Determinants of Sexual Awareness among High School Students in Tokyo, Japan―Post-Interventional Comparison Analysis in Relation to Social Capital

Purpose: This study was to clarify the association of sexual awareness of high school students with cognitive social capital (SC) in Tokyo, Japan. Method: In September 2017, we conducted a survey of 1073 third-grade high school students who were the same students who had participated in the same questionnaire survey at the prior academic year when they were second-grade students. A total of 1073 students were surveyed and 956 students responded. From six to eight weeks prior to this September 2017 survey, we implemented an educational intervention in the students. Then we compared the results of this survey with the previous survey of February 2017. We used logistic regression to assess sexual awareness and sex knowledge, sexually experienced surrounding peers and Self-Esteem score. The study was approved by the Ethical Review Board. Result/Discussion: Sexual awareness of high school students was significantly associated with SC both before and after the intervention. The higher SC one had, the higher sexual awareness was shown and the greater the sexual caution among both boys and girls was indicated. The study clarified the Determinants of Sexual Awareness of High School Students in Tokyo before and after the educational intervention. Conclusion: SC was found to be significantly associated with sexual awareness. SC should be emphasized in promoting adolescent reproductive health for the future.

Determinants of Sexual Awareness among High School Students in Tokyo, Japan—Cross Sectional Analysis in Relation to Social Capital

Purpose: The study aimed to clarify the relationship between cognitive social capital and sexual awareness in high school students in Tokyo, Japan. Method: The self-administered questionnaire survey was administered to 1073 high school junior students in Tokyo in Feb. 2017 (collection rate 94.5%). Final analysis subjects totaled 1011 boys and girls (94.2%). True/false questions on timing to wear condom for sex knowledge, acceptability to sexual behavior of high school students for sexual awareness, sense of community belonging for social capital, existence of sexually experienced peers, and Rosenberg Self-Esteem Scale score (binarized with the mean value) were verified. Multiple logistic regression analysis assigning sexual awareness for dependent variable and sex knowledge, sexually experienced peers and Self-Esteem score for independent variable [model 1], including social capital for independent variable [model 2] was performed. The study was approved by Ethical Review Board of sub-organ. Results and Discussion: Out of subjects, 52.6% answered correctly questions on sex knowledge, 33.2% showed tolerance to sexual behavior of high school students, 68.6% had many peers with sex experience, and 75.9% had a sense of community belonging. In model 1, in both genders, having sex knowledge, high Self-Esteem score, and existence of sexually experienced peers was associated with a sense of intolerance to sexual behavior of high school students. In model 2, in both genders, having a sense of community belonging was associated with a sense of intolerance to sexual behavior of high school students [OR (95% CI): boy 1.11 (0.81 - 1.53), girl 1.14 (0.72 - 1.79)]. Persons with high cognitive social capital were likely to have a cautious sense toward sexual behavior. Conclusion: Cognitive social capital was found to be associated with sexual awareness. Cognitive social capital should be emphasized in promoting adolescent reproductive health for the future.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection(ESD)for early-stage gastrointestinal tumors.The rate of post-ESD bleeding for gastric cancer is higher(around 5%-8%)than that for esophagus,duodenum and colon cancer(around 2%-4%).Although investigations into the risk factors for post-ESD bleeding have identified several procedure-,lesion-,physician-and patient-related factors,use of antithrombotic drugs,especially anticoagulants[direct oral anticoagulants(DOACs)and warfarin],is thought to be the biggest risk factor for post-ESD bleeding.In fact,the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%,which is higher than that in patients not receiving anticoagulants.However,because clinical guidelines for management of ESD in patients receiving DOACs differ among countries,it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice.Given that the pharmacokinetics(e.g.,plasma DOAC level at both trough and T_(max))and pharmacodynamics(e.g.,anti-factor Xa activity)of DOACs are related to risk of major bleeding,plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.

