In order to consider whether the line of thought regarding operative indication should be changed in the light of the recent decrease in the number of operations for peptic ulcer following the introduction of H₂-receptor antagonists, a total of 104 cases of gastroduodenal perforation, including 87 cases of peptic ulcer which had been examined in our department and related facilities, were investigated with regard to the following factors. (1) The mean times elapsing between ulcerative perforation and surgery were 26.1 hours and 9.0 hours in cases where bacteria were present (+) and absent (-) in ascites, respectively. In addition, the ratios of cases showing poor postoperative infectious control was 53.3% and 1.5% in groups where 24 hours or more, and less than 24 hours, elapsed after perforation, respectively, suggesting that 24 hours is a borderline period. (2) Among five cases which showed a good general condition even though free air (+) was found on the simple abdominal radiogram, whose abdominal symptoms were localized and in whom epiboly of the perforation was expected to result in conservative treatment, four cases showed remission of symptoms in 24 hours or less after treatment, while one case showed no improvement of the symptoms, necessitating surgery 24 hours after treatment, although the postoperative course was uneventful. The above results indicate that conservative treatment is possible for some cases such as ours, especially cases of acute ulcerative perforation in younger patients. This led us to the consideration that the course during the 24-hour period after perforation should be observed before deciding on the operative indication.

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In order to identify the clinical and pathological character of gastric cancer among aged patients, the medical records of 19 patients who were over 80 years old and who had undergone laparotomy were reviewed. These patients had poorer resectability and had cancers which were more advanced when compared with younger people, but an increased number of early cases was also observed. Operative complications were not so frequent, and there were no operative deaths. However, there was a tendency for these patients to develop operative complications more easily when preoperative complications were already present. The prognosis for aged patients undergoing curative resection was satisfactory. The conclusions were therefore as follows: Even in old patients over 80 years old, efforts for early defection should be made and radical resection should be performed. However, when the preoperative conditions are poor, efforts should be made to minimize the degree of surgical intervention.

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The usefulness of a new tumor marker, KM01, the monoclonal antibody of which, for established cells of human colonic carcinoma, detects the presence of tumor, was determined using both clinical procedures and an experimental tumor line, and was compared with those of CA19-9, CEA and IAP. The measurement of KM01-RPHA was found to be convenient, showing positive rates of 80.0% and 44.0% in cases of pancreatic carcinoma and gastric cancer, respectively, and furthermore showing a high positive rate of 80.0% in cases of relapsed gastric and colonic carcinomas. Consequently KM01 seems to be useful as a tumor marker. The results of measurements with KM01 and CA19-9 were consistent and the correlation between antibody values of KM-01-RPHA and measurements with CA19-9 was high. The false-positive rate for KM01 was higher than that for CA19-9, suggesting that KM01-RPHA contains antigenic determinants similar to those of CA19-9, facilitating measurement over a wider range than in the case of CA19-9. The antibody value of KM01-RPHA was correlated with CEA but not with IAP. In culutured sera of three kinds of established cancer cells, release of KM01 was found. Among these KUM MK-2 was transplanted into nude mice, and release of KM01 into the sera of the nude mice was initially recognized.

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A case of reconstruction of the carotid artery in radical surgery for thyroid carcinoma is reported.
The patient was a 64-year-old woman who had undergone three operations for thyroid cancer. On the last occasion, lymph node metastasis invading the left common carotid artery was not removed and was left in situ. After heparinization, a temporary shunt was set up between the common and internal carotid arteries. A portion of the common carotid artery which had been invaded by the tumor, measuring 18×9mm, was resected, and the defect was patched with the saphenous vein. The shunt tube was taken out, and the arteriotomies were closed. The longest clamping time was 17 minutes. The blood flow was continuously measured with a Doppler flow-meter throughout the reconstruction. EEG monitoring revealed no abnormalities during and after surgery.

