One hundred and thirty-eight cases undergoing hepatecotmy experienced at our department were subjected to a study of statistical analysis of postoperative infectious complications. The infectious complications occurred in 71 (51.4%) of 138 patients, which were analysed for quantitative values of nine factors and their subcategories. Significantly high frequencies were noted in groups having the following factors: 1) malignant liver disease (p<0.05); 2) extended resection (p<0.05); 3) reconstruction of bilirary tract (p<0.01); 4) intraoperative bleeding in a large quantity (p<0.01); and longer operation time (p<0.01). No significant difference was noted but some tendency increasing the frequency was observed in groups of the following factors; 6) a use of Microtaze; and 7) existence of dead space. On the other hand, 8) preoperative use of antibiotics might decrease the incidense of postoperative complications, and 9) coexistence of liver cirrhosis had no relation. The above 9 factors were treated with the procedure of Hayashi's quantification theory, and high risk group for occurrence of infectious complications after hepatectomy could be selected. In these high risk groups careful perioperative management is necessary, thereby achieves prevention of infectious complications after hepatectomy.

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The usefulness of transesophageal echocardiography (TEE) in establishing the diagnosis of thoracic aortic aneurysm was evaluated. Thirteen patients were referred for this study. Seven had dissecting aortic aneurysms and 6 did true ones. TEE could detect an intimal flap in all 7 patients, an entry in 6 of 7, and a reentry in 2 of 7. TEE was superior to any other imaging methods such as CT, MRI and DSA in visualizing an intimal flap, entry and reentry.
Mural thrombus, calcification, atheroma ulcer and aortic regurgitation were visualized by TEE.
A fuzzy echo in the false (pseudo) lumen was demonstrated in 6 of 7 cases. A flow velocity in the entry was measured, pressure gradient being calculated. Seven cases of dissecting aortic aneurysm were classified according to a fuzzy echo and pressure gradient in the entry.
We believe that TEE is a non-invasive useful imaging method in decision-making of the diagnosis and treatment of thoracic aortic aneurysms including dissecting type.

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In a recent one decade between 1981 and 1990 we have experienced thirty cases of idiopathic infantile gastric volvulus at our clinic. On admission these patients were comprised of 7 neonates, 22 infants, and one schoolchild. Vomiting was the common symptom in 29 cases (96%). Of these 29 cases, at the onset of vomiting, twenty-one cases were in the neonatal period, 7 in the infantile period (less than six months of age), and one was of school age. Most of these patients had developed vomiting starting in the neonatal period and the early infantile period. abdominal distention was observed in twelve cases. Twenty-three cases (76%), were associated with gastroesophageal reflux (GER).
Their treatment was started with preservative therapy, and 24 out of 30 patients could gain a cure. However, in the remaining 6 patients, who were complicated by GER, preservative therapy failed to yield any improvement in the severity of volvulus and GER, surgery leading to curative treatment.
It is believed that idiopathic gastric volvulus is often complicated by GER in the neonatal and early infantile periods. In the diagnosis and treatment of infantile gastric volvulus, we should keep this in mind.

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In 228 patients comprising of 11 with benign gastric disease, 200 with primary carcinoma, and 17 with recurred carcinoma, lymphocyte subsets in peripheral blood, PHA induced lymphoblastogenesis, and serum IAP (immunosuppressive acidic protein) level were investigated preoperatively.
The lymphocyte subsets were analyzed with monoclonal antibodies (OKT3, OKIa1, OKT4, Leu3, Leu8, OKT8, Leu2, Leu15, Leu7, Leu11, IL-2R), and the percentage and number of each subset were compared for clinicopathological factors such as stage, H, P, ps, and n.
With single color flow cytometry, there was no significant difference in the percentage of each lymphocyte subset among the clinicopathological factors. Lymphocyte counts, however, significantly decreased in the patients with advanced cancer compared with those with relative early cancer. With two color flow cytometry for functional T cell analysis, the percentages of cytotoxic T cells and helper T cells in patients with gastric cancer were lower than those in benign disease patients, and the percentage of suppressor inducer T cell in those with cancer was higher, without significant difference. Lowered PHA induced lymphoblastogenesis was noted in an advanced stage compared to that in an early stage. On the contrary serum IAP was higher in an advanced stage, a negative correlation between PHA induced lymphoblastogenesis and serum IAP being demonstrated.

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We studied the relationships between gross and histologic findings in S₁ and S₂ lesions in 41 cases of S₁, S₂ and S₃ advanced gastric cancers. In 27 of the cases, peritoneal lavage cytology was also studied. The serosal surface findings were classified as follows: furs-like, tendon-like, fine-granulated, gross-granulated, nodulated, inflammatory cicatric and whitish cicatric. The classification needed care, especially to distinguish the furs-like surface from the whitish cicatric one. Regarding ps (+) rate, fine-granulated (100%), gross-granulated (87.5%) and furs-like (80%) surfaces had significantly increased in whitish cicatric (0%) one. And these were more useful than S₁ (12.5%) and S₂ (78.8%), to extrapolate gastric wall invasion. Gross classification of serosal surface was not so relevant to histopathological classification, but could roughly estimate infiltration and stroma. In comparison to grossgranulated surface, fine-granulated, tendon-like, furs-like and inflammatory cicatric one were significantly predominant in INFγ, and fine-granulated and tendon-like surface also in scirrhous. These were available to estime infiltrating growth of serosa. Borrmann 4 cases and free cancer cells, by the peritoneal lavage cytology, were found in furs-like, tendon-like and fine-granulated cases.

