Feasibility of augmented rectangle technique in laparoscopic distal gastrectomy: comparison with hemi-double stapling technique in a single-center retrospective cohort study.

PURPOSE: Augmented rectangle technique (ART) anastomosis is a totally intracorporeal anastomosis of laparoscopic distal gastrectomy (LDG), Billroth I (B1) reconstruction for gastric cancer, which secures a wide anastomotic stoma. Since the conventional extracorporeal hemi-double stapling technique (HD) may have a narrow anastomotic stoma, our aim of this study was to evaluate the feasibility and usefulness of ART anastomosis by comparing the surgical outcomes with HD anastomosis. METHODS: Clinical data of 89 patients undergoing LDG with B1 reconstruction were retrospectively collected. Patients were divided into ART group (n = 40) and HD group (n = 49). Surgical outcomes including short-term outcomes, postoperative endoscopic findings, and nutritional factors 1 year after surgery were compared between the groups. RESULTS: Baseline characteristics were similar between the groups. In terms of short-term outcomes, blood loss was less (11.5 mL vs 40 mL, P = 0.011) and postoperative hospital stay was shorter (10 days vs 12 days, P = 0.022) in the ART group. In terms of endoscopic findings, residual food was less (P = 0.032) in the ART group. In terms of nutritional factors, percent decrease of visceral fat area (- 27.6% vs - 40.5%, P = 0.049) and subcutaneous fat area (- 25.7% vs - 39.3%, P = 0.050) 1 year after surgery attenuated in the ART group. CONCLUSIONS: ART anastomosis is superior in perioperative course such as postoperative hospital stay. Moreover, a better nutritional recovery is expected by securing a wide anastomotic stoma leading to a favorable food passage.

Supplemental estrogen and caloric restriction reduce obesity-induced periprostatic white adipose inflammation in mice.

Obesity is associated with an increased incidence of high-grade prostate cancer (PC) and worse prognosis for PC patients. Recently, we showed in men that obesity-related periprostatic white adipose tissue (WAT) inflammation, characterized by macrophages surrounding dead or dying adipocytes forming crown-like structures, was associated with high-grade PC. Possibly, interventions that suppress periprostatic WAT inflammation will improve outcomes for men with PC. Here, we tested the hypothesis that supplemental 17ß-estradiol (E2) could decrease periprostatic WAT inflammation in obese male mice. Mice were fed a high-fat diet to induce periprostatic WAT inflammation before being treated with supplemental E2. E2 supplementation suppressed caloric intake, induced weight loss, decreased periprostatic WAT inflammation and downregulated the expression of genes linked to inflammation including Cd68, Mcp1 and Tnf. Similar to the effects of E2 supplementation, treatment with diethylstilbestrol, a synthetic estrogen, also suppressed caloric intake and reduced periprostatic WAT inflammation. To determine whether the observed effects of supplemental estrogen could be reproduced by caloric restriction (CR) alone, obese mice were put on a 30% CR diet. Like estrogen treatment, CR was effective in reducing body weight, periprostatic WAT inflammation and the expression of pro-inflammatory genes. Transcriptomic analyses of periprostatic fat showed that obesity was associated with enrichment in inflammatory response pathways, which were normalized by both supplemental E2 and CR. Taken together, these findings strengthen the rationale for future efforts to determine whether either CR or supplemental estrogen will decrease periprostatic WAT inflammation and thereby improve outcomes for men with PC.

[A Case of Rectal Obstruction Due to Gastric Cancer Dissemination for Which Rectal Stenting Was Performed Twice].

Malignant colorectal obstruction results in a worse quality of life and makes it difficult for patients to continue chemotherapy. In this paper, we present a case of rectal obstruction caused by gastric cancer dissemination for which rectal stent insertions were performed twice. The patient was a 72-year-old woman. She underwent gastrectomy for Stage Ⅳ gastric cancer (ypT3, N1, M1, P0, H0, CY+). Twenty-eight months after gastrectomy, she experienced rectal obstruction due to peritoneal dissemination. A rectal stent was placed at the stenosis site. She was administered chemotherapy after stenting. Seven months later, she developed rectal obstruction due to tumor in-growth. Rectal stenting was performed again. Subsequently, the patient had no abdominal symptoms until she died, 2 months after the second stenting.

