A series of 686 women with breast cancer who visited the breast clinic and underwent mammographic examination during recent 15 years were subjected to this study.
The subjects were divided into four groups {T(+), C(+), TC(+) and TC(-)} according to the presence or absence of mass density (T) or calcification (C) on mammography. The diagnostic efficiencies of palpation, mammography (MG), ultrasonography (US) and aspiration biopsy cytology (ABC) were compared among them. The proportion suspected as breast cancer by each diagnostic method was the highest in TC(+) group and the lowest in TC(-) group. Futhermore, the diagnostic efficiencies of mammography combined with other diagnostic methods were compared among these four groups. The coincident rate as malignancy in each combination was the highest in TC(+) group and the lowest in TC(-) group. The proportion mistaken as benign was the lowest in combination group of MG and ABC, and the highest on combination group of MG and US.
It has become apparent that the diagnostic efficiency by various diagnostic methods for breast cancer and diagnostic efficiency of mammography combined with other diagnostic methods differ depending on the mammographic findings.

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We retrospectively studied 20 cases of nonpalpable breast cancer, which accounted for 6.2% of total 321 cases of primary breast cancer treated in our hospital. Cheif complaints of these cases were abnormal nipple discharge in 15 cases, breast pain in four cases, and breast cancer family history in one case. The patients with abnormal nipple discharge were examined by occult blood test, cytology and CEA concentration test in discharge, and ductography. Consequently, patients in whom the possibility of breast cancer could not be ruled out underwent selective duct-lobular segmentectomy. Radical surgical operation was decided on the bases of histopathological findings. Two patients who showed microcalcification on a mammogram were diagnosed as having carcinoma by an open biopsy. Two patients who showed having a small irregular hypoechoic mass on an echogram were diagnosed by an echo-guided aspiration biopsy. Histologically, noninvasive ductal carcinoma and invasive ductal carcinoma with a predominant intraductal compornent were frequently seen in the nonpalpable breast cancers. Nodal status was negative in all cases with nipple discharge. On the other hand, it was positive in each one case with microcalcification on mammography or small irregular hypoechoic mass on echography, respectively. It is thought that the clinical approach with examination of nipple discharge as well as imaging examination of the breast greatly contribute to early detection and treatment of nonpalpable breast cancer.

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We perform radiofrequency interstitial thermal ablation (RFA) using a new device for unresectable liver tumors, and evaluate its efficacy and safety. This study Involved a total of 136 liver tumors in 40 patients (including 13 patients with hepatomas and 27 patients with metastases). The size of tumors ranged from 5mm to 126mm. Under ultrasound guidance an electrode cannula was introduced into the tumor, which was then thermally ablated at 80°C to 120°C under ultrasound imaging monitoring, using a RFA device at the frequency of 460kHz. The efficacy of this RFA therapy was evaluated by perioperative and follow-up CT scans and tumor markers. The average follow-up period was 8.5 months. The approaches to the tumors were percutaneous in 18 patients, laparoscopic in four patients and open surgical in 18 patients. The RFA effectively ablated in 127 out of 136 tumors (93.3%). Complications included a skin burn at the grounding pad in one patient, pleural effusion in three patients, ascites in four patients and mild heart failure in one patient; however, there was no serious morbidity such as bleeding and infection. The survival rates at the time up to 20 months were 85.7% for patients with hepatomas and 88.2% for patients with metastases. The present study has demonstrated that the RFA is able to provide a safe and effective means in controlling liver tumors. The long-term study of more patients treated by RFA is warranted.

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In 30 (65.2%) out of 46 cases undergoing hepatectomy for hepatocellular carcinoma (HCC) without absolute noncurative operation, the recurrence occurred. The thrapeutic outcomes in these 30 patients were assesed in reference to modes of recurrence. Patients with multiple recurrence in bilateral lobes or isolateral lobe of the remunant liver had significantly shorter intervals between the initial operation and recurrence compared to patients with other recurrence modes. Patients with multiple recurrence had mostly impaired liver function at the time of recurrence. The treatment for recurrence of HCC was selected based on the number of recurrent lesions and liver function. Local treatments such as hepatectomy, microwave coagulation therapy (MCT), percutaneus ethanol injection therapy (PEIT) were serected for patients with solitary recurrence, and transarterial treatment such as transarterial embolization (TAE) and transarterial infusion (TAI) for patients with multiple recurrence. There was no significant difference among recurrent locations in the cumulative survival rate after recurrence. However a significantly higher survival rate was noted in patients with solitary recurrence than in those with multiple recurrence.

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Eight cases of intrahepatic bile duct cancer with biliary infiltrarion at the porta hepatis were retrospectively studied. Grossly there were seven cases of tumor formation+bile duct infiltraiton type and one case of biliary infiltration type. All cases were in Stage III-IV-B. There were two cases of cur B and six cases of cur C. Only one patient with cur B is recurrence free and alive. One patient with cur C died of other disease 61 months after the operation. The remaining one patient with cur B died of recurrence of the remnant liver. Of the remaining five patients with cur C, three patients died of recurrence in the remnant liver; one patient, of peritoneal dissemination; and one patient, of recurrence in lymph nodes of the mediastinum and neck. One patient whose operation resulted in cur C due to positive surgical stumps of the bile duct underwent rediation therapy, with a good local control. When compared to extrahepatic bile duct cancers, intrahepatic cancers presented difficulty in diagnosis of range of the involved bile duct even by cholangioscopy, because those cancers did not extend in the biliary mucosa, but extended via lymphatic invasion or invasively extended to the Glisson's sheath directly. However, we will follow our guidelines that aggressive resection is employed for patients in whom cur B or higher outcome can be expected, and postoperative radiation therapy is used for patients whose operations result in cur C due to positive surgical stumps.

