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We examined the cross-sectional association between intake of carotenoids with provitamin A activity and carotid artery plaques in 12,773 participants of the Atherosclerosis Risk in Communities Study aged 45-64 y. Usual diet was assessed with a 66-item food-frequency questionnaire. Plaques were examined by B-mode ultrasound of multiple carotid artery segments. In both women and men, those in the highest quintile of carotenoid consumption had a lower prevalence of plaques (women, 25.4%; men, 36.0%) than those in the lowest quintile of carotenoid consumption (women, 29.3%; men, 39.8%). The prevalence odds ratios contrasting extreme intake quintiles were 0.82 (95% CI: 0.70, 0.97) in women and 0.85 (95% CI: 0.72, 1.01) in men. The associations diminished slightly after potential confounders were adjusted for. In women, the inverse association was particularly strong for current smokers (adjusted odds ratio contrasting extreme quintiles: 0.67; 95% CI: 0.45, 0.98). In men, no such effect modification by smoking was seen. The inverse association was somewhat stronger in men aged 55-64 y than in those aged 45-54 y, whereas age made little difference in women. These findings, together with previous findings that carotenoid intake was unrelated to average carotid artery wall thickness, suggest that carotenoids may exert their influence later rather than earlier in the atherosclerotic process, and support the hypothesis that carotenoids or other plant-derived compounds may play a role in preventing arterial plaque formation. Copyright (c) 1998 American Society for Clinical Nutrition [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID19) can cause gastrointestinal complications as well as respiratory tract disease. Coagulation abnormalities and thrombosis frequently occur in COVID19, especially in cases with severe clinical outcome. The relationship between gastrointestinal perforation and coagulopathy due to COVID19 remains unclear., Case Presentation: A 49-year-old female received Chimeric antigen receptor T (CAR-T) therapy for an early recurrence of diffuse large B-cell lymphoma (DLBCL) that was refractory to chemotherapy. She was diagnosed with cytokine release syndrome (CRS) because of a fever and oxygen desaturation, and administered tocilizumab. Forty days after completing CAR-T therapy, she was infected with COVID19 and transferred to our hospital. Her general condition worsened and she developed COVID19 pneumonia, and then steroid pulse therapy was started. While her respiratory condition improved, she experienced pain in the anal region and computed tomography (CT) revealed a rectal perforation. An emergency surgery was undertaken, and the lower rectum wall was found to be completely necrotic. Removal of the necrotic part of the rectum tissue, and drainage and lavage of necrotic tissue in the pelvic cavity were performed. The remaining rectum was resected with partial sigmoidectomy, but we could not make the anal stump closed. In addition, an end colostomy in the sigmoid colon was performed. Histopathological findings showed thromboses in the rectal mesentery veins. After the first surgery, the pelvic abscess cavity persisted and her high-grade fever continued. Reoperation was laparoscopically performed, and she underwent a resection of anal canal with residual necrotic rectal and mesorectal tissue, and a drainage of the pelvic abscess. After the reoperation, her general condition improved and CT showed that the abscess cavity had significantly improved., Conclusions: Gastrointestinal perforation, especially rectal necrosis due to coagulopathy caused by severe COVID19 infection, is a rare but life-threatening complication. Physicians should have a high degree of clinical suspicion for timely diagnosis and management, and surgical intervention is necessary in cases of rectal necrosis., (© 2024. The Author(s).)

Competing Interests: Declaration of competing interest One of the authors declares financial competing interests from Olympus Terumo Biomaterials and AUSPICIOUS.

Background: Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy., Methods: We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification)., Results: Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×10 2 /μL, and 37.4°C, respectively., Conclusions: Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×10 2 /μL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

Dearomatization of pyridines is a well-established synthetic approach to access piperidines. Although remarkably powerful, existing dearomatization processes have been limited to the hydrogenation or addition of carbon-based nucleophiles to activated pyridiniums. Here, we show that arenophile-mediated dearomatizations can be applied to pyridines to directly introduce heteroatom functionalities without prior substrate activation. The arenophile platform in combination with olefin oxidation chemistry provides access to dihydropyridine cis -diols and epoxides. These previously elusive compounds are now readily accessible and can be used for the downstream preparation of diversely functionalized piperidines.

