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Background: Re-operative cardiac surgery after prior coronary artery bypass grafting( CABG), using in situ graft is a challenge. Technical difficulties regarding this procedure include risks of graft injury and myocardial protection. The conventional strategy involves re-sternotomy, dissection, and temporary occlusion of the in situ graft to prevent cardioplegia washout. However, the problem with this procedure is that injury to the in situ graft can result in catastrophic complications., Methods: We reviewed 25 redo cases of patients who had prior CABG with patent in situ grafts. The in situ grafts were dissected and clamped in 18 (group C) patients, whereas in 7 (group U) patients, the in situ grafts were not dissected or clamped. All patients underwent re-sternotomy, aortic cross clamping and cardiac arrest with cardioplegia. Besides, myocardial protection was obtained using moderate hypothermia and systemic potassium injection in group U., Results: There were no injuries to the in situ grafts in either group. The peak creatine kinase-MB values were not significantly different between the two groups. Postoperative ejection fraction was preserved in both groups., Conclusions: The simplified approach of no-clamping technique yielded safety and effectiveness for myocardial protection in redo cases for patients with prior CABG in the presence of patent in situ grafts.

A 79-year-old man presented with progressive congestive heart failure symptom as a result of severe aortic stenosis. A rescue balloon aortic valvuloplasty was performed. After a transient improvement, computed tomographic scan revealed a porcelain aorta, and it showed a high risk for a surgical aortic valve replacement. Routine preoperative coronary angiography revealed tight stenosis of a proximal left anterior descending coronary artery. Percutaneous coronary intervention was performed unsuccessfully due to the severe calcification of the coronary artery. Therefore, a concomitant transapical transcatheter aortic valve implantation and coronary artery bypass grafting via the left thoracotomy was indicated. Under a veno-arterial extracorporeal circulatory support, we performed the transcatheter aortic valve implantation (TAVI) and coronary artery bypass grafting (CABG) successfully via a left thoracotomy. Even though the approach for TAVI is from fifth and CABG is from forth intercostal space respectively, it could be manipulated using the same skin incision. Concomitant TAVI and CABG via the left thoracotomy might be a reasonable and feasible option for the patients presented with severe aortic stenosis and coronary artery disease who are not eligible for conventional surgical solutions.

Some reports have shown that the prognosis of recurrent lung metastases after resection of pancreatic cancer is better than that for other organs. We report on 2 cases of long‒term survival after lung resection for lung metastases from pancreatic cancer. Case 1: A 73‒year‒old man underwent distal pancreatectomy for pancreatic body cancer. Adjuvant chemotherapy of S‒1 was administered for 6 months. At 3 years after surgery, 2 small metastatic nodules were detected in the right lung, and the patient underwent thoracoscopic right upper lobectomy. At 5 years and 9 months after the initial surgery, he is alive without recurrence. Case 2: An 81‒year‒old woman underwent pylorus‒preserving pancreatoduodenectomy for pancreatic head cancer. Adjuvant chemotherapy of S‒1 was administered for 4 months. At 1 year and 9 months after surgery, a metastatic nodule was detected in the left upper lung, and the patient underwent thoracoscopic left upper lobectomy. At 4 years and 6 months after initial surgery, radiation therapy was performed for localized bone metastasis. At 5 years and 1 month after the initial surgery, she is alive without other recurrences. In conclusion, recurrent lung metastases of pancreatic cancer with a small number of metastases may result in long‒term survival following resection.

Upside down stomach (UDS) is a rare type of hiatal hernia. It is categorized by herniation of either the entire stomach or most of the gastric portion of the stomach into the posterior mediastinum. Acute UDS usually presents with abdominal and thoracic symptoms immediately after the stomach rotates, while chronic UDS often has either mild or no symptoms with the entire stomach rotated in the mediastinum. The first case was a 70-year-old female who was admitted with complaints of sudden vomiting and epigastric pain after eating. Computed tomography (CT) revealed UDS. Almost the entire stomach was twisted in the mediastinum, but the fornix was located in the abdominal cavity. After endoscopic reduction, the entire stomach was located in the mediastinum. Her symptoms disappeared and she was able to eat. The second case was another 70-year-old female with multiple hospitalizations due to frequent vomiting after eating. A review of previous CT scans showed a typical chronic UDS with the entire stomach located in the mediastinum. During her most current hospitalization, she was admitted with complaints of frequent vomiting and chest pain after overeating, and a CT showed UDS with only the fornix located in the abdominal cavity. Following hospitalization, the persistent vomiting disappeared and a CT scan at that point revealed that the fornix had returned to the mediastinum and she now had a normal UDS. These results indicate that chronic UDS caused acute symptoms due to "reverse incarceration" in the abdominal cavity through the diaphragmatic hiatus following eating. Chronic UDS is often either asymptomatic or only mildly symptomatic. However, these cases suggest that there is a mechanism whereby chronic UDS may cause acute UDS-like symptoms when the fornix becomes "reversely incarcerated" in the abdominal cavity following eating.

