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Multiple cancer patients who achieve long-term survival are sometimes encountered. Multiple carcinogenesis may occur due to genetic or environmental characteristics. We report the case of a 74-year-old woman who was diagnosed with synchronous double carcinoma of the duodenal papilla and gall bladder without clinical symptoms, who underwent postoperative follow-up for familiar adenomatous polyposis coli with multiple colonic adenocarcinomas, ileal adenocarcinoma, left urinary tract neoplasm, and left upper lobe lung adenocarcinoma. Computed tomography also showed an intraductal papillary mucinous neoplasm of the pancreas and a lesion that was suspected to be uterine body carcinoma; however, they did not show any clear malignant behavior. No metastatic lesions of either of these biliary cancers were observed. Based on preoperative diagnostic imaging, subtotal stomach preserving pancreaticoduodenectomy with gall bladder bed liver resection with D2 lymphadenectomy was planned and R0 resection was achieved. The postoperative histological diagnosis showed early carcinoma of the duodenal papilla and gall bladder pyloric gland adenoma without node metastasis. The postoperative course was uneventful and the patient had a good prognosis without tumor recurrence or new malignant lesions for two years after the last operation, without adjuvant therapy. Six metachronous carcinomas of eight different organ neoplasms were diagnosed, which is rare. This represents the first reported case of ampullary carcinoma in a patient with sextuple cancer., (© 2022. Japanese Society of Gastroenterology.)

Case 1: Left total mastectomy was performed for a 58-year-old woman for diagnosis of left breast cancer. Seven years after surgery, left internal mammary node metastasis revealed. Irradiation was performed on the left chest wall and left supraclavicular area. Six months later, the lymph node swelling disappeared. Thereafter 8 years have passed without recurrence. Case 2: A 65-year-old man had a semi-emergency total gastrectomy for bleeding from gastric cancer. Three years after surgery, anterior pancreatic lymph node metastasis was detected. Radiation therapy was selected because his general condition was not so good. Three months later, lymph node swelling disappeared. Thereafter 4 and a half years have passed without recurrence. Case 3: A 67-year-old man underwent surgery for middle thoracic esophageal cancer after neoadjuvant chemotherapy. Seven months after surgery, left tracheobronchial lymph node metastasis was found. Irradiation was performed to bilateral supraclavicular area and mediastinum in combination with chemotherapy. Three months later, the lymph node normalized, and 6 and a half years have passed without recurrence. All 3 cases in this study were recurrences of regional lymph node. Radiation therapy may be effective for regional lymph node recurrence outside the dissected area or in areas that have been inadequately dissected.

Bacterial condensin preferentially loads onto single-stranded DNA (ssDNA) in vitro and onto rDNA in vivo to support proper chromosome compaction. Thus, the actively transcribing rDNA would provide the ssDNA region for the loading of bacterial condensin. We attempted to detect the ssDNA region in the rrnI gene in situ . Non-denaturing sodium bisulfite treatment catalyzed the conversion of cytosines to thymines (CT-conversion) at the melted DNA of a genome. Using next-generation sequencing, we generated an average of 11,000 reads covering each cytosine on the rDNA segment. In principle, the CT-conversion rate is an accurate guide to detect ssDNA segment. We detected multiple ssDNA segments throughout the rDNA. The deletion mutations of the rDNA hindered the ssDNA formation at the 100-500 bp segment downstream of the promoter. These data support the idea that the ssDNA segment plays a crucial role as the condensin-loading site and suggest the mechanism of condensin loading onto rDNA., Competing Interests: The authors declare no competing interests., (© 2022 The Author(s).)

BACKGROUND Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignancy, and complete resection may provide better patient survival. Hepatectomy for intrahepatic tumor recurrence has not been previously reported. CASE REPORT A 58-year-old woman underwent resection of an IVC-LMS with en bloc nephrectomy, adrenalectomy, and retroperitoneal soft tissue resection without IVC reconstruction 3 years 8 months ago. Twenty-nine months after the primary operation, a solitary intrahepatic liver tumor was found adjacent to the right and middle hepatic veins during imaging follow-up. The patient was diagnosed with LMS recurrence. As her liver functional parameters permitted major hepatectomy, right hepatectomy combined with resection of the vena cava wall leaving a tumor-free margin and securing the confluence of the middle hepatic vein were successfully accomplished via an anterior approach, without adverse events. Intrahepatic metastasis of LMS invading the vena cava wall has been diagnosed historically. Her postoperative course was uneventful, and at 1-year follow-up after the second surgery, she was observed to have no tumor relapse without any adjuvant treatment. Previous reports have shown that IVC-LMS is often observed, and operative risk or prognosis is based on the extension of the LMS toward the hepatic veins or cardiac atrium. CONCLUSIONS Radical hepatectomy for recurrent IVC-LMS has not been previously reported, and our case experience revealed that a challenging surgical intervention resulting in complete tumor removal can provide good survival outcomes.

Objectives: Hepatic transection through an anterior approach is required to successfully complete anatomical hepatectomy for large liver malignancies. The liver hanging maneuver (LHM) is an alternative procedure for transection on an adequate cut plane and may reduce intraoperative bleeding and transection times., Material and Methods: We examined the medical records of 24 patients with large liver malignancies (>5 cm) who had undergone anatomical hepatic resection with LHM (n= 9) or without LHM (n= 15) between 2015 and 2020. Patient demographics, preoperative hepatic function, surgical records, and post-hepatectomy outcomes were retrospectively compared between the LHM and non-LHM groups., Results: The prevalence of tumors >10 cm was significantly higher in the LHM group than in the non-LHM group (p <0.05). Furthermore, LHM was significantly performed to right and extended right hepatectomies in the background normal liver (p <0.05). Although transection times did not significantly differ between the two groups, the amount of intraoperative blood loss was slightly lower in the LHM group than in the non-LHM group (1.566 mL vs. 2.017 mL), and blood transfusion was not needed for patients in the LHM group. Post-hepatectomy liver failure and bile leakage were not observed in LHM. However, the length of hospitalization was slightly shorter in the LHM group than in the non-LHM group., Conclusion: LHM is useful for transecting an adequately cut plane in hepatectomy for liver tumors over 5 cm-in-size located on the right side and achieves better outcomes., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (Copyright © 2022, Turkish Surgical Society.)