Background: Alcoholic steatohepatitis and nonalcoholic steatohepatitis-related liver cirrhosis (ASH/NASH-LC) are major causes of esophageal varices (EVs). However, the association between high visceral fat and exacerbation of EVs remains unclear. The aim of this study was to clarify the association of visceral fat and recurrence rate of EVs in ASH/NASH-LC and to identify independent predictors associated with recurrence., Methods: We retrospectively evaluated data from 94 patients who underwent endoscopic injection sclerotherapy for EVs with ASH/NASH-LC. Using the receiver operating characteristic curve for the cut-off value of visceral fat index (VFI; 46.4 cm 2 /m 2 ), we classified patients as having a high VFI (n = 53) or low VFI (n = 41). Propensity score matching was used to align for background factors, and the recurrence rate of EVs was compared between the two groups. Predictors associated with esophageal variceal recurrence were identified by multivariate analysis. The recurrence rate in patients with viral LC was also investigated., Results: In the overall analysis, the recurrence rate was significantly higher in the high VFI group than in the low VFI group (P = 0.023). The recurrence rate was also higher in the high VFI group than in the low VFI group after propensity score matching, in which 19 patients were matched in each group (P = 0.048). VFI and Child-Pugh score were independently associated with recurrence. Recurrence rates were comparable between the two groups in viral LC patients., Conclusions: Worsening of variceal recurrence was observed in high visceral fat patients in ASH/NASH-LC but not in viral LC. Furthermore, high visceral fat was an independent predictor associated with variceal recurrence.

Background: The incidence of alcoholic liver cirrhosis (ALC) is increasing. However, few reports have focused on ALC-derived esophageal varices (EV). We retrospectively examined differences in overall survival (OS) and EV recurrence rate in patients after endoscopic injection sclerotherapy (EIS) for ALC and hepatic B/C virus liver cirrhosis (B/C-LC)., Methods: We analyzed data from 215 patients (B/C-LC, 147; ALC, 68) who underwent EIS. The primary endpoints were OS and EV recurrence in patients with unsuccessful abstinence ALC and those with uncontrolled B/C-LC, before and after propensity score matching (PSM) to unify the patients' background. The secondary endpoints were predictors associated with these factors, as determined by multivariate analysis., Results: The observation period was 1,430 ± 1,363 days. In the analysis of all patients, OS was significantly higher in the ALC group than in the B/C-LC group (p = 0.039); however, there was no difference in EV recurrence rate (p = 0.502). Ascites and history of hepatocellular carcinoma (HCC) (p = 0.019 and p < 0.001, respectively) predicted OS, whereas age and EV size predicted recurrence (p = 0.011 and 0.024, respectively). In total, 96 patients without an HCC history were matched by PSM, and there was no significant difference in OS or EV recurrence rate (p = 0.508 and 0.246, respectively)., Conclusion: When limited to patients without a history of HCC, OS and the EV recurrence rate were comparable in patients with ALC who continued to consume alcohol and those with B/C-LC without viral control.

A 27-year-old woman was diagnosed with idiopathic thrombocytopenic purpura in the neonatal period, and was admitted to our hospital after presenting with impaired consciousness, purpura, nausea and vomiting, with a platelet count of 10×10 9 /l. Congenital thrombotic thrombocytopenic purpura (cTTP) was suspected on the basis of recurrent thrombocytopenia and impaired consciousness, so tests for ADAMTS13 activity and inhibitor were performed. ADAMTS13 activity was severely decreased, ADAMTS13 inhibitor was negative, and platelet count increased after transfusion of fresh frozen plasma. These findings and the results of genetic testing done on all family members led to a diagnosis of cTTP. cTTP requires differential diagnosis even in adults. If a patient diagnosed with ITP in childhood has a history or findings that suggest cTTP during follow-up observation, it is necessary to actively consider ADAMTS13 testing.

We experienced a case of diffuse large B-cell lymphoma(DLBCL)that developed around the kidney about 1 year after surgery for sigmoid colon cancer. In this case, imaging findings suggestive of liver metastasis were also observed at the same time of diagnosis, therefore, diagnosis was difficult because the possibility of peritoneal dissemination could not be ruled out. The lesion was excised by surgery and a definitive diagnosis was obtained by tissue diagnosis, leading to appropriate treatment. However, one wrong step could lead to the wrong treatment policy. Therefore, when there is any doubt about the diagnosis, it is considered important to proactively perform tissue diagnosis.

