Since 1940 when Karl Adorf von Basedow had first stated the Merseburg's triad, namely hyperthyroidism, exophthalmos, and goiter, we surgeons have struggled with the triad in the treatment of Graves disease. From my 30-year experience with operations and researches on clinical cases of the disease, I have drawn my therapeutic guidelines for surgery of the disease. 1) Based on my statistical studies of a total of 486 cases conducted in 1981, 1991, and 1996, as well as a research on 106 cases of postoperative recurrence, I have found a surgical procedure to prevent the relapse of hyperthyroidism after surgery, super-subtotal thyroidectomy, in which the maximum remnant thyroid tissue must be less than 2g in weight. 2) After I have confirmed that total thyroidectomy is superior to subtotal thyroidectomy in controlling the progress of ophthalmopathy in a research on 58 cases of active opthalmopathy, I employ total thyroidectomy for severe cases of opthalmopathy. 3) In the treatment of goiter, I recommend radioactive iodine therapy prior to surgery, especially for relapsed cases with huge nodules after surgery which make second surgery difficult. After the iodine therapy which reduces the goiter in size, the goiter can be easily removed without complications.

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The purpose of this study was to evaluate the usefulness of sentinel lymph node biopsy (SLNB) with MRI-guided lymph node sampling (MLNS) in breast cancer. Between July 2000 and October 2001, consecutive 85 patients (87 cases of breast cancer) were treated with SLNB using a two-mapping procedure and MLNS. Of the 87 cases, seven cases received preoperative biopsy and four cases neoadjuvant chemotherapy. With SLNB, sentinel node (s) were detected in 86 cases (99%), but not in one case (1%). Positive node in the latter case was detected with MLNS. MLNS successfully pointed out another node positive case which was histologically identified as negative sentinel node by SLNB using a two-mapping procedure. Sentinel node (s) were detected in all seven patients received preoperative biopsy, and in three out of four patients received neoadjuvant chemotherapy. By this combination method of SLNB and MLNS, metastasis to the sentinel node (s) was found in 27 cases (31%), 13 cases of which had no metastasis in the non-sentinel nodes. In addition, 3 of the 13 cases had only micrometastases to the sentinel node. These results suggest that sentinel node is more accurately detected by the combination method of SLNB and MLNS.

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We treated 20 women with advanced breast cancer with weekly 1-hour paclitaxel infusion at 50mg/m² in 6 and 80mg/m² in 14. Median administration time was 10. Response was 50%, with 2 (10%) complete responses and 8 (40%) partial responses. Median time to progression was 14.5 weeks. No severe side effects or hypersensitivity reactions were seen. Response in patients with prior anthracycline or docetaxel treatment was almost the same as that without prior. We therefore concluded that weekly 1-hour paclitaxel infusion is more effective and less toxic than other treatment for advanced breast cancer.

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Using the classification for gastrointestinal injuries advocated by the Japan Traumatic Association, consecutive 115 lesions of 74 cases of traumatic injury of the small intestine treated at the hospital were subjected to a study, which might be the first analysis of multiple cases in Japan. The most common morphology of the injuries was type IIa, accounting for 39.1% (45 lesions). In an analysis of time from an injury to surgery, some patients with a type II injury had symptomatic exacerbations after 24 hours following the injury. It suggested that there might be a silent phase in type II small bowel injuries. Patients with a type III injury underwent surgery several days after the injury; and these injuries were thought to be delayed gastrointestinal injuries. Since some patients with type II and III are asymptomatic immediately after the injuries, clinical observation with time would be important in the treatment of those with a history of getting a bruise on the abdomen. It seems valuable to verify intraabdominal free air by imaging analysis on a wide window of high speed helical CT in the diagnosis. The most common complication was surgical wound infection. From the standpoint of prognosis, we have experienced no deaths due to small bowel injury alone and these patients' lives have been saved in a high rate.

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The aim of this study was to assess the clinical meaning of soluble E-selectin (sE-selectin) concentration in peripheral blood of 58 patients with colorectal cancer, in terms of its relationship to prognosis and immunohistochemically estimated tumor infiltrating lymphocytes. The 7-year disease-free survival and overall survival in the high sE-selectin group (≤30ng/ml) were significantly better than those in the low sE-selectin group (<30ng/ml); 87% and 87% vs. 55% and 61% in the high and low groups, respectively. The mean sE-selectin concentration became significantly higher (24, 29, and 38ng/ml at the grade 0, 1, and 2, respectively) and the prognosis was significantly better according to the grade of CD45RO+ lymphocytes infiltration. The sE-selectin concentration of high-grade infiltration group of CD4+ lymphocytes was significantly higher than the low grade group (36 vs. 23ng/ml). High grade infiltration group of CD8+ lymphocytes tended to show higher concentration of sE-selectin (35 vs. 25ng/ml) and had significantly better prognosis than low grade infiltration group; the 5-year survival rates were 85% and 62%, respectively. In conclusion, the preoperative serum sE-selectin concentration in peripheral blood might be a useful prognostic predictor of colorectal cancer in relation to the activation of anti-tumor immunity, especially memory T cells infiltration to the cancer nests. Further studies are needed to clarify the origin of soluble type E-selectin in peripheral blood and the mechanisms of the activation of antitumor immunity by E-selectin.

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We studied the clinicopathology of 6 patients with invasive pancreatic cancer who survived 5 or more years after resection (long-term survivors) compared to that of 48 patients who survived less than 5 years (mid-/short-term survivors). Long-term survivors had significantly smaller ts-factors (tumor size) and a lower stage than did mid-/short-term survivors. Seen histologically as classified by the General Rules for the Study of Pancreatic Cancer of the Japan Pancreas Society, long-term survivors showed significantly lower retroperitoneal invasion (rp-factor) than mid-/short-term survivors, but long-term survivors included 2 stage III and stage IVa each, 2 cur c, and 2 t3 cases, indicating that some patients with a high stage and intensive local invasion may survive long after resection. Among long-term survivors, 2 had one or two metastatic lymph nodes classified as group I, suggesting that they may survive longterm if given lymph node D1+α dissection. Preoperative serum CA19-9 in long-term survivors were significantly lower than in mid-/short-term survivors. In conclusion, clinicopathology was not a perfect indicator for long-term survival after pancreatic cancer resection, suggesting molecular biologic factors should be studied as prognostic predictors for pancreatic cancer.

