We retrospectively analyzed the records of 29 cases of gastroenterological cancer in aged patients over 85 years treated at the hospital between 1992 and 1996.
There were 13 patients with gastric cancer, 14 patients with colorectal cancer and two patients with gall bladder cancer. Postoperative complications were observed in about half (14 patients) of the subjects. Delirium and respiratory problems were common complications. The mean hospital stay after operation was 38 days, and seven hospital death es occurred, who had advanced cancer. There was no correlation between preoperative laboratory findings and postoperative complications, but operative time and blood loss should be considered risk factors for postoperative complications. Morbidity rate and mortarity rate of patients with colorectal cancer were lower than those of patients with gastric cancer.
In conclusion, operation for elderly patients except those with advanced gastric cancer can be performed safely. The morbidity rate of patients with advanced cancer was very high, but more than 60% of them attained an improvement in performance status. It is thought that operation can be indicated for patients with advanced gastric cancer if the operation may afford an improvement in the quality of life.

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The effects of adjuvant chemotherapy with cyclophosphamide, epirubicin and 5-fluorouracil (CEF therapy) on the ovarian function and bone metabolism were investigated in 44 premenopausal women with breast cancer without distant metastases. The patients were treated with an average of 4.9 cycles of CEF therapy. Endocrine studies and measurement of bone mineral density (BMD) in the lumber spine were performed before and after the therapy. Amenorrhea was observed in 50% of the 44 patients. In the patients developing amenorrhea, serum estradiol decreased and FSH level elevated to post-menopausal levels. Induction of amenorrhea was related to age. No patient under 39 years old stopped menstruating, compared with 11% between 40 and 44, 58% between 45 and 49, and 100% of those over 50. BMD change in the lumbar spine was-3.9% in the amenorrhea group (from 1.063 ±0.111g/cm² to 1.021±0.111g/cm²; p<0.01), but no statistically significant decrease in BMD was observed in the no-amenorrhea group. CEF-induced ovarian failure causes a rapid bone loss in premenopausal patients with breast cancer.

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To assess the long-term cardiac status after surgical closure of atrial septal defects (ASD) in adults, 20 of 62 patients over 20 years of age who underwent surgey during past 15 years participated in this study and underwent cardiac catheterization examination. They were 7 male and 13 female with an average age of 46.2 years, and a mean follow-up period was 23.7 months.
Mean PA pressure decreased significantly from 22.1±8.9 to 15.9± 3.6mmHg, while Qp/Qs and mean-Pp/Ps significantly changed from 3.65±1.58 to 1.09±0.14 and from 0.19±0.18 to 0.10±0.05 respectively.
It was suggested that the obstructive pulmonary vascular change had not progressed so far, and all patients obtained an improvement in the quality of life. Therefore surgical closure for elderly patients with ASD is recommended unless they have major operative risk or severe pulmonary vascular disease with Eisenmenger's syndrome.

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Two procedures, an aneurysmectomy with prosthesis replacement and an exclusion with bypass grafting, were compared as a choice of operative technique for abdominal aortic aneurysm (AAA) and iliac artery aneurysm (IAA). Fifty patients undergone operations for AAA and IAA at the hospital in a recent 3-year period were analyzed.They were 40 men and 10 women, aged from 48 to 82 (mean 69). Twenty-five cases were operated on by aneurysmectomy and 25 cases were by exclusion. The mean aortic cross clamping time was significantly shorter in the exclusion group (56 minutes) than in the aneurysmectomy group (73 minutes). The mean amount of intraoperative bleeding was significantly smaller in the exclusion group (897ml) than in the aneurysmectomy group (1777ml). There were no significant differences in the mean operation time and mean postoperative platelet depletion between the two groups. In all of the exclusion group, CT scanning revealed postoperatively thrombotic occlusion of the excluded aneurysm and no hemorrhagic tendency due to consumption of platelets was observed. The exclusion procedure for AAA and IAA is very useful in the high risk cases to minimize operative stress.

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We studied obstructing colorectal cancer by comparing with those without obstruction to elucidate the long-term prognosis. Subject were 357 patients with colorectal cancer including 79 (21.1%) patients who manifested ileus symptoms initially (obstructed group) and another 278 (79.9%) patients without ileus symptoms (not obstructed group). In this study, we designated the patients with ileus symptoms as those who developed abdominal pain, vomiting, and abdominal distention, had air-fluid level formation in an abdominal simple X-ray film on standing position, and needed some decompression treatment. The obstructing group was comprized of more aged patients and the lesion was frequently found in the descending colon. And more cases with deeper depth of invasion of tumor and metastasis due to peritoneal dissemination were seen in the obstructing group. There were, however, no significant differences between both groups in tumor type, lymph node metastasis, hepatic metastasis, vascular invasion, lynphatic invasion, histologic type, and degree of progress. Overall survival rate was significantly poorer in the obstructing group than that in the other, but no significant difference in the survival rate was noted when curatively resected cases from both groups were compared. According to multivariate analysis, determinant prognostic factors of colorectal cancer were curability, sex, lymph node metastasis, and invasion depth of tumor.

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In this study clinicopathological features and therapeutic guidelines of colorectal cancers involving the adjacent organs were studies.
49 cases of si/ai (histological invasion to the adjacent organs) had poor prognosis compared to 379 cases of se/a2 (histological invasion to the serosa). When the subjects were limited to 22 cases, attained curative operation, five-and ten-year survival rates were 47% and 47% in si/ai cases, versus 65% and 51% in se/a2 cases without significant difference. These findings indicated the adequacy of associated resection of the adjacent organs.
72 cases of Si/Ai (macroscopic invasion to the adjacent organs) with curative operation, the five-year survival rate was 54% and prognostic factor was only the presence of lymph nodes metastasis. On the other hand, no survivous over five years were observed among patients attained non-curative operation whom the application of associated resection of the adjacent organs 68% in Si/Ai cases, and the rate became low in the ureter, bladder, prostate, seminal vesicle, and vagina. Nevertheless, it is impossible to differentiate histologic invasion of cancer from inflammatory adhesion, and the frequency of local recurrence is found to be high from studies of recurred cases. So at present, we have to conduct the associated recection of adjacent organs actively for cases of colorectal cancer which are suspected to have other organ invasion are expected to have a curative opration.

