Sixteen consecutive patients who had been surgically treated for active infective endocarditis are included in this study. The duration from onset of the disease to operation, inflammatory reaction (WBC, CRP), causative organisms, operative findings, operative methods, peri-operative complications, early and late results were reviewed in these patients. Except patients with progressive congestive heart failure, sustained sepsis, major embolization who needed prompt surgical interventions, appropriate antibiotic therapy (2-4 weeks) was successful to combat infection as inflammatory reactions indicated significant reduction (p=0.018). In staphylococcal and fungal patients, surgical intervention should be performed earlier than 2-4 weeks because these organisums have tissue destructive actions. In patients who have locarized infection within valvelar leaflets or choradae, we performed mechanical valve replacement. Early and late results were extremely good (survival rate 0.87). But in patients with severe infection, we must remove the infected tissues as much as possible and reconstruct completely. Prompt diagnosis and treatment of the complications in cooperation with other specialists are essential to have a successful therapeutic outcome.

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The purpose of this study is to clarify differences between thyroid carcinomas associated with Graves' disease (BCa group) and not associated with (PCa group), both clinically, and immunohistologically. We operated on 210 PCa and 11 BCa patients between 1982 and 1996. We investigated tumors, lymphnode metastasis, and extra thyroidal invasion as clinical prognostic factors, and also measured the positive rate of PCNA, and positivity for c-Fos, and c-Myc immunohistologically. From the study, it became evident that the BCa group, compared with the PCa group, had smaller but mutifocal cancer, occasional lymphnode metastasis, and no recurrence even in the advanced cases.
In the immunohistological study, high PCNA positive rates and frequent appearance of c-Fos and c-Myc were seen in Graves' disease patients, and intererestingly, these findings were more obvious in the cancer part of BCa. These results suggest that the icreased proliferating activity associated with Graves' disease plays a role in multifocal carcinogenesis of the thyroid in the BCa group.

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One hundred and thirty-eight patients with breast cancer underwent a breast conservative treatment at the institution in a recent 11-year period from 1989 through 1999, accounting for 23.9% of all patients operated on for breast cancer in the same period. Of 135 patients, excluding three patients who had their treatments changed or died of non-breast cancer, six patients (4.4%) developed recurrence: three had a local recurrence in the preserved breast and the remaining three had a distant recurrnce. They were clinicopathologically investigated. These six patients were characteristically young. Their mean age was 40.7 years (P<0.025). The 5-year disease-free survival rates after breast conservative treatment were 93.5% for the patients with stage I breast cancer, and 82.2% for those with stage II breast cancer. The patients with a large tumor had a poor prognosis (p<0.01).
A lot of fat necrosis was found in the pathological tissues obtained from six patients who were mistakenly diagnosed as having recurrence in the preserved breast. The margin-positive rate was 13.8% for patients who underwent a wide excision of the mammary gland, and 94.7% of the patients with positive surgical margin had an intraductal spread.
For the prevention of recurrence in the preserved breast, we should confirm the diagnosis preoperatively by mammography, ultrasonography, computerized tomography scanning, and magnetic resonance imaging; carry out pathological examination intraoperatively to investigate whether the patient has positive margin; and administer radiotherapy to the preserved breast.

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Recently, it has been increasingly reported that placement of expandable metallic stent (EMS) is useful in treating biliary and esophageal strictures. In the present study, we tried EMS placement in nine patients with left-sided large bowel obstruction for unresectable malignant disease. As a result, seven of the nine patients were able to place EMS. In all the seven patients, constipation was promptly relieved and oral intake became possible. As for complications, one patient had recurrent obstruction 2 months after the first stenting, however, obstructive symptoms were relieved with second EMS placement. No remarkable complications were seen in other patients. Four patients died of cancer, but had no obstructive symptoms from EMS placement to their deaths. The remaining three patients are living and well as longest as 11 months after the placement, and no particular problems have ocuured.
In conclusion, EMS placement, which is less invasive compared to artifical anus and makes spontaneous bowell movement possible, would relieve mental and physical pains to contribute to the improvement of quality of life of patients in terminal stage.

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Monoclonal antibody Ber-EP4 is useful for the differentiation between cells of the mesodermal and epithelial derivation. We conducted immunohistologic examinations using the antibody to Ber-EP4 and cytokeratin (subclass No.8) to study clinicopathologic findings. Subjects were eight patients with combined hepatocellular and cholangiocellular carcinoma (HCC-CCC).
In the HCC-CCC, the area of cholangiocellular carcinoma (CCC) was stained strongly on cytokeratin staining compared with one of hepatocellular carcinoma (HCC). On Ber-EP4 staining, the patient, who showed posttive staining in CCC, revealed positive staining in HCC, too. Both parts had the same immunohistologic property. When clinical data such as existing hepatic impairment and viral infection in each patient are considered, it seems that the result of Ber-EP4 staining can be an indicator to guess the origin of HCC-CCC. It also seems that the result of Ber-EP4 staining is useful to consider whether the malignant tumor in the liver is primary or not.

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Magnetic resonance cholangiography (MRC) was performed on patients with cholelithiasis with dilatation of the common bile duct (more than 10mm in diameter) before surgery, and the advantages and disadvantages were investigated based on laparotomy findings. Subjects were 27 patients with cholelithiasis associated with common bile duct dilatation who were operated on at the department since June 1996. There were 13 men and 14 women. A mean age of them was 68.2±11.2 years, ranging from 43 to 90 years. As preoperative imagings, abdominal ultrasonography (US) and abdominal CT scan were performed in all case; either of intravenous cholangiography (IVC), endoscopic retrograde cholangiography (ERCP), or percutaneous transhepatic cholangiography (PTC) was conducted in them; and MRC was performed in 22 cases except incompatible cases.
Patients were imaged in the coronal planes by 0.5-T MR scanner employing a body surface coil at 10 second catch at a single breath-hold without injection of contrast medium.
Twenty-one (21) out of 27 patients were proven to have common bile duct stones. The overall diagnostic accuracies in US, CT, IVC, and MRC were 40.7%, 62.9%, 68. 4% and 86. 3%, respectively. The diameters of common bile duct were ranged from 10mm to 45mm (mean 15.9± 7.9mm).
MRC allows to assess microstones in the common bile duct, and moreover it is useful for postoperative or allergic patients. However. MRC can necessarily reveal peripapillary diverticulum, and it may overestimate the gallbladder in case of negative cholecystogram.
MRC can noninvasively and repidly reveal the presence of stones in the common bile duct, but further studies are required for a better evaluation of the potential disadvantages of this technique.

