The effect of total parenteral nutrition (TPN) with fat emulsion was evaluated in 20 patients with liver disorders who showed Diabetes Mellitus (DM) type in preoperative oral glucose tolerance test (OGTT). The patients were divided into two groups according to Child's classification (Child A group; 10 cases, Child B group; 10 cases) and they underwent TPN after direct operation for esophageal varices. Blood glucose level in Child B group in the first to third days after operation was over 190 mg/dl and it was higher than that of Child A group during TPN. But blood glucose level of fat containing TPN cases in both groups tended to be lower than that of fat free TPN cases. There was no abnormal finding in liver function tests during TPN with or without fat emulsion after operation. It was indicated that fat containing TPN had little influences on the liver function in patients with liver disorders such as Child A and B who were classified in DM type in preoperative OGTT. Serum essential fatty acids level before operation was lower than normal level, and it further decreased after operation. The decrease was inhibited in patients of both groups undergoing TPN with fat emulsion. The plasma removal rates of fat emulsion (K2 values) during postoperative TPN were higher than those in preoperative period.
It is concluded that the administration of fat emulsion is available to the patients with liver disorder accompanied with DM in OGTT during postoperative TPN.

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Thirty one patients with bone metastasis of differentiated carcinoma of the thyroid were clinically studied, and the following findings factors were noted. 1) Bone metastasis was frequently found in older patients with ages ranging from 40 to 82 years (the mean: 57.6). 2) After the primary carcinoma was found, most bone metastases occurred within 10 years, particularly within 5 years. 3) Metastatic sites in 60% of these patients involved the spine, with 16 patients having isolated bone metastasis and 15 showing multiple metastatic sites in the bone. 4) Anatomically, metastatic sites of papillary carcinoma occurred more frequently in the thoracic and cervical regions of the spine and in the sternum. Follicular carcinoma tended to metastasize throughout the entire bone system 5) Metastasis involving the spine might greatly contribute to clinical manifestations and the cause of death in these patients. These findings indicate that the spine is the most important site of metastasis in patients having bone metastasis of differentiated carcinoma of the thyroid.

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One-hundred and eight young women, aged 35 years or less, have been treated for operable breast carcinoma, except bilateral carcinomas, in our department. These patients were investigated clinicopathologically in terms of the background factors and surgical results comparing to the patients over 35 years old. Breast carcinomas in youngs were characterized by: the large tumor in size; frequent occurrence in pregnant or lactating period; high rate of biopsy performed; and high rate of positive lymph node involvement, compared to the other age group. As a whole, the crude survival rate in the young group was slightly, but not significantly, worse than that in the old. An improvement in surgical results was observed in patients submitted to operation after 1980, especially in an early stage. No significant difference between the two age groups was noted in the incidence by histological types of the tumors, but prognosis of scirrhous carcinomas in youngs was significantly poorer than the other. From the above, we can conclude that appropriate selection of opeartive procedure and postoperative adjuvant therapy according to clinical stage is necessary for the young patients as well as for not-young ones. Especially potent postoperative adjuvant therapy and strict follow-up should not be lacked for scirrhous carcinomas in youngs.

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A cytological examination of pleural lavage with 50 ml saline sterilized was performed before resection in 53 cases of pulmonary lung cancer. The results of pleural lavage were positive in 13 of 53 patients (24.5%). In these 13 patients with positive findings, 9 patients had adenocarcinoma, and 6 patients were p-stage I, one in p-stage II, 4 in p-stage III A, and 2 in p-stage IV. Positive findings significantly correlated to p-factor as compared with negative findings. Nine of 13 patients with positive findings died within 2 years because of distant metastases (5 cases), intrathracic recurrence (2), or other desease (2). When the survival rate was studied according to Kaplan-Meier method, the prognosis in patients with positive findings was poor and no survival for longer than 3 years was recorded. If occult cancer cells present in the thoracic cavity at thoracotomy, even radical operation can allow postoperative recurrence, which might be a possible index for poor prognosis.

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In the treatment of esophagogastric varices, we investigated a combination therapy of modified Hassab procedure, comprising of circulatory stoppage of the lower esophagus and upper stomach, splenectomy, and pyloroplasty, with postoperative sclerotherapy.
In a recent 5-year period from 1985 to 1989, modified Hassab procedure was performed in 16 cases of esophagogastric varices, of which 14 had liver cirrhosis and 2 had idiopathic portal hypertension as the primary disease. Eleven patients had experienced hematoemesis. Emergency operation was performed in 3 cases; scheduled operation in 8; and prophylactic operation in 5. Modified Hassab procedure alone could yield alleviation or disappearance of the varices in 45.5% of the patients. If the varices were left, postoperative sclerotherapy successfully made the remnant varices disappear. Operation was the enough procedure to treat the gastric varices. There was only one operative death in the emergently operated patient. No rebleeding from varices in a distant site was observed.
For esophagogastric varices, combinative modified Hassab procedure makes the sclerotherapy ease, and it can sufficiently treat gastric varices.

