Ninety-seven histologically proven benign tumors and 96 breast cancers were studied to determine the relationship between the diameter measured by palpation and that by ultrasonography. A scatter diagram of the two variables provided a correlation coefficient of 0.95 in the benign group and 0.94 in the malignant group. The ratio of the diameter in palpation to that in the ultrasonogram (ratio of P/U) was 2.00±0.79 in breast cancers and 1.14±0.26 in benign tumors (p<0.01).
When a ratio value of 1.5 or greater was used to indicate malignancy, the sensitivity was 74% and the specificity was 90%.
In conclusion, the ratio of P/U can be considered a useful method to differentiate breast cancer from benign tumor.

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Postoperative alopecia following cardiopulmonary bypass seems to be a minor complication, but it may result in a cosmetic disaster for the patients. Five such cases were reported, and possible causative factors were discussed. This retrospective analysis revealed that severe hypotension and its long duration during bypass were the most important risk factors, and ischemic damage due to scalp pressure appeared to play a role. Since there is no active and effective treatment for this complication, prevention of its occurrence during and after surgery is mandatory. Changing the postion of the patient's head at regular intervals and avoidance of severe hypotension during the bypass may eliminate alopecia. From our experience, the use of arterial pump for the pulsatile flow was the most effective.

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There are many cases of primary liver cancer associated with cirrhosis, presenting problems from the viewpoint of treatment. In our department, 72.7% of 157 patients with primary liver cancer had complicating cirrhosis. Among these 157 cases, hepatectomy was performed in 40 cases, intubation in the hepatic artery in 14, trans-arterial embolization of the hepatic artery by catheter (TAE) in 24, single laparotomy in 12, other forms of surgery in 7, chemotherapy in 35 and no treatment in 25. Mortality due to surgery after hepatectomy was 15%, and the final results for two-year and five-year accumulated survival rates were 38.0% and 30.4%, respectively, showing obviously good results as compared with the other treated groups. TAE was the most effective modality among cases in which it was impossible to perform excision. Factors related to the prognosis after hepatectomy were hemorrhage volume during surgery, operation time, ICGmax, KICG, albumin, S-GOT, S-GPT, glucagon, the rate of increase in blood cyclic AMP after loading, response form of OGTT and hepaplastin test. Thus, it is thought necessary to pay full attention to these factors both preopeartively and during surgery.

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Twelve patients with primary hyperparathyroidism (PHP) have been treated at our department during the past 18 years five men, average age 41 and seven women, 40.3). Investigations were undertaken concerning clinical details, such as age, clinical morbid type, period of morbidity, pathohistological type, anamneses, preoperative localization of the lesion, choice of surgical procedures, and complications.
The 12 symptomatic patients included nine of the “bone change type” and “nephrolithiasis type, ” and their average ages by morbid type were: bone change type-40 and nephrolithiasis type-42.3.
It is desirable to subject symptomatic PHP to surgical treatment as soon as possible once the diagnosis is established because of high renal complications.
For 11 cases out of the 12, satisfactory surgical procedures were feasible through the cervical incision. And the time-consuming, expensive, invasive laboratory tests to localize the lesion can be avoided if diagnosis is made clinically.
Palpation was possible preoperatively if the mass was larger than 2cm in diameter.

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Only 20 cases of pericardial diverticulum are known to have been reported in Japan.
We report the 21st case, recently diagnosed, in a 27-year-old man who had been asymptomatic and was found to have an abnormal shadow on a chest X-ray taken in a mass screening at his office.
The chest X-ray film showed a mass shadow at the right hilar area. On the CT scan, it was a homogeneous well-circumscribed mass with the density of water and without any invading characteristics.
On thoracotomy, it was found a to be a cyst having communication with the pericardium. This was proven by injection of contrast medium into the communicating channel.
Pericardial diverticulum frequently develops at the four corners of the pericardial sac. This is often explained by the weakness of the pericardium at these spots. The pericardium is also said to be weak where the visceral layer turns to the parietal layer, and most weak between the superior vena cava and the azygos vein. The diverticulum of our case originated from the pericardium between the superior vena cava and azygos vein, which supports these explanations.
Our patient showed no malignancy.

