Recently several histologic subtypes of differentiated thyroid carcinomas have been proposed for estimating prognosis of thyroid cancer patients. In this study, therefore, we re-examined 222 patients with papillary carcinoma and 17 with follicular carcinoma especially from the standpoint of clinicopathologic entity of poorly differentiated carcinoma, and undertook the univariate and multivariate analyses for evaluating whether it is of value in estimating survival or disease-free-survival of thyroid cancer patients. As a result, the univariate study showed no difference between papillary and follicular carcinomas, but it showed a significant difference between well and poorly differentiated thyroid carcinomas in survival or disease-free-survival. In the multivariate study, however, the presence of poorly differentiated thyroid carcinoma did not appear as an unfavorable prognostic factor. On the other hand, sex, tumor size and presence of distant metastases and grossly malignant residue in the neck after operation were confirmed as important prognostic factors in the univariate and multivariate studies. These results suggest that the histologic subtyping of differentiated thyroid carcinoma is not necessarily available for estimating the prognosis.

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Twenty-two cases of minute cancer of the thyroid gland experienced at our department for a recent 12 years were retrospectively studied. Minute cancers accounted for 23.7% of all operated thyroid cancers. Of the 22 cases 3 had multiple tumors, and the subjected tumors counted 25. These tumors were found by metastasis to the cervical lymph node in one case, and by medical examination in 21 cases. Calcification was seen in 45.5% of the cases by soft ray radiography. Ultrasonic examination performed on 23 tumors in 20 cases revealed irregular margine in 13 tumors, acoustic shadow lacking in internal echo in 19, and unidentified in one. Histologically there were 24 papillary carcinomas and one follicular carcinoma. Operative procedures included total thyroidectomy in 3, subtotal thyroidectomy in 19, and lymph node dissection in 22 cases which comprised modified neck dissection (MND) on the affected side in 16, lymph node dissection (I-IV) alone in 3, and bilateral MND in 3.
Excepting multiple cancer cases undergone bilateral lymph node dissection, 16 MND cases were examined, and lymph node metastasis was seen in 60% of tumors in the isthmus which were all in group I-IV. While the metastasis was seen in 66.7% of tumors in the flocculus of which 50% were in group V-VII. In an avaraged observation period of 20.7±15.1 months, recurrence in the lymph nodes occurred in 4.5% of the cases.

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It is not rare to encounter a difficulty in diagnosing mucinous carcinoma of the breast for its clinical resemblance to benign diseases. Among 459 cases of breast carcinoma, resected at First Department of Surgery, Yokohama City University Hospital, over the past 14 years between 1975 and 1988, 17 patients (3.7%) were diagnosed as mucinous carcinoma. Excluding two cases of double cancer, 15 cases were studied referring to clinical characteristics and compared with a group of 323 patients with infiltrating duct carcinoma. Preoperative diagnosis of malignancy in mucinous carcinomas by physical examination (inspection and palpation), echography and mammography could be made only in 35.7%, 15.4% and 30.8% of the cases respectively. It was more difficult in tumors smaller than 2 cm in diameter. A combination of these three diagnostic modalities did not increase the rate of correct diagnosis to be more than 50%. However, fine needle aspiration biopsy was found to be very effective in all cases. Compared with infiltrating duct carcinomas, mucinous carcinomas were smaller in size, and had less frequent lymph node metastasis, consequently better prognosis. One exception was the mixed type of mucinous carcinoma, whose prognosis was worse than that of the pure type demanding a careful follow-up.

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Following a prospective randomized trial that have proved that there is no difference in overall survival or in relapse-free survival after mastectomy between with parasternal lymph node dissection and without one, parasternal dissection is not performed actually in Europe and the USA. In Japan the significance of parasternal dissection is not fixed yet. concerning this point, we have investigated our series considering the speciality of the tumor site in the breast.
From 1960 to 1989, 184 patients with breast cancer underwent radical mastectomy with parasternal lymph node dissection. Of these, 25 (13.6%) had parasternal lymph node matastasis. In the 25 cases, the positive rate of parasternal lymph node metastasis was higher in medial and/or central tumors than in lateral tumors. In medial and/or central tumors, the positive rate of parasternal lymph node metastasis was higher in cases having more than 4 positive metastatic axillary lymph nodes and tumors over 5 cm in diameter. In medial and/or central tumors, the rate of relapse was higher and survival rate, lower in the cases with positive metastatic parasternal lymph node than negative cases.
We conclude that parasternal lymph node dissection has the clinical significance because it provides us with an information about prognosis after radical mastectomy in a case of medial and/or central tumor.