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In order to assess the gastrointestinal anastomosis using biofragmentable anastomosis rings (BAR), we investigated peri and postoperative courses of 142 patients with BAR anastomoses comparing with 84 patients with hand suture anastomoses. Anastomotic sites of BAR were small intestime-small intestine in 40 cases, small intestine-colon in 43 cases, colon-colon in 68 cases. The mean time spent for anastomosis were 12.2minutes in BAR and 26.9minutes in hand suture. The excretion of BAR was 20.1 postoperative days in the mean. Anastomotic failures occurred 2.7% in BAR and 5.8% in hand suture. In BAR, Two of them in the symptoms occurred from 7 to 10 days after the operation. Passage disturbances occurred in 9.9% of BAR and in 0% of hand suture, all patients recovered by conservative treatments. In conclusion, BAR is a reliable and simple anastomotic device for colon and small intestine anastomosis. But, special attention should be paid to complications such as ileus, passage disturbance that may occur during the period before the excretion of BAR.

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Tumors arising in the parotid gland are commonly epithelial tumors including pleomorphic adenoma and monomorphic adenoma, and rarely non-epithelial tumors such as lipoma. We report herein a case of lipoma of the parotid gland and discussed the diagnosis and management of the disease. A 53-year-old man was admitted to the hospital because of a non-tender mass in the right parotid gland region which had been noticed four months previously. A soft, movable, ill-circumscribed tumor measuring 50×45mm in diameter was detected in the right parotid gland region without facial nerve palsy and regional node swelling. An ultrasonogram of the tumor showed a clear border hypoechoic mass with heterogeneous internal echo. The CT scan revealed a low density mass with linear structure as septum measuring 108 HE in CT number. The tumor was present in the superficial lobe of the right parotid gland which was compressive for normal parotid gland. We performed a superficial lobectomy for the right parotid gland. The histology of the tumors revealed mature lipoma without malignancy. We reviewed and discussed the diagnosis and management of parotid gland lipoma.

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Primary hyperparathyroidism is rarely complicated with acute pancreatitis of unknown cause. We report a case of primary hyperparathyroidism presented with severe acute pancreatitis. A 50-year-old man developed hypercalcemia during hospitalization for the treatment of acute pancreatitis. Because the level of plasma parathyroid hormone was elevated and a swelling of right parathyroid was revealed by CT scan, we performed an extirpation of the parathyroid grand with adiagnosis of hyperparathyroidism with a tumor of the parathyroid gland. The tumor of the parathyroid gland was diagnosed as benign adenoma pathologically. It was suggested that hypercalcemia and increased plasma parathyroid hormone were associated with onset and aggravation of acute pancreatitis because acute pancreatitis improved with decreases in plasma Ca and parathyroid hormone. We must keep in mind that the patient with acute pancreatitis presented with hypercalcemia may also have primary hyperparathyroidism.

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Acinic cell carcinoma is an entity more than three percent of salivary gland tumor from all site. Acinic cell carcinoma is almost originated in the parotid gland. Submandibular gland originated acinic cell carcinoma is very rare. It is well known that acinic cell carcinoma has a low grade malignant potential because it is relatively poor in atypia and rarely metastasizes.
A 93-year-old woman who had had an asymptomatic left submandibular mass for over 20 years was admitted to the hospital because of recent appearance of tenderness and a growing tendency of the tumor.
We performed an extirpation of the left cervical tumor. Pathological diagnosis was acinic cell carcinoma originated in the submandibular gland. No lymph node and lung metastases were evident.
We present here a this rare case of acinic cell carcinoma of the submandibular gland with over a 20-year history of the illness. This case is oldest patient in Japanese operative cases.

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Diabetic mastopathy has been rarely reported in Japan. It is an uncommon lesion which resembles breast cancer clinically. Therefore, we find difficulty in diagnosing diabetic mastopathy. We report three cases of diabetic mastopathy herein.
All cases were women with the ages ranged from 53 to 77 (mean 62.3) years old. Therapeutic duration for diabetes mellitus ranged from 5 to 30 (mean 18.3) years. Two cases had been receiving insulin therapy. On palpation, all patients had a breast tumor with the diameter ranging from 11 to 45 (mean 23.6) mm. Ultrasonography showed unclear border and heterogeneous lesion. Mammography revealed an iso dense mass in one case. Preoperative fine needle aspiration biopsy were all negative. The pathologic examination revealed epithelioid fibroblasts, lymphocytic lobulitis and keloid like features in all case.
In the treatment of patient with long-standing diabetes mellitus, we should keep diabetic mastopathy in mind.

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The authors describe a case of large endometrial polyp possibly due to tamoxifen (TAM) regimen associated with Paget's disease of the right breast in a postoperative woman with left breast cancer. A 71-year-old woman was admitted to the hospital because of nipple eczema. She had been administered TAM for two years after the previous operation for left breast cancer. As she was diagnosed as having Paget's disease of the contralateral breast by a biopsied specimen, a right mastectomy was performed. Furthermore, a large endometrial polyp 4.0cm in maximum diameter was detected and it was extirpated. Though TAM is widely used as an adjuvant hormone therapy for breast cancer, two years or more prolonged TAM treatment causes proliferative endometrial lesions due to its partial estrogenic action. On the other hand, significant reductions in the incidence rate of contralateral breast cancer have been observed. ER of Paget's cells revealed negative by an immunohistochemical study in this case. Gynecological examination is necessary for the patients administered TAM in spite of the cumulative dose and duration of the regimen.

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A 79-year-old woman was seen at the hospital because of a left breast tumor. A2.0×1.5cm tumor in the AC area and a tumor 1.0cm in size in the AB area which were painful and elastic hard were palpated. Ultrosonography revealed a 1.7×1.6×0.8cm relatively discrete echo with heterogeneous inside in the AC area. Mammography visualized three tumorous shadows, 1.7×1.2cm, 1.0×0.7cm, and 1.0×0.9cm in size, respectively. Biopsy was performed for the tumor in the AC area and angiosarcoma of the breast was diagnosed. A left simple mastectomy was performed. Three were metastatic lesions, 0.7×0.5cm in size in the AB area and 0.9×0.7cm in size in the B area. In the A area, a 0.3×0.2cm metastatic lesion which had not been confirmed by the mammogram was also noted. There have been no signs of local recurrence nor metastasis, as of 6 months after the operation.
Angiosarcoma of the breast is very rare and has a poor prognosis, as only two survivors for 5 years have been reported out of 35 patients seen in the Japanese literature. This paper presents our experience with angiosarcoma of the breast with metastases to subcutaneous fat tissues of the homolateral breast.

