Blood glucose levels were measured every 6 hours for 7 days after gastrointestinal surgery in 34 patients with diabetes mellitus. The effects of different kinds of carbohydrates and routes of insulin administration on blood glucose levels were also investigated. The mean value of the differences in blood glucose levels (the maximum level minus minimum level within a day) was 107.90mg/dl on the first postoperative day, and those on the second to sixth postoperative day ranged from 54 to 72mg/dl. The mean difference increased to 96.51mg/dl on the seventh postoperative day. When glucose was infused as a sole carbohydrate, both maximum and minimum levels of blood glucose on the first postoperative day were significantly higher than those when other carbohydrates were infused together. However, there was no significant difference in the degree of the changes of the blood glucose levels between two groups. When insulin was administered subcutaneously, the mean value of the differences in the blood glucose levels within a day (from the second to fourth postoperative day) was 62.64mg/dl, which was significantly lower (p<0.025) than that when insulin was administered intravenously (91.59mg/dl). We conclude that frequent and accurate measurement of blood glucose levels is most important in the postoperative management of diabetes mellitus.

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The author measured changes in subsets of peripheral lymphocytes in patients with gastric cancer to observehow the postoperative host immunity is influenced by the transfusion.
In the cases without blood transfusion, the CD11(+)CD8(+) cell ratio began to increase at the early time of operation, while the CD4(+)2H4(+) cell ratio decreased. After that, CD11(+)CD8(+) cell ratio returned to preoperative number. CD4(+)2H4(-) cell ratio decreased at the operation and prolonged for a certain period according to the degree of advancement of the disease and operative prceedure. Change of host immunity by blood transfusion performed in addition to surgery was then investigated in 11 stage I+II patients undergoing subtotal resection. Compared with the non-transfusion group, the CD4(+)2H4(-) cell ratio more decreased and the CD11(+)CD8(+) bright cell ratio more increased in the transfusion group, revealing prolonged immunosuppression in the transfusion group.
On the other hand, in 17 patients receiving autogenous blood transfusion, CD11(+)CD8(+) bright cell ratio rather suppressed than in the blood transfusion group, and the CD4(+)2H4(-) cell ratio more increased. Although blood transfusion was found to lead to immunosuppressive responce in this study, the use of autogenous blood transfusion eliminated such response.

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One hundred and fourteen cases of hypertrophic pyloric stenosis (HPS) were operated on at the department from 1968 to 1988. These 114 patients were divided into 5 groups according to operated period and compared with clinical feature, intraoperative findings and measurements of resected muscularis. Patients operated on within 14 days of birth were allocated to group I; patients from 15 to 30 days of birth, group II; patients from 31 to 60 days, group III; patients from 61 to 90 days, group IV; and patients later than 91 days, group V. Group I and II, namely patients operated on in neonatal period, disclosed better preoperative conditions and postoperative clinical course than those of group IV and V, especially group V. Accordingly, more careful pre and postoperative management should be given to patients undergoing operation in a later period.

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The expression of epidermal growth factor (EGF) in terms of proliferation and progress of the tumors was immunohistochemically studied in 94 resected gastric carcinomas by using anti-human EGF antibody. EGF were predominantly expressed in carcinomas of type, ps(+), and in stage III or IV. EGF expression was associated with high incidence of lymph node metastasis. In the carcinomas of C lesion of the stomach, the ratio of EGF(+) cases was higher in poorly differentiated type than in well differentiated type. Five year survival rate of the cases with EGF(+) carcinoma had lower than of EGF(-) cases. These results suggested that expression of EGF could be a valuable marker for predicting prognosis of patients with gastric carcinoma.

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We have investigated the relation between the grade of lymph ducts infiltration in primary lesion and the spread of lymph node metastasis in 236 cases of gastric cancer. This study suggested that lymph node metastasis established at more distal lymph nodes with an increase in the grade of lymph ducts infiltration. The cases exhibiting the same grade of lymph ducts infiltration were classified into proximal lymph nodes metastasis group (group 2) and distal lymph nodes metastasis group (group 3). There were no differences in histologic features of primary lesion between both groups, but poorly differentiated adenocarcinoma was more frequently found in group 3 than group 2. On the other hand an analysis of metastatic regional lymph flow cytometry suggested that natural killer cell ratio increased. So the relation between natural killer cell ratio in the proximal metastatic lymph nodes and the spread of lymph node metastasis was studied in 21 cases of gastric cancer, 8 cases belonged group 2 and 13 cases belonged to group 3. In this study, the NK index which is %(Leu7^-CD16⁺)×3+%(Leu7⁺CD16⁺)×2+%(Leu7⁺CD16^-)×1 was employed. The NK index was 42.1±24.3 in group 2 versus 7.3±5.O in group 3 (p<0.01). It is suggested that in gastric cancer the spread of lymph nodes metastasis may depend on some factors including the histrogical type of carcinoma and response of natural killer cells in the regional lymph nodes.

