A prospective clinical study evaluating short-term changes in body composition and quality of life after gastrectomy in elderly patients receiving postoperative exercise and nutritional therapies.

BACKGROUND: Muscle mass loss after gastrectomy is associated with a negative impact on quality of life (QOL) and long-term prognosis following gastric cancer treatment, especially in elderly patients. We conducted a prospective study to examine short-term changes in body composition and QOL after gastrectomy in elderly patients with gastric cancer who received exercise and nutritional therapies. METHODS: Patients over aged 65 years of age who underwent gastrectomies for gastric cancer were enrolled in our study. Patients received exercise and nutritional therapies with branched-chain amino acid (BCAA)-rich supplements during 1 month after surgery. Body composition was evaluated using InBody S10 before surgery, and at 1 week and 1 month postoperatively. Other variables including QOL status (EQ-5D-5 L), serum albumin level, hand grip strength, and gait speed were evaluated at the same time. RESULTS: Eighteen patients were analyzed. The mean loss of skeletal muscle mass index (SMI) was 4.6% (1 week) and 2.1% (1 month) compared to the preoperative period. QOL scores showed almost the same degree of recovery at 1 month after gastrectomy as preoperative scores. Serum albumin levels, hand grip strength, and gait speed decreased at 1 week and then increased at 1 month after surgery, similar to the changes seen in SMI. CONCLUSIONS: Multidisciplinary approaches play key role in the surgical treatment of elderly patients. Postoperative exercise and nutritional therapies with BCAA-rich supplements may benefit elderly patients after gastrectomy by reducing loss of SMI and decreases in QOL. TRIAL REGISTRATION: UMIN Clinical Trials Registry; UMIN000034374 (registration date: 10/10/2018).

Risk factors associating with delayed gastric emptying after laparoscopic distal gastrectomy.

PURPOSE: The aim of this study was to investigate the incidence of delayed gastric emptying among the patients receiving laparoscopic distal gastrectomy, and to explore their clinical features and risk factors. METHODS: Clinical data were collected for 223 patients who underwent laparoscopic distal gastrectomy for gastric cancer. We retrospectively evaluated the clinicopathological features and analyzed the incidence of delayed gastric emptying among 223 patients. Delayed gastric emptying was diagnosed by patient's symptoms and the plane radiograph with an air fluid level and dilation of the remnant stomach. RESULTS: Delayed gastric emptying was found in five (2.2%) of the 223 patients. By univariate logistic regression analysis, greater American Society of Anesthesiologists Physical Status (ASA-PS) and older age were significantly related to occurrence of delayed gastric emptying. By multivariate logistic regression analysis, older age was independently significantly related to incident delayed gastric emptying. The area under the curve (AUC) ((95% CI) of the receiver operating characteristic (ROC) was 0.842 (0.561-0.957). The best cutoff for discriminating patients with and without delayed gastric emptying was 80 years (sensitivity 80% and specificity 83%). CONCLUSION: Our study found the occurrence of delayed gastric emptying is possibly correlated with age. Therefore, careful perioperative observation in elderly patients may possibly be important for possible development of delayed gastric emptying after laparoscopic distal gastrectomy.

Repair of a perineal hernia with a bladder patch after abdominoperineal resection: A case report and literature review.

Perineal hernia is the protrusion of the intra-abdominal viscera through the pelvic floor. It rarely occurs after abdominoperineal resection but has increasingly occurred after surgical treatment for rectal cancer. A patient was diagnosed as having perineal hernia 10 days after laparoscopic abdominoperineal resection with preoperative radiotherapy and chemotherapy. He presented with epigastric discomfort and perineal wound dehiscence. Perineal hernia was confirmed by computed tomography scan and treated with a semi-emergency surgery. The surgical field was contaminated because of the perineal wound dehiscence. The levator muscle at the pelvic floor was not sufficient, so we used a bladder patch to cover the pelvic inlet. The surgery was performed without any adverse events. To our best knowledge, this is the first case report to present the usefulness of a bladder patch for the treatment of a perineal hernia using a laparoscopic transabdominal approach in emergency situations.

[Effect of Post-Gastrectomy Adjuvant S-1 Chemotherapy on Muscle Volume in Gastric Cancer Patients].

