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Peritoneal Surface Oncology Group International(PSOGI)proposed a novel treatment, named comprehensive treatment for peritoneal metastasis(PM)from colorectal cancer(CRC). The present study demonstrated the efficacies of the treatment regarding the peritoneal sectors and organs involved with PM from CRC.Among 365 patients received laparotomy, 278 CRC patients with PM underwent complete cytoreductive surgery(CC-0).After CC-0 resection Grade 3, Grade 4, and Grade 5 postoperative complication were found in 20(7.2%), 26(9.3%), and 6(2.2%). Five- and 10-year survival rate(YSR)of CC-0 resection were 24.5%, and 11.6% with median survival time(MST)of 42.0 months. Regarding the peritoneal cancer index(PCI)of small bowel(SB-PCI), all patients of PCI B3 died of the disease. In contrast, 10-YSR of patients with SB-PCI of 0, 1, and 2 were 26.1%, 19.5%, and 6.2%, respectively. Ten-YSR of patients with the number of involved peritoneal sectors C9 ranged from 6.9% to 29.8%. MST of patients with PM in each peritoneal sector(sector 0 to sector 8)ranged from 26.4 months to 49.2 months, and 10-YSR ranged from 4.2%to 17.2%. Ten-YSR of patients with involvement of rectum, stomach, liver capsule, seminal vesicle, ureter, uterus, or ovary ranged from 0% to 16.9%.From the present data, PM should be removed aggressively to achieve complete cytoreduction, when the patients with PCIC26, involved peritoneal sectorsC9 and SB-PCIC2 are supposed to receive complete cytoreduction of PM.

Treatment failure after complete cytoreduction for appendiceal mucinous carcinoma peritonei (AMCP)has not been fully investigated. The present study was performed to clarify the risk factor for recurrence after complete cytoreduction for AMCP.A total of 400 patients with AMCP who underwent complete cytoreductive surgery combined with perioperative chemotherapy were investigated.Documented recurrence was developed in 135 (33.8%)patients. The 5- and 10-year progression-free survival was 51% and 49%, respectively. By multivariate analysis, histological subtype of peritoneal disease(high-grade AMCP[AMCP-H]and AMCP-H with signet ring cells), serum CA19- 9 level, and PCIB20 were significantly associated with reduced progression-free survival. In contrast, histologic subtype of mucin without epithelial cells(MWEC)showed the lowest risk for recurrence. Eighty-six patients had localized intra-abdominal recurrence, and 42 patients had diffuse peritoneal recurrence. Recurrence was found in the various peritoneal sectors. Eighty-one patients underwent complete cytoreduction for the recurrence, and the overall survival 5-year survival rate after secondary cytoreduction was 49%.Risk factors for recurrence were histologic subtype, PCI cutoff level, and serum CA19-9 levels. Aggressive second attempt of cytoreduction in patients with localized recurrence improved the survival.

The current standard of treatment for malignant peritoneal mesothelioma(MPM)is cytoreductive surgery(CRS)plus perioperative intraperitoneal or systemic chemotherapy(comprehensive treatment), The present study was performed to clarify the prognostic factors of PMP after comprehensive treatment.Among 63 patients with MPM, male and female patients were 34 and 29. CRSwas performed in 47 patients and complete cytoreduction(CC-0) was performed in 14(22%)patients. Mean numbers of resected peritoneal sectors and organs were 5.2(1-13), and 2.9(0- 9), respectively. Hyperthermic intraperitoneal chemoperfusion(HIPEC)was performed in 27 patients. Grade 1/2, Grade 3, and Grade 4 complications were experienced in 5, 6, and 3 patients, respectively. One patient died of sepsis, and the mortality rate was 2.3%. Independent prognostic factors for favorable prognosis were performance of HIPEC, peritoneal cancer index (PCI)score C12, no distant metastasis and histologic epithelial type. Relative risk of no HIPEC, PCI score B13, presence of distant metastasis and non epithelial type were 7.69, 22.1, 3.6 and 3.9, respectively.Risk factors for death after comprehensive treatment were no HIPEC, PCI score B13, and non epithelial type. However, only 11(17%)patients showed PCI score C12. Accordingly, PCI score should be reducedC12 before CRSby neoadjuvant chemotherapy.

