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In this study we aimed to clarify the effect of passive exercise with blood flow restriction on the cross-sectional area (CSA) and muscle strength around the knee joint. Seven male college swimmers (Age: 19.1±1.1 yr) volunteered to participate in this study. The right leg of all subjects was assigned to the control condition (CON) and the left leg was assigned to passive exercise with blood flow restriction conditions (PEB). In the PEB leg, passive exercise was performed 3 days per week for 8 weeks. The passive exercise consisted of 3 or 4 sets of repeated (150 times) passive knee extension and flexion using a Biodex unit, separated by 3-minute intervals. Before and after the experimental period, the knee extensor-flexor muscle strength was evaluated in the following settings: concentric contraction at angular speeds of 60, 180 and 300 deg⋅s-1 (CC60, 180 and 300), eccentric contraction at angular speeds of 60 and 180 deg⋅s-1, and isometric contraction. Both knee extensor and flexor muscle CSA was also analyzed with MRI before and after the experimental period. In the knee extensor torque, the extent of increase in strength at CC60 was significantly higher (p<0.05) in the PEB legs (16.1±11.5% than the CON legs (4.6±4.8%). Although the CSA of knee extensor and flexor muscles was significantly increased after the experimental period in the both legs (p<0.01, respectively), the percent changes in the CSA of the knee extensor muscles were significantly (p<0.05) higher in the PEB legs (5.2±2.5%) than the CON legs (2.5±1.5). Passive exercise with blood flow restriction could be an effective intervention to increase both muscle volume and strength. [ABSTRACT FROM AUTHOR]

Ankle taping is convenient fixation for ankle instability after lateral ligament injury. There are many reports on ankle taping regarding stability or limitation of plantar/ dorsiflexion or inversion/ eversion. However, no studies have been conducted on the effect of rotatory instability. The biomechanical effect of ankle taping on rotatory instability was examined for lateral ligament injury. Using 8 fresh frozen legs, we made a ligament injury model by sequential cut of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). Each injury model was applied to 39.2N of anterior traction for dorsiflexion and 19.6Nm of torque for internal rotation in the condition of "unfixed", "taping" and "plaster cast". Three dimensional measurements were performed by a magnetic tracking system (3space, Polhemus). Both in the ATFL and ATFL+CFL injury model, the dorsiflexion angle of taping (17.1±4.2° and 17.4±3.5°) was significantly larger than that of plaster cast (9.6±3.2° and 11.9±3.2°) (p<0.05). On the other hand, the internal rotation angle of taping was significantly smaller (7.0±1.6° and 7.7±2.4°) than that of unfixed (17.1± 4.2°and 17.4±3.5°), and there was no significant difference between taping and plaster cast fixation. These results indicate that the limitation of dorsiflexion by taping is less than that by plaster cast and is a good stabilizer for internal rotation instability in the same way as that by plaster cast. [ABSTRACT FROM AUTHOR]

A 68-year-old female patient was referred to our hospital with acute cholangitis. Computed tomography revealed common bile duct dilatation, gallbladder fundal tumor, and gallbladder wall thickening attached to the tumor. Cholangiography revealed pancreaticobiliary maljunction with biliary dilation. The patient was diagnosed with pancreaticobiliary maljunction with biliary dilation and gallbladder cancer and underwent liver S4b+5 and bile duct resection and reconstruction. Pathological results revealed that the gallbladder fundal tumor included sarcoma, and the gallbladder wall thickening had adenocarcinoma;thus, the patient was diagnosed with gallbladder carcinosarcoma.

Serial pancreatic juice aspiration cytological examination(SPACE)has been reported as a reliable preoperative diagnostic method for early pancreatic cancer, when combined with imaging findings suspecting early pancreatic cancer. Among 259 patients with suspected pancreatic cancer who underwent pancreatic resection at our hospital, SPACE was preoperatively performed in 14 cases(5.4%). Of these 14 cases, final pathological diagnosis was pancreatic cancer in 12 patients (86%), including 5 patients with Stage ⅠA pancreatic cancer(35.7%), all of whom had a mass on preoperative CT or EUS. On the other hand, in the other 2 cases(14.3%), CT/EUS detected no mass but focal pancreatic parenchymal atrophy and main pancreatic duct stenosis which were the imaging findings suspecting very early pancreatic cancer such as cancer in situ. Although preoperative SPACE results of these 2 cases were class Ⅳ, final pathological results of resected specimen were low-grade PanIN in both cases. SPACE was considered useful for preoperative diagnosis of pancreatic cancer in our study, however further study is needed to examine its diagnostic accuracy for early pancreatic cancer which does not appear as a mass in any imaging modality.

