Morphology of Palaeospondylus shows affinity to tetrapod ancestors.

Palaeospondylus gunni, from the Middle Devonian period, is one of the most enigmatic fossil vertebrates, and its phylogenetic position has remained unclear since its discovery in Scotland in 1890 (ref. 1). The fossil's strange set of morphological features has made comparisons with known vertebrate morphotype diversity difficult. Here we use synchrotron radiation X-ray micro-computed tomography to show that Palaeospondylus was a sarcopterygian, and most probably a stem-tetrapod. The skeleton of Palaeospondylus consisted solely of endoskeletal elements in which hypertrophied chondrocyte cell lacunae, osteoids and a small fraction of perichondral bones developed. Despite the complete lack of teeth and dermal bones, the neurocranium of Palaeospondylus resembles those of stem-tetrapod Eusthenopteron2 and Panderichthys3, and phylogenetic analyses place Palaeospondylus in between them. Because the unique features of Palaeospondylus, such as the cartilaginous skeleton and the absence of paired appendages, are present in the larva of crown tetrapods, our study highlights an unanticipated heterochronic evolution at the root of tetrapods.

Optical development in the murine eye lens of accelerated senescence-prone SAMP8 and senescence-resistant SAMR1 strains.

The eye lens is responsible for focusing objects at various distances onto the retina and its refractive power is determined by its surface curvature as well as its internal gradient refractive index (GRIN). The lens continues to grow with age resulting in changes to the shape and to the GRIN profile. The present study aims to investigate how the ageing process may influence lens optical development. Murine lenses of accelerated senescence-prone strain (SAMP8) aged from 4 to 50 weeks; senescence-resistant strain (SAMR1) aged from 5 to 52 weeks as well as AKR strain (served as control) aged from 6 to 70 weeks were measured using the X-ray interferometer at the SPring-8 synchrotron Japan within three consecutive years from 2020 to 2022. Three dimensional distributions of the lens GRIN were reconstructed using the measured data and the lens shapes were determined using image segmentation in MatLab. Variations in the parameters describing the lens shape and the GRIN profile with age were compared amongst three mouse strains. With advancing age, both the lens anterior and posterior surface flattens and the lens sagittal thickness increase in all three mouse strains (Anterior radius of curvature increase at 0.008 mm/week, 0.007 mm/week and 0.002 mm/week while posterior radius of curvature increase at 0.002 mm/week, 0.007 mm/week and 0.003 mm/week respectively in AKR, SAMP8 and SAMR1 lenses). Compared with the AKR strain, the SAMP8 samples demonstrate a higher rate of increase in the posterior curvature radius (0.007 mm/week) and the thickness (0.015 mm/week), whilst the SAMR1 samples show slower increases in the anterior curvature radius (0.002 mm/week) and its thickness (0.013 mm/week). There are similar age-related trends in GRIN shape in the radial direction (in all three types of murine lenses nr2 and nr6 increase with age while nr4 decrease with age consistently) but not in the axial direction amongst three mouse strains (nz1 of AKR lens decrease while of SAMP8 and SAMR1 increase with age; nz2 of all three models increase with age; nz3 of AKR lens increase while of SAMP8 and SAMR1 decrease with age). The ageing process can influence the speed of lens shape change and affect the GRIN profile mainly in the axial direction, contributing to an accelerated decline rate of the optical power in the senescence-prone strain (3.5 D/week compared to 2.3 D/week in the AKR control model) but a retardatory decrease in the senescence-resistant strain (2.1 D/week compared to the 2.3D/week in the AKR control model).

Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence?

BACKGROUND: While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias. METHODS: The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias. RESULTS: The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083). CONCLUSIONS: Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.

Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication.

BACKGROUND: Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller­myotomy with Dor­fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia. METHODS: 457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course. RESULTS: mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01). CONCLUSIONS: Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.

High-energy X-ray micro-laminography to visualize microstructures in dense planar objects.