Background/aim: Recent studies have reported that the C-reactive protein (CRP) to albumin ratio (CAR) may be a useful prognostic biomarker in various types of cancer patients. However, the mechanism underlying this observation is unclear. The present study aimed to clarify why the CAR can predict post-esophagectomy prognosis, the relationship between pre- and postoperative CAR, and whether postoperative CAR can predict the prognosis of esophageal cancer patients., Patients and Methods: We investigated 158 esophagectomy patients with esophageal squamous cell carcinoma. Hematological examinations were performed on postoperative days (POD) 1, 3, 5, 7, 10, and 14., Results: Preoperative CAR was a significant independent prognostic factor of overall survival (OS) [hazard ratio (HR)=2.247; p=0.0005], and there was a strong correlation between preoperative CAR and tumor depth. The preoperative high-CAR (pre-high-CAR) group had significantly higher CAR on all postoperative days (POD). We then divided the patients as follows: those with at least two low-CAR days on POD 5, 7, and 10 were assigned to the modified post-low-CAR (mPost-low-CAR) group, and others were assigned to the modified post-high-CAR (mPost-high-CAR) group. The 5-year OS rate was significantly higher in the mPost-low-CAR group than in the mPost-high-CAR group, which predicted a more accurate prognosis (p<0.0001, HR=2.769)., Conclusion: Preoperative CAR was associated with tumor depth and diameter, and patients in the pre-high-CAR group continued to have significantly higher CAR postoperatively. These factors were presumed to reflect disease prognosis. Furthermore, grouping by CAR on POD 5, 7, and 10 reflected patient prognosis more accurately than preoperative CAR., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To evaluate the current status and postoperative course of nutritional management in bridge to surgery(BTS) after colorectal stenting for malignant colorectal stenosis., Subjects and Methods: The study included 242 colorectal cancer cases, 27 cases with malignant colorectal stenosis who underwent BTS group, 24 cases with malignant colorectal stenosis who fasted until the day of surgery and consumed drinking water and Elenthal®(no oral intake group), and 191 cases with non-stenotic colorectal cancer (diet group). The study items selected were nutritional management methods before colorectal cancer resection, nutritional assessment, surgical factors, and postoperative course., Results: The BTS, no oral intake, and diet groups were compared in 27, 0, and 191 patients, respectively. In contrast, the intake of Elenthal® was compared in 4, 20, and 5 patients and total parenteral nutrition in 3, 15, and 1 patients, respectively. There were no differences in nutritional sufficiency during hospitalization. The Onodera Nutritional Index(PNI)was significantly lower in the BTS and no oral intake groups than the diet group at the first outpatient visit before surgery. The PNI was significantly lower in the no oral intake group than in the diet group immediately before surgery. Blood loss was higher in the BTS and no oral intake groups than in the diet group, but there was no difference in operative time. The postoperative course was poorer in the no oral intake group than in the diet group. However, there was no difference between the diet and BTS groups., Conclusion: In patients with obstructive colorectal cancer in whom BTS could be performed, the results suggest that preoperative nutritional management with a high sufficiency rate using the intestinal tract may lead to a postoperative course comparable to that in non-stenotic cases.

Medial meniscal posterior root tears disrupt the "hoop" function of the meniscus and may lead to knee osteoarthritis. Although root repair could be a key to osteoarthritis prevention, this surgery does not necessarily guarantee an optimal result even when combined with meniscal centralization and high tibial osteotomy. To address this issue, we made five modifications to the original combined approach, namely two anchors to fix the root, instead of one; bridging centralization instead of single centralization; release of the meniscotibial capsule vs no release; release of valgus stress before knot tying vs no release; and prohibiting postoperative cross-legged sitting and sitting on heels. The advantages of this approach over the original approach are numerous and comprise ease of performing concurrent open wedge high tibial osteotomy, shorter fixation distance, better anatomical reattachment of the meniscal root, increased bone-meniscus contact and contact pressure, and larger contact area between the capsule and tibial rim. The disadvantages of the approach are that knot-tying is cumbersome, pie-crusting of the medial collateral ligament is necessary in patients not undergoing open wedge high tibial osteotomy, and tears >3 mm from the attachment are a contraindication. We describe the steps in this modified approach in detail., (© 2023 The Authors.)

Patellar subluxation and recurrent dislocation are commonly treated with medial patellofemoral ligament reconstruction, and patients with predisposing factors for these problems often require additional bony realignment procedures. However, these procedures mainly address problems in the axial plane, and patients with medial-compartmental knee osteoarthritis may require further realignment in the coronal plane. In this Technical Note article, we introduce our technique for derotational hybrid closed-wedge high tibial osteotomy. Using this technique, simultaneous 3-dimensional realignment in the axial, coronal, and sagittal planes can be achieved in patients with medial compartmental knee osteoarthritis and patellar subluxation caused by a tibial torsional deformity. The indications for the technique and the preoperative planning assessments involving a static torsional deformity analysis on computed tomography images and a dynamic gait analysis by our walking-on-paper method are presented. This is followed by a detailed description of the surgical procedure, together with consideration of the pearls and pitfalls of the procedure. A video of the surgery performed in a representative case with medial knee osteoarthritis and patellar subluxation in the right knee owing to an outward tibial torsion deformity is also provided., (© 2023 The Authors.)

Background: Totally extraperitoneal (TEP) repair is a recommended procedure for inguinal hernia repair in European hernia guidelines. However, technical challenges have limited its uptake in Japan, where transabdominal preperitoneal (TAPP) repair is more common. We evaluated the association of preoperative subcutaneous fat area (preSFA) with surgical outcomes and identified factors associated with the difficulty of TEP repair., Methods: Clinical data from 62 patients undergoing TEP repair were collected retrospectively. Using the median for the preoperative subcutaneous fat index (preSFI; 45.9 cm 2 /m 2 ), we classified patients as having a high SFI (HSFI) (n=31) and low SFI (LSFI) (n=31). Surgical outcomes and perioperative complications were then compared between these groups. Additionally, TEP repair was divided into five phases (e.g., Phase 1: dissection of the caudal side of the preperitoneal space), and operative time was measured during each phase. Phase 1 was divided into two sub-phases (1A: insertion of the first port, 1B: reaching Cooper's ligament)., Results: Operative time was longer (133 min vs 111 min, P = 0.028) and the peritoneal injury rate was higher (35.5% vs 9.7%, P = 0.015) for the HSFI patients. Furthermore, operative time for HSFI patients was significantly longer during Phase 1 (P = 0.014) and Phase 1A (P = 0.022)., Conclusions: preSFA was associated with a higher peritoneal injury rate and longer operative time in HSFI patients, suggesting that the presence of abundant subcutaneous fat increases the difficulty of TEP repair.

