Nonalcoholic steatohepatitis (NASH), occurs frequently with diabetes mellitus and obesity, contributes to insulin resistance, can develop cirrhosis or even hepatocellular carcinoma (HCC). Although NASH has become more common, its underlying mechanism is still not clear and effective therapy has not been established. Currently, it has been recognized that the multiple parallel factors, including genetic differences, insulin resistance, lipotoxicity and dysbiosis act synergistically in genetically in pathogenesis of NASH. Impaired autophagy parallel to excess lipid supply might explain the progression of NASH to HCC. Liver-specific knockout mice of phosphatase and tensin homolog deleted on chromosome ten (PTEN) develops steatohepatitis followed by HCC, suggesting a potential role for this molecule in development and progression of NASH.

Juntendo, which has a history dating back to the Edo era, has made major contributions to Japan’s healthcare. In the field of obstetrics and gynecology, this school has provided various pioneering innovations and educational efforts including the development of a surgical technique for ovarian cystoma, implementation of the first cesarean section in Japan, and the introduction of painless delivery to this country. On the occasion of my retirement, I would like to highlight certain topics pertaining to clinical practice and research in obstetrics and gynecology during the past decade and how fascinating this field of medicine truly is.

In 1990, the first laparoscopic cholectomy in Japan was performed, having a marked impact on extended laparotomy and extended operation which had been used for a long time. I initiated laparoscopic colectomy in 1993. At the beginning, no surgical text on laparoscopic surgery (LAP) was available and there was no instructor showing me a model, so that everything started from zero. I actively introduced LAP mainly for colorectal and gastric cancers and promoted its development.

A quarter of a century has passed since the initiation of LAP for colorectal cancer. Laparoscopic colectomy has gained popularity recent years. At present, 60-70% of surgical colorectal cancer patients in Japan receive laparoscopic surgery, which is markedly different from the situation at the beginning. Actually, laparoscopic surgery has become the main surgery for colorectal cancer. It is essential for young surgeons responsible for the next generation to acquire the skills of laparoscopic surgery. It was my fortunate that I could be involved to a significant extent in the history of the marked changes in colorectal surgery.

Here, I review my experience and career from my days in Juntendo University to my retirement. When I was a student at the university and during my residency, I came across patients whose conditions were like those I had read about in novels or seen in movies. When I was working at the department of respiratory medicine, I was engaged primarily in research related to the thoracic cavity and clinical practice related to pulmonary circulation and chronic respiratory failure, and I was able to contribute to my colleagues’ research. When I was an administrative official for health insurance, I was able to see the Japanese health insurance system from the perspective of the operator of the system, rather than its users. This experience was extremely useful while I was working at Juntendo Tokyo Koto Geriatric Medical Center. At the Center, for the first time in my career, I was able to witness how a hospital develops and improves over the years.

Objective: The purpose of this study was to investigate the early and long-term outcomes of off-pump coronary artery bypass grafting (CABG) with and without the use of bilateral internal thoracic arteries in diabetic patients.

Materials and Methods: Off-pump isolated and primary CABG for multiple coronary artery systems was conducted on 827 patients in our hospital between July, 2002 and December, 2007. We divided patients into 2 groups: diabetic (n=354) vs. non-diabetic (n=473). All internal thoracic artery grafts were taken using the skeletonization method. We compared early and long-term outcomes between patients with bilateral internal thoracic artery grafts (BITA) and those without (non-BITA) in each group.

Results: BITA was performed on 192 patients (54.2%) in the diabetic group and 225 (47.6%) in the non-diabetic group. No significant differences were observed in early morbidity or mortality between the groups. The Kaplan-Meier survival analysis revealed that freedom from major adverse cardiac and cerebrovascular events (MACCE), cardiac death, and target vessel revascularization were greater in BITA than in non-BITA in the diabetic group (78.8% vs. 66.0%, p=0.027; 92.6% vs. 85.4%, p=0.033; 94.8% vs. 88.4%, p=0.031), but were not in the non-diabetic group. Cox’s proportional hazard model revealed that the incidences of MACCE and cardiac death were decreased by the use of BITA (hazard ratio: 0.56, p=0.030; hazard ratio: 0.36, p=0.030, respectively) in the diabetic group.

Conclusions: Significant reductions were observed in the incidences of MACCE, cardiac death, and target vessel revascularization with BITA in the diabetic group. The bilateral use of skeletonized ITAs in off-pump CABG may provide more benefits for diabetic than non-diabetic patients.

Objective: It is difficult to conduct a randomised control trial in a single institution because of the small number of cases. The current study was conducted to investigate if there is any difference in long-term outcome between laparoscopic surgery (LAC) and open surgery (OC) using propensity-score matching analysis based on prognostic factors.

