To investigate risks of antithrombotic therapy in general surgery, 178 consecutive patients who underwent general surgery from 1998 to 2000 were divided into two groups; the patients who maintained on antithrombotic therapy perioperatively, according to our regimen (n=76) and those who did not (n=102). Both patient groups were compaired for intraoperative blood loss, operation time, postoperative hospital stay, especially for bleeding-related complications. Antithrombotic therapy throughout the perioperative period did not influence the amount of bleeding, operation time, and postoperative hospital stay. It caused only few bleeding complications without increasing the risk of thromboembolism. We conclude that it is possible and desirable to continue anticoaguration and antiplatelet therapy under proper regimen in the case of general surgery.

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To elucidate the incidence and risk factors of distant metastases from thyroid follicular carcinoma, we prospectively examined chest computed tomography (CT) and bone scintigraphy in 21 patients diagnosed as having thyroid follicular carcinoma by histologic examination postoperatively. Distant metastases were detected in three of the 21 patients (14%), including each one in the lung and bone, in the lung, in the bone, respectively. The significant risk factors of distant metastases included age, and high levels of serum thyroglobulin in the preoperative and/or postoperative period. Chest CT detected micrometastases of the lung in two patients with nomal chest radiographs and bone scintigraphy detected bone micrometastases in two patients. None of these three patients had symptoms suggestive of distant metastases. It is important to explore distant metastases in patients with high risks, oldest quartile (65<age) and high serum thyroglobulin level, using chest CT and bone scintigraphy, because early detection of distant metastases of thyroid follicular carcinomas may lead to an improvement of ¹³¹I therapy effect and its resultant survival.

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We developed a marking method for peripheral lung nodules predicted that the localization would be uncertain during surgery, and improved the method by solving some problems. The early method was to place metallic coils near the lesion under a CT-guidance before surgery, and then to perform a wedge resections after confirmation of the lesion by palpating the coils. The early method was conducted in 14 patients including the first patient with metastatic lung tumor in 1989. However, we experienced a few cases that had a deviated coil out of the lung or an impalpable coil for a deep part in the lung. Therefore, for a purpose of a search for coid and traction of the lesion, we improved the method by employing nylon threads attached to both ends of a coil, and fixed an end of the thread to the chest wall since 1998. During surgery, we pulled the threads and successfully performed a wedge resection of the lung including the coil and lesion in 16 cases. The new marking method is extremely useful as traction means in addition to localization diagnosis of peripheral lung nodules.

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In order to obtain reliable prognostic for end-stage gastrointestinal cancer, consecutive 193patient with end-stage gastrointestinal cancer were subjective to an analysis. We evaluated performance status (PS) as an indicators of the level of activity of daily life (ADL), and quality of life (QOL) scores and 28 laboratory data as indicators of QOL. As a results, the mean survival time in patients with PS 4 was 29. 3±5.3 days. Among QOL scores, abdominal fullness, nausea, and total scores in questionnaires were correlated with survival time. Among laboratory data, WBC, IAP, TPA, albumin, prealbumin, transferrin, and PNI were correlated with survival time. In a regression analysis by the Stepwise method, prealbumin, IAP, TPA, PNI and WBC, and nausea were adopted. The development of a high-QOL therapeutic plan requires adequate prediction of the outcomes. For that purpose, it is necessary to prescribe evidence-based therapeutic regimens for patients with end-stage cancer.

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A 61-year-old woman underwent a total gastrectomy with a pancreatectomy and a splenectomy for gastric cancer on December 9, 1997, followed by chemotherapy from January 9, 1998. Intravenous hyperalimentation was begun because of poor oral intake from January 18. From February 10, loss of memory occurred and the level of consciousness was reduced from February 14. On February 15, she suffered from acute circulatory failure. Blood gas analysis showed as follows: pH 7.136, PCO₂ 9.8mmHg, PO₂ 157.0mmHg, HCO₃-3.3mEq/l, and BE -23.4mEq/l, indicating metabolic acidosis. Administration of 500ml of sodium bicarbonate was ineffective. Since the lactic acid level was high at 144mg/dl, lactic acidosis due to VB1 deficiency was diagnosed. Six hours after administration of thiamine, the data of blood gas were improved as follows: pH 7.598 and BE 8.9mEq/l. Both the level of consciousness and circulatory condition were also improved.
We also present some bibliographical comments on lactic acidosis due to VB1 deficiency during intravenous hyperalimantation.

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We report a boy with ectopic cervical thymus required the differentiation from lymphangioma. The patient presented with a right neck swelling in his newborn period and it was diagnosed as cervical lymphangioma 5 months after birth in a previous hospital. He was referred to the hospital because of a soft and solid tumor in the right side of the neck at 1 year old. Ultrasonograhy revealed a cervical tumor consisted of solid and cystic components. The lesion revealed no change with mild swelling until he was 4 years old, when the parents agreed to remove the tumor. Operative findings showed a soft tumor around the carotid artery and jugular vein. It was easily dissected from the surrounding tissue and resected. Pathological diagnosis was normal thymic tissue. Postoperative course was uneventful and the patient was discharged from the hospital 5 days after the operation. The patient has been doing well without any immunological disorders. Cervical ectopic thymus is congenital lesions that result from abnormal thymic migration during embryogenesis. Most of patients are asymptomatic and found accidentally. Preoperative diagnosis of cervical ectopic thymus in children is rarely made even if they present with a cervical tumor. This disease should be listed in the differential diagnoses for cervical tumors in children.

