Factors associated with the job satisfaction of certified nurses and nurse specialists in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs.

BACKGROUND: As the Japanese population ages, the number of cancer patients will likely increase. Therefore, qualified cancer health care providers should be recruited and retained. Nurse job satisfaction is influenced by numerous factors and may affect staff turnover and patient outcomes. OBJECTIVES: To evaluate the job satisfaction of certified nurses and nurse specialists in Japanese cancer care and elucidate factors associated with job satisfaction. METHODS: Participants in this cross-sectional study comprised 200 certified nurse specialists and 1,472 certified nurses working in Japanese cancer care. A chi-square test and logistic regression analysis were conducted to identify job satisfaction factors. RESULTS: Job satisfaction was present in 38.45% and 49.00% of certified nurses and nurse specialists, respectively. Certified nurses associated job satisfaction with cross-departmental activities (OR 2.24, p<0.001), positive evaluation from senior stuff (OR 4.58, p<0.001), appropriate staff allocation (OR 1.75, p<0.001), more than five years certified nurse experience (OR 1.91, p<0.001), and positive evaluation of the development of certified nurses (OR 2.13, p<0.01) and nurse specialists (OR 1.37, p<0.05). Low job satisfaction was associated with working on a ward (OR 0.51, p<0.001) and a capacity of more than 200 beds (OR 0.33, p = 0.00). Certified nurse specialists associated job satisfaction with palliative care team participation (OR 2.64, p<0.05), cross-sectional activities (OR 7.06, p<0.01), positive evaluation from senior stuff (OR 13.15, p<0.001), presence of certified nurses in radiation therapy (OR 2.91, p<0.05), positive certified nurse specialist development evaluation (OR 7.35, p<0.001), medical service fees (OR 3.78, p<0.01), and independent activities (OR 11.34, p<0.01). CONCLUSIONS: We identified factors related to activities, facilities, and the cancer care team associated with job satisfaction of certified nurses and nurse specialists in Japanese cancer care. Suggestions are provided to enhance job satisfaction through Japan's Basic Plan to Promote Cancer Control, which may help hospital administrators retain nursing staff.

Neoline, an active ingredient of the processed aconite root in Goshajinkigan formulation, targets Nav1.7 to ameliorate mechanical hyperalgesia in diabetic mice.

ETHNOPHARMACOLOGICAL RELEVANCE: Goshajinkigan (GJG), a traditional Japanese Kampo formula, has been shown to exhibit several pharmacological actions, including antinociceptive effects. Processed aconite root (PA), which is considered to be an active ingredient of GJG, has also been demonstrated to have an ameliorative effect on pain, such as diabetic peripheral neuropathic pain. We recently identified neoline as the active ingredient of both GJG and PA that is responsible for its effects against oxaliplatin-induced neuropathic pain in mice. AIM OF THE STUDY: In the present study, we investigated whether GJG, PA, and neoline could inhibit Nav1.7 voltage-gated sodium channel (VGSC) current and whether neoline could ameliorate mechanical hyperalgesia in diabetic mice. MATERIALS AND METHODS: To assess the electrophysiological properties of GJG extract formulation, powdered PA, and neoline on Nav1.7 VGSCs, whole-cell patch clamp recording was performed using human HEK293 cells expressing Nav1.7 VGSCs. In addition, the ameliorative effects of neoline on diabetic peripheral neuropathic pain were evaluated using the von Frey test in streptozotocin (STZ)-induced diabetic model mice. RESULTS: GJG extract formulation significantly inhibited Nav1.7 VGSC peak current. Powdered PA also inhibited Nav1.7 VGSC peak current. Like GJG and PA, neoline could inhibit Nav1.7 VGSC current. When diabetic mice were treated with neoline by intraperitoneal acute administration, the mechanical threshold was increased in diabetic mice, but not in non-diabetic mice, in a behavioral study. CONCLUSION: These results suggest that neoline might be a novel active ingredient of GJG and PA that is one of responsible ingredients for ameliorating mechanical hyperalgesia in diabetes via the inhibition of Nav1.7 VGSC current at least.

Case series of in situ pelvic floor reconstruction combining levator ani suture and negative pressure wound therapy for abdominoperineal resection.