High-energy X-ray micro-laminography has been developed to observe inner- and near-surface structures in dense planar objects that are not suitable for observation by X-ray micro-tomography. A multilayer-monochromator-based high-intensity X-ray beam with energy of 110 keV was used for high-energy and high-resolution laminographic observations. As a demonstration of high-energy X-ray micro-laminography for observing dense planar objects, a compressed fossil cockroach on a planar matrix surface was analyzed with effective pixel sizes of 12.4 µm and 4.22 µm for wide field of view and high-resolution observations, respectively. In this analysis, the near-surface structure was clearly observed without undesired X-ray refraction-based artifacts from outside of the region of interest, a problem typical in tomographic observations. Another demonstration visualized fossil inclusions in a planar matrix. Micro-scale features of a gastropod shell and micro-fossil inclusions in the surrounding matrix were clearly visualized. When observing local structures in the dense planar object with X-ray micro-laminography, the penetrating path length in the surrounding matrix can be shortened. This is a significant advantage of X-ray micro-laminography where desired signals generated at the region of interest including optimal X-ray refraction effectively contribute to image formation without being disturbed by undesired interactions in the thick and dense surrounding matrix. Therefore, X-ray micro-laminography allows recognition of the local fine structures and slight difference in the image contrast of planar objects undetectable in a tomographic observation.

High-energy synchrotron-radiation-based X-ray micro-tomography enables non-destructive and micro-scale palaeohistological assessment of macro-scale fossil dinosaur bones.

Palaeohistological analysis has numerous applications in understanding the palaeobiology of extinct dinosaurs. Recent developments of synchrotron-radiation-based X-ray micro-tomography (SXMT) have allowed the non-destructive assessment of palaeohistological features in fossil skeletons. Yet, the application of the technique has been limited to specimens on the millimetre to micrometre scale because its high-resolution capacity has been obtained at the expense of a small field of view and low X-ray energy. Here, SXMT analyses of dinosaur bones with widths measuring ∼3 cm under a voxel size of ∼4 µm at beamline BL28B2 at SPring-8 (Hyogo, Japan) are reported, and the advantages of virtual-palaeohistological analyses with large field of view and high X-ray energy are explored. The analyses provide virtual thin-sections visualizing palaeohistological features comparable with those obtained by traditional palaeohistology. Namely, vascular canals, secondary osteons and lines of arrested growth are visible in the tomography images, while osteocyte lacunae are unobservable due to their micrometre-scale diameter. Virtual palaeohistology at BL28B2 is advantageous in being non-destructive, allowing multiple sampling within and across skeletal elements to exhaustively test the skeletal maturity of an animal. Continued SXMT experiments at SPring-8 should facilitate the development of SXMT experimental procedures and aid in understanding the paleobiology of extinct dinosaurs.

Structural properties in ruptured mitral chordae tendineae measured by synchrotron-based X-ray phase computed tomography.

The link between the structural properties and the rupturing of chordae tendineae in the mitral valve complex is still unclear. Synchrotron-radiation-based X-ray phase computed tomography (SR-XPCT) imaging is an innovative way to quantitatively analyze three-dimensional morphology. XPCT has been employed in this study to evaluate the chordae tendineae from patients with mitral regurgitation and to analyze structural changes in the ruptured chordae tendineae in patients with this condition. Six ruptured mitral chordae tendineae were obtained during surgical repairs for mitral regurgitation and were fixed with formalin. In addition, 12 healthy chordae tendineae were obtained from autopsies. Employing XPCT (effective pixel size, 3.5 µm; density resolution, 1 mg cm-3), the density of the chordae tendineae in each sample was measured. The specimens were subsequently analyzed pathologically. The mean age was 70.2 ± 3.0 in the rupture group and 67.2 ± 14.1 years old in the control group (p = 0.4927). All scans of chorda tendineae with SR-XPCT were performed successfully. The mean densities were 1.029 ± 0.004 in the rupture group and 1.085 ± 0.015 g cm-3 in the control group (p < 0.0001). Density based on SR-XPCT in the ruptured mitral chordae tendineae was significantly lower compared with the healthy chorda tendinea. Histological examination revealed a change in the components of the connective tissues in ruptured chorda tendinea, in accordance with the low density measured by SR-XPCT. SR-XPCT made it possible to measure tissue density in mitral chordae tendineae. Low density in mitral chordae tendineae is associated with a greater fragility in ruptured mitral chordae tendineae.

The pathological conditions and surgical outcomes depending on the degree of hernia in the intra-thoracic stomach.

