[A Case of Inverted LECS for GIST Near the Pylorus Ring].

Laparoscopy and endoscopy cooperative surgery(LECS)is a surgical procedure to avoid excessive resection of the gastrointestinal wall and preserve its function. For gastrointestinal stromal tumors(GIST)near the cardia and pylorus ring, the function of the cardia and pylorus can be preserved by minimum excision and hand-sewn suture closures. Here, we report a case successfully treated with inverted LECS for GIST near the pylorus ring. The patient was a 58-year-old male. Upper gastrointestinal endoscopy had revealed a 45 mm sized SMT near the pylorus ring. Biopsy by EUS-FNA indicated gastric GIST. The tumor was separated from the pylorus ring and inverted LECS was performed. The defect was closed with hand-sewn sutures, forming an L-shape. The postoperative course was good and he was discharged from hospital 10 days after surgery. It is considered that devising the direction of closure by means of the LECS procedure can preserve the pyloric function without passage obstruction or stasis, even for gastric GIST near the pylorus ring.

[Unresectable Advanced HER2-Positive Gastric Cancer Leading to a Perforation during Chemotherapy with Trastuzumab plus Paclitaxel].

The patient was a 70s female with gastric cancer. CT and PET scans revealed metastases of para-aortic lymph nodes, hepatoduodenal ligament lymph nodes, and left supraclavicular lymph nodes. She was diagnosed with T4a, N2, M1(LYM), and cStage ⅣB and was given chemotherapy with paclitaxel due to chronic kidney disease and trastuzumab treatment. We planned to perform radical gastrectomy with lymph node dissection due to the disappearance of FDG uptake except for primary gastric cancer on PET scans 5 months after chemotherapy. However, the patient developed pan-peritonitis due to gastric cancer perforation; therefore, emergency distal gastrectomy with Billroth Ⅱ reconstruction was performed. She received chemotherapy(only trastuzumab)after getting discharged. Reports about gastric cancer perforation during chemotherapy using trastuzumab are rare. We should consider the possibility of perforated gastric cancer during chemotherapy and optimal surgical procedures, including the extent of lymph node dissection in the case of Stage Ⅳ gastric cancer.

Nutritional assessment and surgical outcomes in very elderly patients undergoing pancreaticoduodenectomy: a retrospective study.

PURPOSE: To evaluate and compare the nutritional factors and clinical outcomes of pancreaticoduodenectomy between elderly and non-elderly patients. METHODS: This retrospective study evaluated 122 consecutive patients who underwent pancreaticoduodenectomy from April 2008 to April 2020. Preoperative and postoperative nutritional factors (prognostic nutritional index), complication rates, and survival rates were compared between the elderly (≥ 80 years) and non-elderly (< 80 years) patient groups. Changes in nutrition markers were evaluated before surgery to 1 year after surgery. RESULTS: A total of 20 elderly patients (16.4%) and 102 non-elderly patients (83.6%) underwent pancreaticoduodenectomy. Elderly patients had a significantly lower preoperative prognostic nutritional index than did non-elderly patients. At 3 months postoperatively, elderly patients had a lower albumin level and prognostic nutritional index. The median length of hospital stay was significantly longer (39.9 vs. 27 days, P = 0.004), the rate of death due to other diseases was higher, and the overall survival rate was significantly lower (1-/3-/5 year overall survival rates: 78.1%/26.7%/13.3% vs. 87.1%/54.4%/46.7%; log-rank test, P = 0.003) in the elderly group than in the non-elderly group. CONCLUSIONS: The results suggest that careful patient selection and optimal perioperative care are necessary to determine whether pancreaticoduodenectomy is indicated for elderly patients.

[A Case of Colon Cancer with Suspected DPD Deficiency Causing Severe Adverse Effects following Adjuvant Chemotherapy with Capecitabine].

The present study reports a case of colon cancer in a 76-year-old female who underwent laparoscopic right colectomy. Pathological findings revealed pT3(SS), pN2a, cM0, and pStage Ⅲb. Hence, we administered adjuvant chemotherapy with capecitabine. On day 18, she was urgently hospitalized because of severe oral mucositis(grade 3), diarrhea(grade 3), and leukocytopenia(grade 4). Furthermore, the patient experienced DIC, which gradually improved through intensive conservative treatment. From the clinical course, we suspected that the severe adverse effects were caused due to a deficiency of DPD. We were able to save the patient through early treatment.

