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Background: The present study was conducted to compare and examine the effects of tapping touch and laughter yoga for alleviating depression symptom and stress reactions among older adults requiring home care. Methods: Tapping touch and laughter yoga were administered to 18 older adult day care users. We evaluated participants’ emotional reactions via a two-dimensional mood scale and VAS before and after tapping touch and laughter yoga activities. Results: Activity-based care utilizing tapping touch was effective for reducing feelings of stress, pain, anxiety, and tension by placing users in a more relaxed and stable state. Laughter yoga revealed no significant effects, with the exception of a tendency toward increased comfort. Conclusion: Tapping touch was effective at reducing stress and pain in the present sample. Although laughter yoga was not similarly effective, there is a possibility that modifying its implementation could enhance its efficacy.

Background/aim This study was designed to evaluate the clinical significance of the C-reactive protein-to-albumin ratio (CAR) in patients with rectal cancer undergoing preoperative chemoradiotherapy (CRT) followed by surgery. Patients and methods This retrospective study evaluated the correlation between CAR and prognosis in 115 patients with locally advanced rectal cancer. We also carried out subgroup analyses limited to patients with low modified Glasgow prognosis score (mGPS) (score 0) or pathological TNM stage I-II [ypN(-)]. Results CAR exhibited significant relationships with sex, tumor invasion, recurrence, serum carcinoembryonic antigen, and mGPS. Elevated CAR was an independent prognostic factor for overall survival (OS) and disease-free survival (DFS) among all patients. Elevated CAR also predicted poor OS and DFS in patients with pathological TNM stage I-II [ypN(-)] and low mGPS score. Conclusion CAR is a promising predictor of survival and recurrence in patients with rectal cancer treated by CRT.

A 41-year-old man presented to our hospital with lower abdominal pain and a high-grade fever. Physical examination revealed rebound tenderness and guarding in the lower abdomen. Abdominal X-ray examination showed a radiopaque object in the right lower quadrant of the abdomen. Abdominal computed tomography (CT) demonstrated that the object had a strong artifact with over 10,000 Hounsfield units, as well as ascites around the terminal ileum. We diagnosed acute peritonitis with a suspicion of the perforation due to unknown foreign body and performed an emergency laparotomy. Operative findings showed a contained perforation of a phlegmonous appendicitis, and appendectomy was performed. The resected specimen demonstrated that the appendix contained a fecalith, and histopathological examination showed the crystal structure of barium sulfate in the lumen of the appendix. Unfortunately, we did not obtain the history of screening for gastric cancer using a barium examination one month prior to our appendectomy. Our experience demonstrates the importance of establishing a history of barium examinations of the gastrointestinal tract in a patient with a radiopaque object in the right lower quadrant of the abdomen for early diagnosis of barium appendicitis. Additionally, early diagnosis of barium appendicitis may affect the selection of surgical procedures.

// Koichiro Mori 1 , Yuji Toiyama 1 , Kohei Otake 1 , Shozo Ide 1 , Hiroki Imaoka 1 , Masato Okigami 1 , Yoshinaga Okugawa 1 , Hiroyuki Fujikawa 1 , Susumu Saigusa 1 , Junichiro Hiro 1 , Minako Kobayashi 1 , Masaki Ohi 1 , Koji Tanaka 1 , Yasuhiro Inoue 1 , Yuhko Kobayashi 2 , Yasuhiko Mohri 1 , Issei Kobayashi 2 , Ajay Goel 3 and Masato Kusunoki 1 1 Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan 2 Center for Molecular Biology and Genetics, Mie University, Mie, Japan 3 Center for Gastrointestinal Research & Center for Epigenetics, Cancer Prevention and Cancer Genomics, Baylor Scott & White Research Institute and Charles A Sammons Cancer Center, Baylor University Medical Center, Dallas, TX USA Correspondence to: Yuji Toiyama, email: ytoi0725@clin.medic.mie-u.ac.jp Ajay Goel, email: Ajay.Goel@BSWHealth.org Keywords: iTRAQ-based quantitative proteomic analysis; ezrin; lymph node metastasis; colorectal cancer; biomarker Received: February 02, 2017 Accepted: June 29, 2017 Published: October 30, 2017 ABSTRACT Colorectal cancer (CRC)-associated mortality is primarily caused by lymph node (LN) and distant metastasis, highlighting the need for biomarkers that predict LN metastasis and facilitate better therapeutic strategies. We used an I sobaric T ags for R elative and A bsolute Q uantification (iTRAQ)-based comparative proteomics approach to identify novel biomarkers for predicting LN metastasis in CRC patients. We analyzed five paired samples of CRC with or without LN metastasis, adjacent normal mucosa, and normal colon mucosa, and differentially expressed proteins were identified and subsequently validated at the protein and/or mRNA levels by immunohistochemistry and qRT-PCR, respectively. We identified 55 proteins specifically associated with LN metastasis, from which we selected ezrin for further analysis and functional assessment. Expression of ezrin at both the protein and mRNA levels was significantly higher in CRC tissues than in adjacent normal colonic mucosa. In univariate analysis, high ezrin expression was significantly associated with tumor progression and poor prognosis, which was consistent with our in vitro findings that ezrin promotes the metastatic capacity of CRC cells by enabling cell invasion and migration. In multivariate analysis, high levels of ezrin protein and mRNA in CRC samples were independent predictors of LN metastasis. Our data thus identify ezrin as a novel protein and mRNA biomarker for predicting LN metastasis in CRC patients.

