[A Case of Achieving CR through Chemoradiotherapy for Postoperative Oligo Lymph Node Metastasis in Gastric Cancer].

We present a case of oligo lymph node metastasis in a 70s man who had previously undergone subtotal gastrectomy for advanced gastric cancer in the prepylorus. Postoperatively, adjuvant chemotherapy was administered for a duration of 1 year. During the third postoperative year, elevated tumor markers and lymph node enlargement prompted a diagnosis of lymph node metastasis. Subsequent chemoradiotherapy resulted in a complete response(CR), which has been sustained for 2 years without any recurrence. The outcomes of this case indicate that chemoradiotherapy stands as a viable treatment option for oligo lymphatic recurrence in gastric cancer.

Effective vaccine allocation strategies, balancing economy with infection control against COVID-19 in Japan.

Due to COVID-19, many countries including Japan have implemented a suspension of economic activities for infection control. It has contributed to reduce the transmission of COVID-19 but caused severe economic losses. Today, several promising vaccines have been developed and are already being distributed in some countries. Therefore, we evaluated various vaccine and intensive countermeasure strategies with constraint of economic loss using SEIR model to obtain knowledge of how to balance economy with infection control in Japan. Our main results were that the vaccination strategy that prioritized younger generation was better in terms of deaths when a linear relationship between lockdown intensity and acceptable economic loss was assumed. On the other hand, when a non-linearity relationship was introduced, implying that the strong lockdown with small economic loss was possible, the old first strategies were best in the settings of small basic reproduction number. These results indicated a high potential of remote work when prioritizing vaccination for the old generation. When focusing on only the old first strategies as the Japanese government has decided to do, the strategy vaccinating the young next to the old was superior to the others when a non-linear relationship was assumed due to sufficient reduction of contact with small economic loss.

Single-incision retroperitoneal laparoscopic repair of superior lumbar hernia using self-fixating ProGrip mesh: A case report.

INTRODUCTION: Lumbar hernia is rare and represents less than 1-2% of all abdominal hernias. There are mainly two types of lumbar hernia: superior lumbar hernia and inferior lumbar hernia. CASE PRESENTATION: A 65-year-old woman was admitted complaining of a mass in her left lumbar area. Under a diagnosis of superior lumbar hernia, single-incision laparoscopic retroperitoneal repair was performed. A single, 2-cm-long incision was made and the retroperitoneal space was dissected gradually. The hernia orifice was recognized and hernia sac was slipped from the hernia orifice. The collateral branch of subcostal nerve and iliohypogastric nerve were recognized. Laparoscopic self-fixating mesh was placed to cover the hernia orifice without mesh fixation. The patient remained well with no signs of recurrence. DISCUSSION: In laparoscopic lumbar hernia repair, it is important to be careful not to damage subcostal nerve and iliohypogastric nerve. Self-fixating mesh without fixation is useful due to the prevention from nerve injury. To our best knowledge, this is the first report of single-incision laparoscopic repair for superior lumbar hernia. Single-incision laparoscopic surgery could provide good cosmetic results with minimal incision. CONCLUSION: We successfully performed single-incision retroperitoneal laparoscopic repair of superior lumbar hernia using self-fixating mesh.

Efficacy of Single-incision Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair for Overweight or Obese Patients.

AIM: To evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair in overweight or obese patients. MATERIALS AND METHODS: For outcome analyses, patients were subdivided by body mass index (BMI) as normal-weight (18.5≤BMI<25 kg/m), overweight (25≤BMI<30 kg/m) or obese (≥30 kg/m) and compared. RESULTS: In total, 201 patients were divided into a normal-weight group (n=152) and an overweight/obese group (n=49). Median operative time for unilateral hernia was 72 minutes in the normal-weight group and 95 minutes in the overweight/obese group (P<0.05). No significant differences in operative time for bilateral hernia, bleeding volume, peritoneal injury, conversion to a different procedure, postoperative hospital stay, follow-up duration, complications, or recurrence were identified. CONCLUSIONS: Single-incision laparoscopic surgery for totally extraperitoneal repair, which offers good cosmetic outcomes, seems feasible and safe for overweight or obese patients, although the operation takes longer.