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We report a rare case of stromal sarcoma of the breast. A 48-year-old woman seen at an other hospital for a right breast mass first detected 4 years early was suspected in urtrasonography (us) to have a cyst. The mass grew slowly during observation and she was referred to our hospital. The hard, smoothsurfaced mass was 3.0×2.0cm, well-defined, and movable in the D area of the right breast. Mammmography, us, and magnetic resonance imaging (MRI) suggested breast cancer. Aspiration biopsy classified the mass as class III. Pectoral muscle preserving mastectomy with dissection (level II) of the axillary lymph node (Auchincloss method) was done without anticancer therapy added. The patient is alive and recurrence-free 9 months after surgery. Stromal sarcoma of the breast is difficult to diagnose preoperatively.

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Local recurrence in the remnant breast is one of the problems of breast conserving treatment (BCT). We report a patient with Paget's disease after a BCT. A 49-year-old woman, who had undergone a breast conserving operation with irradiation for left breast cancer at elsewhere in 1997, noticed erosion of and discharge from the left nipple about 6months after the BCT. So she was seen at the hospital on December 13, 1999. On physical examination, no masses were felt in the remnant breast, but a cytological scrape of the left nipple confirmed Paget's disease after BCT. A simple mastectomy was performed. She has been well without recurrence two years after the second operation.
This type of local recurrence in the remnant breast is comparatively rare, however Paget's disease of the nipple should be suspected whenever nipple changes appear after BCT, and we should treat it adequately.

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A 71-year-old woman admitted for a right breast tumor was found in preoperative examinations to have a right breast cancer, T2N0M0, Stage I, necessityating an Auchincloss operation. An infiltrated skin erosion appeared at the surgical site, necessitating a skin biopsy. Histopathological examination of the right breast tumor and the skin biopsy showed Paget's cells and Pagetoid carcinoma, t3n0m0, stage II. Flow Cytometry to determine the degree of genetic malignancy showed an aneuploidy pattern with DNA index, 1.4.

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A case of posterior mediastinal paraganglioma presented with the sudden onset of spontaneous pneumothorax is reported.
A 23-year-old man presented with the sudden onset of chest pain. On chest X-ray films conducted elsewhere, left pneumothorax and a posterior mediastinal tumor were found. He was referred to the hospital for surgery. On admission, he had a transient headache, hypertension, and tachycardia. Serum norepinephrine and urinary VMA levels were high. With a diagnosis of posterior mediastinal paraganglioma, a video-assisted thoracic surgery (VATS) was tried, but in vain. We had to convert to a standard thoracotomy due to the poor control of elevation of blood pressure and massive bleeding. After the operation his temporary headache, hypertension and tachycardia subsided, and the serum value of norepinephrine dropped to the normal range. The resected tumor was 5×4×4cm in size and 46g in weight, and was histologically diagnosed as paraganglioma.

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We report a case of a left pericardial cyst with abnormally high level of CA125 in the cyst fluid. A 42-year-old man was admitted to the hospital because of an chest external injury and was pointed out amediastinal tumor and a fissured fracture. The patient was discharged after the fissured fracture was treated and the mediastinal tumor was followed. Three months later, this patient was admitted again because of chest pain. Chest X-ray film showed expansion of CTR. Chest CT scan and magnetic resonance imaging visualized a 5.0×3.8×4.5cm cystic mass located in the left cardiophrenic angle. Before surgery, under echocardiogram guidance, the cyst was punctured. Intracystic fluid contained high levels of CA125 (141, 906U/l), thought blood levels of tumor markers were in normal ranges. The cyst was resected under thoracoscopic assistance with a suspicion of malignant change of pericardial cyst. Pathological diagnosis was benign pericardial cyst. Malignant change of pericardial cysts is sometimes observed, and consequently we think that therapy for this disease should be selected carefully.

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The subject was a 73-year-old male with a history of artificial prosthesis for an aneurysm of the abdominal aorta at 56 years of age. He was admitted to our hospital for massive hematemesis and melena. Emergency abdominal computed tomography (CT) examinations revealed bilateral femoral artery aneurysm, but there were no false aneurysms at the proximal site of anastomosis with the prosthesis. Emergency endoscopic examination revealed an ulcer in the ascending portion of the duodenum, and the prosthesis was seen exposed at its base. On the basis of these findings, a diagnosis of secondary aortoduodenal fistula was made. At operation, partial dissection of the duodenum containing the ulcer was performed, and the bleeding at the proximal site of anastomosis of the prosthesis was sutured and then reinforced and covered with greater omentum.
Because, even long time has passed since artificial vessel replacement for aortic aneurysm had been performed, perforation to the proximal organs might occur, more careful observation seemed important. It is suggested that endoscopic examinations are more useful for diagnosis than CT examinations and are necessary to make for a definite preoperative diagnosis.