OBJECTIVE: To examine the effect of S-1 adjuvant chemotherapy on muscle volume after curative gastrectomy in gastric cancer patients. PATIENTS: Forty-eight gastric cancer patients (31 men and 17 women) who underwent curative gastrectomy (distal gastrectomy: n=37, and total gastrectomy: n=11) between April 2010 and July 2011 were enrolled in this study. Sixteen patients underwent S-1 adjuvant chemotherapy (S-1 group) for 1 year after the operation, and 32 patients did not (NT group). METHODS: The psoas muscle areas were measured at the fourth lumbar vertebrae on CT images obtained before the operation, and at 6, 12, and 24 months after the operation. Muscle areas was statistically examined by comparing the preoperative and postoperative ratios. RESULTS: The muscle areas 12 months after the operation decreased to 0.86 ± 0.11 in the S-1 group and to 0.96 ± 0.08 in the NT group (p<0.05), and the significant difference disappeared at 24 months (0.93 ± 0.10 vs. 0.93 ± 0.11, NS). In the patients who underwent distal gastrectomy, the muscle areas decreased to 0.90 ± 0.05 in the S-1 group and to 0.96 ± 0.09 in the NT group at 12 months (p<0.05). Meanwhile, in those who underwent total gastrectomy, the muscle areas decreased to 0.80 ± 0.15 and 0.93 ± 0.03, respectively (NS). CONCLUSIONS: S-1 adjuvant chemotherapy affected muscle volume loss after gastrectomy in the gastric cancer patients, but the patients recovered from the adverse effect by 12 months after chemotherapy.

[A case of a patient with giant mucinous cystadenocarcinoma who presented with abdominal pain].

We report a case of a patient in whom a giant mucinous cystadenocarcinoma was treated with distal pancreatectomy. A 37-year-old woman was admitted to the hospital complaining of intermittent epigastric pain. The laboratory data revealed a marked increase in serum levels of carcinoembryonic antigen( CEA 22 ng/mL), cancer antigen( CA) 19-9( 258,129 U/ mL), and CA125 (53 U/mL). A computed tomography (CT) scan revealed a cystic tumor, 15 cm in diameter, in the body of the pancreas. The tumor presented as a multilocular cyst with enhanced nodules. On positron emission tomography (PET)-CT,[ 18F] fluorodeoxyglucose uptake by the nodules of the cyst was noted. Under the diagnosis of malignant mucinous cystic neoplasm, we performed distal pancreatectomy, splenectomy, partial gastrectomy, and left adrenalectomy because the tumor was suspected to be invading the stomach and left adrenal gland. The tumor was histologically diagnosed as invasive mucinous cystadenocarcinoma with ovarian-like stroma. The patient survived for 14 months after surgery without tumor recurrence. Invasive mucinous cystadenocarcinoma of the pancreas has high rates of lymph node metastasis and early recurrence after surgery. We believe that we would have had to perform complete tumor resection equivalent to that of invasive ductal carcinoma of the pancreas if the mucinous cystic neoplasm was found to be malignant preoperatively.

Magnetic resonance evaluation of the associations of thoracic and abdominal aortic plaques with the presence and extent of coronary artery stenosis.

The association between coronary artery disease (CAD) and thoracic aortic plaques has often been reported using transesophageal echocardiography. However, studies showing the association between CAD and abdominal aortic plaques are scarce. CMR can visualize plaques in both the thoracic and abdominal aortas. Using CMR, we investigated the associations of thoracic and abdominal aortic plaques with the presence and extent of coronary artery stenosis in 146 patients undergoing coronary angiography, of whom 108 had CAD. The prevalence of thoracic and abdominal aortic plaques was higher in patients with CAD than in those without CAD (73% and 94% vs. 32% and 79%, p < 0.025). Stepwise increases in the prevalence and extents of both thoracic and abdominal plaques were found depending on the number of stenotic coronary vessels. Plaque extent in the thoracic aorta correlated with the numbers of > 50% and > 25% stenotic coronary segments (rs = 0.30 and 0.41). Plaque extent in the abdominal aorta also correlated with the numbers of > 50% and > 25% stenotic segments (rs = 0.40 and 0.44). Notably, the total plaque extent in the aortas correlated best with the numbers of > 50% and > 25% stenotic coronary segments (rs = 0.41 and 0.49, p < 0.001), and this factor was found to be the best predictor for the presence of CAD by the receiver-operating-characteristics curve analysis. Thus, the total plaque extent in the aortas was found to be more closely associated with the presence and extent of coronary stenosis than the thoracic or abdominal aortic plaque extent.

A possible association between coronary plaque instability and complex plaques in abdominal aorta.

OBJECTIVE: Coronary plaque instability causes myocardial infarction (MI). Angiographic lesions with such instability are complex lesions. Complex carotid plaques were reported to be prevalent in unstable angina. We investigated associations between coronary plaque instability, such as MI and angiographic complex coronary lesions, and aortic plaques. METHODS AND RESULTS: Aortic MRI was performed in 146 patients undergoing coronary angiography, of whom 108 had coronary artery disease (CAD) and 44 also had MI. Prevalence of plaques in thoracic and abdominal aortas was higher in patients with than without CAD (73% and 94% versus 32% and 79%), but it was similar in CAD patients with and without MI. Notably, complex plaques in abdominal aorta were more prevalent in CAD patients with than without MI (36% versus 14%; P<0.025). In multivariate analysis, abdominal complex plaques were associated with MI (odds ratio [OR], 4.5; 95% CI, 1.5 to 13.8). Among patients without MI, thoracic and abdominal complex plaques were more prevalent in patients with than without complex coronary lesions (22% and 33% versus 2% and 7%; P<0.05). Abdominal complex plaques were also associated with complex coronary lesions (OR, 9.8; 95% CI, 1.1 to 85.9). CONCLUSIONS: Complex plaques in abdominal aorta were associated with MI and complex coronary lesions, suggesting a link between coronary and aortic plaque instability.

