Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report

BACKGROUND

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT.

CASE PRESENTATION

A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure.

CONCLUSIONS

Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.

Prognostic significance of a novel index score based on the inflammation-based prognostic scores of patients with colorectal cancer

BACKGROUND AND AIM

This study aimed to clarify the prognostic value of various inflammation-based prognostic scores (IBPSs) in patients who underwent radical surgery for colorectal cancer (CRC) and to develop a novel prognostic index using IBPSs and other predictive factors.

METHODS

Data of 1157 patients who underwent radical surgery for CRC were reviewed. The predictive value of various IBPSs in determining the CRC prognosis was compared. A novel index score based on the IBPSs and other parameters that were associated with survival in patients with CRC was established, and its usefulness was evaluated.

RESULTS

The patients were randomly divided into the training (n = 694) and validation (n = 463) sets. Male sex (P = 0.0001), age ≥ 75 years (P < 0.0001), a carcinoembryonic antigen (CEA) level of > 5 (P = 0.0009), a C-reactive protein/albumin ratio (CAR) of ≥ 0.04 (P = 0.0033), and a prognostic nutritional index (PNI) of < 43.1 (P = 0.0004) were poor independent prognostic factors of overall survival. The novel index score was calculated based on the scores of these five prognostic factors. The Kaplan-Meier survival curves showed that the CRC patients with higher novel index scores in the training and validation datasets had poorer overall survival.

CONCLUSIONS

CAR and PNI were superior to other IBPSs for predicting the prognosis of CRC patients. The novel index score established based on sex, age, CEA level, CAR, and PNI can predict the prognosis of CRC with more precise and clearer stratification than the individual parameters alone.

Phase II clinical trial to study the safety and efficacy of combined S-1 + oxaliplatin therapy as neoadjuvant chemotherapy for locally advanced gastric cancer in older patients

BACKGROUND

Gastrectomy with D2 dissection and adjuvant chemotherapy is the standard treatment for locally advanced gastric cancer (LAGC) in Asia. However, administering chemotherapy with sufficient intensity after gastrectomy is challenging. Several trials demonstrated the efficacy of neoadjuvant chemotherapy (NAC). However, limited studies explored the feasibility of NAC-SOX for older patients with LAGC. This phase II study (KSCC1801) evaluated the safety and efficacy of NAC-SOX in patients with LAGC aged ≥ 70 years.

METHODS

Patients received three cycles of SOX130 (oxaliplatin 130 mg/m2 on day 1, oral S-1 40-60 mg twice daily for two weeks every three weeks) as NAC, followed by gastrectomy with lymph node dissection. The primary endpoint was the dose intensity (DI). The secondary endpoints were safety, R0 resection rate, pathological response rate (pRR), overall survival, and relapse-free survival.

RESULTS

The median age of 26 enrolled patients was 74.5 years. The median DI in NAC-SOX130 was 97.2% for S-1 and 98.3% for oxaliplatin. Three cycles of NAC were administered in 25 patients (96.2%), of whom 24 (92.3%) underwent gastrectomy with lymphadenectomy. The R0 resection rate was 92.3% and the pRR (≥ grade 1b) was 62.5%. The major adverse events (≥ grade 3) were neutropenia (20.0%), thrombocytopenia (11.5%), anorexia (11.5%), nausea (7.7%), and hyponatremia (7.7%). Postoperative complications of abdominal infection, elevated blood amylase, and bacteremia occurred in one patient each. Severe diarrhea and dehydration caused one treatment-related death.

CONCLUSIONS

NAC-SOX130 is a feasible therapy for older patients, although systemic management and careful monitoring of adverse events are necessary.

Prognostic Significance of Preoperative Nutritional Assessment in Elderly Patients who Underwent Laparoscopic Gastrectomy for Stage I-III Gastric Cancer

BACKGROUND/AIM

Surgery for elderly patients with gastric cancer is becoming more common. However, the risk factors of the laparoscopic surgery for these patients are unknown, and thus it is difficult to determine appropriate treatments for such patients. The aim of this retrospective study was to clarify the risk factors for the treatment outcomes after laparoscopic gastrectomy in elderly patients.

PATIENTS AND METHODS

Two hundred twenty-two patients who underwent laparoscopic gastrectomy for primary gastric cancer between January 2014 and December 2017 were enrolled. Clinical characteristics and short- and long-term prognoses were analyzed in 47 patients aged 75 years or older (elderly group) and in 175 patients who were under 75 years old (non-elderly group).

RESULTS

The presence of comorbidities was more common in the elderly group than in the non-elderly group (91.5% vs. 61.7%, p<0.0001). The rate of postoperative complications in the elderly group was significantly higher than that in the non-elderly group (42.6% vs. 22.9%, p=0.01). The 5-year overall survival rate was significantly lower in the elderly group than in the non-elderly group (66.9% vs. 92.2%; p<0.0001). In the elderly group, 5-year overall survival in patients with a low preoperative prognostic nutritional index (PNI) was significantly worse than that in patients with a high preoperative PNI (25.0% vs. 80.9%; p<0.05). Multivariate analysis showed that the PNI value was independently associated with overall survival in elderly patients who underwent laparoscopic gastrectomy (p<0.05). In particular, the rate of non-cancer deaths after surgery in elderly patients was significantly higher than that in non-elderly patients (p<0.05).

