The integration of the intracorporeal triangular anastomotic technique in robotic distal gastrectomy: advancing patient safety and procedural simplicity

BACKGROUND

Robotic distal gastrectomy (RDG) with Billroth I (BI) reconstruction is predominantly performed due to its physiological congruence and simplicity. The Intracorporeal Triangular Anastomotic Technique (INTACT) aims to reduce ischemic areas compared to the conventional Delta-shaped anastomosis using the unique characteristics of robotic surgery to standardize procedures, thereby ensuring safe, simple, and reliable reconstruction. This study aims to investigate the efficacy of the INTACT in RDG with BI reconstruction, focusing on its robotic precision in minimizing ischemic zones and improving surgical reliability.

SURGICAL TECHNIQUE

The posterior duodenal wall is dissected before reconstruction, and the hepatoduodenal ligament is severed to facilitate passive duodenal manipulation. A quarter-circumference incision is created centrally on the anterior wall of the duodenal stump to avoid excessive tension during anastomosis and to ensure an adequate anastomotic diameter. A small opening is established on the greater curvature of the remaining stomach, and the posterior walls of the stomach and duodenum are joined using a Linear stapler in the first fire. A V-shape is created, and two EndoWrist instruments (robotic first and fourth arms) are utilized to grip and extend the anastomosis diameter, completing the anastomosis with a shared hole closure using the Linear stapler. The robotic arms' features improve the physiological integrity and stability of the BI reconstruction.

RESULTS

A total of 81 patients underwent RDG with INTACT from September 2020 to January 2024. The median age was 72 years (range: 31-91), with 49 males and 32 females. The median blood loss was 0 ml (range: 0-200 ml), and the median postoperative hospital stay was 8 days (range: 6-20 days). No cases required reanastomosis during surgery, and no postoperative anastomotic leakage, surgery-related reoperations, or anastomotic strictures were reported.

CONCLUSION

INTACT in RDG can be safely performed. The characteristics of the EndoWrist instruments helped in stabilizing the technique, making it a viable option in robotic-assisted surgeries.

Enhancing surgical outcomes in elderly gastric cancer patients: the role of comprehensive preoperative assessment and support

BACKGROUND

As the prevalence of gastric cancer rises in aging populations, managing surgical risks and comorbidities in elderly patients presents a unique challenge. The Comprehensive Preoperative Assessment and Support (CPAS) program, through comprehensive preoperative assessments, aims to mitigate surgical stress and improve outcomes by enhancing patient awareness and preparation. This study investigates the efficacy of a CPAS program, incorporating frailty and sarcopenia evaluations, to improve short-term outcomes in elderly gastric cancer patients.

METHODS

A retrospective analysis was conducted on 127 patients aged 75 or older who underwent surgery with CPAS between 2018 and August 2023, compared to 170 historical controls from 2012 to 2017. Propensity score matching balanced both groups based on age-adjusted Charlson Comorbidity Index and surgical details. The primary focus was on the impact of CPAS elements such as rehabilitation, nutrition, psychological support, oral frailty, and social support on short-term surgical outcomes.

RESULTS

Among 83 matched pairs, the CPAS group, despite 40.4% of patients in the CPAS group and 21.2% in the control group had an ASA-PS score of 3 or higher (P < 0.001), demonstrated significantly reduced blood loss (100 ml vs. 190 ml, P = 0.026) and lower incidence of serious complications (19.3% vs. 33.7%, P = 0.034), especially in infections and respiratory issues. Sarcopenia was identified in 38.6% of CPAS patients who received tailored support. Additionally, the median postoperative hospital stay was notably shorter in the CPAS group (10 days vs. 15 days, P < 0.001), with no in-hospital deaths. These results suggest that personalized preoperative care effectively mitigates operative stress and postoperative complications.

CONCLUSION

Implementing CPAS significantly enhances surgical safety and reduces complication rates in elderly gastric cancer patients, emphasizing the critical role of personalized preoperative care in surgical oncology for this demographic.

Early detection of occupational cholangiocarcinoma in a high-risk patient under intensive surveillance: a case study

BACKGROUND

Occupational cholangiocarcinoma is associated with exposure to organic solvents, such as dichloromethane (DCM) and 1,2-dichloropropane (DCP). This report describes a case of occupational cholangiocarcinoma detected through regularly imaging following the discovery of elevated serum γ-glutamyl trans peptidase (γ-GTP) levels revealed during regular checkup.

