In order to evaluate OK-432, a streptococcal preparation, as an postoperative remedy for the advanced gastric cancer, patients under 70 years of age undergoing curative A or B surgery from 1981-1992 were picked up and retrospectively examined.
Subjects were 67 patients who received immunochemotherapy using OK-432 (OK-432 group) and 74 receiving chemotherapy alone were served as control (control group). Survival rates were compared between 2 groups by clinicopathological factors. OK-432 group showed significantly better outcomes in curative B surgery (p<0.05), and stage IIIa, b (p<0.01). Pathologically, OK-432 group had significantly better survival rates (p<0.05) in the following factors: se of depth of invasion, diffuse type of Lauren's classification, type 2 of gross appearance, and n₂ of lymp node metastasis. These results suggest OK-432 can be used effectively for patients with advanced gastric cancer after curative B surgery.

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Thirty two patients (1.04%) with malignant lymphoma of the stomach were selected from 3074 patients with malignant tumor of the stomach. They were 14 men and 18 women with a mean age of 56.4 years. Stage (Ann Arbor, p=0.0030), lymph node metastasis (p=0.0076), histological subtype (0.0037), histological grade (Working Formation, p=0.0004) and lymphoma surface marker (T or B, p=0.0021) were correlated with survival. Multvariate analysis using Cox regression method showed no parameter reached the statistical significance. The stage I patient without lymph node metastasis revealed favorable prognoses. Lymph node metastases were observed in 15 (50%) of 30 resected cases, even in 1 (17%) of 6 submucosal lesion. In the patients with positive lymph node metastases, the survival of the patients received adjuvant chemotherapy was better than those without it (16.2 years vs. 2.4 years, p=0.1615). These results showed the radical surgical resection with lymph node dissection was enough for stage I patients, and the postoperative adjuvant chemotherapy was useful in stage II or more stage patients. We think that lymph node dissection is necessary for achieving a curative resection as well for assessing the prognostic factors.

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We have performed D2 lymph node dissection in 520 cases of mucosal confined gastric cancer in a recent 23 year period. In the series we experienced no recurrent cases. Thus limited operation for mucosal cancers is feasible, because of its infrequent lymph node involvement. We studied these 520 cases with regard to lymph node metastases to elucidate a criteria for limited operation, especially for endoscopic mucosal resection (EMR). Twelve cases had lymph node metastases. Overall metastatic rate was 2.1%. The rate of lymph node metastases were high in woman, ly(+) and ul(+) cases, with significant differences. Histologic types had no impact on the metastatic rate. Elevated tumors less than 20mm in diameter and depressed tumors less than 15mm did not involve lymph nodes. Also tumors located in the region C, flat tumors and mixed type tumors were metastasis free. In conclusion, our results justify the general indication of EMR.

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It is still controversial how old patients we should define the young in the colorectal cancer. First we studied the survival rates by age groups and the patients group under 30 years of age had significantly poorer prognosis than those in other age groups. So we defined the patients group under 30-year-old as young patients and the clinicopathological feature in 25 young patients were compared to other parients over 30-year-old. No significant differences were noted in the location of cancer, family history and histological type. Young patients suffered from symptoms for long time and 40% of them had Dukes D disease, and 48% of them underwent palliative operation. However, the prognosis of patients under 30 undergoing curative operation was good. It is likely that the prognosis of young patients with colorectal cancer was poor because of the late diagnosis of cancer rather than because of its aggressiveness in biologic behaivior.

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Seventy surgical cases of ventral incisional hernia performed in our department during the past 15 years were examined regarding background factor, primary disease for the previous operation, location of hernia, subjective symptoms lapse of time before onset of symptoms, and operation procedure. In addition preoperative complications (cure prolonging factor) and postoperative course were studied in 24 cases which were previously operated on at the department. Incisional hernia tended to be frequent in female patients after receiving emergency operations for benign conditions. Most cases occurred within one year after the previous surgery. An important determinant of the hernia was preoperative complications at the previous operation, which occurred in 75.0% of the cases. A relationship between hernia and postoperative complications of the previous operation such as wound infection and wound dehiscence was also suggested. Simple layer-to-layer closure operation had a hernia recurrence rate of 10%. Artificial fascia prosthetic operation, with a recurrence rate of 3.0%, is considered a useful surgical treatment method for large hernias and recurring cases.

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Since 1992 we have performed the laparoscopic cholecystectomy with an abdominal lifting method using an original lifting bar which was newly devised at our department for 100 patients with good results. Our original lifting bar is made of a stainless steel, 5 mm in diameter. It is inserted into the abdominal cavity beyond the right costal arch, is retracted enourh, and then offers a good operative view. This modified lifting bar is especially effective for the obese patients. Our lifting method enables us to use usual operating instruments such as gauze, electric cautery with a long hilt used for laparotomy, and is convenient for aspiration and washing. The method has the advantage that laparoscopic cholecystectomy can be safely performed for the patients with cardiopulmonary complications or those with poor goneral condition without risk of causing pneumoperitoneum.

