Gender equity in surgical instruments: ergonomics of ring-handled forceps.

INTRODUCTION: Female surgeons have ergonomic issues with commercialized instruments tailored for male surgeons. The purpose of this study was to identify satisfaction levels and ergonomic problems of female surgeons while using laparoscopic forceps with ring-handles and suggest improvement measures. MATERIAL AND METHODS: A questionnaire was sent to 19,405 members of the Japanese Society of Gastroenterological Surgery via email between 1 August 2022 and 30 September 2022. It included demographic information and specific questions regarding the use of laparoscopic forceps with ring- handles (ergonomic evaluation, influence of the negative aspects of laparoscopic forceps during surgery, physical discomfort in the hands and fingers, degree of satisfaction, and handle size). RESULTS: Valid responses were received from 1,030 respondents (131 female and 899 male surgeons). The ergonomics of the laparoscopic forceps with ring-handles were rated lower by female surgeons in all ten categories (all p value < 0.05). They also reported a negative impact on surgical manipulation and discomfort to their hands and fingers. CONCLUSIONS: Female surgeons had a wide variety of ergonomic problems when using laparoscopic forceps with ring-handles, and showed lower levels of satisfaction. Developing a different model tailored to female surgeons with smaller hands and a weaker grip could be a viable solution.

Comparison of short term surgical outcomes of male and female gastrointestinal surgeons in Japan: retrospective cohort study.

OBJECTIVE: To compare short term surgical outcomes between male and female gastrointestinal surgeons in Japan. DESIGN: Retrospective cohort study. SETTING: Data from the Japanese National Clinical Database (includes data on >95% of surgeries performed in Japan) (2013-17) and the Japanese Society of Gastroenterological Surgery. PARTICIPANTS: Male and female surgeons who performed distal gastrectomy, total gastrectomy, and low anterior resection. MAIN OUTCOME MEASURES: Surgical mortality, surgical mortality combined with postoperative complications, pancreatic fistula (distal gastrectomy/total gastrectomy only), and anastomotic leakage (low anterior resection only). The association of surgeons' gender with surgery related mortality and surgical complications was examined using multivariable logistic regression models adjusted for patient, surgeon, and hospital characteristics. RESULTS: A total of 149 193 distal gastrectomy surgeries (male surgeons: 140 971 (94.5%); female surgeons: 8222 (5.5%)); 63 417 gastrectomy surgeries (male surgeons: 59 915 (94.5%); female surgeons: 3502 (5.5%)); and 81 593 low anterior resection procedures (male surgeons: 77 864 (95.4%);female surgeons: 3729 (4.6%)) were done. On average, female surgeons had fewer post-registration years, operated on patients at higher risk, and did fewer laparoscopic surgeries than male surgeons. No significant difference was found between male and female surgeons in the adjusted risk for surgical mortality (adjusted odds ratio 0.98 (95% confidence interval 0.74 to 1.29) for distal gastrectomy; 0.83 (0.57 to 1.19) for total gastrectomy; 0.56 (0.30 to 1.05) for low anterior resection), surgical mortality combined with Clavien-Dindo grade ≥3 complications (adjusted odds ratio 1.03 (0.93 to 1.14) for distal gastrectomy; 0.92 (0.81 to 1.05) for total gastrectomy; 1.02 (0.91 to 1.15) for low anterior resection), pancreatic fistula (adjusted odds ratio 1.16 (0.97 to 1.38) for distal gastrectomy; 1.02 (0.84 to 1.23) for total gastrectomy), and anastomotic leakage (adjusted odds ratio 1.04 (0.92 to 1.18) for low anterior resection). CONCLUSION: This study found no significant adjusted risk difference in the outcomes of surgeries performed by male versus female gastrointestinal surgeons. Despite disadvantages, female surgeons take on patients at high risk. Greater access to surgical training for female physicians is warranted in Japan.

Surgical Experience Disparity Between Male and Female Surgeons in Japan.