Background: Intra-articular fibromembranous septum in the radiocarpal joint can cause wrist contracture after distal radial fracture, but the mechanism underlying the formation of the septum is unknown. This study examined the clinical outcomes in patients treated with arthroscopic excision of the septum and the factors associated with formation of the septum in patients with and without a septum., Methods: Fifty-three patients (22 with septum and 31 without septum) treated for intra-articular distal radial fracture with arthroscopy using a volar locking plate and secondary removal of the plate were included. Clinical outcomes and radiological assessments were analyzed., Results: In patients with a septum, the range of wrist flexion and total wrist arc before the second operation were significantly more limited than in those without a septum (p < 0.01 and p = 0.03, respectively). The improvement rate (improvement in wrist arc divided by the wrist arc of the healthy side) after arthroscopic excision of the septum and plate removal was greater in patients with a septum than in those without a septum (6.1% vs. 2.0%, p = 0.08). The significant factors affecting formation of the septum were the residual articular gap and the height of the midradial ridge on computed tomography images., Conclusions: Intra-articular fibromembranous septum after surgically treated intra-articular distal radial fracture affects limited range of motion and secondary arthroscopic excision of the septum improves the wrist range of motion. Anatomical reduction and maintenance of the articular fragment, as well as anatomical characteristics might be causes of septum formation., Competing Interests: Declaration of competing interest None., (Copyright © 2021 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background/aim: The potential for repeat hepatectomy has been increasing in hepatocellular carcinoma (HCC) patients., Patients and Methods: To assess its significance, we examined the clinical features, surgical records, and survival of 279 HCC patients who underwent hepatectomy as primary treatment. Patients were divided into three groups: single hepatectomy without HCC relapse in 97 patients (Group 1), single hepatectomy with HCC relapse in 133 patients (Group 2) and repeat hepatectomy for HCC relapse in 49 patients (Group 3). Group 3 was divided into three subgroups. Multiple, larger size (>5 cm), and confluent nodular HCC., Results: Child-Pugh B patients were significantly higher in Group 2 (p<0.01). The prevalence of histological vascular involvement was significantly higher in Group 2 than in the other groups (p<0.01). Although Group 2 showed significantly poorer survival (p<0.01), the 10-year overall survival in Groups 1 and 3 was over 70% but not different between groups. The relapse-free survival period was significantly correlated with overall survival, and patients with a cancer-free period of over 36 months showed significantly better 10-year survival rates than those with a period of less than 36 months (p<0.01). Patients undergoing 3 or more repeat hepatectomies also showed good survival periods., Conclusion: Careful follow-up and proper decision-making in terms of repeat hepatectomy with multimodal treatments including novel chemotherapies upon assessment of postoperative tumor relapse are important in HCC patients to prolong survival., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Liver regeneration is an extraordinarily complex process involving a variety of factors; however, the role of chromatin protein in hepatocyte proliferation is largely unknown. In this study, we investigated the functional role of high-mobility group box 2 (HMGB2), a chromatin protein in liver regeneration using wild-type and HMGB2-knockout (KO) mice. Liver tissues were sampled after 70% partial hepatectomy (PHx), and analyzed by immunohistochemistry, western blotting and flow cytometry using various markers of cell proliferation. In WT mice, hepatocyte proliferation was strongly correlated with the spatiotemporal expression of HMGB2; however, cell proliferation was significantly delayed in hepatocytes of HMGB2-KO mice. Quantitative PCR demonstrated that cyclin D1 and cyclin B1 mRNAs were significantly decreased in HMGB2-KO mice livers. Interestingly, hepatocyte size was significantly larger in HMGB2-KO mice at 36-72 h after PHx, and these results suggest that hepatocyte hypertrophy appeared in parallel with delayed cell proliferation. In vitro experiments demonstrated that cell proliferation was significantly decreased in HMGB2-KO cells. A significant delay in cell proliferation was also found in HMGB2-siRNA transfected cells. In summary, spatiotemporal expression of HMGB2 is important for regulation of hepatocyte proliferation and cell size during liver regeneration., (© 2022. The Author(s).)

Background: Multiple treatment protocols have been described in literature for the treatment of terrible triad injury (TTI) of the elbow. We believe that repair of the medial collateral ligament (MCL) should be performed in preference to repair of a small coronoid fracture if the elbow is unstable after fixation/replacement of the radial head and repair of the lateral collateral ligament (LCL). The aim of this study is to report the outcomes of surgical treatment of patients with TTI associated with a small coronoid fracture in whom the coronoid fracture was not addressed. Methods: This study is a retrospective case series of 12 consecutive patients who underwent surgery for acute TTI with a small coronoid fracture (9 Regan-Morrey type I and 3 Regan-Morrey type II). Ten patients had complete MCL injuries. All patients underwent repair of the torn LCL and MCL and treatment of the radial head. The coronoid fracture was not surgically treated. At the final follow-up, the range of motion, degree of flexion contracture, Mayo elbow performance score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) were measured. Results: The mean follow-up period was 13.5 months. At the final follow-up, the mean arc of elbow flexion was 132° and the mean flexion contracture was 10°. The mean arc of forearm rotation was 148°. None of the patients demonstrated elbow instability. The mean MEPS was 92.5 points with seven having excellent results and five having good results. The average DASH score was 11.2 points. Conclusions: Our results showed that good elbow stability, arc of motion and clinical outcomes could be achieved without repair of small coronoid fractures in the treatment of TTI. The repair of MCL injuries should be given priority over the fixation of small coronoid fractures to regain elbow stability. Level of Evidence: Level IV (Therapeutic).

Objective: To assess the effectiveness of low-dose mepolizumab as an add-on therapy for treating peripheral neurological symptoms in eosinophilic granulomatosis with polyangiitis (EGPA)., Methods: We prospectively studied 13 EGPA patients with conventional treatment-resistant peripheral neuropathy. Their symptoms (pain, numbness, and muscle weakness) were assessed on a visual analogue scale (VAS) before and after 12 months of mepolizumab therapy (100 mg every 4 weeks). Peripheral eosinophil levels and several biomarkers including urinary levels of eosinophil-derived neurotoxin (EDN) were measured before and after therapy., Results: VAS scores for pain and numbness significantly improved after 12 months of mepolizumab therapy (from 67.0 to 48.0, P = 0.012, and from 67.0 to 51.0, P = 0.017, respectively). However, the VAS score for muscle weakness did not improve (P = 0.36). There were significant correlations between treatment-related changes in urinary EDN levels from baseline to 6 months later and percent changes in the VAS scores of pain and numbness (r = 0.75, P = 0.020; r = 0.88, P = 0.002)., Conclusions: Treatment-resistant peripheral neuropathy in EGPA was significantly improved by low-dose mepolizumab, and effectiveness was correlated with decreased urinary EDN. Because the possibility of a placebo effect cannot be formally excluded, placebo-controlled studies will be required in the future., (© Japan College of Rheumatology 2022. Published by Oxford University Press.)

Case: We describe a patient with incomplete high median nerve palsy after surgical treatment of pediatric supracondylar humeral fracture (SCHF). Preoperative images after 11 months after the surgical treatment of the SCHF showed rotational deformity and an isolated median nerve entrapped between the proximal humerus anteriorly and callus posteriorly in the bony tunnel of the distal humerus. Two years after neurolysis, he showed clinical recovery. Four cases similar to our case were reported previously., Conclusion: Common pediatric fractures may cause unusual neuropathy. Rotational deformity of fracture might be an important factor for isolated median nerve entrapment after SCHF., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B787)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Backgrounds/aims: It is known that preoperative nutritional status can influence patient outcomes after hepatectomy. Prognostic Nutritional Index (PNI) is a useful parameter to reflect patient outcomes undergoing gastro-intestinal surgery. The aim of this study was to retrospectively evaluate relationships of nutritional parameters, demographics, and surgical records with postoperative outcomes in a cohort study., Methods: Curative hepatectomy was performed for 182 patients at the University of Miyazaki between 2015 and 2018. Each preoperative level of albumin, prealbumin, lymphocyte, total cholesterol, or the comprehensively calculated Onodera's PNI was examined as a nutritional parameter., Results: The mean PNI was 39.6 ± 5.1, with PNI below 40 observed in 91 (50.0%) patients. Nutritional parameters were not different among patients with various liver diseases. Serum albumin or prealbumin level was significantly correlated with each hepatic parameter ( p < 0.01). Prealbumin and total cholesterol levels were significantly correlated with postoperative prothrombin activity ( p < 0.05). Albumin or prealbumin levels and PNI were significantly lower in patients with posthepatectomy complications, particularly bile leakage in comparison those without such complications ( p < 0.05). Multiple logistic analysis showed that albumin level was an independent risk factor for complications after hepatectomy (risk ratio [RR]: 1.33) and that lymphocyte count was an independent risk factor for bile leakage (RR: 1.28) ( p < 0.05). The cut-off level of albumin was approximately 3.8 mg/dL and that of lymphocyte count was 1,320/mm 3 ., Conclusions: Preoperative PNI reflected perioperative liver functional status. It was a predictive parameter for postoperative complications, particularly biliary leakage.

