahepatic bile duct that enabled us to perform a complete resection comprising a resection of the extrahepatic bile duct and a pylorus preserving pancreatoduodenectomy (PPPD). There has been no sign of recurrence, as of 2years and 6months after the operation.
Although bile duct papilloma is very uncommon, we have to make a correct diagnosis as well as to take careful atitude for selection of operative procedures and postoperative follow-up in terms of its possible cancer change.

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A 51-year-old woman was admitted to another hospital because of repeated hematemesis which started on September 21, 1994, and was diagnosed as having Felty's syndrome. The patient had been suffering from rheumatoid arthritis for about 10 years and had been pointed out a splenomegaly and esophageal varices 3 years before. The patient was admitted to the hospital for close examination and treatment on January 4, 1995. Physical examination on admission revealed pigmentation in the skin of bilateral legs. Decreases in white blood cells and plateletes counts, positive response to antinuclear antibody, and an increased level of rheumatoid factor were noted. Abdominal CT visualized remarkable splenomegaly. On catheter examination via the hepatic vein, there were some findings suggestive of idiopathic portal hypertension (IPH). For the esophageal varices, endoscopic sclerotherapy was conducted the three times, and thereafter a Hassab operation and hepatic biopsy were performed on March 8. Histopathologic findings of the liver were compatible with IPH. Upper gastrointestinal endoscopic study conducted on the first month after the operation confirmed disappearance of the esophageal varices, and the white blood cells and platelets counts were normalized.

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We present a rare case of primary splenic angiosarcoma of which clinical course was able to be observed, together with a review of the literature.
A 56-year-old woman visited another hospital because of left upper abdominal pain and body weight loss which started in december 1994. She was recommended for admission because of abnormality of the spleen but regected, when no hepatic tumor was reveraled on CT.
Later, she was admitted to the hospital because the abdominal symptom persisted in February 1996. On physical examination at admission, to spleen was palpable four finger's width in the left quadrant of the abdomen. Laboratory studies revealed severe anemia, hemorrhagic tendency, thrombocytopenia and liver dysfunction. A primary splenic angiosarcoma with multiple metastasis to the liver and bone was considered from radiologic findings. After the pathohistological diagnosis was confirmed by biopsy, IL-2 which is considered to have therapeutic effect only to angiosarcoma in this time was administered systemically. But the symptoms progressed worse, and the patient died 57days after the admission.
This time, we experienced a case of primary splenic angiosarcoma that is vey rare, and reported it with some discussion of literatures.

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This paper describe a case of hereditary spherocytosis in a child who required laparoscopic splenectomy. A 3-year-old female child, who had been diagnosed as having hereditary spherocytosis with splenomegaly, underwent a laparoscopic splenecotmy. The patient was placed in a complete decubitus position. The table was flexed to separate the left subcostal margin and iliac crest. A 4-mm laparoscope and other instruments required for 3-mm trocar were used. Good exposure of the laparoscopic visual field was obtained under 6-8mmHg low pressure pneumoperitoneum which was established to secure the laparoscopic visual field. There were no anesthetic complications even though there was continual air leakage observed during the pneumoperitoneum due to a lack of a cuff trachea tube. Hemodynamics, end-tidal CO₂, and transcutaneous O₂ saturation were carefully monitored during the operation, especially as the patient in this case was a child. The endoscopic linear stapler was applied across the splenic hilum, and the stumps of the splenic hilar vessels were additionally ligated by endoloop. Specimen extraction was performed by placing the spleen in a nylon bag for instrumental splenic fragmentation with a morecerator. The operating time was 176min, and postoperative hospital stay was 9 days. Laparoscopic splenectomy in children is considered to be a safe and effective extension of minimally invasive surgery.

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A rare case of spontaneous rupture of renal angiomyolipoma is reported. A 44-year-old woman was seen at the emergency clinic in our hospital because of sudden onset of abdominal pain. Physical examinations revealed preshock state, anemia and an infant-head sized mass with tender on pressure in the right flank. A diagnosis of spontaneous rupture of a right renal tumor was made by ultrasonography and CT scan. Emergency right nephrectomy was carried out. The tumor was composed of fatty tissue in the most part and subcapsular hematoma. So keeping a possible malignant tumor in mind, we added some operations for malignancy. Histopathological examination confirmed the diagnosis of renal angiomyolipoma. A statistical study is made on 81 reported cases of ruptured renal angiomyolipoma in Japan.

