After obtaining clinically oriented and wide variety of education in the medical school and following completion of the strict and demanded post graduate training, American surgeons used to enjoy their practices in the approved hospitals by J. C. A. H. O., which is a non profit peer review organization. However, recent waves of managed care have badly changed the practice of medicine. At present managed care maens only “cost control”, but “quality control” has been neglected. DRG is now well known in Japan. In the future, other systems such as HMO gate keeper, etc. will presumably be introduced to the Japanese medical system. The author describes managed health care in the United States and its problems. It may help readers to foresee medical education and practice in Japan.

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Twenty-four gastrointestinal surgical patients with SIRS were divided into three groups; severe group comprising of nine abdominal infected patients with SIRS for 5 days or more, mild group comprising of seven abdominal infected patients with SIRS for 4 days or less, and non-infected group. In the non-infection group, eight patients undergoing esophagectomy, hepatectomy, or gastrectomy, with uneventful post-operative course were enrolled. We investigated the morphologic changes of granulocytes by flow cytometry in terms of their forward scatter (FSC) and side scatter (SSC), and also investigated their CD11b expression. The level of FSC of the severe group was higher than that of the mild group. The levels of SSC of the severe group were significantly lower than those of the mild and non-infected group at 5 days after the onset of SIRS, although there was no significant difference at the onset of SIRS. The expression of CD11b on granulocytes in the severe group was higher than those in the mild and non-infected groups at the onset of SIRS. Further, in the severe group, the expression of CD11b was kept at a high level even 5 days after the onset in three patients who died compared with the remaing survived patients.
Thus, we conclude that the investigation for morphologic changes and CD11b expression of granulocytes using a flow cytometry would be useful to assess the severity of abdominal surgical diseases patients.

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The purpose of this study was to compare the expression of sialyl Lewis antigens on the cell surface between gastric cancer and non-cancer cells and to elucidate possible roles of the antigens in predicting the development of liver metastasis. In addition, the usefulness as a prognostic factor was investigated. Subjects were 25 patients with advanced gastric cancer (nine with and 16 without liver metastasis). We measured sLea and sLex values expressed on the surface of about 10000-30000 cancer cells and non-cancer cells respectively for comparison. Monoclonal antibodies CA19-9 and KM-93 were used to evaluate the frequency and quantity of the expression by flow cytometry. The frequency and quantity of sLea and sLex in cancer cells were statistically higher than those in non-cancer cells (p<0.05). The frequency and quantity of sLea in cancer cells in the liver metastasis group was statistically higher than those in cases without liver metastasis (p<0.01). The values of expression of sLea on the surface of gastric cancer cells by flow cytometry indicated that there was a correlation with the development of liver metastasis (p<0.01). The frequency of sLea expression reflected clinical prognosis (p<0.05), and comparing to histopathological prognostic factors, it appeared to be superior to lymph node metastasis or depth of tumor invasion. It is strongly suggested that these values may be useful in evaluating the grade of malignancy.

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The aim of the present study is to clarify the point of surgical treatment for intestinal and anal lesions in patients with Crohn's disease. We classified 64 patients with Crohn's disease into two groups; 24 patients undergone abdominal operation and 40 patients without operation. Both groups were compared for some clinical factors, QOL, and means of medical therapy. And we also studied peri-anal lesions which are commonly accompanied with the patients with Crohn's disease. There were no significant differences in onset-age of the disease and sex ratio between two groups. The mean interval between the onset of the disease and operation was about four years. The operative rates in small intestinal type (45%) and small-large intestinal type (40%) were larger than in large bowel type (15%). Bowel resection or strictureplasty was performed because of stenosis or perforation of the intestine. Operative complications were reported in only three patients, and all had improved by conservative therapy. The QOL after operation was significantly better than before operation (admission number, IOIBD score, medical therapy's menu). Exscerbation of the disease occurred in seven patients who needed re-operation. Anal lesions were reported in 42 patients. Of these 42 patients, 22 patients underwent surgical treatment and had good results. Remaining 20 patients had spontaneous remission after the treatment for abdominal lesions. We think that the time of surgical therapy should be decided in terms of improving QOL in patients with Crohn's disease.

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The significance of hepatic arterial infusion chemotherapy (HAI) for unresectable liver metastases from colorectal cancer (CRC) was evaluated. In patients with unresectale liver metastases from CRC whose original lesions were resected at our department previously, 25 patients undergoing HAI with a reservoir were defined as HAI group and 14 patients without HAI as a control group. Those 25 patients received either of the following regimens; hepatic arterial infusion of 5-FU for 2 hours+MMC (MF group); hepatic arterial infusion of 5-FU for 2 hours (5-FU group); and 1 shot of 5-FU+epirubicin+ MMC (FAM group). The mean survival time of the 25 patients in the HAI group was 15.2 months. In the P-factor negative 21 cases at the beginning of HAI, that of HAI effective cases was 22.1 months, versus 13.3 months in non-effective cases. On the other hand, that of regimens were 20.2, 20.0, and 10.9 months in NIF, 5-FU. and FAM groups, respectively. By comparison of cumulative survival rates, HAI group, HAI effective cases, MF group, and 5-FU group showed significant improvement in prognosis. In conclusion, 2 hour continuous HAI with low-dose of 5-FU for unresectable liver metastases from CRC may be helpful for improvement of prognosis.

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We report the computed tomographic diagnosis of non strangulated obturator hernia. We treated 5cases of obturator hernia, in which 3 cases had ileocecalgia and thigh pain due to obturator hernia for many years and received CT examinations when occurred that pain. Retrospectively, any CT revealed non strangulated obturator hernia in 3 cases. We investigated any features of non strangulated obturator hernia from CT exam, and measured the interval of external obturator muscle and pectineal muscle on CT films of obturator hernia's patients and 20 healthy elderly women. On the result, the interval of external obturator muscle and pectineal muscle is average length of 9 mm in cases of non strangulated obturator hernia,24mm in cases of strangulated obturator hernia and 3.8mm in 20 healthy eldely women, which is shorter significantly than that of non strangulated obturator hernia. In the cases of non strangulated obturator hernia, CT revealed linear and nodular high density shadow in the space of external obturator muscle and pectineal muscle, but in the cases of normal women, nothing. We concluded that non strangulated obturator hernia is suspected by CT examination when the interval of external obturator muscle and pectineal muscle is larger than 10mm and linear and nodular high density shadow is appeared in the space of external obturator muscle and pectineal muscle.

