Surgeons are expected to be always creative for surgical operations. This requires deep thoughts and keen idea which are to be proved, evaluated, and improved for a future. In these progressive process, we must possess "surgeon's dream".
A history of cardio-vascular surgery lies in this stream. A shunt operation for the Fallot's tetralogy was Taussig's idea (1945) which was later proved by Blalock. From Bailey's mitral commissurotomy (1948) and a successful open-heat surgery using pump-oxigenator by Gibbon (1954), to a valve replacement with Starr's prosthetic valve (1960), a coronary artery bypass by Favaloro (1969), and more recently, a heart transplantation bridged by an artificial heart; the progress is in the main stream of the phylosophy.
While in our country, there are several innovative operations developed by Japanese surgeons such as Drs. Arai, Kawashima, Saji, Konno, Sohma, Takeuchi, and Muraoka, to whom I send my sincere respects. I also wish that these are followed by a further creative development; A surgeon must pursue his endless dreams.

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Prognosis and prognostic factors in 58 patients with malignant lymphoma of the thyroid gland were analyzed. From 1975 to 1987, 58 patients with non-Hodgkin's lymphoma originating in the thyroid gland were treated at Ito Hospital. Their ages at the time of the initial diagnosis ranged from 36 to 81 years (mean 64.2 years). Twelve of them were male and forty-six female, giving a female-to-male ratio of 3.8. In this study the overall 5 or 10-year survival rate was 61.2% each. The 5-year survival rate in stage IV disease (16.9%) was significantly smaller than that in stage Is (85.7%). By the LSG classification, both the 5 and 10-year survival rates in diffuse lymphomas (50.3% each) were significantly smaller than those in follicular lymphomas (100% each). By the Working Formulation, both the rates in intermediate grade (53.8% each) and high grade (35.3% each) were significantly smaller than that in low grade (100% each). The 5 and 10-year survival rates in patients of 60 years and over (55.5% each) were significantly smaller than those of less than 59-years (84.8% each). Sexual difference offered no apparent correlation to survival. Cell types of non-Hodgkin's lymphomas of the thyroid gland appear to be significant determinants of prognosis of the patients.

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During 6 years between January 1981 and December 1986, 31 patients with ruptured aortic aneurysm, in which 13 had thoracic aneurysms and 18 had abdominal aneurysms, were operated in our institution.
Operative mortarity rate were 15.4% in the thoracic and 27.8% in the abdominal cases.
A possible correlation between operative results and pre- and perioperative volume of blood transfusion was indicated. To improve the results, an appropriate maintenance of blood pressure and rapid treatment from the onset of the disease to the operation might be needed. But especially for thoracic and thoraco-abdominal aneurysms, a diagnosing the lesion and grasping the state of the main branch appeared important, and for this CT and DSA were of value. Aneusysm should be operated in earlier stage as far as general condition of a patient could permit.

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Acute arterial occlusion of the extremities may result in severe and complex metabolic derangement. In order to evaluate the metabolic changes during clamping and after declamping of the infrarenal aorta, biochemical changes such as the blood lactate, pyruvate, aldolase creatinine, myoglobin, CPK, GOT and LDH were measured in ten patients with infrarenal abdominal aortic aneurysms. Blood samples were taken from the common femoral vein before clamping and 30 minutes after clamping of the aorta. Samples were also taken just before declamping and again at 30 and 60 minutes after declamping.
The lactate and pyruvate levels increased significantly during clamping and after declamping. The L/P ratio increased from 21.5±49 before clamping to 27.7±3.8 just before declamping. There were significant statistical differences between the levels before clamping and just before declamping. The aldolase leves also increased significantly after declamping of the aorta. The remaining differences were minimal changes throughout the aortic reconstruction.
It is concluded that the L/P ratio indicates metabolic derangement during clamping of the infrarenal abdominalaorta.

