A retrospective analysis was made on the detection of and infection by multi-drug resistant S. aureus in a single hospital. Materials were the documents of in- and out-patients during 1985 and 1990. Multi-drug resistance was defined as being resistant to four or more systems of antimicrobials. Nosocomial infection was detected by the pattern of drug sensitivity, biotype, and the dates of specimens having had multi-resistant S. aureus.
Eighty percent of all the carriers stayed in either the General Surgery Ward (A) or the Specialized Surgery Ward (B). The numbers of nosocomial propagations were four within Ward A, nine within neighboring Ward B, and six across Ward A and Ward B. Sputum was highly suspicious of causing the propagation. The amount of the third-generation cephems was significantly larger in Ward B than in Ward A (p<0.01) whereas the duration of antibiotic administration was comparable (p>0.05). Patients died with infection included an instance of renal failure caused by antibiotics sensitive to multi-resistant S. aureus..
In conclusion, the use of wide-spectrum antimicrobials should be prudent to avoid the induction of multi-resistant S. aureus., dissemination of which should be strictly monitored among carriers in sputum.

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One hundred and twenty-four patients with primary breast cancer were histologically examined to study blood vessel invasion (BVI) using both factor VIII-related antigen (FVIIIRAg) and Elastica van Gieson (El. v. G.) staining.BVI was found in 43.5% of the subjects. The 10-year survival rate in the patients with BVI was 48.1%, while that for those without BVI as favorable as 75.7% (p<0.001). The frequencies of BVI in papillotubular, solidtubular, and scirrhous carcinomas was 23.3%, 49.0% and 56.7% respectively (p<0.03, p<0.01). The 10-year survival rate for papillotubular carcinomas was 91.3% without BVI versus 42.9% with BVI (p<0.006). The frequency of BVI in node-negative patients was 29.7% while that in node-positive patients was 58.3% (p<0.002). Ten-year survival of node-negative patients with BVI was 63.2%, while that of node-negative patients without BVI was 93.3% (p<0.003).Thus BVI appears to be a major prognostic factor in node-negative breast cancers. In addition, use of both FVIIIRAg and El.v.G. staining proved to be an effective method for studying blood vessel invasion.

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A fundamental and clinical study of a new tumor marker BCA225 was cnducted. The concerntrations of BCA225 of healthy individuals show a logarithmic regularity distribution. The cut-off value was set 160U/ml, when the sensitivity was 72.5%, and specificity was 94.0%. In an assessment clinical utility of BCA225, it was found that the frequency of positive response to BCA225 rose with a progress of the disease, from 6.2% in Stage I, 24.1% in Stage II, 29.4% in Stage III-IV primary breast cancers and 66.7% in recurrent breast cancers. The positive test rate with BCA225 was comparable to or higher than that with CA15-3 or CEA, which were simultaneously examined. The results were further improved by using combination assay. Particularly in recurrent breast cancers, the positive test rate was 77.8% with BCA225 and/or CA15-3 and/or CEA. Though BCA225 lacks specificity to the organ involved in recurrence, the high sensitivity of BCA225 assay to recurrent breast cancer can be put to good use in the postoperative follow up or assessment of a effects of the treatment. The antigen recognized by BCA225 seems to be a glycoprotein, that is essential to the galactopoietic function of mammary cells and makes itself known when these cells are transformed.

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In operations for combined valvular disease including aortic valvular disease (group I) which abounds with extracoronary collateral myocardial blood flow and for mitral valvular disease (group II) which does not abound with extracoronary collateral myocardial blood flow, intraoperative and early postoperative recovery of cardiac function was analized by dividing the subjects into three groups according to time intervals of multidose (cardioplegic (CP) infusion. In group I, postoperative recovery of cardiac function was poor in a subgroup with short CP interval compared to that with long CP interval. In group II, the short CP interval subgroup showed a better recovery. Extracoronary collateral myocardial blood flow has disadvantages to wash out CP solution and to increase the temperature of the myocardium, however, at the same time, it has an advantage to protect the myocardium because the blood supplies oxgen and substrates and wash out the metabolites. As a result of this study, it was comfiemed that CP infusion with a shorter interval provided a better protection of myocardium in the disease where extracoronary blood flow did not abound. In the disease which abounded with extracoronary blood flow, its presence might not be disadvantageous, but rather advantageous for protecting the myocardium.

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In order to clarify the biological properties of poorly differentiated adenocarcinoma of the stomach, a clinicopathological study was conducted for 251 cases by subclassifing into a group having solid-type (51 cases) and the other having non-solid-type (200 cases) tumors.
1) Solid-type tumor was predominant in men, and the average age of patients with non-solid-type tumor was significantly younger.
2) On gross type, Borrmann III and II tumors were common among solid-type cases, whereas type IV and III tumors predominated in the others.
3) There was a significantly higher incidence of venous invasion in the solid-type tumors, with a greater extent of invasion.
4) Metastasis to the lymphnodes was present in 82.0% of the solid-type cases and 79.0% of non-solid-type cases, with no significant difference. However, a significantly (p<0.01) higher incidence of metastasis to the liver was not in solid-type cases (3.0%) than the other (13.7%).
5) Poorly differentiated adenocarcinoma had a poor prognosis. When 5-year survival rate was compared between these subgroups, it was 43.5% for solid-type group and 33.6% for the other, indicating a somewhat favorable prognosis for solid-type tumors.

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In a recent 15-year period from 1976 to 1990, 1146 cases were operated on for gastric cancer, and 34 (3.0%) out of 1146 cases were complicated by liver cirrhosis. There were 30 males and 4 females, and the mean age was 60.7±10.2 years old. According to the Child's classification, 22 cases were classified into group A and 12 into group B. The case of Group C had not been operated on. In macroscopic classification of liver cirrhosis, there were one case of Ko-type and 33 of Otsu-type. Clinical staging resulted in 20 cases in stage I, one in stage II, 7 in stage III and 6 in stage IV, liver metastasis being noted in only one case. Though we tried to minimize the operation time and blood loss, by performing R₀ in 2 cases, R₁, in 14, and R₂ in 18, postoperative course was often complicated by excessive ascites and leakage, leading to hepatic failure. The late-deaths were more commonly caused by hepatic failure rather than by recurrent gastric cancer, in which a possible association of secondary hepatocellular carcinoma was indicated.