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We report two cases whose bedsores were repidly cured with the administration of a high-dose n-3 fatty acid, zinc, and copper-supplemented low residue diet.
In the first case, whose bedsore was refractory in spite of adequate oral intake and careful local management, a low residue diet that included high doses of n-3 fatty acid, zinc, and copper and that complied with Japanese daily nutritional standards was administered instead of the conventional oral diet. In the second case, who was malnourished as a result of poor oral intake, the low residue diet was supplemented to meet the Japanese daily nutritional standards. After the change in nutritional management, protein synthesis and lipid metabolism improved significantly; consequently, the patients' bedsores healed completely after 8 and 10 weeks, respectively. These results suggest that not only local management, but high-quality nutritional management is essential for the treatment of refractory badsores.

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A premenopausal 49-year-old, woman, who noted a mass in her right breast, 7 years earlier was admitted when the tumor occupied her entire right breast. Fine-needle aspiration cytology showed no epithelial cells. Core needle biopsy showed proliferated fibrous connective tissue. We could not distinguish this tumor from a phylloides tumor so we conducted a simple mastectomy, the cut surface of the tumor was whitish, solid, homogeneous, cyst-free and about 15cm at its greatest diameter. Microscopically, the lesion consisted of collagenous stroma with markedly decreased or absent ductal and lobular elements, which we diagnosed as a fibrous tumor. The tumor was the largest among previously reported fibrous tumors.

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A 77-year-old woman was admitted to the hospital for close examination of a SMT-like lesion of the stomach found in a periodic check-up after a mastectomy for right breast cancer 13 years earlier. Thorough examinations detected multiple masses around the stomach, but we could not make a decisive diagnosis. In the diagnosis of these intraabdominal tumors, a laparotomy was performed and peritoneal dissemination, lymph nodes swelling around the stomach and lymph angitis carcinomatosa were seen. The origin was unknown, but to remove the masses as much as possible, a distal gastrectomy, an omentectomy and a partial transverse colectomy were performed. Pathological examination revealed that the breast cancer operated on for 13 years earlier metastasized to lymph nodes and the peritoneum. Low-dose FP regimen was given repeatedly as postoperative chemotherapy. Two years have past and the patient has been free from recurrence. We report this rare case which showed peritoneal dissemination and metastasis to the perigastric lymph nodes after a mastectomy for breast cancer, together with some bibliographical consideration.

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This paper deals with effective weekly paclitaxel + 5'-DFUR therapy for advanced breast cancer refractory to CAF and surgical therapy. A 37-year-old woman was admitted to the department because of right breast tumor with a vertebral tumor. Histological examination revealed breast cancer with bone metastasis. Modified radical mastectomy after 3 courses of CAF therapy was performed. One course of CAF therapy was added after the operation, but a tumor marker continued to increase. The weekly paclitaxel + 5'-DFUR therapy was therefore initiated. After this chemotherapeutic regimen, a marked decrease of tumor marker was observed. No major adverse reactions to this chemotherapy were observed, and good patient's QOL was achieved. Based on these findings, this chemotherapeutic regimen appears to be a new effective treatment for advanced breast cancer.

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This paper reports a case of a 45-year-old woman who had undergone a left mastectomy for left breast cancer of stage II in 1985 and developed an ipsilateral chest wall recurrent tumor 13 years and contralateral axillary metastasis 14 years after the mastectomy.
In the treatment of the left chest wall recurrence, after a partial response to the recurrence was obtained with radiation therapy, a resection of the lesion and a repair of the chest wall were performed. Next year, contralateral axillary lymph nodes were found to be swelling. No primary lesion was detected at the right mammary gland. These swollen lymph nodes were considered as metastasis of the left breast cancer and surgically excised. Histologically it was comprized of adenocarcinoma.
This case is presented together with some bibliographical comments of late recurrence cases of breast cancer reported from 1989 to 1999 in terms of modes of recurrence.

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We present 3 cases of metastatic breast cancer, who developed cardiac tamponade due to malignant pericardial effusion, which was managed successfully to get a good survival for each case. Malignant pericardial effusion is one of the few oncologic emergencies, resulting in cardiovascular collapse and sudden death if not recognized and treated promptly. The incidence of clinically symptomatic malignant pericardial effusion is reported to be 2% in metastatic breast cancer. Because its symptoms and signs and its radiographic signs are not specific, it is difficult to differentiate malignant pericardial effusion from malignant lymphangitis or malignant pleural effusion, without the most sensitive ultrasound imaging. Pericardiocentesis should be conducted as soon as possible for immediate relief and to avoid death. Fluid reaccumulation is usually controlled by sclerosis of the pericardial sac with some agents.Concomitant with local therapy, systemic chemotherapy is considered in patients who are candidates.

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We report a 54-year-old woman with a duplication cyst that was thoracoscopically resected. The patient was seen at the department of internal medicine in our hospital because of a dry cough. She was diagnosed as having a congenital diaphragmatic cyst adjacent to the esophageal muscular layer and situating between the right pulmonary vein and right main bronchus on CT, magnetic resonance imaging and ultrasonic endoscopy. Malignant change of congenital diaphragmatic cyst is rarely reported, but it can cause compression symptom or presentation to lung, esophagus or mediastinum. Even the silent cyst is thus indicated surgery. For that reason, the cyst thoracoscopically removed in this case. The removed cyst was adjacent to the esophageal wall and adherent to the right pulmonary vein, right main bronchus, and pericardium as diagnosed before surgery. Although there is an opinion a small thoracotomy should be made at the same time of VATS or conversion to an usual thoracotomy is advocated, a safe removal of the cyst could be achieved by aspiration, blunt dissection using bipolar forceps and cautery knife in this case. The cyst was histopathologically diagnosed as duplication cyst. The patient was discharged on 8th postoperative day and was free from recurrent at the 7-month follow-up examination.

