Correlations between the morbid condition of liver cirrhosis and plasma free amino acids, immunoreactive insulin (IRI) or immunoreactive glucagon (IRG) were studied. The following results were obtained from two groups of patients with and without encephalopathy:
1) The sum of branched-chain amino acids (BCAA) was closely related to KICG, Bil and NH₃.
2) There was a negative relation between the sum of AAA and KICG, whereas there was a positive relation between the sum of AAA and Bil or NH₃.
3) BCAA/AAA was closely related to KICG, NH₃ and Bul, which were in turn related to cholesterol or albumin.
The following results were obtained from the group without encephalopathy:
1) There was a negative correlation between IRI and I-Leu, Leu or BCAA/AAA;
2) There was a close correlation between IRG and I-Leu or BCAA.
It was thus considered that BCAA and AAA showed a close correlation with liver function, being respectively specific for IRI, IRG and individual amino acids. Therefore pre- and postoperative determination of individual changes in BCAA and of changes in IRI and IRG may provide an important index for nutrition management.

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To investigate the role of degeneration or destruction of white blood cells (WBC) in 5 patients with respiratory dysfunction who underwent surgical operation, we measured the plasma levels of granulocyte elastase (GEL), α1-antitrypsin (α1-AT), WBC and respiratory index. At the same time or after the decrease in WBC, the GEL level was increased and respiratory dysfunction appeared. After operation, the α1-AT level was decreased in 3 out of 5 cases.
It was thought that GEL discharged from WBC may produce endothelial cell damage in the lung. GEL in the lung may be activated as a result of decreased αl-AT after operation. Neutropenia, decreased αl-AT and increased GEL level may play an important role in the etiology of ARDS.

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Although operative methods and management have been improved, but an appreciable number of cases are still subject to reoperation due to postoperative complication. We examined 92 cases of reoperative gastrointestinal surgery experienced in our department during a 14-years period.
The reuslts were as follows: 1) Incidence of reoperation was 3% and there was difference between the previous and latter terms. 2) Although sutural insufficiency was decreased, postoperative bleeding and ileus were increased in the latter term. 3) Reoperation was done more frequently between 1 and 8 days in the previous term and between 14 and 21 days in the latter term. 4) Patients aged between 30 and 80 years accounted for as much as 77% of reoperative cases. 5) The prognosis for reoperation was unfavorable in malignant than in benign primary cases. 6) Of the 92 examined cases, 30 resulted in death, most of which involved reoperation in the early postoperative period. Old persons accounted for 50% of the cases. The prognosis in old patients depends upon the presence of asymptomatic functional disorders of organs.

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Surgical treatment of 14 adult patients with endocardial cushion defect (ECD) between July 1975 and June 1987 was reviewed. The ages ranged from 28 years to 57 years (mean 40). There were 11 females and 3 males.
Pulmonary-sytemic flow ratios ranged from 1.90 to 4.16 (mean 2.92). Atrial septal defects were closed with patches in all cases. Mitral clefts were not touched in 2 cases, repaired at cleft base in 7 cases, repaired at cleft base plus given annuloplasty by Kay's method in 2 cases, and replaced with prosthetic valves in 3 cases. Tricuspid valve replacement was performed in 4 out of 14 (29%) cases. There was one early death due to low cardiac output and one late death due to multiple organ failure. Postmortem histological examination revealed vacuolous degeneration of myocardial cells and thickened intima of pulmonary arteriolae in the former case. Both patients were more than 50 years old and had histories of congestive heart failure. Postoperative improvements in NYHA functional classification and cardiomegaly on chest X-ray were significant in all surviors, and there were no differences between patients with and without heart murmur. Five of 12 survivors were noted to have heart murmur, however pulmonary artery pressure improved and only trace mitral regurgitation remained, as demonstrated by postoperative examination. In conclusion, surgical treatment may be performed for even adult patients with ECD, but it is advisable before cariac function decreases to decompensation and in those whose age exceeds the natural history, that is in the forties or fifties.

