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Background/Aims@#The prediction of invasion depth is important to decide the treatment modality for undifferentiated-type early gastric cancer (EGC) less than 20 mm in size without ulceration. We aimed to identify the endoscopic features associated with submucosal invasion in undifferentiated-type EGC that meet the criteria of size and ulcer status. @*Methods@#A total of 120 patients with undifferentiated-type EGC who underwent endoscopic submucosal dissection (ESD) or gastrectomy between August 2008 and December 2017 were enrolled and reviewed retrospectively. All lesions met the ESD indications except for the invasion depth. We analyzed the endoscopic features of the tumors before resection and invasion depth after resection. @*Results@#There were 97 mucosal and 23 submucosal cancer lesions. Multivariable analysis revealed that the polypoid (OR, 90.8; 95% CI, 3.5~2,346.2) or elevated (OR, 5.0; 95% CI, 1.2~21.3) types, deep depression (OR, 76.0; 95% CI, 4.5~1,284.6), and upper (OR, 22.7; 95% CI, 3.0~170.8) or middle location (OR, 10.3; 95% CI, 1.9~55.4) were significant risk factors of submucosal invasion. @*Conclusions@#The treatment modality for undifferentiated-type EGC of the polypoid/elevated type or with deep depression located in the upper two-thirds of the stomach should be carefully considered, even if the tumor size and ulcer status meet the ESD indications.
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Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.
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Synchronous quadruple colorectal cancer (CRC) is extremely rare without genetic alterations. We present a case of synchronous quadruple CRC with 2 lesions previously obscured by ischemic colitis. A 73-year-old woman was admitted to our emergency department. An abdominal computed tomography revealed ischemic colitis and irregular wall thickening of the sigmoid colon and sigmoid-descending junction, suspicious of 2 colon cancers. A colonoscopy examination revealed a fungating mass 20 cm from the anal verge, as well as ischemic colitis spanning the mucosa from the sigmoid colon to the transverse colon. The patient underwent laparoscopic Hartmann procedure. Pathologic examination confirmed both lesions as adenocarcinomas with microsatellite stable. Seven months postoperatively, instead of a laparoscopic Hartmann reversal, a laparoscopic total colectomy was performed due to the continued presence of severe ischemic colitis. The pathologic report suggested the presence of 2 distinct invasive adenocarcinomas in the descending colon without genetic alterations such as microsatellite instability.
ABSTRACT
Background/Aims@#The prediction of invasion depth is important to decide the treatment modality for undifferentiated-type early gastric cancer (EGC) less than 20 mm in size without ulceration. We aimed to identify the endoscopic features associated with submucosal invasion in undifferentiated-type EGC that meet the criteria of size and ulcer status. @*Methods@#A total of 120 patients with undifferentiated-type EGC who underwent endoscopic submucosal dissection (ESD) or gastrectomy between August 2008 and December 2017 were enrolled and reviewed retrospectively. All lesions met the ESD indications except for the invasion depth. We analyzed the endoscopic features of the tumors before resection and invasion depth after resection. @*Results@#There were 97 mucosal and 23 submucosal cancer lesions. Multivariable analysis revealed that the polypoid (OR, 90.8; 95% CI, 3.5~2,346.2) or elevated (OR, 5.0; 95% CI, 1.2~21.3) types, deep depression (OR, 76.0; 95% CI, 4.5~1,284.6), and upper (OR, 22.7; 95% CI, 3.0~170.8) or middle location (OR, 10.3; 95% CI, 1.9~55.4) were significant risk factors of submucosal invasion. @*Conclusions@#The treatment modality for undifferentiated-type EGC of the polypoid/elevated type or with deep depression located in the upper two-thirds of the stomach should be carefully considered, even if the tumor size and ulcer status meet the ESD indications.
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Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.
