In this study, we measured cytokines such as TNF-α in peripheral blood for 7 days after pancreatoduodenectomy or hepatic resection and investigated effects of preoperatively administered antibacterial agents on changes in these cytokines in terms of types of the agents. Agents and subjects investigated were imipenem/cilastatin sodium (IPM/CS) 1.0g/day in 16 cases; and ceftazidine (CAZ) 2.0g/day in 12 cases. All blood cytokines increased after the operations. Compared with CAZ patients group, the increase in TNF-α was significantly suppressed immediately (4 hours) after the operation, on the first and 7th postoperative days in the IPM/CS patients group.
In short, it is suggested that postoperative changes in blood cytokines are affected by antibacterial agents, and the selection of antibacterial agents can be an important factor in patients undergoing highly invasive operations such as pancreatoduodenectomy and hepatic resection.

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A series of 20 patients who underwent surgical operation at our hospital from August 1998 to September 1999 were applied to use the ozonized olive oil for their intractable fistulae or wounds. There were three cases of intractable fistula after operation for inguinal hernia, including one case of intractable fistula with infected mesh; four cases of fistula after operation for acute appendicitis with peritonitis; five cases of intractable wound after operation for infected epidermal cyst; one case of fistula after incision of infected urachal cyst; three cases of fistula after incision and drainage for perianal abscess, including one case for periviorectal abscess; three cases of fistula after incision and drainage for infected pilonidal sinus; and the remaining one case of lower limb ulceration after sunburn. This ozonized olive oil was fully effective in all 19 cases except for one case of pilonidal sinus. No adverse side effects were observed in the administration of the ozonized olive oil. The main active component of the ozonized olive oil has been found to be triozonide. It was fully effective for a discharge of pus and a formation of granuratlon.

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The frequency of lymph node metastases is increased at the depth of subserosal involvement (ss) of gastric cancer. We investigated and made a comparison between the D2 lymphadenectomy (D2) and extended lymph node dissection (D4') groups.
We performed a retrospective study of 57 gastric cancer patients with ss from 1987 to 1998. They were divided into two groups, 21 cases of D2 group, and 22 cases of D4' group. To comparing the subclassification of ss and the histological grade, no significant difference was found between the two groups in accumulated survival rates. As for the number of metastatic lymph nodes, with in the D2 group, the 5-year survival rate of metastatic cases with less than 3 lymph nodes involved (A group) was 80.8%, and that with more than 2 lymph nodes (B group) was none (p<0.05). On the other hand, in the D4' group, the 5-year survival rate of A group was 91.7%, and the B group was 85.7%, respectively.
To sum up, these findings indicate that D4' lymphadenectomy provides a survival benefit in cases with more than 2 metastatic lymph nodes compared with D2 lymphadenectomy.

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In our hospital, 360 patients with gastric cancer visited from Janury 1989 to November 1998. Of these, 16 patients were less than 40 years old. We investigated and report their clinical backgrounds and prognoses. Of the 16, there were 7 men and 9 women. No significant difference in gender as compared to all patients with gastric cancer was found. Except for one, 6 cases with distant metastasis and peritoneal dissemination died from cancer within 13 months after operation. Seven of 9 have lived without recurrence between 5 and 88 months after curative operation. One of the remaining died from cancer after 40 months. The other's prognosis is uncertain. Generally, juvenile gastric cancer is said to have a poor prognosis. But cases that have undergone radical operations have not had poor prognoses. Accordingly, early diagnosis by upper gastrointestinal series and endoscopy is an important factor for the juvenile.

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A series of 23 cases of diverticulitis of the large intestine operated on at the institution in a recent one decade were subjected to a clinical study. Their mean age was 57.5 years (range; 8 to 89). There were 13 men and 10 women, without significant difference. Affected sites were the right side of the colon in 12 patients and left side of the colon in 11 patients. Preoperative diagnoses included generalized peritonitis in 10 patients and appendicitis in seven patients. Emergency operation was performed in 16 out of these 22 patients. Except two patients who underwent appendectomy with drainage, resection of the intestine more than local excision was performed in 21 patients. Of these 21 patients, one-step approach was employed in 18 patients. Postoperative course was uneventful in 16 out of these 18 patients. However, the remaining two patients with generalized peritonitis due to left colonic deverticulitis who were associated with shock preoperatively had postoperative complications that demanded artificial colostomy and the resultant two-step or three-step operation. Five patients who were associated with shock before surgery had poor prognoses; all five patients experienced postoperative complications and two patients of them died. It is thought that, in patients with diverticulitis of the large intestine who lack in factors suggestive of poor prognosis such as preoperative shock condition, operation on an one-step approach is safely performed, but one-step approach should be avoided for patients with such risk factors, for whom two-or three-step approach is recommended.

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There were 39 patients (9.6%) with multiple colorectal carcinoma identified in operative series of 407 patients in our hospital, three of which had 3 cancers and one of which had 4 cancers. A synchronous multiple colorectal carcinoma was seen in 36 patients, and a metachronous one was seen in three patients. The mean age of the multiple group was older than that of the single group. There was no significant difference between two groups in terms of the incidence of extra colic malignancies and family history of malignancies. The frequency of adenomatous polyps in the multiple group was higher than that of the single group. There were 32 cases of which the second carcinoma was located orally. In 18 cases, preoperative diagnosis was made precisely. In 10 of those cases, the first cancer was located in the anal side. The second carcinomas of the multiple group were seen commonly at the left-sided colon, most of which were in an early stage, and size of which were smaller. There was no significant difference in the 5-year survival rate between two groups. It would be important to give special attention for the elderly patients with adenomatous polyps, considering the possible association of multiple cancer. It is desirable to dissect oral side sufficiently for the patients with tight stricture by cancer.

