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Supplementary Information from Integrative Transcriptome Analysis Reveals Common Molecular Subclasses of Human Hepatocellular Carcinoma

3-dimensional pelvic models based on magnetic resonance images (MRI) can be used to investigate accuracy and specifics of changing pelvic alignment during pregnancy and after childbirth. Few studies have investigated changes of pelvic alignment during pregnancy and after childbirth using three-dimensional pelvic models. This case report documents the changes of pelvic alignment during late pregnancy and after childbirth using MRI-based three-dimensional (3D) pelvic models. This was a longitudinal observation case report. A woman was imaged with MRI at 28 and 39 gestational weeks, as well as 4 and 72 weeks after childbirth. Greater internal, anterior, and downward rotation of both innominates at week 39 was observed from that at gestation week 28. Decreased internal, anterior, and downward rotation of both innominates at week 4 after child birth was observed compared with that at gestation week 39. We report the first case in Japan of changes of pelvic alignment measured using an MRI-based 3D pelvic alignment model during pregnancy and after child birth. This case suggests that the small changes of pubic area and greater separation of anterior portions of sacroiliac joints. Internal, anterior, and downward rotation of both innominates was observed in a Japanese primipara woman having no pelvic pain.

In a car body, there exist thousands of resistance spot welds, which may induce large deformation during the manufacturing process. Therefore, it is expected that automotive industries will develop a method and a computing system for the fast and simple prediction of its deformation. Although the inherent strain method has been used for the fast prediction of arc welding deformation, it has not been applied to resistance spot welding so far. Additionally, the electrical-thermal-mechanical coupling analysis for the deformation induced by resistance spot welding is complicated and much more time-consuming. Therefore, in this study, a nugget model of the resistance spot weld has been developed, and the inherent strain method is extended for use in the fast prediction of resistance spot welding deformation. In addition, the deformation of a vehicle part with 23 resistance spot welds was efficiently predicted within around 90 min using the inherent strain method, displaying good accuracy compared with the measurement.

Summary Objective Meniscal damage is one of risk factors for the development of knee osteoarthritis (KOA). Medial meniscal extrusion (MME) is associated with the progression of cartilage loss in the medial compartment. The objective of this study was to determine the intra-rater repeatability of our method of three-dimensionally analyzing MME in patients with KOA. Design Eight knees with medial KOA were examined in participants aged between fifty and eighty years old. We created three-dimensional models of the tibia and medial meniscus using a 0.4 Tesla MRI scanner and embedded a local coordinate system into the tibia. Repeatability of measurements of the MME volume and width were tested using intraclass correlation coefficient (ICC). Results The ICC for measuring the MME volume was 0.998 [95% confidence interval, 0.992, 1.000]. Measurement error for the MME volume was 0.5–7.0%. The ICC for measuring the MME width was 0.983 [0.924, 0.996]. Measurement error for the MME width was 0.0–11.4%. There was no correlation between the MME volume and width (r = 0.565, p = 0.145). Conclusions This study concluded that three-dimensional volume and width measurements of the MME by a single rater using MRI images had high repeatability even in the limited image quality. The result of non-significant correlation between the MME width and volume suggests that MME width measured using a low-magnet MRI scanner not considered reliable. Further studies are needed to determine the association between the MME volume and disease progression of KOA.

