Using the quantitative computed tomography (QCT) technique, we investigated the vertebral trabecular bone mineral density of 24 subjects with gastric cancer who had undergone a gastrectomy 6 years ago previously. The purpose of this clinical study was to create a guide to therapy for osteoporosis after gastrectomy. QCT values 6 years after surgery had decreased to 108.00±83.38mg/cm³ from 140.52±63.87mg/cm³. The rate by contrast with non-operated age-group standard values 6 years after surgery (119.60±86.46%) was also significantly lower than during the perioperative period (139.64±55.11%). 15 male subjects including 5 who were taking alfacalcidol for 3 year, made a similar reduction. The QCT values in 9 male patients who were taking menatetrenone increased to 97.35±77.59mg/cm³ from 89.89±69.63mg/cm³ after medication, accompanied by the reduction of urine pyridinolin and urine deoxypyridinolin concentrations. Therefore, the possibility that menatetrenone is effective for osteoporosis after gastrectomy is suggested.

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Anaplastic thyroid carcinoma has a dismal prognosis. At present, there is no established therapy for anaplastic carcinoma of the thyroid. Our therapeutic guidelines give priority to chemotherapy and radiotherapy over surgery. We retrospectively reviewed our experience to identify prognostic factors influencing survival. Between 1984 and 1998, 462 patients with thyroid carcinoma were seen at our institution. 15 (3.2%) had anaplastic thyroid carcinoma in this series. Of these, 11 were reviewed in this study. All but one patient died. There was a median survival of 273 days, and the 1-year survival rate was 27.3%. Complete resection and tumor size were significant prognostic factors, whereas age, sex, enlarged lymph nodes, distant metastasis, radiotherapy and chemotherapy demonstrated no significant differences in the survival rate. In conclusion, complete resection should be performed for small anaplastic carcinoma of the thyroid.

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This study was designed to compare preoperative diagnoses of lymph node metastasis of breast cancer using dynamic CT with postoperative histopathological diagnoses. Subjects were 36 cases of primary breast cancer. On palpation, the sensitivity was 87.5%, specificity was 100%, accuracy was 72.2%, positive predictability was 100% and negative predictability was 66.7%; versus 81.3%, 75.0%, 77.8%, 72.2% and 83.3% on dynamic CT, respectively. Dynamic CT was superior to palpation in both the sensitivity and negative predictability. Finding on dynamic CT scan suggesting lymph nodes metastasis Included: (1) case of positive visualization; (2) existence of lymph nodes about 1cm in size depicted by at least three slices with a difference between the right and the left sides. and (3) either concrescence or spicula is confirmed.
We consider that preoperative estimation of lymph nodes matastasis evaluated by dynamic CT can be a useful adjuvant diagnostic procedure.

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The prognosis and QOL after surgical treatment were analized in 31 patients with gastric cancer who underwent an Appleby's operation between 1974 and 1983. No immediate death after the operation occurred. One-year, 2-year, 3-year, 4-year, 5-and 10-year survival rates were 58.1%, 41.9%, 32.2%, 29.2%, 25.8% and 19.4%, respectively. Five patients survive over 15 years after surgical intervention. A mean age of five survivors was 64.6 years. The lesion was located in C region for two cases and in CM region for three cases. Their conclusive stage groupings were Ib (t₂, n₀) in two patients, IIIa (t₂, n₂) in two patients and IVa (t₄, n₂) in one patient. Histologic classifications were por•int in two patients, por•sci in one patient and sig•sci in two patients. Four patients received double tract method after gastrectomy, and one patient did Roux-Y method. Present complications are: iron-deficiency anemia in two, megaloblastic anemia in three, diabetes in three and osteoporosis in one case. All 5 patients have slight or moderate digestion-absorption disorder.
From above findings, preferable indication of this operative procedure for advanced gastric cancer might be that a main tumor locates in C or CM region of the stomach and a cancer stage develops below t₂, n₂ status.

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We studied stage IV gastric cancer cases in our department, and 3-year survial cases. Of 17 cases that were 3-year survival cases, 15 underwent curative B operations, one case underwent curative C operation due to ow (+), and all operative cases were H0, P0. In 3-year survival cases, the number of metastatic group 3 lymph nodes in n3 cases was up to 2 nodes, the number of metastatic group 3 and 4 lymph nodes in n4 cases was up to 3 nodes. Many of the 3-year survival cases underwent postoperative combined chemotherapy with MMC, fluorouracil and immunotherapy. Moreover, one inoperable 3-year survival case got complete response from combined immunochemotherapy with MMC, 5' DFUR and OK-432. These results suggest that to promote long-term survival in stage IV gastric cancer cases, curative B operation and postoperative immunochemotherapy are indicated in cases that have P0, H0 and some metastasis to group 3 or 4 lymph nodes histologically. The prognosis for P(+) and H(+) cases is still poor, and multi-disciplinary treatments including neoadjuvant chemotherapy are recommended for these as well as for cases that have many metastases of group 3 or 4 lymph nodes on preoperative examination.

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The significance of laminin and cadherin expression in human colorectal cancer was investigated by immunohistochemical assay, and its correlation with liver metastasis was analyzed. In the synchronous metastasis group, 17 of 34 cases (50%) showed positive staining of laminin, 14 (41%) of cadherin, and 5 (14%) a decreased rate of cadherin. In the metachronous metastasis group, 17 of 30 (57%) showed positive staining of laminin, 12 (40%) of cadherin, and 6 (20%) a decreased rate of cadherin. In a control group (free of disease for 5 years), in spite of no significant differences in clinicopathological factors compared with the other two groups, only 2 of 37 cases (5%) showed positive staining of laminin, 8 (22%) in cadherin, and 2 (5%) a decreased rate of cadherin. Thus, the metastatic groups were significantly higher than the control group in expression of laminin, but no significant difference in expression of cadherin was observed. These findings suggest that laminin is a useful parameter for predicting liver metastasis.