ABSTRACT
Synchronous quadruple colorectal cancer (CRC) is extremely rare without genetic alterations. We present a case of synchronous quadruple CRC with 2 lesions previously obscured by ischemic colitis. A 73-year-old woman was admitted to our emergency department. An abdominal computed tomography revealed ischemic colitis and irregular wall thickening of the sigmoid colon and sigmoid-descending junction, suspicious of 2 colon cancers. A colonoscopy examination revealed a fungating mass 20 cm from the anal verge, as well as ischemic colitis spanning the mucosa from the sigmoid colon to the transverse colon. The patient underwent laparoscopic Hartmann procedure. Pathologic examination confirmed both lesions as adenocarcinomas with microsatellite stable. Seven months postoperatively, instead of a laparoscopic Hartmann reversal, a laparoscopic total colectomy was performed due to the continued presence of severe ischemic colitis. The pathologic report suggested the presence of 2 distinct invasive adenocarcinomas in the descending colon without genetic alterations such as microsatellite instability.
ABSTRACT
Emphysematous gastritis is an infectious disease in which air is formed in the gastric wall by gas-forming organisms. It is infrequently reported but can be fatal without early diagnosis and treatment. The stomach is rarely infected because of the acidity of the gastric secretions and the rich blood supply. Treatment should be aimed at covering gram-negative organisms and anaerobes using broad-spectrum intravenous antibiotics, and occasional surgical management in order to enhance survival. Risk factors are those that lead to disrupted mucosal integrity, such as corrosive injury, and those that result in an immunosuppressed condition, including diabetes mellitus, chronic kidney disease, immunosuppressive drug use, and subsequent invasion by gas-forming organisms. We experienced a case of emphysematous gastritis that worsened after endoscopy. Aeration during upper endoscopy examination can cause barotrauma to the gastric wall with impairment of the mucosal barrier, resulting in the spread of gastric wall infection to the whole body. Therefore, we report this case and provide relevant literature review to suggest that early endoscopic evaluation can lead to exacerbation of emphysematous gastritis.
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An extragastrointestinal stromal tumor (EGIST) is a gastrointestinal stromal tumor that arises outside of the gastrointestinal tract. Most EGISTs are located in the omentum, mesentery, and retroperitoneum. The occurrence of an EGIST at the perianal region is very rare. Herein, we report our experience with EGISTs in the perianal area and review the literature. A 70-year-old man presented to our hospital with a 2-year history of anal discomfort. A pelvic magnetic resonance imaging scan showed a homogenous, well-defined, soft tissue density mass. The patient underwent mass excision, and the pathological examination confirmed that the mass was an EGIST. The size of the tumor was 4.3×3.2 cm, and the mitotic count was 1 per 50 high-power fields. The tumor cells were immunohistochemically positive for KIT and CD34 but were negative for S-100 and alpha-smooth muscle actin. There were no other abnormal findings in the gastrointestinal tract; upon pathological review, this case was confirmed as perianal EGIST. Therefore, EGIST should be considered as a differential diagnosis of perianal masses.
ABSTRACT
An extragastrointestinal stromal tumor (EGIST) is a gastrointestinal stromal tumor that arises outside of the gastrointestinal tract. Most EGISTs are located in the omentum, mesentery, and retroperitoneum. The occurrence of an EGIST at the perianal region is very rare. Herein, we report our experience with EGISTs in the perianal area and review the literature. A 70-year-old man presented to our hospital with a 2-year history of anal discomfort. A pelvic magnetic resonance imaging scan showed a homogenous, well-defined, soft tissue density mass. The patient underwent mass excision, and the pathological examination confirmed that the mass was an EGIST. The size of the tumor was 4.3×3.2 cm, and the mitotic count was 1 per 50 high-power fields. The tumor cells were immunohistochemically positive for KIT and CD34 but were negative for S-100 and alpha-smooth muscle actin. There were no other abnormal findings in the gastrointestinal tract; upon pathological review, this case was confirmed as perianal EGIST. Therefore, EGIST should be considered as a differential diagnosis of perianal masses.
