One hundred and two patients with gastrointestinal cancer (70 with gastric cancer and 32 with colorectal cancer) were subjected to a study of natural killer cells. Natural killer cell activities (NK activities) were meatured and lymphocyte subsets were analyzed with monoclonal antibodies (Leu7 and Leu11) by using two color flow cytometry.
NK activities decreased with an advance in stage. Leu7^-×Leu11⁺cells decreased with an advance in stage, but Leu7⁺×Leu11^- cells did not. A positive correlation was found between NK activities and Leu7^- ×Leu11⁺ cells.
The results suggest that NK activity reflects the condition of a gastrointestinal cancer patient, and Leu7^-× Leu11⁺ is a useful monoclonal antibody which can mark natural killer cells.

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In order to evaluate the prognostic importance of clinical and histological node informations, we made univariate and multivariate analyses of regional lymph node metastases in 233 patients with operable breast cancer, who were surgically treated from 1973 to 1985. Clinical axillary node status, histological involvement of axillary lymph nodes, their anatomical levels and numbers, and histological involvement of internal mammary lymph nodes were selected as evaluating prognostic factors. The histological presence of axillary node involvement, especially at the distal level, was proved to be the most important prognostic factor. However, it was obscure that either the anatomical level or number of histologically involved axillary lymph nodes had a priority in the prognosis determination. On the other hand, histological involvement of internal mammary nodes appeared to be an important, and independent prognostic factor. Therefore, we concluded that axillary lymph node dissection with a biopsy of internal mammary nodes would provide more accurate informations about the prognosis in patients with operable breast cancer.

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Two hundred and eighty-seven patients with bleeding gastroduodenal ulcer who were admitted with the chief complaints of hematemesis and/or melena were clinicopathologically studied. The operation was performed in 155 (54.0%) patients. Bleeding rates were 78.0% in UL-II, 44.0% in UL-III, and 47.0 in UL-IV. The rates needed emergency operation were 76.5% in UL-II, 42.9% in UL-III and 46.6% in UL-IV. Both bleeding and emergency operation rates were higher in UL-II cases. From an examination of the diameter of exposed vessels in vascular stump-positive cases, the inner-to-outer diameter ratio of the vessels was significantly smaller in UL-II (0.074) compared to UL-IV (0.125) cases. This fact indicates that UL-II cases less frequently associate with intimal hypertrophy, and once the vessels are broken, thrombosis is hard to be formed, accordingly more efforts being demonded for its hemostasis.

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It can be presumed that a recent increase in patients undergone gastrectomy for gastric cancer increases the occurrence of so-called “cancer of gastric remnant”. Eleven cases of cancer of the gastric remnant found at our hospital during the past 5 years were studied for location, intestinal metaplasia in the surrounding epithelium, and prognosis. The 11 cases accounted for 2.7% of all operative cases for gastric cancer in the same period. Of the 11 cases, 7 were first operated on for adenocarcinoma, and 4, for peptic ulcer. Five cases had over 10 years duration between the first operation and the diagnosis of cancer of the gastric remnant. Nine out of the eleven cases received total extirpation of the remnant stomach, one received partial resection, and one was unresectable. Curative resection was able to be done in eight cases. Six out of eight cases of tubular adenocarcinoma had the predominant intestinal metaplasia in the surrounding epithelium. Histological grading was compared with the primary lesion in six cases. The cancer of the gastric remnant had a tendency of poorer differentiation. The mean survival rate of the cases which received curative resection at the 4th postoperative year was 80%. The most important factors to improve the prognosis also seems to be early detection and curative resection.

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Fifty-four children with congenital intestinal atresia and stenosis have been managed at our department between 1968 and 1988. The location of obstruction was the duodenum in 22, jejunum in 16, ileum in 14, and colon in one. There was one neonate with duodenal atresias and colonic atresia. The children were divided into group I (n=17, 1968 to 1974), group II (n=17, 1975 to 1981) and group III (n=20, 1982 to 1988). High risk neonates according to modification of Waterston's criteria represented 17% in group I, 6% in group II and 76% in group III. The incidence of high risk neonates has significantly increased in group III (p<0.01). The mortality was 29% in group I, 35% in group II and 5% in group III. Although high risk neonates increased, the mortality was significantly (p<0.05) reduced during group II and group III. The improved survival in the third 7 year of the series appears to be related to improved neonatal intensive care and operative management, and more frequent use of total parenteral nutrition. Associated anomalies and prematurity do not appear to be the primary determinants of mortality at the present time.

