We focused on the traditional processing method which generates the superior quality of Yamato-shakuyaku. First, we assessed the historical literature written around Edo and Meiji period and rediscovered the traditional air drying method still inherited in Nara Prefecture. Then, we gathered and analyzed the data of medicinal plants production in Nara Prefecture among 1938 and 2019, and investigated the decline of local production and experienced agricultural techniques of peony through the transition of its yield. In order to visualize the ancient knowledge of crude drug manufacturers that contributes to the instruction of the skills for supply of seedlings, cultivation, and processing, we settled the meteorological observation devise at the outdoor drying shelf for 3 years, and recorded the real drying environment. When comparing the meteorological data with other cultivating area of peony using the estimated values of Agro-Meteorological Grid Square Data, the climate of Nara Prefecture was with high temperature and low humidity than other areas, and it seems to be quite suitable for air drying with adequate topography. The wind rose calculated by measured values of wind direction and wind speed showed the wind conditions in Nara that west wind was frequent in daytime and wind conditions are mildly but diversely changing. Among other producing areas of peony, the mechanical drying is major, whereas air-drying with low cost utilizing local environment features is still applied in Nara. We revealed the rationality of traditional methodology by digitization of meteorological factors which can be high added value.

Objective: In recent years, an association between serum soluble immune checkpoint molecules (sICMs) and malignant tumors has been reported, which may become important biomarkers in the future. Although several reports have suggested a correlation between sICMs and prognosis, their origin is unclear. In this study, changes in serum soluble PD-L1 (sPD-L1) during the perioperative period and its origin were analyzed in patients with lung cancer.Patients and Methods: Patients with lung tumors (n=39) were included. Samples for sPD-L1 measurements were collected at five time points before and after surgery, and their changes over time were analyzed. ELISA was used to measure sPD-L1 levels.Results: Thirty-nine patients with lung tumors (31, males; 8, females; age, 74 (years) ± 7.7 (range: 51–89) years; malignancy/benign, 33/6) were enrolled. Eight cases of driver gene mutation-positive tumors were included. Twenty-eight (72%) patients were smokers, and their performance status was 0-1 in all 39 patients. PD-L1 TPS was ≥50%/1–49%/<1% in 8/10/14 patients. Stage I/II/III/IV/postoperative recurrence of lung cancer was observed in 21/0/6/5/1 patients, respectively. There were no significant correlations between sPD-L1 levels and clinicopathological features and no correlation with PD-L1 TPS. Comparing localized lesions (stages I–III) with advanced lesions (stage IV and postoperative recurrence), the distribution of sPD-L1 was slightly higher in advanced lesions, although the difference was not significant. No obvious changes in sPD-L1 expression were observed before and after surgery.Conclusion: sPD-L1 levels tended to be high in stage III and above lung cancer. There was no change in sPD-L1 levels before and after surgery. sPD-L1 levels did not correlate with the PD-L1 TPS.

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.

An eight-year-old girl was referred and admitted to our hospital with the chief complaint of purpura on her lower legs. Blood tests revealed pancytopenia, and bone marrow findings showed marrow hypoplasia. Refractory cytopenia of childhood (RCC) was diagnosed based on the central diagnostic system of the Myelodysplastic Syndrome Committee of the Japanese Society of Pediatric Hematology. Immunosuppressive therapy was performed with the administration of rabbit antithymocyte globulin, methylprednisolone and cyclosporin A,but it was not effective. Eight months after admission to our hospital, Kampo treatment was started based on traditional Kampo diagnosis. After treatment with oral administration of kamikihito and kyukikyogaito, her pancytopenia gradually improved. Erythrocyte transfusion was discontinued after 2 months, and concentrated platelet transfusion also became unnecessary after 3 months. As a result of improvement in pancytopenia, her white blood cell count, hemoglobin value, and platelet count reached almost normal levels after 16 months. The scheduled bone marrow transplantation was canceled. The action mechanisms of kamikihito and kyukikyogaito for RCC are not clear, and their effective rates are also unknown. However, Kampo treatments are less invasive, inexpensive, and have few side effects. We believe that Kampo medicine is a therapeutic method that should be actively attempted in cases of RCC with poor response to standard treatment.

Introduction: This report describes a case of hyperactive delirium induced by tapenatadol whose symptoms were successfully managed with opioid-switching to oxycodon. Case: A 67-year-old female, who had been treated with chemotherapy for malignant thymoma, had to stop chemotherapy because of her carcinomatous pericarditis. Tapentadol 200 mg per day was administrated for her unbearable chest wall tumor invasion-related somatic pain. After a while, insomnia, visual hallucination, thought disturbance, and attention disturbance were appeared. We diagnosed as hyperactive delirium. Because her somatic pain was favorably controlled by tapentadol, we additionally administered quetiapine 50 mg per day instead of replacing tapentadol. Unfortunately, quetiapine was not effective for the delirium. We therefore switched opioids from tapentadol to oxycodon. The delirium was remitted soon after the switching without relapsing of the pain. Conclusion: Tapentadaol reportedly induce hyperactive delirium via its noradrenaline reuptake inhibitory action. This case suggests that switching tapenatadol to other opioid could be an effective option for opioid induced delirium.

