Periaortic Abdominal Fat Area as a Predictor of Surgical Difficulties during Extraperitoneal Laparoscopic Para-aortic Lymphadenectomy.

STUDY OBJECTIVE: To evaluate whether obesity is a marker of surgical difficulty during extraperitoneal para-aortic lymphadenectomy. DESIGN: Retrospective observational cohort study. SETTING: Tertiary medical center in the Kanazawa area of Japan. PATIENTS: Eighty-four patients with primary endometrial cancer who underwent extraperitoneal laparoscopic para-aortic lymphadenectomy (LPAND) between January 2005 and December 2017 were included. INTERVENTIONS: We investigated the correlation between operative times and body mass indexes, visceral fat areas, and periabdominal artery fat areas (PAFAs). The number of lymph nodes harvested was used as an indicator of the degree of surgical completion. MEASUREMENTS AND MAIN RESULTS: There was no correlation between the operative time and body mass index. Significant correlations were observed between operative time and visceral fat area (p = .026; r = 0.243) and between operative time and PAFA (p = .007; r = 0.293). A multivariate analysis showed that PAFA was a significant independent marker that could be used to predict prolonged operative times for extraperitoneal LPAND (p = .045; odds ratio, 3.05). The number of para-aortic lymph nodes harvested was not significant in the high- and low-PAFA groups (22 and 25, respectively; p = .525). CONCLUSION: PAFA is an adequate marker of prolonged operative time for extraperitoneal LPAND among patients with endometrial cancer.

Simultaneous resection of endometrial cancer and high-level paraaortic paraganglioma using retroperitoneoscopic surgery.

•Paraganglioma is sometimes suspected as lymph node metastasis or lymph node recurrence of various malignant tumors.•Retroperitoneoscopic surgery is a valid approach to treat the tumor, located above the renal vein.•Resection using retroperitoneoscopic surgery without catecholamine-related complications is possible.

Acquired hemophilia A manifesting as plasma transfusion-uncontrolled severe bleeding 2 weeks after chorioamnionitis-induced abortion.

Acquired hemophilia A (AHA) is a serious and rare complication of pregnancy, caused by autoantibodies to coagulation factor VIII after delivery. We here report the case of a 36-year-old primigravida woman who developed AHA following chorioamnionitis-caused miscarriage in the second trimester. Thirteen days after abortion, sudden, massive vaginal bleeding occurred with marked prolongation of activated partial thromboplastin time (APTT) in the absence of other abnormal coagulation data. Sequential transfusion of fresh frozen plasma did not achieve normalization of APTT. Further examination confirmed reduction of coagulation factor VIII and the presence of its inhibitor, leading to the final diagnosis of AHA. The patient was effectively treated with bypassing agents (activated prothrombin complex concentrate and recombinant activated factor VII) and immunosuppressive therapy. Fifteen months after remission, the patient became pregnant and successfully achieved term delivery with no signs of recurrence. This case illustrates that AHA should be considered in the occurrence of plasma transfusion-uncontrolled severe bleeding after delivery.

Nerves and fasciae in and around the paracolpium or paravaginal tissue: an immunohistochemical study using elderly donated cadavers.

The paracolpium or paravaginal tissue is surrounded by the vaginal wall, the pubocervical fascia and the rectovaginal septum (Denonvilliers' fascia). To clarify the configuration of nerves and fasciae in and around the paracolpium, we examined histological sections of 10 elderly cadavers. The paracolpium contained the distal part of the pelvic autonomic nerve plexus and its branches: the cavernous nerve, the nerves to the urethra and the nerves to the internal anal sphincter (NIAS). The NIAS ran postero-inferiorly along the superior fascia of the levator ani muscle to reach the longitudinal muscle layer of the rectum. In two nulliparous and one multiparous women, the pubocervical fascia and the rectovaginal septum were distinct and connected with the superior fascia of the levator at the tendinous arch of the pelvic fasciae. In these three cadavers, the pelvic plexus and its distal branches were distributed almost evenly in the paracolpium and sandwiched by the pubocervical and Denonvilliers' fasciae. By contrast, in five multiparous women, these nerves were divided into the anterosuperior group (bladder detrusor nerves) and the postero-inferior group (NIAS, cavernous and urethral nerves) by the well-developed venous plexus in combination with the fragmented or unclear fasciae. Although the small number of specimens was a major limitation of this study, we hypothesized that, in combination with destruction of the basic fascial architecture due to vaginal delivery and aging, the pelvic plexus is likely to change from a sheet-like configuration to several bundles.

Topohistology of sympathetic and parasympathetic nerve fibers in branches of the pelvic plexus: an immunohistochemical study using donated elderly cadavers.