Efficacy of single-incision laparoscopic totally extraperitoneal repair for irreducible or incarcerated inguinal hernia.

INTRODUCTION: The aim of this study was to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (SILS-TEP) of irreducible inguinal hernias and incarcerated inguinal hernias. METHODS: We performed a retrospective analysis of 194 patients, including 16 with irreducible or incarcerated hernia, who had undergone SILS-TEP from May 2016 to December 2017 at Kinki Central Hospital. The outcomes of patients with irreducible or incarcerated hernia and those with reducible hernia were compared. For irreducible or incarcerated hernia, laparoscopic exploration with hernia reduction through an intraumbilical incision was performed. If no bowel resection was needed, one-stage SILS-TEP was performed. If bowel resection was required, two-stage SILS-TEP was performed 2-3 months after the bowel resection. RESULTS: Of the 16 patients, 8 had an irreducible hernia, and 8 had an incarcerated hernia. The eight patients with an incarcerated hernia underwent emergency surgery, and among these patients, two needed single-incision laparoscopic partial resection of the ileum followed by two-stage SILS-TEP. Fourteen patients, excluding the two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by one-stage SILS-TEP. Among these 14 patients, one with an irreducible hernia required conversion to Kugel patch repair. The operative outcomes were generally comparable between the two groups. However, the operative time was longer for unilateral hernia, and more seromas were seen in the irreducible or incarcerated group. No other major complications or cases of hernia recurrence were noted in this study. CONCLUSIONS: SILS-TEP, which offers good cosmetic results, can be safely performed for irreducible or incarcerated inguinal hernia.

Learning curve for single-incision laparoscopic totally extraperitoneal inguinal hernia repair.

INTRODUCTION: The learning curve for totally extraperitoneal repair (TEP) is longer and steeper than that for transabdominal preperitoneal repair (TAPP) due to the preperitoneal view to which the surgeon is not accustomed and the limited working space. The aim of this study was to clarify the learning curve for SILS-TEP. METHODS: A retrospective analysis of 80 consecutive patients with unilateral inguinal hernia was performed. All patients underwent elective SILS-TEP performed by a single learning surgeon with a teaching assistant between July 2016 and March 2018 at Kinki Central Hospital. RESULTS: The operative time decreased gradually after 20 cases and stabilized after 40 cases. The first 40 cases were categorized as the learning period group, and the remaining 40 cases were categorized as the experienced period group. More patients received antithrombotic therapy in the experienced period than in the learning period (P < 0.05). The median operative time was 107 and 60 min in the learning period and the experienced period, respectively (P < 0.05). There were no significant differences in blood loss peritoneal injury, conversion to a different procedure, postoperative hospital stay, complications, and recurrence between the two groups. No major complications or hernia recurrence were noted during follow-up. CONCLUSIONS: The learning curve for SILS-TEP might take 40 cases to reduce the operative time. SILS-TEP can be performed safely by a learning surgeon with a teaching assistant.

[A Case of Disseminated Carcinomatosis of the Bone Marrow Developing 15 Months after Gastrectomy].

The patient was a 60-year-old man who underwent distal gastrectomy for gastric cancer. The pathological diagnosis was Stage ⅡB. He received adjuvant chemotherapy(capecitabine plus oxaliplatin: CapeOX)for 6months and the postoperative course was uneventful. One year and 3 months after surgery, he visited the outpatient department for acute lower back pain. Blood tests showed elevated ALP(3,752 U/L), LDH(308 U/L), and CA19-9(69.4 U/mL)levels. Bone scintigraphy showed multiple bone metastases to the femora, ischium, iliac bone, vertebrae, sternum, costae, and scapulae in a super bone scan. The onset of disseminated intravascular coagulation(DIC)was observed later. The patient was diagnosed with disseminated carcinomatosis of the bone marrow. Radiation therapy was performed and anti-RANKL monoclonal antibody was administered for the bone metastases. Recombinant human soluble thrombomodulin was administered for DIC. He received chemotherapy( TS-1 plus cisplatin: SP)but died 4 months after the diagnosis. The prognosis of disseminated carcinomatosis of the bone marrow is extremely poor. We report this case along with a literature review.

