It is reported that, according to various studies, the rate of people that have been infected with Strongyloides in Okinawa is 12 percent among those over 40 years of age and 6 percent among those over 20 years. Strongyloides infection can frequently progress to the hyperinfection syndrome, with a resultant high morbidity rate following surgery. In order to prevent postoperative infection we studied risk factors associated with Strongyloides infection by comparing 49 demestic cases of Strongyloides infection with 149 controls with stool samples negative for parasites. The risk factors of infection were correlated with old age (over 60 years), male sex, digestive malignancies and HTLV-1 infection. These risk factors might participate in the initial infection or persistence of infection. A thorough knowledge about these risk factors may lead to earlier recognition of this dangerous but treatable disease.

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We quantified telomerase activities in thyroid disease in an attempt to determine its clinical significance. Telomerase activity was detected in 19 of 45 (42%) cancer lesions, No association was found between the positivity of telomerase and clinical features. However, the levels of telomerase activity were significantly higher in elderly patients and in lesions with large diameters, lymph node metastasis, capsular invasion, advanced stages by quantification analysis. Telomerase activity was also detected in some nontumoral specimens from cancer patients and several benign diseases with lymphoid infiltration, but not in any follicular adenoma and normal thyroid tissues. In conclusion, high telomerase activity might indicate advanced stage or poorer prognosis in patients with thyroid cancer. Thus, quantification of the telomerase activity will be applied clinically to support preoperative diagnosis. Moreover, it might be interesting to investigate telomerase reactivation in the process of carcinogenesis in the thyroid gland.

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In a series of 709 patients with breast cancer operated on at the department in a recent three decades from 1968 to 1998, there were 33(4.7%) patients with primary bilateral breast cancer. Eleven patients(1.6%) had synchronous and 22 patients(3.1%) had metachronous bilateral breast cancers. These 33 patients were clinicopathologically compared with those having unilateral breast cancer.
Average age at operation for the first cancer in metachronous patients was 42.9 years, that was significant younger than others. Patients with bilateral breast cancer had history of familial cancer or other multiple primary cancers in a high frequency. In metachronous patients 80% of them found the second cancer by themselves, which 27% of synchronous patients found it by themselves, with a significant difference. The 5-year survival rates were 86.9%, 88.9% and 76.7% in unilateral cases, synchronous cases and metachronous cases, respectively. Therefore, we have recognized the importance of early discovery and treatment of contralateral breast cancer.

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During the past 10 years from 1988 to 1997, 68 lesions in 68 patients were treated by local resection for early gastric cancers at Akita Red Cross Hospital. The criteria for local resection were 1) intramucosal gastric carcinoma (m-carcinoma) within 30mm in size and having a clear tumor margin, and 2) submucosal gastric carcinoma (sm-carcinoma) within 20mm in size and having an intolerance for major surgery. Local resection was performed to all layer resection (AR) and submucosectomy (SM). Of 51 patients, 42 with m-carcinoma and 9 with sm-carcinoma were treated by AR. Forty-five of them were treated successfully by AR, and the rest underwent additional intervention. Of 17 patients, 14 with m-carcinoma and 3 with sm-carcinoma were treated successfully by SM. There were no recurrences of lymph node and distant metastases. The 5-year survival rate was 100% except for other causes of death, and no cancer deaths. These local resections of early gastric cancers were thought to be effective in improving the postoperative QOL of patients without loss of survival benefit.

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It is relatively easy to detect early gastric cancer in the vicinity of the pylorous ring or invading the duodenum by a use of endoscopy, but the satisfactory precise precise diagnosis of the depth and extent of tumor invasion has not been established as yet. This study was designed to elucidate some problems in the diagnosing ability of gastric endoscopy and EUS for such early gastric cancers. Subjects were 26 patients undergone gastrectomy for early gastric caner in a recent 5-year period, consisting of 21 patients whose center of the lesion situated within 2cm from the pylorous ring and five patients whose tumors invaded the duodenum. The correct diagnosing rate of depth of tumor invasion by gastric endoscopy was 69.2•(18/26) in all patients. On the other hand, it was 57.1•(12/21) in 21 patients who underwent EUS. There was a tendency for EUS to give a read-out of the depth which was deeper than actual depth. Furthermore, early gastric cancer invading the duodenum present difficulty in determining the extent by gastric endoscopy especially on the duodenal side of the lesion. It is probably better that doctors use high frequency EUS equipments.

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Risk factors of poor prognosis in nontraumatic large bowel perforation were investigated in 68 patients who received surgical treatment in our hospital during April 1979 and December 1998. Their mean age was 69 years. There were 33 males and 35 females, and a death rate was 14.7%. Types of perforation induced were intra-abdominal free perforation (n=34), intramesenteric perforation (n=19), sealed perforation (n=12), and retroperitoneal perforation (n=3). Eight of the 10 patients who developed shock before surgery were unable to be saved, and pre-operative shock was highly related to prognosis. Factors which were significantly related to poor prognosis were WBC_??_6, 000 before surgery, and occurrence of large bowel perforation on the area lateral to the mesentery. Surgical methods were divided into reconstructive (n=11) or non-reconstructive (n=57), and there was no significant difference on prognosis according to the methods. Prognosis of the patients with intra-abdominal free perforation and who unavoidably received non-reconstructive method was significantly poor. Overall, there was no correlation between prognosis and age, body temperature, presence/absence of intra-abdominal gas, time between the occurrence of perforation and surgery, causative diseases, position of perforation, diameter of perforation, or volume of lavage. In order to achieve a better prognosis, intensive management of shock, which is started prior to surgery, would be an important theme in future studies.