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A 65-year-old woman admitted to the department of internal medicine in our hospital because of right lower abdominal pain, edema and pain of the right lower limb was referred to the department with a diagnosis of occlusion of inferior vena cava. A tumor was palpable in the right lower quadrant of the abdomen, and development of subcutaneous veins and edema of the right lower loimb were confirmed. With an abdominal CT scan, a magnetic resonance imaging scan, and an angiography, leiomyosarcomas rising from the inferior vena cava and right ovarian vein was suspected. The patient was operated on, and a 10×8cm tumor located at the right ovarian vein in the right loin was found. Furthermore, a tumor lcm in diameter was present in the liver S5. Intraoperative froozen section diagnosis was leiomyosarcoma. Anterior surface of the inferior vena cava was incised, an anthrone tube was inserted, and then the tumor in the inferior vena cava was removed under partial extracorporeal circulation.
In this paper, was present this very rare case of occlusion of inferior vena cava caused by leiomyosarcama of right ovarian vein, in which the tumor was successfully removed. Because of its rarity, operative procedures must be sufficiently evaluated before surgery.

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Spontaneous esophageal perforation occurs almost invariably in the left lateral area of the distal esophagus due to anatomical reason and is treated through a left thoracotomy. We report a case of rightsided spontaneous esophageal perforation successfully treated by a primary repair through a right thoracotomy. A 69-year-old man was admitted to the hospital because of severe back pain and epigastralgia. Esophagography revealed a perforation in the right wall of the distal esophagus. Extravasation of a contrast medium was confined to the right side of a mediastinum. Operation was performed 8 hours after the onset of the symptoms through a right thoracotomy. A 4-cm longitudinal tear in the right wall of the esophagus just above a diaphragm was primarily sutured. The contaminated mediastinum was fully debrided and drained. The patient recovered well and was discharged 1 month after the operation. Based on our experience with the case and a review of the literature, we conclude that right thoracotomic approach promises an advantage over left thoracotomy in the treatment of rightsided spontaneous esophageal perforation from the standpoint of both preferable view at primary closure and satisfactory debridement of a contaminated mediastinum.

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A 45-year-old man was admitted to the hospital because of a 6-month history of dysphagia. Radiologic and endscopic examination revealed an esophageal carcinoma with a giant gastric tumor. A distal esophagectomy and a total gastrectomy with an esophagojejunal anastmosis were performed. Histological examination of resected specimen showed that a IIc+IIb-like lesion of the lower portion of the esophagus was well differentiated squamous cell carcinoma (m2), 4.5×4.0cm in size, with marked lymphatic invasion and intramural metastatic foci (6.5×6.0×3.8cm) at the cardial portion. He was discharge from the hospital and has been recurrence free for 8 years 9 months after the surgery.
Esophageal carcinoma with intramural gastric metastasis is relatively rare in a frequency of 1.0_??_4.7% of all esophageal carcinomas. It is often observed that some metastases are larger than primary esophageal tumors, and others show a rapid growth. Patients who have esophageal carcinoma should receive careful examination of the stomach, even though the esophageal carcinoma is in an early stage.

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A 72-year-old man with epigastralgia and appetite loss was found in endoscopy to have a giant submucosal tumor in the middle of the stomach, necessitating total gastrectomy. The resected tumor was 13.5cm in diameter. Four small nodules were seen in other regions of the stomach. Histopathologically, the main tumor consisted of hypercellular spindle or epithelioid cells with several mitosis. Small nodules showed mild proliferation of spindle cells without mitosis, appearing benign. Immunohistochemically, all tumors were positive for CD34 and KIT receptor. We diagnosed the main tumor as malignant gastrointestinal stromal tumor (GIST) and the other tumors as benign. We surmise that the malignant tumor was not derived from the benign one, but the 2 types had occurred separately and developed into benign and malignant forms.

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A 70-year-old woman seen for anemia was found in upper gastrointestinal endoscopy to have a type OIIc lesion at the posterior wall of the gastric body and an unclearly bounded elevated lesion at the bottom. Biopsy specimens from the type O IIc lesion showed signet-ring cell carcinoma and from the elevated lesion highly infiltrated plasma cells. She underwent total gastrectomy. Histopathologically the bottom lesion showed MALT lymphoma and H. Pylori infection. The development of simultaneous primary gastric MALT lymphoma and signet ring cell carcinoma is rare. Some data suggests signet ring cells occurring in gastric MALT lymphoma represent a particular lymphoepithelial lesion in which foveolar cells disaggregated by lymphomatous infiltration acquire a globoid, signet ring appearance. It is thererfor important that physicians bear in mind the possible presence of signet ring cell carcinoma when checking for MALT lymphoma.

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A 60-year-old man with epigastric pain and weight loss was found in endoscopic biopsy to have adenocarcinoma and in abdominal computed tomography to have a metastatic liver tumor.
After total gastrectomy with right liver lobe resection, we histologically recognized a primary gastric choriocarcinoma with adenocarcinomatous component.
Primary gastric choriocarcinoma is rare and its prognosis is dismal. The majority of reported cases had adenocarcinomatous component.

