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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.

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.

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 The incidence of biliary tract stones has widely been reported to be high after gastrectomy. Treatment of biliary tract stones in post-gastrectomy patients was examined retrospectively, particularly minimally invasive therapy with laparoscopic cholecystectomy for gallbladder stones and endoscopic bile duct lithotomy for common bile duct stones. Methods Treatment of 122 post-gastrectomy patients with biliary tract stones was examined retrospectively from 1995 to April 2015. Results Symptomatic biliary tract stones were found in 3.7% of post-gastrectomy patients. The frequency of bile duct stones was higher in post-gastrectomy patients with gallbladder stones (44 %) than in the nongastrectomy patients (11%). Laparoscopic cholecystectomy was carried out in 84% of the patients with gallbladder stones. Endoscopic bile duct lithotomy was feasible in 89% of patients with common bile duct stones. Conclusions Laparoscopic cholecystectomy was feasible for removing gallbladder stones after gastrectomy. Endoscopic bile duct lithotomy followed by laparoscopic cholecystectomy was a good option for patients in whom endoscopic intervention could be performed. On the other hand, choledochoenterostomy could be a good option for patients in whom endoscopic bile duct lithotomy cannot be performed, particularly considering the risk of recurrent bile duct stones.

Background/Purpose Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. Methods A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. Results The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. Conclusions Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

The implication of extremely high preoperative alpha-fetoprotein (AFP) values for the long-term outcomes of hepatectomy for resectable hepatocellular carcinoma (HCC) remains uncertain.A total of 762 hepatectomized HCC patients were divided into 3 groups according to preoperative AFP serum concentrations: 578 patients with AFP100 ng/mL (low [LAP]), 147 patients with AFP 100-4,000 ng/mL (high [HAP]), and 37 patients with AFP ≥4,000 ng/mL (extremely high [EAP]). The clinicopathologic features and prognosis of the EAP group were compared with those of the other 2 groups to investigate their characteristics and whether the choice of hepatectomy was valid.The EAP group had a greater proportion of younger patients and those with hepatitis B compared with the other 2 groups. Large tumor size, poor histologic differentiation, and microscopic vascular invasion were also more common in the EAP group. The recurrence-free and overall survival rates of the EAP group were worse than those of the LAP group (both P.01) but were not greatly different from those of the HAP group (P = .65 and P = .80, respectively). When the analysis was limited to solitary HCC cases, both recurrence-free and overall survival rates of EAP were not significantly different from those of LAP (P = .79 and P = .99, respectively).An extremely high AFP level does not provide additional postoperative prognostic implications beyond those provided by a high AFP level. Hepatectomy should be performed without reservation for cases of HCC associated with an extremely high AFP value.

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.

Small hepatocellular carcinomas (HCC) with poorly differentiated components (PDC) are reportedly at risk of dissemination and needle tract seeding after percutaneous radiofrequency ablation, although it is the preferred treatment for HCC ≤ 2 cm because of the low rate of vascular invasion. On the other hand, the clinical outcomes after hepatectomy for these tumors are still unclear because of their rarity.A total of 233 cases of solitary HCC ≤ 2 cm were retrospectively reviewed and divided into two groups according to the presence of PDC: 199 without PDC (NP-HCCs) and 34 with PDC (P-HCCs). The clinicopathological characteristics and prognosis were compared.A comparison of clinicopathological characteristics showed that the elevation of the tumor markers alpha-fetoprotein (AFP) (20 ng/mL) and des-gamma-carboxyprothrombin (DCP) (40 AU/L) was significantly frequent in P-HCCs. The 3- and 5-year recurrence-free survival rates for P-HCCS were 39 and 29 %, respectively, which were significantly worse than those for NP-HCCs (64 and 50 %, respectively) (p0.01). Initial recurrence of P-HCCs was significantly more frequent, as well as extrahepatic recurrence and advanced recurrence in the early period after the operation. Recurrences with tumor dissemination were observed in 15 % of P-HCCs and 4 % of NP-HCCs (p = 0.03).PDC is present in 15 % of HCC2 cm and should be suspected when the both tumor markers are elevated. Moreover, significantly worse post-hepatectomy outcomes such as early advanced recurrence or recurrence with dissemination should be taken into account if PDC is present even in HCCs ≤ 2 cm.

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.