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The usefulness and assignment of endoscopic ultrasonography (EUS) diagnosis for mucosal and submucosal invasion of eary rectal cancer were investigated in determination of operation method. We studied 18 cases of eary rectal cancer, including 10 cases of m cancer and eight cases of sm cancer, analyzed clinicopathologically after EUS invasion diagnosis and operation. Operative procedures included local resection for m and sm1 cancers, and rectum resection with lymph node dissection for sm2 and sm3 cancers. EUS diagnosis demonstrated accurate diagnosis in 15 cases out of the 18 cases (83.3%) in determination of operation method. Thus it can be evaluated as a significant modality in the invasion diagnosis of eary rectal cancer and determination of operation method. On the other hand, EUS failed to localize cancer in two cases (11.1%) and gave misdiagnosis in one case (5.6%) out of these 18 cases. The reasons of these failures might be due to echo attenuation owing to excessive height of carcinoma, handling difficulties owing to the location of carcinoma, and diagnosis difficulty in fibroplasia surrounding carcinoma. These are assigned to be improved and indicate the necessity of comprehensive diagnosis by rectal endoscopy and digital examination.

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In the management of obstructing colorectal carcinoma, it is controversial whether primary resection and anastomosis should be performed synchronously in an emergency operation. Nine patients with left-side obstructing colorectal carcinoma were managed preoperatively by insertion of a trans-anal decompression tube proximal to the obstruction under colonofiberscope guidance. An emergency operation was avoided, since preoperative colonic lavage and X-ray examination of the proximal colon could be performed using the tube. A one-stage operation was performed in all cases, and the postoperative courses were uneventful. Preoperative management with a trans-anal decompression tube for left-side obstructing colorectal carcinoma was useful in avoiding an emergency operation and allowing a safe one-stage operation.

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We have experienced a case of macrocytic anemia probably caused by administration of 5'-DFUR after operation for gastric cancer. A 69-year-old man who underwent a distal gastrectomy for gastic cancer in Stage IB started to receive oral administration of 5'-DFUR since about one month after the operation. On the 20th week after starting the regimen, RBC count was 172×10⁴/mm³, Hb was 7.3g/dl, and MCV was 127.7fl, showing prominent macrocytic anemia. Blood analysis revealed that vitamin B12 and folic acid levels were over the normal levels. We thought that the anemia might be side effect of 5'-DFUR and the drug was withdrawn. After withdrawal of the drug regimen, a remission in the anemia was attained. In addition, changes in peripheral blood anlyses were studied in 20 patients administered pyrimidine antineoplasms orally. Significant increase in MCV was observed after administration compared to that before administration in them. However, those changes were chronical in all cases except ours presented here that was only one case revealing abrupt and severe anemia. Oral pyrimidine antineoplasms are often used as postoperative adjuvant chemotherapy for gastrointestinal cancers. When they are used, periodic blood analyses are mandatory. And the regimen should be withdrawn as soon as possible if macrocytic anemia is noted.

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A kindred with five members with papillary thyroid carcinoma is reported. The patients were three females and two males. The index patient was a 21-year-old man, whose mother had undergone a surgical therapy for papillary thyroid carcinoma in other hospital 8 years before his admission. In addition his elder brother with papillary thyroid carcinoma visited the hospital. Because of the family history, a screening study for thyroid disease was performed on other six members of the family and revealed that there were two patients with papillary thyroid carcinoma. One was a 49-year-old aunt of index patient and the other was a 79-year-old grand mother. The surgical treatments were performed for four out of these five patients in the hospital. It is believed that total thyroidectomy seems to be the choice of operation for papillary thyroid carcinoma with a familial occurrence. In these cases, however, we employed near total thyroidectomy to prevent from postoperative complications. A family screening study which may permit early detection of the disease should be continued strictly.

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The subject was a 43-year-old woman. She found a painless tumor in the AC region of the right mamma and visited hospital. By palpation, US and MMG, right breast cancer of T1aN0M0stage I was diagnosed, and underwent operation. Histopathological examination of a biopsied frozen section confirmed a definitive diagnosis of invasive adenocarcinoma, and breast conservative surgery was performed. However, in the histopathological examination of the resection stump, ductal spreading of cancer cells were found, and additional total mastectomy was conducted 10 days later. In the macroscopic examination, a gray-white solid tumor 15×10mm in size at a section surface was found. Histologically, the tumor consisted of solid-cell nests with trabecular arrangements, and cartilaginous metaplasia in the cancer. Consecutive transition between the cancer and metaplastic area was noted. In the region of adenocarcinoma, a component of the solid-tubular carcinoma was dominant. All of the n0, ly0, v0, EIC(+), ER and PGR were negative. Breast cancer with cartilaginous and osseous metaplasia belongs to a special type of invasive carcinoma, and the incidence is very rare. Only about 60 cases of this type have been reported in Japan. We present the clinical characteristics and examine prognostic factors of this cancer.

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Tubular carcinoma of the breast is a rare type of breast carinoma which has characteristic histologic findings, especially pure type tubular carcinoma in that lymp node metastases rarely occur and the prognosis is good. We report a case of resected pure type tubular carcinoma of the breast with lymph node metastasis. A 55-year-old woman was referred to the hospital because of a tumor formation at her left breast. The tumor shadow with spicula was identified by a mammogram, but the tumor could not be diagnosed as malignancy by an aspiration cytology. By an excisional biopsy, the tumor was diagnosed as tubular carcinoma. The patient underwent a mastectomy with lymph nodes dissection. Postoperative histological findings revealed pure type tubular carcinoma with axillary lymph node metastasis. Since lymph node metastasis is detected in a pure type tubular carcinoma like in this case, tubular carcinoma should be dealt with the same manner as other invasive carcinomas of the breast are treated.

