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A 72-year-old man underwent right hemicolectomy for transverse colon cancer(pT4aN1aM0, Stage ⅢB), after which he received adjuvant chemotherapy(capecitabine plus oxaliplatin[CAPOX])for 6 months. Three years after the first surgery, FDG-PET/CT revealed a tumor in the abdomen. He underwent a tumorectomy and adjuvant chemotherapy(CAPOX plus bevacizumab[BV])performed for 6 months. Two years after a tumorectomy, the CEA level rose again. He was diagnosed peritoneal metastasis again. A central venous(CV)port was implanted for access to the right internal jugular vein, and he received systemic chemotherapy(fluorouracil, Leucovorin, and irinotecan[FOLFIRI]plus BV)as an outpatient. One year after this recurrence, no peritoneal dissemination was detected by CT. Thereafter, total 49 courses of FOLFIRI plus BV were introduced, but chemotherapy was discontinued due to CV port-related infection. Three months later, low back pain appeared and became a diagnosis of spondylodiscitis. He had surgery, but follow-up CT performed 8 years after the first surgery detected multiple liver metastasis. It was considered necessary to take infection control measures during long-term chemotherapy.

In laparoscopic surgery, intraabdominal examination is occasionally difficult due to restriction of operative field and palpation. This is a case report of a jejunal ectopic pancreas which was incidentally found during laparoscopic surgery. A 49-year- old male underwent endoscopic mucosal resection for a rectal polyp which pathologically resulted in 5,000 μm invasion in submucosa and lymphatic invasion. Laparoscopic low anterior resection was planned for the patient as an additional treatment. During the surgery, irregular shaped tumor-like lesion was incidentally found in jejunum which was located 30 cm distal side from the ligament of Treitz. Partial resection of jejunum was also performed for pathological diagnosis. Resected jejunal lesion was pathologically diagnosed as an ectopic pancreas of Heinrich classification type Ⅰ. Ectopic pancreas is defined as pancreatic tissue which is discontinuous to pancreas, asymptomatic in most cases, but some reported cases of pancreatitis, forming fistula or cancerous change. Reporting with some literature review.

Case 1: A male in his 60s underwent a right transperitoneal laparoscopic partial nephrectomy procedure for a right renal tumor. Rupture of a renal cyst located close to the tumor occurred intraoperatively. The histopathological diagnosis was clear cell renal cell carcinoma (CCRCC), pT1aN0M0, G2, v0, with negative resection margins. At 84 months after surgery, computed tomography (CT) revealed a 10 mm mass in the rectus abdominis muscle at the camera port site used for the partial nephrectomy. An open lumpectomy was then performed and the histopathological diagnosis was CCRCC. One year later, a 40 mm sized mass was detected in the mesentery of the small intestine by CT, which was removed laparoscopically with part of the mesentery and diagnosed as CCRCC. Since that surgery, the patient has been free from recurrence for 8 years., Case 2: A male in his 60s underwent a left retroperitoneal laparoscopic nephrectomy procedure for a left renal tumor. The histopathological diagnosis was CCRCC, pT1aN0M0, G1, v0, with negative resection margins. At 31 months after surgery, CT revealed a 32 mm mass in the retroperitoneal cavity at the right hand port site used for the laparoscopic nephrectomy. The mass was removed with part of the twelfth rib and erector spinae muscles in a lump, and the histopathological diagnosis was CCRCC. Since that surgery, the patient has been free from recurrence for 19 months. For the treatment of solitary port site recurrence of renal cell carcinoma after a laparoscopic radical/partial nephrectomy, we recommend surgical resection for a good prognosis.

Conversion surgery(CS)post chemotherapy for unresectable pancreatic cancer is often reported recently. Although it is still controversial about adaptation of CS, it could possibly be one of the useful choices of treatment for unresectable pancreatic cancer. We report 3 cases of CS which eventually turned out to be pathological complete response.

Immunosuppressive therapy (IST) is the first-line treatment for patients with aplastic anemia (AA) who require blood transfusion when a human leukocyte antigen-matched related donor is unavailable. However, the proportion of patients with AA who are refractory to IST remains high (30%). IST in combination with eltrombopag has been studied in adults, but its efficacy and safety in children have not been established. We present three cases of AA that were initially refractory to IST but improved with additional eltrombopag administration. These patients were successfully managed using this strategy without the use of hematopoietic cell transplantation (HCT). The first patient achieved a complete response within one month after receiving eltrombopag. When the second and third patients were given eltrombopag, they were able to safely reduce the amount of cyclosporin they were given. They avoided blood transfusions, but no measurable response was obtained. The conjunctival icterus was detected and treated using a dose reduction of eltrombopag. Eltrombopag may be effective in children with AA who are refractory to IST, allowing them to avoid blood transfusions and HCT. More cases treated with this strategy are needed to confirm its efficacy and safety for children with AA.

A 12-year-old girl developed Philadelphia chromosome-positive acute myeloid leukemia due to therapy-related myelodysplastic syndrome with monosomy 7 following neuroblastoma treatment. She underwent allogenic bone marrow transplantation from a human leukocyte antigens-DR1 locus-mismatched unrelated donor. However, on day 49 post transplantation, she presented with diarrhea due to gastrointestinal acute graft-versus-host disease (aGVHD), and treatments with prednisolone, budesonide rectal foam, and human mesenchymal stem cells were ineffective. Therefore, vedolizumab was administered from day 100, which improved the symptoms from gut stage 3 to gut stage 1. Consequently, prednisolone was withdrawn without any serious adverse effects. However, the symptoms worsened to gut stage 3 again; therefore, ruxolitinib was administered to achieve complete remission. Vedolizumab exhibits gut-selective action without systemic immunosuppressive activity. Hence, vedolizumab administration before other systemic immunosuppressive agents may be recommended in patients with steroid-refractory gastrointestinal aGVHD. Thus far, only a few reports have been published regarding the administration of vedolizumab and ruxolitinib for steroid-refractory gastrointestinal aGVHD in children. Further evidence should be obtained from patients treated with vedolizumab and ruxolitinib to confirm their effectiveness for pediatric steroid-refractory gastrointestinal aGVHD.

