A surgical training system designed to help trainees acquire laparoscopic surgical skills at a rural Japanese institute.

PURPOSE: The Endoscopic Surgical Skill Qualification System was established in Japan to evaluate safe endoscopic surgical techniques and teaching skills. Trainee surgeons obtaining this certification in rural hospitals are disadvantaged by the limited number of surgical opportunities. To address this problem, we established a surgical training system to educate trainee surgeons. METHODS: Eighteen certified expert surgeons affiliated with our department were classified into an experienced training system group (E group, n = 9) and a non-experienced group (NE group, n = 9). Results of the training system were then compared between the groups. RESULTS: The number of years required to become board certified was shorter in the E group (14 years) than that in the NE group (18 years). Likewise, the number of surgical procedures performed before certification was lower in the E group (n = 30) than that in the NE group (n = 50). An expert surgeon was involved in the creation of the certification video of all the E group participants. A questionnaire to board-certified surgeons revealed that guidance by a board-certified surgeon and trainee education (surgical training system) was useful for obtaining certification. CONCLUSIONS: Continuous surgical training, starting with trainee surgeons, appears useful for expediting their acquisition of technical certification in rural areas.

Number of Examined Lymph Nodes as a Risk Factor for Recurrence in pT1N+ or pT2-3N0 Gastric Cancer.

BACKGROUND/AIM: Japanese Gastric Cancer Treatment Guidelines do not recommend adjuvant chemotherapy after radical gastrectomy for pathological stage (p) T1N+ or pT2~3N0 gastric cancer. However, some patients experience disease recurrence. This study aimed to identify the risk factors for recurrence in pT1N+ or pT2-3N0 gastric cancer. PATIENTS AND METHODS: The study included 157 patients with diagnosed pT1N+ or pT2-3N0 gastric cancer who underwent radical gastrectomy at our institution between January 2001 and December 2020. Clinicopathological data and surgical data were obtained. Independent prognostic factors were analyzed using a Cox proportional hazards regression model. RESULTS: Thirteen patients (8.3%) experienced disease recurrence. Multivariate analysis revealed that the number of examined lymph nodes was an independent prognostic factor for recurrence-free survival (hazard ratio=10.90; 95% confidence interval=1.39-85.86; p=0.023). The group with ≤35 examined lymph nodes had significantly worse recurrence-free survival compared with the group with ≥36 examined lymph nodes (80.7% versus 98.7%; p=0.0005). CONCLUSION: The number of examined lymph nodes (≤35) was an independent risk factor for recurrence after radical gastrectomy with pT1N+ or pT2-3N0 gastric cancer.

Clinical Value of Serum p53 Antibody in the Diagnosis and Prognosis of Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: Identifying useful biomarkers is central to selecting optimal therapeutic strategies for esophageal squamous cell carcinoma (ESCC). Serum p53 antibody (S-p53Ab), squamous cell carcinoma antigen (SCC-Ag), and carcinoembryonic antigen (CEA) were investigated to evaluate the significance of single and combined tumor markers in determining the diagnosis and prognosis of ESCC. MATERIALS AND METHODS: Serum samples were obtained preoperatively from 133 patients with histologically-confirmed ESCC, including 32 patients with stage I (24.1%). Levels of S-p53Ab were assessed by enzyme-linked immunosorbent assay, using a new version of a highly specific, quantitative kit. The cut-off value for S-p53Ab was 1.3 U/ml. RESULTS: S-p53Ab was detected in 39.1% (52 out of 133) of patients with ESCC, including 40.0% (20 out of 50) of patients with early-stage ESCC. Positive rates for S-p53Ab, CEA, and SCC-Ag among patients with stage I ESCC (n=32) were 40.6%, 12.5%, and 31.3%, respectively. Positivity for S-p53Ab was not associated with positivity for CEA or SCC-Ag (p=0.249 and 0.747, respectively). The positive rate for diagnosis of ESCC increased from 39.1% to 65.4% when S-p53Ab was combined with SCC-Ag in this study. We found no significant correlation between the presence of S-p53Ab in ESCC and overall survival. Conversely, Cox regression analysis revealed that the International Union Against Cancer/TNM classification and systemic inflammation score were independent prognostic factors for ESCC in this series (hazard ratio(HR)=3.811, 95% confidence interval(CI)=1.548-9.378, p=0.004; and HR=2.218; 95% CI=1.087-4.523, p=0.029, respectively). Kaplan-Meier analysis revealed significant differences between patients with elevated S-p53Ab and SCC-Ag and patients with elevated levels of only one or neither of these factors (p=0.009). CONCLUSION: The diagnostic rate with S-p53Ab was better than that with SCC-Ag and CEA in patients with early-stage ESCC. Combined detection of S-p53Ab and SCC-Ag can markedly improve diagnostic sensitivity and may permit more accurate stratification of patients with ESCC.