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Docetaxel (taxotere) had successfully prolonged the survival time in a 59-year-old woman with breast cancer having distan metastases to the liver, lung, lymphnodes and bone. Adverse side effects included febrile neutropenia and reactive pleural effusion. The former was avoided by giving fractionated doses, but the later limitted the sequential administration. Despite, a partial response was gained for both the liver and lung metastases, the patient died of brain metastasis.

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A 77-year-old woman had a subcutaneous mass in the anterior chest wall for 2 months duration. She underwent an open drainage at another hospital, but it was unsuccessful. She was refered to the hospital for persistent bleeding and wound pain. On physical examination, there was a 2.5×2cm subcutaneous mass with reddish skin on her anterior chest wall. Histological diagnosis based on an excisional biopsy of the tumor was angiosarcoma. Wide excision was performed without bony chest wall resection. No adjuvant therapies such as radiation were added. She had complained of back pain since 2 months after the operation. Bone scintigram revealed multiple bone matastases. Bearing bone metasatases. She is alive 9 months after the operation.

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Patient 1 was a 65-year-old woman who had a bleeding advanced cancer of the sigmoid colon and 2 vessel coronary artery disease which had been treated by percutaneous transluminal coronary angioplasty (PTCA) unsuccessfully. She underwent a sigmoidectomy following a coronary artery bypass gafting (CABG) under the beating heart without cardiopulmonary bypass (off pump CABG=OPCAB) simultaneously. Composite graft using the in-situ right intrnal thoracic artery (ITA) and the inferior epigastric artery was bypassed to the right cornary artery (RCA) and left ITA to the left descending coronary artery (LAD). Patient 2 was a 79-year-old man with bleeding advanced gastric cancer and 3 vessel coronary artery disease. He had a total gastrectomy after OPCAB (aorta to the RCA and LAD using the saphenous vein). Both patients were discharged with patent grafts.
For the patients with advanced cancer and severe coronary disease, simultaneous treatment seems to be appropriate, making allowances for probable aggravation of the cancer and avoidance of perioperative cardiac events. We think OPCAB is a useful option to minimize bleeding, cardiac events and surgical stress.

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A 61-year-old woman was admitted to the hospital because of dyspnea. There was a previous history of undergoing a thyroidectomy for a thyroid tumor at elsewhere. On admission, airway stricture sound was heard at her throat, and respiratory function tests revealed a mixed ventilatory dysfunction. CT scan of the neck demonstrated a solid mass with clear margin that occupied about 90 percent of the tracheal lumen. Laryngeal fiberscopy showed an easy-bleeding tumor that nearly obstructed the tracheal lumen. A resection of trachea from first ring to fifth ring with end-to-end anastomosis was performed. Histologically, the tumor was cystic adenoid carcinoma arising from the tracheal gland. It penetrated the tracheal wall and extended the adjacent tissues. Postoperative radiation therapy with total dose of 50 Gy was given. She has been well without any signs of recurrence for 1 year after the operation.

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A case of completely resected thymic anaplastic carcinoma is reported. A 59-year-old woman was referred to the hospital because of a mediastinal tumor detected on a chest X-ray film taken during an athmatic attack. Under median sternotomy, the 80×55mm tumor could be removed with surrounding anterior mediastinal lymph nodes. Pathologically the tumor resembled carcinoid. However, tumor cells were negative for both Grimelius'stain and immunochemical stain of chromogranin. Furthermore, neurosecretary granules were not detected by electron microscopy. Finally the tumor was diagnosed as thymic anaplastic carcinoma. Although the tumor invasion was not beyond the capsule, metastasis was observed in one of the dissected lymph nodes. By reason of resemblance to carcinoid, chemotherapy was not performed. Although only Lineac 60 Gy was irradiated, the patient has been recurrence free 27 months after the operation. Most of thymic cancers already invade the surrounding organs at the time of diagnosis and consequently complete resection is difficult. Establishment of the appropriate chemotherapeutic regimen or effective radiotherapy will improve the prognosis.

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The patient was a 21-year-old man. He crashed head-on with a truck while driving a car. He was admitted by ambulance. He vomitted blood a little and his abdomen showed muscular defence. Abdominal computed tomography showed free air and food remnant in the abdominal cavity. We diagnosed gastric rupture. At laparotomy, the stomach was observed to have been lacerated at the anterior wall of the angle. The laceration was sharp and was 5cm in length, so we closed it without debridement. Astriction to the subcapsular injury of the liver and spleen was carried out. The patient had also sustained pulmonary injury, hemothorax, and fractures of the left ribs and right femur, which required blood transfusion of large quantities. At laparotomy, a large amount of food remnant both inside and outside of the stomach was present, so we surmised that the cause of the gastric rupture was increased intraluminal pressure in the stomach.
Besides this case, there have been only 12 case reports of adult gastric rupture from abdominal blunt trauma in the Japanease literature.

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A rare case of cystic lymphangioma of the stomach is reported. After an annual checkup, a 65-year-old man was admitted to our hospital because of a submucosal tumor of the stomach. On endoscopy, augmentation of the tumor from 2cm to over 3cm in diameter of during six months was observed. Preoperative x-ray examination, endoscopic ultrasonography, and computed tomography all revealed a submucosal cystic tumor at the lesser curvature wall of the antrum. In April 1999, a partial gastrectomy was performed. The resected specimen showed a submucosal cystic mass measuring 5.0×1.2×1.5cm. Pathological diagnosis was cystic lymphangioma in the submucosal layer of the stomach. A literature review identified 69 cases reported to far in Japan. The average age was 53.0 years old, with no detectable difference by sex, and it seems that cystic lymphangiomas are located mostly from body to antrum of the lesser curvature of the stomach and in the submucosal layer of the stomach.