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Cystosarcoma phyllodes is occasionally encountered, but its diagnosis is likely to depend on histological examination after its removal. Only a few comprehensive studies concerning its noninvasive diagnosis have been reported. Therefore, focal findings in the breast and ultrasound findings of tumors were investiaged in six cases of cystosarcoma phillodes.
The sizes of the tumors were 3 to 19cm in diameter, and one of them had extensive skin ulceration, which is rare, but differential diagnosis from other malignant diseases with skin ulceration is quite important.
Histological examinations revelaed benign cystosarcoma phillodes in all cases which coincided with the findings of the ultrasound examination. The characteristic findings of ultrasound examination were solid and sometimes cystic patterns with smooth and well defined tumor margins with no acoustic attenuation.
Cystosarcoma phillodes can be diagnosed preoperatively with the combination of careful observation of its clinical manifestations and the use of ultrasound examination.

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We report a case of a 62-year-old woman with aortic regurgitation presenting dove-coo murmur. Operative findings revealed that an embanked protrusion acting as a fulcrum localized at the right coronary cusp of the aortic valve caused the thin, free edge to vibrate like the reed of a wind instrument, thus causing the murmur.

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Two cases of oat cell carcinoma of the esophagus are reported together with a review of the related literature.
Case No. 1, a 54-year-old-man with a 3-month history of dysphagia, was found to have a spiral-shaped lesion 16cm in length along the entire thoracic esophagus (In Im Ei). After preoperative irradiation at a dose of 40 Gy which was fairly effective, radical esophageal resection and reconstruction were performed. The patient was discharged and soon returned to work. Approximately 10 months after surgery, however, a recurrent tumor was found in the superior mediastinum. Irradiation at a dose of 60 Gy and immunochemotherapy with CDDP and OK-432 proved effective, and the patient has survived for approximately 29 months since the first operation, an extremely long period for a case of oat cell carcinoma.
Case No. 2, a 59-year-old man with a 3-month history of dysphagia, was found to have not only a spiral-shaped lesion 10cm in length in the middle to lower esophagus (Im Ei), but also an early-stage cancer (IIa) in the anterior wall of the antrum of the stomach. Because of hepatic and pulmonary dysfunction, surgery was divided into 2 stages. In the early postoperative period after subtotal esophagectomy, however, the patient developed extensive metastasis in the superior mediastinal and abdominal lymph nodes and died of pneumonia caused by Pneumocystic carinii.
Light microscopy revealed the cellular morphology in the esophageal lesions of both cases. Argyrophilic cytoplasm was not demonstrated by histochemistry, but electron microscopy revealed the presence of the neurosecretory granules in the two lesions. Therefore, the esophageal lesions in both cases were diagnosed as oat cell carcinoma.

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We have recently encountered a case of multiple eosinophilic granulomas in the fornix of the stomach. A 51-year-old woman was admitted to our hospital with a chief complaint of epigastralgia. Radiologic and endoscopic examinations showed irregular, excavated and protruded lesions in the fornix. Endoscopic biopsy showed benign findings (Group-I). With a suspicion of gastic malignant lymphoma or reactive lymphoreticular hyperplasia (RLH), total gastrectomy was performed. The resected specimen showed five protruding lesions of various sizes (maximum 1.6×1.3cm, minimum 0.6×0.6cm) with an ulcer at the top of each. Histologic diagnosis was eosinophilic granuloma of the stomach.
One hundred and thirty-three cases of eosinophilic granuloma of the stomach have been reported in the Japanese literature. We discussed the age distribution, sex difference, symptoms, location, size, shape, layer of occurrence, preoperative diagnosis, and treatment of this lesion in the light of these reports.