Afferent limb syndrome (ALS) is caused by an obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis. Here, we describe the first case of ALS to be successfully treated by a laparoscopic approach. A 27-year-old man underwent ileal pouch-anal anastomosis for ulcerative colitis. He was subsequently diagnosed with ALS and underwent ileopexy with laparotomy at 33 years old. Then, 21 months after the first ileopexy, he underwent laparoscopic ileopexy for ALS recurrence. The operative findings revealed a shortened fixed portion of the afferent limb adhering to the right pelvic retroperitoneum, which was regarded as the cause of the acute angulation. The portion of the afferent limb fixed to the abdominal wall was extended under laparoscopic visualization by suturing above the level of the iliac crest. At the 12-month follow-up, the patient remained free of symptoms of obstruction. Laparoscopic ileopexy should be the procedure of choice for patients with ALS.

The aims of this study were to reveal how using the antibiotics recommended by the 2010 Surgical Infection Society (SIS) and Infectious Disease Society of America (IDSA) guidelines can affect the therapeutic outcomes. We reviewed the cases of 53 patients with a postoperative intra-abdominal abscess without anastomotic leakage after gastrointestinal surgery who underwent image-guided percutaneous abscess drainage (PAD) and concomitant antibiotic therapy. The type of antibiotic initially administered was determined based on the surgeon’s judgment. A persistent abscess was defined as one or more PAD procedures resulting in complete resolution after 21 or more days. The recommended antibiotics were defined according to 2010 SIS/IDSA guidelines. All 53 patients had complete resolution without the need for surgery. The results of a multivariable analysis revealed that a C-reactive protein level ≥12 mg/dL and non-recommended antibiotics were significant risk factors for a persistent abscess (P = 0.042 and 0.013, respectively). With regard to a fever lasting more than 48 h, there was a significant difference between the recommended (45.1 %) and non-recommended (72.7 %) antibiotic groups (P = 0.046). Using the recommended antibiotics may shorten the time to defervescence and reduce the risk of a persistent abscess in patients undergoing PAD for a postoperative abscess after gastrointestinal surgery.

Elderly patients are regarded as being at increased risk during major abdominal surgery because of a lack of functional reserve and an increased number of comorbidities. The aim of this study was to compare short- and long-term outcomes of laparoscopic gastrectomy between elderly and young gastric cancer patients. Two-hundred ten patients who underwent laparoscopic gastrectomy for gastric cancer at our institution between January 2001 and December 2011 were included in this retrospective study. Patients were divided into two age groups (younger than 70 years and older than 70 years) and were evaluated with respect to postoperative morbidity, quality of life (QOL), and survival. Postoperative morbidity was similar in elderly and young groups (18.3 vs. 21.6 %; P = 0.718). Overall survival of the elderly group was significantly worse than that of the young group (P

Key Clinical Message Four patients with gastric cancer underwent 5-fluorouracil and cisplatin-based chemoradiotherapy followed by surgery. Expression analysis of chemoradiosensitivity related genes in residual cancer using formalin-fixed paraffin-embedded specimens may be useful when determining a chemotherapy regimen for disease recurrence after chemoradiotherapy for gastric cancer.

Background Central venous catheterization is recognized as a lifeline that is important for chemotherapy or nutritional support in pediatric patients with malignant disease and intestinal failure. This study analyzed the risk of infection with Broviac line use among these patients at a single Japanese center. Methods Two hundred and four Broviac lines were inserted in patients in the pediatric ward from January 2003 to October 2011. We analyzed the risk of catheter-related bloodstream infection (CR-BSI) using clinical characteristics including underlying disease, sepsis history, inserted situation, drug use, and laboratory data at the time of Broviac insertion or before CR-BSI. Results During the study period, data from a total of 15 lines were excluded because of missing blood culture data. In the remaining 189 Broviac lines, 52 lines developed CR-BSI. On univariate analysis, leukemia, infantile Crohn's disease, sepsis history before Broviac insertion, existence of a stoma opening, and immunosuppressant use before CR-BSI were risk factors for CR-BSI. On multivariate logistic regression analysis infantile Crohn's disease, sepsis history before Broviac insertion, and immunosuppressant use before CR-BSI were independently associated with CR-BSI (P = 0.015, P = 0.045, and P = 0.043, respectively). Conclusions Infantile Crohn's disease carries a high risk for CR-BSI because of its pathological condition, the therapeutic drugs required, and surgical intervention.

Our aim was to examine the association between postoperative infection and preoperative systemic inflammation in patients undergoing resection of gastrointestinal cancer. We studied 862 patients who underwent elective gastrointestinal cancer surgery at six institutions. The levels of C-reactive protein and albumin were included as parameters of preoperative systemic inflammation measured using the Glasgow prognostic score. The Glasgow prognostic score was calculated based on the admission data as follows: patients with an elevated level of C-reactive protein (>1.0 mg/dl) and hypoalbuminemia (

Purpose To improve the selection of patients for percutaneous abscess drainage (PAD) to treat postoperative intra-abdominal abscess after gastrointestinal surgery, we investigated the factors predictive of outcome. Methods Of 143 consecutive patients with symptomatic postoperative intra-abdominal abscess after a gastrointestinal tract resection, 104 who underwent image-guided PAD as the initial treatment were reviewed. We assessed the possible associations between successful PAD and patient-, abscess-, surgical-, and drainage-related variables, and investigated the success rates of PAD for patients with vs. those without the factors related to successful outcome. Results Based on monitoring for 1 year after PAD, the success rate of this procedure was 85.6 % (89/104). Multivariate analysis revealed that the interval between surgery and the onset of abscess (p = 0.0234) and a single abscess (p = 0.0038) were independently associated with a successful outcome. Single late-onset abscess resolved completely within 10 weeks in 91.4 % of these patients. Conclusions Despite new strategies aimed at preventing surgical site infection, PAD remains an important factor in the postoperative management of gastrointestinal surgery in Japan. Initial recognition of the day of onset and the number of abscesses are important prognostic factors.

