RESUMEN
OBJECTIVE: The aim of this study was to investigate the diagnostic performance of detecting systemic arterial pulmonary circulation shunts on multidetector row computed tomography arteriography (MDCTA). METHODS: Thirty-five consecutive bronchial artery embolization sessions with preprocedural MDCTA were performed for 32 patients and 35 sessions. The MDCTA studies with computed tomography value of pulmonary trunk visually lower than that of ascending aorta were defined as "diagnostic MDCTA." Angiographic studies and "diagnostic MDCTA" were evaluated, respectively, for shunting into pulmonary artery. Based on the results of angiographic studies, diagnostic performance of "diagnostic MDCTA" was evaluated. RESULTS: The rate of diagnostic MDCTA was 63% (23 of 35). On "diagnostic MDCTA," sensitivity, specificity, and positive and negative predictive values for detecting shunts were 83% 100%, 100%, 94%, respectively. CONCLUSIONS: Systemic arterial pulmonary circulation shunts were detected on "diagnostic MDCTA" with high sensitivity and specificity.
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Arterias Bronquiales/anomalías , Arterias Bronquiales/diagnóstico por imagen , Embolización Terapéutica , Tomografía Computarizada Multidetector/métodos , Arteria Pulmonar/anomalías , Arteria Pulmonar/diagnóstico por imagen , Anciano , Angiografía/métodos , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: We compared iodine concentration in pulmonary ground-glass opacity on iodine density images of contrast-enhanced chest dual-energy computed tomography (DECT) between patients with cardiogenic pulmonary edema (CPE) and acute interstitial lung disease (AILD). METHODS: Five of 12 patients who underwent contrast-enhanced chest DECT to exclude pulmonary embolism were clinically diagnosed with CPE and 7, with AILD. We compared the mean CT value on monochromatic images at 65 keV and iodine concentration on iodine density images between the affected and normal areas. RESULTS: The mean iodine concentrations were comparable between the affected and normal areas (P = 0.3048) in patients with CPE and were significantly higher in the affected than in the normal areas in those with AILD (P < 0.0001). CONCLUSIONS: Measurement of iodine concentration in pulmonary ground-glass opacity of contrast-enhanced chest DECT has the potential to help distinguish CPE and AILD.
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Enfermedades Pulmonares Intersticiales/diagnóstico por imagen , Edema Pulmonar/diagnóstico por imagen , Imagen Radiográfica por Emisión de Doble Fotón/métodos , Adulto , Anciano , Anciano de 80 o más Años , Medios de Contraste , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Estudios RetrospectivosRESUMEN
BACKGROUND: Lynch syndrome is the most common form of hereditary colorectal carcinoma. It is characterized by the presence of germline mutations in DNA mismatch repair genes. Mutation carriers have a lifetime risk of developing colorectal carcinoma of approximately 80%. Current treatment guidelines recommend periodic surveillance for colorectal carcinoma in patients with Lynch syndrome. However, the optimal interval between colonoscopies has not yet been determined. CASE PRESENTATION: We describe a 54-year-old man with Lynch syndrome who was undergoing annual colonoscopy surveillance for the development of colorectal carcinoma. At 54, 57, 59, and 60 years old, a colonoscopy showed high-grade dysplasia and adenoma. Therefore, endoscopic mucosal resection was performed. At 61 years old, a colonoscopy showed metachronous colorectal carcinoma with massive submucosal invasion. He subsequently underwent laparotomy for colorectal carcinoma. CONCLUSIONS: Annual surveillance using colonoscopy can detect colorectal carcinoma at an early stage, leading to reduced mortality. However, some patients might require a laparotomy, as was the case here. More frequent colonoscopic surveillance might be necessary to avoid surgery for colorectal carcinoma in Lynch syndrome patients with multiple risk factors for interval cancer.
