With the view to elucidating risk factors on aged patients with stomach cancer, the correlations of preoperative test results and degree of surgical stress with postoperative complications were examined in 58 patients with stomach cancer, aged of 80 and over. For risk factors, a correlation of abnormal ECG and respiratory dysfunction with postoperative complications was noted, while for surgical stress, combined resection of other organs and intraoperative bleeding showed a correlation with postoperative complications, but the degree of lymph node dissection did not therwith. These results suggest that combined resection of other organs, which causes excess stress and intraoperative bleeding should be avoided as possible as we can, thereby making it possible to carry out radical operation for stomach cancer associated with lymph node dissection R₂ or so even in aged patients.

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The mass screening for thyroid cancer combined with that for breast cancer in females over 30 y. o. had been conducted in Shiga Prefecture from Sep. 1982. First 204 operation cases of thyroid disease (120 benign and 84 malignant cases) experienced in females over 30 y. o. at the department from 1983 to the end of March 1991 were clinically studied by dividing them into a screening group and out-patients group whose lesions were found by another means. 44.2% of benign operated cases were occupied in the screening group and 55.8% in the out-pt group. When compared to out-pt for benign disease, less cases of Basedow's disease were noted in the screened patients but cases of adenoma and adenomatous goiter were equally much in both patients. 67.9% of malignant operated cases were occupied in the screening group and 32.1% in the out-pt group. Although malignant diseases of the screening group had smaller tumor diameter compaired to the others, more lymph node metastasis were found. And minute cancers of the thyroid gland were found in 40.4% of malignant disease in the screening group.
It is though that the mass screening is useful for detecting small thyroid cancer and will help to enlighten the general public and practitioners about the thyroid cancer.

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In a recent 5-year period, 31 cases of primary lung cancer with pleural effusion were experienced at the department. All cases underwent cytological examination of pleural effusion, and 18 cases were negative (negative group) and 13 were positive (positive group). Both groups were compared for prognosis. No 5-year survivor was noted in the both groups, and there was no significant difference in the prognosis between them. though prognoses of them were poor. The existence of pleuritis carcinomatosa in the negative group was examined pathologically for operated cases and roentgenographically for non-operated cases. Of 18 cases in the negative group, at least 7 cases of pleuritis carcinomatosa could be confirmed. A probable factor for poor prognosis in negative group might be admixture of false negative cases of pleuritis carcinomatosa. There is a great possibility of false negative or pleuritis carcinomatosa with non cacerous pleural effusion, if lung cancer is adenocarcinoma with no combined disease such as atelectasis or pneumonia and located in contact with pleura, even though cytology of pleural effusion is negative. In a case of hilar type of lung cancer or hilar lymph node metastasis, we should pay attention to a possible invasion to the greater vessels.

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In order to assess the immune activity in patients with gastric cancer, 82 patients were classified into four stages by histological findings, and lymphocyte subsets were analyzed with monoclonal antibodies including CD3, CD4, CD8, CD11b, CD15, CD45R, CD56, CD57, and Leu8. These measurements were compared by stages of the disease, namely, stage I (23 cases), stage II (16), stage III (19) and stage IV (24).
In T cells, decreases in CD4⁺ CD45R⁺ Leu8⁺ (suppressor inducer T) cells and CD8⁺ CD11b⁺ (suppressor T) cells were observed with an advence in the stage. In NK cells, CD57⁺ CD16⁺ (NK+++) cells decreased with an advence on the stage. In LAK cells, a decrease in CD3^- CD16⁺ CD56⁺ (NK-LAK) cells and an increase in CD3⁺ CD16^- CD56⁺ (T-LAK) cells were noted with an advance in the stage.
These results suggested that, with advance in the stage of gastric cancer, suppressor inducer, suppresser cell subpopulation and NK, NK-LAK cell subpopulation decreased, while T-LAK cell subpopulation increased.

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The utility of para-aortic lymph node dissection was evaluated in a histological study for metastasis in gastric cancer. Para-aortic lymph nodes were dissected from 91 cases of gastric cancer, and metastasis in para-aortic lymph node was histologically confirmed in 21 cases (23.1%). In all cases with para-aortic lymph node metastasis, the depth of invasion was to the serosa (S2) and gastric cancer histological type was moderately or poorly differentiated adenocarcinoma or mucinous carcinoma. All 21 cases with para-aortic lymph node metastasis were associated with n1 (+) and n2 (+) metastasis, but 9 (42.9%) of them were not associated with n3 (+) metastasis. The rates of the metastasized lymph nodes to the total number of n1 (+) and n2 (+) in 21 cases with para-aortic lymph node metastasis were significantly greater than those in other cases without para-aortic lymph node metastasis (p<0.01). Prognosis was poor in cases with para-aortic lymph node metastasis. We would suggest that para-aortic lymph node dissection should be performed in cases with level of serosal invasion of S2 or deeper, as well as in cases without serosal invasion (S0, S1) in which N2 (+) metastasis was found. However, this dissection should not be performed in cases in which metastasized para-aortic lymph nodes constitute a large proportion to the total number of metastasized n2 lymph nodes. It is thought that the number of metastasized n2 lymph nodes may be an indicator for para-aortic lymph node metastasis.