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In a recent one decade from 1978-1988, 34 patients of 80 years and upward treated on for advanced colorectal carcinoma were reviewed. Each patient was classified preoperatively according to the performance status classification of our criteria (Seikatudo Shisu classification), and 3 patients (8.8%) in class 4 were not performed a resection because of severe preoperative conditions. The 3 patients died of other diseases within one year. Considering the advanced age in these subjects, we tried to limit the area of lymph node dissection, to avoid an anastomosis at a low anterior excision site, and to use a draft of extradural anesthesia.
Of the selected 31 patients, 29 (93.5%) underwent resection, which included 25 (80.6%) curative resections. The overall operative mortality rate was 5.9% and the morbidity rate, 42.4%. Of the curatively resected cases, the 1-year, 3-years and 5-years survival rats were 95.7%, 61.7% and 54.8%, respectively. Cancer recurrence and central nervous system deficits had a significant impact on the long term quality of life.

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Twenty-seven patients with colorectal cancer having metachronous liver metastasis were evaluated regarding the clinicopathological features and the treatments. Liver metastasis is likely to occur from a primary lesion in an advanced stage, with lymphnode involvement and venous permeation. Although serum CEA was elevated in 20 patients (91%), the liver secondaries were determined in only 12 patients (60%) at the time of turning positive. The metachronous liver metastasis was determined in 19 patients (70%) within 2 years after resection of the colorectal tumors. Five year-survival rate was 18% and the median survival time, 17 months in all patients with metachronous liver metastasis. Among the extents of liver metastases, the prognosis of patients with H₁ was best as shown by the 5 year-survival rate of 35% and median survival time of 21 months. Among the types of treatments, the prognosis of patients undergone hepatic resection was best, showing 60% of 5 year-survival rate. As to the time of recurrence, the prognosis of patients experienced the metastases within 1 year was as poor as 8.5 months of median survival time. These results suggest that aggressive hepatic resection with early diagnosis of meta-chronous liver metastasis is most preferable.

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Among 276 patients operated on for colorectal cancers at our department from March 1982 to September 1989, 37 with hepatic metastasis, especially 14 undergone hepatic resection were subjected to a study of therapeutic outcomes and clinicopatological features. 1) All resectable cases of heterochronical hepatic metastasis can survive, showing a favorable prognosis. 2) Resectable cases of isochronical hepatic metastasis had poorer prognosis compared with those of heterochronical metastasis. However, when compared with inresectable hepatic metastasis cases, the survival rate was higher and a life-prolonging effect due to hepatic resection could be expected. 3) In cases of which metastasized hepatic lesions locate only in a lateral lobe, we should select lobectomy or a resective procedure where a sufficient distance between the tumor and resected section of the liver is left if the residual hepatic function can permit. 4) For early detection of hepatic metastasis from colorectal cancer, regularized followup with CEA, US, and CT is essential. 5) Histological findings of the primary lesions revealed that significantly high rates of hepatic metastasis were noted in moderately differentiated adenocarcinomas, cancers with positive regional lymph nodes, and those with positive vascular invasion.

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Thirty-nine cases of hepatocarcinoma in stage IV were divided into 17 of resected (noncurative resection; group 1) and 22 of nonresected cases (group 2), and studied for the correlations between the prognosis and treatments. Group 1 patients underwent tumor reduction surgery, followed by transcatheter arterial embolization (TAE) and hepatic arterial infusion (HAI) as well as perioperative ethanol injection (EI) for the remnant carcinoma. Group 2 patients who didn't undergo tumor reduction received intensive treatment such as TAE, HAI, EI, hyperthermia and irradiation.
Results: 1) In cases of Vp0 and 1, the prognosis of group I was better than that of group II (p<0.05). 2) In cases of Vp2 and 3, there was no significant difference in the prognosis between group I and II. 3) In group I, the prognosis of partial hepatectomy (main tumor resection) was better than that of segmental hepatectomy.
These results suggest that tumor reduction surgery, which is not over involvement, with TAE, HAI and EI improve the prognosis of hepatocellular carcinoma even in stage IV of Vp0 or 1.

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In the past we have diagnosed the groin hernias only with physical findings, but now we can reveal them easily and safely by herniography. Herniography can demonstrate hernia sacs filling with contrast medium injected into the peritoneal cavity. This technique was performed for 57 patients with groin symptoms, and the results were as follows.
Herniography demonstrated the sizes and shapes of the sacs in all the hernias with certain physical findings. It revealed non-palpable hernias in 54% of the patients with obscure groin symptoms. There were many asymptomatic hernias in the opposite side of clinically unilateral hernias. Bilaterla hernias were found in 85% of the instances. Multiple hernias in the same side were observed in 27% of the cases.
Herniography can clearly demonstrate: 1) the type of the groin hernia, 2) asymptomatic multiple hernias either in the same or opposite side, and 3) latent hernias. It is a very useful examination for the clinical evaluation of groin hernias inadults.

