Introduction: The Tokyo Guidelines 2018 (TG18) developed from TG13 provides a simple criteria and management strategy for acute cholecystitis. The influence of the timing of percutaneous transhepatic gallbladder drainage (PTGBD) in elective laparoscopic cholecystectomy (LC) for acute cholecystitis on surgical outcome has not been clarified. Methods: 45 patients who underwent PTGBD followed by LC for moderate to severe acute cholecystitis were enrolled in this study. Patients were divided into two groups according to the timing of PTGBD. Group I patients underwent PTGBD within 72 hours of symptoms (n = 28), whereas group II patients underwent PTGBD at more than 72 hours of symptoms (n = 17). Results: Operation time was longer in group II (median 112 versus 146 min) (P = 0.04). The rate of postoperative complica-tions was significantly higher in group II (0 versus 3 cases) (P = 0.05). Conclusions: Patients underwent PTBD at more than 72 hours of symptoms showed higher difficulty in LC. We recommend that PTBD within 72 hours of symptoms for the elective LC is performed in patients with acute cholecystitis.

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Background: Understanding the pathogenesis of nonalcoholic steatohepatitis (NASH) in humans has been hampered by the lack of a comprehensive and physiological small animal model of NASH. We previously reported a dietary (high-fat and high-cholesterol; HFC diet) -induced NASH model that developed advanced fibrosis within a relatively short period (9 weeks) using Sprague-Dawley (SD) rats (age, 9 weeks). Methods: In this study, we evaluated the age-related alterations of NASH in 9-, 18-, and 27-week-old male SD rats that were fed an HFC diet (30% fat, 1.25% cholesterol, and 0.5% sodium cholate, w/w) for 9 weeks (six rats/group). Results: Age-dependent increases in serum transaminases, insulin, and insulin resistance index were observed with or without a significant difference after the 9-week rearing period. Histopathological findings such as hepatic steatosis, lobular inflammation, and hepatocyte ballooning were similar regardless of age, but hepatic fibrosis was more evident in the older groups. Rats in all three groups developed NASH at a high rate (83.3% or higher in each group). The mRNA levels of fibrosis-related genes encoding transforming growth factor-β (TGF-β) and α-smooth muscle actin (α-SMA) in the liver were low in the youngest group and high in the older groups, although this difference was not statistically significant. Conclusion: These results and those from our previous study indicate that a 9-week HFC diet-induced NASH model using SD rats can be applied a relatively wide range of ages (5-27 weeks of old), and that the risk of NASH-related fibrosis increases with age.

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Cytomegalovirus (CMV) colitis associated with chemotherapy for gynecologic cancer is rare. We report a case of CMV colitis linked to treatment with paclitaxel/carboplatin (TC) and bevacizumab (BEV) for ovarian cancer. Our patient was a 59-year-old woman who completed one course of TC chemotherapy and one course of TC + BEV as neoadjuvant chemotherapy for advanced ovarian cancer. On the 7^th day of TC + BEV therapy, she visited our hospital for continuous diarrhea, abdominal pain, and melena. Grade 4 neutropenia and fever were also detected. She was diagnosed as CMV colitis via colonoscopy and histopathological examination. This is the first case report of CMV colitis complicated by chemotherapy-induced febrile neutropenia during the treatment for gynecologic cancer.

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Superior vena cava syndrome (SVCS) is an oncological emergency. Lung cancer is the most causative malignancy. In con-trast, breast cancer rarely causes SVCS. We report a case in which SVCS was caused by mediastinal lymph node metastasis of breast cancer. The patient was a 60-year-old woman who had undergone breast-conserving therapy at another hospital 13 years previously. Her breast cancer was early stage (T1a(5mm)N0M0; Stage IA), and Luminal type (HER2 negative). She had received adjuvant hormone therapy, but dropped out of treatment two years and six months later. Recently, she had developed cough and face edema, and her extrajugular vein was swollen. CT revealed swollen mediastinal and supraclavicular lymph nodes, lung nodules, pericardial effusion, right pleural fluid, and stenosis of the superior vena cava (SVC). She was diagnosed with recurrent breast cancer with SVCS due to mediastinal LN swelling. A core needle biopsy of a supraclavicular lymph node revealed metastasis; the diagnosis was luminal HER2 positive breast cancer. We initiated treatment with radiotherapy for the mediastinal lymph nodes, and then started hormone therapy and anti-HER2 therapy. These therapies provided relief from her symptoms. She is currently alive and continuing hormone therapy and anti-HER2 therapy. In cases of SVCS due to malig-nancy, the biopsy findings should be taken into account when possible. An accurate diagnosis is extremely important for the suitable treatment of SVCS, especially in cases caused by malignancy.

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A 56-year old woman was admitted to our institution for the treatment of pulmonary artery aneurysm and pulmonary valve regurgitation. Multislice three-dimensional computed tomography showed a very large (61 mm in diameter) pulmonary artery aneurysm. Transthoracic echocardiography revealed severe pulmonary valve regurgitation and an enlarged right ventricle. Pulmonary artery aneurysmorrhaphy and pulmonary valve replacement were performed. Postoperative hemodynamics were stable. No recurrent dilatation of the pulmonary artery or cardiac failure was observed 9 months after surgery.

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