[A Case of Laparoscopic Subtotal Gastrectomy with a Very Small Remnant Stomach in an Elderly Patient with Multiple Malignant Gastric Tumors].

An 85-year-old man was referred to our hospital for anemia. Upper gastrointestinal endoscopy showed 6 malignant gastric lesions. Abdominal CT showed a primary tumor. We treated early gastric cancer at the upper stomach with endoscopic submucosal dissection(ESD)to avoid total gastrectomy. We then performed laparoscopic subtotal gastrectomy with a very small remnant stomach. In elderly patients with multiple gastric cancer, it is useful to combine ESD with laparoscopic subtotal gastrectomy with a very small remnant stomach.

Adequacy evaluation of the annual colonoscopic surveillance and individual difference of disease phenotypes in Lynch syndrome.

BACKGROUND: Regular endoscopic surveillance for Lynch syndrome is reported to reduce colorectal cancer (CRC)-related mortality. However, the appropriate surveillance intervals are still unclear. We evaluated the adequacy of annual colonoscopy and investigated the differences in tumor occurrence rates between individual patients. METHODS: In total, 25 patients with Lynch syndrome who underwent colonoscopic surveillance between 2007 and 2016 at the Iwakuni Clinical Center were included. We retrospectively investigated the surveillance frequency and the clinical features associated with tumor development. RESULTS: Colonoscopic surveillance was performed every 397 days on average. A total of 101 tumors, including 8 intramucosal carcinomas and 15 carcinomas, were observed within the study period. Annual colonoscopy detected six malignancies, including a carcinoma requiring surgery. Tumor incidence was associated with tumor existence in the initial colonoscopies (P = 0.018). Patients with a tumor occurrence rate of 0.4 tumors per year during our observation period were significantly more likely to have malignancies detected during regular surveillance than patients who had a lower occurrence rate (P < 0.001). Malignancy occurrence rate was strongly associated with tumor occurrence rate (P < 0.001, R2 = 0.44). CONCLUSIONS: Annual colonoscopic surveillance for Lynch syndrome patients was effective in reducing the risk of CRC progression, but was insufficient to completely avoid surgery. Because the tumor occurrence rate differed substantially between individuals, more intensive surveillance was required for high-risk patients.

Solitary Cardiac Metastasis of Hepatocellular Carcinoma.

Cardiac metastasis originating from hepatocellular carcinoma (HCC) is a rare condition with a poor prognosis. No therapeutic standards for cardiac metastasis originating from HCC have been established. At 19 months after a curative hepatectomy, a 64-year-old Japanese hepatitis B virus-positive male patient experienced solitary cardiac metastasis originating from HCC. The cardiac tumor was discovered in the right ventricle. The patient received three courses of radiotherapy and chemotherapy and survived > 3 years after the initial diagnosis of cardiac metastasis. His case demonstrates that radiotherapy combined with chemotherapy can be an effective treatment for cardiac metastasis.

The Late Phase/Early Phase Ratio of Pancreatic CT Values as a Novel Predictor of Pancreatic Fistula after Distal Pancreatectomy.

Post-operative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy (DP). In this retrospective study, we reviewed the data from patients who underwent DP between 2008 and 2019 in our institute to determine whether the late phase/early phase ratio (L/E ratio) by preoperative computed tomography (CT) scan in the pancreas could predict POPF occurrence after DP. We examined the relationship between preoperative or intraoperative factors and the occurrence of POPF after DP using statistical methods in 23 males and 21 females with a mean age of 73. The mean L/E ratio was significantly lower in the POPF group than the non-POPF group (p=0.035). The L/E ratio had moderate diagnostic accuracy, with a calculated optimal cutoff value of 0.77. In univariate analysis, a significant association was noted between POPF and stump thickness ≥ 16.9, body mass index ≥ 27.5, and L/E ratio ≤ 0.77. In the multivariate analysis, the L/E ratio (odds ratio, 5.96; p=0.036) was an independent risk factor for POPF. Our findings suggest that the pancreatic L/E ratio may predict the occurrence of POPF after DP. This measure may be useful in preoperative risk stratification, patient counseling, and perioperative patient management, improving clinical outcomes after DP.

