We compared the antibacterial effect of a liquid hand-washing disinfectant containing aqua oxidation water with those of other liquid disinfectants, such as povidone-iodine and sterilized water. The bacteria count of the hands was chronologically measured before washing, after washing, and after surgical operations, and the measurements were compared between the subjected disinfectant and other conventional preparations. The antibacterial activity of the liquid disinfectant containing aqua oxidation water was comparable to that of povidone-iodine. These features of aqua oxidation water would make it a viable alternative to conventional liquid disinfectants used for hand washing before surgical operations.

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The major objective of this study was to investigate the specificity of the patients and the pathogenesis of fungal endophthalmitis (FE) after abdominal surgery. Six patients with FE after abdominal surgery (patients group) were subjected to a study. Another patients who underwent abdominal surgery in the same period and suffered from sepsis due to Candida infection (a) or high fever (over 39.0°C of body temperature) indicating Candida high-titer antigen (b) but had not FE were served as control (control group). The previous reports indicated that the critical patients with malignancy or immunodeficient state tend to suffer from FE more easily than non critical patients.
Our study showed that there was a significant difference between the patients group and control group.
1) The mean age of the patients group (61.0±11.3) was significantly younger than that of control group (73.7±7.9).
2) The mean value of serum total protein of the patients group (6.8±0.7g/dl) was higher than that of the control group (6.3±0.5).
3) Five of six patients in the patients group were suffered from the benign diseases. But only two of the eleven patients in the control group were suffering from the benign diseases.
In this study we find that not the critical patients but the patients in good condition tend to be suffering from FE. We discussed our idea about the difference between the past literature and our study.

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We evaluated the results of operative treatment in 10 patients with invasive mediastinal tumor with invasion to the adjacent organs necessitating resection for reconstruction.
Five patients had invasive thymoma, three had germ cell tumor, one had maligna nt lymphoma, and the last one had malignant fibrous histiocytoma (MFH). Ringed ePTFE graft was used to reconstruct the superior vena cava. Prior to resection of the tumor, the graft was interposed between the innominate vein and the right artium to maintain the venous drainage from the brain. All cases are alive and well without any evidence of graft obstruction.
Teflon sheet, Dexon mesh and Marlex mesh were used to repair the defects created in pericardiumm, and there were no remarkable complications postoperatively, including those in the circulatory system.
Marlex mesh was used to reconstruct the chest wall as well as the diphragm.
We conclud that extended operation combined with resection of the adjacent organs for invasive mediastinal tumors can be performed safely and very effectively.

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In a recent 16-year period we experienced 16 cases of pyogenic liver abscess including 8 solotary and another 8 multiple lesions, and studied them in terms of therapeutic methods.
These therapeutic methods included general administration of antibiotics, selective one shot local intra-arterial infusion, ultrasonography-guided drainage (USD), and laparoscopic drainage. The clinical effects were rated as “excellent” if inflammatory reaction disappeared; as “effective” if only antipyretic tendency was observed; and as “ineffective” if no any reaction occurred. Antibiotics were generally administered to 15 out of 16 patients, which resulted in “ineffective” for 13 patients and “excellent” in 2 patients having a solitary lesion of less than 3cm in size. Of these 13 ineffective patients, five patients received selective one shot intra-arterial infusion and “effective” was noted in one and “ineffective” in the remaining four. These 12 patients who did not respond to antibiotics and local infusion regimen underwent USD for seven patients (four solitary and three multiple lesions) or laparoscopic drainage for five with multiple abscess, and their responses to the both regimens were all rated as “excellent”.
It is concluded that pyogenic liver abscess can be cured by general administration of antibiotics and one shot local intra-arterial infusion if the lesion is solitary, but it demands general antibiotics regimen as well as some drainage procedure if the lesion is multiple, for which no therapeutic effect can be expected by only general antibiotics or one shot infusion regimen.

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The expression of epidermal growth factor (EGFR) and c-erbB-2 protein were examined immunohistochemically in a total of 45 cases of bile duct cancer, and corelations between these expressions and clinicopathological variables were analyzed. The expression of EGFR and c-erbB-2 protein were observed in 17 of 45 cases (37.8%) respectively. There were no significant correlation between these expression and clinicopathological factors including the cell differentiation, tumor diameter, depth of invasion, lymph node involvement, stage, and vascular invasion. Five years survival rate in EGFR positive cases was 31.7% versus 61.7% in EGFR negative cases with a significant difference. Prognosis of patients with EGFR positive cancer was worse than those with EGFR negative cancer (p=0.04). Prognosis of patients with lymph node metastasis was also worse than those without lymph node metastasis (p=0.02).
These results suggest that expression of EGFR may serve as a useful biological marker as well as nodal involvement in the bile duct cancer.

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We measured blood levels of prostate-specific antigen (PSA) and γ-semino-protein (γSM) prior to therapy in 80 previously untreated patients with prostate cancer and calculated the PSA/γSM ratio (P/S). Forty-six patients with benign prostatic hyperplasia who had undergone subucapsular resection were served as controls. We measured the volume of the prostate gland by ultrasound before treatment, and the PSA (PSAD) and γSM (γSMD) levels per unit volume were calculated.
The sensitivities of PSA and γSM were 0.9750 and 0.8125, respectively, thus being very high. On the other hand, the specificities were extremly low, being 0.1304 and 0.2391, respectively. Nevertheless, the PSA, γSM, P/S, PSAD and γSMD levels were all significantly higher in patients with prostatic cancer than in those with benign prostatic hyperplasia. Although it is difficult to differentiate between Stage A prostatic cancer and prostatic hyperplasia based on these markers alone, the high sensitivity of PSA for Stage A cancer (89%) suggests that biopsy should be performed at multiple sites when the PSA level exceeds the cutoff value.