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Adenocarcinoma/diagnóstico por imagen , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico por imagen , Detección Precoz del Cáncer/métodos , Neoplasias Primarias Secundarias/diagnóstico por imagen , Adenocarcinoma/genética , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Colon Sigmoide/diagnóstico por imagen , Colon Sigmoide/patología , Colon Sigmoide/cirugía , Colon Transverso/diagnóstico por imagen , Colon Transverso/patología , Colon Transverso/cirugía , Colonoscopía , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/patología , Neoplasias Colorrectales Hereditarias sin Poliposis/cirugía , Humanos , Inmunohistoquímica , Mucosa Intestinal/diagnóstico por imagen , Mucosa Intestinal/patología , Mucosa Intestinal/cirugía , Laparotomía , Masculino , Inestabilidad de Microsatélites , Persona de Mediana Edad , Homólogo 1 de la Proteína MutL/genética , Mutación , Neoplasias Primarias Secundarias/genética , Neoplasias Primarias Secundarias/patología , Neoplasias Primarias Secundarias/cirugía , Pronóstico , Factores de RiesgoRESUMEN
To identify predictive factors for conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy performed for mixed indications as an acute or elective procedure. We retrospectively analyzed the data of 236 consecutive cases of LC performed in our department between January 2012 and January 2015, and evaluated preoperative risk factors for conversion and the usefulness of the 2013 Tokyo guidelines (TG2013) for diagnosing acute cholecystitis. The conversion rate in our series was 8% (19/236 cases). The following independent predictive factors of conversion were identified (p≤0.04): previous upper abdominal surgery (odds ratio (OR), 14.6), pericholecystic fluid (OR, 10.04), acute cholecystitis (OR, 7.81), and emergent LC (OR, 15.8). Specifically for patients with acute cholecystitis defined using the 2013 Tokyo guidelines, use of an antiplatelet or anticoagulant drug for cardiovascular disease (p=0.043), previous upper abdominal surgery (p<0.031) and a resident as operator (p=0.041) were predictive factors. The risk factors for conversion identified herein could help to predict the difficulty of the procedure and could be used by surgeons to better inform patients regarding the risks for conversion. The TG2013 can be an effective tool for diagnosing acute cholecystitis to make informed clinical decisions regarding the optimal procedure for a patient.
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Colecistectomía Laparoscópica/métodos , Colecistectomía/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
We report a case of a granulocyte colony-stimulating factor (G-CSF)-producing gallbladder tumor associated with fever in a middle-aged female. Preoperative blood analysis showed leukocytosis with elevated levels of C-reactive protein and G-CSF. We resected the liver at S4aï¼S5, with regional lymph node dissection and partial resection of the duodenum. Histology revealed undifferentiated carcinoma with spindle and giant cells and papillary adenocarcinoma. Immunohistochemistry revealed Stage IIIB G-CSF-producing gallbladder cancer. Postoperatively, leukocyte and serum G-CSF levels decreased to within normal limits. Adjuvant gemcitabine chemotherapy was administered for 16 months, and she has been recurrence-free for 48 months.
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Carcinoma/metabolismo , Neoplasias de la Vesícula Biliar/metabolismo , Factor Estimulante de Colonias de Granulocitos/metabolismo , Adenocarcinoma Papilar/metabolismo , Adenocarcinoma Papilar/patología , Adenocarcinoma Papilar/cirugía , Antimetabolitos Antineoplásicos/uso terapéutico , Carcinoma/patología , Carcinoma/cirugía , Quimioterapia Adyuvante , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapéutico , Femenino , Neoplasias de la Vesícula Biliar/patología , Neoplasias de la Vesícula Biliar/cirugía , Humanos , Persona de Mediana Edad , GemcitabinaRESUMEN
BACKGROUND: It has previously been reported that a general risk model, Estimation of Physiologic Ability and Surgical Stress (E-PASS), and its modified version, mE-PASS, had a high predictive power for postoperative mortality and morbidity in a variety of gastrointestinal surgeries. This study evaluated their utilities in proximal biliary carcinoma resection. METHODS: E-PASS variables were collected in patients undergoing resection of perihilar cholangiocarcinoma and gallbladder carcinoma in Japanese referral hospitals. RESULTS: Analysis of 125 patients with gallbladder cancer and 97 patients with perihilar cholangiocarcinoma (n = 222). Fifty-six patients (25%) underwent liver resection with either hemihepatectomy or extended hemihepatectomy. The E-PASS models showed a high discrimination power to predict in-hospital mortality; areas under the receiver operating characteristic curve (95% confidence intervals) were 0.85 (0.76-0.94) for E-PASS and 0.82 (0.73-0.91) for mE-PASS. The predicted mortality rates correlated with the severity of postoperative complications (Spearman's rank correlation coefficient: ρ = 0.51, P < 0.001 for E-PASS; ρ = 0.47, P < 0.001 for mE-PASS). CONCLUSIONS: The E-PASS models examined herein may accurately predict postoperative morbidity and mortality in proximal biliary carcinoma resection. These models will be useful for surgical decision-making, informed consent, and risk adjustments in surgical audits.
