Prognostic impacts of categorized postoperative complications in surgery for gastric cancer.

BACKGROUND: Postoperative complications generally aggravate postoperative prognosis and are correlated with both cancer-specific death and death from other causes. METHODS: Subjects were 197 patients who underwent gastrectomy at Kyoto Chubu Medical Center. Cancer-specific survival (CSS) and non-CSS (NCSS) were compared between cases with and without complications. Major complications were classified into C-com and N-com groups based on their prognostic impact on CSS and NCSS, respectively. Uni- and multivariate analyses were conducted using clinicopathological factors. RESULTS: During the study period, 30 patients (15.2%) died from gastric cancer and 34 (17.3%) died from other causes. The incidence of postoperative complications was 16.8%. Sixteen patients with anastomosis leakage, pancreatic fistula, or organ/space surgical site infection had significantly poorer CSS, whereas 30 patients with pneumonia or passage obstruction had significantly poorer NCSS. These were defined as C-com and N-com cases, respectively. In the uni- and multivariate analyses, C-com was a significant prognostic factor for CSS (p = 0.002, p = 0.039) and N-com was a significant prognostic factor for NCSS (p < 0.0001, p = 0.004). C-reactive protein levels indicated intermediate and severe inflammation in N-com and C-com cases, respectively. CONCLUSION: In N-com cases, surgical stress caused disruption of essential organ function, whereas damage in C-com cases occurred mostly in the abdominal cavity but was a risk for cancer regrowth. Thus, different postoperative complications worsen patient prognosis after gastrectomy in different ways. To optimize surgical outcomes, improved selection of treatment strategies for different complication types may be important.

Impact of Preoperative Nutritional Indicator on Poor Postoperative Outcomes in Geriatric Patients with Colorectal Cancer.

The present study aimed to analyze the association between preoperative nutritional assessment and poor postoperative outcomes in geriatric patients with colorectal cancer. This retrospective study included 138 patients aged ≥80 years with colorectal cancer who underwent surgery from January 2013 to December 2018. Patients were classified into two groups according to outcomes, poor group and normal group. Clinicopathological factors were compared between the groups, and the relationships of several nutritional indices were examined. There was no significant difference in sex, age, or preoperative comorbidities. There were significant differences in volume of blood loss and proportion of laparoscopic surgery. The group with poor outcomes had significantly higher neutrophil/lymphocyte ratio (NLR) and modified Glasgow prognostic score (mGPS) than the group with normal outcomes. Multivariate analysis revealed that open approach, high NLR, and category D mGPS were independent risk factors of poor postoperative outcomes in elderly patients with colorectal cancer. Our findings indicate that mGPS and NLR could be useful nutritional indicators of short-term outcomes of surgical treatment in geriatric patients with colorectal cancer. They can be evaluated based on albumin and C-reactive protein levels and blood count, which are inexpensive and beneficial to use in routine clinical practice.

[Two Cases of Blind Pouch Syndrome after Total Gastrectomy].

Blind loop syndrome(BLS)is one of the complications that can occur after intestinal anastomosis. Patients with the syndrome present with various clinical features, including nutrient malabsorption caused by the blind end as a result of the anastomotic morphology. On the other hand, blind pouch syndrome(BPS)is a subtype of BLS. While it has a similar underlying mechanism, the clinical symptoms of patients with BPS are significantly different from those of patients with BLS; ie, the symptoms develop almost locally without nutrient malabsorption. There have been some reports that dealt with BPS as a disease that was distinct from BLS. Since conservative treatment cannot be expected to produce a curative effect in patients with BPS, it is necessary to administer surgical treatment in many cases. Previous studies have reported that resection of the blind pouch, which caused the local symptoms, was a curative surgical procedure for BPS. In the present study, we report 2 cases of BPS after Roux-en-Y reconstruction during total gastrectomy for gastric cancer patients, that were cured by surgical treatment by creating a bypass to the blind pouch.

[Comparison between Overall Survival and Disease-Specific Survival after Surgery in Gastric Cancer].