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We experienced three atypical cases of malignant hyperthermia (MH) who presented with mild hyperthermia, a transient muscle rigidity and myoglobinuria after appendctomy under general anesthesia, and confirmed the elevation of serum muscle destructive enzyme, especially creatine phosphokinase (CPK) in these cases. Then, we analyzed the influence of anestesia method on CPK after appendectomy and studied the condition of occurrence of this condition.
The factors which appeared to the postoperative elevation of CPK in the 117 appendectomized cases were studied using multivariate analysis. The most contributing factor was the dose of SCC. It was followed by age, sex and the postoperative fever in this order. Duration of anesthesia, the dose of halothane and preoperative CPK levels were not correlated with postoperative CPK. A high postoperative CPK level was commonly found in a group of patients that had been administered large doses of SCC of more than 1mg/kg or in an age group from 15 to 40 years. Therefore, it is advisable to use spinal anesthesia on appendectomy, because general anesthesia with large doses of SCC seemed to be related to MH.

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The diagnosis of subacute thyroiditis is not so difficult when it has typical symptoms. But in the case which has no tenderness of thyroid and no acute inflammatory symptoms, it is difficult to distinguish from another thyroid diseases. Recently we have encountered two cases of subacute thyroiditis. At first they were diagnosed as thyroid cancer because of lacking in typical symptoms. Both cases have a tumor in the thyroid, and we could not distinguish them from thyroid cancers by palpation and ultrasonographic findings. It was valuable to establish the diagnosis of subacute thyroiditis be following the changes in palpation and ultrasonographic findings of the tumors.

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Upon performing contact thermography on the patients with breast cancer, the thermograms obtained were classified into 3 types (hot spot: H, irregular vascular pattern: IV, and asymmetrical thermal pattern: AT). The following results have been obtained as a result of making an assessment regarding how the findings are reflected on the classification of clinically morbid periods.
1) Positive AT and IV findings were observed on the thermograms even in the breast cancers in comparatively early stages.
2) H findings showed that the positive rate became higher as tumorous diameter became larger and further that high positive rates were exhibited in scirrhus carcinoma.
3) In the relation with nuclear DNA amount, positive rates of H findings were high in aneuploid cases.
4) The change in thermography showed a positive correlation with the change in dermal blood stream.
From the above, it was found that the contact thermography has a nature a little different from the conventional test methods and that its usefulness was observed rather in the judgement on the malignancy of breast cancer cells but not as diagnostic test method. Further, a possibility of foreknowing the risk of breast cancer to occur was suggested.

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A rare case of accesory breast cancer is reported.
A 60-year-old woman was adommited to our hospital complaining of a small mass in her left axillar resion which had been getting bigger. No palpable lymphadenopathy in the both axillae nor any mass in the left breast were noted. The mass was sized 2×3 cm with distinct irregular boader and fixed to the skin tightly. There was no pigmentation on the covering skin. The exicisional biopsy revealed a 2.1×2.0×2.0 cm tumor not connecting to the left mammrian gland. As histopathological examination revealed some malignant changes of the tumor, a wide resection and lymphandectomy of the left axilla were performed. The specimen showed a mutinous carcinoma with normal mammarian gland and intraductal papilomatosis. No lymphnode showed metastatic changes. Chemotherapy for a half year was performed. In 5 years, she is doing well without any evidence of recurrence.
Forty-two cases of accesory breast cancer in the Japanese literature were reviewed and discussed.

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A 43-year-old male was admitted to a neighborhood hospital with the chief complaints of chest pain and dyspnea. X-ray film at the admission revealed left pneumothorax. Left intrathoracic dranage was performed for 10 days, but an air leakage did not disappeared and the reexpanison of left lung was not good. The patient was referred to our hospital. Pneumothorax was hard to recover only by intrathoracic drainage, then left thoracotomy was performed. Perioperative findings revealed an air leakage from S⁶, pleural thichenings of S⁶ and a cavity in S⁶. A brown colored brittle ball was in the cavity and microscopically the ball was diagnosed as fungus ball. Segmentectomy of left S⁶ was successfully performed. Postoperative course was uneventful. No recurrence of plumionary nosomycosis or pneumothorax has been noted up to now, 3 years after operation.

