The data on 272 patients with esophageal cancer who underwent resection in our department between 1984 and 1994, were reviewed to assess the postoperative infection caused by MRSA, MRSA were isolated from 48 (17.6%) patients, and in the latest 3 years MRSA were isolated from 4 or 5 patients every year. The incidence of patients who had clinical symptons of the infection was 62.5%, and pneumonia, pyothorax and wound infection were common. MRSA were isolated within 5 postoperative days in many patients, and the number of symptomatic patients was high (73.3%) in these patients. In patients with postoperative complications (bleeding, anastomosis insufficiency), MRSA were isolated much more frequently than in patietns without postoperative complications (25.2% v.s. 12.7%). Other pathogens were isolated with MRSA in 64.3% of patients, and the incidence of symptomatic patients was higher in cases with polymicrobial infections than in cases with infectins caused by MRSA alone (68.5% v.s. 43.3%). The most common pathogens isolated with MRSA were gram-negative rods (62.3%). Pseudomonous aeruginosa isolated with MRSA has gradually become resistant to antibiotics. In conclusion, these data indicate that the strict prevention of hospital acquired infections in the early postoperative period and the avoidance of postoperative complications by adequate selection of operation methods and skilled technics are necessary to prevent postoperative infections caused by MRSA in patients with esophageal cancer. The next problem is to come up with a strategy against the polymicrobial infection caused by MRSA and pseudomonous aeruginosa, which is resistant to antibiotics.

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Among two hundreds and twenty eight patients with gastric cancer surgically treated in our department from April, 1991 to March, 1994, 26 patients over 80 years of age were subjected to this study and analyzed from both clinical and economical aspects in comparison with other younger patients. These aged patients were on the average of 82.7 years old. Their cancers were predominantly located in the antrum. Fifteen patients (57.7%) were categorized as stage I.
Forty-two point three percent of the patients underwent operations with lymph node dissection greater than or equal to D2, 26.9% underwent total gastrectomy, 38.5% underwent combined resection of other organs. The degree of lymph node dissection and combined resection of other organs were significantly lower than those of younger patients. Postoperatively, there were respiratory complications in a frequency of 34.6%. Having complications postoperatively, however, there were longer hospital stay and more expensive medical cost than those other patients having no complication.
Their costs had significantly higher in medication, examination and surgical management. From these results, we should try to reduce postoperative respiratory complications by choosing a less invasive surgery. We should also take much effort to shorten their hospital stay with the cooperation of home doctors. These efforts may improve the patients' QOL and reduce their medical costs.

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One-hundred and twenty-five resected cases of colonic cancer were analysed in respect of anastomotic dysfunction including anastomotic leakage and stricture. Anastomotic leakage occurred in 4 cases (3.2%) and anastomotic stricture in 3 cases (2.4%). These tumors were predominantly lacated in the transverse and descending colons. Operative procedures relating to these dysfunction were transevers colectomy and left-sided colectomy. Further, these dysunctions were frequently seen when the anastomotic site presented in an area from the left colon to descending colon. All dysfunctions occurred in cases undergoing layer to layer anastomosis. On the other hand, there was no relationship between these anastomotic dysfunctions and preoperative complications, the degree of tumor occupation with colon circumference and degree of lymphadenectomy. It is known that, compared to the right-sided colon, blood supply is poor and vascular malformation often appears in the left half of the colon. And the anastomosed site tends to be strained. Caution should be employed in performing anastomosis including anastomotic technique to operate colonic cancers which may be involved in the above mentioned conditions.

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One hundred and fifty five patients had been operated on for colorectal cancer in our hospital between 1990 and 1994. They were classified into three groups according to age: 26 patients over 80 years old (Group A); 40 patients from 70 to 79 years old (Group B); and 89 patients less than 69 years old (Group C). Preoperative total complication rates were higher in Groups A and B than in Group C (p<0.01). Cerebrovascular diseases, respiratory dysfunction and hypoproteinemia occurred frequently in Groups A and B. Postoperative total complication rates were also higher in Groups A and B. Respiratory dysfunction and mental disorders were common. Operation methods and time, anesthesia time and the amount of bleeding decreased in the elderly patients (p<0.05). Limited operations and spinal or epidural anesthesia tended to be accepted treatments for Groups A and B.
Because of a rapid increase in pre and postoperative total complication rates among patients over 70 years old, we now categorize patiets over 70 years old as elderly for surgical treatment. We must be especially careful of postoperative respiratory dysfunction and mental disorders in surgical treatment for elderly patients.

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Eighteen aged patients over 85 who were operated on for colorectal cancer at the hospital were subjected to a study to elucidate their clinicopathological characteristics and the significance of such operations.
1) Most patients were detected having a colorectal cancer in an advanced stage, but their lesions were predominantly localized in the large intestine. 2) In 12 (66.7%) out of 14 patients who had no liver, peritoneal, and other distant metastases, dissection of lymph nodes of group I resulted in the curability A. 3) Original cancer deaths were few among the curability A patients and the 5-year survival rate was 53.8%. 4) About half of the patients fell in postoperative delirium. 5) Many patients had some underlying diseases preoperatively, but strict perioperative management permitted to avoid postoperative complications.
We think that the significance of operations for aged patients with colorectal cancer may not lie in operation itself, but the importance of stric and proper perioperative management should be emphasized.

