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BACKGROUND Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2 = 0.870, 90% CI: 0.768-0.972). CONCLUSION The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is an extremely rare benign lesion. We herein report a case of asymptomatic SANT of the spleen in a middle-aged woman with early breast carcinoma and an undiagnosed splenic mass, which was successfully treated by laparoscopic splenectomy and diagnosed postoperatively. We also review the literature on SANT to help make knowledge more accessible when clinicians encounter a splenic tumor. The present case taught us the following lesson: the presence of a splenic lesion during follow-up for malignancy is not always indicative of metastasis. Therefore, SANT should be considered in the differential diagnosis.

Background. Terminal ileum diverticulitis is a rare clinical disease. It can frequently mimic other processes, such as acute appendicitis. Diagnosis and therapeutic decision making (surgical or conservative treatment) can be complex. We report four interesting cases of terminal ileum diverticulitis. Case Presentation. Case 1: a 55-year-old male presented to us with a 3-day history of severe right lower quadrant pain. Computed tomography (CT) showed penetration of terminal ileum diverticulitis. Following a 7-day conservative treatment, he underwent ileocecal resection. Pathology results revealed a false diverticulum and two in five points of perforated terminal ileum diverticulum. Case 2: a 77-year-old male presented to us with severe right lower quadrant pain and unconsciousness. CT showed penetration of terminal ileum diverticulitis and air in the mesentery. Ileocecal resection was performed 2 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 3: a 61-year-old male presented to us with a right lower quadrant pain for 10 days and fever for 6 days. CT showed penetration of terminal ileum diverticulitis and abscess of the psoas muscle. Puncture and drainage of abscess were performed. Laparoscopic ileocecal resection was performed 30 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 4: a 39-year-old female presented to us with right lower quadrant pain for 9 days, suspicious of appendicitis. CT showed abscess of pericecal area. Puncture and drainage were performed. A drainage tube was located into the cecum through the terminal ileum. Conservative therapy was effective, and she was discharged 23 days postadmission. Conclusions. All four cases had right lower quadrant pain. Three cases were diagnosed by CT, whereas one was diagnosed by abscess drainage. Two cases required surgical treatment within 3 days, one within about 1 month, and one case did not require surgery. The decision of whether to manage a patient surgically or conservatively is difficult. It is critical not to delay the decision of performing a surgical treatment until each patient reaches a stable general condition.

We report a resected case of cancer at the ileum of the blind loop. An 81-year-old male underwent an appendectomy for acute appendicitis and an ileotransverse colostomy for postoperative obstruction when he was 14 years old. He underwent radiation therapy for prostate cancer when he was 75 years old. Six years later, enhanced computed tomography revealed a 7 cm mass in the ileum of the blind loop. Colonoscopy showed wall thickening at the ileum of the blind loop, and biopsy revealed an adenocarcinoma. We performed partial resection of the ileum. The patient was discharged 17 days after surgery. Cancer at the ileum of the blind loop after an ileotransverse colostomy has rarely been reported.

Photovoltaic (PV) power generation has a particular problem for grid cooperation in that output can fluctuate due to the shadows created by clouds. If we can grasp the behavior of cloud shadows beforehand, then it may be possible to forecast output fluctuations. In this study, we want to prove if it is possible to calculate power output variation from the accumulated cloud shadow data. Cloud shadow behavior was measured from the ground by photodiodes (PDs) and the cloud shadow vector was calculated from the position and time difference. The time from the calculated cloud shadow vector to the arrival of the cloud shadow and the power generation output was calculated and compared with the actual solar power generation output. Thus, we confirmed that we can predict power generation output from a high correlation of two outputs. We found that prediction is possible, with high precision, at a short distance.

Here, we describe a case of a retroperitoneal liposarcoma successfully managed by laparoscopic surgery. A 72-year-old man underwent abnormal hypertension screening using computed tomography (CT), which revealed a low-density mass measuring 7 cm in diameter in the retroperitoneal space. We diagnosed the mass as a liposarcoma before the operation. The mass was resected laparoscopically. No perioperative complications were encountered, and the patient was discharged on the fourth postoperative day. The pathologic diagnosis was well-differentiated liposarcoma, indicating complete surgical resection. Thus, we conclude that a laparoscopic approach for the patients with retroperitoneal tumors, including liposarcomas, is safe, feasible, and minimally invasive, even if there is a possibility of the tumor being malignant.

Although mesothelin is highly expressed in epithelial mesotheliomas, and also in adenocarcinomas of the ovary and pancreas, the clinical significance of mesothelin in cholangiocellular carcinoma (CC) has not been reported, and its biologic features are largely unknown. In the present study, mesothelin expression was evaluated in 25 patients with CC using a well-characterized mesothelin monoclonal antibody (5B2). A total of 8 of the 25 patients with CC (32%) showed mesothelin immunoreactivity. The 25 patients were divided into 2 groups according to the percentage of tumor cells that were positive for mesothelin expression: negative (n = 17) or focally positive (mesothelin expression evident in less than 50%, n = 4; total, n = 21 for both groups), and positive (mesothelin expression evident in 50% or more, n = 4). The survival periods in both groups were statistically analyzed. The negative/focally positive group showed significantly longer postoperative survival than the positive group (P = 0.006). Also, mesothelin positivity was identified as an independent predictor of short postoperative survival. The present results suggest that mesothelin expression is a prognostic indicator in patients with CC.

