Clinical characteristics of child and adolescent psychiatric outpatients engaging in fireplay or arson: a case-control study.

BACKGROUND: Fireplay and arson incidents among children and adolescents have gained attention because of their potentially severe consequences and societal impacts. Understanding the underlying psychiatric characteristics of individuals engaging in fireplay or arson is crucial for early identification and targeted intervention. However, there is a lack of research conducted in clinical psychiatric populations in this context. This study compared the clinical characteristics of child and adolescent psychiatric outpatients who engaged in fireplay or arson with those without such behaviors. METHODS: A retrospective case-control study was conducted using data collected from patients who visited the Department of Child and Adolescent Psychiatry at Kohnodai Hospital, National Center for Global Health and Medicine in Japan, between April 2014 and March 2022. Medical records were checked to see if the patient had practically committed behaviors that corresponded to fireplay or arson. The case group was identified using this process. After identifying the case and control groups, sex, diagnosis, antisocial behavior, abuse history, and children-to-parent violence were assessed and compared by careful review of medical records. RESULTS: The study identified 64 patients who engaged in fireplay or arson, representing approximately 1.1% of the total 5,587 patients (case group). The median age of the patients' first fire-related behavior was 13 years (range, 6-18 years). In the case group, 14.1% of the cases involved arson, resulting in substantial damage. Of the remaining 5523 patients, 2268 patients had datasets for the first consultation (control group). The most prevalent diagnosis in the case group was attention-deficit hyperactivity disorder (ADHD), present in 57.8% of the cases. The study revealed a significant association between fire-related behaviors and ADHD as well as antisocial behavior. Gender differences were observed, with boys being more likely to engage in fireplay or arson than girls. CONCLUSIONS: This study suggests that clinicians and mental health professionals should closely consider male sex, ADHD, and antisocial behaviors as potential risk factors for fire-related behaviors. Monitoring the case group for the development of psychiatric disorders, including the use of illegal drugs, is recommended to prevent future arson incidents.

Randomized controlled trial comparing cosmetic results of midline incision versus off-midline incision for specimen extraction in laparoscopic colectomy.

PURPOSE: A notable advantage of laparoscopic colorectal surgery is that only a small incision at the extraction site is necessary, which is considered to be cosmetically beneficial. Meanwhile, the optimal extraction site for the resected specimen in laparoscopic colectomy is controversial in terms of cosmetic benefit. This randomized controlled trial compares midline and off-midline extraction sites in laparoscopic colectomy in patients with colon cancer, with consideration of cosmetic benefits as the primary endpoint. METHODS: Included were patients that underwent elective laparoscopic colectomy at WMUH between October 2014 and February 2017. Patients were randomly assigned to either midline incision group or off-midline incision group. Prospectively collected data included cosmetic results (patients and observer assessment scale) and complications including incidence of incisional hernia, SSI, and pain. This trial was registered with UMIN Clinical Trials (UMIN000028943). RESULTS: Finally, 98 patients with colorectal cancer were analyzed. No significant differences were found between the two groups in patient and observer assessment scales of cosmetic results (midline 8 ± 1.1 vs off-midline 11 ± 5.9 p = 0.16, midline 13.5 ± 6.6 vs off-midline 15 ± 11 p = 0.58, respectively) or in postoperative pain. However, incisional hernia occurred in four cases in the midline group (8%), which was significantly higher than that in the off-midline group (no cases, 0%). CONCLUSION: There was no significant difference in terms of cosmetic benefit, the primary endpoint, between the two groups. In this study, only the extraction site location was compared; future studies will examine differences depending on the incisional direction, including the incidence of incisional hernia.

Current situation and clinical burden of pediatricians for children with eating disorders during the COVID-19 pandemic.

During the COVID-19 pandemic, the incidence of eating disorders (ED) has increased not only in Japan but also worldwide. This online survey for pediatricians showed that caregivers tend to visit specific pediatric institutions or child psychiatry departments when children under junior high school age develop eating disorders. There are few pediatric institutions regarding treatment acceptance for children with ED. Of the 34 respondents, 16 (47.1%) answered that the number of visits for children with eating disorders had "stayed the same", one answered it had "decreased" and 17 (50.0%) answered it had "increased" or "increased very much". In addition, 28 of the 34 respondents (82.3%) experienced difficulties with psychotherapy for children with ED. For treating children with ED, pediatricians usually conducted physical examination and have some clinical burden. ED are increasing in the COVID-19 pandemic. Because children with severe ED need to be hospitalized, child and adolescent psychiatric wards are overcrowded and some children with other mental disorders can't be admitted.