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Hepatic resection under the intermittent hepatic vascular exlusion technique (IHVE) was carried out on five patients with liver tumor involving major hepatic vessels which seemed otherwise difficult to resect, and its efficacy was evaluated. The total clamping time was 38 min for 3.8 clampings on average. Division of the right adrenal vein was necessary for a complete hemostasis during hepatic resection under IHVE, which was obtained in four patients. Maneuverability around major vessels was also improved due to IHVE, making the surgery less dangerous. General haemodynamic conditions during IHVE were stable, except for increased vena cava pressure and slightly decreased cardiac output. Postoperative course was uneventful except for pleural effusion in four patients. These results show that IHVE is a useful and safe procedure for hepatic resections, offering a bloodless operative field and improved the maneuverability around major hepatic vessels, in patients with liver cancer involving major hepatic vessels.

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Eighty-seven resected cases of gallbladder carcinoma treated in the hospital and referral hospitals were clinicopathologically reviwed with respect to the resectability and outcome. The relationship between depth of invasion and survival was determined. The 5-year survival rate was 100% for “m” and “pm” lesions. On the other hand, cases which were able to be diagnosed preoperatively were as low as 38.6% for “m” and “pm” lesions respectively. The 5-year survival rate was 55% for “ss”, 34% for “se”, or 15% in “si” lesions. Stage, Binf depth of invasion and number of lymph node metastases were the most important determinants of the resectability and outcome.
The depth of invasion and pattern of tumor spread were most useful in selecting the operative approach. Recently endoscopic ultrasonography has proven useful in determining depth of invasion preoperatively.
In concusion, it is our policy that the choice of operation, i.e., extended cholecystectomy, right hepatectomy, or pancreato-duodenectomy, is determined according to the pattern of spread, depth of invasion, and presence of lymph node metastases.

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In spite of a progress of the imaging diagnosis, many advanced cancers are found in the pancreatobiliary lesion. The operative indication for hepatopancreatoduodenectomy (HPD) has been increasing.
From July 1987 to Aug 1991, HPD was performed in 10 cases. Major hepatic resection in which more than two segments were resected was performed in 7 cases. Minor hepatic resection in which less than two segments were resected was performed in 3 cases. Operative mortality rate was 30% and median survival time was 1.34 years in all HPD cases. While these figures were 28% and was 1.2 years respectively in HPD cases with major hepatic resection. In HPD with major hepatic resection, preoperative high serum bilirubin and cholangitis were considered to be the operative risk factors. The peak value of postoperative serum alkaline phosphatase well corresponded to the results of the operation in survivors. The two non-survivors undergoing HPD with major hepatic resection were all men and their diagnoses were superficial spread type bile duct cancer. Two cases of long survivors were recorded. We would intend to improve the results of HPD by renovation of preoperative and operative management.

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A recent progress in operative techniques and improvement in pre-, intra- and postoperative patient care have enabled the positive application of pancreaticoduodenectomy even to aged patients. Pancreaticoduodenectomy was performed for carcinoma in region of the head of the pancreas in 186 patients in the period from January 1965 to December 1990, including 135 patients under 70 years and 51 patients over 70 years. In this study, comparison was made between two 'age groups, aged group over 70 years and younger group under 70 years. Some underlying diseases were found before operation in 50.4% of younger and 62.7% of aged patients, giving a slightly higher percentage in the group of aged patients. Significant differences was observed between the groups for the time required for operation (p<0.1) and amount of hemorrhage during operation (p<0.01), but nor for the stage of cancer, lymphnode dissection and incidence of postoperative complication. Prognosis was poor in either of the groups except patients with carcinoma of the papilla of Vater. When the average survival duration of aged patients after surgery was compared between pancreaticoduodenectomy and palliative operation, it was longer in the former with a significant difference. Pancreaticoduodenectomy should be applied positively even to aged patients. It is important, however, to employ extended operative procedures such as extended lymphnode dissection and resection involving vessels, fully respecting the quality of life of each individual patient, because those who underwent pancreaticoduodenectomy are liable to develop diarrhea and other digestive disturbance after operation.

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Revascularization was performed in 186 vessels from 144 patients with chronic abdominoaortoiliac occlusive disease (AIOD), and the outcomes were investigated. Fifty-six patients (72 arteries) were treated by anatomic bypass (ANAT), 76 patients (100 arteries) by extraanatomic bypass (EXT), and 12 patients (14 arterires) by thromboendoarterectomy (TEA). The cumulative patency rate after 3 years was 90.6%, and that after 10 years was 88.0%, with no reocclusion after the 4th postoperative year. The patency rate in the ANAT group after 10 years was 93.4%, that in the EXT group after 9 years was 80.3%, and that in the TEA group after 6 years was 100%. Occlusion did not occur in any of the patients with femoro-femoral bypass (F-F) in the EXT group, with a patency rate of 100% after 9 years. However, the patency rate in the patients with axillo-femoral bypass (AX-F) in the same group was 74.2% after 8 years, showing a significant difference from F-F cases. In the Ax-F groups patients with poor run-off in an occlusive site inferior to the superficial femoral artery, higher patency rates were observed in the subgroups that underwent femoro-popliteal bypass (F-P) comparing with the subgroup that did not undergo a procedure to improve the run-off.
It is therefore recommended that patients with AIOD should be treated with ANAT. If EXT is performed, F-F appears the better selection than Ax-F. These results also suggest that F-P should be included in the operative procedure for superficial femoral artery occlusion.

