[Role of peritoneovenous shunt therapy in end-of-life care of refractory malignant ascites cases].

The short- and long-term outcomes of 34 patients with refractory malignant ascites who underwent peritoneovenous shunt (PVS) therapy were retrospectively reviewed. The primary disease was gastrointestinal cancer in 31 patients and gynecologic cancer in 3 patients. Regarding performance status, 21 patients had Eastern Cooperative Oncology Group Performance Status (PS) 2 and 13 patients were PS 3;thus, many were in a poor general condition. After treatment, abdominal distention disappeared in 79.4% of patients, and appetite improved in 60.9%. The median postoperative survival time was 38 days (range, 1-294 days), and 18 patients (52.9%) were discharged. Disseminated intravascular coagulation with clinical symptoms was observed in 3 patients (8.8%), and heart failure was observed in 7 patients (20.6%). PVS therapy was useful in improving the subjective symptoms of patients with refractory malignant ascites and in enabling them to receive care at home. However, serious postoperative complications are a concern, and appropriate preoperative evaluation is necessary.

Laparoscopic portal branch ligation of the right caudate lobe concomitant with portal vein embolization for planned right hemihepatectomy in advanced hepatobiliary cancers.

BACKGROUND: The role of ligation of the portal venous branches to the caudate lobe (cPVL) as preparation for planned major hepatectomy is unclear. The aim of this study was to evaluate the efficacy of laparoscopic cPVL (Lap-cPVL) concomitant with transileocolic portal vein embolization of the right portal venous system (rTIPE), namely, Lap-cPVL/rTIPE, for planned right hemihepatectomy (rHx) in advanced hepatobiliary cancer patients. METHODS: Thirty-one patients who underwent rHx after rTIPE with/without Lap-cPVL between March 2013 and March 2020 were enrolled in this study. The Lap-cPVL was performed for the portal branches of the right caudate lobe. RESULTS: Eight of the 31 patients underwent Lap-cPVL/rTIPE. The degree of hypertrophy was significantly increased in Lap-cPVL/rTIPE (19.3%, range 6.5-25.6%) as compared to rTIPE (7.2%, range - 1.1 to 21.2%) (p=0.027). The functional kinetic growth rate was also significantly increased in Lap-cPVL/rTIPE (5.40%, range 2.17-5.97) than that in rTIPE (1.85%, range - 0.22 to 6.45%) (p=0.046). Postoperative liver failure ≧ grade B occurred in 21.7% of patients in rTIPE, while there was no postoperative liver failure ≧ grade B in Lap-cPVL/rTIPE. Mortality rates were zero after rHx in this study. CONCLUSIONS: Lap-cPVL/rTIPE is safe and provides an additional effect on liver hypertrophy in advanced hepatobiliary cancers.

Preoperative Prognostic Nutritional Index Predicts Long-Term Surgical Outcomes in Patients with Esophageal Squamous Cell Carcinoma.

BACKGROUND: The purpose of the present study is to investigate the utility of prognostic nutritional index (PNI) as a simple and readily available marker in esophageal squamous cell carcinoma (ESCC). METHODS: We retrospectively analyzed 169 patients who underwent potentially curative esophagectomy, for histologically verified ESCC. We decided to set the optimal cutoff value for preoperative PNI levels at 49.2, based on the cancer-specific survival (CSS) and the overall survival (OS) by receiver operating characteristic curve analysis. RESULTS: Multivariate logistic regression analysis identified that TNM pStage III [hazard ratio (HR) 3.261, p < 0.0001] and PNI < 49.2 (HR 3.887, p < 0.0001) were confirmed as independent poor predictive factors for CSS, and age >70 (HR 2.024, p < 0.0042), TNM pStage III (HR 2.510, p = 0.0002), and PNI < 49.2 (HR 2.248, p = 0.0013) were confirmed as independent poor predictive factors for OS. In non-elderly patients, TNM pStage III (CSS; HR 3.488, p < 0.0001, OS; HR 2.615, p = 0.0007) and PNI < 49.2 (CSS; HR 3.849, p < 0.0001, OS; HR 2.275, p = 0.001) were confirmed as independent poor predictive factors for CSS, and OS when multivariate logistic regression analysis was applied. But in elderly patients, univariate analyses demonstrated that the TNM pStage III was the only significant risk factor for CSS (HR 3.701, p = 0.0057) and OS (HR 1.974, p = 0.0224). CONCLUSIONS: The PNI was a significant and independent predictor of CSS and OS of ESCC patients after curative esophagectomy. The PNI was cost-effective and readily available, and it could act as a marker of survival.

Complete abdominal wound and anastomotic leak with diffuse peritonitis closure achieved by an abdominal vacuum sealing drainage in a critical ill patient: a case report.