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We encountered three cases of postoperative cerebrovascular complications out of 64 patients who underwent a radical esophagectomy between April 1996 and December 1997. The complications after esophagectomy included cerebral infarction in two patients (a 75-year-old man and a 76-year-old man) and transient ischemic attack in the remaining patient (a 74-year-old man). Anticoagulant therapy was effective in all three patients. Generally, the patients after radical esopiagectomy are at high risk causing cerebral ischemia, because they are kept slightly dehydrated to protect the respiratory function. Thereafter, since January 1998, patients over 75 years old or with a history of cerebral ischemia have been placed on anticoagulant therapy after radical esophagectomy, and no cerebrovascular complications have been found in the 40 patients, including five patients over 75. We conclude that anticoagulant therapy is essential to prevent cerebrovascular complications after radical esophagectomy in elderly patients or those with a previous history of cerebral ischemia.

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We report a case of chylorrhea following laryngopharyngectomy successfully treated with video-assisted thoracoscopic clipping of the thoracic duct. A 52-year-old man underwent a laryngopharyngectomy and lymphadenectomy of the neck because of hypopharyngeal cancer. He developed chylorrhea from the neck from the operative day. Conservative therapy with local infusion of OK432 for 7 days failed to reduce chylorrhea. We decided to perform the video-assisted clipping of the thoracic duct. Lymphoscintigraphy was performed before operation and no abnormality in thoracic duct was confirmed. Lymphoscintigraphy has been reported to be minimal-invasive and to visualize abnormalities of the thoracic duct instead of radiological lymphography. The thoracic duct was successfully and easily clipped with video-assisted thoracic surgery and chylorrhea completely ceased on the 8th day after the clipping. Generally postoperative chylorrhea has been treated by conservative therapy, and surgical intervention may be performed if it is unsuccessful. But video-assisted thoracic surgical procedure reduces the damage for the patient and economical load accompanied with long hospital stay. Some reports show the benefits of video-assisted thoracic surgery for chylothorax after thoracic surgery, such as pulmonary resection. We believe this method would be useful to stop postoperative chylorrhea even in case of cervical surgery.

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A nursing 31-year-old woman was seen at the hospital because of a left breast tumor measuring 2cm in diameter. A fibroadenoma was suspected since there was a well-demarcated tumor on palpation and ultrasonography. Biopsy specimen showed a yellowish mass with capsule. Histopathological study showed a lactating adenoma that was rich glandular cells' proliferation that formed tubular or acinar structure with secretion in sparse stroma.
Lactating adenoma is a rare entity. For differencial diagnosis, secreting gland and fibroadenoma are raised histopathologically and malignant tumor, fibroadenoma, and phyllodes tumor are raised clinically. However, this desease is hardly diagnosed preoperatively for its rare incidence. This desease should be kept in mind as breast tumor recognized in pregnant and nursing women.

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A case of mucocele-like tumor of the breast is presented. A 47-year-old woman sas seferred to the hospital because of a right breast mass which was pointed out at a mass acreening test for breast cancer. A possibility of breast cancer could not be ruled out by mammography and ultrasoundgraphy of the breast. Aspiration biopsy and cytological examination revealed mucin and epithelial cels which did not show malignant feature. Lumpectomy was performed. Pathological examination using the formalin-fixed and parafin-embeded specimen showed mucocele-like tumor (MLT) of the breast. MLT of the breast is considered binign lesion. However, recently MLTs with mucinous carcinoma or ductal carcinoma in situ have been reported and some researchers have advocated that it is on the borderline between benign and malignant lesions. The case also showed a small part of papillary lesion in the cyst wall. Then, an immunohistological analysis was made. Estrogen receptor was weakly positive, and mutant p53, Ki-67, and c-erbB-2 were negative. These data suggested that the degree of malignancy of the MLT was very low. However, the biological behavior of MLT in the breast is still unknown. Further studies to verify the malignancy of MLT are required for the proper treatment and follow up of this disease.

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We report a recent case of angiosarcoma of the breast without a history of receiving irradiation therapy. A 19-year-old woman was seen at the hospital because she noticed a lump in the area A of right breast with pain in January 1998. A smoothly and elastic soft tumor was palpable. Ultrasonography showed a 1.32×0.68cm mass with low echogenicity. She underwent an incisional biopsy of the breast. It revealed that the tumor was a cyst and perforated when it was incised. The content of the cyst consisted of serous brown liquid. The resected specimen 5mm in diameter was diagnosed as angiosarcoma. Partial resection of the mammary gland without axillary lymph node dissection was performed. The patient is living and well, and has been free from recurrence as of 2 years and 6 months after the operation. Our case is the 8th report on angiosarcoma of the breast under the size of 3cm in the Japanese literature. Some bibliographycal comments are also presented.

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A 41-year-old woman was admitted to the hospital because of a right mammary tumor. A tumor 1.5cm in diameter was palpated in the AD area of her right breast. Incisional biopsy was performed, and well differentiated angiosarcoma was diagnosed pathologically. Right quadrantectomy and axillary lymph nodes dissection were performed. Five years after the operation, she is living without recurrence.
Angiosarcoma of the breast is a rare disease and its prognosis is extremely poor. Therefore, in the treatment of this disease, the early diagnosis and consequent early operation are very important.