Background Medial meniscal extrusion (MME) is an important marker of knee osteoarthritis (KOA) progression. The purposes of this study were: 1) to determine whether there are morphological differences between CT- and MRI-derived tibial plateau models; and 2) to determine whether measurement of MME volume and width using an MRI-derived tibial model is as accurate as measurements on a CT-derived tibial model. Methods This was a cross-sectional study that enrolled ten participants with medial KOA (Kellgren-Lawrence grade 1 to 3). Primary outcome was surface difference of the medial tibial plateau between CT- and MRI-derived models. Furthermore, volume and cross-sectional area of the medial tibial plateau were compared between CT- and MRI-derived models. Measurements of MME volume and width were compared between CT- and MRI-derived tibial models. Results Minimal and maximal surface differences of the medial tibial plateau between the CT- and MRI-derived models were − 0.15 [− 0.44, 0.14] mm (mean [95% confidence interval]) and 0.24 [− 0.09, 0.57] mm, respectively. There were no significant differences in volume and cross-sectional area of the medial tibial plateau between CT- and MRI-derived tibial models. The MME volumes measured on CT- and MRI-derived models were 942.6 [597.7, 1287.6] mm3 and 916.2 [557.9, 1274.6] mm3, respectively (p = 0.938). The MME widths measured on CT- and MRI-derived models were 4.2 [1.9, 6.5] mm and 4.5 [2.2, 6.9] mm, respectively (p = 0.967). Conclusions CT- and MRI-derived models of the medial tibial plateau did not show significant morphological differences. Both CT- and MRI-derived tibia can be used as a reference to measure MME in early-to-moderate medial KOA.

Advanced high-strength steel (AHSS) has been widely used for lightweight body-in-white. However, the fatigue strength of welded joints is not improved even employed AHSS. In this research, the advanced post-weld cold working (PWCW) experiment was proposed to improve the fatigue strength of DP980 spot welded joints. X-ray diffraction (XRD) method was employed to measure the welding residual stress. A numerical model was established to analyze the PWCW induced residual stress as the first try. The influence of the diameter of the cylindric tool used in PWCW on the residual stress of welded joints was also discussed in detail. The hardness distribution on weld joint was increased after PWCW, which represented the plastic strain induced work hardening in DP980 steel. The predicted PWCW induced residual stress had a reasonable agreement with XRD measurement. The PWCW introduced a compressive stress in the weld nugget and its heat affected zone with a value of more than -400 MPa at the edge of joined zone. The strengthened material and compressive stress were beneficial to suppress the generation and propagation of fatigue crack, thereby enhance the fatigue strength of welded joints. Besides, the effect of PWCW continuously strengthened with a larger diameter of tool, especially when the tool diameter was larger than 10 mm. The fatigue strength was almost doubled compared with the as-welded condition. The smaller tool provided a critical requirement for precise positioning. The operation of PWCW was also simple enough to realize the automation, which indicated its potential in manufacturing automotive units.

Background Generally, surgeons’ perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. Methods A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200–499, 500–999, and ≥1000). Results The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the “critical view of safety” technique, identification of Rouviere's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Conclusions Even among experts, surgeons’ perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence. This article is protected by copyright. All rights reserved.

Background Total knee arthroplasty (TKA) is commonly performed around the world. Implant designs include fixed-bearing and mobile-bearing. Mobile-bearing design was developed as a rotating platform that allows axial rotation of the insert around the longitudinal axis. This phenomenon may limit full exploitation of the characteristics of the mobile-bearing insert, which may cause wearing and reduce longevity. However, there is limited knowledge on rotational behavior of the polyethylene mobile-bearing insert under weight-bearing conditions. We aimed at determining the rotational motion of each component at full extension and flexed positions during a squatting activity after TKA. Methods This study was a cross-sectional study (level 4) involving patients with severe knee osteoarthritis scheduled to receive TKA. We examined 13 knees of 11 patients after mobile-bearing TKA (NexGen LPS-Flex, Zimmer Inc.) at 10 weeks and 1 year postoperatively. Four identical metallic beads were embedded into the insert. Wide-base squatting was chosen for analyses. Three-dimensional in vivo poses of the prostheses were created using a 3D-to-2D registration technique. During flexion, rotation of the femoral component relative to the insert (FEM/INS) and tibial component (FEM/TIB) as well as insert rotation relative to the tibial component (INS/TIB) were computed. Repeated measure 2-way ANOVA and post hoc test was used. Results In the fully extended position, FEM/INS was significantly smaller than INS/TIB both at 10 weeks (− 0.3° vs. 6.3°, p = .013) and 1 year (− 0.8° vs. 4.9°, p = .011), respectively. During the squatting activity, rotation motions of FEM/TIB, FEM/INS, INS/TIB were 5.7°, 5.9°, and 1.8° at 10 weeks and 6.3°, 5.5°, and 1.6° at 1 year, respectively. Rotation motion of FEM/INS was significantly greater than that of INS/TIB at both 10 weeks (p p Conclusions The mobile-bearing insert enhances the compatibility of FEM/INS in extension; the amount of INS/TIB rotation is significantly smaller than that of FEM/INS during a squatting activity. This information will inform surgeons to take caution to perform TKA with a fixed insert in which 6.3° of rotational offset would be added to the rotational alignment at FEM/INS at full extension. Trial registration UMIN-CTR, UMIN000024196. Retrospectively registered on 9 September 2016.