CASE PRESENTATION

A 43-year-old man who had been working in a printing company with 15 years of exposure to organic solvents presented to our hospital owing to abnormalities found during a routine checkup. Ultrasound (US) imaging revealed thickening of the gallbladder wall accompanied by gallstones, although in the blood tests, γ-GTP levels were within normal range. Given the high risk of cholangiocarcinoma development, the patient underwent regular monitoring with abdominal US and blood tests at a local doctor's office. At the age of 48, his serum γ-GTP level mildly elevated for the first time, prompting the initiation of semi-annual magnetic resonance cholangiopancreatography (MRCP). By the age of 50 years, dilation in B8 was detected, and one and a half years later, a tumor on the central side of the B8 dilation appeared. The patient was diagnosed with intrahepatic cholangiocarcinoma, which was treated with anterior sectionectomy. Pathological examination revealed an adenocarcinoma with a papillary glandular ductal structure at the root of the B8. In addition, biliary intraepithelial neoplasia (BilIN) and dysplasia have been identified around the tumor and periphery bile ducts and in noncancerous bile ducts. Postoperatively, the patient received 6 months of adjuvant chemotherapy with S-1monotherapy. Eight months after surgery, the patient remained under observation with no signs of recurrence.

CONCLUSIONS

We report a case of occupational cholangiocarcinoma detected during a prolonged period of regular follow-up after exposure to DCM and DCP. Given the delayed carcinogenesis process, occupational cholangiocarcinomas manifest long after exposure to organic solvents, therefore, ongoing screening is extremely important. Vigilance is essential to avoid underdiagnosis, particularly for individuals who are at an increased risk of developing this form of cancer. Continuous monitoring is key to the early detection and effective management of occupational cholangiocarcinoma.

Skeletal Muscle Electrical Stimulation Prevents Progression of Disuse Muscle Atrophy via Forkhead Box O Dynamics Mediated by Phosphorylated Protein Kinase B and Peroxisome Proliferator-Activated Receptor gamma Coactivator-1alpha

Although electrical muscle stimulation (EMS) of skeletal muscle effectively prevents muscle atrophy, its effect on the breakdown of muscle component proteins is unknown. In this study, we investigated the biological mechanisms by which EMS-induced muscle contraction inhibits disuse muscle atrophy progression. Experimental animals were divided into a control group and three experimental groups: immobilized (Im; immobilization treatment), low-frequency (LF; immobilization treatment and low-frequency muscle contraction exercise), and high-frequency (HF; immobilization treatment and high-frequency muscle contraction exercise). Following the experimental period, bilateral soleus muscles were collected and analyzed. Atrogin-1 and Muscle RING finger 1 (MuRF-1) mRNA expression levels were significantly higher for the experimental groups than for the control group but were significantly lower for the HF group than for the Im group. Peroxisome proliferator-activated receptor gamma coactivator-1alpha (PGC-1alpha) mRNA and protein expression levels in the HF group were significantly higher than those in the Im group, with no significant differences compared to the Con group. Both the Forkhead box O (FoxO)/phosphorylated FoxO and protein kinase B (AKT)/phosphorylated AKT ratios were significantly lower for the Im group than for the control group and significantly higher for the HF group than for the Im group. These results, the suppression of atrogin-1 and MuRF-1 expression for the HF group may be due to decreased nuclear expression of FoxO by AKT phosphorylation and suppression of FoxO transcriptional activity by PGC-1alpha. Furthermore, the number of muscle contractions might be important for effective EMS.

A comprehensive study on non-cancer-related mortality risk factors in elderly gastric cancer patients post-curative surgery

BACKGROUND

The increasing incidence of gastric cancer in the elderly underscores the need for an in-depth understanding of the challenges and risks associated with surgical interventions in this demographic. This study aims to investigate the risk factors and prognostic indicators for non-cancer-related mortality following curative surgery in elderly gastric cancer patients.

METHODS

This retrospective analysis examined 684 patients with pathological Stage I-III gastric cancer who underwent curative resection between January 2012 and December 2021. The study focused on patients aged 70 years and above, evaluating various clinical and pathological variables. Univariate analysis was utilized to identify potential risk factors with to non-cancer-related mortality and to access prognostic outcomes.

RESULTS

Out of the initial 684 patients, 244 elderly patients were included in the analysis, with 33 succumbing to non-cancer-related causes. Univariate analysis identified advanced age (≥ 80 years), low body mass index (BMI) (< 18.5), high Charlson Comorbidity Index (CCI), and the presence of overall surgical complications as significant potential risk factors for non-cancer related mortality. These factors also correlated with poorer overall survival and prognosis. The most common cause of non-cancer-related deaths were respiratory issues and heart failure.

CONCLUSION

In elderly gastric cancer patients, managing advanced age, low BMI, high CCI, and minimizing postoperative complications are essential for reducing non-cancer-related mortality following curative surgery.

