Lactosucrose is a non-digestible carbohydrate available for fermentation as a substrate for the intestinal microflora. It has been reported that lactosucrose is selectively used by the Biffidobacterium, and that its number significantly increase after the oral administration. In this study, we have examined the changes of the postoperative serum endotoxin level in ten patients with colorectal cancer. Five patients were served as controls, and the remaining five patients were given 30g of lactosucrose daily, during 1 week up to 3 days before operation. Serum endotoxin levels were measured prior and after lactosucrose ingestion, and also on day 1, 3, 5, and 7 postoperatively. Fecal pH, organic acid contents and intestinal microflora were also analyzed before and after lactosucrose administration. The control group had blood and fecal samples taken in a similar manner to the lactosucrose group. Fecal pH had the tendency to decrease, and the concentration of fecal organic acids had the tendency to increase in the lactosucrose group when compared with the control group. The count of Gram-negative rods, which were reported to produce endotoxin, decreased in a ratio statistically significant (p<0.05) in comparison to the controls. Preoperative administration of lactosucrose improved the intestinal microflora, which was reflected by decreased levels of serum ammonia and endotoxin before surgery, decreased the usual postoperative elevation of serum endotoxin level, leading to a rapid return to the normal level.

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Growth curves of pulmonary metastases in three patients with anaplastic thyroid cancer were analyzed from chest X-ray films. Two of the patients, not undergoing chemotherapy, showed an exponential growth in their pulmonary metastases; tumor doubling time (TDT) was 9.2_??_25.0 days. In the third patient, TDT was as short as 6.2_??_7.6 days, and the effect of aggressive chemotherapy (mainly, adriamycin and cisplatin) correlated well with their growth curve. The growth curve in this patient suggested that pulmonary metastases had already occurred when the original tumor was completely resected. In view of the above metastatic time, systemic chemotherapy, rather than hyperfractionated radiation, should be done first after curative surgery.

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A total of 303 operated patients with breast cancer who underwent aspiration biopsy cytology (ABC) for preoperative diagnosis in the institute from January 1986 to September 1991 were examined for tumor factors responsible for false negative cytology (suspicious, negative or unsatisfactory) and problems relating to the diagnostic accuracy of ABC were evaluated.
The results of ABC diagnosis were positive in 82%, suspicious in 12.3%, negative in 1.4% and unsatisfactory in 4.3% of the patients. There was a significantly higher rate of suspicious as compared to positive in the following five tumor factor categories: tumor size less than 2.1cm, noninvasive carcinoma, histological grade, fat infiltration and vessel invasion. Hence, it is suggested that there is a high likelihood of false negative in ABC diagnosis of small tumors, because it may easily complicate with technical failure in aspiration and these tumor factors may be responsible for suspicious aspirations. Furthermore, without regard to tumor size, tumor factors such as histological grade, fat infiltration and vessel invasion might also be responsible for suspicious aspirations.
The use of the oil-immersion lens in the microscopic diagnosis of low-grade nuclear atypism and the combination of ABC and ultrasound examination as supplemental diagnostic method might make up for the limitations of ABC diagnosis and increase the diagnostic accuracy of breast cancer.

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Preoperative risks were estimated in resected cases of lung cancer associated with pulmonary emphysema. Subjects were 42 out of 136 cases undergone pulmonary resection for a primary lung cancer, which were selected by satisfying the following conditions, as well as by referring pathological findings of resected non-cancerous lung tissues: preoperative FEV_1.0, less than 70%; RV/TLC, more than 35%; and improvement rate of forced expiratory volume in one second after administration of bronchodilator, less than 500ml.
Critical postopertive complications were observed in 15 patients (35.7%). There were 5 operative deaths and another 5 deaths in the hospital among the 15 patients. Predicted-FEVI_1.0/VBSA, %DLco/VA and CT-findings are more important predictors of morbidity and mortality. When the cases had at least 2 out of 3 predictors, namely, P-FEV_1.0/BSA of less than 0.85l/m², %DLco/VA of less than 60% and CT-grade III, postoperative complications occurred in an extremely high rate. Combination of those predictors should be reliabloe estimation of preoperative risk foctors for patients with lung cancer associated with pulmonary emphysema.

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From April 1973 to December 1991, 58 cases of superficial esophageal cancer were experienced in our department and resected operations were performed in 45 cases. The clinicopathological study of these cases indicated the importance of early detection. Further, for early detection, the effectiveness of endoscopic Iodine staining was manifested.
The majority of ep and mm cancers with satisfactory prognosis were O-II type cases. In diagnosis of 0-II type cases, especially in ep and mm cancers, the endoscopic examination with Iodine staining method was more effective than the radiographic examination. From August 1983 to December 1991, the endoscopic Iodine staining method was practiced in 1, 235 patients over fifty years of age. In screening, this method was practiced in 824 cases, and of these 824 cases, five cases of superificial esophageal cancer were detected. The diagnostic rate of these five cases amounted to 0.61% of those screened displaying a higher diagnostic rate than in other reports. Also, a few cases of severe dysplasia were detected, one of which developed into intraepithelial squamous cell carcinoma about six months later. This results suggests the importance of follow-up examinations.

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This is to report on a new device, transjungular obliteration (TJO) as a bloodless treatment of gastric varices, where a catheter is placed into the gastrorenal shunt through the internal jugular vein to obliterate the varices. Subjects were 3 patients with gastric varices. One patient had isolated gastric varices, and the other two patients had esophagogastric varices. Esophageal varices were treated by injection sclerotherapy prior to TJO.
A 5 French occlusive balloon catheter was placed into the gastrorenal shunt through the internal jugular vein to obtain a retrograde obliteration. As the sclerosants, 50% glucose, absolute ethanol and 5% ethanolamine oleate with iopamidol (5% EOI) were used. In all cases, gastric varices were obliterated successfully. Endoscopic examination after the therapy showed the eradication of gastric varices. No complications during or after the therapy were observed. All patients are still alive without recurrence. Therefore, we think that TJO can be one of the effective method for the treatment of gastric varices with gastrorenal shunt.

