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Study Design: Multicenter, prospective registry study., Objective: To clarify minimal clinically important differences (MCIDs) for surgical interventions for spinal metastases, thereby enhancing patient care by integrating quality of life assessments with clinical outcomes., Background: Despite its proven usefulness in degenerative spinal diseases and deformities, the MCID remains unexplored regarding surgery for spinal metastases., Patients and Methods: This study included 171 (out of 413) patients from the multicenter "Prospective Registration Study on Surgery for Metastatic Spinal Tumors" by the Japan Association of Spine Surgeons. These were evaluated preoperatively and at 6 months postoperatively using the Face Scale, EuroQol-5 Dimensions-5 Levels (EQ-5D-5L), including the Visual Analog Scale, and performance status. The MCIDs were calculated using an anchor-based method, classifying participants into the improved, unchanged, and deteriorated groups based on the Face Scale scores. Focusing on the improved and unchanged groups, the change in the EQ-5D-5L values from before to after treatment was analyzed, and the cutoff value with the highest sensitivity and specificity was determined as the MCID through receiver operating characteristic curve analysis. The validity of the MCIDs was evaluated using a distribution-based calculation method for patient-reported outcomes., Results: The improved, unchanged, and deteriorated groups comprised 121, 28, and 22 participants, respectively. The anchor-based MCIDs for the EQ-5D-5L index, EQ-Visual Analog Scale, and domains of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression were 0.21, 15.50, 1.50, 0.50, 0.50, 0.50, and 0.50, respectively; the corresponding distribution-based MCIDs were 0.17, 15,99, 0.77, 0.80, 0.78, 0.60, and 0.70, respectively., Conclusion: We identified MCIDs for surgical treatment of spinal metastases, providing benchmarks for future clinical research. By retrospectively examining whether the MCIDs are achieved, factors favoring their achievement and risks affecting them can be explored. This could aid in decisions on surgical candidacy and patient counseling., Level of Evidence: II., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Prospective multicenter study., Objectives: Palliative surgery is crucial for maintaining the quality of life (QOL) in patients with spinal metastases. This study aimed to compare the short-term outcomes of QOL after palliative surgery between patients with metastatic spinal tumors at different segments., Methods: We prospectively compared the data of 203 patients with spinal metastases at 2-3 consecutive segments who were divided into the following three groups: cervical, patients with cervical spine lesions; thoracic, patients with upper-middle thoracic spine lesions; and TL/L/S, patients with lesions at the thoracolumbar junction and lumbar and sacral regions. Preoperative and postoperative EuroQol 5-dimension (EQ5D) 5-level were compared., Results: All groups exhibited improvement in the Frankel grade, performance status, pain, Barthel index, EQ5D health state utility value (HSUV), and EQ5D visual analog scale (VAS) postoperatively. Although preoperative EQ5D HSUVs did not significantly differ between the groups (cervical, 0.461 ± 0.291; thoracic, 0.321 ± 0.292; and TL/L/S, 0.376 ± 0.272), the thoracic group exhibited significantly lower postoperative EQ5D HSUVs than the other two groups (cervical, 0.653 ± 0.233; thoracic, 0.513 ± 0.252; and TL/L/S, 0.624 ± 0.232). However, postoperative EQ5D VAS was not significantly different between the groups (cervical, 63.4 ± 25.8; thoracic, 54.7 ± 24.5; and TL/L/S, 61.7 ± 21.9)., Conclusions: Palliative surgery for metastatic spinal tumors provided comparable QOL improvement, irrespective of the spinal segment involved. Patients with upper and middle thoracic spinal metastases had poorer QOL outcomes than those with metastases in other segments; however, sufficient QOL improvement was achieved., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: We aimed to evaluate early and late outcomes by comparing open total arch repair and endovascular arch repair using proximal landing zone analysis in a multicentre cohort., Methods: From 2008 to 2019, patients treated surgically for aortic arch disease at six centres were included, excluding cases with type A aortic dissection, additional aortic root replacement, and extensive aortic aneurysm. In all patients and populations with proximal landing zone 0/1 (N = 144) and 2 (N = 187), early and late outcomes were compared using propensity score matching., Results: A total of 1052 patients, including 331 (31%) and 721 (69%) undergoing endovascular arch repair and open total arch repair, respectively, were enrolled. After propensity score match (endovascular arch repair, 295, open total arch repair; 566), no significant difference was observed in in-hospital mortality rate (endovascular arch repair, 6.8%, open total arch repair, 6.2%; p = 0.716). Open total arch repair was associated with a lower risk of all-cause death (log-rank test; p = 0.010, hazard ratio 1.41 [95% confidence interval: 1.17-1.71]). The incidence of aorta-related death was higher in endovascular arch repair (Gray test; p = 0.030, hazard ratio; 1.44 [95% confidence interval; 1.20-1.73]). When compared to endovascular arch repair with proximal landing zone 0/1, open total arch repair was associated with lower risks of all-cause death (log-rank test; p < 0.001, hazard ratio; 2.04 [95% confidence interval; 1.43-2.90]) and aorta-related