The patient is a 71-year-old man. After receiving chemoradiotherapy (CRTx) for an unresectable esophageal cancer, he developed sudden hematemesis during a follow-up examination. Subsequent imaging via contrast-enhanced computed tomography (CT) showed leakage of the contrast medium from the descending aorta into the esophagus. Consequently, an aortoesophageal fistula (AEF) was diagnosed and an emergency thoracic endovascular aortic stent graft repair (TEVAR) was scheduled. However, during the preparation for surgery, the patient vomited a large amount of blood and went into cardiopulmonary arrest. Following the administration of cardiopulmonary resuscitation, a Sengstaken-Blakemore tube (SB-tube) was inserted intranasally to control bleeding and TEVAR was performed to save his life. Although a gastrostomy was necessary after the surgery, the patient was transferred from the hospital on the 32nd day without any complications. Nonetheless, his general condition deteriorated as the cancer progressed and he died on the 103rd postoperative day. It is generally reported that the risk for esophageal perforation is 10-20% in CRTx for unresectable esophageal cancer. Although issues regarding the long-term prognosis of patients treated with TEVAR have been highlighted in recent years, there have also been reports of life-saving cases following its use; in this case, the patient was discharged home after SB-tube insertion and TEVAR with prompt treatment, resulting in his life being prolonged for an estimated 3 months.

No abstract available.
Crohn Disease* ; Food, Formulated* ; Humans ; Infliximab*

　　We report a case of vaginal cuff dehiscence after total laparoscopic hysterectomy that was successfully managed by a newly developed vaginal double-layer circular incision-closure method through a transvaginal approach. The nulligravid postmenopausal patient with cervical cancer received a diagnosis of vaginal evisceration on postoperative day 24. The eviscerated small intestine was pushed back after vaginal douching with normal saline before the procedure. The vaginal mucosa was incised circularly in two layers at the levels of 10 mm and 15 mm from the vaginal stump, and the edges apposed with double-layer closures. She was discharged on postoperative day 3 and followed up for 5 years, with no recurrence of cancer or vaginal dehiscence. This operative method is especially useful for a nulligravida with a small vagina.

　　This retrospective study was carried out to clarify the preventive effect of neutral positioning of both arms on upper extremity neuropathy after gynecological laparoscopic surgery compared with right arm abduction positioning. In 93 cases of right arm abduction positioning >90°, with the left arm tucked in at the side, postoperative right hand numbness occurred in 6 cases (6.5%). In these 6 cases, symptoms disappeared in 4 cases after postoperative day (POD) 1, in 1 case after POD 21, and in the remaining case after POD 41. In 81 cases where both arms were in the neutral position tucked in at the sides with shoulder braces applied, upper extremity numbness was not experienced in any cases; however, shoulder pain developed in 4 cases (4.9%) and was thought to be related to using the shoulder braces. The pain disappeared in 2 cases after POD 1, in 1 case after POD 2, and in the remaining case after POD 3. In right arm abduction positioning without the use of shoulder braces, shoulder pain was not experienced in any cases. Neutral positioning of both arms in gynecological laparoscopic surgical patients was effective for the prevention of upper extremity neuropathy, but measures to alleviate the onset of shoulder pain after change in positioning need to be addressed in the future.

Non-contact anterior cruciate ligament (ACL) injury is one of the most severe knee problems for female athletes. Several studies have reported that the decreased lower limb control of women such as decrease of hip abductions muscle strength increase the risk of ACL injury. Also ACL Injury often occurs as a result of knee valgus collapse during single leg landing or pivoting in sports activities like basketball. Female basketball players often show an excessive knee valgus and hip adduction during the play. The purpose of this study was to analyze the effect of hip abductions muscle strength on knee alignment during a single leg landing. Thirty healthy female basketball players participated in this study. Mean age, height, body weight and plyer career were 17.3 years old±3.7, 162.7cm±17.2, 56.2kg±10.9, 8.9 years±3.8 respectively. All subjects were obtained written consent from after explanation of the procedure. Significant negative correlations showed that greater hip abductor peak torque (hip flexion 0 and 30degrees) exhibited less motion toward the knee valgus direction during single leg landing. And also, dynamic Trendelenburg test showed that all positive reactions cause knee valgus direction. These results suggest keeping proper knee position safety during single leg landing; female basketball player should improve the hip abductions muscle strength. Hip joint control will be a major issue for prevention of the non-contact ACL injury.