BACKGROUND: It has been reported that we should give consideration to death caused by other disease from comparison between overall survival(OS)and disease specific survival(DSS)in several studies. PATIENTS AND METHODS: Relationships between the clinicopathological features of OS and DSS were examined among 197 patients undergoing surgery for gastric cancer. RESULTS: In OS analysis, the Charlson comorbidity index(CCI), pathological T and postoperative complications with Clavien-Dindo Grade≥Ⅲ were associated significantly in multivariate analyses(p=0.009, 0.022, 0.027). On the other hand, in DSS analysis, CCI was not associated, but gender, DG/TG, pathological N and complication were associated significantly( p=0.0002, 0.016, 0.0003, 0.009). CONCLUSION: The complication is a significant prognostic factor of OS and DSS in gastric cancer patients. It is important to pay attention for comorbidities and to prevent the postoperative complications in order to improve the prognosis in gastric cancer surgical therapy.

[Impact of the Age-Adjusted Charlson Comorbidity Index on Postoperative Complications after Gastric Cancer Surgery].

BACKGROUND: The primary objective of this retrospective study was to examine the association between the age-adjusted Charlson comorbidity index(aCCI)score and postoperative complications after gastric cancer surgery. METHOD: A total of 237 patients who underwent distal/total gastrectomy for gastric cancer between 2012 and 2020 were enrolled in this study. The aCCI and CCI were calculated by weighting individual comorbidities. The correlations between the clinicopathologic features, including CCI or aCCI, and postoperative complications were analyzed statistically. RESULTS: Univariate and multivariate analyses demonstrated that both the CCI- and aCCI- high classifications were significant risk factors for postoperative complications. CONCLUSION: The aCCI exhibits a suitable predictive ability for patients undergoing gastric surgery. Although patients with a CCI≤2 showed little risk, patients with an aCCI≥5 were at a high surgical risk and should receive very careful attention for postoperative complication(s).

[A Case of R0 Resection, with Preservation of Bladder Function, of Advanced Rectal Cancer Infiltrating the Bladder with a Single Metastatic Liver Tumor Due to Preoperative Chemotherapy].

A 75-year-old man was diagnosed with advanced rectal cancer infiltrating the bladder and a single metastatic liver tumor. The patient first underwent colostomy followed by 8 cycles of chemotherapy, using a regimen of cetuximab, calcium levofolinate hydrate, fluorouracil and oxaliplatin(Cmab plus mFOLFOX6). This treatment resulted in a partial response(PR). Five months after the first operation, laparoscopic partial hepatectomy(S4), low anterior resection and ileostomy by laparotomy were performed. The pathological findings were T4b, N1b, M1a, H1, ypStage Ⅳa and all surgical margins were negative, so R0 resection was performed for preservation of bladder function. The patient received adjuvant chemotherapy and has survived without recurrence for 10 months after the second operation. The preoperative chemotherapy permitted combined resection of the bladder and urostomy. This is important because a double stoma commonly reduces quality of life. Thus, Cmab plus mFOLFOX6 may be useful as preoperative chemotherapy to preserve bladder function and quality of life.

Is pneumoperitoneum necessary for single-incision laparoscopy-assisted appendectomy for pediatric appendicitis?

INTRODUCTION: Several studies have reported the treatment of pediatric appendicitis with single-incision laparoscopy-assisted appendectomy using a muscle hook without pneumoperitoneum to lift the abdominal wall. However, very few studies have investigated the advantages of this procedure. We examined the utility of this procedure in our department. METHODS: This study included 33 children with appendicitis who underwent single-incision laparoscopy-assisted appendectomy at our hospital from April 2011 to March 2018. Patients were divided into two groups depending on whether they underwent the procedure with pneumoperitoneum: the no pneumoperitoneum group (n = 12) and the pneumoperitoneum group (n = 21). The clinicopathological factors and surgical costs were compared between the two groups. RESULTS: In the pneumoperitoneum group, the procedure was initiated in four patients by lifting the abdominal wall but was changed to include a pneumoperitoneum because of difficulty. There were no significant differences between the two groups with regard to age, sex, or pathological severity. CT revealed a significant difference in the distance from the appendicular root to the umbilicus between the groups. There was a significant difference in the operative duration, but not in estimated blood loss or length of postoperative hospital stay. Complications were observed in one patient in each group. There was a significant difference in cost between the two groups. CONCLUSIONS: Single-incision laparoscopy-assisted appendectomy without pneumoperitoneum is less expensive because certain supplies and CO2 are not required. Because there were no differences in the length of postoperative hospital stay or complications, this procedure may be safe in cases that are expected to be mild.

