On this study limiting to gastrointestinal tract surgery, the relationships between postoperative infections and each factor such as age, type of disease, operative stress, prophylactic antibiotics, serum total protein value, serum albumin value and Iymphocyte counts were examined.
1) The outbreak incidence of postoperative infections in patients with cancer was higher than in those without cancer.
2) There was no significant difference between incidence of infections and kind of prophylactic antibiotics used.
3) With an aging, the incidence of infections increased in patients with benign diseases such as gastroduodenal ulcer and cholelithiais.
4) With an increase in the degree of oparative stress, a higher incidence of infections was observed in patients with malignant diseases such as gastric and colorectal cancers.
5) Postoperative infectious patients showed lowered serum total protein and albumin values before surgery. In addition, these values remarkably decreased in aged patients postoperatively, and their recoveries were delayed.
6) Lowered lymphocyte counts from preoperative period were often found in aged or cancer patients. A significant decrease in this parameter was observed in postoperative infectious patients.

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In the non-cardiac surgery of patients with cardiac lesions careful monitoring and treatment of cardiac function in a perioperative period is the single most important factor, affecting the surgical outcomes. In this study the preoperative cardiac function, treatment and postoperative complications were studied in 24 patients with upper gastrointestinal cancer associating with either ischemic heart disease or valvular disease, to evaluate the surgical indication and to attempt the prediction of post operative complications. In patients with ischemic heart disease, there was no positive correlation between such preoperative finding as chest pain at rest, ECG abnormality at load, or ejection fraction, and the occurrence of postoperative complications. In patients with valvular disease, NYHA classification and ejection fraction were not correlated with the complications. Although it was not possible to predict the occurrence of postoperative complications in this study, perioperative careful evaluation and therapy of cardiac function would enable surgery for cure even in those cancer patients with cardiac lesions.

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The preoperative diagnosis of localization and number of pathological parathyroid glands in very important for surgions. In this paper we describe the diagnostic results of MRI comparing to those of CT, Ultrasonogram and T1-Tc subtraction scintigram.
The materials were 65 parathyroid glands of 19 cases (3 cases of parathyroid adenoma and 16 cases of hyperplasia following chronic renal failure) operated on at the department from May 1989 to December 1990.
Diagnostic sensitivity rate of MRI, CT, T1-Tc and Ultrasonogram were 43.1 (%), 50.8, 52.3 and 55.4, respectively. On the otherhand false negative rates were 0 (%), 2.9, 5.56 and 18.2, respectively. It is concluded that, MRI can not provide excellent results for localizing diagnosis of the pathological parathyroid and general diagnosis based on various imaging methods is recommended.

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The relation of the endocrinological factors to estrogen receptor (ER) status is still unclear. In this paper the effect of hypophyseal gonadotropins on ER status was studied in 40 postmenopausal patients with breast cancer. The plasma luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels before and after luteinizing hormone-releasing hormone (LH-RH) stimulation at an i. v. dose of 100μg were measured time-depedently. ER in the tumor was measured by dextran-coated charcoal methods. Twenty-three out of the 40 patients were ER positive, 17 being negative. The basal levels of LH and FSH were 98.7±45.5 mIU/ml and 105.5±51.2 mIU/ml in ER positive patients, and were 91.4±31.4 mIU/ml and 87.5±32.6 mIU/ml in ER negatives, respectively. There was no significant difference in basal LH and FSH between ER-positive and negative patients. No ER-relating time-dependent pattern in LH and FSH levels was found. Responses after LH-RH stimulation were not different between two groups. In conclusion, hypophyseal gonadotropin levels and its reserves as host factors were not related with ER status in the postmenopausal patients with breast cancer.

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Forty-two anatomical bypass operations (AB) land 48 extraanatomical bypass operations (EAB) performed for aorto-iliac occlusive disease during the last 6 years were compared for long-term results.
(1) Mean age of the patients at the operation were 62.2 years in group AB and 74.1 in group EAB (p<0.001). (2) Patients with Stage III and/or IV after Fontaine represented 19% and 52.1% respectively (p<0.005). (3) Within the first postoperative year, cumulative graft patency in group AB was better than that in group EAB (p<0.05). On the 5th year, however, no difference of the patency was found between the 2 groups (AB: 92.7%, EAB: 80.9%). (4) cumulative 5-year survival rate after surgery were 80.7% in group AB and 38.6% in the other (p<0.05). Graft patency exceeded survival rate at every interval. (5) All thrombosed grafts of 28 femorofemoral bypasses were not externally supported.
It is concluded that for patients older than 70 years of age, extraanatomical bypass operation using externally supported Dacron graft can be performed actively to improve quality of life.

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In 281 patients with pectus excavatum undergoing sternal turnover and overlap (STO-O) or sterno-costal elevation (SCE) in a 3-year period (January 1988 to December 1990), its surgical invasion and postoperative complications were studied on. Of the 281 patients, 37 with the mean age of 23.9 underwent STO-O, and 244 with the mean age of 7.4 did SCE. Combined operation was performed in 12 patients, and reoperation after an operation at other hospital was done in 5. Ten patients received blood transfusion during and after surgery, 57 patients were ventilated mechanically for 2.6 hours following surgery, but none of them showed paradoxical movement of the chest wall. Minor complications occurred in 8% (23) of them; pneumothorax in 5, wound trouble without infection in 12, and wound infection in 6. All wounds were closed by 2.6 months on an average. No patients developed pneumonia or any other severe complication. The mean hospital stay after operation was 8.0 days. In the surgical repair of pectus excavatum, SCE was selected for younger while STO-O for older patients. Both repair procedures could provide minimal surgical invasion and no severe postoperative complications.

