A variety of tumors arising in the neck often provides a difficulty in the diagnosis. Here we present a retrospective clinicopathological study of 108 tumors on the neck except those due to thyroid or parathyroid diseases, in which histological diagnosis could be achieved by biopsy or surgery during a past 12-year period. An analysis of the causes revealed that tumors were as predominant as 73.1% (79 cases) followed by inflammation (15.7%) and congenital diseases (9.3%); and malignant diseases accounted for 15.7%. As to the locations, median cervical cyst was predominant on the anterior region of neck; tumor of salivary gland, on the bilateral regions of neck; and atheroma, lymphoma, and calcified epitherioma, on the posterior region of neck. There were 25 tumors of salivary gland including 20 tumors of parotid gland, 12 pleomorphic adenomas, 3 Warthin tumors, one lypoma, and 2 squamous cell carcinomas. Five tumors of submandibular gland were all pleomorphic adenomas. Neurinomas arised in the hypoglossal nerve in 2 and phrenic nerve in one cases. Thirty-three cases of lymphonodus diseases were comprised of 39.4% of simple lymphadenitis, 24.2% of metastasized cancer, 18.2% of malignant lymphoma and the like, 9.1% of nodular lymphadenitis, and the others. Congenital diseases included median cervical cyst in 6 cases, cyst on lateral region of neck in 3, cystic lymphangioma in one.

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The value of fine needle aspiration biopsy (FNAB), which is safe and simple, in diagnosing thyroid nodules has been established. Commonly, specimens obtained by FNAB are classified into 5 groups from Class I to V.
In this paper, we attempted to reevaluate the specimens belonging to Class III which were undertermined as malignant even though a presence of atypical cells. Of 147 available cases in a recent 3-year period, 16 cases were classified as Class III, of which 5 were diagnosed as benign and 11 as malignant histologically. In a retrospective reevaluation, eight papillary carcinomas were considered malignant, while three follicular carcinomas were judged to be benign. Thus, the tumor of which specimen is classified as Class III should be served as a surgical candidate for histological comfirmation.

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Clinical problems in the preoperative diagnosis of breast cancer were investigated in a total of 197 patients treated at our institute during a period from April 1987 through December 1989.
The final diagnosis, by combination of clinical examination, mammography (MMG), ultrasonography (US) and aspiration biopsy cytology (ABC) resulted in malignant in 79%, suspicious in 20% and benign in 1.0%. Twenty of 62 cases (32%) in which clinical examination failed to diagnose as malignant were demonstrated as malignant by MMG, US and ABC, and the remained 42 cases were confirmed by open biopsy.
Although mammographic visualization of breast masses was affected by the amount of each breast parenchyma and there were 29% of cases nonevaluative by MMG, MMG was found to provide the most accurate diagnosis of microcalcification. Ultrasonographic diagnosis was significantly affected by the degree of both obesity and histological vessel invasion of a tumor which influenced ultrasonographic diagnosis of marginal findings of the tumor. ABC contributed considerably to the diagnosis of breast masses alternative to open biopsy and also showed high accurate diagnostic rate for small breast masses in combination with US. Open biopsy was essential especially in the diagnosis of noninvasive breast cancer and it was useful to measure the level of CEA in nipple discharge when determining open biopsy (microdochectomy) for pathological diagnosis.

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The image diagnosis in early breast cancers in clinically studied.
(1) Echography
(1) After Hitachi EUB2D 7.5 MHZ being used, the accurate diagnosis rate and false negative rate in invasive breast cancers are 90.9% and 9.1%, in tumors less than 1.0 cm in diameter, and 92.0%, 8.0% in those from 1.0 to 2.0 cm respectively. All tumors more than 0.5 cm in diameter can be represented as tumor echo. (2) The accurate rate in non invasive breast cancers is 69.2%.
(2) Mammography
(1) Accurate and false negative rates in invasive breast cancers are 47.1% and 52.9%, in tumors less than 1.0 cm in diameter, and 80.7% and 19.3% in those from 1.0 to 2.0 cm respectively. Diagnostic rate in tumors less than 1.0 cm is bad. It is as not so good as 57.1% in non invasive breast cancers. (2) The 52.9% of infiltrating breast cancer tumors less than 1.0 cm and 83.2% of those from 1.0 to 2.0 cm can be represented as tumor shadow. The previous date was bad. Tumor shadow can be visualized in 57.1% of non invasive tumors. It is 64.7% in invasive ductal carcinomas with a predominant intraductal component. (3) The appearance rates of fine calcification (FC) are 23.5% in less than 1.0 cm and 43.2% in from 1.1 to 2.0 cm invasive cancers, while 50.0% in non invasive ones. (4) The cases having no tumor shadow but FC are found in 25.0% of invasive cancers less than 1.0 cm and 26.7% of those in from 1.1 to 2.0 cm. It is 33.3% in non invasive breast ones.