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The patient, a 68-year-old man, came to our hospital with a major complaint of discomfort in the upper abdominal region. Abdominal CT revealed a tumor with a diameter of about 8cm that had displaced the stomach, pancreatic tail, and hepatic lateral segment. An endoscopic examination of the upper digestive tract exhibited a submucosal tumor-like lesion with ulceration in part lesser extending from the lower part of the gastric body to the curvature of the upper stomach. Biopsy specimens collected from the periphery and bottom of the ulcerous lesion showed Group I and necrotic tissue respectively. From angiography, a darkly stained tumor with the left gastric artery acting as the major artery to supply nutrients was recognized. With a presurgical diagnosis of a gastrointestinal stromal tumor, surgery was conducted. The lesion had directly infiltrated the hepatic lateral segment and the patient was subjected to total gastrectomy, D1 lymph node dissection, and combined resection of the hepatic lateral segment. The histopathological examination revealed the following: HE stain showed that the tumor consisted of proliferating tumor foci of undifferentiated cells; and immunohistochemical staining exhibited positive reactions to Grimelius, neural cell adhesion molecules, and neuron-specific enolase, which led to a diagnosis of a gastric endocrine cell carcinoma. There has been no report on resection of gastric endocrine cell carcinoma with hepatic infiltration. The incidence is considered to be very rare.

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We report a case of perforation of duodenal diverticulum with interesting computed tomography (CT) findings. An 88-year-old woman admitted with acute right lower abdominal pain onset was found in abdominal CT to have a defuse low-density area in the retroperitoneal cavity. Plain radiography of the abdomen showed no free air. Surgery revealed a diverticulum 3cm in diameter in the 2^nd portion of the duodenum, necessitating diveticulectomy and simple closure. Histological examination showed neutrophilic infiltration and fibrinous deposition. The postoperative course was uneventful. Duodenal diverticulum are common, but the perforation is a rare and serious complication.

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A 31-year-old man presented to our hospital with the chief complaint of abdominal pain. Since the cause could not be identified despite various examinations, the patient was carefully followed. The abdominal pain recurred often, and plain X-ray abdomen revealed the presence of gas in the small intestine. The patient was therefore admitted to the hospital.
Abdominal CT showed a tumor-like shadow in the intestinal tract in the lower abdomen. Radiography of the small intestine revealed a longish opacity, resembling a penis, in the direction of the long-axis of the lower ileum, with small-intestinal intussusception proximal to the tumor. Another radiographic examination conducted at a later date, after conservative treatment, revealed persistence of the lesion, 6×2cm in size, although there was improvement in the passage of the contrast medium, and remission of the intestinal intussusceptions. Intussusception attributable to a small-intestinal tumor was diagnosed, and celiotomy was performed. A tumor 5×2cm was palpated in the ileum at a site 80cm proximal to the ileocecum. Invagination of the serous surface and funicular hypertrophy of the mesenterium were observed in the lateral wall on the mesenterial side. Therefore, small intestinal resection was performed. Histopathologically, the tumor was attributed to inversion of the entire intestinal wall. Accordingly, intestinal intussusception attributable to inverted Meckel's diverticulum was diagnosed.

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Inferior mesenteric artery aneurysms are the rarest of all splanchnic artery aneurysms. A 78-year-old woman referred to our Department of Surgery for suspected aneurysm of the inferior mesenteric artery was confirmed in abdominal computed tomography (CT) to have such an aneurysm. Angiography showed a saccular aneurysm of the inferior mesenteric artery 1.6×1.3cm in diameter. We resected and reimplanted the vessel on the abdominal aorta after removing the dilated segment. Histology showed mild calcification with degenerative atherosclerotic change. Postoperative angiography showed the reimplanted inferior mesenteric artery to be patent. The postoperative course was uneventful and she was discharged home on postoperative day 21.

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We describe an adult patient with an intussusception due to an inflammatory fibroid polyp (IFP) in the terminal ileum. A 44-year-old woman complaining of continuous abdominal pain and diarrhea was admitted to the hospital with a diagnosis of acute gastroenteritis. Her symptoms gradually worsened following admission and an abdominal CT scanning suggested an intussusception due to tumors of the small intestine. Therefore, under a lapatoromy, an ileocecal excision was performed immediately. The resected specimen exhibited a 3.0×2.5×3.0cm tumor with four smaller tumors (1.5×2.0cm) extending from the terminal ileum approximately 30cm proximal to the Bauhin valve. The histopathological diagnosis was IFP. Approximately 89% of patients with IFP affecting the small intestine develop intussusception and are diagnosed by pathological examination of the resected specimen. IFP is a probable differential diagnosis in cases of intussusception resulting from a tumor of the small intestine.

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Malignant lymphoma of the ileocecum is comparative rare. We report a case with invagination due to ileocecal malignant lymphoma. A 29-year-old man underwent living-donor kidney transplantation to treat membranoproliferative glomerulonephritis (MPGN) in 1988. Present history: A tumor with repeated tenderness was palpable in the right lower abdomen. Examination findings: In abdominal ultrasonography, we found a concentric ring sign in that area. Abdominal computed tomography (CT) showed a tumor with concentric wall thickening in the ascending colon. Under a diagnosis of ileocecal invagination, we conducted emergency surgery. Operative findings: Approximately 20-cm invagination and torsion of the ileum were observed. A submucosal tumor 25mm in diameter was found at the intruding end of the invagination. Pathology: Invagination with diffuse large malignant B cell lymphoma. The postoperative course was uneventful and the patient was discharged on postoperative day 24.