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Forty-eight aged patients over 75 years old operated on for primary lung cancer, which represented 12.6% of all resected patients for the same disease, were retrospectively studied for surgical outcomes. There were 37 males and 11 females. The eldest patients was 86 years old and 14 patients were over 80. Twenty-five patients were in stage I, 8 in stage II, 11 in stage IIIA, 3 in stage IIIB, and one in stage IV. Histologically 48 resected specimens included each 17 adenocarcinomas and squamous cell carcinomas and 14 other cell types. Pneumonectomy was carried out in 3, lobectomy in 41, segmentectomy in 1, and partial resection of the lung in 3 cases. The cumulative 5 year-survival rate was 20.7% as a whole, showing no histological difference. It is considered that poor surgical outcomes might be lie in frequent occurrence of postoperative complications, and predominance of cases (as much as 31) of relative non-curative resection. Pulmonary functional studies were not helpful in predicting postoperative pulmonary complications. Preoperative general evaluation including intellectual mental function, performance status, and positiveness in daily life, as well as pulmonary function are necessary in aged patients. The elderly patients in performance status 2 and 3 had a tendency to increase complications than those in P.S. 0 and 1. Five-year survival rate of 20.6% in relative non-curative resection cases was not significantly differ from that (16.7%) in absolute non-curative resection cases. Pulmonaly resection with R2 should be performed ever in the aged patients as a rule.

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The changes in the intestinal microflora were examined in patients with advanced carcinoma of the large intestine, and healthy subjects were surved as control. Comparing to control, patients group revealed high fecal moisture and fecal pH, but showed low levels in various organic acids except succinic acid. Only succinic acid was detected in high level and frequency. No significant difference in the number and occupation rate of Gram-positive bacteria participating in the endogenous endotoxin production was noted between both groups. The pattern of fecal microflora in patients group was similar to that in control. However, the aerobic microorganisms including Staphylococcus were highly found in patients group. These results suggested that the colonic enviornment of the patients with large bowel carcinoma was in aerobic state in comparison with healthy subjects.

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Sixteen patients diagnosed as mucinous adenocarcinoma out of 511 patients with colorectal cancer were clinicopathologically studied. the male-to-female ratio was virtually 4:12, there being a female dominance. Thirteen patients were older than 60 years of age. Each half of the tumors were located in the right and left colon respectively. Nine patients showed Borrmann 2 in the gross type. Peritoneal dissemination was observed in 2 patients, but no liver metastasis. Incidence of lymph node metastasis or wall invasion deeper than pm was 71.4% or 92.8%, respectively. All patients underwent tumor resections and 11 (78.6%) patients underwent curative resection. Six patients died of recurrence in intraperitoneal region within 2 years after operation. The 5-year survival rate in all patients was as relatively low as 50%, except 3 deaths due to other diseases and one of unknown prognosis.
In conclusion mucinous carcinomas of the colon and rectum were predominantly in an advanced stage and commonly developed periotoneal recurrence including local recurrence. Thus, the prevention of local and peritoneal recurrence is a key point in the treatment of mucinous adenocarcinomas of the colon and rectum.

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Sixty-four patients with metachronous colorectal cancer who underwent resection at the Cancer Institute Hospital in the past 46 years were reviewed clinically and therapeutically.
The mean age at the times of first colorectal resection was 51.5 years, which was younger than that of single colorectal carcinomas. Forty two patients were men, and 22 were women. Metachronous carcinomas were predominantly located in the right colon relatively to single carcinomas. A family history of colorectal carcinoma was noted for eleven of the 64 patients (17.2% percent). adenomatous polyps were present in 29 of the 64 patients (45.0 persent). Seventeen of the 64 patients (26.6 persent) had histories of malignancies in other organs. We regard these features as the risk factors of metachronous colorectal carcinoma.
The average interval between first and second carcinomas was 95 months and 54.7% of the patients developed a second carcinoma more than five years after the first operation. A long-term follow up would be maudatory.
In several cases, resection area was restricted at the second operation because of the vascular ligation at the first operation. So we believe it is important to preserve main vessels in the patients who have such risk factors if possible.

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In 127 patients who underwent gastrectomy for gastric cancer at the department in a 5-year period (1982-1986) and were followed up by ultrasonography or CT for more than 2 years, postgastrectomy gallstone disease was investigated. The prevalance of gallstone was found in 16 patients (12.9%). Male-to-female ratio was 12:4. The duration from gastric resection to the detection of gallstone disease was within one year in 3 cases; one to 2 years in 3 cases; 2 to 3 years in 5 cases; 4 to 5 years in 2 cases; and over 5 years in 3 cases. The methods of the gastric resection included distal gastrectomy in 5 cases, total gastrectomy in 10 cases, and proxymal gastrectomy in one case. The reconstruction at the gastrectomy were made with Billroth II in 5 cases, esophagojejunostomy with Roux-en-Y in 10 cases, and esophago-gastrostomy in one case. All of them underwent lymphadenectomy at the initial operation. the gallstones were located in the gallbladder alone in 13 cases, common bile duct alone in 2 cases, and both in one case. The incidence of common bile duct stone were considered to be high. Postgastrectomy gallstone disease were predominant in males, and was more frequently found in total gastrectomy-patients with a significant difference. They occupied 23.2% of the total gastrectomy cases. Prophylactic cholecystectomy may be recommended for total gastrectomy patients.