Hepatocellular carcinoma (HCC) often consists of various differentiation components in a single tumor. However, the categorization of histologic grade in hepatectomy for those tumors has not been standardized. Some studies have determined the differentiation grade of the tumor according to its worst component, whereas others have determined it according to its predominant component. The present study aimed to resolve the controversy about whether the worst component or the dominant component determines the nature of the tumor, especially focusing on the presence of a poorly differentiated component (PDC). In total, 427 hepatectomized patients with solitary HCC were divided into three groups, tumors without a PDC (NP), tumors with a PDC but dominantly consisting of non-PDC as poorly contained (PC), and tumors predominantly consisted of a PDC as poorly dominant (PD). PC was compared with PD and NP. Statistical analysis revealed that large tumors and high alpha-fetoprotein level were significantly more frequent in PC than in NP (P

To date, no reported studies comparing anatomical resection (AR) and nonanatomical resection (NAR) for hepatocellular carcinoma (HCC) have restricted cases by tumor location. Thus, right hepatectomy and left lateral sectionectomy are both analyzed together as AR, whereas limited resection of both peripherally and centrally located liver tumors is categorized as NAR. This categorization may result in inaccurate conclusions in the analyses comparing AR and NAR. We conducted a retrospective comparison between AR (n = 30) and NAR (n = 57) for solitary and small (5 cm or less) HCC limited to the left lateral segment (LLS) to clarify whether AR is superior to NAR for HCC in LLS. The 1-, 3-, and 5-year recurrence-free survival rates were 83.3, 71.3, and 52.9 per cent for the AR group and 82.5, 51.0, and 40.7 per cent for the NAR group, respectively ( P = 0.10). The 3-, 5-, and 7-year overall survival rates were 96.0, 82.8, and 77.9 per cent for the AR group and 84.1, 77.0, and 54.2 per cent for the NAR group, respectively ( P = 0.07). The postoperative complication, recurrence patterns, and secondary treatment types after recurrence were not significantly different between the two groups. The multivariate analysis including the confounders related to background liver function indicated AR to be a significant protective factor against recurrence, although AR did not influence overall survival. AR was superior to NAR in preventing recurrence without increasing postoperative risks among patients with small solitary HCC limited to the LLS, although AR could not improve overall survival.

Aim Hepatectomy for hepatocellular carcinoma (HCC) in patients with primary biliary cirrhosis (PBC) has seldom been reported, and the clinical significance of this procedure remains unclear, although HCC has often been observed in end-stage PBC patients. Methods To understand the characteristics of hepatectomy on HCC in PBC patients, we examined seven cases at our institute, as well as 22 reported hepatectomy cases in the English-language and Japanese published work. Furthermore, to assess the treatment efficacy of hepatectomy for HCC in PBC patients, we compared these patients with viral hepatitis patients who underwent hepatectomies at our institute during the same period. Results In the review of 29 cases, more than 70% of the patients were aged over 65 years, and the mean Mayo risk score was low at 5.17. The resected tumors were mainly solitary (79%), and the median maximum tumor size was 37 mm. Approximately two-thirds of the patients met the Milan criteria. In the comparison between the PBC and viral hepatitis cases, there were no differences in the postoperative prognoses, although the tumor size was greater in the PBC cases. Conclusion Hepatectomy for HCC in selected PBC cases is a feasible and potentially curative treatment option, similar to hepatectomy for HCC in viral hepatitis patients. This procedure is particularly useful for patients with preserved liver function who are not ideal candidates for liver transplantation.

Aim In patients with hepatoviral infection, although a wide resection margin can eradicate the microsatellite lesions around hepatocellular carcinoma (HCC), a large-volume hepatectomy may diminish remaining liver function and become an obstacle for treating recurrent HCC. The optimal width of the resection margin for these patients is still controversial. This study was conducted to investigate the optimal resection margin in hepatectomy for hepatoviral infection patients. Methods We retrospectively investigated the influences of the resection margin status on recurrence patterns and long-term prognosis in a group of 311 HCC patients with hepatoviral infection who had a solitary HCC without perioperative anti-HCC treatment. Results The resection margin status did not statistically influence the postoperative recurrence-free and overall survival rates (3-year recurrence-free survival of 61.0% vs 55.1%, P = 0.33; 5-year overall survival of 74.9% vs 81.5%, P = 0.77 in without a margin vs with a margin, respectively), although resection without a margin increased the local recurrence with marginal significance (P = 0.055). Regarding the width of the resection margin, in 30-mm or smaller HCC, resection margin did not significantly improve the prognosis among hepatoviral infection patients. However, for tumors larger than 30 mm, a resection margin wider than 3 mm showed significant impacts on the prevention of recurrence in spite of the influence of multicentric carcinogenesis. Conclusion The resection margin used for eradication of microsatellite lesions showed differences that were dependent on tumor size in hepatoviral infection patients. Resection margin should be based on not only background liver function but also tumor characteristics.