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Neoplasias de los Conductos Biliares/cirugía , Procedimientos Quirúrgicos del Sistema Biliar , Técnicas de Apoyo para la Decisión , Neoplasias de la Vesícula Biliar/cirugía , Hepatectomía , Tumor de Klatskin/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Neoplasias de los Conductos Biliares/mortalidad , Neoplasias de los Conductos Biliares/patología , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Procedimientos Quirúrgicos del Sistema Biliar/mortalidad , Femenino , Neoplasias de la Vesícula Biliar/mortalidad , Neoplasias de la Vesícula Biliar/patología , Hepatectomía/efectos adversos , Hepatectomía/mortalidad , Mortalidad Hospitalaria , Humanos , Japón , Tumor de Klatskin/mortalidad , Tumor de Klatskin/patología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Previous studies for surgical audit have focused on short-term outcomes, such as perioperative mortality. There has been no gold standard how to evaluate quality of care for long-term outcomes in surgical oncology. This preliminary study aims to propose a method for surgical audit targeting long-term outcome following gastrectomy for gastric cancer. METHODS: We prospectively investigated a set of variables relating to physiologic conditions, tumor characteristics and operations in patients who underwent gastrectomy for gastric cancer between June 2005 and July 2008 in 18 referral hospitals in Japan. Overall survival (OS) is the endpoint. Cox hazard regression analysis was used to generate a model to predict OS. The calibration and discrimination power of the model were assessed using the Hosmer-Lemeshow (H-L) test and area under the receiver-operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated 5-year OS rates (OE ratio) was defined as a measure of quality. RESULTS: Among 762 patients analyzed, 697 (91%) completed the 5-year follow-up. The constructed model for OS exhibited a good discrimination power (AUC, 95% confidence interval 0.89, 0.86-0.91), which was significantly better than that for the UICC stage (0.81, 0.77-0.84). This model also demonstrated a good calibration power (H-L: χ(2) = 27.2, df = 8, P = 0.77). The OE ratios among the participating hospitals revealed no significant variation between 0.74 and 1.1. CONCLUSIONS: The current study suggests the possibility of surgical audit for postoperative OS in gastric cancer. Further studies including high-volume centers will be necessary to validate this idea.
