Sixty-five patients with esophageal varices (62 with liver cirrhosis, 2 with idiopathic portal hypertension, and 1 with prehepatic portal obstruction) were treated between September 1972 and September 1983. Of the 65, 42 were operated on (33 by non-shunt methods and 9 by selective shunt procedures) and in 23 high-risk patients 5% ethanolamine oleate was injected into the varices with the aid of a fiberoptic endoscope.
The overall operative mortality rate and the rate of survival for more than 6 months were 16.7% and 61.9% respectively; and those rates for esophageal transection employing the commonest procedure used recently were 8.1% and 84.6%.
We used injection sclerotherapy for 23 high-risk patients with esophageal varices, 16 of which had acute variceal hemorrhage with and without unresectable hepatoma (group 1) and in 7 of the patients who had low hepatic functional reserve, the procedure was prophylactic and elective sclerotherapy (group 2). Bleeding was initially controlled in 15 cases (93.8%) and there was rebleeding in 8 cases (3 with variceal bleeding) but, in group 2, definitive control of bleeding was achieved within 3 to 13 months. The overall mortality rate was 47.3% (62.5% in group 1 and 14.3% in group 2). eleven of the 23 patients have survived 6 months and 4 are alive after more than one year.
These results indicate that injection sclerotherapy can be effective in the urgent control of hemorrhage and in prophylactic and elcetive situations.

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The method of closed single layer-to-layer anastomosis of the digestive tract, that was developed by Matsubayashi in 1976, has been used for every anastomosis of the digestive tract in our department. In the present study, clinical results from this surgical technique used for anastomosis of the large intestine were investigated. The method was also compared with the Albert-Lembert (A-L) method in animal experiments.
Operative results were more favorable with this method than with the A-L method, especially in cases of colocolostomy and colorectostomy. In the healing of the anastomosed part of the dog colon, prompter healing was found after this method, especially in the mucosa and submucous tissue, than after the A-L method. Moreover, from the bacteriological examination of the tissue in the anastomosed area three days after surgery, this method was more frequently found to be associated with sterility, especially in regard to aerobes, than the A-L method.
These results lead us to the conclusion that this method is more useful than the A-L method.

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In order to evaluate glucose metabolism in patients with terminal stage gastrointestinal cancer, an intravenous glucose tolerance test was performed before and during total parenteral nutrition (TPN). At the same time, blood biochemical and nutritional assessments were made.
Before TPN, glucose tolerance had decreased with low insulin secretory response in almost all of the patients. Moreover, the levels of blood glucagon, adrenaline, noradrenaline and cortisol had increased in the patients who died in the early period of treatment. Thus it seemed that the decreased glucose tolerance was due not only to impaired insulin secretion but also to elevated blood glucagon, adrenaline, noradrenaline and cortisol levels.
A high rate of anaerobic glycolysis in neoplastic cells was suggested by the high levels of serum lactic and pyruvic acids in patients with early death.
The patients receiving TPN for 4 weeks or more were divided into 3 groups: Group 1 consisted of patients provided with less than 35kcal of TPN per kg/day; group 2 consisted of patients with 36-45kcal/kg/day, and group 3 with 46 or more kcal/kg/day. In group 3, glucose tolerance was improved after 2 weeks of TPN, and the nutritional state was maintained during the period of TPN treatment. On the other hand, no glucose tolerance improvement nor nutritional maintainance was observed in group 1 and 2 patients.
On the basis of the above findings, it seems that TPN with 46kcal/kg/day or more is needed even in patients with terminal stage malignancey, though it should be kept in mind that impaired glucose tolerance occurs in some of the patients receiving high-caloric amounts of total parenteral nutrition.

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An unusual occurrence of bilateral breast cancer in a 60-year-old woman with von Recklinghausen's disease is reported. Although there were metastases in the bone, the patient underwent bilateral musclepreserving mastectomy (Br+Ax). In the TNM classification, the left breast cancer was T2aN1M1 and the right one was T2aN0M1. Histologically, both were papillotubular carcinomas. The left breast cancer was negative and the right one was positive for both estrogen and progestron receptors.
There are two types of malignant neoplasms associated with von Recklinghausen's disease. One is sarcomatous transformation of neurofibroma and the other type is of association with other malignant neoplasms. Seventy four cases of non-neurogenic malignancies associated with von Recklinghausen's disease in the Japanese literature are reviewed and the problems concerning bilateral breast cancer are also discussed.

