A prospective clinical study evaluating short-term changes in body composition and quality of life after gastrectomy in elderly patients receiving postoperative exercise and nutritional therapies.

BACKGROUND: Muscle mass loss after gastrectomy is associated with a negative impact on quality of life (QOL) and long-term prognosis following gastric cancer treatment, especially in elderly patients. We conducted a prospective study to examine short-term changes in body composition and QOL after gastrectomy in elderly patients with gastric cancer who received exercise and nutritional therapies. METHODS: Patients over aged 65 years of age who underwent gastrectomies for gastric cancer were enrolled in our study. Patients received exercise and nutritional therapies with branched-chain amino acid (BCAA)-rich supplements during 1 month after surgery. Body composition was evaluated using InBody S10 before surgery, and at 1 week and 1 month postoperatively. Other variables including QOL status (EQ-5D-5 L), serum albumin level, hand grip strength, and gait speed were evaluated at the same time. RESULTS: Eighteen patients were analyzed. The mean loss of skeletal muscle mass index (SMI) was 4.6% (1 week) and 2.1% (1 month) compared to the preoperative period. QOL scores showed almost the same degree of recovery at 1 month after gastrectomy as preoperative scores. Serum albumin levels, hand grip strength, and gait speed decreased at 1 week and then increased at 1 month after surgery, similar to the changes seen in SMI. CONCLUSIONS: Multidisciplinary approaches play key role in the surgical treatment of elderly patients. Postoperative exercise and nutritional therapies with BCAA-rich supplements may benefit elderly patients after gastrectomy by reducing loss of SMI and decreases in QOL. TRIAL REGISTRATION: UMIN Clinical Trials Registry; UMIN000034374 (registration date: 10/10/2018).

Case report: A surgically treated case of diaphragmatic clear cell carcinoma without relation to endometriosis.

INTRODUCTION AND IMPORTANCE: Diaphragmatic tumor is a rare neoplastic disease. Only three reports have revealed diaphragmatic primary clear cell carcinoma. On the other hand, secondary membranous nephropathy is sometimes triggered by the carcinoma. We describe a case of primary diaphragmatic clear cell carcinoma without relation to endometriosis or ovarian malignancies, and secondary membranous nephropathy was triggered by diaphragmatic primary clear cell carcinoma. CASE PRESENTATION: A 67-year-old woman was found to have membranous nephropathy due to examination for renal dysfunction. A rare diaphragmatic tumor was identified on CT scan for rule out secondary membranous nephropathy. She had underwent resection of the right diaphragm tumor and reconstruction with expanded polyterafluoroethylene (e-PTFE). CLINICAL DISCUSSION: Pathological examination revealed the presence of clear cells with papillary arrangement and no findings of the endometriosis. Immunohistochemistry revealed that the tumor was positive for CK7, p53, and HNF-1-beta. And there had been no evidence of ovarian malignancies. A diagnosed of clear cell carcinoma of the right diaphragm without relation to endometriosis or ovarian malignancies was made. After resection of the tumor, it was revealed that her renal function was improvement. CONCLUSION: This is the first report of diaphragmatic clear cell carcinoma without relation to endometriosis or ovarian malignancies that caused secondary membranous nephropathy. One year after the resection of the tumor, she is being followed up and has shown no signs of recurrence.

Risk factors associating with delayed gastric emptying after laparoscopic distal gastrectomy.

PURPOSE: The aim of this study was to investigate the incidence of delayed gastric emptying among the patients receiving laparoscopic distal gastrectomy, and to explore their clinical features and risk factors. METHODS: Clinical data were collected for 223 patients who underwent laparoscopic distal gastrectomy for gastric cancer. We retrospectively evaluated the clinicopathological features and analyzed the incidence of delayed gastric emptying among 223 patients. Delayed gastric emptying was diagnosed by patient's symptoms and the plane radiograph with an air fluid level and dilation of the remnant stomach. RESULTS: Delayed gastric emptying was found in five (2.2%) of the 223 patients. By univariate logistic regression analysis, greater American Society of Anesthesiologists Physical Status (ASA-PS) and older age were significantly related to occurrence of delayed gastric emptying. By multivariate logistic regression analysis, older age was independently significantly related to incident delayed gastric emptying. The area under the curve (AUC) ((95% CI) of the receiver operating characteristic (ROC) was 0.842 (0.561-0.957). The best cutoff for discriminating patients with and without delayed gastric emptying was 80 years (sensitivity 80% and specificity 83%). CONCLUSION: Our study found the occurrence of delayed gastric emptying is possibly correlated with age. Therefore, careful perioperative observation in elderly patients may possibly be important for possible development of delayed gastric emptying after laparoscopic distal gastrectomy.

