Day surgery was performed under local anesthesia on 88 cases of relatively early breast cancer. Evaluation was therefore made on the safety, operative results, economy, and level of patient's satisfaction of day surgery to elucidate the present status and problematic points of day surgery for breast cancer. Postoperative complications were observed in 5 patients (5.7%) and one patient underwent a repeated surgery due to postoperative bleeding. On the premise that the unit has prompt ability to cope with emergency, day surgery can be performed. The postoperative results were satisfactory when indications for day surgery were strictly observed. In terms of economic aspect, the economic effect was found to be great, because by decreasing the average period of hospitalization, the medical expenses borne by the individual patient could be saved to be about 1/7 of those involved in hospitalization. However, though the level of patient's satisfaction was high, few patients highly evaluated that reduction of their medical expenses. Despite the decrease in revenue of the hospital, the burden on physicians has on the contrary increased. For the promotion of day surgery, every effort should be made to lesser these unbalances and discrepancies.

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Air leakage from the operation field is a distressing complication in emphysematous lung surgery. It may cause pneumonia, respiratory dysfunction and other grave results. We examined air leakage in 53 emphyse-matous cases in which Gelatin-Resorcin-Formaldehyde (GRF) glue was applied at surgery. Two cases out of 53 patients required re-operation, though the one was caused air leak from new formed bulla which was not applied the glue at first operation. Another case required re-operation just after the first operation because GRF glue bound to the lung tissue unsuccessfully. In as meny as 14 cases re-application of GRF glue was needed during operation. Although we must be careful to keep the glue warm untill application and to bind it with formaldehyde, GRF glue was effective in the treatment of patients with emphysematous lungs. It appears to be valuable in preventing postoperative air leakage and grave complications.

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To define the indication for intrathoracic anastomosis (ITA) in the surgery for esophagial cancer, location of tumor, risk factors of mediastinal recurrence and anastomotic leakage were examined in 68 cases of esophageal carcinoma reconstructed with a gastric tube (GT) between 1993 and 1998. These cases were classified into three groups, namely, IT (group) reconstructed with ITA (n=53), MR (group) reconstructed with an-tethoracic anastomosis (ATA) to avoid GT obstruction due to mediastinal recurrence (n=9), and AL (group) reconstructed with ATA to prepare for probable anastomotic leakage (n=6). We found that in tumors locating less than 24cm (the distance to oral wedge of tumor measured endoscopically), careful consideration must be given to the indication for ITA, because the resection margins were comparatively limited. Most of MR patients showed tumor invasion into adjacent structures (T4) and had extremely poor prognosis. Although several T4 cases were included in IT group, the obstruction of GT was not observed. Therefore, ITA should be preferably indicated to T4 cases because of its functional advantages especially in the early postoperative period. Anastomotic leakage occurred in one of IT group, and five of AL group. Patients with severe liver disfunction as well as liver disfunction associated with diabetes mellitus should be still excluded from the candidates for ITA.

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Roux-en-Y reconstruction is one of the most common procedures after total gastrectomy. Although many patients complain of various symptoms, worsen by taking meals, such as abdominal pain, discomfort, fullness and vomit. These suggest motor disorders in such patients. Manometry was performed to investigate the motility of Roux limb in eight patients in whom total gastrectomy had been performed. The duration of phase III increased in three out of five patients in whom Migrating Motor Complexes were presented. In two patients, phase III was absent and in another abnormal phasic contractions were observed during the fasting recordings. In six patients, the fasting pattern was converted to the fed pattern by meal as controls. The phase III like contractions persisted during the postprandeal period in two cases. The frequency and Motiltiy Index during the postprandeal activities decreased in three and increased in two. Motility abnormalities of the Roux limb were recognized in seven out of eight patients. These findings suggest that motility disorders of the Roux limb play important roles in various abdominal symptoms after total gastrectomy.

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This study was made to compare the clinicopathological findings of 46 patients over 80 years of age (Group 80') operated on for gastric cancer with those of 137 patients aged between 60 and 69 (Group 60'), and to clarify the factors that influence the postoperative complications in Group 80'. Although there were no differences in location of lesion, macroscopic type and histological type between both groups, the incidence of early gastric cancer in Group 80' was lower than in Group 60'. Although there were no differences in the extent of gastrectomy, degree of lymphnode dissection and incidence of combined resection of other organs in Group 80' were lower than in Group 60'. Preoperative complications such as circulatory and neurological dis-eases were more commonly seen in Group 80'. As to postoperative complications, pancreatic juice leakage and anastomotic leakage occurred more frequently in Group 60'. On the other hand, respiratory and neurological complications were more common in Group 80'. In Group 80', the postoperative mortality rate was significantly higher in those whose operation time was longer than 3 hours, those who underwent total gastrectomy or proximal gastrectomy, and those who underwent combined resection of other organs. The cumulative survival rate in Group 80' was significantly lower than that in Group 60', but there was no difference in the relative survival rate.

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Purpose: The purpose of this study is to estimate the accetability of the introduction of day surgery for inguinal hernia.
Subjects: A series of 36 suitable patients underwent day surgery for inguinal hernia from December 1, 1997 to September 30, 1998 were subjected to the study. The male-to-female ratio was 31:5, with a mean age of 52 years. There were 31 external inguinal hernias and five internal inguinal hernias. Mesh plug method was adopted as a surgical procedure and it was performed under epidural anesthesia.
Results: 1) Droping out: None withdrew from the day surgery. 2) As a post operative early complication, the eight patients had hematoma that resolved spontaneously within 7 days. In a few patients wounds became reddish and swelling but did not cause infection. Seroma beneath the wound was observed in only one patient. However it disappeared by a needle aspiration. 3) The quetionnaires for patient's satisfaction with day surgery: “satisfied” or “content” was answered by 97% of the patients. It was ensured that day surgery for inguinal hernia was acceptable.
Conculsion: With respects to the low incidence of complication and patient's acceptance, the availability of the day surgery for inguinal hernia is confirmed.