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In this study, expressions of apoptosis related gene products, p53 protein and bcl-2 protein, and proliferating cell nuclear antigen (PCNA) in cancer tissues were explored by means of immunohistochemical staining, and their correlations with clinicopathological findings and prognosis were comparatively studied. The subjects were 50 patients operated on for colorectal cancer at the hospital. The positive rate to p53 protein was 60.0%, and had no significant correlations with clinicopathological factors. The positive rate to bcl-2 was 52.0%. The bcl-2 positive rates were significantly low in patients groups of depht of tumor invasion of si, ai, or more; venous invasion; lymph nodes metastasis; and hepatic metastasis (p<0.01). A mean of PCNA-LI was 52.8%; it became high in patients groups of lymph nodes metastasis; hepatic metastasis; peritoneal dissemination; and with increase in the depth of invasion. A clearly better prognoses were observed in bcl-2(+) group and low PCNA group than bcl-2(-) group and high PCNA group, respectively. The expression of bcl-2 protein was inversely related to PCNA-LI. It is suggested that the apoptosis related gene product bcl-2 protein deeply participates in the growth and proliferation of colorectal cancer, and can be an important prognostic factor.

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Gastric cancer patients with metastasis limited to a single liver lobe were subjected to pathological study, retrospectively. The primary gastric lesion had been resected in all 16 cases, whereas the liver metastasis were resected in 8 cases. The measured cell proliferation index using Ki-67 antibody kit was not significant between primary and metastatic lesions. However, the vascular endothelial growth factor was significantly lower in liver metastatic lesions (p<0.01). Postoperative surviving period was significantly prolonged in the resected liver metastasis group over the nonresected group (p<0.05). When multiple liver metastasis were confirmed in a single lobe, micrometastasis were proven pathologically in all cases (2/2). The above findings suggest the usefulness of liver resection in gastric cancer patients with liver metastasis that is limited to a single lobe, and the necessity of systematic liver excision in multiple liver metastasis cases.

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We apply laparoscopic transcystic duct stone removal (LTR), as well as laparoscopic cholecystectomy (LC) as one of therapies for cholecystocholedocholithiasis. In performing LTR, we employ the intercostal approach for the choledochus with good outcomes. The procedures are as follows: the gallbladder is disssected from the liver bed and suspended with an endo-loop at the neck. Catheter introducer (CI) is penetrated from the mid clavicular line on the right 6th or 7th intercostal space and inserted into the choledochus through the cystic duct. These procedures enable an easy access and maneuver of choledochoscope via CI. Although the choledocholith is generally removed with the basket forceps, we also apply the transcystic ductal papillary dilatation or an explosion of the stone with pulseddye laser, which depends on clinical case. We applied LTR via this approach to 22 cases out of a total of 1700 cases received LC in our hospital. Removal of stones was successfully performed in all 22 cases without severe complications, and the patients could be discharged after shorter hospital stay. Combination of LTR with LC was least likely to spoil the efficary of LC and the papillary function was preserved. The LTR via intercostal approach is thus advantageous for safe and easy exploration of the common bile duct.

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Twenty-one patients with acute cholecystitis (14 men and 7 women; mean age, 63.5 years) underwent Magnetic resonace cholangiopancreatographic (MRCP) examinations.
The rate of visualization of the biliary tract by MRCP was 100% for the left and right intrahepatic bile ducts, 95.2% for the gallbladder, 100% for the cystic ducts, and 100% for the common bile duct. The locations of stones in acute cholecystitis as evaluated by echography and MRCP were compared with operative findings. Intracystic stones were detected by MRCP at the same rate as echography. However, MRCP was significantly better than echography and computed tomography in detecting small impacted stones in the gallbladder and small free stones in the common bile duct.
The ability of MRCP to noninvasively detect the cause of acute cholecystitis before operation, thus prevented unnecessary surgery and was useful in deciding the therapeutic policy.

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We encountered an extremely large benign phyllodes tumor of the mammary gland. This time, by using a polymerase chain reaction and by analyzing clonality of a phyllodes tumor, we have gained insight into tissue genesis.
A 45-year-old woman was admitted to the hospital becausee of left breast pain and swelling. On admission, she had a 18×16cm carcinoma tumor with redness in the left breast area. It was diagnosed as phyllodes tumor by an aspiration biopsy cytology. An Auchincloss operation was performed. Pathological diagnosis revealed benign phyllodes tumor.
This time, by analyzing clonality of phyllodes tumors, we found that stromal cells of phyllodes tumors were monoclonal. According to Noguchi and others, epithelial and stromal cells are polyclonal in fibroadenoma, but phyllodes tumor has polyclonal epithelial cells, and monoclonal stromal cells.
Discrimination between fibroadenoma and phyllodes tumor is possible by the clonality analysis. Employing the clonality analysis in cytologic examination in the future, preoperative precise diagnosis becomes possible.

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A 42-year-old woman was seen at the hospital because of a left axillar hard tumor (φ3cm) which was pointed out by an annual medical check up. Mammography and ultrasonography did not reveal any tumor of the breast.
Resectional biopsy specimen of the axillar tumor showed metastatic adenocarcinoma. Systemic examinations failed to reveal primary lesion. So occult breast carcinoma was diagnosed and a left modified radical mastectomy was performed. Histological exploration of the resected specimen showed a primary tumor 3mm in diameter in the lateral upper quadrant.
This paper describes the case of occult carcinoma of the breast presented with axillary lymph node metastases, together with a review of the literature.

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This paper deals with the usefulness of continuous hemodiafiltration (CHDF) for acute renal failure after cardiac surgery with cardiopulmonary bypass in a 79-year-old woman. The patient underwent coronary artery bypass grafting with cardiopulmonary bypass for ischemic heart disease. Postoperative cardiac function was poor and oliguria and pulmonary edema occurred. The patient did not respond to administration of diuretics and developed anurea 11 hours after the operation. Immediately CHDF was started from 11 hours to 5 days after the operation. The renal function was gradually improved and CHDF could be withdrawn. The clinical benefit of CHDF for patients is that it diminishes plasma levels of BUN caused by renal failure and inflammatory cytokines caused by cardiopulmonary bypass. It is thought that CHDF is useful for the treatment of acute renal failure in the early postoperative period after cardiac surgery with cardiopulmonary bypass.