BACKGROUND: Negative pressure wound therapy (NPWT) is a widely accepted technique to treat local infectious wounds of the skin, subcutaneous tissue, fascia, or muscle. Recently, several reports describing the efficacy of NPWT for various types of fistulas and anastomotic leaks have been published. We herein describe a patient with an open abdominal wound due to colonic anastomotic leakage and diffuse peritonitis, in whom abdominal vacuum sealing (AVS) as a modified NPWT was useful for the management of this complex wound. CASE PRESENTATION: A 32-year-old man was admitted to our hospital with late presenting traumatic diaphragmatic hernia and strangulated ileum complicated by necrosis of the ileum and transverse colon. He had a history of cervical spinal cord injury due to suicide attempt 14 years earlier and, as a result of cervical spinal cord injury, he was paralyzed in the lower body. The patient underwent an urgent hernia repair and bowel resection. Postoperatively, he developed severe septic shock. On postoperative day (POD) 6, wound dehiscence due to colonic anastomotic leakage with diffuse peritonitis was diagnosed, but he was unable to undergo re-operation because of refractory severe septic shock combined with neurogenic shock due to the cervical cord injury. The patient was treated with AVS therapy. He gradually recovered from septic shock, and the anastomotic leakage healed after a 2-month period. The wound dehiscence was also reduced. The patient resumed oral intake on POD 112 and was discharged on POD 190. CONCLUSIONS: Although surgical repair would be the best method for the treatment of diffuse peritonitis due to gastrointestinal perforation or anastomotic leakage, our case suggests that AVS with 'conventional' drainage is a treatment of choice for open abdominal wounds even in the presence of diffuse peritonitis caused by intestinal anastomotic leakage, especially in patients with poor general medical condition.

[Prolonged Survival Following Chemotherapy in Bone Marrow Carcinomatosis Due to Esophagogastric Junctional Carcinoma - A Case Report].

A 60s-year-old Japanese male underwent curative resection for an advanced adenocarcinoma of the esophagogastric junction(Stage III C), followed by adjuvant chemotherapy.Twenty -one months later, he was admitted to our hospital with a complaint of marked decline in activities of daily living(ADL).The patient was diagnosed with pancytopenia, disseminated intravascular coagulation(DIC), multiple lymph node and bone metastases, and bone marrow carcinomatosis.After completing a sufficient informed consent process, he received chemotherapy along with blood transfusion, and then DIC, pancytopenia, and ADL of the patient improved.However, the lack of response of pancytopenia and DIC to transfusion relapsed and his ADL worsened after the second course of chemotherapy.It was difficult to administer additional chemotherapy in the patient and he died 24 months after surgery.There is no established treatment for disseminated carcinomatosis of the bone marrow, and the prognosis of these patients without treatment is reported to be only one month.Our case with prolonged survival following chemotherapy and blood transfusion may support the clinical usefulness of chemotherapy for bone marrow carcinomatosis from esophagogastric junctional carcinoma.

Right adrenal giant cystic pheochromocytoma: A case report.

A 78-year-old woman was referred to our institution for evaluation and treatment of a mass on her right adrenal gland measuring 12 × 11 × 10 cm. Twenty-four-hour urine analysis revealed a total metanephrine level over 3 times the upper limit of normal. Scintigraphy using 123I-metaiodobenzylguanidine was positive. The mass was resected en bloc by laparotomy after a laparoscopic attempt was unsuccessful. Histopathologic examination revealed a pheochromocytoma of the right adrenal gland, weighing 576 g. The Grading System for Adrenal Pheochromocytoma and Paraganglioma score was 6, and the histology of the tumor was a moderately differentiated type.

Duplicate left gastric artery identified during robot-assisted distal gastrectomy: a case report.

BACKGROUND: Duplicated left gastric artery (LGA) is a rare anomaly. With an incidence of only 0.4%, its clinical significance remains largely unrecognized. CASE PRESENTATION: A 65-year-old man underwent robot-assisted distal gastrectomy for early gastric cancer. After division of the left gastric vein in the left gastropancreatic fold, a slim LGA (LGA-1) was identified and dissected. Careful dissection of the left gastropancreatic fold toward the root of the celiac artery revealed another LGA (LGA-2), which was dissected without difficulty. Postoperative reevaluation of the three-dimensional-computed tomography (CT) angiography reconstructed using the preoperative CT scan identified a 2.7 mm LGA-1, branching from the splenic artery, and a 3.0 mm LGA-2, branching from the celiac artery. To the best of our knowledge, this is only the third reported case of a duplicate LGA in a patient who underwent laparoscopic gastrectomy. Our case is the first to report the use of robot surgery. CONCLUSIONS: Although duplicate LGA is rare and receives little clinical attention, surgeons should keep this vascular anomaly in mind during preoperative evaluation since there is an increased risk for intraoperative bleeding during gastrectomy.

Bowel intussusception and adhesive intestinal obstruction in neurofibromatosis type 1.

