Three hundred and thirty-four cases of upper abdominal surgery wound infection. Pre-and postoperative wound treatment, target organs, operative duration, the presence or absence of wound contamination and the bacterial species of contamination were investigated. Overall infection rate was 12.3%, and when preoperative skin brushing with povidone-iodine combined with postoperative surgical wound lavage treatments were added the infection rate decreased to 9.6% (12/125) from 13.9% (29/209). Diverse incidence was not observed among different target organs, but long operative duration (more than 5 hours) provided significantly high incidence compared to short duration (less than 3 hours). Surgical wounds were washed just before skin closure in 125 cases, and 92 of the 125 (74%) cases were positive for bacterial contamination. Among 82 cases in which external bacterial contamination was confirmed, only three cases had a wound infection, however, seven out of ten cases with internal bacterial contamination presented wound infection. On the contrary, in nine out of 12 cases of wound infection, bacterial culture of lavage of the surgical wound had provided the same bacteria that caused the wound infection. A possibility that contamination with internal bacteria determined in culture of surgical would lavage can be used as a predictive marker for wound infection is suggested.

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A series of 155 cases of differentiated carcinoma of the thyroid have been initially operation on at the institution, and 53 out of these 155 cases which had a minute carcinoma of the thyroid were subjected to a clinicopathological study, An average age was 53 and there were three men and 50 women. We have employed subtotal thyroidectomy with R1 lymph node dissection of the neck as the standard procedure. Histologically, 50 cases had a papillary carcinoma and the remaining three had a follicular carcinoma. Lymph node metastasis was observed in 42% of the subjects, and 25% of them had tumor invasion into the surrounding tissue. The 10 year survival rate of patients with minute thyroid carcinoma except those who died of other disease, however, was a good as 100%. Complications such as imparied thyroid function, tetany, and hoarse were noted in 42%, 6%, and 3%, respectively.
It is thought that even conservation surgery consisting of lobectomy and cervical lymph node dissection can result in a radical operation for minute thy roid carcinoma to avoid complications.

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The temperatures of central portion of both benign and malignant breast tumors were measured directly to study the clinicopathological significance of the tumor temperature. Particularly for malignant tumors, the relationships between the internal temperature and clinicopathological stage as well as prognostic factors such as vacularization were investigated. Subjects were 57 patients with breast tumor including 35 with breast cancer and 22 with fibroadenoma. During a needle aspiration biopsy cytology, a 21-gauge needle with a thermocouple sealed in the tip was inserted in the tumor under ultrasonic guide to measure the internal temperature, while simultaneously measuring the skin temperature just over the tumor. Vascularization of the tumor was determined by immunostaining method using a factor VIII related antigen.
Results: 1) The averaged temperature in the central part of the tumor was significantly higher in malignant cases (p<0.01). 2) The temperature tended to increase as the diameter of the tumor increased. 3) There was no difference in the temperature of the tumor center by tissue types or presence of n, ly, and v, but the temperature tended to increase in stage II tumors compared to stage I tumors. 4) In cases with high density of vascularization in the tumor, a greater difference in the temperature between the center of the tumor and skin over the tumor was noted.
Conclusion: The internal temperature of the breast tumors was significantly higher in the malignant cases than that in benign cases, and a close correlation between the temperature and vascularization of the tumor has been suggested.

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We have revealed that a dynamic study of the breast using MR Imaging technique can estimate objectively benign-malignant differentiative diagnosis. Subjects were 41 cases of breast lesion, including 13 cases of breast cancer, 21 cases of mastopathy, six cases of fibroadenoma and one case of intraductal papillomatosis, and the results of them were investigaged in comparison with histopathological diagnosis. As so the method, we drew up time-signal intensity ratio curve plotting signal intensity ratio at each 30 second of dynamic MR mammography after Gd-DTPA administration. We found a especially high significant difference between breast cancer and mastopathy, within 90 second after Gd-DTPA administration (p=0.0000). Still more, we established cut off point concerning with establishment of 95% confidence interval, that is, at 30 second after Gd-DTPA administration the point equivalent 1.53 at 60 second equivalent 2.00, at 90 second equivalent 2.47, and about this estimating maneuver using the cut off point we named Dynamic ratio method. We can estimate preoperatively not only benign-mallignent differentiative diagnosis with breast tumor, but also neighboring infiltration and lymph node metastasis of breast cancer using this Dynamic ratio method. Over again, Dynamic ratio method provides fine information to preoperative decision of resecting region for breast conserving surgery. The efficiency of this method is sensitivity=92.3%, specificity=89.3% and positive predictive value=80.0%

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To prove the usefulness and pitfall of ultrasonography guided core needle biopsy (US-CNB) for non-palpable tumorous lesions of the breast and to reveal these clinicopathological features, we carried out US-CNB at the outpatient clinic in thirteen non-palpable tumorous lesions in ten cases during a period from May 1996 to Oct. 1996. The results were: 1) The sufficient sampling rate for non-palpable tumorous lesions were which were possible to be pathologically diagnosed 84.6% (11/13). 2) One non-palpable tumorous lesion (class 3 by US-guided fine needle biopsy) was revealed to be a ductal cancer by US-CNB. 3) Most of non-palpable lesions which were visualized as low echogenic tumorous lesions on ultrasonography were revealed to be the epithelial hyperplasia lesion by US-CNB.
These results suggest that US-CNB is an acceptable sampling method for non-palpable tumorus lesion of the breast.

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In a period from 1980 to 1995, we experienced 67 cases of mucinous carcinoma (3.2%) out of 2, 801 primary breast carcinomas. These 67 cases were subjected to a study of clinical features and prognosis. There were 43 pure and 24 mixed types. Mean age of the patients was 54.1±14.2 years. TNM classification almost resulted in Stage I and Stage II but one patient of pure type and one patient of mixed type were in Stage IV. Only two patients (5%) of pure type mucinous carcinoma showed lymph node metastasis. Two patients with pure type mucinous carcinoma experienced recurrence to the lung, but they are still alive, as of 11 years 2 months and 4 years 11 months after the recurrence, respectively.
We suggest that if pure type mucinous carcinoma is exactly diagnosed, the operation without lymphadenectomy may be permitted.