Indium chloride bone marrow scintigraphy for hepatic myelolipoma: A case report

BACKGROUND As hepatic myelolipoma is rarely encountered,its radiological diagnosis using ultrasonography(US),computed tomography(CT),and magnetic resonance imaging(MRI)is challenging.Hepatic myelolipoma is similar to fat-contained hepatic lesions seen in hepatocellular carcinoma and angiomyolipoma.Therefore,further development of techniques to diagnose hepatic myelolipoma is warranted.CASE SUMMARY A 44-year-old obese man was found to have a hepatic lesion during his medical checkup.The lesion was 50 mm×57 mm in size and was detected in segment 8(S8)of the liver by US.The patient was diagnosed with hepatic lesion 20 years ago,but it was left unresolved.The patient had no symptoms,liver dysfunction,hepatitis virus antibody,or tumor marker elevation.Plain CT showed a welldefined lesion in S8 of the liver.The central and peripheral areas of the lesion primarily exhibited fat density and hypodensity,respectively.MRI revealed a capsule-like structure.Biopsy was performed to address the probability of hepatocellular carcinoma.The lesion was pathologically confirmed as a myelolipoma.Bone marrow scintigraphy performed using 111InCl3 revealed accumulation of the radiopharmaceutical in the soft tissue component,except in the fat-dominant part of the tumor,as well as in the surrounding liver parenchyma due to the presence of reticuloendothelial cells in the liver.CONCLUSION This is the first report on the diagnosis of hepatic myelolipoma using 111InCl3 scintigraphy.The effectiveness of bone marrow scintigraphy for diagnosing hepatic myelolipoma might be limited.As radiopharmaceuticals accumulate in both hematopoietic and reticuloendothelial cells,the accumulation of radiopharmaceuticals in the lesion is obscure.

Efficacy of incremental loads of cow's milk as a treatment for lactose malabsorption in Japan

BACKGROUND Lactose intolerance(LI)is commonly seen in East Asian countries.Several studies showed that lactose or milk loading has been used as a treatment for lactose malabsorption(LM)in Western countries,but there have been no reports regarding this type of treatment in Japan.As lactose or milk loading requires ingestion of large amounts of lactose within a short period,this is considered to be too harsh for Japanese people because of their less habitual milk consumption(175 mL per day in average)than Western people.In this study,we demonstrated lactose tolerance acquisition in a suitable way for Japanese.AIM To examine the efficacy of lactose(cow’s milk)loading treatment in patients with LM.METHODS Individuals with abdominal symptoms induced by milk or dairy products(LI symptoms)were identified with a questionnaire.A 20 g lactose hydrogen breath test(LHBT)was carried out to confirm LM diagnosis and to evaluate co-existence of small intestinal bacterial overgrowth(SIBO).Respondents diagnosed with LM were selected as study subjects and were treated with incremental loads of cow’s milk,starting from 30 mL and increasing up to 200 mL at 4-7 d intervals.After the treatment,changes in symptoms and LM diagnostic value of 20 g LHBT were investigated.Stool samples pre-and post-treatment were examined for changes in intestinal microbiota using 16S rRNA sequencing.Informed consent was obtained prior to each stage of the study.RESULTS In 46 subjects with LI symptoms(10-68 years old,mean age 34 years old)identified with the questionnaire,35(76.1%)were diagnosed with LM by 20 g LHBT,and 6 had co-existing SIBO.The treatment with incremental cow’s milk was carried out in 32 subjects diagnosed with LM(14-68 years old,median age 38.5 years old).The mean period of the treatment was 41±8.6 d.Improvement of symptoms was observed in 29(90.6%;95%confidence interval:75.0%-98.0%)subjects.Although 20 g LHBT indicated that 10(34.5%)subjects had improved diagnostic value of LM,no change was observed in 16(55.2%)subjects.Analysis of the fecal intestinal microbiota showed a significant increase in Blautia in 7 subjects who became symptom-free after the treatment(P=0.0313).CONCLUSION LM was diagnosed in approximately 75%of the subjects who had LI.Incremental loads of cow’s milk is regarded as a useful treatment for LM without affecting everyday life.

Medical Education in Japan and Introduction of Medical Education at Tokyo Women's Medical University

Medical education in Japan changed rapidly in the last decade of the 20th century with the introduction of new education methods and implementation of the core curriculum and common achievement testing such as CBT and OSCE.Recently, there have been other movements in medical education in Japan that have introduced "outcome(competency) based education(OBE)" and created a system for accreditation of medical education programs. This report provides an overview of current medical education in Japan. Moreover, it introduces medical education at Tokyo Women's Medical University.