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Clinical characteristics were examined in 49 patients with perforated gastroduodenal ulcer treated in the hospital during the recent 4 years. The mean age of the patients with perforated duodenal ulcer was younger than that with gastric ulcer. Many cases of perforated duodenal ulcer occurred at night and in autumn or winter. On the contrary those of perforated gastric ulcer had no such characteristics. Sixty-six point seven, per cent of the patients with perforated duodenal ulcer had no previous history of any ulcer and the patients with a previous history of an ulcer did not have taken H₂ blocker at the manifestation. The rate of detection of free gas on abdominal X-ray was 86.7% for the perforated gastric ulcers and 77.1% for perforated duodenal ulcers. No association of preoperative leucocytosis were comparatively predominant in aged patients. The positive ratio of bacteria in the peritoneal cavity increased when the time lapse from manifestation of symptoms to surgery was longer than 6 hours. Forty-nine patients recieved extended gastrectomy and the mortality rate was 0%. Two patients with perioperative sepsis were both aged, had longer time lapse from manifestation of symptoms to surgery, and had no leucocytosis.

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Ras p21 oncoprotein (p21) was stained in 126 gastric carcinomas, 58 benign epithelial lesions of the stomach, and 113 histologically normal gastric mucosa specimens adjacent to gastric carcinoma, by immunohistochemical technique using anti-c-Ha-ras p21 monoclonal antibody (NCC-RAS-001). The aim of the study was to determine the clinical significance of the p21 in gastric carcinoma.
The rate of positive staining was significantly higher in carcinomas (79/126) than in benign lesions (17/58), indicating that the p21 plays an important role in malignant transformation of gastric mucosa. Interestingly, the rate of positive staining did not differ between carcinomas and gastric mucosa specimens adjacent to the tumors (71/113). No significant correlation was found between clinicopathological features of carcinoma and the immunoreactivity for the p21, though the positive staining was more often detected in tumors with intestinal metaplasia. The effect of the immunoreactivity for the p21 on survival of the patients was not significant. It is though that the p21 may contribute to malignant transformation of gastric carcinoma but scarcely participate in further development of the tumor.

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Among 405 resected cases of colorectal cancer in the hospital, 61 cases (71 lesions) showing mucosal (m), submucosal (sm), and musclar (pm) invasion were clinicopathologically examined. The sm cancers were classified into sm 1 and sm2 according to the depth of cancer invasion. The mean age was 60.1 years. The male-to-female ratio was 2:1. One case of m cancer and 4 cases of pm cancer had the multiple lesions. Mean tumor diameter was 17.3mm for m, 23.1mm for sml, 25.4mm for sm2, 37.3mm for pm cancers. No depressed lesions were found in m cancers. Histologically, 93.0% of the lesions was well differentiated adenocarcinoma. The lymphatic invasion was observed in 3 lesions (9.7%) of m, 3 lesions (42.9%) of sm 1, 3 lesions (42.9%) of sm2, and 22 lesions (84.5%) of pm cancers. Lymph node involvement was observed in only 4 cases of pm-cancers. From analysis of tumor diameter, depth of invasion, morphology, and ly factor, sm2 cancers satisfying the following conditions; ly (+), over 20mm in diameter, and depressed lesion, are thought to necessiate a radical resection of the colon. The other m and sm cancers may be permitted to follow after polypectomy or local resection. There were one death out of m cancer cases and 4 deaths out of pm cancers. Expecting non-curative resection cases, 4 cases have multiple lesions which demand a long-term follow-up.

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An assessment has been made regarding the lymph node dissection performed on 286 cases of right colon cancer undergoing operation at Cancer Institute Hospital from 1946 to 1989. As a result, it was reconfirmed that almost satisfactory result is obtainable by the existing standard mode of dissection on right colon cancers. However, there are cases in which prolonged prognosis is obtained by adding dissection along the right gastroepiploic artery such as subpylolic nodes, from which it is considered that dissection of the these lesions should be made with the same carefulness as that on the main nodes, particularly, in the so-called surgical trunk along the superior mesenteric vein. Hemicolectomy of the region including the ileocaecum is not necessarily required for the cancer present in the vicinity of the hepatic flexure. And, for the metastasis in the lymph nodes more than 3rd group, no influence is exerted on the prolonged prognosis only by explanation of the range for lymph node dissection.

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One hundred and sixty-two patients with hepatocellular carcinoma (HCC), who underwent hepatic resections except for absolute noncurative resection, were included in this study. In 84 patients of them (group A), CT examination was performed about one month after an injection of Lipiodol (LpCT) for the purpose of preoperative diagnosis. In the remaining 78 patients (group B), preoperative diagnosis was performed by other imaging techniques. With preoperative LpCT the detection rate of multiple lesions increased from 26% to 48%. The index of diagnostic accuracy was calculated. The sensitivity and specificity were 0.86 and 0.80 respectively in group A, and 0.50 and 0.90 respectively in group B. The sensitivity of the former was significantly better than the latter (p<0.05). disease free survival (DFS) in group A was a little longer than that in group B (not significant). DFS in the patients with solitary tumor was also a little longer than that in group B. This tendency was recognized in the comparison between the patients with multiple tumors of group A and those of group B. These findings suggest a possibility that LpCT prior to surgery improves the diagnostic accuracy especially for patients with multiple lesions and