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Mucosal damage to the whole stomach as an esophageal substitute, via the postmediastinal route, was pathologically investigated to elucidate the influence of postoperative radiation therapy. Subjects were 26 and 16 operated cases of esophageal cancer with and without postoperative radiation therapy, respectively. Endoscopic biopsy of the replaced stomach was performed preoperatively, before and after the radiation, and then at various different times for 2 years. The biopsy specimens obtained by endoscopic examination from the upper, middle and lower sites of the stomach were evaluated for the following pathological factors; atrophy, intestinal metaplasia, neutrophil infiltration, edema, erosion, necrosis and atypia. These findings were rated in score and changes in scores were studied. In both radiation and non-radiation groups, the degree of inflammatory change was strongest in the upper site, following middle and lower site in this order, in that some hematogenic involvement was considered. When the both groups compared for the inflammatory change, the changes in the radiation group were stronger than the other group in all sites. Necrosis and especially atypia were seen only in the upper and middle sites of radiated patients. Cronological inflammatory changes in each patient revealed that, as the site went up, the inflammation became stronger and was intensified by radiation therapy. But these inflammatory changes and atypia disappeared within a year after radiation therapy. These results suggest that postoperative radiation therapy would not be contraindicated for patients undergoing an esophageal substitution.

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Among patients who were operated on for colorectal cancer at the center, 30 patients with previous history of undergoing cholecystectomy (Group I) were compared clinicopathologically with 799 patients with a confirmed absence of gallstones (excluding those with a previous gastrectomy history) (Group II).
The male to female ratio was high in females of Group I. The average age was 66.8 in Group I and 60.1 in Group II, suggesting a higher age distribution in Group I. As for the location in the colon, the incidence of the left side of the colon was significantly higher in Group I than in Group II (p<0.05). Macroscopic findings showed a tendency for predominance of Type I in Group I, with a significant difference (p<0.05). No significant differences were recognized in the histologic findings, depth of invasion, lymph node metastasis and vessel invasion. The average level of serum total cholesterol in the right side of the colon was 151.0mg/dl in Group I versus 174.8mg/dl in Group II, with a significant difference (p<0.01). The 5-year survival rates were 59.0% in Group I and 76.2% in Group II in curability A. These results suggest that colorectal cancer following cholecystectomy predominantly occurs in female and aged patients, develops commonly in the left side of the colon in a significantly high frequency, and has a poor prognosis. Serum total cholesterol levels were low in patients with previous history of cholecystectomy, but any finding suggesting a relationship between previous cholecystectomy and the subsequent development of the colorectal cancer was not identified.

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From January 1986 to March 1996, 86 cases have been operated on for abdominoaortoiliac occlusive disease in the hospital. There were 13 female patients who represented 16.3% of all patients. These female patients were assigned to group I and 73 male patients to group II, and were comparatively studied for age distribution, preoperative medical condition, preoperative laboratory data, postoperative complications and surgical results.
The average age in the group I and group II were 74.9 and 67.9 years, respectively. There was no significant difference between both groups in preoperative medical condition except that the group I had more patients with coronary artery disease than group II. Therefore, surgical treatment for coronary artery disease was also required in the group I. Postoperative complications more freguenthy occurred in the group I than the group II. One patient died during surgery in each group.

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The titanium Vascular Closure Staple (VCS) clip application system which had been established for peripheral vascular anastomosis was used in blood access surgery for hemodialysis in our center. Subjects were ten patients undergone blood access operation between February and May of 1997. Operative procedures included arteriovenous fistula in two patients, artificial graft implantation in six patients, reconstruction of the radial artery in one patient, and closure of an artificial graft in one patient. In all patients the vascular anastomosis was completed by using VCS clips, when it took 12 minutes in an average for the artificial graft anastomosis and 8.5 minutes in an average for arteriovenous fistula. No bleeding from the anastomosed site occurred during surgery and after declamping. VCS clip is easy to deal with and shortens the time for anastomosis. On the other hand, VCS clip is expensive and a problem in the cost-performance is still unsolved. In the blood access surgery for hemodialysis, the use of this VCS clip appears beneficial especially for implantation and repair of artificial grafts.

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We think that “Informed Consent” is necessary to achieve good treatment and care for patients with cancer. We tell the truth to our patients regardless of the origin of cancer, staging, age and sex. From June 1992 to December 1995, we informed 707 operated cancer patients of their true diagnoses. We sent questionnaire forms to 538 out of those 707 patients who are still alive and appeared to be able to respond, and recovered the forms filled by them from 499 patients, a recovery rate of 92.8%. This questionnaire survey was made of 476 of the 499 patients whose stages were known. Irrespective of staging of cancer, about 90% of responders answered that it was best to told the truth, whereas 1% of them answered that they wanted to be told a lie even though they had a cancer. Furthermore, in oeder to respect the patient' s right not to know the truth, we started another questionnaire survey hearing of their wills at time of the first visit whether they wish to know their true diagnoses or not in April 1996, and thereafter we have been tellong the true diagnosis to only patients who wished to know. So far after starting the questionnaire, no patient has answered that he or she want to be told a lie even if he or she has a cancer.
We concludd that it is appropriate and possible to tell the truth to cancer patients and this questionnaire survey might contribute to hasten the “Informed Consent” in Japan.

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Gas gangrene in the neck region is very rare. A case of gas gangrene spreading in the neck is reported. A 59-year-old man having a history of diabetes mellitus and chronic hepatitis was admitted to our hospital because of pharyngalgia. He was treated with antibiotics. But he had severe swelling of the neck and a high fever after four days. By x-p and CT, some free air was found in the neck. He was diagnosed as having gas gangrene and had emergency complementary surgical drainage and debridement under general anesthesia. The postoperative course was good without any complications. To diagnose gas gangrene, CT is very valuable. Complementary surgical drainage and debridement are necessary for treatment of gas gangrene.

