The morphometrical evaluation after uvulopalatopharyngoplasty.

OBJECTIVES: The aim of this study was to evaluate the efficacy of uvulopalatopharyngoplasty (UPPP) and the corresponding postoperative morphometrical changes. METHODS: Patients diagnosed with obstructive sleep apnea syndrome who complained of snoring and apnea were enrolled in this study. Pre- and postoperative tests, including CTs, pharyngeal volume (PV), cross-sectional area (CSA), and six-category morphometrical studies, were performed. RESULTS: Of 11 patients included, 10 showed improvement of symptoms. BMI correlated with the respiratory event index (REI). In terms of PV, there was a significantly wider postoperative area. The rate of change between preoperative REI and postoperative REI (ΔREI) correlated with the amount of change of PV between preoperative PV and postoperative PV (ΔPV). CSA increased postoperatively and correlated with REI. Uvula space (UV) and distance between the hyoid bone and the base of the tongue (HB) increased postoperatively, and posterior airway space (PAS) and epiglottic space (Epi) decreased postoperatively. UV and PAS were significant (p = 0.046, 0.014). UV was related to REI. CONCLUSION: Widening the PV, increasing CSA, and the posterior movement of the tongue base after UPPP surgery were found. The improvement of REI did not depend only on volume. These results suggest that it was important not only to widen the PV but also to improve the shape of the pharynx.

A New Method to Detect Variants of SARS-CoV-2 Using Reverse Transcription Loop-Mediated Isothermal Amplification Combined with a Bioluminescent Assay in Real Time (RT-LAMP-BART).

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of which there are several variants. The three major variants (Alpha, Delta, and Omicron) carry the N501Y, L452R, and Q493R/Q498R mutations, respectively, in the S gene. Control of COVID-19 requires rapid and reliable detection of not only SARS-CoV-2 but also its variants. We previously developed a reverse transcription loop-mediated isothermal amplification assay combined with a bioluminescent assay in real time (RT-LAMP-BART) to detect the L452R mutation in the SARS-CoV-2 spike protein. In this study, we established LAMP primers and peptide nucleic acid probes to detect N501Y and Q493R/Q498R. The LAMP primer sets and PNA probes were designed for the N501Y and Q493R/Q498R mutations on the S gene of SARS-CoV-2. The specificities of RT-LAMP-BART assays were evaluated using five viral and four bacterial reference strains. The sensitivities of RT-LAMP-BART assays were evaluated using synthetic RNAs that included the target sequences, together with RNA-spiked clinical nasopharyngeal and salivary specimens. The results were compared with those of conventional real-time reverse transcription-polymerase chain reaction (RT-PCR) methods. The method correctly identified N501Y and Q493R/Q498R. Within 30 min, the RT-LAMP-BART assays detected up to 100-200 copies of the target genes; conventional real-time RT-PCR required 130 min and detected up to 500-3000 copies. Surprisingly, the real-time RT-PCR for N501Y did not detect the BA.1 and BA.2 variants (Omicron) that exhibited the N501Y mutation. The novel RT-LAMP-BART assay is highly specific and more sensitive than conventional real-time RT-PCR. The new assay is simple, inexpensive, and rapid; thus, it can be useful in efforts to identify SARS-CoV-2 variants of concern.

Effects of jaw movement in bimaxillary orthognathic surgery on the upper airway: Computational fluid dynamics analysis.