[A Case of Laparoscopic Distal Gastrectomy for Gastric Cancer with Common Hepatic Artery Anomaly].

A 67-year-old woman with upper abdominal pain was referred to our hospital. Upper gastrointestinal endoscopy revealed a type 3 gastric cancer at the greater curvature of the angular notch. Abdominal CT helped detect the primary tumor. Multi-detector-row computed tomography(MDCT)and 3D-CT angiography revealed a vascular anomaly in which the left gastric and splenic arteries formed the common trunk. The common hepatic and superior mesenteric arteries formed the common trunk. We performed a laparoscopic distal gastrectomy with D2 lymph node dissection. During suprapancreatic lymph node dissection, the surface of the portal vein was difficult to expose toward the left side because the portal vein joined the splenic and superior mesenteric veins on the caudal side. Therefore, the No. 8a lymph nodes were dissected along the anterior hepatic plexus. In cases of common hepatic artery anomaly, identifying the anterior hepatic plexus is useful for the dissection of the suprapancreatic lymph nodes.

[A Case of Surgery for Transversal Colon Cancer with Intestinal Malrotation -Visualizing Method of Blood Flow in the Fluorescence Navigation Period].

BACKGROUND: Anastomotic blood flow evaluation using the fluorescence method with indocyanine green(ICG)is expected to decrease the risk of anastomotic leakage in colorectal cancer surgery. The fluorescence method is considered to be also useful for assessing arterial divergence patterns in patients with special anatomical features. We report a case of transverse colon cancer with intestinal malrotation treated with laparoscopic surgery using the ICG fluorescence method. CASE: A 62- year-old woman who was diagnosed as having transverse colon cancer with intestinal malrotation underwent a laparoscopic transverse colon resection with D3 lymph node dissection. We identified the ileocolic artery and middle colic artery (MCA)after the ICG injection and the severed MCA during lymphadenectomy. We made a final diagnosis of pT2N0M0, pStage Ⅰ. CONCLUSION: The fluorescence method was useful for assessing the arterial divergence pattern in a patient with a special anatomical feature. However, the ICG fluorescence method had some problems, including visualizing blood flow for only a short time and poorly transmitting the dye through thick fat.

Safety of Surgical Treatment for Elderly Patients with Gallbladder Carcinoma.

Gallbladder carcinoma (GBC) is a common malignancy with a poor prognosis. With the average life expectancy increasing globally, the incidence of GBC is predicted to increase as well. We investigated the safety and feasibility of surgical treatment for elderly patients with GBC. We retrospectively compared clinical pathological data and treatment outcomes in 45 consecutive GBC patients (23 patients ≥ 75 years [elderly group] and 22 patients < 75 years [younger group]) who underwent curative resection at the Iwakuni Center from January 2008 to December 2017. The proportion of preoperative comorbidities and anticoagulant use was significantly higher in the elderly group. The American Society of Anesthesiologists score was higher in the elderly versus the younger group, and the elderly group had significantly shorter operation times. Reduced activities of daily living was more common in the elderly versus younger group. The percentage of radical resection and overall 3-year survival (66.6% younger vs. 64.4% elderly) were similar between the groups. Controlling Nutritional Status (CONUT) score ≥ 3 and R0 resection were identified as prognostic factors for overall survival rate among all patients. After careful patient selection.

Reversible generation of large retractive tensile forces in isometric chemo-mechanical actuators composed of nanocomposite hydrogels and aqueous NaCl solutions.

This article addresses the generation of large mechanical forces in muscle-like isometric actuator systems composed of stimuli-responsive nanocomposite hydrogels (NC gels) and aqueous NaCl solutions. NC gels with poly(N-isopropylacrylamide)-clay (PNIPA-clay) network structures exhibit high mechanical toughnesses and reversible swelling/deswelling behavior in the absence/presence of NaCl. NC gels constrained to constant lengths in brine generate enhanced contractive forces due to the salt-induced coil-to-globule transitions that are more than ten times larger than those induced thermally. A retractive tensile force (4 N/170 kPa), comparable to that of human muscle, was repeatedly generated at 20 °C using an appropriately composed NC gel (clay: 2 mol%, PNIPA: 2 M), and by alternating the NaCl concentration between 0 and 5 M. This phenomenon is attributed to the combined effects of enhanced deswelling behavior resulting from the salt-induced coil-to-globule transition of PNIPA and the high stiffness of the deswollen gel due to the NaCl-strengthened PNIPA-clay network.

