Eighteen patients undergoing a laparotomy for gastrointestinal disese after a previous pulmonary resection are reported. Operative procedures at the previous pulmonary resection included lateral complete pneumonectomy in two cases, lobectomy in 15cases, and segmentectomy in one case. Major operative procedures at laparotomy included thoracic total esophagectomy, pancreatoduodenectomy, subtotal gatrectomy and others. Postoperative complications occurred in eight patients (44.4%): three patients developed pulmonary complication, four developed cardiovascular complication and one had metabolic acidosis. There were three postoperatrive deaths, all of whom were at poor risk at an emergency operation for a disease of the digestive tract. However, most patients who electively underwent major digestive tract surgery while receiving active preoperative pulmonary physical therapy did not show any severe postoperative complications. It was thus found that major digestive tract surgery could be safely performed even in patients having previously undergone a pulmonary resection with careful and active preoperative pulmonary physical therapy and post-operative intensive respiratory and circulatory management. And the possibility must be entertained that not only pulmonary complications but also cardiovascular complications may occur far more frequently in such patients.

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Post-operative wound infection was reviewed using clinical factors and bacteriological examination in 102 and 104 patients who underwent upper gastroenterological and colorectal surgery, respectively. Although the positive ratio of the bacterial culture obtained from the upper gastroenterological operative wound showed no statistically significant difference between the positive and negative wound infection groups, the positive ratio of the bacterial culutre in the wound infection group who had colorectal surgery was higher than that of the no infection group with a statistically significant difference (p<0.05). Aerobic Gram-negative rods and anaerobic bacteria were frequently isolated from the operative wound in the colorectal surgery wound infection group. Aerobic Gram-positive cocci from infectious wounds were often isolated in upper gastroenterological surgery, as compared with anaerobic bacteria in colorectal surgery. The incidence at which the same organisms were obtained from the operative wound were isolated as a cause of wound infection was higher in colorectal surgery. Furthermore, wound infection often occurred in bacterial culture negative cases from operative wounds in upper gastroenterological surgery.
In conclusion, the post-operative wound infection is associated with the bacterial contamination occurred in surgery for lower intestine, but not upper intestine.

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The usefulness of postoperative fluid management based on redox theory was investigated. Subjects were 36 patients who underwent high invasive surgeries or the operations with liver damage and whose arterial ketone body ratio (AKBR) had decreased less than 0.7 within 2 weeks after the operation. Of these 36patients, 21 patients were indicated the fluid management based on redox theory (group A) and the remaining 15 patients were not indicated (group B), and the two groups were compared for the postoperative clinical course. No significant differences were found in the perioprative background factors such as the age, gender, type of operation, ICG test, and the amount of intraoperative bleeding between group A and B. AKBRs recovered to more than 0.7 in 13 of 21 cases (62%) within additional 2 weeks (good course) in group A and in 5 of 15 in group B. No significant difference was seen in total cases, however, in the cases which had more than 2 organ damages postoperatively, group A had more cases (4/6, 67%) with good courses than those (1/10, 10%) in group B statistically. In conclusion, the measurement of AKBR enables the postoperative metabolic status to be assessed more accurately and the fluid management based on redox theory is considered to be necessary for the cases complicated with more than 2 organ damages postoperatively.

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Stage classification of gastric cancer was broadly revised in 1993. this time revision made the stage classification so complicated that use of this revised classification becomes diffucult except some much enthusiastic surgeons. The present study was designed to compare the results between the current classification, old one, and a modified classification containing the nodal number concept. Out of 1464 patients underwent surgical resection at the hospital, 879 patients with P0, H0, excluding “m” cancer and t4 were entered in this study. The number of metastatic lymph nodes was categorized into 4 subgroups, according to every five; 0; 1_??_5; 6_??_10; and over 11. According to the current staging, there shows no significant difference in the cumulative survival rate between stage IIIb and IVa. A multivariate analysis showed superiority of current staging to other two staging results, however, the modified old staging also showed significance. So the classification based on lymph node grouping seems to meet the time of courageous changing to the number concept of lymph nodes.

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The clinicopathological features of 21 cases of poorly differentiated adenocarcinoma of the colon and rectum resected in our department from 1988 to 1996 were compared with those of 472cases of well and 162cases of moderately differentiated adenocarcinoma. Poorly differentiated adenocarcinomas were more frequently found in the right side of the colon. Eighty five point seven percent of poorly differentiated adenocarcinomas invaded beyond serosal and adventitical layer, and 28.6% of them had high grade lymph node metastasis. Sixty six point seven percent of poorly differentiated adenocarcinomas were Dukes C and D, and 57.1% were over 3b. Poorly differentiated adenocarcinomas were more advanced than well differentiated adenocarcinomas with significant difference. No differences were observed between poorly differentiated adenocarcinomas and well and moderately differentiated adenocarcinomas in frequency of liver and lung metastasis. However, the incidence of peritoneal dissemination was higher in poorly differentiated adenocarcinomas than in well and moderately differentiated adenocarcinomas at the time of primary surgery and recurrence. The curative A resection was done in 71.4% of poorly differentiated cases, and the five-year survival rate was 77.8% in cases with curative A resection. There was no significant difference in the five-year survival rate between poorly differentiated and well and moderately differentiated adenocarcinomas in case of curative A resection. Advanced disease was more often discovered in patients with poorly differeniated adenocarcinoma, however, the prognosis may be improved by early detection and sufficient lymphadenectomy.

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We evaluated clinicopathological characteristics and prognosis of 45 patients for primary colorectal cancer with invasion to the adjacent organs operated on at the hospital from 1990 through 1996. Only 23 (51.1%) patients of them were verified microscopically to have tumor invasion to the other organs. These cancers were predominantly located in the left side of large bowel and extracolonic invasion frequently involved the urinary bladder, abdominal wall, small intestine, and female genital organs. Microscopic tumor invasion was recognized in the stomach and small intestine most frequently, urinary bladder and uterus next, and the rate of microscopic invasion was low in the abdominal wall compared with other organs. The rate of lymph node metastasis only has a significant difference between clinicopathological studies and microscopic invasion. The rate of microscopic invasion was as high as the clinical stage in pararel. No significant difference in prognosis was found between patients with direct histological invasion and those without such invasion, combined resection of the cancer and the surrounding organs is recommended for better prognosis in colorectal cancer for surgically curative cases.

