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Background Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma. Materials and methods We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction. Results Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group. Conclusions Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.

A microbial community structure of granules harvested from an anaerobic sludge blanket reactor treating phenolic wastewater was investigated using fluorescence in situ hybridization (FISH) and clone library construction. Clones of Syntrophorhabdaceae and Cryptanaerobacter were observed to be responsible for phenol degradation. For accurate taxonomic assignment of Cryptanaerobacter clones, phylogenetic analysis using nearly full-length 16S ribosomal RNA (rRNA) gene sequences was necessary. Three oligonucleotide probes were designed to detect the following three taxonomic groups: Syntrophorhabdaceae, Cryptanaerobacter, and Syntrophus. FISH analysis of thin sections of anaerobic granules showed a random distribution of Bacteria and Archaea. However, a well-defined distribution of Syntrophorhabdaceae, Cryptanaerobacter, and Syntrophus was observed. Cryptanaerobacter and Syntrophus were found on the outer layer of the granules and were closely associated with each other, while Syntrophorhabdaceae was located in the deeper part of the granules. Such specific distribution of the bacteria is most likely due to their metabolic association and affinity for the substrate. Phenol degradation in the granular sludge was observed to be carried out in the following way. First, Cryptanaerobacter converts phenol to benzoate, which is then degraded by Syntrophus into acetate. This syntrophic degradation of phenol occurs near the surface of the granule, where the phenol concentration is high. In the deeper part of the granule, where the phenol concentration is lower, Syntrophorhabdaceae degrades phenol into acetate. We observed that Syntrophorhabdaceae is less likely to produce benzoate as an intermediate to feed the neighboring organisms, which contradicts the theories presented by previous studies.

The down-flow hanging sponge (DHS) reactor is advantageous for sewage treatment since it produces an effluent quality that complies with the standards for reuse and there is little excess sludge. A full-scale DHS module was efficiently employed for the treatment of domestic sewage (200 m

The effect of shock-loading on the performance of a full-scale down-flow hanging sponge (DHS), used to treat effluent from an up-flow anaerobic sludge blanket treating municipal sewage, was evaluated. This full-scale DHS reactor comprises a polyurethane sponge that retains the sludge. It has a capacity of 500 m3/day and, at the time of this study, had been operating at a sewage treatment plant in India for more than 1,300 days. The DHS reactor was exposed to shock loadings of organics at double the normal rate for 400 min under summer and winter conditions. The results showed that the DHS reactor maintained stable operation under the organic shock loading and that it returned to a steady state soon after restart, confirming that the reactor was resilient to organic shock loadings.

The down-flow hanging sponge (DHS) process has been rigorously studied as a significant post-treatment of anaerobically pretreated sewage and later for broader applications in industrial wastewater and pre-settled sewage treatment. The DHS has several advantages over conventional wastewater treatment technologies, i.e., simple process control, less workforce requirement, less footprint, low construction, operation, and maintenance costs due to simple design and less mechanical parts. DHS technology requires no external aeration, which saves energy use and minimizes the associated costs. Low excess sludge yield in the DHS process adds to economic efficiency. DHS achieved high organics removal efficiency up to 99% with considerable nutrient and pathogen removals at extremely short HRT. Up-to-date, six DHS configurations have been developed and extensively tested at pilot scale applications under different operational conditions, i.e., HRTs, OLRs, and SRTs. Accordingly, the DHS module has successfully been translated into full-scale demonstration plants in Japan, India, Egypt, and Thailand. This paper comprehensively reviews the mechanism and development history of the DHS system. The process performance for municipal and industrial wastewaters treatment covers a broad range of parameters, i.e., organics, nutrients, pathogens (bacteria, viruses, parasites) has been summarized. The unique feature of sludge reduction efficiency of DHS is comprehensively discussed. Moreover, the process microbiology, energy efficiency, emerging application of DHS for direct sewage treatment, pilot and full-scale experiences in the last 20 years are also reviewed. DHS technology has not yet being fully explored, mainly for nutrients removal, process modelling, optimization of wastewater and air flow configurations in DHS reactor, and biomass growth, which could help for further advancement in the process for better performance and wider applications.