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In order to determine prognostic factors of Borrmann type 4 gastric carcinoma, 8 long-term survivors and 23 short-term recurrent patients with stage III gastric cancer, who were operated on at the department in a recent 14-year period, were compared for location and size of the tumor, histologic type, serosal invasion, lymph node metastasis, vascular invasion, and mode of recurrence. In evaluation of patients in stage III, which was free from peritoneal and hepatic factors, it was clarified that serosal factor was more valuable than lymph node factor. Lymph node invasion and tumor diameter were also important prognostic factors. Peritoneal lavage cytology revealed carcinoma cells in all patients who had serosal invasion without macroscopic peritoneal dissemination. Analysing the types of the recurrence, the most common type was peritoneal dissemination, that is, prevention of peritoneal dissemination was essential in postoperative adjuvant therapy in patients with Borrmann type 4 gastric cancer.

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Twenty-seven cases of carcinoma of papilla Vater, which were taken by microscopically absolute curative resection, were investigated clinicopathologically. The five-year survival rate for these 27 patients was 56.4% and ten-year survival rate, 50.1%. In point of gross appearance of the tumor, the prognosis of the protruded type was better than of the ulcerated type. Microscopically, the cases with pancreatic invasion or with invasion beyond the duodenal wall showed poorer prognosis than the cases without these factors. The lymphatic involvement were seen mainly at the anterior pancreaticoduodenal region, posterior pancreaticoduodenal region and around the superior mesenteric artery. The prognosis was closely related to lymphatic involvement (p<0.05). However, it should be pointed out that there was a long-term survivor with lymphatic involvement around the superior mesenteric artery as a result of aggressive lymph node dissection. Pancreaticoduodenectomy with lymph nodes dissection including around the superior mesenteric artery should be selected as standard procedure for patients with carcinoma of papilla Vater.

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Fourteen cases of idiopathic perforation of the colon and rectum experienced at the hospital from April 1984 to September 1991 were clinically studied. Idiopathic colorectal perforation was commonly found in aged women whose bowel tended to shop. These perforations were predominantly located in the antimesenteric side of the rectosigmoid junction and sigmoid colon. Five cases presented shock symptoms, and 4 of them were associated with no increased leukocytes. It took 24 hours or less for 7 cases to be operated on from the onset of the symptoms. All 5 shock cases were included in these 7 cases. Severe cases fell in shock state in an early period, and a significantly large number of them had normal or decreased leukocyte count, compared to others. One out of 14 cases was lost because of postoperative complication. The mortality rate was 7.1%. In a relation between operative procedure and postoperative complications, a significantly lower occurrence of postoperative complication was noted in cases undergoing colostomy. Colostomy appeared valuable to prevent postoperative complications. Infection of the surgical wound was the most common complication, and a significantly longer hospital stay was observed in cases complicated by such wound infection.

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Thirty operated cases of colorectal cancer in aged patients over 80 years old were studied with reference to their characteristics, surgical outcomes, postoperative laboratory findings, and postoperative complications.
1) Well-differentiated advanced colonic carcinomas were predominant; and emergency operation for ileus or perforation represented 33.3%. 2) Resection rate was 96.7%; curative resection rate, 79.3%; and 5-year survival rate in curative resections, 54.3%. 3) Postoperative complications occurred in a high rate of 51.7%. The complications were commonly found in a patient group having 4 to 5 abnormal laboratory findings among 8 items and perforation, too. 4) Preoperative abnormal laboratory findings were commonly seen in terms of the lung and nutrition, which well corresponded with frequent occurrence of pneumonia and anastomotic breakdown. Moreover, encephalopathy or phrenophathy characteristic of aged people was also frequently observed. 5) It is thought that safe operation and postoperative management in response to each patient, which are able to prevent these postoperative complications and operative death, are necessary.

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In surgical patients undergoing anal sphincter-saving operation for rectal cancer the occurrence of anorectal dysfunction or dysuria was investigated by operative procedures. Subjects were 20 patients undergoing anterior resection and 6 undergoing Turnbull-Cutait's pull-through operation in a recent 5-year period.
The distance from the anal verge to the colorectal anastomosis in anterior resection cases was longer than that in pull-through operation cases. Among 20 cases of anterior resection and 6 cases of pull-through operation, 7 cases of the former and 2 cases of the latter defecated more than 4 times every day; one case of the former could not distinguish between defecation and flatus; 4 cases of the former and one case of the latter had incontinence of stool; 3 cases of the former and one case of latter had sense of remainder of stool; each one case of both needed an exative; and 5 cases of the former only had dysuria. Though the distance from the anal verge to the anastomosis in the cases with anorectal dysfunction tended to be shorter than that in the cases without anorectal dysfunction for each operative procedure, there was no significant difference in the frequency of anorectal dysfunction and dysuria between them.

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The causes and preventive management were evaluated for intraoperative troubles in 83 cases of laparoscopic cholecystectomy performed at the department since December 1990. In respect of troubles based on insufflation there were 1 omental and 2 subcutaneous emphysemas, and all of which were cured conservatively. Troubles based on operative technique included arterial bleeding in 3 cases, perforation of the gallbladder in 10 cases and injury of cystic duct in one case. One of the arterial bleeding experienced in early days was converted to open surgery for hemostasis, but the others were restored by only clipping. Half of perforations of the gallbladder could not be restored untill the end of cholecystectomy, and therefore the gallbladder was withdrawn from body cavity by putting it into a condom. The injury of cystic duct was due to the side burn of electrocautery, for which a ligation of the cystic duct was performed on the 1st postoperative day. Three cases with bleeding from the liver bed, which could not be well controlled, underwent a removal of insufflation and gauzy oppression for hemostasis. In this paper our cases as well as a review of the literature are presented.