We describe the case of a 44-year-old woman with cerebrotendinous xanthomatosis (CTX) who had a tendon xanthoma on the right olecranon. The patient successfully underwent endoscopic resection. There were no signs of recurrence on MRI 2 years postoperatively. There were no complications related to the surgery, and the patient is completely satisfied with the treatment outcomes. CTX, a genetic metabolic disorder, is associated with the development of tendon xanthomas. Endoscopic resection of tendon xanthoma in the elbow of patients with CTX is a less invasive method than open resection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The therapeutic and diagnostic modalities of light are well known, and derivative photodynamic reactions with photosensitizers (PSs), specific wavelengths of light exposure and the existence of tissue oxygen have been developed since the 20th century. Photodynamic therapy (PDT) is an effective local treatment for cancer-specific laser ablation in malignancies of some organs, including the bile duct. Although curability for extrahepatic cholangiocarcinoma is expected with surgery alone, patients with unresectable or remnant biliary cancer need other effective palliative therapies, including PDT. The effectiveness of PDT for cholangiocarcinoma has been reported experimentally or clinically, but it is not the standard option now due to problems with accompanied photosensitivity, limited access routes of irradiation, tumor hypoxia, etc. Novel derivative treatments such as photoimmunotherapy have not been applied in the field hepatobiliary system. Photodynamic diagnosis (PDD) has been more widely applied in the clinical diagnoses of liver malignancies or liver vascularization. At present, 5-aminolevulinic acid (ALA) and indocyanine green (ICG) dyes are mainly used as PSs in PDD, and ICG has been applied for detecting liver malignancies or vascularization. However, no ideal tools for combining both PDD and PDT for solid tumors, including hepatobiliary malignancies, have been clinically developed. To proceed with experimental and clinical trials, it is necessary to clarify the effective photosensitive drugs that are feasible for photochemical diagnosis and local treatment.

Background: Spontaneous common bile duct (CBD) perforation is an extremely rare disease in adults. We report an adult case of CBD perforation due to choledocolithiasis accompanied with pancreaticobiliary maljunction, which is, to our knowledge, the first such case report based on a search using PubMed., Case Presentation: A 71-year-old woman with consciousness disorder was transported to the emergency department of another hospital. She was diagnosed as having severe peritonitis with septic shock and transferred to our hospital for emergency surgery. Enhanced computed tomography (CT) revealed supraduodenal CBD dilation similar to a diverticulum and a defect of bile duct wall continuity. Furthermore, CT showed a long common channel of the pancreaticobiliary duct, so she was diagnosed as having spontaneous CBD perforation with pancreaticobiliary maljunction. Emergency surgery was performed that revealed a necrotic diverticulum-like change on the supraduodenal part, and a 2.5 × 1 cm perforation was found on the anterolateral wall of the CBD. Peritoneal lavage was performed, and CBD perforation was resolved with a T-tube. The patient suffered refractory intra-abdominal and retroperitoneal abscess formation and bleeding from the abdominal wall, which required a long period of postoperative management. The T-tube was removed on day 136, and the patient was transferred on day 153., Conclusion: The cause of CBD perforation is commonly considered to be increased intraductal pressure or weakness of the bile duct wall. In this case, pancreaticobiliary maljunction may have significantly influenced onset and the postoperative course. This case suggests that early surgical intervention and appropriate drainage are important to ensure survival., (© 2021. The Author(s).)

Background: Both arterial and venous repair are crucial for optimal results in digital replantation. However, anastomosis of veins becomes challenging in very distal fingertip amputation. This study aimed to report the clinical results of an artery-only replantation without vein repair for a distal fingertip amputation and to analyze the survival rate and clinical outcomes based on the amputation level. Methods: We performed a retrospective review of 47 digits in 38 patients who had undergone fingertip replantation with a mean follow-up period of 12 months. All patients had complete fingertip amputation distal to the lunula. Only one central artery repair distal to the arch was performed. All patients received the postoperative protocol including external bleeding and anticoagulation therapy. Results: By Ishilawa's classification, 12 digits in subzone I, and 35 digits in subzone II. 31 of the 47 fingertip replantations (66%) were successful, and a significantly higher survival rate was observed in subzone I than in subzone II. The mean total active motion of surviving digits was 86% of normal side. The mean grip strength was 82% of normal side. The sensory recovery according to modified Highet and Saunders' classification was S4, S3+, S3, and S2 in fingers 19, 2, 5 and 3, respectively. Conclusions: 66% of survival rate was achieved in fingertip replantation distal to lunula which including large number of crushing/avulsion injury. The result of comparison for the survival rate based on amputation level, a significantly higher survival rate was observed in subzone I compared to subzone II. Therefore, the artery-only fingertip replantation had a better indication for distal amputation, and an aggressive attempt for venous anastomosis or drainage, including a secondary surgery for proximal amputation could be attributed to a higher success rate.

Patients with pediatric trigger thumb present with fixed contracture of the interphalangeal joint (IPJ) or snapping of the thumb. We applied a hand-based dynamic splint using coils at the IPJ. The aim of this study was to report the clinical outcomes of splint therapy versus observation. One hundred twenty-nine thumbs (112 patients and 57 boys) were examined retrospectively. At initial presentation, parents selected the treatment after explanation of pathology and consents were obtained. Treatment was concluded when full extension or resolution of the involved IPJ was achieved; alternatively, surgical treatment was offered for patients who failed to improve. Improvement in extension loss to 0° and hyperextension was defined as resolution of the IPJ. Surgery was not selected as a first-line treatment strategy in any of the cases in this study. The rate of resolution was 59% at 31 months of follow-up in the splint group (99 thumbs) and 43% at 30 months in observation group (30 thumbs); there was no significant difference between the groups (P = 0.15). Twenty-one thumbs showed locking of the IPJ in the extended position during splint therapy, but all recovered with a 71% rate of resolution. The splint group showed a higher rate of resolution than the observation group; however, there was no significant difference between therapies. Our study showed that 55% of patients with pediatric trigger thumb showed resolution following conservative treatment for an average of 30 months until surgery could be performed under local anesthesia. Splint therapy and observation are viable treatment options prior to surgery., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: POU1F1 encodes both PIT-1α, which plays pivotal roles in pituitary development and GH, PRL and TSHB expression, and the alternatively spliced isoform PIT-1β, which contains an insertion of 26-amino acids (β-domain) in the transactivation domain of PIT-1α due to the use of an alternative splice acceptor at the end of the first intron. PIT-1β is expressed at much lower levels than PIT-1α and represses endogenous PIT-1α transcriptional activity. Although POU1F1 mutations lead to combined pituitary hormone deficiency (CPHD), no patients with β-domain mutations have been reported., Results: Here, we report that a three-generation family exhibited different degrees of CPHD, including growth hormone deficiency with intrafamilial variability of prolactin/TSH insufficiency and unexpected prolactinoma occurrence. The CPHD was due to a novel POU1F1 heterozygous variant (c.143-69T>G) in intron 1 of PIT-1α (RefSeq number NM&#95;000306) or as c.152T>G (p.Ile51Ser) in exon 2 of PIT-1β (NM&#95;001122757). Gene splicing experiments showed that this mutation yielded the PIT-1β transcript without other transcripts. The lymphocyte PIT-1β mRNA expression was significantly higher in the patients with the heterozygous mutation than a control. A luciferase reporter assay revealed that the PIT-1β-Ile51Ser mutant repressed PIT-1α and abolished transactivation capacity for the rat prolactin promoter in GH3 pituitary cells., Conclusions: We describe, for the first time, that the PIT-1β mutation can cause CPHD through a novel genetic mechanism, such as PIT-1β overexpression, and that POU1F1 mutation might be associated with a prolactinoma. Analysis of new patients and long-term follow-up are needed to clarify the characteristics of PIT-1β mutations.