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We experienced four clinical cases of alpha-fetoprotein (AFP) producing gastric carcinoma. Those four cases were difinitely diagnosed as AFP producing gastric carcinoma, because the serum levels of AFP decreased significantly after surgical removal of the tumors and the localizations of AFP in tumor tissues were demonstrated in all resected specimens by immunohistochemical study (peroxidase-anti-peroxidase; PAP method). It is said that AFP producing gastric carcinomas are characterized by advanced gastric cancer and histologically undifferentiated or poorly differentiated adenocarcinoma.
These four cases also had advanced gastric carcinoma, which were histopathologically papillary, medullary, poorly differentiated and well differentiated adenocarcinomas respectively. AFP producing gastric carcinomas are frequently accompanied with liver metastasis and the prognosis is miserable. Of these 4 cases, 2 already had liver metastasis at surgery, and one developed liver metastasis in an early period after surgery. Their prognoses were poor such as one year survival rate of 25% and the 2 year rate of 0%. From the above, the importance of some strategies or efforts for preventing liver metastasis is emphasized even after curative resection could be attained.

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Clinical and histological characteristics of alpha-fetoprotein (AFP) producing gastric cancers were studied. Four (3.8%) among 104 cases of gastric cancer experienced in the last eight years were AFP-producing gastric cancer. in addition to AFP, the coexistence of carcinoembryonic antigen, ferritin or carbohydrate antigen 199 were found in the tumor cells by immunohistochemical methods. It is suggested that AFP-producing tumor cells might have an ability to differentiate into various forms. Clinically, most of AFP-producing gastric cancers belonged to Borrmann type 2 or type 3. As they were already markedly advanced and with a high frequency of hepatic metastasis during surgery, the prognosis was very poor. In cases of AFP-producing gastric cancer, serum AFP values were found to show a good correlation with the clinical course. It may be useful in predicting the prognosis such as recurrence or liver metastasis.

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A case of duodenal stenosis due to chronic pancreatitis was reported, in addition to a clinical analysis of 20 cases reported in Japan. A 45-year-old male, who has been drinking for 20 years, had the symptoms of rt-hypochondralgia and went without treatment for a few weeks. Then he went to the hospital complaining of nausea and vomiting. Upper gastrointestinal series revealed a whole-circumference stenosis of the second portion of the duodenum. He was admitted to our hospital, because a duodenal tumor was suspected. By endoscopy, duodenal mucosa was found edematous and reddish, but a biopsy showed no malignancy. From the findings of CT-scan, ERCP, and angiography, duodenal stenosis due to chronic pancreatitis was diagnosed. After 2 weeks of conservative therapy, an operation was performed; a gastrojejunostomy and a pancreaticojejunostomy (Roux-en-Y). Two years after the operation, he is healthy and there are no malignant signs.

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Smooth muscle tumors of the small bowel are relatively rare and we have often difficulties to make the correct diagnosis preoperatively. We report a rare case of peritonitis caused by perforation of a smooth muscle tumor of the ileum.
A 57-year-old man was admitted to our hospital with lower abdominal pain of sudden onset. Laparotomy was performed under a diagnosis of acute panperitonitis and a perforated tumor in the ileum was found. Histopathological examination showed a benign leiomyoma with centralnecrosis and a fistula which caused perforation.
The most common symptoms of small intestinal leiomyoma are melena, abdominal pain and palpable mass. This case have lacked in melena before perforation occurred.

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A very rare case of leiomyosarcoma arised in the mesentery has been reported with a review of the literature in Japan. A 72-year-old man visited our clinic due to upper abdominal pain. A fist-sized tumor was found in the upper left abdomen. The tumor mass could be visualized as a clear marginal and internal heterogeneous shadow by computed tomography. Superior mesenteric angiographic findings revealed an irregular tumor stain in the peripheral jejunal artery. On laparotomy, the tumor was found to occur in the jejunal mesentery and could be removed without injurying the intestine. Plenty of the peritoneal dissemination were found simultaneously, most of them being removed. The case was diagnosed as leiomyosarcoma from pathological findings. The patient died on the 78th postoperative day in spite of chemotherapy. The mesenteric leiomyosarcoma is a very rare disease and only 23 cases, including this case, have been reported.
We have difficulties in the early diagnosis of the disease, and when it is detected, the tumor often becomes too huge to resect curatively. The prognosis is poor. Postoperative chemotherapy and radiotherapy can not yield favorable response to the patients, and only effective strategy may lie in aggressive resection of the tumor.