布南色林治疗精神分裂症的临床应用中日专家建议

第二代(非典型)抗精神病药布南色林对多巴胺D_(2)、D_(3)受体和5-HT_(2A)受体均有较高亲和力,而对肾上腺素α_(1)、5-HT_(2c)、组胺H_(1)、毒蕈碱M_(1)和M_(3)等受体亲和力较低。多项短期和长期临床研究显示:该药对精神分裂症的阳性症状、阴性症状均有较好疗效,并改善患者的部分认知症状和社会功能。本文在循证证据和多位中日专家临床用药经验基础上撰写,希望为临床精神科医生提供用药参考,帮助精神分裂症患者早日康复,回归社会。

Clinical features of gastroduodenal injury associated with long-term low-dose aspirin therapy

Low-dose aspirin(LDA) is clinically used for the prevention of cardiovascular and cerebrovascular events with the advent of an aging society.On the other hand,a very low dose of aspirin(10 mg daily) decreases the gastric mucosal prostaglandin levels and causes significant gastric mucosal damage.The incidence of LDAinduced gastrointestinal mucosal injury and bleeding has increased.It has been noticed that the incidence of LDA-induced gastrointestinal hemorrhage has increased more than that of non-aspirin non-steroidal anti-inflammatory drug(NSAID)-induced lesions.The pathogenesis related to inhibition of cyclooxygenase(COX)-1 includes reduced mucosal flow,reduced mucus and bicarbonate secretion,and impaired platelet aggregation.The pathogenesis related to inhibition of COX-2 involves reduced angiogenesis and increased leukocyte adherence.The pathogenic mechanisms related to direct epithelial damage are acid back diffusion and impaired platelet aggregation.The factors associated with an increased risk of upper gastrointestinal(GI) complications in subjects taking LDA are aspirin dose,history of ulcer or upper GI bleeding,age > 70 years,concomitant use of non-aspirin NSAIDs including COX-2-selective NSAIDs,and Helicobacter pylori(H.pylori) infection.Moreover,no significant differences have been found between ulcer and non-ulcer groups in the frequency and severity of symptoms such as nausea,acid regurgitation,heartburn,and bloating.It has been shown that the ratios of ulcers located in the body,fundus and cardia are significantly higher in bleeding patients than the ratio of gastroduodenal ulcers in patients taking LDA.Proton pump inhibitors reduce the risk of developing gastric and duodenal ulcers.In contrast to NSAIDinduced gastrointestinal ulcers,a well-tolerated histamine H2-receptor antagonist is reportedly effective in prevention of LDA-induced gastrointestinal ulcers.The eradication of H.pylori is equivalent to treatment with omeprazole in preventing recurrent bleeding.Continuous aspirin therapy for patients with gastrointestinal bleeding may increase the risk of recurrent bleeding but potentially reduces the mortality rates,as stopping aspirin therapy is associated with higher mortality rates.It is very important to prevent LDA-induced gastroduodenal ulcer complications including bleeding,and every effort should be exercised to prevent the bleeding complications.

Complete laparoscopic resection of the rectum using natural orifice specimen extraction

