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Objective: To clarify whether there are any muscle synergy changes in individuals with knee osteoarthritis, and to determine whether muscle synergy analysis could be applied to other musculoskeletal diseases. Methods: Subjects in this study included 11 young controls (YC), 10 elderly controls (EC), and 10 knee osteoarthritis patients (KOA). Gait was assessed on a split-belt treadmill at 3 km/h. A non-negative matrix factorization (NNMF) was applied to the electromyogram data matrix to extract muscle synergies. To assess the similarity of each module, we performed the NNMF analysis assuming four modules for all of the participants. Further, we calculated joint angles to compare the kinematic data between the module groups. Results: The number of muscle modules was significantly lower in the EC (2–3) and KOA (2–3) groups than in the YC group (3–4), which reflects the merging of late swing and early stance modules. The EC and KOA groups also showed greater knee flexion angles in the early stance phase. Contrarily, by focusing on the module structure, we found that the merging of early and late stance modules is characteristic in KOA. Conclusion: The lower number of modules in the EC and KOA groups was due to the muscle co-contraction with increased knee flexion angle. Contrarily, the merging of early and late stance modules are modular structures specific to KOA and may be biomarkers for detecting KOA. Significance: Describing the changes in multiple muscle control associated with musculoskeletal degeneration can serve as a fundamental biomarker in joint disease.

Summary Objective Abnormal load stress caused by joint instability has been reported to be one of the factors responsible for the development of osteoarthritis (OA). However, few studies have investigated the efficacy of exercise therapy for patients with knee instability-induced OA, and there are no specific treatment guidelines or effects for this form of OA. Therefore, the purpose of this study was to examine the effect of exercise treatments for joint instability in patients with knee OA by a systematic review. Design Systematic review. Results Searches in three databases, PubMed, Cochrane, and the Physiotherapy Evidence Database, yielded 14 articles that were scrutinized, and 6 articles that met the inclusion criteria were selected. Conclusions Exercise therapy focusing on joint instability, including muscle maintenance and strength training, and specific training targeting knee instability have no additional beneficial effects on knee joint instability. However, because of the benefits of treatment protocols based on patient attributes in exercise treatment focused on joint instability, it is necessary to investigate the effects in more detail in the future.

Background Delirium is an important and common medical condition, particularly in hospitalized patients, that is associated with adverse outcomes. The identification, prevention, and treatment of delirium are increasingly regarded as major public health priorities. Purpose The aim of this study was to create a simple-to-use screening tool for delirium in hospitalized patients using clinical manifestations of delirium regularly observed by nurses. Methods This study was conducted using data on 2,168 patients who had been admitted to the surgical ward between January 2011 and December 2014. Data were collected retrospectively from medical records. Univariate and multivariate analyses were performed, and a logistic regression model was constructed for the development of a predictive screening tool. After constructing a new screening tool for delirium, a receiver operating characteristic curve was drawn, the most appropriate cutoff value was decided, and the area under the curve was obtained. Bootstrapping was used for the internal model validation. Results A screening tool for delirium (Subjective Delirium Screening Scale by Nurse) with a total score of 5 points was constructed as follows: 2 points for disorientation and 1 point each for restlessness, somnolence, and hallucination. The area under the curve for the Subjective Delirium Screening Scale by Nurse was 81.9% (95% CI [77.9%, 85.8%]), and the most appropriate cutoff value was determined to be 2 (sensitivity of 61.0% and specificity of 96.7%). Bootstrapped validation beta coefficients of the predictive factors were similar to the original cohort beta coefficients. Conclusions We created a screening tool for delirium using factors that were regularly observed and recorded by nurses. This tool is simple and practical and has adequate diagnostic accuracy.

For clinicians to provide more efficient early mobilization in patients with acute stroke, they must quantitatively evaluate the motion characteristics of the patients. To measure the motion in the acute phase, it is necessary to prevent physical interference between the measurement and medical equipment. This study classified abnormal muscle synergies during sit-to-stand motion in patients with acute stroke by using small, wirelessly operable, noninvasive surface electromyography devices. Four patients with acute stroke and four healthy adults performed a six-directional isometric contraction task and a sit-to-stand motion task. A nonnegative matrix factorization algorithm was applied to the muscle activity data to extract the muscle synergies. Hierarchical cluster analysis was used to classify these synergies. The results suggest that sit-to-stand motion characteristics according to the severity of effects in patients with acute stroke can be quantitatively classified by muscle synergy analysis. The spatial structure of muscle synergies of patients was classified into different clusters from that of the healthy adults. The abnormal muscle synergy in patients with severe paresis is considered severe in that it cannot be modulated according to the task. The muscle synergies in patients with moderate paresis were modulated in the sit-to-stand motion to compensate for extensor muscle weakness. Such abnormal muscle synergy in the sit-to-stand motion is useful as a reference for motion practice, especially for early mobilization after the onset of a stroke. In addition, the results verify that the early to late stages of recovery can be consistently evaluated with this small, wireless noninvasive electromyography device.

Introduction The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method (“reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy. Methods Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated. Results Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis. Conclusion Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Background/Aims: Preoperative lymph node staging in gastric cancer patients is important. The aim of this study was to assess the diagnostic accuracy of computed tomography (CT) in assessing lymph nodes in patients with gastric cancer. Methods: A total of 56 patients had undergone standardized gastric resection with lymphadenectomy between October 2013 and June 2015 were reviewed retrospectively. The short axis diameter of the largest lymph node per station was recorded when reviewing the preoperative CT images. Diagnostic accuracy was calculated by comparing CT with histopathological findings. Results: In 518 stations dissected at surgery, 56 included lymph nodes with metastasis. Among them, lymph nodes were visualized on preoperative CT in 26 stations. No lymph node was detected in 382 stations among 462 infiltration-negative stations. The cutoff of 12 mm had the highest accuracy rate of 0.896. Conclusion: The accuracy of CT in the preoperative diagnosis of lymph node metastasis in patients with gastric cancer remains poor. Therefore, surgeons should pay attention to the visibility of lymph nodes on CT. Detection of lymph nodes on CT can be utilized for a more accurate diagnosis such as fine-needle aspiration biopsy.

