Forty-three patients aged 70 or more undergoing total gastrectomy in our clinic because of gastric cancers during the past 23 years were examined as to their clinical backgrounds, and in the case of curative surgery, elderly patients were compared with those aged less than 39 with respect to long-term recovery states after the operation. In addition, the significance of noncurative total gastrectomy for elderly patients is discussed. In the curative cases, postoperative recovery of the serum total protein level and rehabilitation were satisfactory, while body weight and red cell counts did not become normalized smoothly, and anemia was likely to deteriorate, particulary five to seven years after the surgery. Of the noncurative cases, 39% lived satisfactory daily lives though only for a short term. Thus, it is concluded that every possible effort should be made to carry out total gastrectomy even in elderly patients with gastric cancers if they have indications for surgery, taking operative and postoperative management into consideration.

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The significance of noncurative resection in stage IV gastric carcinoma was studied by analyzing 42 cases with noncurative resection and 21 cases without resection. The one-year survival rate was better for patients with noncurative resection (50.0%) than for those without resection (4.8%). The significant prognostic factors of age, N-factor, and S-factor were not different in the two groups. P₂P₃ and H₂H₃ as poor prognostic factors were more frequent in the nonresection group than in the noncurative resection group. However, when P₀P₁, and H₀H₁ as better prognostic factors were examined, the one-year survival rate was better in the noncurative resection group (60.0% for P₀P₁, and 53.8% for H₀H₁) than in the nonresection group (9.1% for P₀P₁ and 6.3% for H₀H₁). It is concluded that resection is significant for improving one-year survival even in stage IV noncurative cases, if these patients have P₀P₁ and H₀H₁ factors.

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Mechanical suturing was performed in 80 cases of esophagojejunostomy after total gastrectomy during the period from September 1980 to May 1984. Bleeding, a postoperative complication at the suture region, was not found, and leakage and stenosis were found in four cases (5%) respectively. All cases of leakage were treated according to conventrional principles and completely cured. In the four cases of stenosis, dilatation using an endoscope was perfomed in two of the cases and incision by a high-frequency electric knife with an endoscope was done in the other two. Good results were obtained for all four cases. Further, the causes of complications in the suture region by mechanical sutures and suitable countermeasures are discussed in the light of our experience and the related literature.

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The correlation between the radiological and pathological characteristics of cystadenoma of the pancreas was investigaed in two serous and one mucinous cystadenomas. Cystadenoma of the pancreas is pathologically classified as serous or mucinous. Serous cystadenoma frequently develops in the pancreatic head region and consists of groups of small cysts. The epithelium of the cyst consists of squamous or cuboidal cells containing glycogen. It has no malignant potential. Mutinous cystadenoma often develops in the pancreatic body and tail region and is considered to originate in the ductal epithelium.The epithelium of the cyst is columnar and mucinproducing. It has marked malignant potential. These differences in pathologic characteristics, growth pattern and site of origin are reflected in the radiological findings. Significant differences were observed, particularly on the angiogram and CT-scanning. On the angiogram, serous cystadenoma has high vascularity with tumor neovascularity and tumor staining. By CT, it is characterized by a honeycomb appearance. Mutinous cystadenoma is characterized angiographically by hypo-or avascularity. On the CT scan, the major feature is a cystic mass with a thin wall accompanied occasionally by curviliniar septa.

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The diagnostic significance of bile carcinoembryonic antigen (CEA) in biliary diseases was clinically investigated. The determination of CEA was performed by the Z-gel method, and the normal value of plasma CEA was less than 5.0ng/ml. 1) Lyon B bile CEA showed a high value in gallbladder cancer, but was not considered to be of much diagnostic importance as it often showed a high value in cases of cholelithiasis, a benign disease. 2) gallbladder bile CEA showed slight variations, with a mean value of 86.8ng/ml in cases of cholelithiasis, but a conspicuously high value, with a mean value of 6391.9ng/ml, in cases of gallbladder cancer. This showed a high value of 7361.6ng/ml even for stage I, in which radical operation is possible, suggesting that it may be useful for differentiating between gallbladder cancer and other diseases. 3) Biliary bile CEA showed a mean value of 3.0ng/ml in cases of cholelithiasis, 34.4ng/ml in cases of gallbladder cancer and 346.9nglml in cases of biliary cancer, showing a significant increase in biliary cancer. Moreover, before treatment for decreasing jaundice the PTCD bile CEA showed a low value, less than 5.0ng/ml, and a mean value 1.8ng/ml in all cases of cholelithiasis, byt showed a mean value of 54.5ng/ml in biliary cancer. Thus, PTCD bile CEA is can be considered useful for differentiating between benign and malignant cases of obstructive jaundice.