In vivo magnetic resonance evaluation of associations between aortic atherosclerosis and both risk factors and coronary artery disease in patients referred for coronary angiography.

BACKGROUND: Magnetic resonance imaging was recently reported to detect atherosclerotic plaques in thoracic and abdominal aortas. METHODS: Using magnetic resonance imaging, we investigated associations of risk factors and plasma inflammatory markers with plaques in both thoracic and abdominal aortas in 102 patients undergoing coronary angiography. Associations between coronary artery disease (CAD) and aortic plaques were also evaluated. RESULTS: Plaques in thoracic and abdominal aortas were detected in 61% and 90% of patients, respectively. Age and systolic blood pressure correlated with plaque extents in both the aortas. Serum LDL cholesterol level correlated with plaque extent in the thoracic aorta (r(s) = 0.42). The degree of smoking correlated with plaque extent in the abdominal aorta (r(s) = 0.43). In multivariate analysis, age and systolic blood pressure were associated with plaques in both the aortas. The LDL cholesterol and smoking were characteristically associated with plaques in the thoracic and abdominal aortas, respectively. Regarding inflammatory markers, fibrinogen and C-reactive protein levels correlated with total plaque extent in the aortas (r(s) = 0.50 and r(s) = 0.51). Compared with 24 patients without CAD, 78 with CAD more often had plaques in the thoracic (71% vs 29%) and abdominal (95% vs 75%) aortas. Although plaque extents in both the aortas correlated with the severity of CAD, only thoracic plaques were independently associated with CAD. CONCLUSIONS: The thoracic and abdominal aortas may have different susceptibilities to risk factors. However, plasma inflammatory markers appear to reflect total extent of aortic atherosclerosis. Although aortic plaques are common in patients with CAD, only thoracic plaques are an independent factor for CAD.

Pulmonary vein dimensions and variation of branching pattern in patients with paroxysmal atrial fibrillation using magnetic resonance angiography.

UNLABELLED: Pulmonary veins are the most frequent origin of focal and paroxysmal atrial fibrillation. Although radiofrequency ablation has been attempted for the treatment of focal and paroxysmal atrial fibrillation, the anatomy of the pulmonary vein is still not fully understood. To investigate the dimensions and anatomical variation of the pulmonary vein in patients with paroxysmal atrial fibrillation, we performed breath-hold gadolinium enhanced magnetic resonance (MR) angiography using a 1.5 T cardiac MR imager (GE CV/i) in 32 patients with paroxysmal atrial fibrillation (61 +/- 8 years old), 11 patients with chronic atrial fibrillation (64 +/- 9 years old), and 26 patients with normal sinus rhythm (55 +/- 15 years old). Three dimensional images of the pulmonary veins were thus obtained, and the diameters of the most proximal portion of the left or right superior pulmonary vein and left or right inferior pulmonary vein were measured. Pulmonary vein branching variations were determined by a visual qualitative analysis by two separate readers' agreements, who were blinded to any clinical information. We focused on the existence of a complex-branching pattern draining into the orifice of four pulmonary veins. Patients with either paroxysmal atrial fibrillation or chronic atrial fibrillation showed larger superior pulmonary veins than those with normal sinus rhythm (mean +/- SD; in the left superior pulmonary vein, 20 +/- 3 mm, 23 +/- 3 mm vs 16 +/- 3 mm, P < 0.05; in right superior pulmonary vein, 19 +/- 4 mm, 19 +/- 2 mm vs 16 +/- 2 mm, P < 0.05). Complex-branching pattern was frequently observed in inferior pulmonary veins in patients with either paroxysmal atrial fibrillation or chronic atrial fibrillation; 25/32 patients with paroxysmal atrial fibrillation, 11/11 patients with chronic atrial fibrillation, compared to 7/26 patients with normal sinus rhythm. Complex-branching patterns were not observed in superior pulmonary veins in any patients in this cohort. CONCLUSION: In patients with paroxysmal atrial fibrillation or chronic atrial fibrillation, significant pulmonary vein dilation occurred mainly in the superior pulmonary veins, while a complex-branching pattern was frequently observed in the inferior pulmonary veins. These MR angiographic findings might be useful when performing radiofrequency ablation procedures and catheter manipulation for the treatment of paroxysmal atrial fibrillation.