[Relapse-Free Survival of over 54 Months after ESD Resection in an Elderly Patient Considered to Have Non-Curative Early Gastric Cancer].

According to the Japanese Gastric Cancer Treatment Guideline(GL), radical surgery is recommended as an additional treatment for early gastric cancer(EGC)patients with endoscopic submucosal dissection(ESD)evaluated as non-curative for fear of lymph node metastasis(LNM). However, the reported probability of LNM was approximately 10%. Therefore, the recommendation might be aggressive for elderly patients or those in poor physical conditions. Under this context, surveillance post non-curative ESD has emerged as an acceptable option. We reported a case of an elderly patient who survived EGC for over 54 months as relapse-free with ESD resection evaluated as non-curative. An 84-year-old woman underwent ESD in July 2014 for EGC, which was deemed as non-curative with negative surgical margins. The patient had pre-existing severe bronchial asthma. Given the age and the comorbidities, the patient preferred close surveillance to radical surgery. After 54 months of surveillance, no recurrence of the initial EGC was found. However, during the annual check-ups, 2 metachronous cancers were found in July 2016 and June 2018 respectively. Both metachronous cancers were curatively resected with ESD.

[A Case of Advanced Gastric Cancer Who Peritoneal Dissemination but Survived over 40 Months with Locoregional Therapies].

Several recent case reports have demonstrated long survival cases of advanced gastric cancer(AGC)patients suffering from peritoneal dissemination(PD)treatedwith effective chemotherapy; however, these AGC patients have poor prognosis in general. We report a case of AGC who hadsurvivedPD over 40 months with locoregional therapies. A 58-year-oldmale underwent distal gastrectomy for AGC with localized PD. Although we recommended postoperative chemotherapy, he chose surveillance as his will. Eighteen months postoperatively, CT scan revealedrecurrence of PD, andPET -CT showedonly one site of recurrent nodule. The patient chose locoregional therapy, ie, resection of the recurrent nodule instead of chemotherapy. Pathological exam confirmedthe recurrence of AGC, andabd ominal lavage cytology was classifiedas V. Even after these pathological findings, the patient refused to receive chemotherapy. At 39 months postoperatively, he developed subileus due to multiple recurrence of PD. At 40 months postoperatively, we performedchemotherapy because locoregional therapy was not supposedto be appropriate for these multiple lesions. However, the patient movedto another hospital after 1 course of chemotherapy because of his continuedrefusal to receive chemotherapy.

[Esophageal Cancer Surgery in Elderly Patients Aged 80 Years or Older].

As the population ages, the elderly are increasingly affected by esophageal cancer. We reviewed the data of elderly patients, 80 years old or older, who underwent surgery for esophageal cancer to evaluate the safety of surgery in this particular patient population. Twenty-two patients aged 80 or above underwent surgery for esophageal cancer in our department. We analyzed their preoperative assessment, concurrent disorders, surgical techniques used, postoperative course, and complications. Median age of the patients was 83 years. Eleven patients had concurrent hypertension, 5 patients had undergone a malignant tumor operation, and 5 patients had concurrent diabetes. Fifteen patients underwent esophagectomy with right thoracotomy and two-field lymph node dissection(LD), 1 patient underwent esophagectomy with right thoracotomy and three-field LD, 2 patients underwent esophagectomy with left thoracoabdominal incision and two-field LD, 2 patients underwent lower esophagectomy and proximal gastrectomy, and 2 patients underwent transhiatal esophagectomy. Postoperative complications occurred in 14 patients(63%); however, no severe pneumonia was noted. Anastomotic leakage was only observed in 1 patient. All patients were discharged with improved conditions. The mean postoperative hospital stay was 39 days. Esophageal cancer surgery can be performed safely in the oldest of elderly patients with appropriate preoperative assessment, selection of the optimal surgical technique, and perioperative care.

[A Case of Sigmoid Colon Cancer Identified by Gastric Perforation].

