症例は71歳，男性．急性膵炎発症を契機に膵精査を行い，分枝型膵管内乳頭粘液性腫瘍（IPMN）と診断した．しかし手術適応はなく，アルコール多飲歴があり，まず禁酒指導にて経過観察とした．患者は完全に禁酒していたが，４カ月後に膵炎が再発．膵炎の原因となったIPMNの治療目的に亜全胃温存膵頭十二指腸切除を施行した．術中右肝動脈を損傷し縫合止血した．術後膵液瘻を認めた．術後16日目に胸痛後に下血を認め，内視鏡検査で胃空腸吻合部潰瘍が疑われ，露出血管にクリッピングを施行した．その後３回胸痛後に下血を認め，出血源を特定できなかったが，胸痛と出血との間に関連性が疑われた．術後37日目に胸痛を訴えた直後に造影CTを行い，挙上空腸内への仮性動脈瘤穿破を疑ったため，血管造影・動脈塞栓術を行った．膵切除後の消化管出血では，仮性動脈瘤の消化管穿破も考慮すべきであり，疑った場合は積極的に血管造影を行うべきである．

pancreatojejunostomy (H.E stain×100). Invasion of poorly differentiated adenocarcinoma can be confirmed. A 63-year-old man who had undergone pancreatoduodenectomy with modified Child reconstruction for pancreatic carcinoma at the age of 39 visited a nearby clinic because of abdominal fullness. Gastro-intestinal endoscopy revealed he had a remnant gastric carcinoma, and the patient was referred to our hospital. An abdominal contrast-enhanced CT scan revealed infiltration of the pancreatojejunostomy site by remnant gastric carcinoma. We therefore performed an operation. Intraoperative findings showed that the remnant gastric carcinoma had invaded the pancreatojejunostomy. We performed a total gastrectomy with combined resection of the pancreatojejunostomy with a preserving choledocho-jejunostomy. Although a Grade B pancreatic fistula occurred after surgery, the patient was discharged from our hospital on the 32 nd postoperative day. A CT scan revealed peritoneal dissemination 10 months after surgery, but the patient is still alive 11 months after surgery. These are 9 reported cases of resected malignant remnant gastric carcinoma after a pancreatoduodenectomy including 2 cases of combined resection of the original pancreatogastrostomy. To the best of our knowledge our case is the first resected case of malignancy-associated remnant stomach and pancreatojejunostomy involving remnant gastric carcinoma following a pancreatoduodenectomy.

Background Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a useful tool in pancreatic cancer diagnosis. However, the procedure itself may cause peritoneal dissemination and needle tract seeding at the puncture site. We herein report two cases of gastric wall metastasis due to needle tract seeding after EUS-FNA. Case presentation Case 1: A 68-year-old woman was admitted to our hospital for persistent cough. Computed tomography (CT) scan revealed inflammatory changes in the left lung field, and incidentally, a 15-mm hypovascular mass was detected in the pancreatic body. She underwent EUS-FNA and was diagnosed as pancreatic adenocarcinoma. She underwent distal pancreatectomy with splenectomy; however, a small hard mass was observed in the posterior gastric wall during surgery. We performed partial gastrectomy, and the resected specimen was diagnosed as a needle tract seeding following EUS-FNA. She then underwent adjuvant chemotherapy with TS-1, but the pancreatic cancer showed recurrence 6 months after surgery. She died due to peritoneal dissemination 18 months after surgery. Case 2: A 70-year-old man was incidentally detected with a pancreatic body mass on a CT scan as part of his follow-up for recurrence of basal cell carcinoma. He underwent EUS-FNA and was diagnosed as pancreatic adenocarcinoma. He had nodules in both lungs, and it was difficult to differentiate them from lung metastasis of pancreatic cancer. Therefore, he underwent neoadjuvant chemoradiotherapy, and thereafter, the lung nodules showed no changes; hence, he underwent distal pancreatectomy with splenectomy. During surgery, we observed a hard mass in the posterior gastric wall. We performed partial gastrectomy, and the resected specimen was diagnosed as needle tract seeding due to EUS-FNA. He underwent chemotherapy with TS-1, and he is still alive 18 months after surgery at the time of writing. Conclusion For resectable pancreatic body or tail tumors, EUS-FNA should be carefully performed to prevent needle tract seeding and intraoperative as well as postoperative assessment for gastric wall metastasis is mandatory.