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Seventy-four patients undergoing a combined resection of a colorectal cancer and the adjacent organs were clinically reviewed. Fifty-one cases (68.9%) were positive in histological invasion to the adjacent organs (si, ai), and 33 cases (31.1%) were not histologically verified the cancer invasion. The histological depth of invasion of si (ai) was most frequently seen in the small intestine and scarcely in the ureter and abdominal wall. The cumulative 5-year survival rate in the patients undergone the combined resection resulting in curability A or B was relatively high, 65.0%.
The combined resection of the adjacent organs in patients with colorectal cancer is expected to bring a better prognosis. But cancer invasion cannot be histologically verified in some cases undergone the combined resection. In combined resection of the urogenital organs which are closely related to the patient's quality of life, over surgery should be avoided by precise evaluations of the cancer invasion to the adjacent organs.

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The expression of vascular adhesion molecules and neutrophil adherence were investigated in the liver to evaluate the adverse effects of a temporary interruption of the hepatic inflow (Pringle's maneuver) during hepatectomy. In liver tissue specimens obtained from 16 patients (10 with liver cirrhosis (LC) and 6 without LC), immunohistochemical staining was used to detect the expression of granular membrane protein-140 (GMP-140), endothelial leukocyte adhesion molecule-1 (ELAM-1), and vascular cell adhesion molecule-1 (VCAM-1) by the hepatic vascular endothelium. In addition, neutrophil elastase was immunostained. After hepatectomy, the expressions of GMP-140 and VACM-1 were significantly higher in patients with LC than in those without LC. There was weak expression of ELAM-1 in the cirrhotic liver which was observed in 2 cases, but no expression in the non-cirrhotic liver. The adherent neutrohil count in liver tissue after hepatectomy was significantly higher in LC patients than that before hepatectomy as well as than that of non-LC patients.
In conclusion, Pringle's maneuver enhances the hepatic neutrophil adhesion by upregulating the expression of endothelial adhesion molecules during an early period after hepatectomy, which may cause damage to the remnant liver in LC patients.

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During a two and a half year period, 40 cases (11.4%) of laparoscopic cholecystectomy for acute cholecystitis including 11 cases in which preoperatie PTGBD (A) was performed were studied. These cases included GB stones in eight cases, GB and CBD stones in one case, CBD stones in one case and acalculous in one case. These were five males and six females. Their ages ranged from 24 to 78 years with the average being 60.4. The average period from onset to PTGBD(A) was 1.8 days, from PTGBD(A) to LC was 32.2 days and we converted to open surgery in two cases (18.2%). The average time of operation was 231.3 minutes and the average period of postoperative hospital stay was 15.2 days. We encountered no severe intra-and postoperative complications. We conclude that for assuring the safety of LC in patients who resist against the concervative treament or those who show some severe findings in ultrasound, preoperative PTGBD (A) for the management of acute inflammation would be mandatory.

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During a period from July 1982 to April 1995, 71 cases of renal transplantation from 34 living related and 37 cadaveric donors were performed in this institute. We studied 18 cases (25.4%) in which surgical complications were found. From July 1982 through November 1992, the ureter was inserted into the bladder with a Paquin technique, and an Alexandre technique was performed after December 1992. The risk factors of surgical complications were not associated with age, donor, operation time and duration of pre-operative hemodialysis, but these complications were predominantly seen in males. On wound complications there were 5 cases of wound bleeding, 2 cases of abscess, 6 cases of lymphocele, 2 cases of hydrocele testis and one case of incisional hernia. There were 3 cases of ureteric stricture, one case of urinary leakage and 3 cases of vesical bleeding on urinary complications and one case of renal artery stenosis and one case of graft rupture. No urinary complications occurred after we employed an Alexandre technique. Surgical complications were not associated with the rejection, and the graft and patient survival. Meticulous operative technique may be the crucial factor associated with a minimal incidence of surgical complications after renal transplantation.

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In this study the usefulness of the postoperative pain control was comparatively studied in 135 patients undergoing an abdominal surgery at the hospital by dividing into three groups: 1) 90 patients received continuous subcutaneous infusion of buprenorphine; 2) 20 patients received continuous subcutane-ous infusion of buprenorphine using the patient controlled analgesia (PCA) system; and 3) 20 patients received continuous subcutanoeous infusion of pentazocine using the PCA system.
As a result, continuous subcutaneous infusion of buprenorphine was effective in the postoperative pain control, and a use of the PCA system might contribute to the safety personal saving in the medical care. However, it poses a further problem that buprenophine can cause adverse effects such as dizziness and nausea in about 10% of the patients. Continuous subcutaneous infusion or pentazocin was significantly inferior to that of buprenorphine in the analgesic effect and has a problem in the safety.

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Two patients with thyroid carcinoma in childhood were experienced in the last two decades. These cases represeted 0.36% of 553 cases of thyroid malignant tumor operated on at the department. One patient was a 9-year-old boy, having diffuse tumors in the bilateral thyroid glands, cervical lymphnode metastasis, and bilateral multiple lung metastasis. Total thyroidectomy and tracheostomy were performed. The pathological diagnosis was papillary carcinoma. Another patient was a 14-year-old girl, having a 6cm tumor in the left lobe of thyroid gland. Left thyroidectomy was performed. The pathological diagnosis was follicular carcinoma.

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Secretory carcinoma of the breast is rare. We experienced a patient with advanced breast cancer which is pathologically secretory carcinoma.
A 48-year-old female was seen at the hospital because of a hard tumor in the right breast. An irregular elastic hard mass, 4.0×4.0cm in size, was present in the border of A, C and E portion of the right breast. The axillary and supraclavicular lymph nodes were palpable. Lung metastasis was shown on CT examination. After 3 courses of chemotherapy (CAF), a simple mastectomy with axillary lymph node disection was carried out. The pathological examination of PAS and Alcian-blue staining material revealed secretory carcinoma. It has been reported that secretory carcinoma grows slowly, has a relatively good prognosis, and hence it can be indicated more limited operation in the foreign countries. In this country, houever, the disease not uncommonly has positive axillary lymph nodes, in a frequency of 32%. We think that mastectomy with axillary lymph node dissection should be done in initial treatment of this disease.

