Total parathyroidectomy and parathyroid autotransplantation were carried out in 22 patients for renal hyperparathyroidism from 1982.
Severe renal osteopathy (bone pain and/or radiologic signs) was found in all of the patients. Calcium and cPTH levels in the sera were elevated in 36.4% and 100% of the patients, respectively. After total parathyroidectomy, parathyroid tissue was immediately autografted in a forearm muscle. All of the patients showed some improvement in their bone and joint pains. 81.8% of them noted great improvement in these symptoms.
Radiologic signs of renal osteopathy were improved postoperatively within six months. No patient is on replacement therapy or has undergone reoperation for recurrent hypercalcemic hyperparathyroidism. The only postoperative complication was pallsy of the left recurrent nerve in one patient. The six-to 52-month results after total parathyroidectomy with autotransplantation for renal hyperparathyroidism are considered to be satisfactory.

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We present the diagnostic results of palpation, mammography (MMG) and ultrasound (US) in small breast cancers (t_??_2cm).
3106 patients with histologically diagnosed breast disease, including 1941 with small breast lesions, were studied. In each examinations we classified patients diagnosed as having definite or suspected cancer into a positive group and those diagnosed as benign lesions into a negative group.
Positive predictive value of palpation, MMG, or US each was reduced significantly. However, that of combined examinations with palpation, MMG and US were not reduced.
Combined examinations with palpation, MMG and US are necessary for the detection of small breast cancer. Adequate biopsy is also proposed.

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Sixteen cases of intrathoracic esophageal lesion on whom blunt dissection was carried out without thoracotomy were evaluated retrospectively for operative safety and adequacy of indications for intrathoracic esophageal carcinoma.
Results were as follows:
1) Blunt dissection without thoracotomy is safe in cases of intrathoracic esophageal lesion except for those with severe adventitial changes.
2) Blunt dissection is applicable for cases of reduced pulmonary function and those at high risk; therefore, the resectability rate may be increased. Blunt dissection should be considered if resection under thoracotomy is impossible, especially in cases in which cancer invasion is limitted to the lamina propria mucosae, because curative resection can be expected.
3) In other intrathoracic carcinoma cases in which resection under thoracotomy is not suitable because of impaired general condition or distant organ metastasis, blunt dissection may be acceptable given considerations of cancer reduction and/or avoiding such complications as bleeding. It is also important to compare the benefits and disadvantages of blunt dissection with those of other therapeutic methods for these cases in terms of the patient's prognosis and quality of life.

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A clinicopathological study was undertaken in 74 patients with scirrhous carcinoma of Borrmann type 4 gastric cancer. (1) Macroscopically, the majority belonged to the linitis plastica type with giant folds. Most tumors measured 6-15 cm in diameter. (2) Total gastrectomy and lymphadenectomy (R₂ and above) were performed in 77.0%, and gastrectomy with perigastric organ resection in 55.4%. (3) Histological examination revealed poorly differentiated adenocarcinoma in most cases. The depth of gastric wall invasion exceeded “se” in many cases. (4) Liver metastasis and peritoneal dissemination occurred at rates of 5.4% and 35.1%, respectively. The incidence of lymph node metastasis was a high 81.1%. (5) Cross-sections of the ends of excised tissue specimens disclosed a high incidence of tumor infiltration (23.0%). (6) The overall prognosis of scirrhous gastric carcinoma was exceedingly poor. The 1-, 3- and 5-year survival rates were 59.5%, 16.1% and 9.3%, respectively. In comparing curative resection and non-curative resectin, no significant differences were found in survival rates except for the 1-year survival rate (p<0.001). The prognosis of patients with lymph node metastasis was poor. In patients without peritoneal dissemination, the long-term prognosis was poor, though the 1-year survival rate alone was a high 75.0%. (7) The peritoneum was the most frequent site of recurrence in curative resection patients.