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Video-assisted thoracic surgery (VATS) was successful in the treatment of spontaneous hemopneumothorax. A 57-year-old man was admitted to our hospital because he felt chest pain and dyspnea during sleep at night. Chest X-ray film revealed hemopneumothorax in the left side. As soon as a chest tube was inserted, bloody discharge as much as 500ml was obtained, nad then he developed hemorrhagic shock. So VATS was performed in an emergency. We found a torn vessel that was actively bleeding at the top of the thoracic cavity. An ENDO-CLIP was enough to control the bleeding. An apical bulla of the left lung was then resected. His postoperative course was uneventful. We think that VATS is useful for the treatment of spontaneous hemopneumothorax.

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A 69-year-old woman was admitted to our hospital after a hypoechoic tumor in the body of the pancreas was detected by abdominal ultrasonography as mass screening. Endoscopic retrograde cholangiopancreatography showed a mucin-producing papillary tumor (2mm in diameter) in the main pancreatic duct, suggesting an intraductal papillary adenocarcinoma in the pancreas. X-ray examination of the chest showed an interstitial shadow in the lung field, whit was diagnosed as idiopathic interstitial pneumonia (IIP) since there was a history of collagen disease. The patient underwent a segmental resection of the body of the pancreas for a papillary tumor in the main pancreatic duct. On the 7th postoperative day, acute exacerbation of IIP was noted. Although she was placed on high-dose steroid therapy, she died on the 35th postoperative day.
Acute exacerbation of IIP is wellknown to give a poor prognosis, because there is no effective therapy after surgery. Thus, indications for surgery should be carefully considered for patients with IIP, since exacerbation after surgery.

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A case of Pryce I type intralobar pulmonary sequestration is reported. A 24-year-old man was seen at hospital because of hemoptysis. A plain chest roentgenogram and a CT scan showed an abnormal shadow in the left lower lobe. A bronchoscopy revealed hemorrhage from the left basal segment. A MRI-angiography showed an abnormal artery arising from the descending thoracic aorta and supplying the left lower lobe. An aortogram confirmed this finding. The venous drainage was seen into the left lower pulmonary vein. Intralobar sequestration was diagnosed, and a left lower lobectomy was performed successfully. Microscopically, the resected lung had no cysts or fibrosis. Then we classified this case into Pryce I type intralobar pulmonary sequestration. Pryce I type intralobar pulmonary sequestration is very rare and is called anomalous systemic arterial supply to the basal segment. Its definition and classification is a matter of controversial opinion. Some bibliographical comments regarding classification of congenital pulmonary disorders are also presented.

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A case of pulmonary plasma cell granuloma is reported. A 53-year-old man was pointed out an abnormal shadow in the lung field on a chest X-ray film taken for routine physical examination. It was diagnosed as plasma cell granuloma by a transbronchial lung biopsy at a local hospital. He had been observed at the outpatient clinic because he had no subjective symptoms. However he was admitted to our hospital due to sudden hemotysis. Heamophilus parainfluenzae was detected by sputum culture. Chest CT scan revealed a solitary round lesion 7×5cm in diameter in the right upper lobe. A right upper lobectomy with a wedge resection of the middle lobe was performed. Pathological examination revealed plasma cell granuloma with organizing pneumonia pattern. The cause of this lesion remains unknown, but it is usually considered to be some inflammatory or reactive lesions. In our case, pulmonary infection probably triggered the onset of clinical symptoms.

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A 66-year-old man was pointed out having two ulcerative lesions 1.5cm in diameter with crater in the upper body of the stomach by upper gastrointestinal series. Gastric endoscopy revealed submucosal tumorous lesions like dens molaris in morphology. With a biopsy, carcinoid tumor or poorly differentiated adenocarcinoma was diagnosed. Furthermore, negative response to anti-gastric wall cell antibody was disclosed and hypergastrinemia was associated. Total gastrectomy with lymph nodes dissection was performed. Histopathologically, endocrine cell carcinoma (mp, ly₃, v₂, n₁: stage II) in the background of non type A gastritis was diagnosed. The patient died of multiple hepatic metastasis one year and 8 months after the operation.
Endocrine cell carcinoma with hypergastrinemia like this case is rare. And macroscopic and histopathologic characteristics suggestive of classical carcinoid were also revealed in this case. This case is thought valuable in consideration for mechanisms of origin of endocrine cell carcinoma including the possibility of malignant change of carcinoid.

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A case of recurrent gfastric carcinoma (endocrine cell type) successfully treated with combination chemotherapy with divided low-dose FP therapy is reported. The patient was a 47-year-old man who underwent total gastrectomy and combined distal pancreatectomy and splenectomy in June 1995 after receiving a diagnosis of Borrmann type 2 gastric carcinoma. The overall degree of advancement was as follows: H₀, P₀, se, n₂, and stage IIIb. The histologic diagnosis was endocrine cell carcinoma. The patient initially presented with loss of appetite and a palpable abdominal mass 18 months later. Abdominal computed tomography showed metastatic lesions in both lobes of the liver, a metastatic abdominal wall mass 3cm in diameter and located directly below the umbilicus, and a pelvic mass 4cm in diameter. The patient underwent divided low-dose FP therapy, and by the 10th course, the hepatic metastases showed complete responses, and the abdominal wall and pelvic masses showed partial responses. The patient was still in good health 2 year and 6 months after initiation of therapy. These results suggest that combination chemotherapy with divided low-dose FP therapy may be useful for the treatment of highly proliferative cancers such as endocrine cell carcinoma, which exhibits a highmalignant potential, and should be actively employed in the treatment of such cancers.