A distal ileum malignant peripheral nerve sheath tumour after abdominal radiation therapy: case report of a rare tumour

Malignant peripheral nerve sheath tumours (MPNSTs) are malignant tumours arising from a peripheral nerve or displaying nerve sheath differentiation. Most MPNSTs are found on the head, body trunk and extremities, whereas cases in the gastrointestinal are extremely rare. About half arise in neurofibromatosis type 1 patients and 10% arise post-irradiation. This is probably the first small bowel MPNST post-radiation therapy case reported. A 72-year-old female who received radiotherapy 30 years ago for cervical cancer was admitted with progressive abdominal pain and weight loss. Computed tomography revealed a mass with inhomogeneous enhancement in the lumen of the small intestine. Tumour excision was performed with ileocecal and sigmoid colon resection due to suspicion for peripheral tissue invasion. Histopathological examination revealed spindle-shaped cells with focal cartilage differentiation. Together with immunochemistry stain showing complete loss of H3K27me3, a final diagnosis of MPNST was made. The patient is presently under regular follow-ups, and has remained disease-free for 24 months.

[A Case of Locally Advanced Giant Sigmoid Colon Cancer Successfully Treated with Neoadjuvant Chemotherapy]

A 51-year-old woman presented to our hospital complaining of a lower abdominal mass and dysuria. She was diagnosed with advanced sigmoid colon cancer. The tumor was large, involving the bladder, and occupying the pelvic cavity. She received neoadjuvant chemotherapy with 4 courses of mFOLFOX6, in addition to panitumumab. The treatment resulted in a marked reduction of the tumor. A laparoscopic sigmoid colon resection, total cystectomy, neobladder reconstruction, complete uterine and bilateral adnexa resection and partial ileal resection were performed. The histopathological diagnosis was ypT4b(bladder), ypN0, ypStage Ⅱc, all with negative surgical margins. Adjuvant chemotherapy was not administered owing to the patient's refusal. She remained recurrence-free for 3 years of postoperative follow up.

A rare intrahepatic splenosis mimicking hepatocellular carcinoma: A case report

Intrahepatic splenosis (IHS) is a rare disease that is considered to result from heterotopic autotransplantation or implantation of splenic tissue after splenic trauma or surgery. A 46-year-old man with a treatment history of a left lateral liver segmentectomy and splenectomy for a road traffic injury 30 years earlier presented to Sakai City Medical Center (Sakai, Japan) with acute abdominal pain in November 2019. Physical examination showed no significant signs, and serum data were normal. Computed tomography revealed a hypodense mass measuring 2.5x1.7 cm in segment 7 of the liver. Gadoxetic acid-enhanced magnetic resonance imaging showed early enhancement in the arterial phase and washout in the delayed phase. Therefore, laparoscopic surgery was performed with a preoperative diagnosis of hepatocellular carcinoma. Pathological examination of the tumor showed IHS. The postoperative course was uneventful, and the patient developed no new abnormal region in the liver during 2 years of follow-up. The present study presented a case of IHS assumed to be hepatocellular carcinoma. IHS should be considered as a differential diagnosis of a liver mass detected years after splenic trauma or surgery, even in cases with imaging patterns suggesting malignancy.

Development of a novel animal model of rotator cuff tear arthropathy replicating clinical features of progressive osteoarthritis with subchondral bone collapse

OBJECTIVE

To establish an animal model of modified cuff tear arthropathy (mCTA) in order to better replicate the pathophysiology associated with rotator cuff tear-induced humeral head collapse.

DESIGN

mCTA was induced by transection of the rotator cuff, the long head of the biceps brachii (LHB), and superior half of the joint capsule in the right shoulder of 12-week-old rats; the left shoulder underwent sham surgery. The severity of CTA was quantitated using the Murine Shoulder Arthritis Score (MSAS). The trabecular bone of the humeral head and metaphysis was analyzed using bone histomorphometry. The expression of proinflammatory cytokines and catabolic enzymes was evaluated immunohistochemically.

RESULTS

In the mCTA model, the MSAS increased starting from 2 weeks after induction, and there was notable subchondral bone collapse with fibrous cells at 4 weeks. The mCTA cartilage exhibited positive staining for TNF-α, IL-1β/6, MMP-3/13, and ADAMTS5. The trabecular bone volume was reduced not only in the subchondral bone but also in the metaphysis of the humeri, and bone resorption was enhanced in these areas. In the collapsed subchondral bone, both bone formation and resorption were increased. The fibrous cells showed expression of TNF-α, IL-6, and MMP-13, along with specific markers of mesenchymal stem cells. Furthermore, the fibrous cells showed osteoblastic characteristics (RUNX2-positive) and expressed RANKL.

