To prevent postoperative infection, intraoperative antibiotics therapy and washing of the operative wound is performing at the department. This paper discribes the evaluation of the prophylactic effect in 180 surgical cases not involving those with dirty procedures treated from January 1989 to January 1991. Of the 180 cases 84 were given antibiotics (antibiotics group) and 96 were not done (control group), and postoperative occurrence of wound infection and peritoneal infection were evaluated. Excepting cases complicated by anastomotic breakdown, postoperative wound infection was observed in 3 patients (3.6%) in the antibiotics group and in 5 (6.2%) in the control group; postoperative intraperitoneal infection was found in 7 (8.3%) in the antibiotics group and in 10 (11.1%) in the control group. Both wound and intraperitoneal infections were less frequent in the antibiotics group than in the control group, although the differences were not statistically significant. Postoperative bacterial positive ratio was not directly concerning to the ratio of infection growth.
In conclusion, intraoperative antibiotics injection therapy is usefull for post operative infection. But its effects have some limitations. Other foctors such as patients themselves and the causative bacteria may play more important role in one onset of postoperative infection.

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We have not come to any agreement for the therapeutic guidelines for locally invasive differentiated thyroid carcinomas. In this paper long-term therapeutic outcomes and some problems were studied in 28 patients undergoing aggressive surgery for the disease at the department from 1965 to 1989. There were 7 men and 21 women, ranging in age from 29 to 80 years old. In 5 patients the resection of the trachea was required, in 10 the esophagus, 5 both the trachea and the larynx, and in 8 the trachea, the larynx and the esophagus. Ten patients died of the disease. Six died of local neck disease and 4 of distant metastasis. Overall survival rates analyzed by Kaplan-Meier method in 5, 10 and 15 years were 60.5, 38.4 and 38.4%, respectively. Survival rates of the patients aged 60 years and more were significantly worse than that of the patients under 60. These long-term outcomes are not satisfactory in terms of the malignity of this disease, but it can be inferred that early deaths might be greatly attibutable to the conversion of differentiated carcinomas into the poorly differentiated ones. Further adjuvant chemotherapy and radiation therapy would be necessary after surgery to gain an improved survival rate.

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In this study ultrasonic findings of the breast were analyzed, and further examined by using the quantification classification II to improve its diagnositic ability. Among 250 cases undergoing echography of the breast using a 10 MHZ terminal from July 1990 to February 1991, 90 cases including 44 of breast cancer which were able to be histologically diagnosed were subjected. Echographic findings were classified by 7 factors such as shape and verge of the tumor, and analyzed by the quantification classification II in order to distinguish breast cancer from other diseases. In addition, these obtained category scores were applied to calculate for newly diagnosed 34 cases of breast caner. As a result, the eccentric correlation coeficience was largest for verge followed by posterior echo, which might be important factors for differential diagnosis of breast cancer from others. Such findings as irregular belt-like border and weakened posterior echo had a large category score, especially being indicative of breast cancer. The correct diagnosis rate was 86% for breast cancers. It was 85%, when calculated by applying the category scores to the recently diagnosed 34 cases of breast cancer. By making the most use of the category score calculated, more objective diagnostic avility can be achieved.

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To investigate the role of vagus nerve on gut hormone secretion, vagal stimulation evoked by insulin hypoglycemia was loaded for the patients with peptic ulcer before and after vagotomy, and the changes in blood levels of gastrin and secretion were observed. Simultaneously gastric juice was collected and gastric acid output was measured.
Before operation, serum gastrin level increased with insulin hypoglycemia. After selective proximal vagotomy (SPV), serum gastrin level also increased with vagal stimulation. On the other hand after total truncal vagotomy (TV), serum gastrin level did not change with insulin hypoglycemia. Plasma secretion level did not change with insulin hypoglycemia both before and after vagogomy. Gastric acid output decreased after SPV and TV. These findings indicate that SPV is not inferior to TV in decreasing gastric acid output, but also it is more excellent in terms of postoperative gut hormone dynamics and preservation of the peptic function.

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During the period from August 1974 to December 1990, 115 cases of gastric, 97 of duodenal and 23 of combined gastroduodenal ulcer were operated on for gastroduodenal ulcer at the department. Among these cases, operation for perforation was carried out in 8 of gastric, 37 of duodenal and 3 of combined gastroduodenal ulcer. The incidences of perforation were 7.0%, 38.1% and 13.0%, respectively. Since all 3 cases of combined gastroduodenal ulcer developed perforation in the duodenal ulcer, these cases were included in the duodenal perforation group. The ratio of perforation in gastric to duodenal ulcer was 1:5, indicating that the majority of perforation occurred in the duodenal ulcer. The male to female ratio was 6:1, showing a high prevalence of males. Young men were more likely to have duodenal perforation than gastric perforation. The incidence of free air on the plain X-ray film was 75.0% in gastric perforation and 97.5% in duodenal ones. Epigastric sudden pain occurred in 50.5% of gastric and 87.5% of duodenal perforation cases, respectively. Anamnesis of ulcer disease was recognized in 62.5% of perforated gastric ulcer and 47.5% in perforated duodenal ulcer cases. The overall mortality rate was 8.3% (4 cases).

