Mitsuwadai General Hospital

Whether the level of the inferior mesenteric artery ligation affects the incidence of anastomotic leakage remains unclear. To assess the impact of the level of inferior mesenteric artery ligation on blood flow to the anastomotic site and the incidence of anastomotic leakage using indocyanine green fluorescence imaging. A post hoc analysis of the EssentiAL trial. This study was conducted at 41 tertiary referral centers in Japan. A total of 839 patients with rectal cancer (<12 cm from the anal verge) were included. The incidence of anastomotic leakage and perfusion status were compared between the high and low ligation groups. The median fluorescence time was similar at 25 seconds in both groups (p = 0.74). Although no statistical difference was noted, the high ligation group was more likely to have greater outliers in fluorescence time compared to the low ligation group. The high ligation group demonstrated higher poor perfusion rates than the low ligation group (2.8% vs 1.5%). In the high ligation group, anastomotic leakage occurred in 1 case of poor perfusion where additional resection was not performed by the surgeon's intraoperative judgment. In addition, the additional resection rate nearly doubled with the use of indocyanine green fluorescence imaging. After propensity score matching (129 patients per group), the overall anastomotic leakage rate was 13.2% in the high ligation group and 10.9% in the low ligation group ( p = 0.57). This study was a post hoc analysis, the sample size was small, and the anastomosis methods varied. The level of inferior mesenteric artery ligation did not affect blood flow at the anastomotic site or the incidence of anastomotic leakage statistically, but assessing bowel perfusion using indocyanine green fluorescence imaging can offer clinical benefits, optimizing patient outcomes. See Video Abstract . The Japan Registry of Clinical Trials (jRCTs-CRB3180007), the Japanese Clinical Trials Registry (UMIN-CTR000030240). ANTECEDENTES:No está claro si el nivel de la ligadura de la arteria mesentérica inferior afecta la incidencia de fuga anastomótica.OBJETIVO:Evaluar el impacto del nivel de ligadura de la arteria mesentérica inferior en el flujo sanguíneo al sitio de la anastomosis y la incidencia de fuga anastomótica mediante imágenes de fluorescencia con verde de indocianina.DISEÑO:Análisis post hoc del ensayo EssentiAL.ESCENARIO:Este estudio se realizó en 41 centros de referencia terciarios en Japón.PACIENTES:839 pacientes con cáncer rectal (<12 cm desde el márgen anal).PRINCIPALES MEDIDAS DE RESULTADOS:Se compararon la incidencia de fuga anastomótica y el estado de perfusión entre los grupos de ligadura alta y baja.RESULTADOS:El tiempo de fluorescencia medio fue similar a 25 segundos en ambos grupos (p = 0.74). Aunque no se observó ninguna diferencia estadística, el grupo de ligadura alta tuvo más probabilidades de tener mayores valores atípicos en el tiempo de fluorescencia en comparación con el grupo de ligadura baja. El grupo de ligadura alta demostró tasas de perfusión deficiente más altas que el grupo de ligadura baja (2.8 % frente a 1.5 %). En el grupo de ligadura alta, se produjo una fuga anastomótica en un caso de perfusión deficiente en el que no se realizó una resección adicional según el criterio intraoperatorio del cirujano. Además, la tasa de resección adicional casi se duplicó con el uso de imágenes de fluorescencia con verde de indocianina. Después de la comparación por puntaje de propensión (129 pacientes por grupo), la tasa general de fuga anastomótica fue del 13.2 % en el grupo de ligadura alta y del 10.9 % en el grupo de ligadura baja ( p = 0.57).LIMITACIONES:Este estudio fue un análisis post hoc, el tamaño de la muestra fue pequeño y los métodos de anastomosis variaron.CONCLUSIONES:El nivel de ligadura de la arteria mesentérica inferior no afectó estadísticamente el flujo sanguíneo en el sitio de la anastomosis ni la incidencia de fuga anastomótica, pero la evaluación de la perfusión intestinal mediante imágenes de fluorescencia con verde de indocianina puede ofrecer beneficios clínicos, optimizando los resultados del paciente. (Traducción-Dr. Jorge Silva Velazco)REGISTRO DEL ENSAYO:Registro japonés de ensayos clínicos (jRCTs-CRB3180007), Registro japonés de ensayos clínicos (UMIN-CTR000030240).

Background: Caregiving skills for the family members of patients with stroke are considered important in rehabilitation wards. However, few studies have clarified the specific caregiving skills and instructional content required by family caregivers of patients with stroke.