A 73-year-old female was diagnosed with gallbladder cancer, but the future liver remnant volume was deemed insufficient for curative resection. Consequently, transileocolic portal vein embolization was performed. During laparotomy, multiple nodules were palpable on the peritoneal surface of the pelvic floor. Subsequently, staging laparoscopy confirmed the pathological diagnosis of adenocarcinoma in the resected nodules, indicating peritoneal dissemination of gall bladder cancer. Due to this peritoneal dissemination, surgical resection was deemed inappropriate, and the patient was initiated on systemic chemotherapy consisting of gemcitabine and cisplatin. Following 22 courses of chemotherapy, contrast-enhanced computed tomography demonstrated no significant changes in the size of the primary tumor or its location relative to the main vessels, although a small metastatic lesion was identified in the gallbladder bed. At the second staging laparoscopy, any nodules suggesting peritoneal dissemination were observed. Based on these findings, we decided to perform curative resection. The surgical procedure involved right hepatectomy plus segment 4a resection, extrahepatic bile duct resection, and hepaticojejunostomy. Pathological examination revealed ypT3bN0M1(HEP), ypStage ⅣB, with the achievement of R0 resection. The patient survived with no recurrences for 40 months after surgery. These results suggest that aggressive therapeutic strategies, including conversion surgery following systemic chemotherapy, may be beneficial for patients initially deemed unresectable due to gallbladder cancer.

Case 1: A 73-year-old male, who had an intraductal papillary mucinous adenocarcinoma or resectable pancreatic cancer at the uncinate process of the pancreas five years after subtotal esophagectomy for esophageal cancer, underwent pylorus preserving pancreaticoduodenectomy(PPPD). Case 2: A 68-year-old male, who also had a resectable pancreatic cancer at the uncinate process of the pancreas 3 years after subtotal esophagectomy for esophageal cancer, underwent PPPD following neoadjuvant chemotherapy. In both cases, right gastroepiploic artery and vein were preserved to maintain the perfusion of the gastric tube during surgery. Indocyanine Green(ICG)fluorography was performed just before duodenal-jejunal anastomosis, which visually showed the well-perfused gastric tube. Both patients had no necrosis of the gastric tube, nor gastrointestinal obstruction after surgery. Intraoperative ICG fluorography was useful to evaluate the blood flow of the remaining gastric tube visually during PPPD for post-esophagectomy patients.

Background: Inducible laryngeal obstruction (ILO) refers to respiratory disorders caused by airflow limitation in the larynx, including vocal cord dysfunction, and may sometimes be misdiagnosed as bronchial asthma (BA). Here, we report the case of an 11-year-old boy diagnosed with BA in infancy. He was referred to our Allergy Center and was taking a high dose of inhaled corticosteroids (ICS) due to frequent coughing from the age of 10 years and persistent coughing following COVID-19 infection at the age of 11. However, the patient continued to experience frequent coughing attacks and repeated visits to the emergency department after inhalation of β 2 -stimulants failed to improve his cough. We admitted him to the allergy center for examinations to assess the BA severity. In the airway hypersensitiveness test, saline inhalation performed prior to methacholine inhalation caused expiratory stridor and respiratory distress in the larynx, which worsened with β 2 -stimulant inhalation. Based on these results, we ruled out BA and diagnosed ILO. We instructed him on breathing maneuvers, and he was able to respond appropriately when symptoms appeared. We then started reducing his ICS dose.

Hepatocellular carcinoma is associated with a relatively high rate of paraneoplastic syndrome, but the frequency of erythrocytosis is low. We report a case of hepatocellular carcinoma with preoperative erythrocytosis and hypererythropoietinemia. The case is a 50-year-old man who has been cured by interferon treatment for hepatitis C 20 years ago(SVR). He visited our hospital with the complaint of right hypochondrial pain, and was diagnosed with hepatocellular carcinoma, which occupied S8/5/7 of the liver, and showed erythrocytosis and high erythropoietin(Epo)as tumor-related symptoms. A right hepatic lobectomy was performed, and the patient was discharged 13 days after the operation. The red blood cell count and Epo were normalized immediately after the operation. One year and 2 months after the operation, multiple lung metastases recurred, and chemotherapy is currently underway. Hepatocellular carcinoma with erythrocytosis and hypererythropoietinemia has been reported to have a poor prognosis, and multimodal treatment and strict surveillance are considered necessary.