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In order to investigate the pathophysiology of multiple organ failure (MOF) in sepsis, 112 patients with abdominal sepsis were studied.
Twenty-nine of these patients manifested MOF. Severe respiratory failure was observed in these MOF patients, and the activities of serum enzymes such as GOT and LDH were significantly elevated, suggesting that systemic cell damage occurred. While oxygen delivery was maintained with intensive cardiorespiratory care in spite of the severe respiratory failure, both oxygen consumption and mixed venous pH decreased. Therefore, failure of oxygen usage despite its availability occurred in the patients with MOF. This was probably due to arteriovenous shunts or to the direct influence of endotoxin on cell metabolism, and might be the cause of the cell damage.
These results suggest that the improvement of cell metabolism is necessary in the treatment of patients with MOF.

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From January 1977 through December 1982, 297 patients underwent enteral feeding. Among them, postoperative gastric cancer patients accounted for 66%. The feeding was started on the fourth or fifth postoperative day and stopped two to three weeks later in patients whose postoperative courses were uneventful. Complications of the feeding appeared in about 70% of the patients, in whom some nutritional parameters, the serum levels of total protein and albumin deteriorated slightly. Diarrhea and/or soft or muddy stools were the most common complication, octarring in 61.4% of the subjects. Regulation of the feeding speed was thought to be one of the most important measures to avoid this abnormal bowel movement. Since renal failure was present in 2.6% of the patients as a preoperative coexistent disease, a low-residue diet was specially devised, and its clinical usefulness was confirmed in patients with renal failure.

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The role of the intestinal flora played for hearlth is great and now it has been studied especially in relation with carcinogenesis and ageing.
In this study, the authors have examined the influence of the enteral nutrients used after the operation on the digestive tract, concerning changes in the intestinal flora (particularly Bacteroidaceae, Eubacterium, Bifidobacterium and Clostoridium).
The subjects were 20 cases of stomach cancer the ages of the patients ranged from 36 to 72 years. S-185 and B were used for enteral nutrients. Intestinal flora were analyzed by retrieving 10g of feces before and often the operation, until the restoration of normal diet. The analysis was made in accordance with Mitsuoka's method.
The number of bacteria was reduced immediately after operation in both groups due to the influence of antibiotics. In the S-185 group, Bifidobacterium and Bacteroiddaceae appeared after the nutrient was used, and they were in creasing thereafter, while in the B group, Bacteroidaceae appeared in small numbers, and it increased smoothly, but the appearance of Bifidobacterium was delayed, and no increase was noted.
When both groups were compared regarding Bifidobacterium, it was found that it showed a V-shaped recovery in the S-185 group, whereas in the B group, the recovery was delayed.
This may be attributable to the difference of carbohydrates contained in both nutrients.
The autllors also studied on the effects of the changes in the intestinal flora during the pathological states of the patients.

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Carcinoma arising in a thyroglossal duct is comparatively rare. In Japan, only 23 such cases including ours have so far been reported. This patient was a 30-year-old woman with the chief complaint of a mass in the anterior region of the neck. The mass was suspected of being malignant because of the presence of irregular cysts and a solid portion on CT, and was diagnosed as such by aspiration biopsy smear. Surgery by Sistrunk's method and dissection of the cervital lymph nodes were performed. The tumor was pathologically diagnosed as papillary carcinoma arising in a thyroglossal duct remnant, accompanied by metastasis to the cervical lymph nodes.
In diagnosing this condition, a presurgical examination, including CT and aspiration biopsy smear, is necessary because of the occurrence of carcinoma in 1-2% of the cases of thyroglossal duct cystoma. In treatment, dissection of the cervical lymph nodes should be performed in addition to extirpation of the tumor because lymph node metastasis is not rare.