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Neoplasias Gástricas/mortalidad , Neoplasias Gástricas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Gastrectomía , Humanos , Japón , Masculino , Persona de Mediana Edad , Modelos Teóricos , Estudios Prospectivos , Curva ROC , Neoplasias Gástricas/patología , Tasa de SupervivenciaRESUMEN
BACKGROUND: The incidence of complicated choledochocystolithiasis is increasing with the aging of society in Japan. We evaluated the utility of our prediction rule modified estimation of physiologic ability and surgical stress (mE-PASS) in predicting postoperative adverse events in patients with choledochocystolithiasis. METHODS: A total of 4,329 patients who underwent elective surgery for choledochocystolithiasis in 44 referral hospitals between April 1987 and April 2007 were analyzed for mE-PASS along with postoperative events. The discrimination power of mE-PASS was assessed by the area under the receiver operating characteristic curve (AUC). The correlation between ordinal and interval variables was quantified by the Spearman rank correlation (ρ). The ratio of observed-to-estimated mortality rates (OE ratio) was used as a metric of surgical quality. RESULTS: Postoperative in-hospital mortality rates were 0 % (0/3,442) for laparoscopic cholecystectomy, 0.19 % (1/521) for open cholecystectomy, 1.6 % (1/63) for laparoscopic choledochotomy, 1.1 % (3/264) for open choledochotomy, and 5.1 % (2/39) for plasty or resection of the common bile duct. mE-PASS demonstrated a high discrimination power to predict in-hospital mortality; AUC, 95 % confidence interval (CI) of 0.96, 0.94-0.99. The predicted mortality rates significantly correlated with the severity of postoperative complications (ρ = 0.278, p < 0.0001) and length of hospital stay (ρ = 0.479, p < 0.0001). The OE ratios (95 % CI) improved slightly over time; 1.5 (0.25-9.0) between 1987 and 2000, and 0.40 (0.078-2.1) between 2001 and 2007. CONCLUSIONS: The present study suggests that mE-PASS can predict postoperative risks in patients who have undergone choledochocystolithiasis. mE-PASS may be useful in surgical decision making and evaluating the quality of care.
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Colecistectomía , Coledocolitiasis/cirugía , Complicaciones Posoperatorias/epidemiología , Estrés Fisiológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Adulto JovenRESUMEN
Lynch syndrome is an autosomal dominant disease associated with a high incidence of colorectal, endometrial, stomach, ovarian, pancreatic, ureter and renal pelvis, bile duct and brain tumors. The syndrome can also include sebaceous gland adenomas and keratoacanthomas, and carcinoma of the small bowel. The lifetime risk for bile duct cancer in patients with Lynch syndrome is approximately 2 %. The present report describes a case of Lynch syndrome with metachronous bile duct cancer diagnosed at an early stage. The patient was a 73-year-old Japanese male who underwent a successful left lobectomy of the liver, and there was no sign of recurrence for 2 years postoperative. However, this patient harbored a germline mutation in MLH1, which prompted diagnostic examinations for noncolorectal tumors when a periodic surveillance blood examination showed abnormal values of hepatobiliary enzymes. Although most patients with bile duct cancer are diagnosed at an advanced stage, the bile duct cancer was diagnosed at an early stage in the present patient due to the observation of the gene mutation and the preceding liver tumor. This case illustrates the importance of continuous surveillance for extracolonic tumors, including bile duct cancer, in patients with Lynch syndrome.
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Adenocarcinoma Papilar/diagnóstico , Neoplasias de los Conductos Biliares/diagnóstico , Neoplasias Colorrectales Hereditarias sin Poliposis , Neoplasias Primarias Múltiples , Proteínas Adaptadoras Transductoras de Señales/genética , Adenocarcinoma Papilar/genética , Adenocarcinoma Papilar/cirugía , Anciano , Neoplasias de los Conductos Biliares/genética , Neoplasias de los Conductos Biliares/cirugía , Procedimientos Quirúrgicos del Sistema Biliar , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/cirugía , Diagnóstico Precoz , Mutación de Línea Germinal , Hepatectomía , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Masculino , Inestabilidad de Microsatélites , Homólogo 1 de la Proteína MutL , Proteínas Nucleares/genética , LinajeRESUMEN
The case herein pertains to a 78-year-old man, who was referred to our department and in whom esophagogastric junctional cancer, triggering weight loss, was indicated. A 0.75 xx circumferential Type 3 lesion was observed in the esophagogastric junction via upper gastrointestinal endoscopy, and a biopsy revealed a moderately differentiated adenocarcinoma with overexpression of human epidermal growth factor type 2 (HER2). Contrast-enhanced computed tomography (CT) showed multiple enlarged lymph nodes on the lesser curvature of the stomach. The preoperative diagnosis was T4a (SE) N2M0, Stage IIIB esophagogastric adenocarcinoma. Four courses of preoperative chemotherapy consisting of capecitabine plus cisplatin and trastuzumab were administered. The primary lesion showed cicatrization after chemotherapy, and enlarged lymph nodes were not visible on a CT scan. Total gastrectomy, splenectomy, and D2 lymph node dissection were performed. Only a small amount (approximately 5 mm) of the primary lesion remained beneath the abdominal and esophageal mucosa, and the treatment effectiveness was Grade 2. The final diagnosis was T1b (SM) N0M0, Stage IA esophagogastric adenocarcinoma. Survival with no recurrence was confirmed 6 months after surgery. These findings suggest that inclusion of trastuzumab in preoperative chemotherapy regimens improves the degree of curability of HER2-positive esophagogastric junction cancers.