Introduction:Healthy eating and weight control are recommended for cancer survivors; however, dietary interventions are not routinely offered to them. This study aimed to assess the effects of dietary interventions on survival, nutritional status, morbidity, dietary changes, health-related quality of life (QOL), and clinical measures in cancer survivors.Methods:Searches were conducted from October 1, 2018 to November 21, 2011 in the Medline, EMBASE, CENTRAL, Emcare, and DARE electronic databases. We included randomized controlled trials (RCTs) that involved individuals diagnosed with cancer, excluding conference abstracts, case studies, other reviews, and meta-analyses, and screened the articles.Results:Eight studies were included in this meta-analysis. We observed significant improvements in QOL and clinical data in 3 of 6 studies and in one study, respectively, significant weight loss on anthropometry in 2 of 5 studies, and dietary improvement in 4 of 5 studies of adult cancer survivors. However, we did not observe any benefits of dietary intervention for cancer survivors with undernutrition.Discussion:Dietary interventions for adult cancer survivors might contribute to improving their nutritional status; however, further clarification requires a study that standardizes the intervention method. Furthermore, RCTs are required to determine the effects on cancer survivors with undernutrition.

Abstract Eosinophilic esophagitis (EoE) is an allergy-associated clinicopathologic condition gaining an increasing amount of recognition in various areas of the world. While the clinical definition and characteristics may differ depending on country and region, sufficient studies have not yet been performed in Japan. To assess the prevalence of EoE among the Japanese population and the clinical features and the prognosis associated with the disease. Methods Medical data from January 2012 to October 2018 was gathered from nine Japanese clinical institutes. EoE, defined as more than 15 intraepithelial eosinophils per high power field, was determined based on esophageal biopsies. Clinical and endoscopic patterns in the cases with EoE were investigated and compared with 186 age- and sex-matched controls. We also analyzed the treatment and prognosis of an individual patient. Results From 130,013 upper endoscopic examinations, 66 cases of EoE were identified (0.051%; mean age: 45.2 years (range 7-79); 45 males). Patients with EoE had more symptoms (69.7 vs. 10.8%; P &amp;lt; 0.01) such as dysphagia and food impaction, and more allergies (63.6 vs. 23.7%; P &amp;lt; 0.01) compared with the controls. The prevalence of atrophic gastritis was lower in EoE patients than in the controls (20.0% vs. 33.3%). In 55 patients analyzed, 32 patients (78.0%) received proton pump inhibitors with or without swallowed topical corticosteroids. During the follw-up period (mean 23 months), no patient got worse regarding clinical and endoscopic findings. Conclusion The prevalence of EoE in the Japanese population was 0.051% which was comparable with previous reports in Japan. Male predominance, a history of allergies, and the absence of Helicobacter pylori infection might be risk factors for EoE. Our study also indicated that the prognosis of EoE might be relatively good in Japanese populations.

Eicosapentaenoic acid (EPA) is an unsaturated fatty acid with various bioactivities, including antitumor effects. We previously reported a synergistic antitumor effect of cisplatin (CDDP) and EPA. Here, we examined the underlying mechanism. The human oesophageal cancer cell line TE-1 was treated with the combination of EPA and CDDP. Nuclear translocation of NF-κB, a transcription factor involved in cytokine production, was detected by immunohistochemistry. IL-6 levels were measured by ELISA. Apoptosis and cell cycle distribution were evaluated by flow cytometry. Nuclear translocation of NF-κB in TE-1 cells was synergistically decreased by CDDP and EPA. IL-6 production was increased following treatment with CDDP, but treatment with EPA decreased IL-6 levels. Apoptosis was synergistically induced by CDDP and EPA. A G2/M cell cycle arrest was observed with the combination of CDDP and 150 μM EPA, and S phase arrest with the combination of CDDP and 100 μM EPA. The combination of CDDP and EPA synergistically suppresses NF-κB nuclear translocation and increases apoptosis by inducing cell cycle arrest at the S or G2/M phase.