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Between January 1979 and May 1987, 167 patients with abdominal aortic aneurysm or iliac artery aneurysm were subjected to surgery. Of these 167 aneurysms, 22 (13.1%) were ruptured, including two cases of impending aneurysmal rupture. Patient ages ranged between 30 and 83 years (mean: 67.5 years), and there was no significant difference from that of the elective group during the same period. The causes of aneurysm were non-specific inflammation in two patients, mycosis in one and arteriosclerosis in 19. The mean diameter of the aneurysm was 8.7±2.4 cm, which was significantly larger than that of the elective group (p<0.001). The mean amount of blood loss during surgery was 6077±4080 g, which was significantly more than that of the elective group (p<0.001). There was no significant difference in the operation time between the two groups. Postoperatively, there were eight (36.4%) hospital deaths: three from acute circulatory failure and heart failure, two from acute respiratory failure or acute renal failure, and three from MOF due to complications. The prognosis of surgically-treated ruptured abdominal aortic aneurysm has been poor. Although perioperative intensive care is expected to improve the outcome, the only strategy for really resolving this problem is diagnosis and treatment before rupture.

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The clinical records of patients over 80 years old with gastric cancer were reviewed.
One hundred patients were operated on: 78 for advanced cancerand 22 for early cancer. Ninety-five (95%) had resections. Of these 28 underwent a curative operation. Eleven (11%) all with advanced cancer died due to post-operative complications, most of which were suture line failures and pulmonary complications.
These patients were compared with 66 gastric cancer patients treated without surgical precedures because of multiple associated diseases, advanced age or refusal of operation. Of these, 55 (83%) died in association with cancer. Sixty-four percent (14/22) of the non-operated patients with early cancer eventually died of tumor growth.
Our data suggest that surgical operation may be of great value in treating patients over 80 years with advanced cancer as well as those with early cancer.

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We investigated the indication for combined resection of the stomach and adjacent organs in patients diagnosed as having gastric cancer with macroscopic invasion to adjacent organs. The aim of the study was to determine whether the prognosis was related to regions of the gastric wall showing carcinoma invasion, macroscopic type, histological type, location, numbers of invaded adjacent organs, grade of disseminated peritoneal metastasis, grade of liver metastasis, curability of lymph nodes and the histological vertical depth of the lesion. It was found that in patients who underwent combined resection of the stomach and adjacent organs, the prognosis was related to the number of invaded adjacent organs, grade of disseminated peritoneal metastasis, presence or absence of liver metastasis and the grade of curability of lymph nodes, whereas it was not related to the regions of gastric wall showing carcinoma invasion, macroscopic type, histological type, location or vertical depth of the lesion. As mentioned above, combined resection of gastric cancer with macroscopic invasion to adjacent organs is indicated for patients who have only one invaded organ, little or no disseminated peritoneal metastasis and no liver metastasis. Consequently, it is concluded that it is important to perform this type of operation in which the metastatic or majority of the regional lymph nodes are resected.

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Seventy-two patients with generalized peritonitis due to perforated duodenal ulcer were encountered in our department. The mean age and the male-female ratio of the patients were 40.3 years and 6.2:1, respectively. Co-existing preoperative disease, preoperative shock and old age were considered to be prognostic factors for perforated duodenal ulcer. These patients were treated by extended gastrectomy before 1981 but by selective proximal vagotomy after 1982. Since the time required for the operation was shorter and the volume of intraoperative bleeding was smaller in those who underwent vagotomy, the surgical insult was less in this group. On the other hand, there were no differences in postoperative gastric secretion, the ability to eject the gastric contents, time of operation or intraoperative hemorrhage between patients with perforated ulcer and those with unperforated ulcer among those who underwent selective proximal vagotomy.

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One hundred and thirth-five cases were examined by transrectal ultrasonic probe between January 1984 and December 1986. Of those, 63 were cases of rectal cancer. The ultrasonic shape of rectal cancer was classified into four types on the basis of macroscopic and histologic examination. The depth of invasion of type 1 was pm, and maximum diameter (M-M') was found in the first layer on ultrasonogram. The depth of invasion of types 2 to 4 was a₁ or greater. Maximum diameter of type 2 was found near the first layer, type 4 the fifth layer, and type 3 between the first and fifth layers. The depth of tumor invasion, was determined on ultrasonogram by the condition of bottom echoes. Invasion to pm showed low-grade changes in bottom echoes, while a₁(ss), a₂(s) showed in turn greater changes in bottom echoes. Bottom echoes were also influenced by the stromal structure of the tumor. These results indicated that diagnosis of the depth of invasion should be made with reference to changes in the tottom echoes and stromal structure of the tumor.