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We report five cases of metastatic brain tumor preceded by neurological symptoms. All patients received removal of the brain tumors prior to resection of the primary lesions. The primary site of cancer was the lung in 3 patients, and esophagus and breast in one each. The number of brain tumor was one in four patients and 3 in one. The duration from the removal of the brain tumors to the resection of the primary lesions ranged from 0.5 to 6 months. Two patients with lung cancer, who did not undergo postoperative whole brain radiation therapy, died of recurrence of brain tumors 14 months and 15 months after the resection of the primary lesions, respectively. On the other hand, no recurrence of the brain tumor was found in 3 patients with postoperative whole brain radiation. One patient with breast cancer died 14 months, and two patients with esophageal and lung cancer are alive 30 months and 37 months after the resection of the primary lesions, respectively. Curative resection for both brain metastasis and primary lesions was performed in 2 patients surviving for more than two years.
Resection of brain metastasis and primary lesions, and postoperative whole brain radiation therapy according to the progressive extent of the lesions would improve the prognosis.

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An 85-year-old woman was seen at the hospital because of a tumor of the right breast. Aspiration cytology suggested malignant lymphoma, and a radical mastectomy was carried out.
Histopathological examination disclosed non-Hodgkin lymphoma, diffuse large cell type in LSG classification, B-originated type. According to Wiseman's criteria, the tumor was diagnosed as primary malignant lymphoma of the breast. Eight months later, there occurred the signs of relapse in the right chest wall and right supraclavicula lymph nodes. We measured the serum concentrations of the soluble forms of interleukin-2 receptor (sIL-2R) during the clinical course of this case. The sIL-R level which was markedly high in the preoperative examination fell down temperally after the radical mastectomy, but elevated again before the relapse of the disease. Recent studies have indicated that the sIL-2R level is a new prognostic factor of non-Hodgkin's lymphomas. In our case, sIL-2R levels also reflected tumor status in the clinical course of the disease. The sIL-2R level may be prowed to be a useful marker and prognostic factor in the management of primary malignant lymphoma of the breast.

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A 41-year-old woman was admitted to the hospital because of suspected gastric cancer that was pointed out at a health screening test when two small ulcer lesions were revealed on upper gastrointestinal endoscopy. The patient was asymptomatic. There was previous history of undergoing a modified radical mastectomy with postoperative chemotherapy for a right breast cancre 14 months befor. After admission a preoperative biopsy disclosed poorly differentiated adenocarcinoma and she was operated on.
Operative finding included one lesion in the jejunum other than the stomach and the swelling of paraaortic lymph nodes. Distal gastrectomy and partial wedge resection of the jejunum were carried out. Pathological examination of the surgical specimens revealed solid tubular adenocarcinoma in each lesion, therby the diagnosis of metastasis of brest cancer to the stomach and jejunm was made.
Though it has been reported that breast cancer rarely metastasizes to the stomach and jejunum, breast cancer frequently metastasize to various organs, by nature. Entertaining the fact, we have to check up other organs including the gastrointestinal tract during a long postoperative course of the patients with breast cancer.

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A 74-year-old woman was seen at the hospital by an ambulant car because of feeling of heaviness in the chest and dyspnea following flu like symptoms. There was no previous history of trauma, and she had deneyed to undergo any operation for diaphragmatic hernia that was pointed out at the age of 30. After admission, a chest X-ray film revealed a displacement of the mediastinum and a massive gastrointestinal gas image in the left thoracic cavity. A diagnosis of respiratory insufficiency due to diaphragmatic herina was made. CT visualized prolapse of the stomach, small intestine, spleen, and a part of the transverse colon, and atelectasis of the left lower lobe. An operation was electively performed under oblique thoracolaparotomic incision. A diaphragmatic defect was 70×50mm in size and placed dorsolateral to an esophageal hiatus, that was most likely a Bochdalek foramen hernia. The intraperitoneal organs could be easily restored without any adhesion, and no sac was observed. The diaphragm was enhanced by Marlex mesh after it was sutured and closed. When the thoracic cavity was observed, extralobar sequestration was detected just above the diaphragm and it was resected. An abnormal artery 10mm in diameter flowed into the sequestered lung from the aorta, and fine veins running along with the artery were also seen. During postoperative two days, assisted ventilation was performed for hypoventilation due to increased abdominal pressure, but thereafter, the patient recovered her health.

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In this paper, we report a relatively rare case of colliding gastric adenocarcinoma and esophageal squamous cell carcinoma near the esophagogastric junction. A 68-year-old man was admitted to the hospital because of appetite loss and body weight loss. A moderately differentiated adenocarcinoma on the esophagogastric junction was revealed by endoscopic examination and biopsies. In October 1995, a total gastrectomy with D2 lymph node dissection, splenectomy, partial resection of the liver and cholecystectomy were performed in this patient. Postoperative pathological diagnosis was collision tumor of gastric adenocarcinoma and esophageal squamous cell carcinoma. We supporsed that the esophagogastric junction at where squamous cells are adajacent to granudular epithelium should be the origin of the colliding cancer, but contrary to our prospection, cases reports on the colliding cancer at the site were few. As far as we could review, only six cases of colliding gastric adenocarcinoma and esophageal squamous cell carcinoma at the esophagogastric junction have been reported in the Japanese literature.

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We experienced a case of multiple carcinoid of the stomach with hypergastrinemia and type A gastritis in a 35-year-old man. Upper gastrointestinal series revealed an about 1cm polyp of Yamada's type II or III in the posterior wall of the upper body of the stomahc adjacent to the greater curvature and multiple minute polyps ranging from the upper body to fornix. All polyps were diagnosed as carcinoid on endoscopic biopsy. Ultrasonic endoscopy revealed that the lesions were localized in the submucosal layer. Serum gastrin level was as high as 1, 950pg/ml.Total gastrectomy was carried out and multiple gastric carcinoids (sm, n0) with type A gastritis were histologically confirmed. After the operation, serum gastrin level was normalized and the patient has been doing well as of 3 years or more after the operation.
In the treatment of multiple gastric carcinoid with type A gastritis, total gastrectomy with lymph node dissection would have to be the standard operative procedure, in order to resect the fundic gland area completely which can be the origin of carcinoids and endocrine cell micronest.