Importance: Women are vastly underrepresented in surgical leadership and management in Japan. The lack of equal opportunities for surgical training is speculated to be the main reason for this disparity; however, this hypothesis has not been investigated thus far. Objective: To examine gender disparity in the number of surgical experiences among Japanese surgeons. Design, Setting, and Participants: This retrospective, multicenter cross-sectional study used data from the National Clinical Database, which contains more than 95% of all surgical procedures in Japan. Participants included male and female gastroenterological surgeons who performed appendectomy, cholecystectomy, right hemicolectomy, distal gastrectomy, low anterior resection, and pancreaticoduodenectomy between January 1, 2013, and December 31, 2017. Exposures: Differences in the number of surgical experiences between male and female surgeons. Main Outcomes and Measures: The primary outcomes were the total number of operations and number of operations per surgeon by gender and years of experience. Data were analyzed from March 18 to August 31, 2021. Results: Of 1 147 068 total operations, 83 354 (7.27%) were performed by female surgeons and 1 063 714 (92.73%) by male surgeons. Among the 6 operative procedures, the percentage of operations performed by female surgeons were the highest for appendectomy (n = 20 648 [9.83%]) and cholecystectomy (n = 41 271 [7.89%]) and lowest for low anterior resection (n = 4507 [4.57%]) and pancreaticoduodenectomy (n = 1329 [2.64%]). Regarding the number of operations per surgeon, female surgeons had fewer surgical experiences for all 6 types of operations in all years after registration, except for appendectomy and cholecystectomy in the first 2 years after medical registration. The largest gender disparity for each surgical procedure was 3.17 times more procedures for male vs female surgeons for appendectomy (at 15 years after medical registration), 4.93 times for cholecystectomy (at 30-39 years), 3.65 times for right hemicolectomy (at 30-39 years), 3.02 times for distal gastrectomy (at 27-29 years), 6.75 times for low anterior resection (at 27-29 years), and 22.2 times for pancreaticoduodenectomy (at 30-39 years). Conclusions and Relevance: This cross-sectional study found that female surgeons had less surgical experience than male surgeons in Japan, and this gap tended to widen with an increase in years of experience, especially for medium- and high-difficulty operations. Gender disparity in surgical experience needs to be eliminated, so that female surgeons can advance to leadership positions.

A case of strongly suspected Lynch syndrome with colorectal neuroendocrine carcinoma.

BACKGROUND: Neuroendocrine cell carcinomas (NEC) of the colon and rectum are uncommon, representing ~ 0.1% of all colorectal carcinomas. They are associated with a much worse prognosis compared to adenocarcinoma of the colon and rectum, as death occurs in approximately half of all patients within 1 year. Lynch syndrome (LS) is the most common cause of inherited colorectal cancer, accounting for 2-4% of newly diagnosed colorectal cancer cases. This case is extremely rare which was strongly suspected LS as the background, and NEC as the histological type of colorectal cancer. CASE PRESENTATION: The patient was a 44-year-old man presenting with vomiting as the main complaint. He had undergone ileocecal resection for cecal cancer at age 29. The diagnosis was obstructive descending colorectal cancer, and colonoscopy revealed tumors in the rectum and sigmoid colon in addition. Due to multiple occurrences of colorectal cancer and its prevalence in the patient's family, LS was suspected. The operation which was a subtotal proctocolectomy was performed. Pathological analysis revealed complete curative resection and the descending colon cancer of the obstructed portion was at the most advanced pathological Stage IIIC in UICC TNM classification, and the tissue type was a NEC. The Ki-67 index was 70%. The results of the microsatellite instability (MSI) test showed high-frequency MSI. The BRAF V600E variant was negative. The immunoexpression of MLH1 was positive, MSH2 was negative, PMS2 was positive, and MSH6 was negative. CONCLUSIONS: Extended surgery is recommended for incipient colorectal cancer in LS cases in order to reliably reduce the risk of developing metachronous colorectal cancer. The survival outcome of surgery alone on digestive tract NECs, even locoregional lesions that are completely resection, is extremely poor. It is currently unclear if digestive tract NECs develop more readily in patients with LS. The accumulation of additional cases is necessary.

