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The most common sites for recurrence of breast cancer are the lungs, liver, and bones. The frequency of peritoneal, gastrointestinal metastasis is significantly lower than those, and bilateral ureteral obstruction caused by peritoneal metastasis is relatively rare. A 66-year-old woman was referred to our hospital because of appetite loss and frequent urination. She was on adjuvant hormonal therapy for local recurrence of right breast cancer. She was diagnosed with bilateral ureteral obstruction due to extramural compression. Exploratory laparoscopy revealed omental cake and peritoneal nodules of which pathological examination showed peritoneal metastasis of invasive lobular carcinoma. Peritoneal metastases from breast cancer are unusual and consequently difficult to identify without non-invasive tools. Exploratory laparoscopy revealed that the cause of hydronephrosis in this case was peritoneal metastasis of invasive lobular carcinoma. Clinical history and histological study play a pivotal role in determining the correct diagnosis.

Summary: Background: Although the laparoscopic approach reduces pain associated with abdominal surgery, postoperative pain remains a problem. Ultrasound-guided rectus sheath block and transversus abdominis plane block have become increasingly popular means of providing analgesia for laparoscopic surgery. Methods: Ninety patients were enrolled in this study. A laparoscopic puncture needle was inserted via the port, and levobupivacaine was injected into the correct plane through the peritoneum. The patients' postoperative pain intensity was assessed using a numeric rating scale. The effects of laparoscopic nerve block versus percutaneous anesthesia were compared. Results: This novel form of transperitoneal anesthesia did not jeopardize completion of the operative procedures. The percutaneous approach required more time for performance of the procedure than the transperitoneal technique. Conclusion: This new analgesia technique can become an optional postoperative treatment regimen for various laparoscopic abdominal surgeries. What we mainly want to suggest is that the transperitoneal approach has the advantage of a higher completion rate. A percutaneous technique is sometimes difficult with patients who have severe obesity and/or coagulation disorders. Additional studies are required to evaluate its benefits. Keywords: colorectal surgery, nerve block, postoperative pain, rectus sheath block, transversus abdominis plane block

During cancer chemotherapy, drugs such as 5-HT3 receptor antagonists have typically been used to control vomiting and anorexia. We examined the effects of oxytocin (OXT), which has been linked to appetite, on cisplatin-induced anorexia in rats. Fos-like immunoreactivity (Fos-LI) expressed in the supraoptic nucleus (SON), the paraventricular nucleus (PVN), the area postrema and the nucleus of the solitary tract (NTS) after intraperitoneal (ip) administration of cisplatin. We also examined the fluorescence intensity of OXT-mRFP1 after ip administration of cisplatin in OXT-mRFP1 transgenic rats. The mRFP1 fluorescence intensity was significantly increased in the SON, the PVN, and the NTS after administration of cisplatin. The cisplatin-induced anorexia was abolished by OXT receptor antagonist (OXTR-A) pretreatment. In the OXT-LI cells, cisplatin-induced Fos expression in the SON and the PVN was also suppressed by OXTR-A pretreatment. These results suggested that central OXT may be involved in cisplatin-induced anorexia in rats.

We herein describe a surgical case of perforated jejunal diverticulum in an adult patient with alcoholic psychosis and dementia. A 70-year-old Japanese male presented with vomiting and abdominal pain in a mental hospital. He had undergone a distal gastrectomy, the details of which are unclear. He entered the internal medicine ward of our hospital and was diagnosed with bowel obstruction and conservatively treated with a long tube. At the 4th hospital day, he suffered from severe abdominal pain with muscular defense. Computed tomography revealed a dilated small intestine and intra-abdominal free air and ascites. After laparotomy, a perforated jejunal diverticulum was identified at 30 cm along the anal side from the ligament of Treitz. Adhesiolysis and exteriorization of the perforated jejunal diverticulum using a tube were performed, as the status of the patient was too serious to tolerate resection of the small intestine including the perforated lesion. The patient eventually recovered and left the hospital on Day 37 after the operation. This report presents a rare surgical case of perforated jejunal diverticulum due to small bowel obstruction in an adult patient with alcoholic psychosis and dementia.

