Impact of the COVID-19 pandemic on the number and short-term outcomes in hepatectomy for hepatocellular carcinoma: Results from the Japanese National Clinical Database, 2018-2021.

AIM: The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the allocation of medical resources, including cancer screening, diagnosis, and treatment. We aimed to investigate the effects of the pandemic on morbidity and mortality following hepatectomy for hepatocellular carcinoma (HCC). METHODS: We identified patients who underwent hepatectomy for HCC between 2018 and 2021 from the Japanese National Clinical Database (NCD). The number of surgical cases, the use of intensive care units, and the incidence of morbidity were assessed. The standardized morbidity / mortality ratio (SMR) was used to evaluate the rates of morbidity (bile leakage and pneumonia) and mortality in each month, which compares the observed incidence to the expected incidence calculated by the NCD's risk calculator. RESULTS: The study included a total of 10 647 cases. The number of patients undergoing hepatectomy for HCC gradually decreased. The proportion of patients aged 80 years or older increased and that of cases with T1 stage decreased. The proportion of patients who were admitted to the intensive care unit did not change between the pre- and postpandemic period. The mean actual incidence rates of bile leakage, pneumonia, 30-day mortality, and surgical mortality were 9.2%, 2.3%, 1.4%, and 2.1%, respectively. The SMR for the mortalities and morbidities in each month did not increase mostly throughout the COVID-19 pandemic. CONCLUSIONS: The present study showed the decreasing number of resected cases for HCC, while the surgical safety for hepatectomy was enough to be maintained by managing medical resources in Japan.

Laparoscopic resection of a gastric duplication cyst located near the esophagogastric junction.

We herein describe the rare case of a patient with a gastric duplication cyst who underwent laparoscopic resection. A 67-year-old man was referred to our hospital with an intra-abdominal lesion incidentally diagnosed on abdominal computed tomography. Esophagogastroduodenoscopy revealed normal esophageal and gastric mucosa without any lesions. Abdominal contrast-enhanced computed tomography revealed an 18 mm well-defined mass adjacent to the lesser curvature side of the esophagogastric junction. Following clinical diagnosis as an intra-abdominal mass, the patient underwent laparoscopic surgery in a five-port setting. The lesion originated from the stomach, near the muscular layer. The stomach muscle layer was partially resected; however, no communication between the mass and gastric mucosa was identified. Macroscopically, the resected specimen was 19 × 18 mm with a smooth surface and distinct margins. Microscopic examination confirmed the diagnosis of a gastric duplication cyst. The inner surface was covered with gastric gland pit-type columnar epithelial cells without atypia or neoplastic changes. The cyst wall presented layers of mucosa, muscularis mucosae, submucosa, muscularis propria, and subserosa. The patient's course after the procedure was uneventful, and he was discharged 8 days postoperatively. Gastric duplication cysts are rare and mostly asymptomatic, and their laparoscopic partial resection is safe and effective.

Days of the week and 90-day mortality after esophagectomy: analysis of 33,980 patients from the National Clinical Database.

PURPOSE: The effect of the days of the week on the short-term outcomes after elective surgeries has been suggested; however, such data on esophagectomies remain limited. This study aimed to investigate the association between the day of the week and mortality rates after elective esophagectomy using a large-scale clinical database in Japan. METHODS: The data of elective esophagectomies, registered in the National Clinical Database in Japan, for esophageal cancer treatment between 2012 and 2017 were analyzed. We hypothesized that the later days of the week could have higher odds ratios of death after elective esophagectomy. With 22 relevant clinical variables and days of surgery, 90-day mortality was evaluated using hierarchical logistic regression modeling. RESULTS: Ninety-day mortality rates among 33,980 patients undergoing elective esophagectomy were 1.8% (range, 1.5-2.1%). Surgeries were largely concentrated on earlier days of the week, whereas esophagectomies performed on Fridays accounted for only 11.1% of all cases. Before risk adjustment, lower odds ratios of 90-day mortality were found on Tuesday and a tendency towards lower odds ratios on Thursday. In the hierarchical logistic regression model, 21 independent factors of 90-day mortality were identified. However, the adjusted odds ratios of 90-day mortality for Tuesday, Wednesday, Thursday, and Friday were 0.87, 1.09, 0.85, and 0.88, respectively, revealing no significant difference. CONCLUSION: The results imply that the variation in 90-day mortality rates after esophagectomy on different days of the week may be attributed to differing preoperative risk factors of the patient group rather than the disparity in medical care provided.