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We discuss the clinical features of 12 cases of resected colon cancer associated with primary cancer of the uterus. In a recent 17-year period, 517 patients with colon cancer were operated at our department; and 45 patients were associated with extracolonic cancer including 12 patients with uterus cancer which occurred most frequently in female cases. Ten of 12 cases of colon cancer associated with uterus cancer have family history of cancer. In two of three patients who had colon cancer after radiation for uterus cancer, the colon cancer occurred within the field of radiation. One case revealed pathological features similar to radiation induced intestinal damage.
In cases of uterus cancer with family history of cancer or history of irradiation, strict surveillance is considered to be required against second malignancies of the colon.

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A 45-year-old woman was seen at the hospital because of a left breast tumor. A 3×2cm elastic hard, sharply demarcated, and well movable tumor with smooth surface was confirmed in the C area of the left breast. With mammography and ultrasonography, breast cancer was suspected and a biopsy was performed. Histopathological examination and immunohistologic stainings revealed malignant lymphoma, diffuse, large cell and T-cell type. A modified radical mastectomy (Patey method) was performed and one positive node was confirmed in the axillary lymph nodes. About 2.5 months after the operation, the patient experienced recurrence in the mediastinum and after a temporary remission with CHOP-Bleo regimen, she died of leukemic change one year and 7 months later.
This case was thought to be lymphoma type of ATL because of positive response to anti-HTLV-1 antibody. But most cases of T-cell malignant lymphoma of the breast are anti-HTLV-1 antibody positive and have a poor prognosis. These cases might be preferable to be considered as lymphoma type ATL which formed a breast tumor rather than T cell malignant lymphoma arisen in the breast, and hence potent chemotherapy would be mandatary.

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Patients with breast cancer who had contralateral tumor after breast conservative therapy were subjected to a study of the frequency, clinical features and therapeutic methods of the contralateral breast cancer. Between 1983 and 1997, a series of 275 patients with breast cancer were treated conservatively in Mitsui Memorial Hospital, and eight contralateral breast cancers occurred. The cumulative probability of contralateral breast cancer was 2.6% at 5 years. This made no difference from the cumulative rate (2.5%) of local recurrence in the ipsilateral breast. Contralateral breast cancers were noticed by self examination 57.1 months after breast conservative therapy. According to the TNM classification, seven patients had a stage I tumor and one had a stage II tumor. Of the seven patients six were treated also conservatively for contralateral breast cancer. Five-year overall survival rate was 85.7%. We should pay attention to not only local recurrence but also contralateral breast cancer after breast conservativetherapy. Occurrence of complications and cosmetic benefits of bilateral breast conservative therapy are great compared with unilateral breast conservative therapy.

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A 17-year-old woman underwent a general exploration because she came from a family of familial pheo-chromocytoma, when a chest CT scan revealed a throracic aortic aneurysm. The patient was admitted to the hospital for operation. A difference of about 30mmHg in systolic blood pressure between the upper and lower extremities was noted, and left subclavian vascular murmur was heard. Aortic fluoroscopy revealed a stricture of the aorta and a cystic mass 45mm in maximum diameter in the distal arch proximal to coarctation. At operation, the left subclavian artery and distal arch of the aorta were replacel with artificial vessels. Histopathologically, there were defects of of elastic fiber laver in the tunica intima and media in the aortic aneurysmic wall; and aortric wall which was seemingly normal involved necrotic change in the tunica media. These find-ings were similar to those of Marfan syndrome.
There have been only 22 cases of aortic aneurysm associated with coarctation of the aorta including our case as far as we could review. Of these 22 cases, the aneurysm in the center of the coarctation is rarely noted and such cases acconut for about 18% (four cases). It is suggested that some congenital anomaly in the devel-opment might underlie in these cases.

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A 70-year-old woman was referred to the hospital because of a mass on the right side of the neck. She had a 3-cm smooth, elastic soft mass in the right side of the neck. A CT scan dected a 4×3cm tumor with calcification in the right lobe of the thyroid. A 4×2cm smooth and solid mass was accidently found behind the thyroid tumor at the right side of the trachea during the operation. She underwent a right lobectomy with modified neck lymph node dissection and etipation of the pamatracheal tumor preserving the right recurrent laryngeal nerve. Histological examination revealed follicular carcinoma of the thyroid and concominant paratracheal neurinoma. Her postoperative course has been uneventful without any evidence of recurrence and hoarseness. This case of thyroid cancer with paratracheal neurinoma is very rare. So far only six cases have been reported in this country.

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This paper presents successfully recected case of lymph nodes metastasis to the hilus of the lung after resection for a hepatocellular carcinoma in a 63-year-old man. The patient had undergone a posterior segmen-tectomy for a hepatocellular carcinoma in the S7 in October 1993, and then a partial hepatectomy and a partial excision of the lung for metastases to the remnant liver and right upper lobe of the lung 2 years after the initial operation. In August, 1996, a chest CT scan revealed lymph node swelling at the hilum of the lung about 2cm in size which became larger to about 3cm in size 3 months later. It was diagnosed as hilar lymph node metastasis Chemotherapy with mitoxantoron was started in January, 1997, and his clinical course was observed. Chest CT scan in May visualized the enlarged tumor to about 4cm in size but no other lesions. The patient was though to be candidate for operation. Angiography also revealed no invasions into the aorta. On June 25, an excision of the right upper lobe of lung with lymph nodes dissection was performed under a right thoracotomy. The patient was discharged from the hospital 15 days after the operation, and is strictly fol-lowed on an ambulant basis. There have been no signs of recurrence on blood examination and imaging methods as of one year after the operation.