We performed laparoscopic surgery for three cases of colorectal cancer using an 8K ultra-high-definition endoscopic system, which offers 16-fold higher resolution than the current 2K high-definition endoscope. The weight of the camera has been successfully reduced to 370 g. To maximize the advantages of the 8K ultra-high-definition endoscope, surgery was performed by darkening the room and placing a large 85-in. display as close to the surgeon as possible. As a result, the autonomic nerve was preserved, and the membrane structure could be clearly observed. Moreover, we were able to feel the stereoscopic effect near the 3-D image. This suggests the possibility of improved curability and function preservation with the 8K endoscope. Although there are some disadvantages that need to be overcome, the 8K ultra-high-definition endoscope will surely contribute to further progress in laparoscopic surgery.

Purpose We developed a new technique, sutureless mesh fixation, using 2-octyl cyanoacrylate (Dermabond®, a surgical tissue adhesive) for incisional hernia repair. The objective of this article is to introduce the new technique and to examine whether the technique provides sufficient resistance to abdominal pressure.

Hemiplegia patients have complete paralysis of half their body, and encounter many challenges in living an independent life. Rehabilitation of the lower body is more important than that of the upper body for independent living; thus, recovering upper body functions of their paralyzed side is not enough. Rehabilitation robots may be used to assist training without therapists. In this study, a small portable rehabilitation robot was developed for use at home, and a new training method was proposed. This robot consists on an omni wheel mechanism and a force sensor, and is capable of deciding the motion based on the force value. Voluntary movement of a hemiplegia patient is recovered by the rehabilitation robot and proposed training method. Thus, verification experiments were performed using participants with hemiplegia. The CCI (Co-Contraction Index) from after training were smaller than ones of before training, thus the movement skills of the participants improved with respect to controlling force direction and magnitude. Moreover, manual function test (MFT) scores increased as reflected by improvements in the motor function of the upper limb using the proposed training method.

Background: Although the development of lymphatic invasion by gastric cancer has been solved using 'solitary lymph node metastasis' research, few facts are known about the sequential flow following the sentinel station.Aim: In this study, we investigate the lymphatic spread of gastric cancers using 'triple lymph nodes metastases' analysis.Methods: During January 2001 and December 2015, 402 subsequent patients with gastric cancer underwent gastrectomy with standardized lymph node dissection at our institute. Among them, lymph node involvement was revealed in 234 patients by a histopathological study. The lymphatic spread of gastric cancer was analyzed theoretically based on the probability of additional lymph node metastases from each station.Results: The numbers of cases were 64, 41, 17, 23, 17, 13 and 59 according to the number of metastases of 1, 2, 3, 4, 5, 6 and 7 or more, respectively. The lesser curvature lymph node (#3) was the key station and skip metastasis was sometimes seen in lymph nodes of the intermediate region at the solitary lymph node metastasis stage. Some lymphatic flows were demonstrated by double and triple lymph node metastasis analysis, especially many flows from perigastric toward intermediate regions.Conclusion: This study demonstrated theoretically a lymphatic route for gastric cancer cells using a novel methodology. The results may be applicable to making preoperative diagnosis and for deciding on optimal lymph node dissection in gastric cancer surgery.

Refractory esophageal ulcerations occur rarely after cardiovascular surgery, occasionally leading to perforation. There is little consensus on their optimal management. Herein, we present a case of refractory esophageal ulceration after cardiovascular surgery. A 62-year-old woman with Marfan’s syndrome was referred to our hospital with cardiac failure due to aortic regurgitation. She underwent root replacement by the modified Bentall method. Refractory esophageal ulceration developed 3 months later and persisted for 3 months despite conservative therapy. With the patient’s informed consent, Kirschner bypass surgery was performed. A jejunostomy using a 20 Fr. Nelaton catheter was made in the Roux-en-Y loop of the jejunum for postoperative endoscopy. The postoperative course was uneventful and transjejunostomal endoscopy revealed excellent healing of the ulceration. Esophageal bypass surgery and transjejunostomal endoscopy were very effective in this patient with refractory esophageal ulceration.

This study has developed a device and system for the exercise of eccentric contraction of the tibialis anterior, with the objective of maintaining ambulatory function. A system was built that allows for exercises of appropriate load and speed, by providing the trainee with force data in the form of visual feedback. An experimental verification with two healthy participants shows small variation in the Myoelectric data during the repetitive exercise. The result suggest the possibility of higher reproducibility of the proposed exercise in comparison with manual exercise. As a clinical test, elderly ambulatory participants who frequented a day care facility performed exercises for one month (twice weekly) using the proposed device and exercise system. To verify the exercise results, a TUG test was performed, which is an assessment index for functional mobilization capacity. Shorter TUG in the majority of the participants suggests a possible beneficial effect in ambulatory function.

The HyperEye Medical System is a newly developed device that allows for the visualization of the fluorescent image of indocyanine green enhanced by near-infrared light among the surrounding vivid color images. We recently applied this system to confirm the blood flow of an esophageal substitute, and for sentinel node navigation during esophagectomy. Five consecutive patients with thoracic esophageal cancer who underwent a subtotal esophagectomy between June 2010 and May 2011 were enrolled in the study. The esophageal substitute used for reconstruction was the stomach and ileocecum in four and one cases, respectively. In all cases with a reconstructive stomach, fine arterial blood flow and venous perfusion were observed. The blood flow of the reconstructive colon was poor before microvascular anastomosis, however, it dramatically increased after anastomosis. Concerning the sentinel node navigation, the fluorescence of lymph nodes, lymphatic vessels, and the tumor site were detected. The postoperative courses of all cases were uneventful, with no mortalities or anastomotic leakage occurring.