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Whitehead's procedure is a useful radical operation for hemorroids. Recently, it is, however, not so common in Japan because of postoperative untoward complications such as anal stricture and mucosal prolaps.
We made a divice to this Whitehead's procedure so as to which was usually attempted to low type anal atresia. Especially, we would emphasise the importance of decreasing anastmosal tension with creating sliding skin graft around the anus, and fixation of the rectum to the anal sphincter muscular band.
Our modified procedure was attempted 9 cases of several kinds of hemorrhoids, and no anal stricture and mucosal prolaps were encountered for over one year after surgery. In addition, postoperative anal pain was extremely weak in all patients.

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In 65 patients undergoing hepatectomy for hepatocellular carcinoma (HCC) after transcatheter arterial embolization (TAE), the value of preoperative TAE and effective factors possibly influencing upon prognosis were studied. The best advantage of preoperative lipiodol-TAE for HCC was a development on the CT findings of tiny daughter nodules. Whereas, side effects of preoperative TAE were significant decreases of serum albumin and choline-esterase values and a significant prolongation of prothrombin time. Fourteen factors which might affect the prognosis in this treatment were selected and statistically analyzed. Significant difference was noted in 3 factors, namely, the existence of histological portal tumor thrombus, operative curability, and bleeding volume during surgery. From the Claster multi-parametric analysis, more than 50% of survival rate after operation depended upon the following factors; absence of histological portal tumor thrombus, solitary or multiple tumors with diameters of less than 30 mm in a single lobe of the liver, and the age of under 65 years old.

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Fourteen patients with idiopathic thrombocytopenic purpura (ITP) treated with splenectomy in a recent 12 year period from January 1977 to October 1989 have been studied to clarify the effectiveness of splenectomy and the time when its longterm results can be judged. The patients comprised of 5 males and 9 females, with an average age of 39 years old. After splenectomy the numbers of platelets increased in all cases, and in 93% of them the number became more than 50, 000/mm³. The maximum levels were seen in two weeks after splenectomy. Eight out of the fourteen cases (57%) kept their increased platelet levels even more than one month after splenectomy. On the other hand, in six cases the numbers of platelets decreased within a month so that they needed some additive treatments besides surgery. Preoperative injections of γ-globulin were effective in 83% of the patients. In our experiences, a recurrence of thrombocytopenia caused by an accessory spleen was observed, which could be improved by reoperation.
These results suggest that splenectomy is effective in about 60% of ITP patients, and we can predict the effect of splenectomy within a month after surgery. However, because of a possible recurrence of thrombocytopenia due to an accessory spleen we have to follow the ITP patients for long time after splenectomy.

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During the past 15 years, 36 patients were hospitalized for arterial obstructive disease of the arm other than that arising from aortitis syndrome. Seventeen arterial reconstructions (two being repeat operations) in 15 patients with subclavian artery obstruction were performed with grafts of the great saphenous vein. Here, we review indications for surgery and surgical methods. When the obstruction was due to arteriosclerosis obliterans, we treated surgically only those patients (n=10) in whom the so-called subclavian steal syndrome caused brain ischemia. Axillo-axillary artery bypass was the operation of first choice because it causes less operative stress than the other usual methods, and because we found that the patency rate of the grafts was good. When as was the case for five patients with brachial plexus injury, revascularization was necessary, and we planned the operative method according to the region of obstruction. That is, when the obstruction was at the origin of subclavian arteries, carotid-subclavian artery bypass was performed. When the obstruction was at the distal part, vein transplantation was carried out. All grafts were patent and results were satisfactory in all five patients.

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The effect of hydration for preventing from renal dysfunction after major angiographies was studied in patients with arteriosclerosis obliterance, especially those associated with impaired renal function. Five protocols of hydration (On condition that 1000 ml of fluid transfusion were administrated on the day of angiography in all cases, group A: 500 ml/day, for more than 3 days before angiography, group B: no other fluid transfusion, group C: 500 ml/day, for each 5 days before and after angiography, group D: 500 ml/day, for 5 days after angiography, group E: Lipo-prostaglandin E₁, 10μg/body, was injected just before aortography fromthe catheter in suprarenal aorta)were compaired with each other to establish the most effective hydration. Compairing creatinine clearance (Ccr) on the 7th day after angiography with that of preangiography, Ccr values were reduced by 3.7±18.3%, 10.9±23.9% and 15.0±16.3% in group A, B and D respectively while Ccrs were improved by 8.0±11.2%, and 4.6±11.4% in Group C, and E.
Transfusion of 500 ml extracellular fluid/day for each 5 days before and after angiography or administration of Lipo-prostaglandin E₁ just before angiography should be performed for preexisting renal insufficient patients (Ccr<50 ml/min) of ASO. If both of them are performed, the incidence of acute renal dysfunction after major angiography will decrease remarkably.