AIM: To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction(NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.METHODS: Twenty patients who underwent complete laparoscopic anterior resection with NOSE and 50 patients who underwent laparoscopic assisted anterior resection by the conventional method between 2011 and 2012 were studied. Selection for complete laparoscopic anterior resection with NOSE was decided on the basis of tumor size, localization of the tumor, and body mass index. Outcomes related to surgery, including operation time, postoperative wound pain, hospital stay after surgery, the number of totally dissected lymph nodes, postoperative complications(suture failure and wound infection), and anal function, were reviewed retrospectively. Anal function was assessed at 3 and 6 mo after surgery using the Wexner fecal incontinence scoring system.RESULTS: Complete laparoscopic resection with NOSE was performed to completion in all 20 patients. There was no patient emergency that required conversion to conventional laparoscopic surgery or open surgery. The comparison between complete laparoscopic resection with NOSE and conventional laparoscopic surgery showed no significant differences in the maximal diameter of the tumor, number of totally dissected lymph nodes, bleeding volume, mean operation time, time to start of oral ingestion, postoperative hospital stay, and postoperative complications. On the other hand, with regard to pain after epidural anesthesia, the total usage of analgesia in this novel surgical technique was 1.85 ± 1.8 times, whereas it was 5.89 ± 2.86 in conventional laparoscopic surgery(P < 0.001). The postoperative pain period was 1.9 ± 1.9 d in this novel surgical technique, whereas it was 3.43 ± 1.41 d in conventional laparoscopic surgery(P < 0.004). In complete laparoscopic surgery with NOSE, the mean postoperative follow-up period was 20 mo(range: 12-30 mo). Neither local recurrence nor remote metastasis was observed during the follow-up period.CONCLUSION: Complete laparoscopic anterior resection using NOSE does not require any incision and has excellent cosmetic properties, with mitigated postoperative pain.

Assessment of the validity of the clinical pathway for colon endoscopic submucosal dissection

AIM: To determine the effective hospitalization period as the clinical pathway to prepare patients for endoscopic submucosal dissection (ESD). METHODS: This is a retrospective observational study which included 189 patients consecutively treated by ESD at the National Cancer Center Hospital from May 2007 to March 2009. Patients were divided into 2 groups; patients in group A were discharged in 5 d and patients in group B included those who stayed longer than 5 d. The following data were collected for both groups: mean hospitalization period, tumor site, median tumor size, post-ESD rectal bleeding requiring urgent endoscopy, perforation during or after ESD, abdominal pain, fever above 38 ℃, and blood test results positive for inflammatory markers before and after ESD. Each parameter was compared after data collection. RESULTS: A total of 83% (156/189) of all patients could be discharged from the hospital on day 3 postESD. Complications were observed in 12.1% (23/189) of patients. Perforation occurred in 3.7% (7/189) of patients. All the perforations occurred during the ESD procedure and they were managed with endoscopic clipping. The incidence of post-operative bleeding was 2.6% (5/189); all the cases involved rectal bleeding. We divided the subjects into 2 groups: tumor diameter ≥ 4 cm and < 4 cm; there was no significant difference between the 2 groups (P = 0.93, χ 2 test with Yates correction). The incidence of abdominal pain was 3.7% (7/189). All the cases occurred on the day of the procedure or the next day. The median white blood cell count was 6800 ± 2280 (cells/μL; ± SD) for group A, and 7700 ± 2775 (cells/μL; ± SD) for group B, showing a statistically significant difference (P = 0.023, t-test). The mean C-reactive protein values the day after ESD were 0.4 ± 1.3 mg/dL and 0.5 ± 1.3 mg/dL for groups A and B, respectively, with no significant difference between the 2 groups (P = 0.54, t -test). CONCLUSION: One-day admission is sufficient in the absence of complications during ESD or early postoperative bleeding.

Endoscopic diagnosis of pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a junction of the pancreatic and bile ducts located outside the duodenal wall, usually forming a markedly long common channel. As the action of the sphincter of Oddi does not functionally affect the junction in PBM patients, continuous pancreatobiliary reflux occurs, resulting in a high incidence of biliary cancer. PBM can be divided into PBM with biliary dilatation (congenital choledochal cyst) and PBM without biliary dilatation (maximal diameter of the bile duct ≤ 10 mm). The treatment of choice for PBM is prophylactic surgery before malignant changes can take place. Endoscopic retrograde cholangiopancreatography (ERC P) is the most effective examination method for close obs ervation of the pattern of the junction site. When the communication between the pancreatic and bile ducts is maintained, despite contraction of the sphi ncter on ERCP, PBM is diagnosed. In these pat ients, levels of pancreatic enzymes in the bile are gene rally elevated, due to continuous pancreatobiliary reflux via a long common channel. Magnetic resonance cholangiopancreatography and 3D-computed tomography can diagnose PBM, based on findings of an anomalous union between the common bile duct and the pancreatic duct, in addition to a long common channel. Endoscopic ultrasonography and intraductal ultra sonography can demonstrate the junction outside the duodenal wall, and are useful for the diagnosis of asso ciated biliary cancer. Gallbladder wall thickness on ultra so nography can be a screening test for PBM.

