Sixteen-six patients treated surgically for ruptured mitral valve chordae tendineae were investigated to clarify usefullness of mitral valvuloplasty. Of the 16 patients 6 underwent MVP (group MVP) and 10, underwent valve replacement (group MVR). The causes of chordal rupture were idiopathic in 10 (63%), rheumatic in 4 (25%) and infective endocarditis in 2 patients (12%). All cases of group MVP were males and were diagnosed as idiopathic because of mucous degeneration and unknown cause. In idiopathic cases, the interval from onset of heart failure to operation was significantly shorter than that in rheumatic cases (6±7 months versus 52±15 months, p<0.01) and chordae to posterior mitral leaflet were ruptured in 8 cases (80%). Mitral valve repairs were undergone by McGoon's method and mitral valve annuloplasty by Kay's method added in 3 cases. In group MVP pulmonary arterial wedge pressure v wave decreased after operation (from 19±6mmHg to 8±3mmHg). Pulmonary arterial pressure and left ventricular function were improved to normal range, of which values were similar in the two groups. These results suggested that MVP is valuable for ruptured chordae tendineae if an appropriate selection of a patient and opportune operation are made.

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Operations for intrathoracic esophageal carcinomas are commonly associated with a large surgical invasion, and a variety of metabolic disorders is observed after surgery. As to energy metabolism, recent development of calorimeters has enabled us to measure the real time. This time we measured changes in energy metabolism in postoperative patients with intrathoracic esophageal carcinoma, and based on the measurements, reasonable alimentary management was discussed. Measurement items included endocrinologic factors such as catecholamines, glucagon, and cortisol, and matabolic factors such as REE and serum osmorality gap (OG), as well as general biochemical examinations. The measurements were carried out from the preoperative day to 10th postoperative day, and the changes were chronologically analyzed. As a result, increases in serum bilirubin, OG, catecholamines, glucagon and cortisol were noted after surgery. REE started to increase immediately after surgery to be about 130% or 180% of BEE. It is clarified that the optimal calorie to be administered lies in 35-45 Kcal/kg/day after surgery for intrathoracic esophageal carcinoma, which can maintain the energy balance at the positive side.

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For the purpose of studying glucose intolerance in postgastrectomy patients, 34 patients were divided into 4 groups by the diagnostic criteria of the WHO Expert Committee on Diabetes Mellitus in 1980 and those of the Japan Diabetic Association in 1982.
Group I consists of 3 patients with normal type of the diagnostic criteria of the Japan Diabetes Association.
Group II consists of 22 patients with borderline type of the Japan Diabetic Association excluding IGT; all patients with oxyhyperglycemia belong to this group. They had lower glucose tolerance at an early stage after loading with glucose than group I, but had better glucose tolerance than groups III and IV.
Group III consists of 5 patients with IGT in a prediabetic state. They had significantly lower sugar and HbA1 levels than those of group IV, but require strict follow-up, as is the same with patients with diabetes mellitus.
Group IV consists of 4 patients with diabetes mellitus, and 3 of them were treated for the disease preoperatively, and showed significantly higher HbA1 levels than those of the other groups.
HbA1 levels of the postgastrectomy patients were significantly correlated with their fasting blood sugar level. HbA1 can be used as an index of their diabetic condition.

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Six hundred and fifty-four resected specimens of single gastric cancers were measured for the maximum macroscopic diameter and classified by every one centimeter to evaluate clinicopathological findings and prognosis. Moreover, tumors with the maximum diameter of less than 3 cm having n (+) or ps (+) and those with more than 5 cm with P0 and H0 having n (-) or early cancer were served as special examples and examined. A correlation between longer diameter and clinicopathological factors was confirmed until the diameter reached around 10 cm, howver, when it exceeded 10 cm, no apparent correlatio ncould be found. As to the another correlation between the diameter and prognosis, an increase in diameter until 7 cm declined the survival rate to 21.4% from 95.2%. No significant difference in the survival rate was noted when the diameter exceeded 7 cm. From these findings, it can be concluded that the longer diameter of gastric cancer may reflect each clinicopathological factor and prognosis so far as it remains small, but it is getting obscure prognosis of far as it remains small, but it is getting obscure with an increase in tumor size. In addition, the special example with the diameter of less than 3 cm were predominantly included in flat type, por, severe vascular invasion, and INF ρ type. While the special example with the diameter of more than 5 cm were predominantly classified into tours type, sig, and slight vascular invasion.