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No consensus exists on the etiology and diagnostic criteria for Dieulafoy's ulcer. To clarify the characteristics of this disease, clinical and pathological evaluation was made on 13 cases treated surgically in Tokushima Municipal Hospital. It was most frequently found in the upper gastric body (6 patients), while multiple ulcers were found in six cases. The depth of ulceration was UL-II in seven and UL-III in six cases. The ulcerations measured from 3×5 mm to 10×25 mm, with the diameter of the exposed vessels ranging from 1.0 mm to 2.5 mm.
In all cases examined, the exposed vessels run without changing their diameters even after penetrating through the muscular layers, but ruptured after reaching the submucosa. None, however, showed arteritis or aneurysm, and only mild arteriosclerosis was found in one patient. One possible etiology is that the fortuitous occurrence of ulceration over an unusually large submucosal artery may cause it to rupture.
In making the diagnosis of this disease, attention should be paid to abnormal running of large arteries. It is important to confirm hemorrhagic sites by gastrotomy during surgery. In postoperative period, it is necessary to follow the patients closely keeping in mind the possible recurrence of gastric hemorrhage. In addition to this cases, 107 others reported in Japan were reviewed for clinical evaluation.

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To evaluate the effects of vertical banded gastroplasty (VBG) for morbid obesity associated with various complications, the changes in their obesity indexes and complications following surgery were observed. Thirty-six patients with simple obesity have been treated with VBG in our institute for these six years. The obesity index, which was 213±27% preoperatively, decreased to 150±18% at 6 months, 142±19% at one year, 141±17% at 3 years or 141±9% at 5 years after surgery. Obesity-related complications were preoperatively noted in high frequencies, such as 86% for fatty liver, 78% for glucose intolerance, 72% for arthritis, 67% for hyperlipidemia, and 44% for hypertention. With a loss of excess weight, these figures decreased to 9% for fatty liver, 9% for glucose intolerance, and 9% for hyperlipidemia at 3 years after surgery. Surgical complications, which were minor and treatable, were seen in 8.3%.
These results clearly demonstrate that the vertical banded gastroplasty is effective to reduce excess weight as well as complications of morbid obesity.

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Out of 606 cases undergoing total gastrectomy for upper gastric cancer, the status of lymph node metastasis was evaluated in 141 cases of C (E) and 90 of CM (E). In proximal gastrectomy cases, lymph node metastasis of No.4d, 5 and 6 that fell beyond the area of lymph node extirpation were studied. In 141 cases of C and CE, no metastasis occurred in an area from m through pm. In 46 cases of ssα, and ssβ, metastasis occurred. In 90 cases of CM and CME, no metastasis was found in m or sm for No.4d, 5 and 6, while in ssα, and ssβ, metastssis occurred. In prognostic serosal factor positive cases, metastasis was frequently observed.
Of the second group lymph nodes, No.10 and 11 were evaluated in terms of status of metastasis. In C and CE carcinomas, m and sm were free from metastasis. In CM and CME carcinomas, m and sm were free from metastasis. In conclusion, proximal gastrectomy is selectively done in an early stage of carcinoma to promote long-term survival. To ensure a safety zone, m, sm and N (-) of the C area are selected as indications for proximal gastrectomy. To date, the five-year survival rate for the 53 proximal gastrectomy cases encountered has been satisfactory: 88%.

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During a recent 13 years (November, 1975-December, 1988), 565 patients were operated on for carcinoma of the large intestine at our institute. Of the 565 cases 51 (9.0%) had multiple carcinomas involving other organs, consisting of 17 of synchronous multiple carcinoma and 34 of metachronous multiple carcinoma (7 large intestinal carcinoma preceding cases and 27 other organ's carcinoma preceding cases). In this study the 34 metachronous multiple carcinomas were investigated from the viewpoint of clinicopathological findings and prognosis. These cases consisted of 17 males and 17 females, with a mean age of 64.1 years. The interval between the occurrences of two carcinomas was 7 years and 2 months on an average (7 years and 4 months in large intestinal carcinoma preceding cases; 7 years and 2 months in other organ's carcinoma preceding cases). Carcinoma of the other organ was most commonly found at the stomach, 13 of 34 cases; followed by at the uterus, 7 of 34; and at the mammary gland, 4 of 34. Carcinoma of the large intestine was predominantly located at the sigmoid colon and rectum below the peritoneal reflection, macroscopically type 2 was recognized in 21 and type 0, in 2 cases. Histological examination revealed well-or moderately-differentiated adenocarcinoma in the majority of carcinomas arised in the large intestine. Carcinoma of ss (a₁) in the depth of invasion was recognized in 17 cases, most frequently. There were 2 cases of m, both being of other organ's carcinoma preceding cases. The 5-year survival rate in cases of curative resection was 74.6% (80.0% in the former and 73.9% in the latter cases), showing favorable prognosis. These results emphasize the importance of careful follow up after curative resection of the first carcinoma.

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A total of 236 cases operated on for colon cancer in a recent 5 year period was compared for the location of tumor, s-Tchol and s-TG by grouping on whether gallstone was associated or not, and whether cholecystectomy had been done or not. Fecal bile acid deviation before and after cholecystectomy was also comparatively studied in 33 gallstone cases. Twenty-eight cases (11.9%) out of the 236 were accompanied by gallstones. When the cecum and ascending colon were regarded as right side and the discending colon, sigmoid colon and rectum as left side, the proportion occupied right side colon was 33.3% in the associated gallstone group, which was higher than 18.3% in non-associated group with a significant difference (p<0.05). There was same tendency in the location of tumor evaluated by whether cholecystectomy had been done or not. And we didn't recognize any significance in s-Tchol and s-TG evaluated by whether cholecystectomy had been done or not. No significant change in fecal bile acid deviation was also noted between before and after cholecystectomy. Therefore we think that colon cancers and gallstones may have the common risk factors, and besides, we disagree with some reports that cholecystectomy promotes the colon cancer.