Simple Symptom-Based Prediction of COVID-19: A Single-Center Study of Outpatient Fever Clinic in Japan.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) symptoms are not fully understood in non-hospitalized individuals in Japan, and COVID-19 differentiation by symptoms alone remained challenging. Therefore, this study aimed to examine COVID-19 prediction from symptoms using real-world data in an outpatient fever clinic. METHODS: We compared the symptoms of COVID-19-positive and negative patients who visited the outpatient fever clinic at Imabari City Medical Association General Hospital and tested for COVID-19 from April 2021 to May 2022. This retrospective single-center study enrolled 2,693 consecutive patients. RESULTS: COVID-19-positive patients had a higher frequency of close contact with COVID-19-infected patients compared with COVID-19-negative patients. Moreover, patients with COVID-19 had high-grade fever at the clinic compared with patients without COVID-19. Additionally, the most common symptom in patients with COVID-19 was sore throat (67.3%), followed by cough (62.0%), which was approximately twice as common in patients without COVID-19. COVID-19 was more frequently identified in patients having a fever (≥37.5℃) with a sore throat, a cough, or both. The positive COVID-19 rate reached approximately half (45%) when three symptoms were present. CONCLUSION: These results suggested that COVID-19 prediction by combinations of simple symptoms and close contact with COVID-19-infected patients might be useful and lead to recommendations for testing of COVID-19 in symptomatic individuals.

A rare case of Pseudomonas aeruginosa enteritis induced by pembrolizumab.

A 72-year-old male had pseudomonal enteritis related to pembrolizumab. Chemotherapy for hypopharyngeal carcinoma with lung metastasis comprised cisplatin, 5-FU, and pembrolizumab. On day 14 of chemotherapy treatment he had a sudden prominent abdominal bulge, decreased consciousness, and drop in blood pressure in septic shock. CT scan showed marked intestinal gas through to intrahepatic bile ducts. Pseudomonas aeruginosa was simultaneously detected in both blood and stool cultures. Intestinal endoscopy revealed ulcerative lesions from the transverse colon to the rectum. Pathological investigations indicated apoptosis of the villus. The patient was diagnosed with pseudomonal enteritis induced by immune-related adverse events from the use of pembrolizumab. Treatment by corticosteroid and meropenem were subsequently switched to cefepime and metronidazole, and this successfully improved his colitis. In this new era of biological-targeted drugs and as clinical experience grows, we recommend a high level of alertness for potential diagnosis of infectious complications.

Evaluating the daily life of child and adolescent psychiatric outpatients during temporary school closure over COVID-19 pandemic: A single-center case-control study in Japan.

This study evaluated the clinical characteristics of mental health of child and adolescent psychiatric patients during temporary school closure throughout the coronavirus 2019 (COVID-19) pandemic in Japan using the Questionnaire - Children with Difficulties (QCD) and other useful psychological rating scales. The participants were those who visited the Department of Child and Adolescent Psychiatry, Kohnodai Hospital. From those 1,463 participants, case and control groups were selected: 92 patients who visited the hospital during the temporary school closure from March 2020 to May 2020 (case group) and randomly sampled sex- and age-matched 92 patients during the pre-COVID period from April 2017 to March 2020 (control group). QCD is a parent-assessed questionnaire designed to evaluate the difficulties of children along the course of a day, right from waking up in the morning to retiring to bed at night. Lower scores indicate stronger difficulties. QCD scores were compared between the two groups in each of the following age groups: elementary school (6-12 years of age) and junior high school (12-15 years of age). In elementary school students, scores "during school" of QCD indicating functioning or disabilities during school hours were 3.31 ± 2.52 and 4.52 ± 2.33 in case group and control group, respectively (p < 0.05). In junior high school students, scores "Attention-Deficit Hyperactivity Disorder Rating Scale (ADHD-RS)" indicating ADHD symptoms were 16.78 ± 12.69 and 11.80 ± 10.40 in case group and control group, respectively (p < 0.05). The findings suggest that the closure of schools due to the pandemic might worsen difficulties among elementary school patients, and hyperactivity and impulsivity might increase among junior high school patients. The long-term impact of stress caused by school closure on child and adolescent psychiatric patients needs to be investigated in the future.