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Of 294 cases of colorectal cancer treated at Asahikawa Kosei Hospital from Jan. 1985 to Aug. 1990, 9 cases of poorly differenciated carcinoma (PDC) and 10 cases of mucinous carcinoma (MC) were clinicopathologically compared with the remaining 275 cases of differenciated carcinoma (DC). Average age was low and the tumor was more frequently found at right side of the large intestine in the former two groups. Microscopical wall invasion was deeper than or equal to subserosa (ss) in all 19 cases.
Clinicopathological features of PDC were high incidences of lymphnode metastasis (89%), lymphatic invasion (77%), venous invasion (56%) and liver metastasis (33%), all of which were higher than those of DCs. In contrast, it was characteristic that MC had a low incidence of liver metastasis (0%) and high incidence of peritoneal dissemination (40%), indicating a possible different mechanism of metastasis. Prognosis of the patients with PDC was the worst and 4 years survival was 33%. In treatment of PDC, we should remember that it tends to invade the surrounding organs and can metastasize distantly in a high incidence.

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According to “General Rule for Clinical and Pathological Record of Colorectal Cancer”, 33 poorly differentiated adenocarcinomas of the colon and rectum among 569 resected colorectal cancers were clinicopathologically studied, comparing to the most common 355 well differentiated adenocarcinoma. Poorly differentiated adenocarcinomas represented as low as 5.8% of all cancers. When compared to well differentiated adenocarcinomas, poorly differentiated ones were more frequently found in the colon, especially remarkable in the right side, and macroscopically those predominantly included infiltrating ulcer types. Hepatic metastasis was found in a rate of 21.2%; lymph node metastasis, 66.7%; and 27.2% of positive lymph nodes were of the 3rd group of lymph nodes. Invasion depth of s (a₂) and si (a₁) were found in 81.8%; lymph vessel invasion in 97%; and venous invasion was positive in 87.9%. Compared to well differentiated adenocarcinomas, poorly differentiated adenocarcinomas showed significantly high rates in all items, namely, poorly differentiated adenocarcinomas were in more advanced stages such as stage IV and V. Curative resection rate was as low as 54.5%. Five-year survival rate was also low (38.4%) in all 33 cases, but was 59.6% in curative resection cases, that did not significantly differ from 75.1% in well differentiated adenocarcinoma cases.

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Fifty-seven early colorectal cancers were subjected to a clinicopathological analysis. When compared to pedunculated early cancers, sessile early cancers had greater tumors in size and a lower incidence of association of adenoma. Right-sided cancers were predominantly sessile submucosal cancers. Sessile submucosal cancers without adenoma tended to have greater tumor diameter. No invasion into the lymph or venous vessels was found in mucosal cancers. However, submucosal cancers, if those had some factors such as sessile type, tumor diameter of 2 cm or more, deep submucosal invasion, no adenoma component by biopsy, and aneuploid pattern in DNA ploidy, had probable lymph vessel invasion with a high incidence. Accordingly, curative resection should be indicated for cases having such risk factors, considering of possible occurrence of metastasis and recurrence. Endoscopic or local resection can offer satisfactory outcomes for cases without such risk factors.

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Anterior resection using double stapling technique (DST) was performed in fourteen cases of carcinoma of the sigmoid colon and rectum. DST, which was first proposed by Knight and Griffen in 1980, is a mechanical double anastomosis.
We performed DST using ROTICULATOR and PREMIUM CEEA with some our original devices. Consequently, no anastomotic complications such as leakage, stricture and bleeding were experienced. DST has the following advantages; 1) lower anastomosis than single stapling technique; 2) fewer chances for infection; 3) fast and reliable anastomosis; and 4) less postoperative complications. Considering these advantages, application of DST would be actively recommended for anterior resection of rectal carcinoma as well as for high anterior resection of sigmoid colon carcinomas. Moreover endoscopic observation of anastomosed sites was made postoperatively to see the presence anastomotic stricture or pocket formation. There was no anastomotic stricture but pocket formation was found in 3 out of 12 cases.