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It is well known that the progress in the treatments of tuberculosis has led to a remarkable decrease in its occurence, but the disease has never been eradicated. Intracranial tuberculoma is still encountered although the incidence is small. We experienced 2 such cases. The first case arrived in 1964, and the second case in 1982 when we completely forgotten the first experience. The first patient came to our hospital for depression at age 43, was admitted for the loss of consciousness at age 49, and refferd to the neurosurgical department. The second patient was admitted at the age of 49 with local, involvuntary, clonic spasm and numbness as cheif complaint. In the first case, tuberculoma was identified after operation performed under a preoperative diagnosis of meningioma. In second case, it was diagnosed as tuberculoma just before operation. We report the two cases. If a patient complaints of spasm, we should not forgett a tuberculoma as a possibility not only young patients but also in older patients with a history of tuberculosis. The best treatment is the combination of surgical resection of the tumor with steroid and antituberculosis drugs, helped by CT and MRI.

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We experienced a case of primary plasmocytoma arising in the thyroid. A 76-year-old female visited our hospital complaining of a tumor on the right side of the neck. The tumor locating at the posterior part of the right lobe of thyroid was 4.0×3.5 cm in size, with smooth surface, elastic hard, and well-defined border. It was mobable but slightly restricted. Ultrasonography revealed a tumor picture of irregular margin, internal unequal, and slightly unclear border. Scintigram showed a cold nodule at ^99mTc and accumulated picture at ²⁰¹Tl. A possible malignancy could not be denied, right thyroid lobectomy, paratracheal and parathyroidal lymph nodes dissection being done on October 1, 1990. The excised tumor was 3.8×3.5×2.4 cm in size without any infiltration into the adjacent organs. It could be easily removed. Histopathologic examination showed that the tumor consisted of plasma-like cells, leading to a diagnosis of plasmocytoma. Chronic thyroiditis could be seen in the surrounding thyroid tissues.
Immunohistochemical tests resulted in positive against IgG and lambda chain. No abnormalities were noted in bone marrow puncture, general bone X-P, and bone scintigram. No urinary Bence-Jones protein nor blood M protein were determined. Only 12 cases of primary plasmocytoma arising in the thyroid, including this case, can be collected from the literature in this country.

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We report a case of thyroid cancer with primary hyperparathyroidism (1°-PHP) which was found accidentally during the examination of thyroid cancer. A 56-year-old woman was pointed out to have an anterior cervical mass, and was admitted to our department under a diagnosis of thyroid cancer. The patient complained of no subjective symptoms. Preoperative examination for thyroid cancer revealed an increased serum calcium (11.2 mg/dl). Increased serum parathyroid hormone level and urinary output of calcium were also observed, leading to a diagnosis of 10-PTH. Total thyroidctomy with bilateral modified neck dissection and extirpation of right lower parathyroid gland were performed. Histopathological diagnosis was bilateral papillary thyroid cancer and parathyroid adenoma. Serum calcium level decreased soon after operation.
It is usual that thyroid tumors are found during the examination or operation of 10-PHP. On the contrary, we must take care of serum calcium level not be overlook probable 1°-PHP when we treat the thyroid tumors.

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A 48-year-old man complaining of cough and hemosialemesis was diagnosed to have an endotracheal metastatic lesion from giant mediastinal tumor by minute exploration. Immediately, radiation therapy was started but failed in diminishing the tumor size. The patient developed multimetastasis in the lung and died 2 months later. Autopsy revealed a thyroid tumor and mediastinal tumor continuing to the thyroid one. Histopathologically, the thyroid tumor was papillary carcinoma versus the mediastinal tumor, involving undifferentiated carcinoma in the majority and partially, papillary, adenosquamous cell, and mucoepidermoid carcinomas concomitantly. The part of papillary carcinoma in the mediastinal tumor was thyroglobulin stain-positive, in that it can be considered in this case that thyroid papillary carcinoma transformed into squamous cell, mucoepidermoid, and undifferentiated carcinomas.

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A case of follicular adenocarcinoma of the thyroid presenting with stenosis of the cervical esophagus, is reported.
The patient was a 72-year-old woman with the chief complaint of dysphagia. Esophagogram and endoscopy revealed just the stricture of the cervical esophagus, but the histological diagnosis was not obtained. Thyroid scintigraphy and ultrasonography indicated a thyroid cancer invading the esophagus. At operation, a lymph node of 3.0×1.5×1.7 cm in diameter was found to invade the Lt. side of the esophagus and larynx and cause esophageal stricture. Frozen section detected follicular structure in the lymphnode. Total thyroidecotmy, laryngectomy and cervical esophagectomy with bilateral modified radical neck dissection and tracheocutaneostomy were performed. The transplantation of the jejunal free graft between the pharynx and intrathoracic esophagus was done for esophageal substitute. Postoperatively, histological evaluation established the diagnosis of follicular adenocarcinoma of the thyroid.
The cervical esophagus is rarely invaded by the thyroid cancer. In this case the primary lesion in the thyroid was small, and it was first diagnosed when a metastasized lymph node invaded the esophagus. Favorable Prognosis can be expected on the basis of complete resection of all lesions in a case of well differentiated thyroid carcinoma, if it invaded the surrounding organs. The patients is free from recurrence for 1 year and 6 months after operation.