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Renal cell carcinoma easily metastasizes on blood. The most common site is the lung, followed by the liver and bone in this order, but it rarely metastasizes to the pancreas. We report a case of multiple pancreatic metastases from a renal cell carcinoma 12 years after nephrectomy. A 50-yer-old woman, who had undergone a left nephrectomy for a primary renal cell carcinoma 12 years before, was admitted to the hospital because of epigastralgia. Abdominal CT scan, magnetic resonance imaging and angiography demonstrated multiple hypervascular tumors at the pancreatic head and tail. Tumor enucleation was performed. Histrogically the tumors were clear cell subtype carcinoma, which closely resembled the renal cell carcinoma resected 13 years before in the morphologic features. In this case, a suspicion of islet cell carcinoma which was arose preoperatively was ruled out because no endocrinological abnormal findings were revealed, but we had still difficulty in differential diagnosis between metastatic tumors and non-functioning tumors. Reports on resected metastatic pancreatic cancer from renal cell carcinoma are quite rare, and there have been only 29 operated cases in the Japanese literature. Careful long-term follow-up is necessary for the patient after nephrectomy for renal cell carcinom.

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We have successfully resected metastatic lesions in the lung and pancrease 11 years after a radical operation for a renal cancer.
A 64-year-old woman, who was underobservation after a left nephrectomy for renal cell carcinoma in 1984, was pointed out having a tumor shadow in the right lower lung field on a chest-ray film in November, 1995. Abdominal CT was conducted for the purpose of the general exploration, and a tumor about 35mm in the longer diameter which was internally heterogenous and ill-defined was detected in the pancreatic body. With a suspicion of pancreatic tumor and metastatic lung tumor, the patient was operated on.
Histopathologically, the both lesions were darified to be metstases to the pancreas and lung from th 11-year previous renal cell carcinoma. There has been no sign of recurrence and the patient is doingwell, as of 10 months after operation. Renal cell carcinomas can cause delayed and distant metastasis after radical operation, and hense strict post operative obsevation of clinical course including the adjacent organ, the pancreas, is necessary. As to the metastatic foci of the pancreas, a better prognosis can be expected by surgical resection, but its precise inducation would demand further investigation.

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We experienced a rare case of spontaneous mesenteric hematoma. A 73-year-old man was admitted to the hospital because of suddenly developed lower abdominal pain. Abdominal findings showed peritoneal irritation on the left lower quadrant. Abdominal ultrasonography and computed tomography (CT) revealed a well-defined lump measuring approximately 10cm in size. Emergency celitomy was performed and a hematoma was detected in the sigmoid mesocolon. However, there was no intestinal injury or disruption of any blood flow. Accordingly, evacutaion of the hematoma and drainage were undertaken. the postoperative course was uneventful. In the present case, there was no previous history of bleeding tendency nor abdominal trauma.

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A 56-year-old man was admitted to the hospital because of right upper quadrant pain on August 18, 1995. The patient was diagnosed as having cholelithiasis and choledocholithiasis, but a circular tumor in the left superior intrarenal retroperutoneal region was confirmed on an abdominal CT. The tumor was adjacent to the left adrenal gland and was ill-defined. Magnetic resonance imaging (MRI) revealed a low density area on T1-weighted image and a fluid level on T2-weighted image. It was diagnosed as left endocrine non-functioning adrenal tumor. On September 11, the patient was operated on when a spherical tumors 35×34×30mm in size was confirmed on the left side of the inferior mesenteric vein in the retropancreatic region. The tumor was easily freed from the left adrenal gland and completely removed. Histopathologically, it was benign schwannoma in which Antoni type A and B coexisted.
Schwannomas arising in the upper portion of the kidney present difficulty in differential diagnosis from adrenal tumors. In this courtry, only 10cases including this case which were clearly documented have been seen in the literature so far. A review of the Japanese literature mainly based on an analysis of these 10 cumulated cases is also presented here.