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We have conducted the anal function tests in 40cases of hemorrhoid undergoing radical operation (31cases of Whitehead method and 9cases of Milligan-Morgan method); 43cases of the disease treated conservatively; and 40cases as control. Furthermore, 69cases following Whitehead method were subjected to a study of complaints after the method. The results were: 1) The maximum resting pressure of anal canal was high in cases of severe hemorrhoid. On the other hand, the pressure in aged patients with severe hemorrhoid was significantly lower than those in other age groups. 2) There were no significant differences among groups in the maximum sequeeze pressure. 3) The maximum resting pressure of the anal canal initially decreased in patients after Whitehead operation, but thereafter the pressure normarized to the level in control group. No shortening of the high pressure zone length was noted. 4) No severe complaints nor impairments were observed after Whitehead operations.
It was indicated that excess tension of the internal sphincter muscle of anal canal (an increase in the maximum resting pressure) can cause hemorrhoids, and that an increase in fragility of the internal sphincter muscle of anal canal due to aging may be a probable factor causing hemorrhoid. We think that the Whitehead method has minimal complications if we fully understand the procedure, and is useful for severe hemorrhoids because hemorrhoidal veins are completely removed.

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This study was made of 32 cases of ruptured hepatocellular carcinoma (HCC) concerning clinical findings, prognostic factors, and surgically resected cases. The most common complaint was abdominal pain which occurred in 24 cases (75.0%), and relatively few cases (seven cases; 21.9%) were associated with shock. As the initial therapy, emergency transcatheter hepatic artery embolization (TAE) was performed in 20 cases (62.5%), followed by surgical resection in 3 cases after the gain of hepatic function. Six patients (18.8%) encountered with re-rupture. The prognosis after rupture was poor, and a mean survival period was 130 days in non-recected cases. Whereas the longest survival for 8 years and 4 months was sttained in one patient who underwent a surgical resection. In the patients group with conditions including liver cirrhosis, diffuse type tumor, portal vein tumor thrombus positive, PT<70%. T-Bil≥2mg/dl, and Alb<3g/dl, the prognosis was significantly poorer than other patients groups. These factors may be available for prospecting the clinical course after the rupture of HCC.

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Hernioplasty with the use of a mesh prosthesis for inguinal hernia in adults had become popular in Japan. Since April 1992, various operative methods using mesh grafts have been performed at our department, and the results of 160 plug repairs were compared with those of other methods. Two hundreds and sixty-nine adult cases with hernioplasty for inguinal hernia, from January 1991 to December 1996, were investigated. The case breakdown was; Bassini 143, McVay 12, Lichtenstein's tension free hernioplasty 50, Stoppa 13, laparoscopic hernioplasty 5 (TAPP 3 and TEPP 2), preperitoneal approach with laparotomy for gastrectomy and plug repair 160. Plug repair, especially in 137cases with PerFix mesh plug in contrast to other methods, yielded good results, such that the mean operative time was 32.2±12.2minutes, the recurrent rate was 1.3% and complications were continuous pain in 2 and hematoma in 1 case.
According to our experience, plug repair can be recommended as the standard operative technique for inguinal hernia in adults.

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In an 18-year period between 1978 and 1995, 30 patients were admitted to the hospital for treatment of pilonidal sinus. The patients included 29 men and one women, with a mean age of 23.8±5.1 years (range of 18 to 37 years). The location was sacrococcygeal region in all patients. Diagnosis on admission were pilonidal sinus in 28 patients, and anal fistula and infectious atheroma in other two patients. Complaints of onset were swelling with pain in 13 patients, painful mass in 10 patients, pain only in 4 patients and pus discharge in 3 patients. The mean duration of complaints was 13.8months (range of 3 days to 180months). Treatment procedures were redical excision, followed by primary closure in 28 patients and only incision for pus discharge in other two patients. Of the patients who had undergone radical excision, 14 patients experienced minor healing problems and two out of them requied more than 30 days to heal their wounds. Thus, some patients who underwent wide resection, might be indicated a tension-less closure method.

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A 57-year-old man on hemodialysis for chronic renal failure durign these 17years was admitted to the hospital because of gradually intensified symptoms of renal osteodystrophy which started 2-3years before admission. The patient underwent total removal of four parathyroid glands, a total of 600mg in weight, and autotrasplantation. Thereafter high levels of serum Ca and intact-PTH persisted, and so a^99m Tc-MIBI scintigraphy was performed with a suspicion of the presence of the fifth gland that revealed a strong accumulation in the left superior mediastinum. At the initial operation, the gland was not revealed even by ultrasonography, CT scan, ^99mTc-²⁰¹T1 subtraction scintigram. Upon reoperation, a nodular hypertrophic parathyroid gland which was 3.2×1.6×1.2cm in size and 2, 650mg in weight was detected in the same portion.
We think that ^99mTc-MIBI scintigraphy is valuable to detect parathyroid gland and/or excessive glands in case of renal hyperparathyroidism.

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Almost completely necrotized phyllodes tumor the breast is rare. Two such cases are reported here. A 53-year-old woman was seen at the hospital because of a painful mass of the right breast. The tumor was 7.0×6.0cm in size, tens-elastic, and well movable with clear border and remarkable skin redness. Clinically a breast cancer invading the skin was suspected. But any pathognomonic finding could not be obtained by mammography and ultrasonography. Intraoperatively it was diagnosed as fibrous tumor and widely excised. A 19-year-old woman was seen at the hospital because of a painful mass 2.5×2.2cm in size of the left breast. The border of the tumor was unclear and it grew at first and reduced subsequently. No pathognomonic finding would be obtained by mammography and ultrasonography, and then only the tumor was removed under local anesthesia. Histopathologically these tumors were diagnosed as phyllodes tumor with almost complete necrotic change. Phyllodes tumors with necrotic change have finding similar to the breast cancer on physical examination, but microcalcification or spicula formation can not be obtained by mammography. It would be of great help to diagnose necrotized phyllodes tumor with paying attention to such atypical pathological complications.

