[A Case of Clostridium difficile Enteritis with Ileostomy for Rectal Cancer Surgery].

A 74-year-old male presenting with bloody stools was diagnosed with advanced rectal cancer. He underwent robot- assisted low anterior resection and temporary ileostomy. Cefmetazole(CMZ)was administered during surgery and on postoperative day(POD)1. His postoperative course was generally good. On POD8, he developed abdominal fullness, vomiting, renal dysfunction, and hyperkalemia. Plain CT revealed small bowel ileus and outlet obstruction with ileostomy was suspected. A nasogastric tube was placed in the stomach, and a balloon catheter was inserted from the ileostomy to the oral side of the ileum. The patient went into shock on the same day and was transferred to a high-care unit. Contrast-enhanced CT indicated pneumatosis intestinalis of the small bowel and portal venous gas. However, the wall of the small bowel was enhanced, so the patient was observed carefully without attempting an operation. The patient's condition improved with systemic management. On POD10, a stool culture from the ileostomy tested positive for CD toxin. Clostridium difficile enteritis(CDE)was diagnosed. The condition improved with systemic control. On POD52, paralytic ileus recurred, and his stool tested positive for the CD toxin again. The ileus improved with conservative treatment. On POD70, the patient was transferred to the hospital for rehabilitation. We report a case of CDE with ileostomy for rectal cancer surgery.

Decision-making in postoperative chemotherapy for ovarian metastasis from colorectal cancer: a retrospective single-center study.

BACKGROUND: Ovarian metastases from colorectal cancer are relatively uncommon, and no consensus has been reached regarding resection of metastases or chemotherapy before and after surgery. We evaluated the clinicopathological characteristics of ovarian metastases from colorectal cancer and the impact of metastatic resection. We also performed a comparative analysis to clarify the prognostic impact of metastatic resection and the choice of chemotherapy before and after surgery. METHODS: Between 2006 and 2014, 38 patients at our institution underwent resection of ovarian metastases from colorectal cancer. Clinicopathological data were extracted from the patients' records and evaluated with respect to the long-term outcome. For 15 patients with metachronous ovarian metastases who received chemotherapy until immediately before resection, we compared the prognosis with and without changes in the regimen after resection. RESULTS: The 5-year overall survival rate was 19.9%, and the median survival duration was 27.2 months. The survival rate in the R0 resection group (n = 8) was significantly better than that in the R1/2 resection group (n = 30) (P = 0.0004). Patients without peritoneal dissemination (n = 15) or extra-ovarian metastases (n = 31) had a significantly better prognosis than those with peritoneal dissemination (n = 23) or extra-ovarian metastases (n = 7) (P = 0.040 and P = 0.0005, respectively). The progression-free survival and median survival times of patients who resumed chemotherapy after resection without a change in their preoperative regimen were 10.2 months and 26.2 months, respectively, while those among patients with a change in their regimen before resection versus after resection were 11.0 months and 18.1 months, respectively. The difference between the two groups was not statistically significant (progression-free survival time and median survival time: P = 0.52 and P = 0.48, respectively). CONCLUSIONS: Patients who underwent R0 resection of ovarian metastases clearly had a better prognosis than those who underwent R1/2 resection. Additionally, a poor prognosis was associated with the presence of peritoneal dissemination and extra-ovarian metastases. The data also suggested that resumption of chemotherapy without changing the regimen after resection could preserve the next line of chemotherapy for future treatment and improve the prognosis.

Emergency gastrointestinal surgery in patients undergoing antithrombotic therapy in a single general hospital: a propensity score-matched analysis.

