The evaluation of efficacies of povidone-iodine and chlor-hexidine gluconate for surgical handwashing with or without brushes was conducted bacteriologically. Subjects were 33 nurses who work at the operating theater. The median microbial count per hand at baseline (before scrubbing) was 8.0×10³ (n=15). The few minutes consecutive scrub with povidone-iodine did not lead to its decrease, but after the scrub with chlorhexidine gluconate, the microbial counts decreased significantly. However, the microbial count increased to reach or exceed the baseline 2 to 5 hours after the scrub, regardless of the antibacterial agent used. The microbial counts did not reflect the effectiveness of using hand brushes.
As a results, we consider that the brushes are useless and few-minute scrub with chlorhexidine gluconate is useful as surgical handwashing, and repeated washing is advocated in case of long operation.

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Intracystic tumors of the breast are relatively rate, and it is difficult to distinguish between malignant and benign intracystic tumors by imaging evaluation.
Over a period of 7 years we encountered 18 cases of intracystic tumors of the breast, including 12 cases of intracystic carcinoma, 5 cases of intraductal papilloma, and one case of mastopathy, and we evaluated the usefulness of ultrasonography and needle aspiration cytology in making the differential diagnosis.
All cases of malignant intracystic tumor of the breast in this series were carcinomas, and their characteristic ultrasonographic findings were irregular shape and rough border, with half of them exhibiting a boundary echo. Sixteen of the 18 cases were correctly diagnosed by needle aspiration cytology, and the other two were false positive and false negative. All cases in which needle aspiration cytology was carried out under ultrasonic guidance were correctly diagnosed.
A comcination of ultrasonography and needle aspiration cytology for intracystic tumors of the breast seemed to improve diagnostic precision.

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Treatment of breast cancer has been more conservative in the last two decades and the level of axillary dissection has been getting reduced. We evaluated the computed tomographic featurers of axillary lymph nodes in 211 patients with primary breast cancer retrospectively to know whether these features could contribute to predict the necessity of axillary lymph nodes dissection. The sensitivity of axillary CT in detecting malignant nodes was 82.4%, the specificity 70.0%, and the negative predictive value was 84.0%. Correcting the criteria and changing the scanning thickness from 5mm to 3mm. 46 consective patients with breast cancer were estimated prospectively. As a result, the sensitivity was 78.9%, the specificty 88.9%, and the negative predictive value 85.7%. It is concluded that the axillary CT is one of useful modalites in selecting appropriate candidates for ‘operation without axillary lymph nodes dissection’.

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We reviewed clinicopathological features of nine cases of gastrointestinal stromal tumor (GIST) at the hospital in a past 5-year. Four tumors arose from the wall of the stomach, three from the small intestine and two from the large intestine. All patients except one were symptomatic at the time of admission. The tumors of any cases had abundant vascularity and displayed expansive growth on imaging studies prior to the operation. All tumors including one with peritoneal metastasis were resectable. Their mean size was 8.6±4.4cm in diameter. On immunohistochemical examination, any tumors had the phenotypes of neither smooth muscle nor nerve cells. The recurrence had occurred in two cases after the operation. Although GIST is thought to be comprehensive concept on pathology, it could be also applicable to the clinical entity of surgery.

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Surgical stress induces hormonal and cytokein responses in proportion to the extent of insults, and so the plasma concentrations of inflammatory cytokines have been reported to be the useful indicatos of surgical stress. We evaluated the postoperative alterations in concentorations of cytokines in ascites as well as plasma of patients undergoing laparoscopic cholecystectomy and compared them with those of conventional cholecystectomy.
The concentrations of tumor necrosis factor (TNF) -α, interleukin (IL)-6, IL-8 and guranulocytes elastase (GEL) were measured in six patients undergoing a lapaloscopic cholecystectomy (LC group) and five patients undergoing a conventional cholecystectomy (OC group) for choleleithiasis. Samples were collected before and at the 1st, 3rd, and 7th day after the surgery from an antecubital vein, and at the 1st, 3rd day after the surgery from peritoneal exuducates discharged through the abdominal draining tube placed in the surgery at the visceral surface of the right hepatic lobe. TNF-α (pg/ml), IL-6 (pg/ml) and IL-8 (pg/ml) were measured by enzyme-linked sorbent assay, and GEL (μg/l) by enzyme immuno assay.
No statiscally significant changes were obserbed in plasma concentorations of TNF-α, IL-6, and IL-8 of both groups thoughout this stady. In peritonial exuduates, however, the contentorations of IL-6 were 6, 574±2, 286 in LC group and 15, 507±4, 527 in OC group at the 1st day after the surgery, with a significant difference. The concentorations of all cytokines in peritoneal exduates were higher than those in plasma.
In conculusion, the cytokines might be released in the peritoneal cavity. And at the laparoscopic cholecystectomy, IL-6 might be released less than at the conventional cholecystectomy.

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We evaluated a new polyurethane vascular access graft (Thoratec Vascular Access Graft, TVAG) as a vascular access for hemodialysis. Subjects were 16 patients with chronic renal failure and TVAG was implanted as arteriovenous fistula in them. These were one case of loop in the fore arm, one case of a loop in the upper arm, eight cases of straight in the upper arm and six cases of loop configuration in the thigh. TVAG is characterized by its elasticity and self-sealing property that require careful subcutaneous positioning of TVAG and deliberate sutures during anastomosis, but it resulted in no postoperative limb edema and easy hemostasis after needle removal in our subjects. These findings indicate that TVAG can be used for hemodialysis in early postoperative days. In our cases, hemodialysis was able to start with in 4 days after implantation of TVAG, with an average of 2.4 days. Shorter hospital stay is consequently expected. Early occulusion of fistula due to thrombosis occurred in two cases. Thrombectomy was easily performed in both cases using Fogarty balloon catheters and they could be used for hemodialysis again. It is concluded that TVAG is useful as a vascular access for hemodialysis. Further assessment of its long-term patency and possible complications are necessary.