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One-hundred and ten cases of mediastinal tumors treated in our department during a past one decade were subjected to a clinical assessment of surgical outcomes and prognosis by types of tumors. Seventy-one point two per cent of the patients manifesting some symptoms had malignant tumors. This suggested that mediastinal tumors having symptoms predominantly comprised malignant tumors. The frequencies of the medistinal tumors by histologic types were: 28.2% for thymoma, 19.1% for germ cell tumor, 16.4% for neurogenic tumor, 11.8% for bronchogenic cyst, 5.5% for thymic cyst, 3.6% for lymphoma, and 7.3% for miscellaneous tumor. Malignant tumors accounted for 35.5% (39/110) of all mediastinal tumors. As high as 90.3% and 75.0% of thymoma and lymphoma were malignant respectively. Five cases necessitated reconstruction or bypass operation for SVC syndrome with the advanced invasive thymoma. The longest survival period of 3 years and 5 months was recorded. We believe that surgical therapy followed by postoperative adjuvant therapies such as radiation and chemotherapy may promise sumptomatic remission and better prognosis for this patients.

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In order to investigate the applicability of prosthetic graft (PTEF) to selective shunt operation for esophagogastric varices, clinical comparisons between 48 modified distal splenorenal shunts with prosthetic graft and 51 original ones, and between 9 modified left gastric venous caval shunts with prosthetic graft and 9 original ones were performed.
In the modified distal splenorenal shunt group, significant decreases in operation time and blood loss, higher patency rate of the shunt, significant good effect on esophagogastric varices were observed, but incidence of postoperative encephalopathy was slightly higher than that in original shunt group, so operative indication should be more restricted with regard to age and ICG.
In the modified left gastric venous caval shunt group, significant decreases in operation time and blood loss were also observed, but shunt patency rate and effect on esophagogastric varices were similar to those in original shunt group, accordingly a use of prosthetic graft more than 8 mm in diameter is advisable to improve the results.
We believe that more strict selection of patients for prosthetic graft to selective shunt procedure may lead to more improved outcomes.

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We clarified the clinicopathological features of ss gastric cancers and compared with pm (n=57) and se (n=329) gastric cancers for their features. In a recent one decade from 1979 to 1988, 938 patients were operated on for gastric cancer and 104 (11.1%) of them were diagnosed as having ss gastric cancer. Subclassification resulted in ssα in 28, ssβ in 33, (ssγ) in 4, and ssγ in 39 patients. All pm, ss, and se cancers were predominant in men, and the avarage ages were in their sixties. The locations of pm and se cancers were the most frequent in region A followed by M and C in this order, versus M>C>A for ss cancers. Pm and ss cancers predominantly classified into type 2 macroscopically and differentiated-type histologically, but se cancers, type 3 and undifferentiated-type, respectively. Moreover, according to subclassification, ssα and β cancers were predominantly comprised of type 2 and differentiated-type like pm cancers, while ssγ, type 3 and undifferentiated-type like se gastric cancers. The rates of metastasis to the regional lymph modes were 49.1% in pm, 50.0% in ss, and 79.9% in se cancers, showing a significantly high rate in se cancers (p<0.01). The metastasis rate in ss cancers increased with increases in long diameter of the tumor and ss invasion depth. The 5-year survival rates were 82.3% in pm, 75.0% in ss, and 34.7% in se cancers. The ss cancers had significantly better prognosis than that of curatively resected se gastric cancers (p<0.01).

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Twenty-three cases of cancer of the gastric remnant experienced at our department in past one decade were retrospectively studied and the following findings could be drawn out.
1) Cancers arising in the gastric remnant was most commonly found in aged men. 2) Patients group whose initial diseases were malignant had cancers of the gastric remnant in shorter periods after operation compared to other patients group whose initial ones were benign. 3) As to the reconstruction method in the initial operation, patients undergone Billroth II tended to develop cancers in the anastomsed and sutured site of the remnant stomach, in that a reflux of cholic acid into the remnant stomach might probably participate. 4) Remnant stomach cancers occurred within 5 years after the initial operation might include possible synchronous multiple gastric cancers. In such cases more careful consideration is needed pre- and perioperatively. 5) Unfortunately the prognosis of remnant stomach cancer must be said poor in general, however, patients in stage I can sufficiently expect to survive for a long period. The significance of strict postoperative follow-up is reconfirmed irrespective of the nature (benign or malignant) of the initial disease.

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The clinical courses of 178 consecutive patients undergone distal pancreatectomy with gastrectomy for gastric cancer in our department during last 11 years were reviewed, to identify the risk factors related to the development of postoperative pancreatic fistulas. In addition, the usefulness of fibrin glue applied to the stump of pancreas to prevent postoperative pancreatic fistula was also studied. Postoperative pancreatic fistula was present in 43 patients (24.2%). The increased incidence of postoperative pancreatic fistula was observed in patients associated with preoperative disorder of glucose metabolism or liver disfunction, those with far advanced gastric cancer, and those without intraoperative ligation of pancreatic duct on the cut-surface. However, in the courses of 135 patients with suitable ligation of pancreatic duct, 30 pancreatic fistulas (24.6%) occurred postoperatively among 122 patients without the use of fibrin glue, versus only one pancreatic fistula (7.7%) among 13 patients with fibrin glue. These results suggest that optimal evaluation of risk factors can link prevention of postoperative pancreatic fistula and that application of fibrin glue to the stump of pancreas after suitable ligation of pancreatic duct might be useful to prevent from postoperative pancreatic fistula.