A 72-year-old man was referred to our department with suspected intestinal obstruction. CT showed irregular descending colon wall thickening. Lower endoscopy showed severe descending colon stenosis. Biopsy results were group 1. FDG accumulation of significant SUV was found in the lymph nodes on the left supraclavicular region, left axilla, right mediastinum, posterior part of the right diaphragmatic leg, around the abdominal aorta, and in the liver. The accumulation in the descending colon was not definitely neoplastic. Consequently of left axillary lymph node biopsy, axillary lymph node metastasis of colorectal cancer was suspected, and laparoscopic left semicolon resection was performed. Among the simultaneous distant colorectal cancer metastases, Virchow's and left axillary lymph node metastases are extremely rare(0.1%). We report a case of descending colon cancer with simultaneous Virchow's and left axillary lymph node metastases, with some literature discussion.

We report a 76-year-old woman with meningeal carcinomatosis after gastric cancer surgery. During adjuvant chemotherapy, metastasis to the left axillary and Virchow's lymph node was suspected. A resection biopsy revealed gastric cancer metastasis, and PTX plus RAM therapy was started. Due to RAM adverse events, the treatment was changed to weekly nab- PTX, which was continued for about 6 months. During the 8th course, she was hospitalized due to worsening headache and lightheadedness. Meningeal carcinomatosis was diagnosed by cytology of CSF examination and MRI findings. She died on the 16th day after admission. Meningeal carcinomatosis has a rapidly progressive course with poor prognosis. This case shows nab-PTX may have been able to control the progression.

A 60-year-old man visited our hospital to treat a large cystic mass in the pelvis which had been found by abdominal ultrasonography in December 201X. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a multilocular cyst with a maximum diameter of about 10 cm. CT-guided drainage and sclerotherapy with minocycline reduced the size of tumor by 40%, but symptoms such as difficulty of defecation and urinary frequency appeared a year and a half later due to re-enlargement of the cysts. Laparoscopic resection of the multilocular cysts was performed, and all cysts were removed almost completely using transrectal ultrasonography. The multilocular cyst was positive for NKX3.1 by immunohistochemical staining, and was diagnosed as a giant multilocular prostatic cystadenoma. After surgery, the symptoms such as difficulty of defecation and urinary frequency were relieved promptly. One year after the surgery, the patient was free from recurrence of the disease.

A 61-year-old man was admitted due to alcoholic liver cirrhosis, portal vein thrombosis, hepatocellular carcinoma, and chronic pancreatitis. The patient's portal vein thrombosis improved with anticoagulant therapy. Serum amylase gradually increased, but there was no abdominal pain. The patient was placed under observation. The pain in both ankle and knee joints appeared on nine days after admission. Multiple osteonecrotic lesions of both elbows, both knees and both ankle joints were examined using 99m Tc bone scintigraphic examinations. Magnetic resonance of the right ankle joint showed osteonecrosis. The pain of the right ankle joint improved with a decrease of serum amylase. We report that this is a rare case of multiple osteonecrosis caused by exacerbation of chronic pancreatitis.

An 80-year-old woman was treated with pembrolizumab for non-small cell lung carcinoma. The hepatobiliary enzymes of the patient were elevated before the start of the ninth treatment cycle. The patient was diagnosed with pembrolizumab-induced sclerosing cholangitis based on magnetic resonance cholangiopancreatography and liver biopsy. Liver dysfunction improved with steroid therapy, and hepatobiliary enzymes increased again. The patient was treated with methylprednisolone (1000mg/day for 3 days) followed by oral prednisolone (1mg/kg/day). The patient's hepatobiliary enzymes subsequently decreased, and the oral prednisolone was tapered. Another liver biopsy, which showed a decrease in the hepatic CD8+ T cell count, was performed. Liver dysfunction did not recur although steroid therapy was discontinued after 1 year of administration.

A 66-year-old woman who had been receiving medication for hypertension and hyperlipidemia was referred to our hospital for evaluation of a left adrenal tumor (12×8 mm) that was incidentally detected on computed tomography. Her 24-hour urinary catecholamine level was elevated, and metaiodobenzylguanidine (MIBG) scintigraphy revealed increased uptake in the area around the left adrenal gland, necessitating laparoscopic adrenalectomy for preoperative diagnosis of left adrenal pheochromocytoma. Intraoperatively, we detected a para-aortic tumor behind the adrenal gland, and this lesion was excised together with the adrenal gland. However, manipulation of the para-aortic tumor led to elevation in the blood pressure to 170 mmHg. Histopathological examination of the resected specimens revealed an adrenocortical adenoma and a para-aortic ganglioneuroma, consisting of ganglion cells, nerve fibers, and Schwann cells. The patient's blood pressure normalized immediately postoperatively, and MIBG scintigraphy revealed a negative result. Endocrine active ganglioneuromas are rare, and to our knowledge, currently only 8 cases (including ours) have been reported in the Japanese and English literature.

A 72-year-old man presented with right lower abdominal pain. Abdominal enhanced CT showed a large tumor in the ascending colon. Colonoscopyrevealed a type 2 tumor infiltrating three-quarters of the ascending colon. The biopsyspecimen showed a malignant lymphoma. Thus, the patient underwent ileocecal resection with D3 lymph node dissection. The histopathological diagnosis was primarydiffuse large B-cell lymphoma of the ascending colon. Post-operative PET-CT showed disseminated extra-nodal involvement, Stage Ⅳ(Lugano staging system). He was administered 2 courses of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone chemotherapy. However, the patient was diagnosed with progressive disease. He received several chemotherapies and finallydied 8 months after surgery. We report our present case and literature review.

SQUAMOUS CELL CARCINOMA, prostate carcinoma, The patient was a 67-year-old man who visited our hospital with urge incontinence. His serum prostatic specific antigen level was normal (1.191 ng/mL). Digital rectal examination and magnetic resonance imaging suggested common prostatic carcinoma. A transperineal needle biopsy was performed, and the histological diagnosis was squamous cell carcinoma (SCC). The serum SCC-antigen level was normal, and the patient underwent a radical prostatectomy. Computed tomography 15 months later revealed multiple metastases in the lymph nodes. The patient underwent systemic chemotherapy using fluorouracil (5-FU) and cisplatin (CDDP). After 3 courses of chemotherapy, the multiple lymph node metastases could not be detected.

