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The patient is a 74-year-old woman. She had breast cancer(invasive ductal carcinoma, ER[+], PgR[+], HER2[-], Ki-67: 30-40%)and primary right lung cancer with lumbar metastasis, which led to the diagnosis synchronous double cancers of the breast and the lung. We decided to precede surgery for lung cancer because breast cancer was indicated hormonal receptor positive. Breast cancer is treated with anastrozole, thoracoscopic right upper lobectomy was performed for the lung cancer. Radiation therapy was performed for metastatic bone tumors. 13 months later, partial mastectomy sentinel lymph node biopsy performed. The histopathological diagnosis of breast cancer was pT2, pN0, cM0, pStage ⅡA, and histological response was Grade 2a. The remaining breast was treated radiation therapy. The breast cancer has not recurred and is doing well 6 months after surgery. As for primary lung cancer, 19 months have passed since surgery, and the patient is in complete remission without recurrence.

An 88-year-old man underwent thoracoscopic lower lobectomy for left lung cancer at the age of 87. Ten months later, he was examined closely for abdominal distention, frequent constipation, and anemia with a decreased Hb of 6.1 g/dL. The CT scan revealed an irregular tumor with contrast effect. The patient was diagnosed with malignant tumor of small intestine. At laparotomy, a tumor of 5 cm in diameter was found in the jejunum, and small bowel resection was done. Pathological examination revealed that the tumor was a metastasis of lung cancer. Seven months later, the patient is currently an outpatient, with no evidence of cancer recurrence.

Pure amnesia (amnesic syndrome) is an organic brain syndrome characterized by impairment in episodic memory, with either an anterograde or sometimes retrograde loss of memories. Although episodic memory is impaired, semantic memory, immediate memory, and procedural memory are preserved. The Papez circuit is a network of nerve fibers and nerve centers that starts and ends in the hippocampus travelling by way of the fornix, mammillary bodies, anterior thalamic nuclei, cingulate gyrus, and parahippocampal gyrus. A lesion restricted to this circuit often produces pure amnesia. Regions concerned with the Yakovlev circuit also have an important role in memory. Clinical cases of pure amnesia caused by cerebrovascular disease presented following brain imaging and resulted from various different lesions. The cases identified were predominantly thalamic amnesia and hippocampal amnesia. Thalamic amnesia often resulted from an infarction in the territory of the thalamotuberal artery and paramedian thalamic artery although thalamic hemorrhage in medial portion of thalamus also produced pure amnesia. Hippocampal amnesia usually occurred following an infarction in the temporal branches of posterior cerebral artery. Cases of retrosplenial amnesia caused by subcortical hematoma and infarction in the retrosplenial region are also described. In addition, cases of pure amnesia resulting from an infarction in the fornix, mammillary body hemorrhage, and caudate hemorrhage are also shown.

We report a case of a 55-year-old man who developed acute-onset narrowing of his visual field. He showed right homonymous hemianopsia without any other neurological symptoms and signs. Brain CT and MRI showed localized hemorrhage (about 1.6 ml) in the left lateral geniculate body (LGB). A cerebral angiography showed no vascular anomalies of cerebral vessels, and the left anterior choroidal artery and left lateral posterior choroidal artery could be visualized well. He had hypertension, polycythemia and dyslipidemia and was a habitual smoker and an alcoholic. In the literature, various kinds of visual field defects including hemianopsia, upper quadrant hemianopsia, lower quadrant hemianopsia, and horizontal sectoranopia have been reported in eight cases of LGB hemorrhage. Localized LGB hemorrhage was found in only one case out of 2,763 cerebral hemorrhage patients enrolled in our stroke registry for 11 years from 2005 to 2016. Localized hemorrhage of LGB very rarely occurred.

We describe the case of a 48-year-old left-handed woman with unilateral neglect from a brain infarction in the area of the right basal ganglia and temporo-parieto-occipital lobe. When a Kanji character was dictated to her, she wrote only the right side (tukuri) of the character. When copying a picture from the visual image of a left-right asymmetrical object, such as the side view of the dog, she drew the tail and a hind leg immediately but was unable to draw a picture of the dog from the left side. We asked her to imagine going around to the opposite side of the imaginary dog and to draw it from that perspective. She easily drew the left side first, resulting in a left-right inverted picture of what she had previously drawn. She then tried to slowly visualize the missing part of her imagery, and was able to draw only the right tip of the missing part. She could not compose a complete picture of the dog. These findings suggested that the impairment was in the imaging of the left side of a character or object and that this was a case of representational dysgraphia and object representational disorder with unilateral spatial neglect.