Background We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. Methods Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0–6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level. Results Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. ‘Diffuse scarring in the Calot's triangle area’ in the ‘Factors related to inflammation of the gallbladder’ category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. Conclusions A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

Ursodeoxycholic acid (UDCA) is often used to treat cholesterol gallstones. UDCA makes cholesterol stones soluble, thereby improving biliary emptying. Conversely, however, UDCA can also form stones via an unknown mechanism, as shown in a few previous reports of cholangitis caused by the formation of UDCA stones in the common bile duct (CBD). We herein report four cases of recurrent cholangitis resulting from UDCA stones. The withdrawal of UDCA administration was highly effective in these patients. The details of these four cases suggest that clinicians must rethink the indications for UDCA treatment in cases in which cholangitis caused by CBD stones frequently recurs over a short period of time.

Background: Frontal plane knee kinematics are more likely associated with the development or progression of knee osteoarthritis. However, detailed frontal plane knee kinematics remain unclear. Previous studies examined movement during gait, squatting or stair stepping which allowed compensatory motion. However, biomechanical parameters in gait analyses can be modified. Therefore, we analyzed movement during stationary stepping activity while holding a handrail. The purpose was to determine: 1) detailed 6-degrees-of-freedom kinematics during stationary stepping activity in subjects with severe knee osteoarthritis; and 2) the association between unloading and black-loading phases. Methods: Twenty-four patients (32 knees) with severe medial knee osteoarthritis awaiting total knee arthroplasty were enrolled in this study. Knee kinematics was analyzed using a 3D-to-2D registration technique. Results: Knee adduction motion and tibial lateral translation increased from the unloading to weight-loading phase (P=0.027, P

1症例目は30歳の女性で，平成17年，膵尾部粘液嚢胞腺腫に対する膵体尾部切除術後に，腹部CTにて膵切離面に胃を圧排する限局した液体貯留を認めた．2症例目は58歳の男性で，平成20年，膵体尾部癌に対する膵体尾部切除術後に，腹部CTで胃背側の膵切離部周囲に多量の液貯留を認めた．いずれも術後膵液瘻と診断し，内視鏡的経胃ドレナージ術を行った．ドレナージチューブを留置し，胃と内瘻化し，液貯留は縮小した．チューブは内視鏡的に抜去したが，その後，同所に液体の再貯留は認めていない．内視鏡的経胃ドレナージは仮性膵嚢胞の治療法として有効であるとの報告が多い．仮性膵嚢胞にかぎらず，胃に隣接する病変であれば，本症例のように術後膵液瘻に対しても有効な治療法として考えられた．