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Second Department of Surgery, Kinki University School of Medicine A 57-year-old woman was admitted to the hospital because of hypoglycemia. There was a previous history of undergoing a removal of a tumor in the occipital lobe 12 years before admission, which was histologically diagnosed as angioblastic meningioma. The fasting blood sugar level was 30 mg/ml, and both levels of immunoreactive insulin and C-peptide were low. Abdominal ultrasonography, CT scan, magnetic resonance imaging, and arteriography revealed multiple localized tumors in the abdominal cavity and lumbar region. The histological findings of the resected tumor in the lumbar region were compatible with those of hemangiopericytoma and identical to those of the previous brain tumor. Thus, the multiple tumors were diagnosed as metastasis of meningeal hemangiopericytoma. We considered that curative resection was impossible. Arterial embolization for the two large tumors aiming at improving hypoglycemia was successful.

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Second Department of Surgery, Nagoya City University Medical School Recently mastopathy of the breast associated with long-term diabetes has been increasingly reported. We report here two patients with diabetic mastopathy. Patient 1, an 82-year-old woman who had been treated as type2 diabetes for 12 years, noticed a mass in the A-region of the left breast. It was a 22×18mm and dimpling-positive hard mass. The mass was suggestive of cancer on palpation and ultrasonic examination. But it revealed lower density than that of cancer on mammography. No enhancement was demonstrated on magnetic resonance imaging. Patient 2, a 61-year-old woman who had been treated with insulin for 15 years noticed a mass in the C-region of the left breast. It was 28×27mm (insize), dimpling-positive and fixed on muscle membrane. The mass was suggestive of cancer on ultrasonic examination and mammography. Aspiration cytology was done on both masses, but reported as “no cellular material”. We performed core needle biopsies, then diagnosed both cases as diabetic mastopathy. It is recommended performing core needle biopsy on masses suspected of diabetic mastopathy to avoid unnecessary operation.

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A 56-year-old woman was admitted to the hospital because of a large tumor in the right breast. The tumor was 13×10cm in size, with elastic firm consistency. With a suspicion of phyllodes tumor, an excision of the tumor was performed and it was confirmed histopathologically. Simple mastectomy was added because of a small malignant component in the tumor with H-E stain. The tumor was also positive for both CEA and p53 with immunohistochemical stain. Elevated serum CEA level of 9.27ng/ml before operation was reduced to 5.98ng/ml in one month after the removal of the tumor. Malignant phyllodes tumors of the breast are relatively rare. Of these tumors, that with positive CEA stain has been reported to be prone to recur. Strict postperative follow-up would be mandatory for the patient.

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A 32-year-old woman developed spontaneous pneumothorax at the 12th gestational week. After a chest tube drainage, pleurodesis using autologous blood was performed twice. Once she was discharged from the hospital with good results, but soon she had recurrence of pneumothorax. At the 19th gestational week, a thoracoscopic surgery was performed. Postoperative course was uneventful, and she was discharged on the 10th postoperative day. Thereafter, she had no recurrence of pneumothorax, and her spontaneous delivery at the 39th gestational week was uneventful.
Operation for pregnant women should be performed in the second trimester, the 4~8th gestational months. In performing thoracoscopic surgery, special attention should be paid not to cause recurrence in early postoperative days.

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Although esophageal hiatal hernia occurs in a relatively high incidence, esophageal hiatal hernia presenting upside down stomach with volvulus in which the entire stomach prolapsed is rare, especially that associated with multiple gastric cancer.
An 85-year-old woman was admitted to the hospital because of dyspnea on effort and palpitation. Chest plain x-ray film and a chest CT scan revealed deviation of the gastrointestinal tract into the left thoracic part. Upper gastrointestinal series visualized so-called upside down stomach in which the entire stomach prolapsed on the left diaphragm. Upper gastrointestinal endoscopy revealed type 2 gastric cancer in the gastric body and two polyps of Yamada′s type III on the antrum. From these findings, esophageal hiatal hernia with gastric cancer was diagnosed and a distal gastrectomy and plication suture of the esophageal hiatus were performed. On the resected material, all antrum lesions were diagnosed as well differentiated adenocarcinoma. Besides these lesions, type IIa well differentiated adenocarcinoma in the anterior wall of the lower part of gastric body which had not been diagnosed preoperatively was confirmed, quadruple gastric cancer being disclosed.
We have difficulty in conducting sufficient preoperative exploration for esophageal hiatal hernia manifesting upside down stomach due to its anatomical characteristics, and hence careful attitude for preoperative diagnosis would be mandatory.

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This paper presents a case of primary gastric T-cell lymphoma with negative HTLV-1 antibody, together with a review of 17 cases in the Japanese literature. A 67-year-old man was admitted to the hospital because of upper abdominal distress. A large tumor resembling type 2 of gastric cancer was detected at the body of stomach by upper G-I series and endoscopy. The biopsy revealed malignant lymphoma. No other lesions were noted except regional lymph node swelling by CT-scan. Serology was negative for HTLV-1 antibody. A total gastrectomy with a splenectomy and a partial hepatic resection, and lymph node dissection were performed. Histology of the resected material revealed diffuse and mixed cell type of lymphoma. Surface markers for lymphocyte were CD20-/CD3+ and CD4+/CD8-, showing T-cell lymphoma. Nodal recurrences appeared in the cervical region six and 11 months after the surgery. The patient responded well to the CHOP, and then a second-line chemotherapy. He has been living well with a partial response for the postoperative 22 months.
The present case showed almost similar clinicopathologic features to the reported cases. Six-,12and 24-months survival rates of these cases, consisted mainly of Stage IIEs (Ann-Arbor), were 82.5 62.9 and 62.9%, respectively. Therefore, gastrectomy followed by an appropriate chemotherapy was considered to be a treatment of choice for this Stage. Further accumulation of cases would be necessary for determining the treatment or the prognosis of this disease.