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The metastasis of breast cancer to the gastrointestinal organ is not so uncommon in autopsy cases, but we rarely encounter such a case clinically. This paper describes a rare case of gastric and retroperitoneal lymph nodes metastases after radical mastectomy.
A 53-year-old woman developed sense of thirst 2 years and 11 months after a standard radical mastectomy for a left breast cancer (t2n2m0 stage III). Radiological and endoscopic examination of the stomach showed a IIa+IIc like lesion and biopsy specimen obtained from the lesion revealed signet ring cell carcinoma. Under a diagnosis of early gastric cancer, laparotomy was performed, and proved to paraaortic and mesenteic lymph nodes metastases. Radical resection was impossible and gastrectomy was performed. Histological examination showed the tumor mass diffusely invading the submucosal layer but not the mucosal layer, which was almost similar to that of the breast cancer. These findings demonstrated that the gastric tumor resulted from the previously treated breast cancer. Thus, when the patient with previous history of breast cancer has gastrointestinal symptoms, we should consider a possibility of gastrointestinal metastasis from the breast cancer.

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Esophageal lymphangiomas are so rare that only 12 cases have been seen in the literature so far. This paper describes a recent case of esophageal lymphangioma arised in the upper part of the esophagus.
A 59-year-old woman was pointed out a submucosal tumor in the upper part of the esophagus at a medical checkup. Biopsy indicated Group II. The patient was periodically followed thereafter, and 2 years later she was admitted to the hospital because of an enlargement of the tumor and reddish surface. Upper gastrointestinal series revealed a 3.0×2.5cm Yamada type III polyp at the top of lu region of the esophagus. Gastric endoscopy showed an elevated lesion with smooth surface. There was reddness on the surface, but no malignancy was confirmed with biopsy. CT revealed a tumor at the aortic arc level of the esophagus which was growing intraluminally. The tumor was extirpated through the right thoracotomy. Histopathologically it was cavernous lymphangioma.

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Thoracoscopic enucleation of a leiomyoma of the esophagus was successfully performed in a 29-year-old male. The tumor was located in the middle thoracic esophagus. The tumor size was 3.8×1.7×1.2cm. Four trocars were inserted through the right intercostal space for operation. Intraluminal balloon-mounted esophagoscope was useful enough to expose the tumor inner side out of the esophageal wall and the tumor was easily enucleated. After resection, intact esophageal mucosa was confirmed by endoscopy and the proper muscle layer of the esophagus was closed with 3-0 Vicryl. The thoracoscopic approach in comparison with open surgical approach can potentially cause less patient discomfort postoperatively and reduce the hospital stay and recovery period. We think that the thoracoscopic approach for enucleation of leiomyoma of the esophagus will come into the standard procedure.

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Among leiomyosarcomas of the gastrointestinal tract, those arising in the esophagus are relatively rare. We experienced a resected case of intra- and extra-luminally growing leiomyosarcoma of the esophagogastric junction with tumors in the mediastiunm and peritoneal cavity.
A 68-year-old man was admitted to the hospital because of appetite loss. A chest X-ray photograph showed a demarcated large mass shadow behind the cardiac shadow. The mass was examined by a barium examination, gastrointestinal fiberscopy, CT, MRI and angiography, and it was diagnosed preoperatively as leiomyosarcoma occupying the lower esophagus and upper stomach. An operation was carried out. The mass extended from the lower esophagus to the cardia. The border was relatively clear without any invasion or metastasis to other organs or lymph nodes. An esophagogastrectomy was carried out. The tumor consisted of two parts; an extraluminal part (6.0×7.0×8.5cm) and an intraluminal part (4.0×2.5×2.0cm) at the esophagogastric junction with a center ulceration. The histological diagnosis was esophageal leiomyosarcoma arising in the esophagogastric junction.

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Adenoid cystic carcinoma of the esophagus is very rare, and only 67 cases have previously been reported in the world. The prognosis of adenoid cystic carcinoma of the esophagus is reported to be very poor, except in 4 cases showing superficial involvement without metastasis.
We present a long surviving 57-year-old man with adenoid cystic carcinomsa of the esophagus complicated by bilateral multiple lung metastases. He was treated with intensive repeated combination chemotherapy with CDDP and 5-FU, and separate surgical resections for primary and lung metastatic lesions. To date, he has survived for 4 years and 8 months.
In general, the prognosis of adenoid cystic carcinoma of the esophagus is very poor, but multidisciplinary treatment with CDDP, 5-FU and surgical resection may be an effective treatment modality for this cancer.

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Phlegmon of the stomach is a nonspecific suppurative inflammation arising from the submucosal layer extending to the full thickness of the stomach. It often presents difficulty in differential diagnosis from advanced gastric cancer. This paper describes a case of gastric phlegmon which did not respond to conservative treatment and demanded a gastrectomy due to passage disturbance.
An 85-year-old man was admitted to the internal department in our hospital because of fever and appetite loss. Prior to this admission he was treated at another hospital with a diagnosis of pneumonia for about half a month, but appetite loss appeared. After admission UGIS revealed a circumferential irregularity of the wall, linearity and stricture in the pyloric antrum. GIF showed remarkable redness of the mucosa and irregular multiple erosion in the entire pyloric antrum. Biopsy disclosed potent infiltration of inflammatory cells. With a diagnosis of gastric phlegmon conservative treatment was carried out. Inflammatory findings of he gastric mucosa improved, but the stricture at the pylorus came to significant. The patient was transferred to the department of surgery for operation. A distal gastrectomy was carried out. The resected specimen revealed thickness and ulcer in the gastric wall. Histologically severe submucosal fibrosis and infiltration of inflammatory cells were confirmed without any malignant findings. The definite diagnosis of gastric phlegmon was made.