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Forty-six cases of early carcinoma of the lower rectum were investigated clinico-pathologically in order to study the adequate surgical treatments for the disease.
There were 22 “m” cancers invaded the mucosal layer. Local excision was performed in 10 cases of them. No venous invasion and lymphatic vessel invasion were shown in these 10 cases. Bowel resection with lymph node dissection was performed in 12 cases of 22 “m” cancers. Neither venous and lymphatic vessel invasion nor lymph node metastasis were shown in these 12 cases with lymph node dissection. Moreover, there was no complication after the operation in local excision cases. Therefore, local excision would be enough procedure for “m” cancers.
In contrast, there were 24 “sm” cancers invaded submucosal layer. Local excision was performed in six cases of them and bowel resection with lymph node dissection was done in 18 cases. Lymphatic vessel invasion was shown in ten (41.7%) of 24 “sm” cancers, and lymph node metastasis in five (27.8%) of 18 cases with lymph node dissection. Local recurrence on the lower rectum was experienced in one (16.7%) of six cases of local excision. The levels of sm invasion of those cases were all sm2 or sm3 according to Kato's classification. Therefore, in “sm” cases, especially those invaded the deep submucosal layer, lymph node dissection should be performed.
The correct diagnosis of the depth of invasion is one of the most important factors in selecting the appropriate treatment. Endoscopic ultrasonography was useful to diagnose the depth of invasion of cancer preoperatively.

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A 28-year-old woman was found to have a hypoechoic mass in the supero-posterior portion of the thyroid on ultrasonography. It was not diagnosed by aspiration biopsy, however, and tumor resection was performed on May 16, 1997. The tumor originated to the left lateral wall of the hypopharynx. It showed eosinophilic granules in the cytoplasm and stained positive for S-100 protain. A diagnosis of granular cell tumor (GCT) was made histologically.
Cervical GCT is rarely reported in Japan. Complete excision is the preferred treatment for benign GCT, because benign GCT can undergo malignant change.

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Mammary fibromatosis is a rare entity. In Japan, only several cases have been reported. We present a case of mammary fibromatosis with a review of the Japanese literature. A 56-year-old woman was seen at the hospital because of a tumor of the left breast. The tumor measuring 6×4cm in diameter with an unclear border was palpated in the upper quadrant of the left breast with reddness and retraction of the overing skin. IN clinical, radiological and ultrasonographic examinations, it was difficult to distinguish from brest cancer. Cytologic examination was negative for malignant cells. Because we could not rule out a possible malignancy, quadrantectomy was carried out. So a diagnosis of mammary fibromatosis was made. There has not been evidence of recurrence, as of 27 months after the surgery. They are characterised by infiltrative growth and a tendency to recurrence even after resection, but they never metastasize. So follow-up should be especially vigilant.

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A rare case of stromal sarcoma of the breast is described. A 48-year-old woman was admitted to the hospital because of a 3.0×0cm well-defined and movable hard mass with smooth surface in her right breast. Liposarcoma was suspected on aspiration biopsy cytology. Therefore, exploratory excision was performed under local anesthesia, and histological examination showed a stromal sarcoma of the breast. A modified radical mastectomy with dissection of axillaly lymph node (Auchincloss method) was performed. No anticancer therapy was added. There has been no local recurrence nor distant metastasis, as of 10 months after the operation.

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We report a case of malignant phyllodes tumor of the breast which is relatively rare.
A 45-year-old woman was admitted to the hospital because of a rapidly growing mass (6.5×6.5cm) in the left breast. An aspiration biopsy cytology offered a suspicion of malignant phyllodes tumor because of the presence of cells with a highly atypical nuclei, irregular swelling of the nucleous and rough distribution of chromatin. After a modified radical mastectomy, the preoperative diagnosis of malignant phyllodes tumor was histopathologically confirmed. Immunohistologically, the tumor stained positive for c-erbB-2 and negative for estrogen receptors. At present, 1 year 6 months after the surgery, the patient has shown no signs of recurrence or metastasis
The definitive diagnosis of the disease can be made postoperatively in many cases. In this case aspiration biopsy cytology is considered a useful procedure to differentiate malignant tumors from benign ones. The relation between malignant phyllodes tumor and c-erbB-2 expression has not been clarified as yet.

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We experienced a very rare case of breast cancer with osseous and cartilaginou metaplasia which consisted of variegated histopathological findings. A 55-year-old woman was referred to the hospital because of a hollow in her left breast. Palpation, mammography, ultrasonography and aspiration biopsy cytology revealed breast cancer. The cancer was located in C, E, D-area and 3.9×3.7cm in size, and Stage II was diagnosed though lymph node was impalpable (T2a, N0, M0). A modified radical mastectomy was performed.
Histopathologically, the tumor was invasive ductal carcinoma in stage I (t2, n0, m0), with variegated findings such as osseous, cartilaginous, apocrin metaplasia and spindle cell infiltration of the breast. This patient has had no signs of recurrence for one year after the operation.