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A 58-year-old man was admitted to our hospital because of a subcutaneous abscess in the left sternoclavicular region. Two months before, he had undergone resection of a small intestinal puncture after a traffic accident and a left subclavian venous catheter was inserted. The patient underwent surgical exploration with removal of the necrotic bone under a diagnosis of left clavicular osteomyelitis.
We compared this case with 7 previously reported cases, and the results are as follows:
1) The condition that is most often followed by clavicular osteomyelitis is damage to the periosteum or a hematoma around the periosteum caused by venipuncture.
2) It is suggested that bacteria reach the periosteum by the following four routes: catheter infection, bacteremia, direct seeding from the skin where the catheter is inserted, when insertion actually takes place, and through the catheter after insertion.
3) To prevent this complication, it is important to make sure of the indications for subclavian venipuncture and to precisely determine the optimal method.
4) Surgical treatment should be chosen without delay when antibiotic treatment is unavailable.

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Primary angiosarcoma of the breast is a rare disease, accounting only for 0.04% of all malignant breast tumors. Clinical and pathological diagnosis of angiosarcoma of the breast is often difficult due to its deceptively benign-appearance, but misdiagnosis is fatal because of the poor prognosis of the tumor. We experienced a case of angiosarcoma of the breast in a 46-year-old female, initially diagnosed as having cavernous hemangioma. Further investigation with suspicion of angiosarcoma allowed correct diagnosis of angiosarcoma of the breast. Simple mastectomy without axillary dissection was performed and the patient has had no evidence of recurrent disease for 5 years to date. Whenever we encounter with a vascular lesion associated with any breast mass, a high index of suspicion for angiosarcoma is essential.

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Between 1983 and 1996, a series of 240 patients with early stage breast cancer were treated with breast conservative treatment, and 201 patients of them all received irradiation at a dose of 46-60 Gy to the affected breast. Among the 201 patients who received breast irradiation, four (2.0%) patients experienced radiation pneumonia. These four patients with radiation pneumonia presented with coughing from 7 to 20 weeks after irradiation. Chest X-ray film revealed interstitial pneumonia in a lung field where coincided with the irradiated field in them. Three out of four patients demanded steroids, but all patients got well within 4 months. Radiation pneumonia following conservative surgery and radiotherapy for breast cancer is an infrequent complication, but attention should be paid to radiation pneumonia if the patient suffers from persistent coughing after radiotherapy.

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We experienced an interesting case of anterior mediastinal mature treatoma. A 20-year-old woman was admitted to our department with a suspicion of mediastinal tumor found by chest roentgenogram. She had no symptoms but laboratory data showed elevation of serum SCC and CA19-9. Computed tomography and MRI revealed a heterogeneous multi-cystic lesion, measuring 11×11×9.5cm in size, located close to the right side of the heart. Under a diagnosis of anterior mediastinal teratoma, she underwent tumorectomy. The tumor had a capsule and contained fluid like oils, fat, and rice gruel with short hairs. It was histologically proved to be a benign mature teratoma consisting of several components such as epithelium, bone, cartilage, bone marrow, brain, thymus, pancreas, endometrium, endosalpinx and adipose tissue. CA19-9 and CEA were immunohistochemically demonstrated in the tumor cells. Postoperative course was uneventful and SCC and CA19-9 both decreased to within normal range.

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A 44-year-old man with was seen at the hospital because of a tumor in the left lateral chest wall. The tumor was located in the 8th rib of left lateal chest to scapla. Intraoperative exsicional biopsy was conduted, which ruled out any malignant neoplasmas. Complete radical tumorectomy was carried out. Histologically, no atypical spindle-shapd fibroblasts with abundant collagen had grown, and the tumor infiltrated into the muscle and scapla on a permanent paraffin block. The definite diagnosis of extraabdominal desmoid tumor was made. There has been no evidence of recurrence, as of 6 months after the surgery. Extra-abdominal desmoid tumors of the chest wall are rare an only 17 cases have been reported in Japan. In a review of the literature, local recurrence occurs so frequently that the complete surgery should be the treatment of this tumor.
We presented a case of extra-abdominal desmoid tumor with a review of the literature in Japan. The tumor including the first and second ris which was 8.0×6.0×2.5cm in size was resected en bloc.

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In a recent 4-year period we treated six patients with spontaneous rupture of the esophagus. They were all male and middle-aged with an average age of 44.0 years (ranging from 35 to 50). In all cases the rupture episodes were initiated with drinking followed by vomiting. The initial symptoms included epigastralgia in four, peritonitis signs in three, and back pain in two. On chest X-ray examination we found mediastinal emphysema in five, pneumothorax with pleural effusion in three, subcutaneous emphysema in two, and pleural effusion in two cases. On fluoroscopic examination of the esophagus we could detect leakage of the contrast material from the esophagus in only four of six cases. In the remaining two cases the diagnoses were confirmed by thoracocentesis. The average value of the intervals between the rupture episode and establishment of the diagnosis was 33.0 hours. In three patients whose esophageal wall was highly degenerated, an external esophageal drainage was made using a T-tube and two of them took good course. When the T-tube was removed, fibrin glue was injected into the fistula, and so the early and complete healing was accomplished. Because the earlier establishment of the diagnosis makes its clinical course better, we think that it is most important to mind this disease on the primary care.