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A case of eventration of the diaphragm complicated by volvulus at two locations of the digestive tract, namely the sigmoid colon and the stomach at different times has been experienced. This type of case is very rate only two cases have been so far reported by Tanner in Europe and America.
The patient, a 49-year-old male, was additted to our hospital in October 1984 complaining of abdominal pain. Although excision of the sigmoid colon was performed on the diagnosis of volvulus of the sigmoid colon complicated by eventration of the diaphragm, coluvulus of the stomach was discovered only after surgery, necessitating reoperation (gastropexy, retrenchment and suture of the diaphragm). The postoperative course was uneventful. In eventration of the diaphragm, abdominal organs are easily raised to the area just below the diaphragm, possibly causing onset of voluvulus of the sigmoid colon or the stomach. In the two cases reported by Tanner, volvulus of the sigmoid colon occurred after gastrectomy, being the reverse in order of onset with our case. In both cases, treatment for eventration of the diaphragm was not performed upon initial surgery. For cases such as them, it may be necessary to perform one-stages surgery not only for the secondary complicating lesions of the digestive tract. But also for eventration of the diaphragm.

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Disseminated peritoneal metastasis (P₃) of malignant tumor in the upper digestive tract and the presence or absence of ascites were diagnosed by the perrectal ultrasonic method, and the results were studied in comparison with the findings obtained during surgery.
Of 10 cases of progressive cancer, the control, two were clinically diagnosed as ascites-positive and one more case was diagnosed as ascites-positive by this diagnostic method. Malignant tumor cells were proven by the operative findings in all of these three cases. The amount of ascites was 50-100ml, which allowed diagnosis.
Considering the present situation in which diagnosis of the degree of infiltration of a major lesion, metastasis to the liver and metastasis to the lymph node is made possible to some extent by ultrasonography, CT and angiography, making a correct diagnosis of disseminated peritoneal metastasis enables one to determine the degree of advance of lesions and also to avoid surgery that ends up being merely exploratory laparotomy. Accordingly, this diagnostic method will play an important role in determining indications for surgery.

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The cancer family syndrome has been classified as a type of nonpolypotic hereditary colon cancer. The diagnostic criteria of the syndrome were first described by Lynch and Krush in 1973. Herein reported is a case of asynchronous triple cancer which was suspected to be the cancer family syndrome. The patient was a 60-year-old-woman, having a history of sigmoid and rectal cancer without any clinical evidence of polyposis at the age of 40 and endometrial cancer at the age of 57. In June 1984, she was diagnosed as having cancers of the gallbladder and transverse colon; she underwent a palliative operation in July 1984. Pathological examination of all cancers proved adenocarcinomas. Her son had died of colon cancer at the age of 20, and her mother died of gastric cancer at the age of 53. Some of these clinical findings met Lynch's criteria. However, the patient's family history was insufficient to prove autosomal dominant inhertance and to diagnose the cancer family syndrome.
Further study may be needed to establish the diagnostic criteria of the syndrome, which doesn't need proof of its hereditary trait.

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Many reports in Japan show early gallbladder tumor invasion to the mucosa or proper muscle layer. We recently experienced two cases of early gallbladder cancer who were successfully diagnosed by ultrasound.
Case I was a 76-year-old woman who complained of r-hypochondralgia. Ultrasonographically, irregular, weak, mass echo was detected from the body to the neck of the gallbladder. The tumor was suspected of being malignant; thus cholecystectomy and lymph node dissection were performed. Pathologically, it was well-differentiated adenocarcinoma of the gallbladder, invading to the depth of the proper muscle layer but without lymph node metastasis.
Case II was a 35-year-old man who complained of r-hypochondralgia. Ultrasound showed some stones and an irregular tumor 1.2×1.5cm in diameter without acoustic shadow. Papillotubular adenocarcinoma was found only in the mucosal layer with no lymph node metastasis.