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This study was performed on 309 patients with gastric cancer who had undergone resection of grade 2 (R₂) or more, during the period from 1980 to 1985. No metastasis to _??_ lymph nodes was found in cases of early cancer, whereas in advanced cases with serosal invasion, metastasis was found in 16.7%. In cases of region A (lower portion) alone, metastatic rates to first group lymph nodes were as follows: the rate of _??_ in early cancer was 1.9%, and the rate to (6) was 5.8%. In advanced cancer with serosal invasion, on the other hand, the metastatic rate to _??_ was 33.3%, and that to (6) was 45.8%. These rates were higher than that to _??_, 16.7%. The metastatic rate to second group lymph nodes in the case of eraly cancer was 1.9%. The above findings suggest that dissection of _??_ lymph nodes is not necessary in cases without serosal invasion macroscopically at operation of region A cancer. Note:
_??_: lymph nodes along the left gastroepiploic artery, _??_: lymph nodes along the right gastroepiploic artery, (6): subpyloric lymph nodes.

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Changes in lactate dehydrogenase (LDH) isozymes and the mechanism of their elevation in the serum of postoperative cancer patients were investigated.
This study involved 35 operative cases of stomach and colorectal cancer. These patients were subjected to measurement of LDH isozyme pattern at 6-hour intervals during the preoperative period and for an initial postoperative period from the time of their return to the recovery ward through the first postoperative day as well as once daily on the third, fifth, seventh and 14th postoperative days and finally one month after operation. Immediately after operation a marked transient elevation of both serum LDH and LDH 4 and 5 was generally noted, peak levels was observed at the time of return to the recovery ward. The Subsequent fall in enzyme levels was slower in stage I, II and III than in stage IV stomach cancer cases.
It was assumed that increased activities in serum of LDH and LDH 5 in postoperative stage IV or more advanced cases of stomach and colorectal cancers were primarily due to cancer cell while those in stage I, II and III cases were principally due to liver cell deviation.

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From April 1983 to November 1985, we performed colonoscopic examination in 36 cases of ileus. We were able to insert the colonoscope into the ileocaecal region in 63.9% of cases (23/36). No complications were experienced in this study. Adhesive intestinal obstruction was present in 14 cases, 12 (85.7%) of whose obstructive symptoms improved after colonoscopic examination. All cases of sigmoid volvulus were reduced colonoscopically.
Case 1.36y/o male. His chief complaints were lower abdominal pain, and on physical examination, there was mild tenderess in the lower abdomen. Colonoscopic findings showed swelling and purulent coated orifice of appendix. Appendicitis was diagnosed.
Case 2.83y/o female. She was admitted for abdominal pain and vomiting. Her abdominal X-ray showed niveau of the sigmoid colon. We were able to diagnose and reduce the sigmoid volvulus colon. We were able to diagnose and reduce the sigmoid volvulus colonoscopically.
Case 3.64y/o male. He had gastrectomy for cancer five days previously and complained of abdominal distension. His abdominal X-ray showed niveau of the large intestine. Colonoscopy revealed that the large intestine was adhesive and kinking near the splenic flexure. We were able to pass through this point and suck feces and gas from the oral side of the colon.
We conclude that colonofiberscopy is highly useful for ileus.

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To judge the severity of liver cirrhosis, Ozawa et al have studied blood glucose curves of 50g OGTT, and described the relationship between glucose tolerance and severity. However, there is a disadvantage with OGTT in that only the blood glucose curves types can be classified. Moreover, OGTT is influnced by gastric emptying time. We have, therefore, studied iv-GTT and OGTT in 18 recent cases of liver cirrhosis complicated with esophageal varix (LC+varix), and studied the prognosis. The OGTT pattern was of the parabolic type in all cases, whereas K-glucose in iv-GTT was 1.26_??_3.46, showing variations depending on the case. Where a major operation was performed in cases K-glucose<2.0, there was a significant tendency to die of hepatic failure. From this it appears that K-glucose in iv-GTT clearly reflects the severity of liver cirrhosis.

