Usefulness of Novel Atherogenic Lipid Indices for the Evaluation of Metabolic Status Leading to Coronary Heart Disease in a Real-World Survey of the Japanese Population.

We evaluated the usefulness of two novel cholesterol-triglyceride subgroup (CTS) indices, CTSqlt and CTSqnt, that potentially reflect the metabolic status regarding risk of coronary heart disease (CHD) using a retrospective longitudinal study of the Japanese general population. We recruited 12,373 individuals from the annual users of our healthcare center. Among them, the first onset of CHD was recorded in 131 individuals between April 2014 and March 2020. The multivariate Cox proportional hazards regression analyses for all normalized lipid indices revealed that the CTSqnt index showed a comparable hazard ratio for the CHD outcome to non-high-density lipoprotein cholesterol (nonHDL-c) and triglycerides. The HR of the CTSqlt index was significantly lower than for CTSqnt, but still comparable to that for low-density lipoprotein cholesterol (LDL-c). In comparison with the other indices, CTSqlt is more sensitive to risk increment while the index value increases. Linear regression analyses for the CTS indices and previously known lipid indices suggest that the CTSqnt and CTSqlt indices reflect the quantity of atherogenic lipoproteins and particle size (quality) of smaller and denser LDLs, respectively. Furthermore, the CTSqnt/HDL-c index can be used as a comprehensive risk indicator that may represent the status of lipid metabolism determined by the CTSqlt and CTSqnt indices and thus may be useful for screening. The CTS indices can be used to evaluate the metabolic status of individuals, which may increase the risk of future CHD.

Needle Tip Detection Using Ultrasound Probe for Vertical Punctures: A Simulation and Experimental Study.

Current ultrasound-guided punctures are difficult to perform as they are performed at an angle to the ultrasound image of the affected area, resulting in longer puncture times, lower success rates, and higher unexpected injury rates. Vertical puncture techniques have also been investigated, but the principle of needle tip detection remains unclear. To optimize ultrasound probes for puncture, the principle of needle tip detection should be understood. This study aimed to verify the principle of needle tip detection and optimal measurement conditions for vertical puncture. Needle tip detection was performed in animal experiments using a probe with a central puncture slit. Moreover, the needle tip was detected at short distances using a puncture spacer. We also investigated the signal from the needle tip using a ring probe and confirmed the principle of needle tip detection, effect of needle tip angle, and insertion depth on needle tip detection through simulation and experiments. Needle tip detection using ultrasound-guided waves was described, and the relationship among needle tip angle, detection intensity, and phase change was verified. The needle tip can be detected by the leakage of the ultrasound-guided wave generated inside the needle tip.

Laparoscopic-endoscopic cooperative surgery for a duodenal neuroendocrine tumor: A case report.

For neuroendocrine tumor G1, local resection is one of the primary treatment options. Endoscopic submucosal dissection has been proven to ensure complete resection with sufficient margins. However, duodenal endoscopic submucosal dissection has a high risk of duodenal perforation because of the thin duodenal wall and poor endoscopic maneuverability. During laparoscopic dissection, suturing can resolve perforation. Therefore, laparoscopic-endoscopic cooperative surgery (LECS) can ensure complete resection with a minimal margin to prevent stenosis, and suturing can resolve perforation. In short, LECS combines the advantages of both techniques. In the present case, a duodenal neuroendocrine tumor G1 in a 75-year-old man was successfully treated using LECS. The patient remained free from recurrence at 21 months postoperatively. LECS is feasible for a neuroendocrine tumor G1 ≤20 mm in size that has not invaded the muscularis propria or the lymphatic and venous vessels.

ABCG2 expression in colorectal adenocarcinomas may predict resistance to irinotecan.

