Nosocomial propagation of multidrug-resistant Staphylococcus aureus was investigated in patients who underwent gastroenterologic operations. A cluster analysis was attempted to clarify the association of factors among 32 patients, 204 bacterial isolates, and drugs administered. The results showed that first-and second-generation cephalosporins, penicillins, and aminoglycosides were associated with increased resistance. Drugs of each group were given for an average of 5-9 days until the detection of the bacteria.
The results suggest that the use of first-and second-generation cephalosporins and penicillins during gastroenterologic operations was related with increased resistance and thus encourage to minimize their prophylactic administration.

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For ten patients with postoperative infection caused by methicillin-resistant staphylococcus aureus (MRSA), 500 mg of vancomycin (VCM) was administered intravenously every 12 hours by 60-minute infusion. Serum concentrations of VCM were measured time-dependently. In eight patients with normal renal function, whose creatinine clearance (Ccr) levels were above 50ml/min, the mean values of peak concentrations were ranged from 22 to 26μg/ml with no abnormal accumulation. The mean values of trough concentrations (<10μg/ml) on days 14 and 21 increased significantly (p<0.01) than those on day 1. In two patients with impaired renal function, whose Ccr levels were below 40ml/min, both the peak and trough concentrations increased and accumulated. When the trough concentration increased to 10μg/ml or more, VCM was withdrawn. In all patients, no side effects such as nephrotoxicity occurred. Minimum inhibitory concentrations of VCM were ranged from 0.78 to 1.56μg/ml. Every trough concentration was within a therapeutic range.
Our method of VCM administration for postoperative MRSA infection is safe and effective for patients with normal renal function. The monitoring of serum concentrations that may decide the dosage of VCM is neccesary for patients with impaired renal function.

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Each six patients undergoing cardiovascular surgery at the department from November 1993 to June 1994 were assigned to a group received dobutamine alone or another group received dobutamine and amrinone combinedly in an early postoperative period for the purpose of circulatory support. In this study the both groups were compared for hemodynamic response.
There was no significant difference in hemodynamic responses between two groups. Amrinone, known as phosphodiesterase III inhibitor, augment the cardiac function without inclement of O₂ consumption of the myocardium.
The combined use of amrinone and dobutamine which have different mechanisms of action each other can be one of choices for treatment immediately after cardiovascular surgery that exerts a synergistic effect to increase the cardiac function and to decrease the dose of catecholamine.

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Among 500 cases of surgically resected lung cancer in a recent 22-year period from January 1973 to January 1994, there were 29 cases (6%) of multiple primary cancer including 25 cases of double cancer and 2 cases of triple cancer and each 1 case of quartuple and quintuple cancer. Four cases had synchronous and 25 cases had metachronous multiple cancer. The patient's age at the time of the lung resection ranged from 47 to 80 years old (average: 65.8).
The most commn site of the other primary cancers was the head and neck (9 cases), followed by the stomach (6 cases), thyroid (4), colon (3), mamma (2) and liver (2). Nineteen of 29 patients had already died. Ten of them died of lung cancer and the remaining nine of other cancer or MOF. There are five long survivors over 5 years. Therefore, basic diagnostic and therapeutic policies for newly appearing lesions in the lung or other organs should be formalised.
It is considered that such surgical cases might increase henceforth.

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Between April 1980 and December 1994, 20 patients with gastric malignant lymphoma were treated in Tsukuba university hospital. All of the Ann Arbor IE patients (9 cases) received gastric resection as the initial treatment, and have been free of relapse. Four patients in Ann Arbor stage IIE were also resected initially; two patients died of lymphoma, and another two patients received Cis-VACD, THP-CVP chemotherapy for the residual lymphoma, which resulted in complete remission. Ann Arbor stage III and IV patients were initially treated by combination chemotherapy. Three patients with complete response and two patients with partial response subsequently received gastric resection. The former three patients have been in complete remission. However, the latter two patients had a recurrence and died of lymphoma. We propose that patients with Ann Arbor stage IE gastric malignant lymphoma should be treated by operation alone, and Ann arbor stage IIE or more patients by chemotherapy as the initial treatment.

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Forty-six patients with early gastric cancer underwent “transverse gastrectomy” between 1985 and 1993. The indication for this procedure was defined as follows: 1) tumors located in middle or lower part of the stomach, 2) size of tumor under 2 cm and 3) intramucosal cancer. We resected the stomach 2_??_3 cm apart from the tumor segmentally, and performed end to end anastomosis of the remnant stomach. Pyloroplasty was not performed to preserve its founction. From 1991, we tried to preserve the vagal nerve (hepatic and celiac branch). Lymphadenectomy was only performed for perigastric lymph nodes of the lesser and grater cavertuer, and for the samplings of the left gastric and common hepatic lymph nodes. These cases were compered, in terms of post-operative QOL and survival, with the early gastric cancer patients who underwent, during the same period, standard operation procedures of distal gastrectomy radical lymph adenectomy (D2 dissection) and Billroth-I reconstruction. This procedure proves to score higher in the area of QOL than standard operations since it keeps postoperative body weight especially. The survival rate of the patients who underwent this procedure is as well as that in standard operations. This results show that the procedure could be a useful method of treatment for early gastric cancer patients to improve their post-operative QOL as well as being a radical operation.