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Six cases of nonocclusive mesenteric ischemia (NOMI) are presented. All cases had a variety of underlying diseases and causes. The diagnosis of NOMI was confirmed operatively in three cases, by angiography in two cases, and at autopsy in one case. Intestinal infarction was located in the tributary of the superior mesenteric artery (localized type) in three cases and in that of both superior and inferior mesenteric arteries (massive type) in three cases. A possible participation of mesenteric vasoconstriction was considered as a causative factor in all cases of bowel infarction. Bowel resection was carried out and primary intestinal anastomosis or intestinal fistula was performed in all cases. Three cases with limited resection of the small intestine were successfully treated. Other three cases with massive bowel resection died. In massive type necrosis, early diagnosis is particularly required to prevent further and irreversible bowel changes. For that it is important to define the high risk group, and in patients complaining of persistent abdominal pain who may be included in the group, aggresive approach including angiography of the mesenteric artery, followed by selective intraarterial infusion of a vasodilator (papaverine), if the angiography confirms some findings of this disease, may contribute to more improved prognosis.

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There was a variety of operative procedures for rectal prolapse from old times. We performed Ripstein procedure with Teflon mesh for 12 cases of complete prolapse of the rectum. There were 4 men and 8 women. Their ages ranged from 36 to 84 years with the average of 63.2. Duration of the disease was varied, from 7 days to 60 years. There was a previous history of undergoing operation for hemorrhoid in 4 cases. Two young patients were associated with mental disorder. Their rectal prolapses were egg to fistsiaed, and 3 cases were accompanied with incarceration. Postoperative course was uneventful in all cases, but recurrence occurred in 2 cases.
In this hospital Ripstein procedure has been employed for rectal prolapse, with favorable outcome. We think that Ripstein procedure should be aggressively carried out, if the general condition of the patient permits.

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Lymphocyte subpopulation in peripheral blood of patients with colorectal cancer were identified by two colar analysis and flow cytometry using monoclonal antibodies, and serum immunosuppressive acidic protein (IAP) was examined before surgical operation. The absolute number of OKT4⁺2H4⁺ (suppressor inducer T) cell in patients with colonic cancer were significantly lower than those with rectal cancer. There were significant differences between stage I and III, stage I and IV. The absolute number of OKT4⁺2H4⁺ (suppressor T) cells tended to increase as the disease become advanced. There was no significant difference in the absolute number of OKT8⁺Leu15^- (cytotoxic T) and OKT4⁺2H4^- (helper T) cells between colonic and rectal cancer group. Serum IAP in the patients with colonic cancer in stage II, III or IV was significantly higher than that in stage I. Cellular immunity of colorectal cancers have inclined toward minus.

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Significance of flow cytometric (FCM) DNA analysis for assessing malignant potential of colorectal cancer was invastigated using paraffin-embedded materials of 77 patients with the cancer invading the muscular propria. Sixty percent of colorectal cancers were com-posed of diploid and 40% aneuploid. There was no significant difference between diploid and aneuploid groups in ploidy pattern and the factors including sex, age, the site of tumor location, lymphatic permeation, lymph node metastasis, and peritonitis. DNA aneuploid with venous invasion showed significantly higher liver metastasis (p<0.01). Survival rate for 18 months was 84% in both aneuploid and diploid groups. However, Dukes'stage was associated with the motality. The role of FCM in the assessment of prognosis of colorectal cancers deserved further clinical evaluation on malignant potential.

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Hepatopancreatoduodenectomy (HPD) with hepatectomy has been widely employed for advanced biliary tract carcinomas. In this paper 10 patients with biliary tract carcinoma undergoing HPD with hepatectomy were compared with control groups for operative stress, hepatic regeneration, and postoperative complications. These 10 patients were divided into 2 groups, namely 6 undergoing resection of more than 2 segments and 4, less than 2 segments. Another each 10 patients undergoing extended hepatectomy or HPD were severed as control.
HPD patients with hepatectomy of more than 2 segments showed significantly greater values in operative bleeding amount, operating time, and postoperative complications than those of other 3 groups. Postoperative total serum bilirubin significantly increased in HPD with hepatectomy (more than 2 segments) group.
There were no differences in restoration of remnant hepatic volume after extended hepatic lobectomy with or without pancreatoduodenectomy. Median survival after HPD was 12 months. According to a questionnaire survey reported at the 16th Japan Pancreatectomy Society, the commonest cause of hospital deaths in HPD patients was hepatic failure, followed by preoperative T. Bil. level of 3mg/dl or more, age of over 60, hepatectomy of more than 2 segments, and association of vascular reconstruction, in this order (with significant difference).
It is thought that an increase in total bilirubin well expresses a significantly severe operative stress with HPD than that with usual hepatectomy. Accordingly, HPD can escape associating with postoperative hepatic failure and other complications by an appropriate selection of operative candidates preceded by sufficient reduction of serum bilirubin; careful vascular reconstruction; and good nutritional management.

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A total of 125 patients with carcinoma of the pancreatic head region was treated at the department, and 57 out of 125 patients underwent curative resection. Twenty-three of the 57 patients had recurrence of known pattern. In these 23 patients, pathological factors, clinical stage, and postoperative survival time were comparatively studied in terms of presence of hepatic metastasis. Among recurrent cases of cancer of the pancreatic head, 66.7% of them were more than t3, and all of them were more than ly2 and v2. Most tumors were large in size and had advanced vessel involvement. There were no significant correlation between hepatic recurrence and pathological factors in carcinomas of the lower bile duct and ampulla of Vater. Of these 23 recurrent cases, all 4 cases of poorly differentiated adenocarcinoma recurred in the liver. Most recurrent cases of carcinoma of the pancreatic head were in an advanced stage, 44.4% in Stage III and 33.3% in Stage IV. There were no significant differences between hepatic recurrence and stage. All cases of carcinoma of the lower bile duct with hepatic recurrence and 50% of those of ampullary carcinoma with hepatic recurrence were in StageIII 6r more. These findings indicated that most cases with hepatic recurrence were in advanced stage. Average postoperative survival time was short in cases with hepatic recurrence compared with those without hepatic recurrence as to carcinomas of the pancreatic head region. It is thought that metastasis to the liver might be a determinant factor for the prognosis.

