A total of 110 patients who were operated on for gastrointesinal cancer were subjected to a study of elucidating the correlations between intraoperative blood transfusion and postoperative cellular immunological activity. All patients were classified into three groups; homologous transfusion group, autologous transfusion group, and no transfusion group by intraoperative transfusion method. The ratio of CD4 to CD8 (CD4/CD8), natural killer cell activity (NK cell) and immunosuppressive acidic protein (IAP) were compared among these three groups before and after the operation. The NK cell activity decreased after the operation and the decrease was prolonged in the homologous transfusion group with or without leukocyte depletion filter. IAP increased postoperatively in the hemologous group without the filter, which was significantly higher than those of homologous group with the filter and autologous transfusion group. Postoperative infections occurred in 36% of the homologous, 16% of autologous transfusion group, and 2% of no-transfusion group. A significantly higher incidence of postoperative infections complication was noted in homologous group than that of autologous group. Compared with homologous transfusion, autologous transfusion is thought to be very useful in surgeries for gastrointestinal cancers in terms of the maintenance of the cellular immunological activity.

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The purpose of the study is to make a guide to the preoperative examiantion of cardiac function and perioperative management of patients with gastrointestinal cancer associated with heart disease. Subjects were 26patients with heart disease who underwent a gastrointestinal surgery at the institution in a recent one decade. There were 17 patients with gastric cancer and nine with colorectal cancer. As to thier heart diseases, 14patients had ischemic heart disease and 12 had valvular heart disease.
Cardiac functions were initially evaluated by NYHA functional classification and ultrasonic cardiography in all patients. For further evaluation, patients with ischemic heart disease who were classified over class II in NYHA or who had undergone PTCA or CABG, were carefully examined the cardiac function by coronary antigoraphy, exercise of ECG and myocardial scintigraphy. Nitroglycerin was administered intra- and postoperatively in 11 patients with ischemic heart disease. Heparin was administered postoperatively in five patients who had undergone valve replacement. Under these therapeutic guidelines, only one patient with angina pectoris complained of slight chest pain postoperatively.
These results demonstrate that our preoperative examinations of cardiac function and perioperative management may be reasonable. Gastrointestinal surgery for patients with heart disease can be safely performed with proper evaluation of cardiac function and perioperative careful management.

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We investigated the perioperative changes in immunological function of monocytes in patients with gastric or esophageal carcinoma in terms of surface antigen HLA-DR and serum cytokine IL-6 and IL-8 levels. Subjects were 16 cases of curatively resected gastric carcinoma, seven cases of non-curatively resected gastric carcinoma, three cases of curatively resected and four cases of non-curatively resected esophageal carcinoma. Six cases received laparoscopic cholecystectomy for cholecystolithiasis were served as control. Peripheral blood samples were collected from them on the day before operation, 1st, 3rd, 5th, 7th and 14th postoperative day. Of these samples, the mean fluorescence intensity (MFI) of surface antigen HLA-DR expressed on monocytes were analyzed by FACScan, and serum cytokines were analyzed by ELISA.
In patients with gastric carcinoma no significant difference in the MFI of HLA-DR was noted between curatively resected and noncuratively resected groups, but in noncuratively resected group it was significantly lower on 14th postoperative day than that of preoperative day. In patients with esophageal carcinoma, there was no significant difference in the MFI of HLA-DR between curatively resected and noncuratively resected groups on the preoperative day, but in curatively resected group it significantly increased on the 3rd postoperative day. Serum IL-8 level in noncuratively resected gastric carcinoma group was significantly higher than those of curatively resected group on preoperative day and the 1st postoperative day. Serum IL-8 level in noncuratively resected esophageal carcinoma group was significantly higher than that of curatively resected group in perioperative period.
These results suggest that patients with noncuratively resected esophageal carcinoma have fallen into the state of immunosupression of monocytes.

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Pancreatoduodenectomy (PD) has been applied for advanced gastric cancer with pancreatic and/or duodenal invasion. Twenty-one patients with gastric cancer underwent PD in our hospital from 1966 to 1996. No patients were lost to follow up. In this study, the clinicopathological factors and outcomes of these 21patients were analyzed. The numbers of patients with tumor invasion depths of T3 and T4 were 1 and 20, respectively. None had hepatic or peritoneal metastases, the exception being one patients who had adjacent peritoneal dissemination. Curative resection with extended lymphadenectomy beyond D2 was performed in all patients. The cumulative 1-year and 5-years survival rates were 65.2% and 41.5%, respectively. and the median survival time was 593days. There were five 5-year survivors. The survival rate in 5patients with positive lymph nodes on the posterior surface of the pancreatic head (No. 13 lymph node) was significantly lower than that in 16patients without No. 13 lymph node metastasis (p<0.01).
We conclude that long-term survival can be anticipated with advanced gastric cancer even with direct invasion to the pancreatic head, provided that there is no hepatic, peritoneal or No. 13 lymph nodal metastasis, and that the tumor was curatively resected by the PD procedure.

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In a series of operated patients with advanced gastric cancer at the center, patients undergoing pancreato-splenectomy (PS) were compared with those undergoing pancreas preserving operation (PP) for the 5-year survival rate and postoperative quality of life (QOL) according to multivariate analysis. Subjects were 99 patients undergoing PS (PS group) and 47 patients undergoing PP (PP group) excluding those with early cancer of P0, H0. According to the multivariate analysis, a significantly favorable prognosis was noted in the PP group compared with the PS group. In cases of old histological stage III, the 5-year survival rate in the PP group was 66.7% (28 cases) versus 36.4% (66 cases) in the PS group, with a significant difference. Post operative complications, dressing and hospital stay in the PS group were more frequent and longer than thsoe of in the PP group. From these results, we support PP method for advanced proximal gastric cancer.

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We consider that the usefulness of percutaneous transhepatic right branch of portal vein embolization (PTRPE) is to reduce acute and remarkable change in portal circulation before and after right lobectomy of the liver. The pressure (cmH₂O) of portal vein in patients group without preoperative PTRPE elevated from 14.2±4.2 to 22.3±4.3 before and after right lobectomy of the liver. On the other side, in patients group with preoperative PTRPE, lesser change in the pressure was shown, from 21.2±4.6 to 22.8±4.7 before and after right lobectomy of the liver. The portal blood flow in the group without preoperative PTRPE elevated to 121% on an average before and after right lobectomy of the liver. On the other side, in the group with preoperative PTRPE, a lesser change was shown, elevating to 102% on an average before and after right lobectomy of the liver. Regardless of preoperative PTRPE, portal circulation after right lobectomy of the liver was similar to prehepatectomy status. In the group with preoperative PTRPE, portal circulation showed a ramarkable change before and after PTRPE, and it was taken to posthepatectomy status. Irrespectively of the association of liver cirrhosis, the same result was acquired.