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Recently colorectal carcinomas have been increasingly reported, multiple carcinomas of the colon and rectum are not rare, and the hereditary factor seems to be involved in the etiology of such multiple occurrence. Thirty-seven cases of multiple colorectal cancers experienced at the department in a recent 14-year period were clinicopathologically studied. Of these 37 patients, seven patients (15 lesions) had a family history of colorectal cancer within the first degree relatives (positive group) and the remaining 30 patients (65 lesions) had no family history (negative group). Patients in the positive group were younger than those in the negative group. Carcinomas of the positive group were located in more prpximal colon than those of the negative group. Histological examination revealed that most of the first lesions in the positive group were moderately differentiated adenocarcinomas while the second lesions were commonly well differentiated adenocarcinomas. Presence of associated adenomatous polyps was more common in the negative group than in the single carcinomas. The cumulative 5-year survival rate was 62.5% in the positive group and 42.0% in the negative group. All patients in the positive group satisfied the diagnosis criteria of HNPCC (hereditary nonpolyposis colorectal cancer), but the negative group may include initiator of HNPCC.

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From April 1983 to December 1994, 82 infants and children with Hirschsprung's disease were treated at Saitama Children's Medical Center. Of 62 patients with short segment aganglionosis (rectum 33, sigmoid 29), 32 patiens (51.6%) were treated within the first month of life. On the other hand 20 patients with long segment aganglionosis were all neonates, of these five were entire colonic and four were more extensive type. Ten patients were associated with congenital anomalies. Four of them had Down's syndrome, five cardiac anomalies, two congenital deafness, two chromosome disorders other than 21 trisomy, and one imperfrate anus and ectodermal dysplasia, respectively. Three infants with extremely extensive aganglionosis and one with entire colonic aganglionosis associated with 22 q-trisomy were dead. We have been performing Duhamel-Ikeda procedure (Z-shaped anastomosis) using crushing clamps instead of GIA staples. Our new curved clamps, designed to be more effective and safe in crushing, are shown comparing with Ikeda's clamps. Also the type of skin incision in Z-shaped anastomosis are considered in its cosmetic aspects.

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We experienced a case of thyroid oxyphilic cell follicular carcinoma causing tracheal stenosis.
A 62-year-old man was seen at the hospital because of wheezing expirations. A chest X-ray film revealed a tumorous shadow in the left upper mediastinum and displacement and stenosis of the trachea. After admission thyroglobulin (Tg) level in blood increased to 88.9ng/ml. CT and magnetic resonance imaging visualized a tumor shadow extending from the neck to anterior upper mediastinum, displacement to the right of the tracha and esophagus, and a nodular shadow in the lung field. Angiography showed extrinsic pressure, distenstion, and displacement of the brachiocephalic and common carotid arteries; and displacement and narrowing of the internal carotid artery. From needle biopsy findings the patient was diagnosed as the disease and was operated on. At surgery, the tumor extended from the left lobe of the thyroid into the mediastinum, oppressing the vascular vein, and there was infiltration into the trachea and esophagus. Extiraption of the tumor with lymph node dissection in the mediastinum was carried out. The extirpated tumor was 11×8×4cm in size. The section was bright yellowish brown. Histopathologically trabeculer and solid proliferation of large tumor cells with oxyphilic plasma was seen. Postoperative Tg level was normalized. There have been only 37 cases of the disease in Japan so far. This rare case is described here.

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A 62-year-old man was admitted to the hospital because of a lump in the neck. After admission, cervical CT, ultrasonography, scintiscan and blood examination revealed an adenoma of the right lobe of the thyroid with slight hyperthyroidism. At operation, we found two tumors and no connection was found between the tumors and the thyroid gland. Only tumor extirpation was performed. The gross pathological specimens were 50×40 mm and 25×27 mm in size. Histological findings revealed the adenomatous goiters of the two accessory thyroid glands. After the operation thyiroid function tests were within normal limits.
So-called ectopic thyroid glands are classified into two groups whether the thyroid gland is in the right place or not. This case is very rare and is worth for reporting. We think that ectopic thyroid gland with normal thyroid gland should be called accessory thyroid gland.