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In 20 patients admitted to the hospital to receive operation for arteriosclerosis obliterance (ASO), the screening of coronary artery diseases was conducted by using upper body exercise (UBE) ECG. UBE was discontinued in seven patients (35%) because of arm fatigue. The remaining 13 patients reached to sub-maximal heart rate (70% of predicted maximal heart rate according to the reference of American Heart Association). There was no correlation in age and sex between the patient groups with failed and completed examination. In three of thirteen patients, ECG revealed ST-T depression. In another one patient whose pre-exercise ECG was within normal limits, ECG changed to incomplete right bundle branch block after exercise. Selective coronary angiography was performed on all of these four patients. All four patients had coronary stenosis (75% stenosis or more). Though there was no case in which revascularization of the lower extremities preceeded by heart revascularization, strict management of hemodynamics during and around operation assured the safety for the former operation. In conclusion, UBE is useful for the screening of coronary artery diseases in the patient with ASO.

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The foreskins of phimosis in children have been retracted as much as possible at the out-patient clinic, to avoid unnecessary operations. Five-hundred and twenty-seven cases of phimosis were experienced since 1986, and 427 of them were classified into 6 types according to the appearance of the penis and preputial orifice; type I (burried penis, 22 cases), type II (bottle neck, 86), type III (pinhole, 60), type IV (moderate stenosis, 154), type V (mild stenosis, 101), and type VI (scarred stenosis, 4).
The foreskins were unable to retract in 13 cases (59.1%) of type I, 17 cases (19.8%) of type II, and 2 cases (50%) of type VI. In all cases of pinhole type, which looked highly stenotic, the foreskins were retractable. As a result, operation was performed only in 32 cases (6.1%) of all cases. Our best effort to retract the foreskin has reduced the operative indications of phimosis markedly.

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The incidence of non-recurrent laryngeal nerve is claimed to be 0.3-0.9%, and this anatomical anomaly is important in thyroidectomy and parathyroidectomy.
We encountered a right non-recurrent inferior laryngeal nerve, arising from the cervical trunk of the vagus and passing directly to the larynx in a 65-year-old female patient who underwent total parathyroidectomy.
The anomaly of the recurrent nerve is explained by the process of nerve and blood vessel development from the embryologic branchial arches, and since it is known to be associated with anomalous origin of the right subclavian artery from the aortic arch, it is only observed on the right side. In this case, postoperative IV-DSA confirmed the right subclavian artery arising from near the peripheral site compared to the left subclavian artery.
Recurrent nerve injury is one of the most important complications of thyroidectomy and parathyroidectomy, and the neural anatomy must be borne in mind especially at the right side.

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A case of squamous cell carcinoma of the breast, which is regarded as squamous metaplasia with adenocarcinoma, is reported. A 42-year-old woman was seen at the hospital because of a tumor of the left breast and pain. Mammography and echography revealed a breast cancer. Modified radical mastectomy was carried out. Histologically, the tumor was squamous cell carcinoma and axillary lymph node involved squamous cell carcinoma mixing with adenocarcinoma cells. There was recurrence on the left breast skin one year after the operation. The skin biopsy was carried out. Histological examination revealed that the lesion was predominaly comprised of sold-tubular carcinoma cells, with scarce squamous cell components.

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Excepting direct invasion into the esophagus from mediastinal or primary lung cancer, distant esophageal metastasis is rarely encountered. Recently we experienced a case of esophageal metastasis following radical mastectomy for a breast cancer.
A 48-year-old woman developed dysphagia and hoarsness 6 years after radical mastectomy. Esophagogram revealed a smooth stricture of mid and upper-esophagus involving the entire circumference. CT and MRI disclosed a massive tumor in the retromediasternal region. Esophageal biopsy resulted in negative for malignancy. Esophagectomy was carried out under a suspecion of submucosal esophageal tumor or primary malignant tumor in the mediastinum. Histopathologically the excised tumor was adenocarcinoma diffusely invading the submucosa, which was almost similar to that of the breast cancer. Accordingly, it was diagnosed as esophageal metastasis of breast cancer. There has been no recurrence, as of 24 months after the operation.
Esophageal metastasis of breast cancer occurs in a frequency of 1-2%. Further increase in survaval rate of breast cancer patients would increase the occurrence of such metastasis. It is important to consider a possible esophageal metastasis, where we encounter a patient presenting with esophageal narrowing who has a previous history of breast cancer.

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The colon is the very rare site of metastasis of breast cancer. We emphasize that the intestine should be considered as a possible metastatic lesion of the advanced breast cancer from our experience.
A 56-year-old women underwent a standard radical mastectomy for a right breast tumor on July 1990. Pathological diagnosis was infiltrating ductal breast cancer: T1n1 b m0-stage II. The patient was treated with 51 Gy local radiotherapy and chemoendocrinotherapy after surgery as an outpatient. Around February 1991, a tumor marker started to increase. Careful examination could not detect any evidence of recurrence of the breast cancer. However, multiple enlargment of para-aortic lymphnodes was found by CT, and a colon cancer was suspected by barium enema in January 1992. Right hemicolectomy was performed. Histologically, it was found that the breast cancer metastasized to the ascending colon.

