Predictive Postoperative Inflammatory Response Indicators of Infectious Complications Following Gastrectomy for Gastric Cancer.

BACKGROUND: Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy. METHODS: We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification). RESULTS: Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×102/µL, and 37.4°C, respectively. CONCLUSIONS: Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×102/µL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

Preoperative and Postoperative C-Reactive Protein to Albumin Ratio (CAR) as a Prognostic Marker for Survival of Esophageal Squamous Cell Carcinoma Patients After Surgery.

BACKGROUND/AIM: Recent studies have reported that the C-reactive protein (CRP) to albumin ratio (CAR) may be a useful prognostic biomarker in various types of cancer patients. However, the mechanism underlying this observation is unclear. The present study aimed to clarify why the CAR can predict post-esophagectomy prognosis, the relationship between pre- and postoperative CAR, and whether postoperative CAR can predict the prognosis of esophageal cancer patients. PATIENTS AND METHODS: We investigated 158 esophagectomy patients with esophageal squamous cell carcinoma. Hematological examinations were performed on postoperative days (POD) 1, 3, 5, 7, 10, and 14. RESULTS: Preoperative CAR was a significant independent prognostic factor of overall survival (OS) [hazard ratio (HR)=2.247; p=0.0005], and there was a strong correlation between preoperative CAR and tumor depth. The preoperative high-CAR (pre-high-CAR) group had significantly higher CAR on all postoperative days (POD). We then divided the patients as follows: those with at least two low-CAR days on POD 5, 7, and 10 were assigned to the modified post-low-CAR (mPost-low-CAR) group, and others were assigned to the modified post-high-CAR (mPost-high-CAR) group. The 5-year OS rate was significantly higher in the mPost-low-CAR group than in the mPost-high-CAR group, which predicted a more accurate prognosis (p<0.0001, HR=2.769). CONCLUSION: Preoperative CAR was associated with tumor depth and diameter, and patients in the pre-high-CAR group continued to have significantly higher CAR postoperatively. These factors were presumed to reflect disease prognosis. Furthermore, grouping by CAR on POD 5, 7, and 10 reflected patient prognosis more accurately than preoperative CAR.

The development of a flexion range-of-motion-adjustable knee joint for knee-ankle-foot orthoses and evaluation of gait in healthy individuals wearing it.

[Purpose] To develop a knee joint for knee-ankle-foot orthoses that is easy to operate and allows for four levels of knee-flexion-movement adjustment, and to determine the effects of different flexion ranges of motion on knee flexion angle during gait. [Participants and Methods] Participants were eight healthy adults. Knee joint for knee-ankle-foot orthoses were made for each participant, and the knee flexion angle during gait was measured for each of the four knee joint settings: fixed in extension, 15° flexion range, 30° flexion range, and free flexion. [Results] Gait analysis showed that the knee flexion angle in the loading response phase was significantly greater in the 15° flexion range, 30° flexion range, and free-flexion settings than in the fixed-in-extension setting. While in the swing phase, the angle was greatest in the fixed setting, followed by the 15° flexion, 30° flexion, and free settings. [Conclusion] The proposed knee joint, when used in post-stroke gait practice using knee-ankle-foot orthoses, allows the gradual increase in the flexion range of motion of the joint as the weight-bearing capability of the lower limb improves, which would enable task-oriented practice similar to walking with ankle-foot orthoses as the next-stage target movement.

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.

Knee joint movement and muscle activity changes in stroke hemiplegic patients on continuous use of knee-ankle-foot orthosis with adjustable knee joint.

[Purpose] We aimed to evaluate knee joint movement and muscle activity ratio changes in stroke hemiplegic patients in recovery phase after using a knee-ankle-foot orthosis with an adjustable knee joint for 1 month; we also aimed to discuss the practical implications of our findings. [Participants and Methods] The participants were 8 hemiplegic patients in the recovery phase of stroke who were prescribed knee-ankle-foot orthosis with adjustable knee joint. We measured knee joint angles and electromyographic activity of the vastus medialis and biceps femoris during walking in two conditions: the knee-ankle-foot orthosis knee joint fixed in the extended position and the knee joint moved from 0° to 30° in the flexion direction. Measurements were taken 2 weeks after completion to account for habituation of the orthosis and repeated 1 month later. [Results] When the knee joint was moving from 0° to 30° in the flexion direction, the knee joint angle at initial contact and the minimum flexion angle of the gait cycle decreased significantly between the first and second measurements. When knee joint flexion was 30°, the muscle activity ratio of the vastus medialis increased significantly in the loading response and mid-stance compared to when it was fixed. [Conclusion] Setting the knee joint of a knee-ankle-foot orthosis in accordance with the knee joint movement may increase the muscle activity ratio of the vastus medialis from loading response to mid-stance.

