In 85 cases undergone total gastrectomy and 57 esophagectomy for esophageal carcinoma during the past 6 years, the corrected water-balance accumulation was calculated by determining the water intake and output for postoperative 5 days. Based on the oalculation, we intend to demonstrate a contribution of excessive fluid in the body to the development of postoperative pulmonary complications. Remarkable high levels in the correlected water-balance accumulation were noted in cases manifesting postoperative pulmonary complications. The value was also significantly higher in aged patients or a patient group who had impaired renal function preoperatively, indicating that their risks to provoke pulmonary complication might increase. Moreover, the corrected waterbalance accumulation had a closed corelation with FENa, particularly a case in which FENa was still maintained at 1% or more even after the 3rd postoperative day was supposed to be in overhydration. Another significant correlation between an increase in AaDO₂ and FENa was found in patients after operation for esophageal carcinoma.
To prevent postoperative pulmonary complication, the dry side control guided by FENa appears affective.

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We analysed ultrasonographic findings of ninety lesions (55 carcinomas and 35 benign tumors) of 78 patientswith thyroid diseases with nodular lesions retrospectively.
Ultrasonic findings could be classified into three types; cyst-forming type, solid tumor type and only acoustic shadow type. The cyst-forming type was found in 3.6% of carcinomas while in 37.1% of benign tumors. The carcinomas of solid tumor type tended to appear as non-uniform internal echogenicity and irregular marginal sign, but benign tumors appearing as uniform internal echogenicity and regular marginal sign in ultrasonography. The non-uniform internal echogenicity depended on pin point and/or spot-like echo-rich shadow in all the carcinomas and the half of the benign tumors. Moreover, the echo-rich shadow was observed in all cases having calcification, in 80.5% of cases only having hyalinized connective tissues, or in 29.4% of cases without the former described features. Only acoustic shadow type was found in 18.2% of the carcinomas while in 5.7% of benign tumors.
In order to differentiate malignant tumors from benign ones by echography, the significance of detailed examination of its marginal sign and internal echogenicity should be emphasized, excluding lesions showing only acoustic shadow.

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In order to study an availability of a new tumor marker BCA225, serum concentration of BCA225 was measured in 514 healthy individuals, and the baseline value was established from the resuruts. In 58 cases of primary breast carcinoma and 20 of recurrent breast carcinoma, BCA225, CEA, and CA15-3 were compared for the positive rate. Positive rate for BCA225 increased with a progression of the disease which was as high as 70% for recurrent breast carcinoma, Excepting breast carcinoma, BCA225 shoed the positive rate of 10.0% for various types of malignant diseases, 0.0% for benign breast tumors of the mammary gland, or 5.3% for benign breast tumors at othert sites, indicating that BCA225 was specific for breast carcinoma. In a combination assay using BCA225 and/or CEA, the highest positive rate was obtained in both primary and recurrent breast carcinoma in respect to the rerationship with the hormone receptors, the patient group which was negative for both ER and PR showed a high level of BCA225. Histologically the highest positive rate was found in solid carcinomas. A correlation between BCA225 and CA15-3 was observed, in which the condition of these antigens was discussed.

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Influence of obesity as a risk factor of breast cancer was assessed by analysing data of 411 women with primary breast cancer who had been operated on for the past 7 years (1982-88) at our department.
It has been inferred that a recent increase in the incidence of breast cancer would be associated with the secular trend for obesity in the elderly women. Moreover, obesity would positively correlate with the metastasis to regional lymphnodes, staging, and redical mastectomy either of the standard or the extended one. These findings were more clearly observed in the group of postmenopausal cancer patients.
Although the positive rate either to estrogen receptors or progesterone receptors in obese patients was not different from that in non-obese patients, the positive rate to progesterone receptors was significantly lower among older patients.
It is suggested that avoidance from getting obese may prevent from breast cancer primarily, secondarily, and even tertiarily.

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One hundred and thirty six patients with primary breast cancer were microscopically examined by using factor VIII related antigen (FVIIIRAg) staining for studying the blood vessel invasion (BVI), and some correlations between BVI and pathologic factors or 5-year survival rate were discussed.
H.E. and E.v.G. stainings were performed in all the patients and then the main lesions were stained with FVIIRAg. BVI was found in 20.6% or 33.8% of the subjects by E.v.G. or FVIIRAg staining respectively. The 5-year survival rate was 58.7% in FVIIIRAg-positive cases while 77.8% in FVIIIRAg-negative ones with a significant difference.
When the modes of BVI were morphologically classified as thrombotic, floating, infiltrating and mixed types, prognosis in floating type was significantly poor. The frequency of BVI in papillotubular carcinomas was as significantly low as 18.2%. This might contribute to the good prognosis of papillotubular carcinoma. Fourty-three point nine percent of patients with lymph node metastasis had BVI while 24.3% of patients without lymph node metastasis even showed evidence of invasion of the blood veseels. The presence of BVI in patients without lymph node metastasis may explain a possible occurrence of disseminated disease.