Repair of a perineal hernia with a bladder patch after abdominoperineal resection: A case report and literature review.

Perineal hernia is the protrusion of the intra-abdominal viscera through the pelvic floor. It rarely occurs after abdominoperineal resection but has increasingly occurred after surgical treatment for rectal cancer. A patient was diagnosed as having perineal hernia 10 days after laparoscopic abdominoperineal resection with preoperative radiotherapy and chemotherapy. He presented with epigastric discomfort and perineal wound dehiscence. Perineal hernia was confirmed by computed tomography scan and treated with a semi-emergency surgery. The surgical field was contaminated because of the perineal wound dehiscence. The levator muscle at the pelvic floor was not sufficient, so we used a bladder patch to cover the pelvic inlet. The surgery was performed without any adverse events. To our best knowledge, this is the first case report to present the usefulness of a bladder patch for the treatment of a perineal hernia using a laparoscopic transabdominal approach in emergency situations.

Emergency abdominal surgeries remain unchanged in the COVID-19 affected environment: A single-center experience at a community hospital in Japan.

AIM: This study assessed whether emergency abdominal surgeries were changed in the coronavirus disease (COVID-19)-affected environment at a community hospital in Japan, with the goal of planning and preparing hospital resources against the further spread of COVID-19. METHODS: A total of 179 patients who underwent emergency abdominal surgery over 4 months during the pandemic (1 March, 2020 to 30 June, 2020) and a control period (1 March, 2019 to 30 June, 2019) were enrolled in this retrospective study. Patient demographics, hospital visiting patterns (visit time, ambulance transport, and duration of symptom onset to hospital visit), severity of patients' condition, and surgical characteristics were compared between the two periods. RESULTS: The number of patients undergoing emergency abdominal surgery during the pandemic did not decrease in comparison to the control period (89 patients versus 90 patients). The duration of symptom onset to hospital visit during the pandemic was not prolonged compared to the control period. Other hospital visiting patterns, severity of patients' condition, and surgical characteristics were also similar in both periods. CONCLUSION: Although the situation of the pandemic was different between countries and regions, the number of emergency surgeries in our hospital remained unchanged, and those patients visited the emergency room no later than usual.

Emergency surgery for acute cholecystitis associated with cholecystocolonic fistula caused by gallbladder cancer: a case report.

Preoperative diagnosis of cholecystocolonic fistula (CCF) is difficult and the contribution of gallbladder cancer or colon cancer is unclear when there is associated malignancy. We present a case that was diagnosed with acute cholecystitis associated with CCF by multidetector computed tomography (MDCT) preoperatively and malignant neoplasm during emergency surgery. She was finally diagnosed with gallbladder cancer after the operation and underwent a two-stage surgery for regional lymph node dissection. Gallbladder cancer can be a primary malignant cancer causing CCF, whereas MDCT is useful for preoperative diagnosis of CCF. A treatment plan in consideration of gallbladder cancer is advisable for CCF associated with malignant tumor.

Gram staining of gallbladder bile samples is useful for predicting surgical site infection in acute cholecystitis patients undergoing an early cholecystectomy.