A "diversity and inclusion" lecture for promoting self-awareness among medical students.

PURPOSE: The concept of 'diversity and inclusion' is being adopted worldwide, but it is not yet understood well in Japan. We conducted this study to evaluate the impact of a lecture aimed at increasing awareness of academic careers and the benefits of having diversity and inclusion. METHODS: Two female surgeons delivered a 120-min lecture on "diversity and inclusion" to third-year medical students at Tokushima University. To assess the impact of the lecture, a questionnaire was distributed, for participants to complete anonymously before and after the lecture. RESULTS: Eighty-two students participated in the study (39 men, 38 women, and 5 unknown). Based on the questionnaire responses, 57.1% of the students had already perceived inequality in conduct because of gender. A comparison of pre- and post-lecture responses revealed a significant increase in confidence to succeed in their medical career (56.5% vs. 77.5%, p < 0.01). Learners were more likely to believe that gender would not become a barrier to career development (42.4% vs. 66.7%, p < 0.01). Moreover, 90.4% of the students felt positively about a career in surgery following the lecture. CONCLUSION: The lecture promoted awareness about diversity, self-awareness, and career development and motivated students to consider specializing in surgery later in their career.

Laparoscopic instrument for female surgeons: an innovative model for endoscopic purse-string suture.

Commercially available laparoscopic instruments are not designed for female surgeons. We redesigned the endoscopic flexible head purse-string suture instrument for improved use by female surgeons. The weight, total length, and diameter of the swing head handle and clump handle were reduced (786 to 565 g, 715 to 700 mm, 70 to 50 mm, and 30 to 25 mm, respectively). Stroke of the slide for firing and release of the lever was reduced from 92 to 83 mm. This is the first step toward an ergonomic surgical device that considers physical differences related to sex.

Effects of DPP-4 Inhibitors on Blood Glucose Variability in Japanese Patients with Type 2 Diabetes on Maintenance Hemodialysis: A Prospective Observational Exploratory Study.

INTRODUCTION: The precise blood glucose (BG) profile of hemodialysis patients is unclear, as is the effectiveness of dipeptidyl peptidase-4 (DPP-4) inhibitors in hemodialysis patients with type 2 diabetes. Here, we used continuous glucose monitoring (CGM) to evaluate BG variability in these patients and to assess the efficacy of DPP-4 inhibitors, particularly during hemodialysis sessions and at nighttime (UMIN000012638). METHODS: We examined BG profiles using CGM in 31 maintenance hemodialysis patients with type 2 diabetes. Differences between patients with and without DPP-4 inhibitors (n = 15 and 16, respectively) were analyzed using a linear mixed-effects model to assess changes in glucose levels in 5-min intervals. RESULTS: The model revealed that DPP-4 inhibitor use was significantly associated with suppression of a rapid drop in glucose levels, both with and without adjustment for BG levels at the start of hemodialysis. Moreover, the model revealed that the two groups differed significantly in the pattern of changes in BG levels from 0:00 to 6:55 am. DPP-4 inhibitors suppressed the tendency for subsequent nocturnal hypoglycemia. CONCLUSIONS: This prospective observational exploratory study showed that DPP-4 inhibitors could suppress BG variability during hemodialysis sessions as well as subsequent nocturnal changes in patients with type 2 diabetes. TRIAL REGISTRATION: ClinicalTrials.gov identifier, UMIN000012638.

Can rectal washout reduce anastomotic recurrence after anterior resection for rectal cancer? A review of the literature.