BACKGROUND: Abdominoperineal resection (APR) is a standard surgical technique for low rectum cancer with a low recurrence rate. There are some problems associated with APR such as perineal hernia and perineal surgical site infection. Recently, the prophylactic efficacy of negative pressure wound therapy (NPWT) for surgical site infection has been reported. Herein, we analyzed the efficacy of in situ pelvic floor reconstruction combining levator ani suture and NPWT after APR for perineal hernia and perineal surgical site infection. METHODS: We analyzed six patients treated by laparoscopic APR with NPWT combined with levator ani suture retrospectively. The primary endpoints were surgical site infection within 30 days and perineal hernia within 1 year after surgery. The day following surgery, we performed NPWT for the perineal wound using the VAC® abdominal wound management system (KCI, San Antonio, TX, USA). RESULTS: There were four male and two female patients ranging in age from 69 to 86 years (mean: 76 years). The mean NPTW duration was 17 days (13-20 days). The length of the postoperative hospital stay was 14-22 days (median: 18 days). There was no patient with surgical site infection within 30 days or with perineal hernia within 1 year after surgery. CONCLUSION: We experienced the in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR for perineal hernia and perineal surgical site infection. This combination treatment was safe and may be effective for preventing surgical site infection and perineal hernia.

Effect of Vitamin D Supplementation on Relapse-Free Survival Among Patients With Digestive Tract Cancers: The AMATERASU Randomized Clinical Trial.

Importance: Randomized clinical trials of vitamin D supplementation for secondary prevention in patients with cancer are needed, given positive results of observational studies. Objective: To determine whether postoperative vitamin D3 supplementation can improve survival of patients with digestive tract cancers overall and in subgroups stratified by 25-hydroxyvitamin D (25[OH]D) levels. Design, Setting, and Participants: The AMATERASU trial, a randomized, double-blind, placebo-controlled trial conducted at a single university hospital in Japan. Enrollment began in January 2010 and follow-up was completed in February 2018. Patients aged 30 to 90 years with cancers of the digestive tract from the esophagus to the rectum, stages I to III, were recruited. Of 439 eligible patients, 15 declined and 7 were excluded after operation. Interventions: Patients were randomized to receive oral supplemental capsules of vitamin D (2000 IU/d; n = 251) or placebo (n = 166) from the first postoperative outpatient visit to until the end of the trial. Main Outcomes and Measures: The primary outcome was relapse-free survival time to relapse or death. The secondary outcome was overall survival time to death due to any cause. Subgroups analyzed had baseline serum 25(OH)D levels of 0 to less than 20 ng/mL, 20 to 40 ng/mL, and greater than 40 ng/mL; because of small sample size for the highest-baseline-level group, interactions were tested only between the low- and middle-baseline-level groups. Results: All 417 randomized patients (mean age, 66 years; male, 66%; esophageal cancer, 10%; gastric cancer, 42%; colorectal cancer, 48%) were included in the analyses. There was 99.8% follow-up over a median 3.5 (interquartile range, 2.3-5.3) years, with maximal follow-up of 7.6 years. Relapse or death occurred in 50 patients (20%) randomized to vitamin D and 43 patients (26%) randomized to placebo. Death occurred in 37 (15%) in the vitamin D group and 25 (15%) in the placebo group. The 5-year relapse-free survival was 77% with vitamin D vs 69% with placebo (hazard ratio [HR] for relapse or death, 0.76; 95% CI, 0.50-1.14; P = .18). The 5-year overall survival in the vitamin D vs placebo groups was 82% vs 81% (HR for death, 0.95; 95% CI, 0.57-1.57; P = .83). In the subgroup of patients with baseline serum 25(OH)D levels between 20 and 40 ng/mL, the 5-year relapse-free survival was 85% with vitamin D vs 71% with placebo (HR for relapse or death, 0.46; 95% CI, 0.24-0.86; P = .02; P = .04 for interaction). Fractures occurred in 3 patients (1.3%) in the vitamin D group and 5 (3.4%) in the placebo group. Urinary stones occurred in 2 patients (0.9%) in the vitamin D group and 0 in the placebo group. Conclusions and Relevance: Among patients with digestive tract cancer, vitamin D supplementation, compared with placebo, did not result in significant improvement in relapse-free survival at 5 years. Trial Registration: UMIN Identifier: UMIN000001977.

Daikenchuto accelerates the recovery from prolonged postoperative ileus after open abdominal surgery: a subgroup analysis of three randomized controlled trials.

