A multiple regression analysis was utilized on ultrasonographic findings of thyroid nodules to discriminate benign and malignant thyroid nodules preoperatively. Sventy-five patients including 36 histologically verified thyroid cancers and 39 benign nodules during a past one decade were entered in this retrospective study. Ultrasonographic study was carried out by ALOKA SSD-256 and SSD-650 equipped by 5.0 and 7.5 MHz probes. Following items were evaluated by single screneer on the hard copy of ultrasonographic findings; maximal diameter, number of nodules, characteristic of border and boundary appearance, heterogeneity of internal echo, presence of back/strong echo and papillary pattern. Correlation analysis revealed significant relationship between diagnosis and 4 items; boundafy echo, heterogeneity, presence of strong echo and back echo. A discriminative formula was developed through a discriminative analysis by PC-9800 series personal computer system (NCE, JAPAN) using the 4 items. Sensitivity, specificity, and accuracy of the formula were 94.1%, 94.4%, and 92.0% respectively. Further, a prospective study using this discriminative formula results in a correct diagnosing rate of around 90%. It is thought that the formula is simple and reliable in ultrasonographic diagnosis of thyroid nodes.

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Three cases of intracystic breast cancer and 11 cases of intracystic papilloma experienced at the department in a recent 2-year period were subjected to a study of comparing their clinical features and evaluating the diagnostic outcomes of intracystic tumors lesions. Of all 110 cases diagnosed as having a cyst by ultrasonography, intracystic breast cancer represented 2.7% (3 cases) and intracystic papilloma, 10.0% (11 cases). A verage ages of breast cancer and papilloma patients were 52.7 and 40.7 years old respectively, with a significant difference. There was a tendency to greater tumor diameter in breast cancers than papillomas. Mammography, ultrasonography, fine needle aspiration cytology, cytodiagnosis of secrete from the nipple, and mammotec were employed for differential diagnosis between benign and malignancy. Specific findings to breast cancer included microcalcification on X-P (2.13 cases), more than class IV on fine needle aspiration cytology (2/13), and mammotec positive (2/5). The correct diagnostic rate was not favorable. There were no any specific findings to papilloma. It is clarified that we have few clues for differential diagnosis of intracystic tumorous lesions. The best way is to make the definite diagnosis by biopsy for lesions suspected of possible malignancy, even if it appears trifling.

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Ninety two patients with node negative breast cancer operated on at our department in a period between November 1978 and December 1994 were studied for prognostic factors in an attempt to single out the high risk group for recurrence, and the relation between the expression of cyclin D1 oncoprotein and the recurrence was examined in 43 patients. Eight (8.7%) patients experienced a recurrence to date. Disease free survival and sites of recurrence of these patients were not different from those of patients with lymph node metastasis at operation. The recurrence rate was not related to tumor size, tissue infiltration, estrogen receptor expression and adjuvant chemotherapy, but significantly related to age, menopausal status, tumor location, histological type, histological grading and vessel invasions. There was a significant difference between the marked expressed group of cyclin D1 oncoprotein and weakly or not expressed group in the recurrence rate. These results suggested that the high risk groups of node negative breast cancers were those of young age, scirrhous type, histological grade III and vessel invasion, and cyclin D1 expression might be useful prognostic factor of the recurrence.

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To investigate the effects of vagotomy and pyloroplasty on gut hormones and gastroenteric function, this experiment was performed. Subjects were postoperative patients undergoing total truncal vagotomy with pyloroplasty; those undergoing simple closure for perforation of duodenal ulcer; and normal subjecyts as control. In these three groups changes of gut hormone secretion and gastric emptying function were investigated with oral administration of test meal and acetoaminophen.
Fasting serum gastrin concentration elevated after vagotomy. With the test meal stimulation serum gastrin concentration elevated similarly in these three groups. But in the vagotomy group, the depression of gastrin level to the basal value was rapid.
Plasma secretin concentration did not change with the test meal stimulation in three groups.
Plasma CCK concentration did not change after the test meal stimulation in the normal control group and simple closure group, but elevated in vagotomy group.
Gastric emptying function evaluated with acetoaminophen method was accelerated in the vagotomy group.

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Out of 22 cases operated at the hospital for upper gastric cancer in a recent one decade, on 11 cases underwent proxymal gastrectomy and another 11 cases total gastrectomy. We studied the radicality of proxymal gastrectomy in terms of lymph node metastasis and prognosis and evaluated the quality of life of proxymal gasrectomy cases compared to total gastrectomy cases. In total gasrectomy caces, lymph nodes of No.4d, 5 and 6 that fell beyond the area of lymph node dissection for proxymal gastrectomy were free from metastasis. The survival rates between proxymal gastrectomy cases and total gastrectomy cases were not significantly different. In conclusion, the radicality of proxymal gastrectomy that was done in a early stage of gastric cancer was satisfactory. On the other hand in sm and poorly differentiated cases, lymph nodes metastasis of No 7 and 11 occurred. The d2 lymph node dissection was judged better for the cases. As to the quality of life of the patients, there was no significant difference between both groups in per os and body weight loss, laboratory data, and satisfaction after the operation. Further accumulation and analysis will be necessary to improve the quality of life of the patients undergoing proxymal gastrectomy