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An 81-year-old man with early gastric cancer chronic with renal failure was successfully treated by intragastric endoscopic surgery. He had early gastric cancer locating beyond the pyloric ring. After making a temporary gastrostomy under epidural anesthesia, a mucosal resection was performed using a Buess's endoscope. Operation time was 120 minutes. He was discharged from the hospital uneventfully. In conclusion, among minimally invasive surgeries for gastric cancer, this method seems to be advantagenus to lesions locating near the cardia and pylorus and can be recommeded for patients with risk factors such as elderly and same underlying diseases.

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We report a case of dissection of recurrent abdominal paraaortic lymph nodes in a 69-year-old man with gastric cancer. The patient had undergone curative surgery consisting of a distal gastrectomy with D2 lymph node dissection for advanced gastric cancer 16 months before. Histological findings showed mucinous adenocarcinoma and final findings were T3 (SE), N2, H0, P0, stage IIIb, and curability B. This time the patient was admitted to the hospital because of increases in tumor markers such as CEA and CA19-9. Metastasis to paraaortic lymph nodes was diagnosed by ultrasonography and CT scan and the recurrent nodes were dissected. Of 19 dissected nodes, metastasis was found in three in nos. 16 b1 (interaorticocaval, preaortic and lateroaortic), which showed the same mucinous adenocarcinoma as the primary tumor. After the re-operation, the patient has been well and disease-free for 3 years and 3 months. Some reports suggest that lymph nodes dissection can provide therapeutic effects if the number of involved nodes is small and we have few effective chemotherapy for No. 16 recurrence at present. Under these background factors, we think that operation can be recommended if no other distant metastases are present, and this case would offer a basis of performing operation.

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We experienced a very rare case of duodenal stenosis caused by a ruptured aneurysm of the pancreaticoduodenal artery.
A 51-year-old man was admitted to the hospital because of ileus. Small bowel radiography indicated duodenal stenosis. Celiac angiography showed obstruction of the anterior inferior pancreaticoduodenal artery. Pancreatoduodenectomy with right hemicolectomy was performed under the suggested diagnosis of carcinoma of the pancreatic head.
Histologically, a dissecting aneurysm was found close to the thrombus. No carcinoma was seen in the specimen. In this case, distinguishing the aneurysm from carcinoma of the pancreatic head was difficult.

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Case 1. A61-year-old woman who had been followed up with cryptgenic back pain at the department of internal medicine in our hospital for about 3 years, was pointed out having a retroperitoneal tumor by computed tomography. She was referred to the department and was operated on with a diagnosis of retoroperitoneal tumor or submucosal tumor of the duodenum. During surgery, a submucosal tumor was found in the third portion of the duodenum. A partial resection of the duodenum. Case 2. An asymptomatic 70-year-old woman was detected to have a mass in the upper abdomen at a routine medical check up. She was referred to the department and under a diagnosis similar to Case 1, an operation was performed in the same manner. The resected specimens in both cases were covered with a fibrous capsule, and the insides of tumors were white in color, homogeneous, and elastic hard. Microscopically, the tumors were composed of bundles of spindle cells with their nuclei arranged in palsade, and mitosis was scarcely observed. In an immunohistochemical study, the tumors were positive for S-100 protein and NSE but negative for SMA and desmin. These cases were diagnosed as benign schwannoma. We report the two cases of schwannoma of the duodenum which is rare, together with some bibliographical comments.

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From January 1997 to May 1999, six cases of rupture of the small intestine relating to the buckled safety belt were encountered in the hospital. Their ages ranged from seven to 65 years and the male-to-female ratio was two to four. When injured at traffic accident, two patients were driving and other four patients were sitting on a passenger seat. Three patients were operated on immediately after admission, but in other three patients, it took 1 to 3 days until performing operations due to delayed diagnosis. The reasons included that conservative therapy yielded a remission of abdominal symptoms after admission and signs of peritonitis were obscure. The rupture sites were the jejunum in five cases and the ileum with seromuscular tear of the cecum in one case. Two cases of jejunal rupture were associated with mesenteric tears. All patients were performed simple sutures of the ruptured bowel. Their postoperative courses were uneventful, however, 7-year-old boy was re-admitted due to intestinal obstruction, and was operated on again.
Since the safety belt is not necessarily effective to protect the abdomen, more effective restraint systems are needed. Patients with blunt abdominal trauma, especially those who buckled up safety belt, must be admitted for careful examination as well as close clinical observation not to miss the well-timed operation for the small bowel injury.

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This paper presents a case of hemangioma of the small intestine, which is relatively rare, in a 63-year-old woman complaining of anemia. She had been treated for anemia since 1993 when no other abnormalities were revealed on examinations of the stomach and large intestine. In 1996, anemia took a turn for the worse again and an oral fluoroscopy of the small intestine revealed abnormality in the ileum. So the patient was referred to the hospital. After admission, a sounding to the small intestine disclosed a nodular protrusion in the ileum. CT scan visualized a segmented tumor with calcification having marginal irregularity in the small intestine. With a diagnosis of small bowel tumor, the patient was operatec on. At operation, a soft tumor, with the size of about 3cm, about 170cm oral to the terminal ileum was palpated, and distended vessels on serosa were confirmed. Macroscopically, hemangioma was suspected and a partial excision of the ileum was carried out. Histopathological diagnosis was hemangioma of the small intestine. In the treatment of patients with anemia without any abnormalities in the esophagus, stomach, duodenum and large intestine, we must conduct close examination of the small intestine by entertaining the possibility of the disease.