Although the pelvic autonomic plexus may be considered a mixture of sympathetic and parasympathetic nerves, little information on its composite fibers is available. Using 10 donated elderly cadavers, we investigated in detail the topohistology of nerve fibers in the posterior part of the periprostatic region in males and the infero-anterior part of the paracolpium in females. Neuronal nitric oxide synthase (nNOS) and vasoactive intestinal polypeptide (VIP) were used as parasympathetic nerve markers, and tyrosine hydroxylase (TH) was used as a marker of sympathetic nerves. In the region examined, nNOS-positive nerves (containing nNOS-positive fibers) were consistently predominant numerically. All fibers positive for these markers appeared to be thin, unmyelinated fibers. Accordingly, the pelvic plexus branches were classified into 5 types: triple-positive mixed nerves (nNOS+, VIP+, TH+, thick myelinated fibers + or -); double-positive mixed nerves (nNOS+, VIP-, TH+, thick myelinated fibers + or -); nerves in arterial walls (nNOS-, VIP+, TH+, thick myelinated fibers-); non-parasympathetic nerves (nNOS-, VIP-, TH+, thick myelinated fibers + or -); (although rare) pure sensory nerve candidates (nNOS-, VIP-, TH-, thick myelinated fibers+). Triple-positive nerves were 5-6 times more numerous in the paracolpium than in the periprostatic region. Usually, the parasympathetic nerve fibers did not occupy a specific site in a nerve, and were intermingled with sympathetic fibers. This morphology might be the result of an "incidentally" adopted nerve fiber route, rather than a target-specific pathway.

Widening disparity in the geographic distribution of pediatricians in Japan.

BACKGROUND: The shortage of physicians in Japan is a serious concern, particularly in specialties like pediatrics. The purpose of this study was to investigate recent changes in the geographic distribution of pediatricians and the factors underlying this change. METHODS: We investigated the numerical changes in the pediatrician workforce (2002 to 2007) per 100,000 of the population under the age of 15 years in 369 secondary medical areas throughout Japan, using attributive variables such as population size, social and economic status, and pediatric service delivery. We performed principal component analysis and multiple regression analysis. RESULTS: We obtained two principal components: one that reflected the degree of urbanization and another that reflected the volume of pediatric service delivery. Only the first component score was positively correlated with an increased pediatrician workforce per 100,000 of the population under the age of 15 years. We classified the secondary medical areas into four groups using component scores. The increase in pediatrician workforce during this period was primarily absorbed into the two groups with higher levels of urbanization, whereas the two rural groups exhibited little increase. Pediatricians aged 50 to 59 years increased in all four groups, whereas pediatricians aged 30 to 39 years decreased in the two rural groups and increased in the two urban groups. CONCLUSIONS: The trends of the pediatrician workforce increase generally kept pace with urbanization, but were not associated with the original pediatrician workforce supply. The geographic distribution of pediatricians showed rapid concentration in urban areas. This trend was particularly pronounced among female pediatricians and those aged 30 to 39 years. Given that aging pediatricians in rural areas are not being replaced by younger doctors, these areas will likely face new crises when senior physicians retire.

Fetal growth restriction and reversed middle cerebral artery end-diastolic flow with subchorionic placental lake.

Fetal growth restriction (FGR) is frequently associated with uteroplacental insufficiency. Placental lakes are avillous spaces filled with maternal venous blood that usually do not compromise the pregnancy outcome; however, a few reports describe FGR in association with placental lakes. Reversed middle cerebral artery (MCA) end-diastolic flow is a rare event and a potential indicator of poor fetal outcome due to placental insufficiency. We report a case of severe FGR associated with a huge subchorionic placental lake concomitant with reversed MCA end-diastolic flow. We also conducted a literature review.

Amylase-producing ovarian carcinoma: A case report and a retrospective study.

► Amylase-producing ovarian carcinoma may mimic pancreatitis. ► Hyperamylasemia is common in ovarian carcinoma. ► Serum amylase may be a promising tumor marker.

Redefinition of the pelvic connective tissue: in situ histologic examination.

OBJECTIVES: : The objectives of this study were to find a common perspective in clinical and gross/systemic anatomy for the pelvic connective tissue (subperitoneal fascia) and to establish a new pelvic anatomy. METHODS: : The histologic sections from 5 fixed cadavers were obtained from a total of 17 fixed and 11 fresh cadavers. On the basis of our past surgical and research findings, the relationship between the pelvic organs and the pelvic connective tissue was observed from in situ histologic sections of the whole pelvis. RESULTS: : Subperitoneal fasciae, a term that is expressed in gross/systemic anatomy, were manifested as a 3-dimensional structure by a complex of "ligaments," as defined in clinical terminology. In the supine position, this structure consisted of the sagittal plane formed by the rectouterine ligament and vesicouterine ligament; the perpendicular plane by the vesicohypogastric fascia, transverse cervical ligament, and lateral rectal ligament; and the horizontal plane by the superior fascia of the levator ani muscle. CONCLUSIONS: : The ligaments were regarded as a compatible component of the subperitoneal fascia. Our anatomical concept of the pelvic connective tissue differed from that for classic clinical anatomy.