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In a recent one decade (1981-1990) 14 cases of intraoperative biliary injury were experienced at the department, and 6 of them had the injuries at another hospitals. Almost all cases were operated on for the causative disease of gall stones, including common bile duct stones. Intraoperative biliary injury occurred in a frequency of 1.04% in the department. Most common cause of the injury was severe inflammatory adhesion in 9 cases, followed by operative technique in 3, and bile duct anomaly in 2. The site of injury involved the common bile duct in 5 cases, common hepatic duct in 4, junction of biliary tracts in 2, accessory hepato-biliary duct in 2 and cystic duct in one. The repair of the injury was performed intraoperatively in 8 cases, and post-operatively in 6 cases. In respect of operative methods of repair, anastomic stenosis developed in 2 (66.7%) of 3 cases undergoing end-to-end anastomosis of the bile duct and in 2 (28.6%) of 7 cases undergoing choledochojejunostomy. Judging from our experience with the period of presence of stricture, grade of inflammation and method of anastomosis, it was suggested that choledochojejunostomy was superior to end-to-end anastomosis of bile duct.

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This paper describes a case of parathyroid adenoma which was difficult to differentiate from hyperplasia preand intraoperatively due the coexistence of a cyst in another parathyroid gland.
A 21-year-old female was admitted to the hospital because of close examination for hypertension. High levels in serum calcium and parathormone and low level in serum phosphate were revealed, and the patient was diagnosed as primary hyperparathyroidism. Before surgery two enlarged parathyroid glands (right upper and left lower) were delineated by ultrasonography and parathyroid scintigraphy. It was not known whether hyperparathyroidism was caused by double adenomas or hyperplasia, but surgery was performed. During surgery enlarged right upper and left lower glands and a normal left upper gland were observed. The right lower gland was not found in the corresponding area. Without confirming adenoma or hyperplasia, surgery was completed after removing the two enlarged glands. Postoperative histological examination revealed parathyroid adenoma in the right upper gland and a cyst in the left lower gland.

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A 68-year-old female visited the hospital because of a left breast tumor and nipple discharge. Palpation of the breast revealed a tumor 5×4 cm in size in the upper outer quadrant of the left breast with a lot of purulent discharge from the left nipple. Mammography showed a mass with ill-defined margins and ultrasonography showed an irregular, heterogeneous low echoic area of about 4 cm in diameter in the upper outer quadrant of the left breast. Thermography showed that a mass was surrounded with irregular vascular hyperthermia in the left breast. A lactic cytological examination was false positive. Lactic CEA value was as low as 104 ng/ml. These finding indicates a breast cancer, and biopsy was performed. From pathological exploration the tumor was diagnosed as non-invasive apocrine carcinoma of the breast. Radical mastectomy was performed in addition.
The apocrine carcinoma of the breast is pathologically classified into invasive carcinoma, a special type in the general rules for he breast cancer study, and non-invasive apocrine carcinoma of the breast pathologically can not exist in the rules. Here we describe a very rare case which can not but be diagnosed as non-invasive apocrine carcinoma of the breast, which reveals non-invasive ductal carcinoma with intensive apocrine metaplasia, with reference to the literature.

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A case of thoracic pseudolymphoma diagnosed after operation is described.
A 65-year-old male was pointed out on abnormal shadow on chest X-P for medical checkup. The tumor of thorax was excised. Based on the examination of the excised specimen, it was diagnosed as pseudolymphoma. There has been no recurrence of tumor, as of one year after the operation.
It has been reported that pseudolympoma occurs in various organs such as the lung, skin, and salivary gland. No report of pseudolymphoma arising in the chest wall can be seen in the literature. Histologically it mimics extranodular lymphoma, but infiltrated lymphocytes are of low grade malignancy. The prognosis is good. However, we have difficulties in preoperative differential diagnosis. In view of this fact, it is better to select surgical excision first, however, we can select conservative therapy if the tumor is small and no clinical manifestations develop. At any rats strict follow-up should not be neglected.

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In this paper two cases that IVH catheter fragments in the right side circulatory system were transcutaneously removed are reported. Case 1 is an 18-year-old man who was hospitalized for traumatic intracerebral hemorrhage. He pulled out a IVH catheter indwelling in the right subclavian vein by himself, when the catheter was broken and the fragment of it entered through the supra vena cava into right side circulatory system. Case 2 is a 47-year-old woman hospitalizing for cerebral infarction. She also pulled out the catheter by herself. In both cases, catheter fragments were transcutaneously removed by using a basket catheter via the right femoral vein.
It is probable that IVH catheter frequently entered into right side circulatory system in daily medical care. In Japan, only 51 cases that IVH catheter fragments in the right side circulatory system were transcutaneously removed have been reported. The most common mechanism for loss of the catheter was iatrogenic (14 cases), followed by spontaneous break by patients (8 cases). In the all 51 cases the mean age was 47 years and the male-to-female ratio was 2:1, versus 58 years and 5:1 in spontaneous break cases. It can be said that spontaneous break commonly occurred in aged men. In Japan snare loop catheters via the right femoral vein are most commonly used for removals of fragments.