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A 26-year-old man with a 5-year history of Crohn's disease was admitted to the hospital because of diarrhea and abdominal pain. After the first 7 days of treatment by antibiotics, bowel rest and hyperalimentation, he was administered steroid. However, he still complained of left groin pain and left frunk pain with rebound tenderness on day 35 after admission, and a left psoas absess secondary to Crohn's disease was confermed by abdominal CT scan. At laparotomy, the entire large intestine became friable, penetrated to the left Swiss muscle at the descending colon to form a fistula, and another fistula was present between the transverse colon and stomach. So, a partial resection of the descendign colon with drainage as well as a partial resection of the transverse colon including the fistula and a partial gastrectomy were performed simultaneously. After the operation, leakage of the anastomosis occurred twice, forcing the patient to have an ileocolostomy.

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We report a case of peritonitis due to Meckel's diverticulosis with ectopic gastric mucosa and pancreatic tussue. A 29-year-old man was admitted because of right lower abdominal pain. An emergency laparotomy was performed on suspicion of peritonitis due to perforated appendicitis. Although the appendix was normal, Meckel's diverticulum was found about 60cm proximal to Bauhin's valve, and diverticula had formed. Resection of Meckel's diverticulum and peritoneal lavage were performed. Microscopic examination of the resected specimen revealed gastric mucosa and inflamed pancreatic tissue, but perforation of the diverticulum was not found. The cause of peritonitis was not perforation but pancreatitis.

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We report a case of an inflammatory Meckel's diverticulum which include a leiomyoma in the wall. A 61-year-old woman complained of a lower abdominal pain, vomiting and diarrhea. She was admitted to Teikyo University Hospital in March, 1999. There were tenderness and rebound tenderness without muscular guarding in the lower abdomen. The CT scan and the ultrasound study showed a mass 3cm in diameter in the pelvic cavity. Emergency laparotomy revealed a round, reddish and firm tumor with yellowish coating in the antimesenteric side of the ileum. The partial resection of the ileum including the tumor was performed. Pathological examination showed that the inflammatory lesion was a Meckel's diverticulum accompanied with a leiomyoma.

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There aren't many reports of appendix perforation due to foreign bodies. Those foreign bodies which are reported in Japan are almost always fish bones and there are very few cases without fish bones. We report in this paper a case of appendix perforation due to a denture. A 77-year-old man complained of a right lower-quadrant pain when he was admitted for the purpose of rehabilitation after cerebral hemorrhage. He was suspected to suffer from appendicitis and was sent to our department. Abdominal X-ray revealed a radio-nonlucent metallic foreign body about 1cm in size in the right lower abdomen. The same foreign body was also seen, and inflammation change around it was recognized, on computed tomography film. Intestinal perforation due to the foreign body, as well as acute appendicitis, was suspected. An emergency laparotomy was done. There was a perforation in the central region of the appendix which adhered to the retroperitoneum. A spindle-shaped metallic lump about 1cm long appeared on the inside of the appendix. This metallic lump was suspected to be a denture because of its shape. It is said that many cases of digestive tract perforation due to foreign bodies occur slowly and form inflammatory granuloma, but this case occurred rapidly because one side of this foreign body was sharp and its penetration to the wall of the appendix caused the perforation, although just when the patient had swallowed the denture by mistake was not unknown.

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Behçet's disease is an intractable disease with no cure and no established treatment. We report a case of intestinal Behçet's disease that underwent 6 laparotomies during a 23 year period. A 16-year-old man underwent excision of a mass in the ileocecal region. Four years later, he underwent a right hemicolectomy due to a tumor at the anastomotic site. At 25 years of age, he developed an oral aphtoid ulcer, a right genital regional ulcer, skin eruptions on his extremities and a positive needle reaction, which all indicated a diagnosis of intestinal Behçet's disease. He underwent a transverse colectomy because of another tumor of an anastomotic site at 26 years, and a transverse and descending colectomy duo to fistulas between the small intestine and skin at 28, 32 and 37 years of age. Although various treatments were conducted, none was effective. He died at 39 years of age because of a cerebral infarction, which occurred during acute exacerbation of Behçet's disease.

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An 81-year-old man was admitted to the hospital because of pain covering from the left lower abdomen to left lumbar region. On the second day after admission, peritoneal signs appeared. Chest x-ray film revealed free air. Abdominal x-ray examination disclosed rough granular bubble image in the left lower abdomen. Abdominal simple CT scan revealed emphysema image in the vicinity of the left kidney. Enema study with gastrographin showed complete obstruction of the descending colon. From these findings, generalized peritonitis caused by perforation of the descending colon due to cancer was diagnosed and an emergency operation was performed. At operation, perforation about 5cm in size in the descending colon penetrating to the retroperitoneal cavity was present, and at the site a large villous adenoma like polyp was noted. Further, necrosis of the retroperitoneum, exposure of the left iliopsoas muscle and a leakege of intestinal contents into the peritoneal cavity were observed. The patient was successfully saved by resection of the descending colon, intraperitoneal lavage and drainage, and colostomy. A 6.0×2.5cm soft carcinoma in adenoma was confirmed in the descending colon and contralateral side of the tumor perforated. Although retroperitoneal perforation of the colon is rare, we have to keep the disease in mind as a probable differential diagnosis.

