Transmesenteric internal hernia: an unexpected adverse event induced by colonoscopy.

Transmesenteric internal hernia is an uncommon cause of small bowel obstruction that occurs when small bowel loops protrude through a mesenteric defect into the abdominal cavity. Herein, we present an unexpected case of colonoscopy-induced transmesenteric internal hernia. An 81-year-old male patient presenting with intermittent hematochezia and constipation had undergone a laparoscopic left nephrectomy for ureteral cancer. A colonoscopy was performed to identify the etiology of his symptoms. He complained of severe abdominal pain 2 h after the examination despite uneventful endoscopic procedures, including cold snare polypectomy. Contrast-enhanced computed tomography revealed a strangulated small bowel obstruction with a closed-loop formation outside the descending colon. The small bowel loop was incarcerated into the left retroperitoneal space. Emergency laparotomy detected small bowel loops that prolapsed into the nephrectomy pedicle via a descending mesenteric defect, developed during the laparoscopic left nephrectomy. The incarcerated small bowel was detached from the hernia and returned to its normal position, and the mesenteric defect was closed. He demonstrated an uneventful postoperative course, with no internal hernia recurrence after discharge. This case indicates the risk of transmesenteric internal hernia through inadvertently created mesenteric defects should be borne in mind, especially when performing colonoscopies in patients who underwent laparoscopic nephrectomies.

Association of tissue oxygen saturation levels with skeletal muscle injury in the critically ill.

This study aimed to investigate the association between the level of tissue oxygen saturation (StO2) and quadriceps/skeletal muscle dysfunction, measured using the Medical Research Council (MRC) scale and ultrasonography, in critically ill patients. Thirty-four patients hospitalized at the Critical Care Medicine Center of Kindai University Hospital, between January 2022 and March 2023, were enrolled in this study. The StO2 of the quadriceps muscle was measured via near-infrared spectroscopy. Muscle atrophy was measured by the thickness, cross-sectional area (CSA), and echo intensity of the rectus femoris (RF). These values were evaluated every alternate day until 13 days after admission or until discharge, whichever occurred first. Muscle weakness was assessed using the sum score of the MRC scale (MRC-SS), with the patient sitting at bedside. The mean age of the patients was 67.3 ± 15.3 years, and 20 (59%) were men. Seven patients (21%) were admitted for trauma, and 27 (79%) were admitted for medical emergencies or others. The mean score for the MRC-SS was 51.0 ± 7.9 points. RF thickness and CSA significantly decreased after day 7 (p < 0.05). There were no significant changes in StO2 levels during hospitalization. However, there were positive correlations between the nadir StO2 during hospitalization and MRC-SS, and changes in RF thickness and CSA at discharge (r = 0.41, p = 0.03; r = 0.37, p = 0.03; and r = 0.35, p = 0.05, respectively). StO2 in the quadriceps muscle may be useful for predicting muscle atrophy and dysfunction in patients with critical illnesses.

Liver Abscess due to Streptococcus intermedius Bacteremia and Its Association with Colonic Carcinoma: Is Bacteremia with Streptococcus intermedius an Alert for Colonic Carcinoma?

Liver abscess caused by some kinds of Streptococcus group such as Streptococcus bovis group has been recognized to associate with colorectal cancer. Streptococcus milleri group with liver abscess has not been received much attention in this point of view. Here, we report the case of a 63-year-old man who developed liver abscess with S. intermedius, which belongs to the S. milleri group. We confirmed that this case was accompanied by cecal carcinoma by colonoscopy. The tumor was a pathological lead point of intussusception of cecum. On the 26th day, open right hemicolectomy was performed. In this case, bacterial endophthalmitis was a complication due to bacteremia. The patient underwent ophthalmic surgery on the 98th day. Research investigating 16S rRNA of the mucosal colon microbiome reported that the S. intermedius gene was upregulated in patients with colorectal carcinoma. It is recommended that liver abscess with S. intermedius bacteremia should alert the clinician about the risks of carcinoma of the colon and abscess formation in distant organs. We here list the case reports of liver abscess caused by Streptococcus other than S. bovis group, which was associated with colonic carcinoma, and suggest the need for further research about S. milleri group.

