[A Case of Sigmoid Colon Cancer with Horseshoe Kidney].

We reported a case of sigmoid colon cancer with horseshoe kidney. A 79-year-old man had lower abdominal pain and underwent colonoscopy. The results of colonoscopy revealed sigmoid cancer. Preoperative computed tomography revealed horseshoe kidney. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅱa(The 9th Edition). He has not recurred 22 months later after operation. Surgery for colorectal cancer with congenital anomalies of the urinary tract requires attention to intraoperative secondary injuries. Therefore, preoperative evaluation using 3D-CT is useful tool for safety. Operating the proper dissecting normal layer would make safe laparoscopic operation possible without unexpected injuries.

A study of patients whose mode of food intake changed during long-term bedside care.

Hatakeyama M, Shirahase M, Suzuki S, Morita K, Yamashita S. A study of patients whose mode of food intake changed during long-term bedside care. Jpn J Compr Rehabil Sci 2023; 14: 60-68. Objective: The objective of this study was to determine the characteristics of patients who exhibited changes in their food intake level (as determined by the Food Intake Level Scale [FILS] score) while hospitalized for long-term bedside care. Methods: The subjects were 264 patients hospitalized for long-term bedside care. The FILS was used to assess the subjects' mode of food intake on the admission and survey dates. The FILS score was used to divide the patients into three stages: no oral intake, combined oral intake and alternative nutrition, and exclusively oral intake; the patients whose FILS stage on the survey date was different from that on the admission date were examined to determine whether there were any characteristic tendencies with regard to their age, sex, length of hospital stay, level of long-term care needed, primary illness, and dysphagia rehabilitation. Results: Overall, 6.8%, 9.8%, and 4.5% of the subjects showed improvement in the FILS stage, experienced deterioration of the FILS stage, and transitioned to exclusively oral intake, respectively. Further, 33.3% of the improved-FILS stage group were in their ≥90s. The results of the exact binomial test with the entire study cohort as the population proportion showed that there were significantly more females in the improved-FILS group. In addition, 83.3% of those who improved from no oral intake to exclusively oral intake had cerebrovascular disease. No difference in the length of hospital stay and level of long-term care needed was observed in either the improved-FILS or deteriorated-FILS group in comparison to their proportions in the entire study cohort. In the entire study cohort, a greater proportion of the subjects in the improved-FILS group underwent indirect or direct swallowing training than those in the deteriorated-FILS group; the improved-FILS group had no subjects who were assigned to watchful waiting. Conclusion: Most patients who exhibited marked positive changes in their mode of food intake were females or patients with cerebrovascular disease. However, no characteristic attributes were observed among those whose FILS stage deteriorated.

School-Based Stroke Education Through On-Demand E-learning During Coronavirus Disease 2019 Pandemic: Itoigawa Stroke Awareness Campaign.

Introduction Raising stroke awareness is important to shorten the interval from onset to consultation. We performed a school-based stroke education by on-demand e-learning during the coronavirus disease 2019 pandemic. Methods We performed on-demand e-learning and distributed the online- and paper-based manga about stroke for students and parental guardians in August 2021. We carried out this in a manner similar to the prior effective online stroke awareness initiatives in Japan. An online post-educational survey in October 2021 was conducted to evaluate the awareness effects by asking participants about their knowledge. We also investigated the modified Rankin Scale (mRS) at the discharge of stroke patients who were treated in our hospital during the before- and after-campaign periods, respectively. Results We distributed the paper-based manga and asked to work on this campaign to all 2,429 students (1,545 elementary school and 884 junior high school students) who lived in Itoigawa. We acquired 261 (10.7%) online responses from the students and 211 (8.7%) responses from their parental guardians. The number of students who chose all correct answers in the survey significantly increased after the campaign (205/261, 78.5%) compared to that before the campaign (135/261, 51.7%) and those of parental guardians showed similar trends (before campaign 93/211, 44.1%; after campaign 198/211, 93.8%). We investigated 282 stroke patients (90 patients before and 192 patients after-campaign period), and their mRS at discharge after-campaign seemed to be improved. Conclusion Only 10.7% of students and 8.7% of the parental guardians worked on the online survey. However, the number of those who chose correct answers about stroke increased after the campaign. After this campaign, the mRS of stroke patients at discharge improved although it was unclear if this is a direct result of this activity.