CONCLUSIONS

The LHB and the capsuloligamentous complex are critical stabilizers of the glenohumeral joint, serving to prevent the advancement of CTA following massive rotator cuff tears. Fibrous cells appear to play a role in the humeral head bone resorption.

CD204⁺ tumor-associated macrophages are associated with clinical outcome in canine pulmonary adenocarcinoma and transitional cell carcinoma

Tumor-associated macrophages are abundant infiltrating cells in the tumor microenvironment (TME). Macrophages can be classified into several types of subsets based on their immune responses. Among those subsets, M2 macrophages contribute to anti-inflammatory responses and create an immunosuppressive environment that promotes tumor cell proliferation. In a previous study, human cancer patients with high M2 macrophages showed a worse prognosis for many types of tumors. However, studies examining the relationship between M2 macrophages and clinical outcomes in canine tumors are limited. In the previous human and canine studies, CD204 has been used as the marker for detecting M2 macrophages. Then we evaluated CD204+ and total macrophages infiltration and its association with clinical outcomes in canine solid tumors. In this study, we examined dogs with oral malignant melanoma (OMM), pulmonary adenocarcinoma (PA), hepatocellular carcinoma (HCC), and transitional cell carcinoma (TCC). Compared to healthy tissues, CD204+ and total macrophages were increased in OMM, PA, and TCC, but not in HCC. High CD204+ macrophage levels were significantly associated with lung metastasis in TCC (P = 0.030). Kaplan-Meier analysis revealed that high CD204+ macrophage levels were associated with shorter overall survival (OS) in canine patients with PA (P = 0.012) and TCC (P = 0.0053). These results suggest that CD204+ macrophages contribute to tumor progression and could be a prognostic factor in dogs with PA and TCC.

Minimizing invasiveness and simplifying the surgical procedure for upper and middle early gastric cancer with near-infrared light and organ traction

BACKGROUND

Surgeons are often faced with optimal resection extent and reconstructive method problems in laparoscopic gastrectomy for gastric cancer in the upper and middle body of the stomach. Indocyanine green (ICG) marking and Billroth I (B-I) reconstruction were used to solve these problems with the organ retraction technique.

CASE PRESENTATION

A 51-year-old man with upper gastrointestinal endoscopy revealed a 0-IIc lesion in the posterior wall of the upper and middle gastric body 4 cm from the esophagogastric junction. Clinical T1bN0M0 (clinical stage IA) was the preoperative diagnosis. Laparoscopic distal gastrectomy (LDG) and D1 + lymphadenectomy was decided to be performed considering postoperative gastric function preservation. The ICG fluorescence method was used to determine the accurate tumor location since the determination was expected to be difficult to the extent of optimal resection with intraoperative findings. By mobilizing and rotating the stomach, the tumor in the posterior wall was fixed in the lesser curvature, and as large a residual stomach as possible was secured in gastrectomy. Finally, delta anastomosis was performed after increasing gastric and duodenal mobility sufficiently. Operation time was 234 min and intraoperative blood loss was 5 ml. The patient was allowed to be discharged on postoperative day 6 without complications.

CONCLUSION

The indication for LDG and B-I reconstruction can be expanded to cases where laparoscopic total gastrectomy or LDG and Roux-en-Y reconstruction has been selected for early-stage gastric cancer in the upper gastric body by combining preoperative ICG markings and gastric rotation method dissection.

[Successful Treatment with TACE and RFA for a Hepatocellular Carcinoma Case with Lung Metastasis]

We report a hepatocellular carcinoma(HCC)case with lung metastasis that was successfully treated with transarterial chemoembolization(TACE)and percutaneous radiofrequency ablation(RFA). A man in his 60s took right robe liver resection for HCC after TACE for its rupture. Lung metastasis occurred at S1+2 and S6 in the left lung, and an adverse event interrupted standard molecular target therapies. Because extrahepatic metastasis had been seen only in these two locations for a long time, TACE was performed for both metastases. The feeders for both lesions were each intercostal artery, and controlling the drug inflow was necessary to avoid drug influx into the spinal cord branches when S6 metastasis was treated. The viable lesion remained in the S6 lesion, so RFA was added for both lung metastases. 100% tumor necrosis has been observed since the RFA.

[A Case Report of Stage Ⅳb Thoracic Esophageal Cancer Responding to Multidisciplinary Treatment]

A 68-year-old man was referred to our hospital because of back pain during swallowing. Upper gastrointestinal endoscopy revealed a lower esophageal type 3 tumor. The patient was diagnosed with esophageal squamous cell carcinoma by the biopsy specimen. CT scan showed thoracic lower esophagus wall thickening, left paracardiac lymph node swelling, and a low-density area in the liver. Therefore, the patient was diagnosed with Stage Ⅳb esophageal cancer. After introducing cisplatin plus 5-FU combination therapy, the liver metastasis disappeared. After 9 chemotherapy courses, the patient received radical chemoradiotherapy. After completing chemoradiotherapy, the patient was followed up without any treatment. After 3 years since the treatment initiation, the patient is surviving without any relapse.