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Bone and/or bone marrow metastasis (BBM) from gastric cancer is rare, but closely related to disseminated intravascular coagulation (DIC) syndrome.
To detect the patients who might have BBM, serum FDP value was routinely measured in 641 patients with advanced gastric cancer from 1984 to 1988 at National Cancer Center Hospital.
Eleven patients with high level (≥20μg/ml) received bone marrow aspilation cytology and/or bone scintigram. Of these, 4 patients (36.4%) revealed to have BBM. These 4 patients received anti-cancer chemotherapy and ant-DIC therapy instead of surgery, nevertheless they died of DIC within one or two months.
In the group with higher PDP levels, the patients tended to have a more invasive type of cancer with deeper invasion, a larger tumor, more extended lymph node matastasis, more advanced stage and more poorly differentiated cancer.
The five-year survival rate for the patients with FDP<10 μg/ml (47.0%) was significantly higher than those for the patients with 10≤FDP<20 (11.0%) and FDP≥0 (0.0%) (p<0.001).
These data suggest that the FDP value is one of the definitive prognostic factors for the patients with advanced gastric cancer and is useful for screening the patients with BBM.

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Postoperative complications and survival rates of 107 patients over 70 years old, who underwent surgery for gastric cancer, were analyzed. The anastomotic leakage and pulmonary complications more frequently occurred than other age groups. Approximately a half of those patients died of either of the two complications. The data of preoperative laboratory examinations, preoperative complications, age of patients, Stages of the disease and types of operation were not related with the occurrence of postoperative complications. Postoperative complications did not influence the postoperative survival rate. Seven patients died of postoperative complications. All of them had a Stage IV disease. Survival rates of Stage IV patients in an early postoperative period were different, dipending on the presence or absence of postoperative complications. However, this difference disappeared in four months after surgery due to early recurrence death of Stage IV patients. It was found that prediction of postoperative complications from routine labolatory data was difficult in the aged patients with gastric cancer, and that postoperative complications in Stage IV were related with higher mortality. Therefore, special care has to be taken in treating aged patients with Stage IV gastric cancer, to prevent postoperative complications.

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In a recent 12-year period from 1976 to 1987, 1059 patients with gastric cancer were experienced at the department and 78 (7.3%) of them had unresectable gastric cancer. Their average survival period was 5.6 months. These 78 patients were divided into early death (65 patients) and long survived (13) groups, bordering at the survival period of 8 months which was a turning point in the cumulating survival curve. Background factors were compared between both groups. There were significant differences between them in factors making the case unresectable and histologic type. In the early death group more than two unresectable factors, especially factors S, P, and N in a complex manner, were responsible for, while two or less factors in the long survived groups. Well differentiated adenocarcinoma was predominant in long survived group, but poorly differentiated adenocarcinoma, in the other. On the other hand, palliative surgery such as gastrojejunostomy or jejunostomy and adjuvant chemotherapy with MMC and 5-FU did not contribute to better prognosis. To improve the prognosis of unresectable gastric cancer, some new chemotherapy which can efficiently affect prognostic factors is expected.

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Surgical outcomes of 151 abdominal operations in aged patients over 80 years old were studied in terms of life-saving significance, improved quality of life (QOL) and postoperative complications. In 102 elective operations, the operation was life-saving in 5, QOL improved in 58, and operative death occurred in 7 patients. In the remaining 49 emergency operations, surgery was lifesaving in 25, QOL improved in 33, and operative death occurred in 13 patients. Forty-one patients with benign disease necessitated emergency surgery, indicating a dominance of severe diseases. Curative resection of malignant tumors provided better QOL. Of the 20 postoperative deaths, 8 patients were caused by serious diseases (cancer in 4 and shock in 4); 6 by operative complications (anastomotic leakage in 4, pancreatitis and hepatic insufficiency in each one); and 6 by complicated diseases (pneumonia in two, cardiovascular disease in two, cerebral infarction in one and sudden death in another one). Though abdominal operation would carry a high risk to aged patients, about 60% of the patients in this series were able to have improved QOL after perioperative managenent could be cleared. It is concluded that opportune and correct operation, as well as cautious perioperative care, provide a better QOL for aged patients over 80 years old.

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Twenty-six cases of perforation of the small intestine were experienced in a recent one decade. These perforations were caused by abdominal injury in 15 cases, ingested foreign body in 5, malignant tumor in 2. Meckel's diverticulum, incarcerated internal inguinal hernia and Crohn's disease in each one. The average age of 26 patients was 476 years old. The male-to-female ratio was 19.7. All cases complained of abdominal pain at the first examination. Shock was observed in 5 patients. Seventy per cent didn't have a fever. The increase in WBC was observed in 80% of the cases and the mean was 14400/ml. In only 17% of the patients the intra-abdominal free air was confirmed in X-ray films. We did not point out intra-abdominal ingested foreign bodies preoperatively. In most cases diagnosis of acute panperitonitis was made and laparotomy was performed. Only 3 patients, whose perforations were caused by abdominal injuries, could be diagnosed before surgery. Simple closure of the perforation and partial resection were carried out to almost same number of the patients. Postoperative complications were noted in 42% of them, operative death due to endotoxin-shock occurred in one patient. It is difficult to diagnose the perforation of the small intestine preoperatively, because many kinds of disease can cause the perforation and no characteristic symptoms are known. We should try to perform the operation as early as possible.