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A 58-year-old man, with past histories of tuberculosis and diabetes, underwent total gastrectomy with Rouxen-Y reconstruction because of a stage I gastric cancer located at the posterior wall of upper one-third of the stomach. After the operation, malnutritional status of unknown cause and uncontrollable ascites were prolonged in spite of favorable appetite. Although fever, leukocytosis and elevated level in C-reactive protein continued after 18th postoperative day, no pathogenic bacteria were identified in the ascites, blood, urine and sputum. Left pleural effusion developed on 33rd postoperative day, followed by sudden respiratory distress and shock on 33th day, resulting in death on 40th day. Autopsy revealed chronic and acute panperitonitis with a lot of purulent ascites, and histopathological examination revealed disseminated candidiasis with pneumonia, acute pyelonephritis, and microabscess of the liver, pararenal gland and myocardium. It is considered that rapid serological diagnostic methods should be performed under a strong suspicion of fungal infection in cases that inflammatory signs of unknown origin are prolonged after total gastrectomy.

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Squamous cell carcinoma of the breast is a very rare tumor, which commonly contains a little component of either adenocarcinoma or sarcomatous lesion. Moreover, pure squamous cell carcinoma is an exceedingly rare variant of breast cancer. It represents 0.046% to 0.28% of all breast cancers. Only 27 cases have been reported in the Japanese literature until 1990. Herein, an operated case of pure squamous cell carcinoma of the breast is presented.
A 54-year-old woman was admitted to the hospital because of a right breast mass with tenderness. Ultrasonographic examination revealed an irregular hypoechoic mass with cystic component. With needleaspiration cytology, the tumor was diagnosed as squamous cell carcinoma. On December the 2nd of 1991, right standard radical mastectomy was carried out. The tumor was 3.5×2.0cm in diameter, firm and grayish white. The cut surface showed cystic formation, necrosis and hemorrhage of its wall. Histological diagnosis was pure squamous cell carcinoma.

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This paper describes a surgically resected case of granular cell tumor of the esophagus. A 37-year-old man was found having a lesion at the posterior wall of the esophagus in region Ei by endoscopy for observation of clinical course of gastric ulcer. It was a 7×3mm white elevated lesion rising in a gentle curve with a sharow excavation. From biopsy a diagnosis of granular cell tumor was made. Though no histological malignancy was identified, wedge resection of the esophagus under thoracotomy was performed, in terms of morphology of the tumor and patient's age.
Granular cell tumor is commonly found in the tongue, skin, and breast. The tumor arising in the esophagus is so rare that only 84 cases have been reported in Japan up to now. This is generally referred as benign tumor, but we sometimes see malignant cases in the literature. For this, we should take careful attitude for decision-making of therapeutic indication.

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This paper presents an unusual difficulty encountered in clinical differentiation between reactive lymphoreticular hyperplasia (RLH) of the stomach and malignant lymphoma (ML) of the stomach (diffuse lymphoma, mixed type). A 62-year-old female had epigastrial discomfort. Gastorofiberscopy and rentogenography revealed coarse granuliform degenerations with irregular ulcer over the area extending from great curvature of angle, lower and middle portion of the stomach to the posterior wall. Notwithstanding the diagnosis of RLH resulted from biopsy she had to undergo a surgical operation due to still undeniable sign of ML. Pathological findings, however, entailed ML localizing in 3 spots within a wide ranged RLH impairment. Immunohistochemically, RLH impairment was stained by polyclonal antibody, while ML impairment by monoclonal antibody. Of obvious note in this clinical case is the coexistence of wide ranged RLH and partially ranged ML, wherein a transition from the former to the latter is highly probable.

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Recent development of the radioimmunoassay technique has been enabled to measure the low level of serum alphafetoprotein (AFP). A various kinds of malignant tumors, which show elevated serum AFP except hepatic cell carcinomas and embrionic cancers, have been reported.
Those are mainly consisted of gastric cancers and cholangiomas, pancreatic and colorectal cancers have been really reported.
Prognosis of AFP-producing gastric cancers is poor, because of rapid growing, and easily metastasis of the liver and lymphnodes.
Intensive chemotherapy should be recommended for treatment perioperatively. The measurement of serum AFP level may contribute to make diagnosis and to evaluate therapeutic effects.
In this report, we emphasize the importance of strict postoperative follow-up, using regular check of serum AFP, CT scan and ultrasonogram.

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1. This paper describes 2 cases of so-called disseminated bone marrow cancer caused by metastasis of gastric cancer to the bone marrow, which came to an abrupt course.
2. In the diagnosis of this disease, appearance of leukoerythroblastosis and increases in serum LDH and ALP values, in addition to exploration of the bone by making the most use of CT, MRI, and scintigraphy and increases in tumor markers, were useful. For the definite diagnosis, biopsy of the bone marrow was essential.
3. Both 2 cases presenting with lumbago indicate that the diagnosis of this disease is first able to be made by entertaining its possible existence, when a patient without previous history of gastric cancer is encountered. We have learnt that we should not employ symptomatic indication for lumbago desultorily at the outpatient clinic.
4. Moreover, in the treatment of juvenile patient with gastric cancer, if it is poorly differentiated adenocarcinoma or mucus producing carcinoma, sufficient exploration and consideration of the bone marrow metastasis are necesarry, no matter whether the patient undergoes curative or non-curative resection.