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Compared with intussusception in children as a common entity, the disease is relatively rare in adults and the rate of its occurrence after gastrectomy is said to amont to about 1% of all adult cases. This paper presents a case of retrograde jejunal intussusception 9 years after total gastrectomy in an adult.
A 75-year-old man was seen at the hospital because of abrupt abdominal pain and vomiting. The abdomen was soft and no tumor was palpable. Abdominal x-ray film revealed a slight gas image in the small intestine. After admission, bloody discharge from a nasal tube was observed. Abdominal CT scan revealed a tumor with layered structure in the left upper abdomen. Intussusception was diagnosed and a laparotomy was performed. Macroscopically, the invaginated bowel progressing antiperistaltic direction over about 20cm was present at the anal side of Y-anastomosis after total gastrectomy (with Roux-Y reconstruction). After manual replacement, no ischemic changes nor organic disorders were confirmed in the invaginated jejunum and so the surgical incision was closed without any procedure.
Although intussusception after gastrectomy rarely occurs, we must keep it in mind as a probable diagnosis after gastrectomy.

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A 55-year-old man was admitted to the hospital because of sudden onset of right lower abdominal pain. Physical examination revealed severe tenderness with muscle guarding and peritoneal signs in the right lower abdomen. Abdominal simple x-ray films showed air fluid level formation in the small intestine. He underwent an emergency operation under a diagnosis of strangulated ileus. At laparotomy, the appendix adhered to the small intestine at about 150cm to the ileum end, which caused strangulation of the small intestine involving about 50cm in length. An appendectomy and a partial resection of the small intestine which was penetrated by a fish bone were performed. The strangulation was relieved by appendectomy and then the circulation to the small intestine was restored. Therefore, strangulated loop of the small intestine was not resected. Retrospectively, we reviewed abdominal CT scans taken when he was admitted and confirmed a linear calcified foreign body as a fish bone.
It is rare that ingested fish bone perforates or penetrates the gastrointestinal organs, especially the appendix. This case is believed very rare that the penetration of the appendix by a fish bone caused strangulated ileus.

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A 53-year-old man was seen at the hospital because of abdominal pain. There were previous histries of undergoing partial bowel resections twice with a diagnosis of Peutz-Jeghers syndrome (PJS) when he was 22 and 29 years old. Family history disclosed that his elder brother, daughter and niece were all diagnosed as having PJS. There were mild distension and muscle gurding in the abdomen. He had spotty pigmentation at the lower lip. Target-like sign was observed with an abdominal CT scan, and multiple pednculate polyps 10-30mm in diameter and intestinal intussusception were reveald with enterography. Because of repeated ileus, a partial resection of the intestine including the invaginated portion with jejunostomy was performed. After the operation, the remnant polyps were almost resected by enteroscopy through the jejunostomy. The patient was discharged from the hospital after closure of the jejunostomy. Our method is useful for the management of PJS patients, because there is no need of another laparotomy for probable occurrence of intestinal intussusception due to recurrent polyps.

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A patient with acute superior mesenteric artery (SMA) embolism, who received an early diagnosis, was cured by vascular reconstruction alone. A 77-year-old woman with atrial fibrillation and old myocardial infarction visited to our hospital with a complaint of acute abdominal pain. The combination of poor abdominal findings and her past history indicated the diagnosis of SMA embolism. Two hours after onset, emergency angiographic was performed. Angiographic findings revealed a shadow defect in the appearance of the main trunk of the SMA in an area peripheral to the middle colic artery bifurcation, therefore Urokinase was infused directly into the SMA. Because the abdominal pain disappeared, continuous intravenous infusion of anticoagulant and fibrinolysis therapy were selected. Because the abdominal pain redeveloped and blood analysis showed a white cell count of 49300 after ten days from onset, and laparotomy was performed. Laparotomy revealed no evidence of necrosis of the small and large intestine, and embolectomy with a 3Fr Fogarty catheter alone was performed. The rest of the hospital stay was uneventful and the patient was discharged eight weeks after the operation.

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This paper describes a case of intussusception in an adult due to non-classified polyp of the small intestine.
A 48-year-old woman complaining of nausea, vomiting and abdominal pain was conservatively treated at another hospital, but in vain, so the patients was referred to our hospital. CT scan revealed intussusception, and she underwent a partial resection of the small intestine. In the resected material, a long pediculated polyp of Yamada's type 4 was present in the small intestine.
Pathologically, it was diagnosed as “non-classified” polyp, because all the mucosa, muscular layer of mucosa, submucosal tissue, and proper muscle projected that was not applied to the current concept of polyps. With further accumulation of clinical cases of such polyp, a new concept of disease may be established.

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A 74-year-old woman was seen at the hospital because of right hypochondralgia and back pain. A barium enema study and a colonoscopic examination showed an elevated lesion in the ascending colon, and endocrine cell carcinoma was suspected after examination of a biopsy specimen. An abdominal CT scan revealed multiple liver metastases. NSE, a tumor marker, was elavated to 610ng/ml. Ileocecal resection was performed with a diagnosis of cancer of the ascending colon with liver metastasis. Histologically, the tumor consisted of polygonal-shaped cells and grew in a solid pattern without gland formation. Immunohistochemically, tumor cells were positive for NSE and for Synapto-physin, and weakly positive for Chromogranin A. Electron-microscopically, these cells were found to have numerous neurosecretory granules in their cytoplasm. The tumor was conclusively diagnosed as endocrine cell carcinoma. The patient was died of liver failure 39 days after the operation. In a review of the Japanese literature, many cases of colorectal endocrine cell carcinoma have been reported with metastasis of lymph nodes and other organs at diagnosis. In addition to operation, intestive treatment with chemotherapy and radiotherapy are necessary for patients with colorectal endocrine cell carcinoma.