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Over the past 14 years, 17 patients with acute mesenteric arterial occlusion (AMAO) were surgically treated at the First Department of Surgery, Kanazawa University Hospital and its related medical institutions. Among them, 14 patients (82%) had a history of cardiovascular diseases. Although all patients complained of abdominal pain, none had clinical signs of AMAO. Preoperative abdominal ultrasonography revealed some abnormalities in 12 (71%). In 11 patients (65%), the disease could be accurately diagnosed before operation. Resection of the necrotic bowel was performed in 16 patients, and thromboendarterectomy of the superior mesenteric artery in one. Four patients died (23%). All 12 patients who were operated on within 20 hours after the onset survived. Our results indicate that early diagnosis and treatment are essential in achieving excellent therapeutic results of this disease. Thus, screening of high risk individuals and subsequent prompt detailed examination with diagnostic imaging are necessary.

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Thirteen patients with perforation of the small bowel and 18 patients of the large bowel were treated in our department for a 13 year period. The majority (69%) of those with perforation of the small bowel suffered from traumatic injury and the predominant etiologies of perforation of the large bowel were cancer and diverticular disease (61%). Free air on plain X-ray was found only in 8% of the small bowel lesions and in 53% of the large bowel lesions. Simple closure or resection provided excellent outcome in perforations of the small bowel. Operations with colostomy were performed in 9 patients with perforation of the large bowel. All of 14 patients, who were operated on in less than 12 hours after the estimated time of perforation, were survived. The morbidity rate was 15% in perforation of the small bowel, or 50% in perforation of the large bowel (p<0.05). One patient with duodenal rupture died and 3 with large bowel perforation died within 30 postoperative days. Old age, shock, leucocytopenia should be considered as risk factors of multiple organ failure and operative mortality in patients with large bowel perforation. In the treatment of the above cases, preoperative antibiotics, shock management including an administration of protease inhibitor, use of colostomy, and complete irrigation are needed.

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To clarify the clinical feature of obstructive colorectal cancers, a comparative study was made in those 73 cases treated at our hospital, for clinicopathological findings, surgical management and outcomes according to the tumor location. The results were; 1) In right-side obstructive cancers, the tumors showed an expansive growth to make bowel obstruction and peritoneal dissemination was most commonly seen in the non-curative or recurrent cases. On the other hand, the left-side colon cancers commonly showed an invasive growth which made bowel stricture and advanced to haematogenic metastasis. 2) The incidence of non-curative cases was high for over all cases, especially for right-side colon cancer. But the prognosis was good for curative ones. 3) As for the incidence of operative complication and five year survival rate, there was no difference between the cases of primary tumor resection and conventional staged tumor resection, in every part of large bowel. Therefore, it is possible to make primary resection even for the left-side colon and rectal obstructive cancer if the condition is suitable.

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Between 1975 and 1988, 74 among 1037 patients operated on for colorectal carcinoma were diagnosed as having primary carcinomas in other organs. Colorectal carcinoma was frequently found on the right side of the colon. Among carcinomas in other organs, gastric carcinoma was the most common (40.5%), following by uterine carcinoma (15.2%), breast carcinoma and hepatoma (10.3%) each. Extracolic carcinomas appeared as much as two years preoperatively and ten years postoperatively. Gastroenterological carcinomas, mainly those of the stomach, were detected almost at the same time as the operation. Uterine carcinomas were found to precede colorectal carcinomas. It took many years, 16.3 years on an average, after uterine carcinomas were treated for colorectal carcinomas to be found. We suspect that some of these colorectal carcinomas might be induced by radiotherapy. We conclude that the stomach should be carefully examined both preoperatively and during follow-up for colorectal carcinoma, and that some sort of surveillance routine should be established for patients who had treated with radiotherapy for uterine carcinoma more than 5 years previously.

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As the standard surgical procedures for primary varicose veins of the lower extremities, we have been employing the ligation of saphenous veins at upper positions and the removals, ligation of the communicating vein, and excision of superficial dilated veins by skin excisions. However, the perfect achievement of these procedures demands so long time, and sometimes, several skin sites to be excised are needed, providing a serious clinical problem.
This time, in the treatment of superficial dilated veins, we have tried the multiple ligation method to facilitate the thrombus formation in the veins by direct ligation through the skin. Two kinds of ligations, namely vertical ligation in which No.1 braided silk was directly contacted with the veins to facilitate the thrombus; and horizontal ligation in which blockade of venous blood flow led to complete thrombus formation, were performed. These ligations were made at intervals of 12 cm. The stitches were taken out 35 days after surgery when the thrombi might be completed in the veins. This procedure is considered very excellent, because it enebles to simplify the surgical procedure, to shorten the time for surgery, and to alleviate cosmetic complaints.

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We experienced a death case due to enteritis-type MRSA infection after release of ileus.
The case is a 75-year-old male who had received radical operation two times for ectopic double cancer at the stomach and sigmoid colon. After that, the patient was operated on for adhesive ileus and a fistula of the small intestine was formed because of anastomotic leakage. After half year laparotomy was carried out, where partial resection of the jejunum was made at the fistula site and a decompression tube was embeded into the jejunum. However, the tube was closed with a lot of infectious flora due to S. aureus bred in the enteric lumen, which caused insufficiency of inner decompression. Finally the weakened portion of the intestine was perforated and the patient died of DIC. This case was extremely rare in its course. In the postoperative management, we should remember a possible occurrence of insufficient drainage due to infectious flora resulting from debris which was formed by a situation that coagulase of S. aureus affected the blood perioperatively collected in the intestine.