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Funnel chest is often associated with some other congenital disease. Over one hundred and fifty patients with funnel chest had been operated upon for surgical correction in our department by August 1983.
Three patients had congenital heart disease and were treated by a one-stage or two-stage operation for the combination of funnel chest and heart disease.
Two of them had atrial septal defects (ASD) and the other had a patent ductus arteriosum.
One of the ASD patients was treated by a one-stage operation and the others by a two-stage one.
The cosmetic results of the one-stage operation were superior to those of the two-stage one.
Sternal turnover with the abdominal rectal muscle had the benefit of preservation of the resected sternum during extracorporeal circulation and good cosmetic results postoperatively.
However, secure fixation for the removed sternum and careful hemostasis was necessary for a successful one-stage operation.

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A 66-yearold male, who complained of jaundice, was admitted to our hospital. His total bilirubin was 12.7mg/dl. Percutaneous transhepatic cholangiography revealed a stricture of the common hepatic duct at the Aorta hepatis. Therefore he underwent bile duct resection and hepaticojejunostomy. About three weeks later, he suddenly suffered from massive melena with high fever, which subsided spontaneously. Thereafter the attack repeated again and again. But gastroduodenal endoscopy showed no lesion.
Celiac arteriography revealed an aneurysm of the hepatic artery proper. Therefore the common hepatic artery was embolized immediately by a steel coil and Spongel. The aneurysm was not visualized on follow-up angiography one month later. The patient was discharged and remains asymptomatic till now.
Transcatheter arterial embolization may be an advantageous procedure for the management of heaptic artery aneurysm. It should be applied especially to aneurysm secondary to biliary surgery or liver biopsy.

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Isolated iliac artery aneurysms are rare and associated with a high mortality as compared to other more common aneurysms. We proposed to report two recently observed patients with isolated aneurysms of the common iliac arteries who underwent elective operations.
Case 1: A 70-year-old man was admitted because of an asymptomatic abdominal mass. A transvenous arteriogram revealed an isolated aneurysm of the common iliac artery. The aneurysm measured about 12×8cm. Aneurysmorrhaphy and Dacron graft interposition were performed.
Case 2: A 56-year-old man suffered an abdominal pain. Abdominal echographs disclosed aneurysms, and a transvenous arteriogram revealed isolated aneurysms of the bilateral common iliac arteries. The aneurysms measured about 4.5×3.2cm (left) and 3×2cm (right). The aneurysms were resected and Dacron graft interposition was performed.

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A brachial aneurysm is very rare among the peripheral aneurysms. It is reported in the literature that most of them are due to trauma. A 47-year-old male patient with right brachial artery aneurysm was treated successfully by means of a long saphenous vein graft. This patient had no past history regarding trauma in the right hand. The pathological examination of the specimen revealed arteriosclerotic changes in the wall of the aneurysm.
Although arteriosclerosis can play an important role in aneurysmal formation, the process of brachial artery aneurysm does not appear to be explained completely by such changes.

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Five patients with non-severed traumatic arterial obstruction of the extremity were treated during the last four years. Three were males and two were females. The mean age was 33 years with a range of 5-55 years. The cause of injury was a traffic accident in two patients and in the other three, it was industrial, domestic or iatrogenic. In three patients the obstruction was accompanied by a fracture. The anatomical location of the lesion in the five patients was the external iliac, common femoral, popliteal, axillar or brachial artery respectively. The nature of the obstruction was thrombosis in two patients and extrinsic compression or kinking in three.
Only in two patients was the blood supply restored within six hours after injury. In the other three patients, it was restored in about 53, 93 or 172 hours. In all patients, the postoperative course was uneventful.
In general, the permissible time lag between the injury and arterial repair is thought to be 6 to 8 hours, but this time lag is not absolute.

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A 38-year old unmarried female was admitted to our institute on March 29, 1984, with dyspnoea and severe anterior chest pain. She had had symptoms of a duodenal ulcer and gall stones, and also had a history of alcohol abuse during the past several years. Two hours after gastroscopy, she drank a glass of whisky, immediately became nauseated, vomited a small amount of brilliant red blood and suddenly developed dyspnoea, peripheral cyanosis and anterior chest pain. One hour later, she was found to have subcutaneous emphysema in the supraclavicular region, and was transferred to our hospital with a diagnosis of suspicious perforation of the esophagus. Shortly after admission, an upright chest film revealed left pleural effusion.
Gastrographin esophagograms showed leakage from the lower esophagus to the mediastinum. Eight hours after the onset of these symptoms, she underwent left thoracotomy. A 2cm longitudinal full-thickness tear was found on the left lateral aspect of the esophagus approximately 3cm above the diaphragm. Closure by a two-layered technique with 3-0 Dexon and drainage were performed. Her postoperative course was uneventful. She was discharged 3 weeks after the operation. The best prognosticator for the successful outcome in the treatment of this disease is early recognition of the problem. The importance of diagnosis as a prerequisite for successful treatment is emphasized.