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Authors studied clinical features and prognosis in 37 patients with extramammary (vulvar) Paget's disease, experienced at our department. There were slightly more men (54.1%) and a mean age at the first visit was 70.8 years. Mean interval between the estimated onset and first visit was 51.4 months, and 73.0% of them had been treated with ointment conservatively. Itch and local pain as subjective symptoms appeared in 51.4% and 21.6%, and redness/erythema and erosion as objective findings appeared in 59.5% and 35.1% of the patients, respectilely. Nine cases (24.3%) had other primary malignant neoplasm. Of all cases, 33 cases were treated with operation and 27 cases of them underwent lymph node dissection. In pathological findings, 18 tumors were intraepidermal cancer, 11 tumors invaded dermis, and three tumors invaded subcutaneous tissue. Four cases had lymph node metastases. In 10 cases, surgical margin were positive and nine of them were at vaginal and/or anal verge. Authors studied the relevance between lymph node metastases, pathological invasiveness and prognosis. The results revealed that the prognosis deteriorated significantly (p=0.0027) in node positive cases and tended to deteriorate in cases invading over subcutaneous tissue. Based on these results, the authors have proposed a new clinical classification of the disease that might be benefical for prediction of the prognosis.

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To clarify neurological function with respect to puborectalis muscle for rectocele with symptoms such as incomplete evacuation, difficulty in defecation, chronic constipation, soiling, and so on, we examined terminal motor latency in the sacral motor nerves (SNTML). The latency of the response in the puborectalis muscle following transcutaneous stimulation of the spinal column overlying the cauda equina was measured. SNTML was measured in 34 patients with rectocele (females, age 24-79 years, mean age 55.4 years), and the results were compared with data obtained from 10 control subjects (females, age 16-66 years, mean age 49.9 years). Incomplete evacuation and defecation straining were the most common complaint in the patients with rectocele, and they were significantly more common in patients with rectocele compared with normal subjects. Most rectocele cases had a history of childbirth. In 44% of the patients, rectocele was associated with perineal descent. The conduction delay of bilateral SNTML in the patients with rectocele was longer than that in the control subjects. These findings support the hypothesis that the conduction delay of SNTML in rectocele patients is caused by damage (stretch injury, entrapment, and so one) to sacral motor nerves.

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Since October 1994, we have been treating adult groin hernia according to the concept of tension free hernioplasty that was advocated by Lichtenstein. In this study, 61 tension free hernioplasties (including 43 mesh plug repairs and 18 laparoscopic hernioplasties) were compared with 49 conventional hernioplasties which were performed from January 1991 to December 1994.
There was no significant difference in the mean hospital stay, but the tension free hernioplasty was significantly superior to the conventional method in postoperative pain and recurrence rate. Especially mesh plug repair permits to approach with the same knowledge as the conventional hernioplasty demands; does not need such special technique as laparoscopic surgery requires; does not require general anesthesia; shortens the operating time; and saves the medical cost. This mesh plug repair that is minimal invasive procedure in tension free hernioplasty will be a standard operation for adult groin hernia.

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A 65-year-old woman was admitted to the hospital for the purpose of operation for an enlarging left breast tumor in 1996. In 1993, the patient visited another hospital because of a left breast tumor, but thereafter the tumor spontaneously began to shrink and she left it alone. She noticed the tumor starting to grow again in October 1995, when an aspiration cytology biopsy revealed class IIIa and she was referred to the hospital. On admission, a pulmonary metastasis was noticed and clinical staging resulted in stage IV. Modified radical mastectomy (Bt+Ax) was performed on February 27th, 1996. Clinicopathologically, our case followed t 2n 3m 1 stage IV. Histopathological examination revealed that papillotubular carcinoma changed to solid tubular carcinoma or scirrhous carcinoma causing invasion to the outside of the cyst wall. It is thought that the carcinoma became more malignant as it grew, and it is interesting from the point of view of pathogenesis.

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A case of angina pectoris with idiopathic thrombocytopenic purpura in which high dose transvenous γ-globulin therapy followed by coronary artery bypass grafting was successful is reported.
A 66-year-old man was admitted to the hospital because of chest oppression. He was diagnosed as having idiopathic thrombocytopenic purpura by preoperative blood examination. Coronary angiography indicated that the patient was a possible candidate for coronary artery bypass grafting (CABG). High-dose transvenous gamma-globulin therapy (400 mg/kg/day) was performed for five days before surgery. Platelet count increased from 2.2×10⁴/mm³ to 13.2×10⁴/mm³, and CABG was carried out using left internal thoracic artery and saphenous vein graft. Postoperative bleeding quantity was slightly more than usual. We utilized the autotransfusion system to give drained blood collected in the chest tube bag. Administration of platelet-rich fluid decreased the postoperative bleeding. Three months after discharge, he had sucssessfully undergone a partial splenic embolization in another hospital, and then administration of steroid was stopped with a complete remission.

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A mitral valve replacement has been performed on a case of mitral incompetence associated with cerebellar hemorrhagic infarction due to infective endocarditis. During cardiopulmonary bypass (CPB), an antithrombin agent ‘argatroban’ and a low dose of heparin were used as anticoagulants. Administration of argatroban was started 30min. before CPB at a dose of 2.5μg/kg/min, maintained at a dose of 4.0μg/kg/min during CPB, and ceased simultaneously when the CPB was terminated. Heparin was intravenously administered 10 min. before CPB at a dose of 0.5mg/kg. Considering the safety, heparin-coated artificial lung, circuits, reservoir, and cannulae were used. ACT underwent changes between 211 and 267 seconds, and no macroscopic thrombi were seen in the artificial lung and circuits. On postoperative CT scan of the head, no intensified hemorrhage was confirmed. It is thought that this procedure might be beneficial for cardiac surgery in patients associated with cerebral hemorrhage.