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A 61-year-old man admitted to our hospital for a right lower abdominal mass and pain was found in abdominal computed tomography (CT) scan to have an irregular heterogeneous mass. Magnetic resonance imaging (MRI) showed the bowel loop to be displaced by the tumor. Selective superior mesenteric artery (SMA) angiography showed a tumor stain with a few feeders in the mesentery. Laparotomy was done and a tumor arising from the ileal mesentery was resected by combined resection of 40cm of the ileum and end-to-end anastomosis. The resected tumor was 17×13×13cm amd weighted 1, 380g. The pathological diagnosis was leiomyosarcoma of the ileal mesentery. The patient has been doing well with no evidence of recurrence in the 20 months since surgery. Leiomyosarcoma of the small bowel mesentery is rare, and ours appears to be the 28th case reported in the Japanese literature.

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We experienced a case of ulcerative colitis with stricture of the anal canal after a ceco-anal canal anastomosis in which an abdominoperineal resection was performed. An 18-year-old man who had been diagnosed as having peritonitis caused by total colonic type ulcerative colitis, underwent a total colectomy and a cecostomy. Seven months after the initial operation, a ceco-anal canal anastomosis was performed. Twenty-four months after the initial operation, a barium enema revealed severe stricture in the anal canal. Anal canal resection and a cecostomy were performed. On this case, the medication was effective after the surgery, and the cecum and anal canal were used for the anastomosis. However, the recrudescence of ulcerative colitis caused stricture of the anal canal with fecal fistula and perirectal abscess. Those findings indicate that the operative method for ulcerative colitis must be selected after consideration of the quality of life of the patient and recrudescence of the disease.

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An 80-year-old man complaining of pain and swelling in the left lower back was seen at the department of dermatology in our hospital. He had an about 10cm abscess with redness of the skin. After incision and drainage of the abscess, an intractable fistula was formed at the same site. One month later he was found to discharge residue of foods from the fistula and referred to our department. He was diagnosed with to have cancer of the descending colon by a barium enema and colonofiberscopy. Hartmann's operation with D1 dissection was performed on August 17. The resected specimen showed a type 2 tumor about 40mm in diameter in the descending colon with a cutaneous fistula. The histopathological diagnosis was moderately differentiated adenocarcinoma, si, n(-), and curability B. The patient was discharged very much improved on September 5. So far 20 cases of colon cancer with a cutaneous fistula have been reported in Japan. However most fistulas of them existed in the right part of the colon. We report a rare case of descending colon cancer with a cutaneous fistula We must consider the possibility of colon cancer in the treatment of intractable cutaneous fistulas.

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Splenic metastasis of solid cancer is rare. This paper presents a case of splenic metastasis after surgery for colonic cancer in a 78-year-old woman. The patient had undergone a left hemicolectomy for descending colon cancer in May 1999, a lateral segmentectomy of the liver for synchronous hepatic metastasis in July 1999, and removal of metastatic tumors in the abdominal wall in September 2000. During observation of her clinical course after surgery, an increase in CEA was noted. The patient was admitted to the hospital with a suspicion of splenic metastasis on an abdominal CT scan. Abdominal angiography visualized a hypovascular tumor. Splenic metastasis was diagnosed and a splenectomy was performed in March 2002. Histopathologically, the abdominal wall tumors and splenic tumor were both the same moderately differentiated adenocarcinoma as that of the primary colonic cancer, and were thought to be metastatic lesions. As of 3 months after the last operation, CEA is normalized and no signs of recurrence are present.
The significance of splenectomy for splenic metastasis of colorectal cancer is a matter of controversial opinion due to insufficient accumulation of clinical cases. Long-term survivors after splenectomy, however, have been reported so that we would have to perform splenectomy for splenic metastasis in more patients and follow them for a long time.

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A 50-year-old man admitted for periproctal abscess and carcinoma of the sigmoid colon was treated by sigmoidectomy and abscess drainage. Because the anal fistula did not heal easily, it was drained and biopsied 5 months later. Histology showed well-differentiated adenocarcinoma from the fistula track. An anal fistula reached just behind the prostate. Since no positive regional lymph nodes or distant metastases were found, so the patient underwent total pelvic exenteration. Histology showed a strong resemblance to the sigmoid colon carcinoma and very slight mucoid change common in carcinoma of analgland origin. We diagnosed this patient as having an implantation metastasis of sigmoid colon carcinoma. This is only the eighth reported to date to our knowledge.
It is important to clarify the coexistence of carcinoma in a fistula when an anal fistula is detected with carcinoma in the rectum or colon. Furthermore, concomitant colon carcinoma should be ruled out in a case of anal fistula carcinoma.

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A 62-year-old woman had been found in 1995 to have a liver cyst 6cm in diameter with a small cyst in the hilum. Since she was asymptomatic, the cyst remained untreated. In June 2000, the cyst grew to 10cm in diameter and she was admitted for treatment. The cyst was aspirated under ultrasonographic guidance. Endoscopic retrograde cholangiography (ERC) failed. Bile juice was contaminated in the drainage fluid after ERC. High-pressure cystography showed communication of the bile duct. We successfully resected the cyst using intraoperative cholangiography, and the postoperative course was uneventful. The pathological diagnosis was a simple cyst. The cyst wall consisted of fibrous connective and inflammatory granulous tissues and contained a bile duct.