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We investigated the relationship between postopoerative respiratory distress and pulmonary infections in fifty patients who simultaneously underwent esophagectomy and esophageal reconstuction. Pulmonary oxygenation (respiratory Index (RI), A-aDO₂), respiratory hemodynamics (Qs/Qt, Pulmonary microvascular pressure-Coloid osmotic pressure (Pmv-COP)) and biological responses (leukocyte, Complement (C3, C4) were analized.
Results were as follows;
1) RI, A-aDO₂ and Qs/Qt increased on the third postoperative day (POD) and gradually decreased in the patient group without pulmonary infections. In the group with pulmonary infectios, these figures increased remarkably and prolonged for improvement. These did't get improvement and get on exacerabation in the died group due to pulmonary infections.
2) In the died group due to pulmonary infections, Pmv-COP increased but remained at a negative value which kept from the 2nd POD.
3) In the died group, neutrophils were kept at lower levels, while increaded in the other groups.
4) In the group with pulmonary infections, C3 and C4 values were decreased on the 2nd POD which indicated a complement activation.
These findings suggested that after one-stage operation for esophageal cancer the mechanical respiratory distress was kept until the 3rd or 4th POD, and if pulmonary infections occured, then the reactive pulmonary distress was superimposed on it.

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Possible changes in surgical treatment of peptic ulcers at the Kobe University Hospital (First Dept. of Surgery) over the past ten years were explored, dividing the 10 years into the first (1978-1982) and second (1983-1987) periods. The number of hospitalized peptic ulcer cases and the number of surgically treated peptic ulcer cases fel by 50% from the first to the second period. The decrease was particularly marked in duodenal ulcer cases (in comparison with ulcers of the other sites) and intractable ulcer cases (in comparison with ulcers of the other features). The percentage of patients who underwent urgent operation was 37.3% in the first period, which fell to 28.6% in the second period. The number of surgically treated intractable ulcer cases showed a 69.2% reduction in the second period compared to the first period. However, the percentage of cases whose excised specimen was rated as representing giant ulcer, linear ulcer, or U1 IV was higher in the second period than in the first period. Stenosis was found in 7 cases in the first period and 3 cases in the second period. The percentage of hemorrhagic ulcer cases who received conservative treatment or pallilative operation became higher in the second period than in the first period, while the percentage of hemorrhagic ulcer cases who underwent urgent operation decreased from 65.2% in the first period to 33.3% in the second period. In hemorrhagic ulcer cases, the death rate during or after uregent operation rose from 28.7% (first period) to 40.0% (second period).
Perforated ulcer was found in 7 cases in the first period and 1 case in the second period. Of these 8 cases, 4 died (3 in the first period and 1 in the second period). Death rate was particularly high in elderly patients who had no history of ulcer and in patients who received surgery 12 hours or more after perforation.

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A retrospective study has been made on resected 541 cases of early and primary gastric cancer for past 22 years, to know characteristics of early gastric cancer detedted by mass screening. The cases were divided into screening group (n=86) and non-screening group (n=455).
1) In both groups tumors commonly occurred in M-region and lesser curvature site. A greater number of sinking type macroscopically or differenciated type histologically was observed. 2) A lower occurrence in the anterior wall and higher occurrence in the posterior wall were noted in the screening group. 3) The most commonly detected tumors were 1.1 to 2.0cm in longer diameter in both groups. In the screening group no case of minute carcinoma was detected, while minimal for large mass 5cm or more. 4) In the screening cases m cancer was more commonly found than sm cancer, showing lower anginal invasive rate and metastasis rate to the lymph nodes. Accordingly, mass screening can not be expected to detect minute carcinoma because of its essential objective of screening. However, it is advantagous to detecting a large number of early gastric cancers less than 5cm in diameter, accompaning neither vascular invasion nor lymph node metastasis. Further spreded use of mass screening is desired.

