In order to clarify the clinical significance of intratumoral DNA heterogeneity (HE), 22 patients with esophageal cancer and 18 with colorectal carcinoma were studied for clinical stage, recurrence and survival period by dividing into HE and DNA homogeneity (HO) groups. Multiple specimens were obtained from the oral, anal, upper and bottom site of the tumor. DNA analysis of each specimen was done.
Of 22 patients with esophageal cancers, HE was found in 8 (36.4%), and HO in 14 patients. There was no significant difference in the clinical stage between HE and HO groups. The mean recurrence time was 24 months in HE groups, and 14.9 months in HO group, with a significant difference (p<0.05). Mean survival period was 24.1 months in HE and 19.6 months in HO group, a tendency of higher survival rate being noted in HE group. Of 18 patients with colorectal carcinoma, HE was tended to be seen in an advanced stage. The mean recurrence time was 11.5 months in HE and 21.9 months in HO group. Somewhat higher recurrence ratio was noted in HE group. Mean survival period was 8.8 months in HE and 27.0 months in HO group, with a significant difference (p<0.003). Liver metastasis was found in 75% of HE group within 16 months after the operation. It is thought that DNA heterogeneity may have different clinical significance in different carcinomas. In colorectal carcinomas DNA hetrogeneity can be an independent predictor for development of the cancer, especially for future liver metastasis and prognosis.

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In 1746 cases operated on for breast cancer at the department in a recent 28-year period from 1963 to 1990, 61 cases (3.5%) had bilateral breast cancers.
When synchronous bilateral breast cancer is defined as bilateral cancers were operated on at a interval within one year, 17 cases had synchronous and 44 had heterochronous cancers. Average age was 51.6 years in synchronous patients group, versus 46.8 years for the first cancer and 55.8 years for the second in heterochronous patients group. When histologic malignancies are scored according to Bloom & Richardson, the difference between right and left cancers was as small as 0.88 for synchronous or 1.18 for heterochronous group, the similarity of histologic malignancy between right and left cancers being demonstrated. In terms of ploidy pattern and the expression of c-erbB-2 protein, the similarity of bilateral cancers was observed in 66.7% and 75.0%, respectively.
The 5-year survival rate of the patients with bilateral breast cancer was almost the same as those with unilateral breast cancer. The patients who did not receive Tamoxifen after the operation had 2.8 times the average risk of developing 2nd breast cancer as compared with those receiving Tamoxifen.

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Among patients undergoing surgery for lung cancer during a three-year period from 1988 to 1990, 15 patients who were suspected of having ischemic heart disease (HID) and underwent preoperative coronary angiography (CAG) were subjected. In the present study, preoperative evaluation, preoperative treatment, and perioperative and postoperative management were studied.
Ten of the 15 subjects tested with CAG showed significant abnormalities of the coronary arteries and 5 out of the ten revealed no ECG abnormalities in preoperative ECG. Ergometrine maleate tests induced coronary spasms in 5 patients. Two of them had percutaneous coronary angioplasty preoperatively, and another 2 had coronary bypass surgery. All of them had coronary vasodilators during and after surgery, and no serious heart complications were observed during or after surgery. In cases with a slightest suspicion of IHD in preoperative ECG and interviews, operation for lung cancer can be carried out safely, if CAG is carried out and coronary artery lesions are identified.

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From 1975 through 1990, 983 patients received surgery for gastric cancer in the institute. Fifty-nine patients (6.3%) of them, who had pathological positive invasion of cancer cells at the surgical stump according to the General Rule for Gastric Cancer Study, were studied. Ulcerative type was predominant in early cancers while invasive type, in advanced cancerse. Twenty cases (43%) had poorly differenciated adenocarcinoma, and 48 cases (83%) showed deeper invasion in the gastric wall (_??_se). Survival rate of patients with positive stump was worse than that of patients with negative stump. This might lie in a fact that macroscopic noncurative operation was commonly employed in positive group, in a rate of 76%, versus 24% in negative group. Nine cases (1%) were defined as noncurative operation only due to histological positive stump, however, they didn't have additional operation. Two patients in “stage” have been free of disease, and no signs of recurrence. Three of 6 patients in “stage I” have survived without recurrence, and another three died of recurrence of gastric cancer 2 years, 1.2 years and 9 months after the operation, respectively; however any recurrence of cancer at the stump was not observed. These data suggest that another factors (P.H, n) might play an important role to determine the prognosis of these patients with positive surgical stump. Longer-term follow-up study for these patients will be required to survey the influence of positive surgical stump.

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Clinicopathological studies of 273 cases of early gastric cancer which had been operated on in an 18-year period from January 1973 to December 1990 were performed retrospectively, focusing on the lymph node metastasis and the possibility of reduction of surgical procedures. The incidences of lymph node metastasis were 2.0% in m cancers and 17.0% in sm cancers. Lymph node metastasis at No. 4, 5 and 6 were not observed in cancers of the region C, and those at No. 1, 2 and 3 were not observed in cancers of the region A. Gastric cancers of type IIb and IIa less than 2cm in diameter did not show any lymph node metastasis. There was no relationship between histologic type and lymph node metastasis. All six patients, died of the original gastric cancer, had sm cancer with lymph node metastasis. Preoperative diagnosis of the deapth of invasion turned out underestimation compared to actual deapth confirmed by resected specimen in a rate of 6.7%, and hence, sm cancers might not to be candidates for reduction surgery.
From these results, it is indicated that proximal gastrectomy with No. 7, 8 lymph node dissection form cancer in region C and, distal gastrectomy with No. 7, 8 lymph node dissection with hepatic branch of the vagal nerve preserved for m cancer in region A are surgical procedures of choice, and that for IIb and IIa cancers less than 2cm in diameter, gastrectomy with R₁ lymph node dissection is enough.