CONCLUSION

PNI value is an independent prognostic factor for overall survival in elderly patients who have undergone laparoscopic gastrectomy for gastric cancer; therefore, in elderly patients with low preoperative PNI, attention should be paid not only to recurrence of cancer, but also to the deterioration of general condition caused by malnutrition.

Comparison of Laparoscopic and Open Emergency Surgery for Colorectal Perforation: A Retrospective Study

Background: This study aimed to clarify the safety and efficacy of laparoscopic surgery for colorectal perforation by comparing the clinical outcomes between laparoscopic and open emergency surgery for colorectal perforation. Materials and Methods: We retrospectively reviewed the data of 116 patients who underwent surgery for colorectal perforation. The patients were categorized into two groups: the open group included patients who underwent laparotomy, and the laparoscopic group included those who underwent laparoscopic surgery. Clinical and operative characteristics and postoperative outcomes were evaluated. Results: The open and laparoscopic groups included 67 and 49 patients, respectively. More than half of the patients in both groups developed perforation in the sigmoid colon (open, 58.2%; laparoscopic, 61.2%). The most common cause of perforation was diverticulum, followed by colorectal cancer. The mean intraoperative blood loss was significantly lower in the laparoscopic group than in the open group (70.0 mL versus 160.3 mL; P = .0290). The incidence of surgical site infection was lower in the laparoscopic group than in the open group (2.0% versus 13.4%; P = .0430). There were no significant differences in either the short- or long-term outcomes between the two groups. Univariate and multivariate analyses showed that the choice of surgical approach (open versus laparoscopic) did not affect overall survival in patients with colorectal perforation. Conclusion: The laparoscopic approach for colorectal perforation in an emergency setting can be safely performed and provides certain advantages over an open approach in suitable patients.

Enhanced Material Assimilation in a Toroidal Plasma Using Mixed H_{2}+Ne Pellet Injection and Implications to ITER

The ablation and assimilation of cryogenic pure H_{2} and mixed H_{2}+Ne pellets, which are foreseen to be used by the ITER tokamak for mitigating thermal and electromagnetic loads of major disruptions, are observed by spatially and temporally resolved measurements. It is experimentally demonstrated that a small fraction (here ≈5%) of neon added to hydrogenic pellets enhances the core density assimilation with reduced outward transport for the low magnetic-field side injection. This is consistent with theoretical expectations that line radiation increased by doped neon in dense plasmoids suppresses the plasmoid pressure and reduces the E[over →]×B[over →] transport of the ablated material.

Electron temperature and density measurement by Thomson scattering with a high repetition rate laser of 20 kHz on LHD

Thomson scattering measurements with a high-repetition-rate laser have commenced in the Large Helical Device. As an example of the fast phenomena captured by this diagnostic system, measurements at a 20 kHz repetition-rate in hydrogen pellet-injected plasmas are presented. Signal processing methods for this measurement have been developed and electron temperature profiles with almost 70 spatial points were evaluated at time intervals of 50 [Formula: see text]s. After Raman scattering calibration, electron density profiles were derived. Fast changes in the electron temperature and density profiles within 1 ms were observed.

Simple systemic index associated with oxaliplatin‐induced liver damage can be a novel biomarker to predict prognosis after resection of colorectal liver metastasis

Aim

Oxaliplatin, an anticancer drug for advanced colorectal cancer, causes liver sinusoidal damage, sometimes with portal hypertension. We conducted a retrospective comparative study of the relationship of liver sinusoidal disorders and liver function with the prognosis in patients who underwent hepatectomy for colorectal liver metastasis (CRLM).

Methods

In total, 158 patients who underwent hepatectomy for CRLM were included in the study, and the effect of chemotherapy‐associated liver damage on the prognosis was examined.

Results

Preoperative oxaliplatin was used in 75 of 158 patients; of these 75 patients, 26 had intraoperative blue liver (BL). In a comparison of the BL group (n = 26) and non‐BL group (n = 132), patients in the BL group had a significantly lower serum albumin concentration and a significantly higher indocyanine green test result, aspartate aminotransferase‐to‐platelet ratio index (APRI), and FIB‐4 score. Operative morbidities were not significantly different between the two groups. The overall survival rate after hepatectomy was significantly worse in the BL group than in the non‐BL group. In the univariate analysis, the serum albumin concentration, indocyanine green test, a high tumor burden score (TBS), and the APRI were statistically significant poor prognostic factors. In the multivariate analysis, the APRI and a high TBS were independent poor prognostic factors.

Conclusion

The APRI and TBS in patients with CRLM are prognostic predictors after hepatectomy for metastatic liver cancer. This study indicated that liver damage in patients treated with preoperative oxaliplatin has an effect on the prognosis.