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During a 7-year period (1982-1988), a total of 501 patients were surgically resected for gastric cancer and 151 of the 501 underwent total gastrectomy. The 151 patients were divided into mechanical anastomosis group (group A; consisting of 62) and hand-sutured anastomosis group (group B; 89), and the two groups were comparatively studied for complications at the anastomotic sites. Roux-Y anastomosis or jejunal interposition was performed in 59 or 3 respectively in group A; while 86 or 3 respectively in group B. No significant difference between both groups was observed in background factors of operation.
Complications at the anastomotic sites included failure of the suture in 4 (6.5%) for group A and 6 (6.7%) for group B; bleeding from the site in one (1.6%) and one (1.1%); constriction in 5 (8.1%) and 6 (6.7%), respectively. No significant difference between both groups was noted in these incidences of complications.
Mechanical anastomosis, which could lead to no significant difference in the occurrence of complications at the anastomotic sites compared to hand-sutured one, appears valuable in that it can be handled conveniently and shorten a time required for the procedure.

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A total of 38 cases of advanced rectal cancer (radiation group: 25, non-radiation group: 13) was studied in order to clarify the effect of preoperative radiation therapy (42.6 Gy) on lymph nodes metastases in rectal carcinomas. In all cases, microcarbon was submucosally injected into the rectal wall on the day before operation in order to increase the number of removable lymph nodes from resected specimens as many as possible. By this method, the number of lymph nodes detected per specimen increased from 40 to 60. The incidence of lymph nodes metastases was 38.5% in radiation group and 64.0% in non-radiation group. The mean number of lymph nodes with metastases was 8.6 in non-radiation group, however, 2.8 in radiation group. With regard to the relationship between size and number of positive lymph nodes, especially in small lymph nodes measuring less than 3 mm, the incidence of metastases was 6.4% in non-radiation group, whereas 0% in radiation group. As a result, it was evident that preoperative radiation therapy in rectal cancers would reduce the number of positive lymph nodes significantly and the effect of radiation was prominent in small lymph nodes.

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Thirteen patients with congenital biliary dilatation treated in our department were analyzed in relation to its complications and other features. Two of the 13 patients were associated with biliary tract cancer and Both lesions were unresectable, because of their advanced stages. The dilated bile ducts appeared cystic, and the cancers involved the intrahepatic bile ducts and dilated extrahepatic bile ducts. The level of amylase in bile was high, suggesting that prolonged regurgitation of pancreatic juice into the bile ducts had induced the canceration.
Concomitant cholelithiasis was found in 5 patients, 3 of whom had bilirubin calciferous stones. Morphologically, the dilated bile duct was classified as type IV-A in 3 and type Ia and Ib in each one. Stones were intrahepatic in 2 of the 3 cases of type IV-A.
Pancreatic lithiasis was found in 3 patients; stones were present in the Wirsung's canal, Santorini's canal and both canals in each one. Two of the 3 had no positive stones upon roentgenography. The pancreatic stones were removed by papilloplasty or accessory papilloplasty. The 3 patients were treated by resection of the dilated extrahepatic bile duct with bile duct reconstruction. Postoperative pancreatic fistula occurred in 2 patients undergone a second operation after cystoduodenostomy or cystojejunostomy, who could be successfully managed by conservative treatment alone. Prognosis was favorable in all patients except those accompanied by cancers.

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Aiming at more accurate diagnosis of stricture of the bile duct, especially more appropriate differentiation between benign and malignant one, 16 cases of the disease in a 5-year period were retrospectively reviewed for clinical findings and imaging diagnostic methods based on obtained images of the strictures. The results were:
1) Aging was accompanied by a significant increase in occurrence of malignancy; significantly higher levels in WBC, bilirubin and ALP were observed in malignant cases; but no significant difference was noted laboratory findings, sex, disease period, and severity of the disease. 2) Direct cholangiography was considered valuable, however, there were some cases in which we had difficulty in differential diagnosis even by this method. 3) From images of the strictures obtained, the differentiation between benigns and malignancies could be provided by the location but not by the length, minimal diameter, and side of the stricture. Some helpful informations were given from the condition of the wall and form of the stricture. Nevertheless, there remained several cases with difficulties in diagnosis, for which PTCS appeared available.