Transcatheter aortic valve implantation (TAVI)-related Stanford type B aortic dissection is an extremely rare but potentially fatal complication. Here, we present a case of 82-year-old man who developed acute type B aortic dissection during transfemoral TAVI. During successful TAVI procedure, dissection in the descending aorta was demonstrated by transesophageal echocardiography. Computed tomography( CT) clearly showed Stanford type B aortic dissection and an intimal tear in severely tortuous part of the descending aorta. Cause of aortic dissection was supposed to be related to the guidewire or the device that passed across affected position. The patient showed no complication associated with aortic dissection, such as rupture or malperfusion. Therefore, he was treated conservatively, and follow-up CT confirmed progressive clotting of the false lumen. Although the indication for TAVI has got broaden recently, physicians should be always aware of possible aortic dissection.

Purpose: Foreign bodies such as a surgical gauze can be retained in the body after surgery and in some cases cannot be detected by postoperative radiography. The aim of this study was to develop an object detection model capable of postsurgical detection of retained gauze in the body. The object detection model used deep learning using abdominal radiographs, and a phantom study was performed to evaluate the ability of the model to automatically detect retained surgical gauze., Materials and Methods: The object detection model was constructed using a Single Shot MultiBox Detector (SSD) 300. In total, 268 abdominal phantom images were used: 180 gauze images were used as training data, 20 gauze images were used as validation data, and an additional 34 gauze images and 34 nongauze images were used as test data. To evaluate the performance of the object detection model, a confusion matrix was created and the accuracy and sensitivity were calculated., Result: True-positive (TP) rate, true-negative (TN) rate, false-positive (FP) rate, and false-negative (FN) rate were 0.92, 1.00, 0.00, and 0.08, respectively. Accuracy was 0.96, and sensitivity was 0.92., Conclusion: The object detection model could detect surgical gauze on abdominal phantom images with a high accuracy and sensitivity.

A 48-year-old female visited former doctor with abdominal pain and bloating. She was suspected of having pancreatic tumor and referred to our hospital. Abdominal dynamic CT showed multilocular cystic tumor in the pancreatic tail, and chest CT showed multiple lung nodules. From these findings, the patient was diagnosed mucinous cystic carcinoma(MCC)with lung metastases. We performed distal pancreatectomy for the first and lung resection after pancreatectomy. After all, the pathological diagnosis was MCC and metastatic lung cancer from the MCC. The adjuvant chemotherapy was not performed. Eleven months after pancreatectomy and 6 months after lung resection, the patient is still alive without recurrence.

A 60-year-old man underwent distal pancreatectomy with splenectomy and combined resection partially of the stomach, jejunum, and left renal vein. We administered S-1 adjuvant chemotherapy for 1 year. After its completion, the patient showed no evidence of recurrence. However, his carbohydrate antigen(CA)19-9 level was elevated for 1 year and 8 months postoperatively. We administered gemcitabine chemotherapy. He was admitted for bowel obstruction 3 years and 10 months postoperatively. Conservative treatment with an ileus tube did not improve the bowel obstruction. Therefore, we performed the surgery. Intraoperative findings revealed peritoneal nodules invading the small intestine. We performed a small bowel bypass. Pathological examination revealed the peritoneal nodule of pancreatic cancer. Although we administered FOLFIRINOX chemotherapy postoperatively, his CA19-9 level remained elevated for 4 years and 8 months after the first surgery. Therefore, chemotherapy was changed to gemcitabine and nab-paclitaxel. Six years and 11 months after the first surgery and 5 years and 3 months after the diagnosis of peritoneal dissemination, he survives with recurrence. Herein, there were 2 contributors to long-term survival; the patient not only showed positive responses to each chemotherapy regimen but could also continue chemotherapy without developing significant adverse effects.

A 32-year-old woman presented with epigastric pain and an abdominal mass. Abdominal CT showed a 130mm pancreatic tail mass with an enhanced rim, central necrosis, and small calcification. A 6mm lung tumor was also found via chest CT. Her medical history included surgical resection of cerebral solitary fibrous tumor when she was 24 years old. When she was 31 years old, it had recurred but was cured by gamma knife radiosurgery. We performed distal pancreatectomy and splenectomy with lymph node dissection. According to pathological and immunohistochemical findings, it was diagnosed as an anaplastic carcinoma with osteoclast-like giant cells. She underwent surgical resection of the lung tumor 2 months after pancreatic resection and was diagnosed with metastasis from the solitary fibrous tumor. Fourteen months since undergoing pancreatectomy, the patient experienced no recurrence from both diseases. We report a rare resected case of anaplastic carcinoma of pancreas concomitant with recurrent solitary fibrous tumor.

The upper abdomen was imaged with diffusion weighted images for free breathing and respiratory suppression using single shot-echo planar imaging (SS-EPI) and readout segmented-EPI (RS-EPI). We examined the usefulness of respiratory suppression imaging for the subject of healthy volunteers. Motion artifacts, apparent diffusion coefficient (ADC) values, and organs movement distances were evaluated. As a result, motion artifacts and organs movement distances were reduced in respiratory suppression than free breathing. The ADC values did not change. Respiratory suppression was simple and useful. In addition, it was found that RS-EPI imaging could be used for imaging the upper abdomen in the same way as SS-EPI by respiratory suppression.