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We experienced two cases of malignant schwannoma of the stomach which is very rare.
Case 1: a 70-year-old female was found having a submucosal tumor 6 cm in diameter at the greater curvature of the upper body of the stomach. Case 2: A 57-year-old man was found having a submucosal tumor 5 cm in diameter at the fornix of the stomach. Both cases were treated surgically for a possibility of malignancy, because the tumors were relatively bigger in size. Intraoperative frozen sections reveaeld that there was a suspicion of leiomyosarcoma in both cases. They underwent a total gastrectomy with lymph node dissection. On immunohistochemical stainnings the two tumors were positive for S-100 protein, but negative for actin and desmin. The both cases were diagnosed with malignant schwannoma of the stomach. Metastatic liver tumors were identified in case 1 on 2 years and 3.5 year after the first surgery, when a partial resection of the liver was performed respectively. There has been no sign of recurrence as of 2 years after the surgery in case 2.

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A case of Jejunogastric intussusception (JGI) after gastrectomy is presented. A 72-year-old woman was admitted to the hospital because of sudden epigastric pain and vomiting followed by hematemesis. There was a history of undergoing a gastric resection (Billroth II) for a gastric cancer 17 years before. Endoscopic examination revealed that a large reddish-blue intesitne loop filled the lumen of the residual stomach. Abdominal CT also revealed a mass with ringed structure in the gastric remnant and jejunum. Based on the diagnosis of JGI, an emergency laparotomy was performed 24 hours after the onset of the symptoms. At operation, the efferent jejunal loop was found to be intussuscepted retrogradely through the entero-enterostomy and then via the afferent loop into the gastric remnant. After manual disinvagination, a part of gangrenous jejunal intussuscepiens was resected and gastro-jejunostomy was performed with Roux-en Y-type reconstruction. The postoperative course was uneventful and the patient was discharged on 26th hospital day. In a review of the Japanese literature, anather 28 cases of JGI are seen. These 29 cases including our case are characterized by: 1) that Billroth II method was employed in the initial operation in all cases; 2) most cases had a retrograde intussusception of the efferent jejunal loop; 3) the disease suddenly developed after a long-term interval after the initial operation; 4) the diagnosis was easily made by endoscopy, X-ray examination of the stomach, abdominal CT and abdominal ultrasonography; and 5) the prognosis was relatively good by appropriate treatment.

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An 84-year-old man was found to have a hepatic tumor by CT when he was followed up for hepatitis C.
The patient was admitted to the hospital for operation. Abdominal angiography demonstrated two aneurysms 8 mm in diameter of the right gastroepiploic artery. Exteded left lobectomy of the liver and resection of the aneurysms were performed. The patient recovered without any complications. Histopathological study of the resected specimen revealed the aneurysms resulting arteriosclerosis.

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Duodenal carcinoid is a relatively rare entity. It is believed that the carcinoid can be diagnosed by Grimelius nitrate stain because of its perfect positive response to the staining. We experienced a case of asymptomatic duodenal carcinoid, which was negative to Grimelius nitrate stain and ultrastructural examination revealed few neurosecretory granules.
A 62-year-old man was pointed out an elevated lesion with ulcer on the top in the duodenal bulb by an occasional fiberscopic examination for endoscopic infusion therapy. Biopsy revealed a low malignant neuroendocrine tumor and negative Grimelius nitrate stain. Because of poor general status due to liver cirrhosis and esophageal varices, we had followed this tumor for 17 months by fiberscope examinations, until a partial resection of the doudenum was performed. Ultrastructural examination of the resected specimen revealed few neurosecretory granules in the cytoplasms, which might participate with the negative response to Grimelius nitrate stain. The tumor was diagnosed with carcinoid.

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A 68-year-old man was seen at the hospital because of an epigastric pain. Close examination indicated a mild jaundice and endoscopy revealed a slight redness in the duodenal papilla. Endoscopic retrograde cholangiography (ERC) visualized an irregular wall of the papilla. With endoscopic biopsy of the papillary epithelium group III was detected. Since possibility of cancer not ruled out and no tumor formation made a discision-making for a range of resection difficult, pylorus preserving pancreatoduodenectomy (PPPD) was performed. In the resected specimen, a whole-circumferential flat IIb type lesion ranging 15 mm from the papillary portion of the bile duct to common channel was noted. Histologically it was early well differentiated adenocarcinoma invading the Oddi muscle. After the operation the patient is in a good nutrition. There has been no sign of recurrence as of 3 and 6 months. Such flat and invasive papillary carcinomas without tumor formation as our case are uncommon. We need to pay careful attention to possible existence of adenomatous tissue which is often associated with carcinomas of the duodenal papilla.