Background: Mesenteric traction syndrome (MTS) is associated with facial flushing, hypotension and tachycardia. The ways to treat MTS are fluid replacement, administration of vasopressors and nonsteroidal anti-inflammatory drugs (NSAIDs) such as flurbiprofen. In order to stabilize the hemodynamics during operation, preventing MTS is more reasonable. Thus, we investigated the preventive effect of flurbiprofen on MTS, the only injectable formulation which can be used in Japan., Methods: In a prospective randomized study, 24 patients undergoing elective colorectal surgery were assigned to two groups. In one group (n = 11 group F), flurbiprofen (1 mg x kg(-1), 50 mg max) was administered before surgery. In the second group (n = 13; group C), flurbiprofen was not administered. After laparotomy, presence of facial flushing and blood pressure reduction were compared. MTS is defined as facial flushing with concomitant blood pressure reduction., Results: MTS occurred in no patients in group F, but in 11 patients in group C (84.6%, P < 0.05). In cases of the patients in which MTS appeared, facial flushing was observed at 5.9 +/- 5.2 min after starting mesenteric manipulation, and the mean reduction in blood pressure was 40.3% at 9.9 +/- 4.4 min after starting mesenteric manipulation., Conclusions: Our results indicate that pretreatment with flurbiprofen might prevent MTS.

Background: After introducing "BOKUTOH enhanced recvery after surgery (ERAS)" protocol for colorectal surgery in our hospital, the hospital stay after surgery was reduced from 10 days to 7. However, the patients' quality of life (QOL) throughout the perioperative period was not quantified. We assessed the QOL of these patients by using QoR-40J and SF-36v2J (Japanese versions of QoR-40 and SF-36v2) questionnaires., Methods: Twenty-seven colorectal cancer patients undergoing surgery and "BOKUTOH ERAS" protocol management were asked to answer both QoR-40 J and SF-36v2J questionnaires pre- and post-operatively. The scores were evaluated by using Mann-Whitney U-test., Results: From preoperative score (183.5), the scores of QoR-40 J differed significantly on post-operating day (POD) 1 and POD3 (150.9 [15.7] and 168.1 [17.5] points, respectively). Before leaving the hospital (POD6) and after one month from surgery, both QoR40 J and SF-36v2J scores were similar to preoperative ones., Conclusions: Under "BOKUTOH ERAS" protocol management, patients who had had colorectal surgery were able to recover their QOL within 6 days. Thus, leaving hospital by 7 days after surgery was appropriate to our patients.

A 71-year-old man with sigmoid colon cancer was scheduled for the sigmoidectomy under general anesthesia. In preoperative examination, an epiglottic cyst was found accidentally. He had no subjective symptom. Rapid induction with remifentanil, propofol, rocuronium and ephedrine was performed, and the mask ventilation was easy. The Airway Scope (AWS) was inserted at first, but it was difficult to intubate because of the epiglottic cyst. Then a gum elastic bougie (GEB) was inserted under observation by AWS monitor. GEB was passed into the trachea, and the tube was passed over the GEB into the trachea. Combined use of AWS and GEB is useful for endotracheal intubation in a patient with a epiglottic cyst.

Background: Goal directed therapy (GDT) is applied during the initial resuscitation of sepsis, known as early goal directed therapy (EGDT). Recent studies in major abdominal surgery suggested that anesthetic management with GDT may decrease morbidity and hospital stay. We have utilized GDT in major invasive surgery such as pancreatoduodenectomy in November 2009., Methods: In the anesthetic management of pancreatoduodenectomy, 11 patients managed by GDT were compared concerning postoperative hospital stay with 11 patients managed by conventional methods retrospectively. In our GDT protocol, we have set targets in mean blood pressure, oxygen saturation, and stroke volume variation, which is more individualized for each one. With falls below the target, fluid infusion, blood transfusions, and circulatory agonists were administered. In the conventional protocol, anesthesiologist managed the use of anesthetic agents, fluid infusion, blood transfusion, and circulatory agonist, through the observation of the operative field, blood pressure, heart rate and urine output., Results: Patients utilizing the GDT showed shorter postoperative hospital stay (group GDT; 21.8 days vs conventional group; 32.6 days. P<0.05)., Conclusions: Anesthetic management with goal-directed therapy, may have contributed to shorter postoperative hospital stay.