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During the last 6 years, we experienced three resected cases of malignant cystic tumor of the liver. The first patient was a 78-year-old woman. Dilated bile ducts around a cystic tumor were seen in the lateral segment of the liver. The tumor apparently communicated with the B3 bile duct and it was diagnosed as mucin-producing intrahepatic bile duct cancer. Histologically, the tumor invaded the capsule and the surrounding liver parenchyma. The second patient was a 68-year-old man with a multilocular lesion with papillary projection in the segment 4 and 8. Papillary and tubular adenoma cells as well as cancer cells were seen. The lesion was considered to arise from the adenoma. The third patient was a 48-year-old woman with a globular shaped multilocular tumor with papillary projections inside the segment 4. A communication between the tumor and the bile duct was observed. Neither small bile duct around the tumor nor superficial spreading of the tumor into the bile duct was seen. It was considered to arise within the simple cyst. The first patient died of the tumor 25 months after the operation. The second and third patients are alive 56 months and 16 months after the operation, respectively.

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An 83-year-old man underwent hepatic right lobectomy for hepatocellular carcinoma (HCC) in July, 1989, to remove a 18×16×11cm tumor. Macroscopic and histological findings were Eg, F_c (+), F_c-Inf(+), Sf(-), S₁, IM₀, P₀, V_P1, V_V0, B₀, Edmondson III HCC, and T3NOMOStage3. In August, 2000, radiography showed a nodule in the right lung. Chest computed tomography (CT) showed the nodule to be about 3 cm in size at S6. Serum AFP was elevated to 122.8ng/ml. Cytodiagnosis by CT-guided biopsy was class V, suggesting HCC metastasis. The S6 lung tumor resected on September 18, 2000, was found histologically to be HCC. The man is alive l year and 4 months after pulmonary resection with normal AFP and recurrence-free.
Intrahepatic recurrence of HCC is often observed early after hepatectomy and reports of resection for lung metastasis in HCC is rare, especially long after, which makes our case with solitary lung metastasis of HCC 12 years after hepatectomy, of interest.

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We report a case of hepatoblastoma with bilateral lung metastases. A 16-month-old boy admitted with an abdominal mass had very high serum AFP of 1.38×10⁶ng/ml. Chest computed tomography scan showed multiple nodules in bilateral lung fields and abdominal CT a huge hepatic tumor occupying the whole of the left lobe and invading the right lobe. He was diagnosed with Stage IV hepatoblastoma with bilateral lung metastasis and treated with 4 courses of chemotherapy involving cisplatin (CDDP) and pinorubin (THP-ADR) and chemoembolization from the hepatic artery. He underwent a left-extended hepatectomy 3 months after treatment started, 5 partial resections of the bilateral lung 4 months after, and a partial resection of the left lung 2 years and 4 months there after. AFP remains within the normal range 14 months after the last operation and no sign of recurrence has been detected. For patients with advanced hepatoblastoma and bilateral lung metastasis at initial diagnosis, chemotherapy and aggressive surgery enable the primary site to be resected completely and lung metastasis to be controlled, contributed to a good prognosis.

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A 72-year-old man complaining of upper abdominal pain was admitted to the hospital with a diagnosis of gallstone. Endoscopic retrograde cholangiopancreatography disclosed an elevated lesion in the lower bile duct. Adenocarcinoma was suspected by an exfoliative cytodiagnosis. After a percutaneous transhepatic cholangiodrainage for the non-dilated bile duct, a percutaneous transhepatic cholangioscopic biopsy was conducted. Histopathological study resulted in well differentiated tubular adenocarcinoma. In addition, cancr of the sigmoid colon was detected by a barium enema study. From these findings a pylorus preserving pancreatoduodenectomy and a sigmoidectomy were performed. The bile duct cancer was 15mm in diameter and papillary expansion type, ss, n0 and stage II; and the sigmoid colon cancer, sm, n0, and stage I.
In order to make the qualitative diagnosis and to diagnose the extension of bile duct lesion in the horizontal direction, cholangioscopic examination is mandatory. In this case, percutaneous transhepatic cholangioscopic biopsy was very helpful.

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An 8-year-old girl suffering from nausea, upper abdominal pain, cough and fever was diagnosed as having mycoplasma infection and treated with minocycline at elsewhere. Nine days after the diagnosis she developed vomiting and severe upper abdominal pain. On the next day she complained of unbearable upper abdominal pain and there was a board-like rigidity with rebound tenderness in the epigastrium. Examination of the blood showed the white cell count of 25, 500/mm³ and the serum amylase level of 1, 4481U/L. A CT scan of the abdomen revealed and an edematous pancreas surrounded with ascites. She was referred to the hospital with the diagnosis of acute pancreatitis and treated with conventional medical therapy. Acute pancreatitis subsided seven days after admission. A CT scan of the abdomen showed thrombosis of the portal vein but the patient had no signs or symptoms due to portal thrombosis. She was treated with anticoagulant therapy and portal thrombosis disappeared on a CT scan at day 29. Thrombosis of the portal vein derived from acute pancreatitis rarely occurs in young patients.