Purpose: To introduce a simple technique to create a posterior vitreous detachment (PVD) through the posterior precortical vitreous pocket (PPVP) during microincision vitreous surgery using a wide-angle viewing system (WAVS). Methods: This study included 20 eyes of 20 consecutive patients (mean age, 65.6 years; range, 56-76) with a stage 2 or 3 idiopathic macular hole who underwent 25-gauge microincision vitreous surgery using a WAVS and phacoemulsification surgery. A triamcinolone suspension was injected into the vitreous cavity. The triamcinolone facilitated visualization of the posterior wall of the PPVP. Using a vitreous cutter, we suctioned the outer margin of the PPVP. After a resultant small break of the posterior hyaloid membrane developed and enlarged rapidly, a PVD easily expanded at the periphery. Results: Using this technique, we induced a PVD without close proximity to the optic disk and macula. Conclusion: This technique is an easy and safe method for creating a PVD during microincision vitreous surgery using a WAVS.

The patient, a 50-year-old man, had been followed up by a neurologist under the diagnosis of mitochondrial encephalomyopathy. A gallstone detected by abdominal ultrasonography (US) had been present for several years, but localized protrusions of the gallbladder wall were first seen at the fundus in May 1995. Endoscopic US after abdominal US showed several small protruding lesions with maximum diameters of about 7 mm. These lesions had irregular surfaces and low internal echogenicity. An external high echoic layer, which represented the subserosa of the gallbladder, was intact. The lesions were enhanced on CT scanning. No anomalies of the pancreaticobiliary system were detected by endoscopic retrograde cholangiopancreatography. Selective cystic arteriography disclosed slight staining of the body of the gallbladder. Because of the high possibility of gallbladder carcinoma, surgery was carried out. Macroscopy showed several elevated or protruding lesions up to 7 mm in diameter at the fundus of the resected gallbladder. The lesions had rough surfaces and were yellowish in color. Histologic examination showed the lesions to be covered by columnar epithelium, and no cellular dysplasia was detected. Because both pyloric gland-like hyperplasia and smooth-muscle proliferation were observed, the lesions were diagnosed as polypoid myoglandular hyperplasia. We have encountered four other similar cases of this tumor. Accurate diagnosis of these lesions before surgery is sometimes difficult, and the sonographic features of myoglandular hyperplasia have to be recognized in order to distinguish it from early gallbladder cancer.

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

To maintain operative safety, patient selection criteria for single-incision laparoscopic cholecystectomy (SILC) are more stringent than that for traditional laparoscopic cholecystectomy (TLC). No other method could demonstrate the same feasibility and safety as TLC because the patient selection criteria were too restrictive for SILC to compare with TLC. In this study, we conducted a comparative study between our original SILC and TLC for demonstrating similar feasibility and safety among patients who had the same selection criteria as that for TLC. A statistical comparison between 114 patients of SILC and 201 patients of TLC was conducted during the same time period. The preoperative patient characteristics for SILC and TLC showed no statistical difference. In the operative result analysis, a significant disadvantage of SILC was the prolongation of operative time by only 15 minutes. The original SILC was as feasible and safe as TLC and virtually scarless cholecystectomy could be performed without any selection criteria. This was performed using only 2 trocars from an umbilical incision and 2 incisionless extracorporeal retraction devices.

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．

An abdominal abscess caused by spilled stones is a serious complication of laparoscopic cholecystectomy that requires drainage or reoperation to remove the scattered stones. Herein, we report the case of a 50-year-old woman, who was on dialysis for renal failure. She underwent major hepatectomy for a liver abscess caused by stones spilled during laparoscopic cholecystectomy.