PURPOSE: Prolonged postoperative ileus (POI) is a common complication after open abdominal surgery (OAS). Daikenchuto (DKT), a traditional Japanese medicine that peripherally stimulates the neurogenic pathway, is used to treat prolonged POI in Japan. To analyze whether DKT accelerates the recovery from prolonged POI after OAS, we conducted a secondary analysis of three multicenter randomized controlled trials (RCTs). METHODS: A secondary analysis of the three RCTs supported by the Japanese Foundation for Multidisciplinary Treatment of Cancer (project numbers 39-0902, 40-1001, 42-1002) assessing the effect of DKT on prolonged POI in patients who had undergone OAS for colon, liver, or gastric cancer was performed. The subgroup included 410 patients with no bowel movement (BM) before the first diet, a DKT group (n = 214), and a placebo group (n = 196). Patients received either 5 g DKT or a placebo orally, three times a day. The primary endpoint was defined as the time from the end of surgery to the first bowel movement (FBM). A sensitivity analysis was also performed on the age, body mass index and dosage as subgroup analyses. RESULTS: The primary endpoint was significantly accelerated in the DKT group compared with the placebo group (p = 0.004; hazard ratio 1.337). The median time to the FBM was 113.8 h in the placebo group and 99.1 h in the DKT treatment group. CONCLUSIONS: The subgroup analysis showed that DKT significantly accelerated the recovery from prolonged POI following OAS. TRIAL REGISTRATION NUMBER: UMIN000026292.

Laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System with intraoperative fluorescent imaging for acute cholecystitis: A case report.

We report on a laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) using the bright field/full-color fluorescence laparoscope system PINPOINT® (Novadaq, Mississauga, ON, Canada). The patient was an 85-year-old man who was diagnosed with moderate AC. Indocyanine green (ICG) was administered just before surgery, and we used only PINPOINT® to perform the LC. The advantage of this procedure is that it can be performed while viewing ICG fluorescence in the cystic duct. Since the gallbladder is imaged with this technique, it is also advantageous from the perspective of deciding at which layer to detach the gallbladder from the liver. The operative time was 81 minutes, and blood loss was 5 ml. There were no perioperative complications, and the patient was discharged on post-operative day 6.

Clinical pathway after gastrectomy for gastric cancer: A case series of laparoscopic gastrectomy and early oral intake with "iEat™".

INTRODUCTION: We investigated the validity of the clinical pathway of early oral intake using a special type of food "iEat™" for patients after laparoscopic gastric cancer surgery. METHODS: Fifty-two patients who underwent laparoscopic surgery for gastric cancer between April 2012 and October 2013 were the participants. We provided postoperative care in accordance with a clinical pathway for laparoscopic gastrectomy that begins oral intake with "iEat™ the day after surgery. We examined complications resulting from oral intake, postoperative complications, and the length of postoperative hospital stay. RESULTS: Of the 52 patients, 30 underwent distal gastrectomy and 22 underwent total gastrectomy. 50 patients was able to start early oral intake in accordance with our clinical pathway. No anastomotic leak complications were observed, and 9 patients (17.3%) developed complications as results of surgery. There was no complication related to early oral intake with "iEat™". Re-operation were performed in two cases. Overall mean and median postoperative hospital stays were 8.3 days and 6 days, respectively. There was a single case of hospital re-admission. The completion rate of this early oral intake clinical pathway was 86.5%. CONCLUSION: Clinical pathway of recovery program combined laparoscopic suregry and early oral intake with "iEat™" could be useful for gastric cancer. This study indicates that using non-liquid food like iEat™ can be feasiblel, and water or liquid food don't have to be used in early oral feeding after laparoscopic gastrectomy.

Endoscopic submucosal dissection for the diagnosis and therapy of pedunculated gastric cancer with prolapse into the duodenal bulb: A case report.