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Surgical outcomes of congenital soft tissue A-V fistulas and hemangiomas in 22 patients, comprising of 8 males and 14 females, are reported. Their ages ranged from 2 months to 46 years old with a mean of 18.9. These patients were followed up one to 17 years with a mean of 10.4. The chief complaints included swelling in all patients, bleeding in 3 and pain in 3. Sixteen patients had a solitary hemangioma and 6 had multiple hemangiomas. Fifteen hemangiomas were well defined and 7 were diffuse. The tumors were located at the head and neck in 11, the body in 8 and the extremities in 9. No patient had either congestive heart failure secondary to an A-V fistula or Kasabach-Merritt syndrome. Surgical procedures included extirpation in 17 patients, ligation of the feeder vessels followed by extirpation in 1, and ligation and embolization in 4. After extirpation, direct closure was achieved in 16 and free myocutaneous flap implantation was performed in 1 for reconstruction.
At the time of discharge no residual hemangioma was detected in 16 patients, and the size had decreased in 6. One patient with giant hemangioma of the face and neck died after the third operation. The remaining 21 patients are alive, and 12 have no recurrence. Nine patients are considered to have a good result. Extirpation for localized and well defined hemangiomas was curative. Ligation and embolization were effective for extensive or diffuse hemangiomas.

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A 16-year-old female visited our hospital because of a mass on the neck. On physical examination, masses were palpated in the left supraclavicular fossa and on the left anterior chest wall. Biopsy studies provided no definitive diagnosis, and exploratory operation was carried out. The masses on the chest wall and in the supraclavicular fossa could be resected, but a third mass in the thymus was tightly adhered to the pericardium and could only be partially resected. Pathologic examination of the resected specimens indicated Hodgkin's disease, nodular sclerosis. The patient has been managed postoperatively by alternating COPA-ABVD therapy.
Although Hodgkin's disease can be successfully treated by chemotherapy and radiation therapy, the frequency of local recurrence is considered to be high in cases with very large masses in the mediastinum even after combination chemotherapy and radiation therapy. In adition the diagnosis of Hodgkin's disease, nodular sclerosis is often difficult. For these reasons, surgical resection is considered to be important both for the diagnostic purpose and as a part of the adjuvant therapy in anterior mediastinal tumors showing chest wall infiltration.

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A 52-year-old female swallowed an alkali (a toilet wash containing 4% NaOH at pH 13.5) in a suicide attempt, who was under the treatment of episodes of convulsion. There was a history of mental detardation Stricture of the esophagus and stenosis of pylorus and antrum of the stomach were recognized 5 days after swallowing alkali. The patient was taken conservative treatment, but stricture of the esophagus did not improve. She was admitted to the hospital for operation of esophageal reconstruction. Esophageal reconstruction using pedunculated colon flap and pyloroplasty were performed 16 weeks after injury. In upper and lower portions of the esophagus, which are physical esophageal narrowings, the most of the mucous membrane was absent, thickening of the esophageal wall with fibrosis, which extended partially to serosa, was also recognized. In addition to regargitation of foods in the trachea following operation, pyloric stenosis appeared 4 weeks after operation. Feeding was discontinued temporarily, and gastrectomy was performed 6 months after esophageal reconstruction. After gastrectomy, symptoms of regargitation and pyloric stenosis abated. General condition of the patient improved thereafter, and she was discharged.

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A case of gastric carcinoid tumor occurred eleven years after subtotal gastrectomy due to gastric ulcer is presented. A 62-year-old man visited the hospital because of tarry stool.
Fluoroscopy of the remnant stomach revealed a sclerosed wall at the anastomosed site. An irregular elevated lesion around the site undergoing gastroduodenostomy and stenosis in the same region with rigidity were noted by endoscopy. The patient was diagnosed as having a poorly differentiated adenocarcinoma by endoscopic biopsy.
Total gastrectomy combined with splenopancreotectomy was carried out and reconstructed with Roux-en Y method.
Histologically it was a gastric carcinoid tumor in H₀P₀, ss. Lymphnode metastasis was found in the sub-pyloric region.
It is considered that multiple gastric carcinoid occurring under some conditions such as pernicious anemia may directly result from continuous stimulation by gastrin, and hence, malignant change can not start in the remnant stomach after antrectomy. In terms of this, this case is rare.

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We report a very rare case of small cell carcinoma of the stomach. A 73-year-old man, complaining of an epigastric mass, was admitted to our hospital for close examination. An Endoscopic approach revealed a Borrmann type 3 tumor at the antrum of the stomach, subsequently partial gastrectomy was performed with following findings (P₀H₀N₄ (+) S₃, in Stage IV, and non-curative B resection. Histological final diagnosis was small cell carcinoma of the stomach with findings of intermed., IFN-_γ, ly₃, v₁, n₄ (+), aw+ and ow-. Although the immunochemotherapy was attempted to, abdominal wall invasion from the rapidly growing residual carcinoma of the duodenal stump, obstructive jaundice and liver metastases were found two after months operation. Twenty cases of small cell carcinoma of the stomach which can be categorized into the ectopic hormone-producing tumors, have been reported in Japan. The prognosis of this disease is very poor resulting from rapidly developing metastases and invasion in an early phase of the disease.