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Mucocele of the appendix is defined as a state where an appendiceal lumen is filled with mucus. It is noted that one of the conditions for this occurrence is a lack of free communication between the appendiceal lumen and the cecal one. In this study we report a case of mucocele in which the free communication to the cecum was observed before operation.
A 79-year-old female was admitted with the chief complaints of lower abdominal pain and a mass in the right lower quadrant. A plain X-ray film of the abdomen showed a fist-sized tumor shadow covered with calcification at the right iliac fossa. In addition, radiographic appearances of ultrasound sonography, computed tomography, and barium enema indicated a possibility of mucocele of appendix. Operation was performed. The tumor was found to be the swollen appendix like a cyst and drainaged to the cecum. Pathologically it was a mucinous cystadenoma of the appendix which had both acute and chronic inflammations.
It is extremely rare to observe such a mucocele of the appendix with free communication to the cecal lumen. A possible explanation for the formation of the tumor is that after mucocele was formed by the blockade of the appendix, the blockade was corrupted by the repeated inflammation.

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Lipomas are the second most common benign colonic tumor, next to adenomatous polyp in frequency, but are relatively rare. They are usually submucosal or pedunculated tumors. It is said that, though small lipomas are asymptomatic, these lipomas larger than 2 cm in diameter may produce symptoms such as abdominal pain, bleeding and intussusception.
A case of caecal lipoma which could not be differentiated from acute appendicitis is presented. A 85-year-old female with right lower abdominal pain underwent laparotomy for suspected appendicitis. There was no inflammatory change in the appendix, but was a soft tumor palpated in the caecum. Caecotomy made it possible to diagnose and remove the pedunculated tumor.
Three cases of caecal lipoma which were misdiagnosed as acute appendicitis have been reported. Because of the difficulty in distinguishing the lipoma from malignancies such as cancer, we are apt to employ excessive operation. By regarding the fact that colonic lipomas are extrinsically benign, appropriate judgment based on operative findings may lead to appropriate operation.

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Solitary ulcer syndrome of the rectum is a venign disease that forms nonspecific ulcer at the rectum. It is unfamilliar in Japan, and its ulcerative type is often misdiagnosed as carcinoma, and elevated type as adenoma. Therefore it is very important to know this disease for avoiding oversurgery. This disease is probably related to excessive straining at evacuation with consequent prolapse of the rectal mucosa which leads to ischemic changes. We present 3 young patients with solitary ulcer syndrome of the rectum, 2 of the 3 patients were elevated type and one, mixed type. Patients comprised two 16-year-old males and 35-year-old female. They originally have a habit of defecating for a long time and had strong straining. They visited our hospital because of anal bleeding and pain. Barium enema and sigmoid colonoscopy revealed small finger tip sized polipoid lesions at the lower rectum in two patients with elevated type, and ulceration in the remaining one with mixed type. Transanal surgical polypectomy was performed in the two patients with elevated type, and suppository of steroid hormone was used in the patients with mixes type. Histological studies revealed specific findings of this disease such as fibromuscular obliteration, leading us to diagnose them as typical solitary ulcer syndrome.

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A relatively rare case of leiomyoma of the sigmoid colon is described. The case was a 46-year-old female with the chief complaint of melena. Barium enema and endoscopy of the colon revealed a subpedunculated submucosal tumor of the sigmoid colon. Sigmoidectomy was performed. The tumor was 4.0×3.6×2.8 cm in size and was covered with normal epithelium. It was a leiomyoma which might arise in the muscular layer of mucosa.
A total of 54 cases of leiomyoma of the colon was collected from the Japanese literature and reviewed. Some considerations of the treatments are also presented.

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The clinicopathological studies on ovarian metastasis from the colorectal cancer were carried out. From 1972 to 1989, 385 female patients were managed by resection for primary colorectal cancer at our department. Six patients had ovarian metastasis from colorectal cancer (1.6%). The primary tumor was in the cecum in one case; in the ascending colon, two; in the sigmoid colon, two; and in the rectum, one. There was no relation between the location of the primary tumor and ovarian metastasis. An average age of six patients was 50.2 years, which was younger than that of female patients without ovarian metastasis. The primary lesions involved the serosa. Lymph node involvement and lymphatic invasion were present in all cases, and venous invasion and peritoneal disseminating metastasis were present in 4 and 3 of the 6 cases respectively. ER staining by immunohistological method was negative in all cases.