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Recently abnormal nipple discharge in nonlactating breast were increased.
This report is based upon a study of 178 patients between 1974 and 1983 at Konan Hospital, who had spontaneous nipple discharge unaccompanied by a dominant breast mass.
Types of nipple discharge were listed as bloody or serosanguineous, serous or watery and milky.
An analysis of 23 patients submitted to microdochectomy revealed, that 12 patients were positive for cancer by resected specimen.
Histopathologic diagnoses of cancer were, non infiltrating papillotubular carcinoma, non infiltrating medullarytubular carcinoma, intra ductal papillotubular carcinoma, intra cystic papillotubular carcinoma, infiltrating papillotubular carcinoma and infiltrating medullarytubular esrcinoma.
All of the 12 patients were followed by modified or standard radical mastectomy.

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The authors recently experienced three cases of hemorrhagic pericarditis. The first was a 27-year-old male with the complaint of cough and chest oppression who was referred to our department for pericardiectomy and pleuropericardial fenestration. He was pathohistologically diagnosed as chronic pericarditis at surgery and gained temporary remission postoperatively. The real diagnosis of malignant lymphoma was made by biopsy of the cervical lymph node, and he died one year and nine months following surgery.
The second patient was a 21-year-old male with the complaint of cough and exertional dyspnea who underwent pericardiectomy and pleuropericardial fenestration with temporary remission. He was pathohistologically diagnosed as having chronic pericarditis. He received a second look operation 40 days following surgery because of recurrence of massive pleural effusion and was diagnosed as having malignant schwannoma of the heart. He died six months following surgery.
The third patient was a 28-year-old female with the complaint of exertional dyspnea who underwent pericardiectomy and pleuropericardial fenestration and was diagnosed as chronic pericarditis. She followed an uneventful course for four years following surgery.
It might be said, therefore, that careful follow-up should be the rule for patients with hemorrhagic pericarditis.

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A 53-year-old woman with a 28-year history of dysphagia was admitted to the National Tosei Hospital because of the increasing intensity of her complaint. The patient suffered from corrosive esophagitis and subsequent stricture caused by ingestion of sulfuric acid 28 years earlier. An upper gastrointestinal series revealed circular stenosis with an irregular elevated lesion at the site of the lower esophagus. Carcinoma developing at the site of the corrosive esophageal stricture was suspected and resection of the lower esophagus followed by intrathoracic esophagogastrostomy was performed. Histopathological studies of the resected specimen showed papillary adenocarcinoma at the site of the stricture of the lower esophagus lined by columnar epthelium.
The papillary adenocarcinoma of this patient was believed to have developed at the lower esophagus which had been transformed into Barrett's esophagus through chronic esophageal irritation following corrosive esophagitis and continuing dysfunction of the EC junction.
This case is believed to be the first report of esophageal adenocarcinoma developing at the site of corrosive stricture found in either Japanese or foreign literature.

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A 57-year-old man who had suffered cerebral infarction for about one year was admitted to Itoigawa hospital in Niigata because of frequent vomiting.
Radiographically, the pylorus of the patient showed string sign, and endoscopic examination revealed pyloric stenosis representing a uterine cervix-like appearance of unknown genesis. Endoscopic dilatation of the pylorus was successfully performed.
But one month after the treatment, recurrence of the symptoms was recognized, followed by retreatment by using endoscopy, resulting in no marked improvement of symptoms.
Because of the failure of the endoscopic treatment, the patient underwent pyloroplasty of the Heinecke-Mikulica type when the pylorus showed extramural hypertrophic protrusion.
Histologic examination of the resected specimen showed hypertrophy of pyloric circular smooth muscles.
A diagnosis of adult hypertrophic pyloric stenosis was made on the basis of the radiographic, endoscopic and histologic findings described above.
Postoperative roentgenographic examination disclosed no passage disturbance of the pylorus.
The patient has been well for about a year postoperatively without serious symptoms from this particular disorder.

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A patient with leiomyoblastoma of the stomach is presented along with a review of 143 cases in Japan.
A 59-yearold male was admitted to the Kazuno General Hospital in February 1982 with no gastrointestinal complaints. An upper gastrointestinal series showed a filling defect with a bridging fold in the body of the stomach on the greater curvature. Endoscopy revealed an intramural tumor with no ulcer. Biopsies indicated only chronic inflammatory changes. A standard Billroth-I gastrectomy was performed. The specimen showed intraluminal and extraluminal growth, measuring 2.5×2.5×2.5cm. The final histological diagnosis of the tumor was leiomyoblastoma.
We reviewed 143 cases of leiomyoblastoma.
The results are summarized as follows:
1. Males have a slight predominance (52.6% male, 47.4% female).
2. Tumors occur most commonly in the fifth through sixth decades of life, and they metastasize infrequently (7.0%).
3. Patients had symptoms of abdominal pain, indigestion, gastrointestinal bleeding, or notation of an abdominal mass. However in 10.6%, there were no complaints.
4. The most common location of the tumor was in the body of the stomach.
5. In 35.9%, the tumors were growing intraluminally and measured 5cm or less in diameter.
6. Ulceration of the gastric mucosa was found in 50%.
7. Gastric resection was performed in 93.4%.