Highlights • Splanchnic venous thrombosis caused by superior mesenteric vein thrombosis is rare. • Delayed diagnosis and/or treatment can result in acute intestinal infarction. • Protein C deficiency is rare. • Insufficient awareness can result in mismanagement of splanchnic venous thrombosis. • Coagulation disorders contribute to acute intestinal infarction of unknown cause., Introduction and importance Splanchnic venous thrombosis (SVT) originating in the superior mesenteric vein (SMV) is rare and may cause acute intestinal infarction (AII). Protein C deficiency (PCD) results in thrombophilia. Presentation of case Acute unexplained SVT originating in the SMV and portal vein was detected in 68-year-old man. Pan-peritonitis and AII were diagnosed and emergency surgery performed. Part of the small intestine was necrotic and partial resection without anastomotic reconstruction was performed. Heparin was administered intravenously continuously from postoperative day (POD) 1. Hereditary, heterozygous, type 1 PCD was diagnosed postoperatively. The anastomosis was reconstructed on POD 16. Warfarin was substituted for heparin on POD 22. No recurrent thrombosis occurred during 2 years of follow-up. Clinical discussion Patients with the rare condition of SVT require prompt diagnosis and treatment and may have underlying disease. PCD can cause SVT even in intact veins and anticoagulation therapy should be administered immediately postoperatively. Misdiagnosis and/or delayed treatment of SVT can result in AII, a life-threatening condition with a high mortality rate. Insufficient clinician awareness can result in serious mismanagement of patients with PCD and SVT; emergency patients with AII caused by unexplained SVT should therefore be further investigated for prothrombotic states and assessment of coagulation–fibrinolysis profiles to clarify the underlying mechanism. Conclusion We here present a thought-provoking emergency case of AII associated with acute SVT caused by underlying PCD that was successfully treated by two-stage surgery and anticoagulation therapy. This case provides a timely reminder for emergency clinicians and gastrointestinal surgeons.

BACKGROUND Advanced gastric cancer (GC) with liver metastasis is often characterized by multiple and bilobular metastases and may also be associated with extrahepatic metastatic lesions. Hence, many physicians consider that radical surgeries are contraindicated for liver metastases from GC (LMGC). According to the 2017 Japanese treatment guideline for GC, a smaller number of liver metastases without unresectable factors may be an indication for liver resection (LR) with curability. The actual 5-year overall survival (OS) rate ranges from 0 to 0.37. AIM To present the institutional indications for LR for LMGC and identify important factors for prognostic outcomes. METHODS In total, 30 patients underwent LR for LMGC during a 14-year period, and we evaluated the clinical, surgical, and oncological findings. In all patients, radical surgery with intentional lymphadenectomy was performed for the primary GC. The median follow-up duration after the initial LR was 33.7 mo, and three patients with no recurrence died of causes unrelated to the LMGC. The OS and recurrence-free survival rates after the initial LR were assessed. RESULTS Seventeen patients had metachronous LMGC. The initial LR achieved curability in 29 patients. Perioperative chemotherapy was introduced in 23 patients. The median greatest LMGC dimension was 30 mm, and the median number of LMGC was two. Twenty-two patients had unilobular LMGC. The 5-year OS and recurrence-free survival rates were 0.48 and 0.28, respectively. The median survival duration and recurrence-free duration after the initial LR were 16.8 and 8.6 mo, respectively. Twenty-one patients developed recurrence after the initial LR. Additional surgeries for recurrence were performed in nine patients, and these surgeries clearly prolonged the patients’ survival. Pathological serosal invasion was an independent predictor of a poor prognostic outcome after the initial LR. Aggressive LR may be indicated for carefully selected patients with LMGC. CONCLUSION Our results of LR for LMGC seem acceptable. Additional surgeries for recurrence after the initial LR might prolong OS. Pathological serosal invasion is important for poor prognostic outcomes.