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A 39-year-old man was brought into the emergency department in our hospital because of abdominal pain and abdominal distention. Computed tomography revealed abdominal fluid and a 20×20×6cm giant polycystic tumor at the backward of the stomach. After an emergency angiography and an embolization at the left gastric artery, the patient was admitted. No defenite diagnosis was made with ultrasonography, gastrointestinal endoscopy, endoscopic retrograde cholangiopancreatography, enhanced abdominal computed tomography and magnetic resonance imaging. Resection of the tumor with a partial resection of the stomach was performed. Leiomyosarcoma of the stomach was suspected by postoperative histopathological examination. But the tumor was definitely diagnosed as gastrointestinal stromal tumor in immunostaining. We infered that the growth of the tumor with polycystic change might be due to the intramural bleeding of the tumor. It seems to be extremely rare that gastrointestinal stromal tumor with polycystic change occurs, and so we report this case together with some bibliographical comments.

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First Department of Surgery, Kagawa Medical University A 67-year-old man was admitted to the hospital because of a palpable abdominal tumor. An infant head sized tumor was felt at the right side of the upper abdomen. On a blood analysis, anemia and an increase in CEA level (37.6ng/ml) were noted. Abdominal ultrasonography and a contrast-enhanced CT scan revealed a large cystic tumor, about 12cm in longer diameter with thickened wall. Gastric endoscopy revealed advanced gastric cancer, Borrmann type III, located lower anterior body of the stomach. Operation was carried out with a diagnosis of extragastric growth type carcinoma of the stomach. Subtotal gastrectomy with lymph node dissection (D3) and a partial resection of the transverse colon were performed. This type of gastric cancer is extremely rare, and its prognosis is very poor.

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We report a case of total papillectomy for adenoma of the duodenal papilla that is a rare disease.
A 70-year-old woman was pointed out swelling of the duodenal papilla by an upper gastrointestinal endoscopic examination at regular medical check-up. Histological diagnosis of biopsied material was adenoma of the duodenal papilla. Total papillectomy and sphincteroplasty were performed. Histological diagnosis of the resected specimen was papillotubular adenoma and there was no evidence of malignancy.
There has been no consensus regarding carcinogenesis of the papilla and the biological malignancy. So there are no established diagnostic methods and standard therapy for adenoma of the duodenal papilla. We consider that total papillectomy should be the first choice of the therapy for adenoma of the duodenal papilla. If intraoperative frozen section examination or postoperative histological examination reveals malignant findings, we have to alter into or add pancreatoduodenectomy.

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A 53-year-old woman with von Recklinghausen's disease was admitted to the hospital because of abdominal pain and vomiting. She had been diagnosed as von Recklinghausen's disease at the age of two, and undergone removals of left and right retroperitoneal neurofibromas at the ages of 41 and 53respectively as well as spinal neurofibroma at the age of 41. Since 50 years of age, diarrea and intractable peptic ulcer appeared and at the same time, hypergastrinemia was noted. Zollinger-Ellison syndrome had been suspected. On the 4th hospital day, massive melena occurred. Endoscopic examination showed multiple duodenal ulcers and a submucosal tumor close to the Papilla Vater. As she had marked hypergastrinemia to 1160pg/ml, Zollinger-Ellison syndrome was suspected. Pancreaticoduodenectomy was performed, when a submucosal tumor close to the Papilla Vater and lymph node metatstasis were found. Pathological examination revealed doudenal cartinoid 4mm in diameter, which was positive for gastrin by immunohistochemical staining. Hypergastrinemia disappeared postoperatively.

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A case of perforation of ischemic ileitis caused by stenosis of the transverse colon due to recurrence of gastric cancer is reported here. A 71-year-old man was admitted to the hospital because of mild abdominal pain at the end of December in 1997. About 2 months before admission, the patient had undergone a total gastrectomy, a cholecystectomy, a splenectomy, an associated resection of pancreatic body and tail, and a partial resection of mesentery of the transverse colon for gastric cancer in the hospital. On January 14,1998. the abdominal pain suddenly aggravated, and a laparotomy was performed with a diagnosis of generalized peritonitis. There were diffuse and moderate dilatation and edema of the ileum and a perforation 4 mm in diameter on the ileum at the reverse side to that where the mesentery adheres, and about 30 cm distal from the terminal ileum. The transverse colon revealed a narrowing caused by adhesion due to recurrence of the gastric cancer. A partial resection of the small intestine was performed and an artificial anus was made at the ileum. Bases on histopathological findings of the resected ileum. perforation of ischemic ileitis was diagnosed.
It is thought that the narrowing of the transverse colon due to recurrent gastric cancer caused the dilatation and resultant ischemia of the small intestine to lead to multiple ulcers. And one of them might perforate.

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Ischemic enteritis of the small intestine is a rare entity and is classified into temporary, stricturing, and gangrenous forms. The temporary and stricturing forms are called ischemic enteritis of the small intestine in a narrow sense, but we think that these forms might be different in the severity resulting from the degree of ischemia. Here we report two cases of ischemic enteritis of the small intestine, one case of stricturing form and the other of gangrenous form.
Patient 1, a 77-year-old man, was admitted to the hospital because of abdominal pain and vomiting. Conservative treatment improved these symptoms and he was discharged from the hospital. However, he was readmitted because of intestinal obstruction. Fifty-five days after the onset of the first symptoms, a laparotomy was performed and a whole circumferential stenosis about 15 cm in length was found at the ileum. Histopathological examination showed U1-II widespread ulcer with marked infiltration of inflammatory cells and fibrosis. The definite diagnosis of ischemic enteritis was made.
Patient 2, a 68-year-old woman, underwent an emergency laparotomy for peritonitis. Pulsation at the main branches of the superior masenteric artery were palpable. Hemorrhagic necrosis of the jejunum about 15 cm in length occurred whole circumferentially and through the entire layers of the intestinal wall. A partial resection of the small intestine was performed.