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Ectopic breast cancers are rare and commonly appear in the axillary region. Ectopic breast cancers arised in the thoracic wall have been hardly reported in Japan so far. This is to report a rare case of accessory breast cancer occurred in the left thoracic wall.
A 46-year-old woman visited another hospital because she noticed a hard mass in the left lateral thoracic wall, and pointed out having another mass in the anterior chest wall. Extirpation for only the lateral thoracic wall mass was conducted, and the pathological diagnosis of open biopsy was poorly differentiated adenocarcinoma. Inspite of internal and gynecological assessment, we could not find any primary cause. As transferred to our department, we performed an aspiration needle biopsy, and the result was class IV. The patient was operated on with a diagnosis of breast cancer by means of Bt+Ax+Ic. Pathological report showed the accessory breast cancer in the preparation, and the diagnosis of invasive solid-tubular carcinoma was made. The patient has been doing well without any recurrence as of 27months after the operation.

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The surgical results of postinfarction ventricular septal defect have been variable. Traditional “Dagett's method” has consisted of infarctectomy and reconstruction of the septum and ventricular walls, but infarctectomy results in significant compromise in cardiac function. In recent two cases, we employed the new technique introduced by Komeda and David for the reconstruction of the left ventricle using a single pericardial patch. Both patients were uregently operated on using this technique, and a CABG operation was performed in one of them simultaneously. One patient had a residual shunt but was hemodynamically stable. This method has advantages of postoperative cardiac function, preventing ventricular aneurysm and decreasing postoperative bleeding, but a residual shunt should be cared because a plane patch has to be sutured to endocardium like a dome in this method.

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Mediastinal tumor is a disease that we usually experience in general practice. We present a rare case of double bronchogenic cysts which originated from the paraesophageal and paratracheal regions. A 51-year-old man was admitted to the clinic because of an abdominal shadow on a chest X-ray film at a screenign examination. Chest X-ray films on admission revealed a clear tumor shadow at the right upper mediastinum. In addition, a clear soft tissue mass 3cm in diameter was demonstrated at the right upper mediastinum on a chest CT scan. On magnetic resonance imaging (MRI), two tumors with the size of 4cm at the right upper mediastinum were separately found. High signal intensity was shown on Tl-weighted images and very high signal intensity on T2-weighted images in both tumors. Enhancement effect by Gadolinium was not found. Therefore, the tumors were suspected of cystic mass. It was easy to remove both tumors. The cysts contained a kind of jelly like mucus. Both tumors were diagnosed as bronchogenic cyst by pathological examination. We would emphasize that esophageal lesion of the neck was found by chest MRI (coronal view) in this case. We have to examine preopertively by paying consideration to possible multiple occurrence of bronchogenic cysts.

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A 70-year-old male was brought to our hospital because of an accident. He showed a shock signs such as hypotension and respiratory disturbance in the early stage, despite other traumatic injury being absent in the thoracoabdominal region. He was diagnosed as having trumatic left diaphragmatic hernia applying with multiple fractures in the extremities and splenic rupture, by roentogenographic examinations.
Emergency laparotomy was carried out. The affected organs, the stomach, ometum, transverse colon and spleen were returned to the abdominal cavity and the injured diaphragm was closed directly. Postoperative course was uneventful and the patient was discharged from the hospital 26 days after the surgery.
Frequent observation of physical findings and periodic radiographic examinations are thought to be imperative in making a diagnosis as early as possible in blunt thoraco-abdominal trauma.

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A successfully operated case of esophageal hiatal hernia in which the entire stomach and a wide range of transverse colon were incarcerated with mesentery axial gastric volvulse accompanied by a cancer of the transverse colon, that is extremely rare, is reported.
An 88-year-old woman was admitted to our hospital because of epigastralgia. Echocardiogram revealed atrial fibrillation, and a chest X-P showed abnormal shadow. So, ultrasonography, CT, upper and lower gastrointestinal series were conducted. And the patient was diagnosed as having an esophageal hiatal hernia in which the entire stomach and a wide range of the transverse colon were incarcerated with mesentery axial gastric volvuse accompanied by a cancer of the transverse colon and cholecystolithiasis. Right hemicolectomy, cholecystectomy, reduction suture of the right loop of esophageal hiatus, fixation of anterior wall of the gastric body, and pyloroplasty were performed. Postoperative course was uneventful. Atrial fibrillation disappeared and no abnormal findings were seen on imaging methods.
The patient was discharged from our hospital on the 34th hospital day.

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A 67-year-old man who was staying in the hospital for treatment of bronchial asthma and chronic pulmonary emphysema abruptly developed an abdominal pain and fell into a shock state. Laboratory date indicated anemia. Abdominal CT carried out with a diagnosis of hypovolemic shock revealed extravasation of a contrast medium to the peritoneal cavity. We suspected bleeding from the liver parenchyma, and carried out an abdominal angiography. Angiography revealed three aneurysms of the right gastric artery and one of them was ruptured. TAE was performed successfully, but re-bleeding from the aneurysms was noted an hour later.
Emergency laparotomy showed hemoperitoneum due to.the ruptured aneurysm of hte right gastric artery. The aneurysms with right gastric artery about 3cm in length were resected. In postoperative course, hemostasis was completely attained, but the patient died of respiratory failure on 46 postoperative day.
Twenty-four cases of ruptured gastric artery aneurysm have been reported in Japan, and most of the patients underwent surgery. Though none of these patients were successfully treated with TAE alone, abdominal angiography or TAE should be performed first, if the patient is in poor condition.