Medical students' perceptions of emergency medical care before and during the coronavirus disease 2019 pandemic.

Aim: Understanding how medical students perceive emergency medical care is important in promoting education and recruitment in the field of emergency medicine. This study aimed to clarify the perceptions of undergraduate medical students on emergency medical care with a focus on comparing their perceptions before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Fourth-year undergraduate medical students were invited to complete a self-administered questionnaire in 2017 and 2020. Free comments on emergency medical care were analyzed via text mining. The relationships among categorical words were evaluated via correlation matrix and correspondence analysis. Results: The number of written words per student were not significantly different between 2017 (4.9 ± 3.4) and 2020 (5.3 ± 4.1). In 2017, the most frequently used word was "busy," and the words "patients," "life," and "care" were not related to each other significantly. In 2020, the frequency of the word "busy" decreased and the word "patients" was related to "life" (P < 0.01) and "care" (P < 0.01). In the correspondence analysis, seven words including "life" and "care" were associated with "patients," which demonstrates that these words tended to occur together. Conclusions: Although the responses of the medical students regarding emergency medical care before and during the COVID-19 pandemic included similar words, their expressions tended to be related to patient care or patient life during the pandemic. This change in perception might cultivate a sense of mission and responsibility and an interest in emergency medical care among medical students.

Outcomes after out-of-hospital cardiac arrests by anaphylaxis: A nationwide population-based observational study.

AIM: The objective of this study was to focus on outcomes of anaphylaxis-associated out-of hospital cardiac arrest (OHCA) in non-cardiac cases. METHODS: All residents with OHCA due to non-cardiac cause in Japan from 2013 to 2015 were included for analysis. Propensity score matching and logistic regression analyses were used to assess outcome-related factors in anaphylaxis cases and non-anaphylaxis cases. The comparison group was comprised of non-anaphylaxis cases, which consisted of other cases of non-cardiac etiology. RESULTS: A total of 375,874 OHCA cases were included, of which 148,598 were due to non-cardiac cause. In these non-cardiac OHCA cases, 147 were due to anaphylaxis, with an annual incidence of 0.04 per 100,000. In the patients' characteristics, witnessed ratio, shockable rhythm, defibrillation by emergency medical services (EMS), and treatment with adrenaline by EMS were significantly greater in the anaphylaxis cases compared with the non-anaphylaxis cases. In anaphylaxis cases, the crude 1-month survival rate (32.7% versus 5.3%) and crude favorable neurological outcomes rate (24.5% versus 2.2%) were higher compared with non-anaphylaxis cases (P < 0.001). The differences in outcomes between the two types of cases were also marked after we adjusted these variables by propensity score matching. By logistic regression analyses, administration of a drug by EMS was negatively associated with good neurological outcomes (odds ratio, 0.27; 95% confidence interval, 0.09-0.87), but bystander cardiopulmonary resuscitation was positively associated with good neurological outcomes (odds ratio, 2.33; 95% confidence interval, 0.99-5.52). CONCLUSION: Neurological outcome was markedly more favorable in cases with anaphylaxis than non-anaphylaxis cases. Further studies are needed to explain this result.

Heuristic bias in perception of medical students relating to out-of-hospital cardiac arrests.