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We evaluated the expandable metallic stent (EMS, GIANTURCO-RÖSCH Z-STENTS, 12mm in diameter, Cook, Bloomington, IN, USA) for use as an endoprosthesis in esophageal stricture, in comparison with a plastic prosthesis (PPS, ESOPHAGEAL PROSTHESIS, 14mm in diameter, Sumitomo, Tokyo, Japan). From April 1987 to March 1995, EMS was intubated in three patients with esophageal stricture caused by lymph node metastasis from colon cancer, corrosive esophagitis and primary esophageal cancer, respectively. An additional three patients were intubated with PPS for esophageal strictures due to primary esophageal cancer, recurrence of gastric cancer and invasion of cardiac cancer, respectively. EMS and PPS were intubated under local or general anesthesia. One of the three patients intubated with EMS was able to ingest semisolid food after treatment, but the other two patients could not ingest food because of restenosis and reflux esophagitis. A bronchoesophageal fistula developed in one patient treated with EMS and migration occurred in another. On the other hand, two out of the three patients intubated with PPS were able to ingest semisolid food following this procedure, although the other patient could not because of ileus due to peritonitis carcinomatosa. Restenosis of the distal edge of the plastic prosthesis caused by tumor growth occurred in one case and mild reflux esophagitis in another. The insertion of EMS was easy to perform but the removal was impossible. Intraluminal restenosis occasionally occurred in EMS, but not in the PPS intubated patients. The insertion of PPS was necessary under general anesthesia on a case by case basis. In general, migration, bleeding and penetration occurred in both groups. For the management of esophageal stricture, a good knowledge of the characteristics of the endoprosthesis (EMS or PPS) and its selection criteria are important. The indication for an esophageal endoprosthesis should be carefully determined.

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A 70-year-old male was admitted to our hospital with a complaint of dysphagia. The patient had experienced dysphagia since 32 years of age with gradual exacerbation over the previous 10 year. He was diagnosed as having achlasia. An esophagram revealed dilatation of the lower esophagus and narrowing of the gastroesophageal junction. On endoscopy, a slightly depressed lesion was detected in the middle of the esophagus. Lugol staining showed an irregular-shaped, non-stained lesion measuring about 4cm in diameter. The pathological findings indicated moderately differentiated squamous cell carcinoma. We diagnosed achlasia associated with superficial esophageal carcinoma (Type 0-IIc). Blunt dissection was performed. Macroscopically, the lesion was 3.6×2.8cm in size. Pathological studies revealed a poorly differentiated squamous cell carcinoma reaching to the muscularis mucosae (mm3). Although many achlasia cases with advanced esophageal carcinoma have been reported, those associated with superfical carcinoma, like our case, are rare.

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A 48-year-old man had clashed with a central separating line on a highway when he had been driving his car equipped air bag after drinking about five a.m. on November 2, 1996. He had not worn a seat belt, but the air bag operated. Once he went to the office, but an abdominal pain that he had at the clash was intensified and he was transferred to the hospital by an ambulant car about eleven a.m. There were prominent abdominal distension and tenderness in the entire abdomen. Abdominal CT revealed intraabdominal bleeding and a tumor with high and low density portions concomitantly on the posterior wall of the stomach. An emergency operation was carried out, and approximately 1.5l of hemorrhagic ascites was noted, as well as an extramurally growing tumor with the size of 95×85×62mm in the posterior wall of the middle portion of the gastric body adjacent to the greater curvature. The surface of the tumor was irregular and elastic hard. The tumor itself presented a state of hemangioma and bled. A gastrectomy was conducted with a diagnosis of leiomyosarcoma of the stomach. Histopathologically it was leiomyosarcoma of low grade of malignancy. The postoperative course was uneventful and the patient was discharged from the hospital on the 24th hospital day. When only airbag operates without wearing a seat belt, in almost all cases, the face, neck, and chest are injured and the abdomen is rarely involved. It is thought interesting that this case had an abdominal injury in which only gastric leiomyosarcoma was injured and other organs were intact.

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A 30-year-old woman was admitted to our hospital because of sudden hematemesis. Emergency endoscopic examination of the stomach revealed a submucosal tumor with giant ulcer and another submucosal tumor. The former was located in the upper corpus, and the later was in the lower corpus.
Biopsies from the ulcer edge showed only leiomyoma. However, the size (about 5cm in diameter), appearance, easy bleeding, and diagnostic images suggested leiomyosarcoma. Accordingly, operation (total gastrectomy+D2 lymph node resection) was performed. Histopathological examination revealed that two lesions were other leiomyosarcomas and that there was lymph node metastasis. Multiple gastric leiomyosarcomas are reported in only 10 cases (including ours) in Japan. This case is thus considered to be rare.

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During the recent three decades from 1966 to 1995, we treated 5 patients with gastric tube cancer after a radical esophagectomy for an esophageal cancer. These patients were subjected to a study of age, location of cancer, operative procedure, pathological findings, route of reconstruction at esophagectomy, as well as endoscopic findings, prognosis and the same factors mentioned above at surgery for gastric tube cancer. Mean age was 62 years (range: 57 to 68 at esophagectomy). All cases had undergone an transthoracic esophagectomy. Three cases were reconstructed via retrosternal route, and two cases via posterior mediastinal route at the time of esophagectomy. On the other hand, at the time of operation for gastric tube cancer, a mean age was 68.4 years (range: 63 to 71). Four cancers were located in the antrum, and three cases were performed surgical local resection (SLR). Three cases keep no evidence of disease, but one was dead due to exacerbation of the disease and one died of pneumonia after surgery for the gastric tube cancer. We suggest that SLR is useful technique for early cases, because of difficulty in radical resection for gastric tube cancer. It is important to go through endoscopic examination more than once a year regularly after surgery to detect the disease in an early stage.

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We present the case of a 66-year-old female with massive bleeding from a duodenal diverticulum. She had been admitted to our hospital twice because of tarry stool. The bleeding source had not been detected at the initial admission or two years later. She was readmitted because of marked tarry stool. Gastroduodenal fiberscopy showed blood coagula in a duodenal diverticulum but no bleeding from the stomach or bulbus. Upper gastrointestinal series showed two large duodenal diverticula in the duodenal second portion. No other examinations showed lesions that could be considered bleeding sources. Duodenal diverticulum was diagnosed as the bleeding source. Diverticulectomy with a Roux-en-Y duodenojejunostomy was performed. We report our patient and a review of the japanese literature.