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A case of stomal carcinoma occurred 48 years after gastrojejunostomy for benign pyloric stenosis is reported. The case involved a 72year-old man who underwent a gastrojejunostomy in the upper body on the greater curvature for benign pyloric stenosis in 1945. In 1985, a stomal ulcer was detected by endoscopic examination, and thereafter he received the endoscopic examination every year. In 1993, histological study of biopsy specimens from the stomal ulcer showed moderately differentiated adenocarcinoma, and total gastrectomy and resection of the stoma including the jejunum were performed on March 22, 1994. Resected specimen revealed another ulcer lesion besides the ulcer lesion shown with endoscopic study. Histological examination of this lesion confirmed signet ring cell carcinoma. Moreover, microscopic finding revealed the features of gastritis cystica polyposa under the cancer lesion in the submucosal region. A total of 33 cases of gastric cancer following gastrojejunostomy without gastrectomy have been reported in Japan, indicating a correlation between regurgitation of bile juice and carcinogenesis.

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Crohn's disease is non-caseous granulomatous inflammatory disease affecting from the oral cavity through anus discontinously and transemurally. It is often complicated by stricture, fistulization, abscess formation, and bleeding, but free perforarion is a very rare complication of the disease. Since 1935 when Arnheim first stated this complication, it has been increasingly reported in Japan, and 108 cases can be seen in the literature.
This paper reports a case of perforation of the small intestine due to Crohn's disease.
A 34-year-old man was seen at the hospital becaused of sever right lower quadurant pain with tenderness, muscle gurding, and rebound tenderness. The patient was operated on immediately under a diagnosis of acute peritonitis.
A thickening of the ileum was observed over about 35cm in length at a site about 10cm from the ileocecal junction. A perforation of the terminal ileum 30cm from the ileocecal junction at the mesenteric border was seen. After intraperitoneal irrigation, a part of the ileum was excised. The resected specimen showed longitudinal ulcer, and Crohn's disease of the intestine was diagnosed histpathologically. The postoperative follow-up of this patient has continued for 6 months, and so far there has been no sign of recurrence. This patient presented with abrupt abdominal pain and fever without any prodrome, and was suspected of having Crohn's disease when an emergency operation was conducted with a diagnosis of perforative peritonitis. Some notes in terms of acute abdomen of the disease are also presented here.

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We experienced a case of Crohn's disease of the small intestine with intestinal bleeding causing a perforation of the ileum. The patient was a 23-year-old man who had been diagnosed as Crohn's disease the age of 16. He was seen at the emergency clinic of the department of internal medicine in our hospital because of abdominal pain after he ate and drunk immodertely. He was admitted with a diagnosis of intestinal obstruction. On the next day, anal bleeding and muscle guarding appeared. Abdominal CT scan demonstrated free air. So an emergency operation was performed. Upon laparotomy, a moderate volume of bloody ascites and a perforation on the mesentery side and about 70cm oral from the terminal ileum were present. A portion of the intestine oral side from the perforation remarkably dilated; its inside was filled with a large volume of clots; and the mesentery surrounding the perforation swelled with clots in it. A partial resection of the ileum was carried out. Macroscopically, a portion of longitudinal ulcer on the mesentery side was seen to perforate. Based on operative and pathological findings, it was inferred that submucosal vessels surrounding the ulcer broke to form clots in the mesentery and intestine which resulted in an increase in internal pressure of the intestine causing the perforaiton. We report a case here because perforation in Crohn's disease associated with intestinal bleeding was thought to occur uncommonly.

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A 52-year-old woman who ate 15 persimmons daily for these 3 months and then developed an abdominal pain and vomiting was referred to the hospital with a diagnosis of intestinal obstruction from another hospital. After admission an intestinal fluoroscopy revealed a stenosis in the lower part of the small intestine. Ultrasonography of the portion showed a tumor 4.5cm in size with acoustic shadow. An operation was performed with a suspicion of intestinal obstruction due to persimmon bezoar. During the operation, a walnut-sized foreign body which impacted in the ileum 40cm oral side from the ileocecal region was removed by incising the ileum at a portion just above the foreign body. an analysis of the stone revealed that the main ingredient was tannic acid. The foreign body was diagnosed as persimmon bezoar.
Intestinal obstruction due to gastric stone presents difficulty in preoperative diagnosis and is often diagnosed after laparotomy. It is important not only to hear patient's favorite foods carefully, but also to conduct intestinal fluoroscopy. And if any stricture of the small intestine is revealed and a hyperechoic image with acoustic shadow is shown by ultrasonography of the obstructed portion, it is desirable to make diagnosis by entertaining intestinal obstruction due to persimmon bezoar as a probable diagnosis.

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Meckel's diverticulum is an embryomorphorous vitelline intestine and represents about 1-2% of all autopsy cases. It is said that about 8-22% of all people having the diverticulum manifest some symptoms, and it commonly occurs in children, 80-90% of them, and rarely in adults. Recently we experienced a case of volvulus of Meckel's diverticulum in an adult.
A 29-year-old man was seen at the hospital because of abdominal pain, and was admitted for close examination and treatment. On the second hospital day peritoneal sign appeared, and an emergency operation was carried out with a diagnosis of peritonitis. Upon laparotomy, there was a volvulus of Meckel's diverticulum in the ileum about 60cm oral side from the ileocecal region causing necrosis of the diverticulum. So a resection of the verticulum and abdominal drainage were performed. Postoperative course was uneventful. The patient was discharged from the hospital on the 15th hospital day.

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A 59-year-old woman was admitted to the hospital because of vomiting and weight loss. No symptomatic remission was attained with conservative treatment. Physical examinations revealed no abnormal findings in the upper and lower digestive tracts, but blood examination showed high level of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9). She was diagnosed as having a cancer of the jejunum on double contrast barium studies of the small intestine, and was operated on.
Of 145 cases of primary cancer of the small intestine reported in a recent one decade in Japan, 16.8 percent of the cases showed high level of srum CEA and 37.1 percent of the cases showed high level of serum CA 19-9. In particular, serum level of CA 19-9 showed over 100U/ml in 22.8 percent of the cases. These data suggest that CA 19-9 may be as a useful tumor marker of small bowel cancer in the patient.