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A man who had previously undergone an esophagectomy for squamous cell carcinoma and total gasterectomy for adenocarcinoma of the cardia of the stomach had had his esophagus replaced with a colon graft. He had undergone 25 bougie treatments for repeated benign strictures of the reconstructed esophagus. After that, benign stricture was treated with a self-expanding metal stent. Five months later the lower part of the stent eroded though the esophagus into the trachea and left main bronchus, forming tracheoesophageal and bronchoesophageal fistulas.
A second self-expanding metal stent was placed to cover the fistulas. Two weeks later the whole collection of stents eroded through the esophagus into the trachea. The membranous portion of the thoacic trachea was completely destroyed by the metal stent in the reconstructed esophagus, forming a giant 13cm fistula. He developed severe thoracic empyema and aspiration pneumonia, necessitating surgery for the tracheoesophageal fistula. The 2 stents and eroded esophagus (colon graft) were resected. The tracheoesophageal fistula was repaired with a free graft of the left fascia lata and the right latisumus dorsi muscle flap. Patch repair with fascia lata and reinforcement with the latisumus dorsi muscle flap were successful. A temporry esophagostomy for proximal esophagus and jejunostomy were made.

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We report a case of simultaneous multiple distant metastasis to the bilateral lungs, bone and brain, occurred 7.5 years after a radical operation for Stage I lung cancer.
A 63-year-old man, who had undergone a left upper lobectomy and lymph nodes resection for primary lung adenocarcinoma 7.5 years earlier was referred to the hospital because of his right back pain. He was pointed out a hot spot at his rib, small nodules in his brain, and multiple small nodules in his bilateral lungs. He underwent a VATS biopsy for diagnostic intention. It revealed multiple distant metastasis to the bilateral lungs, bone and brain occurring 7 and half years after surgery for left lung adenocarcinoma. Despite chemotherapy and γ-knife therapy, he died on December 23, 2001.
Stage I non-small cell lung cancer rarely recurs after elapsing for over 5 years, but we should keep such late metastasis in mind not to overlook signs of recurrence.

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A 76-year-old man was transferred to the hospital after a traffic accident. He was diagnosed as having traumatic diaphragmatic hernia by magnetic resonance imaging (MRI) scan. MRI revealed that the stomach had been transported into the thoracic cavity.
Via the laparoscopic approach, the stomach and greater omentum reposed in the abdominal cavity and the ruptured diaphragm was sutured directly. The day after the operation, the patient could start oral intake and walking on.
Laparoscopic approach is minimally invasive and useful for the observation of the injured organs not only in the abdominal cavity but also in the thoracic cavity. Moreover the conversion to laparotomy is easier in the laparoscopic approach than thoracoscopic approach. It is supposed that the laparoscopic surgery may be beneficial and minimally invasive for traumatic diaphragmatic hernia.

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A rare case of early esophageal cancer associated with polymyositis is presented. A 73-year-old man was referred to the hospital because of bilateral edema and arthralgia of the hands in October 2000. The patient was diagnosed with polymyositis by: musle weakness of the extremities; elevated levels of creative kinase, transaminase, LDH, aldolase and myoglobin on blood chemistry; electromyogram; and muscle biopsy. Endoscopic examination to screen for possible malignancy disclosed squamous cell carcinoma in the lower thoracic esophagus. Elevated levels of creatine kinase, transaminase, LDH, aldolase and myoglobin were normalized and muscle weakness resolved following treatment with 50mg/day of prednisolone. Partial esophagectomy was performed with gastric reconstruction via a posteriormediastinal approach. Macroscopically a 0-IIc type tumor measuring 1.2 ×1.5cm was observed in the lower thoracic esophagus. Pathological examination of the resected specimen revealed well differentiated squamous cell carcinoma, ly ₀ , v ₀ , INFβ, ow(-), aw(-), pT1b, pN0, pM0 and pStage I. As of 10 months after the resection of the esophageal cancer, polymyositis remains relieved and no recurrence of cancerhas occurred.

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A 62-year-old woman admitted for dysphasia was found in esophagography and esophagoscopy to have a pedunculated polypoid tumor 30cm from an incisor. Biopsy revealed carcinosarcoma, necessitating subtotal esophagectomy with 3-field lymphadenectomy. On gross appearance, the tumor showed an unclassifiable appearance, type 5s. It consisted of 2 types of malignant lesion bordered by a transient zone histologically. One lesion was sarcoma stained immunohistochemically with HHF 35, vimentin, and a-smooth muscle actin, and the other squamous cell carcinoma positive to type 1 cytokeratin. Based on this evidence, we concluded this tumor to be so-called carcinosarcoma. Histologically, paratracheal and posterior mediastinal lymphnodes included malignant cells and adjuvant chemotherapy (5-FU and CDDP) was conducted following surgical exploration. One year later, a metastatic lesion was recognized in the lateral segment of the liver in computed tomography. A transhepatic arterial injection of CDDP 50mg on day 1 and intravenous infusion of 5-FU 1, 000mg on days 1 to 5 was repeated 3 times in 6 months because surgery would injure the reconstructed gastric tube. The metastatic lesion disappeared completely after chemotherapy. Multiple recurrent lesions appeared in the liver 12 months later after the complete response, eventually leading to her death of cancer. Few reports have been made on chemotherapy for such liver metastasis.
Guidelines of the Japanese Society for Esophageal Diseases