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This case report describes inflammatory carcinoma of the breast. Breast cancer which is characterized by skin erythema and swelling of the breast is designated inflammatory carcinoma of the breast. Compared to usual breast cancers, inflammatory breast cancer has a poor prognosis and is classified into special types of the disease. The operation has been a tatoo for the disease, because once the 5-year survival rate was as low as several per cent only by operation. Thereafter, with an advance in studies, the survival rate has been increasing 50% or more with intensive therapy including surgery and chemotherapy in a recent one decade.
A 60-year-old woman was seen at the hospital because of a rapid growth of breast tumor and significant erythema and swelling, and was diagnosed as having an inflammatory breast cancer. She was treated by pre and postoperative chemotherapy with cyclophosphamide, adriamycin, and 5-fluorouracil (CAF) combined with a modified radical mastectomy. Chemotherapy combined with operation is useful for inflammatory breast cancer we must actively employ the therapy as well as study to make further progress.

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Our uncommon experience with a case of accessory breast cancer is described. A 67-year-old woman was seen at the hospital because of a left axillary tumor. An excisional biopsy of the tumor revealed medullary carcinoma with mammary gland, without connection to the proper mammary gland. There was no other primary lesion in general exploration and clinical findings also offered a suspicion of accessory breast cancer. A wide local resection with lymph nodes dissection level III was carried out. She is doing well without any evidence of recurrence, as of 10 months after the operation.

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One-stage operation was carried out for concomitant infrarenal abdominal aortic aneurysm and an advanced cancer of the sigmoid colon. Since this patient also has a recurrence of lung cancer, one-stage operation was necessary to avoid loosing the chance for lung operation. In this case, resection and grafting of the aneurysm preceded left hemicolectomy. The colon was prepared preopertively, and the retroperitoneum was closed densely and wrapped with gauze to prevent graft infection. To protect the operation field from intestinal fluid and intestinal mucosa, a gastro-intestinal autosuture device (GIA) was used for resection of the colon. The postoperative course was uneventful without graft infection. Our result suggests that the one-stage operation is possible for concomitant abdominal aortic aneurysm and advanced colonic cancer in the same opertive field under a careful attention to prevent graft infection.

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A 73-year-old man who visited another hospital because of abrupt chest and back pain and hematemesis was referred to the hospital for close examination. An emergency endoscopy revealed an ulcer with exposed vessels on the right side wall of the lower esophagus. Hemostatic procedure was conducted. Endoscopy on the next day demonstrated a successful hemostasis, but foam formation was noted in the ulcer base. So a diagnosis of perforation of esophageal ulcer was made. No findings of regurgitant esophagitis were present on endoscopy. The patient had no previous history of esophageal ulcer nor drinking habit, though he had been given antibiotics and non-steroidal anti-inflammatory drug (NSAID) 3 days before admission at another hospital with a diagnosis of acute upper respiratory inflammation. He was in the habit swallowing drugs without water in that retained drugs in the esophagus for a long time might cause the esophageal ulcer which perforated. During clinical observation under conservative treatment, an extraparietal pleural abscess was confirmed. For that CT-guided drainage was conducted with a successful result. The patient was dischaged from the hospital.
This case is presented, together with some bibliographical notes on the medication caused perforation of esophageal ulcer and its conservative treatment.

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We experienced a case of esophageal cancer successfully resected three years after ensuring bypass operation due to direct tumor invasion to the left main bronchus and radiotherapy. A 68-year-old man was admitted to the hospital becauset of dysphagia and was diagnosed as having an esophageal cancer without distant metastasis in Oct. 1992. Radical esophagectomy with three-field LN dissection was planed, but ended in esophageal bypass because the cancer had invaded the left main bronchus. After the operation radiotherapy (60 Gy) with low dose cisplatin was performed. During a 3-years follow up period since then, neither regrowth of the main tumor, nor distant metastasis had been detected. In Feb. 1996, we resected the excluded esophagus through a left thoracotomy, mostly because the tube esophagostomy had seemed to spoil the QOL of the patient, but partly because we had been afraied of residural tumor. The strong adhesion between the tumor and left main bronchus was noted, however, we could separate the two structures successfully. The resected specimen had no viable cancer cells and the dissected mediastinal lymph nodes were all negative for metastasis histopathologically. Until now he has been well with no signs of recurrence.

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A 37-year-old woman was admitted to the hospital for an early gastric cancer. She was a member of a family who have venous thromboembolic episodes in a high incidence, and had been diagnosed as having hereditary antithrombin III (ATIII) deficiency, with the ATIII activity of 56.8%. This time a distal gastrectomy was performed with a diagnosis of IIc cancer of the angular notch. For perioperative management antithrombin III concentrates were administered and the plasma ATIII level (ATIII activity) was maintained at values in excess of 80% for postoperative one week. No thrombotic complications occurred as judged by clinical examination. It has been confirmed that any operation can increase a risk of association of thrombosis in this congenital disorder. When ATIII consumption is enhanced (for example, during sugical procedures), usual antithrombotic therapies such as administration of heparin are not enough and replacement therapy may be necessary in order to normalize ATIII level.

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A 49-year-old woman was admitted to the hospital because of epigastralgia and dizziness. An endoscopic examination of the upper gastrointestinal (UGI) tract revealed a submucosal tumor (SMT) with bleeding in the doudenal third portion. She underwent a partial resection of the duodenum including the tumor, with reconstruction after the fasion of duodeno-jejunostomy (end-to-side) using EEA. Eight months after the operation, no recurrence or stenosis of the anastomotic site was observed by endoscopy of the UGI tract. Barium meal did not show any disturbance of the passage. In this case gross findings of the resected material revealed a mass with both intra-and extra-canallicular extension but no evidence of invasion of the tumor into the pancreas.
Histological findings of the tumor showed that solid nests and neoplastic cells exhibited spindles with spindle nucleui. Mitosis of the nucleus was hardly detected. Immunohistochemical examinations were negative for smooth muscle actin (SMA) and desmin, and partially positive for S-100 protein and neuron specific enolase (NSE). We speculate that the tumor did not originate from smooth muscle tissue but from neural tissue and that it was a gastrointestinal autonomic nerve tumor (GANT).