An 81-year-old man with esophageal cancer had undergone subtotal thoracic esophagectomy and retrosternal reconstruction using a gastric tube. He developed anemia. Gastrointestinal endoscopy was performed, which revealed a tumor in the posterior wall of the lower part of the gastric tube. Biopsy revealed well-differentiated adenocarcinoma. There was no lymph node metastasis and no distal metastasis on CT. We performed partial resection of the stomach tube because of his age and physical condition. We identified the position of the tumor by upper gastrointestinal series CT and gastrointestinal endoscopy. The tumor was located on the posterior wall of the lower part of the gastric tube and the back of the sternum lower border. Marking was performed by gastrointestinal endoscopy before operation. We simulated the operation and decided to perform laparostomy without sternotomy incision. We cut the anterior wall of the gastric tube in front of the tumor using the endoscope. We could then confirm the diagnosis of cancer, and clipped and removed the tumor from the posterior wall. The resected site was sutured with 4-0 absorbable thread. The pathological diagnosis was T1a(M)N0M0, ly0, v0, PM0, DM0, pStage ⅠA.

We report a case of mediastinal lymph node recurrence of esophageal cancer after endoscopic submucosal dissection (ESD). We first administered chemotherapy and then performed esophagectomy. A 78-year-old man underwent ESD for early esophageal cancer at a different hospital in January 2015. H e was diagnosed pathologically with scc, pSM1, pHM1, pVM0, ly0, v0. Additional treatment was not administered because of his age. In June 2017, chest enhanced CT showed swollen mediastinal lymph nodes. This was diagnosed as a recurrence of esophageal cancer, and he presented at our hospital. We first performed chemotherapy for that lesion, because the swollen lymph node was large and may have invaded the surrounding organs. We then performed esophagectomy.

We report a rare case of liver recurrence of gastric cancer 14 years and 3 months after curative gastrectomy. An 81-yearold man underwent total gastrectomy, D2 lymphadenectomy, Roux-en-Y reconstruction, and cholecystectomy for advanced gastric cancer in November 2002. H e was diagnosed pathologically with M, Type 5, 53×42 mm, tub2>tub1, pT4a, ly2, v2, pN1, pPM0, pDM0, M0, pStage ⅢA(JGCA 15th). Postoperative adjuvant therapy was not administered. He was followed up for 5 years after surgery without adjuvant therapy, and he did not exhibit recurrence. In February 2017, he experienced difficulties in swallowing and visited our hospital. Abdominal contrast-enhanced CT showed an 8×5 cm liver tumor in the lateral segment. Part of the tumor protruded to outside of the liver, and the tumor invaded and pushed the jejunum in the Roux limb. We performed liver biopsy and diagnosed him with liver metastasis of recurrent gastric cancer. Late relapse after gastrectomy, especially after 10 years or more, is very rare.

In elderly patients, surgical procesure is decided considering the general condition and surgical invasion. The aim of this study was to clarify the appropriate rage of lymph node dissection for elderly colorectal cancer patients. One hundred forty one colorectal cancer patients aged 75 years or more, who underwent R0 colorectal resection with D2 or D3 lymph node dissection in clinical T3/T4 or clinical N+, were enrolled in this study. The patients whose tumor located in the rectum below the peritoneal reflection(Rb)were excluded. Five-year overall survival(OS)rate and disease specific survival(DSS)rate were 79.1% and 89.4%, respectively. More than 2 preoperative co-morbidities and macroscopic type 3-5 were independent prognostic factors in OS, whereas the rage of lymph node dissection was not risk factor. When comparing the outcomes of D2 and D3 dissections by age, D3 dissection was better tendency in DSS in patients aged under 80, however, D2 dissection was better tendency in patients aged 80 or more. In elderly colorectal cancer patients, there was no difference in prognosis between D2 and D3 dissection, and especially in patients aged 80 years or more, D2 might be sufficient if R0 resection was possible.

Between November 2011 and November 2014, we performed a tunica albuginea incision with tunica vaginalis flap coverage (TAI＋TVFC) on 5 out of 15 patients who underwent surgery for testicular torsion. Of those 15 patients, 7 underwent orchidopexy alone (Group A), 5 underwent TAI＋TVFC (Group B), and 3 underwent an orchidectomy procedure (Group C). All were followed for 1 year and preservation of testicular volume ＞50% on the contralateral side in ultrasound measurements was considered as salvaged. During the follow-up examinations, no testicular atrophy was noted in Group A. In Group B, tension and testis color were immediately improved in all 5 patients after TAI＋TVFC, while blood perfusion was also improved after the operation. Also 3 patients in Group B were considered to be salvaged, while testicular atrophy occurred in 2 after 8 or more hours from onset until surgery. Our results indicated that TAI＋ TVFC is useful for restoring blood flow after surgery for testicular torsion, although the so-called'Golden time'for torsion surgery has a significant impact in such cases.

Purpose: The aim of this study is to evaluate complications of gastrectomy for gastric cancer in patients aged over 85 years., Patients and Methods: Thirteen patients received curative gastrectomy between April 2007 and March 2008. The surgical complications were evaluated using the Clavien-Dindo classification., Results: There were 11 patients aged 85-89 years and 2 who were over 90 years old. The median body mass index was 18. Nine patients underwent distal gastrectomy and 4 underwent total gastrectomy. The median operation time was 142 minutes and the median blood loss was 148 mL. Complications greater than Grade 2 were observed in 5 patients(38.5%). All complications were Grade 2. No surgical mortality was observed., Discussion: The morbidity rate in elderly patients over 85 years of age may be higher than in patients aged 75 and lower. Our results suggest that gastrectomy for patients aged over 85 years is acceptable.

A 58-year-old man with no history of cardiac disease was scheduled for a cerebral aneurysm clipping surgery. Anesthesia was administered with propofol, rocuronium, fentanyl, and remifentanil. At the end of the surgery, extubation was performed 3 min after the administration of 200 mg sugammadex, along with a simultaneous blood-pressure decrease with ST elevation on lead II. Cardiopulmonary resuscitation was per- formed owing to the occurrence of lethal arrhythmia, and the patient was successfully resuscitated. Subsequent emergent coronary angiography revealed normal coronary arteries. Twelve days after the first surgery, a tracheostomy was performed owing to persistent disturbance of consciousness. Anesthesia was administered with sevoflurane, fentanyl, and rocuronium. Sugammadex 200 mg was administered after the insertion of a tracheal cannula, and 5 min later, the blood pressure were gradually decreased with ST depression on lead V5. Finally, cardiopulmonary resuscitation was required, and the patient recovered again. An acetylcholine provocation test performed later showed positive results. We suspect sugammadex to be the cause of coronary vasospasm, because the time courses of the two cardiac arrest episodes after sugammadex administration were very similar. Therefore, clinicians should consider sugammadex as one of the causative agents of cardiac arrest in the operating room.