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Among 87 patients who underwent surgery for cholelithiasis in our department during the 21 month period January 1983 to September 1984, histologic examinations during and after surgery revealed that four patients had gall bladder cancer. Early diagnosis of gall bladder cancer is so difficult that abdominal ultrasonography can hardly differentiate either the infiltrative lesions or elevated lesions of less than 10mm. This difficulty even extends to ERCP, so that there have been cases in which no image in the gall bladder appeared. As the prognosis of gall bladder cancer is generally poor, the excised gall bladder must be examined macroscopically as soon as possible. Moreover, rapid histologic examination should be carried out in suspicious cases so that any gall bladder cancer can be discovered earlier. Fixation of the excised gall bladder in formalin for 5-10 minutes can make the nature of the mucous membrane clearer, resulting in easier detection of abnormality. We have found this to be a useful method. Furthermore, extensive cholecystectomy should be performed as there is a possibility of cancer invasion into external sites even if the cancer is only Stage I. Accordingly, when gall gladder cancer is initially differentiated by histologic examination after surgery, secondary surgery should be performed as soon as possible.

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A case of choledocholithiasis associated with progressive muscular dystrophy (PMD) is reported.
The patient was a 57-year-old woman who had developed a waddling gait and muscle weakness of the extremities and was diagnosed as having PMD at the age of 50.
Seven year later, she experienced vomiting and pain in the upper abdomen and was diagnosed as having choledocholithiasis.
Physical examination and biopsy of the skeletal muscle revealed that PMD was the limb-girdle type, and cholangiography showed stones in the common bile duct and gallbladder.
The patient was operated on under general anesthesis. Anesthesia was performed according to the method of socalled modified neuroleptanesthesia (using diazepam, pentazosine, and nitrous oxide) without any trouble. Pancronium was used as a muscle relaxant during anesthesia.
Cholecystectomy, choledocholithotomy and T-tube drainage were uneventfully performed through a right sub-costal incision.
Rehabilitation was started from early in the postoperative period, and the patient was discharged on foot on the 40th day after the operation.

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The patient, a 54-year-old man, had received a fracture of the left rib two years previously, and subsequently suffered from upper abdominal pain in July 1983. In September of that year, he was admitted to our Department of Internal Medicine complaining of pyrexia, left abdominal pain and tarry stool. Cholelithiasis, splenic abscess and diverticulosis in the sigmoid colon were diagnosed by abdominal echoscope, CT, enema and so on. In October of the same year. cholecystectomy, splenectomy and sigmoidectomy were performed. The size of the spleen was equal to that of a child's head, from which approximately 300ml of pus flowed out, and colibacillus and anaerobes were isolated. The gall baldder showed strongly inflammatory, signs and c concretion was found trapped within Hartmann'spouch. Inflammatory findings of diverticulum in the colon were not strong.
Splenic abscess is a relatively rare diease and only 25 cases have been reported in Japan. The causes of isolated splenic abscess are thought to be as follows; (1) hematogenous spread of bacteria from a focus of infection, (2) trauma, (3) inflammation occurring due to the influence of peripheral organs, (4) splenic infarction, (5) hemoglobin abnormality. The cause in our case was thought to be (1), and totalization of the cases reported in Japan revealed that the most common cause was also (1).

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We measured postoperative amylase-creatinine clearance ratio (ACCR) and amylase isoenzymes, and evaluated their clinical significance in the early diagnosis of postoperative pancreatitis.
It was shown that in cases with perforated duodenal ulcer, serum amylase was not always elevated. Thus, the leakage of pancreatic juice into the peritoneal cavity alone cannot be held responsible for an elevated level of serum pancreatic amylase, i.e., damage of the pancreatic exocrine glands should be considered. Similarly, postoperative patients with elevated serum pancreatic amylase, although suspected of stomal insufficiency, may suffer from acute pancreatitis.
We report here two interesting cases with normal serum amylase but abnormal ACCR postoperatively. Acute pancreatitis was found to develop subsequently in these two patients. As a result, it is suggested that prolonged ab-normal ACCR may predict the possibility of postoperative pancreatitis.
As ACCR is associated with renal tubular function, increased ACCR is not specific to pancreatitis. However, ACCR is sensitive to pancreatitis. We concluded that serial measurements of ACCR and amylase isoenzymes are helpful in the early diagnosis of postoperative pancreatitis.