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The colon is the least common site for leiomyosarcoma (LMS) throughout the entire gastrointestinal tract. Fifty-eight cases of colonic LMS have been so far reported in the Japanese literature. We report a case of large LMS which arised in the transverse colon.
The case was a 53-year-old man complaining of upper abdominal pain with a palpable hand-grip sized mass in the right upper quadrant. Although computed tomograpy scan revealed a low density area in the tumor which acounted for central necrosis, preoperative diagnosis was colonic carcinoma. Right hemicolectomy with lymph nodes dissection (R₃) was performed. The tumor, 170×105×70 mm in size, and of intraluminal type, was located at the transverse colon adjacent to the hapatic flexure. Neither lymph node involvement nor liver metastasis was present.
Receiving no chemotherapy, the patient has spent 4 years and 2 months without any sign of recurence or metastasis.

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Upper gastrointestinal bleeding of unknown origin is a severe complication often developed after abdominal surgery. We experienced a case of postoperative ruptured pseudoaneurysm of the hepatic artery, which could be successfully managed by means of TAE. A 67-year-old man was diagnosed as having a bile duct carcinoma. Pancreatoduodenectomy and resection of the common bile duct were performed.
Postoperative course was relatively uneventful except a minor leakage at the anastomosed site of the stomach to pancreas, however, on 111th day after surgery, massive hematoemesis and melena occurred, with attendant hypovolemic shock. Emergency endoscopy failed to reveal any sources of bleeding. Laparotomy gastrotomy performed on the following day also could not find the bleeding source. After the operation, the patient continued to bleed. Abdominal angiography revealed two ruptured pseudoaneurysms of the common hepatic artery. The bleeding was successfully stopped by means of trans-arterial emborization (TAE) of the common hepatic artery. The patient is presently doing well without complaints. A review of 26 cases of postoperatively ruptured pseudoaneurysms of the hepatic artery and reported in the literature is also descrived.

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We report a case of spontaneous cholecystoduodenal fistula. A 76-year-old man complained of epigastralgia and vomiting. After relieving transient ileus, a 20 mm-sized gallstone was extripated out of the anal canal which was stenotic due to previous operation of internal hemorrhoids.
Abdominal plain film, ultrasonogram, and CT showed pneumobilia and gallstones. Endoscopic retrograde cholangiogram and upper GI tract series revealed a communication between the gallbladder and duodenum, and we got a diagnosis of spontaneous cholecystoduodenal fistula and residual stones in gallbladder. So radical operation was performed for prevention from recurrent gallstone ileus, secondary biliary infection and liver dysfunction. There was a fistula of 15 mm in diameter between the ampulla of gallbladder and the bulbus of duodenum. Operative cholangiogram revealed no other fistula, and cholecystectomy, closure of the fistula, choledochotomy and T-tube drainage were performed.
Spontaneous internal biliary fistulas are abnormal communications between the biliary tract and its adjacent organs, caused not by such external factors as operation and injury. Eighty-five to ninety percent of the cases are caused by cholelithiasis. It principles of treatment are followings: 1) treatment of basic disease, 2) resection and closure of fistula, and 3) appropriate drainage of biliary tract.

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Adenomyomatosis is a benign tumor which causes thickening of the gallbladder wall due to proliferation of Rokitansky-Aschoff sinus. Since differentiation from gallbladder cancer by imaging diagnosis is difficult, a great deal of hardship is often encountered for the differentiation and treatment.
A 49-year-old man presented at our hospital, because abnormality in blood chemistry was detected at health screening. But no abnormalities were found by physical and hematological examination on admission. Abdominal echography revealed a hyperechoic image with wall thickening at the base of the gallbladder. Endoscopic retrograde cholangiopancreatography showed a localized shadow defect at the base of the gallbladder. Although a benign tumor was suspected, a possibility of gallbladder cancer could not be dismissed. The gallbladder with its base attached to the liver was excised in a wedge shape. From the intraoperative findings, the lesion was judged as N (-) SoPoHoHinfoBo, Stage I. There was a mass of 2.5×2 cm in size localized at the base of the resected gallbladder. The wall was thickened to 13 mm. The diagnosis of adenomyomatosis was histologically established.
When a mass is detected in the gallbladder by abdominal echography, cholecystography or abdominal CT, it is necessary to keep in mind the likelihood of adenomyomatosis and to be scrupulous by prudent in differentiation from gallbladder cancer.