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A rare case of intestinal volvulus with chylous ascites in a child is described.
A 13-year-old girl was admitted to the hospital because of low abdominal pain with sudden onset. There were tenderness and vebownd tendesness. CT scan revealed a lot of ascites and bowel obstruction. On emergency laparotomy, chylous ascites, intestinal volvulus rotating clockwise by 360, ischemic changes of the small intestine, and dilation of lymphducts in the mesenterium and intestinal serosa were observed. Since the small intestine was quickly recovered from the ischemic change after manual reduction of the voluvulus, intesitinal resection was not performed. In addition, cecum mobile and Meckel's diverticulum were found, which were considered the causative factor of the volvulus. Appendectomy and diverticulectomy were performed.
Postoperative course was uneventful, and there has been no sign of recurrence as of four years after the operation. It is thought that, though the origin of chylous ascites was obscure, the presence of cecum mobile might induce the intestinal volvulus to cause obstruction of the lymphducts, with the consequent lymphorrhea.

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It sometimes happens that the small intestine is delayingly disturbed because of ischemia resulting from injuries of mesenteric vessels due to a blunt abdominal trauma. This time, we report a case of ileal necrosis due to a mesenteric injury diagnosed after an operation that was performed for peritoneal irritation after three days from a blunt abdominal trauma. A 51-year-old man was seen at our hospital because his car was crushed by his own traffic accident and his chest and abdomen hit hard the steering wheel. The laboratory data on admission showed increases in white blood cells and CRP, but otherwise normal, therefore intraperitoneal viscera were not suspected to be injuried. But, on the 3rd hospital day, his abdominal pain increased in intensity and the peritoneal irritation and the remarkable inflammatory findings on laboratory data appeared, therefore, we performed an operation under a preoperative diagnosis of peritonitis. There was the ileal full thickness necrosis 7 cm wide at oral portion in about 90cm from the ileum end. The border between necrotic portion and normal portion was well-defined, and the mesentery of necrotic gut was lacerated. But there was no perforation of the small intestine, and an ileectomy was carried out. It was suggested that the delayed small intestinal necrosis was caused by the ischemia resulting from the injury of mesenteric vessels due to the blunt abdominal trauma.

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Postoperative enterocutaneous fistula is a very serious problem in abdominal surgery. Here in we report a case successfully treated for enterocutaneous fistula with two layer local flaps. Under a diagnosis of ascending colon cancer, a 78-year-old man had undergone right hemicolectomy and resection of the involved ileum and abdominal wall. On the 10th postoperative day, enterocutaneous fistula occurred at the midline incision. Although we tried various conservative treatments, the fistula had not closed six months after the first operation. Thus, we decided to attempt operative treatment. Under local anesthesia, the fistula was closed with a “donor flap”, and the new skin defect was covered with a “rhomboid flap”. Using these two layer local flaps, fistula closure was achieved, and the patient was discharged without fistula recurrence.

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We report a case of peritoneal mesothelioma with small intestinal perforation. The patient was a 64-year-old man admitted to our department because of right lower abdominal pain. Previously, he had been diagnosed as having asbestosis. The patient had rebound tenderness on physical examination and free air shadow under the bilateral diaphragma was revealed by chest X-ray examination. We performed emergency laparotomy under a tentative diagnosis of generalized peritonitis due to intestinal perforation. We detected a 5cm primary tumor under the right diaphragm, the peritoneum showed extensively scattered numerous nodules less than 2cm, and a perforating metastatic tumor on the ileum located 20cm from Bauhin's valve. We performed partial resection of the ileum and reconstruction by end-to-end anastomosis. Postoperative histopathological findings revealed that the tumor of the ileum was a peritoneal mesothelioma and the central necrosis in the tumor was perforated. Histological confirmation can be achieved by immunohistochemical study with colloid-Fe. Perforated small intestinal tumor leading to peritoneal dissemination of mesothelioma is not a common disease. However, it should be taken into consideration in the differential diagnosis of other diseases caused by generalized peritonitis.

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A 57-year-old man was seen at the hospital because of fever, right lower abdominal pain, and anal bleeding. An operation was performed with a preoperative diagnosis of appendicitis with abscess formation or diverticulitis. Upon laparotoy, a tumor in the mesentery of the ileum about 2m and 70cm distant from the Bauhin valve was found. The tumor was 11.5×9.0×8.5cm in size, had a communication with the intestine, and was filled with hematoma. The section of the tumor was cystic, a part of the cystic wall was thickened and reddish brown in color. Histopathologically it was diagnosed as leiomyoblastoma. There has been no sign of recurrence as of 5 months after the operation and the patient is doing well.
A total of 51 cases of leiomyoblastoma of the small intestine have been reported in this country. A mean age was 54.3, and there were 34 men and 18 women. The maximum diameter of these tumors was 7.8cm in average. The tumors tended to be found in upper portion of the small intestine. Those patients commonly complained of anal bleeding and black stool, and more than half of them had anemia. Abdominal tumor and abdominal distention were noted in 16 cases and fever in 8 cases. In almost all cases, surgions found a great deal of difficulty in diagnosis preoperatively and eventually made it after the operation.

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We experienced a case of leiomyoblastoma of the small intestine. A 57-year-old man was admitted to the hospital because of anal bleeding and severe anemia. However, gastrofiberscopy, total colonoscopy, CT, barium enema and abdominal ultrasonography revealed no significant findings. We concluded that the bleeding focus must be in the small intestine. At laparotomy, a solid tumor protruding toward the extraserosal space was observed at 1m oral from the ileum. A partial resection of the ileum was performed, with a successful result. Histologically, tumor cells with characteristic perinuclear halos were observed, and a diagnosis of leiomyoblastoma was made.

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Comparing to cancers of other organs, primary lung cancer tends to metastasize to distant organs because of the biological characteristics of the origin as well as the specificity of the structure of lung tissue. The metastases of lung cancer most frequently appear in the lung, liver, bone, kidney, adrenal gland, and brain, but rarely in the small intestine. This time we experienced a case of jejunal metastasis of lung cancer presenting anal bleeding which was successfully resected.
A 54-year-old man was referred to the hospital because of anal bleeding and severe anemia 2 years after a left pneumonectomy for a moderately differentiated adenocarcinoma of the left lung (B⁶). Radiological examination demonstrated a fist-sized tumor involving the jejunum, 100cm distal from the Treitz ligament. Partial resection of the jejunum en bloc with the mesenteric mass involving the jejunal wall was performed. Histopathologic examination of hte jejunal tumor revealed moderately differentiated adenocarcinoma, confirming the diagnosis of metastasis of pulmonary carcinoma. Small bowel metastasis of pulmonary carcinoma with clinical manifestations in relatively uncommon. There have been 110 cases including ours of small bowel metastasis of pulmonary carcinoma in the literature so far. Postoperative survival period of these patients ranged drom 2 to 26 months, and 84% of the patients died within 6 months after operation. Although prognosis of the patient is poor, resection is indispensable for a better qulity of life.