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We studied 24 candidates for hepatectomy with CTAP and helical CT. According to size, we classified all nodules detected with CTAP into two groups (over and under 1cm in diameter of tumor size). CTAP detected 101 nodules over 1cm in diameter, whereas helical-CT detected 36 nodules (35.6%). CTAP detected 20 nodules under 1cm in diameter, whereas helical-CT detected only 4 nodules (20%). Five patients, 3 with HCC and 2 with metastases, were judged to have no indications for hepatectomy. In these 5 cases, CTAP detected 63 nodules of which 47 were over 1cm in diameter and 16 under 1cm in diameter. On the other hand, helical-CT detected 13 nodules (27.7%) over and 4 nodules (25%) under 1cm in diameter. CTAP was more sensitive for the detection of nodules under 1cm in diameter than helical-CT. The 3 cases with HCC and the 2 with metastases judged to have no indication for hepatectomy after CTAP represent a rather high ratio. In these cases, helical-CT was not sufficient for ether diagnosis or decision making regarding operability. We consider CTAP to be essential in the study of hepatic tumors.

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In a recent one decade from 1984 to 1994, a series of 107 patients with hepatocellular carcinoma (HCC) with liver cirrhosis underwent hepatectomy at the department. Of these 107 patients, 30 patients who had a platelet count of less than 100, 000 were selected and divided into two groups: splenectomy group in which splenectomy was associated with hepatectomy (n=12); and non-splenectomy group in which only hepatectomy was performed (n=18). In order to elacidate the significance of associated splenectomy, the both group were compared for background factors, changes in blood biochemical parameters between pre and post-operation, postoperative mobidity, recurrence rate, and the influence on the postoperative chemotherapy.
There was no significant difference between both groups in background factors, postoperative mobidity, and recurrence rate. Patients of the splenectomy group had a better postoperative liver function (srum total bilirubin value and prothrombin time) than those of non-splenectomy group. In the splenectomy group, postoperative chemotherapy could be performed completely because the number of white blood cells and platelets increased significantly, while the chemotherapy had to be discontinued in 4 patients of the non-splenectomy group.
These results suggest that the splenectomy combined with hepatectomy is a useful method in the treatment for the patients with HCC and hypersplenism caused by cirrhosis.

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A case of non-recurrent laryngeal nerve is presented. A 63-year-old woman was admitted to the hospital because of a thyroid cancer. At the operation, the left recurrent nerve was seen in the usual position. But the right recurrent nerve was not present in the right tracheoesophageal groove. The right non-recurrent laryngeal nerve was arising from the cervical trunk of the vagus, and passing transversely into the right side of trachea. A post operative angiogram showed an abnormal right subclavian artery which directly arised from the distal part of aortic arch. She had no trachyphonia, dyspnea nor dysphagia. The right recurrent laryngeal nerve is embryologically related to the fourth arch vessel which becomes the right subclavian artery. Rarely, when the fourth vessel disappears, this nerve is not arrested by this vessel and arises directly from the vagus. Consequently, the right subclavian artery arises from the distal aorta, just distal to the left subclavian artery, and crosses to the right behind the trachea and esophagus. So, it can be associated with dysphagia. This type of anomaly is rare, but surgeons should know the presence of the non-recurrent laryngeal nerve for thyroidectomy. It is also necessary to follow the occurrence of dyspnea and dysphagia.

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Mediastinal ectopic parathyroid tumors have been surgically treated by midline sternotomy or thoracotomy, but these procedures have demerits to offer a severe postoperative pain and a cosmetic problem due to its large surgical wound. Recently, thoracoscopic surgery has expanded with advances in endoscopic surgical instrumentation. We report two patients with mediastinal ectopic parathyroid tumor who underwent successful thoracoscopic excision. A 23-year-old woman was admitted to the hospital for evaluation of ureterolithiasis and hypercalcemia. Hormonal study revealed high level of serum intact parathyroid hormone. Ultrasonographic examination failed to detect any parathyroid tumor. ^99mTcmethoxy-isobutyl-isonitrile scintigraphy (MIBI) and magnetic resonance imaging (MRI) revealed on intrathymic mass, 3×2cm in size. Another patient was a 73-year-old woman. She had a 10-year history of hypercalcemia and ureterolithiasis, and underwent an initial parathyroid surgery in other institute 8years before admission, that failed to remove the parathyroid tumor. The tumor was located in the anterior side of the upper thoracic esophagus, which was detected clearly by MIBI scintigram and MRI. For both two patients, right thoracoscopic approach was performed and the tumors were successfully removed. Postoperative course was uneventful, and the outcome of surgery was excellent in two cases. Our initial experiences are encouraging enough to suggest that thoracoscopic excision in patients with intrathoracic parathyroid tumor is a beneficial therapeutic option, which is easy, safe, less invasive and lead to early convalescence.

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A 21-year-old woman was seen at the hospital because of rapidly enlarging left breast. On physical examination, a 11×9×9cm elastic hard, and well movable tumor which occupied the BDE area of the left breast was present. With ultrasonography and magnetic resonance imaging (MRI), a solid tumor with small cysts was confirmed. With a diagnosis of phyllodes tumor, a wide-ranging resection with a margin 3cm in width of normal mammary tissue was performed when both the nipple and areola mammae were preserved. A defect in the mammary gland was reconstructed by using a flap made of musculus latissimus dorsi with sufficient subcutaneous adipose tissue. After the operation, histological diagnosis of juvenile fibroadenoma of the breast was made.
Both juvenile fibroadenoma and phyllodes tumor of the breast are fibroepithelial tumor or occurring in juveniles, and the clinical differentiation between them is often difficult. It is important to make the correct preoperative diagnosis because both diseases demand different treatment each other. If the lesion of juvenile fibroadenoma is greater than 10cm in size, enucleation of the lesion leaves a large defect with a resulting change in shape of the breast that will give a mental blow to the patient. Thus, we think that the mammaplasy using a flap of musculus latissimus dorsi should be entertained as one of therapies.