To analyze the role of cytoreductive surgery(CRS)plus perioperative chemotherapy on the survival of colorectal cancer(CRC)patients with metachronous peritoneal metastasis(PM). A comprehensive treatment consisting of neoadjuvant chemotherapy plus CRS was performed in 291 CRC patients. Among the 291, 142 and 149 patients had synchronous and metachronous PM, respectively. The results showed no survival difference between the 2 groups. Median survival time(MST)of patients with metachronous PM with complete cytoreduction(CCR-0), small bowel(SB)-PCIC2, PCIC14 and differentiated histologic type ranged from 3.1 to 4.1 years. Five-year survival rates of metachronous group of the CCR-0, SB-PCIC2, PCI C14 and differentiated histologic type ranged from 25.8 to 38.9%. However, the 5-year survival rates of the incomplete cytoreduction(CCR-1), SB-PCIB3, PCIB15 and poorly differentiated type were significantly lower than those of the CCR-0, SB-PCIC2, PCIC14 and differentiated histologic type. Postoperative Grade 3, and Grade 4 morbidity were experienced in 11(5.8%)and 16(10.7%)in metachronous group. Mortalities of metachronous group were 1.3%(2/149). The comprehensive treatment can be performed safely and improves the survival of CRC patients with metachronous PM. After NAC, patients with SB-PCIC2, PCIC14 and differentiated type of histology are candidates for CRS, and CCR-0 resection combined with HIPEC is recommended.

Ovarian growing teratoma syndrome (GTS) is a rare disease characterized by growth of a benign tumor during or after chemotherapy, following the removal of germ cell gonadal cancers. Although benign, GTS tumors grow gradually and may compress surrounding organs. In addition, up to 3% of GTS cases can undergo malignant transformation. It is, therefore, needed to treat GTS. No standardized management protocol has been established to treat GTS; however, surgical resection is likely the only effective treatment because tumors in GTS are resistant to chemotherapy and radiation therapy. However, complete resection with conventional procedures is sometimes difficult when peritoneal metastasis is widespread. We report a rare case of ovarian GTS with widespread peritoneal metastases, which was totally resected by peritonectomy procedures. A 45-year-old Japanese woman was initially diagnosed with an immature teratoma grade 3, which was treated by hysterectomy and bilateral salpingo-oophorectomy. Adjuvant chemotherapy was performed after surgery with bleomycin, etoposide, cisplatin, and other chemotherapies. Due to recurrence of a chemoresistant tumor and normalization of tumor markers, GTS was suspected. She was referred to our institute, and complete cytoreductive surgery was performed using peritonectomy procedures, including parietal peritoneal resection, greater omentectomy, lesser omentectomy, rectosigmoid colectomy, diaphragm dissection, and cholecystectomy. A complete cytoreduction with no visible residual tumor tissue was achieved.

Treatment failure after complete cytoreduction for peritoneal metastasis(PM)from colorectal cancer(CRC)has not been fully investigated. The present study was performed to clarify the risk factors for recurrence after complete cytoreduction for CRC with PM and the role of repeat surgery for recurrence.A total of 205 patients with CRC who underwent complete cytoreductive surgery combined with perioperative chemotherapy were investigated.Recurrence occurred in 149(73%)patients. The 5-year overall and progression-free survival rates were 26%and 7%, respectively. By multivariate analysis, positive cytology, serum CEA level higher than normal range, and small bowel peritoneal cancer index B3 were significantly associated with reduced progression-free survival. Blood-borne recurrence was found in 62 (44%)of 149 patients. Repeat surgery was performed in 44(30%), and complete removal was performed in 28(64%) patients. Long-term survival after repeat surgery was experienced in patients with localized peritoneal recurrence and/or liver recurrence.This study showed that a second attempt at cytoreduction in patients with localized intra-abdominal and liver recurrence is of benefit. Blood-borne recurrence was found in 44% of recurrent patients. The prophylaxis of recurrence should therefore be performed using systemic chemotherapy after CRS plus HIPEC.

In the past, peritoneal surface malignancy (PSM) was considered as a final stage of cancer, and patients were offered the best supportive care. Recently, a new therapeutic alternative approach based on the combination of surgery with chemotherapy was developed. In this curative intent, the macroscopic disease was treated with cytoreductive surgery (CRS) combined with perioperative chemotherapy, including neoadjuvant chemotherapy, hyperthermic intraoperative intraperitoneal chemotherapy, extensive intraoperative peritoneal lavage and early postoperative intraperitoneal chemotherapyThis article reviews the mechanisms of the formation of PSM, quantitative estimation of PSM and residual disease, multimodal treatment, value of laparoscopy, prognostic factors and patients' selection for the multimodal therapy.Recent studies show that CRS plus intraperitoneal chemotherapy applications confer prolonged survival in patients with PSM from colorectal, gastric, ovarian, appendiceal mucinous carcinoma and diffuse malignant peritoneal mesothelioma. The comprehensive treatment is now justified as state-of-the-art for patients with peritoneal metastasis.