New diagnostic strategy using narrow-band imaging (NBI) during laparoscopic surgery for patients with colorectal cancer.

BACKGROUND: Accurate tumor stage diagnosis during laparoscopic surgery remains difficult. We clarify the impact of new diagnostic strategy using narrow-band imaging (NBI) during laparoscopic surgery for colorectal cancer compared with other strategies. METHODS: We defined angiogenesis (Ag) and fibrosis (Fib) grades using NBI laparoscopy (lap-NBI), and assessed the clinicopathological features associated with these grades for 67 patients with colorectal cancer who underwent surgery. We assessed vessel density and gray scale with computer software. RESULTS: NBI-Ag-grade and NBI-Fib-grade of the serosal surface of cancer lesions and peritoneal nodules correlated with vessel density and gray scale of those assessed by Image J computer software. NBI-Fib-grades of liver nodules also correlated with gray scale. NBI-Ag- grade and Fib-grade of the serosal surface of cancer lesions correlated with pathological depth of invasion. These NBI grades of pathological metastatic peritoneal nodules were higher than those of pathologically benign peritoneal nodules. NBI- Fib grades of pathological metastatic liver nodules were higher than those of pathologically benign liver nodules. In multivariate analysis, lap-NBI was associated with different diagnosis for T3, T4 and non-T3, and non-T4. Moreover, lap-NBI was associated with different diagnosis for T4 and non-T4. Predictive value for T4 by lap-NBI showed high sensitivity (85%) specificity (87%), positive predictive value (74%), negative predictive value (93%), and overall accuracy (87%). Sensitivity and overall accuracy of lap-NBI was superior to that of other diagnostic modalities. CONCLUSION: We clarified the usefulness of the new diagnostic strategy using lap-NBI during laparoscopic surgery for colorectal cancer in comparison with other strategies.

High visceral to subcutaneous fat area ratio predicts early postoperative small bowel obstruction after surgery for colorectal cancer.

PURPOSE: Risks for postoperative small bowel obstruction have been demonstrated in several reports, most of which indicated male sex was a risk factor, but with the reason remaining unknown. We tested the hypothesis that it could be because males have more visceral fat than females. This prospective observational study aims to examine risks of early postoperative small bowel obstruction (EPSBO) after colorectal cancer surgery and the association between visceral to subcutaneous fat area ratio (V/S ratio) and EPSBO. METHODS: Four hundred and seventy-four patients who underwent colectomy for colorectal cancer in our hospital were enrolled in this study. The influence of several factors including V/S ratio on the development of EPSBO was analyzed. RESULTS: Thirty-one of the 474 patients (6.5%) developed EPSBO. EPSBO occurred more frequently in males (p = 0.03) and cases who developed postoperative anastomotic leakage (p < 0.001) or wound infection (p = 0.02). Higher V/S ratio was strongly related to male sex (p < 0.001). Multivariate analysis revealed higher V/S ratio (OR 2.25; p = 0.049) and anastomotic leakage (OR 5.86; p < 0.001) were independent risk factors for EPSBO. CONCLUSION: Higher V/S ratio was significantly related to EPSBO, suggesting that one of the reasons EPSBO was more likely to occur in males because they have more visceral fat than females. Preoperative identification of this risk factor could help us watch out for this potential complication.

What is related to postoperative outcome of frail status in elective colorectal cancer surgery?