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A recent case of malignant fibrous histiocytoma arised in the male breast is reported with a review of the literaure. A 31-year-old man, who underwent resection for a tumor in the right breast 10 years before, again found a slightly enlarging, painless tumor 3×2 cm in size in the inside (D) region of the right breast. Excisional biopsy revealed grayish white tumor with a clear margin. Histologicaly, the tumor was composed of spindle shaped cells of a storiform pattern, which was diagnosed as malignant fibrous histiocytoma of the breast. Simple mastectomy was added to this patient. The tumor invaded the fat tissues. No postoperative adjuvant chemotherapy was given. The patient made an uneventful recovery and is now free of disease one year and two months the patient after surgery.

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A 59-year-old man with inflammatory abdominal aortic aneurysm was successfully operated upon. The patient was referred to our hospital because of abdominal pain. CT scan showed a dilated abdominal aorta which had a remarkable mantle consisted of the soft tissues. On operation, the aneurysm showed shiny, fibrous and white surface tightly adhering to the jejunum and mesenterium. Conventional surgical procedure with an artificial graft replacement was performed. The pathological examination of the aortic wall revealed atherosclerosis with marked fibrous thicking and inflammatory cellular infiltration. The lymphocytes and plasma cells in the media and adventitia were predominantly found. Because of remarkable adhesion of the aneurysm to the surrounding tissues, the freeing of the aneurysm was minimized to prevent its resultant surgical invasion, that would have the priority in surgical procedures.

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A 20-year-old female with a left atrial tumor which was found by echocardiography developed cardiac tamponade and transferred to our hospital for urgent operation. Complete surgical resection of the tumor with 3/4 the left atrial wall, 1/2 atrial septum and 1/2 right atrial wall was performed because its macroscopic findings were malignant. Therefore extended reconstruction was made by using Dacron fabric sheet including reanastomosis of all pulmonary veins. Pathological diagnosis of this tumor was myxosarcoma. Neither cardiac dysfunction nor severe arrhythmia was observed in postoperative course. She completely returned to work two month later, but had recurrence with lung metastasis four month later and died eleven month after operation in spite of chemotherapy. The prognosis of cardiac malignant tumors is poor, because some clinical manifestations first call for the treatment. Like this case, operative procedure can provide complete rehabilitation, even if it is temporary, in that we would call attention to the significance of this surgical procedure.

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A 69-year-old male, who had retended for more than 33 years due to injury of the lumbar spine, complained of dyspnea and was diagnosed as tension pneumothorax associated with giant bulla. Eight years before, the patient had undergone thoracic drainage for 2 weeks under a diagnosis of spontaneous pneumothorax at a near practitioner. A giant bulla, which was found on a chest X-ray film and chest CT, was occupying the entire left lung field on admission. Thoracic drainage was started immediately after admission, but failed to relieve dyspnea. Further inserting a drain into the bulla could provide symptomatic remission, but could not dilate the affected lung. According to Naclerio-Langer method, surgical treatments including resection of bulla were performed. Excepting bedsore, postoperative course was uneventful. Arterial blood gas analysis revealed that PaO₂ and PaCO₂ were improved to 60 mmHg and 43 from preoperative 52 and 37, respectively. The patient was discharged on 40th day after surgery.

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In 5 patients with left N3 lung cancer, we performed mediansternotomy followed by mediastinal lymphadenectomy after standard pulmonary resection.
Preoperative chemotherapy was performed for 3 patients, but partial response was obtained in only one patient who had small cell carcinoma. Upper lobectomy was performed for 3 patients and pneumonectomy for 2. R3 β lymphadenectomy was performed for all but one who recieved R3 γ lymphadenectomy (pathologically N3 γ).
There were several postoperative complications such as left recurrence nerve palsy, tachycardia, polyuria, and ARDS subsequent to aspiration pneumonia. Only polyuria was thought to be caused by stress due to the surgical method. One operative death due to ARDS occurred.
Postoperatively, chemotherapy was given to 2 patients and a combination of chemotherapy with radiation therapy, to 2 patients. Two patients are alive 6 months and 12 months after surgery respectively, but the latter had right supraclavicular lymph node metastasis and carcinomotous pericarditis. Two patients died 14 and 15 months after surgery respectively. In both patients, mediastinal lymph nodes were first detected as the site of recurrent carcinoma.
These findings seem to indicate that extended lymphadenectomy can improve overall survival in left N3 lung cancers, if the treatment of regional recurrence as well as chemotherapy for remote metastases can be appropriately performed.

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We describe a case of congenital diaphragmatic hernia, in which multiple defects were found in the right diaphragm and through 3 defects of them the liver protruded. The case was a 42-year-old male who was referred to our department for minute examination for an abnormal shadow on a chest X-ray film and was admitted. Chest X-ray film revealed polyp-like tumor shadow protruding upward. CT, MRI, and scintigraphy of the liver failed to offer any definite diagnosis. Exploratory thoracotomy was carried out. Operative findings included 3 protrusions of the liver covered with parietal pleura in the central tendon of the diaphragm, and a large number of several mm-sized defects around the main defects. Only a case of congenital diaphragmatic hernia, in which multiple diaphragmatic defects associated with several liver protrusions has been reported up to now as possible as we can review.