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A 54-year-old man accidentally swallowed a spoon while attempting to clear his throat following nausea after a meal. Since abdominal plain radiography showed a spoon in the stomach, he was admittedas an emergency patient. Abdominal plain radiography the following day showed that the tip of the spoon had advanced to the duodenal bulbs, but remained in the stomach, necessitating upper gastrointestinal endoscopy. Endoscopy showed that the tip of the spoon had advanced through the pyloric ring into the duodenal bulbs, and that its handle was sinking into the wall of the lower part of the greater curvature of the stomach. Using snare forceps for polypectomy, we pulled out the spoon while the spoon handle was kept in an overtube. The spoon was found to be a tablespoon 18.5cm long and 4.0cm wide. Endoscopic removal is the firstchoice of treatment for foreign bodies in the stomach, and laparotomy is commonly used for long foreign bodies. In so far as we know, only 2 cases, including ours, were reported in the literature of endoscopic removal of gastric foreign bodies over 18cm long.

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The significance of hepatic resection in liver metastasis from gastric cancer remains unclear. We reported two cases of liver metastasis from gastric cancer successfully treated by hepatectomy withdisease-free survival, and discussed whether surgical removal was effective treatment. Case 1: A 72-year-old man underwent distal gastrectomy for gastric cancer located at the antrum of the stomach (tub2, SM, ly2, v0, N2). Six months later, liver metastasis arose at S3 segment, and then treated by S3 sub-segmentectomy. The patient remains well and no sign of recurrence is evident at 36 months after hepatectomy. Case 2: A 65-year-old man underwent distal gastrectomy for gastric cancer located at the lower body of the stomach (pap-tub, SS, ly1, v0, N2). 18 months later, liver metastasis arose at S5 segment, and then treated by S5 sub-segmentectomy. The patient remains well and no sign of recurrence is evident at 62 months after hepatectomy. The number and chronology of liver metastasis among these two disease-free survivors were single and metachronous, and they had broad tumor-free margins (>10mm).
We concluded that liver metastasis from gastric cancer without other metastatic lesions should be indicated for hepatectomy, and that surgical removal should be recommended especially for single and metachronous cases.

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A 67-year-old man was seen at the hospital because of sudden epigastralgia and a sense of abdominal dropsy, and was followed by administering analgesics since February 1999. In November 1999, epigastralgia and an intestinal atresia symptom appeared, and the patient was admitted to the hospital. The patient was diagnosed as having small bowel volvulus because an abdominal computed tomography demonstrated whirl sign and an abdominal angiography demonstrated baber pole sign, and he underwent surgery. At surgery, the jejunum was twisted around the superior mesenteric artery counterclockwise by 180, °and the mesentery caused inflammatory adhesion with the vermiform appendix. Because no necrotic bowel was recognized, a reduction of the volvulus and an appendectomy were performed.
We report the case of secondary small bowel volvulus which followed chronic coarse and accompanied with premonitory symptoms for about 8 months, together with some bibliographical comscents.

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D-lactic acidosis is an extremely rare complication after massive small bowel resection in childhood. The authors present here such a case. A male infant was born with 40 weeks gestation and 2, 574g of body weight. After birth, he was diagnosed as having congenital ileal atresia. An ileocolostomy was carried out because the atresia was very near the ileocecal valve and huge dilatation of the ileum. Finally, the length of remaining small intestine was 75cm. After the operation, he suffered from occasional diarreas and growth difficulty.
At the age of 4 months, he was admitted to the hospital because of tachypnea of unknown causes. Although he was diagnosed as having cryptogenic metabolic acidosis, he was discharged soon because it disappeared spontaneously. Two weeks later, he was readmitted because of more severe acidosis. A possibility of metabolic acidosis caused by chronic diarrhea and lack of vitamine Bl were ruled out. Levels of L-lactate was within normal limit. Levels of D-lactate was not measured because of technical difficulties. He was definitely diagnosed as having D-lactic acidosis, because his stool cultures revealed abnormal distributions of bacterial flora which were mostly occupied by Lactobacillus frementum. Sodium bicarbonate was given per os for 3 months. After taking the therapy of sodium bicarbonate, noepisodes of acidosis occurred, and stool culture revealed normal bacterial flora.

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Adult onset reversed rotation of the bowel is extremely rare. We report here an adult case of reversed rotation causing acute intestinal obstruction. A 36-year-old man was admitted to a private clinic because of vomiting, diarrhea, and abdominal pain. These symptoms persisted for two days and an abdominal X-ray film revealed gas shadow of the dilated intestine with niveau sign. He was diagnosed as having intestinal obstruction and transferred to the hospital. A barium enema study showed a bird beak sign with obstruction of the ascending colon. He underwent an emergency laparotomy and was given a diagnosis of axis rotation of the colon. Operative findings revealed a reversed rotation of the bowel. The cecum was unfixed and twisted to cause the intestinal obstruction. After releasing the rotation, a cecopexcy to the parietal peritoneum and an appendectomy were performed, but no colonic resection was reguired because there was no vascular disturbance.

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We herein present a case of Crohn's disease who underwent several operations for recurrent massive bleeding. A 30-year-old woman who had undergone a laparoscopic partial colectomy and strictureplasty in 1998, was admitted to the hospital because of fever, nausea and diarrhea on May 5, 2001. Massive anal bleeding occurred on May 8. Emergency angiography was conducted and an arterial bleeding point was identified. Ileo-cecal resection involving the bleeding point was performed. Re-operation was conducted on suspicion of anastomotic leakage on the first day after the first operation. Massive blood was detected in the small intestine and the bleeding point was revealed on the 10cm proximal from the anastomosis. An additional 15cm segment was resected at this point. About one month later, she was operated on for recurrent severe anal bleeding but the bleedig point was not identified.
Twenty-five cm segment of the terminal illeum involving successive active ulcer and 10cm length of ascending colon were resected at this operation.