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In 86 patients with colorectal cancer of the following types: colon cancer (50 patients), rectal cancer (34 patients) and cancerization from familial polyposis (2 patients), the relation between antibacterial colorectal preparation and postoperative infection was studied.
Oral antibiotics were preoperatively medicated to 16 patients as antibacterial preparation, and 70 patients were not medicated.
The infection rate of the operated field in the medicated group was lower than that in the non-medicated group, but, on the contrary, it was much higher in the non-operative area of the former group. The postoperative infection rate turned to be higher in medicated group than in non-medicated group. In particular there was a tendency to have MRSA infection in the patient group received oral antibiotics preoperatively.

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Radical Surgery for rectal cancer with pelvic lymphadenectomy often causes postoperative sexual and urinary dysfunctions. In order to avoid these problems, it is necessary to adopt conservative surgical treatment of autonomic nerve presevation. However, one should be cautious about this operation, and we believe that this operation can be indicated for tumors infiltrating into the muscularis propria in the absence of lymph node metastases histologically [refer to pm (+), n (-)]. In order to know what macroscopic evaluation of progression of the tumor was comparable to this histological evaluation of pm (+) and n (-), patients with rectal cancer were investigated by using a protocol.
Eighty-six cases of rectal cancer.
1) Invasion of tumors into the rectal wall
2) Lymph node metastases
3) Macroscopic evaluation of tumor progression in the cases with pm (+), n (-)
4) Histological examination in the cases with AoN (-), AoN₁(+), A₁N (-), A₁N₁ (+)
5) Survival rate
A macroscopic evaluation of tumors infiltrating into the rectal wall (Ao) is agreeable with a histological evaluation (pm). A macroscopic evaluation of lymph node metastases N (-), N₁ (+) turned out to be n (-) by a histological examination in most cases. The survival rate of the cases with a macroscopic evaluation of AoN (-), AoN₁ (+) is comparable to the one with tumors with pm (+), n (-) as determined by a histological evaluation. In conclusion, this surgery is indicated for the cases with Ao and N (-), N₁ (+) by a macroscopic evaluation.

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It is well known that hepatic metastasis is a very important prognostic factor of colorectal cancer. The survival of patients with colorectal cancer is increasing, partly because of the aggressive treatment of hepatic metastasis or prevention against recurrence in the remnant liver following recent development of new techniques for liver surgery and postoperative management.
We reviewed patients undergoing resection of hepatic metastasis of colorectal cancer and investigated the indication for this type of surgery. Among 325 patients with colorectal cancer experienced in a past 16-year period, 54 (16.6%) developed hepatic metastasis. Seventeen of the 54 patients with hepatic metastasis (synchronous in 11 cases and metachronous in 6 cases) underwent surgery of their liver tumors. The 50% survival time of the liver resection group was 3.75 years versus 0.75 years in the nonresection group. There was no significant difference in survival rate between the liver resection and nonresection groups in patients with synchronous hepatic metastasis, but a marked difference of survival was found in patients with metachronous metastasis.
We experienced 5 patients (29.4%) who have a long recurrence-free period after hepatic resection, in that the clinical significance of liver resection should be emphasized for better prognosis of colorectal cancer with liver metastasis.

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To evaluate preoperative hepatic arterial infusion chemotherapy (HAI) for hepatocellular carcinoma, results in 19 cases treated with HAI and 28 cases without HAI were compared retrospectively.
Preoperative HAI caused deterioration of the hepatic functional reserve and increased the incidence of postoperative complications.
Histological findings in the resected specimens after HAI showed a high incidence of tumor necrosis and inflammatory infiltration into the parenchyma. Although postoperative recurrences were less, survival rate and disease free survival rate were low in patients with HAI.
In conclusion, HAI before hepatectomy did not contribute to the patients with hepatocellular carcinoma in late evaluation of hepatectomy.

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Six cases (8 lesions) of pyogenic liver abscess were reviewed clinically. In clinical findings, the frequencies of fever, abdominal pain, and poor appetite as the chief complaint, epigastralgia as physical finding, and leukocytosis, CRP strong positive, and liver disfunction as laboratory findings were high. Three cases of liver abscess were caused by biliary tract disease, and another 3 cases had unknown etiology. All 8 lesions were located in the right lobe. A species of Klebsiella pneumoniae was found in the abscess culture in 5 cases and anaerobic bacterium in 1 case. Tumor type in ultrasonography and uneven type in CT were thought characteristic imaging findings in an early stage of pyogenic liver abscess. As there is discrepancy between phase of clinical onset and phase discovered as liver abscess in imaging diagnosis, imaging examinations are necessary to be repeated if liver abscess is clinically suspected. Enhanced CT findings are more effective than US findings to discover the liver abscess. Cases of small liver abscess of cystic type in ultrasonography or even type in CT cured rapidly by PTAD. This finding suggests that punction and drainage of the abscess only once without PTAD may be indicated to these cases.

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Common duct bile samples from 157 patients undergoing percutaneous transhepatic biliary drainage (PTBD) and gallbladder bile samples from 10 patients undergoing cholecystectomy for acute cholecystitis were cultured aerobically and anaerobically. There were 60 patients with common duct obstruction due to stones and 97 patients with common duct obstruction due to tumors. Seventy-one percent of the patients with stones and 32% of the patients with tumors yielded bacteria on cultures of the bile. The organisms commonly isolated included Escherichia coli, Klebsiella and Enterococcus in both patients with stones and tumors. The rate of bacterial isolation from bile cultures showed no significant difference between those having fever and those without fever in patients with stones. However, in patients with tumors, those having fever showed significantly high rate of positive bile culture compared to those without fever. The rate of positive bile culture was significantly high in those having leucocytosis compared to those without leucocytosis in both patients with stones and tumors. In patients with tumors, those having mild icterus showed high rate of positive bule culture compared to those having sever icterus. It is concluded that PTBD should be performed as soon as possible regardless of serum total bilirubin levels in the cases having fever or leucocytosis to prevent severe cholangitis.