An 81-year-old woman presented with progressive congestive heart failure. Seventeen years before, she had undergone mitral valve replacement with a mechanical prosthesis. Echocardiography revealed severe aortic stenosis with a depressed left ventricular ejection fraction of 32%.At first, rescue balloon aortic valvuloplasty (BAV) was performed. After transient improvement of symptoms, she was readmitted 2 months later with recurrence of severe congestive heart failure. Transcatheter aortic valve implantation (TAVI) with an Edwards Sapien valve was performed. During the procedure, BAV was performed to confirm that the balloon did not interfere the movement of the mechanical valve. Moreover, supported by a veno-arterial extracorporeal membrane oxygenation, we could prevent myocardial ischemia during rapid pacing and slowly deploy the valve in a precise position. TAVI can be safely and successfully performed in patients with a preexisting mechanical mitral prosthesis.

A 22-year-old woman was admitted to our hospital with persistent nausea and no apparent cause. There was no preceding infection. The patient lost consciousness for several seconds. Based on an electrocardiographic diagnosis of paroxysmal sinus arrest (PSA), a temporary pacemaker was implanted. She did not develop syncope, but vertigo, nystagmus, diplopia, and limb paresthesia were observed. Brain MRI revealed a high-intensity lesion in the dorsal medulla on FLAIR images. As the serum anti-aquaporin 4 (AQP4) antibody was positive, the patient was diagnosed with neuromyelitis optica spectrum disorder (NMOSD). After she received steroid pulse therapy (methylprednisolone at 1,000 mg/day for three days) twice, her symptoms markedly improved. In this patient, PSA was considered to be a symptom of area postrema syndrome of NMOSD. Therefore, NMOSD should be considered as a possible cause of PSA.

Since the first report in 2003, bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been increasing, without effective clinical strategies. Osteoporosis is common in elderly women, and bisphosphonates (BPs) are typical and widely used anti-osteoporotic or anti-bone-resorptive drugs. BRONJ is now a serious concern in dentistry. As BPs are pyrophosphate analogues and bind strongly to bone hydroxyapatite, and the P-C-P structure of BPs is non-hydrolysable, they accumulate in bones upon repeated administration. During bone-resorption, BPs are taken into osteoclasts and exhibit cytotoxicity, producing a long-lasting anti-bone-resorptive effect. BPs are divided into nitrogen-containing BPs (N-BPs) and non-nitrogen-containing BPs (non-N-BPs). N-BPs have far stronger anti-bone-resorptive effects than non-N-BPs, and BRONJ is caused by N-BPs. Our murine experiments have revealed the following. N-BPs, but not non-N-BPs, exhibit direct and potent inflammatory/necrotic effects on soft-tissues. These effects are augmented by lipopolysaccharide (the inflammatory component of bacterial cell-walls) and the accumulation of N-BPs in jawbones is augmented by inflammation. N-BPs are taken into soft-tissue cells via phosphate-transporters, while the non-N-BPs etidronate and clodronate inhibit this transportation. Etidronate, but not clodronate, has the effect of expelling N-BPs that have accumulated in bones. Moreover, etidronate and clodronate each have an analgesic effect, while clodronate has an anti-inflammatory effect via inhibition of phosphate-transporters. These findings suggest that BRONJ may be induced by phosphate-transporter-mediated and infection-promoted mechanisms, and that etidronate and clodronate may be useful for preventing and treating BRONJ. Our clinical trials support etidronate being useful for treating BRONJ, although additional clinical trials of etidronate and clodronate are needed.