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A malignant mucocele-like tumor of the breast, which is a rare entity, is entity, is reported. A 41-year-old woman had noticed a lump of the right breast one week before she visited the hospital. Physical examination revealed a 1.6×1.2cm elastic hard, smooth, surfaced, and well movable nodule in the upper lateral quadrant of the right breast. A distance of nipple and nodules was 2cm. Regional lymph node was not palpable. Mammography revealed a homogeneous mass lesion with halo and smooth margin. Calcification and spicula were not detected. Echography revealed a cyst-like hypoechoic lesion in the mammary gland, which was smooth margin but irregular shaped as small papillary lesions and septum.
On aspiration cytology, a small quantity of gelly like substance was aspirated. Cytological diagnosis was class IIIb, and mucinous carcinoma was suspected. Histological examination revealed mucinous cysts with extrvaseted mucin, which were lined by low columner epithelium with low papillary projections and bridge formation. Histological diagnosis was made as malignant mucocele-like tumor of the breast.

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A 62-year-old woman was admitted to the hospital because of a right breast tumor. Previous history disclosed that she underwent a mastectomy for a malignant lymphoma of the left breast with 3courses of VEMP regimen 6years before. Thereafter she was doing well without any sign of recurrence until the contralateral breast mass occurred. Based on the result of an aspiration biopsy cytology (ABC) and a rapid progress of the tumor, it was diagnosed as malignant lymphoma of the breast. Further, an exploration of the wholebody revealed a tumor in the uterus. As no other lesions were detected, a mastectomy and hysterectomy were performed. Histological study of the resected materials revealed diffuse large cell type that was more malignant than the former lesion, but it was obscure whether these lesions were recurrence from the malignant lymphoma of the left breast or metachronous occurrence. In the treatment of malignant lymphoma, the patient should be strictly followed for a long time by entertaining a probable relapse.

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Metastatic adrenal tumors are found in a high incidence at autopsy, but are rarely resectable clinically. A resected case of metastatic adrenal tumor from a lung cancer is reported. A 63-year-old man, who had been operated on for an adenocarcinoma of the lung 7 month before was pointed out having a left adrenal tumor on computed tomography (CT). Hematological examination showed a high CEA level of 46.2ng/ml.
CT, abdominal ultrasonography, and magnetic resonance imaging (MRI) showed a left metastatic adrenal tumor from the lung cancer (well differentiated adenocarcinoma; t2n0M0 in stage II). The tumor was successfully resected. The adrenal tumor was confirmed a metastasis from the lung cancer by pathological examination. The postoperative course was uneventful and he had been treated by chemotherapy with CDDP, MMC and VDS from 14th post operative day. He was dischargd as cured on 42nd postoperative day.
Recentable metastatic adrenal cancer from lung cancer has been reported in only 13 cases in Japan including the present case. The metastatic adrenal tumor should be excised when the adrenal metastasis is solitary and the primary lesion is well-controlled.

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A 34-year-old woman who had had induced abortion once but not delivered, was admitted to the hospital because of hemoptysis. Chest X-ray film showed a solitary nodule shadow ont the upper lobe of the left lung. Bronchial fiberscope did not detect any lesion, and percutaneous needle biopsy did not establish the diagnosis. Due to continued hemoptysis, an upper lobectomy of the left lung was performed. Microscopically the tumor was diagnosed as choriocarcinoma composed of cytotrophoblasts and syncytiotrophoblasts. In further examination after the operation, there was no abnormal findings in her uterus and bilaterla adenexa, but human chorionic gonadotrophin (HCG) and β-HCG in serum showed high level. So chemotherapy was conducted four times, and HCG and β-HCG in serum dropped to normal level.
Pulmonary choriocarcinoma is often found as metastatic tumor, but this case had a solitary tumor of the lung and no abnormal lesion was detected in the other organs. So we think that the tumor was primary.
Primary pulmonary choriocarcinoma is very rare. This case of the disease which was curatively treatment by operation and postoperative chemotherapy is reported with some notes.

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We present a rare case of so-called carcinosarcoma of the esophagus in a 51-year-old man who experienced a local reccurence 2 years after resection of the primary lesion. The patient was admitted to the hospital because of dysphagia. X-ray and endoscopic examination of the esophagus revealed a polypoid lesion with irregular ulceration in the Im portion of the esophagus. Biopsy revealed squamous cell carcinoma. Endoscopic ultrasonography disclosed that the polyp like elevation was a tumor arising in the lamina muscularis mucosae. Subtotal esophagectomy (R₃) was carried out. On histophathological and immunohistochemical examinations, the ulcerative area was well differentiated squamous cell carcinoma and the polyp was sarcomatous change, and the tumor revealed so-called carcinosarcoma of the esophagus. The tumor was 45×35mm in size, the depth of tumor invasion was mp and no metastasis was found in the resected lymph nodes. Postoperative course was uneventful. Two years after the operation, the ptient experienced a local recurrence when the serum level of SCC as a tumor marker increased and recurrence of squamous cell carcinoma component was suspected. The recurred tumor decreased in size by radiation therapy with 5-Fu regimen, and subjective symptoms disappeared.

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A 70-year-old man was referred to the hospital because of abnormal shadow of the stomach which was pointed out at another hospital. UGI and GIF revealed giant folds and an elevated lesion at the body near the greater curvature, but a biopsy showed group II. With a diagnosis of submucosal tumor of the stomach, an operation was performed on May 23. Upon laparotomy, a tumor about 25cm in size with infiltrative proliferation into the diaphragm and left-sided abdominal wall, and numerous peritoneal dissemination were noted. So only a biopsy was conducted.
Histopathologically, a starry-sky image was revealed, and the diagnosis of Burkitt lymphoma of the stomach was made. After the operation, the tumor rapidly enlarged. So the CHOP regimen was immediately started and abdominal tumr was not felt within only 5 days and his general condition rapidly improved. However, the LDH level abruptly increased to 19700IU/L on December 3, the patient developed neutropenia due to bone marrow recurrence, and died on December 23. On bone marrow puncture, tumor cells occupied 87% and the translocation of chromosomes (8:14) was recognized. There have been only 11 cases of Burkitt lymphoma of the stomach in the Japanese literature. The prognosis of adult patients with the disease was extremely poor like this patient.

