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Vascular anomalies, as described by the Adachi classification, are an inevitable issue for gastric cancer surgery. Here, we report a safe technique for laparoscopic lymph node dissection in a patient with Adachi typeⅥ vascular anomaly. The patient is a 72-year-old woman, who presented with a submucosal gastric cancer located on the lesser curvature of the stomach. Preoperative MDCT revealed Adachi type Ⅵ vascular anomaly. At laparoscopic surgery, we first identified the portal vein. Then, dissection of the hepatoduodenal and No. 8a lymph nodes was performed from the location near the portal vein at the superior portion of the hepatoduodenal ligament to that near the splenic vein superior to the pancreas. This avoids the disorientation that may result from anomalous vessels and prevents error that can lead to vascular complications. Subsequently, she underwent D1 plus gastrectomy. Her postoperative course was uneventful. Our surgical technique offers a safe approach for laparoscopic gastrectomy in the patient with Adachi type Ⅵ vascular anomaly.

To perform safe and radical pancreaticoduodenectomy, adequate knowledge of the branching and running course of the common hepatic artery is necessary. Formation of a common trunk by the common hepatic artery and superior mesenteric artery, called the hepatomesenteric trunk, is very rare. When it occurs, the common hepatic artery arising from the hepatomesenteric trunk usually runs behind the pancreas head. In the present case, however, it ran through the pancreatic parenchyma. Therefore, pancreaticoduodenectomy for duodenal carcinoma was performed with preservation of the intrapancreatic common hepatic artery. When pancreaticoduodenectomy is performed in patients with a replaced common hepatic artery running through the pancreatic parenchyma, it is necessary to preoperatively determine whether to preserve or resect the common hepatic artery in the pancreas with consideration of the curability. If resected, whether to reconstruct it must also be determined. If reconstructed, the reconstruction method must be determined, and if not, it is important to perform preoperative coiling of the common hepatic artery and intraoperative measurement of the hepatic blood flow with a Doppler flow meter.

The survival benefit of extended surgery for advanced pancreatic cancer has been denied by four randomized controlled trials. However, there still is confusion and conflict over the definition and effective treatment strategy for so-called locally advanced or borderline resectable pancreatic cancer. Although there are a number of reports that showed outcomes of preoperative chemotherapy or chemoradiotherapy for this disease, the definitions and treatment regimens described in these studies vary. Moreover, all of the studies were Phase I / II trials or retrospective analysis, and there is no Phase III trial currently focused on this issue. It is urgently necessary to establish an international consensus on the definition of borderline resectable pancreatic cancer. The usefulness of neoadjuvant treatment for this disease should also be elucidated in future clinical trials. In this review article, we discuss the current understanding and definition of borderline resectable pancreatic cancer, and the value of neoadjuvant treatment strategy for treating it.

Our patient was a 57-year-old male with a history of esophageal cancer. He was referred to our hospital for squamous cell lung carcinoma(SCC). Chest computed tomography identified a mass in the left lung field, which was suspected to be invading the reconstructed gastric tube, left subclavian artery, common carotid artery, and distal aortic arch. He was diagnosed as primary pulmonary squamous cell carcinoma(SCC)because six years had already passed since a previous surgery for early esophageal cancer. He received three courses of induction chemotherapy including S-1/CDDP. We evaluated the therapy as a partial response. He underwent an extended resection of distal aortic arch and left subclavian artery with left upper lobectomy, and those vessels were reconstructed using prosthetic grafts. Pathological findings showed the tumor as a well differentiated SCC of pT4N0M0 at stage III A, with a residual tumor on the reconstructed gastric tube, even though the effect of induction chemotherapy was Ef2. He received three courses of S-1/CDDP after surgery. The patient has been well without recurrence for 31 months after surgery.

Effective mechanisms of laser photocoagulation for neovascularization in diabetic retinopathy were investigated in regard to change in oxygen pressure in the retina and vitreous and cytokines related to ischemia. The mechanism of laser photocoagulation is suggested to be as follows. 1. Destruction of the outer retina, especially of photoreceptors that have high oxygen consumption decreases metabolic function of the outer retina and its oxygen consumption. 2. The destruction allows increase of oxygen diffusion from choroidal vessels to inner retina, which improves the metabolic function by equilibrating oxygen demand and supply in the inner retina. (3) Production and secretion of neovascular factors such as vascular endothelial growth factor (VEGF) is decreased by the improvement of hypoxia. 4. The neovascularization is decreased by the synergistic effect between the neovascular factors and suppressors such an VEGF, fibroblast growth factor (FGF), and transforming growth factor-beta (TGF-beta). The improvement of the retinal ischemia and the decrease of cytokines are implicated in the regression of neovascularization by the laser photocoagulation for diabetic retinopathy.