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A 72-year-old woman was seen at the hospital because of a right lower abdominal pain. Abdominal ultrasonography showed an ileocecal tumor. Barium enema study did not visualize the appendix but demonstrated a polypoid defect of the cecum. Abdominal computed tomography revealed a thickening of wall and a cystic change at the head of cecum. On physical examination, there were tenderness and the egg-sized tumor in the right lower abdomen. Anemia and an elevated serum carcinoembryonic antigen were noted in the laboratory data. The patient was diagnosed as having an appendiceal carcinoma preoperatively and underwent a right hemicolectomy. Microscopic examination showed well differentiated adenocarcinoma of the appendix. No chemotherapy was added. There has been no recurrence, as of two years after the operation.
Primary appendiceal carcinomas are rare and account for 0.08% of all resected appendices. As the disease is similar to acute appendicitis, it often presents difficulty in pereoperative diagnosis. We report this case which was successfully diagnosed before operation with a review of the literature.

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We report a case of pseudomyxoma peritonei of ovarian origin associated with mucinous cystadenocarcinoma of the appendix. A 65-year-old woman was admitted to the hospital because of lower abdominal pain and sense of lower abdominal fullness. Ultrasonography and computed tomography of the abdomen showed multiple septations in a large amount of ascites. A diagnosis of pseudomyxoma peritonei was made, and a laparotomy was carried out. It was found that a left ovarian cyst of over fist-size containing geratinous material was ruptured. The peritoneal cavity was filled with such a similar material. The appendix swelled and was firm on palpation. Left oophorectomy and appendectomy were performed. Furthermore, cisplatinum was administrated intraperitoneally, after gelatinous material was washed out with dextran solution. Histologically, mucinous cystadenocarcinomas were identified within both of the left ovary and appendix. It was thought that the both tumors had arised independently based on macroscopic findings at operation and microscopic findings. She has been in good health for more than 7 years after the operation. In this patient adjuvant therapy with dextran and cisplatinum was effective. And we think that simultaneous appendectomy would be indicated for the patient with pseudomyxoma peritonei of ovarian origin.

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It is difficult to diagnose primary carcinomas of the vermiform appendix in an early stage preoperatively. The definite diagnosis of the disease is established by postoperative pathological examination in many cases. We report two cases of primary carcinoma of the vermiform appendix in an early stage. Another such 19 cases seen in the Japanese literature are also reviewed.
A 62-year-old women was admitted to the hospital because of right lower abdominal pain. Appendectomy was performed with a diagnosis of acute appendicitis. Microscopically, the tumor was well differentiated adenocarcinoma limited to the mucosa, but invaded the margin. So 18 days later, an ileocecal resection (D2) was added.
A 44-year-old owman was admitted to the hospital because of right lower abdominal pain. Operation was performed with a diagnosis of acute appendicitis. But a flat elevated tumor was recognized in the neck of the appendix during the surgery. So the appendix was removed completely with the neck tumor. Microscopically, the tumor invaded the submucosa. Forty-two days later, an ileocecal resection (D2) was performed. No residual tumor and lymph nodes metastasis were recognized in two cases.
We would emphasize the importance of importance of microscopic inspection during surgery as well as pathological examination after surgery by entertaining a possibility of malignant tumor in cases of adult acute appendicitis.

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A 71-year-old woman on hemodialysis for 18 years underwent a laparotomy with a diagnosis of peritonitis at the hospital, when localizing necrosis was detected in the cecum and ascending colon. A right hemicolectomy was performed and reconstructed with end-to-end anastomosis between the small intestine and transverse colon where revealed macroscopically favolable blood flow. But the patient developed hypotension during hemodialysis on the 4th day after the operation, and then an abdomonal pain on the next day. Laparotomy was conducted again with a diagnosis of anastomotic breakdown, and a colostomy of the transverse colon was carried out. Histopathologically, no arterial obstruction was noted in the resected colon, and the diagnosis of necrotizing ischemic colitis due to non-occlusive mesenteric ischemia (NOMI) was made. It was thought that genesis of suture failure might result from a decrease in the mesenteric perfusion due to hypotension during hemodialysis.
There have been 57 reported cases of ischemic colitis in hemodialysis patients in these 15 years. Their average duration of hemodialysis was 8.2 years and 58.7% of these lesions were in the right side of the colon. Most patients complained of only abdominal pain and were not associated with anal bleeding. It is desirable that resection of the necrotized colon should be followed by colostomy and then anastomosis on a two-step approach. As perioperative management, caution should be employed to possible occurrence of hypotension during hemodialysis.

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Desmoid associated with familial adenomatous polyosis (FAP) presents difficulty in its complete extripation and recurs in a high frequency, and hence, we have difficulties in the treatment. This paper reports an extremely rare case of FAP accompanied with desmoid in an intestinal anastomotic site. A 28-year-old man who had a family history of FAP associated with intractable intra-abdominal desmoid was diagnosed as having FAP. Total colectomy, ileo-anal anastomosis and diverting ileostomy were performed under a diagnosis of FAP accompanied with colonic cancers. After closure of the ileostomy, he had ileus symptoms, for that a laparotomy was performed. The desmoid was observed in the intestinal anastomotic site at the closure of ileostomy. Resection of the corresponding anastomotic site and ileostomy were carried out because the desmid was considered to be the origin of intestinal obstruction. Although the recent aggresive surgical treatment has much improved the prognosis of the patients with FAP, the development of the desmoid seems one of the unfavourable prognostic factors. We think that the appropriate operative procedures to prevent desmoid development may be necessary for improvement of the prognosis of FAP's families with intractable intra-abdominal desmoids like this case.

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A 45-year-old man was admitted to the hospital because of pelvic metastasis of colonic cancer in January, 1996. There were previous histories of undergoing a resectin of the transverse colon for an advanced colonic cancer in May 1994 and a low anterior resection with removal of paraaortic lymph nodes for recurrence to the mesosigmoideum in January 1995. In his family history, there were 7 patients with cancer in his relatives in the seventh degree. On February 7 1996, we inserted catheters from the bilateral superficial femoral arteries to the opposite internal iliac arteries and embolized bilateral upper, lower gluteal arteries with use of metallic coil. We indwelt a the port under the skin of his lower abdominal wall. Then intra arterial injection of CDDP, 5FU and leucovorin was started on February 19 and irradiation at a dose of 50Gy/25 fr was conducted for 6 weeks from April 1. The tumor was softened early in May. We confirmed the ulcer scar at the same portion with the colon endoscopy on May 2. He was discharged from the hospital without prominent side effects. Thereafter the intraarterial infusion chemotherapy was continued once a week on an ambulant basis. As of 1997, the tumor is slightly growing up, but we evaluate that this methods is valuable because symptomatic remission and a shrinkage of the tumor were obtained for a while.