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Indication and limitation of total pelvic evisceration (TPE) were evaluated in 113 patients with colorectal cancer (Si, Ai) invading the adjacent structures and 33 patients with local recurrence in the pelvic cavity underwent surgery during 1959 to May, 92'. TPE was performed in 21 patients (11 with primary cancer and 10 with recurrence). The si, ai rate in 113 patients with primary cancer (Si, Ai) was as low as 55.8%, however si, ai, rate in uterus, vagina and ureter was as high as more than 75%. Cumulative 5-year survival rate in resected cases combined with pelvic organ was 57.9% (TPE cases: 59.9%, non TPE cases: 56.6%), which was significantly higher than 10.6% in no combined cases.
It is concluded that a case, which is diagnosed as Si, Ai by preoperative dynamic CT and MRI, and has no dissemination and distant organ metastasis, with lymph node metastasis of less than N₂, can be considered a possible candidate for TPE combined with sacral resection, entertaining a lack in ew.

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This study was designed to select factors which influence the local recurrence after curative resection for rectal cancer. The subjects were 159 such patients who were able to be followed for 2 years or more.
Local recurrence developed in 11 (6.9%) out of the 159 patients, whose 5-years survival rate was as poor as 10.9%. With a statistical analysis the important clinicopathological factors influencing the local recurrence were: Infilitrating type in macroscopic form, lymph vessel invasion, aneuploid pattern in DNA ploidy pattern by flow cytometry, and degree of lymph node dissection as operation procedure.
On the other hand, hematogenous recurrence developed in 24 (15.1%). The important factors influencing the hematogenous recurrence were: depth of invasion, lymph node metastasis, lymph vessel invasion, and clinical staging. No correlation with operative procedures was noted.
These findings indicate that exhaustive dissection of lymph nodes is important for prevention of local recurrence and multidisciplinary therapy including chemotherapy and radiotherapy is important for prevention of hematogenous recurrence.

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An evaluation of 34 patients with abdominal incisional hernia treated in a recent one decade has been conducted. Nine patients were males, and 25, females. The mean age was 55.7 years in the males and 64.1 years in the females. Hence the disease might be common in aged females, and this tendency was remarkable in cases with long interval from laparotomy to the operation for incisional hernia. Incisional hernias occurring within 1 year after laparotomy seemed to be attributed largely to technical problems at closure of the abdomen. Adequet considerations at the time of laparotomy may prevent this disease to some degree. On the other hand, incisional hernias occurring 10 years or more after laparotomy were frequently observed in the lower abdomen in females. Such hernias were not often noticed and left untreated because of a small hernia hilus and few symptoms. However, since complications such as incarceration frequently occurred during their course, treatment at an early stage is needed.

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A 49-year-old man was referred to the hospital because of a swelling and pain of the left femur. He had a fever from 12 days before and claudiacation from 9 days before. In addition, he had respiratory disturbance on his first visit. From his clinical course and local findings, gaseous gangrene was suspected. Plain reontgenography and CT revealed gasses in the subcutaneous tissue and muscularis. The necrotic fascia of the left femur was resected and the wound was left open. Postoperatively, septic shock and respiratory failure appeared. At 12 hours after the operation new pus and necrosis of the fascia appeared. Lower leg was amputated and his life was saved. From cultures of pus obtained from the wound, E. faecalis was isolated and identified. Then, E. faecalise was replaced by Pseudomonas aeruginosa, MRSA and fungi. When an inflammatory lesion of the soft tissue is progressive and associated with systemic symptoms, roentgenographic examinations under a suspicion of possible gaseous gangrane is essantial, followed by marking the differentiation between infections due to clostridium and non-clostridium for better decision of treatment policy. This case is thought very interesting in that the patient had not history of trauma or any underlying diseases such as diabetes mellitus.

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Spontaneous CSF otorrhea is a rare condition, and about forty cases have been described in the literature to date. Here a case of spontaneous CSF otorrhea is reported.
A 37-year-old man had suffered from recurrent bacterial meningitis and CSF otorrhea. Left mastoidectomy was carried out on May, 1989, by an otologist in the other hospital, but the origin of CSF leakage coudn't be identified. The patient was admitted to our hospital on January, 1990, to treat CSF otorrhea. Left temporal craniotomy was carried out. A dural defect was found in the left middle cranial fossa connecting to a bony defect at the left tegmen tympani. The defect was repaired by packing the tegmen tympani with fascia and fatty tissues. CSF otorrhea completely disappeared postoperatively.
Spontaneous CSF otorrhea should be considered as a cause of recurrent bacterial meningitis. High resolution CT scan and MRI will be very useful in the diagnosis of this rare problem.

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A case of wuchernde Struma of the thyroid associated with dyshormonogenetic goiter is reported. A 75-year-old woman was seen at the hospital because of enlarging tumor on the neck and dysphagia. There was a previous history of undergoing right thyroid lobectomy for congenital goiter. A fist-sized tumor was palpabled in the left anterior neck. Dyshormonogenetic goiter was diagnosed by perchlorate positive discharge. On suspicion of thyroid carcinoma due to findings of neck X-ray, ultrasonogram and computed tomography, total thyroidectomy was performed. The resected thyroid was 15.3×7.6×7.0 cm (220 g) and showed the solid appearance with many hard tumors in the fibous capsule. Histologically, the thyroid was like a adenomatous goiter, partially associated with poorly differentiated follicular carcinoma (wuchernds Struma).
Dyshormonogenetic goiter is defined as defect in the steps involved in thyroid hormone synthesis due to inborn errors of metabolism which in turn causes hyperplasia of the thyroid. Ten cases of thyroid carcinoma associated with dyshormonogenetic goiter including this case have been reported in the world.