Early Neuropathy Related to Oxaliplatin Treatment in Advanced and Recurrent Colorectal Cancer.

BACKGROUND/AIM: Chemotherapy dose adjustments in colorectal cancer are usually based on body surface area (BSA). The goal of this study was to investigate patients with nutritional disorder who developed early peripheral neuropathy due to inappropriate dose adjustment of oxaliplatin. PATIENTS AND METHODS: The study subjects were 88 patients with advanced or recurrent colorectal cancer who underwent chemotherapy with oxaliplatin. The psoas muscle area (PMA) was used as a nutritional index. Mild (grades 0-1, MN group) and severe (grades 2-3, SN group) peripheral neuropathy was defined using neurotoxicity criteria of Debiopharm. RESULTS: Severe peripheral neuropathy developed in 29 patients (33.0%). The total oxaliplatin dose/PMA was significantly higher for the SN group (107.6±8.5 mg/cm2) and compared with the MN group (53.8±6.0 mg/cm2) in univariate (p<0.0001) and multivariate (p=0.012) analyses. CONCLUSION: In order to prevent peripheral neuropathy from chemotherapy for colorectal cancer, dose adjustment of oxaliplatin should be based on PMA, in addition to BSA.

[Impact of Preoperative Comorbidities on Long-Term Prognosis in Elderly Patients with Gastric and Colorectal Cancer].

BACKGROUND: There has been an increase in the number of elderly cancer patients with preoperative comorbidities, which decrease the safety of surgical therapy. Assessment of comorbidities is useful for prediction of the outcome of treatment in these patients. PATIENTS AND METHODS: The Charlson comorbidity index(CCI)was determined in 83 elderly patients undergo- ing surgery for gastric and colorectal cancer. Relationships of CCI with prognosis were examined in pathological R0/R1 and R2 cases. RESULTS: In the R0/R1 group, CCI was significantly associated with overall survival in univariate(p=0.027)and multivariate( p=0.031)analyses. Mortality from other diseases within a year after surgery for patients with CCIB4 was significantly higher than that for those with CCIC3(11.0% vs 1.4%, p=0.028). CONCLUSION: CCI is an independent prognostic factor after surgery for elderly patients with gastric and colorectal cancer.

[Impact of Muscle Mass Reduction on Postoperative Adjuvant Chemotherapy and Long-Term Prognosis in Patients with Gastric Cancer].

BACKGROUND: Measuring the area of the psoas muscle on computed tomography is useful for the evaluation of skeletal muscle mass. The skeletal muscle is thought to be involved in weight loss after gastric surgery, and weight loss causes a decrease in compliance with chemotherapy continuity. PATIENTS AND METHODS: The psoas muscle index(PMI)was determined in 33 patients undergoing surgery for Stage Ⅱ-ⅢB gastric cancer. The rate of change in PMIwas calculated, and patients were classified into maintained and reduced muscle groups using a cutoff of -0.23 month-1. Relationships between the rate of PMIchanges and prognosis and chemotherapy continuity were examined. RESULTS: The rate of PMIchanges was significantly associated with recurrence-free survival in univariate(maintained vs reduced muscle: p=0.002)and multivariate(p= 0.0018)analyses. A reduction in the muscle mass was associated with dropout from adjuvant chemotherapy and was a predictor of a poor prognosis. CONCLUSION: The rate of PMIchanges is related to the period of adjuvant chemotherapy and is an independent prognostic factor after surgery for StageⅡ-ⅢB gastric cancer.

Laparoscopic intraperitoneal onlay mesh for pediatric incisional hernia-a case report.