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A case of intracystic accessory breast cancer associated with contralateral non-infiltrating breast cancer which is exceptionally encountered is described. A 57-year-old woman was admitted to the hospital because of a left axillary tumor. No breast tumors were palpable and there were no significant findings on mammography. But ultrasonography revealed a right breast tumor. Excisonal biopsies of the left axillary tumor and right breast tumor were performed. Histological findings revealed that the left axillary tumor was intracystic papillary adenocarcinoma of the accessory mammary gland and the right breast tumor was non-infiltrating ductal carcinoma. A wide local resection with left axillary lymph node dissection and a right radical mastectomy were carried out. No other cancerous lesions including lymph node metastasis and infiltrating cancer of the breast were found. She is doing well without any evidence of recurrence, as of one year after the operation.

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A 43-year-old woman was admitted to the hospital because of a lump in her right breast detected by mass screening in July 1992. Although aspiration biopsy cytology (ABC) of the lump revealed class 1, an excisional biopsy was performed to rule out malignancy. The diagnosis of lobular carcinoma in situ (LCIS) was made and a wide excision was subsequently performed. The surgical margin of the resected specimen was positive for LCIS. The patient was regularly followed by ultrasonography (US) every 3 months and by mammography every 6 months based on informed consent. US showed a hypoechoic mass 5mm in diameter in the prior excisional region in February 1996. The ABC of this mass again showed class 1. The tumor then gradually increased in size. Since the tumor had become 8mm in diameter in July 1997, an excisional biopsy was performed. The resected specimen was diagnosed by histology as an infiltrating lobular carcinoma and subsequent total glandectomy with axillary lymph node dissection was performed. It seemed a valuable clinicopathological observation that the LCIS had developed into an infiltrating lobular carcinoma in five years.

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We have experienced a case of penetrated ulcer of the reconstructed gastric tube to the pericardium.
A 67-year-old man was admitted to the hospital because of sudden onset of anterior chest and neck pain in February 1999. There was a previous history of undergoing a subtotal esophagectomy and a retrosternal esophagogastrostomy for carcinoma of the middle intrathoracic esophagus 4 years before admission. Chest X-ray film showed the air in the pericardial space, and computed tomography revealed the penetration of the gastric tube to the pericardium. He fell into shock condition, and percutaneous pericardial drainage was immediately performed. Conservative therapy by administration of antibiotics and H₂-blocker, and placement of a nasogastric tube was done thereafter. His general condition improved temporally. Inspite of the treatment, his respiratory condition became worse 14 days after the drainage, and he died of multiple organ failure subsequent to sepsis 18 days after the drainage. At autopsy, ulcer penetration of the gastric tube to the pericardium 15.5cm distal from the esophagogas-troanastomosis was confirmed. The size was 6×3cm. No recurrence of the esophageal cancer was observed. It is considered that the operative lavage and drainage in the pericardial space along with resection of the gastric tube and esophagocutaneostomy should be performed after improving the general condition temporally due to percutaneous drainage. We must bear in mind that ulcer of the reconstructed gastric tube can be fatal because it may cause penetration to the pericardium or large vessels. Some bibliographical comments in terms of therapeutic problems are also presented here.

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A 12-year-old boy who had cerebral palsy was brought to the emergency outpatient unit in our hospital because of fever and vomiting persisted for a few days. Plain chest X-ray film showed a round shadow at the bifurcation of the trachea, suggesting an esophageal foreign body. Under general anesthesia, a removal of the foreign body was performed using a direct esophagoscope. The foreign body was an electric battery, and was relatively easy to remove. Stenosis of the esophageal lumen on the anal side was detected, and esophageal dilatation was performed, causing perforation at the stenotic site. Immediately, surgery was performed. The perforation was present in the anterior wall of the esophagus. An incision was made above the perforation site to examine the esophageal lumen. In the esophagus on the anal side, a two-thirds circumferential ulcerative lesion was detected, suggesting cicatricial stenosis related to this lesion. The ulcerative cicatricial tissue was resected with a portion of muscle layer. In the posterior wall, interrupted suture of the normal esophageal mucosa was performed in the esophageal short axis direction. In the anterior wall, two-layer interrupted suture was performed in the esophageal long axis direction. The patient was in the respiratory control for a week. Postoperative course was uneventful and the patient was discharged from the hospital on 31st hospital day.

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A case of esophageal hiatal hernia in which the gastric vestibule, duodenal bulb and transverse colon were incarcerated is reported. A 79-year-old woman was admitted to the hospital because of vomiting. Chest roentogenogram showed gastroenteric gas which seemingly overlaped on the bilateral lung field and cardiac shadow. Upper gastrointestinal series revealed mixed type hiatal hernia and the gastric vestibule almost obstructed in the hernial hilum. Gastrografin enema examination showed that the transverse colon migrated into the mediastinum. The patient was diagnosed as having mixed type hiatal hernia in which the gastric vestibule and transverse colon were incarcerated, and was operated on. Upon laparotomy the transverse colon, duodenal bulb, gastric vestibule and fundus were incarcerated in the open esophageal hiatus. The incarcerated organs were reduced into the intraperitoneal cavity, and the esophageal hiatus was repaired. Any recurrence of hernia has not been found as of one year after the operation. It must be taken into consideration that the esophageal hiatal hernia can be accompanied by incarceration of the intraperitoneal organs.

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We report a very rare case of neuroendocrine cacinoma metastasizing to a distant lymph node. An 81-year-old woman, was admitted to our hospital omplaining of epigastric dyscomfort. A Borrmann type 3 tumor occupying the anterior wall of the gastric antrum was found by gastrography and gastroendoscopic examination. Computed tomography (CT) revealed regional lymphnode metastasis, but no other obvious metastasis was observed. Distal gastrectomy with lymph node dessection was performed. Histologic findings of the resected tumor were consistent with a diagnosis of neuroendocrine carcinoma. The patient was discharged, however, and complained of a right lateral abdominal tumor about 18 months after gastrectomy. Abdominal ultrasonography, CT and Gallium scintigraphy revealed a malignant tumor on the right abdominal wall. The histological diagnosis with needle biopsy indicated metastatic neuroendocrine carcinoma. The tumor was dissected and histologic findings was confirmed metastatic neuroendocrine carcinoma in the lymph node. Tumor cells were stained positive by the chromogranin A and neuron-specific enolase on immunohistochemical staining, and electron microscopic examination showed neurosecrectory granules. Although the prognosis of this desease is very poor, the patient has survived without hepatic metastasis after dissection of the metastatic tumor. We describe our case of discriminating carcinoid with a review of the literature.