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A case of perforated pyometra associating with diffuse peritonitis is reported. An 88-year-old woman was referred to the hospital by a phisician because of a suspicion of acute appendicitis. Simple abdominal X-ray film revealed no free air. Abdominal enhanced CT revealed collection of fluid in the Douglas' pouch and uterine. White blood cell count increased and CRP level was high. The patient was diagnosed as having diffuse peritonitis caused by intestinal perforation and immediately operated on.
On lapalotomy, it ws found that the anterior wall of the uterine body perforated and pus flowed out from the site.
With a diagnosis of perforated pyometra associated with diffuse peritonitis, histerectomy and bilateral salphingoophorectomy with abdominal drainage were performed.
Postoperative course was uneventful. Histological examination of the surgical specimen revealed no findings of malignancy. In a case of acute abdomen in aged woman, this disease should be considered and appropriate examination would permit to make the diagnosis of the disease preoperatively.

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A case of focal arterial hypogenesis of the external iliac artery in a 71-year-old man is reported. The patient suffered from cold sensation in the right leg and intermittent claudication since he was 45years old. In April, 1994, he was referred to the hospital because complete obstruction of the right common iliac artery was indicated on MR angiography at another hospital. On arterial angiography, the right common iliac artery was completely obstructed, and the common iliac artery was imaged by the route of a collateral vessel. A diagnosis of arteriosclerosis obliterans was made and he underwent an operation on July 5, 1994. The external iliac artery became narrow and small from just after the bifurcation of the internal iliac artery, and its diameter was 4mm. The internal space of the artery was completery obstructed. Using Woven Double Verour 8mm, an aortofemoral (right) bypass was performed. Histopathologically the internal elastic plate in the hypogenetic region was retained whole-circumferentially that revealed the difference from ordinary tissue changes in arteriosclerosis. On the basis of these observations, patient was diagnosed as having hypogenesis of right external iliac artery accompanied by arteriosclerosis postoperative couse was unoventful. There has been neither intermittent claudication nor cold sensation in the leg as of about 3years after the operation. Hypoplasia of the artery is so rase that only six cases have been reported in this country.

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Necrotizing fasciitis is relatively rare. We report a case of necrotizing fasciitis secondary to anorectal abscess.
A 32-year-old man was admitted to the hospital because of perianal pain. The patinet had had incision and drainage for anorectal abscess on outpatient base at a clinic, but the condition was aggravated. The patient was admitted to the hospital when the seemed very sick and showed oliguria and shock. At the right side of his anus there was seriously gangrenous skin with erosion and subcutaneous hemorrhage. We performed additional incision, drainage and resection of necrotic tissue 11×6cm in size under spinal anesthesia. There was neither purulent discharge nor muscular involvement. After the surgery the patient was transferred to the intensive care unit, because shock and acute renal failure persisted since before surgery and respiratory failure subsequently occurred. Despite our treatment, he died of DIC and MOF three days after admission. Culture yielded Escherichia coli and Bacteroides.
We consider that our case was compatible of necrotizing fasciitis. Necrotizing fasciitis is surgical emergency with high mortality rate. Early diagnosis and wide resection of necrotic tissue are very important.

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We experienced a case of synchronous triple cancer of the breast kindey and uterus, which were successfully resected.
A 48-year-old woman was seen at the hospital because of a tumor in D area of the left breast in May 1995. Incisional biopsy speciemen revealed invasive ductal carcinoma, and in June she underwent a modified radical mastectomy (Auchincloss method). Histological examination showed invasive ductal carcinoma of papillotubular type. Abdominal CT examination before mastectomy revealed a tumor in the left kidney, bilateral ovarian cysts and endometrial hyperplasia. Thus secondly total hysterectomy and resection of bilateral ovaries and left kidney were done in August. Histologically, the renal tumor was renal cell carcinoma, common type, clear cell sub types, and the tumor of the uterus was well differentiated aderiocarcinoma.

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