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65-year-old woman was admitted to the hospital because of intractable lower abdominal pain which had been lasting for nearly two years. There was a history of pulmonary tuberculosis (Tbc) which was successfully treated with anti-Tbc agents at the age of twenty years old. Chest and abdominal X-ray examinations revealed calcified lesions which were presumed healed tuberculotic lesions. Barium enema showed shortening of the ascending colon, distorted cecum with pseudo-diverticula and a fistula formation between the stenotic terminal ileum and transverse colon. Right hemicolectomy including the fistula was performed. The patient recovered without any complications and was discharged from the hospital on 45th postoperative day. Although no histological evidence was obtained, intestinal tuberculosis was strongly suspected as a cause of ileo-colonic fistula in this case. Intestinal tuberculosis is liable to extend on the surface of the intestial wall, but does not tend to reach to the deep organs. It is very rare that the disease forms a fistula between organs. We reviewed previously reported six cases of intestinal tuberculosis with fistula formation in Japan.

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We experienced a patient suffering from frequent anal bleeding whose bleeding site was difficult to be determined even by upper and lower endoscopic examinations. To identify the lesion of bleeding, an exploratory laparotomy was performed. It was found that the cause of bleeding was due to multiple peptic ulcers of the small intestine. Myeloblasts appeared in the peripheral blood with the time. Bone marrow biopsy showed the typical myelofibrosis. It is known that myeloproliferative diseases including Polycythemia vera are often accompanied with peptic ulcer. In this case; however polycythemia was not evident because of anemia due to frequent anal bleeding for intestinal multiple peptic ulcers. This report describes the case of myeloproliferative disease that presented difficulty in diagnosis and was eventually found by multiple peptic ulcers.

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Lipoma of the large intestine has been thought to be a relactively rare entity so far, but recently it has been increasingly reported with an increased performance of colorectal examinations. This time we experienced a case of lipoma of the ascending colon presenting with intussusception.
A 56-year-old woman was admitted to the hospital, because repeated constipation and abdominal pain for several months caused intestinal obstruction. CT visualized a concentric circular multilayer structure in the right hypochondrial region which was characteristic of intussusception. Barium enema study revealed clab's claw like shadow. After it was repaired under fluoroscopy, an about 8×5cm tumor was visualized. Biopsy did not provide the definite diagnosis, but CT value was -78.8 that was consistent with the value for fat tissue. The ascending colon was resected. Histologically it was lipoma with the size of 7.5×3.5×3.5cm composed of matured fat cells.

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We report a case of leiomyosarcoma of the rectum with liver metastasis resected by a Miles operation and left hepatic lobectomy. A 67-year-old man was seen at the hospital because of difficult defecation and bloody stool. Barium enema and anoscopy revealed a submucosal tumor of the rectum with ulceration of which inferior margin was 5cm distant from the anal verge. By a needle biopsy, it was diagnosed histologically as leiomyosarcoma. The giant rectal tumor which occupied the entire pelvic cavity and a solitary lesion in S₄ segment of the liver were revealed by CT scan. The excised tumors by Miles operation followed by left hepatic lobectomy were 13×12cm and 10×9cm in size respectively and the both lesions had the central necrosis.
Leiomyosarcoma of the rectum is a relatively uncommom entity. Most of all grow expansively, and symptoms of this disease appear slowly. So, aggressive resections of the primary and metastatic lesions should be determinant prognostic factors.

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An 84-year-old woman was seen at the hospital because of perianal itching and erythema with occational slight bleeding. A well demarcated eczematous perianal lesion, a few cm in diameter, was noted. A tumor which protruded in the anal canal was found near the skin lesion. There were secreting mucoid substanse, which had an ill-smelling.
A diagnosis of Paget's disease was made by biopsy of the perianal skin. Barium enema study disclosed diverticula and a polyp in addition to the lesion in the anal canal. The patient had no other abnormality in the abdomen or thorax. The CEA value was within the normal range.
Two months later, the perianal skin lesion was resected with the tumor in the anal canal after colostomy under spinal anesthesia. The excises tumor was 2.5×1.5cm in size.
Histological diagnosis of the anal tumor was made as mucinous adenocarcinoma infiltrating into the muscularis propria, and of the perianal Paget's disease was confirmed.
The patient has been doing well with no evidence of recurrence as of 4 years and 2 months after the operation.

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Biliary cystadenocarcinoma is a relatively rare disease, and only 90 cases have been reported in Japan. We report a case of biliary cystadenocarcinoma with a review of the literature. A 52-year-old female was admitted to the hospital because of general fatigue. Abdominal ultrasonography, CT, MRI, arteriography revealed a cystic tumor in the right hepatic lobe suspicious of intrahepatic cholangiocarcinoma, and an extended right hepatic resection (right trisegmentectomy) was performed. Intraoperative ultrasonography was very useful to decide the resection line. The cystic tumor (5×7×8cm) consisted of mucinous substance and papillary tumor arising from the cystic wall. Histologically the tumor was diagnosed as biliary cystadenocarcinoma. It is speculated that the tumor might come from malignant change of cystadenoma because of the coexistence of benign cells, strongly atypical cells and the transitional zone of those inthe cystic wall. The patient is doing well and there has been no sign of recurrence as of 4 yers after the surgery.

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We experienced a case of amputation neuroma at the common bild duct where a T-tube was inserted when cholecysectomy and choledochotomy drainage were carried out 3 years before.
A 51-year-old man was admitted to the hospital because of general fatigue. On admission jaundice and tenderness at the epigastric region were confirmed. Close examination revealed an annular stricture of the bile duct. After a relief of obstructive janudice with PTCD, biopsy under PTCS disclosed no malignancy. An operation was performed with a diagnosis of benign bile duct stricture. Operative procedures included an excision of hte bile duct and Roux-en Y anastomosis. Histopathological examination of the excised specimen indicated a diagnosis of amputation neuroma.
Biliary amputation neiromas are rare and only 45 cases including this case have been reported in Japan. Bile duct stricture due to amputation neuroma presents difficulty in differential diagnosis from cancers only by imagings. Biopsy under PTCS appears useful. All cases reported were operated on, however, non-surgical procedures such as ballon dilatation method and fistulization using a stent should be considered.