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Seventy-four patients with extrahepatic bile duct cancer were treated during the past 10 years. The extrahepatic bile duct cancers, especially unresectable cases, were reviewed.
The cumulative 3-year survival rate after curative operations was 54%, and the 5-year rate 35%. Then cumulative 3-year survival rate after noncurative operations was 13%. The unresectable cases treated by biliary intestinal bypass after reduction of jaundice all died within two years. However, the prognosis varied with bypass method. In this study, we mainly examined the difference between choledochojejunostomy and bypass operation using a T-tube. Mean survival period in the former group was 5 months, and in the latter 8.6 months. All patients in the former group were dead within one year, but the cumulative 1-year survival rate of the latter group was 30%. Good prognosis was obtained with the biliary intestinal bypass method using a T-tube.

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Since incisional hernia is one of the major factors in morbidity after abdominal surgery, its incidence is of concern to abdominal surgeons. In 1972-1981, 31 patients were operated on for incisional hernias following abdominal surgery in the Yachiyo Hospital.
The mean age of the patients was 60 years. There were 26 females and five males. The location of hernia was as follows: upper midline in five, lower midline in 13, right lower quadrant in 10, and other locations in five cases. Ten cases developed incisional hernias within one year of operation, while 13 cases developed hernia more than 10 years after opration. It seems that a difference in possible causal factors might have existed between the two groups. Computed tomography was useful for preoperative evaluation of contents in the hernia sac.
These patients were divided into five groups: 21 patients in whom vertical abdominoplasties were used and 10 who underwent transverse abdominoplasty. Fascial graft was applied in four cases.
The technique for repairing incisional hernia should be selected according to the contents in the hernia sac, its size, its form, and the duration of the asymptomatic period after past laparotomy. The main technical points are as follows: 1. if possivle, avoidance of resecting the peritoneal sac, like the keel operation; 2. transverse abdominoplasty where applicable; 3. reinforcement with fascial autogtaft, if necessary. Satisfactory results were observed in this series.

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No uniform treatment for infantile lymphangioma, which is often encountered in routine examinations in pediatric surgery, has yet been established, and the treatment of cases oftern presents is great difficulty.
Infantile lymphangioma was therefore studied in 88 patients (101 sites). Lesions of the cervix occurred at the highest incidence (in 41 patients), and most of them had cystic hygroma. In 27% of the patients, the lymphangioma had advanced and coexisted in the mediastinum, oral cavity, axilla and arms. Another 27% of the patients had such dangerous complications as infection, dyspnea and dysphagia, necessitating emergency treatment. Four of nine patients with lesions of the abdominal region were brought to hospital with ileus. Surgical excision was performed in 77 patients, 23 of whom were also treated with bleomycin. Seven patients were treated with bleomycin alone, and four showed spontaneous disappearance of the lesion. Based on this study, it seems necessary for the degree of invasion of lymphangioma to peripheral sites, complications and age to be taken into account in selecting therapeutic procedures and determining the time to begin treatment.

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The concept of carcinoid was introduced by Oberndorfer in 1907, for small tumors arising in the small intestines. Recently, however, cases of carcinoid tumors arising outside the gastrointestinal tract (thymus, ovary, etc.) have been increasingly reported. We encountered a tumor that was diagnosed as carcinoid tumor of the thyroid after thorough examination by optical and electron microscopy and immunohistochemical techniques.
The patient was a 76-year-old woman with a tumor mass on the anterior aspect of the neck and symptoms that resembled those of the carcinoid syndrome: flushing, dizziness and diarrhea. Both thyroid and parathyroid were functioning normally and blood calcitonin levels were within the normal range. Left hemithyroidectomy was carried out on June 15, 1985. The postoperative course was uneventful and various symptoms were attenuated.
Our survey of the literature disclosed that no primary carcinoid tumor arising in the thyroid has been reported previously, and that not only the definition of carcinoid tumors arising in the thyroid but also the classification of so-called C-cell origin tumors of the thyroid remain unclear. The case is therefore reported with some discussion.