Unusually high levels of serum p53 antibody in recurrent gastric cancer.

Serum tumor markers in patients with cancer assist with establishing diagnosis, estimating prognosis, monitoring treatment, and detecting tumor recurrence. Changes in the p53 tumor suppressor gene are the most common genetic abnormalities in many different human malignancies. Several studies have demonstrated that serum p53 antibodies (S-p53Ab) comprise an early marker of malignant disease, a marker for treatment effects and a prognostic factor for patients with several types of tumors. We recently reported that S-p53Ab is useful for patients with gastric cancer. We describe a rare situation in which unusually high serum p53 antibodies helped to detect recurrent gastric cancer in the small intestine after gastrectomy. Further studies are required to gain a more precise understanding of the clinical impact of S-p53Ab titer monitoring in gastric cancer.

Predictive parameters of intraoperative blood loss in patients who underwent pancreatectomy.

BACKGROUND/AIMS: Despite recent advances in surgical techniques, blood loss is an important factor associated with postoperative outcomes in pancreatectomy. It is useful to identify risk factors of increased blood loss. METHODOLOGY: The clinical records of 161 patients who underwent an elective pancreatectomy for peripancreatic diseases between 1994 and March 2011 were retrospectively examined. Univariate and multivariate analysis of clinicopathological and surgical parameters influencing intraoperative blood loss were performed. We determined the cut-off value of the amount of blood loss based on the analyzed results. RESULTS: The mean and median blood loss was 1346±901 and 1070 mL, respectively. Red cell blood transfusion was performed in 72 patients (45%). Based on ROC analysis, the predictive value of blood loss in patients who received red cell blood transfusion was 880 mL (p <0.001); however, blood loss was not significantly associated with postoperative complications (p = 0.40). The cut-off level of estimated amount of blood loss in the present study was set at 880 mL. Male patients, fatty pancreas, higher serum alkaline phosphatase level, longer operating time, performance of pancreaticoduodenectomy (PD) and combined resections of adjacent major vessels were associated with significantly more increased blood loss (p <0.05). Based on multivariate analysis, longer operation time over 480 minutes and performance of PD were significantly associated with increased blood loss (p <0.05). CONCLUSIONS: Attempting to reduce operating time in cases of PD is necessary to reduce intraoperative blood loss.

Predictors of intraoperative blood loss in patients undergoing hepatectomy.

PURPOSE: Despite recent advances in surgical techniques, blood loss can still determine the postoperative outcome of hepatectomy. Thus, the preoperative identification of risk factors predicting increased blood loss is important. METHODS: We studied retrospectively the clinical records of 482 patients who underwent elective hepatectomy for liver disease, and analyzed the clinicopathological and surgical parameters influencing intraoperative blood loss. RESULTS: Red cell transfusion was required for 165 patients (35 %). Based on blood transfusion requirement and hepatic failure, we estimated predictive cut-off values at 850 and 1500 ml. The factors found to be significantly associated with increased blood loss were as follows: male gender, obstructive jaundice, non-metastatic liver carcinoma, Child-Pugh B disease, decreased uptake ratio on liver scintigraphy, platelet count, or prothrombin activity, longer hepatic transection time, operating time, the surgeon's technique, J-shape or median incision, major hepatectomy, and not using hemostatic devices (p < 0.05). Multivariate analysis identified male gender, low prothrombin activity, longer transection time, longer operation time, and not using hemostatic devices as factors independently associated with increased blood loss (p < 0.05). CONCLUSIONS: Male gender and low prothrombin activity represent risk factors for increased blood loss during hepatectomy. Moreover, every effort should be made to reduce the transection and operating times using the latest hemostatic devices.