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Two thousand cases of solitary early gastric cancer were comparatively studied by dividing into each 1000 cases for the first and latter halves. When compared to the patients group for the first half, the proportion of aged patients over 70 years old increased, while by macroscopic types, type IIc increased but type IIc + III and type III decreased in the patients group for the latter half. The ratio of elevated versus depressed type was changed to 1/4 in the latter from 1/3 in the first half, indicating an increase in depressed type. Cancers arising in the upper stomach were doubled. Furthermore, in the latter half, the lesions less than 2cm in diameter were more frequently detected, while those more than 4.1cm being less frequently found. Surgery was decreasingly carried out in the latter half, because endoscopic excision bacame common for cancers less than 1cm in diameter. Patients having lymphnode metastases tended to decrease as a whole. In addition to an increase in detection of gastric cancers by mass screening or phisical examinations, a remarkable increase in detection of early cancers by practiticing doctors was noteworthy. It can be concluded that recent gastric cancers are commonly found in early stages with smaller size, which may promises of complete treatment for the patients by surgery or endoscopic excision.

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Clinicopathological findings in gastric cancer were examined comparatively between 51 young patients (under 40 years) and 231 prime patients (in their sixties).
The incidence of gastric cancer for young patients group was 6.5% of all patients with gastric cancer, and female ratio in sex distribution was significantly high (p<0.01) compared with prime patients group. For macroscopic and histological types, the former group showed significantly high (p<0.01-0.05) rates of infiltrating type and poorly-differentiated type compared with the latter group. Histological progressive degree and resection rate had no difference between both groups. For non-healing factor and mode of recurrence, the former group showed less liver metastasis and more peritoneal disseminations that the latter group. No intergroup differences were noted in the resective ratios of lymphnodal metastasis, liver metastasis and peritoneal dissemination by wall penetration degree. Gastric cancer in stage II showed favorable prognosis for the former group compared with the latter group, but no intergroup differences were noted for stage I, III, and IV.

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Among 327 patients operated on for colorectal carcinoma in Hiratsuka City Hospital during 1970-1989, 61 patients of 75 years and upward (H group) were selected and compared for the clinicopathologic details and prognosis with 57 patients under 50 years (LM group). There were no significant difference between these two groups in the rates of resection, curative resection and operative death. A significantly higher frequency of rightsided tumors was noted in H group. No significant difference was observed in the frequency of patients having distant metastases. Proportion of patients with negative regional lymph node metastasis in H group was 68.4%, whereas 47.4% in the LM group with a significant difference (p<0.05). Proportion of each clinicopathological stages due to Astler-Coller showed a significant difference between these two groups. The proportion of patients who were in stage A was 18.0% in H group, whereas 1.8% in LM group, with a significant difference (p<0.05).
Proportion of mucinous adenocarcinoma in H or LM group was 1.6% or 12.3% respectively, with a significant difference (p<0.05). Cumulative 7-year survival rates were 22.3% in H and 60.2% in LM group, with a significant difference (p<0.01). On the other hand, colorectal cancer-related 7-year survival rates in the H and LM groups were 68.5% and 81.6% respectively, of which difference was not significant. It is concluded that there is obvious Clinicopathologic difference between elderly and relatively younger patients, and that the operative indication for colorectal cancer in the elderly is justifiable and should not be restricted only by a risk factor of age.

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Forty-six patients after pancreatoduodenectomy or total pancreatectomy were measured for serial changes in postoperative plasma levels of ALP, γ-GTP, and LAP, in which preoperative existing of choledochal dilatation was assessed to be contributory to the changes or not. ALP, γGTP and LAP returned to the normal levels 3 months after the operation in patients in whom choledochal dilatation was noted preoperatively. In patients without preoperative choledochal dilatation, γ-GTP and LAP also returned to the normal levels 3 months after the operation, while ALP remained elevated. In this group of patients, biliary stasis was suspected. These results suggest that small stoma of the choledochojejunostomy may play a causative role in biliary stasis.

