The development of a flexion range-of-motion-adjustable knee joint for knee-ankle-foot orthoses and evaluation of gait in healthy individuals wearing it.

[Purpose] To develop a knee joint for knee-ankle-foot orthoses that is easy to operate and allows for four levels of knee-flexion-movement adjustment, and to determine the effects of different flexion ranges of motion on knee flexion angle during gait. [Participants and Methods] Participants were eight healthy adults. Knee joint for knee-ankle-foot orthoses were made for each participant, and the knee flexion angle during gait was measured for each of the four knee joint settings: fixed in extension, 15° flexion range, 30° flexion range, and free flexion. [Results] Gait analysis showed that the knee flexion angle in the loading response phase was significantly greater in the 15° flexion range, 30° flexion range, and free-flexion settings than in the fixed-in-extension setting. While in the swing phase, the angle was greatest in the fixed setting, followed by the 15° flexion, 30° flexion, and free settings. [Conclusion] The proposed knee joint, when used in post-stroke gait practice using knee-ankle-foot orthoses, allows the gradual increase in the flexion range of motion of the joint as the weight-bearing capability of the lower limb improves, which would enable task-oriented practice similar to walking with ankle-foot orthoses as the next-stage target movement.

Feasibility of augmented rectangle technique in laparoscopic distal gastrectomy: comparison with hemi-double stapling technique in a single-center retrospective cohort study.

PURPOSE: Augmented rectangle technique (ART) anastomosis is a totally intracorporeal anastomosis of laparoscopic distal gastrectomy (LDG), Billroth I (B1) reconstruction for gastric cancer, which secures a wide anastomotic stoma. Since the conventional extracorporeal hemi-double stapling technique (HD) may have a narrow anastomotic stoma, our aim of this study was to evaluate the feasibility and usefulness of ART anastomosis by comparing the surgical outcomes with HD anastomosis. METHODS: Clinical data of 89 patients undergoing LDG with B1 reconstruction were retrospectively collected. Patients were divided into ART group (n = 40) and HD group (n = 49). Surgical outcomes including short-term outcomes, postoperative endoscopic findings, and nutritional factors 1 year after surgery were compared between the groups. RESULTS: Baseline characteristics were similar between the groups. In terms of short-term outcomes, blood loss was less (11.5 mL vs 40 mL, P = 0.011) and postoperative hospital stay was shorter (10 days vs 12 days, P = 0.022) in the ART group. In terms of endoscopic findings, residual food was less (P = 0.032) in the ART group. In terms of nutritional factors, percent decrease of visceral fat area (- 27.6% vs - 40.5%, P = 0.049) and subcutaneous fat area (- 25.7% vs - 39.3%, P = 0.050) 1 year after surgery attenuated in the ART group. CONCLUSIONS: ART anastomosis is superior in perioperative course such as postoperative hospital stay. Moreover, a better nutritional recovery is expected by securing a wide anastomotic stoma leading to a favorable food passage.

[A Case of Rectosigmoid T1b Cancer Which Had Been Under Control by Combination of Loco-Regional Therapies].

According to the Japanese Colorectal ESD/EMR guidelines, radical surgery should be recommended for additional treatment of T1 colorectal cancer(CRC)if pathological findings of the lesion after endoscopic resection show unfavorable factors to be evaluated as curative resection, considering the probability of lymph node metastasis and general condition of patients. We report a case of a 74-year-old man with T1b rectosigmoid(RS)cancer, whose pulmonary metastasis(PM) was curatively resected during the postoperative period of ESD for primary lesions. The patient underwent ESD in November 2018 for Type 0-Isp CRC in the RS junction, revealed using colonoscopy, which was performed for the examination of blood stool in September 2018. The patient had suffered from pulmonary tuberculosis in his thirties and regularly visited our hospital for COPD. He was under close observation after ESD because the depth of the lesion, which was pathologically diagnosed as T1b, was the only factor evaluated as non-curative. In April 2020, chest CT and FDG-PET/CT findings revealed the occurrence of PM. Subsequently, video-assisted wedge resection of the lung was performed for the treatment of PM, which was pathologically confirmed with a size of 10 mm. The patient has survived relapse-free to date, for 30 months after the resection of the primary lesion.