[Case of Robot-Assisted Low Anterior Resection with Total Cystectomy for Rectal Cancer Invading the Urinary Bladder/Prostate in Collaboration with Urologists]

We present a case of a 72-year-old man diagnosed with rectal cancer invading the urinary bladder/prostate. Preoperative chemoradiotherapy substantially reduced the tumor size. In collaboration with urologists, robot-assisted low anterior resection with total cystectomy was performed using the da Vinci Xi system. Depending on the surgical situation, the colorectal surgeon and urologist could smoothly and rapidly play the role of a console surgeon. Although the first robot-assisted multi-organ resection of our institution, the surgery was completed safely without any complications. Although the patient developed urinary tract infection postoperatively, he recovered and was discharged after postoperative 23 days. In conclusion, robot-assisted surgery would be useful in pelvic surgery involving multiple departments such as colorectal surgery, urology, and gynecology.

AB0971 Relationship between walking speed and lower limb skeletal muscle mass in patients with knee joint disorders

Background

Knee joint disorder is one of the factors causing frailty in the elderly, which is associated with a decrease in walking speed.

Objectives

We measured the walking speed of patients scheduled to undergo primary total knee arthroplasty (TKA) and examined factors correlated with walking speed.

Methods

The patients with knee disorders scheduled to undergo knee arthroplasty at our hospital between July 2020 and May 2021 were included. They were assessed for basic attributes, clinical assessment including Kness Society Score (KSS), degree of pain on walking by visual analogue scale (VAS), range of motion (ROM), and also leg skeletal muscle mass index (SMI; whole-body mode DXA), quadriceps strength by dynamometer with written consent (UMIN ID: 000040940). And Japanese Cardiovascular Health Study criteria for frailty, and sarcopenia by Asian Working Group for Sarcopenia 2019 criteria were evaluated.

Results

Demographic data of 83 patients (65 women, mean age 74.9 years) included in this study was shown in Table 1. The distribution in frailty is 36.2% and that in sarcopenia is 7.3%. Most of the patients with frailty with knee disorder did not suffer from sarcopenia. A multivariate analysis was conducted with walking speed as the objective variable and the dependent variables as age, gender, pain VAS on walking, KSS, leg SMI, quadriceps strength, and ROM. The results showed that age and ROM in flexion were significantly and independently associated with walking speed (P=0.01, 0.03). Gender, pain VAS on walking, KSS, leg SMI, quadriceps strength, and ROM in extension were not significantly associated with walking speed (P=0.92, 0.11, 0.11, 0.52, 0.85, 0.52).

Conclusion

Among the patients with knee disorders immediately before arthroplasty, frailty was not caused by sarcopenia. Age was found to be the most correlated factor with walking speed, and walking speed became slower with age. In addition, poor flexion angle was also the factor for delayed walking speed, but it did not correlate with lower limb skeletal muscle mass or quadriceps strength. In this study pain on walking was not significant factor for walking speed, because it was observed in most of all cases.

FactorGroup　disease (n)osteoarthritis78 (94%)　rheumatoid arthritis5 (6.0%)body mass index (kg/m2)　25.54 (4.11)pain VAS on walking　37.08 (26.35)total Knee Society Score　77.66 (27.85)range of motion (degree)flexion119.46 (12.88)　extension-9.58 (6.59)quadriceps power (N)　122.00 [53.00, 350.00]waling speed (m/sec)　0.95 (0.33)grip power (kg)　20.24 (6.97)skeletal muscle mass index (kg/m2)appendicular6.50 [4.92, 9.85]　lower limb5.06 [3.76, 7.56]Frailty (n)none10 (12.5%)Pre-frail41 (51.2%)　frail29 (36.2%)Sarcopenia (n)none76 (92.7%)sarcopenia4 (4.9%)　severe sarcopenia2 (2.4%)

mean (standard deviation)

; median [min max]

Disclosure of Interests

None declared

[A Case of Advanced Hepatocellular Carcinoma That Caused Rapid Re-Growth Due to Lenvatinib Withdrawal]

Lenvatinib is reported to have a stronger angiogenesis-inhibiting effect in hepatocellular carcinoma(HCC)than sorafenib, but in many cases dose reduction and withdrawal are required due to the occurrence of adverse events. We report 12 cases of using lenvatinib for advanced HCC in our hospital together with a case of rapid re-growth due to withdrawal of lenvatinib. In 2 cases, metastases of HCC were controlled and radically resected. All patients required lenvatinib withdrawal due to Grade 3 adverse event, except for 2 cases that started with dose reduction. There were 3 cases in which drug withdrawal was required for 2 weeks or more, and in 2 of them, rapid re-growth of tumor was observed during the drug withdrawal and the treatment could not be continued. Although the use of lenvatinib may results in tumor shrinkage, suggesting that prolonged drug withdrawal may make disease management difficult. It is important to manage adverse events and minimize days of drug withdrawal by reducing the dose and systematically discontinuing the drug.