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Attention is called to a fact that Vibrio vulnificus can cause serious septicemia in people with impaired liver function. We have expierienced a case of Vibrio vulnificus infection with fatal outcome.
A 46-year-old man developed watery diarrhea and vomiting on the day after returning from Phillipine. On the day the patient was admitted to the hospital because of extremely high fever (40°C) with chill and erythema of the both lower extremities. There were previous histories of recieving gastrectomy and having liver cirrhosis and diabetes mellitus. Soon after admission, he became shock with sepsis and acute renal failure, and died 17 hours thereafter notwithstanding of intensive resuscitation. Vibrio vulnificus was isolated from blood culture.
Since primary septicemia caused by Vibrio vulnificus progresses to death so rapidly, early recognition of the disease and prompt treatment would be mandatory.

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We experienced a case of abscess of the neck caused by Mycobacterium tuberculosis, which was precisely diagnosed by the polymerase chain reaction (PCR) method. A 67-year-old woman was seen at the hospital because of a swelling in the right anterior region of the neck which was noticed 3 weeks before and then associated with skin redness and hot sensation. On physical examination, along the lateral edge of the right sternocleidomastoid muscle, a fixed and elastic-hard mass measured 6.5×4.5cm was palpated without tenderness. Although needle aspiration of the mass revealed a purulent content, microscopic examination demonstrated no causative microorganisms including mycobacteria and aerobic bacteria. Histology of the mass was necrotizing lymphadenitis without granulation. Since PPD reaction was strongly positive, tuberculosis was highly suspected. The PCR method successfully detected the DNA specific to tubercle bacillus from the neck mass. Subsequently anti-mycobacterial therapy was started without any delay and the mass regressed.

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Methicillin-resistant staphylococcus aureus (MRSA) causing infections lack in effective medicines, are refractory, and easily provide severe condition. Its prophylaxis and early diagnosis are very important.
A 24-year-old postpartal female who had a cesarean section delivery with preventive antibiotics therapy, progressed a right breast abscess in spite of antibiotics therapy (amoxicillin/cva) one month after the delivery. Clinical course and ultrasound examination revealed antibiotics-resistant breast abscess. Non smelled greyish-white pus was obtained by puncture and the culture grew a methicillin-resistant staphylococcus aureus, sensitive to minocycline and arbekacin. After immediate hospitalization, she was treated with intravenous arbekacin and oral minocycline in addition to irrigation and drainage of the abscess. She was discharged from the hospital 14 days after admission. MRSA-pneumonia, MRSA-enteritis, and MRSA-caused surgical wound infection are well-known, but MRSA-mastitis is rare. However, it can be inferred that MRSA-mastitis should be increasingly seen with recent expansion of MRSA. Here this case as well as a review of the literature is presented.

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Seven cases of noninvasive carcinoma of the breast and 8 cases of invasive ductal carcinoma with a predominant intraductal component were clinicopathologically studied to determine the possibility of ultrasonic diagnosis. Both patient groups showed similar clinical features. Palpation of noninvasive carcinomas resulted in benign diseases such as mastopathy and fibroadenoma, but that of intraductal-predominant carcinomas turned out malignant in half of them. Ultrasonic diagnosis indicated malignancy for only one case of noninvasive carcinoma (diagnosing rate of 25%), versus for 2 cases (40%) of in intraductal-predomi nant carcinoma. In both groups, tumors ranged from around 1cm to the maximum of nearly 10cm in size, were not associated with lymph node metastasis and were in Stage I according to tn(N)m classification. The longest survival period of 6 years was noted in both groups, and there have been no recurrence in all patients. Both groups revealed almost similar ultrasonic pictures which could not be differentiated from each other. These pictures were characterized by ill-defined, inner echos in variety, and relatively low echoic tumor with small ratio of the length-to-breadth. From these findings, all patients of both groups can be possible candidates for limited operation, however, some question would be still remained in terms of the necessity of limph node dissection and extent of resection in breast conservation procedure.

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Breast cancer can easily metastasize to the local skin, regional lymph node, lung, and bone and seldom to the liver and brain. But the intestine is a really rare first recurrent site. A 68-year-old woman was referred to the hospital who had a previous history of undergoing modified radical mastectomy for a right breast cancer (T2a, NOMO, Stage II) 7 years before. The resected specimen revealed scirrhos carcinoma with one positive node in the axillary lymph node and ER (+), PgR (-). The patient had been in excellent state before visit to other hospital when she developed upper abdominal distension, nausea, and vomiting, upper gastrointestinal barium studies and abdominal ultrasonography, revealed a narrowing in the third portion of the duodenum. Abdominal CT and upper abdominal angiography on admission indicated a tumor of the pancreas head. Under a diagnosis of pancreatic cancer, laparotomy was performed. Abdominal exploration revealed that a part of the transverse colon adhered to the third portion of the duodenum with disseminated nodules. Histological examination revealed that nodules on the serous membrane of the transverse colon were metastatic nodules from breast cancer. This case offers an interesting consideration in terms of metastasizing pattern of breast cancer.

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Five cases of duplication of the inferior vena cava associating with colorectal cancer were experienced at the hospital from January 1988 to September 1991. There were 4 males and one female. Their ages ranged from 47 to 72 years with an average of 60.4. All 5 patients had asymptomatic duplication of the inferior vena cava. All the duplications were accidentally found when the patients were receiving the treatment for colorectal cancer. Colorectal cancers which offered a chance to detect the duplication comprized of rectal cancer in 3 cases, transverse colon cancer in one, and double cancer of the caecum and stomach in one case. Preoperative imaging successfully visualized the duplication of the inferior vena cava in 4 out of 5 cases, however, in the remaining one case, differential diagnosis from paraaortic lymph node swelling was difficult. In terms of morphology according to Huntington and McClure classification, 3 cases which were confirmed during surgery had type BC and the remaining 2 cases were inferred also having type BC based on imaging diagnosis.