Background: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reducing complication rates, and shortening hospital stay following colorectal surgery in Europe. In cooperation with colorectal surgeons, ERAS protocols were initially introduced in our hospital to the patients undergoing open colorectal resection in July 2010., Methods: Length of postoperative hospital stay was compared of 139 consecutive patients undergoing open colorectal resection before (n = 96) and immediately after implementing ERAS (n = 43)., Results: In the ERAS group, length of postoperative hospital stay was significantly reduced from 12.7 +/- 7.7 to 9.3 +/- 6.2 days (P < 0.0001). Oral intake, one of important ERAS elements, both before and after surgery had dramatically changed, implying tolerance of ERAS protocol in Japan., Conclusions: We, anesthesiologists as perioperative physicians, can improve key elements of perioperative care such as patients' counseling, perioperative analgesia and early mobilization by collaboration with surgeons and nurses, to facilitate postoperative recovery.

Background: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reducing complication rates, and shortening hospital stay following colorectal surgery in Europe. In cooperation of colorectal surgeons and anesthesiologists, ERAS protocols were initially introduced in our hospital to the patients who underwent open colorectal resection in July 2010., Methods: Using a questionnaire, we surveyed the change of surgeons' opinion against anesthesiologists after introduction of ERAS among 15 surgeons at Metropolitan Bokutoh hospital., Results: Surgeons realized that introduction of ERAS made strong communication between surgeons and anesthesiologists. And they also thought it is not surgeons themselves nor anesthesiologists themselves but 'team care' which could produce positive outcome of ERAS., Conclusions: Introduction of ERAS as collaboration of surgeons and anesthesiologists resulted in facilitating communication of surgeons and anesthesiologists.

Background: In the cases in which the flexibility of the patient's neck is limited, it is often difficult to achieve intubation. Fiberoptic intubation has been chosen for patients with arthroses. However, as it requires techniques, it has been difficult for inexperienced anesthesiologists., Methods: Awake induction using AirWay Scope was performed for 8 patients with cervical spinal diseases. Midazolam, propofol or dexmedetomidine is selected as a sedative drug., Results: Intubation was performed easily and safely without any complications in all cases. No patients had memories of intubation., Conclusions: Awake intubation using AirWay Scope for patients with cervical spinal diseases is a safe and useful anesthesia method. As dexmedetomidine causes no respiratory depression and can expect cooperation from patients, it may give safe and efficient sedation in awake intubation cases.

Purpose: To compare surgically induced astigmatism among 3 sizes of temporal corneal incisions in cataract surgery., Patients and Methods: A retrospective review was carried out of case records of 48 patients (64 eyes) who underwent cataract surgery. The length of the corneal incision was 1.6 mm in five eyes, 2.2 mm in 33 eyes, and 3.0 mm in 26 eyes. Astigmatism was measured by keratometry readings before and 1 week, 1 month, and 3 months after surgery. Surgically induced astigmatism was calculated by vector analyses using the Cravy method., Results: One week postoperatively, the mean surgically induced astigmatism was 0.00 +/- 0.69 diopter(D) in the 1.6 mm group, -0.05 +/- 0.61 D in the 2.2 mm group and 0.44 +/- 0.57 D in the 3.0 mm group. Three months after surgery, the mean surgically induced astigmatism was -0.05 +/- 0.08 D in the 1.6 mm group, -0.04 +/- 0.47 D in the 2.2 mm group and 0.47 +/- 0.59 D in the 3.0 mm group. The surgically induced astigmatism was significantly less in the 2.2 mm group than in the 3.0 mm group., Conclusion: The amount of induced astigmatism was significantly less in temporal corneal micro-incision cataract surgery than in small incision surgery.

