An observational study of oral functions in patients aged from 20 to 49 years.

PURPOSE: The purpose of this study was to analyze oral functions (MOF: maximum occlusal force; MTP: maximum tongue pressure; and MF: masticatory function) in Eichner A subjects aged from 20 to 49 years. METHODS: The data of three oral functions in Eichner A patients aged from 20 to 49 years were extracted. The mean values, subjects with lower values than the thresholds, and the differences among ages, and between sexes were investigated retrospectively. RESULTS: Although the mean values of these oral functions in 183 subjects were higher than the thresholds, the numbers of the subjects with lower values than the thresholds were 30 in MTP, 19 in MOF, and only three in MF. No significant effects of ages on all oral functions were identified and all functions in males were significantly higher than those in females. The subjects whose two functions were lower than the thresholds were nine females, eight of whom were associated with malalignment. CONCLUSION: Although the mean values of oral functions were higher than the thresholds, some patients showed lower values, especially in MOF and MTP, even though they were unaware of any inconvenience. Patients with malalignment might be associated with declined oral functions.

[A Case of Early Ascending Colon Cancer Complicated the Mesenteric Phlebosclerosis Who Underwent Laparoscopic Subtotal Colectomy].

A 71-year-old woman who have been taking Sanshishi for 50 years until the age of 70 for dermatitis underwent colonoscopy( CS)to reveal the reason of abdominal pain. CS showed ascending colon tumor(AT)with major axis 3 cm and suspicious of the mesenteric phlebosclerosis. Although endoscopic submucosal dissection(ESD)was performed for AT, colon perforation due to colonic wall fibrosis was occurred and ESD was suspended. Therefore, surgical resection was planned. Intraoperative observations by laparoscopy showed that the color of colon serosa from the cecum to the splenic flexure was grayish white and colonic wall thickening with lead tubular change was observed. From the descending colon to the sigmoid colon, wall thickening was mild, and Haustra was confirmed. Although the tumor location was in the ascending colon, laparoscopic subtotal colectomy and functional end-to-end anastomosis of ileum and sigmoid colon was performed for safe intestinal anastomosis. For treat of colon cancer complicated mesenteric phlebosclerosis(MP), endoscopic resection is considered difficult due to fibrosis and extended resection of the colon may be required to reduce the risk of anastomotic leakage. Herein, we report our case and details of past reported literatures.

Feasibility and Efficacy of Neoadjuvant Chemotherapy without Radiotherapy for Locally Advanced Rectal Cancer.

OBJECTIVES: This retrospective study explored the feasibility of neoadjuvant chemotherapy (NAC) without radiotherapy in patients with locally advanced rectal cancer (LARC). METHODS: Patients with clinical stage of T3-T4 and/or N-positive LARC patients were included. We retrospectively analyzed patients' NAC-related and perioperative outcomes. RESULTS: The study enrolled 30 patients. mFOLFOX6 or SOX plus cetuximab was administered to 12 patients with the wild-type RAS gene and FOLFOXIRI or SOXIRI to 18 patients with mutant-type RAS. The NAC completion rate was 90.0%. All patients underwent total mesorectal excision, and 29 patients underwent combined bilateral lateral lymph node dissection. The R0 operation rate was 90.0%. Although the postoperative complication rate was 40%, no complications were associated with NAC. The response rate of NAC and the proportion of histological anti-tumor effect grade ≥ 2 were 56.7% and 46.7%, respectively. CONCLUSIONS: NAC was considered to be a safe, feasible treatment option for LARC.

[Laparoscopic Total Pelvic Exenteration of Locally Advanced Rectal Cancer Invading Urogenital Organs].

Application of laparoscopic surgery(Lap)for colorectal cancer has expanded, and laparoscopic total pelvic exenteration (TPE)of locally advanced rectal cancer(LARC)invading the urogenital organs has been introduced in some institutions. In our institute, we have performed Lap TPE and posterior-TPE(PPE)in a total of 6 LARC patients so far. Here, we report the surgical technique of Lap TPE, and the associated surgical and short-term outcomes. We performed Lap TPE and Lap PPE in 3 patients each. Operation time was approximately 562 min, and the blood loss was 310 mL on an average. No patient developed postoperative complications above Clavien-Dindo Grade Ⅲ. One patient exhibited recurrence in the liver and another in peritoneum in the Lap PPE group. No recurrence was observed in the Lap TPE group(median follow-up period: 24.5 months). Although Lap TPE and PPE are difficult to perform and time consuming, it is suggested that these procedures may help reduce the intraoperative bleeding volume and shorten the length of postoperative hospital stay compared to open TPE and PPE.

Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version.

Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).