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In 137 patients with cirrhosis undergoing partial hepatectomy for hepatocellular carcinoma, the relationship of early postoperative hepatic failure to preoperative hepatic function, the extent of hepatectomy, and a blood loss during operation was studied.
Thirteen cases developed hepatic failure within one month after operation, in which the preoperative K_ICGextent of hepatectomy, and blood loss during operation were related to the onset of hepatic failure. The incidence of hepatic failure was high when the preoperative K_ICG was 0.1 or less, then two or more regions of the liver were resected, and when operative blood loss was 3, 000 ml or more. When all these three factors were scored, the sum was useful as an index for predicting postoperative occurrence of hepatic failure and for determining the surgical indications and techniques.

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In order to clarify clinical and therapeutic features in aged patients over 80 years old with cholelithiasis, 363 patients treated at our department during a recent one decade were retrospectively studied by comparing with younger age groups. Patients in their seventies accounted for 16% (59 cases) and those over 80 years old, 6.1% (22). Clinical features in aged patients (over 80) were characterized by:
1) Stones were frequently existed in the choledochus and frequently composed of pigment stones.
2) Bacteria were found in culture of bile taken from almost all patients.
3) Once symptoms occurred, patients tended to become seriously ill, and emergency operations were often performed.
4) The frequency of postoperative complications were same as that in age group sixties or seventies.
From the above, we emphasize that surgery should be performed at the point of onset over 80 years old under sufficient pre and postoperative management. In addition misdiagnosis was often made preoperatively, and we also emphasize that we should not neglect preoperative ultrasonography.

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Sixty-one patients with acute embolism necessitaing surgical treatment during a recent one decade were subjected to a retrospective study of time intervals from the disease to the initation of treatment, what courses the patients had taken until their arrivals to our hospital, therapeutic outcomes, and prognoses. Though about 41% of the patients had visited some medical institutions, their treatments were delayed until about 12 hours had passed. Five out of 6 patients undergoing amputation were refrred to our hospital by other institutions to where the patients first visited. Three death cases also came to our hospital in the same manner. For the reasons mentioned above, we keely felt the necessity of recognization and enlightment about this disease.

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A 60-year-old female patient with a large thyroid nodule of 10-year duration visited our hospital. The nodule was 12×7.5 cm in size in the left thyroid lobe. The thyroid function test revealed euthyroid state. A cold nodule was revealed by ^99mTc thyroid scintigraphy, and a hot nodule by ²⁰¹T1 thyroid scintigraphy. Fine needle aspiration biopsy of the thyroid nodule was class III. Subtotal thyroidectomy and bilateral modified neck dissection were carried out. Histopathological examination revealed a thyroid follicular carcinoma. Four years after thyroid operation, a chest roentgenogram showed multiple nodules of varying size throughout both lung fields. The patient complained of palpitation, excessive sweating, and loss of body weight. Serum T₄ and T₃ increased mildly, but serum TSH was not detectable. ¹³¹I whole body scanning revealed uptake of right cervical region and bilateral lung fields. ¹³¹I therapy was carried out (100 mCi). After six months, second ¹³¹I therapy was carried out (180 mCi). A chest roentgenogram revealed markedly diminished lung metastases and serum T₄ and T₃ declined under normal ranges. After then, ¹³¹I therapies were carried out for extended lung metastases 3 years (150 mCi) and 6 years (150 mCi) after first ¹³¹I therapy. She is healthy and well with lung metastases 7 years and 4 months after first ¹³¹I therapy.

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A 70-year-old female with adenoma of the nipple associated with multifocal cancer in the right breast is reported. The patient visited our hospital because of palpable nodules in AE (subareolar) and BA area of the right breast. Standard radical mastectomy was carried out with preoperative diagnosis of multifocal carcinoma of the right breast. Histopathological investigation revealed a solid tubular carcinoma in BA area, and adenoma of the nipple which was invaded by intraductal carcinoma closely located in AE area. The diagnosis of adenoma of the nipple still remains confusing because of resemblance in proliferation pattern of the mammary ducts to those of carcinomas, histologically. An association of adenoma of the nipple with carcinoma has been rarely reported and the present case is the second in Japan.

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We experienced 3 cases of postoperative chylothorax, which might be caused by leaked chyle from excised (or dissected) site of the thymus following cervical dissection accompanied by ligation of thoracic duct, or superior mediastinal dissection including thymus excision for advanced thyroid carcinoma or recurred breast cancer. Consideration of mechanisms of the occurrence in these 3 cases provided a speculation that ligation of the thoracic duct made the internal pressure of the duct increase, a reflux of chyle to the lymphatic pathway between the thoracic duct and thymus occurred, and finally chyle leaked from the thymus to cause chylothorax. In this manner, when thymus excision (or dissection) is performed in patients whose thoracic duct was ligated at the cirvical site, careful attitude is essential to prevent leakage of chyle before it happens.
In the treatment of the disease, conservative treatments such as sustained intrathoracic drainage, nutritional management through the central vein, and internal pleurodesis led to heals for all 3 cases. Conservative treatments can be recommended for such chylothorax.