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Eighty-five patients, with malignant obstructive jaundice whose serum T-bilirubin (T-Bil) were less than 10 mg/dl were allocated to pancreaticoduodenectomy. In order to study the significance of the preoperative percutaneous transhepatic biliary drainage (PTBD), the 85 patients were divided into 3 groups according to serum T-Bil level, namely, group A comprising of 26 with serum T-Bil levels of more than 3mg/dl with preoperative PTBD; group B comprising of 9 with the levels of more than 3mg/dl without PTBD; and group C comprising of 50 with the levels of lesser than 3mg/dl without PTBD. Furthermore, complications of PTBD were evaluated in 469 patients with benign or malignant obstructive jaundice for the same period.
After pancreaticoduodenectomy the morbidity was 23% in group A, 22% in group B, or 30% in group C, while the mortality was 8%, 0%, or 4% respectively, with no remarkable difference. These figures might indicate operative risks themselves. On the other hand, post-PTBD morbidity was not so low as 16.8% and the mortality 1.1%. Preoperative PTBD did not reduce operative risks. Therefore in patients with malignant biliary obstruction presenting serum T-Bil levels of less than 10mg/dl, pancreaticoduodenectomy should be performed without preoperative PTBD.

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erebral metastses of gastric cancers are rare. We report two cases of cerebral metastases after radical gastrectomy. These metastatic tumors were successfully resected. Both cases had Borrmann 2 gastric cancers of the gastric body and total gastrectomy was carried out. The presenting symptoms of the metastses were conciousness disturbance and right hemiparesis for the first case, and headache for the second. On CT contrastenhancing lesion in the left occipital lobe in the first case, and in the right parieto-temporo-occipital lobes in the second. Both cases did not disclose metastases in other organs, and this justified a craniotomy for tumor resection. Histopathology confirmed its gastric cancer origin.
The authors would like to emphasize the importance of a close follow-up of post-gastrectomy patients since some of such cerebral metastses may respond to multimodality treatments including surgical resections.

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We report two cases of recurred breast cancer in the thoracic wall, in which the whole layer of the thoracic wall was excised and then reconstructed by sandwiching a resin-board with Marlex mesh.
Case 1 was a 45-year-old woman who had a recurrence on the thoracic wall 3 years after radical operation for breast cancer. The whole thoracic wall including the sternum and right ribs from the 1st through 4th as well as skin was excised, and ossiferous thorax was reconstructed with Marlex sandwich in which latissimus dorsi flap procedure was applied. Case 2 was a 68-year-old woman who had a recurred lesion in the skin over the right thoracic wall 2 years and 9 months after radical mastectomy. Excision of the whole layer of the thoracic wall including right ribs from 1st through 3rd, right clavicle, and a part of sternum, and a wide range of regional lymphnode excision of right supraclavicular fossa were carried out. Reconstruction of the thoracic wall was also performed in the same manner.
Marlex sandwich which was prepared by actual measurement was boiled and kept in an autoclave under sterile condition. Postoperative courses of the 2 patients were uneventful. From the viewpoint of emotional and cosmetic aspects of breast cancer patients, this procedure should be tried if a patient is a possible candidate.

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Three cases of breast cancer associated with pregnancy were reported. Two of the patients died of stage IV disease, 2 months and 17 days after delivery respectively. A third patient underwent radical mastectomy for stage I disease and the pregnancy was terminated by D & C. Then she gave birth to a child 16 months later and is well now, 5 years after surgery. It is said that breast cancer detected during pregnancy or lactation accounts for only 0.4-3.8% of this malignancy and its incidence is 1 per 3000 pregnancies. If it is reviewed for women of childbearing age, the incidence naturally increases to be as large as about 5 to 8 times the figure for entire breast cancers.
Correct diagnosis of breast cancer occurring during pregnancy or lactation is often difficult to make owing to hormonal breast changes and tends to be deferred until advanced stages of the disease. However, we can find a lot of reports describing that no significant difference in disease course has been found between pregnant patients and non-pregnant ones, if the both patients groups were compared in the same stage. Accordingly, the more active diagnostic and therapeutic approach is strongly recommended for a breast mass which is formed during pregnancy or lactation.

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Pure red cell aplaisa (PRCA) is a rare, refractory atuo-immune disease, and produces chronic progressive anemia because of a failure of erythropoiesis. Half the patients with PRCA are associated with thymoma. Thymomectomy or thymectomy is not sufficient to restore the hemopoiesis in this disease. Steroid therapy is thought to be the most useful treatment for PRCA, but the effective dosage of steroids is controversial. We reviewed cases of PRCA from the viewpoint of sterioid therapy, including these 2 cases (one died of post-trasfusion hepatitis, and the another died of penumonia due to massive steroid dosage). As a result, conventional steroid dosage (<0.5mg/kg/day) may not be sufficient to improve anemia, but massive dosages (1mgkg/day-1, 5mg/kg/day) seem to be optimal for restoring the hemopoiesis.