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We report a case extraluminally growing cancer of the jejunum with intraabdominal abscess formation.
A 62-year-old woman with previous history of undergoing a laparotomy for acute pancreatitis 45 years earlier was referred to the hospital because of close examination of anemia and low proteinemia. These conditions were pointed out when she visited a clinic complaining of general fatigue. A tumor was palpated in the left upper quadrant of abdomen on admission. Abdominal CT scan showed a large cystic mass with intra-luminal gas between the stomach and pancreas, and multiple liver metastases. Intestinal fluoroscopy and fiberscopy confirmed the diagnosis of jejunal adenocarcinoma with abscess formation around the tumor. The patient was operated on. We report the case of intestinal cancer showing such arare morphology as to form an intraabdominal abscess.

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We report a case of malignant schwannoma of the small intestine in a 76-year-old man with von Recklinghausen's disease. When he had been 63-year-old, he had undergone an emergency laparotomy for melena. At that operation, bleeding from a protruding tumor into the jejunal cavity had been found, and the jejunum including this tumor had been resected partially. Histological examination had indicated the diagnosis of schwannoma, in which the possibility of malignancy could not be ruled out. He had been doing well for 13 years. When he became 76-year-old, he was admitted to the hospital because of melena again. Abdominal CT scan showed a 10.5×9cm tumor in the lower abdominal cavity. A tumorectomy was performed under a preoperative diagnosis of bleeding from a solid tumor invoving the small intestine, which was highly suspected of malignant change of schwannoma. Histological diagnosis was nonepithelial malignant tumor. We definitely diagnosed the case as malignant schwannoma from his clinical course. He was discharged from the hospital, but died of abdominal local recurrence 4 months after the second operation.

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A 61-year-old man was seen at the hospital because of right upper abdominal pain and appetite loss lasting for one week. Computed tomography of the abdomen showed portal venous gas, thrombus in the right portal vein and abscess along the superior mesenteric artery (SMA). He had conservative therapy, because the origin of the abscess was obscure and he did not have rebound tenderness on the abdomen. Operation was conducted for recurred inflammation on day 24 after admission. Operative findings showed that retroperitoneal abscess along the SMA was resulted from perforation of gangrenous acute appendicitis. Therefore, an incision and a drainage for the abscess and an appendectomy were performed. With cultivation of pus collected during the operation, a Bacteroides was detected. Enphysematous cholecystitis occurred on day 19 after the operation, and was treated by percutaneous gallbladder drainage. He was discharged on day 45 after the operation. This is the second case of portal venous gas due to perforated acute appendicitis reported in the Japanese literature.

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Disorders of the large and small intestines after pelvic irradiation are classified into early and late complications. Common late complications are stricture and perforation. Some cases with such complications are indicated for surgical therapy. Moreover, it is suggested that radiation induced cancer can occur in patients surviving more than 5 years after radiotherapy. Patient 1, a 78-year-old woman, had been treated by surgery and pelvic irradiation for uterine cancer 20 years earlier. She had been suffered from constipation for a long time after the treatment. This time, examinations revealed a whole-circumference stricture and cancer of the sigmoid colon. Sigmoidectomy was performed. Pathological diagnosis was carcinoma in radiation colitis. Patient 2, a 73-year-old woman, had been treated by surgery and pelvic irradiation for uterine cancer 15 years earlier. This time, she admitted to the hospital because of intestinal bleeding. Angiography showed hemorrhage in the ileum. Arterial injection of vasopressin succeeded in hemostasis. However, the procedure caused marked stricture of the sigmoid colon unexpectedly. A sigmoidectomy and a partial resection of the ileum were performed. Pathological diagnosis was radiation colitis and ileitis without malignant findings. Patients with long interval after pelvic irradiation must be carefully followed from the standpoint of late complications and cancer.

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A 37-year-old man with bleeding at evacuation and fever who visited a local clinic and was referred to us was found in colonofiberscopy to have a type 2 tumor of the sigmoid colon. Biopsy specimens showed atypical spindle cell infiltration. Direct ileal imaging from the sigmoid colon by barium enema showed a coloileal fistula. Computed tomography (CT) findings suggested infiltration of the sigmoid colon tumor into the bladder. Based on a diagnosis of extensively infiltrating malignant tumor of the sigmoid colon, we conducted sigmoidectomy and partial ileocystectomy. Histopathological findings indicated hyperplasia of spindle cells accompanied by large irregular nuclei and multinucleated giant cells but no definite adenocarcinoma component or metastasis to the lymph nodes. Immunostaining was negative for smooth muscle actin, c-kit and CD34 but positive for cytokeratin, leading to a diagnosis of sarcomatoid carcinoma. Transitional epithelial carcinoma within the mucosal membrane and nearby infiltration of spindle cells were noted in the extracted bladder.

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This paper deals with a case of perforation of the lower rectum (Rb), which is a rare entity, in an elderly. An 81-year-old woman was admitted to the hospital because of abdominal pain. Abdominal CT scan revealed effusion surrounding the rectum and air fluid level. Emergency barium enema visualized parenteral outpouring of a contrast material from the lower rectum. With a diagnosis of rectal perforation, an emergency laparotomy was performed on the same day and perforation of the lower rectum and its surrounding abscess formation were confirmed. No apparent tumorous nor ulcerative lesions were observed at the perforation. A Hartmann operation was performed. The postoperative course was uneventful. Histopathological study also revealed no characteristic findings. Idiopathic rectal perforation was diagnosed.

