The usefulness of the recently developed ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson Co.) for subtotal thyroidectomy in the treatment of Graves' disease was compared with that of a conventional method which was characterized by grasping of a portion of thyroid tissue with ring forceps, dissecting and then ligating the isolated segment of tissue (forceps method). Subtotal thyroidectomy was performed by means of the Harmonic Scalpel in 31 patients and the forceps method in 14 patients. The weights of the removed portions of the thyroid gland were statistically matched in the two groups. Use of the Harmonic Scalpel shortened the operating time, lessened the size of the thyroid remnant and permitted earlier removal of the postoperative drains. The difference between both methods was especially remarkable in intra- and postoperative blood losses; those were 58±61ml and 50±42ml in Harmonic scalpel method versus 144±108ml and 137±118ml in forceps method respectively, with significant differences (p=0.0121, p=0.0237). No postoperative complications were encountered in either group. All of the patients were euthyroid after the operations. These findings indicate that the Harmonic Scalpel may be useful in performing subtotal thyroidectomies for the treatment of Graves' disease.

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A series of 27 cases of acute appendectomy undergone laparoscopic appendectomy (LA) at the hospital from April 1997 to March 1999 ware compared to 30 cases undergone open appendectomy (OA) in the same period to assess the usefulness of LA. The comparison was made for operating time, blood loss, time for drain-removal, length of hospital stay, patient number of analgesic use, postoperative complications and total cost of hospitalization. It was found that LA was significantly associated with a less blood loss, a shorter time for drain removal, a shorter hospital stay, and fewer patient number of analgesic use. Wound complications such as wound infection and intra-abdominal abscess were none in the LA group but three in the OA group, without significant difference. There was no significant difference in operating time between LA and OA groups. The operation charges were significantly more expensive in LA group, but total cost of hospitalization was almost equal in both groups. In conclusion, LA that is superior to OA in the postoperative quality of life is recommended as a procedure of choice for the management of acute appendicitis, though there is little difference between them in the total cost of hospitalization.

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The purpose of this study was to determine the clinicopathological differences between cancers in the right-sided colon and those in the left-sided colon. After excluding multiple cancer cases, 620 patients with primary colon cancer were enrolled in this study. They comprised of 269 patients with right-sided colon cancer and 351 with left-sided colon cancer. We compared the two groups with respect to clinicopathological findings.
The patients with right-sided colon cancer tended to have larger tumors, less differentiated tumors such as poorly differentiated adenocarcinoma, signet ring cell carcinoma and mucinous carcinoma, and higher prevalence of distant lymphnode involvement and peritoneal metastasis, than those with left-sided colon cancer. There were, however, no significant differences in histological staging and survival rates in these two groups.

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Nine patients presenting with foreign bodies in the rectum in a recent 14-year-and-one month period from May. 1986 to June. 1999 are clinically studied, together with 55 patients in the Japanese literature.
There were seven men and two women who ranged in age from 15 to 43 years. The average age was 29.6. The patients presented with complaints such as foreign body in seven cases and abdominal pain in two cases. The most common cause was anal eroticism in eight cases. The patients often came to the hospital at night because of a sense of shame. There were two patients who repeatedly came to the hospital because of foreign bodies through the anus. All foreign bodies (in eight cases) were removed transanally, except one patient whose foreign body (a pencil) was surgically removed because the foreign body caused perforating peritonitis. The foreign objects included spray can in two cases, wire in two cases, and proof, bottles, vibrator, pipe, pencil, and confection caddy in each one case.

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We evaluated the indication and problems of percutaneous transhepatic cholangiographic drainage (PTCD) under ultrasonography-guided puncture using the 21G needle with catheter in order to decrease the X-ray radiation to the operator's hands. The catheter of the 21G needle is flexible and we can performed cholangiography and insert guide wires and drainage tubes from outside of X-ray field. By this reason this method of PTCD can decrease X-ray radiation to the hands.
These procedures of PTCD were performed in 214 times of 190 patients in our hospital. The punctures of the bile duct were successfully performed in all cases, but insertion of the drainage tube failed in 12 times because of insufficient dilatation under 5mm in diameter and hardness of the bile duct.
As a result it is considered that this method is indicated for dilatation of the bile duct over 5mm in diameter and that the suitable angle of puncture and selection of an appropriate catheter are important.
The complications in this series were bile duct bleeding in two cases, deviation of the catheter in four cases and serious shock in one case.

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From 1969 to 1998, a series of 27 patients were operated on for pancreatic injury in our institute. There were 11 cases of type I, 7 cases of type II, 6 cases of type IIIa, and 3 cases of type IIIb pancreatic injury according to the pancreatic injury classification of the Japanese Association for the Surgery of Trauma. Twenty-two patients had injury to more than two organs, 3 patient died, and 4 patients had injury to more than four organs. Several methods of operative management were performed: simple drainage (n=8), mobilization and drainage of pancreas (n=7), distal pancreatectomy (n=6), pancreaticoduodenectomy (n=5), and Letton & Wilson method (n=1). Four patients who underwent simple drainage developed traumatic pancreatitis, and one patient developed traumatic pancreatitis following mobilization and drainage of the pancreas. We suggest that pancreatic contused lesions should be cleaned thoroughly and the whole pancreas should be mobilized and drainaged properly. Furthermore, either distal pancreatectomy or pancreaticoduodenectomy are useful procedures as treatments of choice for pancreatic injury involving the main pancreatic duct.

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With respect to the immunohistochemical expression of TS, 18 cases of triple cancers were studied and all included gastric cancer. Of the gastric cancers, 3 were synchronous and the others were metachronous against 1 or 2 other cancers. The histological stages of gastric cancer ranged from stage I to IV, and included 9, 5, 2 and 2 cases in the ascending order of stage, respectively.
Overall expression of TS was 38.9% in gastric cancers. Chronologically, the rates were 12.5%, 37.5% and 50.0% in preceded, simultaneous and followed gastric cancers, respectively. TS was detectable in 76.0% of other cancers examined, of which colorectal cancer composed one third. Among 10 cases in which TS was examined in each triple cancer site, 2 had 3 cancers with TS(+), 5 had 2 cancers with TS(+) and 3 had 1 cancer with TS(+) and none had TS(-) in all. Prognosis was poorer for the group with positive TS in more than 2 cancer sites than in less TS positivity.
Therefore, it was considered that the prognosis of the triple cancer patients could be more predicted by combining TS positivity of each cancer.