BACKGROUND: The incidence of incisional hernia in pediatric patients is low in comparison with that reported in adults. In the pediatric population, primary closure has generally been favored. However, synthetic or biomedical mesh offers advantages in the repair of larger defects when primary closure is difficult. The use of laparoscopic intraperitoneal onlay mesh (IPOM) in the adult population has been well documented. In the pediatric population, a few laparoscopic approaches with direct suturing have been proposed; however, there are no reports of laparoscopic repair with the use of IPOM. CASE PRESENTATION: The patient was a 1-year-old girl with epigastric incisional hernia after an operation to correct a complete arteriovenous septal defect. The fascial defect (size 30 × 35 mm) was large; thus, direct suturing was considered to be associated with a high risk of thoracic deformation and recurrence. Laparoscopic IPOM was performed. The fascial defect was detected precisely through the laparoscopy, and non-absorbable mesh was placed through a 12-mm trocar. Minimal incisions were required for the trocars, and extensive dissection of the abdominal wall structure was not needed. This procedure allowed for the integrity and functional status of the abdominal wall to be maintained. CONCLUSION: Laparoscopic IPOM is a minimally invasive and cosmetically acceptable method that can be applied to the treatment of large incisional hernias in children.

[Difficult Airway Management in a Low Birth Weight Infant Using an Upper Gastrointestinal Endoscope].

We report a successful tracheal intubation in a low birth weight infant with difficult airway by using an upper gastrointestinal endoscope. A 1-day-old female weighing 1.8 kg having micrognathia, lateral facial cleft, and bilateral microtia suggestive of Goldenhar syn- drome complicated with total anomalous pulmonary venous connection was scheduled for surgical repair of duodenal atresia. Awake intubation was planned because of anticipated difficult intubation. Direct laryn- goscopy with Miller blade (size 0) after intravenous lidocaine did not visualize the larynx or epiglottis (Cor- mack-Lehane grade 4). After several failed attempts at intubation using BURP procedure, Pentax Airway Scope? equipped with a neonatal-type Intlock* (ITL- N) was tried but a good view of the larynx was not obtained because of the narrow oral cavity and copious secretion. After failed attempts with Airway Scope?, an upper gastrointestinal endoscope was inserted into the oral cavity and equipped insufflation and suctioning of the secretion were utilized, which provided a good view of the vocal cords and enabled nasotracheal intu- bation. An upper gastrointestinal endoscope could provide a good view of the larynx by using insufflation, and suc- tioning, and can be one of the useful devices for tra- cheal intubation of difficult airway.

Successful use of recombinant activated factor VII (eptacog alfa, Novoseven®) in a refractory bleeding during pediatric cardiac surgery: a case report.

A 2-year-and-7-month-old boy underwent an emergent reconstruction surgery of the right ventricle-pulmonary artery (RV-PA) conduit. Although he was successfully weaned from cardiopulmonary bypass (CPB) after reconstruction of the RV-PA conduit, the bleeding continued despite the massive transfusion of red blood cell (RBC), fresh frozen plasma (FFP), and platelets. Because of persistent bleeding and abnormal coagulation laboratory results, we administered the recombinant activated factor VII (rFVIIa), which was not approved for use in the treatment of post-CPB coagulopathy. After administration of rFVIIa, his coagulation data dramatically improved, the bleeding decreased, and the operation was able to be finished.

Metal-free [2 + 2 + 1] annulation of alkynes, nitriles, and oxygen atoms: iodine(III)-mediated synthesis of highly substituted oxazoles.

The metal-free [2 + 2 + 1] annulation of alkynes, nitriles, and O-atoms for the regioselective assembly of 2,4-disubstituted and 2,4,5-trisubstituted oxazole compounds has been achieved by the use of PhIO with TfOH or Tf2NH. The present reaction could be applied to a facile synthesis of an anti-inflammatory drug.

Relative intensities of prompt γ-rays from the 35Cl(n,γ)36Cl reaction with thermal neutrons as secondary γ-ray intensity standards.

