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An 87-year-old man visited our hospital with a chief complaint of melena. Invagination caused by rectal cancer or sigmoid colon cancer was suspected as a result of physical and radiological examinations. Since there were no subjective symptoms, laparoscopic surgery was planned electively. As an operative finding, a tumor was found in the rectosigmoid colon and caused invagination. The invagination was released during an operation, and high anterior resection with D3 dissection was performed laparoscopically. The operation time was 108 minutes and the amount of blood loss was 22 mL. Although anastomotic leakage occurred as a postoperative complication, recovery was achieved conservatively by percutaneous drainage. In many cases, invagination of adults is caused by a solid tumor such as bowel carcinoma, which commonly occurs at the cecum or sigmoid colon. Although invagination of the rectosigmoid colon fixed to the retroperitoneum is relatively rare, the fragility of the supporting tissues in the pelvis accompanied by aging is considered to be a cause. In cases of a large tumor occupying the lumen of the intestine, appropriate preoperative diagnosis is needed and the method of operation should be chosen carefully.

We report a rare case of generalized peritonitis caused by nontraumatic, intraperitoneal rupture of the ureter. An 80-year-old woman with a history of bilateral vesicoureteral reflux and long-term urethral indwelling catheter drainage presented with a very distended abdomen. Computed tomography showed massive ascites and intraperitoneal free gas. We performed an emergency laparotomy, assuming a gastrointestinal perforation; but could not find a cause of generalized peritonitis. Postoperatively, she presented with anuria and massive peritoneal drainage. The findings of a cystogram confirmed intraperitoneal ureteral rupture. She was managed successfully with ureteral stenting. The diagnosis of this condition requires a high degree of clinical suspicion, along with radiographic evidence and peritoneal fluid analysis. Image-guided interventions play a crucial role in the management of ureteral urine leaks after a correct diagnosis has been made.

管外型十二指腸憩室のまれな合併症として, 十二指腸閉塞をきたした症例を報告する. 症例は76歳の女性. 心窩部痛, 食欲低下, 嘔吐を主訴に入院となる. 腹部CT検査にて十二指腸の拡張, 総胆管と胆嚢の拡張, 胆嚢周囲に液体の貯留を認めた. また, 十二指腸水平部に食物塊を入れた憩室を認めた. 十二指腸狭窄による十二指腸内圧上昇によって, 逆流性胆管炎を生じたものと考えイレウス管を挿入した. 十二指腸の減圧によって胆管炎は軽快したが, 食物は通過せず手術を施行した. 手術所見では十二指腸水平部に大きさ7cmの食物塊を含む憩室があり, これが十二指腸を圧迫し通過障害をきたしたものと考え, 憩室を切除した. 術後経過は良好であった.

破裂性腹部大動脈瘤は, 非破裂性に比べて未だ救命率が低い. われわれは最高齢者に属する破裂性腹部大動脈瘤の緊急手術を経験し, 救命しえた. 症例は90歳女性. 近医より腰腹部痛および拍動性腫瘤のため腹部大動脈瘤切迫破裂の診断にて本院紹介入院となった. 入院後ショック状態となり腹部大動脈瘤破裂と診断し緊急手術を行った. 開腹時, 後腹膜腔に血腫の拡がりが見られ Fitzgerald 分類III型であった. 手術は胃小網を切開し, まず横隔膜下にて大動脈を遮断し出血をコントロールした後, 腎下部大動脈に遮断を変更した. 瘤後壁に5×1.5cmの破裂口を認めた. 16×8mm Y-graft を用いた人工血管置換術を行った. 手術時間は5時間5分, 術中出血量は6200mlであった. 術後腸管虚血症状もなく約1か月して退院した. 高齢者であっても迅速な判断と綿密な術後管理によって救命することができる.

The patient, a 51-year-old male, suffered from two gunshot injuries in the right chest and abdomen. Computed tomography (CT) revealed right hemothorax, pulmonary trauma, hepatic, pancreatic, duodenal and transverse colic injury and postcaval trauma. An emergency operation was performed to repair these injured parts. During surgery, there was massive bleeding from the injured inferior vena cava. Duration of the surgery was 8.5hr and blood loss was 8, 000ml. Massive bleeding due to leakage of pancreatic juice occurred 23 days after surgery. A superior mesenteric angiogram showed extravasation from the right branch of the middle colic artery. Transcatheter arterial embolization (TAE) was successfully performed by using gelatin sponge. The patient was discharged on the 120th postoperative day. Preoperative CT was helpful in diagnosing trauma from the gunshot injuries. After surgery, TAE was useful for postoperative bleeding. We suspect that the gunshot injuries caused the pseudo aneurysm.

A 20-year-old female, who had had an exploratory laparotomy without successful results at the age of 8 years old and therefore had undergone paracentesis intermittently, was admitted to our hospital, complaining of general lassitude and abdominal distension with ventral girth of 89 cm. The patient was diagnosed as congenital chylous ascites by lymphography, which showed lymphtransudation to the retroperitoneum and the aplasia of thoracic duct. At operation, 11.61 of chylous ascites was collected and the abnormal retroperitoneal lymphatics were divided and ligated. Post-operatively, the quantity of ascites decreased, and one year after the operation, she was fully rehabilitated with ventral girth of 66 cm without administration of any diuretics.