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In our hospital we have experienced 11 cases of postoperative acute myocardial infarction (post operative AMI) the past 5 years.
The early onset group, which showed AMI within 48 hours after operation, was compared with the late onset group, which showed AMI over 48 hours after operation, in terms of interval to onset, risk factors and so on. As a result we concluded the following:
1) The factors of age, sex, method of anesthesia and total volume of blood transfusion did not greatly affect the onset of postoperative AMI.
2) The early onset group had a better prognosis than the late onset group.
3) The late onset group, which had a poor prognosis, consisted of many cases of malignancy and had a longer operation time than the early onset group.
4) If the patients of postoperative AMI included respiratory problems, the mortality rate was relatively high.

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An insolated iliac artery aneurysm is a rare vascular disease for which surgical treatment should be considered, because the prognosis is extremely poor once rupture occurs. We report a case of isolated bilateral common iliac and internal iliac artery aneurysms associated with a DeBakey IIIb type dissecting aortic aneurysm.
A 75 year-old male deveroped severe back pain 2 years prior to admission. He was admitted to our hospital complaining of a right lower abdominal mass. The pulsatile mass was suspected of being a right common iliac artery aneurysm, and a left common iliac artery aneurysm was also detected by arteriography. The patient underwent arterial replacement using a Y-shaped Dacron graft with a left extra-peritoneal approach. The internal iliac artery was also reconstructed with a straight Dacron graft since internal iliac artery aneurysms were found during the procedure.
Isolated iliac artery aneurysms have a high protential for rupturing as compared to abdominal aortic aneurysms. Therefore surgical intervention is strongly recommended.

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Cases of complication of arteriosclerotic cardiovascular disease and malignant tumor are increasing with the prolongation of patients' age and the progression of treatment for malignant tumor.
From May 1985 to April 1986, we experienced seven patients with these lesions, all of when were male. Four patients had gastric cancer, two others had prostatic cancer and one had renal cancer.
We have done total of ten surgical treatments in these patients: A-C bypass grafting (1 case), abdominal aortic aneurysmectomy (2 cases), thoracic aortic aneurysmectomy (1 case), aorto-femoral bypass grafting (4 cases) and femoro-popliteal bypass grafting (2 cases). All cases showed improvement, and there were no early or late deaths.
To prolong life and improve its quality in these patients, surgical treatment should be done actively for arteriosclerotic cardiovascular disease as well as in cases in which a malignant tumor is present and is not in the terminal stage.

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A case of leiomyosarcoma of the duodenum accompanied with nonrotation was reported. The patient was a 39-year-old man who complained of a mass the size of a child's head in the epigastrium. The upper gastrointestinal series demonstrated moderate lateral displacement of the discending duodenum, and a vertical duodenum that did not cross the midline. Barium enema showed a left-sided colon and entirely right-sided small bowel, indicating nonrotation. On selective celiac angiogram, it was noted that the tumor was nourished by the superior pancreaticoduodenal artery. The tumor showed mottled staining with contrast medium, indicating hypervascularity. Ultrasonography revealed a large mass with a thick echogenic wall and sonolucent center. Operation was performed under the diagnosis of submucosal tumor of the duodenum. At surgery, a large tumor involving the first portion of the duodenum with peritoneal dissemination was identified. To remove the lesion, subtotal gastrectomy was performed. The histologic examination revealed that the tumor was leiomyosarcoma.