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A retrospective study of 76 patients undergone PTCD (included 11 cases of PTGBD) in our clinic for the past seven years was conducted to determine the efficacy of PTCD and benefits of different operative treatments. Fifty-seven patients with malignant tumor (either bile duct, pancreas head, or gallbladder cancer) were divided into three treatment groups: Group I, curative operation (9 patients); Group II, palliative operation such as internal drainage (15); and Group III, PTCD alone (33). Seventeen of 19 benign cases with PTCD were suffered from choledocholithiasis and cholangitis. Both total serum bilirubin prior to PTCD and the drainage time to attain the normal range (less than 3.0 mg/dl as serum total bilirubin level) were significantly low in the benign group compared to the malignant group (p<0.01). The survival rates in the malignancies tended to be lowered from bile duct, pancreas head, to gallbladder cancers in this order. Group I patients showed the best survival, whereas the median survival period in group II patients was 125 days which did not differ from that in group III (PTCD alone) (116 days). From these findings, the significance of adequate selection of palliative surgical treatments such as by-pass operation should be emphasized to reduce hyperbilirubinemia in the patients with unresectable malignant tumor.

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Among 28 resected cases of carcinoma of the pancreas, 24 excepting 4 death cases due to operation or other diseases were clinicopathologically studied. The 24 patients could be classified by macroscopical staging as 6 in stage II, 11 in stage III, and 7 in stage IV. Histologically there were 13 curative resection and 11 noncurative resection cases.
In 13 histologically curative cases one-, 3- or 5-year survival rate was 50%, 37.5%, or 37.5%, respectively. While 11 noncurative cases included no survivals longer than 23 months, and the one-year survival rate was 21.8%. When compared with long survival cases for histological type, moderately differentiated tubular adenocarcinoma appeared predominant in cancer-deaths within one year and noncurative resection cases. As to histological tumor extension, both two long survivers had sa, rpa, n(-), and pv0v0; cancer-deaths were positive against all factors excepting pv; and noncurative resection cases tended to have an extrapancreatic extension. Four of 6 curative resection cases were found to have liver metastasis by necropsy, which indicated that the important factor for long survival might lie on active approach to prevent the liver from metastasizing.

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Pancreaticoduodenectomy was performed on 53 patients during the post one decade (1978-1988), and their postoperative complications were studied. There were 40 males and 13 females, with ages ranged from 32 to 78 years (The mean was in their fifthies). Postoperative complications developed in 29 of the 53 patients, the overall mortality being 55 percent of the 29 complications recorded, a local complication of pancreatic leakage was frequent (55%). Post operative hemorrhage either from the gastrointestinal tract or from the wound occurred in 8 patients (15%). The major common complications (cardiac failure, renal failure etc.) occurred in 19 patients (34%), which were frequently associated with local complications such as pancreatic leakage and postoperative hemorrhage. One patients (1.9%) died in the early postoperative period. The deaths were due two times to a complicated pancreatic leakage and due to three times to massive uncontrolled bleeding. The level of preoperative serum bilirubin was not correlated with postoperative complications and deaths. Pancreatic leakage and hemorrhage were omnious occurrences with high mortality. We must remember that the most appropriate timing of pancreaticoduodenectomy varies with each patients.

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Venous dilatation in the absence of varicose vein of the lower extremities is a rare disease. A case of venous aneurysm of the external jugular vein is reported.
The case was a 49-year-old female who was admitted to our hospital with the chief complaint of a tumor on the right side of the neck. The soft tumor 3×2 cm in size was palpable on the right side of the neck. MR angiography revealed a venous aneurysm of external jugular vein with thrombus formation. The venous aneurysm was excised under general anesthesia. The operative findings well coincided with those of MR angiography. Histopathologic examination revealed a thinned venous wall, structural anomaly of venous muscle and intimal thickness in part.
The MR angiography is non-invasive and able to provide more accurate information about the peripheral vascular diseases.

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It is believed that CA19-9 is positive to gastrointestinal carcinomas at a high rate. CA19-9 is rarely found in a high value associated with the existence of thyroid carcinoma. Recently we experienced a case of thyroid carcinoma accompanied by high serum CA19-9 value, in which PAP method successfully demonstrated that CA19-9 was produced from the tumor tissues histologically.
The case was a 73-year-old man, who visited our hospital complaining of a tumor in the right side of the neck. Needle biopsy could diagnose the tumor as papillary carcinoma. Among tumor markers only CA19-9 value was as high as 200 U/ml. Gastrointestinal series revealed no abnormalities. From cervical CT, DSA, and thyroid scintigram findings, the tumor was diagnosed as thyroid carcinoma or lymph node metastasis of thyroid carcinoma. Right thyroid lobectomy, excision of the right cervical tumor, and regional lymph node dissection were carried out. CA19-9 staining using PAP method in the excised specimen led to the confirmation of the stained tumor cells, CA19-9 production from the tumor being demonstrated.