Single-incision laparoscopic preperitoneal mesh repair of supra-pubic incisional hernia: A case report.

INTRODUCTION: Repair of supra-pubic incisional hernia is still challenging because of the highest pressure at the lower abdominal wall in the erect position. Recently, laparoscopic preperitoneal mesh repair has been gradually reported. CASE PRESENTATION: A 77-year-old woman underwent single-incision laparoscopic preperitoneal mesh repair under a diagnosis of a supra-pubic incisional hernia, measuring 7 × 4 cm. A single, 2.5-cm, intraumbilical incision was made, followed by creation of the preperitoneal space. Then, the posterior rectus sheath and peritoneum were opened, and laparoscopic exploration was performed. After dissection of the supra-pubic hernia content, the tube for degassing the abdominal cavity was inserted into the abdominal cavity, and the peritoneum and the posterior sheath were closed. The preperitoneal space was dissected gradually, and circular dissection of the hernia sac was performed. The proximal sac (peritoneum) was sutured continuously. A 15 × 10 cm mesh was placed in the preperitoneal space and fixed securely with absorbable tacks at the pubic bone, Cooper's ligament, and the rectus abdominis muscle, respectively. After degassing the preperitoneal space, a second laparoscopic exploration was performed to confirm the secure suture of the peritoneum and no injury of the abdominal organs. At 4-month follow-up, the patient remained well with no signs of recurrence. DISCUSSION: Single-incision laparoscopic preperitoneal mesh repair could minimize the recurrence of supra-umbilical incisional hernia and perioperative complications. CONCLUSION: Single-incision laparoscopic preperitoneal mesh repair, offering good cosmetic results, might be useful for repair of supra-pubic incisional hernia.

Intraabdominal actinomycosis resulting in a difficult to diagnose intraperitoneal mass: A case report.

INTRODUCTION: Actinomycosis is a chronic suppurative granulomatous disease caused by Actinomyces israelii. Preoperative confirmed diagnosis is very difficult, so most cases are diagnosed preoperatively as malignant tumors. We report a case of intraabdominal actinomycosis which was difficult to diagnose preoperatively. PRESENTATION OF THE CASE: A woman, 60 years old, experienced discomfort in her lower right abdomen. She complained of nausea and anorexia and visited our hospital. Laboratory blood tests, abdominal CT, and abdominal MRI led to a diagnosis of a uterine sarcoma or primary intestinal mass, and she underwent surgery. Her histopathological diagnosis was intraabdominal actinomycosis. DISCUSSION: Actinomycosis is a chronic purulent granulomatous inflammation caused by Actinomyces israelii. No clinical symptoms or laboratory findings are characteristic of abdominal actinomycosis, so this disorder is very difficult to diagnose preoperatively. Therefore, many cases are diagnosed as malignant tumors and undergo surgery. After surgery, long-term antibiotic treatment (penicillin) is usually administered. CONCLUSIONS: We reported a case of intraabdominal actinomycosis that resulted in a difficult to diagnose intraperitoneal mass. When a large intraperitoneal mass is found, actinomycosis needs to be included as one of differential diagnoses.

Primary splenic malignant lymphoma mimicking metastasis of rectosigmoid cancer: A case report.

INTRODUCTION: Primary splenic malignant lymphoma is quite a rare disease, and its preoperative diagnosis is difficult. CASE PRESENTATION: An 80-year-old man was diagnosed with advanced rectosigmoid cancer with liver and splenic metastases, for which he underwent single-incision laparoscopic high anterior resection for the primary rectosigmoid cancer. After chemotherapy, he underwent laparoscopy-assisted splenectomy and open partial hepatectomy of segment 3 and segment 5/6 of the liver. The resected specimen of the spleen showed primary splenic malignant lymphoma. DISCUSSION: A diagnosis of primary splenic malignant lymphoma seems to be made only occasionally at splenectomy. Patients with primary splenic malignant lymphoma treated by curative resection at an early clinical stage have a more favorable prognosis. Laparoscopy-assisted splenectomy is useful for reducing surgical invasiveness. CONCLUSION: Primary splenic malignant lymphoma should be included among the differential diagnoses of splenic tumors in patients with colorectal cancer with multiple metastases. Curative resection might be a therapeutic option for the treatment of primary splenic malignant lymphoma. Laparoscopy-assisted splenectomy is a useful strategy for reducing surgical invasiveness.