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OK-432, a hemolytic streptococcal preparation, was given orally (11 cases) and intracutaneously (14 cases) to intramucosal gastric cancer patients as postoperative adjuvant immunotherapy. The following results were obtained.
1) Oral administration of OK-432 enhanced the skin reactions to PPD, Su-PS and Su-PR to an extent similar to that after intracutaneous administration of OK-432.
2) Oral administration of OK-432 caused greater increases in the absolute count and the OKT-3 positive cell ratio of peripheral lymphocytes than did intracutaneous administration of it.
3) Oral administration of OK-432 enhanced the PHA blastoid reaction of peripheral lymphocytes to a greater extent than did intracutaneous administration of it.
4) No side effects were noted after oral OK-432 administration.
Thus, oral administration of OK-432 is considered to be a therapy which activates general cellmediated immune response, with effects that are comparable to those of intracutaneous administration of OK-432. Favorable results are anticipated upon further clinical evaluation of this extremely easy and safe dosing method.

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Clinicopathological review was made of 18 cases of malignant lymphoma of the stomach who were admitted to the hospital from April 1972 to December 1987. During the same period, a total of 1192 cases of malignant tumors of the stomach were surgically treated, accordingly, malignant lymphoma cases amounted to 1.5% of the total. The patients with the averaged age of 59.7 years included males and females at the same ratio. Preoperative diagnosis with assurance is so difficult that only 38.9% of the cases could be successfully diagnosed as gastric malignant lymphoma.
Macroscopically, broken or surface type was more frequently observed, while histologically, all cases belonged to diffuse lymphoma, the large cell type being most frequently occurred.
Prognosis of cases with stage I and n(-) is relatively favorable, however, a possible development of lymphonodus metastasis in high rate is recorded even in sm cases that might demand more aggressive operation and/or chemotherapy.

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Fourteen patients with pancreatic cysts who had undergone surgical treatment between 1975 and 1987 were retrospectively investigated. Surgical treatments performed on these patients consisted of simple drainage for 3 patients, distal pancreatectomy for 8, pancreatoduodenectomy, total pancreatectomy, and total pancreatectomy follwoed by segmental auto-transplantation for eachone. Abdominal pain still remained postoperatively in two of the three patients undergone simple drainage. Eleven patients undergone pancreatectomy for removal of cysts had not any abdominal pain postoperatively. Complete extirpation of pancreatic cysts by pancreatectomy is preferable because of effective relief of pain. All patients who had distal pancreatectomy did not require insulin supplement. In five patients who underwent distal pancreatectomy. no remarkable change in glucose tolerance was observed postoperatively.

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The clinical feature of a patient is described in whom diffuse goiter was the first clinical manifestation of systemic amyloidosis. A 55-year-old man had been suffering from renal tuberculosis for a long time. At admission, his phisical e amination revealed diffuse goiter with uneven surface and hard consistency. Laboratory data showed normal serum levels of TSH and thyroxine, and low serum level of triiodotyronine. CT scan showed a heterogenous, diffuse swelling of the thyroid gland with irregular margin. Scintigram with ²⁰¹Tl showed diffuse uptake. He underwent total thyroidectomy and the histological diagnosis was amyloid goiter. Subsequently, several biopsies were taken from the stomach, rectum and liver. Histological examination revealed amyloid deposition in the each organ. These findings suggested that he had systemic amyloidosis caused by renal tuberculosis.
Although amyloid infiltration in the thyroid gland is common in amyloidosis, a few cases of goiter have been reported as a first clinical manifestation of systemic amyloidosis. Therefore, this interesting case is reported with special reference to image diagnosis.

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Primary sarcoidosis of the breast is a rare disease and only 21 cases have been reported since the first case by Scott.
Recently, the authors experienced a slowly growing tumor in the breast of a 18-year-old female. The biopsy specimen suggested a sarcoid granuloma and the tumor was extirpated. The histology of the resected specimen was almost similar to that of biopsy. This is the third case in Japan, and the details of our case are reported including the review of the literatures.