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A 49-year-old woman consulted with a hospital because of epigastralgia and was pointed out a pancreas tumor by an abdominal ultrasonography. She referred to the hospital in order to take a close examination for the pancreas tumor. Abdominal CT scan showed a cystic lesion in the pancreatic body and a dilatation of the main pancreatic duct in the pancreatic head. MRCP and pancreatography revealed a mass defect like a nodular lesion in the main pancreatic duct in the pancreatic head, and a large amount of mucus flowing out from the papilla of Vater was endoscopically found. We diagnosed the case as intraductal papillary-mutinous tumor with two lesions locating in the pancreatic head and body. Therefore, a pancreatoduodenectomy was performed. The fresh specimen showed multiple cystic lesions in the pancreatic body that was diagnosed pathologically as intraductal papillary-mucinous carcinoma, but no lesion was present in the main pancreatic duct in the pancreatic head. We keenly felt the difficulty in diagnosing the extension of the lesion on the intraductal papillary-mucinous tumor.

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Non-functioning adrenocortical carcinoma is a rare disease. The treatment for this disease should be surgical resection, and generally, chemotherapy and radiation are thought to be ineffective for this disease. We experienced a patient with non-functioning adrenocortical carcinoma responded well to adjuvant chemotherapy with o, p'-DDD after a non-curative surgical resection, who has been alive and well for 6 years after the non-curative operation. A 62-year-old woman was admitted to the hospital because of left back pain and a huge mass at the left upper abdomen. Preoperative diagnosis was a left adrenocortical tumor with tumor thrombosis in the vena cava inferior on the basis of abdominal CT scan, magnetic resonance imaging, angiography and venography. At surgery, the tumor thrombus could not be removed, and the thrombus was remnant, an extirpation of the left adrenocortical tumor with a left nephrectomy was performed. After the surgery, histological diagnosis was adrenocortical carcinoma. Adjuvant chemotherapy with o, p'-DDD was started, and the remnant tumor was remarkably reduced. A solitary plumonary metastasis was resected 4.5 years after from the primary surgery.

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We report a case of ileal metastasis of renal cell carcinoma (RCC) in a 72-year-old man. The patient had a history of undergoing a right nephrectomy and a left lower lobectomy for RCC with lung metastases in September 1996. He was admitted to the hospital because of bloody stools in October 1997. Ultrasonography and computed tomography of the abdomen showed an abdominal mass. With a suspicion of bleeding from the abdominal mass, a laparotomy was performed. The tumor was presented in the ileum about 100cm from the ileocecal region and a partial ileectomy was performed. The histopathologic findings were compatible with metastatic clear cell carcinoma of renal origin. Thereafter no anal bleeding occurred, however, the patient was associated with renal failure and died in February 1998. Small bowel metastasis of renal cancer is reportedly rare and such 14 cases including our case are presented here.

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A 70-year-old man followed up at the department of urology for renal cell carcinoma with multiple pulmonary metastasis was admitted to the department of internal medicine for bloody stool and lower abdominal pain. Aggravation of abdominal pain and distension was noted, and plain abdominal radiography showed ileus. Abdominal enhanced computed tomography (CT) showed concentric layering in the ileum. We suspected ileus due to intussusception and conducted emergency surgery. We found a 3cm tumor 10cm from the terminal ileum, with intussusception on the oral side. After intussusception was repaired, we partially resected 10cm of the ileum, including the tumor. Pathological findings were metastasis of primary renal cell carcinoma to the small intestine. The postoperative course was uneventful and the man was discharged on postoperative day 18. He is being followed up as an outpatient.
Metastasis of primary renal cell carcinoma to the small intestine is rare, and only 17 cases reported in Japan, including the present case.

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We report a patient with prostate cancer presenting as annular rectal constriction. A 71-year-old man diagnosed with a rectal tumor by barium enema examination of the colon reported to the Emergency Department on July 21, 2000, for worsening abdominal pain, and admitted immediately. Abdominal computed tomography showed annular constrictipon and wall thickening of the lower rectum with enlargement and calcification of the prostate. The patient could not tolerate endoscopic examination of the colon because of severe anal pain. Rectal cancer with prostatic invasion was diagnosed, and the patient underwent abdominalperineal resection of the rectum and needle biopsy of the prostate at 6 sites on August 7. Resected specimens showed annular thickening and sclerosis of the wall of the lower rectum. The histological diagnosis was prostate cancer with rectal invasion. Serum PSA just before surgery was 14.7ng/ml. After surgery, antiandrogen was administered orally. Although invasion of the rectum by prostate cancer is relatively rare, it should be considered in the presence of annular constriction of the lower rectum and enlargement of the prostate.