We report a case of sigmoid colon cancer that was incidentally found using CT that was performed for upper abdominal pain. An 83-year-old man with a long history of lung tuberculosis and idiopathic pulmonary fibrosis presented with upper abdominal pain. CT findings revealed free gas around the stomach. He was diagnosed with upper gastrointestinal perforation and his condition improved after undergoing conservative treatment. Upper endoscopy revealed an irregular ulcer at the angular incisure of the stomach with thickened folds, but biopsy resulted in a Group 1 classification. CT findings also incidentally revealed sigmoid colonic wall thickness, and colonoscopy showed a type Ⅰ lesion in the sigmoid colon, which biopsy resulted in Group 5, and we performed sigmoidectomy for sigmoid colon cancer under a combination of spine-subarachnoid and epidural anesthesia because of his respiratory dysfunction.

[A Case of Thoracic Esophageal Cancer That Caused Necrosis of a Reconstructed Colon Ten Years after Esophagectomy].

Necrosis of a reconstructed organ after esophageal cancer surgery is a very serious complication that often occurs soon after the surgery. We report a case of emergency surgery that was performed to treat necrosis of a reconstructed colon 10 years after esophagectomy. A 73-year-old man was admitted to our hospital with complaints of chest pain. His history included a proximal gastrectomy for gastric cancer. His present illness includes endoscopic mucosal resection for superficial esophageal cancer in 1995. Subtotal esophagectomy and right colon interposition through the retrosternal route were performed due to a recurrence in the same lesion in 2005. The patient was immediately hospitalized due to chest pain in 2015. An upper gastrointestinal endoscopy revealed extensive necrosis in the colon. He underwent an emergency operation. The surgical operations included reconstructed colonic resection by longitudinal sternotomy, esophagostomy, gastrostomy, and drainage procedure. The patient is currently under rehabilitation at a referral hospital. There has been no report on the occurrence of necrosis in the reconstructed colon 10 years after esophagectomy.

[A Case of Recurrent Jejunal Stenosis after Total Gastrectomy Treated with Self-Expandable Metallic Stent].

Case is a 66-year-old male. He was inserted covered self expandable metallic stent(SEMS)for jejunal stenosis due to gastric cancer recurrence. Migration was occurred after 4 days from stent replacement. We had removed SEMS by endoscopy, and re-inserted non-covered SEMS. Two months later, stent stenosis was occurred by tumor ingrowth. We tried to insert another stent in the stenotic stent. The patient was able to maintain oral intake without complication for 3 months. SEMS placement would improve a quality of life for selected patients with recurrent jejunal stenosis.

[A case of a recurrent hepatic metastasis occurred after curative resection of ascending colon cancer and a hepatic metastasis responding completely to capecitabine plus bevacizumab].

Although hepatic resection is the most effective therapy for patients with liver metastasis from colorectal carcinoma, a subset of patients cannot undergo surgical treatment for several reasons, including age-related general health decline or poor conditions associated with coexisting diseases, even if the lesions are resectable. A 75-year-old man with a recurrent lesion in the liver underwent right hemicolectomy and partial hepatic resection to treat colonic cancer and a liver metastasis, followed by uracil and tegafur plus Leucovorin( UFT+LV) as adjuvant chemotherapy at 6 months after the initial surgery. Although the lesion was resectable, the patient preferred chemotherapy to surgery, and capecitabine plus oxaliplatin plus bevacizumab was administered; however, the treatment was stopped in the middle of the second course because of oxaliplatin -related toxicities. Capecitabine plus bevacizumab was introduced as the following chemotherapy regimen, and no adverse reactions were observed during this therapy. After 5 courses of administration, the lesion disappeared on CT examination, and no new lesions were found after 9 courses. Thus, the treatment response was classified as complete response (CR) and remains as such after 13 courses.

Impact of ward pharmacist-led antimicrobial stewardship in intensive care units.

Various outcomes of mortality, medical costs, and antimicrobial usage result from antimicrobial stewardship (AS) programmes. Here, we clarified the effects of AS implementation by a well-trained pharmacist in an open intensive care unit (open ICU) through a retrospective, comparative study of 5123 open ICU patients of Tokai University Hospital. The 12 months before and after AS implementation were considered the control and study periods, respectively. After AS implementation, the number of AS cases increased significantly. The period until the implementation of therapeutic drug monitoring was significantly shortened, and antimicrobial drug usage increased significantly. The methicillin-resistant Staphylococcus aureus (MRSA) detection rate decreased significantly. Earlier and more frequent AS implementation could enhance treatment effects, possibly decreasing the MRSA incidence. Despite active AS implementation, antimicrobial drug usage did not necessarily decrease. ICU pharmacists with experience in AS should take on leadership roles and implement active AS strategies in open ICU settings.