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We reported a case of thymic Hodgkin's disease performed a resection with reconstruction of the superior vena cava (SVC) after chemotherapy. A 39-year-old woman was admitted to the hospital because of irritative cough and fever. Dilatation of the neck vsen and anterior chest veins were noted. On a chest CT scan, and anterior mediastinal mass (65×50mm) with direct invasion to the SVC was revealed. Needle biopsy revealed a pathological diagnosis of thymoma. Neoadjuvant chemotheraphy was performed. As the tumor was markedly reduced insige, an extended thymo-thymomectomy combined with resection of the SVC and brachiocephalic vein was performed, . Since a postoperative histology showed thymic Hodgkin's disease, additional chemotherapy (COPP) was given. Although thymic Hodgkin's disease is a rare entity, care must be exercised to differentiate if from thymoma. In this case which was associated with superior vena cava syndrome, chemotherapy combined with surgical resection wfs efficacious.

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A 38-year-old woman, who had had sometimes light left back pain, was referred to the hospital because of abnormal shadow on a chest X-ray film at a mass screening. Chest CT scan showed a giant, well-defined, expansive and solid tumor occupied more than half of the left hemithorax. Operative findings revealed that the tumor was extrapulmonarily growing from the visceral pleura of the left S^6-10 and involving the pulmonary artery and bronchus. Left pneumonectomy and systematic hilar and mediastinal lymphadenectomy were performed. The tumor measured 21×11×7cm and weighed 1750g. The section was grayish white in color and there was no necrosis nor lymph node metastasis. Histopathologically fibroblast like spindle cell manifested patternless pattern. Immunohistochemically, the tumor was negative for EMA, cytokeratin and S-100, while positive for Vimentin, indicating CD34 negative. These findings were morphologically compatible with solitary fibrous tumor. The postoperative course was uneventful. She is living and well without evidence of relapse, as of 5 years after the operation.

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Reconstructive operation using a free jejunal graft that was doublefolded and pouched with a use of an endostapler was perfomed after phyngolaryngectomy in three patients with infrapharyngeal cancer. The grafting was successful in all patients without any complication due to the procedures. Free jejunal graft which has the histological advantage in that it restores the continuity of the mucous membrane, has become the first choice tissue material for reconstructive surgery because of recent technical progress and spread of the microvascular surgery. However, the graft is replaced merely as a passive conduit in the pharyngolaryngectomy that would deteriorate the second phase of the physiological swallowing. There should be some place to pursue the optimal design of the graft conduit for satisfactory passage. We report our trial to make the doublefolded pouched jejunal graft using the staplers, so that the long defect between the pharyngeal end and the esophagus with large caliber discrepancy can be reconstructed conceptually in a simple straight end to end anastomosis.

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We report two cases of gastrointestinal stromal tumor with von Recklinghausen's disease.
Patient 1, a 49-year-old man with von Recklinghausen's desease was admitted to the hospital because of hematemesis. Emergency endoscopic examination revealed a submucosal mass in the 3rd portion of the duodenum. Abdominal CT scan demonstrated a solid mass with the size of 4cm contiguous to the Treitz ligament. Laparotomy showed a submucosal tumor originated from the 4th portion of the duodenum, and a partial resection of the duodenum and jejunum was performed.
Patient 2, a 68-year-old man with von Recklinghausen's desease was operated on for rectal cancer. During laparotomy, multiple small submucosal tumors were found in the jejunum and a partial resection of the jejunum was performed.
Immunohistochemically, the both tumors showed positive for c-kit (CD117), and were diagnosed as gastrointestinal stromal tumor (GIST) in a narrow sense. It is believed that most non-epithelial tumors associated with von Recklinghausen's disease are neurogenic, however, such tumors categorized into GIST in a narrow sense will increase in a progression of immunohistochemical examinations.

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A case of jejunogastric intussusception (JGI) after gastrectomy is presented. A 77-year-old man was admitted to the hospital because of sudden onset of epigastric pain and vomiting followed by hematemesis.
There was a previous history undergoing a partial gastrectomy (Billroth II) for peptic ulcer at another hospital 30 years before admission.
Endoscopic examination revealed a large reddishblue intestinal loop in the residual stomach and an abdominal CT scan also revealed a mass with ringed structure in the gastric remnant.
Based on the diagnosis of JGI, an emergency laparatomy was performed. At operation, through the gastrojejunostomy, the afferent jejunal loop had intussuscepted into the residual stomach in a normograde manner. After a mild strangulation could be reduced by manipulation, the long afferent loop was fixed on the retoperitoneum and a Brauns anastomosis was performed to prevent recurrent intussusception.
Postoperative course was uneventful.

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A 53-year-old woman was admitted to the hospital because of upper abdominal pain with urticaria. The patient was diagnosed as having advanced gastric cancer on upper GI endoscopy. Endoscopic examination revealed a tumor with ulceration and edematous marginal swelling at the antrum, and a small worm seemed to be Anisakis larva embedded to the base was found. Anisakis larva was removed with forceps. After this procedure, abdominal pain and urticaria improved in two days. Three weeks later, a distal gastrectomy was performed. A histopathological study of the resected materials disclosed that there was no inflammatory cell infiltration or gronuloma formation due to gastric anisakiasis. This rare case in which Anisakis larva embedded to gastric cancer is reported together with a review of the litarature.

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An 80-year-old man complaining of right upper abdominal pain was referred to the hospital with a diagnosis of acute abdomen. On admission systolic blood pressure was 70mmHg and the patient developed circulatory shock. There were tenderness and muscle guarding in the right upper quadrant of the abdomen. Abdominal ultrasonography revealed a swelling of the gallbladder, thicking of the cystic wall, gallstones, and ascites. An irregular stain around the pancreas head was shown in a contrast CT scan, suggesting retroperitoneal bleeding of that area. An emergency angiography revealed a ruptured aneurysm of the anteriosuperior pancreaticoduodenal artery and it was successfully treated with transcatheter arterial embolization (TAE) using platinum coils. Eighteen days after the admission, cholecystolithiasis was revealed by abdominal CT scan and pancreatitis caused by cholecystolithiasis was thougut to be the pathogenesis of the aneurysm and its rupture. Fifty-two days after the admission, a cholecystectmy and a choledocholithotomy were performed. We report a patient with ruptured aneurysm of the anteriousuperior pancreaticoduodenal artery who was successfully saved by TAE using platinum coils.