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Adenoma of the nipple is an uncommon lesion of the breast. It can be clinically mistaken for Paget's disease, because the both have common clinical features such as erosion, ulcer, and crust of the nipple. Histologically this disease also mimics syringocystadenoma papilliferum, intraductal papilloma and well-differentiated adenocarcinoma. This paper describes a case of adenoma of the left nipple in a 60-year-old married woman, who was seen at the hospital because of bloody nipple discharge and a firm erosive lump measuring 8×8 mm in the nipple.
The number of cases previously reported under these various terms in Japan is only 22 (including this case). These 22 cases were reviewed in terms of the clinical and pathological features of this entity.

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Three cases of synchronous and primary bilateral breast cancer in which the diagnostic imaging was very useful are described.
Case 1: A 63-year-old female. A 46×36 mm tumor was palpated in the right region C, but no palpable tumor in the left breast. Ultrasonography showed a hypoechoic lesion of about 5 mm in diameter on the left breast. Intraoperative frozen section diagnosis revealed bilateral breast cancers. Case 2: A 76-year-old female. A nodule 20 mm in diameter in the right region C and a 20×20 mm tumor in the left region AE were palpated. Mammography and ultrasonography revealed an irregular shaped tumor shadow of about 9 mm on the right breast. We suspected as cancer as well as on the left breast. Case 3. A 53-year-old female. Bilateral breast nodules, a 80×80 mm nodule centering in the right region C to cover the entire breast and a 24×22 mm nodule in the left region C, were palpated. Mammography and ultrasonography revealed irregular shaped tumor shadows. Histological examination showed intraductal components in bilateral breasts of all three cases and they were diagnosed as primary bilateral breast cancer.
Mammography and ultrasonography of which resolution has been improved are useful to detect breast cancer in an early stage. It is necessary to explore the contralateral breast closely with possible synchronous bilateral breast cancer in mind.

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A 42-year-old woman was admitted to the hospital because of a huge tumor, 11×15 cm in size, of the left breast with bloody discharge from the skin erosion. Computerized tomography and echography revealed a large cystic mass with a small solid tumor beside it. About 400 ml of old blood was aspirated by fine needle aspiration cytology but no malignant cell was observed. Frozen section examination following excisional biopsy showed the tumor to be malignant. Modified radical mastectomy was performed. Histologically, almost of the mass lesion was occupied with the cyst with true wall, and the solid tumor beside the cyst is invasive ductal carcinoma. The carcinoma invaded beyond the cyst wall, in which vessels were exposed into the cyst. It is considered that the bleeding from these vessels resulted in the formation of such large cystic mass.
The relative risk of developing subsequent breast cancer among women with breast cystic disease is approximately two to four times that in women without breast cystic disease. However, this is a very rare case of breast cancer concomitant with huge cyst due to the rupture of the tumor vessels into the cyst.

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A case of primary malignant lymphoma arising in the breast is reported. A 35-year-old woman visited a near by hospital because a palpable and painless mass in the left breast, which was noticed in May 1991, showed an increasing tendency. Excision of the tumor was carried out. Histopathologically it was found a malignant lymphoma and the patient was transferred to the hospital. On admission no tumor nor superficial lymph node was palpable in the bilateral breasts. As a result of general Gallium scintigraphy and other methods, no other tumor nor swelled lymph node was revealed. Histophatologically the lymphoma was of B lymphocyte origin, and was diffuse type, medium-sized cell type by LSG classification. From the above, the tumor was diagnosed as primary malignant lymphoma of the breast in Stage IA by Ann-Arbor classification. On June 13 1991 left simple mastectomy with left axillary lymph node dissection was performed. As postoperative chemotherapy, epirubicin hydrochloride 10 mg on the first postoperative day and cyclophosphamide 100 mg on the 8th day were intravenously administered. Oral cyclophosphamide 100 mg was strated since the 6th day. Postoperative course was uneventful and the patient was discharged from the hospital on June 27 1991. There has been no signs of recurrence and metastasis up to now.

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Castleman lymphoma was first reported by Castleman as a case of mediastinal lymphnode hyperplasia in 1954. In Japan, that was first reported by Inada et al., in 1958. This paper describes a case of mediastinal Castleman lymphoma with a review of 218 cases in the Japanese literature. A 28-year-old male was admitted because of an abnormal shadow on a homogeneous mass (4.0×3.0cm) at the rt-anterolateral side of 7th vertebra. T2 weighted MR image demonstrated the tumor as a hyperintense lesion. The size of resected tumor was 4.0×2.8×2.5cm. It revealed gray colored homogenous section. According to the Keller's classificasion histological diagnosis was hyaline vascular type Castlman lymphoma.

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Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm. It may sometimes influence the hemodynamics severely. A case of ACF caused by rupture of abdominal aortic aneurysm into the inferior vena cava is presented.
A 68-year-old male was admitted to the hospital because of sudden onset of general fatigue indicating acute cardiac failure. A pulsatile abdominal mass was found in association with a thrill and bruits on the right side of the mass. A diagnosis of ACF was made based on the clear findings of enhanced CT. The fistula was closed from within the opened aneurysm sac and aortic continuity was restored with a Dacron bifurcation graft. Widened pulse pressure, high CVP, high cardiac output and tachycardia were improved immediately after the reconstructive surgery.
Although the diagnosis of ACF usually requires angiography for confirmation, CT scanning is useful for preoperative assessment of aneurysm and can demonstrate the presence of ACF.