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Laparoscopic cholecystectomy is a procedure demanding no laparotomy, in which cholecystectomy is carried out under laparoscopy. It is now practiced in many institutions in Europe and the United States. The indication for laparoscopic cholecystectomy includes chronic calculous cholecystitis or polyp of the gall bladder not completely ruled out malignancy. Since the first laparoscopic cholecystectomy had been successfully carried out in our department in Japan on May 29th 1990, 5 selected cases were treated with this procedure up to date. If clipping and dissection of the cystic duct and artery are nicely carried out, subsequent cholecystectomy can be carried out without any difficulties. Therefore ERCP is the procedure routinely performed prior to indicate this procedure to know the anatomical architecture of the cystic duct. This method is advantegeous in comparison with the conventional open cholecystectomy, because of less surgical stress, less postoperative pain, rapid postoperative recovery and cosmetic ally as well. We believe that this procedure should be recommended for some selected cases having reasonable indications. Moreover, this is the procedure which must be performed by experienced surgeons in biliary surgery.

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A 64-year-old female was admitted with the chief complaint of right hypochondriac pain. On ultrasonography, ERCP and PTC, she was diagnosed to have a biliary dilatation. A choledochal septal formation and (or) anomalous arrangement of pancreatico-biliary tract were (was) suspected as its causes. Cholecystectomy, choledocholithotomy, excision of choledochal cyst, lateral lobectomy of liver and end to side anastomosis of bile duct to jejunum (Roux-en-Y) were performed. Intraoperative selective contact cholangiopancreaticography disclosed normal arrangement of pancreatico-biliary tract, but the values of amylase in biliary tracts agreed with “A plan of diagnostic criteria of anomalous arrangement of pancreatico-biliary tract”. So, there is a discrepancy between its radiographic and assistant diagnostic criterion.
A circular narrowing site of the choledochus was located outside of the pancreas, its inner surface was smooth and looked like pinhole. A choledochal septal formation was not found. Histologically, the narrowing site was dominant of fibrosis, invaded diffusely by inflammatory cells and diagnosed as chronic choledochilitis. We concluded that the cause of biliary dilatation was due to a congenital benign circular narrowing of the choledochus.
There are few reports that a choledochal septal formation caused a biliary dilatation, but as far as the authors could investigate, there is no report like this.

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A 65-year-old man was admitted to our hospital with the complains of sudden sever epigastralgia and intermittent melena in 23 May, 1988. A tumor with goose egg size was palpable at the epigastrial region with tenderness. He had anemia, hyperamylasenemia and possitive occult blood. Abdominal echography and computed tomograpy revealed a pancreatic cyst of 50×45 mm in size. Enhanced computed tomography revealed an circular stain in this cyst. A possibility of hemorrage into a pancreatic cyst was considered. Celiac angiograpy could catch a moment when intermittent and jet-like hemorrhage occurred into the pancreatic cyst from the splenic artery. Radical operation was performed. It was found that the splenic artery adjacent to the pancreatic cyst ruptured due to inflamation to bleeding into the cyst, which was discharged to the duodenum from Papilia Vater through the main pancreatic duct. This is a very rare case of pancreatic pseudocyst in a moment of intermittent and jet-like bleeding into the cyst could be visualized.

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A 41-year-old woman was referred to our hospital because of a suspected lower abdominal tumor. Laboratory studies showed markedly elevated serum CA19-9 levels of 1220 u/ml. Ultrasonography and computed tomography revealed a large cystic tumor in the body and tail of the pancreas. Partial resection of the body and tail of the pancreas was performed under a diagnosis of benign mucinous cyst adenoma, which was comfirmed by histological examination postoperatively. The tumor was 18×17×8 cm in size and weighed 1570 gm. The intra-cystic CA19-9 level was also markedly elevated up to 3, 800, 000 u/ml. Endothelial cells in the cystic tumor positively reacted to CA19-9 immunohistochemical staining.
Cyst adenoma of the pancreas is now increasingly diagnosed due to recent advancements in radiological techniques such as US, CT and MRI. However, benign mucinous cyst adenoma of the pancreas associated with markedly elevated CA19-9 levels remains rare, and to our knowledge, this is the third case of its kind reported in the domestic literature.

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The case involves a 71-year-old male under strict observation for chronic pancreatitis. Computed tomography and ultrasonography indicated a cyst in the pancreas head and dilatation of the main pancreatic duct. endoscopic retrograde pancreaticography showed the same main duct dilatation and a partial filling defect image in the cyst. The duodenal papilla was swelling, widely opened, and emission of viscous mucus was noted. Pancreatic-oduodenectomy was performed based on a preoperative diagnosis of a mucin producing pancreatic carcinoma. Perioperative use of pancreatic duct scope was proved effective in determing the lesions, and curative operation had done. Histopathological examination revealed a well differentiated papillary adenocarcinoma. A review of 91 cases reported in Japan was also described.