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We report herein an unusual case of advanced gastric cancer in a 60-year-old man who survived over 10 years after a gastrectomy which resulted in non curative operation for wide-ranging involvement of lymph nodes extending to the paraaortic lymph node. The patient underwent a total gastrectomy, distal pancreatectomy, and splenectomy with D3 plus partial D4 lymph node dissection for advanced gastric cancer of Borrmann type 3 in 1983. Post operative histological examination revealed poorly differantiated adenocarcinomas in 45 out of the 52 resected lymph node including paraaortic lymph node. The patient uneventfully recovered and was discharged on the day 35 after the surgery. No postoperative chemotherapy was added. The patient had been followed on an ambulant basis for 2 years after the surgey, but thereafter he discontinued visiting the hospital. Ten years after the surgery, the patient was seen at the clinic because of intermittent abdominal pain. Abdominal X-ray, computed tomography and abdominal echogram revealed choledocholithiasis and a tumor mass along the abdominal aorta. The patient underwent a radical surgery for choledocholithiasis and excisional biopsy for histologic diagnosis of the tumor mass along the abdominal aorta. Postoperative histological examination of the biopsy sample revealed poorly differantiated adenocarcinoma. These findings showed that the remnant cancer cells coexisted with the patient without marked growth and expansion during 10 years after the surgery. We might have to reconsider the significance of dissection of paraaortic lymph node in the operation of gastric cancer.

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A 30-year-old man was admitted to the hospital because of left hypochondralgia on a fasting stomach and tarry stool. Gastroscopy revealed a large submucosal tumor-like lesion in the middle body on the grater curvature. Biopsy of the tumor showed squamous cell carcinoma. Extensive survey did not reveal any cancer except the stomach one; hence the diagnosis of primary squamouscell carcinoma of the stomach was made. Total gastrectomy combined with partialresection of the transverse colon, splenectomy and cholecystectomy was performed. Macroscopic findings revealed a large gastric tumor, about 7cm in longitudinal diameter, laying beneath the mucosal layer. Histological examination disclosed that nearly the whole part of the tumor consisted of pure well differentiated squamous cell carcinoma, except a very limited portion of the gastric mucosa, where poorly differentiated adenocarcinoma with signet ring cell was found, which showed a smooth transition to squamous cell carcinoma. According to the General Rules for the Study of Gastric Cancer, 12th ed., proposed by the Japan Gastric Cancer Association, primaryadenosquamous cell carcinoma of the stomach was diagnosed in this case.
There is no sign of recurrence as of 1 year and 3 months after the operation.

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We experienced a case of right paraduodenal hernia causing strangulation of the small intestine. A 18-year-old female was seen at the hospital because of severe abdominal pain. She had a tender, fist-sized tumor at the right mid-abdomen. Abdominal computed tomography (CT) demonstrated clustering loops of the small intestine along with thickened mesenterium and mesenteric vessels in linear structure. These findings suggested the existence of strangulation of the small intestine. At laparotomy, it was found that the small bowel was impacted into the right side of the retroperitoneal space through an opening of the right paraduodenal portion, the finding being consistent with right paraduodenal hernia. The incarcerated bowel was repositioned and the opening was closed. Paraduodenal hernia is one of the internal abdominal hernias which is seldom encountered in daily practice. Therefore, an intestinal obstruction secondary to internal hernias can be hardly diagnosed preoperatively. However, the cystic accumulation of the small intestine on CT images is characteristic of this pathology, and may be great help in the preoperative diagnosis as was the present case. It is advised that paraduodenal hernia should be taken into account in the diagnosis of the intestinal obstruction, particularly, in patients without any history of laparotomy.

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A case of primary lymphoma of the duodenum is presented. A 67-year-old man was admitted to the hospital because of an epigastralgia and tarry stools. We recognized anemia at his blood test. Upper GI endscopic examination showed an ulcerative lesion at the duodenal second portion. Biopsy specimen yielded the findings suggestive of malignant lymphoma. Pancreaticoduodenectomy with Imanaga method repair was carried out. Histologic examinasion of the duodenal lesion revealed non Hodgkin lymphoma, diffuse large cell type. A complete remission was attained after the operation. There has been no sign of recurrence of the lymphoma for these five months. We are going to add chemotherapy to him.

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We experienced a case of lymphangioma of the jejunum in which the location of tumor was able to be diagnosed preoperatively. A 52-year-old woman was admitted to the hospital because of left abdominal pain and nausea. Plain abdominal roentgenogram showed a little gas shadow of the small intestine. Neither endoscopic examination of the upper gastrointestinal tract nor abdominal ultrasonography disclosed any abnormalities. X-ray examination of the small intestine revealed a lobulated filling defect in the jejunum, measuring 2 cm in size. Partial resection of the jejunum was performed. The tumor was located at 130 cm apart from the Treitz's ligament, measuring 15×20 mm in size and yellowish white in color. Histopathologically it was diagnosed as cavernous lymphangioma. Lymphangioma of the small intestine is so rare that only 26 cases have been reported in Japan.