Irinotecan is a key drug for patients with advanced and recurrent colorectal carcinoma. However, the efficacy of irinotecan is not sufficient; partly, as there is no useful marker to predict chemosensitivity to the drug. The aim of the present study was to evaluate whether the expression levels of adenosine triphosphate-binding cassette sub-family G (WHITE) member 2 (Junior blood group) (ABCG2) in primary colorectal tumors predict chemoresistance to irinotecan. Using the resected primary tumor specimens of 189 patients with colorectal cancer, the association between the immunohistochemical expression of ABCG2 protein and the results of the collagen gel droplet embedded culture drug sensitivity test, performed to evaluate the chemosensitivity to SN-38 (an active metabolite of irinotecan), was investigated. Among the 189 patients, 17 received irinotecan-based chemotherapy, and their responses and progression-free survival (PFS) were analyzed. The tumors of patients with increased ABCG2 expression accounted for 60% of the tumors examined, and were significantly more resistant to SN-38, compared with patients with low ABCG2 expression (P<0.001). In a multivariate logistic regression analysis, increased expression of ABCG2 protein was an independent and significant predictor of resistance to SN-38, increasing the risk of resistance by 12-fold. Increased expression of ABCG2 and a low sensitivity to SN-38 was significantly associated with resistance to irinotecan-based chemotherapy (P=0.01 and 0.028, respectively). The median PFS of patients with increased expression of ABCG2 was significantly shorter, compared with patients with low expression levels of ABCG2 (104 vs. 242 days; P=0.047). The increased immunohistochemical expression of ABCG2 in primary tumors may be a useful predictive biomarker of resistance to irinotecan-based chemotherapy for patients with recurrent or metastatic colorectal cancer.

Active and Passive Haptic Training Approaches in VR Laparoscopic Surgery Training.

Laparoscopic surgery has become a widely performed surgery as it is one of the most common minimally invasive surgeries. Doctors perform the surgery by manipulating thin and long surgical instruments precisely with the assistance of laparoscopic video with limited field of view. The power control of the instruments' tip is especially very important, because excessive power may damage internal organs. The training of this surgical technique is mainly supervised by an expert in hands-on coaching program. However, it is difficult for the experts to spend sufficient time for coaching. Therefore, we aim to teach the expert's hand movements in laparoscopic surgery to trainees using VR-based simulator, which is equipped with a guidance force display device. To realize the system, we propose two haptic training approaches for transferring the expert's hand movements to the trainee. One is active training, and the other is passive training. The former approach shows the expert's movements only when the trainee makes large errors while the latter shows the expert's movements continuously. In this study, we validate the applicability of these approaches through tasks in VR laparoscopic surgery training simulator, and identify the differences between these approaches.

Evaluation of Network-Based Minimally Invasive VR Surgery Simulator.

In this paper, we report a result of an experiment of a field trial of our network-based minimally invasive surgery simulator. In our previous paper, we proposed a network-based visuohaptic surgery training system for laparoscopic surgery. In addition, we proposed a volume-based haptic communication approach, which allows participants at remote sites on the network to simultaneously interact with the same target object in virtual environments presented by multi-level computer performance systems, by only exchanging a small set of manipulation parameters for the target object and additional packet for synchronization of status of binary tree and deformation of shared volume model. We implemented the approach into our network-based surgery simulator, and field trial of the simulator at three locations was performed.

Initial experiences with MR Image-guided laparoscopic microwave coagulation therapy for hepatic tumors.