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Thymic carcinoids are so rare that only 102 cases have been previously reported in Japan. We recently encountered the following two cases.
Case 1: A 41-year-old man complaining of cough and fever took chest radiogram, which revealed a tumor in the anterior mediastinum. He underwent tumor resection with lymphadenectomy through a combined approach of posterolateral thoracotomy and transsternotomy, and received postoperative radiation. The tumor measured 10×9cm, and confirmed to be a carcinoid histologically with Grimelius silver staining. The patient died of pleural recurrence and bone marrow metastases 26 months after operation.
Case 2: A 37-year-old woman free of complaints was found to have a tumor in the anterior superior mediastinum by mass screening chest radiography. She underwent tumor resection with lymphadenectomy through a median sternotomy, and postoperative radiation. The tumor measured 8×7cm, and was confirmed to be a carcinoid histologically. Eleven month's follow-up has been uneventful.
A review of the total of 104 including these cases revealed that the male-to-female ratio was 4:1; 25% of the cases were asymptomatic; and condiderable number of long survivals could be seen in spite of frequent occurrence of local invasion or lymph node metastasis. The first choice treatment for carcinoid tumor should be surgical excision of the tumor including regional lymphonode excision followed by radiation and/or chemotherapy.

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A 45-year-old man was admitted to hospital with the chief complaint of dyspnea. Phlebography showed obstructions of the superior vena cava and left brachiocephalic vein. Percutaneous needle biopsy led to a diagnosis of thymoma. Since the mass was considered unresectable, bilateal axillo-femoral bypass was performed by using prosthetic grafts made of spinal supported EPTFE (expanded polytetrafluoroethylene).
After surgery patient's condition was dramatically improved, however, postoperative irradiation and chemotherapy were beyond for saving his life and the patient died on 120th postoperative day.The patient was free from superior vena caval syndrome on his postoperative course, the prosthetic grafts being considered efficatious for remission of distress and prolongation of his life.
Seventy-eight cases of reconstruction of the superior vena cava using Prosthetic graft have been reported in Japan during the last 5 years. This report also reviewed the graft patency depending on reconstruction sites and prosthetic materials in 61 grafts of 43 cases that made reference to the graft patency in the reported 78 cases.

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Two cases of pericardial diverticulum were reported. Case 1 in a 62-year-old woman complained of a sensation of chest compression, in which chest X-ray and CT-scan examinations revealed a left upper mediastinal mass. Case 2 was a 32-year-old woman with an abnormal shadow in the right cardio-phrenic angle detected by chest X-ray and CT-scan examinations. She had no complaint nor symptom. In the two cases, CT-scan density was equal to that of water. Surgical extirpation carried out in these cases proved the communication between the cyst and pericadialcavity. Histologically, the two cases had the thin wall with flat meaothelium and diagnosed as pericardial deverticulum.
Pericaldeal diverticulum is a comparatively rare disease. The clinical entity of the disease was discussed in 28 cases reported in Japan, inlcuding these 2 cases treated in our hospital.

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It is generally accepted that serum carbohydrate antigen 19-9 (CA19-9) level is often high in patients with carcinoma of the alimentary tract, especially the biliary tract and pancreas, but rarely in patients with carcinoma of the lung.
A case of carcinoma of the lung presenting high serum CA19-9 level in a 62-year-old male is reported. On admission, his serum CA19-9 level was 73660U/ml. Histologically the tumor showed well differentiated papillary adenocarcinoma and the presence of CA19-9 was immunohistochemically demonstrated in the cancer cells.Postoperatively his serum CA19-9 level transitorily dropped, but elevated up to 198200U/ml as the metastatic lymph nodes grew up. Seven cases of lung cancer with more than 10000U/ml of serum CA19-9 level have hitherto been reported in Japan, five of which had adenocarcinomas and two mucoepidermoid carcinomas.
It is known that CA19-9 is present in the normal bronchial gland epithelium, therefore a lung cancer presenting high serum level of CA19-9 may originate from the bronchial gland.

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Esophageal tuberculosis rarely occurs, with only a few reported cases to date. Here, we present two cases of esophageal tuberculosis and discuss the diagnostic procedure to ensure favourable prognosis. Case 1 underwent bypass operation under a false diagnosis of esophageal cancer and died 5 months after surgery. Following a similar X-ray and endoscopic tentative diagnosis of esophageal cancer. Case 2 gave a cancernegative endoscopic biopsy result and underwent supraclavicular lymph node biopsy which led to the discovery and confirmation of esophageal tuberculosis. Appropriate antituberculotics were administered promptly and no surgical operation was performed. Case 2 showed a favourable prognosis. The discrimination between esophageal tuberculosis and cancer is considerably difficult by image diagnosis, and since it is important urgently to administer some appropriate antituberculotics in the event of esophageal tuberculosis, supraclavicular lymph node biopsy is strongly recommended when any cancer cells can not be detected by endscopic biopsy or other histological examinations. This approach might avoid unncessary surgical invasion such as esophagectomy.