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Lithium carbonate is a drug for manic depression. We experienced an operated patient with hyperparathyroidism which might be induced by lithium.
A 54-year-old woman had been received lithium carbonate 600-1200 mg daily for manic-depressive psychosis since 1980. In 1989, the patient was pointed out hypercalcemia, and she was referred to the hospital because of suspected hyperparathyroidism caused by lithium carbonate in January 1990. Serum calcium and iPTH levels were as high as 13.1 ml/dl and 12.4% pg/ml, respectively. Parathyroidectomy of the right lower gland was carried out under the diagnosis of hyperparathyroidism. The tumor was 419 mg in weight and was adenoma histologically. There has been no recurrence for one year and 11 months after the operation. It can be thought that two actions of lithium, namely, parathyroid hormone-releasing action from the parathyroid tissues and growth promoting action, might cause hyperparathyroidism. If lithium induces hyperparathyroidism in the normal gland, one could make a possible candidate for subtotal thyroidectomuy (hyperplasia). If lithium promotes hyperparathyroidism, the appropriate treatment would be excision of the adenoma. For rational selection of operative procedure, the improtance of clarification of etiology for the disease is emphansized.

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A 56-year-old man was admitted to the hospital because of acute putative cholangitis with septic shock and acute renal failure (ARF). Examination on admission did not display any disorder of calcium metabolism. Intensive care including continuous arteriovenous hemofiltation (CAVH) enabled to perform radical operation on 12th hospital day. Postoperatively he underwent CAVH for ARF land showed hypercalcemia (15.2 mg/dl) at the phase of recovery from acute renal failure. Serum PTH level elevated to 5.1 ng/ml at the same time. Despite of improvement of general condition, significant symptoms related to hypercalcemia including restlessness, distraction, thirsty and fatigue were revealed. Administration of elcitonin and washout therapy were effective for the treatment of hypercalcemia. However, symptoms of hypercalcemia persisted. On several examinations a left parathyroid tumor over 1 cm in diameter which was causative of hypercalcemia was found. On 93rd hospital day, the tumor was extirpated. It was histologically diagnosed as eosinophilic adenoma. Laboratory data and neurological condition hecame to normal on the next day. In present case a parathyroid adenoma, existed previously on admission, was probably stimulated during ARF and induced hypercalcemia. With a progression of emergency treatment, further increase in patients with renal failure who are treated for a longer period can be considered, when strict observation of the parathyroid function would be necessitated.

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A 37-year-old woman with minimal breast cancer, who was successfully diagnosed by preoperative aspiration cytology and underwent radical operation, is reported. The patient visited the hospital because of a palpable small mass as large as a little finger tip in the medial inferior part of the left breast. Although the results of physical examination, mammography and ultrasonography suggested a chronic mastopathy, aspiration cytology revealed adenocarcinoma. The patient received modified radical mastectomy (Patey's method). Histopathologically, the tumor was diagnosed as a noninvasive ductal carcinoma, 1.8×1.5 mm in size, localized within the lacteal duct. Aspiration cytology is thought an useful diagnostic method even for minimal breast cancer.

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A 42-year-old female visited the hospital because of a right breast tumor. On the first visit she had already massive local lymph nodes involvements and multiple bone metastases (T₃N₂M₁, stage IV). Irradiation and chemoendocrine therapy were repeatedly performed after standard radical mastectomy, but the patient died of far advanced distant metastases at 19th month after the onset. Histological examination of the resected tumor revealed a variety of features, i.e., papillo-tubular growth, sarcomatous growth mainly composed of spindle cells, and the transition between the two. Thus, the tumor was diagnosed as papillo-tubular carcinoma with spindle cell metaplasia. Immunohistochemical stainings of the tumor showed that vimentin existed only in the sarcomatous region, and keratin was not detected in the tumor. The prognosis of patients with spindle cell carcinoma (so-called carcinosarcoma) is thought to be similar with that of common type of breast carcinoma, but it is still in controversy. Therefore, we investigated the relation between the prognosis and the existence of vimentin as a marker of sarcomatous change of the tumor in 65 patients with breast carcinoma. Vimentin was immunohistochemically detected in 7 carcinomas, in which a decrease in keratin was observed. Such findings indicated a decrease of feature of epitherial cell in the vimentin-positive carcinomas. Four out of the 7 patients with vimentin-positive tumor had metastatic lesions, and showed a poor prognosis compared to that of vimentin-negative patients.

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A 59-year-old woman was admitted to the hospital because of paralysis of the lower extremities and dysurea. There was a previous history of radical operation for a right breast cancer 13 years before. Recently transversal lesion of the upper thoracic spinal cord progressed rapidly and she could not walk at all. Osteolytic change was observed on the first thoracic verteble, and osteoplastic change, on the 2nd and 3rd ones. However, there were nither deformity nor crushing of cerbetrae. The laminectomy and removal of pedunculated extradural tumor from the first thoracic verbebla were done to release the commpression to the spinal cord. A metastasis from the breast cancer was revealed by a histological examination. The transversal lesion of the spinal cord recovered completely by combined therapy with irradiation, cytotoxic drug and endocrine agent. The tumor regression also evidenced by normalized serum tumor makers. Thus the usefulness of tumor marker monitoring was confirmed.