death (Gray's test; p = 0.002, hazard ratio; 1.67 [95% confidence interval; 1.25-2.24]). There was no difference in the risk of all-cause death (log-rank test; p = 0.961, HR; 0.99 [95% confidence interval; 0.67-1.46]) and aorta-related death (Gray's test; p = 0.55, hazard ratio; 1.31 [95% confidence interval; 1.03-1.67]) between endovascular arch repair with proximal landing zone 2 and open total arch repair., Conclusions: Open total arch repair was considered the first choice based on early and late results; however, endovascular arch repair may be a useful option if the proximal landing zone is limited to zone 2., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Local recurrence is common after curative resections of rectal cancer. Surgical resection is considered a primary curative treatment option for patients with locally recurrent rectal cancer (LRRC). LRRC often requires a combined resection of other organs, especially in the case of posterior recurrence, which requires a combined resection of the sacrum, making the surgery highly invasive. Venous thromboembolism (VTE) is one of the lethal complications in the postoperative period, particularly in the field of pelvic surgery. We found no reports regarding the risks of postoperative VTE in surgery for LRRC, a typical highly invasive procedure in the field of colorectal surgery. This study aims to evaluate the risk of postoperative VTE in surgery for LRRC patients., Methods: From April 2010 to March 2022, a total of 166 patients underwent surgery for LRRC in the pelvic region at our institutions. Clinicopathological background and VTE incidence were compared retrospectively., Results: Among the 166 patients included in the study, 55 patients (33.1%) needed sacral resection. Pharmacological prophylaxis for prevention of VTE was performed in 121 patients (73.3%), and the incidence of VTE was 9.09% (5/55 patients) among those who underwent surgery for LRRC with sacral resection, while it was 1.8% (2/111 patients) in those without sacral resection. In univariate analysis, the combination with sacral resection was identified as a risk factor for VTE in surgery for LRRC (p = 0.047)., Conclusions: This study demonstrates that surgery for LRRC combined with sacral resection could be a significant risk factor for VTE., (© 2024. The Author(s).)

Objective: This study aimed to elucidate postoperative outcomes in patients with spinal metastases of prostate cancer, with a focus on patient-oriented assessments., Methods: This was a prospective multicenter registry study involving 35 centers. A total of 413 patients enrolled in the Japanese Association for Spine Surgery and Oncology Multicenter Prospective Study of Surgery for Metastatic Spinal Tumors were evaluated for inclusion. The eligible patients were followed for at least 1 year after surgery. The Frankel Classification, Eastern Cooperative Oncology Group Performance Status, visual analog scale for pain, face scale, Barthel Index, vitality index, indications for oral pain medication, and the EQ-5D-5L questionnaire were used for evaluating functional status, activities of daily living, and patient motivation., Results: Of the 413 eligible patients, 41 with primary prostate cancer were included in the study. The patient-oriented assessments indicated that the patients experienced postoperative improvements in quality of life and motivation in most items, with the improvements extending for up to 6 months. More than half of the patients with Frankel classifications B or C showed improved neurological function at 1 month after surgery, and most patients presented maintained or improved their classification at 6 months., Conclusion: Surgical intervention for spinal metastases of prostate cancer significantly improved neurological function, quality of life, and motivation of the patients. Consequently, our results support the validity of surgical intervention for improving the neurological function and overall well-being of patients with spinal metastases of prostate cancer., Competing Interests: Declaration of competing interest The Authors declare that there is no conflict of interest., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

The therapeutic benefit of recently developed mutant KRAS (mKRAS) inhibitors has been limited by the rapid onset of resistance. Here, we aimed to delineate the mechanisms underlying acquired resistance to mKRAS inhibition and identify actionable targets for overcoming this clinical challenge. Previously, we identified Syndecan-1 (SDC1) as a key effector for pancreatic cancer progression whose surface expression is driven by mKRAS. By leveraging both pancreatic and colorectal cancer models, we found that surface SDC1 expression was initially diminished upon mKRAS inhibition, but recovered in tumor cells that bypass mKRAS dependency. Functional studies showed that these tumors depended on SDC1 for survival, further establishing SDC1 as a driver for the acquired resistance to mKRAS inhibition. Mechanistically, we revealed that the YAP1-SDC1 axis was the major driving force for bypassing mKRAS dependency to sustain nutrient salvage machinery and tumor maintenance. Specifically, YAP1 activation mediated the recovery of SDC1 localization on cell surface that sustained macropinocytosis and enhanced the activation of multiple RTKs, promoting resistance to KRAS-targeted therapy. Overall, our study has provided the rationale for targeting the YAP-SDC1 axis to overcome resistance to mKRAS inhibition, thereby revealing new therapeutic opportunities for improving the clinical outcome of patients with KRAS-mutated cancers.