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An operated case of esophageal which was successfully treated with preoperative CDDP-5Fu regimen is reported, together with a review of the literature.
A 67-year-old woman came to the hospital because of epigastralgia. On upper endoscopic examination, an esophageal cancer Type 2 was found at the abdominal esophagus (Ea). Biopsy of the tumor revealed moderately differentiated squamous cell carcinoma. Preoperative chemotherapy was started with 70mg/m² of CDDP on the day first followed by 800mg/m² of 5-Fu for consecutive 3 days. After the regimen upper gastrointestinal series and endoscopy revealed a slight decrease in tumor size but the response was judged no change. The tumor invaded the muscularis propria on endoscopic ultrasonography. On 18th day after preorerative chemotherapy right thoracotomy, lararotomy, and intrathoracic anastomosis were performed. Gross examination of the tumor showed MoPloAoNo. Histopathologicaly many foreign body giant cells were seen in the submucosal and subserosal layers, but no cancer cell was detected. The effect of this chemotherapy corresponded to Ef3 in the histologic criteria for the effect of anticancer chemotherapy. In additional 15 cases which wer done chemotherapy on our protocal, 2 cases corresponded to Ef2. Further examination of this chemotherapy would be also necessary in metastasized lesions.

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Recently the sclerotherapy for esophageal Varices is rapidly spreading and becomes a first choice therapy in many hospitals.
We experienced a case of advanced esophageal cancer 20 months following sclerotherapy using polidocanol for esophageal varices with alcoholic cirrhosis.
It is well-known that erosive or chemical esophagitis can be the structural origin for esophageal cancer. There have been 8 cases of esophageal cancer following selerotherapy for esophageal varices in the Japanese literature, in that we discussed whether there was some etiologic correlation between sclerotherapy and esophageal cancer.

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Small-bowel obstruction with bezoars in a gastrectomized patient is rare. A 54-year-old man was admitted to the hospital because of upper abdominal pain and nausea which developed 2 days after he ate a lot of persimmons. There was a history of undergoing distal partial gastrectomy for duodenal ulcer when he was 26 years old. Strict examinations revealed that a foreign body caused small bowel obstruction, and conservative treatment was started. However, these symptoms were getting worse, emergency operation being carried out. During surgery a hen's egg-sized foreign body was found in the small intestine about 150cm distal from the Treitz's ligament. The foreign body was removed through enterotomy. The postoperative course was uneventful and the patient was discharged from the hospital. The foreign body was inferred to be gastric bezoar.
Twenty-eight cases seen in the Japanese literature were also discussed.

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We report a case of gastric lipoma, which is a relatively rare tumor of the stomach. A 61-year-old female visited a nearby practitioner because of epigastric pain. The upper gastrointestinal series revealed a gastric tumor, so she was referred to the hospital for further examination. The gastroendoscopy showed a submucosal lesion, which had a low density in computed tomography with no enhancement by contrast medium. The endoscopic ultrasonography showed the echogenic tumor placed in the third layer of the gastric wall. A diagnosis of gastric lipoma was made and the tumor, 55×35mm in size and 20g in weight, was resected. Pathological examination confirmed the diagnosis. With the aid of computed tomography and endoscopic ultrasonography, which can visualize the size, location within the gastric wall, morphology, and quality of the tumor, preoperative diagnosis of the gastric lipoma is no more the difficult one. These examinations also serve in choosing a proper way of treatment.

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Recently a case of multiple gastric carcinoma occurring 19 years after gastrojejunostomy was experienced.
A 59-year-old man was referred to the hospital under a diagnosis of multiple gastric carcinoma resulting from X-ray examination, endoscopy and biopsy of the stomach at nearly hospital, to where he visited because of hematemesis in November 1987. There was a history of undergoing freeing of intestinal adhesions and gastrojejunostomy for intestinal obstruction when he was 40 years old. After admission to the hospital, operation was carried out in March 1988. Intraopertive findings included P₀H₀N₀S₂ and subtotal gastrectomy including a part of the anastomosed small intestine was radically performed. The resected specimen revealed 4 different lesions, namely, Borrmann type 2 (tub₁, ss) in the pylorus vestibule, Borrmann type 1 (por, pm) in the anastomosed site of the stomach and jejunum, IIc (por, sm) in greater cuavature of the body of the stomach, and IIc (tub₁, sm) in lesser cuavature of lower body of the stomach.
Occurrence of gastric carcinoma following gastrojejunostomy, especially multiple type, has been rarely reported in Japan. This case which was accompanied by a change of extensive gastritis cystica polyposa in the submucosal layer ranging from the anastomosed site to greater cuavature of the body of the stomach was very interesting. Some literature notes are also presented here.

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We report a cured case of acute afferent loop syndrome using a conservative approach. A patient with acute afferent loop syndrome occurring in the 6th year after total gastrectomy for gastric cancer, underwent conservative treatment with abstinence from food and water, total parenteral nutrition, insertion of a Denis tube, and treatment with Prostarmon F, Solu-medrol, and Futhan without improvement. The patient was then given Goreisan and Daikenchuto for diuresis and normalization of intestinal peristalsis. Urine output increased within several hours and distention of the afferent loop disappeared in one day. Goreisan did not affect serum electrolyte levels, although it showed a marked diuretic effect. Daikenchuto was effective for restoration of normal intestinal peristalsis, relieving abdominal pain, and inducing regular bowel movements. Chinese medicine formulations thus appeared to be very useful provided that they were appropriately indicated.

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A case of primary tuberculosis of the jejunum which repeated chronic ileus symptoms for a long term and presented difficulties in diagnosis is described.
A 64-year-old woman was seen at the hospital because of chronic abdominal distension and abdominal pain. A chest X-ray film revealed no abnormality but abdominal simple X-ray film showed a significant dilatation of the small intestine and fluid level. Barium meal method revealed a cystic and abnormally dilated lesion in a part of the small intestine. Laparotomy findings included a cystic dilated lesion in the jejunum with a narrowing in the anal side, and numerous swelling mesenteric lymph nodes. Excision of the intestine with end-to-end anastomosis was performed. Based on histopathological examination of the excised specimen, a diagnosis of tuberculosis was made.
This case was not of lung tuberculosis associating with intestinal tuberculosis, but of so-called primary tuberculosis of the small intestine. It is rare to encounter such a case as presenting abnormal cystic dilatation and repeating ileus symptoms like this case. In this case an elevated serum CA-125 level was noted in the clinical course. For this, some notes are also presented here in terms of literature review.