Purpose: To evaluate the protective effect of intravitreal bevacizumab (IVB) and sub-Tenon triamcinolone acetonide (TA) against choriocapillaris occlusion induced by photodynamic therapy (PDT). Methods: This prospective, nonrandomized, consecutive study included 80 eyes of 80 patients with polypoidal choroidal vasculopathy who underwent an initial PDT. The posttherapeutic follow-up periods were more than 3 months (mean, 9.3 months). Patients were divided into three groups consecutively: the PDT group included 21 eyes of 21 patients treated with only PDT, the TA group included 32 eyes of 32 patients treated with PDT and a sub-Tenon injection of 20 mg TA, and the IVB group included 27 eyes of 27 patients treated with PDT and an intravitreal injection of 1.25 mg bevacizumab. Indocyanine green angiography (ICGA) was performed before and 3 months after PDT. The degree of choriocapillaris occlusion was assessed in the marginal zone of the PDT area based on the background hypofluorescence seen on ICGA quantified by densitometry (Imagenet). Results: ICGA at 1 and 5 min showed hypofluorescence in the marginal zone in all eyes 3 months after PDT. The hypofluorescence became indistinguishable from the background fluorescence 15 min after treatment in some eyes; however, the relative hypofluorescence persisted in some cases. The rates of fluorescence intensity in the marginal zone compared to those in the untreated area, i.e. the percentage of baseline fluorescence, were 0.60, 0.65 and 0.73 at 1, 5 and 15 min after dye injection in the PDT group, respectively, 0.64, 0.68 and 0.82 in the TA group, and 0.64, 0.73 and 0.90 in the IVB group. The intensity of the fluorescence was significantly (p < 0.05) higher in the TA group at 15 min and in the IVB group at 1, 5 and 15 min compared with the PDT group. Conclusions: IVB and TA reduced choriocapillaris occlusion after PDT. IVB appeared to have a stronger protective effect than TA in this therapeutic regimen.

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．

Mulvihill-Smith syndrome (MSS) is characterized by premature aging, multiple pigmented nevi, decreased facial subcutaneous fat, microcephaly, short stature, mental retardation and recurrent infections, however the adult phenotype of MSS has yet to be delineated. We report a 28-year-old woman with Mulvihill-Smith syndrome, who had a solid pseudopapillary cystic tumor of her pancreas at age 17 years. Her distinctive sleep pattern includes severe insomnia with disappearance of sleep spindles and K-complexes, persisting muscle tone, and loss of slow wave sleep. The clinical and neurophysiological studies are compatible with agrypnia excitata, a sleep disorder attributable to a dysfunction of the thalamo-limbic system. Brain magnetic resonance imaging and single photon emission computed tomography revealed structural and functional deficits in the dorsomedial region of the thalamus and indicated that an alteration in the thalamo-limbic system may underlie the sleep disturbances in MSS. Furthermore, the rapid and severe decline in acquired cognitive function showed the distinct cognitive impairments resembling dementia, including intellectual deficits, memory disorder and executive dysfunction. We posit that an early onset tumor, sleep disorder and cognitive decline are adult manifestations of Mulvihill-Smith syndrome.

To compare the images of choroidal vasculature obtained by laser speckle flowgraphy (LSFG) and indocyanine green angiography (IA), and to evaluate the imaging of choroidal hemodynamics in eyes with polypoidal choroidal vasculopathy (PCV) using LSFG. We performed IA and wide-field LSFG, which measures the index of blood velocity (mean square blur rate; MBR) in 25 eyes with PCV. We constructed an MBR map of the sequential MBR images (600 × 280 pixels) from four or five pulsations during measurement (4.5 s). A grayscale composite map of a still image was obtained by averaging the cumulative sum of the MBR map. We compared the angiographic images of the grayscale composite map to IA results and evaluated the choroidal hemodynamics of 25 eyes with PCV in the MBR map. The choroidal vasculature on the grayscale map had a resolution similar to the IA results. The grayscale map detected branching network vessels in 20 (80%) of the 25 eyes and polypoidal lesions in 11 (44%) eyes. The MBR map showed that the pulsations of the branching network vessels and polypoidal lesions were synchronized with the cardiac rhythm. The fluctuation rates of the PCV lesions during one pulsation ranged from 8.3% to 26.7% (mean, 13.6%) and from 7.3% to 24.6% (mean, 15.9%) for the intact choroid. The MBR map showed the watershed zone and highest signal intensity in the macula. Using an MBR map, wide-field LSFG revealed the pulsating choroidal hemodynamics of the posterior fundus. A grayscale composite map showed the fine choroidal vasculature whose resolution was comparable to that of IA. The branching network vessels of PCV showed that pulsation was synchronized with the choroidal vessels. Wide-field LSFG showed the highest choroidal blood flow in the macular area and the presence of a watershed zone.