BACKGROUND: Microbiological assessment of gallbladder bile is important for postoperative management in cholecystectomy for acute cholecystitis (AC). Gram staining is used as the first step in the assessment, in order to preliminarily detect bacteria in the bile sample. This study was conducted to evaluate the clinical significance of Gram staining results in the development of postoperative surgical site infection (SSI) in AC patients. METHODS: A total of 428 AC patients, who underwent an early cholecystectomy with microbiological assessment of gallbladder bile, were enrolled in this retrospective study. The clinical usefulness of the Gram staining results was evaluated by univariate and multivariate regression analyses. RESULTS: Of the 428 patients, 298 patients (69.6%) were diagnosed with bile infection by the Gram staining method. The rate of SSI was higher in patients with bile infection (9.7%) than in those without the infection (0.8%). The multivariate analysis indicated that the bile infection diagnosed by Gram staining (odds ratio: 9.091; P = .033) was an independent factor to predict SSI development, along with open surgery. CONCLUSIONS: Gram staining diagnosis of bile infection in an early cholecystectomy for AC is useful for predicting postoperative SSI development, which should benefit postoperative management.

Dementia in elderly patients undergoing early cholecystectomy for acute cholecystitis: a retrospective observational study.

BACKGROUND: Dementia often adversely affects postoperative outcomes in surgical patients. This study evaluated postoperative outcomes among elderly patients with and without dementia undergoing early cholecystectomy for acute cholecystitis (AC). METHODS: A total of 182 patients over 85 years of age who were diagnosed with AC and treated from January 2005 to March 2018 were reviewed retrospectively; 59 patients who underwent early cholecystectomy were enrolled. The complication rates, length of postoperative hospital stay, and rates of routine discharge (i.e., returning to their preoperative living location) were compared between two groups of patients with and without dementia. RESULTS: The overall complication rate after early cholecystectomy for AC in 59 patients was 11.9%, and there was no mortality in this series. The median postoperative hospital stay was 9.0 days, and the routine discharge rate was 89.8%. Of the 59 patients, 22 patients (37.3%) had a history of dementia. Complication rates were comparable between the groups, despite the rate of delirium development being significantly higher in the dementia group. The median length of postoperative hospital stay and routine discharge rates did not significantly differ between groups. CONCLUSIONS: Early cholecystectomy for patients with AC over 85 years of age was performed safely, and elderly patients with dementia had similar postoperative outcomes as compared with patients without dementia.

A resected case of recurrent ITPN in the remnant pancreas after pancreatoduodenectomy.

BACKGROUND: Since intraductal tubulopapillary neoplasm (ITPN) is a rare disease, the clinical features of ITPN, especially the characteristics related to recurrence, have not been revealed. We performed a total remnant pancreatectomy for a patient whose ITPN recurred 16 months after pancreatoduodenectomy (PD). We report useful findings to clarify how ITPN reoccurs based on this experience and previously reported cases. CASE PRESENTATION: A 61-year-old male patient was diagnosed with pancreatic cancer and underwent PD. However, a postoperative pathologic examination diagnosed ITPN with invasive cancer. After receiving adjuvant chemotherapy, he was hospitalized for pancreatitis 16 months after the operation. He was diagnosed as having recurrence near the pancreato-jejunal anastomosis based on detailed examinations and underwent a remnant total pancreatectomy. From the results of the histopathological examination, he was found to have a recurrence of ITPN as a polypoid mass without invasion distant from the surgical stump of the first operation. Furthermore, tumor cells floating in the main pancreatic duct distant from the main tumor were observed at three locations. REVIEW OF THE LITERATURE: Including our case, five cases of recurrence in the remnant pancreas after surgery for ITPN have been reported. Recurrence in the main pancreatic duct was observed in four of these five cases. The primary tumor, which recurred in the remnant pancreas after surgery, was characterized as being relatively small and less invasive; however, Ki-67 labeling index was high. In immunohistochemical examination, the expression of MUC6, which is not one of characteristics of ITPN, tended to be positive. CONCLUSION: In this case, tumor cells were floating inside the pancreatic duct at several locations. From the results of this case and a review of previous reports, the cause of ITPN recurrence in this case seemed to be due to tumor cells leaving the tumor and implanting into the pancreatic duct.

Phase IIb, Randomized, Double-Blind, Placebo-Controlled Study of Naldemedine for the Treatment of Opioid-Induced Constipation in Patients With Cancer.