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A 52year-old woman was admitted to the hospital because of an anterior neck swelling and palpitation, Ca and Ca-ion were 11.7 mg/dl and 2.84 mEq/l respectively. Tyroglobulin was 230 ng/ml. Lateral neck radiography revealed micro calcification in the thyroid gland. A 3.2 cm×2.2 cm mass in the left lobe and cystic lesion in the right lobe were recognized by ultrasonograms. Parathyroid tumors existed in the dorsal side of the left lower lobe on computed tomograms and dorsal side of the right lobe in magnetic resonance images. We suspected a thyroid carcinoma with adenomatous goiter associated with hyperparathyroidism. At operation total thyroidectomy with modified radical neck dissection for the thyroid carcinoma and total parathyroidectomy were performed. Histological diagnosis was papillary carcinoma with paratracheal lymph node metastasis and encapsulated follicular carcinoma on the resected tissue of the left lobe accompanied with adenomatous goiter. Then three parathyroid glands showed hyperplasia and another one did not. The postoperative couse was uneventful and has been no local recurrence nor distant metastasis, as of 5 years after the operation. No case of hyperparathyroidism with multiple thyroid lesions, papillary and follicular carcinomas, and adenomatous goiter has been seen in the literature as far as we could review.

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This paper describes a case of squamous cell carcinoma of the thyroid gland. A 64-year-old female was seen at the hospital because of a rapidly enlarging mass at the anterior region of the neck. There was a previous history of being diagnosed as thyroid cancer which was judged inoperable about 12 year before. Pathological diangosis of squamous cell carcinoma was obtained by incisional biopsy. After denial of metastasis from the other organs, total thyroidectomy was performed. It is believed that primary squamous cell carcinoma of the thyroid gland can occur by a direct transition from adenocarcinoma or change of follicular epithelium cells. The transition from adenocarcinoma of the thyroid gland is most believable in this case.

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A case of left breast cancer associated with Recklinghausen's disease is reported, together with a review of the Japanese literature. A 70-year-old woman was seen at the hospital because of a left breast mass 3.5×3.0 cm in size. There was a history of having numerous tumors and cafe au lait spots in the whole body skin since her youth. And her father and one of two daughters have been diagnosed as Recklinghausen's disease. Fine needle aspiration cytology offered a diagnosis of breast cancer. Left modified radical mastectomy (Brt+Ax) was performed. Histologically, the breast tumor was invasive ductal carcinoma (papillotubular carcinoma) with lymph node metastasis. It was breast cancer of t2 n1 α M0 in stage II.
Recklinghausen's disease is often associated with non-epitherial and/or neurogenic malignant tumor, but uncommonly with epitherial malignant tumor. As far as we could examine, twenty-six cases of breast cancer with Recklinghausen's disease have been reported in the Japanese literature. Eighteen of twenty-two cases described their preoprative stagings were in more than Stage II. Therefore, when we encounter Recklinghausen's disease, systemic and careful examination are essential, especially care must be taken not to misdiagnose a breast cancer as skin tumor in these cases.

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Accessory breast cancer is rare. Two cases of accessory breast cancer are described here.
[Case 1] A 58-year-old woman was referred to the hospital after biopsy of a right axillary tumor at elsewhere. The excisional biopsy of the tumor revealed papillo-tubular carcinoma with mammary gland, without connection to the proper mammary gland. Modified radical mastectomy was performed. No lymph node metastasis was recognized. She is doing well without any evidence of recurrence, as of 6 years after the operation.
[Case 2] A 64-year-old woman was admitted to our hospital because of a right axillary tumor. The excisional biopsy of the tumor revealed scirrhous carcinoma with mammary gland, without connection to the proper mammary gland. A wide local resection with axillary and subclavian lymph node dissection was performed. Six axillary lymph nodes were involved. She is doing well without any evidence of recurrence, as of 7 months after the operation.
Sixty-five reported cases of accessory breast cancer in the Japanese literature, including these cases, are reviewed and discussed.

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An extremely rare case of primary hemangiopericytoma of the chest wall is reported. A 46-year-old female was admitted to the hospital because of a right back pain. An extrapleural tumor of 2.0×2.0cm in size was detected by the chest computerized tomography (CT) scanning. The tumor was excised with a part of the 4th and 5th ribs. The pathohistological diagnosis was low-grade malignant hemangiopericytoma. Tumor cells were immunostained positively only to vimentin. The postoperative course was unevenful. The patient is now doing well as of 7 months after the operation. Hemangiopericytomy is a vascular tumor in which pericytic cells of vessel walls proliferate. It often recurs or metastasizes in spite of its benign histopathological feature. So careful follow up is important. It commonly occurs in the soft tisues of the lower extremities, especially in the thigh, perive cavity, and retroperitoneum, and rarely in the chest wall. This paper also describes a review of hemangiopericytoma arising of the chest wall seen in the Japanese literature.

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We experimented a resected case of thymolipoma in an asymptomatic 24-year-old man. The patient has been pointed out a widning of the mediastinum by routine chest roentgenography when he was 11 and 20 years old, and had been diagnosed as cardiac hypertrophy. In 1993, a chest roentgenogram revealed a mass-like shadow at the mediastium, and he was admitted to the hospital with a suspected mediastinal tumor. The mass of the right anteroinferior mediastinum which was clearly shown by chest CT scan and MRI was diagnosed as mediastinal lipoma, thymoma, or thymolipoma. On July, 1993, median sternotomy was performed. The tumor, 20×7.5×3.5cm in diameter and 200g in weight, was removed together with both lobes of the thymus and mediastinal adipose tisse (extended thymectomy). Histological examination confirmed that it was thymolipoma consisting of lipomatous and thymus tissue. The postoperative course was very satisfactory and he was diwcharged as cured on 14th postoperative day. There has been no sign of reccurrence, as of 22 months after the surgery.