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Among diaphragmatic hernias, relatively rare Morgagni hernia in a patient is reported, together with a review of the literature. A 71-year-old woman complained of nausea and vomiting. Chest rentogenogram, gastrointestinal series, barium enema and chest CT showed the righ-sided Morgagni hernia prolapsed with the stomach and transverse colon. Herniorrhapy was performed by abdominal approach. Two hundred and fifty-three cases of Morgagni hernia were reported in the Japanese literature until 1989, comprising of 64 males and 179 females except for 10 cases with unknown sexuality. The disease was common in an age group under 6 or over 51 years old, and was predominant in females (males versus females: 1 vs. 2 and more). With respect to hernia contents, the great omentum was common and followed by the transverse colon, small intestine and liver. Only 14 cases, with had hernia contents of the stomach and transverse colon like this case, have been reported and the majority of the cases involved older females. Chest CT is useful for qualitative diagnosis when the hernia content is the great omentum. Transabdominal approach is recommended when the preoperative diagnosis can be made as Morgagni hernia.

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A 75-year-old woman was found to have a polypoid lesion in the stomach at a mass screening of the upper G. I. tract, and was admitted to our hospital. Double contrast study of the stomach showed a pedunculated polyp at the lesser curvature of the mid-corpus. Endoscopically the pedunculated polyp covered with normal mucosa was widely eroded on the head. Partial gastrectomy was performed under a diagnosis of gastric cancer suggested by the endoscopic biopsy. The resected stomach revealed a pedunculated tumor, 4.0×3.3×3.0 cm, with a central ulceration at the mid-corpus. Histologically the tumor was composed of small, uniform tumor cells arranged in solid nests. Grimelius' stain showed abundant argyrophil granules in the cytoplasm of the tumor cells. There were neither regional lymph nodes involvement nor distant metastases. Plasma serotonin, secretion, and urinary 5-HIAA levels were within normal limits after gastrectomy. Peristalsis, weight pulling on a polypoid protuberance, and ptosis of the gastric wall with aging are considered to be the causes resulting in pedicle formation. We also reviewed the literature on pedunculated gastric carcinoids in Japan and foreign countries.

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Combination chemotherapy with etoposide, epirubicin (adriamycin) and cisplatin (EAP chemotherapy) successfully provided a surgical resectability for advanced gastric cancer of Borrmann type 3 in a 19-year-old female. In the patient angiography revealed that the splenic and superior mesentric veins were obstructed by the cancer tumor, which was evaluated inoperable. EAP chemotherapy was started under intravenous hyperalimentation. Upper gastrointestinal series 2 weeks after chemotherapy revealed a remarkable decrease in the tumor size (decreasing rate: 94%). Elevated tumor markers on admission also decreased, when the tumor was judged as operable. On the 4th week after chemotherapy, total gastrectomy and splenectomy were performed. Macroscopically, it was of P₀H₀S₂N₃₍₊₎ in stage IV. Histopathologically it was a signet ring cell carcinoma. The efficacy of EAP chemotherapy was evaluated as grade 2 according to the histologic efficacy criteria. After additional postoperative EAP chemotherapy, the patient was discharged.

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We seldom find reports describing progressive systemic sclerosis (PSS) associated with a malignant tumor in the domestic litarature. Here we present a recent case of PSS associated with gastric cancer, with some discussion from a review of the literature.
A 63-year-old woman attending our hospital for suppurative wound on both index fingures was pointed out to have anemia. Upper gastrointestinal series revealed a IIc-like advanced gastric cancer ranging from the body of the stomach to the antrum. Raynaud's symptom was present and the patient was also diagnosed as PSS. A subtotal gastrectomy was performed as to preserve some portion of the stomach, as she had an erosive lesion in the lower portion of the esophagus. Reconstruction was done by jejuno-interposition method. Only six cases or PSS associated with gastric cancer have so far been reported in Japan, including this case. It is interesting indeed, that five of the six cases had poorly differetiated adenocarcinoma, and of Borrmann type IV. Circulatory disturbance due to arterial narrowing and esophageal lesions are common in patients with PSS. Therefore, consideration for reconstructive method should be taken for the prevention of complications such as anastomotic insufficiency and esophageal stenosis due to regurgitation esophagitis.

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We experienced a case of gastric carcinoid accompanied with multicentric early gastric cancer in a 74-year-old woman. The resected specimen consisted of three histopathological components: cancer of Yamada IV typed polypoid (tub 1, depth m) measuring 2.8×2×1 cm in size at the anterior wall of the antrum; wide spread IIc lesion (tub 1tub 2, depth m) measuring 7×4.5 cm in size at the anterior and posterior wall of the gastric body including gastric angle; and small sized carcinoid lesion measuring 1.5×0.7 cm in size proliferating at submucosal lesion at the lesser curvature and posterior wall of the antrum. In the light of literature in Japan, 36 clinical cases of gastric carcinoid accompanied with gastric cancer including our case have been reported. Among these 36 cases, a case of gastric carcinoid with multicentric gastric cancer is only ours.
Recently atrophic gastritis is thought to be a factor inducing either multicentric gastric cancer or gastric carcinoid, and similary the surrounding mucosa of our resected specimen showed an atrophic change. From the above mentioned, in the elderly, we think that the numbers of the case with complicated lesions both of gastric cancer and gastric carcinoid based on the atrophic gastritis are increasing.