Discrepancies between classic anatomy and modern gynecologic surgery on pelvic connective tissue structure: harmonization of those concepts by collaborative cadaver dissection.

OBJECTIVE: The purpose of this study was to solve a disagreement regarding the anatomy of the pelvic connective tissue in 19th and 20th century, and to establish new surgical anatomy. STUDY DESIGN: The study involved the dissection 26 female cadavers. The ligamentous structure of the pelvis was examined by developing the paravesical and pararectal spaces, using our standard procedure of radical hysterectomy. RESULTS: The lateral ligamentous structure of the pelvis was a plate complex, which consisted of the vesicohypogastric fascia, the transverse cervical ligament, and lateral ligament of the rectum. The 3-dimensional relationship of this complex and the pelvic organs was sagittaly perpendicular. The pelvic connective tissue was classified into 2 systems, musculofascial and mesentery-like structures. CONCLUSION: The authors examined the discrepancies in 19th century anatomy for the pelvic connective tissue that is widely accepted in today's medical field, therewith proposing a new surgical anatomy for this structure.

Efficacy of intraperitoneal continuous hyperthermic chemotherapy as consolidation therapy in patients with advanced epithelial ovarian cancer: a long-term follow-up.

This trial was performed to determine the efficacy and progression-free and overall survivals of patients with advanced ovarian cancer who had been treated with intraperitoneal hyperthermic chemotherapy (IPHC). Ten patients with advanced ovarian cancer participated in this trial and were treated with IPHC. The median progression-free and overall survival rates for all patients treated in this study were 41.2 and 70.2 months, respectively. Two of ten patients received optimal primary cytoreduction surgery followed by IPHC; four of ten, optimal interval debulking surgery followed by IPHC; and four of ten, negative second-look operation followed by IPHC. The groups had 5 and 14.5, 17.75 and 38, and 82.75 and 130.25 months median progression-free and overall survival rates, respectively. Grades 3-4 toxicity included myelosuppresion, and nephropathy was detected. One patient required blood transfusions due to grade 4 anemia and thrombocytopenia. Another patient developed grade 3 nephrotoxicity but did not require continuous hemodialysis. IPHC was feasible, produced manageable toxicity, and showed promise for the treatment of advanced ovarian cancer. Negative second-look laparotomy followed by IPHC was especially effective when consolidation intraperitoneal chemotherapy had been indicated. It produced excellent median progression-free and overall survival rates.

Caspase 3-mediated focal adhesion kinase processing in human ovarian cancer cells: possible regulation by X-linked inhibitor of apoptosis protein.

OBJECTIVE: Cell adhesion is an important cell survival determinant and disruption of integrin-mediated signal transduction may be involved in anchorage-dependent cell death. We have examined the processing of focal adhesion kinase (FAK), a component of integrin-mediated signal transduction, in a cisplatin-sensitive human ovarian epithelial cancer cell line (OV2008), to test the possible role of FAK degradation in the control of apoptosis via regulation of cell attachment. METHODS: FAK processing after cisplatin treatment in the absence or presence of various caspase-inhibiting substances was analyzed by Western blot. Caspase-inhibiting activities were introduced using cell-permeable peptides or adenoviral vector. RESULTS: Cisplatin-induced caspase 3 and FAK cleavage, cell detachment from the growth surface, and apoptosis in a temporally related and concentration-dependent manner. FAK fragments were detected exclusively in cells detached from the culture surface. Addition of active caspase 3 to the whole cell lysate elicited a similar pattern of FAK cleavage. Pretreatment of whole cell lysates and cells with tetrapeptide inhibitors of caspases significantly decreased FAK cleavage induced by exogenous active caspase 3 and cisplatin, respectively. Overexpression of X-linked inhibitor of apoptosis protein (Xiap), an endogenous caspase inhibitor, attenuated the cisplatin-induced FAK processing, morphologic changes, and apoptosis. The inhibitory action of Xiap was abolished with the deletion of a functional motif required for caspase inhibition. CONCLUSION: These findings are consistent with our hypothesis that FAK processing is in part mediated by caspase 3, the activation of which is modulated by Xiap.