Recurrence-free survival as a surrogate endpoint for overall survival after neoadjuvant chemotherapy and surgery for oesophageal squamous cell carcinoma.

BACKGROUND: Overall survival is considered as one of the most important endpoints of treatment efficacy but often requires long follow-up. This study aimed to determine the validity of recurrence-free survival as a surrogate endpoint for overall survival in patients with surgically resectable advanced oesophageal squamous cell carcinoma (OSCC). METHODS: Patients with OSCC who received neoadjuvant cisplatin and 5-fluorouracil, or docetaxel, cisplatin and 5-fluorouracil, at 58 Japanese oesophageal centres certified by the Japan Esophageal Society were reviewed retrospectively. The correlation between recurrence-free and overall survival was assessed using Kendall's τ. RESULTS: The study included 3154 patients. The 5-year overall and recurrence-free survival rates were 56.6 and 47.7% respectively. The primary analysis revealed a strong correlation between recurrence-free and overall survival (Kendall's τ 0.797, 95% c.i. 0.782 to 0.812) at the individual level. Subgroup analysis showed a positive relationship between a more favourable pathological response to neoadjuvant chemotherapy and a higher τ value. In the meta-regression model, the adjusted R2 value at the institutional level was 100 (95% c.i. 40.2 to 100)%. The surrogate threshold effect was 0.703. CONCLUSION: There was a strong correlation between recurrence-free and overall survival in patients with surgically resectable OSCC who underwent neoadjuvant chemotherapy, and this was more pronounced in patients with a better response to neoadjuvant chemotherapy.

Development and validation of a predictive model for in-hospital mortality from perioperative bacteremia in gastrointestinal surgery.

PURPOSE: Prognostic scores require fluctuating values, such as respiratory rate, which are unsuitable for retrospective auditing. Therefore, this study aimed to develop and validate a predictive model for in-hospital mortality associated with gastrointestinal surgery for retrospective auditing. METHODS: Data from patients with bacteremia related to gastrointestinal surgery performed at Shizuoka General Hospital between July 2006 and December 2021 were extracted from a prospectively maintained database. Patients suspected of having a positive blood culture with contaminating bacteria or missing laboratory data were excluded. The remaining patients were randomly assigned in a 2:1 ratio to the deviation and validation cohorts. A logistic regression model estimated the odds ratios (ORs) and created a predictive model for in-hospital mortality. The model was evaluated using receiver operating characteristic (ROC) curves and calibration plots. RESULTS: Of 20,637 gastrointestinal surgeries, 398 resulted in bacteremia. The median age of patients with bacteremia was 72 years, and 66.1% were male. The most common pathogens were Staphylococcus (13.9%), followed by Bacteroides (12.4%) and Escherichia (11.4%). Multivariable logistic regression showed that creatinine abnormality (P < 0.001, OR = 3.39), decreased prognostic nutritional index (P < 0.001, OR = 0.90/unit), and age ≥ 75 years (P = 0.026, OR = 2.89) were independent prognostic factors for in-hospital mortality. The area under the ROC curve of the predictive model was 0.711 in the validation cohort. The calibration plot revealed that the model slightly overestimated mortality in the validation cohort. CONCLUSIONS: Using age, creatinine level, albumin level, and lymphocyte count, the model accurately predicted in-hospital mortality after bacteremia infection related to gastrointestinal surgery, demonstrating its suitability for retrospective audits.

The impact of contour maps on estimating the risk of gastrointestinal stromal tumor recurrence: indications for adjuvant therapy: an analysis of the Kinki GIST registry.