Background/Aim: Enforced expression of the connexin (Cx) 32 gene, a member of the gap junction gene family and a tumor suppressor gene in human renal cell carcinoma (RCC), enhanced vinblastine (VBL)-induced cytotoxicity in RCC cells due to suppression of multidrug resistance 1 (MDR1) expression. Furthermore, in RCC the Cx32 gene is silenced by hypermethylation of CpG islands in a promoter region of the Cx gene. In this study, we investigated if the green tea polyphenol epigallocatechin-3-gallate (EGCG) could enhance susceptibility of RCC cells (Caki-1, a human metastatic RCC cell) to VBL. Methods: The effects of EGCG on Caki-1 cells were estimated by WST-1 (cell viability), real-time RT-PCR (mRNA level) and immunoblotting (protein level). We estimated the methylation status in the promoter region of the Cx32 gene in RCC cells by methylation-specific PCR. Each protein function was inhibited by small interfering RNA (siRNA) and specific inhibitors. Results: The EGCG treatment elicited significant upregulation of Cx32 in Caki-1 cells, and the induction of the Cx led to the suppression of MDR1 mRNA expression through inactivation of Src and subsequent activation of c-Jun NH2-terminal kinase (JNK). Chemical sensitivity to VBL in Caki-1 cells was increased by EGCG pretreatment, and this effect was abrogated by siRNA-mediated knockdown of Cx32. Conclusion: This study suggests that the restoration of Cx32 by EGCG pretreatment improves chemical tolerance on VBL in Caki-1 cells via the inactivation of Src and the activation of JNK.

Background Lower albumin-globulin ratio (AGR) is associated with increased mortality in several cancers. However, no studies have evaluated the relationship between the AGR and prognostic outcome in esophageal cancer (EC) patients. Methods To identify indicators of early recurrence and poor prognosis, we assessed the clinicopathological findings and preoperative laboratory data (carcinoembryonic antigen [CEA], squamous cell carcinoma antigen, total protein, and albumin) of 112 EC patients who underwent surgery. The AGR was calculated as albumin/(total protein–albumin). Results A lower AGR was significantly associated with tumor progression. The CEA level was an independent predictor for overall survival (OS) and disease-free survival (DFS). The AGR and CEA combination was identified as a feasible indicator of poor prognosis and early recurrence. Among EC patients without lymph node metastasis, those with lower AGR had poorer DFS and OS than those with higher AGR. Conclusion AGR was identified as a significant predictor of OS and DFS in EC patients. Among EC patients without lymph node metastasis, AGR may help identify candidates who might benefit from more intensive adjuvant therapy.

Dysregulation pattern of microRNA-7 (miR-7) and the clinical significance of its expression in colorectal cancer (CRC) are unresolved. Here, we investigated the relationship between clinicopathological factors, including prognostic outcome, and miR-7 expression in CRC tissues. We analyzed miR-7 expression levels by real-time reverse transcription polymerase chain reaction in 210 colorectal tissues (196 CRCs and 14 normal mucosae from healthy volunteers). miR-7 expression levels were significantly up-regulated in CRC tissues compared to normal colorectal mucosae. Elevated miR-7 expression was significantly correlated with tumour depth, venous invasion, lymphatic invasion, lymph node metastasis, and liver metastasis. High miR-7 expression was significantly associated with poor overall survival in patients with CRC (p=0.010). Moreover, miR-7 expression was an independent prognostic factor in patients with CRC (hazard ratio=1.854, 95% confidence interval=1.016-3.540; p=0.044). miR-7 acts as an oncogene in CRC and is significantly associated with tumour progression and poor prognosis.

The discovery of biomarkers to predict the potential for lymph node (LN) metastasis in patients with colorectal cancer (CRC) is essential for developing improved strategies for treating CRC. In the present study, they used isobaric tags for relative and absolute quantitation to conduct a proteomic analysis designed to identify novel biomarkers for predicting LN metastasis in patients with CRC. They identified 60 differentially expressed proteins specifically associated with LN metastasis in CRC patients and classified the molecular and functional characteristics of these proteins by bioinformatic approaches. A literature search led them to select heat shock protein 47 (HSP47) as the most suitable candidate biomarker for predicting LN metastasis. Validation analysis by immunohistochemistry showed that HSP47 expression in patients with CRC and the number of HSP47-positive spindle cells in the tumor stroma were significantly higher compared with those in adjacent normal colonic mucosa, and the number of the latter cells increased with tumor progression. Further, the number of HSP47-positive spindle cells in stroma was a more informative marker for identifying LN metastasis than HSP47expression. Multivariate analysis identified spindle cells that expressed elevated levels of HSP47 as an independent predictive biomarker for CRC with LN metastasis. Moreover, these cells served as an independent marker of disease-free and overall survival of patients with CRC. Their data indicate that the number of HSP47-positive spindle cells in the stroma of CRC may serve as a novel predictive biomarker of LN metastasis, early recurrence and poor prognosis.

Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure for ulcerative colitis, but pouch failure or pelvic sepsis still occurs in some patients. We conducted this study to investigate the cause of pouch failure and evaluate defecatory function after pelvic sepsis. A total of 234 patients who underwent restorative proctocolectomy were enrolled. We analyzed the cause of pouch failure, as well as defecatory function and manometric outcomes, with and without the complication of pelvic sepsis. Pelvic sepsis developed in 29 (12.3%) of the 234 patients who underwent restorative proctocolectomy (pelvic sepsis group). The pelvic sepsis led to pouch failure in two of these patients (as a vaginal fistula in one and ileo-anal anastomotic leakage in one). Of the remaining majority of patients who did not suffer pelvic sepsis (control group), nine suffered pouch failure (as vaginal fistula in four, perianal abscess in two, pouch-spinal marrow fistula in one, and chronic pouchitis in two). There were no significant differences in defecatory function or manometric outcomes between the two groups. In the pelvic sepsis group, stool frequency was significantly correlated with white blood cell count (P = 0.01) and the duration until onset of pelvic sepsis (P

Background and Objectives Distant metastatic relapse occurs in approximately 20% of rectal cancer patients treated with 5-fluorouracil (5-FU)-based chemoradiotherapy (CRT) followed by surgery. This study aimed to investigate mRNA level of 5-FU metabolizing enzymes in post-treatment specimens and to evaluate their predictive value of distant recurrence after CRT. Methods Forty patients with rectal cancer underwent 5-FU-based CRT followed by surgery. After microdissection, total RNA of residual cancer was isolated from formalin-fixed paraffin-embedded (FFPE) specimens. Thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), thymidine phosphorylase (TP), and orotate phosphoribosyl transferase (OPRT) as 5-FU metabolizing enzyme were measured using real-time reverse transcription polymerase chain reaction. Results Patients (n = 6) who developed distant recurrence had a significantly higher TS (P = 0.01), DPD (P = 0.02), and TP (P = 0.01) levels, compared with those patients (n = 34) without recurrence. High TS, DPD, and positive lymph node metastasis (pN) were significantly poorer prognostic factors for DFS (TS: P

Antimicrobial prophylaxis (AMP) can reduce the risk of surgical site infection (SSI) in gastroenterological surgery; however, in Japan its use was not fully recognized before 2000. The first nationwide guideline was published in 2001, since when the use of AMP has improved gradually. We conducted this study to investigate the current implementation of AMP in colorectal surgery and adherence to recommended practices for preventing SSI in Japan. A questionnaire survey was sent to hospitals accredited by the Japanese Society of Gastroenterological Surgery and the Japan Society for Surgical Infection (JSSI). The questionnaire focused on the AMP regimen used for colorectal surgery. Responses were received from 721 (58%) of the 1249 hospitals that were sent the survey. The initial AMP dose was administered within 1 h before incision at 94% of the responding institutions. AMP was discontinued within 24 h of surgery at only 10% of institutions. Second-generation cephalosporins were administered at 84% of the institutions. The appropriate use of AMP in colorectal surgery is incomplete in certified institutions in Japan. The fact that many institutions administer AMP for longer than recommended is a problem that needs to be addressed.

The aim of this study was to determine if the placement of prophylactic drains influences the incidence of postoperative adverse events in neonates.Neonatal patients undergoing laparotomy between April 2000 and December 2007 were prospectively assigned to aggressive peritoneal cavity lavage, without the placement of prophylactic drains, before abdominal closure (non-drainage group, n = 111). The historical control group consisted of neonates who underwent laparotomy with routine prophylactic drain placement between January 1993 and March 2000 (drainage group, n = 87). The incidence of postoperative adverse events was compared between the two groups.There were no significant differences in the incidence of overall complications (drainage, 48%; non-drainage, 36%: p = 0.08), infectious complications (drainage, 34%; non-drainage, 26%: p = 0.20) or surgical site infections (drainage, 20%; non-drainage, 14%: p = 0.25) between the two groups. In the subgroup analysis, the incidences of total postoperative complications and infectious complications were significantly higher in the drainage group compared with the non-drainage group for upper gastrointestinal tract operations (52 vs. 20%; 39 vs. 6.7%) (p = 0.04 and 0.02, respectively).Prophylactic drainage did not reduce the incidence of postoperative complications, and the placement of drains may possibly increase the incidence of infectious complications.

A novel iridium complex with an iminonitroxide bipyridine ligand, [Ir(ppy) 2 (MebpyIN)]Cl (ppy = 2-phenylpyridine and MebpyIN = 4-methyl-4'-(1-oxyl-4,4,5,5-tetramethylimidazolin-2-yl)-2,2'-bypyridine), was prepared as a preluminescent probe to detect free radicals. Although a related material, [Ir(ppy) 2 (bpy)]Cl, exhibits strong red luminescence, the emission of [Ir(ppy) 2 (MebpyIN)]Cl was quenched nearly completely by the nitronyl radical moiety in the ligand. However, the carbon-centered free radicals, generated from azobisbutyronitrile by UV irradiation, brought about a dramatic recovery of the luminescence of [Ir(ppy) 2 (MebpyIN)]Cl, with a linear relation between the luminescence intensity, and the free radical concentrations up to 120 mM. EPR measurements indicated that the luminescence recovery was caused by the free radical trapping at the nitronyl-radical moiety.