Fosfomycin (FOM), a drug with unique mechanism of action against bacteria, was prospectively compared with cefmetazole (CMZ) and flomoxef (FMOX) to assess its effectiveness in preventing postoperative infections after upper gastroenterological and hepatobiliary surgery. FOM (2g/dose), CMZ (1 g/dose), or FMOX (lg/dose) was infused intravenously 2-3 times daily for basically 4 days including the day of surgery in order to examine whether or not infections would develop after surgery. According to the analysis results of 162 cases, efficacy in preventing infection was 86.8% for FOM, 73.1% for CMZ and 83.3% for FMOX, showing no significant differences among the 3 groups. Thus FOM was considered as efficacious as CMZ or FMOX in prophylaxis against postoperative infections. There were no adverse reactions in the FOM or CMZ group, but 3 cases of adverse reactions occurred in the FMOX group. Based on the above results, the usefulness of FOM for prophylaxis against postoperative infections has been confirmed. At present, the first- and second-generation cephems are most frequently used for prophylaxis against postoperative infections. In order to prevent an increase of resistant strains due to inappropriate use of these drugs, FOM, having no cross resistance with currently used drugs, is a promising candidate for prophylaxis against postoperative infections.

Purpose: To examine the etiology and management of buttonholes created during laser in situ keratomileusis (LASIK)., Patients and Methods: Retrospective review of case records of 1010 eyes of 514 patients who underwent LASIK. Four eyes of 4 patients developed a flap buttonhole, and subsequent laser ablation was not performed. Retreatment was done after a mean interval of 6 months., Results: The etiology of a buttonhole was considered to be misuse of microkeratome in 1 patient and desiccation of the cornea in 2 patients, and could not be determined in 1 patient. Uncorrected visual acuity in those 4 patients was 1.2, 1.2, 0.9, and 1.5 respectively, after retreatment. The mean preoperative spherical equivalent was -5.47 diopters(D), and the mean spherical equivalent before retreatment was -5.19 D. The mean preoperative corneal refractive power of 43.53 D flattened to 42.88 D before retreatment. The mean preoperative corneal astigmatism of 1.63 D increased to 2.06 D before retreatment., Conclusion: Misuse of microkeratome and desiccation of the cornea may cause a buttonhole. If a buttonhole is created, retreatment by LASIK scheduled several months later may achieve good uncorrected visual acuity.

A 74-year-old man developed aphasia, weakness of the right upper extremity and left limb-kinetic apraxia. Brain MRI showed an infarct in the area supplied by the left middle cerebral artery. Cerebral angiography revealed high grade stenosis with plaques of bilateral proximal internal carotid arteries. The carotid endarterectomy of the left carotid artery was performed three months later. After this operation his left limb-kinetic apraxia improved. We considered transhemispheric diaschisis, callosal apraxia or diagonistic dyspraxia as a possible cause of this rare symptom.

We experienced a rare case of sinus histiocytosis with massive lymphoadenopathy (Rosai-Dorfman disease) accompanying hypertrophic cranial pachymeningitis. The patient is a 64-year-old woman with an early symptom of rt. peripheral facial palsy. She had a 4-month history of headache with a 5-week history of numbness in the rt. supraorbital nerve area, and lost her weight by 10 kg in 2 months. She developed rt. trochlea nerve palsy and numbness in the lt. mandibular nerve area. Laboratory findings showed that ALP, LDH and CRP were higher than normal. Of CT, MRI and MRA, the images of her head were normal. However, the Gd-enhanced MRI only showed a diffuse pachymeningeal enhancement. After about 3 months from the onset of rt. peripheral facial palsy, she died of DIC of unknown etiology. As a result of examinations in anatomical pathology, she was diagnosed as having sinus histiocytosis with massive lymphoadenopathy (Rosai-Dorfman disease). There were a large number of histiocytes on the pachymeninx. These findings suggest that hypertrophic cranial pachymeningitis caused multiple cranial neuropathy. We emphasize that use of Gd-enhanced MRI in the early stage is important for diagnosis.