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Granular cell tumor (GCT) of the esophagus has been considered to be a relativety rare disease, but the patients with GCT have been increasingly reported with a recent progress of endoscopic diagnosis. GCTs of the esophagus are rare in the upper region and common in the middle to lower region.
HistoHistopathologically, immunohistostaining of GCTs reveal the existence of S-100 protein. GCT is en-doscopically resectable in many cases. The authors experienced a case of GCT of the cervical esophagus. A 47-year-old woman was endoscopically proved to have an elevated lesion in the cervical esophagus. It was found to be a submucosal tumor of oval in shape and 40mm in the maximum diameter, and surgically resected. The resected material was proved to be a 40×30×25mm solid tumor and the cut section presented yellow to white in color. Histopathological diagnosis was GCT. It is believed that primary GCT of the esophagus occurs rarely in the cervical region.

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A case of adenocarcinoma of the Barrett esophagus after a gastrectomy for gastric ulcer is reported. An 81-year-old man was admitted to the hospital because of an epigastralgia. There was a previous history of undergoing distal gastrectomy with Billroth I reconstruction for gastric ulcer at the age of 45. Upper gastrointestinal endoscopy revealed an alteration of the esophageal mucosa that seemed to be Barrett epithelium. An ele-vated lesion was shown at the 30cm distant from the incisor, and biopsy specimen showed findings of esophageal cancer. Total esophagectomy, lymph nodes dissection of thoracic and abdominal region, and retrosternal right colic reconstruction were performed. Pathologically, an elevated lesion was 2.7×1.8cm in size and mucosal change of white colorization covered 4.7cm in length. Histologically, the elevated lesion was diagnosed as well differentiated adenocarcinoma, because atypical glandular epithelium forming papillary proliferation was comfirmed in the lesion. He has been well without any signs of recurrence for 3.5 year after the operation.

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A 49-year-old man was seen at the hospital because he was pointed out having a gastric lesion at a physical examination. A submucosal tumor 1cm in diameter located paracardia was observed with endoscopy. There was no connection between the tumor and the proper muscle layer because the tumor had high mobility within the submucosal layer. We tried an endosopic resection for the gastric lesion 2 weeks later. After the tumor resection, the proper muscle layer was clearly observed in the resected surface, and no bleeding nor perforation was seen. And a pathological study documented us that the tumor was removed with wrapped capsule and without any proper muscle layer component. So we thought that the proper muscule layer had been slightly damaged by the endoscopic procedure. However, he was seen at the hospital again because of perforation of the stomach about 7 hours passed after the endoscope procedure. It is not able to rule out the possibility of delayed perforation of the stomach after the endoscopic procedure, nevertheless the damage of the proper muscle layer would be slight and no immediate perforation would be observed. It is very important to close a mucosal defect by endoscopic procedure with crips or any other goods.

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We present a patient with extragastric pedunculated gastric leiomyoma together with some bibliographical discussion.
A 74-year-old woman had jaundice, with a lesion in the duodenal papilla. A gastric tumor was detected on abdominal computed tomography, but there were no abnormal findings in other examinations. Gastric submucosal tumor was diagnosed, and surgery was performed to remove this tumor and the duodenal papillary lesion. A tumor growing extramurally in a pedunculated manner was observed in the greater curvature-side on the anterior wall of the gastric antrum. Since this tumor was within the range covered by pancreaticoduo-denectomy for a duodenal papillary lesion, it was also removed in lump. The tumor was 3.0×2.5×1.5cm in size, lobular and tuberous, grayish black, elastic and soft, and fragile. Histopathologically, it was a myoepithe-lial tumor without malignant findings, and leiomyoma was diagnosed. The proper muscular tunic occupied by the tumor was growing in a pedunculated manner, and extragastric pedunculated gastric leiomyoma was sus-pected. This leiomyoma is extremely rare, and so far only 23 cases have been reported in Japan.

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An 86-year-old woman underwent a pylorus preserving gastrectomy (PPG) for early gastric cancer at the lesser curvature. Since the 10th postoperative day, the patient complained of nausea and vomiting. Upper gastrointestinal roentgenography revealed a remarkably dilated residual stomach and delayed gastric emptying. Oral erythromycin (600mg/day) was given to the patient for two weeks. This medication improved the symptoms rapidly, and the patient started eating on the 31st postoperative day. Erythromycin is effective not only as an antibiotic but also as an agonist to cell receptors of motilin that enhances gastric emptying. We conclude that erythromycin is effective for delayed gastric emptying after PPG.

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A 69-year-old man was seen at the department because of epigastralgia on the left side and vomiting. Admixture of an ulcerative lesion and a torose lesion of the body of the stomach were observed by an endoscopy. The diagnosis of malignant lymphoma (diffuse large B cell type) was made based on a biopsy. Instead of preoperative chemotherapy as one of the choices of treatment a lapalotomy was performed with the aim of avoiding the risk of perforation of the ulcer legion. Direct invasion of the tumor into the pancreas, spleen and transverse mesocolon and widespread invasion around the left part of the diaphragm were observed. Therefore, the lesion was unresectable. The postoperative course was satisfactory, and THP-COP therapy was started. But headaches occurred at 38 postoperative day, and then blurred vision and dextral deviation of the right eye also occurred. Depression of the optic nerve by a tumor was observed in the ocular orbit by computerized tomography of the head; thus, metachoronous metastasis of the malignant gastric lymphoma to the intraorbital tissue was diagnosed. Steroid and radiation therapy at 26 Gy were administered. The symptoms were alleviated and also the tumors disappeared as observed by computerized tomography. Although intraorbital metastasis of malignant lymphoma has rarely been reported, we have experienced this case which showed a remarkable response to radiation therapy at the metastatic focus. When we consult the case of malignant gastric lymphoma, it is necessary to consider the metachronous onset in the general organs.

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We report a case of cancer arising in the reconstructed gastric tube 16 years after a radical operation for esopageal cancer in a 68-year-old man.
There was a previous history of undergoing a subtotal esophagectomy with retrosternal reconstruction using gastric tube for an esophegeal cancer at the age of 52. This time when 16 years had elapsed after the operation, he was admitted to the hospital because of abdominal pain and nausea due to adhesive ileus. A tumor in the reconstructed gastric tube was pointed out by a gastric endoscopy. The tumor was diagnosed as moderately differentiated adenocarcinoma on biopsy specimens and we performed an operation. Gastric cancers arising in the reconstructed gastric tube are sometimes found in the advanced stages and resultantly have poor prognosis. It is suggested that periodical endoscopic examinations for more than 10 years after radical esophgectomy are important to make the early diagnosis of cancer of the gastric tube.