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A case of early thoracic esophageal carcinoma detected after an operation for hypopharyngeal carcinoma in a 55-year-old man is reported. Four months after the operation for hypopharyngeal carcinoma, esophagram showed an elevated superficial lesion in the thoratic esophagus. He was referred to our department for further examination. An endoscopic examination revealed the reddish, irregular epithelium around the protruded lesion. Iodine staining revealed the much more widespred lesion. The biopsy disclosed that the lesion was a squamous cell carcinoma, and subsequently the patient was operated upon on March 15, 1989. The microscopic examination showed a large area of intraepithelial carcinoma and dysplasia with an area of submucosal carcinoma.
From a fact that a patient with head and neck cancer frequently associated with an esophageal carcinoma in an early stage, endoscopic examination at well as the use of iodine staining is essencial for such patients to detect a possible early esophageal carcinoma.

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A 48-year-old man, who was diagnosed as von Willebrand's disease at the age of 34 years, underwent gastric mass survey and further examination revealed an early gastric cancer in the anterior wall of the middle body. Subtotal gastrectomy with R₂ lymph node dissection was performed. Immediately before surgery, DDAVP wa given to the patient with a satisfactory response of the ristocetin cofactor activity (64-112%) and there was no serious hemorrage during the procedure. Immediately after surgery abnormal bloddy discharge from the drain occurred, so heat-treated factor VIII concentrates were administrated. After then postoperative course was uneventful. This appears the first report that radical operation for gastric cancer was successfully carried out in a patient with von Willebrand's disease in Japan.

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We report a case of leiomyoblastoma of the jejunum in a 43-year-old man, who complained of melena, light abdominal pain, and an abdominal mass. He had experienced massive melena 2 times, 6 and 10 years ago. The mass was 17×13cm in size and X-ray examination showed a filling defect existing at the jejunum 4cm distal from the Treitz's ligament. Endoscopy confirmed its location and angiography showed hepatic metastasis. An operation was successfully performed. The resected specimen showed a necrotic polypoid tumor measuring 15.0×12.5×11.0cm, and partial perforation to the omentum.
Microscopic examination confirmed that the tumor was leiomyoblastoma. Leiomyoblastoma of the intestine is so rare compared to that of the stomach, as far as we could review, that only 27 oases including this case had been reported in Japan.

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In a 79-year-old woman complaining of epigastralgia and bloody diarrhea, physical examination revealed a firm palpable mass in the upper right abdomen. The mass was movable, and had severe tenderness. Abdominal ultrasonography showed a 7×9cm mass formed with hyperrchoic layer and hypoechic layer (multiple concentric ring sign) in the right abdomen. This appearance was diagnostic of intussusception. On laparotomy ileo-ileo-colic intussusception was noticed, where a 15×14×14mm lipoma of the ileum was the lead point.
Adult intussusception is a relatively rare condition. Recent studies reported the usefulness of ultrasonography for the diagnosis of the disease. In this adult case ultrasonography also showed the typical apperance for intussusecption, and was quite valuable for making the diagnosis.

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A case of xanthogranuloma arising in the appendix is reported.
A 62-year-old female was admitted to our hospital complaining of discomfort after urination and macroscopic hematuria.
Cystoscopic evaluation concluded a solid none-papillous tumor existing on the dome and its pathohistological diangosis was transitional cell carcinolna (Gradel-2). However, CT examination demonstrated aboult a diameter of 3 cm sized tumor growing extramurany from the urinary bladder.
Operative findings showed that the tumor existed between the appendix and urinary bladder and had remarkable adhesion to the both organs. Therefore partial cystectomy and right hemicolectomy were extensively perfomed because of a possible malignancy.
The pathohistological features of the tumor indicated a xanthogranuloma arising in the appendix. A brief discussion was added on this rare case.

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We experienced a case of intussusception associated with Schonlein-Henoch purpura. A one-year-old boy who had been admitted with complaints of abdominal pain and tarry stool was diagnosed as Schonlein-Henoch purpura. During medical treatment he had a sudden ileus and was diagnosed as intussusception by a barium enema study. Operation revealed an ilio-colic type intussusception. The postoperative couse was uneventful by giving blood coagulation factor XIII. Recently there were some reports of a specific decrease of coagnulation factor XIII in children with Schonlein-Henoch purpura, and this case also showed a remarkable decrease. Thus it was suggested that the blood coagulation factor XIII regimen was effective for surgical complication of Schonlein-Henoch purpura.