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Two cases of primary small bowel cancer showing extraluminal growth are repoted. Case 1 was a 61-year-old woman, who presented with abdominal pain. X-ray examination of the small bowel showed a diverticular like pooling of contrast material in the jejunum. CT showed air within the tumor. Angiography revealed encasement of the jejunal artry. Case 2 was a 72-year-old man, who presented with general fatigue. X-ray examination of the small bowel showed irregular pooling of barium with ileal stenosis. The CT and angiographic findings were similar to those in case 1. Surgical treatment consisted of resection of the tumor with the invaded adjacent organs in both cases. Histologically, both tumors showed moderately-differentiated adenocarcinoma. Carcinoma with extraluminal growth should be kept in mind when an extraluminally-growing malignant tumor of the small bowel is differentially diagnosed.

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A 23-year-old man visited our hospital with a complaint of abdominal pain. On physical examination, an unmovable mass we palpable in the right lower quadrant. Ultrasonogrphic examination and computed tomography showed a solid tumor in the same place. Barium enema study detected an irregular-shaped tumor in the cecum. The endscopic diagnosis was malignant lymphoma of the terminal ileum. On laparotomy, a 6×6×5cm tumor was found in the terminal ileum. A right hemicolectomy and lymphnode dissection for the middle mesenteric artery region were performed. Histologically, the tumor proved to be diffuse medium-serized B-cell type malignant lymphoma. The patient received 5 kur of chemotherapy (TCOP) and has done well without recurrence to date. It is difficult to diagnose primary malignant lymphoma of the small intestine preoperatively, and the prognosis of this disease is differs according to clinical stage, histopathology and curative vesus non-curative operation. Therefore, it is important to diagnose the clinical stage by conducting systematic examinations preoperatively.

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Since January 1996 laparoscopic appendectomy (LA) has been peformed on 21 children in whom appendicitis could not be confirmed by preoperative diagnosis by conventional methods. The patients included 13 males and 8 females, ranging from 6 to 15 years old. We performed LA with the same trocar for children as that for adults by the three-puncture method. The laparoscopic diagnoses were phlegmonous appeddicitis in 11 children and catarrhal in 10. The operation time was 12_??_42 (mean 25.5) minutes. Only one presented a postoperative complication, subcutaneus hematoma due to trocar injury (Case 3). The advantages of LA include reduction of mental damage to children. LA provides not only benefits for surgeons but also several advantages for children. From our experience, LA might be extended more widely, probably to most cases of appendicitis in children.

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Primary carcinomas of the appendix, especially mucinous adenocarcinomas, manifest various clinical symptoms and present difficulty in preoperative diagnosis. The reasons are: 1) the appendix itself is anatomically an intraperitoneal floating organ; and 2) a variety of clinical symptoms depend on the direction that mucus produced by mucinous adenocarcinoma infiltrates into the surrounding tissues. Recently we experienced three cases of mucinous adenocarcinoma of the appendix with each different direction of infiltration.
Case 1: A 59-year-old man complaining of abdominal pain and high fever underwent a laparotomy with a suspicion of appendicitis. Operative findings revealed swelling and perforated appendix into the mesoappendix. Histological examination revealed mucinous cystadenocarcinoma. An additional ileocecal resection was performed.
Case 2: A 53-year-old woman complaining of vomiting and diarrhear underwent a laparotomy with a suspicion of peritoneal pseudomyxoma. Operative findings revealed a mucinous cystadenocarcinoma perforated at the tip of the appendix. Appendectomy and intra-peritoneal administration of CDDP were conducted.
Case 3: An 80-year-old woman was admitted to the hospital because of high fever and general fatigue. Abdominal CT indicated a retroperitoneal abscess. Total colonoscopy revealed the tumor of the cecum. Ileocecal resection was performed. Histological examination revealed mucinous cystadenocarcinoma of the appendix infiltrated into the retroperitoneum and developed a colonic fistula.
These three cases had the same disease, but different perforated site due to progression of mucus might cause entirely different clinical symptoms each other.

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Recently obstructive colitis has been gradually recognized. We reprort a rare case of perforating obstructive colitis. A 67-year-old man was admitted to the faculty because of acute lower abdominal pain. An abdominal X-ray showed neither free air nor small intestine gas. But an operation was carried out with a suspicion of shock state due to peritonitis, because there were muscle defense, tenderness, rebound tenderness in the lower abdomen, and hypotension. On laparotomy there were ascites that was soiled by the content of the colon, a perforation of the anterior wall of the rectum, and a rectal carcinoma in the anal side (Ra). Therefore the diagnosis was made as diffuse peritonitis due to perforation based on obstructive colitis. Hartmann operation was performed, since the general condition was poor. On the resected specimen, the normal mucosa 3cm in length between the rectal cancer and perforative site was seen. Histopathological examination showed an ischemic change in the perforative site. Postoperatively, the patient suffered from pseudomembranous colitis and the separation of surgical wound which needed reoperation. But the patient was discharged from the faculty 50 day after the operation.

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We report a case of colon cancer in a 26-year-old woman presenting in an unprecedented form. The patient was admitted to the hospital because of ileus. The transverse colon was completely obstructed. We inserted an ileus-tube and reduced the intestinal pressure. After neoadjuvant chemotherapy, we performed a curative operation. Macroscopically, the length of the obstructed portion was 5mm and there were no elevated or ulcerative lesions. Microscopically, there was well differentiated adenocarcinoma in a narrow extent of mucosa, but cancer cells widely invaded the subserosa. It is possible to be the originating case in hereditary nonpolyposis colorectal cancer (HNPCC).