INTRODUCTION: Contour maps enable risk classification of GIST recurrence in individual patients within 10 postoperative years. Although contour maps have been referred to in Japanese guidelines, their usefulness and role in determining indications for adjuvant therapy is still unclear in Japanese patients. The aims of this study are to investigate the validity of contour maps in Japanese patients with GIST and explore the new strategy for adjuvant therapy. MATERIALS AND METHODS: A total of 1426 Japanese GIST patients who were registered to the registry by the Kinki GIST Study Group between 2003 and 2012 were analyzed. Patients who had R0 surgery without perioperative therapy were included in this study. The accuracy of contour maps was validated. RESULTS: Overall, 994 patients have concluded this study. Using contour maps, we validated the patients. The 5-year recurrence-free survival rates of patients within the GIST classification groups of 0-10%, 10-20%, 20-40%, 40-60%, 60-80%, 80-90%, and 90-100% were 98.1%, 96.6%, 92.3%, 48.0%, 37.3%, 41.0% and 42.4%, respectively. We confirmed that this classification by contour maps was well reflected recurrence prediction. Further, in the high-risk group stratified by the modified National Institutes of Health consensus criteria (m-NIHC), the 10-year RFS rate was remarkably changed at a cutoff of 40% (0-40% group vs. 40-100% group: 88.7% vs. 50.3%, p < 0.001). CONCLUSION: Contour maps are effective in predicting individual recurrence rates. And it may be useful for the decision of individual strategy for high-risk patients combined with m-NIHC.

Comparison of efficacy between clazosentan and fasudil hydrochloride-based management of vasospasm after subarachnoid hemorrhage focusing on older and WFNS grade V patients: a single-center experience in Japan.

Subarachnoid hemorrhage often leads to poor outcomes owing to vasospasm, even after successful aneurysm treatment. Clazosentan, an endothelin receptor inhibitor, has been proven to be an effective treatment for vasospasms in a Japanese randomized controlled trial. However, its efficacy in older patients (≥ 75 years old) and those with World Federation of Neurosurgical Societies (WFNS) grade V has not been demonstrated. We retrospectively evaluated the efficacy of clazosentan in older patients and those with WFNS grade V, using real-world data. Patients with subarachnoid hemorrhage treated before and after the introduction of clazosentan were retrospectively evaluated. The patients were categorized into two groups (clazosentan era versus pre-clazosentan era), in which vasospasm management and outcomes were compared. Vasospasms were managed with fasudil hydrochloride-based (pre-clazosentan era) or clazosentan-based treatment (clazosentan era). Seventy-eight patients were included in this study: the clazosentan era (n = 32) and pre-clazosentan era (n = 46). Overall, clazosentan significantly reduced clinical vasospasms (clazosentan era: 31.3% versus pre-clazosentan era: 60.9%, p = 0.01), delayed cerebral ischemia (DCI) (9.4% versus 39.1%, p = 0.004), and vasospasm-related morbidity and mortality (M/M) (3.1% versus 19.6%, p = 0.03). In subgroup analysis of older patients or those with WFNS grade V, no significant difference was observed in clinical outcomes, although both DCI and vasospasm-related M/M were lower in the clazosentan era. Clazosentan was more effective than fasudil-based management in preventing DCI and reducing vasospasm-related M/M. Clazosentan could be used safely in older patients and those with WFNS grade V, although clinical outcomes in these patients were comparable to those of conventional treatment.

[Aortic Arch:Embryology and Remodeling].

A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this anatomical variation during angiography. Patients with disorders such as Down syndrome and congenital heart disease show a high incidence of an aberrant right subclavian artery, and this anomaly can cause symptomatic esophageal or tracheal compression. The root of the aberrant artery may show dilatation(referred to as a Kommerell diverticulum), dissection, intramural hematoma, or rupture necessitating cardiac intervention using a surgical or endovascular approach. Neurointerventionalists should have working knowledge of the anatomy to rapidly understand the anatomy and ensure a safe procedure. A left transradial approach should be considered if prior knowledge of the aberrant subclavian anatomy is available.

[Utility of abdominal ultrasonography in the management of ulcerative colitis:proposal of a new scoring system].