Puberuline C ( 1 ) is an architecturally complex C 19 -diterpenoid alkaloid with a unique ring fusion pattern. The 6/7/5/6/6/6-membered rings (ABCDEF-rings) contain one tertiary amine and six oxygen functionalities, and possess 12 contiguously aligned stereocenters, three of which are quaternary. These structural features of 1 make its chemical construction exceptionally challenging. Here, we disclose the first total synthesis of 1 . The synthesis was accomplished from 2-cyclohexenone ( 9 ) by integrating radical cascade and Mukaiyama aldol reactions as the key transformations. A double Mannich reaction fused the A- and E-rings, and Sonogashira coupling attached the C-ring, efficiently leading to ACE-rings with the requisite 19 carbons of 1 . The chemically stable tertiary chloride of the ACE-ring structure was then transformed to the corresponding bridgehead radical, which participated in the simultaneous cyclization of the B- and F-rings via a highly organized radical cascade process. This unusual step installed five contiguous stereocenters, including two quaternary carbons, without damaging the preexisting multiple polar functionalities. Subsequently, the intramolecular Mukaiyama aldol reaction between silyl enol ether and acetal was realized by applying a combination of SnCl 4 and ZnCl 2 , forging the last remaining D-ring of the hexacycle. Finally, 3 was elaborated into 1 through regio- and stereoselective functionalizations of the BCD-rings. Our novel radical-based strategy achieved the total synthesis of 1 in 32 total steps from simple 9 , demonstrating the power of the radical cascade reaction to streamline the assembly of highly complex molecules.

Objective: To describe the incidence of injuries and illnesses sustained during the Tokyo Summer Olympic Games from 23 July to 8 August 2021., Methods: We recorded the daily number of athlete injuries and illnesses (1) through the reporting of all National Olympic Committee (NOC) medical teams and (2) in the polyclinic and medical venues by the Tokyo 2020 medical staff., Results: In total, 11 315 athletes (5423 women, 48%; 5892 men, 52%) from 206 NOCs were followed up prospectively for the occurrence of injury and illness. NOC and Tokyo 2020 medical staff reported 1035 injuries and 438 illnesses, equalling 9.1 injuries and 3.9 illnesses per 100 athletes over the 17-day period. Altogether, 9% of the athletes incurred at least one injury and 4% at least one illness. The incidence of injury was highest in boxing (27%), BMX racing (27%), BMX freestyle (22%), skateboarding (21%), karate (19%) and handball (18%), of which both BMX freestyle and skateboarding were new events, and lowest in diving, road cycling, rowing, marathon swimming and shooting (1-2%). Marathon and artistic swimming presented the highest illness incidences (both 8%), followed by skateboarding and karate (both 7%). In the study period, COVID-19 affected 18 athletes, accounting for 4% of all illnesses and 0.16% of all athletes. Exertional heat illness affected 78 athletes (18% of all illnesses, 0.7% of all athletes), the majority (88%) resulting in no time lost from sport., Conclusion: Overall, 9% of the athletes incurred an injury and 4% an illness during the Games. Comprehensive countermeasures helped mitigate both COVID-19 and exertional heat illnesses., Competing Interests: Competing interests: TSo works as scientific manager in the Medical and Scientific Department of the International Olympic Committee. KS is co-editor of the British Journal of Sports Medicine – Injury Prevention & Health Protection. MM is deputy editor of the British Journal of Sports Medicine. RB is director of the Medical and Scientific Department of the International Olympic Committee. LE is head of scientific activities in the Medical and Scientific Department of the International Olympic Committee, and editor of the British Journal of Sports Medicine and associate editor of the Journal of Bone and Joint Surgery., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

We report a case of resectable pancreas tail cancer treated with 2 courses of neoadjuvant therapy which is gemcitabine and S-1 therapy, and pathological diagnosis of the resected specimen revealed pathological complete response. A 56-year- old woman was referred to our hospital because she had back pain after eating for 5 months and her previous abdominal ultrasonography revealed an enlarged pancreatic tail. The tumor size was reduced from 30 mm to 12 mm, and the chemotherapy response was judged to be partial response. The patient underwent distal pancreatectomy, splenectomy, and D2 lymph node dissection. Intraoperative findings showed a pancreatic tail with a depression and surface erythema, thus we also diagnosed the patient as having pancreatic capsular invasion(S1). Postoperative histopathological examination revealed a 10×10 mm area of pancreatic parenchyma, which was replaced by fibrous tissue, with no evidence of active cancer cells. The patient was discharged from the hospital on the 14th after surgery.

