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Cesarean section for placenta previa accreta spectrum carries a significant risk of massive hemorrhage. Hence, it is necessary to understand the various hemostatic procedures, damage control surgery and resuscitation for massive hemorrhage, and systemic management against hypovolemic shock and coagulopathy. In cases of placenta previa with previous cesarean section, the operation should be performed in a tertiary medical facility with well-trained staff and blood availability for transfusion. Preoperative placement of an intra-arterial balloon occlusion catheter in the common iliac artery or aorta is useful for preventing massive hemorrhage.

When cesarean hysterectomy is scheduled in cases of placenta previa accreta/increta/percreta, it is necessary that the departments of obstetrics, anesthesiology, blood transfusion, urology, and radiology hold a preoperative conference to assure full preparation for the surgery. A ureteral stent inserted just before cesarean section serves as a marker. A uterine incision should be made at a site free of placental contact. The presence/absence of bladder invasion by villi, adhesions, and the degree of vascularization greatly influence the amount of bleeding, and bleeding control is a key point. For prevention of massive hemorrhage, methods of blood flow blockage, such as balloon occlusion catheterization of the aorta or common iliac artery, should be considered. Stored autologous blood and Cell Saver should be prepared. When hysterectomy is performed with the placenta left in situ, handling of the elongated cardinal ligament, ureteric injury, and bladder injury are important issues because the lower uterine segment is enlarged with the placenta. If blood flow is not blocked, separation of the bladder at the area of placenta percreta should be performed as the last step, to reduce bleeding (Pelosi's method). At this time, after handling of the cardinal ligament, bladder separation can be performed more safely if the posterior vaginal wall is incised and exposed first.In cases of placenta accreta or partial placenta accreta/increta/percreta, a diagnosis of morbidly adherent placenta may not be obtained until separation of the placenta is performed. If bleeding from the placental separation surface cannot be controlled, total hysterectomy should be performed without hesitation.

AIMS We investigated whether common iliac artery balloon occlusion (CIABO) was effective for decreasing blood loss during cesarean hysterectomy (CH) in patients with placenta previa with accreta and was safe for mothers and fetuses. METHODS Of the 67 patients who underwent CH for placenta previa with accreta at our facility from 1985 to 2014, 57 patients were eligible for the study. The amount of intraoperative bleeding during CH was compared between three groups: surgery without blood flow occlusion (13 patients), internal iliac artery ligation (15 patients) and CIABO (29 patients). Additionally, multivariate analysis was performed to assess risk factors for massive bleeding during CH. RESULTS The mean blood loss in the CIABO group (2027 ± 1638 mL) was significantly lower than in the other two groups (3787 ± 2936 mL in the no occlusion, 4175 ± 1921 mL in the internal iliac artery ligation group; P

Aim Massive obstetric hemorrhage (MOH) requires prompt transfusion of red blood cells and coagulation factors. Because MOH has a diverse pathogenesis, the shock index (SI) alone may be insufficient for determining blood transfusion. Here, we retrospectively analyzed patients with MOH to determine usefulness of the indicators of shock including the SI in evaluating the need for blood transfusion. Methods We reviewed records of 80 emergency referral patients who had received blood transfusions at our department between 1 January 2009 and 31 July 2011. The shock indicators for blood transfusion are estimated blood loss, fibrinogen level, hemoglobin concentration, the Japan Society of Obstetrics and Gynecology disseminated intravascular coagulation (JSOG DIC) score and the SI. The strength of the correlation of each shock indicator with the transfusion volume was ranked using Spearman's rank correlation coefficient-ρ and multivariate analysis. Results Although the SI showed significant positive correlation with blood transfusion volume for red blood cell concentrate (RCC) and fresh frozen plasma (FFP) in patients with dilutional coagulopathy, a stronger correlation was seen with the fibrinogen level and JSOG DIC score. In patients with consumptive coagulopathy, the strongest correlation was seen between RCC transfusion volume and fibrinogen level, and between FFP transfusion volume and JSOG DIC score followed by fibrinogen level. In multivariate analysis, only fibrinogen level was significantly associated with both RCC and FFP massive transfusion. Conclusion Because MOH has a diverse pathogenesis, various indicators should be evaluated. Among shock indicators, fibrinogen level was the best indicator of the need for blood transfusion following MOH.

Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation ( 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3–1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3–1.4 may be desirable.

悪性線維性組織球種 (Malignant Fibrous Histiocytoma以下MFH) の,後腹膜原発例は比較的稀で,局所再発や他臓器転移等のため予後は極めて不良である.症例は, 74歳の男性で,左下腹部の腫瘤を主訴に来院した.腹部CTおよびMRIで,辺縁不整,内部不均一の10cm大の腫瘤を左下腹部に認め,血管造影検査では左総腸骨動脈造影で腫瘍濃染像を認めた.以上より後腹膜由来の肉腫を疑い腫瘍摘出術を施行した.切除された腫瘍は, 14×12×11cm, 490gで病理組織学的所見では, storiform-pleomorphic typeのMFHと分類された.術後6週目に施行した,胸腹部単純CTにて局所再発および多発性肺転移を認め,術後16週目に呼吸不全で死亡した.本疾患は,再発,転移率高く,自験例のように術後急速な経過をたどることもある.