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A 57-year-old man who had undergone a total gastrectomy, a right hemicolectomy and a partial sigmoidectomy for advanced gastric cancer, advanced cecal cancer and early sigmoid colon cancer six years earlier, was admitted to the hospital because a rectosigmoid lesion was detected by colonofiberscopic examination for postoperative cancer surveillance. Dye spraying colonofiberscopic findings showed a flat elevated lesion with a central depression, 20mm in diameter. On magnifying colonofiberscopic observation, we recognized a type III_L pit pattern in the outer portion, and an irregular pit pattern which was judged to be a type V pit pattern in the inner part. This lesion was diagnosed as a nongranular type of laterally spreading tumor with submucosal invasion. A high anterior resection of the rectum with lymph node dissection of the second group was performed. Histopathological findings showed well differentiated tubular adenocarcinoma, m, ly₀, v₀, with high grade dysplastic tubulovillous adenoma in the outer portion. The expression of p53 protein showed diffuse stain both regions of cancer and adenoma. Analysis of microsatellite instability revealed that all lesions were of microsatellite stability including previously resected three cancer lesions.

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A 59-year-old man, who had undergone a sigmoidectomy for cancer of the sigmoid colon in 1993 and had no recurrence until February 2001, was found having a round tumor near the anastomosis on colonoscopy. Under a diagnosis of submucosal tumor or recurrence of colonic cancer, an operation was performed on March 29. A spherical and hard mass 2cm in diameter near the anastomosis was found. A partial colectomy including the tumor was performed. The tumor was submucosal cyst in which benign colonic mucosa lined the lumen of the cyst. The cyst was composed of concentrated mucus and barium. These features were compatible with those of implantation cyst.
Implantation cyst is rare, especially at the anastomosis in the previous operation and only two cases including this case have been reported in Japan.

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A 49-year-old woman was admitted to the hospital because of prolapse of a tumor through the anus with bleeding at defecation. Physical examinations revealed that a pedunculated tumor, 4cm in diameter, prolapsed through the anus. Scout abdominal films showed gas in the rectum outlined the intussuscepted large intestine. The sigmoid tumor with intussusception prolapsing through the anus was diagnosed. Transanal local excision aiming at a total biopsy and repositioning of the intussusception was performed. Intraoperative frozen section diagnosis was adenocarcinoma. A sigmoidectomy with lymph node dissection was added after the operation. The pathological diagnosis was Ip type well differentiated adenocarcinoma with the invasion depth of m. This unusual case of sigmoid cancer with intussusception prolapsing through the anus which is the 38th case in Japan, is presented.

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A 78-year-old man with prominent anemia was admitted to the hospital for further investigation of apositive reaction test for occult blood. A colonoscopy revealed middle rectal carcinoma. Since the patient also had ileus as a result of a rectal obstruction caused by the carcinoma, an ileus tube was transanally inserted to decompress the intestine. Lavage of the colon via the decompression tube was conducted every day. Fever and peritoneal signs localized in the median lower abdomen appeared on the 10th day after insertion, but no aggravation of the subjective and objective symptoms was noted. The patient was observed, and an elective surgery was performed on the 13th day after the insertion of the tube. During the laparotomy, penetration into the anterior abdominal wall was observed in the region of the rectum proximal to the tumor, possibly caused by the compression at the end of the ileus tube.
Per anal decompression tube is considered to be very useful, although some complications associated with the use of the tube have been reported. Careful observation of abdominal symptoms are thus important to ensure that potential complications are quickly recognized.

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A 77-year-old woman was seen at the hospital because of anal pain and induration. She had been pointed out a fistula-in-ano at elsewhere, but she let it alone for about 6 years. When a resection of the fistula was performed under lumber anesthesia, we found mucoid tissue in the fistula. The frozen histological findings indicated that it was mucinous carcinoma, and so further operation was needed. Abdominoperineal resection of the rectum with D21 ymphadenectomy was performed. Histologically Paget's cells were seen in the edge of the skin resected. After a mapping was made at the department of dermatology, a curative resection of the skin with fat tissue under the skin was performed. No signs of recurrence have been detected for 19 months since the third operation.
Particular attention should be paid to probable association of malignancy in the treatment of fistulain-ano with chronic inflammation. Mapping is very beneficial to assess the spread of perianal Paget's disease.

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We present a case of liver cell adenoma (LCA) difficult to differentiate from focal nodular hyperplasia. A 22-year-old woman admitted for an abdominal tumor was found in blood analysis to have negative markers for hepatitis viruses. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a 8cm mass in the lateral lobe of the liver, well enhanced and having a central scar. Hepatic angiography showed a hypervascular lesion in the left lobe of the liver, necessitating hepatectomy. On the cut surface, fibrous scar tissue was found in the toumor center, so the tumor was diagnosed as focal nodular hyperplasia (FNH) rather than LCA. Microscopically, the rumor consisted of cords l or 2 cells thick of hepatocytes with mild atypia and no bile duct in the tumor. The final pathological diagnosis was LCA. LCA is difficult to differentiate from FNH and highly differentiated HCC. The disease is a relatively rare benign tumor of the liver in Japan, which is why we report it together with a review of the literature.

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Benign bile duct strictures occurring in 3% to 5% of patients after major hepatic resection are difficult to treat. We report a case of bile duct stricture after right hepatectomy treated with an expandable metallic stent. A 69-year-old man underwent right hepatectomy for hepatocellular carcinoma. Twelve months after hepatectomy, obstructive jaundice appeared and bile duct stricuture was pointed out. From abdominal computed tomography, endoscopic retrograde cholangiography and perctaneous transheic biliary drainage indicated the stricture was probably due toliver rotation associated with hepatic regeneration. The stricture was dilated with a biliary balloon dilator and a plastic stent tube was placed through the stricture for six months. When the stent tube was removed, obstructive jaundice re-appeared. An expandable metallic stent was then used to dilate the stricture, with no recurrence of obstructive j aundice or cholangitis in the ensuing fifteen months suggesting that dilation using an expandable metallic stent is useful in treating benign strictures after hepatectomy.