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Malignant change of the aberrant pancreas in the stomach is very rare, and there have been only 23 cases in Japan. We report a case of gastric cancer arising from the aberrant pancreas. A 46-year-old woman, who had been followed up for 7 years after a submucosal tumor of the gastric angle was diagnosed, underwent a distal gastrectomy because a gastric endoscopy revealed type 3 gastric cancer in the same region. Histological examination of the resected stomach revealed acinar cell carcinoma. There was no remarkable finding in the pancreas during the operation. In addition, there has been no case report of this histopathological type of gastric neoplasm. This case was diagnosed as one of malignant change from the aberrant pancreas in the stomach. Partial resection of the liver was performed for a solitary metastatic hepatic tumor 21 months after the gastrectomy. And interesting changes in blood levels of trypsin were observed before and after twice operations.

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A 73-year-old man was seen at the hospital because of slight fever. Gastric endoscopy revealed a type I elevated lesion in the anterior wall of the middle to upper porrtions of the gastric body. Biopsy indicated well differenciated adenocarcinoma. Abdominal CT scan revealed multiple metastatic lesions in the both lobes of the liver. To relieve hemorrhage from the primary foci and passage disturbance, a subtotal gastrectomy (D1+#8) and hepatic artery cannulation were performed. We treated the liver metastases with hepatic arterial infusion of Cisplatin (10mg) and 5-fluorouridine (250mg) and oral administration of 5'-deoxy-5-fluorouridine (5'-DFUR, 600mg). After treated with this regimen for 2 Kurs, the liver metastases disappeared completely on computed tomography. He had been well with no evidence of recurrence for 16 months after the operation by only oral administration of 5'-DFUR.

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Adenoma of the papilla of Vater is considered to be a relatively rare disease. We report a case of the disease without symptoms that we have recently encountered. A 75-year-old woman was found to have an enlargement of the papilla of Vater during an endoscopic examination of the upper digestive tract, and she was admitted to the hospital for thorough examination. Endoscopy of the duodenum revealed an approximately 1cm coarse nodular bulge in the papilla of Vater, which was diagnosed as adenoma by a biopsy. A total extirpation of the papilla of Vater with reconstruction of the papilla was performed. The postoperative course was uneventful. There have been no signs of recurrence as of one year after the operation. It is thought that total extirpation of the region with reconstruction which makes much of patient's QOL is a valuable therapy for the disease if no residual adenoma is left.

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Gastrointestinal carcinoid is commonly found in the duodenum. We experienced two cases of carcinoid tumor of the duodenum; one case of advanced carcinoid tumor of the Vater's papilla and another case of early carcinoid tumor of the second portion of the duodenum. Patient 1, a 53-year-old woman was admitted to the hospital for epigastralgia. We detected a protruded tumor 20mm in diameter at the papilla, and a pancreatoduodenectomy was performed. Patient 2, a 57-year-old woman, was pointed out having an abnormality of the stomach at a health screening. We detected an elevated tumor 10mm in diameter at the 2nd portion endoscopically. A partial resection of the duodenum and a right nephrectomy were concurrently performed because a right renal tumor was also detected.
Since early carcinoids seem to be submucosal tumor in morphology, constructive biopsy is useful for making the diagnosis. A local resection including endoscopical resection may be indicated for the tumor if it is under 10mm in diameter or its histologic invasion is limitted to the layer of musclar propria. But radical operation is necessary in accordance with carcinoma, if the size of tumor is over 20mm in dameter or histologic invasion is above the layer of musclar propria.

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The term “gastrointestinal stromal tumor (GIST)” is used to describe gastrointestinal non-epithelial tumors composed of spindle cells, although diagnostic criteria for GIST have not been established yet. We recently experienced a case of GIST of the duodenum. This case is herein reported and discussed with reference to previous cases reported in Japan. A 62-year-old woman was admitted to the hospital because of melena and anemia. Gastric endoscopy detected a submucosal tumor with central ulcer in the second portion of the duodenum, On CT, the tumor measured 4cm in diameter and was solid with a well-delineated border. Angiography showed a hypervascular tumor. Leiomyosarcoma was suggested and a pylorus-preserving pancreatoduodenectomy was performed. Histopathologically, the tumor was composed of spindle cells, and there was no mitosis. Immunohistochemical study revealed that the tumor was positive for vimentin, CD-34 and c-kit protein, and partially positive for S-100 protein while it was negative for desmin, SMA, HHF-35, and NSE. Therefore, this tumor was diagnosed as uncomitted type of GIST.

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A 22-year-old man was admitted to the hospital because of epigastric pain and vomiting. Upper gastrointestinal endoscopy showed a dilatation from the stomach to duodenum. An upper gastrointestinal study revealed stenosis of the jejunum, abnormal position of the duodenojejunal junction, and the proximal jejunal loops to the right of the midline. Barium enema study showed that the ascending colon dislocated to the midline (left-sided colon). Abdominal CT scan revealed a whirl-like pattern, consistent with proximal jejunum encircling the superior mesenteric artery. Enhanced CT scan also showed SMV rotation sign, proximal SMV lied on the right ventral aspect of the SMA. A diagnosis of malrotation of the intestine with volvulus of the midgut was made. At laparotomy, the midgut twisted clockwise by 360°. Ladd's procedure and appendectomy were performed.
Although the midgut volvulus is rare in adults, preoperative diagnosis may be made if the possibility of this disease is kept in mind.