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Situs inversus viscerum occurs in one of every 5, 000 to 10, 000 births, and it is accompanied by some anomalies frequently. A 64-year-old man was admitted to the hospital because of epigastric pain. Gastrointestinal fiberscopy revealed a convergence of stomach fold, and a diagnosis of adenocarcinoma was made on biopsy. Abdominal ultrasonography also revealed cholelithasis. The diagnosis of situs inversus viscerum had been made in another hospital previously. No associated malformation in the large vessels of the heart was noted preoperatively. Total gastrectomy with lymph node dissection and cholecystectomy with intraoperatively cholangiography were carried out. Postoperative course was uneventful. There have been no signs of recurrence, as of one year after the operation. We report our case together with a review of the literature.

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A patient with congenital duodenal atresia, who underwent a duodenojejunostomy 21 years before needed a reoperation for postoperative anastomotic stenosis and intractable ulcer. Recently the standard surgical technique for duodenal atresia has been changed from duodenojejunostomy to duodenoduodenostomy because the latter is more physiologic operative procedure with a lower rate of complication. In this case, a postoperative blood examination revealed Helicobacter Pylori infection. It is thought that the operative procedure of duodenojejunostomy as well as Helicobacter Pylori infection might contribute to cause such deep ulcers at the gastric pylorus and anastomotic site. Therefore preoperative examination for Helicobacter Pylori infection and appropriate treatments would be necessary for cases like this case.

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Leiomyosarcomas of the duodenum are relatively rare and only some 330 cases have been reported in the Japanese literature. Among these duodenal leiomyosarcomas, tumors originating from the duodenal bulb represent only 10%. We experienced two cases of leiomyosarcoma of the duodenal bulb in which a segmental resection of the duodenal bulb was successfully perfomed. Patient 1, an 83-year-old woman, was found to have a submucosal tumor of the duodenal bulb during examination for marked anemia. Leiomyosarcoma of the duodenum was suspected and she underwent a segmental resection of the duodenum. Patient 2, a 69-year-old woman who had been followed up for a submucoal tumor in the duodenal buld for 9 years, was finally diagnosed as having a duodenal leiomyosarcoma. She underwent a segmental resection of the duodenum. The first patient is still alive 52 months after the operation and the other patient is also recurrence-free 13 months after the surgery. It is thought that segmental resection of the duodenum is appropriate treatment for leiomyosarcoma of the duodenal bulb.

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This paper presents a case of non Hogdikin's lymphoma of the duodenum which was preoperatively diag-nosed. A 66-year-old woman was admitted to the hospital for the evaluation of a duodenal tumor, which was incidentally detected by routine examination of GI upper series. Duodenography demonstrated a giant whole circumferential elevated lesion with crater in the upper duodenal flexure. Endoscopic examination of the duodenum showed the whitish irregular elevated lesion. Biopsy specimens taken from the lesion revealed diffuse growth of medium sized atypical lymphoid cells, suspected non Hodgikin's lymphoma (NHL). Ultrasonography and CT scan showed a thickness of the duodenal wall which was suspected of invasion to the pancreas. Pancreatico-duodenectomy with lymphnodes dissection and reconstruction by means of Child II method was performed. Histologically the tumor was diagnosed as NHL (diffuse medium sized B cell type) spread involving the subserosa. Adjuvant chemotherapy (VEPA) was performed postoperatively. No recurrence has oc-cured 12 months after the operation. Primary malignant lymphoma of the duodenum is relatively rare and there have been only 57 cases (including our case) diagnosed before operation.

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A 65-year-old man was seen at the hospital because of abdominal distension. There was a previous history of undergoing a distal gastrectomy with Billroth I method for perforation of gastric ulcer 14 years ago. Upper gastrointestinal series revealed gastrectasis of the remnant stomach. Endoscopic study revealed a cilli-ary elevated lesion at the anal side of the anastomosed site. Biopsy disclosed group III.
Because of papillary proliferation of lacunar epithelium on a histologic study, it was diagnosed as stricture due to an adenoma arisen in the duodenum at anal side of anastomosed site. Upon laparotomy, a hen's egg sized tumor was present in the descending portion of duodenum which caused duodenal intussusception. Intraoperative frozen section diagnosis revealed papillary adenocarcinoma, and a pancreatoduodenectomy was performed. The definite diagnosis was carcinoma of the papilla Vater. Abdominal CT performed on the 15th month after the operation demonstrated hepatic metastasis.
This operated case of papillary carcinoma showing an extremely rare growth pattern that manifested no jaundice but caused duodenal intussusception is reported.

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A 64-year-old woman was seen at the hospital because of epigastric discomfort and an abdominal mass, and was diagnosed as having a duodenal cancer on radiologic and endoscopic examinations. An alpha fetopro-tein (AFP) level of 480ng/ml was found on admission. An operation was performed under a diagnosis of AFP-producing duodenal cancer. At laparotomy, it was found that the main tumors developed on the bulbus of the duodenum with swelling of the periaortic lymph nodes. Pancreato-duodenectomy and dissection of D 4 were performed according to the general rules for gastric cancer study in Japan. The resected tumor was a Borrmann type 3 invading the head of the pancreas. The histological diagnosis was moderately differentiated tubular adenocarcinoma not composed of carcinoma cells with clear cytoplasm as in hepatoid carcinoma. Pro-duction of AFP in the tumor was demonstrated by an immunohistochemical technique (streptavidin biotin method).
AFP-producing tumors have been increasingly reported, but cases of primary duodenal cancer producing AFP are very rare. Here, we describe a case of AFP-producing duodenal cancer evidenced by immunohis-tochemical staining with some bibliographical comments.

