As we are faced with an aging society, the number of cases of pyogenic spondylitis is increasing, as well as compromised hosts, diabetic patients and those requiring long-term artificial dialysis, and cancer treated by chemotherapy. Patients suffering from lumbago with high fever are not diagnosed as pyogenic spondylitis until they consult an orthopedic doctor. This situation is showing an increasing tendency. We encountered 100 cases of pyogenic spondylitis in the 9 years from 2001 to 2009. We achieved good results by conservative therapy.

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Little attention has been given to anesthesia when creating and/or removing a Peritoneal Access (PA). The purpose of this study was to evaluate the usefulness of a Rectus Sheath Block (RSB), Transversus Abdominis Plane block (TAP) or combined procedure in access surgery of Peritoneal Dialysis. In PA surgery, analgesia in the abdominal cavity is not needed because the PA catheter tip is guided to the appropriate position based on the patient's visceral sense. Thus it might be inferred that anesthesia is suitable for PA surgery. Ninety-eight adults underwent catheter insertion PDI, catheter removal PDR, or simultaneous PDRI (68/22/8 each), and 56 patients received infiltration anesthesia, 12 block anesthesia in PDI, and 17/5 in PDR, 5/3 in PDRI. Methods: For infiltration anesthesia, local anesthetic was administered by the surgeon as requested by the patient, whereas, an RSB and/or TAP block were performed unilaterally by the anesthesiologist. When using infiltration anesthesia, the respective average dosage of anesthetic was 32.5, 24.8, and 50.8ml in PDI, PDR, and PDRI, respectively; anesthetic exceeded 20ml in 58 cases (74%). Significant differences were recognized in PDRI vs. PDR, PDRI vs. PDI, and PDI vs. PDR. The combination of RSB and TAP block was used for 16 (80%), infiltration anesthesia was required in 14 (70%). There was no significant difference in surgical time and in the number of requests for analgesic treatment by the method of anesthesia. It seemed that a sufficiently anesthetized area is obtainable with RSB and TAP block under limited anesthetic dosage. The abdominal wall block is useful and is suggested to be the best method for PA operation.

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For a medical malpractice civil suit, the means by which to obtain medical information is important. Previously, an adviser elected by the court stood in the central core, but now, a written opinion requested by a plaintiff or a defendant takes that place. Regarding the way to obtain the medical knowledge in the judicial process, this paper introduces judicial advice, written opinion, expert committee, turn-to-mediation, accident investigation report, death certificate, medical certificate by post-doctor, doctor-hearing, and record of the hearing from another doctor, and assesses these practices according to merits and demerits. As for my recent 12 cases as attorney passed first judgment and later became final (except for settlement cases, because trial was not sufficient), the table indicates the case summary and point, hospital department, court location/medical expert court or ordinary court, date of judgment, existence of an attorney for plaintiff or none, presence of a written opinion requested by the plaintiff or no/if yes, examination of the opinion writer or no, presence of a written opinion requested by the defendant or no/if yes, examination of the opinion writer or no, advice or no, result of the judgment, appeal or no, special mention. The civil law system in Japan stands in adversary system, which is clear through proof and argument by parties among sharply clashing interest, therefore, advice on the judicial process is like aninquisitorial system, but the written opinion matches the adversary system of the judicial process. The advice has no means to ensure a sufficiently fair and neutral process, it takes long time, and there are other problems. Thus, conference advice by 3 doctors forced to solve the problems shows legal suspect, although the written opinion must center in judicial process for resolution. Because the judicial process must be offense and defense about the written opinion, it is necessary to attach a written opinion for the plaintiff(patient side)on the presenting petition, while, the defendant (doctor side), first, has to supply counterargument and counterevidence based on medical textbook, and if not sufficient, decide to present a written opinion. With written opinions presented by both sides, the judge must advise both sides to compromise by impression, but if this is not successful, slide to concentrated examination, not only parties themselves but also an opinion writer of a plaintiff. Advice is a last resort at the end of resources. Thus, written opinion is so important that it will be named party's advice.

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Few reports discuss the growth progress of superficial carcinomas of the esophagus and numerous questions remain, thus we evaluated the carcinoma growth progression in 53 cases of submucosal carcinomas of the esophagus. Regarding growth form and speed, we examined 11 cases with an inspection history within the past two years. The growth form could be roughly classified into 3 types: patterns A, B (B-1, B-2, B-3), and C. The 53 cases of submucosal carcinomas of the esophagus were classified into these 3 types; most patterns were B-2 and, then pattern A. As for growth speed, it was surmised that patterns A and C were fast, and pattern B-1 was the slowest, and patterns B-2 and B-3 in the middle. In connection with histological type, there were many cases from which poorly differentiated type of squamous cell carcinoma permeates deeply into submucosal layer in pattern A. Pattern B was also to have a high rate of poorly to moderately differentiated type of squamous cell carcinoma, and it participates in growth progression into the submucosal layer.