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It is rare that malrotation of the intestine in adult is diagnosed preoperatively. A 27-year-old man visited a hospital with anorexia and vomiting. First, he was diagnosed as having duodenal obstruction by ultrasonographic examination and CT scanning, and he was treated with stomach tube conservatively. However, a duodenography revealed a stenosis of the third portion of duodenum, and an angiography revealed branches of small intestine occuring from the right side of superior mesenteric artery, and colonic branches from the left side. Finally, malrotation of the intestine was diagnosed. The patient was sent to the hospital for operation. Intraoperative findings showed correct position of the colon, torsion of the small intestine clockwise by 180 degree around the axis of ileum about 10cm distant from the terminal ileum by strangulation occuring at the middlemesenterium of transversus colon, and stenosis of the duodenum. The torsion was reduced, and the stranguration was dissected. The small intestine was arranged to right side, the colon to left side, and an appendectomy was performed. It was considered a case of malrotation by 180 degree in Kakuda's classification. In the case of ileus of upper gastrointestinal tract, this disease must be kept in mind as a probable differantial diagnosis.

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This paper describes a case of Crohn's disease causing ileal perforation which demanded an emergency laparotomy. A 26-year-old man was admitted to the hospital because of abrupt onset of abdominal pain. Abdominal X-ray film revealed ileal gas. Abdominal ultrasonography and computed tomography revealed free air. An emergency operation was performed with a diagnosis of perforated peritonitis. In addition to a large amount of purulent fluid, a perforation of the small intestine was detected at a site of 50cm from the ileocecal junction. About 20cm of the ileum was resected. Macroscopically, the ileum was diffusely erythematous and edematous, with longitudinal ulcer on the mucosa. Histologically, transmural inflammation with noncaseous granuloma was seen and Crohn's disease was confirmed. This relatively rare case of Crohn's disease causing perforated peritonitis is presented together with a review of the literature.

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A case of ileal endometriosis presented with intestinal obstruction is reported.
A 44-year-old woman, complaining of abdominal pains around menstrations, had been observed as bysmenorrhea for about one year because no abnormalities were revealed on gynecological examinations. The patient became to complain of severe abdominal pains and vomiting since a month ago and was admitted to this hospital under the diagnosis of intestinal obstruction.
A laparotomy was performed, for conservative therapies were unsuccessful. Flextions, adhesions and intestinal wall thickness of the ileum at the 20cm oral portion from the terminal ileum were observed and the oral side intestine from this portion was markedly dilated. A segmental resection of the ileum was performed and the lesion was diagnosed as ileal endometriosis on pathological examinations.
It is very difficult to diagnose endometriosis of the small intestine preoperatively, because this disease rarely involves the small intestine and presents with intestinal obstruction. We have to keep this disease in mind on adult woman who manifest gastrointestinal symptoms associated with dysmenorrhea. A careful observation is reguised after operation, because it can frequently recur and often has multiple lesions.

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A 46-year-old man was admitted to the hospital because of abdominal pain and vomiting. The abdomen was distended. There were tenderness, rebound tenderness, and muscle guarding in the right lower quadrant of the abdomen. Simple abdominal x-ray film revealed prominent gas and niveau formation of the small intestine. Intestinal obstruction and peritonitis due to acute appendicitis were suspected, and an emergency operation was performed. During surgery, a moderate amount of yellow transparent ascites was present in the abdominal cavity, but only mild inflammatory findings were seen in the appendix. An exploration of the abdominal cavity revealed an induration in the ileum about 130cm to the ileum end. An oral portion of the ileum from the induration dilated and the narrowed intestinal lumen at the site might cause intestinal obstruction. A partial resection of the ileum including the induration was performed. After the operation when the resected material was opened, redness and thickening of the mucosa were seen. Pathologically transmural infiltration of inflammatory cells mainly composed of eosinophilic leukocytes at the induration was confirmed. Eosinophilic enteritis was diagnosed.

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This paper present a case of ileocecal volvulus causing extensive intestinal necrosis.
A 78-year-old woman was admitted to the hospital because of abdominal pain and symptoms of intestinal obstruction. Plain abdominal X ray film showed air-fluid level and a markedly distended bowel with gas in the right abdomen. Abdominal CT scan revealed an abnormally distended and thickened wall of the colon. The right lobe of the liver and right kidney were displaced and it was remarkable for the right kidney which was displaced to the middle retroperitoneal space. Bloody ascites was confirmed by a peritoneal puncture and we performed an emergency operation under a diagnosis of strangulating obstruction. At laparotomy ischemic change and necrosis of the ileocecal portion were identified, and it was twisted clockwise by 180 degree and was strangulated by a fibrous band. There was further extensive bowel necrosis due to mesenteric circulatory disturbance. A broad resection including the small intestine and the right side of the colon was performed. The remnant small intestine was approximately 50cm in length. Three months after the initial surgery, the alimentary tract was reconstructed by jejunocolostomy. The patient was weaned from total parenteral nutrition and was discharged from the hospital on 145th postoperative day. This is the first case of ileocecal volvulus complicated with necrosis of the extensive intestine in Japan.

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A 63-year-old man was seen at the hospital because of heart burn, bloody stool and abdominal fullness. After close examination, a left upper abdominal mass was diagnosed as mesenchymal tumor arising from the transverse mesocolon, which involved the transverse colon, stomach and jejunum. Enbloc resection of the huge tumor mesuring 16×12×9cm was performed. There was a 9×8cm type 3 tumor on the mucosa of the transverse colon. The tumor was diagnosed as neuroendocrine carcinoma of the transverse colon pathologically with immunohistochemical stains. He died of multiple liver metastases three months after the operation.

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A 68-year-old man was admitted to the hospital for investigation of anemia and bloody stools. Colon fiberscopy showed a type III tumor of the sigmoid colon and a type I rectal tumor. Histological examination of biopsy specimens taken from both these tumors offered a diagnosis of adenocarcinoma, but there was no evidence of metastasis to other organs. Laparotomy findings showed N0, H0, P0, and a hard ligamentum around IMV from the sigmoid colon tumor was present. Intraoperative frozen section diagnosis of this hard ligamentum was adenocarcinoma. An anterior resection with complete excision of the tumor with the hard ligamentum was carried out. Histological findings of the sigmoid colon tumor showed a2, n2, and those of the rectal cancer showed mp, n0. Both tumors were confirmed to be moderately differentiated adenocarcinoma. Tumor thrombosis was demonstrated in IMV, and invasion was found in the external inferior mesenteric vein. The patient recovered uneventfully and is currently alive with no evidence of recurrence 30 months after the operation. This patient presented with a very unusual mode of metastasis and invasion, for that we had difficulty in making diagnosis preoperatively. We emphasize that the complete resection of cancer with tumor thrombosis prevents the migration of cancer cells through tumor thrombosis.