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A clinical evaluation of induction and recovery times using a new volatile agent sevoflurane was made in 20 adult patients whose ASA status was 1 or 2. In the operating room, monitors were placed in each patient. Slow induction with 33% oxygen-nitrous oxide and 1% sevoflurane was started by using facemask. The sevoflurane concentration was gradually increased to 4% and maintained until the endotrachial intubation. Avarage induction period was 2.38±0.62 minutes, and the loss of eyelid reflex was 2.23±0.66 minutes. Average time of 9.58±1.90 minutes was required to facilitate the endotracheal intubation. Maintenance of anesthesia with 33% oxygen, nitrous oxide and 1_??_2% sevoflurane was continued until the operation was over. Following the end of operation, all anesthetic discontinued, and ventirated with 100% oxygen. Avarage awaking time from the end of operation was 5.45±1.76 minutes, and extubation period was 7.99±1.93 minutes. We concluded from this study that the induction with and recovery from sevoflurane anesthesia were very quick. Further favorable outcomes will be expected of sevoflurane in venous occasions.

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Recent experience with a rare case of acinic cell carcinoma originating from the minor salivary gland, which metastasized to the lymph node in the submandibular region following repeated recurrence after the initial operation 30 years before, is reported here.
The patient was a 66-year-old man. There were histories of undergoing the initial operation for a tumor in the right oral vestibule at elsewhere about 30 years before and the second operation for a tumor in the same region 5 years before, of which details were unknown.
Recently the patient visited the hospital because of tumors of the submandibular region and minor salivary gland. Aspiration biopsy cytology of both tumors showed class IIIb. The right submandibular gland with the tumor and the tumor of minor salivary gland were therefore removed. The final histological examination showed the lymphnode metastasis in the submandibular region from the acinic cell carcinoma originating from the minor salivary gland. It is generally known that the acinic cell carcinoma of the salivary gland is relatively low grade malignant, although the recurrence rate isn't low. In this case reoperation for the radicality was not performed, because the patient and his family never hoped, where long-term follow up would be mandatory.

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Clear cell carcinoma of the thyroid is a subtype of follicular carcinoma and a relatively rare disease. It often metastasizes hematogenically and has a poor prognosis. Recent experience with an operated case of clear cell carcinoma of the thyroid developed after previous operation for a breast cancer is described with a review of the literature.
A 50-year-old woman was seen at the hospital because of hoarseness and a tumor of the neck. Based on ultrasonography and aspiration cytology, the tumor was diagnosed as thyroid carcinoma. There was a history of undergoing radical mastectomy for a breast cancer 7 years before, and hence the patient turned out to have heterochronous double cancer of the breast and thyroid. Preosperative ultrasonography revealed tumors in the left lower pole, right upper and lower poles of the thyroid. Subtotal thyroidectomy was performed. It was thought that the carcinoma of the thyroid was multi-centric origin, coexisting of papillary carcinomas and clear cell carcinomas.There has been no recurrence of thyroid carcinoma up to now, and the patient is followed on an ambulant basis.

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Differentiated carcinoma of the thyroid has a good prognosis. However, once it extensively invades the surrounding organs, associated excision of the involved organs is necessary. Recent experience with three cases of thyroid carcinoma invading the trachea and cervical esophagus, which necessitated total thyroidectomy and resection of the pharynx, larynx, cervical esophangs, with reconstruction of the cervical esophagus with transplantation of free jejunum, is described here.
Case 1 was a 70-year-old woman. She underwent this operative procedure for a recurrent carcinoma of the thyroid invading the trachea and esophagus. No postoperative complication was found. Eight months later, she died of recurrence in the mediastinum from the thyroid carcinoma. Case 2 was a 57-year-old woman. She underwent this procedure for thyroid carcinoma with solitary lesion in the lung and infiltration into the trachea and esophagus. After the operation a transient dysphagia was observed. The patient has been having a comfortable daily life, as of 3 years after the operation. Case 3 was a 74-year-old woman. She was operated on by this procedure for thyroid carcinoma with multiple metastasis in the lung and infiltration into the trachea and esophagus. As of 2 months after the operation, dyspnea disappears and remarkable remission in performance status has been noted.

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Multiple schwannoma of cervical sympathetic origin is very rare, and we report the second case of this disease in Japan.
A 38-year-old woman was seen at the hospital because of tumor on the right side of the neck. No pigmented spots on the surface of her body were detected. The tumor was palpated on the medial upper one-third of the right sterno-mastoid muscle. It had a smooth surface, and was a 3×2cm elastic hard tumor without spontaneous pain or tenderness. Another tumor, 2cm in diameter, was detected over the right subclavian artery by ultrasonography, CT and MRI. Operation was performed under a suspection of multiple schwannoma. Postoperatively, both tumors were diagnosed as schwannomas of sympathetic origin. Homer's syndrome has continued for seven months after the operation, but there has been no sign of recurrence of the tumors.
Enhanced-MRI using Gd-DTPA seemed to be very useful in diagnosing this disease.

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A 31-year-old woman was seen at the departments of otorhinology and internal medicine because of hoarseness persisting from around February 1988. Close examinations were performed and tuberculous lymphadenitis in the left hilum of the lung associated with left recurrent laryngeal neuroparalysis was suspected. Tuberculostatic therapy failed to improve hoarseness and a tumor shadow did not diminish. On July 13 1990, the patient was operated on purposes of diagnosis and treatment at the department. On thoracotomy it was found that the tumor arised in the thoracic vagus nerve; was 4×6cm in size in the vicinity of the arterial ligament; continued to the cervical vagus nerve keeping a width of about 1cm in the head-side; and shifted to the abdominal vagus nerve with a normal thickness in the tail-side. The intrathoracic vagus nerve was excised as much as possible. Based on intraoperative findings CT and MRI were performed postoperatively, and it turned out the tumor running from the bilateral vagus nerves of the neck to the chest vagus nerve. After the operation the patient was referred to the department of dermatology and was diagnosed as Von Recklinghausen's disease. Neurofibroma arising in the intrathoracic vagus nerve is very rare. There has been no report of this disease extending from bilateral vagus nerves of the neck to that of the chest.