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The background factors and surgical results of 546 patients with arteriosclerosis obliterans (ASO) in an early group (between January 1976 and December 1989) were compared with those of 454 patients in a later group (between January 1990 and July 1998).
The later group was older than the early group and had less critical leg ischemia. In the later group, there were more patients with diabetes mellitus and renal failure. There were no significant differences between the two groups in bypass patency rates and hospital deaths.
It is necessary to develop a new therapy which prevents intimal hyperplasia and arteriosclerosis.

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Abscess of the iliopsoas muscle caused by MRSA is a rare entity. This paper report is a case of abscess of the iliopsoas muscle and pulmonary suppurative disease which might be caused by MRSA septicemia in a patient with chronic renal failure on hemodialysis.
A 41-year-old woman who had been undergoing hemodialysis was admitted because of fever and left lumbar pain. Pelvic and thoracic CT scan offered diagnosis of abscess of the left iliopsoas muscle and pulumonarry suppurative disease. An incisional drainage was performed. On admission, MRSA was isolated from incubation of arterial blood as well as from incubations of pus and sputa. So VCM was administered. After enucleation of a drain, re-retention of pus was observed. Second incisional drainage was performed on the 8th postoperative day. After the reoperation, lavage through the drain was repeated. The high fever was normalized and a significant decrease in size of the abscess was confirmed on pelvic and chest CT scans in 7 weeks after the operation. The patient was discharged very much improved on the 13th weeks after the operation.

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The association of myasthenia gravis and Graves' disease is not infrequent. If a patient has these two diseases and requires surgical treatment, a two-stage operation consisting of subtotal thyroidectmy followed by thymectomy through median sternotomy has been the common surgical practice.
Recent advances in perioperative management allow us to perform simultaneous subtotal thyroidectmy and thymectomy. In additions endoscopic thymectomy is cosmetically preferable and less invasive than conventional procedures. We treated a 27-year-old woman patient who had myasthenia gravis and Graves' disease, performing a simultaneous subtotal thyroidectmy and endoscopic thymectomy. This simultaneous operation is the first case reported to our knowledge.

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A 63-year-old woman was admitted to the hospital because of appetite loss, dry mouth, and slight disturbance of consciousness on February 3, 1999. There was a previous history of undergoing a total thyroidectomy for differentiated thyroid cancer and multiple bone metastasis followed by TSH inhibition regimen and internal irradiation with ¹³¹I (3 times) in December 1995. Thereafter she had been followed up in our outpatient clinic until this admission. On admission, blood and biochemical examinations showed inflammatory findings and hypercalcemia. Chest x-ray film revealed multiple pulmonary metastasis. On ⁶⁷Ga scintigraphy, faint accumulation in the bilateral middle and lower lung fields and left iliac region were demonstrated. Histological findings of metastasized portion of the left iliac bone were not contradictory to those of undifferentiated cancer. In the clinical course after admission, the metastatic lung lesion abruptly enlarged, respiratory condition became worse, and the patient died on March 12, 1999. Increases in various serum cytokines such as G-CSF and PTHrP were confirmed that might cause inflammatory findings including leukocytosis and hypercalcemia.

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We report herein a rare case of an adenomyoepithelioma of the breast. A 21-year-old woman was admitted to our hospital for a painless lump in the upper outer area of the right breast. Ultrasonography of the breast demonstrated a 5-cm hypoechoic mass with a clear border and posterolateral shadow. The ratio of breadth to length of the tumor was 0.31. Ultrasound-guided fine-needle aspiration cytology showed class II. Wide excision of the tumor was performed. Histologically, the tumor was composed of proliferation of both epithelial and myoepithelial cell components. The mitotic index of the clear myoepithelial cells was low. Follow-up for fifty-six months has revealed no evidence of local recurrence or metastatic spread of the tumor. To our knowledge, this patient is the youngest one with this disease reported in the literature.

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Tubular adenoma is a rare benign tumor of the breast that commonly occurs in young women. We report a case of tubular adenoma of the breast which was difficult to diagnose. A 71-year-old woman visited the hospital because of a left breast mass. She had three children. There was no discharge from the left nipple, and she felt no pain. Ultrasonography revealed a well demarcated and heterogeneous mass, which was 2.5×2.5×2.4cm in size, and was located in the C and D area of the left breast. Mammography showed spicula in the mass. The preoperative pathological diagnosis by aspiration biopsy cytology was adenocarcinoma, therefore, a modified radical mastectomy was performed. However, intra-operative pathological diagnosis was tubular adenoma. Misdiagnosis of a breast cancer sometimes occurs in aspiration cytology when degeneration or central infarction has occurred as in tubular adenoma. Therefore, consideration of this disease as an initial diagnosis is essential to prevent unnecessary mastectomy.

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We experienced a case of male intracystic carcinoma of the breast with lymphatic metastasis. A 70-year-old man was seen at the department because of a right breast mass. A solid tumor in the cyst measured 48×45×42mm in diameter was revealed on ultrasonography. After making a diagnosis of intracystic carcinoma by a mammogram, ultrasonography and an excisional biopsy, a modified mastectomy with lymph node resection was perfomed. Histologically, it was diagnosed as papillally intracystic carcinoma with metastasis to the axillary lymph node.
Intracystic carcinoma of the breast in male is a rare disease, and 13 cases have been reported in the Japanese litarature. So far no metastases to the axillary lymph nodes have been reported, and tumor excision without lymph node dissection has been the satisfactory treatment for male intracystic carcinomas. It may be necessary, however, to indicate lymph nodes dissection case by case.