[A Case of Resected Type 4 Rectal Cancer with Difficulty in Preoperative Diagnosis].

We reported a case of Type 4 rectal cancer performed laparoscopic surgery. A 73-year-old man had diarrhea and constipation and underwent colonoscopy. From the first colonoscopy, histological findings of biopsy showed non-neoplastic cells. The results of colonoscopy strongly suggested the possibility of Type 4 rectal cancer. Therefore, we performed colonoscopy twice and he was diagnosed Type 4 rectal cancer. Computed tomography revealed no distant metastasis. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅲc(The 9th edition). He then received adjuvant chemotherapy but was relapsed at bones and lymph nodes. He died 18 months later after surgery.

[A Case of Appendiceal Metastasis from Hilar Cholangiocarcinoma with Acute Perforated Appendicitis and Cholecystitis].

An 88-year-old woman had been diagnosed with hilar cholangiocarcinoma for 3 years since she received metallic stents for malignant biliary obstruction, and observed without any aggressive medical treatment. She was admitted to our hospital for further investigation of her abdominal pain. Abdominal CT showed an enlarged gallbladder, fluid collection in the right paracolic gutter, and swollen appendix. Laboratory tests showed high-grade inflammation. She was diagnosed with acute perforated appendicitis with acute cholecystitis. Laparoscopic cholecystectomy and appendectomy were performed. Perforation was confirmed intraoperatively in the appendix wall and accumulation of pus was found in the right paracolic gutter. There were no macroscopic findings of metastasis and peritoneal dissemination. Microscopic examination of the resected appendix showed adenocarcinoma cells positive for CK7 and negative for CK20 and CDX2, and were predominantly infiltrated from the muscular layer to the serosa of the appendix wall, with a diagnosis of appendiceal metastasis from hilar cholangiocarcinoma. Metastatic appendiceal carcinoma is rare, and appendiceal metastasis from hilar cholangiocarcinoma is extremely rare. Herein, we report a rare case of metastatic appendiceal carcinoma from hilar bile duct cancer with acute perforated appendicitis and cholecystitis along with findings of previous literature.

[A Case of Rectal GIST Resected using the TAMIS Method].

We reported a case of rectal gastrointestinal stromal tumor(GIST)performed transanal surgery. A 46-year-old woman was pointed out uterinal cancer and lower rectal GIST. After operation for uterine cancer, GIST was treated. Because of the patent's opinion for anal preservation, chemotherapy with imatinib for 3 months was performed and local resection was done by transanal minimally invasive surgery(TAMIS). The histopathological diagnosis was low-grade GIST and immunostaining showed the tumor was positive for c-kit, CD34, DOG-1 and α-SMA. Because capsule of the GIST was damaged intraoperatively, imatinib therapy was started and she has no recurrence after 2 years.

Efficacy of Emergency Room Skip Strategy in Patients Transferred for Mechanical Thrombectomy.

