A total of 3, 437 cases were laparotomized in this department during the 10-year period from January 1976 through December 1985. Of these cases, 45 (1.3%) developed organ failure as a postoperative complication, four of these were less than 39 years old, 9 were from 40 to 49 years, 5 from 50 to 59 years, 15 from 60 to 69 years, and 12 were more than 70 years old. Sixty percent (27 cases) were comparatively aged (more than 60 years). More pulmonary insufficiency, hepatic insufficiency and DIC developed in the older patients than in younger ones. These afflictions appeared in as many as 48% of the older cases. The aged subjects had a high mortality due to organ failure, and should take special care of postoperative pulmonary complications. Infections as postoperative complications often cause organ failures, so the aged subjects in particular should attach much importance to the treatment of their postoperative infections.

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With the improvement in end results for mammary cancer that have resulted from early detection and treatment, various kinds of reduction surgery are increasingly being performed. Further, the demand for reconstructive mammaplasty is gradually increasing. Mastectomy with preservation of the papilla and areola mammae was carried out in 14 patients with mammary cancer; reconstructive mammaplasty was also undertaken in two phases. The most important factor in determining the appropriateness of this surgery was considered to be the distance from the tumor to the papilla mammae. It is therefore necessary to measure the distance both on the breast and on mammograph.
No patient has had local recurrence or remote metastasis during the postoperative observation period (29 months at longest and 12 months at shortest). Reconstructive mammaplasty with preservation of the papilla and areola mammae is assumed to be safe if its suitability is carefully evaluated.

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In 99 cases (62 in males, 37 in females) undergoing total gastrectomy during the 10.5 years since September 1975, the Roux-en Y, ρ-type reconstruction was performed. Clinical evaluation of postoperative esophageal reflux was undertaken, based on clinical symptoms, contrast X-ray examination, endoscopy and manometric investigation to the types of gastro-jejunostomy: Graham type anastomosis (GA) in 36 cases, manual anastomosis (MA) in 38 cases and EEA-autosuture anastomosis (EEA) in 25 cases. The following results were obtained. Clinical symptoms suggestive of reflux esophagitis appeared in 44.8% of the MA group and in 8% of the EEA group, but not in the GA group. Esophageal reflux on X-ray examination occured in 28.9% of the MA group, but in only 2 cases of the EEA group and in only one case of the GA group. Endoscopic examination showed definite reflux esophagitis in 4 cases of the MA group, but there was no endoscopic abnormality in groups EEA and GA. The tone value measured by an open-tip method in the high pressure zone (HPZ) was lowest in the MA group. The tone value was significantly higher in the GA group than in the other 2 groups and was almost the same as that of the normal control. Values of length at the HPZ showed findings similar to the tone values. The jejuno-esophageal pressure gradient in the GA group was significantly lower than in the other 2 groups. Those values were significantly in patients with clinical complaints than in those without complaints. A common cavity phenomenon was noted in 4 cases of the MA group by test reflux examination of the jejuno-esophageal portion using a 3-lumen catheter.
According to these results, it appears that Graham anastomosis following total gastrectomy was the best reconstruction method from the point of view of postoperative reflux esophagitis, esophageal manometric observation was very useful for the clinical evaluation.

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With the development of digestive surgery, extended operations have become more common. disorders associated with this trend are also increasing, changes in bone after gastrectomy being one of them. It is believed to take several years before such bone changes appear. For diagnosis, roentgenography of bone should be performed in addition to biochemical tests involving serum levels of calcium, phosphorus and alkali-phosphatase, bone biopsy has to be performed for definite diagnosis.
In order to detect and treat bone symptoms early on, the amounts of bone minerals were measured for clinical study by determining mineral concentrations in bone by the noninvasive use of gamma-ray-diluted americium as well as biochemical tests.