An 81-year-old man was referred to our department because of rapid progression of a cystic lesion in the pancreatic tail. Abdominal CT revealed a heterogeneously enhancing tumor, measuring 70mm in diameter, in the pancreatic tail, encompassing a low-density area with calcification and directly invading the spleen. We diagnosed the patient with malignant transformation of solid-pseudopapillary neoplasm and performed distal pancreatectomy with splenectomy, partial transverse colectomy, and partial resection of the diaphragm. Histopathological examination revealed anaplastic carcinoma of the pancreas of the spindle cell type, and R0 resection was achieved. Anastomotic leakage of the transverse colon occurred on postoperative day 4, and ileostomy was performed. Multiple liver metastases were observed on postoperative day 27, and the patient was orally administered with S-1. Although he was discharged on postoperative day 50, he died of cancer on postoperative day 61. Anaplastic carcinoma of the pancreas has a poor prognosis, and an early multidisciplinary treatment should be performed.

At present, there is no apparent consensus about the indications for hepatectomy for liver metastases of gastric cancer. In this study, we identified factors of poor prognosis to investigate the indications for hepatectomy in 24 cases of hepatectomy for liver metastases of gastric cancer at our hospital during a period from August 2001 to September 2017. The 1-, 3-, and 5- year survival rates in all 24 cases were 63%, 21%, and 17%, respectively. Single variable analysis revealed that significant factors of poor prognosis were 3 or more liver metastases, synchronous liver metastasis, and positive surgical margin. Multivariable analysis revealed that significant independent factors of poor prognosis were synchronous liver metastases(HR 4.71, 95%CI: 1.08-21.79, p=0.040)and positive surgical margin(HR 5.95, 95%CI: 1.56-25.81, p=0.009). These findings indicated that, in cases of metachronous tumors and negative surgical margin, favorable prognosis can be expected following surgical resection for liver metastases of gastric cancer.

Rupture of hepatocellular carcinoma(HCC)is a disease wherein the prognosis is poor. In this study, we investigated cases of rupture of HCC that we encountered over 18 years. The age of onset ranged 48-76 years(67 years on average). The patients included 5 males and 1 female. All the cases experienced onset with rapid abdominal pain or loss of consciousness. Shock conditions appeared in 3 cases. Arrest of bleeding was possible by transcatheter arterial embolization(TAE)in all the cases. Subsequently, systemic search and evaluation of hepatic functional reserve were conducted. Hepatectomy was performed in all the cases. No notable complications occurred after the surgery. Two patients with recurrent peritoneal dissemination died of the original disease within 2 years. In the other 3 patients, recurrence has not occurred, and 2 of them have achieved long-term recurrence-free survivals for 4 years or longer. Therefore, based on the findings, we consider that longterm survival can be expected, depending on individual cases.

1 H-MRS, which is a method of measuring fat and iron deposits in the liver, has a single voxel spectroscopy imaging method called high-speed T 2 -corrected multiecho (HISTO) based on the STEAM method. If HISTO measurement accuracy is high, it will be one of the biomarkers, so the measurement accuracy was examined. We imaged a self-made phantom simulating a known amount of fat and iron deposition in the liver. A regression analysis of HISTO-measured values for hepatic fat phantom was performed. In addition, regression analysis was performed on the hepatic iron phantom for the R 2 values obtained from the T 2 values measurement and the actually measured value of the HISTO. From the regression analysis, the correlation coefficients were 0.999, 0.992 and 0.977, respectively. The measurement accuracy of HISTO is high, and the reliability of the obtained fat and iron deposit value is high.

Readout segmented EPI (readout segmentation of long variable echo-trains: RESOLVE) segmented k-space in the readout direction. By using the partial Fourier method in the readout direction, the imaging time was shortened. However, the influence on image quality due to insufficient data sampling is concerned. The setting of the partial Fourier method in the readout direction in each segment was changed. Then, we examined signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and distortion ratio for changes in image quality due to differences in data sampling. As the number of sampling segments decreased, SNR and CNR showed a low value. In addition, the distortion ratio did not change. The image quality of minimum sampling segments is greatly different from full data sampling, and caution is required when using it.