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Metastatic carcinoma of the breast from extramammary carcinoma is unusual, especially from carcinoma of the colon. A case of breast metastasis from carcinoma of the colon is reported. A 72-year-old woman was performed a left hemicolectomy for cancer of the descending colon (Stage IV) in June 1996. Lung metastasis was detected in September 1997. Circumscribed left breast tumor with a rapid growth was detected in September 1998, and a fine-needle aspiration cytology resulted in class V (adenocarcinoma). Extirpation of the tumor was performed under a suspicion of breast metastasis from carcinoma of the colon. The tumor was capsulated and measured 1.8cm in diameter. The tumor was diagnosed as breast metastasis from extramammary carcinoma histologically, because moderately differentiated adenocarcinoma was distributed in periductal and perilobular areas in absence of intraductal and intralobular proliferation. The tumor was histologically and immunohistochemically similar to the previously operated colon carcinoma. We diagnosed the tumor as breast metastasis from carcinoma of the colon. She died of growing lung metastasis from the colon carcinoma in April 1999.

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A 48-year-old woman, showing a huge tumor shadow on the right side of the chest by roentgenogram, was admitted to our hospital. CT-scan showed that the tumor, 20cm in diameter, ocuppied the lower half of the right thoracic cavity, and expanded to the liver. MRI suggested, direct invasion of the liver by the lung tumor through the diaphragma. From angiographic examination, the main vessels of the tumor arose from the right inferior phrenic artery. The inferior vena cava, the right inferior pulmonary artery and vein, and the right hepatic vein were intact. The pathologic diagnosis of the specimen obtained by percutaneous needle biopsy was a fibrous tumor of the pleura. An operation was performed using a midsternal and right subcostal incision to resect the tumor completely. The tumor was 19.5×16.5cm in size and 2056g in weight. Pathological features were compatible with fibrous tumor of the pleura, and results of immuno-pathological examination was Desmin & cytokeratin negative, but vimentin & CD34 positive.

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A 91-year-old woman was seen at the hospital because of fever up and languidness. Pneumonia of the right lung was diagnosed and she was admitted to the hospital, with an improvement. After admission an elastic hard subcutaneous tumor of her right scapulal area was recognized. The tumor showed a rapid growth to 9cm in diameter and swelled. On an aspiration cytology, class IV was revealed, and sarcoma was suspected. Hard lymph nodes of her right axilla and right supraclavicle were palpable. There was a suspicion of metastatic lymph nodes. CT scan revealed a tumor of S6-bifurcation of the right bronchiole and primary lung cancer was suspected. Considering the patient's great age, a resection of the tumor of the back, a biopsy of the lymph node of the supraclavicle and a bronchoscopy were performed under general anesthesia. Histological examination revealed malignant fibrous histiocytoma (MFH), ordinary type, of the back, the metastatic lymph node of the supraclavicle and the primary adenocarcinoma of the lung. Thereafter, a rapid growth of the residual tumor in the supraclavicle was started. Intra-arterial injection of pirarubicin (50mg/body) was performed twice, but in vain. Multiple lung metastasis appeared and grew rapidly. Then she died and autopsy was performed. Reported cases of MFH associated with cancer are generally classified into two groups, namely MFH induced by radiotherapy for cancer (former group) and MFH without relation with radiotherapy (later group). There have been 30 cases in the latter group in Japan. We think that multiplicity of cancer and MFH of no relation with radiotherapy might occur incidentally in this case.

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We recently encountered two cases of Morgagni's hernia with severe symptoms. Chest roentogenograms showed abnormal shadows from air pockets in the right cardiophrenic angle in both patients. The first patient was a 63-year-old woman who was referred to our hospital because of dyspnea, with repeated bouts of pneumonia and bronchial asthma. A barium enema demonstrated that colon was incarcerated in the right thoracic cavity behind the sternum and was compressing the lung. The second patient was an 83-year-old woman who was referred to our hospital because of vomiting and abdominal pain. Chest CT, gastrointestinal series, and ultrasonography showed prolapse of the stomach and transverse colon. Upon the diagnoses of Morgagni's hernia, surgical repair was done by the transabdominal approach in both cases. After surgery, symptoms improved and the abnormal shadow in the X-ray photograph disappeared. We conclude that an operation should be carried out as soon as this disease is discovered.

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This paper presents a successfully surgical case of esophageal hiatal hermia in which the entire stomach and a large section of transverse colon were incarcerated with gastric volvulus in an organoaxial form, that is extremely rare.
A 70-year-old woman was admitted to Umezawa clinic because of anterior chest pain, chest oppression and dyspnea after meals. Chest roentogenogram showed a gastric air bubble with fluid level in the posterior mediastinum. So, an upper gastrointestinal series and gastrointestinal endoscopy were conducted. The patient was diagnosed as having an esophageal hiatal hernia with gastric volvulus in an organoaxial form, and was admitted to our hospital. CT and a lower gastrointestinal roentgenograms revealed on esophageal hiatal hernia in which the entire stomach and a large section of transverse colon were incarcerated with gastric volvulus in an organoaxial form.
Reduction suture of the right loop of the esophageal hiatus, Nissen procedure, and pyloroplasty were performed.
No postoperative complication occurred. The patient was discharged from our hospital on the 18th hospital day. She is free symptom and enjoying daily life.

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In July 1990, a 29-year-old man showed an abnormal shadow in a chest roentgenogram in a routine health examination. He was diagnosed with submucosal tumor (SMT) in the lower esophagus and his clinical course was observed. In December 1997, he was admitted to our hospital because of growth of the tumor. Esophagography revealed a filling defect shadow, 5cm in diameter, in the left wall of the lower esophagus, but endoscopy showed no ulcer. Computed tomography showed a low density tumor shaped like a horseshoe in the lesion. He was diagnosed with leiomyoma and an operation was perfomed. Thoracotomy on the left 7th intercostal route was performed, finding a tumor in the shape of a horseshoe in the lower esophagus, projecting to the thoracic cavity. The tumor did not invade the surrounding tissue, and we treated it successfully by enucleation without injury of the mucosa. The resected specimen was 7.5×5×5cm in size, and the cut surface of the solid tumor was light yellow. The diagnosis of leiomyoma was confirmed histopathologically.
We concluded that SMT shaped like a horseshoe in the lower esophagus is characteristic of leiomyoma, and we should perform enucleation if possible to preserve the functions of the esophagus and stomach.