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Hemodynamic changes in the portal system after distal splenorenal shunt were evaluated by visceral angiography in 56 patients in the early postoperative period and 22 patients in the late postoperative period. These patients consisted of the following three groups: those with Warren's procedure, those with incomplete splenopancreatic disconnection of the splenic vein (SPD) and those with complete SPD. The following results were obtained. (1) The diameter of the portal vein and the portal pressure were significantly decreased in all three groups. (2) In the early postoperative period, portal vein perfusion was well maintained in all three groups. Hepatofugal collaterals for the shunt developed to a significantly greater extent in the Warren's procedure group. However, the development of these collaterals was satisfactorily prevented in complete SPD group. (3) In the late postoperative period, patients who underwent Warren's procedure had developed numerous collaterals and a decrease in portal vein perfusion. In contrast, portal vein perfusion was satisfactorily maintained in the complete and incomplete SPD groups, in spite of the incompleteness of the procedure to prevent the development of collaterals. It was concluded, therefore, that the Warren's procedure resulted in many more hemodynamic changes in the portal system in the late postoperative period, whereas SPD was suitable for the prevention of portal vein perfusion.

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A case of Sipple's syndrome associated with liver metastasis from medullary carcinoma of the thyroid is reported.
A 63-year-old man with suspected pheochromocytoma developed uncontrollable hypertension unresponsive except to phentolamine during surgery for left retinal detachment. A preoperative diagnosis of Sipple's syndrome had been made by hormonal and radiological examinaiton. Multiple, hard, whitish-yellow nodules were found in the bilateral hepatic lobe during laparotomy and were proved to be hepatic metastases from medullary carcinoma by histological examination with H.E., CEA and calcitonin staining. Transarterial injection of adriamycin and lipiodol was performed for these hepatic metastases after right adrenalectomy, total thyroidectomy and resection of cevical lymph nodes. The patient is currently ambulatory without any symptoms 22 months after thyroidectomy.
A few descriptions of Sipple-like symptoms associated with liver metastasis of medullary carcinoma of the thyroid in the Japanese literature are reviewed, and we discuss this syndrome in the light of the present case.

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The occurrence of apocrine carcinoma of the breast is rare, ranging from 0.2% to 1.5% of all breast carcinoma. We recently experienced a case of this special entity.
The patient was a 41-year-old woman who had a slightly irregular hard mass 1.6×1.5 cm in diameter in the lower lateral quadrant of the right breast. No enlarged lymph nodes were palpable in the axillae. Preoperative diagnosis made by mammography, breast ultrasonography and aspiration cytology was carcinoma of the breast. The patient underwent an excisional biopsy of the mass.
Histological examinations revealed apocrine carcinoma of the breast. Microscopic characteristics were large (cuboidal) cells with acidophilic cytoplasms and hyperchromatic nuclei, and the presence of so-called “snouts” of acidophilic cytoplasm projecting from the central poles of the cells. Concomitant infiltrating ductal carcinoma was scattered, but not prominent. Subsequently, a right modified radical mastectomy was performed. The post-operative course was uneventful, and she is now well and without disease.

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We encountered a case of yolk sac tumor of the anterior mediastinum that survived for 19 months as a result of agressive treatment consisting of surgery, chemotherapy, a nd radiation.
A 15-year-old male was diagnosed as having amediastinal teratoma from a large mediastinal mass seen on the chest radiography and significant elevation of serum alpha-fetoprotein (AFP). A thoracotomy was carried out and the pathological diagnosis of the tumor removed was teratoma combined with yolk sac tumor. AFP was re-elevated a month after the operation, and the chest radiograph revealed local recurrence and lung metastasis, requiring further treatments with radiation and cytotoxic drugs. Yolk sac tumor is reported to be almost invariably fatal, and the patient reported here also died within 19 months after the operation, enabling us to recognize that chemotherapy, after all, plays a key role in the treatment of the disease.