A 47-year-old woman came to our hospital with left lower abdominal pain in April 2013. An abdominal computed tomographic (CT) examination revealed left hydronephrosis secondary to a 7 cm retroperitoneal cyst near the left common iliac artery and ureter. Serum tumor markers including CEA, CA19-9, and CA125 were negative. Although CT guided needle aspiration of the cyst successfully relieved severe left flank pain, the cyst again increased in size, causing left hydronephrosis, though examinations for fluid tumor markers and cytology were negative. Two months later, the patient underwent open fenestration. The final pathological results demonstrated a mesothelial cyst without malignant findings. Six months after the operation, the patient was doing well without recurrence of symptoms.

We prospectively investigated the safety and efficacy of sunitinib using a modified regimen (2 weeks on/1 week off) in 24 patients (22 males, 2 females ; age range 39-86 years, median 64 years) with metastatic renal cell carcinoma (RCC). During the observation period (3-62 weeks, median 21 weeks), thrombocytopenia was seen in 13 (54.2%), leukopenia in 11 (45.8%), hand-foot syndrome in 5 (20.8%), hypertension in 4 (16.7%), and hypothyroidism in 3 (12.5%) patients, while grade 3 or higher adverse events were found in 4 (16.7%), 1 (4.2%), 1 (4.2%), 2 (8.3%), and 0 patients, respectively. Of the 21 patients evaluable for response, 5 (23. 8%) showed partial response, 8 (38.1%) stable disease, and 8 (38.1%) progressive disease. This new modified regimen may lead to a reduction in adverse events for treatment of patients with metastatic RCC as a substitute for the standard dosing regimen of sunitinib.

We report seven cases of anesthetic management for pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension (CTEPH) during past seven years in our hospital. All the patients were suffering from right heart failure and pulmonary hypertension, and the preoperative mean pulmonary artery pressure (mPAP) was 51.2 +/- 10.2 mmHg, and the pulmonary vascular resistance (PVR) was 894.2 +/- 207.7 dyne x sec(-1) x cm(-5). The surgical operation was performed using the deep hypothermia and circulatory arrest technique. The postoperative mPAP and PVR decreased to 15.5 +/- 7.5 mmHg and 181.6 +/- 84 dyne x sec(-1) x cm(-5), respectively. The patients' symptoms such as shortness of breath, and dyspnea improved and they were discharged without any serious complications.

Objectives: The study was conducted to analyze risk, causes and places of death, and related factors among elderly with and without dementia in a community., Methods: In 1994, the entire elderly population, aged 65 and older in city K were surveyed for their health status. Among them, 201 were diagnosed as suffering from dementia by psychiatric doctors, according to DSM-III-R. Date, causes and places of death were surveyed individually using the vital statistics record of the national government, for ten years from July 1, 1994. The risk of death adjusted for age-classes, was analyzed with the Cox proportional hazard model. Median survival time was calculated using the Kaplan-Maier method, and causes and places of death were analyzed with the chi2 test. Ten factors at the baseline study were examined for each sex, to analyze their relations to death., Results: Among 198 elderly with dementia followed, 170 died (85.9%), while 1696 (33.9%) died in the 5004 non-dementia group. The hazard ratio for dementia/non-dementia was 2.99, and the female/male was 0.56, stratified by age-classes. The rate for death due to CVD in the elderly with dementia was particularly high accounting for 37.1% of the total. With the CVD and undifferentiated types of dementia, the rate was 47.0%. The rate for malignant tumor was low. In the dementia group, mortality at nursing homes was higher and at hospitals/clinics was lower, compared to non-dementia group (p< 0.05). When stratified by age-classes, the factors significantly related to death of the elderly with dementia were severity of dementia (male), type of dementia (female), being bed-ridden and having impaired walking or toileting capabilities (both sexes)., Conclusions: Dementia is a significant death related factor for elderly people, particularly linked to mortality from cerebro-vascular disease. The type and severity of dementia, and walking or toileting activities appear significant to be factors for death of elderly with dementia.

The purpose of this study was to clarify the efficacy of behavioral, stress and immunological evaluation methods in music therapy (MT) with elderly patients with senile dementia. The MT group consisted of 8 elderly patients with dementia and the control group included 8 similarly matched patients. A total of 25 sessions of music therapy were conducted for one hour, twice each week for three months. The Mini-Mental State Exam (MMSE), Gottfries-Brane-Steen Scale (GBS), and Behavioral Pathology in Alzheimer's Disease Rating Scale (Behave-AD) were used to evaluate behavioral changes. Saliva Chromogranin A (Cg A) and Immunoglobulin A (Ig A) were used to assess changes in stress and immunological status, respectively. The results of the study were as follows: 1. In GBS, the mean score of "different symptoms common in dementia" improved significantly after MT. 2. The mean Behave-AD score of "paranoid and delusional ideation" was also significantly improved (p<0.05) after the intervention. 3. In the 25th session, mean saliva Cg A was significantly decreased after MT (p<0.05). IgA was slightly increased prior to intervention. Our results suggest that a combination of behavioral, stress and immunological evaluation methods were valuable for assessing changes that occurred during MT for elderly patients with dementia.

The authors report the successful case of combined therapy using surgery and stereotactic radiosurgery for facial schwannoma in the middle cranial fossa, and discuss the surgical strategy for preservation of facial nerve function. This 27-year-old man presented with a 9-year history of right facial palsy and spasm. CT scan and MR imaging demonstrated a tumor 3 x 3 x 4 cm in size extending to the intradural middle cranial fossa from the petrous bone. After total removal of the intradural tumor, gamma knife radiosurgery was performed for residual tumor in the petrous bone. The marginal dose to the tumor was 12 Gy. Facial spasm disappeared, but facial palsy is unchanged 14 months after the radiosurgery.