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Recent experience with two cases of postgastrectomy jejunal intussusception in which CT played an important role in diagnosing is described with a review of the literature.
Case 1: A 66-year-old man was admitted to the hospital because of an attack of upper abdominal pain and hematcemesis. Laparotomy was performed 54 hours after the onset. After resection of the necrotic intestine, the intact parts were end-to-end anastomosed.
Case 2: A 48-year-old man was admitted to the hospital because of repeated upper abdominal pain and vomiting. No symptomatic remission could be attained by conservative therapy, so laparotomy and reduction were performed.
There was a previous history of gastrectomy in both cases. After uneventful 20 years, case 1 developed this disease with acute course and the other with chronic course. Like these 2 cases, there are two different types in jejunal intussception after gastrectomy, acute and chronic, so its diagnosis is not easy. Some characteristics in CT scan, however, are especially useful in the diagnosis of this disease. We have to take careful consideration to this disease when we examine post gastrectomy onset of upper abdominal pain.

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Encapsulating peritonitis is a relatively rare disease in which the intraperitoneal organs are enclosed in membranous sheaths. No accepted opinions for the etiology and treatment have been established as yet.
A 77-year-old woman was seen at the hospital because of frequent vomitings. On physical examination a giant mass locating entire the abdomen was palpated, and edema was found in the bilateral lower extremities. Imaging diagnosis disclosed a giant intraperitoneal cyst oppressing the intestine and a right hydronephrosis. Giant ovarian cyst was suspected. On laparotomy brown effusion gushed out. The effusion (about 4, 700ml) was removed by aspiration when it was disclosed that the intraperitoneal organs were covered with thick capsule and pressed against the retroperitoneum. It looked like as if the entire intraperitoneal organs were removed and this capsule and lateral peritoneum formed a giant lumen. The capsule was soft but was unable to free. A part of the capsule was taken and after a Neraton tube was inserted into the abdomen, the surgical wound was closed. Histologically the capsule was collagenized connective tissue. The capsule formation appears to be attributable to a fact that fibrins deposit to the surface of the intestinal serosa when reactive ascites is absorbed in the periotneum.

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The patient was a 67-year-old man. There was a history of undergoing right hemicolectomy for a preoperative suspicion of colonic cancer which was diagnosed as Crohn's disease by postoperative histological examination at elsewhere. From 1.5 years after the operation the patient had alternative diarrhea and constipation and was seen at the hospital. Colon irrigoscopy revealed an apple core-like lesion at the anastomosis. Biopsy indicated non-specific inflammatory granulation, so the relapse of Crohn's disease was suspected. During examinations intestinal obstruction developed and partial resection of the constrictive lesion was performed. From pathological study of the resected specimen a diagnosis of intestinal tuberculosis was made.
Intestinal tuberculosis is characterized by strong tendency to natural heal and time-dependent spectrum of morphological changes. For that the disease sometimes presents difficulty in differential diagnosis from Crohn's disease and other inflammatory diseases of the intestine. The importance of continuous observation of the lesion should be emphasized in the diagnosis of the disease.

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The appendix mucocele is a rare disease and often presents difficulty in diagnosis before operation. We experienced a case of mucinous cystoadenoma of the appendix with high serum CEA level.
A 74-year-old man was admitted to the hospital because of severe dizziness due to melena. When a mass was palpable in the right lower abdominal quadrant. Gastro and colonofiberscopies revealed no cause of melena but a SMT like elevation in the cecum. Barium enema examination showed the extraluminal compression of the ascending colon, but the appendix could not be visualized. A cystic mass contacted with the right kidney was revealed by ultrasonography and CT scan. The renal cell carcinoma was suspected by fine needle aspiration biopsy. Suspected of malignancy with the high level of serum CEA, right hemicolectomy and right nephrectomy with lymph nodes dissection were performed.
Histological, the tumor was mucinous cystadenoma of the appendix with no severe atypical cell. Melena was from ileal ulcer which was included in the resected lesion. After the operation, the serum CEA has smoothly fallen to normal level. This disease may result in pseudomyxoma peritonei with poor prognosis. Here the importance of the complete resection so as not to lose the time after diagnosis is emphasized.

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Primary adenocarcinoma of the appendix is rarely encoutered and has been reported about nearly 200 cases in the Japanese literature. This paper reports a case of appendiceal adenocarcinoma and a review of the previous literature. A 61-year-old woman was admitted to the hospital because of lower abdominal pain. On physical examination, her abdomen was flat and soft, and there was no palpable abdominal mass. Abdominal ultrasonography and CT scan showed a solid mass approximately 5cm in diameter in the right lower abdomen, and the barium enema revealed a deformity lesion of the ileocecal region. Surgical operation was performed on under a diagnosis of ileocecal tumor, then an inflammatory induration of the appendix was found in the ileocecal region and an ileocecal resection was performed. On opening the resected specimen, a tumor of approximately 3cm was observed in the neck of the appendix, and histological examination revealed well differentiated adenocarcinoma, Dukes'A. Postoperative course was uneventful and the patient was discharged on the 20th postoperative day without complications. Adenocarcinoma of the appendix has been reported to present difficulty in diagnosis before surgical intervension, however, it is thought that barium enema, ultrasonography and CT scan are useful examinations for the preoperative diagnosis of this disease.

