Comparative studies were performed on the rate of isolation and susceptibility of S. aureus isolated from clinical materials and airborne flora in wards. The following results were obtained.
1. The incidence of infection caused by S. aureus was higher in neonates and infants than in children aged over 1 year. It was observed that the susceptibility of S. aureus to antibiotics was obviously different between primary and postoperative infection. It was particularly poor in the latter when treated by third-generation cephem antibiotics.
2. In terms of the isolation of S. aureus in airborne flora in wards, it was more frequently isolated in children's wards. With respect to susceptibility, the isolates from children's wards were resistant to many antibiotics, including cefazolin and gentamicin. In our series, 16.7% of S. aureus were methicillin resistant, 90% of which were isolated in children's wards. These results indicated that surgical infection caused by S. aureus was largely related to airborne flora. It is important to keep the environment clean and to use antibiotics properly and adequately.

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Thirty cancer patients were treated by using a vascular access devices (VAD) combined with radio-frequency local hyperthermia (RFLH) with or without charcoal hemoperfusion. The mean observation period was 7.85 months. Favorable responces (better than minor response by the criteria for the evaluation of responces to treatment for solid cancer) were obtained in 40% of the patients.
Complications occurred in 26.7% of the patients. However, none of them were serious. The complication rate was only one complication for every 841 days of cumulative function time of the 30 patients. The complications were local hematoma around the VAD (2 cases), duodenal ulcer (1 cases), ulcer in the perineal and gluteal region (2 cases), thrombosis of the catheter of the VAD (3 cases).
The incidence of local hematoma and thrombosis of the catheter were reduced after the medical staff were familiarized with the techniques of implantation and maintenance of the VAD. Ulcers did not occur also after the tip of the catheter was more super-selectively placed, or the anticancer agent was more selectively given by embolization of the gastro-duodenal artery or superior gluteal artery.
Application of the VAD is considered safe and useful for intra-arterial cancer chemotherapy.

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Three hundred and seventy-six female patients with primary breast cancer who had undergone curative operation during the 20 years from Apirl 1965 through December 1984 were analyzed clinicopathologically.
The present study indicated that the parasternal lymph nodes should be dissected in patients with tumors larger than 1 cm in diameter located in the inner half of the breast and those with tumors located in the outer half with axillary lymph node involvement.
Consequently, modified radical mastectomy (Br+Ax+Mn) might well be indicated for patients with tumors smaller than 1 cm in diameter and located in the inner half or smaller than 2 cm in diameter and located in the outer half with neither axillary lymph node involvement nor infiltration into the pectoral muscle and/or fascia.
The prognosis of patients with parasternal involvement was generally unfavorable, but some patients with a low degree of involvement survived over 10 years.
In contrast, adjuvant radiotherapy following radical operation carries the risk of locoregional morbidity, and seems to have only minor benefits in improving the prognosis of patients. At present, the dissection of parasternal lymph nodes is preferable to radiotherapy in the treatment of patients with breast cancer.

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The pattern of recurrence after mastectomy in 260 patients who had undergone a radical operation for breast cancer over the past 15 years and 4 months was studied. The number of patients in whom cancer recurred at the site of the initial occurrence was the largest for bone, 18, followed by 10 for a lymph node, 9 for the lung, 7 for the liver, 3 for the contralateral breast, 2 for the brain, and 1 for a local site. The mean period between the opeartion and recurrence (latent period) according to the site of recurrence was 13 months for the liver, 15 months for a lcoal site, 18 months for the brain, 28 months for the lung, 30 months for bone, 32 months for a lymph node, and 35 months for the contralateral breast. There was 3 patients with a recurrent breast cancer less than 2 cm in diameter (T0, T1), and all 3 of them showed histological findings indicating lymph node metastasis. There were 8 patient with recurrence unassociated with lymph node metastasis (n0), 6 of whom had a tumor 30 mm or more in diameter and in 7 of whom histological examination revealed ductal carcinoma of the solid type. There were 9 patients with recurrence among the patients with parasternal lymph node metastasis, showing a trend toward an increase in recurrence among the patients who had undergone no radiation after mastectomy.