Clay-Alcohol-Water Dispersions: Anomalous Viscosity Changes Due to Network Formation of Clay Nanosheets Induced by Alcohol Clustering.

Clay-alcohol-water ternary dispersions were compared with alcohol-water binary mixtures in terms of viscosity and optical absorbance. Aqueous clay dispersions to which lower alcohols (ethanol, 1-propanol, 2-propanol, and tert-butanol) were added exhibited significant viscosity anomalies (maxima) when the alcohol content was 30-55 wt %, as well as optical absorbance anomalies (maxima). The maximum viscosity (ηmax) depended strongly on the clay content and varied between 300 and 8000 mPa·s, making it remarkably high compared with the viscosity anomalies (2 mPa·s) observed in alcohol-water binary mixtures. The alcohol content at ηmax decreased as the hydrophobicity of the alcohol increased. The ternary dispersions with viscosity anomalies exhibited thixotropic behaviors. The effects of other hydrophilic solvents (glycols) and other kinds of clays were also clarified. Based on these findings and the average particle size changes, the viscosity anomalies in the ternary dispersions were explained by alcohol-clustering-induced network formation of the clay nanosheets. It was estimated that 0.9, 1.7, and 2.5 H2O molecules per alcohol molecule were required to stabilize the ethanol, 2-propanol, and tert-butanol, respectively, in the clay-alcohol-water dispersions.

Removal of naphthols and analogues by the combined use of an oxidoreductase polyphenol oxidase and a biopolymer chitosan from aqueous solutions.

In this study, the combined use of an amino group-containing polymer chitosan and an oxidoreductase polyphenol oxidase (PPO) was applied to the removal of naphthols and dihydroxynaphthalenes (DHNs) from aqueous solutions. The process parameters, such as the pH value, temperature and enzyme dose, were discussed for PPO-catalysed oxidation of 1-naphthol. The optimum conditions of enzymatic oxidation of 1-naphthol were determined to be pH 8.0 and 40 °C. Under the optimum conditions, PPO-catalysed oxidation of 1-naphthol increased with an increase in the enzyme dose. Quinone derivatives enzymatically generated were chemisorbed on chitosan beads and the initial velocity of PPO-catalysed oxidation increased with an increase in the amount of added chitosan beads. A specific initial velocity of 0.0675 µmol/U·min was obtained in the PPO concentration range below 200 U/cm³ and 1-naphthol was completely removed within 24 h by quinone adsorption on chitosan beads (0.20 cm³/cm³) at a PPO concentration of 100 U/cm³. The removal time was shortened by increasing the enzyme dose or the amount of added chitosan beads. 2-Naphthol was also completely removed at an initial concentration of 0.05 mM or less by prolonging the reaction time, since PPO-catalysed oxidation of 2-naphthol was much slower than that of 1-naphthol. In addition, this procedure was also applied to the removal of DHNs. These results revealed that the procedure constructed in this study was an effective technique to remove naphthols and DHNs from the aqueous medium.

Analysis of surgical outcomes of diverticular disease of the colon.

We analyzed retrospectively the surgical outcomes of diverticular diseases of the colon at the surgical division of Fukuyama Medical Center. Data were collected from 39 patients who underwent surgery for diverticular disease at Fukuyama Medical Center. Thirty-nine patients were admitted between 2005 and 2010. The mean age of the 39 patients was 63.6 years. The collected data included patient demographics, patient history, type of surgery and complications. Patients were divided into 2 groups, Elective vs. Emergent group, right vs. left colon group and laparotomy vs. laparoscopic approach. Multivariate analysis of the logistic model of morbidity revealed a significantly higher rate in the left colon and the Cox proportional hazards model clearly showed fewer postoperative hospital days with the laparoscopic approach. Surgical procedures should be decided in reference to the particular clinical and pathological features of diverticular disease to gain an acceptable morbidity and mortality rates.