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A 53-year-old man was admitted to the hospital because of anal bleeding and lumbago. Barium enema and colonoscopic examinations revealed sigmoid colon cancer, and computed tomography revealed metastasis to the caudate lobe of the liver. A low anterior resection and a resection of the caudate lobe of the liver were performed. Pathological diagnosis was poorly differentiated adenocarcinoma. (se, ly₁, v₂, ow(-), aw(-), ew(+)) After the operation that resulted in curability B, bleeding through the abdominal drains was observed, and severe thrombocytopenia and elevated fibrin/fibrinogen degradative products (FDP) were indicative of disseminated intravascular coagulation (DIC). Despite the treatment with gabexate mesilate, the bleeding tendency was not improved. Since a bone scintigraphy demonstrated diffuse abnormal uptake of isotope, a bone marrow biopsy was performed. As a results, DIC associated with systemic bone marrow metastasis was diagnosed. Sequential methotrexate and 5FU (MTX-5FU) therapy (MTX 30mg/m², 5FU 600mg/m²) was introduced. After 7 courses of the chemotherapy, he recovered from DIC accompanied by an increase in platelet count and decreases in FDP and CEA (carcinoembryonic antigen) levels. It is suggested that the suquential MTX-5FU therapy was effective for DIC due to systemic bone marrow metastasis in the present case of sigmoid colon cancer.

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We report a rare case of synchronous multiple carcinomas of the colon. A 65-year-old man visited our hospital because of anal bleeding. Colonoscopy disclosed an ulcerative lesion in the sigmoid colon and 10 polypoid lesions in the ascending and sigmoid colon. After endoscopic polypectomy of the 10 polypoid lesions, anterior resection with lymph node dissection was performed for the ulcerative lesion. Histological study revealed one advanced carcinoma with invasion of the subserosa, 5 early carcinomas with invasion of the mucosa or submosa, and 3 adenomas with moderate to severe atypia. The genetic instability of these 9 lesions was examined using microsatellite assay. In all of these lesions, no replication errors were detected at any of the microsatellite loci analyzed.

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The biopsy specimen from a gastric ulcer of a 65-year-old man was histologically diagnosed as a MALT lymphoma. Barium enema and colonoscopy also revealed a submucosal tumor in the rectum. The histological diagnosis was a carcinoid tumor. Total gastrectomy with splenectomy, cholecystectomy, jejunal pouch interposition, and transanal local excision of the rectum were performed. The lymphoma was located at the cardiac portion and upper body of the stomach, 5.0×4.0cm in size, histologically diagnosed as low-grade B-cell MALT lymphoma, and classified as superficial type. By Ann Arbor classification, it was in stage IE. Ova of Schistosoma japonicum were found occasionally in duodenal submucosa and regional lymph node. The rectal carcinoid, 1.2×1.3cm in diameter, was a semipedunculated type that had invaded proper muscle with minimal lymphatic and venous invasion. Immunohistochemical study showed positive reaction for Fontana-Masson, Grimelius, chromogranin A, and neuronspecific enolase. Low-anterior resection with total mesorectomy was recommended because of the carcinoid's large size and histologically invasive characteristics. However, the patient rejected the radical reoperation and was followed-up. At two years postoperation there is no evidence of recurrence. Although coexistence of malignant disease with carcinoid or schistosomiasis japonica have been reported, this is the first report of rectal carcinoid with gastric malignant lymphoma and schistosomiasis japonica.

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Pancreatic injury is uncommon. We have often had difficulty determining a therapy that improves recovery. We report a case of IIIb pancreatic injury that underwent a life-saving operation on the fourth day after traffic accident. A 19-year-old man had a traffic accident and contused the right hypochondral area on October 10, 1997. The next day, he was referred a to doctor, who diagnosed the pancreatic injury with abdominal CT scan and other studies. The patient recieved conservative therapy for his severe condition. He was referred to us for the purpose of undergoing an operation. At the first clinical examination, his abdominal defense reaction was noted, therefore, an emergent operation was conducted. At laparotomy, a small amount of serous ascitis and inflamatory adhesion around pancreas were observed. The pancreatic head was divided vertically and the pancreatic main duct also comletely damaged. Pancreatojejunostomy was carried out because the severe injuries made preservation of the pancreatic head and duodenum impossible. He has made good progress and was discharged 29 days after operation.

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An asymptomatic 61-year-old man had a splenic artery aneurysm anomalously originating from the superior mesenteric artery. It was diagnosed through a series of examinations including ultrasonography, abdominal CT scanning and angiography. It was a succular aneurysm, 30mm in size, behind the pancreas and was surgically resected to avoid probable rupture. Histologically, fibromuscular dysplasia was evidenced. Splenic artery aneurysm originating from the superior mesenteric artery is a rare entity and six similar cases reported in the literature, are reviewed.

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We report an operated case of primary malignant lymphoma of the spleen which was detected during close inspection for fever of unknown origin. A 68-year-old woman who had a fever of unknown origin lasting for about one month with recent one-week high fever (38°C) and associated abdominal pain was referred to the hospital. Abdominal CT and ultrasonogram revealed a splenic tumor. Splenectomy with regional lymphnodes dissection was performed. Histological diagnosis was malignant lymphoma, diffuse medium-sized cell type of the spleen and lymphnode. Adjuvant chemotherapy with CHOP was added and the patient was discharged from the hospital. One year later, malignant lymphoma recurred in the right axillary lymph node, that was successfully managed by CHOP therapy and a local excision. Although primary malignant tumors of the spleen are extremely rare, the patient with the disease has a poor prognosis. It is thought that tumorous lesion of the spleen would demand aggressive surgical therapy and adjuvant chemotherapy.