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It is rare that Crohn's disease causes perforation. This paper describes a case of Crohn's disease causing ileal perforation.
A 20-year-old man was admitted to the hospital because of abdominal pain. The abdomen was distended and muscle guarding and Blumberg sign were observed. Chest X-ray film revealed no free air under the diaphragm. White blood cell count was 10600, with neutrophilia. The patient was diagnosed as peritonitis and emergency operation was carried out. At laparotomy, perforation of the ileum associated diffuse peritonitis was observed. Partial ileal resection and drainage were performed. In the resected specimen cobblestone appearance and longitudinal ulcer were observed. Histologically, transmural inflammation with noncaseous granuloma was seen and Crohn's disease was confirmed. The patient was discharged on the 38th day after surgery. There has been no recurrence, as of 2 years after the operation, and the patient is followed on an ambulant basis.
Two hundred-odd cases and 56 cases of perforated Crohn's disease have been reported in the world and Japan respectively so far. A review of the literature is also presented here.

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Two operated cases of intestinal anisakiasis were reported. First case was a 47-year-old female complaining of abdominal pain, and was exposed with the diagnosis of generalized peritonitis. The edematous jejunum with swollen lymphonodes located 160cm from the ligament of Treitz was found. Segmental resection of the jejunum was performed and a larva penetrating the mucosa was revealed. Second case was a 48-year-old male complaining of abdominal pain. An abdominal X-ray film demonstrated a air-fluid level of the small intestine. The patient was exposed with the diagnosis of ileus, and an elastic soft tumor was detected in the jejunum 270cm from the ligament of Treitz. Enterotomy and removal of the stool were performed. In the immunological examination, the larva in the stool belonged to anisakias. Patients with intestinal anisakiasis sometimes present the symptoms of peritonitis and ileus, and the definitive diagnosis can be made only after laparotomy.

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Gastrointestinal hemorrhage, especially small bowel hemorrhage has various causative diseases, sometimes presents as massive or intermittent bleeding, and hence, the preoperative diagnosis and proper selection of treatment are often difficult. Here 3 cases of small bowel hemorrhage, in which bleeding sites were preoperatively determined with satisfactory outcomes, are described.
Case 1: Angiographic study revealed a jejunal tumor and partial resection was performed. Pathological diagnosis was leiomyoma.
Case 2: X-ray examination of the small intestine and angiographic study revealed ulcerative lesions of the terminal ileum, followed by partial resection. Pathological diagnosis was non-specific multiple ulcer of the small intestine.
Case 3: Blood pool scintigraphy suggested active bleeding from the terminal ileum. Intraoperative endoscopy showed a small elevated lesion and partial resection was performed. Pathological diagnosis was cavernous hemangioma.
When small bowel hemorrhage is clinically suspected, active use of angiography, blood pool scintigraphy, or intraoperative endoscopy is recommended to detect the source of bleeding.

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Most Meckel's diverticula are silent but occasionally cause some complications including intestinal obstruc-tion, bleeding and perforation which are indicated surgical treatment. Here two such cases of Meckel's diverticulum necessitating emergency operation are described. One case is a 20-year-old man hemorrhagic shock from intra-diverticular ulcer due to ectopic gastric mucosa. The other case is a 16-year-old girl. She had an intestinal obstruction and necrosis of Meckel's diverticulum due to its axial volvulus. Though radiologic studies are useful for diagnosis of Meckel's diverticulum, it is very difficult to make a correct diagnosis in case of emergency. When we encounter a case presenting sustained massive melena from unknown origin, or a case in which intestinal strangulation is suspected but upper gastrointestinal series and colorectal examination revealed no abnormality, probable existence of Meckel's diverticulum can be considered and agressive laparotomy followed by appropriate treatments is recommended.

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We experienced a case of synchronous double cancer consisting of gastric cancer and heterotopic pancreatic cancer in the jejunum.
A 64-year-old male visited the hospital because of abdominal pain on his right side. On close examination the patient was diagnosed as having a gastric cancer and underwent laparotomy.
Laparotomy revealed a tumor in the jejunum 110cm anal side from the Treitz ligament. The jejunum formed a loop about 50cm long with infiltration into the serosa.
Total gastrectomy and partial resection of the jejunum were performed. According to pathological diagnosis, the gastric lesion was poorly differentiated adenocarcinoma and the jejunal lesion was Heinrich type I heterotopic pancreatic cancer. Two cases of heterotopic pancreatic cancer in the jejunum have been seen in the Japanese literature so far, and this case may be the third report.

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Primary carcinoma of the ileum is less common compared with those of other sites of the gastrointestinal tract.Most of those cases are diagnosed after laparotomy under an advanced state such as ileus. Here a rare case of primary carcinoma of the ileum diagnosed preoperatively by endoscopic biopsy is described.
A 74-year-old man complaining of abdominal pain and constipation, was found to have a tumor at the terminal ileum by double contrast radiography. With endoscopic biopsy the definite diagnosis of carcinoma of the ileum was made. Ileocolectomy and lymph node dissection were carried out. Histopatholigical findings revealed that the lesion was a well-differentiated adenocarcinona.
Primary carcinoma of the ileum often occurs in the terminal ileum. This case suggests that the careful radiographic or endoscopic study near the terminal ileum is important for the early diagnosis of this disease.