Enhancement of Cr(VI) ion adsorption by two-step grafting of methacrylamide (MAAm) and 2-(dimethylamino)ethyl methacrylate (DMAEMA) onto polyethylene plate.

Polyethylene (PE) plates grafted with a neutral hydrophilic monomer, methacrylamide (MAAm), and a cationic monomer, 2-(dimethylamino)ethyl methacrylate (DMAEMA), (PE-g-PMAAm)-g-PDMAEMA plates, were prepared by the two-step photografting. The Cr(VI) ion adsorption of the resultant (PE-g-PMAAm)-g-PDMAEMA plates was investigated as a function of the initial pH value, temperature, and grafted amounts of PMAAm and PDMAEMA. The adsorption capacity of the (PE-g-PMAAm)-g-PDMAEMA plates had the maximum at the initial pH value of 3.0 and the initial adsorption rate increased with the temperature and increased with the amount of grafted DMAEMA. This result suggests that protonated dimethylamino groups present in the inside of the grafted layer are increasingly involved in the Cr(VI) ion adsorption by the increase in the water absorptivity through the formation of the intermediate grafted layer of PMAAm. The maximum adsorption ratio of 0.510 was obtained for a (PE-g-PMAAm)-g-PDMAEMA plate with GMAAm = 30 µmol/cm2 and GDMAEMA = 1.7 µmol/cm2. The maximum adsorption capacity obtained in this study was comparable to or higher than those of other adsorbents for Cr(VI) ions. The adsorption behaviour obeyed the pseudo-second order kinetic model and was well described by the Langmuir isotherm model, suggesting that the adsorption of Cr(VI) ions occurs through the electrostatic interaction between protonated dimethylamino groups and HCrO4- ions. Cr(VI) ions were successfully desorbed in such eluents as NaCl, NaCl containing NaOH, NH4Cl, NH4Cl containing NaOH, and NaOH and (PE-g-PMAAm)-g-PDMAEMA plates were repeatedly used without considerable loss in the adsorption capacity.

Distinct effects of tissue-type plasminogen activator and SMTP-7 on cerebrovascular inflammation following thrombolytic reperfusion.

BACKGROUND AND PURPOSE: Thrombolysis therapy using tissue-type plasminogen activator (t-PA) is occasionally accompanied by harmful outcomes, including intracerebral hemorrhage. We have reported that Stachybotrys microspora triprenyl phenol-7 (SMTP-7), a candidate thrombolytic drug, has excellent therapeutic effect on cerebral infarction in embolic stroke model in mice; however, little is known regarding whether this agent influences cerebrovascular inflammation following thrombolytic reperfusion. The current study aimed to compare the effects of recombinant t-PA (rt-PA) and SMTP-7 on cerebrovascular inflammation. METHODS: The impact of rt-PA- and SMTP-7-induced thrombolytic reperfusion on leukocyte dynamics was investigated in a photochemically induced thrombotic middle cerebral artery occlusion (tMCAo) model in mice. RESULTS: Both rt-PA and SMTP-7 administration in tMCAo mice (each 10 mg/kg) resulted in thrombolytic reperfusion. The SMTP-7-administered mice showed relatively mild rolling and attachment of leukocytes to the vascular wall in the middle cerebral vein, with weak peroxynitrite reactions and proinflammatory gene expression (IL-1ß, TNF-α, ICAM-1, and VCAM-1); thus, a small infarct volume compared with rt-PA-administered mice. In vitro study suggested that rt-PA at 20 µg/mL, but not SMTP-7 at a similar concentration, promotes cytokine-induced reactive oxygen species generation in cultured endothelial cells; moreover, SMTP-7 suppressed cytokine-induced VCAM-1 induction in the cells and leukocyte/ endothelial cell adhesions. CONCLUSIONS: Relatively mild cerebrovascular inflammation and cerebral infarction in the SMTP-7 mice, compared with in rt-PA mice, is thought to be caused at least in part by direct antioxidative actions of SMTP-7 in ECs.