A 70-year-old man was admitted to our hospital with acute abdominal pain. Abdominal CT showed a 6-cm-sized tumor near the third portion of the duodenum, and a duodenal GIST was suspected. Although the abdominal pain was intense and the tumor was suspected to be ruptured, the vital signs were stable; therefore, we initially planned to perform an elective surgery. However, because the pain could not be controlled, the surgery was performed on the 6th day of hospitalization. The tumor appeared to be a duodenal GIST because it was pulling the third portion of the duodenum inwards. It had a strong tendency to infiltrate the surrounding organs; therefore, forced resection of the right colon, which is the surrounding organ, was performed. Pathological findings showed that the resected specimen was a desmoid tumor and the surgical margins were negative. The postoperative course 1 year after surgery was favorable, and no tumor recurrence occurred. We report a case of desmoid tumor, which caused acute abdominal pain.

The aim of this study was assessment of the laparoscopic surgery after using ileus tube(trans-anal or trans-nasal)for obstructive colorectal cancer compared with non-obstructive cancer., Method: Between April 2010 and March 2019, 129 patients underwent laparoscopic colorectal surgery. 97 patients were non-obstructive colorectal cancer(group N)and 32 patients were obstructive colorectal cancer(group O). Differences between the groups were analyzed using the Mann- Whitney's U-test, as appropriate., Result: In group O, the length of hospital stay was significantly long. There were no significant differences between-group differences in the operation time, estimated blood loss, the rate of conversion to open surgery and postoperative complications., Conclusion: The laparoscopic colorectal surgery is feasible in patients treated with using ileus tube for obstructive colorectal cancer.

Purpose: Replantation of multidigit amputations is difficult to perform due to severe damage to the digits, prolonged operative time, and ischemia. This study aimed to report the clinical results of multidigit replantation., Methods: A retrospective case series of 34 digits belonging to 12 consecutive patients who underwent multidigit replantation was conducted. Patients with injury in at least one or more amputated fingers proximal to the insertion of the flexor digitorum superficialis tendon were included. The mean follow-up duration was 18.1 months. The number of amputated digits, mechanism and zone of injury, survival rate, and clinical outcomes, including the range of motion, grip strength, and sensory recovery, at the final follow-up were reviewed and analyzed., Results: The mean number of amputated digits per patient was 2.8. Complete survival was achieved in 27 of 31 digits (87.1%). The mean final percentage of total active motion of injured digits was 47.0%, and the mean percentage of grip strength was 45.9% of the contralateral uninjured side. The comparison between patients with two and three amputated digits showed that there was no significant difference in both survival rates and functional outcomes., Conclusions: The results showed that both the survival rates and functional outcomes of multidigit replantation were as good as those of single-digit replantation, and there was no significant difference for outcomes between patients with two and three amputated digits. These results suggested that all multidigit replantations should be performed regardless of the number of injured digits or amputation zones., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Intraductal papillary neoplasm of the bile duct (IPNB) is defined as a non-invasive malignancy; however, since there are disparities in its histological diagnosis, the operative strategy for typical IPNB has not yet been established. A 69-year-old male was diagnosed with a bile duct mass lesion at the confluence of the cystic duct by ultrasonography without clinical symptoms. Liver functional parameters and tumor markers were within normal ranges. Computed tomography showed an enhanced tumor with no findings of ductal invasion or node metastasis. The tumor was exposed in the hepatic duct lumen and biopsy via SpyGlass DS cholangiography revealed that it was a low-grade papillary lesion, indicating type 1 IPNB. Under preoperative diagnostic modalities, limited resection of the extrahepatic bile duct with D2 lymphadenectomy was planned and R0 resection was achieved. The postoperative histological diagnosis was type 1 IPNB without node metastasis. The postoperative course was uneventful and a good prognosis is expected at this stage. In the field of biliary surgery, although extended resection is generally performed for bile duct carcinomas, satisfactory limited surgical resection is possible for type 1 IPNB with lower malignant behavior.

The efficacy of adjuvant photodynamic therapy (PDT) using the new photosensitizer, talaporfin sodium (TPS) has been clinically examined in some patients with bile duct carcinoma (BDC). Based on our previous cohorts, a prospective clinical trial was attempted; however, only two cases were ultimately enrolled in 27 months. A 664-nm semiconductor laser (100 J/cm 2 ) was applied through an endoscope to the tumor lesion within 6 h of an intravenous injection of 40 mg/m 2 TPS according to the protocol for lung cancer. Case 1 was an 82-y.o. female patient with BDC at the left hepatic duct with biliary obstruction, percutaneous transhepatic biliary drainage (PTBD) was achieved, and the patient did not consent to surgery. She was followed up for 15 months to search for non-surgical treatments and eventually received PDT. Although mild photosensitivity occurred, she was discharged without severe adverse events. Biliary stenosis markedly extended and a PTBD tube was scheduled at 1 month. However, cancer immediately metastasized to the liver and she died 155 days after PDT. Case 2 was a 70-y.o. female with perihilar BDC and multiple biliary stenoses. Multiple biliary stenting was considered to be difficult. She received PDT and no adverse events were observed. Biliary stenoses markedly improved and multiple stenting was successfully performed. On day 132, she died of cancer progression. These two cases demonstrated the safety and efficacy of biliary malignant stenosis soon after PDT; however, long-term survival and a sufficient quality of life were not achieved. The combination of the PDT protocol and system chemotherapy or brachytherapy needs to be examined in clinical trials for advanced stage BDC.