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Recently, four patients were treated for chylothorax complicated in thoracic surgery for lung cancer. Three of them were improved by conservative therapy (drainage with restriction of oral intake and intravenous replacement in two and the addition of pleurodesis with OK-432 in one). It seemed that OK-432 was highly effective. The other patient underwent ligation of the thoracic duct. Postoperative drainage ranged from 14 to 42 days (average, 25 days).
We concluded that conservative treatment should be abandoned if there is a loss of chyle of more 500 ml per day in an adult for more than five days.

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The prognosis for elderly patients with perforated gastric or duodenal ulcers is poor because of reduced reserve force of various organs and coexistence of some other disease. Special care is needed in the treatment of these patients. Over the past 10 years, 59 patients with perforated gastric or duodenal ulcers were treated at the Kobe University Hospital (the First Department of Surgery) or the Kakogawa City Hospital. Of these patietns, 8 were over 70 years old. In these 8 elderly patients, we analyzed the influence of background variables on their prognosis. Four of the 8 patients had an earlier history of ulcers. Thus, in many of the cases studied, the time from onset of the ulcer to perforation was short. Only about 20.0% of the patients had some subjective or objective symptoms (such as paroxysmal epigastralgia and Blumberg's sign), while the rate of detection of free gas on abdominal X-ray films was as high as 75.0% (this figure was comparable to that for the other age groups). The mortality of elderly patients with perforated ulcer was high (50%). Factors presumably affecting their prognosis are the presence/absence of some other serious disease and the length of time from the onset of perforation to surgery. Extensive gastrectomy seems to be the basic surgical technique suitable for elderly patients with a perforated ulcer.

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We reviewed the deaths of 380 patients with early gastric cancer resected at our hospital during the past 21 years, especially deaths from recurrence of cancer. Up to now, 46 deaths have been confirmed, consisting of 2 from surgical invasion, 17 from cancer and 27 from other deseases such as cerebrovascular disorders, cardiac diseases and pneumonia. Out of 17 cancer deaths, 4 died of cancer of other organs than the stomach, 4 of newly developed cancer in the residual stomach after operation, and 9 of recurrent gastric cancer (recurrent mortality 2.5%). Deaths from recurrent cancer after curative resection occurred in 8 cases (recurrent mortality 2.1%). When stratified by depth of infiltration, the recurrent mortality of m (mucosal) cancer was 1.0% (2/210), and that of sm (submucosal) cancer was 3.7% (6/163). However, in sm cancer infiltrating deeply into the submucosal layer, the recurrent mortality was as high as 12.5%, unlike that in slightly inflitratin sm cancer. The recurrent mortality of differentiated cancer was 3.2%, higher than that of undifferentiated cance, 0.7%. Further, cases of early cancer who died from cancer recurrence were histologically positive to lymph node matastasis and vascular invasion.

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Among 899 patients who had undergone resection for gastric cancer, excluding remnant or multiple cancer, over the past 14 years in our hospital, 98 patients (10.9%) had cancer localized in the C region. Cancer of the gastric cardia as defined by Nishi et al. was found in 37 out of these 98 patients, amounting to 4.1% of the total number of resected gastric cancers. The characteristics of cancer of the gastric cardia were studied by comparison with other cancers localized in the C region, and the following results were obtained. Cancer of the gastric cardia was most frequently found in males, being 4.3 times as frequent as in females. The macroscopically depressed type, mainly IIc, and histologically differentiated type were predominantly found among early cancers. On the other hand, advanced cancer frequently presented Borrmann type 3 macroscopically and was histologically of the differentiated type, although there was no significant difference in frequency from the undifferentiated type. The five-year survival rate of patients given curative resection was 67.6%.