症例は68歳の女性で，C型慢性肝炎の経過観察中に腹部超音波検査で肝腫瘍を指摘された．US上腫瘍は肝S7に，辺縁に高エコー帯を伴う17 mm大の境界明瞭な低エコー結節として描出された．内部には5 mm大の無エコー域を伴っていた．造影CTで病変はドーナッツ状にenhanceされ，門脈相では低吸収域を示した．術前の大腸内視鏡検査で小さなS状結腸癌が発見されたが，画像は肝細胞癌・転移性肝癌のいずれにも典型的ではなく，鑑別診断に腐心した．切除の結果，腫瘍は中心部に壊死を伴う，境界明瞭な白色調の結節で，組織学的には紡錘型細胞により構成され，肉腫様肝細胞癌と判定した．腫瘍は薄い被膜を伴い，高分化型肝細胞癌が辺縁を輪状に取り囲んでいた．本例はTAEなどの前治療もなく，臨床症状を欠き，肉腫様肝癌としては極めて小さい．肉腫様肝癌の自然史を考えるうえで示唆に富む症例と考えられたので報告を行った．

症例は47歳の男性で, 人間ドックにて肝内腫瘍性病変の増大を指摘され精査目的にて消化器内科へ入院となった. 腹部超音波検査上, 肝右葉下縁に径36mm大の腫瘍を認めた. 腹部造影CTでは動脈優位相で濃染する肝外性の腫瘍性病変が認められ, 腹腔内腫瘍の診断で手術目的にて外科転科となった. 腹腔鏡下に腫瘍切除術を施行した. 術中所見では腫瘍は右腹壁から腹腔内に突出する径3cm大の腫瘍で, 流入血管をLCSで処理し, 腹腔鏡下にて腫瘍を切除した. 切除標本は3.6cm大, 白色充実性腫瘤であった. 病理組織学的検査所見では紡錘形細胞がpattern less patternをとって増生し, 免疫組織学的染色ではCD34 (+), MIC-2 (+), bcl-2 (+), S-100 (-), SMA (-), EMA (-) を示し, 腹壁原発の孤立性線維性腫瘍と診断した. 腹膜由来の孤立性線維性腫瘍は胸壁原発に比べてまれである. 本例は本邦報告例中最小であり, 腹腔鏡下に切除した初例と考えられた.

Background Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform. Results One patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013. Conclusions Our new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD. Trial registration ISRCTN16761283. Registered 16 January 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12893-015-0061-x) contains supplementary material, which is available to authorized users.

Molar sites of the mandible can provide larger quantities of autogenous bone than other intraoral sites. We clinically investigated the bone harvest procedure from the mandibular molar region. The subjects were 21 patients (28 regions) who underwent veneer grafting, onlay grafting, sinus lifting, or combinations of these procedures. The fragments were harvested from cortical bone in the mandibular body, and their mean size was 14.6×22.4 (range of minor axis 10-25, range of major axis 10-40) mm on each side. The fragments were used inblock or particulate form, and the platelet rich plasma was used to promote bone proliferation and avoid complications. As for the results of bone augmentation, we could obtain adequate bone volume for the placement of fixtures in all patients. The mean extent of augmentation was equivalent to 3.24 (range 1-8) teeth, and the mean number of implants placed was 2.81 (range 1-7) fixtures. Two cases of mental nerve paresthesia and 1 case of boneexposure occurred as postoperative complications. In addition, bone blocks cracked in 2 patients at the time of fixture placement. However, the outcome of all cases of implant treatment was uneventful. This preliminary modified technique for harvesting bone from the ramus was useful for bone augmentation in patients undergoing implant treatment.

症例は77歳の男性で, 胸部放射線療法や間質性肺炎の既往はない. 2004年8月胃癌腹膜播種転移のためPaclitaxel(以下, PXLと略記)による化学療法を施行した. 治療中, 呼吸苦を生じ, 胸部CTで両側に網状陰影を認めPXLによる間質性肺炎と診断した. ステロイドパルス療法, 人工呼吸管理を行って, 一時改善傾向を認めたが全身状態が悪化し永眠された. 癌化学療法としてのPXLによる間質性肺炎は14例の報告があり, うち本症例を含めて5 例の死亡例があった. 明らかな予後因子はなかったが本症例においてはKL-6が予後の指標として有効であった.PXLの投与を行う際には定期的な観察が必要である. さらに, つねに間質性肺炎の可能性を疑い, 発症した際は, ただちに投与を中止し治療を開始しなければならない.