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A 53-year-old woman was admitted to the hospital because of abdominal distention in 1995. There was a history of undergoing a wedge gastric resection for a leiomoyblastoma of the stomach at another hospital in 1985. On admission to the hospital, a tumor was palpable in the right upper abdominal quadrant, as a size of childhead, and elastic hard consistency. Abdominal CT showed a low density mass in the left lobe of the liver. The wall of the tumor was enhanced in the contrast CT scan. The angiography of the celiac artery showed that the main artery was stretched by the mass and a part of the tumor was feed by the left hepatic artery. Resection of the tumor with a caudate hepatic lobectomy was performed. The final diagnosis of the tumor was liver metastasis of the leiomyoblastoma. Postoperative course was uneventful and the patient was discharged from the hospital on 17th day after the operation.
Only 15 cases of leiomyoblastoma of the stomahc with liver metastasis have been reported previously in Japan. And six cases had liver reccurence after resection of the primary tumor.
We report a rare case which could be resected the liver metastases 10 years after the operation for the gastric leiomyoblastoma.

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We successfully treated two cases of gastric small cell carcinoma that is rare with postoperative modified EAP regimen. A 70-year-old woman with Borrmann 3 type gastric cancer with multiple liver metastases underwent a distal gastrectomy and a lateral hepatic segmentectomy. The histological findings showed diffuse proliferation of small cells with little cytoplasm forming a pseudo-rosette structure and trabecular disportion. The final diagnosis of small cell carcinoma with partial differentiation to adenocarcinoma was made. Atypical small cells were positive for immunohistochemical stains of NSE and chromogranin-A, and negative for CEA. Modified EAP therapy was conducted, and consequently the liver metastases disappeared. There has been no evidence of recurrence as of 23 months after the operation. Another 71-year-old man with Borrmann 3 type gastic cancer underwent a distal gastrectomy. The histological and immunohistochemical findings were much the same as the former's. Modified EAP therapy was conducted, and the para-aortic lymph node metastases disappeared for a time, but he died of peritonitis carcinomatosa 16 months after the operation. These tumors presented here might derive from pluripotential primitive cells that can differentiate into both neuroendocrine and epithelial cells. It is said that the small cell carcinoma of the stomach has a poor prognosis, but we consider that the carcinoma often responds to chemotherapy.

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We report a case of early gastric mucosal cancer which showed 340U/ml of CA19-9 in serum. A 75-year-old man demonstrated an abnormality in the stomach on a screening by barium meal study. Gastroscopy revealed a IIb type gastric cancer in the body of the stomach. Total gastrectomy with lymph node dissection was performed. Histopathologically the gastric cancer was mainly poorly differentiated tubular adenocarcinoma and partially moderately differentiated tubular adenocarcinoma, depth as m, infγ, ly(-), v(-), n(-), ow(-), aw(-), and stage Ia. Immunohistochemical staining for CA19-9 was positive in the part of the moderately differetiated tubular adenocarcinoma. The level of serum Ca19-9 decreased rapidly after the operation and reached the normal ragne (30U/ml) by the second postoperative month. It is uncommon that the early gastric cancer shows a high level of CA19-9. This case, however, suggests that it can occur if the tumor cells themselves have a high producing ability of CA19-9 and CA19-9 easily flows into the blood stream.

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We report a case of early gastric cancer with a high level of serum CA19-9 (400IU/ml). A 62-year-old man was admitted to the hospital because of abnormality of the stomach by screening. Gastric endoscopy visualized a type IIc lesion on the posterior wall of the lower body following the biopsy result of “poorly defferentiated adenocarcinoma”. At gastrography, sclerosing features of the cardiac wall were identified. At the preoperative state, serum level of CA19-9 was 400IU/ml (normal range:<37). Total gastrectomy with splenectomy was performed, because of the white sclerosis of the serosal surface. Histhologically, the lesion, measuring 12×12mm, revealed poorly differentiated adenocarcinoma (m, ly0, v0, n0). Immunohisthochemically, carcinoma cells were positively-stained for CA19-9 and negatively-stained for CEA. Postoperative course has been uneventful. Serum CA19-9 level decreased within the normal range on the postoperative 21th day. Caution is advisable to perform the preoperative examination because of this rare presence of early gastric cancer with high level of serum CA19-9.

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This report includes two cases of malignant acanthosis nigricance.
Case 1: A 63-year-old man visited the department of dermatology in our hospital because of itchy blackning legions of face and neck. Since skin biopsy led to diagnosis of acanthosis nigricance, the patient was subjected to general screening for malignant disease. As a result, a gastric cance was found. (Borrmann type 3) Laparotomy was performed on April. 6, 1988, but resection was impossible on account of advanced cancer infiltration. This patient died of cancer after 3 months.
Case 2: A 75-year-old man visited the department of dermatology in our hospital because of blacking lesions in the face and scrotum. Because tumor marker was abnormal (CEA 41.6), general screening for malignant disease was enforced. As a result, a gastric cancer (Borrmann type 3) was found. Total gastrectomy was performed in combination with Roux-en Y method on July. 20, 1995. This patient is still living as of 22 months after the laparotomy.

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A case of carcinoid of the accessory papilla which is extremely rare is reported. A 52-year-old man consulted another a hospital for hematemesis and was diagnosed as gastric ulcer. During the treatment of gastric ulcer, a submucosal tumor of the duodenum was detected and he was sent to the hospital. The tumor was located on the anterior wall of the duodenal second portion, at 2.5cm oral side of Vater papilla, measuring about 10mm in diameter. Accessory papilla was not identified on examinations. Biopsy showed carcinoid cells invaded the smooth muscle. Pancreaticoduodenectomy with adjacent lymph node dissection was performed. Resected specimen showed the carcinoid tumor invaded submucosal layer in the accessory (papilla, measuring 12×12mm, with adjacent lymoh node metastasis. The careful choice of treatment is needed in treatment of carcinoid tumor near the accessory papilla, even if, it is small in size and not invaded to muscular layer. And the smooth muscle in biopsy specimen is a special bundle of smooth muscle in the accessory papilla like a sphincter of Oddi.

