Impact of pathological complete response following neoadjuvant chemotherapy (gemcitabine, nab-paclitaxel, S-1) and radiation for borderline resectable pancreatic cancer: a case report and review of literature.

BACKGROUND: Pancreatic cancer (PC) is a highly lethal malignancy, even if surgical resection is possible (median survival: < 30 months). The prognosis of borderline resectable pancreatic cancer (BR-PC) is even worse. There is no clear consensus on the optimal treatment strategy, including pre/postoperative therapy, for BR-PC. We report a patient with BR-PC who achieved clinical partial response with neoadjuvant chemoradiation therapy (NACRT) and underwent curative resection, resulting in pathological complete response (pCR). CASE PRESENTATION: A 71-year-old man with jaundice and liver dysfunction was referred to our department because of a 48-mm hypo-vascular mass in the pancreatic head with obstruction of the pancreatic and bile ducts and infiltration of superior mesenteric vein and portal vein. The lesion was identified as atypical cells which suggested adenocarcinoma by biopsy, and he was administered NACRT: gemcitabine and nab-paclitaxel, following S-1 and intensity modulated radiation therapy. After reduction in the tumor size (clinical partial response), pancreaticoduodenectomy was performed, and pCR achieved. Postoperative adjuvant chemotherapy with S-1 was initially administered and the patient is currently alive with no recurrence as of 2 years after surgery. CONCLUSIONS: NACRT is a potentially useful treatment for BR-PC that may lead to pCR and help improve prognosis.

Thoracoscopic intraoperative esophageal close technique for long-gap esophageal atresia.

Long-gap esophageal atresia (EA) remains a challenging operative procedure. Several techniques have been reported to resolve the problem of distance between the proximal and distal esophagus. We report a thoracoscopic intraoperative esophageal close technique for long-gap EA. A female neonate was born at 39 weeks of gestation with long-gap EA (five vertebrae). The patient underwent thoracoscopic esophageal anastomosis after esophageal elongation. Careful dissection of the proximal and distal esophagus was performed; however, the distance between them was still long. Extra-thoracic traction sutures were placed at the upper esophagus. Then, a Neraton catheter was inserted trans-orally and the upper esophagus was pushed and opened. An internal traction suture was placed between the Neraton catheter and lower esophagus. The gap between the proximal and distal esophagus could be approximated by pulling the Neraton catheter. Esophageal anastomosis was performed successfully. Our thoracoscopic intraoperative esophageal close technique was simple and useful.

[A Case of Gallbladder Cancer with Long Survival Treated with Resection after Downstaging with GC Therapy].

A 68-year-old woman with a chief complaint of obstructive jaundice was referred to our hospital. She was diagnosed with gallbladder cancer with invasion to the liver, extrahepatic bile duct, right hepatic artery and portal vein. After endoscopic retrograde biliary drainage, she received chemotherapy with gemcitabine and cisplatin. After 9 courses, the size of the tumor and the lymph nodes decreased, and we planned surgery. There were no unresectable factors, and the right hepatic artery and portal vein were detached from the tumor. We performed a subtotal stomach-preserving pancreaticoduodenectomy and gallbladder bed resection. We then performed adjuvant chemotherapy with S-1 for 1 year. The patient remains alive without recurrence, 5 years after the surgery. We report the case of advanced gallbladder cancer with downstaging after GC therapy.

Air in the right ventricle and vein after basilar skull fracture: a case report.

BACKGROUND: Air in the venous system may cause vascular air embolism, which is a potentially life-threatening event. The presence of air in venous system after basilar skull fracture is very rare. CASE PRESENTATION: A 77-year-old man fell from a truck bed and suffered head and neck trauma. On hospital arrival, his consciousness was clear and his vital signs were stable. His chief complaint was pain in the back of his head and neck. Head CT showed traumatic subarachnoid hemorrhage in the right frontal area and basilar skull fracture of the occipital bone. Whole body CT showed pneumocephalus and air in the jugular vein and right ventricle. The patient was placed in the supine position in a state of absolute rest to prevent vascular air embolism and was treated conservatively. On hospital day 3, CT was reperformed, revealing disappearance of air in the right ventricle and decreased air in the veins of the head and neck. On hospital day 4, the air in the veins disappeared completely on CT. He did not experience vascular air embolism after increasing of his activity level (e.g., raising his head on hospital day 3 and standing and walking alone on day 5). He was discharged 34 days after admission without sequelae. CONCLUSIONS: Head trauma patients with basilar skull fracture might develop vascular air embolism if physicians fail to detect air in the venous system on hospital arrival. A high degree of suspicion regarding air in venous system or heart is required when patients present with such injuries.