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Recently the associated resection or reconstruction of vessels including portal vein has been increasingly prevailed in abdominal operations, where a use of Bio-Pump^® as the extracorporeal circulation can be seen for some cases. However, the use for surgery of the inferior vena cava (IVC) is rare.
This paper describes recent experience with the use of Bio-Pump^® in two cases for veno-venous (v-v) shunt during resection of the tumors which were involved in the NC. The case 1 was of renal cell carcinoma of the right kidney developing in the suprahepatic NC with forming a tumor thrombus. The case 2 was of malignant teratoma of the retroperitoneum expanding to the NC and diaphragm. The right nephrectomy and thrombectomy with the partial resection of NC were performed in case 1. In the other case, segmental resection of NC was carried out when the tumor was resected. In both cases Bio-Pump^® was used for v-v shunt at 400-900ml/min for 80 and 254 min respectively. Operations were safely done by using Bio-Pump^® without any abnormal change in the hemodynamics. There was no blood clotting, hemolysis and air emboli in the shunt tube.
Active v-v bypass techniques using Bio-Pump^® can be used in abdominal surgery safely, and it may improve the resectability of abdominal tumors.

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This paper describes a case of arteriovenous fistula which is relatively rare in ruptured abdominal aortic aneurysm (AAA).
A 67-year-old man visited a nearly hospital because of abrupt hematouria and referred to the hospital under a diagnosis of AAA. On admission intracardiac catheterization revealed accerelated cardiac output O2-step up at the left common iliac vein. Aortography showed an arterioveneous fistula in the left iliac vein. In the operation, under the left sided retroperitoneal approach, the fistula was closed via inside of the left common iliac aneurysm using several mattress sutures. during the procedure, back-flow of the blood through the fistula was readily controlled by Fogarty Balloon Catheter indwelt in the left common iliac vain. The aneurysm was then replaced conventionally by a bifurcated vascular prosthesis. The postoperative course was uneventful and he is free from any symptoms. For better prognosis of this disease, early diagnosis and early treatment are mandatory.

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A case of giant organized hematoma in the right chest wall which was rapidly enlarged 36 years after right thoracoplasty is described. A 57-year-old woman was admitted to the hospital because of a tumor in the right chest wall. There was a history of undergoing right peumonectomy with thoracoplasty for pulmonary tuberculosis 36 years before. Ultrasonography and computed tomography revealed a giant heterogenous tumor with thick capsule in the right chest wall. Magnetic resonance imaging revealed fresh or old bleeding in the tumor. Right axillary artery feeded the tumor and pooling of contrast medium was seen in the tumor by angiography. Under the suspicion of hemangioma, operation was performed. The tumor was located at the back of major or minor thoracic muscle and at the outside of ribs. The tumor was 15×8×7cm in size and 410g in weight. Pathological findings revealed organized hematoma without neoplastic lesions. This case was very rare and it was supposed that the repeated brake down of regenerated capillaries in the pleura with chronic inflammation had promoted the growth of the hematoma.

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This paper presents a case of malignant lymphoma of the chest wall, which developed 30 years after thoracoplasy for tuberculous pyotholax. A 70-year-old man was admitted to the hospital because of fever and a large mass of the chest wall. There were previous histories of undergoing artificial pneumotholorax for pulmonary tuberculousis 45 years before and thoracoplasty for right pyotholax 30 years before. Computed tomography and Ga scintigraphy were useful for diagnosis. The patient received resection of the tumor and drainage for complicated pyotholax. Histologically and immunologically, the tumor was disclosed as malignant lymphoma, diffuse large cell type B cell type. Chemotherapy was started after the operation. The patient was alive 18 months after the onset of symptoms, but complete remission has not been attained as yet.
Recently patients with malignant lymphoma of the thoracic wall after a long silent period from pulmonary tuberculosis have been increasingly reported. All patients having a primary lesion in the pleula had previous history of artificial pnemotholax or tuberculous pyotholax. Diffuse large cell type and B cell type are most common and the prognosis is poor. This disease appears important in diagnosis of patients with previous history of pulmonary tuberculosis, and demands early diagnosis and multidisciplinary treatment.

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A 34-year-old man visited a nearby hospital because of epigastralgia and dorsalgia following vomiting after lunch. Panperitonitis due to unknown origin was suspected, and then he was sent to the emergency and critical medical center. Since spontaneous rupture of the esophagus was diagnosed with minute examination, an emergency left anterolateral thoracotomy was selected through the 5th intercostal space about 10 hours after the onset. A large amount of turbid pleural effusion in the thoracic cavity, and a large quantity of food particles in the mediastinal space were observed. As a longitudinal tear, about 5cm long, was revealed in the left wall of the lower esophagus, a simple esophageal suture and thoracic drainages were performed. After the operation suture insufficiency occurred, and then an abscess was complicated in the thoracic cavity. In spite of continuous thoracic irrigation with hyperalimentation and antibiotics administration, esophago-bronchial fistula with MRSA infection developed. With these conservative therapy, the refractory fistula could be successfully closed. Spontaneous rupture of the esophagus with esophago-bronchial fistula is very rare. Even though suture insufficiency occurs and refractory fistula develops, it can be healed with conservative therapy like this case. The importance of performing the adequate thoracic drainage should be emphasized for this disease.

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A case of hepatic metastases from resected gastric leiomyoblastoma is reported. A 37-year-old woman was admitted to the hospital because of hematemesis, melena and general fatigue. She was preoperatively diagnosed as leiomyoblastoma by endoscopic examination, and underwent proximal gastrectomy. The excised tumor with an ulcer was 7.5×5.5×5.0 cm in size.
Histological findings showed typical leiomyoblastoma with 50 mitotic figures/50 high power fields, and DNA ploidy pattern was diploid. The patient experienced recurrence and died of multiple hepatic metastases about two years later.
Although leiomyoblastoma is recognized as benign in general, 20 (7.3%) out of 272 cases of gastric leiomyoblastoma reported in the Japanese literature are of malignant and their prognoses are poor.
These 20 cases were clinicopathologically studied by dividing into benign and malignant groups, and some factors including age, location, maximum diameter of the tumor, and presence of ulcer appeared participate in the biological malignant potential.