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Adenoma of the papilla of Vater is a relatively uncommon disease. A case of such a lesion associated with multiple adenoma of the colon is presented. A 67-year-old man was admitted to the hospital because of high fever and jaundice, and diagnosed as having a tumor of the papilla of Vater and polyps of the colon. The tumor was treated surgically by a local excision of the papilla of Vater with papilloplasty. His postoperative course was uneventful. The colonic polyps were excised endoscopically. In a histological study, the tumor of the papilla of Vater was adenoma, and colonic polyps were carcinoma in adenomas. There have been no established therapies for the disease. We think that a local excision of a tumor of the papilla of Vater is the treatment of choice when it's malignancy is not confirmed. The patient with the disease has to undergo colonoscopic examination for probable association of colonic adenoma.

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A 29-year-old man was urgently admitted to the hospital because of abdominal pain and vomiting. He developed waterly diarrhea on the second day after admission. Moreover, an abdominal computed tomography showed massive ascites, intestinal edema and paralytic ileus on the sixth day.Emergency laparotomy was performed with a diagnosis of acute peritonitis. At operation, 1800ml of serous ascites and severe inflammation of the small intestine were noted. Ninety centimeter of the necrotic small intestine was resected, followed by establishment of jejunostomy and ileostomy. Histological examination of the resected material revealed fibrinoid necrosis with neutrophil infiltration at submucosal small artery and the diagnosis of polyarteritis nodosa was made. The patient suffered from renal failure after the operation, but he recovered with hemodialysis. Steroid therapy was conducted as a treatment of primary disease. Polyarteritis nodosa with necrosis of the small intestine is relatively rare. All the cases reported in Japan are accumulated and some bibliographical notes are also presented.

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We report a case of Recklinghausen's disease with a stromal tumor (ST) of the small intestine causing perforative peritonitis, followed by hepatic abscess after operation.
A 53-year-old woman was admitted to the hospital because of abdominal pain which occurred sometimes since mid-March and intensified entire the abdomen in the night of April 3, 1997. Abdominal CT demonstrated free air, and so an emergency operation was performed. Upon laparotomy, a tumor in the small intestine causing a perforation at the oral side intestine was found. Partial resection of the intestine and abdominal drainage were conducted. The histopathological exploration of the resected material offered the diagnosis of ST. In the postoperative course, she developed fever on and after the sixth postoperative day. Abdominal CT on the 19th postoperative day revealed a low density area about 3cm in diameter in the S6 of the liver. With a diagnosis of hepatic abscess, a drainage tube was dwelt in the tumor and percutaneous transhepatic drainage was conducted. The hepatic abscess was successfully treated by the conservative therapy.

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Press-Through package (PTP) is an excellent wrapping deveice of the pills commonly used today. Besides its convenience and superiority in practical use, PTP simultaneously poses a special problem. If mistakenly swallowed, it becomes a gastrointestinal foreign body. A sharp and hard edge injures the oral cavity, throat, esophagus or other soft tissues when it is swallowed without pill extripation. This paper deals with such a case of perforation of the terminal ileum caused by a sharp edge of PTP which was mistakenly swallowed, together with a review of 16 cases reported in the Japanese literature. A 75-year-old man who had black stools lasting for 4 days and a lower abdominal pain lasting for one day underwent an emergency operation with a diagnosis of panperitonitis. During surgery, a perforation was found in the terminal ileum, and a resection of the ileocecal region was conducted. Resected material revealed that a sharp edge of PTP (a pottasium chloride preparation) stuck into the terminal ileum. He recovered uneventfully after the surgery. In a recent background where the number of senile people is increasing, we have to consider the accidental injuries due to mistakenly swallowed PTP that provoke serious medical problems nowadays. Most of these accidents have been occurred through carelessness. Some preventative measures for such undesirable complication are urgently required. For this purpose, improvement of PTP disign to avoid a hard and sharp edge may become a solution, as well as guidance to patients for correct administration of PTP drugs.

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Malignant tumors of the small intestine lack in specific symptoms so that it is difficult to diagnose in an early stage. This paper reports a case of primary malignant lymphoma of the ileum which presented difficulty in differentiation from periappendicular abscess.
A 20-year-old woman was occasionally febrile and had an abdominal pain scince November in 1996. In February, 1907 she noticed a mass in the right lower quadrant, and was admitted to the hospital because of right lower abdominal pain. On admission a hard tumor whose surface was smooth was palpated on the McBurney point where there were tenderness and Blumberg's sign. Anemia and inflammatory response were also noted. At first a periappendicular abscess due to acute appendicitis was suspected by clinical features and the findings of US and CT. Finally a primary tumor of the ileum, in particular malignant lymphoma was suspected and an operation was performed. Upon laparatory, a fist-sized tumor was placed in the ilececal junction and a right hemicolectomy was carried out. Histological diagnosis was diffuse and large cell type of malignant lymphoma. Postoperatively no legion was detected in the other organs. It was diagnosed as primary malignant lymphoma of the small intestine.

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Eosinophilic enteritis is a relatively rare entity that causes inflammation with eosinophilic infiltration into the gastrointestinal tract. Sometimes peripheral eosinophilia occurs in patients with the disease. We report a case of eosinophilic enteritis accompanied with peritonitis due to intestinal perforation three times when laparotomies were performed.
A 25-year-old man underwent laparotomy three times due to peritonitis caused by intestinal perforation with eosinophilic enteritis in December 1990, September 1995 and May 1996. At the first laparotomy in our institution, a partial resection of the small intestine was performed, and histological examination revealed eosinophilic enteritis. He has been followed with predonisolone per os after the third surgery. There have been relatively few reports of eosinophilic enteritis with repeated perforation.