Laparoscopic-assisted Stamm-gastrostomy: technical modifications to ease suturing inside the minimal trocar site.

Laparoscopic gastrostomy tube placement has been increasingly adopted by pediatric surgeons. We herein report our experience with the performance of a laparoscopic-assisted Stamm-operation inside the minimal trocar site without the extension of the trocar site incision or mini-laparotomy. We present some technical modifications that facilitate suturing inside the minimal trocar site. METHODS: A retrospective chart review was conducted of cases involving patients who underwent laparoscopic-assisted gastrostomy, using a simple extracorporeal method inside the trocar site from April 1998 to March 2018. RESULTS: One hundred five gastrostomy tubes were placed in a laparoscopic-assisted operation. All but two of the cases involved patients with neurological impairment. The mean age was 12.5 years; 28 cases were > 16 years of age. Seventy-five cases underwent gastrostomy during laparoscopic fundoplication. All gastrostomy procedures were completed without intraoperative difficulties; however, 8 cases, which involved a thick abdominal wall, required extension of the trocar site. No cases required conversion to open gastrostomy. No major complications were observed. Two patients developed continuous peristomal cellulitis after surgery, due to the mismatch of the site position and an unsuitable button device size. CONCLUSION: We demonstrated that laparoscopic gastrostomy with fully extracorporeal suturing within the trocar site is feasible and beneficial, especially for the most neurologically impaired pediatric cases. Technical modification, changing the order of the process, and suturing technique in the minimal space, made it easier to perform the procedures inside the minimal trocar hole.

Spatiotemporal dengue fever hotspots associated with climatic factors in Taiwan including outbreak predictions based on machine-learning.

Early warning systems (EWS) have been proposed as a measure for controlling and preventing dengue fever outbreaks in countries where this infection is endemic. A vaccine is not available and has yet to reach the market due to the economic burden of development, introduction and safety concerns. Understanding how dengue spreads and identifying the risk factors will facilitate the development of a dengue EWS, for which a climate-based model is still needed. An analysis was conducted to examine emerging spatiotemporal hotspots of dengue fever at the township level in Taiwan, associated with climatic factors obtained from remotely sensed data in order to identify the risk factors. Machinelearning was applied to support the search for factors with a spatiotemporal correlation with dengue fever outbreaks. Three dengue fever hotspot categories were found in southwest Taiwan and shown to be spatiotemporally associated with five kinds of sea surface temperatures. Machine-learning, based on the deep AlexNet model trained by transfer learning, yielded an accuracy of 100% on an 8-fold cross-validation test dataset of longitudetime sea surface temperature images.

Portal venous gas in intestinal malrotation with mild midgut volvulus.

BACKGROUND: Portal venous gas has been considered as a radiological sign requiring urgent operative intervention; however, the reports concerning portal venous gas associated with favorable outcome are recently increasing. CASE PRESENTATION: We describe a 9-month-old boy with acute onset high fever and vomiting. The ultrasonography demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign suggesting an intestinal malrotation with midgut volvulus, but with no signs of residual intrahepatic gas. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Detorsion and Ladd's procedure were completed laparoscopically. CONCLUSIONS: Transient portal venous gas bubbles may be generated even in the mild intestinal volvulus with no bowel ischemia. Ultrasonography can be a sensitive detector to visualize such small amounts of gas.

Blowhole tangential cecostomy and transanal tube insertion for neonatal cecal perforation in a patient with Hirschsprung's disease in the earlier definitive operation era.

BACKGROUND: Although uncommon and seldom experienced, intestinal perforation is a well-known complication of Hirschsprung's disease (HD). A literature review revealed that the cecum, including the appendiceal base, is a site of perforation. The cecum is not suitable for making an ordinary loop colostomy, and the optimal operative strategy remains to be established. CASE PRESENTATION: We present a combination technique composed of tangential cecostomy at the perforated portion and postoperative care with a transanal indwelling tube, which was used in the treatment of a 3-day-old boy with cecal perforation with long-segment Hirschsprung's disease. A temporary simple blowhole stoma and continuous decompression with daily irrigation via a transanal indwelling tube in the distal colon achieved a secure recovery and was followed by a definitive operation in the early period. The combination of tangential cecostomy and transanal indwelling catheter management led to the preservation of the ileocecal valve. CONCLUSIONS: We review the Japanese literature and emphasize the usefulness of this combination technique by blowhole tangential cecostomy and transanal tube insertion for neonatal cecal perforation in patients with HD in today's early definitive operation era.