INTRODUCTION: Preoperative diagnosis of gastric cancer invasion is not always sufficiently accurate. Diagnostic endoscopic submucosal dissection (ESD) can be performed for the purpose of accurate decision making and to avoid partial treatment vs aggressive over-treatment. We present a patient with the gastric cancer with indeterminate pre-operative diagnosis for depth of the invasion. CASE PRESENTATION: A 70-year-old man presented at our hospital because both anti-Helicobacter pylori (Hp) IGG antibody and serum pepsinogen (PG) levels were classified as positive. Upper gastrointestinal endoscopy was performed, and a large (3.5 cm) pedunculated polyp-shaped gastric cancer with prolapse into the duodenal bulb was found. [fluorine-18]-fluorodeoxy-glucose (18F-FDG)-positron emission tomography (PET)/computed tomography (CT) imaging showed high 18F-FDG uptake, suggesting the possibility of advanced gastric cancer. Since the pre-operative diagnosis of the cancer invasion was indeterminable, diagnostic ESD was performed. The pathohistological diagnosis was early gastric cancer (33 × 35 × 20 mm, well differentiated tubular adenocarcinoma [tub1], pT1a[M], ly[--], v[--], UL[--], pHM0, pVM0) according to the Japanese classification of gastric carcinoma. DISCUSSION AND CONCLUSION: It was reported that ESD for early gastric cancers that met the expanded criteria was acceptable and should be the standard treatment instead of gastrectomy. The expanded criteria included cancer confined to the mucosa (cT1a), a single primary intestinal-type gastric adenocarcinoma, an ulcer-negative lesion of any size. We reported a case of pedunculated gastric cancer with prolapse into the duodenal bulb that could be treated by ESD. The present case is a good example of diagnostic ESD being used to minimize the damage of gastric cancer treatment.

Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System.

INTRODUCTION: The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts' fluorescence with a bright-field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence. METHODS: A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver. RESULTS: The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15-, 18-, and 24-h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15-h group and decreased thereafter. CONCLUSIONS: In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.

Prophylactic retention suture for surgical site infection: a retrospective cohort study.

BACKGROUND: Surgical site infection (SSI) is a common complication of gastrointestinal surgery. Because retention suture is known to prevent abdominal wound dehiscence, it is only considered indicated in high-risk patients. At present, there are no clear indications for retention suture. The purpose of this study was to analyze the effect of prophylactic retention suture and to determine what situations indicate prophylactic retention suture against SSI. MATERIAL AND METHODS: Between January 2014 and January 2016, 135 patients who underwent midline laparotomy in our hospital were analyzed. Inclusion criteria for this study were patients with American Society Anesthesiologists' physical status classification system (ASA-PS score) ≥ 3 or emergent surgery. RESULTS: Of the 135 patients, 30 (22.2%) received prophylactic retention suture. Diabetes mellitus, surgical wound classification, large incision, and retention suture were associated with SSI in multivariate analysis. In subgroup analysis, SSI risk factors were analyzed in each surgical wound classification. Only in surgical wound classification class II and III did retention suture significantly reduce the risk of SSI (odds ratio = 0.100 [0.012-0.837], P = 0.034). In class IV, however, half the patients developed SSI, regardless of retention suture. Table 3 summarizes the results of the subgroup analysis. CONCLUSIONS: The present data suggest that prophylactic retention suture reduces SSI for surgical wound classification class II or III. For class IV operations, however, other methods to prevent SSI are necessary.

New method of indocyanine green fluorescence sentinel node mapping for early gastric cancer.

BACKGROUND: The present study describes the retrospective feasibility study of ICG fluorescence SN mapping in back-table for early gastric cancer using PINPOINT®. METHOD: SN mapping were performed as following; the day before surgery, 0.5 ml ICG was injected endoscopically in four quadrants of the submucosa surrounding the gastric cancer using an endoscopic puncture. Intraoperatively, the gastrocolic ligament was divided to visualize all possible directions of lymphatic flow from the stomach. PINPOINT® (NOVADAQ, Canada) was used to illuminate regional lymph nodes from the serosal side. Positive staining was confirmed by at least 3 surgeons and an endoscopist during surgery (Figure 1). Lymph node dissection and gastrectomy were performed according to the criteria of gastric cancer treatment guidelines of JGCA. RESULT: All 6 patients had gastrectomy with laparoscopic approach. ICG positive lymphatic flow and lymph nodes were able to be observed in all the patients. Final pathological diagnosis was all StageI and curative resection. All the patients had ICG positive lymphatic area in left gastric artery (LGA) area. Two patients with tumor located in L area had ICG positive flow to right gastroepipoloic artery (RGEA) area. The mean of ICG positive lymph nodes was 8.6. One patient had a metastatic lymph node in station No.4, which was positive for ICG. CONCLUSION: Our method made identification of ICG positive lymph nodes easy in SN mapping in back-table under room light. Although further accumulation and analysis are necessary, we may be able to apply this method for intraoperative SN mapping of laparoscopic gastric cancer surgey.