Preceding propagation of turbulence pulses at avalanche events in a magnetically confined plasma

The preceding propagation of turbulence pulses has been observed for the first time in heat avalanche events during the collapse of the electron internal transport barrier (e-ITB) in the Large Helical Device. The turbulence and heat pulses are generated near the foot of the e-ITB and propagate to the peripheral region within a much shorter time than the diffusion timescale. The propagation speed of the turbulence pulse is approximately 10 km/s, which is faster than that of the heat pulse propagating at a speed of 1.5 km/s. The heat pulse propagates at approximately the same speed as that in the theoretical prediction, whereas the turbulence pulse propagates one order of magnitude faster than that in the prediction, thereby providing important insights into the physics of non-local transport.

Indications for conversion hepatectomy for initially unresectable colorectal cancer with liver metastasis

PURPOSE

Selected patients with initially unresectable colorectal cancer (CRC) and liver metastases undergo conversion surgery after appropriate chemotherapy. The prognosis of these patients is good, with some even cured of the disease. This retrospective, single-institution study analyzes the clinical importance of patient characteristics on the outcomes of conversion hepatectomy.

METHODS

We evaluated 229 consecutive patients with initially unresectable CRC and liver metastasis, who underwent systemic chemotherapy. The patients were assigned to groups depending on conversion hepatectomy.

RESULTS

Conversion hepatectomy was performed in 30 patients (13.1%). The proportion of patients with extrahepatic metastasis was significantly lower in the conversion group than in the unresectable group (30.0 vs. 66.8%; P < 0.01). The rate of left-sided primary colorectal tumors was significantly higher in the conversion group than in the unresectable group (96.7 vs. 65.8%; P < 0.01). Multivariate analyses identified that left-sided tumors, no extrahepatic metastasis, H1 or H2 grade CLM, and treatment with molecular-targeted agents were associated with conversion hepatectomy (odds ratios: 16.314, 4.216, 7.631, and 4.070; P < 0.01). Overall survival was significantly longer in the conversion group than in the unresectable group (MST: 50.0 versus 14.7 months; P < 0.01).

CONCLUSION

Left-sided primary tumors, absence of extrahepatic metastases, H1 or H2 grade, and use of molecular-targeted agents were associated with successful conversion hepatectomy; thus, patients with these characteristics may be candidates for conversion therapy.

Efficacy and safety of neoadjuvant chemotherapy for locally advanced gastric cancer in elderly patients: A phase II trial (KSCC1801)

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Background: Gastrectomy with D2 dissection and adjuvant chemotherapy is currently the standard treatment for locally advanced gastric cancer (LAGC) in Asian countries. However, administering chemotherapy with sufficient intensity after gastrectomy is often challenging. Thus, several trials have been undertaken to demonstrate the efficacy of neoadjuvant chemotherapy (NAC). NAC-SOX regimen for LAGC has been already shown to reduce distant micro-metastasis and to improve the R0 resection rate by tumor shrinkage in Asian trials. However, there have been few studies of the feasibility of NAC-SOX for elderly patients with LAGC. KSCC1801 is a phase II study to evaluate the safety and efficacy of NAC-SOX in elderly patients aged 70 years or over with LAGC. Methods: Patients received three cycles of SOX as neoadjuvant chemotherapy followed by gastrectomy with D2 dissection. Oxaliplatin was administered intravenously (130 mg/m2) on day 1, and S-1 was administered orally (80- 120 mg/day) for 14 days followed by 7-day rest period. The primary endpoint was the dose intensity (DI). A sample size of 25 was set according to a one-sided significance level of 0.025 and a power of 80% on the basis of a one-sample t-test and assuming a null hypothesis of a 75% DI and an alternative hypothesis of an 85% DI with an estimated standard deviation of 14%. The secondary endpoints were safety, R0 resection rate, response rate, overall survival, and relapse-free survival. Results: Twenty-six patients were enrolled in this study. The median age was 74.5 years. The median DI in NAC-SOX was 97.2% for S-1 and 98.3% for oxaliplatin. Three cycles of NAC could be performed in 25 patients (96.2%), of whom 23 (88.5%) underwent gastrectomy with D2 dissection. The R0 resection rate was 92.3% and the pathological response rate (≥grade 1b) was 62.5% [95% confidence interval: 40.6 - 81.2]. The major adverse events (≥grade 3) were neutropenia (20.0%), thrombocytopenia (11.5%), anorexia (11.5%), nausea (7.7%) and hyponatremia (7.7%). Postoperative complications of abdominal infection, elevated blood amylase, and bacteremia occurred in one patient each. One treatment-related death occurred, probably due to severe diarrhea and dehydration. Conclusions: NAC-SOX was feasible and promising even in elderly patients. Systemic management and more careful monitoring of adverse events are necessary for elderly patients. Clinical trial information: jRCTs071180001.