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A case of spontaneous rupture of the sigmoid colon with Ehlers-Danlos syndrome in a 60-year-old woman is reported, whose life could be successfully saved. The patient was admitted with sever lower abdominal pain. On laparotomy a 12cm perforation was found on the antimesenteric side of the sigmoid colon, and Hartmann's operation was performed. She was diagnosed as Ehlers-Danlos syndrome by clinical signs and histopathological findings of the skin, but immunofluorescence with anti-collagen antibody showed that the distribution pattern of type I, III, IV and V collagen in the skin was normal. So, it seems that further examination of cultured skin fibroblasts from the patient is necessary.
In the domestic literature, this is the first case of colonic perforation With Ehlers-Danlos syndrome, in which patient's life could be saved. For better management of this syndrome, it is important to avoid an increase in intraintestinal pressure. Moreover, primary anastomosis and subsequent closure of the colostomy should be avoided for the colonic perforation associated with this syndrome.

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In a recent 6-year period we have treated five patients with villous adenoma of the colon. This paper describes a discussion of the association of this condition with cancer of the colon and its therapeutic guideline.
It was found three (60%) out of these five patients with villous adenoma were complicated by cancer of the colon. Three (0.9%) out of 349 patients with cancer of the colon who had undergone surgery were diagnosed as having villous adenoma. The main signs and symptoms of this condition included prolapse of the tumour mass from the anal annulus, dysfunction of bowel movement, and secretion of mucous. The guideline for surgical treatment was to keep the area of excision localized so as to avoid excessive surgical invasion.
The villous adenoma and the cancerous tissue were excised en block followed by a perioperative pathological diagnosis. It was concluded that this degree of excision might be adequate if the tumour invasion was retained within mucosal layer.
We hope to treat a further number of such patients, therefore be able to provide an adequate postoperative follow-up and establish more appropriate therapeutic guidelines.

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A 91-years old woman was admitted to our hospital with the chief complaint of bloody stool. Sigmoid colon cancer like type III in macroscopic classification was found 15cm distant from the anal edge by colonoscopy. In resected specimen, the ulcreation of the tumor looked like a punched out lesion from the surrounding mucosa, measuring 2.5×1.5cm in size. Pathological findings revealed a well-differentiated adenocarcinoma located in the ulcerated area and cancerous invasion in the proper muscle. This unusual form, pm, INFβ, lyl, vl, ow (-), aw (-), and n (-), was possibly advanced type IIc or III.

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It is uncommon that an adenoma primarily arises in an artificial anus. We encountered such a rare case in a 56-year-old male who underwent Miles' operation for rectal cancer in 1975 and right hemicolectomy for cecal cancer in 1977-Both resections were curative and no signs of recurrence were observed after the operations. The patient visited our hospital because of hemorrhage from the artificial anus in 1987, and a thumb tipsized mass found at the site. Carcinoma in adenoma was diagnosed via biopsy. The artificial anus was dissected from the surrounding tissues and circumcised at 1cm from the oral margin of the tumor. Pathohistological examination revealed a mucous cancer extending to the submucosa at the center of the adenoma. Adenoma arising in the artificial anus has only been reported in three cases of ulcerative colitis and one case after Miles' operation. It has not been reported that a carcinoma in adenoma has arisen in the artificial anus like this case.

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A 58-year-old woman who copmplained of a weight loss and change in the sence of taste was admitted due to a large abdominal mass on the right upper quadrant. Echography, computed tomography and angiography revealed the large hepatic tumor which was fed by the right anterior inferior branch of hepatic artery. After a ligation of the right hepatic artery the tumor was extirpated by the dissection of the feeding vesgels. It showed a variety of histological features such as funicular, solid, pseudoductal, and indurated ones. After 15 months the metastases were noticed in the abdominal wall and liver, however, one of the lesions only in the abdomial wall could be extirpated. After 19 months the intrahepatic metastases became bigger and now metastasis was observed in the peritoneal cavity. After 30 months the metastses of the jejunal mesenterium was extirpated to prevent the intestinal obstruction. After 48 months she died of cahexia due to the enlarged metastatic tumors and the disturbance of the intestinal passing. This case can be classified into the protrusive type among the extrahepatic growing type of hepatocellular carcinomas according to the classification by Ichikawa. It can be said rare in the survival period for as long as 4 years that is the longest one among 62 cases of this classification reported in Japan.