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In patients with acute arterial ischemia of the lower limb, the correlations between prognosis, namely limb salvage rate and operative mortality, and perioperative factors including duration of ischemic symptoms, degree of ischemic symptoms on admission (Balas' cathegory), etiology (embolism or thrombosis), initial treatment (thrombolysis or surgical arterial reconstruction), and occlusive artery were evaluated. Both amputation rate and operative mortality were 0% in patients undergoing surgical treatment within 6 hours after onset, while the prognoses of the limb and life were dependent on the degree of ischemic symptoms rather than ischemic duration in other cases undergoing either treatment over 7 hours after onset. Neither initial treatment nor etiology of arterial occlusion decided the prognoses, whereas the amputation rate and mortality were higher in cases with occlusion of the aorta, iliac or femoral artery than of peripheral arteries. The causes of operative death were predominantly myocardial infarction or MNMS in thrombosis cases and cerebral attack in embolism cases.

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Two hundred and thirty-three legs of 162 patients with varicose veins were treated by sclerosing therapy. Procedures included stripping of the great saphenous veins in the thigh followed by sclerosing therapy in 58 legs, high ligation of the great or lesser saphenous veins combined with sclerosing therapy in 113 legs, and sclerosing therapy alone in 62 legs. Stripping was done only for the thigh, and no damage on the saphenous and sural nerves occurred. When compared the high ligation group with striping group, the former procedure which is performed under local anesthesia offered ledd surgical invasion, as well as significantly shorter operation time and hospital stay than those of the latter procedure.
Sclerosing therapy for varicose veins would not be the radical management but should be considered a support simplifing the surgical procedures.
Most complications including intravenous thrombosis, induration, and contact dermatitis were associated with sclerosing therapy. Intravenous thrombosis after sclerosing therapy is the most considerable complication causing induration and pigmentaion.

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A nine-year-old boy with follicular carcinoma of the thyroid is reported. His mother noticed a mass in his right anterior side of the neck at the age of eight. The tumor was 2.0×1.8cm in size in the right lobe of thyroid with Class II of aspiration cytology. But 5 months later, it showed a slight enlargement and Class III, and was suspected of malignancy. Right hemithyroidectomy and cervical lymph node dissection were performed. The resected tumor was 2.4×1.8×1.5cm in size. Histological diagnosis was widely invasive follicular carcinoma of the thyroid and two node metastases. He has been free from recurrence or metastasis for the following 12 months. Thyroid carcinoma in a child aged under 10 years is very rare. A total of 14 cases, including this case, seen in the Japanese literature are reviewed in terms of clinicopathological aspects.

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A case of angiosarcoma of the brest which is a very rare entity with poor prognosis is presented in this paper.
A 24-year-old female was admitted to the hospital because of a rapidly enlarging tumor of the right breast. A 10×10cm elastic soft and illdefined tumor was palpated in the right breast. The skin over the tumor was bluish in color. Histological study of open biopsied specimen revealed angiosarcoma. Modified radical mastectomy was performed. In this particular case, 700, 000 unit IL-2 was intravenously administered for 14 days as postoperative adjuvant chemotherapy. She is leading a normal social life 10 months after the surgery without any recurrent signs.
A case of angiosarcoma of the brest is very rare and only 18 cases including our case have been reported in the Japanese literature. A careful follow-up study is necessary, because the prognosis of this entity is extremery poor, although histological findings only show a mild atypism.

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We recently treated a 44-year-old female patient with a painless mass measuring 12×12×10mm in her right nipple with a clinical and cytological diagnosis of adenoma of the nipple, local enucleation of the mass preserving the nipple was successfully performed. Adenoma of he nipple is an uncommon lesion which is often mistaken clinically for Paget's disease and misinterpreted pathologically as adenocarcinoma.
Thirty-four cases of this tumor have been reported in Japan so far. The most common symptom is erosion of the nipple in 61.8%, followed by induration or tumor formation in 44.1% and nipple discharge in 26.5%. Paget's disease and papilloma should be differentiated from the disease in preoperative diagnosis. Adenoma of the nipple is a benign lesion without precancerous significance which is successfully treated by a limited surgery.

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Werner's syndrome is an autosomal recessive disease with premature senility, scleroderma-like changes, characteristic habitus & stature, and often complicated with a malignant tumor.
This paper reports on a very rare case of breast cancer as a complication in Werner's syndrome. A 48-year-old female was seen at our department because of 1cm tumor in A region of her left breast. The tumor was diagnosed as left breast cancer (T2a, No, Mo, stage II). Modified radical mastectomy was performed. Pathological diagnosis was solid-tubular carcinoma, f, s, n_o. DNA ploidy pattern was aneuploidy. Amplification of c-erbB-2 gene was not found. Postoperative course was uneventrul. We should entertain a possible association of breast cancer in the treatment of Werner's syndrome, though it occurs in a low frequency.