Even though management of pseudomyxoma peritonei (PMP) was improved with cytoreductive surgery (CRS) and hyperthermic chemotherapy (HIPEC), several aspects of PMP still need to be optimized, including patient selection for surgery and prognostic factors. We assessed the role of preoperative carcinoembryonic antigen (CEA) levels in PMP patients treated with CRS and HIPEC.A total of 449 PMP patients with documented preoperative CEA levels referred to our center between 2005 and 2011 underwent CRS and HIPEC. The association between CEA levels and characteristics of patients with PMP was assessed with χ (2) test, linear correlation, and logistic regression analyses. Survival analysis was performed with Cox proportional hazard model.Median age was 55 (range 19-84) years. There were 245 (54.5 %) females and 204 (45.5 %) males. Preoperative CEA levels were elevated in 328 (73 %, sensitivity) patients with PMP. Preoperative CEA levels were also related to peritoneal cancer index (P0.0001), cytoreductive surgery scores (P0.0001), progress free survival (P0.001) and overall survival (P0.001) in patients with PMP.Our results indicated that preoperative CEA levels are useful in predicting the extent of disease and surgical success as well as progress-free and overall survival in patients with PMP treated with cytoreductive surgery and HIPEC.

As a peritoneal surface malignancy, primary peritoneal papillary serous carcinoma (PPPSC) almost always occurs in women. Our search of the literature found only two previous case reports of men with PPPSC, both with very short survival. We report the case of a 63-year-old man with PPPSC, treated effectively with cytoreductive surgery and docetaxel-based hyperthermic intraperitoneal chemotherapy following six cycles of docetaxel-based laparoscopic neoadjuvant intraperitoneal and cisplatin-based systemic chemotherapy. Furthermore, we detected intraoperative intraperitoneal spreading of the tumor after the oral administration of 5-amino levulinic acid (5-ALA). The patient remains in good health without ascites 18 months after his diagnosis. Thus, primary peritoneal papillary serous carcinoma should be managed by intraperitoneal chemotherapy combined with peritonectomy procedures. Moreover, the intraoperative detection of the intraperitoneal spreading of the tumor after administering oral 5-ALA shows that this is an exciting and promising diagnostic technique, which needs to be confirmed by further studies.

Mechanisms of the Formation of Peritoneal Surface Malignancy on Omental Milky Spots from Low Grade Appendiceal Mucinous Carcinoma Purpose: Omental milky spot (OMS) is considered to have an important role in the formation of peritoneal surface malignancy (PSM). However, human OMS and cancer metastasis has not been fully clarified. The present study demonstrates the mechanisms of the formation of metastasis on the omental milky spots (OMS) from the low grade AMC. Methods and materials: To clarify the mechanism of the formation of peritoneal metastasis in low grade appendiceal mucinous carcinoma (AMC), 195 low grade AMC showing peritoneal cancer index (PCI) of ≤28 were studied for the distribution of peritoneal metastasis. Peritoneum was resected from 10 patients, and was prepared as whole-mount extending specimen. The specimens were studied by 5’-nucleotidase and alkaline phosphatase double stain and immunohistologic staining by D2-40, anti-CD31 and anti- Ki-67 monoclonal antibody. Furthermore, peritoneal parts were observed by scanning electron microscopy. Results: Pelvic and subdiaphragmatic peritoneum were involved in 164 (84%) and 143 (73%) patients. Greater omentum was involved in 135 (69%) patients. Under the SEM observation, no typical milky spots were observed on the peritoneum except for the greater omentum. Surface of OMS was covered with cuboidal mesothelial cells. Between the cuboidal mesothelial cells, many stomata were found. After digestion of OMS by 6N KOH, disk-like peritoneal pouch was detected at OMS. Small holes were found on the collagen plate covered on the bottom of the pouch. Below the pouch, initial lymphatic vessels closed to the pouch with stomata. Agglomerated blood capillaries distributed around the initial lymphatics. Metastasis foci were found around the stomata on OMS, but were not detected on the flat mesothelial cells on the greater omentum.. Conclusion: Peritoneal free cancer cells from low grade AMC may be adsorbed at stomata and adhere on the OMS. Then, they proliferate on OMS.