While the ultrasonic aspirator (UA) has been widely used as one of the indispensable tools in the field of neurosurgery, a potential risk when using the present UA is injury to the neurovascular structures due to ultrasonic pulverization and constant forceful suction power. We have devised a small variable action suction adapter that can be used in a similar manner to conventional surgical suction tubes. The UA control unit and the handpiece used in this study were the Sonopet UST-2000 and HA-01, respectively (M & M Corporation Tokyo, Japan). The handpiece is slim, with the mid-portion diameter of 13 mm, and it weighs 100 grams. A variable action suction adapter was made from polycarbonate of 15 x 12 x 13 mm in size. The adapter was connected to the suction tube using a Y-shaped connector (Fig. 2 A), which was integrated into the handpiece. The suction power is regulated by variably closing the oval-shaped hole. The adapter can be variously placed on and rotated around the handpiece (Fig. 2 B and C) so that either the right or left hand handles it in a similar fashion to conventional suction tubes. We used this UA in surgery for 8 patients with large brain tumors (meningioma in 5 cases, metastatic brain tumor in 2 cases and glioma in one case). It reduced the risk of suction-related injury to the neurovascular structures and was handled in a similar manner to conventional suction tubes. This adapter ensures the complete control of suction power, which will reduce the risk of suction injury.

Three patients with 3-channeled dissection were operated upon. Images of the dissection were enlargement of the false lumens, compression of the true lumen by enlarged false lumens and visceral arteries of false lumen origin. These prevent the use of cardiopulmonary bypass (CPB) and cause malperfusion of the viscera. Three-channeled dissecion is easy to rupture for its peculiar anatomy and total repair of the thoraco-abdominal aorta is mandatory. Fenestration brings functional recovery of malperfused viscera and enables the patients to be placed on CPB for total repair. Two patients underwent infrarenal and descending aorta fenestration followed by the total repair of thoraco-abdominal aorta successfully. A third patient has been placed on the strict CT follow-up following the infrarenal fenestration.

We report a rare case of a patient manifesting trigeminal neuralgia with the offending artery transfixing the trigeminal nerve. A 67-year-old woman was admitted with typical episodes of trigeminal neuralgia on the right side. Magnetic resonance angiograms revealed the right superior cerebellar artery (SCA) compressing the nerve. Through a retromastoid suboccipital craniotomy on the right side, the right SCA was found to compress the root entry zone (REZ) and then penetrate the portio major of the trigeminal nerve. The nerve was dissected parallel to the axis, 7 mm distally from the transfixing point to facilitate transposition of the SCA. In addition to anchoring the distal portion of the SCA to the tentrium, a prosthesis was interposed between the proximal portion and the pons to secure the decompression. The pain was completely relieved immediately after operation with no neurological deficit. Procedures, such as the longitudinal rhizotomy employed in this case, must be carried out for microcompression, in response to individual anatomical variations in neurovascular structures.

Since paraclinoid aneurysms exhibit considerable variations in the surrounding skull base structures, some skill and experience are considered essential for their microsurgical treatment. On the other hand, intravascular coil embolization would be free from these extravascular factors. Fifty-two aneurysms in 48 patients were treated microsurgically. They were divided into an early series treated before 1995 and a late series treated after 1996. Three aneurysms in 3 patients were treated by intravascular surgery. Preoperative neuroimages, topographic anatomy and surgical results were compared retrospectively. The results in the microsurgical late series were better than those in the early series. While 89% of the patients exhibited excellent results with two patients left with partial visual field defect (7%) and one death (3%) in the early series, the rates in the late series were 95%, 5% and 0%, respectively. Complications and failure in neck clipping were considered to be due to such topography as, 1) C3 aneurysms extending into the anterior clinoid process, 2) multiple aneurysms, 3) ophthalmic artery originating near the dome, 4) atheroma or calcification at the neck, 5) marked medical shift of C2 segment, and 6) tight adhesion of the dural ring to the dome. Coil embolization was successful in two aneurysms, while it was given up in one. We currently propose that intravascular surgery is indicated for cases 1), 4), 5) and 6), and microsurgery would be more advantageous for cases where the neck is broad and where the topography concerning aneurysmal multiplicity or the branching site of the ophthalmic artery is not fully understood by preoperative imaging.

Parent artery occlusion therapy has been used as an alternative for directly untreatable basilar head giant aneurysms. However, some aneurysms still require additional technique to further induce intraaneurysmal stagnation and thrombosis. Using a hydraulic model, half-life of the dye in the model aneurysm was measured as an index of the intraaneurysmal stagnation. The ratio of diameters (D1, D2) of the two posterior communicating arteries (PCom) is defined as diameter ratio (DR) (D1/D2, D1 < D2). Occlusion therapy was simulated in 4 different sites. The most distal site was at the distal BA (Type A) and the most proximal site at the bilateral VA (Type D). The additional technique investigated was bypass placement to the P2 segment of the posterior cerebral artery (PCA) on the smaller PCom side. The half-life was 2.5 +/- 0.2 (mean +/- 2SD) sec before occlusion. Occlusion therapy significantly increased the half-life depending on the occlusion site and DR values with the maximum values of infinite in Type A and 25 sec in Type D. Placement of the bypass decreased the tangential flow volume to the aneurysmal neck, and increased the time markedly in Types A and B, considerably in Type C and slightly in Type D. Parent artery occlusion therapy has been considered less beneficial for patients with a diameter ratio of less than 0.70 since aneurysmal stagnation depends on the diameter ratio. Bypass placement additional to the occlusion therapy is very useful in enhancing the aneurysmal stagnation, which would make those patients indicated for the therapy.

This study evaluated the usefulness of axial source images of magnetic resonance angiography (MRA) on preoperative depiction of surgical topography around posterior communicating artery aneurysms. Twenty patients with posterior communicating artery aneurysms, two ruptured and eighteen unruptured, underwent conventional angiography as well as axial source and projection images obtained by three-dimensional time-of-flight MRA techniques. By comparing the topography based on these angiograms to that confirmed during surgery, we evaluated useful information specific to the source images of MRA. Source images of MRA visualized the posterior communicating artery and the anterior choroidal artery in eighteen cases (90%) and five cases (25%), respectively. The posterior communicating artery was recognized at a higher rate by source images of MRA than by conventional angiography (65%), while the anterior choroidal artery was recognized at a lower rate than by combined angiography (75%). We realized some specific information to the source images of MRA including the topographical relations between the aneurysmal neck and the orifice of the posterior communicating artery, the relations between the aneurysmal dome and the oculomotor nerve and the aneurysmal dome buried into the temporal lobe. The information suggested a satisfactory direction of safe aneurysmal clipping so as not to occlude the posterior communicating artery. It was concluded that the source images of MRA provided additional useful information on surgical topography in 60% of the cases involving posterior communicating artery aneurysms. Although not essential in every case, the information would be beneficial in cases with the aneurysmal dome suspected to be in the temporal lobe or when the surrounding topography can not be clearly understood by angiography.