Background Gallbladder cancer (GBC) is the most common biliary malignancy and has the worst prognosis, but aggressive surgeries [e.g., resection of the extrahepatic bile duct (EHBD), major hepatectomy and lymph node (LN) dissection] may improve long-term survival. GBC may be suspected preoperatively, identified intraoperatively, or discovered incidentally on histopathology. Aim To present our data together with a discussion of the therapeutic strategies for GBC. Methods We retrospectively investigated nineteen GBC patients who underwent surgical treatment. Results Nearly all symptomatic patients had poor outcomes, while suspicious or incidental GBCs at early stages showed excellent outcomes without the need for two-stage surgery. Lymph nodes around the cystic duct were reliable sentinel nodes in suspicious/incidental GBCs. Intentional LN dissection and EHBD resection prevented metastases or recurrence in early-stage GBCs but not in advanced GBCs with metastatic LNs or invasion of the nerve plexus. All patients with positive surgical margins (e.g., the biliary cut surface) showed poor outcomes. Hepatectomies were performed in sixteen patients, nearly all of which were minor hepatectomies. Metastases were observed in the left-sided liver but not in the caudate lobe. We may need to reconsider the indications for major hepatectomy, minimizing its use except when it is required to accomplish negative bile duct margins. Only a few patients received neoadjuvant or adjuvant chemoradiation. There were significant differences in overall and disease-free survival between patients with stages ≤ IIB and ≥ IIIA disease. The median overall survival and disease-free survival were 1.66 and 0.79 years, respectively. Conclusion Outcomes for GBC patients remain unacceptable, and improved therapeutic strategies, including neoadjuvant chemotherapy, optimal surgery and adjuvant chemotherapy, should be considered for patients with advanced GBCs.

Targeted temperature management, or therapeutic hypothermia, is a potent neuroprotective approach after ischemic brain injury. Hypothermia should be induced as soon as possible after the onset of a...

In this case report, we present an adult case of scoliosis following intrathecal baclofen (ITB) therapy. A 56-year-old female with stroke-induced right spastic hemiparesis for seven years underwent implantation of an ITB pump. Satisfactory spasticity control was achieved using 30 µg/day of baclofen; however, she began to complain of lumbar pain in the postoperative year (POY) 1. Scoliosis, which was not recognized preoperatively, was confirmed in POY 2 (Cobb angle of 19 degrees). It further progressed into a walking disturbance in POY 5 (Cobb angle of 28 degrees). Hence, posterior fusion with decompression was planned. Following the removal of the ITB pump, spasticity management was replaced by Botox injection. However, the progression of scoliosis and neurological conditions stabilized after the removal, and decompression surgery was electively performed in POY 6. Scoliosis remained stable during the two-year follow-up period (Cobb angle of 28 degrees). This case demonstrates the potential risk of ITB-induced scoliosis in an adult patient. Careful preoperative investigations and postoperative follow-up are recommended for patients on ITB therapy.

A method named sequence-specific capture of oligonucleotide probes (SCOPE) was developed for quantification of microbial rRNA molecules in a multiplex manner. In this method, a molecular weight cutoff membrane (MWCOM) was used for the separation of fluorescence-labeled oligonucleotide probes hybridized with rRNA from free unhybridized probes. To demonstrate proof of concept, probes targeting bacteria or archaea at different taxonomic levels were prepared and were hybridized with rRNAs. The hybridization stringency was controlled by adjusting reaction temperature and urea concentration in the mixture. Then, the mixture was filtered through the MWCOM. The rRNA and hybridized probes collected on the MWCOM were recovered and quantified using a spectrophotometer and fluorospectrometer, respectively. The method showed high accuracy in detecting specific microbial rRNA in a defined nucleic acid mixture. Furthermore, the method was capable of simultaneous detection and quantification of multiple target rRNAs in a sample with sensitivity up to a single-base mismatch. The SCOPE method was tested and benchmarked against reverse transcription-quantitative PCR (RT-qPCR) for the quantification of Bacteria, Archaea, and some key methanogens in anaerobic sludge samples. It was observed that the SCOPE method produced more reliable and coherent results. Thus, the SCOPE method allows simple and rapid detection and quantification of target microbial rRNAs for environmental microbial population analysis without any need for enzymatic reactions. IMPORTANCE Microorganisms play integral roles in the Earth’s ecosystem. Microbial populations and their activities significantly affect the global nutrient cycles. Quantification of key microorganisms provides important information that is required to understand their roles in the environment. Sequence-based analysis of microbial population is a powerful tool, but it provides information only on relative abundance of microorganisms. Hence, the development of a simpler and quick method for the quantification of microorganisms is necessary. To address the shortcomings of a variety of molecular methods reported so far, we developed a simple, rapid, accurate, and multiplexed microbial rRNA quantification method to evaluate the abundance of specific microbial populations in complex ecosystems. This method demonstrated high specificity, reproducibility, and applicability to such samples. The method is useful for quantitative detection of particular microbial members in the environment.

