The aim of this study is to assess surgical margin status, which is an important factor as a cause of local failure after breast conserving treatment (BCT) and to evaluate the utility of probe lumpectomy (PL). Subjects were 78 cases treated by BCT at the hospital between 1993 and 1999. PL was carried out under local anesthesia. In PL the tumor was resected with a normal tissue margin of 15mm from areolar side and 10mm from the other side. We examined the extent of cancer using multiple sections of surgical specimens. After 7 days when pathological surgical margin was positive, we carried out reexcision with axillary dissection or mastectomy. When margin was negative, we performed only axillary dissection under general anesthsia. Positve final rates of overall, PL and non-PL were 21.8%, 6.1% and 33.3%, respectively (PL vs. non-PL p<0.0005). Two patients who had done non-PL and also had positve margin suffered from local recurrence. The outcomes of modalities such as magnestic resonance imaging, CT or frozen section diagnosis to predict the extent of cancer before or during operation were insufficent. Knowing the information of cancerous extent correctly using PL before BCT is useful not only to get negative final margin but also to obtain the informed consent.

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The activities of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) were studied in patients with breast cancer in our hospital. In comparisons between normal and tumor tissues for TS and DPD activities, the TS activity was high in tumor tissues compared to that in normal tissues (p=0.0211), while the DPD activity tended to be high in tumor tissues. The TS activity was higher in tumor tissues than in normal tissues in stage I+II patients (p=0.0288). In terms of those activities in tumor tissues, a higher TS activity was noted in stage I+II (p=0.0345) tumors, and a higher DPD activity was noted in tumor tissues in stage III+IV (p=0.0066). A higher tendency of TS activity in tumor tissues than that in normal tissues was observed at nO (p=0.0601). A higher TS activity was demonstrated in tumor tissues at tl+t2 (p=0.0278). TS activity at tl +t2 was high in tumor tissues (p=0.0227). As for histologic types, mucinous cancer revealed a higher TS activity than other types.
These findings indicate a possibility that the TS activity can be an indicator for antineoplastic efficacy but may not display the biological malignancy of the breast tumor.

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Bleeding from colonic diverticulum is liable to stop spontaneously, but on the other side, such patients are at high lisk of having recurrence. In a recent 3.5 year-period, we have performed transcath-erter arterial embolization (TAE) for 10 patients with bleeding from colonic diverticulum, out of 11 patients who had been underwent angiography, including eight men and three women, with mean age of 70. In this study the usefulness of TAE was investigated.
The bleeding sites were located in the ascending colon for seven patients and in the sigmoid colon for three patients. Extravascular leakage of a contrast material was observed in seven patients and dilated vessels were seen in three patients. These 10 patients were subjected to TAE using microcoil. In three patients treated in the early years, the marginal arteries or their central sides were embolized, while the vasa recta was embolized in seven patients in the recent years. No intestinal necrosis nor stenosis was observed in all of them. One out of the ten patients experienced rebleeding 6 months later, but successful hemostasis was attained by second TAE. No operation had been performed. Except one patient who died of other disease, all patients are alive and well.
It is thought that TAE for bleeding from colonic diverticulum can be an alternative therapy for operation, though we must continue to study the long-term prognosis by further observation of clinical courses of the patients.

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The purpose of this study was to examine complications and complaints of inguinal hernioplasty with Prolene™ Hernia System. Subjects weer 68 patients (75 cases) who underwent hernioplasty at our department between September 1998 and December 1999. The male-to-female ratio was 47:21, and a mean age was 68.8 years. As for complications, postoperative seromas in 10 cases (14.7%) and hematomas in two cases (2.9%). They were improved with conservative therapy. No infection nor recurrence had noted in our department.
A questionnaire survey asking postoperative complaints was conducted, and we recovered 46 replies. It was revealed that postoperative pain vanished in about one week and the patients returned to their former lives in about two weeks.
The reply “I have not had a hard time of the postoperative pain” was obtained from 51% of the responders and “I have not felt so bad with the Prolene mesh” from 55.1%. Then, consequently we have arrived at a conclusion that the inguinal hernioplasty with PHS is a good procedure in terms of minimal postoperative complications and complaints.

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Since the opening of the hospital in 1988, we have performed the day surgery for pediatric inguinal hernia. In this study, a reevaluation of the day surgery system was conducted mainly based on a questionnaire survey for the children's families. We sent questionnaire forms to 55 cases undergoing the day surgery in the hospital after 1995, and recovered filled forms from 42 cases. These 42 cases were subjected to the study.
As a result, 92.5% of the subjects replied ‘satisfactory’ for the day surgery. On the other hand, 42.9% of the subjects replied to feel anxiety for the day surgery, and 14.3% answered that they could not fully understand the day surgery only by explanation by hospital stuffs.
Although this day surgery system meets the patient's need, further our efforts to persuade them of the recognition and safety for the system would be required.

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A 64-year-old woman was admitted to the hospital because of swelling of her right upper limb and neck. She had been pointed out a goiter 30 years before admission and followed at another hospital. Since she had an arteriovenous shunt in the right arm at her 61-year-old of age, her right upper limb and neck swelled gradually.
Chest X-ray film showed a tumor shadow in the superior mediastinum. Magnetic resonance imaging revealed a narrow right jugular vein, which was remarkably compressed by the goiter, with stagnation of bloodstream. The patient was diagnosed as having a giant intramediastinal goiter with superior vena caval syndrome. Nearly total thyroidectomy was performed. The pathological diagnosis was adenomatous goiter. After the operation, the swelling of the right upper limb and neck disappeared.
Malignant lung cancers account for most cases of superior vena caval syndrome, but on the other hand, thyroid disease account for rare cases. In this case the increase in venous pressure by the arteriovenous shunt might take part in casing the disease, too. We must also take into consideration the thyroid disease in making an arteriovenous shunt.