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Adenocarcinoma/tratamiento farmacológico , Anticuerpos Monoclonales Humanizados/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Unión Esofagogástrica/patología , Terapia Neoadyuvante , Neoplasias Gástricas/tratamiento farmacológico , Adenocarcinoma/cirugía , Anciano , Humanos , Masculino , Receptor ErbB-2/metabolismo , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugía , TrastuzumabRESUMEN
Lynch syndrome is an inherited syndrome associated with the development of colorectal and various other cancers. A 65- year-old male underwent a laparoscopic-assisted right hemi-colectomy for ascending colon cancer (cStage II). Histologically, his tumor was diagnosed as a poorly differentiated adenocarcinoma. Lymphocytic reactions, such as tumor-infiltrating lymphocytes (TIL), and Crohn's-like reactions, were observed. Genetic testing revealed the presence of a pathogenic mutation in the MLH1. In the Lynch syndrome, the most frequently observed findings include the accumulation of mutations, and an early onset of familial colon cancer. Although the case presented here did not show the typical clinical findings of Lynch syndrome, histological examination of the lymphocytic reactions proved useful for screening for Lynch syndrome. Herein, we establish the important role of the pathologist in alerting the clinician to the possibility of Lynch syndrome when the findings of TIL and Crohn's-like reactions are detected.
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Neoplasias del Colon/etiología , Neoplasias Colorrectales Hereditarias sin Poliposis/complicaciones , Linfocitos Infiltrantes de Tumor , Proteínas Adaptadoras Transductoras de Señales/genética , Adulto , Anciano , Neoplasias del Colon/patología , Reparación de la Incompatibilidad de ADN , Femenino , Humanos , Masculino , Persona de Mediana Edad , Homólogo 1 de la Proteína MutL , Proteínas Nucleares/genética , LinajeRESUMEN
Lynch syndrome is an inherited autosomal dominant disorder caused by germ-line mutation of mismatch repair genes, in which a malignant tumor develops at a young age in the colon, endometrium, stomach, or other tissues. A 54-year-old patient with gastric cancer received pylorus-preserving gastrectomy, and a genetic examination confirmed a pathological variation of the MLH1 gene. Five years after surgery, an upper gastrointestinal endoscopy revealed a residual 0 -IIa+IIc gastric tumor approximately 2 cm in size extending from the anastomotic site to the lesser curvature side of the stomach. The remaining stomach was completely removed. The final diagnosis was T1b (SM) N1M0, StageIB gastric cancer. Microsatellite instability was positive, and we attributed the cancer to Lynch syndrome. In Lynch syndrome, the risk of multicentric gastric cancer is higher than normal, and for the initial therapy, preventive total gastrectomy should be considered as an option.