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A variety of resection with reconstruction procedures was studied in postirradiation ulcer on the chest wall after mastectomy. Subjects were 7 patients who had post-irradiation ulcers on the chest wall associated with intractable infections or fistulas. The patients were treated surgically, and various degree of chest wall defects were safely repaired with local flap, omental transposition and myocutameous flap. Post-surgical results were satisfactory, and the quality of life was remarkably improved in all cases. However, minor complications such as wound infection and fistula were frequently encountered.
Once postirradiation ulcer is infected, it is liable to be intractable or can progress rapidly, in that early surgical resection of the affected chest wall, if possible, is believed to be potentially curative. As to the reconstruction, myocutaneous flap was efficiant, and a use of any kinds of artificial prostheses should be avoided.

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It is extremely unusual for gastric cancer to metastasize to the mammary gland, a site where metastasis is known to be generally rare. This paper reports a resent case of metastasis of gastric cancer to the mammary gland. The case was a 29-year-old woman, who was diagnosed as having a non-resectable gastric canser (Boor 4, undifferentiated adenocarcinoma) in January 1987 and underwent chemotherapy. A painless flat mass mesuring 30×25 mm was palpated in the A region of the right mammary gland in March of that year. Mammography revealed no tumor shadow, but ultrasonography showed a low-echo area with clear margins. From cytology of needle biopsy specimens, a dignosis of metastatic gastric cancer was made, on the basis of the characteristic features of the tumor cells and their arrangement. Despite chemotheraphy and radiotherapy, the patient died of carcinomatous lymphopathy 5 months after the manifestation of the metastatic cancer in the mammary gland. The limphatic route was speculated to have been responsible for the metastasis.

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A 40-year-old woman had been treated with low anterior resection for rectal cancer nine years before, and with left upper lobectomy for lung metastasis of the cancer three years before. Since around four months before, the serum level of carcinoembryonic antigen started to elevate gradually, and the mass in the left chest wall was noticed. En-block resection of the chest wall including three ribs and a part of the lung was performed, and a large defect after wide resection of the chest wall was reconstructed with marlex mesh which was used as a prothetic material. The post-operative course was quite uneventful. She complained of neither paradoxical movement of the chest wall nor foreign body reactions postoperatively. The mass was diagnosed as metastasis of the rectal cancer, histologically.
Eight months after discharge, multiple metastases in her both lung were noticed. The patient was admitted again and now in the treatment with immunochemotherapy.

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Esophago-originated leiomyoma is regarded as rare among digestive leiomyomas and is often detected occasionally in health examination or examination of other diseases probably because of its scarce symptoms. We experienced a case of esophageal tumor, i.e. 0.7×0.5 cm micro submucosal tumor noted in the lower thoracic esophagus during the time-course observation of a duodenal ulcer and grown up as large as 4.4 cm in 2 years of course thereafter. The case is a 69-year-old man, who was practically asymptomatic but esophageal transillumination, endoscopy, ultrasonoscopy and CT suspected an esophageal leiomyoma, which was thus operated on. No supposed malignant macroscopic findings were noted peroioperatively and enucleation was carried out. Neither malignancy was revealed by pathohistological examination of the resected specimen, thus elading to diagnosis as leiomyoma. The most important disease in need of the differentiation from the present disease is leiomyosarcoma, and we often find difficulties in diagnosing the former partly because of its low rate of positive findings in biopsy. For the present case, preoperative labolatory findings and perioperative macroscopic findings led to the judgement as benign tumor and no malignancy was noted by postoperative pathological examination, so that diagnosis as leiomyoma was formed.