Peritoneal dissemination is a frequent pattern of recurrence and metastasis of small bowel malignancy (SBM). However, the survival of patients with peritoneal dissemination from SBM is not clear, and there is no consensus on the treatment for it. A total of 31 selected patients with peritoneal dissemination from SBM were treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) between January 2006 and January 2014. The major focus of this study was overall survival, as well as morbidity and mortality. Twenty-five patients had small bowel adenocarcinoma (SBA), and six patients had non-adenocarcinoma SBM. HIPEC was performed on 21 patients, and 21 patients received complete cytoreduction. There was no treatment-related mortality, and eight (25.8 %) patients had grade 3–4 complications. Until the latest follow-up, the median survival of 31 patients after CRS and HIPEC was 36 months (range 5–95 months), and the median survival after diagnosis was 51 months (range 18–101 months). For 25 patients with peritoneal carcinomatosis from SBA, the median survival after CRS and HIPEC was 36 months (range 6–95 months), and the median survival after diagnosis was 50 months (range 18–101 months). Multivariate analysis revealed that peritoneal cancer index

Pseudomyxoma peritonei (PMP) is a rare locoregional disease characterized by disseminated intraperitoneal mucinous tumors. However, little is known about PMP from urachal neoplasm as a result of its rarity.A total of 9 patients with PMP of urachal origin were treated by cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) in our institution. All specimens of surgeries were submitted for pathologic examination. Representative slides of tumors and normal urachus were submitted for immunohistochemical staining.Four patients were men; the median age was 48 years (range 27-65 years). Initial radiologic examination of all patients showed a cystic tumor located between posterior aspect of umbilicus and the dome of urinary bladder, with or without leaking mucin. Complete CRS and HIPEC were performed in all patients. Until the latest follow-up, local recurrence occurred in 1 patient. Other 8 patients had a median disease-free survival of 27.5 months. Primary urachal tumors of 9 cases were all mucinous adenocarcinoma. Six patients had low-grade mucinous carcinoma peritonei, and 3 patients had high-grade mucinous carcinoma peritonei. Signet ring cells were noted in 4 patients. All tumor specimens of 9 patients were diffuse positive for CK-20, CDX-2, MUC-2, and MUC-5AC, and were variant positive for CK-7.PMP arising from urachus comes from neoplastic cells with development of intestinal-type mucinous neoplasm. It shares a similar pathophysiology as PMP from appendix. CRS including total urethrectomy, partial cystectomy, and peritonectomy plus HIPEC can be considered as a new option of treatment for PMP originating from urachus.

In the past 5 years, endoscopic neck surgery has been performed by various surgeons in Japan. However, many problems remain to be solved, including indications for this related in malignant thyroid tumors. For small thyroid cancers and legions suspected of malignancy, we found that we could obtain radicality in endoscopic neck surgery that was comparable to that attainable by conventional methods. Here, we describe our recent endoscopic surgical experience in five patients with preoperative diagnoses of definite or suspected thyroid carcinoma.

We report an endoscopically assisted total diverticulectomy for Zenker's diverticulum. Skin incisions were made at the anterior axillary line, the center of the sternum, and the neck as portals for endoscopical instruments. The skin was retracted with hooks which provided an excellent view of the working space. The diverticulum was fully exposed and resected by using a multifire endoscopic stapler. This approach is minimally invasive in comparison with the conventional open cervical approach.

Invagination induced by a long intestinal tube is rarely encountered. We report herein one such case of a 62-year-old man who was successfully treated by laparoscopically reducing the invagination, then performing partial resection of the small intestine.

A 70-year-old man was admitted to the hospital because of melena and hypovolemic shock. A preoperative diagnosis of aortoenteric fistula was made by imaging assessment. Embolization of the origin of the right common iliac artery was performed, and the gastrointestinal bleeding stopped. After the patients cardiorespiratory function had become stable, laparotomy was performed. It revealed an ilioappendiceal fistula through the iliac artery aneurysm. The fistula was closed, the appendix was resected, and the aneurysm was satisfactorily dissected. Aortoenteric fistula is generally a rare entity. The prognosis is thought to be poor because of the difficulty of early diagnosis and complication by sepsis. We report a case of common iliac artery aneurysm with ilioappendiceal fistula in which the patient's life was saved by embolization and operation.

Management of peritoneal disseminated gastric cancer (GC) remains a challenging problem. The purpose of our study was to evaluate the outcome of bidirectional induction chemotherapy [bidirectional intraperitoneal and systemic induction chemotherapy (BIPSC)] in patients with peritoneal carcinomatosis (PC) arising from GC who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).Overall, 194 patients with PC arising from GC were treated with BIPSC comprising intraperitoneal docetaxel at a dose of 20 mg/m(2) and cisplatin at a dose of 30 mg/m(2) followed by four cycles of oral S-1 at a dose of 60 mg/m(2). CRS and HIPEC were performed in responders to BIPSC.Of these 194 patients, 152 (78.3 %) underwent CRS and HIPEC between January 2005 and December 2012. Treatment-related mortality was 3.9 %, and major complications occurred in 23.6 % of patients. The median survival rate was 15.8 months, with 1-, 2-, and 5-year survival rates of 66, 32 and 10.7 %, respectively, in the patients treated with combined treatment. Multivariate analysis identified pathologic response to BIPSC (p = 0.001), low tumor burden [peritoneal cancer index (PCI) ≤ 6] (p = 0.001), and completeness of CRS (CC-0, CC-1) (p = 0.001) as independent predictors for a better prognosis.As a viable option, BIPSC with CRS and HIPEC for patients with PC arising from GC may be performed safely, with acceptable morbidity and mortality, in a specialized unit. Response to BIPSC, optimal CRS and limited peritoneal dissemination seem to be essential to achieve the best outcomes in these patients.