Objective: Time to recanalization is directly linked to cerebral infarction prognosis. However, patients transferred from another hospital take longer to arrive than those transported directly. To minimize time to recanalization, the emergency room (ER) skip strategy for hospital transfers was executed and reviewed. Methods: From April 2019, patients transferred from another hospital for mechanical thrombectomy were carried into the angio-suite using emergency service stretchers. Results for these patients (ER skip group) were compared with those for patients transported directly to our hospital (Direct group). Results: Among 108 cases in 32 months, 99 patients (91.7%) had major cerebral artery occlusion and underwent endovascular treatment. No differences in age, baseline National Institutes of Health Stroke Scale score, effective recanalization rate, or proportion of posterior circulation cases were seen between groups. The ER skip group (26 patients) showed significantly longer median time from onset to arrival (240 vs. 120 min; p = 0.0001) and significantly shorter median time from arrival to groin puncture (11 vs. 69 min; p = 0.0000). No significant differences were evident in time from groin puncture to recanalization (39 vs. 45 min), time from onset to recanalization (298 vs. 244 min), or rate of modified Rankin Scale score 0-2 after 90 days (42.3% vs. 32.9%). Median time from alarm to recanalization (266 vs. 176 min; p = 0.0001) was significantly longer in the ER skip group. Door-to-puncture (DTP) time for the Direct group gradually fell as the number of cases increased, reaching 40 min by the end of study period. In contrast, DTP time for the ER skip group remained extremely short and did not change further. The proportion of patients who underwent both CT and MRI before endovascular treatment was significantly lower in the Direct group (30.1%) than in the ER skip group (57.7%). In the ER skip group, median length of stay in the primary hospital was 119 min, and the median duration of interhospital transfer was 16 min. Conclusion: The ER skip strategy for patients transferred with large vessel occlusion achieved favorable outcomes comparable to that for direct transport cases. Direct transport to a thrombectomy-capable stroke center remains ideal, however, because the time to intervention is improving for direct transport cases each year.

[A Case of Rectal Cancer with Protein-Losing Gastroenteropathy].

We report a case receiving laparoscopic surgical resection of rectal cancer with protein-losing gastroenteropathy. A 58- year-old man was referred to our hospital because of melena, diarrhea, and anorexia. He showed septic shock, anemia, and hypoproteinemia. CT scan showed a rectal tumor with regional lymph node swelling and a cavernous lung lesion with a pulmonary embolus. Ninety-five days after admission to intensive care, he was introduced to our department because of the disappearance of a lung lesion indicating a lung abscess. Colonoscopy showed a cauliflower-like type 1 rectal cancer lesion. He experienced laparoscopic low anterior resection 121 days after admission. He was discharged without problems 66 days after the operation. After 8 months of surgery and no chemotherapy, he had no recurrence of rectal cancer. Colon cancer with protein-losing gastroenteropathy is rare and shows a typical cauliflower-like type 1 tumor appearance. Hypoproteinemia can be improved after resection of colon cancer.

[A Case of Laparoscopic Surgery for Sigmoid Lymph Node Metastases after Surgery for Rectal Cancer].

Herein, we report a case of laparoscopic surgery for sigmoid lymph node metastases after surgery for rectal cancer. A 58- year-old man underwent laparoscopic surgery for rectal cancer. He underwent D2 lymph node dissection, and he was undergoing dialysis for renal disease as a complication of diabetes. CT imaging performed 15 months after surgery revealed recurrence of tumors in the sigmoid lymph nodes. Subsequently, laparoscopic removal of the sigmoid lymph nodes was planned, as the patient had no tumor recurrence at any other location, and because his condition was not suitable for chemotherapy. The postoperative course was uneventful, and the patient was discharged a few days after surgery.

Proton-sensing receptor GPR132 facilitates migration of astrocytes.

Astrocytes are one of the first responders to central nervous system (CNS) injuries such as spinal cord injury (SCI). They are thought to repress injury-induced CNS inflammation as well as inhibit axonal regeneration. While reactive astrocytes migrate and accumulate around the lesion core, the mechanism of astrocyte migration towards the lesion site remains unclear. Here, we examined possible involvement of acidification of the lesion site and expression of proton-sensing receptors in astrocyte migration, both in mice models and in vitro. We found that the expression of several proton-sensing receptors was increased at the lesion site after SCI. Among these receptors, Gpr132 was expressed in primary cultured astrocytes and exhibited significant enhanced expression in acidic conditions in vitro. Furthermore, astrocyte motility was enhanced in acidic media and by Gpr132 activation. These results suggest that acidification of the lesion site facilitates astrocyte migration via the proton-sensing receptor Gpr132.

[A Case of Superior Mesenteric Artery Syndrome Following Transverse Colon Cancer Surgery].