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We experienced a rare case of lung, and bone metastases from follicular carcinoma of the thyroid, presenting with hyperthyroidism induced by triiodothyronine (T₃), which was secreted from metastatic lesions after surgery for primary lesion.
A 42-year-old female suffering from a tumor of the neck for past 3 years consulted us in Mar. 1977. It was a thyroid tumor of 7 by 5 cm in size, elastic hard and smooth surface in palpation. She didn't have thyroid dysfunction. Under a clinical diagnosis of thyroid adenoma, left hemithyroidectomy was performed. Although the tumor was histologically diagnosed being follicular carcinoma, she was followed without any other treatments. Three years after surgery, modified neck dissection was done for regional lymph nodes metastases, and TSH suppression therapy was added. Seven years after the first surgery, lung and liver metastases were found and remained thyroid was removed for the ¹³¹I irradiation. Following 3 years, twice ¹³¹I and external irradition for pain control of sacral metastasis were performed. TSH suppression therapy by T₃ (25 μg/day) and T₄ (100 to 200 μg/day)administration was also continued, but the metastatic lesions gradually enlarged. Eleven years after the first surgery, the elevation of serum T₃ and TSH receptor antibody were found, and one year after that she manifestated palpitation as a symptom of hyperthyroidism. The stop of T₃ and T₄ administration failed to control the thyrotoxicosis, and methylmercaptoimidazol (30 μg/day) was needed. The patient died of respiratory insufficiency caused by the enlarged pulmonary metastasis.
T₃ production in the metastatic lesions and the increase of its release to blood according to tumor growth were thought to be main factors for hyperthyroidism in this patient. Autoimmune disorder also may participate in the occurrence of hyperthyroidism.

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Parathyroid adenomas are often presented with hypercalcemia, and a few are palpable as a tumor of the neck, which are occasionally cancers. In addition, parathyroid adenomas rarely lead to infarction of the tumor, coming to symptomatic remission, but seldom accompaning by impaired function of the parathyroid gland. In this paper we describe a rare case of the disease.
A 39-year-old man visited our hospital for parathyroid adenoma which was diagnosed by a near practitioner based on his complaints of right lower leg pain and a tumor of the neck. The patient manifested tetany immediately after admission, however, from serum examination and echography performed on the day of admission, he was diagnosed as parathyroid adenoma with diffuse fibrous osteisis. The tumor was extirpated.
Postoperative pathological observation revealed that almost part of the tumor was necrotic and a part of the capsular of the tumor, slightly viable. These findings suggested that the functioning tumor preoperatively led to infarction, and because the patient was in hungry bone state, hypocalsemia occurred accompanied by its resultant transient tetany.

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We report a case of breast cancer associated with a pituitary adenoma. The patient was a 44-year-old woman. She noticed signs of acromegaly about 22 years ago. At the age of 43, she found a painless mass of the left breast, and consulted our hospital. A diagnosis of breast cancer associated with acromegaly was made. After intra-arterial chemotherapy, extended radical mastectomy and partial hypophysectomy were performed sequentially. The breast cancer was in stage IIIb (T_4bn₀M₀, scirrhous type), and was estrogen receptor positive. No recurrence was noted as of 2 years after surgery. The pituitary adenoma was eosinophilic.
It is unknown if the development and growth of breast cancer is accelerated by human growth hormone. The incidence of breast cancer in persons with acromegaly may be more than expected.

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A case of adenoid cystic carcinoma of the breast is reported. A 70-year-old woman was referred to our clinic with the chief complaint of right breast pain. The impression of the mass was chronic mastopathy, but a possible malignancy was suspected ultrasonographycally. Excisional biopsy and pathological examination revealed an adenoid cystic carcinoma. Patey operation was performed, no metastasis to axillary lymph node being found. Histologically, the tumor was characterized by “cysts” with a cribriform pattern. Histochemically, hyaline material inside “cysts” were alcian blue-positive and PAS-negative or weakly positive, and contents of the duct structures gave a positive reaction with PAS but negative with alcian blue. Immunohistochemically, CEA (carcinoembryonic antigen) and secretory component were disclosed in the duct structures, but none in the “cysts”.

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Cardiac herniation through traumatic rupture of the pericardium is a very rare occurrence. We experienced two such cases during the past three years. Case 1 was a 32-year-old female who was admitted to our hospital following a free-fall. Cardiac herniation was incidentally diagnosed on emergency thoracotomy for suspected lung laceration. Case 2 was a 25-year-old male who sustained thoracic injury with a motorcycle accident. Cardiac herniation was preoperatively diagnosed with a plain chest film. Circulatory states in both cases were stabilized following the reduction of the herniated heart. Plain chest film is considered to be the most useful tool for the diagnosis. It generally shows following findings; the heart markedly displaced to the left, right border of the spine visualized, pneumopericardium, and abnormal notch on the left heart immediately below the pulmonary artery. In addition to these findings, the curve shadow possibly attributed to the retracted pericardium may be specific. Emergency thoracotomy seems to be indicated in all cases of suspected cardiac herniation, since myocardial ischemia with cardiac failure may be caused by constriction of the great vessels or left anterior ascending coronary artery.