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PURPOSE: Colon perfusion status is one of the most important factors for the determination of postoperative anastomotic complications. Colonic hypoperfusion can be induced by inferior mesenteric artery (IMA) ligation in some patients. This study aimed to evaluate atherosclerotic risk assessment and vascular parameters of CT angiography as predictors of colonic hypoperfusion. METHODS: This prospective study was conducted at a tertiary referral hospital and included 46 rectosigmoid colon cancer patients undergoing laparoscopic anterior resection between August 2013 to July 2014. Atherosclerotic risk scores were assessed using the Framingham cardiovascular risk score system. The IMA length, branching pattern, atherosclerotic calcification, and intermesenteric artery and mesenteric vascular diameters were evaluated using CT angiography. Mesenteric marginal artery pressures were measured before and after IMA clamping. The mean arterial pressure (MAP) index was calculated by dividing the mesenteric marginal MAP into the systemic MAP to determine the mesenteric hypoperfusion status after IMA clamping. A critically low MAP index was defined as <0.4. RESULTS: Critically low MAP index (<0.4) was observed in 6 cases (13.0%) after IMA clamping. Atherosclerotic calcification of the IMA and superior mesenteric artery occurred in 11 (23.9%) and 5 patients (10.9%), respectively. Low MAP index was associated with high atherosclerotic risk score and short IMA length, rather than atherosclerotic calcification and other vascular parameters of the major mesenteric arteries. Multivariate analysis indicated that high atherosclerotic risk and short IMA length were independent predictors of critically low MAP index. CONCLUSION: Atherosclerotic risk assessment and IMA length were useful predictors of the mesenteric hypoperfusion status following IMA ligation during laparoscopic rectosigmoid colon surgery.
Subject(s)
Humans , Angiography , Arterial Pressure , Arteries , Atherosclerosis , Colon , Colonic Neoplasms , Constriction , Ligation , Mesenteric Arteries , Mesenteric Artery, Inferior , Mesenteric Artery, Superior , Multivariate Analysis , Perfusion , Prospective Studies , Risk Assessment , Tertiary Care CentersABSTRACT
PURPOSE: We evaluated the relationship of cancer-associated fibroblasts (CAFs) and desmoplastic reactions with cancer invasiveness and long-term outcomes in patients with colorectal cancer (CRC). METHODS: Histologic evaluation of mature CAFs and desmoplasia was performed by observing the collagen fiber structure and fibroblast cytomorphology in the intratumoral stroma and invasive front of CRC tissues. Cancer-cell invasiveness was evaluated using lymphatic invasion, vascular invasion, perineural invasion, tumor budding, and tumor growth patterns. Overall survival and systemic recurrence were analyzed. A network analysis was performed between CAF maturation, desmoplastic reaction, and cancer invasiveness. RESULTS: The proportions of mature CAFs in the intratumoral stroma and the invasive front were 57.6% and 60.3%, respectively. Epidermal growth factor receptor (EGFR) overexpression was significantly higher in the mature CAFs in the invasive front as compared to immature CAFs. Lymphatic invasion increased as the number of mature fibroblasts in the intratumoral stroma increased. Tumor budding was observed in almost half of both mature and immature stroma samples and occurred more frequently in infiltrating tumors. On network analysis, well-connected islands were identified that was associated with EGFR overexpression, CAF maturation, and infiltrating tumor growth patterns leading to tumor budding. CONCLUSION: The maturity of CAFs and desmoplastic reactions were associated with cancer invasion. However, the cytomorphologic characteristics of CAFs were insufficient as an independent prognostic factor for patients with CRC.
