Purpose : Although mortality and morbidity rate of high-level hepatobiliary pancreatic (HBP) surgery has been improved, which remains still high in some procedures. The difficulty of high-level HBP surgeries are varies depending on the surgical complexity, thereby perioperative outcomes can be variable. The aim this study was to establish a novel difficulty classification of high-level HBP surgeries and to assess its validity.
Methods : High-level HBP surgeries were classified into four groups, A to D, in order of increasing difficulty, based on the expert opinion. A total of 473 patients who underwent high-level HBP surgery from July 2014 to July 2021 in our hospital were classified into aforementioned four groups, and surgical and postoperative outcomes of which were compared.
Results : The numbers of patients in each difficulty group were as follows : A (n＝62), B (n＝278), C (n＝74) and D (n＝59). Operation time and blood loss showed a significant stepwise increase in the group A to D (p<0.001 and p<0.001 respectively). The duration of postoperative hospital stay also increased significantly from the group A to D (p<0.001). The incidence of complications over Clavien-Dindo classification IIIa increased in group A to D significantly (35.5％ vs 35.3 vs 37.8 vs 54.2％ ; p＝0.021). However, the 90-day mortality rates did not differ within four groups (1.6％ vs 0.4％ vs 2.7％ vs 1.7％ ; p＝0.394).
Conclusions : The novel difficulty classification of high-level HBP surgeries can predict surgical risk in each surgical procedure. Further large-scale nationwide study should be warranted to confirm these results.

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Objective : Although high-dose medroxyprogesterone acetate (MPA) has been used as a fertility-preserving therapy for early stage, G1 endometrioid carcinoma and atypical endometrial hyperplasia (AEH), the therapy was associated with a high recurrence rate. However, there is little evidence regarding the usefulness of readministration of MPA for intrauterine recurrence, therefore, we investigated its effectiveness and safety.
Methods : We retrospectively analyzed 29 patients of endometrioid carcinoma G1 and AEH who underwent high-dose MPA therapy from 1998 to 2020 at Shinshu University hospital.
Results : Of a total 29 patients, eight were endometrioid carcinoma G1, and 21 were AEH. The median age at the start of the first MPA therapy was 34 years (25-46 years), and the complete response (CR) rate was 88％ for endometrioid carcinoma G1 and 95％ for AEH. The recurrence rate was 78％ (21 of 27 CR patients). Eight patients (endometrioid carcinoma G1 : two patients, AEH : six patients) underwent the re-administration of MPA, and the CR rate was 100％. A total hysterectomy was finally performed on 18 patients, all patients are alive and disease-free. Eight of 12 patients (67％) who attempted pregnancy after high-dose MPA therapy achieved pregnancy, and six patients (50％) delivered a healthy full-term live birth. Only after MPA re-administration, the rate was 50％.
Conclusion : Although this study was conducted in a small number of cases, the CR rate with MPA readministration was high, and several cases achieved live births, therefore, it was considered to be a treatment option.

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Aim : This study aimed to evaluate the demographic and clinical characteristics of children who present to the emergency room with seizures and determine the etiology to appropriately treat these patients.
Methods : This hospital-based retrospective cohort study was conducted using data retrieved from the medical records of 1600 seizure cases treated at the Emergency and Pediatric Departments of Ina Central Hospital from January 2010 to December 2019.
Results : Of the 1600 cases, 1248 (78％) were associated with fever and 1228 (98.3％) were diagnosed with febrile seizures. Epilepsy was the most frequent cause of seizures without fever (75％). A total of 222 patients (17.3％) visited multiple times (maximum seven times). Complex febrile seizures increased the chances of being diagnosed with epilepsy later. Six cases (0.3％ of all visits) were diagnosed with acute encephalitis/encephalopathy ; however, there were no cases of meningitis. Body temperature at the visit was significantly lower, whereas age and previous occurrence of seizures were significantly higher in the epilepsy group with fever than in the febrile seizure group. In contrast, the recurrent seizure frequency during the same episode was significantly higher in the acute encephalitis/encephalopathy group than in the epilepsy group without fever.
Conclusion : Clinical characteristics and backgrounds such as age, body temperature, seizure history and recurrent episodes can be the important factors to predict the cause of seisures to ensure appropriate treatment of pediatric patients experiencing seizures in an emergency outpatient department.

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Background : As the first commercially available device to treat mitral regurgitation (MR) percutaneously, the MitraClip transcatheter edge-to-edge repair (TEER) system was approved for use in Japan in 2017.
Objective : We evaluated the efficacy and safety of MitraClip TEER during its first year of implementation at our hospital in comparison with previous studies.
Methods : This retrospective study included 23 consecutive patients who underwent MitraClip TEER for MR between October 2021 and September 2022 at Shinshu University Hospital. The primary outcome was MR reduction ≤ 2＋ and New York Heart Association (NYHA) class improvement at 30 days.
Results : The majority of the 23 patients (91.2％) were NYHA class III or IV at baseline. A reduction in MR grade to less than moderate was achieved in all patients at discharge and in 22 (95.7％) patients at 30 days. NYHA class improvement was observed in 21 (91.2％) patients at the study end point. No procedural complications were encountered.
Conclusion : The MitraClip TEER procedure improved MR grade and symptoms without any major complications in patients with moderate-to-severe or severe MR. These results corroborated those of earlier reports and demonstrated the short-term efficacy and safety outcomes of the MitraClip at our institution.

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Purpose : Computed tomography (CT)-guided marking is performed to assist nodule localization before videoassisted thoracoscopic surgery. Several complications associated with CT-guided marking, such as pneumothorax, pulmonary hemorrhage, and air embolism, have been reported. Air embolism is an infrequent but serious complication. We hypothesized that CT-guided marking while breath-holding during exhalation might be effective in preventing air embolism. This study aimed to validate the safety and efficacy of CT-guided marking while breath-holding during exhalation.
Methods : This retrospective study was performed in 90 patients, who underwent 93 CT-guided marking procedures while breath-holding during exhalation for 93 nodules between July 1997 and January 2023. CT and clinical findings regarding pneumothorax, intrapulmonary hemorrhage, and air embolism were assessed. Risk factors for complications were evaluated by univariate and multivariate analysis.
Results : Pneumothorax and intrapulmonary hemorrhage were observed in 62 and 34 patients (66.7 and 36.6％), respectively. No air embolism was observed. A smaller nodule diameter and longer puncture distance were independent risk factors for pulmonary hemorrhage, while there were no independent risk factors for pneumothorax to clarify when to place a hook-wire while breath-holding during exhalation.
Conclusion : CT-guided marking while breath-holding during exhalation showed no air embolism or serious complications and seems effective in preventing air embolism.

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