Impact of COVID-19 pandemic on short-term outcomes after low anterior resection in patients with rectal cancer: Analysis of data from the Japanese National Clinical Database.

Aim: The Coronavirus Disease 2019 (COVID-19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short-term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan. Methods: Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID-19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator). Results: This study included 74 181 patients, including 43 663 (58.9%) from COVID-19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30-day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas. Conclusion: Although the pandemic temporarily decreased the ICU admission rate, its impact on short-term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan.

Gastric cancer with Fanconi anemia in adolescent and young adult patient diagnosed by comprehensive genome profiling using next-generation sequencing.

Recently, the results of gastric cancer treatment have improved; however, its characteristics in adolescents and young adults are not well known. We report the case of a patient with advanced gastric cancer, Fanconi anemia (FA), and primary biliary cholangitis. A 26-year-old woman visited a local physician complaining of epigastralgia. Esophagogastroduodenoscopy revealed edematous changes with poor distension and circumferential thickened folds with erosions in the gastric body. Biopsy results of the lesion specimens revealed poorly differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography revealed gastric wall with irregular thickness, several nodules in the peritoneal cavity, and a mass lesion in the right ovary. We diagnosed the patient with T4N2M1 stage IV gastric cancer accompanied by peritoneal and ovarian metastases and initiated nivolumab with S-1 plus oxaliplatin as the first-line treatment regimen. Because of immune-related adverse events after one course of systemic treatment, the regimen was changed to ramucirumab combined with nab-paclitaxel chemotherapy as the second-line treatment. After three cycles of weekly nab-paclitaxel with ramucirumab, the decreased platelet count did not recover, and her general condition gradually deteriorated. Comprehensive genome profiling using next-generation sequencing was performed to determine the feasibility of genotype-matched therapies. Alterations in FA complementation group A (FANCA) F1263del (49.1%) and E484Q (12.3%), which encode a key component of the multiprotein FA complex, were identified. The patient died 10 months after treatment initiation. In conclusion, when treating malignancies in adolescent and young adult patients, the genomic background should be considered.

Laparoscopic partial splenectomy in a patient with splenic hemangioma after distal gastrectomy for a neuroendocrine tumor.

Herein, we report the case of a patient with splenic hemangioma after distal gastrectomy who was treated with laparoscopic partial splenectomy. A 64-year-old woman previously underwent laparoscopic distal gastrectomy with regional lymph-node dissection for a gastric neuroendocrine tumor (G3) with venous infiltration and no lymph-node metastases. Periodic follow-up abdominal computed tomography revealed a well-defined, heterogeneous mass in the lower pole of the spleen 5 years after the operation, which grew from 12 to 19 mm 1 year later. A laparoscopic partial splenectomy was planned. During surgery, a smooth-surfaced mass with a lighter color than that of the surrounding area was observed at the lower pole of the spleen. The inferior polar branch of the splenic artery was transected, and the ischemic area of the lower pole of the spleen, where the tumor was present, was confirmed. First, the line used to perform splenic transection was determined using soft coagulation. The splenic parenchyma was then gradually transected using a vessel-sealing device system, and partial splenectomy was possible with almost no bleeding. The patient was discharged on postoperative day 8 without any complications. Pathological examination revealed a hemangioma without any malignant findings. Laparoscopic partial splenectomy is a safe and useful procedure that can be performed, considering the tumor size and location.

A case of perioperative artificial pancreas therapy for a patient with esophageal cancer with type 1 diabetes.