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A 70-year-old man was seen at the hospital because of rectal bleeding and anal pain. Barium enema fluoroscopy revealed an elevated lesion in the lower portion of the rectum. Colonoscopic examination showed a type 2 tumor (Borrmann) with easy bleeding. Because carcinoma cells were confirmed in the biopsied spicemens, an abdominoperineal resection along with lymph nodes dissection (D3) was performed.
Microscopically, it was shown that the tumor consisted of small cell undifferentiated carcinoma with neuroendocrine character; it was composed of small oval and/or polygonal cells which had round nuclei with a high nuclear to cytoplasmic ratio. Further, an electron-microscopic study revealed that there were a small number of neuroendocrine granules scattering in the cytoplasm of the tumor cells. The cytoplasm also contained a moderate number of rough endoplasmic reticulum, and focally prominent Golgi complex as well. The findings were consistent with those of endocrine cell carcinoma of the rectum.
Endocrine cell carcinoma of the rectum that is thought to be biologically malignant and to have a poor prognosis extremely rare. It is similar to small cell carcinoma of the lung in morphology, but we have hardly head that the disease well responded to multi-agents chemotherapy. Since treatment of this tumor is different from that of other types of carcinoma, the differential diagnosis is, therefore, of great importance.

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A 65-year-old man was seen at the hospital because of anal bleeding. There was a past history of a fistula-in-ano for about 30 years that was operated on at the age of 56. Postoperative course was uneventful except an operative hard scar. In March 1996, he had a symtom, anal bleeding, and a tumor on the left side of the anus was pointed out. The tumor had grown in the left ishiorectal fossa with an extraluminal growth by CT and MRI. By colonoscopy, the tumor had a submucosal-tumor like appearance, and the biopsy from the errosion of the anal canal mucosa led to the diagnosis of adenocarcinoma. An adomino-perineal resection of the rectum with D2 lymphadenectomy and extensive perineal skin resection was carried out. Histopathological findings of the resected specimen revealed a well differentiated adenocarcinoma at superificial mucosa of the anal canal and the fistula, and a mucinous adenocarcinoma at the deep portion of the fistula. The tumor was fistula-cancer after the operation for the fistula-in-ano.

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We have performed less invasive thrombectomy for idiopathic thrombosis in the portal vein at the umbilical region by inserting an endoscope through the ligamentum teres hepatis. A 73-year-old woman was admitted to our hospital because a tumor in the portal vein at the umbilical region was detected at another hospital. Pylethrombosis was diagnosed by imasing methods and thrombectomy was performed by inserting a portal endoscope through the ligamentum teres hepatis. Intraoperative examination of a frozen section revealed a benign lesion and pathological examination of the permanent preparation also showed a benign lesion. No stricture or deformation was seen of the site of thrombectomy and the operation was safely completed. The postoperative course was uneventful. There has been no recurrence of a tumor shadow or stricture in the portal vein up to now. It is thought that this procedure may be a useful treatment for thrombosis, because it is less invasive, enables us to observe the inside of the portal vein shortens the time of blocking the portal blood flow, and can avoid unnecessary hepatic dysfunction.

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Comparing to adenocarcinomas, neuroendocrine carcinomas of the stomach are less reponsive to antineoplasms such as mytomicin (MMC), and are indicated to Etoposide or Cisplatin just like lung small cell carcinomas. The prognosis of neuroendocrine carcinoma of the stomach is extremely poor, because it can easily metastasize to the liver and peritoneum, and then rapidly grow. Most metastatic lesions of the liver from adenocarcinomas are avascular or hypovascular, but some of neuroendocrine carcinomas are hypervascular. We think that these cases are possible candidates for embolization of hepatic artery. This patient survived for 1 year and 9 months after the operation with the aid of hepatic arterial infusion of Etoposid, Cisplatin and hepatic arterial embolization. In order to find out a metastatic lesion and start the treatment earlier, we should examine the patient ever 3 months by imaging procedure such as echogam or CT.

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We experienced a case of colonic cancer with multiple liver metastases which were successfully treated by resection of the colonic cancer, followed by intra-arterial chemotherapy and hepatectomy. The patient was a 42-year-old man. The primary transverse colonic cancer was resected, but liver resection was impossible because 4 metastatic lesions were recognized. Therefore we performed intra-arterial chemotherapy through the hepatic artery using 5-fluorouracil (5-FU) and mitomycin C (MMC) for 2months. The metastatic liver lesions disappeared completely, with the normalized level of serum CEA. However a tumor 2cm in diameter was detected in the liver on CT, when level of serum CEA increased to 17.7ng/ml. Partial hepatectomy was performed on this time, and a tube was inserted from the hepatic artery selectively. After the second operation, infusion chemotherapy with 5-FU, MMC and adriamycin (ADM) was started through the hepatic artery. Five months later, CT showed no metastatic tumor, and serum CEA decreased to the normal level. The patient who has been followed up by CT and CEA level is doing well without recurrence or relapse, as of 12years after the initial operation.