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Four hundred and one cases of submucosal gastric carcinoma were divided into three groups according to the extent of submucosal invasion and the possibility of limited operation such as surgical local resection or D1+No. 7 lymph node dissection was examined. The groups consisted of carcinomas of microscopic invasion (sm1: 137 cases), those of macroscopic moderate invasion (sm2: 165 cases), and those of macroscopic massive invasion (sm3: 99 cases). In each group, histological nodal involvement was analyzed according to tumor location, macroscopic type and tumor size. As a result, the surgical local resection could be indicated for 1) sm1 tumors located at upper third, 2) elevated lesion of sm1 and 3) all sm tumors within 1 cm in size. And D1+No. 7 dissection was indicated for 1) all sml tumors, 2) all sm tumors located at upper third, 3) all elevated lesions and 4) all sm tumors within 2 cm in size, whereas the sum satisfying with D1+No. 7 dissection were 101 cases (sm1: 59, sm2: 26, sm3: 16) excluding the high risk cases with nodal involvement such as undifferetiated type and lesions accompanying with ulcer or ulcer scar. As the lymphatic permiation markedly increased in sm2 (83%) compared with sm1 (37%) cases, limited operation would be theoretically applyed to sm1 carcinomas with safety. However, D2 dissection should be recommended in cases which were suspected of sm invasion, because the accuracy rate of preoperative or operative diagnosis of sm1 was not sufficient in the present time.

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We defined the cancers of the remnant stomach as those which probably arose in the remnant stomach independently from the initial lesion after an interval of more than 5 years following the initial operation. And the patients were divided into two groups for comparison; eight patients who had a cancer after an interval of less than ten years (short-term group) and another eight patients, more than ten years (long-term group). As a result, only three cases which had gastric ulcer as the initial lesion came from the long-term group, involving two cases of B-II reconstruction. Thirteen casees of gastric cancer included 12 cases of early gastric cancer. Compared with the short-term group, the long-term group was characterized by younger average age at the initial operations; more symptomatic patients when cancer of the remnant stomach developed; and more advanced cancers. But there was no significant difference in histopathological findings and location of the cancer between the two groups. There were each one patient with stage IV cancer who died of recurrence in both groups. Except them all patients had a cancer less than stage II and were radically operated on, being alive. Good prognosis of the disease has been shown. It is thought that early detection of the cancer of the remnant stomach is important for an improvement of therapeutic results; and for tha, periodic endoscopic examination for a long time and aggressive follow up for them after gastrectomy are needed.

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We studied the usefulness of three dimensional helical CT (3D-CT) combined with drip infusion cholanigoiography for determining the application of laparoscopic cholecystectomy (LC) and evaluating the cholecyst severity. The subjects were 56 patients who underwent LC with preoperative 3D-CT. Paticularly, in 42 patients undergoing endoscopic retrograde cholangiography (ERC) and 3D-CT simultaneously, the results with both methods were compared.
The detection rates of the orginal site, forward and backward direction, and left and right direction in the confluence form of the cystic duct by means of 3D-CT versus ERC were 100% vs. 92.9% 92.9% vs. 71.4%, and 92.9% vs. 88.1%, respectively. Abnormal biliary distribution was visualized in 5 cases and all of them were depicted by 3D-CT. The 3D-CT was superior to ERC in terms of X-ray dose and cost.
These results indicate the usefulness of 3D-CT as a LC preoperative examination.

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We have studied 53 resected cases of gallbladder carcinoma to clarify prognosis-regulating factors. All pathologic factors including dysplasia were examined first in 3 groups categorized according to depth of invasion, then in ss-cancer-group, where further consideration was given in relation to survival rates. The probability of finding dysplasia was higher as invasion was less severe (p<0.01). As for ss-cancergroup study, the results were as follows: outcome was significantly worse in cases of positive lymphatic invasion (p<0.05), positive bile duct invasion (p<0.01). and extensive subserosal invasion (p<0.01). Carcinoma associated with dysplasia showed a better outcome (p<0.01). Also, better outcome was assumed in cases of papillary adenocarcinoma (pap) and negative lymph node invasion. Regarding INF, results were ranked with α, β, and γ in this order, and for the depth of subserosal invasion, ss₁, ss₂, and ss₃. No significant relation was found in factors such as macroscopic form, tumor site, desmoplasia, venous invasion, perineural invasion and hepatic infiltration. The fact that gallbladder carcinoma associated with dysplasia showed a good outcome suggests that whether dysplasia is found or not can be a new prognosis regulating factor.

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The results of microsurgery carried out during associated arterial resection with reconstruction in cases of progressive pancreatic and biliary tract cancer accompanyning by infiltration into the hepatic or superior mesenteric artery were investigated. The significance and problem in performing this procedure are briefly discussed.
Of 10 patients subjected to this study, 6 patients had pancreatic carcinoma and 4, biliary tract cancer. Portal vein resection was performed in 6 cases. In 7 cases, in which postoperative blood circulation of the reconstructed artery was checked by arteriography, excellent patency was confirmed. Six patients had postoperative complications and 4 of the 6 died postoperatively resulting from complications accompanied with reconstruction of the hepatic artery. The longest postoperative survival period was 11 months in patients with pancresatic carcinoma and 14 months in cholangiocarcinoma.
Microsurgery-applying associated arterial resection with reconstruction improved the rate of postoperative patency of arteries, however, it could not contribute to improve the surgical outcome in patients with pancreatic or extrahepatic biliary tract carcinoma.