We reported a case of superior mesenteric artery(SMA)syndrome after decreased body weight and unstable oral intakes due to anastomotic leakage of postoperative transverse colon cancer. A 63-year-old man underwent laparoscopic left hemicolectomy and D3 lymph node dissection with a diagnosis of transverse colon cancer. He had postoperative anastomotic leakage and was discharged after conservative treatment on postoperative day 35. However, he had visited our hospital by the symptom of bowel obstruction caused by anastomotic stenosis and had been admitted twice. After second colonoscopic balloon dilation on postoperative day 129, he was diagnosed as anastomotic perforation and emergency reoperation was performed. In the postoperative course, he repeated vomiting and his body weight decreased and superior mesenteric artery syndrome was diagnosed. He improved after conservative treatment by fasting, a nasogastric intubation and total parenteral nutrition and was discharged 22 days after the diagnosis.

What can we learn from the effect of trihexyphenidyl on motor fluctuations during continuous levodopa-carbidopa intestinal gel infusion (LCIG)? - First documented case.

Motor fluctuations can be seen even during treatment with continuous levodopa-carbidopa intestinal gel infusion (LCIG). We report on a middle-aged man with advanced Parkinson's disease (PD) on LCIG in which motor fluctuations have been improved with an anticholinergic. To the best of our knowledge, there have been no previous LCIG cases reported with motor fluctuations responding to non-dopaminergic agent, which might reveal some clues to its pathophysiology. Long-term oral levodopa treatment is associated with development of potentially disabling motor complications including motor fluctuations and dyskinesias in the majority of patients with PD. It has been suggested that motor complications are related to the nonphysiological restoration of brain dopamine with intermittent administration of standard oral levodopa. LCIG significantly reduces "off" time and increases "on" time without dyskinesia in comparison to standard oral levodopa through consistent plasma concentration of levodopa to restore brain dopamine in a more physiological manner. However, it has been reported that PD patients on LCIG often worsen during the afternoon hours, even with stable plasma concentration of levodopa. This raises the possibility that additional factors to dopamine deficiency could play a role in occurrence of motor fluctuations. Here we offer a hypothesis that altered cholinergic signaling could also be involved in the pathophysiology of motor fluctuations, based on our clinical evidence that anticholinergic drug has eliminated motor fluctuations during LCIG in a patient with PD. Further studies for non-dopaminergic along with dopaminergic signaling may be needed to better understand the pathophysiological basis of motor complications in PD.

[A Case of Small Intestinal Cancer Resected by Laparoscopic Surgery].

We report a case of laparoscopic surgical resection of a small intestinal cancer. A woman in her 40s was referred to our department for prolonged abdominal problems(epigastralgia, nausea, diarrhea, and constipation). CT scan revealed a small intestinal tumor with dilatation of the oral side of the intestine. She was admitted to our hospital, and an ileus tube was introduced. One week after admission, she experienced laparoscopic partial resection of the small intestine. She was soon discharged without any problems and has had no recurrence of small intestinal cancer after 8 months of surgery without any adjuvant chemotherapy. Small intestinal cancer is frequently detected in an advanced stage, resulting in poor prognosis, but curative surgery can improve the prognosis. Optimal therapy for small intestinal cancer has not been established yet because it is rare. A multi-centered study of small intestinal cancer for the establishment of its diagnosis and therapy needs to be conducted.

Impact of endoscopic stent insertion on detection of viable circulating tumor cells from obstructive colorectal cancer.

The placement of a self-expanding metallic stent (SEMS) in obstructive colorectal cancer (OCRC) is acknowledged to be a safe and effective procedure for the relief of obstruction. However, there is concern that shear forces acting on the tumor during stent expansion may release cancer cells into the circulation, resulting in a poor prognosis. The aim of the present study was to determine whether colonic stent insertion increases viable circulating tumor cells (v-CTCs). A telomerase-specific replication-selective adenovirus-expressing GFP (TelomeScanF35) detection system was used to detect v-CTCs in 8 OCRC patients with a SEMS before and after stent insertion and after surgical resection. In 7 patients, a SEMS was inserted as a bridge to surgery (BTS), and in one patient, a SEMS was inserted for palliation. Surgical resection (R0) was performed in 7 patients. Four patients had no v-CTCs before SEMS placement, two of four measurable patients had an increased number of v-CTCs after SEMS placement (1-3 v-CTCs), and one of two patients with increased v-CTCs developed distant lymphatic metastasis despite curative resection. Four patients had v-CTCs (1-19 cells) before SEMS placement, and two of these four patients had an increase in the number of v-CTCs (20-21 cells) after SEMS placement, while one of the four patients died early with distant metastasis. The present study demonstrated that endoscopic stent insertion for OCRC may result in tumor cell dissemination into the peripheral circulation and may induce distant metastases.

