Gait analysis was conducted on 7 healthy pregnant women (pregnant group) and 6 non-pregnant women (pseudo-pregnant group) using a 3-D motion analysis system (VICON 460) and two forceplates (Kistlar 9286A). The data was collected at 8-9 months of gestation (pregnant condition) and 4-8 months postpartum (non-pregnant condition) in the pregnant group. In the pseudo-pregnant group, the participants walked with a 5kg-load on their belly (pregnant condition) and without any load (non-pregnant condition). Comparisons using two-way ANOVAs with repeated measures were conducted. Interaction of group × condition was not observed in the measured gait parameters except the angle of the maximum hip adduction. Main effect in the condition and the group was found in some parameters. In the pregnant condition, gait velocity was slower (pregnant group 68.7±8.6 m/min pseudo-pregnant group 63.8±4.8 m/min) than in the non-pregnant condition (pregnant group 75.5±3.2 m/min pseudo-pregnant group 69.8±8.7 m/min). The second vertical peak ground reaction force was smaller in the pregnant condition (pregnant group 105.4±4.8 % pseudo-pregnant group 108.4±6.3 % of body-weight) than in the non-pregnant condition (pregnant group 114.3±7.4 % pseudo-pregnant group 113.5±4.2 % of body-weight). These results demonstrated that pregnant condition changed kinetic and kinematic characteristics of the gait.

Objectives: To evaluate the efficacy of tegafur–uracil (UFT), a prodrug of 5-fluorouracil, plus cisplatin and dexamethasone in patients with docetaxel-refractory prostate cancers.

Methods: Twenty-five patients with docetaxel-refractory prostate cancer were administered oral UFT plus intravenous cisplatin (UFT-P therapy) and dexamethasone. Treatment responses were assessed monthly via prostate-specific antigen (PSA) level measurements. Treatment-related adverse events and overall survival were also assessed.

Results: UFT-P therapy resulted in decreased PSA levels in 14 (56%) patients and increased PSA levels in 11 (44%). In patients with increased PSA levels, 7 (64%) of the 11 patients displayed decreased PSA doubling times. The UFT-P therapy response rate was 84% (21/25 patients). Imaging studies revealed that tumor shrinkage during UFT-P therapy occurred in 1 patient in whom bilateral hydronephrosis caused by lymph node metastasis improved. The median survival time from docetaxel initiation was 36 months. In UFT-P-treated patients, the median PSA progression and overall survival times were 6 and 14 months, respectively. UFT-P treatment-related adverse events were mild diarrhea, general fatigue, and anorexia. Treatment was not discontinued for any of the patients. UFT-P therapy did not cause serious hepatic or renal dysfunction or pancytopenia.

Conclusions: UFT-P therapy is a safe and effective treatment for patients with docetaxel-refractory prostate cancer, although large-scale, multicenter, prospective studies are needed to validate these findings.

Cerebral air embolism caused by lung cancer is extremely rare, especially if not associated with invasive procedures such as needle biopsy. We describe the case of an 86-year-old man with squamous cell lung carcinoma of the left lung. He developed a bad cough and subsequently suffered left hemiplegia. Brain computed tomography (CT) on admission showed no abnormal findings. Diffusion-weighted magnetic resonance (MR) imaging revealed high intensity lesions in the right frontal lobe and right parietal lobes. Repeated brain CT revealed air densities around the high intensity lesions on previous MR imaging, compatible with air embolism causing cerebral infarction. Chest CT confirmed a left pulmonary hilar mass invading the left pulmonary vein, left atrium, and main bronchus. Air densities were found in the left heart ventricle. These radiological findings were attributed to cerebral air embolism associated with advanced lung cancer. Shortly afterwards he died of progressive respiratory failure. Our case reveals two important aspects. First, cerebral air embolism can be caused by lung cancer invading the pulmonary vein, left atrium, and main bronchus without iatrogenic causes. Therefore, we should pay special attention to the etiology when the patients with lung cancer in the advanced stage developed cerebral infarction. Second, repeated CT is recommended if cerebral air embolism is suspected because initial head CT does not always reveal air bubbles.