Background: To evaluate the clinical significance of Mac-2 binding protein glycosylation isomer (M2BPGi), we investigated the relationship between M2BPGi and clinicopathological and surgical parameters and posthepatectomy complications., Materials and Methods: We examined M2BPGi in 115 patients with hepatic malignancies undergoing hepatectomy. Significance as an independent prognostic marker was determined with multivariate logistic regression analysis., Results: The mean serum M2BPGi level was 1.14 ± 1.03 C.O.I. (range 0.2-5.79). M2BPGi in the chronic viral hepatitis group (1.42 ± 1.25) was significantly higher than that in the other disease groups (p < 0.05). The M2BPGi level correlated negatively with platelet count, LHL15 and GSA-Rmax (r = -0.36, -0.69 and -0.56, respectively; p < 0.01) but correlated positively with serum hyaluronate level (fibrotic marker), ICGR15 and HH15 (r = 0.52, 0.63 and 0.57, respectively; p < 0.01). In 53 patients examined for histological hepatic fibrosis, the M2BPGi level was highest for hepatic fibrosis stage 4, indicating cirrhosis (2.15 ± 1.56), and was significantly higher than that for stages 0-2 (p < 0.05). M2BPGi level did not correlate significantly with any surgical parameters. The preoperative level correlated significantly only with increased alanine aminotransferase level (r = -0.21, p < 0.05) and was significantly higher in patients with (1.35 ± 0.78) than without (1.11 ± 1.07) hepatectomy-related complications (p < 0.05). Area under the ROC curve analysis for prediction of hepatic fibrosis score 4 showed a cut-off value of 0.78 for M2BPGi to have high sensitivity (90%) and specificity (58%). For postoperative hepatectomy-related complications, only the M2BPGi level (at a cut-off value 0.90) tended to show significance (p = 0.06)., Conclusions: The non-invasively measured serum level of M2BPGi reflected impaired liver function or cirrhosis and hepatectomy-related complications after surgery, making it potentially useful as a complementary parameter accompanying other liver function parameters., Competing Interests: There are no conflicts of interest., (© 2019 The Author(s).)

Background: The indocyanine green retention rate at 15 min (ICGR15) is a marker of the liver function and is useful for planning hepatectomy. To clarify the ICGR15 and the related clearance value (ICGK) calculated by a dye-dilution cardiac output flowmetry (DCOF), we examined the correlation and clinical significance of the ICGR15 values determined by DCOF and those determined with the conventional blood sampling (BS) procedure., Methods: We extracted liver function parameters, including the ICGR15 modified value and ICGK, and the extent of hepatectomy from the clinical and surgical records of 63 patients with various liver diseases in whom the ICGR15 (actual value), R15m (mean), and K (clearance rate per minute) were measured by DCOF., Results: All the patients were classified as Child-Pugh grade A. Hepatic complications were observed in 10 (16%) patients, but there was no mortality. The mean values of ICGR15 determined by BS (R15-BS) and DCOF (R15-DCOF) were 12.2 ± 8.1% and 11.2 ± 8.7%, respectively. The mean R15m determined by DCOF (R15m-DCOF) was 15.7 ± 10.2%. Significant differences were observed between R15-BS and R15-DCOF (1.1 ± 4.8%; p = 0.002) and R15m-DCOF (4.0 ± 5.9%; p < 0.001). The difference between R15-BS and R15m-DCOF was greater than that between R15-BS and R15-DCOF. Correlation between R15-BS and R15-DCOF was significant r = 0.839 (p < 0.001)., Conclusions: The ICGR15 measured by DCOF shows comparable reliability and stability to the BS method, which is useful for planning hepatectomy.

Background: To clarify the usefulness of identification of hepatic segmentation stained with an indocyanine green-photodynamic eye (ICG-PDE) system, we sequentially investigated the matching of visualization during hepatectomy in 40 patients at two institutions between 2009 and 2017., Methods: A low dose of ICG was administered into the portal flow to stain the estimated segments of the liver to be resected during hepatectomy, and segmentation images were observed using a PDE camera. Intraoperative ICG-PDE could be carried out for all patients without side effects., Results: Complete segmental identification of the liver by blue dye stain and ICG-PDE was achieved in 30 (75%) and 35 (88%) patients, respectively, but the prevalence between them was not significantly different (p = 0.302). ICG-PDE segmentation in the estimated area was incomplete in three patients, and complete failure (no staining) was observed in two patients. The border between the posterior section and the caudate was identified in two patients., Conclusion: This preliminary study showed ICG-PDE to be a useful tool for clearly determining liver segmentation to estimate the area for resection.

Background: The relationship between posthepatectomy complications and liver functional parameters was preliminary reported in a pilot study. The present study sequentially evaluated the clinical significance of maximal removal rate of technetium-99m-galactosyl human serum albumin (GSARmax) in the future remnant liver (rGSARmax) in patients to predict posthepatectomy complications., Methods: Between 2010 and August 2017, GSARmax, rGSARmax, their difference (Dif), and the rGSARmax to GSARmax ratio were examined in 247 additional patients who underwent hepatectomy for liver and biliary diseases. Hepatectomy-related postoperative complications (i.e. long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 73 (29.6%) patients., Results: The median and mean preoperative GSARmax values were 0.477 and 0.498±0.166 mg/min, respectively; rGSARmax values were 0.341 and 0.366±0.145 mg/min, respectively; Dif values were 0.105 and 0.132±0.111 mg/min, respectively; and the rGSARmax to GSARmax ratio values were 0.774 and 0.746±0.177, respectively. Among these, the GSARmax and rGSARmax values were significantly correlated with the liver functional parameters ICGR15, LHL15, HH15, prothrombin activity, serum hyaluronic acid level, and platelet count (all P<0.01). The rGSARmax values were significantly lower in patients with long-term ascites (P<0.05), and the predictive cutoff values of rGSARmax were 0.290 mg/min; however, the multivariate logistic regression analysis showed that rGSARmax was not independently related to long-term ascites., Conclusion: When accompanied by other functional liver reserve parameters, rGSARmax seemed to be an alternative liver functional parameter related to ascites.

Condensins play essential roles in the compaction and segregation of chromosomal DNA in life forms ranging from bacteria to higher organisms. To elucidate the molecular mechanisms underlying these roles, it is crucial to determine how and where condensins are loaded to chromosomal DNA. Here, we describe in vivo and in vitro assays for monitoring the topological loading of two bacterial condensins, Smc-ScpAB and MukBEF. A key step in these assays is washing the samples with a high concentration of salt in order to discriminate between electrostatic and topological binding of the bacterial condensins to DNA. In addition, isolation of bacterial condensin and DNA complexes prevents any undesired interaction between them due to cross-linking reagents. These methodologies provide reproducible and reliable results for the loading of topologically bound proteins such as bacterial condensins.

Background: Although recent advances in surgical techniques and perioperative management have reduced the morbidity and mortality after hepatectomy, hepatic insufficiency after major hepatectomy remains an important concern. This study aimed to clarify the risk factors for post-hepatectomy liver insufficiency., Methods: We enrolled 103 consecutive patients who underwent major hepatectomy which was defined as resection of four or more segments. Hepatic insufficiency is defined as an increase in serum total bilirubin after hepatectomy of 7 mg/dL or more, or death from multiple organ failure. We compared the patient disposition, demographics, perioperative factors such as surgical method, combined procedure, morbidity and so on between the patients with or without hepatic insufficiency., Results: Hepatic insufficiency occurred in 14 patients (14%) and six of them died during the hospital stay (6%). Risk factors by univariate analysis were the percentage of hepatic parenchyma to be resected (P = .025), combined procedure (P = .008) and postoperative morbidity excluding hepatic insufficiency (P < .001). A combined procedure (P = .036) and postoperative morbidity excluding hepatic insufficiency (P = .002) were a significant risk factor by multivariate analysis., Conclusion: Unless remaining liver after hepatectomy has enough volume, combined procedure may account for hepatic insufficiency, which can follow the development of postoperative morbidity., (Copyright © 2018. Published by Elsevier Taiwan LLC.)