Background and Aim: We seek for the accurate and simple method for detecting sentinel nodes of gastric cancer which can be popularized in community hospitals. The indocyanine green (ICG) fluorescence-guided method is reported to be sensitive. However, the ordinal fluorescence cameras have gray scale imaging and require a dark room. We have developed a new device, Hyper Eye Medical System (HEMS) which can simultaneously detect color and near-infrared rays and can be used under room light. This study was planned to examine whether submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery. Methods: The patients underwent gastrectomy for clinical T1a (mucosa)–T2 (muscularis propria) and clinical N0 were enrolled in the present study. As a preliminary trial, one case each of the ICG 25 and 100 µg/mL, injected on the day before operation and intraoperative injection, was examined. Then, 10 cases injected 50 µg/mL ICG on the day before operation were examined. Results: The ICG fluorescence of the patient injected 100 µg/mL was too intense and that of the patient injected 25 µg/mL was too faint. Sentinel lymph nodes were detected in all of 10 cases injected 50 µg/mL, the day before operation and number of sentinel lymph nodes per patient was 3.6 ± 2.1. Metastasis was observed in one case. All of ICG fluorescence-positive sentinel nodes were positive for the metastasis. In the patient who underwent intraoperative injection, sentinel lymphatic basins could be identified. Conclusion: The present study shows that HEMS-guided abdominal surgery is feasible under room light. Submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery.

Background and Aims: The most effective treatment would be neoadjuvant chemoradiotherapy (NACRT) plus surgery with three-field lymphadenectomy, if tolerability and complications are acceptable. The aim of this prospective study was to evaluate the tolerability of NACRT+ systematic three-field lymphadenectomy. Methods: A total of 127 cases of advanced esophageal carcinoma were objected, among which 32 had NACRT, being the cases suspected to cT3–T4 or

Esophageal neuroendocrine carcinomas are rare, aggressive and have a poor prognosis. Combined therapy using chemotherapy, radiotherapy and/or surgery appear effective for them. Upper gastrointestinal endoscope of a 65-year-old male revealed a localized ulcerative lesion in the middle esophagus. Histology of biopsy specimens indicated a neuroendocrine carcinoma. A computed tomography showed an esophageal tumor with enlarged mediastinal lymph nodes. The patient was administered neoadjuvant chemotherapy consisting of 5-fluorouracil and cisplatin, which led to partial response. Subtotal esophagectomy with three-field lymphadenectomy was performed. Pathologically, the tumor was 25 mm and infiltrated the proper muscle layer. The tumor cells were arranged in microtubular structures, with small and round cells containing scanty cytoplasm, and exhibited intense mitosis 51/10 HPF. They were positive for synaptophysin and chromogranin A, and Ki-67 labeling index was 70% - 80%. These findings led to the diagnosis of neuroendocrine carcinoma of small cell type. The patient was administered adjuvant chemotherapy using cisplatin and CPT-11, and he is now alive disease-free at the time of this writing.

The aim of this study was to investigate the efficacy of diagnosing depth of wall invasion of gastric cancer on endoscopic images using computer-aided pattern recognition. The back propagation algorithm was used for computer training. Data of 344 patients who underwent gastrectomy or endoscopic tumor resection between 2001 and 2010 and their 902 endoscopic images were collected. The images were divided into ten groups among which the number of patients and images were almost equally distributed according to T staging. The computer learning was performed using about 800 images from all but one group, and the accuracy rate of diagnosing the depth of wall invasion of gastric cancer was calculated using the remaining group of about 90 images. The various numbers of input layers, hidden layers, and learning counts were updated, and the ideal setting was decided. Similar learning and diagnostic procedures were repeated ten times using every group and all 902 images were tested. The accuracy rate was calculated based on the ideal setting. The most appropriate setting was a resolution of 16 × 16, a hidden layer of 240, and a learning count of 50. In the next step, using all the images on the ideal setting, the overall accuracy rate was 64.7%. The diagnostic accuracy was 77.2, 49.1, 51.0, and 55.3% in the T1, T2, T3, and T4 stagings, respectively. The accuracy was 68.9% in T1a(M) staging and 63.6% in T1b(SM) staging. The positive predictive values were 80.1, 41.6, 51.4, and 55.8% in the T1, T2, T3, and T4 staging, respectively. It was 69.2% in T1a(M) staging and 68.3% in T1b(SM) staging. Computer-aided diagnosis is useful for diagnosing depth of wall invasion of gastric cancer on endoscopic images.

A 56-year-old man was diagnosed with esophageal cancer by upper gastrointestinal endoscopy for examination of dysphagia. The patient had undergone total gastrectomy and jejunal interposition 4 years previously for a gastric cancer at the pT1N0M0 stage according to the UICC-TNM classification. Enhanced CT findings revealed a 3-cm-diameter mass located near the superior mesenteric artery. We conducted subtotal esophagectomy associated with partial jejunectomy including mesojejunectomy. The mass was histologically diagnosed to be mesojejunal lymph node metastasis from esophageal cancer. Mesojejunal lymph node metastasis from esophageal cancer developing after total gastrectomy has been reported in only three cases including ours. The present lymph node metastases may have occurred via the newly developed lymphatic drainage route through the esophagojejunostomy, and this metastatic lymph node can be considered the regional lymph node. Therefore, resection of the interposed jejunal limb with mesojejunectomy may be rational in surgery on esophageal cancer developing after total gastrectomy.

