Hybrid robot-assisted abdominoperineal resection supported by simultaneous trans-perineal approach for anal gland adenocarcinoma with vaginal invasion: a case report.

Hybrid surgery (abdominal robotic approach with a trans-anal approach) has been reported to improve oncological outcomes in cases involving advanced cancer or technical difficulties. A 74-year-old woman presented with anal pain and stenosis. Examination revealed palpable sclerosis on the anterior wall at the anal verge with possible vaginal invasion. A biopsy revealed an adenocarcinoma. We performed a two-team robot-assisted abdominoperineal resection combined with resection of the vagina supported by a simultaneous trans-perineal approach. After rendezvous at the posterior side, the abdominal team cut the posterior wall of the vaginal vault while the perineal team confirmed the surgical margin. Histopathological findings identified the tumour as an anal gland adenocarcinoma (pT4b [vagina] N0M0 pathological stage IIC) with a negative circumferential resection margin. Hybrid surgery combined with resection of the posterior wall of the vagina may be performed safely and is a valuable surgical option for multimodal treatment of anal adenocarcinomas.

Supporting general medicine residents in Japan: From the perspective of Japanese Association of Family Physicians Trainees, official committee of JPCA.

As an official subcommittee of the Japan Primary Care Association, Japanese Association of Family Physicians Trainees aims to support residents in (1) acquiring knowledge, skills, and experience; (2) building networks; (3) acquiring an international perspective; and (4) lifelong careers and has supported general medicine residents since 2017. Nevertheless, the publication of the letter, hoping for these support, would hinder the reach of such information to the residents who really need it. This could be because many young physicians, who do not belong to the JPCA, such as trainees who aim to become hospitalists, are getting registered in general medicine residency programs certified by the Japanese Medical Specialty Board. We should reveal the current situation surrounding Japanese residents more clearly and collaborate across organizations.

Visualization of Anorectal Lymphatic Flow Using Indocyanine Green Fluorescence Imaging: An Observational Study.

BACKGROUND/AIM: Currently, only a small part of functional lymphatic flow around the anorectal region has been anatomically analyzed. Despite the fact that local recurrence is often experienced in the pelvic floor, the functional lymphatic network in this region has rarely been studied due to difficulties in observation. This prospective observational study aimed to observe anorectal lymphatic flow around the pelvic floor using intraoperative indocyanine green fluorescence imaging during laparoscopic or robot-assisted rectal surgery. PATIENTS AND METHODS: Fourteen patients who underwent laparoscopic (n=7) or robot-assisted (n=7) surgery without any preoperative therapy between April and December 2022 were enrolled. Indocyanine green solution (0.25 mg) was injected into the submucosa at the dentate line of the anterior, posterior, and bilateral walls prior to surgery. During and after total mesorectal excision, lymphatic flow was observed using a near-infrared camera system. RESULTS: Lymphatic flow visualized by indocyanine green was detected not only in the already-known route from the low rectum to the lateral pelvic lymph nodes via the lateral ligament, but also in the novel route from the low rectum to the surface of the levator ani muscle and hiatal ligament. Fluorescence was widely spread in the pelvic floor between the longitudinal muscle of the low rectum and the surface of the levator ani muscle. CONCLUSION: Even though the results are preliminary since histological analyses were not performed, a novel widespread lymphatic network on the surface of the levator ani muscle originating from the longitudinal muscle fibers of the low rectum was revealed.

[A Case of Hormone Receptor‒Positive HER2‒Negative Advanced/Recurrent Breast Cancer with 1.5 Years Withdrawal Period of Palbociclib Showed a Good Response Treated by Abemaciclib and Fulvestrant].

A 58‒year‒post‒menoposal woman was presented with left chest pain and shortness of breath because her breast cancer metastasized to the skin, lung, and pleural dissemination. In late‒line treatment for hormone receptor‒positive HER2‒negative advanced/recurrent breast cancer, we experienced a patient with tumor shrinkage leading to pain relief who was treated with a second combination of a CDK4/6 inhibitor and fulvestrant. Due to her poor performance status, she was treated with combined therapy to avoid severe adverse events. The CDK4/6 inhibitor was reintroduced after 1.5 years withdrawal period of endocrine therapy during anticancer drugs and radiation treatment. It has also been reported that withdrawal of CDK4/6 inhibitors might restore susceptibility related to the inhibitory signal. Rather than sequentially administering combined endocrine therapy with a CDK4/6 inhibitor, the withdrawal strategy of endocrine therapy continuing to administer anticancer drugs should be considered in case of reintroduction of CDK4/6 inhibitor.

Usability and performance of a wearable tele-echography robot for focused assessment of trauma using sonography.