The transcallosal approach has been widely used for tumors located near the midline of the anterior part of the lateral ventricle, while the transcortical approach is known to provide a wide surgical field in cases of hydrocephalus. However, it is not always easy to choose the appropriate approach in individual cases. The size of the visualized field obtained via the surgical approach is one of the most important factors determining the accessibility of the lesion. In this study, we investigated the difference in the sizes of the fields afforded by these two approaches on the basis of our clinical experience and simulation studies. We surgically treated intraventricular pathology located at the anterior part of the lateral ventricle in five patients with tumors and one with a cyst. Tumors with lateral extension of less than 20 mm were approached via the transcallosal route, and those with more than 20 mm of lateral extension via the transcortical route. In the simulation study, the size of the surgical field was measured through a 3-cm incision of either the cerebral cortex or the corpus callosum under various conditions of ventricular enlargement. Two patients treated via the transcortical approach underwent subtotal removal; one of them had a large bilaterally extending tumor measuring 50 mm in its greatest diameter, and the other had tumor involvement of the fornix. The other three tumors and the cyst were totally resected. While postoperative subcortical hematoma developed in two patients, one each treated via the transcortical and the transcallosal approach, no deficits remained at discharge. Since enucleation procedure was insufficient in patients with hard tumors, a wider surgical field than that in patients with soft tumors was considered necessary. When combined approaches are considered indispensable for a patient with a massive tumor, the transcortical approach may be indicated for priority of order to prevent bilaterally residual tumors. The simulation study disclosed that, in either approach, wider surgical field was obtained as the size of ventricle increased. However, the transcallosal approach afforded a wider field than did the transcortical approach not only in ventricules of normal size but also in mild hydrocephalus with cortical thickness of between 30 and 40 mm. The transcortical approach, on the other hand, produced a much wider field in more advanced hydrocephalus with a thickness of less than 30 mm. A wider surgical field can be obtained by certain tactics such as upward retraction of the incised corpus callosum, moving the cortical window, or oblique or transverse cortical incision.

Aneurysms of the extracranial internal carotid artery are rare but may present as a mass, with ischemic symptoms, or with fatal hemorrhage. We operated on aneurysms in four patients, two males and two females, whose ages ranged from 47 to 57 years. While a lot of etiological factors for the aneurysms have been known to include trauma, vascular dysplasia, infection or surgery using patch graft for carotid endarterectomy, three aneurysms in our series were atherosclerotic and one was spontaneously dissecting. One patient had focal neurological deficit due to embolism, two presented with a growing cervical mass, and one was symptom-free. The aneurysm was located proximal below the angle of the mandible in three patients and was distal above the angle in one. All patients were found able to tolerate test occlusion of the internal carotid before surgery. The aneurysm was trapped in one case (case 1) and was encased by vascular prosthesis in another (case 4). In the other two cases, arterial reconstruction after aneurysmal resection was carried out. In one case out of the two, the aneurysm was located at the level of 2nd cervical vertebral body (case 2). Vertical mandibular osteotomy was performed posteriorly to the exit of the inferior alveolar nerve from the bone, which gave a good view of the upper third of the internal carotid artery and facilitated primary end-to-end anastomosis. In the other case in which there was a dilated distal carotid artery and multiple aneurysms at the basilar and bilateral vertebral arteries (case 3), an extracranial-intracranial (EC-IC) saphenous vein bypass was inserted so as not to increase the hemodynamic stress in the posterior circulation. Except for a transient lower cranial nerve palsy in one case (case 2), there were no incidences of morbidity or death. Magnetic resonance angiography (MRA), Doppler ultrasonography or three-dimensional CT angiography (3-D-CT-A) was found useful in evaluating the change of aneurysmal size. It is essential in surgery for an internal carotid artery aneurysm to choose an appropriate approach characterized by its size and location. It may be important in cases with associated vascular lesions to estimate the potential hemodynamic change that might be induced by aneurysmal surgery.

A 32-year-old man was admitted to our hospital because a cardiac tumor had been pointed out by a physician. CT scans showed a mass lesion with irregular patterns in the right atrium. The patient had the diagnosis of a malignant cardiac or pericardial tumor and an operation was performed. The mass originated from the right atrium included massive coagulated blood, and was resected with the pericardium and the right pleura. The histological diagnosis was malignant hemangioendothelioma. We present this case because only 35 patients with cardiac malignant hemangioendothelioma were reported in Japan.

We experienced a case of primary anterior mediastinal liposarcoma with a heterotopic mass in the pericardium of same histology. Twenty reported cases in Japan were also studied. The patient was a 50-year-old male who visited the hospital because of an abnormal shadow on a chest X-ray. The diagnosis of anterior mediastinal tumor was confirmed by a chest CT. The patient underwent a complete resection of the mediastinal and intrapericardial masses. The histologic diagnosis was a well differentiated liposarcoma of Enzinger's classification. No evidence of recurrence or metastasis was detected in the third postoperative year. Liposarcoma is rarely seen in the mediastinum. Since radiotherapy and chemotherapy are ineffective therapeutic modalities, surgery would be the treatment of choice and complete surgical resection is mandatory.

