Is Palliative Gastrojejunostomy for Malignant Gastric Outlet Obstruction an Optimal Choice for Very Elderly Patients? A Report from a Long-Lived Country.

BACKGROUND: Gastrojejunostomy (GJ) is a surgical option for malignant gastric outlet obstruction (mGOO). Confronting an aging society, the demand to treat elderly cancer patients with unresectable malignancies is increasing; however, the benefit of GJ to the very elderly (≥ 80 years of age) has never been investigated. METHODS: This multicenter, retrospective review included 108 patients who had undergone GJ for mGOO from two medical centers in Japan, one of the most long-lived countries. Patients were divided into two groups, with 80 years of age as the cut-off. Various factors, including surgical complications and patient survival, were compared. RESULTS: GJ in the very elderly (aged ≥ 80 years) was associated with a higher incidence of surgical complications (p = 0.049), such as delayed gastric emptying (DGE; p < 0.001), aspiration pneumonia (p = 0.029), and consequent mortality (p = 0.016). Age ≥80 years was also identified as an independent predictor of DGE (odds ratio 6.444, p = 0.005) and survival after GJ (hazard ratio 7.767, p = 0.016). In particular, the median survival time after GJ in the population aged ≥80 years with gastric cancer was only < 2 months. About the surgical procedure, antiperistaltic anastomosis with partial stomach partitioning (PSP) yielded the lowest occurrence rate of DGE (3.4%) and aspiration pneumonia (1.7%). CONCLUSIONS: GJ does not seem to be the optimal choice for very elderly patients, particularly those with gastric cancer. If performed, antiperistaltic anastomosis with PSP should be employed to reduce the surgical complications.

Surgeons' involvement in COVID-19 treatment: a practice by a regional core hospital in Japan to avoid physician burnout.

BACKGROUND: To prevent task accumulation on certain divisions, our institution developed a unique system of allocating inpatient treatment of COVID-19 patients to doctors who were not specialized in respiratory infections. The objective of this study was to investigate whether surgeons can be involved in the COVID-19 inpatient treatment without negatively affecting patient outcome, and how such involvement can affect the wellbeing of surgeons. METHODS: There were 300 patients diagnosed with COVID-19 and hospitalized from January to June 2021, and 160 of them were treated by the redeployed doctors. They were divided into 3 groups based on the affiliation of the treating doctor. Patient characteristics and outcomes were compared between the groups. In addition, the impact of COVID-19 duty on participating surgeons was investigated from multiple perspectives, and a postduty survey was conducted. RESULTS: There were 43 patients assigned to the Department of Surgery. There were no differences in the backgrounds and outcomes of patients compared with other groups. The surgeon's overtime hours were significantly longer during the duty period, despite no change in the number of operations and the complication rate. The questionnaire revealed that there was a certain amount of mental and physical burden from the COVID-19 duty. CONCLUSION: Surgeons can take part in inpatient COVID-19 treatment without affecting patient outcome. However, as such duty could negatively affect the surgeons' physical and mental wellbeing, further effort is needed to maintain the balance of fulfilling individual and institutional needs.

Laparoscopic isolated liver segmentectomy 8 for malignant tumors: techniques and comparison of surgical results with the open approach using a propensity score-matched study.

PURPOSE: Anatomic isolated liver segmentectomy 8 (ILSeg8) for malignancies remains technically challenging. The feasibility, safety, and oncologic validity of laparoscopic ILSeg8 are undefined, and thus were evaluated in comparison with the open approach. METHODS: This study enrolled 35 open and 29 laparoscopic ILSeg8 cases of hepatocellular carcinoma (n = 47), metastatic liver tumors (n = 16), and intrahepatic cholangiocarcinoma (n = 1) at our institution. The surgical techniques were based on the pre-hepatectomy extrahepatic Glissonian pedicle control, followed by cranial-to-caudal parenchymal dissection from the hepatic vein root side. The short- and long-term outcomes after ILSeg8 were retrospectively evaluated and compared between the open and laparoscopic approaches using 1:1 propensity score matching (PSM). RESULTS: Both before and after PSM, the laparoscopic ILSeg8 group had significantly less blood loss, lower postoperative serum bilirubin level, and a shorter postoperative hospital stay than the open group. The overall survival rates were comparable between the laparoscopic and open groups before (P = 0.017) and after (P = 0.043) PSM, with the similar recurrence-free survival rates between the groups. In a multivariable analysis of the cohort before PSM (n = 64), the laparoscopic approach was identified to be an independent factor for favorable overall survival (hazard ratio = 0.20, P = 0.039). CONCLUSION: Laparoscopic ILSeg8 using the extrahepatic Glissonian approach and hepatic vein root at first parenchymal dissection was feasible, safe, and oncologically acceptable. In ILSeg8 for malignancy, the laparoscopic approach potentially confers short-term advantages over the open approach with comparable long-term outcomes in select patients.

