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It is said that malignant pheochromocytomas represent about 10% of all pheochromocytomas, and no effective treatment has been established for malignant pheochromocytoma if it is associated with multiple organ metastases before surgery. We experienced a rare case of giant malignant pheochromocytoma with coexistence of poorly differentiated neuroendocrine tumor and its hepatic metastasis. A 37-year-old man was seen at the hospital because of left lateroabdominal pain. At initial visit, a giant tumor 17cm in diameter was noted in the retroperitoneum. The patient also had attacks of hypertension. With close examination, the tumor was diagnosed as pheochromocytoma. Besides the tumor, scattered tumors were observed in the liver, indicating malignant pheochromocytoma. The tumor was extirpated. Histopathologic examination of the specimen revealed malignant pheochromocytoma with coexistence of poorly differentiated neuroendocrine tumors. Only poorly differentiated neuroendocrine tumors occurred in the hepatic metastatic foci. Although the origin of pheochromocytoma is still obscure, here we report this valuable case of malignant pheochromocytoma with neuroendocrine tumors which may be involved in the genesis of the disease.

A 48-year-old woman was admitted to the hospital because of intestinal obstruction. A long intestinal tube was inserted for aspiration therapy. Symptomatic remission was attained temporarily, but on the fourth day after the insertion the patient had a pain in the left upper abdomen and a tumor was palpated in the same region. Emergency abdominal ultrasonography and CT revealed invagination of the intestine at where the tube was induwelled. Emergecy operation was performed. At about 70cm from the ligament of the Treitz, the jejunum on the anal side. Invagination was reduced and the necrosed intestine was resected. Simultaneously, a cancer was observed in the splenic flexure of the trnsverse colon, and a exision of the colon was performed. In this paper a case of invagination probably caused by a long intestinal tube is reported.

We experienced a case of malignant phyllodes tumor requiring an emergency operation for bleeding. A 44-year-old woman was referred to the hospital because of a recently enlarging tumor of the left breast. There was a previous history of undergoing an excisional biopsy for a left breast tumor existing at the same area which was diagnosed as benign phyllodes tumor at another hospital 4 years and 7 months before. After admission, a 12×9cm soft tumor of the left breast was palpated. Numerous hematomas were noted on ultrasonography, which were drained from an incision of the tumor, yielding approximately 100ml of bloody fluid. After 7 days, the tumor appeared to be infected and the patients' anemia was worsening. An emergency simple mastectomy was performed. Histologically the resected specimen showed a malignant phyllodes tumor. In this case, it appeared that the remnant of benign phyllodes tumor became malignant and developed intratumorous hemorrhage. Wide excision of a tumor including surrounding tissues and close follow up may therefore be indicated for cases diagnosed as benign phyllodes tumor.

A 53-year-old male patient, who had a history of 30 years of heavy intake of alcohol, admitted for sudden massive melena during observation for chronic pancreatitis. The patient was diagnosed by abdominal ultrasonic, CT examinations and photosyntigraphy of hemorrhage from the gastrointestinal tract as melena caused by colonic penetraction of intrapseudocystic hemorrhage of the pancreas. Conservative treatment provided temporary improvement, but the patient had another massive melena, for which operation was performed. Incision of the transverse colon revealed penetration with cyst in the pancreas tail. The pancreas tail including cyst, the spleen and the transverse colon were resected together. Histopathological examination revealed presence of arterial wall and penetration in part of cyst wall. The patient was relieved and discharged after treatment of intractable pancreatofistula. Most of hemorrhage from the gastrointestinal tract of pseudocyst of the pancreas have poor prognosis, we concluded that the treatment for this disease was hemostasis and surgical resection of whole pseudocyst of the pancreas. A case of pseduocyst of the pancreas resulting with hemorrhage form the gastrointestinal tract is presented here with a review of literature.

The significance of the intraluminal lavage in the low anterior resection of the rectum was studied in 68 cases which were operated on for a rectal carcinoma during 1981 through 1991. These cases were divided into three groups by the anastomotic technique; double stapling technique (DST) in 19 cases, single stapling technique (SS) in 39 cases, and hand suture (HS) in 10 cases. No correlation was seen betweem the anastomosis recurrence and pathological findings such as tumor size, depth of invasion, oral and anal distance of free margin, histologic type of carcinoma, vascular invasions and lymph node metastasis. However, a strong correlation was observed between the anastomosis recurrence and anastomotic technique, showing the DST to be the most frequent method of anastomosis recurrence with a statistical significance (p

