Tottori Prefectural Kousei Hospital

Several studies have investigated the safety of laparoscopic gastrectomy (LG) for gastric cancer (GC). However, many of these studies excluded older patients, and few multicenter studies have compared LG and open gastrectomy (OG) in older patients with GC. We compared the postoperative short- and long-term outcomes of LG and OG in >75 years old patients with GC in a multicenter study. The study included 926 patients aged >75 years who underwent gastrectomy from January 2003 to December 2017 at 12 regional hospitals. After propensity score-matching (PSM), the two surgical groups' short- and long-term outcomes were analyzed. PSM was applied for variables such as sex, depth of tumor invasion, lymph node metastasis, histologic type, pathological stage, gastrectomy, and lymph node dissection. After 1:1 matching, 258 cases in each group were analyzed. The LG group showed significantly longer surgery times and reduced blood loss (p<0.001). There were no significant differences in the incidence of postoperative complications graded Clavien-Dindo ≥ II between the groups (23.6% vs. 19.4%, p=0.239). However, the LG group had lower and higher incidences of pneumonia (1.9% vs. 5.4%, p=0.035) and pancreatic fistula (PF; 4.7% vs. 0.04%, p=0.003), respectively. The two groups had no significant overall and disease-specific survival differences across all stages. In patients aged >75 years with GC, LG can be a viable approach with careful clinical management for the risk of PF, without compromising long-term survival.

ABSTRACTINTRODUCTIONSpontaneous regression of cancer is rare. Although the underlying mechanism is unknown, immunological responses are thought to be involved.CASE PRESENTATIONAn 82-year-old Japanese man presented with an incidental bile duct tumor and a dilated common bile duct noted on computed tomography of the abdomen. The scan also showed a 1.1 cm snowball-like shadow in the right lower lobe of the lung. Subsequently, he developed obstructive cholangitis and underwent endoscopic retrograde biliary drainage. Over 4 years of follow-up, the lung nodule repeatedly increased and decreased in size, and new nodules appeared and disappeared. A bronchoscopic biopsy was then performed to evaluate an enlarged nodule, which was consistent with squamous cell carcinoma. He underwent right lower lobectomy with ND1b lymph node dissection. The final diagnosis was pulmonary squamous cell carcinoma (pT1cNXM0).CONCLUSIONSImmune response activation may have caused the observed tumor shrinkage. Careful follow-up is warranted owing to the possibility of regrowth.

BackgroundAdjuvant chemotherapy for stage II colorectal cancer (CRC) is considered appropriate for patients with risk factors for recurrence, rather than for all patients uniformly. However, the risk factors for recurrence remain controversial, and there is limited information, especially for elderly patients. The Geriatric Nutritional Risk Index (GNRI) is widely used as a simple nutritional screening tool in the elderly and is associated with cancer prognosis and recurrence. This study aimed to investigate the risk factors for recurrence in the elderly with stage II CRC, focusing on the GNRI.MethodsWe enrolled 348 elderly patients (≥ 75 years) with stage II CRC who underwent curative resection at the Department of Surgery, Tottori University and our 10 affiliated institutions. The patients were divided into GNRIhigh (≥ 93.465) and GNRIlow (< 93.465) groups.ResultsThe GNRIlow group showed a significantly worse overall survival (OS), cancer-specific survival (CSS), and relapse-free survival (RFS) (P < 0.001, P < 0.001, and P < 0.001, respectively). In a multivariate analysis, GNRIlow (hazard ratio [HR]: 2.244, P < 0.001), pathologic T4 stage (HR: 1.658, P = 0.014), and moderate to severe lymphatic or venous invasion (HR: 1.460, P = 0.033) were independent factors affecting RFS. By using these three factors to score the risk of recurrence from 0 to 3 points, the prognosis was significantly stratified in terms of OS, CSS, and RFS (P < 0.001, P < 0.001, and P < 0.001, respectively). The recurrence rate for each score was as follows: 0 points, 9.8%; 1 point, 22.0%; 2 points, 37.3%; and 3 points, 61.9%.ConclusionsGNRIlow, pathologic T4 stage, and moderate to severe lymphatic or venous invasion are high-risk factors for recurrence in the elderly with stage II CRC. The scoring system using these three factors appropriately predicted their recurrence and outcome.

