Realizing the Wishes of Terminal Patients: Caregiving Transport Efforts for End of Life in the Kuji Area of Japan.

Background: There are some restrictions in Japan regarding end-of-life care. For example, only physicians can legally issue death certificates. By law, ambulance staff members perform cardiopulmonary resuscitation (CPR) for all patients with cardiopulmonary arrest (CPA). Therefore, it is difficult to transport patients to hospitals without CPR, even in cases of terminal patients with do-not-attempt-resuscitation (DNAR) order. Furthermore, there is no 24-hour home care nursing system in our area. Therefore, terminal patients are unable to spend their last moments at their home in the Kuji area. Objective: To design a system in which terminal patients who wish to spend their final moments at their home can be transported to the hospital without CPR after at-home CPA and a system to avoid confusion between ambulance staff and family members using instructions provided by the physician. Setting/Subjects: The subjects were terminal patients with DNAR order who wanted to stay at home. The instruction to not perform CPR after CPA was created as a document by physicians. Patient information was shared with the fire department; patients were transported to our hospital without CPR after at-home CPA. Results: In total, 26 patients died during the study period; eight received emergency transport to the hospital without CPR after CPA. CPR was not performed for any patient. Conclusion: A system transporting terminal patients without CPR after CPA was necessary in our area. This instruction allows terminal patients to spend their last moments where they wish and avoids unwanted CPR and troubles after CPA.

[A Case of More Than Five-Year Survival of Carcinoma Associated with Anal Fistula Effectively Treated by Combined Modality Therapy].

The patient was a 56-year-old man who presented with perianal pain and a perianal abscess. After admission, he underwent debridement and colostomy due to poor control of the perianal abscess. Following a biopsy of the resected specimens, he was diagnosed with adenocarcinoma in the anorectal fistula. CT and MRI revealed that the tumor had invaded into the internal obturator muscle. Therefore, preoperative chemoradiotherapy and chemotherapy were given for locally advanced cancer. Subsequent to tumor shrinkage, we performed an abdominoperineal resection. Histopathologically, no cancer cells were detected on the surgical margin, and the effect of the preoperative therapy was judged to be Grade 1b. There has been no indication of recurrence of cancer after 5 years.

Clinical evaluation of complete solo surgery with the "ViKY®" robotic laparoscope manipulator.

BACKGROUND: Advancement in both surgical technique and medical equipment has enabled solo surgery. ViKY® Endoscope Positioning System (ViKY®) is a robotic system that remotely controls an endoscope and provides direct vision control to the surgeon. Here, we report our experience with ViKY®-assisted solo surgery. METHODS: We retrospectively examined 25 cases of solo surgery TAPP with ViKY®. ViKY® was setup by the surgeon alone, and the setup duration was determined as the time at which the side rail was positioned and that when the endoscope was installed. For assessing the control unit, the number of false movements was counted. We compared the operative results between ViKY®-assisted solo surgery TAPP and the conventional method with an assistant. RESULTS: The average time to set up ViKY® was 7.9 min. The average number of commands for ViKY® during surgery was 98.3, and the average number of errors and no response of control unit was 7.9. The mean duration of surgery was 136 min for the ViKY® group, including the setup time, and 117 min for the conventional method. No case required an assistant during the operation. There was also no difference between the two groups with regard to postoperative complications and the rate of recurrence. CONCLUSIONS: ViKY® proved reliable in recognizing orders with very few failures, and the operations were performed safely and were comparable to the conventional operations with assistants. Solo surgery with ViKY® was beneficial in this clinical evaluation.