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A 47-year-old woman was seen the hospital because of a tumor of the right breast and axillar tender masses. Aspiration cytology suggested malignant non-epithelial tumor, and modified radical mastectomy was carried out. Histologically, the tumor was non-Hodgkin lymphoma, diffuse mixed type on LSG classification. Postoperative examination disclosed no abnormal findings and so it was diagnosed as primary malignant lymphoma of the breast. Two years have passed since postoperative chemotherapy, but there have been no signs of recurrence. This disease is relatively uncommon and 133 cases have been reported in Japan. The clinical features of this disease could be drawn as follows: (1) The right c side resion was predominatly exsited, and the tumor size on diagnosis was bigger than that of the breast cancer. (2) Any preoperative image diagnoses were not useful, and excisional biopsy led to a correct diagnosis.(3) The 5-year survivasl rate of primary malignant lymphoma of the breast was poorer than that of breast cancers, 37.5%. (4) Prognosis was strongly related to tumor size and axillar lymph node involvement. Curative operation inclusivc of chemotherapy and radiotherapy should be also taken into consideration for the better prognosis.

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Mediastinal yolk sac tumor is an infrequent malignant germ cell tumor, occurring predominantly in younger men, and long-term survival is very rare.
We encountered a case of recurrent mediastinal yolk sac tumor which rapidly enlarged in the thoracic cavity, with an increase in serum alpha-fetoprotein about one year after excision of the primaly lesion. An aggressive treatment consisting of chemotherapy with CDDP, BLM, and VBL followed by surgery performing at when normalization of APF level was confirmed achieved a successful outcome.
It is suggested that AFP is well correlated with the diagnosis, clinical course and prognosis, and combination of chemotherapy and surgical resection may improve the survival rate of patients with mediastinal yolk sac tumor.

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A 73-year-old man diagnosed as having unstable angina underwent A-C bypass procedure employing the internal thoracic artery (ITA), gastroepiploic artery and saphenous vein. Six days later, complication of mediastinitis due to MRSA developed and was treated with irrigation using antibiotic and povidone-iodine solution. On the 13th postoperative day massive hemorrhage suddenly occurred from the pericardial drainage tube, and emergency operation was carried out. During surgery rupture of the ITA was revealed. After ligation of the ITA, the infected sternum and costal cartilages were removed and bilateral pectoralis major muscles were transposed on the anterior mediastinum. The mediastinal infection was well controlled without dysfunction of the pectoralis major muscles by the 49th postoperative day. It was considered that the transposition of the pectoralis major muscles was effective for mediastinitis after A-C bypass procedure in this patient.

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This paper describes a recent experience with foreign bodies in the diaphragm and lung, which might be due to acupuncture and caused intermittent anterior chest pain in a 46-year-old man, together with some discussion on the route of invasion of them.
The patient, who had been treated at nearby hospital under a diagnosis of angina pectoris, was seen at the hospital. There was a history of undergoing acupuncture one year before, when he was suffering from lumbago. The acupuncture needle pricked the back at the height from the first to the third lumbar supine. No episode existed that the needle pricked elsewhere. A little while after that time, the anterior chest pain developed. Simple chest X-ray film and echocardiography revealed three needles left as the foreign bodies, two in the diaphragm and one in the lung penetrating into the pericardium. At the time of thoracotomy, one needle penetrated into the pericardium was successfully removed, but the others were not found. After surgery, the anterior chest pain was gone. Since the total length of the three pieces of needle matches the length of one Japanese needle of the acupuncture, it is considered that one needle which was pricked into the back was broken and moved through the diaphragm to the lung. This is a first case as the foreign body. The residual two pieces of the needle is to be strictly followed for symptoms and locations.

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A case of adult Bochdalech hernia in a naturally healthy 45-year-old woman is reported. The patient was seen at the hospital for further examination, because she was indicated as having an abnormal shadow in the left lower lung field after consulting a nearby doctor for a slight abdominal pain. Barium enema revealed a dislocation of the colon into the thorax through the left posterior-lateral diaphragma and adult Bochdalech hernia was indicated. The resection method used for the postero-lateral diaphragma defect was done via the abdominal cavity, resulting in a 5-year trouble-free period. Adult Bochdalech hernia is relatively rare, and only 69 case sincluding this case have been reported in the Japanese literature. Most cases involved persons in their twenties and the oldest was a 76-year-old person. The most common symptom included a slight abdominal pain, cough, or ileus. Since some cases affected by ileus driven shock, and mother and child died together due to herniation were reported, radical operation should be recommended when asymptomatic.

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We report here a recent experience with a case of Morgagni hernia involving the transverse colon and greater omentum.
A 72-year-old woman, who had been having discomfort of the right thoracic region without consulting any hospital for 6 years, was seen at a nearby physician because this discomfort became continuous and was pointed out an abnormal shadow on chest X-ray examination. The patient was referred to the hospital. In the front view of the chest by simple X-ray photograph, a shadow of a mass containing air with a relatively clear margin was shown in the right lower pulmonary field. In the lateral view, a similar finding was located adjacent to the rear side of the sternum at the lower frontal pulmonary septum. By intestinal contrast X-ray photography, thoracic putting-in of the transverse colon was detected. In addition, chest CT revealed a prolapse of the intestinal tract, extending from the rear side of the sternum to the frontal pulmonary septum. Based on the above findings, the patient was diagnosed as Morgagni hernia and subjected to surgical operation. The surgery was performed via the celiac route. The transverse colon was found to put in through a fissure gap under the right diaphragm. The intestinal tract putting-in was about 7cm in length and the hilus of hernia was 5×4cm in size. The cyst of the hernia was turned around into the peritoneal side, and could not be excised. The hilus of the hernia was then closed by knotted sutures. After the surgery, discomfort in the thoracic region felt before the surgery was improved and the abnormal shadow in the X-ray photograph disappeared.