BACKGROUND: In recent years, the number of patients requiring surgery for intra-thoracic stomach (ITS) has been increasing due to the effects of obesity and gibbus due to aging. The aim of this study is to assess the effects of the degree of hernia on the pathological conditions and surgical outcomes in ITS patients. METHODS: ITS was defined as cases in which over 50% of the stomach had deviated into the mediastinum by esophagogastric fluoroscopy and/or computed tomography, with 65 patients who underwent laparoscopic surgery as the initial surgery included. We compared the pathological conditions and surgical outcomes by dividing the subjects into 3 groups: Group A: 50%- < 75%; Group B: 75%- < 100%; and Group C: 100% (upside-down stomach), depending on the degree of deviation into the mediastinum of the stomach. RESULTS: The breakdown of patients was 33 in Group A, 21 in Group B, and 11 in Group C. Regarding the preoperative pathological conditions, Group C had a high body mass index (BMI) and a low score for factor V according to upper gastrointestinal endoscopy (p = 0.0109, p = 0.0062, respectively). While the surgical results indicated that the operation time was extended depending on the degree of hernia (p = 0.0051), there was no marked difference in other surgical outcomes or the postoperative course among the three groups, with a high degree of satisfaction. CONCLUSIONS: In the case of ITS, although the operation time was extended depending on the degree of the hernia, the surgical outcomes were the same, and overall good results were obtained.

Double-multilayer monochromators for high-energy and large-field X-ray imaging applications with intense pink beams at SPring-8 BL20B2.

In this study, double-multilayer monochromators that generate intense, high-energy, pink X-ray beams are designed, installed and evaluated at the SPring-8 medium-length (215 m) bending-magnet beamline BL20B2 for imaging applications. Two pairs of W/B4C multilayer mirrors are designed to utilize photon energies of 110 keV and 40 keV with bandwidths of 0.8% and 4.8%, respectively, which are more than 100 times larger when compared with the Si double-crystal monochromator (DCM) with a bandwidth of less than 0.01%. At an experimental hutch located 210 m away from the source, a large and uniform beam of size 14 mm (V) × 300 mm (H) [21 mm (V) × 300 mm (H)] was generated with a high flux density of 1.6 × 109 photons s-1 mm-2 (6.9 × 1010 photons s-1 mm-2) at 110 keV (40 keV), which marked a 300 (190) times increase in the photon flux when compared with a DCM with Si 511 (111) diffraction. The intense pink beams facilitate advanced X-ray imaging for large-sized objects such as fossils, rocks, organs and electronic devices with high speed and high spatial resolution.

Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia?

BACKGROUND: Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. METHODS: We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. RESULTS: Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. CONCLUSION: The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia.

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

Surgical management of primary undifferentiated pleomorphic sarcoma of the rectum: a case report and review of the literature.

BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that has been reclassified from malignant fibrous histiocytoma with the development of the pathological diagnosis. It principally occurs in the extremities but rarely occurs in the rectum. We herein report a rare case of UPS arising in the rectum. CASE PRESENTATION: A 85-year-old woman was referred to our hospital with a complaint of anal pain, which had persisted for several months. Computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. Colonoscopy revealed a submucosal elevation in the rectum without any exposure of the tumor to the surface. Contrast-enhanced CT and magnetic resonance imaging revealed an 80-mm mass that originated in the rectal muscular propria, and we suspected a gastrointestinal stromal tumor. No lymph node metastasis or distant metastasis was observed. We performed a laparoscopic Hartmann's operation. Intraoperatively, severe adhesion around the tumor caused tumor injury and right ureteral dissection. Thus, laparoscopic right ureteral anastomosis and ureteral stenting were additionally performed. The operation time was 6 h and 3 min, and the estimated blood loss was small. The patient was discharged without complications 25 days after surgery. A pathological examination showed that the tumor was composed of highly heterogeneous cells with no specific differentiation traits, leading to a diagnosis of UPS. Contrast-enhanced CT performed 2 months after surgery showed bilateral pelvic lymph node enlargement, which indicated recurrence. Considering the patient's age, we performed radiotherapy (50 Gy/25 Fr targeting the pelvic region). At present, 16 months have passed since the completion of radiotherapy. Contrast-enhanced CT shows that the recurrent lymph nodes have disappeared, and no new distant metastasis has been observed. CONCLUSIONS: We reported a case of UPS arising in the rectum. The surgical procedure and indication of preoperative therapy should be carefully selected because complete removal of the tumor is desirable in UPS.

Correlation between our symptom-based scoring system and the Eckardt score for assessing patients with esophageal achalasia.