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A 77-year-old woman was admitted to our hospital because of a right preauricular mass, which was palpated as a 3.5×4.0cm sized tumor. This tumor had gradually enlarged since 7 years ago when a contralateral adenolymphomama (Warthin's tumor) was removed. Ultrasonography revealed a wellcircumscribed and low echoic tumor. CT scan showed a homogenously enhanced tumor with a lowdensity area inside. The tumor was extirpated under a diagnosis of parotid tumor, which was histologically lympoma of mucosa-associated lympoid tissue (MALToma) arising from a history of chronic parotitis. The patient remains well with no evidence of recurrence 4 years after the removal. Bilateral parotid tumors of diffrent histology are extremely rare, and this is the 8th such case in the literature, and the first to combine adenolymphoma and MALToma.

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To evaluate surgical outcomes in primary hyperparathyroidism (PHP), we introduced quick intraoperative measurements of parathyroid hormone (I-PTH). This paper deals with two patients with PHP who had a previous history of undergoing thyroidectomy and in whom I-PTH measurement was especially helpful. Patient 1 had undergone a subtotal thyroidectomy for Graves'disease. This time the intraoperative measurement indicated a sufficiently decreased I-PTH after a resection of the enlarged parathyroid gland which was recognized preoperatively, and hence the operation was completed. Patient 2 had received a left thyroid lobectomy for a thyroid papillary cancer. There was no gland enlargement in the area where the lesion had been suggested by a preoperative localization study. Based on the intraoperative measurements of I-PTH in the bilateral internal jugular veins, an ectopic parathyroid tumor was successfully identified and removed.

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A 69-year-old woman was admitted to our hospital because of a tumor in her right breast measuring 8.0×8.0cm without enlargement of axillary lymph nodes. A homogeneous tumor shadow was seen on the mammogram and an ultrasonogram showed a mosaic pattern, thickened walls and high back echo of the tumor. Chest roentgenogram revealed pleural effusion in the right lung and a CT of the chest showed destruction of the ribs. Since malignancy was present, partial mastectomy of the right breast including resection of the 6th and 7th ribs was performed. The pathology of the biopsy reported tuberculosis, based on the observation of epithelioid granulation, Langhans giant cells and tuberculous necrotic tissues. Oral antituberculosis regimen with isonicotinic acid hydrazide, rifanpicin and etambtol was started. It is important that physicians bear in mind the possible presence of tuberculosis when checking for breast tumors.

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A 27-year-old woman noticed a left breast tumor in June 1998 and visited our hospital on July 1, 1998. A 2.0×2.0cm left breast mass in the A area was palpable and suggestive of fibroadenoma. Three months later, the tumor had grown, and was obtained by aspiration cytology biopsy, determined class III therefore, excisional biopsy was performed to rule out malignancy on December 14, 1998. The tumor was surrounded by thin capsule and consisted of relatively dense small round tubules. The connective tissue was scarce, however, mature collagen fibers were present. The tubules did not exhibit the complete two-cell layer pattern, and attenuated myoepithelium was seen. Also, mitosis and lactating changes were not observed, and the background mammary gland was normal. The pathological diagnosis was tubular adenoma. Cases of tubular adenoma of the breast are very rare and only 36 cases including ours have been reported in Japan. Since tubular adenoma of the breast is a benign disease, excisional biopsy is adequate for curative therapy, and no recurrence has been reported.

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A case of spindle cell carcinoma of the breast with liver metastasis is reported. A 48-year-old woman had noticed a left breast tumor in June 1998. She was admitted to the hospital because of rapid enlargement of the tumor on September 4, 1998. A 18×13×10cm tumor was palpated at the entire left breast, that had na ulcerative region at the B area. The tumor was diagnosed as a malignant tumor by a needle biopsy, but the histological type did not demonstrated. Preoperative study revealed a solitary tumor at the lateral segment of the liver. Modified radical mastectomy was performed with a preoperative diagnosis of malignant breast tumor with liver metastasis on September 21, 1998. Postoperative histopathological examination revealed spindle cell carcinoma with axillaly lymph node metastasis. No systemic metastasis without liver metastasis was revealed, and so a lateral segmental resection of the liver was performed. A histopathological examination revealed a metastatic liver tumor of the breast cancer. The patient received hormonotherapy and chemotherapy postoperatively and she has been from recurrence, as of 8 months after the operation.

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A 70-year-old woman was seen at the hospital because of an egg-sized mass at dorsal side of contralateral upper limb. There was previous history of undergoing a radical mastectomy for left breast cancer in the lower median quadrant 18 years before admission. The histological type was papillotubular adenocarcinoma (T2b N1b M0, Stage II) and she had remained free of disease except for left arm edema. After admission the mass was originally considered a malignant tumor derived from soft tissue because of its long interval after the initial surgery and rareness of recurrence of breast cancer on the site.
A histological examination on the resected tumor revealed that it was rare distant recurrence of breast cancer and no other recurrence signs were detected by further clinical examination. Late phase recurrence of breast cancer occurs mainly at local skin or lymph nodes, but rarely at distant subcutaneous tissue. We report an uncommon case of late phase recurrence of breast cancer. It is worth while paying much attention to longer and more precise follow-up observation on bresat cancer patients.

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[Case 1] An 80-year-old woman with anterior chest skin metastasis from breast cancer 22 years following a radical mastectomy was treated with a combination of 5'-DFUR and tamoxifen since March 1994. But the tumor increased progressively. So tamoxifen was converted into medroxyprogesterone acetate (MPA) from July 1996, and soon the tumor started to decrease, and almost disappeared 6 month later. [Case 2] A 68-year-old woman underwent a modified radical mastectomy for a breast cancer in 1966. Twenty-eight years after the operation, in March 1994, she noticed an axillar and a supraclavicular lymph node swelling. Operation resulted in an incomplete resection. Combined chemotherapy with cyclophosphamide, epirubicin and 5-FU had to be withdrawn because of its side effect. And a right pulmonary metastasis was discovered. These metastatic lesions did not respond to a treatment with 5'-DFUR, but an additional administration of MPA from August 19961ed to complete disappearance of the residual supraclavicular lymph node and pulmonary metastases. No tumor relapse has been observed until May 1999. Late recurrence of the breast cancer with more than twenty years of latent period is very rare, and the usefulness of MPA regimen for such cases is suggested.