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We report two cases of radio-guided parathyroidectomy using a gamma probe (Navigator^®) for primary hyperparathyroidism. Patient 1 was a 52-year-old woman. Despite uncertain preoperative localization with echography and CT, ^99mTc-MIBI scintigraphy revealed an abnormal tumor closed to the left lower lobe of the thyroid. Patient 2 was a 66-year-old woman who had undergone a subtotal thyroidectomy for Graves' disease at the age of 42. CTscan and magnetic resonance imaging revealed an abnormal tumor behind the remnant right lobe of the thyroid. Preoperative localization of ^99mTc-MIBI scintigraphy was unclear. Sestamibi was injected and radioactivity was measured pre- and intraoperative periods with a gamma probe. The gamma probe made the accurate localization of the radioactive parathyroid tumor (patient 1: inferior area of the left thyroid lobe, patient 2: superior area of the remnant left thyroid lobe) under general anesthesia. The resected tumor of the patient 1 measured 11×6mm in size, weighed 410mg, and that of patient 2 17×14mm, 361mg respectively. The pathological diagnosis was parathyroid adenoma in both cases.
The gamma probe is useful not only to localize the parathyroid tumor in primary hyperparathyroidis-m accurately but also to provide a cosmetic benefit and less invasive surgery.

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A 76-year-old woman was seen at the hospital because of a left anterior neck tumor. Physical examination revealed a 7.5×4.5cm hard mass in the left lobe of her thyroid. Based on the findings of the aspiration biopsy cytology, the tumor was diagnosed as papillary carcinoma of the thyroid. A subtotal thyroidectomy and a modified radical neck dissection were performed (T4, Ex2, Nla). Because the huge tumor and the metastatic lymph nodes invaded the left recurrent laryngeal nerve, the nerve was sacrificed. We could not anastomose the recurrent laryngeal nerve directly because the proximal edge of the nerve could not be identified. Furthermore, we could not use the left ansa cervicalis for the reconstruction because of its condition. So we anastomosed the distal stump of left recurrent laryngeal narve to the right ansa cervicalis which was brought up by passed in front of the trachea. After the operation, hoarseness due to unilateral vocal cord paralysis was observed. But her voice was improved gradually. Five mouths later, the patient was satisfied with her voice. Recurrent laryngeal nerve reconstruction with contralateral ansa cervicalis was effective for the improvement of the phonation of the patient who underwent recurrent nerve severance.

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This paper deals with a case of pseudoaneurysm of the neck associated with von Recklinghausen disease.
A 60-year-old man seen at the emergency clinic in our hospital because of left shoulder pain and a swelling on the left side of the neck. Close examinations revealed spontaneous rupture of a branch from the left subclavian artery and a pseudoaneurysm of the neck. An emergency operation was performed. At operation, the left thyrocervical trunk was almost dissected at its root and a formation of pseudoaneurysm at the site was observed. The thyrocervical trunk was ligated at the root which led to a successful hemostasis. Postoperative course was uneventful. There has been no re-bleeding for 2 years and 2 months after the operation.
Sometimes von Recklinghausen disease is associated with vascular lesions, however, it rarely causes aneurysms or spontaneous rupture of arteries. So far, only 17 cases of aneurysm and 18 cases of spontaneous rupture of arteries have been reported in the Japanese literature.

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A61-year-old woman was seen at the hospital because she noticed a left breast mass. A well movable tumor was palpable in the C area of left breast. Ultrasonography revealed a 12×9×8mm demarcated iow-echoic region with slightly heterogeneous inside. Mammography visualized a partially irregular image in the left berast. Needle aspiration biopsy cytology disclosed nucleoli as well as relatively numerous cells, indicating class III. Under local anesthesia, an excisional biopsy was perfor-med. Aa a result of histopathological exploration, ductal carcinoma was diagnosed and a radical operation was performed. Despite the pathological diagnosis of ductal carcinoma, the tumor cells were positive for S-100 protein and HHF-35 and vascular infiltrating was revealed. The definite diagnosis of malignant adenomyoepithelioma was made.
In the diagnosis of the disease, histopathological and electron microscopic findings are helpful. Adenomyoepithelioma manifesting malgnant features is so rare that only two cases have been reported in Japan.

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An 86-year-old woman complaining of edema in the lower limbs and general fatigue was admitted to the hospital because she was pointed out having a right breast tumor at another hospital. This tumor was large occupying the entire right breast and elastic soft with a swelling of lymphonodi axillares. We noticed preoperatively that she had a pancytopenia, of unknown origin and an operation was preceded by sufficient blood transfusions. Nevertheless, active bleeding occurred and continued after the operation. Reoperation was performed, when a puncture of the marrow was carried out to examine tha cause of pancytopenia. Myelodysplastic syndrome was confirmed on this procedure. After a resection of the breast tumor, pancytopenyia was recovered gradually. Now, about 9 months after the operation, neither anemia nor a loss of platelet cells has occurred. We present a case because it is speculated that the treatment of one of double cancers provided an improvement of MDS, other malignancy.

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We experienced a rare case of spindle cell carcinoma of the breast. A 46-year-old woman was admitted to the department because of a left breast lump. She underwent a modified radical mastectomy with a preoperative diagnosis of normal type breast carcinoma. The tumor was pathologically diagnosed as spindle cell carcinoma. The spindle cell component was immunoreactive for vimentin and EMA (epithelium membrane antigen). No metastases were found in the axillary lymph nodes. The pathological stage was t2n0m0. The patient has been free from recurrence, as of 14 months after the operation. Spindle cell carcinoma of the breast is an uncommon tumor. Histologically, its dominent component consists of sheets of spindle-shaped cells and includes contiguous carcinoma components. Despite its sarcomatous features apparently, spindle cells are derived from epithelial cells of the mammary glands. A total of 62 cases collected from the Japanese literature including this case were reviewed clinicopathologically. Spindle cell carcinomas were thought to be bigger in size than normal type breast carcinomas. Otherwise, lymphogenous metastases occurred infrequently. Many cases have cystic lesions. Therapy and prognosis of the disease are still controversial, but many patients experienced hematogenous metastases in their early stages. Strict observation and careful treatment would be mandatory for the disease.