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Leiomyosarcoma of the stomach is rare and represents 0.1-1.5% of all tumors of the stomach. It often metastasizes to the liver in a frequency of 20-30%.
This time a patient with liver metastasis from gastric leiomyosarcoma 10 years after gastrectomy which was able to be resected was experienced. A 74-year-old man was admitted to the hospital because of general fatigue.
There was a previous history of undergoing total gastrectomy for a 7 cm leiomyosarcoma of the stomach and a cancer lesion of IIc in the pylorus 10 years before. CT, MRI and angiography on adomission revealed that he had a metastasis in the anterior superior segment of the liver. Anterior segmentectomy of liver was performed.
There are few reports on resected cases of the stomach, but survivors for more than 12 months are included, incicating a relatively favorable prognosis. It is a fact that leiomyosarcomas do not respond to any chemotherapy and radiotherapy, where if we encounter a resectable case, aggressive attitude for resection would be recommended.

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Carcinoma of the digestive tract accompanied with myelodysplastyic syndrome (MDS) is clinically rare, having only 5 cases reported in Japan. During the surgical treatment for a case with MDS, infection must be prevented, and the operation has to be performed carefully. Recently we experienced a case of multiple gastric cancer associating with MDS which was successfully treated by increasing leukocytes due to administration of G-CSF.
A 67-year-old man was admitted to the hospital because of sudden hematemesis, who was followed on an ambulant basis for 2 years under a diagnosis of MDS. On admission, a severe pancytopenia was recognized. One lesion of Borr. 2 type on the cardia and another lesion of IIc type on the posterior wall of lower corpus of the stomach were found by an endoscopic examination. G-CSF was administered for 5 days preoperatively (total 375μg), and the leukocytes count increased to more than 8000/mm³. The operation including total gastrectomy, lymph node dissection, and splenectomy was performed. After the operation, G-CSF 75μg daily was administered for 3 days, the course being uneventful. During surgical therapy for the case accompaning with MDS, appropriate administration of G-CSF is useful for preventing infection.

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We experienced a case of ruptured aneurysm of the anterosuperior-pancreatoduodenal artery causing a retroperitoneal angioma. The patient was seen at the hospital because of upper abdominal pain. Simple abdominal X-ray examination, abdominal ultrasonography (US), upper gastrointestinal endoscopy, blood chemical tests revealed no subnormal findings. The patients was admitted for observation of clinical course, however, several hours later the patient had a sever upper abdominal pain. Abdominal US visualized a retroperitoneal angioma. Under a diagnosis of ruptured aneurysm of the abdominal artery, emergency angiography of the abdomen was carried out which led to the definite diagnosis of rupture of anterosuperior pancreatoduodenal aneurysm. No other aneurysm was found in the inteperitoneal arteries. Operative procedures after laparotomy included ligations of gastroduodenal artery side and superior mesentric artery side of the aneurysm for hemostasis, removal of the angioma, and abdominal drainage. Postoperative course was uneventful. Postoperative abdominal angiography showed favorable circuration in the head of pancreas. The etiology of this aneurysm was unknown, because no histopathological examination had been performed. However, there were previous histories of reciving general bruise 15 years before and undergoing therapy for hypertension since 20 years before. Possible two causes due to trauma or arteriosclerosis are suggested.

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Recent experience with heterochronous double cancer of the rectum and stomach in a 67-year-old man, associating with superior mesenteric arterial embolism in the course of observation which could be successfully managed by extensive excision of the intestine, is described. the patient was admitted to the hospital because of severe abdominal pain. There were previous histories of having a rectal cancer which was treated by low anterior excision 5 years before and an early gastric cancer 3 years before, for which the patient denied to be treated. Laparotomy was carried out within 5 hours after the onset of the pain. During surgery, necrotizing lesions extending from the duodenal horizontal portion to entire the small intestine, and from the ileocecal region to remnant sigmoid colon were found. Partial excision of the duodenum, total excision of the small intestine, and extended excision of the colon were performed.
Reconstruction was impossible and gastrostomy was made. Resected specimen showed a thrombolic embolism caused by a thrombus at the root of superior mesenteric artery. After surgery the patient was able to take fluids in the combinative use of IVH, but the impaired hepatic function and jaundice were aggravated. He died of MOF on the 42nd postoperative day. It is indicated that, if laparotomy can be performed in an early period after the onset of the disease, and if every effort is made to prevent shock and MOF after surgery, we can expect a long survival in these patients even though extended excision of the intestine can not be avoided.

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A 66-year-old man visited a nearby hospital because of constipation and anal bleeding. Endoscopic examination and barium enema offered a suspicion of ischemic colitis of stricture type, and conservative treatment was performed. However, stricture of the rectum became severe to turn out sub-ileus, and the patient was admitted to the hospital. Anterior resection of the rectum was performed. Histopathological diagnosis was Crohn's disease of the rectum. Postoperative course was eventful and he recovered his daily activities. Seventeen cases of Crohn's disease of the rectum were reported in Japan from 1968 to 1990. Only 4 of 18 cases of Crohn's disease of the rectum were diagnosed preoperatively. Thirteen cases underwent resection. No recurrence have been noted in resected cases, though the length of the follow up period still presents some problem. Resection as a treatment of this disease is recommended.