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A 66-year-old diabetic woman with old myocardial infarction was admitted in a state of shock complaining of sustained severe chest pain. Immediately performed coronary angiography revealed complete occlusion of the right coronary artery associated with significant stenosis of the left main trunk (LMT). An intraaortic balloon pump was inserted and emergency bypass surgery was performed 6 hours after admission.
A saphenous vein graft was anastomosed to the anterior descending coronary artery. Her postoperative course was stomy, but finally she recovered and is now free from chest pain 2 years and 6 months after operation.
An indication of emergency bypass surgery for LMT lesion and pertinent application of preoperative IABP are briefly discussed.

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We experienced a case in which central retinal artery occlusion provided a clue for a definitive diagnosis of cardiac myxoma in the left atrium. A 15-year-old girl presented with sudden loss of vision in her left eye associated with a transient ischemic attack. Ophthalmologic evaluation demonstrated permanent visual loss of the left eye according to the obstruction of the central retinal artery. Echocardiography showed typical findings of a left atrial myxoma, which was suggested as a source of emboli. A radical operation for the cardiac myxoma was performed under cardiopulmonary bypass two months later. From a review of the literature, cardiac disorders account for 7.4-28.2% of the underlying factors for occlusion of the central retinal artery. Rheumatic valvular disease and mitral valve prolapse are common but cardiac myxoma is extremely rare. Through examination including echocardiography should be considered in young patients with retinal embolism and early surgical treatment is essential, if an operable disease is found.

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Concomitant thoracic and abdominal aortic aneurysms have not been rarely described recently. Such double aneurysm in the thoracic and abdominal regions has many problems in selecting operative method, assistant device, or either single or two staged operation for the timing.
A 62-year-old man with concomitant thoracic and abdominal aortic aneurysms, which were recognized about 7 years after the Bentall's operation, underwent single staged operation for the double aneurysms. We describe the case as well as some dicussion of the relevant literature including preoperative anticoaglant therapy.

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With a widespread mass-examination of lung cancer and a progression of diagnosis technology, multiple lung cancer is increasingly found. As to synchronous and bilateral multiple lung cancer, it is few to be able to obtain the preoperative diagnosis for both sides, and besides, there is a variety of arguments in the treatments. In this paper we report on a case of synchronous and bilateral multiple lung cancer, in which right upper lobecotmy and left upper segmetal excision were successfully performed on an one-step approach by using mediastinotomy and anterolateral thoracotomy.
A 64-year-old male was pointed out to have abnormal shadows in the both upper lung fields on a chest X-ray film and visited our hospital. By TBLB a tumor of the left upper lobe was diagnosed as adenocarcinoma. Mediastinotomy was performed, perioperative biopsy indicating that a tumor of the right upper lobe was squamous cell carcinoma. Hence right upper lobectomy and left upper segmental excision were performed on an one-step approach.
Such one step surgical approach appears valuable for patients presenting favorable general condition with residual respiratory function. Moreover, mediastinotomy offers less pain, preserve the respiratory muscle, and maintain the pulmonary function, in that it can be recommended for selected patients in terms of radical treatment of lung cancer.

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In this country, only 3 resected cases of synchronous (within 1 year) double cancer of the lung and pancreas have been reported. There appeared no report describing surgery on metachronous (more than a year) double cancer of the lung and pancreas. We present a case in which pancreatoduodenectomy and reconstruction of the portal vein were performed for a pancreatic cancer 2 years and 11 months after right upper lobectomy for a lung cancer. At the time of detecting the secondary cancer in this case, a possible bone metastases from lung cancer was suspected. However, based on 2 facts, namely, 1) that the progress of bone metastases was gradual, and 2) that the patient displayed obstructive jaundice requiring some surgical procedure, laparotomy was indicated.

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We encountered 3 rare cases of delayed Bochdalek's hernia.
Case 1: A two-month-old boy. Although alar collapse was noted at birth, this boy grew without marked abnormalities. However, facial cyanosis after suckling, decreased suckling power and frequent vomiting were observed at 2 months after birth, and his chest radiograph disclosed a lesion in the left lower lung field, leading to emergency hospitalization.
Case 2: A three-month-old girl. This girl was also urgently admitted because of frequent vomiting after suckling and radiographic evidence of a lesion in the left lower lung field.
Case 3: A six-month-old boy. This boy began to frequently vomit after suckling, and showed an abnormal gas opacity on the left diaphragm in a thoracoabdominal radiograph; therefore, he was urgently admitted.
These 3 children underwent diaphragm plastic surgery (suture and closure) through transperitoneal approach, and have shown uneventful postoperative results. We herein report these 3 cases in addition to a discussion on the literature.