腹腔鏡下鼠径ヘルニア修復術の経腹腔的アプローチ（TAPP）は，前方アプローチのメッシュ手術より利点が多い．しかし，新たな手技習得が必要でラーニングカーブが長いため本邦では必ずしも普及していない．筆者らは，TAPPの手技的難点を軽減する目的に，経皮的に鼠径部腹膜前腔にロピバカインとエピネフリンの膨潤麻酔剤希釈液約150ml注入することを先行する膨潤TAPPを考案し22例を経験した．対象は，男21例，女性1例で平均年齢は58.2歳，24病変，間接ヘルニア19病変，直接ヘルニア5病変であった．手技的に，従来TAPPと比べて，腹膜前腔の膨化によって層確認が容易となり剥離しやすく，出血も少なく，比較的確実な手術が可能となった．合併症は，血腫，水腫各1例でいずれも軽微で，術後疼痛も少ないと考えられた．今後，さらなる症例集積と従来TAPPとの比較試験による検証が必要であるが，膨潤TAPPは従来TAPPを手技的，臨床的に改善すると推察された．

Zebrafish pectoral fin bud formation is an excellent model for studying morphogenesis. Fibroblast growth factors (Fgfs) and sonic hedgehog (shh) are essential for pectoral fin bud formation. We found that Fgf16 was expressed in the apical ectodermal ridge (AER) of fin buds. A knockdown of Fgf16 function resulted in no fin bud outgrowth. Fgf16 is required for cell proliferation and differentiation in the mesenchyme and the AER of the fin buds, respectively. Fgf16 functions downstream of Fgf10, a mesenchymal factor, signaling to induce the expression of Fgf4 and Fgf8 in the AER. Fgf16 in the AER and shh in the zone of polarizing activity (ZPA) interact to induce and/or maintain each other's expression. These findings have revealed that Fgf16, a newly identified AER factor, plays a crucial role in pectoral fin bud outgrowth by mediating the interactions of AER-mesenchyme and AER-ZPA.

We describe the case of a patient with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was successfully treated by laparoscopic surgery. A 62-year-old man with a long history of hepatitis C-induced liver cirrhosis was admitted to our institution because of recurrent postprandial periumbilical pain. Eight years earlier, he had undergone radiofrequency ablation for hepatocellular carcinoma at hepatic segment VIII. Computed tomography, gastrografin enema examination revealed transverse colon obstruction because of a diaphragmatic hernia. We diagnosed diaphragmatic hernia associated with the prior radiofrequency ablation treatment. The patient underwent laparoscopic repair of the diaphragmatic hernia. Though the patient experienced the recurrence once, relaparoscopic treatment has improved the patient's conditions. Thus, diaphragmatic hernia can develop as a complication of radiofrequency ablation treatment. A laparoscopic approach is safe, feasible, and minimally invasive, even in patients with cirrhosis who develop iatrogenic diaphragmatic hernia as a complication of radiofrequency ablation treatment.

A 60-yr-old man having hepatitis C virus-associated liver cirrhosis and hepatocellular carcinoma underwent living donor liver transplantation using a left liver graft. On post-operative day 20, the patient developed a large amount of ascites and hypovolemic shock because of decreased venous return. Emergency laparotomy revealed that fixation of the round ligament to the abdominal wall was loose, and free movement of the graft into the right subphrenic space had caused twisting the hepatic vein. After upward traction of the round ligament, two Foley balloon catheters were inserted into the right subphrenic space to maintain the graft in the midline portion. The catheters with the balloons were removed on day 30 after re-operation. This method is easy, simple and inexpensive for the treatment of hepatic venous outflow block after partial liver transplantation.

A 76-year-old woman was diagnosed of mucinous cystadenocarcinoma of the appendix. Since there was wide direct invasion into the right psoas muscle, she was judged as inoperable although she had no bowel obstruction. She was received FOLFIRI and bevacizumab treatment. After the first cycle, the tumor progressed rapidly and formed the abdominal wall abscess at the right groin. Since she had a fever and pain at the right groin and the abscess reached the hypodermic, we put a drainage tube into the abscess. The tube was placed, which made her symptoms improved markedly. We have been continuing with FOLFIRI treatment and drainage for 10 months without progressive disease. We report a rare case of the conservative therapy of mucinous cystadenocarcinoma of appendix with abdominal wall abscess.