We hereby report a case in which a patient with multiple lung metastases of pancreatic cancer continued chemotherapy and maintained good performance status(PS)for 48 months after recurrence. But her disease progressed rapidly after withdrawal of chemotherapy, resulting in her death in a short period of time. The patient was a 66-year-old woman who underwent a substomach preserving pancreaticoduodenectomy for pancreatic head cancer at the age of 60 years. She was diagnosed as fT3N1M0, fStage ⅡB. During postoperative adjuvant chemotherapy S-1, multiple lung metastases were noted on CT scan 2 years after surgery. Thereafter, she was treated with gemcitabine(GEM)alone, GEM plus nab-paclitaxel(GnP), nal-CPT-11 plus 5-FU plus Leucovorin, and FOLFIRINOX for 48 months sequentially. Each of which achieved a best overall response SD or better. However, Trousseau syndrome developed following community-acquired pneumonia during chemotherapy withdrawal due to myelosuppression. The disease progressed rapidly and resulted in her death 50 months after relapse. The results suggest that chemotherapy may have contributed significantly to disease control in this case.

Objective: This study aimed to clarify the effects of bridge to surgery(BTS)for malignant colorectal stenosis on the nutritional and immunological status., Subjects and Methods: A total of 19 patients with colorectal cancer who underwent BTS were included. We examined the technical success of stenting, clinical improvement, treatment progress after BTS, and nutritional and immunological status changes before and after BTS., Results: There were 19 technically successful cases and 18 clinically improved cases. One patient(Score 0)had an obstruction after BTS, which improved after stent repositioning. The CROSS Score before and after stenting improved in all patients. Scores 0 to 4 improved in 12 patients, Scores 0 to 3 in 5 patients, and Scores 3 to 4 in 2 patients. The median time to resume eating was 3 days, and the median surgery time was 25 days. The final diet before operation for colorectal consisted of a rokubugayu(rice gruel: polished rice content 12%)in 1 case, zengayu(rice gruel: polished rice content 20%)in 8 cases, soft diet in 5 cases, and regular diet in 5 cases. Before and after BTS, the nutritional and immunological status decreased significantly(p<0.05)with albumin levels ranging from 3.9- 3.5 g/dL, BUN/Cr from 24.8-12.5, and neutrophil-to-lymphocyte ratio from 3.8-2.5; however, no significant fluctuations in the prognostic nutritional index were observed., Conclusion: BTS enabled the nutritional management using the intestinal tract and improved the patient's immune status.