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Intussusception caused by a tumor of the small intestine is a rare disease. This paper describes a patient witn malignant lymphoma of the ileum causing intussusception who was admitted to the hospital because of ileus and was diagnosed as intussusception by CT and ultrasonography, leading to operation. A 73-year-old man complaining of abdominal pain and a weight loss was admitted for ileus. Conservative therapy failed to improve the patient's condition. CT scan and ultrasonography revealed intussusception of the distal ileum. Using Gastrografin^TM, an enema reduction was temporarily sustained. A polyp-like mass, 8cm in diameter, was detected in the ascending colon. As the ileus condition persisted, right hemicolectomy was carried out 3 days later. A 6×5×4cm tumor was found in the distal ileum. Histologically it was malignant lymphoma. CT scan and ultrasonography are useful diagnostic methods for intussusception. A possibility of malignant tumor should be suspected in adult cases of intussusception.

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Recently sigmoid-visceral fistula which is a candidate for surgical treatment is increasingly encountered, with an increase in the frequency of sigmoidal diverticulitis. In patients complaining of bladder distress and intestinal dysfunction, the early diagnosis with barium enema and cystoscopic examination is important, bearing in mild a possible occurrence of sigmoid-visceral fistula.
Careful attitude is mandatory to rule out probable association of malignant disease from the overlapping of the sigmoid colon in barium enema examination and the inflammatory changes in cystoscopic examination.
As for the operation, an one stage procedure consisting of resection of the fistula with the bowel is recommended. Partical cystectomy was not necessary in two cases experienced.
This paper reports a case of sigmoid-visceral fistula with a review of the literature.

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A 52-year-old man was seen at the hospital because of massive melena at defecation. On digital examination of the rectum a movable elastic hard mass was palpated. A rectal carcinoma was suspected. Barium enema and rectoscopy revealed a hemi-circumference and gently rising torous lesion about 50cm distant from the anal verge, and its center involved a shallow ulcerative lesion and erosion. From biopsy findings a diagnosis of inflammatory epithelium was made, but a sigmoidal cancer was strongly suspected. Laparotomy was carried out. During surgery a tumor of hen's egg size was palpated in the sigmoid colon but no serosa invasion was noted. It was determined as P₀H₀N₀ (n₀)S₀(s₀) and sigmoidectomy R2 was carried out. Resected specimen revealed a 6×5cm torous lesion of Yamada's type I accompanying by an ulcerative lesion in the mucosa. Histopathologically it was diagnosed as submucosal lipoma of the large intestine.
This paper describes a relatively rare resected case of lipoma of the large intestine presenting with melena, with a review of the literature.

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A 61-year-old man was seen at the hospital because of general fatigue and tarry stool. Barium enema revealed a leakage of medium from the transverse colon to the duodenum and jejunum. A diagnosis of invasion of a transverse cancer into the jejunum and duodenum was made. Right hemicolectomy partial excision of the small intestine, and pancreatoduodenectomy were carried out. Histopathologically it was well differentiated adenocarcinoma of the colon involving poorly differentiated and mucinous components, of sin n(-) P₀H₀M(-)in Stage III. The operation resulted in curative resection. There has been no sign of recurrence, as of one year and eleven months after the operation.
Two fistulas formed between organs is very rare and this case was the 3rd domestic report following Ogawa and Yasunaga and others. Colon cancers with gastrointestinal fistula are often of low malignancy compared to macroscopic findings. If radical resection is successfully performed, better prognosis than that of colonic cancers invading multiple organs without forming a fistula can be expected. Accordingly, without bewidering by local extension of the lesion, aggresive radical operation would be desired.

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We report a case of intrahepatic stones with severe delay of bile excretion in which there were no signs of recurring stones at three years and two months after biliary diversion. The patient was a 50-year-old man. There was a history of undergoing cholecystectomy, choledochotomy and papillosphincteroplasty for stones in the choledochus and gallbladder in August 1983. Recurred intrahepatic stones were found in October 1988. Hepatobiliary scintigraphy following percutaneous transhepatic cholangioscopic lithotripsy revealed a marked delay of bile excretion. Based on this finding, a diagnosis was reached of intrahepatic stones caused by reflux of digestive remnants and pancreatic juice. Choledochojejunostomy was performed in February 1989. Hepatobiliary scintigraphy performed in April 1992 showed that greatly delayed bile excretion still continued, but no recurred stones were found. The results in this case indicate that papillosphincteroplasty is not an appropriate means of surgical reconstruction for cases of intrahepatic stones with marked bile retention, and that biliary diversion rather should be the treatment of choice. It is also found that hepatobiliary scintigraphy is useful for determining the course of postoperative treatment in such cases.

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Icteric type hepatoma represents about 2% of all hepatocellular carcinomas. Since it is often associated with jaundice and severe liver cirrhosis, few cases have been successfully operated on the prognosis is poor. This paper presents a resected case of icteric type hepatoma.
A 64-year-old man was admitted to the hospital because of upper abdominal pain. Blood examination revealed elevated biliary enzyme levels. Abdominal ultrasonography and CT showed a dilated intrahepatic bile duct and tumor shadow in the left lobe of the liver. PTC confirmed a mold-filling defect covering from the left intrahepatic bile duct to the common bile duct. A diagnosis of hepatocellular carcinoma extending from the left lobe to portal hepatis was made, and extended left lobectomy and incision of the common bile duct were carried out. Postoperative course was uneventful and there have been no signs of recurrence as of 6 months after the operation.
Curative resection cases of icteric type hepatoma by hepatectomy are so rare that only 28 cases including this case have been seen in Japan. Averaged survival period was as poor as 4.1 months, but curative resection cases were able to have relatively good prognosis. Here some literatute review is also presented.