Health-related quality of life after esophagectomy in patients with esophageal cancer

Esophageal cancer is one of the malignant tumors with the poorest prognosis. Esophagectomy, which is the mainstay of curative-intent treatments, imposes excessive surgical stress on the patients, and postoperative morbidity and mortality rates after esophagectomy remain high. On the other hand, the number of survivors after esophagectomy for esophageal cancer is increasing due to recent improvements in surgical techniques and multidisciplinary treatments for this cancer. However, esophagectomy still has a great influence on the fundamental aspect of patients' lives, that is, the health-related quality of life (HR-QOL), including their physical, emotional, and social functions in the short- and long-term postoperatively. HR-QOL is a multifactorial concept used to assess the symptoms and functional changes caused by the disease itself and treatments from the patients' perspectives. Therefore, assessing the HR-QOL of patients with esophageal cancer after esophagectomy is becoming increasingly important. However, the status of HR-QOL changes after esophagectomy has not been satisfactorily evaluated, and there is no worldwide consensus as to how the postoperative HR-QOL can be improved. This review aimed to raise awareness of healthcare providers, such as surgeons and nurses, on the importance of HR-QOL in patients with esophageal cancer after curative-intent esophagectomy by providing multifaceted information concerning the short- and long-term HR-QOLs, including the status of changes and the determinants of HR-QOL after esophagectomy, and furthermore, essential points for improvement of HR-QOL after esophagectomy.

Electro-optically Q-switched operation of a high-peak-power Tb:LiYF4 green laser

We report on an electro-optically Q-switched Tb:LiYF₄ green laser pumped by a frequency-doubled optically pumped semiconductor blue laser. The electro-optically Q-switched characteristics were studied under a wide range of repetition rates from 200 Hz to 50 kHz using a KD₂PO₄ Q-switch. Up to 198 µJ of pulse energy was obtained with a pulse width of 248 ns at a repetition rate of 200 Hz, corresponding to a peak power of 797 W at 544 nm.

Comparison of laparoscopic surgery with open standard surgery for advanced gastric carcinoma in a single institute: a propensity score matching analysis

BACKGROUND

Compared with open standard gastrectomy (OG), laparoscopic gastrectomy (LG) did not result in inferior disease-free survival for early-stage and locally advanced gastric cancer (AGC). However, whether LG for AGC in elderly patients is more beneficial than OG is unclear.

METHODS

This study examined 458 patients with AGC. The mortality, morbidity, and prognosis were compared by age, gender, T and N factors, and pathological stage in the LG and OG groups using propensity score matching analysis. For the final analysis, 151 pairs of patients were selected from at each group.

RESULTS

The results showed that no significant difference in mortality and morbidity existed between the two groups. The 5-year relapse-free survival (RFS) rates were 70% and 62% in the LG and OG groups, respectively (p = 0.104). The 5-year RFS rates in patients with pathological stages I, II, and III who had undergone LG were 84%, 80%, and 55%, respectively, and 78%, 70%, and 45%, respectively, in those who had undergone OG (p < 0.005). The 5-year RFS rates in nonelderly patients who underwent LG or OG were 75% and 68%, respectively, and 58% and 40%, respectively, in elderly patients who underwent LG or OG (p < 0.005).

CONCLUSION

The 5-year RFS rates in patients with AGC at each stage did not significantly differ between LG and OG. However, the benefits at 5-year RFS in patients who underwent LG compared with OG were larger in elderly patients than those in nonelderly patients.

Neutrophil-to-lymphocyte Ratio as a Predictor of Malignancy of Intraductal Papillary Mucinous Neoplasms

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) can lead, via the adenoma-carcinoma sequence, to invasive adenocarcinoma, which has a poor prognosis. Most IPMNs do not meet the indications for surgery and instead are monitored regularly, but no biomarkers of malignant transformation during surveillance have been established.

PATIENTS AND METHODS

A total of 50 patients with IPMN who underwent pancreatectomy were evaluated retrospectively. Clinicopathological parameters during the surveillance period before surgery were assessed to explore biomarkers for predicting malignancy.

RESULTS

The serum level of carbohydrate antigen 19-9 was significantly higher in IPMN-derived invasive adenocarcinoma. The neutrophil-to-lymphocyte ratio was significantly lower in low-grade IPMN than high-grade and Inv-IPMN cases by univariate and multivariate analysis. Disease-free survival was significantly shorter in patients with high-grade and invasive IPMN compared with those with low-grade IPMN. In patients whose preoperative surveillance was performed for more than 12 months, the neutrophil-to-lymphocyte ratio was significantly higher in those with high-grade and invasive IPMNs compared with patients with low-grade IPMN in the year before surgery.

CONCLUSION

The NLR is a useful biomarker for distinguishing between low-grade and high-grade IPMN and thus should be monitored during surveillance.

Wireless Light-emitting Marker Using Magnetic Field Resonance for Laparoscopic Gastrointestinal Surgery

BACKGROUND

In laparoscopic gastrointestinal surgery, the location of the tumor is identified mainly with marking methods, such as ink tattooing and intraoperative gastrointestinal endoscopy and marking with a metal clip followed by confirmation with intraoperative x-ray fluoroscopy. Each method has disadvantages, such as complexity, instability of ink sticks, and radiation exposure. Thus, a simple and less-invasive marking method is needed.

METHODS

We developed a wireless light-emitting marker with a miniature light-emitting diode that uses a magnetic field resonance mechanism. It emits 4 individual colors-red, blue, green, and white. We confirmed the usefulness of this marker system in ex vivo and in vivo animal experiments.