Introduction: We report a case of embolic stroke with an atypical course after endovascular therapy performed during the subacute stage of progressive stroke, where symptom relapse could not be controlled despite medical treatment., Case Presentation: An 81-year-old woman developed slight weakness in her left leg and was hospitalized three days after the onset of symptoms. On admission, her consciousness was almost clear and she exhibited left hemiparesis. The computed tomography(CT)and magnetic resonance imaging(MRI)revealed a cerebral infarction in the right caudate head and corona radiata, and CT perfusion showed no difference in the cerebral blood flow. However, three-dimensional computed tomography angiography showed right M1 occlusion. Considering the clinical course of the leg weakness without atrial fibrillation, antiplatelet therapy for atherosclerotic cerebral infarction was administered. Five days after the symptom onset, the left hemiparesis deteriorated. CT and diffusion-weighted MRI showed increasing edema associated with the cerebral infarction, and CTP showed decreased cerebral blood flow in the right middle cerebral artery region. Because angiography revealed an obstruction involving a long lesion with loss of contrast, we suspected an embolic stroke. Endovascular surgery was performed successfully using the Penumbra system. Postoperatively, the hemiparesis resolved and the patient was transferred to the rehabilitation hospital., Conclusion: In rare cases, patients with an embolic stroke develop gradual progression of symptoms. To differentiate between cardioembolic stroke and atherosclerotic cerebral infarction in such patients, a follow-up examination of the brain blood flow must be performed, especially when there is a change in symptoms. This may provide useful information for intravascular treatment even in the subacute period.

Calcimimetics allosterically activate the calcium receptor (CaR) and inhibit the secretion of parathyroid hormone (PTH). Cinacalcet hydrochloride (cinacalcet) has been approved as the first calcimimetic drug for the treatment of secondary hyperparathyroidism (SHPT) in patients with hemodialysis. Cinacalcet improved the achievement of target serum PTH and Ca levels and helped drastically reduce the number of parathyroidectomies. However, cinacalcet has side effects involving the gastrointestinal tract, such as nausea and vomiting, which makes it difficult to increase the dose and may result in reduced compliance. Evocalcet has been developed to improve defects of cinacalcet for management of SHPT. Evocalcet acts as an allosteric modulator of CaR, just like cinacalcet. However, its metabolic pathway is different from that of cinacalcet. The metabolism of evocalcet by cytochrome P450 is very low, so evocalcet has higher bioavailability. As a result, its pharmacologically effective dose for the inhibition of PTH secretion is lower than that of cinacalcet. Evocalcet had less of an effect on the gastrointestinal tract than cinacalcet because of the reduced dose required. In a clinical trial with a randomized, double-blind, head-to-head comparison study, it was also confirmed that the incidence of gastrointestinal-related adverse events was lower in the evocalcet group than in the cinacalcet group. Evocalcet may thus be a potent option for the management of SHPT.

A 74-year-old man was admitted for evaluation of a pancreatic tumor. Abdominal CT revealed a multilocular cystic tumor with thickened septal walls and an enhanced mural nodule in the head of the pancreas, as well as enlarged para-aortic lymph nodes. FDG-PET revealed FDG accumulation in the nodule and in the para-aortic nodes. The tumor was diagnosed as intraductal papillary mucinous carcinoma (IPMC) with para-aortic lymph node metastases. After 2 courses of chemotherapy with gemcitabine and nab-paclitaxel, the tumor decreased slightly in size, but the lymph nodes did not change. Surgery was then performed. Intraoperative pathology examination confirmed that the para-aortic lymph nodes had only inflammatory swelling. Accordingly, pylorus-preserving pancreaticoduodenectomy was performed. Histopathology examination revealed atypical cells without invasion, and IPMC (TisN0M0;stage 0) was diagnosed. It is thus important for selection of the appropriate treatment approach to determine if enlarged para-aortic lymph nodes are benign or malignant.

We report the case ofan elderly patient with squamous cell carcinoma(SCC)ofthe breast, which showed negative conversion after endocrine therapy. An 82-year-old woman with a diagnosis ofER -positive SCC(cT1N0M0, StageⅠ)received primary endocrine therapy with 5 hormonal medicines. Following the endocrine therapy, she underwent mastectomy and axillary node resection. Histological examination confirmed a diagnosis of ER-negative SCC. At 10 months after the operation, she was doing well with no evidence ofdisease without postoperative adjuvant therapy. Thus, clinicians should be aware that the ER status may change after primary endocrine therapy. For elderly patients with breast cancer, it is important to be aware that primary endocrine therapy can become ineffective due to ER-negative conversion and aging due to prolonged treatment.

The patient was a 66 year-old male. Computed tomography (CT) angiography showed a huge aneurysm(120 mm) in the aortic arch and chronic type B aortic dissection(45 mm) in the descending aorta. Echocardiography showed patent ductus arteriosus( PDA). Because of pulmonary hypertension due to PDA, it was considered unacceptable to put him under general anesthesia twice. We performed thoracic endovascular aortic repair (TEVAR) via the ascending aorta and total arch replacement (TAR) simultaneously to prevent paraplegia. After establishment of cardiopulmonary bypass( CPB), a stent graft was inserted via the ascending aorta to cover the dissection site of descending aorta, the aorta was opened under circulatory arrest, and PDA was suture closed. Another stent graft whose two proximal rows of Z-stent was removed, was inserted to descending aorta via the ascending aorta landing on the previous stent graft. The proximal end of this stent graft was anastomosed to the distal end of the prosthetic arch graft and arch branches were reconstructed as usual. The postoperative course was uneventful.