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.

Effectiveness of a knee-ankle-foot orthosis with a knee extension aid in gait training for stroke patients.

Murayama M. Effectiveness of a knee-ankle-foot orthosis with a knee extension aid in gait training for stroke patients. Jpn J Compr Rehabil Sci 2021; 12: 32-37. Objective: To evaluate the effectiveness of a knee-ankle-foot orthosis (KAFO) with a newly developed knee extension aid in gait training for stroke patients with severe leg paralysis. Methods: The participants were 7 recovering stroke patients prescribed a KAFO. With the KAFO knee joint set to allow free flexion, knee flexion angle, lower limb muscle activity, and time of plantar ground contact were measured during assisted walking with the knee extension aid or a conventional support loop. Results: When first using the knee extension aid, knee flexion angle at initial ground contact was significantly decreased and time from heel strike on the paralyzed side to forefoot strike was prolonged compared with the support loop. After using the knee extension aid for 1 week, in addition to the two parameters above, maximum knee flexion angle during the swing phase, knee extension displacement from the maximum flexion angle to initial ground contact, and the muscle activity ratio of the biceps femoris during the swing phase were significantly increased compared with the support loop. Conclusion: This knee extension aid may be indicated for patients who have difficulty in initial heel strike due to excessive knee flexion at the end of the swing phase.

[A Case of Rectosigmoid T1b Cancer Which Had Been Under Control by Combination of Loco-Regional Therapies].

According to the Japanese Colorectal ESD/EMR guidelines, radical surgery should be recommended for additional treatment of T1 colorectal cancer(CRC)if pathological findings of the lesion after endoscopic resection show unfavorable factors to be evaluated as curative resection, considering the probability of lymph node metastasis and general condition of patients. We report a case of a 74-year-old man with T1b rectosigmoid(RS)cancer, whose pulmonary metastasis(PM) was curatively resected during the postoperative period of ESD for primary lesions. The patient underwent ESD in November 2018 for Type 0-Isp CRC in the RS junction, revealed using colonoscopy, which was performed for the examination of blood stool in September 2018. The patient had suffered from pulmonary tuberculosis in his thirties and regularly visited our hospital for COPD. He was under close observation after ESD because the depth of the lesion, which was pathologically diagnosed as T1b, was the only factor evaluated as non-curative. In April 2020, chest CT and FDG-PET/CT findings revealed the occurrence of PM. Subsequently, video-assisted wedge resection of the lung was performed for the treatment of PM, which was pathologically confirmed with a size of 10 mm. The patient has survived relapse-free to date, for 30 months after the resection of the primary lesion.

Gait and Muscle Activity Changes in Patients in the Recovery Phase of Stroke with Continuous Use of Ankle-Foot Orthosis with Plantarflexion Resistance.

OBJECTIVE: Previous studies have suggested that the use of an ankle-foot orthosis may cause disuse atrophy of the tibialis anterior muscle. The objective of this study was to explore gait and muscle activity changes in patients in the recovery phase of stroke with 2-month use of an ankle-foot orthosis that provided plantarflexion resistance. METHODS: The participants were 19 patients in the recovery phase of stroke who were prescribed an ankle-foot orthosis that provided plantarflexion resistance. We measured ankle and shank tilt angles as well as electromyography activity of the tibialis anterior and the soleus during 10-m walk tests. Measurements were taken on three occasions. The first was 2 weeks after delivery of the orthosis, 1 and 2 months after the initial measurement, and the third 2 months later. Changes in gait parameters were analyzed between the first and second measurements and between the second and third measurements. RESULTS: Between the second and third measurements, significant increases were observed in plantarflexion and shank forward tilt angles and the activity ratio of the tibialis anterior during loading response compared with other phases. CONCLUSIONS: Plantarflexion movement induced by an ankle-foot orthosis with plantarflexion resistance could increase the activity ratio of the tibialis anterior during loading response.

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.

[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.

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.

[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 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 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 Obstructive Jaundice Caused by Recurrent Gastric Cancer Previously Treated with Distal Gastrectomy and Roux-en-Y Reconstruction Whose Obstruction Was Relieved by ERCP for Altered Gastrointestinal Anatomy Using Conventional Endoscopes].