RESULTS

In the ex vivo experiment in porcine intestines, use of the wireless marker was successful, as each color of emitted light was recognized from outside the intestine. In the live animal experiment, it was confirmed that the light emitted by the marker system was visible in the porcine intestinal tract during laparoscopic surgery. The light emitted by the wireless marker in the intestinal tract was confirmed with a laparoscope in a simulated animal surgery.

CONCLUSION

We have developed an innovative, radiation-free and reliable light-emitting marker system that uses a magnetic field resonance mechanism that emits four colors of light during laparoscopic surgery.

Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer

BACKGROUND

Ectopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH.

CASE PRESENTATION

Here, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely.

CONCLUSION

Customized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.

Cardiac tamponade in a long-term survival esophageal cancer patient after esophageal bypass and chemoradiotherapy: a case report

Esophageal bypass surgery is an effective treatment strategy for esophageal cancer with esophago-tracheobronchial fistula. We herein report an esophageal cancer patient with esophago-pulmonary fistula who achieved a long-term survival but died suddenly because of cardiac tamponade. A 70-year-old male patient with esophago-pulmonary fistula due to esophageal tumor invasion underwent definitive chemoradiotherapy as the initial treatment. Esophageal bypass surgery followed by additional chemotherapy was performed, and the patient survived for a long time. Four years and six months later, a small abscess in an esophago-pulmonary fistula was visualized on computed tomography. One month later, he suffered suddenly severe dyspnea and died. An autopsy suggested that the direct cause of death had been cardiac tamponade due to atrio-pericardial fistula. Definitive therapy for esophageal cancer with fistula after esophageal bypass is an effective treatment, but close special attention must be paid to the possibility of irradiation-related late toxicity.

Laparoscopic Total Gastrectomy for Remnant Gastric Cancer: A Single-institution Experience and Systematic Literature Review

BACKGROUND/AIM

The safety and efficacy of laparoscopic total gastrectomy (LTG) for remnant gastric cancer (RGC) remains unclear. The purpose of this study was to compare the clinical outcomes of LTG with open total gastrectomy (OTG) for RGC.

PATIENTS AND METHODS

Twenty-two patients who underwent total gastrectomy for RGC were enrolled in this study.

RESULTS

LTG was carried out in seven patients, and OTG was performed in the remaining 15 patients. The mean operation time in the LTG group was longer than that in the OTG group. The estimated blood loss in the LTG group was less than that in the OTG group. No cases in the LTG group required open conversion. Postoperatively, the first meal and defecation were earlier in the LTG group than in the OTG group. The overall survival rates of the two groups were comparable.

CONCLUSION

Laparoscopic total gastrectomy is a feasible surgical option for RGC.

Graphene Q-switched Tb:LiYF4 green laser

We report the Q-switched operation of a Tb³⁺-laser for the first time, to the best of our knowledge. The passiveQ-switching was realized by a 15% Tb:LiYF₄ gain medium and a single-layer graphene saturable absorber. An average output power of 744 mW at 544 nm was achieved with slope efficiency of 41%, pulse width of 2.9 µs, and repetition rate of 38.7 kHz. The corresponding pulse energy and peak power were calculated to be 19.2 µJ and 6.6 W, respectively.

The Preoperative Prognostic Nutritional Index Predicts the Development of Deep Venous Thrombosis After Pancreatic Surgery

BACKGROUND/AIM

Pancreatic surgery is associated with a high risk of developing deep venous thrombosis (DVT) and malnutrition. We aimed to evaluate the factors predicting the development of DVT, focusing on nutrition assessment tools.

PATIENTS AND METHODS

One hundred patients who underwent pancreatic surgery were postoperatively examined for DVT. We assessed the risk factors for the development of DVT after surgery.

RESULTS

Postoperative DVT was detected in 11 patients (11%). Patients who developed DVT after surgery were significantly older (p=0.016) and had higher preoperative D-dimer levels (p=0.005) than those who did not. The preoperative prognostic nutritional index (PNI) was mostly associated with the development of DVT (p=0.079). Furthermore, PNI ≤44.3, BUN >20 mg/dl, D-dimer ≥1.9 μg/ml were independent predictors for the development of DVT after surgery.

CONCLUSION

A poor nutrition status and dehydration should be preoperatively improved for patients who are identified, as having a high risk of developing DVT after pancreatic surgery.

Efficient visible laser operation of Tb:LiYF4 and LiTbF4

We report laser operation of two Tb³⁺-activated gain media, Tb:LiYF₄ and LiTbF₄, in yellow or/and green spectral region. A record-high slope efficiency of 63% among Tb³⁺-lasers and maximum output power of 1.17 W (incident power of 2.79 W) at around 544 nm were obtained with a c-cut 15%Tb:LiYF₄ crystal. The yellow laser characteristics in σ-polarization were studied. A slope efficiency of 21% at 582 nm was achieved. More importantly, we succeeded in laser operation of LiTbF₄ for the first time to the best of our knowledge. Laser oscillation at around 544 nm yielded a maximum slope efficiency of 45%. This points toward the possibility of producing high-energy pulsed lasers using LiTbF₄, which features a high active-ion concentration as well as relatively long lifetime.