Repeat hepatectomy with systemic chemotherapy might improve survival of recurrent liver metastasis from colorectal cancer-a retrospective observational study.

BACKGROUND: Although hepatectomy for metastatic colorectal cancer (mCRC) prolongs survival in up to 40% of people, recurrence rates approach 70%. We used a multidisciplinary approach to treat recurrent liver metastases, including chemotherapy, surgery, and palliative care. On the other hand, development of chemotherapeutic agents is remarkable and improves long-term survival. However, whether chemotherapy and repeat hepatectomy combination therapy improve survival or not is still unclear. The aim of this study was to analyze the outcomes of repeat hepatectomy with systemic chemotherapy for mCRC. METHODS: Following Institutional Review Board approval, we reviewed the records of all patients who underwent hepatectomy for mCRC between 1974 and 2015 at Fujita Health University Hospital. We used the Kaplan-Meier method to estimate overall survival from the first and last hepatectomy in multi hepatectomy cases after 2005 and compared outcomes between groups using the log-rank test. RESULTS: A total of 426 liver resections were performed for mCRC; of these, 236 cases were performed after 2005 (late group). In 118 (50%) cases, the site of recurrence was the liver, 59 (50%) underwent repeat hepatectomy, and 14 cases had ≥ 2 repeat hepatectomies. Overall survival (OS) before and after 2005 was 42.2 and 64.1 months, respectively, with the late group having better OS compared to the early (1974-2004) group. OS for single hepatectomy cases was 83.2 months, for two hepatectomies was 42.9 months, and for three hepatectomies was 35.3 months. In total, 59 patients did not undergo surgery after recurrence with an OS of 28.7 months. Mortality of the second and third repeat hepatectomy was 1.7% and 15.3%, respectively. CONCLUSION: Repeat hepatectomy with systemic chemotherapy for mCRC is feasible and might achieve improved survival in carefully selected patients.

Acute immobilization stress following contextual fear conditioning reduces fear memory: timing is essential.

BACKGROUND: Histone acetylation is regulated in response to stress and plays an important role in learning and memory. Chronic stress is known to deteriorate cognition, whereas acute stress facilitates memory formation. However, whether acute stress facilitates memory formation when it is applied after fear stimulation is not yet known. Therefore, this study aimed to investigate the effect of acute stress applied after fear training on memory formation, mRNA expression of brain-derived neurotrophic factor (BDNF), epigenetic regulation of BDNF expression, and corticosterone level in mice in vivo. METHODS: Mice were subjected to acute immobilization stress for 30 min at 60 or 90 min after contextual fear conditioning training, and acetylation of histone 3 at lysine 14 (H3K14) and level of corticosterone were measured using western blot analysis and enzyme-linked immunosorbent assay (ELISA), respectively. A freezing behavior test was performed 24 h after training, and mRNA expression of BDNF was measured using real-time polymerase chain reactions. Different groups of mice were used for each test. RESULTS: Freezing behavior significantly decreased with the down-regulation of BDNF mRNA expression caused by acute immobilization stress at 60 min after fear conditioning training owing to the reduction of H3K14 acetylation. However, BDNF mRNA expression and H3K14 acetylation were not reduced in animals subjected to immobilization stress at 90 min after the training. Further, the corticosterone level was significantly high in mice subjected to immobilization stress at 60 min after the training. CONCLUSION: Acute immobilization stress for 30 min at 60 min after fear conditioning training impaired memory formation and reduced BDNF mRNA expression and H3K14 acetylation in the hippocampus of mice owing to the high level of corticosterone.

[A Case of Colon Metastasis from Breast Cancer with Resection by Laparoscopic Surgery].

A 50-year-old woman underwent breast-conserving surgery and axillary lymph node dissection for left breast cancer in May 2003. She received chemotherapy and radiation for lymph node, lung, and brain metastases. In October 2015, because of abdominal pain and melena, she underwent colonoscopy for suspected sigmoid colon metastasis from breast cancer. We performed laparoscopic sigmoidectomy and diagnosed sigmoid colon metastasis from breast cancer after histopathological examination. Colon metastasis from breast cancer can occur, although it is very rare.

A bilateral thoracic approach for esophageal cancer in the prone position.