[A Case of Complete Response to Lower Rectal Cancer after Preoperative Chemotherapy with CapeOX Therapy].

A 70 -year-old male patient was referred to our hospital with the chief complaint of hemafecia. Colonoscopy was performed and revealed bulky rectal cancer at 10 cm from the anal verge. After 4 courses of capecitabine plus oxaliplatin(Ca peOX)therapy as preoperative chemotherapy, colonoscopy and computed tomography(CT)revealed significant reduction of the tumor. We performed laparoscopic lower anterior resection and ileostomy. Histopathological examination revealed no residual tumor cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year postoperatively.

Single-incision laparoscopically assisted appendectomy performed by residents is safe and feasible: A single institution, retrospective case series.

INTRODUCTION: To confirm the safety and feasibility of single-incision laparoscopically assisted appendectomy (SILA) performed by resident doctors. MATERIALS AND METHODS: We retrospectively analyzed 86 consecutive patients who underwent SILA between August 2010 and August 2016 at Kinki Central Hospital. During this period, 9 residents and 6 board-certified attending surgeons performed SILA. Data on the patients' characteristics and perioperative complications were collected from their medical records. RESULTS: Resident doctors operated on 55% (47/86) of patients undergoing SILA. There were no significant differences between the groups with regard to patient characteristics. Mean operative time in the resident and staff surgeon groups was 74 min and 71 min, respectively (p = 0.5). Median blood loss in both the resident and staff surgeon groups was 0 mL (p = 0.3). The rate of conversion to a different operative procedure was 4% (2/47) in the resident group and 3% (1/39) in the staff surgeon group (p = 1). All three above-mentioned procedures, two (4%, 2/47) in the resident group and one (3%, 1/39) in the staff surgeon group, were converted to multi-port laparoscopic appendectomy. The mean postoperative hospital stay was 5 days for both the resident and staff surgeon groups (p = 0.7). Perioperative complications developed in 9% (4/47) of the patients in the resident group and 21% (8/39) of the patients in the staff surgeon group (p = 0.1). CONCLUSIONS: SILA performed by residents under the guidance of a staff surgeon is safe and feasible.

A resected case of medullary carcinoma of the ascending colon followed by infarction of the greater omentum mimicking anastomotic leakage.

INTRODUCTION: Medullary carcinoma is a rare type of colorectal adenocarcinoma, and omental infarction is a rare cause of acute abdomen. PRESENTATION OF CASE: A 72-year-old woman underwent single-incision laparoscopic right hemicolectomy for ascending colon cancer. Pathological examination showed a medullary carcinoma (MC) of T4aN0M0 Stage IIB. Her postoperative course was uneventful, and she was discharged on postoperative day (POD) 6. From POD 7, she suffered from fever, and she returned to the hospital on POD 9. Plain computed tomography showed free air beside the anastomotic site around the elevated density of fat tissue and gallbladder wall thickening with a gallstone. Suspecting anastomotic leakage with acute cholecystitis, probe laparotomy was performed. Intraoperative observation confirmed omental infarction with acute cholecystitis, and no leakage was found at the anastomotic site. Therefore, the necrotic part of the greater omentum was resected, and cholecystectomy was performed. She has remained well, with no evidence of recurrent cancer during the 12 months of follow-up without chemotherapy after the surgery for MC of the ascending colon. DISCUSSION: MC should be distinguished from other more aggressive, non-glandular tumors of the colon because MC appears to have a better survival outcome than undifferentiated colon adenocarcinoma. Omental infarction should be considered in the differential diagnosis of acute abdomen after surgery. CONCLUSION: A rare case of medullary carcinoma of the ascending colon followed by infarction of the greater omentum mimicking anastomotic leakage is presented.