Diagnostic efficacy of gadoxetic acid-enhanced MRI for hepatocellular carcinoma and dysplastic nodule

AIM:To evaluate the relationship between the signal intensity of hepatobiliary phase images on gadoxetic acid-enhanced magnetic resonance imaging(MRI)and histological grade.METHODS:Fifty-nine patients with 82 hepatocellular lesions were evaluated retrospectively.Hepatobiliary phase images on gadoxetic acid-enhanced MRI were classified into 3 groups:low,iso or high.Angiographyassisted computed tomography(CT)findings were also classified into 3 groups:CT during arterial portography,and CT hepatic arteriography:A:iso,iso or low;B:slightly low,iso or low;;and C:low,high.We correlated angiography-assisted CT,hepatobiliary phase findings during gadoxetic acid-enhanced MRI and histological grades.Furthermore,correlations between MRI findings and histological grade for each hemodynamic pattern were performed.Correlations among radiologicaland pathological findings were statistically evaluated using the chi-square test and Fisher's exact test.RESULTS:There was a significant correlation between histological grade and hemodynamic pattern(P<0.05).There was a significant correlation between histological grade and signal intensity in the hepatobiliary phase(P<0.05)in group A lesions.There was no significant correlation between histological grade and signal intensity in the hepatobiliary phase in group B or C lesions(P>0.05).CONCLUSION:Signal intensity in the hepatobiliary phase correlated with histological grade in the lesions that maintained portal blood flow,but did not correlate in lesions that showed decreased or defective portal blood flow.

Pancreatic neuroendocrine tumor and solid-pseudopapillary neoplasm: Key immunohistochemical profiles for differential diagnosis

AIM To reveal better diagnostic markers for differentiating neuroendocrine tumor(NET) from solid-pseudopapillary neoplasm(SPN), focusing primarily on immunohistochemical analysis.METHODS We reviewed 30 pancreatic surgical specimens of NET(24 cases) and SPN(6 cases). We carried out comprehensive immunohistochemical profiling using 9 markers: Synaptophysin, chromogranin A, pancytokeratin, E-cadherin, progesterone receptor,vimentin, α-1-antitrypsin, CD10, and β-catenin.RESULTS E-cadherin staining in NETs, and nuclear labeling of β-catenin in SPNs were the most sensitive and specific markers. Dot-like staining of chromogranin A might indicate the possibility of SPNs rather than NETs. The other six markers were not useful because their expression overlapped widely between NETs and SPNs. Moreover, two cases that had been initially diagnosed as NETs on the basis of their morphological features, demonstrated SPN-like immunohistochemical profiles. Careful diagnosis is crucial as we actually found two confusing cases showing disagreement between the tumor morphology and immunohistochemical profiles.CONCLUSION E-cadherin, chromogranin A, and β-catenin were the most useful markers which should be employed for differentiating between NET and SPN.

Carcinogenesis and chemoprevention of biliary tract cancer in pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is a high risk factor for biliary tract cancer. In PBM, since the pancreatic duct and bile duct converge outside the duodenal wall beyond the influence of the sphincter of Oddi, pancreatic juice and bile are constantly mixed, producing a variety of harmful substances. Because of this, the biliary mucosa is repeatedly damaged and repaired, which causes an acceleration of cell proliferative activity and multiple gene mutations. Histological changes such as hyperplasia, metaplasia, and dysplasia ultimately result in a high incidence of carcinogenesis. In a nationwide survey by the Japanese Study Group on PBM, coexisting biliary tract cancer was detected in 278 of the 1627 registered cases of PBM (17.1%). Of these cases, in those with dilatation of the extrahepatic bile duct, cancer was often detected not only in the gallbladder but also in the bile ducts. More than 90% of cancer cases without dilatation of the extrahepatic bile duct develop in the gallbladder. Standard treatment for PBM is a cholecystectomy and resection of the extrahepatic bile duct. However, cholecystectomy alone is performed at nearly half of institutions in Japan. Conversely, reports of carcinogenesis in the remnant bile duct or pancreas after diversion surgery are steadily increasing. One of the causes for this is believed to be an accumulation of gene mutations which were present before surgery. Anticancer drugs are ineffective in preventing such carcinogenesis following surgery, thus the postoperative administration of chemopreventive agents may be necessary.