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A 3-month-old infant with intractable heart failure who underwent a successful primary physiological correction is presented in this report.
The operation was performed using a cardioplumonary bypass with deep hypothermia and cold potassium cardioplegic solution. Rastelli's procedure was carried out using a 12 mm heterograft valved conduit (Carpentier-Edwards). In order to accommodate the size of the pulmonary artery to the graft, pulmonary artery widening with an autogenous pericardium was carried out.
Postoperative hemodynamic results were satisfactory. Angiographic studies demonstrated excellent anastomosis between the conduit and pulmonary artery, and satisfactory valvular function of the graft. The pressure gradient across the valved conduit was estimated to be 21 torr, within the acceptable range, by Doppler echocardiogram.
In order to reduce the increased risk of pulmonary vascular disease in the truncus arteriosus, a primary correction should be performed in early infancy.

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A rare case of so-called sclerosing hemangioma of the lung encountered is a 76-year-old female was analyzed through clinical and pathological study by electron microscopy. We found that tumor cells had features of pulmonary alveolar epithelial cells and were near to hamartoma of the lung tissue. The 196 cases, including our case, that have been reported in Japan were reviewed and discussed.

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The authors experienced a rare case of lung cancer within a giant bulla complicated with intrabullous infection. A 72-year-old male had been found to have a giant bulla in the right upper lung about six years before he was admitted to our hospital for the chief complaint of fever. Chest roentgenography revealed a neveau formation coincident with the giant bulla. Based on the above findings and persistent fever, the patient was preoperatively diagnosed as having infectious pulmonary cyst. Thoracotomy was performed to resect his right upper lobe, and a tumor of 11×10 cm surrounded by the bulla was found to occupy two-thirds of the right upper lobe. Postoperative histopathological examination revealed that the tumor was lung cancer (poorly differentiated adenocarcinoma) growing inside the wall of the giant bulla. Retrospecitve re-examination of the chest X-ray film showed that the tumor image did not overlap the neveau in decubitus position, thus indicating the usefulness of this imaging technique in combination with different positions for diagnosis of bulla accompanied by infection. There have been 30 documented cases in Japan, including the present case, of lung cancer presumably developing from the wall of giant bulla.

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We report a very rare condition that we treated surgically. The patient was a 38-year-old-male with a history of melena, which had occurred on five occasions. Following this, he was examined by a local physician, who had diagnosed gastric deformation of unknown etiology. After another episode of melena, the patient consulted our hospital. Careful inspection of thoracic X-ray films, together with endoscopy and contrast medium imaging resulted in a diagnosis of gastric volvulus with a hemorrhagic gastric ulcer.
Gastrectomy (Billroth-I method) was performed. The presence of a gastric volvulus made diagnosis easier. However, chronic cases without the complication of gastric ulcer might be more difficult to diagnose and may not receive the necessary surgery. There is, therefore, no definitive surgical procedure for this condition.
It is necessary to carefully consider age, complications, and their severity when examining patients with suspected gastric deformation.

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Non-specific multiple ulcers with perforation of the small intestine is a rare disease; there are only 8 cases in the Japanese literature. A case of this disease is discussed with reference to the literature.
A 49-year-old man, who had been sick with pulmonary tuberculosis about 30 years ago, admitted to our hospital for close investigation of an abnormal shadow on plain chest X-ray film. He received an emergency operation for panperitonitis during this hospitalization.
Operative findings revealed six indurations the size of a thumb head that were palpable sporadically about 50 cm oral from the end of the ileum, two of which were perforated. We could not diagnose Crohn's disease or intestinal tuberculosis, but performed an ileocecotectomy. Postoperatively, these lesions were diagnosed as non-specific multiple ulcers of the small intestine by close histopathological investigation.
The specific findings for preoperative diagnosis of this disease are not known. The final diagnosis can be performed only by close histopathological investigation.