In the management of ulcerative colitis (UC), colonoscopy (CS) is considered essential for diagnosis;however, its invasiveness poses a challenge. Conversely, recent advancements in ultrasound diagnostic devices have improved imaging quality for the digestive tract, rendering them valuable in UC management. Therefore, this study aimed to elucidate the correlation between abdominal ultrasonography (AUS) and CS in assessing UC activity. The indices adopted for UC evaluation using AUS were as follows:1) bowel wall stratification, 2) bowel wall thickness, 3) bowel wall flow at power Doppler, 4) presence of increased brightness of inflammatory fat, and 5) presence of mesenteric lymph node swelling greater than 5mm. Subsequently, we developed a new AUS index for UC, termed the UCUS score, which comprises the aforementioned five indices. Finally, we compared the UCUS score with representative endoscopic indices, the Mayo endoscopic sub-score, and the Ulcerative Colitis Endoscopic Index of Severity. The results demonstrated that our proposed UCUS score better reflected disease activity than individual items assessed separately. ROC curve analysis revealed a UCUS score cutoff of 3 points. Therefore, a UCUS score of ≥3 points indicates the need for further examination with CS. Conversely, a score below 3 points suggests low disease activity, and in situations when evaluating treatment effectiveness, AUS could potentially substitute for CS. We believe that the UCUS score is an important source of information to understand the patient's condition and to motivate the patient to undergo endoscopy.

Systemic inflammation score as a predictor of death within one year after esophagectomy.

BACKGROUND: After radical resection for esophageal cancer, death within 1 year of surgery can occur due both to recurrence and to other diseases, even after postoperative complications have been overcome. This study identified risk factors for early death within 1 year of esophagectomy for reasons other than death in hospital in patients undergoing esophagectomy for esophageal cancer or esophagogastric junction cancer. METHODS: We reviewed 366 patients who underwent esophagectomy without adjuvant treatment between January 2009 and July 2022 for thoracic esophageal cancer or esophagogastric junction cancer. Patients who died within 1 year excluding in-hospital death were compared with those who did not. Multivariable logistic regression analysis was used to identify predictors of death within 1 year after surgery. RESULTS: Death within 1 year occurred in 32 of 366 patients, 24 from primary disease and 8 from other diseases. Deaths within 1 year were significantly older than the other cases, had significantly lower % vital capacity (%VC), and occurred significantly more often in cases in advanced stages of disease. In a multivariable analysis, a systemic inflammation score (SIS) based on serum albumin level and lymphocyte-to-monocyte ratio was identified as an independent predictor of death within 1 year. As SIS increased, %VC decreased significantly, and CRP level and neutrophil-lymphocyte ratio increased significantly. There was no relationship between SIS and pN. Death within 1 year increased as SIS increased (p = 0.001 for trend). CONCLUSION: SIS assessment undertaken before beginning esophageal cancer treatment is a useful predictor of death within 1 year of surgery.

A nationwide survey on the safety of cricothyrotomy: a multicenter retrospective study in Japan.

BACKGROUND: Cricothyrotomy is a widely performed potentially life-saving treatment to secure an airway in emergencies. It is also a pneumonia-preventing treatment to secure an expectorant route in patients with difficulty self-expelling sputum; however, its safety and usefulness remain unclear. Thus, we conducted a nationwide survey of cricothyrotomy. METHODS: We retrospectively collected and analyzed cricothyrotomy data from the institutions certified by the Japan Broncho-Esophagological Society or the Japanese Esophageal Society. Ultimately, 116 facilities responded to the survey and the present study included 1001 patients from 26 facilities who underwent cricothyrotomies from January 1, 2010 to December 31, 2021. RESULTS: Cricothyrotomy was performed for sputum suctioning after esophagectomy or other surgical procedures in 945 (94.4%) cases and for emergency airway clearance in 48 (4.8%) cases. Complications during puncture were observed in 12 (1.2%) cases. We found significantly fewer complications during puncture for sputum suction (1.0%) compared with emergency airway clearance (4.2%) (p = 0.002), and also at the condition after esophagectomy (0.5%) compared with other surgical procedures (7.8%) (p < 0.001). Complications after puncture were observed in 45 (4.5%) cases, and we found significantly fewer complications after puncture at the condition after esophagectomy (4.2%) compared with other surgical procedures (11.8%) (p = 0.032). There were no significant differences in the type of kit used for complications during and after the puncture. CONCLUSIONS: Cricothyrotomy for prophylactic sputum suctioning after esophagectomy was safer compared to emergency airway clearance. However, future studies should verify the efficacy of cricothyrotomy.