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A 73-year-old woman complaining of lumbago was referred to the hospital with a diagnosis of left hydronephrosis. Retrograde pyelography showed a stenosis of the left ureter. Abdominal CT scan demonstrated a tumor of the sigmoid colon adjacent to the left ureter and multiple liver metastasis. Barium enema study and colonofiberscopy revealed no tumor except diverticulosis in the sigmoid colon. We performed an operation a suspicin of cancer of the sigmoid colon with an extramural progeression. Sigmoidectomy and a partial resection of the ureter were carried out. On the resected material, only slight erosion was present on the mucosa, but extramural progression of the tumor was main. Pathological findings showed moderately differentiated adenocarcinoma, si, ly2, V1, and n2. Multiple diverticula were scattered in the vicinity of the tumor. It is etiologicaly thougt that the reason why the tumor in this case disclosed such a specific growth pattern lies in the origin of the colon cancer which might be these diverticula.

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In 78-year-old woman with chronic liver disease, multiple tumors in the left hepatic lobe were disclosed during a periodic ultrasound examination. She had a history of local rectal resection for a 1.5cm carcinoid with invasion of the muscularis propria, in 1985. Under the diagnosis of hepatocellular carcinoma, she underwent a laparotomy in May, 1995. Considering her age and hepatic functional reserve, lateral segmentectomy with additional microwave coagulonecrotic therapy (MCN) was selected instead of left hepatectomy. Histological findings of the resected tumors showed a structure similar to that of the previous rectal carcinoid (trabecullar growth pattern, Soga type B), thus, the hepatic tumors were diagnosed as metastatic hepatic carcinoid from the rectal primary after 12 years of dormancy. Therefore a rectal carcinoid invasion of the muscularis propria, irrespective of size, should be treated carefully. The histological structure of the carcinoid might exhibit a slow-growing behavior. Since her postoperative course was uneventful and she is doing well two years and six months after operation, hepatectomy combined with MCN was the appropriate modality in this case.

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A 72-year-old man had perianal erythematous elevated lesion with itching. Initial clinical therapy with ointment in other hospital was not effective and he was seen at the hospital. Physical examinations demonstrated a 6×6cm lesion around the anus and a biopsy revealed Paget's cells in the epidermis. Barium enema studied and abdominal computed tomography (CT) did not reveal any abnormal signs in the colorectum. So perianal Paget's disease was diagnosed.
Perineoabdomino-perineal resection was performed for complete resection of the pagetoid lesion because Paget's disease has been reported to be associated with malignancies in a high frequency. Surgical margin of the perianal skin was decided by mapping biopsy distant from the elevated lesion by 3cm.
Resected specimen revealed perianal Paget's disease and adenocarcinoma of the anal canal sequentially. So pathological diagnosis was perianal Paget's disease associated with anal canal cancer. Perianal Paget's disease occurs in a relatively low frequency and is often diagnosed as incurable eczema or dermatomycosis. In the diagnosis of perineal skin lesions attention must be paid to differentiated the disease from others. If perineal Paget's disease is diagnosed, close exploration and treatment under consideration of probable and frequent association of malignant tumors are needed.

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We successfully saved a patient with rupture of a hepatic artery aneurysm. A 20-year-old man was brought into hospital by ambulance because of abrupt development of abdominal pain and shock. An abdominal ultrasonogram demonstrated a small mass and intraperitoneal fluid accumulation. Pancture of this space, disclosed pooling of intraperitoneal bleeding.
Surgical treatment was performed on emergency, and the rupture of a hepatic artery aneurysm was diagnosed. As it was diffucult to resect the aneurysm, we had sutured that wall and both the gastrodeodenal and common hapatic arteries were ligated proximal to it. The postoperative course was uneventful.
Hepatic artery aneurysm is a relatively rare entity. But if the ptient is seen in emergency situations after rupture, the clinical course can be clitical. In the treatment of patients with intraabdominal bleeding of unknown origin, we have to decide the treatment as soon as possible keeping the possibility of the disease in mind.

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A 72-year-old woman was found to have a proper hepatic arterial aneurysm on CT scan for preoperative evaluation of ascending colon cancer. Follow-up CT scan confirmed the aneurysm's enlargement. Transcatheter arterial embolization (TAE) for the aneurysm was not performed because of risk of rupture. Resection of the aneurysm was completed with right and left hepatic arteries on the distal side, and common hepatic and gastroduodenal arteries on the proximal side. After ligation of the left and common hepatic arteries, the right hepatic artery was anastomosed to the gastroduodenal artery for hepatic arterial reconstruction. Postoperative doppler ultrasonography showed adequate blood flow to the right hepatic artery. The postoperative hematological examination demonstrated no severe hepatic injury. Three months later, angiography showed patency of the anastomotic site with no stenosis. Although the incidence of performing TAE for hepatic arterial aneurysm has been increasing, there was significant risk of rupture during this procedure. Resection of the aneurysm is thought to be the optional treatment for this disease.

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A 49-year-old man was admitted to our hospital because of obstructive jaundice. ERCP showed that the lower portion of the common bile duct was severely compressed and stenotic. Abdominal angiography, MR angiography and 3D-CT demonstrated an aneurysm of about 3cm in diameter of the anterior branch of the right hepatic artery. There observed Arterioportal shunt from the aneurysm and dilataion and tortuosity of the hepatic artery were observed to result in compression of bile duct. Transcatheter arterial embolization using platinum coils was peformed. The coils were successfully placed an the feeding artery. Blood flow into the aneurysm decreased remarkably, and subsequently jaundice improved gradually.