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Serum carcinoembryonic antigen (CEA) values were determined in 123 patients with colorectal carcinoma preoperatively. Serum CEA titers above 5.1 ng/ml were considered to indicate positive cases. Preoperatively 50.8% of all patietns had a positive test result. According to stage classification, the assay was positive in 9.1% of patients with stage I tumors, 50.9% with stage II, 38.9% with stage III, 33.3% with stage IV and 88.9% with stage V. Among cases of small cancers less than 2 cm in size, there were no positive results.
Histopathological evaluation of the tumor included evidence of lymphatic vessel and venous invasion and degree of wall penetration. A low serum CEA level in colonic cancer cases suggested that the tumor was localized within the bowel wall and the patient underwent curative resection. The higherst values were found in patients with liver metastasis. Serum CEA levels tended to be elevated when hepatic metastasis, peritoneal dissemenation, serous invasion and wall penetration were present. However, CEA value was not directly correlated with either lymphatic vessel or venous invasion.

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One hundred and twenty nine patients with cystic lesions of the liver including 108 cysts, 17 abscesses and 4 hematomas were examined by ultrasound.
We studied the usefulness of ultrasonically guided percutaneous puncture and drainage for 23 of 129 patients with cystic lesions of the liver including 7 of 108 cysts, 15 of 17 abscesses and one of 4 hematomas.
Ultrasonically guided percutaneous catheter drainage was useful for 13 of 15 patients with liver abscess and one with hepatic hematoma.
Seven patients with large cyst of the liver were treated with absolute ethanol injection under ultrasonically guided puncture. After treatment, remarkable shrinkage of all cysts was observed on the ultrasonogram.
For early reduction of huge cysts of the liver over 15 cm in diameter continuous drainage and repeated injection of absolute ethanol were useful.
Histopathlogical findings of hepatic cyst after absolute ethanol injection therapy showed not only degeneration of the epithelial lining cells but also intramural bleeding, degeneration and necrosis.
As treatment with ultrasonically guided percutaneous puncture and drainage is simple and harmless, we conclude that this procedure is effective for treatment of cystic lesions of the liver.

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Three patients with severe tetanus were successfully treated by barbital therapy.
In the management of tetanus it is important to provide treatment for frequently occurring convulsion or an accumulated convulsive status in addition to antitoxin therapy. The present three patients with severe tetanus showed almost complete suppression of convulsion by administration of thiamylal at a maintenance dose of 4 mg/kg/h. It is necessary, however, to take into account the necessity of using an artificial ventilator, possible occurrence of pulmonary complications accompanied by increased sputum production, heart failure and hypotension. Medication should be discontinued after the dose has been gradually decreased for 2-3 days, when the convulsion has been completely suppressed for 1-2 weeks after initiation of the therapy.

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We report a 49-year-old woman with advanced thyroid carcinoma that could be resected by left lobectomy with partial resection of the left internal jugular vein, recurrence nerve and esophageal muscle.
She visited our department with the complaint of hoarseness, difficulty in swallowing and limited neck movements.
In preoperative angiography, the left jugular vein was not visualized and the common carotid artery was pushed to the external anterior region. Direct invasion to esophageal muscle was suspected on CT.
A tumor (15×15 cm in size, 400 g in weight) was found in the left lobe of the thyroid, with many small cysts. In the center of the tumor, there was a parenchymal hard nodule and fibrosed bundle, indicating malignancy.
The left jugular vein and recurrence nerve were completely involved and direct invasion of about 3 cm to esphageal muscle was noticed.
The common carotid artery and trachea were not directly invaded and could be dissected.
The tumor was histopathologically diagnosed as papillary carcinoma, and direct invasion to esophageal muscle was demonstrated.

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A case of mediastinal hemangiopericytoma is presented.
Hemangiopericytoma is a rare tumor and in Japan there have been only 210 cases since Ohta first reported it in 1913. This tumor consists of pericytes and shows a characteristic pattern with reticulin staining. Although these tumors can exist in any part of the body, most of them occur in the lower extremities and retroperitoneal space.
Tumors in the mediastinum are extremely rare. CT and angiography are useful in diagnosis. The best treatment for this tumor is surgical removal. Radiation therapy and chemotherapy are not effective. The survival rate in these patients is inversely proportional to the size of the tumor. In our case, the patient has survived one year without disease.