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A resected case of bronchogenic cyst arising in the middle region of the mediastinum which had no communication with the bronchus is described.
A 65-year-old female was admited to the hospital because of strange feeling of the right back region. A chest X-ray film disclosed an abnormal mediastinal shadow and after further examination, a tumor, about 7.0×6.5cm in size, locating near the trcheal bifurcation was revealed. Operation was performed as the middle region of mediastinal tumor. The tumor was situated in the area surrounded anteriorly by the right main bronchus, medially by the esophageal lateral wall and posteriorly by the azygos vein. Tumor extirpation was performed, no communication between the tumor and the bronchus was demonstrated during surgery. Pathologic examination of the cyst revealed that the inner wall of the cyst was covered with ciliated columnar epithelium, and it was diagnosed as bronchogenic cyst. In general the disease manifests different clinical symptoms depending on the presence or absense of communication between the cyst and tracheobronchial tree. Besides, it sometimes occurs solitary in an uncommon site, or sometimes dose not present with the typical pictures of the cyst. In the imaging diagnosis of this disease, these points should be entertained.

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Four cases of multiple primary lung cancer were experienced at the department during the past twelve years. There were each two synchronous and metachronous cancers. Squamous cell carcinomas (SCC) were found in two cases, SCC and adenocarcinoma (AD) in one case, and adenosquamous carcinoma and AD in one case. Case 1. A 60-year-old man with SCC of the respiratory system underwent left lower lobectomy. There was a previous history of right middle and lower lobectomy seven years before. Case 2. A 67-year-old man with synchronous multiple lung cancer underwent right middle and lower lobectomy. Case 3. A 75-year-old woman had an adenocarcinoma of the left lingular segment 3 years after right middle and lower lobectomy for an adenosquamous carcinoma of the lung. As the patient refused any operation, radiotherapy was performed and she is alive bearing the cancer. Case 4. A 65-year-old man had SCCs in bilateral lower lobes due to chromium exposure. The patient underwent radiation and bronchial artery infusion, followed by left lower lobectomy. Then, laser therapy was scheduled for the lesion in the right lower lobe, however, the patient died of postoperative pneumonia. Some discussion on these cases of multiple primary cancer of the lung is presented, with a review of the literature.

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Recent experiance with 3 cases of catamenial pneumothorax is descrived. Patients were 40, 25 and 33-year-old wemen. Clinical diagnosis of catamenial pneumothorax was made based on their history and thoracotomy was performed in all 3 cases. The pneumothorax was localized on the right side in 2 cases and on the left side in another. In all cases, no lesions were observed on the diaphragmatic pleula, but on the viseral pleula adhesion with palietal pleula (2 cases) and numerous blebs (1 cases) were observed, and microscopic examination revealed the presense of endometrial tissue in these lesions. In Japan, 53 cases of catamenial pneumothorax, incruding these 3 cases, have been reported, but intra-thoracic endometriosis was histologically recognized in 25 cases. Out of these 25 cases, endometrial tissue was found on the diaphragma in 19 cases, and only in 6 cases found on the viseral pleula.

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A rare experience with malignant lymphoma of the rib is reported in the light of the related literature.
A 39-year-old male patient visited our hospital because of right back pain. The patient was diagnosed as having a malignant tumor of the right fifth rib from a chest X-ray film, CT and MRI. Intraarterial infusion chemotherapy reduced the tumor size remarkably and a radical operation could be undertaken. Histopathological findings showed a malignant lymphoma of the bone, diffuse large cell type (B). Adjuvant general chemotherapy was also performed and the patient feels well without any recurrence, as of ten months after the operation.

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A case of esophageal hiatus hernia presenting with upside down stomach is experienced. An 87-year-old woman was admitted to the hospital because of feeling of oppression in the chest and epigastric pain. From upper abdominal series the patient was diagnosed as upside down stomach type esophageal hiatus hernia. Endoscopic examinations of the esophagus and stomach revealed an association of multiple gastric ulcers. The patient was considered a possible candidate for operation. Operation was performed according to Hill's procedure, and simultaneously extended gastrectomy was done for the multiple ulcers. The patient developed pulmonary complication after surgery, but she recovered. No recurrence of hernia has not been experienced afterward.

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Postoperativemyocardial infarction frequently occurs in the patients with angina pectoris or with history of myocardial infarction. Therefore, surgical operation for some disease with a coronary heart disease is controversial.
A case of thoratic esophageal cancer recieving radical esophagectomy following successful percutaneous transluminal angioplasty (PTCA) is reported. A 64-year-old male was admitted to the hospital because of upper abdominal pain. There was a history of an attack of a myocardial infarction of the inferior wall when he was 53 years old. He had been suffering from angina pectoris for these 2 months before admission. Esophagography, endoscopy, and endoscopic ultrasonography indicated an early esophageal cancer. Coronary arteriography revealed 90% stenosis on the segment 2 of the right coronary artery. PTCA was performed and the stenosis was improved from 90% to less than 10%. One week later, total tharatic esophagectomy followed by a posterior mediastinal reconstruction using a gastric tube was carried out. Postoperative course was satsifactory. The patient is doing well now with niether evidence of recurrence of cancer not the attack of angina pectoris at the 24th month following the operation.
Radical operation is encouraged to perform for the esophageal cancer with coronary heart disease, provided that preoperative PTCA is successfully carried out.