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Carbohydrate antigen 19-9 (CA19-9) has a strong correlation with pancreatic and biliary carcinomas and is widely used as a tumor marker. Resently we sometimes see reports describing that respiratory diseases are associated with an abnormally high level of CA19-9.
In this paper we discribed a case of pulmonary sequestration with the high serum value of CA19-9. A 19-year-old man was referred to the hospital because of the fever and cough. The Chest X-ray revealed a cystic shadow in the right lower lung field. Selective angiography showed an aberrant artery arising from the abdominal aorta, into the bilateral lower lung segment. Right lower lobectomy was performed.
The immunohistochemical study of lung tissues was to be positive CA19-9 staining on the surface of broncheal epitherum. Serum CA19-9 levels gradually decreased and reached the normal serum level after 4 months after surgery. CA19-9 exists in the normal bronchial gland. It is thought that respiratory disease should be considered as a possible diagnosis for elevated CA19-9 level.

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A 75-year-old man was admitted to the hospital because of a suspected lung cancer at routine chest X-ray examination. Tracheobronchoscopy and transbronchial lung biopsy demonstrated squamous cell carcinoma of the right upper lobe. His peripheral blood count showed pancytopenia and he was diagnosed as myelodysplastic syndrome (MDS), refractory anemia, based on dysplastic findings of the bone marrow. He received perioperative transfusion of packed red blood cells and platelets, and recombinant human granulocyte colony-stimulating factor (rhG-CSF) was added. Right upper lobectomy and mediastinal-hilar lymph node dissection were carried out. After the operation he was successfully treated with antibiotics and rhG-CSF for postoperative pneumoniae. He is now doing well with no evidence of recurrence, as of 18 months after the surgery.
An operating case of lung cancer with MDS is described with a review of the literatutre. It is considered that perioperative management with transfusion and rhG-CSF is reasonable for MDS patients.

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We experienced a patients with spontaneous rupture of the esophagus who was sulvaged by cardioplasty with gastric patch (fundic patch) 30 hours after the onset. Sudden vomiting, epigastralgia and dyspnea after a meal occurred in a 64-year-old female. Chest X-ray examinations showed a pleural effusion in the left lung field on the 2nd day after admission to the hospital. We make a diagnosis of spontaneous rupture of the esophagus, because fiberoptic esophagoscopy revealed a perforative lesion in the lower esophagus. Cardioplasty with gastric patch (fundic patch) was performed 30 hours after the onset. Postoperative course of the patient was progressing favorable. This surgical procedure (fundic patch) was very useful in this patient with spontaneous esophageal rupture who was missed due to delayed diagnosis.

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A 77-year-old man was admitted to the hospital because of anorexia and vomiting. Upper GI series and gastric endoscopy revealed a nodular tumor locating at the antrum and its resulting pyloric stenosis. A biopsied specimen of the tumor showed moderately differentiated adenocarcinoma and the tumor was associated with a high serum alpha-fetoprotein (4232ng/ml). At surgery, a Borrmann I type tumor, measuring 6×4.5×3cm was located at the pre-pylorus, invading the doudenal bulb. No distant metastasis was noted and a subtotal distal gastrectomy was performed. Histological examination revealed trabecular pattern of the tumor cells, and immunohistochemical AFP staining was positive. With these findings, it is considered that the case is of typical hepatoid adenocarcinoma of the stomach.

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We report herein a case of malignant Schwannoma of the stomach in a 42-year-old man complaining of anal bleeding who was diagnosed accurately preoperatively by fiberoptic examination. Histopathological examination of the biopsy specimen revealed that the tumor was consisted of bundles of spindle-shaped cells with frequent mitotic figures arranged in palisading pattern. Furthermore, positivity for vimentin and S-100 protein was confirmed immunohistologically. In spite of curative total gastrectomy, liver metastases developed 10 months after the operation.
Because of the lack of diagnostic criteria and prognostic indicators, there remain differences in opinions about standard operation for this disease. Metastases were almost always due to hematogeneous in a review of the literature, and lymphogeneous metastases and peritoneal dissemination were seldomly observed. Therefore, adequate removal of the tumor without extensive regional lymph node dissection can be regarded sufficient treatment of the tumor.

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This paper describes a case of malignant lymphoma of the stomach in which a complete remission was confirmed in the resected specimen after preoperative VEPA regimen.
A 76-year-old woman was seen at the hospital because of an upper abdominal pain. Gastric endoscopy visualized an irregular elevation with a giant ulcer in the lesser curvature of distal portion of the body of the stomach and a lesion connecting to the elevation extended to the lower body of the stomach. Biopsy indicated malignant lymphoma, diffuse large cell type. For this the VEPA preoperative regimen was started and discontinued when she got half through one course because of her great age. Endoscopy revealed a significant diminution in the lesion. So total gastrectomy and splenectomy with lymph node dissection (D2) were carried out. Histopathologically it was P0H0N(-)ps(-) and in Stage I according to the General Rules for the Gastric Cancer Study. No cancer cells were detected through all sections of the specimen and regional lymph nodes. We determined as complete remission.