Surgical site infection (SSI) prolongs hospital stay, increases medical costs, and occasionally leads to mortality. Our goal was to clarify the differences in SSI incidence between our own data and the National Nosocomial Infections Surveillance (NNIS) data.From January 2003 to December 2006, we prospectively collected surveillance data from patients who were undergoing elective colorectal resection at the Mie University Graduate School of Medicine.Three hundred fifty-five elective colorectal resections (144 colon surgeries, 211 rectal surgeries) were included. The median patient age was 57.4 years. SSIs were identified in 60 patients. Cumulative SSI incidence was 16.9%. The average SSI onset was 8.7 days (range = 3-20 days) after operation. Nineteen patients (19/30:31.7%) developed SSI within 6 days of the operation. The incidence of SSI occurring within 6 days after the operation was 5.4%.Seventeen percent of SSIs occurred despite the use of perioperative management according to the CDC guidelines. We reported a much higher SSI incidence than that in the NNIS data. However, the SSI incidence within 6 days of surgery was similar to that of the NNIS data. The difference in SSI incidence between our data and that of the NNIS range may result from the different strict surveillance periods.

Postoperative hospital-acquired pneumonia (HAP) is recognized as a major risk associated with surgery. Although upper abdominal surgery is known to have the highest incidence of postoperative HAP, little is known about the risk factors that contribute to HAP after gastric cancer surgery. The aim of this study was to determine the incidence and risk factors for HAP after elective surgery for gastric cancer. We conducted prospective surveillance of all elective gastric resections by surgeons in ten affiliated hospitals, including ours, from May 2001 to May 2005. The outcome of interest was postoperative HAP. Univariate and multivariate analyses were performed to determine the predictive significance of variables in gastric cancer surgery. A total of 529 patients undergoing elective operations for gastric cancer were admitted to the program. Postoperative HAP was identified in 20 patients (3.6%). Univariate and multivariate analyses showed that male gender and intra- and/or postoperative blood transfusion were independently predictive of postoperative HAP. Male gender and intra- and/or postoperative blood transfusion were independent risk factors for the development of HAP after elective resection of gastric cancer. Surgeons should keep these risk factors in mind when managing postoperative patients.

Background and aim: Postoperative leukocytapheresis (LCAP) reduces surgical site infection (SSI) in ulcerative colitis (UC) patients undergoing proctocolectomy with ileal pouch–anal anastomosis (IPAA). To clarify the effect of postoperative LCAP on circulating neutrophils, we investigated neutrophil function before and after LCAP in UC patients undergoing proctocolectomy with IPAA. Method: Circulating neutrophils were obtained from 29 UC patients undergoing IPAA before and after postoperative LCAP. The phagocytic activity was measured using Escherichia coli BioParticles. Neutrophil viability after co-culture with E. coli was measured by flow cytometry. Inflammatory cytokines in patient serum and supernatants after co-culture of neutrophils with E. coli were measured by enzyme-linked immunosorbent assay. Results: No difference in phagocytic activity was found between preand post-LCAP neutrophils. The percentage of necrotic neutrophils was significantly decreased in post-LCAP neutrophils cocultured with E. coli. Serum neutrophil elastase (NE) after LCAP was significantly increased. No difference in cytokine production was found between pre- and post-LCAP neutrophils cocultured with E. coli. NE and tumor necrosis factor (TNF)-α levels in supernatants of post-LCAP neutrophils cocultured with E. coli were higher in patients with longer operating time and higher postoperative neutrophil count, respectively. Phagocytic activity of post-LCAP neutrophils was lower in the longer operating time group. Serum TNF-α level after LCAP was higher in the SSI group. Conclusion: Postoperative LCAP decreases the subset of circulating neutrophils, which induces necrosis against bacterial infection. This suggests a possible mechanism of prevention of SSI.

Background The optimum duration of antimicrobial prophylaxis in elective gastric cancer surgery is still open to question. This multicentre randomized clinical trial compared a single-dose with a multiple-dose regimen of antimicrobial prophylaxis for prevention of surgical-site infection. Methods Between May 2001 and December 2004, 501 patients undergoing elective surgery for gastric cancer in ten centres were allocated randomly to single- or multiple-dose antimicrobial prophylaxis. The primary outcome measure was the incidence of surgical-site infection, analysed by intention to treat. Results Some 243 patients who received a single dose and 243 who received multiple doses of antibiotics were included in the final analysis. The surgical-site infection rate was 9·5 per cent (23 of 243) and 8·6 per cent (21 of 243) respectively (difference 0·9 (95 per cent confidence interval − 4·3 to 5·9) per cent). Antimicrobial prophylaxis had no major adverse effects. Conclusion The incidence of surgical-site infection in elective gastric cancer surgery was similar with both antibiotic prophylaxis regimens.

The use of preoperative oral antibiotics during preparation for elective colorectal surgery remains controversial. This was a prospective randomized clinical trial to compare the efficacy of intravenous antimicrobial prophylaxis alone with combined oral and intravenous antimicrobial prophylaxis for surgical site infection (SSI) in patients undergoing elective colorectal surgery.Five hundred patients were enrolled in this study. Of these, 491 were randomly assigned to receive either intravenous antimicrobial prophylaxis or combined oral and intravenous antimicrobial prophylaxis. The primary outcome was the incidence of SSI within 6 weeks of elective colorectal surgery.The incidence of SSI was similar in the two treatment groups: intravenous alone, 10.7%; and oral and intravenous, 7.0% (difference 3.7%; 95% confidence interval -4.8% to 5.6%). No critical adverse events were reported.The addition of oral antibiotics to intravenous antimicrobial prophylaxis showed no advantage in the prevention of SSI.