Patient: Male, 70 Final Diagnosis: Metachronous pancreatic metastasis Symptoms: None Medication: — Clinical Procedure: Surgery Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Pancreatic metastasis from colorectal cancer is rare and can masquerade as primary pancreatic cancer. Case Report: A 70-year-old male was diagnosed with advanced rectal cancer with multiple liver metastases. After neoadjuvant chemotherapy, he underwent radical surgery for the primary tumor and hepatectomy for multiple liver metastases. Adjuvant chemotherapies and additional surgeries were subsequently required for recurrences in the liver, lung, and lymph nodes. A diffuse hypovascular nodule in the pancreatic head and a solitary liver metastasis were detected 2.5 years after the initial surgery and he accordingly underwent further chemotherapy. However, the pancreatic tumor progressed, invading the pancreatic duct and biliary tract. Obstructive jaundice finally prompted discontinuation of chemotherapy and he underwent biliary drainage. His diffuse and hypovascular tumor was clinically and radiographically diagnosed as a primary pancreatic cancer. Pancreatic resection for the pancreatic tumor and hepatectomy for the liver metastasis were performed 4.2 years after the initial surgery, achieving radiographic and surgical curative resection. Pathological examination of the surgical specimen resulted in a definitive diagnosis of metachronous pancreatic metastasis from his primary rectal cancer. Despite further chemotherapy, his general condition worsened; however, he remains alive 5.4 years after the initial surgery, with best supportive care. Conclusions: Pancreatic metastasis originating from rectal cancer can masquerade as primary pancreatic cancer clinically and radiologically. Multimodality treatment is mandatory for metastatic colorectal cancer. Aggressive surgeries for pancreatic metastasis should be considered if curative resection appears possible radiographically and/or intraoperatively.

BACKGROUND Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula. CASE SUMMARY The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL. CONCLUSION CLL has therapeutic potential for postoperative pancreatic fistula.

BACKGROUND Aneurysm of the inferior pancreaticoduodenal artery (IPDA) is rare among visceral artery aneurysms. Aneurysm and/or pancreatitis may have a causal relation with hemosuccus pancreaticus (HP). HP causes an obscure bleeding in the digestive tract, and this rare disease may lead to life-threatening condition. Although interventional radiology is generally employed as the initial treatment for visceral aneurysms, aneurysmic recanalization is a critical problem. CASE REPORT A 58-year-old male was incidentally diagnosed as groove pancreatitis, and his pancreatitis was successfully treated by conservative management. One year later, an IPDA aneurysm was detected in image studies. Gastrointestinal bleeding was objectively observed, and a diagnosis of asymptomatic HP was made. Arterio-pancreatic duct fistula was suspected, but was not identified. Coil embolization was successfully completed. Six months later, he suffered a relapse of HP, and visited our emergency unit. Pseudocystic lesion around metallic coils were confirmed. Subtotal stomach-preserving pancreaticoduodenectomy without any extended resections was performed. Intentional dissections of nerve plexuses and lymph nodes were all waived. Even a pancreatography of the resected specimen did not clarify his arterio-pancreatic duct fistula. He was discharged at postoperative day 10, and smoothly returned to his work. CONCLUSIONS Pancreatic juice-related complications after advanced pancreaticoduodenectomy for malignancies are often intractable. However, simple pancreaticoduodenectomy which omits extended resections and intentional dissections is safe and feasible for benign diseases. After the initial interventional radiology for pancreatic aneurysms, an elective pancreatic surgery should be considered to avoid unwanted recanalization and refractory HP.