We evaluated four representative chemotherapy regimens for unresectable advanced or recurrent KRAS-wild type colorectal cancer: mFOLFOX6, mFOLFOX6+bevacizumab (Bmab), cetuximab (Cmab), or panitumumab (Pmab). We employed a decision analysis method in combination with clinical and economic evidence. The health outcomes of the regimens were analyzed on the basis of overall and progression-free survival. The data were drawn from the literature on randomized controlled clinical trials of the above-mentioned drugs. The total costs of the regimens were calculated on the basis of direct costs obtained from the medical records of patients diagnosed with unresectable advanced or recurrent colorectal cancer at Yamagata University Hospital and Yamagata Prefecture Central Hospital. Cost effectiveness was analyzed using a Markov chain Monte Carlo (MCMC) method. The study was designed from the viewpoint of public medical care. The MCMC analysis revealed that expected life months and expected cost were 20 months/3,527,119 yen for mFOLFOX6, 27 months/8,270,625 yen for mFOLFOX6+Bmab, 29 months/13,174,6297 yen for mFOLFOX6+Cmab, and 6 months/12,613,445 yen for mFOLFOX6+Pmab. Incremental costs per effectiveness ratios per life month against mFOLFOX6 were 637,592 yen for mFOLFOX6+Bmab, 1,075,162 yen for mFOLFOX6+Cmab, and 587,455 yen for mFOLFOX6+Pmab. Compared to the conventional mFOLFOX6 regimen, molecular-targeted drug regimens provide better health outcomes, but the cost increases accordingly. mFOLFOX 6+Pmab is the most cost-effective regimen among those surveyed in this study.

We report the case of a patient with triple negative breast cancer(TNBC)who showed isolated brain metastasis relatively soon after pathological complete response(pCR)to neoadjuvant chemotherapy. A 45-year-old woman with a diagnosis of TNBC(T2N1M0, Stage II B)received neoadjuvant chemotherapy with 5-FU/epirubicin/cyclophosphamide(FEC), followed by docetaxel. After the neoadjuvant chemotherapy, she underwent mastectomy and axillary lymph node dissection. Histological examination of the resected specimens revealed pCR. Brain metastasis, however, developed 7 months after the resection. She underwent total removal of the brain tumor and 50 Gy irradiation to the right frontal lobe. Histological examination confirmed a diagnosis of metastasis from TNBC. She is doing well with no evidence of disease 81 months after resection of the brain metastasis. This case and a review of the literature suggest that the clinician should be aware that brain metastasis from breast cancer may develop even after achieving pCR to neoadjuvant chemotherapy. Surgical resection followed by radiotherapy may provide a survival benefit for selected patients with isolated brain metastasis from breast cancer.

Background: Chronic subdural hematoma(CSDH)generally occurs in the elderly, and is usually treated by burr-hole craniotomy with closed-system drainage. Treatment of recurrent CSDH is more challenging, especially when the hematoma is multi-lobular. A variety of approaches to the management of multi-lobular CSDH have been described, including evacuation through a wide craniotomy, placement of an Ommaya reservoir, subdural peritoneal shunting, and embolization of the middle meningeal artery. We have previously reported a method of evacuating multi-lobular CSDH through a small craniotomy using a rigid endoscope and aspiration tube. The objective of this study was to compare our operative method with others from the literature., Materials and Methods: Between January 2012 and October 2016, eight patients diagnosed with multi-lobular CSDH using computed tomography(CT)imaging underwent endoscopic evacuation. First, we established a 3×3cm craniotomy at a position where a rigid endoscope and aspiration tube would be able to reach as much of the hematoma cavity as possible in the longitudinal plane. Second, after identifying and removing the outer membrane of the CSDH with the scope, we evacuated the hematoma longitudinally, keeping the inner membrane intact. We also applied monopolar diathermy to any obvious bleeding points and the capillary network on the outer membrane of the CSDH, using the aspiration tube., Result: The mean duration of surgery was 42 minutes. Follow-up CT scan revealed no recurrence in any of the cases, and neurologic function improved in all patients postoperatively., Conclusion: A multi-lobular CSDH can be drained quickly and effectively using a rigid endoscope and aspiration tube through a small craniotomy. In a cohort of eight patients, postoperative neurologic recovery was observed in all cases with no evidence of recurrence. This technique could be used in any facility with ready access to CT imaging and a rigid endoscope.