The Impact of Immunonutritional and Physical Status on Surgical Outcome After Pancreaticoduodenectomy in Elderly Patients

BACKGROUND/AIM

The aim of this study was to determine the significance of immunonutritional and physical index in the assessment of risk associated with pancreaticoduodenectomy (PD) in the elderly.

PATIENTS AND METHODS

This study enrolled 92 patients who underwent PD. They were divided into 2 groups: Group A included patients 79 years and younger (n=79) and Group B patients 80 years and older (n=13). Among 37 patients, physical function and body composition were also evaluated.

RESULTS

Significantly higher neutrophil-lymphocyte ratio, lower prognostic nutritional index (PNI), and controlling nutritional score were observed in Group B. Muscle strength and walking ability were significantly impaired in Group B, although there was no significant difference in body composition. Age was not correlated with the incidence of postoperative complications, overall survival or recurrence-free survival by univariate and multivariate analysis.

CONCLUSION

PD is justified for the elderly, with acceptable morbidity and prognosis. However, immunonutritional status and physical function are significantly impaired; thus, appropriate case selection and active nutritional support are required for the elderly.

Nd3+-activated CaF2 ceramic lasers

Nd,Y:CaF₂ and Nd,La:CaF₂ ceramics featuring good optical quality have been fabricated by reactive sintering and a hot isostatic pressing method. The transmission spectra, emission spectra, and fluorescence decay curves were measured. Lasing at 1064 and 1065 nm was observed in Nd,Y:CaF₂ and Nd,La:CaF₂, respectively, upon quasi-continuous-wave pumping by a diode laser emitting at 791 nm. To the best of our knowledge, this is the first demonstration of Nd³⁺-activated CaF₂ ceramic laser.

Effect of Systematic Conversion to Generic Mycophenolate Mofetil (MMF) in Kidney Transplantation: A Single-Center Clinical Experience from Japan

INTRODUCTION

Recently, more and more generic drugs have been used for immunosuppressive drugs in the field of organ transplantation. Some reports have indicated that blood concentration of most generic drugs is difficult to maintain stability, and it may cause the difference in graft survival of transplanted organs between original drugs and generic drugs. In this article, we report the cases could not maintain blood concentration of generic drugs of mycophenolate mofetil (MMF).

RESULTS

In 4 cases out of 5 cases that we had to change original MMF to generic MMF, there were cases that blood concentration level was not stabilized. There were possibility that the lowered blood concentration level of MMF caused a rejection, in two cases. Mean MMF trough level was decreased from 3.6 ± 1.9 μg/mL to 0.6 ± 0.4 μg/mL. Due to the early detection, it did not become severe or failure of graft function, however, we cannot deny the possibilities that side effects were increased and rejection rose. In these cases, we discontinued to use the generic drugs thereafter due to unstable plasma concentration of MMF.

DISCUSSION

Some reports have indicated that failure to maintain plasma concentration of MMF leads to rejection. Therefore, maintenance of effective plasma concentration and prevention of rejection are essential to long-term graft survival in kidney transplant.

CONCLUSION

Generic drug formulations may exhibit differences in effects and absorption compared to the brand-name drug. If the generic drug should be used, patients should be closely monitored.

Compact, highly efficient, 2.1-W continuous-wave mid-infrared Fe:ZnSe coherent source, pumped by an Er:ZBLAN fiber laser

In this Letter, we report a compact and robust coherent source, operating in mid-infrared (IR) and based on the Fe:ZnSe chalcogenide gain medium, optically pumped by an Er:ZBLAN fiber laser. The output power of 2.1 W with a 59% slope efficiency with respect to the absorbed pump power at liquid nitrogen cooling is achieved. We show that strong re-absorption at a high pump power and iron ion doping concentrations leads to a continuous tuning of central wavelength from 4012 to 4198 nm. The robustness of a high-power Er:ZBLAN fiber laser combined with prominent spectroscopic properties of Fe:ZnSe media pave the way for the development of a reliable tunable continuous-wave mid-IR sources for scientific and industrial purposes.

Safety of Elderly Living Kidney Donors: 2 Cases of Donors Older Than 80 Years: A Case Report

Much controversy exists over the performance of elderly living donor kidney transplantation. We report the safety of 2 cases of elderly living kidney donations in our hospital. CASE 1: An 82-year-old man was a living kidney donor for his 56-year-old son. The donor suffered from hypertension, but has successfully managed his blood pressure with only one medication. His serum creatinine was 0.7 mg/dL and inulin clearance was 122.5 mL/min, which met the usual criteria for living kidney donors. This was his son's secondary kidney transplantation, and no other donors existed. CASE 2: An 80-year-old woman was a living kidney donor for her 45-year-old son. Her serum creatinine was 0.61 mg/dL and inulin clearance was 71.7 mL/min, which met the marginal kidney donor criteria. In both cases, we determined that the donor kidney function was acceptable. Though we explained the risks of the transplantation thoroughly, the patients' strong will to offer a kidney to their family member did not change. We decided to carry out the transplantation. At the time of publication, nearly 2 years have passed since the transplantation, but both donors and recipients are doing well. In the future, it seems more likely that the number of elderly living donor kidney transplantation will rise. On one hand, there is no absolute contraindication for elderly donors, while on the other hand, the criteria for a living kidney donor must be strictly examined. Furthermore, careful observation of both donors and recipients after transplantation is required.