A 60-yr-old man having hepatitis C virus-associated liver cirrhosis and hepatocellular carcinoma underwent living donor liver transplantation using a left liver graft. On post-operative day 20, the patient developed a large amount of ascites and hypovolemic shock because of decreased venous return. Emergency laparotomy revealed that fixation of the round ligament to the abdominal wall was loose, and free movement of the graft into the right subphrenic space had caused twisting the hepatic vein. After upward traction of the round ligament, two Foley balloon catheters were inserted into the right subphrenic space to maintain the graft in the midline portion. The catheters with the balloons were removed on day 30 after re-operation. This method is easy, simple and inexpensive for the treatment of hepatic venous outflow block after partial liver transplantation.

From the photosynthetic green sulfur bacterium Chlorobium tepidum (pro synon. Chlorobaculum tepidum ), we have purified three factors indispensable for the thiosulfate-dependent reduction of the small, monoheme cytochrome c 554 . These are homologues of sulfur-oxidizing (Sox) system factors found in various thiosulfate-oxidizing bacteria. The first factor is SoxYZ that serves as the acceptor for the reaction intermediates. The second factor is monomeric SoxB that is proposed to catalyze the hydrolytic cleavage of sulfate from the SoxYZ-bound oxidized product of thiosulfate. The third factor is the trimeric cytochrome c 551 , composed of the monoheme cytochrome SoxA, the monoheme cytochrome SoxX, and the product of the hypothetical open reading frame CT1020. The last three components were expressed separately in Escherichia coli cells and purified to homogeneity. In the presence of the other two Sox factors, the recombinant SoxA and SoxX showed a low but discernible thiosulfate-dependent cytochrome c 554 reduction activity. The further addition of the recombinant CT1020 protein greatly increased the activity, and the total activity was as high as that of the native SoxAX-CT1020 protein complex. The recombinant CT1020 protein participated in the formation of a tight complex with SoxA and SoxX and will be referred to as SAXB (SoxAX binding protein). Homologues of the SAXB gene are found in many strains, comprising roughly about one-third of the thiosulfate-oxidizing bacteria whose sox gene cluster sequences have been deposited so far and ranging over the Chlorobiaciae, Chromatiaceae, Hydrogenophilaceae, Oceanospirillaceae , etc. Each of the deduced SoxA and SoxX proteins of these bacteria constitute groups that are distinct from those found in bacteria that apparently lack SAXB gene homologues.

OBJECTIVE. To determine the effects of pancreatoduodenectomy on hepatic fat content, hepatic CT attenuation was evaluated after pancreatoduodenectomy.CONCLUSION. Pancreatoduodenectomy had a significant influence on hepatic fat content and was associated with frequent occurrence of hepatic steatosis, which was easily recognized with CT.

A new die-to-database high-resolution reticle defect inspection platform, TeraScanHR, has been developed for advanced production use with the 45nm logic node, and extendable for development use with the 32nm node (also the comparable memory nodes). These nodes will use predominantly ArF immersion lithography although EUV may also be used. According to recent surveys, the predominant reticle types for the 45nm node are 6% simple tri-tone and COG. Other advanced reticle types may also be used for these nodes including: dark field alternating, Mask Enhancer, complex tri-tone, high transmission, CPL, etc. Finally, aggressive model based OPC will typically be used which will include many small structures such as jogs, serifs, and SRAF (sub-resolution assist features) with accompanying very small gaps between adjacent structures. The current generation of inspection systems is inadequate to meet these requirements. The architecture and performance of the new TeraScanHR reticle inspection platform is described. This new platform is designed to inspect the aforementioned reticle types in die-to-database and die-to-die modes using both transmitted and reflected illumination. Recent results from field testing at two of the three beta sites are shown (Toppan Printing in Japan and the Advanced Mask Technology Center in Germany). The results include applicable programmed defect test reticles and advanced 45nm product reticles (also comparable memory reticles). The results show high sensitivity and low false detections being achieved. The platform can also be configured for the current 65nm, 90nm, and 130nm nodes.

Purpose Laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) is technically difficult and not infrequently followed by postoperative complications and pain, especially when performed by inexperienced surgeons. To simplify TAPP and reduce postoperative pain, we devised a novel procedure whereby TAPP is carried out after the inguinal preperitoneal infiltration of diluted lidocaine and epinephrine saline solution and carbon dioxide gas (tumescent TAPP). This report introduces the concept of tumescent TAPP and summarizes its operative results. Methods About 120 ml of diluted lidocaine and epinephrine solution and 60 ml of CO2 gas were infiltrated into the inguinal preperitoneal space through a transabdominal needle before TAPP. Tumescent TAPP was performed for 400 patients (355 men, 45 women; mean age, 63.2 years). Results Using tumescent TAPP, we found it easier to confirm the inguinal anatomy and dissect the preperitoneal layer and inguinal floor, with less bleeding. The mean operation time was 101.9 min and there were few perioperative complications and minimal pain. Conclusions Tumescent TAPP makes conventional TAPP easier and safer; however, this procedure should be verified by a comparative study with conventional TAPP.