Background: I have studied endoscopic surgery for breast diseases and have studied 3-dimensional computed tomographic lymphography for sentinel node biopsy. In this chapter, I introduced my works of the endoscopic breast surgery. I devised a new endoscopic operation for breast diseases: video-assisted breast surgery. The goal of endoscopic breast surgery is to obtain better cosmetic outcomes.
Methods: A 2.5-cm axillary or periareolar skin incision was made. Under video assistance, the mammary gland was partially or totally resected with a gasless method. A transaxillary retromammary route approach was used even for tumors of the medial aspect of the breast. For malignant tumors, sentinel node biopsy was performed, and axillary nodes were dissected. Breast reconstruction was performed simultaneously.
Cosmetic results: Cosmetic results were assessed with a standard 4-step method and the method described in the Japanese guidelines for breast-conserving therapy. More-objective quantitative methods are breast retraction assessment, the method reported by the research group of Sawai, and ABNSW, a 5-item, 4-step method that evaluates asymmetry (A) , breast shape (B) , nipple deformation (N) , skin condition (S) , and wound scar (W) . The cosmetic results in endoscopic breast surgery showed that almost 90% of patients received a total score greater than 11 points, which indicates that this video-assisted breast surgery achieves better cosmetic results. The reconstruction methods in breast-conserving therapy are mammary gland translocation, the lateral tissue flap filling method, and absorbable thread mesh filling. The filling methods are superior to the translocation at the point of less deformation of the breast shape. Reconstruction with filling methods will allow wider excision of the mammary gland while achieving better cosmetic results.
Results: Video-assisted breast surgery is less invasive, produces no scars on the breast skin, and achieves better aesthetic outcomes for patients with breast cancer. It also improves quality of life. The long-term results of this surgery in regards to morbidity have proven good after a maximum follow-up period of 8 years.
Conclusions: Video-assisted breast surgery achieves good locoregional control and provides aesthetic advantages. It can be used to treat multiple breast diseases and advanced disease after preoperative systemic treatment.

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Background: I have studied endoscopic surgery for breast diseases and 3-dimensional (3D) computed tomographic (CT) lymphography for sentinel node (SN) biopsy. In this second in a series of reports, I explain the techniques of 3D-CT lymphography. 3D-CT lymphography can show the detailed lymphatic flow from the breast tumor toward the SNs and the exact local relation between axillary lymph nodes. I have developed this 3D image-processing system to more precisely depict the anatomical structures of the mammary lymphovascular system. This system allows us to systematically collect axillary lymph nodes, including SNs.
Methods: 3D-CT lymphography was performed to mark SNs on the skin on the day before surgery. Above the tumor and near the areola, 2ml of Iopamiron 300 was injected subcutaneously. Sixteen-channel multidetector-row helical CT scan images were obtained 1 minute after injection to detect SNs, and after 3 and 5 minutes to observe lymph flow into the venous angle. The scan images were reconstructed to produce 3D images. SN biopsy was performed with the dye-staining method and endoscopy.
Results: 3D-CT lymphography accurately showed lymphatic flow from the tumor to SNs. We classified the relationship between the lymph ducts and the drained SNs into 4 patterns. Following up 3 and 5 minutes after injection of the contrast agent, we can follow the lymph ducts beyond the SN into the second and third nodes toward the venous angle with the complex plexus. The figure of the axillary nodes shows 5 beads-like grouped nodes. 3D-CT lymphography can also recognize the metastatic patterns of the enhanced lymph node. These patterns will predict the metastasis before SN biopsy. 3D-CT lymphography can also be used to detect lymph flow from the arm to avoid harming the arm lymph channel during axillary node dissection and SN biopsy.
Conclusions: With 3D-CT lymphography, we can more accurately and precisely recognize lymph flow and the positional relations of SN and axillary nodes to surrounding anatomical structures.

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Pulmonary injury is a common complication of cardiac surgery. Numerous studies have been shown that cardiopulmonary bypass (CPB) is associated with significant inflammatory response, ischemia and reperfusion injury, histopatological changes such as pulmonary edema and atelectasis, and endothelial dysfunction of the pulmonary vessels. However, current surgical practice includes no strategy for active lung protection, because after the start of CPB, the lungs are disconnected from the mechanical ventilator and are left collapsed for the entire duration of CPB. We investigated the efficacy of low-frequency ventilation (LFV) and continuous positive airway pressure (CPAP) during CPB to reduce post-CPB lung injury.
Our experimental study was performed in 18 Yorkshire pigs subjected to 120 minutes of CPB (1 hour of cardioplegic arrest) followed by 90 minutes of recovery. Six pigs served as controls with the endotracheal tube open to the atmosphere during CPB. The remaining 12 pigs were divided into 2 groups of 6: during CPB 1 pig in each group received CPAP of 5cm H₂O, and the other 5 pigs received LFV (5breaths/minute) with air (21% oxygen) at a tidal volume of 8 to 10mL/kg. Lung tissue biopsy and broncoalveolor lavage samples were obtained serially for measurement of adenine nucleotides (ATP, ADP, AMP) , lactate, DNA levels, and histology. Hemodynamic data and arterial blood gases were also collected throughout the study.
In LFV pigs improvements in PO₂ and A-aDO₂ after CPB were significantly greater than in the no protection group. The CPAP pigs did not show significant deterioration in PCO₂ after CPB (p=0.08) , although the PO₂ level was similar to that in the no protection group.
Lung injury was observed as atelectasis and pulmonary edema on light microscopy and type I cell edema and microvilli diminutions of type II cells on electronic microscopy. In LFV pigs, there was significantly less derangement on all pathological examinations during and after CPB than in the no protection pigs. CPAP also brought improvements in pathological changes to some extent. although the benefits were less than with LFV.
Ischemic changes appeared as increased DNA levels in bronchoalveolor lavage fluid, decreased total adenine nucleotide levels, and increased lactate levels in lung tissue. The LFV pigs showed less derangement in these variables than did the control group. CPAP seemed to provide some benefits for these changes during CPB, but these benefits did not reach the level of statistical significance.
In summary LFV during CPB reduces tissue metabolic and histopathological damage in the lungs and is associated with improved postoperative gas exchange in an experimental pig model. The mode of action of this technique is probably a reduction in ischemic changes and the prevention of atelectasis.