PURPOSE: Percutaneous thermal ablation is used for treating hepatic tumors. Recent advances in laparoscopy and imaging modalities have led to the development of a novel image-guided minimally invasive loco-regional treatment. The aim of this trial was to apply laparoscopic assistance to magnetic resonance (MR) image-guided thermoablation instead of ultrasonography, because of its various advantages. METHODS: Patients with hepatic tumors and liver cirrhosis underwent magnetic resonance (MR) image-guided laparoscopic microwave coagulation therapy using a borescope and endoscopic forceps. Six cases of laparoscopic microwave coagulation treatment using MR image guidance were successfully performed between January 2000 and December 2008. Tumors were detected, punctured, and ablated in an open-configured MR scanner. A total of nine hepatocellular carcinoma nodules were preoperatively identified in S3, S5 and S6 (mean diameter = 20.8 ± 5.4 mm). RESULTS: MR-guided microwave coagulation was laparoscopically achieved in all patients without any significant complications that required invasive treatment. The mean length of the operation was 275.3 ± 60.5 min, and the mean postsurgical hospital stay was 10.0 ± 2.3 days. Postoperative confirmation scanning was performed without moving the patients. CONCLUSION: MR-guided laparoscopic microwave coagulation therapy is an effective treatment for hepatic tumors adjacent to other organs, as it allows for more accurate detection of lesions and for tumors to be treated safely while avoiding adjacent organs. It is less invasive than conventional procedures, because the MR real-time guidance enabled continuous monitoring throughout the procedure.

Resectable carcinoma developing in the remnant pancreas 7 years and 10 months after distal pancreatectomy for invasive ductal carcinoma of the pancreas: report of a case.

BACKGROUND: Pancreatic ductal adenocarcinoma, which represents 90% of pancreatic cancers, is one of the most lethal and aggressive malignancies. Operative resection remains the only treatment providing prolonged survival, however, recurrence of pancreatic ductal adenocarcinoma occurs in up to 80% of patients with pancreatic cancer within 2 years of a potential curative resection. There are few reports of pancreatic carcinoma recurrence (primary second cancer) in the remnant pancreas after pancreatectomy. CASE PRESENTATION: A 52-year-old woman underwent a distal pancreatectomy for pancreatic cancer in September 2004. Adjuvant chemotherapy was started after surgery and continued for 4 years. In March 2012, marked elevation of DUPAN-II was observed, followed by an irregular stenotic finding in the main duct. We performed an en bloc resection of the remnant pancreas in July 2012. Histologically, the tumor contained a second primary pancreatic carcinoma with lymph node metastasis. At follow-up 20 months after the second operation, the patient was alive without recurrence. Fourteen cases of resectable cancer developing in the remnant pancreas after a pancreatectomy for cancer have been reported; a minority of these was identified as second primary tumors. Therefore, our patient's primary second cancer is a rare event. CONCLUSION: The patient is considered to have shown a rare, unique pancreatic cancer recurrence. Persistent elevation of a tumor marker and extensive imaging led to proper diagnosis and treatment.

Cell transplantation therapy for a rat model of secondary lymphedema.

BACKGROUND: Although lymphedema is a progressive and lifelong condition, substantial advances in therapeutic intervention are limited. The development of a novel therapy for lymphedema is urgent for those patients suffering from it. The aim of this study was to investigate the usefulness of a new cell transplantation therapy in the rat tail model of secondary lymphedema. MATERIALS AND METHODS: We prepared two cell sources, human dermal microvascular endothelial cells (HDMECs) and lymphatic endothelial cells (LECs), which were collected from the resected normal dermis of patients with breast cancer. After the animal model of secondary lymphedema of the nude rats' tails was established, phosphate-buffered saline, purified LECs, or unpurified HDMECs were injected in the rats' tails five times for more than 14 d. The evaluations were performed by measuring the circumference, fluorescence lymphography, and histologic analysis of the rats' tails between each group. RESULTS: The isolated cells by the simple immunomagnetic sorting from HDMECs were positive for a pan-endothelial marker (CD31) and lymphatic-specific markers (podoplanin, lymphatic vessel endothelial hyaluronan receptor-1 [LYVE-1], and prospero homebox 1 [Prox-1]), and were considered to be LECs. In the cell transplantation group, which was injected with human LECs, the circumference, lymphatic flow, and thickness of the skin of the rat tail became thinner than the groups injected with unpurified HDMECs or phosphate-buffered saline. Immunohistochemistry of the rat tails showed that the number of own lymphatic vessels was increased in the purified LEC transplantation group compared with the other groups. Furthermore, in the LEC transplantation group, some vessels were immunopositive for human-podoplanin or -LYVE-1 and the areas adjacent to the vessels were rat-podoplanin or -LYVE-1 immunopositive. CONCLUSIONS: Our findings indicate that cell transplantation therapy using human LECs improved the secondary lymphedema in the nude rat tail. This therapeutic strategy may merit clinical investigation in patients with lymphedema.