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An 81-year-old man was seen at the hospital because of upper abdominal pain and general fatigue. Physical examination showed tenderness in the epigastric region. Blood laboratory data revealed that the white blood cells count was 14, 470/mm³, C-reactive protein was 15.3mg/dl, CEA was 0.5ng/ml and CA19-9 was 2.00U/ml. Abdominal ultrasonography and CT scan revealed multilocation and homogeneous cystic lesion 15cm in diameter in the lateral segment of the liver. Because of unsuccessful antibiotics administration for his inflammation, percutaneous transhepatic drainage of the liver cyst guided by ultrasonography was carried out. The cyst contained yellow milky fluid with inconsequential cloud, 680ml in amount, in which CEA was 71.6ng/ml and CA19-9 was 2000U/ml. Of the fluid of the liver cyst, cultures for bacteria or fungi were negative, and a cytology indicated Class I with numerous neutrophils. Inflammatory findings were gradually improved after the drainage of the cyst. Cystography was not able to detect a communication between the cyst and the bilialy tract. It is crucially rare that infection intervenes in the liver cyst, we report this case of infected liver cyst which was successfully managed by percutaneous transhepatic drainage.

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A 55-year-old woman with a past history of diabetes was admitted to the Kanazawa National Hospital complaining of high fever, general malaise, and disturbance of consciousness. The findings of ultrasonography and X-CT scan showed a gas-producing pyogenic abscess approximately 12cm in diameter in the right lobe of the liver. Immediately after diagnosis, percutaneous transhepatic abscess drainage was performed under ultrasonographic guidance. Klebsiella was detected by culture of drained pus. The findings of laboratory examinations showed dehydration, septic shock, and disseminated intravascular coagulation. Abscess drainage was effective, however, a granulomatous liver abscess was detected by X-CT and MRI in spite of the reduction of the abscess cavity. On hospital day 68, the patient underwent partial hepatectomy of segment 7 and 8, because it seemed unlikely that the abscess would heal completely by drainage alone. Thereafter, the patient recovered uneventfully and has been leading a healthy life without recurrence. Hepatic resection after adequate drainage is considered an effective procedure for cases of intractable pyogenic liver abscess.

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A 76-year-old man had undergone an extended right hepatectomy and a descending colectomy for synchronous double cancer, giant hepatocellular carcinoma and cancer of the descending colon in April, 1997. In the clinical findings at the operation he had multiple intrahepatic metastasis (IM3) and involvement of carcinoma cells in the portal vein (VP2). Multiple liver metastases had been well controlled by hepatic arterial infusion chemotherapy. Nine months later, he complained of being short of breath.
Ultrasonic cardiography and chest computed tomography revealed massive hypertrophy of the right ventricle. We diagnosed the case as cardiac metastases of the rihght ventricular wall from hepatocellular carcinoma. For 6 months from the detection of cardic metastases to his death due to cardiac failure, the general status had been maintained by means of palliative therapy. The representative distant metastatic organs of the hepatocellular carcinoma are the lung, bone and adrenal gland. We report a rare case of hepatocellular carcinoma with cardiac metastases. This case in also interesting to consider the pathway for hepatocellular carcinoma cells reaching to the heart.

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Many variations of biliary system exist, including the point of junction of the cystic duct. However, reports of low-junction of the cystic duct with the common bile duct dilatation are few.
We experienced a case of low-junction of the cystic duct causing complication of biliary dilatation.
A 79-year-old woman was admitted with right hypochondralgia. Abdominal ultrasonography revealed distension of the gallbladder and dilatation of the common bile duct. A common bile duct stone and sludge were detected. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic biliary drainage were performed. Although an anomalous union of the pancreaticobiliary system was not evident, low-junction of the cystic duct with the common bile duct was revealed. Cholecystectomy, choledochotomy and cholangioscopy were performed, and the common bile duct dilatation was improved. It was considered that the distal common bile duct was affected by the low-junction of the cystic duct, and resulted in cholestasis. Thus far, no recurrence of bile duct stone has a been noted. Common bile duct dilatation was remained. In conclusion, biliary dilatation in this case was considered chronic cholestasis caused by the low-junction of the cystic duct. It should be consider that we cautiously follow up this patient.

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A 79-year-old woman was hospitalized due to fever and liver dysfunction. Ultrasound examination revealed papillary tumors at the fundus and neck of the gallbladder, 27×16mm and 14×9mm in size, respectively. The depth of tumor invasion was considered to be pm by EUS. Since no liver metastasis nor lymph node metastasis was detected by abdominal CT, an operation was carried out under the diagnosis of multiple early carcinomas of the gallbladder. The tumors were based at the abdominal wall side of the gallbladder. The operative findings were T₁N₀H₀P₀M(-): Stage I, and cholecystectomy with R1 lymph node dissection was performed. Furthermore, a type I tumor 24×16mm in size in the fundus, and a type IIa tumor 12×7mm in size in the body of the gallbladder and no cholelithiasis were observed. Pathological diagnosis was pm, ly₀, v₀, pn₀, n₀, for both lesions. Histologic type was pap for the fundus lesion and tub₁ for the body lesion. The patient is doing well and is without signs of recurrence 2 years after surgery.
Although the reported cases of multiple carcinomas of the gallbladder are increasing, only in our case could the lesions be diagnosed for depth of tumor invasion, preoperatively, as far as we could review.

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This paper presents a case of gallbladder cancer with a high level of alpha-fetoprotein (AFP). A 69-year-old man was admitted because of a pain below the right costal margin. Based on various examinations a diagnosis gallbladder cancer was determined. Extended resection of the gallbladder was carried out. Histopathologically, the gallbladder tumor was adenosquamous carcinoma, and adenocarcinoma was present in lymph node metastasis. Immunohistochemically, the carcinoma cells showed positive staining for AFP in only the lymph node metastasis. After operation, the level of AFP converted to negative. These findings suggest that gallbladder carcinoma cells produce AFP.