Randomized phase II study of daily and alternate-day administration of S-1 for advanced gastric cancer (JFMC43-1003).

PURPOSE: Although S-1 based chemotherapy for patients with advanced gastric cancer has generally been accepted in Japan, discontinuations of treatment have been reported due to grade 3 or more adverse events. The present randomized phase II study was conducted to test whether alternate-day administration of S-1 would be comparably efficient and reduce adverse events compared with conventional daily administration in the first-line chemotherapy for advanced gastric cancer. METHODS: 132 patients with advanced gastric cancer were randomly assigned to 1:2 ratios to receive treatment with daily at a standard dose of 80 mg/m2/day or alternate-day administration group received S-1 on 4 days a week. The primary end point was progression-free survival (PFS), and the secondary end points were safety, overall survival, time to treatment failure (TTF), disease control rate, and response rate. RESULTS: The 6-month PFS rate of the alternate-day administration group was 20.9% and failed to show significant difference from the pre-specified threshold at 15% (p = 0.117), whereas that of the daily administration group was 39.1% and significantly higher than the threshold (p = 0.001). The hazard ratio of the alternate-day administration group compared with the daily administration group was 1.753 (95% confidence interval (CI) 1.15-2.68, p = 0.010). With regard to OS, the hazard ratio of the alternate-day administration group compared with the daily administration group was 1.487 (95% CI 0.97-2.29, p = 0.072). The median TTF were 4.2 and 2.8 months in the daily and alternate-day administration group, respectively (p = 0.007). CONCLUSION: The alternate-day administration of S-1 was not recommended as the first-line therapy for patients with advanced gastric cancer.

Continuous Intraoperative Neuromonitoring Study Using Pigs for the Prevention of Mechanical Recurrent Laryngeal Nerve Injury in Esophageal Surgery.

PURPOSES: During esophageal surgery, clamping injury and injury associated with the use of energy devices are common mechanisms underlying intraoperative recurrent laryngeal nerve (RLN) damage. Recently, intraoperative neuromonitoring (IONM) has been applied to prevent RLN injury. This study was aimed at investigating the changes in the EMG signals associated with clamping injury of the RLN caused by picking up of the nerve with tweezers in domestic pigs. METHODS: Six domestic pigs (12 RLNs) underwent continuous IONM (CIONM) by our original automated periodic vagal nerve stimulation method. RESULTS: Our system can be used safely and accurately. The signals showed a decrease of the amplitude when the RLN was picked up and closed slowly by the double-action Maryland with jaw covers. If the clamp was released before the signal amplitude decreased to 50% of the baseline, the signal showed gradual recovery to the baseline in 12 ± 3 minutes. CONCLUSION: Although there were limitations in our study using domestic pig, including the small sample size, our results are expected to contribute to a decrease in the incidence of RLN damage during esophageal surgery.

Breakthrough chemotherapy-induced nausea and vomiting: report of a nationwide survey by the CINV Study Group of Japan.

BACKGROUND: We conducted a nationwide survey on chemotherapy-induced nausea and vomiting (CINV) in Japan and demonstrated good compliance with Japanese CINV guidelines, resulting in good control of vomiting. However, almost half the patients experienced breakthrough CINV. We analyzed the survey results in relationship to the management of patients with breakthrough CINV. METHODS: This multicenter, prospective, observational study analyzed data for 1910 patients in Japan scheduled for moderately or highly emetogenic chemotherapy (MEC and HEC, respectively). Patients who developed CINV despite prophylactic use of antiemetics were administered rescue drugs. Patients who received cisplatin-based HEC (C-HEC), non-cisplatin-based HEC (N-HEC), or MEC were evaluated separately. RESULTS: A total of 989 patients experienced CINV, of whom 412 (44%) received rescue antiemetics during the study period. The rate at which patients with breakthrough CINV were started on rescue drugs ranged from 13% to 24%. Rescue drugs were given more frequently on days 2-4 for C-HEC and MEC and on days 1-2 for N-HEC. Eighty-six percent of patients received metoclopramide or domperidone. 5-HT3 receptor antagonists, antipsychotics, and anti-anxiety drugs were used for 11-5% of patients. The mean duration of antiemetic use was 2.6 days. CONCLUSIONS: Fewer than half of the patients with breakthrough CINV were treated with rescue antiemetics, suggesting that CINV was mild in the remaining patients. However, CINV was sufficiently severe to prevent eating in other patients, indicating the need for new drugs with different mechanisms to control CINV.