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Three cases of gastric carcinoid experienced in our department of surgery during the last 8 years are reported. The incidence among cases of gastric cancer during the same period was 0.8%. Case 1 showed almost the same finding as that seen in early gastric cancer IIa+IIc in the body of the stomach, with pernicious anemia. Only one case of association with pernicious anemia, as seen in this case, has been reported in the Japanese literature. Case 2 had MEN-1-type adenomatosis. In this case carcinoid was found as a submucosal-type tumor in the body of the stomach. This case was multihormonal. In case 3, extremely pronounced gastric secretion suggested Zollinger-Ellison syndrome, but because of emergency surgery, serum gastrin lvels were not measured. Polypoid-type carcinoid on the pyloric ring and gastric ulcer in the angle were found. Cases 1 and 2 had hypergastrinemia and in case 3 hypergastrinemia was suspected clinically. All of these cases failed to demonstrate gastrin in the tumor by the peroxidase-anti-peroxidase method. Glucagon in the tumor was present in all three cases. In case 2, hyperinsulinemia and positive staining for insulin in the tumor were also revealed.

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We experienced a case of early gastric cancer associated with ITP, and gastrectomy and splenectomy were subsequently performed. As a preoperative treatment, the patient was given 303mg/kg of complete molecular-type Ig for five days, inducing an increase in the number of thrombocytes from 12, 000/mm³ to 79, 000/mm³. Although the volume of bleeding during surgery was 706g and the level of thrombocytes was maintained immediately after surgery, the level decreased rapidly and bleeding began due to drainage on the seventh day after surgery. However, the wound was subsequently healed again with the same dose of Ig preparation. The postoperative course was uneventful for a while but no increase in thrombocytes could be achieved by administration of prednisolone, resulting in the appearance of hemothorax, hematuria and subsequently death due to hemoptysis on the 65th day after surgery.
Therapy with a large quantity of complete molecular-type Ig for ITP may be very useful for surgical procedures necessitating a transient increase in thrombocytes, whereas further consideration regarding its medication and dosage may be needed before applying it as a form of radical treatment.

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A 62-year-old woman who had undergone subtotal gastrectomy for gastric carcinoma in October 1982 had been followed by administration of FT207 orally. She had been well until January 1986 when she developed small bowel obstruction. She had shown an initial improvement by conservative treatment but again developed symptoms in February of the same year. This small bowel obstruction persisted, showing a variable course, and laparotomy was performed. A mass 2cm in diameter was located at a site of the mesentery of the jejunum, 1.2m distant from Treitz's ligament. With suspicion of primary or metastatic tumor of the small intestine, jejunectomy of about 30cm length including the mass was performed with end-to-end anastomosis. Histological findings revealed metastatic signet ring cell carcinoma. Among cases of metastatic tumor of the small intestine, few cases are solitary such as the one in this case since many are due to the extension of end-stage malignant tumors into the abdomen. However, these tumors clinically present as acute abdomen such as perforation, intususception, obstruction and bleeding, when they pose problems. Consequently, a disease condition such as the one in this case should be taken into consideration in diagnosis and treatment when small bowel obstruction or bleeding of unknown origin is present.

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The patient was a 54-years-old housewife, whose chief complaint was abdominal pain. The preoperative diagnosis was acute abdomen with perforation of the stomach or bowel. The operative findings were disseminated carcinomatous metastasis in the abdominal cavity from an unknown primary lesion and perforation of transverese colon. The patients life saved, and fecal peritonitis was cured by resection of the transverse colon recoginizing the existence of the perforation and irrigation of the abdominal cavity. The primary lesion of this cancer could not be diagnosed by various examinations including fluoroscopy and endoscopic examination in the pre- and postoperative period. The primary lesion of the cancer was found at autpsy to be a Borrmann 4 typed stomach cancer.
We classified this perforation of the transverese colon as diastatic perforation although there was no obstruction at the anal side of the bowel. The form of perforation in this patient was somewhat similar to idiopathic perforation of colon with a long longtudinal tear at the antimesenteric border. Consideration of the perforative mechanism in this patient suggests some difficulty of the classification of idiopathic perforation, spontaneous perforation, stercoracious perforation, or diastatic perforation. Further, the pathologic factors of these perforatins and their different mechanisms need to be considered.