IL-1ß Derived Th17 Immune Responses Are a Critical Factor for Neutrophilic-Eosinophilic Airway Inflammation on Psychological Stress-Induced Immune Tolerance Breakdown in Mice.

INTRODUCTION: Asthma is an inflammatory reaction mediated by type 2 helper T (Th2) cells and is known to increase eosinophil levels. Our previous study showed that stress-related asthma can cause neutrophilic and eosinophilic airway inflammation by suppressing immune tolerance. However, the mechanism of stress-induced neutrophilic and eosinophilic airway inflammation remains unclear. Therefore, to elucidate the cause of neutrophilic and eosinophilic inflammation, we investigated the immune response during the induction of airway inflammation. In addition, we focused on the relationship between immune response modulation immediately after stress exposure and the development of airway inflammation. METHODS: Asthmatic mice were induced by three phases using female BALB/c mice. During the first phase, the mice were made to inhale ovalbumin (OVA) to induce immune tolerance before sensitization. Some mice were exposed to restraint stress during the induction of immune tolerance. In the second phase, the mice were sensitized with OVA/alum intraperitoneal injections. In the final phase, onset of asthma was induced through OVA exposure. Asthma development was evaluated based on airway inflammation and T-cell differentiation. Microarray and qPCR analyses were used to enumerate candidate factors to investigate the starting point of immunological modification immediately after stress exposure. Furthermore, we focused on interleukin-1ß (IL-1ß), which initiates these immune modifications, and performed experiments using its receptor blocker interleukin-1 receptor antagonist (IL-1RA). RESULTS: Stress exposure during immune tolerance induction increased eosinophil and neutrophil airway infiltration. This inflammation was associated with decreased T regulatory cell levels and increased Th2 and Th17 levels in bronchial lymph node cells. Microarray and qPCR analyses showed that the initiation of Th17 differentiation might be triggered by stress exposure during tolerance induction. IL-1RA administration during stress exposure suppressed neutrophilic and eosinophilic airway inflammation via Th17 reduction and Treg increase. CONCLUSIONS: Our results show that psychological stress causes both eosinophilic and neutrophilic inflammatory responses due to the breakdown of immune tolerance. Furthermore, stress-induced inflammation can be abolished using IL-1RA.

Postsurgical dural supply to the spinal cord arteriovenous malformation in spinal arteriovenous metameric syndrome.

Dural supply from the external carotid system in cerebral arteriovenous malformations (AVMs) is well known, but actual angiographic evidence of dural supply to spinal cord AVMs (SCAVMs) has not been reported. Here, we report a case of dural supply to the conus SCAVM in the spinal arteriovenous metameric syndrome segment 25-30. Thirteen years after spinal surgery (T12-L2 laminoplasty), spinal angiography showed multiple dural supplies from the dorsal somatic branches, prelaminar arteries, and radiculomeningeal arteries to the SCAVM at the level of the previous spinal surgery. To the best of our knowledge, this is the first reported case with dural supply to the spinal cord. This case demonstrates that the extradural and extraspinal branches can supply the spinal cord in rare instances of spinal dural adhesions following repeated hemorrhages and surgical intervention under a metameric link background.

FLOW-diverted Glue Embolization to Target lesions (FLOW-GET) technique for spinal vascular diseases: A technical note.

We present and exemplify the flow-diverted glue embolization to target lesions (FLOW-GET) technique for spinal vascular diseases. In this technique, the occlusion of the posterior intercostal artery or dorsal muscular branch by coils diverts the injected glue from the segmental artery to the target lesions. This technique was applied to a ruptured retrocorporeal artery aneurysm and spinal dural arteriovenous fistulas. The FLOW-GET accomplished the complete obliteration of all lesions. This simple and useful technique can be applied to spinal vascular lesions even if a microcatheter is not placed in proper feeders or advanced close to the shunt points or aneurysms.

Long-term adjuvant therapy for high-risk gastrointestinal stromal tumors in the real world.