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While mitroflow pericardial valve is a homograft for valve replacement having salient characteristic features, clinical evidence indicates that primary tissue failure may occur early after its use in occasional cases and the durability of the prosthesis per se is not reliably long. In a case to be presented here, primary tissue failure occurred with the prosthetic valve in a 40-year-old female, necessitating re-valve replacement 2 years and 5 months after the initial operation. In this unusual instance, a thread got entangled with the stent, gave rise to a tear of the prosthesis, thus causing mitral regurgitation to supervene. Strange to say, the thread was certainly not the one we used and derived from quite an unknown source. However, there is no denying the fact that no meticulous care was taken during and after surgery upon this patient and this calls for grave reflection.

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A 33-year-old woman was emergently admitted to the ICU because of severe hemoptysis. There was a history of chronic sinusitis. Observed by bronchofiberscopic examination. Chest X-ray film showed dextrocardia and infiltration shadow in both lower lung fields. Consecutively, bronchogram, bronchial arteriogram, pulmonary perfusion scanning and inhalation scanning examination revealed that the right lower lobe was ectatic and dysfunctional. Surgical treatment was performed at this area. The cilia of this bronchial mucous membrane showed missing and irregular arrengement of the microtubles and a defect of dynein arma by electron microscopic examination. This patient was diagnosed as Kartagener's syndrome, which is now considered as a type of primary ciliary dyskinesia.

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A 67-year-old female was referred to the hospital because of an esophageal tumor. On detailed questioning, she has no serious complaint except anemia. There was neither dysphagia nor hematemesis or melena. Fluoloscopic examination of the esophagus disclosed a large polypid lesion, measuring grossly 7 cm×3 cm in size, in the upper esophagus. On esophagoscopy, the lesion was described as submucosal bluish soft mass. Computed tomography showed a well defined mass with calcific densities in the upper esophagus, but contrast medium did not enhance the mass. MRI also showed a solid tumor in the upper mediastinum. Doppler echogram could not detect massive blood flow in the mass.
Surgical treatment was performed. The esophagus was approached with open-door method and thoracic esophagus was resected. Histological diagnosis was cavernous hemanginoma.
Hemangioma of the esophagus usually demands some treatment, because it can cause hemorrhage irrespective of its size. Fifty-nine cases of esophageal hemangioma have been reported in Japan. Of these, 25 cases had tumors over 4 cm in diameter and underwent surgical treatment. Other patients with smaller tumor less than 3 cm in diameter received either non-invasive surgery or conservative treatment.

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Primary leiomyosarcoma of the esophagus is a rare disease. It is hardly diagnosed preoperatively, because it is a submucosal tumor. Recent experience with 2 cases of leiomyosarcoma of the esophagus, in which we were able to perform radical operation under the definite diagnosis resulting from preoperative examinations, is reported.
Case 1 is an 81-year-old woman complaining of dysphagia. An esophagogram revealed a tumor of 6 cm in longer diameter in Ei region. Esophagoscopy showed a protruded lesion lobulating like a polyp, locating at 30 cm from the incisor line. As as result of biopsy, it was diagnosed as leiomyosarcoma. Intrathoracic anastomosis of the esophagus and remnant stomach under left thoracoabdominal incision was performed. The excised tumor was 3.5×6.0cm in size, presenting as protruded type with lobulation. Histopathologically it was leiomyosarcoma of the esophagus with a metastasis in the left cardiac lymph node.
Case 2 was a 61-year-old man complaining of dysphagia and hematemesis. An esophagogram revealed a tumor 8 cm in longer diameter in the EiC region, presenting as tumor type with ulceration. Esophagoscopy showed a protruded lesion with a high of about 2.5 cm locating at 40 cm from the incisor line, which was accompanied with deep ulcer on the anal side. As a result of biopsy, it was found a leiomyosarcoma. Jejunal interposition between the esophagus and remnant stomach under left thoracoabdominal incision was performed. Excised specimen was 4.5×6.0×4.0 cm in size. Histopathologically it was a leiomyosarcoma.

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An 81-year-old woman was admitted to the hospital because of nousea and sever dysphagia. X-ray examination of the esophagus revealed sclerosis of the wall and a narrowing from the middle intrathoraic esophagus (Im) to the intrathoraic esophagus (Ei). CT scan of the chest showed thickening of the wall of the esophagus. Gastro-duodenoscopy could not inserted because of sever stenosis of the esophagus. One month later cervical lymph nodes were palpated and excisional biopsy specimen showed diffuse medium sized type malignant lymphoma classified by LSG classification. Stenosis of the esophagus was improved by chemotherapy, but two months later recurrence was suspected. Endoscopy showed a protruding lesion with ulceration, and biopsy specimen revealed malignant lymphoma similarly.
Malignant lymphomas of the gastrointestinal organs are sometimes found in the stomach and small intestine, but rarely in the esophagus. This paper describes a very rare case of malignant lymphoma of the esophagus.