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A case of 64 year-old woman with squamous cell carcinexamination revealed squamous cell carcinoma with keratinization, accompanied with no glandular formation. A PAS stain and Alcian-Blue stain positive substance suggesting mucous formation was identified. Electron microscopic examination revealed a few intracytoplasmic lumina, suggesting that this was similar to pure squamous cell carcinoma, and originated from adenocarcinoma cells through squamatization.
Preoperatively serum squamous cell carcinoma related antigen (SCC) showed an elevation, and resolved after operation. SCC is available for the marker of squamous cell carcinoma of the breast during a follow-up period.

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During the last decade, we surgically treated 196 cases of breast cancer, which included 2 cases of male breast cancer. The two patients, 52-and 51-year-old men, complained of tumor formation in the nipple region. Both cases were suspected of having malignancy by ultrasonography and diagnosed as breast cancer with needle biopsy. Postoperative findings were t1 n0 M0, stage 1, and modified radical mastectomy was proceeded for the 1st case or standard radical mastectomy for the other. There are no recurrent signs for postoperative 7 years and 10 months or 9 months respectively.
Generally, male breast cancer has been thought to have poor prognosis, but recent improvements in diagnostic methods and treatments could offer various different findings. A review of our cases and relevant references hasindicated a relatively good prognosis for male breast cancer, especially for that in early stages. And modified radical mastectomy appears to be applicable to the Stage 1 and N₀ cancers.

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We experienced one case of human pulmonary dirofilariasis, which had been characterized recently as one of Zoonoses. A 70-year-old female, who had been suffering from hypertension for a long time, had a coin lesion in the periphery of the left upper lung field on the chest roentgenogram. Partial resection of the lung was, therefore, performed under the tentative diagnosis of lung cancer. Diagnosis of this disease was established by histopathological findings and serological examinations (Agar-gel diffusional absorptional assay, enzyme-linked immunosorbent assay and mixed passive hemagglutination assay).
This disease is extremely rare. But it is clinically important, because of difficulties to differentiate from lung cancer and other respiratory diseases, and to diagnose preoperatively.
We discussed the literatures of this disease in Japan, especially about clinical features.

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Erosion and ulceration caused by the reflux esophagitis are often observed in patients with esophageal hiatal hernia. In these patients it is often difficult to diagnose whether these lesions are benign or malignant, especially when the biopsy specimens show severe atypia which is occasionally seen in the esophageal squamous epithelium with long-term inflammation.
Three cases of reflux esophagitis caused by the esophageal hiatal hernia diagnosed by pathological examination as the squamous cell carcinoma in the lower esophagus are reported. Of these cases, one underwent total thoracic esophagectomy but no malignant lesion was found in the serial specimens. The other two cases recieved esophagoscopic examination several times and were finally diagnosed as non-malignant, esophagitis. These findings indicate that the patients with reflux esophagitis have to be carefully treated. On the other hand, it is well known that chronic inflammation due to reflux esophagitis is one of the risk factors of esophageal cancer.
Therefore, patients with reflux esophagitis should be followed up for a long period after being diagnosed as esophagitis.

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A 40-year-old male patient was referred to our hospital with compalints of poor appetite, epigastralgia, and a body weight-loss during past one month.
X-ray examinations proved an irregular contour and stiffness of the distal part of the stomach. Several ulcerative lesions were also revealed mainly in the pyloric antrum. Gastric endoscopy showed multiple ulcers with irregular shapes and nodular mucosal changes spreading from the lower body to the pyloric antrum. Those findings suggested a possible gastric cancer of Borrmann type 4. However, no evidence of malignancy was obtained from biopsy specimens.
Serological test for syphilis resulted in strongly positive, and history taking in detail revealed that he had had a chance of syphilitic infection about 2 months ago.
Those facts finally indicated gastric syphilis, and a diagnostic anti-leutic treatment using AMPC was started. The treatment recovered his appetite in 2 weeks. The X-ray and endoscopic examinations proved marked improvement of the gastric lesions in about a month.
Final diangosis of gastric syphilis was confirmed from the efficacy of the diagnostic treatment with AMPC, although Treponema pallidum was not disclosed in any biopsy specimens.
Reports of gastric syphilis for the past 10 years in Japan are reviewed on the aspect of diagnosis.