ObjectiveWe examined the benefits of a community‐based program combining physical exercise, cognitive training, and education on dementia and lifestyle habits.MethodsThis crossover open‐label trial included 141 community‐dwelling elderly people with suspected mild cognitive decline (MCD). Subjects were assigned to a 6‐month intervention‐first/6‐month observation‐second (INT‐OBS) group or an OBS‐INT group. The 6‐month intervention consisted of 2 h of physical exercise, cognitive training, and classroom study or rest once weekly. Primary outcome was change in Touch Panel‐type Dementia Assessment Scale (TDAS) score.ResultsTDAS score improved significantly during the intervention period compared with the observation period for all subjects (P < 0.05). Some physical functions also improved significantly during the intervention period compared with the observation period in the OBS‐INT group (P < 0.05).InterpretationThis community‐based program improved both cognitive and physical function in elderly people with suspected MCD.

Bile leakage after hepatectomy is a common complication. The purpose of the present study was to retrospectively evaluate the usefulness of non-surgical management of bile leakage after hepatectomy, using 12-year data from a single center study. Data from 15 patients (13 men, two women; mean age 67.1 ± 7.0 years) who had undergone non-surgical management for bile leakage between January 2005 and November 2017 were retrospectively reviewed. We categorized bile leakage as central (n = 5) or peripheral (n = 10) leakage based on communication with the biliary tree. Percutaneous bile leakage drainage and/or endoscopic naso-biliary drainage (ENBD) (n = 2) or the rendezvous technique (n = 3) was successfully performed in five central-type cases, while all peripheral-type cases were treated with drainage alone; only one case required additional ethanol ablation. Bacterial bile cultures were positive in 11 cases and negative in four cases. The drainage catheters were removed after complete resolution in 13 cases (86.7%), while two patients with cases of peripheral-type leakage died due to cancer progression while the drain was in place. No case needed conversion to reoperation. The mean duration of drainage therapy in all cases was 210.1 ± 163.0 days (range 17-531 days), with 316.8 ± 180.8 days in the central type and 156.7 ± 131.5 days in the peripheral type; this duration was not significantly different (P = 0.129). Non-surgical treatment is a minimally invasive and effective management strategy for postoperative bile leakage and the modality used depends on the type of bile leakage encountered.

症例は49歳男性，主訴は呼吸困難．2011年から毎年職場検診で胸部異常影を指摘され，2015年に呼吸困難が増強し前医受診．精査で左胸腔内腫瘤を認め当院紹介となった．胸部CTで左胸腔内全体を占拠し，左肺を縦隔側に圧排する26×16 cmの腫瘤を認め，MRIのT2強調で内部はモザイクパターン，壁はバンド状の低信号を呈し，Chronic expanding hematomaが疑われた．手術は血行動態や出血時の迅速な心囊アプローチを考慮して胸骨正中切開で行った．腫瘤壁は肥厚して強固に壁側胸膜，肺と癒着していた．内部血腫を吸引除去して肋間開胸を追加，横隔膜との強固な癒着を剥離して左肺を温存，腫瘤を完全に切除した．手術時間7時間，出血103 ml．経過から適切なアプローチを選択し，肺温存により呼吸機能は著明に改善できた意義は大きかった．

A 59-year-old male was admitted to our hospital with an abnormal shadow on a chest X-ray. Right pneumonectomy and lymph node dissection (ND2a) were performed. A pathological examination revealed adenocarcinoma( pT3N2M0). Fourteen years later, chest computed tomography(CT) showed a tumor shadow in the lower lobe of the left lung. His pulmonary function was sufficient to allow a 2nd operation. He underwent wedge resection of the lower lobe of the left lung with the assistance of extra corporeal membrane oxygenation (ECMO). His postoperative course was uneventful. A pathological examination revealed large cell neuroendocrine carcinoma, which was 18 mm in diameter. His performance status declined slightly, but he had no problems associated with the activities of daily life. The patient is currently alive 6 months after the 2nd operation without any sign of recurrence. ECMO is a useful technique for thoracic surgery after pneumonectomy.

Behçet's disease (BD) is a rare chronic systemic vasculitis of unknown etiology that presents in young adults. We report a very rare case of a left subclavian artery pseudoaneurysm identified after a left clavicle fracture in a 70-year-old man with a 40-year history of intestinal BD. The patient received fixation by banding to treat a fracture after falling from a bed about 5 months previously, and he was referred to our hospital due to the finding of a left subclavian pulsatile mass. As enhanced computed tomography showed a left subclavian artery pseudoaneurysm, it was repaired using an endovascular stent graft.