Knee joint movement and muscle activity changes in stroke hemiplegic patients on continuous use of knee-ankle-foot orthosis with adjustable knee joint.

[Purpose] We aimed to evaluate knee joint movement and muscle activity ratio changes in stroke hemiplegic patients in recovery phase after using a knee-ankle-foot orthosis with an adjustable knee joint for 1 month; we also aimed to discuss the practical implications of our findings. [Participants and Methods] The participants were 8 hemiplegic patients in the recovery phase of stroke who were prescribed knee-ankle-foot orthosis with adjustable knee joint. We measured knee joint angles and electromyographic activity of the vastus medialis and biceps femoris during walking in two conditions: the knee-ankle-foot orthosis knee joint fixed in the extended position and the knee joint moved from 0° to 30° in the flexion direction. Measurements were taken 2 weeks after completion to account for habituation of the orthosis and repeated 1 month later. [Results] When the knee joint was moving from 0° to 30° in the flexion direction, the knee joint angle at initial contact and the minimum flexion angle of the gait cycle decreased significantly between the first and second measurements. When knee joint flexion was 30°, the muscle activity ratio of the vastus medialis increased significantly in the loading response and mid-stance compared to when it was fixed. [Conclusion] Setting the knee joint of a knee-ankle-foot orthosis in accordance with the knee joint movement may increase the muscle activity ratio of the vastus medialis from loading response to mid-stance.

[Relapse-Free Survival of over 54 Months after ESD Resection in an Elderly Patient Considered to Have Non-Curative Early Gastric Cancer].

According to the Japanese Gastric Cancer Treatment Guideline(GL), radical surgery is recommended as an additional treatment for early gastric cancer(EGC)patients with endoscopic submucosal dissection(ESD)evaluated as non-curative for fear of lymph node metastasis(LNM). However, the reported probability of LNM was approximately 10%. Therefore, the recommendation might be aggressive for elderly patients or those in poor physical conditions. Under this context, surveillance post non-curative ESD has emerged as an acceptable option. We reported a case of an elderly patient who survived EGC for over 54 months as relapse-free with ESD resection evaluated as non-curative. An 84-year-old woman underwent ESD in July 2014 for EGC, which was deemed as non-curative with negative surgical margins. The patient had pre-existing severe bronchial asthma. Given the age and the comorbidities, the patient preferred close surveillance to radical surgery. After 54 months of surveillance, no recurrence of the initial EGC was found. However, during the annual check-ups, 2 metachronous cancers were found in July 2016 and June 2018 respectively. Both metachronous cancers were curatively resected with ESD.

[A Case of Thoracic Esophageal Cancer That Caused Necrosis of a Reconstructed Colon Ten Years after Esophagectomy].

Necrosis of a reconstructed organ after esophageal cancer surgery is a very serious complication that often occurs soon after the surgery. We report a case of emergency surgery that was performed to treat necrosis of a reconstructed colon 10 years after esophagectomy. A 73-year-old man was admitted to our hospital with complaints of chest pain. His history included a proximal gastrectomy for gastric cancer. His present illness includes endoscopic mucosal resection for superficial esophageal cancer in 1995. Subtotal esophagectomy and right colon interposition through the retrosternal route were performed due to a recurrence in the same lesion in 2005. The patient was immediately hospitalized due to chest pain in 2015. An upper gastrointestinal endoscopy revealed extensive necrosis in the colon. He underwent an emergency operation. The surgical operations included reconstructed colonic resection by longitudinal sternotomy, esophagostomy, gastrostomy, and drainage procedure. The patient is currently under rehabilitation at a referral hospital. There has been no report on the occurrence of necrosis in the reconstructed colon 10 years after esophagectomy.

[A Case of Advanced Gastric Cancer Who Peritoneal Dissemination but Survived over 40 Months with Locoregional Therapies].

