Evaluation of the advantage of surgeons certified by the endoscopic surgical skill qualification system participating in laparoscopic low anterior rectal resection.

Background: A technical qualification system was developed in 2004 by the Japan Society for Endoscopic Surgery. An analysis of the EnSSURE study on 3188 stage II-III rectal cancer patients, which was performed by including the participation of qualified surgeons as assistants and advisers without restricting their participation as operators, revealed that the participation of technically qualified surgeons in surgery improved the technical and oncological safety of laparoscopic rectal resection. Aim: This secondary retrospective analysis of the EnSSURE study examined the advantage of qualified surgeons participating in laparoscopic low anterior resection (LAR). Methods: The outcomes of low anterior resection were compared between groups with and without the participation of surgeons qualified by the Endoscopic Surgical Skill Qualification System (Q and non-Q groups, respectively). We used propensity score matching to generate paired cohorts at a one-to-one ratio. The postoperative complication rate, short-term results (hemorrhage volume, operative time, number of dissected lymph nodes, open conversion rate, intraoperative complication rate, and R0 resection rate), and long-term results (disease-free survival rate, local recurrence rate, and overall survival rate) were evaluated. Results: The frequencies of postoperative complications, anastomotic bleeding, and intraperitoneal abscess were significantly lower, the operative time was significantly shorter, the postoperative hospital stay was significantly shorter, and the number of dissected lymph nodes was higher in the Q group. No significant differences were observed in disease-free survival, local recurrence, or overall survival rate rates between the groups. Conclusion: The participation of qualified surgeons in LAR is technically advantageous.

Predictive factors of perforated appendicitis: Impact of the C-reactive protein level.

BACKGROUND: Perforated appendicitis without an associated abscess necessitates emergency surgery. However, it is difficult to predict the presence of perforation before surgery, and the predictive factors are still unclarified. Our purposes were to characterize a patient population with perforated appendicitis without an associated abscess to identify the preoperative predictive factors of appendiceal perforation. METHODS: We retrospectively identified 150 patients who underwent appendectomy for acute appendicitis at our institution from June 2018 to November 2020. Logistic regression analysis was performed to analyze the concurrent effects of various factors on the prevalence of perforated appendicitis. RESULTS: Forty (29%) of 150 patients had appendiceal perforation detected intraoperatively. Of these 40 patients, only 19 had appendiceal perforation detected on preoperative computed tomography. Multivariable analysis found that a higher C-reactive protein level, higher total bilirubin level, and the presence of an appendiceal fecalith were independent predictive factors for appendicitis with perforation. CONCLUSION: Our analysis suggests that the presence of an appendiceal fecalith, a total bilirubin level of more than 21.38 µmol/L, and a C-reactive protein level of more than 3.0 × 104 µg/L are predictive factors of perforated appendicitis.

Successful Treatment of Protein-Losing Enteropathy After Superior Mesenteric Artery Occlusion without Surgery.

BACKGROUND Protein-losing enteropathy as a complication of superior mesenteric artery occlusion is extremely rare and severe, and sometimes requires intestinal resection. However, the ideal treatment strategy has not yet been determined. CASE REPORT A 77-year-old man with underlying hypertension and diabetes was admitted to the Emergency Department with acute abdominal pain after eating. Contrast-enhanced computed tomography revealed complete occlusion of the superior mesenteric artery with thrombosis, and superior mesenteric artery occlusion was diagnosed. It was successfully treated with interventional therapy, followed by continuous intra-arterial prostaglandin E1 infusion and continuous intravenous heparin infusion. However, the patient developed hypoproteinemia and diarrhea about 10 days after the interventional therapy. Colonoscopy and X-ray studies did not reveal any abnormal findings; however, technetium-99m-labeled human serum albumin scintigraphy indicated protein-losing enteropathy. With total parenteral nutrition and protein-rich oral nutrition, with protein intake at twice the amount in a standard diet, serum albumin improved from 15 g/L to 32 g/L after treatment. Additionally, we administered diuretics to avoiding edema related to the hypoproteinemia. The patient recovered from the hypoproteinemia and diarrhea without complications. CONCLUSIONS Protein-losing enteropathy is an extremely rare but critical complication of superior mesenteric artery occlusion. Treating the underlying pathology is the mainstay of protein-losing enteropathy and dietary modifications also play a critical role. Our patient was successfully treated with strict nutritional therapy, combined oral protein-rich nutrition and total parenteral nutrition, which avoided surgery.

Helicobacter pylori-negative Differentiated Adenocarcinoma of the Stomach.

A 58-year-old Japanese man was diagnosed with differentiated adenocarcinoma of the stomach. Histological findings of the resected specimen revealed well- to moderately-differentiated tubular adenocarcinoma (tub1, tub2), 13 mm in diameter, which invaded into the submucosa (SM1, 300 µm) and lymphovascular lumen (ly1). Serum antibody against Helicobacter pylori (Hp) and the (13)C-urea breath test were negative, and there were no atrophic changes in the tumor-adjacent mucosa. The immunohistochemical analysis showed that gastric mucin (MUC5AC) was strongly positive and intestinal mucin (MUC2) was weakly and partially positive. According to these results, the final diagnosis of Hp-negative well-differentiated early gastric cancer was made.

A novel combined laparoscopic-endoscopic cooperative approach for duodenal lesions.