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Kasabach-Merritt syndrome is commonly caused by infantile hemangioma. This time we experienced a case of hemangioma of the liver associated with Kasabach-Merritt syndrome in adult which was successfully treated by ligation of the hepatic arteries, with a long-term uneventful postoperstive corse.
A 40-year-old woman was admitted to the hospital for futher examinations of an abdominal tumor. A diagnosis of multiple giant hemangioma of the bilateral liver lobes was made. No abnormalities were noted in laboratory data. The patient was strictly followed in the clinic. Three months later, the tumor size increased and severe coagulopathy developed. Anti-DIC therapy was started, but was not effective. At surgery, the middle and left hepatic arteries were ligated, because the right portal vein was stenotic on angiography. The patient recovered from DIC after the surgery. She has been leading a normal social life without any symptoms due to the hepatic hemangioma for the last 15 years.

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We present two cases of inflammatory pseudotumor (IPT) of the liver and a review of the literature. Case 1: A 56-year-old woman was admitted to the hospital because of appetite loss and vomiting. Abdominal ultrasonography and CT scan showed a heterogeneous mass with irregular margin in the right lobe of the liver. Pelvic CT scan demonstrated an irregular-shaped tumor 6×5cm in size. Under a presumable diagnosis of pelvic tumor with liver metastasis, hysterectomy, bilateral oophorectomy and right lobectomy of the liver were performed. Histological diagnosis was endometroid adenocarcinoma of the right ovary annd IPT of the liver. Case 2: A 51-year-old man was admitted to the hospital because of fever. Abdominal ultrasonography and CT scan demonstrated an irregular heterogeneous mass with 4.3cm in diameter in S6, 7 of the liver. Histological findings of needle biopsy specimen revealed inflammatory fibrous tissue with infiltration of macrophages, lymphocytes and plasma cells. Since malignant disease could not be completely ruled out, a right lobectomy of the liver was carried out. Histologically, the diagnosis of IPT was established. It is suggested that we should entertain the disease as a probable diagnosis for liver tumors with inflammatory reaction.

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The left triangular ligament of the liver is frequently transected using electrocautery without closure of the surgical stump in the course of the upper abdominal surgery for wide exposure of the cardiac parts of the stomach. There, however, have been few reports of some complications due to this procedure. We experienced a case of postoperative bile leakage from the cut-edge of the hepatic side of the left triangular ligament transected during a total gastrectomy.
A 75-year-old man underwent a total gastrectomy with a distal pancreatectomy, a splenectomy, a dissection of the regional lymph nodes including those in the hepatoduodenal ligament, and a cholecystectomy for Borrmann-type3 gastric cancer. Soon after the operation, a large amount of bile discharge through a drain placed in the left subphrenic space was noticed. Seven hours later, an exploratory laparotomy revealed bile leakage from the transected left triangular ligament of the hepatic side. It was sutured afte a partial resection for sampling. Histological examination disclosed the existence of large aberrant bile ducts in the laft triangular ligament. Thereafter, his postoperative course was uneventful.
This complication is thought to be rare, but great care should be exercised if the surgical stump of the ligament is left unclosed after transection.

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A 63-year-old male was diagnosed with a simple liver cyst in 1990, but he did not receive any follow-up for around 5 years. In June 1997, he was admitted to our hospital for further examination when an abdominal US showed multilocular cysts with irregular walls and septa in segments 5 and 6. Liver function and serum tumor markers were within normal ranges. MRI revealed hyperintensity due to hemorrhage at the bottom of the cyst content. A hypervascular portion was seen on the cystic wall in CT during arteriography and enhanced MRI. From these findings, this tumor was regarded as hepatic cystadenoma/adenocarcinoma with hemorrhage. A partial hepatectomy of segments 5 and 6 with cholecystectomy was carried out. Pathological diagnosis was intracystic hemorrhage of a simple cyst. Intracystic hemorrhage of a simle cyst in the liver should be considered in differential diagnosis among cystic liver diseases, because this disease is relatively rare and mimics hepatic cystadenoma/adenocarcinoma in medical imagings.

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A 60-year-old man was admitted to the hospital for general treatment of a liver abscess. The blood antiamebic antibody titer and treponema pallidum hemagglutination test (TPHA) of the patient showed positive responses reactions. Abdominal computed tomography (CT) revealed a single low density area involving mono-bubble gas in the right lobe. To investigatecausative bacteria and treat the liver abscess, percutaneous transhepatic abscess drainage (PTAD) was performed. Colon fiber revealed multiple ulcerative lesions throughout the entire large intestine excluding the rectum. These findings suggested the amebic liver abscess via transportal infection from amebic colitis. The space of the abscess cavity gradually decreased, but PTAD radiography revealed a hepatoduodenal fistula, which was not closed and refractory. So a lapalotomy was performed leading to a complete cure. The liver abscess, which perforates the digestive tract and forms fistula like in this case is extremely rare. Only 21 cases have been seen in the Japanese and English literature.

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This paper reports a case of adenosquamous cell carcinoma of the liver. A 68-year-old man was seen at the hospital because of poor appetite. On physical examination, a fist-sized tumor was palpated in the left upper abdomen. As for tumor markers, increases in CEA, CA19-9, and DUPAN-2 were noted. Imaging procedures revealed a tumor about 10cm in diameter in the lateral segment of the liver, and invasion into the stomach and spleen was suspected. Further, complete atrophy of the right lobe of the liver was confirmed. ICG 15 min-retention rate was 24% and disappearance rate was 0.08%, suggesting impaired hepatic function. We wavered to make decision whether it was operable or not, but we employed to operate on. The reasons lay in that the internal segment enlarged and the lateral segment was mostly occupied by the tumor, suggesting that the capacity of the hepatic parenchyma to be resected might be minimal. Operative procedures included a lateral segmentectomy of the liver, a total gastrectomy, and an associated resection of the pancreas and spleen. Based on histopathological study after the operation, adenosquamous cell carcinoma of the liver was diagnosed. The patient was associated with DIC and died of hepatic failure on the 25th postoperative day.
It is case that called for our reflection in operative indication.