Japanese Practice Guidelines for Fecal Incontinence Part 2-Examination and Conservative Treatment for Fecal Incontinence- English Version.

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version.

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Short-term outcomes of laparoscopic lateral pelvic node dissection for advanced lower rectal cancer.

BACKGROUND: The laparoscopic magnified visual effects and evolution of the laparoscopic camera system have recently enabled us to observe details in the deep pelvic floor. Indications of laparoscopic surgery for colorectal cancer have been expanded, and laparoscopic (Lap) lateral pelvic node dissection (LLND) has been introduced in some institutions. We investigated the feasibility of Lap LLND in patients with locally advanced rectal cancer (LARC). METHODS: Lap LLND was performed in 38 patients diagnosed with cT3-4 or cN1-2 cancer during 2014-2018. We retrospectively analyzed their surgical and short-term outcomes. RESULTS: Laparoscopic surgery was performed in all patients. cStages II/III/IV were found in 6/31/1 patients, respectively. Among them, 25 patients underwent neoadjuvant chemotherapy without radiotherapy. Lap unilateral LLND was performed in 6 patients and Lap bilateral LLND was performed 32 patients. The number of harvested lymph nodes (LNs) were 4 in the unilateral group and 15 in the bilateral group. Operation time was 531 min, and blood loss was 105 ml. Oral intake has started on postoperative day (POD) 3, and pelvic drain was removed on POD 7. Hospital stay was 18.5 days. Seven patients developed a neurogenic bladder (all Clavien-Dindo grade (CD) II and all occured in the bilateral LLND group), one patient developed abdominal bleeding (CD IIIb) and one patient developed anastomotic leakage (CD IIIb). Pathological results revealed 2/5/16/14/1 patients with pStages 0/I/II/III/IV, respectively. Four patients had histopathologically verified lateral pelvic lymph node metastases. There were no local recurrences after curative surgery (median follow-up 24.2 months). CONCLUSION: Although the median follow-up period is relatively short and further follow-up is necessary, oncologically, especially in the point of local control rate, Lap LLND appears to have acceptable in the treatment of LARC without radiotherapy in experienced centers. Further investigations focusing on indications and the Lap LLND procedural technique are required.

[A Case of Intraperitoneal Bleeding Due to Vitamin K Deficiency after Laparoscopic Total Pelvic Exenteration for Advanced Rectal Cancer].

A 70-year-old man underwent a colonoscopy and enhanced CT for scrutiny of his anemia. These examinations revealed rectal cancer(cT4b[rectal mesenteric infiltration], N3M0, cStage Ⅲc). We introduced neoadjuvant chemotherapy(NAC) (cetuximab plus oxaliplatin plus S-1, 4 courses)for this patient and diagnosed ycStage Ⅲc(ycT4bN3M0)after the therapy. We performed laparoscopic total pelvic exenteration with bilateral pelvic lymph node dissection. Cefmetazole was administered as a preventive antibiotic in the perioperative period(intraoperatively to postoperative day 3). On postoperative day 4, intra-abdominal heavy bleeding occurred. Blood examination revealed remarkable coagulation disorder with parameters such as APTT 58.9 sec, PT-INR 3.33, and a remarkably high PIVKA- / Ⅱ score of 11,754 mAU/mL. Based on these findings, the patient was diagnosed with complicated vitamin K(VK)deficiency. The coagulation disorders improved following the administration of VK. VK is a fat-soluble vitamin, and the main absorption pathways are dietary, intestinal bacterial production, and recycling in the VK metabolic cycle. In our case, it was considered that the causes of VK deficiency were a marked decrease in VK intake, impairment of the VK metabolic cycle due to taking antibiotics with a N-methyl-thiotetrazole group, and deficiency of VK accompanying suppression of the intestinal flora by antibiotics. We should also consider VK deficiency when patients are diagnosed with postoperative bleeding.

[Intussusception Due to Inflammatory Polyp in the Ileum after ESD for Rectal LST].

A 69-year-woman was admitted to the clinic in August 2018 because of general fatigue and low appetite.She had occult blood-positive and was referred to our hospital for further investigations.There was LST in the rectum for which colonoscopy and ESD were performed.She had abdominal pain and slight fever on postoperative day 1.Abdominal CT showed an intussusception in the ileum.We could not achieve endoscopic de-torsion and carried out laparotomy.The intussusception was found to be strangulated due to inflammatory polyp and mesenteric adhesion.The affected portion was resected.Although treatment for low hypoalbuminemia and neurogenic cystitis was required, she was discharged on postoperative day 28.

[Repeat Hepatectomy for Primary Hepatic Neuroendocrine Carcinoma in the Remnant Liver Nine Years after the First Resection].