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Nine patients who developed recurrence in the anastomosed site following low anterior resection for rectal cancer between 1990 and 1991 underwent endoscopic ultrasonography (Orinpus's scanning type with an Aloca's probe). In this study the diagnostic efficasy of this method for local recurrence was evaluated with reference to results of other imaging procedures together with clinical symptoms, findings of physical examination and measurement of tumor markers. Endoscopy revealed easily hemorrhagic ulcer at the anastomosed site in one patient; submucosal elevated lesion and oppressed stricture at the anastomosed site or its surrounding area in 7 patients; and no abnormal findings in one patient. Histological diagnosis could be attained in 4 cases by biopsy. Locally recurrent lesions were identified by pelvic CT or MRI in 8 patients. Endoscopic ultrasonography successfully revealed lesions in all patients. In one patient, ultrasonography delineated a 5-mm hypoechoic lesion that had not been detected by pelvic CT.
Although endoscopic ultrasonography dose not facilitate qualitative diagnosis and assessment of invasion to the pelvic wall, this method appears to be of value in examining suspected local recurrence in patients after low anterior resection for rectal cancer.

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Breast cancer often metastasizes to the lung, bone, pleura, and liver. Except for the liver, intraabdominal organs, especially the colon may be a rare site for distant metastasis from breast cancer. We experienced a case of metastatic colon cancer of breast cancer which progressed to the termination due to association of perforated apendicitis.
A 58-year-old woman with a previous history of undergoing extended radical mastectomy for left breast cancer in Stage IIIa in December 1988 visited a nearby hospital because of abdominal distension and abdominal defecation in November 1991. Bariumenema revealed narrowings of the transverse and sigmoid colons, patient was immediately admitted to the hospital, because she developed abdominal pain, anorexia and general fatigue. Two days after admission, the patient suddenly fell into shock. Emergency surgery was carried out, but she died of septicemia. Pathological postmortem diagnosis was panperitonitis due to perforation of associated appendicitis. Metastatic foci of invasive lobular carcinoma of the breast were detected in the colon, ovary and uterus.
This case calls for reflection that careful observation of clinical course and examination should offer correct diagnosis of metastasis to the extrahepatic organs in the abdominal cavity from breast cancer, if no lesions are detected in the common sites for metastasis.

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A 65-year-old woman was seen at the hospital because of bleeding on defecation. An elevated lesion of 4cm in diameter was found in the posterior wall of the rectum. Possible malignancy was suspected. Clamp biopsy, however, revealed no malignant findings, endoscopic findings changed rapidly, and it was difficult to make a diagnosis. Finally, transanal partial excision of the rectum was performed under lumber anestesia, and a malignant lymphoma was found. No other lesions were detected. A diagnosis of malignant lymphoma arising in the rectum was made. Abdominoperineal excision of the rectum (R3) was performed. There were two lesions, 35×33mm and 10×8mm in size, were noted in the excised specimen. Histopathologically lymphocytic infiltration of medium sized-type, lacking in atypia and being confined to proper muscle layer, was confirmed but no lymph node metastasis was found. It was in Stage I according to Naqvi's classification and was of folicular medium cell type (B cell type) according to LSG classification. After the operation 2 courses of CHOP regimen were conducted. There has been no recurrence as of 1 year and 4 months after the operation and the patient is followed on an ambulant basis.

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We experienced a case of Inose-type encephalopathy due to a gastro-renal veno-venous shunt, in which remarkable symptomatic remission was attained by operative ligation of the shunt.
A 67-year-old female was seen at the hospital because of syncope attack. Brain infarction was suspected. Neurological examination on admission revealed no abnormality, but trigeminal wave was observed by electroencephalogram. Abnormally increased blood ammonia level was noted. The patient was diagnosed as having a portal-systemic shunt and transferred to the department for operation. During the operation the shunt vessel, about 13mm in diameter, which flowed into the left renal vein was observed, and it was ligated and dissected. The patient was discharged on 43rd day after the operation. As of one year and six months after the operation, there have been no symptoms of the encephalopathy.
For Inose-type encephalopathy without severe liver disfunction like this case, surgical approach is recommended.

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Hepatic lymphorrhea rarely occurs after surgery and only 8 cases of this disease have been seen in the Japanese literature. This paper describes such a rare case of intractable hepatic lymphorrhea after an operation for a gastric cancer.
A 59-year-old man was admitted to the hospital because of poor appetite. On November 21 1991, the patient underwent subtotal gastrectomy under a diagnsosis of gastric cancer. After the operation ascites appeared and repeated paracenteses of the ascites did not yield any response. Lymphangiography through the lymph vessel of the dosum of the foot revealed no lymphorrhea. Since the ascites was yellow and transparent and involved cells were all lymphocytes, hepatic lymphorrhea was suspected. On July 20 1992 laparotomy was performed. Lymphatic leakage was found from the subhepatic space, but ligature of the lymphatic vessel was impossible. After isozine solution and antibiotics were applied, followed by scattering of fibrin paste to the same region, the operative wound was closed. Postoperative course was uneventful without any collection of ascites. The patient was discharged from the hospital.