Esophagectomy in the prone position has recently been introduced as a less-invasive procedure for treating esophageal cancer. We herein present a case of esophageal squamous cell carcinoma (ESCC) treated with a bilateral thoracic approach in the prone position. The patient was a 69-year-old male diagnosed with middle thoracic ESCC. Computed tomography scans and fluorine-18-fluorodeoxyglucose revealed possible metastasis to the lymph nodes on the left dorsal side of the descending thoracic aorta (DTA). After preoperative chemotherapy, we dissected the lymph node metastasis on the left dorsal DTA using the left thoracic approach, following resection of the ESCC by a right thoracic approach in the same prone position. The postoperative course was uneventful, and the patient was discharged 23 days after surgery. A bilateral thoracic approach for esophageal cancer in the prone position may be a new option for surgically treating esophageal cancer.

Enhanced-view totally extraperitoneal repair in a morbidly obese patient with epigastric and umbilical hernias in combination with rectus diastasis: A case report.

INTRODUCTION: The use of enhanced-view totally extraperitoneal (eTEP) repair for patients with ventral hernias has become more widespread due to its ability to prevent mesh-and-tacker-related complications by placing the mesh in the retrorectus space. However, the efficacy of eTEP repair in obese patients remains unknown. Herein, we report a case of a morbidly obese patient with epigastric and umbilical hernias in combination with a rectus diastasis repaired using the eTEP technique. PRESENTATION OF CASE: A 42-year-old man with a history of spontaneously reduced incarcerated epigastric hernia two weeks previously was referred to our hospital. His body mass index (BMI) was 42.9 kg/m2. Abdominal computed tomography revealed a small epigastric hernia, an umbilical hernia, and a rectus diastasis. We performed eTEP repair. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. There has been no evidence of hernia recurrence after a follow-up period of 2 years. DISCUSSION: We consider that the eTEP technique is rarely affected by intra-abdominal fat because endoscopic manipulation is performed in the bilateral retrorectus and preperitoneal spaces. Moreover, the eTEP allows the epigastric artery perforator to be spared. Therefore, eTEP repair is considered the best surgical option for morbidly obese patients with ventral hernias in combination with rectus diastasis. CONCLUSIONS: This case provides support for the efficacy of eTEP repair in morbidly obese patients with epigastric and umbilical hernias in combination with a rectus diastasis.

Simplified risk stratification in early cholecystectomy for acute cholecystitis based on age: A report from an institution with zero mortality.

BACKGROUND/PURPOSE: The existing risk stratification for early cholecystectomy in patients with acute cholecystitis (AC) is complex. This study aims to establish a simpler risk assessment for surgical complications after cholecystectomy based on age group. METHODS: This single-center retrospective observational study enrolled 350 patients diagnosed with AC who underwent early cholecystectomy within 72 h of diagnosis from 2013 to 2021. Patients were divided into three subgroups based on age: young (<65 years), elderly (65-79 years), and very elderly (≥80 years). Since no mortality was observed, risk factors for the Clavien-Dindo (CD) grade ≥ II complications were identified within the entire cohort and in each subgroup. RESULTS: There were 120 young, 130 elderly, and 100 very elderly patients. The overall prevalence of complications with CD grade ≥ II was 11.1%. Age and Tokyo Guidelines 18 (TG18) severity were independent risk factors for surgical complications in the whole cohort. Subgroup analysis revealed that there was no independent risk factor in the young group. Meanwhile, age and poor physical status were independent risk factors in the elderly group, and TG18 severity in the very elderly group. CONCLUSION: Evaluation of only age, physical status, and TG18 severity may be sufficient for risk stratification of surgical complications of AC.

Laparoscopic repair for interparietal hernia after enhanced-view totally extraperitoneal hernia repair: A case report.

INTRODUCTION: The enhanced-view totally extraperitoneal (eTEP) technique, an endoscopically performed Rives-Stoppa method, has been used extensively for ventral hernia repairs. However, in this technique, the necessity of posterior rectus sheath re-approximation and mesh fixation remains unclear. There are a few reports of post-eTEP interparietal hernias (IHs) occurring because of dehiscence of the re-approximated posterior rectus sheath; however, IH secondary to mesh migration is rare. Herein, we report a rare case of IH due to mesh migration after eTEP repair for an incisional hernia. PRESENTATION OF CASE: A 70-year-old man underwent eTEP repair for an incisional hernia using a self-gripping mesh without mesh fixation and posterior rectus sheath re-approximation one year previously, developed an IH. An elective laparoscopic surgery revealed an orifice to the retrorectus space as though the IH sac between the retrorectus muscle and the posterior layer including the bilateral posterior rectus sheaths, peritoneum, and mesh. We placed eight transmural sutures with 0 nylon thread and closed the orifice. The patient was then discharged on postoperative day two and was asymptomatic at 24 months without evidence of ventral hernia recurrence. DISCUSSION: We consider that strenuous activity and deep bending may cause mesh migration or dislocation. If that occurs in the early post-eTEP period without posterior rectus sheaths closure, the vulnerable peritoneal area will be exposed, which consider to be an IH orifice. CONCLUSIONS: Even after using the self-gripping mesh in eTEP repair, mesh fixation remains the best option to prevent postoperative complications, including IH.