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The Su-PS and Su-PR skin reaction was determined in 144 patients with gastric cancer, and the following results were obtained.
1) The Su-PS and Su-PR skin reaction was found to be a possible parameter for determination of immunological competence accompanying the advance of gastric cancer.
2) The Su-PS skin reaction was a parameter representing the sensitivity of gastric cancer patients to OK-432.
3) Changes in the Su-PS skin reaction provided an index for evaluating the therapeutic effects of OK-432 administration in patients with gastric cancer.
These results suggest that the Su-PS and Su-PR skin reaction tests are important in the treatment of patients with gastric cancer.

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In 530 resected cases of gastric cancer, scirrhous carcinoma occurred in 51 (21 males, 30 females). Operative methods were total gastrectomy in 36 cases and subtotal gastrectomy in 15 cases. Combined resection of adjacent organs was done in 34 cases (66.7%). Most of the cases were classified histologically as poorly differentiated adenocarcinoma. Most of the cases were exposed to the serosa, and most of the cancers were in stage IV. The 4-year-survival rate (y.s.r.) was 9.5%, which is worse than other macroscopic types. The 3-y.s.r. for curative resection cases was 34.4% (n=27) and 5.8% (n=24) for non-curative resection cases, a significant difference (p<0.02). The 3-y.s.r. for tumors 8.0 cm or less was 45.2% (n=15) and 12.8% (n=36) for tumors more than 8.0cm, also a significant difference (p<0.05). The 3-y.s.r. under the classification by Iwanaga was: linitis plastica type, 5.6% (n=18); superficial IIc type, 68.6% (n=8); erosive type, 21.2% (n=18), and stenotic type, 33.3% (n=7, 2-y.s.r.). The survival in the superficial IIc type was significantly better than the linitis plastica type (p<0.02). The methods of adjuvant chemotherapy had no influence on the prognosis. From the above, extended radical operaton of total gastrectomy or combined resection is necessary to improve the prognosis in scirrhous carcinoma.

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We evaluated the results of surgical treatment obtained from 173 patients with gastric cancer with peritoneal dissemination over a 16-year period and studied applications for surgery and the significance of palliative resection.
1) In all groups of P₁, P₂ and P₃ patients, results for resected cases were more favorable than those for non-resected cases, and some, although not many, of the resected P₁ and P₂ patients survived for three years.
2) Depending on surgical procedure and dissection, the results for cases with subtotal resectin were more favorable than those for cases with total resection, and the results for cases with R₂ dissection were more favorable than those for cases with R_0-1, dissection.
3) It was highly possible for the lives of P₁ and P₂ patients to be prolonged by resection, indicating that R₂ dissection is favorable. However, the direct mortality for P₃ patients was high, and it was impossible to expect prolongation of patients' lives by resection. P₃ patients were therefore not considered to be candidates for surgery.

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Various symptoms in obstructive arterial disease seem to be derived from ischemia due to a decreased blood flow in the peripheral tissues. Diagnostic imaging is usually used to determine the pathological condition of the disease.
Determination of tissue blood flow, however, is a more accurate diagnostic method. By using the electrochemical hydrogen clearance method, which is less invasive, tissue blood flow was determined at the ischemic gastrocnemius muscle during rest and exercise, before and after revascularization. With regard to the site of obstruction, tissue blood flow was found to be lower in the peripheral region than in the central. The degree of increase in tissue blood flow during exercise was also lower in cases of obstruction in the peripheral region. Comparison of blood flow before and after revascularization demonstrated the usefulness of determining local tissue blood flow. In addition in cases of diabetic angiopathy, the degree of increase in tissue blood flow during exercise was low, even though there was no obvious obstruction on arteriography, suggesting a pathological nature different from that of arteriosclerosis.

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Spinal anesthesia is a good choice for surgical treatment of the lower extemities in chronic rheumatoid arthritis (RA) patients. Local anesthetics which have been used for spinal anesthesia are not sufficient for RA surgery, because of their short duration. Thirty RA patients and twenty-five non-RA patients were divided into two groups, one group was given plain 0.5% bupivacaine, a long acting drug, as a spinal anesthetic, the other was given 1-2% lidocaine, a short acting drug as a spinal anesthetic. The duration of motor block, and sensory block, as well as blood pressure and heart rate, were recorded in each patient.
Isobaric 0.5% bupivacaine showed 259.7+42.6 minutes of motor block in RA patients, and this duration is long enough to perform satisfactory RA joint surgery. Hemodynamic changes (blood pressure and heart rate) were minimal and no complications were observed during or after the operation. The above data indicated that 0.5% bupivacaine spinal anesthesia is an effective method for lengthy surgery. The 1.5% lidocaine spinal anesthesia showed 38.7+8.9 minutes of motor block. This is a short duration was just enough to manipulate the operated knee joint. There were no complications during or after operation with 1.5% lidocaine.