局所進行乳癌に対しては集学的治療の施行が勧められ，術前化学療法(neoadjuvant chemotherapy, NAC) は最も重要な治療の1 つである．我々は，切除不能乳癌Stage IIIB 症例のNAC 奏効例を経験した．NAC 後のCT，MRI 等の画像診断による臨床診断では腫瘤残存を認めたが，手術後の病理ではわずかに腫瘍細胞集塊を認めるのみであり，組織学的治療効果判定はGrade 2b であった．局所進行乳癌に対するNAC の効果判定は，それ以後の治療方針に重要な影響を及ぼすが，画像による効果判定と病理学的効果判定は必ずしも一致しないことがある．

開腹胆嚢摘出術後に急激な経過を呈したAeromonas sobria感染の1例を経験したので報告する．症例は66歳，男性．落下結石性胆管炎に対して内視鏡的乳頭筋切開（EST）術を施行し，再発予防のため胆嚢摘出の適応となった．術中，胆汁滲出による軽度の汚染があったが，通常通り術野を洗浄し終了した．術後35時間頃突然，ショック状態となった．CTで創部の筋層・皮下にガスを認めたため，筋膜縫合部まで開放したところ腐敗臭を伴う排液を認めた．血液，創，便より本菌が検出された．創洗浄，広域抗生剤投与，循環呼吸管理，さらに血液浄化を施したが，敗血症による多臓器不全のため死亡した．本例は井戸水を常飲しており，自然水中に広く分布する本菌が保菌状態にあり，ESTが影響して胆道に潜伏していたと推定した．本属菌の創傷感染は急激に重篤化する特徴を有するため，消化器術前における井戸水飲用の問診に対して注意が喚起された．

The purpose of this study was to investigate whether intravenous (i.v.) administration allowed docetaxel to penetrate ascites in gastric cancer patients with peritoneal dissemination. Twelve patients with disseminated gastric carcinoma were enrolled in the study. All patients received docetaxel-containing drug regimens: i.v. administration of 40 mg/m(2) docetaxel in 6 patients, and 60 mg/m(2) in the remainder. Docetaxel concentrations in the plasma and ascites were measured. Docetaxel was detected in the ascites of 4 patients in the 40 mg/m(2) group and 5 patients in the 60 mg/m(2) group. The highest concentration of docetaxel in plasma was detected at immediately after administration (median: 1,660 ng/mL, 501-2,560 ng/mL), after which it gradually decreased. The highest concentration of docetaxel in ascites was observed at ~7 h after administration and varied among cases (median: 18 ng/mL, 11-52 ng/mL). Intravenous administration allows to penetrate ascites in gastric cancer patients with peritoneal dissemination.

The incidence of delayed bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasms is reported to be approximately 5 %. We examined whether postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method is a useful measure for preventing delayed bleeding after ESD. A total of 234 gastric epithelial neoplasms were treated from June 2007 to May 2012. Post-ESD coagulation (PEC) and clipping for part of the vessels was performed for 154 lesions from June 2007 to June 2010. A total of 80 lesions were treated using the 2C method from July 2010 to May 2012. During ESD, the locations of the arteries were recorded on a schematic diagram of the lesion. Arteries were defined as regions of arterial bleeding that required coagulation or apparent arteries in which preventive coagulation was performed. When ESD was completed, soft coagulation was performed for arteries in the resection area using hemostatic forceps, followed by arterial clipping for additional strength. Coagulation also was performed continuously for visible vessels in the resection area. This was a retrospective study. The incidence rates of delayed bleeding after ESD, as evidenced by hematemesis or melena, or the presence of anemia (decline in Hb >2 g/dl) that required emergency endoscopy were recorded. Delayed bleeding occurred in 7 (4.5 %) of the 154 cases treated using PEC and in 1 (1.3 %) of the 80 cases treated using the 2C method. The mean time required for the 2C method was 15.0 ± 7.0 min (range, 5-44 min). The mean number of clippings per lesion was 3.8 ± 2.8 (range, 0-13). Almost all clips fell off within 2 months of the procedure. Coagulation plus artery-selective clipping (the 2C method) of post-ESD ulcers might effectively reduce the incidence of delayed bleeding after ESD for gastric neoplasms.

術前に部位診断をしえた小腸血管腫の1例を経験したので報告する．症例は69歳，男性．大腸癌術後，貧血を認めた．上部下部消化管内視鏡では出血源を認めず，小腸の精査を行った．カプセル内視鏡により小腸出血を疑い，ダブルバルーン内視鏡により小腸腫瘍と診断，出血源と考え点墨を行い，小腸部分切除術を施行した．腫瘍は5mmと小さく，病理組織診断より血管腫の診断となった．小腸出血の診断はこれまで解剖学的特徴から困難であった．また，これまで広く行われてきた血管造影，出血シンチによる検出はある程度の持続的出血がなければ困難である．本症例は小腸内視鏡により出血源を術前に同定しえた症例であり，今後，原因不明の消化管出血において，カプセル内視鏡やダブルバルーン内視鏡が診断の中心となっていくと考えられる．