A 72-year-old female with type 1 diabetes, a history of interstitial pneumonia, and diabetic ketoacidosis was admitted to our hospital with dysphagia. Endoscopy revealed a circumferential neoplastic lesion in the upper to middle esophagus, and a biopsy revealed squamous cell carcinoma. Computed tomography revealed invasion of the left main bronchus, and induction chemotherapy was initiated with a diagnosis of unresectable locally advanced esophageal cancer. After one course of induction chemotherapy, the tumor size reduced, bronchial invasion improved, and thoracoscopic esophagectomy was performed. During surgery and until 3 days after surgery, the patient's blood glucose level was controlled using an artificial pancreas, and the target blood glucose range was set at 140-180 mg/dL. On the fourth postoperative day, the patient was managed using a sliding scale. Mean blood glucose was 186.7 ± 70.0 mg/dL for 3 days before surgery, 190.5 ± 25.0 mg/dL during artificial pancreas therapy from the surgery to the next day, 169.8 ± 22.0 mg/dL during artificial pancreas therapy on the second to third postoperative days, and 174.5 ± 25.0 mg/dL during sliding scale therapy for 4-15 days after surgery. No hypoglycemia or ketoacidosis was noted.

The impact of COVID-19 for postoperative outcomes using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer.

Background: The coronavirus disease 2019 (COVID-19) pandemic had resulted in either failure to provide required medical resources or delayed treatment for gastric cancer patients. This study aimed to investigate the impact of COVID-19 on the incidence of postoperative complications using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer. Methods: We collected the data of patients who underwent distal gastrectomy from January 2018 to December 2021 from the National Clinical Database (NCD), a web-based surgical registration system in Japan. The number of surgical cases, the use of intensive care units, and the incidence of morbidity per month were analyzed. We also calculated the standardized mortality ratio (SMR), defined as the ratio of the number of observed patients to the expected number of patients calculated using the risk calculator established in the NCD, for several morbidities, including pneumonia, sepsis, 30-day mortality, and surgical mortality. Results: A decrease of 568 gastrectomies was observed from April 2020 to May 2020. Although the absolute number of patients admitted to intensive care units had declined since 2020, the proportion of patients admitted to the ICU did not change before and after the pandemic. Mortality and critical morbidity (such as pneumonia and sepsis) rates were not worse during the pandemic compared to pre-pandemic periods per the SMR. Conclusions: Surgical management was conducted adequately through the organized efforts of the entire surgery department in our country even in a pandemic during which medical resources and staff may have been limited.

Frailty and Colorectal Surgery: Review and Concept of Cancer Frailty.

Frailty is characterized by reduced physiological reserves across multiple systems. In patients with frailty, oncological surgery has been associated with a high rate of postoperative complications and worse overall survival. Further, given that cancer and frailty can co-exist in the same patient, cancer and cancer-related symptoms can rapidly accelerate the progression of baseline frailty, which we have termed "cancer frailty". This distinction is clinically meaningful because the prioritization of interventions and the treatment outcomes may differ based on health conditions. Specifically, in patients with cancer frailty, improvements in frailty may be achieved via surgical removal of tumors, while prehabilitation may be less effective, which may in turn result in delayed treatment and cancer progression. In this review, we focused on challenges in the surgical treatment of non-metastatic colorectal cancers in patients with frailty, including those related to decision making, prehabilitation, and surgery. Potential recommendations for treating patients with cancer frailty are also discussed.

A Case of Tracheoesophageal Fistula in a Non-metastatic Site During Lenvatinib Treatment for Hepatocellular Carcinoma.

BACKGROUND/AIM: We report a case of tracheo-esophageal fistula at a non-metastatic site during lenvatinib treatment of hepatocellular carcinoma with multiple bone metastases. CASE REPORT: A 58-year-old male patient was diagnosed with hepatocellular carcinoma with multiple bone metastases and was treated with atezolizumab-bevacizumab. However, as the bone metastasis progressed, palliative radiation therapy was administered to the third thoracic vertebra, and lenvatinib was administered as a second-line treatment. The patient was hospitalized for aspiration pneumonia five months later. Chest computed tomography and bronchoscopy revealed a 5 cm tracheoesophageal fistula located 3 cm cranial to the carina. We diagnosed a benign tracheoesophageal fistula due to lenvatinib because his previous CT scan showed no metastases at the site of the fistula, and we performed esophageal bypass surgery 4 weeks after discontinuation of the lenvatinib. CONCLUSION: To the best of our knowledge, this is the first case report of tracheoesophageal fistula at a nonmetastatic site during lenvatinib treatment for hepatocellular carcinoma.