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A case of advanced gastric carcinoma (type 3) diagnosed as unresectable, successfully underwent a radical operation after two courses of the combination chemotherapy with 5-FU, MMC and ADM followed by oral administration of 5'-DFUR. The gastric lesion was proven Stage IVb [AM, 3T4 (SI), N₃, P₁, H₀, M₀] and pathologically well to moderately differentiated adenocarcinoma at the first operation. Since the 8th postoperative day, two courses of FAM therapy (300mg/m² of 5-FU I. V. on day 1, 8, 29, 36, 13mg/m² of ADM I. V. on day 1, 29, 6.5mg/m² of MMC I. V. on day 1) has been applied. Within three months, the abdominal mass disappeared, passage of the stomach and vomiting improved, and the serum CEA level returned to a normal range. Endoscopically, the main gastric tumor was remarkably diminished. The general condition improved and body weight increased. After discharge, the administration of 600mg 5'-DFUR p.o./day was started. From the 40th month, severe anemia continued and became uncontrollable. In the 44th month from the first chemotherapy, a subtotal gastrectomy was performed with regional lymph nodes dissection. Histological findings of the specimen including regional lymph nodes revealed a mardked effect of anticancer agents, and proved the operative radicality.

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A 65-year-old man was admitted to the hospital because of epigastric discomfort. X-ray examination revealed an elevated lesion in the body of the stomach and a polypoid lesion in the duodenal bulb. Endoscopic examination showed a 18×16mm IIa+IIc gastric tumor. The polypoid lesion of the duodenal bulb could not be detected by endoscopy. The biopsy specimen from the gastric lesion showed histological evidence of malignancy.
Distal gastrectomy was performed including the duodenal polyp adjacent to the pylorus. Histological examination showed that the lesion of the stomach was moderately differentiated tubular adenocarcinoma that invaded the submucosal layer without lymph node metastasis and that the duodenal polyp was 10×10×10mm well-differentiated adenocarcinoma limited to the mucosal layer. The patient is well two years after the operation, without any evidence of recurrence. The family and past histories of this patient meet the criteria of hereditary nonpolyposis colorectal cancer. Our survey of the literature suggested that this is the 8th reported case of early carcinoma of the stomach associated with early duodenal carcinoma in Japan.

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A 79-year-old woman was seen at the hospital because of an abdominal pain, vomiting, and diarrhea. The patient was admitted with a diagnosis of acute enteritis and passage disturbance and successfully managed by conservative treatment. After discharge from the hospital, the patient was readmitted because of intestinal obstruction. Intestinal fluoroscopy revealed a localized narrowing. Surgical exploration revealed a strangulated upper portion of the intestinal loop, which involved a stenosed part 6cm in length. No necrosis nor hemorrhagic change was observed in the intestine and mesenterium. From gross, angiographic, pathological findings of excised stenosed intestine, the patient was diagnosed as having an ischemic stenosis of the small intestine. We can consider probable ischemic factors including blood flow disturbance due to incomplete strangulation of the intestine, arteriosclerosis, dehydration and an increase in inner pressure of the intestine resulting from the bent intestine. Here we also present some notes on ischemic stenosis of the small intestine based on 40 cumulated cases in this country including or case.

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Acute mesenteric artery embolism is a curable disease if the diagnosis and therapy are instituted before irreversible changes have occurred. We experienced a case of acute mesenteric artery embolism which was treated by second look procedure about 40 hours after embolectomy that permitted us to excise the small intestine in a minimal range.
A 71-year-old man was admitted to the hospital because of severe abdominal pain. Superior mesenteric artery angiogram demonstrated embolus completely occluding the SMA. Emergency laparotomy was performed. Large segment of the intestine revealed ischemic change. We performed embolectomy of SMA. About 40 hours after embolectomy, second look procedure was performed. Only small segment of the intestine was necrosed. Bowel resection about 150 cm and anstomosis was carried out. The patient died of cardiac arrest on the 66th day after onset of th diseases. Second look procedure after embolectomy appears useful for evaluation of bowel viability.

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We report a case of leiomyosarcoma of the ileum presenting with ruptured liver abscesses. A 76-year-old woman was admitted to the hospital because of fever, abdominal pain, tenderness and muscular defense. Ultrasonography and CT scan of the upper abdomen showed ascites and low density lesions in dthe liver. Emergency laparotomy showed panperitonitis due to ruptured liver abscesses. A Streptococcus intermedius and Candida albicans were cultured from the purulent fluid collection. At the operation, abdominal cavity inspection revealed an 11 cm solid tumor arising from the pelvis, identified as leiomyosarcoma with central necrosis draining to the ileal lumen. Segmental resection of the ileum was performed 39 days after the first operation when her general condition was restored. The liver abscesses were considered originating from infection of the tumor with central necrotic cavity, disseminating to the liver through the portal blood.

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A 46-year-old male was admitted to the hospital because of intermittent lower abdominal pain and mucinous bloody stool. A mass of big egg size was palpated in his right lower abdomen. Barium enema showed a tumor in the terminal ileum and colonoscopic examination revealed a tumor with red erosions on the surface, which moved to-and-fro through the Bauhins valve. The tumor was diagnosed as malignant lymphoma by biopsy from the erosion.
Malignant lymphoma of the ileum often causes adult intussusception, and presents difficulty in preoperative diagnosis. Colonoscopic observation and biopsy of the tumor are valuable, but actually, these measures have hardly contributed to make the definite diagnosis so far. In such a case as ileal tumor associating with intussusception is suspected, colonoscopy and accurate biopsy are indispensable. The establishment of this technique will increase the correct diagnosing rate before surgery for malignant lymphoma of the ileum.