The patient was a 55-year-old man who had undergone extended right lobectomy of the liver with a diagnosis of primary hepatic carcinoid tumor. Nine years after the operation, enhanced abdominalCT revealed a tumor measuring 2.2 cm in the remnant liver. He was diagnosed with recurrence of primary hepatic neuroendocrine carcinoma and underwent partial hepatectomy. Pathologically, the tumor cells had round nuclei and formed trabecular patterns. Immunohistologically, the cells were positive for CD56, synaptophysin, and chromogranin A. The Ki-67 index was 6%, which was equivalent to Grade 2 in the WHO classification revised in 2010. Since there were no other lesions suspected to be the primary site other than in the liver, it was diagnosed as recurrence of the primary hepatic neuroendocrine carcinoma. Two years after the operation, he was diagnosed with recurrence of primary hepatic neuroendocrine carcinoma and underwent partialhepatectomy again.

Peritoneal dissemination of ascending colon cancer demonstrating relapse-free survival for 40 months with panitumumab monotherapy: A case report.

INTRODUCTION: The prognosis of metastatic colorectal cancer (mCRC) patients receiving multiple cytotoxic agents and targeted therapies (CATT) has improved, but a complete cure by CATT is still very rare. PRESENTATION OF CASE: We report the successful treatment of ascending colon cancer complicated by peritoneal disseminations (PDs) with panitumumab (Pmab) plus mFOLFOX6 therapy. A 67-year-old male patient was diagnosed with clinical stage IV cancer of the ascending colon with PDs, and underwent ileostomy. Eighteen courses of Pmab plus mFOLFOX6 caused remarkable tumor shrinkage and the disappearance of PDs on ECT. Laparotomy revealed tumor shrinkage and scarring at the PD sites. We performed right hemicolectomy, subtotal omentectomy, and ileostomy closure as curability B surgery. Seven months later, new PDs were detected by ECT so we resumed Pmab plus mFOLFOX6 therapy. After nine courses of treatment, the target lesion had completely disappeared. After a total of 20 courses, we changed to Pmab monotherapy as maintenance therapy because there was no recurrence. Forty months after the initiation of Pmab monotherapy, there has been no oncologic progression. DISCUSSION: Pmab plus mFOLFOX6 treatment resulted in a complete response for PDs, which is extremely rare for CATT. CONCLUSION: We consider that Pmab therapy should be introduced for the treatment of mCRC complicated by PDs.

[A Case of Abdominal Compartment Syndrome after Laparotomy for Peritonitis Caused by Colon Perforation Due to Gallbladder Carcinoma].

A70 -year-old man with a diagnosis of panperitonitis caused by colon perforation due to invasion of gallbladder cancer was transferred to our hospital. The next day, an emergency operation was performed. During laparotomy, the ascending colon was perforated; therefore, ileocecal resection was performed. Six hours after the operation, the stoma became ischemic with marked abdominal distention. The intra-abdominal pressure increased to 28 mmHg, and the patient was diagnosed as having abdominal compartment syndrome(ACS). He immediately underwent decompressive laparotomy at bedside. Multiple organ failure was avoided and he recovered, but he died of advanced gallbladder cancer 4 months after the surgery. This case suggests that immediate surgical decompressive laparotomy for ACS can prevent multiple organ failure.

[A Case Report of Bypass Surgery for a Perforated and Unresectable Gastric Cancer].

A 74-year-old man was admitted to a clinic because of epigastralgia in June 2018. He was referred to our hospital for further examination of right hydronephrosis. He was diagnosed as having type 2 gastric cancer in the middle gastric body and lesser curvature, with an upper gastric fiber, swollen para-aortic lymph node, and right hydronephrosis by using abdominal computed tomography. PET-CT revealed no hot spot in the para-aortic lymph node but revealed a hot spot in the lower small bowel. He was admitted to our hospital because of severe abdominal pain and appetite loss and underwent a reduction and palliative surgery for the unresectable gastric cancer. The omental cavity was perforated and penetrated into the retroperitoneum. He underwent esophageal jejunal bypass and intestinal fistula tube insertion in the stomach. He had a central vein port and was discharged from our hospital. He was able to eat during his short overnight stay at our hospital after the operation but died on postoperative day 30.

[Complete Obstruction of the Ascending Jejunal Limb due to Adhesion of the Y Loop after Total Gastrectomy].

A 43-year-woman who had undergone total gastrectomy for gastric cancer was admitted to our hospital because of lower abdominal pain 2 months after the operation. Abdominal computed tomography revealed an ascending jejunum dilation. Gastrointestinal endoscopy showed a complete obstruction in the ascending jejunum. A laparoscopic operation on the 14th hospital day revealed that the complete obstruction of the ascending jejunal limb was due to adhesion of the Y loop after total gastrectomy. She underwent division of the adhesion and was discharged on the 17th postoperative day.

