We use evidence-based algorithms to treat abnormal scarring, including keloids and hypertrophic scars (HSs). This involves a multimodal approach that employs traditional methods such as surgical removal, postoperative radiotherapy, corticosteroid injection, laser, and silicone gel sheets. As a result, the rate of abnormal scarring recurrence has decreased dramatically over the past 10 years. However, several problems remain to be solved. First, despite the optimization of a radiotherapy protocol, over 10% of cases who are treated with surgery and postoperative radiotherapy still recur in our facility. Second, the treatment options for cases with huge keloids are very limited. To address these problems, we performed basic research on the mechanisms that drive the formation of keloids and HSs. Extrapolation of these research observations to the clinic has led to the development of two treatment strategies that have reduced the rate of abnormal scar recurrence further and provided a means to remove large scars.
Our finite element analysis of the mechanical force distribution around keloids revealed high skin tension at the keloid edges and lower tension in the keloid center. Moreover, when a sophisticated servo-controlled device was used to stretch wounded murine dorsal skin, it was observed that the stretched samples exhibited upregulated epidermal proliferation and angiogenesis, which are also observed in keloids and HSs. Real-time RT-PCR also revealed that growth factors and neuropeptides are more strongly expressed in cyclically stretched skin than in statically stretched skin. These findings support the well-established notion that mechanical forces on the skin strongly influence the cellular behavior that leads to scarring.
These observations led us to focus on the importance of reducing skin tension when keloids/HSs are surgically removed to prevent their recurrence. Clinical trials revealed that subcutaneous/fascial tensile reduction sutures, which apply minimal tension on the dermis, are more effective in reducing recurrence than the three-layered sutures used by plastic surgeons. Moreover, we have found that by using skin flaps (e.g., perforator flaps and propeller flaps), which release tension on the wound, in combination with postoperative radiotherapy, huge keloids can be successfully treated.

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Objective: To investigate the importance of sufficient dissection of the interhemispheric and sylvian fissures, an orbitocranial approach was used for clipping of ruptured anterior communicating artery aneurysms.
Patients and Methods: From January 1998 through March 2009, 41 patients underwent surgery for subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm. Their mean age was 58.4 years, with a range of 37 to 84 years. The preoperative World Federation of Neurosurgical Societies grade was I to III in 32 patients and IV to V in 9 patients. The direction of the aneurysm was upward in 23 patients, forward in 14 patients, and backward in 4 patients. Seven patients had a large aneurysm.
Results: All patients underwent surgery during the acute stage following the subarachnoid hemorrhage (day 0-2). A right orbitocranial approach was used for most patients, but a left orbitocranial approach was used for 9 patients because of the presence of a complicated aneurysm and the positional relationship of the left-right A2 segment. In 12 patients, external decompression was performed. The outcome, using the Glasgow Outcome Scale, was good recovery in 24 patients, moderately disabled in 8 patients, and severely disabled in 4 patients, and 5 patients died. Temporary eye movement disorders developed after surgery in 5 patients but resolved in all patients within 2 months. No patients had olfactory disturbance.
Discussion: Using the orbitocranial approach and sufficient dissection of the interhemispheric and sylvian fissures, we could secure a broad field of vision and surgical field, which contributed to a safe operation. The only postoperative complication caused by the surgical approach was temporary eye movement disorder. Thus, for some patients with aneurysms of the anterior communicating artery, the orbitocranial approach contributes to improved outcomes.

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This study aimed to examine whether morphological changes during the early stage of treatment or indices of proliferation, apoptosis, or hormone receptors are reliable predictors of the hormonal response to uterus-preserving high-dose progestin therapy in patients with endometrial adenocarcinoma. Seven patients (5 good responders and 2 poor responders) with presumptive stage IA endometrial adenocarcinoma treated with 600 mg/day of medroxyprogesterone acetate were reviewed. Epithelial cell size and stromal area observable on microscopic examination of hematoxylin and eosin-stained sections, and immunostaining labeling indices for Ki-67 nuclear antigen, single-stranded DNA, estrogen receptor, and progesterone receptor were semiquantitatively analyzed before treatment and after 4, 8, 12, and 16 weeks of treatment using computer imaging programs. The mean ratio of cell size after 4 weeks of treatment to that before treatment in good responders was 3.83, whereas the ratios in the 2 poor responders were 1.08 and 0.98. The mean Ki-67 nuclear antigen labeling index before treatment was 37.2% for the 5 good responders but was 51.0% in the 2 poor responders. The indices of the poor responders remained high (20%-77%), even after 16 weeks of treatment; in contrast, the indices of the good responders were low (0.4%-7.3%) throughout the treatment period. No definitive differences in labeling indices for single-stranded DNA, estrogen receptor, or progesterone receptor were observed between good and poor responders or at different stages of treatment (p>0.05). In conclusion, a higher epithelial cell size ratio after 4 weeks of treatment in conjunction with lower Ki-67 nuclear antigen labeling indices could be a potential predictor of hormonal response.