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Mesenteric panniculitis is an unspecific inflammatory disease rarely induced in the mesenterium. Most of such cases have a chronic course and are difficult to diagnose clinically. We examined one case of mesenteric panniculitis which may have occurred after an acute course, and in the present report we review 24 Japanese cases including our own with special reference to etiology and pathologic conditions.
The patient, a 31-year-old male, had pharyngitis resulting in paralytic ileus on the eighth day after occurrence. As the cause remained unknown, the patient underwent exploratory laparotomy, and he was diagnosed as having mesenteric panniculitis from findings at the time of laparotomy and histologic images.
The disease is characterized by frequent occurrence in the mesenterium of the small intestine or sigmoid colon, the formation of a tumor in the abdomen and the symptoms of ileus or enteritis. Although the cause of our case was unknown, its manifestation was strongly assumed to be related to allergic reaction complicated by inflammation considering the fact that many cases of this disease present signs of inflammation before the occurrence. As there have been only a few cases reported with acute course, our case, suggesting the etiology of the disease, is thought to be interesting.

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A 24-year-old man, whose aunt and grandmother had died of colon cancer, whose mother had intestinal polyposis and who had many relatives on his mother's side suffering from various intestinal diseases, experienced lower abdominal pain and bloody stoool. X-ray and endoscopical examination of the gastrointestinal tract disclosed polyposis throughout the colon and several polyps in the stomach and small intestine, some of which were biopsied and which revealed no malignancy histologically. Ostemoa in the right mandibula and hard palate were also discovered. These findings led to a diagnosis of Gardner's syndrome. To prevent malignant change in these polyps and to preserve the normal function of defecation, total colectomy followed by ileorectal anastomosis was performed. The resected specimen showed 279 various types of polyps (2-12mm in diameter) which had a histology of tubular adenoma. Postoperative defection state was good. For the remaining polyps in the rectum, serial endoscopic resection was planned from three weeks after the operation.

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It has been said that carcinomas of the large intestine, breast and corpus uteri share a common pathogenic factor, since these carcinomas often occur simultaneously. When multiple primary carcinomas are simultaneously present, other carcionmas may be ignored resulting in difficult problems with treatment.
In the present paper, two cases of synchronous multiple primary carcinomas are reported. One of the patients, an 81-year-old woman, had multiple carcinomas, medullary ductal carcinoma in the breast and moderately differentiated adenocarcinoma in the large intestine, and she underwent simple mastectomy and then excision of the anterior rectum (Hartmann method, R2) three weeks later. The other patient, a 46-year-old woman, had moderately differentiated adenocarcinoma in the large intestine and well differentiated adenocarcinoma in the corpus uteri and she underwent right hemicolectomy (R2) and simple total hysterectomy simultaneously. Although both cases first presented symp-toms of colonic carcinoma, careful examination at the time of admission detected a tumor in the breast and abnormal hemorrhage from the genital region, suggesting the presence of other carcinoma. The postoperative courses of these patients were uneventful, and both have been without any sign of relapse to date over the past nine months.
Seven cases, including our case, in which multiple primary carcinoma such as colonic carcinoma and breast cancer or carcinoma of the corpus uteri had been detected, were reviewed and discussed.

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The number of reports on villous adenoma of the large intestine has recently been increasing, but most of the lesions are located in the rectum and the sigmoid colon. Villous adenoma of the cecum is very rare, and there are only four cases including the present one, as far as we could investigate. The patient was a 75-year-old woman. She visited our department with the complaint of right hypogastric pain. She was diagnosed as having a villous adenoma of the cecum by enema and radiography, and endoscopy of the large intestine. Resection of the ileocecum (R₂) was performed because of the size of the tumor and the high incidence of a complication of cancer. Examination of the excised specimen revealed that the tumor was 3×3×3.5cm in size and sub-pedunculated. Histopathological examination revealed that two-thirds of the tumor was a villous adenoma and the remaining third was a well-differentiated tubular adenocarcinoma. It has been reported that the incidence of the complication of cancer in villous adenoma is 89.2% in Japan. Villous adenoma is thus liable to be wide-based and the size is 2cm or more in most cases, seemingly showing severe malignancy. For treatment, a small tumor should be totally resected under endoscopic observation, and if intestinal resection is necessary, the lesion should be operated on as carcinoma of the colon.