Mechanism of the formation of peritoneal metastasis (PM) through lymphatic vessels was studied. Materials and methods: Parietal peritoneum was divided into 8 regions, and specimens of each zone were removed from patients with PM. The specimens were stained with enzyme histochemical staining for alkaline phoshatase (ALPase) and 5-Nase activity, and with immunohistochemical staining with D2-40. Surface of the peritoneum and subperitoneal tissue were observed by a scanning electron mcirosopy. Results: Well-developed lymphatic lacunae were found in the shallow submesothelial layer of 7 regions except for the anterior abdominal wall. Lymphatic vessels were found in the deep submesothelial layer up to 200 micrometer from the peritoneal surface. The mesothelial stomata directly connect with the submesothelial lymphatic vessels through holes of the macula cribrifolmis. Migration of cancer cells through stoma was found, and cancer cells were detected in the submesothelial lymphatic lacunae. Lymphatic vessels are not found in the center of established PM, but were found in the adjacent normal tissue. In the subperitoneal tissue outside the PM, morphological findings suggesting lymphangiogenesis designated as cystic Lymphatic Island, ladder formation, budding, and extension of lymphatic vessels were found. Conclusion: The triplet structure consisting of mesothelial stomata, holes on macula cribriformis and submesothelial lymphatic lacunae is essential for the migration of peritoneal free cancer cells into the submesothelial lymphatic lacunae. The rout of the formation of PM through peritoneal lymphatic vessels was named as translymphatic metastasis.

During the last 7 years, 21 patients with DMPM were treated. Histologic types were epitheloid type in 18 patients, biphasic type in 2 patients and sarcomatoid type in 1 patient. Preoperative systemic chemotherapy, hyperthermic intraperitoneal chemotherapy(HIPEC) by laparoscopy(LHIPEC), and intraperitoneal(IP) chemotherapy were done in 14, 3 and 1 patients, respectively. Cytoreductive surgery(CRS) was done in 13 patients. Ten patients received HIPEC after CRS. Partial responses were experienced in 4 of 13 patients treated with preoperative systemic chemotherapy. One of three patients treated by LHIPEC showed complete response. Among 13 patients received laparotomy, complete removal of PC was done in 4(31%) patients. The other 9 patients who received incomplete cytoreduction had diffuse involvement on the small bowel and its mesentery. All over 5-year survival was 17%. Patients treated with HIPEC survived significantly longer than non-HIPEC group. Neoadjuvant laparoscopic HIPEC may have a great role in the preoperative control of small PC on the surface of small bowel.

Background. Patients with early stage of pseudomyxoma peritonei (PMP) are sometimes difficult to diagnose the primary sites and intraperitoneal spread of tumor and to perform a cytological study.Methods. Patients without a definitive diagnosis and with unknown extent of peritoneal spread of tumor underwent laparoscopy. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) was administered as part of the same intervention. The results of treatment were evaluated at the time of second-look laparotomy (SLL) as a subsequent intervention.Results. Eleven patients were managed by diagnostic laparoscopy followed by laparoscopic HIPEC (LHIPEC). The operation time of laparoscopic examination and LHIPEC was 177 ± 26 min (range 124–261 min). No intraoperative complication was experienced. The peritoneal carcinomatosis index (PCI) score by laparoscopic observation was 16.5 ± 6.4 (range 0–30). One patient with localized pseudomyxoma peritonei (PMP) mucocele did not received LHIPEC; the other 10 patients with peritoneal metastases (PM) were treated with LHIPEC. After LHIPEC, ascites disappeared in 2 cases and decreased in the amount in the other 8 cases. Nine patients underwent SLL and cytoreductive surgery (CRS) combined with HIPEC. The duration between LHIPEC and SLL ranged from 40 to 207 days (97 ± 40 days). The PCI at the SLL ranged from 4 to 27 (12.9 ± 7.1). The PCI at the time of SLL decreased as compared to PCI at the time of diagnostic laparotomy in 7 of 9 patients. Median follow-up period is 22 months (range 7–35). All 11 patients are alive.Conclusion. The early results suggest that laparoscopic diagnosis combined with LHIPEC is useful to determine the surgical treatment plan and reduce the tumor burden before definitive CRS at SLL.