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A 55-year-old woman was seen at the hospital because of a right breast tumor and pain. On clinical examination, there was an elastic soft, ill-defined tumor with the diameter of 1.0cm in the A-area of the right breast. Ultrasonography suggested papillo-tubular carcinoma, and a specimen of a core needle biopsy showed invasive ductal carcinoma. Then we performed a quadrantectomy with axillary lymph node dissection. Histological examination revealed adenoid cystic carcinoma. Adenoid cystic carcinoma of the breast has a relatively good prognosis. Breast conserving operation is recommended for the disease if surgical margin is free, though long term and careful follow-up of the clinical course would be needed.

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A 70-year-old man with cervicomediastinal cystic lymphangioma which is relatively rare was successfully treated by operation. He had undergone a resection of the left lower lobe of the lung for lung cancer three and a half years before and had had no evidence of relapse. Periodical chest CT scan showed a left cervico mediastinal low dense mass involving the left common carotid artery and subclavian artery. Cervical ultrasound examination visualized multiple cystic masses. Lymphangioma rather than recurrence of lung cancer was suspected and a resection was performed by a neck collar incision and a median sternotomy. The tumor was localized from 3cm above the top of the thyloid gland to the aortic arch and medially reached to the right side of the anterior surface of the vertebra behind the esophagus. Left common carotid artery and subclavian artery were preserved by cutting the tumor. Tumor dissection was very difficult because of fibrosis due to mediastinal lymphadenectomy at the previous operation, however, the tumor was completely resected. The tumor was 9cm in maximum diameter and multiple cystic lesion with serous fluid. Pathological diagnosis was cystic lymphangima. He is alive and well wihthout relapse, as of 18 months after the operation.

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A 58-year-old man was admitted to our hospital because of syncope, and cerebral infarction was diagnosed. On admission, electrocardiography revealed fibrillation, and a large left atrial tumor was demonstrated by echocardiography. We resected the left atrial tumor and performed a simple left atrial procedure to treat the chronic atrial fibrillation by a biatrial operation. Transesophageal echocardiography was used to evaluate the tumor and the mitral valve. Histological examination revealed that the tumor was a myxoma with a Gamna-Gandy body. After the operation, sinus rhythm was restored, and atrial systolic function recovered.
Systemic embolization is an important problem in surgery for atrial myxomas and atrial fibrillation, and thus it is useful to perform a simple left atrial procedure with resection of the atrial myxoma. We have tried several operative techniques to treat atrial myxoma and have found that it is important to understand their features, and to select the best method on a case by case basis in view of the probable postoperative arrythmias.

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Intravenous leiomyomatosis (IVL) is a rare benign tumor that originates from uterine myoma and rarely extends from the ovarial vein to heart through vena cava inferior (IVC)
A 47-year-old woman showed ECG abnormality without symptoms in a regular health check up with her local physician. A cardio echogram revealed a RA mass and the physician referred her to us with a diagnosis of RA tumor. There was a history of undergoing a total hysterectomy 2 years previously. A CT scan and an angiography also revealed an RA tumor.
Open heart surgery was performed with the diagnosis of RA mxsoma. A tumor was found in the RA arising from IVC but could not be totally resected because of partial but firm adhesion to on the IVC wall. A histological study showed a benign leiomyoma.
IVC graphy and magnetic resonance imaging one year later showed the remaining tumor extending from the lower IVC to hepatic vein level.
IVC was incised in the upper and lower parts and the tumor was totally removed under a partial cardiopulmonary bypass.
The patient followed a successful course.

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A 71-year-old woman was referred to the department bacause of a pulsatile abdominal mass. CT scan showed an abdominal aortic aneurysm with the maximum diameter of 6cm. Platelet count was 12.0× 10⁴/mm³ two and a half years before admission, 9.3×10⁴/mm³ one year before admission and 6.4×10⁴/mm³ on the day before operation and the value of PAIgG was increased to 116.4ng/10⁷ cells. On the day before operation 15g of γ-globulin was transfused. On the operation day the same amount of γ-globulin and 20 units of platelet and on the first postoperative day 10 units of platelet were transfused. The aneurysm was successfully replaced with a Y graft without any complications. Platelet count was 12.8×10⁴/mm³ just after the operation, 9.7×10⁴/mm³ on the second day, and increased to the maximum of 23.4×10⁴/mm³ on the 18th day. Then it turned to decrease and dropped to 7.0 × 10⁴/mm³ 10 months after the opration. With the administration of highdose of γ-globulin and platelets, the aneurysm was replaced safely.

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We treated two patients with intrapulmonary lymph node (IPLN), which were shown as a nodular subpleural shadow by chest computed tomography (CT) scan and diagnosed after resection through thoracoscopic surgery.
Case 1, a 72-year-old man, was seen at the hospital for a regular medical check up. Chest CT scan showed a nodular shadow measuring 7mm in diameter in the S¹⁰segment of the left lung, and a wedge resection was performed through thoracoscopic surgery to obtain the diagnosis.
Case 2, a 64-year-old woman, was seen at the hospital because of cough. Chest CT scan showed a nodular shadow measuring 6mm in diameter in the S⁹ segment of the left lung. After wait and see for 3 months, CT scan showed a slight enlargement of the nodule, and therefore, a wedge resection was performed through thoracoscopic surgery.
It is sometimes difficult to differentiate a subpleural IPLN and small peripheral lung cancer with CT scan. It should be considered that an intrapulmonary subpleural nodular lesion might be an IPLN even if it shows malignant features on CT scan, and biopsy through thoracoscopic surgery is necessary to gain the histological diagnosis.