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A case of so-called carcinosarcoma of the esophagus in a 76-year-old man is reported. The tumor with ulceration (Borrman III type) was grossly found at Im-portion of the esophagus but not a polypoid lesion. Subtotal esophagectomy was performed surgically. With hematoxylin-eosin staining, the resected specimen revealed poorly differentiated squamous cell carcinoma with pleomorphic cell sarcomatous stroma. To examine the features of sarcomatous lesion, the tumor was stained immunohistochemically with antibodies against keratin (high molecular and low molecular type), epithelial membrane antigen (EMA), α₁-antichymotryspin (α₁-ACT) and vimentin respectively. The sarcomatous cells of this tumor showed the results of negative staining for keratin, positive staining for EMA, vimentin and α₁-ACT, indicating characters of both epithelial and mesenchymal origin. The present case was considered so-called carcinosarcoma (squamous cell carcinoma with pleomorphic cell stroma) which derived from epithelial origin, and it was immunohistochemically suggested that cancer cells obtained a mesenchymal character at the level of intermediate filaments.

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A 57-year-old man visited the hospital because of discomfort of the epigastric region in 1982. An upper GI series and endoscopic examination revealed a polyp in the lesser curvature of the gastric antrum, but a directivision gastric biopsy was negative. In 1989 discomfort of the epigastric region appeared again. An upper GI series and endoscopic examination revealed an early gastric cancer other than the polyp. Distal gastrectomy was performed. The polyp was a cyst of the stomach and in pathological examination of the resected stomach, cysts were distributed diffusely and ATP was partially seen in a mucosal layer.
Multiple diffuse submucosal cysts have been discussed in an association with malignant neoplasms. Recently attention is called to the successful diagnosis of the disease by endoscopic ultrasonography. This case presented here with a brief discussion had developed a gastric cancer and ATP 7 years after suspicion of this diseases.

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A case of gastric cancer metastasized to the breast and skin in a 37-year-old female is reported.
Two months after total gastrectomy for a poorly differentiated adenocarcinoma of the stomach, a subcutaneous nodule appeared on the left anterior chest wall. Multiple nodules appeared on the anterior chest wall including the right breast and abdominal wall, successively. Though total mastectomy was carried out because of marked enlargement of the right breast mass, she died four weeks after the operation. The histological examination of the resected mass revealed metastasis of the gastric cancer.
From the findings that no metastatic lesion was detected in the liver nor the lung, multiple lymph nodes were swollen around the abdominal aorta, cancer cells were observed in the lymphatic vessel of the resected breast, and skin metastasis appeared only on the anterior chest and abdominal wall, lymphatic metastatic route was speculated in this case.
As the metastases to the breast and skin are the extensive progress of the gastric cancer, chemotherapy should be selected firstly, and then a plan of the later treatment should be decided in consideration of the effect of the chemotherapy.

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During 26 years and 6 months (from January 1965 to June 1991), eleven patients with malignant myogenic of stomach origin were experienced. Malignant myogenic tumors represented 0.93 per cent of 1297 malignant primary tumors of the stomach in the same period, and 50 per cent of 24 myogenic tumor of the stomach. Five-year survival rate was 75 per cent. These findings were almost comparable to those reported in many other papers. Six out of 11 cases presented with an abnormal tumor, so this would be a distinctive complaint in malignant myogenic tumor of stomach origin. In this study, the convalescence was parallel to the histological malignancy (mitosis rate). Postoperative deaths due to early recurrence commonly occurred in cases with a tumor diameter of 10 cm or more. A great contribution of tumor diameter to the prognosis was considered. Regardless of tumor size and invasion depth, lymph node metastasis rarely developed. Many of the lymph node metastases were in the first field, and each one in the second and third field was noted.

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Four operated cases of ischemic lesion of the small intestine are described. The average age was 73-year-old. There were each two males and females. All patients presented with intestinal obstruction with panperitonitis. Two patients had hypertension and cerebral infarction and one had diabetes as underlying disease. It took about 38 hours on average from the onset of symptoms to the operation. The lesions were found in the jejunum to ileum in 2 cases and in the ileum in another 2 cases.
Operative procedure included extended small intestianl resection in 2 cases; partial resection of the ileum including necrotic lesions in one and explorately laparotomy in the remaining one because no obvious necrotic lesion appeared. Histologically, 2 cases had ischemic necrosis of the small intestine caused by thrombosis of the superior mesenteric vein and the other case causing by sclerosis of the superior mesenteric artery. Two out of the 4 cases died.
It was supposed that high risk group in this disease might be aged people more than 80 years old with venous complications, such as hypertension, cerebral infarction and diabetes mellitus, and probable causes of this disease might be postoperative reobstruction and recurrent necrosis. Administration of ulinastatin was effective in the prevention of postoperative acute circulating injury, liver and renal dysfunction, and DIC.

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Seven cases of intestinal tuberculosis diagnosed after laparotomy were analyzed. All cases were accompanied by perforation or obstruction of the small intestine. Four of them had active pulmonary tuberculosis. All cases were recieving antituberculosis therapy from preoperative period. Histological examination of the intestine revealed a tuberculose nodule in only two cases. Detection of the causative bacteria could be achieved also in only one case. On the other hand, his tological examination of the mesenteric lymph node offered available information in 5 cases. In the diagnosis of small intestinal tuberculosis, we should be careful not to enmeshed in histological findings of the lesion which might lead to misdiagnosis. Global consideration based on histological findings of the mesenteric lymph node, intraoperative findings and reactivity to the antibiotics would make a correct diangosis. For the intestinal tubercdulosis medical therapy is the first choice and surgical therapy should be done to the patients associating with some complications such as perforation and obstruction.