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We experienced a case of infravalvular left ventriclar-right atrial communication, in which a communication opening was seen at a little to right ventricle of tricuspid valve ring. Harsh systolic murmur similar to that peculiar to ventricular septal defect (VSD) was heard. Chest roentgenography revealed an enlarged right atrium, and cardiac echography showed a blood flow of left ventriclar-right atrial shunt. Intracardiac catheterization exhibited an increase in oxigen partial pressure at the right atrium. Angio cardiography confirmed the presence of shunt from left ventricle to right atrium.
This cardiac disease is rare, and a total of 63 cases reported in Japan was analysed to clarify the characteristic features.

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We recently experienced an uncommon case of thrombosed intraluminal prosthesis, which was inserted in the ascending aorta.
A 61-year-old man with acute type I aortic dissection was treated using intraluminal prosthesis. Prulent exsudate from the median incision was persistent until sternal wire was removed. Postoperative aortography showed well functioning graft. Four months later, Y graft implantation with fenestration was applied to the infrarenal aortic lesion. During the operation his hemodynamics came to be unstable. Aortography revealed severe stenosis of intraluminal graft. Emergent thrombectomy was unsuccessful. Intraluminal graft was nearly occluded by the chronic thrombus. Candida albicans was cultured from the thrombus and granulation tissues around the graft. The thrombus was a bacterial thrombus caused by candida albicans, which might gradually grow to plug up the graft lumen. This case could not be saved because of delayed diagnosis. When we encounter a patient undergoing replacement of chest aorta followed by an infection at the excised site, a possibility of graft infection should be kept in mind usually and a careful follow-up is essential to prevent a complication being irreversible.

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A 41-year-old woman was admitted to our hospital with the chief complaints of right lower abdominal pain andedema in the lower extermities. The diagnosis of gallstone disease associated with a retroperitoneal tumor of the infiltrated range was was made by using ultrasonography, computed tomography angiography. Primary tumor in the inferior vena cava or invasion of retroperitoneal tumor was suggested by postcavarography and magnetic resonanse imaging test. First of all, cholecystectomy was performed because of the complication of cholelithiasis. The tumor was a yellowish-white massive one with approx. 6 cm in diameter sitting to the lower surface of the liver, and internal and upper regions of the right kidney, and existed so as to eject from the inferior vena cava. The combined resection of the right kidney was performed, because resections of the partial postcaval walls and the tumor, and its ablastions were difficult. The double lineserial cross suture of the amputation stump of the inferior vena cava was carried out. The chemotherapy was concomitantly used as an auxotherapy. The postoperative couse was favorable, and the patient is under observation on ambulatory basis as of now progressed for 4 months. Eighteen cases of primary leiomyosarcoma in theinferior vena cava including this case have been reported in our country so faras we studied, and we also presented a discussion of some references because of its seldom occurrence.

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Pulmonary sequestration is a relatively uncommon cystic lung disease. Six cases of the disease treated in our department up to now, are clinically studied. The patients were comprised of 1 nowborn, 1 infant. 2 schoolboy and girl, and 2 adults. Five cases had intralobar sequestration, and the remaining one, extralobar sequestration. Three cases were left sided, and 3, right sided.
Initial manifestations by which the disease was found included infectious symptoms such as repeated pneumonia, hemosputum, and hemoptysis in 4 cases, and dyspnea in one, but one case was accidentally found by chest X-ray without any complaints. Correct preoperative diagnosis could be achieved in 2 out of 4, in which angiography was performed, but in the other 4 cases, differential diagnosis from other cystic lung diseases was difficult. All cases were operated on. Except a case of extralobar sequestration, lobectomy or segmentectomy was done. The extra lobar sequestration had a Congenital adenomatoid malformation (CCAM) in the same side, and sequestrated lobe was also CCAM.

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We experenced five cases of comparatively rare primary volvulus of the small intestine, and all were completely cured. The patients comprised two girls aged 11 and 7 and three female neonates. The two girls could be cured by reduction of the intestinal volvulus, but intestinal resection was necessary in the three neonates.
We investigated 42 including these 4 cases of this disease reported in Japan. Among these 42 cases, 31 (74%) were neonates and only 7 (16%), children. Treatment involving reduction of the intestinal volvulus only was carried out in 18 cases (42%) and intestinal resection in 20 cases (48%). Since strangulation of the small intestine is severe and necrosis is apt to appear at a comparatively early stage in this disease, emergency surgical treatment based on early diagnosis is necessary.

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A case of primary sall bowel volvulus presenting with diffuse peritonitis is reported. A 54-year-old man was admitted to a near hospital with the complaint of abdominal pain, and palliatively treated at the hospital. But his symptoms were not improved, so he was refered to our hospital. On admission the abdomen was distended and muscular defense and Blumberg sign were noted. Abdominal X-ray film showed a small bowel gas shadow with niveau. Emergency operation was carried out because his symptoms suggested diffuse peritonitis. On laparotomy, massive small bowel necrosis was found and the root of the small intestinal mesentery was twisted clockwise about 360°. Resection of the length of the survived intestine was 1.2 m. We diagnoted as primary small bowel volvulus because the bands and adhesion were not noted in the abdominal cavity. The patient was treated with TPN and ED after operation and was discharged on the 50th day. Primary sall bowel volvulus rarely occurs, but demands careful attention in its possible severe progress.

