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A patient was 70-year-old female. Because unknown fever following operation of left knee in December 20XX-1, abdominal simple CT was performed, diagnosed as cholecystitis and liver abscesses. However, her unknown fever did not improve with antibiotics therapy. Abdominal enhanced CT and MRI revealed to gallbladder cancer with liver invasion and metastases. These lesions were relatively localized in liver S4a/S5 and gallbladder, hepatoduodenal mesentery. Because unknown fever was exhausting, cholecystectomy, S4a+S5 hepatectomy with extrahepatic bile duct resection and lymph node dissemination were performed in January 20XX+1. In these pathological findings, there were moderate to poorly differentiated adenocarcinoma with squamous cell differentiation in almost area of gallbladder, diagnosed as adeno-squamous carcinoma with liver invasion and metastasis(pT3a[SI][H-inf], int, INF-β, ly1, v3, pn1, pN1, pM1, pStage ⅣB). One months after operation, abdominal CT revealed multiple liver metastatic recurrences. She died 7 months after operation. Although gallbladder adeno-squamous carcinoma has a poor prognosis, these many cases had a tendency to local infiltration accompanied with tumor fever. If curative resection might be obtained and the symptoms might be improved, aggressive resection should be performed.

A 69-year-old female underwent a mesh repair for an abdominal incisional hernia 4 years previously in our hospital. She visited local hospital for abdominal pain and fever. Abdominal CT showed a localizes abscess formation above the mesh, then she was taken to our hospital. We suspected mesh infection and performed emergent mesh removal. After the operation, we examined for her anemia. Her colonoscopy and CT findings pointed to transverse colon cancer. We performed right hemicolectomy, and final diagnosis was transverse colon cancer pT4aN0M0, pStage Ⅱb. She underwent adjuvant chemotherapy, and 9 months after surgery, no recurrence was found.

A 60's woman was admitted to our hospital because of palpitations that occurred with exertion. Coronary angiography computed tomography(CT)of suspected angina detected a tumor in the pancreatic head region. Abdominal CT showed a poorly enhanced 40×32 mm solid tumor in the hepatoduodenal ligament that contained a fatty component and calcification. During surgery, the tumor was located in the hepatoduodenal ligament, adhered to the pancreatic head, common hepatic artery, gastroduodenal artery, portal vein and common bile duct. However, the tumor was resected by preserving them. The tumor contained stratified squamous epithelium, a sebaceous gland, nerve, a pancreatic gland, and an adrenal gland. The histological diagnosis was a mature cystic teratoma. The patient showed no recurrence in 2 years and 10 months post-surgery. Mature teratomas in the hepatoduodenal ligament are extremely rare. Some reports showed that combined resection was performed when the tumor was in contact with the common bile duct, portal vein, and arteries. However, in our case, the tumor was removed relatively safely without combined resection.

The patient was a 79-year-old woman. In January 20XX, upper gastrointestinal endoscopy revealed a duodenal tumor with bleeding and ulceration. This tumor was diagnosed as a duodenal neuroendocrine tumor(NET)based on biopsy findings. In March 20XX, the patient underwent pancreatoduodenectomy with lymph node dissemination. Based on these pathological findings, the tumor was diagnosed as a duodenal NET(G2)with a lymph node metastasis(T2, N1, M0, Stage Ⅲ). Twenty months after the operation, abdominal CT revealed multiple liver metastases(S4, S7, and S8). After this recurrence, she underwent the subcutaneous somatostatin analogue injection therapy every 28 days, and transarterial chemoembolization( TACE)when these recurrent tumors showed remarkable regrowth, once a year, accounting for her age. She has maintained good disease control for 5 years.

The incidence of postoperative infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in Japan has been increasing dramatically. In March 1990, we assigned special doctors in infection control (infection control doctor, ICD), and defined comprehensive controls against MRSA infection. A total of 3536 cases of digestive tract surgery performed at our department were studied during the period between September 1987 and August 1997. We changed the use of antibiotics to prevent postoperative infection. Cefazolin (CEZ) was employed for surgery of the upper digestive tract, including esophagus, stomach, duodenum, and gallbladder. Cefotiam (CTM) was employed for surgery of the lower digestive tract, liver, and pancreas. In esophageal resection, the tracheal tube was extracted during the early postoperative period, and for cervical esophagogastroanastomosis, the autosuture was changed to layer-to-layer anastomosis. We have achieved successful control of postoperative MRSA infection, the incidence having decreased to 0.3% (9/2703). In conclusion, our methods of control against postoperative MRSA infection implies that comprehensive measures of prevention, including the reviewed specification and usage of antibiotics and operation management, have been well implemented. This value is the lowest and the first of any domestic hospital or institute in Japan, suggesting a continued and significant decrease.