There have been many reports on ERCP for patients with alteredgastrointestinal anatomy(AGA), using balloon-assisted enteroscopy(BAE); however, BAE is not commonly usedin practice because it requires special endoscopic systems and accessories, which are time-consuming to operate. For this reason, patients with AGA who suffer from obstructive jaundice (OJ)might receive PTBD in general practice during emergency situations. We report a case of OJ, caused by recurrent gastric cancer andpreviously treatedwith distal gastrectomy andRoux -en-Y reconstruction(DGRY). The obstruction was relieved by ERCP for AGA, using conventional endoscopes. A 74-year-oldwoman, who hadpreviously undergone DGRY for advanced gastric cancer(AGC)andhadbeen receiving first-line chemotherapy for AGC recurrence, was admitted to our hospital for treatment of OJ, causedby progression of recurrent AGC, in July 2016. ERCP for AGA was performedusing conventional endoscopes, andOJ was successfully relievedby the insertion of a self-expandable metallic stent. Subsequently, second-line chemotherapy was administeredandthe patient enteredPR after 2 courses of chemotherapy.

The Influence of Neoadjuvant Chemotherapy with Docetaxel, Nedaplatin and 5-Fluorouracil After Esophagectomy.

BACKGROUND: Neoadjuvant chemotherapy (NAC) with docetaxel, nedaplatin and 5-fluorouracil (5-FU) in esophageal cancer may adversely affect the postoperative clinical course following esophagectomy. PATIENTS AND METHODS: We investigated the perioperative white blood cell count (WBC), C-reactive protein (CRP), serum albumin, body temperature (BT), heart rate (HR), respiratory rate (RR), water balance, partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio, postoperative complications and systemic inflammatory response syndrome (SIRS) in patients who underwent NAC or surgery alone (SA group). RESULTS: In the NAC group, the preoperative WBC (p=0.015) and postoperative day (POD) 3 BT (p=0.049), as well as RR (p=0.037) were lower, whereas the POD 2 PaO2/FiO2 ratio was higher (p=0.047), compared to the SA group. No differences in the incidence of postoperative complications and SIRS were observed between the groups. CONCLUSION: NAC using docetaxel, nedaplatin and 5-fluorouracil was tolerated and feasible in esophageal cancer.

[A Case of Malignant Colonic Obstruction Bearing Another Synchronous Obstructive Lesion in the Anal Side of the Colon].

There are several reasons for failure in the insertion of a self-expandable metallic stent(SEMS)into a malignant colonic obstruction(MCO)including difficulty in insertion of the catheter or guidewire through the stenotic lumen into the oral side or perforation relatedto the technique. Herein, we report a case of MCO bearing another synchronous obstructive lesion in the anal side of the colon that couldhave explainedthe difficulty in the insertion of the SEMS into the stenosis locatedin the oral side, which might have indicated the need for an emergency operation for relieving the obstruction. A 76-year-oldman with epigastralgia andmelena was admittedto our hospital andhe was diagnosedwith a MCO in the ascending colon. A series of examinations performedafter admission revealedthat the patient hadanother synchronous obstructive lesion in the descending colon, which made colonoscope insertion at the oral side difficult. The next day after admission, we observed that fasting relievedthe patient from abdominal pain causedby obstruction; therefore, we performedSEMS insertion into the MCO of the descending colon followed by SEMS insertion into the ascending colon after 6 days. These serial SEMS insertions facilitated the oral administration of the diet and the patient was discharged 15 days after admission. The patient was readmittedto our hospital andhe underwent a radical operation for both lesions in June 2015.

Additional Surgery After Non-curative Resection of ESD for Early Gastric Cancer.

AIM: The appropriate additional surgery after non-curative resection of Endoscopic Mucosal Resection (ESD) for early gastric cancer is herein discussed. PATIENTS AND METHODS: Data on 54 patients after non-curative resection of ESD were evaluated. These patients were broadly classified according to the risk of lymph node metastasis with lesions into group A (without risk) (n=26) and group B (with risk) (n=28). Their treatment results were evaluated. RESULTS: The incidence of residual lesion was 7.7% in group A and 14.3% in group B. Risk factors were piecemeal resection, involvement of the horizontal margin (HM1) or unclear involvement of the horizontal margin (HMX) and with ulceration. Lymph node metastasis was detected in one patient with lymphatic invasion, total diameter of 3 cm or more and submucosal invasion over 0.5 mm (SM2). The 5-year survival rate was 93% and none of the patients died of gastric cancer. CONCLUSION: Follow-up observation was reasonable in group A. Patients who are judged as having undergone piecemeal resection, HM1 or HMX and with ulceration, should be treated by additional surgery and patients judged with SM2 or total diameter of 3 cm or more or lymphatic invasion should be treated by additional surgery with lymphadectomy in group B.