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Gastric volvulus is principally a disease for infants and uncommonly occurs in adults. In this paper, a case of gastric volvulus in an adult is reported. A 71-year-old woman was admitted to the hospital because of upper abdominal pain and vomiting. On an endoscopic study of the stomach, the endoscope was not able to reach to the pyloric part of the stomach due to prominent deformity of the stomach. Abdominal CT scan revealed the remarkably extended stomach. Gastric volvulus was diagnosed. Endoscopic reduction resulted in incomplete reduction and the patient was operated on. At laparotomy, the stomach twisted longitudinally as well as traversally, without hiatal hernia of the esophagus. The stomach was reduced and fixed to the abdomonal wall. There are some case reports that no recurrence has been observed after endoscopic reduction. In the treatment of gastric volvulus that strongly resists the reduction like in this case, laparoscopic reduction must be kept in mind, though we did not employ it for this case.

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Blunt abdominal trauma commonly affects the small intestine, and injury of the stomach rarely occurs. This paper presents a case of rupture of the stomach due to a blunt abdominal trauma.
A 62-year-old man injured in a traffic accident while he was driving his car about 2 hours after a supper. He buckled up his shoulder strap. When he was first seen at the hospital, abdominal pain was present, but no peritoneal signs nor abnormalities on an abdominal CT scan were revealed. Most severe pain was noted at the right thigh. He was admitted to the hospital with diagnoses of bruise to the head, contusion wound to the face, bruise to the chest and abdomen, and dislocation and fracture of the right hip joint. On the next day, abdominal pain mainly localized to the epigastrium lasted. There were Blumberg signs but no muscular defense was noted. Abdominal CT scan on the next day revealed intraabdominal free air. The patient was operated on with a diagnosis of rupture of the intestine. At laparotomy, rupture about 1cm in size was found at the sphincter posterior wall of the lesser curvature. No injured organs other than the stomach were demonstrated. The injured site was sutured and covered with greater omentum. Wound infection occurred after the operation but improved. The patient was transferred to the department of orthopedics in our hospital for the treatment of dislocation and fracture of the right hip joint.

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We report a relatively rare case of a cyst of the stomach with a review of the literature. A 40-year-old man was pointed out an adbominal mass by ultrasonography in his routine medical check-up. The mass was diagnosed as submucosal tumor of the stomach and he was referred to out surgical department. An ultrasonogram revealed a hyperechoic mass and an operation was performed. A cystic mass was palpated and was diagnosed as cyst of the stomach. Enucleation of the tumor was carried out. Histologically, the tumor was enterogenous cyst of the stomach. Postoperative course was uneventful and he was discharged on the 12th day after the operation. No recurrence of the tumor has been noticed. It is well known that leiomyosarcoma is the most frequent in the submucocal tumors of the stomach and enterogenous cyst of the stomach is relatively rare. Its classification and treatment have not been established as yet.

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A 72-year-old man was admitted to the hospital because of upper abdominal pain and abdominal full sensation. Gastrointestinal fiber revealed a gastric ulcer in the upper portion in the gastric body adjacent to the greater curvature. Abdominal CT showed the fluid collection in the upper abdomen and the tomor with the size of 8cm between the left lobe of the liver and spleen. Emergency operation was carried out with the diagnosis of intra-abdominal bleeding and tumor. Approximately 1L of hemorrhagic ascitis was noted, as well as the extramurally growing tumor in the upper portion of the gastric body adjacent to the greater curvature A total gastrectomy with lymph nodes dissection (D1) and ρ-Roux en Y anastomosis was performed. The resected material revealed that the tumor formed small ulcer on the gastric mucosa at the upper portion of gastric body adjacent to the greater curvature, mainly grooved extramurally, and a portion of the tumor destructed with torn capsule. It is uncommon that the disease presented with abdominal bleeding from the tumor. Pathological diagnosis was leiomyosarcoma of the stomach. It is difficult to diagnose the extramurally growing leiomyosarcoma of the stomach preoperatively. Reviewing the past reports of the extramurally growing leiomyosarcoma of the stomach presented with intraabdominal bleeding, clinicopathological features were investigated.

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Cases of leiomyosarcoma of the remnant stomach are very rare, and only thirty-two have been reported in Japan.
A 62-year-old woman who had undergone a distal gastrectomy (Billroth I) for gastric carcinoma 11 years previously was admitted with anorexia. Submucosal tumor of the remnant stomach was diagnosed by gastrointestinal series. An abdominal CT-scan showed a huge irregularly enhanced tumor, and a low density area in the liver was suspected metastasis. Angiography of the celiac axis demonstrated a tumor staining with hypervascularity, supplied by the short gastric artery and the left hepatic artery. A resection of the total remnant stomach was performed with lymph node dissection, splenectomy, distal pancreatectomy (body-tail), cholecystectomy, resection of the lateral segment of the liver, enucleation of the tumor located anterior segment of the liver and anastomosis of Roux-en Y method. The resected tumor measuring 20×15×12cm in size showed growth extragastric. Histological findings revealed leiomyosarcoma of the remnant stomach with liver metastasis.

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Gastric perforation in early gastric cancer is a rare condition. We present a case of early gastric cancer with gastric perforation, on whom radical surgery was performed by the two-step procedure. A 59-year-old woman was admitted to our the hospital because of epigastralgia. A plain chest X-ray revealed free air under the diaphragm, and CT showed a hole at the anterior gastric wall, which was highly suggestive of gastric perforation. Therfore an emergency operation was carried out and a part of the omentum was applied to cover a perforation area. There was a perforation measuring 8mm in diameter on the lesser curvature in the upper anterior wall. On the 10th postoperative day, fiberscopy revealed an advanced gastric cancer of type III+IIc at the perforation area. Histological diagnosis of the biopsy specimens was signet-ring cell carcinoma. She underwent total gastrectomy with splenectomy with D2 lymphadectomy 24 days after the previous operation. The invasion of the cancer was within the mucosa histopathologically. The final diagnosis was gastric perforation underlying early gastric cancer. No signs of recurrence have been detected as of 7 months after the operation.
In the treatment of gastric perforation, we recommend the two-step approach; the omental coverage is performed, followed by radical surgery if fiberscopy reveals gastric malignancy after the omental coverage.