Background. Even though cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are associated with a high morbidity and mortality rates, it has been reported that CRS and HIPEC improved survival of selected patients with peritoneal carcinomatosis. We aimed to report morbidity and mortality results of CRS and HIPEC from a single institution in Japan.Methods and Results. Total of 284 procedures of CRS were performed on patients with pseudomyxoma peritonei, peritoneal carcinomatosis (PC) from colon cancer and gastric cancer between 2007 and 2011 in our institution. The morbidity rate was 49% of all procedure, and grades I/II and grades III/IV complications were 28% and 17%, respectively. Most frequent complication was surgical site infections including intraabdominal abscess. The mortality rate was 3.5%, and reoperation was needed in 11% of all procedures. Univariate and multivariate analysis showed peritoneal carcinomatosis index (PCI) greater than 20 was the only significant factor for occurrence of postoperative complications (P<0.01). In contrast, HIPEC significantly reduced postoperative complications (P<0.05).Conclusions. The morbidity and mortality rates of our institution are comparable with previous reports that are in acceptable rates. Optimal patient selection such as patients with PCI less than 20 seems to be of paramount importance to CRS and HIPEC.

A 64-year-old woman was admitted to the hospital because of abdominal pain. On physical examination, a large tumor in the right abdominal region was found. An abdominal X-ray film showed a round-shaped calcification in the same region. Abdominal CT and MRI examinations revealed a retroperitoneal tumor with calcification, but the definite diagnosis could not be made preoperatively. Tumor extraction was performed. The tumor was 13.4cm×8.8cm in size and 640g in weight. The inside of the tumor was solid with diffused calcification. The section was yellowish. Histopathologically, the tumor was a lipoma with fatty degeration and no malignancy was found. The pathogenesis of the calcification was not clear. A histopathologic findings that there was membranlous lipodystrophy indicates that calcium deposits resulting from a long-term ischemic change of the lipoma might be a probable etiology.

Since July 1992, laparoscopic inguinal hernia repair was performed to 19 adult cases, and prosthetic repair by preperitoneal posterior approach (Nyhus-method), to 11 cases (high risk group for general anesthesia). And, conventional hernia repair was conducted to 24 cases from Jan' 1991 to June 1992. The postoperative results of three groups were comparatively examined. No recurrence was observed on these three groups, though postoperative time for observation is still short in each method group. Laparoscopic repair demanded twice longer operation time than the conventional repair, but it was associated with groin pain and swelling in only a few particular cases. There was no significant difference in postoperative hospital stay among the three grousp. It seems that laparoscopic repair should be indicated for the aged, large hernia ring, hard laborer, and recurrent hernia which is intractable by conventional procedure. Laparoscopic repair is reasonable operation which does not bring out postoperative groin pain and possibility of recurrence, because it dose not destroy any anatomical structure of inguinal region. Recently, tension free repair has become the principal procedure, and so, inguinal hernia repair will be mostly performed by laparoscopic repair.

われわれは比較的稀な大腸印環細胞癌の生物学的特性を知るために,組織学的多様性のみられる同一腫瘍内で部位別の細胞増殖活性とDNA ploidy patternを比較検討した.前者の検討にはMIB抗体を用いたKi-67染色が有用であり,後者の検討には顕微鏡下で印環細胞を識別できるPAS/DAPI二重染色が有用であった.同一腫瘍内で細胞外粘液の貯留する印環細胞群は二倍体細胞が中心るみられた.印環細胞が結節状構築を示し,また未分化細胞のみられる部位では異倍体と多倍体細胞の出現傾向がみられKi-67陽性細胞比率は粘液貯留部位と比較して高値であり(p