Methods of Cleaning Taps to Prevent Hospital-Associated Infections: An Environmental Survey-Based Study.

In hospitals, outbreaks can occur due to pathogens accumulating in the areas around the wards' washbasins. Carbapenem-resistant Enterobacterales (CRE) was detected in an environmental survey in the high-care unit of a university hospital in Isehara, Japan, and effective cleaning methods were investigated. This study investigated methods of cleaning taps using commonly used detergents and disinfectants, and it assessed their effectiveness in removing hard scale and pathogens, including CRE. The taps were cleaned using various methods and cleaning agents, including environmentally neutral detergent, citric acid, baking soda, cleanser, 80% ethanol, 0.1% sodium hypochlorite, and a phosphoric acid-based environmental detergent (Space Shot). The cleaning effect was assessed based on the agent's effectiveness at removing hard scale from taps. Biofilms and scale were identified on taps, and several bacterial species were cultured. Only phosphoric acid-based detergent was effective at removing hard scale. After cleaning with the phosphoric acid-based detergent, the bacterial count decreased, and no CRE or other pathogens were detected. These results provide a reference for other facilities considering introducing this cleaning method.

Evaluation of the basic assay performance of the GeneSoc® rapid PCR testing system for detection of severe acute respiratory syndrome coronavirus 2.

In the ongoing coronavirus disease 2019 (COVID-19) pandemic, PCR has been widely used for screening patients displaying relevant symptoms. The rapid detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enables prompt diagnosis and the implementation of proper precautionary and isolation measures for the patient. In the present study, we aimed to evaluate the basic assay performance of an innovative PCR system, GeneSoC® (Kyorin Pharmaceutical Co. Ltd., Tokyo, Japan). A total of 1,445 clinical samples were submitted to the clinical laboratory, including confirmed or suspected cases of COVID-19, from February 13 to August 31. Specimen types included nasopharyngeal swabs. The sampling was performed several times for each patient every 2-7 days. Using this system, sequences specific for SARS-CoV-2 RNA could be detected in a sample within 10-15 min using the microfluidic thermal cycling technology. Analytical sensitivity studies showed that GeneSoC® could detect the target sequence of the viral envelope and RNA-dependent RNA-polymerase (RdRp) genes at 5 and 10 copies/µL, respectively. The precision of the GeneSoC® measurements using clinical isolates of the virus at a concentration of 103 copies/µL was favorable for both the genes; within-run repeatability and between-run reproducibility coefficient of variation values were less than 3% and 2%, respectively; and the reproducibility of inter-detection units was less than 5%. Method comparison by LightCycler® 480 showed the positive and negative agreement to be 100% [(174/174) and (1271/1271), respectively]. GeneSoC® proved to be a rapid and reliable detection system for the prompt diagnosis of symptomatic COVID-19 patients and could help reduce the spread of infections and facilitate more rapid treatment of infected patients.

First successful case of percutaneous transabdominal thoracic duct embolization (PTTDE) for chylous ascites resulting from laparoscopic gastric cancer surgery.

A 61-year-old woman underwent laparoscopy-assisted distal gastrectomy (LADG) with extragastric lymph node dissection (D2). Two months later, she was readmitted to hospital to be treated for chylous ascites. Oral intake was discontinued and total parenteral nutrition started, but increasing body weight and decreasing serum albumin concentration was not controllable. Percutaneous transabdominal thoracic duct embolization (PTTDE) was performed on the 8th day after the readmission. Five days after PTTDE, oral intake was resumed. Seventeen days after PTTDE, the patient was discharged without recurrence of ascites. She has remained asymptomatic. We describe here the first patient with chylous ascites two months after LADG with D2 dissection for early gastric cancer who was successfully treated by PTTDE.

Simultaneous Endoscopic Resection of Superficial Cancers of the Hypopharynx and Esophagus: A Case Report.