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Biliary cystadenoma is very rare indeed, but is known to have a tendency to malignant alternation. We reported a case below.
A 67-year-old female underwent operation with epigastralgia as chief complaint. A deroofing was carried out and no malignancy was confirmed by intraoperative frozen section. Postoperative histological diangosis was made as biliary cystademoma. We examined 8 cases of biliary cystadenoma and 47 cases of biliary cystic adenocarcinoma reported in Japan. We tried to clarify the difference between biliary cystadenoma and biliary cystic adenocarcinoma from the view-point of imaging diagnosis.
The following was revealed: 1) Cystic adenocarcinoma often has interamural papillary projections in CT and US. 2) Papillary tumor was enhanced by contrasted CT. 3) Internal solid components had an accumulation of contrast material in angiograpy.

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A case of absence of gallbladder assoiated with choledocholithiasis and Meckel's divertuculum was reported. The case was a 69 year old male complaining of right hypochondric pain. After clinical evaluation, the patient was diagnosed as choledocholithiasis, but the gallbladder was not detected.
Operation was performed, where the dilated common bile duct and 2 stones admitted in the duct were found but the gallbadder was absent. Furthermore Mekel's diverticulum was found at 75cm oral side from the end of ileum. Choledocholithectomy, T-tube drainage and resection of Meckel's diverticulum were performed.
Congenital absence of the gallbladders is one of the rare biliary anomalies. In adults, 77 cases were reported in Japan. Chief complaints included abdominal pain, fever, and icterus. These cases associated with dilated common bile duct in 48.1% or choledocholithiasis in 31.2%. Operation is commonly indicated for cases having choledocholithiasis, however, under a fact that the aging may be often accompanied by stones, careful follow-up is necessary lithiasis, however, under a fact that the aging may be often accompanied by stones, careful follow-up is necessary especially for cases of suspicious absence of gallbladder.

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A 71-year-old female was referred to our hospital with the complaint of right lower abdominal pain. Abdominal X-ray examination proved pneumobilia. Ultrasonography revealed a wall thickness of the gallbladder and irregular mass. Gastroendoscopy revealed the open position of fisutula. Upper gastrointestinal series revealed fistulas at the pars descendens duodeni and common bile duct, of Which open positions were confirmed by gastroendoscopy.
Operation was done on January 12th in 1989, and choledocho-duodenal and choledocho-colic fistula were found. Cholecystectomy and colectomy were performed.
On microscopic findings a gallbladder cancer was found, which was well differentiated adenocarcinoma, and invaded the subserosa.
We can find out no malignancy in the fistulas. Five cases of gallbladder cancer with choledocho-duodenal and choledocho-colic fistulas repeated in Japan, were also reviewed.

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Two cases of solid and cystic tumor (SCT) of the pancreas in 18-and 24-year-old women were reported, and the clinical problems in 102 cases reported in Japan were discussed.
The 2 patients complained of upper abdominal mass. Ultrasonography and computed tomography revealed a cystic tumor of body or tail of the pancreas. Each tumor was excisedby distal pancreatectomy which was histologically confirmed to be SCT of the pancreas. Reaction to α1 antitrypsin staining was negative in the former case while postive in te latter case. Histologically invasion, however, was observed in both cases.
Of 102 cases of SCT of the pancreas reported in Japan, the majority of which was accounted for females with the average age of 31 years, 32 had tumors at the head and 66 at the body or tail of the pancreas. Malignancy was confirmed in 36 cases including 30 showing histological invasion and 6 having metastases and/or recurrence, accordingly surgical procedure is preferable to select according to as the procedures for pancreatic carcinoma.

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A 78-year-old woman was admitted to our hospital with the chief complaint of abdominal distension. An abdominal ultrasonography and CT scan showed multiple septations in a large amount of ascites, which is a characteristic finding of pseudomyxoma peritonei. Operative findings included mucinous tumors in the right ovary and the appendix. Microscopically, well-differentiated adenocarcinomas were identified within both of these organs.
After the surgical resection of the tumors, a Tenckhoff catheter was positioned within the abdominal cavity. Through the catheter, the peritoneal lavage was performed everyday, and four cycles of intraperitoneal 5-FU administration were executed for four months following the surgery.
Serum and ascitic CEA, CA19-9, and CA125 were miraculously decreased, and no mucinous tumor was identified at the staging laparotomy after the completetion of the intraperitoneal chemotherapy.