胆管拡張を伴う膵胆管合流異常症に合併した胆嚢上皮内癌の1例を経験した.術前の画像検査では指摘困難な病変であり,胆嚢癌の高危険群における予防的切除の必要性および切除検体の詳細な検索の重要性を考える上で示唆に富む症例と考えられたので報告する. 症例は53歳女性で胃癌の手術目的で入院した.術前の腹部エコーで総胆管拡張を指摘され, ERCPで膵胆管合流異常症(戸谷分類Ia型)と診断された.幽門側胃切除術に胆嚢および胆管切除肝管十二指腸吻合術を併施した.切除胆嚢粘膜は全体に過形成性で体底部に中～高度の異形成を認めた.この異形成の一部に上皮内癌を認めた.免疫組織学的には上皮内癌と異形成に相当する部位の一部でp53が陽性であった.

大動脈弓部への浸潤と診断された食道癌患者に対し食道大動脈瘻の危険性が高いと判断し,大動脈ステントを予防的に留置した.症例は70歳,男性.嚥下困難を主訴に入院した.化学放射線療法による治療中に大動脈浸潤と診断されたためステントを留置した.ステントは高いflexibiltyを持つMatsui-Kitamuraステント(MKステント)®を使用した.その後食道縦隔瘻からの肺炎が重篤となり死への転機をとった.病理解剖で食道大動脈瘻を認めたが,大動脈ステントで完全にカバーされており出血はなかった.大動脈浸潤食道癌に対する予防的ステント留置を試みて有効であった1例を経験したので報告する.

出血性胆嚢炎はまれな疾患である. 抗凝固療法中に胆嚢内出血を発症し, 頸部嵌頓結石のため診断に難渋し, 特異な画像所見を呈した1例を経験した. 症例は69歳の女性. 主訴は上腹部痛. 大動脈弁置換術後の抗凝固療法中であった. 来院時, 貧血と肝機能障害があり, 超音波検査では胆石を認めるのみであった. 貧血が進行したためCT と超音波検査を再度行い, 胆嚢の著明な腫大と壁肥厚, 頸部嵌頓結石を認めた. 胆嚢内容は超音波検査やMRIで2層に分かれ水平面を形成していた. 胆石の頸部嵌頓と胆嚢内出血を伴う胆嚢炎と診断し開腹胆嚢摘出術を施行した. 摘出胆嚢には悪性所見を認めず, 出血性胆嚢炎と診断した. 抗凝固療法中の出血性胆嚢炎は本邦では6例の報告しかなく, 胆石発作を原因とした症例は本例のみである. 出血性胆嚢炎は画像診断の進歩により予後が改善している.

Diffuse liver hemangiomatosis with giant cavernous hemangioma in adult is extremely rare. A 35 year-old woman presented to hospital with main complaint of epigastric pain and abdominal fullness. An enhanced computed tomography scan revealed a massive liver tumor in right lobe about 150 mm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. She underwent right hepatectomy. Histologically, it was diagnosed as a cavernous hemangioma. And also, hemangiomatous lesions were scattered around the Glisson’s capsule on the back ground liver. These hemangiomatous lesions were not recognized preoperatively. Even if we couldn’t diagnose hemangiomatosis around the main giant hemangioma preoperatively, we need to take enough surgical margins because the giant hemangioma has the potential to have small hemangiomatous lesions around the tumor. We reported right hepatectomy for giant cavernous hemangioma with diffuse hepatic hemangiomatosis without an extrahepatic lesion in an adult.