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A 53-year-old male was seen at the hospital because of a tumor on the right side of the neck. It was measured 4.5×3.8 cm in size and palpated in the anterior margin of the sternocleidomastoid muscle on the right side of the neck. CT scan revealed a cystic lesion with homogenous low density area, and the tumor was diagnosed as lateral cervical cyst. However, histologically, squamous cell carcinoma was found in the non-neoplastic squamous epithelium lining the cyst wall. Therefore, we definitely diagnosed it as branchiogenic carcinoma.

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Nonrecurrent inferior layngeal nerve (NRILN) leaves the vagus trunk directly, usually running between the thyroid gland and trachea, and enter the larynex. Recently, we experienced a rare case of NRILN running between the thyroid gland and sternothyroid muscle. The case was accompanied with aberrant right subclavian artery. We often confirm the esophageal notch induced by aberrant subclavian artery by barium meal test before operation. To prevent the injury of the nerve, careful manuever, visualization of the recurrent nerve during the operation, and barium meal test before operation are important in clinical aspects.

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Granular cell tumors are fairly common, but they seldom occur in the breast. A case of granular cell tumor of the breast in a 34-year-old woman is described. Physical examination showed a lump 1 cm in diameter in the lower inner quadrant of the left breast. Mammographic and echographic features strongly indicated breast cancer. Because aspiration biopsy cytology revealed Class III, an excisional biopsy was performed, and a diagnosis of granular cell tumor was made. Histologically the tumor cells showed abundant granular cytoplasm. On immunohistochemical stainings the granules were positive for PAS, NSE, and vimentin, but were negative for HHF35 and alpha-smooth muscle. The granular cell tumor presents difficulty in differential diagnosis from cancer without biopsy becasue of their mimicking clinical features. We surgeons have to avoid overdiagnosis and oversurgery.

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A case of rapidly enlarged recurrent phyllodes tumor during pregnancy is reported. A 31-year-old woman, who had been fellowed up after a resection of benign phyllodes tumor of the left breast about 7 months before became aware of induration at the same site of the first operation in April 1994.
In Junuary 1995, she was 6-week pregnant and the induration rapidly enlarged with pregnancy progressed. Clinically malignant phyllodes tumor was suspected. Left modified radical mastectomy was performed with artificial abortion. But pathological diagnosis was benign phyllodes tumor, though the cell densities in epithelial and interstitial components were high compared to those in the former histopathological examination. In this case artificial abortion was performed simultaneously. Further discussion should be have on the relationship between artificial abortion and prognosis of phyllodes tumor.

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A 41-year-old woman had felt a pain and noticed a mass in the right breast since March, 1993, but she did not consult any hospital and had been treated by some folk medicien. Five months later the mass started to enlarge rapidly, and eventually it penetrated the skin to be exposed on the surface during a further 5-month period. The patient was admitted to the hospital for operation. On admission the tumor presented a cauliflower like proliferation occupying the entire right breast. It was 23×19.4cm in size, easily hemorrhagic, and discharged a large quantity of exudate. Pathological diagnosis on biopsy at another hospital indicated that the tumor was benign phyllode tumor. But we were not able to rule out a possibility of malignancy, because the tumor rapidly enlarged in one year and was huge in size. Modified radical mastectomy (Patrey method) and full-thickness graft were performed. Histopathological examination confirmed malignancy. There has been no sign of recurrence, as of about 2 years after the operation. She is doing well.

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A 54-year-old woman was seen at the hospital because of a tumor of the right breast. Histopathological examination revealed a carcinoma 3cm in diameter in the lower of the right breast. Bone scincigraphy revealed a metastatic lesion of the 10th rib. Standard radical mastectomy was performed and chemotherapy was added. Postoperative histopathological examination revealed apocrine carcinoma (t2, n2, M1, and Stage IV).
Apocrine carcinoma representing 0.2-1.0% of all breast cancers is rare and is said to have a better prognosis than those of ordinary breast cancers. The present case, however, had a distant metastasis that is very uncommon and would demand further careful attentions to the treatment.

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We experienced two cases of breast cancer with synchronous or metachironous liver metastasis successfully treated with chemoendocrine therapy mainly using mitomycin (MMC). Case 1: A 41-year-old woman with right breast cancer of T2aN1bM1 (liver) underwent a modified radical mastectomy. There after the patient was treated by combination chemoendocrine therapy with ADM, CPA, and 5-FU during hospital stay, followed by the therapy with 5'-DFUR at a dose of 1, 200 mg/day, tamoxifen at 20 mg/day p.o., and MMC at 10 mg/month (totally 100 mg) i. v. after discharge. The size of the liver lesions reduced effectively and serum CA15-3 level was normalized (from 124 to 9 U/ml) within a year. Case 2: A 55-year-old woman underwent a standard radical mastectomy for a left breast cancer of T1aNoMo eight years before. She also underwent lymph node on the left side of the neck and radiation therapy against lymph node metastasis 66 months after the mastectomy. The liver metastasis was found by the elevation of serum CEA and CA15-3 levels. She was treated by the similar combination therapy with UFT at a dose of 400 mg/day p.o. Medroxyprogesterone acetate at 600 mg/day p.o. and MMC at 10 mg/month i.v. (totally 100 mg). The low density areas of the liver almost disappeared and serum CEA and CA15-3 levels decreased to 2.3 ng/ml and 8 U/ml, respectively. Both estrogen receptor and progesteron eceptor levels were positive in these two cases.