Tea crude extracts effectively inactivate severe acute respiratory syndrome coronavirus 2

It is well known that black and green tea extracts, particularly polyphenols, have antimicrobial activity against various pathogenic microbes including viruses. However, there is limited data on the antiviral activity against severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), which emerged rapidly in China in late 2019 and which has been responsible for coronavirus disease 2019 (COVID‐19) pandemic globally. In this study, 20 compounds and three extracts were obtained from black and green tea and found that three tea extracts showed significant antiviral activity against SARS‐CoV‐2, whereby the viral titre decreased about 5 logs TCID₅₀ per ml by 1·375 mg ml⁻¹ black tea extract and two‐fold diluted tea bag infusion obtained from black tea when incubated at 25°C for 10 s. However, when concentrations of black and green tea extracts were equally adjusted to 344 µg ml⁻¹, green tea extracts showed more antiviral activity against SARS‐CoV‐2. This simple and highly respected beverage may be a cheap and widely acceptable means to reduce SARS‐CoV‐2 viral burden in the mouth and upper gastrointestinal and respiratory tracts in developed as well as developing countries.

A safe and simple procedure for laparoscopic hepatectomy with combined diaphragmatic resection

Diaphragmatic resection may be required beneath the diaphragm in some patients with liver tumors. Laparoscopic diaphragmatic resection is technically difficult to secure in the surgical field and in suturing. We report a case of successful laparoscopic hepatectomy with diaphragmatic resection. A 48-year-old man who underwent laparoscopic partial hepatectomy for liver metastasis of rectal cancer 20 months ago underwent surgery because of a new hepatic lesion that invaded the diaphragm. The patient was placed in the left hemilateral decubitus position. The liver and diaphragm attachment areas were encircled using hanging tape. Liver resection preceded diaphragmatic resection with the hanging tape in place. Two snake retractors were used to secure the surgical field for the inflow of CO₂ into the pleural space after diaphragmatic resection. The defective part of the diaphragm was repaired using continuous or interrupted sutures. Both ends of the suture were tied with an absorbable suture clip without ligation. In laparoscopic liver resection with diaphragmatic resection, the range of diaphragmatic resection can be minimized by performing liver resection using the hanging method before diaphragmatic resection. The surgical field can be secured using snake retractors. Suturing with an absorbable suture clip is conveniently feasible.

In vitro evidence of propagation of superoxide dismutase-1 protein aggregation in canine degenerative myelopathy

Canine degenerative myelopathy (DM) is a progressive and fatal neurodegenerative disorder that has been linked to mutations in the superoxide dismutase 1 (SOD1) gene. The accumulation of misfolded protein aggregates in spinal neurons and astrocytes is implicated as an important pathological process in DM; however, the mechanism of protein aggregate formation is largely unknown. In human neurodegenerative diseases, such as amyotrophic lateral sclerosis (ALS), cell-to-cell propagation of disease-relevant proteins has been demonstrated. Therefore, in this study, propagation of aggregation-forming property of mutant SOD1 protein in DM in vitro was investigated. This study demonstrated that aggregates composed of canine wild type SOD1 protein were increased by co-transfection with canine mutant SOD1 (E40K SOD1), indicating intracellular propagation of SOD1 aggregates. Further, aggregated recombinant SOD1 proteins were released from the cells, taken up by other cells, and induced further aggregate formation of normally folded SOD1 proteins. These results suggest intercellular propagation of SOD1 aggregates. The hypothesis of cell-to-cell propagation of SOD1 aggregates proposed in this study may underly the progressive nature of DM pathology.

Retrograde endoscopic submucosal dissection for early thoracic esophageal carcinoma

Although the standard treatment for intramucosal esophageal cancer without lymph node metastasis is endoscopic submucosal dissection (ESD), we sometimes encounter patients who are not able to undergo a transoral endoscopic examination. Here, we report a surgical procedure consisting of transgastric retrograde ESD to treat early esophageal cancer (T1a-EP, N0, M0) because of a stricture after hypopharyngeal cancer surgery. This retrograde ESD procedure can be a safe and effective treatment option for early esophageal cancer. This is the first report of a surgical retrograde ESD method for esophageal cancer.