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A 66-year-old man was pointed out a nodular shadow in the left lung at a chest X-ray film before operation for cataract and was treated with a diagnosis of pulmonary tuberculosis, with a resultant decrease in size of the tumor. One year later, a chest X-ray film revealed increase in the nodular shadow, and levels of tumor markers were noted elevated. Cytology, however, resulted in negative. Transbronchial lung biopsy and CT-guided transcutaneous needle lung biopsy were performed and mucous-producing adenocarcinoma was suspected. A left lower lobectomy of lung was performed. It was a grossly white jelly-like tumor and histologically mucious cystadenocarcinoma.
Although mucinous cystadenocarcinoma of the lung is of low grade malignancy and belongs to a rare entity, we must consider the disease in the differential diagnose, if the clinical course appears to be unexpected in cases once diagnosed to be pulmonary tuberculosis of lung suppuration. In case of mucious cystadenocarcinoma, transbronchial lung biopsy alone often presents difficulty in making the diagnosis, whereas transcutaneous lung biopsy and/or needle aspiration biopsy cytology are of value, and recommended to performed activity.

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A 60-year-old woman was incidentally found to have a tumorous shadow in the left lung S₆ on a chest x-ray film while she was seen at the department of internal medicine in our hospital. The patient had been suffering from anemia, and consequently with a suspicion of a primary or metastatic tumor, close gastrointestinal exploration was performed. Colonofiberscopy revealed a type 2 tumor of the ascending colon. Biopsy resulted in group V. On July 27, 1994, a right hemicolectomy was performed. Histopathologically it was mucinous carcinoma, ss, ly1, v1, and n₂(+). One month later, a segmental excision of the left lung (S₆) was performed because the tumor of the left lung S₆ was thought to be primary pulmonary cancer, namely double cancer. Histopathologically mucinous carcinoma was comfirmed and pulmonary metastasis of the colonic caner was diagnosed.
Lung metastasis of colonic cancer has a poor prognosis and the metastatic lung cancer is rarely resected. This patient, however, has been free from any signs of recurrence as of 5 years after the operation.

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A 50-year-old woman was admitted to the hospital because of an abnormal shadow detected incidentally by a routine chest X-ray, examination 4 years previously, when she was asymptomatic. The tumor gradually increased in size in those years. After admission, a partial resection of the lung including the tumor was performed. The tumor was attached to the visceral pleura of right lower lobe by a pedicle. Pathologically the tumor was solitary fibrous tumor of the pleura (localized fibrous mesothelioma). The histogenesis of solitary fibrous tumor is still controversial, but the mesencymal origin is preferred on the basis of immunohistochemical findings including CD34 positivity. In this case tumor cells also demonstrated positive for CD34.

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Primary lipoma of the diaphragm is extremely rare. This paper presents a case of diaphragmatic lipoma which was diagnosed by an operation in a patient presented with feeling of oppression in the right hypochondrium. A 56-year-old man was seen at the hospital because of a feeling of oppression in the right hypochondrium. Abdominal echography, CT scan, and magnetic resonance imaging revealed a tumor locating between the right diaphragm and liver. With a diagnosis of lipoma arising in the liver or diaphragm, the patient was operated on. At laparotomy, a tumor yellowish white in color connected to the right diaphragm by a pedicle with the size of tip of the small finger was confirmed. The pedicle of the tumor was ligated by a 1.0 silk thread and dissected. Pathological study of the excised material disclosed that the tumor was lipoma.

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A case of esophageal cancer associated with dermatomyositis is presented. The patient was a 68-year-old man. In January 1997, edematous erythema appeared on the neck and then extended to the arms, legs and body. In July, the patient was reffered to the hospital because of erythema and pain of the extremities and muscle weakness. On blood chemistry, the levels of creatine kinase and aldolase elevated. He was diagnosed as having dermatomyositis by skin biopsy. For the purpose of detecting malignant tumor, an endoscopic examination was carried out. And squamous cell carcinomas at middle third of the thoracic esophagus were found. On July 31, a subtotal thoracic esophagectomy was performed with gastric tube reconstruction via posterior mediastinal route. Pathological examination of the resected specimen showed moderately differentiated squamous cell carcinoma, superficial carcinoma of the esophagus, sm3, ly2, vl, PT_1b, PN₀, PM₀ in pStage I. After the resection, the concentrations of creatine kinase and aldolase were normalized, and dermatomyositis was relieved. We should carry out examination for detecting the malignant tumor soon after the diagnosis of dermatomyositis.

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Here we report a patient who suffered from acute gastric dilatation after overeating and developed gastric necrosis.
A 25-year-old man visited his family doctor complaining of abdominal pain and vomiting. Since a markedly dilated stomach was found to occupy the entire abdomen on a plain X-ray film, a gastric tube was inserted and about 3500ml of gastric contents were aspirated. His symptoms then improved and he was treated conservatively. However, blood was discharged through the gastric tube and he was transferred to the hospital. Emergency endoscopy revealed a large amount of clotted blood in the stomach and two massive ulcers were present in the regions of the fornix and gastric angle. Blood was oozing from the whole stomach. Because blood loss of 80 to 100ml/hour from the gastric tube continued, we performed a total gastrectomy with Roux-en-Y reconstruction. No postoperative complications occurred and he was discharged from the hospital.

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We report a case of gastrojejunocolic fistula probably caused by stomal ulcer after gastrectomy. The patient was a 72-year-old woman. She had undergone a distal gastrectomy for gastric ulcer 22 years before. She visited another hospital for watery diarrhea in February 1997 and was found to have a polyp of the colon. She underwent a laparotomy, but no symptomatic remission was attained. she was seen at the hospital because of abdominal pain and diarrhea in March 1999, and was hospitalized for examination and treatment. Upper gastrointestinal endoscopy revealed active stomal ulcer. The reconstruction after the previous gastrectomy was made by means of Billroth II method. Multiple lumens were identified near the anastomosis, and one of them had opened to the colon. Subsequent radiologic examinations revealed gastrojejunocolic fistula. Partial resection of the stomach and jejunum, and closure of the fistula of the transverse colon were successfully performed. After the surgery, diarrhea improved and there was a weight gain of 8kg in two months.