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Apple core sign in barium enema is assumed to be characteristic of advanced ulcer-forming colon cancer invading the subserosa with a size of more than 3 cm in diameter. We experienced two cases of sigmoid colon diverticulitis with apple core sign on preoperative barium enema. In both cases colonoscope could not pass through the stenosis. Although biopsies taken from that region showed no malignancy, possibility of carcinoma could not be excluded and laparotomy was performed. Case 1 was a 64-year-old man. Barium enema revealed an apple core sign with diverticula at the sigmoid colon. Sigmoidectomy was performed. Histological diagnosis was inflammatory stenosis resulted from diverticulitis, and there was no malignant findings. Case 2 was a 47-year-old man. Left hemicolectomy was performed because of an apple core sign at the sigmoid colon and diverticular in the descending and sigmoid colon demonstrated on the barium enema. Histological examination of the resected colon revealed diverticulitis. These two cases suggest that colon diverticulitis can demonstrate an apple core sign due to the fibrous hyperplasia of the serosa caused by chronic inflammation in the adjacent plural diverticula.

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Tow cases of vesicosigmoidal fistula due to the diverticulitis of the sigmoid colon are reported. The first case is a 55-year-old man. He was admitted to the hospital because of cloudy urine. Barium enema showed diverticulosis of the sigmoid colon and a fistula from the sigmoid colon to urinary bladder. Primary resection of the sigmoid colon and wedge resection of the bladder were performed. The second case is a 74-year-old woman. She was admitted because of fecaluria. Cystoscopy, cystography and colonoscopy could reveal no colonovesical fistula, but barium enema showed diverticulosis of the entire colon and a fistula from the sigmoid colon to urinary bladder. Left hemicolectomy, wedge resection of bladder, drainage of retroperitoneal abscess due to diverticulitis of the desending colon, and cholecystectomy were carried out. Post operative were unevenful in both cases.
One-hundred and ten cases of colonovesical fistula due to diverticulitis of the sigmoid colon reported in the Japanese litarature are also reviewed.

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This paper reports on patient with Gardner's syndrome. A 51-year-old man was admitted to the hospital because of diarrhea and bloody stool. Barium enema and colonofiberscopy disclosed multiple polyps and two advanced cancers of the transverse colon and rectum. Gastrofiberscopy revealed fundic gland polyposis. Soft tissue tumor of the left shoulder was excised and diagnosed as lipoma histologically. Osteomas in the mandibula and the sacrum were also discovered. A family history of polyposis coli was denied. A proctocolectomy and J ileal pouch anal anastomosis were performed by the invagination method using PCEEA. The resected intestine showed approximitry 2500 polyps, diffusely scattered over the intestinal mucosa from the cecum to the rectum. Histologically, the polyps showed the findings of tubular, tubulovillous and villous adenoma, and the cancers of the transverse colon and the rectum were reported to show the well differentiated adenocarcinomas, infiltrated to subserosa and proper muscle layer, respectively. The loop ileostomy was closed in 8 months after surgery. Postoperative defecation was good.

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A case of undifferentiated carcinoma (endocrine cell carcinoma) of the colon is reported.
A 43-year-old man visited the hospital because of bloody stool. A descending colon cancer was detected by barium enema and endoscopy. Left hemicolectomy with lymph nodes dissection (R₃) was performed. The resected tumor with the size of 2.8×2.5×1.3 cm showed Yamada's III type polyp with deep ulceration which shaped a flower bud. Histopathological investigation revealed undifferentiated carcinoma (endocrine cell carcinoma), because Grimelius' stain showed argyrophil granules but PAS stain did not show mucin production. Histological diagnosis was pm, n₂ (+), P₀, H₀ M (-), ly₃ v₀ and stage IV. Although immunochemotherapy was attempted to, the patient died of liver and paraaortic lymph nodes metastases on 129th postoperative day. The prognosis of this disease is very poor resulting from rapidly developing metastasis and invasion in an early phase of the disease.

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Among primary malignant lymphomas of the intestine, those arising in the large intestine are relatively rare. Here a giant malignant lymphoma of the ascending colon, of which resected tumor weighed 1.5 kg is described.
A 57-year-old man was admitted to the hospital because of massive melena. Barium enema, ultrasonography, computed tomography and angiography, revealed a tumor of ileocecal region. On laparotomy, a giant tumor in the ascending colon and swelling of regional lymph nodes were seen, and right hemicolectomy with dissection of regional lymph nodes was carried out on suspicion of malignant tumor. Pathologically, it was non-Hodgkin's lymphoma, diffuse large cell type according to lymphoma study group classification and was positive for cell surface markers anti B-cell antigen. Four courses of CHOP chemotherapy were performed, and the patient is followed on an ambulant basis. There has been no recurrence, for 10 months after the operation.

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A case of hepatic abscess which was possibly caused by penetrated gastric ulcer is described.
A 68-year-old man was seen at the hospital because of upper abdominal pain and fever. Abdominal ultrasonography and abdominal CT examination showed the cavity of a hepatic abscess with gas and thickening of the gastoric wall. On gastro-fiber examination a deep ulcer (A2-stage) at the gastric angle was recognized. The lesion was diagnosed as hepatic abscess due to penetration of the gastric ulcer. Against the hepatic abscess, the percutaneous transhepatic abscess drainage (PTAD) was performed. Streptococcus salivarium was detected on the bacterial culture examination of the abscess discharge. No communication of the abscess cavity into biliary tract or alimentary tract was found on the hepatic abscess cavitography.
It is considered that the hepatic abscess in this case might be caused by penetrated gastric ulcer, because (1) there was a penetrated gastric ulcer; (2) there was a gas in the cavity of the abscess; and (3) Streptococcus salivarius was isolated from culture of abscess discharge. This case is very uncommon, in that there has been no case report of liver abscess of such mechanism of occurrence.