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Reoperation of recurrent hyperthyroidism after thyroidectomy for thyrotoxicosis is an unsettled matter because the surgical techique is much more difficult and postoperative complications occur more frequently. The case reported here is a patient who has been surgically treated and pursued a good postoperative course after reoperation.
The patient was a 39-year-old female who was admitted for reoperation of recurrent hyperthyroidism 7 years after thyroidectomy for thyrotoxicosis. On admission, her thyroid was enlarged and the thyroid function placed her in a condition of thyrotoxicosis. Following the control of thyrotoxicosis, thyroidectomy was performed the residual thyroid tissue weighed 5gm. Her postoperative course was uneventful and she has been doing well with no evidence of recurrent thyrotoxicosis or postoperative hypothyroidism.

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The relationship of thyroid carcinoma to Graves' disease is unclear. We report our experience with Graves' disease and concurrent carcinoma and review the literature. During the 20-year period from January 1966 through December 1985, 127 patients were treated at our department for Graves' disease. Thyroid carcinoma complicated 6 cases (4.7%) classified as latent (3 cases), occult (2 cases) and clinically significant (1 cases) types.
The clinicopathological study revealed that most of the nodules were less than 2cm in diameter and tended to metastasize to the regional lymphnodes and then relapse. This leads to the speculation that hyperthyroidism dose not inhibit the growth and possibly not the genesis of thyroid carcinoma. So we must take care of concurrent carcinoma in treating Graves' disease.

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Mediastinal goiter is a comparatively rare disease. Three skin incisions (collar incision, median sternotomy, thoracotomy) are available for operation and the one used should be dicided according to the individual case.
All operations in this study were performed by collar incision. One in four cases was malignant; the others were benign.
The symptoms of mediastinal goiter are due to pressure on the mediastinal structures, but symptomless cases are commen and include malignant cases. When mediastinal goiter is observed, it should be operated on as soon as possible.

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The patient was a 65-year-old man in whom hypercalcemia and irregular bradycardia were found during follow-up observation for chronic pancreatitis. He underwent surgery on the basis of a detailed examination and diagnosis of primary hyperparathyroidism. A preoperative ECG revealed bradycardia with reduced ST in leads II, III and aVF, reduced QT and irregular P wave (serum Ca, 17.4mg/dl; pulse rate, 40/min). The serum Ca level increased transiently by 1.2mg/dl after excision of the tumor, and began to decrease rapidly about five and a half hours later, to become almost normal on the following day. After surgery, the pulse rate was improved, and the reduction of QT and the decrease in ST on ECG were eliminated, yielding regular pulses with sinus rhythm. The effects of hypercalcemia on the vagus nerve and the conduction system of the heart and myocardium have been cited as causes of bradycardia. In our case, involvement of the valgus nerve was suggested by the imporvement in bradycardia with atropine and exercise. In addition, postoperative improvement in wandering-pacemaker and the lack of difference in PQ time before and after surgery suggest influence on the sinoatrial node. Detailed elucidation of the pathogenic mechanism will, however, require further investigation.