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Background: In patients with clinically node-negative breast cancer, diagnosed with palpation and several types of imaging examination, sentinel lymph nodes accurately predict the status of the other axillary nodes, which determine the nature of subsequent adjuvant treatment. In addition, compared with axillary lymph node dissection, sentinel-node biopsy results in less postoperative morbidity, including pain, numbness, swelling, and reduced mobility in the ipsilateral arm.
Methods: We analyzed the validity of the sentinel node biopsy procedure using dual-agent injection of blue dye and radioactive colloid performed in our hospital from May 2006 through March 2010. A total of 258 breasts of 253 patients were studied. Simultaneous axillary lymph node dissection was performed only if rapid intraoperative diagnosis identified metastasis in sentinel lymph nodes. The identification rate, accuracy, provisional false-negative rate, which was calculated with data from all 65 patients whose sentinel lymph nodes had metastasis, and axillary recurrence rate of sentinel node biopsy were calculated.
Results: The sentinel node identification rate was 99.2%, and the accuracy of sentinel lymph node status was 98.0%. The provisional false-negative rate was 7.7%. During an observation period averaging 24 months, axillary recurrence was observed in only 1 of 256 cases (0.4%), and there were no cases of parasternal recurrence. In patients who underwent sentinel-node biopsy without axillary lymph node dissection, there was no obvious morbidity.
Conclusion: Our sentinel-node biopsy procedure yielded satisfactory results, which were not inferior to the results of previous clinical trials. Thus, we conclude our sentinel-node biopsy procedure is feasible. If the efficacy and safety of sentinel-node biopsy are confirmed in several large-scale randomized controlled trials in Europe and the United States, sentinel-node biopsy will become a standard surgical technique in the management of clinically node-negative breast cancer.

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Hemoglobin H (HbH) disease is the severe nonfatal form of α-thalassemia syndrome. It is usually caused by molecular defects of 3 of 4 α-globin genes (--/-α) which cause α-globin expression to be decreased. HbH disease is rare in Japan. Here, we report on a 6-year-old girl with HbH disease who had profound hypochromatic and microcytic anemia. Analysis of the α-globin genes of the patient's family showed that the father, who was Japanese, had an abnormal gene with a 3.7-kb deletion (-α^3.7/αα), and the mother, who was Filipino, had a deletion removing both α-globin genes of the Filipino type (--^FIL/αα). Neither parent had anemia. The patient was found to have HbH disease with a heterozygous genetic abnormality (--^FIL/-α^3.7). Recently, the number of marriages of Japanese to natives of areas where thalassemia is epidemic has increased. Therefore, the incidence of HbH disease can be expected to increase in Japan. Long-term follow-up will be needed to evaluate the long-term complications and to improve the quality of life of patients with HbH disease.

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Most hepatic cysts are asymptomatic, but complications occasionally occur. We describe a patient with biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection. A 60-year-old Japanese woman was admitted to our hospital because of a nontender mass in the right upper quadrant of the abdomen. Laboratory tests revealed the following: serum total bilirubin, 0.6 mg/dL; serum aspartate aminotransferase, 100 IU/L; serum alanine aminotransferase, 78 IU/L; serum alkaline phosphatase, 521 IU/L; and serum gamma glutamic transpeptidase, 298 IU/L. Abdominal computed tomography, ultrasonography, and magnetic resonance cholangiopancreatography revealed a huge hepatic cyst, 13 cm in diameter, at the hepatic hilum, accompanied by dilatation of the intrahepatic bile duct and obstruction of the common bile duct. We diagnosed biliary obstruction due to a huge hepatic cyst at the hepatic hilum, and laparoscopic surgery was performed. A huge hepatic cyst was seen at the hepatic hilum. After needle puncture of the huge cyst, the anterior wall of the cyst was unroofed, and cholecystectomy was done. Intraoperative cholangiography through a cystic duct revealed stenosis of the duct. Subsequent decapsulation of the cyst was performed in front of the common bile duct. After this procedure, cholangiography revealed that the stenosis of the common bile duct had resolved. Histopathological examination of the surgical specimen confirmed the hepatic cyst was benign. The postoperative course was uneventful, and the results of liver function tests normalized. The patient was discharged 7 days after operation. Computed tomography 3 months after operation revealed disappearance of the hepatic cyst and no dilatation of the intrahepatic bile duct.