Evaluation of haptic teaching approaches for laparoscopic surgery training.

Laparoscopic surgery, one type of minimally invasive surgery (MIS) is a very important surgery technique which requires advanced surgical technique. At present, expert one-on-one teaching mainly supports the training of these advanced surgical techniques. However, time constraints prevent experts spending the amount of time desired for this training. Therefore, we aim to support training using a VR-based laparoscopic surgery simulator equipped with a guidance force display. This increases the amount of training a trainee can avail of while at the same time allow the expert and the trainee to increase the quality of the limited one-to-one time together. The first step of our research is to investigate approaches that displays the guidance force to teach experts hand movements. In this study, we used two guidance force-display approaches: Instrument-guiding approach and Hand-guiding approach. Through evaluative experiments, we found that the Hand-guiding approach is more suitable for skill transfer than the Instrument-guiding approach in particular tasks. The results are described below.

Utility of a microwave surgical instrument in sealing lymphatic vessels.

BACKGROUND: This study assessed the ability of a novel microwave coagulation surgical instrument (MWCX) to seal lymphatic vessels when compared with LigaSure (Valleylab, Boulder, CO), the Harmonic Scalpel (HS; Ethicon Endo-Surgery, Cincinnati, OH), and electric cautery. METHODS: The burst pressure of pig inguinal lymphatic vessels was assessed after the sealing of vessels with each surgical instrument. The rate of lymphorrhea from pig mesenteric lymphatic vessels was also investigated using indocyanine green and visualized with the Photodynamic Eye system (Hamamatsu Hotoniks, Hamamatsu, Japan). RESULTS: Burst pressures were higher with MWCX (average, 300 mm Hg), LigaSure (average, 290 mm Hg), and HS (average, 253 mm Hg) when compared with electric cautery (average, 152.3 mm Hg; vs MWCX: P = .002, vs LigaSure: P = .002, vs HS: P = .004). The rate of lymphorrhea was significantly lower with LigaSure (13.3%), HS (18.8%), and MWCX (13.3%) when compared with electric cautery (77.3%; vs LigaSure: P < .001, vs HS: P < .001, vs MWCX: P < .001). CONCLUSIONS: MWCX was equivalent to LigaSure and HS in terms of the ability to seal lymphatic vessels.

Laparoscopic surgery simulator using first person view and guidance force.

In general, minimally invasive surgery is seen as the most difficult surgery because there is limited field of view with an endoscope and force sensation from surgical instruments such as forceps is poor. Especially in early clinical education for medical students, a virtual reality surgical simulator would be an effective tool. In this paper, we propose a visuohaptic surgery training system for laparoscopical techniques. We recorded a video from a first person point of view of the instructor (expert). And we also recorded operation information (i.e. trajectory) of surgical instruments of the instructor. Then, we displayed the recorded video and the guidance force to trainees. We constructed a prototype surgery training system and the effectiveness of our approach was confirmed.

Feasibility and toxicity of docetaxel before or after fluorouracil, epirubicin and cyclophosphamide as adjuvant chemotherapy for early breast cancer.