症例は71歳の男性で, 深達度T2の下部直腸癌に対し, 術前放射線化学療法を施行し, T1への腫瘍縮小を認めたことから, 十分なインフォームドコンセントのうえ, 局所切除術を施行した. 病理診断でpathological complete responseであった. 術後化学療法も併用し, 術後3年5か月無再発生存中である. 下部進行直腸癌に対する手術は, 補助療法の進歩に伴い, 機能温存ならびに縮小へと向かう傾向にあるが, 放射線化学療法を併用し, 局所切除術で対応することに十分なコンセンサスは得られておらず, 今回良好な経過を認めた1例を経験したので報告する.

半側空間無視（USN）は右半球損傷患者に多くみられるが，右半球では空間性注意のネットワークを形成しているため，左半球損傷に比べてUSNの出現頻度が高いと言われている。治療については近年プリズム適応法（PA）が注目を浴びているが，空間表象を再構築することでUSNを改善するといわれている。今回我々はUSNに交叉性失語を合併する右半球損傷患者にPAを実施し，良好な成績が得られた。交叉性失語は生来右利きの人が右半球損傷により失語を生じるというもので，言語中枢が左半球に側性化されていないと考えられる。今回の結果は，空間表象機能は右半球優位のままで脳機能の冗長性が個体内でも生じることを示唆しており，治療法の選択に注意が必要であると思われた。

Aim: The purse-string suture is the most important part of the procedure in stapled hemorrhoidopexy affecting resection of an ideal mucosal rectal ring. We designed a prospective, randomized study to evaluate the safety and clinical outcome of a 6-stitch purse-string suture compared with a more simple 3-stitch purse-string suture intended to achieve certain interruption of the hemorrhoidal artery. Methods: Ninety patients were randomly assigned to undergo stapled hemorrhoidopexy with either a 6-stitch (n = 45) or a 3-stitch (n = 45) purse-string suture. Operative data and postoperative complications were compared between the 2 groups. The ring of excised rectal mucosa was examined histologically. Anal physiology was also assessed. Results: Although there were no statistically significant differences in postoperative complication rates, histological analysis of the excised mucosa, or anorectal function between the 2 groups, the 3-stitch procedure was significantly superior to the 6-stitch procedure in terms of intraoperative hemostasis and operative time, especially in advanced surgery. Conclusion: Once the learning curve has been completed, a 3-stitch purse-string suture in stapled hemorrhoidopexy could be an alternative to the 6-stitch suture, with effective hemostasis and a shorter operative time.

Afferent limb obstruction can be a persistent complication after restorative proctocolectomy with ileal pouch-anal anastomosis. We present a case of afferent limb obstruction complicated by a long efferent limb of the ileal pouch that we successfully treated with side-to-side anastomosis of the afferent and efferent limbs. The procedure involved using a transanal endoscopic stapling device assisted by transanal endoscopy with a thin intestinal video endoscope. This allowed reliable, safe visualization of the lesion from the tight pouch-anal anastomosis and facilitated repair with an endoscopic stapling device. Because the technique was performed without enterotomy, it reduced the risks of contamination and leakage from transabdominal small bowel anastomosis. Laparotomy view also prevented of injury to the pouch itself and entrapment of the mesentery of the afferent and efferent limbs of the pouch between the stapler anvils.

Preoperative preparation of the bowel includes two methods, mechanical bowel preparation (MBP) to remove gross feces and oral antibiotic bowel preparation (OABP) to reduce the colonic bacterial load. MBP and OABP have been performed since the 1940s to 1950s. MBP is routinely performed to reduce the morbidity and mortality of elective colorectal surgery and has been a surgical dogma since the early 1970s. However, numerous prospective, randomized, controlled trials and meta-analyses have questioned the need for MBP in elective colorectal surgery, and a meta-analysis showed that significantly more anastomotic leaks were found after MBP. OABP decreases postoperative infectious complications considerably, although the results differ with the type of antibiotic used. Recently, several large retrospective studies have demonstrated that MBP plus OABP is associated with reduced postoperative infectious complications including surgical site infection rates after elective colorectal surgery. Further prospective, randomized trials of MBP and OABP alone and in combination should be conducted.

We investigated whether serum markers and clinical factors could be used to preoperatively predict lymph node (LN) metastasis in colorectal cancer (CRC).The present study enrolled 157 curative CRC patients for whom preoperative serum carcinoembryonic antigen (CEA), systemic inflammatory markers (C-reactive protein (CRP) and angiopoietin-like protein 2 (ANGPTL2)) and objective preoperative clinical factors were available as indicators of pathological LN status.Specific clinical factors, including gender, tumor size, histopathology of biopsy sample and tumor morphology, were significantly correlated with LN metastases. Additionally, CEA, CRP and ANGPTL2 levels were also predictive factors for LN status. Multivariate analysis revealed that clinical factors, including gender, histopathology, tumor morphology and ANGPTL2, were identified as independent predictive factors for LN metastases. A combination of clinical factors reached high predictive accuracy of LN metastases and, combined with clinical factors, ANGPTL2 further improved the accuracy.Serum ANGPTL2 improves preoperative detection of LN metastasis in CRC.

In Japan, sterile water is used for rinsing in surgical handwashing, whereas in Western countries tap water is generally used. We conducted this study to examine the conditions and the equipment that affect bacterial contamination in tap water and to determine whether the tap water in our institute is suitable for surgical handwashing.First, we examined the water pipes and measured the free chlorine content in the tap water in the operating room. Next, we recruited 40 volunteers and conducted preliminary tests with sterile water. Thirty of these subjects participated in a handwashing test using tap water.The mean free chlorine levels in the tap water and the sterile water were 0.30 +/- 0.05 and 0.07 +/- 0.03 mg/l, respectively. The handwashing test using tap water showed immediate, persistent, and cumulative bacteria activity within the minimum limits set by the Food and Drug Administration (FDA).The free chlorine levels in the tap water in our institute satisfied Japanese health regulations. Moreover, the handwashing test met the criteria of the FDA. Thus, we conclude that this tap water is safe to use for rinsing in surgical handwashing.