Enhanced-view totally extraperitoneal repair in a patient with incisional hernia after robot-assisted laparoscopic radical prostatectomy: a case report.

BACKGROUND: Although laparoscopic incisional hernia repair, especially laparoscopic intraperitoneal onlay mesh, is a widely used technique, it can cause serious complications, including mesh erosion, adhesive bowel obstruction, and chronic pain. The enhanced-view totally extraperitoneal (eTEP) technique has been reported to prevent such complications by placing the mesh in the retrorectus space. Here, we report the case of a patient with post-robot-assisted laparoscopic radical prostatectomy (RARP) incisional hernia repaired using the eTEP technique. CASE PRESENTATION: A 67-year-old man, who underwent RARP for prostate cancer 4 years ago developed an incisional hernia. Abdominal computed tomography showed the presence of an epigastric incisional hernia measuring 4 cm long and 3.7 cm wide. We performed an eTEP repair. We closed the hernia defect using a 0 barbed suture and placed a self-gripping mesh measuring 20 cm long and 15 cm wide in the developed retrorectus space with no fixation. There were no postoperative complications, and the patient was discharged on postoperative day 2. CONCLUSIONS: eTEP repair is considered an extremely effective surgical treatment option for incisional hernias because of its few resulting postoperative mesh-and-tacker-related complications.

Urgent intraoperative endovascular stent placement to resolve acute hepatic or portal venous obstruction during liver surgery: a case series.

BACKGROUND: Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. CASE PRESENTATION: We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). CONCLUSIONS: The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

[Advanced gastric cancer in an elderly woman showing histopathologic CR after a course of S-1 and CDDP combination therapy].

An 80-year-old woman was diagnosed with advanced gastric cancer of T2N0H0P0M0, Stage IB. She was strongly advised to undergo surgery, but refused this option. Because the performance status (PS)was 1, combination chemotherapy with S1 100 mg/day (day 1-21) and CDDP 50 mg/m2 (day 8) was initiated. After one course of treatment was completed, she changed her mind and expressed the wish to undergo an operation for her disease, which led to proximal gastrectomy (double tract reconstruction) being performed. A histopathological examination revealed CR of the disease with no cancer cells. As the population grows older, the number of elderly patients with advanced gastric cancer will increase in the future. Therefore, S-1 and CDDP combination therapy may be a treatment of choice for gastric cancer with dose reduction according to patient status, if the elderly patient refuses a curative operation. It may well prove to be an effective treatment in the elderly provided the dosage and administration are appropriate.

[A case of high CEA colon cancer responding to neoadjuvant chemotherapy with FOLFIRI].

We report a case of high CEA advanced colon cancer, which we were able to down stage after treatment with FOLFIRI-1. The patient was a 56-year-old woman who had advanced sigmoid colon cancer with high CEA. It was suspected that the tumor had directly invaded the ovary by CT scan. For curative operation, hysterectomy was considered necessary. Neoadjuvant therapy was performed to avoid an extensive operation. After the fourth course, according to colonoscopy and CT findings, a significant tumor reduction was obtained. Sigmoid colorectomy with D3 nodal dissection was then performed. The histological diagnosis was pT1, pN0, PStage I. The histological effect was observed in lymph node metastasis. The patient was recurrence free at her 3-year follow-up examination.

Comparison of ultrasound colored image views produced by application of statistical analysis of radio-frequency signals and histological findings in patients with chronic hepatitis C.