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A 31-year-old man was emergently admitted to the department of gastroenterological medicine in our hospital because of abrupt massive anal bleeding. Upper and lower gastrointestinal endoscopy and angiography faild to identify the bleeding site. A total of about 7500ml of anal bleeding was noted during these three days, but hemostasis was achieved conservatively. Intestinal fluoroscopy revealed a true diverticulum with peristalsis in the contralateral mesentery at 40cm from the terminal ileum. It was diagnosed as Meckel's diverticulum, but Tc scintigraphy did not visualize the diverticulum. Angiography confirmed abnormal vessels distributed in the diverticulum. It was determined that massive anal bleeding was originated from the Meckel's diverticulum. On November 15, 1996, a partial resection of the ileum including the diverticulum was performed under laparoscopy. Histological examination of the resected material revealed regeneration of epithelia at the top of the diverticulum which appeared to be a repairing process of acute mucosal lesion.
Differing from usual bleeding from Meckel's diverticulum, massive bleeding in this case was thought to occur from the acute mucosal lesion of the diverticulum.

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A 44-year-old man was seen at the hospital because of intensifing abdominal pain and repeated vomiting which lasted from the day before. There were tenderness in the entire abdomen which intensified at the right lower abdomen, rebound soreness and muscular defense. Simple abdominal X-ray film revealed a dilatation of he small intestine. Abdominal CT visualized a thickening of the intestinal wall, a narrowing in the lumen, and a pool of ascites ascites at the Douglas' pouch. An emergency operation was performed with a diagnosis of peritonitis. Upon middle and lower abdominal midline incision, a moderate degree of pool of yellow and transparent ascites was confirmed; serosa about 15cm in length in the ileum 110cm oral side from the terminal ileum changed color to reddish brown; and a significant narrowing of hte lumen due to edema with an oral side dilatation from the site was confirmed. A part of the intestine about 20cm in length including the portion was resected. The resected material showed edematous mucosa and swollen mucosal folds. Histopathologically, diffused infiltration of eosinophils was confirmed from submucosal layer to subserosal layer, and so the definite diagnosis of eosinophilic enteritis was made.
Eosinophilic enteritis is a rare entity. Fouteen cases of the disease seen in the Japanese literature including this case are reviewed.

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Impalement injury is a rare course of blunt injury. We experienced two cases of impalement injury to the rectum. Case 1: When a 63-year-old woman fallen on her gluteal region, a bamboo stump penetrated her rectum via the anus. Abdominal X-ray examination disclosed free air bilaterally beneath the diaphragm. The injury reached the peritoneal cavity, and she was diagnosed with panperitonitis. Case 2: When an 8-year-old boy jumped from a height of 2 meters, his bottom penetrated by an iron stake about 20cm in longth. Fistelography reveaeld that the injury extended through his rectum, but did not reach the periotneal cavity. Both patients underwent emergency operations, in which the rectal injury was reparied and a loop colostomy was formed with sigmoid colon. The postoperative clinical course was unremarkable in both cases, and the loop colostomies were closed 3 and 2months after operations, respectively. Rapid diagnosis of injury to the internal organs is most important in impalement injury, and clostomy and drainage from the basis of successful treatment of impalement injury of the rectum.

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A 28-year-old man was seen at the hospital because of intermittent lower abdominal pain and abdominal distention. A fist-sized mass was palpated in the right lower abdomen. Barium enema study and abdominal ultrasonography showed a polypoid lesion intussuscepted into the cecum from terminal ileum. Colonoscopy revealed a polypoid lesion with erosion in the ascending colon. Biopsied specimens from the tumor was diagnosed as malignant lymphoma. We performed a right hemicolectomy. The tumor 6.5×7.5cm in size and 4.5cm in height was located in the terminal ileum. Histological study revealed the malignant lymphoma diffuse, large cell type (B cell type).
Malignant lymphoma of the ileum sometimes causes intussusception. It often demands emergency operation due to intestinal obstruction or anal bleeding, and hence it is hard to make the definite diagnosis preoperatively. For making the definite diagnosis, colonoscopic biopsy is useful. Aggressive colonoscopic observation and precise biopsy of the tumor should make the preoperative correct diagnosis possible.

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A case of primary T cell of the small intestine with perforated peritonitis is reported.
A 26-year-old man who had 2-month lasting poor appetite, high fever of unknown origine, and abdominal pain lost his body weight by 6kg, and the abdominal pain spreaded entire the abdomen one day before adomission. The patient was admitted to the hospital with a suspicion of peritonitis. Plain abdominal X-ray films and computed tomography revealed remarkable ascites and free air. Emergency laparotomy was performed under a diagnosis of perforative peritonitis. Two sites of perforations associated with ulceration were present in the small intestine approximetely 15cm and 80cm from the ligament of Treiz. Partial resections of the small intestine were performed. A histological diagnosis of diffuse lymphoma, mixed-sized, T cell type was confirmed from the positive findings immunochemical stain with UCHL1. The patient was discharged from the hospital 36days after operation.
A total of 15 cases of primary T cell lymphoma of the small intestine including our case have been reported in the Japanese literature.

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Altough mucocele of the appendix is not a rare disease, that causing intussusception is extremely rare. Only 33 cases of mucocele causing intussusception have been reported in Japan. We present the case of a 46-year-old female. She visited our hospital presenting with abdominal pain and bloody stool. She was diagnosed as having intussusception using abdominal ultrasonography (US) and computed tomography (CT).
Gastrografin enema showed a crab-finger finding in the transverse colon, and reduced the intussusception. After reduction, a hemispherical protrusion in the cecum remained. Because this hemispherical protrusion in the cecum was proved to be a part of a cystic mass adjacent to the cecum, the patient was diagnosed as having had intussusception caused by mucocele of the appendix, and ileocecal resection was performed. Histologically, the mucocele was diagnosed as mucinous cystadenoma.
We emphasize that ultrasonography and/or computed tomography are valuable for the precise preoperative diagnosis of this disease through imaging both the target sign and the cystic mass adjacent to it.

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We report a rare case of perforation of diverticulum of the sigmoid colon with gas in the portal venous system and retroperitoneal emphysema. A 75-year-old man was seen at the hospital because of abrupt onset of lower abdominal pain and anal bleeding, and was admitted with a suspicion of ischemic colitis on an emergency colonoscopy. Conservative therapy was started, but on the 6th day the abdominal pain was intensified and muscular defense appeared. After a Hartmann operation was conducted, septic shock was lasted and the patient died on the 6th postoperative day. Histologic study of the resected material showed perforation of diverticulum of the sigmoid colon. Generalized peritonitis due to diverticular perforation of the large intestine is relatively common in aged people, but this case which were accompanied by gas in the portal venous system and emphysematous change in the retroperitoneum is rare. Some notes are also presented.