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We report a case of splenic hamartoma, which is a rare entity, with renal cell carcinoma. A 45-year-old woman was incidentally found to have a splenic tumor and a left renal tumor at a medical checkup on suspicion of gastric submucosal tumor. Laboratory data on admission were normal. Abdominal ultrasonography and computed tomography (CT) showed a 7×5cm hypoechoic and low density solid mass in the spleen and a 3cm mass in the left kidney. On contrast CT scan, the splenic tumor was not enhanced. Splenic angiograms showed a hypervascular tumor. Laparotomy was performed on the diagnosis of left renal cell carcinoma and a suspicion of splenic metastasis. During surgery, the spleen was covered with normal capsule and swelled to the size of goose's egg; and the lesion which looked like gastric submucosal tumor was found to be caused by oppression due to a hepatic cyst in the lateral segment of the left hepatic lobe. A splenectomy and a left nephrectomy were performed. The cut surface of the resected spleen showed uncapsulated red tumor. The histological findings of the splenic tumor revealed a hamartoma consisting of red pulp components and the findings of renal tumor revealed renal cell carcinoma.

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Two cases of splenic metastasis from colon carcinoma without other organ metastasis are reported.
Patient 1 was a 76-year-old man, who underwent a right hemicolectomy for ascending colon carmcinoma. Twenty two months later, a splenectomy and partial resection of the pancreas were performed for solitary metastasis to the spleen. He was alive with local recurrence 25 months after the second operation. Patient 2 was a 74-year-old man, who underwent a right hemicolectomy for ascending colon carcinoma. One year later, a splenectomy and caudal pancreatectomy was performed for solitary splenic metastasis from the ascending colon carcinoma. He was alive with no evidence of recurrence 5 months after the second operation. In both patient 1 and 2, the histological diagnoses of both the colon and splenic tumors were the same.
Splenic metastasis after a colorectal carcinoma operation is rare. Only 30 cases including ours have been reported in Japan. Most splenic metastases occurred within 1 year after the colorectal operation, and prognosis was poor. Micrometastasis to the spleen might have already occurred at the time of operation for colorectal carcinoma, therefore, intensive chemotherapy after operation is recommended for splenic metastasis from colorectal carcinoma.

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A 69-year-old woman was seen at the hospital because of the left lower abdominal pain. An elastic hard mass with tenderness, approximately 10cm in diameter, was palpated on physical examination. White blood cell count was 10, 900/mm³ and CRP was 2.60mg/dl. Ultrasonography showed a hypoechoic and ill-defined mass connecting with the digestive tract. CT scan showed a low density mass with a linear calcification. An inflammatory tumor due to bowel penetration with a fish bone was strongly suspected based on a patient interview as well as findings of examinations. Barium enema study showed extrinsic pressure on both the left side of the transverse colon and sigmoid colon. At laparotomy, a tumor situating between the transverse colon and sigmoid colon was found. A partial colectomy including the tumor was performed. The resected tumor was yellowish-white in color containing puss and a fish bone of 2.5cm in diameter. When intraabdominal tumors of unknown origin are encountered, a possibility of some intestinal penetration with foreign body, such as a fish bones, should be considered. In making preoperative diagnosis, detailed patient interview and imaging diagnoses are also important.

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A 37-year-old man was admitted to the hospital because of abdominal pain. Abdominal CT scan revealed thrombosis in the superior mesenteric vein. Fluoloscopic study of the small intestine revealed, at least, two stenoses in the superior portion of the jejunum. We diagnosed the case superior mesenteric vein thrombosis and multiple stenosis of the small intestine. Resection of the stenotic portions of the small intestine and stricture plasty were porformed. Microscopic examination revealed regenerational epithelium without submucosal tissue in stenotic portions, and fibrous tissue replaced muscle layer, which changed to a scar. The postoperative course was uneventful. He gained 10kg in weight, and improved nutritional condition.

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We experienced a case of mesenteric venous thrombosis which is a rare disease. A 69-year-old woman complaining of chest discomfort was transferred to the hospital with an ambulance car. On admission, dyspnea and severe metabolic acidosis were recognized, and we care respiratory and circulatory condition intensively. However, on the 3rd day after admission abdominal pain and fullness occurred. She was followed as intestinal obstruction of unknown etiology, but on the 5th day after admission peritoneal sign was recognized. An emergency laparotomy was carried out, when necrosis was observed in the almost entire colon and a part of the ileum. A subtotal colectomy, a partial resection of the ileum and an ileostomy were performed. Histopathologically full thickness necrosis of the intestine and relatively fresh thrombi in the mesenteric vein were revealed. As shown in our case, this disease is lack of specific symptoms and various clinical courses can be observed, for that early diagnosis is difficult. Our case is thought to be especially rare because the main ischemic lesion lay in the colon.

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A 64-year-old woman underwent an exploratory laparotomy under a diagnosis of peritonitis carcinomatosa of unknown origin in July 1991. There was gross ascites in the abdominal cavity, and a tumor was found at the transverse mesocolon and on the surface of rectum. The histologic finding of biopsied specimen of the tumor was adenocarcinoma.
No primary malignant tumor was detected on any organs by a whole body imaging. She was diagnosised as peritonitis carcinomatosa of unkown origin, and carboplatin-based chemotherapy was started. After the treatment the volume of ascitis decreased, and the tumor remarkably diminished in size.
In June 1997, the tumor invaded the transverse colon, and a partial transverse colectomy was performed. Histologic finding of the tumor was papillary adenocacinoma. From these clinical findings, we diagnosed this case as peritoneal serous papillary carcinoma (PSPC).
PSPC is considered to be a disease originating from the peritoneum, and is an uncommon entity. Here we present the patient with PSPC who had good response to chemotherapy with surgical operation, and has been alive for eight years after the therapy.

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Mesenchymal chondrosarcoma is a rare condroic tumor that was first reported by Lichtenstein and Bersteinin 1959. So far about 200 cases have been reported in the literature. We report a case of mesenchymal chondrosarcoma probable arishing in the retroperitoneum. The patient was a 65-year-old man who underwent a surgical resection. However, the patient died of multiple recurrence in the peritoneal cavity 20 months after the surgery. To our knowledge, there have been only five prior cases of retroperitoneal mesenchymal chondrosarcoma in the Japasese and English literature. In a review of these cases including our case, it is concluded that the prognosis is poor and multi-agent chemotherapy is not helpful. Radical surgery would remain the mainstay of therapy.