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Leiomyosarcoma of the small intestine is rare, and tends to metastasize hematogenously to the liver or peritoneum. We experienced a resected case of solitary retoroperitoneal metastasis 5 years after the primary resection of jejunal lesion. A 50-year-old man undergoing a partial resection of the jejunum for a jejunual endoenteric leiomyosarcoma without postoperative chemotherapy 5 years before was pointed out having a mass at the caudal side of the pancreas by abdominal CT scan. Under a probable diagnosis of recurrence of the jejunal leiomyosarcoma, an excision of the tumor was performed.
As the route of metastasis in this case, lymph node metastasis was most likely, but a possibility of another primary tumor could not be ruled out. In the Japanese literature only another one case has been reported in which retroperitoneal recurrence of small intestinal leiomyosarcoma was successfully excised. Leiomyosarcma of the small intestine would demand careful follow up and active resection if it recurs.

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Schwannoma of the small intestine is very rare, especially malignant schwannoma. There have been only 16 cases in the Japanese literature. We experienced a case of preforated malignant schwanoma of the jejunum.
A 68-year-old man was seen at the hospital because of a severe abdominal pain. Gastro-intestinal series with gastorografin showed an abnomal shadow and a leakage of contrast medium from the jejunum 10 cm from the Treitz ligament. Perforation of the jejunum was suggested. At operation a partial resection of the jejunum involving the elastic-hard tumor at the mesentric side was performed. No peritoneal dissemination nor liver and lymph node metastasis was recognized. Microscopically the tumor consisted of spindle cells and round cells. The tumor very mimicked leiomyosarcoma. On immunohistochemical staings the tumor was positive for S-100 and negative for desmin. Then histological diagnosis of the tumor was malignant schwanoma of th jejunum. The patient died of recurrence in the abdominal cavity after 2 years and 5 months after the operation.

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We report a case of leiomyosarcoma of the ileum that is rare in tumors of the gastrointestinal tract. A 70-year-old man was admitted to the faculty because of tumor in the right lower abdomen. On barium study of the small intestine, a narrowing of the lumen and leak of barium out of the lumen were detected in the ileum. Abdominal ultrasonography visualized a well defined mass that was heterogenous in the internal echo. Abdominal CT showed an enhanced tumor measuring 8×9cm, in which the cystic formation was seen with air density area. Angiographically there was a tumor stain feeded from the ileal branch. Leiomyosarcoma was strongly suspected preoperatively, and a partial resection of the ileum including the tumor was carried out. In resected specimen, the extraluminally grown tumor and the ulcer were recognized in 80cm oral from the ileocecal valve. The portion that appeared to be a cyst on CT was proven to be necrotized abscess cavity and be passed to the ulcer. Histopathological diagnosis was made as leiomyosarcoma because mild nuclear atypism, two mitotic figures in ×400 field, the tumor more than 5cm in diameter, central necrosis, and ulcer formation were confirmed.

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We experienced a rare case of leiomyosarcoma of the jejunum with von Recklinghausen's disease (VRD). A 59-year-old woman was seen at the hospital because of anemia and epigastraligia. On physical examination, there were cafe au lait spots and multiple skin nodules over the entire body which revealed VRD. Because an abdominal tumor was found around the umbilicus, ultrasonography, X-ray examination of the small intestine, CT and angiography were carried out. They suggested a small dumbbellike tumor (7cm in diameter) of the jejunum. At operation, the intra-extratubal growing tumor was found in the proximal jejunum and a partial enterectomy was performed. The histopathological examination showed that it was leiomyosarcoma.
There are only 30 reported cases of leiomyosarcoma of the gastrointestinal tract with VRD which include the present case just reported. Some notes on the desease in a review of the literature are also presented here.

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A 62-year-old man was admitted to the hospital because of anal bleeding. Abdominal ultrasonography and computed tomography showed a mass of the right lower abdomen. Gastrointestinal barium studies revealed stenosis of the ileum, and angiography demonstrated a hypervascular mass. With a preoperative diagnosis of tumor of the small intestine a partial resection of the ileum was performed. The excised tumor was 7.0×5.0 in size. Pathologically diffuse proliferation of malignant plasma cells was shown. No M. protein and Bence Jones protein were detected. Bone scan and bone marrow puncture were unremarkable. Therefore we diagnosed the tumor as extramedullary plasmacytoma originated from the ileum. Extramedullary plasmacytoma of the small intestine is extremely rare. We report such a rare case with a review of the literature.

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A 67-year-old man was admitted to the hospital because of increasing right lower abdominal pain and fever elevation. On physical examination a tumor was palpated in the right lower abdomen. It was associated with redness and tenderness, and muscle guarding was present. Laboratory data showed the existence of severe inflammation. CT and echogram revealed intra-abdominal abscess close to the abdominal wall. Then drainage was performed. Irrigography showed multiple diverticula of the appendix, cecum and ascending colon. Tip of one of the appendiceal diverticula was communicated to the abscess cavity. Ileocecal resection was performed for abscess formation due to perforation of the appendix. Histological diagnosis was pseudo-diverticula of the appendix and cecum.
Surgical treatment including prophylactic appendectomy would be necessary especially for the aged with appendiceal diverticula because of the high risk of perforation and abscess formation.

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Disease of the appendix are common for our clinical surgions, but tumorous lesions in the appendix are relatively rare. Recently we experienced a case of appendiceal mucocele with a high level of serum CEA which was diagnosed preoperatively. A 66-year-old woman was seen at the hospital because of epigastric pain. Upper gastrointestinal series was performed and a high level of CEA in serum was pointed out. Barium enema examination showed a submucosal tumor in the cecum without demonstrating the appendix. On abdominal US and CT examination, a cystic mass with homogenous content was observed in the pelvic cavity and a diagnosis of appendiceal mucocele was estabilished. Ileocecal, resection was performed. Pathologically, it was diagnosed as mucinous cystadenoma. Serum CEA level, which had been as 11.8ng/ml, went down to the normal range 3.2ng/ml after the operation. The patient is followed up on an ambulant basis. There has been no sigh of recurrence and seurm CEA level is kept within the normal range, as of 2 years after the operation.