We describe renal mucinous tubular and spindle cell carcinoma (MTSCC) that metastasized to the lymph nodes seven years after radical nephrectomy. An 80-year-old man was admitted for treatment of a right renal tumor. A 6.5×6.0-cm tumor in the right kidney (cT1bN0M0) revealed by abdominal computed tomography was treated by laparoscopic radical nephrectomy. The pathological findings at that time suggested papillary renal cell carcinoma type 1. Imaging findings seven years later revealed enlarged pre-caval and right external iliac lymph nodes indicative of delayed metastasis, and these were treated by laparoscopic lymphadenectomy. The pathological findings and re-evaluation of the primary tumor suggested MTSCC. The patient remains free of metastasis at 24 months of follow-up. MTSCC has been a distinct entity in the World Health Organization classification of kidney tumors since 2004. Tumors consist of tubules and cords separated by pale mucinous material in some areas, whereas others have dense cellularity without significant mucin. They are usually of low malignant potential, and metastasis has rarely been reported. To our knowledge, this is the first report of MTSCC with retroperitoneal lymph node metastasis treated by lymphadenectomy.

A 35-year-old man attended our hospital with complaining of epigastric pain and vomiting. He was diagnosed with bowel intussusception based on the target sign revealed in the upper jejunum by abdominal computed tomography. However, the cause of the intussusception was not clear. Insertion of an endoscope into the jejunum revealed prominent edema in the upper part of the jejunum, and Anisakis simplex was identified at the site and removed. Symptoms rapidly improved after endoscopic treatment. We report this case because surgery was avoidable and because we are aware of no previous reports of small intestinal intussusception caused by anisakiasis that has been diagnosed and treated endoscopically.

A 52-year-old man was referred to our hospital complaining of right lower abdominal pain. He was diagnosed with appendicitis complicated with a liver abscess and underwent an appendectomy. After antibiotic treatment following surgery, the liver abscess penetrated the right lung, which was considered to be drained from a hepatobronchial fistula. Due to the effect of drainage, the liver abscess immediately improved and the patient was subsequently discharged.

This is a micro-ethnographic study focusing on a traditional custom at Tōshi Island in Japan. When first-born sons in the island graduate from junior high school, they form a small group of neya-ko (quasi-brothers) and sleep over at neya-oyas’ (quasi-parents) house every night until they become 26 years old. They keep the quasi-family relationship alive and help each other all through life. We investigated the maintenance process of this cultural custom by participant observations and unstructured interviews. Because of the recent drastic environmental changes around the island, people face difficulties maintaining the custom. In spite of these circumstances, they have been able to maintain the custom not by challenging the environmental changes, but by constantly changing the custom itself to fit the environment. Their flexible decision making may derive from their ecological basis as fishermen. Based on the findings, we discuss the sustainability of cultural customs facing environmental changes.

Purpose: We herein report the clinical outcomes of hyperthermic intraperitoneal chemotherapy(HIPEC)in patients at high risk of colorectal peritoneal metastasis., Patients and Methods: We enrolled 21 patients with advanced colorectal cancer who were received HIPEC between 2009 and 2014. Retrospectively, we evaluated the short-term and long-term outcomes of these cases., Results: We performed HIPEC for 12 patients with primary cancer and 9 with recurrent cancer. Perioperative complications characteristic of HIPEC did not occur. Seventeen patients(81%)had postoperative recurrence, 5 of whom had a peritoneal recurrence, and all of them already had synchronous peritoneal metastasis at the time of HIPEC. Patients with a higher peritoneal cancer index(PCI)had a tendency towards a higher rate of peritoneal recurrence than those with a lower PCI(11[median]vs 4; p=0.08).

Objective :Successful endoscopic surgery for intracerebral hemorrhage has previously been hampered by impaired visualization during the operation to remove the clot, leading to a relatively low removal efficiency for hematomas. However, in multiple case series, intracerebral hematomas have been reported to be removed using endoscopic visualization. Although using tubular retractors in cranial surgery is one technique to gain access to deep-seated lesions, it is difficult to confirm the depth of the retractor's sheath in the surgical field using only the outer sheath. We built various-sized cylinders, developed by the Japan Science and Technology Agency's(JST)program for revitalization promotion, with scales that are visible during both endoscopic and radiographic procedures. We report the use of these cylinders in clinical cases. Method and Results :The JST-developed cylinders benefit from new techniques for plating and tantalum film implantation used to form tubes made of fluorinated ethylene propylene. We successfully removed various hematomas using these cylinders, as we were able to clearly visualize the border of the brain parenchyma and the depth of the hematoma using the cylinder. Conclusion :Cylinders with visible scales for both endoscopic and radiographic uses developed by the JST programs may provide greater patient safety during endoscopic surgery. We next plan to improve the hardness, length, and smoothness of the groove on the cylinder.