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Pelvic exenteration for local progression of rectal cancer has achieved satisfactory results. Hepatic resection of metastases from rectal cancer has also yielded good results and prognosis. However there have a yet been few reports which have concerned themselves with simultaneous combination of these two operative procedures. We report a case where resection of hepatic metastases and pelvic exenteration were simultaneously performed. This case was a 62-year-old man. He visited the hospital because of a hematuria. A complete medical examination revealed infiltration of rectal cancer to the prostate and further to the urinary bladder as well as multiple metastases to the liver. The primary lesion was a circumferential lesion present in the rectum and three metastatic lesions, measuring 1.5×1.5cm, 4.5×4.5cm, and 4.5×4.5cm, were found in segment 3, 4 and 7 of the liver respectively. Pelvic exenteration, with lymph node dissection of compartment three, left hepatic lobectomy and partial resection of posterior-upper segment (S7) were performed. In addition, colostomy and urinary diversion were performed.
Histological diagnosis was a moderately differentiated adenocarcinoma of the rectum with lymphnode metastases. The patient was complicated by post operative MRSA pneumonia necessitating respiratory management, but his hepatic and renal functions were kept intact.
Carcinoembryonic antigen value was more than 50ng/ml before operation, which decreased to 8ng/ml postoperative day.
The patient was discharged on the 57th postoperative day.

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A 51-year-old man was seen at the hospital because of left hypochondralgia. Simple abdominal X-ray film revealed a metal piece, which was likely a sewing needle, at the left border of the 3rd lumbar vertebra and close to the anterior abdominal wall. On abdominal CT the metal piece appeared to exist in the lateral segment of the liver. Laparotomy was performed and it was found that a sewing needle protruded from the surface of the lateral segment of the liver. An inflammatory streak was confirmed between the liver and stomach. It inferred that the needle swallowed by mistake penetrated the stomach to migrate to the liver. The needle was a 36mm sewing needle. It rarely occurs that a swallowed sharp foreign body by mistake penetrates the stomach with migration to the liver. Eighteen such case reports seen in the literature were also analyzed in this paper.

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This paper presents a case of inflammatory pseudotumor of the liver in a 76-year-old female. She was admittedto the hospital because of general fatigue and low grade fever. Laboratory data showed increase in ESR and CRP, and mild impairment of liver function, but tumor markers remained normal.Image diagnosis following computedtomography, ultrasonography revealed a space occupying lesion in the right lobe of the liver. Hepatic angiographyrevealed a hypervasucular lesion surrounded with obstructed small vessels.The tumor size was found to bediminished on echography performed one month later. These findings suggested an inflammatory pseudotumor ofthe liver. Since we could not rule out the malignant tumor, subsegmentectomy (S4, S5) of the liver wasuneventfully performed. The cut surface of the tumor was yellowish-white, and 3.0×2.0×1.5cm in size.Histologically, the tumor was characterized by fibrous cell proliferation and chronic inflammatory cells, indicatingchronic inflammatory tumor.This disease should be entertain as one of probable tumor lesions of the liver andneedle biopsy can provide the definite diagnosis.The previous reports comprising 19 cases of pseudotumor of theliver in Japan are also reviewed.

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Liver metastases from advanced lung carcinoma have not been the target of aggressive treatment probablybecause of poor results. However, the recent progress of arterial chemoembolization therapy may make it possibleto improve the response. We present a case of multiple liver metastases detected 18 months after curative resectionof lung adenocarcinoma responding to the intermittent arterial infusion with degradable starch microsphere (DSM). With this therapy tumor markers markedly decreased, and all small metastatic lesions disappeared onimaging examinations. Single residual metastatic lesion in the liver diminished from 55mm to 30mm in diameter, so the lesion was surgically resected.The resected specimen was mostly necrotic with a few surviving colonies ofsignet ring cell carcinoma.The patient died of liver recurrence 17 months later, i.e., 25 months after initiation ofarterial infusion therapy. This type of chemoembolization therapy has been employed for 7 cases of small cellcarcinoma of the liver metastasized from lung cancer in the literature, and 4 of the 7 cases responded to the therapy.Aggresive application of this therapy for liver metastasis of lung cancer may bring better prognosis to these patients.

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Carboplatin (CBDCA) is a derivative of cisplatin (CDDP). It has an almost equipotent antineoplastic activity tothat of CDDP with lesser adverse effects than those of CDDP. This paper describes an excellent result ofintrahepatic arterial infusion therapy with CBDCA for a case of advanced hepatocellular carcinoma causing atumor thrombus in the portal trunk.
A 59-year-old man was first diagnosed as inresectable hepatocellular carcinoma in June 1990, and underwent intrahepatic arterial infusion of ADM/MMC/LPD at angiography and TAE with sponzel slender pieces. However, 3 month later an enlargement of the tumor and tumor thrombus in the portal trunk were found and intrahepatic arterial infusion of CBDCA was carried out. After the CBDCA infusion 2 times, AFP value which elevated to 21, 000ng/ml at maximum decreased within normal range. CT conducted in March 1991 confirmed a diminished main tumor in the right lobe and disappearance of daughter nodule in the left lobe of the liver. Angiography also revealed decreases in the tumor size and degree of deapth of staining, and disappearance of tumor thrombus, the efficacy of CBDCA being indicated. Repeated imaging diagnosis in July 1991 showed the same findings. The case was considered resectable and right lobectomy of the liver and partial hepatectomy (S2) were performed in September 1991. Histopathological examination of the resected specimen revealed that more than 95% portion of the tumor in the right lobe was replaced by fibrous tissue and clear cell type of hepatocellular carcinoma was only found partially. The portal tumor thrombus was organized and its lumen was patent again. Postoperative course was uneventful. There has been no recurrence, as of 8 months after operation.