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Aneurysms of renal artery are frequently aocompanied with hypertention. We experienced a case renovascular hypertention because of right renal artery aneurysm after reconstruction of fibromuscular dysplasia. The patient was a 34-year-old female. She was operated for renovascular hypertention because of renal artery stenosis at 20 was a 34-year-old female. She was operated for renovascular hypertention because of renal artery stenosis at 20 have an aneurysm of right renal artery in August 1986 and admitted to our hospital on November 15. Blood pressure was 180/120mmHg (right arm) and 172/130mmHg (left arm); plasma renin activity (PRA) 3.5ng/ml/hr; and renal vein renin activity (RVRA) was 6.2ng/ml/hr at the right side and 4.7ng/ml/hr at the left side. RVRA ratio in the right to left was 1.32. The shape of aneurysm was oval with its size of 17×35mm. The operation was performed with nephrectomy. Blood pressure became normal postoperatively and PRA decreased to 0.49ng/ml/hr.

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We rarely encounter aneurysms in the abdominal visceral arteries, paticularly an inferior mesenteric aneurysm. This paper describes a case of inferior mesenteric aneurysm associated with aortitis syndrome in a 56-year-old woman. The patient was seen with the chief complaint of systoric murumur centering on the umbilical area. CT of the abdomen revealed a round tumor, 2cm in diameter with peripheral calcification on the left side of the aorta. With aortography, a diagnosis of aneurysm developed in the root of the inferior mesenteric artery was made. In anticipation of the risk of rupture, operation was performed. After aneurysmectomy, the right internal iliac artery and the drainage artery stump were anastomosed end to end to rebuild blood flow to the intestine. The aneurysm was a sacciform, 3.0×2.0×2.2cm in size, laterally protruding with a 2×1cm lacuna. Marked stenosis of te cut-off ends of the feeder artery was noted. Histologically, the internal elastic laminae of the aneuryms wall divaricated to disappear, and a remarkable calcification was obserbed. This aneurysm was diagnosed as poststenotic dilatation due to aortitis, secondarily added by arteriosclerotic changes.

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This paper describes our second experience of advantitial cystic disease of popliteal artery in a 56-year-old man who could be diangosed preoperatively and successfully treated. This may be 34th case reported in Japan.
The patient suffered from sudden onset of claudication on left lower thigh. The symptoms fluctuated day by day in spite of medical care, and reduced by rest. Accurate preoperative diagnosis was made by characteristic features such as a narrowing popliteal artery and periaterial cystic figures in arteriogram, ultrasonogram and enhanced CT. Cystectomy was carried out and the symptoms disappeared post-operatively.
Preoperative diagnosis of this disease may not be so difficult when one knows well about several characteristics in clinical symptoms and imaging examinations.

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Isolated aneurysm of internal iliac artery is infrequent, but often leads to the rupture with a high rate compared to another peripheral aneurysms. We reported a case of ruptured aneurysm of internal iliac artery treated with ligation and embolization.
A 84-year-old man complained of abdominal pain and lumbago, and was found to have a ruptured, isolated left iliac artery aneurysm by ultrasonography. Transcatheter embolization tried first was failed because of severe arteriosclerosis. Then we carried out laparotomy and ligated the proximal part of the left iliac artery. However, the pulsation of the aneurysm was still continued, which obliged us to occulude aneurysm with coils and Gelfoam, resulting in the disappearance of pulsation and successful embolization.
This procedure recommended when the proximal ligation offers an unsatisfactory effect for the ruptured aneurysm of the internal iliac artery.

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A case of solitary benign schwannoma arising in the left brachial plexus with intrathoracic extension is presented. The patient was a 54-year-old woman, who was first found to have an abnormal shadow at the left lung apex on routine chest X-ray examination. A left supraclavicular mass was subsequently also discovered. She complained of severe radiating pain in the lateral left upperarm upon compression of the mass. The tumor was completeley resected from the brachial plexus by supraclavicular approach, where thoracotomy was not needed. Postoperatively, there was no neurological problem.

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Between April 1985 and October 1988, we performed operations for ten surgical patients with shizophrenia in five males and five females, aged 26 to 70 years (the mean of 45.4 years). These patients have been troubled with shizophrenia for 2 to 41 years with the mean of 18.4 years before operation. They had laparotomy in five, thoracotomy in one and some kinds of operation in four. Operation was performed under satisfactory general amesthesia maintained with enflurane, nitrous oxide and oxygen in nine patients except one.
All of them were given antipsychotic drugs until the day before operation, and early in the postoperative course, most of them received a resumption of these drugs. All patients were cared postoperatively in surgical ward and had uncomplicated courses. Pre and postoperative management was made satisfactorily by assistance of psychriatrists.
According to these experiences, it appears that pre and postoperative management for the patients withshizophrenia can be safely made if surgeons could be offered an appropriate assistance by psychiatrists.

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