PURPOSE: The Eckardt score (ES) is a famous scoring system used for assessing achalasia patients. We studied the correlation between our scoring system and the ES and examined the relationship between each score and the pathophysiology of achalasia. METHODS: The subjects were 143 patients with diagnosed achalasia. We assessed the frequency and degree of dysphagia, regurgitation (vomiting), and chest pain on a 5-point scale from 0 to 4, with the product of the frequency and degree score defined as each symptom score (0-16). The sum of the three symptom scores was the Total Symptom Score (TSS). We then studied the correlation between the TSS and the ES, including whether these scores reflected the pathophysiology. RESULTS: The median scores were 20 for TSS and 6 for the ES, indicating a high correlation between the two scores (r = 0.7280, p < 0.0001). A relationship was found between the morphologic type and both scores (TSS: p = 0.002, ES: p = 0.0036). On creating a receiver operating characteristic (ROC) curve for the Straight type and each score, the AUC was 0.6740 for TSS and 0.6628 for ES. CONCLUSIONS: A high positive correlation was found between the TSS and the ES. Both scoring systems reflected the morphologic type well, demonstrating that the TSS was a scoring system comparable to the ES.

Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience.

PURPOSE: To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. METHODS: We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. RESULTS: Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. CONCLUSIONS: Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.

Relationship between esophageal achalasia subtypes and esophageal clearance.

BACKGROUND: The diagnosis and pathological evaluation of esophageal achalasia have been improved dramatically by the development of high-resolution manometry. It is currently known to be divided into three subtypes. However, the differences between subtypes in terms of esophageal clearance remain unclear. AIMS: To compare the pathology of subtypes in patients with esophageal achalasia from the perspective of esophageal clearance. METHODS: We classified the patients diagnosed with esophageal achalasia into three subtypes based on the high-resolution manometry findings and compared the patient background, esophagography findings, esophageal manometry findings, timed barium esophagogram (TBE) findings, and their symptoms. We also calculated the esophageal clearance rate from TBE to investigate the relationship with the subtypes. RESULTS: There were 71 cases of Type I, 140 cases of Type II, and 10 cases of Type III. No differences by subtype were found in patient background or symptoms. Regarding the esophageal manometry findings, the integrated relaxation pressure was high in Type II (p = 0.0006). The esophagography revealed a mild degree of esophageal flexion in Type III (p = 0.0022) and a high degree of esophageal dilation in Type I and II (p = 0.0227). The esophageal clearance rate in descending order was: Type III, II, and I (height: p = 0.0302, width: p = 0.0008). CONCLUSIONS: The subtypes by high-resolution manometry diagnosis had an association with the esophagography findings and best reflected the esophageal clearance, with no correlation to the patient backgrounds and symptoms.

Optical development in the zebrafish eye lens.

The optics of the eye is the key to a functioning visual system. The exact nature of the correlation between ocular optics and eye development is not known because of the paucity of knowledge about the growth of a key optical element, the eye lens. The sophisticated optics of the lens and its gradient of refractive index provide the superior optical quality that the eye needs and which, it is thought, has a major influence on the development of proper visual function. The nature of a gradient refractive index lens, however, renders accurate measurements of its development difficult to make and has been the reason why the influence of lens growth on visual function remains largely unknown. Novel imaging techniques have made it possible to investigate growth of the eye lens in the zebrafish. This study shows measurements using X-ray Talbot interferometry of three-dimensional gradient index profiles in eye lenses of zebrafish from late larval to adult stages. The zebrafish lens shows evidence of a gradient of refractive index from the earliest stages measured and its growth suggests an apparent coincidence between periods of rapid increase in refractive index in the lens nucleus and increased expression of a particular crystallin protein group.

Over ten-year outcomes of laparoscopic Heller-myotomy with Dor-fundoplication with achalasia: single-center experience with annual endoscopic surveillance.

BACKGROUND: Laparoscopic Heller-myotomy with Dor-fundoplication (LHD) is the standard surgical treatment for achalasia; however, surgical outcomes over a period greater than 10 years have not been well-explored. The objective of this study was to evaluate the long-term outcomes of LHD for achalasia based on a single-center experience. METHODS: Patients who underwent LHD between 1994 and 2019 were included. Of these, we excluded patients who had undergone foregut surgery or whose follow-up data were unavailable. Esophagogastroduodenoscopy (EGD) findings and postoperative persistent and/or recurrent symptoms had been assessed annually. Disease-free rates were calculated using Kaplan-Meier analysis. RESULTS: A total of 530 patients (mean age 45.0 years with 267 men) were included. The median follow-up period was 50.5 months. More than 10 years' data were available in 78 patients (14.7%). The cumulative rates of freedom from dysphagia, vomiting, chest pain, and Eckardt score > 3 at 10 years after LHD were 80.1%, 97.5%, 96.3%, and 73.5%, respectively. Probability of esophagitis during 10 years after surgery was 34.4% of patients based on Kaplan-Meier estimation. Approximately 3/4th of patients who had post-LHD esophagitis showed mild esophagitis of Los Angeles classification grade A. Fifteen patients (2.8%) were required a revision of primary LHD. Six patients (1.2%) developed esophageal cancer with an incidence was as high as 219.8/100,000 person-year. All patients with esophageal cancer were found to have early stage tumors that were successfully resected. CONCLUSIONS: Symptomatic relief post-LHD lasted for over 10 years. The incidence rate of esophageal cancer was high. Regular EGD surveillance seems to be helpful for early detection of esophageal cancer early.