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Pericardial cysts are relatively rare. Three cases of pericardial cyts are presented in this paper.
A 63-year-old man (Case 1) was pointed out an abnormal shadow on a chest X-ray film at another _??_ospital. A 58-year-old woman (Case 2) was pointed out an abnormal shadow on X-ray examination at a _??_edical checkup. A 48-year-old woman was also pointed out an abnormal shadow on a X-ray film at a _??_edical checkup. These three asymptomatic patients were admitted to the hospital for further examina_??_on. Chest X-ray revealed a large smooth mass in the right cardio-phrenic angle in case 1 and 3, and in _??_e right upper mediastinum in case 2. Chest CT demonstrated a homogenous cystic mass adjacent to _??_ight heart border in case 1, 2 and 3. Surgical extirpation was carried out in all cases. These was a _??_ommunication between the cyst and pericardial cavity in case 2 and 3, and no communication in case 1.
Histologically, all cases are very similar to normal pericardium having thin wall with flat mesoth_??_lium. fibrous, fatty connective tissue with no evidence of malignancy. Although pericardial cysts are _??_ncommon benign abnormalities, we consider that the surgical attack on the pericardial cyst must be _??_arried out as early as possible, because of latent malignant change, compression and rupture to near _??_rgans.

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A 67-year-old man developed strangulated ileus during clinical observation for an abdominal aneur_??_m, underwent an excision of the small intestine, and then, on the second postoperative day, the _??_eurysm ruptured which was successfully treated by synthetic replacement.
It is generally thought inappropriate to perform a possibly contaminated gastrointestinal tract _??_eration and synthetic replacement simultaneously. Further, if both operations are to be performed on _??_two-step approach, no standerdized view on the appropriate interval between the operations has been _??_tablished. In this case, we had to perform the replacement 53 hours after the gastrointestinal surgery _??_r extended necrosis of the intestine, but the postoperative course was uneventful without any severe _??_mplications. We also present some notes on the operative procedures and postoperative management _??_patients with gastrointestinal disease and abdominal aneurysm.

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A 17-year-old boy, who had suffered from an injury to his chest three days before, was pointed out right pneumothorax and a foreign body in the right thoracic cavity and refferred to our hospital. His vital signs including respiratory functions were fair and hemothorax was not seen. Emergency operation was done by thoracoscopic technique, which is application of thoracoscopic bulla resection. He had no complications and felt less pain after the surgery.
The thoracoscopic procedure has been applied for emergency operation in a few cases. Only three cases including ours have been reported as foreign body removal by thoracoscope. This procedure has many advantages of less surgical stress, less postoperative pain, and minimal cosmetic problems. If the patient's general condition permits, this procedure would be the first choice of procedure to remove intrathoracic foreign body.

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A 66-year-old man was admitted to the hospital because of upper abdominal symptoms including recurrent vomiting and epigastric pain. Upper gastrointestinal series indicated that the patient had a paraesophageal hiatal hernia with gastric volvulus in a mesenteroaxial form. Laparotomy was carried out, and we confirmed that, since the fixation of the duodenum to the retroperitoneum was loosened, the pyloric antrum and duodenal bulb headed by the lesser omentum were prolapsed into the mediastinum, causing gastric volvulus in a mesenteroaxial form. After the hernia was relieved and excised, the paraesophageal hiatal hernia was closed by plication suture using a Teflon patch.
In this country a relatively few cases of adult hiatal hernia of the esophagus associating with gastric volvulus have been reported so far. This paper presents our recent experience with an adult case of esophageal hiatal hernia with gastric volvulus in a meseteroaxial form, with a review of the literature.

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An operated patient with carcinoid of the esophagus developed metastases ot the lymph nodes of the neck and mediastinum 15 months and died 21 months after the operation, though the primary lesion invaded the submucosa and had no vasucular invasion (ly0, v0) nor lymphb node metastasis (n0). In this paper we discussed about therapeutic guidelines for esophageal carcinoid based on our experience and other 12 operated cases in Japan.
Operated cases of esophageal carcinoid had a poor prognosis. All fatal cases were associated with lymph node metastasis or recurrence. Long surviving factors may include: (1) tumor diameter of less than 2 cm, (2) invasion depth of less than sm, and (3) negative lymph node metastasis.
In the treatment, it is important to entertain that the tumor has malignant characteristics equipotant to entertain that the tumor has malignant characteristics equipotent to cancers, and to perform an operation with sufficient lymph node dissection, especially for tumors with a diameter of more than 2 cm. Furethermore, adjuvant therapies such as irradiation and chemotherapy should be considered for tumors with invasion depth of more than sm or with lymph node metastasis.

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We experienced three cases of advanced esophageal cancer which were successfully treated by chemotherapy with CDDP and 5FU added radiation from both outside and inside of the esophagus.
Case 1: A 50-year-old man with cancer of the intrathoracic middle portion of esophagus was suspected of having an invasion into the aorta, and underwent radiochemotherapy. After the treatment, his clinical staging came to Stage III which was judged curatively operable. Lymph nodes dissection with total excision of the thoracic esophagus was carried out. No histological remnant was confirmed. The patient is doing well, as of 18 months after the operation.
Case 2: A 68-year-old man with Stage III cancer of the intrathoracic esophagus underwent radiochemotherapy, because he refused operation. Biopsy after the treatment disclosed that the cancer disappeared. There has been no sign of recurrence, as of 12 months after the treatment.
Case 3: A 48-year-old man with cancer of the intrathoracic middle to inferior portion of esophagus was suspected of having metastases to the periaortic region and intraperitoneal lymph nodes. It was thought that a curative resection was impossible and radiochemotherapy was performed. After the treatment the tumor decreased in size. The patient is doing well under the treatment, as of six months after the operation.
In the treatment of patients with advanced esophageal cancer, an appropriate selection of the treatment is important by considering the quality of life of the patient. Radiochemotherapy is an effective therapeutic method for such patients.