Introduction/Background Sit-to-stand task is an important and kinetically challenging task for stroke patients. From the muscular strength perspective, it is well known that a large knee extension moment is required to lift the thigh. Energy flow from trunk and shank to lift the thigh has already been shown. Therefore, kinematic coordination is also necessary for the sit-to-stand task. Material and method In this study, sagittal movement onset of each segment of the body (thorax, pelvis, thigh, shank), hip joint center (HJC), and knee joint center (KJC) were compared between young (YOUNG, three people) and elderly (ELDERLY, four), and stroke patients (STROKE, three) for sit-to-stand task. We used VICON Nexus 2.5 (VICON corp.) to measure the body kinematics. Fig. 1 presents temporal order of movement onset of the body parts. The time difference within 0.005 [sec] is regarded as simultaneous, and a single quotation is added on number. The group difference existed between YOUNG and ELDERLY (e.g. mean thigh-shank was 0.13, −0.07 [s], respectively; P = 0.01). ELDERLY and STROKE (two-thirds people, paretic side) had similar timing. Conclusion In YOUNG, there is a possibility that trunk flexion lead to the translation of HJC and KJC, so that tilted the shank forward. Also, these results were consistent with a previous study that movement (work) of the trunk and shank contributes to lift the thigh. ELDERLY and some STROKE were different from this order. They may have used the movement strategy inferior in terms of energy cost, because the movement trajectory of healthy adults is controlled so that the torque of each joint is minimized. Although movement coordination is difficult to evaluate, we could provide basic knowledge from the standpoint of kinematics.

63 Background: The neutrophil-lymphocyte ratio (NLR) is associated with the inflammatory status of patients with some cancers. We hypothesize that increased NLR was associated with prognosis in patients with stage II/III esophagogastric adenocarcinoma. Methods: We retrospectively analyzed 220 patients with stage II/III gastric cancer who underwent curative resection with suitable lymphadenectomy at our hospital, between 2000 and 2014. All patients underwent baseline staging, including blood tests, computed tomography, and endoscopic biopsy. The relationship between NLR and clinical outcomes was analyzed by univariate and multivariate analyses. Results: Average age was 67.9 [95% confidence interval (CI); 43.8, 92.1] years, and majority of the patients were male. After surgery, 111 (50.5%) patients underwent adjuvant chemotherapy, most of all patients received S-1 according to Japanese treatment guideline. Median follow-up time was 74.8 (95% CI; 69.9, 79.7) months. The preoperative NLR was 3.2 (95% CI; -4.2, 10.6), whereas the postoperative NLR was 3.0 (95% CI; -6.9, 12.8). In univariate analyses, age, stage, preoperative NLR, baseline CA19-9 levels, postoperative white blood cell (WBC) count, postoperative hemoglobin levels, postoperative NLR, increased NLR after surgery and adjuvant chemotherapy were associated with overall survival (OS). In multivariate analyses, age ( p < 0.001), stage ( p = 0.001), and increased NLR after surgery ( p = 0.048) were associated with OS. The prognosis of patients with increased NLR after surgery was observed to be worse than that of those with decreased NLR after surgery ( p = 0.001). Conclusions: Our findings indicated that increased NLR after curative resection was associated with poor OS in patients with locally advanced esophagogastric adenocarcinoma, suggesting that perioperative increased NLR was a potentially useful marker for individual therapy.

In an attempt to improve survival of patients with locally advanced esophageal cancer, chemoradiotherapy consisting of cisplatin, 5-fluorouracil (5-FU), and irradiation has recently been used. For such patients, concurrent chemoradiotherapy using docetaxel in combination with cisplatin and 5-FU has been introduced and is under evaluation. We herein report an esophageal cancer patient with concomitant distant lymph node metastasis in whom a complete response was achieved by chemoradiation therapy. A 46-year-old man was diagnosed as having stage IV A esophageal cancer with synchronous bulky metastasis in the celiac lymph node, and concurrent chemoradiotherapy was started. Chemotherapy consisting of docetaxel (30 mg/m2 on days 1, 8), cisplatin (60 mg/m2 on day 1), and 5-FU (200 mg/m2/day, continuous infusion on days 1–14) was performed for 2 cycles. At the same time, irradiation therapy (1.8 Gy/day on 1–5 days every week for 6 weeks) was employed for both local and metastatic lesions. Although the patient experienced severe hematological toxicity throughout the course, chemoradiotherapy resulted in complete regression of both local and metastatic disease. Subsequently, he was followed as an outpatient without any maintenance therapy, and he has been free of disease for 38 months after completion of the combination therapy. Thus, concurrent chemoradiotherapy may be effective for esophageal cancer, even with visceral metastasis.

腹膜由来の腫瘍性・嚢胞性疾患は稀であり，その診断基準などについてはいまだに不確定な部分も多い．今回われわれは，鼠径ヘルニアの手術中に発見されたmesothelial cystsの3例を経験した．症例はいずれも鼠径ヘルニア嚢内に嚢胞性病変を認め，病理組織所見も併せて2例をsimple mesothelial cysts，1例をmultilocular mesothelial cystsと診断した．過去の報告や成書も参照して本疾患の疾患概念や分類について検討したところ，同一の病態に対してmulticystic mesotheliomaとmultilocular mesothelial cystsの複数の診断名が存在し，混乱を生じていると考えられた．両者を明確に区別しうる診断基準を設けることが，本疾患の疫学や病態を明らかにする上で有用であると考えられた．また鼠径ヘルニア手術中に本疾患が見出される機会は意外に多いものと考えられ，見落とさないよう注意が必要である．

We report a rare case of leiomyosarcoma of the lower esophagus that was treated by endoscopic resection. A 56-year-old man was referred to our hospital in October 2005 because of mild discomfort around the lower esophagus upon swallowing for 2 months. The esophagogram showed a filling defect at the lower esophagus. It revealed a giant polyp tumor arising from the right wall of the lower esophagus. The diameter of the top of the tumor was 25 mm. Upper gastrointestinal endoscopic study revealed that the lesion was a tumor with a large stalk at the right side in the lower esophagus. The lesion was at 38 cm from the incisors. Histological study of the biopsy samples revealed the tumor was a leiomyosarcoma by morphological features of the tumor in hematoxylin and eosin stain. Computerized tomographic (CT) scan showed the tumor protruded into the lumen of the lower esophagus but into none of the lymph nodes, nor was distant metastasis seen. Endoscopic resection was performed with an electric snare. The tumor was completely resected without any trouble. The tumor was composed of spindle cells with irregular nuclei and numerous mitotic figures were present. The immunohistochemical staining showed positive for p53. The Ki67 labeling index was 8.7%, which was consistent with leiomyosarcoma. It also showed positive for smooth muscle actin, caldesmon, and calponin but negative for c-kit, CD34, and S-100. These histopathological findings disclosed a leiomyosarcoma. The patient is asymptomatic and disease free after a 2-year follow up. We believe that endoscopic resection will be an option for an intraluminal polypoid form of esophageal leiomyosarcoma.