Background and Objectives : Proximal junctional kyphosis (PJK) and failure (PJF), the most prevalent complications following long-segment thoracolumbar fusions for adult spinal deformity (ASD), remain lacking in defined preventive measures. We studied whether one of the previously reported strategies with successful results-a prophylactic augmentation of the uppermost instrumented vertebra (UIV) and supra-adjacent vertebra to the UIV (UIV + 1) with polymethylmethacrylate (PMMA)-could also serve as a preventive measure of PJK/PJF in minimally invasive surgery (MIS). Materials and Methods : The study included 29 ASD patients who underwent a combination of minimally invasive lateral lumbar interbody fusion (MIS-LLIF) at L1-2 through L4-5, all-pedicle-screw instrumentation from the lower thoracic spine to the sacrum, S2-alar-iliac fixation, and two-level balloon-assisted PMMA vertebroplasty at the UIV and UIV + 1. Results : With a minimum 3-year follow-up, non-PJK/PJF group accounted for fifteen patients (52%), PJK for eight patients (28%), and PJF requiring surgical revision for six patients (21%). We had a total of seven patients with proximal junctional fracture, even though no patients showed implant/bone interface failure with screw pullout, probably through the effect of PMMA. In contrast to the PJK cohort, six PJF patients all had varying degrees of neurologic deficits from modified Frankel grade C to D3, which recovered to grades D3 and to grade D2 in three patients each, after a revision operation of proximal extension of instrumented fusion with or without neural decompression. None of the possible demographic and radiologic risk factors showed statistical differences between the non-PJK/PJF, PJK, and PJF groups. Conclusions : Compared with the traditional open surgical approach used in the previous studies with a positive result for the prophylactic two-level cement augmentation, the MIS procedures with substantial benefits to patients in terms of less access-related morbidity and less blood loss also provide a greater segmental stability, which, however, may have a negative effect on the development of PJK/PJF.