Obliteration procedures for large high-flow arteriovenous malformations (AVM) were simulated using a compartmental flow model to investigate the role of altered autoregulatory conditions in the development of hyperperfusion and normal perfusion pressure breakthrough (NPPB). Since the arterioles are primarily responsible for autoregulatory function, the role of these structural changes on the development of hyperperfusion was also studied by evaluating the wall thickness (T), internal radius (Ri) and tangential wall stress (sigma). As the AVM flow was decreased during the obliteration procedures, the perfusion pressure (delta P) of the brain tissue surrounding the AVM increased. When the autoregulatory condition was impaired [AR (-)] and the lower limit of the autoregulatory pressure range (LAR) was shifted from 60 mmHg (LAR60) to 40 mm Hg (LAR40), the flow volume in the surrounding brain (Fb) increased markedly, from 67 ml/100g/min to 92 ml/100g/min, with the progress of the obliteration procedures. In these conditions, T/Ri was supposed to be constant and sigma value increased uniformly. In the presence of the autoregulatory mechanism [AR (+)], T/Ri increased against increasing delta P, which resulted in smaller sigma value than that under AR (-) conditions. When the contracted vascular wall yielded on the process of increasing wall stress, delta P and feeder pressure (Pf) decreased to some degree. Concomitantly increase of the sigma value and marked hyperperfusion developed in the brain. The yield of the contracted vascular wall would result in the decrease of a pressure gradient across the arteriole and the reciprocal increase of pressure load on the walls of the capillary and venula, which might lead to NPPB. Since the decrease of delta P or Pf during the progress of the obliterating procedures is considered specific to the appearance of hyperperfusion or NPPB, monitoring these parameters would be useful for its early detection. If the upper limit of the autoregulatory pressure range was assumed to decrease and become the yield point in the brain surrounding high flow AVMs, hyperfusion or NPPB could be considered to develop in the conditions with the autoregulatory pressure range being narrowed and/or shifted to the lower pressure level. Induced systemic hypotension was found to be effective in reducing the magnitude of Fb, delta P, and Pf when induction was appropriately performed in stepwise fashion. T/Ri and sigma were kept in narrow ranges compared to those before induction of hypotension.

A 67-year-old man with aortic regurgitation underwent aortic valve replacement with a 25 mm St. Jude Medical artificial valve. Intraoperative observation found several ruptured fibrous bands between the noncoronary cusp and sino-tubular ridge over the left noncoronary commissure. The same structure was observed at the left cusp, which were not ruptured. The ascending aorta was dilated to about 4 cm in diameter, so was wrapped with an artificial graft to prevent aneurysmal change. Pathological examination revealed chronic valvulitis and degenerative change at the aortic valve, and idiopathic medial degeneration at the aortic wall.

A number of surgical experiences with paraclinoidal carotid artery aneurysms have been reported recently. However, neuroradiological examinations can not sufficiently visualize the topographic relations around the aneurysms due to variations in the size of the anterior clinoid process (ACP) or course of the carotid artery in individual cases. Although three-dimensional computerized tomography angiography (3-D-CT-A) is known to be useful for the surgical management of cerebral aneurysms in common locations, its usefulness for paraclinoidal carotid artery aneurysms has not been investigated. Ten cases involving a total of 13 aneurysms located in the clinoid portion of the carotid artery were included in this study according to Al-Radham's classification (Table). The CT scan used was an X Force system manufactured by Toshiba Electric Co, Japan. Non-ionic, iodinated contrast solution, a total of 2ml/kg, was intravenously infused at a rate of 2ml/sec. Helical scanning was begun 30 seconds after initiating the infusion, 1mm pitch/1.5 second/rotation. 3-D images and original images of axial slices were compared to conventional angiography, DSA and surgical findings. The 3-D images of 3-D-CT-A was able to demonstrate both aneurysms located in the C2 segment of the carotid artery (groups I and II), and five of nine carotid cave aneurysms (group III). The aneurysms located more proximally (group IV or V) could not be visualized.(ABSTRACT TRUNCATED AT 250 WORDS)

Numerous anatomical observations of the transverse sinus (TS) have been reported and features of this sinus, as assessed by cerebral angiography, are referred to in many monographs. However, there are no studies on the hemodynamics in the TS. We recently investigated the TS, using cerebral angiography with cinematographic films. The subjects were 35 patients who underwent angiography of 3 or 4 vessels at our institute, using Seldinger's method. The contrast material was infused manually. Cinematography permitted observation of the size of the bilateral TS and the direction of blood flow. Depending on the features of the bilateral TS, the patients could be divided into three groups. Type I (cases where the right TS was dominant) accounted for the highest percentage (54.3%, 19/35). In 11 of these 19 cases, the left TS also showed antegrade blood flow. In 6 of the Type I group, the blood flow through the left TS was in two directions (towards the Torcular Herophili and towards the left sigmoid sinus). In the other two cases rated as Type I, the blood flow through the left TS was in the direction from the Torcular Herophili to the right TS. Fourteen cases (40.0%) were rated as Type II (in which both sinuses were similar in size). In 13 of these 14 cases, blood flow through the bilateral TS was almost symmetrical (Type II-A). In one of the 14 cases, the blood flow through the left TS was in two directions (towards the Torcular Herophili and towards the left sigmoid sinus).

Acute valvular obstruction caused by vegetation is a rare complication infective endocarditis. To our knowledge, only 9 cases and an autopsy case by Roberts have been reported since 1967. A 46-year-old man admitted with a chief complaint of pyrexia for 2 months duration. Within 24 hours of admission, the patient noticed of increased shortness of breath. Physical examination and the chest X-ray confirmed the pulmonary edema. An echocardiogram revealed a huge echogenic mass that was adherent to the mitral leaflet and obstructed the orifice completely. Soon after the patient fell into cardiogenic shock, an emergency mitral valve replacement was undertaken. At operation, multiple verrucae arising from the entire mitral leaflet was seen to occlude the orifice. The vegetation was excised and replaced with a # 25 Omnicarbon prosthesis. Postoperatively, the patient developed multiple organ failure caused by cardiogenic and septic shock which responded well to intensive medical treatment consisting of hemodialysis and continuous arteriovenous hemofiltration. Angiographically, a mycotic aneurysm in the left radial artery was found on the 18th postoperative day. After extirpation of the infective focuses, the postoperative course had stabilized. Mitral obstruction due to infective endocarditis is a fatal disease. Prompt diagnosis with echocardiogram and an emergency surgery should be undertaken to save the patient.

A case of successfully treated traumatic aneurysm of the thoracic aorta with severe major air way compression was reported. A 38-year-old man, who had a history of blunt chest trauma in a traffic accident twenty years ago, complained of asthma-like coughing chest CT scan and angiogram showed a saccular aneurysm of desending aorta compressing the isthmus of the trachea and the esophagus severely. Resection of the aneurysm and prosthetic graft replacement was undertaken successfully with the aid of F-F bypass. The trachea and the esophagus were well decompressed and the patient recovered well with no complaints.