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A 70-year-old woman was admitted to the hospital because of dyspnea and stridor. Preoperative bronchofiberscopy revealed a wide-based polypoid lesion in the upper trachea at 23cm from his frontuppe teeth. Deformity of tracheal cartilages was observed in a chest computed tomography. Under a diagnosis of adnoidcystic carcinoma, operation was performed with a collar incision and median ster-notomy. Two and a half trancheal cartilages including the tumor were removed annularlly with end to end anastomosis. The patient underwent an uneventful recovery. Postoperative pathologic diagnosis was pleomorphic adenoma of the trachea. Compared to primary malignancies of the trachea, the benign tumors are unusual, especially pleomorphic adenoma. Care should be taken for adequet therapy of tracheal tumors, because these tumors are often misdiagnosed as chronic obstructive pulmonary diseases.

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A 49-year-old female was admitted to the hospital because of an abnormal shadow on a chest X-ray film. Chest X-ray examination revealed an about 3×2 cm an sharply circumscrived tumor overlapping cardiac shadow and chest CT showed a tumor in the left lower posterior mediastinum. Neurogenic tumor or congenital cyst was suspected. We performed thoracoscopic surgery when the polypiform tumor wlas found arising from the parietal pleura of the discending aorta near the diaphragm. This tumor was diagnosed as extralobar pulmonary sequestration because of abnormal artery fed from the aorta and postoperative microscopic findings. The postoperative course was uneventful, and she was discharged 5 days after the operation without wound pain. Thoracoscopic surgery is very useful for diagnosis and treatment of intrathoracic tumors, because it provides minimal surgical intervention and pain.

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We experienced two cases of pulmonary thromboembolism after rectal operation. Pulmonary thromboembolism occurred on 14th postoperative day in case 1, on sixth postoperative day in case 2. Pulmonary perfusion scan was useful for diagnosis and thrombolytic therapy was successful. Lithotomy position, obesity and dehydration were important factors for pulmonary thromboembolism, and lymphadenectomy around the internal iliac vessels was another important factor in case 1. To avoid, diagnose and treat pulmonary thromboembolism after rectal operation, we should attempt to shorten operative time at lithotomy position; take care of clinical symptoms; and carry out pulmonary perfusion scan and subsequent thrombolytic therapy in an early phase.

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We report a case of rapidly growing pulmonary carcinosarcoma admixed with osteosarcomatous component. A 66-year-old male was admitted to our hospital because of hemosputum. A chest X-ray film and CT showed a tumor mesured 9×8cm in the middle field of the left lung. Squamous cell carcinoma was suspected by cytological examination of sputum. Left upper lobectomy and partial resection of the left lower lobe were performed. Histologically, the tumor was composed of carcinomatous (squamous cell carcinoma and adenocarcinoma) and sarcomatous (fibrosarcoma and osteosarcoma) elements, and there was an apparent transition of the squamous cell carcinoma into the fibrosarcoma, so the patient was diagnosed as so-called carcinosarcoma of the lung. Postoperative chemotherapy was performed, but the patient died seven months after the operation.
In a review of 25 Japanse cases of pulmonary carcinosarcoma described in the literature since 1974, only 4 cases including our case had both the transposition between two elements and sarcomatous component with obvious differentiation. We thought that these cases occupied an intermediate position, between the so-called carcinosarcoma and true carcinosarcoma. Because some cases could not be classified according to the conventional pathological classification, we think that pulmonary carcinosarcoma might be classified by some other different method.

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We experienced a case of lung cancer with metastasis to the stomach and small intestine causing massive anal bleeding which necessitated an emergency operation.
A 72-year-old man was found to have a malignant tumor of the stomach at another hospital and was admitted to the hospital for operation. After admission a lung cancer (large cell carcinoma) at the left B¹⁰ was detected on examination. Anal bleeding started on and after 2nd week of admission which did not respond to the conservative treatment. So an emergency operation was carried out. During surgery a tumor in the pyloric antrum of the stomach and 12 tumors existing in a portion of the intestine starting at 60 cm from the Treitz ligament to 120 cm from the ileum end were found. All these tumors bled. Marked swellings of perigastric lymph nodes and mesenteric lymph nodes were noted. Gastrectomy with excision of the small intestine by about 260 cm was carried out. Histopathologically the patient was diagnosed as having metastatic cancers of the stomach and small intestine from the lung cancer. It has been reported that the metastasizing rates of lung cancer to the stomahc and small intestine are about 4% each of all necropsy cases. There are fewer patients who are diagnosed as having such as metastatic lesion of lung cancer and necessitate treatment while they are alive.