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Esophageal cancer commonly metastasizes by the lymphatic circulation and rarely by the bloodstream. Its brain metastasis is exceedingly rare. We experienced a resected case of cancer of the lower esophagus with markedly elevated CEA which indicated synchronous multiple brain metastases. A 69-year-old man was admitted to the hospital because of dysphagia. Upper gastrointestinal series and endscopy revealed a cancer of the lower esophagus. Lymph node involvement in the upper abdominal region was seen, but neither lung nor liver metastasis was present. Subtotal esophagectomy and thoracic anastomosis were performed. After the operation, neurological symptom rapidly progressed and brain CT revealed multiple brain metastases. Probable rapid worsing of brain stem symptom was considered, aggressive resection of the brain tumors with post operative radiotherapy was performed, leading to good result. Considering quality of life of patients, the significance of aggressive resection is emphasized even for advanced esophagus cancer with distant metastases.

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This paper describes a case of Appleby's operation with reconstruction of hepatic artery by saphenous vein grafting for an advanced gastric carcinoma. A 74-year-old man had an advanced gastric carcinoma with direct invasion to the lateral segment of the liver and transverse mesocolon. Total gastrectomy, distal pancreatectomy, splenectomy, choleiystectomy, lateral segmentectomy of the liver, and partial resection of the transverse colon were performed. Since the common hepatic artery was entangled by the metastatic lymph nodes, the celiac artery was excised at its root and the proper hepatic artery and gastroduodenal artery were divided. To avoid ischemic liver damage, the hepatic artery was reconstructed using a saphenous vein graft. Postoperative liver function was satisfactorily maintained.

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Fifteen cases of primary gastrointestinal malignant lymphoma, including 10 of gastric, 3 of small intestinal, and 2 of colorectal lymphoma, experienced at the department were retrospectively studied in terms of the prognosis. There was a tendency to poorer prognosis in malignant lymphomas of the intestinal tract compared with those of the stomach. For this, we are able to consider some reasons that intestinal lymphomas hardly manifest clinical symptoms compared to others, and that those lymphomas are mostly in an advanced stage when detected, because diagnostic examinations for them are difficult. Several prognostic factors were studied, and a clear correlation with the depth of invasion was found. Survival rate of patients having a tumor invading submucosal tissues or less was 100%, which was significantly better than those having a tumor invading the muscularis propria. As to clinical staging, classifications according to “The General Rules for Clinical and Pathological Studies on Cancer of Colon, Rectum and Anus” clearly reflected the prognosis.
Of these 15 patients, compared to patient group with poor prognosis died within 2 years, almost patients who could safely see the 2nd year after surgery survived or survive for more than 5 years. It is considered important for gaining better prognosis to observe strictly the postoperative course for 2 years or more.

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Essential thrombocytosis is a disease belonging to the chronic myeloproliferative disease, and platelet function abnormalities are seen at a high rate in most cases. Not a few points still to be clarified in regard to the pathology, treatment, and prognosis of this disorder, and it is characterized by such phenomena as hemorrhage and thrombosis which seem on first glance to be incompatible. We experienced a case of protal hypertension due to thrombocytosis in a 52-year-old man who was associating with gigantic splenomegaly, esophageal varices, and gastric varices, for which esophageal transection and splenectomy were performed. During the 13th year after the operation he developed hematemesis due to a rupture of duodenal varices, and this was complicated by varices in the superior mesenteric vein. The bleeding in the ruptured varices was able to be stopped by endoscopic sclerotherapy.

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A case of retroperitoneal abscess due to a penetration of the duodenum by an ingested fish bone, in which emergency operation could saved the patient's life, is reported. This is the second case in Japan. A 65-year-old man was admitted to the hospital because of abdominal pain. There was a history of gastrectomy for gastric ulcer 16 years before. A abdominal plain X-ray photograph and abdominal CT revealed a retroperitoneal abscess due to the penetration of the duodenum by a foreign body. Laparotomy revealed the retroperitoneal abscess and the penetration of the posterior wall of the second portion of duodenum. The foreign body was recognized in the residual stomach by gastrofiberscope during operation and was taken out through gastrostomy. The foreign body was 58 mm in length, which was the longest ingested fish bone ever reported in Japan. In a review of 59 domestic cases of damaged gastrointestinal tract due to a fish bone, it is thought that the damaged portion and type of the lesion are not be able to be predicted by the length of the fish bone ingested by mistake.

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Recently primary adenocarcinoma of the small intestine has been increasingly reported on, however, it is still a relatively rare neoplasm. Here recent experience with a case of the disease is described with a review of the literature.
A 37-year-old woman was admitted to the hospital because of nausea and vomiting. Upper abdominal series and US of the abdomen revealed a carcinoma of the jejunum. On laparotomy the tumor was found locating at about 40cm from Treitz' ligament, presenting as a whole-circumference obstruction. Partial resection of the jejunum, dissection of regional lymph node, and jejuno-jejunostomy were performed. No lymph node metastasis or distant metastasis was presented.
In this case, it took about 5 months for making the definite diagnosis from the onset. If we encounter a patient who has an intestinal obstruction, who complains some gastrointestinal symptoms, or whose occult blood test results in positive, appropriate exploration of the small intestine would be important, entertaining a possibility of this disease.