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A case of diaphragmatic hernia caused by a trauma is reported, and the differential diagnosis of this disease is also discussed in this paper.
A 57-year-old man was admitted to hospital because of nausea and dyspnea on February 25 1991. There was a previous history of multiple fracture of the left ribs 36 years before when be met a cave-in accident at a coal mine. Two years later the patient was pointed out dislocation (arised) of the diaphragma at a medical checkup, but he neglected any treatment. On this admission, chest radiography revealed a gastrointestinal gas shadow in the left lung field. Dyspnea was resuscitated by N/G tubing. The gastric volublus was observed in GI series and left diaphragmatic cruris was unclear in CT-scan. We diagnosed his condition as the diaphragmatic bernia. The operation was performed via abdominal approch. There was a defect of 10cm in diameter in the posteo-lateral point of left diaphragma, and the stomach, spleen, small and large intestine were escaped into the thoracic cavity. The defect was repaired with a prostate. The patient was discharged from the hospital 19 days after the operation uneventfully. Based on the presence of previous his history of trauma, no evidence of intestinal malrotation, and the location of its wide defect, the patient was diagnosed as traumatic diaphragmatic hernia.

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A new surgical approach using esophageal mucosal stripping technique in the treatment of major leakages of the esophagojejunostomy after total gastrectomy is presented. This procedure is indicated for patients with such major leakage in whom local infection can not be controlled even by sufficient drainage and nutrition management and fatal septic process is progressing. This procedure was successfully performed in 2 such patients.
First, the intrathoracic esophageal mucosa is stripped off by the help of a vein stripper after separating the anastomosis. Edematous part of the jejunal end is resected and the stump is closed. After a Witzel jejunostomy is performed, the closed limb is brought out to the level of the abdominal wall and fixed subcutaneously. The cervical esophagus is exteriorized and both proximal and distal ends of the intrathoracic esophagus are tied.
The merits of this approach are: 1) The ultimate objective which is mandatory for the treatment of infection is achieved, because the source of contamination is eradicated. 2) It is a rapid and technically easy procedure resulting in less operative trauma to the already compromised patient. 3) Enteral feeding can be started immediately after operation. 4) Differing from whole esophageal stripping, there is no risk of iatrogenic dissemination of infection intramediastinally. Hemostasis is easily achieved by the tamponadary effect of the accumulated blood in the esophageal muscle tube.

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A case of duodenal carcinoid metastasizing to lymph nodes in the posterior region of the pancreatic head, which was difficult to distinguish from a retroperitoneal tumors, is described.
A 48-year-old woman was pointed out having a palpable tumor in the right upper abdomen at a periodic examination. Ultrasonography and CT revealed a 7.5cm tumor in the posterior region of the pancreatic head. The patient was admitted to the hospital for further examination. ERCP showed a small elevated lesion, 1.5cm in diameter, with a delle oral-side to the papilla of Vater. From biopsy results a diagnosis of duodenal carcinoma was made. Entertaining a possibility of primal lymph node metastasis or retroperitoneal tumor because of too large lesion as a tumor, existing in the posterior region of the pancreatic head, pancreatoduodenectomy was carried out.In the resected specimen, there were three tumors, namely a 1.5×1.5×1.0cm tumor in the duodenum, and 4.5×5.5×4.5cm and 3.0×2.5×2.5cm tumors at the back of the pancreas. Histopathologically the three tumors were positive for Grimerius staining, and were diagnosed as primary duodenal carcinoid with metastases to the lymph nodes at the back of the pancreas.
It is thought that pancreatoduodenectomy with lymph node dissection is necessary even for a duodenal carcinoid of less than 2cm in the maximal diameter.

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Ischemic enteritis uncommonly occurs in the small intestine and such enteritis causing intestinal obstruction is rarely encountered. This paper describes a case of ischemic jejunitis causing intestinal obstruction with a review of the Japanese literature.
A 77-year-old female was admitted to the hospital because of abdominal distension and vomiting. There was a history of hypertension. Physical findings on admission revealed paralytic ileus. Conservative treatment improved abdominal distension and allow the patient oral intake. But 4 weeks later, the patient developed abdominal distension again, and mechanical obstruction of the jejunum was indicated by abdominal X-ray examination. Coservative treatment for 3 days failed to improve the condition. Laparotomy was performed and segmental stenosis of the jejunum about 15cm in length at about 60cm distant to the Treitz's ligament was found. The jejunum oral to the stenosis was remarkably distended. Pulsation was not palpable at the marginal artery of the stenotic segment, but the supuior mesenteric artery was found to be normal. Resection of the stenotic jejunum and end-to-side anastomosis were performed. Histopathologically the patient was disgnosed as ischemic enteritis with necrosis of mucosa and marked siderofer cell infiltration.

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The hamartoma in the small intestine is extremely rare. There have been only 8 reported cases including this case in Japan. In these 8 patient group, the mean age was 36.1 years old. The male-to-fimale ratio was 5:3. showing a slight dominance in men. There was no significant difference between the jejunum and ileum on the site of the tumor. All tumors were smaller than 5cm in diameter.
This case was occasionally found during an operation for a gastric cancer, that might, suggest the importance careful intraoperative examination for an asymptomatic tumor of the small intestine.

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This paper presents a case of primary ileal undifferentiated carcinoma as well as a clinicopathological study of 95 cases of primary small intestinal carcinoma in Japan from 1965 to 1990. A 63-year-lld man was admitted to the hospital. Laparotomy was carried out under a diagnosis of ileus. A hard tumor was found at the ileum 150cm oral side from the Bauhin. The tumor was polypoid type with the size of 4×3cm. Histological type of the tumor was undifferentiated carcinoma (P₀, H₀, ss, ly₂, v₀ n (-), M (-), ). Curative operation was performed.
Of 95 cases of primary small intestinal carcinoma, 59 lesions in the jejunum and 33 in the ileum were diagnosed histologically. Sixty-four tumors (69.6%) were found within 49cm from the Treiz and Bauhin. In these parts of the small intestin, well and moderately differentiated adenocarcinomas were dominant (87-88%). And the rate of poorly differentiated adenocarcinomas and undifferentiated carcinomas was only 12 to 13%. On the other hand, the rate of poorly differentiated adenocarcinomas and undifferentiated carcinomas increased to 35.7% in the jejunum and ileum which were over 50cm far from the Treiz and Bauhin.
In 13 cases showing preoperative serum CEA level of over 5ng/ml, 9 (69.2%) were non-curatively resected. Five of the 9 cases had peritoneal dissemination, 3 liver metastasis, 2 para-aortic lymph node metastasis, and 2 severe local invasion. So it was suggested that preoperative serum CEA level would be a good marker reflecting the stage of small intestinal carcinomas.