Safety trial of high-intensity focused ultrasound therapy for pancreatic cancer

AIM:To evaluate the safety and clinical application of high-intensity focused ultrasound(HIFU)therapy for unresectable pancreatic cancer(PC).METHODS:Thirty PC patients(16 cases in stage III and 14 cases in stage IV)with visualized pancreatic tumors were admitted for HIFU therapy as an optional local therapy in addition to systemic chemotherapy or chemoradiotherapy.Informed consent was obtained.This study began at the end of 2008 and was approved by the ethics committee of our hospital[Institutional Review Board(IRB):890].The HIFU device used was the FEP-BY02(Yuande Bio-Medical Engineering,Beijing,China).RESULTS:The mean tumor size after HIFU therapy changed to 30.9±1.7 mm from 31.7±1.7 mm at pre-therapy.There were no significant changes in tumor size,mean number of treatment sessions(2.7±0.1 mm),or mean total treatment time(2.4±0.1 h).The rate of symptom relief effect was 66.7%.The effectiveness of primary lesion treatment was as follows:complete response,0;partial response,4;stable disease,22;progressive disease,4.Treatment after HIFU therapy included 2 operations,24 chemotherapy treatments,and 4 best supportive care treatments.Adverse events occurred in 10%of cases,namely pseudocyst formation in 2 cases and mild pancreatitis development in 1.However,no severe adverse events occurred in this study.CONCLUSION:We suggest that HIFU therapy is safe and has the potential to be a new method of combination therapy for PC.

Arterial-phase contrast-enhanced ultrasonography for evaluating anti-angiogenesis treatment: A pilot study

AIM:To verify whether arterial-phase contrast-enhanced ultrasonography(CEUS) of tumor parenchymal tissue is useful for evaluation of anti-angiogenesis agents.METHODS:Rabbits with liver tumor were subjected to CEUS,and images of the nodular maximal diameter in vascular phase were recorded.Image analysis was performed to plot the time intensity curve(TIC) at the tumor parenchyma,which set the diameter of the region of interest of intensity measurement.The TIC was calculated to obtain the time to peak intensity(TPI) and the magnitude of PI.Rabbits were randomly assigned to a treatment group with sorafenib and a control group.Two weeks later,the same ultrasound examination was repeated followed by pathological testing to assess the effect of sorafenib on the liver tumor.RESULTS:In four rabbits in the treatment group,the rate of change of tumor size was decreased comparedwith that of the control(the rate 2.3 vs 7.9,P = 0.02).The TPI of the treatment group elongated significantly(the rate 3.1 vs 1.1,P = 0.07 for SonoVue,2.0 vs 0.88,P = 0.09 for Sonazoid).The magnitude of PI showed no significant changes.In pathological examination,capillary diameters in the treatment group were significantly smaller than those in the control group(26.4 vs 42.8 μm,P = 0.013).CONCLUSION:Analysis of the TIC in the arterial phase of tumor tissue could evaluate the efficacy of antiangiogenesis drug treatment in liver tumor.

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Endoscopic ultrasonography (EUS)-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). In the present study,we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCP. We performed the procedure in 2 papilla of Vater,including one resectable case,and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope,a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation,or papillary balloon dilator,a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 (75%) of 4 cases,an indwelling plastic stent was placed,and in one case in which the stent could not be advanced into the bile duct,a naso-biliary drainage tube was placed instead. In all cases,the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case,pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory,EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.