Pediatric cholecystolithiasis is a relatively rare disease, but it is recently increasing in Japan. Laparoscopic cholecystectomy (LC) is a standard procedure for cholecystolithiasis not only in adults but also in children, and we are aggressively introducing single-incision laparoscopic cholecystectomy (SILC) at our hospital. We reviewed the patient characteristics, operation procedures and outcomes of 7 children (15 years old and under) with cholecystolithiasis who underwent LC in our hospital between August 1995 and December 2015. The 7 patients included 5 males and 2 females, with a mean age of 8 years 6 months. Underlying diseases were found in 5 patients (cerebral palsy in 2 patients, pancreaticobiliary maljunction with common bile duct stones in 1, acute lymphocytic leukemia in 1, hereditary stomatocytosis in 1), and none were found in the other 2. LC (3 conventional LC and 2 SILC) was performed in 5 of the patients. Laparoscopic choledocholithotomy was performed in 1 patient and laparoscopic splenectomy (LS) was performed in 1 patient at the same time. The mean operative time in all the cases of LC was 108 (70-140) minutes (conventional LC 113 (70-140) min, SILC 100 (90-100) min). Intraoperative cholangiography was performed in 4 cases and omitted in 3 cases. The only postoperative complication was a wound infection in 1 patient. The umbilical skin incision length in the SILC was 2.0 cm. We conclude that LC can be safely performed for children with cholecsytolithiasis, and that SILC is feasible and advantageous in terms of its improved cosmesis.

INTRODUCTIONThe presence of a ventriculoperitoneal shunt has been considered to be a contraindication for laparoscopic surgery till date; however, laparoscopic cholecystectomy was recently reported as safe for patients with this shunt.PRESENTATION OF CASEWe present the first case, to the best of our knowledge, of laparoscopic colectomy for cecal cancer in a patient with a ventriculoperitoneal shunt. A 59-year-old woman with a ventriculoperitoneal shunt for hydrocephalus was referred to our hospital with cecal cancer. Laparoscopic cecal cancer resection was performed successfully and uneventfully by manipulating the shunt.DISCUSSIONClamping of the shunt catheter at the subcutaneous region was performed before insufflation of carbon dioxide to prevent adverse effects from the pneumoperitoneum.CONCLUSIONWe believe that laparoscopic colectomy for colon cancer can be performed safely in patients with a ventriculoperitoneal shunt by optimal manipulation of the shunt.

消化管の一部が右横隔膜下と肝臓の間に嵌入した病態をChilaiditi症候群と呼ぶ．今回われわれは絞扼性イレウスを合併し腸切除を要した，小腸型Chilaiditi症候群の1例を経験したので報告する．症例は52歳女性，腹痛・嘔吐にて当院受診．CTで絞扼性イレウスを合併した小腸型Chilaiditi症候群と診断し，同日緊急開腹術を施行した．開腹所見では肝右葉表面と右横隔膜下との間に小腸が嵌入し，絞扼していた．嵌入小腸を整復したが，壊死小腸の切除を要した．Chilaiditi症候群は大多数が結腸のみの嵌入で，無症状であれば経過観察される場合が多い．しかし小腸型Chilaiditi症候群の場合は，イレウスの合併による緊急手術の必要性を考慮に入れた慎重な経過観察が必要と考えられる．

症例は65歳，男性．腹痛・高度の貧血を主訴に当院入院．血液生化学検査で貧血・CRPの上昇を認め，腫瘍マーカー（CA19-9）の上昇を認めた．腹部CT・腹部MRIで小腸壁肥厚を伴う腫瘤像を認め，両側副腎に転移を疑う腫瘤性病変を認めた．小腸腫瘤性病変からの出血が貧血の原因と診断し，緊急手術を施行した．開腹所見ではTreitz靱帯から20cmの空腸に下行結腸浸潤を伴う腫瘤と腸間膜リンパ節転移を認めたため，小腸・下行結腸部分切除術を施行した．両側副腎腫瘍は遠隔転移と診断し，根治的切除は困難と考え切除しなかった．病理組織学的には異型性の強い細胞を認め，免疫染色では上皮系マーカーのCAM5.2・AE1/AE3，間葉系マーカーのvimentinのみが陽性で，原発性小腸未分化癌と診断した．原発性小腸未分化癌の報告は少なく極めて稀である．今回われわれは，両側副腎転移を伴った原発性小腸未分化癌の1例を経験したので文献的考察を加えて報告する．

A 62-year-old man who had acute rectal obstruction due to a large rectal cancer is presented. He underwent emergency laparoscopic colostomy. We used the laparoscopic puncture needle to inject analgesia with the novel transperitoneal approach. In this procedure, both ultrasound and laparoscopic images assisted with the accurate injection of analgesic to the correct layer. The combination of laparoscopic visualization and ultrasound imaging ensured infiltration of analgesic into the correct layer without causing damage to the bowel. Twenty-four hours postoperatively, the patient’s pain intensity as assessed by the numeric rating scale was 0-1 during coughing, and a continuous intravenous analgesic was not needed. Colostomy is often necessary in colon obstruction. Epidural anesthesia for postoperative pain cannot be used in patients with a coagulation disorder. We report the use of a novel laparoscopic rectus sheath block for colostomy. There has been no literature described about the nerve block with transperitoneal approach. The laparoscopic rectus sheath block was performed safely and had enough analgesic efficacy for postoperative pain. This technique could be considered as an optional anesthetic regimen in acute situations.