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A case of tumor arising from a Meckel's diverticulum with gastrointestinal bleeding is reported. A 69-year-old man was admitted to the hospital because of melena. No bleeding site was identified by a lower gastrointestinal endoscopy. A retrovesical tumor about 7cm in diameter was detected by a pelvic computed tomography. Intestinal penetration of the retrovesical tumor was diagnosed. Rebleeding occurred, and an emergency operation was performed, when a 8×7×7cm solid tumor was revealed on the anti-mesenteric side of the ileum 100cm apart from the ileocecal valve. Partial resection of the ileum including the tumor was performed. On the resected material, an opening due to a Meckel's diverticulum was confirmed on the ileal mucosa and the tumor was solid which communicated with the diverticulum.
Histopathologically, it was leiomyosarcoma arisen from Meckel's diverticulum. In this case, the partial resection of the ileum was useful that resulted in a radical therapy for the diverticulum and a complete hemostasis for gastrointestinal bleeding.

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A 61-year-old man was seen at the hospital because of melena and anemia. No bleeding lesions were revealed by an angiography and a colonofiber-scopy. We could find a bleeding lesion in the terminal ileum by ^99mTc hemorrhagic scintigraphy. Under laparotomy, bloody fluid was observed in the entire colon and terminal ileum. We could touch a tumor in the terminal ileum. Partial resection of the ileum was performed. The pathological diagnosis of this tumor was lipoma with erosion on its mucosal surface.
Hemorrhagic scintigraphy can detect even minute and intermittently bleeding lesions of the gastro-intestinal tract. It is especially useful for the small intestine.

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A 79-year-old woman was admitted to the hospital because of sudden onset of lower abdominal pain. She had undergone an aortocoronary bypass procedure after acute myocardial infarction at the age of 66. Thereafter she had been treated with anticoagulant agents including warfarin, and given antihyper-tensive and antiarrhythmic agents. On admission laboratory data including thrombotest (19%) showed depressed coagulability. Peritoneal signs appeared on the next day. She underwent an emergency laparotomy under a preoperative diagnosis of perforative peritonitis. The bowel wall showed a segmen-tal, diffuse necrotic change. The superior mesenteric artery was found to be patent. The histologic picture of the resected specimen revealed hemorrhagic necrosis in the mucosa and submucosa. She was diagnosed as non-occlusive mesenteric infarction (NOMI). Heparin therapy was started by continuous intravenous infusion on the postoperative day, and thereafter warfarin was started again after the beginning of oral intake. There were neither episodes of hemorrhage nor thromboembolism. No aggravation of her cardiovascular disease occurred. In the treatment of patients with abdominal pain who have had cardiovascular disease, it would be necessary to determine whether they belong to the high risk group or not as soon as possible and to conduct examinations and subsequent therapies by keeping the possibility of NOMI as well as mesenteric occlusion in mind. And it is thought that anticoagulant therapy may be ineffective for prevention of NOMI.

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Portal vein gas, which is a rare complication of intestinal necrosis, is a sign of poor prognosis.
We encountered 4 patients with intestinal necrosis accompanied by portal vein gas. The 4 patients consisted of 3 females and 1 male with a mean age of 78.5 years. The main complaint was abdominal pain in all patients. Portal vein gas was detected by US in 1 patient and by CT in the remaining 3 patients. Two patients were diagnosed as having non-obstructive intestinal infarction underwent segmentectomy of the small intestine and were discharged from the hospital. The 2 patients with infarction in the superior mesenteric artery underwent excision of the small intestine in a large area and the right part of colon, but died 20 days and next day, respectively, after the surgery. Usually, portal vein gas with insestinal necrosis has poor prognosis, but because there have been survivors, laparotomy should be imediately performed if portal vein gas is detected in patients in whom intestinal necrosis is suspected.

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A 78-year-old man was admitted to the hospital because of severe abdominal pain lasting for two day. There was a history of undergoing an appendectomy 30 years before and having brain infarction 13 years before admisson. Physically, remarkable abdominal distension and reduced bowel sound were noted, however, no muscular deffence was recognized. Abdominal X-ray CT scanograms showed a severe calcification of the superior mesenteric artery and significant dilatation of the small intestine. The patient took an urgent course into shock for an hour. We diagnosed the case as embolism of the superior mesenteric artery, and an emergency laparotomy was performed. Intraoperatively, it was noticed that the ileum was obstructed by many pieces of tangles at a kinked site due to the previous appendectomy. Ileotomy was performed and the tangle pieces were removed. However, he could not recover from shock and died two days after the operation. We asked his family menber about his eating habits and it was clarified that he ate a lot of tangle's roots, 'ne-konbu' one week before admission. Small intestinal obstruction with tangle is a rare entity and we found a great deal of difficulty in preoperative diagnosis.

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An 80-year-old man was seen at the hospital because positive fecal occult blood was pointed out elsewhere. Colonoscopy and a contrast enema revealed, a pedunculated polyp about 20mm in size in the sigmoid colon. Biopsy indicated that the lesion belonged to Group I. Polypectomy was performed and juvenile polyp was diagnosed. The so-called solitary juvenile polyp is found in all the generations, and bimodal age distribution of the prevalence has been reported, but occurrence in old persons aged above 70 years is relatively rare. When solitary pedunculated (sub) polyp of 10-20mm in size is found from the sigmoid colon to rectum, juvenile polyp seems to be necessary to keep in mind as a differential diagnosis in addition to adenoma and cancer, even for elderly patients. This urged us to report.