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From 1983 to 1996, a series of 41 patients with metastatic lung tumors were surgically treated at our department, and four (9.8%) patients out of them underwent resections more than three times (ranging three to eight times). The primary tumors involved osteosarcoma in 2 cases, adenoid cystic carcinoma of orbita in one case and leiomyosarcoma of uterus in one case. In this study we evaluated functional changes in the operated lunb after surgical treatments. In most operations, partial excision of the lung was performed. Decrease in vital capacity remained at around 90% of the preoperative VC progressively decreased and two cases undergone resections five times or more revealed decreases to 41% and 31%, respectively. No significant changes were noted in FEV_1.0% and electrocardiogram did not show the pattern of right heart failure. Except one patient, all patients are alive at present and 3-to 9-year survival after the initial operation have been attained. We suppose that multiple thoracotomies are necessary for metastatic lung tumors, but careful postoperative management is mandatory for patients undergoing unilateral thoracotomies more than three times because remarkable decrease in the lung function in unavoidable.

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We successfully saved a patient with traumatic complete rupture of the right main bronchus by performing a bronchoplasty.
A 16-year-old man was referred to the hospital with a diagnosis of right pneumothorax due to a traffic accident. Chest simple x-ray film and chest CT scan visualized the remarkably crushed right lung and hemopneumothorax. Two intrathoracic trocars were inserted. Respiratory failure occurred 9 hours after the trauma, and so the patient was managed by differential lung ventilation via double lumen endobronchial tube. The patient was suspected to have any injuries at the level of the right main broncus, and underwent an emergency operation 30 hours after the trauma. Operative findings included intrathoracic complete rupture of the right main bronchus and remarkably crushed right upper lobe of the lung. A right upper lobectomy and a bronchoplasty were performed. Postoperative course was unevenful and the patient was discharged from the hospital on 48th postoperative day.
In this case, the management of differential lung ventilation was useful as preoperative respiratory management. And bronchoplasty is thought to be an ideal operative procedure in terms of preserving the lung function.

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Many operative methods for esophageal achalasia have been reported and reviewed since past. However, each of methods has both merits and demerits and no most recommendable method has been established as yet. The concept of surgical treatment can be described as followings; (1) to improve swallowing disturbance, (2) to prevent reflux, (3) to keep efficacy permanently and (4) to be minimally invasive. We attempted a transfer of gastric wall combined with a device of shape of gastric wall and Hill's procedure for three cases of esophageal achalasia. Our device was successful, especially for prevention of reflux. These three patients have never complained of swallowing diturbance and refux for 4 years and 6 months after the operation.

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Small intestinal obstruction with bezoars is a rare entity and we find a great deal of difficulty in preoperative diagnosis. We report a case of the disease in a gastrectomized patient with a review of the literature. A 79-year-old gastrectomized woman was emergently admitted to the hospital because of repeating nausea and vomiting. She ate 15 persimmon fruits for a week befor the onset of thease symptoms. Endoscopic and upper GI X-ray examination, ultrasonography (US), CT scan, and magnetic resonance imaging (MRI) revealed a mass containing big amount of the air component in the jejunum. The cause of the ileus was diagnosed preoperatively as a bezoar formed by persimon fruits. Surgical treatment was performed because the symptoms were unchanged by the conservative therapy for a week. A hen egg sized forein body that was a bezoar was found in the jejunum about 30cm distal from the Treitz's ligament. The bezoar 5×3×3 in size was removed through enterotomy. Postoperative course was uneventful. The patient was discharged from the hospital 14 days after the operation.
Twenty-four cases of the small intestinal obstruction due to bezoars including this case have been reported in the Japanease literature. In all cases bezoars were surgically removed. It is considered that a bezoar ileus can be diagnosed by preoperative examinations of the small intestine. If bezoars drop to the intestine, surgical extirpation is demanded. Considering that the disease has a good prognosis, early diagnosis and early operation are recommended to avoid unnecessary enterectomy.

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A 45-year-old man with giant leiomyosarcoma of the stomach, which showed a pedunculated and cystic development, was successfully treated by surgical operation. The patient complaining of right hypochondralgia was referred to the hospital because of a cystic tumor adjacent to the liver. An extraluminal submucosal tumor, especially leiomyosarcoma, was preoperatively suspected. A total gastrectomy combined with splenectomy and lymph node dissection was performed. In the resected specimen, the tumor growing outside the fornix of the stomach with a large cystic change was present. It was 18×12×10cm in size and 800g in weight and involved darkred fluid (150ml). Histologically, smooth muscle actin staining was positive. The final diagnosis was leiomyosarcoma of the stomach. Giant leiomyosarcoma of the stomach showing a pedunculated development with the maximum diameter of more than 15cm is rare, and only 10 cases including this case have been reported in the Japanese literature.

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A 55-year-old woman was referred to the hospital because of a tumor in the left upper quadrant, and was admitted with a suspicion of intraabdominal malignant tumor. Abdominal CT revealed a well demarcated tumor about 15cm in longer diameter, with cyctic change partially and heterogeneous internally which was adjacent to the stomach. Upper gastrointestinal series and endoscopy revealed an extrinsic compression in the posterior wall of the lower body of the stomach without any mucosal abnormality. The connection between the tumor and gastric wall was unclear by an endoscopic ultrasonography. Abdominal angiography demonstrated feeding vessels of the tumor from the bilateral gastroepiploic arteries and the left gastric artery. Under the diagnosis of exogastric leiomyosarcoma, an excision of the tumor and a partial resection of the stomach and transverse colon were performed. The tumor arose from the gastric body and adhered to the transverse colon. Resected material was 17×16×9cm in size and 1.370g in weight. It was diagnosed histologically as leiomyosarcoma arising from the muscularis propria of the stomach.
In this case, angiography was the most useful to confirm the originating organ of the huge exogastric leiomyosarcoma in all diagnostic methods.

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A 60-year-old man was admitted to our hospital in a state of shock caused by hematemesis. Emergent endoscopic examination revealed a deep ulcer at the greater curvature of the gastric body and a cavity at the bottom of the ulcer. Computed tomography showed a giant cystic lesion reaching the pelvic cavity, and Gastrografin retention in the mass suggested connection with the stomach. Angiography showed that the tumor was supplied by the left gastric artery and was hypervascular with tumor stain. Total gastrectomy, distal pancreatomy and splenectomy were performed. The resected specimen was 29×16cm with giant central necrosis. Histological and immunohistochemical studies showed that it was negative for vimentin and S-100 protein, and positive only for CD 34. Therefore, this tumor was identified as a stromal tumor, uncommitted type.