A 79-year-old man was referred to our hospital because of sudden upper abdominal pain. Enhanced computed tomography revealed a huge multilocular cystic tumor with a thickened wall, which was connected with the main pancreatic duct of the pancreatic body. Abscess formation was seen inside the omental bursa; however, there were no signs of direct invasion of the cystic tumor into the stomach or transverse colon. Therefore, we performed emergency endoscopic naso-pancreatic drainage(ENPD)under the diagnosis of an intraperitoneal abscess caused by rupture of intraductal papillary mucinous carcinoma(IPMC). Four weeks later, distal pancreatectomy with omentectomy was performed to achieve curative resection of the ruptured IPMC. The postoperative course was uneventful and the patient was discharged on postoperative day 14. The pathological diagnosis was noninvasive IPMC. No signs of recurrence were seen until 12 months after surgery. Rupture of IPMC into the intraperitoneal space is rare; however, the prognosis is relatively poor because of the difficulty of curative resection. ENPD drainage before surgery is potentially useful for patients with ruptured IPMC to control local inflammation, which improves surgical curability.

Case 1: A 40-year-old man was diagnosed with remnant pancreatic cancer invading the celiac axis 8 months after pancreaticoduodenectomy for pancreatic head cancer. As his gastroduodenal artery had been resected, the patient underwent preoperative coil embolization of the common hepatic artery for the development of extrahepatic collaterals. Eighteen days after the coil embolization, remnant pancreatectomy combined with celiac axis resection without reconstruction was performed. The patient was discharged without postoperative hepatic complications. Case 2: A 62-year-old woman was diagnosed with remnant pancreatic cancer 13 months after distal pancreatectomy with celiac axis resection for pancreatic body cancer. As the coil that had accidentally migrated to the proper hepatic artery during preoperative coil embolization for initial surgery remained, the flow to the liver through the gastroduodenal artery had weakened. In contrast, collateral flow from the right inferior phrenic artery to the right hepatic artery had increased. Remnant pancreatectomy with gastroduodenal artery resection was performed with no postoperative hepatic complications. Changes in the hemodynamics of the liver, resulting from preoperative coil embolization, may reduce the risk of postoperative hepatic ischemia after remnant pancreatectomy combined with hepatic arterial resection.

A 50-year-old man was diagnosed with multiple bilobar liver metastases of rectal neuroendocrine tumor(NET). Although he received octreotide for 6 months and everolimus for 10 months, the liver metastases gradually increased in size. Therefore, we decided to perform transcatheter arterial infusion(TAI)with miriplatin. The serum total bilirubin level increased to 13.1 mg/dL 9 days after treatment, and it took 2 months to return to the normal range. CT scan demonstrated that most of the liver tumors had remarkably shrunk 4 months after treatment, and the patient has no sign of tumor regrowth even 12 months after treatment. Retrospective analysis of our cases(98 procedures of[transcatheter arterial chemoembolization: TACE]or TAI for liver tumors performed at the Department of General Surgery, Chiba University from 2012 to 2015)revealed that serum biliary enzymes levels 7 days after TACE were significantly higher in patients with metastatic liver tumors than those in patients with hepatocellular carcinoma. These data suggest that the TACE procedure might lead to severe damage of the biliary system in patients with metastatic liver tumors. Although the morbidity rate of TAI is very low, the procedure should be performed with caution, especially for patients with liver metastases.

Trousseau's syndrome refers to cerebral infarction associated with hypercoagulability caused by cancer. Here, we report a case of Trousseau's syndrome in a patient with pancreatic cancer undergoing surgery. A 71-year-old woman was diagnosed with pancreatic head cancer with portal vein invasion; she underwent pancreaticoduodenectomy combined with portal vein resection. Pathological examination showed poorly differentiated adenocarcinoma with para-aortic lymph nodal metastasis. Although the patient had an uneventful postoperative course, she suddenly developed right hemiplegia and dysarthria 6 weeks after surgery, resulting in multiple cerebral infarctions scattered over both hemispheres. Owing to elevated D-dimer and CA125 levels as well as multiple liver metastases, the patient was diagnosed with Trousseau's syndrome and treated using heparin-based anticoagulant therapy. However, her cerebral infarction progressed rapidly and she died within 35 days of admission. Therefore, Trousseau's syndrome should be suspected when a patient with cancer is diagnosed with cerebral infarction, and anticoagulation therapy with heparin should be promptly initiated.

Platelet transfusion is indispensable for current medical treatments of hematological disorders. However, alternative platelet sources are urgently needed due to the inadequate donor blood supply, particularly of HLA/HPA-matched platelets. The advent of 'iPS cell (iPSC) technology' was considered in light of this problem, which yielded the idea of iPSC-derived platelet production. The safety of iPSC-derived cell therapy is critical, but platelets can be gamma-irradiated prior to their use. Thus, there is an advantage in terms of clinical application. The remaining developmental aim of the in vitro iPSC-derived platelet generation process is to further scale up industrialized culture and production for the packaging of washed-type platelet concentrates, and a laboratory scale production system has already been optimized in preparation for meeting this goal.