Several recent case reports have demonstrated long survival cases of advanced gastric cancer(AGC)patients suffering from peritoneal dissemination(PD)treatedwith effective chemotherapy; however, these AGC patients have poor prognosis in general. We report a case of AGC who hadsurvivedPD over 40 months with locoregional therapies. A 58-year-oldmale underwent distal gastrectomy for AGC with localized PD. Although we recommended postoperative chemotherapy, he chose surveillance as his will. Eighteen months postoperatively, CT scan revealedrecurrence of PD, andPET -CT showedonly one site of recurrent nodule. The patient chose locoregional therapy, ie, resection of the recurrent nodule instead of chemotherapy. Pathological exam confirmedthe recurrence of AGC, andabd ominal lavage cytology was classifiedas V. Even after these pathological findings, the patient refused to receive chemotherapy. At 39 months postoperatively, he developed subileus due to multiple recurrence of PD. At 40 months postoperatively, we performedchemotherapy because locoregional therapy was not supposedto be appropriate for these multiple lesions. However, the patient movedto another hospital after 1 course of chemotherapy because of his continuedrefusal to receive chemotherapy.

[Esophageal Cancer Surgery in Elderly Patients Aged 80 Years or Older].

As the population ages, the elderly are increasingly affected by esophageal cancer. We reviewed the data of elderly patients, 80 years old or older, who underwent surgery for esophageal cancer to evaluate the safety of surgery in this particular patient population. Twenty-two patients aged 80 or above underwent surgery for esophageal cancer in our department. We analyzed their preoperative assessment, concurrent disorders, surgical techniques used, postoperative course, and complications. Median age of the patients was 83 years. Eleven patients had concurrent hypertension, 5 patients had undergone a malignant tumor operation, and 5 patients had concurrent diabetes. Fifteen patients underwent esophagectomy with right thoracotomy and two-field lymph node dissection(LD), 1 patient underwent esophagectomy with right thoracotomy and three-field LD, 2 patients underwent esophagectomy with left thoracoabdominal incision and two-field LD, 2 patients underwent lower esophagectomy and proximal gastrectomy, and 2 patients underwent transhiatal esophagectomy. Postoperative complications occurred in 14 patients(63%); however, no severe pneumonia was noted. Anastomotic leakage was only observed in 1 patient. All patients were discharged with improved conditions. The mean postoperative hospital stay was 39 days. Esophageal cancer surgery can be performed safely in the oldest of elderly patients with appropriate preoperative assessment, selection of the optimal surgical technique, and perioperative care.

[A Case of Obstructive Jaundice Caused by Recurrent Gastric Cancer Previously Treated with Distal Gastrectomy and Roux-en-Y Reconstruction Whose Obstruction Was Relieved by ERCP for Altered Gastrointestinal Anatomy Using Conventional Endoscopes].

There have been many reports on ERCP for patients with alteredgastrointestinal anatomy(AGA), using balloon-assisted enteroscopy(BAE); however, BAE is not commonly usedin practice because it requires special endoscopic systems and accessories, which are time-consuming to operate. For this reason, patients with AGA who suffer from obstructive jaundice (OJ)might receive PTBD in general practice during emergency situations. We report a case of OJ, caused by recurrent gastric cancer andpreviously treatedwith distal gastrectomy andRoux -en-Y reconstruction(DGRY). The obstruction was relieved by ERCP for AGA, using conventional endoscopes. A 74-year-oldwoman, who hadpreviously undergone DGRY for advanced gastric cancer(AGC)andhadbeen receiving first-line chemotherapy for AGC recurrence, was admitted to our hospital for treatment of OJ, causedby progression of recurrent AGC, in July 2016. ERCP for AGA was performedusing conventional endoscopes, andOJ was successfully relievedby the insertion of a self-expandable metallic stent. Subsequently, second-line chemotherapy was administeredandthe patient enteredPR after 2 courses of chemotherapy.

[A Case of Recurrent Jejunal Stenosis after Total Gastrectomy Treated with Self-Expandable Metallic Stent].