Undifferentiated carcinoma of the esophagus (UEC) is an uncommon esophageal malignancy, and patients with UEC have an especially poor prognosis because of extensive metastasis even at an early stage. A standard treatment regimen for UEC has not yet been established. We have experienced a case with UEC (T2N1, stage II) that achieved complete remission by chemoradiotherapy [cisplatin (CDDP) + 5-fluorouracil (5-FU), 50 Gy]. A 67-year-old man with a 4-cm type 1 tumor in the middle thoracic esophagus was diagnosed as UEC (non-small cell type) histologically. Computerized tomographic (CT) scan of the chest showed metastatic lesions at the right recurrent nerve lymph nodes. Although the lesion was diagnosed as T2, N1, and stage II, the patient was judged to be a severe case because surgical control of UEC is almost impossible even at the early stages. Chemoradiotherapy (CRT; CDDP + 5-FU, and radiation) was selected for this case. In the first course of CRT, the patient was given CDDP (20 mg/m2) and 5-FU (700 mg/m2) for 5 days and concurrent external-beam irradiation (30 Gy, 2 Gy/day × 15 days) in the “long-T” field including the cervical and mediastinal lymph nodes. The second course was the same chemotherapy (CDDP 20 mg/m2/day + 5-FU 700 mg/m2/day, 5 days) with externalbeam irradiation (2 Gy/day) for 10 days (5 days/week, 2 weeks). After the first course of CRT, the patient already had achieved complete remission (CR). An upper gastrointestinal endoscopic study showed the tumor had almost disappeared and was covered by normal epithelium. Histological study from the biopsy samples showed there were no viable cancer cells at the lesion. CT scan of the chest showed the metastatic lesions at the right recurrent nerve lymph nodes had reduced. After the second course of CRT had been completed, the patient was discharged from the hospital. The patient is still alive with no cancer relapse at 2.5 years after the treatment. Further studies to clarify the response rate and survival effect of CRT in patients with UEC are expected.

Background Pylorus-preserving gastrectomy (PPG) with extensive lymph node dissection is useful for treatment of early gastric cancer with preservation of function. This technique could be improved by using laparoscopy-assisted gastrectomy. Study design Between September 2000 and September 2004, 109 patients with T1 gastric cancer underwent surgical treatment; 72 underwent laparoscopy-assisted PPG (LAPPG) and 37 underwent conventional PPG (CPPG). Total numbers of dissected lymph nodes, retrieval at each lymph node station, intraoperative blood loss, and operation times were used as measures of the quality of lymph node dissection to compare the procedures. Continuous data are summarized as mean ± SE. Results Operation times with the LAPPG procedure (279 ± 6 minutes) were significantly, but only 20 minutes, longer than with CPPG (259 ± 8 minutes) (p = 0.047), although estimated blood loss for LAPPG patients (153 ± 13 mL) was not significantly different for those undergoing CPPG (184 ± 13 mL, p=0.13). Mean total number of dissected lymph nodes was 32.3 ± 1.6 in the LAPPG group and 28.5 ± 2.2 in the CPPG group (p = 0.16). There was no significant difference in the number of lymph nodes retrieved for any of the nodal stations between the LAPPG and CPPG procedures. Conclusions Clinical outcomes of surgical treatment were comparable for gastric cancer patients who underwent LAPPG and those treated with CPPG in terms of station-dependent lymph node dissection and estimated blood loss.

Background Laparoscopic surgery of the gastrointestinal tract involves a reduced immune response compared with open surgery. The aim of this study was to assess manual handling of the gut in open procedures as the principal cause of the enhanced immune response. Methods Eighteen Landrace pigs underwent gastrectomy by three different methods: conventional open wound with bowel manipulation, laparoscopically assisted gastrectomy, and gastrectomy without manipulation using a combination of open wound and laparoscopic surgical devices. Local inflammatory changes were assessed by ascites formation, intestinal adhesion development and intestinal inflammatory gene expression. Associated systemic inflammatory changes were determined by measuring portal and systemic plasma endotoxin levels, plasma inflammatory cytokine levels, liver inflammatory gene expression and transaminase levels. Results Significantly more postoperative intra-abdominal fluid and adhesions were seen in the open group. The expression of inflammatory cytokines was significantly greater in the intestine and liver in the open group. Portal and systemic levels of endotoxin, inflammatory cytokines and transaminases were also higher. Conclusion Manual handling of organs during gastrectomy is an important contributor to the molecular and humoral inflammatory response to surgery, supporting the use of minimally invasive techniques in gastrointestinal surgery.

In the present study, we aimed to establish an additional standardized protocol with a higher H. pylori eradication rate in the remnant stomach. Fifty-five H. pylori-positive patients were randomly allocated to one of three regimens: LAC--lansoprazole, amoxicillin, and clarithromycin b.i.d. for 7 days (n = 17); LAC+CET--LAC b.i.d. plus cetraxate q.i.d. for 7 days (n = 20); and LEFT--LAC for 7 days in a horizontal body position on the left side for 30 min (n = 18). Patient compliance and side effects were checked via interviews. H. pylori eradication was successful in 75, 72, and 41% in LAC+CET, LEFT, and LAC, respectively. The eradication rate was significantly higher in LAC+CET than in LAC (P = 0.024) but not in LEFT (P = 0.058). Adverse events that occurred in each group were almost all mild ones. Cetraxate plus LAC for 1 week is a safe and effective regime for the eradication of H. pylori in patients after partial gastrectomy.