A 77-year-old woman with a productive cough and fever was admitted to the hospital. Pulmonary and endobronchial tuberculosis, pneumonia of the left upper lobe, and stenosis of the left main bronchus were diagnosed. She was given the antimycobacterial drugs isoniazid, rifampin, and streptomycin, and her condition improved. Two months later, bronchoscopy revealed semilunar-shaped stenosis of the left main bronchus, and auscultation revealed wheezing in the middle-end expiratory phase. A continuous flow murmur (Levine III) was also heard at the left anterior chest wall. Cardiac catheterization with subclavian arteriography revealed two left subclavian-pulmonary shunts. In a case of systemic-pulmonary shunt such as this, the bronchial stenosis could be surgically repaired, but the result would be an increase in dead space. If left untreated, the pulmonary hypertension would progress and symptoms of pulmonary disease would become more severe. Subclavian-pulmonary artery shunt is a very rare complication of pulmonary tuberculosis. Surgical treatment should consist of open bronchoplasty along with lobectomy and removal of the shunt, rather than embolization of the shunt and endoscopic bronchoplasty.

Choroidal neovascularization was produced in 18 eyes of 12 rhesus monkeys by application of intense krypton laser photocoagulation. Eight weeks or later, a total of 34 choroidal neovascularizations were treated either by dye laser at wavelengths of 577 or 630 nm or by argon blue-green laser. The treated lesions were evaluated clinically and histopathologically from 24 hours to 3 months after treatment. All the treated lesions were apparently healed by each of the 3 laser modalities. Histopathologically, all the treated choroidal neovascularizations were occluded 24 hours after treatment. At 2 weeks to 3 months after treatment, newly-formed choroidal vessels were present in 3 of 9 lesions (33%) after 577 nm dye laser treatment, in 8 of 9 lesions (89%) after 630 nm dye laser treatment, and in 5 of 8 lesions (62%) after argon blue-green laser. These results seemed to show the clinical superiority of 577 nm dye laser in treating choroidal neovascularization.

The author treated experimentally produced choroidal neovascularization (ChNV) with mild dye laser photocoagulation (PHC). We treated these ChNVs with 590 nm wavelength, 200 microns spot size, 0.2 second duration and 50 mW of power. Eleven eyes of nine rhesus monkeys were used. Then these ChNVs were examined clinically and histopathologically at 24 hours, 2 weeks and a month after therapeutic PHC. Small ChNVs, less than 1/3 disc diameter healed successfully and histopathologically most of them were coagulated and disappeared. A few poorly developed ChNVs remained, but were well enveloped by the proliferating retinal pigment epithelial (RPE) cells. On the other hand, ChNVs of more than 1/3 disc diameter did not respond to weak PHC, grew actively over a month, and were not completely surrounded by proliferating RPE cells. These results suggest that by mild PHC, small ChNVs may be treatable, however, in large ChNVs, mild PHC may rather accelerate their activity.

As a special lecture at the 95th annual Congress of the Japanese Ophthalmological Society in 1991, we presented experimental studies on choroidal neovascularization (ChNV), and clinical studies on senile disciform macular degeneration (exudative age-related macular degeneration). We produced experimentally ChNV on monkey eyes using intense photocoagulation with krypton laser. We showed the retinal pigment epithelium (RPE) played a heavy role as inducer or inhibitor for ChNV at different stages of development or involution of experimental ChNV. Senile disciform macular degeneration is becoming a leading cause of blindness in the elderly in Japan. We examined 473 eyes in 398 cases of this disease during the past 5 years. Nineteen percent were bilaterally affected, males were affected 3 times prevalent than in female, and average age was 67 in years. Predisposing signs were degeneration or atrophy of RPE, hard or soft drusen, and serous detachment of RPE in the macula. In early stage, serous retinal detachment stage appeared and showed good outcome by laser treatment. Subretinal hematoma form showed next better outcome in acute onset and acute course. Advanced form of disciform lesion showed worse outcome. A form (subretinal cystic form) associated with large serous RPE detachment showed the worst outcome and scarcely indicated for laser treatment. We describe clinical features of each form and stages of the disease and clinical course. Early detection, early correct diagnosis and early laser treatment must be essential for prevention of blindness due to this disease.