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A 58-year-old man complained of tarry stool and hematemesis. Endoscopy revealed an elevated lesion with ulceration involving the lower third of the esophagus. A biopsy showed poorly differentiated squamous cell carcinoma. Preoperative laboratory studies showed M-protein in serum (IgG-λ) and the bone marrow aspirate contained increased plasma cells by 18%. A skull radiograph showed only small areas looked like punched-out lesion. The preoperative diagnosis of hemorrhagic esophageal carcinoma associated with multiple myeloma in an early stage was made. The patient was treated with esophgogastrectomy (A₂N₃M₁Pl₀). The specimen revealed the typical histology of plasmacytoma (a₂n₃m₁ly₃v₀).
The tumor cells were shown, by the immunoperoxdase technique, to contain IgG-λ type light chain. After surgery, pleural effusion, ascites and the mass lesion in the left pleural cavity revealed, and they contained many plasmacytes. Although the patient received adjuvant chemothrapy, he died of sepsis caused by agranulocytosis and respiratory failure. Only three plevious cases of primary esophageal plasmacytoma have been reported in the world. This is the first case in Japan.

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We experienced a case in a 54-year-old female having duplicated early esophageal cancer and thyroid cancer heterochronously.
The patient had operated on for thyroid cancer 12 years ago and undergone left lateral neck dissection for cervical recurrence of thyroid cancer 11 years ago.
She complainted of cervical discomfort when she ate something last year, and underwent endoscopic examination three times a year. Three times examinations suggested an esophageal cancer and she was admitted to our hospital. Furthermore, a left cervical lymphnode swelling was found. Close examination led to a diagnosis of epithelial esophageal cancer. Cervical lymphnode swelling was diagnotic of recurrence of thyroid cancer because there was no lymphnode metastasis in epithelial esophagial cancers emprically. Under the diagnosis we performed blunt dissection and lymphatectomy. Resected specimen revealed that the left cervical swelling was papirally adenoma and esophageal cancer was in an early stage with depth of ep.
Double primary cancer of thyroid cancer and esophageal cancer, especially in an early stage, is extremely rare, and perhaps this case may be the first reported in Japan.

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We report a case of extramurally growing pedunculated leiomyoma in the stomach, together with a review of the literature.
The case was a 66-year-old female complaining of no particular subjective symptoms. Abdominal simple X-ray film revealed a tumor associated with calcification in the upper abdomen. We had difficulties in preoperative diagnosis, because CT, ultrasonography, gastric fluoroscopy, barium enema, and angiography failed to visualize the original organ. Histological examination of the resected specimen indicated a leiomyoma in the stomach. We can rarely find case reports on such a giant, extramural, and pedunculated leiomyoma in the stomach like this case. Furthermore, it is common that we have difficulties in differentiating whether the leiomyoma is benign or malignant, in that further strict observation is needed.

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We experienced a case of early gastric carcinoma of type IIc occurred 36 years after gastrojejunostomy in the pyloric stenosis due to gastric ulcer.
This case is a 56-year-old man. A concave lesion and concentrated pattern of mucous membrane connecting to the gastrojejunostomy regions of the greater curvature of corpus ventriculi were noted. The patient was diagnosed as having a signet-ring cell carcinoma by endoscopic biopsy. Gastrectomy of the pyloric side including anastomotic regions was carried out, and reconstructed by Roux-en-Y method. The macroscopic type of the extirpated sample was early gastric cancinoma of type IIc and histologically it was in H₀P₀n₀ m: stage I. The tissue type was signet-ring cell carcinoma. With regard to the developmental mechanisms of gastric carcinoma after gastrojejunostomy, a chemical factor due to stimulus of duodenal juice is the most important. Endoscopy is useful for the diagnosis of the disease, especially, changes of surroundings of the anastomotic region should be marked in the follow up of stomach performed gastrojejunostomy.

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Clinicopahtological characteristics of gastric cancer with high serum alpha-fetoprotein in 3 cases were studied. The 3 cases were men in their sixties. The main disease focus located in the C (one case) and A regions (two). One case belonged to Borrmann type 1 and two did to type 2. Histologically, one cancer was a well differentiated tubular adenocarcinoma, and the remaining two moderately differentiated tubular adenocarcinomas. The cancers of all three cases had no subserosal penetration and were all of intermediate type as to the amount of stroma. In every case, lymph node metastasis was observed, and liver metastasis was not observed at the time of operation for gastric cancer. However multiple liver metastasis was found in case 1 on the 3rd month after operation, and he died after two months. As to case 2 three metastasis lesions were found in the right lobe of liver on the 8th month after operation, but there was no recurrence after liver resection. Case 3 had no recurrence up to now after gastrectomy. These clinicopathological characteristics of gastric cancer presenting with elevated AFP indicate the importance that we should predict liver metastasis based on a change in serum AFP, and treat preventively before actual manifestation of liver metastasis.