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Neoplasias Colorrectales Hereditarias sin Poliposis/complicaciones , Neoplasias Gástricas/patología , Proteínas Adaptadoras Transductoras de Señales/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/cirugía , Gastrectomía , Mutación de Línea Germinal , Humanos , Masculino , Persona de Mediana Edad , Homólogo 1 de la Proteína MutL , Proteínas Nucleares/genética , Linaje , Píloro , Neoplasias Gástricas/genética , Neoplasias Gástricas/cirugíaRESUMEN
Lynch syndrome is an inherited syndrome associated with the development of colorectal, endometrial, stomach, and other cancers; it is caused by defects in the mismatch repair genes. Such patients are at risk of developing multiple abdominal cancers after colectomy, and the presence of adhesions may render future abdominal surgeries difficult. We recommend that patients with Lynch syndrome should be considered good candidates for laparoscopic surgery. A 43-year-old Japanese man was admitted following a positive fecal occult blood test result. The patient was diagnosed with multiple colon cancers in the right colon. He had undergone endoscopic mucosal resection for a colon polyp when he was 24 years of age. Two people among his father's second-degree relatives had colorectal cancer, and he fulfilled the revised Bethesda guidelines. He underwent laparoscopic-assisted right hemicolectomy and D3 lymph node dissection. Microsatellite instability testing indicated the presence of MSI-H, and genetic testing demonstrated a pathogenic mutation of MLH-1.
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Neoplasias del Colon/cirugía , Neoplasias Colorrectales Hereditarias sin Poliposis/cirugía , Neoplasias Primarias Múltiples/cirugía , Proteínas Adaptadoras Transductoras de Señales/genética , Adulto , Neoplasias del Colon/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Humanos , Laparoscopía , Masculino , Homólogo 1 de la Proteína MutL , Mutación , Neoplasias Primarias Múltiples/genética , Proteínas Nucleares/genética , LinajeRESUMEN
We report a case of advanced colon cancer with multiple liver metastases treated by two-stage laparoscopic surgery. An 82-year-old woman, whose main complaint was constipation, was diagnosed with stage IV sigmoid colon cancer. With the aim of decompressing the colon, a transanal decompression tube was inserted. She underwent laparoscopic-assisted sigmoidectomy and D3 lymph node dissection, and an ileostomy was created. Systemic chemotherapy was administered immediately after the operation. After 4 courses of chemotherapy, she underwent the second operation, i.e., laparoscopic- assisted partial hepatectomy and radiofrequency ablation of liver metastases. Cases of obstructive colon cancer are more advanced than cases of non-obstructive colon cancer. Systemic treatments are required after the resection of primary tumors. We aim to improve the prognosis of patients with obstructive colon cancer by the use of laparoscopic surgery.
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Laparoscopía , Neoplasias Hepáticas/cirugía , Neoplasias del Colon Sigmoide/cirugía , Anciano de 80 o más Años , Colectomía , Femenino , Hepatectomía , Humanos , Neoplasias Hepáticas/secundario , Estadificación de Neoplasias , Neoplasias del Colon Sigmoide/patologíaRESUMEN
BACKGROUND AND OBJECTIVES: This study evaluated the ability of general surgical models to predict postoperative morbidity and mortality in liver surgery. METHODS: The postoperative course and mortality rates predicted by general surgical models were investigated in 960 patients who underwent hepatectomy or ablation therapy for primary or metastatic liver carcinoma. RESULTS: The area under the receiver operative characteristic curve (95% confidence intervals) for detecting postoperative liver failure was 0.89 (0.84-0.94), 0.85 (0.78-0.92), and 0.78 (0.72-0.85) for the estimation of physiologic ability and surgical stress (E-PASS) model, the modified E-PASS (mE-PASS) model, and the Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, respectively, and those for detecting in-hospital mortality were 0.85 (0.76-0.93), 0.85 (0.78-0.92), and 0.79 (0.71-0.87), respectively. Nevertheless, all of the models overpredicted the overall mortality rate (by 2.3-fold for E-PASS, 2.3-fold for mE-PASS, and 2.9-fold for P-POSSUM). CONCLUSIONS: The general surgical risk models demonstrated high discriminatory power for predicting postoperative outcomes in liver surgery, but overpredicted the overall mortality rate by more than twofold. Therefore, these models should be refined to make them more suitable for predicting liver surgery outcomes.