The prevalence of calcification around odontoid process and the incidence of crowned dens syndrome in the neurosurgical ward: A single institution's analysis.

OBJECTIVE: The objective of this study is to assess the prevalence and natural history of odontoid calcification and to identify factors related to its progression to crowned dens syndrome (CDS). METHODS: We reviewed a consecutive series of patients who underwent head CT upon admission to the neurosurgical ward of Niigata Prefectural Shibata Hospital. We evaluated the relationship between the presence of odontoid calcification and the patient's age, sex, and primary disorder for admission. The incidence of CDS was also determined, and factors related to the progression of odontoid calcification to CDS were analyzed. RESULTS: Odontoid calcifications were found in 88 out of 554 patients (15.9%) undergoing CT scans. Age, female, and stroke were predictive of odontoid calcification. The odds ratios (95% CIs) for age, female, and stroke estimated from the logistic analysis were 1.084 (1.054-1.114; p < .0001), 1.746 (1.06-2.875; p = .029), and 1.909 (1.123-3.247; p = .017), respectively. Eleven (12.5%) of the 88 patients with odontoid calcification developed CDS. The age, sex, and primary disorder for admission were not associated with the onset of CDS. CONCLUSIONS: Odontoid calcification is observed incidentally on head CT. Clinicians should keep in mind that patients with odontoid calcification might develop CDS, even if they are asymptomatic at the time of CT examination.

[A Case of Radical Resection of Rectal Cancer with Multiple Liver and Lung Metastases after Preoperative Chemotherapy].

We report a case of radical resection of rectal cancer with multiple liver and lung metastases after preoperative chemotherapy. A 54-year-old woman presented with abdominal pain and loss of body weight due to rectal cancer with multiple liver and lung metastases. Therefore, the patient received 14 courses of bevacizumab+mFOLFOX6, and 7 courses of panitumumab+FOLFIRI. After the chemotherapy, the size of the distant metastases reduced by 62% on computed tomography, according to RECIST. Due to the reduction in size, a conversion surgery was attempted. First, an abdominal operation with laparoscopy was performed, and 2 months later an operation to resect the lung metastases via thoracoscopy was performed. Currently, 3 months after surgery, the patient is alive, without recurrence.

[A Case of Locally Advanced Rectal Cancer Successfully Treated by Conversion Surgery after Multidisciplinary Treatment].

A 70-year-old woman who complained of abdominal pain and a prolapsed tumor from the anus was diagnosed with an intestinal obstruction resulting from anal canal cancer. Computed tomography (CT) and magnetic resonance imaging revealed a huge tumor (11×5×12 cm) invading the vagina and levator ani muscle. Enlarged inguinal lymph nodes on both sides indicated metastasis. The clinical stage was T4b (vagina, levator ani muscle, and pudenda) N0H0M1a (LYM), stage IV (Japanese Classification of Colorectal Carcinoma: 8th edition). As curative resection was not possible, a transvers colostomy was performed to relieve the intestinal obstruction. This was followed by chemoradiotherapy (45 Gy/1.8 Gy×25; TS-1, 80 mg/body for 2 weeks and a 1-week interval, for 2 courses) and up to 10 courses of Bev+mFOLFOX6 continuously. After this regimen, there was a remarkable reduction in tumor size. Positron emission tomography-CT revealed no FDG uptake in the primary rectal site or inguinal lymph nodes, but a maximum standardized uptake value (SUVmax) of 6.3 was detected in the vagina. Six weeks after chemotherapy, the patient underwent a pelvic exenteration including resection of the vagina, bladder, and pudenda. The pathological stage was yp T4b (vagina) N0H0M0, stageⅡ. Curative resection was performed, and the patient had a Grade 2 pathological response after chemoradiotherapy.