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The patient was 59-year-old man. He had a selective proximal vagotomy with pylorectomy and a reconstruction of gastrojejunostomy for duodenal ulcer 22 years ago. Nov. 1998 he visited our clinic because of epigastric pain and received gastric fiberscopy to be diagnosed as the gastric cancer that was located just oral to the anastomosis site of the stomach and the jejunum. Gastrectomy was performed safely.
Gastric cancer following vagotomy is a rare entity and there have been only 22 cases in the Japanese literature. In our institution, vagotomy has been performed in a series of 395 patients from 1972 to 1999, and this patient was the third case that experienced gastric cancer after vagotomy. We present this third case with a review of the literature in terms of the correlation between vagotomy and development of gastric cancer.

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This paper presents a resected case of gastric cancer arisen in the gastric tube which was elevated via retrosternal route at an operation for esophageal cancer 19 years before. The operation for the esophageal cancer was performed on December 19, 1979, when it was Mt-Lt, pT2, pN2, and in pStage III. The patient had been recurrence-free until January 1998, when the patient was admitted to the hospital because of dysphagia. Massive anal bleeding also occurred. As a result of close examination, cancer of the gastric tube was pointed out. The problems lay in the route elevating the gastric tube and the shortness of the remnant esophagus. However, there is a report ensuring that the primary feeding vessels can be dissected, and so we decided to carry out an operation. At operation, the right gastroomental artery was dissected under a median sternotomy and was resected at 6cm distal to the gastric tube. Reconstruction was made by using the ileum and right side colon involving the rihght colonic artery and middle colic artery as vascular pedicles, with a successful outcome.

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We report a case of small bowel hemorrhage due to secondary amyloidosis accompanied by chronic rheumatoid arthritis (RA) together with some bibliographical consideration.
A 51-year-old woman having underlying disease of RA from 1993 was admitted to the hospital because of inflammation of the mouth, abdominal pain and diarrhea. After her admission, she was attacked by various symptoms. Finally, she developed massive intestinal bleeding and an emergency operation under a diagnosis of small bowel hemorrhage was performed. The bleeding point could not be identified by inspection and palpation, and then we put a scope in the intestine and excised the oozing jejunum whose length was 80cm. The mucosa of the resected jejunum had diffuse upheavals of various sizes, and histopathological examination revealed doposits of amyloid in the submucous vascular wall. Immunohistologically, the amyloid was determined as AA protein. Her amyloidosis was thought to be secondary to RA. In the post operative course, no re-hemorrhage occurred by total parenteral nutrition over a year.

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A 61-year-old woman was admitted to the hospital because of a right lower abdominal tumor and pain lasting for about 17 years. Abdominal CT scan indicated an intussusception in the ascending colon, but the right lower abdominal tumor disappeared spontaneously. An idiopathic intussusception was suspected, because no possible causes could be determined by aggressive imaging studies. At laparotomy, intussusception due to a tumor in the ileum locating 50cm to the terminal ileum was detected, and the affected portion was resected. The resected specimen showed a submucosal tumor 2.5×2.5×2.5cm in size and several polyps of 4mm in size. Histopathologically they were benign lipoma and inflammatory polyps, respectively. We report this case with a review of a total of 153 cases of adult intussusception reported for a last one decade in Japan.

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A 7-month-old boy was admitted to the hospital because of bilous vomiting and abdominal distension lasting for 4days on August 24, 1993.
The abdomen was distended and tympanic. A plain abdominal X-ray film showed a fluid level in the dilated intestinal loop. No abnormalities were revealed on a barium enema study. An emergency laparotomy was performed with a diagnosis of intestinal obstruction.
Omphalomesenteric band remnants were observed between the umbilical region and the end of the dilated small intestine, and at the tip of Meckel's diverticulum which was found about 20cm proximal to ileocecal valve. The dilated small intestine twisted around the band toward more than 180 degree to counterclockwise direction and the band strangled the Meckel's diverticulum and the anal side of the ileum.
A short segment of the ileum involving the Meckel's diverticulum was resected and an end-to-end anastomosis was performed.
A histopathological examination of the omphalomesenteric band revealed that the band contained mucosa and muscularis propria on the diverticulum side, and the dilated blood vessels on the umbilical side.

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We experienced two cases of intussusception of the small intestine probably caused by an indwelling ileus tube.
Patient 1, a 59-year-old woman, underwent a jejunectomy for adhesive ileus after operation for gastric cancer and renal tumor. An ileus tube was indwelt until 6th hospital day as a splint. The patient developed ileus condition early after removal of the tube. The patient was diagnosed as having recurrence of ileus and was operated on. At laparotomy, we confirmed three intussusceptions, two in the jejunum and one in the ileum, which were reduced by means of maneuver. Patient 2, a 72-year-old man, underwent a resection of the intestine for adhesive ileus after traumatic rupture of the small intestine. During indwelling an ileus tube for the purpose of splint, ileus recurred on the 3rd hospital day. CT scan offered a suspicion of intussusception and the patient was operated on. Upon laparotomy, it was revealed that the upper part of the jejunum invaginated, and a jejunectomy was performed. Both cases were thought to be of intussusception due to ileus tube for splint.
Out of 24 cases seen in the Japanese literature, nine (38%) cases of intussusception were caused by ileus tube for the purpose of splint after operation which mostly developed early after removal of the tube. In the case of usage of ileus tube to prevent postoperative ileus, careful observation of the clinical course would be mandatory considering a possible association of the disease.

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An 82-year-old woman had undergone an operation for a tumor of the uterine body at the department of gynecology in our hospital, which resulted in an exploratory laparotomy because it was determined to be inoperable due to severe infiltration into the surrounding tissues in December, 1995. Intraoperative biopsy of the tumor revealed spindle cell tumor. While she was followed in the gynecological clinic thereafter, an abdominal pain and a feeling of oppression in the abdomen appeared. So she was admitted to the department. On admission, the tumor was 13×11cm in size on an abdominal CT scan and fistulization between the small intestine and tumor was revealed on UGI. In March 1999, an operation for bypass formation was performed when the tumor was found not to arise in the uterine and was easily dissected from the uterine. The tumor with the small intestine by 150cm in length was successfully removed. Gross study of the resected material showed that the tumor originated from the small intestine. Immunohistologically, the tumor was positive for smooth muscle action, vimentin, and c-kit, while negative for CD34. Gastrointestinal stromal tumor (GIST) of the small intestine was definitely diagnosed.