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We have experienced 3 cases of benign intestinal lesion in an 18-year-old male with an ulcerating Meckel's diverticulum and associated massive melena, in a 65-year-old female with jejunal AVM, and in a 44-year-old female with jejunal hemangioma. All three cases were got well after operation and followed up.
From these experiences the following facts could be drawn out: (1) In dealing with acute or chronic gastrointestinal bleeding of unknown etiology, vascular lesion on the small intestine should be considered as a possible case; (2) Immediate abdominal angiography may be useful for diagnostic and therapeutic aids in intestinal diseases associating with massive malena; (3) When the sourse of bleeding is difficult to identify macroscopically during operation, it is recommendable and even essential to perform intraoperative endoscopy while irrigating the international lumen; (4) In order to minimize the intestinal resection, operation should be most desirably performed while the lesion in bleeding if clinical conditions permit; (5) When the location of the lesion can not be found during surgery, a resection longer than angiographically estimated segment of the intestine is advisable to minimize the bleeding lesion left unresected.
Diagnosis and treatment in the 3 cases are delineated with some comments about relevant literature.

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Intrauterine intussusception is one of the causes of congenital intestinal atresia. But apple peel type is exceedingly rate. A case of apple peel type intestinal atresia with meconium peritonitis due to perforation of intrauterine intussusception is reported.
A new born female baby, birth weight 2345 g, with remarkable abdominal distension was admitted to our department. On lapalotomy, fibrinous adhesions were present. Atretic site was located at about 45 cm just distal to Treitz' ligament. Distal end was ruptured and a polypoid prominence was found in the ruptured area. The length of the distal ileum was about 30 cm to the ileum end, including 5 cm in length of apple peel type. Dilated proximal end and 5 cm of distal ileum (apple peel type were resected and end to back anastmosis was performed. Although residual small intestine was about 70 cm in length distal to Treitz' ligament, she is getting near normal growth.

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Mesenteric cysts are relatively rare. Here we report a case of mesenteric lymphangioma presenting with symptoms of acute abdomen.
An 18-year-old male was admitted with sudden epigastralgia. On physical examination his abdomen was stony hard with severe muscular guarding. Laboratory study showed leukocytosis and abdominal plain film revealed niveau. Ultrasonography showed a distended intestine and ascites. The patient was diagnosed as strangulation ileus and underwent emergent operation. At laparotomy massive bloody ascites and torsion and gangrene of small intestine were found. Furthermore a fist-sized tumor was seen in the mesentery of small bowel 1.5 m distant from the ligament of Treitz. The tumor with gangrenous intestine was resected. Histopathological examination revealed dilated numerous cavities covered with epithelioid cells, leading to the diagnosis of cavernous lymphangioma.

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We report a case of jejunogastric intussusception developed 15 years after gastrectomy, together with cumulated cases of postlaparotomy intussusception in adults and children from the domestic literature in which their differential pictures of the disease between both age groups are reviewed.
A 59-year-old male visited our hospital complaining of upper abdominal pain and hematemesis, who had undergone gastrectomy with BII procedure for gastric ulcer 15 years before. As a result of UGI and GIF, it was diagnosed as intussusception of the efferent crus of jejunum into the residual stomach, laparotomy being performed. During surgery it was found that the efferent crus by about 30 cm retrogressively prolapsed into the stomach to form a triple cyclindrical intussusception. A mild strangulation could be reduced by manipulation. Post-operative course was uneventful.
In the past 4 decades, postlaparotomy intussusception has been reported in 266 adults and 53 children in this country. The manifestations can be predominantly seen after gastrectomy in the former, while after operation for retroperitoneal tumor in the latter. A difference lies in that the intussusceptions in children occurred in an extremely early period of around 5 days after surgery, most of which could be manually reduced, but those in adults developed in around 10 days after surgery, which commonly demanded excision of the intestine.

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An artificial tooth swallowed in error caused appendiceal abscess 2 years later. This case is described with reference to the literature. A 47-year-old man was presented with lumbago and fever, as well as right lower abdominal pain, which had been disregarded. Physical examination revealed knock pain over the right lumber region, tenderness and peritoneal signs in the right lower quadrant. The body temperature was 38.2°C with a leukocyte count of 12500. Microscopic hematuria was not recognized. Abdominal radiography revealed a radiopaque foreign body, 10×8 mm in size, in the right lower quadrant. Enhanced CT disclosed a uniform low density area in the right ileopsoas muscle with a high density spot in the retroperitoneal cavity. An emergency operation was performed under a diagnosis of appendiceal abscess due to a foreign body. An appendix showing inflammatory swollen was extensively adhesive to the retroperitoneum and ileopsoas muscle.
There was an egg-sized abscess in the ileopsoas muscle. Appendectomy was completed with drains left in the peritoneal cavity and abscess. The excised appendix contained the artificial tooth which had been swallowed 2 years before. This experience suggested the importance of a careful study on anamnesis and abdominal plain films for diagnosing appendicitis due to foreign bodies before operation.