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We had experienced a case of gastric carcinoma with selective ACTH deficiency. The carcinoma was located on the posterior wall near the lesser curvature of upper gastric body and revealed a IIc like advanced gastric carcinoma. This patient has been taking hydrocorcisone 15 mg/day as steroid hormone for about four years. Which indicated the high risk of anastomotic failure. Therefore partial gastric resection without anastomosis was performed, although it was in an advanced stage. Since the secresion of corcisol could be hardly anticipated, methylprednisolone sodium succinate 300 mg/day was administered for two days after operation, and after that, the dose was gradualy decreased. Post operative course was successful and now the patient is under careful follow-up. We cannot find any reports of surgical treatment of gastric carcinoma associated with selective ACTH deficiency to date. This case which was considered the first one is presented with a review of the literature.

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A surgically treated case of primary early cancer of the duodenal bulb was reported. The case was a 68-year-old man without any symptoms who was admitted to our hospital for further investigation, because an abnormarity of the stomach was suspected by mass screening examination. X-ray examination of the upper gastrointestinal tract revealed a round, well defined and elevated lesion, 4.5 cm in diameter, on the posterior wall of the duodenal bulb, and no abnormal findings in the stomach. Endoscopic examination showed a polypoid lesion with cauliflower-like appearance and the endoscopic biopsy specimen revealed an adenocarcinoma. Under a preoperative diagnosis of cancer of the duodenal bulb, pancreatoduodenectomy and lymphnode dissection were performed, because the tumor size was as large as 4.5 cm in diameter and possible metastases to the regional lymphnodes were not excluded. The resected tumor was 4.5×3.7 cm in size and 1.5 cm in height.
Histological diagnosis was a well differentiated adenocarcinoma limited within the mucosa with no lymphnode metastasis. Postoperative course was uneventful and the patient is enjoying a symptom-free life as of 10 months after the operation.

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A case of primary volvulus of the small bowel in an adult (58-year-old woman), who was transferred to our department in an arrested condition due to septic shock caused by intestinal necrosis and operated on after successful resuscitation, is presented.
Reports on the primary volvulus of the small bowel are few in Japan. Special care should be taken for this disease because it develops necrosis rapidly resulting in a high mortality.

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A 72-year-old woman was carried in our hospital with the chief complaints of abdominal distention and vomiting. The patient was diagnosed as occlusive ileus due to a rectal cancer and temporally double barrelled colostomy with sigmoid colon was performed. After that, although the patient had sufficient evacuation, a progressing abdominal distention was found. Abdominal CT revealed a locally enlarged digestive tract at a location where the lower abdominal distention was seen. The patient was diagnosed as having localized ileus developed anal-side from the preternatural anus, and radical operation was performed. These ileus episodes were clarified to be caused by advanced cancers existing at the sigmoid colon and upper rectum (synchronous multiple cancer).
Preoperative examination often fails to offer full informations about multiple cancer, especially for patients undergone emergency operation due to colon cancer-caused ileus or perforation or those presented with severe occlusion due to anal-side colon cancer. We should remember a possible existence of multiple cancer in the treatment of colon cancer in all cases.

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In the treatment of congenital intrahepatic biliary dilatation, there arise a problem of postoperative cholangitis due to residual cystic intrahepatic bile duct. We experienced two patients with the disease who had received inadequate initial operations at other hospitals and referred to our hospital. First case had had a cyst excision with hepaticojejunostomy under the diagnosis of congenital choledochal cyst at the other hospital. This patient was admitted to our hospital because of recurrent cholangitis after surgery. Percutaneous transhepatic cholangiography and computed tomography showed cystic dilatation of the bile duct of the 2nd, 7th and 8th segments with intrahepatic lithiasis. Partial resection of the 2nd segment, and 7th and 8th subsegmentectomy including dilatated bile ducts were performed for type IV-A of congenital intrahepatic biliary dilatation classified by Todani. Second case had undergone transduodenal sphincteroplasty following cholecystectomy for cholelithiasis at the other hospital. This patient had recurrent episodes of high fever and epigastralgia. Cystic dilatation of the bile duct with stones in the posterior segment of the liver was revealed by cholangiography. Right hepatic lobectomy was carried out for Todani's type V with intrahepatic lithiasis. Surgery for the two cases was followed by complete cessation of cholangitis. It is important to confirm whether there are intrahepatic lesions before treatment of this disease. Hepatectomy is the most reasonable procedure for the cystic dilatation of the intrahepatic bile duct.