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We successfully treated a patient with cancer of the duodenal papilla associated with idiopathic thrombocytopenic purpura (ITP), who was on high dose steroid regimen, by performing high-dose immunoglobulin therapy and a splenectomy prior to radical operation. The patient was a 66-year-old woman. After reducing the dose of steroid and confirming an increase in platelet count from 132, 000 to 470, 000/μl, the patient underwent a radical operation (pylorus preserving pancreatoduodenectomy with lymph node dissection) for the cancer of the duodenal papilla. During and after surgery, no bleeding tendency occured. The postoperative course was unevetful. After discharge, the patient has been followed at our outpatient clinic and the platelet count has been within normal range. In case of ITP, high-dose immunogulobulin therapy and splenectomy are expected to increase platelet count successfully in a short time without any marked adverse reactions. This combination therapy and the second staged radical operation seem to be a good option in cases requiring invasive operations like the present case.

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We experienced four cases of advanced duodenal bulb cancer which is relatively rare. Chief complaints of the cases were upper abdominal mass in two cases, icterus and shortness of breath in each one case, and there were few gastrointestinal symptoms. Operative procedures included pancreatoduodenectomy in two cases, distal gastrectomy and duodenal bulb resection in one case, and gastrojejunostomy in one case. All three patients whose tumors were resected had type 3 carcinoma, with microscopic invasion depths of ss, as and si, respectively. Histologic types were tub2 in two cases, pap and muc in each one case, that were relatively well differentiated types. Radical operation was difficult for all the patients because they had advanced P, H, and H factors, and consequently there were no survivors for more than 2 years.

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A 59-year-old man was admitted to the hospital because of positive fecal occult blood tests. Colonoscopy examination revealed an elevated lesion, 10mm in diameter, in the terminal ileum. A histological diagnosis of carcinoid was made based on a biopsy specimen taken from the lesion. Since no apparent lymph nodes nor distant metastasis was noted, a laparoscopy-assisted ileocecal resection with regional lymph node dissection was performed. On the resected material, a 1.0×0.9cm, oval and demarcated carcinoid tumor limited in the submucosal layer was present lcm to the Bauhin valve of the terminal ileum. It was chromogranin A positive. Histologically, carcinoid tumor, classical type, was diagnosed. Metastasis in the paraileal lymph node was detected. It is said that carcinoid tumor of the ileum prones to metastarize in a high rate even if the tumor is small in diameter and dose not invade the muscularis. Laparoscopy-assisted ileocecal resection with lymph node dissection can be indicated for carcinoid tumor of the ileum end without apparent distant metastases.

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A 37-year-old man was admitted to the hospital because of lower abdominal pain. On admission, a fist-sized tumor with smooth surface associated with tenderness was palpated in the lower abdomen. On blood analysis, mild inflammatory findings were noted. Abdominal CT scan and magnetic resonance imaging revealed a soft parts tumor with calcification in the pelvic cavity. Angiography of teh superior mesenteric artery visualized accumulation of a contrast material. From these findings, a laparotomy was performed with a suspicion of a tumor arising in the mesentery or small intestine. At surgery, a tumor about 10 cm in size was present on the middle portion of the mesentery. A partial excision of the small intestine including the tumor was performed. The tumor was white in color and an elastic hard spherical tumor. Histopathologically, it was mainly composed of fibroblasts and collagen fibrils, and was diagnosed as desmoid tumor arisen in the mesentery. Postoperative course was uneventful. The patient was discharged from the hospital on the 16th postoperative day. Since the desmoid tumor is a rare entity, this case is presented with a review of the literature.

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A 39-year-old man was admitted to the hospital because of ileus in December, 1997. Upper gastrointestinal endoscopy and colonofiberscopy showed no abnormal findings. X-ray examination of the small intestine showed ten ulcers with fold convergency, multiple focal rigidities, multiple stenoses in the ileum. Several clinical findings and typical x-ray findings indicated so-called “nonspecific multiple ulcers of the small intestine” and, therefore, oral administration of Mesalazine was started. X-ray examination of the small intestine showed eight ulcer scar formations in July, 1998. In June, 1999, he was readmitted to the hospital because of ileus due to a 2-month withdrawal of Mesalazine. X-ray examination of the small intestine showed a stenosis with pseudo-diverticular formation. Although the medical treatment for the nonspecific multiple ulcers of the small intestine had been ineffective, our case is thought to be a very rare case which was successfully treated by oral administration of Mesalazine alone.

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An 89-year-old man was seen at the hospital because of right lower abdominal pain. Chest plain x-ray film revealed intraabdominal free air image. Abdominal CT scan demonstrated intraabdominal free air image and an isodensity mass about 5cm in diameter in the right lower quadrant of the abdomen. An emergency operation was performed with a diagnosis of perforation of gastrointestinal tumor. At laparotomy, a tumor with perforation at the terminal ileum and a swelling of mesenteric lymph node were present. An excision of the ileocecum was performed. The resected material revealed type II tumor of which bottom of ulcer partially perforated. Histopathologically, it was diagnosed as B-cell type malignant lymphoma, non-Hodikin disease, follicular lymphoma medium size cell type according to the Lymphoma Study Group Classification. Postoperative course was uneventful and the patient could recover from peritonitis. About 2 months later when it was close to the time of discharge, the patient abruptly presented cancerous lymphangitis like chest findings and died.
Although no chemotherapy was given to the patient because of his advanced age, some chemotherapy had to be performed because the tumor was in stage I at a postoperative general exploration. This is a case asking us to reconsider.