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A 67-year-old woman with Budd-Chiari syndrome was admitted to our hospital for operation. Preoperative cavography showed occlusion of the inferior vena cava and well-developed collateral veins. The patient underwent direct reconstruction with endovenectomy and patch angioplasty of the obstructed cava using partial cardiopulmonary bypass. The markedly dilated varicose veins of the bilateral lower extremites and subcutaneous veins of the abdominal wall disappeared immediately after the operation Postoperative cavography showed the patency of the inferior vena cava. Direct reconstruction foi Budd-Chiari syndrome using partial cardiopulmonary bypass is useful for protecting the liver and reducing intraoperative bleeding.

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A 69-year-old man was seen at the hospital because of a liver tumor, which was detected at a medical checkout. There was a history of recieving an examination for a neck tumor 53 years before. On admission, a hard tumor was palpated at his neck. Abdominal simple X-ray film revealed many spotty calcification and atrophy of the spleen. US revealed a hypoechoic tumor 40×31mm in size at the segment VI. CT showed many spotty calcification around the branch of the celiac artery and a low density mass at the segment VI. Density of the liver was high (80 HU). From preoperative US guided puncture, a diagnosis of intrahepatic bile duct carcinoma was made. Partial resection of the liver was performed. Pathological examination revealed cholangiocarcinoma (mixed type). The patient died of recurrence 3 year after the operation.

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A relatively rare case of mucin-producing cholangiocarcinoma with repeated abnormal hepatic functon for about 3 years in a 59-year-old man who was successfully diagnosed and radically operated on, is reported. There was a previous history of undergoing a laparoscopic cholecystectomy in July 1991. Thereafter abnormal hepatic function was confirmed, but it was conservatively treated. In May 1992, the same symptoms appeared and ultrasonography (US) showed a tumor shadow in the bile duct with a dilatation of the intrahepatic bile duct. Transendscopic cholangioscopy revealed a blackish green and jelly-like substance was removed by transendoscopic papillotomy, and then the hepatic function was normalized. In January 1993, the same symptoms occurred again and US visualized dilatation of the left intrahepatic bile duct and common bile duct and a tumor shadow in the bile duct. With aspiration biopsy cytology of the bile duct, a diagnosis of cholangiocarcinoma of class V was made. Left lobectomy of the liver and resection of the common bile duct were performed. A stricture of the bile duct was mild, and it was thought that the imparied hepatic function which was repeated might be caused by obstruction due to mucin produced by the tumor.

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We experienced two cases of non-functioning endocrine cell tumor of he pancreas which is relatively rare. Case 1 involved a 38-year-old man. He was seen at the hospital because of back pain and was found out a huge hypervascular tumor positioned in the pancreatic tail. Infiltration into the stomach, spleen, retroperationeum, and left kidney and metastasis to the right kidney were confirmed. Biopsy under laparotomy was made. He is doing well while carring the cancer, as of 1.5 years after the operation. Case 2 involved a 34-year-old women. She was seen at the hospital because of a pancreatic tumor which was pointed out at medical checkup in other hospital. Close examination disclosed a hypervascular tumor about 3cm in diameter at the uncus of the pancreas. Pancreatoduodenectomy was carried out and the difinite diagnosis of non-functioning endocrine cell tumor of the pancreas was made.
Furthermore, a histopathological study was conducted on these two cases and autopsy cases of carcinoid glucagonoma which were accidentally found out. As a result, a significant increase in cell number per unit square in case I and an evident increase in nuclei in case 2 were ovserved.

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We experienced a rare case of splenic cyst with a high serum CA19-9 level.
A 38-year-old man was admitted to the Fuji hospital, complaining of abdominal fullness and constipation. Preoperative blood examination showed a high level of serum CA19-9 (1666U/ml). Ultrasonography and CT of the abdomen showed a large cystic tumor at the splenic hilus. Splenectomy and distal pancreatectomy were performed, as extensive adhesions were present. Intracystic CA19-9 was very high (above 24×10⁴). On immunohistochemical staining with anti-CA19-9, the epithelium of the cyst showed a positive reaction. After the operation, the elevated serum CA19-9 decreased to normal range.

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A 23-year-old woman underwent a total splenectomy for rupture of the spleen due to a trafficaccident. On admission, a mild thrombocytosis was noted and the resected spleen was 147g in weight, showing a slight splenoma. After the operation, thrombocytosis became prominent and aspirin and dipyridamole were administerted to prevent thrombosis, but the platelet count increased to 1, 950, 000/mm⁸ on the 14th hospital day. On the 31st postoperative day, hemoglobinuria appeared abruptly, and relative thrombocytopenia, high level of LDH, increase in BUN, and appearance of clastic erythrocytes were confirmed. The patient was diagnosed as hemolytic uremic syndrome (HUS). HUS was successfully managed by administration of ticlopidine and heparin while it stayed in a relatively mild state. As of 3 months after the operation, however, the platelet count is still kept at high level, around 1, 200, 000/mm⁸ and antiplatelet regimen is still continued.
No case of HUS caused by thrombocytosis has been reported as far as we could review, and this case is so rare. In this case, an increase in megakaryocytes was noted in a bone marrow picture. In is thought that underlying primary thrombocytosis might cause this abnormal increase in platelets.

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There are 30 reports on colonic carcinoma with splenic metastasis in the Japanese literature and the hematogeneous route of splenic metastasis has been suggested. We report a case of resected solitary splenic metastasis with subcapsular bleeding after resection of carcinoma of the descending colon. A 76-year-old male underwent resection of a pulmonary tumor in the left lobe on March 14, 1994 and right hemicolectomy for carcinoma of the descending colon on April 20, 1994. Histology revealed well differentiated adenocarcinoma of the colon with pulmonary metastasis, judged to be stage IV (ss, n1(+), P0, H0, M(+)), as proposed by the Japanese Colorectal Society. The serum CEA level rose again, reaching 7.3ng/ml six months later. Results of abdominal computed tomography showed a splenic tumor, 4.0×3.0cm in diameter. Ultrasonography revealed the tumor to have a round mosaic echoic area pattern. He rejected splenectomy for the metastatic lesion. Sudden left upper abdominal pain developed on September 5, 1995. Computed tomography and ultrasonography showed rupture of the splenic tumor with subcapsular bleeding. The patient thus accepted operation. A splenectomy was performed on September 25, 1995. Histological findings of the resected splenic tumor revealed the same histological type as the primary colonic lesion.