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In the 15 years from 1969 to 1983, 229 patients with primary ileus not caused by previous laparotomy were treated in Okayama Saiseikai General Hospital. This was 25.7% of all operative cases of ileus. As for the primary disease, colon cancer was the most common. Sixty patients had histories of previous laparotomies, but in these cases, primary ileus occurred more than five years after the first operationd.
Among the patients, 61.6% were more than 60 years old, and primary diseases varied in the different age groups.
In 113 cases, the duration of illness was less than three days, but in ileus of the colon, many patients suffered from symptoms of subileus.
For the diagnosis. plain radiogram and barium enema are important, and we should diagnose carefully on the basis on anamnesis and synthesis of the radiographic findings.

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Actinomycosis is chronic suppurative granulomatous disease caused by a Actinomyces israeli. Actinomyces israeli is an anaerobic, gram-positive bacteria that forms part of the normal flor of the human mouth and gastrointestinal tract. Cervicofacial, thoracic, and abdominal actinomycosis are the three most common forms of the disease. Since the lesions of actinomycosis are characterized by the presence of firm indurated masses, it is difficult to differentiate abdominal actinomycosis from malignant tumors.
Two cases of abdominal actinomycosis that were initially diagnosed as sarcoma are reported.
Case 1: A 64-year-old woman was admitted to our hospital, complaining of a mass (9×23cm) in the umbilical region. A preoperative diagnosis of saroma of the abdominal wall was made by ultrasonography and CT.
Case 2: A 48-year-old man complained of a mass (10×12cm) in the right upper quadrant. A preoperative diagnosis of sarcoma of the great omentum was made by ultrasonography, CT, barium enema and angiography.
In both cases a mass composed of abdominal wall, great omentum and transverese colon was resected en block. The cut surface of specimens showed abscesses and histologic examination showed “sulfur granules.”
Both cases are expected to be cured by wide surgical excision of the involved tissues, without administration of penicillin.

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Acute appendicitis is the most common gastrointestinal disease, but it is very difficult to select and operate only for suppurative appendicitis among many patients complaining of lower abdominal pain. Thus, we undertook retrospective investigation of the correlations between many indices, such as abdominal findings by palpation (Blumbergs sign, muscular defense), white blood cell counts, body temperature and operative findings concerning the appendix, in 358 patients who underwent appendectomy from 1980 to 1983.
1. Muscular defense was correlated with perforation, coated pus, and destruction of the appendiceal mucosa, and it was the most reliable indicator for surgery.
2. The incidence of postoperative wound infection was 2.8%, and almost all developed in patients who had undergone surgery for perforative appendicitis.
3. There were no differences in the postoperative wound infection rate despite the fact that many kinds of antibiotics were administered. Thus, when we undertake surgery for perforated appendicitis, we should treat the wound carefully during the operation in order to avoid infection.

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Villous tumor of the rectum with serum electrolyte disturbance in a 77-year-old man was recorded. The patient had suffered from mucous diarrhea since the age of 57. At the time of his admission, loss of serum electrolytes (Na 119.6mEq/l; K 3.4mEq/l; Cl 77mEq/l), azotemia (BUN 118mg/dl; creatinine 7.1mg/dl) and dehydration were noted. These severe conditions were improved with a rather small dosage of fluid and elecrolyte infusion because of his activity for oral intake of food and water. After this preoperative procedure, abdominoperineal amputation of the rectum and regional lymphadenectomy were performed. The villous tumor, 13×12×2cm in size, occupied the lower part of the rectum and consisted of villous adenoma and tubulovillous adenoma as well as well-differentiated adenocarcinoma. The mucous secretion appeared in the area of villous adenoma. The patient had an uneventful clinical course and was relieved. However, he suddenly died 10 months after the operation. The autopsy revealed cortical necrosis of the bilateral kidneys. There was no neoplasm.
Loss of serum electrolytes and water in a patient with villous tumor of the colon is called “depletion syndrome”. The mechanism of the occurrence of this syndrome is uncertain as yet, but a vicious cycle may participate in its development.