Background: The population affected by colorectal cancer is growing, and there is an increasing need for prevention of functional decline following treatment. We proposed that the Kihon Checklist published by the Japanese Ministry of Health, Labor, and Welfare would be an appropriate means of frailty assessment for prediction of postoperative complications in older patients with colorectal cancer. This prospective cohort study aims to identify the factors influencing postoperative frailty. Methods: We prospectively enrolled consecutive patients with colorectal cancer and aged ≥ 65 year (N = 500) between May 2017 and December 2018. Eligible patients were assessed with the Kihon Checklist prior to surgery and 30 days after surgery. The main measures were variables related to postoperative change in view of frail status. Results: According to the Kihon Checklist questionnaire, 164 patients were frail preoperatively and 172 patients were frail postoperatively, whereas 38 patients changed from "nonfrail" before surgery to postoperative "frail." Overall complications were counted in 97 patients (19.4%), and 5 patients died. Performance status ≥ 2, history of laparotomy, open surgery, complication, ostomy creation, and delirium were significantly associated with changing postoperative "frail" (P = .014, P = .023, P = .006, P < .001, P = .023, and P = .024, respectively). In multivariate analysis, independent related factors of changing postoperative "frail" were complication (odds ratio 2.69, 95% confidence interval 1.19-6.09, P = .018) and ostomy creation (odds ratio 2.32, 95% confidence interval 1.01-5.33, P = .047). Conclusion: The Kihon Checklist questionnaire could identify the factors related to postoperative change of frailty status in older patients with colorectal cancer. This cohort concluded that whether postoperative complication occurred or not was closely associated with perioperative change of frailty status.

Prognostic value of CD155/TIGIT expression in patients with colorectal cancer.

INTRODUCTION: The interaction of CD155 with its ligand, the T cell immunoreceptor with Ig and ITIM domains (TIGIT), is being studied owing to its potential to act as a target in the treatment of various solid tumors. However, the relationship between CD155 and TIGIT in colorectal cancer (CRC) prognosis is not known. We hypothesized that the TIGIT-CD155 pathway suppresses the attack of T cells on tumors, thereby affecting CRC prognosis. METHODS: We examined the expression of CD155 and TIGIT using immunohistochemical staining in 100 consecutive patients with CRC who underwent complete resection of ≤Stage III tumors at Wakayama Medical University Hospital between January and December 2013. We assessed the correlation between CD155 and TIGIT expressions and prognosis as well as the clinicopathological background of CD155 and TIGIT. RESULTS: Patients with high CD155 and TIGIT expressions showed worse prognosis than those with other levels of expression (p = 0.026). In multivariate analysis that also included the existing prognostic markers, high CD155 and TIGIT expressions were identified as independent poor prognostic factors. CONCLUSIONS: The interaction between CD155 and TIGIT possibly plays an important role in the immunological mechanism of CRC. Therefore, it may be possible to effectively predict the postoperative prognosis of CRC by evaluating the combined expression of CD155 and TIGIT. The study findings suggest that CD155 and TIGIT can predict clinical outcomes, thereby contributing to the personalized care of CRC.

Appendiceal goblet cell adenocarcinoma with peritoneal recurrence 9 years after surgery.

Goblet cell adenocarcinoma is extremely rare tumor in which the same cells have both exocrine and neuroendocrine properties. It is considered to be more aggressive than conventional carcinoids and more likely to cause metastasis. We report a case of goblet cell adenocarcinoma that developed late peritoneal recurrence, and we review pertinent literature. A 63-year-old male underwent appendectomy for acute appendicitis. Histopathological findings of appendectomy specimen showed mixed adenoneuroendocrine carcinoma, and positive resection margin. He also underwent laparoscopic ileocecal resection and apical lymph node dissection. After 9 years, he presented with ileus and abdominal CT examination indicated possible peritoneal dissemination. Laparoscopic observation revealed disseminated nodules throughout the entire abdominal cavity, and the patient underwent resection of the omental nodule and gastrointestinal bypass surgery. Previous appendectomy specimens showed goblet cell adenocarcinoma (GCA) according to the 5th edition of the WHO classification. Omental specimens confirmed the histopathological findings, and we diagnosed peritoneal recurrence of appendiceal goblet cell adenocarcinoma. Goblet cell adenocarcinoma may develop and cause late recurrence, and long-term follow-up may be required.

[A patient with multiple sclerosis who developed bilateral optic neuritis and central trigeminal myelin lesion].