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A 75-year-old female was admitted to the hospital because of a right-sided abdominal pain, distension and their recurrence. The patient repeated vomiting caused by intestinal obstruction. Double contrast radiography showed characteristic findings of intestinal tuberculosis with scarred area and deformed intestinal lumen in the cecum and in the right-sided colon. Colonoscopy showed circular, girdle-like ulcer, pseudo-diverticulum and inflammatory polyps. Intestinal tuberculosis was highly suspected, but was not confirmed by biopsy specimens. Right hemicolectomy was performed because of repeated intestinal obstruction and of being afraid of aggravation of small intestinal lesion by antituberculosis. Histopathological study demonstrated characteristic tuberculous granuloma with caseation necrosis in the intestinal wall as well as in the regional lymph nodes. The patient has been treated with antituberculosis chemotherapy and free from recurrence, as of one year after the operation.

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A 63-year-old man was admitted to the hospital because of bloody stool and abdominal fullness. The tuberculin reaction was surely positive, but bacteriological examination of the feces resulted in negative. A chest X-ray film showed a characteristic shadow in the left upper lobe. Radiological examination of the sigmoid colon revealed diminishing of haustra, narrowing and shortening of the colon, but there was no ulcerative lesion. Moreover, elevated lesion was found in the descending colon. An inflammatory disease of the colon was strongly suspected, but the differential diagnosis for malignancy was difficult. Therefore, sigmoidectomy with dissection of regional lymph node was performed. The histologic examination showed the specific inflammatory change of tuberculitis in the bottom of diverticulum. We report a very rare case suggested tuberculous colitis, in the view of the tuberculous colitis associated with diverticulum, and of the mechanism of the onset intuberculous colitis. No such case has been seen in the Japanese literature so far.

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The authors report two surgical cases of a cecal cancer complicated with abdominal fistula. The first case was an 86-year-old female and the second case was a 63-year-old male. Both patients discharged mucinous liquid through a fistula at the right lateral abdomen. In both cases, colon balium enema showed an abnormal shadow at the cecal lesion, respectively, and abdominal computed tomography (CT) revealed the presence of the tumor in the retroperitoneal space. Fistulography showed a communication with the ascending colon in each case. At laparotomy the tumor in the ileocecal lesion extending into the retroperitoneal space was found out. Right hemicolectomy and lymph node dissection were performed in both cases when the tumors was found to contain mucinous material. The first patient was well for 5 years and 3 months and the second patient has been well 1 year and 6 months after the operation.

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A 33-year-old pregnant woman had constipation, abdominal pain and fullness since the 7th week of pregnancy, but she was diagnosed as hyperemesis gravidarum. After her delivery on the 34th week of pregnancy, she was seen at the hospital because of persisting symptoms. Abdominal swelling, hepatomegaly and ascites were noted. As a result of various examination, ileus due to a sigmoid colon-cancer was diagnosed, and sigmoidectomy was performed after 10 days of delivery. Opertive diagnosis was sigmoid colon cancer, which was circ, 3-type, 3.0×3.0cm size, SE, P0, H3, M(-), N2(+), Stage 4. Histological diagnosis was well-differentiated adenocarcinoma. Postoperative chemotherapy was done to the metastasis of the liver with reservoir, but she died of liver failure 3 months after of the surgery.
Colorectal cancer in pregnancy is rare. Only 28 cases have been reported in the Japanese literature, and generally their prognoses were poor. Even if the patient with suspected colorectal cancer is a pregnant woman, appropriate examination including occult blood and ultrasonography which have no effects on the fatus sould be aggressively tried.

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A rare case of perforated diverticulum of the transverse colon was experienced. Perforated diverticulum of the transverse colon presented difficulty in diagnosis preoperatively, because it can produce abdominal pains in every area of the abdomen; has no characteristic clinical findings; and our clinical surgeons pay less attention to the existence of the disease as a probable differential diagnosis due to its low frequency. Our case involved an 81-year-old woman complaining of a lower abdominal pain and abdominal disention. Peritoneal signs were minimal and we had difficulty in diagnosis. With barium enema study due to gastrographin, intestinal leakage of contrast medium at the left-sided transverse colon was suspected. Abdominal CT also visualized a pool of the medium out of the intestine. An emergency operation was performed with a diagnosis of perforated transverse colon. Histopathological diagnosis of perforation of the pseudodiverticulum was made.
We see 30 reported cases of the disease in the English and none in the Japanese literature as far as we could review. Their clinical features and the diagnosis and treatment of the disease are also discussed in this paper.

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We experienced a case of endometriosis of the rectum forming an ovarial cyst with endometriosis and fistula.
A 34-year-old woman was admitted to the hospital because of anal bleeding and lower abominal pain. Colonoscopic examination revealed a submucosal tumorous lesion in the rectum. Barium enema showed a leakage and retention of contrast medium from the rectum. CT and magnetic resonance imaging visualized a cystic tumor of the rectum. A diagnosis of fistula formation of endometrial ovarian cyst to the rectum was made. Because of persisting anal bleeding, excision of the rectum including the cyst, fistula and adnexa uteri was carried out. The excised specimen revealed an infiltration of the endometrial gland into the muscular layer of the rectum. There has been no sign of recurrence, as of about 4 years after the operation. It is though that agressive surgical treatment is necessary for fistula-forming endometriosis of the intestine.