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A 73-year-old woman was seen at our hospital because of abidominal distension and vomiting. An upper gastorointestinal endoscopy and colonofiberscopy revealed no abnormal findings. Intestinal fluoroscopy showed a tumor with stricture in the small intestine. Thereafter, the patient developed an intestinal obstruction and was admitted to our hospital. After admission, a partial excision of the amall intestine was performed. The intestinal tumor had produced a narrowing of the entire circumference of the small intestine at a point 100cm on the anal side of the Treitz'ligament. Three intramural metastases were also observed. Histologically, the tumor was identified as an undifferentiated carcinoma infiltrating the subserosal layer. Further immunohistochemical examination disclosed the differentiation of neuroendocrine cells and the overexpression of p53. Three months after the operation, the patient was readmitted to the hospital because of another intestinal obstruction. The recurrence of the small bowel cancer was confirmed, and a gastorojejunostomy and a gastrostomy were perfomed. The patient died from the rapid progress of cancer 6 months after the onset of the symptoms. An extremely rare case of an undifferentiated cancer with neuroendocrine differentiation of the small intestine is pressented here.

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A 54-year-old man who had undergone a total gastrectomy for gastric cancer 9 years previously was perfomed an adhesiotomy for repeated ileus and an ileus tube was inserted as intestinal splint intraoperatively. On the third postoperative day, vomiting occurred. Abdominal CT scan and ultrasonography indicated intussusception, therefore an emergency operation was performed. During surgery, three intussusceptions in the small intestine were noted. The proximal intussusception was antegrade and both of the distal two intussusceptions were retrograde. The two retrograde intussusceptions could be repaired manually, whereas a partial resection of the small intestine was needed for the antegrade one. In this case, it was suggested that the antegrade intussusception was caused by the telescoping of the intestinal wall pleats which was formed as a result of the presence of the tube, and that on the other hand, retrograde ones were due to removal of the tube. We sometimes encounter clinical cases of intussusception associated with an ileus tube in the literature, but there have been only two case reports of three intussusceptions including our case in Japan. When the ileus tube is in place, full attension would be mandatory, even after removal of the tube.

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A 72-year-old woman was admitted to the hospital because of right lower abdominal pain. There were previous histories of undergoing an appendectomy at the age of twelve and a lysis for ileus at thirty-two. On admission, a painful mass was palpable on her lower abdomen and a computed tomography revealed strangulated intestine at the right lower abdominal cavity. With a diagnosis of strangulated ileus, she underwent an emergency laparotomy on the same day. During the operation, an abnormal retrocecal fossa was found measuring 2cm in diameter and the distal ileum was incarcerated through this fossa. The incarceration was reduced by an incision of the retroperitoneum. The reduced intestine was 30cm in length without necrosis. No resection of the intestine was needed. A retrocecal hernia is rare and the cause of this disease is still unknown. The present case is notable because previous operations including appendectomy might be related to the incident of the retrocecal hernia.

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This paper presents a case of sigmoid colon cancer with liver metastasis occurred 9 years and 8 months after an operation for the primary legion in which the metastatic foci could be resected radically.
A 50-year-old man was referred to the hospital for evaluation of a solitary occupy legion with the size of 40mm in S3 of the liver at a total medical check up. There was a previous history of undergoing a sigmoidectomy for sigmoid colon cancer at the age of 41 at our hospital. Chest CTscan, abdominal CTscan, gastrointestinal fiber, and colonoscopic fiber revealed no primary malignant neoplasmas, and a hepatectomy of lateral segment of the liver was performed. Microscopically, no residual cancer was recognized at the surgical margin. Histopathological findings of the resected material indicated well differentiated adenocarcinoma compatible with the sigmoid colon cancer. It was considered that the hepatic legion was metastasis of the sigmoid colon cancer treated 9 years and 8 months before admission.
Colorectal cancer can metastasize to distant organs several years after operation like in this case, and consequently long-term and strict follow-up is required after curative resection of the primary legion.

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The authors have encountered four cases of stercoral ulcer of the rectum. These cases comprised of a man and three women, ranged from 38 to 84 of age. They were admitted to the clinic because of sudden onsets of bloody stool after bouts of troublesome defecation. Emergency sigmoidoscopies, performed after the patients were given glycerin enemas, revealed (dependenting on the patient); spotty redness, erosion, disapperance of blood vessels, exsudative changes, homorrhage of the mucous membrane and irregular superficial ulcers in the patient's lower rectum. A biopsy taken from the lesion revealed denuded mucosas and, in some cases, hemorrhage into the interstitial tissue or superficial epithelium was replaced by fibrinous exsudate intermingled with a few polymorphonucleal leukocytes. Almost all the patients revealed a tendency to constipation, but all were in good physical condition and not bed ridden. In addition, the patients had been suffering from mental weakness, depression, hypertension and asthma respectively. The causes of this disease are thought to be: impact on the faecal materials, troublesome defecation and a mechanical pressure effect on the mucosa. The patients recovered after several weeks through normalization of their bowel habits.

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A 73-year-old man, who had no particular history, was admitted to the hospital because of melena. The appetite was fair and bowel movements were good. No tumor was palpable by a digital examination. Colonoscopy revealed a rectal ulcer with bleeding which located at the middle portion of the rectum. The biopsied specimen showed no malignant lesion, but conservative treatment was unsuccessful. Partial resection of the rectum was performed under a diagnosis of hemorrhagic rectal ulcer. Pathological findings of the resected specimen revealed ulcer with irregular margin, 2×2cm in size, reached to the muscle layer in depth (U1-III). Infiltration of inflammatory cells and granulation tissue were histologically noted. No specific findings suggestive of inflammatory bowel disease nor Behcet disease were noted. Therefore non-specific rectal ulcer was diagnosed. Moreover, endoscopic findings of ulcer in this particular case were not comparable to those of ulcer seen in the patients with acute hemorrhagic rectal ulcer, stercoral ulcer, or rectal mucosal prolapse syndrome. No causes of this ulcer could be determined.

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This paper deals with a case of gastrointestinal stromal tumor (GIST) of the rectum which was resected 3 years after observation as leiomyoma. A 71-year-old man was admitted to the hospital because of perianal discomfort and lower abdominal pain. He had been followed with a diagnosis of rectal lyomyoma in another hospital for these three years, but recently perianal discomfort and lower abdominal pain developed and he was admitted o the hospital. After a close exploration, a possibility of malignancy could not be ruled out and an abdominoperineal resection of the rectum was performed. The tumor was sharply demarcated and did not invade the surrounding tissues. With an immunohistochemical exploration of the resected material, GIST of uncommitted type was diagnosed. There have been no signs of recurrence as of one year after the operation.
GIST is a new category and there is no established definition of the malignancy. This paper presents the clinical significance of immunohistochemical classification together with bibliographical comments.