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Dai-kenchu-to, a traditional Japanese herbal medicine (Kampo), has been used for the treatment of postoperative ileus after abdominal surgery. However, its efficacy and mechanisms remain to be fully elucidated. For nearly a decade, the efficacy and mechanisms of Dai-kenchu-to have been reported on and well established. Several studies have shown Dai-kenchu-to to accelerate gastrointestinal transit. Moreover, some recent reports have also indicated that it may also increase the intestinal blood flow. A Japanese nationwide multicenter, doubleblind, placebo-controlled study of Dai-kenchu-to following a colonic cancer resection was launched in 2009. The results of this study are therefore highly anticipated.

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The lower urinary tract symptoms in elderly men are composed of from voiding symptoms and storage symptoms. The representative disease with voiding symptoms is benign prostatic hyperplasia, and the representative syndrome with storage symptoms is overactive bladder and nocturia. Diagnosis by asking questions that use International Prostate Symptom Score and the overactive bladder symptom score is important. The first-line drugs for the treatment of the lower urinary tract symptoms are α1-blockers. Behavior therapy and anticholinergic drugs are also useful for treating storage symptoms.

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In recent years, elderly patients with dementia have been increasing in Japan. It is currently estimated that behavioral and psychological symptoms of dementia (BPSD) occur in approximately 80% of the elderly patients with dementia. As BPSD occur more frequently in elderly patients with dementia, the caregivers burden increases. Although non-pharmacological interventions can reduce BPSD in patients with dementia, antipsychotic medications have been used to treat severe BPSD. Physicians should be particularly careful in the use of antipsychotic medications in the elderly, which have been associated with dangerous adverse effects. Donepesil not only improves the cognitive dysfunction of Alzheimer disease patients, but may also relieve BPSD in these patients. Moreover, the effects on BPSD of yokukan-san, Kampo medicine, have been reported in elderly patients with dementia. A multicenter randomized crossover study, which we participated in, confirmed that yokukan-san is effective in the treatment of BPSD and that no rebound related deterioration occur after withdrawal of yokukan-san. The effects of yokukan-san on BPSD have been reported to influence gamma-amino-n-butyric acid and serotonin receptors.

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Immunohistochemistry is a technique to examine the expression and distribution of biomolecules in situ using antibodies labeled with enzymes, such as horseradish peroxidase. Generally, both immunohistochemistry and immunofluorescence are termed as immunostaining, because localized biomolecules in situ are detected with antigen-antibody immunoreactions producing color signals. Immunostaining techniques are divided into 3 types: direct, indirect, and amplification methods (peroxidase-antiperoxidase, avidin-biotin complex, and polymer). Because each method has advantages and disadvantages, the method should be selected according to the biological purpose. In this technical note, we describe mechanisms and procedures for immunostaining, including immunohistochemistry and immunofluorescence.

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A 33-year-old woman was referred to us by the department of urology because of cyclic bladder pain during menstruation. Cystoscopy showed a 3.5-cm-diameter tumor in the bladder mucosa, and a biopsy showed chronic cystitis. Transvaginal ultrasound and pelvic magnetic resonance imaging revealed a left endometrial ovarian cyst. Although a biopsy did not prove bladder endometriosis, we diagnosed bladder endometriosis on the basis of the characteristic clinical findings. Laparoscopic partial cystectomy for bladder endometriosis and left ovarian endometrial cyst resection were performed. The bladder was closed in one layer using Z sutures with #3-0 polyglactin 910. Indigo carmine dye was then used to check for any leakage. The procedure lasted 4 hours, and the estimated blood loss was 10mL. There were no technique problems or complications. The Foley catheter was removed after 7 days. The symptoms had resolved by 4 weeks after surgery, and the patient was released to routine follow-up. The patient had complete resolution of bladder symptoms and cyclic pelvic pain and was delighted with the absence of pain and the cosmetic result.

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