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An 88-year-old man had multiple anal fistula left untreated for 20 years. Recently, bloody mucous disharge was observed from anal fistula, and was admitted to the hospital for operation of the anal fistula.
External openings were located in the direction of 1, 3 and 5 O'clock. Cytologic examination of mucous bloody discharge was performed, but no malignant findings was obtained. An operation for anal fistula was performed, but a possibility of fistula cancer could not be ruled out. Intraoperative histological examination of wall of the anal fistula indicated adenocarcinoma. Abdomono-perineal resection was carried out under the diagnosis of fistula cancer.
Histopathologically, it was mucin producting well differentiated adenocarcinoma with papillary structure which was localized within surface of the fistula. It was comparatively early fistula cancer without muscular invasion. This case will suggest fistula cancer may arise from wall of fistula. This type of early stage of fistula cancer has been reported in only 3 cases in our country.

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Accessory liver is a rare congenital abnormality. Only 77 case have been reported in the Japanese literature including or case.
A 74-year-old female was admitted to the hospital because of general fatigue. Various imaging methods revealed a tumor in the right subphrenic area. We suspected that this tumor was origniating in the liver or in the right adrenal gland.
Preoperative definite diagnosis was not made, but a possibility of co-existence of malignant lesions was not ruled out. So an operation was performed. Entering into the abdominal cavity, found a tumor adherent to the right adrenal gland and compression the right lobe of the liver. Macroscopically, and direct connection between the accessory liver the primary liver was found out. The tumor with the right adrenal gland was excised. The pathological examination of the resected tumor revealed the normal hepatic lubule and no bile stagnation. Furthermore, this tumor contained a hematoma surrounded with lepatic tissue. We considered that the blood vessels, portal vein and bile duct were communicated with the primary liver through a restiform part. However, it is still unclear why the hematoma was occurred.

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We experienced a case of Biloma which was formed by bile juice leakage into the subcapsular space of the liver due to incarcerated bile duct stone.
An 80-year-old woman was admitted to the hospital because of fever and right hipochondralgia. Abdominal CT-scan and ultrasonography on admission demonstrated a stone, 1cm in diameter, in the dilated common bile duct and a giant cystic lesion in the subcapsular space of the right hepatic lobe. Under ultrasonographic guidance, the cystic lesion was percutaneously drained. The aspirated fluid revealed bile and she was diangosed as having a biloma accopanied with bile duct stone. The continuous drainage of the biloma brought about disappearance of cystic lesion 19 days after admission and the bile stone had pased through the papilla Vater.
Bilomas are predominantly reported to develop traumatically or iatrogenically. In the Japanese literature, 21 cases of spontaneously developed biloma have been reported which were associated with hepatobiliary diseases. Fifteen of 21 cases had bile duct stones.
In suspected patients of biloma, percutaneous drainage should be done to make the definitive diagnosis and to relief the symptoms by indwelling a catheter for continuous drainage.

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A 49-year-old man underwent a curative gastrectomy for a type 3 advanced gastric cancer. Liver dysfuntion was recognized 10 days after the operation. PTCD was carried out because of complete obstruction at the middle portion of the common bile duct. Under a diagnosis of biliary obstruction due to inflammation, second time operation was performed. A mass formation was recognized around the hepatoduodenal ligament. Adenocarcinoma cell invasion was found in the connective tissue in the induration at the biliary obstruction by intraoperative frozen section diagnosis. Only the biliary reconstruction was impossible. Expandable metallic stent was inserted using the route of PTCD after the operation. On the 30th day after the insertion, the PTCD tube was removed and complete biliary endoprosthesis was accomplished. From just before discharge, UFT-E 1.5g/day and PSK 3g/day were administered. Moreover CDDP 25 mg and MMC 2 mg were injected at the time of consultation. The injections were carried out 16 times until now. As of 1 year and 6 months after insertion of the stent, no evidence of exacerbation of gastric cancer has been recognized and the patient leads an ordinary life. During this period, no evidence of cholangitis and dilatation of intrahepatic bile duct on X-ray is recognized.

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We reported a case of symptomatic hepatic cyst treated by laparoscopic deroofing operation. An 85-year-old man was admitted to the hospital because of right upper abdominal fullness and pain. Prior to admission he underwent ethanol infusion therapy three times at another hospital, but no response was observed. Ultrasonography revealed and giant hepatic cyst located in the right lobe (S6). At first, we performed the injection of absolute ethanol into the cyst through the catheter after US-guided drainage. But the volume of discharge did not decrease and the symptoms remained when the flow of the discharge was clumped. So we tried to treat him under laparoscopy, that is to say, a 6cm diameter fenestra of the cyst was made by laparoscopic procedures. There was no complication during or after the surgery. His complaints disappeared and he was discharged from the hospital 12 days after the operation. Laparoscopic deroofing operation can not be indicated for all hepatic cysts, because the location of the cyst is the determinant factor. If the procedure is employed for carefully selected patients, the patients can have a great benefit of laparoscopic procedure.