PURPOSE: To assess the tissue characteristics of chronic liver disease, we statistically analyzed the speckle signal from liver parenchyma. SUBJECTS AND METHODS: Analysis was performed for 65 patients with biopsy-proven chronic hepatitis C; individuals with fatty liver, heavy drinkers, and those with a thick abdominal wall were excluded. The probability density function of radio-frequency signal amplitude was statistically analyzed using a new analytical method. We focused on strong signals which deviated remarkably from the Rayleigh distribution. By applying the analytical results, lesions that caused the strong signals were displayed as red scatter overlaid on B-mode images (we called the red scatter "US-Red" in this study). US-Red% occupancy on the color image was statistically compared with pathological findings. RESULTS: US-Red suggests the existence of an acoustic reflectional plane mainly formed of fibrous bridge and septa. US-Red% increased significantly with progression of liver fibrosis stage. US-Red% varied widely in cirrhosis, and US-Red% in the large nodule group was significantly higher than that in the small nodule group. CONCLUSION: The results suggest that US-Red% is useful for evaluating liver fibrosis stage (F1-3) and the size of nodules in cirrhosis. In addition, visually detecting the acoustic reflectional plane, which increases with progression of disease, as color images will be clinically beneficial.

[Successful resection of an advanced gastrointestinal stromal tumor by neoadjuvant chemotherapy with imatinib- a case report].

We report a case of a large gastric gastrointestinal stromal tumor (GIST), which we were able to curatively resect after treatment with a daily dosage of 400 mg imatinib for 3 months. The patient was a 46-year-old man whose chief complaint was anemia. Historical diagnosis by endoscopic biopsy was a c-kit-positive GIST of the stomach. From a CT scan, it was suspected that the tumor had directly invaded the pancreas. The tumor was 9 cm in size. For this case, total gastrectomy with distal pancreato splenectomy was necessary for curative resection. Imatinib mesilate was administered as neoadjuvant therapy according to the NCCN guidelines. After 3 months of treatment, CT revealed a dramatic reduction in tumor diameter of 61% and showed direct invasion of the pancreas. The radical operation was considered feasible and a partial gastrectomy was performed. The tumor did not invade other organs, and radical surgery was possible without rupture. The patient was recurrence free at his 12-month follow-up examination.

Association of advanced glycation end products, evaluated by skin autofluorescence, with lifestyle habits in a general Japanese population.

Objective Accumulation of advanced glycation end products (AGEs) occurs during normal aging but markedly accelerates in people with diabetes. AGEs may play a role in various age-related disorders. Several studies have demonstrated that skin autofluorescence (SAF) reflects accumulated tissue levels of AGEs. However, very few studies have investigated SAF in the general population. The purpose of the present study was to more thoroughly evaluate the potential association among SAF, chronological age, and lifestyle habits in the general population. Methods A large cross-sectional survey of 10,946 Japanese volunteers aged 20 to 79 years was conducted. Volunteers completed a self-administered questionnaire and underwent SAF measurement on their dominant forearms. The associations of SAF with age and lifestyle habits were analyzed using a multiple stepwise regression analysis. Results Age was independently correlated with SAF. Lifestyle habits such as physical activity, nonsmoking, adequate sleep, low mental stress level, eating breakfast, and abstaining from sugary food were each independently associated with lower SAF. Conclusions SAF was associated with age and healthy lifestyle habits in this general Japanese population. The present study suggests that SAF measurement is a convenient tool for evaluating habitual lifestyle behaviors and may have potential for preventative health education.

Intermittent intense exercise protects against cognitive decline in a similar manner to moderate exercise in chronically stressed mice.

It is well known that regular low or mild exercise helps to improve and maintain cognition. On the other hand, ever thought many people prefer high-intensity exercise (e.g., running, swimming, biking, soccer, basketball, etc.) to get rid of stress or improve their health, the previous studies reported that intense exercise either impairs cognition or has no effect on cognitive function. However, we previously showed that intermittent intense exercise prevents stress-induced depressive behavior in mice in a similar manner to moderate exercise. On the basis of this finding, we investigated the effect of intermittent intense exercise on cognitive deficit in chronically stressed mice. A total of forty mice were evenly divided into control, stressed, stressed with moderate exercise, and stressed with intense exercise groups. The stressed mice were chronically exposed a restraint stress (10 h/day, 6 days/week for 7 weeks). The exercised mice were subjected to intermittent intense or endurance moderate running on the treadmill three times a week. Cognition was evaluated using the Morris water maze test and the object recognition test. Chronic stress decreased cognition, and newborn cell survival and blood vessel density in the hippocampus. However, both regular intense and moderate exercise prevented decrease of cognition, improved newborn cell survival and blood vessel density. These findings suggest that intermittent intense exercise may protect against decrease of cognition in a similar manner to moderate exercise and that both exercise-induced protection of decrease of cognition is closely related to newborn cell survival and angiogenesis in the hippocampus.