BACKGROUND: The tolerance and safety associated with the administration order of the anthracycline and taxane drugs have not been evaluated. PATIENTS AND METHODS: Breast cancer patients with node-positive or high-risk patients with node-negative were eligible. The feasibility and toxicity were evaluated in the following regimens--arm A, 3 courses of fluorouracil 500 mg/m(2), epirubicin 100 mg/m(2) and cyclophosphamide 500 mg/m(2) (FEC) followed by 3 courses of docetaxel 100 mg/m(2) (DOC); arm B, 3 courses of DOC followed by 3 courses of FEC. RESULTS: Forty-two patients were registered. The relative dose intensity was 94.2 % for FEC and 97.8 % for DOC in arm A, and 98.9 % for DOC and 95.2 % for FEC in arm B. In arm A, grade 3 or higher hematological toxicity was observed in nine patients, and febrile neutropenia developed in three patients with FEC. In arm B, grade 3 or higher hematological toxicity was observed in seven patients, but febrile neutropenia was not noted in any patient. CONCLUSION: The regimens in both arms A and B were safe regarding adjuvant chemotherapy for early breast cancer. However, DOC followed by FEC might be more tolerable. Further studies will maximize the results obtained with DOC followed by FEC.

[Current situation and issues regarding preoperative chemotherapy for HER2-positive breast cancer].

OBJECTIVE: The clinical significance of preoperative chemotherapy, including trastuzumab for HER2-positive breast cancer, was examined based on hormone receptors(HR)to clarify future issues. SUBJECTS: 104 HER2-positive breast cancer patients who completed preoperative chemotherapy and underwent surgery from May 2005 to August 2010. All patients received sequential treatment with taxane±trastuzumab for FEC(5-FU+epirubicin+cyclophosphamide)therapy, and from 2008 they received trastuzumab postoperatively for one year. RESULTS: Concerning the histological effects, the rate of comprehensive pCR(CpCR)in the 104 patients(31 HR-negative administered trastuzumab, 15 HR-negative not administered trastuzumab, 28 HR-positive administered trastuzumab, 30 HR-positive not administered trastuzumab)was 65%, 47%, 21% and 23% for each group, respectively CpCR was a significant factor(p<0. 05)in prolonged distant disease-free survival(DDFS)in the HR-negative group. Distant metastasis occurred in 14 patients, namely, brain metastasis in 7 patients(4 HR-negative administered trastuzumab, 1 HR-negative not administered trastuzumab, 2 HR-positive administered trastuzumab). The therapeutic efficacy was pINV in 5 of these 7 patients(3HR-negative administered trastuzumab, 1 HR-negative not administered trastuzumab, 1 HR-positive administered trastuzumab), and 4 of those 5 patients received trastuzumab postoperatively. DISCUSSION: The responsiveness to preoperative chemotherapy including trastuzumab for HER2-positive breast cancer differs between HR-positive and HR-negative. pINV patients seem to be at a high risk for brain metastasis regardless of HR, and it may be difficult to suppress its occurrence only with trastuzumab adjuvant therapy.

Clinical trial of cisplatin-conjugated gelatin microspheres for patients with hepatocellular carcinoma.

PURPOSE: We report our initial experience with the transarterial chemoembolization (TACE) of unresectable hepatocellular carcinoma (HCC) using cisplatin-conjugated gelatin microspheres (Cis-GMS). METHODS AND MATERIAL: Nineteen patients with 25 HCC nodules (mean diameter 23.0 mm) were treated by selective TACE using 50- to 100-µm Cis-GMS. Tumor necrosis and postembolization syndrome were assessed during the follow-up. The tumor response was evaluated on contrast-enhanced computed tomography images at 1 and 3 months after TACE using Cis-GMS. RESULTS: All procedures were technically successful in all patients; following the TACE using Cis-GMS, there were no major complications, and postembolization syndrome was minimal. At the 1-month follow-up, the response rate was 12 of the 25 (48%) and 21 of the 25 (84%) HCC nodules based on RECIST 1.1 and EASL criteria, respectively; at the 3-month follow-up, it was 10 of the 25 (40%) and 14 of the 25 (56%) HCC nodules, respectively. CONCLUSION: Our initial experience with using Cis-GMS for TACE suggests that these drugs may represent an optimal treatment option for the treatment of advanced HCC and that the use of gelatin microspheres loaded with chemotherapeutic agents warrants further study.