Portal vein thrombosis (PVT) is a serious complication after hepatobiliary-pancreatic surgery. Portal vein thrombosis often develops in patients with liver cirrhosis (LC) postoperatively, although they have low platelet counts. Platelet activation is one of the causes of thrombosis formation, and soluble form of glycoprotein VI (sGPVI) has received attention as a platelet activation marker. We had prospectively enrolled the 81 consecutive patients who underwent splenectomy (Sx) and/or hepatectomy: these patients were divided as Sx (n = 38) and hepatectomy (Hx, n = 46) groups. The 3 patients who underwent both procedures were added to both groups. Each group was subdivided into patients with non-LC and LC: non-LC-Sx (n = 22) and LC-Sx (n = 16), non-LC-Hx (n = 40) and LC-Hx (n = 6). The presence of PVT was diagnosed by using enhanced computed tomography (CT) scan. Platelet counts were significantly lower in LC-Sx than in non-LC-Sx, and incidence of PVT was significantly higher in LC-Sx than in non-LC-Sx (68.8% vs 31.8%, P = .024). Soluble form of glycoprotein VI /platelet ratios on preoperative day and postoperative day 1 were significantly higher in LC-Sx than in non-LC-Sx. Incidence of PVT was significantly higher in LC-Hx than in non-LC-Hx (50.0% vs 7.5%, P < .01). Soluble form of glycoprotein VI /platelet ratios were significantly higher in LC-Hx before and after Hx, compared to non-LC-Hx. Patients with LC stay in hypercoagulable state together with platelet activation before and after surgery. Under this circumstance, alteration of portal venous blood flow after Sx or Hx is likely to cause PVT in patients with LC.

3,102,039 8/1963 Manecke ................................. 106/712 4.946,505 8/1990 Jungk ....... ... 106/712 5,008,143 4/1991 Armanini ......... ... 106/436 5,199.986 4/1993 Krockert et al...... ... 106/712 5,215,584 6/1993 Buxbaum et al. ... ... 106/712 5,484,481 1/1996 Linde et al. ..... ... 106/712 5,541,096 7/1996 Nomura et al........... ... 435/176 5,558,708 9/1996 Johansen, Jr. et al. ................. 106/712

A 93-year-old woman with a past history of recurrent rectal prolapse was admitted to our hospital for small bowel evisceration through the anus. A 100-cm segment of the small bowel, appearing dark-red in color, was found prolapsing through the anus. Abdominal CT showed invagination of a small bowel segment into a rectal perforation, and prolapse of the small bowel through the anus. We made the diagnosis of rectal perforation with transanal small bowel evisceration, and performed emergency surgery. At oper-ation, we found an approximately 25-mm perforation in the anterior wall of the rectum and invagination of the small bowel into the rectal lumen through the rectal perforation. We carefully reduced the prolapsed small bowel segment and performed primary closure of the rectal perforation. In addition, we performed a sigmoid colostomy because of concern about leakage. Also, a 100-cm segment of the prolapsed small bowel was resected because of ischemic changes. The patient was discharged on the 20th postoperative day with no complications. However, recurrence of the rectal prolapse was confirmed 2 months after the operation. Therefore, at 7 months after the first operation, we performed abdominoperineal resection as a curative treatment for the rectal prolapse.

Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair.From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board–approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (<70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses.Overall, 524 patients underwent surgical PEH repair (<70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients <70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence.PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.

