Evaluation of Perioperative Intestinal Motility Using a Newly Developed Real-Time Monitoring System During Surgery.

BACKGROUND: This study aimed to investigate perioperative intestinal motility using a novel bowel sound monitoring system in patients undergoing breast and neck surgery. MATERIALS AND METHODS: This study enrolled 52 patients who underwent surgery for breast cancer, thyroid tumor, and parathyroid tumor at Kochi Medical School from May 2019 to June 2020. Perioperative bowel sound counts (BSCs) were recorded using a newly developed real-time analysis system in the operating theater. Clinical information and BSC per minute (cpm) data during the preanesthetic, preoperative, operative, postoperative periods, and period in recovery room were obtained to compare between each period. The Mann-Whitney U and Pearson Chi-square tests were used in data analysis. RESULTS: The BSCs during the intraoperative period and postoperative period were significantly decreased compared to those during the preanesthetic period (0.07 cpm versus [vs.]. 1.4 cpm, P = 0.002 and 0.1 cpm vs. 1.4 cpm, P = 0.025, respectively). The preoperative BSC with a preanesthetic BSC < 1.4 was significantly lower than that with a preanesthetic BSC ≥ 1.4 (0.40 cpm vs. 1.78 cpm, P = 0.006). The preanesthetic, preoperative, and postoperative BSCs with an intraoperative BSC < 0.07 were significantly lower than those with an intraoperative BSC ≥ 0.07 (0.48 cpm vs. 2.83 cpm, P = 0.007; 0.40 cpm vs. 1.81 cpm, P = 0.008; and 0.07 cpm vs. 0.42 cpm, P = 0.006, respectively). CONCLUSION: The real-time bowel sound analysis system demonstrated an inhibitory effect associated with anesthetic and surgical stress on intestinal motility as the BSC sequentially.

[A Case of Early-Onset Breast Cancer for Which the Operative Indication for Breast Conservation Was Based on BRCA Genetic Testing].

We report a case of a patient with early-onset breast cancer who decided to undergo adaptation for breast-conserving surgery based on the results of genetic testing. A 25-year-old woman became aware of a lump in her left breast and visited a nearby hospital, where she was diagnosed with breast cancer. She has no personal history. Her paternal grandfather was diagnosed with rectal cancer at age 60. Ultrasonography revealed an irregularly-shaped hypoechoic mass measuring 3.8 cm in the C area of her left breast and an enlarged lymph node 2.0 cm in diameter in the left axillary area. The breast tumor was pathologically diagnosed as invasive ductal carcinoma by core needle biopsy and was immunohistochemically characterized as ER(-), PgR(-), and HER2(-), s o-called triple negative. Moreover, lymph node metastasis was confirmed by fine needle aspiration cytology. She underwent neoadjuvant chemotherapy and achieved a clinical complete response. A woman with early-onset triple negative breast cancer has a high probability of hereditary breast and ovarian cancer, with a high risk of ipsilateral second breast cancer after conserving surgery. Thus, BRCA genetic testing may be necessary before surgery. As no pathogenic mutation wasfound in BRCA 1/2 in this case, the patient underwent breast-conserving surgery followed by radiation therapy for the conserved breast. The patient remained healthy and without any recurrence 4 years and 2 months after surgery.

A Novel Color Fluorescence Navigation System for Intraoperative Transcutaneous Lymphatic Mapping and Resection of Sentinel Lymph Nodes in Breast Cancer: Comparison with the Combination of Gamma Probe Scanning and Visible Dye Methods.

BACKGROUND: This study evaluated the clinical efficacy of a novel imaging system (HyperEye Medical System [HEMS]; Mizuho Corp., Tokyo, Japan) that uses the near-infrared (NIR) fluorescence of indocyanine green to analyze sentinel lymph node (SLN) biopsies for the staging of breast cancer. METHODS: This study enrolled 91 patients with histologically confirmed breast cancer that was clinically node negative with a tumor size <3 cm. We compared SLN identification rates between HEMS and conventional methods (gamma probe scanning using a colloidal radioisotope [RI] and a blue dye method) by analyzing the relationships of lymphatic to axillary lesions and SLNs. RESULTS: The identification rate of SLNs was 100% using HEMS, 97.8% using the RI method, and 95.6% using the blue dye method. Two types of lymphatic pathway (LP) were detected in 39 patients (42.9%) and also clearly identified using HEMS-captured color and NIR fluorescence. The incidence of two or more SLNs was significantly higher in patients with a two-route LP to the axilla group than in those with only one route (p < 0.001; 43.6 vs. 9.6%). CONCLUSIONS: The HEMS NIR fluorescence color imaging method is a promising potential modality for higher-level identification of SLNs than a standard combination of the RI and blue dye methods.