Patients with borderline resectable pancreatic cancer have a poorer prognosis than patients with resectable pancreatic cancer, but some cases treated with neoadjuvant chemoradiation therapy and radical surgery (R0 surgery) show long-term survival. A 72-year-old woman presented with a history of back pain and weight loss. Computed tomography revealed a cancer of the pancreatic body encasing the celiac trunk, common hepatic artery, and portal vein. After neoadjuvant chemotherapy ( S-1) and carbon-ion radiotherapy, the tumor was considered to be resectable. Distal pancreatectomy with en bloc celiac trunk resection (DP-CAR), portal vein resection, and reconstruction was performed. The histopathologic findings showed that the effect of NACRT was gradeⅡa (Evens' classification), and the surgical margins were histologically clear. S-1 was administered again for half a year as postoperative chemotherapy. With post-operative follow-up of 1 year and 1 month after surgery, the patient shows no signs of recurrent disease.

Pancreatic acinar cell carcinoma is rare. There is no consensus on a treatment strategy for metastatic lesions to the liver. We report of a 68-year-old man who received total pancreatectomy for pancreatic acinar cell carcinoma. One year after surgery, abdominal enhanced CT showed a small liver tumor in segment 8. We diagnosed this tumor as hepatic metastasis of pancreatic acinar cell carcinoma, and we resected it via partial liver resection. Pathological studies indicated a metastasis from pancreatic acinar cell carcinoma. The patient has been alive without recurrence for 7 months after the hepatectomy. There is no consensus on surgery for hepatic metastasis of acinar cell carcinoma, but if surgical resection is possible and safe, we consider it an appropriate treatment option.

We report the case of a 77-year-old woman with mediastinal lymph node metastasis of combined hepatocellular and cholangiocarcinoma who was successfully treated with S8 segmentectomy and lymphadenectomy. A hepatic nodule was detected in segment 8 during follow-up computed tomography (CT) after left iliac arterial aneurysm repair. The patient was diagnosed with a hepatocellular carcinoma (HCC), and transcatheter arterial chemoembolization (TACE) was selected for HCC because of the patient's condition. The levels of tumor markers did not change after TACE was performed twice. Therefore, TACE treatment was considered to be ineffective for HCC, and the patient was admitted to our hospital for surgical resection. In addition to the primary lesion, a lymph node with a diameter of 20 mm was detected in the anterior mediastinum using CT and magnetic resonance imaging(MRI). We did not find any other metastases, and therefore, S8 segmentectomy and lymphadenectomy in the anterior mediastinum were performed. Recovery was uneventful, and the patient was discharged from the hospital on postoperative day 12. Based on histopathologic findings, combined hepatocellular and cholangiocarcinoma with mediastinal lymph node metastasis was confirmed. Levels of tumor markers normalized, and the patient survived without recurrence for 6 months.

A 70-year-old woman was diagnosed with pancreatic head cancer with hepatic artery invasion by multi-detector computed tomography (MD-CT). After 3 courses of gemcitabine plus S-1 neoadjuvant therapy, the tumor size was not diminished; however, the tumor marker CA19-9 level was decreased to less than 90% of its initial level. Pancreaticoduodenectomy combined with hepatic artery resection was performed, and an end-to-end anastomosis was made between the common and proper hepatic artery to reconstruct the hepatic artery. The pathological examination indicated adenosquamous carcinoma, no vascular invasion, and negative margin status, and the efficacy of chemotherapy was classified as GradeⅡb using Evans' classification. Usually, pancreatic head cancer with hepatic artery invasion is considered unresectable due to its high morbidity/mortality and poor prognosis. However, with the recently developed surgical strategy and appropriate therapeutic interventions, such as a combination of neoadjuvant chemotherapy and resection/reconstruction of the hepatic artery, a curative operation can be feasible for locally advanced pancreatic head cancer.

The quality of life of patients with recurrence of biliary cancer is remarkably diminished by the occurrence of refractory ascites caused by peritoneal dissemination or portal vein obstruction. In this study, we examined the effectiveness of peritoneovenous shunting (PVS) in patients with refractory ascites after recurrence of biliary cancer. PVS was performed 7 times in 5 patients, with 6 shunts (85.7%) placed from the left-side abdomen to the left subclavian vein. During the median observation period of 136 days, the ascites and symptoms of abdominal distension disappeared in 4 patients. Severe complications consisting of shunt obstruction in 2 patients and post-shunt coagulopathy in 1 patient were also observed. PVS is a useful palliative therapy for refractory ascites in patients with recurrence of biliary cancer. In patients after cancer resection, an appropriate choice of a safe placement route is critical for avoiding abdominal organ injury. The feasibility of PVS in patients with refractory ascites should be considered carefully and in context of their prognosis and performance status because severe complications may occur after this procedure.