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A 36-year-old man was admitted to our hospital with a chief complaint of lower abdominal pain. Emergency laparotomy was performed under a diagnosis of strangulated ileus. The duodenum was found to run behind the mesenterium of the ascending colon and the small bowel emerged below the terminal ileum into the peritoneal cavity. The small bowel was necrotic for a length of 3 m due to volvulus of the intestine, which existed in the peritoneal cavity. The operative diagnosis was right paraduodenal hernia, the sac of which was the mesenterium of the ascending colon. Resection of the necrotic intestine was done and the oral section of bowel was pulled through the incision made in the mesenterium, followed by end-to-end anastomosis. The postoperative course was uneventful. Right paraduodenal hernia, a type of internal hernia, is a rare disease. An understanding of embryology is important when performing surgery in such cases.

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This paper describes three cases of intussesception due to colon cancer and provides a review of the literature. Case 1 was a 72-year-old man with constipation and loss of appetite. He developed colorectal intussesception due to type 2 carcinoma (4×3.8 cm, depth ss) of the sigmoid colon. Case 2 was a 39-year-old woman with abdominal pain and melena. Extraanal prolapse of the tumor was found. She developed colorectal intussesception due to pedunculated villous tumor (6×4.5×3 cm, depth m) of the sigmoid colon. Case 3 was a 76-year-old woman with diarrhea and tarry motions. A coiled spring sign was detected by preoperative barium enema and intussesception was diagnosed. There was colorectal involvement causd by type 1 carcinomas (5.5×4×3 cm and 3.5×2.5×2 cm, depth s) of the sigmoid colon.
On reviewing 43 cases so far reported in Japan, including the present 3 patients, intussesception caused by colon cancer was found to be rather frequent in females over 70 years of age. Preoperative detection was possible in 53.5%. The main sites of cancer development were the coecum (20 cases, 46.5%) and sigmoid colon (18 cases, 41.9%). Macroscopically, the tumors consisted of the protuberant type (22 cases, 48.9%) and type 2 (12 cases, 27.9%). Relatively early cancers (m, sm, pm) were found in 30.2%.

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We report a case in which a swallowed pickled plum seed completed a colon obstruction. Ileus caused by a foreign body impacted in a colon tumor has not been previously reported in Japan, to our knowledge. In other countries, four such cases have been reported.
In this case, a 62-year-old man was admitted to our hospital because of ileus. A left-sided colectomy was performed. The cause of ileus was recognized at this time as an impacted foreign body (pickled plum seed) in colon carcionma.
The oral side of the tumor appeared to be funnel-shaped, while the anal side of the ulcer which was located in the center of tumor appeared as a steep cliff. This shape enabled the foreign body to slip into the ulcer of tumor and become impacted there. Under the condition of hard and solid stools, ileus of a colon tumor without foreign body may happen in the same way.

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Diverticulum of the appendix has been often reported in Europe and the United States. However, in Japan, only 44 cases have appeared in the literature and only 4 of them were diagnosed as diverticulum of the appendix before surgery.
Five patients diagnosed a having diverticulum of the appendix are presented in this report: Case 1. A patient diagnosed as having appendicitis underwent surgery. A diverticulum was found in resected specimen of the appendix. Case 2. After a diagnosis of appendicular diverticulum was made by barium enema examination, appendectomy was performed. The others (cases 3-5) were diagnosed by barium enema examination.
The number of cases without symptoms is considered to increase with careful investigation, and we suggest that surgery may not be required in such cases.

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The first case report in Japan of breast metastasis originating from clear cell carcinoma of the kidney is presented. A 63-year-old woman complained of a 2.0 cm-sized lump in her left breast 3 years after radical nephrectomy. No other recurrent disease was found on routine evaluation for metastasis. Modified radical mastectomy (Auchincloss) revealed that the metastatic lesion was solitary and axillary lymph nodes were not involved. The patient is now alive eleven months after mastectomy, with subsequent lung metastases. A review of the literature on eight cases reported abroad is also presented.

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We present a case of vaginal reconstruction used the sigmoid colon for congenital vaginalabsence.
The patient was 18-year-old unmarried female. Colpotomy and laparoscopy revealed vaginal absence, bicornous rudimentary uterus and normal sized ovaries. Endocrinological examination and genotype were normal. The patient was diagnosed as having Rokitansky-Küster-Hauser syndrome.
Several means of forming artificial vagina have been described. The most important factor in the choice of operation is to construct a natural and permanent artificial vagina.
We think from our experience that the formation of an artificial vagina from the sigmoid colon is one of the best methods.