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Usual adrenocortical adenoma is a common disease involving in Cushing's syndrome, but ectopic adrenocortical adenoma in the abdomen is extremely rate so far as we could review. Recently we experienced a case of huge adrenocortical adenoma arised in the accessory adrenal which was successfully resected.
A 74-year-old woman was emergently admitted to the hospital because of acute abdomen with a shock state in September, 1994. CT and magnetic resonance imaging revealed a retroperitoneal tumor 18cm in size with a small quantity of intraperitoneal bleeding and hemorrhage in the tumor. After observation of the clinical course conservatively, an angiography visualized entering arteries (lumbar arteries L2_??_5) to the tumor and a vein (inferior vena cava) coming from it in February, 1995. In March, 1995, a surgical excision of the tumor was performed. The excised tumor was 18cm in size and histopathologically adrenocortical adenoma.
The adrenal cortex originates from mesodermal peritoneal epithelium like the kidney, and hence, it is genetically rare that adrenocortical adenoma appears ectopically.

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We report a rare case of congenital mesoblastic nephroma (CMN). A one-month-old boy was admitted to our hospital due to a right abdominal mass. Abdominal computed tomography, intravenous pyelography and echography revealed a tumor originating from the right kidney. A right nephrectomy was performed with the diagnosis of CMN or Wilms tumor. The tumor was covered with renal capsule and limited to the kidney. There were no lymphnode metastases in the abdominal cavity. The tumor was 9.0×6.5×6.0cm and weighted 212g. The pathological diagnosis was mixed type CMN. He had no therapy after surgery. He remains well eight years to date since surgery.
CMN is a relatively rare renal tumor of neonates and young infants. The prognosis is us usually good in those whose tumors are resected. However a few cases develop recurrences and metastases, such that careful follow-up is needed after surgery.

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We experienced an uncommon case of advanced carcinoma of the gallbladder which metachronously metastasized to the uterus and large intestine after a long lapse following the operation for the primary lesion.
A 75-year-old woman was seen at the hospital because of uterine bleeding, and was admitted for close examination. Abdominal CT revealed an irregular tumor at the cervix of the uterus, and the patient was operated on. Upon operation, the main lesion positioned in the cervix of the uterus and infiltration into the rectum and urinary bladder was confirmed. In addition to excision of the uterus and ovaries, associated resection of a part of the bladder and rectum and colostomy were performed. Histopath-ologically, resected specimens were poorly differentiated adenocarcinoma which resembled the gallbladder carcinoma 7 years earlier and the former metastasis to the rectum one year earlier. It is said that carcinoma of the gallbladder rarely metastasizes to other organs, especially to the cervix of the uterus. The postoperative course was uneventful. There is still a possibility of metastasizing to other organs and we would have to cocontinue a strict observation of her clinical course.

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A case of Fournier's gangrene with wide-ranging subcutaneous emphysema which continuously extended from the left upper to left lower limbs is reported, together with a review of the literature.
A 51-year-old man was seen at the hospital because of pain, swelling, and reddening of the scrotum and perineum. Inflammatory reaction was remarkable and crepitant sensation was confirmed from the neck to left lower limb. CT revealed continuous subcutaneous emphysema covering from the left upper limb to left lower limb. On the day of admission, an emergency operation was conducted, when removal of necrosed tissues from the perianal area and scrotum as well as incision from the chest wall to lower abdominal wall and drainage was carried out. On the eighth postoperative day an increase in inflammatory area was confirmed, and so incision and drainage were added.
This disease often has a fatal course. We need to provide an appropriate early treatment and repeated incision with drainage in accordance with an increase in the inflammatory area.

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A 36-year-old man, who underwent ileocecal resection and partial resection of the small bowel for mesenteric fibromatosis in 1992, noticed an egg-shaped tumor in his right lower abdomen three years after that operation. Abdominal CT (computed tomography) revealed a tumor with homogenous enhancement using contrast medium on the right side of the abdominal aorta, and MRI (magnetic resonance imaging) showed an irregularly hyperintensive mass on a T2 weighted image. He underwent surgery again. Not only the tumor pointed out preoperatively, but also another small tumor was found on his mesentery. We performed a partial small bowel resection and colectomy. Histological examination demonstrated remarkable proliferation of fibroblasts surrounded by numerous collagen fibers without distinct atypism. This finding was exactly the same pattern as that seen at the first operation. Finally, we diagnosed recurrence of mesenteric fibromatosis.

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This paper presents three cases of obturator hernia which were successfully diagnosed by CT before operation. In Case 1, an 85-year-old woman was admitted to the department of medicine in our hospital because of abdominal pain and vomiting. She was diagnosed as having a right obturator hernia by CT and was transferred to the department. Upon alparotomy, a portion of the intestine about 60cm oral side from the ileocecal region was incarcerated into the right obturator foramen and necrosed. A resection of the small intestine was conducted. In Case 2, a 77-year-old woman complaining of abdominal pain and vomiting was referred to the department by another hospital with a diagnosis of intestinal obstruction. CT examination revealed a right incarcerated obturator hernia. Upon laparotomy a portion of the intestine about 8cm oral side from the ileocecal region was incarcerated into the right obturator foramen with necrosis. A resection of the small intestine was performed. In Case 3, a 74-year-old woman presented with abdominal distention and vomiting was referred to the department with a diagnosis of intestinal obstruction by another hospital. CT visualized incarceration of a right obturator hernia and an operation was carried out. A portion of the intestine about 40cm oral side from the ileocecal region was incarcerated into the right obturator foramen but no necrosis was noted. So the small intestine was not excised.
All three cases were able to be diagnosed CT preoperatively that would emphasize the usefulness of this imaging procedure for diagnosis of the disease.

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