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Inflammatory fibroid polyp (IFP), which is defined as an inflammatory tumor of unknown etiology arising in the gastrointestinal organs, uncommonly occurs in the small and large intestine. Only 50 cases in the small and 10 in the large intestine can be seen in the Japanese literature as much as we can review. Case 1 was a 40-year-old woman. She was admitted to the hospital because of lower abdominal pain and constipation. A tumor of the ovary was suspected and the patient was operated on. An intussusception provoked by a tumor was found in the ileum. Partial excision of the ileum was performed. A 4×4×5cm pedunculated polyp was found. Case 2 was a 43-year-lold man. He was pointed out having a polyp of the large intestine on medical checkup. A 3×2cm sausage-like tumor was found in the sigmoid colon. Partial excision of the sigmoid colon was carried out. In both tumors hyperplasia of sparse chollagen fibers and fibroblasts, and infiltration of lymphocytes, plasmocytes, and mainly eosinophils were observed.

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A 43-year-old woman was admitted to the center because of sudden abdominal pain and abdominal distention. Plain X-ray films of the abdomen showed comma-shaped, markedly distended bowel, suggestive of the sigmoid colon, in the left lower quadrant. Barium enema demonstrated an abrupt cut-off and the bird beak sign in the sigmoid colon. Preoperative diagnosis of sigmoid volvulus was made and emergency laparotomy was performed. No abnormalities were found on the sigmoid colon. The cecum was markedly distended and counter-clockwise cecal twisting by 360 degrees around the first portion of the ascending colon was observed. Definite diagnosis of a cecal volvulus was established. Since the patient had a long mobile cecum, was made cecopexy between the cecum and parietal peritoneum was following detorsion of the volvulus. The post-operative course was uneventful and she has been having no recurrence after the operation. Cecal volvulus is a relatively rare disease, therefore the correct preoperative diagnosis is difficult. Given the cecum was viable, cecopexy was a proper choice of treatment.

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Pseudomembranous colitis can be cured by conservative therapy in most cases, however, delayed diagnosis may necessitate surgical therapy for complications such as perforation and stenosis. Recently, we experienced a case of pseudomembranous colitis which was treated with sigmoidectomy because of hypoproteinemia. A 45-year-old woman had been prescribed antibiotics by a nearby practitioner because of common cold. After taking the antibiotics, the patient developed diarrhea and for a subsequent 5 months she was given various types of antibiotics and antidiarrhetic agents. Gradually, diarrhea with blood and mucus and lower abdominal pain became apparent. Enema demonstrated insufficient extension of the sigmoid colon, and colonoscopy exhibited redness and swelling of the mucosa and adhesion of pus coat. Moreover, Tc-albumin scintillation showed a protein loosing from the sigmoid colon. Sigmoidectomy was conducted for the treatment of protein loosing enteropathy. Histological examination of the extracted specimen, however, revealed pseudomembranous colitis. In light of these facts, pseudomembranous colitis should be suspected in patients who develop diarrhea during or immediately after administration of antibiotics, and appropriate treatment in the early stage is important.

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A 14-year-old girl was admitted to the hospital because of watery diarrhea and edema of the lower extremities. Barium enema and endoscopy of the large intestine revealed multiple colorectal polyps with a circumferential II_a. group-like elevated lesion at the rectum. Leakage of isotopes from the rectum to the sigmoid colon was proved on ^99mTc-HSA scintigram, and marked hypoproteinemia (TP 3.7g/dl), low level of IgG and increase in α₁-antitrypsin clearance were recognized. From the above findings a diagnosis of multiple cold-rectal polyps with protein losing gastroenteropathy was made. Although the intestinal lesion in this patient was a tubular adenoma with slight atypia, it was a so-called II_agroup-like lesion macroscopically, assuming a form whose canceration rate is called high, and was complicated with protein losing gastroenteropathy. And hence proctosigmoidectomy was performed though the patient was young. This paper describes this case together with some literature discussion.

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We report a case of leiomyoblastoma of the mesocolon, together with a brief review of the literature. A 79-year-old female was admitted to the hospital because of an abdominal mass. Abdominal CT scanning revealed a giant tumor with septums in the upper abdomen. Abdominal angiography showed a tumor shadow fed by the middle colic artery with an early venous filling. Under a diagnosis of primary tumor arising in the transverse mesocolon, operation was performed. During operation a tumor, 15×15×12cm in size and 1, 430g in weight, was found in the transverse mesocolon, and the tumor was removed with partial resection of the mesocolon and omentum. Historogical diagnosis was leiomyoblastoma of the transverse mesocolon. She has been doing well for 3 years and 6 months after the operation without any metastasis or recurrence.

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Recent experience with rare case of cecum cancer with an ovarian Brenner tumor is described. An 87-year-old woman was admitted to the hospital because of abdominal fullness, nausea and constipation. The physical examination demonstrated distension of the abdomen, tenderness, a mass in the right lower abdominal region and supracervical region. Barium enema and colonofiberscopy revealed a cecum cancer (Borrmann-1 type), and adenocarcinoma was diagnosed by the biopsy. Moreover, abdominal ultrasonography and CT showed the metastasis to the liver and right ovary. Operation was performed, and the laparotomy findings revealed an advanced cecum cancer with peritoneal dissemination, lymph node swelling, invasion into the right lobe of the liver and a tumor of the right ovary. The situation of the laparotomy seemed to be metastasis to the ovary or synchronous double cancer. The resected specimens revealed a mucinous adenocarcioma of the cecum and a Brenner tumor of the ovary. We reported a rare case of cecum cancer complicated with a Brenner tumor in the light of the related literature.