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A 58-year-old man visited another hospital because of general fatigue and fever. He has never been abroad. CT revealed an area of hypoabsorption in the right lobe of the liver. Under a diagnosis of liver abscess antibiotic regimen was started, but no remission could be attained. The patient was referred to the department. On admission an increased leucocytes and impairment of the liver function were noted. CT revealed a huge hypoabsorbent area in the right lobe of the liver. Drainaging of the abscess and administration of antibiotics were started, however, no remission was obtained. As strong positive response to serum amebic antibody was observed, a diagnosis of amebic liver abscess was made. Antiamebic agents were administered. Unfortunately, severe jaundice and ARDS developed and the patient died of liver and respiratory failure on the 39th hospital day. These findings indicated that the patient had fluminating amebic liver abscess who might infected through some route in Japan. From this experience, we would emphasize the importance of early diagnosis and efficient prevention of complications. Some notes on relevant literature are also presented.

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An operated case of Mirizzi syndrome presenting with stenosis extending to the intrahepatic ducts is reported.
A 63-year-old man presented with a sudden onset of jaundice and fever. Laboratory data revealed a total bilirubin of 12.1 mg/dl. Ultrasonography and CT revealed gallstones within the gallbladder and marked wall thickness of the neck and solid mass continuous with the gallbladder in the liver. ERCP demonstrated the obstruction of the cystic duct and a 5 cm smooth stricture of the common hepatic duct. Administration of antibiotics improved his complaints and total bilirubin decreased to 2.2 mg/dl, however, ERCP performed again after the improvement showed a progression of the stricture and additionally stenosis of the intrahepatic ducts.
At surgery, the gallbladder neck and porta hepatis formed a mass. However, intraoperative ultrasonography revealed a gallstone impacted in the neck of the gallbladder and no invasive lesions in the liver, accordingly presumptive intraoperative diagnosis of Mirizzi syndrome was made. Cholecystectomy with partial hepatectomy including the gallbladder bed, and resection of the biliary tract were performed. The postoperative course was uneventful. Pathologic histology revealed chronic cholecystitis and marked fibrosis of the biliary tract and no malignant change was found.

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Torsion of the gallbladder in children is a very rare condition. Only 23 children have been reported in the Japanese literature. Because of its rarity, the correct diagnosis is very difficult to make preoperatively. Only four cases were accurately diagnosed in the series of 23 cases. We experienced such a case in a 3-year-old girl who was diagnosed as having acute perforative appendicitis before surgery. On laparotomy, the enlarged and necrotic gallbladder was revealed. It was a floating gallbladder, which twisted clockwise by 180° around the cystic duct. Cholcystectomy was performed and the patient was discharged from the hospital in a well improved condition on the 9th hospital day.

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A very rare case of multiple advanced carcinoma of the gallbladder in the different histological types was experienced.
The patient was a 69-year-old man. Ultrasonography revealed a 3×3×cm elevated lesion and wall thickness. The lesion was diagnosed as carcinoma of the gallbladder. Intravenous cholangiography showed no visualization of the gallbladder. Possible coexistence of some lesion in the neck was suspected, but no lesion was found by US and CT. Simple cholecystectomy was made.
Gross examination of the excised specimen showed carcinomas of 4×4×4 cm in the fundus, and 1×1×cm in the neck. No abnormal findings were not found between two lesions. Microscopic examination revealed adenosquamous cell carcinoma in the fundes and adenocarcinoma in the neck. Both lesions were advanced carcinoma in the same level (ss).
There was no intramucosal invasion nor vessel invasion between two lesions. Preoperative examination, operative findings, and examination of excised specimen, there were no direct invasion, lymphnode metastasis, nor distant metastasis. So we could not find no biological differentiation between two lesions.

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A 29-year-old woman, who had been treated for acute pancreatitis on an ambulant basis, developed pancreatic lithiasis and cysts within a short period of observation. Afterward she was admitted to the hospital because of left flank pain, back pain, and fever. As a result of clinical examinations, a rapid growth of the cyst out of the pancreas was pointed out. Resection of the pancreatic body and tail, excision of the cyst, removal of the pancreatic lithiasis, and pancreaticojejunostomy were performed. Histologically, chronic pancreatitis with pancreatic pseudocyst was diagnosed. Acidophilic substance with calcification in the pancreatic duct would suggest the development of the pancreatic lithiasis.

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The most important part of reconstruction after pancreaticoduodenectomy is the anastomosis between the remaining pancreas and intestinal tract. While re-establishment of pancreatic-intestinal continuity has generally been accomplished in some manner between the pancreas and the upper jejunum, reconstruction by pancreaticogastrostomy was performed in six patients who recently underwent pancreaticoduodenectomy at the department. In this report the technique and outcomes of the method are described with a review of the literature.
There were no anastomotic leakage and postoperative pancreatitis. Nausea and/or vomiting attributable to pancreaticogastrostomy were observed, but the degree was mild and all these symptoms spontaneously disappeared. Upper gastrointestinal bleeding occurred in one patient, which was successfully managed by conservative therapy.
Reconstruction with pancreaticogastrostomy appears excellent, because its technique is relatively easy and anastomotic leakage rarely occurs. For this, the technique would be recommended high risk groups such as aged patients. Further studies are needed to elucidate changes in the endocrine and exocrine of the remaining pancreas and pathological changes of the gastric mucosa.