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Primary carcinoma of the vermiform appendix is a rare disease, and its preoperative diagnosis is difficult. We suspected this condition preoperatively in 2 cases and demonstrated its concurrence with a gallbladder carcinoma in one of them.
Case 1 was a 49-year-old female with the chief complaint of right lower abdominal pain. A mass was palpated in this region, and barium enema studies revealed a filling defect in the cecum. Ultrasound examination of the abdomen showed a cystic pattern, and the CT image of the mass was cold in the center and well enhanced in the margins. From these findings, appendicular tumor was suspected, and ileocecectomy (R2) was performed. Pathologic examinations indicated a diagnosis of mucinous cystadenocarcinoma.
Case 2 was an 83-year-old female. A gallbladder tumor was detected during close evaluation of unexplained fever. Barium enema studies for staging of this tumor showed a filling defect in the cecum. suggesting a concurrence of appendicular tumor. Cholecystectomy and right colectomy (R2) were carried out. Pathologic diagnosis was well differentiated adenocarcinoma for the gallbladder tumor and mucinous cystadenocarcinoma for the appendicular tumor.

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We experienced a case of pneumatosis cystoides coli in a 51-year-old female complaining of repeated abdominal pain, who had no particular disease and family histories. Barium enema examination revealed many smooth-surfaced polypoid lesions at splenic flexure area of the left colon. Abdominal CT and endoscopic examination of the colon showed multiple polypoid lesions. The patient was diagnosed as pneumatosis cystoides intestinalis (PCI) and was successfully treated with hyperbaric (2.5 ATA, 60 min. per day) oxygenation (OHP) therapy for 8 days. The lesions completely disappeared, and no recurrence has been found for 4 years thereafter. PCI is a relatively rare disease and a variety of the therapies has been reported. Hyperbaric oxygenation therapy used in this case is excellent in that it can offer a reliable therapeutic effect with shorter period.

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A 38-year-old man was admitted to our hospital with the chief complaint of mucobloody stool on May 30, 1990. The patient had been diagnosed as ulcerative colitis, left sided type, 21 years before. Barium enema and colonoscopy revealed a slightly elevated rectal tumor, 3 cm distant from the anal verge, where stricture of the lumen was seen. Rectal biopsy showed adenocarcinoma, and rectal amputation was performed. On histological examination of the specimen, well-moderately differentiated adenocarcinoma was infiltrated through the wall with nodal involvement, and dysplasia was found in the surrounding mucosa. Furthermore, rectal carcinoid (2 mm in diameter) was found at 8 cm oral to the carcinoma. In the treatment of long standing ulcerative colitis, it is important to pay careful attention for possible association of carcinoid as well as carcinoma.

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A case of biliary strongyloidiasis is reported with a review of the literature.
A 42-year-old female who had lived in Okinawa prefecture until the age of 17 was admitted under the diagnosis of acute cholecystitis with abscess formation. She underwent cholecystectomy, external choledochostomy using a T-tube and drainage procedure of the abscess. Diagnosis of biliary stronglyloidiasis was made by detection of eggs, female imagines and rhabditiform larvae of Stronglyoides stercoralis in the bile collected through the T-tube. Although the bile duct stricture with irregular mucosal surface remained over the 40th postoperative day, administration of thiabendzole resulted in remarkable improvement of the stricture with normalized serum level of alkaline phosphatase. She was found to be a carrier of ATL by serological examination, not presenting as overt ATL. This case is very interesting in that bile duct stricture was found at the site where heterotopic metabiosis was found; vermicidal effect could be directly observed by bile examination; and the patient was a carrier of ATL.

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We experienced a case of pancreatic serous cystadenoma found in an inpatient treated for indefinite complaints. The patient was a 66-year-old woman with the chief complaint of numbness of her both hands without any digestive symptoms. Abdominal ultrasonography and CT showed a tumor picture, ERP did an exclusive picture of the pancreatic duct, and a slightly hypervascular pattern by angiography. The patient was diagnosed as having a cystadenocarcinoma of the pancreatic body and operation was carried out. The tumor disclosed 4×4.5 cm in size, clearly demarcated picture, cleavage surface with many microcysts containing serosity like substance. Histopathologically, it was pancreatic serous cystadenoma with no finding of malignancy.

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We reported a case involving a giant serous cystadeoma of the pancreas that was difficult to diagnose preoperatively due to its specific radiological findings. The patient was a 75-year-old woman suffering from abdominal mass and discomfort. Abnormal gas in mass shadow, showing air-fluid level, was observed in an abdominal plain X-ray film. CT scan revealed a cystic mass having a mixture of low and high density areas. Endoscope and upper gastrointestinal series did not reveal any fistulation to the tumor. From the diagnosis of cystic tumor of the pancreatic head, we performed pancreatoduodenectomy. The tumor weighed 1035 g, and consisted of numerous small cysts and a large cyst. This large cyst showed pin-point fistulation in thirds of the duodenum. This fistula explained the abnormal gas on preoperative plain X-P. Histologically the tumor was diagnosed as serous cystadenoma of the pancreas. Such tumors are relatively rare and the preoperative diagnosis can be made by US, CT, and angiography. However, in tumors growing as large as penetrating to the intestine like this case, it is not always easy to diagnose preoperatively because of its specific findings.