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A 78-year-old man was admitted to the hospital because of hypogastric pain. Abdominal X-ray film and computed tomography revealed retroperitoneal gas. Retroperitoneal perforation of the ascending colon was suspected, and an emergency operation was performed 3 hours after the onset of symptoms. No gross fecal soiling of the peritoneal cavity could be detected, since an abscess dur to the oral perforation of a cancer of the transverse colon was covered by the retroperitoneal adipose tissue.
Abscess drainage with right hemicolectomy was performed. So far 22 cases of retroperitoneal perforation of the ascending colon have been reported, and five out of six patients reported in 1990's were successfully saved. The prognosis of retroperitoneal abscess due to colonic perforation is better than that of colonic perforation into the free peritoneal cavity, so without septic shock, active curative treatment should be performed.

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A case of multiple primary colonic cancer in a 57-year-old man is reported. The patient had undergone operations for cecal cancer at age 40, rectal cancer at age 43, descending colon cancer at age 56 and transverse early colon cancer (type IIc) at age 57. The 4th cancer (IIc) was thought to be de novo cancer because there was no adenomatous component. His family history made it clear that he is a member of HNPCC. Follow-up colonoscopy revealed the slightly elevated small lesion in a transverse colon which was resected by EMR successfully 7 months after 4th operation. Histologically this lesion was consisted mainly of adenoma and well differentiated intramucosal adenocarcinoma was noted in the center, supporting the adenoma-carcinoma sequence.
This case shows that the strict follow-up by endoscopy will make it possible to treat the multiple primary cancer by endoscopy in HNPCC. And for estimating the natural history of colorectal cancers, it is very interesting that different types of colonic cancers developed in the same body of HNPCC.

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A 48-year-old man was seen at the hospital because of sudden diarrhea and weight loss. There were previous histories of a sigmoid colon cancer and descending colon cancer. His father, uncle and brother also had a history of colonic cancers. Barium enema study and colonoscopy showed a cancer of the transverse colon with a fistula to the jejunum and a rectal cancer. Exploratory laparotomy revealed another cecal cancer. Subtotal colectomy with a partial excision of the jejunum was performed. Rectal tumor was resected later by the transsacral approach. Histologically the transverse colon cancer was well differentiated adenocarcinoma and the pathological staging was IIIa such as si, n1, p0, H0 and M(-). The cecal and rectal cancers were in early stage. A detailed family history certified the hereditary nonpolyposis colorectal cancer (HNPCC). The fistula-forming colonic cancers and HNPCC have some similar characteristics as followss: 1) The age of the onset is young. 2) They are often of low malignancy compared to the clinical findings such as local extension and number of lesions. 3) Histologically the rate of mucinous components is relatively high compared to usual colorectal cancers.

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Two cases of endocrine cell carcinoma of the large bowel are reported, with a review of 42cases of the disease reported in the Japanese literature. Case 1: A 53-year-old woman was seen at the hospital because of diarrhea. A cancer of the ascending colon with peritoneal dissemination was detected by barium enema study, colonoscopy and abdominal computed tomography (CT). Right hemicolectomy was performed for the primary cancer. The patient is so far doing well without any symptoms 13months after the surgery. Case 2: A 66-year-old woman was seen at the hospital because of bloody stool. A low rectal cancer with multiple liver metastases was discovered by colonoscope and CT. Abdominoperineal resection with combined resection of posterior vagina wall was performed. The patient died of liver meastasis 59 days after the surgery. Histological examination of resected materials from both patients showed that each tumor consisted of polygonal-shaped cells and grew in solid pattern without gland formation. Microscopically the tumors were poorly differentiated adenocarcinoma. On immunohistochemical study, both tumors were positive for chromogranine A. Therefore, the definite diagnosis of endocrine cell carcinoma was made in each case. In a review of the Japanese literature, endocrine cell tumors often occurred in the rectum, had more malignant potential in lymphatic, vascular and liver metastases, and the prognosis was so poor that 17 out of 42patients died within one year.

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We report unusual two cases of local recurrence of villous tumor of the rectum after a transsacral excision, in which the recurrent tumor was situated outside the mucosal layer of the rectum. We believe that the lesion resulted from the implantation of tumor cells in the surgical track.
Case 1: Involved a 72-year-old woman. Previous history disclosed that she underwent excision of a rectal villous tumors 30mm in diameter via transsacral approach. Histologically it was carcinoma in adenoma. Surgical cut end was positive for adenoma. Eight years after the primary operation, a 30×30×35mm mucinous adenocarcinoma was discovered in the rectal wall accompanied with peritoneal dissemination.
Case 2: A 64-year-old man. He underwent an operation of a rectal villous tumor that was 40mm in diameter by a transsacral approach. Histology confirmed a well differentiated adenocarcinoma accompanied with no evidence of invasive malignancy. Surgical cut end was negative for adenoma and carcinoma. Three years and one month after the surgery, 40×40×35mm extrarectal adenocarcinoma was detected. It is probable that tumor cells sewn into the surgical stumups in Case 1 and the implantation of tumor cell sewn into the surgical stumps in Case 1 and the implantation of tumor cell during the first operation in Case 2 was responsible for the recurrence. And it is suggested that transsacral excision for the large rectal villous tumors with long diameter have a increased risk of developing a recurrence.

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We report two cases of primary malignant lymphoma of the rectum. The first case involved a 70-year-old man with a lsp polyp of 2 cm in size with slight center depression at the posterior wall of the lowest portion of the rectum. Histological examination on biopsy showed Non-Hodgkin's lymphoma, diffuse medium cell type. Abdominoperineal excision of the rectum with regional lymph nodes dissection was performed. Histopathologically reactive lymphoid hyperplasia (RLH) was suspected, but DNA hybridization analysis confirmed the rearrengement of the H-chain J-region. consequently the diagnosis of B-cell lymphoma was made. The second case involved a 55-year-old woman who had a hemisphere shaped elevated lesion of 3 cm in size covered with normal mucosa at the posterior wall of the upper portion of the rectum. Low anterior resection with regional lymph nodes dissection was performed under the diagnosis of submucosal tumor of the rectum. The pathological examination showed that the tumor was composed of proliferation of centrocyte-like-cells combined with lymphoepitelial lesion at the mucosa and the epithelial gland.
Immunohistochemical examination showed that L-26 was positive on these tumor cells. The diagnosis of MALT lymphoma was made. As these two patients are expected to obtain a complete cure by the resection, they are kept under medical observation without chemotherapy after the surgery.