Diagnosis and treatment of superficial laryngopharyngeal cancers has recently received considerable attention. Here, we present a case of superficial hypopharyngeal cancer and superficial esophageal cancer treated with simultaneous endoscopic laryngopharyngeal surgery (ELPS) and endoscopic submucosal dissection (ESD). The patient was a 67-year-old man. During his follow-up for distal gastrectomy-performed earlier for stomach cancer-upper gastrointestinal endoscopy revealed three primary cancers: a superficial hypopharyngeal cancer, superficial esophageal cancer, and esophagogastric junction cancer. After total resection of the remnant stomach, combined hypopharyngeal ELPS with esophageal ESD was performed. He developed aspiration pneumonia after surgery but recovered and was discharged on the 16th day. Thus, safe and effective endoscopic therapy can be performed even for double superficial cancers of the laryngopharynx and esophagus.

Pioglitazone Inhibits Periprostatic White Adipose Tissue Inflammation in Obese Mice.

Obesity is associated with an increased incidence of high-grade prostate cancer and poor prognosis for prostate cancer patients. Recently, we showed that obesity-related periprostatic white adipose tissue (WAT) inflammation, characterized by crown-like structures (CLS) consisting of dead or dying adipocytes surrounded by macrophages, was associated with high-grade prostate cancer. It is possible, therefore, that agents that suppress periprostatic WAT inflammation will alter the development or progression of prostate cancer. Pioglitazone, a ligand of PPARγ, is used to treat diabetes and possesses anti-inflammatory properties. Here, our main objectives were to determine whether pioglitazone inhibited obesity-related periprostatic WAT inflammation in mice and then to elucidate the underlying mechanism. Treatment with pioglitazone reduced the density of CLS in periprostatic fat and suppressed levels of TNFα, TGFß, and the chemokine monocyte chemoattractant protein-1 (MCP-1). Importantly, the ability of pioglitazone to suppress periprostatic WAT inflammation was abrogated in MCP-1 knockout mice. Pioglitazone caused dose-dependent induction of both adiponectin, an anti-inflammatory adipokine, and its receptor AdipoR2 in cultured 3T3-L1 cells and in periprostatic WAT of obese mice. Pioglitazone blocked TNFα-mediated induction of MCP-1 in 3T3-L1 cells, an effect that was attenuated when either adiponectin or AdipoR2 were silenced. Taken together, pioglitazone-mediated induction of adiponectin suppressed the elevation in MCP-1 levels, thereby attenuating obesity-related periprostatic WAT inflammation. These findings strengthen the rationale for future efforts to determine whether targeting the PPARγ-adiponectin-MCP-1 axis will decrease periprostatic adipose inflammation and thereby reduce the risk of high-grade prostate cancer or improve outcomes for men with prostate cancer. Cancer Prev Res; 11(4); 215-26. ©2017 AACR.

Innovations for Cervical Esophagogastrostomy in Thoracic Esophageal Cancer Operations.

Three-field lymph node dissection is now performed in operations for advanced thoracic esophageal cancer, with an associated improvement in outcomes. However, reconstructive surgery following resection of the esophagus is frequently associated with the occurrence of anastomotic leakage. Once it occurs, major problems can arise such as decreased quality of life, protracted hospitalization, or even death. This is why there has been a large number of innovations in and modifications to reconstructive surgery. The standard procedures in our Department for advanced thoracic esophageal cancer are subtotal esophagectomy and three-field lymph node dissection. The thin gastric tube along the greater curvature is used as the reconstructed organ in reconstructive surgery, performing a cervical esophagogastrostomy. Innovations have been made to reconstructive surgery in order to prevent anastomotic leakage. This procedure markedly reduces anastomotic leakage, and also reduces anastomotic stricture, which likely makes it an extremely useful procedure that any surgeon can perform.

Characteristic features of Japanese women's hair with aging and with progressing hair loss.