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We experienced a patient with diverticulitis of ascending colon who was operated on for stricture and abscess formation and found to have multiple colonic muco-submucosal elongated polyps (CMSEPs). This case is reported together with some bibliographical comments.
A 35-year-old man was seen at the hospital because of pain in the right abdomen. The patient was conservatively treated with a suspicion of colonic diverticulitis. Colonofiberscopy revealed a narrowing and multiple polyps in the cecum. Fluoroscopic study of the small intestine visualized a longitudinal ulcer on the ileum. Ileocecal stricture due to Crohn disease was suspected and the patient was operated on, when an inflammatory tumor about 7cm in size was confirmed in the region and ileocecal resection was performed. The resected material revealed a fistula between terminal ileum and the ascending colon and six polyps like tongue about 1.5-2.0cm in size in the cecum. Histopathological diagnosis was made as abscess formation due to diverticulitis. Crohn disease was negated by pathological findings. As for the multiple polyps, surfaces of the polyps were covered with normal mucosa and dilatation of submucosal veins and lymphatic vessels, proliferation of edematous connective tissue were seen. The polyps were clarified to be CMSEP. This is the first case report of juvenile colonic diverticulitis associated with multiple CMSEIs.

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This paper deals with the microsatellite instability in a patient with hereditary nonpolyposis color-ectal cancer (HNPCC). The patient was a 66-year-old woman. There were previous history of undergoing a hysterectomy for uterine cancer at the age of 416, and an extended right hemicolectomy for synchronous double cancer of the ascending and transverse colon in our hospital at the age of 58. Her family history disclosed that her father died of lung cancer, her mother died of uterine cancer, two of her sisters died of colon and gastric cancer respectively, and another two of her sisters had colon and uterine cancer respectively. After the last operation, she was diagnosed as having gastric and rectal cancer simultaneously, and we performed a distal gastrectomy and a Miles operation.
Histopathologically, both tumors were well differentiated adenocarcinoma. We found the genetic instability for the rectal specimen using a microsatellite assay. The patient and her family should be considered to have an increased risk of an additional primary cancer.

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A 67-year-old man was diagnosed as having a giant tumor of the transverse colon and an extended right hernicolectomy was performed. During laparotomy, obvious swelling of lymph nodes from group 1 to 3 were seen. We dissected those 88 lymph nodes including four paraaortic lymph nodes. Histological-ly, the tumor was well differentiated adenocarcinoma (ss, ly1, v0). The only one paraaortic lymph node out of all 88 dessected lymph nodes was positive. He has been doing well without any recurrence as of one year and three months after the operation.

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Colorectal metastasisof breast cancer is clinically rare. The large intestine is uncommonly affected by cancer of the other organs so that we rarely encounter clinical cases of metastatic colorectal cancer. Recently we experienced a patient with metastasis to the descending colon from bilateral inflammatory breast cancer who survives more than 2 years by a left hemicolectomy followed by postoperative chemotherapy.
A 42-year-old woman was seen at the hospital because of abdominal distention 5 months after she noticed bilateral breast indurations which were left alone. Bilateral inflammatory breast cancer with metastasis to the bilateral axillary and left subclavian lymph nodes was suspected, and the patient was admitted. Barium enema study revealed a narrowing in the descending colon. A left hemicolectomy was performed with a suspicion of primary colonic cancer. Histopathologic pictures of the resected material offered a diagnosis of colonic metastasis of breast cancer. As an adjuvant chemotherapy, CAF regimen was conducted, with a resultant PR. She is living and well, as of 2.5 years after the operation.
There have been few reports on colorectal metastasis of breast cancer in Japan. To our best knowledge, only 16 cases including our case have been seen in the literature. This paper presents the case with bibliographical comments.

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This paper presents a case of ruptured amebic liver abscess with panperitonitis. A 33-year-old man was admitted to the hospital because of fever and sever pain of the entire abdomen. Laboratory tests revealed leucocytosis and liver dysfunction. Abdominal ultrasonography and an abdominal CT scan demonstrated two abscesses in the right lobe of the liver. The patient was diagnosed as having ruptured liver abscess with panperitonitis and underwent an emergency operation on the same day. Pus of an “anchovy sauce” appearance was obtained from the liver abscesses. Surgical drainage of the abscesses and peritoneal cavity, and an appendectomy were performed. Postoperatively the patient had a persistent fever. After administration of metronidazole, his condition recovered markedly. Entamoeba histolytica was not found in the pus of the abscesses, but found in the wall of appendix. Amebic liver abscess was finaly diagnosed based on the results of a serologic test.

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A 69-year-old man was admitted to the hospital for colonic stenosis. With close examination, the stenosis was found to be caused by type II cancer of the sigmoid colon. At the same time, a liver tumor was revealed. Abdominal CT scans revealed a low density mass 3.5cm in diameter in the area of S5 of the liver. CT during arterioportography visualized a wedgeshaped defect at the portion seperated by the portal veins, involving the tumor. CT arteriography visualized an accumulation of a contrast material around the tumor showing a low density mass. No difinitive diagnosis was made. After a sigmoidectomy, a granuloma was revealed by intraoperative echo-guided hepatic biopsy, which predominantly comprised of infiltration of chronic inflammatory cells. The case of inflammatory pseudotumor of the liver associated with malignant tumors should be carefully diagnosed. Therefore, it is important to diagnose by a true-cut biopsy to portions including inside of the tumor and its margin with different echoic levels, under ultrasonographic guidance.