In this chapter, we introduce a stair-climbing robot developed in our laboratory. This robot consists basically of two body parts connected by springs, and hops as a result of the vibration of a two-degrees-of-freedom (2-DOF) system. The excellent combination between the frequencies of the robotic body vibration and the tread-riser interval of stairs enables a small and simple robot fast stair climbing, soft landing, and energy saving. In an attempt to give the robot mobility in an environment such as an office building having steps and stairs, various mechanisms have been proposed and developed. Each one of which has different characteristics. For example, wheel-based robots are very simple in terms of both mechanical design and control, and they can travel quickly and stably. But their size tends to be big for climbing stairs, as they cannot surmount a riser higher than their wheel radius. On the other hand, although crawler-type robots can climb over a riser higher than a wheel-based robot, they are slow and noisy. Typical examples of crawler-type robots are TAQT (Hirose et al., 1992) that can carry a human and Kenaf (Yoshida et al., 2007) for rescue operations. Legged robots, especially humanoid ones, are well suited for climbing stairs, but require many DOFs and complex control. Honda’s ASIMO (ASIMO OFFICIAL SITE), AIST’s HRP (Harada et al., 2006) and Waseda University’s legged robot (Sugahara et al., 2007) are good examples. In addition, the hybrids of these types have been proposed and have improved upon mutual demerits. Chari-be (Nakajima et al., 2004), with two wheels and four legs, travels quickly on its wheels over flat terrain, and climbs using its legs in rough terrain such as a step and stairs. A biped-type robot with a wheel at the tip of its legs (Matsumoto et al., 1999) climbs stairs smoothly. RHex (Altendorfer et al., 2001) has six compliant rotary legs and travels speedily not only up and down stairs, but also even uncertain terrain such as a swamp. Moreover, modular robots such as an articulated snakelike robot and special mechanisms for stairs have also been proposed. Yim’s snake-like robot (Yim et al., 2001) climbs stairs, transforming its own loop form into a stair shape. These excellent mechanisms have improved the manoeuvrability of the robot for rough terrain, but as most are general-purpose robots for rough terrain, a more specialized mechanism must be developed if we focus solely on stair-climbing ability in an office building. 3

Two aged patients with common bile duct stones (CBDS) who were successfully treated by using ESWL are described.A male case of CBDS developed cholangitis for an edema at the papilla Vater by endscopic sphincterotomy (EST) and incarceration of crushed stones by ESWL, but cholangiodrainage and further ESWL made him free from stones.Another female case of CBDS had obstructive jaundice for incarceration of CBDS, and PTCD made her jaundice decreased. After the decrease of jaundice, ESWL was performed for CBDS and without EST she became stone free with dripping glyceryltrinitrate (GTN) into the bile duct.We presented those two cases, as well as the safety of this ESWL treatment.ESWL for CBDS is more recommendatory for high risk cases which are probably inoperable and cases with giant CBDS which are difficult to be removed endscopically. On the other hand, we refer the therapy for CBDS dripping GTN into the bile duct.

Clinical and histological characteristics of alpha-fetoprotein (AFP) producing gastric cancers were studied. Four (3.8%) among 104 cases of gastric cancer experienced in the last eight years were AFP-producing gastric cancer. in addition to AFP, the coexistence of carcinoembryonic antigen, ferritin or carbohydrate antigen 199 were found in the tumor cells by immunohistochemical methods. It is suggested that AFP-producing tumor cells might have an ability to differentiate into various forms. Clinically, most of AFP-producing gastric cancers belonged to Borrmann type 2 or type 3. As they were already markedly advanced and with a high frequency of hepatic metastasis during surgery, the prognosis was very poor. In cases of AFP-producing gastric cancer, serum AFP values were found to show a good correlation with the clinical course. It may be useful in predicting the prognosis such as recurrence or liver metastasis.

Stromal cell-derived factor-1 alpha (SDF-1α) is expressed in injured myocardium and plays a key role in the repair of the injured myocardium. This study examined whether SDF-1α in the circulation may have a prognostic information in patients with heart failure (HF). SDF-1α levels in plasma from a peripheral vein (PV) were measured using ELISA in 297 patients with chronic HF defined by the Framingham criteria, who had LV functional abnormalities (102 patients in NYHA class II, 65 in NYHA III, 32 in NYHA IV), and in 50 age- and sex-matched controls. The levels were also measured in plasma from the aorta (AO) and the coronary sinus (CS) in a subgroup of 82 HF patients. Then, all patients with HF were prospectively followed for 60 months or until occurrence of cardiac death or hospitalization with worsening HF. PV levels of SDF-1α were higher in HF patients than controls (2661 ± 67 vs. 2320 ± 55 pg/mL, p < 0.01), and patients with higher NYHA class had higher SDF-1α levels (ρ = 0.41, p < 0.0001). The PV levels of SDF-1α were similar between patients with ischemic HF (n = 204) and non-ischemic HF (n = 93). During follow-up, 19 cardiac death and 69 hospitalization occurred. The PV levels of SDF-1α were higher in patients with an event than those without an event (2820 ± 78 vs. 2490 ± 38 pg/mL, p < 0.01). In a multivariate Cox hazards analysis, a higher level of SDF-1α (> 3040 pg/mL, defined by ROC analysis) was a predictor of events that was independent of age, LVEF, use of medications, and BNP levels (HR 2.1, 95% CI 1.2–4.2, p < 0.01). Moreover, the CS - AO difference in SDF-1α levels, reflecting release from the heart, was higher in patients with (n = 21) than without an event (n = 67) (80 ± 46 vs. −32 ± 33 pg/mL, p < 0.01). The CS - AO difference in SDF-1α levels was positively correlated with the PV levels (r = 0.22, p < 0.05). Both the CS - AO difference in SDF-1α levels and the PV levels had a significant positive correlation with PV levels of BNP and an inverse correlation with LVEF. Higher SDF-1α levels in the peripheral circulation independently predict a worse outcome in patients with chronic HF. SDF-1α is released from the heart in proportion to the severity of LV dysfunction via a compensatory mechanism and may partly contribute to increased circulating levels of SDF-1α in chronic HF.