PURPOSE: Three years of adjuvant imatinib is the standard therapy for gastrointestinal stromal tumors (GISTs) with high-risk features. The prognostic effects of long-term adjuvant therapy are unknown. PATIENTS AND METHODS: The prospective registry study recruited 515 patients with high-risk GISTs between Dec. 2012 and Dec. 2015 were analyzed. The primary endpoint was recurrence-free survival (RFS), and secondary endpoints include overall survival (OS) and safety. The study was designed to compare RFS after 3.5 years of 3-year adjuvant therapy (3.0 ± 0.5 years: 3-year group) with that of more than 3.5 years (median 5.2 years: longer group). RESULTS: Five-year RFS and 5-year OS were 68.2% (95% confidence interval [CI] 63.8-72.1) and 92.3% (95% CI 89.5-94.4), respectively. The recurrence rate during adjuvant was estimated to be 2.9/100 person-years (95% CI 2.0-4.1) and those after the end of adjuvant, which appeared similar irrespective of the adjuvant duration or reason to stop adjuvant, were estimated 12.0/100 person-years (95% CI 10.2-14.0). The 5-year RFS rates of 3-year and longer groups were 78.7% (95% CI 70.8-84.7) and 92.7% (95% CI 85.2-96.4), respectively. RFS after 3.5 years of the longer group was significantly better than that of the 3-year group (adjusted hazard ratio [HR] 0.56; 95% CI 0.39-0.78; P < 0.001). CONCLUSION: The recurrence risk of high-risk GISTs after adjuvant therapy is similar irrespective of the adjuvant duration and imatinib adjuvant may not cure but may delay recurrence. RFS after long-term adjuvant therapy appeared better than that after 3-year adjuvant.

New response evaluation criteria using early morphological change in imatinib treatment for patients with gastrointestinal stromal tumor.

BACKGROUND: The introduction of molecularly targeted drugs, including imatinib, has greatly improved the prognosis of gastrointestinal stromal tumor (GIST), and based on the different response image, the methods of response evaluation have been established for GISTs. Furthrmore, the best response evaluation using them has been reported to be associated with progression-free survival (PFS) in imatinib treatment. However, since it is more important to predict the clinical outcomes of imatinib treatment in "early treatment phase", new predicting factor in earlier stage is desired to work out the whole strategy of each patient. Early morphological change (EMC) was previously reported as a predictive marker for molecularly targeted drugs in metastatic colorectal cancer. The purpose of the present study was to verify the efficacy of EMC in predicting the outcome in patients with GIST receiving imatinib at early evaluation. METHODS: We retrospectively reviewed 66 patients. EMC in computed tomography (CT) image was evaluated, and the patients were categorized into two groups: active MR (morphological response) (+) group and active MR (-) group. We investigated the association between the presence of active MR and clinical outcomes. RESULTS: Forty-five patients had active MR ( +). The median progression-free survival (PFS) in patients with/without active MR was 49/23 months (P = 0.0039). CONCLUSION: The evaluation criteria based on EMC could be a sensitive method to predict the clinical outcome of imatinib treatment for patients with unresectable GIST.

Impact of preoperative tumor rupture timing on gastrointestinal stromal tumor prognosis: a retrospective multicentric cohort study.

BACKGROUND: A gastrointestinal stromal tumor rupture entails a high risk of recurrence even after curative surgery. However, the definition of rupture is unclear, and the question of whether patients with a minor rupture should be treated with adjuvant imatinib remains controversial. METHODS: The present, retrospective, multicentric study enrolled 57 patients with gastrointestinal stromal tumor with a minor/major tumor rupture, of whom 46 were finally found to be eligible for analysis. Tumor ruptures were subclassified by their degree, timing and cause. Multivariate analysis was performed to identify the risk factors of all types of recurrence as well as of peritoneal recurrence only. RESULTS: The study cohort included minor (n = 24), intraoperative (n = 19) and iatrogenic (n = 20) ruptures besides the typical types (major, preoperative and spontaneous). All intraoperative ruptures were iatrogenic. In total, 27 patients (58.7%) had a recurrence in the peritoneum (n = 17) and/or the liver (n = 13) during a median follow-up period of 5.8 years, but no recurrence was observed in patients with tumor rupture as a single, high-risk factor. Multivariate analysis found the timing of tumor rupture to be an independent risk factor of poor recurrence-free survival (hazard ratio: 2.37; 95% confidence interval: 1.02-5.49; P = 0.045). CONCLUSIONS: Preoperative tumor rupture in patients with a ruptured gastrointestinal stromal tumor was associated with poor recurrence-free survival. Our results suggested that a distinction should be made between preoperative and intraoperative tumor ruptures when considering the indications for adjuvant imatinib therapy for gastrointestinal stromal tumor patients with tumor rupture as a single, high-risk factor of recurrence.