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A 43-year-old man with the chief complaint of epigastralgia was diagnosed as having a submucosal tumor of the stomach. Distal gastrectomy and lymph nodes dissection (R2) were performed. The tumor was located in the greater curvature from the body to the antrum of the stomach, and showed intra and extraluminal growth, measuring 15.0 ± 8.5 ± 5.5 cm with ulceration. The specimen had a huge foci of hemorrhage and necrosis, presenting as a cyst contained dark red fluid, 760 ml in volume. The patient has been well for 3 years and 10 months after operation. In addition to 143 cases of leiomyoblastoma of the stomach reviewed by Ono and the coworkers in 1982, 124 cases thereafter were collected and allocated to group A (26 cases accompanying by hemorrhagic and necrotic foci) and group B (98 cases without them). Group A included 4 cases of the intraperitoneal hemorrhage. There was no statistical difference between two groups in the distribution of age, sex and location, but there was in the growth form and size of tumors (p<0.005). In short, an increase in size of tumors presenting as extraluminal growth increase the frequency of association of hemorrhagic and necrotic foci.

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In terms of the literature, leiomyoma of the stomach with a diameter of more than 15 cm is designated as giant leiomyosarcoma. This disease is relatively rare. There were less than 100 cases including this case in the Japanese literature as far as we could review. Here such as case is described with a review of the literature. An 81-year-old man was admitted because of a left lateral abdominal tumor. On admission, an elastic-soft and infant's head-sized tumor ranging from the left lateral to upper abdomen was palpated. Abdominal CT and abdominal ultrasonography revealed a giant tumor with a diameter of 20 cm ranging from the upper to left lateral abdomen. Gastric endoscopy, enema, and abdominal angiography were added, but failed to offer preoperative definite diagnosis. On laparotomy the giant tumor was found only to connect with the middle part of the body of stomach. A diagnosis of submucosal tumor arising at the stomach was made. Subtotal gastrectomy with complete resection of the tumor was carried out. Resected tumor was 3, 100 g, 18×19×19 cm in size, and was diagnosed as gastric leiomyosarcoma histologically. There has been no recurrence up to now, 11 months after the operation.

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In a 56-year-old man under the treatment of gastric ulcer with anemia, a submucosal tumor in the posterior wall of the middle portion of gastric corpus was accidentally found by upper gastrointestinal series and gastroendoscopy. Abdominal CT and unltrasonography revealed a solid mass about 7 cm in diameter, locating in front of the pancreas and presenting as extragastrical growth. An extragastrically growing leiomyosarcoma was strongly suspected preoperatively. On laparotomy, an egg-size tumor was found to be arising from the posterior wall of the corpus of the stomach. The mass was pedunculated and encapsulated with no evidence of invasion into the surrounding organs. No hepatic metastasis nor peritoneal dissemination was found. Subtotal gastrectomy with dissection of regional lymphnodes (R₁) was performed. The resected mass measured 7.5×6.2×4.2 cm in size and lobulated with partial cystic degeneration.
Pedunculated gastric leiomyomas growing extragastrically behave specifically and differently from those presenting as other growth patterns. Here we describe a case and discuss its clinicopathological features and some problems in the surgical treatment.

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A 58-year-old man visited our clinic because of right upper abdominal pain. An upper GI series revealed lateral displacement of the antrum and the first portion of the duodenum by a large mass, but ulcer was not detected. The mass was disclosed the continuity to the pancreas by CT. Celiac arteriography demonstrated hypervascularity and mottled tumor stain at the right side of the pancreatic arcade and the tumor was fed by superior pancreatic-oduodenal artery. Pancreatic or duodenal tumor was suspected and operation was performed. Laparotomy revealed the tumor arising from the first and second portion of the duodenum and growing extraluminally, 8×5 cm in size, partially invading the pancreas and gastroduodenectomy was performed. Histological diagnosis of the operated specimen revealed leiomyosarcoma of the duodenum.