Subject(s)
Humans , Collagen , Colorectal Neoplasms , Fibroblasts , Islands , ErbB Receptors , Recurrence , Wound HealingABSTRACT
Gastric tuberculosis accounts for approximately 2% of all cases of gastrointestinal tuberculosis. Diagnosis of gastric tuberculosis is challenging because it can present with various clinical, endoscopic, and radiologic features. Tuberculosis manifesting as a gastric subepithelial tumor is exceedingly rare; only several dozen cases have been reported. A 30-year-old male visited emergency room of our hospital with hematemesis and melena. Abdominal CT revealed a 2.5 cm mass in the gastric antrum, and endoscopy revealed a subepithelial mass with a visible vessel at its center on gastric antrum. Primary gastric tuberculosis was diagnosed by surgical wedge resection. We report a rare case of gastric tuberculosis mimicking a subepithelial tumor with acute gastric ulcer bleeding.
Subject(s)
Adult , Humans , Male , Diagnosis , Emergency Service, Hospital , Endoscopy , Gastrointestinal Hemorrhage , Hematemesis , Hemorrhage , Melena , Pyloric Antrum , Stomach Ulcer , Tomography, X-Ray Computed , Tuberculosis , Tuberculosis, GastrointestinalABSTRACT
Mycotic aneurysms of the common carotid artery (CCA) are very rare and warrant surgical treatment to prevent rupture and death. A 89-year-old man who complained of a sore throat and swelling of the right side of neck. He had no history of trauma or neck infection. Physical examination revealed hard and pulsatile mass. Computed tomography showed initially pseudoaneurysm rupture on the right CCA with surrounding inflammation. The emergency operation revealed mycotic aneurysm rupture with CCA necrosis and was successfully done by wide debridement and carotid artery resection with interposition bypass. The resected tissue and blood culture grew growth of Staphylococcus aureus group. We report a rare case of mycotic aneurysm of right CCA that treated by bypass interposition.
Subject(s)
Aged, 80 and over , Humans , Aneurysm, False , Aneurysm, Infected , Carotid Arteries , Carotid Artery, Common , Debridement , Emergencies , Inflammation , Neck , Necrosis , Pharyngitis , Physical Examination , Rupture , Staphylococcus aureusABSTRACT
PURPOSE: The aim of this study is to evaluate the safety and usefulness of indocyanine green (ICG) angiography in laparoscopic colorectal surgery and to explore its educational benefits in surgical beginners. METHODS: From July to October of 2015, a total of 21 patients with colorectal cancer underwent laparoscopic surgery using the fluorescence-guided imaging system, IMAGE1 S™ (Karl Storz, Germany). Real-time ICG fluorescence images and red inversion images were juxtaposed with standard white-light images for assessment of colonic perfusion. A surgical beginner group comprised of medical students (n=11) and surgical residents (n=11) were then questioned postoperatively about the colonic transection line and mesenteric vascular integrity across various image modes to determine the most proper view for surgical decision. RESULTS: A total of 21 patients underwent laparoscopic colorectal surgery using ICG angiography. Mean patient age was 69.7 years (52~77 years). Mean time-to-detection for the marginal arteries and colonic wall were 26.7 (range, 4~45) and 47.3 (range, 20~77) seconds, respectively. No injection-related adverse events were observed. Rate of change in the colonic transection line across modes was 59.9% (33.3~66.7%) in the surgical beginners. Decisions made by surgical beginners on the transection line were varied with the standard image, but converged to 81.8% in the ICG with red inversion mode. Surgical beginners preferred ICG with red inversion mode for assessment of mesenteric vascular integrity. CONCLUSION: ICG angiography seems to be safe and useful in evaluating colonic perfusion for transection decisions and could have educational benefits for surgical beginners in training to make surgical decisions.