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A 55-year-old woman was seen at the hospital because her stools were positive for occult blood at medical checkup. Barium enema study revealed a polyp about 10mm in diameter in the rectosigmoid. Colonoscopy demonstrated a 9× 7mm sessile poly with central depression at the same portion and a polypectomy was carried out. Since histological examination of the polypectomy specimen showed adenocarcinoma with positive polypectomized stump, high anterior resection was performed. Resected specimen revealed moderately differentiated adenocarcinoma which remained in the colonic wall and invaded the subserosal layer with vessel invasion and lymph node metastasis. Eleven cases of small advanced colorectal cancer under 10mm in size have been reported in Japan including our case. We should take a careful attitude to apply the polypectomy for small colorectal lesions.

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An 82-year-old man was admitted to the hospital because of hematemesis, vomiting and high fever. There was a history of undergoing a low anterior resection for a rectal cancer 3 years previously. On admission, ultrasonography and CT scan of the abdomen showed bilateral renal pelvic dilatation (hydronephrosis) and a mass in the pelvic cavity. colonoendoscopy revealed complete obstruction of hte colon at the site of anastomosis. He was diagnosed as to have recurrent rectal cancer involving the bilateral ureters and anastomosed colon.
To maintain the renal function and patient's condition, percutaneous right nephrostomy and descending colostomy were constructed. After the construction of discending colostomy, a lowdose FP (5-FU+CDDP) chemotherapy was started. The low dose FP therapy resulted in successful management of ureteral obstruction caused by the recurrent rectal cancer. In the FP therapy, 5-FU was administered at a dose of 250mg/body by continuous intravenous infusion for 7 days, and CDDP was intraarterially infused via an intraarterial port which dwelt in the aorta at a dose of 5mg/body for 5 days with 2-day resting period (the therapy conducted for 2 weeks; one course). On and after the 27th day after the therapy, the patient was ablet to urinate by himself. After 4.5 courses of the therapy, a 64% of reduction of the tumor (partial remission) was confirmed on CT and the ureteral obstruction was improvd. The patient was discharged from the hospital. During the therapy no adverse side effects were observed.
The low-dose FP chemotherapy is safe and useful for the patient with recurrent rectal cancer.

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A 52-year-old man was admitted to the hospital for a left inguinal hernia and it was repaired. Postoperative plain X-ray film showed an abnormal shadow which pressed the ascending colon in his right flank. Computed tomography and drip infusion cholangiography (DIC) demonstrated that the abnormal shadow was a part of an abnormally big and deformed liver which pressed the ascending colon to the left and reached the pelvic cavity. The gallbladder was included in the abnormal part of the liver in the right flank. The hepatic ducts once united to form the common hepatic duct in the abnormal part, then ascended receiving the cystic duct and changing the name into the common bile duct, and flowed into the duodenum. DIC and ^99mTc-PMT cholescintigraphy showed the choleric excretory function being in good condition. Because of good liver and choleric excretory function, this anomaly of the liver was not considered to be pathological. Although minor variations in size and form of the liver are not uncommon, true anomaly in the form of the liver like this case is exteremly rare and has not been reported at least in Japan.

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Mucin producing bile duct tumor is a rare disease and 104cases of the disease have been described in the Japanese literature. Of those 104 cases, 91cases were malignant and only 7 cases included ours were benign. We experienced a case of mucin producing bile duct adenoma with repeated acute pancreatitis. A 48-year-old woman was admitted to the hospital for with a diagnosis of repeated acute pancreatitis. ERCP revealed a defect in a dilated common bile duct and a slightly dilated posterior intrahepatic bile duct. EST was performed and revealed the defect in the common bile duct was mucin. No abnomality was found in the pancreatic duct. Peroral cholangioscopy revealed that mucin was localised only in a posterior intrahepatic bile duct. Posterior hepatic segmentectomy was performed under the diagnosis of mucin producing bile duct tumor of posterior intrahepatic bile duct. The resected specimen showed a flat glanular elevation lesion with the diameter of 7mm in locally dome like dilated posterior intrahepatic bile duct. The histopathological diagnosis was papillary adenoma.

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We report a case of rare carcinoid tumor of the gallbladder. A 79-year-old woman was admitted to the hospital because of upper abdominal pain. A man's fist sized hard tumor without accompaning tenderness was palpable at the right hypochondrial region, and abdominal ultrasonography and computed tomography revealed a tumor in the gallbladder, about 9cm in diameter, which had clear border and diffuse intratumor density. With a diagnosis of gallbladder tumor with low suspicious of cancer, a cholecystectomy was performed. The resected tumor was 91×81mm in size, and no invasion into the surrounding tissue nor metastasis to the liver and regional lymph nodes was recognized. Pathologically it was carcinoid tumor of the gallbladder and the tumor involvement remained in the submucosal layer. She had been well without any recurrence for 20 months after the surgery.

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A 45-year-old woman was admitted to the hospital because of severe anemia and marked hepatosplenomegaly. Hematological examination showed severe anemia., thrombocytopenia and hepatic dysfunction. Abdominal computed tomography, ultrasonography and angiography demonstrated tumor-like multiple lesions in the liver and the spleen. Echo-guided needle biopsy of the liver suggested epithelioid hemangioendothelioma. Because of deterioration of anemia (RBC 90×10⁴/mm³) and DICP (Platelet 1.2×10⁴/mm³), a splenectomy was performed. Histological examination revealed angiosarcoma of the spleen associated with liver metastasis. The tumor cels showed positive staining for Factor Vllrelated antigen and CD31 immunohistologically. Postoperatively, the patient was treated with hepatic intra-arterial chemotherapy (FAM) and systemic administration of interleukin-2. She died of hepatic failure due to increase of liver tumors. Primary splenic angiosarcoma is rare, and only 21 cases have been reported in the literature in Japan. Of these 21 cases, 12 cases underwent a splenectomy including only one survived case more than 6 months. this disease presents difficulty in early diagnosis and has a poor prognosis, and so it must be kept in mind as a probable differential diagnosis for splenic tumors.