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Recently we had a patient with occult breast carcinoma complaining chiefly of a tumor in the right axilla.
The incidence of occult carcinoma at our clinic is quite low: one case in 1, 100 primary breast cancer cases (0.09%).
The patient, a 44 year-old woman, noticed a tumor about 4cm in diameter in the right axilla, and was examined at the Surgical Department of our hospital. A biopsy of the right axilla led to the diagnosis of metastatic adenocarcinoma. Breast examinations showed no findings, and other systemic examinations were non-contributory.
On suspicion of occult carcinoma of the breast, a modified radical mastectomy was performed. Subsequent histological examination showed an 8mm mass in the outer inferior region. The histological diagnosis was infiltrating medullary carcinoma with lymphoid infiltration.
As reported elsewhere in the references, when a patient has an axillary mass in the absence of breast abnormality, a search for a primary focus in other organs should be made first. If no such anomalies are found, radical mastectomy of the breast should be performed without hesitation.

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A 62-year-old male patient suffering from abdominal aortic aneurysm developed acute occlusion of both iliac arteries due to embolism originating from large floating thrombi in the aneurysm. Shortly after successful thromboembolectomy in the left lower extremity, typical symptoms of DIC developed such as ecchymosis, a drastic decrease in platelet count, a decrease in fibrinogen level, and an increase in the fibrin degradiation product (FDP). These were successfully controlled within 3 weeks by gabexate mesilate (FOY^⊗) and heparin. Then the aneurysm was radically operated using a prosthetic Y graft, under normal conditions of blood coagulation. When the aneurysm was opend, a large quantity of fresh and old coagula appeared occupying almost all of the space in the aneurysm lumen. This suggested the existance of a localized field of abnormal hypercoagulation and accelerated fibrinolysis. Although abdominal aortic aneurysms are rarely complicated by DIC, care must always be taken not to overlook this. DIC is one of the most serious risk factors in aortic aneurysms.

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On gastroesophagoscopy during a routine medical examination, a 57-year-old woman was found to have a minute depressed lesion with reddening of the surrounding mucosa on the wall of the thoracic esophagus. The lesion was subsequently identified by biopsy as squamous cell carcinoma and was referred to us. X-ray examination on admission failed to delineate the lesion, but endoscopy disclosed a minute erosion-like depressed lesion of the esophageal mucosa situated at a distance of 25cm from the incisors. Under the diagnosis of early esophageal cancer she underwent total thoracic esophagectomy and an operation of retrosternal quasi-total gastric reconstruction. In the excised portion of the esophagus there was a shallow depressed lesion, 4×2mm in size, surrounded by a slightly reddened area of mucosa. This was shown histologically to consist of a squamous cell carcinoma 1mm in diameter confined within the mucosal epithelium and haloed by an area of dysplasia 3mm in diameter. Leukoplakia and chronic inflammatory cell infiltration were also present as concomitant changes. Of all cases of intraepithelial cancer of the esophagus so far reported in Japan, data compiled from 28 well documented cases were analyzed for pathological and other conditions.

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Primary duodenal carcinoma is an unusual lesion.
Recently, case reports have been increasing and more than 200 cases have been reported in Japan. But primary carcinoma of the duodenal bulb is still rare.
Here, 78-year-old woman with primary carcinoma of the duodenal bulb is reported.
She complained of tarry stool and was diagnosed by UGIS as having duodenal tumor. Segmental resection was performed with dissection of the regional lymph nodes.
Another 50 cases of primary carcinoma of the duodenal bulb in Japan were collected and analyzed as to sex, age, symptoms, gross findings, size, histology and operation.
In older woman, primary carcinoma of the duodenal bulb occurs more often than other duodenal cancer. Many of the cancers are polypoid lesions. Further study may be necessary to establish the best operation for this disease.

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Intramural gastrointestinal hematoma (IGH) is a well recognized complication of trauma, anticoagulant therapy and many types of bleeding diathesis. IGH in hemophiliacs is uncommon, but recently cases have been reported here and there. We have experienced a case of intramural hematoma of the jejunum in a hemophiliac A. It is reported here with a review of the literature.
The patient, a 31-year-old male, a known severe hemophiliac A, was admitted to our hopsital with complaints of abdominal pain and vomiting of material resembling coffee-grounds. Laboratory data revealed a white blood cell count of 17, 800/mm³, a hemoglobin level of 16.6 g/gl and a hematocrit 48.7%. On physical examination, there was abdominal tenderness. A plain X-ray film of the abdomen showed distended loops of the small intestine. under a diagnosis of acute abdomen, laparotomy was performed. Intramural hemorrhage appeared extending 30 cm along the jejunum. The affected part of the small intestine was resected.
Our literature search produced 27 cases of IGH in hemophiliacs in foreign countries and 6 cases in Japan, including the one just reported. In IGH, conservative management including replacement therapy is chosen initially, and surgical intervention is reserved.