PURPOSE: A surgical approach with minimal invasion and excellent outcome for removal of duodenal lesions, using laparoscopic-endoscopic cooperative surgery (LECS), was established. PATIENTS AND METHODS: Two patients underwent the resection of duodenal lesions with our novel LECS approach. Case 1 (age: 49 years; male) had a 20-mm 0-IIa-like lesion (group IV tumor on biopsy) in the duodenal bulb. LECS interventions, performed under general anesthesia, employed a total of four trocars. The extent of lesions was determined with the endoscopic submucosal dissection (ESD) technique. The affected duodenal wall was then perforated before a one fifth turn resection was performed to expose lesions of the whole layer. A tumor, confirmed under laparoscopy, was turned over toward the abdominal cavity to facilitate resection. Case 2 (age: 49 years; female) had 20-mm 0-IIc lesions (group III adenoma) located at the second portion of the duodenum. LECS procedures for duodenal resection were performed in a manner similar to case 1 . A total of five trocars were used. RESULTS: Histologic diagnosis of the tumor in case 1 was tubular adenoma with moderate atypia (size: 20 x 12 mm). As for case 2, histopathologic findings confirmed a tubular adenoma with moderate atypia (size: 18 x 18 mm) and an adenoma-negative surgical margin. The postoperative courses, in both cases, were uneventful. CONCLUSIONS: Although only 2 cases were surgically intervened with limited experience, the present novel LECS approach allowed a reliable, adequate resection of tumors located in the duodenum, with abbreviated operation times (156-179 versus 202-229 minutes), minimal bleeding, less postoperative stress imposed on the surgeons, and an uneventful postoperative course, compared to conventional surgical methods.

[A case of complete response (CR) persisting for 3 years and 3 months from combination therapy of S-1 and CDDP in a patient with advanced gastric cancer with multiple liver metastases].

The case was a 70-year-old man with type-2 gastric cancer in the lesser curvature accompanied by multiple liver metastases. He received combination chemotherapy of S-1 and CDDP. S-1 was administered at 100 mg/body/day for 21 days followed by withdrawal for 14 days, and CDDP was prescribed at 80 mg/body/day div on day 8. After 3 courses of treatment, the multiple liver metastases disappeared. The primary gastric lesion had changed to a scar and endoscopic biopsy revealed no cancer cell. After the 4th course, we changed the therapy to S-1 alone and after that to UFT alone. Now, 3 years and 3 months after inducing CR, the patient continues to receive UFT with no regrowth of the tumor.

Detection of amyloid beta protein in the urine of Alzheimer's disease patients and healthy individuals.

To seek for a new valid biomarker using non-invasive specimens for the diagnosis of Alzheimer's disease (AD) and mild cognitive impairment (MCI), we carried out the detection of amyloid beta (Abeta) protein in urine. Ten-millilitre urine samples were first sedimented with trichloroacetic acid, and the pellets were resuspended for further analysis by Western blotting with anti-Abeta antibody. The detection sensitivity of the method was 40pg/ml. Rates of subjects positive for monomeric Abeta according to their clinical dementia rating (CDR) were 11.1% for CDR 0, 62.5% for CDR 0.5, 83.3% for CDR 1, 54.5% for CDR 2 and 0% for CDR 3. A single Abeta band relative to the CDR score reflects an alteration in the production, solubility and clearance of Abeta in the brain. Thus, the method could be used as both a diagnostic and monitoring tool in assessing AD and MCI patients during disease-modifying therapies.

Early oral feeding should be resumed following the resolution of gastric ileus.

BACKGROUND/AIMS: The main aim of the study was to assess the feasibility of early mobilization and early feeding following the resolution of gastric ileus in patients who have elective open colonic surgery. METHODOLOGY: This was a randomized controlled trial of patients who were assigned to one of the following two groups. Group 1: patients were encouraged to mobilize postoperatively. A radiopaque marker was given orally on the first postoperative morning and X-ray film was taken daily until more than 70% of the markers had been emptied out of the stomach. Then patients received a diet regardless of flatus or defecation. Group 2: patients were not enforced to mobilize and allowed a diet following flatus or defecation. RESULTS: No significant differences were noted in age, sex, and type of procedures in either group. No patient in group 1 vomited postoperatively, while postoperative time to oral diet was significantly shorter than that to the resumption of bowel function. No significant difference was seen in the incidence of complications. The time to first flatus in group 1 (median, 48 hours) was significantly shorter than that in group 2 (median, 67 hours). The length of hospitalization in group 1 (median, 7 days) was significantly shorter than that in group 2 (median, 10 days). CONCLUSIONS: Early mobilization and early feeding following the resolution of gastric ileus is safe and feasible without vomiting in patients who have elective colonic surgery.

Anal endosonography in the diagnosis and management of perianal endometriosis: report of a case.

We report a rare case of perianal endometriosis, diagnosed in a 39-year-old woman who presented with a several-day history of a painful mass in the perineum. Perianal examination showed redness and swelling in the right anterior direction. A soft tumor was palpated, but there was no evidence of an episiotomy scar, or of fistula orifices. An anal endosonography in the right anterior direction revealed a sharply defined lesion, 17 x 14 mm in diameter, with high echoic enhancement at its center. The lesion was located along the edge of the external anal sphincter but did not involve it. Based on these endosonographic findings, the tumor was not considered to be an abscess or fistula. We detected its location, and judged it possible to enucleate the tumor under local anesthesia without injuring the anal sphincter. The operation was performed uneventfully and a histological diagnosis of endometriosis was confirmed. Using anal endosonography, we were able to determine the exact anatomic relationship of the lesion in the internal and external sphincter, which substantially influenced the diagnosis and operative procedures.