The use of untreated sewage in agriculture is gaining attention as a result of rapid urbanization and increased global water scarcity. However, the incidence of waterborne infections among farmers in such areas is increasing due to the exposure of contaminated sewage. The aim of this study was to estimate the risk and health impact related to waterborne infections in farmers using agricultural drainage wastewater (ADW) for irrigation in the West Nile Delta. A total of nine viruses were detected by quantitative PCR and quantitative real-time PCR in ADW samples collected from the Dishody drain, which was found to be the most polluted branch drain in the region through a water pollution survey. The results of quantitative microbial risk assessment and disability-adjusted life year evaluation indicated that ADW of the Dishody drain is not acceptable for irrigation reuse. A water recirculation system including appropriate sewage treatment technology must be quickly installed to reduce microbial risks for farmers in the West Nile Delta.

Case series Patients: Female, 53-year-old • Female, 70-year-old • Female, 53-year-old • Female, 48-year-old • Male, 66-year-old • Female, 43-year-old • Male, 76-year-old Final Diagnosis: Local recurrence Symptoms: Asymptomatic Medication: — Clinical Procedure: Surgical resection Specialty: Surgery Objective: Unusual setting of medical care Background: Advanced malignancies in the lower abdomen easily invade the retroperitoneal and pelvic space and often metastasize to the paraaortic and pelvic lymph nodes (LNs), resulting in paraaortic and/or pelvic tumor (PPT). Case Reports: A total of 7 cases of aggressive malignant PPT resection and orthotopic replacement of the abdominal aorta and/or iliac arteries with synthetic arterial graft (SAG) were experienced during 16 years. We present our experience with aggressive resection of malignant PPTs accompanied by arterial reconstruction with SAG in detail. The primary diseases included 2 cases endometrial cancer and 2 cases of rectal cancer, and 1 case each of ovarian carcinosarcoma, vaginal malignant melanoma, and sigmoid cancer. Surgical procedures are described in detail. Briefly, the abdominal aorta and iliac arteries were anastomosed to the SAG by continuous running suture using unabsorbent polypropylene. Five Y-shaped and 2 I-shaped SAGs were used. This en bloc resection actually provided safe surgical margins, and tumor exposures were not pathologically observed in the cut surfaces. Graphical and surgical curability were obtained in all cases in which aggressive malignant PPT resections were performed. The short-term postoperative course of our patients was uneventful. From a vascular perspective, the SAGs remained patent over the long term after surgery, and long-term oncologic outcomes were satisfactory. Conclusions: To our knowledge, this case series is the first report of aggressive malignant PPT resection accompanied by arterial reconstruction with SAG. This procedure is safe and feasible, shows curative potential, and may play a role in multidisciplinary management of malignant PPTs.