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The purpose of this investigation was to clarify the characteristics of heatstroke in the Jonan district of Tokyo. We retrospectively evaluated the age, gender, comorbidity, situation at the time of onset, and prognosis of 16 severe heatstroke patients at Showa University Hospital and compared these characteristics with Heatstroke STUDY2010. The period of this study was from June 2009 to September 2011. The M: F gender ratio was 9: 7, and the mean of age was 73.8 years. The situation at the onset was normal daily life in almost all cases. The details of these cases are normal indoor life (73%), walking (20%), rest room (7%). The comorbidites were sequela of the central nervous system (100%), rhabdomyolysis using continuous hemodiafiltration (6%), disseminated intravascular coagulation[DIC] (44%), and liver damage(38%). Regarding the prognosis, the mortality rate was 6% (only one case). Although the summer of 2010 was the hottest in Japanese surveillance history, the difference between the years from 2009 to 2011 was not apparent as far as we looked over the difference between cases at Showa University Hospital. The reason why the proportion of DIC was apparently high at Showa University Hospital is speculated to be that the mean of age at Showa University Hospital is higher than Heatstroke STUDY2010. On the other hand, the mortality rate at Showa University Hospital is lower than Heatstroke STUDY2010. We believe this is because all cases at Showa University Hospital were admitted to the intensive care unit and treated with critical care. In conclusion, the most effective strategy for heatstroke in the Jonan district is to prevent classical heatstroke of elderly people. The provision of services for elderly people is, therefore, necessary to improve heatstroke morbidity in the Jonan district.

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In this study, we performed detailed examination of the terminal facial nerve branches to the mimetic muscles, particularly the branches terminating in the orbicularis oculi muscle and orbicularis oris muscle. Examination was performed on 20 Japanese adult autopsy cases, involving 20 hemi-faces. The mean age was 87.4 years (range: 60-99 years). There were 10 men and 10 women (10 left hemi-faces and 10 right hemi-faces). In each case, the facial nerve was exposed through a preauricular skin incision. The main trunk of the facial nerve was dissected from the stylomastoid foramen. A microscope was used to dissect and observe the terminal branches to the periphery. The temporal branch was distributed to the orbicularis oculi muscle in all cases and the marginal mandibular branch was distributed to the orbicularis oris muscle in all cases. The zygomatic branch was distributed to the orbicularis oculi muscle in all cases, but it was also distributed to the orbicularis oris muscle in 8 of 20 cases. The buccal branch was distributed to the orbicularis oculi muscle in 5 cases. There was no significant difference in the variations. According to textbooks, the temporal branch and zygomatic branch innervate the orbicularis oculi muscle, and the buccal branch (or the buccal branch and marginal mandibular branch) innervates the orbicularis oris muscle. In this study, we dissected the terminal facial nerve branches that terminate in the orbicularis oculi muscle and orbicularis oris muscle and examined their course and distribution in great detail. The results revealed multiple anomalies which are not described in conventional textbooks; these anomalies may compensate the movements of the muscles.

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Preoperative lung function tests are useful to evaluate the preoperative pulmonary condition and to detect a high risk of postoperative pulmonary complications. But, maximum expiratory effort by patients is necessary to determine lung function. On the other hand, it is believed that respiratory system impedance using an impulse oscillatory system (IOS) can quickly evaluate total airway resistance (R₅), large airway resistance (R₂₀), small airway resistance (R₅-R₂₀) and capacitive reactance (X₅) under breathing at rest. In this study we used regression analysis to evaluate the relationship between parameters in IOS and non-IOS. Six hundred-twenty patients (20 to 89 year of age) scheduled for elective surgery were studied. IOS and non-IOS, such as spirometry, maximum expiratory flow-volume curve and single N₂ washout curve were preoperatively measured to investigate the relationship between parameters in IOS and non-IOS. We examined the relationship between IOS and non-IOS by calculating Pearson's product-moment correlation coefficient. Regression equations obtained between IOS and non-IOS parameters were statistically significant (p<0.05). In the linear regression equation, the highest correlation coefficient (R²) was 0.267 between X₅ and FEV_1.0. Similarly, in the regression equation curve, the highest R² value was 0.293 between X₅ and FEV_1.0. In the linear regression equation in the set of 45 a significant difference was observed, the combination R² value did not reach 0.1 was 22 pairs and it was equivalent to about half of. In the evaluation using the regression equation curve between each parameter of the IOS and the conventional inspection methods a high linear regression analysis correlation was observed. However, the correlation was not high enough to substitute the test with IOS.