Gastric and Bone Metastases Arising from Invasive Lobular Carcinoma With Ductal Carcinoma Occurring in one Breast Synchronously.

BACKGROUND/AIM: We report the case of a patient with gastric and bone metastases arising from an invasive lobular carcinoma of the breast coexisting with ductal carcinoma at the same time. CASE REPORT: A 68-year-old woman with gastric and right costal tumors was referred to our hospital. Esophagogastroduodenoscopy (EGD) revealed irregular, slightly elevated lesions extending from the gastric body to the antrum, and biopsy specimens revealed a poorly differentiated adenocarcinoma. Furthermore, abdominal contrast-enhanced computed tomography (CT) revealed extensive wall thickening with homogeneous enhancement in the stomach. 18F-2-deoxy-2-fluoro-glucose positron emission tomography (FDG-PET) showed intense FDG uptake in the right mammary gland and right third rib. Moreover, fine-needle aspiration of the third right rib lump and the right breast mass lesion was performed, and subsequent pathological investigations revealed metastatic adenocarcinoma and invasive ductal carcinoma, respectively. Immunohistochemical examination revealed that estrogen receptor was strongly positive (>95%) in breast cancer and focally positive (<5%) in gastric cancer with bone metastasis. In addition, another right breast tumor was detected by breast magnetic resonance imaging (MRI), and biopsy revealed invasive lobular carcinoma that matched the histological findings of bone and gastric lesions, including immunohistochemical examination. The patient was treated with an aromatase inhibitor, a CDK4/6 inhibitor, and a receptor activator of nuclear factor-kappa B ligand (RANKL) monoclonal antibody. She showed no symptoms or disease progression at 9-month follow-up after the initiation of systemic drug treatment. CONCLUSION: Invasive lobular carcinoma can metastasize to the gastrointestinal tract, and new treatment developments are expected as more cases will accumulate in the future.

Successful treatment of gastric cancer with gastroduodenal intussusception by laparoscopic distal gastrectomy.

We report a case of a 93-year-old woman with gastric cancer who presented with gastroduodenal intussusception and was treated with laparoscopic distal gastrectomy. Esophagogastroduodenoscopy showed a giant protruding lesion in the gastric antrum extending into the duodenal bulb, and biopsy confirmed a well-differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) revealed a well-defined mass with homogeneous enhancement and a stalk arising from the distal stomach extending into the duodenal bulb. With a clinical diagnosis of gastric cancer with gastroduodenal intussusception, the patient underwent laparoscopic distal gastrectomy with regional lymph node dissection and reconstruction using the Billroth I method. Reduction of the intussusception was performed through a 4 cm incision under the xiphoid process in the epigastric region because it could not be laparoscopically reduced. Gross examination of the resected specimen showed a well-circumscribed, elevated lesion measuring 11.2 × 4.7 × 3.6 cm in the antrum. Microscopic examination of the elevated tumor confirmed the diagnosis of well-differentiated adenocarcinoma invading the gastric submucosal layer without lymph node metastasis. There was no lymphatic or venous invasion or lymph node metastasis. The postoperative course was uneventful, and her hemoglobin level improved to 11.9 g/dL. The patient has been postoperatively well without evidence of recurrence for 3 months. Part of the superficial spreading-type tumor may be drawn into the duodenum under strong peristaltic movement because it does not infiltrate the muscle layer.