Japan Aerospace Exploration Agency's public-health monitoring and analysis platform: A satellite-derived environmental information system supporting epidemiological study.

Since the 1970s, Earth-observing satellites collect increasingly detailed environmental information on land cover, meteorological conditions, environmental variables and air pollutants. This information spans the entire globe and its acquisition plays an important role in epidemiological analysis when in situ data are unavailable or spatially and/or temporally sparse. In this paper, we present the development of Japan Aerospace Exploration Agency's (JAXA) Public-health Monitoring and Analysis Platform available from JAXA, a user-friendly, web-based system providing environmental data on shortwave radiation, rainfall, soil moisture, the normalized difference vegetation index, aerosol optical thickness, land surface temperature and altitude. This system has been designed so that users should be able to download and utilize data without the need for additional data processing. The website allows interactive exchange and users can request data for a specific geographic location and time using the information gained for epidemiological analysis.

Long-term outcome of peroral endoscopic myotomy for achalasia treatment in a 9-year-old female patient.

Achalasia is a primary motility disorder with incomplete lower esophageal sphincter relaxation; it has an annual incidence of 0.11 cases per 100 000 children. Peroral endoscopic myotomy (POEM) is a new endoscopic treatment method for achalasia. Reports about POEM in pediatric patients are rare. We herein report the case of a 9-year-old female patient with achalasia who underwent POEM. The patient underwent endoscopic balloon dilatation because medication was not effective at a previous hospital; however, endoscopic balloon dilatation was not effective either. She then underwent successful POEM upon admission at our hospital. The patient was symptom-free at 2 years postoperatively with no signs of esophagitis in the absence of proton-pump inhibitor therapy.

Successful treatment of an infected wound in infants by a combination of negative pressure wound therapy and arginine supplementation.

OBJECTIVE: Wound dehiscence caused by surgical site infection (SSI) presents a complicated problem. Negative pressure wound therapy (NPWT) was developed to treat wound dehiscence. Nutritional treatment using arginine has also been recently shown to be effective for the treatment of pressure ulcers. Therefore, wound complications due to SSI were treated using NPWT combined with nutritional therapy with an arginine-rich supplement (ARS). METHODS: Six pediatric patients with wound dehiscence due to SSI received this combined therapy. RESULTS: The average age of the patients was 12.2 mo. The operations that these patients underwent included laryngotracheal separation, radical operation for spinal bifida, gastrostomy, colostomy, anorectoplasty, and tumor extirpation. A local wound infection induced wound dehiscence in all patients. Therefore, NPWT was introduced with an enteral administration of ARS. All wounds completely healed within 1 mo after the introduction of this combined therapy without any other complications from the NPWT or ARS. A follow-up study at 6 mo after this therapy was completed showed no complications associated with the wounds. CONCLUSION: This combination therapy using NPWT and ARS administration was effective in inducing early healing of infected wound complications after surgery.

A case of cystic biliary atresia with an antenatally detected cyst: the possibility of changing from a correctable type with a cystic lesion (I cyst) to an uncorrectable one (IIId).

This report presents the case of a 6-day-old male with cystic biliary atresia (CBA), and the cyst was detected antenatally. Antenatal ultrasonography suggested the possibility of CBA or a choledochal cyst at 16 weeks' gestation. However, the cyst disappeared during the later gestational period. The cyst was detected again by preoperative imaging. Surgical cholangiography at 30 days of age confirmed CBA, but the common hepatic duct (CHD) was extremely narrow. The histopathological findings revealed the partial obstruction of CHD. These findings suggest that correctable CBA (I cyst) may change into uncorrectable CBA (IIId).

Neonatal gastrointestinal perforation.

Infants, especially extremely low birth weight infants (ELBWIs, birth weight <1,000 g) continue to have a high mortality after gastrointestinal (GI) perforation. In Japan, the overall mortality rate for neonates under 30 days having GI perforation was 31.6% in 2003. From 1974 to 2003, 34 cases of GI perforation in neonates were treated surgically in Fukuoka University Hospital. The overall mortality rate was 50% (17 of 34). Etiologies included necrotizing enterocolitis (NEC) (35.3%), meconium peritonitis (25%), idiopathic (25%), and gastric perforation (11.8%). The present series was divided into four groups: survival and non-survival neonates of the early (1974 to 1997) and recent (1998 to 2004) periods. Several prognostic factors of neonatal GI perforation were compared between several groups. The gestational week (GW) at birth, birth weight (BW) and weight at operation were significantly lower for non-surviving neonates in the recent period compared with the other three groups. Although a real improvement in surgical outcome was noted with improved neonatal intensive care management, the mortality rate was still high, especially in extremely premature cases under both 1,000 g and 29 GWs. The vast majority of these extremely premature babies thus comprised the NEC patients. It is therefore necessary to substantially improve the medical treatment level for such premature babies.