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We report a resected case of mucoepidermoid carcinoma of the pancreas which is very rare. A 48-year-old woman complaining of epigastralgia and back pain was admitted to our hospital. Abdominal echography, abdominal computed tomography and celiac angiography revealed a small-hen-egg-sized, relatively well demarcated hypovascular mass in the pancreatic body. ERCP revealed a localized stenosis of the main pancreatic duct in pancreatic body. We suspected of pancreatic cancer originated from the pancreatic body, and performed total pancreatectomy and resection of portal vein. From pathological exploration this case was diagnosed as having a mucoepidermoid carcinoma. Mucoepidermoid carcinoma of the pancreas is very rare and only two cases have been reported in Japan. The lesion of this case shows pancreatic substantial spreading and hematogenous metastasis (liver metastasis), poor prognosis being inferred. Histologic feature of this case is characterized by its differentiation pattern to different two cell types, namely, squamous cell and mucous producing cell. This is very suggestive in an investigation of the histological genesis of pancreatic cancer.

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A case of torsion of the wandering spleen is reported.
A 13-year-old girl visited our hospital complaining of abdominal pain, diarrhea and vomiting. Ultrasonography and CT scan revealed a solid tumor in the left lower abdomen. Blood examination revealed slight anemia, inflammatory changes and elevated CA125 value (465 IU/ml).
Operation was performed on the fourth hospital day with a diagnosis of torsion of a ovarian tumor. at laparotomy the tumor was comfirmed with a wondering spleen, which adhered to the greater omentum and sigmoid mesocolon. No supporting ligament of the spleen could be found, and the pedicle was twisted clockwise by about 360°. The spleen was considered to be in the condition of hemorrhagic infarction, and splenectomy was performed. The resected spleen was 19×10×5.5 cm in size and weighted 500 g. Postoperative course was uneventful and the patient was discharged from the hospital at 13th postoperative day.
Sixty-four cases of wandering spleen, including this case, have been reported in Japan. Thirty-eight (59%) out of the 64 cases necessitated surgical treatment for complicated torsion of the pedicle.

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Pheochromocytoma developed in two members (a brother and sister) of a family inheriting von Hipple-Lindau disease is reported. The brother had multiple pheochromocytoma associated with reversible renal artery stenosis. His sister had malignant non-functioning pheochromocytoma with tumor embolus of the portal vein. She died of bleeding from gastric varix.
The significance of regular screening including ultrasonography and computed tomography of the abdomen must be emphasized for family members of von Hippel-Lindau disease, because early detection of tumor is indispensable to improve the curability of malignant pheochromocytoma. In this sister' case we should reflect for delayed diagnosis of pheochromocytoma because of lacking screening.

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Recently, widespread use of ultrasonic examination during the perinatal period has increased an opportunity to detect asymptomatic or small cysts in newborns, and it has also become known that these cysts have a natural tendency to disappear. From this, we can not reach any consensus of its correct treatment. We experienced 5 cases of neonatal ovarian cysts, of which 2 were diagnosed before birth. In 4 of the 5 cases, natural course was observed; in 2 cases cysts started to reduce within 1 week and disappeared within 1 month after birth; and in the other 2 cases, no reduction was observed and the lesions were excised on the 20th and 40th day of life, respectively. The remaining one case was found to have a large cyst on the 28th day after birth and operated on. From these findings, we think proper to treat the cysts according to the following guidelines: when cysts with a diameter of less than 4 cm are detected before birth or during an early postnatal period, the natural course should initially be observed. If a tendency for regression is not observed in 1-2 weeks, or if the cyst is larger than 4 cm, it should be treated by aspiration of the contents. While thus preventing torsion, it is though best to observe course of such ovarian cysts.

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We describe a case of synovial sarcoma arising in the abdominal wall, which is the second in this country, and only 17 cases have been reported in the overseas literature.
A 20-year-old man presented with a large, left upper quadrant mass of two years period. There was no history of weight loss or any symptoms. Physical examination was unremarkable with the exception of a palpable, flat, slightly tender mass, 13 cm in diameter, occupying the left upper quadrant. Routine laboratory tests revealed no abnormality. Chest radiograph was normal. Abdomen radiograph showed right-medial dislocation of the small intestine by a large soft tissue mass, which had faint calcification within itself. Abdominal angiograph did not reveal any feeding artery to the mass. Ultrasonograph showed a cystic structure of the mass with some debris and small cysts. Abdominal computed tomography revealed an intramural cyst-like tumor protruding the peritoneal cavity with calcification. Apossible malignancy could not be denied, and aparotomy was performed. It was found that a soft tissue mass was arising between the transversus abdominis and internal oblique muscles and partly invading the rectus abdominis muscle. The mass was covered with peritoneum and there was no invasion into the intraperitoneal organs. The tumor was resected en bloc with the peritoneum, transversalis fascia, transversus and internal oblique muscle. Histological examination revealed the typical features of synovial sarcoma which was the mixture of two cell types including epithelioid and fibrosarcoma-like structure.

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