Induction of PIR-A/B+ DCs in the in vitro inflammatory condition and their immunoregulatory function.

BACKGROUND: Dendritic cells (DCs), primary antigen-presenting cells, are now well known as an immunoregulator of many aspects of immune responses including inflammatory bowel diseases (IBDs) such as Crohn's disease and ulcerative colitis. We have reported that PIR-A/Bhigh cDCs (conventional DCs) appeared in dextran sodium sulfate (DSS)-induced colitis and serve as a negative immunoregulator in an animal model of IBD. The immunoregulatory role of PIR-A/B+ cDCs was confirmed in both an in vitro culture system and an in vivo transfer experiment. Here, we have investigated the differentiation process of PIR-A/B+ cDCs in an in vitro inflammatory environment and examined their functions. METHODS: cDCs were isolated from the large intestinal lamina propria from C57BL/6 mice and cultured in an inflammatory environment (IL-1, IL-6, TNFα, and LPS). The appearance of PIR-A/B+ cDCs was determined after 24 h, and the in vitro-induced PIR-A/B+ cDCs were functionally and genetically examined. RESULTS: PIR-A/B+ cDCs were detected after a 24-h culture only in the inflammatory environment, and the cells acted as a negative immunoregulator when examined in an allogenic mixed leukocyte reaction (MLR). The message level of IL-27 was highly upregulated in PIR-A/B+ cDCs, while that of high mobility group box 1 protein (HMGB1) was downregulated in these cells. This was well in accordance with the fact that PIR-A/B+ cDCs showed a suppressive function against activated T cells. We found that PIR-A/B+ cDCs produced IL-27, as verified by an ELISA assay, and that the inhibitory effect by PIR-A/B+ cDCs was, at least partially, due to IL-27. Furthermore, CD85d+ cells, a human counterpart of mouse PIR-A/B+ cDCs, were found in the lamina propria of the colon of the patients with ulcerative colitis, but not in the similar part of the non-inflammatory area of colon specimens from patients with colon cancer. CONCLUSIONS: PIR-A/B+ cDCs induced in an in vitro inflammatory environment model showed a suppressive function against activated T cells by producing an inhibitory cytokine.

[A Case of Port Site Recurrence of Gallbladder Carcinoma after Laparoscopic Cholecystectomy].

The patient was a 76-year-old man who underwent laparoscopic cholecystectomy with a diagnosis of cholecystolithiasis. Since the definite diagnosis of gallbladder carcinoma was made after the operation, he underwent additional resection. Four years later, he revisited the hospital complaining of painful swelling of the port site of his epigastrium. Magnetic resonance imaging of the abdomen revealed a mass 3.4 cm in diameter at the epigastrium. Thus, port site recurrence of gallbladder carcinoma was the suspected diagnosis. We resected the peritoneum, rectus abdominis muscle, and skin, as well as the tumor, and the abdominal wall was reconstructed using synthetic composite mesh. Histological examinations revealed recurrence of gallbladder carcinoma. Port site recurrence of gallbladder carcinoma is known to have a poor prognosis, but long survival can be expected in patients after complete resection of the metastatic lesion, if the recurrence develops more than a year after the initial operation.

[Internal Hernia after Distal Gastrectomy for Gastric Cancer Triggered by Retroperitoneal Recurrence].

A 77-year-male who had undergone distal gastrectomy with Roux-en-Y reconstruction received the tegafur/gimeracil/ oteracil adjuvant chemotherapy for about 1 year. 32 months after surgery, liver hilus lymph nodes and peritoneal recurrence were found. For obstructive jaundice, the metallic stent was implanted under double balloon-ERCP(DB-ERCP). He was treated 13 courses with SOX, preceded PTCD and re-implanted metallic stent for re-obstructive jaundice 52 months after the initial surgery. Although the jaundice was improved, he came to vomit after meal. Abdominal computed tomography revealed internal hernia. He had undergone the operation on the 8th hospital day. The hernial orifice was found in the mesentery defect due to peritoneal recurrence. He was able to eat after that operation but he was passed away POD-85 by the primary disease.

[A Case of Pancreatic Neuroendocrine Tumor with Necrolytic Migratory Erythema].

A 45-year-old man was admitted because of necrolytic migratory erythema. A computed tomographic scan of the abdomen revealed a 4.5cm mass in the tail of the pancreas. We performed distal pancreatectomy and splenectomy, and a definitive diagnosis of pancreatic neuroendocrine tumor(WHO class grade 2)was made histopathologically.