This study is to evaluate the associations between long-term survival and stage I breast cancer by examining the hormonal receptor (HR) and human epidermal growth factor receptor-2 (HER2) status.A total of 1595 breast cancer patients who were seen from 1990 to 2008 with surgery as first treatment and pathology stage I (T1N0) were included in this study. HR and HER2 status were used to approximate breast cancer subtypes. Additionally, ten-year relapse-free survival (RFS) rate and failure patterns of each subtype were evaluated. Multivariate analyses were performed in each subtype to identify the risk factors of recurrence.Luminal-like (HR positive and HER2 negative) stage I patients showed a 10-year RFS rate of 89.5%, HER2 positive 92.9%, triple negative 91.1%, and unclassified subtype 86.2% (p = 0.089), respectively. The 10-year overall survival was 94.1% in luminal-like subtype, 90.1% in HER2, 94.5% in triple negative, and 85.3% in unclassified subtype. The independent recurrence risk factors in luminal-like subtype were ≤40 years of age (hazard ratio [HR] 2.2, 95% confidence interval [CI], 1.1–4.4), nuclear grade III (HR 2.7, CI, 1.4–5.3), and tumor >1.5 cm (HR 1.8, CI 1.0–3.4), and in unclassified subtype ≤40 years of age, tumor >1.5 cm, and adjuvant hormonal therapy. No risk factors were identified in HER2 or triple negative subtype.The factors associated with poor prognosis of stage I breast cancer vary by subtype. No risk factors were identified in HER2 subtype or triple negative patients. Tumor size >1.5 cm, age ≤40 years and nuclear grade 3 are the risk factors associated with poor prognosis in luminal-like subtype.

The "sump syndrome" is an unusual complication of side-to-side choledochoduodenostomy in which the portion of the common bile duct distal to the anastomosis acts as a sump and may collect bile, stones, food, and other debris. Partial or complete obstruction of the stoma and resultant bacterial proliferation may result and lead to recurrent cholangitis or pancreatitis. A single hepatic abscess as a complication of the sump syndrome has been reported only once. We have recently seen a patient presenting with multiple hepatic abscesses as a complication of the sump syndrome. This is the first report of endoscopic treatment of this syndrome associated with a hepatic abscess. The literature on the endoscopic approach to this problem will be reviewed.

Prediction of mortality risk is important in the management of chronic heart failure (CHF). The aim of this study was to create a prediction model for 5-year cardiac death including assessment of cardiac sympathetic innervation using data from a multicenter cohort study in Japan.

OBJECTIVES The study objectives were to create a cardiac metaiodobenzylguanidine (mIBG) database using multiple prospective cohort studies and to determine the quantitative iodine-123-labeled mIBG indices for identifying patients with chronic heart failure (HF) at greatest and lowest risk of lethal events.BACKGROUND Although the prognostic value of cardiac mIBG imaging in patients with HF has been shown, clinical use of this procedure has been limited. It is required to define universally accepted quantitative thresholds for high and low risk that could be used as an aid to therapeutic decision-making using a large cohort database.METHODS Six prospective HF cohort studies were updated, and the individual datasets were combined for the present patient-level analysis. The database consisted of 1,322 patients with HF followed up for a mean interval of 78 months. Heart-to-mediastinum ratio (HMR) and washout rate of cardiac mIBG activity were the primary cardiac innervation markers. The primary outcome analyzed was all-cause death.RESULTS Lethal events were observed in 326 patients, and the population mortality rate was 5.6%, 11.3%, and 19.7% at 1, 2, and 5 years, respectively. Multivariate Cox proportional hazard model analysis for all-cause mortality identified age (p < 0.0001), New York Heart Association (NYHA) functional class (p < 0.0001), late HMR of cardiac mIBG activity (p < 0.0001), and left ventricular ejection fraction (LVEF) (p = 0.0029) as significant independent predictors. Analysis of the 512-patient subpopulation with B-type natriuretic peptide (BNP) results showed BNP (p < 0.0001), greater NYHA functional class (p = 0.0002), and late HMR (p = 0.0011) as significant predictors, but LVEF was not. The receiver-operating characteristic determined threshold of HMR (1.68) identified patients at significantly increased risk in any LVEF category. Survival rates decreased progressively with decreasing HMR, with 5-year all-cause mortality rates >7% annually for HMR <1.25, and <2% annually for HMR.>= 1.95 Addition of HMR to clinical information resulted in a significant net reclassification improvement of 0.175 (p < 0.0001).CONCLUSIONS Pooled analyses of independent cohort studies confirmed the long-term prognostic value of cardiac mIBG uptake in patients with HF independently of other markers, such as NYHA functional class, BNP, and LVEF, and demonstrated that categoric assessments could be used to define meaningful thresholds for lethal event risk. (C) 2013 by the American College of Cardiology Foundation