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A case of giant esophageal leiomyoma with 15cm in long diameter developed into the thracoabdominal space is reported with some considerations of the literature. A 34-year-old male with epigastralgia had been pointed out a protrusion in the lower esophagus 11 years before. Upper gastrointestinal series revealed a stenosis from the intrathoracic middle esophagus to cardial lesion. Endoscopic examination revealed a submucosal tumor in the esophagocardiac lesion. CT and MRI showed a giant submucosal tumor circumfused the esophageal lumen and developed into the thoraco-abdominal space. Lower esophagectomy and upper gastrectomy reconstructed with jejunal transfer were performed under the left anterolateral thoracotomy and laparotomy. The resected tumor was 15×10.5×10cm in size, and benign leimyoma histopathologically. Postoperative course was uneventful. The patient was discharged from the hospital on the 25th postoperative day.

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This paper describes a case of laparoscopically resected leiomyoblastoma, with a review of the literature. A 39-year-old man was found having a submucosal tumor (SMT) in the posterior wall of the stomach. It was diagnosed as leiomyoma preoperatively. Laparoscopic local excision of the stomach including the tumor was carried out. Pathological diagnosis of the resected apecimen was leiomyoblastoma, but mitotic figures were lacked. We evaluated the tumor asbenign and did no additional operation. Recent examination one year and four months after the laparoscopic operation showed no gastric deformity nor sign of recurrence. The patient's quality of life is the same as before the operation.
Leiomyoblastoma is a rare tumor among various gastric SMTs. If it is small in size, the differential diagnosis from leiomyoma of leiomyosarucoma is difficult to make. Therapy of leiomyoblastoma usually comprises prophylactic lymphadenectomy and gastrectomy, considering the malignancy. Local resection is rarely performed. Howerver, for small gastric SMTs of with preoperative diagnosis whether benign or malignant is difficult, the treatment of choise may be a minimal invasive laparoscopic resection first, and if pathological diagnosis is malignant, additional radical operation is followed. Such strategy will spare unnecessary gastorectomies.

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A 62-year-old man was seen at the hospital because of a left abdominal tumor and pain. CT and US demonstrated a cystic tumor of 30 cm in diameter with heterogeneous internal structure and multiple cystic tumors of the liver. Aspiration cytology of the tumor showed round shape cells with clear vesicles. Operation was performed for abdominal fullness of the tumor. The tumor was growing from the stomach, and the multiple liver metastases were revealed. Resection of the tumor with partial gastrectomy was done. Round shape cells were shown in the specimen microscopically. And the tumor appeared to stain by anti-ploriferating cell nuclear antigen. Post-operative couse was stable. Chemoterapy was performed, but the liver metastases had progressed. The patient died 13 months after the operation. Postmotem microscopic findings of the liver metastases were the same as the operative specimen.
In a review of the literature in Japan, leiomyoblastoma of the stomach with liver metastases has a very poor prognosis, with a mean survival of about one year. We should entertain the disease as a probable diagnosis for intraabdominal huge tumors with liver metastases.

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We encountered a patient left paraduodenal hernia. A 45-year-old male had been suffering from an occasionally developed upper abdominal pain for 12 years. He was seen at the visited our hospital because of an upper abdominal pain and vomiting 7 years before, when close examination showed no findings and the symptoms improved. Subsequently, intermittent abdominal pain developed but improved in a short time. This time, he was admitted to the hospital because of a marked upper abdominal pain. Plain X-ray examination of the abdomen revealed niveau of the small intestine in the left upper abdomen. CT scanning also showed a cystic accumulation image of the small intestine at the same site. A diagnosis of strangulation ileus was made, and laparotomy was performed. A left paraduodenal hernia was observed. The hernial content was reduced, and the hernial orifice was closed.
There are 81 reported patients with paraduodenal hernias including ours in Japan. The disease occurs in a low incidence and often demands an emergency operation. However, since characteristic findings are present, the preoperative diagnosis of paraduodenal hernias can be made by taking into consideration the possibility of this disease.

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Malignant lymphoma of the small intestine are relatively rare which lack in specific symptoms and are often found out in an advanced stage. This paper reports a rare case of primary malignant lymphoma of the small intestine which caused an incaceratedinguinal hernia.
A 39-year-old man was admitted to the hospital bacause of a right lower abdominal tumor. He noticed the tumor about 7 months before and developed poor appetite and nausea 2 months before. On admission his abdomen was flat and soft, and an egg-sized tumor was palpated at the right inguineal region. No anemia nor jaundice was noted. There were no swollen superficial lymph nodes. CT-scan and selective contrast radiography of the small intestine indicated the incerated inguinal hernia of the small intestine. In laparotomy the ileum 5 cm to oral side from Bauhin valve was incarcerated in the right imternal inguinal ring. The patient underwent ileocecal resection and repair of the right inguinal hernia. The resected specimen showed that the incarcerated hernia was caused by the small intestinal tumor. Histological diagnosis was diffuse and large cell type of malignant lymphoma. Postoperatively CHOP regimen added and the patient is strictly followed up on an ambulant basis.