Maxillomandibular repositioning in orthognathic surgeries has both morphologic and functional effects. These surgeries are thought to change the pharyngeal space and cause obstructive sleep apnoea syndrome, however. The primary purpose of this study is to evaluate the effects of jaw movement in bimaxillary orthognathic surgery on airway function and to identify the morphometric factors that can predict postoperative airway function. The subjects were 11 males and 12 females who had undergone orthognathic surgeries of the maxilla and mandible. The results of cephalometric analysis, cross-sectional area of the pharynx (CSA), pharyngeal volume and computational fluid dynamics (CFD) were compared. The CSA of the nasal (CSA1), total volume and total nasal volume decreased after surgery with statistical significance. Velocity at the oropharyngeal space (V2) increased after surgery with statistical significance. V2, CSA of the oropharyngeal space (CSA2) and PV were correlated with the horizontal posterior movement of point B, point Menton and overjet. V2 and CSA2 were correlated with SNB before and after surgery in all 46 analyses. Changes in pharyngeal airflow were more affected by pressure drop in the pharyngeal space (ΔPp) than by pressure drop in the nasal space (ΔPn). The relationship between the actual amount of change in the cephalometric reference point and the airway function is evident. CFD may thus be very useful as morphological analysis in preoperative treatment decision making.

Laparoscopic Repair Using Self-Fixating Mesh in an Adult Patient with a Sciatic Hernia and Irreducible Small Bowel: A Case Report and Literature Review.

Sciatic hernia is a rare type of pelvic floor hernia. The herniated tissue can include the ureter, small and large bowel, and ovary, among other tissues. Only a few cases of laparoscopic treatment for a sciatic hernia with small-bowel incarceration have been reported. We report our experience using a laparoscopic approach for treatment of sciatic hernia in an 83-year-old woman and review the literature on sciatic hernias. The patient was referred to our hospital complaining of constipation and abdominal bloating. Computed tomography (CT) scanning showed a right sciatic hernia containing the small bowel. Laparoscopic repair of the sciatic hernia was performed using a self-fixating mesh. The patient was discharged after an uneventful postoperative course and has not developed abdominal bloating or constipation postoperatively. In conclusion, a sciatic hernia was successfully repaired using a laparoscopic trans-preperitoneal approach and ProGrip Self-Fixating Mesh.

Detection of SARS-CoV-2 and the L452R spike mutation using reverse transcription loop-mediated isothermal amplification plus bioluminescent assay in real-time (RT-LAMP-BART).

The new coronavirus infection (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be fatal, and several variants of SARS-CoV-2 with mutations of the receptor-binding domain (RBD) have increased avidity for human cell receptors. A single missense mutation of U to G at nucleotide position 1355 (U1355G) in the spike (S) gene changes leucine to arginine (L452R) in the spike protein. This mutation has been observed in the India and California strains (B.1.617 and B.1.427/B.1.429, respectively). Control of COVID-19 requires rapid and reliable detection of SARS-CoV-2. Therefore, we established a reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay plus a bioluminescent assay in real-time (BART) to detect SARS-CoV-2 and the L452R spike mutation. The specificity and sensitivity of the RT-LAMP-BART assay was evaluated using synthetic RNAs including target sequences and RNA-spiked clinical nasopharyngeal and saliva specimens as well as reference strains representing five viral and four bacterial pathogens. The novel RT-LAMP-BART assay to detect SARS-CoV-2 was highly specific compared to the conventional real-time RT-PCR. Within 25 min, the RT-LAMP-BART assay detected 80 copies of the target gene in a sample, whereas the conventional real-time RT-PCR method detected 5 copies per reaction within 130 min. Using RNA-spiked specimens, the sensitivity of the RT-LAMP-BART assay was slightly attenuated compared to purified RNA as a template. The results were identical to those of the conventional real-time RT-PCR method. Furthermore, using a peptide nucleic acid (PNA) probe, the RT-LAMP-BART method correctly identified the L452R spike mutation. This is the first report describes RT-LAMP-BART as a simple, inexpensive, rapid, and useful assay for detection of SARS-CoV-2, its variants of concern, and for screening of COVID-19.

Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2021.