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This paper describes a case of primary adenocarcinoma of the appendix in a 53-year-old woman, together with an analysis of 132 cases seen in the Japanese literature from 1985 to 1995. The patient was admitted to the hospital because of right lower quadrant pain lasting for about one month when the pain was repeatedly intensified and relieved. With abdominal ultrasonography and computed tomography, a preoperative diagnosis of ileocecal abscess associated with appendicitis was made. An ileocecal resection including a two-third portion of the oral side ascending colon was performed. Histologically it was adenocarcinoma of the appendix. In a review of 132 cases reported in Japan in a recent decade, the chief complaints were unspecific such as right lower quadrant pain in 40%, abdominal mass in 14% and genitourinary complaint in 11% of the cases. Twenty-one patients had no symptoms caused by the appendiceal lesion. Preoperative diagnosis was made as acute appendicitis in 26%, cecal cancer in 6%, cancer of the ascending colon in 4%, ileocecal mass in 3% and cancer of the sigmoid colon in 2%, whereas cancer or tumor of the appendix in 20%. Another review of Japanese cases before 1987 shows that the correct preoperative diagnosis was made in much fewer cases than those of the last 10 years. In our review the number of the patients diagnosed as appendiceal carcinoma or appendiceal tumor, who preoperatively underwent ultrasonography, computed tomography, barium enema, or colon fiberscopy, was double of those whose preoperative diagnoses were incorrect. This fact shows that these methods should be tried to improve the preoperative correct diagnosing rate.

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The case involved a middle-sized 61-year-old man. Temporal transverse colostomy was made because of anastomotic leakage with pan-peritonitis 7 days after a low anterior resection for a lower third rectal cancer using double stapling technique. After 4 months and 22 days, a stoma closure operation was done, but re-leakage occurred at the old anastomotic site. We had to make another temporal colostomy at the ascending colon. Before closure operation for the second colostomy, we defined the status of healing of the old anastomotic leakage by some tests such as pressure test, defecation and flatus test. Thereafter a stoma closure operation was carried out 1 year and 4 months after the temporal ascending colostomy. The following course was uneventful. When we plan to close the temporal colostomy made emergently for anastomotic leakage after low anterior resection, we should decide the appropriate time for the closure, after making sufficient arrangements including background factors and the degree of the leakage, healing status of the anastomotic site, and a possible re-leakage.

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A 63-year-old man who had been followed up for chronic hepatitis B and A-Pshunt in lateral segment of the liver was admitted to the hospital because of a cancer of the ascending colon. The lesion of the liver had a very slow growth. Right hemicolectomy and lateral segmentectomy of the liver were performed. The tumor of the liver was pathologically diagnosed as non Hodgkin lymphoma. Primary Malignant lymphoma of the liver is very rare. There are only 53 cases of primary hepatic lymphoma reported in the world by our knowledge. We can expect that combination of hepatectomy and chemotherapy lead to a relatively good prognosis.

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We report a case of colonic cancer in which multiple hepatic metastases found intraoperatively were treated with microwave coagulation therapy and thereafter those metastases were histologically proved to be completely necrotized. A 58-year-old woman was admitted to the hospital because of colonic obstruction due to an advanced colonic cancer. Preoperative CT scan and ultrasonography revealed no hepatic metastases. When a left colectomy for the colonic cancer was performed, five metastatic lesions in the liver smaller than 1 cm in S4. S5, S6 and S7 segments were found out. A microwave needle electrode was inserted into the hepatic lesions to coagulate them in situ. Seven months after the operation a new metastatic lesion of the liver was detected, and nine months after the operation an extended right hepatectomy including all previously coagulated metastases was performed. Liver specimen histologically showed that coagulated hepatic metastases were completely necrotized. There has been no sign of recurrence, as of 18 months after the hepatectomy. We would stress that multiple hepatic metastses can be controlled with microwave coagulation therapy that offers a possibility of curative hepatic resection.

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A 67-year-old man was admitted to the department because of a hepatocellular carcinoma (HCC) with cirrhosis. On admission ICGR₁₅ was 32.5%, ICGRmax 0.32 mg/kg/min, endotoxin (Et) 22.0 pg/ml and hyaluronic acid (HA) 256 ng/ml, indicating extremely poor function of the liver and reticulo-endothelial system. Partial resection of the liver (S8 and S5) was performed with a microwave coagulator to treat multiple HCC. The patient developed deep shock and liver ischemia 8 hours postoperatively because he was imprudently given an antipyretic for a fever. Et, interleukin-6 (IL-6) and fibronectin (FN) levels at that time were 94.7 pg/ml, 1200 pg/ml and 170 μg/ml respectively. Endotoxin absorption (PMX) and plasma exchange (PE) were performed to prevent severe complications and Et, IL-6 and FN levels returned to the normal range. The patient was discharged from the hospital on the 39th postoperative day.
The function of reticuloendothelial system in patients with cirrhosis becomes worse due to high levels of Et and HA. Thus this case study indicates the importance of measurement of Et, FN and IL-6 levels immediately after operation. If any abnormity is found in these measurements, immediate steps are required to eliminate the Et by PMX and increase FN by PE, thereby preventing additional severe complications.