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A 58-year-old female, who had papillary adenocarcinoma arising from unilocular cyst in the liver, underwent left lobectomy and survived for more than three years, showing the longest survival among Japanese cases of adenocarcinoma arising from liver cyst.
Malignant change of simple cyst of the liver has been considered to be very rare, but the results of our review of cases reported in Japan revealed that this condition has not infrequently been reported as cystadenocarcinoma.
From our review of Japanese literature, 33 cases of cystic adenocarcinoma of the liver including our case may be divided into the following three groups; a) adenocarcinoma arising from liver cyst, 24 cases b) cystadenocarcinoma from cystadenoma, 4 cases c) primary cystadenocarcinoma, 5 cases.
The recent development of diagnostic imaging modalities has resulted in an increases frequency of detection of liver cysts and papillary projection of liver cysts which suggest that this condition is not as rare as used to be thought. Detailed examination and follow-up are therefore thought to be necessary.

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Hemorrhagic cholecystitis is one of the rare complications of acute cholecystitis.
Recently, a 73-year-old man with Adams-Stokes syndrome had a relapse of acute cholecystitis resulting in hemorrhage in the gallbladder. Clinically, he was free of signs of hemobilia, as we found hematoma in the gallbladder upon surgery. We had trouble in diagnosis and the method of treatment, and he showed little progress toward recovery. In arriving at a diagnosis, we found that ultrasonography and CT scan were complementary to each other. Early detection of rare complications of acute cholecystitis is important, and serial follow-up with both ultrasonography and CT scan is, therefore, extremely helpful.

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A 51-year-old woman admitted with right hypochondralgia, palpable mass and fever was given extended right hepatic lobectomy combined with pancreato-duodenectomy for advanced carcinoma of the gallbladder which had infiltrated to the liver and duodenum. The patient died 4 years and 6 months after surgery and the autopsy revealed recurrence in the abdomen as well as metastasis to the left supraclavicular fossa and right lung.
This operation method is ideal for advanced carcinoma of the gallbladder, giving apparently improved prognosis to allow long-term survival.
Removal of lymphnodes of the superior mesenteric artery radicle and paraaorta is necessary for more radical treatment.

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A rare case of wandering spleen was experienced in our clinic. An 8-year-old girl was hospitalized as an emergency case with complaints of severe abdominal pain and vomiting. The patient's general condition deteriorated and preoperative diagnosis was impossible. An emergency laparotomy revealed a large mass with a long twisted pedicle. The mass was diagnosed as a wandering spleen and splenctomy was performed. Considering the patient's age and the important role of the spleen in the immunologic respose to infection, splenic autotransplantation after splenectomy was attempted. The postoperative course was uneventful. Postoperative liver-spleen scan confirmed the presence of regenerated splenic tissue located in the left upper quadrant. We consider that splenic autotransplantation after splenctomy due to wandering spleen could be a significantly useful therapeutic method.

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Four cases of hemobilia presenting with intracystic bleeding were treated between January 1982 and March 1986. We analyzed their B-mode sonograms, evaluated the diagnostic significance of ultrasonography and investigated the influence of two factors, blood volume in the galbladder and passage of time, on the appearance.
The ultrasonography in the cases of moderate or more sever bleeding showed characteristic hyperechoic opacities within the distended gallbladders, having mixed patterns and with a tendency to show an increase in the sonolucent areas with time. By contrast, the cases of slight bleeding demonstrated gravity-dependent layering hypoechoic findings which are seen in other diseases.

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