In Japan, with the increasing prevalence of gastroesophageal reflux disease (GERD) and growing public interest, the Japanese Society of Gastroenterology issued Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009 and a revised 2nd edition in 2015. A number of studies on GERD were subsequently conducted in Japan and abroad, and vonoprazan, a potassium-competitive acid blocker (P-CAB), became available for the first time in Japan in February 2015. The revised 3rd edition (Japanese edition), which incorporates new findings and information, was published in April 2021. These guidelines are summarized herein, particularly sections related to the treatment of GERD. The important clinical issues addressed in the present revision are (i) the introduction of treatment algorithms that classify GERD into reflux esophagitis and non-erosive reflux disease, (ii) the clarification of treatment algorithms based on to the severity of reflux esophagitis, and (iii) the positioning of vonoprazan in the treatment for GERD. The present guidelines propose vonoprazan as the initial/maintenance treatment for severe reflux esophagitis. They also recommend vonoprazan or PPI as an initial treatment for mild reflux esophagitis and recommended PPI and proposed vonoprazan as maintenance treatment. These updated guidelines offer the best clinical strategies for GERD patients in Japan and hope that they will be of global use for the diagnosis and treatment for GERD.

Impact of Second-line Chemotherapy on Prognosis: Response of Advanced Gastric Cancer to Taxanes Plus Ramucirumab.

BACKGROUND/AIM: The impact of clinical response to taxanes plus ramucirumab (RAM) on overall survival (OS) has not been clarified for advanced gastric cancer (AGC), although this type of therapy is already in use as second-line chemotherapy (CTx). This study aimed to investigate the prognostic impact of the clinical response to taxanes plus ramucirumab (RAM) for AGC patients. PATIENTS AND METHODS: This study included AGC patients treated with paclitaxel (PTX) or nab-paclitaxel (nab-PTX) and RAM. A retrospective analysis of response and survival rates in consecutive medical records of patients was performed. RESULTS: Forty-two patients were enrolled. Median progression-free survival and OS were 5.4 months [95% confidence interval (CI)=4.440-6.361] and 11.8 months (95% CI=8.648-15.019), respectively. In Cox-hazard multivariate analysis, peritoneal metastasis [hazard ratio (HR)=2.830; 95% CI=1.320-6.067; p=0.008], and disease control rate (HR=0.310; 95% CI=0.129-0.741; p=0.008) were independent factors. CONCLUSION: The response to taxanes plus RAM CTx had an impact on the survival of patients with AGC.

New Modified Transoral Approach to Remove a Hilar Stone of the Submandibular Gland: A Case Report.

Nerve damage and intraoperative bleeding for the removal of the hilar stones are possible. We used the new modified lateral oral floor approach with a 2-3 cm longitudinal mucosal incision outside of the Wharton's. There were no complications and our technique seemed to be effective.

Postoperative functional evaluation of obstructive sleep apnea syndrome by computational fluid dynamics.

The aim of this study is to evaluate the efficacy of uvulopalatopharyngoplasty and the corresponding postoperative airflow. Eleven patients diagnosed with obstructive sleep apnea syndrome who complained of snoring and apnea were enrolled in this study. Computational fluid dynamics (CFD) was implemented. CFD could be accomplished in nine cases. Airflow analysis was not possible in cases with a high respiratory event index (REI) score. Before surgery, stenosis was identified in the oropharynx and epiglottic area. And the airflow velocity and pressure were found to have significantly decreased in the oropharynx postoperatively, while in the epiglottic area, those data had increased postoperatively in some cases. The velocity and pressure of the oropharynx are related to REI score. From the CFD analysis, airflow analysis is important for evaluating the apnea state. It is suggested that the postoperative function can now be predicted preoperatively.

An advanced case of gastric histiocytic sarcoma treated with chemotherapy and gastrectomy: a case report and review of literature.

Histiocytic sarcoma is a relatively new disease category and the gastrointestinal origin is sporadic. We report a case of a 74-year-old woman who underwent chemotherapy and proximal gastrectomy for extremely rare, advanced gastric histiocytic sarcoma. The resected specimen was subjected to numerous immunostainings to meet the diagnostic criteria of histiocytic sarcoma and was positive for the histiocyte markers' cluster of differentiation 68 and lysozyme. The markers of Langerhans cells, follicular dendritic cells, and myelocyte were all negative. Six reports of surgical resection of histiocytic sarcoma originating in the stomach exist, including our case. We reviewed the clinical course and the histological and immunohistochemical diagnostic features of surgically resected gastric histiocytic sarcoma.