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We report two cases of prolonged hypercapnia following laparoscopic cholecystectomy. Case 1: A 44-year-old man suffered from recurrent right subcostalgia and icterus and gallstones were pointed out. He underwent a laparoscopic cholecystectomy. During the operation P_ETCO₂ was not markedly elevated, but upon a awaking P_ETCO₂ increased and hypercapnia was prolonged until the 3rd postoperative day. One year and 7 months later he was admitted for pneumonia and aphea. During this hospitalization we examined his disease in detail and made a diagnosis of central alveolar hypoventilation due to mitochon drial disease. About two years later, he returned to the hospital because of lower limb weakness. Then, his respiratory state progressively deteriorated and he was intubated. Finally, he died of perforative peritonitis due to a duodenal ulcer. Case 2: The 65-year-old mother of case 1 complained of back pain, right subcostalgia and general fatigue. She had a laparoscopic cholecystectomy and took almost the same postoperative course as her son. Nasal BIPAP was performed to treat sleep apnea. Her sleep apnea and fatigue improved.
Many factors causes hypercapnia following laparoscopic surgery. Needless to say, these two cases had rare disorders, but we must treat the various etiologies of this problem.

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We present four cases of gallbladder cancer producing alphafetoprotein (AFP), which is commonly produced by hepatomas and yolk sac tumors, but is rarely produced by digestive organ cancer including gallbladder cancer except hepatoma. Four specimens showed a tumor grown papillarily and the countent of gallbladder had been filled with tumor. Histopathologically most part of these tumors showed hepatoid pattern. Immunohistochemically, the carcinoma cells showed positive staining for AFP, and were similar to those of the AFP producing adenocarcinoma of the stomach in The General Rules for the Gastric Cancer Study. After operation, the level of AFP had decreased significantly in all cases.
The cancer of the gallbladder producing AFP is the peculial pattern of growth and that of pathological findings. We have a patient living for seven years and two for three years, so we think that the cancer of the gallbladder producing AFP should be resected as well as the cancer of no producing AFP.

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We report a rare case of descending colonic stenosis complicated by traumatic pancreatitis.
A 45-year-old man visited our hospital complaining of epigastric and back pain. ERCP and barium enema revealed pancreatic duct dilatation, a cyst in the tail and descending colonic stenosis. Repeated biopsies of the colon showed no malignancy. Colonic stenosis gradually improved and we then performed division of the pancreas and pancreaticogastrostomy. We should pay attention to colonic stenosis as an initial sign of pancreatitis.

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A 60-year-old woman was admitted to the hospital because of right lower abdominal pain in May, 1996. The patient occasionally felt abdominal pain since July, 1995 and was pointed out having a deformation of the ileocecum by a barium enema study at another hospital in December. After admission, a colonoscopic examination revealed an elevated lesion at the root of appendix. The lesion revealed a morphology of submucosal tumor centering at the appendiceal openning, the appendiceal openning dilated, and a part of the tumor with reddening was exposed. Biopsy offered no definitive diagnosis. Because of persisting abdominal pain, a removal of the appendix with partial excision of the cecum was carried out with a diagnosis of tumor of the root of appendix. The resected appendix was grayish white in color and elastic slightly hard. Histopathological diagnosis of ectopic endometriosis was made.
Gastrointestinal endometriosis is relatively rare, especially that arised in the appendix. This rare case of endometriosis of the appendix with some notes is reported in this paper.

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External endometriosis is a condition in which tissue like that of the uterine mucosa occurs outside the uterus. External endometriosis arising in the skin represents about 1.1% of all cases of endometriosis, and among of them, umbilical endometriosis is very rare that occupies about 30%. This paper presents a recent case of umbilical endometriosis.
A 46-year-old woman was admitted to the hospital because of an umbilical tumor. Hemorrhage from the foramen in the center of the tumor was recognized during menstrual period. She was diagnosed as having umbilical endometoriosis. Excision of the umbilical tumor under laparotomy was performed. Omphaloplasty was performed using a free skin flap to repair a skin defect at the umbilical region. Pathologically it was umbilical endometoriosis having the structure with tubular pattern like endothelium of the uterus.
The histogenesis of the external endometoriosis is not known, but there are four hypotheses; (1) retrograde menstruation, (2) a result of endometrial metaplasia of the peritoneal serosa, (3) mechanical transplantation in surgical scar, and (4) vascular or lymphatic dissemination. The umbilical endometoriosis as observed in this case supports the fourth hypotheses.

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A 65-year-old woman was seen at the hospital because of abdominal discomfort and a mass in the right lower quadrant, came to our hospital. Leukocyte count was with normal limits, and abnormally high levels of CRP and ESR were noted. The abdominal tumor was about 4cm in diameter, which contained stone like shadow in its center. Right hemicolectomy was carried out on May 16, 1995, nevertheless we could not come to the definite diagnosis. Pathological findings revealed that the tumor was tuberculous mesenteric lymph nodes.
Tuberculous mesentric lymphadenitis often presents with abdominal tumor accompanied with slight inflammatory reaction, but it presents difficulty in preoperative diagnosis because of its variety in clinical manifestation. Therefore, we have to gain pathological diagnosis as soon as possible for making the therapeutic plan, when the abdominal mass is likely to be caused by tuberculosis.

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An operated case of mesenteric venous thrombosis which is rare is reported. A 38-year-old man was admitted to the hospital because of diffuse abdominal pain, nausea, and vomiting. Abdominal computed tomography (CT) revealed ascites and remarkable swelling of the intestinal wall and mesenterium. Laparotomy after 96hrs from the onset disclosed a lot of bloody ascites and intestinal gangrene. Massive thrombus was found in the mesenteric vein. At the operation the affected bowel was resected. Subsequently the remained small intestine became 120cm in length. He had portal vein thrombosis in the postopertive course. It was treated with administration of urokinase. The patient recovered well and was discharged from the hospital. In the postoperative management of this serius disease, surgions should be alart to recurrence of thrombosis, and its prevention and early diagnosis are essential.