Real-time bowel sound analysis using newly developed device in patients undergoing gastric surgery for gastric tumor.

BACKGROUND AND AIM: Objective measurements are not available for determining bowel sounds. The present study sought to evaluate the efficacy of a novel bowel sound monitoring system for perioperative use in patients undergoing gastric surgery. METHODS: The study enrolled 14 patients who underwent surgery for gastric cancer at Kochi Medical School from 2017 to 2018. Preoperative and postoperative bowel sounds were recorded using a newly developed real-time analysis system in the operating theater and recovery room. Clinical information and bowel sound count data were obtained to compare preoperative and postoperative measures. RESULTS: The median preoperative and postoperative bowel sound counts across all patients were 1.4 and 2.5 counts per minute (cpm), respectively. In patients who underwent laparoscopic gastrectomy, the postoperative bowel sound count was significantly higher than that recorded preoperatively (2.3 vs. 1.6 cpm, P = 0.005). The findings also revealed a significant negative correlation between postoperative bowel sound count and operation time (r = -0.714, P = 0.003). CONCLUSIONS: The real-time bowel sound analysis system tested herein presents a promising diagnostic tool to quantitatively evaluate bowel movements associated with surgery. Our results suggested a need for shorter operation times for gastric procedures with respect to peristalsis recovery and supported the use of minimally invasive surgery.

Evaluation of Follow-up Examinations Using Ultrasonography for Patients With Thyroid Nodules Initially Diagnosed as Benign.

BACKGROUND/AIM: The aim of this study was to determine the natural history of benign thyroid nodules using ultrasonography. PATIENTS AND METHODS: The records of 223 patients with benign thyroid nodules treated at the Kochi Medical School from 2010 to 2012 were reviewed retrospectively. Repeated ultrasonography was performed, and the findings were directly compared with previous images. RESULTS: The median change in the size of the nodules was 0.01 cm/year, although the size of six nodules (2.7%) increased more than 0.5 cm/year, and these nodules were removed surgically. Nineteen patients (8.5%) underwent surgery during the follow-up period. Compared to those who did not undergo surgery, the size of the nodules was larger and the rate of change in nodule diameter was higher in those undergoing surgery. The pathological diagnosis based on repeated fine needle aspiration cytology was benign nodules in 16 patients and papillary cancer in three patients. CONCLUSION: Even if a thyroid nodule is initially diagnosed as benign, it may have malignant potential. Therefore, so as not to miss malignancies, nodules should be carefully re-evaluated to assess their growth or change in size using ultrasonography.

Spontaneous rupture of abdominal wall after breast reconstruction using deep inferior epigastric perforator flap following mastectomy for breast cancer.

BACKGROUND: The demand for breast reconstruction after mastectomy is rising. The use of deep inferior epigastric perforator (DIEP) flap in autologous reconstruction is a popular approach. There were some reports about abdominal complications after breast reconstruction. However, there was no report about spontaneous rupture of abdominal wall. CASE PRESENTATION: A 46-year-old female patient was diagnosed with left breast cancer. Left mastectomy with sentinel lymph node biopsy was performed, and the breast was reconstructed using DIEP flap simultaneously. She suffered heavy abdominal pain and vomiting at postoperative day 4. Computed tomography showed bowel herniation into the subcutaneous tissue caused by left abdominal wall rupture. The abdominal wall was sutured and repaired using mesh by emergency surgery. CONCLUSIONS: To the best of our knowledge, this is the first case about spontaneous rupture of abdominal wall after breast reconstruction using DIEP flap to be reported in the English literature. DIEP flap on breast reconstructive surgery may cause spontaneous rupture of abdominal wall.

Gastric outlet obstruction caused by metastatic tumor of the stomach originating from primary breast cancer: A case report.

