Laparoscopic repair of an incarcerated inguinal hernia containing the sigmoid colon with a colonoscope.

Here, we report the first case of laparoscopic surgery to repair an incarcerated colonoscope in an inguinal hernia containing the sigmoid colon. After colonoscopy was performed on a 74-year-old man with positive fecal occult blood test results, the colonoscope could not be withdrawn. A bulge consistent with an incarcerated colonoscope was found on examination of the patient's left inguinal area. Computed tomography revealed and led to the diagnosis of an incarcerated colonoscope in the sigmoid colon within the inguinal hernia. After confirmation during emergency laparoscopic surgery, the incarcerated sigmoid colon was reduced, and the colonoscope was removed under radiographic and laparoscopic guidance. No ischemic changes or serosal injuries were observed, averting the need for resection. A transabdominal preperitoneal approach with a mesh was then used to repair the inguinal hernia laparoscopically. The patient's postoperative recovery was uneventful, and no recurrence was observed at the 1-year follow-up.

Tissue-Engineered Hepatocyte Sheets Supplemented with Adipose-Derived Stem Cells.

The ability to engineer biologically viable hepatocytes and tissue matrices with long-term functional maintenance has attracted considerable interest in the fields of hepatocyte transplantation and liver tissue engineering. Here, newly developed hepatocyte sheets supplemented with adipose-derived stem cells (ADSCs) were evaluated to assess the effects of ADSCs on hepatocyte function and engraftment into the subcutaneous space. Eight-week-old male C57BL/6J mice were used as donors, and 6-week-old male C.B-17/Icr-scid/scid mice were used as recipients. Hepatocyte-ADSC composite sheets were developed using temperature-responsive culture dishes. Hepatocyte viability in the hepatocyte-ADSC composite sheets was evaluated in an in vitro assay, and the outcome of subcutaneous transplantation of the sheet was evaluated. Hepatocyte viability was sustained in the hepatocyte-ADSC composite sheets in vitro. Albumin secretion was significantly higher (p = 0.015) in the hepatocytes of the hepatocyte-ADSC composite sheets (70.5 µg/mL) than in hepatocyte-only sheets (24.0 µg/mL). Cytokine assays showed that hepatocyte growth factor and interleukin-6 were contributed by ADSCs and not hepatocytes, which were not capable of constitutively secreting them. Immunohistochemically, phosphorylated STAT3 and c-MET expression in hepatocytes in the hepatocyte-ADSC composite sheets was significantly higher than that in the hepatocyte-only sheets. Engraftment of the transplanted hepatocyte-ADSC composite sheets was significantly enhanced without pretreatment of the subcutaneous tissue to induce a vascular network. In the hepatocyte-ADSC composite sheets, the viability of the hepatocytes was significantly maintained as the co-cultured ADSCs provided cytokines, enhancing pivotal cell signaling necessary for hepatocyte activity. Impact statement Hepatocyte transplantation is a safe, less invasive bridge treatment for liver transplantation, but its effectiveness is low and transitory. Herein, we introduce newly developed hepatocyte-adipose-derived stem cell composite sheets with improved strength, easier transplantation, and increased hepatocyte viability in the subcutaneous transplantation compared with hepatocyte-only sheets.

[The Evaluation of Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer].

We evaluated the efficacy of neoadjuvant chemotherapy(NAC)for 38 patients with locally advanced rectal cancer (LARC). We administered mFOLFOX6 in 15, FOLFIRI in 3, CAPOX in 10, IRIS in 1 and FOLFOXIRI in 9 patients. We also used bevacizumab in 31 and panitumumab in 7 patients. There were 27 male and 11 female patients, with a median age of 64 years, and location was RS 2, Ra 9, Rb 21, and P 6. Synchronous distant metastasis was recognized in 13 patients. Nine patients had suffered adverse event of Grade 3, however all patients could complete NAC. Clinical response was CR 3, PR 31, SD 4, response rate was 91.9%, and reduction rate was 43.3(range 18.8-100)%. Clinical response of distant metastasis was CR 3, PR 9 and SD 1. Laparoscopic surgery was performed in 29 patients. Postoperative complications of Grade 2 of Clavien- Dindo classification were recognized in 14 and Grade 3 in 4 patients. Three- and five-year overall survival rate of 25 patients without distant metastasis were 79.6% and 74.9%, respectively; and 13 with distant metastasis were 61.6% and 52.6%, respectively. The efficacy, safety and postoperative outcomes of NAC for LARC are favorable, and we think that NAC will be one of the treatments for LARC.