Analysis of the short-term outcomes after esophagectomy for esophageal cancer during the COVID-19 pandemic using data from a nationwide Japanese database.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic had adversely impacted cancer screening, diagnosis, and treatment. We investigated the change in medical resource, such as the intensive care unit use, and short-term outcomes after esophagectomy during the pandemic. METHODS: Data of patients who underwent esophagectomy for esophageal cancer registered in the National Clinical Database (NCD) in Japan from January 2018 to December 2021 were analyzed. The time series change in the number of surgical cases; usage of intensive care unit; incidence of morbidity and mortality; standardized mortality and morbidity ratio (SMR) for 30-days mortality; surgical mortality; and morbidities for pneumonia, sepsis, unplanned intubation, and anastomotic leakage were evaluated. RESULTS: The annual number of patients undergoing esophagectomy remained similar from 2018 to 2021. The negative impact of the pandemic on medical resources was strongly identified in the patients from an epidemic area where there is a higher cumulative number of infections per population as compared to all prefectures. The proportions of patients admitted to the intensive care unit were 91.4%, 93.0%, 91.6%, and 90.5% in 2018, 2019, 2020, and 2021, respectively. Moreover, 93.3%, 94.0%, 92.0%, and 90.9% patients who underwent surgery in an epidemic area were admitted to the intensive care unit in 2018, 2019, 2020, and 2021, respectively. However, the morbidity and mortality rates during the pandemic did not worsen according to the SMR values. CONCLUSIONS: Esophagectomy was performed during the pandemic despite limited medical resources by a systematic endeavor of the entire surgical department in Japan, without increasing the incidence rate of worse outcome.

Feasibility and Safety of Adjuvant Chemotherapy for Resected Colorectal Cancer in Patients With Renal Insufficiency: A Pooled Analysis of Individual Patient Data from Five Japanese Large-scale Clinical Trials.

BACKGROUND/AIM: The incidence of chemotherapy-related adverse events in colorectal cancer patients with renal insufficiency has been compared to patients with normal renal function in only a few studies. The purpose of this analysis was to verify the feasibility and safety of adjuvant chemotherapy for postoperative colorectal cancer patients with renal insufficiency. PATIENTS AND METHODS: Adverse events and discontinuation of adjuvant chemotherapy for patients with curatively resected locally advanced colorectal cancer were examined using a combined database of individual patient data obtained from five large-scale clinical trials (n=4,106). The renal function of patients was classified into Level (L) 1-2: ≥60 ml/min and L3-4: <60 ml/min. RESULTS: As Grade 3 adverse events, hematological toxicities, such as neutropenia and anemia, and gastrointestinal disorders, such as diarrhea and vomiting, were significantly more frequent in the L3-4 group. Moreover, the time-to-treatment discontinuation in the L3-4 group was higher (hazard ratio=1.21, p=0.0012). T factor, N factor, and creatinine clearance level were found to be independent risk factors for the discontinuation of adjuvant chemotherapy. In the subgroup analysis of FOLFOX, neutropenia and diarrhea were significantly common in the L3-4 group, but neurotoxicities were not different. There was no significant difference in the discontinuation of adjuvant FOLFOX. CONCLUSION: Adverse events of adjuvant chemotherapy in patients with resected colorectal cancer were associated with renal insufficiencies. Since adverse events have the potential to shorten the duration of treatment, especially when using chemotherapy without oxaliplatin, careful management, including dose reduction, may be important in patients with renal insufficiency.

Effects of the COVID-19 pandemic on gastroenterological surgeries in 2020: A study using the National Clinical Database of Japan.

Aim: This study aimed to investigate the effect of the coronavirus disease pandemic on the number of surgeries for gastroenterological cancer cases in Japan. Methods: The data recorded in the National Clinical Database of Japan between 2018 and 2020 were utilized for this study. Five specific surgeries for primary cancers and surgery for acute diffuse peritonitis were considered the primary endpoints. We divided the study period into the prepandemic and postpandemic (after April 2020) periods and examined the number of surgeries in relation to clinical factors. Results: Overall, 228 860 surgeries were analyzed. Among the five primary cancer surgeries, the number of distal gastrectomies for gastric cancer decreased the most (to 81.0% of the monthly number in the prepandemic period), followed by that of low anterior resections for rectal cancer (91.4%). In contrast, the number of pancreaticoduodenectomies for pancreatic cancer increased by 7.1%, while that of surgeries for peritonitis remained stable. This trend was observed nationwide. We also noted a marked reduction in the number of distal gastrectomy (to 72.5%), low anterior resection (84.0%), and esophagectomy (88.8%) procedures for T1 tumors. The noncurative resection rate and mortalities were low despite the increased proportion of T4 tumors and older patients. Conclusion: A marked reduction in surgeries for gastric and rectal cancers with early T factors may reflect prioritization of surgeries and reduction in cancer screenings. Although the quality of the surgery was maintained in terms of reduced mortalities and morbidities, the long-term effects of this pandemic should be monitored.