Background: Laparoscopic gastrectomy has several difficult points including, lymph node dissection and resection of several blood vessels for trainee surgeons. Recently, preoperative evaluation of vasculature based three-dimensional (3D) imaging technique resulted in a significantly improved clinical outcome in abdominal surgery. The aim of this study is to investigate the usefulness of the 3D image in laparoscopic gastrectomy for trainee surgeons. Method: We adopted a multiphase CT protocol to acquire 3 image sets (arterial, portal, and equilibrium phases). 3D-reconstruction of gastric vasculature was made using data from a contrast enhanced MDCT and SYNAPSE VINCENT software. Whole pancreas, spleen, gastric vasculature were extracted from MDCT scans and traced. Thirty three patients, who underwent laparoscopic gastrectomy for gastric cancer during the period between Jan 2013 and May 2014 were examined in this study. Four trainees performed a 19 laparoscopic gastrectomy, while 14 laparoscopic gastrectomy were conducted by the two trainers. The surgical outcomes in both groups and the pattern of gastric vasculatures were evaluated. Result: 3D imaging technique showed a correct positional relationship between the stomach, gastric vessels, pancreas and spleen. Surgical outcome including estimated blood loss, and operative time in trainee group were not significantly different compared to trainer group. 3D imaging technique showed a correct positional relationship between the stomach, gastric vessels, pancreas and spleen. Regarding vascular pattern detected by 3D imaging, the origins of IPA were RGEA in 12 cases (36%), GDA in 8 cases (24%).bifurcation of RGEA and GDA in7 cases (21%), and not detected in 1 case (3%), respectively. The types of confluence of IPV were RGEV in 16 cases (48%), ASPDV in 10 cases (30%), and not detected in 7 cases (21%), respectively. Conclusions: 3D imaging technique might contribute to successful laparoscopic gastrectomy. Preoperative 3D-simulation techniques enabled trainee surgeons to easily and safely perform laparoscopic gastrectomy.

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.

An 85-year-old malnourished man was admitted with ischemia-induced necrosis of the rightleg and high-risk factors, including chronic obstructive pulmonary disease, pneumonia, andinfection of the necrotic leg. We controlled the infection and provided proper nutrition.Using light general anesthesia and a nerve block, we amputated the leg above the knee. Thepatient could eat and drink the same day following the surgery, and respiratoryrehabilitation was begun the next day. His postoperative course was uneventful. Our casesuggests that maintenance of good nutrition may play a key role for high-risk eldersundergoing leg amputation.

The patient was a 49-year-old woman. She developed retroperitonitis and retroperitoneal emphysema due to iatrogenic duodenal perforation. We inserted a nasogastric tube into her stomach in order to decompress the gastrointestinal tract, and cefoperazone and proton pump inhibitors were administered intravenously. Her symptoms of retroperitonitis were then reduced. However, she developed enteritis suspected due to MRSA infection complicated by acute respiratory distress syndrome, acute renal failure and shock. We administered vancomycin via nasogastric tube, but her symptoms did not improve, so we added shojokito. She relieved her bowels after the administration of shojokito, and an antipyretic tendency was observed. Her breathing status recovered to normal, her blood pressure was stable, and her general condition gradually improved.
In recent years, we have not had many opportunities to perform Kampo treatment for severe infection cases needing hospitalization, but Kampo application has the potential to enhance the efficacy of infection treatments. Thus we advocate the active carrying out of Kampo treatment for patients with intestinal infection.

We report two cases of inchinkoto treatment for obstructive jaundice via autoimmune pancreatitis (AIP). Case 1 : A 38-year-old male. After completion of treatment for Mikulicz disease, obstructive jaundice developed. A diagnosis of AIP was based on a high IgG 4 blood level and image views. T-Bil stayed above 20 mg/dl and there was no improvement by oral administration of prednisolone (PSL), ursodeoxycholic acid, or bilirubin adsorption therapy. Upon inchinkoto administration, T-Bil promptly fell to 3 mg/dL. Case 2 : A 77-year-old male. He suffered from itching and constipation, and blood data showed a pattern of obstructive jaundice. Image views suggested AIP, but a duodenal papillary biopsy could not provide a definitive diagnosis. Inchinkoto was administered, and the itching and constipation had mostly disappeared within 1 week. However, these symptoms recurred after one month. A definitive diagnosis of AIP was then reached based on a pancreas biopsy, and a PSL regimen was initiated. From these two cases, we consider that inchinkoto is useful for improving the symptoms of obstructive jaundice induced by AIP.