Mesenteric panniculitis is an unspecific inflammatory disease rarely induced in the mesenterium. Most of such cases have a chronic course and are difficult to diagnose clinically. We examined one case of mesenteric panniculitis which may have occurred after an acute course, and in the present report we review 24 Japanese cases including our own with special reference to etiology and pathologic conditions. The patient, a 31-year-old male, had pharyngitis resulting in paralytic ileus on the eighth day after occurrence. As the cause remained unknown, the patient underwent exploratory laparotomy, and he was diagnosed as having mesenteric panniculitis from findings at the time of laparotomy and histologic images. The disease is characterized by frequent occurrence in the mesenterium of the small intestine or sigmoid colon, the formation of a tumor in the abdomen and the symptoms of ileus or enteritis. Although the cause of our case was unknown, its manifestation was strongly assumed to be related to allergic reaction complicated by inflammation considering the fact that many cases of this disease present signs of inflammation before the occurrence. As there have been only a few cases reported with acute course, our case, suggesting the etiology of the disease, is thought to be interesting.

The patient was a 78-year-old female who had a 70-year history of dysphagia. The initial surgery was performed using esophago-cardioplasty with gastric patch (Sato-Hirashima method). Three months later, the patient again complained of dysphagia. In esophageal achalasia of the sigmoid type, a reservoirlike portion of the esophagus dilates and protrudes to the right thoracic cavity. Thus it was considered that surgery was necessary to prevent the retention of food in the esophagus. The second operation was performed by the right throraco-abdominal approach. The lower part of the esophagus including the fundic portion of the stomach was resected. Esophageal plication on the right longitudinal wall by Lembert sutures was applied to repair the sigmoid-like protruding portion of the esophagus. After esophago-gastrostomy, introversion suturing of the stoma was carried out to prevent reflux of the gastric contents. The postoperative course was excellent and the patient's weight had increased 10kg three months postoperatively. The incidence of re-surgery for esophageal achalasia is 10%, the hightest being that for sigmoid type, grade III. We conclude that the first choice of surgical procedures for this type of esophageal achalasia is a combination of a) resection of esophago-fundic portion and b) plication of the protruding portion of the esophagus.

Even if surgery is performed, diffuse infiltrative carcinoma of the colon is a disease having a poor prognosis. Two cases of this disease are described. Case 1. An 82-year-old woman was admitted to this hospital with a one-month history of constipation and lower abdominal pain. Barium enema examination showed an apple core sign in the rectum. Computerized tomography (CT) of the abdomen showed thick paraaortic tissue and lymph node swelling in the mesocolon, which indicated wide spread invasion by the cancer. Case 2. A 50-year-old woman was admitted because of lymph node swelling in the supraclavicular region. Barium enema examination showed stenosis 16cm in length in the sigmoid colon with spicula and cobble stone-like formation. CT findings were similar to those in case 1. In both cases, surgery to releave the stenosis was performed. The postoperative course worsened and death resulted 43 days (case 1) and 100 days (case 2) after surgery. The wall of the resected colon was 13 to 10 mm thick and the mucosal surface presented a cobble stone-like appearance without a clear margin of the cancer. Histological examination revealed poorly differentiated adenocarcinoma with edematous, scirrhotic changes in the submucosal layer and highly invaded lymphatic vessels. To our knowledge, 101 cases of diffuse infiltrative carcinoma of the colon have already been reported in Japan. A summary of these cases is presented.

We examined two cases of a colonic type of primary cancer of the appendix with unusual metastasis. One occurred as carcinomatous pleurisy with unknown primary lesion and the other as signet ring cell carcinoma of the appendix with multiple intramural metastases in the small intestine. We studied the metastatic pattern in these cases, and discuss its pathogenesis on the basis of 94 cases reported in the literature during a five-year period. In primary cancer of the appendix with unusual metastasis, there was a close relationship between histopathological findings and tumor development. It is thus important to take histopathological features into account when selecting a method of treatment. This disease seems liable to result in extramural development. It also shows active lymph node metastasis and end metastasis. From these findings, it is considered necessary to actively perform extended radical operation for this disease.