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Percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous transhepatic choledochoscopy (PTCS) can be employed as preoperative diagnosis of bile duct cancer, when caution should be exercised to posibble complications including intrahepatic hemangioma, choleperitonitis, peritonitis carcinomatosa, and implantation of cancer cells. This time we experienced a case of mucus producing bile duct carcinoma recurred in the PTCD fistula.
A 51-year-old woman underwent preoperative PTCD with a diagnosis of intrahepatic bile duct cancer. On the 34th day after hepatectomy or 49th day after a PTCD tube was inserted, an induration was felt in subcutaneous tissue at the fistula which was the same site as the PTCD tube was inserted. With a diagnosis of recurrence to the subcutaneous tissue at the PTCD fistula, the tumor was excised. Histopathological findings of the site was the same as those of intrahepatic bile duce carcinoma. However, on the 150th day after the PTCD tube was inserted, another induration was felt at the same site. It was diagnosed as re-recurrence, and an excision of the tumor and associated resection of the 7 and 8th libs and diaphragm were performed. In a review of the literature, recurrence of bile duct cancer to the PTCD fistula is rare, but there may arise some future problem in the management of PTCD.

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We successfully treated a patient with traumatic pancreatic transection by pancreatogastrostomy aiming at the preservation of the pancreas.
A 32-year-old woman was seen at the hospital by an ambulance car for a traffic accident. Fracture of the right medial malleolus of the tibia and traumatic left hemopneumothorax were noted. The patient was admitted to the hospital. On admission no abdominal abnormalities were found out and abdominal ultasonography also revealed no abnormality in the abdominal cavity. Epigastric pain occurred about 6 hours after the trauma and re-ultrasonography visualiged a small tumorous mass in the body of the pancreas. Injury of the pancreas was suspected. Ultrasonography was performed in different times thereafter and an enlargement of the tumor was shown. After emergency endoscopic retrograde cholan-giopancreatography (ERCP), an emergency operation was carried out with a diagnosis of complete pancreatic transection. The pancreas was completely transected at the body. Entertaining her age, we employed a pancreatogastostomy for the purpose of preserving the body and tail of the pancreas. The post-operative course was uneventful without any complications. The pancreatic function has been kept in a good condition.
We often see reports of removing the tail-side pancreas for pancreatic transection in a review of the literature. In terms of preservation of the pancreas, pancreatogastrostomy appears to be recommended, because it permits less anastomoses and minimal complications.

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Generally insulinomas occur solitary and are candidates for operation with a good prognosis by complete resection. But it involved by MEN type 1, such insulinomas have sometimes multiple nodules, making complete excision difficut. It is important to make the correct diagnosis preoperatively. A 38-year-old man developed hypoglycemic shock when a non-functioning pituitary adenoma was removed at the hospital. Preoperative procedures for the diagnosis of localization such as arteriography, computed tomography, magnetic resonance imaging, percutaneous transhepatic portal catheterization (PTPC) indicated that the tumor was solitary insulinoma arising in the tail of the pancreas, which, whiout any other nodule could be detected by the intraoperative sonography. No other nodules besides the main tumor were detected by intraoperative observation and palpation, so distal pancreatectomy was performed.
Histopathological examination of the resected specimen revealed three small nodules besides the main tumor, and all were diagnosed as insulinoma. As MEN type 1 insulinomas are sometimes found with multiple small nodules like our case, intraoperative tumor localization with carefull observation and high sensitive ultrasonography, as well as preoperative one, is regarded important for the more accurate localization of the insulinoma.

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A 52-year-old man lost consciousness and was admitted to the our hospital by an ambulance. He had felt malaise and hungry every time before admission. After admission hypoglycemia attacks occurred many times. We thought that an insulinoma might exist, and tried many examination about it. Computed tomography ultrasonography and angiography revealed no evidence of tumor. On PTPVS evidence of high uptake of insulin was confirmed at distal site of the splenic vein.
A distal pancreatectomy was performed with a diagnosis of insulinoma, and hypoglycemia attacks disappered. Pathological diagnosis was “Islet Cell Hyperplasia”.
In Japan a total of 16 cases of islet cell hyperplasia have been reported so far. In most cases researchers described that they had difficulty in making definitive diagnosis preoperatively and performed operations under a suspicion of probable existence of insulinoma.
We report this case with a review of its diagnosis and therapy.

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A 66-year-old man with leiomyosarcoma of the pancreas is reported. The patient was admitted to the hospital because of an epigastralgia. A hypervascular cystic tumor of the pancreas was suspected by CT, ultrasonography and angiography. Laparotomy was performed and a 7×6cm cystic tumor was found at the pancreas body and tail. The tumor invaded the posterior wall of the stomach. Multiple metastasis of the liver was present. Distal pancreatectomy was carried out, and the opertion was absolute non-curative. Pathological examination revealed leiomyosarcoma of the pancreas and its metastasis of the liver. On 11th operative day, the patients went into a shock condition due to the hemoperitoneum, and hemostasis, gastrostomy and cholecystostomy were emergently performed. The hemorrhage from the inferior pancreatoduodenal artery due to invasion of the remnant tumor was revealed. The patient died of multiple organ failure on the 35th postoperative day. Autopsy revealed metastasis of the bilateral kidneys, peritoneum, left hilus pulmonis and bone marrows (L4, S1, S3).
Leiomyosacoma of the pancreas is very rare. Only 26 cases have been reported in world literature. On differential diagnosis of cystic and hypervascular tumors of the pancreas, leiomyosarcoma which is a cystic and moderately hypervascular tumor should be entertained as a probable diagnosis.