Fluoride-fiber-based side-pump coupler for high-power fiber lasers at 2.8 μm

A side-pump coupler made of fluoride fibers was fabricated and tested. The tested device had a coupling efficiency of 83% and was driven with an incident pump power of up to 83.5 W, demonstrating high-power operation. Stable laser output of 15 W at a wavelength of around 2.8 μm was achieved over 1 h when using an erbium-doped double-clad fiber as the active medium. To the best of our knowledge, this is the first time a fluoride-glass-fiber-based side-pump coupler has been developed. A test with two devices demonstrated further power scalability.

Robustness of adult female survival maintains a high-density sika deer (Cervus nippon) population following the initial irruption

Context Irruption of large herbivore populations is characterised by three distinct phases: (1) an exponential increase in population to a peak abundance; (2) a population crash; and (3) a second increase to another population peak, typically lower than the first peak of abundance. However, there has been little study of age- and sex-specific factors that affect the post-initial irruption interactions with food sources. Aims We aimed to investigate annual survival rates of sika deer (Cervus nippon Temminck, 1838) in the sequent irruption of a population on Nakanoshima Island, Lake Toya, Japan, with a chronically high density during the period 2002–12. Methods Survival monitoring data were obtained for 219 individuals (93 males and 126 females) using radio-collars. Annual survival was quantified, and related factors, i.e. deer abundance and winter severity, were determined by model selection using Akaike information criterion values. Key Results The results showed that annual survival rates across sexes and age classes (fawn, yearling, prime-aged, old) decreased with increasing population density, snow depth and winter precipitation. Winter severity had a greater effect on adult survival than density regulation. Nevertheless, female adult survival was maintained at a high level, with a mean of 0.84 (95% CI: 0.80–0.88). Key conclusions Robust survival rates for adult females might contribute to the maintenance of a high-density sika deer population in the post-initial irruption. Implications We suggest that in the absence of predation and hunting, sika deer population is not able to self-regulate to the density level that avoids an irreversible impact on plants.

Efficacy and safety of paclitaxel/ramucirumab as the second-line chemotherapy in Japanese patients with advanced gastric cancer

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Background: Second-line chemotherapy can now be considered as a proven treatment option for metastatic or locally advanced gastric cancer (AGC). Two global randomized phase III trials (REGARD and RAINBOW) showed that survival benefit was significantly observed in patients treated with ramucirumab (RAM) alone and in combination with weekly doses of PTX, compared with placebo, respectively. The purpose of the study is to evaluate the efficacy and safety of weekly dose of PTX combined with RAM practically as the second-line treatment in Japanese patients with AGC refractory to an S-1-containing chemotherapy regimen. Methods: We conducted a retrospective review of the data of 18 patients with AGC who received more than 2 cycles of PTX/RAM combined chemotherapy as the second-line regimen following S-1-based treatment. The objective response rate (ORR), adverse events, progression-free survival (PFS) and overall survival (OS) were analyzed and compared with PTX monotherapy group. Results: Median number of courses were 5 for the PTX/RAM group and the discontinuation of treatment except for disease progression was found in 2 cases (33.3%). The rates of hematological toxicities of higher than grade 3 were 33.3% in the PTX/RAM group, which were higher than those found in the PTX groups. The tumor responses of the PTX/RAM group were 22% for the ORR and 78% for the DCR, compared with 21% and 48% in the PTX group, respectively. The dose intensities of PTX were 72.4% in the former group. The survival data showed that the MST after second-line exposure was 290 days and the median PFS was 131 days in the PTX/RAM group, compared with 159 days and 90 days in the PTX group, which were not significantly different. Conclusions: PTX/RAM might be one of the best regimens for Japanese patients with AGC as the second-line treatment following S-1-containing chemotherapy.

A facile, selective, high recovery system for precious metals based on complexation between melamine and cyanuric acid

We developed a facile, selective, high recovery system for precious metals based on complexation between melamine and cyanuric acid (denoted as MC) through hydrogen bonding.

Comparison of open, laparoscopic, and hand-assisted laparoscopic devascularization of the upper stomach and splenectomy for treatment of esophageal and gastric varices: a single-center experience

INTRODUCTION

Laparoscopic devascularization of the upper stomach and splenectomy (Dev+Sp), is technically difficult in patients with portal hypertension because of enlarged collateral vessels and spleen. This report presents the efficacy and safety of hand-assisted laparoscopic (HALS) Dev+Sp.

METHODS

Ten patients underwent HALS Dev+Sp as a treatment for esophagogastric varices between 2005 and 2012 (HALS group). A vessel-sealing system was used for devascularization of vessels. An autosuture device was applied to dissect the splenic hilum and the left gastric and enlarged short gastric vessels. The operative and postoperative data were compared between patients who previously underwent laparoscopic Dev+Sp (LAP group, n = 9) and conventional Dev+Sp (OP group, n = 10) between 2001 and 2008.