Case is a 66-year-old male. He was inserted covered self expandable metallic stent(SEMS)for jejunal stenosis due to gastric cancer recurrence. Migration was occurred after 4 days from stent replacement. We had removed SEMS by endoscopy, and re-inserted non-covered SEMS. Two months later, stent stenosis was occurred by tumor ingrowth. We tried to insert another stent in the stenotic stent. The patient was able to maintain oral intake without complication for 3 months. SEMS placement would improve a quality of life for selected patients with recurrent jejunal stenosis.

[A Case of Malignant Colonic Obstruction Bearing Another Synchronous Obstructive Lesion in the Anal Side of the Colon].

There are several reasons for failure in the insertion of a self-expandable metallic stent(SEMS)into a malignant colonic obstruction(MCO)including difficulty in insertion of the catheter or guidewire through the stenotic lumen into the oral side or perforation relatedto the technique. Herein, we report a case of MCO bearing another synchronous obstructive lesion in the anal side of the colon that couldhave explainedthe difficulty in the insertion of the SEMS into the stenosis locatedin the oral side, which might have indicated the need for an emergency operation for relieving the obstruction. A 76-year-oldman with epigastralgia andmelena was admittedto our hospital andhe was diagnosedwith a MCO in the ascending colon. A series of examinations performedafter admission revealedthat the patient hadanother synchronous obstructive lesion in the descending colon, which made colonoscope insertion at the oral side difficult. The next day after admission, we observed that fasting relievedthe patient from abdominal pain causedby obstruction; therefore, we performedSEMS insertion into the MCO of the descending colon followed by SEMS insertion into the ascending colon after 6 days. These serial SEMS insertions facilitated the oral administration of the diet and the patient was discharged 15 days after admission. The patient was readmittedto our hospital andhe underwent a radical operation for both lesions in June 2015.

[Analysis of Palliative Stent Placement for Acute Malignant Colorectal Obstruction].

INTRODUCTION: Recently, endoscopic placement of self-expanding-metal stents (SEMS) has been widely performed for treatment of acute malignant colorectal obstruction. This study aimed to compare the efficacy of SEMS placement as palliative treatment with that of surgical treatment in patients presenting with acute malignant colorectal obstruction. MATERIALS AND METHODS: A retrospective review was performed for 20 patients with unresectable malignant colorectal obstruction who had received insertion of SEMS (n=9) or surgical treatment (n=11) for palliation between July 2006 and M ay 2014. RESULTS: Patients who had received SEMS were in poorer clinical condition regarding age and performance status. Duration of treatment was significantly lesser and the postoperative date of initial oral intake after intervention was statistically earlier in the SEMS group. SEMS-related morbidity was found in only 2 cases of obstruction due to tumor ingrowth; these patients were successfully treated by reinsertion of SEMS. The prognosis of both groups showed no statistical difference. CONCLUSION: Palliative SEMS placement for unresectable colorectal malignant obstruction in patients with more severe clinical condition relieved obstruction without severe morbidity. Palliative SEMS placement could be an alternative to surgery for the treatment of acute unresectable colorectal obstruction.

[The case of a patient who experienced perforation related to sigmoid colon cancer, was bearing a hepatic metastasis, and who underwent radical resection for advanced colon cancer after a salvage operation for pan-peritonitis and chemotherapy].

Colorectal cancer associated perforation initially develops as pan-peritonitis but easily progresses to septic shock, which can be fatal. As such, it can be hard for patients to recover from this pathological condition. A 79-year-old man who was suffering from pan-peritonitis due to sigmoid colon cancer-associated perforation and also had a metastatic hepatic lesion was admitted to our hospital. He underwent an emergency operation in October 2012. Due to hemodynamic instability, peritoneal lavage and drainage, and stomal formation were performed during the operation. Polymyxin-B direct hemoperfusion (PMXDHP) and continuous hemodiafiltration (CHDF) were performed for septic shock and acute renal failure, respectively. The patient was administered 5 courses of chemotherapy consisting of capecitabine, oxaliplatin, and bevacizumab (Cape+L-OHP +Beva) with no severe adverse reactions; the primary colonic and metastatic hepatic lesions showed a good response to the chemotherapy. A radical resection for the sigmoid colon cancer, including a partial hepatic resection for the metastatic lesion, was performed in May 2013. Surveillance examinations have indicated that the patient is recurrence-free 13 months after radical resection.