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A case of fatty changed, extremely well differentiated hepatocellular carcinoma formed large hyperplastic tumor is reported. A 49-year-old man was pointed out the liver disfunction at a medical checkup and underwent also examination at elsewhere. Ultrasonography (US) revealed a 60mm mosikeechoic tumor in the posterior superior segment (S₇). The patient was referred to the hospital. On admission he was diagnosed as hepatocellular carcinoma on imaging diagnosis which was avascular in spite of large size of the tumor. Especially an imaging in an abdominal angiography for the area consistent with the tumor showed negative evidence of hepatocellular carcinoma. A S₇ subsegmentectomy was performed. The difinitive pathological diagnosis was fatty changed and extremely well differentiated hepatocellular carcinoma, seen in the hyperplastic area. The tumor contained fatty cell in all areas. Well differentiated hepatocellular carcinoma cells were scattered partly and the liver stracture was still intact. A recent progress in imaging studies has facilliated the discovery of small liver tumors, in that large HCCs are comparatively easy to diagnose. Extremely well differentiated and fat-containing tumors often lack blood supply compared to advanced HCCs. Our experience indicates that we have to entertain a possible diagnosis of early HCC for an extremely large tumor in the liver over 60mm in diameter which does not destroy the liver structure.

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We successfully saved a patient's life who developed severe hyperbilirubinemia after choledochotomy by treating according to hepatic failure and by closing an external fistula.
A 53-year-old man was pointed out having gallstone when he was treated for hepatitis type C on an ambulant basis. HCV antibody was positive. On and after 4th hospital day, an increase in direct type dominant T-Bilirubin and increased and diluted exudate from a T-tube were observed. According to the treatment for postoperative hepatic failure. G.I. treatment was started, the T-tube was clamped, and eventually T-Bilirubin gradually decreased.
We sometimes experience that a large quantity of diluted bile juice is exuded from an external fistula in cases of impaired liver function or cirrhosis, but we are not able to find courage to perform the internal fistulization at present. It is thought that internal fistulization of external biliary fistula with make bile acid increase, an increase in endotoxin inhibit, the hepatic blood flow increase, and the relief of obstructive jaundice stimulate. When a case of hyperbillirubinemia exuding a large quantity of diluted bile juice from an enternal fistula is encountered, we can expect to accelerate the relief of obstructive jaundice by clamping of the T-tube. This procedure appears to be worth to try before plasma exchange.

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A 59-year-old man was urgently admitted to the hospital because of upper abdominal pain and hematemesis, who had been diagnosed as cholecystolithiasis at another hospital. On gastroduodenal endoscopy, hemorrhage from the papilla vater was identified and endoscopical bile duct drainage was performed. He was diagnosed as cholecystolithiasis and cholecystitis after CT examination and other examinations. Before operation, he vomited blood again and emergency abdominal angiographic examination was performed. A ruptured aneurysm of cystic artery was found and extravasation stopped after embolization of the cystic artery using a coil. Thereafter a fistula of doudenum into the gallbladder was formed. Cholecystectomy and closure of duodenal fistula were performed.
Aneurysm of the cystic artery is a rare cause of hemobilia and angiographic examination is essential for hemostasis as well as diagnosis.

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A 78-year-old man was seen at the hospital because of right hypochondralgia. Abdominal imaging revealed an air in the gallbladder and intrahepatic bile duct. Abdominal ultrasonography revealed a high echogenic area where coincided with the gallbladder and another high echogenic area due to gas in the intrahepatic bile duct. Under a diagnosis of acute emphysematous cholecystitis (AEC), percutaneous transhepatic gallbladder drainage (PTGBD) was carried out immediately. With cultivation of bile juice collected during drainage, Clostridium perfringens was detected. Fifteen days after the drainage, a cholecystectomy with mini-laparotomy was carried out easily. The treatment of choice for AEC has been considered to be early surgery because of high risk of gangrene and perforation of the gallbladder wall, therefore PTGBD has been thought to be contraindication. In this patient, PTGBD was chosen for the initial intervention and the post-drainage course was uneventful. It is considered that PTGBD can be employed for AEC in the majority of the cases.

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A 53-year-old woman without particular subjective symptom was pointed out a dilatation of the common bile duct by an abdominal ultrasonography on a medical checkup. No abnormalities were noted in laboratory studies of peripheral blood, biochemical analysis, and tumor makers. DIC examination suggested a dilatation of the common bile duct. ERCP examination visualized a shadow defect 7mm in size in the lower bile duct. A cancer of the lower bile duct was suspected and whole stomach preserving pancreatoduodenectomy was carried out. Resected specimen revealed a whole-circumferential elevated lesion of the lower bile duct. Histopathologically it was hyperplasia of the mucosa with slight inflammation (inflammatory hyperplasia). A rare entity of benign biliary stricture in this case together with a review of the Japanese literature is presented here.

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The utility of abdominal computed tomography (CT) was evaluated in 8 patients with pancreatic trauma in an acute phase of injury. Abdominal CT findings seen in early period after injury were determined in 2 patients with type I injury, 2 patients with type II injury, and 1 patient with type IIIa injury, and 3 patients with type IIIb injury (The Japanese Association for the Surgery of Trauma Classification of Pancreatic Injuries). In patients with type II and III injuries, the adipose tissues of the pre-renal space, transverse mesocolon, and mesentery of the small intestine increased in density, suggesting severe pancreatic damage. Distinction between types II and III injuries was sometimes difficult. In one patinet who was suspected of pancreatic disruption on CT scan, intraoperative pancreatography revealed no major duct disruption, and in another patient, pancreatography showed major duct disruption, although CT suggested a type II injury. Since the key determinant of the outcome of pancreatic trauma is the presence or absence of ductal injury, pancreatography should be performed aggressively in such patients to discriminate type III without any delay and to avoid mis-judgement in selecting candidates for surgery.

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The rule of the surgical treatment of insulinoma is its perfect resection, but the localization of insulinoma is very important to select the operative procedure.
We experienced recently an insulinoma that was detected by preoperative procedure and enucleated successfully with intraoperative ultrasonography (US) and CUSA (Cavitron. Ultrasonic Surgical Aspirator). A 28-year-old female had a cold sweat and numbness in the hands sometimes from the summer of 1991. In May, 1993, she was admitted to the hospital because of cold sweat and numbness in the whole body. An intraparenchymal insulinoma of the pancreas head was detected by abdominal US, CT, and angiography. The tumor was enucleated safely by using intraoperative US and CUSA at a low amplitude. There has been no evidence of recurrence in postoperative examinations.