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A case of strangulating obstruction caused by mesodiverticular vascular band is deseribed. A 3-year-old boy was admitted to the department because of abdominal pain and vomiting. A plain X-ray film of the abdomen showed a fluid level in the dilated intestinal loop and ultrosonic study demonstrated both the some amount of ascites and weakness of intestinal peristalsis around the right lower quadrant of the abdomen.
The patient underwent emergency operation and was found a strangulated intestine with moderate vascular disturbance and both the Meckel's diverticulum and a about 2 cm length band coursing from the tip of the diverticulum to the anterior leaf of mesentery of the terminal ileum about 40 cm proximal from the ileocecal valve. The main reason of the intestinal obstruction was considered that above band compressed the wall of the bowel at 3 cm proximal to the diverticulum, and strangulation occurred by twisting of the mesentery with about 50 cm length of the ileum toward 180 degree to clockwise direction as a volvulus. Then, the diverticulum was removed by wedge resection following reduction of the intestinal obstruction. The histopathological examination revealed that the band contained not only arterial component but also venous one.
The embryological view of the vitelline vein, which has not arrived at any agreement as yet, and a review of 24 cases reported in Japan are presented.

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This report describes one autopsy case of colony stimulating factor producing leiomyosarcoma of the ileum. A 74-year-old man was admitted to our hospital with a loss of appetite and epigastralgia. At admission patient had a dilated chest subcutaneous veins, axilla and inguinal lymphnode swelling, and a huge tumor in the left abdomen. Blood chemical examinations resulted in the white blood cell count of 22500 mm³, serum LDH of 825 IU, and ALP of 24.6 KAU. CT revealed a giant mass in the abdomen and angiography showed a tumor stain in the mesentery, but no abnormality was found by enema. There was no passage disturbance in the upper gastrointestinal tract. After admission the condition of the patient abruptly wortheded, and he died on the 20th hospital day. Autopsy disclosed that the tumor was leiomyosarcoma of the ileum. Immunochemical stainning using polyclonal CSF antibody was weakly positive in the tumor tissues.

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Diverticulum of the vermiform appendix is a rare disease and only 66 cases have been reported in Japan. In this paper, a case of the disease is described. A 23-year-old woman was admitted to the hospital because of right lower quadrant pain. Acute appendicitis was suspected and operation was performed. A tumor with a size of the thumb was palpated on the mesentery of the vermiform appendix. Appendectomy was carried out. Gross examination of the appendix revealed an absence of inflammation but a tumor formation with partial abscess in the appendiceal submucosa, and some structure seeming diverticulum. Histopathologically 4 diverticulum ducts and abscess due to diverticulitis were observed. These diverticula were diagnosed as pseudodiverticula. In the treatment of appendiceal diverticulum, operation is, of course, indicated, if diverticulitis developed. If an asymptomatic diverticulum is accidentally found by barium enema or in the operative course for other reason, appendectomy is recommended, because it is less invasive surgical procedure and appendiceal diverticulum has a high risk of perforation compared to colic diverticulum.

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A case of pseudomembranous colitis presenting with tachycardia, fever, and shock, but not accompanying by abdominal pain and diarrhea in an early stage after gastrectomy is described. Pseudomembranous colitis, if it occurs in an early stage after gastrointestinal operation, often lacks in abdominal symptoms. This case, being sucessfully diagnosed to start the treatment in a relatively early postoperative period, is rare.
A 52-year-old man underwent total gastrectomy for primary malignant lymphoma. Cefotaxim (CTX) administration was started on the day of operation. From the 3rd postoperative day severe tachycardia, fever, and shock occurred, and nosotropic therapy failed to improve the general condition. Cause searching try also failed to disclose any complications such as anastomotic leakage and abdominal bleeding. On the 4th day a large amount of water diarrhea appeared. Endoscopic examination of the large intestine was performed. Based on macroscopic findings and biopsy cytodiagnosis, a diagnosis of pseudomembranous colitis was made. Administration of vancomycin hydrochloride and a large quantity of transfusion led to rapid symptomatic remission.

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A relatively rare operated case of signoid colon cancer synchronously associated with multiple myeloma (MM) is reported.
A 64-year-old man pointed out hypergammaglobulinemia from the biochemical examination was diagnosed as having IgG (λ) type MM by electrophoresis and bone marrow biopsy. Two weeks after the melphalan treatment was begun, he underwent a barium enema and was diagnosed as having a sigmoid colon cancer. sigmoidectomy with lymph nodes dissection was performed. The patient left our hospital 30 days after the operation. Unfortunately he acquired a pulmonary infection due to pancytopenia caused by MM and died 11 months after the melphalan treatment, or 9 months after the operation.
We should use caution with any other cancer patient which is complicated by MM. It is rare that colorectal cancer is associated with MM, but not rare that MM is associated with malignant disease. We should pay attention to renal failure and leakage from colorectal anastomosis in the operative management of colorectal cancer complicated by MM, because MM is a high risk disease accompanying with renal dysfunction and hypoalbuminemia.