Background. Postoperative small bowel obstruction following abdominal procedures is more common in patients who have undergone laparotomy. However, little is known about the influence of climate on the incidence of postoperative small bowel obstruction. Methods. To evaluate whether seasonal climatic variations are a risk factor for postoperative small bowel obstruction, hospital-based, retrospective case series was designed from medical records of 230 patients suffering from postoperative small bowel obstruction admitted to the Tokyo University Branch Hospital. Detailed analysis of weather charts from the Japanese Meteorological Agency and review of medical records for selected patients who were diagnosed with postoperative small bowel obstruction. The obstruction was diagnosed by abdominal X-ray imaging, clinical examination, and patient interviews. Results. A total of 233 patients diagnosed with postoperative small bowel obstruction were identified. Analysis of the medical records of these 233 patients revealed that the variables associated with an increased risk of postoperative small bowel obstruction included low ambient temperatures of 5–10 °C, an increase in air humidity by 40–50% and air pressure of 1010–1015 hPa. Conclusion. The typical winter weather in Tokyo is characterised by low temperatures, low humidity and moderate air pressure. These winter climate conditions could be correlated with an increased incidence of postoperative small bowel obstruction in Tokyo during our observation period.

Many reports on the diagnostic efficacy of the [13C] urea breath test ([13C] UBT) for the detection of Helicobacter pylori in the residual stomach have shown negative results. We previously reported on the utility of [13C] UBT and conducted an evaluation to establish a standardized protocol with a shorter sampling time for [13C] UBT in partial gastrectomy patients. Sixty-two patients who had undergone partial gastrectomy were included. The [13C] UBT protocol included ingestion of 100 mg [13C] urea, use of mouthwash, and the body in a horizontal position on the left side. The sensitivity of [13C] UBT was 95.7%. Thirty minutes and a cutoff of 2.0 per thousand were found to be optimal for the test, with the body position horizontal on the left side. In the present protocol [13C] UBT appears to be a reliable and convenient tool with the same accuracy rate as other routine tests in patients with a remnant stomach.

We report a case of gastric outlet stenosis successfully diagnosed as an antral stenosis of the stomach in an 80-year-old male. Severe stenosis can be very difficult to diagnose and treat because it may be difficult to visualize the gastrointestinal tract in the area distal to the stenosis. In the present case, it had not been possible to view the area distal to the stenosis by endoscope using hyoscine-N-butylbromide (Buscopan). Peppermint oil solution is clinically inert but can inhibit gastrointestinal motility. In a recent double-blind, double-dummy controlled trial we showed that intraluminally administered peppermint oil solution was a more effective and safer antispasmodic agent than Buscopan. In the present case, where there was severe antral stenosis of the stomach, use of peppermint oil solution as an antispasmodic enabled us for the first time to successfully extend the tip of the endoscope to the duodenal bulbs in the area distal to the stenosis.

Histologic examination lacks the sensitivity to detect micrometastases in gastric cancer lymph nodes. In the present study, we applied a real-time RT-PCR approach to the quantitative detection of micrometastases in gastric cancer lymph nodes and compared diagnostic power with routine histology and immunohistochemistry. We studied 392 lymph nodes from 21 gastric cancer patients who underwent curative surgery. Real-time quantitative RT-PCR was performed on a LightCycler instrument using a hybridization probe for carcinoembryonic antigen (CEA) and cytokeratin-20 (CK20) as marker genes. Immunohistochemistry with antibodies to wide-keratin was also performed in the lymph nodes to compare the sensitivity and specificity. Median (average) values of CEA mRNA in lymph nodes in patients with histology+, immunohistochemistry+/histology−, immunohistochemistry−/histology− and negative control results were 4,600 (16,000), 200 (400), 0 (9.8) and 0 (0.6), respectively. There were some false-negative results with simple CEA and CK20 real-time RT-PCR due to the presence of low gene-expressing gastric cancers as revealed by CEA and CK20 immunohistochemistry. CEA in combination with CK20 (duplex) real-time RT-PCR partially covered this weakness. Consequently, all 71 histology+ lymph nodes were positive for duplex real-time RT-PCR as well as wide-keratin immunohistochemistry. Positivity rates by histology, wide-keratin immunohistochemistry and duplex real-time RT-PCR were 18.0% (71/392), 20.9% (82/392) and 25.8% (101/392), respectively. In 2 of 8 patients with pT1N0, positive lymph nodes were observed by real-time RT-PCR but not by immunohistochemistry. These results indicate that duplex quantitative real-time RT-PCR is the most sensitive method for detecting micrometastases and useful for evaluating the prognostic significance of lymph node micrometastasis in gastric cancer patients. © 2003 Wiley-Liss, Inc.

Background/Aims: Many of the reports on the diagnostic efficacy of the 13C-urea breath test (13C-UBT) for the detection of Helicobacter pylori in the residual stomach have shown negative results. We conducted an evaluation to establish a standardized protocol and an appropriate cutoff value for 13C-UBT in partial gastrectomy patients. Methods: Forty-two patients undergoing partial gastrectomy were included. Three gastric biopsies from the anastomotic site and mid-to-high body were taken at panendoscopy for histology, culture and rapid urease test (RUT). The 13C-UBT protocol included ingestion of 100 mg 13C-urea, use of mouthwash, and the body in a horizontal position on the left side. Six breath samples were taken after ingestion. Results: The Δ13CO2 values were significantly elevated in infected patients at all time points, and values were higher at 20 min and thereafter than at an earlier time point. The sensitivity of 13C-UBT was 96.3% with the cutoff of 2.0‰ at 40 min. The accuracy rates were highest with 13C-UBT, culture, RUT and histological tests, in that order. Conclusion: Forty minutes and a cutoff of 2.0‰ were found to be optimal for the test, with the body position horizontal on the left side. In the present protocol 13C-UBT appears to be a reliable tool with the same accuracy rate as other routine tests in patients with a remnant stomach.