BACKGROUND: There have been few studies of the features of hair with aging and hair loss in Japanese women. OBJECTIVE: Features of Japanese women's hair with aging and with progressing hair loss were investigated. METHODS: Japanese women with hair loss (n=46) or with no or less hair loss (n=113), aged 14-68 years, were studied. Severity of hair loss was rated by visual comparison with six standard photographs. Hair density, hair growth rate, and hair diameter were analyzed by phototrichogram. Follicular units were deduced by a non-invasive method using tree-view analysis on scalp imaging. RESULTS: Hair loss in Japanese women is commonly characterized by a diffuse central pattern occurring after approximately 40 years of age. Hair density declines with age after the 40s. The reduction resulted from an increase in the number of one-haired follicular units and a reduction of three- and more-haired follicular units. Both the ratio and the growth rate of anagen hair also declined with age after the 40s. Mean hair diameter and the ratio of thick hairs increased with age from about 10 to 40 years, and decreased with progressing hair loss. There were few vellus-like hairs in women with hair loss, in comparison with male-pattern baldness. CONCLUSION: In Japanese middle-aged women, hair density declined with age without the appearance of hair loss. Hair loss appeared after approximately 40 years of age. The major causes might be reduction of hair density and the ratio of thick hairs, but not an increase of vellus-like hairs.

Performance Evaluation of a Newly Developed and Fully Automated Bacteriological Analyzer "RAISUS ANY" for Antimicrobial Susceptibility Testing of Fastidious Bacteria Haemophilus influenzae and Streptococcus pneumoniae.

OBJECTIVE: Antimicrobial susceptibility testing for fastidious bacteria, such as Haemophilus influenzae (H. influenzae) and Streptococcus pneumoniae (S. pneumoniae) has been performed manually. We evaluated the performance of a newly developed fully automated system for rapid bacterial identification and antimicrobial susceptibility testing "RAISUS ANY" (Nissui Pharmaceutical Co., Ltd.). METHODS: We evaluated the performance of "RAISUS ANY" for measurement of minimal inhibitory concentrations (MICs) of H. influenzae and S. pneumoniae, in comparison with the manual method (DP34, Eiken Chem. Co., Ltd.). The repeatability of MICs was studied using the reference strain of these bacteria, obtained from the American Type Culture Collection (ATCC, Manassas, VA, USA). RESULTS: The comparison with the manual method for 35 and 36 clinical strains of H. influenzae and S. pneumonia showed 62.9-100% and 86.1-100% agreement, respectively. Five of 35 H. influenzae strains that showed a trailing effect were stably and accurately measured for MICs without a variation among the examiners. CONCLUSION: In conclusion, the automated system "RAISUS ANY" provided a reliable MICs data for H. influenzae and S. pneumonia, suggesting its improvement in performance and reliability for routine antimicrobial susceptibility testing in clinical bacteriological laboratories.

The Implementation of a Hospital-wide Practice for the Selective Use of Carbapenems Based on the Monitoring of Susceptibility of Pseudomonas aeruginosa Isolates.

OBJECTIVES: To control carbapenem-resistant Pseudomonas aeruginosa, we implemented a hospital-wide policy concerning the selective use of carbapenems based on the monitoring of P. aeruginosa isolates for susceptibility to five carbapenems using a customized dry plate method. In this study, we retrospectively investigated the outcome of our measures to control carbapenem-resistant P. aeruginosa. METHODS: To select effective carbapenems, 100 clinical isolates were collected, and the minimum inhibitory concentration (MIC) to 5 carbapenems (IPM/CS, MEPM, DRPM, BIPM and PAPM/BP) was monitored using a customized dry plate method from 2006 to 2013. Carbapenems, which were associated with a high rate of drug resistance in P. aeruginosa, were restricted from use during our intervention study. The antimicrobial use density per 100 bed-days (AUD100) of carbapenems and the detection rates of carbapenem (IPM/CS and MEPM)-resistant P. aeruginosa were determined during the period of the intervention. RESULTS: The isolates consistently showed higher rates of drug-resistant P. aeruginosa in IPM/CS and PAPM/BP. Thus, DRPM, MEPM and BIPM were adopted for hospital-wide use. The detection rates of all IPM/Cs and MEPM-resistant P. aeruginosa significantly decreased. Meanwhile, the consumption of carbapenems showed an increasing trend. CONCLUSIONS: The outcome of the hospital-wide implementation of the selective use of carbapenems based on periodic monitoring of the susceptibility of P. aeruginosa isolates was retrospectively studied. Implementation of this measure might have contributed in part to the control of carbapenem-resistant P. aeruginosa in our hospital.