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Double cancer, which has been considered a relatively rare disease, is increasingly documented with a recent progression in the diagnosis and treatment. However, it can be extremely rare in the combination of the organs affected by cancers. We experienced a case of synchronous double cancer, which were found as tumors of the head of pancreas and right kidney by abdominal ultrasonography and CT for the chief complaint of right hypochondralgia. The double cancer could be successfully resected with total pancreatectomy and right nephrectomy. About 10 months later, the patient died of multiple metastases to the small intestine, descending colon, liver, and lung from the pancreatic lesion. Some documents report that the cancer of the pancreas can be associated with a cancer in the other organ in a relatively high frequency. Once a cancer of the pancreas is found, a possible existence of double cancer should be considered.

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We experienced a case of malignant primary lymphoma of the spleen. The case was a 72-year-old male complaining of poor appetite. Abdominal screening CT revealed a tumor mass of the spleen. Various imaging methods failed to offer the definite diangosis, and laparotomy was carried out. A possible malignant tumor was suspected from perioperative findings. Splenectomy, including lymph node dissection surrounding the hilum of spleen and splenic arteries, and associated excision of tail of pancreas were performed. From histopathological findings, it was definitely diagnosed as malignant lymphoma of duffuse large cell type according to LSG classification. Similar tumor cells were found at lymph nodes of the hilum of spleen, which might be in stage 2 by Ahmann classification. A total of 103 cases of primary malignat lymphoma of the spleen was seen in the Japanese literature so far as we could review. However, many reports did not describe what criteria made the authers diagnose as primarily arising in the spleen. In this report statistical analysis was performed on 61 of the 102 cases which satisfied the diagnosis criteria advocated by Spier and others.

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This paper describes a case of congenital mesenteric hiatus hernia associated with small bowel obstruction, as well as a review of 144 cumulative cases reported in the Japanese literature.
The case was a 54-year-old male with the chief complains of abdominal pain and vomiting. The patient was diagnosed as ileus and underwent laparotomy. During surgery, a 6×5cm defected opening with smooth margin locating at the mesenterium about 10 cm oral-side from the end of ileum was found. It was a hiatus hernia that approximately 60 cm of the ileum protruded through the opening. Moreover, obstruction involving the ileum was found which coincided with the location of the defected opening. Hence closure of the defected opening and colectomy at the obstructed site were carried out. Histological findings of the obstruction included a segmental complete defection of the specific muscle layer, which bore a striking resemblance to that of the atretic site of congenital atresia of small intestine.

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A case of bilateral common iliac and femoral artery anerysms which was found in a patient undergoing hemodialysis for chronic renal failure is reported. A 69-year-old male, who had been receiving hemodialysis from 3 months before, noticed pulsatile tumors at the bilateral inguinal regions. The patient was transferred to our surgical department. From physical findings and imaging methods such as X-ray CT scan, ultrasonography, and angiography, the tumors were diagnosed as bilateral common iliac and femoral artery aneurysms. Under general anesthesia, the common iliac artery aneurysm was exteriorized, the femoral artery aneurysm was excised, and then Y-shaped artificial vessel grafting between the abdominal aorta and bilateral superficial femoral arteries was carried out. A use of automatic suture instrument TA for excised ends was effective in minimizing the surgical invasion by excision of the abdominal aorta and common iliac artery. Postoperative course was uneventful and the patient was discharged on 28th day after surgery.

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Two cases of Castleman's lymphoma (CL) are reported. Asymptomatic thirty-nine-year-old man had a mid-mediastinal mass, showing no abnormal labo data, which was resected and diagnosed as HV type of CL. He has been very well for seven years since then. The second case was a seventy-year-old male, complaining of chest pain, without any abnormal labo data, who had coin lesions in both lungs and a retroperitoneal mass. All those lesions were removed, and the both pulmonary ones were diagnosed as adenosquamous carcinoma histologically, and the retroperitoneal mass as HV type of CL. This case was lost one year postoperatively because of multiple metastases of the lung carcinoma to the brain, lung and bones, bringing on aspiration pneumonia.
These Castleman's lymphomas are solitary and localized HV type and have different clinical pictures each other. We discussed the clinical pictures, especially the etiology, location, associated malignancy, treatment, prognosis, and the findings of immunohistostaining.

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