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This is a case report of a metastatic ascending colon cancer after radical operation for a breast cancer.
A 56-year-old woman was admitted to the hospital because of right lower abdominal pain in July 1991. There was a history of undergoing standard radical mastectomy for a left breast cancer on August 1983. On October 1 1991 emergency operation was performed under a diagnosis of ileus. During operation a tumor 3 cm in diameter was found in the ascending colon which presented with whole-circumference stricture.
Histological findings of the breast cancer resected in 1983 revealed a solid tubular carcinoma partially included scirrhous carcinoma, and histological structure of this tumor in the ascending colon was similar to that of the breast cancer. The tumor of the ascending colon was diagnosed as a metastatic lesion from the breast cancer.
It is rare that intestinal metastases from breast cancers are found when patients are alive. Especially metastases to the colon and rectum are rare and 27 cases have been reported in the world. The age when metastases were found is 56 years old in average, and a disease-free interval after operations for breast cancers is about 7 years. The appendix is the most common metastatic site from breast cancer, and histologically lobular carcinomas are predominant.

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This paper present a satisfactory outcome with Marlex sandwich method using Marlex mesh and polymethyl-methacrylate (a resin) after resection of the sternum for a recurred primary sternal chondrosarcoma in a 72-year-old man. There was a history of undergoing an extirpation of a sternal tumor in April 1986 at the department of orthopedics. The patient experienced a recurrence around July 1990 and was referred to the department. The tumor was 7.5×4.0 cm in size. On operation the sternum was cut just above the adhered portion to the 2nd limb as the upper end and removed including bilateral 2, 3, 4, 5, and 6th costal cartilages. A resin board with numerous small holes was made to be put between doubled Marlex mesh, with which the defect in the chest wall was filled and sutured for reconstruction of the chest wall. Postoperatively no foreign body reaction was observed and postoperative course was uneventful.

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Veno-arterial bypass after coronary artery bypass grafting was successfully performed for 25 hours in a 67-year-old female with inveterate cardiac infarction and angina pectoris. The patient has lesions of RCA#1 100%, LAD#790%, #9-175%, and LCX#14 100%. On 49th postoperative day the patient died of sepsis and multiple organ failure. Acute pancreatitis was established as the cause of death by postmortem examination.
Though it been said that acute pancreatitis hardly occurs after thoracotomy, this experience indicates the importance of pneuventing pancreatic ischemia in extracorporeal circulation as a probable cause for postoperative pancreatitis.

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We experienced a relatively rare case of inflammatory pseudotumor of the lung. An 18-year-old man was admitted to the hospital because of an abnormal shadow in the right upper lung field on chest X-ray. The diagnosis of inflammatory pseudotumor has been often made by postoperative histopathological study. In this case, the diagnosis could be established preoperatively by an echo-guided percutaneous needle biopsy which permit to obtain plenty of specimen.

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Pulmonary arteriovenous fistula is a relatively rare disease, but recently case reports of this disease can be increasingly seen.
A 54-year-old male was admitted to the hospital because of chest abnormal shadow. The CT, MRI and pulmonary arterial angiography revealed a simple pulmonary arteriovenous fistula on the left lower lobe. An excision of the fistula was tried, but the fistula was too large to excise completely and left lower lobectomy was added. Postoperative course was uneventful and the patient was discharged from the hospital on the 32nd postoperative day.
Lobectomy and segmentectomy have been widely performed on this disease. Recently an excision or occlusion of the fistula is coming to be a best procedure in order to prevent the lung function. However, any recurrence and remainance of the fistula should be avoided even if this disease is benign.
We emphasize the necessity of lobectomy and segmentectomy in some cases.

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A 48-year-old man on maintenance hemodialysis for chronic renal failure during these 10 years was pointed out an abnormal shadow on the left upper field at a routine medical checkup. Transbronchial lung biopsy revealed a lung cancer. Left upper lobectomy and mediastinal lymph node dissection were performed without any complications. Histologically, large cell carcinoma was diagnosed and metastases were found in the left upper lobe lymph nodes (T2N1M0). Because of hyperkalemia, he was performed hemodialysis just after 7 hours from the operation. There were no troubles during the hemodialysis. Nafamostat mesilate was used for anti-coagulant reagent. Postoperative course was uneventful. The patient died of multiple brain metastases 15 months after the operation. We emphasize that pulmonary resection for patients with lung cancer on hemodialysis have to be performed, if the surgical indication can be considered.

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A 61-year-old woman visited the institution because of gradually progressive dysphagia and dyspnea. Esophagography and CT revealed an esophageal submucosal tumor suspecting leiomyosarcoma. After the tumor was diagnosed as leiomyosarcoma pathologically during thoracotomy, esophagectomy, esophagostomy, and gastrostomy were performed. The operation was separated in two times because of her poor general condition. At the 2nd month after esophagogastrostomy, the patient died of DIC and MOF. Autopsy revealed infections of tissue of the whole body, but no bacterium was detected. No recurrence nor metastasis of sarcoma was observed. In this case the patient has dysphagia 3 years before, but, she had never consulted a nearby hospital when she first developed dyspnea. When she was seen at the institution, a collection of thoracic fluid and lowered lowered lung function were already present, which made some efficacious impossible. It is difficult to decide whether the myogenic tumor of the esophagus is benign or malignant. On the contrary, thoracotomy today can be performed safely and endoscopically resectable cases can be increasingly found. We should decide a surgical prosedure after correct diagnosis is made by strip biopsy in a small tumor or by thoracotomy in a large tumor like this patient.