Gastrointestinal endoscopic practice during COVID-19 pandemic: a multi-institutional survey.

Introduction. An on-going coronavirus disease 2019 (COVID-19) has become a challenge all over the world. Since an endoscopy unit and its staff are at potentially high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we conducted a survey for the management of the gastrointestinal endoscopic practice, personal protective equipment (PPE), and risk assessment for COVID-19 during the pandemic at multiple facilities.Methods. The 11-item survey questionnaire was sent to representative respondent of Department of Gastroenterology, Osaka City University Hospital, and its 19 related facilities.Results. A total of 18 facilities submitted valid responses and a total of 373 health care professionals (HCPs) participated. All facilities (18/18: 100%) were screening patients at risk for SARS-CoV-2 infection before endoscopy. During the pandemic, we found that the total volume of endoscopic procedures decreased by 44%. Eleven facilities (11/18: 61%) followed recommendations of the Japan Gastroenterological Endoscopy Society (JGES); consequently, about 35%-50% of esophagogastroduodenoscopy and colonoscopy were canceled. Mask (surgical mask or N95 mask), face shield/goggle, gloves (one or two sets), and gown (with long or short sleeves) were being used by endoscopists, nurses, endoscopy technicians, and endoscope cleaning staff in all the facilities (18/18: 100%). SARS-CoV-2 infection risk assessment of HCPs was conducted daily in all the facilities (18/18: 100%), resulting in no subsequent SARS-CoV-2 infection in HCPs.Conclusion. COVID-19 has had a dramatic impact on the gastrointestinal endoscopic practice. The recommendations of the JGES were appropriate as preventive measures for the SARSCoV-2 infection in the endoscopy unit and its staff.

Diaphragmatic plication for diaphragmatic eventration caused by chronic constipation: a case report.

Diaphragmatic eventration in an adult patient is a rare condition. We describe a case of an elderly patient with hemidiaphragm dysfunction caused due to chronic constipation. A 67-year-old woman with a medical history of descending colon cancer that was treated 24 years before undergoing partial colectomy was admitted to our hospital with complaints of progressive shortness of breath and dyspnea on exertion for the past few months. She had no past history of any trauma. The patient had previously been suffering from chronic constipation after surgery. Physical examination revealed distension and incisional hernia of the abdomen. Chest X-ray demonstrated the high position of the left dome of the diaphragm with the megacolon gas. Chest and abdominal computed tomographic scans disclosed left diaphragmatic displacement containing the stomach and megacolon and abdominal incisional hernia. We performed open laparotomy, repair of abdominal incisional hernia using mesh, and diaphragmatic plication with nonabsorbable polyester suture and pledgets. Postoperative imaging confirmed the significant improvement of the patient's left lung space and clinical resolution of her respiratory symptoms. We describe the case of a patient with diaphragmatic eventration that was caused due to chronic constipation who underwent successful surgical repair.

Preoperatively diagnosed gastric collision tumor with mixed adenocarcinoma and gastrointestinal stromal tumor: a case report and literature review.

Reports of gastric collision tumors, comprising adenocarcinoma and gastrointestinal stromal tumor, are extremely rare. Here, we report the case of a 68-year-old male who was diagnosed with a lower-body, moderately differentiated, tubular-type adenocarcinoma and submucosal tumor and underwent an elective D2 distal gastrectomy. The tumor cells of the gastrointestinal stromal tumor were positive for H-caldesmon and CD117, weakly positive for smooth muscle actin and DOG-1, and negative for desmin, S-100 protein, CD31, and AE1/AE3. The tumor had grown into a mixed form of adenocarcinoma and gastrointestinal stromal tumor. Thus, we report the first case of a preoperatively diagnosed collision tumor in the stomach consisting of adenocarcinoma and gastrointestinal stromal tumor.

Ligation and Fibrin Glue Spraying for Intractable Chylous Ascites after Radical Gastrectomy for Gastric Cancer: Case Report and Literature Review.