AIM: The aim of this study was to assess the perceptions of medical students with respect to out-of-hospital cardiac arrests focusing on the frequency and survival and to identify potential problems in resuscitation education. METHODS: Fourth-year medical students in a six-year undergraduate educational system were asked to guess the number of out-of-hospital cardiac arrests with cardiac etiology per year in Japan, related data such as the one-month survival rate from out-of-hospital cardiac arrests with cardiac etiology and the number of deaths from traffic accidents for comparison. The guesses of students were compared with actual statistical data. RESULTS: The incidence of out-of-hospital cardiac arrests was clearly underestimated by the students compared to the real statistics. The median guessed number of out-of-hospital cardiac arrests ranged from 6000 to 20,000 while the real statistics ranged from 73.023 to 78.302 by year (P â€‹< â€‹0.001 for all years). In contrast, the guessed number of deaths from traffic accidents was markedly overestimated: the median guessed number ranged from 8000 to 20,000 and the real statistics were 3694 to 4438 (P â€‹< â€‹0.001 for all years). The one-month survival rate was also underestimated: the guessed number was 50% and the real rate was 11.5 to 13.5% (P â€‹< â€‹0.001 for all years). CONCLUSIONS: Out-of-hospital cardiac arrests are underestimated in frequency, and survival after an arrest is overestimated by medical students. To recognize and to understand the heuristic bias in perception of learners is needed for resuscitation education in addition to promote resuscitation skills of learners.

Clinical predictors of bevacizumab-associated intestinal perforation in non-small cell lung cancer.

Background Bevacizumab (Bev) is generally well-tolerated, and Bev-associated intestinal perforation (BAP) is a rare albeit serious side effect in cases of non-small cell lung cancer (NSCLC). Therefore, the present study aimed to identify clinical predictors of BAP to help predict and manage the development of life-threatening intestinal complications among patients receiving Bev. Methods This retrospective study evaluated demographic, clinical, and treatment factors for patients with NSCLC who were treated with Bev between February 2010 and August 2015 at our center. Results We identified 314 regimens (208 patients; median age: 65 years; 115 women) for analysis, which included 119 first-line regimens, 74 s-line regimens, and 121 third-line or later regimens. BAP occurred in 7 cases (2.23% among all regimens and 3.37% among all patients), which generally occurred during first- or second-line treatment and was caused by ulcerative colitis (1 case), colon diverticulitis (1 case), and idiopathic perforations (5 cases). Univariate analyses revealed that BAP was significantly associated with deteriorating PS during the first cycle of chemotherapy (odd ratio [OR]: 11.07, 95% confidence interval [CI]: 2.37-51.63, p = 0.0022), grade ≥ 3 diarrhea (OR: 11.37, 95% CI: 2.37-54.50, p = 0.0024), febrile neutropenia (OR: 9.16, 95% CI: 1.98-42.49, p = 0.0047), and stomatitis (OR: 4.60, 95% CI: 1.01-21.04, p = 0.0492). Conclusions Among patients with NSCLC, BAP was associated with deteriorating PS during the first cycle of chemotherapy, grade ≥ 3 diarrhea, febrile neutropenia, and stomatitis. Therefore, careful observation is needed for patients with NSCLC who receive Bev in any line of treatment, especially if they develop serious side effects that affect their PS or mucous membrane.

Comparison of the clinical courses and chemotherapy outcomes in metastatic colorectal cancer patients with and without active Mycobacterium tuberculosis or Mycobacterium kansasii infection: a retrospective study.

BACKGROUND: Although active Mycobacterium tuberculosis (MTB) or Mycobacterium Kansasii (MK) infection could be present in patients with metastatic colorectal cancer (m-CRC), no study is available on the clinical courses and chemotherapy outcomes of these patients. The present study therefore aimed to retrospectively examine whether m-CRC patients with and without active MTB or MK infection could receive cancer chemotherapy similarly. METHODS: This study enrolled 30 m-CRC patients who received first-line chemotherapy between January 31, 2006 and January 31, 2013 at our institution, The clinical courses and tumor response of those with and without active MTB or MK infection were examined and compared. RESULTS: Of 30 m-CRC patients, 6 had active MTB infection, 1 with active MK and the other 23 had neither MTB nor MK. No significant demographic differences were observed between patients with MTB or MK and those without. Chemotherapy response rates of all patients, those with MTB or MK, and those without were 40.0%, 28.6% and 43.5%, respectively. Among patients with MTB or MK, 1 treated with bevacizumab experienced grade-3 hemoptysis while others did not report any severe toxicity. Median survival time of all studied patients, those with MTB or MK, and those without was 26.3, 36.7 and 22.6 months, respectively. No significant difference in overall survival was observed between patients with MTB or MK and those without. Multivariate analysis revealed that performance status and liver metastasis were significant prognostic factors of overall survival (P = 0.004 and 0.030, respectively), whereas other factors, including MTB or MK infection, were not. In our study, all 7 patients with MTB or MK did not experience infection relapse during or after cancer chemotherapy. CONCLUSIONS: Our results indicate that m-CRC patients with MTB or MK should be able to safely and effectively continue cancer chemotherapy to subsequently achieve comparable survival duration to those without the infection if they receive proper MTB or MK treatment.