Introduction: In cases of transport by rescue helicopter or ambulance of patients having ingested hazardous substances, medical personnel may be at a certain risk of inhaling the substances. However, few reports have addressed such risk of causing secondary casualties., Purpose: This simulation study aimed to assess the risk of inhalation of hydrogen sulfide and chlo-opicrin in the cabin of a helicopter or an ambulance transporting a patient who has ingested calcium polysulfide or chloropicrin, which were previously reported to cause secondary casualties., Method: Concentrations of hydrogen sulfide and chloropicrin were assessed on the following as-umptions :The patient ingested 100 mL of the causative or original chemical. All chemical substances reacted with the gastric juice or were thoroughly vomited and evaporated uniformly within the cabin space of the helicopter or ambulance. Environmental conditions were 20 *degrees at 1 atmosphere of pres-ure in a 5 m3 cabin volume in the helicopter and a 13.5 m3 cabin volume in the ambulance., Results: In the case of calcium polysulfide ingestion which produced hydrogen sulfide, its concen-ration reached 774 ppm in the helicopter and 287 ppm in the ambulance. For chloropicrin ingestion, the concentrations were 4,824 ppm and 1,787 ppm, respectively., Discussion: The simulated concentration of hydrogen sulfide was more than 500 ppm in the heli-opter, which may lead to respiratory paralysis and death. The simulated concentration of chloropicrin was more than 300 ppm, which has a risk of death within 10 minutes. Currently, as far as Japanese laws are concerned, there are no restrictions requiring pretransport assessment or setting criteria for transporting patients who might have ingested hazardous substances that could cause secondary casu-lties when vomited., Conclusion: When patients who might have ingested hazardous chemicals are transported, it is important to recognize the risk of causing secondary casualties by vomiting the chemicals.

We report a case of subarachnoid hemorrhage due to rupture of a cerebral aneurysm in a 29-year-old woman in the 34th week of pregnancy. The aneurysm at the anterior communicating artery was up to 10 mm in diameter on magnetic resonance imaging and scheduled for emergent coil embolization. Simultaneously, obstetricians determined that cesarean section should be performed. Maintaining anesthesia by propofol and remifentanil, coil embolization was first performed to avoid aneurism re-rupture, and the patient was then transferred from an angiography room to an operating room where a cesarean section was performed. After delivery, fentanyl 600 μg was intravenously administered, and the patient was extubated immediately after the operation without any complaints. The neonate (weighing 1,882 g, Apgar score 4 at 1 min and 5 at 5 min) also recovered with no complications after 24 hr artificial ventilation. In conclusion, intravenous anesthesia mainly with remifentanil is adequate for a pregnant patient receiving cesarean section preceded by neurosurgery.

Combined valve surgery is usually performed with standard sternotomy although the efficacy and safety of single valve surgery with partial sternotomy has been established. We report a successful case of triple valve surgery with lower partial sternotomy. A 69-year-old woman underwent aortic valve replacement, mitral and tricuspid valve repair via lower partial sternotomy for moderate aortic and mitral valve regurgitation as well as severe tricuspid valve regurgitation. The operation was successfully performed with enough surgical field, without using any specific technical devises for minimally invasive cardiac surgery or blood transfusion. The ascending aorta, the superior vena cava and the right femoral vein were cannulated for cardiopulmonary bypass. The procedure was completed as in a conventional approach, except for a small incision for the femoral vein. This approach has several advantages;less trauma, less pain, earlier recovery, and better cosmetic outcomes. Triple valve surgery can be completed using lower partial sternotomy with benefits.

The incidence of pulmonary hemorrhage during cardiac operation is not freqent but one of severe and lethal complications. We report a case of massive pulmonary hemorrhage, hemoptysis, suspected to be induced by a Swan-Ganz catheter. The patient had satisfactory progress postoperatively. An 80-year-old female patient underwent mitral valve replacement, tricuspid annuloplasty, and maze procedure. A Swan-Ganz catheter was inserted via the right jugular vein and fixed just at 40 cm as in usual preoperative induction. Operative procedures were uneventful, but active and massive airway hemorrhage started while weaning off cardiopulmonary bypass. A hematoma spreading under the visceral pleura of the right middle-lobe lung was found. We immediately replaced the endotracheal tube with a double-lumen one, and promptly decided to do lung lobectomy. These strategies were very helpful to rescue the patient, and led to her good recovery after the severe pulmonary hemorrhage, possibly induced by a catheter.