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A 70-year-old man, who complained of anemia like symptoms and was found having a tumor of the small intestine in a gastrointestinal series at another hospital, was referred to the hospital. Angiography revealed a tumor stain. Abdominal contrast enhanced CT scan visualized a tumor image. And malrotation of intestine was suspected. With a preoperative diagnosis of a tumor of the small intestine, the patient was operated on. At surgery, a tumor with the maximum diameter of 6cm like a submucosal tumor was present in the jejunum. A partial excision of the jejunum was performed. The entire small intestine occupied the right falf of the abdominal cavity and the appendix was located in the left upper abdomen, indicating malrotation of intestine. With histopathological findings and immunostaining findings, primary malignant GIST uncommitted type of the jejunum was diagnosed.
With a recent progression in immunohistochemical exploration, clinical cases of GIST have been increasingly reported. Our experience with GIST of the jejunum causing intestinal bleeding is presented here.

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Crohn's disease confined to the appendix is rare and we found reports of only 11 other cases in Japan. We present a case of Crohn's disease of the appendix in a 27-year-old man. He was admitted to the hospital because of lower abdominal pain on October 14, 1999. Physical examination at that time revealed rebound tenderness and muscle guarding of the right lower quadrant of the abdomen. Abdominal ultrasonography and an abdominal CT scan revealed a swollen tumor shadow in the ileocecal region. The preoperative impression was inflammatory tumor due to acute appendicitis. A lapalotomy was performed and the appendix was found to be markedly enlarged (60×30mm). Ileocolectomy with D2 lymph node clearing was performed with a tentative diagnosis of appendiceal malignant tumor. At the operation, the small intestine and colon showed no abnormal findings.
Histopathologically, the specimen had a full-thickness appendiceal wall showing inflammation with lymphoid and neutrophil aggregation, and showed a non-caseating small granuloma composed of epithelioid histiocytes and multinucleated giant-cells. Crohn's disease of the appendix was diagnosed. He has had no signs of recurrence of the disease as of 6 months after the operation.

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Diverticulitis of the appendix is a relatively rare entity. We have great difficulties in making diagnosis for the disease, and consequently the patients with the disease are often operated on under preoperative diagnosis of acute appendicitis.
We experienced a case of diverticulitis of the appendix, in which the diverticula contained fish bones and crab claws. A 38-year-old man was admitted to the hospital because of right lower quadrant pain. Acute appendicitis was diagnosed by physical examination, ultrasonography and abdominal CT, and an appendectomy was performed. Diverticulitis of the appendix was found in the resected specimen. Retrospective study revealed that sonographic findings of this case had typical characteristics of diverticulitis.
It is thought that we are able to diagnose diverticulitis of the appendix preoperatively in patients who are suspected to have acute appendicitis, if we pay careful attention to the possible existence of the disease.

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A 70-year-old man was admitted to the hospital because of melena and hypovolemic shock. A preoperative diagnosis of aortoenteric fistula was made by imaging assessment. Embolization of the origin of the right common iliac artery was performed, and the gastrointestinal bleeding stopped. After the patients cardiorespiratory function had become stable, laparotomy was performed. It revealed an ilioappendiceal fistula through the iliac artery aneurysm. The fistula was closed, the appendix was resected, and the aneurysm was satisfactorily dissected.
Aortoenteric fistula is generally a rare entity. The prognosis is thought to be poor because of the difficulty of early diagnosis and complication by sepsis. We report a case of common iliac artery aneurysm with ilioappendiceal fistula in which the patient's life was saved by embolization and operation.

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Malrotation of the intestine is seen mostly in infants, and is rarely found after adolescence. This paper describes our recent experience with a case of malrotation with midgut volvulus diagnosed by visual examinations in adolescence after long-term abdominal symptoms.
A 17-year-old man was seen at the hospital because of abdominal pain. The cecum and ascending colon were found to be located at the mid-upper abdomen by a barium enema examination. Abdominal enhanced CT scan revealed SMV rotation sign and a whirlpool sign. The patient was diagnosed as having malrotation with volvulus and was operated on. At operation, the patient was found to have a mlrotation with non-rotation of the midgut and with two sites of volvulus. Respective volvulus had taken place in a clockwise direction by 360 degrees. First, each volvulus was untwisted in the opposite direction. Then the Ladd's technique was carried out, followed by an appendectomy. He has been doing well without any symptoms after the operation.
Although the both malrotation and volvulus are quite rare, we would be able to diagnose the diseases by the presence of characteristic pictures on various imaging examinations.

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Endocrine cell carcinoma of the colon is highly malignant, matastasizes to other organs early, is often detected in an advanced stage, and consequently has a very poor prognosis. A rare case of endocrine cell carcinoma coexisted with adenocarcinoma in the ascending colon following a resection of early cancer of the tranverse colon is reported. A 69-year-old woman was admitted to the hospital because two independent tumors were found in the ascending colon. There was a history of undergoing a resection of an early stage of colon cancer one and half years before admission. Bariun enema study and colonoscopy revealed an early stage carcinoma of IIa type and a yellowish submucosal tumor with central indentation in the ascending colon. Ileocecal resection was performed for these tumors. The submucosal tumor, 13×8×10mm in size, penetrated into the musuclaris propria. The tumor was consisted of large atypical polygonal cells which were positive for chromogranin and synaptophysin stainings. Electron micrograph showed an inclusing of neuroendocrine granules of the neoplastic cells in the cytoplasm. Histology of the submucosal tumor revealed endocrine cell carcinoma. Neuroendocrine cell carcinoma of the colon is a rare condition, and only 42 cases have been reported in the Japanese literature. This is the first case of the endocrine cell carcinoma with synchronous adenocarcinoma in the colon after metachronous adenocarcinoma of the colon. The patient has survived 2 years and 6 months after the surgery with no signs of recurrence.