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We retrospectively analyzed 137 consecutive gastric cancer patients who underwent delta-shaped anastomosis in totally laparoscopic distal gastrectomy (LDG). Surgical outcomes of LDG, such as operative results and postoperative complications were compared with those of the 62 laparoscopy-assisted distal gastrectomy (LADG) patients. As compared with LADG group, the LDG group had a significantly shorter operation time (219 vs. 287 min, p < 0.001). There was no significant difference in the extent of lymph node dissection, the number of lymph nodes dissected, postoperative complications, and length of hospital stay between the two groups. From the viewpoint of surgical outcomes, LDG is a safe and feasible procedure for gastric cancer.

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We successfully treated 2 cases of severe asthma attack that showed response to initial treatment by intravenous infusion of magnesium sulfate (MgSO₄). Total serum magnesium (tMg) and ionized magnesium (iMg) and ionized calcium (iCa) were measured before and after 1 hour administration of MgSO₄. Compared to before the MgSO₄ administration, both cases showed an increase in tMg and iMg and a decrease in the iCa/iMg rate. We propose that the changes in the iCa/iMg rate may serve as an index of the effect of intravenous magnesium. To clarify the efficacy and safety of intravenous MgSO4 in the treatment of asthma, many cases should be studied.

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An 82-year-old woman underwent radical surgery for descending colon cancer. During surgery, functional end-to-end anastomosis (FEEA) was performed using a suturing device. Pathological examination demonstrated D, Wel (tub1>pap, muc), pT3 (SE), N1, M0, H0, P0, fStageIIIa. Anastomotic recurrence located in the FEEA suture line took place three times in two years. For the first two recurrent tumors, anastomosis resection with D1 lymph node resection was performed. FEEA was performed in the first three operations. Finally the Hartmann procedure was performed. Anastomotic recurrence often occurs at FEEA suture lines. In our hospital the rate of anastomotic recurrence is 1.4%. We encountered a very rare case of repeat anastomotic recurrence due to tumor implantation after curative surgery for descending colon cancer.

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We demonstrate here a novel technique of video-assisted thoracoscopic surgery-hepatectomy (VATS-H) for a liver tumor located in the subdiaphragmatic area based on a preoperative three-dimensional visualization system. Computed tomography study was performed for a 64-year-old HCC male patient; liver structures were segmented as viewed by the preoperative three-dimensional visualization system (SYNAPSE VINCENT: Fujifilm Medical, Tokyo, Japan). Moreover, the virtual thoracoscopy was used to indicate the accurate port position for hepatectomy. The surgeon planned the resection preoperatively and read the resection mapping as a reference guidance during the procedure. Three cases of VATS-H were performed for liver neoplasm. Using intraoperative thoracoscopic sonography (IOTS), the portion of the diaphragm located just above the tumor was cut and opened using Laparoscopic Coagulating Shears. IOTS was performed on the liver surface, and the margin of tumor was marked by electric cautery. For the resection of liver, bipolar radiofrequency device (RFA, Habib 4x^™, Rita, USA) was used for precoagulation before transection of liver and coagulation of liver parenchyma during the transection of the liver. The operating time was 140 minutes. The operative blood loss was 30g. To date, no complication after surgery had occurred. VATS-H under the guidance of the preoperative three-dimensional visualization system was useful for a liver tumor located in the subdiaphragmatic area.

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The patient was a 77-year-old woman who was examined at our hospital for the chief complaint of sudden presyncope. A detailed examination led to the suspicion of insulinoma. Dynamic CT revealed a 10-mm nodular shadow in the pancreatic body; the patient was diagnosed with insulinoma in the pancreatic body through selective intra-arterial calcium-stimulated hepatic venous sampling (ASVS). Virtual laparoscopic images were created based on this CT image, and the data was transferred to an iPad for intraoperative reference. We subsequently performed laparoscopic distal pancreatectomy using these images. We could safely proceede with the operation while confirming the position of the primary vessel, and we were able to identify an appropriate pancreatic resection line while verifying the position of the tumor. After the surgery, her symptoms became less severe, with no complications such as pancreatic fistula or hypoglycemic attack, and she was discharged. An operative guide using virtual laparoscopic images is considered to be useful for the safe performance of laparoscopic distal pancreatectomy.

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Although schwannomas are common in the neck, brain, and extremities, they are relatively rare in the gastrointestinal tract and particularly rare in the large intestine. We here present a rare case of schwannoma arising from the sigmoid colon. A 73-year-old woman presented to nearby clinic with abnormalities on colorectal cancer screening, and an elevated lesion, suggestive of a submucosal tumor, was observed in the sigmoid colon by colonoscopy. Although the endoscopic biopsy results showed normal mucosa, laparoscopy assisted partial resection of the sigmoid colon was performed in order to rule out gastro intestinal stromal tumor (GIST). Pathological examination of the resected specimen demonstrated spindle cells in a submucosal lesion. Immunohistochemical staining was strongly positive for S-100 protein, and negative for c-kit and smooth muscle actin; Ki-67 showed a low rate positive. Thus, the diagnosis of schwannoma in the sigmoid colon was confirmed.

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