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Two extremely rare cases of blind pouch perforation of the colon are reported and discussed with a review of the Japanese literature.
Case 1: A 60-year-old man was admitted to the hospital because of a cancer of the sigmoid colon. There were previous histories of undergoing an appendectomy and subsequent laparotomy for intestinal volvulus after the operation at the age of 19, and a gastrectomy for a gastric cancer at the age of 56. After admission a perforation was observed at the blind pouch of the ascending colon following side-to-side jejuno-transverse colostomy. Ascending coiectomy including the perforation of the ascending colon was carried out, but he died on 25th postoperative day.
Case 2: A 64-year-old woman was admitted to the hospital because of perforative peritonitis. There were previous histories of undergoing a right colectomy for cecum mobile at the age of 28 and a hysterectomy for hysteromyoma at the age of 50. After admission a stercoraceous perforation of blind pouch of the transverse colon following end-to-side jejuno-sigmoid colostomy was noted, and partial transverse colectomy and end-to-end jejuno-transverse colostomy were performed. Postoperative course was uneventful. She was discharged from the hospital on 25th postoperative day.

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A 52-year-old woman was admitted to the hospital because of severe abdominal distention. But she had no abdominal pain and nausea. Abdominal roentgenogram showed marked dilatation of the colon. Barium enema and colonofiberscopy revealed no other organic obstruction. The patient was diagnosed as Ogilvie's syndrome. Decompression of the colon distention using colonofiberscope was not successful. An ileus tube was colonoscopically placed in the sigmoid colon and continuous decompression was very successful. Ogilvie's syndrome is usually resolved with decompression treatment using a colonoscope or suction tube. Intitial attempt of conservative treatment is very important.

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We reported a case of idiopathic rectal bleeding which was probably caused by the Dieulafoy's type ulcer of the rectum. A 59-year-old male was admitted to the hospital because of massive anal bleeding with shock condition. Emergency colonoscopy and abdominal angiography were performed for the detection of bleeding source, but it could not be determined. Emergency open laparotomy was performed for the detection of bleeding source, because the massive bleeding persisted. It was disclosed that the bleeding source was the rectal wall about 2 cm oral side from the dentate line. Erosion or ulcer did not be recognized around the bleeding point. The bleeding stopped with ligating the lesion via anal approach. We diagnosed the lesion with Dieulafoy's type ulcer of the rectum based on the clinical course and intraoperative observation.
Recently, Dieulfoy's type ulcer of the colon which can cause massive anal bleeding has become increasingly recognized, and several cases of duodenal, jejunal, and colonic Dieulafoy's type ulcer have been identified. We must keep it in our mind and rapid treatments are required in front of the patient with massive anal bleeding.

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We experienced two cases of multiple colorectal cancer and multiple dysplasia. Case 1: A 60-year-old male who had been suffering from ulcerative colitis for 8 years underwent total colectomy and ileostomy with a diagnosis of rectal cancer. He had multiple dysplasia and two cancers including well and poorly differentiated adenocarcinoma in the lower and upper portions of the rectum, respectively.
Case 2: A 56-year-old female had been suffering from serious ulcerative colitis for 14 years. Surveillance colonoscopy found her multiple dysplasia-associated lesions or mass and she underwent total colectomy and ileostomy. Patients with ulcerative colitis belong to the high risk group developing colorectal cancer. It is important to find dysplasia at surveillance. The existance of dysplasia-associated lesions or masses suggest the presence of cancer or potential to cancer, and are possible candidates for operation. We think it is desirable to resect colorectal mucosa as much as possible which may have a potential to malignacy in the presence of cancer as well as dysplasia.

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This paper presents two cases of rectal cancer accompanied with radiation colitis. Case 1 was a 53-year-old woman, who had a history of underdoing radiation therapy for a uterine cervical cancer 11 years before. She was seen at the hospital because of constipation and pointed out a IIa like lesion on the rectum by colonoscopy. Abdominoperineal resection was performed. The surgical specimen showed the IIa like lesion on the rectum. Pathological findings revealed well differentiated adenocarcinoma. Immunohistochemical staining of p53 showed positive cells in atrophic glands. Case 2 was a 62-year-old woman complaining of diarrhea. There was a previous history of receiving radiation therapy for a uterine cancer 20 years before. Colonoscopy showed a Borrmann type 2 cancer on the rectum. Abdominoperineal resection was performeed. Histological findings revealed moderately differentiated adenocarcinoma invading to the propria muscle. The features of radiation colitis were observed around the cancer int he two cases which provided a clue to diagnose the lesions with radiation induced cancer.

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A case of intussusception caused by a carcinoma of the sigmoid colon with prolapsing through the anus is reported.
A 70-year-old man was admitted to the our hospital because of an abdominal pain and prolapsing intestine through the anus. Colonoscopic findings detected a colonic tumor at the apex of the prolapsing intestine. Hartmann's operation with excision of the large intestine including the tumor was carried out after manual reduction of the intussusception. Resected specimen was sigmoid colon cancer of Borrmann type 2 in the size of 4.0×3.2 cm histologically. Postoperative course was uneventful.
Thirteen cases of intussusception caused by a carcinoma of the sigmoid colon with a prolapse through the anus which have been reported in the Japanese literature which are also reviewed.