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A case of double pylorus is reported and the relevant literatures are reviewed and discussed.
A 39-year-old female was first seen on August 5, 1986, with the chief complaints of epigastric and back pains after meals which were developed around June, 1986 and gradually aggravated. Radiological examinaiton of the upper gastrointestinal tract and gastric endoscopy revealed a possible double pylorus. Conservative treatments were started and her course was observed. on the contrary, however, no remission was noted, with more marked symptoms. Accordingly, the patient was admitted to our hospital in January 1987 for further diagnostic scrutiny and operative treatment if necessary. Gastric endoscopic examination, where a cannula for ERCP was inserted from the fistula and pigment was infused, could comfirm a regurgitaiton from the normal pylorus. The patient was diagnosed to have a double pylorus, and received Billroth I gastrectomy on January 16, 1988.

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The sessile polypid lesion of gastric mucosa, that had developed at the residual site of gastric anastomosis and proposed to be termed "gastritis cystica polyposa" (GCP) or "stomal polypoid hypertrophic gastritis" (SPHG), is a peculiar and rare mucosal condition. Recently we have experienced a case of type I early carcinoma of the remnant stomach occurring near SPHG. A 52-year-old woman who had a distal gastrectomy with reconstruction by the Billroth II method 12 years before because of stomach ulcer. In 1979 endoscopic examination showed polypoid lesion on the gastrojejunostomy site. Following this in June of 1987 the biopsy specimens from the polypoid lesion showed Group IV and polypectomy was curried out. Subtotal resection of the residual stomach was carried out, because polypectomy specimen was diagnosed as papillary adenocarcinoma (P₀H₀N₀S₀ stage I). Macroscopically, mucosal thickening was circular at the anastomosis of remnant stomach and three polyps were overegrown. Histologically, one polyp was found cystic degeneration of the pseudo-pyloric glands indicating SPHG. Another polyp was confirmed a papillary adenocarcinoma remaining in the mucous layer.

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A case of leiomyosarcoma of the duodenum, that was hard to diagnose before operation, is reported. A 55-year- old male was admitted with complaint of epigastralgia. Gastroendoscopy revealed an ulcer in the second portion of the duodenum, and its pathological diagnosis turned out to be leiomyosarcoma. He was treated with pancreaticoduodenectomy. The tumor, 5.4×5.5×5.6cm in size, belonged to the mixed type, and partially invaded the capsule of the pancreas.
204 cases including this case, which had been reported in Japan, are reviewed here. Pancreaticoduodenectomy and partial duodenectomy have been mainly performed for the disease with poor prognosis. Progress in diagnostic techniques had permitted the early detection of this, and as many as 100 cases were reported in the recent five years, hereafter, earlier diagnosis and radical treatments such as pancreaticoduodenectomy are needed for the improvement of prognosis.

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To obtain symptomatic remission, five patients with severe dumping syndrome have received reoperations. The patients, including two males and three females, had undergone gastrectomy when they were from 25 to 50 years old because of gastric ulcer (in 4 cases) or gastric cancer (in one).
The first surgical procedures were pylorous-side gastrectomy in 4 and pylorous-side subtotal gastrectomy in one case. Four cases of gastric ulcer or one of gastric cancer received Polya or Billroth I anastomosis respectively. Excepting one case, dumping syndrome occurred around postoperative 3 weeks to one month, and a difficuty to work and a weight-loss due to malnutrition were noted. They have been sufering from the syndrome for 3 to 27 years.
Preoperative X-ray examination and gastric scan revealed a significantly stimulated exhausion of the stomach in each case. In the reoperation, the jejunum, 5-9cm, was placed antiperistaltically between the residual stomach and duodenum, and vagotomy was added to the residual stomach. Though one case needed the third sugical treatment, symptomatic remisson was noted in all cases and scintigram revealed a shortening of exhausion time of the stomach.