Hemodynamic effects of amrinone and the changes in pulmonary shunt were studied in patients for open heart surgery. Eighteen patients were allocated into two groups (group L, H) on the first day of surgery. Group L consisted of 10 patients who received moderate-dose catecholamine (DOA + DOB < 12 micrograms.kg-1.min-1) and group H consisted of 8 patients who needed high-dose catecholamine (DOA + DOB > or = 12 micrograms.kg-1.min-1) to maintain normal hemodynamics. After baseline measurement, amrinone infusion was started and the dose was increased by every 2 hours (5, 10, 20 micrograms.kg-1.min-1). At dose of 20 micrograms.kg-1.min-1, cardiac index increased significantly in group L but not in group H. SVRI and PVRI decreased by dose related fashion in both groups. Systemic arterial pressure was unaltered in group L while it decreased significantly in group H. PaO2 decreased and pulmonary shunt increased in both groups. These results suggest that inotropic response of amrinone depends on the basal level of myocardial contractility although vasodilative property and the effect on the pulmonary shunt are almost similar in both groups.

We reported a rare case of multiple cavernous angioma accompanied with a convexity meningioma. A 41-year-old female developed generalized convulsion on October 8, 1985. Plain computed tomography (CT) scan revealed a round heterogeneous density mass in the right parietotemporal region, which was homogeneously enhanced. Angiography demonstrated a tumor stain fed by the right angular artery and the posterior branch of the right middle meningeal artery. Total removal of the tumor was performed. Since histological examination disclosed meningothelial cells, whorl formation, polymorphism and necrotic tissue, she received radiation therapy (total 50Gy) under the diagnosis of anaplastic meningioma. On November 10, 1988, she suddenly developed headache, nausea, motor weakness and homonymous hemianopia on the left side. CT scan revealed intracerebral hemorrhage (ICH) near the region where the meningioma used to be. Magnetic resonance image (MRI) demonstrated a high intensity mass at T1-weighted image and mixed intensity mass at T2-weighted image. Furthermore, there were multiple low intensity spotty lesions at the cerebral and cerebellar hemisphere in T1 and T2-weighted image. A few parts of these lesions showed central high intensity cores and perifocal low intensity areas, which were called ring formations or reticulated cores with black rims. The multiple lesions could not be detected by CT scan. ICH was evacuated. Histological examination revealed no specific pathology except necrotic tissue around the hematoma wall. Diagnosis of radiation necrosis was made. On October 25, 1992 she suddenly complained of left hemihypesthesia. CT scan demonstrated two high density spotty areas at the left caudate head and right thalamus. MRI showed these two lesions as reticulated cores with black rims.(ABSTRACT TRUNCATED AT 250 WORDS)

We managed ten cases of EC-IC bypass using a vein graft; six cases with multiple cerebral arterial occlusion and four cases with aneurysm necessitating therapeutic occlusion of the parent artery (Table). Patency of the graft was confirmed in seven cases on long-term follow-up ranging from 7 months to 5 years. Of the ten cases, two died within 7 days after surgery from causes unrelated to the bypass and one was lost in follow-up surgery. Hemorrhagic infarction was observed in two cases, one of which underwent removal of the hematoma. In five cases with cerebral occlusive disease, there were no additional ischemic events and two cases with giant aneurysms showed improvement of visual acuity and extraocular movement. We improved on several surgical techniques for vein graft. We used small hemoclips to occlude branches of the saphenous vein instead of ligating them, which shortens the harvesting time of the saphenous vein. Vessel cannula with a small-sized elegant tip and one-directional valve (DLP, INC., USA) was also used to inflate or deflate vein grafts with saline. It was easily attached to the graft and minimized air entrapment in the lumen. Small clips for microvascular anastomosis (Mizuho INC., Japan) were used to temporarily occlude branches or perforators from the recipient artery. One of the branches of the graft was dissected long enough, through which intraluminal air or thrombus was washed out at the final stage of the surgery. These procedures are useful for shortening occlusion time of the recipient artery and decreasing the risk of embolism.

A 44-year-old female with left to right shunt and persistent left superior vena cava (PLSVC) suspected of unroofed coronary sinus defect with patent right SVC and innominate vein was treated surgically. PLSVC was ligated and coronary sinus ostium was closed with a EPTFE patch. Roof defect of coronary sinus was left open and allowed the coronary venous blood to drain into the left atrium. Patient recovered well and post-operative cardiac catheterization revealed no significant right to left shunt nor desaturation of arterial blood. In the correction of unroofed coronary sinus defect and PLSVC and no other intra-cardiac defect, ligation of PLSVC and closure of coronary sinus ostium was simple and effective, although it was not anatomically corrected.

A 50-year-old male developed gait disturbance and bilateral sensory disturbance in territories below Th 11 level in February, 1990. On February 26, 1990, an intradural tumor was partially removed at Th 11-12 levels, which was histologically diagnosed as glioblastoma multiforme; followed by post-operative radiotherapy (40Gy to the tumor area). CT scan of the brain was unremarkable and he was discharged home as ambulatory in July, 1990. Gait disturbance, occasional headache and vomiting developed in June, 1991. MRI revealed multiple spinal cord tumors at Th 11-12 and L 2-3 levels, as well as multiple intracranial tumors in the cerebellum, cingulate gyrus, and sylvian fissure, all of which were thought to be located in the cerebrospinal fluid (CSF) space. VP shunt was performed for hydrocephalus. MRI taken 2 months after operation demonstrated diffuse subarachnoid dissemination and new spinal cord tumors at C 3-4 and Th 3-10 levels. Although pathology of the intracranial tumors was not confirmed, dissemination from the spinal tumor was strongly suggested by the evidence including the long interval after the spinal cord operation, the location of the multiple tumors in the CSF space, and the simultaneous intraspinal dissemination. Only 31 cases with intracranial dissemination from malignant spinal astrocytoma or glioblastoma have been reported, and, of these, most were located around the brainstem, cerebellum, and other regions bordering the CSF space. In malignant spinal cord tumor, every effort should be made to prevent CSF dissemination at operation or to detect it as early as possible thereafter. MRI was found to be the most effective method for evaluating CSF dissemination.