Perioperative non-tumorous factors associated with survival in HCC patients who underwent hepatectomy.

AIM: To clarify perioperative factors associated with poor survival following hepatectomy. PATIENTS AND METHODS: Clinical parameters and stress score, including surgical stress score (SSS) and comprehensive risk score (CRS) were examined from 183 hepatocellular carcinoma patients who underwent hepatectomy. RESULTS: Factors associated with tumor relapse were increased blood loss/weight, uncontrolled ascites and grade B liver damage (p<0.05). Ascites was identified as an independent risk factor by multivariate logistic regression analysis. Increased blood loss/weight, transfusion, high SSS, high CRS, ascites, and grade B liver damage were associated with poor disease-free survival (p<0.05). Increased blood loss/weight, transfusion, ascites, and grade B liver damage were associated with poor overall survival (p<0.05), and ascites, transfusion, male sex and grade B liver damage were identified as independent risk factors. CONCLUSION: Reducing blood loss and avoiding transfusion appear important for improving prognosis. Maintenance of liver function is necessary in cases showing poor liver function and uncontrolled ascites.

Biomechanical analysis of gait and sit-to-stand patterns using a specially made knee supporter in healthy young and elderly individuals.

This study examined the ergonomic effects of a specially made knee supporter containing spiral bone springs aimed at reducing physical stress on the leg muscles during sit-to-stand (STS) and walking. Twelve young females and fifteen elderly subjects performed STS and treadmill walking with and without a specially made supporter, which may be a simple device for aiding STS and/or walking. During STS, electromyography (EMG) was observed from the vastus lateralis of the right leg. The root mean square (RMS) and mean power frequency (MPF) were calculated from the observed EMG. The changing rate of maximal leg acceleration, the third time derivative of the leg position, was also assessed during treadmill walking at a freely chosen stride frequency and speed. A significant decrease in the RMS was observed during STS when wearing the supporter in both groups. A significant increase in the changing rate of maximal leg acceleration was found during walking with the supporter in both groups. MPF significantly increased when wearing the supporter only in the young group. These results showed that the supporter with spiral bone springs reduced physical stress placed on the quadriceps muscles during STS and walking. This ergonomic contrivance will reduce the possible "risk" of stumbling and/or falling in elderly individuals. The reduced physical burden on the quadriceps muscles will also reduce or delay muscle fatigue, which will further result in an increase in the amount of daily physical activities exhibited in physically poor populations.

[A case of cardiac tamponade induced by gastric cancer responding to S-1].

A 56-year-old man was admitted to our hospital for gastric cancer. He had dyspnea before admission. Chest CT scan showed massive pericardial and pleural effusion. He was treated by cardiac drainage, and cytology of the effusion showed class V. We injected mitomycin C 10 mg into the pericardiac cavity, and also administered S-1 100 mg per day. His dyspnea improved and he was discharged. Afterward the dyspnea re-appeared, and he died 9 months after the diagnosis. We report this rare case of cardiac tamponade induced by gastric cancer responding to S-1 with a review of the literature.

Expression of PAC1 receptor in rat thymus after irradiation.

In the present work, PAC1-R (G-protein-coupled receptor specific for PACAP) was detected on cells in the normal thymus. Immunohistochemically PAC1-R was expressed strongly in stromal cells of the thymic medulla. Positive cells were also observed in the thymus of fetal and old adult rats. After 8 Gy irradiation to 9-week-old rats, PAC1-R expressions in the thymus decreased and almost recovered by day 21. The expression of PAC1-R mRNA was weak in the thymus and decreased further after irradiation. The expression almost recovered by day 28. Hip and hip/hop variants, which were not expressed in the normal thymus, were expressed in the thymus on days 3, 5 and 21 after irradiation. The expressions of IL-6 and IL-10 tended to increase initially after irradiation then decreased. Histologically, the thymic structures were destroyed on day 3 after irradiation and the thymus almost recovered by day 21. Thus PACAP is thought to be one of the important factors for cross-talk between cells involved in thymic regeneration.