Patient: Male, 70-year-old Final Diagnosis: Liver disease Symptoms: Asymptomatic Medication:— Clinical Procedure: Hepatectomy Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Mucinous cystic neoplasm (MCN) of the liver is a rare hepatic neoplasm: a cystic, mucus-producing tumor. Histopathologic examination reveals ovarian-like stroma. The origin of MCN of the liver is still unknown, although ectopic ovarian-like stroma in the liver has been suggested as a possibility. We document a thought-provoking case of MCN of the liver, and intratumoral fatty tissue may support the opinion that ectopic ovarian-like stroma in the liver is a possible origin for both MCN and ovarian teratoma. Case Report: An expansive 10.5-cm cystic tumor was incidentally detected in a 71-year-old woman. Imaging studies revealed that the tumor was multiloculated, with cyst contents comprising mucus, muddy-looking fluid (inspissated bile), and hematoma. Imaging studies revealed fatty tissue and calcifications in the cyst walls. The diagnosis of MCN of the liver was made, although MCNs have never been reported to include fatty tissue. Extended left lobectomy was performed, and the tumor was curatively removed without any rupture. A multilocular cyst, mucus, calcifications, and fatty tissue were clearly observed on gross inspection. Histopathological examination revealed ovarian-like stroma. Evidence of malignancy was not detected. Her postoperative course was uneventful. To the best of our knowledge, our patient is the first case of MCN of the liver with intratumoral fatty tissue. This case may support the hypothesis that MCN originates from ectopic ovarian-like stroma in the liver. Conclusions: We documented a thought-provoking case of MCN of the liver in detail, and this MCN accompanied with fatty tissue might originate from ectopic ovarian-like stroma.

Introduction and importance The most common liver malignancies are hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma may invade the portal vein (PV). An association between diffuse large B-cell lymphoma (DLBCL) and primary biliary cholangitis (PBC) remains unclear. We herein report a thought-provoking case of a difficult-to-diagnose liver tumor with PV thrombosis in a PBC patient. Presentation of case A 66-year-old woman had PBC, systemic sclerosis, diabetes, and osteoporosis. A solitary liver tumor accompanied by macrovascular thrombosis in the PV was detected incidentally. Based on dynamic imaging findings, we considered the tumor to be intrahepatic cholangiocarcinoma, and right lobectomy with lymphadenectomy was performed. Unexpectedly, pathological assessment made a definitive diagnosis of DLBCL that did not invade the vessels and bile duct. In fluorine-18-fluorodeoxyglucose positron emission tomography, abnormal accumulations were clearly observed in the breast tissue and peritracheal, parasternal, mediastinal, and pericardial lymph nodes. The patient achieved complete remission after systemic chemotherapy, and there has been no recurrence 3 years after surgery. Clinical discussion Primary lymphoma in the liver is rare, and we did not consider our patient's tumor as primary liver lymphoma. Our case actually showed no tumor thrombosis in the PV. Although autoimmune disorders may increase the risk of non-Hodgkin's lymphoma, an association between DLBCL and PBC is still unclear, and we must remember that DLBCL may develop rarely in a PBC patient. Conclusion Our case report provides a timely reminder for clinicians and surgeons in the fields of hepatology and hematology., Highlights • The most frequent liver neoplasms are HCC, ICC, and metastatic tumors. • HCCs often cause portal thrombosis. • Primary liver lymphoma is rare, and generally does not invade the vessels. • An association between diffuse large B-cell lymphoma and PBC remains unclear. • We describe a thought-provoking case of a difficult-to-diagnose liver tumor in PBC.

BACKGROUND Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD. AIM To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD. METHODS We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients’ clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated. RESULTS The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated. CONCLUSION Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

When performing pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein, division of the splenic vein may cause sinistral portal hypertension resulting in gastrointestinal bleeding, splenic congestion, and hypersplenism. To prevent these adverse events, it is important to intentionally decompress the splenic vein. This report is of a 68-year-old woman with stage IA carcinoma of the head of the pancreas who survived for more than six years following tumor resection and pancreaticoduodenectomy and distal splenorenal shunt. A 68-year-old woman was diagnosed with carcinoma of the head of the pancreas that involved the confluence of the superior mesenteric vein, portal vein, and splenic vein. No unresectable cancer sites or distant metastases were detected. Pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein was performed. The superior mesenteric vein and portal vein were anastomosed in the end-to-end fashion, and the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. At 22 months after the initial surgery, the patient underwent partial lung resection for a metachronous lung metastasis. For 6 years after the initial surgery, the venous reconstructions have maintained their patency without any obstruction of splenic venous flow, and the patient has remained in good health without further metastases or recurrences. This case has shown the importance of early diagnosis of carcinoma of the head of the pancreas, as appropriate and timely surgical management can result in good outcome. This patient responded well and remains alive six years following pancreaticoduodenectomy and preservation of the spleen with the use of a distal splenorenal shunt.

