Standard laparoscopic colorectal surgery requires additional incision or enlargement of the trocar incision for the retrieval of the surgical specimen. A natural orifice specimen extraction （NOSE） procedure, in which the specimen is retrieved through the anus or vagina without any additional skin incision, requires purse-string suture （PSS） of the rostral intestinal segment in order to fix the anvil head of the stapler and perform extracorporeal mechanical anastomosis. Colorectal surgery has a limited NOSE in cases where the end of the rostral segment could be pulled through the anus. Broader application of NOSE depends on intracorporeal PSS. We developed a new forceps for intracorporeal PSS during NOSE and evaluated its efficacy. The PSS instrument was refined to pass through a 12-mm trocar in an intracorporeal PSS and achieve anastomosis using double stapling. In trials utilizing an endoscopic practice box, regular spacing of stitches during PSS were consistent （n＝10）, and tight intracorporeal anastomosis of the porcine colon was successfully performed （n＝2）. We then confirmed efficacy through an operation on a pig. Our novel PSS device will help us perform NOSE not only in laparoscopic colorectal surgery but also in any operation requiring intracorporeal PSS, which should contribute to further advances in endoscopic digestive surgery.

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A patient’s pain intensity rating alone is insufficient grounds for determining the pain medication and dosage to administer daily. This study aimed to investigate whether a convenient assessment method could be developed that would reflect the effectiveness of an opioid analgesic on cancer patients’ pain management. We investigated pain intensity （worst, least, average, current） and the effectiveness of the opioid rescue medication in terms of patient satisfaction. This study used Spearman’s rank correlation coefficients to evaluate the relationships between patient satisfaction with rescue medication and both pain intensity and the medication’s perceived effectiveness. Data from 60 participants with a mean age of 60.5±11.4 years （range: 31-79 years） were analyzed. Thirty-eight （63.3%） participants were male, and 22 （36.7%） were female. The correlations found between rescue medication satisfaction and both the worst numerical rating scale （NRS） rating （r＝−0.15, P＝0.16） and the average NRS rating （r＝−0.13, P＝0.13） were not statistically significant. A significant positive correlation was observed between rescue medication satisfaction and the medication’s perceived effectiveness （r＝0.79, P＜0.0001）. Patient satisfaction with their rescue medication can be routinely assessed without imposing a significant burden on the patient. A new assessment method incorporating rescue medication satisfaction and pain intensity measures could allow routine pain assessments to reflect both pain intensity and the effectiveness of opioid analgesics. This new assessment method is potentially preferable to self-reported pain intensity and can identify patients for whom treatment is a priority. It also facilitates rapid dose adjustments and reduces the side effects of overdose due to unnecessary increases in opioid analgesics.

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This study investigated retrospectively the diagnostic yield and complication rate of transthoracic needle biopsies for posterior thoracic pulmonary lesions using C-arm cone-beam computed tomography （CBCT）. The risk factors for pulmonary hemorrhage were evaluated. Our study included 113 patients with 113 posterior pulmonary lesions （mean longest diameter: 30.6mm, and mean depth: 4.7mm） through the erector spinal muscles using a 19/20-gauge coaxial system. The diagnostic performances of procedures for malignant lesions and the incidence of complications after biopsies were also assessed. The patient-related and procedure-related variables were investigated. Risk factors for pulmonary hemorrhage were analyzed with a multivariate logistic regression analysis. Findings revealed 99 malignant, 13 benign, and one intermediate lesion. Sensitivity, specificity, and diagnostic accuracy rates were 100％ （99/99）, 92.3％ （12/13）, and 99.1％ （111/112）, respectively. Air embolization, hemothorax, hemoptysis, pneumothorax, and pulmonary hemorrhage, occurred in 0, 2, 12, 48, and 70 procedures. The averaged spinous process-pleura depth and the traversed lung parenchyma depth achieved by the introducer needles were 54.2mm and 27.4mm, respectively. The needle position at the pleural puncture site within the intercostal space was in middle （31％） and inferior （69％） areas. The incidence of pulmonary hemorrhage was significantly higher in smaller lesions （p＝0.001）. Manual evacuation was performed in five procedures for patients with pneumothorax. The chest tube placement （trocar＞8 Fr） was performed in two procedures in patients with hemothorax and pneumothorax. In conclusion, the biopsy method with a posterior intercostal approach for posterior thoracic pulmonary lesions yielded high diagnostic accuracy and few major complications.

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Azithromycin （AZM） injection tends to increase injection site pain when administered in excess of 2mg/ml. As AZM is frequently used in combination therapies, it is expected to be administered at a high concentration in clinical use due to fluid restrictions. Therefore, in this study, the relation between AZM concentration and injection site pain was examined. From January 2012 to July 2017, we retrospectively investigated the medical records of patients who were administered AZM by injection at Showa University Fujigaoka Hospital. Vascular pain was related to intensive care unit （ICU） administration （P＝0.003） compared with that in general wards and a long duration of administration （P＝0.002）. The number of days of AZM injection should be kept as short as possible. Given that the risk of injection site pain is increased in the ICU, we recommend switching to oral administration. Further collection of safety data in patients on fluid restriction is necessary, and high concentration AZM administration should be considered.

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Necrotizing sialometaplasia is a benign lesion affecting the minor salivary glands of the hard palate. This lesion may be clinically and histopathologically confused with malignant lesions. A case of a 47-year-old man who presented with necrotizing sialometaplasia on the left side of the hard palate is herein reported. A biopsy was performed, and the condition was diagnosed based on immunohistochemistry. The lesion receded following treatment with tranexamic acid and sodium azulene sulfonate. The symptom of painful swelling on the hard palate subsided within 10 days. The palatal lesion had disappeared completely 4 months later.

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