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A 70-year-old man was admitted to the hospital because of severe epigastralgia. On admission, he had a sign of panperitonitis. Abdominal computed tomography and ultrasonography showed a small fluid collection around the gallbladder and right subphrenic space. Neither gallstones nor free air were observed. Emergency laparoscopy to identify the origin of the panperitonitis revealed biliary fluid from the gallbladder. Since the perforation of the gallbladder was confirmed, an emergency laparoscopy was developed to perform a cholecystectomy without having open surgery. This case was diagnosed as spontaneous perforation of the gallbladder because of the absence of gallstones in the resected specimen and a negative result in a bacterial culture of the biliary ascites. Spontaneous perforation of the gallbladder is a rare entity and is diagnosed only after open surgery in most cases. This case demonstrated the usefulness of laparoscopy for spontaneous perforation of the gallbladder that served both diagnostically and therapeutically.

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A 63-year-old man admitted for surgery for emphysematous cholecystitis with pneumobilia mainly reported chills and shivering. Abdominal X-ray showed gas in the upper right abdomen near the gallbladder. Computed tomography showed gallstones and extensive gas in the gallbladder and intrahepatic bile duct. Under a diagnosis of emphysematous cholecystitis with cholangitis, we conducted endoscopic nasobiliary drainage (ENBD) and administered antibiotics immediately upon admission. After his general condition improved, we conducted elective cholecystectomy, choledocolithotomy, and T-tube drainage 4 days after ENBD. The postoperative course was uneventful and he was discharged on postoperative day 31. Emphysematous cholecystitis with cholangitis is generally treated by emergency surgery, which, however, involves risks. In this case, elective surgery could be done after ENBD, avoiding emergency surgery.

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A 69-year-old woman complaining of vomiting and disturbance of consciousness was diagnosed as having diabetic coma based on prominent hyperglycemia at another hospital. Since necrosis of the left inferior limb progressed, an amputation of the left inferior limb was performed. Antidiabetic therapy was maintained after the operation, however, vomiting persisted and the patient could not eat. Abdominal plain X-ray film revealed a circular calcification in the right upper quadrant of abdomen and pneumobilia in the biliary tract. Gastroduodenal fluoroscopy and an abdominal CT scan visualized stones in the stomach and duodenal bulb. Gastroendoscopic study revealed stones impacted into the duodenal bulb. An operation was performed with a diagnosis of gallstone ileus and cholecystoduodenal fistula, and the body of gallbladder was found to penetrate to the anterior wall of the gastric pylorus. The gallstone was present in the stomach, was as large as 5×5×10cm in size and 130g in weight, and was impacted into the pyloric ring. The gallstone was the largest among all stones as far as we could review. Lithotripsy, cholecystectomy, and closure of the fistula were simultaneously performed.
Gastric outlet obstruction caused by a gallstone (Bouveret's syndrome) is a rare entitiy. This paper deals with this case of gallstone ileus caused by impacted gallstone in the gastric pylorus that occurred when it passed through the cholecystogastric fistula, together with a review of the literature.

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We report a case of synchronous double cancer, early gallbladder cancer and bile duct cancer, which is very rare. A 78-year-old man was seen at the department of internal medicine in our hospital because of epigastralgia. Abdominal CT scan visualized thickening of the gallbladder wall from the neck to body. And the common bile duct dilated to 18mm in diameter, but there were no stones. No pancreatic tumor nor lymph node swelling was also present. Endoscopic retrograde cholangio pancreatography revealed the dilated common bile duct and a filling defect 14mm in diameter in the common hepatic duct. EUS showed a localized thickening of epithelium of the gallbladder. A diagnosis of gallbladder and common hepatic duct tumors was made, and the patient was referred to the department. Under the diagnosis, a laparotomy was performed. Although gallbladder tumor was obscure, a nodular lesion 10mm in diameter was present in the common hepatic duct and it was diagnosed as bile duct cancer. A resection of the extrahepatic bile duct and an anastomosis of the common hepatic duct to jejunum were performed. Histopathological diagnosis was upper bile duct cancer and gallbladder cancer with tumor invasion of mucosa, without lymph nodes metastasis and vascular infiltration.

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Pancreas divisum is a relatively rare entity. It has clinically received attention in connection with chronic pancreatitis, but there have been few reports on the disease associated with pancreatic cancer. This paper deals with a case of pancreas divisum associated with cancer of the dorsal pancreas. The patient was a 75-year-old woman. There were previous histories of undergoing a right hemicolectomy for transverse colon cancer 8 years and undergoing a polypectomy for sigmoid colon cancer 4 years before admission. During observation after the second operation, an abnormally high level of CEA and a weight loss of about 4kg for 2 years were noted. Abdominal CT scan revealed a tumor of the pancreatic tail, and the patient was referred to the department. Endoscopic retrograde pancreatography (ERP) via the main papilla visualized only ventral pancreatic duct as horse's tail appearance. ERP via accessory papilla revealed discontinuity of the pancreatic duct at the pancreatic tail, but no abnormalities were found in the pancreatic duct at the pancreatic head and body. From these findings, pancreatic tail cancer arising in the dorsal pancreas in pancreas divisum was diagnosed and an excision of the pancreatic body and tail with an associated resection of the spleen was performed.
So far 34 cases of pancreas divisum with pancreatic cancer including our case have been reported in Japan. Of the 34 cases, 32 cases were of dorsal pancreatic cancer. It is one of characteristics that the disease was not prone to cause obstructive jaundice.

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A 71-year-old woman was diagnosed as suffering from acute pancreatitis because of epigastric pain and an elevation of serum amylase level. Symptomatic remission was attained by conservative therapy, however, dilation of the main pancreatic duct was found still remained on an abdominal a ultrasonography and computed tomography. Endoscopic retrograde cholangiopancreatography revealed a stenosis of the main pancreatic duct and a tapering obstruction of the first branch just upstream of the stenotic main pancreatic duct. Endoscopic ultrasonography showed a low echoic mass with high echoic spots inside. Pylorus-preserving pancreatoduodenectomy with regional lymph node dissection was performed. Histologically, localized fibrosis accompanied with atrophied pancreatic parenchyma and dilated pancreatic branches was found. Micropapillary adenocarcinoma within the mucosa was found in the stenotic portions of the main pancreatic duct and its branch. This case was classified into stage I. Carcinoma in situ of the pancreas is defined as the cancer that is confined to within the mucosa of the pancreatic duct which is flat, if present, or micropapillary. Reports of pure carcinoma in situ without infiltrating components are very few. We report a case of carcinoma in situ of the pancreas presenting with acute pancreatitis.