BACKGROUND: This study aimed to review and evaluate the surgical outcomes, particularly intraoperative severe blood loss and postoperative blood complications, of emergency gastrointestinal surgery in patients undergoing antithrombotic therapy (AT). Emergency surgeries for patients with antithrombotic medication have been increasing in the aging population. However, the effect of AT on intraoperative blood loss and perioperative complications remains unclear. METHODS: We retrospectively reviewed 732 patients who underwent emergency gastrointestinal surgery between April 2014 and March 2019. Patients were classified into AT group and Non-AT group, and propensity score-matched analysis was performed to compare the short surgical outcomes between the groups. Additionally, risk factors in severe estimated blood loss (EBL) and postoperative bleeding complications were assessed. RESULTS: Altogether, 64 patients received AT; 50 patients and 12, and 2 were given antiplatelet and anticoagulant, and both drugs, respectively. After propensity score matching, EBL (101 vs. 99 mL; p = 0.466) and postoperative complications (14 vs. 16 patients; p = 0.676) were similar between the groups (63 patients matched paired). Intraoperative severe bleeding (EBL ≥ 492 mL) occurred in 44 patients. Multivariate analysis using the full cohort revealed that antithrombotic drug use was not an independent risk factor for severe bleeding and postoperative bleeding complications. CONCLUSIONS: This study demonstrated antithrombotic drugs do not adversely affect the perioperative outcomes of emergency gastrointestinal surgery.

Emergency laparoscopic ileocecal resection for a low-grade appendiceal mucinous neoplasm with impending rupture: A case report.

INTRODUCTION AND IMPORTANCE: We report the case of a patient with a low-grade appendiceal mucinous neoplasm (LAMN) who underwent emergency laparoscopic ileocecal resection to avoid the metastatic spread of tumor cells due to an impending rupture. CASE PRESENTATION: A 55-year-old woman presented to our hospital with pain in the right lower quadrant of the abdomen. Computed tomography revealed a markedly tense appendiceal mucinous tumor with surrounding inflammation, and laboratory test results showed elevated serum C-reactive protein (7.47 mg/dL), indicating impending rupture of the appendix. Magnetic resonance imaging revealed nodules inside the appendix, suggesting the possibility of appendiceal cancer. We performed emergency laparoscopic ileocecal resection with regional lymph node dissection. The tumor was pathologically diagnosed as a LAMN without rupture. CLINICAL DISCUSSION: LAMN is classified as a clinically malignant tumor because it can cause pseudomyxoma peritonei due to perforation or the presence of residual tissue. Although an appendectomy would be appropriate for LAMN if the tumor margin is secured, ileocecal resection with lymph node dissection is necessary when preoperative discrimination of appendiceal cancer is impossible. CONCLUSION: Further studies of preoperative imaging for appropriate differential diagnosis were necessary.

Modified sensory feedback enhances the sense of agency during continuous body movements in virtual reality.

The sense of agency refers to the feeling of control over one's own actions, and through them, the external events. This study examined the effect of modified visual feedback on the sense of agency over one's body movements using virtual reality in healthy individuals whose motor control was disturbed. Participants moved a virtual object using their right hand to trace a trajectory (Experiment 1) or a leading target (Experiment 2). Their motor control was disturbed by a delay in visual feedback (Experiment 1) or a 1-kg weight attached to their wrist (Experiment 2). In the offset conditions, the virtual object was presented at the median point between the desired position and the participants' actual hand position. In both experiments, participants reported improved sense of agency in the offset condition compared to the aligned condition where the visual feedback reflected their actual body movements, despite their motion being less precise in the offset condition. The results show that sense of agency can be enhanced by modifying feedback to motor tasks according to the goal of the task, even when visual feedback is discrepant from the actual body movements. The present study sheds light on the possibility of artificially enhancing body agency to improve voluntary motor control.

[Two Cases of Pneumocystis Jirovecii Pneumonia during Chemotherapy for Gastrointestinal Cancer].