We report the case that a patient with Neurofibromatosis type 1 experienced bowel intussusception and adhesive intestinal obstruction. Bowel intussusception was considered to be due to long intestinal tube and multiple intraabdominal lesions including gastrointestinal stromal tumors (GISTs).

Accurate prediction of severe postoperative complications after pancreatic surgery: POSSUM vs E-PASS.

BACKGROUND/PURPOSE: Few reports have evaluated the differences in the predictive accuracy between the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and estimation of physiologic ability and surgical stress (E-PASS) in pancreatic surgery. Thus, we evaluated the accuracy and similarity of POSSUM and E-PASS for the prediction of severe postoperative complications (PCs) after pancreatic surgery. METHODS: We enrolled 343 consecutive patients who underwent pancreatic surgery in our department between April 2006 and September 2017. The difference in predictive values of POSSUM and E-PASS for the occurrence of PCs ≥ Clavien-Dindo grade IIIa (PCs-CD ≥ IIIa) was nonparametrically compared. The predictive accuracy and similarity of each tool was examined using the receiver operating characteristic (ROC) curve and linear regression analyses. RESULTS: Forty-five patients developed PCs-CD ≥ IIIa. E-PASS had a significantly higher predictive value for estimating PCs-CD ≥ IIIa occurrence (P = .002) than did POSSUM. The area under the curve value in ROC analysis was significantly higher in E-PASS than in POSSUM (0.643 vs 0.543, P = .014), with a weak positive correlation in the predictive value between E-PASS and POSSUM (R2  = .333, P < .001). CONCLUSION: Estimation of physiologic ability and surgical stress was useful for predicting severe PCs after pancreatic surgery and had a higher accuracy than POSSUM.

Inter- and Intrafractional Variation in the 3-Dimensional Positions of Pancreatic Tumors Due to Respiration Under Real-Time Monitoring.

PURPOSE: To quantify the 3-dimensional pancreatic tumor motion during the overall treatment course using real-time orthogonal kilovoltage X-ray imaging. METHODS AND MATERIALS: This study included 10 patients with pancreatic cancer who underwent 6-port static intensity modulated radiation therapy with real-time tumor tracking in 15 fractions, except for 1 patient (5 fractions). The tumor and abdominal wall positions were acquired simultaneously during the overall treatment course. Then the tumor motion amplitude and reference positions were determined. RESULTS: The mean tumor amplitudes were 4.9, 6.5, and 13.4 mm in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively. The intrafractional variations of the reference tumor position were up to 5.4, 10.2, and 10.7 mm in the LR, AP, and SI directions, and those of the reference abdominal position were up to 10.5 mm. The reference tumor position drifted significantly in the AP and SI directions after 10 minutes, and that of abdominal wall motion drifted during the first 15 minutes (P<.05). The interfractional variation of the reference tumor position after setup correction, based on bony structures, was up to 8.9, 9.8, and 11.0 mm in the LR, AP, and SI directions, respectively. CONCLUSIONS: Appropriate respiratory motion management techniques should be applied for the accurate localization of pancreatic tumors.

Highly efficient photocatalytic oxygenation reactions using water as an oxygen source.

The effective utilization of solar energy requires photocatalytic reactions with high quantum efficiency. Water is the most abundant reactant that can be used as an oxygen source in efficient photocatalytic reactions, just as nature uses water in an oxygenic photosynthesis. We report that photocatalytic oxygenation of organic substrates such as sodium p-styrene sulfonate occurs with nearly 100% quantum efficiency using manganese(III) porphyrins as an oxygenation catalyst, [Ru(II)(bpy)(3)](2+) (bpy = 2,2'-bipyridine) as a photosensitized electron-transfer catalyst, [Co(III)(NH(3))(5)Cl](2+) as a low-cost and weak one-electron oxidant, and water as an oxygen source in a phosphate buffer solution (pH 7.4). A high-valent manganese-oxo porphyrin is proposed as an active oxidant that effects the oxygenation reactions.

Inverse relationship between serum erythropoietin and blood lead concentrations in Kathmandu tricycle taxi drivers.

OBJECTIVE: Kathmandu tricycle taxi drivers, whose environmental lead (Pb) exposure is ascribable mainly to vehicular exhaust, were studied to examine a dose-response relationship between blood Pb (Pb-B) and serum erythropoietin (sEPO) concentrations. METHODS: Subjects were 27 drivers and 9 non-drivers. They were non-anemic healthy men with normal renal function. Pb-B was measured by an atomic absorption spectrometer with a graphite furnace, and sEPO was determined with a sandwich-type enzyme-linked immunosorbent assay. RESULTS: sEPO levels in drivers were lower than those of non-drivers, while Pb-B levels in drivers were higher than those of non-drivers. There was an inverse relationship between Pb-B and sEPO. CONCLUSIONS: The data suggest that Pb inhibits renal EPO production in a dose-dependent manner in persons with subclinical Pb toxicity. sEPO may serve as an early biochemical marker of subclinical Pb toxicity.