Local recurrence rates of rectal cancer after anterior resection remain high, despite the continued efforts of surgeons to devise preventive measures. Anastomotic recurrence, a form of local recurrence, may be caused by the implantation of exfoliated cancer cells during resection, and rectal stump washout has been proposed as a way to reduce the risk of this occurring. In this review article, we explore the mechanism of anastomotic recurrence after low anterior resection for rectal cancer, and examine the history and effectiveness of rectal washout on reducing recurrence rates, with a focus on washout solutions, procedures, and devices. Despite the lack of evidence from randomized trials, rectal washout with normal saline or diluted iodine is performed almost routinely during low anterior resection. Clamping is usually done using cross-clamps, linear staplers, tourniquets, and other devices. Although viable cancer cells may be shed into the rectal lumen during surgical resection, their impact on anastomotic recurrence remains uncertain. However, washout poses little or no harm to patients, and appears acceptable as a routine procedure. Randomized controlled trials or large observational studies may help to clarify the best practices for rectal washout.

Transanal total mesorectal excision of giant villous tumor of the lower rectum with McKittrick-Wheelock syndrome: a case report of a novel surgical approach.

BACKGROUND: McKittrick-Wheelock syndrome (MKWS) is caused by a villous tumor of the rectosigmoid colon with hypersecretion of mucus containing electrolytes. Complete resection of the tumor is needed to cure this disease. Transanal total mesorectal excision (TaTME) is currently a promising treatment for lower rectal tumor because of the reliability of its resection margin especially in bulky tumor. We present this first case report of a TaTME for MKWS with a lower rectal tumor. CASE PRESENTATION: An 81-year-old woman was admitted to our hospital with diarrhea and acute renal failure. Computed tomography and magnetic resonance imaging examinations revealed an 80-mm-sized enhanced tumor located in her lower rectum without lymph node swelling and distant metastasis. A giant villous tumor secreting mucus was seen in the lower rectum to the anal canal during colonoscopy. The result of tumor biopsy was adenocarcinoma. To preserve the anal function and ensure distal margin, we chose TaTME for curative resection. After improving the electrolyte imbalance, TaTME was performed successfully and R0 resection was achieved. There was no sign of recurrence or electrolyte depletion for 1 year after the surgery. CONCLUSION: TaTME could be a promising surgical approach for giant villous tumor with MKWS in the lower rectum.

[A Case of Interstitial Pneumonitis Induced by TAS-102 for Liver and Lung Metastasis of Colorectal Cancer].

A 78-year-old man who developed metastatic liver and lung cancer after undergoing surgery for rectal and sigmoid colon cancer was treated with TAS-102 as fourth-line chemotherapy. He developed high fever and dyspnea and was referred to the emergency room 16 days after receiving the first course of TAS-102. Chest X-ray and computed tomography examinations showed bacterial pneumonia. He was treated with tazobactam/piperacillin, but developed severe dyspnea 4 days later. A diffuse ground-glass appearance was observed in both the lungs on chest X-ray examination, and drug-induced interstitial pneumonitis was suspected. Oxygenation and respiratory support were immediately administered, and steroid pulse therapy with methylprednisolone at 1,000mg/day was initiated. His symptoms and radiographic findings dramatically improved. The TAS102-J003 trial, a double-blind phase 2 trial, showed that interstitial pneumonitis occurs at a rate of only 0.9%, but can lead to severe complications, as observed in the present case. The possibility of interstitial pneumonitis should always be considered when a patient develops a fever and respiratory disorder during treatment containing TAS-102.

[Pathological Complete Response in a Case of Advanced Esophageal Cancer with Widespread Lymph Node Metastases Treated Using Preoperative Chemotherapy with Docetaxel, Cisplatin, and 5-FU(DCF therapy)].

The patient was a 66-year-old woman, who was diagnosed with cT3N3M0, cStage III esophageal cancer with widespread lymph node metastases in the mediastinum and abdomen. She was treated with 2 courses of chemotherapy with docetaxel/ cisplatin/5-FU(DCF therapy). CT and FDG PET-CT showed a significant reduction in both the primary tumor and the metastatic lymph nodes following treatment. We performed subtotal esophagectomy and gastric tube reconstruction with lymphadenectomy. The histopathological findings showed no residual viable tumor cells or foreign body-type giant cells with necrosis. The pathological effect of chemotherapy was defined as Grade 3(pCR). Our case suggested that DCF chemotherapy is potentially a very effective treatment for advanced esophageal cancer with widespread lymph node metastases.