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We report a rare case of carbohydrate antigen (CA) 19-9 producting mucinous gastric cancer with too much secreting. A 46-year-old man was pointed out high value of serum CA19-9 by a routine health examination. So He was admitted to the hospital in order to rule out malignant disease. He was diagnosed as having advanced gastric cancer at the posterior wall on the antrum by gastrointestinal endoscopy.
Distal gastrectomy with regional lymph node dissection was performed. Microscopic examination revealed that the cancer was arose from mucous nodose and immunohistochemical stain of the resected material was positive for anti-CA19-9 monoclonal antibody was positive. The value of serum CA19-9 increased after admission and remarkaably decreased to the normal range after the gastrectomy. The normalized CA19-9 level has been kept up to nou for 3 years. Patients group with high CA19-9 valeu has a poor prognosis, and hence further strict observation of his clinical course will be nesessary.

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We report a case of gastric cancer with acromegaly in a 48-year-old man. He had a history of undergoing a total thyroidectomy for a thyroid cancer. His acromegaly was noticed in 1994 at another hospital. This patient showed typical acromegalic face and increased basal secretion level of GH and insulin like growth factor I (IGF-I). He was incidentally found to have a gastric cancer. Macroscopically it was 0 IIc type and 7mm×3mm in size. The patient was transferred to our department and underwent a partial resection of the stomach. Histological diagnosis was poorly differentiated adenocarcinoma with limited invasion to the submucosal layer. The previous reports mentioned about a high degree of association of acromegaly with neoplasm. However, gastric cancer in acromegalic patient is relatively rare, the continuous higher level of GH and IGF-I might influence carcinogenesis of this patient. The association of malignancy is an important factor for the prognosis in patients with acromagaly. It should be kept in mind in the long term observation of such patients.

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A case of brunneroma in the second portion of the duodenum is reported. A 59-year-old woman who visited a local practitioner because of tarry stool and general fatigue was referred to the hospital with a diagnosis of upper GI bleeding. Upper GI series revealed a pedunculate polyp in the second portion of the duodenum, and an endoscopy captured an evidence of bleeding from the duodenal polyp. A histological examination of biopsied specimens offered a suspicion of brunneroma, however, a possibility of malignancy could not be ruled out. With the most probable diagnosis of brunneroma, a surgical resection of the duodenal polyp was performed. The resected specimen was 70×36×19mm in size and was diagnosed as brunneroma pathologically, With a recent progression in technique of endoscopic therapy, case reports of endoscopic therapy for brunneroma has been increasing. Resection of giant brunneroma by endoscopic polypectomy has a risk of provoking bleeding or perforation, and it may be impossible to withdraw the resected specimen via pyloric ring. In selecting therapeutic method for giant duodenal polyp, out decision-making must be made carefully case by case, and we have not to mind selecting surgical approach if it is more appropriate.

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A 65-year-old man visited the hospital because of general fatigue and anemia. Hypotonic duodenography revealed a filling defect at the second portion of the duodenum. Endoscopic examination revealed a tumor with easy bleeding ulcer at the oral side of the Papilla Vater of the duodenum. Preoperative examinations showed that the tumor which was 5.5cm in diameter, solid, well-delineated, and hypervascular, and had developed extramurally from the second portion of the duodenum to the retroperitoneum. Under the diagnosis of duodenal tumor, a pylorus preserving pancreaticoduodenectomy was performed. At laparotomy, a mass with a smooth surface and located in the posterior wall of the duodenum was found. There was no metastasis. Histopathologically, this tumor was mainly composed of proliferated spindle cells that had mitotic figures by 6/10 high power field. Immunohistochemical study showed that the tumor was negative for smooth-muscle actin, desmin, neuron specific enolase and S-100 protein. Therefore, it was diagnosed as a duodenal stromal tumor that was suggestive of malignancy because of its 5.5cm diameter and frequent mitosis. There has been no signs of local recurrence and metastasis as of 4 months after the operation. However, the patient requires careful follow-up.

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We report two patients with intestinal obstruction caused by Meckel's diverticulum.
Case 1: A 19-year-old man with intestinal obstruction was admitted to our surgical section. He was treated during several hospitalizations for similar symptoms and gained eventual relief by conservative treatment. Finaly, laparotomy was performed because conservative therapy was no longer effective. At laparotomy, intestinal stenosis was observed, and partial excision was carried out. Invagination of the bowel revealed that complete introversion of a Meckel's diverticulum had caused the intussusception. Case 2: An 18-year-old man with abdominal pain and vomitting was admitted to our hospital. A laparotomy was performed under a diagnosis of small bowel obstruction. At laparotomy, small bowel obstruction due to a mesodiverticular-vascular band was observed. We cut this band, and resected the Meckel's diverticulum. Both patients are now doing well.

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We experienced two cases of gastrointestinal stromal tumor of the small intestine presented with hemorrhage. Patient 1, a 64-year-old woman, was seen at the hospital because of melena. On abdominal ultrasonography, a tumor was detected in the median lower abdomen. It was diagnosed as jejunal tumor by superior mesenteric arteriography. Partial rescction of the jejunum was performed. The resected tumor was a 60×50×35mm, cineritious, solid hemorrhaging submucosal tumor. Patient 2, a 72-year-old woman, was seen at the hospital because of melena and hematemesis. Endoscopic examination showed a submucosal tumor with bleeding in the second portion of the duodenum. Partial resection of the duodenum was performed; the resected tumor was a 35×35×25mm benign submucosal duodenal tumor. Histopathologically, the tumor was mainly composed of less atypia fascicular proliferation of spindle cells in both cases. Immunohistological examinations revealed the tumors to be gastrointestinal stromal tumor (GIST). Submucosal tumors of the small intestine are often detected by hemorrhage; in these cases possibility of GIST should be considered and carefully investigated.