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The case of a patient who had lithiasis enclosing ascaris in the common bile duct after invasions of ascaris into the biliary tract twice and who underwent lithotomy eight years thereafter is reported.The patient was a 44-year-old man. An ascaris invaded the biliary tract eight years ago and was spontaneously excreted. One month after that, another ascaris invaded. We attempted to an enucleate it but were unable to do so, and it eventually died in the common bile duct. On endoscopic retrograde cholangio-pancreatography (ERCP) before his discharge, an ascaris remnant was found in the common bile duct. The patient was then admitted to our hospital because of lithiasis in the common bile duct and underwent operation. Two bilirubin-calcium stones were found in the common bile duct and were enucleated. When the stones were examined, the ascaris body was found within them, suggesting that the stone had enclosed the ascaris body, with a core that was the remnant of the ascaris body from eight years ago. As there have been no reports presenting the course of ascaris invasion into the biliary tract, death of the ascaris and lithogenesis enclosing the ascaris, our case is considered to be interesting.

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Abscesses developing within the retroperitoneal space are serious surgical infections which are associated with prolonged morbidity and high mortality unless diagnosed early and treated adequately. Two cases encountered recently in our clinic are reported, and the records of 39 patients with proven abscess of the retroperitoneal space seen in Japan during the period between 1959 and 1983 have been reviewed.
Case 1. A 36-year-old man had undergone cholecystectomy and papilloplasty for acute cholecystitis and cholecysto-choledocho-lithiasis. At the fourth day after surgery, dark reddish dirty discharge spewed out from the right flank drain. The patient underwent surgical exploration and a diffuse retroperitoneal phlegmon was drained after the 12th day. Culture of the pus was positive for Enterobacter, Klebsiella, etc. He did not do well and died at the 60th postoperative day.
Case 2. A 54-year-old man was operated upon for retroperitoneal hematoma due to rupture of an anterior superior pancreaticoduodenal arterial aneurysm. At the fifth day after the operation, dirty pus was noticed in the drain. Culture of the pus grew Streptococcus faecalis, Bacteroides fragilis, etc. He was treated with numerous drugs, but he died 46 days postoperatively.
The age range in the Japanese series was from newborn to 78 years. In this group, the causes and anatomical locations of infection were renoureteral in seven, gastrointestinal in eight, tuberculosis in ten, and postoperative in six. Of all, five cases were diagnosed at autopsy, 26 cases operated upon and one of them died;however, of nine nonoperative patients, six died. It seems that early diagnosis and adequate therapy may diminish mobidity and mortality.

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A 71-year-old male with severe paresis due to old cerebral infarction was admitted with the complaint of a large pulsatile mass in the lower abdomen. CT and echogram showed the mass as bilateral isolated iliac artery aneurysm. At the operation, it was proven that this aneurysm was located in the bilarteral common iliac artery and the left internal iliac artery, and that its maximum diameter was 4cm in the right common iliac artery and 7cm in the left.
Exclusion of the aneurysm with Y-dacron graft interposition was performed because resection of the aneurysm was difficult.
The postoperative course was uneventful. Postoperative CT revealed thrombotic occlusion of the excluded aneurysm.
The rate of rupture of these aneurysms is high, as an average of 40 to 60%, and the mortality connected with the ruptured aneurysms is also high. Therefore, patients with this disease should be submitted to surgical repair of the aneurysm when diagnosed.

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This report describes a successful operative case of acute pyogenic iliopsoitis and the surgical considerations of this condition.
A four-year-old boy was admitted to the National Misasa-Onsen Hospital. His complaints were fever, pain in the left femoral joint and mass formation in the left iliac fossa. The psoas position was observed, and CT scanning revealed an abscess in the left iliac fossa. The diagnosis of acute pyogenic iliopsoitis was made.
The abscess was opened and drained by the extraperitoneal route. The patient's postoperative course was good.
Cases of acute pyogenic iliopsoitis have become quite rare in Japan, especially in surgical clinics.
The pathogenesis is discussed.
There are no reports about the relationship between iliopsoitis and Cronh's disease in Japan.