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Adenocarcinoma arising in the Barrett's esophagus has lately attracted clinical attentions. Although many cases have been reported in the Occident, only 20 cases are reported in Japan up to now. Here we describe a case of adenocarcinoma arising in the Barrett's esophagus.
A 63-year-old male was admitted to our department for a 2×2 cm irregular surfaced tumorous lesion in the lower esophagus revealed by esophagography at the annual medical examination. The lesion was identified as adenocarcinoma based on biopsy, and the patient underwent partial esophagectomy, total gastrectomy and esophago-jejunostomy. Histologically, the protruded lesion was composed of moderately differentiated tubular adenocarcinoma existing in the Barrett's epitherium which extended 4 cm toward oral side from the esophagogastric junction. The patient is alive with no recurrence sign of the carcinoma about 15 months after operation. We examined 21 cases of adenocarcinoma arising in the Barrett's esophagus reported in Japan. It was revealed that early adenocarcinoma was relatively often found in the Barrett's esophagus, however, many cases with highly lymphnode metastases were also often found. So, radical operation is required for adenocarcinomas arising in the Barrett's esophagus according to esophageal squamous cell carcinoma.

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A 56-year-old male with dysphagia was discovered to have a half-sphere like submucosal tumor, 6 cm in diameter, on the left side of the lower esophagus by esophagogram. One month after first examination he complained of chest pain and melena, and his esohagogram revealed that the lesion changed to ulceration. Endoscopic biopsy could not detect malignant cells. The tumor was demonstrated as growing from proper muscle layer, which was in homogeneous inside and had unclear border. Under a diagnosis of malignant submucosal tumor including leiomyosarcoma, subtotal esophagectomy was performed. Resected specimen showed submucosal growth (3.8×3.2 cm), and historogically diagnosed as esophageal leiomyosarcoma. The esophageal leiomoysarcoma was reported in only 62 cases in Japan. The mean age is 53.5 years old, and male to female ratio, 1:3, 57% of the cases locating in the lower esophagus. The mean size of the tumor is 7.9 cm in diameter and 45% of the cases are in the range of 3-6 cm, 1-year survival rate being 81%. The metastasis is predominantly found in the liver (35%). Preoperative correct diagnosis rate is 20%. In the qualitative diagnosis of submucosal tumor EUS would play a important part in future.

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A case of calcified gastric leiomyoma is reported. A 76-year-old female complaining of upper abdominal pain was pointed out calcifications on an abdominal plain X-ray film, and an abdominal tumor touching to tail of the pancreas on CT. On laparotomy performed under a diagnosis of pseudo-pancreatic cyst, the tumor was found to be a gastric leiomyoma growing as extrastomach.
To our knowledge, in Japan, 12 cases of calcified leiomyoma of the stomach have been reported. From a review of these literature, calcified leiomyomas, when compared to noncalcified leiomyoma, are characterized by 1) to be predominant in aged women; 2) to be frequently in the middle of the stomach, where the leiomyomas attend to show no manifestations; and grow extrastomachically. These characteristics and pathologic findings suggest that a possible inclusion of dystrophic calcification might contribute to the mechanism of the calcification. In addition it was extremely remarkable that all calcifications were massive type.

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A 77-year-old woman under the treatment for hypertension was pointed out to have a right upper abdominal tumor. Various examinations such as ultrasonography and CT revealed a solid tumor. Abdominal angiography showed that the tumor was being fed by left gastric artery and right gastroepiploic artery. The tumor appeared a primary leiomyoma of the stomach. It was large in size and was questioned whether to be benign or malignant. From internal characteristics of the tumor revealed by abdominal US and CT, and angiographic findings, it was finally diagnosed as extramurally growing leiomyoma, surgery, being performed. The tumor was growing peduncularly from the lesser curvature-side on the posterior wall of angular notch. The tumor including the peduncle base was extirpated. It was 8×7×4 cm in size, and a leiomyoma histologically. In the qualitative diagnosis and exploration of primary lesion in this case, abdominal angiography was particularly valuable.
Peduncularly growing leiomyomas of the stomach are rarely seen in the literature, and we often have difficulties in the histopathologic diagnosis to distingush malignant from benigh, in that further through and careful observation of the course is necessary.

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We report a case of asymptomatic duodenal carcinoid in a 50-year-old male patient. A filling defect was detected on routine upper gastrointestinal X-ray examination, and serious and a sessile polyp of 5 mm in diameter was endoscopically observed. Biopsy revealed typical features of carcinoid. Partial resection of the duodenal was performed. The tumor was confirmed in the mucosa which was type B by Soga's classification. Immunohisto-chemically, numerous secretary granules of gastrin-positive and somatostatin-negative were observed. This patient is doing well with no signs of recurrence 12 months after surgery.

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A 56-year-old man was admitted with a 10 day history of persistent melena and a fever of two week's duration. On examination he was toxic; temperature 38°C, pulse rate 130/min, and BP 80/50 mmHg. Abdominal examination revealed tenderness in the right lower abdomen. Blood profile showed Hgb. 10.2 g/dl, total leucocyte count 3000/μl, GOT 120, and GPT 62 mU/ml. Blood and stool culture did not show any pathogenic bacteria. Fiberscopy and angiography did not detect any bleeding focus. He developed massive melena with peripheral circulatory failure resistant to blood transfusion. Emergency laparotomy was performed. Multiple ulcers in the terminal ileum with mesenteric lymphadenopathy were detected. Proximal 180 cm of ileum showed tell-tale sign on its serosal surface. Ileocecal resection was performed with the resection of the ulcer bearing area of the ileum. The culture from resected mesenteric lymph nodes was positive for Salmonella typhi organism. Histological examination of resected specimen showed massive intramural hemorrhage associated with infiltrated large lymphocytes and typhus cells. The patient made a rapid recovery with chloramphenicol therapy in the postoperative period.