Abnormal development of intrinsic innervation in murine embryos with anorectal malformations.

INTRODUCTION: Constipation, soiling, and incontinence are common problems after definitive repair of anorectal malformations (ARMs) in children. We studied the expression of substance P (SP), vasoactive intestinal peptide (VIP), and c-kit in the rectum of murine embryos with or without ARMs at later developmental stages. METHODS: On the 9th embryonic day (E9), pregnant Institute of Cancer Research mice were fed etretinate, a synthetic vitamin A analogue (60 mg/kg), whereas controls were fed only with sesame oil. Embryos were excised between E14 and E18, and prepared for histological examination. The SP, VIP, and c-kit expressions were examined by immunohistochemical staining for the SP, VIP, and c-kit antigens, respectively. RESULTS: On E14 and E15, the expression levels of the anti-SP and anti-VIP antibodies in the rectum did not differ between the control and etretinate-treated group. However, as compared to the controls, a decreased SP and VIP immunoreactivity was observed in the circular muscle layer of the rectum between E16 and E18. On the other hand, on E14 and E15, the expression of anti-c-kit antibody in the rectum did not differ between the etretinate-treated and control group. However, c-kit immunoreactivity was slightly higher in the circular muscle layer of the rectum in the controls on E16 and E17, and considerably higher on E18 than that of the muscle layer in the etretinate-treated group. CONCLUSION: At later developmental stages, the expression levels of SP, VIP, and c-kit reduced in the circular muscle layer of the rectum in mice with etretinate-induced ARMs. This result indicates that reduced SP, VIP, and c-kit expression levels in the circular muscle layer may cause severe constipation in children who develop severe ARMs after definitive surgery.

Myeloid cells positive for CD10 at invasion front can predict poor outcome in stage II colorectal cancer.

BACKGROUND: Prediction of poor patient outcome as a effect of adjuvant therapy in stage II colorectal cancer (CRC) remains a matter of controversy. Tumor expression of CD10 and CD15 is reportedly related to poor outcome in CRC. In this study, we investigated whether the expression of CD10 and CD15 is a predictor of outcome and the effect of adjuvant therapy in stage II CRC. MATERIALS AND METHODS: Immunohistochemical analyses for CD10 and CD15 and some additional markers (CD11b, CD14, CD163, CD3, and CD20) were performed using paraffin sections of CRC specimens from 57 patients who had undergone curative surgical treatments between 1998 and 2004. Forty of these patients received postoperative adjuvant therapy. We distinguished between expression in tumor cells (tCD10 and tCD15), in stromal cells (sCD10), and infiltrating immune cells (iCD10 and iCD15). RESULTS: Expression of iCD10 was observed in 21.1% (12/57) of the specimens examined. Of all expression patterns, only iCD10 expression at the cancer invasion front was a useful predictor of a disease-free period and overall survival in stage II CRC. Adjuvant therapy improved the outcome of iCD10(+) patients. CD10(+) immune cells were heterogeneous in origin and partially overlapped the cells positive for myeloid lineage markers, including CD11b and CD15. CONCLUSIONS: iCD10 expression at the tumor invasion front is a useful marker for predicting a high risk of recurrence and mortality in stage II CRCs. CD10(+) immune cells appear to be of myeloid origin.

Non-Epstein-Barr virus associated lymphoepithelioma-like carcinoma of the inferior common bile duct.