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A case of rectal cancer metastasizing to only the spleen is reported. The patient was a 70-year-old man who had undergone subtotal gastrectomy with lymphnode dissection (R2) under a diagnosis of early gastric cancer in the department 8 years before. The patient has been followed up, and high serum levels of tumor markers were found. Barium enema showed a stenosis on the upper part of the rectum. Abdominal CT offered a suspicion of metastasis to the spleen. As endoscopic biopsy estimated the malignant tumor on the rectum, the low anterior resection and splenectomy were performed. The pathological specimen of the spleen showed the metastases of rectal carcinoma. After the resection of those lesions, the tumor markeres decreased to normal limit. This patient is doing well 1.5 years after surgery. A solitary metastasis to the spleen is considered very uncommon.
It is suggested that serum CEA well corellates with clinical course in the metastasis to the spleen. Relatively good prognosis can be expected for resectable cases having a metastasis to the spleen, and hence, such cases might be candidates for radical operation.

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Two cases of resectable metastatic colo-rectal cancer are reported. Case 1 was a 75-year-old male, complaining of melena. There was a history of distal gastrectomy performed under a diagnosis of Borrmann type 2 gastric cancer 3 years and 5 months before. Histological findings showed the poorly differentiated adenocarcinoma with signet-ring cell carcinoma. It was absolute curative operation with P₀, H₀, n₁, and pm. This time barium enema radiograph and colonoscopy revealed Borrmann type 3 lesion in the transverse colon and Borrmann type 1 lesion in the descending colon and rectum (Rb). It was difficult to discriminate the lesions from primary multiple colo-rectal cancer preoperatively. Case 2 was a 57-year-old female, complaining of a tumor in the right abdominal region. There was a history of total gastrectomy due to a type 5 gastric cancer 3 years and 9 months before. Histological findings showed poorly differentiated adenocarcinoma with signet-ring cell carcinoma. It was absolute curative operation with P₀, H₀, n₁, and ssγ. This time barium enema radiograph showed the fixed transverse pararell fold and an elevated lesion in the ascending colon. Colonoscopy showed severe stenosis of the lumen with nodular elevations and ulcers. Histological examination of the biopsy specimen demonstrated poorly differentiated adenocarcinoma with signet-ring cell carcinoma in the lamina propria mucosae. It was possible to diagnose case 2 as a metastatic colo-rectal cancer preoperatively. The most probable mode of metastatis to the colon and rectum appeared to be lymphogenic.

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Carcinoid tumor arising from the colon is a relatively rare entity. A case of perforated sigmoid colon carcinoid is reported.
A 67-year-old female was diagnosed as having peritonitis due to perforation of a sigmoid colon cancer, and underwent sigmoidectomy. The tumor was about 10 cm in diameter and about 5 mm size of perforation was noticed in it. Diffusely infiltrating carcinoid tumor was recognized microscopically. The patient developed multiple liver metastasis shortly after the operation. Inspite of frequent hepatic arterial infusion of chemotherapy, she dided 10 months after the operation. We have experienced twenty-nine cases of carcinoid tumor arising from the digestive tract in as relatively low as a recent one decade, but only two cases from the colon. The rate is 6.9%. The case of perforated colon carcinoid is quite rare and we found only one case in the literature. The clinical course and prognosis in this case were discussed.

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In four cases of cyst of the liver, CA19-9 in the cyst wall was explored immunohistologically.
Three cases without renal failure showed serum CA19-9 level of less than 37 U/ml. Remarkably higher CA19-9 levels in the cystic fluid than the serum ones were shown, namely, more than 10, 000 U/ml in 2 cases and 1, 300 U/ml in one case. In the remaining case with renal failure, CA19-9 was 1, 300 U/ml in the serum or more than 10, 000 U/ml in the cystic fluid. Localized CA19-9 in the epithelial cells of the cyst wall of the liver was found in all the four cases.
From the above findings, it is suggested that the epithelial cells of the hepatic cyst wall secrete CA19-9 into the cystic fluid.

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A 43-year-old man underwent subtotal pancreatectomy for chronic pancreatitis with subcutaneous and bone marrow fat necrosis. Postoperatively symptoms of chronic pancreatitis and subcutaneous necrosis resolved, but bone marrow fat necrosis became worse. The patient died of multiple organ failure 3 years and 5 months after the operation.
Chiari first reported an association between subcutaneous fat necrosis and pancreatic disease in 1883 and subsequently several additional cases were reported in Europe and the United States of America. In Japan, few cases of fat necrosis have been reported, and this case is only the 11th. Seven cases were associated with acute or chronic pancreatitis and three cases were postoperative complications. If the release of pancreatic enzymes into the general circulation secondary to pancreatic inflammation is the primary etiologic factor in fat necrosis, then treatment by subtotal pancreatectomy is a reasonable approach. This case supports this hypothesis, at least in cases of subcutaneous fat necrosis.