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Perioperative fluctuations in pulmonary function and nutritional state in a patient on home oxygen therapy (HOT) who had malneutrished for advanced gastric carcinoma which intussuscepted into the duodenum with ball valve syndrome are reported.
An 83-year-old man, whose pulmonary function (FEV 1.0%) and undernourishment were rapidly deteriorating, was admitted to the hospital because of dyspnea, vomiting, and weight loss. After a distal gastrectomy, body weight, FEV 1.0%, and prognostic nutritional index were prominently inproved up to the state before HOT induction. In patients with latent chronic occlusive disease of the lung or those on HOT, determinant factors on the pulmonary function might be perioperative changes in nutritional state from preoperative malnutritional state due to associated malignancy to postoperative improved nutritional state along with improved feeding.

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A case of mesenteric venous thrombosis causing extensive small bowel necrosis during treatment for cerebral hemorrhage. A 72-year-old woman, who was admitted to the department of internal medicine in our hospital for treatment of intracerebral hemorrhage since October 1997, was referred to the department because of anal bleeding, a significant decrease in blood pressure, abdominal tenderness, and muscle gurding on February 6, 1998. Echo-guided puncture of peritoneal fluid confirmed bloody ascites. Emargency operation was performed under a diagnosis of perforation of the small intestine. There existed the necrotic ileum proximal 60cm and distal 160cm from the ileocaecal valve was resected and mesenteric venous thrombosis. About 130cm of the intestine was resected in determining intestinal viability safety included the necrotized bowel. Anticoagulant therapy, as not given, because of intracerebral hemorrhage. There have been no signs of recurrence as of nine months after the operation. If bowel ischemia occurs, the superior mesenteric vein is commonly involved and the affected bowel becomes edematous and necrotic. So anal bleeding suggests severe edema and necrosis of the intestine, and in this case the prognosis is believed to be poor. We must keep in mind the condition as a probable differential diagnosis for patients manifesting acute abdomen with vascular disease.

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A 24-year-old man was seen at the hospital because of right lower abdominal pain. With a diagnosis of acute appendicitis and pan-peritonitis, the patient was operated on. During the surgery, a perforated point 0.5cm in size was found in the anti-mesenteric side of the jejunum, 180cm from the Treitz's ligament. On the mesenteric side, the greater omentum and Douglas' pouch with multiple white nodules were found. Pathologically we diagnosed this case as leiomyosarcoma of the jejunum and peritoneal dissemination. No adjuvant chemotherapy was given. He survived for only 4 months after the operation. Leiomyosarcoma of the jejunum with perforation is rare. A total of 19 cases of the disease which have been reported in a recent one decade from 1988 to 1998 are reviewed.

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A case of endometriosis of the appendix and ileum is reported.
A 42-year-old woman was seen at the hospital because of dizziness on October 13, 1997. Because mild anemia was noted in the laboratory data and occult blood reaction was positive, she was admitted for further examination. No abnormal physical condition of her abdomen was observed. A barium enema study revealed the absence of the flow of contrast medium to the appendix and a deformation of the ileocecum. A colonoscopic examination revealed an elevated lesion like submucosal tumor with a smooth surface at the appendical opening. From these findings, an ileocecal resection and a partial resection of the ileum were performed on November 22 with a diagnosis of a submucosal tumor of the cecum. During operation a tumor measuring 2cm in maximal diameter was found at the root of the appendix and adhesion of the ileum was observed. Macroscopically the solid tumor, measuring 1.5×1.8cm in diameter was present at the root of the appendix. Histopathological diagnosis was endometriosis of the appendix and ileum.

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A case of incarcerated inguinal hernia in which a perforated appendicitis with purulent peritonitis is reported. A 69-year-old man presented with a painful mass in the right side of groin, which was not associated with nausea and vomiting. White blood cell count and C-reactive protein were moderately elevated. Abdominal X-ray films showed mild distention of the small intestine but no evidence of obstruction. Abdominal ultrasonography above the inguinal bulge showed fluid retention and an appendix-like structure protruding from the right internal inguinal ring. A diagnosis of right incarcerated inguinal hernia was made and an emergency operation was performed. The hernia sac was tense and thickened with inflammation. The sac was opened to reveal an inflamed appendix adhered to the sac. An appendectomy was performed easily after enlarging the internal inguinal ring with a primary repair of the inguinal hernia. The patient had an uneventful postoperative course. This condition is so rare that we clinicians find a great deal of difficulty in making accurate diag-nosis preoperatively. However, present illness of tender inguinal hernia without ileus symptoms and abdominal ultrasonography above the inguinal bulge should be helpful for the accurate preoperative diagnosis.

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An 81-year-old woman was admitted to the hospital because of abdominal pain and nausea, and diagnosed as having intestinal obstruction. There was no previous history of undergoing laparotomy. Conservative ther-apy could not be curative, and retrocecal hernia was diagnosed by abdominal CT scan. Laparotomy was per-formed under epidural anesthesia. At surgery, a well-defined 1.5cm opening was found, and distal ileum was incarcerated through this opening. We incised the retroperitoneum from the opening, and extracted the incar-cerated ileum. Intestinal resection was not required. Paracecal hernia is so rare that only 34 cases have been reported in the Japanese literature. Furthermore, accurate preoperative diagnosis is very difficult and has been successfully made in only four cases. We report this case with a review of the literature.