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We successfully diagnosed a patient as wandering spleen preoperatively and performed a splenopexy. A 5-year-old girl visited another hospital because of a periomphalic pain, and was pointed out dislocation of the spleen. With close examination she was diagnosed as having a wandering spleen, and was admitted to the hospital for operation. Operative exploration revealed that the spleen lacked peritoneal structure for fixation and twisted clockwise by three turns. but no infarction was found, with sound pulsation of the splenic artery. Intraoperative trans-splenic portography confirmed the patent splenic vein, and consequently splenopexy was performed.
Wandering spleen is a rare entity and we are often compelled to operate on without making the definite diagnosis for the disease. But a recent progression in imaging diagnosis this disease has been increasingly diagnosed preoperatively. In this case abdominal ultrasonography was most useful. In the treatment splenectomy is often employed because of infarction due to torsion of the organ. Attention has been called to the fact that infectious diseases can occur after splenectomy in pediatric patients. It is desirable to make an early diagnosis and to employ spleen-preserving splenopexy.

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This paper describes a case of adult mesoblastic nephroma (AMN) which is a very rare benign hamartoma of the kidney. A 44-year-old man was seen at the hospital because of back and right flank dull pain. Imaging method revealed a right upper abdominal mass and he underwent a right nephrectomy. Macroscopical examination revealed a 10.5×9.5×6.0cm, soft and expansive growth and on section homogeneous and solid tumor yellow-white in color replaced the upper side of the kidney. And it had sharply marginal separation to the normal kidney in spite of no capsule. Histopathologically, the tumor composed of spindle and/or polygonal shape nuclear and fibrotic bundle (Desmin+, MSA+, S100-protein-), smooth muscle cell, vesel (HMB-45-), fat cell and tubular or cystic epithelium resembled urinary tubules (CAM5.2+) and each component concomitantly existed in the entire tumor. These findings suggest that AMN is a very slowly growing congenital mesoblastic nephroma and its epithelial component belonged to the tumor elements. Moreover, the smooth muscle of vessels bore no relation to immature melanosome which is commonly seen with angiomyolipoma.

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We experienced a case of renal cell carcinoma metastasizing to the cerebellum and lung after a 9-year interval which were successfully resected. The case was a 69-year-old man. There was a Previoushistory of undergoing a right nephrectomy for a renal cell carcinoma in 1991. In October, 1984, an ocipital pain appeared and a mass lesion was revealed in the cerebellum on CT scan which was excised in January, 1985. Histologically the lesion was diagnosed wit metastasis of renal cell carcinoma. Radiotherapy and chemotherapy were added after the operation.
Two mass lesions were found in his right lung on chest X-ray and chest CT scanning in October, 1993, and were diagnosed as metastases of renal cell carcinoma by needle biopsy. He underwent partial resection of the right lung (S³, S⁶) in December, 1993.
Lung metastasis is most common in renal cell carcinomas. Cerebellar metastasis wihtout pulmonary metastasis is very rare, and no such case as lung metastasis is removed after resection of cerebellar metastasis had been reported in the Japanse literature so far. In our case, metastatic route and clinical course are very interesting. We hope our case can contribute to consider treatment of metastatic lesion of renal cell carcinoma.

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Cushing's synrome commonly occurs due to pituitary adenoma, and sometimes due to adrenal tumor. We experienced a case of this syndrome occurring 3 years after an operation for a non-functional pituitary adenoma.
A 69-year-old female who underwent surgical treatment for a pituitary adenoma 3 years before was admitted to the hospital because of fatigue and hypertension. Physical and endocrinological examination suggested Cushing's syndrome. Abdominal ultrasonography and CT scan revealed a right adrenal tumor 20 mm in diameter. Adrenal scintigraphy under dexamethazone suppression revealed the tumor was functional. Laparoscopic enucleation of the adrenal tumor was successfully carried out. Pathological findings revealed it an adenoma of the adrenal gland. Three cases of adrenal tumor combined with a pituitary tumor had been reported, two cases were heterochronous and the remainder was synchronous. The relationship between the previous pituitary tumor and adrenal tumor is unclear, because pituitary lesion was non-functional chromophobic adenoma. Careful follow up is required for the patient who had an endocrine organ tumor because it can be duplicated metachronously like example well known syndrome Multiple endocrine Neoplasms.

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We report a case of retroperitoneal cystic mesothelioma. The patient was a 42-year-old woman with no particular problems in her medical history. She first presented to another hospital becouse of common cold, where an abnormal mass in her lower abdomen was pointed out. Then she was admitted to the hospital. The findings obtained by Computed tomography, ultrasonography and barium enema showed a large cystic tumor probably originated from the retroperitoneum. Laparotomy was performed. Surgical exploration showed that a solitary cystic mass was located behind the descending colon and compressed the colon imward. The postoperative histological findings revealed that the tumor was cystic mesothelioma. This histological classification can be achieved by histochemical and immunohistochemical studies with keratin, colloid-Fc and CEA. Retroperitoneal cystic mesothelioma is not a common disease, however, it should be taken into consideration in the differential diagnosis of abdominal masses.