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A rare case of solid and cystic tumor of the pancreas is described with a review of 121 collective cases reported in Japan.
A 22-year-old woman consulted our hospital because of continuous upper abdominal pain. A fist-sized tumor was palpated in the right upper abdomen. CT scan showed a cystic tumor located in the head of the pancreas, with the size of 15 cm in diameter. The patient was operated on. The tumor was well encapsulated with a firm, white, fibrous capsule, and was resected. No infiltration into the pancreas parenchyma was noted.
On the cut surface, the tumor was composed of solid and cystic lesions, with necrotic and hemorrhagic materials. Microscopically the tumor tissue showed pseudopapillary stractures with numerous PAS-positive granules. Some of tumor cells were positive for α₁-antitrypsin. Electron micrograph showed that tumor cells were rich in mitochondria, and some of them contained zymogen-like granules. From these findings the diagnosis of solid and cystic tumor was made. The patient is doing well up to now, 12 months after surgery. A total of 122 cases including this case seen in the Japanese literature were reviewed to clarify the clinical and clinicopathological features.

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This is a report of a case of nonfunctioning islet cell carcinoma which occupied almost the entire upper abdomen in a 72-year-old female complaining of an upper abdominal tumor and epigastric pain. She had the tumor for 10 years and it's size increased slightly over the last three years. Enhanced CT pictures showed irregular tumor staining and a cystic pattern. An angiography revealed the hypervascular tumor. Serum levels of various endocrine hormones were within normal range. Therefore, the tumor was thought to be a nonfunctioning islet cell tumor of the pancreas. During surgery it was found that the tumor was located in the tail and body of the pancreas, and was 15×13×8.0 cm in size with macroscopic small metastatic lesions in the liver. Postoperative histopathological examination revealed malignancy with venous and lymphatic invasions.
Nonfunctioning islet cell tumors are rare, have a high frequency of malignancy, but grow slowly, and the prognosis after surgical resection is generally good. In this case recurred liver metastasis could be detected by remarkable increase in serum neuron specific enolase which had been monitored after surgery, its availability as a tumor marker being suggested.
Aiming at life-prolongation, intensive treatments including intra-arterial infusion chemotherapy and transhepatic arterial embolization are now in consideration.

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Congenital mesoblastic nephroma is a kind of the renal hamaltoma. It occurs in a frequency of 7% of all renal tumors in children, but is so rare in adults that only 5 domestic and 3 foreign cases are seen in the literature. Congenital mesoblastic nephroma is a benign tumor clinically and histologically, however, it is difficult to distiguish it from renal cell carcinomas, based on symptoms and various imagings. In this paper an extremely rare case of this disease in an adult is reported, with some discussion on its clinical and pathological features from a review of the literature.
A 41-year-old woman was seen because of a left upper abdominal tumor. The patient was suspected to have a renal cell carcinoma from abdominal ultrasonography, DIP, abdominal CT, and angiography of the kidney. Left nephrectomy and lymph node dissection surrounding the abdominal aorta and vena cava inferior were carried out. Histopathologically it was diagnosed as congenital mesoblastic nephroma.

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A 43-year-old female having felt a sense of fullness in the upper abdominal region lasting from some years before went to a hospital and was indicated to have a right epigastric mass. The patient was introduced to our hospital. From abdominal ultrasonography, CT, and angiography findings, a retroperitoneal cyst was suspected. Operation was performed. The excised specimen was a single, giant cyst with very thin wall, containing about 2, 300 ml of serous fluid. Histologically, the cyst was an adrenal angiomatous cyst.
Adrenal angiomatous cysts are rare, and commonly benign. Conservative treatment such as puncture and aspiration can sufficiently manage, but for giant cyst like this case, surgical operation would be indicated, because of possible risks such as an association of pressure symptoms and spontaneous rupture of the cyst.

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A case of lymphangioma of the lesser omentum is reported.
A 55-year-old man was admitted to our hospital because of abdominal distention. Laboratory data showed nothing in particular. Ultrasonography and computed tomography showed a multilocular cystic tumor situated among the liver, the stomach and the pancreas. The tumor was connected with a structure, which was probably the lesser omentum. The tumor was soft and its shape was altered with change in position. X-ray of the stomach, ERCP and angiography revealed only the findings of compression and magnetic resonance imaging showed low intensity area in T-1 and high intensity area in T-2. Under a diagnosis of lymphangioma of the lesser omentum, laparotomy was performed. The tumor was surrounded by the lesser omentum and connected with the lesser curvature of the stomach, but was not connected with the liver and the pancreas. The tumor was 8×7×5 cm in size and a multilocular cyst. Histologically, the diagnosis of lymphagioma was established.
Lymphagmoma of the lesser omentum is very rare and 14 cases seen in the Japanese literature were reviewed.