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Tuberculous abscess of the spleen is an extremely rare disease and there have been about ten reported cases in Japan. We recently treated a patient with splenic tuberculous abscess by a laparoscopic splenectomy. A 27-year-old woman undergone a spinal curettage and fusion for spinal caries about 3 years earlier had an abscess formation in the spleen. The antituberuculous therapy for 2 years was ineffective for the spleen abscess, and the patient was admitted to the hospital. Computed tomography of the abdomen revealed a non-enhanced and cystic mass in the spleen. Magnetic resonance imaging showed a hypointence mass in the spleen on T1 and T2-weighted spin echo images. For diagnosis and therapy of the splenic mass which was suggestive of mycosis, tuberculoma, or solid tumor, we performed a laparoscopic splenectomy. On the cross section of the extirpated spleen, an encapsulated abscess formation containing caseous material was found. Pathological findings, epithelioid granuloma, and PCR for tuberculosis confirmed the diagnosis of tuberculous splenic abscess.

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A case of localized peritoneal malignant mesothelioma which was resectable is reported. A 76-year-old woman was admitted to the hospital because of an abdominal tumor. Tentative diagnosis of gastrointestinal stromal tumor originated from the transverse colon was made and laparotomy was performed. The tumor was originated from the mesentery of transverse colon, involving the right colonic and ileo-colonic arteries. The tumor did not directly invaded the surrounding organs. Right hemicolectomy was performed. Histologically, the tumor consisted of round and polygonal cells displaying a solid and epithelial-like growth pattern. Rounded tumor cells with deeply eosinophilic, glassy cytoplasm, suggestive of rhabdoid cells, were found. Immunohistochemically, the tumor cells showed staining for calretinin and cytokeratin (CAM5.2). The cytoplasm of the rhabdoid cells was strongly stained with desmin. The existence of rhabdoid cells has been mentioned in various tumors and thought as a predicting factor of poor prognosis. A careful follow up keeping in mind entertaining the aggressive malignancy of rhabdoid cells is needed in this case.

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We report a case of retroperitoneal dedifferentiated liposarcoma. An 80-year-old woman admitted for left upper abdominal pain and a mass diagnosed as a pancreatic tumor and retroperitoneal abscess was found on admission to have a tumor 20×15cm palpable in the left abdomen. Abdominal computed tomography showed 2 retroperitoneal lesions, 1 having a slightly low-density area continuous with pancreatic body-tail and I having a low-density area located caudally with both areas enhanced irregularly. Based on preoperative diagnosis of pancreatic tumor and retroperitoneal tumor, we surgically resected the retroperitoneal tumor with the pancreatic body and tail. Resected specimens consisted of 3 different tumors that, in pathology, were (1) well-differentiated liposarcoma (lipoma-like), (2) myxoid malignant fibrous histiocytoma (MFH) and (3) pleomorphic MFH. The diagnosis was dedifferentiated liposarcoma with 2 MFHs dedifferentiated, originating from lipoma-like liposarcoma. We had difficulty in diagnosis because the dedifferentiated parts, such as MFH, occupied most of the tumor.

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A 61-year-old woman, who had repeatedly admitted to the department of internal medicine in our hospital for ascites retention and hepatic encephalopathy due to non-B and non-C hepatic cirrhosis since March 1999, was seen at our department because of a painful tumor at the umbilical region on January 25 2001. Incarcerated umbilical hernia was diagnosed and a manual repair was immediately performed. Thereafter incarcerated hernia was repeated four times and the patient was admitted to the hospital. After control of ascites in the internal department, an operation under local anesthesia with 1% lidocaine was performed on April 6 2001. A 10cm longitudinal median incision was made on the abdomen centering the navel; and after subcutaneous tissue was dissected, a hernia opening was exposed. The hernia opening was closed by using PROLENE Hernia System^®, size M. A total amount of 1% lidocaine was 40ml. The postoperative course was uneventful and the patient was discharged from the hospital on the 6th postoperative day. There have been no signs of recurrence, as of December 2001.

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We performed repairs of femoral hernias using PROLENE Hernia System^® with partial resection of small intestine through the inguinal operative scar to three patients. The male-to-female ratio was 1:2. A mean age of them was 74 years. The all patients were diagnosed as having strangulated femoral hernia by abdominal CT. The posterior inguinal floor was opened to find strangulated femoral hernia under general anesthesia. Femoral ring was excised to remove incarceration of small intestine and partial excision of the small intestine was performed via the inguinal region. Repairs of femoral hernias using PHS combined with closure of femoral ring by onlay patch were performed via the inguinal region. One L size and two extra L size of PHS were used. As for postoperative complications, all patients have not experienced severe complication and recurrence.

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We report a case of huge presacral epidermal cyst in an adult. An 80-year-old woman was admitted to the hospital for the treatment of a presacral mass. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a presacral cystic tumor located between the retrorectal and presacral space, which measured 30cm×18cm×15cm in size. The cystic tumor was removed by the transsacral approach. The tumor was diagnosed as epidermal cyst, because no dermal appendages or teratomatous elements were seen.

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We successfully treated a case of bilateral deep femoral aneurysms, which are very rare among peripheral aneurysms, by ligations of the bilateral deep femoral arteries. He is doing well postoperatively. It is difficult to diagnose this rare disease before symptoms are manifested, because of its anatomical position. An early operation is mandatory because of a rapid growth and a high risk of rupture. The paper presents this rare case with a review of the literature.

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