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A case of synchronous double cancer of the esophagus and gallbladder associated with exophageal achalasia was experienced.
A 73-year-old male was admitted to the hospital because of hematoemesis. He had been having passage disturbance of foods for about 50 years, with which he never visited any hospital. On admission an esophageal tumor associated with esophageal achalasia was found by esophagogram and endscopic examination. The esophageal cancer was ulcer type existing in Im and achalasia was F_III type. Immediately subtotal resection of the esophagus followed by reconstruction with stomach tube was performed. Histopathologically the cancer was squamous cell carcinoma with a depth of invasion of mp, and the ganlion cells disappeared in the lower two third portion of the resected esophagus.
Six month later, another tumor was found in the gallbladder by sonography, and extensive cholecystectomy was performed. Histological findings revealed adenosquamous cell carcinoma.
This case is calculated as the 53rd report of the esophageal cancer associated with achalasia in Japan. However, any case reports like this one of concurrent cancer with achalasia were not seen in the literature as far as we could examine.

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A case of histologically proven gastric sarcoidosis in a patient who was operated on under a suspected diagnosis of gastric cancer and another case of pm invasive cancer of the stomach with sarcoid nodules found in the regional lymph nodes and gastric walls are reported. Case 1: A 68-year-old male with the chief complaint of anorexia was noted on barium swallow to have fibrotic changes in the walls of the middle and lower portions of the stomach on the greater and lesser curvature. Gastroscopy revealed erosion and ulcers of irragular shape in the same areas, but biopsy proved negative. Because the possibility of diffuse carcinoma or malignant lymphoma of the stomach could not be ruled out, total gastrectomy was performed. Histologically, there were noted epithelioid granulomas containing giant cells of Langhans and involving the deep mucosal layers and the serosa of the entire stomach and sarcoid nodules in all resected lymph nodes, and a diagnosis of gastric sarcoidosis was thus made.
Case 2: A 52-year-old male was admitted to the hospital because of epigastric pain. With gastroscopy and barium swallow, a IIc lesion on the anterior wall of the lower portion of the stomach as diagnosed as being a signet-ring cell carcinoma of a depth of invasion of pm. Minute intramucosal epithelioid granulomas were also found in the pyloric region. As few reports are available so far on sarcoidosis of the digestive tract, notably stomach, its clinical significance was studied and discussed.

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A biochemical Study was conducted in a case of alpha-fetoprotein (AFP) producing gastric carcinoma with high preoperative serum AFP level (14656 ng/ml), which metastasized to the liver postoperatively. Some notes on the relevant literatur is also presented here. After surgery serum AFP level rapidly decreased to 1057.7 ng/ml and AFP positive cells were found by immunoperoxidase staining accoding to the peroxidase-antiperoxidase (PAP) technique. Thus the patient was diagnosed as having an AFP-producing carcinoma of the stomach. Histologically AFP-producing cells were more commonly found in undifferentiated hepatoid cells than the others. Furthermore, in a study of crossed immuno-affinoelectrophoresis with lentil lectin, concanavalin A-nonreactive of serum AFP was lower (15%) than differentiated AFP producing gastric carcinoma. This was near to that of hepatoid celler carcinoma (5±7%). Serum AFP level, however, showed a reelevation and abdominal CT four months after the operation revealed multiple liver metastasis. It is through that some preventive treatments are important against liver metastasis in a case showing a high level of preoperative serum AFP.

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A case of perforated gastric cancer associated with the delivery which was initialy misdiagnosed as abruption of placenta is presented.
A 28-year-old multipara presented with acute abdomen at the 37th gestational week. Her symptoms were accepted as abruption of placenta and induction of delivery was performed on the next day of admission. Abdominal pain, however, persisted thereafter, and an abdominal simple X-ray film revealed a free air. Laparotomy was carried out. Perforated lesion was observed at the vestible of the stomach and plombage of the lesion was performed. Postoperatively scirrhous carcinoma of the stomach was suspected by the finding of the progressive narrowing of the stomach on barium-meal study. Again laparotomy was performed with unsuccessful outcome because of extensive invasion of the carcinoma and the patient succumbed 13 months after the initial operation.

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Postoperative morbidity and mortality are reported to be high in patients with polycythemia vera (PV). A case of successful gastrectomy in a 82-year-old man associated with PV is described. The patient has been placed on an alkilating agent (mitobronitol) since he was diagnosed as PV at a cerebral attack 11 years ago. In 1989 the patient was admitted to the hospital because of upper abdominal discomfort. Upper abdominal series revealed an advanced gastric cancer locating in the antral lesser curvature. Red blood cell count was 4, 010, 000/mm³, white blood cell count was 6200/mm³, platelet count being 668, 000/mm³. On May 15, 1990, total gastrectomy was carried out under general anesthesia. No ascites was observed. The gastric cancer was of P₀H₀S₂N₂ in Stage III. Ulinastatin 200, 000 units daily was started immediately after the operation. On the day of operation the platelet count increased to 732, 000/mm³ and activated coagulation time (ACT) was shortened to 46 seconds. Continuous IV infusion of heparin 400-600 units/h was given from the 2nd to 11 postoperative day to keep ACT at about 150 seconds. Mitobronitol regimen was resumed on 9th day when the patient was permitted to take orally. No postoperative hematological complications occurred, and the patient was discharged from the hospital on the 20th postoperative day. It is speculated that hematological care is mandatory to control not only the pre-disseminated intravascular coagulation-state of PV, but also the perioperative hypercoagulative state.