Background Bispectral index (BIS) monitoring is a widely used non-invasive method to monitor the depth of anesthesia. However, in the event of surgeries requiring a frontal approach, placement of the electrode may be impossible at the designated area to achieve a proper BIS measurement. Methods We developed an investigational interface device to connect needle-electrodes to BIS sensors. The safety and clinical performance were investigated in patients who underwent surgery. Direct BIS values from a disposable BIS electrode and indirect values via the interface device were simultaneously recorded from the same areas of electrode placement in a single patient. The agreement between the direct and indirect BIS values was statistically analyzed. Results The interface device with a silver electrode demonstrated sufficient electric conduction to transmit electroencephalogram signals. The overall BIS curves were similar to those of direct BIS monitoring. Direct and indirect BIS values from 18 patients were statistically analyzed using a linear mixed model and a significant concordance was confirmed (indirect BIS = 7.0405 + 0.8286 * direct BIS, p Conclusions The interface device provides an opportunity for intraoperative BIS monitoring of patients, whose clinical situation does not permit the placement of conventional adhesive sensors at the standard location.

Need of self-sustaining wastewater treatment plants (WWTPs) has become critical to cope up with dynamics of the environmental regulations and rapid advancements in the contemporary technologies. At present there are limited number of self-sustaining WWTPs around the world. The aim of this chapter is to present state -of- art of Downflow Hanging Sponge (DHS) system which was developed as a post treatment unit of Upflow Anaerobic Sludge Blanket (UASB) from sustainability perspective. DHS system is a non-submerged fixed bed trickling filter (TF) that employs a core technology of polyurethane sponges as a media where the microorganisms thrive and major treatment processes take place. This chapter reviews the introduction of DHS system (UASB+DHS) summarizes the quantitative analysis of environmental, economic and social sustainability using indicators. Furthermore, self-sustaining prospects of DHS system are assessed and discussed by comparing with conventional TF (UASB+TF).

The advanced simulated moving bed (ASMB) chromatography, which is a new operating strategy in the chromatography process, is proposed and a case study of design and process development is presented. The ASMB strategy divides the operation of the conventional simulated moving bed (SMB) carried out in a single step into five substeps. A detailed analysis based on simulation is carried out, which shows improvement in purity and recovery over the conventional SMB process. The model mismatch in the complex operations is resolved by a novel parameter estimation approach, where multiple data sets obtained from pilot plant experiments refine the model parameters. It was demonstrated in a separation case study of glucose and fructose that the proposed model refinement approach using 20 data sets from ASMB pilot plant experiments improves the prediction from the one obtained only through a single-column chromatography experiment. The refined model will be a powerful tool for the design and control of the ASMB process.

Background For left-sided pancreatic ductal adenocarcinoma (PDAC), radical antegrade modular pancreatosplenectomy (RAMPS) is a reasonable surgical approach for tumor-free margin resection and systemic lymph node clearance. In pancreaticoduodenectomy for PDAC, the superior mesenteric artery (SMA)-first approach (or the “artery-first approach”) has become the standard procedure. With improvements in laparoscopic instruments and techniques, some surgeons attempted to apply laparoscopic RAMPS (L-RAMPS) for carefully selected patients with left-sided PDAC. However, owing to several technical difficulties in this procedure, its application remains uncommon. Moreover, the artery-first approach in L-RAMPS has not been reported. Here, we developed the artery-first approach L-RAMPS for left-sided PDAC and have presented the same in this report. Case presentation Between June 2014 and July 2015, 16 patients with left-sided PDAC were referred to our division for pancreatic resection. The following technique was used for performing L-RAMPS on 3 of the 16 patients (19%). Six trocars were placed. After opening the omental bursa, only the middle segment of the pancreas was initially separated from both the left renal vein and the SMA. We termed this procedure as the “artery-first approach using a dome-shaped dorsomedial dissection (3D) technique.” This 3D technique enabled the interruption of the entire arterial supply to the specimen while preserving the venous drainage through the splenic vein for preventing venous congestion. The technique also contributed to the early detection of no tumor infiltration into the SMA and the early determination of posterior dissection plane. After pancreatic neck transection, the splenic artery and vein were divided. Finally, the pancreatic tail and spleen were dissected in a right-to-left direction. All operations were completed without any intraoperative complications. The median blood loss and retrieved lymph node count were 75 mL and 37, respectively, which were superior to those reported by other previous studies on L-RAMPS. All resection margins were free of carcinoma. No severe postoperative complications were observed. Conclusions The artery-first approach L-RAMPS using 3D technique is safe and feasible to perform. The significance of our proposed procedure is minimal blood loss and precise lymphadenectomy. Therefore, this novel technique may become the preferred treatment for left-sided PDAC in selected cases.