Background: Medial meniscus posterior root tears (MMPRTs) can result in the development of osteoarthritis or osteonecrosis. Clinical experience suggests that symptoms such as dull pain or discomfort in the popliteal area or the calf area, which are sometimes misdiagnosed as sciatic nerve pain, may precede impending rupture. We found that bone marrow edema emanating from the meniscal root on magnetic resonance imaging (MRI) scans-spreading roots sign-may indicate the preliminary stage of an MMPRT. The purpose of this study was to evaluate the efficacy of the spreading roots sign as an MMPRT-predictor., Methods: In a retrospective study, we reviewed the chart data and MRI results of patients who had required surgery for an acute MMPRT. We grouped patients by whether or not they had reported the above-mentioned precursory symptoms prior to acute rupture (precursory symptom group/non-precursor group), and when possible, we examined MRI scans to identify with which events the appearance/disappearance of the spreading roots sign coincided. Sex, age, body mass index, bone mineral density, radiological parameters, and MRI parameters were compared between groups., Results: Data from 24 patients (precursory symptom group, n = 17 [70.8 %]; non-precursor group, n = 7 [29.2 %]) were included; data from 5 patients included MRI scans prior to acute rupture. There were no significant differences between precursory symptom and non-precursor groups, except for the ratio of the presence of the spreading roots sign (p = 0.005). The appearance of the spreading roots sign on MRI scans coincided with the onset of precursory symptoms, and its disappearance coincided with acute rupture and the appearance of other MRI signs typical of MMPRT (white meniscus/truncation/meniscal extrusion/giraffe neck signs)., Conclusions: Our findings suggest that the spreading roots sign can be used as a unique precursory sign for MMPRT., Competing Interests: Declaration of competing interest Dr. Ryuichi Nakamura has a consultancy with Olympus Terumo Biomaterials. All other authors have no conflicts of interest relevant to this article to declare., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: One-stage bilateral total knee arthroplasty (TKA) has the advantages of a single hospital stay, shorter rehabilitation, and reduced financial burden on patients. However, perioperative bleeding is greater with one-stage bilateral TKA than with unilateral TKA and is more likely to require allogeneic blood transfusion. At our hospital, we normally store autologous blood about 1 month before surgery to reduce the need for allogeneic blood transfusion and avoid its adverse reactions as much as possible. The purpose of this study was to determine the efficacy of preoperative autologous blood storage for patients undergoing one-stage bilateral TKA., Methods: We retrospectively examined the allogeneic blood transfusion avoidance rate and the perioperative decrease in hemoglobin (Hb) level in 166 patients according to whether or not they had preoperative autologous blood stored. The patients for whom blood was stored were then subdivided according to whether the amount of blood stored was 400 mL or 200 mL., Results: Excluding allogeneic transfusion cases, the mean perioperative decrease in Hb was significantly lower in the patients with stored blood than in those without stored blood (3.5 g/dL vs 4.4 g/dL, p < 0.001). The allogeneic blood transfusion avoidance rate was significantly higher in the group with stored blood (98.5% vs 86.7%, p < 0.01). In the group with stored blood, the transfusion avoidance rate was higher, but not significantly, in the subgroup with 400 mL of blood stored than in those with 200 mL of blood stored (100% vs 97.5%) and the mean perioperative decrease in Hb was 3.5 g/dL in both blood storage volume groups., Conclusions: Preoperative autologous blood storage can help increase the likelihood of avoiding allogeneic blood transfusion in patients undergoing one-stage bilateral TKA., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: Total hip arthroplasty is a very effective reconstructive surgery but is often associated with massive perioperative bleeding, which leads to anemia. Tranexamic acid (TXA) minimizes bleeding and the need for blood transfusion. However, no universal standard TXA dosing regimen has been established. The objectives of this study were (1) whether there was a difference in the amount of decrease in perioperative mean hemoglobin (Hb) level between a single topical administration of TXA and intravenous and topical combination administration, and we also investigated whether there was a difference in the amount of decrease in the perioperative mean Hb level due to the difference in the local dose of TXA., Methods: We retrospectively reviewed 292 hips between June 2013 and October 2020. The decrease in Hb level (difference between the preoperative value and the 7-day postoperative value) was used to estimate total perioperative blood loss. The mean perioperative reduction in Hb was compared between hips that received intravenous TXA preoperatively and intra-articular TXA at wound closure (combination administration group) and those that received only intra-articular TXA (single dose group). It was also compared by different local doses of tranexamic acid., Results: The mean reduction in Hb was significantly smaller in the combination administration group than in the single dose group. However, no significant difference was observed due to the difference in the local dose of TXA administered at the time of wound closure., Conclusion: Reducing perioperative bleeding decreases the invasiveness of surgery, which is important from the perspective of medical safety., Competing Interests: Conflict of InterestsThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2022.)

Purpose: Augmented rectangle technique (ART) anastomosis is a totally intracorporeal anastomosis of laparoscopic distal gastrectomy (LDG), Billroth I (B1) reconstruction for gastric cancer, which secures a wide anastomotic stoma. Since the conventional extracorporeal hemi-double stapling technique (HD) may have a narrow anastomotic stoma, our aim of this study was to evaluate the feasibility and usefulness of ART anastomosis by comparing the surgical outcomes with HD anastomosis., Methods: Clinical data of 89 patients undergoing LDG with B1 reconstruction were retrospectively collected. Patients were divided into ART group (n = 40) and HD group (n = 49). Surgical outcomes including short-term outcomes, postoperative endoscopic findings, and nutritional factors 1 year after surgery were compared between the groups., Results: Baseline characteristics were similar between the groups. In terms of short-term outcomes, blood loss was less (11.5 mL vs 40 mL, P = 0.011) and postoperative hospital stay was shorter (10 days vs 12 days, P = 0.022) in the ART group. In terms of endoscopic findings, residual food was less (P = 0.032) in the ART group. In terms of nutritional factors, percent decrease of visceral fat area (- 27.6% vs - 40.5%, P = 0.049) and subcutaneous fat area (- 25.7% vs - 39.3%, P = 0.050) 1 year after surgery attenuated in the ART group., Conclusions: ART anastomosis is superior in perioperative course such as postoperative hospital stay. Moreover, a better nutritional recovery is expected by securing a wide anastomotic stoma leading to a favorable food passage., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The patient was a 57-year-old man who visited the department of neurosurgery for headache and lightheadedness. He was admitted with a diagnosis of brain tumor based on imaging findings. Severe brain dysfunction and mild ataxia were observed, and craniotomy tumor resection was performed 5 days after admission. He was diagnosed with brain metastasis of colorectal cancer based on histopathological examination and endoscopic findings, and was therefore referred to our department. No extracranial metastases were observed, laparoscopic-assisted low anterior resection was performed 1 month after the craniotomy. The final diagnosis was rectal cancer(Ra), pT3N0M1a(BRA), Stage Ⅳa. Three months after the craniotomy, subsequent MRI examination revealed a new metastatic lesion inferior to the tumor excision cavity, and gamma knife radiosurgery was performed. However, because an increasing tendency was noted, craniotomy was performed again 7 months after the first craniotomy. Following operative treatment, follow up has been performed without adjuvant chemotherapy or prophylactic irradiation, the patient has survived without recurrence at 34 months postoperatively. Here, we report a valuable rare case of solitary brain metastasis of colorectal cancer in which prognosis could be expected by radical resections.