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We report a case of emergency coronary artery bypass grafting via a left anterior small thoracotomy (LAST) without cardiopulmonary bypass for unstable angina with systemic lupus erythematosus (SLE). A 72-year-old woman was admitted for severe angina pectoris. She had an 18 year-history of steroid treatment for SLE. Coronary angiography revealed the causative lesion in the left anterior descending artery (LAD) seg. 6, just proximal with 95% stenosis. We were apprehensive about catheter intervention for this stenotic lesion due to the high risk possibile left main trunk injury, and chose coronary artery bypass grafting. We selected LAST as the surgical procedure without cardiopulmonary bypass, in consideration of several factors: she had bilateral lower limb vascular disease, other organs'conditions were unknown, her advanced age and her lack of daily activity. The left internal thoracic artery (LITA) was anastomosed to the LAD seg. 8 under beating heart conditions. The operation was without complication, the post-operative course was satisfactory, and supplemental steroid administration was not required. Postoperative angiography showed the LITA graft had good patency with no stenosis. In conclusion LAST procedure without cardiopulmonary bypass can be considered a useful technique for treating a patient with SLE on an emergency basis.

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A 92-year-old man was admitted to the hospital because of an incidentally diagnosed abdominal aortic aneurysm more than 8cm in size by abdominal CT scan and magnetic resonance imaging during the invertigation of cholecystolithiasis. Following the question of his condition, a myocardial scintigram was performed, which showed an ischemic chnge in the anterior cardiac wall. After coronary angiography, he underwent percutaseous transluminal coronary angioplasty with stent insertion in the left anterior desending coronary artery. Thereafter abdominal aortic aneurysm repair and cholecystecotmy were performed. The postoperative course was uneventful.
Presently in Japan, we have an increasing older population in whom abdominal aortic aneurysm repair is needed. This case report indicates that even a 92-year-old man, who was the oldest case in previously reported Japanese, can be operated on successfully after the treatment of risk factors, and in consideration of the mean life expectancy, patient's activities daily and informed consent of his family.

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We have experienced a case of leiomyosarcoma of the inferior vena cava (IVC). A 45-year-old woman was admitted to the hospital because of abdominal pain localized in the right lateral region. An 8cm-sized tumor was palpable in the right upper quadrant. Abdominal ultrasonography, CT scan and magnetic resonance imaging showed the tumor in the IVC. Venography revealed a 10cm-sized filling defect of contrast a material. The IVC was obstructed and there were collateral vessels. Primary tumor of the IVC was diagnosed. The tumor, IVC and right kidney were resected en bloc. The stump of IVC was closed with the patch of Gore-Tex. The stump of iliac vein was sutured directly. Histologic analysis revealed leiomyosarcoma of the IVC. Liver metastasis was recognized 4 months after the operation and local reccurence occurred 8 months after the operation. She died 18 months after the operation.

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We encountered a case of desmoid tumor of the chest wall. A 38-year-old woman was admitted to our hospital because of a left chest-wall tumor. The tumor was hard and fixed on the left chest wall and 10×12cm in diameter. CT scan and MR Imaging demonstrated the tumor was a solid mass with expansive growth involving the left ribs. Needle biopsy showed growth of collagen fibers without nuclear pleomorphism, suggestive of a desmoid tumor. The tumor was removed together with the left mammary gland and chest wall, however, the nipple and skin of left breast were conservative. Reconstruction of the left breast and chest wall were performed using Marlex mesh and a rectus abdominis musculocutaneous flap. The histological examination confirmed that the tumor was desmoid tumor, but without infiltration of the ribs and pleura. The cosmetic outcome has been excellent with no recurrence 10 months after operation. We reviewed 52 cases of desmoid tumor of the chest wall in Japan. Our review shows that wide resection has a good prognosis compared with simple resection.

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A 46-year-old man was admitted to the hospital because of a precordial tumor with neurotic symptoms of the left upper limb. Fibrous dysplasia of bone was diagnosed by ultrasonography-guided needle biopsy. However, chest CT scan, magnetic resonance imaging, bone scintigraphy, and angiography offered a suspicion of osteosarcoma of the rib. With the preoperative diagnosis, resections of the 2nd and 3rd ribs and extirpation of the tumor were performed. A thoracoplasty using a myocutaneous flap made of latissimus dorsi muscle with the gth rib was performed for a defect in the thoracic wall after the extirpation. The extirpated material was diagnosed as well differentiated costal osteosarcoma arisen in the rib histopathologically. Postoperative course was uneventful and the patient was discharged from the hospital on 22nd postoperative day.
Thoracoplasty using myocutaneous flap made of latssimus dorsi muscle with rib may be a valuable thoracoplastic procedure in terms of benefits in cosmetic plastiology such as avoidance of deformity of the thorax and in respiration-aiding strategy for postoperative pulmonary dysfunction such as mediastinal flutter.