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The patient was a 73-year-old male who came to the outpatient clinic for edema of both lower extremities and lower back pain. A large pelvic tumor was noticed. Abdominal exploration revealed a large cystic mass in the pelvis that seemed to arise from the jejunal wall, and it was excised.
The pathological diagnosis was epithelioid leiomyosarcoma.
This rare tumor is especially rare in the small intestine.

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A case of postoperative intussusception in an 11-month-old girl is reported. She underwent posterior gastropexy for sliding hiatal hernia, but because of a passage disturbance of the pylorus, pyloroplasty was done on the 12th postoperative day. Nasogastric output increased on the 4th day after pyloroplasty. Abdominal plain X-P showed dilatation of the intestinal loops. Because of her stable hemodynamic condition, nonoperative management was continued. When her condition changed to the toxic state 4 weeks later, emergent laparotomy was performed and ileo-ileal intussusception was reduced manually. Subsequent convalescence was uneventful.
Postoperative intussusception should be suspected in any infant with early evidence of intestinal obstruction, and prompt laparotomy should be undertaken.

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A case of solitary tuberculoma of the liver is presented with a review of 18 cases reported in the Japanese literature.
A 60-year-old female was admitted, complaining of fever and right hypochondriac discomfort. Abdominal CT and ultrasonographic imaging revealed a tumor located in S4 and S8 of the liver. Hepatic angiography also demonstrated a tumor shadow with mild vascularity and tumor stain, suggestive of hepatoma. Hepatic resection of S2, S3, S4, and S8 was performed. Pathological examination of the resected specimen disclosed non-caseous granuloma and acid-fast bacilli with Ziehl-Neelsen staining.
A survey of the 18 cases revealed the following features: The age distribution was biphasic with peaks at 20 and 40 years. The sex distribution was equal. Fever, abdominal pain, and mass were commonly encountered as clinical manifestations. Only three of the 18 cases were diagnosed correctly and two of these three cases underwent echo-guided needle biopsy. In 15 cases, surgical resection was performed and in only one was chemotherapy alone administered. Recovery was good and neither recurrence nor death was reported.
Difficulties in the imaging diagnosis and the efficacy of echo-guided needle biopsy were emphasized.

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Biliary peritonitis due to rupture of the bile duct is a rare disease. Among such cases, we have experienced the even rarer condition of biliary peritonitis due to rupture of the bile duct caused by cholangiocarcinoma.
The patient was an 80-year-old man who complained of severe epigastric pain. Although biliary peritonitis was not indicated by diagnostic imaging, findings in the abdominal region upon physical examination and changes in laboratory data led to a dignosis of biliary peritonitis. Therefore, after drainage and PTCD, excision of the portal bile duct and cholangiojejunostomy were performed. The patient's postoperative course was favorable, resulting in discharge 34 days after surgery. Based on our search of the literature, this patient represents the first reported case of biliary peritonitis caused by rupture of the intrahepatic bile duct due to portal cholangiocarcinoma.
It is difficult to preoperatively determine the site and degree of biliary leakage. It is also difficult to decide whether and when to perform emergency surgery, and the surgery is often limited to drainage and fistulation. Therefore, radical surgery on the basis of sufficient understanding of the lesion is required in the early stage, before the condition develops into general peritonitis.

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Presented here are two young male patients with Klinefelter's syndrome, of the rare karytotype 48, XXYY, combined with hypostatic leg ulcers. Because the incidence of varices and/or hypostatic leg ulcers is much higher in Klinefelter's syndrome than in the normal population, a differential diagnosis of Klinefelter's syndrome must be made when the patient is young and has a refractory venous ulcer in the lower leg.

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