Unlabelled: We report 2 cases of pancreatic neuroendocrine tumor with liver metastases successfully treated with multidisciplinary therapy, including multiple surgical resections. Case 1: A 63-year-old man underwent distal pancreatectomy and portal vein resection for a pancreatic body tumor. Histological analysis revealed the tumor was a pancreatic neuroendocrine tumor (p-NET), classified as NET G2. His metachronous liver metastases were treated with lateral sectionectomy and 2 rounds of transcatheter arterial chemoembolization (TACE). He is being treated with everolimus for para-aortic lymph node metastases and is alive 90 months after the primary operation. Case 2: A 64-year-old man underwent distal gastrectomy for a duodenal ulcer and distal pancreatectomy for a pancreatic tumor. The histological diagnosis was gastrinoma classified as NET G2. Hepatectomy (segmentectomy of segment 8 and partial hepatectomy) was performed twice for metachronous liver metastases. Everolimus has been administered for liver and para-aortic lymph node metastases, and the patient is alive 108 months after the primary operation., Conclusion: Multidisciplinary treatment should be considered for patients with p-NETs with multiple metastases.

In 2014, we reported the first trial based on outpatient parenteral antimicrobial therapy (OPAT) with continuous infusions in Japan. Following this, we found many patients who were eligible for OPAT but could not undertake it owing to difficulties in accessing the clinic daily. To overcome this problem, we created a model in collaboration with visiting nursing stations and started providing OPAT with the services. We report herein on a summary of the investigation of the first 10 patients treated under this model. We collected data pertaining to diseases, organisms, antimicrobials, treatment duration, bed days saved, outcome, readmission rate, and cost reductions associated with these patients. The most commonly targeted disease was osteomyelitis, followed by infective endocarditis. The condition of nine of the patients was complicated by bacteremia. The most commonly targeted organism was Staphylococcus aureus. Cefazolin was the most frequently prescribed antimicrobial, followed by Penicillin G. The median duration for OPAT was 12 days (range: 5-23 days). The total number of bed days saved was 129. All patients completed the planned OPAT. Eight patients were cured and two showed improvement. Only one patient was readmitted within a month after the completion of therapy. The estimated medical cost reduction was 496,540 yen, which is approximately 4,200 US dollars. Collaboration with visiting nursing stations provided OPAT to the patients who had difficulties in accessing the clinic daily. Our study shows that OPAT administered by continuous infusion in collaboration with home-visit nursing services would be a safe and feasible practice for efficient bed utilization and medical cost saving.

A 61-year-old woman was referred to our hospital because of jaundice and general itching. Computed tomography (CT) scan demonstrated that the tumor was located in the caudate lobe of the liver with hilar invasion and involved the hepatic inferior vena cava (IVC) and the right renal artery and vein. The patient was diagnosed with locally advanced intrahepatic cholangiocarcinoma, for which she underwent right hemihepatectomy with right caudate lobectomy, portal vein resection, hepatic IVC resection, extrahepatic bile duct resection, and right nephrectomy. IVC was reconstructed using vascular prosthesis by expanded polytetrafluoroethylene (ePTFE)-ringed graft. The patient's postoperative course was uneventful. The patient was treated with gemcitabine for postoperative chemotherapy, and 3 years after the operation, she died due to recurrence resulting from peritoneal dissemination. Although the thrombosis-related vascular prosthesis obstruction had occurred 2 years after the operation, no clinical symptom were noted, such as lower leg edema or renal dysfunction, during the postoperative course. Hepatic IVC prosthesis reconstruction for locally advanced cancer with extensive IVC invasion can be a useful surgical procedure for improving the resection rate and maintaining quality of life (QOL) in such cases.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas often contains multifocal lesions, and total pancreatectomy is sometimes needed for curative resection. We report here our experience with a case of IPMN with multiple invasive carcinoma foci that was successfully treated with total pancreatectomy. A 66-year-old man had jaundice, and a computed tomography (CT) scan revealed a hypovascular mass in the pancreas head in conjunction with calcification and dilation of the entire main pancreatic duct. He was diagnosed with pancreas head cancer and chronic pancreatitis, and a pancreaticoduodenectomy was planned. Intraoperative pathological examination revealed papillary growth of high grade dysplasia in the main and branch duct epithelium and perineural invasion of the atypical glands. After 2 additional resections, we performed a total pancreatectomy. Pathological findings showed that the pancreas head tumor was an invasive carcinoma derived from main-duct IPMN of the pancreas. It was a mucinous carcinoma with calcification. Moreover, we found other multiple, discontinuous invasive foci in the body and tail of the pancreas which were undetectable by preoperative imaging. This case was highly suggestive for preoperative diagnosis for pancreas tumor and developmental pattern of main-duct IPMN.