A 66-year-old female with severe heart disease had been irradiated for an intrahepatic bile duct carcinoma, which was found during the bypass operation for recurring CBD stone. Six months later, she was seen at the cardiosurgery department because of palpitation and general fatigue. Laboratory data suggested severe anemia (Hb 5.1 g/dl) and she was immediately admitted to the hospital for further investigations. No specific finding was observed by any examinations. Blood transfusion 6 units/day for 3 days improved Hb level up to 10.1g/dl, and the patient was discharged temporarily. After the discharge, Hb level had kept decreasing gradually and the patient was re-admitted to the department for detailed examinations. The gastrointestinal endoscopic examination revealed massive bleeding from the liver side of the anastomosis of choledochoduenostomy, but exact bleeding point was not determined. Celiac arteriography also failed to identify the bleeding point. However, to avoid the risk of shifting to DIC, transcatherter embolization (TAE) was performed on the proper hepatic artery, which was thought to be responsible for the hemobilia. Thereafter slight epigastralgia and minimal liver disfunction occurred transiently, but severe anemia was getting better and no active bleeding was revealed by further gastrointestinal endoscopy, with an excellent outcome. We herein report this rare case of which hemobilia due to an intrahepatic bile duct carcinoma was successfully treated with TAE, along with some consideration of previously revised articles.

A 71-year-old woman progressively developed esophageal stricture during a follow-up observation of reflux esophagitis after operation for duodenal ulcer-induced perforative peritonitis. The patient was treated first by baloon dilatation, but, as perforation of the esophagus developed, another operation by the procedure used for achalasia was performed after closing the perforated site of the esophagus. She is recovering favorably under good condition of oral feeding. This case suggests that esophageal stricture associated with reflux esophagitis may be induced not only by dysfunction of protective factors such as esophagus, lower esophageal sphincter, but by excess of attacking factors. Also suggested by this case is that fundoplication applied to achalasia is useful in some cases of reflux esophagitis complicated with esophageal stricture but without hiatal hernia.

One hundred and ninety-four colorectal cancer patients (colon cancer 111, rectal cancer 83) who underwent a curative resection were analized in order to evaluate the influence of the number of dissected lymph nodes upon the postoperative long-term survival rate. The tumor depth of invasion was pm or more in all cases, but none had distant metastasis before surgery. In colon cancer, the group of cases with 20 or more dissected lymph nodes showed better 5-year survival rate than that with 10 or less lymph nodes dissected though the degree of lymph node dissection is the same between both groups (p

Cystic lymphangioma arises as a malformation of the lymphatic tissues and is a benign tumor generally found on the neck or below the jaw of an infant. Recently, an operation for a giant cystic lymphangioma at the axilla which developed during pregnancy was undertaken in our department. A 43-year-old woman first noticed a mass in her left axilla during her second pregnancy, which showed a tendency to enlarge during her third pregnancy. The patient underwent drainage by a local physician several times but the tumor did not resolve, so she was referred to our hospital. Ultrasonography and CT indicated a cystic tumor under the axillary veins and arteries, while angiography showed an avascular lesion. Extirpation under general anesthesia revealed that the tumor was a multilobular giant cyst (19.0×14.0×12.0cm) containing clear yellow fluid. The histopathological diagnosis of the tumor was cystic lymphangioma.There have been many reports on giant lymphangioma in the mesentery or retroperitoneum, but few have mentioned it at the axilla. Because they may grow and become enormous during pregnancy as occurred in the present case, we believe that such cystic tumors of the axilla are better extirpated at an early stage without being repeatedly drained.

The difference between over and beyond 3 years survivals was studied in cases undergone hepatic resection for hepatocellular carcinoam. Fifty-three cases were operated on and the factors which allowed to expect for over 3 years survivals after hepatic resection were: 1) The average tumor size was within 3.5×3.2cm. 2) The tumor/hepatectomized area ratio was within 30±10%. 3)AFP reduction ratio before and after hepatic resection was over about 96%. And as the ratio was higher, the longer survival period could be expected. Other factors such as tumor thrombus in the portal vein and classification of cell atypia (Edmondson's classification) could not yield any definite prospects for over 3 years survival. Moreover, multiple primary tumors also had no possibility of long survivals in our series.

A 66-year-old male was admitted to the hospital for diagnosis and treatment of a rectal lesion which was pointed out by health care system. All a about 20mm in diameter located about 5cm from the analring was observed by colonoscopy. The lesion was well differentiated adenocarcinoma. On December 2, 1995 we tried an endoscopic mucosal resection (EMR) for it. Mucosal defect department was about 4cm in diameter. Proper Muscular was observed clearly that department, however, it was stopped bleeding sufficiently. Although there was no peritoneal sign on the next mornig. WBC was 24, 600/mm3 and CRP was 10.5mg/dl on a blood biochemistry inspection. There was a gas image around both iliopsoas muscle in an abdominal X-ray examination, and a diagnosis of retroperitoneal emphysema was made. The internal rectal pressure is increasing by air feeding, when lower rectal lesions are resected by using an endoscope. There is possibility that retroperitoneal emphysema may be induced after EMR depending on the size resected mucosa. Therefore, the mucosal defect department should be repaired by a transanal approach.