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A case of insulinoma in which intraoperative monitoring of plasma immunoreactive insulin (IRI) level was useful as an index for excision of the tumor was experienced. This case had a typical insulinoma satisfying Whipple's three signs. Preoperative abdominal ultrasonography, CT, and angiography revealed a tumor in the head of the pancreas. A bisferious atypical pattern was shown by 75 g OGTT. The tumor was yellowish brown, solid, 9×9 mm in size, and 1.1 g in weight. Insulin staining was positive. Histologically it was diagnosed as insulinoma. Plasma IRI level remarkably decreased immediately after the tumor was excised, and the decreased level was maintained to the end of the operation. No hyperglycemic rebound after the excision of the tumor was noted. As an index of tumor excision, intraopertive monitoring of plasma IRI level was useful. On the 3rd month after surgery the fasting blood sugar and plasma IRI were as stable as around 90 mg/dl and 10 uU/ml or less, respectively. Preoperative pancreatic polypeptide was as high as 815 pg/ml, but, it rapidly decreased after the operation and was in normal range (114 pg/ml) on the 3rd month postoperatively. The significance as a marker for insulinoma was confirmed.

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We experienced a case of splenic hamartoma associated with hepatic hemangioma and ovarian dermoid cyst. Splenic hamartoma is very rare and only 38 cases included this case can be seen in Japan. This paper describes this case with review of the literature.
A 56-year-old female was seen at the hospital because of a fever and was diagnosed as having a splenic tumor, hepatic hemangioma and right ovarian dermoid cyst. Splenectomy and right oophorectomy were performed because the splenic tumor could not be denied malignant involvement. The resected spleen was 120 g in weight and 12×8×7 cm in dimension. In lower pole of the spleen there was a dark-red colored tumor (7×7 cm in size) with clear boundary, and it was diagnosed as red pulp typed hamartoma histologically. The resected ovary was 10×7×6 cm in dimension which included hair follicles, sebaceous glands, fatty tissue and so on. It was histologically diagnosed as dermoid cyst.

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A very rare case of enteric cyst arising in the retroperitoneum is described here, with some discussion on the relevant literature.
A 21-year-old Philippine woman was seen at the hospital because of an enlarging tumor of the right upper abdomen with right hypochondralgia. The tumor had been pointed out 5 years before, but she asked for no treatment. The patient was suspected to have a hepatic tumor and was admitted to the hospital. Echography revealed an infant-head sized, multilobular cystic mass extending from the subhepatic space to anterior aspect of the right kidney. CT also visualized a low density mass in the same part. Angiography revealed no vessels of the tumor coming from the hepatic artery, but showed only an opressed figure. Malposition of the inferior vena cava to the left was found. The tumor enucleation was performed under a diagnosis of retroperitoneal teratoma. The excised tumor was a cyst weight 2200 g. Histopathologically it was an enteric cyst consisting of adenocytes similar to intestinal epithelial cells presenting with PAS-positive, no malignant picture being seen.
Retroperitoneal enteric cyst is so rate that only 4 cases can be seen in the Japanese literature.

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Three cases of malignant fibrous histiocytoma (MFH) arising in the abdomen and retroperitoneum are described. Case 1 was a 34-year-old man. There was a history of receiving radiotherapy after ascensus resection of the scrotum, and in the course of close medical observation, a tumor appeared in the peritoneum. Operation was performed and the tumor was found to be a MFH. The patient experienced a local recurrence which well responded to chemotherapy, however, he died of lung metastasis. Case 2 was a 79-year-old man. He had a MFH in the mesentery of ileocecal region which rolled up the ileum, where a part of the ileum necrosed. Excision of the ileum and ascending colon was performed. Case 3 was a 72-year-old woman, who was referred to the hospital because of an abdominal tumor. Operation was carried out and a huge MFH in the retroperitoneum invading the diaphragm and right kidney was found.
Generally, MFH has poor prognosis and is liable to recur locally and to metastasize, in that sufficient resection of the tumor involving the surrounding connective tissue is essential. Adjuvant chemotherapy, however, can produce an excellent clinical effect in some cases and should be applied as possible as we can.

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It is relatively rare that schwannomas arise in the vagal trunk of the neck or brachial plexus. This paper presents a case of heterochronous schwannomas arising in the left vagal trunk of the neck and brachial plexus. A 52-year-old woman was seen at the hospital because of enlarging left subclavicular tumor with a spontaneous pain, which was noticed 5 years before. There was a history of undergoing enucleation of a schwannoma which occurred in the left left vagus nerve on the neck 17 years earlier. On palpation the tumor was elastic hard and hen's egg-sized. CT, ultrasonography, and needle aspiration biopsy revealed that the tumor was a schwqnnoma of the left brachial plexus. Tumorectomy (intracapsular shelling out) was performed under general anesthesia. Postoperative examination revealed no further neurological deficit of the left upper extremity. Tumorectomy of the schwannoma from the brachial plexus can cause postoperative neurological deficit of the upper extremity. So it seems better to enucleate intracapsularly for thepostoperative quality of life.

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