The impact of the American Society of Anesthesiology-Physical Status classification system on the treatment and prognosis of patients with esophageal cancer undergoing esophagectomy.

BACKGROUND: The American Society of Anesthesiologists-Physical Status (ASA-PS) classification system has been shown to predict morbidity and mortality after surgery. However, the impact of the ASA-PS on esophageal cancer treatment remains unclear. This study examined both the impact of the ASA-PS on treatment, including surgery and perioperative chemotherapy, and the prognostic effects of ASA-PS class in patients who had undergone esophagectomy for thoracic esophageal cancer or esophagogastric junction cancer. METHODS: ASA-PS status was collected for 301 patients who had undergone esophagectomy between January 2007 and June 2016 for thoracic esophageal cancer or esophagogastric junction cancer at a single institution. As the ASA-PS was updated in 2014, the previous classifications of all patients were reevaluated using the updated standard by a surgeon with the previous classifications masked. The dose intensity of preoperative chemotherapy was also compared across classes. Multivariate Cox regression analysis was used to analyze the association between ASA-PS class and overall survival. RESULTS: Patients whose reevaluations had placed them in a more severe ASA-PS class showed significantly poorer overall and cancer-specific survival rates. The dose intensities of cisplatin and 5-fluorouracil for preoperative chemotherapy were significantly lower in patients in the more severe ASA-PS classes. Multivariate analysis showed that ASA-PS class was an independent prognostic factor for overall survival. CONCLUSION: Preoperative ASA-PS classification may influence the intensity of perioperative treatment and may be a valuable long-term prognostic factor for patients with esophageal cancer undergoing esophagectomy.

Direct observation and analysis of TET-mediated oxidation processes in a DNA origami nanochip.

DNA methylation and demethylation play a key role in the epigenetic regulation of gene expression; however, a series of oxidation reactions of 5-methyl cytosine (5mC) mediated by ten-eleven translocation (TET) enzymes driving demethylation process are yet to be uncovered. To elucidate the relationship between the oxidative processes and structural factors of DNA, we analysed the behavior of TET-mediated 5mC-oxidation by incorporating structural stress onto a substrate double-stranded DNA (dsDNA) using a DNA origami nanochip. The reactions and behaviors of TET enzymes were systematically monitored by biochemical analysis and single-molecule observation using atomic force microscopy (AFM). A reformative frame-like DNA origami was established to allow the incorporation of dsDNAs as 5mC-containing substrates in parallel orientations. We tested the potential effect of dsDNAs present in the tense and relaxed states within a DNA nanochip on TET oxidation. Based on enzyme binding and the detection of oxidation reactions within the DNA nanochip, it was revealed that TET preferred a relaxed substrate regardless of the modification types of 5-oxidated-methyl cytosine. Strikingly, when a multi-5mCG sites model was deployed to further characterize substrate preferences of TET, TET preferred the fully methylated site over the hemi-methylated site. This analytical modality also permits the direct observations of dynamic movements of TET such as sliding and interstrand transfer by high-speed AFM. In addition, the thymine DNA glycosylase-mediated base excision repair process was characterized in the DNA nanochip. Thus, we have convincingly established the system's ability to physically regulate enzymatic reactions, which could prove useful for the observation and characterization of coordinated DNA demethylation processes at the nanoscale.

Preoperative skeletal muscle index and visceral-to-subcutaneous fat area ratio are associated with long-term outcomes of elderly gastric cancer patients after gastrectomy.