This case report describes an 83-year-old man with intrahepatic cholangiocarcinoma who was referred by a local hospital. Abdominal computed tomography (CT) showed a large tumor in hepatic segments 4, 5, and 8 involving the right hepatic vein and inferior vena cava, which is normally indicative of an unresectable locally advanced tumor. After systemic chemotherapy with gemcitabine and cisplatin, the observed decrease in the level of tumor marker suggested that the cancer was responding to treatment, while radiological findings showed the main tumor shrunk without the presence of distant metastases. Thus, hepatic left trisectionectomy with bile duct resection was performed after portal vein embolization. Pathological examination revealed negative margins (R0). Eighteen months after surgery, the patient is free of disease and shows no signs of recurrence. An initially unresectable, locally advanced biliary tract cancer may be down sized by chemotherapy, which makes radical resection possible, at least in a proportion of patients. This approach provides longer survival and may have a potential for disease eradication as a new multidisciplinary approach for patients with unresectable locally advanced biliary tract cancer.

A 70-year-old man was diagnosed with local recurrence 1 and half years after pancreatoduodenectomy for extrahepatic cholangiocarcinoma. Progression of the recurrent tumor involved the portal vein, even though the patient had received chemotherapy (gemcitabine). Although no clinical symptoms caused by portal venous stenosis were found at the time, we performed percutaneous transhepatic portal vein stenting to avoid interrupting chemotherapy. Eighteen months after this procedure, the patency of the portal vein stent was well maintained, and the patient was treated with S-1 chemotherapy continuously without any symptoms related to portal venous stenosis reported. Prophylactic portal vein stenting without clinical symptoms of portal vein stenosis is a useful procedure, not only for palliative care but for improving the prognosis of patients with cholangiocarcinoma by continuous chemotherapy.

Hereditary angioedema (HAE) is a disease that is characterized by localized edema that can occur anywhere in the body, and is caused by a mutation of the C1-inhibitor gene. In the oto-rhino-laryngological region, it occurs in the mouth, pharynx, larynx, and on the face. Occasionally, laryngopharyngeal edema can in particular sometimes be fatal. We report herein on a case of a 59-year-old female who was admitted to our hospital for further evaluation and treatment of laryngopharyngeal edema. She had a history of subcutaneous edema during pregnancy and ascites of unknown origin without a definitive diagnosis. On admission, there were low C1 inhibitor and complement C4 levels, and normal C1q levels. As the patient had no family history of HAE, we performed gene analysis, which revealed mutation of the C 1-inhibitor gene in Exon7. In cases of HAE without family history, gene analysis is required for accurate diagnosis.

We reported a rare case of cardiac lipoma in the left ventricular apex. A 67-year-old woman who was diagnosed with cardiac tumor in the left ventricular apex was underwent the extirpation of the tumor via left ventriculotomy with the aid of intraoperative epicardiac ultra-sound. An intraoperative epicardiac ultra-sound is a very useful tool to document a location of the tumor, and a left ventriculotomy approach for the extirpation of the tumor provides a good operative field.

Basic principles for simulation of acute reference dose (ARfD) setting were defined based on the work of Solecki et al. (2005). The principles are: (1) Appearance of acute toxicity within 24 h after oral administration. (2) Rationale for setting toxicity that appears or could appear after single oral administration. (3) ARfD setting is assumed to be necessary for all pesticides. (4) ARfD setting is not necessary when the value is at or above the cutoff level. (5) The setting basically applies to the general population. (6) ARfD is set based on the lowest NOAEL among all the available study data concerning endpoints for acute effects. (7) Effects of exposure during critical periods should be considered as endpoints for ARfD setting. (8) The approach for the safety coefficient is the same as that for acceptable daily intake. (9) If available, human data are acceptable as an endpoint for ARfD setting.

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.

We report a case of mediastinal lymph node metastasis from rectal cancer successfully treated by carbon ion radiotherapy. A 65-year-old woman underwent sigmoid colostomy against unresectable rectal cancer. After chemoradiotherapy, primary rectal cancer became resectable and low anterior resection was performed. Curative local resection was done and chemoradiotherapeutic effect was grade 2. Chemotherapy after the operation wasn't effective enough and the size of the mediastinal lymph node increased. So she underwent carbon ion radiotherapy (52.8 Gy) which markedly decreased the lymph node size (-48%). Multi-modality therapy, such as radiation, chemotherapy, operation and carbon ion radiotherapy was applied. Successfully, locally advanced rectal cancer was resected and distant lymph node metastasis was controllable.