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The case involved a 71-year-old man. When he was 60-year-old, he got an early gastric cancer of IIc type at the antrum. On preoperative examination for gastrectomy a retroperitoneal tumor was pointed out. The 9×7×4cm ovarian shaped tumor was located in the retropanreatic space between IVC and portal vein. Subtotal gastrectomy and extripation of the retroperitoneal tumor was carried out. The retroperitoneal tumor was dignosed as extraadrenal pheochromocytoma during the operation, because he was attacked by hpertension on extirpation of the tumor. When he was 67-year-old, he got another early gastric cancer of IIa type in the residual stomach and underwent total resection of the residual stomach. Three years later when he was 70-year-old, two small liver tumors and two small retroperitoneal tumors with diameters of 1_??_2cm were detected in the follow up study, There were no symptoms of excessive catecholamine secretion, but these small tumors were diagnosed as recurrent foci of pheochromocytoma by ¹³¹I-MIBG scintigraphy and slightly increased catecholamine values in blood and urine. In spite of previous two surgical operations, another exploration was done and these recurrent foci were resected successfully. Ten months later now, we don't find any recurrent foci on follow up studies as yet.

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A case of epigastric hernia associated with mesenterium communae is reported. Twenty years prior to admission, a 71-year-old woman noticed a hen egg-sized mass at the upper abdomen, which gradually grew larger and larger. The patient presented herelf with abdominal pain and a soft mass, 120 by 140mm in size, protruding at the epigastrium. A barium meal study revealed that the abdominal mass contained almost the whole length of the bowels from the jejunum to the sigmoid colon. Under the diagnosis of epigastric hernia, herniorrhaphy was performed on March 6, 1991. There was a defect of the linea alba measuring 4 by 4cm and a part of the colon was adherent to the hernia sac. In addition, exploration of the abdomen revealed that the small and large intestines have a common mesenterium. Thirty two patients with epigastric hernia have been reported in the Japanese literature, but this is the first description of the association of the hernia and mesenterium communae.

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Obturator hernia is a rare entity. In most cases the small intestine is involved. Recent experience with a case of obturator hernia in which the small intestine and right ovary were simultaneously incarcerated is reported.
An 88-year-old woman developed an abdominal pain and vomiting after a dinner and then felt a pain in the right thigh which gradually increased. The patient was emergently admitted to the hospital with a diagnosis of intestinal obstruction like symptoms based on a plain abdominal X-ray film. Howship-Romberg sign was noted and so ultrasonography (US) of the inguinal region and CT scan of the pelvic region were carried out. The patient was diagnosed as right obtulator hernia and was operated on emergently. During operation the ileum about 20cm from the ileocecal region and the right ovary were incarcerated into a righ obturator was confirmed. Incarceration of the ileum was Richeter type, and when it was reduced, the ileum was found to include a necrosed part. Partial excision of the ileum was carried out and the right ovary was repaired. Making the definite diagnosis of obturator hernia in this case, US of the inguinal region and CT scan of the pelvic region were valuable. In addition incarceration of the ovary was able to be retrospectively confirmed by US. Although it took only 24 hours from the onset of symptoms to operation in this case, the incarcerated intestine wa already necrosed. This fact means that this disease should be diagnosed as early as possible and laparotomy which permits us to observe the entrie intestine is recommended.

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Extended profundoplasty is an effective procedure for limb salvage when the proximal zone of the profunda femoris artery has an occlusive lesion. Between 1987 and 1994 six patients with the critical leg ischemia underwent the extended profundoplasty for limb salvage or relief of rest pain. There were all men except one, with an average age of 79. All lesions were caused by arteriosclerosis obliterans and were critical as rated as Fontaine classification III or IV preoperatively. The ankle/brachial pressure index (API) were 0.27 and 0.46 in two limbs, and it could not be determined in the remaining four limbs. An inflow correction was necessary in five limbs, axilloprofunda bypass in three, and femoroprofunda bypass in two. The API increased to an average of 0.6 postoperatively, and the ischemic symptoms were relieved.
It is concluded that the success of the extended profundoplasty may save critical ischemic limbs.

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A 54-year-old woman was referrd to the service for further examination of a mass in the pelvis. A soft mass was palpable with the finger tip on the posterior wall of the rectum. CT scans showed a well marginated cystic lesion with a smooth surface, which measured 8cm in diameter at the retrorectal space. Bariumenema examination demonstrated forward displacement of the posterior wall of the rectum. Transrectal endoscopic ultrasonography revealed a large hyperechoic mass with some hypoehoic spots. The scan identified all layer of the rectal wall, and showed the capsule of the tumor and no evidence of tumor invasion to the rectum. The mass was excised via a transsacral approach. Examination of the resected specimen revealed a smooth-walled biloculated cyst measuring 9×6×5cm and containing greyish granular material. Microscopically, the cyst wall was composed of stratified squamous epithelium without any skin appendages, so a diagnosis of epidermoid cyst was made.
There have been 17 cases of developmental cyst and only 7 cases of them had presacral epidermoid cyst up to 1994 in Japan. Complete excision of those presacral cysts is advised because of possible complications including infection and malignancy.

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