We used Cusco vaginal speculum in harvesting saphenous vein graft (SVG) as an assist device for making a skin tunnel. After making 2 incisions of 3 to 4 cm, the SVG was dissected in a usual procedure. Then Cusco vaginal speculum was inserted into the skin tunnel between the 2 incisions. The SVG was dissected in a usual fashion under direct vision with the speculum. This procedure requires only small incisions, short learning curve and low cost. The new technique using Cusco vaginal speculum can be a reliable option for harvesting SVG.

Vesicovaginal fistulas (VVFs) caused after radiation are difficult to repair and require interposition of non-irradiated, well-vascularized tissue between urinary bladder and vagina. A 48-year-old female suffered cervical cancer and underwent radical hysterectomy followed by radiation therapy which caused VVF. The initial surgical repair performed 3 months after development of VVF, was unsuccessful because of the absence of peritoneum or omentum to interpose between urinary bladder and vagina probably due to history of cesarean section and radical hysterectomy. The second surgical repair was performed 15 months after the first surgery utilizing a rectus abdominus myofascial (RAM) interposition flap. Fifteen months after the second operation, she remains free from incontinence. This case suggests that RAM is useful even for postradiation VVF.

Our patient was a 58-year-old man who was diagnosed with a large bowel obstruction caused by ascending colon cancer, together with multiple liver metastases for which a right hemicolectomy was performed. After the operation, he developed disseminated intravascular coagulation(DIC)and severe anemia. Bone marrow biopsy findings led to a diagnosis of disseminated carcinomatosis of the bone marrow caused by colon cancer. We administered S-1+oxaliplatin(SOX) and bevacizumab( BV)chemotherapy, which improved the DIC. The patient was discharged from the hospital. After a total of six courses of chemotherapy, the carcinoma became resistant. We changed the drug regimen and his clinical condition improved. He survived for 292 days from the onset of disease.

The number of the chemical compounds handled in current Japan is approximately 60,000, and approximately 1,500 of new chemicals are registered every year. Approximately 200 chemicals are regulated. The prescribed industrial disease occurs 200-320 cases in a recent year, and the half are caused by unregulated chemicals. In this report, recent cases, especially the chemicals of which uses are increasing or newly introduced, such as hydrofluoric acid and nitrogen-based organic solvent, are described about onset situations, symptoms and the preventive measures required in handling. In addition, national preventive measures against industrial diseases by the exposure to chemical compounds are described.

Purpose: We evaluated usefulness of transcatheter arterial embolization (TAE) for deep renal injury, and investigated whether there is any difference in outcomes for transcatheter arterial embolization (TAE) performed for deep renal injury in a large-sized hospital (university hospital) in comparison with a middle-sized hospital (local hospital)., Methods: We retrospectively reviewed the outcomes of 42 patients with renal injury who were transported to the critical care center of Nippon Medical School (NMS) Hospital in Tokyo from April 2001 to April 2011 and 33 patients of renal injury transported to the critical care center of Ohtawara Red Cross (ORC) Hospital in Tochigi prefecture from April 2001 to April 2009. Therefore, a total of 75 patients, which is the sum of the patients presenting to both the hospitals for renal injury were reevaluated according to the guidelines developed by the Japanese Association for the Surgery of Trauma (JAST) and published in 2008., Results: Forty-two patients in NMS hospital included 6 women and 36 men who were 16 to 88 years old (mean 41.6), and they were divided into Type I (16), Type II (11), and Type III (15) and were treated with bedrest (30), TAE (7), or laparotomy (5). Five patients died, but no one succumbed solely due to the renal injury. On the other hand, 33 Patients in ORC Hospital included 8 women and 25 men who were 16 to 87 years old (mean 46.6). They were divided into Type I (9). Type II (12), and Type III (12) and were treated with bedrest (24) or TAE (9). Eight patients died, but no one succumbed solely due to the renal injury. Sixteen patients were treated successfully with TAE in the 2 hospitals, and 15 of these 16 patients were divided into type III renal injury. Therefore, we believe that nephrectomy should be avoided in such patients because of the benefits offered by TAE., Conclusion: TAE was found to be useful for the treatment of type III renal injury in both institutions, irrespective of the size of a hospital.

A 64-year-old male patient was diagnosed with rectal gastrointestinal stromal tumor(GIST)by prostate biopsy, because of high PSA. We considered that a radical operation was impossible because the tumor occupied the pelvis, and we suspected prostate invasion. After neoadjuvant chemotherapy(imatinib mesylate 400 mg/day), the tumor size was reduced(90×85 mm→60×50mm), and we could thus perform radical resection. The patient is currently receiving adjuvant chemotherapy (imatinib mesylate 400 mg/day), without recurrence.