Prognostic factors in gastrointestinal perforation.

BACKGROUND/AIMS: Postoperative complications associated with gastrointestinal (GI) perforation may lead to a poor prognosis. The goal of the study was to identify factors required for the establishment of appropriate perioperative procedures in such cases. METHODOLOGY: The subjects were 51 patients with GI perforation treated from July 2007 to June 2008 in six hospitals in the Minamikawachi district. RESULTS: The perforation sites were the large intestine in 22 cases, small intestine in 15, stomach in 7 and duodenum in 7. Postoperative complications developed in 25 cases (49%), including infection in 20 and respiratory dysfunction in 13. Hospital mortality was 25% and the major causes of death were infection and respiratory dysfunction. The mortality was 52% and 0% in patients with and without postoperative complications, respectively. The mortality was 69% in the 13 patients with postoperative respiratory dysfunction compared to 11% for patients without respiratory dysfunction. Of the 7 patients with large intestine perforation, 4 were treated with sivelestat sodium. These 4 patients had a high mean SOFA score (11.5±1.3), but 2 out of 4 survived. CONCLUSIONS: Postoperative complications occurred in approximately half of the patients with GI perforation and were associated with a poor prognosis. Prevention of respiratory dysfunction is particularly important for an improvement of outcome.

Complete response to preoperative chemoradiotherapy in highly advanced gastric adenocarcinoma.

This report presents a case of highly advanced gastric cancer that achieved a histologically complete response (CR) to preoperative chemoradiotherapy with S-1 plus low-dose Cisplatin. A 60-year-old male patient underwent FDG positron emission tomography (PET) during a routine health examination. The patient was found to have swollen paraaortic lymph nodes. Shortly thereafter, he was diagnosed with gastric carcinoma with a type 2 tumor in the antrum with paraaortic lymph node metastases based on FDG-PET, endoscopic examination and abdominal computed tomography. After the completion of chemoradiation therapy (CRT), the tumor and the paraaortic lymph node metastases disappeared. The patient underwent surgery 5 wk after the completion of CRT, including a subtotal gastrectomy with Roux-en-Y reconstruction, D3 lymph node dissection and a left adrenalectomy. No cancer cells were detected in the resected specimen either in the primary lesion or lymph nodes, thus confirming a pathologically CR to CRT (CR grade 3). The patient has been stable and well without any evidence of recurrence for 48 mo after surgery. Such a preoperative CRT regimen might therefore be very effective for treatment of some advanced gastric cancers.

Small bowel obstruction due to an intramesosigmoid hernia diagnosed by multidetector row computed tomography: a case report.

Small bowel obstruction caused by an internal hernia involving the sigmoid mesocolon is rare, and this condition is difficult to diagnose clinically. We herein report a case of small bowel obstruction due to an intramesosigmoid hernia that was diagnosed by a 64-row multidetector computed tomography and surgically treated.

Duodenogastric reflux after choledochoduodenostomy: evaluation by technetium-99m scintigraphy.

BACKGROUND/AIMS: Persistence of dyspeptic symptoms after choledochoduodenostomy (CDD) is common. There is evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR after CDD. METHODOLOGY: A total of 6 patients who had undergone cholecystectomy with a standard side-to-end CDD for choledocholithiasis or Lemmel syndrome were studied by symptom evaluation, biliary scintigraphy and endoscopy at least 6 months after surgery. Duodenogastric reflux was quantified using continuous intravenous infusion of 99mTc-HIDA. RESULTS: The incidence of DGR after CDD was 67% compared to healthy control. In the majority of the patients the DGR was mild to moderate, but not with the clinical symptoms. CONCLUSIONS: 99mTc-HIDA scanning of the hepatobiliary system is a reasonable and reliable method for the quantitative evaluation of DGR. CDD is associated with a high incidence of DGR, but its occurrence does not produce significant clinical symptoms.