血友病Bは比較的稀な疾患であるが,わずかな出血が致命的となる危険性があり注意が必要である.今回われわれは血友病B患者に対し,第IX因子を補充し安全に肝切除を施行しえたので報告する.症例は67歳の男性. 1984年血友病Bを指摘.胆嚢総胆管結石症に対し,第IX因子製剤使用下に内視鏡的乳頭切開術,腹腔鏡下胆嚢摘出術を施行した既往がある.今回腹部CTにて肝S6に腫瘤性病変を指摘され入院した.入院時活性化部分トロンボプラスチン時間が42.1秒と延長し,第IX因子活性は18%と低下していた.第IX因子投与量は｛(上昇目標%)×体重/日｝単位として計算し,術当日より7日目まで5,000単位/日,その後2,500単位/日として12日目まで補充を行い,第IX因子活性は術直後に120%まで上昇し,以後も75%以上で推移した.肝部分切除を施行したが異常出血は認められず,またDICの併発もなく,第IX因子製剤の投与量として過不足のないものと判断された.

A 19-year-old woman was admitted to the hospital because of abdominal distension and an intra-abdominal cystic tumor. She had several hemangiomas in the right side of the body and a history of undergo-ing a resection of cervical spinal hemangioma at the age of 13 years old, when she was diagnosed as having Cobb syndrome. On admission, numerous angiomas covering from the right jaw to right thorasic part were seen, and a soft tumor extending to under the umbilicus was palpated. Abdominal ultrasonography, CT scan, and magnetic resonance imaging revealed a multilocular cystic tumor 14cm in diameter adjacent to the right kidney. It was diagnosed as retroperitoneal giant lymphangioma. At operation, a sharply demarcated, yellowish white cystic tumor was present which was successfully removed after communication with retroperitoneal lymphatic vessel under the left renal vein was confirmed. Histopathological diagnosis was lymphangioma. Cobb syndrome consists of a vascular skin nevus associated with an angioma in spinal cord and only about 40 cases were reported in the literature. This case had hemangiomas in other than the same derma-tomes as spinal hemangioma, and the abdominal lymphangioma might be considered as a finding of Cobb syn-drome.

1987年から1998年9月までの原発性肺癌877例のうち, 小腸転移にて手術を施行した4例を経験した. 肺癌の組織型は腺癌2例, 小細胞癌1例, 大細胞癌1例で, 肺癌診断時遠隔転移が認められたのは3例, 認めなかったのは1例であった. 腹部症状は3例が腹痛, 1例が下血を呈し, 肺癌の診断から腹部症状の出現までの期間は平均7.3か月であった. 診断としては腸重積が2例, 穿孔1例, 腸閉塞1例であった. 全例空腸部分切除術を施行した. 術後の生存期間は遠隔転移を認めた3例で平均21日, 認めなかった1例は7.5か月生存した.肺癌小腸転移手術例はまれであるが, 近年増加傾向にある. 腹部症状出現時すでに進行した状態で予後は極めて不良であるが, 姑息的手術を行うことで一時的にも症状の改善が得られ, 全身状態が許されれば, 手術を考慮すべきと思われる.

We report two cases of incisonal hernia at the trocar site after laparoscopic cholecystectomy. A 62-year-old woman, was admitted to the hospital because of a small lump in the periumbilical area which appeared one year after a laparoscopic cholecystectomy. Under a diagnois of incisional hernia. an operation was perfomed, which revealed a fascial defect at the 10mm trocar site of the previous operation. Another patient was a 49-year-old-obese woman. who complained of a symptom complex of intestinal obstruction with an abdominal swelling at the right umbilical area three days after an uneventful laparoscopic cholecystectomy. Abdominal CT revealed an incisional hernia by showing a prolapse of the small intestine under the skin. Operation was perfomed, and a fascial defect was found at the right side of the supraumbilical 10mm trocar site. Few reports of the incisional hernia after laparoscopic cholecystectomy have been reported, but it can occur obese patietns whom suture closure is incomplete. Abdminal CT scan is useful for deagnosis and offers precise diagnosis even if the elevation is minimal in an early stage. It is the most important to suture the fascia of the 10mm trocar site completely.