Purpose This randomized, double-blind, multicenter study aimed to determine the dose of naldemedine, a peripherally-acting µ-opioid receptor antagonist, for future trials by comparing the efficacy and safety of three doses of naldemedine versus placebo in patients with cancer and opioid-induced constipation. Methods Patients ≥ 18 years old with cancer, an Eastern Cooperative Oncology Group performance status ≤ 2, who had been receiving a stable regimen of opioid analgesics for ≥ 2 weeks, had at least one constipation symptom despite laxative use, and no more than five spontaneous bowel movements (SBMs) during the past 14 days, were randomly assigned (1:1:1:1) to oral, once-daily naldemedine 0.1, 0.2, or 0.4 mg, or placebo, for 14 days. The primary end point was change in SBM frequency per week from baseline during the treatment period. Secondary end points included SBM responder rates, change from baseline in the frequency of SBM without straining, and complete SBM. Safety was also assessed. Results Of 227 patients who were randomly assigned, 225 were assessed for efficacy (naldemedine 0.1 mg, n = 55; 0.2 mg, n = 58; 0.4 mg, n = 56; placebo, n = 56) and 226 for safety. Change in SBM frequency (primary end point) was higher with all naldemedine doses versus placebo ( P < .05 for all comparisons), as were SBM responder rates and change in complete SBM frequency. Change in SBM frequency without straining was significantly improved with naldemedine 0.2 and 0.4 (but not 0.1) mg versus placebo (at least P < .05). Treatment-emergent adverse events were more common with naldemedine (0.1 mg: 66.1%; 0.2 mg: 67.2%; 0.4 mg: 78.6%) than placebo (51.8%); the most common treatment-emergent adverse event was diarrhea. Conclusion Fourteen-day treatment with naldemedine significantly improved opioid-induced constipation in patients with cancer and was generally well tolerated. Naldemedine 0.2 mg was selected for phase III studies.

Up-regulation of Kv7.1 channels in thromboxane A2-induced colonic cancer cell proliferation.

Thromboxane A2 (TXA2) is known to stimulate colonic cancer cell proliferation, although the mechanism has not been clarified. In this study, we compared the expression levels of Kv7.1 K(+) channels between human colorectal cancer tissue and the accompanying non-tumor mucosa. Kv7.1 proteins were found to be consistently up-regulated in the cancer tissues from different patients. Kv7.1 was also expressed in human colonic cancer cell lines. Treatment of colonic cancer cells with 9,11-epithio-11,12-methano-thromboxane A2 (STA2), a stable analogue of TXA2, significantly increased whole-cell K(+) currents sensitive to chromanol 293B, an inhibitor of Kv7.1 channels, in parallel with an increased expression of Kv7.1 proteins. In contrast, TXB2, an inactive metabolite of TXA2, had no effects on expression level and function of Kv7.1. A TXA2 receptor antagonist (SQ29548) and an inhibitor of cAMP-dependent protein kinase (Rp-8-Br-MB-cAMPS) inhibited STA2-induced increases in both Kv7.1 expression and chromanol 293B-sensitive K(+) currents. Interestingly, STA2-stimulated proliferation of colonic cancer cells was inhibited by chromanol 293B. These results suggest that Kv7.1 channels are involved in the TXA2-induced cancer cell proliferation and that they are up-regulated by the TXA2 receptor-mediated cAMP pathway.

Pancreatic nonfunctioning neuroendocrine tumor with the main pancreatic duct obstruction presenting as excessive hyperglycemia: a case report and review of the literature.

We present the case of a 65-year-old man with a pancreatic nonfunctioning neuroendocrine tumor causing main pancreatic duct obstruction that presented as excessive hyperglycemia. We considered the tumor elicited worsening of diabetes in this case, and we performed review of the relevant literature.

[Complete response achieved in a case of gastric gastrointestinal stromal tumor by administration of imatinib mesilate with concurrent relatively high-dose steroid therapy to control side effects].