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A 71-year-old woman was found to have an increase in AFP while she was followed for type C chronic hepatitis in the department of internal medicine in our hospital. She was diagnosed as having hepatocellular carcinoma at the liver S8 with the size of 2.5cm, and was transferred to the department of surgery for treatment. Under a small open thoracotomy, microwave coagulation therapy (MCT) was performed. A needle biopsy cytology resulted in moderately differentiated hepatocellular carcinoma. After AICT, AFP level rapidly increased and a dynamic CT scan about 3 months later revealed remarkable early enhancement at the site of MCT. Barsed on fluoroscopic patterns, recurrence occurred in more malignant histology of moderately to poorly differentiated type. There were no formations of A-P shunt and A-V shunt, and two times of TAE were successful. Approximately 4 years later, the patient died of hepatic failure.
MCT is a valuable local therapy for liver cancer, but sometimes, insufficient therapy permits abrupt progression of the tumor. This case which is suggestive is presented here.

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A 62-year-old man complaining of epigastric pain was diagnosed as having gallbladder stone on close examinations. Since he had undergone a distal gastrectomy with Billroth II reconstruction for duodenal ulcer at the age of 23, endoscopic retrograde cholangiopancreatography (ERCP) was impossible and we could not obtain detailed information about the biliary system before operation. Considering his previous history of undergoing the gastrectomy, a cholecystectomy under laparotomy was performed when the cystic duct and cystic artery were confirmed at the Calot triangle. However, further pursuit of the procedure revealed a cord running from the neck of the gallbladder to porta hepatis other than them. Intraoperative fluoroscopy through the cord visualized around the root of the right hepatic duct that demonstrated there was a communication with the hepatic duct. Double cystic duct was diagnosed and the ligature and resection were performed. Double cystic duct accounts for as rare as 0.03% of all indications for biliary operation, however, attention should be paid to the possibility of the disease in performing operation in order to prevent postoperative bile leakage.

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We experienced a case of choledocholithiasis in which a metal clip used for closure of surgical stumps of the cystic duct at a laparoscopic cholecyst-ectomy had migrated into the common bile duct to from choledocholith.
A 60-year-old man, who had undergone a laparoscopic cholecystectomy for cystic stones elsewhere 3 years before, visited another hospital because of jaundice. The patient was referred to the hospital with a diagnosis of obstructive jaundice. After admission to the hospital, cancer of the common bile duct was diagnosed and the patient was operated on. The resected material disclosed no pathological malignancy, but there was a clip in the lumen of common bile duct and choledocholith was confirmed at the same site. As one of latent complications after laparoscopic cholecystectomy, formation of choledocholith due to migrated clip must be kept in mind. The necessity of long-term follow-up for postoperative patients is suggested.

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Cholecystocolic fistula is rare of all internal biliary fistulae. Two patients with cholecystocolic fistula are presented. The first patient, a 77-year-old man, presented with pyrixia. Pneumobilia from the gallbladder to transverse colon was detected with an abdominal CT scan. Diagnosis of cholecys-tocolic fistula was made with an endoscopic retrograde cholangiopancreaticography (ERCP). At operation, a cholecystectomy and a partial resection of the transverse colon including the fistula were performed. The second patient, a 71-year old man, presented with upper abdominal discomfort. Pneumobilia of the intrahepatic duct was detected with an abdominal ultrasonography and an abdominal CT scan. Diagnosis of cholecystocolic fistula was made with ERCP. At operation, a cholecystectomy, a partial resection of the transverse colon including the fistula and an end to end anastomosis were performed.
In both cases, ERCP was useful for detecting the existence of the fistula. This disease would require cholecystectomy and resection of the wall of the colon including the fistula to attain a curative operation.

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A 39-year-old man was admitted to the hospital because of epigastralgia. Abdominal ultrasound study and an abdominal computed tomography showed a whole-circumferential thickening of the wall and stones in the wall of the gallbladder. ERCP showed anomalous arrangement of the main pancreatic duct and common bile duct of non dilatation type. From these findings, a diagnosis of adenomyomatosis of the gallbladder associated with anomalous arrangement of the pancreaticobiliary duct was made. Because anomalous arragement of the pancreaticobiliary duct of non dilatation type has a risk of having carcinoma in the gallbladder, a laparoscopic cholecystectomy was performed. The histological findings of the resected gallbladder disclosed adenomyomatosis of generalized type and no carcinoma was involved in the specimen. Including this case, 11 cases of the adenomyomatosis of the gallbladder associated with anomalous arragement of the pancreaticobiliary duct have been repoted in the Japanese literature. There are four cases of dilatation type and seven cases of non dilatation type. In all four cases of dilatation type. cholecystectomy and resection of the extrahepatic bile duct with hepatico-jejunostomy were performed. In six out of the seven cases of non dilatation type, cholecystectomy was performed.

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A 73-year-old man was referred to the hospital because a tumor of the gallbladder was pointed out by ultrasonography at another hospital on November 19, 1996. The patient had been suffering from right hypochondralgia, body weight loss, and repeated fever and pain since April of the year. On ad-mission, WBC was 18, 200/mm³, ALP was 960IU/l, and γ-GTP was 103IU/l. Imaging procedures visualized the gallbladder as an 8×7cm, relatively demarcated solid tumor with necrotic center; tumors with the diameter of less than 3cm in S4b, 6, and 8 of the liver; and swollen paraaortic lymph nodes. Angiography revealed that the tumor was hypovascular and there was an encasement of the cystic artely. With a diagnosis of gallbladder carcinoma, hepatic resections (S4a+5+6) were performed by using 800ml of autol-ogous blood transfusion on December 2. Histologically, it was undifferen-tiated spindle cell carcinoma of the gallbladder, composed of sarcomatoid portion mostly with severe tumor necrosis and adenocarcinoma component partially. The patient was discharged from the hospital 24 days after the operation. Thereafter, PEIT for hepatic metastasis was unsuccessful and the patient died of liver failure 8 months after the operation.

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A case of somatostatinoma of the pancreas head is reported. A 64-year-old woman underwent an abdominal computed tomography because she was pointed out occult blood of the urine, and was discovered to have a tumor of the pancreas head incidentally. Imaging examination such as abdominal angiography showed a hypervascular tumor. We suspected endocrine tumor and examined hormone levels in the blood. Serum somatostatin level was high. Pylorus preserving pancreatoduodenectomy was performed with a preoperative diagnosis of somatostatinoma. The tumor was 3.5×3.5×2.3cm in size, and was somatostatin antibody positive in an immunohistological study.