238 Objectives The aim of this study was to create prediction models for cardiac death (CD) using a multicenter I-123 MIBG database of heart failure (HF) patients with long-term follow-up. Methods Out of a pooled database of HF patients (n=1322) who underwent MIBG studies at 6 centers in Japan, 933 patients whose outcome at 5-years (y) was confirmed were selected (follow-up period, median 7.1y, range 0.1-14.6 y; number of CD: 205). Multivariate logistic regression analysis was performed for 5y CD including HF death, sudden CD and death from acute myocardial infarction. Net reclassification improvement (NRI) analysis was performed using prediction models without and with late heart to mediastinum ratio (HMR). The event risks were classified into 5y CD ranges of ≤5%, 5-25% and ≥25%. Results In the analysis without HMR, 4 parameters (4P) were significant predictors of CD: NYHA functional class, age, gender and ejection fraction. HMR was significant when added to produce a 5-parameter (5P) model. The receiver-operating characteristic area under the curve increased significantly from 0.75 for 4P model to 0.78 for 5P model (p=0.0015). In patients with CD, addition of HMR slightly improved the risk classification (NRI 4.9%, p=0.096). In patients without CD, however, the 5P model with HMR significantly improved NRI by 9.0% compared with results with the 4P model (p Conclusions MIBG HMR was highly predictive of 5y CD. The 5P model including HMR improved risk stratification of HF patients, particularly for reclassifying patients into the lower risk groups.

Although the prognostic value of cardiac MIBG imaging in chronic heart failure (HF) patients has been shown, a large cohort database would enable development of powerful evidence for establishing the efficacy of quantitative MIBG markers to identify high-risk HF patients. A cardiac I-123-

This paper presents a very simple way to design a robotic system having a visual feedback loop. Generally, human motor control is constructed on the basis of a largely-delayed dynamic system from the viewpoint of neurophysiological aspect and musculoskeletal structure. In particular, the optic nerve system potentially contains large delay time for image capturing and its processing that is absolutely imperative not only for human usual movements but also for robotic operations. Despite that, conventional robotic systems have been being explored for an extremely-fast processing system that is constructed on recent ultra-high-speed cameras. This study elaborates on the stability of soft-fingered manipulation on a situation at which enormously large time-delays exist. In addition, we show that, even in that case, the design method for controlling a target object grasped by a two-fingered robotic hand can be simply described. Finally, we say that the large time-delay system is an advantage architecture for achieving refined movements of humans and robots.

To carry out the decomposition of chlorinated aromatic compounds such as dioxins, which are hard to decompose at room temperature, nanoscale α-Fe · Fe3O4 composite particles were synthesized via α-FeO(OH) obtained by the reaction of ferrous sulfate and sodium carbonate aqueous solutions and contained 0.25 wt% precious metals (Pt, Pd, Rh and Ru). As the result of the decomposition of chlorobenzene (CB) using the composite particles containing precious metals, it was shown that Rh · α-Fe · Fe3O4 and Ru · α-Fe · Fe3O4 composite particles exhibit superior dechlorination function. Ru · α-Fe · Fe3O4 composite particles were selected because of their low price. For the application of dioxin decomposition at room temperature in contaminated soil, an extractive reagent was selected. Successively, the decomposition of dioxins in extracted-reagent- suspended soil using Ru · α-Fe · Fe3O4 composite particles was carried out at room temperature for seven days, and the initial Toxicity Equivalency Quantity (TEQ) values of dioxins in the solvents and soils decreased to 41-63% after the decomposition.