[Eight Cases of Esophagus and Tracheobronchial Stenting for Advanced Esophageal Cancer].

Malignant stricture and fistula of the esophagus and tracheobronchus adversely affect the quality of life(QOL)in patients with advanced esophageal cancer. Stenting is one ofthe therapies available for these patients. We investigated the outcomes ofesophagus and tracheobronchial stenting in our institution. Eight patients with advanced esophageal cancer underwent double stenting from 2010 to 2016. Among them, 4 patients underwent double stenting as planned. One patient underwent an emergency tracheal stenting because ofstenosis ofthe trachea caused by esophageal stenting. Three patients underwent tracheobronchial stenting later on because ofan increase in the tumor size after esophageal stenting. Dysphagia score was improved in 5(67.5%)out ofthe 8 patients. Respiratory symptoms were improved in all patients, and 4 patients(50.0%) were discharged. The median survival time after esophageal stenting was 70.5 days. Esophagus and tracheobronchial stenting for advanced esophageal cancer was useful for the improvement of the QOL.

Modeling, Measuring, and Compensating Color Weak Vision.

We use methods from Riemann geometry to investigate transformations between the color spaces of color-normal and color-weak observers. The two main applications are the simulation of the perception of a color weak observer for a color-normal observer, and the compensation of color images in a way that a color-weak observer has approximately the same perception as a color-normal observer. The metrics in the color spaces of interest are characterized with the help of ellipsoids defined by the just-noticeable-differences between the colors which are measured with the help of color-matching experiments. The constructed mappings are the isometries of Riemann spaces that preserve the perceived color differences for both observers. Among the two approaches to build such an isometry, we introduce normal coordinates in Riemann spaces as a tool to construct a global color-weak compensation map. Compared with the previously used methods, this method is free from approximation errors due to local linearizations, and it avoids the problem of shifting locations of the origin of the local coordinate system. We analyze the variations of the Riemann metrics for different observers obtained from new color-matching experiments and describe three variations of the basic method. The performance of the methods is evaluated with the help of semantic differential tests.

[A Case of Recurrent Gastric Cancer with Recurrent Celiac Lymph Node Metastasis Successfully Treated with Chemoradiotherapy and CPT-11 plus CDDP Therapy].

Chemotherapy is performed for the recurrence of gastric cancer in many cases. We report a case of recurrent lymph node metastasis successfully treated with chemoradiotherapy and chemotherapy. A man in his 60s underwent total gastrectomy and D2 dissection in 2009. The pathological diagnosis was poorly differentiated adenocarcinoma, T4a, int, INF b, ly2, v2, LN#2: 2/3, #3: 1/4, #7, 8, and 9: 3/4, stage III B. Although we administered S-1/UFT as postoperative adjuvant chemotherapy, a strong rash appeared and the patient ceased chemotherapy. Eight months later, the rash had disappeared. We started chemotherapy with paclitaxel(PAC). CT performed 1 year postoperatively showed celiac lymph node(#9)metastasis. Chemoradiotherapy( RT+PAC)and additional CPT-11(98mg)and CDDP(49mg)treatment were administered. The lymph node (#9)was cicatrized after 8 cycles. Forty-two months after the end of treatment, the patient has had no recurrence. It is thought that chemoradiotherapy is an effective cure for local recurrence of gastric cancer.

Efficacy of preoperative dexamethasone for postoperative nausea and vomiting after laparoscopic cholecystectomy: a large-scale, multicenter, randomized, double-blind, placebo-controlled trial in Japan.