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A 62-year-old woman was found having type A gastritis and multiple carcinoids on the upper body of stomach on an endoscopic study. The patient was associated with bronchial asthma which initiated at the age 60. Urinary 5-HIAA and blood serotonin levels were normal. Each tumor was minite and it appeared possible to resect endoscopically. However, a total gastrectomy was counducted, because of her backgroung factors of type A gastritis and multiple occurrence, and a character of the disease that the tumor can invade the submucosal layer in an early phase. After the operation her asthma disappeared.
A possibilty can be considered that the tumor in this patient might be positive for anti-histaminic antibody and bronchial asthma might arise from the tumor. And another possibility was thought that, since the tumor was minute, hypergastrinemia with gastritis type A might stimulate minute endocrine cell foci to provoke histamin production, inducing bronchial asthma.
In a review of the Japanese literature as possible as we could, there have been no cases of gastric carcinoid in which associated bronchial asthma disappeared after the operation. This case which was thought valuable is presented here.

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We report a case of gastric cancer with high serum levels of IL-6 and G-CSF. A 76-year-old man was admitted to the hospital presented with high grade fever. Although biochemical tests indicated an inflammatory reaction (WBC 11, 800/mm³, CRP 13.9mg/dl) and consequently infection, no other evidence of infection was odtained upon further clinical examinations. Furthermore, a possibility of autoimmune disease was ruled out based on the laboratory data and physical findings. Endoscopic examination, prompted by occult blood in the stool, identified two separate gastric cancer lesions in the antrum and body of the stomach. The fever was resistant to various antibiotics, but administration of Naproxen at a dose of 600mg per day p.o. was effective. We reasoned that the fever was in some way associated with the gastric cancer. After a distal partial gastrectomy was performed, a dramatic crisis, involving rapid reduction of fever and a simultaneous decrease in the levels of IL-6 and G-CSF, occurred. Immunohistochemical stainings for both IL-6 and G-CSF on surgical specimens were negative. We believe that the high serum IL-6 and G-CSF levels were the result of immunoreaction to gastric cancer rather than direct secretion from the cancer cells.

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Gastric perforation in early gastric cancers is relatively rare and often demands an emergency surgery. We describe a case of early gastric cancer with gastric perforation, in which an elective radical surgery for the gastric cancer was performed following a successful conservative treatment. A 49-year-old woman was seen at the department because of abrupt left hypochondoric pain. A plain abdominal X-ray photograph showed free air under the diaphragm and perforation of the upper gastrointestinal tract was suspected. The patient underwent conservative treatment for the perforation. Fiberscopy revealed an early gastric cancer of type IIc+III at the greater curvature of the fornix 10 days after the conservative treatment for the perforation. Histological diagnosis of biopsy specimens was signet-ring cell carcinoma. She underwent a total gastretomy with D₂ lymphadectomy. The invasion of the cancer was within mucosa histopathologically. The final diagnosis was gastric perforation underlying early gastric cancer. No recurrent disease has been detected as of 1 year and 3 months after the operation. Fifty cases of gastric perforation underlying early gastric cancer seen in the Japanease literature are also reviewed.

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A rare case of jejunal perforation caused by a metastatic tumor from gastric cancer after subtotal gastrectomy is reported. An 82-year-old man had undergone subtotal gastrectomy for advanced cancer, which penetrated serosa without invasion of adjacent structures with no distant metastasis, with conclusive stage IIIb, resulting in conclusive curability B in September 1992. On October 10, 1994, he was admitted with a chief complaint of abdominal pain. A chest roentgenogram showed free air below the right diaphragm. Although an upper GI series did not reveal a perforated lesion, an emergency operation was performed for the diagnosis of panperitonitis due to bowel perforation. There was a perforated lesion in the jejunum located 35cm distal from the Treitz ligament, and two other tumors were located 62cm and 94cm distal from the Treitz ligament. In the mesenterium, metastatic lymph nodes were swollen like beads but no peritoneal dissemination was found. Partial resection of the jejunum including the perforated lesion and the other two tumors was performed. Histologically, all metastatic tumors showed poorly differentiated adenocarcinoma similar to the primary gastric cancer, and the intramural tumor showed mocosal and serosal layer involvement. It was thought that a metastatic tumor of the small intestine from the primary gastric cancer had caused the jejunal perforation.

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A 45-year-old man was found to have a large polyp in the desending colon, and was admitted to the hospital for resection at laparotomy.
Preoperatic endoscopy revealed a submucosal polyp of Yamada type III in the second portion of duodenum. Abdominal CT findings were negative and an endoscopic biopsy did not show malignancy. Surgical resections for these tumors were performed on an one-step approach.
Immunohistochemically NSE, chromogranin A and S-100 protein stainings of this duodenal tumor were positive. Histology revealed gangliocytic paraganglioma and no malignancy. Among duodenal submucosal tumors which are believed to be relatively rare, those arising in the second portion of duodenum are so rare that only 18 cases including ours have been reported in Japan.

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Angiosarcomas of the gastrointestinal tract are extremely rare. A case of angiosarcoma of the duodenum, which was suspected to be metastatic, is reported. The patient, a 73-year-old woman, was admitted to the hospital because of vomiting. Partial resection involving from the duodenum to jejunum was carried out under a diagnosis of duodenal tumor. The resected material showed a low elevated tumor, 6.0×6.0cm in size.
Pathological diagnosis was angiosarcoma. Some papules dark violet in color were found at the forehead and right thigh 20 days after the operation. She had already noticed these lesions, two months before the surgery about the forehead lesion and postoperatively about the right thigh lesion. Excisional biopsy of the papule revealed an angiosarcoma which was the same finding with the duodenal tumor. She was diagnosed with having a pathological fracture of the right femoral bone two years before admission. No histological examination in the fracture site was performed at that time. It was assumed that the angiosarcoma of the duodenum might be metastasis from the right femoral bone or the skin where malignancies occur somewhat more frequently.