Background: The glissonean pedicle approach was introduced by Couinaud and Takasaki in the early 1980s. The key of the glissonean pedicle approach is clamping the pedicle first, secondly confirming the territory, and finally dissecting the liver parenchyma. In this presentation, we introduced our recent refinements of glissonean pedicle approach for liver resection. “Approach to the glissonean pedicles at the hepatic hilus” Couinaud described three approaches to the hepatic hilus. 1) Intra-fascial access (Control method): The conventional dissection at the hilus or within the sheath is referred to as intrafascial access However, dissection performed under the hilar plate is dangerous and surgeons have to consider any variations of the hepatic artery and bile ducts. 2) Extra-fascial access (Glissonean pedicle approach): The glissonean pedicle is dissected from the liver parenchyma at the hepatic hilus before dissecting the liver parenchyma. This procedure prevents intrahepatic metastasis of HCC, which spreads along the portal vein and improves the overall survival after surgery. 3) Extra-fascial and transfissural access: If the main portal fissure or the left suprahepatic fissure is opened after dissecting the liver parenchyma, the surgeon can confirm the pedicles that arise from the hilar plate or the umbilical plate. “Operative techniques” 1) Preoperative 3D simulation of the precise anatomy of portal vein, hepatic artery and bile duct at hepatic hilus should be performed. 2) Right glissonean pedicle: The hilar plate is detached from the quadrate lobe. The assistant pulls the liver parenchyma cranially and the operator conversely pulls the hepatoduodenal ligament caudally. Mayo scissors are inserted along the liver parenchyma between the liver parenchyma and glissonean capsule (Fig.1). Then forceps are inserted in the same way and the right main pedicle is taped (Fig.2). The right anterior and posterior glissonean pedicles are taped as well. 3) Left glissonean pedicle: The hilar plate is detached from the liver parenchyma. Then, the Arantius duct is confirmed and the left pedicle is dissected along the left pedicle at the ventral side of the Arantius duct. “Pitfall of glissonean pedicle approach” The right pedicle should be dissected in the liver side as much as possible to prevent the injury of left hepatic duct. If possible, the right pedicle is recommended to be dissected at the level of the second branches separately (Fig.3). The right posterior hepatic duct sometimes branches from the left hepatic duct and the Arantius duct is confirmed and the left pedicle should be dissected along the left pedicle at the ventral side of the Arantius duct because the right posterior hepatic duct branches from the left hepatic duct at the dorsal side of Arantius’ duct. In addition, the intraoperative cholangiogram should be used in the case with the abnormal anatomy of bile duct. Conclusions: Any anatomical hepatectomy can be performed using “glissonean pedicle approach” which allows simple, safe and easy liver resection.

Combination of retrospective and prospective study.

Background/Aims: The Japan Gastroenterological Endoscopy Society (JGES) has published guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. These guidelines classify endoscopic ultrasound-guided biliary drainage (EUS-BD) as a high-risk procedure. Nevertheless, the bleeding risk of EUS-BD in patients undergoing antithrombotic therapy is uncertain. Therefore, this study aimed to assess the bleeding risk in patients undergoing antithrombotic therapy. Methods: This single-center retrospective study included 220 consecutive patients who underwent EUS-BD between January 2013 and December 2018. We managed the withdrawal and continuation of antithrombotic agents according to the JGES guidelines. We compared the bleeding event rates among patients who received and those who did not receive antithrombotic agents. Results: A total of 18 patients (8.1%) received antithrombotic agents and 202 patients (91.8%) did not. Three patients experienced bleeding events, with an overall bleeding event rate of 1.3% (3/220): one patient was in the antithrombotic group (5.5%) and two patients were in the non-antithrombotic group (0.9%) (p=0.10). All cases were moderate. The sole thromboembolic event (0.4%) was a cerebral infarction in a patient in the non-antithrombotic group. Conclusions The rate of EUS-BD-related bleeding events was low. Even in patients receiving antithrombotic therapy, the bleeding event rates were not significantly different from those in patients not receiving antithrombotic therapy.

Background/Aims: Bleeding is a complication of endoscopic snare papillectomy for ampullary tumors. This study aimed to investigate the clinical efficacy of hypertonic saline-epinephrine (HSE) local injection before endoscopic papillectomy for prevention of bleeding. Methods: We retrospectively reviewed the data of 107 consecutive patients with ampullary tumors who underwent endoscopic papillectomy. The rates of en bloc resection, pathological resection margins, and prevention of immediate or delayed bleeding in the simple snaring resection group (Group A) and the HSE injection group (Group B) were compared. Results: A total of 44 and 63 patients were enrolled in Groups A and B, respectively. The total complete resection rate was 89.7% (96/107); the clinical complete resection rates in Group A and Group B were 86.3% (38/44) and 92.1% (58/63), respectively (p=0.354). Post-papillectomy bleeding occurred in 22 patients. In Groups A and B, the immediate bleeding rates were 20.5% (9/44) and 4.8% (3/63), respectively (p=0.0255), while the delayed bleeding rates were 7% (3/44) and 11% (7/63), respectively (p=0.52). The rates of positive horizontal and vertical pathological margin in both groups were 27% and 16%, respectively. Conclusions HSE local injection was effective in preventing immediate bleeding and was useful for safely performing endoscopic papillectomy for ampullary tumors.

The treatment by Kampo decoction is partly covered by National Health Insurance in Japan. However, this system is facing bankruptcy crisis because of rising prices of crude drugs in China, their main producer. The board of crude drug materials of the Japan Society for Oriental Medicine (JSOM) distributed questionnaires to 7416 JSOM member doctors, and performed statistical analysis (with JSOM approval) of 1877 answers to visualize the data. Twenty-six percent of respondents said that they had prescribed a decoction, and 29% of respondents said they had not, but wanted to prescribe a crude drug. Eighty-eight percent of doctors who prescribe decoctions offered medical treatment primarily to insured patients. Nine percent offered medical treatment at patients' own expense. The latter group prescribed decoctions more frequently. Many doctors were aware of the financial risk of prescribing crude drugs imposed by the drug price standard and rising crude drug import prices. Four hundred and fifty­-five doctors explained when they were most inclined to prescribe a decoction. Thirty-five percent of these said they used decoctions when they couldn't treat patients with extracts. This result implies a necessity for decoctions. Many doctors said they prescribed decoctions for autoimmune or allergic diseases. Financial constraints were the most frequently cited barrier to treatment with decoctions. This survey made clear the financial difficulties clinics are facing. We therefore calculated the amount of crude drugs used for decoctions to validate the possibility of their domestic production.