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Three surgical cases of hepatocellular carcinoma in patients undergoing hemodialysis for chronic renal failure were experienced.
Case 1: A 49-year-old man, maintained on hemodialysis for 10 years, underwent a posterior segmentectomy. The postoperative course was uneventful, but a biliary fistula developed. It subsided later. Two years after the operation, recurrence of carcinoma was noted in the residual liver, and a transcatheter arterial embolization was performed.
Case 2: A 53-year-old man, maintained on hemodialysis for 5 months, underwent a medial segmentectomy. An intraperitoneal abscess developed after the operation, which subsided later. The patient is closely followed on an ambulant basis.
Case 3: A 57-year-old man, maintained on hemodiaysis for 4 years, underwent a lateral segmentectomy. The postoperative course was uneventful. Case 1 and 2 were associated with hepatitis C, and both histopathological examinations showed chronic hepatitis in nontumorous liver tissues. Case 3 was not associated with viral hepatitis, and showed liver fibrosis in nontumorous liver tissue. Two of these patients were complicated by intraperitoneal infections, but these did not become fatal complications.
With careful operative mainpulation and postoperative observation we were able to perform the hepatectomies safely. Bearing in mind that such a characteristic status as immunocompromized host is usually found in hemodialysed patients, careful attitude for decision-making of operative candidate and extension of surgery is essential.

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This paper describes a case of hepatocellular carcinoma (HCC) with intrahepatic bile duct development, in a patient who was anicteric and without dilatation of the intrahepatic bile ducts.
A 76-year-old woman was admitted to the hospital because of elevated AFP level in September. There was a history of TAE for HCC in the medial segment of the liver about one year and 5 months before. AFP was 2, 430ng/ml, and 15-minute ICG delaying rate was 20%. Ultrasonography and CT revealed a lesion of 1.7cm in diameter in the anterosuperior segment (lesion A) and 1.5cm lesion in the medial segment (lesion B). Furthermore, a lesion of 1.5cm in diameter was noted cranial to the bifurcation of the portal vein (lesion C). Lesion C appeared to be covered with a thick capsule, but its continuity with the bile duct was unclear. Lesion A and B were diagnosed as HCC preoperatively, but C was undiagnosed at the time of laparotomy. By means of intraoperative ultrasonography and cholangiography, lesion C was found to be a HCC extending from the right hepatic duct to the common hepatic duct. Since the patient had cirrhosis of the liver and was also of advanced age, partial resection of the anterior and medial segments was performed, and the tumor in the bile duct was excised. Histological examination showed that lesion A, B, and C were all HCC with a trabecular pattern.

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The trimethadione (TMO) tolerance test, an estimation based on serum dimethadione (DMO)/TMO ratio (DMO is the only metabolite of TMO) was used to quantitatively confirm the functional hepatic parenchyma after hepatectomy. Hepatic functional reserve was confirmed to be improved when measured by TMO tolerance test after transarterial embolization(TAE)for ruptured case of hepatocellular carcinoma.
The patient well tolerated hepatectomy. Accordingly, activation of hepatic functional reserve with TAE was tried on 3 patients who were diagnosed inoperable because of decreased hepatic functional reserve. In these patients, DMO/TMO ratios also increased after TAE and were considered operable. Hepatectomies were carried out and all 3 patients well tolerated the surgery. Histological examination of resected hepatic specimens revealed the regenerative nests at the sites where TAE did not affected. TMO tolerance test was able to evaluate the improvement in hepatic functional reserve, based on the hepatic parenchyma lregeneration. Thus, this test can be applied to evaluate the hepatic functional reserve in cases with decreased hepatic functional reserve.

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A 69-year-old woman was admitted to the hospital because of dull pain in the right hypochondrium. An egg-sized mass was palpated in the right hypochondrium, accompanied with tenderness. Serum CA125 level, a tumor marker, was elevated. Ultrasonogram revealed an enlarged gallbladder, in which the wall the wall was hole-circumferentially hypertrophic and heterogeneous echoic mass was observed at the neck. Operation was performed 1 month after the onset, with suspicion of gallbadder cancer. On the operation, the gallblader was congestive and swollen. When adhesion was dissected, the gallbladder was found to be twisted clockwise by 180 at the neck. Gallbladder torsion was noted as a Gross type I “floating gallbladder”.
Gallbladder torsion is regarded as an acute abdomen. A review of 250 cases reported in Japan revealed that the operation was performed in 22.0% of them on and after 4 days and in 9.3% on and after 8 following the onset of the disease. The degree of the torsion of all cases in which operation was performed on and after 4 following the onset, including this case, remained within 360. The degree of gallbladder torsion might affect the clinical course, and clinically the degree of 360 might be a critical point.

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A case of primary carcinoma of the cystic duct is reported. A 74-year-old woman was admitted to the hospital because of epigastric pain. There were no jaundice nor palpable mass in the right upper quadrant. Ultrasonography showed a tumor in the cystic duct and a stone in the gallbladder. Endoscopic retrograde cholangiography showed a filling defect in the cystic duct. Cholecystectomy was performed under a preoperative diagnosis of tumor of the cystic duct with gallstone. The mucosa of the resected gallbladder was normal, but a 1.1×0.7cm papillary tumor was found at the cystic duct. Histologically the tumor revealed papillary adenocarcinoma. The carcinoma was limited in the fibromuscular layer but carcinoma cells were found at the surgical margin of the cystic duct. As the second look operation resection of the bile duct with dissection of the regional lymph nodes was performed. Resected specimen revealed fibrous thickening of the wall of the remnant cystic duct but no evidence of malignancy. As of 8 months after the operation, her clinical course is good and there has been no evidence of recurrence.

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A 69-year-old female was seen at the hospital because of constipation. A nodular tumor in the ceacum was found by total colonoscopic examination. Histological diagnosis of the specimen was well differentiated adenocar-cinoma. After admission, abdominal ultrasonic examination revealed a polypoid cancer on the fundus of the gallbladder. Cholecystectomy and ileocecal resection were carried out at the same time. In Japan, we believe this to be the second reported case of primaly double early cancer of the gallbladder and colon. The importance of systematical preoperative examination should be emphasized.