A carcinoma displaying undifferentiated features with dense lymphoplasmacytic infiltration is defined as a lymphoepithelioma-like carcinoma (LEC), and some of LEC is associated with Epstein-Barr virus (EBV). All of the 13 previously reported cases of LEC of the biliary system were intrahepatic in location. Herein, we describe the first case of LEC of the inferior common bile duct. A 68-year-old Japanese man, who had been previously treated for hepatocellular carcinoma using microwave coagulation therapy, was found to have tumors of the common bile duct and pancreas head. Histopathological study of the resected tumor showed solid or cohesive nests of large undifferentiated cells with irregular large vesicular nuclei and nucleoli. Around the tumor cell nests, dense lymphoplasmacytic infiltration was observed. Focal glandular differentiation (approximately 5%) was also present. These histopathological features corresponded morphologically to LEC. Immunohistochemically, the tumor cells were positive for cytokeratin (CK) 7, CK 19 and CA19-9, but negative for CK 20 and Hep Par 1. In situ hybridization for Epstein Barr virus early small RNAs disclosed no nuclear signal in tumor cells. Therefore, a diagnosis of non-EBV-associated LEC of the inferior common bile duct was made. Although the prognosis of the biliary LEC is thought to be better than that of conventional cholangiocarcinoma, the differences in prognosis between EBV-positive and -negative cases have not yet been established. Therefore, additional case studies will be needed to clarify the clinicopathological features of LEC of the biliary tract.

Resting energy expenditure in patients undergoing pylorus preserving pancreatoduodenectomies for bile duct cancer or pancreatic tumors.

We measured the energy expenditure weekly in patients undergoing a pylorus preserving pancreatoduodenectomy for bile duct cancer or pancreatic tumors. Twelve patients (5 women and 7 men; mean age 70.1 years) were enrolled in this study, and their resting energy expenditure levels were determined by indirect calorimetry. In these patients, a significant correlation was observed between the measured resting energy expenditures and the predicted resting energy expenditures calculated by the Harris-Benedict equation. The resting energy expenditures measured before surgery were almost the same as the predicted resting energy expenditures (measured resting energy expenditure: 22.4 ± 3.9 kcal/kg/day vs predicted resting energy expenditure: 21.7 ± 2.0 kcal/kg/day). The measured resting energy expenditure/predicted resting energy expenditure ratio, which reflects the stress factor, was 1.02 ± 0.10. After the pylorus preserving pancreatoduodenectomy, a significant increase in energy expenditure was observed, and the measured resting energy expenditure was 25.7 ± 3.5 kcal/kg/day on postoperative day 7 and 25.4 ± 4.9 kcal/kg/day on postoperative day 14. The measured resting energy expenditure/predicted resting energy expenditure ratio was 1.16 ± 0.14 on postoperative day 7, and 1.16 ± 0.18 on postoperative day 14 respectively. In conclusion, patients undergoing a pylorus preserving pancreatoduodenectomy showed a hyper-metabolic status as evaluated by their measured resting energy expenditure/predicted resting energy expenditure ratio. From our observations, we recommend that nutritional management based on 30 kcal/body weight/day (calculated by the measured resting energy expenditure×activity factor 1.2-1.3) may be optimal for patients undergoing a pylorus preserving pancreatoduodenectomy.

Indocyanine green fluorescence imaging system for sentinel lymph node biopsies in early breast cancer patients.

PURPOSE: This study presents a new method that enables the detection of sentinel lymph nodes (SLN) with high sensitivity using indocyanine green (ICG) fluorescence imaging. METHODS: This study enrolled 128 patients with clinically node-negative breast cancer. Fluorescence imaging was obtained after ICG was injected into the areola. Subcutaneous lymphatic channels were immediately visible. RESULTS: Lymphatic channels and SLN were successfully visualized in all patients. One lymphatic channel was 60%, two channels were 24%, and three channels were 16%. The number of fluorescence SLN ranged from 1 to 6, and blue-dyed SLN ranged from 0 to 3. In the latter, SLN were not identified in 44 patients. Nineteen patients had pathologically identified lymph node metastases. All of them were recognized by fluorescence imaging, but 8 patients had lymph nodes with metastases were not identified by dye method. CONCLUSION: This ICG fluorescence imaging technique is feasible and safe for detecting SLN in a less invasive manner than conventional mapping, with real-time observations.