Predicting Post-Hepatectomy Liver Failure Using Intra-Operative Measurement of Indocyanine Green Clearance in Anatomical Hepatectomy.

BACKGROUND: Prediction of post-hepatectomy liver failure (PHLF) based on remnant liver function reserve is important for successful hepatectomy. The aim of this study was to investigate whether intraoperative indocyanine green (ICG) clearance in a future remnant liver was a predictor of PHLF. METHODS: This prospective study enrolled 31 consecutive patients who underwent anatomical hepatectomy between June 2016 and August 2019. Intraoperative ICG plasma disappearance rate (ICG-PDR) and ICG retention rate at 15 min (ICG-R15) were measured after clamping the selective hepatic inflow to the liver to be resected. The discriminative performance of the ICG-associated variables for the prediction of PHLF grade B/C was evaluated by receiver operator curve (ROC) analysis. RESULTS: Of the operations performed, 87.1% were major hepatectomy. PHLF Grade B/C was observed in eight patients (25.8%) with no mortality. The concordance indices of intraoperative ICG-PDR and ICG-PDR for predicting PHLF were 0.834 (95% CI, 0.69-0.98) and 0.834 (95% CI, 0.69-0.98), respectively. A subgroup analysis of patients with preoperative biliary drainage (BD) (n = 17) showed that the concordance indices of intraoperative ICG-PDR increased to 0.923 (95% CI, 0.79-1.00). CONCLUSIONS: Intraoperative ICG clearance in the remnant liver was a promising predictor for PHLF in patients undergoing anatomical hepatectomy, especially in patients with BD.

[FOLFIRINOX for Locally Advanced and Recurrent Pancreatic Cancer with UGT1A1 *6 and or UGT1A1*28 Polymorphisms-A Report of Two Cases].

Treatment containing FOLFIRINOX was planned to be administered to a 51-year-old man with locally advanced pancreatic cancer as second-line chemotherapy and to a 66-year-old woman with recurrent pancreatic cancer as third-line chemotherapy in their treatments. Since both patients were revealed to harbor UGT1A1 polymorphisms, which were highly associated with irinotecan-induced toxicity(the former: UGT1A1 *6/*28, the latter: UGT1A1*6/*6), there was no alternative hopeful treatment other than FOLFIRINOX for them. Therefore, FOLFIRINOX was administered very carefully. Although both patients showed Grade 4 neutropenia during the initial course, it was controllable with G-CSF administration and following stepwise reduction of the irinotecan dose. Severe diarrhea and other adverse events were not observed in both cases. Since the determined regimen of FOLFIRINOX for patients with high-risk UGT1A1 polymorphisms has not been developed yet, it would be critical to accumulate and review an experience of FOLFIRINOX administration for these patients.

[A Case of Locally Advanced Breast Cancer Successfully Treated with Local Control That Achieved a Pathological Complete Response after Bevacizumab and Paclitaxel Combination Chemotherapy].

A 68-year-old woman with a 5-year history of an untreated left breast tumor presented to our hospital. She was admitted for untreated diabetes and severe anemia. The cause of the anemia was bleeding from the tumor, and she was referred to our department. She was diagnosed with T4bN0M0, stage IIIb breast cancer. First, we initiated hormonal therapy. However, the tumor did not decrease in size. We then administered chemotherapy. The tumor markedly decreased in size, and mastectomy and axillary lymph node dissection were performed. The response was a pathological complete response. She is currently undergoing hormonal therapy at the time of this writing.

[End-of-Life Home Care for a Young Patient].

