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A case of adult Bochdalek hernia with gastric volvulus in a naturally healthy 54-year-old man is described. The patient was seen at the hospital because of epigastralgia, appetite loss and weight loss for 6 months. He was diagnosed as Bochdalek hernia with gastric volvulus by chest X-ray photographs, contrast radiography of the upper gastrointestine and thoracic CT scans. At laparotomy the stomach was rotated around its mesenteric axis and the antrum was dislocated into the thorax through the left posterior-lateral diaphragm defect. His symptoms disappeared after the operation. Adult Bochdalek hernia with gastric volvulus is very rare and only 5 cases including this case have been reported in this country. In the case of adult Bochdalek hernia with gastric volvulus, definitive operation should be selected even if the patients is asymptomatic.

For the better pathophysiological understanding of ischemic colitis, a clinical analysis of 24 cases of this disease in a 13-year period from 1979 to 1992 was conducted. The distribution of ages was 19-89 and there were 9 males and 15 females. As to disease type, transient type was noted in 15 cases, stricture type in 5 cases, and gangrenous type in 4 cases. Most of them had some underlying diseases. Eighteen patients had bowel diseases which increased the intraintestinal pressure, and 7 patients had cardiovascular diseases. These patients first manifested abdominal pain or melena in a relatively high frequency. The diagnosis was made mostly based on colonoscopic findings in transient type of patients; barium enema in stricture types; and operative findings in gangrenous types. Conservative treatment was performed in 17 patients, elective operation in 2 patients, and emergency operation in 5 patients. It has been emphasized that ischemic colitis has a close relation with cardiovascular diseases. However, our results suggest that ischemic colitis has a close relation with the increased intralumenal pressure of the bowel as well as cardiovascular disorders.

The results of treatment of eight cases of ulcerative colitis and five cases of Crohn disease experienced in our department were investigated. Five of the eight cases of ulcerative colitis achieved remission by conservative treatment alone, and the mean proportion of relapse into the active stage of the lesion, reckoned in months after discharge was 32%. As for surgical cases, total colorectectomy-ileostomy, subtotal colectomy-anastomosis of the ascending colon and rectum and the Kock method were respectively performed in each case. On the other hand, two of the five cases of Crohn disease showed postoperative relapse. In one case presenting relapse in the duodenum and pyloristenosis, gastrectomy (the Billroth II method) was performed and another case achieved remission using Salazopyrin. Many cases of ulcerative colitis are benign and are found in juveniles, necessitating the positive consideration of the conservative method of spontaneous anus. With regard to the surgery for Crohn disease, the cause of relapse is unknown, and there have also been cases of relapse reported from microlesions so small that they are impossible to diagnose during surgery. It may therefore be necessary to deal cautiously with excision of a skip lesion in which there is no complication or en bloc excision of each lymph node.

Clinical features and the results of treatment in 61 cases of ulcerative colitis (34 males and 27 females) were analyzed. In most of the cases (47 cases, or 77%), the age at which the disease occurred was estimated to be between 10 and 39 years. Early complaints were mucous bloody stools (seen in 77% of all cases), diarrhea (66%) and abdominal pain (23%). Fifty patients were treated medically and 11 were treated surgically (urgent or semi-urgent surgery in 4 cases and non-urgent surgery in 7 cases). Of the 4 patietns who underwent urgent or semi-urgent surgery, 2 had perforations and the other 2 had fulminant type ulcerative colitis. The fatality rate for these 4 patients was 50%. Of the 7 patients who underwent non-urgent surgery, 4 had been treated medically for less than 5 years; in these 4 cases, the active stage occupied more than 50% of the total observation period, and the average relapse frequency was over 1.3 times per year. The other two patients, who underwent non-urgent surgery, had been treated medically for more than 5 years; they had been treated with more than 10, 000 mg of Predonine (prednisolone acetate) and it was difficult to discontinue their steroid therapy. Carcinogenesis was seen in one patient who had a relapsing-remitting type of ulcerative colitis which affected the entire large intestine and which had initially occurred 24 years earlier (this gave an incidence of carcinogenesis of 1.6%). The results of this study suggest that patients with severe ulcerative colitis (including the fulminant type) should be surgically treated in time rather than adhering to conservative treatment, in order to reduce the current high mortality rate during or following urgent surgery.

In the past 15 years, 101 cases of peptic ulcer in patients over 60 years of age were treated in our department. Of 101 patients, 76 had gastric ulcer, 16 had duodenal ulcer and 9 had combined gastric and duodenal ulcer. The number of peptic ulcers treated surgically has been decreasing recently, while the percentage of peptic ulcers in the aged has been increasing. Of these 101 cases, 52.4% of the patients had no past history of ulcer, and 49.3% had suffered from the disease for less than six months. In regard to symptoms, 71.3% of patients complained of abdominal pain, and 36.6% showed gastrointestinal hemorrhage. The indications for laparotomy were hemorrhage, perforation and stenosis in 48.6% and intractability in 47.2%. The rate of preoperative complications and the rate of emergency operations tended to increase with age. Although there was a complete absence of mortality in the patients without preoperative complications, that among patients with preoperative complications in emergency operations was a high 46.2%. How to avoid emergency operations in the aged remains a problem to be solved in the future.