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A 49-year-old man admitted to hospital because of anal bleeding in 1994, when no bleeding point identified by gastrointestinal series. The patient was followed on an ambulant batis after conservative hemostasis. In December 1995, the patient was admitted again to the hospital because of anal bleeding. Angiography revealed no abnormalities and his clinical course was conservatively observed under blood transfusion. Angiography was performed again because tha anal bleeding became worse. When 1, 000 units of heparin was administered through the superior mesenteric artery, an extravasation was confirmed from an abnormal vessel branched from periphery of the iliac artery. Hemorrhage from the ileum was diagnosed and an emergency laparotomy was performed. During operation, a diverticulum in the ileum 60cm oral from the terminal ileum was found, and a partial excision of the ileum including the same portion was carried out. On the resected material, three ulcers were present in the diverticulum. Histopathologically, there was ectopic gastric mucosa at the tip of the diverticulum and Meckel's diverticulum was diagnosed.
Complications of Meckel's diverticulum include hemorrhage, intestinal obstruction, and diverticulitis. Hemorrhage commonly occurs in children or younger, and rarely in adults. It may be necessary to entertain the possible diagnosis of adult Meckel's diverticulum for small bowel bleeding of unknown origin.

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A case of hemorrhagic diverticulum of the descending colon in which the bleeding site was confirmed by an endoscopy with a successful resection in reported.
A 46-year-old man was seen at the hospital because of anal bleeding without probable provoking cause on June 1, 1998. Colonoscopic fiber revealed a diverticulum in the vicinity of the splenic flexure of the colon as well as an exposed vessel in the base of the diverticulum which might be bleeding site. After admission, conservative therapy was continued, but thereafter intermittent anal bleeding persisted. On June 3, massive anal bleeding occurred again and the patient fell into pre-shock sate, an emergency operation being performed. When the ascending colon was moved, a diverticulun 1cm in diameter was noted on the contralateral colonic mesentery several centimeters anal from the splenic flexure. Intraoperative endoscopy disclosed bleeing from the same portion. A local excision of the diverticulum was performed. Histopathologically, a part showing intimal hypertrophy and organization infthe submucosal artery at the diverticulum's base was observed, and there was fiber change associated with lymphocytes and eoshinofilic infiltration surrounding the vessel. And a broken part in the vascular wall was confirmed that was thought to be bleeding site. Postoperative course was uneventful. There has been no re-bleeding up to now.

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Basaloid cell carcinoma of the anal canal in a malignant tumor, which is similar to a basal cell carcinoma of the skin histopathologically. In a review of the Japasese literature, 35 cases of basaloid cell carcinomas of the anal canal including our case have been reported so far. We present a case of basaloid cell carcinoma of the anal canal, together with some biliographical comments. A 64-year-old woman was admitted to our hospital because of fresh anal bleeding and a right inguinal tumor. A tumor with irregular surface was recognized between the anal canal and anal skin, and bilateral inguinal lymph nodes were swelling. A barium enema examination revealed an irregular mass in the anal canal. Squamous cell carcinoma was recognized by the biopsy specimens of the tumor. Abdominosacral rectal amputation and lymph node dissection were performed. The tumor was 2 type mass and 4×3cm in diameter, between the anal canal and anal skin. The histopathological diagnosis was basaloid cell carcinoma (T2 N2) in stage IIIb. Adjuvant chemotherapy was performed. There have been no signs of recurrence as of one year after the operation.

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A 67 and a 17-year-old women were diagnosed as having a cystic lesion at the tail of the pancreas by ultrasonography, CT, magnetic resonance imaging, endoscopic retrograde pancreatography, and angiography. Since a possibility of malignant disease could not be ruled out, a laparotomy was performed. Both lesions had no communication with the spleen. Histopathologic ally, both cysts in them were lined with stratified squamous epithelium, were not associated with appendages of the skin, and had splenic tissues at the lateral. So a diagnosis of epidermoid cyst arising in the accessory spleen at the pancreatic tail was made.
The spleen is the organ originated in mesoderm and lacks epithelial component that make cyst formation difficult, especially that in the accessory spleen. There have been few cases of epidermoid cyst of accessory spleen at the pancreatic tail that might pose problems of differential diagnosis. Here our recent experiences with two such cases are presented with a review of the literature. As for the origin of the lining cell of the cysts, it is inferred to be aberration of epithelium of the pancreatic duct to the accessory spleen at the pancreatic tail, because tissue of the pancreatic duct was confirmed in the pericystic fiberous tissue and communication with cystic epithelium was suggested.

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Myelolipoma of the adrenal gland is a rare non-functioning benign tumor and is known to be often associated with diabetes mellitus (DM), hypertension, obesity and endocrine disorders. We experienced a case of myelolipoma of the left adrenal gland associated with subclinical Cushing syndrome, which improved after surgical resection of the tumor.
A 64-year-old woman who had been under medical treatment for hypertension for 24 years and for DM for 1 year, was suspected to have a left adrenal tumor by computed tomography (CT). She was admitted to the hospital on April 9, 1998.
Examination revealed an 8×9cm tumor of the left adrenal gland. Fasting blood sugar was 288mg/dl and serum cortisol level was 78.4μg/ml, suggesting subclinical Cushing syndrmome. An extirpation of the left ad-renal tumor was performed on May 12. Histological diagnosis of the resected specimen was adrenal myelol-ipoma. After the operation, blood sugar was normalized to be 101mg/dl, and obesity and hypertension were relieved. She was discharged uneventfully, without any medication. In a review of the literature, there have been some cases of the disease associated with diabetes mellitus, but this is the first case suggesting the correlation between myelolipoma and associated subclinical Cushing syndrome.

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In a recent 5-year period, we experienced four patients with intraperitoneal spontaneous rupture of the bladder associated with radiation cystitis. All patients were female (5670 years old) and had received a pan-hysterectomy and postoperative radiation therapy (45 Gy in two cases and unknown in another two cases) for uterine cancer. The time internals after irradiation until the onset of spontaneous rupture ranged from 8 to 15 years. Laparotomy was performed in three cases, percutaneous drainage in one case, and a catheter was placed in the bladder in all cases.
In a review of the Japanese literature, 15 cases of intraperitoneal spontaneous rupture of the bladder associated with radiation cystitis, including our cases, have been reported. Some bibliographical notes are also presented.