Blood flow evaluation using PINPOINT® in a case of incarcerated inguinal hernia: A case report.

Indocyanine green (ICG) fluorescence for intestinal blood flow has been reported, but application during laparoscopic surgery for incarcerated inguinal hernia has not been reported. Here, we report the case of a patient with an incarcerated inguinal hernia in whom the bowel was preserved after evaluation of intestinal blood flow with ICG fluorescence using PINPOINT®, a brightfield full-color, near-infrared fluorescence camera. A man in his 80s was diagnosed with incarcerated inguinal hernia and underwent laparoscopic surgery. The ascending colon and mesentery showed deep red discoloration on gross evaluation. However, intravenous injection of ICG revealed uniform fluorescence of the mesentery and bowel wall, indicating the absence of irreversible ischemic changes of the bowel. As such, no resection was performed, and transabdominal preperitoneal patch plasty was completed. The patient had a good postoperative course. In this case, ICG fluorescence with the PINPOINT was useful to avoid bowel resection during laparoscopic surgery.

Crus incision without repair is a risk factor for esophageal hiatal hernia after laparoscopic total gastrectomy: a retrospective cohort study.

BACKGROUND: Although postoperative esophageal hiatal hernia (EHH) is primarily considered a post-operative complication of esophagectomy, it is also a rare post-operative complication of laparoscopic total gastrectomy (LTG), with a reported incidence rate of 0.5 %. The purpose of this study is to analyze the incidence, clinical features, and prevention of EHH following LTG for gastric cancer. METHODS: Between October 2008 and July 2014, 78 patients who underwent LTG for gastric cancer in our hospital were analyzed. We compared the crus incision group (in which the left crus of the diaphragm was incised without suture repair) with the crus conserving or repair group (in which the crus was preserved or the crus was incised and underwent suture repair). The primary endpoint was incidence of postoperative EHH. RESULTS: Of the 78 patients, 7 (9.0 %) developed postoperative EHH. Three of seven patients (42.9 %) were symptomatic and required an emergency operation for intestinal obstruction. Four of seven patients (57.1 %) were asymptomatic and did not require an operation. Incising the left crus of the diaphragm without suture repair during LTG was considered the only risk factor for postoperative EHH (0 of 29 for preserving the crus or incising and performing suture repair of the crus vs. 7 of 49 in crus incision without suture repair; p = 0.033). CONCLUSIONS: The present data suggest that incision of the crus without suture repair is associated with EHH after LTG. If crus incision is required, crus repair may be effective for the prevention of postoperative EHH.

A case of incarcerated femoral hernia with intestinal blood flow assessment by brightfield full-color near-infrared fluorescence camera: Report of a case.

INTRODUCTION: Indocyanine green (ICG) fluorescence has been reported for examining intestinal blood flow (IBF), but not in the case of bowel released from entrapment in a femoral hernia. We report the case of a patient with incarcerated obturator femoral hernia in whom the bowel was preserved after evaluation of IBF with ICG fluorescence using a brightfield full-color near-infrared fluorescence camera. PRESENTATION OF CASE: A woman in her 60s was diagnosed with incarcerated femoral hernia and underwent surgery. Laparotomy was performed to reduce bowel incarceration via an anterior approach. The small bowel showed deep-red discoloration on gross evaluation, but intravenous injection of ICG revealed uniform fluorescence of the mesentery and bowel wall. This indicated an absence of irreversible ischemic changes to the bowel, so resection was not performed and a modified Kugel herniorrhaphy was performed. The patient showed a good postoperative course. CONCLUSION: In herniorrhaphy with mesh, minimization of bowel resection is important for preventing postoperative infection of the mesh. In this case, ICG fluorescence with a near-infrared fluorescence camera was central to reducing bowel resection. ICG fluorescence may be useful for evaluating IBF in surgery for incarcerated femoral hernias.