[Long-term Results Regarding the Instability of Decompressive Surgery without Fusion for Degenerative Spondylolisthesis].

PURPOSE: The long-term results of decompressive surgery for degenerative spondylolisthesis (DS) were evaluated with reference to instability. MATERIALS AND METHODS: Patients (n=48) undergoing decompressive surgery without fusion were studied. The diagnosis of spondylolisthesis was made based on the presence of sagittal vertebral slippage greater than 3mm. Instability was defined as translation more than 2mm on lateral functional radiography. Surgical interventions were divided into two groups: bilateral laminotomy (n=25)and laminectomy (n=23). Clinical results were evaluated according to the McCulloch's classification and Japanese Orthopedic Association(JOA)score. RESULTS: Of 48 patients, 25 showed preoperative instability. Eleven patients showed both pre-and postoperative instability. The mean pre-and postoperative slippages were 7.5 and 7.6mm, respectively. Of 23 patients without preoperative instability, nine developed postoperative instability. In this group, slippage changed from 6.2 to 6.1mm. Instability was not related to slippage progression. Surgical results of patients undergoing laminotomy were superior to those undergoing laminectomy. The mean pre-and postoperative JOA scores and recovery rate were 14.5, 20.9, and 63.1 in instability group patients with laminotomy and 15.6, 23.2, and 59.0 in the non-instability group, respectively. Surgical results were similar and not related to preoperative instability. Low back pain (LBP) showed no correlation to the degree of slippage, instability, and surgery type. LBP improved in each group. CONCLUSIONS: Instability, defined by vertebral translation on lateral functional radiography, did not affect the surgical results of patients with DS treated with laminotomy.

A case of adenoid cystic carcinoma of the esophagus.

Esophageal adenoid cystic carcinoma (EACC) is a very rare form of malignant tumor in the esophagus. Here, we report the case of a 78-year-old man who was diagnosed with EACC by preoperative endoscopic biopsy. Thoracoscopy-assisted subtotal esophagectomy with lymph node dissection was carried out. Microscopic examination of the resected specimen suggested that the tumor invaded to submucosal layer and showed no lymph node metastasis. Histologically, tumor primarily exhibited an alveolar solid pattern with partial cribriform and tubular patterns. Alcian blue staining showed many mucoid materials within the glandular cavity formed by tumor cells. Immunohistochemical studies revealed that the tumor cells reacted with pan-cytokeratin immunostains and expressed vimentin and S-100 protein. Collectively, the tumor was diagnosed as primary EACC, T1bN0M0 according to "Japanese Classification of Esophageal Cancer 10th edition." The patient showed no recurrence sign 12 months after the surgery.The current study also reviewed 35 EACC cases reported in Japanese literatures from 1990 to 2014. Combined with our case, we found that EACC is less frequently accompanied by lymph node metastasis as compared to esophageal squamous cell carcinoma, especially at the early stage. The prognosis of EACC is relatively better when tumors have no lymph node metastasis.

[A Case of Small Bowel Cancer Treated with Laparoscopic Surgery].

We report a case of small intestinal adenocarcinoma treated with laparoscopic surgery. A 70-year-old woman had abdominal pain and epigastralgia. There were no abnormal findings on upper and lower endoscopy. The symptoms continued for 4 months after endoscopy, so she presented to our hospital. After CT examination, small bowel cancer with ileus was suspected. An ileus tube was inserted to relieve the bowel pressure and she was diagnosed with ileum cancer by enteroscopy. Laparoscopic surgery was performed and the pathological stage was determined as pStage Ⅲa. She was treated with oral chemotherapy (UFT plus LV) and had no recurrence 6 months after surgery.