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A 45-year-old woman was seen at the hospital because of headache, palpitation, and general fatigue, and underwent close examination for detected severe anemia. Abdominal ultrasonography, CT scan, and magnetic resonance imaging revealed a solid tumor about 7cm in diameter adjacent to ventral of the uterus. Fluoroscopic study of the small intestine revealed no prominent stenosis nor tumor shadow. At laparotomy, an extraluminally growing fist-sized tumor in the ileum 70cm distal from the terminal ileum was found. The ileum was excised. Histopathologically the tumor was composed of dense proliferation of spindle cells and storiform pattern was obviously seen. Malignant fibrous histiocytoma of usual type was diagnosed. There have been no signs of recurrence and the patient is doing well as of 3.5 years after the operation.
Malignant fibrous histiocytoma of the small intestine is a very rare entity and 14 cases have been reported in Japan. It commonly occurs in middle to elderly men, and often presents with intestinal obstruction and hemorrhage. So we have difficulty in preoperative diagnosis. Although the patients manifesting peritoneal dissemination and hematogenic metastasis have a poor prognosis, long-term survival can be expected for the patients having lymph nodes metastasis and invasion into the surrounding organs by radical operation.

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We report a rare case of acute appendicitis which was probably caused by a fish bone. The patient was a 21-year-old woman, who was examined at our hospital with the chief complaints of right lower abdominal pain and diarrhea. At the time of examination, localized pain, tenderness, and mild muscular defense were observed in the right lower abdomen. In the hematological examinations, the leukocyte count was 13900/μl and CRP level was 1.0mg/dl. As an abdominal CT demonstrated swelling of the appendix vermiformis and a linear high-density area, fecalith was suspected. Based on the above findings, an operation was performed with a diagnosis of acute appendicitis. The postoperative pathological diagnosis was phlegmonous appendicitis, and a fish bone of 1cm in length was found in the excised appendix lumen. Appendicitis was thought to have developed from obliteration of the appendix lumen, which was caused by a fish bone, and accompanying bacterial infection and induction of inflammation.

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We report three cases of mucinous cystadenoma of the appendix presented with different processes, and discuss recent trends of preoperative diagnosis and treatment for the disease in a review of 64 cases seen in the Japanese literature for recent 5 years. [Case 1] A 69-year-old man was detected a high level of serum CEA during an examination for his complaint of appetite loss. Mucinous cystadenoma of the appendex was diagnosed by imaging studies. [Case 2] An 85-year-old woman had been performed herniorrhaphy for femoral hernia. The removed hernia sac contained mucinous tumors, which were suspected pseudomyxoma peritonei by a histological examination. The patients was operated on without any differential diagnosis from ovarian cyst, and appendiceal mucocele was revealed. [Case 3] A 68-year-old woman was incidentally detected having a cystic mass in the right lower abdomen by ultrasonogra-phic study at a medical check up. The disease was diagnosed by close examinations. In all these cases partial cecectomy was performed. In a review of the literature, a recent increase in the rate of correct preoperative diagnosis for this disease has been shown. However the disease still presents difficulty in distinguishing between benign and malignant tumors. Then, extensive operations more than ileocecal resection were selected in over half the cases. We suggest that minimally invasive surgery should be selected at primary laparotomy, following enough informed consent about a possibility of re-operation.

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Ogilvie syndrome is an acute pseudo-obstruction of the colon without mechanical stenosis, the and pathogenesis of which is still unknown. This paper presented two cases of Ogilvie syndrome.
Case 1: A 57-year-old man was admitted to the hospital because of symptoms suggesting intestinal obstruction. Through examination revealed no mechanical stenosis of the colon. Since decompression for the dilated colon using colonos-copy was not successful, sigmoidostomy was performed because of the risk of colon perforation.
Case 2: A 75-year-old man with no past history of disease, was admitted with abdominal fullness and dilation of the colon. Various examinations revealed an extremely dilated colon without mechanical'stenosis, and the diagnosis of idiopathic Ogilvie syndrome was made. This case was treated by colonos-copic decompression.
In the literature, colonoscopic decompression is the first treatment of choice before surgery in some cases of the Ogilvie syndrome. In this paper, two cases of Ogilvie syndrome treated endoscopically or operatively are reported.

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Malignant jejunocolic fistula resulting from invasion of colon cancer are rare. This report deals with the jejunocolic fistula due to cancer of the transverse colon. A 50-year-old man was admitted to the hospital because of appetite loss and body weight loss. Barium enema, upper gastrointestinal series and abdominal CT scan showed a malignant fistula between the jejunum and transverse colon. We diagnosed the patient as having colonic cancer with jejunocolic fistula and performed an operation. Intraoperative findings included the childs head-sized mass of the transverse colon involving a part of the jejunum and pancreas tail. Transverse colectomy, patrtial resection of the jejunum, disal pancreatectomy and splenectomy were performed. Cholecyctectomy was added for assosiated gallstone and cholecystitis which were confirmed by preoperative examinations. Pathological examination revealed a well differentiated adenocarcinoma without lymph node metastasis [si, n(-), P₀, H₀, ]. Eighty-seven cases of intestinal fistula due to colon cancer have been reported in the Japanese literature so far, and twenty-three cases of them were jejunocolic fistula. We emphasize that most of these cases can be candidates for radical resection because these colon cancers forming fistula have a low grade of biological malignant potential.