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Six cases of gastrointestinal and mesenteric injuries in seat belt wearers, which were encountered from May, 1984 to December, 1987 in the Department of Gastroenterological Surgery of Saga Medical School, are reported.
The six cases consisted of one case of jejunal perforation, two of perforations of both the small intestine and colon, one of seromuscular tears of both the small intestine and colon, and two of seromuscular tears of the colon. Three of five colonic injuries were seromuscular tears of the colon accompanied with mesenteric tears or hematomas. Five were males and one was femals, and their ages ranged 32 to 69 years with the average of 51.7 years. There was one death that was attributable to the anastomotic leakage followed by septic shock relating to over surgery for her attendant compromised condition. All patients except the female showed favorable and satisfactory postoperative courses.
Even a careful preoperative evaluation can not afford an accurate diagnosis to blunt gastointestinal injuries. Computed tomography is the most useful diagnostic imaging for concomittent identification of both intraabdominal free air and fluid collection in such patients.
Since the legislation of compulsory seat belt wearing in Japan, it seems that blunt abdominal injury due to seat belt may increase with an increase in number of traffic accidents.
It is emphasized that we must carefully evaluate the patients of automobile accidents, bearing the fact in mindthat seat belt wearers have an unusually higher incidence of blunt gastrointestianl and mesenteric injuries.

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It has been well understood that rectal carcinoma in the young adults has poor prognosis due to its low resectability. In this case, rectal tumor could be removed curatively by sphincter reserving operation in combination with preoperative radiation therapy.
The patient is a 23-year-old female who had a tumor with ulceration in its center locating about 4cm proximal to the anal verge. It could be completely resected by pull-through operation combined with preoperative radiotherapy at a total dose of 42.6 Gy. Pathological examination showed that lymph nodal involvement was negative and that the margin of resection was free from cancer cells.
The tumor was found to be decreased by 26% roentgenographyically, or by 33% in volume ultrasonographically. Histologically, radiation effect was assessed moderately.
A marked postoperative decline in serum CEA from as high as 10.22ng/ml to the normal level has been observed. The patient is well and alive up to present.

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The present paper describes a case of adenosquamous carcinoma of the pancreas, together with reveiw of Japanese cases.
A 63-year-old man was admitted because of jaundice. Pancreaticoduodenectomy was carried out under the diagnosis of carcinoma of the head of the pancreas. Postoperative microscopic examination revealed adenosquamous carcinoma of the pancreas. Adenosquamous carcinoma rarely occurs in the pancreas, and only 27 cases including our case have been reported between 1973 and 1987 in Japan. The ages of the patients ranged from 39 to 75 years (average: 58.7 years), and the male-to-female ratio was 2.4:1. Angiography pointed out tumor stains in 27.3% of the cases.
This type of cancer has more poor prognosis, therefore it is important to make an early clinical diagnosis.

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A case of a rupture of splenic artery aneurysm, which is considered a rare condition, was successfully diagnosed preoperatively and treated. A review of the cases documented in Japan is also reported.
A 60-year-old female was referred to us with complaints of sudden onset of epigastralgia and nausea. A child's fist sized, elastic hard mass with smooth surface in the left upper quadrant of the abdomen led the patient to receive CT scan and angiography, which revealed an aneurysm of 6.0×5.0cm in diameter at the root of the splenic artery. Severe anemia indicated an emergency laparotomy on the next day after admission. The aneurysm was found to be so close to the celiac axis that the abdominal aorta was clamped and the aneurysm was treated with aneurysmotomy and arteriorraphy, following splenectomy. The patient made an excellent recovery and was sent home on the 24th postoperative day. As far as we could find in documents, this case was the 31st one in Japan. Splenic artery aneurysms will be diagnosed more frequently because of further improvement of diagnostic techniques such as angiography.