Subject(s)
Humans , Angiography , Arteries , Colon , Colorectal Neoplasms , Colorectal Surgery , Fluorescence , Indocyanine Green , Laparoscopy , Perfusion , Students, MedicalABSTRACT
PURPOSE: Laparoscopic total extraperitoneal (TEP) repair of inguinal hernia is technically challenging enough to build high barrier to entry. The purpose of this study was to identify clinical factors influencing technical difficulty with laparoscopic TEP according to learning period. METHODS: We conducted a retrospective study of 112 adult patients who underwent laparoscopic TEP for unilateral inguinal hernia from January 2009 to September 2013. A technically difficult case was defined as the 70th percentiles or more in the distribution curve of operative time, major complication, or open conversion. RESULTS: The rate of body mass index (BMI) above 25 kg/m2 was significantly higher in the difficult group than the nondifficult group in the learning period of laparoscopic TEP (57.9% vs. 26.8%, respectively, P = 0.020). However, in the experience period, it revealed no statistical difference with technical difficulty (31.3% vs. 33.3%, respectively, P = 0.882). In multivariate analysis, BMI (> or =25 kg/m2) was identified as a significant independent factor for technical difficulty with laparoscopic TEP in the learning period (odds ratio, 4.572; P = 0.015). CONCLUSION: Patient's BMI (> or =25 kg/m2) can create technical difficulty with laparoscopic TEP only in the learning period, but not in the experience period. Therefore BMI could be applied as one of the guidelines for patient selection, especially for surgeons in the learning curve of laparoscopic TEP.
Subject(s)
Adult , Humans , Body Mass Index , Hernia, Inguinal , Herniorrhaphy , Laparoscopy , Learning Curve , Learning , Multivariate Analysis , Operative Time , Patient Selection , Retrospective StudiesABSTRACT
PURPOSE: The present pilot study was conducted to detect putative cancer stem cell (CSC) from the hepatic portal system and peripheral blood in the colorectal cancer patients and to compare them to healthy donor and diverticulitis patients. METHODS: Laboratory study was performed to identify the expression of cell surface markers, epithelial cell adhesion molecule (EpCAM), cytokeratin (CK) 18, CK20, CD44, and CD133, on several colon cancer cell lines. Clinical pilot study was conducted to detect putative circulating CSC as EpCAM+CD133+ cell in colorectal cancer (n = 10), diverticulitis (n = 5), and four healthy donors, by using flow cytometry. Blood was drawn from the hepatic portal system and peripheral vein. RESULTS: On laboratory study, EpCAM was expressed in whole colon cancer cell lines, and CD44 and CD133 were simultaneously expressed in 50% of the cell lines with stemness phenotype, but CK18 and CK20 were not expressed in most of the cell lines. On clinical study, the mean EpCAM+CD133+ cell counts of 11.6/105 in the hepatic portal system were somewhat lower than 15.4/105 in peripheral vein (P = 0.241). As for diverticulitis patients, EpCAM+CD133+ cells were also detected to have steeper dropped to near zero, after the surgery. CONCLUSION: The numbers of putative CSC were not statistically different between the detection sites of the portal vein and peripheral vein in the colon cancer patients. Therefore, we may not have benefitted by getting the cells from the hepatic portal system. In addition, the CD133+EpCAM+ cells in the colon cancer patients might contain normal stem cells from cancer inflammation similar to diverticulitis.
Subject(s)
Humans , Cell Count , Cell Line , Colonic Neoplasms , Colorectal Neoplasms , Diverticulitis , Epithelial Cells , Flow Cytometry , Inflammation , Keratins , Neoplastic Stem Cells , Phenotype , Pilot Projects , Portal System , Portal Vein , Stem Cells , Tissue Donors , VeinsABSTRACT
PURPOSE: The risk factors of pseudomembranous colitis (PMC) are well known. However, there have been no studies of PMC after gastrointestinal operation. The aim of this study was to evaluate the risk factors and to establish the guiding principles for PMC after gastrointestinal operation. METHODS: We performed a retrospective study of 39 PMC patients after gastrointestinal operation from January 2004 to December 2008. A control group of one hundred and seventeen matched to a PMC group by date of operation was chosen in a random fashion. Preoperative, operative, and postoperative factors of PMC were evaluated. RESULTS: The incidence of PMC after gastrointestinal operation was 0.63%. On univariate analysis, among preoperative factors, albumin, PT-INR and neutropenia were significant risk factors for PMC. There was no difference in the operative factors. Among postoperative factors, duration of cephalosporin, aminoglycoside, H2 blocker administration were significant risk factors for PMC after gastrointestinal operation. And transfusion, duration of NPO, length of stay in intensive care unit (ICU) and postoperative intraabddominal abscess, pneumonia were also significant risk factors. On multivariate analysis, the independent risk factors for PMC after gastrointestinal operation were duration of aminoglycoside administration, transfusion volume and length of stay in ICU. When period of study was divided by three months, incidence of PMC at a specific period was high. After limiting of prophylactic antibiotics, incidence of PMC fell to 0.36%. CONCLUSION: To prevent PMC after gastrointestinal operation, we need sustained efforts to establish stricter guidelines about prophylactic antibiotics and transfusion, and to minimize length of stay in ICU.