[Ascending Colon Cancer with Hemophilia A Treated with Laparoscopic Right Hemicolectomy under Control of a Blood Coagulant Factor-A Case Report]

Here, we report a case of ascending colon cancer successfully treated with laparoscopic right hemicolectomy in a 74- year-old man with a medical history of hemophilia A. He was admitted to our hospital because of bloody stool and diagnosed with type 2 ascending colon cancer based on colonoscopy findings. Preoperatively, blood transfusion and administration of recombinant factor Ⅷ products were performed. Surgery involved laparoscopic right hemicolectomy plus group 3 lymph node dissection. No complications, such as bleeding, occurred during hospitalization. The patient was discharged on postoperative day 8. There have been a few reports of laparoscopic surgery for patients with hemophilia. However, this case suggests that it can be safely performed with planned factor Ⅷ supplementation in the perioperative period.

Utility of novel Omnipolar activation mapping for the detection of ventricular premature contraction origin

Background

Bipolar electrograms are significantly influenced by direction of the propagating wavefront in relation to the recording bipole. Omnipolar voltage mapping may be superior to standard bipolar mapping since it obtains maximum voltage of all possible bipolar electrode orientations without the need for catheter rotation. Therefore, omnipolar maps can provide voltage maps with larger voltages as well as better defined boundaries.

Purpose

Whether omnipolar activation maps also describe better activation maps versus traditional bipolar maps during ventricular premature contraction (VPC) catheter ablation is unclear.

Methods

A high-density mapping catheter was advanced to the ventricular outflow tract and a high-resolution activation map was created. Each electrode along and across the splines of the catheter are 4mm apart. Bipoles were calculated along (MAP 2), across (MAP 3) and bidirectional (MAP 4) the splines while omnipoles (MAP 1) were derived from a right triangle clique. Within a square area, four omnipolar and two bipolar values along, across and bidirectional values were defined.

Results

Though the earliest activation site was vague by along and across maps (arrow), white color became evident by bidirectional map, and the VPC origin became distinct with omnipolar mapping. RF lesions were given via an open-irrigated ablation catheter targeting a lesion size index 5.0. The VPC was eliminated by radiofrequency ablation.

Conclusion

Omnipolar activation mapping may be more accurate than traditional bipolar mapping during ventricular premature contraction (VPC) catheter ablation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Time course of improvement in novel nitric oxide-regulated hormones in response to exercise training in middle-aged and older adults

Introduction

Cardiovascular disease risk augments with advance of age. The mechanism of the increased cardiovascular disease risk by aging is related to attenuation of arterial function via endothelium-derived relaxing factor, such as nitric oxide (NO). Recently, apelin and adropin have identified as NO-upregulated hormones, whereas augmented secretion of asymmetric dimethylarginine (ADMA) have identified as NO-downregulated hormones. However, the effects of exercise training-induced changes in NO-regulated hormones on the reduction of arterial stiffness via NO productions remain unclear.

Purpose

This study aimed to determine the time-dependent changes in NO-regulated hormones related to exercise-training effects of arterial stiffness via NO productions in healthy middle-aged and older adults.

Methods

Thirty-two Japanese healthy middle-aged and older subjects (67±1 years) were randomly divided into two groups: exercise intervention and sedentary controls. Subjects in the training group completed 8-week of aerobic exercise training (60–70% peak oxygen uptake [VO2peak] for 45 min, 3 days/week). We evaluated plasma nitrite/nitrate (NOx), apelin, and ADMA levels, serum apelin level and carotid-femoral pulse wave velocity (cfPWV) as an index of arterial stiffness, measured every 2 weeks for 8-week in the training group.

Results

cfPWV was gradually declined from baseline to 8-week and significantly decreased from baseline at weeks 6 (P&lt;0.05) and 8 (P&lt;0.01). Plasma NOx level was gradually elevated during exercise intervention and significantly increased from baseline at weeks 6 (P&lt;0.05) and 8 (P&lt;0.01). Interestingly, plasma apelin and serum adropin levels were gradually elevated during exercise intervention and significantly increased from baseline at weeks 4, 6 and 8 (each P&lt;0.01). Additionally, plasma ADMA level was significantly decreased at 8-week intervention (P&lt;0.01). Furthermore, the exercise training-induced increase in plasma NOx level was significantly correlated with the changes in circulating apelin (r=0.505, P&lt;0.05), adropin (r=0.662, P&lt;0.01), or ADMA (r=−0.483, P&lt;0.05) levels before and after the 8-week. The exercise training-induced increase in plasma NOx level was significantly correlated with training-induced changes in circulating apelin (r=0.483, P&lt;0.05) or adropin (r=0.556, P&lt;0.05) before and after the 6-week.