Background: Although hepatectomy IVa + V with bile duct resection (BDR) for T2 gallbladder cancer (GBC) is performed in our institution, limited surgery is occasionally selected. This study aimed to clarify the significance of BDR for advanced GBC without biliary infiltration., Methods: Sixty-seven patients were enrolled who underwent surgery for pT2 or higher GBC without biliary infiltration. The patient disposition, demographics, clinicopathologic factors, disease-free survival (DFS) and overall survival (OS) were compared between the BDR group (n = 33) and non-BDR group (n = 34)., Results: There were no significant differences in TNM factors, R0 rate, morbidity rate and rate of adjuvant chemotherapy between the two groups. The patients in the BDR group were significantly younger, had more lymph nodes harvested than those in the non-BDR group, and more frequently underwent hepatectomy IVa + V and extended lymphadenectomy. There were no significant differences in the OS and DFS rates between the two groups., Conclusion: The significance of BDR for pT2 or higher advanced GBC without biliary infiltration was equivocal because the patients received no survival benefit by undergoing BDR., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Carpal tunnel syndrome is a compression neuropathy of the median nerve at the wrist; its symptoms include neuropathic pain and sensory and motor disturbance distributed by the median nerve. Carpal tunnel syndrome and hypercholesterolemia have similar backgrounds, but the effect of these similarities on postoperative outcomes has not been reported. Using multivariate analysis, the authors analyzed the relationship between prognostic factors, including the presence of hypercholesterolemia, and subjective postoperative outcomes of patients with idiopathic carpal tunnel syndrome., Methods: Of 168 hands with carpal tunnel syndrome that were treated surgically, 141 that were followed up and assessed 1 year postoperatively or thereafter were included. The mean postoperative follow-up period was 40.8 months. Surgery was performed through a small palmar skin incision under local anesthesia. The outcomes were postoperative symptoms, including pain and numbness, and overall Kelly assessment., Results: Preoperative numbness and pain resolved and alleviated in 94 of 141 hands and was diminished in 59 of 64 hands. Univariate analysis showed that postoperative numbness and Kelly assessment were significantly associated with hypercholesterolemia. Multivariate analysis showed that postoperative numbness was significantly associated with smoking and hypercholesterolemia, and Kelly assessment was significantly associated with smoking (adjusted OR, 3.3; 95 percent CI, 1.1 to 10; p = 0.04) and hypercholesterolemia (adjusted OR, 2.9; 95 percent CI, 1.4 to 6.3; p = 0.01)., Conclusion: Hypercholesterolemia, usually a systemic condition in sites other than the hand, is associated with the subjective evaluation of postoperative symptoms in patients with idiopathic carpal tunnel syndrome., Clinical Question/level of Evidence: Risk, III.

Purpose: The International Study Group of Liver Surgery (ISGLS) proposed a definition and grading system for posthepatectomy liver failure (PHLF). We evaluated the usefulness of residual liver function estimation using Tc-galactosyl human serum albumin (Tc-GSA) for the prediction of PHLF., Methods: Patients with liver tumors (n = 136) and scheduled for hepatectomy underwent Tc-GSA scintigraphy. Based on their imaging data, the maximal GSA removal rate (GSA-Rmax)was calculated using multicompartment analysis. We also calculated GSA-Rmax in the predicted residual liver (GSA-RL) whose volume was determined on computed tomography (CT) scans. We compared the age, sex, 15-minute indocyanine green retention rate; albumin, bilirubin, hyaluronic acid, and type 4 collagen levels; the Child-Pugh classification; residual liver volume; residual liver percentage; GSA-Rmax; and GSA-RL in patients with and without PHLF. Univariate and multivariate logistic analyses were used for statistical assessments., Results: Of 136 patients, 17 (12.5%) met the ISGLS criteria for PHLF (ISGLS-PHLF). There was a statistically significant difference in the age, albumin level, Child-Pugh classification, residual liver volume, residual liver percentage, GSA-Rmax, and GSA-RL between patients with and without PHLF. Based on multivariate analysis, GSA-RL and the residual liver volume were significant independent predictors of ISGLS-PHLF (P = 0.004 and P = 0.038, respectively). The odds ratio was 149423 for GSA-RL and 1.003 for the residual liver volume., Conclusions: GSA-RL calculated using Tc-GSA scintigraphy was the most useful independent predictor for ISGLS-PHLF.

Background: Prognosis in patients with hepatocellular carcinoma (HCC) is not only influenced by tumor-related factors but also by the background liver functions. The maximal removal rate of technetium-99m-galactosyl human serum albumin (GSA-Rmax) of the remnant liver (rGSA-Rmax) is a useful candidate for predicting the liver function and clarifying the relationship between the remnant liver functional reserve and tumor-free survival in patients who have undergone hepatectomy., Patients and Methods: One hundred and sixty-five patients with HCC who underwent curative hepatectomy were divided into three groups of hepatitis B virus (B-HCC; n=42), hepatitis C virus (C-HCC, n=58), and non-B, non-C (NBNC-HCC, n=65). The relationship between rGSA-Rmax and survival was examined by univariate and multivariate analyses., Results: In the C-HCC group, the albumin, or LHL15, level was significantly lower, and alanine aminotransferase, ICGR15, and the prevalence of grade B liver damage were significantly higher than other two groups (P<0.05). GSA-Rmax or rGSA-Rmax was not different between the three groups. Lower GSA-Rmax and rGSA-Rmax were only significantly associated with lower tumor-free survival in the C-HCC group by the univariate analysis (P<0.05) but not significantly by the multivariate analysis., Conclusion: GSA-Rmax and rGSA-Rmax reflect the severity of liver dysfunction and furthermore, the lower rGSA-Rmax is useful as a complementary factor to predict the early HCC recurrence after hepatectomy.

Pancreatic cancer patients have a poor prognosis because of a low rate of resection that results from distant metastases or local advancement. We report a successful case of unresectable locally advanced pancreatic cancer in a patient who was curatively resected after combination therapy with nab-paclitaxel (nab-PTX) and gemcitabine (GEM). A 61-year-old man was referred for treatment of a 45-mm pancreatic tail tumor involving the celiac axis, common hepatic artery, and splenic artery that appeared as an abnormal soft-density mass on imaging. This patient's tumor was defined as unresectable due to local advancement, and, therefore, the powerful combined chemotherapy regimen of nab-PTX with GEM was initiated to allow for possible resection later. After three cycles of chemotherapy, a CT scan revealed that the soft-density mass around the celiac axis and common hepatic artery had dramatically disappeared, and the tumor was then determined to be a resectable lesion. Thus, distal pancreatectomy with en bloc celiac axis resection was performed and curability was achieved. There has been no tumor recurrence or distant metastasis at more than 12 months after surgery, and the patient remains alive at 17 months after initial chemotherapy.