Thoracoscopic surgery in children in the Kyushu area of Japan.

BACKGROUND: Recently, minimally invasive thoracoscopic surgery has offered several options for both the diagnosis and surgical treatment in the field of pediatric surgery. This report reviews the surgical experience in order to assess the problems including the complications, encountered during thoracoscopic surgery in children under 15 years of age in the Kyushu area, Japan. METHODS: From 1993 to 2005, 153 boys and 103 girls underwent thoracoscopic surgery for chest disease. Pertinent information included number of operations for each year, sex, age, indication, treatment procedure, follow-up duration, cause of conversion to thoracotomy, method of treatment, and complication. RESULTS: There has gradually been an increase in the number of operations every year. These included procedures for funnel chest, n= 121; pneumothorax, n= 25; mediastinal tumor, n= 25; palmar hyperhydrosis, n= 23; neuroblastoma, n= 11; and cystic lung disease, n= 10. A large portion of the surgery was for patients under 1 year of age excluding neonates. Approximately half of the procedures were for the excision of a neuroblastoma. Approximately half of the patients older than 5 years of age underwent Nuss procedure for funnel chest. Almost all of the pneumothorax and palmar hyperhydrosis surgery was for patients 14 or 15 years old. Three patients required a conversion to a standard thoracotomy. Six complications occurred. There was no mortality associated with the thoracoscopic surgical procedures. CONCLUSIONS: Thoracoscopy is a useful diagnostic and therapeutic tool for both infants and children. Various thoracoscopic complex procedures have been performed both safely and effectively.

Iatrogenic ileal perforation: an accidental clamping of a hernia into the umbilical cord and a review of the published work.

This report describes the case of an ileal perforation secondary to clamping of the exomphalos minor in 3-day-old girl. Eighteen accidental clamping or cutting cases were found in the published work. It is thought that this defect resulted from either the clamping, ligation or cutting of the bowel in a small unrecognized omphalocele. These complications are extremely rare, but should be held in mind when performing an umbilical ligation.

Ultrastructural evaluation of type II pneumocytes in the hypoplastic lung of rabbit fetuses induced by oligohydramnios.

AIM: The present study was carried out using electron microscopy to evaluate the expression of lamellar bodies in type II pneumocytes of fetal rabbit lungs with hypoplasia induced by oligohydramnios. METHODS: Using an amniotic shunting rabbit model, the lungs obtained from 32 fetuses, including 16 experimental fetuses (shunting group) and 16 control fetuses (control group), were used for electron microscopic studies. At least 250 type II pneumocytes per fetus were photographed. The number of lamellar bodies per type II pneumocyte was counted. RESULTS: The number of lamellar bodies per type II pneumocyte of the shunting group was consistently and significantly less than that of the control group (5.49 +/- 2.07 vs 7.58 +/- 2.08; P < 0.01). CONCLUSIONS: These results suggest that the occurrence of hypoplastic lungs induced by oligohydramnios is associated with an immaturity of the surfactant system, especially the expression of the lamellar bodies of type II pneumocytes.

Effect of maternal dexamethasone treatment on the type II pneumocytes in hypoplastic lung by oligohydramnios: an ultrastructural study.

A previous study documented the effects of maternal corticosteroid treatment on structural growth and functional development in fetal lungs associated with pathogenic conditions such as oligohydramnios using immunohistochemical and morphometric analyses. The purpose of the present study was to examine the effect of maternal dexamethasone treatment the expression of lamellar body in type II pneumocytes of the fetal rabbit lungs with hypoplasia induced by oligohydramnios using electron microscopy. Using an amniotic shunting rabbit model, pregnant rabbits were injected intravenously with either 0.1 ml of saline or 0.25 mg/kg/day of dexamethasone in 0.1 ml of saline 48 and 24 h before the delivery of fetuses, at day 30 of gestation. The number of lamellar bodies per type II pneumocyte was counted in each group using electron micrographs. The number of lamellar bodies per type II pneumocyte in the lungs of the shunted group that received saline was consistently and significantly less than that of the other three groups (5.49 +/- 2.07 vs. 7.34 +/- 2.27: shunted group that received dexamethasone, 7.58 +/- 2.08: non-shunted group that received saline, 7.79 +/- 1.90: non-shunted group that received dexamethasone; P < 0.01). These results suggest that maternal dexamethasone treatment accelerates the maturation of the surfactant system, especially the expression of lamellar bodies in type II pneumocytes, even in hypoplastic lungs induced by oligohydramnios.