RESULTS

The mean operative time was 328, 336, and 245 min (P < 0.05) and the mean blood loss was 1786, 981, and 250 mL (P < 0.05) in the OP, LAP, and HALS groups, respectively. Laparoscopic surgery was converted to HALS in one patient and to open surgery in three patients. There were no conversions in the HALS group. There was no significant difference in the cumulative recurrence rate and bleeding rate in the groups.

CONCLUSION

HALS Dev+Sp is a feasible and effective surgery in patients with portal hypertension.

Portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) is considered to be a frequent complication of liver cirrhosis. However, unlike PVT in patients without cirrhosis, very few data are available on the natural history and management of PVT in cirrhosis, despite its association with potentially life-threatening conditions, such as gastroesophageal bleeding and acute intestinal ischemia. Moreover, no consensus regarding PVT in cirrhosis exists. Suggested causes of PVT in cirrhosis include reduced portal blood flow velocity, multiple congenital or acquired thrombophilic factors, inherited or acquired conditions, and derangement of liver architecture. However, the understanding of PVT in cirrhosis is incomplete. In addition, information on the management of PVT in cirrhosis is inadequate. The aims of this review are to: (1) assemble data on the physiopathological mechanism, clinical findings, diagnosis and management of PVT in cirrhosis; (2) describe the principal factors most frequently involved in PVT development; and (3) summarize the recent knowledge concerning diagnostic and therapeutic procedures.

Hepatic vein waveform and splenomegaly predict improvement of prothrombin time after splenectomy in hepatitis C virus-related cirrhotic patients

AIM

Whether hepatic function can recover in cirrhotic patients after splenectomy remains controversial.

METHODS

All consecutive Japanese patients with hepatic cirrhosis due to hepatitis C who had undergone elective splenectomy in Kyushu University Hospital between January 2008 and December 2009 were included in this retrospective study. Prothrombin time, serum albumin and total bilirubin concentrations were reviewed before and after splenectomy and analyzed to clarify whether splenectomy improves hepatic function in patients with cirrhosis and to determine the factors predictive of improvement in hepatic function.

RESULTS

Prothrombin time and total serum bilirubin concentration improved after splenectomy; however, serum albumin concentrations did not increase significantly. Twelve months after splenectomy, total serum bilirubin had decreased by over 0.3 mg/dL in 52.3% of patients and prothrombin time had improved by over 10% in 52.3% of patients. Multiple linear regression analysis identified hepatic vein waveform (HVWF) type I (P = 0.0174) and spleen weight (P = 0.0394) as independent predictors of improvement in prothrombin time and preoperative total serum bilirubin (P = 0.0002) as the only independent predictor of decrease in total bilirubin. Total bilirubin and prothrombin time were significantly improved after splenectomy in patients with HVWF type I, however, they were not improved in patients with HVWF type II.

CONCLUSION

Prothrombin time and total bilirubin improve in approximately half of cirrhotic patients within a year after splenectomy. HVWF type I and splenomegaly may be predictive factors for improvement in prothrombin time after splenectomy in patients with cirrhosis due to hepatitis C.

Deformation Behavior, Processability and Physical Properties for Biaxially Oriented Film of LLDPE

The bubble deformation behavior of double bubble tubular film (DBTF) of linear low density polyethylene (LLDPE) is experimentally analyzed. Also investigated is how the bubble deformation behavior of the stretched films are changed by stretching conditions, especially stretching temperature, and how the properties of stretched films are influenced by stretching conditions.

From the results, the optimum conditions required to obtain a stable bubble and good properties for the DBTF of LLDPE are indicated. The relationship between the DBTF and laboratory tenter stretched film (LTSF) is investigated in order to predict the processability and the properties of the DBTF by using the laboratory tenter biaxial stretcher. This method is not only more time efficient, but also reduces overall costs of developing the DBTF.

Stretchability and Properties of LLDPE Blends for Biaxially Oriented Film

In order to improve the stretchability of linear low density polyethylene (LLDPE) for double bubble tubular film (DBTF), the blending of LLDPEs have been investigated. Three LLDPEs of varying densities were blended, and several films having different densities, molecular-weight distributions and composition distributions were produced. The stretchability and properties of these films were investigated and the relationship between the stretchability and the material properties were also discussed. The material properties of LLDPE which showed better stretchability were reported. Furthermore, the stretchability of LLDPE by using the laboratory tenter stretched film (LTSF) and the DBTF were compared. The prediction of the stretchability for the DBTF by using the LTSF was reported.

Stretchability and Properties of Various LLDPE for Biaxially Oriented Film

Stretchability and properties of linear low density polyethylene (LLDPE) blends for biaxially oriented film was investigated in the previous report [1]. That report focused on changing the film density by blending three different densities of LLDPE. The relationship among stretchability, film density and the composition distribution was explored. In this report, several different densities and melt flow indices (MFI) of LLDPE were examined. A film with a density of about 0.915 g/cm3 displayed the best stretchability, while films not less than 2 g/10 min MFI had poor stretchability. The most suitable composition distribution for stretching was reported. The properties of biaxially oriented films were also evaluated. Furthermore, the relationship between the laboratory tenter stretched film (LTSF) and the double bubble tubular film (DBTF) was investigated. There was a correlation between the density in film over 0.910 g/cm3 and the stretchability of the DBTF and LTSF.