Chylous ascites associated with radical resection of gastric cancer is a serious clinical condition. Lymph node dissection is indispensable during gastrectomy for gastric cancer. However, postoperative chylous ascites prolongs the hospital stay and re-operation. There are few reports on this subject. Most cases of chylous ascites resolve without treatment, but the condition can result in substantial morbidity. The definition of chylous ascites is ambiguous and varies in the English literature. In this report, we discuss a case of chylous ascites in a 68-year-old man who underwent distal gastrectomy for early gastric cancer at our hospital. He was admitted 8 months after surgery with a main complaint of abdominal swelling. Abdominal puncture helped to diagnose chylous ascites with marked elevation of triglyceride level. The patient received a hypercaloric infusion through a central line, and octreotide acetate, but did not improve. After assessment of lymph outflow by lymph scintigraphy, surgical ligation of the lymph vessels was performed through laparotomy. The volume of milky-white ascites in the abdominal cavity was 3,000 mL. Macroscopically, the fluid was confirmed as flowing from behind the common hepatic artery. Thus, ligation was performed. Chylous ascites has not recurred at 12 months after the re-operation. In summary, a case of chylous ascites after radical gastrectomy for gastric cancer was successfully treated by surgery. We review and discuss the relevant literature.

Laparoscopic repair of a Bochdalek hernia in an elderly patient: a case report with a review from 1999 to 2019 in Japan.

BACKGROUND: A Bochdalek hernia (BH) is a congenital defect of the diaphragm that generally presents in the newborn as life-threatening cardiorespiratory distress. In contrast, the diagnosis of a BH in adults is rare. Surgical repair for adult BH is recommended, but the optimal surgical method remains unclear. CASE PRESENTATION: A 75-year-old woman presented with progressive dyspnea and back pain, and a diagnosis of BH was made based on chest X-ray and computed tomography. Laparoscopic evaluation revealed a defect in the left posterior attachment of the diaphragm, and a left-sided BH without hernia sac was diagnosed. Parts of the stomach, small intestine, colon, pancreas, and spleen had prolapsed into the left thoracic cavity, without ischemic change, and these herniated organs were reduced to the abdominal cavity. A direct closure of the hernia orifice was possible by the laparoscopic suture technique using a mesh reinforcement. The patient made an uneventful recovery, and no recurrence was found in the 2-year follow-up. CONCLUSION: A recently published study reviewing detailed cases of repair of adult BH from 1999 to 2019 identified 96 cases, including the present case. The number of reports on laparoscopic and/or thoracoscopic surgery for BH in adults has recently increased, and the approach for repairing BH should be selected carefully on a case-by-case basis.

Pedunculated esophageal carcinoma endoscopically removed using SB knife Jr with detachable snare after neoadjuvant chemotherapy.

An 82-year-old Japanese man with alcoholic liver cirrhosis was referred to our hospital for treatment of advanced esophageal cancer. A protruding tumor was endoscopically observed in the middle thoracic esophagus, and pathological findings of the biopsy specimens revealed a squamous cell carcinoma. The clinical tumor staging was stage II (T3N0M0). The patient received two courses of neoadjuvant chemotherapy with 5-fluorouracil and nedaplatin. After the treatments, computed tomography showed significant reductions in the size of the target tumor. However, radical esophagectomy was not performed because the patient refused major invasive treatments. Instead, endoscopic resection was performed using a combination of polypectomy and endoscopic submucosal resection (ESD). To prevent bleeding during endoscopic treatment, we applied a detachable snare to the base of the tumor and cut the stalk using by an SB knife Jr, without hemorrhage. The pathohistology of the resected specimen was positively showed cancer cells on the margin of the esophageal carcinoma stalk. At 4 weeks after the initial operation, an additional ESD was successfully performed, which pathologically led to radical removal. The patient survived for more than 18 months after beginning the initial treatment. We describe a successful treatment using endoscopic resection after chemotherapy for advanced esophageal cancer with high surgical treatment risks.