[Current status and evaluation of thoracoscopic esophagectomy for thoracic esophageal cancer].

The current status and evaluation of esophagectomy by thoracoscopic approach for thoracic esophageal cancer are described. The esophagectomy by thoracoscopic approach for thoracic esophageal cancer have been reported in some Instituts since 1996 in Japan. In 10 years, series consisting a large number of esophageal cancer patients have been treated with esophagectomy by thoracoscopic approach and evaluated about operative safety, curabirity and postoperative morbidity. Now, the establishment of training system is the most important subject to achieve the standardization of thoracoscopic esophagectomy for thoracic esophageal caner.

[Treatment of oncogenic emergencies in esophageal disease].

Common oncogenic emergent conditions of the esophagus are esophageal fistula with malignancy and peptic ulcer, perforation by a foreign body, and rupture (Boerhaave's syndrome) and bleeding with malignancy. The current standard of palliative therapy for patients with malignant tracheoesophageal fistula is endoscopic replacement using covered self-expandable metallic stents in the esophagus and/or trachea. We successfully treated two patients with esophageal bleeding caused by malignant ulceration. To prevent the formation of an aortoesophageal fistula, a covered self-expandable metallic stent was inserted into the esophagus and aorta. Insertion of covered self-expandable metallic stents in patients with esophageal malignancies significantly improves dysphagia, seals fistulas/perforations and ulcerations, and is associated with acceptable morbidity and mortality rates. Spontaneous esophageal rupture, also known as Boerhaave's syndrome, is a rare condition. Primary repair is appropriate for ruptures diagnosed early. Many are diagnosed late and T-tube drainage may be the simplest way to manage this difficult condition in this situation.

Concurrent chemoradiotherapy with protracted infusion of 5-FU and cisplatin for postoperative recurrent or residual esophageal cancer.

BACKGROUND: We carried out the present study to investigate the feasibility and effectiveness of concurrent chemoradiotherapy (CT-RT) for postoperative recurrent esophageal cancer, which are, at present, unclear. METHODS: Between 1998 and 2002, 16 patients with postoperative loco-regional recurrence of esophageal cancer, and two patients with incompletely resected esophageal cancer were treated with concurrent CT-RT. Patients received protracted infusion of 5-FU 250-300 mg/m(2) on days 1 to 14, 1 hour infusion of cisplatin 10 mg/body on days 1 to 5 and 8 to 12, and a concurrent radiotherapy (RT) dose of 30 Gy in 15 fractions over 3 weeks. This treatment schedule was repeated twice with a gap of 1 week, for a total RT dose of 60 Gy administered over 7 weeks. RESULTS: Of the 18 patients, 13 (72%) completed the CT-RT protocol. A total RT dose of 60 Gy was administered for all except two patients, and doses of chemotherapy were reduced for five patients. Although grade 3 hematological toxicities were frequently noted, non-hematological toxicities of grades 3 and 4 were few. Of the 18 tumors, five (28%) showed complete response (CR). For patients without prior chemotherapy, the CR rate was 40% (4/10). The 2-year survival rate of 13 patients without distant metastases was 19%, with a median survival time of 9.5 months. CONCLUSION: The concurrent CT-RT protocol appears feasible and effective for patients with postoperative recurrent or residual esophageal cancer.

[Minimally invasive esophagectomy with 10 cm thoracotomy assisted thoracoscopy for the thoracic esophageal cancer].