The incidence of non-recurrent laryngeal nerve is claimed to be 0.3-0.9%, and this anatomical anomaly is important in thyroidectomy and parathyroidectomy. We encountered a right non-recurrent inferior laryngeal nerve, arising from the cervical trunk of the vagus and passing directly to the larynx in a 65-year-old female patient who underwent total parathyroidectomy. The anomaly of the recurrent nerve is explained by the process of nerve and blood vessel development from the embryologic branchial arches, and since it is known to be associated with anomalous origin of the right subclavian artery from the aortic arch, it is only observed on the right side. In this case, postoperative IV-DSA confirmed the right subclavian artery arising from near the peripheral site compared to the left subclavian artery. Recurrent nerve injury is one of the most important complications of thyroidectomy and parathyroidectomy, and the neural anatomy must be borne in mind especially at the right side.

Aim: Our purpose was to evaluate the effect of internal iliac ligation as a bleeding control during cesarean hysterectomy for placenta accreta. Methods: We retrospectively reviewed the cases of placenta accreta receiving cesarean hysterectomy during the period of 1987–2006 in the Saitama Medical Center. The clinical outcomes of these patients either receiving or not receiving internal iliac artery ligation were compared in terms of bleeding amount, and length of hospitalization. The bleeding amounts in the variants of placenta accreta managed with internal iliac artery ligation were also analyzed to determine whether the different pathological findings would affect blood loss during cesarean hysterectomy. Results: Among 23 cases, the mean blood loss during the operation and the length of hospitalization after the operation, with or without internal iliac artery ligation (IIAL) were not significantly different. There was no significant difference between the mean blood loss and the pathological findings of cases managed with IIAL. Conclusion: In cases of placenta previa accreta, ligation of the internal iliac artery did not significantly contribute to hemostasis during cesarean hysterectomy.

A rare case of breast cancer associated with von Recklinghausen's neurofibromatosis is reported. This case and review of the literature illustrate the problems of clinical diagnosis.A 66-year-old woman who had undergone sigmoidectomy for sigmoid colon cancer two years previously, was admitted to the hospital because of a left breast skin retraction in October, 1998. The patient had von Recklinghausen's disease (neurofibromatosis type 1). The TNM clinical staging was TlcNOMO. Modified radical mastectomy was performed. The histopathological diagnosis of the breast tumor was invasive ductal carcinoma and the skin tumor was neurofibroma. The pTNM pathological staging was pTlcNlaMO.Among patients similar to our case, almost all were staged higher than T2. This may be because multiple neurofibromas obscure breast mass at palpation, leading to delayed detection of the cancer. Systemic and careful exploration is essential for patients with von Recklinghausen's neurofibromatosis to detect breast cancer at an early stage.

In 1967, A Recomendation of IAEA, concernning Radiation Protection Standard for Radioluminous Timepiece was issued.Accordingly checking method become necessary for control radioactivity which is used for timep ece. After studied about the method of direct measurement, the following have been concluded.I. The method of measurement for Pm-147 radioactive selfluminous Paint.(1) To convert all beta emission to bremsstrahlung, Samples were covered with acryl resin plate, thickness 1mm, (2) Measurement of bremsstrahlung was made by wide end window GM tube. (3mg/cm2, 50mm dia)(3) To eliminate the geometrical effect, the GM tube was set at 10cm far from the source and measurable area was restricted under 60mm diameter.(4) The cpm of samples were compared with cpm of standard Pm-147 radioactive selfluminous paint which was measured by the same method. As the results, the inspection of radioactivity used was able to achieve under the error of 10%.II. The method of measurement for H-3 radioactive selfluminous paint.(1) Total luminousity of H-3 radioactive paint was measured by photomultiplier tube.(2) To eliminate the geometrical effect, the height of PM from source was fixed 25mm and the measurable area was restricted under 25mm diameter.(3) The luminousity of Samples were compared with the standard H-3 radioactive selfluminous paint which was the similar product as samples, and its decay of luminousity was well controled. As the result, the error of this measurement will be about 10%.

The majority of radioactive self-luminous paint produced in Japan uses 147Pm. The characteristics of the radiation from a 147Pm-activated self-luminous plate which had a luminous area of 12×8 cm2 and radioactivity of 12.5 mCi were examined. Bremsstrahlung was produced from the luminous plate absorbing the 220 keV β-particles of 147Pm. The energy of the bremsstrahlung was analyzed with use of both NaI scintillation and Ge solid state detectors: the spectrum obtained showed a peak at around 50 keV and also a small peak due to γ-rays emitted from the 147Pm at 121 keV. Measurements of the bremsstrahlung made with Lauritsen electroscope, film badges, fluoroglass dosimeters and thermoluminescent dosimeters gave estimated exposure rates of at most only 0.5 and 0.3 mR/hr respectively at distances from the plate of 3 and 7 cm.