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This paper describes a case of primary myelofibrosis (PMF) associated with splenic infarction which was treated by splenectomy.
A 58-year-old man who had been diagnosed as PMF 1.5 years before was admitted to the hospital because of splenomegaly, left hypochondralgia, high fever and marked decrease in peripheral platelet (1-2×10⁴/μl). Abdominal CT scan and RI scintigraphy indicated multiple splenic infarction. Splenectomy was performed because his symptoms were aggravated. After the operation hypochondralgia and fever disappeared and the patient was discharged from the hospital on 30th postoperative day. For severe thrombocytopenia, administration of “platelet concentrate” during perioperative period contributed to preventing hemorrhagic diathesis, and the huge spleen 2330g in weight could be easily resected with only 300g of intraoperative bleeding without complications. Some authors have reported that splenectomy in PMF patients is much riskier than that in other diseases. We suppose that splenectomy in PMF patients may be recommended not to improve hematological findings, but to relieve severe symptoms due to splenic infarction like this case.

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Renal cell carcinoma easily metastasizes on blood. The most common site was the lung, followed by liver and bone in this order, but it rarely metastasized to the pancreas. This paper presents a patient undergoing nephrectomy for a primary renal cell carcinoma 9 years before had 3 metastatic tumors in the pancreas which were successfully resected. The pathological findings of the specimen showed the metastasis of renal cell carcinoma in the pancreas. The resection of metastatic pancreatic cancer from renal cell carcinoma can be seen in only 11 cases in the Japanese and 13 cases in the foreign literature, since Jenssen and others had reported in 1952. It is that the pancreatic head is the common metastatic site, and near half of these cases were operated on after 10 years or more after nephrectomy for the primary renal cell carcinoma.

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A 53-year-old female was admitted to the hospital because of lower abdominal pain and in the same part a tumor was palpated. Ultrasonography reveled a well-defined hypoechoic solitaly tumor sized 9×5cm. CT demonstrated the tumor and its peripheral area was enhanced moderately. Under a diagnosis of mesentric or omental tumor, operation was performed. Two adjoined tumors were originated from the greater omentum. The excited solitary tumors were 12×10×7cm (460g) and 5.5×2.5cm (20g) in size. Histological diangosis was leiomyosarcoma. Seven months later, the sign of peritoneal recurrence was detected. A palliative excision of the tumors and colostomy were made After that, residual tumors increased rapidly, and she died 2 months after the operation. Further progress in clarifying preoperative radiological pictures of this disease and in treating recurrence, especially peritoneal recurrence are desired.

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An 18-year-old female was admitted to the hospital because of an abdominal mass and pain. The mass was palpable in the left abdomen with a size of 20×20cm. CT scan showed irregular patterns in the mass and the margin was enhanced. In MRI, T₁-weighted image revealed a low signal intensity tumor and T₂-weighted image revealed a high signal intensity tumor. Angiography disclosed the right and left gastroepiploic arteries feeding the tumor. A diagnosis of a primary tumor of the greater omentum was made, and operation was carried out. Operative findings disclosed the tumor arising in the greater omentum and peritoneal dissemination in the Douglas'pouch. The tumor with the greater omentum was resected. The tumor was 25.0×22.5×8.8cm in size and 4000g in weight. Histological diagnosis was malignant hemangioendothelioma. Only two cases of malignant heman-gioendothelioma of the greater omentum have been reported except this case in Japan.

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A case of peritoneal malignant mesothelioma is reported, with some discussion based on the Japanese literature. A 65-year-old man was admitted to the hospital because of abdominal distention in April 1990. As the patient had ascites and node in the Douglas' pouch, a tentative diganosis of peritoneal dissemination from unknown origin was made and exploratory laparotomy was performed. On laparotomy it was found that the greater omentum was replaced with tumor mass and the peritoneum was extensively scattered with numerous nodi 1cm in diameter. Histopathologically, cubic tumor cells lacking the atypia showed a ductal structure, were PAS-positive, and were able to be digested by hyaluronidase. Accordingly, the diagnosis of epithelial type of mesothelioma was confirmed. One week after laparotomy, continuous hyperthermic peritoneal perfusion using CDDP and Mitomycin C was started. Decrease of the ascitic fluid and the degeneration of tumor cells were observed.
Until the end of 1990, 240 cases of peritoneal mesothelioma have been reported in Japan. Their average age was 54 years. The male-to-female ratio was 4:3. The diagnosis is difficult without laparotomy or laparoscopy. CDDPbased intraperitoneal chemotherapy seems to be the best available treatment at present. Nevertheless, peritoneal mesothelioma has still poor prognosis.

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This paper presents a recent experience with a case of retroperitoneal malignant fibrous histiocytoma.
A 62-year-old woman was seen at the hospital because of an abdominal tumor.A 12×10cm tumor mass extending from the left hypochondrium to left lateral region was palpated.Abdominal ultrasonography and CT visualizied a well defined oval tumor. Angiography confirmed a serpentine irregular vascular figure.It was diagnosed as sarcoma arising in the retroperitoneum and the tumor was removed.The well encapsulated tumor was 11.5×10.5×8.5cm in size and 560g in weight.The cut surface was solid, scattered with cysts with less than 1cm in size, and partially included hemorrhagic portions. Histological diagnosis of malignant fibrous hystiocytoma was made.No radiotherapy or chemotherapy was conducted postoperatively. There has been no recurrence, as of one year and 9 months after the operation.As this disease is considered to arize in the retroperitoneum in a relatively high frequency, further such cases may be increasingly reported. Preoperative imaging methods present difficulties in definite diagnosis of this disease. Good prognosis can not be expected for the advanced tumor. Early surgical removal of the tumor would be the best and only therapy.

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A relatively rare case of epigastric hernia in a 72-year-old female is reported.
The patients was admitted to the hospital because of an epigastric mass, pain and vomiting. A 6×5×4cm soft mass in the upper abdomen was palpated. The reduction of the mass was possible. Upper GI series and computed tomography revealed that antral portion of the stomach was incarcerated into the abdominal mass. At surgery, epigastric hernia with a 3×3cm sized opening was found in the linea alba. The postoperative course was uneventful. There has been no sign of recurrence up to now.
Epigastric hernia is relatively uncommon in Japan, and in addition to this case, 21 cases can be seen in the Japanese literature, as far as we could review

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