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A 13-year-old girl was seen at the hospital because of a tumor of the left upper quadrant of abdomen. Tumor markers including CEA, CA19-9, and CA125 were all in normal ranges on general blood tests and biochemical studies. Imaging procedures revealed a 11×10cm cystic lesion with sep-tum at the pancreatic tail. A resection of the pancreatic body and tail was performed. No histologic malignancy was demonstrated and so mucinous cystadenoma was definitely diagnosed. CEA, CA19-9, and CA125 levels in the cystic fluid were as high as 1, 300ng/ml, 15, 817U/ml, and 134U/ml, respectively. CEA, CA19-9 and CA125 stainings by means of enzyme-anti-body method yielded positive responses in the epithelial cells of the cystic wall, indicating secretion of CEA, CA19-9, and CA125 to the cystic lumen. This case was thought to be an interesting instance in consideration of the significance of increases in these tumor markers in the cystic fluid. In addition, it is rare that mucinous cystadenoma is confirmed in such a juvenile like this case. The patient is the youngest among those patients in Japan as far as we could review.

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A 40-year-old woman with tuberous sclerosis and bilateral renal angiomyolipomas who was followed in the clinic was found that the angiomyolipomas increased to be 25×20×11cm in size on the left and 20×20×11cm on the right. And she had experienced intraperitoneal rupture of the left renal angiomyolipoma three times, when she developed sudden onset of severe abdominal pain, abdominal distension and shock. At the third rupture, she could not recovered from the shock state by the rapid transfusion. Therefore we performed an immediate selective transcatheter arterial embolization with coiles to the posterior branch of the left renal artery which fed the major part of the tumor 25×14×11cm in size having many pseudoaneurysms. After that the blood pressure became stable. Following the emborization, high fever and abdominal pain persisted for two weeks. Three months after the operation, the left renal tumor was decreased to 17×17×8cm in size, and until now no signs of rupture have been demonstrated.
In domestic cases in the literature including this case, selective transcatheter arterial embolization for renal angiomyolipoma was successful in hemostasis of the tumor. No re-rupture occurred and shrinkage of the tumors was recorded in all cases in which clinical courses were described. It is suggested that the transcatherter arterial embolization is an excellent therapy to hemostasis and tumor shrinkage for ruptured renal angiomyolipoma.

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Two cases of prostatic cancer presented with stricture over the entire circumference of the rectum are reported. Case 1: An 85-year-old man who had been pointed out prostatic hypertrophy 7 years before was admitted to the hospital because of dyschezia. Colonoscopy showed a high degree of stricture at a portion 3cm from the anal verge, but no tumorous lesion with smooth surface in the rectum. Abdominal CT scan and magnetic resonance imaging (MRI) revealed diffuse thickening of the rectum and irregularity of the prostate. Prostatic cancer with invasion into the rectum was diagnosed and an artificial anus was made in the sigmoid colon. After the operation, hormonal therapy was started and no increase in the tumor size has been observed up to now.
Case 2: A 72-year-old man was admitted to the hospital for exploration with a whole-circumferential stricture of the rectum. Fluoroscopic study showed a severe stenosis in the lower portion of the rectum. Transrectal biopsy specimen of the prostate showed poorly differentiated adenocarcinoma. Hormonal therapy was started, but the patient developed jaundice and intestinal obstruction due to invasion of the tumor. Relief of obstructive jaundice and an artificial anus were performed but the patient died of progressed renal failure.
During laparotomy in both cases, disseminated sclerosis of mesenterium of the rectum and retroperitoneum were noted. These findings suggested that prostatic cancer progressed and presented with stricture of the rectum. Although it is rare that prostatic cancer progresses to cause rectal stricture, early intensive therapy considering the QOL of the patient is needed.

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Subcutaneous lifting laparoscopic surgery was successfully performed in the treatment of an urachal remnant. A 23-year-old woman was seen at the hospital because of umbilical pain. At first, she was diagnosed as having omphalitis. Then, she underwent an incision and drainage of the infected site and received antibiotics, however, she had not responded to the treatment. Since an abdominal ultrasonography and abdominal CT scan showed a mass running from the umbilicus in the direction of the bladder, she was again diagnosed as having infected urachal remnant and was admitted for operation.
At the operation, the urachus was detected easily, which was divided at the bladder apex and extirpated. The operation time was 130 minutes, and the estimated blood loss was minimal. Her postoperative course was uneventful, and she was discharged from the hospital on the 8th postoperative day.
Urachal remnant is comparatively rare and desirable to be excised because it is possible to cause infection and malignancy. This paper presents a case of an infected urachal remnant excised by a subcutaneous lifting laparoscopy, together with some bibliographical comments.

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Internal hernias are uncommon, especially broad ligament hernia. Preoperative diagnosis of this disease is considered to be very difficult. We experienced a case of broad ligament hernia in which preoperative abdominal CT findings was helpful to make the diagnosis.
A 49-year-old woman without any previous surgical history was admitted to the hospital because of abdominal pain and vomiting. Abdominal X-P showed niveau sign. She was treated conservatively with a long tube, but no symptomatic remission was obtained at the next day. Abdominal CT scan showed ascitis and several air-fluid levels of the small bowel deviated the uterus to the left side in the small pelvic cavity. We considered a broad-ligament hernia, and performed an emergency operation. Surgical exploration showed that there was an about 2cm defect in the right broad-ligament with a portion of ileum about 3cm in length, 60cm from the ileocecal valve herniated through this hiatus. The herniated ileum was releaced from obustruction and the hiatus was sutured. Any resection of the ileum was not performed.
Is has been known that broad ligament hernia is rare disease entity and presents difficulty in diagnosis preoperatively. We report a case of broad ligament hernias in which preoperative abdominal CT scan, it provided clues for the diagnosis.