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A case of splenic artery aneurysm accompanied by an abdominal aortic aneurysm is reported. The patients, a 71-year-old woman, was found to have a pulsating abdominal tumor when she was admitted to the hospital because of hypertension. Angiography of the abdominal aorta revealed an 8 cm×10 cm abdominal aortic aneurysm, and a 1.2 cm×1.2 cm splenic artery aneurysm. The abdominal aorta was replaced a Y-shaped double veloar knitted dacron graft, and splenectomy including the splenic artery aneurysm was performed. Histological findings showed that both the abdominal and splenic artery aneurysms are relatively arteruosclerotic changes. Splenic artery aneurysm are relatively rare and to date only 159 cases have been reported in Japan. Since mortality and morbidity rates are high, intensive care and imidiate surgery are necessary.

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Eosinophilic enterogastritis is regarded as an idiopathic disease which induces infiltration of eosinophils into various layer of the gastrointestinal tract. This disease commonly involves the gastric antrum, and frequently has been reported in the European and American literature but rarely in the Japanese literature.
In this case, eosinophilic gastritis with a concaved lesion was found at the upper body of the stomach, and subtotal gastrectomy was performed because the lesion was refractory to conservative therapy. The final diagnosis of this disease was made by the pathohistological findings.

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Leiomyoma (LM) and leiomyosarcoma (LMS) of the duodenum are relatively rare, and precise, differential diagnosis is not necessarily easy in either case.
We report one case each of LM and LMS, and review the 165 cases of LM (1935-1985) and 126 cases of LMS (1975-1985), including our cases, in the Japanese literature.
1) The main symptom of LM is melena; that of LMS, abdominal mass. 2) If an upper gastrointestinal series reveals displacement of the stomach and duodenum, widening of the duodenal sweep, fistula, cavity and others, LMS is highly likely. 3) LMS is disclosed as variegated findings on US and CT. 4) If angiography reveals encasement, LMS is highly likely. 5) LM is usually 2-5 cm in size, and LMS 10-15 cm. 6) LMS is often associated with liver metastases.
From these findings we think that, in addition to histological findings, the size and nature of the tumor, especially biological malignancy, should be referred to in determining the treatment for LM and LMS.

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Preoperative diagnosis of the tumors of the small intestine is generally considered to be difficult. We were able to diagnose a benign hemorrhagic tumor of the small intestine by preoperative angiography in a patient who had bloody stools and abdominal pain. This patient is described with a review of the literature.
A 47-year-old male complained of bloody stools and abdominal pain, and presented with marked anemia on admission. No lesion considered to be the source of bleeding was detected by close examination of the upper and lower digestive tract. The presence of a bleeding lesion in the small intestine was suspected and angiography was performed. A high-density image of a tumor supplied by a branch of the jejunary artery was observed, and emergency operation was carried out. A mass, partially accompanied with vessel exposure, was found 230 cm anally from the ligament of Treitz and was resected. Histologically, the tumor was leiomyoma of the jejunum.
Angiography, especially the disital subtraction type, is useful when a bleeding tumor of the small intestine is suspected, as in this patient.

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A 26-year-old female visited Rokko Hospital complaining of dry cough. The disorder was diagnosed as a mediastinal tumor by chest X-ray and CT. She underwent resection for the mediastinal tumor. Although the postoperative course was favorable, she complained of abdominal pain and fever 1 year and 3 months after the operation. Laparotomy was performed and leiomyosarcoma in the small intestine was confirmed and resected. The mediastinal tumor was diagnosed as a malignant schwannoma because of the operative and histopathological findings at the time of the first surgical operation. However, further immunohistological studies for S-100 protein indicated that the mediastinal tumor was a metastatic lesion of leiomyosarcoma of the small intestine.
Leiomyosarcoma of the small intestine rarely metastasizes into the mediastinum, and it is usually difficult to reach a correct preoperative diagnosis because of its rarity and variable pathological features. Its histological findings are similar to those of malignant schwannoma because of the presence of bundles of spindle cells. The present studies suggested the importance of the recently introduced immunohistological method for S-100 protein in addition to routine histological methods such as PAS and silver impregnation for pathohistological differential diagnosis.