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A 63-year-old man was pointed out an abnormal shadow of the stomach by upper gastrointestinal series at an annual physical examination. He was diagnosed as having a submucosal tumor of the stomach at the department of internal medicine in our hospital. He had been followed up because he was a symptomatic and the size of tumor was less than 2cm. Since histological examination of biopsy specimens offered no certain clue and the tumor was growing rapidly, he was referred to our department and a proximal gastrectomy was performed. The resected specimen showed that the tumor 3cm in diameter existed in the area from submucosal layer to subserosa with well-defined margin. Histopathologically, the tumor was composed of spindle cell proliferation with a thin fibrotic capsule partially. Immunohistochemical study showed that the tumor was negative for smooth muscle antigen (SMA), S-100 protein and so on, but was positive for CD34 only. Therefore it was diagnosed as gastric stromal cell tumor with uncertain origin that represented neither typical leiomyoma nor schwannoma. Mitotic index was 3-5/10 high power field (borderline). The concept of stromal tumors has not been yet established, and so we report this case with literary consideration.

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Aneurysm of the gastroduodenal artery is uncommon. It repesents 1.5 percent of all splanchnic artery aneurysms. We experienced a case of gastroduodenal artery aneurysm ruptuted into the duodenum.
A 81-year-old man was admitted to the hospital because of recurrent massive hematemesis. There was a previous history of undergoing a partial gastrectomy for an early gastric cancer 10 years before. He had been well until a month earlier, when massive hematenesis suddenly developed. Gastroduodenal endoscopy revealed a submucosal mass just distal to the gastrodudenal anastomosis and a shallow bleeding ulcer on the top of the lesion. The bleeding was interrupted by endoscopic clipping temporally. But an emergency operation was needed because of rebleeding and consequential hemorrhagic shock. During surgery we found a an anerrysm of the gastroduodenal artery of 1.2cm in size, which impacted into the duodenal wall. Since the aneurysm bound to the duodenal wall so tightly, a part of gastrointestinal wall and the aneurysm were resected en bloc. About 60 percent of peripancreatic aneurysms evolve as complications of acute or chronic pancreatitis and about 30 percent of these lesions are caused by an atherosclerotic process. When we encounter a patient who lacks in characteristic symptoms and has relapsing bleeding from the upper gastrointestinal tract, aneurysm of the gastrointestinal artery should be entertained as a probable diagnosis.

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We have experienced a case of arteriovenous (arterioportal) fistula between the right gastroepiploic artery and vein after gastrectomy. A 45-year-old man without any complaints was unexpectedly pointed out of a thrill of the upper abdomen. In spite of an increase in portal blood flow, the portal venous pressure was kept at a normal level (13cm H₂O), which did not influence to the liver confirmed by microscopical examination. After the resection of the fistula the hepatic blood reduced to a half, the portal blood flow reduced to one third, and the portal blood pressure was 11cm H₂O. The postoperative course was uneventful without any changes in the hepatic function.
It si considered that the case did not show portal hypertension due to the short duration from the onset, small size fo the fistula and the normal compliance of the portal system without any hepatic disease.

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An 86-year-old male was admitted to the hospital because of an epigastralgia. A polypoid lesion in the duodenal bulb was revealed by endoscopic examination and was diagnosed as well differentiated adenocarcinoma from biopsy specimen. Surgical polypectomy was performed since the polyp was flat and elevated lesion with the maximum diameter of 25 mm. Histologically, this tumor was considered to be derived from ectopic gastric mucosa in the duodenal bulb. Most duodenal cancers are cancers in adenoma or cancer de novo, and duodenal carcinoma arising from ectopic gastric mucosa is very rare.

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In rarely occurs that a bezoar formed following an operation incarcerates into the small intestine causing intestinal obstruction. This paper describes a case of intestinal obstruction due to persimmon bezoars which occurred 25 years after a selective vagotomy with pyloroplasty, together with a review of the literature.
A 60-year-old man visited another hospital because of an epigastric pain and vomiting, but his symptoms became severe. Two days later the patient was admitted to the hospital with a diagnosis of intestinal obstruction. There were previous histories of undergoing an appendectomy at the age of 10 and a selective vagotomy with pyloroplasty for duodenal ulcer at the age of 35. After this admission conservative treatment was attempted, but his status did not improve. Operation was performed, and tumors in the stomach and ileum were detected. As a result of analysis of the compositions, the both tumors appeared to be persimmon bezoar.