[Surgical Resection for Advanced Gastric Cancer with Portal Vein Tumor Embolus - Two Cases].

Gastric cancer with portal tumor embolus is rare and there is no definite strategy for its surgical resection. We report 2 cases ofgastric cancer with portal vein tumor embolus treated using gastrectomy and thrombectomy. Case 1: The patient was a 56- year-old man. We performed total gastrectomy, distal pancreatectomy, splenectomy, and thrombectomy. The patient was treated with 4 courses ofS -1 plus CDDP chemotherapy followed by S-1 administration. Eight months after surgery, CT revealed metastasis in the left adrenal gland and he died 2 years after surgery. Case 2: The patient was a 57-year-old man. We performed total gastrectomy, distal pancreatectomy, splenectomy, partial resection of the transverse colon, and thrombectomy. The patient was treated using adjuvant S-1 chemotherapy followed by UFT administration for 3 years. The patient has been alive with no tumor recurrence for the past 10 years. If there is no other therapeutic option for portal vein embolus, gastrectomy with thrombectomy could increase the possibility oflong -term survival.

Extracapillary proliferation and arteriolar hyalinosis are associated with long-term kidney survival in IgA nephropathy.

BACKGROUND: The Oxford classification of IgA nephropathy consists of four markers as prognosticators. We retrospectively examined the relevance of extracapillary proliferation involving cellular and fibrocellular crescents (Ex) and arteriolar hyalinosis (A) on the long-term outcome of renal function. METHODS: A total of 314 Japanese patients who were diagnosed with IgA nephropathy, with 12 months or more of follow-up period were included in this study. A total of 186 patients were with UP ≥ 0.5 g/day. Patients with diabetes mellitus or severe kidney injury (eGFR < 30 ml/min/1.73 m(2)) were excluded. The presence of Ex and A were scored 0 in the absence, and 1 in the presence, of each lesion. The end point was determined as a 50 % reduction in initial eGFR or end-stage renal disease defined as eGFR < 15 ml/min/1.73 m(2). RESULTS: In univariate analyses, the kidney survival rate was significantly lower in patients with Ex1 and A1 if UP ≥ 0.5 g/day. In the patients with UP < 0.5/day, none of the clinical and pathological parameters was determined as a risk factor. In the multivariate model including pathological parameters, Ex1 and A1 were independent risk factors for renal outcome if UP ≥ 0.5 g/day. In those patients treated with RAS-blocker or treated before introduction of methylprednisolone pulse therapy, Ex was the only independent risk factor. In multivariate analysis including clinical parameters, eGFR alone was a risk factor, due to strong correlation with other parameters. CONCLUSION: Ex and A would be associated with the renal outcome of the patients with UP ≥ 0.5 g/day.

Multicenter Phase II study of FOLFOX or biweekly XELOX and Erbitux (cetuximab) as first-line therapy in patients with wild-type KRAS/BRAF metastatic colorectal cancer: The FLEET study.