Systemic treatment for metastatic or advanced colorectal cancer(mCRC)has remarkably progressed during recent years. All previously untreated mCRC patients at our institution between November, 2007 and June, 2010 were retrospectively evaluated. Of 72 patients, 39 were treated with chemotherapy alone, and 33 were treated with chemotherapy plus bevacizumab(BV). The median progression-free survival(mPFS)was 329 days in the group given chemotherapy plus BV, compared with 209 days in the group given chemotherapy alone(p=0. 0189). In sub-group analysis of those treated with chemotherapy plus BV, mPFS between 70 y/o

A 42-year-old woman presented with rapid myalgia of the thigh and muscle weakness in the proximal limbs with markedly elevated serum CK. Despite positive for antibodies to anti-nuclear, anti-ds-DNA, anti-ss-DNA, anti-Sm, anti-SS-A/Ro, C-ANCA, anti-U1-RNP and anti-ribosome and slight lymphocytopenia and hypocomplementemia, there was no symptom associated with systemic lupus erythematosus (SLE). Proteinuria and hematuria were initially considered to be associated with renal damage due to myoglobinuria. Muscle MRI demonstrated high signal intensities in the rectus femoris. Muscle biopsy of the rectus femoris demonstrated a mild variation in fiber size, a few necrotic and several regenerating fibers and minimal lymphocytic infiltration in the endomysium, which suggested myopathic changes with mild necrotic and regenerating processes. Thus she was diagnosed as idiopathic myositis at first, and was treated by corticosteroid therapy. Her myalgia and CK level improved, but the proteinuria and hematuria were persistent. A renal biopsy demonstrated lupus nephritis, and SLE with myositis was confirmed. She was treated with additional tacrolimus administration, and her proteinuria and hematuria also improved. The present case suggests that patients who predominantly present with myositis accompanied by nephritis and autoantibodies should be considered as SLE with myositis.

Objective: Severely handicapped children and adolescents have reduced bone mineral density and high prevalence of pathological fractures. Bone quantitative ultrasonography (QUS) is a radiation-free method for assessing bone density. It is portable and easy to use in subjects with severe bodily deformities., Methods: We evaluated 166 students (age 6-20 years) at a school for disabled children for bone mineral density using the osteo-sono-assessment index (OSI) calculated by measuring the velocity of ultrasound waves, the speed of sound (SOS) and the transmission index (TI), at the calcaneus. All examinations were performed using an AOS-100 analyzer (ALOKA Ltd., Tokyo, Japan). The Gross Motor Function Classification System (GMFCS) for cerebral palsy was also applied. We assessed OSI for dietary texture modifications and methods of feeding., Results: Those with pathological fractures tended to have lower OSI than other students. Such fractures were individually unrelated to age, sex and GMFCS. OSI was significantly higher at GMFCS level I than level II. OSI in levels I to III was equally significantly higher than that in levels IV and V. As to feeding methods, the tube feeding group tended to have lower OSI than the oral ingestion group. In the oral ingestion group, those receiving a regular diet had significantly higher OSI than the mixed-minced diet group. However, students with a gastrostomy tended to have higher OSI than those receiving gastro-nasal tube feeding., Conclusions: Gross motor function (applied GMFCS) is a major factor affecting bone mineral density. Tube feeding reduces bone mineral density. However, forced oral intake may also reduce it. In the tube feeding group, a modified diet of appropriate texture delivered via gastrostomy may be the key to improving bone mineral density.

A 73-year-old man was followed up for HCV-associated chronic hepatitis and hepatocellular carcinoma (HCC), developed in segment 8 of the liver. Radiofrequency ablation (P-RFA) was used to treat the tumor in June 2004. Afterwards, the patient underwent repetitive transcatheter arterial chemoembolization (TACE) against recurrent tumors 5 times. An abdominal computed tomogram (CT) showed an infiltrative mass in the left liver with tumor thrombus invading into the umbilical portion. Transarterial infusion (TAI) therapy of cisplatin (CDDP) was performed 2 times, in January and June of 2010. The size of the main tumor was decreased according to CT, and tumor marker levels such as AFP and PIVKA-II also decreased, but tumor thrombus of the portal vein developed into the main trunk (Vp4). We started therapy with sorafenib in July, 2010. Two months later, an abdominal CT revelaed further reduction of the main tumor and a shrunken tumor thrombus of the portal vein back to the left lobe. The therapeutic effect of sorafenib against HCC with tumor thrombus of the portal vein continued for 9 months.