Focused Assessment with Sonography for Trauma (FAST) is widely used as a first lifesaving step for patients suffering from internal bleeding. Because it may take a long time to transport such patients to a hospital, a wearable and portable tele-echography robot that a paramedic can attach to the patient has been developed. In the current study, experiments were conducted to evaluate the usability and performance of attached FAST. The proposed robot must be attached to 4 areas to perform FAST. The time required for attachment and the positions of attachment completed by 9 non-medical staff members, as well as the time it took for the FAST to reach a medical doctor, were measured. The echo images obtained when the patient's body was in motion were evaluated by a medical doctor. The robot could be attached to all 4 areas within approximately 5min, and the maximum gap was 4.8cm. This indicates that a paramedic who has received training in emergency medical care should be able to attach the robot to a patient quickly and accurately. Additionally, it was confirmed that the robot could be used to complete FAST under a doctor's control within 9min and that the extracted echo images were suitable for FAST. A comparison of the results with current ambulance transportation time confirmed that FAST could be completed approximately 14min before the patient reached the hospital. The results of the current study indicate that the robot is worth using, is suitable for FAST, and will be effective in emergency medical care.

Organ boundary determination algorithm for detecting internal bleeding.

The purpose of this paper is to propose an organ boundary determination method for detecting internal bleeding. Focused assessment with sonography for trauma (FAST) is important for patients who are sent into shock by internal bleeding. However, the FAST has a low sensitivity, approximately 42.7 %. This study aims, therefore, to construct an automatic internal bleeding detection robotic system on the basis of ultrasound (US) image processing to improve the sensitivity. We developed method for determining algorithms of organ boundaries by low-brightness set analysis, and we detected internal bleeding by the proposed method. Experimental results based on clinical US images of internal bleeding between Liver and Kidney showed that proposed algorithms had a sensitivity of 77.8% and specificity of 95.7%.

Noninvasive internal bleeding detection method by measuring blood flow under ultrasound cross-section image.

The purpose of this paper is to propose noninvasive internal bleeding detection method by using ultrasound (US) image processing under US cross-section image. In this study, we have developed a robotic system for detecting internal bleeding based on the blood flow measured by using a noninvasive modality like an US imaging device. Some problems related to the measurement error, however, still need to be addressed. In this paper, we focused on US image processing under US cross-section image, and constructed blood flow measurement algorithm under US cross-section image for internal bleeding detection. We conducted preliminary blood flow measurement experiments using a phantom containing artery model and a manipulator equipped with a US probe (BASIS-1). The results present the experimental validation of the proposed method.

Blood flow measurement algorithms to detect bleeding source noninvasively.

The purpose of this paper is to propose ultrasound visual servoing algorithms for controlling a robotic system equipped with an ultrasound probe for large pulsation and a displacement towards the out-of-plane of a US image. In this study, we aim to develop a robotic system for detecting bleeding source based on the blood flow measured by using a non-invasive modality like an ultrasound (US) imaging device. Some problems related to the measurement error still need to be addressed. As the first step in solving these problems, we focused on the large pulse amplitude and displacement of the artery towards the out-of-plane of a US image, and developed US visual servoing algorithms to control the probe. We conducted preliminary blood flow measurement experiments using an phantom containing artery model and a manipulator equipped with a US probe (BASIS-1). The results present the first experimental validation of the proposed algorithms.

Evaluation of a wearable tele-echography robot system: FASTele in a vehicle using a mobile network.

This paper shows the focused assessment with sonography for trauma (FAST) performance of a wearable tele-echography robot system we have developed that we call "FASTele". FAST is a first-step way of assessing the injury severity of patients suffering from internal bleeding who may be some time away from hospital treatment. So far, we have only verified our system's effectiveness under constantly wired network conditions. To determine its FAST performance within an emergency vehicle, we extended it to a WiMAX mobile network and performed experiments on it. Experiment results showed that paramedics could attach the system to FAST areas on a patient's body on the basis of the attaching position and procedure. We also assessed echo images to confirm that the system is able to extract the echo images required for FAST under maximum vehicle acceleration.

Portable and attachable tele-echography robot system: FASTele.

The purpose of this report is to propose portable and attachable tele-echography robot system: FASTele. Focused assessment with sonography for trauma (FAST) is important for patients who have shock by internal bleeding. However, the patient has little time, and transportation to a hospital may take too long. A system which enables FAST more quickly is required. Therefore, we aim to develop a tele-echography (FAST) robot system that can be used by a paramedic easily for shock patient in ambulance or at injury scene. To develop the system, portability and usability (for paramedic) are significant issues. We developed a tele-echography robot system which has 4-DOF. The robot is attached to each roughly FAST areas of patient body (body-based set up) and remotely fine-tuned position by a specialist in a hospital. The robot can control the posture of probe by curvature rails. The mechanism that maintains passively the contact force between the probe and patient's body surface by using springs enables the robot small and lightweight. Feasibility experiments of FAST are reported.