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A rare case of goblet cell carcinoid of the vermiform appendix is presented. A 71-year-old man was seen at the hospital because of right lower abdominal pain. Appendectomy was performed with a preoperative diagnosis of acute appendicitis. However, histological examination revealed a goblet cell carcinoid tumor of the appendix (ss, ly1, v0). A subsequent right hemicolectomy with lymph node dissection was carried out. No residual lesion or lymph node metastasis was identified in the specimen. At his 1-year postoperative evaluation, the patient was asymptomatic. Goblet cell carcinoid of the appendix has been histologically classified as a variant of carcinoid tumor, however, it is potentially malignant and it should be recognized as a variant of adenocarcinoma. Therefore, aggressive surgical treatment is necessary.

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Appendiceal cancer is extremly rare and common in aged patients. We experienced two young patients with appendiceal cancer which were detected with manifestations mimicking acute appendicitis.
Case 1: A 21-year-old man underwent a laparotomy with a preoperative diagnosis of local peritonitis due to chronic appendicitis. During operation, pseudomyxoma peritonaei arising in the appendix was found. The appendix and metastatic greater omentum were removed as possible as we could. Microscopic examination of the resected appendix showed pseudomyxoma peritonaei caused by a mucinous cystadenocarcinoma.
Case 2: A 33-year-old woman underwent a laparotomy with a preoperative diagnosis of acute appendicitis. During operation, the swollen appendix to 20cm in size was noted. Appendectomy was performed. Microscopic examination of the resected appendix revealed well diffentiated adenocarcinoma. So, an ileocecal resection with lymph node dissection was added.
We should keep this rare tumor in mind as a probable differential diagnosis for appendicitis, and carefully examine the resected material of the appendix pathologically, regardless of age.

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A case of panperitonitis caused by microperforation of Meckel's diverticulitis is reported.
A 41-year-old man was admitted to the hospital because of vomiting and diffuse abdominal pain following epigastralgia. An emergency operation was performed with a diagnosis of acute panperitonitis. On laparotomy, a large amount of purulent fluid and Meckel's diverticulum that adhered to the mesenterium sigmoideum were found. A wedge resection of the ileum including the diverticulum was performed. No perforation was detected macro and microscopically, but it is sure that there was a microperforation from these findings.
Although the clinical course in this case was similar to those of perforated gastroduodenal ulcer and appendicitis, we were able to differentiate it from others by the localization of tenderness.

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A case of synchronous gastric metastasis from a transverse colonic carcinoma in a 68-year-old woman is reported. She was admitted to the hospital for evaluation of anemia and epigastric discomfort. Ba enema study and colonoscopy revealed a circumferential carcinoma of 3' type in the transverse colon. No hepatic metastasis nor peritoneal dissemination was seen on abdominal CT and ultrasonography. She underwent the operation on October 29, 1997. Intraoperatively, besides the colonic carcinoma, a finger-sized intramural solitary mass in the lesser curvature of the stomach was recognized, and a gastrectomy was added. Histopathological examination revealed well differentiated papillo-tubular adenocarcinoma in the colon, and a well defined solitary node measuring 2.5cm in diameter within the proper muscle layer of the stomach. Histologically, the gastric lesion showed also adenocarcinoma with close similarity to that in the colonic one. Thus, it was diagnosed as gastric metastasis from the colonic carcinoma. There have been 11 cases of gastric metastasis from colorectal carcinoma including this case so far. This is the first case in which synchronously metastasized lesion and the primary lesion were simultaneously resected. In this case, elevated CEA level was normalized after the operation, so tat we are to observe carefully the clinical course whether simultaneous resection provides an improvement in the prognosis.

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Both primary malignant lymphoma of the large intestine and aberrant pancreas into the small intestine are rare. We have experienced a case of malignant lymphoma of the sigmoid colon with aberrant pancreas into the jejunum.
A 71-year-old woman was admitted to the hospital because of bleeding at defication. Gastrointestinal exploration revealed a tumor with ulcer at the sigmoid colon. Biopsy offered a diagnosis of malignant lymphoma. No other abnormalities were shown on general exploration. Sigmoidectomy was conducted with a diagnosis of malignant lymphoma of the sigmoid colon. During operation, two tumors 1cm in size were revealed in the jejunum and were locally excised. The tumor of the sigmoid colon was 4.0×3.5cm in size, and malignant lymphoma of diffuse medium cell type, histopathologically. The depth of invasion of tumor was ss and no lymph node metastasis was noted. Immunohistochemical studies revealed B-cell type. The tumors in the jejunum were Heinrich II type aberrant pancreas. There have been no signs of recurrence, as of 20 months after the operation. The patient is followed on an ambulant basis.

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A rare case of situs inversus totalis associated with a colonic cancer is reported. A 73-year-old man was admitted to the hospital because of general fatigue and severe anemia. Abdominal ultrasonography and chest X-P revealed dextrocardia. Double contrast barium enema study and colonoscopy revealed an advanced cancer in the descending colon. The patient was operated on after his general condition was improved by conservative therapy. Upon operation the left-right reversal position in internal organs and a tumor in the descending colon were confirmed. Situs inversus totalis is a rare congenital malformation, but it is no morbid importance. However it may present difficulty to perform an operation. This paper shows that this technique can be safely, speedy and effectively applied in the setting of situs inversus totalis, although attention must be paid to the details of the left-right reversal, anatomical assessment of the lesions, organs and vessels.