Condensins load onto DNA to organize chromosomes. Smc-ScpAB clearly loads onto the parS sites bound by Spo0J, but other loading site(s) must operate independently of parS. In this study, we asked where and how Smc-ScpAB normally selects its loading site. Our results suggest that rDNA is also a loading site. A pull-down assay revealed that Smc-ScpAB preferentially loads onto rDNA in the wild-type cell and even in a Δspo0J mutant but not in a Δsmc mutant. Moreover, we showed that deletion mutants of rDNAs cause a defect in nucleoid separation, and at least two rDNAs near oriC are essential for separation. Full-length rDNA, including promoters, is required for loading and nucleoid separation. A synthetic defect by deletions of both rDNA and spo0J resulted in more aberrant nucleoid separation. We propose that a single-stranded segment of DNA that is exposed at highly transcribed rRNA operons would become a target for Smc-ScpAB loading., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The VIO soft-coagulation system (VIO) with a monopolar electrode is a novel hemostatic device that provides hemostasis by superficial contact at the bleeding site without carbonization. Because heat injury remains a concern, surgical records and postoperative liver dysfunction were retrospectively evaluated in a cohort study., Methods: Between September 2010 and March 2016, 322 patients underwent hepatectomy in which hemostatic devices were used at two institutions. Surgical results with use of VIO at one institute (VIO group) were compared with those without use of VIO at a second institute (control group), and propensity analysis was performed., Results: In limited resection and segmentectomy or sectionectomy performed in the VIO group, the prevalence of liver cirrhosis was significantly higher and the operation time was significantly longer in comparison with the control group (p < 0.05). In all hepatectomies, postoperative levels of total bilirubin and aspartate or alanine transaminase tended to be increased and prothrombin activity tended to be lower in the VIO group in comparison with the control group (p < 0.05). The prevalence of hepatic failure in the VIO group was significantly higher in comparison with that in the control group (p < 0.05). In cases of segmentectomy or sectionectomy, blood loss was significantly increased in the VIO group in comparison with that in the control group (p < 0.05) Propensity score matching showed that although the surgical records and outcomes were not significantly different between the groups, postoperative liver dysfunction was significant in the VIO group in comparison with the control group (p < 0.05)., Conclusions: Mild postoperative hepatic thermal injury with VIO was confirmed, and therefore, surgeons should take care when using the VIO system to make frequent wide resected cuts on the surface of the liver., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Recently, posthepatectomy complications have been predicted by advances of new liver functional parameters, and the technetium-99m-galactosyl human serum albumin (GSA) liver scintigraphy has been applied widely for this purpose. We evaluated the clinical significance of the regional maximal removal rate (GSA-Rmax) in patients with various liver diseases as predictors of posthepatectomy complications., Patients and Methods: Between 2012 and March 2016, we examined 200 patients who underwent hepatectomy for liver and biliary diseases. The patients' background liver conditions included chronic viral liver diseases in 147 patients, normal liver in 44 patients, and others in nine patients. Hepatectomy-related postoperative complications (i.e. long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 69 (35%) patients. A multivariate logistic analysis was carried out to detect the predictive parameters for complications., Results: The median and mean preoperative GSA-Rmax was 0.420 and 0.448±0.148 mg/min, respectively. The GSA-Rmax was significantly correlated with liver functional parameters of ICGR15, LHL15, HH15, platelet count, prothrombin activity, and serum hyaluronic acid level (P<0.01), and was significantly correlated with postoperative total bilirubin level and C-reactive protein level (P<0.05). With respect to patient outcomes, GSA-Rmax was significantly lower in patients with long-term ascites (P<0.05). The predictive cutoff value for posthepatectomy long-term ascites for GSA-Rmax was 0.421 mg/min. However, the multivariate logistic regression analysis identified that a higher serum hyaluronic acid level and a lower platelet count were significant, independent factors, but not lower GSA-Rmax., Conclusion: GSA-Rmax is one of the liver functional parameters and is a complementary parameter to predict postoperative hyperbilirubinemia, inflammatory responses, and ascites when Tc-GSA scintigraphy is performed.

Colitis-associated colorectal cancer (CAC) is known to occur in long-standing and extensive ulcerative colitis (UC). Furthermore, UC is known to complicate primary sclerosing cholangitis (PSC), which subsequently results in an increased risk of developing cholangiocarcinoma. We report a case of colitis-associated rectal cancer (CARC) accompanied by intrahepatic cholangiocarcinoma (ICC) based on UC and PSC. A 73-year-old man had suffered from UC for 19 years. During surveillance colonoscopy, a tumor was found in the rectum that was pathologically diagnosed as CARC from the resected specimen. Abdominal computed tomography also revealed a localized dilation of the intrahepatic bile duct, and endoscopic retrograde cholangiography revealed a band-like stricture. This remarkable tumor lesion was not observed in the hepatic duct. Left hepatectomy was performed because of the suspicion of possible ICC at the stenosis of the hepatic duct. The presence of ICC was confirmed at the lesion causing the stricture. The pathological diagnosis from the resected specimen was ICC based on PSC. Adjuvant chemotherapy for ICC was performed for 6 months. Neither cancer has recurred for 2.5 years after hepatectomy. Patients with PSC concomitant with UC should be considered a high-risk group for CAC and ICC.

Background: To reduce cholangitis after pancreaticoduodenectomy (PD), we perform 'hepaticoplasty', in which the left side of the bile duct is cut to widen the diameter of the bile duct wall before hepaticojejunostomy. The aim of this study was to clarify the usefulness of hepaticoplasty to reduce cholangitis after PD., Methods: From January 2002 through December 2010, 161 patients underwent PD and were enrolled in this study. Patient demographics, surgical factors, and clinical and biochemical parameters were evaluated to examine the factors predictive of cholangitis after PD and confirm the usefulness of hepaticoplasty., Results: Cholangitis after PD occurred in 13 patients (8.1%). Multivariate analysis revealed that the ratio of the postoperative bile duct diameter to that before surgery was the only independent risk factor for cholangitis after PD (p = 0.0012). In the small bile duct group, in which the diameter was ≤15 mm before surgery (n = 99), hepaticoplasty reduced the narrowing of the bile duct after PD, and no cholangitis occurred. There were no complications related to hepaticoplasty., Conclusions: The ratio of postoperative reduction of the bile duct diameter to that before surgery was found to be the only risk factor for cholangitis after PD. Patients with a small bile duct of ≤15 mm in diameter preoperatively might benefit from hepaticoplasty to widen the bile duct diameter and prevent cholangitis after PD., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: In August 2012, an outbreak of enterohaemorrhagic Escherichia coli (EHEC) O157 infection was investigated by the City of Sapporo and Hokkaido Prefectural Government. The initial notification reported an illness affecting 94 residents of 10 private nursing homes distributed across multiple areas of Hokkaido, the northernmost island of Japan; at this time three cases were confirmed as EHEC O157 infection. The objectives of the investigation were to identify the source of infection and recommend control measures to prevent further illness., Methods: A suspected case was defined as a resident of one of the private nursing homes in Hokkaido who had at least one of the following gastrointestinal symptoms: diarrhoea, bloody stool, abdominal pain or vomiting between 10 July and 10 September 2012. Cases were confirmed by the presence of Shiga toxin 1- and 2-producing EHEC O157 in stool samples of suspected cases. We conducted an epidemiological analysis and an environmental investigation., Results: We identified 54 confirmed and 53 suspected cases in 12 private nursing homes including five fatalities. Of the 107 cases, 102 (95%) had consumed pickles, all of which had been manufactured at the same facility. EHEC O157 isolates from two pickle samples, 11 cases and two staff members of the processing company were indistinguishable. The company that produced the pickles used inadequate techniques to wash and sanitize the vegetables., Discussion: Contaminated pickles were the likely source of this outbreak. We recommended that the processing company improve their methods of washing and sanitizing raw vegetables. As a result of this outbreak, the sanitation requirements for processing pickles were revised.