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.

The computed tomography (CT) morphology after chemotherapy is reportedly correlated with the histopathologic response to chemotherapy and a better surgical outcome in patients with colorectal liver metastases (CLM). However, the true prognostic advantage of CT morphology remains uncertain. The prognostic advantage of CT morphology was validated in 86 patients who underwent surgical resection for CLM after undergoing a 5-fluorouracil-based chemotherapy regimen with or without bevacizumab. An optimal morphologic response was observed in 18 (22.8 %) patients, and a strong correlation between the CT morphology and tumor viability was confirmed (P

Background: Pancreatic carcinoma is one of the most lethal cancers. Because pancreatic carcinoma is still very difficult to diagnose in its early stage, many of these patients will be considered unsuitable for surgery. If a cytological diagnosis is obtained at initial endoscopic retrograde cholangiopancreatography (ERCP), suitable treatment will be initiated without delay. Methods: To increase the number of exfoliated cells from the pancreatic duct, we devised a new technique, pancreatic duct lavage fluid (PDLF), following bronchoalveolar lavage fluid. The present paper reports the effectiveness of cytological examination using PDLF in the diagnosis of pancreatic carcinoma. We examined 18 pancreatic carcinoma cases. After the endoscopic retrograde pancreatography (ERP), PDLF was collected from a double-lumen catheter inserted into the main pancreatic duct. Saline injected from the lumen for the injection, and PDLF was aspirated from the other lumen for the guidewire at the same time. The cytological examination was performed using PDLF. Results: Exfoliated cells were more frequently found in PDLF from all patients. In 15 cases (83%), cytological examination of PDLF revealed positive cytological results as the diagnosis of pancreatic carcinoma. Conclusion: Cytological examination using PDLF has a high sensitivity for detection of pancreatic carcinoma. The new examination, PDLF, is simple, safe and effective, so we expect PDLF to become widely popular.

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.

Background and study aims: Contact endoscopy is a technique allowing detailed magnified imaging of living epithelium, used extensively to assess tissues of gynecological and laryngeal origan. We used this technique during cholecystectomy to investigate its potential value for staging laparoscopy in gallbladder cancer. Patients and methods: Eight patients with gallbladder cancer, four with mucosal hyperplasia, two with benign polyps and nine with gallstones were evaluated. During surgery, the lens of the contact endoscope (8715AA, 5.5 mm in diameter with a 0° angle) was placed in contact with the serosa of the gallbladder and observations were performed at magnifications of 60 × and 150 ×. Results: Enlarged color images of the subserosal layer of the gallbladder were obtained. In normal mucosa, a fine vascular network with flowing erythrocytes was observed in the subserosal layer. Subserosal fat appeared as tortoiseshell-like markings, shown histologically to be clumps of fat cells surrounded by fine fibrous tissue. A gap between the deep vessels and the superficial vessels in the subserosal fat was also observed. The same findings were detected in gallbladder cancer patients where invasion was limited to the muscular layer. However, in patients with advanced gallbladder cancer, with invasion beyond the muscular layer, both the vessel gap and the fat tissue markings were absent. There was also encasement of the vessels and decreased intravascular flow of erythrocytes. Conclusions: The contact endoscope can be useful in differentiating between early and advanced gallbladder cancer and has some potential for use in staging laparoscopy for gallbladder cancer.

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.

alignant gallbladder polyps typically increase in size much more rapidly than benign gallbladder lesions.1 In this report, we describe a patient with polypoid gallbladder cancer that had unusual ultrasonographic features at its first appearance. The polyp was defined by a highly echoic, thick rim with low internal echogenicity. In addition, a smaller polyp was detected inside the larger lesion. To our knowledge, such findings have not been reported previously. The resected specimen revealed that the outer polyp consisted of a brown capsule that was formed by organized blood clots. The rapid increase in the size of the polyp noted on ultrasonography was caused by hemorrhage from the inner polyp.