Subject(s)
Humans , Abscess , Anti-Bacterial Agents , Enterocolitis, Pseudomembranous , Incidence , Intensive Care Units , Length of Stay , Multivariate Analysis , Neutropenia , Pneumonia , Retrospective Studies , Risk FactorsABSTRACT
The collision tumors have been reported in various organs and represent the coexistence of two adjacent but histologically distinct tumors in an organ without any histological admixture. A gastric collision tumor is rare and most gastric collision tumors involve an adenocarcinoma colliding with a lymphoma. A 48-year-old man was referred to our hospital for an evaluation of dyspepsia and upper abdominal discomfort. Endoscopy demonstrated the presence of an ulcerative lesion in the gastric antrum. The biopsy specimens confirmed a pathological diagnosis of an adenocarcinoma. After a radical subtotal gastrectomy, a thorough Histopathological examination revealed a collision tumor: a well-differentiated adenocarcinoma in the superficial layer (mucosa, submucosa) and a poorly differentiated neuroendocrine carcinoma in the deeper layer (muscularis propria, serosa). The patient received combination chemotherapy with cisplatin and etoposide. Para-aortic lymph node enlargement was observed on the abdominal computed tomography scanning, 3 years after surgery. The patient underwent chemotherapy with TS-1, and the size of lymph nodes was reduced. The patient continues to do well after a follow up period of 5 years 3 months. We report this case of gastric collision tumor (adenocarcinoma and neuroendocrine carcinoma) with a brief review of the relevant literature.
Subject(s)
Humans , Middle Aged , Adenocarcinoma , Biopsy , Carcinoma, Neuroendocrine , Cisplatin , Diagnosis , Drug Therapy , Drug Therapy, Combination , Dyspepsia , Endoscopy , Etoposide , Follow-Up Studies , Gastrectomy , Lymph Nodes , Lymphoma , Pyloric Antrum , Stomach , Stomach Neoplasms , UlcerABSTRACT
Clinical and roentgenological follow-up study is carried out on 66 cases of femoral neck fractures, treated at the department of orthopaedic surgery, National Medical Center with at least 8 months after treatment. And gained the result as follows; 1. Sixty six cases were comprised of 30 males and 36 females, and 40 out of 66 were over 50 years old. 2. The most common cause of fracture was due to direct or indirect trauma caused by falling or stumbling accidents. 3. Sixty one percent of the cases were rather old and neglected cases after injury. 4. Among 66 patients, 34 were treated by internal fixation, 17 Austin-Moore prosthetic replacements, 1 hip fusion and 14 cast immobilization only. For internal fixation, devices were 26 Smith Petersen nails, 4 compression hip nails, 3 multiple pins and I sliding nail. 5. The incidence of avascular necrosis was 12 percent in 34 cases treated by internal fixation and 36 percent in non-operative treatment. The incidence of non-union was 6 percent in internal fixation, and 36 percent in latter group. 6. Avascular necrosis and non-union after internal fixation were most common in Pauwels type III. 7. Austin-Moore prosthetic replacement has been prefered in elderly patients regardless of the duration between injury and treatment.