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Biliary stricture of the hepatic hilus is caused by malignant diseases in most cases. But we successfully diagnosed a case of hilar biliary stricture as benign preoperatively based on the findings of percutaneous transhepatic cholangioscopy (PTCS) and changes in the biliary image with time.
A 61-year-old woman was admitted to the hospital because of anemia, fever and obstructive jaundice. Percutaneous transhepatic biliary drainage revealed the severe hilar biliary stricture, cholelithiasis, choledocholithiasis and biliobiliary fistula connecting to the common hepatic duct and gallbladder. We diagnosed this case as inflammatory stricture due to cholecystitis, because the stricture gradually improved with time, and PTCS biopsies of mucosa of the gallbladder and fistula disclosed no malignancy. At the same time, carcinoma of the sigmoid colon and its liver metastasis were found spontaneously, and sigmoidectomy, left caudate lobectomy, lithotomy after choledochotomy and biopsy of the gallbladder were performed. Histopathological findings confirmed the diagnosis. After the operation, endoprosthesis with a catheter was carried out for the hilar biliary stricture. Authors recommend the use of PTCS for the diagnosis and treatment of hilar biliary stricture which presents difficulty to determine whether it is benign or not.

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Acute hemorrhagic cholecystitis is a rare cause of hemobilia and can develop into jaundice, hematemesis, and right upper abdominal pain. We report a case of acute hemorrhagic cholecystitis. A 66-year-old man visited our hospital because of upper abdominal and chest pain. On examination, his pulse rate and blood pressure were 80/min and 170/100mmHg, respectively. Abdominal tenderness and guarding were recognized. Laboratory data showed inflammatory findings as follows: white blood cell 13, 600/mm³, total bilirubin 1.2mg/dl, GOT 67IU/L, and ALP 151IU/L. Abdominal CT revealed swelling of the gallbladder and its content was iso-dense, with a hight-density area in the stomach that suggested bleeding. A diagnosis of acute hemorrhagic cholecystitis was made and an emergency operation was performed. At laparotomy, there was a gangrenous lesion between the cystic duct and the neck of the gallbladder. No abnormality was found except in the gallbladder, and cholecystectomy was performed. Histological examination revealed almost normal mucosa of the gallbladder and no arteriosclerosis, so we suppose that the cause of the bleeding was idiopathic. The patient was discharged on the 17th postopera-tive day without complications.

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We report a case of temporary pancytopenia with hypoplastic bone marrow after an operation for hilar bile duct carcinoma. A 51-year-old man was admitted to the hospital because of jaundice. Close examinations revealed hilar bile duct carcinoma. He underwent a left hepatectomy, a bile duct resection, and an intraoperative radiation therapy (20Gy). Moreover, he received remote after loading system (24Gy) because of positive surgical margin. On 54th day after the operation, he complained of general fatigue and laboratory examinations revealed pancytopenia and renal failure. Thereafter the number of platelet cells decreased to 12, 000 and white blood cells to 500. Biopsy of the bone marrow revealed hypoplastic change. Steroid pulse and symptomatic therapies were effective and he recovered 64 days after the operation. The cause of suppression of the bone marrow was still abscure. He had no fever and abnormalities on examinations for coagulants. It is necessary to start treatments for bone marrow suppression as soon as possible. And it is thought that there are some cases of unknown orgin for which steroid pulse therapy is useful in addition to medication with glanulocyte stimulating factor or platelet transfusion.

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This paper presents a case of squamous cell carcinoma of the gallbladder with cholecystoduodenal fistula. A 48-year-old woman was admitted to our hospital because of loss of appetite and body weight. Ultrasonography and abdominal CT showed a large mass with infiltration to the liver and accompanied by free air in its central part. An upper gastrointestinal series revealed a narrowed segment of the duodenum. Under a diagnosis of gallbladder cancer with infiltration to the liver and the duodenum, a hepatopancreatoduodenectomy was carried out. The tumor was a massive type, and cholecystoduodenal fistula and cholecystitis were recognized. Histopathologically the tumor was squamous cell carcinoma of the gallbladder. Our operation was curative. Therefore, a radical operative procedure is recommended for a favorable prognosis.

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A 46-year-old man was admitted to the hospital becouse of fever and epigastralgia. A chest X-ray examination revealed left pleural effusion. He received antibiotic therapy under a diagnosis of pleuritis. By a reason of slight elevation of amylase in serum and urine, a pancreatic cyst was pointed out with CT. The patient developed bloody sputa and dyspnea since September 4th. Thoracocenthesis disclosed an elevation of amylase value in pleural effusion. MRCP of the abdomen demonstrated a fistula between the retroperitoneum and pleural cavity. Internal drainage of gastrocystostomy was performed in November 29th and intraoperative US and cystography identified the same findings as of preoperative MRCP revealed. Postoperative course was almost uneventful and the pseudopancreatic cyst disappeared. Pseudopancreatic cyst with pleural effusion in chronic alcholic pancreatitis is relatively rare. We report this case in which pancreaticopleral fistula was demonstrated by MRCP, intraoperative US and cystography and a cure could be yielded by gastrocystostomy.

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A 1 year and 5 month-old male was admitted because of pancreatitis. US and CT showed a swollen pancreas and ascites. Although conservative therapy decreased the serum amylase value, jaundice and abdominal distension appeared. The fluid obtained by intraabdominal puncture revealed bile juice. Emergent operative findings disclosed a perforated bile duct on the upper of the pancreas and T-tube drainage was carried out. Cholangiography conducted via the T-tube showed cylinderical dilatation of the common bile duct and pancreaticobiliary maljunction. Cholecystectomy, choledochus duct excison and hepaticojejunostomy were performed. Physicians should consider pancreaticobiliary maljunction as a cause of pancreatitis and obstructive jaundice, and recognize that perforation of the bile duct can be associated with this condition. Key words: pancreatitis, pancreaticobiliary maljunction.