We studied on the prevalence of drug-resistance among 65 homeless cases who were admitted and treated for active tuberculosis at the Nakano National Chest Hospital during the period from 1990 to 1992 and at the International Medical Center of Japan during the period from 1993 to 1994. Resistance to one or more first line antituberculous drug were revealed in 14 cases out of 65 (21.5%) in initially treated cases 6 out of 43, and in retreated cases 8 out of 22. The prevalence of drug resistance in this study was significantly higher compared with 2 out of 39 cases (5.1%) in our previous report during the period from 1986 to 1988. In these drug-resistant cases, multidrug-resistant cases, namely, resistant to at least 2 drugs including both INH and RFP were founded in 6 cases (9.2%). Compared with drug-sensitive cases, the negative convertion rate of bacilli was lower and the number of defalters was significantly larger. It was suggested that higher prevalence of drug-resistance and defalting from the adequate treatment in homeless cases of tuberculosis possibly makes the prognosis of drug-resistant tuberculosis worse and treatment of such cases more difficult.

For the purpose to compare the effectiveness of SM and EB as a third drug in the standard regimens and to know whether the addition of SM twice weekly to INH and RFP could be acceptable for the treatment of pulmonary tuberculosis, the efficacy, adverse effects and results of long-term follow-up of the groups consisting of 105 patients treated with SM twice weekly for 6 months in addition to INH and RFP for 9 months (S2 group) and 107 patients treated with EB for 6 months in addition to INH and RFP for 9 months (E group) were observed. The speed of negative conversion of sputum and that of X-ray findings improvement were slightly faster in S2 group than E group but the difference was statistically not significant. The incidence of adverse effects such as elevation of serum transaminase values, gastrointestinal troubles, drug allergy and others was not similar in two groups. The relapse was observed in 2 cases of S2 group and 5 cases of E group. We concluded that SM twice weekly to INH and RFP is similarly effective as EB in combination with INH and RFP, and the this regimen could be used as standard regimen for pulmonary tuberculosis.

A 62-year-old man was found to have recurrent hepatocellular carcinoma (HCC) 2 cm in diameter in the left lobe in June 1990. After right lobectomy of the liver which contained the tumors of S6 2 cm and S8 3 cm in diameter 7 months before, the patient was treated with hepatic arterial embolization (TAE) combined with infusion of anti-cancer drug (ADM, CDDP) four times since June 1990. HCFU 300 mg per day was administered orally since June 1990. Since the 3rd TAE in December, 1990, the tumor stain in the left lobe disappeared for 10 months till October, 1991. No remarkable side effect of HCFU was noticed during this period. HCFU administration combined with TAE effectively prevented post-surgical recurrence of HCC in this case.

A phase 1 study of etoposide for hepatocellular carcinoma and cholangiocarcinoma was undertaken by single arterial infusion (9 cases; range of doses levels; step 1: 50 mg/m2, step 2: 75 mg/m2, step 3: 120 mg/m2). Mild leukopenia (2500/mm3 in step 2 and 2400/mm3 in step 3) was observed in 2 cases. Thrombocytopenia or anemia was not observed in these doses. Hypotension was experienced 2 hrs. after infusion in one case of step 2. The post-infusion plasma decay of etoposide was biphasic with t1/2 alpha ranging from 0.59 approximately 0.63 h and t1/2 beta ranging from 5.40 approximately 6.57 h. AUC0-24 increased in association with the increase of the doses. Hepatic artery infusion of etoposide was performed without serious complication and the dose limiting toxicity was leukopenia.

In 24 patients with subarachnoid hemorrhage (SAH) who were admitted within 48 hours after the onset, the activity of dopamine-beta-hydroxylase (DBH) in peripheral venous plasma was analyzed applying the method described by Nagatsu and Udenfriend (Clin. Chem., 18: 980-983, 1972) with a minor modification. Plasma samples were serially collected every a few days for three days to four weeks after the onset. DBH activity in peripheral venous plasma increased markedly after the onset, reaching the highest level within 48 hours, and thereafter declined time-dependently for about two weeks. There was no significant difference in the plasma DBH activities on admission between patients with and without cerebrovascular spasm revealed by angiography. The decline of the activity was significantly remarkable in patients with spasm compared with those without spasm. The difference was most prominent around the 7th day after the onset when spasm was shown most frequently. Neurosurgery or administration of analgesics and/or sedatives had little effect on the changes in plasma DBH activity in acute SAH. The activity correlated with the pressure of cerebrospinal fluid (r = 0.587, P less than 0.05), when it was higher than the normal range. With these results we obtained following: 1) The activity of sympathetic nervous system increases following SAH for a week after the onset. 2) The activity declines more rapidly in patients with cerebrovascular spasm than those without spasm, when it was judged from the activity of plasma DBH activity.