BACKGROUND: In recent years, there has been an increasing incidence of Pneumocystis jirovecci pneumonia(PCP)in immunosuppressed non-HIV patients. However, only a few studies on PCP developed during chemotherapy for gastrointestinal cancer have been reported. Case 1: A 72-year-old man was complaining of dyspnea during chemotherapy for unresectable gastric cancer. The patient showed high ß-D-glucan levels, and his sputum tested positive for sputum Pneumocystis PCR. Even after TMP-SMX administration, the patient's respiratory condition worsened; hence, intubation was needed. Finally, he died without showing any improvement. Case 2: A 75-year-old man underwent chemotherapy for a recurrence of cecal cancer and received steroid pulse for adverse events of optic neuritis. However, his respiratory condition worsened. Furthermore, his sputum tested positive for Pneumocystis PCR. Intensive care including TMP-SMX administration followed to improve his condition. DISCUSSION: PCP with non-HIV has a more acute onset and a poorer prognosis than that with HIV. It is necessary to identify PCP when there is a rapid progression of respiratory symptoms and pneumonia in cancer patients undergoing chemotherapy or steroid treatment.

[A Case of Duodenal Cancer with Advanced Lymph Node Metastasis Treated with mFOLFOX6 Preoperative Chemotherapy].

A 60-year-old man underwent surgical distal gastrectomy 10 years prior to receiving treatment for stomach cancer. He visited our hospital with complaints of abdominal fullness and weight loss. Abdominal computed tomography(CT)revealed intestinal blockage starting at the duodenum near the Treitz ligament. During upper alimentary canal endoscopy, a type 2 tumor coveringthe entire circumference of the horizontal duodenum was found, and biopsy results indicated that the tumor was a well-differentiated adenocarcinoma. Although no distant metastasis was observed in the abdominal CT scan, multiple attached bulky lymph nodes were observed leadingto a suspicion of metastasis. Finally, the patient was diagnosed as having progressive duodenal cancer accompanied with advanced lymph node metastasis. A gastrojejunal bypass surgery with laparoscopy was performed. When the patient's overall condition improved, mFOLFOX6 chemotherapy was started, and 6 courses were completed. As the sizes of the primary tumor and bulky lymph nodes decreased, surgery to completely remove the cancer was performed. UFT/UZEL supplemental postoperative chemotherapy was administered for 6 months. The patient remained alive, with no remissions 3 years post-surgery.

[Two Cases of Peritoneal Dissemination of Gastric Cancer Treated with CART Followed by Chemotherapy].

BACKGROUND: Cell-free and concentrated ascites reinfusion therapy(CART)is useful for relief of the symptoms caused by malignant ascites. We experienced 2 cases of untreated gastric cancer with massive ascites due to peritoneal dissemination, to whom chemotherapy was successfully introduced as a result of improvement of general conditions achieved by CART. Case 1: A 56-year-old woman with massive ascites was introduced for the treatment of gastric cancer. After a CART, oral ingestion became possible and S-1 plus oxaliplatin(SOX)therapy was introduced. Three courses of SOX therapy were possible until just before her death with 6 times of maintenance CART in total. Case 2: An 80-year-old man was introduced for the same reason. After a CART, he was treated with 4 courses of trastuzumab plus capecitabine plus oxaliplatin(Tra plus CapeOX)therapy with 5 times of maintenance CART in total. DISCUSSION: CART is useful for alleviating symptoms caused by malignant ascites and makes systemic chemotherapy possible because it improves and maintains the general conditions.

Laparoscopic surgery for repeated cecal volvulus with intestinal malrotation: A case report.

This is the first report of laparoscopic surgery for an advanced-age patient with cecal volvulus accompanied by intestinal malrotation. A 96-year-old woman who had previously undergone laparotomy for cecal volvulus underwent emergency laparoscopic surgery for recurrent volvulus. Because the cecum was about to rupture but not ischemic, we untwist the intestinal volvulus and fixed the cecum to the abdominal wall with a single suture. Five days after the surgery, the volvulus between the suture and the hepatic flexure of the colon recurred. We performed a second laparoscopic surgery in which we fixed the right side of the colon to the abdominal wall after diagnosing intestinal malrotation. Given its positioning, the sign of malrotation would not have been visible on preoperative CT images. As shown by this case, intestinal malrotation might lie behind the repeated cecal volvulus, and laparoscopic surgery may be a good option for volvulus with intestinal malrotation, even in cases with obstruction.