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A mucus-secreting tubular adenocarcinoma was diagnosed on the biopsy specimen from a tumor recently formed in the gluteal region of a 57-year-old man who had been suffering from chronic pyoderma in the same region for 28 years. Miles' operation with extensive resection of the gluteal region was carried out for the anorectal malignancy. The surgical specimen exhibited no gross abnormality in the anorectal mucosal surface, but revealed histological evidence of a mucus-secreting adenocarcinoma originating in the anal glands showing definite transitional alteration, with a widespread subcutaneous invasion in the gluteal region. The histochemical evidence of negative O-acylated sialic acid and positive thionine in the lesion was also compatible with pathogenesis of this particular lesion arising from the anal glands.

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During the period between 1980 and February 1985, 29 cases of septic shock were experienced and surgically reated in our department. Among these 29 cases, 18 presented endotoxemia, the average number of organs suffering failure being 2.7, the mortality being 50.0% and the prognosis being poor. Occurrence of DIC was highlighted as the cause and this was investigated. The rate of endotoxemia associated with DIC was high, 39.0%, the mortality being 85.7%. On the other hand, the mortality of patients with endotoxemia without DIC was low, 23.0%, being almost similar to that of patients without endotoxemia. These results suggested that the prognosis would be fairly good unless DIC was a complicating factor during the onset of endotoxemia, so that it may be necessary to commence anti-DIC therapy at the time of pre-DIC.

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A 69-year-old woman underwent bilateral axillofemoral bypass surgery for abdominal aortic stenosis. She complained of a sensation of coldness in the lower extremities and intermittent claudication. Abdominal X-ray film showed the severely calcified abdominal aorta. After the operation, her symptoms disappeared.
In this case, direct anastomosis between the aorta and artificial graft was impossible because of calcification of the abdominal aorta, and extraanatomic bypass surgery was performed.
An axillofemoral bypass operation is frequently used for aortoiliac occlusive disease. But we think that a patient with severe complaints due to abdominal aortic stenosis, especially with a severely calicified aorta, has good indication for this procedure.

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A successful case of superior mesenteric arterial embolectomy with bowel resection is reported.
The patient, an 82-year-old man with atrial fibrillation and cerebral infarction, complained of severe periumbilical pain of acute onset. Physical examination of the abdomen did not reveal tenderness or rebound tenderness. Alightly increased small bowel gas was shown on plain abdominal X-ray film. Ultrasonography and CT of the abdomen revealed no abnormal findings. Since mesenteric arterial occlusion was suspected, intravenous digital subtraction angiography, followed by selective superior mesenteric arteriography, was performed. The artery was completely obstructed at 5cm distal from its origin. About five and a half hours after the onset of the symptoms, the patient underwent an operation. Embolectomy with a Fogarty catheter and small bowel resection of about 65cm were performed. Postoperatively, he was complicated with aspiration pneumonia and renal failure, but he soon recovered.
This patient is the oldest of the successful cases of superior mesenteric arterial embolectomy to be reported in the Japanese literature.

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Periarteritis nodosa is considered to be one of the collagen diseases and presents various clinical symptoms due to its invasion to general organs. Symptoms in the digestive tract, especially, are found at a relatively high rate, occasionally necessitating laparotomy. We have experienced a 51-year-old male patient with a chief complaint of upper abdominal pain, who was diagnosed preoperatively as having cholelithiasis. Moreover, laparotomy revealed that the patient had multiple ulceration of the small intestine and he was diagnosed as having periateritis nodosa from histologic findings.
With regard to periarteritis nodosa in Japan, 42 patients, 28 male and 14 female, with an average age of 51.0, have undergone laparotomy. Four cases (9.5%) had been preoperatively diagnosed. As to the area showing lesions, 22 patients (52.4%), had a lesion in the small intestine, 9 (21.4%) in the stomach and 4 (9.5%) in the appendix vermiformis. Moreover, steroids had been preopeartively administred in 13 cases (31.0%). The disease period in these cases was longer than that of the non-admininistration group and mortality due to surgery tended to be a little lower.

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