Surgeries for cancer of the esophagus are still associated with a high rate of postoperative morbidity. There are few reports of perioperative nutritional support for patients undergoing esophageal cancer surgery, and there is insufficient evidence to recommend routine use of immunonutrition in these patients. The aim of this study was to determine whether preoperative immunonutrition positively influences key clinical outcomes such as postoperative infectious complications, mortality, length of hospital stay, and short-term survival in this population.We undertook a retrospective investigation of the effects of preoperative nutritional support on the postoperative course of esophageal cancer surgery at the Department of Gastroenterological Surgery, International University of Health and Welfare Mita Hospital, Tokyo, Japan.Fifty-five patients who underwent esophagectomy for esophageal cancer were included in this study. Of the 55 patients, 26 patients consumed a liquid dietary supplement (IMPACT group) before surgery and 29 patients did not (STANDARD group).Before surgery, the IMPACT group consumed 750 ml (3 packs)/day of Impact for 5 consecutive days.The analysis was based on postoperative complications, hospital mortality, length of hospital stay, and short-term survival.Significantly fewer patients developed postoperative infections in the IMPACT group compared with the STANDARD group (p=.007): 4 of 21 patients in the IMPACT group and 10 of 29 patients in the STANDARD group. Either an infectious complication or another complication developed in 8 patients in the IMPACT group and 13 patients in the STANDARD group, with the result that 6 patients in the STANDARD group died of postoperative complications (p=.001). The duration of hospitalization was 34 days in the IMPACT group and 48 days in the STANDARD group; hence, hospitalization was significantly shorter in patients treated with Impact (p=.008). The mean 6-month survival rates for the IMPACT group and the STANDARD group were 92% (24/26) and 72% (21/29), respectively (p=.028).Simple preoperative supplementation significantly improved outcome. Administration of the supplemental diet before esophageal surgery appeared to be an effective strategy in reducing infectious complications, mortality, and hospitalization, and improving short-term survival.

症例は66歳の男性で腹部腫瘤を主訴に当科入院した. 24年前の胃切除術の既往があった. CT上腫瘤は低濃度で不均一に造影された. MRIではT2像にて内部不均一な低信号を示し, Gd T1像で辺縁とT2像上の高信号部分に造影効果を認めた. 腹腔内異物肉芽腫の診断で腫瘤を摘出した. 腫瘤割面にガーゼと肉芽組織を認め, 組織学的には繊維成分を含む肉芽組織が異物巨細胞・泡沫細胞を伴って認められた. 腹腔内異物肉芽腫の画像所見として特異的なものは少ないが, MRIではT2像で低信号と高信号を呈するものに大別され, おのおの増殖性変化と浸出性変化を反映する. この両変化の割合により多彩な画像所見を呈する. 本症例のCT・MRI上の画像所見は, 組織学的所見を如実に描出していた. 腹腔内異物肉芽腫は画像診断により術前診断のみならず, 組織学的所見の推測まで可能と考えられた.

Background Hepatic artery thrombosis after liver transplantation remains a significant cause of graft loss and death. Retransplantation is a difficult option after living-related liver transplantation in Japan. Methods Twenty-seven patients underwent living-related liver transplantation with left-sided liver grafts donated from their relatives. The hepatic artery was anastomosed end to end under a surgical microscope. Anticoagulant therapy was maintained for 2 weeks after operation. Routine post-transplant Doppler ultrasonography together with serum blood tests were performed twice a day during the first 2 weeks. Results Three patients developed hepatic artery occlusion, which was identified by routine Doppler ultrasonography before the serum transaminase values increased on days 7, 7 and 3 after surgery respectively. In two of the three patients, no apparent arterial thrombosis was recognized and vasospasm was therefore considered to be the cause of the occlusion. Arterial patency was restored by urgent revascularization with reanastomosis in all patients, but one patient with a functional graft died from a cerebral haemorrhage on day 47. Conclusion Early diagnosis of hepatic artery occlusion by routine Doppler ultrasonography and revascularization of the graft is an indispensable strategy for preventing graft loss after living-related liver transplantation.

Background We previously reported that safety and efficacy of mucosal cutting biopsy for diagnosing included 2 cm or less gastric GISTs. However, there have been no reports stating the clinicopathological characteristic and clinical handling of the patients with 2 cm or less gastric GISTs. The aim of our study is to investigate the clinicopathological characteristic and clinical handling of the patients with 2 cm or less gastric GISTs. Methods The 19 patients diagnosed with GIST by mucosal cutting biopsy were divided into 2 groups: Group I; subjects were GISTs with 2 cm or less, Group II; subjects were GISTs >2 cm. We compared the 2 groups in terms of mean age, tumor size, tumor site, histopathological risk grade. In cases that underwent surgery with a diagnosis of GIST, we compared the pre- and postoperative histopathological diagnosis, and the histopathlogical risk grade within each group. Results The mean age and tumor size were significantly higher in Group I than in Group II. Meanwhile, there were no significant differences between the 2 groups, sex ratio, tumor site. All lesions were at histopathological risk grade at very low risk and low risk respectively. In 17 patients with GIST who underwent surgery, the histopathological diagnoses, immunostaining were in agreement with those from the mucosal cutting biopsy specimens in all cases, but mitotic count of one patient was not in agreement in group II. Conclusions The 2 cm or less gastric GISTs diagnosed with histpathlogical very low risk can be considered acceptable to follow-up.

A case of unusually hypermobile floating gallbladder in a 79-year-old woman with histologically distinct double cancers of the gallbladder is described. The patient presented with an abdominal cystic mass, which was palpable with easy mobility from the right lower quadrant practically to the left upper quadrant. Exploratory laparotomy was performed and the cystic mass was found to be a floating gallbladder. The cystic duct was elongated and obstructed, and had a long mesentery. After the operation, latent double cancers of the gallbladder were discovered on histopathological examination. The obstruction of the cystic duct was due to chronic inflammation and had resulted in hydrops of the gallbladder. This was suspected to have played an important role in the carcinogenesis. We believe that this is the first report of a floating gallbladder associated with double gallbladder cancers.