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A 70-year-old male was seen at the hospital because of an epigastric discomfort and epigastric tumor. A fistsized, elastic hard and unmoved tumor was palpable in the upper, a little right abdominal region. Abdominal ultrasonography and CT scan showed a 7.0×5.5cm tumor of the pancreas head oppressing the portal vein and inferior vena cava, and angiography showed a hypervascular tumor. No primary nor metastatic lesion was recognized in the limbs and soft tissue in the body. Tumor markers and serum bilirubin level were within normal limit, but a pylorus preserving pancreaticoduodenectomy was performed under a diagnosis of malignant tumor of the pancreas head. By the pathological findings and special dyeing the tumor was diagnosed as malignant fibrous histiocytoma (MFH).
MFH has a tendency to enlarge rapidly without provoking jaundice, ever if it arises in the pancreas head, but active resection can be a curative therapy.

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A 45-year-old man was seen at the hospital because of epigastric pain, nausea and vomiting. Radiography and endoscopy of the upper digestive tract suggested pyloric stenosis. On blood examination, the carbohydrate antigen 19-9 (CA19-9) and gastrin levels increased to 347U/ml, and 829pg/ml, respectively. Distal gastrectomy was performed. Histopathological examination revealed adenocarcinoma cells resembling the epithelium of the pancreatic duct existed betweeen the submucosal and subserosal layers as well as heterotopic pancreas in the focus. On immunohistological staining, the epithelium of the aberrant pancreatic duct as well as the cancer cells were positive for CA19-9. Furthermore, cancer cells were partially positive for gastrin. Therefore, the present case was diagnosed as primary adenocarcinoma of aberrant pancreas in the stomach wall. Carcinoma of aberrant pancreas in the stomach is extremely rare, and only 18 cases have been reported in Japan.

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A 60-year-old man was seen at the hospital because of abdominal pain. Before surgery a most probable diagnosis was tumor in the body of the pancreas. On exploration of the resected material before formalin fixation, it appeared a primary tumor of the pancreas with extensive central necrosis. Histopathologically the patient was diagnosed as having an acinar-islet cell carcinoma.
Acinar-islet cell carcinomais a very rare entity. There have been only five cases in the Japanese literature so far as we could review. In this paper six cases including ours are reviewed in terms of the imaging diagnosis. On abdominal ultrasonography these tumors were visualized as well-defined tumor with heterogenous internal echo. On abdominal CT these tumors were characterized by well-defined tumor with low-dencity area. Endoscopic retrograde cholangio-pancreatography showed no charsacteristic findings. With abdominal angiography deep stained tumors were confirmed, but no encasement was seen in them.

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In order to prevent complication due to ischemia resulting from resection of the common hepatic artery at Appleby's operation, intraoperative hepatic circulation should be evaluated objectively. We experienced a case of cancer of the pancreatic head in which intraoperative saturation of heaptic venous oxgen (Shvo2) was measured, and after comfirming a sustained low level, the common hepatic artery was successfully reconstructed without any complications.
A 66-year-old man was admitted to the hospital because of epigastric pain. He was diagnosed as having a cancer of the body and tail of the pancreas on imaging methods, and was operated on. On laparotomy it was found that the tumor invaded the root of the common hepatic artery. An Appleby's operation, therefore, was performed. When the common hepatic artery was tentatively shuted off, the Shvo2 decreased to 39% from 70% which gradually increased to 50% after reopenning the artery, but did not recover the level before the procedure. After the common hepatic artery was reconstructed, Shvo2 level increased to 70%. Histologically the tumor was moderately differentiated adenocarcinoma.
Intraoperative monitoring of Shvo2 is a useful method to evaluate continuously the intraoperative hepatic circulation at real time, and the common hepatic artery should be reconstructed to prevent complication due to ischemia, if the level was kept at less than 60%.

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This paper describes a patients surviving for about 10 years after a total pancreatectomy for an adenosquamous cell carcinoma of the pancreas, together with a review of the literature.
A 36-year-old man was admitted to the hospital because of an upper abdominal tumor. With close examination, the patient was diagnosed as having a carcinoma of the body of the pancreas. On December 2, 1985, a total pancreatectomy with combined resection of the portal vein was carried out. After the operation the tumor was histologically diagnosed with adenosquamous cell carcinoma of intermediate type, IFNγ, ly1, v1, ne1, mpd(+), s2, rp2, ch0, du0, pvp2, pvsp2, asp2, p1(-), pw(-), bdw(-), and ew(+). And it was rated as t3, n1 ((8) 5/8, (18) 2/5, totally 7/50), stage IVa and curability B. As to chemotherapy, cisplatin (100mg) was preoperatively administered via the celiac artery, followed by oral tegafur in a dose of 600mg/day for postoperative one year. Adenosquamous cell carcinoma of the pancreas is a relatively rare entity. Some researchers have reported that the entity has a poor prognosis among invasive pancreatic duct cell carcinomas. This patient, however, has recovered his social activity and there has been no sign of recurrence as of 10 years after the total pancreatectomy.