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An 18-year-old female visited our hospital with a complaint of a tumor in the left hypogastric region. Computed tomography revealed a tumor extending from the second lumbar vertebra to the pelvic cavity. Angiography delineated an abnormal blood vessel branching from the left iliac artery and the lumbar artery. The patient underwent surgery with the diagnosis of retroperitoneal tumor. The tumor was the size of an infant's head, multilocular and full of pale yellow serous fluid and clots. Histiologically it was diagnosed as malignant hemangiopericytoma. Two weeks later the patient developed multiple metastases in the bilaterel lung and lumbar vertebrae, and at present, 14 months after operation, she is under combined treatment. Hemangiopericytoma is relatively uncommon, with 223 cases having been reported in Japan. Only 21 of the 223 cases were of retroperitoneal origin. The averageage of patients is 36 years, and the male/female ratio is 9:12. Malignant tumor was found in 11 of 12 cases in which malignancy could be evaluated, and six cases presented matastase. In spirt of combined treatment, the prognosis is poor, with no patients surviving more than 2 years.
In the present report the authors describe a surgically treated case of malignant hemangiopericytoma occupy in the retroperitoneum.

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We report two adult cases of benign presacral tumor. A 51-year-old female, complaining of constipation and dysuria, was operated on using an abdominal approach. The other patient, an asymptomatic 39-year-old female, was operated on using a sacral approach. The pathological diagnosis was epidermoid cyst and dermoid cyst, respectively. Adult presacral tumor is a rare tumor and the operative approach adopted should be determined by careful preoperative examinations such as ultrasonography, CT scan and angiography.

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The present paper reports a case of severe pelvic fracture resulting in hemoperitoneum, hemothorax and cardiac tamponade. A 31-year-old woman was found unconcious after plunging from the third floor of a building in an attempted suicide. She was in shock and her blood pressure was 50 mmHg by palpation on arrival. Since roentgenography revealed pelvic fracture and bilateral leg fracture, and no other traumas were noted, she was diagnosed as having hemorrhagic shock due to pelvic fracture. On the 2nd day exploratory laparotomy was performed for suspected hemoperitoneum because her hemodynamic state was not stabilized by massive blood transfusion. Severe retroperitoneal hemorrhage and small amount of blood in the abdominal cavity, which was presumably exuded from the retroperitoneum, were found. On the 5th day the patient presented elevated CVP and tachycardia. Diagnosis of hemothorax and cardiac tamponade was made by chest roentgenography and echocardiography. Her hemodynamic condition became stable after a massive amount of bloody pleural fluid and bloody pericardial effusion was discharged by drainage of the thoracic cavity and drainage with pericardiotomy. As shown in the present case, patients with pelvic fracture tend to develop not only retroperitoneal hemorrhage but various pathological conditions. Therefore, careful management of their general condition, including respiration and circuration, as well as prompt and appropriate care, are required in addition to treatment of fracture.

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Twent-one cases of peripheral arterial disorders reconstructed 23 times by EPTFE with a spiral support (IMPRA) were analyzed. The results were as follows;
1. The cases consisted of ASO (11), aortitis syndrome (2), embolism (2), peripheral arterial aneurysm (2), abdominal aneurysm (1), Burger's disease (1), thoracic injury (1) and acute arterial obstruction (1).
2. The graft size was 8 mm in 11 cases and 6 mm in 12 cases. Almost all grafts were patent except for the case of Burger's disease (patency rate, 95.4%) throughout 12 months of follow-up.
3. One graft was obstructed in a patient with aortitis syndrome and two cases of anastomotic stenosis occurred during lingterm follow-up. These three cases were reconstructed with a 6 mm IMPRA.
4. No graft was obstructed in the ASO patients. Other grafts were also patent except for the cases of inflammatory arterial disease. From the above-mentioned results, it can be concluded that IMPRA grafts are excellent for peripheral arterial reconstruction.

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