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Among various tumors of the small intestine which lack in specific clinical manifestations, leiomyomas or leiomyosarcomas often present as melena and anemia as the chief complaints. Six cases of leiomyoma or leiomyosarcoma of the small intestine, including 2 of leiomyosarcoma and 4 of leiomyoma, experienced at our department in a past 6-year period were clinically studied. A close examination of the small intestine is needed for a patient complaining of melena and anemia but revealing no lesion on the upper digestive tract or colon. Angiography can offer valuable informations of the size or site of a tumor; whether it is multiple; invasion into the surrounding tissues; and existence of liver metastasis. Moreover, it will enable to detect such tumors in early stages. When we must determine whether a tumor is benign or malignant, careful attention should be paid not only for a pattern of karyomitosis but also for other factors such as diameter of the tumor. A case having some factors indicating poor prognosis needs a careful follow-up, as well as aggressive treatments, especially for liver metastasis.

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Leiomyoma is the most common benign neoplasm of the small intestine. It is not rare to encounter emergency operation cases for massive hemorrhage, intestinal obstruction or peritonitis caused by leiomyoma of the small intestine, because we have difficulties in preoperative diagnosis. Recently, we experienced a case of this condition which required an emergency operation. The case is a 29-year-old man with the chief complains of epigastralgia and melena. Evaluation of the stomach, duodenum and colon failed to find the lesion. On the course of attempting the evaluation of the small intestine, the patient developed hypotension due to massive melena. Emergency laparotomy was performed and an elastic tumor of 1 cm in diameter, located at 190 cm anal from the Treitz's ligament was found. A wedge resection of the jejunum bearing tumor was satisfactory to prevent bleeding. Histological diagnosis of leiomyoma could be obtained. The massive melena might be caused by the bleeding in the tumor of the small intestine which penetrated the intestinal lumen.

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We encountered a case of recurrence after operation for mesenteric fibroma in a 30-year-old woman. After giving birth to the second child 2 years before, she had undergone extirpation of a tumor and extensive resection of the small intestine for mesenteric fibroma of the small intestine.
Two years later the patient noticed a tumor in the lower right region of the abdomen, was diagnosed as having postoperative recurrence, and reoperated on.
The tumor arised in the mesentery of the small intestine and infiltrated into the right ureter and most part of the small intestine. After extirpation of the tumor and subtotal resection of the small intestine, the case presented with shortened small intestine syndrome with the residual small intestine of 20 cm. One year later the patient died of deteriorated general condition after repeated admissions.
The common factors inducing fibroma included trauma from surgery and effect of pregnancy. In this case the relationship between fibroma and these factors is also suggested. So far as reports on mesenteric fibroma in Japan are concerned, no mention is made of recurrence probably because of insufficient follow-up investigation.
This is considered a case of early recurrence developed 11 months after surgery.

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We experienced a case of focal nodular hyperplasia (FNH) of the liver in a 50-year-old man. Fifty-seven cases of focal nodular hyperplasia reported in Japan in the light of the literature revealed that it was difficult to diagnose preoperatively and was a disease demanding definite differentiation from hepatocellular carcinoma (HCC).
In this case, abdominal sonography, abdominal computed tomography and abdominal angiography failed to differentiate from HCC.
It is generally said that histopathological diagnosis is important in diagnosing FNH, and we were able to diagnose it by histopathological findings of the resected specimen postoperatively. The first choice of the treatment of FNH, though it has been considered a benign disease, is thought to remove surgically, because it can be occasionally accompanied with malignancy or rupture into the abdominal cavity.

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It is general that the metachronous metastasis of primary colorectal cancer to the liver occurs within 3 years after surgery, and it rarely occurs after 3 years. This time we could successfully resect a hepatic metastasis which was found 8 years and 6 months after resection of the primary lesion.
A 60-year-old male was referred to our hospital because of the elevated serum CEA. He had undergone sigmoidectomy for primary colon cancer in Oct. 1980, which was 3.5×3.0 cm in size and moderately differentiated tubular adenocarcinoma of type 2. Abdominal US, CT and celiac angiogram demonstrated a mass, 5×5 cm in size, at the anterior segment of the liver. Extended right hepatic lobectomy was performed. The hepatic lesion was diagnosed as tubular adenocarcinoma that was similar to the primary sigmoid colon cancer in the histological feature.
It seemed inevitable that the periodical measurements of serum CEA and evaluative imagings should be taken for a long term.

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Torsion of gallbladder is a comparatively rare disease and requires emergency operation. We describe here a case of torsion of gallbladder, presented with peritoneal irritation symptoms in which abdominal ultrasonography suggested acute cholecytitis and operation was performed. Diagnosis of the disease is also discussed.
An 88-year-old woman complaining of right lower abdominal pain was found to have a swollen gallbladder with thickened wall by abdominal ultrasonography. The patient was diagnosed as acute cholecystitis associated with peritonitis, and conservative treatment was begun. However, no symptomatic remission was noted, emergency laparotomy being carried out. Laparotomy findings showed that the swollen gallbladder was twisted clockwise by 900 degree (2.5 turns) at its neck. After releasing the torsion, cholecystecotmy was performed together with torsion choledochography.
Torsion of gallbladder is difficult to differentiate from other acute abdomens. In this case, preoperative ultrasonography revealed a clear stoppage between the lumen of the swollen gallbladder and the common bile duct, a finding suggestive of the disease. The value of abdominal ultrasonography is emphasized.