We report a case of long-term survival of a patient who received low-dose 5-fluorouracil and cisplatin (FP) systemic chemotherapy and underwent partial resection of the lung for a tumor thrombus in the inferior caval vein (IVC) and multiple lung metastases from recurrent hepatocellular carcinoma (HCC). The patient was a 66-year-old man who was admitted to our hospital for the treatment of a 13-cm liver tumor. He underwent an extended posterior sectionectomy of the liver. Pathological diagnosis revealed moderately differentiated hepatocellular carcinoma (vp1, vv1, sm[-, 1.5mm], ch, T3N0M0, stage III). At 3 months postoperatively, computed tomography (CT) revealed a tumor thrombus in the IVC and multiple (>20) lung tumors that were considered HCC recurrences. Low-dose FP systemic chemotherapy was initiated, and the tumors reduced in size. However, a new lesion in the left lung was detected at 13 months postoperatively. Thoracoscopyassisted resection of the tumor that was histologically diagnosed as an HCC metastasis was performed at 26 months postoperatively. The patient is cancer free at 46 months postoperatively. Therefore, low-dose FP systemic chemotherapy is one of the therapeutic options for the treatment of HCC recurrences of IVC tumor thrombi and multiple lung metastases. However, the occurrence of new lesions should be carefully monitored.

Objectives: Health insurers in Japan are required to provide health checkups specifically designed to detect signs of metabolic syndrome. Since National Health Insurance organizations have been increasing their numbers of low-income beneficiaries, this observational study was carried out to investigate the differences between persons with differing household income levels based on the factors associated with their participation in health checkups., Methods: The data source for this study was a database of scored answers in collected, unsigned questionnaires provided by the National Health Insurance of Sapporo City. The survey was conducted in 2009, approaching 3000 beneficiaries aged 40-74 years and sampling 4 groups divided by household income and participation in the 2008 health checkup. The survey included questions about demographics, awareness of the details of the health checkup, and knowledge of lifestyle-related diseases. Valid answers from 1656 respondents were analyzed using multiple logistic regression analysis., Results: After analyzing the level of awareness of health checkup details among subjects and its association with checkup participation, knowledge of the locations where the checkups were held showed the highest adjusted odds ratios. Multivariate logistic regression analysis showed that the following factors were associated with participation in checkups in both lower- and higher-income groups: previous and regular participation in health checkups, willingness to attend the next checkup, and status of family or friends regarding checkup participation. In addition, that a substantial out-of-pocket cost for the checkup was not levied had a significant relationship with checkup attendance in lower-income beneficiaries, while personal obligation to undergo regular health checkups regardless of the busyness of their schedules was found to have a significant relationship in higher-income beneficiaries. In addition, logistic models that excluded factors of previous and future health checkup participation indicated that participation in health checkups in the lower-income group was associated with an interest in health checkup test items, smoking habits, and the perception of the importance of undergoing health checkups even without specific symptoms, while an interest in healthy lifestyles was found to have a significant relationship with participation in health checkups in the higher-income group., Conclusion: The study showed that awareness of checkup locations and regular attendance at health check-ups are strongly related to participation. Some differences in factors associated with health checkup participation were detected among individuals with differing income levels.

A nucleotide sequence of the whole genome of Bacillus subtilis phage SP10 was determined. It was composed of 143,986 bp with 236 putative open reading frames (ORFs). Sixty-five of 236 predicted ORFs showed high similarity to that of SPO1, and the genome organizations of the two phages were similar to each other. SP10 belongs to the Myoviridae family, for which the well-studied phage SPO1 is the representative phage. Hence, we compared SP10 to SPO1. The SP10 genome DNA showed different sensitivity to restriction enzymes than SPO1, due to differences in base modification. According to transcriptional analysis, the gene expression of regulatory network of SP10 was similar to SPO1. It was observed that RNA polymerase containing sigma-A was inactive in directing the host genes but active in directing the phage genes. It appeared that the association of sigma-A with the core enzyme complex of RNA polymerase was strengthened during development.

Pairs of the ECF sigma factor and its anti-sigma factor, SigW and RsiW, of Bacillus-related species that inhabit extreme environments were heterologously expressed in B. subtilis. All the RsiWs, membrane proteins, failed to fill their function of repressing cognate SigW activity, despite their close structural similarities. Particularly, uncontrolled expression of Oceanobacillus iheyensis OISigW due to abortive OIRsiW was harmful to B. subtilis. Analysis of revertants of this growth defect and site-directed mutagenesis indicated that the insertion of six and a minimum of three hydrophobic amino acid residues occurring in the transmembrane region allowed OIRsiW to function as anti-OISigW. Subcellular localization of OIRsiW was detected by immunoblot analysis, suggesting that both the wild-type and the mutant form of OIRsiW were localized to the membrane. An appropriate length of a transmembrane region required for proper integration into the membrane after translocation might vary among these Bacillus-related species.

Genetically modified maize MON863 (MON863), which has passed a safety examination in Japan, is commercially cultivated in the United States as a food and a resource for fuel. Maize is an anemophilous flower, which easily hybridizes. However, an official method for quantifying the content of MON863 has not been provided yet in Japan. We here examined MON863 contamination in maize-processed foods that had no labeling indicating of the use of genetically modified maize.From March 2006 to July 2008, we purchased 20 frozen maize products, 8 maize powder products, 7 canned maize products and 4 other maize processed foods. Three primer pairs named MON 863 primer, MON863-1, and M3/M4 for MON863-specific integrated cassette were used for qualitative polymerase chain reaction (PCR). A primer pair "SSIIb-3" for starch synthase gene was used to confirm the quality of extracted DNA. The starch synthase gene was detected in all samples. In qualitative tests, the MON863-specific fragments were detected in 7 (18%) maize powder products out of the 39 processed foods with all the three primer pairs.We concluded that various maize processed foods on the market were contaminated with MON863. It is important to accumulate further information on MON863 contamination in maize-processed foods that have no label indication of the use of genetically modified maize.

Objective: Isolates of M. tuberculosis were analyzed for their DNA fingerprints to facilitate understanding of ongoing transmission of tuberculosis in Sapporo (population 1.87 million), Japan, where the incidence rate of tuberculosis was 15.0 per 100,000 in 2004., Subject: Out of all tuberculosis patients registered in the city from November 1998 to December 2003, isolates from culture-positive respiratory tuberculosis cases for whom written informed consent had been obtained, were analyzed by restriction fragment length polymorphism (RFLP). The study included 345 cases (249 men and 96 women) whose isolates were available for DNA patterns., Method: Using standard IS6110-RFLP typing, cases whose isolates shared identical fingerprints were considered to belong to the same cluster. Proportions of clustered cases were evaluated according to their clinical and socio-economical characteristics., Results: Out of 345 cases, 207 (60.0%) were classified into 59 clusters, and 15% of clustered cases having definite epidemiological links. Multiple logistic regression analysis in men showed that age and infectiousness were significantly related to clustering. The adjusted odds ratios (OR) [95% confidence intervals (CI)] were 0.17 [0.03-0.79] for 30-59 years, 0.15 [0.03-0.69] for 60 years or over and 2.35 [1.17-4.70] for those cases assigned as the highest level of transmission of tuberculosis from the infectiousness index of cases. For women the final model showed the adjusted OR [95% CI] were 0.52 [0.22-1.22] for those with previous history of tuberculosis and 0.33 [0.06-1.85] for diabetics. In male cases with a previous history of tuberculosis, most highly infectious cases were significantly associated with clustering (OR [95% CI], 4.53 [1.16-17.68])., Conclusion: The results suggest that highly infectious male tuberculosis cases with endogenous reactivation have contributed to recent transmission of tuberculosis in the studied area.