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Two cases of ulcerative colitis with colorectal cancer are described, and both cases show the long-term episodes.
Case 1: A 56-year-old man had a history of ulcerative colitis, by 10 years after the onset, in which chronic, persistent, ulcerative, and diffuse inflammatory was found in the entire colon. Endoscopy was performed because of his chief complaint of abdominal distension and found a tumor in the sigmoid colon. Total colectomy, ileoanal anstomosis and ileostomy were performed. The tumor was confirmed histologically as poorly differentiated adenocarcinoma. The stage was classified as IIIb. In addition seven other lesions were also found which were poorly differentiated adenocarcinoma. At the three months after the surgery, gastrostomy and jejunostomy were performed because of the onset of cancerous ileus. The patient died of cancerous peritonitis on the 139th postoperative day from the first surgery.
Case 2: A 44-year-old woman had a history of ulcerative colitis, by 25 years after the onset, in which ulcerative and diffuse inflammation ws found in the left colon. Aspects of improvement and exacerbation were repeated. Colonoscopy was performed because of her chief complaint of diarrhea and melena and found a tumor in the rectum. Total colectomy, ileoanal anastomosis and ileostomy were performed. The tumor was confirmed histologically as mucinous carcinoma. The stage was classified as IV. At the one year after the surgery, metastasis to the right ovary and the onset of cancerous peritonitis were found. Hysterectomy with adnexectomy and ileectomy was performed. The patient died of cancerous pleuritis on the 3rd postoperative month.
It is known that there are some cases of the colonic cancer associated with long-standing ulcerative colitis (UC). Recently, cancer-surveillance colonoscopy for long-standing UC has become common and some cases of early cancer have been reported. However, developing cancer is still great in number, and there are many cases of poor prognosis different from general colonic cancer. In these cases presented here, deaths resulting from the early relapse after surgery might be attributable to missed opportunity of early detection and the hystologic types of colonic cancers, poorly differentiated adenocarcinoma in case 1 and mucinous carcinoma in case 2.

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Among malignant lymphomas of the intestine, those arising in the rectum are rare, especially Burkitt lymphoma. A 54-year-old woman visited another clinic because her stool was positive for occult blood. A breast-like submucosal tumor at Rb region of the rectum was revealed by colonoscopy and barium enema study. Carcinoid tumor was suspected and an endoscopic polypectomy was performed. Histological diagnosis was malignant lymphoma with positive cut end. Then she was referred to the hospital. After admission, a low anterior resection with D3 lymph nodes dissection was performed. Histological grading was sm3, n₀, H₀, P₀, M (-), and stage I. Histological and imunohistological diagnosis of the resected specimen was Burkitt lymphoma B-cell type. She has been doing well without any evidence of recurrence for six months after surgery. In this paper, we clinico-pathologically reviewed 85 cases of malignant lymphoma of the rectum reported in Japan from 1981 to 1996. And 30 cases of rectal malignant lymphoma in which lymph node metastases were noted were reviewed with regard to the relationship between macroscopic findings, max size of the tumor and the grade of invasion.

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Despite the clear visualization of a hepatic tumor on various imaging modalities, no tumor was able to be identified by intraoperative ultrasonography and in the resected material in a 38-year-old man.
The patient was incidentally found to have a hepatic tumor 1.5 cm in diameter in the S6 of the liver on CT scanning. In the liver surrounding the tumor, diffuse fatty infiltration was seen, and the tumor was revealed as strong echoes on ultrasonography, hypoattenuation area on precontrast CT, hyperintensity on T1-weighted magnetic resonounce imaging (MRI), and isointensity on T2-weighted magnetic resonounce imaging (MRI), and isointensity on T2-weighted images. On angio-CT, the portal blood flow in the tumor was equipotent to that of surrounding liver, and a decrease in arterial blood flow was observed. With a preoperative diagnosis of well differentiated hepatocellular carcinoma, the patient was operated on. With intraoperative ultrasonography as well as on a section of the resected material, no tumor was demonstrated. Histopathologically, it was moderate degree of fatty droplets and no findings suggestive of tumor image were noted.

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A 42-year-old woman had been treated for Budd-Chiari syndrome with stenosis of hepatic veins at the hospital since 1984. Serum AFP was elevated up to 1000ng/ml in february, 1995. Abdominal CT scan revealed a tumor, 2cm in diameter, in the lateral segment of the liver. Angiography revealed a hypervascular tumor in the lateral segment of the liver. The disease was diagnosed as Budd-Chiari Syndrome complicated by hepatocellular carcinoma. Both of HBs antigen and HCV antibody were netative.
Partial resection of the lateral segment of the liver was performed in May 24. The surface of the liver was soft and roughly irregular. It seemed that its macroscopic findings were not suggestive of cirrosis but congestion. Postoperative course was uneventful. Macroscopically the resected tumor was the nodular type and 3.0×2.8×2.3cm in diameter. Histological examination of the resected specimen showed moderately differentiated hepatocellular carcinoma (Edmondson II).
The frequency of Budd-Chiari syndrome complicated by hepatocellular carcinoma without viral hepatitis is comparatively rare. It is suggested that the etiology of hepatocellular carcinoma with Budd-Chiari syndrome might be hepatic cell damage and regeneration due to chronic congestion of the liver.

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Cholecystogastric fistula that is one of the spontaneous internal biliary fistula is relatively rare. We report a case of the disease associated with intestinal obstruction with a review of the literature. A 77-year-old woman was seen at the hospital because of nausea and vomiting. Abdominal X-ray film showed niveau and pneumobilia Ultrasonography (US) showed gallbladder stone, thus gallstone ileus was suspected. But abdominal CT did not reveal any stone in the intestine, and so we could not prove that this ileus was gallstone ileus UGI did not reveal fistula, but GIF revealed fistula in anterior wall, lesser curvature and antrum of the stomach.
ERCP examination detected that contrast medium flowed from the gallbladder to stomach through this fistula.
The diagnosis of cholecystogastric fistula was made and the gastric wall around the fistula with gallbladder was resected.