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A case of obstructive colitis secondary to carcinoma of the sigmoid colon is reported. Preoperative doublecontrast study demonstrated ulcerations of the descending and transverse colon. There was a segment of normal mucosal pattern just proximal to obstructing sigmoid cancer. This finding was thought to be important in the diagnosis of obstructive colitis. At laparotomy, healthy appearance of the serosa made it difficult to appreciate the presence of ulcerations. Operative colonoscopy was helpful to determine the extent of bowel resection. Left hemicolectomy and transverse colostomy were carried out. Postoperative course was uneventful.
It is said that we often have difficulties in the preoperative diagnosis of the disease. However, most cases present with incomplete obstruction and preoperative double-contrast study of oral-side intestine can be done in some of them. In enema not only ulceration but also normal mucosal pattern are important. The value of operative colonoscopy in determining the extent of bowel resection is emphasized.
The pathogenesis of obstructive colitis is probably related to bowel ischemia resulted from increased intraluminal pressure.

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A rare case of adenosquamous carcinoma of the colon supposed to be the cancer family syndrome was reported together with a review of the literature.
A 24-year-old man was admitted to our hospital because of lower abdominal pain. He was diagnosed as having a cancer of the descending colon with metastasis to the anterior segment of the liver. Left hemicolectomy with regional lymphonode dissection and partial resection of the liver were carried out. Histological examination revealed an adenosquamous carcinoma of the colon. As far as we could examine, only 60 cases of adenosquamous carcinoma of the colon have been reported in Japan.

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We report a case of agenesis of the right lobe of the liver, which was demonstrated by imaging studies, in a patient with epiglottis carcinoma with the metastases to the cervical lymph nodes and liver. A 62-year-old male was admitted to our hospital because of a right cervical tumor. All laboratory findings, including those related to the hepatic function, were within normal limits. Abdominal ultrasonography and CT scanning showed the absense of the liver in the postero-lateral area to the Cantile line. The left lobe of the liver was markedly enlarged. Ultrasonography revealed only one hepatic vein. Abdominal angiography showed the absence of the right hepatic artery and right branch of the portal vein. The patient was diagnosed as agenesis of the right lobe of the liver by these imaging studies.

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A retospective study was made of 6 cases of the liver abscess after pancreatoduodenectomy (PD). All 6 cases have patient choledochojejunoanastomosis, and no signs of intestinal obstruction due to the recurrence of cancer or mechanical adhesion. In last 21 years (1968-1988), we experienced 584 cases of PD, and the incidence of such a postoperative liver abscess was 1%. Primary disease comprised malignant in 5 cases and benign in 1 case. Two types of reconstruction order had been choosen, namely Billorth type I for 3 cases, and Billorth type II for 3 cases. Postoperative period after PD differed in each cases ranging from 1 month to 4 years 8 months. Correct diagnosis was made in 5 cases by CT or needle aspiration, and 2 were successfully treated by antibiotics alone, abscess drainage being added to another 3 cases for cure. One case was misdiagnosed as liver metastasis of the primary cancer, and died of sepsis one month after administration of anticancer agents and steroids.
Liver abscess is one of fetal complicatons after PD, so early diagnosis and suitable treatment are needed.

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We recently experienced a case of unresectable hepatocellular carcinoma (HCC), to which under laparotomy a double lumen balloon catheter (5Fr, Swan-Ganz) was surgically inserted into the proper hepatic artery through the gastroduodenal artery and the tip of the catheter was localized around the bifurcation of the right & left hepatic artery for intermittent hepatic arterial occlusion (IHAO) with infusion chemotherapy. And to this patient Penrose drain was inserted into the foramen of winslow.
Postoperative course was good, but on the 6th postoperative day, massive bleeding from the Penrose drain was recognized. X-ray film on emergent angiography of the hepatic artery through the S-G catheter revealed intraabdominal bleeding from the 8 mm-sized pseudoaneurysm at the origin of the left hepatic artery. Hemostasis could be obtained by blood transfusion and administration of hemostatic drugs.
This pseudoaneurysm of the left hepatic artery was thrombolized by the S-G catheter during a therapeutic period with IHAO. In conclusion only 6 cases of ruptured pseudoaneurysm of the hepatic artery have been reported at the light of literature in Japan and so ruptured pseudoaneurysm was thought to be a rare disease, but we must pay more careful attention to the diagnosis and treatment of it.