We report the case of a young patient(under 40 years)with a malignant tumor; this is an age when a person is involved in social activity and is productive. A variety of activity largely has a negative influence on family at death of such a patient. After fighting this illness for a long time, home medical care was administered, and I experienced a case of a 31-year-old patient with malignant melanoma who was administered end-of-life home care. He had a diagnosis of right leg malignant melanoma approximately 5 years ago. Palliative medical care was decided, after aggressive treatment for approximately 5 years, including an operation, and home medical care was hoped, after this was introduced at our department of surgery. I performed pain control in this patient after hospitalization at approximately one week and the patient was shifted to home medical care. The patient could only swallow water, and oral medication could not be ingested because the patient was bedridden. The mother who was the main caregiver quit her work and devoted herself for care. I performed pain control mainly by administering oxycodone and a steroid and an anti-inflammatory, which were given intravenously along with the antianxiety drug. During home medical care, I focused on pain control, but the patient expressed gratitude for the main caregiver that was witnessed by the family. The patient died 26 days after the initiation of at-home care. Nursing care insurance is not available for young patients, and home help is limited. I quit work for the caregiver, and including contrivance of the future life, there is much limitation with the aspect of the income. A younger patient experiences temper, as well as physical pain, enough for mental and social pain is necessary.

[Assessment of our home care and home palliative care].

We conducted home care and home palliative care from the department of home care. We provided home care services to 190 patients(105 men, 85 women)in October 2013. Their average age was 78.7(range: 32-102)years old, and home care had been underway from 1 day to 8 years, 10 months. Among all participants, 168(88.4%)suffered from malignant diseases, 168 patients had died, and over half of deceased patients(88 out of 168)had died at home. We used opioids for control of cancer pain, carried out home parenteral nutrition(HPN), home enteral nutrition(HEN), percutaneous endoscopic gastrostomy( PEG), and removed pleural effusion and ascites during home care. In order to facilitate the practice of palliative care by the palliative care team, which consists of various medical staff in the hospital, we are giving high priority to education and enlightenment in the hospital. To provide enlightenment, education, and cooperation between regional home care and home palliative care, we are also conducting educational lectures in the regional party of the Iwaki city medical associate, and providing combined educational-medical training for home care and home palliative care by various medical staff.

Immunosuppression involving increased myeloid-derived suppressor cell levels, systemic inflammation and hypoalbuminemia are present in patients with anaplastic thyroid cancer.

Anaplastic thyroid carcinoma (ATC) is one of the most aggressive neoplasms in humans and myeloid-derived suppressor cells (MDSCs) contribute to the negative regulation of immune responses in the context of cancer and inflammation. In order to investigate the pathophysiology of thyroid cancer, peripheral blood mononuclear cells (PBMCs) were obtained from 49 patients with thyroid cancer, 18 patients with non-cancerous thyroid diseases and 22 healthy volunteers. The MDSC levels were found to be higher in patients with any type of thyroid cancer (P<0.05), patients with ATC (P<0.001) and patients with medullary thyroid carcinoma (P<0.05), when compared to patients with non-cancerous thyroid diseases. The MDSC levels were also higher in patients with stage III-IV thyroid cancer compared to those in patients with non-cancerous thyroid diseases (P<0.05). The stimulation index (SI) of phytohemagglutinin (PHA)-induced lymphocyte blastogenesis was significantly lower, the C-reactive protein (CRP) levels were significantly higher and the serum albumin levels were significantly lower in patients with ATC compared to those in patients with non-cancerous thyroid diseases. The SI was significantly lower in stage III and IV thyroid cancer compared to that in non-cancerous thyroid disease (P<0.05). Furthermore, the CRP levels were higher and the concentration of albumin was lower in stage IV thyroid cancer compared to those in non-cancerous thyroid disease (P<0.05). Patients with thyroid carcinoma were then classified into one of two groups according to a %PBMC of MDSC cut-off level of 1.578, which was the average %PBMC of MDSC of patients with any type of thyroid carcinoma. In patients with higher MDSC levels, the production of CRP and interleukin (IL)-10 was significantly higher (P<0.05) and the albumin levels were significantly lower (P<0.05) compared to those in patients with lower MDSC levels. These data indicate that MDSCs are increased in patients with ATC. Furthermore, these patients exhibited suppression of cell-mediated immune responses, chronic inflammation and nutritional impairment.