The relative intensities of 16 prompt γ-rays from the (35)Cl(n,γ)(36)Cl reaction with a thermal neutron were precisely determined as secondary γ-ray intensity standards with HPGe detectors. The detection efficiencies were calibrated from 0.2 to 10.8 MeV using the standard sources (152)Eu and (56)Co and the (14)N(n,γ)(15)N reaction. We performed appropriate analyses for the evaluation of doublet peaks, subtraction of mixing with escape γ-rays and other corrections; consequently, the values were determined within 1% accuracy. Relative intensities in the range of 0.7 to 8.6 MeV are proposed as reliable secondary standards for 16 γ-rays.

The butenolide signaling molecules SRB1 and SRB2 induce lankacidin and lankamycin production in Streptomyces rochei.

New signaling molecules that induce lankacidin and lankamycin production in Streptomyces rochei were extracted from the culture filtrate and purified by Sephadex LH20 and silica gel chromatography with the help of bioassay. Chiral HPLC and ESI-MS analyses indicated the presence of two active components--SRB1 and SRB2--and their molecular formulas were established to be C15H24O5 and C16H26O5, respectively. By extensive NMR analysis, SRB1 and SRB2 were determined to be 2-(1'-hydroxy-6'-oxo-8'-methylnonyl)-3-methyl-4-hydroxybut-2-en-1,4-olide and 2-(1'-hydroxy-6'-oxo-8'-methyldecyl)-3-methyl-4-hydroxybut-2-en-1,4-olide, respectively. These structures were finally confirmed by chemical synthesis and the absolute configuration at C-1' was determined to be R in each case. The synthetic 1'R isomers induced production of lankacidin and lankamycin at around 40 nM concentrations. SRB1 and SRB2 are therefore distinct from the well-known 2,3-disubstituted γ-butyrolactone molecules such as A-factor, virginia butanolide, and SCB1 and and belong, like avenolide, recently isolated from Streptomyces avermitilis, to the γ-butenolide family.

[Induction of general anesthesia in pediatric patients].

The induction of general anesthesia is one of the most stressful procedures during the perioperative period for pediatric patients. Postoperative negative behavioral changes, such as nightmares or separation anxiety are reported in the children undergoing general anesthesia. To avoid these problems, the anesthesiologists have to pay more attention to the psychological needs of young patients as well as the technical aspects. Preoperative interview is important to identify the child who has extreme fear and anxiety. Premedication with sedatives and psychological preparation are effective for the smooth induction. In this article, preparation for the induction and practical skills of the induction in children, newborns, as well as patients with difficult airway and with full stomach are summarized.

Anesthetic management of bidirectional cavopulmonary shunt in a patient with pulmonary atresia with intact ventricular septum associated with sinusoidal communications.

Pulmonary atresia with intact ventricular septum (PAIVS) is sometimes associated with coronary artery anomalies, including right ventricle (RV)-to-coronary artery fistulas (sinusoidal communications), coronary artery stenoses, and coronary artery occlusions. In some cases, the coronary circulation depends entirely or partly on the desaturated systemic venous blood supply from the RV. Under these circumstances, decompression of the RV can result in fatal myocardial ischemia. A 6-month-old boy, diagnosed with PAIVS associated with sinusoidal communications, underwent a bidirectional cavopulmonary shunt procedure under venoarterial cardiopulmonary bypass (CPB). During CPB, to prevent RV decompression, we maintained right atrial pressure above 5 mmHg and used a pump perfusion rate of 30%-40% of the calculated value based on body surface area. Although electrocardiography showed slight ST depression and bradycardia, myocardial contractility after weaning from CPB was adequate to maintain the circulation with the administration of dobutamine and atrial pacing. In patients with PAIVS and RV-dependent coronary circulation, it is important to maintain coronary artery perfusion throughout the period of anesthesia.

Anesthetic management of a 9-year-old child undergoing resection of a tracheal tumor.

Primary tracheal tumors in children are rare. We report the anesthetic management of a 9-year-old child undergoing resection of a midtracheal tumor obstructing approximately 73% of the tracheal lumen. To prepare for any possible airway emergency during the induction and maintenance of anesthesia, we ascertained preoperatively that a mini-tracheotomy tube could be inserted at the distal portion of the tracheal lesion. Oxygenation and ventilation were adequately maintained throughout the period of anesthesia. Anesthetic management for tracheal tumor resection should reflect the location of the tumor and the degree of tracheal obstruction.