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A 2-year and 11-month-old boy complaining of severe abdominal pain and fever was referred to the hospial with a diagnosis of peritonitis. When he was first seen, the abdomen was distended and a hard tumor 6cm in size with tenderness was palpated on the right abdomen near the umbilicus.
Laboratory data showed elevated serum AFP (3, 246ng/ml) and anemia. An abdominal computed tomography revealed a solid mass with ascites, measuring 6×4cm in size. Under the diagnosis of spontaneous rupture of the abdominal tumor, an emergency operation was performed. There were massive bleeding and necrotic tissue into the abdominal cavity due to the ruptured tumor. The tumor was considered to originate from the urachus. The tumor was easily removed. Histologically it was typical yolk sac tumor of urachus origin. Postoperative chemotherapy with PVB was given. A complete cure was attained in this patient and it has been maintained as of one year after the operation. We report a rare case of spontaneously ruptured primary urachal yolk sac tumor.

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A 48-year-old woman was admitted to the hospital because of a painless tumor in the right inguinal region. There was a previous history of undergoing a simple hysterectomy for uterine leiomyoma eight years before admission. Physical examinations revealed a right inguinal tumor, which was hard, fixed, and 2×2cm in size. Ultrasonography revealed the right inguinal tumor to be a low echoic lesion, and a tentative diagnosis was a swollen lymph node. Fine needle aspiration cytology of the tumor showed few lymphoid cells and some epithelial cells with a little nuclear atypia, suggesting metastatic adenocarcinoma. Barium enema study, trans-vaginal ultrasonography and computed tomography of the pelvis did not show any primary cancer lesions. To make the precise diagnosis, an excisional biopsy of the right inguinal tumor was performed. The tumor was strongly adherent to adjacent tissues. Histological examination revealed endometrial glands and stroma surrounded with fibrous tissues, without any findings of malignancy. From these findings, the tumor was diag-nosed as inguinal endometriosis. The inguinal region is a rare site for endometriosis that accounts for about 0.4% of all sites involved with endometriosis. This very rare case with some bibliographical comments are presented.

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Four cases of nontraumatic hematoma of the abdominal wall are presented with a review of the litera-ture.
All four patients had precipitating causes such as bleeding tendency, cough, oral intake of anticoagulant, and exercise for the abdominal muscle. They were treated by removal of hematoma and drainage. In three out of four cases, the definite diagnosis was attained by preoperative imaging procedures including ultra-sonography (US) and CT, but removal of hematoma and drainage were performed due to an increasing ten-dency of the hematoma and severe abdominal pain. The remaining one patient whose definite diagnosis could not be made preoperatively was operated on for the purpose of diagnosis.
In the treatment of abdominal hematoma, conservative therapy is principally employed. For that, the cor-rect diagnosis is mandatary. In order to attain the definite diagnosis of the disease, we must keep it in mind and can rely upon US and CT findings which are very valuable. Especially, CT is capable of offering subjec-tive evaluation, and hence CT should be actively used for cases in which US reveals only uncertain findings.

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Today various kinds of musculocutaneus flaps have been introduced and used for defects after resection of malignant tumors which invade the abdominal wall. We experienced two cases of abdominal malignant tu-mor which invaded their abdominal wall, including a neuroendocrine carcinoma arisen from the transverse colon in case 1 and a mucinous adenocarcinoma right above the pubic bone in case 2. After the resection of the tumor, we used the tensor fascia lata (TFL) muscle and musculocutaneus flaps as muscle pedicle flaps. Though one patient of them died due to a rapid progression of the original malignant disease 3 months after the surgery, both patients had no trouble with their abdominal wall such as infection or hernia.
So we think that the TEL flaps can be used safely and fairly easily to reconstruct the defect of the ab-dominal wall even for general surgeons. And the TFL flap method would be recommended for cases of ab-dominal reconstruction with a high risk of infection or with a probable retardation of cure.

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We report a case of lymphangioma of the lesser omentum which could not be differentiated from a pancreatic cyst despite an analysis by ultrasound, computed tomography, or magnetic resonance imaging. A 71-year-old man who had been treated for cholelithiasis at the hospital was pointed out having an intraabdominal cyst. The imaging analysis revealed a unilocular cystic tumor about 5cm inmaximum diamater among the liver, stomach and pancreas. The correct diagnosis was established via laparotomy and subsequent pathologic interpretation, which revealed lymphangioma of the lesser omentum. Lymphagioma of the lesser omentum is a rare condition. There have been only 26 cases including ours in the Japanese leterature. Total excision is the only effective method of treating this benign tumor.

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A case of generalized peritonitis occurred eight months after a pylorus preserving pancreatoduodenectomy was experienced. The patient developed anastomotic leakage at the anastomosed site between the pan-creas and jejunum after the initial operation. The leakage was cured conservatively, but some mechanism of causing stricture at the anastomosed site might occur in the course of cure. A slight dilatation of the pancreatic duct in the remnant pancreas and segmental low density area in the parenchyma were confirmed. Local-ized pancreatitis due to impaired defluxion of pancreatic juice was thought. The patient presented with abrupt onset of abdominal pain during observation of clinical course after the operation on ambulant basis. An emergency operation was performed with a diagnosis of generalized peritonitis, when a great volume of purulent fluid retention with high level of amylase was found in the abdomen. Pronounced inflammation was noted in the vicinity of the remnant pancreatic tail on the posterior surface of the remnant stomach. We diagnosed the case as generalized peritonitis due to inflammation of the remnant pancreas. After the operation, a contaminated exudate with high amylase level which was not pure pancreatic juice was continuously drained from an indwelt drain on the gastric posterior surface, that offered a suspicion of breakdown of the pancreatic duct. It is thought that anastomotic leakage caused impaired defluxion of pancreatic juice to induce the inflammatory breakdown of the pancreatic duct, with an aid of increasing internal pressure of the intestine due to adhesion as well.