　　We report a case of subcutaneous port-site hematoma developed on day 6 after laparoscopic left-sided salpingooophorectomy. To start the procedure, three ports were placed in the umbilicus and in each lower quadrant using bladeless trocars. No bleeding was observed at the trocar sites after insertion or withdrawal. The patient was discharged on postoperative day (POD) 3, but returned to the emergency outpatient department with acute left lower abdominal pain on POD 6. Dynamic CT revealed a port-site hematoma with active bleeding from a subcutaneous artery. Hemostasis was achieved easily by opening the trocar wound. Dynamic CT was useful to locate the bleeding vessel and enabled use of a minimally invasive procedure to control bleeding.

　　We have developed a new surgical procedure for uterine prolapse of round ligament suspension to the psoas minor tendon by the use of a laparoscope. Here, we describe the new technique and report the outcome of surgery in three cases.　　Operative procedure: The fundus of the uterus is lifted back up to its natural position by fixing the round ligament of the uterus to the psoas minor tendon after incising the peritoneum covering psoas. It is important to use the tendon as a stronger reattachment site in addition to the psoas major muscle. The round ligament is tacked to the tendon by a 2-0 nonabsorbable suture on bilateral sides. The second suture may be added if the uterus is not appropriately lifted up by the first suture. The retroperioneum is closed by a continuous 3-0 absorbable suture after fixation.　　Cases: Two patients with severe uterine prolapse and one patient with a mild condition went through the operation safely and have experienced no recurrence for 10 to 24 months. One severely ill patient complained about post -operative right inguinal pain early and another with the severe condition complained that something felt wrong with the right thigh.　　We propose the operation of laparoscopic round ligament psoas minor tendon-hitching as a safe and effective surgical treatment for uterine prolapse.

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.
Adenoma/pathology/*surgery ; Adult ; Aged ; Aged, 80 and over ; Ampulla of Vater/pathology/*surgery ; Biopsy ; Common Bile Duct Neoplasms/pathology/*surgery ; Dissection/*methods ; Duodenoscopy/*methods ; Feasibility Studies ; Female ; Humans ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; Treatment Outcome

　　Placental abruption occurs suddenly and may cause maternal and fetal mortality. Forced delivery is the only way to improve perinatal outcome, but the aftereffects could be severe despite a high survival rate.　　Our hospital manages approximately 170 cases of maternal transport annually, including cases of severe placental abruption. Longer transport time can lead to undesirable maternal and fetal outcome. Hence this study, we compared the perinatal backgrounds and outcome of placental abruption retrospectively between the cases managed by maternal transport and by the local hospital (our hospital). The study included 54 cases of placental abruption during the period from January 2008 to December 2012, of which 27 cases were managed by our hospital, the other halves were managed by maternal transport. There were 6 intrauterine fetal deaths but not a single maternal death. There were no significant differences in the amount of blood lost and obstetric DIC (disseminated intravascular coagulopathy) score between two groups (p＝0.342, p＝0.649), and the number of cases that needed anti-DIC therapy and blood transfusion in each group was statistically similar (p＝0.807, p＝0.115). The time taken from the on-set of placental abruption to delivery was significantly shorter for the cases managed by our hospital (in-hospital management 143±133 minutes, maternal transport management 265±176 minutes, p‹0.05), while obstetric DIC score and Apgar score showed no significant differences (p＝0.336, p＝0.780) between the two groups. Thus, it could be said there were no correlations between the time taken from onset to delivery and perinatal outcome. It should be noted, however, maternal and fetal outcome of placental abruption could be fatal even with the rapid intervention, so quick diagnosis and management at the first contact are crucial. Thus, we concluded that forced delivery managed by the local hospitals is necessary for the potential better perinatal outcome, and an ideal system to manage maternal and/or neonate transport after the delivery should be established immediately.

  In order to intervene in the management of pain of cancer from an early stage. Our palliative care team (PCT), including pharmacists, makes the ward rounds (screening rounds) of the patients receiving opioids at our hospital. The purpose of this study was to analyze the effects of screening rounds activity by the PCT and its current problems, and to explore how to resolve the problems. We retrospectively studied the records of 196 patients who had receivede interventions by the PCT, with regard to intervention status and prescription proposal (228 subjects) about drug therapy by us. Study groups were as follows: 103 patients to whom interventions were deliveed at the request of medical doctors (intervention request group) and 93 patients who had interventions by the PCT after PCT-screening rounds (screening group). PCT-screening rounds caused to increase the number of interventions by the PCT. After PCT-screening rounds, the cases of intervention started by the request of medical doctors, who had given no heed to PCT intervention, also increased in numher. In this study, some problems with palliative intervention were also brought to light. Even in the screening group where the PCT largely intervened, 33% of prescription proposal by the PCT was ignored. This problem may be, at least in part, due to inadequate communication between PCT and ward staff through an electronic medical recording card, leading to poor relationship between PCT and ward staff. In the future, the PCT needs to work cooperatively with ward staff through direct communication such as medical conference to perform better intervention.