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A 54-year-old woman was admitted to the hospital for close examination of hepatic tumors. There were previous histories of undergoing a modified radical mastectomy for left breaset cancer in February 1993 and a laparoscopic cholecystectomy for gallbladder stone in July 1994. Thereafter, in January 1997, a CT scan visualized hepatic tumors in S6 and S7 which tended to increase in size, leading to the present admission. On admission, the patient was asymptomatic and blood chemical analysis revealed normal findings. CT scan and magnetic resonance imaging revealed ring like enhancement of the tumors and metastatic hepatic cancer was suspected. So a posterior segmentectomy of liver was performed. Histopathological diagnosis was inflammatory pseudotumor (IPT). On a bacteriological study, Klebsiella oxytoca was isolated.
The origin of hepatic IPT is still obscure. We herein present the case with some bibliographical comments from various points of view including imaging diagnosis.

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Although carcinoma of the papilla Vater is said to have relatively good prognosis, it is not uncommon to recur. We present a patient with carcinoma of the papilla Vater who had experienced hepatic recurrence 5 years after pancreatoduodenectomy and has been recurrence free for further 5 years or more after extended right lobectomy of the liver for the hepatic metastasis.
A 41-year-old woman complaining of fever and jaundice underwent a pancreatoduodenectomy for carcinoma of the papilla Vater in October 1989. Histopathologically, it was papillary adenocarcinoma, pat Acbpd, panc0, dul, n0, and stageII. Five years after the operation, the patient was seen at the hospital because of fever, and was found to have simple hepatic metastasis about 10cm in size with necrotic center in the right lobe of the liver (S8). An extended right lobectomy of the liver was performed for the metachronous hepatic metastasis. At the same time, the diaphragm involving by the tumor was removed.
The patient has been alive without recurrence for more than 5 years after hepatectomy. We suggest that hepatic resection for hepatic metastasis of carcinoma of the papilla Vater should be performed if it is possible that might lead to long-term survival for the patient. We report this very rare case, in which long-term survival could be achieved after hepatectomy for hepatic metastasis of carcinoma of the papilla Vater.

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We report a case of peritoneal dissemination of hepatocellular carcinoma with unknown primary lesion in the liver. A 56-year-old man was admitted to the hospital for close examination of abdominal distension with bloody ascites. Ultrasonography, CT scan and angiography revealed only a hemangioma 2cm in size in the liver but no other space-occupying lesion in the liver. Laboratory examination showed only an elevation in serum alpha-fetoprotein (AFP; 870ng/ml). Liver function was within normal ranges. The patient had been exposed to asbestos for 30 years, so that malignant peritoneal mesothelioma was suspected. On July 22, 1997, an exploratory laparotomy was performed, which revealed about 4, 000ml of bloody ascites and multiple nodular hemorrhagic tumors approximately 1.0cm in size disseminated on the peritoneum and mesentery. Histopathologically the tumors resected from the peritoneum were diagnosed as hepatocellular carcinoma. Although intraperitoneal infusion of CDDP 100mg reduced ascites, patient's general condition gradually deteriorated. The patient succumbed to peritonitis carcinomatosa on December 11, 1997. An autopsy revealed no primary tumor lesion in the liver nor in any other organs. This case might have developed ectopic hepatocellular carcinoma in the abdominal cavity.

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A 69-year-old man was admitted to the hospital because of abdominal pain and vomiting. There was tendemess and muscle guarding over the abdomen. Simple abdominal X-ray film revealed niveau formation of the small intestine. Ultrasonography and CT scan of the abdomen showed a fluid collection around the gallbladder. Under a diagnosis of generalized peritonitis, an emergency operation was performed. Laparotomy showed bilous fluid in the peritoneal cavity, and the bile leak was found from white-colored part of the gallbladder. Cholecystectomy and intraoperative cholangiogram were performed. Cholangiogram was negative for choledocholithiasis or long common channel. Culture of bile yielded no growth of bacteria. There were no evidence of thickness and no stone in the gallbladder. Histologically, ther was slight inflammatory change of the gallbladder wall and localized necrosis associated with venous thrombosis was found. The case reported here appears as spontaneous perforation of the gallbladder due to localized infarction.

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A 69-year-old man was admitted to the hospital because of gradually increasing difficulty in eating in 10 days of medication for his chief complaint of epigastric pain at another hospital. There was tenderness covering from the epigastrium to right hypochondriac region. On blood analysis, white blood cell count was 13850/μml, platelet count was 92000/μml, and CRP was 35.5mg/dl, indicating severe infection. Abdominal CT scan revealed subdiaphragmatic ascites and thickening of the gallbladder, presenting cholecystitis. There were no apparent stones. Upon laparotomy, there were large volumes of purulent ascites and Eiterbelag in the fundus of the gallbladder, and a perforation of the gallbladder. Histopathological findings included bleeding and infiltration of neutrophile over the full thickness of the cystic wall and necrosis of the cystic wall at the perforated site. Arteriosclerosis was observed in arteriolae.
Attention has come to be paid to the presence of arteriosclerosis as an underlying disease for acalculous cholecystitis in outpatients. It is thought that acaluculous cholecystitis is caused by ischemia due to arteriosclerotic occlusion of arteriolae. In this case, ischemia due to arteriosclerosis might cause the disease.