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We report a case of ileal duplication with intestinal obstruction in a nursling. A 5-month-old boy was admitted to the hospital because of vomiting. Intestinal obstruction at the end of the ileum was diagnosed based on abdominal ultrasonography and X-ray examination.
Conservative treatments were not effective and an emergency laparotomy was performed. We detected duplication at end of the ileum and resected the ileocecal region and duplication. The duplication led to the normal intestine and resembled Meckel's diverticulum. We diagnosed it as ileal duplication since it was localized on the mesenteric side at the end of the ileum.
Ileal duplication communicating with the normal intesine and of a cystic shape is rare. Our case exhibited a very strong resemblance to Meckel's diverticulum on microscopic and macroscopic examinations. Some bibliographical comments with reference to differentiation of the disease from Meckel's diverticulum are also presented here.

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An 83-year old woman was emeregently admitted to the hospital because of increasing low abdominal intermittent pain and fullness, which had occurred sometimes. There were no chracteristic findings in a plain abdominal X-ray film and ultrasonography. Abdominal CT demonstrated whirling mesentery adjacent to the mass with a calcification placed centrally, and a whirl-like pattern of the small bowel loops. In reviewing sagittal views of MRI, the patient was diagnosed as having a small bowel volvulus. A conservartive therapy was performed because no ischemic nor edematous changes were seen in the intestinal wall. But, whirl-like pattern did not disappear on CT even 10 days after the conservative therapy. and detorsion had to be performed operatively at laparotomy, it was found that the volvulus was twisted by 720° clockwise rotation around the mesenterium about 70cm from Treitz ligament to the ileo-cecal part. Abdominal CT and MRI are considered to be useful in the early diagnosis of small bowel volvulus. In this case, emergently operations were not necessarily needed under no inflammatory signs in the intestinal mucosa, even if a typical whirl-like pattern was demonstrated.

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A 22-year-old woman who underwent an appendectomy with a diagnosis of acute appendicitis developed an intestinal fistula on the 8th postoperative day. Conservative therapy was unsuccessful and a laparotomy was performed on 101st day after the appendectomy. Based on intraoperative findings, the patient was diagnosed as having Crohn disease and underwent an ileotomy. The excised material revealed longitudinal ulcer and cobble stone appearance. Histopathological study also disclosed a granulomatous lesion extending to the full thickness, the definite diagnosis of Crohn disease being made. Repeated histologic study of the resected appendix revealed glanuloma without caseous necrosis, and it was thought that Crohn disease also existed in the appendix.
External intestinal fistula is a rare complication after appendectomy. If such fistula is intractable like in this case, allowances must be made for possible association of Crohn disease in the treatment.

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We experienced a case of intussusception caused by metastasis to the small intestine from lung cancer.
A 68-year-old man who stayed at the hospital after an excision of a metastatic tumor in the thoracic wall associated with the lib presented with abdominal distention and vomiting, There was a previous history of undergoing an excision of the right lower lobe with the rib for a lung cancer 7 months before admission when it was diagnosed as carcinosarcoma histopathologically. Abdominal simple x-ray examination revealed fluid level formation and CT scan showed intussusception of the small intestine. Laparotomy was performed, and intussusception headed by a tumor in the jejunum about 160cm from the Treiz's ligament was found which was resected. The tumor had the maximum diameter of 13cm and was diagnosed as metastasis of pulmonary carcinosarcoma histopathologically. The patient died of carcinomatous pleurisy on the 6th week after the operation.
There have been 35 cases of intussusception due to small bowel metastasis of pulmonary cancer, including this case, as far as we could review. All patients were male and in most patients radical resection was impossible. The prognoses were poor and most patients died within 6 months after eperation for intussusception.

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We experienced a case of intussusception associated with Schonlein-Henoch purpura (SHP) in an adult.
A 69-year-old man was admitted to the hospital because with of abdominal pain. Ultrasonography and CT scan showed multiple concentric signs, and a gastrograffin enema study showed an invagination at the transverse colon. Abdominal pain intensified and general condition worsened, emagency laparotomy was carried out.
During operation an ileo-colic type intussusception was revealed. Ileocecal resection was performed. Edematous bowel provoked the intussusception and the bowel became the top of the intussusception.
Finally, he was diagnosed as SHP by histopathological examination and purpura of lower limbs which appeared after the operation.
Cases having SHP in adults, in which open laparatomy is carried out, are very rare. Only nine cases have been reported in Japan so far.

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A case of preoperatively diagnosed mucinous cystadeno-carcinoma of the appendix is reported with a review of the literature. A 65-year-old man was admitted to the hospital because of right lower abdominal pain and a palpable mass in the same quadrant. Abdominal computed tomography revealed a mass lesion of the caecum, and a colon fiberscopy was performed. A submucosal tumor-like elevated lesion of the appendix orifice was revealed and a biopsy material taken from the epithelia of the appendix orifice revealed mucinous carcinoma with signet-ring cell carcinoma. Right hemicolectomy with D₃ lymph node dissection was carried out. Microscopically it was mucinous cystadeno-carcinoma with signet-ring cell like components, se, n₁, stage III.

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A 61-year-old woman who was pointed out having cholelithiasis at another hospital about 3 years before was admitted to the hospital for operation on July 28. 1997. Endoscopic retragrade cholangio-pancreatography (ERCP) was conducted as preoperative examination on August 8. It revealed cholecystolithiasis as well as an immovable circular filling defect about 2mm in diameter. An operation was performed with diagnoses of cholecystolithiasis and a common bile duct tumor on August 13. After cholecystectomy, hepatoduodenal mesentery was freed to expose the anterior surface of the common bile duct, when a circularly elevated serosa of the bile duct with the size of about 2mm was confirmed. When we observed the common bile duct from mucosal surface by incising it, an about 2mm-sized, grayish white, and circular tumor was noted and was excised. Histopathologically, it was diagnoted as fibroepitherial hyperplasia. Extrahepatic benign tumor is a relatively rare entity. Most of those tumors are found in the lower portion of bile duct (terminal portion of the common bile duct and papillary bile duct), but those tumors arising in the porta hepatis, upper and middle portions of bile duct have been found in only 22 cases including this case in Japan. Some bibliographical comments from the standpoint of analysis of these cases are also presented.