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This paper presents a case of spontaneously perforated pyometra associated with peritonitis. An 82-year-old woman was referred to the hospital because of abdominal pain, nausea and vomiting, while she was hospitalized for multiple myeloma in another hospital. Simple abdominal X-ray film revealed niveau of the intestine, but no free air. Abdominal CT scan revealed fluid collection in the Douglas pouch. One day later, the lower abdominal tenderness became severe and Blumberg's sign and muscular defense of the lower abdomen were observed. The patient was diagnosed as having peritonitis caused by intestinal perforation. Laparotomy levealed that the posterior wall of the uterine body had been perforated and pus flowed out the site. Based on a diagnosis of perforated pyometra we performed a hysterectomy and bilateral salpingoophorectomy. Histopathological exploration revealed no findings of malignancy, but severe arteriosclerosis was noted in the tunica muscularis uteri. In elderly female patients presenting acute abdomen and suspected to be in an immunodepressive state with arterial sclerosis, pyometra should be considered since it is a relatively frequent disease in them.

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The great majority of tumors arising in the retroperitoneum are non-epithelial tumor. Primary retroperitoneal mucinous cystadenocarcinoma is very rare. We present such a rare case with some notes on 23 cases reported in the Japanese literature. A 39-year-old woman was admitted to the hospital because of distention and tenderness of the right lower quadrant of the abdomen.
Abdominal imagings revealed a giant cystic mass 20×18×15cm in size and an intracystic tumor 2cm in diameter. Abdominal angiography revealed displacement of the left lower abdominal vessel. Barium enema study showed no abnormal findings other than oppression image. At laparotomy, a large cystic tumor was found in the leftlateral abdominal region which showed extramural pressure to the colon. Macroscopic photograph of resected specimen showed simple large cyst with protruding papillary tumor inside of the cyst and the inner space was filled with mucinous fluid. Histologically, it was mucinous cystadenocarcinoma. The mucinous fluid and cystic wall were CA19-9 positive on immunohistochemical studies.
The Patients is living and has been free from recurrence for 2 years after the operation. Since no abnormalities in other organs have been seen, we think that the tumor was primary retroperitoneal mucinous cystadenocarcinoma.

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Autosomal dominant polycystic kidney disease is associated with multiple cysts in various organs including the kidney, liver, pancreas, and spleen. Increased intraabdominal pressure due to such condition causes adult umbilical hernia and inguinal hernias. We have a great deal of difficulty in the treatment. We repaired two recurrent adult umbilical hernias and one incarcerated adult umbilical hernia associated with polycystic kidney disease by using a prosthetic material. Prolene^® hernia system, which is devised for inguinal hernia repair, has three attached components. Its underlay patch provides a posterior abdominal wall repair. Its connector, which is depressed in the center, has the desirable attributes of a plug repair. Its onlay patch covers the anterior abdominal wall and prevents a hernia of the linea alba. There have been no signs of recurrence in all patients and the umbilical dimple which has been intact gives them satisfaction.

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We report three cases of Richter's hernias follwing laparoscopic surgery. All three patients complained of nausea, vomiting, and abdominal pain within a week after the laparoscopic operation. An abdominal X-P revealed air fluid level and an abdominal ultrasonogram demonstrated that the intestine was incarcerated into the abdominal wall. Richter's hernia was diagnosed and three patients were operated on. At surgery the small bowel was incarcerated into the abdominal wall where the trocar was inserted at the first operation. In one case a partial resection of the small bowel was performed because it necrotized, and in other two cases the incarcerated small bewel was returned to the abdominal cavity All three patients had an uneventful postoperative course and was discharged from the hospital. It was found that, in all the patients, trocars over 10mm in diameter were used and the defects on the abdominal wall not closed that might cause Richter's hernia. The fascia must be closed, when trocars over 10mm in diameter are used in laparoscopic surgery.

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Obturator foramen hernia is a relatively rare disease and is likely to occur in aged, thin females. Herein we report a case of obturator foramen hernia associated by incarcerated femoral hernia. A 95-year-old woman was seen at the hospital because of nausea and vomiting. At admission, she was diagnosed with incarcerated femoral hernia due to swelling at the right lower area of the groin. Because an abdominal simple X ray demonstrated intestinal obstruction as well as Howship-Romberg sign was obtained, a pelvic CT was performed. The pelvic CT demonstrated right obturator hernia. At laparotomy, a large omentum was incarcerated at the right femoral ring while the small intestine 130cm proximal from the terminalileum showed Richter type hernia at the right obturator foramen. Operative procedures included: reposition of the large omentum and the ileum; resection of a part of the large omentum; and closure of the hilus of the hernia. With a recent progression in imaging procedures, clinical cases diagnosed as obturator foramen hernia preoperatively have been increasing. Aggrssive examination sincluding CT scan are useful in making preoperative diagnosis of the disease, especially not to overlook associated hernia which is difficult to be detected by palpation like in this case.

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A 12-year-old Japanese girl presented with a subcutoneous tumor on her back. Since 6 years old when she had a pilomatrixoma on her right arm, She had had a total of six pilomatrixomas on the left shoulder, left cheek, right back, left back and neck. All these lesions were surgically removed and diagnosed as pilomatricoma on histological examinations. This time, the tumor on her back was also resected and proved to be the seventh pilomatricoma.
Pilomatricoma is a benign subcutaneus tumor which frequently involves the head, neck and upper extremities in young women and usually occurs as a solitary legion. Multiple pilomatricoma, mostly 2 or 3 incidents, has been reported to occur in approximately 10% of all cases. However, a case of 7 tumors like this case is rare. The associations of multiple pilomatricoma and myotonic dystrophy have been occasionally seen in the literature. Although pilomatricoma is generally considered benign tumor, it car gradually in crease in size if it is let alone and there are a few reports of malignant pilomatricoma. It is suggested that pilomatricoma should be removed as soon as possible.

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