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We report a case of alpha-fetoprotein-positive advanced acinar cell carcinoma of the pancreas which was highly sensitive to the intra-arterial infusion of chemotherapeutics.
A 41-year-old woman was admitted to the hospital because of jaundice. Preoperative computed tomography revealed a mass extending from the head to body of the pancreas. Angiography via gastroduodenal artery and dorsal pancreatic artery showed hypervascularity at the lesion. Serum alphafetoprotin level at the preoperative stage was extremely high, 23, 003 ng/ml. On laparotomy, severe invasion of the malighant tissue was found to the adjoining tissue of the pancreas. The lesion was judged to be unresectable. Therefore, gastrojejunostomy, ligation, of the right gastric artery and biopsy were performed. The histopathological finding indicated acinar cell carcinoma of the pancreas with proliferation of malignant neoplastic cells, which were immunohistochemically positive with antibodies against AFP.
Intra-arterial superselective infusion of chemotherapeutic agents (EPIR 60 mg, MMC 20 mg, 5-FU 500 mg) was done twice after the operation. The size of the tumor was and the serum alpha-fetoprotein level markedly decreased. Quality of life of the patient improved after these treatments.

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We describe a case of multiple cerebral infarction secondary to an extra-adrenal pheochromocytoma preoperatively.
A 48-year-old woman under treatment for diabetes and hypertension which were pointed out at medical checkup had paroxysmal headache in the early hours of the morning. She was admitted to the hospital for the evaluation of secondary hypertension in January, 1994.
On physical examination, an elastic hard mass approximately 5cm in diameter was observed in the right lower abdomen. Laboratory studies showed abnormal elevation of catecholamines, especially noradrenaline, in both serum and urine. CT scan, MRI, ¹²³I-MIBG scintigraphy and angiography revealed the para-aortic solid mass at the level of the fourth lumbar vertebra. Based on these findings, we diagnosed this case as extra-adrenal pheochromocytoma.
But right-sided hemiparesis occurred suddenly on May 13, and head CT scan showed multiple cerebral infarction. After improving in condition, an encapsulated, yellowish, solid tumor was excised through the abdominal approach on April 7. The tumor had no local invasion, lymph node involvement and other abnormal masses.
As of one and half years after the operation, the patient is doing well without recurrence in both clinically and endocrinologically.

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We experienced a case of strangulated ileus due to transomental hernia in a pregnant woman without previous history of undergoing laparotomy.
A 35-year-old woman arrived at the hospital by ambulance because of an upper abdominal pain and vomiting. She was at 19 weeks gestation and her past medical or surgical histories are unremarkable.
Abdominal sonography demonstrated markedly dilated intestine and a simple abdominal X-ray film showed some enlarged intestinal gas shadow on the epigastric region.
The patient was diagnosed as intestinal obstruction of unknown origin and received conservative therapy for 2 days. But her condition grew worse, then an emergency operation was performed.
At surgery, the jejunal loop was found to have herniated into the lesser sac space through a hiatus in the greater omentum, and lightly strangluated. The jejunal loop was reduced and the hiatus was closed. The postoperative course was uneventful. The patient had a normal spontaneous term delivery at our hospital.
Transomental hernia is a rare disease, especially intestinal obstruction during pregnancy. For such a patient the importance of early diagnosis and appropriate operation within an adequate time period should be emphasized.

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We experienced a patient with lymphangioma of the lesser omentum who was first suspected of the disease by imaging diagnoses and ultrasonography-guided needle aspiration cytology, and was definitely diagnosed as it by extirpation of the tumor.
A 39-year-old man staying at the hospital for the treatment of hemorrhagic gastric ulcer was found having a 11×5cm multilocular cystic tumor locating among the left lobe of the liver, lesser curvature of the stomach, and pancreas on abdominal ultrasonography and abdominal CT. Upper gastrointestinal series revealed an extramural pressure on the lesser curvature by the tumor. Angiography visualized expansive and extending images of the left gastric artery and splenic artery. Ultrasonography-guided needle aspiration cytology showed mainly lymphocytes without any malignant cells. Extirpation of the tumor was carried out. The extirpated specimen revealed multilocular cystic tumor which had not solid portion in the cyst and contained yellow, transparent and serosity liquid. Histopathologically it was lymphangioma.
It is thought that preoperative diagnosis of lymphangioma of the lesser omentum is made with difficulty only by imagins. In all reported cases including our case undergoing preoperative needle aspiration cytology, mainly lymphocytes were revealed. When needle aspiration cytology for a cystic tumor of the lesser omentum provides the above mentioned findings, a possibility of the disease may be strongly suggested.

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We experienced a case of lymphatic cyst of the retroperitoneum presenting with acute abdomen.
A 5-year-old girl in an internal treatment for fever and abdominal pain at another hospital was emergently admitted to the hospital, because no symptomatic remission could be attained. Physical examination of the abdomen revealed tenderness, abdominal distention, and peritoneal sign from the periomphalic region to left lower abdomen. Abdominal plane X-ray film showed accumulation of intestinal gas, but did not reveal air-fluid level formation. Abdominal ultrasonography visualized a multilocular tumor showing a cystic echo pattern in the outside of the intestine. An emergency operation was performed with a diagnosis of acute abdomen with a retroperitoneal cyst. A 80×160×50mm tumor with smooth surface arising in the retroperitoneum in the vicinity of hilum of the spleen was found out. The tumor partially involved mesentery, but it could be excised en-block. The inner portion of the tumor was multilocular and filled with yellow mucoid material with partially solid component. Histopathologically it was lymphatic cyst.