Materials: Two hundred and sixteen patients with locally-advanced colon cancer who underwent surgery with curative intent at our department between 2002 and 2010 were enrolled in the current study.

Methods: Propensity score matching analysis and Inverse Probability Weighting (IPW) estimator were used to adjust for differences in the clinicopathological severity between LAC and OC.

Results: Before propensity score matching analysis recurrence-free survival in LAC was statistically better than that in OC (Hazard ratio= 0.59, 95% CI 0.35-0.98, p=0.04), and no statistically significant difference was recognized for cancer-specific survival (Hazard ratio=0.63, 95% CI 0.27-1.37, p=0.25). After propensity score matching analysis there were no statistically significant differences for recurrence-free (Hazard ratio=0.91, 95% CI 0.41-2.01, p=0.81) or cancer-specific survival (Hazard ratio=1.38, 95% CI 0.41-4.82, p=0.59). In addition, the IPW estimator revealed that the difference for recurrence-free survival was not significant between the two groups.

Conclusion: The one-to-one pair propensity score matching successfully balanced the clinicopathological factors between LAC and OC. The propensity score matching analysis demonstrated no significant difference between LAC and OC.

A 68-year-old male presented with an abnormality on upper gastrointestinal endoscopy during a health check. He was diagnosed with malignant melanoma of the esophagus using biopsy tissue and admitted for surgery. Thoracicoabdominal computed tomography did not reveal any tumor lesions in the esophagus wall. Swelling of the lymph node and metastases were not found in other organs. The preoperative diagnosis was T1N0M0 and stage I disease, and an operation was performed. The patient was diagnosed with T1a-LPM, N0M0, stage 0 according to the Japanese Classification of Esophageal Cancer. Melanosis was diagnosed in gross appearance in the black mucous membrane part without the upheaval.

Nine months have elapsed since surgery, and the patient has survived without recurrence. Esophageal malignant melanoma is a relatively rare disease, and there are no treatment guidelines. We report our experience with a case of resection of esophageal malignant melanoma.

Endoscopic sinus surgery is widely accepted as a primary surgical modality for the treatment of inflammation, trauma, benign tumors, and fibro-osseous lesions. Recent advances in instrumentation, surgical navigation, and skull base reconstruction have enabled endoscopic skull base surgery to emerge as a minimally invasive technique for selective cases. The centripetal endonasal technique consists of 5 main steps including i) reduction of the neoplasm volume, ii) centipetal subperiosteal ethmoidal-nasal removal, iii) removal of bone underlying the tumor, iv) removal of the dura, olfactory bulb, and peri-orbit, and v) skull base duraplasty, which enables dissection of the sinonasal tract in several blocks for the radical removal of a malignant neoplasm. We present our experiences of endoscopic endonasal anterior skull base surgery for 5 cases of sinonasal malignancies with relatively long-term follow-ups of from 41 to 122 months. No local recurrence or distant metastasis was observed. There was no cerebrospinal fluid leak after duraplasty or postoperative infection. The use and indications for endoscopic endonasal surgery of sinonasal malignancies involving the anterior skull base have been expanding. Relatively low-grade malignancies such as olfactory neuroblastoma, adenocarcinoma, and chondrosarcoma in selective cases are good indications for endonasal endoscopic approaches.

Diffusion magnetic resonance imaging (dMRI), which was established in the mid 1980’s, is an imaging technique that is based on the diffusion of water molecules in tissue. Initially it was an isotropic diffusion-weighted imaging (DWI) technique, and has been widely used mainly for investigating the tissue microstructural changes in neurological abnormalities, especially ischemic stroke. Many studies have been conducted to validate the usefulness of DWI in clinical settings and to improve the technique. Diffusion tensor imaging (DTI) was later introduced to deal with the anisotropic diffusion; the use of an ellipsoid tensor model means that the size and the direction of the water diffusion can be delineated. DTI and its developments are becoming powerful tools, and have become the standard imaging techniques for analyzing white matter fiber structure and connectivity in vivo. Furthermore, to facilitate researchers in applying DTI for multi-subject studies, tract-based spatial statistics (TBSS) was developed. TBSS is a voxelwise statistical analysis that was originally used to evaluate the fractional anisotropy (FA) values in the white matter. Thereafter, diffusion kurtosis imaging (DKI) was developed to overcome the limitations of DTI such as the non-Gaussian characteristics of tissue and the crossing fiber problems. The latest promising technique is neurite orientation dispersion and density imaging (NODDI), which can be used to show the microstructural changes of brain tissue more sensitively and specifically.