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Transmesenteric hernia is a relatively rare entiry and nearly 130 cases have been reported in Japan so far.
We describe a case of transmesenteric hernia with postoperative intussusception. A 14-year-old boy was admitted to the hospital because of epigastralgia lasting for one day, followed by vomiting and abdominal pain at the periumbilical region on the next day. He had no previous history of abdominal operation. In the next morning after admission, he had severe abdominal muscle guarding, then underwent an emergency surgery. A defect of mesoileum with the size of 4cm in diameter was found at the 80cm from the end of ileum, and the ileum about 70cm in length from the end of ileum had protruded through the defect. The herniated intestine was pulled out, and the defect was closed. This ileum was not excised because of no gangrenous lesion in the affected intestine. The abdominal distention was observed 10days after the operation. An abdominal radiogram showed niveau sign of the small intestine, and antegrade small bowel series with contrast medium (Gastrographin^®) through a nasointestinal tube showed the coil spring sign. Under the diagnosis of postoperative small-bowel intussusception, the patient was reoperated on. The intestines adhered to the peritoneal wound and mildly distended, but the appearance of the intestine was almost normal. The intussusception of the intestine was easily repaired by Hutchinson maneuver. The second postoperative course was uneventful.
A transmesenteric hernia is rare, however, we should take notice it when we encounter the mechanical bowel obstruction.

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A case of intramesosigmoid hernia in a 79-year-old man is reported herein. The patient was admitted to the hospital because of abdominal fullness and nausea. No symptomatic remission could be achieved with a conservative treatment. An exploratory laparotomy was performed on the 7th day after the onset of symptoms.
There was incarceration of the small bowel 50cm proximal from the terminla ileum into a mesenteric defect of the left side of sigmoid colon. The operative diagnosis was intramesosigmoid hernia. We easily reduced the incarcerated ileum with manual procedure, and closed the hernia orifice 1.5×2.0cm in size because of no circulation obstacle of the affected ileum.
Intramesosigmoid hernia is a very rare type of internal hernia. The cases of intramesosigmoid hernia so far reported in Japan were all of the right side type. This is the first case of the left side type of intramesosigmoid hernia.

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We experienced a resected case of solitary schwannoma of the greater omentum. A 54-year-old man was admitted to the hospital because of sudden abdominal pain on September 19, 1996. Abdominal tumor having multiple cystic lesions and enhancing solid lesions. Abdominal angiography showed a moderately hypervascular tumor with tumor vessels supplied by the dilated right gastroepiploic vessels. We diagnosed the tumor to be originated from the greater omentum. extirpation of the tumor was performed on October 11, 1996. The tumor, measuring 24×22×9cm in diameter and weighing 3.6kg, was originated from the greater omentum. Histological examination proved that the tumor was benign schwannoma. Postoperative course was uneventful and the patient was discharged from the hospital 2weeks after the surgery.
Schwannoma of the greater omentum is extremely rare. There have been reported only 8cases including our case in both the Japanese and English literature.

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A 67-year-old woman receiving treatment for brain infarction and diabetes mellitus had epigastric discomfort. The tumor in the upper abdomen was pointed out by abdominal ultrasonography. Based on abdominal CT, MRI, upper GIU series, endoscopic ultrasonography and agniography, the patient was suspected to have a leiomyosarcoma of the stomach and was operated on. A dark reddish hypervascular tumor located only in the lesser omentum was excised easily. Histologically, it was diagnosed as leiomyosarcoma. Primary leiomyosarcomas of the lesser omentum are rare. Twenty cases of the leiomyosarcoma reported in Japan including this case are reviewed here and possible anatomical geneses are discussed.

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It is said that mucolytic therapy may lead to improve the quality of life in patients with intractable pseudomyxoma peritonei. With the aid of an available dextran sulfate solution having established the safety following intraperitoneal administration, mucolytic therapy was performed with good results. The patient was a 62-year-old man with prominent symptoms due to abdominal distension. Mucolytic therapy with Low-molecular dextran^® and MDS^® was tried. The amount of mucus discharge was 1740ml on the 4th day after intraperitoneal administration of 500ml of the former preparation, and come to a total of 5615ml by adding up those on the 3rd, 5th and 6th days after administration of 200ml of the latter preparation. And then symptomatic remission was attained. Although the patient died of complicated intraperitoneal infection 16months after his first visit, he was able to keep a good appetite without any symptoms such as abdominal distension and intestinal obstruction from the operation to death. Mucolytic therapy with dextran sulfate solution should be considered to be a choice of therapeutic measure because of its ability to improve the patient's quality of life. In addition, some mechanisms of action of the therapy is described in the article.

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We describe a rare case of appendicial infarction in incarcerated indirect inguinal hernia with a review of 10cases including our case seen in the Japanese literature.
A 36-year-old man was admitted to the hospital because of right inguinal pain, without mass formation. On admission, we had difficulty in diagnosis. But an ultrasound (US) and a computed tomography (CT) were helpful and showed a lumen structure, which was finished as blind wedge in the right inguinal canal. Operative findings disclosed that the appendix was strangulated at the internal inguinal ring. Therefore, appendectomy and iliopubic tract repair were performed in the same wound. The pathological diagnosis of the resected appendix was hemorrhagic infarction. the postoperative course was uneventful and the patient was discharged from the hospital 10days after the surgery.
Incarcerated inguinal hernia are not uncommon and the small intestine or omentum commonly herniates into the inguinal canal, but the appendix is rarely incarcerated. It is supported that there have been few reports of such hernia in the Japanese literature. In the diagnosis of this rare entity, US and CT of the inguinal region are helpful if we keep in mind the possibility of the disese.

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Most of Spigelian hernias occur in the lower abdomen. There is no domestic report of the disease arising from upper reaches of the semilumar line. In the foreign literture, the incidence of “upper” Spigelian hernia is only 3%, especially the case in the subcostal region has been reported only once. We report a case of Spigelian hernia originating from the right subcostal region. The patient was a 69-year-old woman who had no previous abdominal injury. There was bulging arised from the right upper quadrant, when she had severe cough due to pneumonia. It was observed at standing position, and disappered in the left lateral position. A wide-ranging defect of the abdominal muscle was palpated. On abdominal CT scan, there were defects of internal oblique muscle and transversus abdominis muscle at the lateral side of rectus muscle in the right upper quadrant. And intestinal gas shadow was observed just under the external oblique muscle. She was diagnosed as having a ventral hernia. Uppon laparotomy, there was a hernia sac (12×5cm) under the external oblique muscle, and the size of hernia orifice was 10×4cm. No hernia content was noted. The orifice with internal oblique muscle and transversus abdominis muscle was closed with interrupted suture, followed by repair using polypropylene mesh.

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