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We experienced a case of serous cystadenoma of the pancreas which was diagnosed after operation with a preoperative diagnosis of non-functioning islet cell tumor of the pancreas.
A 68-year-old woman was pointed out having a tumor about 1cm in size at the pancreatic body on an abdominal ultrasonography when she had a physical examination. Ambulation began for close examination. Contrast enhanced CT revealed a dense tumor shadow. With magnetic resonance imaging, it showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. No accumulation of a contrast material revealed on Gd. ERP disclosed no abnormal pancreatic findings. EUS visualized a hypoechoic shadow. After admission, an angiography revealed accumulation of a contrast material. There were no abnormalities in blood biochemistry and endocrinological data. With a diagnosis of non-functioning islet cell tumor, a resection of the body and tail of the pancreas was performed on March 23, 1998. After the operation, serous cystadenoma was diagnosed histopathologically.
With a recent progression of imaging diagnoses and a spread of medical checkup, cystadenomas of the pancreas have been increasingly detected. We must entertain serous cystadenoma of the pancreas as a probable differential diagnosis for pancreatic tumors.

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This parer presents a case of pancretic cancer with liver and para-aortic lymph nodes involvement which was unresectable for prominent lymph nods metastasis and well responded to chemotherapy with low dose cisplatin and 5-fluorouracil. This patient was a 49-year-old man. After the unresectable operation, he was treated with chemotherapy of low dose cisplatin (CDDP) and 5-fluorouracil (5-FU) with low dose FP therapy which was given weelky by i. v. drip infusion at the first day. The combination of intravenous infusion of 5-FU (250mg/body) and CDDP (20mg/body) adminintered weekly. At 10 weeks, the serum CA19-9 and DUPANII level decreased within normal limits and the metastatic liver tumor and pancreatic cancer disappeared. The patient was discharged from the hospital and was given the low dose FP therapy biweekly on outpatient setting. Urticaria which is side effect of CDDP appeared after 38 courses of the low dose FP therapy, and thereafter only 5-FU (150mg/day oral) was given. After that, the tumor stopped to grow. The patient has been doing well as of 5 years after the admission. The lom dose FP therapy for patients with unresectable pancreatic cancer is recommended for selected cases.

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A 42-year-old woman was hospitalized, after a splenic mass was detected during a health care examination. The splenic mass was located on the superior area of the spleen, and measured 6.5cm in diameter. Since the patient was asymptomatic she was only followed up, but one-year later, the mass was enlarged. Splenectomy was carried out for the primary splenic tumor. The histological diagnosis was inflammatory pseudotumor of the spleen, which is very rare, and a difficult preoperative diagnosis to make. If the tumor enlarged and symptom are difficult to distinguish from other diseases, splenectomy should be conducted for definitive diagnosis.

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Seven cases of enterovaginal fistula which had been operated on at the hospital in a recent 12-year period are reported. Their mean age was 59.0 years and their chief complaint was vaginal discharge of stool. Barium enema study and colonoscopy revealed enterovaginal fistula in five out of seven patients. All patients were seen enterovaginal fistula by vaginoscopy. From these studies, enterovaginal fistula was diagnosed in all patients. Their primary diseases causing enterovaginal fistula were obstetric trauma at delivery in three patients, sigmoid diverticulitis in two patients and postoperative complication in the remaining two patients. Two patients with sigmoid diverticulitis underwent sigmoidectomy including sigmoidovaginal fistula, and the other patients underwent transvaginal closure of the rectovaginal fistula. Only one patient with rectovaginal fistula secondary to postoperative complication was treated by laparoclosure with a diverting colostomy after failures of transvaginal and transsacral closure. All enterovaginal fistulas healed successfully and all patients have been free from relapse.

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A 70-year-old woman complaining of upper abdominal pain and vomiting was admitted to the hospital with a diagnosis of intestinal obstruction. Abdominal CT scan revealed that the dilated small intestine oppressed the bladder with caliber change in the small intestine at the same portion. Internal hernia was suspected and an emergency operation was perfomed. Laparoscopic observation revealed that the hernia opening was situated at the supravesical fossa and the small intestine protruded through the opening and necrosed. The definite diagnosis of strangulated ileus due to impaction of the small intestine into the internal hernia of the supravesical fossa was made. So a small incision was made at an appropriate location that enabled us to perform a laparotomy. Operative procedures included a partial excision of the small intestine, a rerection of the hernia sac, and suture of the hernia opening.
Internal hernia of the supravesical fossa is an extremely rare entity and there have been no case reports which were diagnosed preparatively. This paper presents a case of the disease in which characteristic CT findings offered a clue for diagnosis and then laparoscopic exploration contributed to diagnosis and treatment, together with some bibliographical comments.

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A 55-year-old woman was diagnosed as having Paget's disease by a biopsy of eczematous perianal skin, which was detected when she underwent an operation for hemorrhoids at another hospital, and was referred to the hospital. Unclear lesion with irregular margin spreaded over the pudendum and perianal skin, reaching to the urethral meatus, ostium of the vagina and dentate line. Forty biopsies were taken to decide the precise border of the disease before operation. Extensive resection of the skin was performed with 2-cm margin from the border of the lesion. The urethral meatus, ostium of the vagina and anus were reconstructed by skin grafting. Temporary diversion colostomy and cystostomy were performed to avoid infection of the wound. The margin of the resected material was free of Paget's cells. Postoperative course was uneventful and after the closure of the temporary colostomy and cystostomy, the functions of the urethra, vagina and anus were revealed to be successfully preserved. This case in which precise mapping of the lesion and thick-split grafting were of great value in the function preserving operation for widespread perianal Paget's disease is presented with some bibliographical comments.