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We experienced a resected case of small liver cancer one year and 2 months after resection of a colon cancer in a 33-year-old man. He had undergone right hemicolectomy for a ceacal cancer and the ascending colon polyps, and resection of a duodenal polyp. After that, the level of α-fetoprotein increased. A small liver cancer 1.5cm in size was detected and anterior segmentectomy was carried out.
This case was the youngest one reported in the double cancer of hepatocellular carcinoma and extrahepatic malignancies. Two cases of hepatocellular carcinoma and two cases of colon cancer were seen in his family. The family element was suggested in the cause of these cancers. This case reconfirmed the importance of the family history in the early diagnosis and treatment of the cancer.

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Gallstone ileus is a relatively rare complication of gallstones. It is also rare that cholecystogastric fistula is responsible for this condition. We recently encountered a case of gallstone ileus caused by cholecystogastric fistula. In this case, a radical and one-stage operation on the ileus and the biliary tract was possible under the accurate preoperative diagnosis.
A 67-year-old woman was seen at the hospital because of abdominal flatulence and vomiting. When hospitalized, she was in a shock due to ileus. After the improvement of her systemic condition by transfusion therapy and decompression using an ileus tube, a cholecystogastric fistula was detected by endoscopic radiography, and a stone within the intestine, by radiography using an ileus tube. Radical operation was subsequently performed.
In the treatment of gallstone ileus, both relief of the ileus and disposal of the internal biliary fistula are required. This condition can be treated radically with one-stage operation after appropriate management and accurate diagnosis.

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Serum CA19-9, DU-PAN-2, and SPan-1 are useful markers for diagnosing malignant tumors of the pancreas and biliary organs, however, these tumor markers can be positive for benign diseases. Recently a case of cholecystolithiasis with choledocholithiasis showing CA19-9 of more than 10, 000U/ml, DU-PAN-2 of 930U/ml, and SPan-1 of 1, 900U/ml was experienced. Sometimes we see benign cases with positive CA19-9, but rarely encounter cases with positive DU-PAN-2 and/or SPan-1. Here this case as well as a review of the literature is presented.
A 75-year-old woman consulted a nearby practioner because of abdominal pain, jaundice and fever, and was referred to the hospital for close examination. Percutaneous transhepatic cholangiography and drainage of the gallbladder was performed. Tumor markers gradually decreased with an improvement of jaundice. Based on cholecystographic findings, the patient was diagnosed as cholecystolithiasis with choledocholithiasis. Operation was performed and both cholecystolithiasis and choledocholithiasis were confirmed, but no malignancies were found in the gallbladder macroscopically and histologically. After the operation negative-conversion of these tumor markers was noted, and the patient was discharged from the hospital.

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Most carcinomas of the gall bladder are adenocarcinomas and adenosquamous cell carcinomas represent only about 5% of all gall bladder carcinomas. This paper describes a very rare case of adenocarcinoma and adenosquamous cell carcinoma coexsting in the gall bladder.
An 87-year-old woman was seen at the hospital because of sudden right hypochondralgia. From clinical symptoms, findings, and various imaging methods, the patient was diagnosed as acute cholecystitis and cholecystectomy was performed. There were stones in the gall bladder, a lesser tubercle-like elevated lesion in the fundus of the gall bladder, and a papillary tumor in the cervical part of the organ. Histopathologically the lesion in the fundus was adenosquamous cell carcinoma in which adenocarcinoma partially accompanied by keratinization and a transition into squamous cell carcinoma. On the other hand, the lesion in the cervical part of the gall badder was adenocarcinoma. The both lesions were independent and no continuity between them was found. Multiple carcinoma of he gall bladder, coexisting of adenosquamous cell carcinoma and adenocarcinoma, has not been reported in Japan so far. A review of the relevant literature is also presented here.

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We report an operated case of intractable pancreatic fistula following pancreatoduodenectomy. A 76-year-old man underwent pancreatoduodenectomy because of a lower bile duct carcinoma. The patient developed external pancreatic fistula 26 days after the operation. Fistulography showed no communication between the pancreatic duct and jejunum. Conservative treatment was started, however, the discharge through the fistula did not decrease. To satisfy the patient's wish to improve the quality of life, surgical treatment was indicated 2 months after the development of the fistula. On September 18, 1991, end to side anastomosis of pancreatic fistula to a Roux-en-Y limb of the jejunum was performed. Postoperative course was uneventful and the patient became able to carry on routine activity.
Most pancreatic fistulae can be treated conservatiely. However, in some cases with proximal pancreatic duct obstruction, surgical treatment is recommended.

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A 59-year-old man on long-term hemodialysis (HD) was successfully operated on for abdominal aortic aneurysm. An abdominal pulsatile mass was detected when HD was started. Computed tomography and echograms showed an infrarenal abdorminal aortic aneurysm. Before surgery, HD was done three times weekly with nafamostat mesilate as an anticoagulant and with transfusion of two packs (260ml) of concentrated red blood cells. HD was done on the day before and again on the morning of the operation, the laboratory test results showed a hematocrit of 31%, blood urea nitrogen of 31mg/dl, serum creatinine of 5.9 mg/dl, and serum potassium of 4.1mEq/l. During surgery, a fusiform aortic aneurysm with a maximum diameter of 5.5cm was replaced with a Y-shaped graft of woven Dacron covered with albumin and autoclaved. Two days after surgery, HD with nafamostat mesilate was resumed on a three times weekly schedule. Complications did not develop and the patient was discharged on day 13 after surgery. Use of an anticoagulant such as nafamostat mesilate that decomposes rapidly makes possible HD immediately before and immediately after the operation. Thus patients on long-term HD may be able to undergo resection of abdominal aortic aneurysm as safely as those without renal failure.