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We report a case of retension cyst of the pancreas extended to the spleen, and formed a pseudocyst there with splenic cyst. It was difficult to distinguish benign cyst from malignant cystic tumor; cystic adenoma or adenocarcinoma. A 47-year-old man was referred to the institute with a suspicion of pancreatic cystic tumor during the course of chronic pancreatitis. Abdominal urtrasonography, CT scan and magnetic resonance imaging revealed a cystic lesion on the pancreas tail, 13×12cm in size. The wall of the cyst was thickened partly, and there was a solid part which looked like septums. ERP revealed the dilated main duct without communication to the cyst. We diagnosed the case as probable cystic neoplasm of the pancreas and performed a distal pncreatectomy and a splenectomy.
Histologically, ductal epitheliums of the pancreas remained partly on the cystic wall of the pancreas side so that the cystic lesion was diagnosed as retention cyst of the pancreas. But the wall of the cyst was consist of the spelic cell without capsule of the spleen. Further more, cysts were recognized in the spleen.
It is etiologically concluded that the retension cyst of pancreas formed the pseudocyst in the spleen and then splenic infarction occurred due to compression by the pancreatic cyst, causing the splenic cysts.

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We report a rare case of intrascrotal extratesticular scwannoma. A 46-year-old man was seen at the hospital because of a swelling of right scrotal content lasting for two years. An elastic soft mass with the size of small egg which was situated away from the testis and spermatic cord was palpated. Ultrasonography revealed the similar findings. The tumor was extirpated. Histopathologically it was schwannoma. The intrascrotal schwannoma has been reported in only three other patients in Japan.

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A 47-year-old woman was admitted to the hospital because of right lower abdominal pain and vomiting. On palpation, there were tenderness and slight muscular defense in the right lower quadrant. The white blood cell count increased to 14900/μl. A abdominal pain X-P showed niveau sign. Abdominal CT revealed the dilated small intestine and displacement of the uterus left laterally. Emergency operation was carried out with a suspicion of acute appendicitis. There was no abnormal findings around the ileocecal region, but traces of strangulation were found at a distance of 30cm and 35cm from the ileocecal region. Fathermore, an abnormal defect in the right broad ligament 3cm in diameter was recognized. We diagnosed this case as intestinal obstruction caused by internal herniation through a defect in the right broad ligament. The blood flow at strangulated ileum was well, so any resection of the bowel was not performed. The defect of the borad ligament was closed by direct suture. Internal herniation through a defect in the broad ligament is extremely rare. The CT findings such as displacement of the uterus caused by dilated small intestine is a significantly feature for this disease.

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A 20-year-old man clashed against another car during driving a truck and transferred to another hospital on July 30, 1996. X-ray examination revealed a fracture of the right tibia and then a gradually intensifying left lower quadrant pain occurred. On the same day, the patient was referred to the hospital. After admission, an abdominal ultrasonography and a CT scanning revealed a left retroperitoneal hematoma. Hypotension and tachycardia also appeared. With a suspicion of injury of the retroperitoneal organ or retroperitoneal vascular injury, an emergency operation was carried out. During operation, a left retroperitoneal hematoma was confirmed. With the hematoma was removed, a rupture about 3.5cm in length in the left common iliac vein was present. The diagnosis of injury of the left common iliac vein was made.
There has been no case of solitary injury of the common iliac vein without injuries of the abdominal organs or pelvic fracture due to abdominal blunt trauma in the Japanese literature as far as we could review. This case with some bibliographical comments is presented here.

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A 53-year-old man was seen at the hospital because of upper abdominal pain. CT revealed a 3.5×2.2cm oval enhanced tumor shadow on the left adrenal head side. With an abdominal angiography, the feeding vessel was determined to be the left inferior phrenic artery.The retroperitoneal tumor was extirpated with a diagnosis of neurogenic tumor. During the operation, blood pressure (218/100) elevated with in serum epinephrine and norepinephrine to 3, 680pg/ml and 17, 716pg/ml, respectively, that demanded the management with α-blocker. Histopathologically it was diagnosed as paraganglioma.
Twenty-nine per cent of these paragangliomas are malignant and easily infiltrate into nerves and vessels. The 5-year survival rate is 19% in malignant non-curative resection cases. At the present time when we do not have any reliable method to diagnose the malignant potential of the disease postoperatively, radical resection in an early stage would be essential. Further, since plenty of vessels in the lesion can cause intraoperative hypertension, management of such hypertension and tender manipulatin after have determined the anatomy of those vessels are important.

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A 22-year-old woman was admitted to another hospital because of lower abdominal pain. she underwent a laparotomy under a diagnosis of torsion of the ovarian cyst. During surgery, necrosis of the small intestine was found, and she was immediately transferred to the hospital. Abdominal CT scan showed that the small intestine with thick wall was markedly distended and filled with fluid and air. C-shaped, fluid-filled small-bowel loop with a twisted mesentery was also seen. At emergency operation, we found that the small intestine was incarcerated into an abnormal defect in the mesentery in the ileum and the incarcerated intestinal loop was twised along its long axis. Necrotic bowel by 150cm was resected and the defect was closed. Postoperative course was uneventful.
Adult transmesenteric internal hernia is a relatively rare disease. This paper presents our case with some bibliographical comments on 13 cases which have been seen in the Japanese literature.