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A 19-year-old woman was admitted to the hospital because of abdominal distension and an intra-abdominal cystic tumor. She had several hemangiomas in the right side of the body and a history of undergo-ing a resection of cervical spinal hemangioma at the age of 13 years old, when she was diagnosed as having Cobb syndrome. On admission, numerous angiomas covering from the right jaw to right thorasic part were seen, and a soft tumor extending to under the umbilicus was palpated. Abdominal ultrasonography, CT scan, and magnetic resonance imaging revealed a multilocular cystic tumor 14cm in diameter adjacent to the right kidney. It was diagnosed as retroperitoneal giant lymphangioma. At operation, a sharply demarcated, yellowish white cystic tumor was present which was successfully removed after communication with retroperitoneal lymphatic vessel under the left renal vein was confirmed. Histopathological diagnosis was lymphangioma. Cobb syndrome consists of a vascular skin nevus associated with an angioma in spinal cord and only about 40 cases were reported in the literature. This case had hemangiomas in other than the same derma-tomes as spinal hemangioma, and the abdominal lymphangioma might be considered as a finding of Cobb syn-drome.

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Incarcerated appendix in an inguinal hernia is an uncommon condition. We experienced a rare case of an abscess of the abdominal wall which was caused by an incarcerated appendix in an inguinal hernia.
A 71-year-old woman was admitted to the hospital because of a right inguinal swelling and purulent discharge. She also had von Recklinghausen's disease. Abdominal CT revealed a high density area with the air in the abdominal wall extending to the peritoneal cavity. We performed an emergency operation on a suspicion of the right incarcerated inguinal hernia with abdominal wall abscess. A drainage for the abscess was per-formed but no cause of the abscess formation could be identified. An incarcerated appendix in the right inguinal fossa was found out by a laparotomy. Appendectomy, hernia repair and peritoneal drainage were carried out. After the operation, a recurrent abscess was drainaged. She was discharged on the fifth postoperative month.
It was difficult to preoperatively diagnose this rare case. In the treatment of incarcerated inguinal hernia without ileus symptoms, we must entertain a possibility that the content of hernia may be the appendix.

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We present a surgically treated case of bilateral common femoral arterial aneurysms (CFAAs). Bilateral and simulfaneous occurrence of CFAA is rare. The patient was a 64-year-old man. He has suffered from angina pectoris, diabetes mellitus and hypertension since he was 52 years old. When he was 58 years old, he had a ruptured abdominal aortic aneurysm which was surgically treated with a bifurcated knitted Dacron graft. And then he suffered from myocardial infarction at the age of 64, when a coronary angiography with an additional angiography revealed bilateral CFAAs. As he recovered from the myocardial infarction, he was transferred to our institute for surgical intervention of the aneurysmal disease. These aneurysms were both of spindle shape and 22×25×30mm in size on the right and 32×35×40mm on the left. Upon surgery, the aneurysms were incised and replaced between the common femoral artery and superficial femoral artery, and between the graft and the profunda femoral artery, with knitted Dacron grafts, bilaterally. He recovered without any complications. Postoperative iv-DSA showed smooth blood flow through the grafts without any stenosis.

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A 21-year-old woman was seen at the hospital because of lower abdominal pain. A soft mass was palpable with the fingertip on the posterior wall of the rectum. CT, magnetic resonance imaging and transrectal ultrasonographic examination showed a presacral cystic tumor. The tumor was resected by using a sacral approach. Histological examination showed that the tumor wall was made of squamous epithelium without any adnexal structure, and hence it was diagnosed as epidermoid cyst.
In a review of the Japanese literature, 31 cases of presacral epidermoid cyst are seen. Complete excision of those presacral cysts is advised because of possible complications including infection and malignancy.

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A 74-year-old woman was seen at the hospital because of appetite loss and general fatigue. Upper gastrointestinal series revealed that the stomach covering almost whole length was axially twisted and protruded into the mediastinum. CT and Magnetic resonace imaging (MRI) revealed prolapsing small intestine and transverse colon into the mediastinum and cholelithiasis as well Barium enema study visualized abnormal movable ascending and descending colon. With a diagnosis of upside down stomach, mesenterium commune, umbilical hernia and cholelithiasis, the patient was operated on. Operative procedure included Nisseen fun-doplication+pyloroplasty, appendectomy, repair of umbilical hernia, and cholecystectoy.
In this country, upside down stomach is so rare that 10 cases including our cases have been reported so far, and all cases exepting our case were not associated with mesenterium commune and umbilical hernia. It is inferred that there must be congenital problem such as poor coaptation or elasticity of the connective tissue in this case.

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Hemorrhagic diathesis due to viper bite is caused by disseminated intravascular coagulation (DIC) in most cases. We experinced a case of viper bite, with that different clinical course from previous reports. A 71-year-old man who was bitten at the left 4th and 5th fingers was brought into the hospital by ambulance. During a tension decrease incision for severe swelling of bitten region. he suddenly had massive hematemesis. Multiple hemorrhagic erosion at the upper esophagus to upper stomach was ensured by an emergency endoscopic examination of the upper digestive tract. The platelet count decreased markedly to 0.5× 10⁴/mm³, but another coagulation examination was normal. The platelete count was recovered to 14×10⁴/mm³, on the next day. Consciousness loss lasted for 3 days after viper bite. These symptoms were improved by administration of antivenin and nosotropic therapy and the patient was discharged from the hospital 20 days after viper bite. Viper bite can follow such atypical course as this case did and careful attension is necessary.

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We report a case of multiple primary tumors pointed out during 11 years after operation for breast cancer in a 57-year-old woman.
The patient had been operated on for Lt. breast cancer at the age of 46, gastric cancer at 47, and brain tumor at 51. Thereafter she had been followed until 57 years of age, when a chest X-ray film showed an abnormal lung shadow. With a diagnossis of metastatic lung cancer, the tumor was resected. It was found that the lung tumor was originated from neither breast nor stomach cancer, but from cancer of the sigmoid colon which newly occured.
In obserbation of clinical course after surgery for a malignancy, we must always entertain probable ma-lignancies in other organs.

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