重症筋無力症 (以下MGと略す) の胸腺外科80例 (胸腺腫非合併群55例・合併群25例) に聞き取り調査を行い, 病悩期間の中で「初診～確診」期間を検討した.「初診～確診」期間は22.0ヵ月 (胸腺腫非合併群36.8ヵ月, 合併群4.2ヵ月) で, 「初診～疑診」期間21.4ヵ月, 「疑診～確診」期間0.6ヵ月の結果から, 有効な病悩期間短縮の目標は疑診までの期間である.受診施設・診療科は, 初診では眼科など対症状的な診療所受診が多く, 疑診・診への経過に伴い国公立・大学病院の内科・神経内科へと紹介される傾向があり, 疑診まで2.71施設, 確診まで3.17施設が費やされていた.初診時診断は「MGである・MGの疑い」32%・「正常」16%・「非言及」41%であった.胸腺腫合併群の「初診～確診」期間は非常に短く, 腫瘍がMG疑診の根拠と成り得た例を除外しても傾向は変わらず, 胸腺腫非合併群においても合併群と同程度に「初診～確診」期間の短縮が可能と言える.「初診～疑診」期間の長期化は, 誤診・症状の軽快・有症状非受診・多施設受診・別疾患治療などが理由であった.「初診～疑診」期間の短縮には, MG発症後に受診されやすい診療科に対してMG情報を, もっと多く発信する必要がある.

ラットを用い, Methicilline耐性黄色ブドウ球菌 (以下, MRSAと略記) 生菌を腸管内に接種し, MRSA腸炎発症誘因の解明と全身感染症への移行経路の解明を目的に実験検討した. MRSA腸炎は胃切除後に多く, 抗菌剤投与で腸内細菌叢が変化した状態に起こりやすいとされている. そこで, 抗菌剤投与群と非投与群, 胃切除群と非切除群に分け比較検討した. 胃切除前Kanamycin, Metronidazole投与群では, MRSA接種1日目より便中にMRSAが106CFU/g検出され, 非投与群では, MRSA接種4日目までは102CFU/g, 5日目から105CFU/g検出され, 前老が有意に多かった. 術後Latamoxef非投与群では接種したMRSAは増殖しなかった. MRSA接種前後の抗菌剤投与下で胃切除群と非切除群の便中MRSA菌数の比較では前者が有意に多かった. MRSAの臓器内移行をみると, まず肝臓からMRSAが検出され, 腸管内のMRSAが腸管壁から門脈, 肝臓を経由し, 全身感染を引き起こすことが示唆された.

A 61-year-old man had a right pneumonectomy for bronchogenic carcinoma. Empyema with bronchial fistula developed on the 30th postoperative day. After 46 days of tube drainage, an omental flap was drawn into the pleural cavity through the subcutaneous space from the abdominal cavity, and fixed over the fistula; the empyema cavity was obliterated with a thoracoplasty. Two months after this radical surgery, the empyema cavity was found to be less than 30 ml by computed-tomography of the chest. He was discharged 75 days after the radical surgery for empyema with bronchopleural fistula.A 50-year-old man with old tuberculous pleurisy, had removal of an empyema sac and decortication of the lung 38 days after tube drainage. However, on the 11th postoperative day he developed empyema and a bronchopleural fistula, which was successfully closed by an omental pedicle flap with thoracoplasty 48 days after the first radical surgery. He was discharged 28 days after the 2nd radical surgery for empyema with bronchopleural fistula.Transposition of an omental flap for fixation on a fistula and for filling up an empyema cavity with a thoracoplasty for reduction of a dead space is an effective treatment of empyema with bronchopleural fistula.

Two cases of occult breast cancer that we encountered are reported inaddition to the discussion on the literature. Case 1 was a 57-year-old woman who visited our department because she moted masses in the left axillary and supraclavicular fossae. When the mass in the left axillary fossa was examined via biopsy, it was diagnosed as metastatic adenocarcinoma. Because a mammogram showed very small calcification, but a possible malignant tumor in other organs was clinically denied, she was diagnosed as breast occult cancer. This patient underwent extended radical mastectomy of the left breast; the tumor was defined as T0, N3, M0 and stage IIIb. Case 2 was a 64-year-old woman who visited our department with the main complaint of an egg-sized painless mass in the left axillary fossa. Because the mass was diagnosed as metastatic adenocarcinoma via biopsy, her whole body was examined, a nd a mass, measuring about 2cm in diameter, was detected in the left thyroid lobe. While we were thinking of a possibility of breast occult cancer, we undetook operation based on suspected thyroid adenocarcinoma. Because that tumor was found to be benign goiter during operation, total mastectomy was performed at the same time. Her breast tumor was histopathologically defined as medullary tubular carcinoma with infiltration to a very limited extent.