The characteristics of sludge retained in a down-flow hanging sponge reactor were investigated to provide a better understanding of the sewage treatment process in the reactor. The organic removal and sulfur oxidation conditions were found to differ between the first layer and the following three layers. It was found that 63% and 59% of the organic matter was removed in the first layer, even though the hydraulic retention time was only 0.2 h. It is thought that the organic removal resulted from aerobic and anaerobic biodegradation on the sponge medium. The sulfate concentration increased 1.5–1.9-fold in the first layer, with almost no subsequent change in the second to fourth layers. It was shown that oxidation of sulfide in the influent was completed in the first layer. The result of the oxygen uptake rate test with an ammonium nitrogen substrate suggested that the ammonium oxidation rate was affected by the condition of dissolved oxygen (DO) or oxidation–reduction potential (ORP).

A down-flow hanging sponge (DHS) reactor has been developed as a cost-effective wastewater treatment system that is adaptable to local conditions in low-income countries. A pilot-scale DHS reactor previously demonstrated stable reduction efficiencies for chemical oxygen demand (COD) and ammonium nitrogen over a year at ambient temperature, but the pathogen reduction efficiency of the DHS reactor has yet to be investigated. In the present study, the reduction efficiency of a pilot-scale DHS reactor fed with municipal wastewater was investigated for 10 types of human pathogenic viruses (norovirus GI, GII and GIV, aichivirus, astrovirus, enterovirus, hepatitis A and E viruses, rotavirus, and sapovirus). DHS influent and effluent were collected weekly or biweekly for 337 days, and concentrations of viral genomes were determined by microfluidic quantitative PCR. Aichivirus, norovirus GI and GII, enterovirus, and sapovirus were frequently detected in DHS influent, and the log10 reduction (LR) of these viruses ranged from 1.5 to 3.7. The LR values for aichivirus and norovirus GII were also calculated using a Bayesian estimation model, and the average LR (±standard deviation) values for aichivirus and norovirus GII were estimated to be 1.4 (±1.5) and 1.8 (±2.5), respectively. Quantitative microbial risk assessment was conducted to calculate a threshold reduction level for norovirus GII that would be required for the use of DHS effluent for agricultural irrigation, and it was found that LRs of 2.6 and 3.7 for norovirus GII in the DHS effluent were required in order to not exceed the tolerable burden of disease at 10-4 and 10-6 disability-adjusted life years loss per person per year, respectively, for 95% of the exposed population during wastewater reuse for irrigation.

Biometrics have been used in person authentication. However, conventional biometrics have a vulnerability to the identity theft, especially in user management systems. In order to prevent the identity theft, the effective way is to authenticate continuously. However, the continuous authentication requires unconscious biometrics. The authors have been studied to use brain waves as the unconscious biometrics. In conventional studies, the authors had used spontaneous brain waves; however, their verification performance was not so high. Thus, the authors propose to use evoked potentials by supersonic sounds, which cannot be perceived by human beings. In this paper, the authors examine the characteristics of evoked potentials by supersonic sounds and confirm that the spectrum in the band is increased at the electrodes on the back of the head. This phenomenon could be used as an individual feature in person verification.