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We experienced a case of traumatic right diaphragmatic hernia presenting with abrupt onset of ileus symtoms.
A 78-year-old man was seen at the hospital because of adrupt onset of abdominal pain. About 10 months before, he had been treated for fracture of the femur due to a traffic accident at the department of orthopedics in our hospital, when no thoracoabdominal trauma was seen and no abnormalities were confirmed on chest simple x-ray test. On admission, an elevation of the right diaphragm and air under it which might be colic air were noted. And the strangulated transverse colon due to enema was observed. With a diagnosis of obstructive phase of traumatic diaphragmatic hernia, an emergent operation was performed. On laparotomy, a defect 3cm in diameter was found at the central tendon of the right diaphragm. Moreover, some part of the transverse colon and greater omentum had moved into cavity without hernia sac. Prolapsed organs were reduced into the abdominal cavity and the ruptured diaphragm was directly closed without resection of the colon. In this case, it is etiologically thought that increased pressure in the abdominal cavity by constipation and enema made the interval phase for 10 months into the obstructive phase.

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Omental hiatus hernia is a relatively rare entity of all intraabdominal hernias. This time we experienced an extremely rare case of the disease associated with hiatus herina of the esophagus.
An 82-year-old woman was seen at the hospital because of upper abdominal pain, and was admitted with a diagnosis of intestinal obstruction. A fluoroscopic study through a long intestinal tube revealed the incarcerated jejunum in a hiatus hernia of the esophagus. The patient was operated on. Upon laparotomy, the jejunum which prolapsed from an omental hiatus hernia along with the fundus of the stomach were incarcerated in the hiatus hernia of the esophagus. No intestinal necrosis was noted, and so a closure of the omental hernia, plication sutures for the esophageal hernia, and posterior fixation of the gastric fundus were performed.
In treating intestinal obstruction in elderly patients without previous history of laparotomy, if malignant diseases can be ruled out and conservative treatments are ineffective, laparotomy is a consideration by entertaining a possibility of internal hernia.

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Gastric metastases to other organs are often unresectable, and even resectable caases have to have an extremely poor prognosis. This time we experienced a long-term survivor for 7 years and 2 months after the initial operation for gastric cancer; during of which multiple metachronous extraperitoneal metastases were successfully treated by operations, radiation and chemotherapy.
The patient was a 56-year-old woman who had undergone a total gastrectomy with D2 lymph nodes dissection for advanced gastric cancer in July, 1990. Four years later, the patient was admitted to our department because of an umbilical tumor and was diagnosed as having an umbilical metastasis, socalled Sister Mary Joseph's nodule, from a previously-treated gastric cancer by fine needle aspiration cytology. She underwent an extirpation of the umbilical tumor.
Three months later she noticed a swollen lymph node in the right axilla and several nodules suggesting intramuscular metastases in the abdominal rectus muscle. Furtheremore, 4 months after the extirpation of the axillary lymph node, which was histologically diagnosed to be metastatic gastric cancer, her right breast showed a cancerous skin change and bilateral inguinal lymph nodes enlarged. Therefore, radiation therapy at a total dose of 50Gy on both sites was added, followed by several courses of systemic chemotherapy using methotorexate and 5-fluorouracil.
Our aggressive combined therapy was effective, and gave her a long-term surrvival without spoiling the quality of her life for as long as 7 years and 2 months.

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A 44-year-old man treated for Behçet disease was admitted because of epigastralgia. Uppergastrointestinal endoscopy, revealed a IIc-type, early gastric carcinoma at the posterior wall of the gastric body, so total gastrectomy was performed. Histologically, poorly differentiated adenocarcinoma was confirmed on mucosal layer only, however more mucosal carcinoma was also detected. BehÇet disease with carcinoma of digestive tract are very rare.

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We evaluated 9 patients with bone metastasis and 81 patients with other metastases from gastric cancer from a total of 587 patients with gastric cancer over the past 16 years. We evaluated both groups. Tumor size was significantly smaller and the rate of localized type was significantly larger in patients with bone metastasis than the other metastases. There were more patients with signet ring cell carcinoma. The depth of cancer invasion was high in both groups. More than 50% of patients with bone metastasis had lumbago. Localization of bone metastasis was vertebra in 44% and was diffuse in 44%. Serum alkaline phosphatase (ALP) levels were elevated even in the asymptomatic period and were more sensitive than LDH and carcinoembryonic antigen (CEA) in patients with bone metastasis.
Bone scintigraphy was useful for the diagnosis of bone metastasis. When ALP is elevated in asymptomatic patients with advanced gastric cancer, we should perform bone scintigraphy to facilitate earlier detection of bone metastasis.

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A 62-year-old man developed a refractory duodeno-cutaneous fistula after undergoing an operation for postoperative adhesion. Five previous simple anastomotic closure failed at another hospital. He underwent long-term intraveous parental hyperalimentation and showed hypoablbuminemia. We started elementary diet and performed an adhesiotomy electively. After successful dissection of postoperative adhesion, the duodenal defect was covered with elevated jejunum, and side-to-side duodeno-jejunostomy was performed. To facilitate decompression of he duodenum, a cholecystostomy and insertion of a cannula into the pancreatic duct was carried out. His postoperative course was uneventful. The large duodenal defect was a good candidate for a side to side anastomosis using elevated jejunal segment in such as this case.

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We experienced a case of malignant lymphoma of the duodenum with a 3 year interval from the detection to operation.
A 70-year-old man with a past history of diabetes mellitus and brain infarction was admitted to the our hospital because of appetite loss in September 1994. The laboratory findings pointed out an increased number of white blood cells, and bone marrow analysis revealed atypical cell. Endoscopic examinations showed a localized lesion without ulceration, of which surface was seen in the duodenal first portion. The specimen taken from this lesion revealed moderately infilteration of atypical lymphocytes, suspected non-Hodgkin's lymphoma (diffuse, small cell type), and immunohistological study revealed that tumor cells were B-cell origin. The patient, however, withdrew the treatment. In August 1997, the patient was readmitted to the hospital because he was pointed out the deformity of the pyloric antrum at mass screening for gastric cancer. With endoscopy and biopsy, malignant lymphoma was diagnosed and the tumor diameter became double. Operation was performed, and an elevated tumor was seen at the first portion of the duodenum. Furthermore, metastases were seen in the lymph nodes. On a histological study, the preoperative diagnosis was confirmed. After the operation, chemotherapy with VEPA was started. The patient is doing well for the 18 months following the operation. Primary malignant lymphoma in the duodenum is rare in Japan, only 64 cases have been reported in the literature.