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We have recently encountered a case of primary carcinoma of the jejunum associated with intussusception and cerebral metastasis. A 55-year-old man was admitted to our hospital, with a chief complaint of hypochondralgy. Although barium studies failed to demonstrate abnormal findings, whole body CT scan revealed mass shadow in the tail of the pancreas with elevation of serum CA19-9 levels, and primary tumor of the pancreas was suspected. The patient developed ileus soon after admission, and urgent surgery showed polipoid tumor associated with intussusception in the jejunum about 100cm distal from the ligament of Treitz. The resectedtumor was histologically diagnosed as pooly differentiated adenocarcinoma of jejunum and tumor metastasis in the regional lymphnodes and the tail of the pancreas. In the postoperative period, the patient complained of the headache, and tumor shadow was pointed out on the CT scan of the head. Craniotomy was performed, but the patient died of the cancer two months later.
Primary carcinoma of the small intestine is an infrequently encountered tumor that is difficult to diagnose preoperatively. The tumor is rarely associated with intussusception or cerebral metastasis. These characteristic features are reviewed and discussed.

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A case of fuluminating Crohn's disease presented with diarrhea in the seventh month of pregnancy, accompanied with ileus, congestive heart failure and massive fresh blood in the stools. Cesarean section was combined with total colectomy and ileocolectostomy. The patient and baby were saved. TPN was performed for postoperative management of nutrition, and enteral nutrition using elemental diet was also effective in the phase between TPN and regular diet.
Such cases should be dealt with by a cooperating team of surgeons, obstetricians, internists, and pediatricians.

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A case of intestinal Behçet's disease which presented diffuse colonic ulceration is reported.
A 32-year-old man with a one-year history of Behçet's disease was admitted to Gifu University Hospital because of recurrent eye symptoms. During his stay in the Department of Ophthalmology, he complained of right lower abdominal pain and diarrhea. Physical examination showed signs of peritoneal irritation, and laboratory data revealed findings of marked inflammation. However, since there was no sign of intestinal perforation or obsturction on abdominal X-ray film, conservative treatment was employed. Thereafter, his hospital course was uneventful. Barium enema performed three weeks later showed multiple ulcerative lesions of almost the entire colon. The ulcers were oval, punched out and less than 1.5cm in diameter, characteristic of intestinal Behçet's disease.

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Villous adenoma of the large intestine has been regarded as a relatively rare disease in Japan. It has attracted attention as a tumor that has peculiar macroscopic morphology, a high rate of canceration, and is accompanied by electrolyte abnormalities or dehydration. We have experienced three cases of villous adenoma of the large intestine, which are presented here with 72 cases reported in Japan, together with a discussion of the literature.
1) The male to female ratio was 29:43, with a greater frequency in females.
2) The average age was 62.2 years.
3) The chief complaints of melena, musous descharge and diarrhea were found in 83.3% of the cases.
4) The site of occurrence was the rectum in 60 cases (83.3%) and sigmoid colon in four (5.6%).
5) Malignant changes were seen in 60.3% of cases, and if the diameter of the tumor was more than 5cm, malignant changes were seen in 72.7%.
6) In 32 out of 49 cases of villous adenoma of the rectum (65.3%) operations were performed in accordance with rectal cancer. Among them, infiltrative cancer was found in only 13 cases (26.5%).
The operative method must be carefully selected for amputation of the rectum without using the natural anus.

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A case of carcinoma of the colon associated with tuberculosis is reported. The patient was a 56-year-old woman in whom intestinal tuberculosis was suspected during emergency surgery for intestinal stenosis. Since perioperative histological examination revealed a concomitant carcinoma, right hemicolectomy was performed. Annular ulcerative lesions appeared in the entire periphery near Bauhin's valve in the markedly deformed ileocecum. Histologically, the cancer was a mucocarcinoma invading the subserosal layer. The colon contiguous to this area had mucosal bridges and a zone of mucosal atrophy combined with many ulcerative scars. Although tubercle bacillus and caseous granuloma were not identified, these lesions seemed to represent an old case of intestinal tuberculosis.
A total of 34 cases of this combination reported in Japan are reviewed and studied clinicopathologically together with the present case.