症例は53歳,男性.血尿を主訴にて発見された膀胱腫瘍にて当院入院.術前精査にてS状結腸癌,膀胱浸潤と診断された.骨盤壁への浸潤傾向も強く横行結腸人工肛門造設後,術前補助療法として放射線療法(45Gy/25Fr)ならびに併用化学療法(Pharmacokinetic Modulating Chemotherapy: UFTE 400mg/day×7daysと5-FU 600mg/m2/24hriv/weekの併用)を施行した.補助療法に対し,腫瘍は著明に縮小したため開腹術施行.膀胱との剥離は可能であり,大腸亜全摘術並びに上行結腸人工肛門造設術を施行した.術後外来化学療法を施行しているが術後8カ月,無再発生存中である.切除不能大腸癌においては切除率を向上させるための治療を第一選択とし,またその機会を逃さずvolumere ductionを施行することが予後に寄与すると思われた.

Purpose. To evaluate the effectiveness of Seprafilm in preventing abdominal adhesions after radical resection of rectal carcinoma, and to observe whether Seprafilm had any adverse effects in patients treated with radiotherapy and chemotherapy. Methods. A total of 62 patients participated in this prospective randomized clinical study, which was conducted to compare the outcomes of patients operated on with Seprafilm (SEPRA+) with those operated on without Seprafilm (SEPRA-). All patients received preoperative radiotherapy, followed by a two-stage operation, and 5-fluorouracil (5-FU)-based systemic chemotherapy. The primary endpoint of severity and extent of adhesions were evaluated at the time of ileostomy closure. The secondary endpoint included the recurrence of tumors, late complications, and outcome. Results. Seprafilm significantly reduced the adhesions in both the midline incision area and peristomal area. This in turn reduced the operation time, blood loss, and extent of the incision at ileostomy closure. Seprafilm was not associated with any postoperative complications or chemoradiation-related toxicity, nor did it affect recurrence or survival rates. Conclusion. Seprafilm effectively reduced abdominal adhesions in chemoradiated patients, and had no adverse effects on the oncologic results of fully introduced adjuvant therapy. Thus, Seprafilm is a safe and effective tool for use in rectal carcinoma surgery.

Sentinel node (SN) biopsies might be useful for performing minimally invasive surgery without interrupting surgical curability. This study examined the cause of false negativity during laparoscopic lymphatic mapping and SN biopsies for early-stage gastric cancer. Thirty-seven patients with gastric cancer (preoperative stage T1-2 or N0) who underwent laparoscopic lymph node mapping and SN biopsies between March 2001 and June 2004 were enrolled in this study. The tracer, patent blue and technecium-99m-labeled tin colloid, was injected endoscopically. Blue-stained or radioactive nodes were defined as SNs. Gastrectomy with lymphadenectomy was performed then the results of the SN biopsies were compared with the final diagnosis of the removed lymph nodes in permanent sections. Sentinel nodes were successfully identified in 35 patients (94.6%), and they were positive in 3 of 4 patients with metastatic lymph nodes; sensitivity was 75% and specificity was 100%. Sentinel node status could therefore be used to diagnose lymph node status with 97.1% accuracy. Of 6 SNs with metastasis, 5 showed radioactivity, and only 2 were blue stained. In the false negative case, a radioactive SN with metastasis in the right paracardial region was missed during laparoscopic mapping. An error in laparoscopic intracorporeal detection of the radioactive node with metastasis occurred because we could not eliminate the shine-through effect. We found that during laparoscopic SN mapping there is a high risk of false negativity with SNs located in the right paracardial region. To apply laparoscopic SN mapping to early-stage gastric cancer patients, the shine-through effect must be eliminated because radiotracers are essential for this method.

痔瘻癌は難治性痔瘻の経過中に発生するまれな疾患であるが, 長期経過中に発症するため, 確定診断は遅れがちとなる. 今回, 15年以上の慢性痔瘻経過中に発症した痔瘻癌の2例につき文献的考察を含め報告する. 症例1は62歳の男性で, 痔瘻根治術後17年目に再発を来し, 外科的治療にて改善せず, 粘液分泌と疼痛を伴う腫瘤を形成し紹介となった. 同部位の生検で痔瘻癌と診断し腹会陰式直腸切断術を施行した. 術後10年の現在無再発生存中である. 症例2は49歳の男性で, 約18年の慢性痔瘻の経過があり, 肛門狭窄のためS状結腸人工肛門造設術を施行後, 当院紹介となった. 瘻孔からの生検にて痔瘻癌と診断. 腹会陰式直腸切断術を施行した. 術後6年目に腹膜播種にて死亡した. 慢性難治性痔瘻においては, 痔瘻癌も念頭におき, 定期的な画像検査や生検を行い, 早期診断に努めることが重要であると考えられた.