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We describe here each rare case of porcelain gallbladder and limy bile, in which abdominal simple X-ray examination revealed calcified lesion in the gallbladder.
The case of porcelain gallbladder was a 40-year-old male complaining of epigastric pain. Cholecystectomy was carried out. The extirpated gallbladder, with 3 stones in it, had the stony hard and fragile wall due to calcification. Histologically the mucous membrane peeled off, and the wall was associated with diffuse calcification and fibrosis, but no malignancy was found.
The other case was a 57-year-old female who was diagnosed as limy bile by X-ray examination and was operated on. The bottom room of the sandglass-shaped gallbladder, due to adenomiomatosis, was filled with limy bile. The main ingredient of the limy bile was calcium carbonate.

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A 77-year-old woman was admitted to our hospital with the complaints of loss of appetite and jaundice. Percutaneous Transhepatic Cholangiography (PTC) and CT-scan on admission revealed a 33 mm×26 mm sized mass of the gallbladder associated with regional metastatic lymph nodes and complete obstruction of the common hepatic duct. On the 9th hospital day gastrojejunostomy and PTC drainage via left hepatic duct were performed. The patient received both of 5 FU (500 mg) and MMC (10 mg) intravenously on the 4th postoperative day and OK-432 (5KE) orally twice a week for about 5 weeks from the 10th postoperative day. On the 20th posttherapeutic day by OK-432, common bile duct was patent to duodenum and a very rare type of the abnormal connection between the choledochus and pancreatic duct (Kimuras' classification: I type; Sanos' classification: α type; Ohi's classification: A type) was recognized by PTC. CT-scan revealed that the size of gallbladder cancer was diminished and regional metastatic lymph nodes were vanished on the 30th posttherapeutic day by OK-432.
In conclusion, from the above mentioned, oral administration of OK-432 may be effective for advanced cancer of the digestive organs.

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A 56-year-old female came to our hospital with the complaints of abnormal behavior followed by consciousness disturbance while being hungry. The blood sugar level on admission was low (24 mg/ml) but IRI was high (23.8μU/ml). Imaging diangosis indicated an insulinoma of the pancreatic head, and operation was performed. During operation catheterization was made into the portal vein, and glycemia was monitored, IRI value being measured by Quick IRI method. The hyperglycemic rebound appeared 2 hours after the removal of the tumor, but IRI became normal immediately after the removal. These findings indicates that Quick IRI method should not be lacked to convince of the complete excision of the insulinoma during operation. We report a total of 10 insulinomas experienced at our department.

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We report a case of congenital multicystic dysplastic kidney in a new born, in whom prenatal ultrasonography revealed multiple cysts in the right kidney, and an abdominal mass was palpated in the right upper quadrant. Exploration revealed multiple cysts in the right nonfunctioning kidney. The newborn had been diagnosed as congenital multicystic dysplastic kidney and followed up. At four months of age, hypertension and elevated plasma renin activity were noticed. After the newborn underwent nephrectomy, blood pressure and plasma renin activity were resolved. Microscopic inspection showed typical features of the congenital multicystic dysplastic kidney without malignant change. In Japan, 174 cases have been reported to June 1989. Generally, the treatment of the patient is surgical resection and postoperative complications are rare. We can find an opinion by Bloom et al, that non surgical approach is recommended because the disease has favorable prognosis. However, nephrectomy should be considered, since serious complications such as malignancy and hypertension have been associated in 1.7% of patients with retained congenital multicystic dysplastic kidney.

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We experienced a case of paroxymal pheochromocytoma where the symptoms were successfully controlled by labetalol despite abnormally high blood levels of adrenalin before operation. The case was a 26-year-old male who had been treated at a local clinic under a diagnosis of intrahepatic hematoma for the past six years. At the time of investigation in our hospital, hypertension and palpitations were noted, and a right adrenal pheochromocytoma could be diagnosed by imaging and hormonal examinations. Catecholamine levels in both blood and urine were high, and in particular the adrenalin level was more than 300 times the normal one, which is higher than those in any other previously reported cases. For preoperative control, labetalol (an α β blocker) was found to be effective, and careful pre- and perioperative handling of this patient led to safe resection.