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A case of eosinophilic enteritis presented with intestinal obstruction in a 6-year-old boy is reported. The patient was seen at the hospital because of fever, abdominal pain, and vomiting. The abdomen was distended. There were tenderness and muscle guading over the abdomen. Simple abdominal x-ray film and abdominal CT scan revealed significant gaseous distention and niveau formation of the small intestine. With a suspicion of strangulated ileus, an emergency operation was performed. Upon surgery, an induration like lesion was found in the middle portion of the small intestine about 150cm oral side from the terminal ileum. The induration was diagnosed as a cause of intestinal obstruction, and a partial excision of the small intestine was performed. Histopathologically, infiltration on inflammatory cells mainly composed of eoshinophile was confirmed in the submucosal layer of the excised intetine. The diagnosis of eosinophilic enteritis was made. Postoperative course was uneventful and the patient was discharged from the hospital on 17th hospital day.
It is though that we have great difficulty in discision making of preoperative diagnosis and indication of surgical therapy for the disease, especially for emergency cases.

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A 65-year-old man was transferred to our hospital because of meteorism, low-grade fever and vomiting while being hospitalized in the psychiatry department. As a result of abdominal CT and colonoscopy, we made a diagnosis of obstructed sigmoid-colon cancer. A retrograde bowel drainage tube was placed through the anus. As the intestinal obstruction improved gradually, preoperative examination and irrigation of the colon became possible. During operation, the end of the tube was found in the abdominal cavity and outside of the colon covered by the large omentum, which had adhered to the oral side of the tumor. It is assumed that as the intestinal obstruction was relieved and the edema of the large intestine improved, the tube formed a straight line and punched out the intestinal tract wall by the constant stimulation of the tube end. We thought that the intestinal perforation should be noted as a complication of retrograde bowel drainage.

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We describe a case of amebic colitis associated with penetration of the abdominal wall. A 61-year-old man was admitted to our hospital with abdominal pain and diarrhea. He had never gone abroad. He was diagnosed as having a pericecal abscess, and an emergency operation was performed. During the surgery, colitis was found throught the colon and was associated with ulcers. Furthermore, the cecum was swollen like a tumor, and the sigmoid colon was penetrated to the abdominal wall. Three-quarters of the colon was resected. Postoperative complications included anastomotic leakage and DIC, however he finally attained remission.
In Japan, amoebiasis is an infrequent infectious disease although, its prevalence had been high before and during the war. No more than 10 patients developed this disease in 1978. However, amoebiasis has been increasing recently, especially, in patients who have returned from abroad and have practiced homosexual behavior. The mortality rate of patients who underwent operation because of bowel perforation, is very high. In this cases, prompt diagnosis and treatment is important. Physicians consider this disease during in daily medical examinations and treatments.

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A 58-year-old woman was admitted to our hospital because a cecal tumor was detected by colonofiberscopic examination, following a positive fecal occult blood test.
Colonofiberscopic findings showed a nodule-aggregating tumor in the appendiceal region of the cecum, 45mm in diameter, and determined the biopsy specimen to be group 3. An iliocecal resection with lymphnode dissection of the third group was performed under a preoperative diagnosis of cancer with submucosal invasion of the cecum. Histological examination revealed that the tumor was well differentiated tubular adenocarcinoma with invasion of the mucosa.

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We encountered a case of rectal leiomyosarcoma with perianal Paget's disease. A 74-year-old man visited our hospital complaining of anal pain and bloody stool. Barium enema examination showed a protruding lesion in the rectum, and endoscopic diagnosis was a submucosal tumor of the rectum.
The patient underwent Miles operation for a malignant rectal tumor.
Hpwevers, histological diagnosis is unexpectedly determined to be leiomyosarcoma and perianal Paget's disease.
Perianal Paget's disease is often associated with a rectal or anal malignant tumor, but is rarely associated with a rectal leiomyosarcoma.

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A 51-year-old woman was admitted to the hospital because of left advanced breast cancer. On admission the coagulation system was normal. After chemotherapy, a left modified radical mastectomy was performed. Histopathological findings included invasive ductal carcinoma, scirrhous carcinoma, s, and n3(+). Oral administration of toremifene citrate (TOR), doxifluridine (5'DFUR), and medroxyprogesterone acetate (MPA) was started. On the 75th day after administration, remarkable ascites and edema of the lower extremities were noted. Abdominal CT scan revealed a large amount of ascites and thrombotic obstraction. Abdominal angiography revealed complete obstraction of the portal vein and a development of collateral vessel. Since only medication could not control the ascites and abdominal distention and respiratory impairment became worse, a shunt between peritoneal space and vein was made, leading to a remission of patient's subjective symptoms. The patient, however, died of aggravated hepatic failure 8 months after the first operation.
The causative relation between MPA and thrombosis has not been clarified as yet, but it is inferred that portal vein thrombosis may be caused by MPA because no obvious other causes are present.