The clinical impacts of postoperative complications after colon cancer surgery for the clinical course of adjuvant treatment and survival.

AIM: We investigated whether or not postoperative complications (POCs) themselves have a negative survival impact or indirectly worsen the survival due to insufficient adjuvant chemotherapy in a pooled analysis of two large phase III studies performed in Japan PATIENTS AND METHODS: The study examined the patients who enrolled in 1304, phase III study comparing the efficacy of 6 and 12 months of capecitabine as adjuvant chemotherapy for stage III colon cancer patients and in 882, a phase III study to confirm the tolerability of oxaliplatin, fluorouracil, and l-leucovorin in Japanese stage II/III colon cancer patients. In our study, POCs were defined as the following major surgical complications: anastomotic leakage, pneumonia, bowel obstruction/ileus, surgical site infection, postoperative bleeding, urinary tract infection, and fistula. Patients were classified as those with POCs (C group) and those without POCs (NC group). RESULTS: A total of 2095 patients were examined in the present study. POCs were observed in 169 patients (8.1%). The overall survival (OS) rates at 5 years after surgery were 75.3% in the C group and 86.5% in the NC group (p = 0.0017). The hazard ratio of POCs for the OS in multivariate analysis was 1.70 (95% confidence interval, 1.19 to 2.45; p = 0.0040). The time to adjuvant treatment failure (TTF) of adjuvant chemotherapy was similar between the groups, being 68.6% in the C group and 67.1% in the NC group for the 6-month continuation rate of adjuvant chemotherapy. The dose reduction rate of adjuvant chemotherapy and adjuvant treatment suspension rate were also similar between the groups (C vs. NC groups: 45.0% vs. 48.7%, p = 0.3520; and 52.7% vs. 55.0%, p = 0.5522, respectively). CONCLUSION: POCs were associated with a poor prognosis but did not affect the intensity of adjuvant chemotherapy. These results suggested that POCs themselves negatively influence the survival.

What is the optimal range of glycemic control for non-diabetic patients undergoing gastroenterological surgery? A single-center randomized controlled trial using an artificial pancreas.

BACKGROUND: This study aimed to determine the optimal target range of perioperative glycemic control for gastroenterological surgery. A closed-loop-type artificial pancreas (AP) was used to diminish the negative impact of hypoglycemia and glycemic variability during tight glycemic control. METHODS: In this single-center randomized trial, non-diabetic patients were assigned to tight (80-110 mg/dL) or moderate glycemic control (110-140 mg/dL) groups between August 2017 and May 2021. AP was used from the intraoperative period until discharge from the intensive care unit. The primary endpoint was the serum interleukin (IL)-6 level on the third postoperative day (3POD), and the secondary endpoints included clinical outcomes. RESULTS: Recruitment was closed before reaching the planned number of patients due to slow enrollment. Tight glycemic control (n = 62) resulted in lower mean glucose levels than moderate glycemic control (n = 66) (121.3 ± 10.8 mg/dL vs. 133.5 ± 12.0 mg/dL, p < 0.001). Insulin was administered at a 65% higher rate for tight glycemic control, achieving appropriate glucose control more than 70% of the treatment time. No hypoglycemia occurred during the AP treatment. No significant difference was observed in serum IL-6 levels on 3POD (23.4 ± 31.1 vs. 32.1 ± 131.0 pg/mL, p = 0.64), morbidity rate, surgical mortality rate, or length of hospital stay between the two groups. CONCLUSIONS: Clinically relevant short-term results did not differ, implying that 80-110 and 110-140 mg/dL are permissible glycemic control ranges when using AP in non-diabetic patients undergoing gastroenterological surgery. (Registered in UMIN; UMIN000028036).

Association between Serum Zinc Levels and Clinicopathological Characteristics in Patients with Gastric Cancer.