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A 50-year-old male complaining of left hypochondralgia was admitted to our hospital on December 17, 1985. A preoperative diagnosis of the transverse colon cancer with direct invasion to the stomach was made by examinations.
Curative operation (left hemicolectomy with distal gastrectomy, distal pancreatectomy, splenectomy and partial resection of the diaphragm) was performed on December 27, 1985. On gross appearance there was a 120mm colon tumor invading the stomach wall with gastrocolic fistula. Microscopically papillotubular adenocarcinoma invaded the mucosal layer of the stomach.
The patient is working without any sign of recurrence 16 months after surgery.
Smith et al emphasized in their report that microscopically colon cancer with gastrocolic fistula tends to be of a lower grade and lymphatic metastasis is rare. Nine cases of the tumor reported in Japan conformed to their opinion.

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We experienced three cases in which extirpation of locally recurrent colorectal cancer was combined with sacral resection.
Case 1: A 70-year-old man underwent low anterior resection for rectal cancer. Three years later a local recurrent lesion was found near the sacrum. Then the tumor was excised with sacral resection (S2-3). Case 2: A 50-year-old man, who had undergone Miles' operation for rectal cancer 13 months before, was diagnosed as having local recurrence near the coccyx. The recurrent cancer was locally excised with sacral resection (S3-4). Case 3: A 53-year-old woman undergone Hartmann's operation for cancer of the sigmoid colon. Twelve months later a local recurrent lesion was found near the residual rectal stump. The residual rectum was combined with resection of the sacrum (S2-3) and the vagina.
The prognosis is not good in patients who receive reoperations for locally recurrent tumors in the pelvis, but extirpation of local tumors seems to help extend survival time and symptom-free intervals.
Periodical follow-up studies should be made from the early post-operative period. The earlier a recurrent lesion is found, the less invasive resection is required. High amputation of the sacrum (S2-3) caused neither musculoskeletal disability nor bladder dysfunction.

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A 76 year-old woman was admitted on September 12, 1983, complaining of constipation and rectal incontinence since 1957. Severe stenosis of the rectum at 6cm oral from the anal verge and a large lipomatous tumor in the pelvic cavity were found. On November 14, 1983, amputation of the rectum with resection of the pelvic tumor and ileocecal resection were performed, because multiple circular stenoses were also observed in the distal ileum during the operation.
Pathological examination revealed that the rectal stenosis was caused by a circular ulcer scar penetrating to the surrounding adipose tissue which was a part of the pelvic tumor. Broad squamous metaplasia of the rectum was observed at the anal side of the stenosis. The pelvic tumor was 15×9×6cm in size, and was composed of mature adipose tissue.
No description of such an unusual case has ever been reported. The peculiar findings of this case were considered to result from a penetrating rectal ulcer scar of 26 years' duration.

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A 9-year-old boy was admitted to our clinic because of epigastralgia, fever, and janudice.
This patient was diagnosed as having congenital spherocytosis with cholelithiasis and underwent splenectomy, cholecystectomy, and choledochotomy with favorable results.
Because of a frequent association of cholelithiasis with congenital spherocytosis, it is necessary to examine for cholelithiasis. On the contrary, this disease should be considered in young patients with cholelithiasis including congenital biliary anomalies or infection.
Congenital spherocytosis is an important cause of congenital hemolytic anemia in Japan. Reported cases of cholelithiasis with related congenital spherocytosis are discussed.

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The major etiologies of pancreatic pseudocysts are generally considered to be traumatic and nontraumatic pancreatitis. Acceptance of surgical therapy for pancreatic pseudocysts is wide-spread, but there is a lack of agreement concerning the most suitable operative method. Pancreatic pseudocysts are associated with severe complications, infection, hemorrhage and perforation during the preoperative course. Further, they rarely undergo spontaneous resolution. Thirdly, there is little possibility of malignancy. Recently, after external drainage, a partial pancreatectomy, total gastrectomy and spleenectomy were carried out in a case of infected pancreatic pseudocyst. The results were good in terms of decreasing the incidence of recurrence and other complications.
The results suggest that a positive individualized approach is necessary for traumatic pancreatic pseudocysts.

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