Nozzle banks for an ejector-chemical oxygen-iodine laser consisting of two-dimensional slit nozzles with a trip-jet mixing system were tested in the cold- and hot-flow operation regimes. Horizontal Pitot scan experiments demonstrated that the mixing ability of the trips is excellent. The Mach number of the mixed flow was approximately 3. The gain measurements were conducted, and the results of measurements revealed that the maximum gain was around 0.6%/cm. The gain cut-off length was more than 200mm. The lasing experiments were also conducted, and the power was about 3kW at the chemical efficiency of about 20%.

直腸早期癌の内視鏡的-外科的治療法選択のポイントは根治性を維持しつつ排便, 排尿, 性機能温存をいかに行うかである.治療法選択には正確な壁深達度診断が最重要であり, より積極的な低侵襲, 縮小手術の選択には脈管侵襲の存在診断が不可欠である.リンパ節転移率は, sm1-4.8%, sm2, 3-19.3%であるが, 脈管侵襲の有無で分けると, sm2, 3は, 脈管侵襲 (-)-0-0%, 脈管侵襲 (+)-26.0%と有意差を認める.直腸切断術を避けるには, P, Pに近いRbの下部直腸の病変は積極的に内視鏡的切除, 局所切除を行い, 壁深達度, 脈管侵襲の有無を知り治療法を厳格, 正確に決定する必要がある.m, sm1はもちろん, sm2, 3であっても脈管侵襲 (-) であれば, リンパ節転移陽性の可能性は極めて低く, 多くは内視鏡的切除, 局所切除が許容でき, 直腸切断術が回避できる.追加, 拡大切除の郭清度は, リンパ節転移例が全例n1 (+) であり, 完全な自律神経機能温存を図る意味で, 上方D2, 側方D1の原則D1で良い.

A retroperitoneal hemangioma is a rare disease. We report on the diagnosis and treatment of a retroperitoneal hemangioma which had uncommonly invaded into both the pancreas and duodenum, thus requiring a pylorus preserving pancreaticoduodenectomy (PpPD). A 36-year-old man presented to our hospital with abdominal pain. An enhanced computed tomography scan without contrast enhancement revealed a 12 cm × 9 cm mass between the pancreas head and right kidney. Given the high rate of malignancy associated with retroperitoneal tumors, surgical resection was performed. Intraoperatively, the tumor was inseparable from both the duodenum and pancreas and PpPD was performed due to the invasive behavior. Although malignancy was suspected, pathological diagnosis identified the tumor as a retroperitoneal cavernous hemangioma for which surgical resection was the proper diagnostic and therapeutic procedure. Reteoperitoneal cavernous hemangioma is unique in that it is typically separated from the surrounding organs. However, clinicians need to be aware of the possibility of a case, such as this, which has invaded into the surrounding organs despite its benign etiology. From this case, we recommend that combined resection of inseparable organs should be performed if the mass has invaded into other tissues due to the hazardous nature of local recurrence. In summary, this report is the first to describe a case of retroperitoneal hemangioma that had uniquely invaded into surrounding organs and was treated with PpPD.

Key Clinical Message We propose that surgical resections of peritoneal metastases arising from hepatocellular carcinoma are an option for selected patients with controlled HCC in the liver, and without metastases in other organs, when the complete removal of such metastases can be achieved, especially in the case of patients with normal liver function.

食道癌切除再建術後長期経過における問題点を探るため非再発症例の検討を行った. 術後他因死症例の検討から食道癌術後の患者には肺炎, 全身衰弱に代表される特徴的リスクが明らかとなった. 再建術式別には明らかな差はなかった. 術後心不全死は術前または術後に放射線治療を受けた患者に有意に高頻度であった. 術後5年以上無再発生存例の5年経過後の平均生存期間は8.35年で同一性年齢構成の一般集団の平均余命16.75年より明らかに短かった. 術後5年以上経過した無再発生存症例のアンケート調査から胆汁逆流を中心とする術後の生活上の問題が明らかとなったが, 胸骨後, 後縦隔の2つの再建経路の間に明らかな優劣は見出せなかった. 多くの長期生存者は術後の生活状況を受け入れてはいるが現在の術式が問題なしとはできない. 食道癌切除再建術においては術後患者の注意深い追跡とともに今後のさらなる術式の工夫が必要である.