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Carcinoma/mortalidad , Hepatectomía/efectos adversos , Hepatectomía/mortalidad , Fallo Hepático/epidemiología , Neoplasias Hepáticas/mortalidad , Modelos Estadísticos , Técnicas de Ablación/efectos adversos , Técnicas de Ablación/mortalidad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma/patología , Carcinoma/cirugía , Niño , Femenino , Indicadores de Salud , Mortalidad Hospitalaria , Humanos , Fallo Hepático/patología , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Medición de Riesgo , Análisis de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: We recently modified our prediction scoring system "Estimation of Physiologic Ability and Surgical Stress" and have designated the current version mE-PASS. This scoring system has been designed to obtain predicted postoperative mortality rates before surgery and this study was performed to assess its usefulness in elective surgery for gastric carcinoma. METHODS: We investigated seven variables for mE-PASS and evaluated the postoperative course in 3,449 patients who underwent elective surgery for gastric carcinoma in Japan between August 20, 1987 and April 9, 2007, in order to quantify the predicted in-hospital mortality rates (R). The calibration and discrimination power of R were assessed using the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratios of observed-to-estimated mortality rates (OE ratios) were quantified as a measure of quality. RESULTS: The overall postoperative morbidity and mortality rates were 19.0 and 2.0%, respectively. R demonstrated good power in calibration (χ(2) value, 12.5; df 8; P = 0.89) as well as discrimination (AUC, 95% confidence intervals: 0.80, 0.75-0.85). The OE ratios between hospitals ranged from 0.44 to 1.8. Overall, the OE ratios seemed to improve with time (OE ratio, 95% confidence intervals: 1.3, 0.73-2.4 for the early period between 1987 and 2000; 1.0, 0.59-1.7 for the middle period between 2001 and 2004; and 0.65, 0.36-1.2 for the late period between 2005 and 2007). CONCLUSION: Based on these findings, mE-PASS might be useful for medical decision-making and for assessing the quality of care in elective surgery for gastric carcinoma.
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Procedimientos Quirúrgicos Electivos/métodos , Calidad de la Atención de Salud , Neoplasias Gástricas/cirugía , Estrés Fisiológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Toma de Decisiones , Procedimientos Quirúrgicos Electivos/mortalidad , Procedimientos Quirúrgicos Electivos/normas , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos , Neoplasias Gástricas/patología , Adulto JovenRESUMEN
We report a 83-year-old female with bile duct cancer who underwent subtotal stomach preserving pancreatoduodenectomy. Pathologically, her tumor was diagnosed as adenosquamous carcinoma of the lower extrahepatic bile duct with final stage IVb[pT3pN3M(-)].The prognosis of patients with adenosquamous carcinoma of the bile duct is very poor, and the reason is thought to be its tendency to invade the pancreas.Although she was an aged patient, we performed adjuvant chemotherapy using gemcitabine.No recurrence has occurred until this day, 30 months after the operation.This is thought to be an effect of the adjuvant chemotherapy, considering its poor prognosis.
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Neoplasias de los Conductos Biliares/patología , Conductos Biliares Extrahepáticos/patología , Carcinoma Adenoescamoso/patología , Anciano de 80 o más Años , Antimetabolitos Antineoplásicos/uso terapéutico , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Extrahepáticos/cirugía , Carcinoma Adenoescamoso/cirugía , Terapia Combinada , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapéutico , Femenino , Humanos , Estadificación de Neoplasias , Inducción de Remisión , GemcitabinaRESUMEN
C-H/N-H bond functionalization for direct intermolecular aryl C-N couplings is a useful synthetic process. In this study, we achieved metal-free cross-dehydrogenative coupling of phenols and anilines with phenothiazines using hypervalent iodine reagents. This method affords selective amination products under mild conditions. Electron-rich phenols and anilines could be employed, affording moderate-to-high yields of N-arylphenothiazines. Aniline amination proceeded efficiently at 20 °C, a previously unreported phenomenon.