We have been successfully performing minimally invasive esophagectomy through a 10-cm thoracotomy and two trocar ports. Esophagectomy can be performed safely and efficiently via the thoracoscopy. We have also adapted hand assisted laparoscopic surgery (HALS) for the abdominal procedure through a 7-cm laparotomy and three trocar ports. One of the important points of esophagectomy for thoracic esophageal cancer is performing lymphadenectomy near either side recurrent laryngeal nerve. Another important point is to preserve the bronchial branch of the vagus nerve and both bronchial arteries if they are without cancerous invasion. We also preserve the azygos vein and the thoracic duct to minimize surgical invasion. Standard thoracotomy and laparotomy are significantly invasive procedures with potential complications and prolonged healing; minimally invasive esophagectomy has the potential to minimize morbidity and decrease healing time.

Prospective trial of concurrent chemoradiotherapy with protracted infusion of 5-fluorouracil and cisplatin for T4 esophageal cancer with or without fistula.

PURPOSE: A prospective trial of concurrent chemoradiotherapy (CT-RT) with a protracted infusion of 5-fluorouracil and cisplatin was performed to evaluate the safety and efficacy of this protocol for T4 esophageal cancer (UICC 1997). METHODS AND MATERIALS: Between 1998 and 2000, 28 patients with T4 esophageal squamous cell carcinomas were treated with concurrent CT-RT. Of the 28 patients, 15 had Stage III, 5 Stage IVA, and 8 Stage IV disease. Five of the T4 tumors had evidence of fistula before treatment. Patients received a protracted infusion of 5-fluorouracil 300 mg/m(2)/24 h on Days 1-14, a 1-h infusion of cisplatin 10 mg/body on Days 1-5 and 8-12, and concurrent radiation at a dose of 30 Gy in 15 fractions during 3 weeks. This schedule was repeated twice, with a 1-week split, for a total RT dose of 60 Gy during 7 weeks for 25 patients. For the remaining 3 patients, 30 Gy of preoperative CT-RT was administered. RESULTS: Of the 25 patients who were treated with the full dose of CT-RT, 14 (56%) completed the two courses of the CT-RT protocol, and 8 patients (32%) received the full dose of RT but a reduced dose of chemotherapy. Eight (32%) of the 25 tumors showed complete regression. Although Grade 3 hematologic toxicities were frequently noted, Grade 4 or more hematologic toxicities were few. Of the 5 T4 fistulous tumors, 2 demonstrated the disappearance of the fistula after CT-RT. However, the worsening or development of an esophageal fistula was noted in 5 patients. The 2-year survival rate for patients with Stage III was 27%, and the median survival time for those with Stage III and Stage IVA+IV was 12 and 5 months, respectively. CONCLUSION: Despite its significant toxicity for esophageal fistula, this concurrent CT-RT protocol of protracted 5-fluorouracil infusion and cisplatin appears feasible and effective for T4 esophageal cancer with or without fistulas.

Suppression of T-cell function in gastric cancer patients after total gastrectomy with splenectomy: implications of splenic autotransplantation.

Background. In Japan since the 1960s, patients with gastric cancer have routinely had splenectomy combined with gastrectomy to ensure that lymph node dissection is complete. However, the influence of splenectomy on long-term immunity is unclear.METHODS: Forty-nine gastric cancer patients who underwent total gastrectomy for cure with ( n = 25) and without ( n = 24) splenectomy were assessed for immunologic function, including the proportion of lymphocyte subsets, purified protein derivative from tuberculin (PPD) response, natural killer (NK) activity, and phytohemagglutinin (PHA) response.RESULTS: Peripheral T-cell mediated functions, e.g., PPD and PHA response, were significantly suppressed in patients who underwent gastrectomy with splenectomy compared with those who had gastrectomy alone. Decreased T-cell subsets (CD 3+, 4+, 8+) and increased NK cell subsets (CD 16+, 57+) were observed in patients who underwent splenectomy. Patients who did not undergo splenectomy had immunologic responses within the normal range.CONCLUSIONS: Splenectomy decreased T-cell mediated responses over the long term. As a potential means to co-rrect this T-cell dysfunction in patients with splenectomy, splenic autotransplantation should be considered in future research.