Conclusions

These results suggest that the NO-upregulated hormones (apelin and adropin) were increased at the early stage of exercise training intervention and NO-downregulated hormone (ADMA) was decreased at the late stage of exercise training intervention, and these changes in NO-regulated hormones may be contributed to the reduction of arterial stiffness in the middle-aged and older adults.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported by a Grant-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan.

62 Time course of improvement in secretory unbalance of asymmetric dimethylarginine and nitric oxide productions in response to exercise training in middle-aged and older adults

Funding Acknowledgements

Supported by Grants-in-Aid for Scientific Research (#17H02182, #16K13059, M. Iemitsu; #18J01024, S. Fujie)

Introduction

Aging is well known to elevate risks of cardiovascular diseases. As a mechanism of these increased risks with aging, a reduction of nitric oxide (NO) production via augmented secretion of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO synthesis is related. Habitual aerobic exercise has shown to improve secretory unbalance of endothelium-derived regulating factors with aging, such as increase in NO and decrease in ADMA, resulting in the reduction of arterial stiffness. However, the time course of improvement in secretory unbalance of NO and ADMA productions in response to exercise training in middle-aged and older adults remains unclear.

Purpose

This study aimed to determine the time course of changes in plasma nitrite/nitrate (NOx) and ADMA levels related to exercise-training effects of arterial stiffness in healthy middle-aged and older adults.

Methods

Thirty-two Japanese healthy middle-aged and older subjects (67 ± 1 years) were randomly divided into two groups: exercise intervention and sedentary controls. Subjects in the training group completed 8-week of aerobic exercise training (60-70% peak oxygen uptake [VO2peak] for 45 min, 3 days/week). We evaluated plasma NOx and ADMA concentrations and carotid-femoral pulse wave velocity (cfPWV) as an index of arterial stiffness, measured every 2 weeks for 8-week in the training group.

Results

cfPWV was gradually declined from baseline to 8-week and significantly decreased from baseline at weeks 6 (P &lt; 0.05) and 8 (P &lt; 0.01). Plasma NOx level was gradually elevated during exercise intervention and significantly increased from baseline at weeks 6 (P &lt; 0.05) and 8 (P &lt; 0.01). Interestingly, plasma ADMA level was significantly decreased at 8-week intervention (P &lt; 0.05). Furthermore, the exercise training-induced reduction in plasma ADMA level was negatively correlated with the change in plasma NOx level before and after the 8-week (r = -0.483, P &lt; 0.05). The exercise training-induced change in plasma ADMA concentration was positively correlated with training-induced change in cfPWV before and after the 8-week (r = 0.633, P &lt; 0.01). Additionally, there was a negative correlation between the changes in plasma NOx level and cfPWV before and after the 8-week (r = -0.642, P &lt; 0.05).

Conclusions

These results suggest that habitual aerobic exercise can normalize the secretory unbalance of NO and ADMA productions in 6 to 8 weeks, and these balance normalizations may be contributed to the reduction of arterial stiffness in the middle-aged and older adults.

[A Case of Two Curative Resections for the Peritoneal Dissemination of Transverse Colon Cancer]

No large clinical trials have been conducted to prove the efficacy of peritoneal dissemination resection for colorectal cancer, and no evidence has shown the usefulness of resection for metachronous peritoneal dissemination. An elderly woman in her 70s underwent a laparoscopic transverse colectomy for transverse colon cancer in 2014, which was performed by another physician. The pathological diagnosis was tub2-por>muc, pT3, ly2, v0, pN2, and pStage Ⅲb. The patient was followed up with capecitabine plus oxaliplatin(CapeOX)therapy as an adjuvant chemotherapy for 6 months. Three years postoperatively, the CEA level increased to 10 ng/mL, and CT showed a nodular shadow in front of the left prerenal fascia. After the diagnosis of peritoneal dissemination recurrence and 8 courses of capecitabine plus bevacizumab therapy, other metastases were not observed. She was referred to our hospital for surgery and underwent laparoscopic peritoneal dissection at 3 years and 6 months after the first operation. Only one apparent disseminated recurrent lesion, which was resectable, was observed. However, at 4 years and 9 months after the initial operation, CT showed a recurrence of Douglas pouch peritoneal dissemination without any other obvious metastasis. Laparoscopic low anterior resection of the rectum and hysterectomy were performed. Here, we encountered a case that could be radically resected for peritoneal dissemination twice after the colon cancer surgery.