BACKGROUND: The clinical benefit of cetuximab combined with oxaliplatin-based chemotherapy remains under debate. The aim of the present multicenter open-label Phase II study was to explore the efficacy and safety of biweekly administration of cetuximab and mFOLFOX-6 or XELOX as first-line chemotherapy in patients with metastatic colorectal cancer. METHODS: Sixty-two patients with previously untreated KRAS/BRAF wild-type metastatic colorectal cancer were recruited to the study between April 2010 and May 2011. Patients received one of two treatment regimens, either cetuximab plus mFOLFOX-6 (FOLFOX + Cmab) or cetuximab plus biweekly XELOX (XELOX + Cmab), according to their own preference. Treatment was continued until disease progression or the appearance of intolerable toxicities. The primary endpoint was response rate; secondary endpoints were progression-free survival, overall survival, disease control rate, dose intensity, conversion rate to surgical resection, and safety. RESULTS: The response rates in the FOLFOX + Cmab (n = 37) and XELOX + Cmab (n = 25) groups were 64.9 % (24/37) and 72.0 % (18/25), respectively. The median PFS in the FOLFOX + Cmab and XELOX + Cmab groups was 13.1 months (95 % confidence interval [CI] 12.1-17.5) and 13.4 months (95 % CI 10.1-17.9), respectively. Neutropenia was the most frequent grade 3/4 adverse event in both groups (33.9 %), followed by anorexia, acneiform eruption, skin fissure and paronychia. A waterfall plot of tumor diameter showed prominent shrinkage of the tumors in 88.7 % of patients. CONCLUSIONS: The results of the present study indicate that biweekly cetuximab plus mFOLFOX-6/XELOX is an effective and tolerable treatment regimen. Biweekly administration of cetuximab requires only one hospital visit every 2 weeks, and may become a convenient treatment option for patients with KRAS/BRAF wild-type metastatic colorectal cancer. TRIAL REGISTRATION: This study is registered with University Hospital Medical Information Network (UMIN 000003253 ). Registration date is 02/24/2010.

Predicting prolonged hospital stay after laparoscopic cholecystectomy.

INTRODUCTION: Widespread application of laparoscopic cholecystectomy (LC) has resulted in a high complication rate and leads to prolonged hospital stays. This study aimed to investigate the preoperative and intraoperative clinical factors that relate to prolongation of hospital stay. METHODS: We studied 370 patients who underwent LC for gallbladder disease between 2008 and 2012. Clinical risk factors were retrospectively collected. The clinical pathway for LC was indicated for all patients, and they were divided into two groups according to postoperative length of stay (LOS): the normal duration group (LOS ≤5 days) and the long duration (LD) group (LOS ≥6 days). Multiple regression analysis was used to predict risk factors that identified hospital prolongation to create a LOS prediction score. RESULTS: The normal duration group was 236 patients and the LD group was 134. Seventeen patients (4.6%) required conversion from laparoscopic to open surgery. LOS was 4.82 days in the normal duration group and 12.08 days in the LD group. In the LD group, 18.7% of the patients stayed more than 14 days, but no patients were readmitted. Thirteen clinical factors were statistically different between the two groups. ASA score and LC difficulty were the most predictive risk factors for LOS prolongation. LOS prediction score consisted of eight variables selected from 13 factors; it helped determine the likelihood of whether a patients' hospital stay was prolonged (sensitivity, 82.1%; specificity, 75.0%). CONCLUSION: Thirteen factors closely related to hospital stay duration and LOS prediction score could predict the prolongation of a patient's hospital stay.

Ergonomic evaluation of a mechanical anastomotic stapler used by Japanese surgeons.

PURPOSE: The satisfaction rating of currently available mechanical staplers for Japanese surgeons with small hands is low. To identify the issue, we examined the relationship of hand dimensions and grip force with the operation force of a mechanical circular stapler. METHODS: Hand dimensions and grip force were measured in 113 Japanese surgeons (52 men and 61 women). We then evaluated the relationship between grip width and the operation force required to push the lever of the stapler, at three points on the lever, using a digital force gauge. RESULTS: The optimal grip width of the dominant hand was 62.5 ± 8.5 mm for men and 55.5 ± 5.9 mm for women (p < 0.001). The maximum grip force of the dominant hand was 44.2 ± 6.1 kg for men and 29.7 ± 4.5 kg for women (p < 0.001) and the maximum operation force required to push the lever 7.0, 45.0, and 73.0 mm from the end of the lever was 21.8, 28.6, and 42.4 kg, respectively. CONCLUSIONS: To our knowledge, this is the first ergonomic study of a surgical stapler to be conducted in Asia. Firing the stapler by gripping the proximal side of the lever is physically impossible for most Japanese women surgeons since the required operation force exceeds the maximum grip force, which probably accounts for the stress perceived by these women.