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A 61-year-old woman was admitted to the hospital because of a cystic mass in the lateral segment of the liver. Examinations revealed a multi-locular cystic lesion with a protruded portion inside. She was diagnosed as having a cystic neoplasm of the liver. Cytology of the cystic fluid revealed no malignant cells. The level of CA19-9 in the cystic fluid was high (32, 263 U/ml) and CEA was normal. Left hepatic lobectomy was performed. Histologically, simple liver cyst was confirmed. At the time of operation, CA19-9 level in the cystic fluid was over 120, 000 U/ml and CEA was 215 ng/ml. Immunological tissue staining proved that CA19-9 and CEA were positive in the epithelial cells of the cyst. It is suggested that tumor markers in the cystic fluid is not always diagnostic for tumorous or malignant lesion.

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A 68-year-old woman was admitted to the hospital because of an upper abdominal pain. Ultrasonography and CT-scan revealed a tumor in the gallbladder, obstruction of the common bile duct and remarkable swelling of lymph nodes. Hematological examinations showed obstructive liver dysfunction and a high α-fetoprotein (AFP) level of 503ng/ml. The AFP subfraction analyzed by crossed immunoaffinoelectrophoresis with lentil lectin and concanavalin A was not hepatocellular type. Percutaneous transhepatic cholangiodrainage was attempted, but soon after the inserted tube was dislodged, requiring an emergency surgery. A curative operation was impossible, because metastatic lymph nodes has surrounded the large vessels very tightly. We performed choledochocystectomy and biliojejunal anastomosis for mass reduction and biliary drainage. AFP temporarily decreased after the operation, but it increased gradually till she died of carcinomatosa peritonitis 5 months postoperatively. Histologically the tumor was poorly differentiated adenocarcinoma and a small number of tumor cells at the bile duct were positive for AFP-immunostaining.
An analysis of the doubling time of AFP in cancers of the biliary systems seen in the literature indicates the need for the intensive treatment including radical surgery.

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We present a case of Mirizzi syndrome causing a stricture located in only the right hepatic duct without any symptoms.
A 70-year-old man who had an asymptomatic cholelithiasis was admitted to the hospital, because dilatation of the right intrahepatic duct was detected by abdominal ultrasonography that was performed to examine liver dysfunction in detail. Computed tomography showed a thickened gallbladder with an impacted stone in its neck. The stricture of the right hepatic duct was then revealed by MRI and PTC, suggesting Mirizzi syndrome as a diagnosis. Cholecystectomy and choledochostomy with a T-tube were carried out. Inflammation and direct pressure of the impacted stone in the neck of the gallbladder caused the stricutre of the right hepatic duct. The findings indicated it in type I Mirizzi syndrome of McSherry's classification.
Mirizzi syndrome causing a stricture localized in the right hepatic duct is uncommon, but the possibility must be entertained that malignant diseases of the biliary system may include asymptomatic Mirizzi syndrome like this case.

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We experienced a case of Paget's disease of the breast in a renal transplant recipient. The patient was a 47-year-old female who had undergone renal transplantation 6 years earlier with a favorable clinical cource by administration of immunosuppresssant. She recieved biopsy of the skin of the right nipple, because she had noticed intractable scab of the right nipple. She was diagnosed as Paget's disease of the breast. In preoperative examination some masses were pointed out in the mammary gland. The patient was diagnosed as Paget's disease with mass lesion and was performed a modified radical mastectomy.
Recently, renal transplantations to the patients with chronic renal failure have been increasing by performed because of a progress of the immunosuppressants. So the increased carcinogenicity in the recipients should be taken into account, and we should further discuss the direction for some proper use of antineoplastic agents and immunosuppressants.

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Almost all cases of metastatic malignant tumor in the cervical lymph nodes have been considered out of surgical treatment. We experienced that cervical dissection prolonged the life of the patient for about one year and a half, who had metastases in the cervical lymph nodes, of which origin was the cancer of the uterine cervix.
A 71-year-old woman was admitted to the hospital because of left cervical tumor. Aspiration biopsy revealed it to be metastatic squamous cell carcinoma. We diagnosed it as the metastases from a cancer of the uterine cervix, because she had a past history of the cancer and because we could not find any lesions in other organs. Modified radical neck dissection of the left side was performed. She was able to live a daily life for about one year and a half. She had black thyroid due to intake of a large dose of minocycline for radiation cystitis.
It should be known that some cases of the distant metastases in the cervical lymph nodes may be possible candidates for surgical treatment and that intake of minocycline may change the color of the thyroid grand to be black, but keep its function intact.