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Aneurysms of the iliac artery mostly occur in association with abdominal aortic aneurysms, and isolated occurrence of such aneurysm is uncommon. Recently we experienced three cases of isolated iliac artery aneurysm successfully treated by graft replacement.
Case 1: A 70-year-old man was seen at the hospital because of pulsative tumors in the bilateral thighs. Angiography revealed aneurysms in the bilateral common iliac arteries and internal iliac arteries involved in the bilateral femoral arteries. Case 2: A 70-year-old man was seen at the hospital because of a lower abdominal pain. Abdominal CT and angiography revealed aneurysms in the bilateral common iliac arteries. Case 3: An 81-year-old man was seen at the hospital because of intermittent claudication. Abdominal CT and angiography showed aneurysms in the bilateral internal iliac arteries. In case 1 and 2 graft replacement was performed, and the aneurysms in the bilateral internal iliac arteries in case 1 were kept intact. In case 3 aneurysmectomy was performed after ligation of the distal and proximal arteries of the aneurysm. All patients had uneventful postoperative course. We emphasize that early elective excision and grafting of the defect are desirable if the general condition of the patient permits, because isolated iliac aneurysms are often asymptomatic and fatal once ruptured.

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We have experienced five operated cases of pilonidal sinus in a 8-year period from 1987 to 1995. All patients are slightly corpulent, younger males with hairy constitution. Four out of the five cases had undergone inappropriate treatments under a wrong diagnosis of anal fistula, abscess in the sacrococcygeal area, or suspected actinomycosis.
Operative procedures included rotetion flap method attached to fascia of major gluteus muscle for four cases, and marsupialization for one case.
Basic ideas of operation for pilonidal sinus are complete excision of the original foci, prevention of dead cavity, avoidance of tense skin suturing. The rotation flap method is rational, because reduction in the tension of skin suture is achieved by suturing fascia of the gluteus maximus muscle previously. On the other hand, the marsupialization is rational in the meaning of prevention of dead cavity formation, because the marginal skin and bottom of the wound is sewed up previously that contributes to a reduction of wound area.
Both the rotation flap method attached to fasica of the gluteus maximus muscle and the marsupialization are effective operative methods for pilonidal sinus.

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Recently clinical cases of double cancer have been increasingly reported, particularly in a combination of cancers of the gastrointestinal organ and other organ. This time, we experienced a case of rare double cancer in a combination of cancer of the bile duct with multiple gastric cancer which were both in an early stage.
A 72-year-old man presenting with obstructive jaunice was found having a full circumferantial torous lesion in the choledochus terminal (Bi). The cytologic examination of bile showed it to be Class 5. In addition, a gastroscopic examination revealed two lesion of type IIa and one lesion of type IIa+IIc. With a diagnosis of double cancer in combination of the bile duct cancer and multiple early gastric cancer, a pancreatoduodenectomy was carried out. The removed specimens revealed that, all of the bile duct cancer and three gastric cancers were of early cancees which remained in the mucous membrane. Since such cases of double cancers may increase more and more in the future, it was considered necessary to perform the preoperative evaluation keeping a possible double cancer in mind.

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This paper described a pacient whose ileum, cecum, colon, rectum, and anus wre doubling.
A 69-year-old man was admitted to the hospital because of anal bleeding. Colonofiberscopy revealed a rectal cancer 3.0×3.0 cm in size. Upon further examination, a second anus was found. During the surgery, a duplicated ileum, appendix, cecum, colon, rectum, and Meckel's diverticulum were seen. A post operative examination revealed a duplicated urinary bladder and urethra. Epispodia was also observed.
The rectal cancer was moderately differentiated adenocarcinoma (mp, INFβ, lyo, vo, Ho, and M(-)). A polyp in the main colon and two polyps in the accesory colon were observed, but none of these were malignant.
Angiography of the superior and inferior mesenteric vessels was performed. The splitting of the vessel between the main colon and the accessory colon did not occer at the trunk vessel, but rather at the peripheral vessels.
In Japan, there have been only three reported cases of total duplication of the large bowel. However, all of these involved children under two years of age. Our case appears the first adult case of total duplication of the large bowel in Japan.

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We have experienced a case of synchronous multiple cancers of the stomach, colon, kidney and rectum, which were successfully resected. A 65-year-old man was admitted to the hospital because of vomitting after drinking. Barium enema revealed a cancer of the rectum and polyps in the colon. Two papillary polyps in the ascending and descendingcolons, and a polyp in the transverse colon were polypected beforeoperation. Endoscopy disclosed a gastric cancer which was in the middle third. An abdominal ultrasonography and computed tomographyrevealed a right renal tumor. Operation was proceeded with abdominal median incision to resect the right kidney and distal stomach, followed by a resection of the rectum above the peritoneal reflection. Histologicsally, the gastric tumor was moderately differentiated adenocarcinoma, colonic polyps were well differentiated adenocarcinoma; the rectal tumor was well differentiated adenocarcinoma; and right renal tumor was granular cell type of renal carcinoma. There was a possibility that the rectal cancer might be a metastatic lesion, however, we considered it was a solitary carcinoma because of no communications intra and etramurally and its location. So all lesions were not metastatic each other and the definitive diagnosis of synchronous quadruple cancer was made. The etiology of these multiple cancers is still obscure.

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