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This paper describes a rare case of small leiomyosarcoma, with a diameter of less than 4 cm, of the jejunum, which was found in a patient undergoing examination for anemia who had no abdominal symptoms.
A 58-year-old woman was seen at the hospital because of general fatigue. She presented with moderate anemia. No abnormality was found in the stomach, duodenum and large intestine. However, angiographic findings revealed a tumor stain of walnut size in the branches of upper jejunal artery. The patient was diagnosed as having a jejunal tumor, and underwent laparotomy. Extra and intra luminally growing type of tumor, 4.0×2.5×2.5 cm in size, was found at 70 cm from the Treitz's ligament, and was removed by partial resection of the jeujunm. The postoperative course was uneventful and the anemic state was improved for better.
Generally, the prognosis of this disease is poor, and only effective therapy is the early resection. Therefore, aggressive examination of the small intestine must be performed for patients who show anemia and positive occult blood in stool and have no cause in the stomach, duodenum and large intestine. In this case, angiography is useful in the diagnosis of both existence and quality.

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This paper describes a rare case of primary carcinoma of the appendix with pseudomyxoma peritonei.
A 65-year-old female complained of right lower abdominal pain. Physical examination showed a marked tenderness and peritoneal sign in the right lower abdomen. Iliopsoas sign showed strong positive. Abdominal ultrasonography revealed a hypoechoic lesion with partially hyperechoic lesion, but vermiform appendix was not visualized. A possible diagnosis of retroperitoneal abscess formation due to perforation of acute appendicitis was made. Emergency operation was carried out. Intraoperative findings showed pseudomyxoma peritonei infiltrating into the right retroperitoneal cavity. Right hemicolectomy was done. Resected specimen revealed a tumor of the appendix, measuring 6.5×4.0 cm. Histopathological examination showed mucinous cystoadenocarcinoma of the appendix. Postoperative course was uneventful and the patient was discharged on the 19st hospital day.

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Myxedema coma occurs when hypothyroidism is neglected without treatment for a long term. Progressive disturbance of consiousness is the main sign of the disease and results in serious coma.
Recently a case of respiratory failure due to myxedema coma after colonic surgery was experienced. A 75-year-old woman was admitted to the hospital because of lower abdominal fullness. Emergency laparotomy was carried out under a diangosis of volvulus of the sigmoid colon.
Postoperatively, endocrine functional tests were ordered because of delayed postanesthetic recovery and primary hypothyroidism was found. She recovered well under administration of thyroid hormone and adrenal corticosteroids in spite of the sudden attack of respiratory failure.
Myxedema coma is very rare in surgical cases. The mortality rate is 50-80%, prognosis is very poor. A concealed myxedema coma should be considered before surgery and the immediate administration of thyroid hormone is effective.
Endocrine functional test is mandatory when a patient appears delayed recovery from anesthesia and or has a sudden onset of respiratory failure.

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The present paper describes a case of acute inferior mesenteric artery occulussive disease. A 79-year-old female was admitted to the hospital because of abdominal pain, tarry stool, and vomiting. On admission the patient was in shock and had a distended and hard abdomen. Abdominal simple X-ray films showed a remarkable gaseous shadow in the small and large intestine. Intestinal obstruction was suspected and emergency laparotomy was performed. It was found that intestinal necrosis presented in a region of inferior mesenteric artery and the inferior mesenteric artery was pulseless. The patient was diagnosed as acute inferior mesenteric artery occulussive disease. Left hemicolectomy and colostomy were conducted. Postoperative course was uneventful. Including this case, 13 have been reported in the Japanese literature so far. All 13 cases had a poor prognosis, in that the importance of early deiagnosis and early treatment should be emphasized.

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A case of colon cancer in pregnancy is reported. A 37-year-old pregnant woman visited a nearby hospital because of diarrhoea and bloody stool, which developed in the later period of pregnancy. She was diagnosed as gestosis and underwent cesarean section. After the surgery, however, bloody stool still continued and she was referred to the hospital. As a result of various examinations, an advanced colon cancer was found in the ascending colon and right hemicolectomy was performed. Histological diagnosis was well-differentiated adenocarcinoma, pm, ly₁, v₀, n₁, ow(-), aw(-), absolute curative operation.
Colorectal cancer in pregnancy is rare. It is said that one or two among 100, 000 pregnant women may have the disease. An association of colonic cancer is particularly rare, and only 36 cases can be seen in the Japanese literature. This case was the 37th one. In view of this possible association in pregnant women, we would emphasize the importance of early detection and early diagnosis by appropriate examinations.

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A patient with advanced rectal cancer which necessitated total removal of intrapelvic organs was able to be followed up for 2 years 7 months after the reconstruction with Sheele's bladder substitute. For this the patient's strong will for recovering social activities was satisfied. The patients was a 52-year-old man. There was a history of pulmonary resection of the right upper lobe and thoracoplasty for pulmonary tuberculosis. The patient underwent transurethral prostatectomy in 1988, when an ulcer was noted in the posterior wall of the bladder. The ulcer was not cured. In, April 1989, a Borrmann II tumor was detected by colonoscopy in the rectum 10 cm oral to the anus, and a diagnosis of ademocarcinoma was made by biopsy. Pelivic CT scan revealed invasion to the posterior wall of the bladder, the right ureter and the ileocecum, and the lesion was considered as advanced rectal cancer on May 9, 1989. Low anterior resection of the rectum, resection of the posterior wall of the bladder, ileocecal resection, and partial resection of the right ureter were carried out. Intestinal continuity was made by rectosigmoidostomy, ileo-ascending colon anastomosis. Reconstruction of the urinary bladder was made using substitute. Which was made by prepaing a 30 cm ileal loop into which the bilateral ureters were grafted. And this ileal loop was anastomosed to the auterior wall of the bladder. This bladder substitute had a capacity of 600 ml and tolerated a maximum internal pressure of 50 mmHg. Evacnation of urine was performed by adding abdominal pressure at the time of louer abdominal distension feeling. No urinary in captiuence bas been noted residual urine.