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The case of a 54-year-old woman who was admitted to our hospital in November 1982, with a complaint of hypoglycemic attack and unconsciousness, is reported in the present paper. She was diagnosed as having insulinoma and underwent excision of the cauda corpus pancreatic. The patient had had headache, nausea, vomiting and sometimes a paralysis of both lower extremities since two or three months prior to admission. Insulinoma was suspected from blood chemistry examination, and mass was found in the cauda corpus pancreatis by angio-CT, echography and selective celiac arteriography. A surgical operation was performed for insulinoma. During the operation, an approximately 1×1cm mass was found at a site slightly toward the caudal side from the corpus pancreatis, and excision of the cauda corpus pancreatis was undertaken. The tumor was considered to be an islet cell adenoma histologically. Based on the Gomori aldehyde Fuchsin staining and the enzyme-labelled antibody technique (or peroxidase anti-peroxidase technique) it was considered to be a β-cell tumor (so-called insulinoma). The postoperative course was uneventful, and hypoglycemic symptoms have disappeared. These results lead us to the conclusion that abdominal angiography was useful in the determination of mass localization.

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We studied on clinical manifestations of possible anisakiasis intestinalis causing acute intestinal obstruction.
We have experienced 26 patients (males 22, females 4, mean age 42.4yr.) from January 1980 to March 1983. In 21 patients such episodes occured in winter and 21 patients had eaten raw fish within 2 days from the onset of the symptoms. The signs and symptoms were severe intermittent abdominal pain with slight vomiting, low grade fever and mild leukocytosis. In almost all cases eosinophilia occured within 2 weeks after the onset of the symptoms. X-ray revealed localized dilation of the small intestine. By conservative treatment for a few days all patients could be cured completely, so usually surgery is not necessary for the treatment.
For the diagnosis of possible anisakiasis intestinalis, signs and symptoms, clinical course and eosinophilia within 2 weeks after the onset are helpful.

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The incidence of small intestine cancer is very low as compared with other digestive tract cancers. Our experience with regard to jejunal cancer diagnosed by preoperative biopsy is reported in the light of some related literature, and cases of small intestine cancer, except for duodenal cancer and ileocecal cancer, which had been reported in Japan, were totalized. One case, a 57-year-old woman, who had an initial complaint of anemia alone, was suspected as having ajejunal tumor from X-ray examination of the digestive tract and was definitively diagnosed as having jejunal cancer by endoscopic biopsy and angiography. In 310 cases, reported during the past 15 years in Japan, the number of cases of jejunal cancer was comparatively greater than that of ileal cancer (2.2:1) and each cancer was located mainly at a site near Treitz's ligament of Bauhin's valve. Preoperative diagnosis was made in only 54 cases (7.4%). X-ray examination of the digestive tract, endoscopy and angiography had been used as examination method. The rates of diagnosis were 19.4% for X-ray examination of digestive tract alone, 50.0% for endoscopy without biopsy, 100% for endoscopic biopsy and 31.0% for angiography, so that endoscopy was shown to be the most excellent method. The site diagnosed by endoscopy was limited to a site near Treitz's ligament or Bauhin's valve.

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In order to clarify actual states of disseminated intravascular coagulation (DIC) and multiple organ failure (MOF) in endotoxin shock, changes in blood coagulation and organ failure were investigated. MOF was found in all 14 patients with endotoxin shock. Among the cases of organ failure, 13 cases of pulmonary failure, 12 cases of renal insufficiency, ten cases of DIC, five cases of heart failure, five cases of liver failure and four cases of digestive tract bleeding were found. Moreover, ten of 13 pulmonary-failure cases, ten of 12 renal-insufficiency cases, three of five heart-failure cases, three of five liver-failure cases and three of four digestive-tract-bleeding cases were associated with DIC. The number of cases of initial organ failure, found when endotoxin shock occurred, was greatest in pulmonary failure, and almost corresponded to the time that DIC occurred. The sthenia of coagulation was observed to precede pulmonary failure. Especially, changes in coagulation, found before changes in platelets, meant decreases in anti-thrombin-III values. There was a close relationship beteen DIC and MOF in the patients with endotoxin shock.

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