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Recently anomalous junction of pancreaticobiliary duct is drawing reseacher's attentions in relation to the mechanisms of the onset of cancer of the gallbladder. We describe a rare case of early gallbladder cancer associated with anomalous junction of pancreatobiliary duct, together with a review of the literature.
A 52-year-old female complained of epigastric pain. Abdominal ultrasonography and abdominal CT revealed a cystic tumor. Endoscopic retrograde cholangiopancreatography showed a noncholangiectatic and pancreatic duct-type anomalous junction of pancreatocobiliary duct. Cholecystectomy with resection of the base of liver were carried out. In the resected specimen a 25×15×10 mm papillary tumor was found in the body of gallbladder. Histopathological examination exposed that it was a papillary adenocarcinoma and early carcinoma of the gallbladder with the depth of pm. Postoperative course was uneventful and the patient was discharged on 21st day after operation. Of case reports from Japanese literature so far as we could review, only few reports clearly described the histological tumor invasion, and this case might be the 7th report in Japan.

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Biloma is a rate morbid state in which bile leaks outside the biliary tract and forms a localized cyst without extensive biliary peritonitis.
Two cases of biloma: traumatic intrahepatic biloma and spontaneous extrahepatic biloma were reported mainly the clinical course and treatment of the lesions and 41 cases reported in Japan, were analyzed. Case 1 was a 20-year-old man with an intrahepatic biloma due to trauma cured by drainage under the ultrasonic guidance. Case 2 was a 71-year-old man with an extrahepatic biloma caused by incarceration of choledocholithiasis. He was cured completely by laparotomy. The definite diagnosis of biloma is done based upon the analytical results of biliary constituents in the liquid leaked. Drainage under the ultrasonic guidance is performed to treat hight-risk traumatic bilomas, but laparotomy seems to be required in patients with spontaneous biloma for the treatment of underlying disease.

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Aneurysms of the spleen are relatively rare, and are found in a frequency ranging from 0.01% to 0.04% at necropsy. In Japan more than 170 cases have been documented. In this paper we describe a case of splenic aneurysm coexisting with a splenic cyst.
A 62-year-old female was pointed out to have a swelling of the spleen at medical examination, and was admitted to the hospital for further close examinations. Ultrasonography and CT revealed a 87×81 mm splenic cyst, a 20×28 mm splenic aneurysm, and liver cirrhosis. Selective angiography of the celiac artery showed the partially calcified aneurysm at slightly central-side of hilum lineis. Excision of tail of pancreas including the aneurysm and splenectomy were carried out. The disease, lacking in specific manifestations, is associated with portal hypertension in a frequency of about 50% of the cases. When a swelling of the spleen and portal hypertension are found, we should bear in mind a possible occurrence of the disease and, if it is actual, operation in an early stage should be given priority over other treatments, because it has a high mortality, if ruptured.

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A case of von Recklinghausen's disease associated with nonfunctioning pheochromocytoma and malignant schwannoma is reported. A 48-year-old female came to our hospital with the chief complaints of fever and abdominal mass. She had generally spread small skin tumors with café au lait spots. Her glandmother, mother and sister had been also pointed out to have von Recklinghausen's disease. Abdominal ultrasonography, computed tomography and angiography showed a huge adrenal tumor 13 cm in diameter and an egg-sized retroperitoneal tumor. The adrenal tumor appeared cystic and was suspected of abscess formation due to infection. As laboratory examinations revealed no endocrinological activity of the adrenal tumor, both tumors were resected without any preoperative treatments. The removed adrenal tumor measured 13×15×13 cm and weighed 649 g. The center of the tumor was necrotic and contained brownish pus. The retroperitoneal tumor measured 5×5×3 cm and was yellow in color. The histological examination revealed malignant pheochromocytoma and malignant schwannoma, respectively. The patient is well at present, one and half year after operation.

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Torsion of omentum is a relatively rare disease, and 70 cases have been reported in Japan up to now. We report on a case of torsion of omentum accompanied by incarcerated right lateral inguinal hernia, which developed at a swing in golf by ill chance, together with a review of these 71 cases.
A 54-year-old man was seen in our hospital complaining of right lower abdominal pain. From clinical findings, partial incarceration in the intestine or abscess formation due to perforation of appendix was suspected. Laparotomy was carried out. Laparotomy findings revealed the greater omentum to form a fist-sized lump besides hemorrhagic serous ascites; the tip of the lump tapered and incarcerated to the right medial inguinal ring; and its central-side, being slender, was twisted counterclockwise by 3 turns. No abnormalities were noted in the appendix vermiformis. The greater omentum was resected at a normal site, repair of hernia and appendectomy being performed.
Documented cases in this country comprised 45 cases of secondary (63%), 21 of idiopathic (30%), and 5 of unknown (7%). It was in only one case that definite diagnosis could be made preoperatively. Forty-nine cases (69%) were diagnosed as appendicitis preoperatively. Extirpation of the strangulated greater omentum is the recommendatory treatment offering a favorable prognosis.