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Though nasogastric intubation has been pointed out as a cause of benign acquired esophageal stenosis, no report of complete obstruction can be found. This is the first report of complete esophageal obstruction probably due to this intubation.
A 19-year-old girl accidentally stabbed herself with chopsticks in the upper cervical esophagus. Two hours later, she was brought to a hospital for severe dyspnea caused by huge retropharyngeal emphysema. This ruptured into the right pleural cavity and she had an emergency drainage operation. The nasogastric tube was left indwelling for 6 days after the operation. The patient was then transferred to Toranomon Hospital, and her esophagus, which was found completely obstructed in the lower half, was successfully resected and reconstructed.
Histological examination showed the cause of the esophageal obstruction to be circular detachment of the mucosa due to acute superficial inflammation and postinflammatory healing process. The constitutional factors were also suspected, because her incisional wounds became hypertrophic scar and she developed early postoperative bowel obstruction due to excessive adhesion.
Though this case seems to be a very rare one in which several unfavorable factors coincided, each factor alone is not uncommon. From this point of view, precautions to take during nasogastric intubation are discussed.

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A case of leiomyoblastoma of the stomach and a review of the Japanese literature were reported.
The patient was a 37-year-old female whose chief complaint was discomfortness in the epigastrium.
In this case, Gastro Intestinal series, gastroscopy, and angiography were performed.
The histological diagnosis was made by endoscopic biopsy from the ulceration of the tumor preoperatively.
Under the diagnosis of leiomyoblastoma of the stomach, distal gastrectomy was performed with removal of lymphnodes.
Reviewing in the literatures it is difficult to make a histological diagnosis preoperatively. Histological diagnosis was made in only 4 out of 19 cases by biopsy from the ulceration and the dimple of the surface of the tumor.
In 16 out of the 19 cases, ulceration and a dimple were found on the surface of the tumors.
It is important to take the biopsy specimen from this area in order to make a histological diagnosis preoperatively.
Reviewing the Japanese cases revealed that one total gastrectomy, two subtotal gastrectomies, and distal gastrectomy in the remainder were performed with or without removal of lymph nodes.
The method of the operation should be established in the near future in regard to the size, the type of growth, and the degree of malignancy of the tumor.

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The patient was a 67-year-old man who complained of gastric disomfort. Gastric X-ray examination revealed that he had a polypoid lesion on the greater curvature in the lower gastric body. It was suspected of being a gastric submucosal tumor with a small dimple on the top of the tumor.
By endoscopic examination, a polypoid lesion of Yamada type I, with a slightly red mucosla surface was found.
Biopsy was performed by sampling four specimens from the peak of this lesion. Group IV was revealed in the first sample, and the patient was found to have a type IIa early gastric cancer.
The operative diagnosis was H0P0N0S0, Stage I, and an R2 resection was performed.
The pathologic diagnosis was well-differentiated tubular adenocarcinoma, a solitary minute gastric cancer, 3×3mm in size and depth to the mucosa.

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The diagnosis of hepatolithiasis, a condition which had previously been difficult to diagnose and treat, has become easier because of ultrasonic examination and puncture under ultrasonographic imaging. The results of treatment have also improved with the development of lithotomy under percutaneous cholangiographic observation by ultrasound, i.e., the application of ultrasonic examination and puncture. However, cholangiocarcinoma occurring as a complication of hepatolithiasis remains an important problem. The clinical course of a 28-year-old male patient who suffered cholangiocarcinoma associated with hepatolithiasis for 12 years is reported with references to the Japanese literature. Since cases of cholangiocarcinoma associated with hepatolithiasis are considered to result from repetition of chronic intrahepatic cholangitis and bile stagnation, it is necessary for the treatment of hepatolithiasis to perform ultrasonic examination together with biopsy of the bile duct in the liver by selective arteriography, biliary cytodiagnosis or cholangioscopy, even after lithotomy, and to continue careful postoperative observation.