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The diagnosis and management of blunt thoracic aortic injuries have seen significant changes over the last decade. The purposeful delay of definitive repair by aggressive blood pressure management has been suggested to be safe, and deliberate nonoperative management may be a reasonable alternative in selected patients with minimal aortic injuries detected with contrast-enhanced computed tomography. We report a case of acute aortic dissection due to blunt thoracic aortic injury resulting in splanchnic ischemia, for which we selected primarily nonoperative management, because the aortic tear was small but was complicated by multiple trauma. Although acute aortic dissection is an uncommon presentation of blunt injuries of the thoracic aorta and the poor prognosis has not been adequately emphasized, close observation, to evaluate the dissection and to determine whether splanchnic ischemia has developed, is recommended for patients for whom delayed definitive repair or nonoperative management has been selected.

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Traumatic injury of the superior mesenteric vein (SMV) by blunt trauma is a rare but frequently fatal injury. Although simple ligation should be considered for a patient in unstable condition, its complications have not been reported in detail. A 47-year-old man was struck on the abdomen during a fight. When he was transferred to a local hospital, he complained of severe abdominal pain. Computed tomography (CT) of the abdomen showed fluid accumulation in the peritoneal cavity and a hematoma around the root of the mesentery, with leakage of contrast material. When the patient was transferred to our emergency department, the hemodynamic status did not improve after rapid fluid resuscitation with 1,500 mL of crystalloid. Emergency laparotomy was performed 4 hours after the injury. Two lacerations of the proximal SMV were observed. The SMV was ligated owing to the unstable hemodynamic status. On postoperative day (POD) 5, abdominal radiography showed dilated loops of bowel, suggesting ileus of the small bowel. A CT scan with contrast enhancement showed that the wall of the small bowel was thickened. On POD 11, a CT scan showed that the collateral vessels that drain the mesenteric circulation had not developed. However, collateral vessels were revealed on a 3-dimensional CT scan, and, on POD 23, a CT scan showed that the collateral vessels had developed. The patient was discharged on POD 37. This case demonstrates that simple ligation of the proximal SMV leads to the development of collateral vessels and is useful for preventing side effects and improving outcomes.

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We describe a patient with complete chorioamniotic membrane separation (CMS). During embryologic development, the chorionic and amniotic membranes each arise from their own germ layers and form a celomic cavity in the first trimester of pregnancy. By the early second trimester, the cavity has shrunk and the membranes become conjugated. However, the membranes may separate spontaneously or because of an invasive intrauterine procedure. This pathologic condition is referred to as CMS. Extensive CMS can lead to miscarriage, fetal death, neonatal death, amniotic band syndrome, umbilical cord complications, and preterm delivery. In this case, CMS was detected in the 29th week of pregnancy with a routine ultrasonographic examination in the absence of a distinct non-reassuring fetal status or an abnormality of the intrauterine environment. The patient had undergone amniocentesis at 16 weeks of pregnancy for chromosomal analysis. Ultrasonography showed a floating membranous structure in almost every view of the intra-amniotic cavity. Thus, complete CMS was believed to have occurred. Therefore, precautionary checkups and examinations were periodically performed. Childbirth took place uneventfully by means of elective cesarean section in the 37th week of pregnancy. Because pathological examination showed complete CMS, the validity of the prenatal diagnosis was confirmed.

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There have been several studies of adverse perinatal outcomes associated with the indiscriminate use of labor-inducing drugs. However, the present results indicate that the appropriate use of labor-inducing drugs is not unsafe and improves neonatal outcomes in abnormal deliveries.

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