A 70-year-old woman was admitted to our hospital due to bilateral optic neuritis and left facial sensory disturbance that became exacerbated over 10 days. Both serum and cerebrospinal fluid (CSF) were negative for aquaporin 4 antibody and myelin oligodendrocyte glycoprotein antibody. A high level of myelin basic protein (MBP) in her CSF was observed. Brain MRI showed a high T2 signal and contrast enhancement of the bilateral optic nerve, intramedullary tract and central myelin lesion in the trigeminal nerve. After intravenous methylprednisolone pulse therapy, her visual impairment and facial sensory disturbance gradually improved. She was diagnosed with clinically isolated syndrome, based on 2017 McDonald criteria. A diagnosis of multiple sclerosis (MS) was suspected due to the trigeminal myelin lesion confined to the central myelin portion and high level of MBP in the CSF. Treatment with dimethyl fumarate has been effective for preventing recurrence in 13 months in this patient. The central-peripheral myelin transitional zone at the trigeminal nerve is located 1-6 mm from the pons, where central myelin changes to the peripheral myelin. This patient showed a high T2 signal at the trigeminal nerve 3 mm from the pons on MRI, suggesting the involvement of a central trigeminal myelin lesion. Findings of a central trigeminal myelin lesion on MRI may aid in differentiating between MS and seronegative neuromyelitis optica spectrum disorder.

Case-control study on clinical characteristics of child and adolescent psychiatric outpatients with child-to-parent violence.

OBJECTIVES: To the best of our knowledge, no case-control study on child and adolescent psychiatric outpatients has investigated the clinical characteristics of patients with child-to-parent violence (CPV). The current study aimed to evaluate the clinical characteristics of child and adolescent psychiatric patients with CPV. SETTING AND PARTICIPANTS: This research included child and adolescent psychiatric patients who were aged 10-15 years during their initial consultation. The participants were allocated to one of two groups: children with CPV (CPV group, n=109) and without CPV (non-CPV group, n=713). OUTCOME MEASURES: This study analysed data including age, sex, diagnostic classification of the primary diagnosis, antisocial behaviour, suicidal attempt or self-harm and refusal to attend school. Moreover, a history of abuse by parents was investigated. Psychological rating scales such as the Spence Children's Anxiety Scale, Depression Self-Rating Scale for Children, Tokyo Autistic Behavior Scale, Attention-deficit/Hyperactivity Disorder-Rating Scale and Oppositional Defiant Behavior Inventory were used. RESULTS: Of 822 patients who sought consultation in our department, 109 (13.26%) were included in the CPV group during the first consultation. Compared with the non-CPV group, the CPV group had significantly higher proportions of patients who experienced physical abuse, psychological abuse and who witnessed violence between parents. Meanwhile, the proportion of patients with neurodevelopmental disorders was significantly higher in the CPV group than in the non-CPV group. Regarding developmental characteristics, impulsivity might be correlated with CPV. Moreover, violence and behavioural problems outside of home were associated with CPV. CONCLUSIONS: In patients with CPV who sought consultation, the findings of the current study should be considered to understand invisible side and to facilitate the use of appropriate treatment approaches. However, a prospective study should be performed to investigate the causality between CPV and clinical characteristics.

Current use of attention-deficit hyperactivity disorder (ADHD) medications and clinical characteristics of child and adolescent psychiatric outpatients prescribed multiple ADHD medications in Japan.

BACKGROUND/AIM: Patients with attention-deficit hyperactivity disorder (ADHD) manifest symptoms of hyperactivity, impulsivity, and/or inattention. ADHD medications available in Japan are limited compared with those in Western countries. Prescribing status has not been sufficiently evaluated in clinical settings in Japan. This study investigated the current use of ADHD medications and characteristics of patients who received multiple ADHD medications in a clinical setting in Japan. METHODS: Study participants were those who visited the Department of Child and Adolescent Psychiatry, Kohnodai Hospital between April 2015 and March 2020. We investigated patients who received osmotic-controlled release oral delivery system methylphenidate, atomoxetine, or guanfacine. A retrospective case-control design was used to evaluate the characteristics of patients who received multiple ADHD medications. Patients who were given three ADHD medications were defined as the case group. Randomly sampled sex- and age-matched patients diagnosed with ADHD were defined as the control group. We compared data for child-to-parent violence, antisocial behavior, suicide attempt or self-harm, abuse history, refusal to attend school, and two psychological rating scales (the ADHD-Rating Scale and Tokyo Autistic Behavior Scale). RESULTS: Among the 878 patients who were prescribed any ADHD medications, 43 (4.9%) received three ADHD medications. Logistic regression revealed that children with severe ADHD symptoms, autistic characteristics, or tendency of child-to-parent violence were more likely to have been prescribed three medications during their treatment. CONCLUSIONS: Our findings suggest the approach to prevent the use of multiple ADHD medications. A prospective study to investigate the causality between prescribing status and clinical characteristics is warranted.