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Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. We often encounter a great difficulty in differentiation it from cancer of the gallbladder, which also has a thick and irregular gallbladder wall similar to this rare condition. We present a rare of XGC associated with cholecystocolonic fistula.
A 69-year-old woman complaining of hypochondralgia and slight fever was transferred to the hospital with a diagnosis of gallstones and cholecystitis from her home docter. Abdominal CT scan revealed an extremely irregular and thick wall of the gallbladder along with stones, suggesting cancer of the gallbladder. A percutaneous transhepatic gallbladdergraphy (PTGB) demonstrated gallstones and the irregular and thick cholecystic wall with cholecystocolonic fistula. A selective celiac angiogram indicated a hypervascular well-outlined mass supplied by the cystic artery, and carcinoma of the gallbladder was also suggested. With a suspicion of carcinoma of the gallbladder with gallstones, an exploratory operation was performed when intraoperative frozen section diagnosis did not reveal cancer cells but inflammatory findings in the cystic wall. So only cholecystectomy was performed. Surgical specimen revealed that the gallbladder was 6×3cm in size and had a yellow and reddish wall. Histopathologically, remarkable inflammation with infiltration of lipid-laden histocytes was shown. XGC was diagnosed. When cancer of the gallbladder is suspected, we must examine and the patient bearing the disease in mind as a possible differential diagnosis.

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Bile duct carcinoma, which produces clinically recognizable mucus, is defined as mucin producing bile duct carcinoma. A rare case of mucin producing cholangiocarcinoma with acute pancreatitis is reported.
A 64-year-old man was admitted to the hospital because of abdominal pain and vomiting. On admission, amylase was 4158U/L, and leukocytosis and abnormal liver function were noted. Acute pancreatitis was diagnosed. Ultrasonography visualized dilation of the common bile duct and swelling of the pancreas. Computed tomography showed a tumor shadow in the caudate lobe of the liver. On endoscopic retrograde cholangiopancreatography, a dilated common bile duct and mucus retention in the biliary tract were revealed. With aspiration biopsy cytology of the tumor, a diagnosis of cholam-giocarcinoma was made. Resection of the segment (S) 1+S4a+S5 was performed. Grossly, a 4×3cm gelatinous tumor was present at the caudate lobe. Histopathologically the liver tumor was mucinous adenocarcinoma of the intrahepatic bile duct and invaded the hilar bile duct. We considered that the acute pancreatitis might be caused by obstruction of the pancreatic duct due to mucin produced by the tumor. There have been no signs of recurrence nor pancreatitis, as of 3years after the operation.

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We reported a case of asymptomatic extra-adrenal pheochromocytoma after perforating diverticulum of the sigmoid colon. A 63-year-old man was admitted to the hospital because of lower abdominal pain. Sigmoidectomy and atemporary colostomy were performed, and the post operative course was uneventful. Before the operation, and abdominal CT scan and ultrasonography showed incidentally an adrenal tumor with cystic component. But we left it alone at that time, because of emergency operation. Thereafter the tumor slightly enlarged in size. After close examination of radiological images and endocrinologic studies, the tumor was diagnosed as adrenal or extra-adrenal pheochromocytoma. The tumor was removed. The removed tumor was diagnosed as extra-adrenal pheochromocytoma histopathologically. No crisis occurred in the clinical course, but a high level of catecholamine was included in the cystic component.
It is necessary to consider that the high level of catecholamine might be included in the cystic pheochromocytoma even in the asymptomatic case.

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A 62-year-old woman with umbilical hernia had been incidentally pointed out a left adrenal tumor by a CT scan in 1988, when only repair of the hernia had been performed. Thereafter she was followed in the outpatient clinic. In 1997, she developed diabetes mellitus and hypertension. In November 1997, she complained of abdominal pain and was diagnosed as having relapse of umbilical hernia and a left adrenal tumor again. As serum noradrenalin and urinary normetanephlin levels were high, functional adrenal tumor was selected. However, there was no abnormality in MIBG-scintigraphy nor growing tendency in size in CT and MRI examinations. So a repair of the hernia preceded to other treatments. In April 1999, all levels of serum catecholamines and their urinary metabolites became high and the patient was definitely diagnosed as having pheochromocytoma. A laparoscopic left adrenalectomy was successfully performed. The tumor was wellcapsulated and 2.4×2.3×1.6cm in size. Pathological diagnosis was also pheochromocytoma. In conclusion, the assay for urinary metabolites of catecholamines is advantageous in screening of adrenal incidentaloma.

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A case of nonfunctioning adrenocortical carcinoma which is extremely rare is reported. A 45-year-old woman was admitted to the hospital because of gradually intensitying left hypochondralgia in a month and high fever. Abdominal ultrasonography showed a retroperitoneal mass about 10 cm in size. Adrenal origin was suspected strongly by angiography, but hormonal activities were in normal ranges, both adrenocortically and adrenomedullary. With diagnosis of non-functioning adrenocortical tumor, the tumor and left kidney were resected en-bloc, because direct invasion of the tumor to the left kidney was suspected. Adrenal dysfunction was not observed through out of the operation. In histopathological examination, it was diagnosed as adrenocortical carcinoma based on 1-2 mitotic figures per 10 high-power fields, considerable proportion of cells with eosinophilic cytoplasm, and tumor necrosis. The patient is scheduled to be given chemotherapy with low dose of CDDP+5-FU after the operation in the outpatient clinic, for preventing distant hematogenic metastasis that is common for the disease.

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Rupture of the urinary bladder is rare. But rupture of the bladder caused by radiation cystitis has increased recently accompanied by the popularization of radiation therapy. An 80-year-old woman was urgently admitted to the Department of Internal Medicine in our hospital because of lower abdominal pain. There was a previous history of undergoing a hysterectomy and bilateral adnexectomy with lymphnode dissection followed by radiation therapy. Abdominal X-ray examination showed distended small intestine with niveau formation. Conservative therapy was performed under a diagnosis of incisional ileus, but no remission was attained. She was referred to the Department of Surgery. Because peritonitis was suspected, an emergency laparotomy was performed. The distended small intestine was severely adhered to the bladder wall. When we peeled this adhesion, a tip of a bladder catheter appeared through the ruptured bladder, and the adhered point of the small intestine was almost obstructed. The definite diagnosis of rupture of the urinary bladder causing incisional ileus was made.