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Paraduodenal hernia is a kind of intra-adbdominal hernia, and 74 cases have been reported during 88 years from 1902 to 1990 in Japan. This patients group comprised 58 (75%) males and 13 (20%) females with 3 (5%) unknowns; the hernia occurred in the left side for 38 (51%), right side for 27 (37%), and unknown for 9 (12%). The disease is believed to be complicated with malrotation of the intestine. However, only 11 cases of right paraduodenal hernal with malrotation of the intestine have been reported. This case, a 47-year-old man, who had complained at times a severe upper abdominal pain for 5 years, admitted with a severe abdominal pain and vomiting. From the past history and the intestinal fluoroscopy a kind of internal hernia was suspected and the diagnosis of left paraduodenal hernia was confirmed during the operation. This case is a first report of left paraduodenal hernia with a definite malrotation of the intestine in Japan. Seventy four cases of the disease reported in Japan are reviewed here and possible pathogenic geneses are discussed.

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A 54-year-old male was admitted to our hospital with a half-year history of cough. Physiological examination revealed an unmovable, infant's head-sized mass at the left lateral abdominal region. CT scan and ultrasonography showed irrguler and partly cystic patterns in the mass of 35×20 cm in size. Angiography disclosed encasement and A-V shunt of the left gastroepiploic left hepatic, and left phrenic arteries which fed the tumor.
Laparotomy and left thracotomy were performed on October 26th, 1988. The tumor was partly covered with the omentum with enlaged vessels, and adhered to the spleen, left diapragma, left lobe of the liver and sotmach.
In order to remove the tumor, splenectomy, partial left lobectomy of the liver and resection of the diaphragma were performed. Macroscopically the tumor was 40×26×15 cm in size and 5800 g in weight and the surface was irregular with lobulation. Histologic diagnosis was liomyosarcoma.

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This time, we experienced a huge retroperitoneal liposarcoma (hereafter to as the present disease). The present disease commonly lacks in clinical manifestations due to the anatomical situation and is often discovered after developing to a huge tumor.
For the diagnosis of the present disease, CT and MRI were useful. In CT. it presented as a low density tumor showing the CT values of -13-99 which are about the same as those of fat and the inside was heterogeneous without enhancement by the contrast medium. In MRI, it was heterogeneous of a low density in T₁ image, a part of which showed a shelflike high intensity. In Gd-DTPA, an irregular contrast enhancement was observed at the marginal area. Angiography revealed a hypovascular tumor nourished mostly by arborizations from capsular artery system.
Histopathologically, it was a mixture of well differentiated and myxoid types.

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A case of retroperitoneal undifferentiated carcinoma was reported. The patient was a 47-year-old man suffered from chronic hepatitis (non A non B) for several years. In the beginning of the last year, serum levels of AFP and CA125 increased markedly. Computed tomography showed several masses surrounded the head of the pancreas. Pancreatico-duodenectomy was performed for exclusion of the tumors, which were enlarged lymphnodes. Those tumor markers decreased to the normal level postoperatively. The histological findings of small portion of the tumor showed a hepatocellular-like carcinoma and so its diagnosis of “hepatoid carcinoma” was doubtful. As we could get unknown origin, this case was reported here as that of AFP producing retroperitoneal undifferentiated carcinoma.

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We report a case of isolated internal iliac aneurysm presenting with a big retroperitoneal cystic tumor, with reviewing the literature.
The case was a 71-year-old man who complained of ischuria and constipation caused by ruptured internal iliac aneurysm. Digital examination revealed a pulseless tumor and pelvic CT and US showed the big cystic lesion. The operation was performed under a diagnosis of primary retroperitoneal tumor, but a hematoma of 12×16 cm in size and right internal iliac aneurysm of 5×6 cm in size were presented. Right common iliac artery was ligated and endoaneurysmorraphy was performed. The artifical graft was replaced between the abdominal aorta and right external iliac artery.
Postoperative angiography showed that the patency of the graft was good. There was no finding of impared function of the rectum and bladder.

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Among complications after grafting of an artificial vessel, false aneurysm due to the teared artificial vessel is extremely rare. We experienced such a rare case in a 78-year-old man. The patient was found to have multiple false aneurysms on the graft itself 7 years and one month after right axillary-femoral artery bypass operation for arteriosclerosis obliterans, by using Cooley double velour knitted Dacron. The graft was removed and replaced with EXS Dacron graft. The extirpated specimen was closely examined. In addition, a review of the literature was made of false aneurysms due to teared graft.

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