PURPOSE: Sarcopenia is a risk factor of severe surgical complications, short-term outcomes, and long-term outcomes for patients with gastric cancer. Several computed tomography (CT) measurements have been performed to diagnose sarcopenia. However, the optimal CT measurements for determining long-term outcomes have not been revealed. METHODS: A retrospective review of gastric cancer patients with clinical stage I, II, or III who underwent gastrectomy at age 75 years or more at Shizuoka General Hospital from 2007 to 2015 was performed. Using preoperative CT, skeletal muscle index (SMI), total psoas area, intramuscular adipose tissue content in multifidus muscle, morphologic change of psoas muscle, and visceral-to-subcutaneous adipose tissue area ratio (VSR) were measured in the third lumbar section. A Cox regression analysis was used to explore prognostic factors for overall survival. RESULTS: A total of 257 patients were reviewed. There were 171, 53, and 33 patients with clinical stages I, II, and III, respectively. A multivariate analysis indicated that, in addition to age, performance status, clinical stage, and types of resection, which are known prognostic factors, SMI and VSR are prognostic factors (p = 0.016, 0.046, respectively). The prognostic score, which was the frequency of positive SMI and VSR values within the cutoff, also indicates overall survival. The five-year OS rates of patients with prognostic scores of 0, 1, and 2 were 90.9%, 62.3%, and 52%, respectively (p < 0.001). CONCLUSION: Preoperative SMI and VSR were prognostic factors for the overall survival of elderly patients with gastric cancer after gastrectomy.

A novel omnidirectional tin-alloyed ring retractor for craniotomy in neurosurgery: technical note.

In neurosurgical operations, proper craniotomy using retractors is necessary. Various surgical instruments are used for this purpose, including standard retractors and multipurpose head frame retractor systems. However, the conventional multipurpose head frame system is often not optimal for use in some craniotomies and postures because of its size and complexity of setting. We have invented a new omnidirectional tin-alloyed (ODT) ring retractor for craniotomy with malleability and shape memory characteristics to resolve these issues. It is principally elliptical in shape, approximately 30 × 20 cm in diameter, and sufficiently firm. Accordingly, this ODT ring can retract the surgical field in all directions. Here, we report our experiences of 281 neurosurgical craniotomies using this ODT ring retractor system in various craniotomy sites and postures. Our novel ODT ring retractor is useful because of its low profile, multidirectional retractability, and less obstructiveness with its malleability. It could be used with pediatric patients where strong traction is not desirable.

Simmons Angled microguidewire INsertion to the Target (SAINT) technique in neuroendovascular therapy.

Advancing appropriate microcatheters is essential for treatment. However, we still encounter inaccessible arterial branches because of the anatomical arrangement. While many successful techniques regarding microcatheters have been reported, there have been very few reports of microguidewire-shaping techniques. We developed the Simmons-Angled microguidewire INsertion to the Target (SAINT) technique for insertion of the microguidewire into inaccessible arterial branches. The SAINT technique is feasible for selection and insertion into arteries that are inaccessible with conventional methods.

[A Case of Bilateral Carotid Injury Caused by Vinyl Umbrella Penetration Successfully Treated with Endovascular Therapy].

Here, we have reported a case pertaining to a 59-year-old man with bilateral traumatic carotid artery injury caused by vinyl umbrella penetration who was successfully treated. The patient fell from the stairs while holding an umbrella, which penetrated his neck. On admission, the patient was in a comatose state and the umbrella had been removed. Active bleeding was observed on the left side of the neck. Hence, tracheal intubation was performed to support respiration. Neck and head contrast-enhanced CT revealed bilateral extravasations from the carotid arteries and right middle cerebral artery(MCA)occlusion. Left carotid angiography showed extravasation from the external carotid artery(ECA), which was treated with coil embolization. Right carotid angiography revealed bleeding from the ECA and internal carotid artery(ICA)and occlusion of the MCA. The ECA and ICA were occluded by coil and n-butyl-2-cyanoacrylate embolization. After the procedures, the patient developed a large right cerebral infarction with massive brain swelling; therefore, external decompression was performed. Subsequently, the patient became alert and was able to walk with support within a month. Bilateral carotid injury is severe and difficult to treat. Endovascular therapy may be effective for the management of bilateral carotid injuries.