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This paper presents a case of external hernia of fovea supravesicalis diagnosed laparoscopically and repaired by mesh plug method, together with some bibliographical comments.
A 76-year-old woman was admitted to the hospital because of a right inguinal tumor. A laparoscope was inserted under general anesthesia to make pneumoperitoneum, when a hernia opening was present in the inner part from the right inside umbilicus fold. We were able to diagnose the case as external hernia of fovea supravesicalis. But the hernia opening in this case differed from usual circular and concave hernia openings and looked like a slit. We had great difficulty with making the diagnosis even by an aid of laparoscopy. Due to patient's request, it was repaired by using mesh plug method. Postoperative course was uneventful and there have been no signs of recurrence as of one year after the operation.
External hernia of fovea supravesicalis has been reported in nine cases including this case so far, but this may be the first report that mesh plug method is used for the disease.

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A case of testicular feminization syndrome (TFS) diagnosed at an operation for inguinal hernia is reported. The patient was officially registered as a 7-year-old girl. She had a left inguinal mass and was diagnosed as having inguinal hernia by a local physician and referred to the hospital. There was a previous history of undergoing an operation for right inguinal hernia 2 years before admission. At that time, there was undertaken mass near the inguinal sac. Her condition and all examinations were normal. At operation, there was a testis near the inguinal sac. So, endocrine and hormonal examinations were performed. At last TSH was diagnosed. It is very important to find and diagnose this syndrome as soon as possible for deciding to sex for social. The girl with TSH often has inguinal hernia. In the treatment of girl's inguinal hernia, the presence of the syndrome must be kept in mind and appropriate is desirable if it is diagnosed.

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We report a case of endometriosis of the inguinal region which is relatively rare. A 40-year-old woman was admitted to the hospital because of a painful right inguinal mass during menstruations. Based on her clinical history and radiological findings, endometriosis of the right inguinal region was diagnosed. At surgery, the tumor extended the extraperitoneal portion of the round ligament and adhered firmly to around tissues. So this tumor was excised completely with firm and adhered tissues. Endometriosis was confirmed pathologically. Postoperative course was uneventful. There have been no recurrent signs as of one year 3 months.
This case is believed to be the 41st case on record in Japan. The average age of these patients is 39 years old and this disease has a preference for the right side. The preoperative correct diagnosis was made in 32% of the reported cases. Medical history of pain and a swelling aggravated during menstruation is a very useful clue for diagnosis. The primary treatment is complete surgical excision and the extensive lesion must be removed from the operative field because there is a report of recurrence.
Some discussion on the etiology and management of endometriosis of the inguinal region is also presented.

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A 25-year-old woman was admitted to our hospital because of an adhesive ileus due to an operation for right ovarian cyst performed two years earlier. Partial resection of the ileum was done and the postoperative course had been uneventful. Four months later, she had a symptoms of ileus again. Conservative therapy using a naso-gastric tube was attempted. An abdominal roentgenogram and CT scans revealed intra-abdominal free air on the third day. Therefore, emergent laparotomy was performed. An adhesion between the preceding anastomotic site and the oral side of the ileum was found. No evidence of gastrointestinal perforation in spite of completion of intraoperative gastrofiberscopy and air leak test in the peritoneal cavity using saline was found. Only ablation of the adhesion was performed, and the postoperative course was uneventful. Complete remission of ileus is essential in treating pneumoperitoneum complicated with adhesive ileus.

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We have experienced a patient with superior mesenteric vein thrombosis, who had been followed for liver cirrhosis. This patient was admitted to the hospital because of vague abdominal pain lasting for three days. His abdominal pain gradually worsened, and peritoneal sign appeared on the second hospital day. A abdominal CT scan showed a portal vein thrombus and massive edema of the mesenterium. Under a diagnosis of superior mesenteric thrombosis, an emergency laparotomy was performed and only a completely necrotic segment of the small bowel (200cm) was resected without anastomosis. At the second look operation which was performed in two days, an additional resection of the bowel, 20cm in length with poor viability, was performed with end-to-end anastmosis. With anticoagulation therapy, there have been no signs of recurrence as of 22 months after the operation. Because this patient also had esophageal varices, the portal hypertention is considered to cause the superior mesenteric vein thrombosis. It should be emphasized that in spite of less coagulability in the patients with liver cirrhosis, portal hypertensive state can be a trigger of the superior mesenteric vein thrombosis.

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We experienced a case of acute peritonitis caused by chlamydia trachomatis infection. A 45-year-old woman complaining of abdominal pain and high fever was sent to our department with a suspicion of acute appendicitis. There were muscular guarding and Blumberg sign in the lower abdomen. Because of abnormally high levels of WBC and CRP and renal dysfunction, she was diagnosed as having acute peritonitis. Although the cause was obscure, an operation was performed. After abdominal drainage, she recovered. We diagnosed the case as acute peritonitis caused by chlamydia trachomatis infection, because antibody of chlamydia trachomatis level was abnormally high. The infection of chlamydia trachomatis has been getting more recently. We should consider acute peritonitis caused by chlamydia trachomatis infection when we encounter acute peritonitis in women.

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We encountered an adult case of mature giant retroperitoneal teratoma showing high serum level of CA19-9 preoperatively, in which the localization of CA19-9 in the resected material was confirmed immunohistochemically. This case is presented with some bibliographical comments.
A 35-year-old man was admitted to the hospital because of pressure sensation on the upper abdomen and upper abdominal pain. Before operation, serum 19-9 was as high as 110U/ml. Ultrasonography, CT scan, and magnetic resonance imaging revealed a giant monolocular cystic tumor in the left upper abdomen, with heterogeneous inside and calcification partially. With a diagnosis of retroperitoneal tumor, the tumor was removed. The tumor was 17.5×15.3×10.3cm in size and 1, 581g in weight, with smooth surface. It was single cystic, inside of the cystic wall was like epidermis, and the inside of the cyst was filled with gruel component of yellow ocher in color. Histologically, it was mature teratoma composed of three germ layers, and localization of CA19-9 in the intestinal and bronchial epithelia in the tumor tissues was able to be confirmed. After the removal of the tumor, serum CA19-9 level was rapidly normalized. There have been no signs of recurrence as of 5 months after the operation, though it is a short time observation.

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