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A 74-year-old man who had stayed at another hospital because of fever and leukocytosis of unknown origin was transferred to the hospital with a suspicion of having hepatic and pancreatic tumor in April, 1998. On admission, the white blood cell count was 27100/μl, body temperature was 37.1°C, and serum CRP was 19.3mg/dl. CT scan revealed a tumor 5cm in size at the caudate lobe of the liver, with lymph nodes metastasis. A open biopsy performed on May 19 revealed blood G-CSF level of 144pg/dl which was five times as high as the standard level. Histopathologically, the biopsied material showed undifferentiated carcinoma and was G-CSF positive on an immunostaining assay. Thereafter, radiation therapy at 40Gy was given that resulted in decrease in G-CSF level to 37.3pg/dl and a symptomatic remission. The patient was discharged from the hospital on June 30. The patient, however, died of hepatic failure in November, 1998. In a review of the Japanese literature, 244 case of G-CSF-producing tumor have been reported up to the end of 1998. Primary sites of these tumors included the lung in 80 cases, thyroid in 20 cases, and bladder in 19 cases. In 14 cases of G-CSF producing tumor of the liver, an extremely poor prognosis as short as 2.8 months on an average was noted after the increase in white blood cell count. These has been no case report that describes successful radiotherapy for the tumor arisen in the liver.

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A 62-year-old man who complained of weight and appetite loss was pointed out gastric abnormality at a mass screening study for gastric cancer. He had severe anemia and showed high levels of serum AFP (6, 970ng/ml) and CEA (60.6ng/ml). Upper GI series revealed a type II tumor located from the posterior wall to the greater curvaturer of the antrum. Ultrasonographic study and CT scan demonstrated an extra gastric extension and multiple liver metastasis. We diagnosed that this case was not a candidate for curative operation, but performed a distal gastrectomy because of bleeding from tumor. Pathologically it was hepatoid adenocarcinoma and the localization of AFP and CEA were shown by immunohistochemical study. NSE and hCG were negative. After the operation, serum AFP increased to 30, 800ng/ml and he developed jaundice and liver dysfunction due to severe progression of liver and lung metastases. On the 44th postoperative day, the patient died of liver failure. Just before death, serum AFP and CEA amounted to 188, 000ng/ml and 372ng/ml respectively. The prognosis of the AFP producing gastric cancer is poor, particularly that of the hepatoid adenocarcinoma. In this case, the disease prognosed rapidly to its termination, too.

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A 41-year-old woman was admitted to the hospital because of intestinal obstruction. An ileus tube was inserted and we found out a complete obstruction of the ileum. Ultrasonography, CT scan and angiography visualized multiple liver tumors. With a suspicion of intestinal obstruction due to an ileum tumor and multiple liver metastasis, a partial resection of the ileum, a lateral segmentectomy and a cholecystectomy were performed. Histological examination revealed that the tumor of the ileum was atypical poorly differentiated adenocarcinoma (ss, ly0, v0, n0) and the tumor cells of both the ileum and liver had more undifferentiated appearance than carcinoid. Immunohistochemical stainings (grimelius, S-100, NSE) were positive, indicating that they have neuroendocrine differentiation. Electron microscopy revealed dense core granules. Therefore, it was diagnosed as neuroendocrine carcinoma of the ileum with multiple liver metastasis.
After discharge, intra-arterial chemotherapy (FAM) was started on ambulant basis in the treatment of remaining liver tumors. The patient is alive 8 months after the operation with no sign of growing of the remnant tumors.

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Hepatic metastasis of breast cancer is often multiple and unresectable, and generally has a poor prognosis. This time, we report a case of hepatic metastasis cohich developed after curative resections for bilateral breast cancer, and which was itself successfully resected. The patient was a 44-year-old woman. In July 1993, the patient underwent a pectoral-muscle-preserving mastectomy (Kodama's method) with R2 for a left breast cancer, which resulted in an absolutely curative operation. It was t1n0m0 in Stage I and solid tubula adenocarcinoma histologically. During observation of the clinical course, a contralateral breast cancer was detected, for which a pectoral muscle-preserving mastectomy (Kodama's method) with R2 was performed, resulting in an absolutely curative resection. The resected tumor was t2n0m0 in Stage I and the histologic type was scirrhous carcinoma. Thereafter endocrine chemotherpy was given. Ten monghs later, hepatic metastases involving the S2 and S8 were confirmed and an anterior segmetectomy and a partial hepatectomy (S2) were performed. At present, the patient has been free from recurrence and is doing well under chemotherapy.

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Congenital bile duct dilation is a rare disease. Although classified into 3 types by Alonso-Lej, recently, Todani has classified 5 types with the idea of anomalous junction. Choledochocele is quite rare among the several varieties of the disease.
The patient was a 60-year-old man who was admitted to our hospital with epigastralgia and fever. Liver and gallbladder enzyme levels were abnormally increased. CT examination revealed swelling of the galbladder, and dilation of the common bile duct and the intrahepatic bile duct. Endoscopic retrograde cholangiopancreatography showed a slight dilatation of the common bile duct, a cyst-like distension of the lower bile duct, and no presence of pancreaticobiliary maljunction. Therefore, a correct diagnosis of choledochocele was made. Endoscopic sphincterotomy is frequently selected as therapy for choledochocele. We performed surgical sphincteroplasty and cholecystectomy as a precaution against cholecystic cancer and other complications.

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We experienced a case of breast cancer metastasized to the pancreas 22 years after operation for the primary lesion. A 60-year-old woman was admitted to the hospital because of fever and jaundice. Preoperative imaging methods indicated a tumor of the pancreatic head, but apparent findings of metastatic pancreatic cancer were lacked. Since there was a previous history of undergoing a resection for pulmonary metastatic foci 11 years before admission, pancreatic metastasis of breast cancer or primary pancreatic cancer was diagnosed. A pancreatoduodenectomy was performed. Pathological exploration of the resected material revealed entirely similar findings to those of primary breast cancer and pulmonary metastatic foci, which were compatible with pancreatic metastasis of breast cancer.
It is very rare that pancreatic metastasis of cancer is indicated for surgical resection. Although this patient presented difficulty in differentiation from primary pancreatic cancer, she was determined to be a candidate for operation based on the following reasons: 1) Imagings revealed the foci localized in the pancreas and its circumference: 2) If the tumor was metastatic pancreatic tumor, it was slow growing and 11 years had past after the operation for lung metastasis: and 3) Patient's preoperative general condition was good. As of one year after the resection, the patient is being followed in the outpatient clinic, though she has another recurrence.