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We experienced a case of FNH presented difficulty in preoperative diagnosis due to its specific morphology. A 57-year-old man visited the department of urology in our hospital for examinations of occult blood in urine. By CT scan, a liver mass was pointed out casually. He was admitted to the hospital for further examinations. Ultrasonography revealed multiple hyperechoic lesions with mosaic pattern in the anterior-inferior segment and in posterior-inferior segment. CT scan showed LDA with calcification. MRI showed a low intensity mass in T1 and a high intensity mass in T2, with internal low intensity in both images. Angiography showed a peripheral enhancement and the colloid scintigraphy showed a defect. Angio-CT graphy showed a peripheral enhancement around the central non-enhanced area. A needle biopsy showed an appearence like HCC. An operation was performed by anterior inferior and posterior inferior segmentectomy. The resected tumor showed a huge fibrous scar and a mass with obscure border around it. Pathological examinations showed no malignant changes and there was a scar and vessels like a hemangioma in the center of the tumor, which indicated that the tumor was FNH with a curious and specific morphology. In many kinds of preoperative image studies, angio CT was most valuable in our case.

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We report a patient with cilliated hepatic forgut who was suspected to have a cystic carcinoma before operation due to a high level of CEA in the hepatic cyst (114,000 ng/ml).
A 55-year-old woman was admitted to the hospital because of pain and numbness of the whole body, and she was pointed out having a hepatic lesion. Abdominal sonography showed a 3.2 × 2.7 cm hypoechoic lesion in the anterior segment of the liver, and there was a matter of liquid with a convex surface in the cyst. Enhanced CT showed a low density area and a slight enhanced lession around the cyst. Since we could not rule out a possibility of cystadenoma and CEA level in the cyst was as high as 114,000 ng/ml, the patient was operated on. Upon lapalotomy, the cyst protruded from the liver two thirds and the intraoperative frozen section diagnosis of the spcimen revealed no malignancy. So an enucleation of the cyst was performed. Histopathologically, the inner surface of cyst wall was covered with cilliated trabecular cells, and the cyst was diagnosed as ciliated hepatic forgut cyst.

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A 65-year-old female and a 63-year-old male underwent distal gastrectomy with lymph node dissection for gastric cancer. To achieve en bloc lymph node dissection according to the Japanese General Rules for Gastric Cancer Study, the left gastric artery was ligated by the usual method. AST, ALT, and LDH increased greatly after the gastrectomy, and a high fever continued for two weeks. A postoperative CT scan showed S 3 segment infarction (Couinaud classification) in the first case and lateral segment infarction in the second case. About one year after surgery, both lesions had complete atrophied. Ligation of an accessory hepatic artery from the left gastric artery can cause liver infarction. An accessory hepatic artery is present in 10_??_30% of persons as a branch of the left gastric artery. However, liver infarction is rare because of the dual blood supply from the hepatic artery and portal vein. Although the mechanism of liver infarction has not been clarified in these cases, we have to keep in mind the possibility of liver infarction in ligation of the left gastric artery.

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A 62 year-old man, who was followed for an increase in ALP and anemia on an ambulant basis, was diagnosed with having an approximately 4cm tumor mass in the liver on CT. ERCP showed an irregularity of the intrahepatic bile duct, and venography showed narrowing of the inferior vena cava (IVC) and development of collateral vessels from the IVC to the azygos vein. We suspected advanced cholangiocellular carcinoma and performed a hepatectomy. The tumor was intraoperatively frozen sectioned and diagnosed as cholangiocellular carcinoma. But on postoperative microscopic examination, fibrosis and lymphocyte infiltration were seen in the tumor, and no malignant cells were detected. Histopathologically the tumor was inflammatory pseudotumor (IPT) of the liver, sclerosing type. Thus this was a case of liver IPT that showed atypical image findings, complicating stenotic IVC, and presented difficulty in diagnosis. There have been no previous reports in the Japanese literature describing a stenotic IVC caused by IPT of the liver. Therefore this case is very unique.

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A 68-year-old woman was found to have a rectal cancer by close examinations including lower gastrointestinal series for CREST syndrome complicated by primary biliary cirrhosis (PBC). Her CREST syndrome was of complete type involving all five symptoms and her PBC was asymptomatic. Histological features on liver biopsy indicated stage 2 according to Scheuer classification. During operation, a 2.0×1.7cm tumor of type 2 at the posterior wall of the rectum Ra was found, and a low anterior resection of the rectum with D 3 lymph node dissection was performed. Histopathologically, the tumor was moderately differentiated adenocarcinoma with the invasion depth of a 2 and in Stage IIIa with metastasis to lymph nodes of group I. Postoperative course was uneventful without any complications such as anastomotic failure. Generally, PBC in patients with CREST syndrome complicated by PBC has a good prognosis and is often asymptomatic with mild hepatic impairment. It is thought that such patients can be candidates for usual operations with dissection and reconstruction, not for more limited surgeries. As far as we could review, there has been no such case as rectal cancer is associated with CREST and PBC. This case which is very uncommon is presented here with some bibliographical comments.

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We report a case of bile duct cystadenocarcinoma of the liver with obstructive jaundice.
An 83-year old man was admitted to the hospital because of jaundice. PTCD was performed for obstructive jaundice. Since a discharge from PTCD tube was mucous substrates and on imaging diagnosis multicystic lesion existed in the right lobe of the liver, we diagnosed the case as bile duct cystadenocarcinoma of the liver. Then an extended right lobectomy and a resection of the extrahepatic bile duct with lymph node dissection were performed. Histologically bile duct cystadenocarcinoma was confirmed. It is speculated that our case might come from malignant change of cystadenoma, because of the existence of the transitional zone of adenoma and cancerous cells. The tumor invaded the hepatic parenchyma, portal vein and billiary tract, but lymph node metastasis was not found. The patient is doing well and there has been no recurrence as of 2 years and 9 months after the surgery. The prognosis of invasive type of bile duct cystadenocarcinoma is relatively poorer than non-invasive type, but we speculate that improvement of the prognosis can be acquired by surgical resection.