Introduction: Although it was reported that serum zinc levels were lower in patients with various malignancies, serum zinc levels of patients with gastric cancer were not well documented. Objectives: This study aimed to evaluate the association between clinicopathologic features and serum zinc levels in preoperative patients with gastric cancer. Methods: The study enrolled 83 patients scheduled for gastric cancer surgery at the Kochi Medical School. Clinical data were obtained to investigate associations between clinicopathological features, including nutritional indicators and serum zinc levels. Serum zinc deficiency was defined as serum zinc level <80 µg/dL. Results: The median zinc level of the 83 patients was 73 µg/dL (range, 20-152 µg/dL), and serum zinc deficiency was present in 66.3% of patients. Albumin was significantly lower in the zinc low level group than in the normal group (3.9 g/dL vs. 4.4 g/dL, p < 0.001), and the median serum zinc level was significantly lower in the albumin <4.1 g/dL group than in the albumin ≥4.1 g/dL group (69 µg/dL vs. 82 µg/dL, p < 0.001). Lymphocyte count was significantly lower in the zinc low level group than in the normal group (1,500 vs. 1810 years, p = 0.041). The median serum zinc level was significantly lower in the age ≥74 group than in the age <74 (71 µg/dL vs. 76 µg/dL, p = 0.002). Serum zinc levels showed a significant positive correlation with serum albumin (r = 0.637, p = 0.009). Conclusion: Serum zinc deficiency was found in 66.3% of preoperative patients with gastric cancer, which was highly correlated with serum albumin.

Laparoscopic treatment for multiple huge diospyrobezoars in the stomach.

We report a case of a patient with multiple diospyrobezoars, a phytobezoar attributed to persimmons (Diospyros kaki) consumption, in the stomach, who was treated with laparoscopic complete surgical excision. A 76-year-old man with gastric phytobezoars presented to our hospital. Abdominal contrast-enhanced computed tomography revealed three well-defined, oval, nonhomogeneous masses with a mottled appearance in the stomach. Esophagogastroduodenoscopy revealed three large brown solid phytobezoars and gastric ulcers at the gastric angle. The clinical diagnosis was diospyrobezoar, and, due to the huge masses, the patient eventually underwent laparoscopic treatment when the medical and endoscopic approaches were unsuccessful. After gastrotomy in the anterior wall of the stomach, the phytobezoar was mobile inside the stomach, which was opened beside the gastric incision. The three phytobezoars were removed through the wound protector using sponge-holding forceps; the hole in the gastrotomy was closed in the mucosal and seromuscular layers with an intracorporeal suture technique. The weight and size of the phytobezoars were 140 g and 115 × 55 × 50 mm, 70 g and 55 × 45 × 35 mm, and 60 g and 50 × 40 × 35 mm, respectively. The patient was discharged on the 8th postoperative day without any complications. Laparoscopic surgery to extract bezoar is the treatment of choice for this rare entity, because it is a safe and effective approach.

Early stoma closure after low anterior resection is not recommended due to postoperative complications and asymptomatic anastomotic leakage.

The safety of early stoma closure after lower anterior resection (LAR) for rectal cancer remains controversial. In this study, patients scheduled to undergo LAR and stoma creation for rectal cancer were recruited. In absence of anastomotic leakage on radiological examination, closure of the diverting ileostomy was performed within 2 weeks. The primary endpoint was incidence of the colorectal anastomosis leakage after early stoma closure. Because of the slow accrual rate, the study was closed before recruitment reached the planned number of patients (n = 20). Among the 13 patients enrolled between April 2019 and March 2021, early stoma closure was performed in seven patients (53.8%). Non-clinical anastomotic leakage, leakage identified only on radiological examination, occurred in five cases, resulting in rescheduling of stoma closure. One patient did not undergo early stoma closure due to ileus. After stoma closure, colorectal anastomotic leakage manifested in one case; its incidence rate was 14.2%. Surgical site infection occurred in 42.8% of patients. This study revealed that asymptomatic anastomotic leakage occurred frequently. Considering the low rate of successful cases and the high rate of complications, early stoma closure within 2 weeks after LAR should not be performed routinely. Trial registration: (UMIN000036382 registered on 03/04/2019).