RESUMEN
BACKGROUND: We recently modified Estimation of Physiologic Ability and Surgical Stress, our prediction scoring system. OBJECTIVE: This study evaluated the usefulness of our modified version for colorectal carcinoma in comparison with existing models. DESIGN: This investigation studied a multicenter cohort. SETTINGS: The study was conducted in regional referral hospitals in Japan. PATIENTS: Patients were included who underwent elective surgery for colorectal carcinoma. MAIN OUTCOME MEASURES: Postoperative morbidity, mortality, and predicted mortality rates for original and modified Estimation of Physiologic Ability and Surgical Stress were investigated in 2388 patients in comparison with existing European models. RESULTS: Among the models, the modified Estimation of Physiologic Ability and Surgical Stress demonstrated the highest discriminatory power in terms of in-hospital mortality (area under receiver operating characteristic curve: 0.84 for Estimation of Physiologic Ability and Surgical Stress, 0.87 for modified Estimation of Physiologic Ability and Surgical Stress, 0.84 for Portsmouth modification of POSSUM, 0.74 for ASA status-based model), as well as 30-day mortality (area under receiver operating characteristic curve: 0.82 for Estimation of Physiologic Ability and Surgical Stress, 0.84 for modified Estimation of Physiologic Ability and Surgical Stress, 0.81 for POSSUM, 0.78 for colorectal POSSUM, 0.76 for Association of Coloproctology of Great Britain and Ireland score). British models, in general, overpredicted postoperative mortality rates by more than 10 times. LIMITATIONS: The current study analyzed only the Japanese population treated in medium-volume centers. CONCLUSIONS: Among the models, modified Estimation of Physiologic Ability and Surgical Stress was the most accurate in predicting postoperative mortality in colorectal carcinoma surgery. These findings should be validated in Western populations, because the Japanese population may differ from Western populations in terms of body shape or reserve capacity.
Asunto(s)
Carcinoma/cirugía , Neoplasias del Colon/cirugía , Procedimientos Quirúrgicos Electivos/mortalidad , Mortalidad Hospitalaria , Auditoría Médica , Complicaciones Posoperatorias , Neoplasias del Recto/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Teóricos , Valor Predictivo de las Pruebas , Indicadores de Calidad de la Atención de Salud , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Anastomotic leak (AL) is a dangerous postoperative complication in gastrointestinal surgery. The present study focuses on whether our prediction scoring system, "Estimation of Physiologic Ability and Surgical Stress" (E-PASS), could predict occurrence of AL and its prognosis in various kinds of gastrointestinal surgical procedures. METHODS: We prospectively investigated parameters of E-PASS, absence or presence of AL, and in-hospital mortality in 6,005 patients who underwent elective digestive surgery with alimentary tract reconstruction in 45 acute care hospitals in Japan between 1 April 2002 and 31 March 2007. RESULTS: Incidences of AL were 19.6% for esophagectomy via right thoracotomy and laparotomy, 11.7% for pancreaticoduodenectomy, 7.4% for low anterior resection, 4.0% for total gastrectomy, 1.8% for open distal gastrectomy, 1.3% for open colectomy, for an overall incidence of 4.1%. The incidence in each procedure significantly correlated with median value of surgical stress score of the E-PASS (R = 0.78, n = 11, p = 0.0048). The incidences of AL increased when Total Risk Points (TRP) of the E-PASS increased; 1.1% at the TRP range of <500, 2.8% at 500 to <1,000, 4.8% at 1,000 to <1,500, and 13.6% at ≥ 1,500 (p < 0.0001). In patients who suffered from AL, an in-hospital mortality rate at TRP < 1,000 was significantly lower than that at TRP of ≥ 1,000 (1.1 vs. 15.9%; p = 0.00019). CONCLUSIONS: The E-PASS, requiring only nine variables, may be useful in predicting AL and its prognosis.