Dielectrophoresis-assisted massively parallel cell pairing and fusion based on field constriction created by a micro-orifice array sheet.

In this paper, we present a novel electrofusion device that enables massive parallelism, using an electrically insulating sheet having a two-dimensional micro-orifice array. The sheet is sandwiched by a pair of micro-chambers with immersed electrodes, and each chamber is filled with the suspensions of the two types of cells to be fused. Dielectrophoresis, assisted by sedimentation, is used to position the cells in the upper chamber down onto the orifices, then the device is flipped over to position the cells on the other side, so that cell pairs making contact in the orifice are formed. When a pulse voltage is applied to the electrodes, most voltage drop occurs around the orifice and impressed on the cell membrane in the orifice. This makes possible the application of size-independent voltage to fuse two cells in contact at all orifices exclusively in 1:1 manner. In the experiment, cytoplasm of one of the cells is stained with a fluorescence dye, and the transfer of the fluorescence to the other cell is used as the indication of fusion events. The two-dimensional orifice arrangement at the pitch of 50 µm realizes simultaneous fusion of 6 × 10³ cells on a 4 mm diameter chip, and the fusion yield of 78-90% is achieved for various sizes and types of cells.

Hexavalent Cr ion adsorption and desorption behaviour of expanded poly(tetrafluoro)ethylene films grafted with 2-(dimethylamino)ethyl methacrylate.

A new polymeric adsorbent for Cr(VI) ions based on an expanded poly(tetrafluoroethylene) (ePTFE) film was prepared by the combined use of the pretreatment with oxygen plasma and photografting of 2-(dimethylamino)ethyl methacrylate (DMAEMA). The grafting of DMAEMA was characterized by XPS and FT-IR spectroscopic measurements. The adsorption behaviour of DMAEMA-grafted ePTFE (ePTFE-g-PDMAEMA) films was investigated as a function of the experimental parameters, such as the initial pH value, temperature, and grafted amount. The adsorption capacity and initial adsorption rate had the maximum values at the initial pH value of 3.0. On the other hand, the adsorption capacity became almost constant at temperatures higher than 30°C, although the adsorption rate increased over the temperature. The adsorption behaviour obeyed the pseudo-second-order kinetic model and well expressed by the Langmuir isotherm equation with higher correlation coefficients. These results indicate that the adsorption of Cr(VI) ions occurs through the electrostatic interaction between protonated dimethylamino groups on a grafted PDMAEMA chain and HCrO4- ions. Cr(VI) ions were successfully desorbed from Cr(VI)-loaded ePTFE-g-PDMAEMA films in the eluents, such as NaCl at 0.50 M, NH4Cl at 0.50M, and NaOH at 1.0 mM, and ePTFE-g-PDMAEMA films were repeatedly used for adsorption of Cr(VI) ions without appreciable loss in the adsorption capacity. It should be noted that Cr(VI) ion adsorptivity with a high initial rate was conferred to the ePTFE films. The results obtained in this study emphasize that ePTFE-g-PDMAEMA films can be applied as an adsorbent for Cr(VI) ions.

RecG interacts directly with SSB: implications for stalled replication fork regression.

RecG and RuvAB are proposed to act at stalled DNA replication forks to facilitate replication restart. To define the roles of these proteins in fork regression, we used a combination of assays to determine whether RecG, RuvAB or both are capable of acting at a stalled fork. The results show that RecG binds to the C-terminus of single-stranded DNA binding protein (SSB) forming a stoichiometric complex of 2 RecG monomers per SSB tetramer. This binding occurs in solution and to SSB protein bound to single stranded DNA (ssDNA). The result of this binding is stabilization of the interaction of RecG with ssDNA. In contrast, RuvAB does not bind to SSB. Side-by-side analysis of the catalytic efficiency of the ATPase activity of each enzyme revealed that (-)scDNA and ssDNA are potent stimulators of the ATPase activity of RecG but not for RuvAB, whereas relaxed circular DNA is a poor cofactor for RecG but an excellent one for RuvAB. Collectively, these data suggest that the timing of repair protein access to the DNA at stalled forks is determined by the nature of the DNA available at the fork. We propose that RecG acts first, with RuvAB acting either after RecG or in a separate pathway following protein-independent fork regression.