Influence of hypergastrinemia secondary to long-term proton pump inhibitor treatment on ECL cell tumorigenesis in human gastric mucosa.

Proton pump inhibitor (PPI) therapy causes hypergastrinemia, which could promote the development and progression of neuroendocrine tumors (NETs). Concerns have been raised about the safety of long-term PPI use due to a possible increased risk of NETs. This study aimed to investigate the association between hypergastrinemia and the risk of NETs. Twenty outpatients presenting with serum gastrin levels greater than 400 pg/mL after long-term PPI treatment were registered in this study. Immunohistochemical analyses for chromogranin A (CgA), Ki67, gastrin and CCK/B gastrin receptor (CCKBR) were performed, and positive cell numbers were counted. There were no NET or gastric epithelial neoplasia cases observed among any of the 20 patients examined throughout the PPI treatment period. Histologically, ECL cell hyperplasia were shown in all patients. However, no relationship was found between serum gastrin levels and the number of CgA positive ECL cells. There was also no relationship between serum gastrin levels and the proportion of Ki67 positive cells or the density of CCKBR positive cells. The data indicate no relationship may exist between NETs and hypergastrinemia secondary to PPI treatment in patients having no, or mild, atrophic gastritis.

Pulmonary metastasectomy for esophageal basaloid squamous cell carcinoma component at 66 months after esophagectomy.

BACKGROUND: Solitary pulmonary metastasis from esophageal basaloid squamous cell carcinoma (BSCC) components is an extremely rare recurrence of esophageal squamous cell carcinoma (SCC). CASE PRESENTATION: A 68-year-old Japanese woman was found to have a suspected malignant mass, approximately 2 cm in diameter, in her left lower pulmonary lobe, at 66 months after undergoing a curative esophagectomy with three-field lymph node dissection for esophageal SCC with a focal basaloid component. After a CT-guided biopsy, pathological examination indicated a metastasis from esophageal BSCC components. She underwent a thoracoscopic partial resection of the left lower pulmonary lobe for the solitary pulmonary metastasis. The pathohistology of the resected specimen led to diagnosis of metastatic esophageal BSCC, which showed immunohistochemical findings similar to those of the primary esophageal carcinoma. The patient received two courses of adjuvant chemotherapy (5-fluorouracil, docetaxel plus nedaplatin) and recovered to resume a normal life with maintenance therapy. However, multiple lung and brain metastases were diagnosed at 2 years after the pulmonary metastasectomy. She survived 5 years and 6 months after the pulmonary metastasectomy, but died at 10 years and 6 months after her initial esophagectomy. CONCLUSION: This was a rare surgical resected case of solitary pulmonary metastasis from esophageal BSCC components.

Racemose hemangioma of the bronchial artery mimicking esophageal submucosal tumor: a case report.

Primary racemose hemangioma of the bronchial artery is a rare congenital disease that is occasionally complicated by aneurysms. An asymptomatic 78-year-old man was referred to our hospital with an esophageal submucosal tumor that was endoscopically found in the upper thoracic esophagus in a health check-up. Physical examination findings were unremarkable. Contrast-enhanced chest computed tomography with three-dimensional image reconstruction and selective bronchial arteriography resulted in a definitive diagnosis of primary racemose hemangiomas of the bronchial arteries accompanied by left bronchial artery aneurysm. Because rupture of a bronchial artery aneurysm can cause critical life-threatening hemorrhage, bronchial arterial embolization using coils and a mixture of N-butyl-2-cyanoacrylate and iodized oil was thus performed for bronchial artery aneurysm. Postoperative course was uneventful, and the patient was discharged on the third postoperative day. Computed tomography performed after 6 months revealed no enhancement of the aneurysms. In conclusion, we report a case of an asymptomatic primary racemose hemangioma of the bronchial artery accompanied by an aneurysm that mimicked a submucosal esophageal tumor. We also reviewed other Japanese case of primary racemose hemangioma of the bronchial artery accompanied by aneurysm based on the literature.