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A 54-year-old man was admitted to the hospital because of diarrhea. When he was first seen, examination of blood showed anemia, and further close examinations including upper gastrointestinal series and barium enema study revealed duodenocolic fistula. Colonofiberscopy revealed a type 2 elevated lesion in the ascending colon in the vicinity of the hepatic flexure. Advanced colonic cancer with duodenocolic fistula was diagnosed. Extended right hemicolectomy, pylorus preserving pancreatoduodenectomy, and partial hepatectomy (S5) were performed. Histopathological diagnosis was A, 8×6cm in size, Si (duodenum), P0, ly3, v3, ni, n0, ow(-), and aw(-). There have been no signs of recurrence and the patient is living and well, as of 48 months after the operation.
There is a chance of long-term survival for the patient with advanced colonic cancer with duodenocolic fistula by extended operation, if the cancer is locally infiltrating type.

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A 54-year-old man was seen at the hospital because of pneumaturia, fecaluria, diarrhea, and fever, and was admitted for close examination and treatment of vesical fistula. He complained of slight lower abdominal pain. Abdominal CT scan revealed remarkable swelling of colonic and bladder walls as well as inflammatory findings in their circumferences. Barium enema and cystography visualized no fistula. Fistulography using a colonofiberscope visualized a fistula. Colonofiberscopy failed to confirm colonic cancer due to stenosis at the fistula because it was present in the back of the fistula. And diverticulitis of the colon was suspected as a cause of fistulation. At operation, a tumor was palpable in the colon at the stenosed portion, and cancer of the sigmoid colon was diagnosed. Although the colon and bladder were adhered firmly, dissection of them was possible. Operative procedures included a resection of the sigmoid colon and a partial resection of the bladder. An opening of the fistula was seen in the vicinity of anal side to the cancer. Histopathologically, infiltration of cancer into the fistula opening was confirmed, but apparent infiltration of inflammatory cells were observed in the fistula wall. It is thought that fistulation in this case might not formed from ulcer center of the cancer which directly invaded the bladder, and a possibility of association of vesical fistula due to diverticulitis of the sigmoid colon in the vicinity of the colonic cancer could not be ruled out.

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Despite the wide acceptance of less invasive surgery for prolapse recti in elderly patients, the optimal surgical approach for prolapse recti in young adults remains controversial. We herein report a case ofprolapse recti in a young man who was successfully treated by anterior resection with pexy of the colorectum to the sacrum.
A 22-year-old man was admitted to the hospital because of rectal prolapse by about 6cm, which had been repeatedly repositioned manually for these 3 years. Barium enema study demonstrated marked dilatation of the lower rectum. Magnetic resonance imaging showed extremely low Douglas l pouch and thickened rectal wall. Anterior resection with pexy of the colorectum to the sacrum was performed. The postope rative course was uneventful. There have been no signs of recurrence, as of 20 months postoperatively. This approach which can be a radical operation in terms of the genesis of the disease is considered to be one of better surgical procedures in young adults with prolapse recti.

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A 58-year-old man complaining of stools with slime and blood-streaking was referred to the hospital because he was pointed out having malignant rectal lymphoma on colonofiberscopy at another hospital. After admission, no lesions in the other organs were revealed by preoperative close examination. Stage II was suspected according to Nagvi's classification and an operation was performed prior to chemotherapy. Paying consideration for bladder function, abdominoperineal excision of the rectum and lymph nodes dissection (superiorly D3 and laterally D2) were employed according to operations for rectal cancers. The excised lesion was 11.2×11.0×3.0 cm in size and type 2 like, and no infiltration into the adjacent organs were revealed. Histopathological findings resulted in al, and superiorly n3 and laterally n2. CHOP therapy was started on the 30th postoperative day but no effects were demonstrated after 2 courses of the therapy. Recurrence occurred in the perineum on 80th postoperative day and the patient died of advanced peritoneal dissemination on 140th day after the operation. With our experience of this case, it is inferred that the outcome of chemotherapy might be a determinant factor for prognosis. And we reflect that we had to consider intraarterial chemotherapy or radiation therapy as well when general chemotherapy was judged to be ineffective for the patient.

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A 32-year-old woman was seen at the clinic because of a tumor of the anus. She has noticed the tumor for a month. When she was first seen, a round protuberant nodule was observed on the subcutaneous area near the anal verge. The diameter of the nodule was 1cm. When the nodule was incised by a scalpel, a white tumor was found. An excision of the nodule was performed under local anesthesia. The first histopathological examination indicated granular cell tumor, however, the pathologist reported that tumor cells probably still existed near the stump edge of the sample. Therefore, a wide resection was performed to remove the surrounding scar tissue. The second histopathological report showed no tumor cells anywhere. It is said that 2% of granular cell tumors have malignancy, though most tumors are benign. In the treatment of induration or tumor near the anus, granular cell tumor should be considered.

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A 39-year-old man underwent a proximal gastrectomy in October 1997 for a preoperatively diagnosed submucosal tumor located in the upper stomach, and the pathological postoperative diagnosis of the tumor was gastrointestinal stromal tumor (GIST), uncommitted type. In October 1998, abdominal CT study revealed multiple liver tumors, and by abdominal ultrasonography and abdominal MRI study, the liver tumors were diagnosed as multiple metastases of the gastric GIST. In December, right hepatectomy and partial hepatectomy on S1, S3, and S4 segments were performed, and a hepatic arterial infusion port was implanted. Pathologically, liver tumor cells were similar to the primary gastric tumor cells, therefore, the liver tumor was diagnosed as metastases of the gastric GIST, uncommitted type. About 1 year is passed after hepatic resection, and no recurrence is detected. Hepatic resection seems to be effective therapy for liver metastasis of the gastric GIST as well as liver metastasis of the gastric leiomyosarcoma.