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We herein report a case of rehepatectomy for a recurrent hepatic metastasis with adjacency to the remnant main Glisson's sheath.
The patient was a 61-year-old man who underwent a high anterior resection (D2) and an insertion of an intra-hepatic arterial catheter for a rectal carcinoma with hepatic metastases in June, 1994. Miocroscopic findings showed moderately differentiated of ss, n 1 (+), P0, H2, ly1, v0, aw (-), ow (-), ew (-), and in stage IV. adenocarcinoma. Intra-hepatic arterial infusion chemotherapy was performed after the surgery. Extended left lobectomy and a S 7 partial resection were performed about 8 months after the initial surgery. Single hepatic metastatic lesion was detected about 20 months after the initial hepatectomy. Abdominal CT revealed a 7-cm sized hepatic tumor invaded the remnant main Glisson's sheath that suggested a difficulty in resecting it. But we successfully performed rehepatectomy curatively. The postoperative course was uneventful. There have been no signs of recurrence for one year after the rehepatectomy.

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A case of localized inflammatory biliary stenosis which presented difficulty in differentiation from bile duct cancer is reported. A 66-year-old man was admitted to the hospital because he was pointed out elevations in biliary enzymes at blood biochemical analysis. No anemia nor jaundice was noted. No abdominal tumor was palpated. Abdominal CE-CT revealed a dense tumor shadow at the hepatic hilar region. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed a stenosis covering from the left the and right hepatic ducts to common hepatic duct. Abdominal angiography visualized a faint accumulation of a contrast material where corresponded to the tumor. With a diagnosis of bile duct cancer at the hepatic hilar region, a resection of central two segments of liver and a total resection of caudate lobe were performed. Histopathologically, no malignancy was confirmed, and infiltration of inflammatory cells mainly comprizing of lymphocytes and plasmacytes and proliferation of fibroblasts were demonstrated in the vicinity of the bile duct. It was chronic inflammatory stenosis of the dile duct.
It is etiologically suggested that the biliary stenosis in this case might be unlikely caused by secondary sclerotic cholangitis due to bacterial ascending cholangitis, but likely by localixed primary sclerotic cholangitis (PSC), that is a specific type of PSC.

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Only fourteen cases of metastatic carcinoma of the gallbladder have been reported in Japan. We report two additional surgical cases. Case 1: A 62-year-old male whose history included total gastrectomy for gastric carcinoma ten months before admission underwent colectomy because of transverse colon carcinoma. Preoperative ultrasonography and an X-ray CT scan revealed a tumor in the gallbladder, and cholecystectomy was also performed. The histological findings were submucosal proliferation of the same signet-ring cell carcinoma as the previous gastric carcinoma.
Case 2: A 70-year-old female complained of right hypochondral pain and high grade fever. Because ultrasonography demonstrated a solid tumor in the gallbladder, surgical removal was performed. Histological examination showed signet-ring cell proliferation in the proper muscle without mucosal or serosal involvement, and a diagnosis of metastatic carcinoma of the gallbladder was made based on these findings.

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Solid cystic tumor of the pancreas is rarely seen in young males. We report here a solid cystic tumor of the pancreas in a boy who has had no recurrence for more than ten years. A 12-year-old Japanese male was admitted to our hospital in September 1987 complaining of dull upper abdominal pain. On admission, a 6cm tender, elastic hard mass was palpable in the upper abdomen. Routine blood studies yielded values within the normal range, except for moderate elevation of T-bil, GOT, GPT, and ALP. Serum neuron-specific enolase (NSE) was slightly elevated. Ultrasonography and a computed tomography scan revealed an encapsulated, cystic mass with a solid component, 6cm in diameter, located in the head of the pancreas, and a dilated gallbladder and intrahepatic bile duct. Percutaneous transhepatic gallbladder biliary drainage (PTGBD) was performed and cholangiography demonstrated narrowing of the distal common bile duct. Celia angiography revealed a hypovascular mass. Subsequently, pylorus-preserving pancreatico-duodenectomy was performed. The resected tumor measured 7.0×6.5×6.0cm, and was covered with a firm, fibrous capsule. Histological examination revealed that the cyst was lined by pseudopapillary epithelial cells, and that mitoses were rare. Immunohistochemical studies showed immunoreactivity for a α 1-antitrypsin (AAT) and NSE. We determined the tumor to be a solid cystic tumor of the pancreas. The patient has been well for ten years and eight months since surgery, with no signs of recurrence.

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Sweet disease is an inflammatory dermatologic disorder of unknown origin and is characterized by: 1) fever: 2) increase in neutrophile in peripheral blood; 3) painful elevated eruptions commonly occurred in the face, neck and extremities: and infiltration of neutrophile into the dermis. It is known that the disease can be associated with a variety of malignant tumors in a high frequency. Recently we experienced a case of Sweet disease with a cystadenoma of the pancreas.
A 43-year-old woman who had been diagnosed as Sweet disease 5 years before and had gained a remission by administration of steroids developed fever and dermal symptoms in October, 1994, and was diagnosed as having a recurrence of Sweet disease. Abdominal CT revealed a cystic lesion in the body and tail of pancreas. A resection of the body and tail of pancreas was performed. Operative findings included multilocular cyst 9 cm in diameter and a collection of 120ml of mucous in the body and tail of pancreas. Histopathologically mucinous cystadenoma of the pancreas was considered. It is thought that, in making the definite diagnosis of Sweet disease, the exploration of possible tumorous lesions should not be lacked.