During a period of 1969-88, 30 patients (14 males and 16-females) with primary varicose veins suffered from incurable leg ulcer were operated on in our institution. The average duration lasting lower extremity symptoms was 9.8 years in males or 10 years in females. While the average duration suffered from incurable leg ulcer was 14.6 months in males or 5.5 months in females. Solitary leg ulcers were seen in 23 cases and multiple ulcers in 7. Small ulcers measuring less than 2cm in diameter were completely cured by extensive whole saphenous vein stripping and excision of varices. For larger ulcers extrafascial or subfascial ligation of perforator branches with valve incompetence were performed. Furthermore, middle layer skin grafting was necessary for extensive ulcers measuring more than 3cm in diameter. Among 30 patients 9 needed skin grafting, and we have no experience of recurrence of treated ulcers. Thus incurable leg ulcer could be healed completely by operation within the average of 2.3 months.

A case of splenic artery aneurysm accompanied by an abdominal aortic aneurysm is reported. The patients, a 71-year-old woman, was found to have a pulsating abdominal tumor when she was admitted to the hospital because of hypertension. Angiography of the abdominal aorta revealed an 8 cm×10 cm abdominal aortic aneurysm, and a 1.2 cm×1.2 cm splenic artery aneurysm. The abdominal aorta was replaced a Y-shaped double veloar knitted dacron graft, and splenectomy including the splenic artery aneurysm was performed. Histological findings showed that both the abdominal and splenic artery aneurysms are relatively arteruosclerotic changes. Splenic artery aneurysm are relatively rare and to date only 159 cases have been reported in Japan. Since mortality and morbidity rates are high, intensive care and imidiate surgery are necessary.

Nineteen patients with chronic juxtarenal aortic occlusion were analysed in regard to preoperative state and results. Of the 19 patients, 11 who were evaluated preoperatively to have a high risk for surgery underwent extra-anatomic bypass grafting (EABG) and the remaining 8 had desobliteration, including thromboendarterectomy in 3 and anatomical bypass grafting in 5. The average age was 71 years in the EABG group and 59 in the direct desobliteration group. The frequency of preoperative complications such as ECG abnormality and renal dysfunction was higher in the former group, although there was no difference in the chief complaints between the two groups. Preoperative angiography revealed occlusive lesions of the renal artery in 11 (47%) of 19 patients. In all cases of EABG group, axillo-femoral bypass grafting was performed, and a good long-term patency was achieved although there were two early and three late deaths. Thromboendarterectomy applied to three patients in the direct desobliteration groups resulted in early reocclusion, whereas anatomical bypass grafting in the remaining five patients caused satisfactory restoration of distal blood flow for a long time.

A case of a 4-year-old girl who underwent successful correction of a Collett Edwards type II truncus arteriosus following bilateral pulmonary artery banding is reported herein. The diagnosis of Collett Edwards type II truncus arteriosus was made when she was 5 months of age, after which the bilateral pulmonary artery banding was performed. This proved very effective and enabled elective radial surgery to be done. The radical operation was performed safely by a modified version of Rastelli's procedure. The patient had an uneventful recovery and is now well with no symptoms one year following her operation.

A case of ischemic colitis following abdominal aortic aneurysmectomy in a 74-year-old male is reported. The patient was admitted to the hospital with a complaint of severe abdominal pain. A ruptured abdominal aortic aneurysm was suspected, and emergency laparotomy was performed. At the operation a massive hematoma was encountered in the retroperitoneal space caused by rupture of an abdominal aortic aneurysm. Aneurysmectomy was performed uneventfully. The left colon appeared to be viable at the end of the procedure. Three days after the operation he had diarrhea, and the symptoms of bowel ischemia progressed. Colonoscopy on the 7th day after the first operation revealed ischemic colitis. He was treated conservatively for 2 weeks without significant improvement. On the 19th postoperative day uncontrollable massive melena occurred. Emergency laparotomy was carried out again, and resection of the left colon and transverse colostomy were done. The postoperative course after the second operation was uneventful, and the patient is doing well now. Although clinically significant ischemic colitis following aortic reconstruction is rare, colonoscopy after the operation is useful for early recognition of ischemic changes before clinical manifestations.

The authors previously showed that a vascular prosthesis made of ultrafine polyester fibers (UFPF) had high healing ability even when of low porosity. In this study, new highly porous vascular grafts fabricated from UFPF (water porosity: 3,600 ml/min/cm2, 8 mm in inner diameter and 5 cm in length), were developed and implanted in the thoracic descending aorta of dogs to evaluate their endothelialization capability. Two weeks after implantation, many colonies of endothelial cells with openings of capillary blood vessels were noted, even in the middle portion of the grafts. Numerous fibroblasts and capillary blood vessels were also observed in the synthetic walls. These results suggest that UFPF vascular grafts provide a suitable microenvironment for infiltration and proliferation of fibroblasts, which are accompanied by the capillary formation as nutrient supply; these capillaries provide multiple sources of endothelial coverage on the luminal surface. It is expected that the new, highly porous vascular grafts may have rich endothelialization capability and stable healing properties in humans.