Improvement of Sense of Agency During Upper-Limb Movement for Motor Rehabilitation Using Virtual Reality.

Sense of agency refers to the feeling of controlling one's own body. Many patients surviving from a stroke lose the sense of agency over their body. This is due to impairments in both motor control and sensory brain functions. As a result of this lack in the sense of agency, stroke patients tend to lose the intention of moving the paralyzed limb, which results in further deterioration of brain functions and worsening muscles and joints. The present study proposes a motor rehabilitation system using virtual reality to improve the sense of agency during upper-limb movement which is required for various daily life activities such as eating meals and operating devices. Specifically, participants were instructed to move their hand to track a moving target ball in a virtual reality environment, while the position of their real hand was measured via a motion capture system. Participants were shown another ball presenting the position of their hand in virtual reality. We tested the proposed system with healthy participants, of which the motor control was disturbed by a 1-kg weight attached on the wrist. Participants reported their sense of agency after each trial. The results showed that the sense of agency was enhanced by the proposed intervention. Our results pointed out a potentially useful method to improve the sense of agency during body movements using modified visual feedback, which may contribute to the development of rehabilitation for stroke patients.

The Readiness Potential Reflects the Reliability of Action Consequence.

Humans are capable of associating actions with their respective consequences if there is reliable contingency between them. The present study examined the link between the reliability of action consequence and the readiness potential (RP), which is a negative potential observed from about 1-2 s prior to the onset of an action with electroencephalography. In a condition of constant outcome, the participants' voluntary action always triggered beep sounds; thus, they were able to perceive the contingency between their action and the sound. In contrast, in a condition of inconstant outcome, the participants' actions only triggered the sound in half the trials. We found that both the early and late RPs were larger in the condition of constant compared to the condition of inconstant outcome. Our results showed that the RPs preceding the voluntary action reflected the reliability of action consequence. In other words, the action-effect contingency enhanced neural activities prior to the action.

Strength of Intentional Effort Enhances the Sense of Agency.

Sense of agency (SoA) refers to the feeling of controlling one's own actions, and the experience of controlling external events with one's actions. The present study examined the effect of strength of intentional effort on SoA. We manipulated the strength of intentional effort using three types of buttons that differed in the amount of force required to depress them. We used a self-attribution task as an explicit measure of SoA. The results indicate that strength of intentional effort enhanced self-attribution when action-effect congruency was unreliable. We concluded that intentional effort importantly affects the integration of multiple cues affecting explicit judgments of agency when the causal relationship action and effect was unreliable.

Goal-Directed Movement Enhances Body Representation Updating.

Body representation refers to perception, memory, and cognition related to the body and is updated continuously by sensory input. The present study examined the influence of goals on body representation updating with two experiments of the rubber hand paradigm. In the experiments, participants moved their hidden left hands forward and backward either in response to instruction to touch a virtual object or without any specific goal, while a virtual left hand was presented 250 mm above the real hand and moved in synchrony with the real hand. Participants then provided information concerning the perceived heights of their real left hands and rated their sense of agency and ownership of the virtual hand. Results of Experiment 1 showed that when participants moved their hands with the goal of touching a virtual object and received feedback indicating goal attainment, the perceived positions of their real hands shifted more toward that of the virtual hand relative to that in the condition without a goal, indicating that their body representations underwent greater modification. Furthermore, results of Experiment 2 showed that the effect of goal-directed movement occurred in the active condition, in which participants moved their own hands, but did not occur in the passive condition, in which participants' hands were moved by the experimenter. Therefore, we concluded that the sense of agency probably contributed to the updating of body representation involving goal-directed movement.

Recurrent colorectal cancer after endoscopic resection when additional surgery was recommended.

AIM: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation. METHODS: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended. RESULTS: The recurrence patterns were: intramural local recurrence (five cases), regional lymph node recurrence (three cases), and associated with simultaneous distant metastasis (three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases (enteritis). CONCLUSION: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.