Two endogenous γ-lactones, 3-hydroxy-4-butanolide (1) and 2-hydroxy-4-hydroxymethyl-4-butanolide (2) have been identified as substances that enhance, respectively, satiety and hunger by their effects on the feeding behavior and the central neurons of rats. To determine the stereochemistry of the physiologically active isomers, all the stereoisomers of these two lactones were synthesized and their effects on the feeding behavior and humoral factors were assessed by infusion into the rat third cerebroventricle. Among four isomers, (2S,4S)-2-hydroxy-4-hydroxymethyl-4-butanolide (2a) was most effective in elicitating the feeding and caused potent hypoglycemia with hyperinsulinemia. (S)-3-Hydroxy-4-butanolide (1a) suppressed the food intake more potently than the antipode and caused humoral responses reciprocal to those of 2a. From these facts, it was concluded that 1a and 2a are physiologically active forms for conveying intrinsic signals of satiety and hunger to neurons in the hypothalamus.

1,5-Anhydroglucitol (1-DG) and 2-deoxy-D-glucose (2-DG) have been found to show delayed suppression of food intake succeeding to an initial hyperphagia. In addition, 1-DG which has been physiologically traced was suggested to provide physiological signals for control of food intake. In order to clarify the molecular structural mechanisms of feeding suppression induced by glucose analogues, feeding behavioral modes of action in 5 deoxy analogues of glucose were examined. The experiments were carried out in a sound proof room illuminated daily from 0800-2000 hr using adult male rats. Test solutions were infused around 1950 hr into the intra-ventricle III. Decrease of food intake and body weight was observed during the first day after 1-DG injection, while it reverted to their initial levels on the second day. 2-DG had the same suppressive effect on the first day. The magnitude of suppression elicited by 5-thioglucose was about ten times that produced by equimolar 1-DG. 1,2-Dideoxy-D-glucose, however, was less potent than 1-DG for producing anorexia. In contrast to these analogues, 1-deoxy-D-mannose did not produce any changes in food intake or body weight. Taken together with these results, it is highly probable that oxygens at the position of carbon 1,2 and 5 of glucose may play an important role on producing feeding suppression.

In order to study rhythm in Mongolian gerbils (Meriones unguiculatus) , their feeding and drinking behaviors as well as motor activity were examined under lighting conditions of 12:12 hr light-dark and constant dark cycles. The experiments were carried out in a sound-proof room illuminated from 0800-2000 hr under conditions of temperature at 21 + 2° C and humidity at 60 + 5 %. In contrast to albino rats, significant differences between light and dark variations in feeding, drinking and motor activity were not observed in gerbils. Under a constant dark condition, once again, there was the absence of daily fluctuations in these behavioral measures. However, when these data were analyzed by means of the cor-relogram, it was found that gerbils ate and drank according to clear circadian rhythms under both conditions of light-dark and constant dark lighting regimens. A diurnal cycle in motor activity was shown to be a 12 hr period in a light-dark regimen, while it vias prolonged to a 24 hr period under a oondition of constant dark. Thus, a subtle analysis of behavioral patterns revealed that gerbils belonged to nocturners and owned diurual rhythms in feeding, drinking and exploratory behaviors. The phasing of these rhythms except motor activity were similar to those in rats.

Under natural circumstances,twilight is known to play an important role in behavioral and metabolic changes in mammals. Since experimental rooms are usually illuminated by on-off lighting system, an artificial twilight system was devised and its effect on feeding, drinking and motor activity was compared with those in on-off system. Following 10 days of on-off lighting (a 12:12 light-dark cycle), a twilight regimen was introduced. Illuminant intensity increased from 0 to 90 lumen during a 2 hr period of dawn and decreased reversely during same hour period of dusk. Three different types of twilight conditions were tested, i.e., (1) dawn: 0800-1000 hr and dusk: 1800-2000 hr, (2) dawn: 0600-0800 hr and dusk: 2000-2200 hr, (3) dawn: 0600-0800 hr and dusk: 1800-2000 hr. Total amount of 24-hr consumptions or activity was not influenced following the twilight conditions. Immediately after a period of dawn started, rats decreased food and water intake subsequent to their increase during the later periods of dark. During a dusk period, food and water intake increased markedly during twilight conditions in type 3. In type 1, however, such facilitated effects were not found.