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We report two patients with sclerosing encapsulating peritonitis (SEP) who were treated successfully by surgical management. Patient 1 was a 49-year-old woman who had undergone continuous ambulatory peritoneal dialysis (CAPD) for 9 years until she had abdominal pain, vomiting and diarrhea. She was diagnosed as having SEP and conservative therapy was started. As no remarkable improvement was gained by conservative therapy kept for two years, she underwent an adhesiotomy. Patient 2 was a 57-year-old woman who had undergone CAPD for 13 years until she had abdominal distention, general fatigue and diarrhea. She was diagnosed as having SEP. Like patient 1, in July 1999, the patient underwent an adhesiotomy and a partial resection of the ileum. After the operation, both patients have experienced no major complications and now are followed on ambulation without recurrence related to SEP.

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The patient, a 47-year-old man, had a chief complaint of epigastric pain. A detailed examination led to a diagnosis of pseudomyxoma paritonei. On December 1, 1998, he was subjected to an appendectomy, omentectomy, removal of mucus, and dissolution of the mucus followed by irrigation. Ports were left within the peritoneal cavity. From January, 1999, abdominal pain was occurred, he was also treated with intraperitoneal 5-FU on ambulatory basis but abdominal pain was continued. Starting in May 1999, his medication was changed to oral 5-FU and intraperitoneal OK-432. The patient's abdominal pain eased but he was re-admitted for an ileus on April 6, 2000. On the 20^th of the same month, a laparotomy was performed, which revealed the multiple presence of mucus in the mesentery and intestinal tract. The small intestine was also obstructed with a brownish nodular lesion. The mucus was eliminated as much as possible; the intestinal obstruction was corrected; and the intestinal ports were replaced. A pathological examination indicated the presence of a hematoma. The tumor marker levels were reduced immediatly after the start of intraperitoneal administration of OK-432 and the second operation. It was concluded that the removal of as much as possible, oral administration of 5-FU, and intraperitoneally delivered OK-432 are effective therapeutic modalities.

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Cervical discitis is a relatively uncommon disease in the pyogenic spinal infection. This paper deals with a 60-year-old man developed cervical discitis caused by methicillin-resistant Staphylococcus Aureus (MRSA) after a proximal gastrectomy with jejunal interposition. He was admitted to the hospital because of gastric cancer. After undergoing an operation for gastric cancer, he developed pneumonia and septicemia caused by MRSA following re-operation for suture failure. Pneumonia and septicemia subsided, but he had sudden onset of quadriplegia and sensory disturbance on 67th postoperative day. Magnetic resonance imaging indicated cervical discitis at the level of C4-5. On account of his progressive paralysis, surgical curettage of infected tissue and anterior fusion was performed on 71st postoperative day. MRSA was identified from the resected specimen. Postoperative course was uneventful. He could walk with assistance, and was discharged from the hospital on 176th postoperative day.
In case that a compromised host after surgery develops neck or lumbar pain and infectious conditions, we have to take into consideration about the possibility of pyogenic spinal infection.

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A 73-year-old woman with swelling, numbness, and burning in the left leg was found in color doppler imaging ultrasonography to have a 4×3cm low echoic mass at the dorsal femoral artery and vein. Computed tomography (CT) showed a uniform mass near the iliopsoas muscle compressing the femoral vein from behind. We diagnosed iliopsoas bursitis because of the cystic mass near the iliopsoas muscle at the ventral hip joint bursa seen in magnetic resonance imaging (MRI) joint cavity. Venography indicated femoral vein obstruction. She underwent aspiration of the cystic mass by ultrasound-guided puncture under temporary vena cava inferior (VCI) filter insertion. We aspirated about 15ml of yellowish hypermucous fluid. Venography after aspiration showed the femoral vein obstruction had disappeared. A week after aspiration, CT findings was rest of cystic mass. We followed her up for a few months but magnetic resonance venography (MRV) findings showed no femoral vein obstruction. Four months after aspiration, CT showed no cystic mass. Her symptons disappeared and her subsequent course appears satisfactory.

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A 67-year-old male seen for a right breast tumor and dysphagia was found in esophageal endoscopy and nipple discharge cytology to have simultaneous breast and esophageal cancer. We carried out necessitating total mastectomy and lymph node dissection. One month after that, we conducted esophagectomy with 3-field dissection and adjuvant chemotherapy due to lymph node metastasis from esophageal cancer. We found 12 cases in the Japanese literature of simultaneous cancer in the male breast and elsewhere. We concluded that advances in other organ cancer influenced prognosis by treatment progress and early detection in male breast cancer. We also concluded that recurrence of esophageal cancer and development of multiple cancers should be considered based on the clinical stage and overexpression of p53 in immunohistochemistry.

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We report a case of hereditary nonpolyposis colorectal cancer (HNPCC) with syncronous stomach and gallbladder cancer. A 65-year-old woman with a history of left breast cancer and a family history of 2 her sisters having colorectal cancer reported upper abdominal pain and was diagnosed with cholecystlithiasis. After detailed examination, she was diagnosed with early gastric cancer and transverse colon cancer. The gastric cancer was treated by endoscopic mucosal resection, and moderately differentiated adenocarcinoma of the stomach was diagnosed histopathologically. Right hemicolectomy and cholecystectomy were done. Histopathological examination showed moderately differentiated adenocarcinoma of the transverse colon with lymph node metastasis and well-differentiated tubular adenocarcinoma of the gall bladder. Based on these findings, we made a diagnosis of typy II Lynch syndrome.

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