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Two cases of intractable massive ascites following radical gastrectmy for an early gastric cancer are reported. One case was a 79-year-old male and the other was a 57-year-old female. Both cases had been infected hepatitis C virus. Ascites was confirmed hepatic lymphorrhea, because it had appeared clearly yellowish fluid indicating high specific gravity and high protein density and containing much lymphocytes without chyle.
Intraperitoneal infusion therapy with OK-432 was performed for both cases. Six times of the infusion procedure (total 75 KE) were done for the former case, and 3 times (total 25 KE) for the other case. After this therapy, ascites disappered. Both patients were discharged on the postoperative 89th and 75th day, respectively.
In conclusion, we considered that the intraperiteal infusion regimen with OK-432 may be efficient therapy for intractable ascites due to postoperative hepatic lymphorrhea.

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Pancreatic fistula following total gastrectomy with distal pancreatectomy can cause massive intraperitoneal bleeding from the the exposed main vessels. It is known as a fatal postoperative complication. We here report three cases of postoperative intraperitoneal massive bleeding due to pancreatic fistual.These three patients underwent distal pancreatectomy with total gastrectomy for a gastric cancer. Pancreatic fustula occurred postoperatively in all three cases, leading to massive intraperitoneal bleeding. Emergency operation for hemostasis was successfully carried out in all cases. In addition, we used an occlusion balloon catheter in order to control the bleeding from the abdominal aorta with a favorable outcome. We consider that this catheter is quite effective against excessive intraperitoneal bleeding, because it reduced a loss of blood and maintained the hemodynamic state.

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A 69-year-old man underwent an aorto-right femoro-popliteal bypass operation for complete occulusion of the right common iliac artery. From the eighth to 16th postoperative day the patient ran a high fever over 38°C and an increase in inflammation reaction was confirmed. Various examinations were performed under a suspecion of postoperative infection, but the origin was unknown. On the 47th postoperative day and after he complained of lumber pain and was almost unable to take sitting posture or to move. With magnetic resonance imaging, bone scintigraphy and Ga-scintigraphy, pyogenic spondylitis was suspected. The patient was transferred to the department of orghopedics in our hospital. Surgicaltreatment was thought as a probable selection, but a long-term conservative therapy was employed, with a succssful outcome. The patient was discharged from the hospital.

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A 65-year-old man was admitted to the hospital because of general fatigue and anorexia. He was diagnosed as having a gastric cancer and sarcoma of the lung or pleural mesothelioma by gastric endoscopy and lung biopsy. Serum level of CA19-9 was 80U/ml (<37) and CEA was 32ng/ml (<2.5). After total gastrectomy, serum CEA decreased to 8.7ng/ml and CA19-9 elevated to 563U/ml. The lung tumor was rapidly growing and a chest pain increased. Forty days after the first operation, partial resection of the right upper lobe with thoracic wall resection was performed. Histologically, malignant localized mesothelioma was diagnosed. Serum level of CA19-9 decreased to 65U/ml. Postoperative course was uneventful, but he died of cachexia five months after the administration. The incidence of malignant mesothelioma is rare and the prognosis of the disease is very poor, so this is the first operated case of synchronous double cancer (malignant mesothelioma and gastric cancer). Immunohistological staining showed CA19-9 in both mesothelioma and gastric cancer. We suppose that CA19-9 was produced during the differential process of the mesothelioma.

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A 55-year-old male was admitted to the hospital because of obstructive jaundice. Percutaneous transhepatic cholangio-drainage was performed and cholanigography showed an irregular stenosis of the common bile duct, indicating a pancreatic cancer. Ultrasonography, computed tomography and angiography indicated a tumor in the lower part of the right kidney, suggesting a renal cancer. Pancreatoduodenectomy and right nephrectomy were carried out simultaneously under a diagnosis of synchronas double cancer of the pancreas and kidney. Pathologically, the tumor of the pancreas was well differentiated tubular carcinoma, and another tumor of the right kidney was renal cell carcinoma (clear cell subtype). Postoperative course has been uneventful up to 16 months after the operation.
Double cancers including pancretic cancer have been reported in about 10% of all pancreatic cancers. However, double cancer found at the pancreas and kidney is uncommon. Only seven cases have been reported in the literature so far. In this paper, a case of synchronous double cancer found at the pancreas and kidney is presented with a review of the literature.

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Ingested foreign body is a relatively common entity and infant cases represented about 60-80% of all cases. Most adult cases occurred in psychopathic patients or those who attempted suicide. These ingested foreign bodies are often evacuated naturally and few cases have been operated on. In this paper 12 operated cases of ingested foreign body in adults are clinically studied. Nine (75%) of 12 patients had psychic disease of were defendants in the detention house. They swallowed incredible foreign bodies for instance an antenna and wire intentionally. In these cases, it is possible that they swallowed some X-ray permeable materials, and it is uncetrain when they swallowed the foreign bodies, because antipsychal drugs should mask their abdominal symptoms. So careful observation is important and we recommend to operate on them aggressively to avoid a possibility causing perforation or intestinal obstruction.

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