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In a past 8-year period, three cases of giant cavernous hemangioma of the liver have been encountered in our hospital. The male-to-female ratio was 1:2, an average age being 44.3 year-old. The patients were diagnosed as cavernous hemangioma by selective hepatic angiography showing multiple dense tumor stain persisted throughout the artery and venous phase. Two out of the three cases were treated by surgical resection; one underwent lateral segmentectomy of the liver, and the other, partial hepatectomy. In the remaining case which had diffuse growth of the tumor with coagulopathy (Kasabach-Meritt syndrome), ligation of the middle and left hepatic artery was performed. The prognoses of these cases are satisfactory.
According to these results and the literature describing cavernous hemangioma of the liver, it is concluded that surgery might be indicated to the patients having a rapidly growing hemangioma, or to the patients with a tumor size of over 4 cm in diameter. Moreover, ligation of the hepatic artery is recommended for unresectable tumors.

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A case of amputation neuroma of the common bile duct after surgery for cholelithiasis is reported. A 78-year-old man complained of jaundice and right hypochondralgia one year after cholecystectomy and choledochotomy. Endoscopic retrograde cholangiopancreatography showed a choledochal stone and the segmental stricture of the mid-common bile duct, which was diagnosed as a benign lesion of the fibrotic change due to the previous operation. The mid-common bile duct was resected and choledochojejunostomy was performed. The elastic hard mass was observed at the stenotic lesion of the choledochus and was diagnosed as amputation neuroma histologically.
Analysis of twenty four cases reported in Japan indicated the followings: (1) The preoperative diagnosis was difficult, only one case (4%) was conclusively diagnosed before operation: (2) Nine cases (3%) had been supposed to be malignant tumors and consequently some of them received the inappropriate treatments such as conservative treatments without operation or excessively aggressive operation. (3) All of the operated cases revealed a favorable prognosis. When the patients with the past history of choledochotomy have the choledochal stenosis, the possibility of amputation neuroma should be considerd.

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We experienced a case of traumatic neuroma incidentally noted in the gallbladder resected for choledo-cholithiasis. Ultra-sonography, computed tomography, and intravenous cholangiography indicated stones in the common bile duct in an 85-year-old female and operation was performed. Many stones were found din the dilated common bile duct. The gallbladder was atrophic and its wall thickened and hardend. Microscopically, thickening of the gallbladder wall was due mainly to nodular proliferation of peripheral nerve fascicles. A diagnosis of traumatic neuroma was made over.
Traumatic neuroma in the gallbladder is very rare and a review of the literature disclosed only two cases of it. This paper presents the third case of traumatic neuroma of the gallbladder, with some discussion of its symptoms and pathogenesis.

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We studied the effects of lymph node metastasis on cholangiocarcinoma. In cholangiocarcinomas that developed below the hepatocholangic confluence, the presence or absence of lymph node metastasis affected the resection rate and curative resection rate. However, the effects of lymph node metastasis on cholangiocarcinomas of the hepatic hilus region was minor, and an involvement of the V·Hinf factor was considered important. The positive lymph node metastasis rate in carinoma of less than 3 cm in diameter was 38%; and in those of 3 cm or above lymph node metastasis was observed at a rate of 56%. Moreover, as the serosal infiltration increased, the positive lymph node metastasis rate rose. In some cholangiocarcinomas of the superior and middle regions, lymph node metastasis was observed on the posterior surface of the pancreatic head or upper root of the mesentery.
In the treatment of cholangiocarcinoma, it is suggested that, regardless of the region affected, expanded operation to purify the lymph nodes over a wide area is necessary.

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We have experienced three cases of pancreatitis associated with primary hyperparathyroidism (PHT). As both hypercalcemia and hyperparathyroidoholmonemia improved after parathyroidectomy, the level of serum amylase decreased gradually, which speculated some relationship between hypercalcemia and injury of the pancreas. Case 1: A 71-year-old woman was pointed out pathorogical bone fracture of the pelvis, hypercalcemia and hyper-parathyroidoholmonemia. After minute examinations she was diagnosed as PHT. Several months later she complained of sever epigastralgia and diagnosed as chronic pancreatitis, because CT examination showed a dilatation of pancreatic duct and pancreatic stones. After extirpation of parathyroid adenoma, as both hypercalcemia and hyperparathyroidoholmonemia improved the level of serum amylase decreased gradually. Case 2: A 57-year-old woman complaining of high fever and abdominal pain visited to the hospital and was diagnosed as acute pancreatitis. At the same time ureteral stones and hypercalcemia were found, and a diagnosis of HPT was made. Case 3: A 25-year-old woman was admitted to our department because of severe epigastralgia and hypercalcemia, and diagnosed as pancreatitis associated with PHT.

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Two cases of pseudotumorous pancreatitis which were difficult to differentiate from pancreatitis are reported together with some discussion. Case 1 was a 58-year-old man who admitted to our hospital complaining of jaundice. A tumor was found at the head of pancreas, and the common bile duct and pancreatic duct in the tail of pancreas dilated. Various imaging methods failed to differentiate from pancreatic cancer, cytology of bile juice resulted in class IIIb, pancreatoduodenectomy being performed. Case 2 was a 38-year-old man who was referred to our hospital by a near practitioner for a suspicion of pancreatic cancer. He was a heavy drinker and complained of epigastric and back pain. A tumor was found at the head of pancreas accompaning by jaundice, dilated pancreatic duct in the tail of pancreas being seen. It was difficult to distinguish from a pancreatic cancer, and pancreatoduodenectomy was performed.
Although there have been reported varied differentiating methods such as imaging diagnostic methods and blood biochemical examinations including tumor markers, no definite has been established as yet. Most potent clue for pseudotumorous pancreatitis may lie in that the tumors often diminish. However, we do not know the period neccessary for observation of the clinical course, and besides, prognosis of pancreatic cancer is extremely poor, in that we should not hesitate to undertake surgery.