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An 80-year-old man was seen with a palpable fist-sized tumor in the right lower quadrant of the abdomen on his first visit. A barium enema study and a colonofiberscopic examination suggested the presence of a submucosal tumor located in the cecum and extending to the ascending colon. The CEA level was as high as 10.0ng/ml. Upon operation the resected tumor was found to be 8cm in size and was located in the ascending colon and cecum. The tumor was covered with normal mucosa. Histopathologically, the tumor was almost entirely covered with normal mucosa, with defects of thhe mucosa in limited areas where granular changes were macroscopically observable. The cancer foci were exposed in the regions of these defects. The tumor was diagnosed as a poorly differentiated, INF-β, ly2, vl, ew(-), ow(-), aw(-), P₀H₀n₁SiM(-), adenocarcinoma in stage IIIa. The intense interstitial infiltration of neutrophiles in the tumor was also observed.
Only 18 cases of colorectal cancer presenting as a submucosal tumor have been documented. This paper presents the characteristic histopathological findings of this interesting case together with some bibliographical comments on the mode of development and extension and the histopathological characteristics of tumors.

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Primary anorectal malignant melanoma is a fairly rare, usually lethal neoplasm because it is prone to metastasize tothe whole body in an early stage. We herein present a case of primary malignant melanoma arising in the anal canal. An 85-year-old man was seen at the hospital because of anal bleeding and anal pain. On digital examintion, a small subcutaneus mass 1.0cm in size could be palpated. Initially, a surgical excisional biopsy was performed and the resected specimen revealed malignant amelanotic melanoma histopathologically. The patient was immediately treated by a wide local excision. The patient experienced distant metastases to the lung, skin and liver, and died 3 years 10 months after the surgery.
The QOL of this patient had been well without any evidence of local recurrence in this period.

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A 49-year-old man was admitted to the hospital because of a cystic mass in the body of the pancreas by ultrasonology. Abdominal computed tomography showed a cystic mass 4×3cm in diameter enhanced in the early phase. Magnetic resonance imaging showed bilocular cysts whose margin was smooth and cyst wall was highly and homogeneously enhanced in a dynamic study. With a suspicion of nonfunctioning endocrine tumor or solid and cystic tumor, a pylorus preserving pancreaticoduodenectomy was performed. The tumor 4.3×3.3 in diameter developed in the pancreas body and its surface was reddish and smooth. The cystic formation of the tumor was caused by necrosis and degeneration. Pathological and immunohistochemical studies indicated nonfunctioning islet cell tumor. Nonfunctioning endocrine tumors are rich in vascularity and so cystic formation rarely occurs in them, though it becomes common as the tumors increase in size. This case of nonfunctioning cystic endocrine tumor which showed cystic formation regardless of its size (as small as maximum diameter of 4.3cm) is rare in a review of the literature.

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We report a case of splenic cyst with high serum level of CA19-9. A 52-year-old man complaining of epigastric pain was found to have a splenic cyst by examinations at another hospital, and was seen at the hospital. Abdominal CT scan revealed a 10×15cm cyst. Blood biochemical study disclosed that serum CA19-9 level was as high as 146.1U/ml. The patient was temporarily followed in the outpatient clinic. However, 4 months later, CA19-9 level remarkably increased to 485.2U/ml. The patient was admitted to the hospital for operation, because a possibility of malignancy could not be ruled out. At operation, the pancreatic tail was found to be adherent to the cystic wall, and the cyst was removed by a resection of the pancreatic tail. Histopathologically, the cystic wall was partially covered with squamous cells where revealed positive response to specific immunostaining to CA19-9. Serum level of CA19-9 was normalized on the 10th hospital day which was kept thereafter. In the case of splenic cyst with high CA19-9 level like this case, we must actively operate on by keeping the possibility of malignant disease in mind.

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A 50-year-old man who had been operated on for fibrosarcoma of the right upper arm, was admitted to the hospital because of a right adrenal tumor. Abdominal ultrasonography and computed tomography disclosed an abnormal tumor in the right adrenal gland. Bone scintigraphy showed metastatic bone tumor. The adrenal tumor was enlarging quickly, and so we considered that operation was indispensable. Under a suspicion of adrenal metastatic tumor, a right adrenalectomy was performed. Resected specimen showed a 5.4×4.4cm tumor, contained coagulating tissue. Histological findings were the same as those of fibrosarcoma of the right arm. Adrenal metastasis of fibrosarcoma was diagnosed. The metastatic adrenal tumor is rare, especially that of fibrosarcoma. Although the prognosis of metastatic adrenal tumor is usually poor, a better prognosis can be expected by positive excision of the tumor, if the original foci is well controlled and no other prominent metastasis is present.

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A 59-year-old man underwent a total gastrectomy for advanced gastric cancer of type 2 in March 1997. Histopathologically it wan T2NOHOPOCYXMO in Stage IB. In addition a radical operation for a right external inguinal hernia was performed on the 4th week after the operation. About 22 months later, tumor markers increased and an abdominal CT scan visualized periaortic lymph nodes metfstasis. Systemic chemotherapy was performed. The patient became to notice cords at the bilateral inguinal regions and a pain-ful walnut-sized tumor covering from the right inguen to scrotum. Biopsy revealed that the tumor was adenocarcinoma and had many morphological resemblances to those of the previous gastric cancer resected about 2 years before. With a diagnosis of of scrotal metastasis from the gastric cancer and systemic chemotherapy was started. After the chemotherapy, the right inguinal pain was alleviated and the patient is strictly followed up.