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This paper describes two adult cases of intestinal obstruction caused by an omphalomesenteric duct remnant.
The two male patients presented here, aged 43 years and 20 years respectively, free of previous laparotomy, had emergency surgery and were found to have an omphalomesenteric duct remnant. The remmnants were composed of Meckel's diverticulum and a fibrous band which connected the umbilicus and the tip of the diverticulum.
In one case the fibrous band and the diverticulum compressed the small intestine, while in the other the small intestine created a volvulus around the umbilicus.
A short segment of ileum involving Meckel's diverticulum and the fibrous band was resected and end-to-end anastomosis was performed in both cases.
In patients with a negative history of abdominal surgery, an omphalomesenteric duct remnant should be considered as the cause of intestinal obstruction. In operative management, it is important not to leave intestinal mucosa adjacent to the umbilicus.

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In Japan, rectal carcinoid has so far been regarded as a disease of comparatively low incidence and as benign in most cases. Up to 1982, however, 25 cases of metastatic carcinoid had been reported.
During the past 10 years, we have experienced 7 cases of rectal carcinoid, in 3 of which liver and bone metastasis wea present.
Neuron-specific enolase stain was positive in the 6 cases of rectal carcinoid examined by the enzyme-labeled antibody method. We discuss these 7 cases with additional discussion of the rectal carcinoid-producing mother cell.

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Leiomyosarcoma of the alimentary tract is a relatively uncommon disease, but recently, some cases have been reported in Japan. Because of the severe liver metastasis and poor prognosis, surgical treatment of liver metastasis of leiomyosarcoma has been rare.
In a patient with leiomyosarcoma of the rectum, liver metastasis was diagnosed by abdominal CT scan, because of the presence of an intrahepatic low-density area. A right partial lobectomy was performed and liver metastasis of the leiomyosarcoma of the rectum was diagnosed histopathologically.
Liver metastasis of leiomyosarcoma is difficult to diagnosis because its clinical findings often differ. It is important to diagnose liver metastasis early as possible, by means of ultrasonography and computed tomography. Further more, hepatectomy for metastasis of leiomyosarcoma is useful for treating this disease, so in general should be performed.

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A echogenic mass of 8 mm in diameter was detected by ultrasound in the liver of a 26-year-old man with normal liver function tests. Ten months later, it has grown by 2 cm. Angiography did not demonstrate a spoke-wheel pattern but faint staining of the tumor was seen. Plain CT and CT with bolus injection disclosed a low-density area that was not enhanced. With angio-CT, it was enhanced as a high-density area containing small low-density nodules. The resected specimen revieled a yellowish solid mass without fibrous capsule. Histological diagnosis was hepatocellular adenoma (HCA). Contraceptives and other drugs were not administered in this patient. The doubling time of this tumor was 96 days. HCA is demonstrated as a low-density area by CT, but angio-CT revealed it as a hypervascular tumor. These facts have not been reported and may contribute to the clinical diagnosis of HCA.

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A case of hepatocellular carcinoma (HCC) with localized bile duct dilation and lymph node metastases which was resected is reported.
A 64-year-old man was admitted to the hospital because of a liver tumor which was found incidentally at another hospital. Diagnostic imagings revealed a 4 cm-in-diameter tumor in the medial segment of the liver associated with bile duct dilation of the lateral inferior segment of the liver and lymph nodes swelling named No.12. A celiotomy was carried out under the suspected diagnosis of cholangiocellular carcinoma (CCC). Extended left hepatectomy with lymph nodes dissection was performed. Histologically, all lesions were HCC without any component of CCC.
HCC with localized bile duct dilation, especially resected one, is rare and misleading to the diagnosis of CCC. Bile duct dilation due to a liver tumor is characteristic of CCC, but it is not diagnostic to CCC.