Care for children's mental health during the COVID-19 pandemic in Japan.

COVID-19 causes very serious issues all over the world. In Japan, the number of new infections in Tokyo exceeded 2,000 for the first time on 7 January 2021, and the situation is becoming increasingly serious. Japan is in the midst of its third big outbreak. Japanese society will face several challenges regarding children's mental health during the COVID-19 pandemic. In order to develop healthy minds in children, it is important to view the changes in children's minds in a positive light and promote their healthy emotional development while correctly fearing COVID-19. This sense of social stagnation and uncertainty is likely to increase feelings of insecurity and isolation among children. It is also important to prevent the repetition of child abuse in the home due to parental unemployment, alcohol problems, and reduced contact with non-family members in stay home and the recession as a result of COVID-19. During the pandemic, adults should be sensitive to the unusual behavior of children. We propose six suggestions of care for children during the COVID-19 pandemic.

Laparoscopic anterior resection with or without transanal tube for rectal cancer patients - A multicenter randomized controlled trial.

BACKGROUND: In rectal cancer surgery, insertion of transanal tube has been shown to have efficacy to prevent anastomotic leakage. This randomized controlled study aims to clarify the incidence of anastomotic leakage with or without transanal tube in patients with rectal cancer. METHODS: Patients who underwent elective low anterior resection were randomly allocated to either have transanal tube insertion or not for five days after surgery. We examined the incidence of anastomotic leakage, postoperative 30-day morbidity and mortality. RESULTS: 157 patients were randomized to the transanal tube group or the no-transanal tube group. Symptomatic anastomotic leakage occurred in six patients (7.6%) of the former group and eight patients (10.3%) in the latter group, without significant difference (p = 0.559). There was also no significant difference in morbidity between groups (p = 0.633) and no mortality was detected. CONCLUSIONS: Transanal tube insertion had no significant benefit towards prevention of anastomotic leakage in rectal cancer surgery.

Preoperative detection of KRAS mutated circulating tumor DNA is an independent risk factor for recurrence in colorectal cancer.

Preoperative ctDNA status in relation to recurrence in cases of CRC remains unclear. We examined preoperative ctDNA detection by targeting KRAS gene mutations as a predictive marker for recurrence after CRC surgery. We measured the preoperative KRAS mutated ctDNA status and analyzed the correlation with clinicopathologic features of 180 patients that underwent surgery for CRC. We studied the association between preoperative KRAS mutated ctDNA and postoperative recurrence in patients (n = 150) that underwent radical surgery. KRAS mutated ctDNA was detected in 59 patients (32.8%). Median mutant allele frequency of KRAS in ctDNA was 0.20%. KRAS status in ctDNA and lymph node metastasis and distant metastasis were not significantly different. Among patients that underwent radical resection, recurrence occurred in 21 (14.0%, median follow-up 24 months). In Kaplan-Meier analysis, preoperative detection of KRAS mutated ctDNA was associated with inferior recurrence-free interval (RFI) (p = 0.002) and recurrence-free survival (RFS) (p = 0.025). In a multivariate Cox proportional hazards model, preoperative detection of KRAS mutated ctDNA was an independent factor related to both RFI (HR = 3.08; p = 0.012) and RFS (HR = 2.18; p = 0.044). Preoperative measurement of KRAS mutated ctDNA could be useful to decide postoperative treatment.

Optimal Assessment of Frailty Predicts Postoperative Complications in Older Patients with Colorectal Cancer Surgery.