Effects of the preoperative IRP values on the pathophysiology of patients with esophageal achalasia and on the treatment outcome of laparoscopic Heller-Dor surgery.

PURPOSE: One diagnostic criterion of esophageal achalasia is that the integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) is at least 15 mmHg. Moreover, while the standard surgical treatment for esophageal achalasia is laparoscopic Heller-Dor surgery (LHD), there have been insufficient investigations concerning the surgical outcomes from the perspective of the preoperative IRP value. METHODS: We split 121 cases in which LHD was performed as an initial treatment on patients with esophageal achalasia, into two categories according to the IRP median value, and performed a comparative investigation of the surgical outcomes with regard to the preoperative pathophysiology and symptoms. RESULTS: The IRP median value was 29.6 mmHg. The high IRP group consisted of younger individuals and low BMI (p = 0.004 and p = 0.0273, respectively), and the percentage of Chicago classification Type II and III was high (p = 0.029) and the regurgitation score in the preoperative symptoms was high (p = 0.0043). However, no differences in the surgical outcomes were confirmed. CONCLUSION: In patients with esophageal achalasia, the degree of the preoperative IRP value affects the age, BMI, preoperative LESP, and preoperative regurgitation symptoms. However, there were no effects on the surgical outcomes, with the surgical outcomes being satisfactory, regardless of the IRP value.

The patient characteristics of esophageal carcinoma following laparoscopic myotomy for esophageal achalasia.

BACKGROUND: It is common knowledge that esophageal achalasia patients have a high risk of developing esophageal carcinoma. The present study assessed the characteristics of esophageal carcinoma patients following laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia. METHOD: Among 622 cases which were esophageal achalasia patients and underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not esophageal carcinoma occurred following surgery. RESULTS: Six cases (0.96%) of postoperative esophageal carcinoma were confirmed. The characteristics of the cases in which esophageal carcinoma occurred were older age, longer disease duration (p = 0.0362 and 0.0028, respectively), decreased sphincter pressure of the lower esophagus, a high rate of sigmoid esophagus, and a long esophagus lateral diameter (p = 0.0214, 0.001, and 0.0416, respectively). Moreover, no differences in surgical outcomes were confirmed and there were no differences in symptoms from before and following surgery. CONCLUSION: The characteristics of esophageal carcinoma patients with achalasia following laparoscopic myotomy were an older age, longer disease duration, and greater progression of disease pathophysiology.

Incidence and Relapse Triggers of Childhood Idiopathic Nephrotic Syndrome between 2006 and 2016: A Population-Based Study in Fukushima, Japan.

Childhood idiopathic nephrotic syndrome (NS) is defined by proteinuria and hypoproteinemia. The incidence of childhood idiopathic NS varies with age, race, residential areas, and social conditions. In Japan, its incidence was estimated to be 6.49 cases/100,000 children. Our study aimed to investigate the incidence, characteristics, and rate of relapse of idiopathic NS in Fukushima between 2006 and 2016. Overall, 158 children aged from 6 months to 15 years old (65.8% male) developed idiopathic NS (median age at onset, 5.3 years). The peak age at onset was three years. The average annual incidence of childhood idiopathic NS was 5.16 (range, 3.47-9.26) cases/100,000 children. The highest incidence was in 2011, which was the year of the Great East Japan Earthquake and nuclear power plant accident, and reportedly caused psychological distress in the children at the time. Conversely, the five-year birth cohort showed minor difference from 2008 to 2012. The rate of incidence in males aged < 5 years was thrice greater than in females of the same age and almost the same for males and females aged 11-15 years. Of 507 total relapses in 115 NS children, common triggers of relapses were steroid discontinuation or reduction and infection. The average annual incidence of childhood NS based on the Fukushima population was lower than previously reported in Japan, and the annual incidence has changed over an 11-year period. These changes may be affected by social or environmental factors, including mental stress associated with lifestyle changes after the disaster.