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It has been reported that diverticulum of the small intestine represents about 2.7% of all diverticula in the digestive tract. Recently we experienced a rare case of multiple deverticular in the entire small intestine from the duodenum to ileum with a perforated diverticulum among of them.
A 79-year-old woman was admitted to the hospital because of a high fever and abdominal pain. On the 22nd hospital day, a plain X-ray film of the abdomen revealed free-air. However, the patient refused an emergency laparotomy. Conservative therapy was started, with a temposal remission.
On the 101st hospital day a plain X-ray film of the abdomen showed free-air level again. The patient was operated on with a preoperative diagnosis of perforation of diverticulum. A 20cm segment of the terminal ileum including the parforated diverticulum was resected. The patient resulted in complete recovery after the operation.
We report the very rare case of perforated jejuno-ileal pseudo diverticulosis, with a review of the leterature.

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Two patients with fibroma of the ileum, which was incidentally found during operation for other purpose, are presented. Case 1: A 75-year-old man. There were previous histories of undergoing an appendectomy for acute appendicitis at 18 years of age and successively, undergoing an ileocolic anastomosis for ileus. In a past 5-year period, he had been hospitalized five times for the treatment of ileus. Recently he was seen at the hospital because of an abdominal pain and vomiting. He was diagnosed as ileus and subjected to laparotomy. Since adhesive ileus was found, adhesiotomy was performed with simultaneous excision of the ileum for about 15cm in order to remove the ileocolic anastomosis site. A tumor of 20×15×15mm was found in the excised portion of the ileum, and this tumor was histologically identified as fibroma. Case 2: A 72-year-old woman showed positive reaction to occult blood in the stool examination. Close examination revealed an Isp tumor of 27×20×6mm in size in the ascending colon. This tumor was identified as adenoma by biopsy. Since a passibility of malignancy was not ruled out, a surgical removal was planned. By laparoscopic examination, a 5mm tumor was found in the ileum 8cm from the ileocecal valve. Therefore, a right hemicolectomy including the ileal tumor was performed assisted with a laparoscope. Histologically the tumor of the ileum was identified as fibroma and that of the colon as adenoma.

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Malrotation of the intestine are seen mostly in infants presenting with upper gastrointestinal obstruction. It is an important entity in the pediatric surgery. In the meantime, malrotation of the intestine is rarely encountered in adults and often detected accidentally in patients under treatment for any other disease. This paper describes our recent experience of the disease in an adult patient with acute appendicitis which we had difficulty in diagnosis due to the presence of malrotation of the intestine.
A 66-year-old man was seen at the hospital because of left lower quadrant pain. Under a suspicion of diverticulitis of the sigmoid colon, the patient was conservatively treated. However, the abdominal pain was intensified, and abdominal CT revealed an abscess beneath the abdominal wall in the left lower quadrant. The patient was diagnosed with intraabdominal abscess due to perforation of the intestine and was operated on. During operation, malrotaion of the intestine was confirmed and the appendix was located at the left lower quadrant which perforated at the root forming the abscess in a space surrounded by the ileocecal region, sigmoid colon, and abdominal wall. Since the inflammation at the ileocecal region was severe, the ileocecal region was resected and the Ladd ligament was separated for the malrotation of the intestine.

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Primary malignant lymphoma of the large intestine is comparatively rare. A case of invagintion caused by a primary malignant lymphoma in the cecum is reported here.
A 76-year-old man was admitted to the hospital because of repetitive abdominal pain. The fist-sized movable tumor was palpated in the hypochondrium. Barium enema revealed a cup-shaped or ring-like defect at the end of the barium column. The invagination was reduced by air inflaction and the tumor shadow was shown in the cecum. The cross-section of the tumor invaginated in the distended large intestine was shown by CT scan. Endoscopy revealed the elevated and eroded tumor with uneven surface. Therefore, he was diagnosed as having the invagination due to malignant tumor in the cecum and then a right hemicolectomy (D3) was performed. No peritoneal dissemination and no invasion into the surrounding fatty tissue or other organs was seen in the operation. Pathological diagnosis was malignant lymphoma, diffuse, mixed, B-cell type, se, and n2 (+). After the surgery, chemotherapy (CHOP) was carried out. The patient is alive with no recurrence sign.

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Owing to the slow growing biological features of colorectal cancers, recurrent lesions of large bowel malignancies are often re-resectable if found earlier.
A 59-year-old woman primarily suffered from a T/C cancer had been operated on five times for her consecutive recurrent cancer. And she was alive for about five years. Though she was symptomless and serum levels of tumor markers were normal, we performed regular follow-up examinations and found out all five recurrent lesions.
To improve the postoperative survival rate of colorectal cancers, close and intense follow-up is necessary. Furthermore, we must pick up the high risk group of recurrence to make effective and early detective follow-up. In general, prognostic factors of high risk groups are depth of invasion, histological type, lymph node metastasis, lymphatic invasion and venous invasion. In addition, we must recognize the histological type diversion at the deepest invasive area and perineural invasion as important poor prognostic factors.

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We report a case of hepatic angiomyolipoma (HAML) in a 45-year-old man who was pointed out a hepatic tumor by ultrasonography on medical chekcup. After admission ultrasonography demonstrated a well-demarcated, hyperechoic tumor. Plain CT showed a low-density lesion with a high-density area. Hepatic angiography revealed a deep stained tumor and hypervascularity. From these findings, HAML was highly suspected. But, since possible malignancy could not be ruled out, a partial hepatic resection of the right posterior segment was performed. HAML is extremely rare among hepatic benign tumors, and only 54 cases have been reported in Japan, including ours. Many cases underwent surgical intervention, but recently some cases which were followed up only by biopsy have been reported. Histologically, they were characterized by an admixture of adipose tissue, blood vessels and smooth muscle, so the image findings varied with the difference in these 3 components and normal hepatocytes. Therefore, in spite of a recent development in diagnostic imaging techniques, there are cases which present, preoperatively difficulty to differentiate especially from hepatocellular carcinoma undergoing fatty degeneration or other malignant tumors. No malignant hepatic angiomyolipoma has been reported, but some cases with nuclear atypia can be seen. Therefore, it is necessary to make a careful dicision of therapeutic guideline for this type of tumor.