Until now, 21 cases of Crohn's disease (78% of total cases of this disease) have been surgically treated at our department. Of thse cases, 14 received a curative surgery (complete resection of the lesion). We analyzed postoperative relapes of the disease in these 14 cases. Postoperative relapse was seen in 2 (50%) of the 4 patients with Crohn's disease of the small bowel and 3 (33%) of the 9 patients with Crohn's disease of the small and large bowels. Of these 5 cases of postoperative relapse, 4 had relapse at a site close to the anastomoses. The mean timespan from the surgery to the relapse was 3 years and 3 months in patients with Crohn's disease of the small bowel and 11 months in those with Crohn's disease of the small and large bowels. The relapse rate was 13% for the patients with a preoperative IOIBD (International Organization for the Study of Inflammatory Bowel Disease) score of 4 or less and 67% for those with a preoperative IOIBD score of 5 or more. Of the 9 cases in whom the unaffected intestine was resected for 10 cm more proximal (adoral) from the lesion, no one showed postoperative relaps. Of the 5 cases in whom the unaffected intestine was reseacted for less than 10 cm proximal from the lesion, all showed postoperative relapse. However, no correlation was found between the relapse rate and the length of the resected unaffected intestine distal (towards the anus) from the lesion. Reoperation was done in 2 cases because of fistulation.

This paper describes upper gastrointestinal hemorrhage after surgical treatment of primary colorectal cancer. During the past six years, operations have been carried out on 127 patients with primary colorectal cancer. Of these, 13 patients (10%) had postoperative bleeding from the upper gastrointestinal tract. This type of bleeding occurred in 5 (26%) of 19 patients undergoing urgent surgery. With regard to the operation methods, low anterior resection and colostomy frequently induced postoperative hemorrhage, in 3 of 11 cases (27%) and 4 of 15 cases (27%) respectively; however, abdomioperineal rectal amputation did not give rise to such bleeding in any of 23 cases. Gastrointestinal hemorrhage was also noted in 4 of 11 patients having diabetes mellitus as a preoperative complication; 2 of the 4 died. This arouses prognostic concern.Of the 13 cases with postoperative gastrointestinal hemorrhage, 10 were relieved with conservative hemostasis.Therefore, prophylactic administration of Cimetidine seems to be effective in the high-risk group for postoperative gastrointestinal hemorrhage.

The causes of upper digestive tract bleeding after hepatic abscission were analyzed in this study by dividing subjects into 2 groups (cirrhosis and cirrhosis-free) and taking liver function, blood coagulation surgical stress, and the kinetics of gastric acid secretion into account. The results were as follows. Upper digestive tract bleeding occured in 1 case of 15 (6.7%) in the cirrhosis-free group and in 5 cases of 19 (26.3%) in the cirrhosis group. One case was fatal. Postoperative upper digestive tract bleeding was found to have no clear relationship to the extent of the hepatic abscission or to the volume of bleeding during surgery. When compared with the cirrhosis-free controls patients with cirrhosis showed significantly worse values of GPT, TTT, ICGK, ΔIRI/ΔBS, IRI max, and hepaplastin. In the cirrhosis group the preoperative MAO value was ortho-acid (5_??_20 mEq/h) in 10 cases and hypo-acid (below 5 mEq/h) in 8 cases. All of the 5 cases which developed bleeding after surgery were in the orthoacid condition. These results indicate that patients showing a preoperative MAO value of over 5 mEq/h need to be given cimetidine positively, starting immediately after surgery.

A retrospective study of patients with peptic ulcer admitted to the First Department of Surgery, School of Medicine, Kobe University, was made into the actual conditions of the surgical treatment of the ulcer after the introduction of cimetidine. The patients were divided into two groups, the first belonging to the period between 1976 and 1980 and the second belonging to that between 1981 and 1985 (July). A remarkable decrease was seen in the second group in the number of cases and operations. Especially noticeable was a decline in the number and rate due to intractability among such cases. But an increase was noted in the number of operations for complications of the ulcer (hemorrhage, perforation). There was a higher rate of complications in the second group in comparison with the first. There was no difference in the rate of occurrence of ulcers or shock. In cases of serious hemorrhage with duplicated complications, a barrier was observed in the efficacy of cimetidine, and the rate of cases requiring urgent surgery was still as high as 42.1%.

Possible changes in surgical treatment of peptic ulcers at the Kobe University Hospital (First Dept. of Surgery) over the past ten years were explored, dividing the 10 years into the first (1978-1982) and second (1983-1987) periods. The number of hospitalized peptic ulcer cases and the number of surgically treated peptic ulcer cases fel by 50% from the first to the second period. The decrease was particularly marked in duodenal ulcer cases (in comparison with ulcers of the other sites) and intractable ulcer cases (in comparison with ulcers of the other features). The percentage of patients who underwent urgent operation was 37.3% in the first period, which fell to 28.6% in the second period. The number of surgically treated intractable ulcer cases showed a 69.2% reduction in the second period compared to the first period. However, the percentage of cases whose excised specimen was rated as representing giant ulcer, linear ulcer, or U1 IV was higher in the second period than in the first period. Stenosis was found in 7 cases in the first period and 3 cases in the second period. The percentage of hemorrhagic ulcer cases who received conservative treatment or pallilative operation became higher in the second period than in the first period, while the percentage of hemorrhagic ulcer cases who underwent urgent operation decreased from 65.2% in the first period to 33.3% in the second period. In hemorrhagic ulcer cases, the death rate during or after uregent operation rose from 28.7% (first period) to 40.0% (second period). Perforated ulcer was found in 7 cases in the first period and 1 case in the second period. Of these 8 cases, 4 died (3 in the first period and 1 in the second period). Death rate was particularly high in elderly patients who had no history of ulcer and in patients who received surgery 12 hours or more after perforation.