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Internal hernia is not a common cause for intestinal obstruction. Among of those hernias, a very rare internal herniation through an abnormal defect in the broad ligament of the uterus is reported. A 77-year-old woman was admitted to the hospital because of abdominal pain and vomiting. CT examination demonstrated that the uterus deviated to the left and the right broad ligament was extended due to the distended small intestine. An internal herniation through a defect in the broad ligament suspected, but there was a history of undergoing an operation for ligation of the uterine tube and adhesive ileus was also probable. The patient was treated conservatively with a long tube, but no symptomatic remission was obtained. So, a strangulated herniation through a defect of the right broad ligament of the uterus was diagnosed and an operation was performed. At laparotomy, the ileum, approximately 40cm in length and 240cm proximal to the ileocecal valve, was herniated through an abnormal defect in the broad ligament of the uterus. Right round ligament was cut and the incarceration was reduced. This disease presents difficulty in preoperatively diagnosis, but CT examination is helpful in diagnosis. When we encounter patients with intestinal obstruction of unknown origin, CT examination must be performed.

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Endometriosis of the umbilicus is rare, and account for about 0.2% of all endometriosisexterna. We report a case of endometriosis of the umbilicus with a review of the literature.
A 47-year-old woman was seen at the hospital because of umbilical pain and bloody discharge from the umbilicus throughout menstrual period. A spherical mass, 1cm in diameter with slight tender, was palpable around the umbilical region. Abdominal CT scan revealed a solid tumor 12mm in diameter. Based on the clinical symptoms and histopathological features of the biopsied specimen, we diagnosed the tumor as endometriosis of the umbilicus.
Under general anesthesia, an enucleation of the tumor was performed. It was diagnosed as endometriosis histopathologically. There have been no signs of the recurrence after the operation.

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A 74-year-old man came to our hospital complaining of constipation. He was diagnosed with descending colon cancer and underwent a left hemicolectomy. He started taking meals on the 9th day after operation, but had repeated vomiting one or two hours after meals. Abdominal computed tomography revealed that the third portion of duodenum was compressed between the SMA and abdominal aorta, and that the stomach and duodenum were dilated. Gastroduodenography showed a straight line cut-off of the third portion of the duodenum, and stomach and duodenum dilatation after that. He was diagnosed as having SMA syndrome after left hemicolectomy. Conservative therapy for about two weeks was not effective, and he underwent surgical reoperation. The root of the mesenterium including the SMA had occluded the third portion of the duodenum, and a gastrojejunostomy was performed. The change of anatomical characteristics between the SMA and duodenum is considered one of the causes of SMA syndrome. In this case, the root of mesenterium was thought to be retracted inferiorily by the colonic anastomosis. The postoperative course was uneventful. Anterior transposition of the duodenum, duodenojejunostomy, and Treitz's ligament resection are known as other surgical procedures for treatment of this disease.

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We report a case of a mesenteric cyst. A 49-year-old woman visited her home doctor because of abdominal pain. Because an abdominal cystic tumor was suggested, the patient referred to our hospital. By using abdominal ultrasonography, computed tomography, and angiography, she was diagnosed as having either a mesenteric cyst or an omental cyst, and an operation was performed. The tumor was found in the posterior side of the transverse mesocolon, but no communication with transverse colon or other organs was observed. The tumor was extirpated completely. The tumor was a unilocular cystic mass, and was filled with light-yellowish serous fluid. The histopathological diagnosis was a mesenteric cyst. A diagnosis of cystic mesothelioma was confirmed from the positive findings to immunochemical staining with EMA, cytokeratin, thrombomodulin, and vimentin. Adult mesenteric cysts are relatively rare. This paper describes such a case with a review of the literature.

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A rare case of omental torsion secondary to left inguinal hernia is reported.
A 33-year-old man was admitted to our hospital complaining of left lower abdominal pain. A diagnosis of incarcerated inguinal hernia was made, because of a left inguinal hernia with expansion and severe pain. During the emergency operation, necrotic omentum, hernia insult, was observed, therefor lower abdominal skin incision was added. The greater omentum was adhered at the hernia porte and was rotated in a 720 °clockwise direction. Resection of the necrotic portion of the omentum and hernioplasty was performed.

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We encountered a case of transomental hernia that was diagnosed preoperatively as an internal hernia. An 84-year-old woman was referred to our hospital by a nearby practitioner because of right lateral abdominal pain and vomiting. There was no previous history of laparotomy. A plain X-ray of the abdomen showed a fluid level, and we made a diagnosis of bowel obstruction. Conservative treatment by insertion of a long-tube was performed. As double stenosis of the small intestine was detected by long-tube enterogram, therefore, laparotomy was carried out under a diagnosis of ileus due to internal hernia. At surgery, the small intestine was herniated through the abdominal hiatus of the greater omentum. One intestinal loop was strangulated, but not necrotized. The strangulation was released and the abdominal hiatus was opened, and intestinal resection was not required.
We think that the long-tube enterogram provided important information in this case, which could be performed by radical laparoscopic surgery.