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We studied the significance of ultrasonography in the diagnosis and treatment of liver abscess in 6 patients.
The most common ultrasonographic patterns of liver abscess were hypoechoic or mixed internal echo, irregular contour and distal sonic enhancement.
One patient was treated with antibiotics only, but the other 5 patients underwent ultrasonically guided percutaneous catheter drainage and received concomitant antibiotics.
Ultrasonically guided percutaneous catheter drainage was useful for 4 of 5 patients.
There was one death that was attributable to sepsis relating to inadequate drainage.
We conclude that ultrasonically guided percutaneous catheter drainage is an effective method for treatment of liver abscess.

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Primary neoplasms of the hepato-gastric omentum are uncommon, A 47-year-old male was admitted to our hospital with no complaint, to undergo a health examination. Upper gastrointestinal radiography, gastroscopy, ultrasonography, computed tomography, ERCP and celiac angiography were performed. They revealed an upper abdominal tumor which was solid and spherical, and was in contact with but not continuous with the liver, the pancreas and the stomach. Operative diagnosis was a primary tumor of the hepato-gastric omentum, and histopathologically it was found to be a benign leiomyoma. There have been 32 cases of tumors of the hepato-gastric omentum reported in the Japanese literature. Ten of these cases were of leiomyoma (3 benign and 7 malignant). Confirmation of preoperative diagnosis is very difficult, but ultrasonography, computed tomography and celiac angiography are relatively usuful.

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We recently encountered a case of cystadenoma of the appendix with structual dysplasia. A 71-year-old woman was operated on for acute appendicitis because of ileocecal pain, tenderness in the ileocecal region, muscular defense, Blumberg's sign and tumor-like resistance. However, she was found to have a mucocele of the appendix. Ileocecal resection was performed.
The mucocele of the appendix was sausage shaped and measured 12×5×5cm. It was yellowish white and glossy. The wall was elastic hard. The inner surface was rough and yellowish white. The cavity of the mucocele was filled with a gelatinous substance and was comunicated to the internal cavity of the caecum.
Pathologically, it was diagnosed as a cystadenoma of the appendix with structual dysplasia, suggesting the possibility of a potential carcinoma.

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A 72-year-old woman admitted in our clinic complaining a right hypochondralgia, nausea and vomitting. Preoperative diagnosis was common bile duct stone and diverticulum in the area of the papilla of vater. She underwent cholecystectomy and choledocholithotomy. Immediately after the operation, she complained a right hypochondralgia, fever and jaundice. A diagnosis of Lemmel syndrome was made and underwent diverticulectomy.
The second case was a 71-year-old woman, who admitted in our clinic complaining of right hypochondralgia, fever, and jaundice. A diagnosis of Lemmel syndrome was made by endoscopic retrograde cholangiopancreatography and upper gastrointestinal contrast studies. She underwent diverticulectomy. Post-operative condition were satisfactory in both.

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A case of hyperthyroidism in a 16-year-old female with mongolism is reported. The association of mongolism with hyperthyroidism has been reported rarely. Since the first report on mongolism with hyperthyroidism by Gilchrist in 1946, only 20 cases in foreign countries and 4 cases in Japan, by Okajima et al, have been added. After admission with a chief complaint of struma, detailed examinations revealed hyperthyroidism simultaneously. A scintiscanned shadow resembling a cold nodule and a small palpable nodule in the left lobe of the thyroid suggested the probability of malignancy. A left hemithyroidectomy was performed. The pathological finding was diffuse hyperplasia with microadenoma of the thyroid.
Biliographic studies on hyperthyroidism with mongolism were added.

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Among renal benign tumors renal angiomyolipoma is interesting for the specific image of the affected tissues and its relationship to tuberous sclerosis.
The case of a 19-year-old woman with tuberous sclerosis who also had renal angiomyolipoma with development of a hemorrhagic cyst is reported. On her admission she had a facial rash and mental disturbance and she had a history of epilepsy. A nephrogenous cyst was diagnosed by abdominal findings and CT, and laparotomy was performed. The cyst, growing from the kidney and greatly compressing the stomach and transverse colon, was easily enucleated. In the enucleated sample, the cyst had developed sequentially from the upper pole of the kidney, collecting a quantity of blood components within its lumen, and two walnut-size projecting masses were found at the lower pole of the kidney. The image of the tissue showed angiomyolipoma with oncogenous proliferation of vessels, lipocyted and smooth muscle cells. Most vessels with proliferation of angiomyolipoma are abnormal and rhexis occurs easily, causing hemorrhage. Because this hemorrhage often influences prognosis, it is necessary to evaluate the condition of the patient by CT and angiography regularly and to give appropriate treatment.

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