OBJECTIVES: The increasingly elderly worldwide population has affected the incidence of colorectal cancer. Establishment of reliable assessment of frailty and proposals for multi-disciplinary interventions are urgently required in oncology practices. Kihon Checklist (KCL) was published by the Japanese Ministry of Health, Labor and Welfare originally to identify individuals ≥ 65 years old at probable risk for requiring care or social support. We investigate the validity of KCL for frailty assessment to predict postoperative complication in older patients with colorectal cancer. METHODS: Consecutive colorectal cancer patients aged ≥ 65 (n = 500) were prospectively examined between May 2017 and December 2018. Preoperative frailty assessment was conducted by the G8 questionnaire and KCL. The main outcome measures were correlation between frailty, other clinical variables, and postoperative complications within 30 days after elective surgery. RESULTS: Of the 500 patients, 278 (55.6%) and 164 (32.8%) patients were classified as 'frail' by G8 and KCL, respectively. Overall complications counted among 97 patients (19.4%), and they were significantly associated with KCL ≥ 8-frail (46/164, p = 0.001), as opposed to G8 ≤ 14-frail (56/278, p = 0.531). Multivariate analysis showed that KCL ≥ 8 (hazard ratio 1.88, 95% confidence interval 1.16-3.04, p = 0.011) was an independent risk factor for these complications. CONCLUSIONS: KCL assessment can identify frail older patients likely to suffer from postoperative complications after colorectal cancer surgery. Preoperative screening of frailty, particularly by KCL, would help older patients prevent their worse outcomes in colorectal cancer. TRIAL REGISTRATION: UMIN000026689.

Small intestinal arteriovenous malformation treated by laparoscopic surgery using intravenous injection of ICG: Case report with literature review.

INTRODUCTION: Approximately 5 % of gastrointestinal bleeding is due to small intestinal bleeding. Bleeding from small intestinal arteriovenous malformation (AVM) is rare, with few reported cases. Finding the precise location and boundary is difficult during surgery, so we tried using intravenous injection of indocyanine green (ICG). Use of ICG in a case of intestinal AVM is reported here for the first time, with a review of the literature. PRESENTATION OF CASE: A 48-YEAR-old male had anemia and low hemoglobin level (Hb) 4.0 g/dL. After several examinations including small intestinal endoscopy, capsule endoscopy and angiography, AVM was identified. Preoperative diagnosis was AVM caused by branching of the ileocolic artery (ICA). Meanwhile, macroscopy showed engorgement of the vein in the ileum wall and mesentery, the boundary of which was unclear. We performed intra-operative monitoring with ICG. After intravenous injection of ICG, the boundary and location became clear. The abnormal ileum was 30 cm in length and located 130 cm from the Treitz ligament, which was different from angiographic findings. Pathology showed dilated vascular hyperplasia of the submucosa, tunica and chorionic membrane. Final diagnosis was ileum AVM. The postoperative course was uneventful and gastrointestinal bleeding stopped. CONCLUSIONS: ICG monitoring aided diagnosis and treatment of Ileum AVM, which was treated by laparoscopic surgery.

Quantitative Indocyanine Green Fluorescence Imaging Used to Predict Anastomotic Leakage Focused on Rectal Stump During Laparoscopic Anterior Resection.

Background: Anastomotic leakage (AL) is arguably the most troublesome complication of anterior resection (AR). In recent years, however, indocyanine green (ICG) fluorescence imaging has been recently used to evaluate blood flow in the anastomosis site, and it has been suggested that AL may be predicted. We reported the effectiveness of predicting AL in colorectal cancer surgery by observing a quantitative laparoscopic ICG fluorescence imaging for the first time. The purpose of this study was to predict the risk of postoperative AL by quantitative laparoscopic ICG fluorescence imaging focused on the rectal stamp, which is one of the major causes of AL in AR, and to construct diverting stoma (DS) only in appropriate cases. Methods: We studied the 25 patients who underwent elective laparoscopic AR for rectal cancer at our hospital between July 2016 and June 2017. Before enforcing double-stapling technique anastomosis, we injected ICG intravenously, and laparoscopically evaluated blood flow on the rectal stump. We analyzed quantitatively the relationship between various parameters and AL. Results: Median T0, from when the ICG was injected intravenously and the ICG disappeared from the injection route to the rise of the histogram of intensity, in AL group was significantly longer than that in non-AL group (P = .03). There were no other significant differences between AL and non-AL groups. Conclusions: T0 was longer in patients with AL than in those without. If prolonged T0 can be recognized intraoperatively, it will be possible to construct DS for appropriate patients only.