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This paper describes a case of sigmoidal cancer which had severe liver hilus lymph nodes metastases from a metastatic liver tumor with calcification. A 53-year-old woman visited a near clinic because of Herpes Zoster. She was pointed out having a large liver tumor by abdominal ultrasonography and was referred to the hospital. The liver tumor had severe calcification and liver hilus lymph nodes metastases. Serum CEA showed high level, and barium enema revealed a sigmoidal tumor.
An angiography and other examinations showed a stenosis and obstruction of the extra hepatic bile duct, right hepatic vein and portal vein. Sigmoidectomy, lymph nodes dissection, right hepatectomy and liver hilus lymph nodes dissection were performed. This case which had a liver hilus lymph nodes metastases from a metastatic liver tumor was rare.
In the surgical treatment of such metastatic liver tumor, the liver hilus lymph nodes dissection would have to be recommended.

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This paper describes a rare case of inflammatory pseudotumor in the liver. A 54-year-old man was admitted to the hospital because of a middle grade fever and left upper abdominal pain. Erythrocyte sedimentation rate was elevated and C-reactive protein was positive. Abdominal ultrasonography showed a heterogenous but clearly defined low echoic area about 2cm in diameter in the hepatic lateral segment. Abdominal computer tomography (CT) detected a low density area in the same hepatic lateral segment, and the contrast enhanced CT demonstrated a mass lesion composed of low density area with ring-shaped enhancement in its perimeter. We performed partial resection of the hepatic lateral segment and found a well-circumscribed and yellowish tumor of 2cm in diameter in the inferior lateral segment of the left lobe. Histological examination of the tumor verified the presence of plasma cells and inflammatory cells in glanulomatous tissue composed of collagen fibers. From this, the tumor was diagnosed as inflammatory pseudotumor of the liver.

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A case of primary hepatic carcinoid, of which definite diagnosis had not been made preoperatively but was first established by a resected specimen was experienced. A 56-year-old woman was seen at the hospital because of poor appetite and a weight loss. Various imaging methods indicated a tumor of the liver, and hepatocellular carcinoma or hemangioma was suspected. The tumor was excised by extracorporeal hepatectomy. Intraoperative frozen section diagnosis resulted in hepatocellular carcinoma. However, postoperative histopathological examination revealed that tumor cells had small oval-shaped nuclei and presented acinous pattern, trabecular arrangement, and rosette-like formation. Grimelius and Fontana-Masson stainings were negative. Immunohistologically serotonin and neuron specific enolase (NSE) stainings were positive, and the tumor was diagnosed as carcinoid. Since postoperative exploration of the gastrointestinal organs showed no abnormalities and it occurred solitary, the carcinoid tumor was thought arising in the liver. This case was so rare that only 11 cases of this disease have been seen in the Japanese literature.

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Four resected cases of hepatocellular carcinoma (HCC) with extrahepatic growth are clinicopathologically studied. Three of these tumors were showing the protrusive growth, and the other having an obvious pedicle. The preoperative diagnosis of HCC with extrahepatic growth was not successful in two cases, because these tumors had blood supply from some arteries except hepatic artery. Liver cirrhosis were found in all the cases. A partial hepatectomy was performed in three cases and lobectomy in the remaining one, however, all the patients experienced recurrence in the residual liver and died within 11 months after the operation. Eighty cases seen in the literature and these 4 cases were reviewed, and it is emphasized that a systematic segmentectomy or lobectomy should be performed on this type of HCC irrespective of its growth pattern, namely, protrusive or pediculate.

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Ectopic liver is a rare congenital abnormality, with only 50 cases reported in Japan prior to 1991. A case of ectopic liver originating from the gallbladder was incidentally discovered in a 64-year-old woman during a laparoscopic cholecystectomy for a polyp of the gallbladder. The ectopic liver appeared to be a 5mm extramural gallbladder polyp. Macroscopically, the ectopic liver was attached to the gallbladder by avascular connective tissue without any direct connection to the liver itself. No morphological abnormality was observed in the abdominal cavity including the liver. Histologically the ectopic liver bore a strong likeness to the liver, namely, it had the Glisson's capsule, bile ducts, arteries and veins originating from the cystic artery and vein, and hepatocytes which produced bile.
Extopic livers usually have no clinical significance and are discovered incidentally during autopsy, laparotomy or laparoscopy. However, some cases of ectopic liver cirrhosis and matastatic carcinoma to the ectopic liver have been reported.

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A very rare case of left-sided gallbladder was experienced. During surgery for a Stage IV gastric cancer in a 62-year-old woman, a left-sided gallbladder of Gross II type was found, in which the gallbladder fossa was placed on the left side of the ligamentum teres of the liver and the cystic duct opened on the left side of the common bile duct. Forty-seven cases reported in Japan including this case were reviewed. The male-to-female ratio was 19: 28, whit an average age of 54.9 years. Their chief complaints were predominantly epigastralgia due to complications and this disease lacked in own characteristic symptoms, accordingly, preoperative correct diagnosing rate was as low as 46%. The most common complication was gallstone in 30 cases (64%), followed by hepatic diseases in 26 (55%), malignant tumors in 11(23%), and intestinal malformation and others in 10 (40%), in this order. Of these 47 cases 19 (40%) were thought of congenital malformation. Thirty-three (77%) cases were operated on for complications. This disease can be diagnosed by means of noninvasice imaging methods such as CT and ultrasonography. In the treatment of the disease careful attention should be paid for possible complications.

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A case of traumatic bile duct stenosis successfully treated with percutaneous transhepatic cholangioscopic (PTCS) dilatation is reported with a review of 22 collective cases seen in the Japanese literature.
A 53-year-old man was admitted to the hospital because of jaundice developed two weeks after an upper abdominal blunt trauma. Benign bile duct stenosis was suspected by clinical course and diagnostic imagings. Definite diagnosis was made by PTCS. After PTCS dilatation the patient remains clinically well for 2 years. Of the 22 collected cases 16 underwent laparotomy because of difficulties in diagnosing definitely, and 4 cases including this case underwent endoscopic dilatation with a successful result. Because of physiological superiority of PTCS dilatation compared to operative procedure, an application of this procedure should be considered for management of traumatic bile duct stenosis.