Surgical anatomy of innervation of the gallbladder in humans and Suncus murinus with special reference to morphological understanding of gallstone formation after gastrectomy

瞄准：澄清人的胆囊的神经分布，与在胃切除术以后的胆石形成的词法理解的特殊参考。方法：肝，胆囊和包围结构在乙醇沉浸于茜素红 S 的 10 mg/L 答案在死尸染色周围神经(n = 10 ) 。在区域的神经分布完全在一台双目显微镜下面被把。同样，在 10 Suncus murinus 的一样的区域的神经分布(S。murinus ) 被检验采用整个山免疫组织化学。结果：胆囊的神经分布通过二条线路主要发生了。一个人从前面的肝的丛，神经分布沿着膀胱的动脉和管发生了。总是，这条线路通过了肝十二指肠系带。另外的线路从以后的肝的丛，神经分布沿着膀胱的管 vent 集合发生了。这条线路也通过了肝十二指肠系带欧洲粪金龟子突围。类似的结果在 S 被获得。murinus。结论：从经由膀胱的动脉或管的前面的肝的丛的线路为保存胆囊神经分布是关键的。淋巴节点解剖可以明确地在胃切除术以后在肝十二指肠系带影响胆石的发生。而且，从经由到胆囊的胆总管和膀胱的管的以后的肝的丛的线路不应该被不顾。丛的保藏可以在胃切除术以后稀释胆石形成的发生。

A predictive factor for the response to S-1 plus cisplatin in gastric cancer

AIM:To prove that the protein expression level of thymidylate synthase is a predictive factor for the response to S-1/cisplatin(CDDP)chemotherapy in gastric cancer.METHODS:We measured the protein expression levels of thymidylate synthase(TS),dihydropyrimidine dehydrogenase(DPD),and orotate phosphoribosyltrans-ferase(OPRT)in advanced gastric cancer.Before S-1/CDDP chemotherapy,tumor specimens from primary sites were obtained by endoscopic biopsy and analyzed by enzyme-linked immunosorbent assay.The chemo-therapeutic effects on the primary sites were evaluated by endoscopic biopsy performed more than once after S-1/CDDP chemotherapy.The effects are a predictive factor for the response to S-1/CDDP chemotherapy inpatients with advanced gastric cancer,as evaluated by endoscopic biopsy over time.RESULTS:The protein expression level of TS was significantly higher(P<0.05)in the tumor than in the normal tissue,and significantly lower(P<0.05)in the responders than in the non-responders.We were able to evaluate the correlation between changes in the protein expression levels of TS,DPD and OPRT and chemotherapeutic responses in 7 patients by assessing tumor tissues more than twice.In the responders,the protein expression level of TS was<40 ng/mg protein.However,there were significant increases in the protein expression levels of TS(P<0.01)and DPD(P<0.05)after chemotherapy in 3 patients.In these cases,the patient assessment changed from"responder"to"non-responder".In the non-responders,the protein expression level of TS was>40 ng/mg protein.CONCLUSION:We have confirmed that the protein expression level of TS is a predictive factor for the response to S-1/CDDP chemotherapy in patients with advanced gastric cancer.

Cell sheet technology for regeneration of esophageal mucosa

The progress of tissue-engineering technology has realized development of new therapies to treat various disorders by using cultured cells. Cell-and tissue-based therapies have been successfully applied to human patients, and several tissue-engineered products have been approved by the regulatory agencies and are commercially available. In the review article, we describe our experience of development and clinical application of cell sheet-based regenerative medicine.Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been shown to be useful for removal of gastrointestinal neoplasms with less invasiveness compared with open surgery, especially in esophageal surgery. However, postoperative inflammation and stenosis are major complications observed after intensive mucosal resection. Therefore, we have developed novel regenerative medicine to prevent such complications and promote wound healing of esophageal mucosa after EMR or ESD. Transplantable oral mucosal epithelial cell sheets were fabricated from patients' own oral mucosa. Immediately after EMR or ESD, fabricated autologous cell sheets were endoscopically transplanted to the ulcer sites. We performed a preclinical study with a canine model. In human clinical settings, cell culture and cell sheet fabrication were performed in clean rooms according to good manufacturing practice guidelines, and pharmaceutical drugs were used as supplements to culture medium in place of research regents used in animal study. We believe that cell-based regenerative medicine would be useful to improve quality of life of patients after EMR or ESD.