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A 46-year-old man who had been pointed out having a pancreatic tumor at a complete physical examination but let it alone for 2 years was admitted to the hospital for close exploration in January, 1997. Ultrasonography revealed a 2.0×1.9cm low echoic tumor with a calcified center at the pancreatic body. CT scan visualized a tumor with periphery of iso-density to the pancreas and a internal portion of low density with calcification partially. No lymph nodes swelling was confirmed. Endoscopic retrograde cholangio-pancreatography revealed no findings other than faint oppressed image of the main pancreatic duct. Abdominal angiography revealed no obvious feeding vessels nor accumulation of a contrast material. Since a possibility of malignancy could not be ruled out, a pancreatosplenectomy was performed on July 17, 1997. Histopathologically it was acinic cell carcinoma. Postoperative course was uneventful. There have been no signs of recurrence as of 2 years after the operation.
This case of acinic cell carcinoma which is a relatively rare entity is reported here, together with immunohistologic and electron microscopic findings.

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A case of splenic abscess successfully treated with percutaneous drainage is reported. A 78-year-old man was suffered from ileus due to cancer of the sigmoid colon and an artificial stoma was made. After the operation, spike fever was continued and an abdominal CT scan leaded to a diagnosis of splenic abscess. Percutaneous drainage of the splenic abscess brought him a good condition. Percutaneous drainage of splenic abscess has not yet become a common procedure due to a potential risk of bleeding, but it seems to be a safe and effective treatment for the splenic abscess. In future the procedure will be the therapy of choice.

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The adrenal gland is one of the common organs of hematogenous metastasis from hepatocellular carcinoma (HCC), but such cases have been rarely reported so far. The reasons were because most metastasis occurs intrahepatically, the prognosis is poor, and resultantly distant metastasis rarely becomes an object for treatment. We experienced a case of left adrenal metastasis from HCC in a 65-year-old man during treatment for C type cirrhosis and HCC. PIVKA-II increased remarkably and left adrenal gland metastasis of HCC was diagnosed. Because the primary tumor was controlled by PEIT and no other metastases were found, an adrenectomy was performed. There have been no signs of recurrence as of 8 months after the operation. A total of 61 cases of adrenal metastasis of HCC, including this case, have been reported. Changes in level of the patient's tumor maker such as AFP or PIVKA-II were clinically useful for the detection of the metastatic lesions and the evaluation of therapeutic effects. In conclusion, active management and surgery are recommended for metastasis to the adrenal glands, if intrahepatic recurrence and other extra hepatic metastasis are controlled.

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A 46-year-old man was admitted to the hospital because of a submucosal tumor found at the left side of rectum at a medical checkup. CT and magnetic resonance imaging showed a retrovesical fist-sized cystic tumor divided by septum and filled with mucous fluid, with a solid portion. Transrectal puncture-cytodiagnosis of the tumor resulted in class 1. Under a diagnosis of benign retrovesical tumor, a transabdominal extirpation of the tumor was performed. Histological diagnosis was benign schwannoma, but we could not determine the origin. Therefore, we finally diagnosed the case as retrovesical schwannoma. Only 31 cases of retrovesical schwannoma have been reported in Japan. In most of them, the tumors were palpable by digital examination. We have realized that digital examination is very valuable.

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Hepatic portal venous gas which is associated with a variety of gastrointestinal disorders is relatively rare entity. It is said to be a sign of poor prognosis. This time we have experienced a case of strangulated ileus of the small intestine due to mesenteric hiatal hernia with hepatic portal venous gas.
A 62-year-old man presented with abrupt onset of abdominal pain. On admission, an abdominal CT scan revealed no hepatic portal venous gas and intestinal obstruction was diagnosed. Abdominal pain became worse and another abdominal CT scan on the next day offered a diagnosis of hepatic portal venous gas due to intestinal necrosis. An emergency operation was performed. At surgery, a hiatus was present on the small bowel mesentery. A wide-ranging resection of the small intestine was performed due to strangulated ileus. Postoperative course was uneventful. Abdominal CT scan is of value in diagnosing hepatic portal venous gas that indicates the presence of severe intestinal necrosis. Emergency laparotomy, however, appears to yield the patient a good prognosis.

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We report a case of hemangioendothelioma arising in the intrapelvic retroperitoneum, which is thought to be relatively rare.
A 34-year-old woman was seen at the hospital because of lower abdominal pain. She had been under observation for these three years since she was found having uterine leiomyoma and a pelvic tumor at a mass screening for uterine cancer. Because the pelvic tumor was enlarging, she was admitted to the hospital for examination. Various imaging techniques such as ultrasonography, CT, magnetic resonance imaging and angiography showed a hypervascular retroperitoneal tumor in the pelvic cavity. At laparotomy, the tumor was almost softly palpated and was shrunk by slight compression. Operative finding and frozen section examination indicated hemangioma. On postoperative histological examination using some immunological stains, the tumor revealed positive responses to factor VIII associated antigen, CD-34 and Ki-67. Definite diagnosis of low grade malignancy of hemangioendothelioma was made.

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Malignant fibrous histiocytoma (MFH) originating in the retroperitoneal region is rarely encountered and its prognosis is very poor because of the local recurrence and metastases to other organs. A 74-year-old man was seen at the hospital because of a lt. lower abdominal swelling. Abdominal CTscan and magnetic resonance imaging (MRI) showed a tumor-like lesion at the lt. lower abdominal area, 10cm in size with marginal irregularity and inner density was heterogenous. Angiography from the lt. common iliac artery demonstrated a tumor stain. Under a suspicion of retroperitoneal sarcoma, an operation was performed. A resected tumor was 14×12×11cm in size and 490g in weight. With pathological findings, the tumor was diagnosed as MFH (storiform pleomorphic type)
Chest and abdominal CT scans performed 6 weeks from after the operation showed a local recurrence and multiple lung metastases. The patient died of respiratory faliure 16 weeks after the surgery. MFH has sometimes rapid cource like this case.

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