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We experienced a case of focal nodular hyperplasia (FNH), which is a tumor-like lesion of the liver. A 43-year-old woman was admitted to the hospital because of left hypochondralgia. Abdominal echography, CT, and MRI visualized a tumor in the left lateral segment of the hepatic lobe. A possible malignancy could not be denied and excision of the lesion was carried out. From histopathological examination the tumor was diagnosed as FNH of the liver. Recently, attention is called to administration of female hormone preparation as a probable etiologic factor for heaptic FNH. There was a 10-year history of taking an oral contraceptive for the treatment of dysmenorrhea in this patient. It is strongly suggested that hepatic FNH may be related to long-term administration of the oral contraceptive.

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We experienced a case of membranous stenosis in the extrahepatic bile duct in a 53-year-old woman with gallstone who visited the hospital to undergo laparoscopic cholecystectomy. Twenty-one cases of this disease reported in Japan and this case were examined about the following:
1. The course from the motive of diagnosis to the definite diagnosis.
2. The location of septum and the presence or absence of stone.
3. The ethiology of the septum.
4. Treatment of the disease.
Abdominal pain and jaundice were common as the chief complaints and ERC was the best method to reach the definite diagnosis. The ethiology of the disease has been explained either by a congenital theory or acquired theory. However, the congenital theory is predominant at present, because there are some cases of onset in children, there are some cases without stones, histologically the septum and bile duct wall have the same structure, and infiltration with inflammatory cells is found seldom. Since calcium bilirubinate considered to be formed by cholengitis induced by stenosis is observed by 84.6% at hepatic sites near to the septum, removal of the septum is required in the treatment.

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A 76-year-old man complaining of nausea and vomiting was pointed out abnormality of the stomach at gastric mass screening examination. There were previous histories of undergoing cramitomies 2 times for meningioma. These symptoms of nausea and vomiting developed 7 years after the first operation. Minute examinations offered a preoperative diagnosis of gastric cancer and hepatocellular carcinoma, and subtotal gastrectomy and partial hepatectomy were carried out. Pathological diagnosis of the hepatic specimen turned out the metastatic tumor of meningioma. Flow cytometric analysis of the metastatic tumor cells from five parts of the specimen showed that all of them had diploidy. The percentage of these cells in the S+G₂M phases of the cell cycle was high, an average of 15.4%.

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An 83-year-old woman was admitted to the hospital because of right epigastralgia. On admission she had a sign of peritonitis. Abdominal computed tomography showed a fluid collection around the gallbladder and right subphrenic space. Peritoneocentesis showed biliary ascites. Under the diagnosis of biliary peritonitis, an emergency operation was performed. The operation showed irregular localized necrosis accompanied by perforation on the fundus of the gallbladder. Cholecystectomy and abdominal drainage were performed. Resected specimen showed no gallstone, but slight inflammatory change of gallbladder wall and many thrombi within the intramural vessels around the necrotic lesion were observed. Bacterial culture of the bile was negative. Postoperative course was uneventful. The case reported here appears as idiopathic perforation of the gallbladder due to localized infarction.

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This paper presents a patient with mucinous cystadenocarcinoma of the bile duct, who was able to undergo radical operation after the extension of the cancer invasion was preoperatively diagnosed by percutaneous transhepatic cholangioscopy (PTCS), with a review of the literature.
A 57-year-old woman was admitted to the hospital because of heart burn and general fatigue. On admission, alkaline phosphatase activity was 12.6 KAU, leucine aminopeptidase was 26mu/ml, carcinoembryonic antigen was 7.9ng/ml, and carbohydrate antigen CA19-9 was 71U/ml. Computed tomography and abdominal ultrasonography visualized dilation of the common bile duct and intrahepatic bile ducts. There was a honeycomb-like tumor stain in the area of cholangiectasis in the left lobe of the liver. The patient was treated by PTCD before cholangioscopy was done by the same route. These findings led us to the diagnosis of mucinous cystadenocarcinoam of the bile duct that had spread from the common bile duct to the intrahepatic bile ducts, as seen from the biopsy specimens. Extended lobectomy of the left lobe, resection of the extrahepatic bile ducts except for the right hepatic duct and common bile duct, and lymph node dissection were carried out. The adenocarcinoma was well differentiated and had not invaded the stroma of the liver or the perineural region.

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This paper describes a surgical resection of a solitary cystic recurrent tumor in the splenic flexure in a patient with hilar carcinoma of the bile duct, who also experienced a local recurrence one year earlier. A 56-year-old woman was admitted to the hospital because of appetite loss and left upper abdominal pain. These were previous histories of undergoing left hepatectomy and caudate lobectomy as a complete curative operation for a left hilar carcinoma of the bile duct in December 1989; and enucleation of a tumor recurring at the residual liver cut surface with a high level of CEA in September, 1991. This time CT showed an abdominal cystic tumor about 5cm indiameter in the splenic flexure, barium enema revealed a stenosis of splenic flexure due to extraserosal compression, and carcinoma cells (class V) were evidenced by the aspiration cytology. The third operation was done with a preoperative diagnosis of the recurrence of the hilar bile duct carcinoma. The tumor was placed in the omentum with invasion into to the colon, of which pathological findings were considered as the recurrence.