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Puptured pyometra which was preoperatively misdiagnosed as perforation of the intestinal tract in an 88-year-old female was described.
The patient suddenly developed abdominal pain during hospitarization for fracture of the lumbar vertebra.The peritoneal irritation sign was present in the area centering the lower abdomen. Plain X-ray examination of the abdomen showed pneumoperitoneum. These findings suggested intestinal perforation. However, laparotomy revealed ruptured pyometra.
Ruptured pyometra is a relatively rare disease, and only 14 patients including this patient have been reported in Japan since 1977. Plain X-ray films of the abdomen show pneumoperitoneum due to gas-producing microorganisms in about half of patients with this disease. This often causes making a misdiagnosis of perforation of the intestinal tract, or acute abdomen, leading to laparotomy. The most common cause of pneumoperitoneum is perforation of the intestinal tract. However, other possible causes, as in this patient, should be also taken into consideration. Ruptured pyometra may increase with the aging of the society. As a cause of panperitonitis in aged females, the possibility of this disease should be kept in mind.

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A case of transepiploic hernia, a very rare type of internal hernia, is described with a review of the literature.
A 59-year-old man was seen at the hospital because of epigastric pain and nausea, and was admitted for close examination. After upper gastrointestinal series was taken, a plain X-ray film of the abdomen showed a fluid level in the dilated intestinal loop. Ultrasonic study demonstrated both the dilated intestinal loop and some amount of ascites. A diagnosis of intestinal obstruction was made and a laparotomy was performed.
Laparotomy findings included increased ascites, presence of a hiatus about 5cm in diameter in the omentum, through which a portion of the small intestine by about 30cm prolapsed and was strangulated. As vascular disturbance of the strangulated intestine was speculates moderate, closure of the hiatus was performed. Liquid diet was started around 10th day after the operation, but ileus symptoms occurred again. Ileus tube was inserted. G.I. series revealed a disappearance of Kerckring's folds and dilated small intestine, and hence, excision of the ileum by about 35cm with end-to-end anastomosis, ileum to ileum, was carried out.
In the Japanese literature, 18 cases of omental hernia (type A) have been reported sofar, and one further case is considered worthy of report.

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The paper presents a case of retroperitoneal schwannoma arising in the femoral nerve.
A 53-year-old woman under the treatment for chronic hepatitis as an outpatient was pointed out having a tumor in the right lower abdomen, and was admitted to the hospital for examination. Ultrasonography, CT and MRI revealed a multilocular tumor opressing the iliopsoas muscle to the median side in the right retroperitoneal cavity. The patient was diagnosed as having a retroperitoneal tumor and was operated on. During surgery it was found that the tumor arised in the femoral nerve. The femoral nerve was excised and the tumor was extirpated. Pathohistologically it was cystic schwannoma.
In terms of imaging diagnosis of retroperitoneal tumors, CT and ultrasonography have been said useful. In this case preoperative MRI could visualize the femoral nerve as the primary site and offer a suspecion of retroperitoneal schwannoma. MRI was able to visualize the tumor in three dimentions and the combination with CT and ultrasonography made the qualitative diagnosis possible. The usefulness of MRI for this tumor should be emphasized.

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Three cases of obturator hernia preoperatively diagnosed by pelvic computed tomography are reported.
All cases were elderly women with symptom of ileus. Howship-Romberg sign, an oppressed symptom of obturator nerve, was positive in one patient. All cases could be preoperatively diagnosed by pelvic computed tomography which demonstrated a clearly incarcerating bowel into the obturator foramen. Computed tomography seems very useful for the diagnosis of obturator hernia.

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Recent experience with making the correct preoperative diagnosis of strangurated obturator hernia, in which abdominal ultrasonography and CT were very useful, is reported on.
An 81-year-old woman (gravida 7, para 7) was admitted to the hospital because of severe lower abdominal pain.
There was a 7-year history of receiving the treatment for occasional severe pain in the area of the right hip joint by an orthopedist. Physical examination showed marked abdominal distension and visible peristalsis. Howship-Romberg sign was elicited. Ultrasonography revealed a round hypoechoic mass in the medial part of the right inguinal ligament. CT scan of the pelvic region showed a round homogeneous density mass between the right pubic and internal obturator muscles. Under a diagnosis of strangurated obturator hernia, emergency operation was performed. A part of intestinal loop was strangurated into the right obturator canal. Reduction of the strangurated intestinal loop was done. The hernia sac was inverted, ligated and excised. Several discolored spots were also found on the intestinal wall, suggesting that stranguration and spontaneous reduction had occurred repeatedly. Obturator hernia is a rare but possible cause of intestinal obstruction in the aged patients, especially in females. The use of ultrasonography and CT scan as well as elicitation of Howship-Romberg sign are essential in the early diagnosis of the disease.

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A case of drug intoxication, which caused rhabdomyolysis of the left extremities, multiple organ failure including renal failure, DIC, and ARDS, and systemic metabolic disorder, was experienced. For local lesions, surgical treatment with fasciotomy was performed, and for renal failure, hypermyoglobinemia, and systemic metabolic disorder, blood purification was done. It took for 52 days and 61 days to normalize the oxygenizing potential and to be freed from blood purification, respectively. On 90th hospital day paralysis disappeared and surgical wounds were closed. On 110th day symptomatic remission was attained and the patient was discharged from the hospital. At etiology of this disease, possible contribution of chemical mediators released with reperfusion after ischemia is thought. Accordingly, in the treatment of this disease, local proper treatments as well such treatments considering chemical mediator strategy as blood purification methods and administration of proteinase inhibitors are necessary.

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