Predictive Postoperative Inflammatory Response Indicators of Infectious Complications Following Gastrectomy for Gastric Cancer.

BACKGROUND: Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy. METHODS: We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification). RESULTS: Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×102/µL, and 37.4°C, respectively. CONCLUSIONS: Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×102/µL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

[Examination of stent treatment and bypass surgery for unresectable advanced gastric cancer].

This study was conducted to analyze the outcomes of endoscopic stent placement (n=9) and bypass surgery (n=9) with regard to perioperative complications and dietary intake conditions in patients with unresectable advanced gastric cancer with stenosis. Regarding perioperative complications, 1 patient in the stent group experienced a stent failure and 1 patient in the bypass group developed an adhesive ileus. Dietary intake began from the first day in the stent group and from the fourth day in the bypass group, and it was continued for 55 and 113 days, respectively. There was no difference in the introduction of chemotherapy or length of treatment between the groups, and the survival period for the patients in the stent and bypass groups was 83 and 127 days, respectively. Endoscopic stent placement for unresectable advanced gastric cancer with stenosis is a safe and effective method for improving the quality of life( QOL) of patients.

[A case of a recurrent hepatic metastasis occurred after curative resection of ascending colon cancer and a hepatic metastasis responding completely to capecitabine plus bevacizumab].

Although hepatic resection is the most effective therapy for patients with liver metastasis from colorectal carcinoma, a subset of patients cannot undergo surgical treatment for several reasons, including age-related general health decline or poor conditions associated with coexisting diseases, even if the lesions are resectable. A 75-year-old man with a recurrent lesion in the liver underwent right hemicolectomy and partial hepatic resection to treat colonic cancer and a liver metastasis, followed by uracil and tegafur plus Leucovorin( UFT+LV) as adjuvant chemotherapy at 6 months after the initial surgery. Although the lesion was resectable, the patient preferred chemotherapy to surgery, and capecitabine plus oxaliplatin plus bevacizumab was administered; however, the treatment was stopped in the middle of the second course because of oxaliplatin -related toxicities. Capecitabine plus bevacizumab was introduced as the following chemotherapy regimen, and no adverse reactions were observed during this therapy. After 5 courses of administration, the lesion disappeared on CT examination, and no new lesions were found after 9 courses. Thus, the treatment response was classified as complete response (CR) and remains as such after 13 courses.

[Study of decreased oral intake in patients receiving neoadjuvant chemotherapy for esophageal cancer].

Patients often experience decreased oral intake due to primary systemic therapy (DCF [docetaxel, cisplatin, and fluorouracil ] therapy) administered during the treatment of esophageal carcinoma; measures to cope with this problem have been sought. We therefore examined the relationship between the presence or absence of decreased oral intake and blood biochemistry( serum albumin[ Alb] level, white blood cell[ WBC] count, neutrophil count, and serum sodium[ Na] level) during the 12 courses of DCF therapy administered as primary systemic therapy to 6 patients with esophageal carcinoma. Decreased oral intake occurred frequently from day 6 to day 12 after the initiation of DCF therapy. During this period, decreased serum Alb levels were observed in patients with decreased oral intake but not in patients without decreased oral intake. The incidence of decreased oral intake was 100% in patients whose serum Alb levels decreased to <3.5 g/dL, but it did not exceed 33.3% in patients whose serum Alb levels were ≥3.5 g/dL. The serum Na level, WBC count, and neutrophil count were less affected than the serum Alb level, suggesting that decreased oral intake was associated with decreased serum Alb level.

Preoperative and Postoperative C-Reactive Protein to Albumin Ratio (CAR) as a Prognostic Marker for Survival of Esophageal Squamous Cell Carcinoma Patients After Surgery.