This is the first report associating heterotopic pancreas in the gallbladder and elevated pancreatic enzymes in bile.A 60-year-old woman underwent abdominal ultrasonography at a medical check-up, revealing a nodular protrusion at the neck of the gallbladder. It seemed likely to be a lymph node, but we could not exclude the possibility of gallbladder cancer. In order to make a correct diagnosis, laparoscopic cholecystectomy was successfully performed. Pathological examination revealed heterotopic pancreatic tissue in the gallbladder wall. In addition, we detected elevated levels of amylase and lipase in gallbladder bile.Preoperative diagnosis of heterotopic pancreas in the gallbladder is difficult. However, an increase of pancreatic enzymes in gallbladder bile may potentially play an important role in the occurrence of acalculous cholecystitis and biliary cancer. We need more accumulation of cases to know the true significance of this anomaly.

The proper extent of lymph node dissection for esophageal carcinoma at the junctional portion of the cervical and the upper thoracic esophagus was discussed. Thirty-six resected cases were analyzed concerning the extent and the incidence of lymph node metastasis. The most frequent site of positive nodes was found to be the junctional area between the neck and the upper mediastinum at a rate of 77.8%. Most of these were detected along the recurrent laryngeal nerves. Carcinoma whose main portion was located in the cervical esophagus (CeIu) showed no lymph node metastasis in the middle or the lower mediastinum. However, cervical node metastasis was found in the upper region of the neck, where thoracic esophageal carcinomas hardly metastasized. On the other hand, when the main portion was located in the upper thoracic esophagus (IuCe), cervical node metastasis was confined within the lower part of the neck. The involvement of the lymph nodes was recognized not only in the middle mediastinum but also in the abdomen. Based on these clinical data, we conclude as follows. 1) CeIu carcinoma requires wide node clearance in the neck, as in the case of hypopharyngeal or cervical esophageal carcinoma. Upper mediastinal dissection through median sternotomy is neccessary, while middle or lower mediastinal dissection through right thoracotomy is not mandatory. 2) In the case of IuCe carcinoma, limited neck dissection so far as the lower part of the neck, mainly below the level of the omohyoid muscle, may be sufficient. However, right thoracotomy is needed to eliminate possible metastasis in the middle and lower mediastinum. Abdominal node dissection is also essential considering the possible incidence of metastatic nodes in the left gastric area.

Introduction Classically defined cystic duct carcinoma is extremely rare owing to its strict diagnostic criteria, which are not suitable in actual clinical settings. Recently, several new classifications of cystic duct carcinoma were reported, which defined it as a tumor with its center located in the cystic duct. On the other hand, the incidence of cystic duct carcinoma, based on the new classifications, is not rare, but all reported cases are advanced. Presentation of case A 77-year-old man with dilatation of the common bile duct, a stricture at the level of the cystic duct junction, and a filling defect of contrast medium into cystic duct in endoscopic retrograde cholangiopancreatography was diagnosed with cystic duct carcinoma. Radical cholecystectomy with bile duct resection was performed. In the resected specimen, we found that a 2 cm tumor whose center was located in the cystic duct and vertically limited to the mucosal layer. Horizontally, the tumor was superficially spread in the gallbladder, which were also limited to the mucosal layer. Discussion Here we report a first case of early cystic duct carcinoma diagnosed according to a new classification that had spread superficially into the gallbladder. When treating an early cystic duct carcinoma, it is important to note that even localized carcinoma can potentially invade into adjacent organs or metastasize to regional lymph nodes due to the location of cystic duct. Conclusion It is suggested that perform radical resection such as cholecystectomy with gallbladder fossa resection, extrahepatic bile duct resection and regional lymphadenectomy is the treatment of choice.