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A 72-year-old male with a chief complaint of right hypogastric pain was diagnosed as having torsion of the gallbladder by abdominal ultrasonography prior ot surgery and successfully treated by an emegency operation. Abdominal ultrasonography provided characteristic findings of torsion of the gallbladder such as 1) pronounced swelling of the gallbladder, 2) circumscribed thickening of the gallbladder wall, 3) displacement of the gallbladder, 4) free internal gallbladder echo and 5) a volvulated gallbladder neck delineated at a high echo level. It is anticipated that abdominal ultrasonography will yield an increasing number of preoperatively diagnosed cases of gallbladder torsion if the possibility of this disease is taken into account in the diagnosis of patients with abdominal pain.

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A case of acute emphysematous cholecystitis is reported in which abdominal CT examination was useful for differential diagnosis.
A 49-year-old man with no eventful history was ademitted to the hospital because of epigastric pain. A plain film image showed an abnormal gas shadow within the wall of the gallbladder. Abdominal CT examination confirmed the air-fluid level in the lumen of the gallbladder. These findings suggested acute emphysematous cholecystitis. Cholecystectomy was immediately performed. The distended gallbladder showed gangrenous cholecysitis, and the cystic duct was found to be obstructed by a small calcium bilirubinate stone at operation. Culture of the intraoperative gallbladder bile was positive and Bacteroides spp. was found. Pathological examination of the resected gallbladder showed gangrenous cholecystitis and emphysema of the mucosa. By progressive diagnostic imaging of the abdomen, we were able to make an early diagnosis of this disease. This was valuable since early operation is the best choice of treatment.

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Plasma exchange as a treatment for severe pancreatitis aims at reducing circulating enzymes derived from the inflamed pancreas. On the other hand, among organ failures, renal failure is not a rare complication of severe pancreatitis and hemodialysis is thought to be an effective procedure in such cases. Recently, we experienced a case of severe acute pancreatitis which was successfully treated by plasma exchange combined with hemodialysis at the same time. The patient was a 27-year-old man, who drank up to half a bottle of whisky almost every day. He had abdominal symptoms of epigastralgia and distension and was hospitalized in a state of shock. He was diagnosed as having severe acute pancreatitis and was resistant to conservative treatment for the accompanying renal and hepatic failure and disturbance of consciousness. Plasma exchange combined with hemodialysis, with the respective filters set in an alignment, was performed three times bigining 10 days after admission.
His condition took a turn for the better in terms of chemical analysis of the blood and clinical symptoms after this treatment and he recovered without any remaining complications. The CT-score was 22 points on admission and it was reduced to 0 point 5 months later when he was discharged.

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A case of metastatic adrenal cancer in a 59-year-old male complaining of low grade fever and gereral fatigue is reported.
He had had a left lower lobectomy for adenosqamaous cell carcinoma of the lung 15 months earlier.
Computed tomography, ultrasonography and angiography revaled a left adrenal tumor which was successfully resected.
The adrenal tumor was confirmed as a metastasis from the lung cancer, by histopathological examination.
If no metastatic foci are found in other organs, excision of the metastatic adrenal cancer should be performed.

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A 62-years-old man who complained of hematochezia was admitted to our hospital with suspected rectal cancer. Several examinations revealed two independent tumors in the rectum, and his discourse was diagnosed as primary rectal cancer with simultaneous prostate cancer involving the rectum. The patient underwent total pelvic exenteration for enbloc removal of the lesions. Pathological diagnosis of both of these independent lesions was prostate cancer involving the rectum. Reported incidences of prostate cancer involving the rectum are less than 10%. Furthermore, two independent rectal lesions with an intact mucosa between them are quite uncommon. This patient had Klinfelter's syndorome, which may be coincidental in this patient, but the incidence of cancer in these parients is reported as high.

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