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This paper presents a case of cyst adenocarcinoma of the pancreas that was able to be diagnosed by ultrasonically guided aspiration cytology. A 66-year-old man was reffered to the hospital because of high value of serum amylase in a mass screening examination. Abdominal ultrasonography and computed tomography revealed a small cystic lesion at the pancreatic head. Endoscopic retrograde pancreatic ductgraphy revealed no communication between the main pancreatic duct and the cystic lesion nor malignant findings for this lesion. The patient was strictly followed up. During 6 months thereafter the cystic lesion became large and ultrasonically guided aspiration cytology was performed. It showed the malignant cell cluster of papillary adenocarcinoma in the mucinous background. Therefore pancreatoduodenectomy was performed. Generally, it is very difficult to diagnose the cystic lesion of the pancreas preoperatively, but ultrasonically guided aspiration cytology is very useful not only for the diagnosis but also for dicision-making of operative indication.

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Congenital urinary umbilical fistula is a rare disorder among anomalies of the urachus. We experienced such a case in an infant.
A 7-month-old male infant was seen at the hospital because of discharge from a fistulous opening in the umbilicus, following the delayed separation of the umbilical cord in his neonatal period. The umbilical fistulography and retrograde cystgraphy revealed a fistula from the umbilicus to urinary bladder. Under general anesthesia, radical excision of the entire fistulous tract was performed with resection of the apex of the urinary bladder. From the preoperative contrast study, intraoperative and histological findings, the patient was diagnosed as to have the urinary umbilical fistula due to hypoplasia of the urachus. The postoperative course was uneventful. The possibility must be entertained that abnormality of the umbilicus or umbilical cord is congenital urinary umbilical fistula.

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Actinomycosis is caused by Actinomyces, and classified into 1) cervicofacial infection, 2) thoracic infection, 3) abdominal infection, and 4) others. Cervicofacial infection is the most common. Urogenital actinomycosis, especially actinomycosis in the uracheal remnants is so rare that only 10 cases including this case can be seen in the literature.
A 52-year-old female who worked in a meat store was seen at the hospital because of fever and a painful low abdominal mass. Severe inflammatory reaction was found in a blood test. Urachal cyst or urachal tumor was suspected radiographically. The patient underwent total removal of the mass with combined resection of the greater omentum, fundus of urinary bladder, and sigmoid colon, which were strictly adhered to the mass. It was 6×4×2cm in size, and appeared to be granulated tissue with necrosis in the center. Actinomycosis was diagnosed pathologically by the findings of sulfur granule. Postoperative course was uneventful, and she was discharged on the 36th hospital day. There has been no recurrence during these 18 months after the operation.

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This paper presents a rare case of spontaneously perforated pyometra in an 87-year-old woman.
The patient visited a nearly doctor because of pain in the stomach. Peritonitis due to perforated appendicitis was suspected and the patient was referred to the hospital. Muscular defense was confirmed in the abdomen with an increase in WBC. A plain X-ray film of the abdomen revealed no free air. On laparotomy, flowed pus and the perforation was found at the fundus of the uterus. A diagnosis of uterus perforation associating with a pyometra was made, and panhysterectomy was performed. Histological examination revealed no evidence of malignancy. The postoperative course was satisfactory and the patient was discharged on the 20th day after the surgery.

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This paper describes a rare case of long-term survival of the pseudomyxoma perotonei. A 20-year-old female was seen at the hospital because of upper abdominal pain. Abdominal ultrasonography and CT revealed a cystic mass in a large amount of ascites. A laparoscopic study indicated the findings of pseudomyxoma peritonei. The patient underwent surgical resection of both the ovaries, appendix and omentum, and removal of free mucus as much as possible. Microscopic examination showed mucinous cystadenoma of the right ovary. After the surgical treatment, the drains were positioned into the abdominal cavity. Through the drains, repeated intraperitoneal washing was performed with 5% glucose, and intraperitoneal chemotherapy was done with an alkylating agent, thiotepa. Postoperative clinical course was uneventful and the patient has survived for 13 years after the first treatment.

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A 19-year-old man was seen at the hospital because of a left lower abdominal tumor. The tumor was infant's head in size and unmovable. Abdominal CT and angiography revealed a retroperitoneal tumor with plenty of blood flow. A possibility of malignant tumor was suspected and operation was carried out. Histopathological examination resulted in that the tumor was an intramuscular angioma arising in the retroperitoneal iliopsoas muscle, without malignant findings. Intramuscular angiomas are benign tumors and commonly found in the skeletal muscles of the extremities. The tumor in this case, however, arised in the left ileopsoas muscle and grew in the retroperitonum.
The intramuscular angioma of the retroperitoneum is rare, but when we encounter a tumor with plenty of blood flow, this this type of tumor should be entertained as a probable diagnosis. In terms of this point, this paper also presents the methods of diagnosis, laparotomy findings, and some device for excision procedure.

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Retroperitoneal cavernous hemangiomas are rare and 17 cases have been reported in theJapanese literature so far. We report our experience with a case of this disease and review 18 cases.
A 72-year-old woman, who was followed on an ambulant basis for gastrectmy at the age of 70, was pointed out having a tumor mass in the right upper abdomen, which was elastic hard, poor in movability, and 5cm in diameter with smooth surface. The patient was admitted to the hospital for further examination. This mass was resected as retroperitoneal tumor. The resected specimen was 9×7×6.5cm in size, 155g in weight, and covered with fibrous capsule. Pathological diagnosis was cavernous hemangioma which was composed of the dilatated vessels covered with the one-layer endothelium.
In a review of 18 patients seen in the literature including this patient, there were 9 males and 9 females, with an average age of 45.1 years. No definite diagnosis of retroperitoneal cavernous hemangioma could be achieved by preoperative imagings such as CT, ultrasonography, and angiography. All patients underwent extirpation of the tumor and had good prognosis. Generally retroperitoneal cavernous hemangioma presents difficulty in preoperative diagnosis and can develop recurrence or malignant change, even if it is benign at the present time. Thus the importance of complete extirpation of the tumor should be emphasized.