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A 59-year-old female was referred to the hospital because of a left breast tumor. On admission, laboratory findings revealed abnomality in her hepatic function and elevated levels of serum tumor markers such as AFP, CEA, CA19-9, DUPAN-2, CA15-3, TPA and CA12-5. HCV antibody was positive.
The breast tumor was visualized as heterogenous tumor by ultrasonography which was suspected of primary breast cancer. Histological examination of the resected specimen indicated primary breast cancer. Abdominal ultrasonography and CT revealed an illdefined and low-absorbent tumor in the Seg5-8 and a well-defined and high-absorbent tumor in the Seg 8. These liver tumor presented difficulty in differential diagnosis from metastases of the breast cancer. The patient died of liver failure following rupture of esophageal varix.
Autopsy revealed the cirrhotic liver with tumots, the tumors contained elements of both hepatocellular carcinoma and cholangiocellular carcinoma, and so the possible diagnosis of metastasis of the breast cancer was ruled out.
A relatively rare case of combined hepatocellular and cholangiocellular carcinoma is reported.

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A 65-year-old male complaining of a lower abdominal dull pain was admitted to the hospital because liver dysfunction was found by blood examinatin. CT scan and angiography revealed a hepatocellular carcinoma (HCC) with metastasis to the right adrenal gland. Posterior-segmentectomy of the liver combined with chlecystectomy and right adrenalectomy was performed. The patient had a recurrence in the liver and lung metastais but is alive for 16 month after the surgery. Although metastases to the adrenal glands are reported to be found in 8.8% of all autopsy cases of the HCC, cases undergoing an adrenalectomy are very rare. We discussed the effectiveness of the resection of adrenal metastasis in the HCC patients in 11 cases, from a review of the literature combined with our case. Four cases underwent resections of both primary and metastatic lesion simultaneously, and remaining seven cases, nonsimultaneously. There were no major complications with surgery in any cases except for the only one case which underwent bilateral adrenalectomy. We suggest that the adrenalectomy should be taken into consideration as an effective approach for improving the prognosis of the HCC with unilateral adrenal metastasis.

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We experienced a rare case of cholecystitis, cholecystolithiasis and acute pancreatitis, revealing heterotopic pancreatic tissue in the cystic duct by the postoperative pathohistological examination. This paper presents the case with a review of the literature.
A 52-year-old woman was seen at the hospital because of an upper abdominal pain. Elevated liver function levels and markedly high amylase in urine and blood were noted by biochemical examinations. Abdominal ultrasonography and CT scan revealed cholecystolithiasis and hypertrophy of the cystic wall, but no marked change was noted on images of the pancreas. Being diagnosed as cholecystitis, cholecystolithiasis, and acute pancreatitis, an operation was carried out when the symptoms ameliorated. The excised gallbladder showed hypertrophy of the wall, with multiple small black stones inside, Further, there existd two cholesterol polyps. Pathohistological examination of the excised specimen reveaeld heterotopic pancreatic tissue of the Heinrich II type consisting of acini and excretory ducts about 1 mm in size located from the lamina propia to tonica muscularis in the cystic duct.

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We experienced a case of abdominal abscess caused by missed gallstones during laparoscopic cholecystectomy.
A 59-year-old man underwent a laparoscopic cholecystectomy and choledocholithotomy for gallstones, acute cholecystitis and choledocholithiasis. During the operation the gallbladder wall was injured and gallstones were missed into the abdominal cavity. But the postoperative course was uneventful and the patient was discharged from the hospital. On the fifth month after the operation the patient was admitted to the hospital because of a right lateral abdominal pain, weight loss, and slight fever. An abdominal abscess on the dorsal side of the right hepatic lobe and two stones in the abscess were confirmed. Symptomatic remission was attained by percutaneous puncture of the abscess. However, on the tenth month after the operation abdominal abscess recurred. Once the abscess improved by transcutaneous drainage, but recurred again. Under general anesthesia drainage of the abscess and removal of the stones were performed. Postoperative course was uneventful. There has been no sign recurrence up to now.
It is important for perfoming laparoscopic cholecystectomy to prevent not to miss stones. Since in very few cases of missed stones reoperation has been required, we think we need not change to laparotomy to remove the missed stones when stones were missed during the operation.

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Squamous cell carcinoma of the common bile duct is extremely rare. We report such a case with a review of the literature. A 75-year-old man was admitted to the hospital because of obstructive jaundice. Abdominal computed tomography revealed a tumor of the lower common bile duct and swollen gallbladder and bile duct. PTGBD was performed. Cholangiography visulaized a circular stenosis of the lower common bile duct, and cytology of the bile was class IV. Panceaticoduodenectomy was performed. The tumor was nodular type and the pathological findings showed squamous cell carcinoma. The histology of the metastatic lymph node was also squamous cell carcinoma.