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Splenic lymphangiomas are rare. We describe a case of splenic lymphagioma, together with a review of 37 cases documented in Japan.
A 43-year-old female, complaining of pain in the left back beginning from the fall of 1989, visited a near practitioner and was found to have an abnormality in the spleen by ultrasonography. The patient was referred to our hospital. Ultrasonography and CT revealed a cyst of about 3 cm in diameter and many small cysts around the major cyst. Thus, splenic cyst was diagnosed. Splenectomy was performed on April 18, 1990. The excised spleen weighed 110 g, and many cysts of various sizes were found on the cut surfaces. Histopathologically, endothelial cells were observed in the cyst wall, the disease being diagnosed as splenic lymphangioma.
Compilation of cases of splenic lymphangioma reported in Japan revealed that this disease was predominant in females of 30-50 years of age, and that palpable abdominal swelling and splenic swelling were most common symptoms i.e., 67%. No specific changes were noted in blood biochemical examinations, but 3 cases manifested symptoms suggestive of hyperfunction of the spleen such as thrombocytopenia. Splenectomy had been performed in all cases. A mean weight of excised spleens was 1090 g, and the number of cysts was multiple except for one case. Calcification of the spleen was recorded in 22%.

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A 75-year-old postmenopausal woman with virilization, as demonstrated by temporal baldness, hirsuism, and mustache is presented.
Laboratory data on admission revealed polycythemia, markedly elevated plasma testosterone level (29 ng/ml), and normal 17-KS value. Abdominal echography and CT-scan revealed a solid mass of the left ovary. The presumptive diagnosis was a virilizing ovarian tumor. The patient underwent bilateral salpingo-oophorectomy. The resected left ovary measured 3×3×2 cm, and weighted 13 grams.
Microscopically, both ovaries were composed of hilar cells. Postoperatively, the plasma testosterone level was recovered to the normal level. The patient has remained asymptomatic.
Hilus cell tumors of the ovary are very rare. In Japan, only 4 cases have been reported on the litrature, and besides, bilateral hilus cell tumors are so rare that the case is the 3rd in the world.

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An abdominal tumor in a 45-year-old woman could be excised, and the tumor was found to be arising in the mesocolon and similar to a papillary adenocarcinoma histologically. Because of an underlying possibility of peritoneal dissemination from some primary cancers of other organ, through investigation of the gastrointestinal tract and exploratory laparotomy including right salpingo-oophorectomy were performed but failed to discover any abnormal lesions. Thus the tumor was supposed to be a papillary carcinoma of peritoneum origin. Elevation in the level of serum CA-125 was a useful marker for early detection of repeatedly relapsed tumors. Adjuvant chemotherapy including Epirubicin, Cisplatin and Cyclophosphamide seemed effective in this case and the patient survives for more than 6 years without any clinical evidence of recurrent tumor.

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Remnant sciatic artery or its aneurysm is extremely rare because the sciatic artery is the main blood pathway in the initial term of embryonal period, and only 14 cases have been reported in Japan. This time we experienced a case of remnant sciatic artery aneurysm presented with right sciatica-like symptom.
A 71-year-old woman complaining of right lower leg pain at exercise was referred to our clinic because of a right gluteal aneurysm diagnosed by CT at her near practitioner. Digital substraction arteriogram showed that an enlarged right internal iliac artery passed posteriorly across the right hip and down the posterior aspect of the femur to the popliteal artery. With a diagnosis of persistent sciatic artery a bypass grafting between external iliac artery and popliteal artery using ringed EPTFE graft was performed. As the blood flow of the popliteal artery was supplied by persistent sciatic artery, the proximal and distal sides of the aneurysm were ligated. The aneurysm remained opened. Pathological examinaiton indicated an atherosclerotic aneurysm.

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A 68-year-old woman was suffering from long-lasting (about 3 months) pain and coldness of the right lower leg after bicycle riding, which were relieved in one or two hours of resting. Angiography revealed a nodular shadow defect 4 cm in length on the right popliteal artery. CT showed cystic lesions in the popliteal region which involved the artery. At operation, the cystic adventitial disease of the popliteal artery connected to a popliteal cyst was removed and end to end anastomosis was performed for the reconstruction of the artery.
Cystic adventitial disease of the popliteal artery is a rare entity with about 200 cases reported in the world. The etiology of the disease remains unclear. The authors collected and analyzed 38 cases reported in Japan and came to the hypothesis that a popliteal cyst is one of the causes of the cystic adventitial disease of the popliteal artery. Until the etiology is well elucidated, one must excise the cystic lesion en-bloc with the popliteal artery and a possibility of the connection between the cystic lesion and adjacent knee joint should be carefully examined during the operation and also by pathological studies.

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