BACKGROUND Gastric adenocarcinoma of the fundic gland type (GAFG) is an extremely rare neoplasm that consists of a mixed proliferation of oxyntic and chief cells. Differential diagnosis of GAFG is difficult in the absence of infiltration. Here, we report a case of GAFG and discuss the clinicopathological features. CASE REPORT A 78-year-old man was diagnosed with gastritis and reflux esophagitis, status after esophagectomy for carcinoma of the esophagus in 2015. The patient underwent repeated gastric biopsies in 2017 and an atypical epithelium was observed, but no diagnosis was confirmed. There was no evidence of tumor extension in the submucosa. The tumor was resected via endoscopic mucosal resection, and pathological examination was performed. Microscopic findings revealed an oxyntic-type gastric mucosa with atypical dense or dilated glands with abundant pale basophilic cytoplasm and round nuclei with prominent nucleoli. The majority of the tumor cells resembled chief cells, suggesting they were derived from gastric fundic glands. However, the tumor appeared to have no submucosal infiltration or focal stromal desmoplastic reaction. Sections stained positive for MUC6 and pepsinogen-I in chief cells, and H+/K+ ATPase and PDGFRa in parietal cells, but were mostly negative for CDX2, chromogranin A, synaptophysin, and CD10. Sections stained for mib-1 expressed very low proliferative activity, with an average of 10%. Staining for TP53 overexpression was negative. CONCLUSIONS Immunostaining markers are a supportive tool for histological diagnosis of GAFG. However, if there is no infiltration, as in our case, it is difficult to consider it as a malignant tumor. Further elucidation is needed in the future, including an officially accepted diagnostic name.

According to the Japanese Colorectal ESD/EMR guidelines, radical surgery should be recommended for additional treatment of T1 colorectal cancer(CRC)if pathological findings of the lesion after endoscopic resection show unfavorable factors to be evaluated as curative resection, considering the probability of lymph node metastasis and general condition of patients. We report a case of a 74-year-old man with T1b rectosigmoid(RS)cancer, whose pulmonary metastasis(PM) was curatively resected during the postoperative period of ESD for primary lesions. The patient underwent ESD in November 2018 for Type 0-Isp CRC in the RS junction, revealed using colonoscopy, which was performed for the examination of blood stool in September 2018. The patient had suffered from pulmonary tuberculosis in his thirties and regularly visited our hospital for COPD. He was under close observation after ESD because the depth of the lesion, which was pathologically diagnosed as T1b, was the only factor evaluated as non-curative. In April 2020, chest CT and FDG-PET/CT findings revealed the occurrence of PM. Subsequently, video-assisted wedge resection of the lung was performed for the treatment of PM, which was pathologically confirmed with a size of 10 mm. The patient has survived relapse-free to date, for 30 months after the resection of the primary lesion.

We investigated the significance of transitions in the neutrophil-to-lymphocyte ratio(NLR)before and after TACE for HCC could be a predictor of prognosis. The subjects were 108 patients with the first TACE performed from January 2010 to December 2019. NLR was calculated before and 1 month after TACE, and the relationship with therapeutic effect and prognosis was examined. When the transition of NLR before and after TACE was classified into 3 groups with a cut-off value of 5.0, group A(less than 5.0 after TACE): 52 cases(48.1%), group B(5.0 or more after TACE): 33 cases(30.6%)and C group(5.0 or more before and after TACE): 23 cases(21.3%). Median survival time were 25.0 months in group A, 18.5 months in group B, and 12.7 months in group C(p=0.0005). In multivariate analysis, treatment effect, NLR transition, AFP value, and serum albumin level were prognostic factors for HCC after TACE. Changes in NLR before and after TACE may help predict more detailed prognosis.

We report 4 cases of liver metastasis from renal cell carcinoma(RCC). Case 1: 72 years old, female. Pancreatic metastasis was resected 7 years after resection of left RCC, and hepatic posterior sectionectomy was performed for multiple liver metastases 2 years later. After that, multi-organ metastasis appeared and she died of the primary disease. Case 2: 72 years old, male. Liver metastasis and right RCC appeared 16 years after resection of left RCC, and hepatic posterior sectionectomy and partial resection of right kidney were performed. Nine months later, liver metastasis recurred and hepatic partial resection was performed. Case 3: 55 years old, male. After surgery for right RCC with tumor thrombus in the right atrium, multiple lung and liver metastases appeared, and hepatic central bisectionectomy was performed after chemotherapy. Case 4: 60 years old, male. Multiple pancreatic and lung metastases appeared 10 years after resection of left RCC, and most of them shrank or disappeared with chemotherapy. But increasing metastases appeared in the tail of pancreas and the right lobe of liver 16 months later, and hepatic subsegmentectomy and distal pancreatectomy were performed. Multidisciplinary treatment such as aggressive chemotherapy and excision is expected to improve the prognosis for liver metastasis from RCC.