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A 61-year-old male patient underwent resection of a metastasized lesion to the ribs from a hepatocellular carcinoma followed by partial resection of the liver including the primary lesion.
The patient complained of swelling and pain in the back, and a child-fist sized tumor locating at the right side of the 10th thoracic vertebra was palpated. Resection of the 9, 10, and 11th ribs combined with thoracic wall was performed, followed by radiation therapy. From histological examination, hepatocellular carcinoma was strongly suspected. Abdominal ultrasonography and CT were carried out, and a low density area 3 cm long was found in S5 of the liver. Partial resection of the liver and cannulation into the proper hepatic artery through the gastroduodenal artery were performed and an Edmondson grade II hepatocellular carcinoma was found by pathology.
Some cases of hepatocellular carcinoma with bone metastasis, if the primary lesion is small and in an early stage, can be expected to have favorable prognosis after resection. This case is also expected having good prognosis by aggresive resections followed by intensive therapy including radiation or chemotherapy.

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A case of choledochocele, which is an Alonso-Lej type III congenital biliary dilatation, associating with stones only in the cyst is experienced.
A 39-year-old woman was admitted to the hospital because of submucosal tumor of the duodenum which was pointed out by endoscopic examination at medical checkout. Sometimes the patient had mild right hypochondralgia but she did not consult with any hospital. On this admission abdominal ultrasonography, CT, and ERCP revealed choledochocele of Scholz type B associating with stones in the cyst. Operation was carried out. On laparotomy levels in pancreatic enzymes such as amylase in the cystic bile juice were high; an opening 1 mm in size was found in the posterior wall of common duct due to papilloplasty and 3 stones were found in the cyst. The cyst wall was excised and sutured with the duodenal wall. Histologically the internal surface of the cyst was consisted of duodenal mucosa, and no malignancy was noted in the gallbladder. This case is the 59th in Japan. The disease is associated with stones and pancreatitis, as well as a malignant neoplasm in a relatively high rate. Probable actions of pancreatic enzymes to the cyst wall and biliary tract are inferred, where intra and postoperative histological exploration would be also necessary.

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A case of traumatic common bile duct (CBD) obstruction is reported. A 38-year-old male was admitted to the hospital because of injury of the liver and pancreas by a traffic blunt trauma. CT 10 days after the trauma showed a cystic change of the pancreas head. The cyst almost disappeared 1 month later and strictures of the CBD and main pancreatic duct were recognized in the pancreas head on ERCP. The patient was once discharged with almost normal labolatory data. Three months later, however, he was re-admitted because of obstructive jaundice, which was managed by PTBD. Cholangiogram with both PTBD tube and ERCP showed a complete obstruction of CBD, 7 mm in length, at the pancreas head. Fistulous tract of PTBD was dilated and re-cannalizatin with a cholangiofiberscopy was intended in vain. Choledocho-duodenostomy was performed without postoperative complications. Obstruction of CBD was inferred to be caused by CBD injury and fibrous change during cure of the pancreatic pseudocyst.

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Recently double cancer has been increasingly reported with an increase in the aged population, an advance of diagnostic instruments and a technical improvement of cancer therapy.
It is exceedingly rare that synchrous double cancer of the bile duct and lung has been successfully resected. This paper describes a resected case of synchronous cancer of extrahepatic bile duct (adenocarcinoma) and lung (squamous cell carcinoma).
A 68-year-old man was admitted to the hospital for close examination because of bloody phlegm, a tumorous lesion on a X-ray film, and jaundice. By TBLB, a tumor of the left lower lobe was diangosed as squamous cell carcinoma. By PTCS biopsy, a stenosis of the distal bile duct was diagnosed as moderately differentiated adenocarcinoma. A preoperative diagnosis of synchronous double cancer of the bile duct and lung was made.
It was judged impossible to resect the both carcinomas on an one-step approach in terms of surgical invasion. Intra-arterial infusion therapy with CDDP via the left bronchial artery was performed for the lung carcinoma, followed by left lower lobectomy with combined resection of the chest wall and ribs 42 days after pancreato-duodenectomy.
It is generally accepted that we must give a surgical priority to the more advanced cancer responsible for the prognosis of the patient carrying synchronous double cancer.
Multidisciplinary treatment and aggresive surgical intervention may bring the patient a long-term survival and favorable prognosis.

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Recent progression in medical thechnology has enabled us to diagnose some gallbladder carcinomas in a relatively early stage. It is the present condition, however, that almost gallbladder carcinomas are still detected in an advanced stage. This paper describes a case of gallbladder carcinoma associating with cholecystocolonic fistula.
A 79-year-old woman was admitted to the hispital because of an abdominal mass. Based on examinations with ultrasonography. CT, barium enema, and ERCP, the patient was diagnosed as having a gallbladder carcinoma, cholecystocolonic fistula, and choledocholith, and was operated on. It was found that the gallbladder was separated from the liver; most of the organ was filled with carcinoma cells, infiltrating into the transverse colon; a cholecystocolonic fistula 7 mm in diameter existed at the cervical region; and 3 calcium bilirubinate stones presented in the common bile duct. Cholecystectomy, incision of the common bile duct, insertion of T-tube, and partial excision of the transverse colon were carried out. Histologically it was a moderately differentiated papillary carcinoma, 7×4×2 cm in size, infiltrating into muscular layer of the transverse colon. The fistula was mostly comprized of inflammatory changes, which might be an internal biliary fistula due to cholecystitis associated with the carcinoma. There has been no signs of recurrence, as of one year after surgery, and the patient is followed on an ambulant basis.
This paper also presents some notes on accumulated 20 cases from the Japanese literature.