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Tuberculous peritonitis is now a rare disease in Japan. It lacks specific symptoms, and hence presents difficulty in diagnosis. We experienced a case of tuberculous peritonitis diagnosed by an exploratory laparotomy. A 27-year-old woman was admitted to the hospital because of fever, abdominal distension, and abdominal pain. Abdominal CT scan and ultrasonography revealed ascites. The aspirated ascitic fluid was an exudate, but cytology and bacterial cultures were negative. The ascitic fluid showed high level of ADA activity, but was negative for tubercle bacilli on smear microscopy and PCR method. Carcinomatous peritonitis due to ovarian carcinoma was suspected, because of the high level of serum CA-125. Scince the patient did not respond to conservative therapy, an exploratory laparotomy was performed. Operative findings showed thickened omentum, fibrinous adhesion between intestinal loop, and broad fibrin on parietal peritoneum. The thickened omentum and the appendix covered with white belag were resected. Histological examination comfirmed the diagnosis of tubercu-lous peritonitis. After anti-tuberculous therapy was started, the patient satisfactorily improved. Tuberculous peritonitis should be taken into consideration in differential diagnosis from carcinomatous peritonitis.

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Disseminated metastasis of hepatocellular carcinoma is relatively rare and it can occur as a complication after rupture of hepatic cancer, PEIT, and needle biopsy. This time we experienced a case of huge intrapelvic metastatic tumor appeared following PEIT.
A 66-year-old man was found having a hepatic tumor (S6) on an abdominal CT scan one year after operation for cancer of the sigmoid colon, and underwent PEIT with a diagnosis of hepatocellular carcinoma. About 2 years later, the patient was seen at the hospital because of difficulty in urination. At close examination, a huge tumor occupying the minor pelvis between the rectum and bladder was visualized on pelvic CT scan magnetic resonance imaging. Colonofiberscopy disclosed a type 2 tumor in the rectum. Rectal cancer was suspected. But a biopsy disclosed hepatocellular carcinoma like pattern partially and abnormally elevated levels of AFP and PIVKA-II were demonstrated. So peritoneal dissemination of hepatocellular carcinoma was suspected and a pelvic exenteration was performed.
PEIT is being performed in numerous institutions as a therapy for hepatocellular carcinoma, but it causes disseminated metastasis, thought it is uncommon. Caution for the possibility is advisable.

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We experienced a rare case of bilateral superior lumbar hernia associated with left inguinal hernia in an adult. An 85-year-old woman was admitted to the hospital for a repair of left inguinal hernia and was found to have bilateral lumbar hernia. An abdominal CT scan showed low-density masses at bilateral lumbar muscle defects as well as a protrusion of the intestine through the right defect. At surgery, the right defect was 1.5cm in diameter while the left was 1.0cm in diameter. Bilateral defects were closed directly with lumbar muscles. The postoperative course was uneventful and no recurrence has been seen. In a review of the Japanese literature, 26 cases of the adult superior lumbar hernia have been reported and our case reported here is the third case as bilateral superior lumbar hernia in adults and also as the third case associated with inguinal hernia.

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A 14-year-old boy was admitted to our hospital because of the acute onset of abdominal pain while playing basketball. After several examinations, he was diagnosed with gastric volvulus. Treatment with gastrofiberscope was tried, but it was unsuccessful, so we performed an emergency operation.
Under laparotomy, herniation of the spleen and the upper part of stomach were secognized in the site of foramen Bochdalek, so direct closure of the hernia orifice was carried out. There was no hernia sac, and the size of the hernia orifice was 5× 5cm in diameter. This is the orifice was 5×5cm in diameter. This is the 118th reported case of in the Japanese literature.

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We described a case of incarcerated femoral hernia due to Meckel's diverticulum. A 76-year-old male was seen at the hospital because of a right femoral irreversible tumor with severe pain lasting for three days. On admission, an egg-sized, elastic hard, poorly movable tumor with smooth surface, was palpated under the right inguinal ligament. There were signs of advanced inflammatory reaction (WBC: 18800/μl and CRP: 16.8mg/dl). Ultrasonography revealed that the tumor had wall with triple layered structure, which was considered to be the intestine. With a suspicion of incarcerated femoral hernia due to the intestine causing intestinal necrosis, an emergency operation was performed on the same day. Diverticulum about 10cm oral side to the ileocecal region, was found which was necrotized due to incarceration at its neck under the inguinal ligament. Accordingly, a wedge resection of the diverticulum and a radical operation for hernia were performed. Histopathological examination revealed the diverticulum with the full thickness of the ileum. And, the diverticulum occurred at the end of the ileum. In these reasons, we made the diagnosis that Meckel's diverticulum was the hernia content.

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A 54-year-old woman had complained of convulsion during postoperative adjuvant therapy with CMF therapy and medroxyprogesterone acetate (MPA) for brast cancer. Brain metastasis was suspected. Radiographic studies (MRI etc) revealed meningioma in the parasagittal sinus and malignant brain tumor (metastasis from brast cacer or glioma) in the deep frontal lobe. A craniotomy was performed. Histopathological diagnoses were fibroblastic meningioma and anaplastic astrocytoma (Grade III), respectively. Immunohistochemical studies of the meningioma revealed negative response to estrogen receptor, weakly positive response to progesterone receptor (PgR) and the presece of a small number of Ki-67 positive cells. These results suggested that MPA decreased PgR and growth fraction of the meningioma. She received postoperative whole brain radiation and gamma knife radiation. She received second craniotomy because of growthing of residual glioma. She died 15 months after the operation.

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This paper presents a case of familial adenomatous polyposis (FAP) with primary cancers on multiple organs and hepatic metastases.
A 62-year-old woman was admitted to the hospital because of jaundice and epigastralgia. There were previous histories of undergoing a total colectomy for FAP with multiple colonic cancers 4 years before admission, undergoing an endoscopic resection for early gastric cancer 10 months, and having a dilatation of the intrahepatic bile duct 2 years after the colectomy.
A CT scan and a needle biopsy of the liver tumors revealed multiple liver metastases. An endoscopic examination by using a duodenoscope revealed the cancer around the orifice under the swollen papilla.
It was inferred that the papillary cancer may have already occurred 2 years before when the biliary dilatation was found, but was failed to be diagnosed correctly.
Since FAP is a systemic disease, an intensive screening is necessary for other extra-colonic organs.

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