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This paper describes a successful management of an operated infant with congenital biliary atresia by administering prostaglandin El immediately after Kasai's operation. The infant was a 19-day-old male. He had gray-white stool on the 10th day after birth. On the 19th day he was referred to the hospital because of yellow-stained conjunctiva. Based on closed examination biliary atresia was suspected and laparotomy was carried out on 49th day. Intraoperative findings and cholangiogram were compatible to biliary atresia and hepatic portoenteros-tomy was performed. For the purpose of promotion of bile outflow, the patient was applied to continuous administration of prostaglandin El intravenously. Serum total bilirubin levels (5.8mg/dl) decreased to 2.0mg/dl on the 15th postoperative day and no ascending cholangitis appeared. The patient was discharged from the hospital on 70th day and is strictly followed on an ambulant basis. Prostaglandin El, which is clinically used to preserve the liver, would be expected as a cholagogue in patients with biliary atresia after Kasai's operation.

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This paper describes a very uncommon case of duplication of the common bile duct, empting into the stomach, and an anomaly of superior mesenteric artery branching off celiac artery.
A 68-year-old man presented with upper abdominal pain. Under a preoperative diagnosis of submucosal tumor of the angular notch of the stomach, laparotomy was carried out. During surgery the site diagnosed as the submucosal tumor was found to be the orifice of the ectopic bile duct, which was different from the common bile duct and reached to the angular notch from the bile duct of portahepatis. There was a pure pigment stone in the ectopic bile duct. No malposition of the extrahepatic bile duct and gallbladder was observed. No anomalous arrangement of pancreatobiliary duct was also noted. Cholelithotomy and T-tube drainage were performed for the ectopic bile duct, and gastrostomy was also done to confirm the orifice. This case demonstrated that duplication of the common bile duct empting into the stomach should be considered in the differential diagnosis of submucosal tumor of the stomach. A review of the literature in terms of the mechanisms of duplication of the common bile duct, branching morphology, and therapies is also presented here.

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A case of congenital absence of the gallbladder associated with choledocholithiasis is reported. An 89-year-old woman was admitted to a nearby hospital because of jaundice and a fever. Based on closed examination she was diagnosed as choledocholithiasis, and tranferred to the hospital for operation. CT scan and ERCP demonstrated stones in the common bile duct.
On laparotomy the dilated common bile duct and 2 stones in the duct were found. The gallbladder was absent. Choledocholithotomy and T-tube insertion were performed. T-tube cholangiography also showed the absence of the gallbladder.
Congenital absence of the gallbladder is one of the rare biliary anomalies. In the reported cases, 27.1% were associated with choledocholithiasis.

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Cholesterosis of the common bile duct has been thought to be very rare compared with that of the gallbladder. We followed up a case of this disease for 6 years after operation, and assessed the clinical significance of this abnormal findings.
A 55-year-old man was admitted to the hospital for operation of a gallbladder polyp. Since DIC showed an irregular filling defect in the lower part of the common bile duct, intraoperative cholangioscopy was performed and yellowish-white multipolypoid cholesterosis was revealed in the same location. This lesion taken by fogarty catheter was proved to have foamy cells in the subepithelial layers histologically. This patient undertook cholecystectomy and T-tube drainage, but this lesion was remained in spite of removing some polyps through T-tube postoperatively. He has been nevertheless symptom-free and normal in laboratory examination while the same DIC findings are still seen. So we should avoid over'surgery for this lesion, which seems to have less significance clinically.

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In a 5-year period between 1986 and 1990, 31 patients with untreated renal cell cancer were admitted to the facility. Six patients of them were found to have a cancer of another organ. Here 2 case of double cancer of the stomach and kidney are described. The remaining 4 cases had cervical cancer in one, seminoma in one, and transional cell carcinoma of the urinary bladder other than real cell cancer. Some note on multiple cancer relating to renal cell cancer are also presented here.

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In a recent 5-year period seven cases of obturator hernia were experienced. This paper presents specific features and problems in the diagnosis and treatment of the disease. All the patients were females. Their ages ranged from 63 to 91 years old, with the average of 76.7 years old. Thin and rather small women predominated in them. Six cases presented with symptoms of ileus, while only one presenting with peritonitis symptoms where the incarcerated intestine caused a perforation. Preoperative diagnosis could be achieved in three cases, all of which exhibited Howship-Romberg sign. One of the 3 cases was confirmed having an incarcerated intestine by X-ray examination and ultrasonography of the small intestine. During surgery it was found that the hernias contained the small intestine alone, which were predominantly the ileum ranging 80 to 120cm away from the end of the ileum. Four cases underwent resection of the intestine. The necessity of resection of the intestine was more enhanced as the time interval from the onset of hernia to operation became longer. There was one operative death among 7 cases. In conclusion, we should always entertain a possible occurrence of the disease for aged patients with ileus of unknown etiology, and it is important to check the presence of H-R sign by detailed asking. For making the definite diagnosis, US and CT may contribute it in an early phase.

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Ingrown nail is not uncommon, but the disease has been rarely subjected to some studies up to now. In this paper 103 lesions of 80 patients with ingrown nail of the first toe operated on at our hospital from April 1989 to October 1991 are presented in terms of operative procedures, with some discussion.
Patients with ingrown nail were predominant in their teens or twenties, representing about two-third of all patients. The male-to-female ratio was 1:1.2, showing a predominance in women. Somewhat larger number of lesions were located in the right side. Many lesions in both right and left sides were commonly found in the outside region. Postoperative recurrence was noted in 11 cases (10.7%), of which lesions were mostly found in the right inside or left outside areas. These recurrence patterns were: appearenece of spire of the nail in 6 cases; recurrence of ingrown nail in 4; and epidermoid cyst formation in one.
In the treatment of ingrown nail, surgical treatment is recommended at present, though, the importance of more careful and certain operation would be emphasized.

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