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With recent progression and widespread use of angiography, splenic artery aneurysm is increasingly detected, however, its rupture into the stomach has been reported in only 4 cases in Japan.
In this paper, a case of rupture of splenic artery aneurysm into the stomach is described, with a review of 48 such cases seen in the Japanese literature. A 51-year-old man was admitted to another hospital because of repeated massive hematemesis and melena. After conservative therapy, a submucosal tumor was suspected with endoscopic examination and the patient was sent to the hospital for further examination. He was diagnosed as rupture of splenic artery aneurysm with ECHO, CT and angiography. Resection of the aneurysm with combined resection of the stomach wall, spleen and pancreas tail was performed. Postoperative course was uneventful.
In the treatment of splenic artery aneurysm, early operation would be mandatory for patients who are pregnant and/or whose aneurysm is too large to be dangerous for perforation, as well as those having small aneurysms with diameter of 3.0 cm or less because of their potential of perforation.

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An 83-year-old man underwent partial excision of the colon for a cancer of the descending colon on December 5, 1990. On the 8th postoperative day the patient suddenly had a fever. A fungus was detected at the tip of a catheter used for intravenous hyperalimantation, however, blood culture resulted in negative, and no antimycotic agent was administered. Around one month after operation lumbago and pains at the lower extremities developed. Paralysis of the lower half of the body occurred around 90 days after surgery. High levels of mycotic index and serum Darabinitol were shown. Candida tropicalis was isolated from the cerebrospinal fluid. Roentgenography revealed a destroyed picture of pyramid in the 6 and 7th thoracic vertebrae and in 4 and 5th lumbar vertebrae, and an irregular narrowing of the intervertebral disc. MRI showed an extrinsic pressure coming from the anterior on the spinal cord at the 6 and 7th thoracic vertebrae. The patient was diagnosed as candidiasis spondylitis and candidiasis meningitis. He could recover after 4-month administration of antimycotic agents. This extremely rare case of mycosis profunda which might be caused by a catherter used for intravenlous hyperalimentation is described, together with a review of the literature.

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Recently as the angiography including cardiac catheterization is performed more frequently with an increase in arteriosclerotic diseases, local complication at a puncture site has become a serious problem. We experienced three complications of arteriovenous fistula, acute arterial thrombosis, and pseudoaneurysm in two cases. The arteriovenous fistula in case 1 at the right groin arose from the puncture of the superficial femoral artery at the origin where the femoral vein was dorsal to the femoral artery. Acute arterial thrombosis at the contralateral site in the same case was resulted from detachment of atheromatous plaque while compression after catheter removal. Pseudoaneurysm in case 2 occurred in the brachial artery. The patient had systemic hypertension and the puncture hole was about one third of the external diameter of the artery. Inappropriate compression of the puncture site lead to the formation of pseudoaneurysm. These complications are deeply related to arteriosclerosis. The intimal change, decrease of the wall elasticity and increased movability of the artery make manual compression difficult, thus forming the basis of the complications. Hypertension and/or hypercoagulability might be additional factors. Appropriate puncture and compression will be in need to prevent the local complications.

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Two cases of lower extremity embolism originated from mural thrombus of the proximal artery are presented. Case 1: A 53-year-old man was admitted to the hospital because of rest pain in the both legs. IV-DSA showed occlusion of distal branches of the deep femoral and popliteal arteries of the right lower extremity. Intra-opeative aortogram showed a defect of contrast media at just proximal of the aortic bifurcation. White mural thrombus was easily removed from slightly thickened intimal surface. Case 2: A 48-year-old man was admitted to the hospital because of rest pain of the right big toe. Arteriogram showed a partial defect of the common iliac artery caused by thrombus at the bifurcation of the right iliac artery, and segmental defects of the deep femoral, anterior tibial, and posterior tibial arteries. Thromboembolism of the peripheral arteries originated from the iliac mural thrombus was suggested. White thrombus in the common iliac artery and dark red thrombus in the internal iliac artery were successfully removed.

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Even in recent years there have been reports of multiple organ failure or death from the bite of a mamushi pit viper. In August 1989 we encountered a 68-year-old man who had marked swelling over an area extending from the lower extremities to the trunk after he was bitten by a mamushi pit viper. Conservative treatment was employed for the patient, it seemed to be successful, however, suddenly he developed sepsis on the 13th hospital day and died on 15th day. If relief incision had been performed, the number of complications probably would have been lower than it was. During the subsequent one-year period 9 cases of mamushi pit viper bites were experienced. Four out of the 9 patients with marked swelling were treated by relief incision, and three of the 4 had no secondary disease or complication. Immediately after the relief incision, swelling began to diminish in 3 of the 4 patients. One patient bitten in the hand developed swelling extending to the chest and neck, causing dyspnea. Mamushi antitoxin was administered to only one of the 4 patients treated by relief incision. The relief incision enabled easy discharge of the edmatous fluid induced by mamushi poison, leading to prevention of a secondary disorder, compartment syndrome. When edema invades the forearms or thighs causing swelling, and numbness, and pain in the peripheral side are severe, relief incision should be performed.

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