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A case of Pseudocyst of the Retroperitoneum
A 50-year-old woman was seen at the hospital because of left upper abdominal pain and pointed out having a cystic tumor at the tail of pancreas by abdominal CT scan. We diagnosed the case as cystic tumor of the pancreas and performed a resection of the cystic tumor, because this tumor was retroperitoneal tumor above the tail of pancreas. The tumor was 4.5×3.5×3cm in size, including yellow mucinous fluid. Histologically, the tumor had collagenous tissue without epithelial cells, and was diagnosed as pseudocyst.
We consider that retroperitoneal cysts without epithelial cells can be called pseudocyst of the retroperitoneum. Only eight cases of pseudocyst of the retroperitoneum have been reported in the Japanese literature. This rare case is presented together with some bibliographical notes.

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A 67-year-old man was seen at the department of internal medicine in our institution, because of an abdominal growth and distension. With a diagnosis of retroperitoneal tumor, he was referred to the department of surgery. The abdomen conspicuously swelled and a solid elastic tumor was palpable. Abdominal CT scan visualized a 26×25×15cm encapsulated tumor with cystic but partially solid inside. With the diagnosis of retroperitoneal tumor, partial resections of the ileum, ascending colon and sigmoid colon were carried out. The tumor weighed approximately 7kg including the contents intraoperatively drawn out, and was the largest in the 57 cases reported in Japan between 1995 and 1998. Pathologically it was benign schwannoma. Postoperative course was uneventful. The patient is doing well, as of 6 months after the operation.

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A 77-year-old woman was seen at the hospital because of abdominal pain. The entire abdomen was tender and boad-like. Abdominal x-ray film revealed air image in the vicinity of the right kidney. Retroperitoneal emphysema and peritonitis due to gastrointestinal perforation was suspected, and an emergency operation was performed. At laparotomy, an infant-fist sized tumor was confirmed at the hepatic flexure of the colon and the oral side of the tumor penetrated to the retroperitoneum. So a right hemicolectomy was performed. The resected material revealed a carcinoma of type 2 over the almost entire circumference of the hepatic flexure of the colon, which penetrated to the retroperitoneum through a perforation 1.5cm distal to the carcinoma. Histopathologically, there was normal mucosa about 1.5cm in length with edema between the tumor and perforation. It was diagnosed that perforation was caused by obstructive colitis due to entirely circumferential colon carcinoma. The patient was discharged from the hospital very much improved on the 16th day after the operation.

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A 57-year-old woman was admitted to the hospital because of abdominal pain and an abdominal tumor in the umbilical region. White blood cell count and CRP were elevated. Abdominal simple X-ray films showed distension of the small intestine and computed tomography revealed the intestine and fat tissue incarcerated into subcutaneous space of the umbilical region. It was diagnosed as incarcerated umbilical hernia and an emergency operation was performed. Partial resection of the intestine had to be done, because 7 days had passed after the onset of the incarceration. Postoperative course was uneventful and she was discharged from the hospital 15 days after the operation.
In a review of the Japanese literature in a recent one decade, 11 cases of incarcerated adult umbilical hernia, including our case, have been reported. Some bibliographical notes are also presented.

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An 81-year-old woman was admitted to the hospital with an abrupt history of right lower quadrant pain and righ thigh pain. Pelvic CT scan revealed incarcerated small intestine between the right pectineus muscle and the internal obturator muscle. Diagnosis of incarcerated right obturator hernia was determined, but on admission the symptoms disappeared. Pelvic CT scan demonstrated no incarcerated small intestine though an unusual space was detected between the right pectineus muscle and internal obturator muscle. This finding confirmed that the incarcerated obturator hernia had been reduced spontaneously. The patient underwent elective operation by the inguinal method under epidural anesthesia. The obturator formen was examined via an extraperitoneal approach. The hernial sac was excised, and the hernial hilum was covered with Teflon mesh sutured to the Cooper's ligament and the internal obturator muscle. The postoperative course was uneventful, and the patient left the hospital 10 days after the operation. An adequate view for the operative maneuver can be obtained and the stress on the patient can be minimized by the inguinal method. This method appears to be useful in such cases when the small intestine is not incarcerated, or there is little possibility of intestinal perforation as determined by early diagnosis of obturator hernia.

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We report a case of metachronous duplication of left breast cancer and leiomyosarcoma of the jejunum associated with Recklinghausen's disease. The case involved a 74-year-old woman. There was a previous history of undergoing a modified radical mastectomy for left breast cancer in December 1993. Histologically, the breast tumor was invasive ductal carcinoma (papillotubular carcinoma). The patient had been free from recurrence after the surgery until June 1998, when she was seen at the hospital because of paraumbilical pain. Over fist-sized tumor was palpated in the left upper abdomen, so an operation was performed after further examination. An extraluminaly growing tumor 10×10×5cm in size was found in the jejunum of 90cm distal to the Treitz's ligament. A minimal resection of the jejunum was done because of liver metastasis and extensive peritoneal dissemination. Histological examination revealed leiomyosarcoma of primary jejunal lesion, liver metastasis, mesenterial lymph node metastases and peritoneal dissemination.
There have been three case reports about duplication of breast cancer and leiomyosarcoma of the gastrointestinal tract with Recklinghausen's disease in Japan. Because Recklinghausen's disease is benign disease itself, and associated malignant disease, including duplication, determines the prognosis, we must make every effort to detect probable malignancies in other organs in early stages for patients with the disease.

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