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Multicystic peritoneal mesothelioma is a very rare tumor and its histochemical findings are similar to the cystic lymphangioma. It is hard to differentiate them by macroscopic and usual microscopic findings. Histochemical, immunochemical and electron microscopic studies are needed to get differential diagnosis.
In this paper, we report the first case of multicystic peritoneal mesothelioma in Japan. A 40-year-old man was admitted to our hospital because of the abdominal distension and a mass. Giant elastic soft tumor was palpable in the right upper quadurant of abdomen. Multicystic tumor was detected by US and CT. It was resected on Oct. 25, 1989. The tumor was 20×14×7 cm in size and arised in the greater omentum. Clear and serous fluid was filled in multilocular spaces in this tumor and jelled nodles were recognized in some places. It was diagnosed as multicystic peritoneal mesothelioma in pathologic examiantion.
The patient has been in good condition and no recurrences can be found during 8 months after operation.

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Relatively rare hernias include obturator hernia in aged patients. We experienced 3 cases of obturator hernia presenting with complicated manifestations. Case 1 presented with an intermuscular abscess in the left thigh. The abscess was drainaged, and the herniation was cured thereafter. Case 2 showed recurrent ipsilateral obturator hernia ten years after former herniation was cured operatively. Case 3 presented with panperitonitis due to perforation of iluem, and emergent operation saved the patient. All 3 cases had peculiar manifestations and we had difficulties in the preoperative diagnosis and treatment. The key points for diagnosing obturator hernia are: 1) to doubt of its existence; and 2) to relay on CT among imaging methods. While it is emphasized for treatment that the hilus should be reinforced by covering not only with peritoneum but also with ovary and its ligament. A review of more than 200 cases of obturator hernia reported in Japan since 1926 is also described.

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Intrathoracic aneurysms of the subclavian artery are rare and the operative procedures varied from location to location of the aneurysms. A case of arteriosclerotic intrathoracic aneurysm of the left subclavian artery is reported. The case was a 63-year-old man who was found to have a left superior mediastinal mass by chest roentgenogram. Angiography and CT revealed that it was an aneurysm of the intrathoracic left subclavian artery. The chest was opened by trap-door style incision. Under the temporary bypass which was bridged from the ascending aorta to the left common carotid and to the right femoral artery with Y-shaped woven Dacron graft (16×8 mm), the aneurysm was easily removed. The left subclavian artery was reconstructed with left carotid artery bypass graft reversely.
This procedure was again useful for keeping brain perfusion to remove the intrathoracic subclavian aneurysm.

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A 51-year-old female suffering from congestive heart failure was admitted.
Examinations revealed a formation of right iliac arteriovenous fistula caused by rupture of a right iliac artery aneurysm.
At operation, the arteriovenous fistula with 8 mm in diameter was divided and closed with matress and over-and-over suture with 5-0 Prolene. After the right common iliac artery aneurysm was resected, this artery was reconstructed with a double velour woven dacron graft with a diameter of 8 mm. The postoperative course was uneventful.

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A case of impending rupture of multiple peripheral aneurysm could be successfully managed with prosthetic graft replacement. The case was a 76-year-old male complaining of a pulsatile tumor in the right inguinal region with pain. Another pulsatile tumors were found in the left inguinal region and right popliteal fossa, namely the patient was suffered from multiple aneurysm. The right femoral aneurysm accompanied by remarkable tenderness was diagnosed as impending rupture. Pulsation was palpable in the peripheral arteries of both lower extremities. In surgery two-step approach was employed. At the first step, the both femoral aneurysms were excised, and prosthetic graft replacement was performed using 8 mm E-PTFE graft. The blood flow in the right femoral deep artery could not be preserved, because the deep artery associated with the aneurysm. Three weeks later, the right popliteal aneurysm was replaced with 8 mm E-PTFE graft. Histopathologically the aneurysms were arteriosclerotic.
Multiple peripheral aneurysm increasingly occurs and has a poor prognosis resulting from arterial embolism due to intratumal thrombi or rupture of an aneurysm. Aggressive operation is recommended as soon as it can be diagnosed.

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Myonephropathic metabolic syndrome (MNMS), a metabolic disorder associated with acute arterial infarction of the extremities, may be caused by harmful factors released from the ischemic extremities and has a poor prognosis. In this paper we describe a case in which perfusion of affected extremity was performed to prevent MNMS, followed by perioperative hemocatharsis (blood adsorption by activated charcoal) for venous blood of the affected extremity. Classification of MNMS by stages and the treatments are also documented. A 84-year-old man visitied the hospital because of sense of coldness and muscle rigidity on the left lower extremity. He had had atrial fibrillation and cerebral infarction. Physical findings revealed acute ischemic symptoms which started at the inguinal region and run down from it. Thrombectomy with Fogarty catheter and relief incision were performed as emergency operations. With activated charcoal column after perfusion of affected extremity, 2360% of myoglobin flown out could be removed. This case did not present with any organ impairments and his life could be successfully saved. Perioperative blood adsorption with activated charcoal may be recommended for prevention of MNMS.

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