Long-term effects of intrauterine exposure to mono-n-butyl phthalate on the reproductive function of postnatal rats.

PURPOSE: Although it is well known that phthalate esters induce testicular dysfunction in both adult and immature rats, there have been few reports on the long-term effect of phthalate esters on the testicular function of male rats exposed to phthalate esters in utero. This study was designed to assess the long-term effects of the mono-n-butyl phthalate (MBP) ester on the testicular function of neonatal and adult rat offspring from pregnant dams exposed to phthalate esters during gestation. METHODS: Pregnant rats were administered MBP [0.5 g/(kg body weight/.d); 4 days] by gavage from the 15th to the 18th gestational day. Rats administered solvent only were used as control subjects. After the rats' puberty, using male pups whose testes descended normally, the authors examined their fertility while also measuring their testicular weights, mean seminiferous tubular diameter, and the developmental grade of the germ cells (Johnsen score) in their testes. Next, in neonatal rats, the authors measured the testicular concentration of the Mullerian inhibiting substance (MIS) protein using enzyme-linked immunoassay and the expression level of the MIS messenger RNA using the quantitative polymerase chain reaction method as a marker of the Sertoli cells' function. Next the concentration of testosterone protein using a radioimmunoassay as a marker of the Leydig cells' function was measured. RESULTS: The pregnancy rate of the female rats coupled with MBP-treated male rats decreased significantly in comparison with that of the female rats coupled with control male rats (P < .01). Both the testicular weight and the Johnsen score in the MBP-treated group were decreased significantly more than those of the control group (P < .05). Neither the concentration of the MIS protein nor the expression level of the MIS messenger RNA in the MBP-treated neonatal testes differed from those of the control testes, whereas the concentration of testosterone protein in the neonate testes decreased significantly in the MBP-treated group in comparison with that of the control group (P < .01). CONCLUSIONS: A prenatal short-time exposure to MBP induces a long-term effect on postnatal rats and impairs reproductive function in male offspring probably by inhibiting the Leydig cells' rather than Sertoli cells' function in the fetal period.

Effects of the prenatal administration of cimetidine on testicular descent and genital differentiation in rats.

BACKGROUND: Cimetidine has been shown to induce gonadal and sexual dysfunction in men. This study aimed to clarify the effect of cimetidine on testicular descent and genital development in utero. METHODS: Pregnant rats (280 to 330 g) were separated into 4 groups. In group 1, the rats were injected subcutaneously with a dose of 600 mg/kg of cimetidine twice on days 15, 16, 17, and 18 of gestation. In group 2, the rats were injected with a dose of 300 mg/kg of cimetidine twice in the same way as in group 1. In group 3, the rats were injected with a dose of 150 mg/kg of ranitidine twice in the same manner as in the above groups. In group 4, the rats were injected with the same volume of saline. At birth the anogenital distance was measured, and the incidence of testicular descent was examined in male offspring at 90 days of age. Next, the testes were weighed and histologically examined. The chi-square test and Student t test were used to perform statistical analyses of the results. RESULTS: At birth, the anogenital distance (AGD) index in male offspring decreased significantly in groups 1 and 2 in comparison with groups 3 or 4. However, there was no significant difference in the AGD index between groups 3 and 4. At 90 days of age, the incidence of cryptorchidism was 55.3% in group 1 and 25.9% in group 2. In contrast, all testes descended into the scrotum in both groups 3 and 4. The incidence of cryptorchidism was significantly higher in group 1 than in groups 2 (P <.05), 3, or 4 (P <.01), while the incidence of cryptorchidism was also significantly higher in group 2 than in groups 3 or 4 (P <.01). The weight of the testis decreased significantly more in the undescended testis than in the scrotal testis (P <.01); however, there was no significant difference in the weight of the scrotal testes among the 4 groups. The histologic development of the undescended testes showed an absence of germ cells and smaller tubes in comparison with those of scrotal testes, which showed an advanced differentiation of germ cells and larger tubes in all 4 groups. CONCLUSIONS: These findings suggest that the antiandrogenic effect of cimetidine inhibits both the testicular descent and genital differentiation in fetuses and also causes cryptorchidism in postnatal rats. These same events might also occur in human fetuses when high doses of cimetidine are administered to pregnant women around the end of the first trimester.