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A 59-year-old man was admitted to our hospital because of a left lower-quadrant abdominal mass. General examination was negative except for a firm, smooth, fixed mass 4×3cm in size situated in the left lower quadrant of the abdominal wall. Abdominal CT revealed a well-defined tumor, which compressed the small intestine, and attached to the abdominal wall muscle at the level of the iliac crest. Dynamic CT revealed a hypervascular and capsulated tumor, which was enhanced heterogeneously, and had a very high-density area with an oval shape. Abdominal MRI revealed a heterogeneous mass both on T1 and T2 weighted images. Needle biopsy suggested a fibrous tumor. During operation, the tumor was found to arise on the inner surface of the anterior abdominal wall. Resection en bloc with peritoneum, transversus muscle, and internal oblique muscle with a 2cm surgical margin was carried out. The cut surface of the tumor was of a multinodular configuration, with solid nodules and hemorrage. The histological diagnosis was monophasic type synovial sarcoma. Synovial sarcoma is a malignant softtissue tumor arising in the vicinity of joints, and reported examples arising in the anterior abdominal wall are rare. Dynamic CT was very useful and well correlated with the morphologic appearance.

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(Case 1) A 70-year-old man was admitted to our hospital because of abdominal distension. An abdominal computed tomography scan showed a large cystic mass of the stomach. The patient was diagnosed as having a submucosal tumor of the stomach and was operated on. (Case 2) A 59-year-old man was admitted to our hospital because of melena. An abdominal computed tomography scan and ultrasonography showed a mass of the small bowel. Partial resection of the jejunum was performed with a diagnosis of small-bowel tumor. During laparotomy in both cases, a large number of small nodules of peritoneum were noted. Histologically, and immunohistochemically, both of the tumors were diagnosed as gastrointestinal stromal tumors (GIST), uncommitted type, with peritoneal dissemination. The prognosis of GIST with unresectable peritoneal dissemination is poor, therefore, surgical resection should be done as soon as possible.

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This paper presents a case of perforative peritonitis of the small intestine caused by a stick tea, so-called ‘bocha’ in Japanese, under the presence of postoperative adhesion. A 77-year-old man was admitted t the hospital because of sudden onset of abdominal pain. There was a past history of undergoing a low anterior resection for a rectal cancer 2 and a half years before admission. Abdominal CT scan showed free air spaces and a lot of ascites. Under a diagnosis of gastrointestinal perforative peritonitis, an emergency operation was performed. Upon laparotomy, a part of the ileum was led into the true pelvic cavity and tightly adhered. The mesentery was necrotic at the folded region and a stick like foreign body projected through the ileal wall, where a spot perforation was found. An ileal resectin by 15cm with necrotic mesentery was performed. The foreign body was proven to be a stick tea, so-called Bocha in Japanese, about 5cm long. Such foreign body can pass through the intestine under normal condition, but it was caught at the wound and stenosed portion of the intestine due to postoperative adhesion, the perforation.

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A case of peritoneal metastasis of breast cancer which is relatively rare is reported here.
A 43-year-old woman, who underwent a mastectomy for right breast cancer on February 7 1995, was seen at the hospital because of abdominal pain which appeared since the middle of October 1996. Barium enema and colonoscopic studies indicated metastasis of breast cancer to the large intestine. On November 1, the patient was operated on. At upper abdominal midline incision, ascites and peritoneal dissemination were confirmed, and the tumor arisen from the descending colon was unmovable. From these findings, we determined that a radical operation was impossible and performed a loop colostomy in the transverse colon. Histopathological study of a specimen collected from the greater omentum during surgery offered a diagnosis of peritoneal metastasis of the breast cancer.
It takes a relatively long time for breast cancer to metastasize to the peritoneal cavity and digestiveorgans. So we have to make every effort to detect early and treat the metastasis by active exploration of the gastrointestinal organs, if the postoperative patient with breast cancer complains of gastrointestinal symptoms.

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A 58-year-old woman was admitted for Stanford A acute aortic dissection. We performed ascending aorta and aortic arch replacement for aortic dissection. Since the 10th postoperative days (POD), she had a high fever (more than 38°C) and showed an increase of inflammatory reaction. She compained of chest discomfort and back pain on the 20th POD. At the 70th POD, she developed lower limb paraplegia. Magnetic resonance imaging and X-ray indicated pyogenic sponylditis. Therefore, we consulted orthopedic surgeons and performed an operation. We consider pyogenic spondylitis as a complication of aorta and aortic arch replacement for aortic dissection.

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A case of Schwannoma of the left brachial plexus that extended into the thoracic cavity and caused fracture of the left first rib is presented. A 33-year-old woman suffered from a sudden onset of left shoulder pain at coughing. Chest X-ray film revealed fracture of the left first rib and a left apical mass. The tumor was subcapsularly resected with thoracoscopic surgery. The resected tumor was Schwannoma arisen from the brachial plexus of nerve trunk. After the operation, the patient developed a mild motor inpairment of the muscles controlled by median and ulnar nerve. This postoperative neurological problem was improved in 6 months. It should be kept in mind that tumors arising in the brachial plexus are a probable differential diagnosis for tumors at the pulmonary apex, even if no neurological symptoms are seen in the upper extremities.

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A case of asynchronous multiple cancers including quadruple colon cancers, gastric cancer, and lung cancer is described.
The patient, a 57-year-old man, was diagnosed at the age of 46 in 1986 with early gastric cancer. In 1993, double ascending colon cancers, and in 1995 left lung cancer were found and surgically treated.
Double sigmoid colon cancers were revealed in 1997, and all carcinomas were resected radically.
No sign of recurrence or metastasis has been detected since the last operation. This patient has multiple polys in the residual colon and stomach, and takes Sulindac to control growth of sporadic polyps. Replication errors in DNA, which may play an important role in development of multiple primary cancers, were observed in thia case. The patient should be considered to have an increased risk of an additional primary cancer.

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