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Primary splenic malignant lymphoma (PSML) is a relatively rare entity that so far some 100 cases have been reported in Japan. With a recent advance in various imagings including ultrasonography (US), the disease has been increasingly diagnosed preoperatively. The authers present two cases of PSML experienced at the hospital. Both patients were admitted to the hospital because of abdominal pain and a localized splenic tumor on US and CT. Characteristic abnormal findings in them on admission included high level of LDH; positive response to HCV antibody; an poorly demarcated hyperechoic mass with heterogenous center on US; internally heterogenous low density mass on CT; hot spots at ⁶⁷Ga on scintigraphy; cold spots on ^99mTC; and hypervascular mass on angiography. Based on these findings, the patient was diagnosed as having a PSML and underwent a splenectomy. On cross section of the resected material, a yellowish white, nodular, and solid tumor was revealed. Histopathologically, it was diffuse, large cell type, B cell malignant lymphoma. Adjuvant chemotherapy was conducted and the patients was able to have a relatively favorable prognosis.
There exist lots of differences in histology and prognosis between patients with PSML in Japan and those in the Western countries. The cases of PSML associated with some hepatic disorder were more common in Japan than in others.

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A case of endometriosis with a giant tumor in the pelvic cavity presenting with intestinal obstruction is described.
A 48-year-old woman was referred to the hospital after colostomy for intenstinal obstruction at another hospital, where she consulted about severe abdominal distention and was diagnosed as having a rectal tumor causing intestinal obstruction. On admission abdominal CT scans and MR images revealed a large tumor occupying the pelvic cavity. The tumor filled the lumen of the rectum to cause complete obstruction and extended to the uterus, sacrum, and left piriformis muscle. It was unable to make a diagnosis by endoscopic bioposies, but CT-guided biopsy successfully provided the definite diagnosis of endometriosis for us. Medication for the disease was started thereafter. It is suggested that we have to make the diagnosis for large tumors in the pelvic cavity causing intestinal obstruction by entertaining not only malignancies such as rectal or ovarian cancer but also endometriosis as possible different diagnosis. If the definitive diagnosis is unable to be made by endoscopic biopsy, CT-guided biopsy is recommended.

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A case of mesenteric panniculitis with a tight stricture of the intestinum is reported. A 63-year-old man was admitted to the hospitl because of constipation and abdominal pain. An operation was carried out following the conservative treatment for about two months. Both the large bowel (transverse colon_??_upper rectum) and mesentery which were thickened with inflammation, were resected. An anastomosis with a J-shaped colonic reservoir was performed, then a loop ileostomy was done. The patient evacuates the bowels two times daily without any hindrance in daily activities at present. He is followed on an ambulant basis.

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A 74-year-old man was admitted to the hospital because of lower abdominal pain. Abdominal CT examination demonstrated fluid collection and free air in the abdominal cavity.
Ultrasonography-guided abdominal paracentesis revealed the feculent fluid. From the previous summer, a cancer of the sigmoid colon had been pointed out by colonoscopy at other hospital. But he refused the operation because of his declined physical strength, and had left it alone. Emergency operation was performed under the diagnosis of fecal panperitonitis due to perforation of the sgimoid colon cancer. Preoperatively his general condition fell down to toxic shock state, WBC and platelets decreased dramatically during the operation. He needed artificial ventilatin for 2weeks in the ICU and postoperative blood chemistry data demonstrated elevation in CPK and myoglobin, with myoglobinuria derived from rhabdomyolysis. Renal dysfunction was improved by conservative therapy, so, he did not require hemodialysis. Remarkable muscle weakness was noted immediately after the operation but the patient was able to walk at discharge by physical therapy. Many conditions that trigger rhabdomyolysis have been reported in the literture, but there are few cases of rhabdomyolysis accompanied by sepsis due to surgical infection. Recently the mechanism of the degeneration of muscle proteins in the sepsis has been elucidating. Cytokines such as IL-1 and TNF appear to participate in the degeneration of the muscle proteins. We should pay attention to the muscle as a target organ for improving the surgical outcome in the management of patients with severe surgical infection.

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A 47-year-old man was seen at the hospital because of gastroenteritis. On physical examination a tumor was palpated in the lower abdomen. CT showed a solid and low density tumor on the ventral surface of the sacrum in the pelvic cavity. Magnetic resonance imaging (MRI) demonstrated no involvement of the sacrum. Surgical operation was performed under the diagnosis of retroperitoneal tumor. The tumor which adhered tightly to the periostium of sacrum, was resected together with some parts of sacral nerves. Resected tumor was 14.5×8.5×6.5cm in size, and weighed 440g. It was a solid and grayish yellow tumor with fibrous capsule. Histopathological examination revealed fibrous histiocytoma of the retroperitoneum.
Fibrous histiocytoma commonly arise in the cutaneous tissue, but rarely in the retroperitoneum. The retroperitoneal tumors present dificulty in diferential diagnosis and are often malignant. So retroperitoneal tumors should be resected as completely as possible with combined resection of adjacent tissue or organs. And MRI is thought to be useful for demonstrating the relationship between the pelvic tumor and surrounding tissue or organs.

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Two adult cases of sliding inguinal hernia are presented. Adult sliding inguinal hernia is an uncommon disease in Japan because many surgeons are unfamiliar with its anatomy and pathogenesis.
Therefore, patients with this type of hernia would usually undergo an operation for an other inguinal hernia type. We could not obtain a correct diagnosis before surgery because this disease is difficult to diagnose.
The key points in this operation is perfect closure of the internal ring and strict repair of posterior inguinal wall. We should choose an approciate procedure to prevent recurrent hernia as this type is known to have a high rate of recurrence.

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We have successfully managed a 34-year-old man with popliteal artery entrapment syndrome by a left popliteal artery bypass operation for intermittent left calf claudication; and by prophylactic transection of the right medial head of the right gastrocnemius muscle for the asymptomatic right lower extremity. Because the lower right extremity did not show ischemic symptoms in particular, but the popliteal artery showed interruption upon stress-angiography.
Popliteal artery entrapment syndrome is an uncommon congenital disorder of the artery, caused by faulty insertion of the mediate gastrocnemius muscle caput or popliteal muscle. It is possible to inhibit progression of the disease by conservative therapy, but a cure cannot be expected. The choice of surgical procedure depends entirely upon the condition of the popliteal artery. When the popliteal artery has had no permanent structural changes, myotomy may prove to be curative. When structural changes have already occurred, in addition to the correction of the anatomic abnormalities, replacement of the artery with a vein or by thromboendarterectomy angioplasty may be required to restore flow. Most case reports indicate that unilateral correction is sufficient, but it is essential to examine both limbs, since bilateral corrections may be necessary.
From our experience with this patient, we recognized the importance of a positive operative indication, because the prognosis for immediate restoration of flow to the extremity is excellent.

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