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A 58-year-old man was seen at the hospital because of a left lower abdominal mass. Abdominal CT revealed a giant tumor in the left lower abdomen, which had infiltrated into the left rectus muscle of the abdomen, being adjacent to the left iliopsoas muscle and greater psoas muscle posteriorly, and displacing the left exterior iliac artery and vein posteriorly. Because a malignant fibrous histiocytoma or liposarcoma was suspected from percutaneous needle biopsy, extended resection with a sufficient surgical margin from the tumor and reconstruction of the abdominal wall using autologous fascia lata to make up for a defect of the abdominal wall were conducted. The histopathological diagnosis was made as polymorphic liposarcoma, and the CYVADIC therapy was carried out to prevent any postoperative remote metastases.
Liposarcoma arising in the abdominal wall is extremely rare, and there are no such case reports in Japan. Reconstruction of the abdominal wall using autologous fascia lata, which carriers a low risk of infection, is useful for malignant soft tissue tumors in the abdomen that require both abdominal wall reconstruction together with extensive local resection and postoperative chemotherapy.

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A 69-year-old woman underwent a laparotomy with a preoperative diagnosis of umbilical tumor, right inguinal hernia and cholelithiasis in May 1986. Operative findigns showed pseudomyoma peritonei arising in the appendix and it caused the both umbilical and inguinal hernias containing gelatinous mucus. After repairing the hernias, the appendix and metastatic greater omentum were removed as possible as we could. Although abdominal cavity was washed out with bolous normal saline solusion, a large quantity of gelatinous material was left. A 60mg of mitomycin C was dispersed in the abdominal cavity. Tegafur suppository at a dose of 750mg per day was prescribed on and after postoperative day 15 (until October 1988). Thereafter, she underwent laparotomies for three times in January and September 1987 and October 1988 with a diagnosis of cicatricial hernia, and complete response to postoperative chemotherapy was confirmed because no mucinous tumor was identified in the abdominal cavity. The patient is doing well without any signs of recurrence as of 11 years after the initial laparotomy.

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Cavernous lymphangiomas commonly found in the neck and axilla of the infant, but rarely in the retroperitoneal in the adult. We report a rare case of retroperitoneal cavernous lymphangioma in a 59-year-old female. She was referred to the hospital for investigation of an abdominal tumor which was found incidentally at another hospital. She was symptom-free and laboratory study revealed no abnormality though an ultrasonography showed a right retroperitoneal polycystic tumor which compressed the right kidney and gallbladder. On operation, the polycystic tumor measuring 16.3×11.5×5.2cm in size tightly adhered to the right renal artery which was feeding the tumor. The tumor was completly excised from the retroperitoneal space anterior and inferior to the right kidney. The final pathologic diagnosis was cavernous lymphangioma. No malignat findings were noted.

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Intestinal obstruction is a rare complication during pregnancy, and almost all causes are considered to be secondary adhesions in a patient with a surgical history. During pregnancy, there have been only a few reported cases of internal hernia. An internal hernia is formed by the protrusion of a viscus through a peritoneal fossae or anomalous opening in the mesentery leading to its encapsulation within a compartment of the abdominal cavity. The difficulty of diagnosis of the disease associated with pregnancy which limits diagnostic investigation also brings a dangerous combination of bowel obstruction.
We present a case of internal hernia caused by anomalous opening in the falciform ligament in a pregnant woman of the 37th week of gestation. She underwent a cesarean section, followed by lapalotomy which revealed intestinal obstruction through the opening in the ligament falciform. The ligament was divided and 40cm of the small intestine was resected.
In patients with symptoms suggestive of bowel obstruction during pregnancy, internal hernia must be included in the probable differential diagnoses.

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A 72-year-old woman was seen at the hospital because of discomfort on a bulge in the left lower quadrant which had been noticed for 10 years. There was no previous history of undergoing operation. The bulge 4cm in diameter was present in the left lower quadrant in the erectile position, but it reduced in the supine position. Other abnormalities were not noticed on the physical examination. Though we could not detect the content of the bulge on ultrasonography and computed tomography, a Spigelian hernia was suspected. The patient was operated on. After division of the aponeurosis of external oblique muscle, the preperitoneal fat pad was seen, and a defect 7×3cm in size in the aponeurosis of internal oblique muscle and transverse abdominal muscle was also revealed. The content of the bulge was found to be the preperitoneal fat pad. We considered that the weakness of aponeurosis of the internal oblique muscle due to aging might cause the hernia.

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A 32-year-old woman was seen at the hospital because of a mass and pain below the umbilicus. Abdominal ultrasonography indicated that the mass was a portion of the small intestine, and the dilated small intestine in the abdominal cavity was also revealed. She was admitted for an emergency surgery under a diagnosis of incarcerated lower abdominal linea alba hernia. The incarcerated hernia was released after anesthetic muscular relaxation. The sac was found protruding through the linea alba defect and dissected out, then the hilus of the hernia was closed.
Linea alba hernia is a very rare condition, and only 40 cases including our case have been reported in Japan. The hernia occurred in the lower abdomen in only three cases of them. All three of these patients were obese females, and abdominal high pressure due to obesity in combination with weakness of the linea alba was considered to be the main cause of the lower abdominal linea alba herniae.
We reported this case with reviewing of linea alba herniae in Japan.

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We report a case of non-clostridial gas gangrene (NCGG) with untreated diabets mellitus, which was successfully treated by oxygen at high pressure (OHP). A 39-year-old man had been diagnosed as diabetes mellitus some years before, but had not been treated. On April 1994 he was admitted to another hospital because of fever elevation and a swelling of the left foot. Administration of antibiotics was not effective nd a plain roentgenogram revealed gases in the subcutaneous tissue and muscularis. Therefore, he was referred to the hospital. Immediately after admission, adequate control of serum glucose, random skin cutting, administration of antibiotics and prostaglandin E₁ and OHP were carried out. Gases disappeared after OHP and he recovered with conservative treatment without amputation of the left foot, though it took a long time. A diagnosis of NCGG was made because Peptostreptococcus anaerobius was isolated on admission. OHP is effective for the treatment of NCGG as this case suggested. Therefore, OHP should be employed aggressively and we have to take more careful attitude to the amputation of the affected limb in the patients with diabetes mellitus.

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