BACKGROUND/AIM: Recent studies have reported that the C-reactive protein (CRP) to albumin ratio (CAR) may be a useful prognostic biomarker in various types of cancer patients. However, the mechanism underlying this observation is unclear. The present study aimed to clarify why the CAR can predict post-esophagectomy prognosis, the relationship between pre- and postoperative CAR, and whether postoperative CAR can predict the prognosis of esophageal cancer patients. PATIENTS AND METHODS: We investigated 158 esophagectomy patients with esophageal squamous cell carcinoma. Hematological examinations were performed on postoperative days (POD) 1, 3, 5, 7, 10, and 14. RESULTS: Preoperative CAR was a significant independent prognostic factor of overall survival (OS) [hazard ratio (HR)=2.247; p=0.0005], and there was a strong correlation between preoperative CAR and tumor depth. The preoperative high-CAR (pre-high-CAR) group had significantly higher CAR on all postoperative days (POD). We then divided the patients as follows: those with at least two low-CAR days on POD 5, 7, and 10 were assigned to the modified post-low-CAR (mPost-low-CAR) group, and others were assigned to the modified post-high-CAR (mPost-high-CAR) group. The 5-year OS rate was significantly higher in the mPost-low-CAR group than in the mPost-high-CAR group, which predicted a more accurate prognosis (p<0.0001, HR=2.769). CONCLUSION: Preoperative CAR was associated with tumor depth and diameter, and patients in the pre-high-CAR group continued to have significantly higher CAR postoperatively. These factors were presumed to reflect disease prognosis. Furthermore, grouping by CAR on POD 5, 7, and 10 reflected patient prognosis more accurately than preoperative CAR.

Preoperative bone mineral density in gastric cancer patients.

BACKGROUND/AIMS: It has been reported that there is a high rate of bone mineral density (BMD) loss after gastrectomy for gastric cancer. To clarify the course of postoperative BMD loss, it is necessary to precisely determine the preoperative BMD of gastric cancer patients. METHODOLOGY: From October 2005 through September 2008, preoperative BMD was measured in 91 patients (59 males and 32 females, mean age of the patients was 67.3 years) who underwent gastrectomy for gastric cancer. Then, the percentage of the subject's BMD divided by the BMD of young adult mean (YAM) (% of YAM) was obtained for each subject and the incidence of osteoporosis as well as the relationship between % of YAM and the patient's clinico-pathological factors or biochemical parameters was examined. RESULTS: The incidence of osteoporosis was 15.4%. There is a correlation between BMD in preoperative gastric cancer patients and serum albumin levels, and BMD decreases further in the elderly and individuals with a BMI lower than 18.5. CONCLUSIONS: From the viewpoint of osteoporosis prevention, this suggests the importance of nutritional management for elderly gastric cancer patients with associated nutritional disorder.

[Evaluation of pre-operative chemotherapy with S-1 plus CDDP against advanced gastric cancer with paraaortic lymph node metastasis].

We evaluated the effectiveness of pre-operative chemotherapy with S-1 plus CDDP against advanced gastric cancer with paraaortic lymph node metastasis. 8 patients received pre-operative chemotherapy with S-1 plus CDDP, according to the following regimen: S-1, 80 mg/m(2), was administered for 21 consecutive days followed by a 14-day rest period, and CDDP, 60 mg/m(2), was administered on day 8. The adverse event rate was 50%. However, a grade greater than 3 was not revealed. There were 5 partial responses (PR) and 3 stable diseases (SD). We performed 7 total gastrectomies and one distal gastrectomy, and the surgical curability (cur) resulted in 6 cases of cur B and two cases of cur C. The histological antitumor effect was grade 2 in three cases. The median overall survival rate was 623 days and the one-year survival rate was 75%. Analyzing for overall survival with antitumor effect and operative curability, both groups of PR and cur B prolonged survival. Pre-operative chemotherapy with S-1 plus CDDP, when used against advanced gastric cancer with paraaortic lymph node metastasis, might be an effective treatment.