The most common sites of breast cancer metastasis are the bone, liver, lung and brain, while gastrointestinal metastasis from breast cancer is rare. We herein present the case of a 68-year-old woman who was admitted to our department with nausea and appetite loss. The patient's medical history included right mastectomy with sentinel lymph node biopsy 5 years earlier for invasive lobular carcinoma, measuring 6.2 cm in greatest diameter, without lymphovascular invasion. Two years after the surgery, the patient developed brain metastasis and underwent metastasectomy to control the neurological symptoms, including unsteadiness and asthenia. After the second surgery, the patient received systemic chemotherapy using S-1, followed by bevacizumab plus paclitaxel. However, due to bevacizumab-related cardiotoxicity, the treatment was switched to eribulin. On esophagogastroduodenoscopy, an elevated lesion was identified in the antrum, causing severe narrowing of the gastric outlet. Biopsy and histological examination of the tumor revealed infiltration of the gastric wall by undifferentiated neoplastic cells with poor adhesion, morphologically similar to invasive lobular carcinoma, and immunohistochemical staining was positive for estrogen receptor, mammaglobin and GATA3. Finally, 18F-2-deoxy-2-fluoro-D-glucose (FDG) positron emission tomography combined with computed tomography imaging revealed FDG uptake across the thickness of the antral wall. The patient was diagnosed with gastric metastasis from the original breast cancer and subsequently underwent endoscopic self-expandable metallic stent (SEMS) placement. There were no procedure-related adverse events, and the patient remained alive under best supportive care 4 months after SEMS placement. To the best of our knowledge, this is the first reported case of gastric outlet obstruction caused by metastatic breast carcinoma managed by SEMS placement. While such a diagnosis is rare, clinicians treating patients with gastric metastases should be aware of possible gastric outlet obstruction and SEMS placement as an effective palliative intervention.

Clinical presentation and treatment of gastric metastasis from other malignancies of solid organs.

The aim of the present study was to analyze the clinicopathologic features and treatment outcomes of gastric metastasis from other malignancies of solid organs. A review was conducted of patients with metastatic tumors in the stomach from other malignancies of solid organs detected endoscopically at the Department of Surgery, Kochi Medical School, from January 1991 to December 2015. Seven patients (four men and three women), with a median age of 64 years (range, 42-71 years), had metastatic gastric tumors. Median tumor size was 7.3 cm (range, 2.5-12.0 cm). The primary malignancy leading to metastatic tumors in the stomach was esophageal cancer in three patients, breast cancer in two patients, renal cell carcinoma in one patient, and ovarian cancer in one patient. Gastric metastasis presented as solitary lesions in six patients and as multiple lesions in one patient. Four patients had solitary gastric metastasis, whereas three had multiple metastases in other organs. The median tumor size was significantly smaller in patients with solitary rather than multiple metastases (4.6 vs. 12.0 cm, respectively; P=0.038). Three patients received systemic therapy and four underwent surgical resection of the metastatic tumor, and of these, only one was alive 58 months after surgery. Clinicians should be aware of the possible existence of metastatic gastric cancer, especially in breast carcinoma and esophageal cancer. Surgical resection may considerably improve patients' quality of life, and could be of benefit when there is a risk of bleeding and/or a solitary metastasis.

Evaluation of the minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: A retrospective cohort study.

INTRODUCTION: An accurate differential diagnosis between single adenoma (SA) and multiglandular disease (MGD) remains difficult in Technetium-99m sestamibi scintigraphy (MIBI)-negative patients with primary hyperparathyroidism (PHPT). The aim of the present study was to evaluate the minimally invasive parathyroidectomy (MIP) in patients with PHPT. METHODS: Clinical records of 48 patients who underwent neck exploration between November 2002 and June 2012 in Kochi Medical School Hospital were reviewed retrospectively to identify candidates that underwent for MIP which was defined as the selective removal of a SA using less invasive surgery. RESULTS: The preoperative detection rate of lesions using ultrasonography, MIBI, computed tomography, and magnetic resonance imaging was 90%, 83%, 76%, and 55%, respectively. Although all 39 patients in the MIBI-positive group were diagnosed with an SA and subsequently underwent curative MIP, 3 patients in MIBI-negative group (n = 6) were MGD, who underwent neck exploration. Preoperative mean intact parathyroid hormone (419 pg/ml vs. 149 pg/ml; P < 0.01) and alkaline phosphatase levels (746 U/l vs. 277 U/l; P < 0.01) were significantly higher in the SA than MGD group. CONCLUSIONS: In MIBI-negative patients with indications for surgery, MIP should not be carried out without a clear localization of SA, or in MGD.