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We have experienced a case of huge synovial sarcoma of the retroperitoneum which was successfully resected.
A 55-year-old woman who had been noticed of a lower abdominal tumor since around 1995 was referred to the hospital with a suspicion of retroperitoneal tumor in January, 1997. After admission, abdominal CT scan and magnetic resonance imaging (MRI) revealed that the tumor was persent in the left retroperitoneum and rolled up from the aorta to left iliac artery about 13cm in length, and that the left kidney revealed hydronephrosis. Angiography showed that the tumor was poor in vascularity. CT guided needle biopsy presented a possibility of malignant tumor. A laparotomy performed on March 17 revealed that the tumor about 14×9cm in size was present in the retroperitoneum and rolled up the left hilum of kidney and ureter. An extirpation of the tumor except a small part of it which was left intact and a left nephrectomy were conducted. Histopathologically, the resected tumor was multilocular with a collection of a dark red fluid in it. Tumor cells in the solid part were of short spindle. The diagnosis of synovial sarcoma of the retroperitoneum was made. Infiltration of tumor cells was confirmed in the left renal pelvis and ureter. Postoperative course was uneventful and the patient is followed on an ambulant basis.

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A 51-year-old woman was seen at the hospital because of a right abdominal mass and abdominal distension. She was diagnosed as having a pseudomyxoma peritonei and operated on. At operation, there was a cystic tumor in the right retroperitoneal cavity which was occupied with gelatinous material, and it was infiltrating into the abdominal cavity where a large quantity of same material also existed. We could not abrade the cystic tomor from the ascending colon. There were a few nodules at the sigmoid colon that were considered the dissemination. The appendix was difficult to be identified because of a previous history of undergoing an appendectomy. Right hemicolectomy including the cystic tumor, sigmoidectomy, omentectomy, bilateral oophorectomy and intraperitoneal lavage with 5% glucose were performed. Then cisplatin 100mg was infused into the abdominal cavity. Microscopic examination of the cystic tumor showed mucinous cystadenoma. After the operation, intraperitoneal lavage was performed many times and cisplatin 200mg was infused into the abdominal cavity through a reservior. During the same period, chemotherapy with 5-FU was also given to the patient. This paper presents a rare case of pseudomyxoma peritonei with a main tumor in the retroperitoneal cavity, together with a review of the literature.

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Arteriovenous fistulas between the common iliac vessels secondary to iliac artery aneurysm are rare. The patient exhibited unilateral lower-extremity venous return insufficiency and ischemia. An 83-year-old man was admitted complaining of left leg swelling, cyanosis, a nd pain. Digital subtraction angiography showed an 80×70mm aneurysm of the left common iliac artery. The patient had unilateral lowerextremity venous retrun insufficiency and ischemia. Rapid visualization of the inferior vena cava and retrograde opacification of the left iliac vein indicated the presence of an arteriovenous fistula between the common iliac artery and vein. Prompt surgery revealed a 5×5mm fistula in the posterior aneurysmal wall. The fistula was closed from within the iliac aneurysm, and bypass grafting was performed with a prosthetic graft. Patients with arteriovenous fistulas have a variety of clinical findings. A high level of suspicion, immediate diagnosis, and prompt surgical intervention are critical for successful management.

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We have experienced a case of infection of an artificial vessel due to acute appendicitis in a 50-year-old man. The patent had undergone an abdominal arota-right femoral artery bypass operation using an artificial vessel in 1990. In 1995, he developed suppurative gonarthritis of the right lower limb, femoral osteomyelitis, and inflammation of the gastrocnemius and femoral muscles. These symptomas were improved by chemotherapy and incision drainage, though the etiology was unknown. In 1997, occlusion of the artificial vessel and suppurative lesions in the peripheral dorsal region of the foot and 3rd toe occurred, and a removal of the artificial vessel was conducted on November 8. On November 10, pus and intestinal juice like material flowed out from the wound. CT revealed gas in the retroperitoneal space, and a laparotomy was performed with a suspicion of perforation of the intestine. During operation the necrosed appendix, abscess formation and small bowel perforation were confirmed, and an appendectomy and a partial resection of the small intestine were carried out. Histologically, the appendix presented gangrenous appendicitis that might cause infection and occlusion of the artifical vessel. After the operation the inflammation was alleviated. There have been no signs of recurrence, and the patient is doing well.

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A 62-year-old man was seen at the hospital because of dysphagia. Upper gastrointestinal series and endoscopic examination showed a type 2 lesion at the cardia and a Borrmann type 5 lesion in the stomach. Biopsy specimens demonstrated squamous cell carcinoma and signet ring cell carcinoma, respectively. A collision tumor was strongly suspected. The resected material showed the type 2 lesion measuring 6.0×5.0cm and the Borrmann type 5 lesion measuring 8.5×5.5cm which located close to each other at the cardia. Histologically, the esophageal squamous cell carcinoma and the gastric signet ring cell carcinoma were separated only by a thin fibrous tissue, and there was no histological transition between two lesions. With respect to metastatic sites, only one component from each tumor was seen.

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A case of starch granuloma and gauseoma in a 74-year-old woman, who had a past history of undergoing an oophorectomy 30 years before admission, is reported. She was admitted to the hospital because of tarry stool, and diagnosed as having an ascending colon cancer concomitant with tumors in the liver and the mesentery.
A right colectomy and a partial hepatic resection were performed and the both mass were proved to be foreign body granuloma by the histological examination. Polarized light microscopic examination revealed starch powder in the liver granuloma and cotton fiber in the mesenteric granuloma. The former was characterized by the finding called “Maltese cross”. These granulomas were thought to come from starch glove powder and gauze lint retained after the oophorectomy. Although few cases of starch granuloma have been reported in Japan, a great number of cases can be seen in the foreign literature. It is said that surfaces of globes should be washed sufficiently before surgery to prevent the disease.
Starch granuloma and gauseoma should be suspected in case of unknown mass with a history of laparotomy, and polarized light microscopic examination is useful to define the origin of this kind of granuroma.

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