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A 72-year-old female visited our hospital, because an abdominal mass was pointed out by medical examination. The mass was palpable at the right upper abdomen, which was movable and as large as an infant's head. On diagnostic imaging methods, the surrounding organs were found to be compressed by the tumor. Abdominal angiography revealed the feeding artery and faint hypervascularity of the tumor. Mesenteric tumor was suspected and laparotomy was performed. The tumor was connected with only the lesser omentum and developed in the bursa omentalis, being excised easily. Other abdominal organs were normal and there were neither lymph node swelling nor peritoneal dissemination. The excised tumor was 17×12×11 cm in size, and 1110 g in weight. Histologically, it was diagnosed as leiomyosarcoma. The postoperative course was uneventful and the patient is alive and well without any recurrence at present. Primary leiomyosarcomas of the lesser omentum are rare and only 13 cases have been reported in Japan. Further discussion is made by reviewing the literature.

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This is a case report of left subclavian vein thrombosis in a chronic dialysis patient with functioning brachialmedian A-V fistula of the ipsilateral arm.
A 50-year-old man undergoing continuous hemodialysis for 15 years was admitted to the hospital because of disabled left arm due to severe swelling which developed about one year before and gradually worsened. Phlebography showed total occlusion of the left axillary-subclavian vein and marked development of collateral superficial vein. Left axillary-internal juglar vein bypass was made with a 8 mm ringed E-PTFE graft. In postoperative course, functional disability in the left arm resolved rapidly although swelling of the upper arm remained for several months. Graft patency was confirmed by postoperative phlebography and was indebted to the presence of A-V fistula.
Deep vein thrombosis complicated by A-V fistula in hemodialysis patients usually occurred secondary to central vein (CV) catheterization for temporary blood access. However, in this case there was no history of CV catheterization and the cause of deep vein thrombosis was unclear.

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Persistence of the sciatic artery, a rare vascular anomaly, has been reported in about 75 cases in Europe and the U.S. and 17 clinical cases in Japan. A 28-year-old female was admitted to the hospital because of hemihypertrophy and superficial venous dilatation of the left lower limb about 6 years before. Angiographic examination revealed the persistent sciatic artery on the left side. Stripping had been performed for superficial varicosity, but she developed venous stasis symptom again half a year later. So aneurysmorrhaphy of the common iliac artery was made to reduce blood flow over the dilated common iliac artery. This time the patient visited the hospital because of an abdominal tumor and increased venous stasis symptoms. Angiography showed an aneurysm from the abdominal aorta below bifurcated renal artery to sciatic artery. At surgery, a Y-shaped woven dacron graft was placed from the infra-renal artery to right common iliac and left extermal iliac artery. The left internal iliac the politeal artery were ligated, and a PTFE graft was placed from the left leg of the Y-shaped graft to the popliteal artery. Pathological finding was medianeclosis.

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Abnomalities in serum cholinesterase (ChE) are rarely reported in Japan. In the past 20 years, 30 cases have been reported and only three of these occurred in children. We experienced a patient presenting with very low ChE levels who had an attack of prolonged apnea over along period following a radical operation on a right external inguinal hernia. The patient was an one-year-old female infant. There was no past or family history and no abnormalities in ordinary tests on admission. Anesthesia was induced by 10 mg of SCC intravenously and was maintained by GOF after intubation. The operating time was 13 minutes, but spontaneus respiration was delayed to appear postopertively. The serum ChE was 1 mu/ml (normal range: 173432 mu/ml) and it took about 3 hours were spontanous respiration appeared. The postoperative course was favorable thereafter. The diagnosis of the disease was suspected from nerve stimulation during anesthesia, and was confirmed by taking blood samples. It appears that a nerve stimulator is effective as a monitor of prolonged apnea.

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Malignant mesenchymoma is a tumor consisting of two or more clearly identifiable and immature mesenchymal elements. In this paper a rare experience with malignant mesenchymoma presenting as a giant tumor in the thigh is described with a review of the literature. An 83-year-old woman visited the hospital because of a giant tumor on the left thigh. A giant soft tumor with a diameter of 23 cm was confirmed. Operation was carried out and well capsulated tumor was excised with the gratiris muscle. The excised tumor was 26×23×22 cm in size and 2.6 kg in weight. Two finds of histopathological findings were shown in the tumor. One was a rhabdomyosarcoma, embryonal type. The other was a well differentiated liposarcoma sclerosing type. Therefore, the patient was diagnosed as having a malignant mesenchymoma.

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