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The adrenal tumor arising from the peripheral sympathetic nervous system is rare in adults.
About 100 cases of neuroblastoma in adults and about 20 cases of ganglioneuroma of the adrenal have been reported in Japan.
Here, two cases of a 36-year-old man with neuroblastoma (rosette formation type) of the left adrenal and a 44-year-old man with ganglioneuroma of the right adrenal are reported.

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Phenochromocytoma is usually discovered because of hypertension. Other diverse manifestations are: gastrointestinal complications, such as ileus, persistent constipation, intestinal ischemia and gastrointestinal bleeding.
We report a case of 72-year-old female with pheochromocytoma who had a complication of paralytic ileus. High catecholamine levels in blood and urine and a mass of hypodensity originating from the right adrenal gland on CT suggested a pheochromocytoma. She underwent emergency surgery because of paralytic ileus. It is postulated that the increasd blood catecholamines released from the pheochromocytoma caused a persistant vasoconstriction which resulted in widespread hemorrhagic necrosis of the intestines.
Six patients with pheochromocytoma accompanied by paralytic ileus were found in Japanese literatures. All cases were diagnosed as malignant pheochromocytoma and had multiple metastases.

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A case of paragnaglioma which is rare among the retroperitoneal tumors is reported with review of the literatures. The patient, a 64-year-old man who had the complaints of paresthesia in the lower extremity and abdominal fullness during treatment for old myocardial infarction, was diagnosed to have a retroperitoneal tumor. Laparotomy revealed the encapsulated tumor of 5.5×5.5×4.5cm, weighing 74 grams. The histological diagnosis was paraganglioma.

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An abdominal case of Castleman's disease was reported.
A 56-year-old-man was admitted with a tumor mass detected by sonography. The specimen removed by laparotomy was diagnosed histologically to be a tumor of Castleman disease.
There were 112 cases reported in Japanese literatures after the first report by Inada in 1958.

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We experienced a rare case of arterial stenosis caused by bulldog forceps used in femoropopliteal bypass operahon.
A 70-year-old female visited our department complaining of pain in the right lower extremity. Various examinations indicated that she was suffered from complete obstruction of the superficial femoral artery due to arteriosclerosis obliterans. Femoropopliteal bypass operation was performed. Postoperative roentgenography revealed a stenosis at a place beneath the graft anastomosis, namely, at a place where bulldog forceps appeard to be applied. Basic endoscopical findings also supported the stenosis caused by hemostat. She was treated with angioplasty by inserting a balloon through the resected artificial vessel, and her postoperative course was uneventful.
Even a hemostat should be used with careful attention. Furthermore, intra-anginal endoscopy through the artificial vessel and balloon angioplasty are possible applicable diagnostic and therapeutic procedures to stenosis at the anastomosis.

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Impalement injury is an unique open injury which can be characterized by a penetrating, contused wound combining two distinct factors of stab wound and blunt trauma. Therefore, for its complexity appropriate managements are necessary in the treatment of this injury. From the review of nine impaled patients treated in our institute over the past seven years, the diagnosis and treatment especially perioperative management were evaluated. It was characteristic that all patients were hemodynamically stable without any episodes of hemorrhagic shock. In addition, enhanced CT scan was considered of great help obtaining an accurate route of impalement preoperatively. The patients of this type of injury may be well treated according to the following principles of perioperative managements; 1) the involved organs and the relationship to the great vessels should be assessed preoperatively; 2) the impaled object should be extricated under appropriate vascular control and direct vision; 3) the injured sites or organs should be appropriately managed; and 4) the route of impalement should be exposed as entirely as possible and debridement, hemostasis and drainage of the route should be completed.

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