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A 42-year-old woman visited the hospital because of upper abdominal pain and tumor. Gastric barium study showed the compression on lesser curvature, but mucosal appearance was normal on the gastrofiberscopy, and all tumor markers were in normal ranges. Ultrasonography, CT and MRI showed an over 10 cm size unhomogenous tumor between the liver and pancreas adjacent to stomach. Total gastrectomy with regional lymph nodes dissection was carried out under a presumptive diagnosis of leiomyosarcoma. No lymph node metastasis was found. Histologically it was diagnosed as malignant leiomyoblastoma of the stomach. Four months later a tumor which might be a metastatic lesion was detected around the pancreas tail on CT. The tumor rapidly enlarged. On the 5th month after the operation, relaparotomy was performed and metastasizing lesion was also confirmed in the lateral segment of the liver. Resection of the pancreas tail, splenectomy and partial resection of the liver were carried out, followed by adjuvant chemotherapy.
There is an opinion that this tumor has a low grade of malignity compared to carcinomas and can be successfully treated by a small operation. However, radical operation which involves lymph node dissection and adjuvant chemotherapy seems to be necessary as in gastric cancer and leiomyoblastoma, even to this tumor, particularly to those with high rate of nucleomitosis.

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A 56-year-old man visited the hospital because of abdominal pain. Simple abdominal X-ray films revealed an intestinal obstruction, and a long tube was intubated for intestinal decompression. X-ray contrast examination of the small intestine demonstrated a rather smooth stenosis of about 7 cm in length in the ileum. Barium enema of the large bowel was normal. A tumor of the small intestine was suspected, because there was only a single focus. Operation was performed. After entering the peritoneal cavity, the ileum 90 cm proximal to the ileocecal valve was found to be involved by a partly whitish colored mass of hen's egg size. The regional lymph nodes were enlarged to little fingertip size on palpation. About 30 cm of the small intestine was resected together with the tumor and regional lymph nodes. The resected specimen had a thick intestinal wall and a deep ulcer perpendicular to the long axis of the intestine. Histological examination showed that the ulcer was U1 III. Langhans giant cells and caseating tubercules were seen in both the ulcer and the regional lymph nodes, so small intestinal tuberculosis was diagnosed histologically. Chest X-ray films were normal and the tuberculin reaction test was negative in this patient. There is a recent growing tendency to reveal no abnormal findings in a chest X-ray film in cases of intestinal tuberculosis.

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A case of appendicitis caused by anisakiasis was experienced. A 16-year-old woman was admitted to our hospital because of acute appendicitis. She had eaten fresh “Sushi” 5 days before admission. Appendectomy was performed and anisakiasis of the appendix was revealed. Anisakiasis is commonly found in the stomach (92.7%), and occurs in the intestine in a frequency as low as 4.4%. In particular, there has been no report on anisakiasis of appendix in Japan up to now. This case is thought very rare.

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The clinical features of 6 operated cases of Crohn's disease experienced at the department were studied. The anatomical sites of these lesions were the small bowel, small and large bowels, and large bowel (including one case of rectal Crohn's disease) in each two cases. Indications for surgery included intestinal stricture in four cases, abscess, and fistula in each one case. Intestinal stricture was seen in two cases of enteritis, one case of enterocolitis, and one case of colitis (rectal lesion). Abscess and fistula were seen in one case of enterocolitis and colitis, respectively. Bowel resection was performed as short in length as possible, about 10 cm length from the margin of the main lesion. The postoperative recurrence occurred in one case. In this case, the recurrence lesion was improved by medical treatment. There were no cases of reoperation and death. Although postoperative follow-up is limited in durations from one and a half to ten years, all 6 patients are working without recurrence now.
We discussed surgical treatment for Crohn's disease including indication for operation, surgical procedures and prognosis, together with a review of the literature.

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This paper describes a case of solitary splenic metastasis 2 years and 9 months after curative resection of an early gastric cancer, which was treated by splenectomy.
A 63-year-old man was seen at the hospital because of a fever and left abdominal pain. Ultrasonography, computed tomography and angiography, splenic abscess and splenic tumor revealed. Splenectomy was performed. No hepatic metastasis, lymph node metastasis or peritoneal dissemination was observed. The surgical specimen exhibited a tumor in a size of 5×4.5 cm in the splenic parenchyma, and histopathological findings proved the lesion to be well differentiated adenocarcinoma. The histopathological image closely resemmbled that of the early gastic cancer excised 2 years and 9 months before. It was diagnosed as metastasis of the gastric cancer into the spleen. Splenic metastasis can be seen at times in a state associated with multiple metastatic lesions in terminal cancers, but solitary splenic metastasis is rare. Particularly the splenic lesion metastasized from gastrointestinal cancer for which splenectomy was successfully performed is so rare that only 12 cases have been reported in Japan as far as we can review. Among the 12 cases no other case of splenic metastasis from an early cancer can not be seen.

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A 61-year-old female was admitted to the hospital because of general fatigue and hoaresness. An elastic soft, smooth surfaced and nontender mass was palpable in the left lobe of the thyroid gland. Radiographic examinations revealed a benign thyroid adenoma. Abdominal ultrasonography, however, a 9×7cm solid tumor presenting as well-defined heterogenous internal echoic picture between the spleen and left kidney. CT and MRI indicated a well-defined homogenous adrenal mass. In endocrinologic examination elevated serum DHEA-sulfate, progesteron, and urinary 17-KS were noted. Functioning adrenocortical tumor was suspected and adrenalectomy was performed. The removed adrenal tumor was 10×8×7cm in sizeand 295g in weight and covered with thin fibrus capsule. Its cut surface was brown. It was a elastic hard and solid tumor, scatering with hemorrhagic and necrotic lesions. Histologically the tumor was adrenocortical carcinoma. The patient is well as of half year after the operation.