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A case of multiple hepatic metastases of rectal cancer in which histologic complete necrosis was confirmed by hepatic resection after intrahepatic arterial infusion therapy is reported.
A 62-year-old woman had two metastatic lesios in the right lobe of the liver 3 months after a high anterior resection for rectal cancer. Intrahepatic arterial infusion therapy with 30mg of ADR, 10mg of MMC, and 5ml of lipiodol was performed. Thereafter intermittent intrahepatic arterial infusion therapy was performed through an indwelt reservoir; and the total doses amounted to 21.3g for 5-Fu and 80mg for CDDP, comprising of 4 times of 5Fu 2000mg/m²/48hrs qw, 5 times of 5-Fu 1000mg/m²/5hrs qw, and 4 times of 5-Fu 1000mg/m²/5hrs qw added 20mg CDDP. No shrinkage of hepatic metastatic foci was revealed on CT findings. A hepatectomy was performed. Histopathological exploration revealed that hepatic metastatic foci showed prominent degenerative necrosis and no viable tumor cells were demonstrated. There have been no signs of recurrence, as of 4 years and 10 months after the hepatic resection.
In this case, the degree of shrinkage on imaging of the metastatic foci did not compatible with histological effects of the infusion therapy, and hence the difficulty in evaluating the effect of intrahepatic arterial infusion therapy has been suggested.

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At our institute, laparoscopic hepatectomy for hepatocellular carcinoma has been successfully performed in two cases. Each tumor was located solitarily, one in segment IV of the liver and another in the segment VI. Introducing a minimum of four trocars, the exact location of the tumor and the distance from main vessels to the tumor were determined by laparoscopic intraoperative ultrasonography. Hepatic parenchymal resection was carried out using a laparoscopic coagulating shears in combination with a microwave tissue coagulator to minimize the blood loss. After the operation, these patients made a rapid recovery. Although this technique has been available for good quality of life to the patient, a longer time for observation of the clinical course will be necessary to determine the long-term effectiveness.

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Billiary endocrine carcinomas are rare, especially endocrine cell carcinoma of the bile duct.
A 67-year-old man was admitted to the hospital because of obstructive jaundice. After a percutaneous transhepatic cholangiodrainage (PTCD), a pylorus preserving pancreatoduodenectomy was performed with a diagnosis of carcinoma of the lower bile duct. Histological exploration offered a diagnosis of endocrine cell carcinoma of the bike duct. One year and 9 months after operation, reoperation was performed for disseminated metastases to the liver and percutaneous area along the pathway of PTCD. Although usual endocrine cell carcinomas have poor prognosis, the patient has been recurrence free as of 2 years and 2 months after the reoperation, with a favorable clinical course. Further, disseminated metastasis after PTCD is rare, but some preventive stratedies for recurrence at the fistula as well as observation of clinical course by entertaining a possible disseminated metastasis along the pathway of PTCD are required, if a good prognosis can be expected for the original disease.

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We recrently experienced three cases of pancreaticogastrointestinal anastomosis reconstruction after pancreaticoduodenectomy.
Case 1: A 48-year-old roan underwent PPPD-IV C for gastrinoma of the duodenum. After the operation, he had repeated pancreatitis. Therefore a resection of pancreatogastomy and reconstruction anastomosis of pancreatojejunostomy were performed.
The patency of the main pancreatic duct was confirmed at the second operation. We think that the cause of repeated pancreatitis might lie in the resected portion of the pancreas and anastomosed location at pancreatogastomy in the stomach.
Case 2: A 74-year-old woman underwent PPPD-II for a lower bile duct cancer. And then hemorrhage occurred due to the leakage of pancreatojejunostomy. The second operation was done, when a resection of the pancreatojejunostomy and reconstruction of pancreatogastomy were carried out.
Case 3: A 49-year-old man underwent PPPD-II for mucin producing tumor (MPD) of the pancreas before ten years. After the operation, gradually progressed stenosis of pancreatojejunostomy and recurrence of MPT around superior mesentri aretery (SMA) occurred. A resection of the tumor around SMA and reconstruction anastomosis in choledocojejunostomy and pancreatojejunostomy were performed.
Todays, either benign or malignant tumors at the pancreas are indicated pancreatoduodenostomy. We suggest that any acute and chronic complications of pancreatogastrointestinal anastomosis can be recovered by positive operation reconstructing anastomosis.

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This paper deals with a case of superior mesenteric vein thrombosis diagnosed by an abdominal CT scan, causing small bowel stricture 2 months after intraarterial thrombolytic method with resultant symptomatic remission, which demanded a laparotomy.
A 68-year-old man was brought to the hospital with a 7-day history of increasing nausea, vomiting. Contrast-enhanced CT scanning comfirmed mesenteric venous thrombosis. An arteriogram was obtained with injections into the superior mesentery, and the patient was given urokinase 240, 000 units daily for 5 consecutive days through an endhole catheter. The patient appeared stable without any symptoms. On the following day, 2 months after the therapy, the patient became worse with increasing pain and nausea. Partial resection of the small intestine was performed. Resected specimen showed severe stenosis 5 cm in length with necrotic change in the ileum. Microscopically, penetrated ulcer with granulomatous panniculitis and submucosal hemorrhage were observed. Postoperative course was uneventful.

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Retroperitoneal leiomyosarcoma is a relatively rare disease, and the prognosis is usually poor.
A 64-year-old woman came to our hospital with the chief complaint of left back pain. A CT scan revealed a heterogeneous mass adj acent to the left kidney, approximately 8.0×7.0cm in size. A needle biopsy specimen showed leiomyosarcoma.
The tumor was removed transabdominally together with the left ovarian artery. A pathological study offered a diagnosis of leiomyosarcoma, suspected to have arisen from the left ovarian artery.
The patient remains alive, with neither recurrence nor metastasis 13 months after the operation.

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An 88-year-old woman complaining of abdominal pain and vomiting was admitted to the hospital. She had a history of 2 episodes of incarceration of the right obturator hernia that were successfully treated by naso-intestinal tube drainage. However, this time an operation was indicated. At laparotomy, the small intestine at 100cm on the oral side from the terminal ileum incarcerated in the right obturator canal. The incarcerated bowel was reduced easily, and was not necrotic. The hernial ring was 8mm in diameter. The hernial sac was inverted toward the abdominal cavity and incised to expose the obturator canal. Hernial repair by inlay graft using the Marlex mesh to cover the canal was carried out after trimming the mesh. The postoperative course was uneventful and she was discharged on 14th day after operation.
This method can repair the obturator hernia without causing tension to the surrounding tissue and compression of the obturator vessels and nerve. We think that this technique is very useful for repair of obturator hernia.

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