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We experienced an operated case of left adrenal ganglioneuroma. An asymptomatic 48-year-old man was detected to have a 10×6cm mass between the spleen and left kidney by ultrasonography during a routine health care examination. Laboratory data were almost normal including sera levels of catecolamines. Needle biopsy under ultrasonography to obtain the definite diagnosis offered a suspicion of pheochromocytoma with class 3. The tumor with left adrenal gland was completely removed. The definite diagnosis of benign ganglioneuroma was made based on pathological findings. Ganglioneuromas present difficulty in preoperative diagnosis even though several examinations including needle biopsy are performed. Further studies to make the definite diagnosis of the disease would be necessary.

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A rare case of metastases to the caudate lobe and vagina from a rectal cancer is described. A 74-year-old woman was admitted to the hospital because of a vaginal tumor and a liver tumor in the S 1 segment. There was a history of undergoing a low anterior resection for a colorectal cancer (mod. diff. adenocarcinoma, ss, stage II) and a left nephrectomy for a renal carcinoma 4 years before admission. On admission CEA level in serum elevated to 41.5ng/ml. Abdominal plain CT demonstrated a 4.0×3.0cm tumor with extensive calcification in the S 1 segment of the liver. Contrast CT showed faint enhancement. The tumor was revealed as low intensity on T 1-weighted MRI and high intensity on T 2-weighted MRI. Ultrasonography guided needle biopsy for the liver tumor revealed adenocarcinoma. With the preoperative diagnosis of metastases to the caudate lobe and vagina from the rectal cancer, an operation was performed. The liver tumor was localized in the left caudate lobe, and the tumor did not infiltrate into the inferior vena cava and hepatic vein. A partial resection of the caudate lobe for the liver tumor and a local resection of the vaginal wall for the vaginal tumor were performed. Histologically metastases of the rectal cancer to the caudate lobe and vagina was confirmed.

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A case of primary peritoneal serous papillary adenocarcinoma is reported. A 63-year-old woman who underwent herniorrhaphy for a left inguinal hernia on February 16 1989, was found to have several hard nodules in the hernia sac and peritoneal cavity. Pathologic examination of these nodules revealed metastatic adenocarcinoma and the serum level of CA 125 was considerablly elevated. The patient had a ileocecal resection and a left oophrectomy for ileocecal and Douglas tumors on June 23, 1989. But at this time, primary site of the tumor was not determined by clinical and pathologic examinations.
The patient was followed by serum level of CA 125 and periodic CT scan. On May 23 1991, the patient underwent posterior pelvic exentration and splenectomy for Douglas tumor and metastasis of the spleen. By pathologic examination of twice surgical specimens and clinical findings of this patient, the tumor was finally diagnosed as primary peritoneal serous papillary adenocarcinoma.
No postoperative chemotherapy was given and the patient died of respiratory failure caused by pleuritis carcinomatosa on November 15, 1995.

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Diverticulm of the appendix is a relatively rate entity. Recently we experienced a case of diverticulum of the appendix which was diagnosed preoperatively and a case of generalized peritonitis due to perforation of appendiceal diverticulum. These two cases with some bibliographical comments are presented here.
Patient 1, a 62-year-old man was referred to the hospital because of increasing right hypocondralgia which moved gradually from a right lower abdominal pain which appeared about one week before and resisted to treatment at another hostital. On admission, Various examinations under a suspicion of cholelithiasis revealed no stones. Barium enema study showed multiple diverticula covering from the ileocecal region to ascending colon, and diverticulum of the appendix. Laparotomy was performed with a diagnosis of diverticulosis of the large intestiine amd appendix.
Patient 2, a 38-year old man was seen at the hospital because of abdominal pain. There were a tenderness entire the abdomen and strong muscular defense. Abdominal ultrasonography revealed ascites in the Douglas's pouch. An emergency operation was performed with a diagnosis of diverticulosis of the large intestine and perforation of appendicitis. The excised appendix revealed having several diverticula, one diverticulum of which perforated. Appendiceal diverticulitis presents difficulty in differentiation from acute appendicitis through the clinical course. However, careful observation of the clinical course is important by entertining a fact that perforation can occur at a high rate even in asymptomatic patients.

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We present a 66 year-old man with recurrent mesothelial cyst arising from the periumbimulcal peritoneum after a laparoscopic excision. The symptom was postprandial umbilical discomfort. A monoloculated abdominal cyst was detected on CT. The cyst was located under the umbilicus without any enteric or urinary tract connection. Aspiration cytology of the fluid was negative. containing scanty mesothelial cells. The cyst was continuous with the umbilical fibrous tissue, resulting in the incomplete excision through the laparoscopic route. The lining epithelium was immunohistochermically positive for cytokeratin. negative for Factor VIII and vimentin. Thus the histological diagnosis was a mesothelial cyst occurring from periumbilical peritoneum. Since the cystic mass grew larger, it was resected under laparotomy 16 months after the laparoscopic surgery.
The monoluculated mesothelial cyst is a kind of retention cyst. The lararoscopic excision may be accepted as the first trial prior to laparotomy. When the correct diagnosis can be entabilshed, the injection of a sclerosing agent may be one of choice prior to surgery as is effective in multicystic mesothelioma. We think that the laparoscopic excision should be recommended to the patient after he or she accepts our detailed explanation about a possible local recurrence with the procedure.

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A 66-year-old woman with advanced breast cancer (T3 N3 M1) who had been under treatment with chemotherapy and oral medroxyprogenterone acetate (MPA) 1, 200mg/kg complained of a pain of the right lower extremity on the 57 th day after administration of MPA. Angiography offered a diagnosis of acute arterial embolism of the lower extremity and a thromboembolectomy was performed. After the operation, the dose of MPA was reduced to 600mg/kg and warfarin and an antiplatelet were combinedly used for a prophylactic purpose. Two months later, however, acute arterial embolism of the lower extremity occurred again. Thromboembolectomy and grafting were performed. Oral administration of MPA was discontinued and the patient was under observation while warfarin and the antiplatelet were consistently administered. The patient has been free from recurrence for about 2 years.
In this case both oral doses of 1, 200mg/kg and 600mg/kg of MPA induced throombosis and prophylactic oral medication for thrombosis was iniffective. It is suggested that, in the use of MPA, we must remain alert for occurrence of thrombosis irrespective of dose level and discontinue immediately after onset of the disease is noticed.

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