我々は頭頸部がん治療において機能回復を最終目標としている。そこで, 確実な原因療法が最重要であるが, 機能温存のために必要最小限の切除を考慮し機能回復に努めている。しかし, 生命医学, 機能回復医学の両面を一人で行うことは一般に困難であるため, 以下のようなチームが必要となる。1) 診断チーム2) 腫瘍治療チーム3) 機能回復チームまた, チームを編成する上で以下の点を考慮している。(1) 一人の指揮者がいること ; 様々な治療が常にこの指揮者にフィードバックされるようにし, 治療体制を見通す。(2) 各々の治療内容の理解。(3) 治療のブラックホールをつくらない。(4) 担当医同士の意思の疎通をよくする。(5) 目の前にいる患者に何ができるかを常に考える。(6) 執刀医を増やし積極的な討論を可能にする。現時点では口腔機能を回復したとは言い難いため, 関連各科が一緒になって取り組むことが不可欠である。また, 心のケアを考えていきたい。

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.

Statement of problem Although 1-piece implants are associated with positive clinical outcomes, including improved implant stability, overall survival rate, and marginal bone levels, a few studies have suggested that 1-piece implants have low success rates. Purpose This prospective multicenter study evaluated the efficacy of 1-piece implants placed in immediate function in private clinic-based and hospital-based settings with a focus on marginal bone level changes and esthetic outcomes over a 3-year follow-up period. Material and methods A total of 93 one-piece implants (29 maxillary, 64 mandibular) were placed in 63 participants (25 men and 38 women) at 1 university hospital and 3 private clinics. The implants were restored with interim crowns immediately after placement. Clinical and radiographic evaluations of marginal bone level, implant stability, periimplant mucosa, and plaque and papilla indices were performed at the time of implantation and after 6, 12, 24, and 36 months. Results The 3-year cumulative implant survival rate was 100%. After implant placement, mean bone levels changed from -0.16 ±1.41 mm at 24 months to 0.40 ±1.46 mm at 36 months. Clinical parameters, including implant stability, periimplant mucosa, and plaque index, remained stable from 3 to 36 months during follow-up. The papilla index score increased over time. Conclusions Within the limitations of this prospective study, marginal bone level was maintained, soft tissue integration was achieved, and a cumulative survival rate of 100% was obtained for 1-piece implants. The present findings indicate that 1-piece implants are an effective treatment option for immediate function situations.

The pancreas and duodenum are uncommon sites for metastasis from renal cell carcinoma. Pancreatic or small intestinal metastases mainly occur when there is widespread nodal and visceral involvement and evidence of metastatic disease elsewhere in the body. We describe herein the case of a 68-year-old man in whom metastases arising from renal cell carcinoma developed concomitantly in the duodenum and pancreas. The patient presented with duodenal bleeding; but as no other metastatic lesions were observed at the time of surgery, total pancreatectomy with duodenetomy was performed. We believe that metastases may easily develop in the duodenum and pancreas owing to the similar tissue characteristics.

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.

Background: Posthepatectomy liver insufficiency is one of the most serious problems associated with a major hepatic resection, especially in the cirrhotic liver, which has less functional reserve than the normal liver. Evaluation of morphologic liver regeneration is important in cirrhotic rats, as well as in the normal liver, and assessment of functional capacity in cirrhosis is clinically important for preventing hepatic insufficiency of the remnant liver after hepatectomy. Methods: We evaluated the functional capacity of the cirrhotic liver induced by carbon tetrachloride in rats and studied the correlation between morphologic and functional restoration of the liver after partial hepatectomy in comparison with healthy rats. Morphologic restoration of the liver after hepatectomy was evaluated on the basis of remnant liver weight, proliferating cell nuclear antigen labeling index, and the DNA content of the regenerating liver. Functional restoration was evaluated by the indocyanine green disappearance rate and serum aminopyrine clearance. Results: Morphologic restoration in cirrhotic rats was delayed in comparison with healthy rats. Although functional capacity in the cirrhotic rats was diminished, functional restoration was advanced after a two-thirds hepatectomy, in comparison with morphologic restoration. Conclusions: Functional restoration in cirrhotic rats after partial hepatectomy is advanced in comparison with morphologic restoration. (Surgery 1999;126:541-7.)

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.