広範なリンパ節転移を伴う進行直腸癌においては,拡大郭清を行っても多くの場合,予後不良で手術単独の成績には限界がある.今回,鼠径リンパ節転移を伴った直腸癌に対し,術前放射線照射を含む集学的治療により良好な経過を呈した1例を経験したので,若干の文献的考察を加えて報告する. 症例は64歳,男性で右鼠径部の硬結を主訴に来院した.大腸内視鏡検査にて直腸癌と診断し, CT・MRIでは,右鼠径部と骨盤内に多数のリンパ節腫大を認めた.手術単独での治療は困難と判断し,術前補助療法として,鼠径部を照射野に含めた,高線量外照射 (5Gy×4Fr) と, pharmacokinetic modulating chemotherapy: UFT 400mg/日, 5-FU 600mg/m2/24h/週を施行後,側方リンパ節郭清を伴わない腹会陰式直腸切断術を施行した.術後Leucovorinを加えたPMCを施行し,術後3カ月目に鼠径リンパ節腫大は消失し,術後2年11カ月現在, CR継続中である.

This study sought to describe a procedure involving laparoscopically assisted total gastrectomy (LATG) with sentinel node biopsy (SNB) and to evaluate the results of the first three patients. LATG for early gastric cancer was performed with sentinel node (SN) identification using a combined patent blue-violet dye and 99mtechnetium-labeled tin colloid technique. Laparoscopically resected SNs were processed for frozen section examination by routine hematoxylin and eosin (H&E) and immunohistochemical cytokeratin (IHC-CK) stains. LATG consists of a four-surgical port technique, removal of the specimen through a small 5-cm laparotomy, and stapled Roux-en-Y esophagojejunostomy. Five patients were candidates for LATG with SNB between March 2001 and June 2003; two had open surgery because of a tumor extending the serosal surface and peritoneal dissemination, whereas in the remaining three, SNs were successfully identified and evaluated with no evidence of sentinel node (micro) metastases intraoperatively. Based on the results of SNB, three patients underwent LATG with adequate lymphadenectomy. Mean operative time and blood loss were 375 min and 219 mL, respectively. No dissected lymph nodes had evidence of metastasis by H&E and IHC-CK on permanent sections. LATG with SNB followed by adequate lymphadenectomy is technically feasible, and with its acceptable operative time and blood loss, presents an excellent therapeutic option for early gastric cancer; while SNB and subsequent frozen section analysis by H&E and IHC-CK staining is a rapid and reliable diagnostic method for intraoperative detection of SN (micro) metastasis. This combination treatment is a promising alternative to laparoscopic gastrectomy with conventional lymphadenectomy.

Groin dissection remains the treatment of choice for malignant neoplasms of the skin in the lower extremities and perineum. We sought to quantify the hospital complications after groin dissection, and to identify the patient- and procedure-related factors affecting these complications. We reviewed 20 consecutive patients who underwent a collective 25 groin dissections for malignant neoplasms of the skin between 1996 and 2002 to determine the incidence and degree of morbidity, and to analyze the clinical factors associated with morbidity. An S-shaped incision was used for the first 8 procedures, whereas a straight incision was used for the next 17. The overall incidences of complications were 24% for wound infection, 52% for skin flap problems, 32% for seromas, 40% for edema, and 4% for hemorrhage, whereas the incidences of moderate to severe complications were 16% for wound infection, 16% for skin flap problems, 12% for seromas, 4% for edema, and 4% for hemorrhage. The incidence of wound infection tended to be higher after S-shaped incisions than after straight incisions (P = 0.059), and the incidence of leg edema was significantly higher after S-shaped incisions than after straight incisions (P = 0.028). S-shaped incisions more often resulted in lymphatic collection and stagnation, with a higher incidence of wound infections and leg edema than straight incisions. Therefore, we now perform straight incisions to minimize the risk of wound infections and leg edema.

腹腔鏡補助下S状結腸切除術後に発生したトロカー挿入部Richter herniaの2例を経験した. 1例は第2病日,もう1例は第3病日にイレウス症状で発症した.いずれも右下腹部の12mmトロカー挿入部に発生した.筋膜,腹膜の縫合が不完全であったことが原因と考えられた. 8mm以上のトロカー挿入部は筋膜,腹膜を死腔が消失するように縫合することが推奨されている.トロカー挿入部ヘルニアは術後10日以内に発症する急性期型と数カ月以上経過して発症する晩期型の2型に分類可能である.急性期型は晩期型と比較してイレウスを発症することが多く,特にRichter herniaによる絞扼性イレウスを高頻度に認めるため注意が必要である.

Background/Aims: Intraoperative lymphatic mapping and sentinel node (SN) biopsy can potentially be combined with minimally invasive surgery, but there are few reports of laparoscopic lymphatic mapping for gastrointestinal cancer. We examined the feasibility and accuracy of laparoscopic lymphatic mapping in predicting lymph node status in patients with gastric cancer. Methods: Seventeen patients with gastric cancer invading the mucosal or submucosal layers (T1) underwent laparoscopic gastrectomy with lymphatic mapping between March 2001 and May 2002. The day before surgery, a technetium-99m-labelled tin colloid solution was injected endoscopically around the tumor. Immediately after the pneumoperitoneum, patent blue was injected. Gastrectomy was performed in all patients, and blue-stained or radioactive nodes were defined as SNs. Fresh SNs were immediately processed for frozen-section examination by hematoxylin-eosin (H&E) and immunohistochemical (IHC) staining. All non-SNs harvested from resected specimens were subjected to histological examination with H&E. Results: SNs were detected in all patients by combination of the two kinds of tracers. Three patients had lymph node metastases in their final examination, and SNs in these 3 were operatively diagnosed as positive by H&E or IHC staining. Lymphatic mapping and SN biopsy under laparoscopic surgery were performed with 100% accuracy. Conclusion: Our preliminary study shows the feasibility of intraoperative lymphatic mapping in laparoscopic gastrectomy for T1 gastric cancer.