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This paper describes a case of amusing retroperitoneal teratoma, with a review of the pertinent literature.
A 35-year-old female, who had been diagnosed as having a retroperitoneal tumor when she was 3 years old, was seen at the hospital because of severe epigastralgia caused by cholecystolithiasis. She had been refused to extirpate the tumor by various reasons for a long time. Plain roentgenogram of the abdomen revealed a large right lateral abdominal mass containing osseous structure. In computed tomography, the tumor was detected as multiloculated and cystic mass including colorful content as bone and adipose tissue in the cyst, locating anterior to the right kidney. Preoperative diagnosis was benign retroperitoneal teratoma, and she resolved to undergo extirpation of the tumor with cholecystectomy at last. At laparotomy, the tumor was displaced the adjacent organs (right kidney, pancreas head, duodenum and inferior vena cava), and adhered to them besides. Gross findings of the specimen included encapsulated, multiloculated and cystic tumor containing sebaceous like material and yellowish fat including hair and bone in the cyst, with 15.3×10.8×7.9cm in size and 570g in weight. Histologically, the tumor revealed matured benign teratoma of all three germ layers. The patient has been in good health without a sign of recurrence for 2 years and 4 months after the operation.

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We experienced a case of arterial thrombus of the right lower limb in a patient with nephrotic syndrome in exacerbation. The patient was a 40-year-old man. He was seen at the hospital because of abrupt pain of the right lower limb. Clinical laboratory examinations disclosed a significant increase in blood fibrinogen, decreased ATIII, hypoalbuminemia, hypercholestelemia, and severe proteinuria. While anticoagulant and antifibrinolytic therapy was being carried out, thrombectomy was performed via Fogarty catheter. Finally, however, amputation of the lower limb was unavoidable for the patient.
Entertaining a liable association of thrombus in patients with nephrotic syndrome, especially in exacerbation phase, treatment of the underlying disease as well as careful attitude for diagnosis, treatment, and prevention of possible thrombus is necessary.

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We experienced a case of abdominal tuberculous lymphadenopathy which was difficult to be distinguished from metastatic disease and malignant lymphoma with various radiographic modalities and its clinical course.
A 31-year-old man was seen at the hospital because of fever and cough. Chest X-ray revealed pleural effusion and abdominal ultrasography showed a tumor near the pancreas head. Pleural effusion was diagnosed as tuberculous pleuritis and treated by isoniazid, rifanpicin and streptomycin. From the clinical course, the tumor near the pancreas head was suspected of relating to abdominal tuberculous lymphadenopathy, but no definite diagnosis could be attained by abdominal CT, endoscopic retrograde cholangiopancretogram, and abdominal angiogram. Moreover, since no change or decrease in size of the tumor was observed with the tuberculochemotherapy, we were left to examine a possibility of a malignant disease and proceeded to perform an exploratory laparatomy.
We admitted the difficulty to establish the differential diagnosis of Abdominal lymphadenopathy.

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In a 4-year period from April, 1988 to March, 1992, we performed surgical operation for 12 patients with psychiatric disease. There were 8 men and 4 women, with an average age of 56.5 years. These patients have been troubled with various psychiatric diseases, such as shizophrenia in 7 cases, dementia, mania and depression, Parkinson's disease, mental disorder by methanphetamine and alcholism in each one case, for 3 months to 35 years before the operation.
Operations were performed emergently in 5 cases (41.7%) and under general anesthesia in 10 cases (83.3%), Catecholamine-resistant hypotention, suspected to be induced by long-term medication of antipsychotic drugs, was observed in 5 cases (41.7%) in the period of intra-and postoperative stages.
Antipsychotic drugs were given until the day before operation, and restarted with meals in all cases. However strange and disquieting behaviors were observed in 6 cases (50%) postoperatively, all of them could be discharged from the hospital with recovery of their surgical diseases. In the management of surgical psychiatric patients, causion should be exersized to the possible occurrence of intra-and postoperative catecholamine-resistant hypotension.

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A 14-year-old girl was admitted to the hospital for a suspecion of metastatic liver mass on abdominal CT and ultrasonography. There was a history of undergoing bilateral oophorectomy with histerectomy for a left ovarian immature teratoma 2 years before. After the operation chemotherapy was added. On admission ultrasonography revealed a solitary metastatic tumor in the S₈ are of the liver, but abdominal angiography showed no abnormal finding. MRI revealed an apparent extrahepatic tumor. The patient was diagnosed as having a disseminated metastatic tumor in the right diaphragm. There was no other abnormal finding, so a laparotomy was performed.
The tumor was on the right diaphragm and compressed the liver. There was neither adhesion nor invasion into the liver. Some red bean or broad bean-size disseminated tumor were found in the Douglas pouch, anterior wall of the rectum and right kidney area. All those tumors were excised. These tumors were mature teratoma histologically. In general, extra or intrahepatic tumors often present difficulty in diagnosing. This paper describes such a case in which MRI was useful in differential diagnosis.

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