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A 51-year-old man visited another hospital because of an intractable abscess of the abdominal wall at operative scar resulting from a laparotomy which was performed for panperitonitis with appendicites 21 years before. The patient did not respond to drainage and was referred to the hospital. After admission conservative treatment resulted in reported relapase of the abscess for a long-term. Biopsy showed growing lesions of no atypical spindle-shaped fibroblasts with abundant collagen and we suspected of a desmoid tumor. Abdominal CT revealed a homogenous density tumor which projected to the abdominal cavity. Laparotomy was performed under general anesthesia, and a hard tumor was found adhering to the urinary bladder. A wide local resection of the tumor with partial wall of the urinary bladder was carried out. The resected elastic hard tumor, measuring 8×5cm, showed a smooth surface, whitish and solid cut surface, and was histologically diagnosed as desmoid tumor. The desmoid tumor was noted more often on fertilizable young women, and so this case appeared interesting for consideration of probable etiology of the desmoid tumor.

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Four cases of obturator hernia experienced at the hospital in a recent 5.5-year period are presented, together with a statistical study of 77 cases seen in the Japanese literature since 1990, including our four cases, and diagnosis and therapeutic outcomes of the disease in these years as well as some problems related thereto are discussed.
All our four cases were diagnosed preoperatively within 2 days after admission, including one case suspected of this disease based on our previous experience, and three cases being Howship-Romberg's sign positive, wherein two cases were diagnosed definitely by pelvic CT scan. All of them required no resection of the intestine but only reduction of the incarcerated intestine and suture of the obturator. Their postoperative courses were uneventful.
In a statistical analysis of the 77 cases collected, the preoperative correct diagnosing rate was noted improved to 72.3% by employment of CT and ultrasonography, while resection of the intestine was noted high in 55.8%, especially in 85.7% with those diagnosed intraoperatively. On the other hand resection of the intestine in those preoperatively diagnosed was noted in 44.6%. Most of them required no resection of the intestine being operated within 2 days after admission. It is considered that recently preoperative diagnosing rate of this disease has improved, but to avoid resection of the intestine, early diagnosis and early operation within 2 days after admission are important.

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A 43-year-old man who had been suffering from severe liver cirrhosis was seen at the hospital because of a right inguinal tumor which often interfered with his daily activities. With a diagnosis of inguinal hernia the patient was operated on. And it was found that the tumor was not the hernia but remarkably dilated ectopic varices which prolapsed from the internal inguinal canal. Three months later the patient died of liver failure. Autopsy revealed that this patient was also associated with malformation of the inferior vena cava. The following etiologic route was suggested; the portal vein→superior mesenteric vein→retroperitoneal vessels→remnant right inferior caval vein→inferior caval vein.
Under the portal hypertension, the varices had occurred in the right inferior caval vein, and it made a tumor like a inguinal hernia through the internal inguinal canal.

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We experienced a case of synchronous triple cancer involving the stomach, bladder and lung.
A 67-year-old man was admitted to the hospital for operation of an abdominal aneurysm. With a close examination of gastrofiberscopy before the operation, an early gastric cancer was detected. The patient was operated on for the abdominal aneurysm and gastric cancer in April, 1994. Following the operation, tumors of the bladder were diagnosed by bloody urine. The tumors were resected by endoscopy in July, 1994. Histopathologically the tumors were early bladder carcinoma, transitional cell carcinoma. The third cancer was diagnosed by bloody sputum. With bronchoscopy, an advanced lung cancer (scc) was detected. Pneumonectomy of the right lung was performed in February, 1995. Histologically it was well differentiated squamous cell carcinoma in stage IIIA.
The first and second cancer were early cancer, but the third cancer was advanced though all cancers were synchronously detected within one year.

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A case of synchronous triple cancer of the colon and bilateral kidneys, which were diagnosed preoperatively and resected successfully is reported.
A 73-year-old man was referred to the hospital for occult blood. A cecal cancer was revealed by barium enema and colonoscopy, and bilateral renal tumors were visualized by abdominal CT. Aortography showed hypervascular tumors in the bilateral kidneys, which were diagnosed as renal cancer.
After no often organ metatasis was confirmed a right hemicolectomy and right partial nephrectomy were performed simultaneously. Four weeks after the initial operation, a left radical nephrectomy was performed. Renal dysfunction was not experienced later. The cecal cancer was histologically diganosed as well differentiated adenocarcinoma, with cancer cells confined within mucosa. Pathological diagnosis of the right renal lesion was alveolar type, common type and clear cell subtype of the renal cell carcinoma, and that of the left renal lesion was papillary type, common type and clear cell subtype of the renal cell carcinoma. No lymph node metastasis or vascular invasion was noted. The postoperative course was uneventful and the patient is strictly followed up.

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We report a case of metachronous quadruple cancer with all lesions resected duaring a 6-year period.
A 63-year-old man was operated on for a middle pharynx tumor at the age of 57 and for a cancer in the oral cavity at the age of 61. Subsequently, an abnormal shadow was seen on a chest X-ray film and the patient underwent a left upper lobectomy. The lung tumor was pathologically diagnosed as “primary lung cancer”. Duaring this admission, a minute esophageal tumor was also detected duraing esophageal endoscopy and the lesion was excised by endoscopic mucosal resection.
These has been no sign of recurrence as of 10 months after the 4th operation. Some notes on 33 cases of quadruple cancer seen in the Japanese literatiure are also presented here.

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