This study examined the impact of the degree of occlusion in colorectal cancer during the perioperative period. The subjects included 207 patients who underwent elective colorectal cancer resection. The degree of obstruction at the first medical examination was evaluated using the ColoRectal Obstruction Scoring System(CROSS). We classified the subjects into two groups(CROSS score 0-2, CROSS score 3-4)and assessed their associations with clinicopathological factors, nutritional immune status, and postoperative course. Compared to the CROSS score 3-4 group, the CROSS score 0-2 group(42 subjects [20.3%])had a higher proportion of subjects with ≥2 lesions, T4, Stage classification Ⅳ, CEA >5.0 ng/mL, prognostic nutritional index( PNI)≤40, controlling nutritional status( CONUT) score ≥2, modified Glasgow prognostic score (mGPS)2, weight loss rate>2.3, mini nutritional assessment-short form(MNA®-SF)score <12, neutrophil lymphocyte ratio(NLR) ≥4.0, postoperative complications, and postoperative hospital stay >16 days( p<0.05). Our findings suggest that the degree of occlusion in colorectal cancer is associated with clinicopathological and nutritional/immune factors and is reflected by the postoperative course.

Diagnosis and treatment of superficial laryngopharyngeal cancers has recently received considerable attention. Here, we present a case of superficial hypopharyngeal cancer and superficial esophageal cancer treated with simultaneous endoscopic laryngopharyngeal surgery (ELPS) and endoscopic submucosal dissection (ESD). The patient was a 67-year-old man. During his follow-up for distal gastrectomy-performed earlier for stomach cancer-upper gastrointestinal endoscopy revealed three primary cancers: a superficial hypopharyngeal cancer, superficial esophageal cancer, and esophagogastric junction cancer. After total resection of the remnant stomach, combined hypopharyngeal ELPS with esophageal ESD was performed. He developed aspiration pneumonia after surgery but recovered and was discharged on the 16th day. Thus, safe and effective endoscopic therapy can be performed even for double superficial cancers of the laryngopharynx and esophagus.

We hereby report a case of advanced and recurrent colon cancer with long-term survival after 7 repeated surgical resections. A 73-year-old woman initially underwent right hemicolectomy and partial hepatectomy for an ascending colon cancer with synchronous liver metastasis. Pathological diagnosis of the tumors were moderately differentiated adenocarcinoma and metastasis to the liver compatibly. Final clinical stage was diagnosed as fT3N2M1(H1), fStage Ⅳ. But she was interrupted oxaliplatin-based adjuvant chemotherapy after 6 courses of CAPOX because of adverse drug reaction. One year after first operation, partial resection of right lung was performed for lung metastasis. Two years after first operation, 2nd resection of liver was performed for 2 liver metastatic lesions. Three years after first operation, 3rd partial liver resection, 2nd and 3rd partial lung resections were performed for metachronous metastases during 1 year. After 3 years recurrence free period, she complained of an induration of right neck and diagnosed as neck and supra clavicular lymph nodes metastases. Lymph nodes resection was performed. After the last operation, she has no sign of cancer recurrence for 1 year and 7 months, eventually she has been alive for 7 years and 7 months after the initial operation.

A 74-year-old man underwent a medical examination for anemia and had a positive fecal occult blood test. Ascending colon cancer was detected by colonoscopy. Since it was unresectable, a bypass operation was performed to prevent digestive symptoms prior to chemotherapy. The bypass was performed by cutting the ileum and attaching the oral side to the transverse colon with side to side anastomosis. The other end of the terminal ileum was anastomosed to the transverse colon on the oral side of the prior anastomosis, making a pretzel shaped bypass. There were no postoperative complications and the patient was treated with chemotherapy from postoperative day 23.

We assessed the therapeutic effect of curative resection in patients with multiple relapses of colorectal cancer using the time to surgical failure(TSF)as an index. We included 24 patients who experienced recurrence after curative resection of primary colorectal cancer at our department between 1993 and 2015. Curative resection for multiple relapses was possible in these patients. The sites of recurrence included the liver, lungs, peritoneum, lymph nodes, localized, and brain in 9, 8, 3, 3, 2, and 1 patients, respectively. The relapse occurred in 2 organs in 2 patients. The TSF after curative resection of recurrent lesions was 25.6 months, with a 5-year TSF-free rate of 40.2%. The clinicopathological factors associated with poor prognosis were age B65 years at the time of recurrence, absence of distal metastasis at primary onset, and only 2 curative resections for relapses. However, there was no difference in prognosis because of the number of twice recurrent lesions. Therefore, curative resection should be proactively performed as long as feasible in colorectal cancer patients with multiple lesions or multiple relapses.