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Acute peritonitis due to a perforation of infected urachal cyst is rare and 9 cases including this case have been reported in Japan. A 41-year-old male was seen at the hospital because of lower abdominal pain with a low grade fever. A 3 cm paintful tumor was palpated approximately on the median of the lower abdomen but no peritoneal irritating sign was noted. Ultrasonography (US) revealed a possible tumor arising in the urachal cyst localized in the extraabdomen beneath the rectus abdominis muscle. CT, however, pointed out a low density area under the rectus muscle but it was unclear whether the mass was localized in the intraabdomen or extraabdomen. In the course of conservative treatment, peritoneal irritating sign and fever appeared. US was performed again, and acute peritonitis due to perforation of the infected urachal cyst was suspected. Total urachectomy was carried out. Postoperative course was uneventful and the patient was discharged from the hospital.
Generally infected urachal cyst is treated by antibiotics followed by radical operation of an one-step approach. During this preoperative period US would be very useful to observe the infected urachal cyst with a rare possibility of perforation into the abdomen.

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A case of minor omental cyst discovered by an abnormal shadow of the mediastinum in a chest X-ray film is repoted. A 52-year-old man was pointed out an abnormal shadow of the mediastinum in a chest X-ray film on mass screeing, and was admitted to the hospital for minute examination. CT and angiography indicated a hernia of a minor omental cyst to the mediastinum. Operation was done by thoracotomy and laparotomy. In laparotomy, a 10×6 cm cyst in minor omentum was shown to slide into the mediastinum through the esophageal fissure. After removing the cyst, Nissen's fundplication was performed to prevent postoperative hernia of esophageal fissure. In histological findings, the cyst was lymphangioma but no malignant sign was shown. There was no problem in the postoperative course.

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A case of abdominal desmoid tumor in a relatively aged woman was experienced. A 60-year-old woman was seen at the hospital because of a tumor in the right lower abdomen. It was a hard and unmovable tumor measuring 9×9 cm. Abdominal ultrasonogram disclosed a mass lesion showing heterogenous echogenicity without a clear border. Abdominal CT revealed a tumor of which density was higher than that of the soft tissue with strong enhancement by a contrast medium. Laparotomy was performed under general anesthesica, and a very hard tumor was found in the right rectal muscle adhering to the major omentum and transverse colon. The patient underwent wide local resection of the tumor with 1 cm surgical margin. The defect of the abdominal wall was repaired with Marlex mesh (polypropylene). Histologically, fibrous tissue interlaced with the surrounding muscle and adipose tissues without cytologic atypism were observed. A diagnosis of the abdominal desmoid tumor was made. No tumor has recurred for one year and eight months after the operation.

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A case of arteriosclerosis obliterans with ischemic ulcer treated by totally implanted arterial access system is described. The patient was a 96-year-old man with ischemic ulcer (Grade 4 of Fontaine's classification) in the right 2, 3, and 4th toes. Angiography revealed an obstruction of the popliteal artery and poor run off to the peripheral artery. Reconstruction by bypass grafting was not indicated and intravenous injection of LipoPGE₁ was not effective. So a totally implanted arterial access system was used and LipoPGE₁ was injected through the system repeatedly. Though the minimum amputation of the toe was required, perioperative peripheral circulation was sufficient and wound healing was satisfactory.

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A case of isolated true aneurysm of the deep femoral artery in a 79-year-old man is reported, together with a review of 64 cases seen in the Japanese literature.
The patient was admitted to the hospital because of a tumor in the left thigh. As there was no distal vascular occlusive disease, only the isolated aneurysm in the deep femoral artery was resected without a revascularization. The removed aneurysm was a true arteriosclerotic aneurysm, with dimensions of 9.5×7.0×8.0 cm. The patient has been free from symptoms as of 21st month postoperatively.
Including this case, 64 cases of this condition have been reported in Japan. Their mean age (68.1 years old) was high, and most patients (58) were males. In 9 patients, aneurysms occurred bilaterally. Coexistence of aneurysms in other arteries was found in 22 patients (31 arteries). Rupture of the aneurysm had occurred in 29 patients. The aneurysm was attributed to arteriosclerosis in as much as 49 patients.
One patient was treated by catheter embolization, and the other patients were treated by aneurysmectomy or ligation of the artery. In 24 patients, revascularization was also carried out. Except for 2 patients in whom amputation of the extremities was performed, all patients had good prognoses.

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A case of solitary iliac aneurysm which ruptured into the left common iliac vein and presented with heart failure is experienced. An 85-year-old man under the treatment of heart failure which suddenly developed 2 years before was admitted to the hospital becase of an early gastric cancer. Digital examination and computed tomography revealed an aneurysm of the iliac artery. Arferiography showed the arteriovenous fistula between left internal iliac artery and left common iliac vein. One stage operation was performed on this patient, taking account of his age, general condition, and the prognosis of the early gastric cancer. Closure of the fistula and the interposition graft between common and external iliac artery were performed. Then partial resection of the antrum was performed. Disappearance of A-V shunt resulted in remarkable decrease in CTR. There were no complications after the operation including graft infection. One stage operation for this patient was thought to be very useful.

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Perineal liposarcoma is exceedingly rare. A 72-year-old man was seen at the hospital because of a perineal tumor. Diagnostic imagings indicated a pararectal tumor and an operation was carried out. Histologically it was well-differentiated liposarcoma of the sclerosing type. This was the first case in Japan. Five other reports of retrovesical or perineal liposarcoma was culled from the literature in foreign countries. A total of cases of liposarcoma including the present case reported between 1904 and 1988, are also reviewed here.

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