We present a 53-year-old man who underwent proximal gastrectomy for gastric gastrointestinal stromal tumor (GIST) in August 2005. Imatinib mesilate (imatinib) 400 mg/day was started in February 2006 for left adrenal metastasis. Tumor size markedly decreased by April 2006, but medication had to be discontinued due to a pruritic rash. A distal pancreatectomy, splenectomy, and left adrenectomy were performed in August for recurrent adrenal metastases. Imatinib 200 mg/day started postoperatively was discontinued immediately due to fever and pruritus. Local recurrence with peritoneal dissemination was found in February 2007. Imatinib 100 mg/day with prednisolone (PDL) 5 mg/day was discontinued in two days due to pruritic dermatitis. Imatinib 200 mg/day with PDL 40 mg/day was restarted in April due to an increase in tumor size. Treatment continued without obvious side effects, and PDL dosage was tapered to 10 mg/day. The tumor was no longer visible on CT in May 2008, and complete response is being maintained as of August 2009.

Histological complete response in advanced gastric cancer after 2 weeks of S-1 administration as neoadjuvant chemotherapy.

Single-agent or combined chemotherapy with the novel oral fluoropyrimidine anticancer drug, S-1 (TS-1), has been reported to be useful for the treatment of advanced gastric cancer. Here, we report a patient with advanced gastric cancer achieving a complete response (CR) after 2 weeks of administration of S-1 as neoadjuvant chemotherapy. A 78-year-old woman with epigastric pain was diagnosed as having advanced gastric cancer. S-1 was administered orally, at a dose of 50 mg twice a day every day for 2 weeks, followed by a 2-week drug-free period. No obvious adverse reactions occurred. Subsequently, the patient underwent distal partial gastrectomy with D2 lymph node dissection. Pathological examination indicated no remnant signet-ring cells in the excised specimen, no lymph node metastasis, and unnatural fibrosis in one of the No. 3 lymph nodes. The neoadjuvant chemotherapy induced a CR according to the Japanese classification of gastric carcinoma.

Upregulation of thromboxane synthase in human colorectal carcinoma and the cancer cell proliferation by thromboxane A2.

Tumor growth of colorectal cancers accompanies upregulation of cyclooxygenase-2, which catalyzes a conversion step from arachidonic acid to prostaglandin H(2) (PGH(2)). Here, we compared the expression levels of thromboxane synthase (TXS), which catalyzes the conversion of PGH(2) to thromboxane A(2) (TXA(2)), between human colorectal cancer tissue and its accompanying normal mucosa. It was found that TXS protein was consistently upregulated in the cancer tissues from different patients. TXS was also highly expressed in human colonic cancer cell lines. Depletion of TXS protein by the antisense oligonucleotide inhibited proliferation of the cancer cells. This inhibition was rescued by the direct addition of a stable analogue of TXA(2). The present results suggest that overexpression of TXS and subsequent excess production of TXA(2) in the cancer cells may be involved in the tumor growth of human colorectum.

Primary abscess of the omentum: report of a case.

We report a case of a primary abscess of the omentum without any obvious etiology. A 62-year-old man was referred to our clinic with lower abdominal pain, and computed tomography showed an intra-abdominal abscess in the left pelvic area. Laparotomy revealed that the abscess adhered to the urinary bladder and abdominal wall, but no perforation of the alimentary tract was identified and there was no foreign body in the abscess cavity. A culture of the abscess fluid grew Clostridium perfringens. The patient was discharged on the 16th hospital day after an uneventful postoperative course without any complications.

Expression of ATP1AL1, a non-gastric proton pump, in human colorectum.

The expression of mRNAs encoding a human nongastric proton pump (ATP1AL1) in the colorectum was investigated. The real-time PCR gave significant levels of signals not only in the distal part of human colon and rectum, but also in the proximal part of the colon. ATP1AL1 mRNA was overexpressed in 12 out of 20 human colorectal adenocarcinomas compared with the level in the accompanying normal mucosa. It is noted that astonishing levels of the mRNA overexpression were found in 4 carcinomas, which were detected even by Northern blot. The very high levels of ATP1AL1 mRNA expression in some cancer tissues may be connected to an unknown specific pathophysiological condition.