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A 16-year-old girl was operated on for unknown perforation of the transverse colon on May 14th, 1995. Her family has a kindred of familial adenomatous polyposis (FAP), however, she had no polyps of the colon. After the surgical treatment, we adopted unresectable tumors in the mesenterium of the small intestines. A biopsy of the tumors showed fibromatosis (desmoid tumor). In the knowledge that breast cancer as well as desmoid tumor is dependent on hormone, we instituted the same endocrine therapy against the desmoid tumors; goserelin acetate (3.6mg/month), tamoxifen (20mg/day) and fadrozole hydrochloride (2mg/day). We recorded the tumor's fluid degeneration and a decrease in size over an 8 month period.
Desmoid tumors are pathologically benign, but locally invasive and said to be recurrent in a high rate after the surgical treatments. We got sufficient response to treat the desmoid tumor by endocrine therapy without severe side effects. Henceforth, endocrine therapy rather than surgery will be one of the strategies against desmoid tumors.

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Transepiploic hernia often develops into strangulated ileus, while an accurate preoperative diagnosis is difficult to make because is lacks specific symptoms. A 58-year-old man was admitted to the hospital because of ileus. He had no previous history of undergoing surgery. The patient was conservatively observed with a long tube. On the next day, he was referred to the department of surgery because of progressive abdominal pain and the occurrence of muscle defense. Abdominal CT scan showed ascites and dislocation of the small intestine over the transverse colon. Strangulated ileus due to an internal hernia was diagnosed and an emergency operation was thus performed. On entering the peritoneal cavity, the ileum was found to have prolapsed through a hiatus of the omentum measuring about 5cm in diameter, and had become strangulated. We performed an open incision of the hiatus of the omentum to release the strangulation, because the ileum did not develop necrosis. We were able to correctly diagnose strangulated ileus before it progressed to necrosis of the intestine. We should pay special attention to such cases of strangulation because transepiploic hernia often develops into fatal necrosis of the small intestine within a short period of time.

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A 70-year-old man was admitted to the hospital because of abdominal distension. A mass about 10cm in diameter was palpable in the left upper abdomen. Upper gastrointestinal roentogenogram and endoscopic examination of the stomach showed extensive impingement of the posterolateral wall in the body of stomach. Abdominal computed tomography showed a 16cm mass in the left superior abdominal space. An operation was performed under a radiological diagnosis of a giant tumor in the abdominal space. Peritoneal metastases at the greater omentum and retroperitoneum were identified intraoper-atively. The giant mass arose from the posterior wall of the gastric body and invaded the left diaphragm. Total gastrectomy and lymph node dissection (D2) were performed. The specimen had foci of hemorrhage and necrosis, and weighted 3141g. Morphological diagnosis was leiomyosarcoma with no lymph node metastasis. On immunohistochemical examinations, tumor cells were negative for smooth-muscle actin and desmin of the muscle marker, and negative for S100 protein and neuron specific enolase of the neurogenic marker. But the lesions were positive for CD34. From immunohistochemical features, the tumor was diagnosed as gastrointestinal stromal tumor of uncommitted type. Multiple hepatic and peritoneal metastases were revealed, as of 10 months after the operation.

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We report a case of idiopathic retroperitoneal fibrosis forming a localized tumor, which is relatively rare. A 55-year-old man was found to have a retroperitoneal tumor by abdominal ultrasonogram at a medical check up and was admitted to our hospital. On admission, he was asymptomatic and no physical abnormalities were seen. Abdominal CT scans revealed a mass in the left retroperitoneal space. The mass was confirmed to show low intensity on both Tl and T2 weighted images in MRI, which suggested fibrous component. Since a possibility of malignant tumor could not be still ruled out, the tumor was removed for the purpose of examination and treatment. The pathological diagnosis was idiopathic retroperitoneal fibrosis. The patient is strictly followed in the out patient clinic and no signs of recurrence have been observed. It is necessary to consider idiopathic retroperitoneal fibrosis in case of retroperitoneal localized mass.

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A rare case of primary clear cell adenocarcinoma of the retroperitoneum is reported. A 58-year-old woman, who underwent total hysterectomy and bilateral salpingo-oophorectomy for cervical carcinoma at the age of 44 years old, was pointed out having a tumor of the ascending colon. On close examination, an 8×6cm huge pelvic tumor was found out by computed tomography. Transrectal needle biopsy of the tumor showed adenocarcinoma of unknown origin. She underwent an ileocecal resection and a resection of the retroperitoneal tumor. The tumor was located in the retroperitoneal cavity at the left side of the rectosigmoid. It was adherent to the rectal mesocolon, stump of the vagina and bladder. Histological examination showed clear cell adenocarcinoma of the retroperitoneum, and the colon tumor was revealed to be well differenciated adenocarcinoma, m, n0. The patient received chemotherapy for ovarian carcinoma because both this tumor and ovarian clear cell adenocarcinoma seemed to be of miillerian origin. There have been no signs of recurrence as of 14 months after the surgery.
As far as we could review, no such case as clear cell adenocarcinoma arising from the retroper-itoneum like our case has been reported in Japan.

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A 76-year-old man was admitted to the hospital because of a right pulsatile, palpable, and asymptomatic axillary mass, which was increasing its volume in last 5 or 6 years. There was no known previous history of axillary infection, trauma, nor crutch use. No other pulsatile mass was found on physical examination. Ultrasonographic examination and an angiogram demonstrated an aneurysm without thrombus involving the third portion of axillary artery, 25mm in diameter. The aneurysm was thought to have occurred solitarily. At surgery, surrounding inflammatory reaction was mild, but the aneurysm which was 20mm in diameter was adherent to median nerve. So the aneurysm was resected, but a part of the adherent wall was left intact. The artery was transected at both sides of the aneurysm and reconstructed by a grafting with a prosthetic graft (PTFE with rings-6mm). Pathologic examination revealed that this case was true aneurysm with atherosclerotic changes. The patient had an uneventful postoperative recovery, and left the hospital 12 days after the operation.
Atherosclerotic aneurysm of the axillary artery is very rare. In a review of the literature, only 11 cases including our case have been reported. We present this rare case of atherosclerotic aneurysm of the axillary artery, together with some bibliographical comments.

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