Protein-energy malnutrition is a common disorder in the elderly. Although serum albumin is commonly used as a nutritional marker, data is lacking on serum albumin levels in the elderly. The purpose of this study was to determine whether serum albumin levels decrease with advancing age and to establish reference value and interval of laboratory data for elderly people (75 years and over). Blood samples from 13821 healthy people, 42064 outpatients, and 15959 inpatients were collected during 2008. Blood from 127 of our nutrition support team (NST) patients was also collected during August 2006 and May 2009, and analyzed. Serum albumin, hemoglobin, total cholesterol levels and lymphocyte count were determined. We analyzed the change in each parameter in accordance with age, compared the data for elderly people with younger people, and established new reference values. Clinical outcomes were examined depending on the improved reference values. Albumin was lower in older persons than in younger persons. The estimated reference value and interval were 42 (48–36) g/l in older persons and was much lower in NST patients. Hemoglobin was decreased while cholesterol and lymphocyte count were not changed in older persons: all were markedly decreased in NST patients. Terms of hospital stay were significantly longer and mortality rates were significantly higher in older persons, comparing from above to below using a new reference value of albumin (36 g/l). The serum albumin level decreases with advancing age, but it was maintained to some extent in healthy older people. Serum albumin levels related to the clinical outcome. Hemoglobin and cholesterol levels and lymphocyte count were all lower in NST patients. These measurements may be valuable markers of nutritional status and can help in guiding the need for nutritional support.

Non-occlusive mesenteric ischemia (NOMI), leading to intestinal gangrene without a demonstrable occlusion in the mesenteric artery, is a rare condition with extremely high mortality. We report a case of NOMI diagnosed preoperatively by computed tomography and treated successfully with surgery, assisted by indocyanine green (ICG) fluorescence in the HyperEye Medical System (HEMS), a new device that can simultaneously detect color and near-infrared rays under room light. This allowed for precise intraoperative evaluation of the mesenteric and bowel circulation. Although the necrotic bowel wall of the distal ileum and the segmental ischemia of the jejunum were visible, the jejunum was finally preserved because perfusion of ICG fluorescence was confirmed. The patient, an 84-year-old man, had an uneventful postoperative course and is alive without critical illness 8 months after surgery. We report this case to demonstrate the potential effectiveness of HEMS during surgery for NOMI.

Gastric neuroendocrine carcinomas are rare and have a poor prognosis, and the diagnostic criteria for this disease have recently changed. We herein report a case of sporadic gastric neuroendocrine carcinoma. A 75-year-old man was referred to our hospital with epigastric pain. Endoscopic examination revealed a localized ulcerative lesion (diameter, 4 cm) at the upper stomach. The diagnosis on biopsy was neuroendocrine carcinoma. Total gastrectomy with D2 lymphadenectomy, splenectomy, and cholecystectomy was performed. Pathologically, the tumor infiltrated the subserosal layer, and 6/49 lymph nodes were involved. The tumor was uniform in shape and arranged in a rosette-like structure to form solid nests, with medium-sized, round-to-cuboid-shaped tumor cells and intense mitosis 46/10 HPF. It was positive for synaptophysin and chromogranin A, and the Ki-67 labeling index was 70–80%. The diagnosis of neuroendocrine carcinoma was made according to the WHO 2010 criteria. The patient was followed up for three years without recurrence.

A Bochodalek hernia is rarely seen in adults. An 18-year-old man was referred to our institute with the chief complaint of a sudden onset of left subcostal pain, nausea, and vomiting. A radiograph and a computed tomographic scan of the chest revealed a Bochodalek hernia. Emergency surgery was thus performed. The herniated organs were put back into the peritoneal cavity and the hernial hilum was closed. The postoperative course was uneventful. A routine chest radiograph 1 month before had shown a slight elevation of the left hemidiaphragm and further examination using computed tomography suggested a Bochodalek hernia, but he had merely been followed up since there were no symptoms. As soon as a diagnosis is made, specific repairs should be carried out even if no symptoms are present, to prevent such complications as strangulation or perforation.

To investigate the phenomenon of remnant gastric motility and emptying after local resection.Fifteen dogs were divided into three groups: a control (CONT) group, a group that underwent local resection of the greater (GREAT) curvature, and a group that underwent resection of the lesser (LESS) curvature. We conducted a strain gauge force transducer study, a [(13)C]octanoic acid breath test ((13)C-OBT), and a mosapride citrate effect test. Based on these results, we worked out the receptive relaxation (RR), motility index (MI), and postprandial period (PP) in the postprandial state, and the frequency, duration, and MI of phase III in the fasted state. The half emptying time (T (1/2)) of (13)C-OBT was also calculated. The MI was compared according to the mosapride effect test results.Postprandial RR, antro-pyloro-duodenal coordination, and fasting contractions were maintained in all three groups. Receptive relaxation was significantly shorter in the LESS group than in the other groups. Motility index was significantly lower in both treatment groups than in the CONT group. The PP was significantly longer in the GREAT group than in the other two groups. The (13)CO(2) excretion curves did not differ significantly among the groups. The duration of phase III was remarkably less in the treatment groups than in the CONT group, and MI was significantly lower in the LESS group than in the other groups in the fasted state. The MI increased remarkably after mosapride administration in the CONT group, showing no differences in other objective groups.Gastric function was maintained after gastric local resection, although its motility decreased.

A 71-year-old man with a Helicobacter pylori infection-negative and API2-MALT1 translocation-negative extranodal marginal-zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type of the stomach has been followed conservatively for over 5 years. The lesion has shown no major morphological changes or malignant progression into a diffuse large-cell type during the time course. The absence of genetic translocation of API2-MALT1 was confirmed with fluorescence in situ hybridization (FISH). The prognosis of H. pylori-negative and API2-MALT1 translocation-negative low-grade MALT lymphoma is unknown, and a standard treatment for such lymphoma has yet to be defined. The case of MALT lymphoma negative for both of the above factors that we report has shown no obvious rapid progression or malignant change over the long-term course. Although curative operation and/or chemoradiotherapy should still be discussed as the treatment of choice, the treatment of this type of lymphoma must be carefully determined on a case-by-case basis, according to its biological status and prognosis.