BACKGROUND: To assess the efficacy of preoperative dexamethasone for postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC) in Japan. METHODS: A total of 270 patients at eight hospitals were randomized to receive dexamethasone 8 mg (n = 136) or placebo (n = 134) intravenously before LC. The primary endpoint was the degree of PONV and antiemetic requirements within 24 h after LC. Secondary endpoints were postoperative complications, postoperative hospital stay, and cost of hospital stay. This study was registered: UMIN-CTR (UMIN000003841). RESULTS: Within 6 h after LC, 17% (23/136) of patients in the dexamethasone group versus 24% (32/134) in the placebo group reported nausea (P = 0.3), and 5% (7/136) versus 7% (10/134) reported vomiting (P = 0.2). Metoclopramide 10 mg was used 0.09 ± 0.31 versus 0.14 ± 0.35 times (P = 0.2). From 6 to 24 h, 10% (14/136) versus 13% (17/134) reported nausea (P = 0.5), and 5% (7/136) versus 5% (7/134) reported vomiting (P = 0.8). Metoclopramide was used 0.04 ± 0.19 versus 0.03 ± 0.17 times (P = 0.8). Postoperative complications and postoperative hospital stay did not differ significantly between the two groups, but the cost of hospital stay was slightly higher in the dexamethasone group (P < 0.05). CONCLUSIONS: Routine use of preoperative dexamethasone for PONV after elective LC in Japan was not shown to have a clinical advantage.

[A Case of Small Intestinal Cancer Repeating an Ileus Symptom Complicated with Refractory Arrhythmia].

A 56-year-old man had been treated for hypertrophic cardiomyopathy since childhood. He had been treated for refractory ventricular tachycardia (VT) with interventricular septum cauterization, catheter ablation, and implantation of a defibrillator. He had been treated at home for several years. The ileus that developed in July 2014 was relieved by conservative medical treatment once, but it recurred after oral intake of food a short time later. The obstruction was due to a small intestine cancer that was diagnosed by enteroscopy. After considering the risks of surgery due to the cardiac problem and the quality of life due to ileus caused by the mass, we resected it. This surgery was not a radical resection because of peritoneal dissemination. He started oral food intake postoperatively, and returned to home care. Three months after surgery, oral chemotherapy was administered after considering his stable cardiac function in addition to his coherent mental status. An adverse event of severe watery diarrhea developed, and VT caused by dehydration occurred. After the chemotherapy was discontinued, he recovered in intensive care. He returned to home care at his prior status for 9 months postoperatively.

[A Case of Carcinosarcoma of the Esophagus Treated with Chemoradiotherapy].

Carcinosarcoma of the esophagus is a rare malignant neoplasm. We report a case of an 87-year-old man treated with chemoradiotherapy. The main presenting complaint was hiccups. Histological analysis of a biopsy from the tumor demonstrated a carcinosarcoma. The clinical diagnosis was T2N0M0, cStageⅡ. In consideration of his advanced age, a past history of cerebral infarction, high blood pressure, aortic valve sclerosis, and chronic renal failure (Cr 1.5-1.8 mg/dL), chemoradiotherapy consisting of TS-1 40 mg/day with radiotherapy of 66 Gy was administered to the patient. The carcinosarcoma decreased in size on endoscopic examination in response to the chemoradiotherapy. Surgery with extended lymphadenectomy for esophageal carcinosarcoma is the standard treatment, but chemotherapy may be a good choice for local control for patients who cannot undergo surgical resection.

[Clinical evaluation of the risk factors for liver abscess after TACE or RFA].

Radiofrequency ablation(RFA)and transcatheter arterial chemoembolization (TACE) are widely enforced as a standard combined therapy for liver cancer. Liver abscess occurs occasionally as a complication. This clinical study was conducted to determine risk factors for liver abscess. We investigated the clinical background of 10 cases complicated by liver abscess in 957 cases of patients who underwent TACE or RFA for liver cancer at Minoh City Hospital between April 2002 and March 2012. Risk factors for liver abscess were analyzed statistically in comparison to a control group without liver abscess. Diabetes and a history of biliary tract organic disease were statistically significant independent risk factors determined by multivariate analysis. We consider patients with a history of biliary tract organic disease, or who have a potential biliary tract infection, and diabetes, to be susceptible to infection. A case presenting with diabetes and a history of biliary tract disease is in a high-risk group, so treatment with TACE or RFA for such cases should be considered carefully.