Background/aim: Postoperative venous thromboembolism (VTE) is a well-recognized complication that leads to morbidity and mortality. Lateral lymph node dissection (LLND) for rectal cancer is thought to potentially increase the risk of VTE due to its technical complexity. However, the relationship between LLND and VTE remains inadequately understood. The aim of this study was to elucidate the impact of LLND on the incidence of postoperative VTE., Patients and Methods: This is a retrospective analysis of patients who underwent rectal cancer resection between 2010 and 2018 to identify the risk factors associated with postoperative VTE. Patients were divided into two groups: those who underwent surgery with LLND (LLND+ group) and those who underwent surgery without LLND (LLND- group)., Results: A total of 543 patients were enrolled in this study, and 113 patients underwent surgery for rectal cancer with LLND. VTE developed in 8 patients (1.47%), with the incidence rates being 4.42% in the LLND+ group and 0.69% in the LLND- group, respectively (p=0.012). Three of 8 patients had developed severe postoperative complications, and the other two patients needed intraoperative repair of the iliac vein during LLND procedure. Multivariate analysis identified the incidence of postoperative complications and LLND as the independent risk factors of VTE., Conclusion: Patients undergoing rectal cancer surgery with LLND should be closely monitored for signs of VTE., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: The efficacy of anterior column realignment (ACR) remains relatively unclear, possibly because some safety concerns have limited its adoption and extensive evaluation. The authors aimed to study whether a minimally invasive surgery (MIS) triad consisting of ACR, lateral lumbar interbody fusion, and percutaneous pedicle screw fixation in a select group of adult spinal deformity (ASD) patients helps shorten fusion length without compromising clinical and radiographic outcomes over a minimum 2-year follow-up period., Methods: A series of 61 ASD patients (mean age 72.8 years) with pelvic incidence (PI) - lumbar lordosis (LL) (PI-LL) mismatch > 10° underwent the short-segment MIS triad (mean fusion length 3.0 levels) as a single-stage operation with a mean operative time and estimated blood loss of 157 minutes and 127 mL, respectively. Exclusion criteria were 1) thoracic scoliosis as the main deformity, 2) thoracolumbar junction kyphosis > 25°, 3) ankylosed facet joints, and 4) previous spinal fusion surgery. Seven patients, who needed fusion to be extended to S1, underwent mini-open transforaminal lumbar interbody fusion at L5-S1., Results: The segmental disc angle at the ACR level more than quintupled, averaging from 2.9° preoperatively to 18.9° at the latest follow-up (p < 0.0001). LL, in turn, nearly doubled from 17.0° to 32.8° (p < 0.0001) and PI-LL decreased by nearly half from 28.8° to 13.2° (p < 0.0001). At the same time, other spinopelvic deformity parameters as well as Oswestry Disability Index (ODI) scores significantly improved. Patients were divided into two groups at the latest postoperative evaluation: 36 patients whose PI-LL improved to < 10° and 25 patients who maintained a PI-LL mismatch > 10°. Binary logistic regression revealed preoperative PI-LL mismatch as the only factor that significantly influenced this dichotomous separation postoperatively. Receiver operating characteristic curve analysis identified the critical preoperative mismatch of 26.4° with 68% sensitivity and 84% specificity. Despite this different radiographic consequence, the two groups had an equally successful clinical outcome with no significant difference in ODI scores., Conclusions: As long as the ASD characteristics are consistent with the authors' exclusion criteria, the short-segment MIS triad served as an excellent surgical option in the patients with preoperative PI-LL mismatch < 26.4°, but the technique also worked well even in those with a mismatch > 26.4°, although ideal spinopelvic alignment targets were not necessarily achieved in these patients.

Background/aim: Locally recurrent rectal cancer (LRRC) involving the upper sacrum is generally considered a contraindication for curative surgery. In the surgical management of LRRC, sacrectomy is frequently performed to secure clear resection margins. Nonetheless, the indications for high sacrectomy remain controversial due to potential postoperative complications, questions about radicality, and the increased complexity of the operation. Furthermore, comprehensive studies addressing this issue are notably absent. This study aimed to assess the feasibility, safety, and surgical prognosis in high sacrectomy for LRRC., Patients and Methods: All patients with LRRC who required concomitant sacrectomy, but did not include the inferior margin of the second sacral vertebra, between 2003 and 2014, were reviewed retrospectively., Results: Eight patients with a median age of 59 years were included in this study. The proximal resection line for sacral bone resection was the central part of the S1 vertebra in one patient, lower edge of the S1 vertebra in six patients, and central part of the S2 vertebra in one patient. Negative margin resection was achieved in five out of the eight patients. The median operative time was 922 min, and the median operative blood loss volume was 6,370 ml. Major complications included pelvic abscess (n=5), ileus (n=1), and pulmonary vein embolism (n=1), none of which proved fatal during the postoperative period. Both the 5-year local re-recurrence-free survival rate and the 5-year distant metastasis-free survival rate were 50% (4/8)., Conclusion: High sacrectomy is safe and feasible to achieve negative margins in patients with LRRC., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: We present the surgical approaches and short-term (2 years postoperative) results pertaining to circumferential minimally invasive spine surgery (CMIS) with lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw application for adult idiopathic scoliosis (AS)., Methods: We enrolled eight patients with AS who underwent CMIS (2018-2020) and examined the number of fused levels, upper instrumented vertebra, lower instrumented vertebra, number of LLIF-treated segments, number of preoperative intervertebral fusions, intraoperative blood loss, operative time, various spinopelvic parameters, Oswestry Disability Index, low back pain, visual analog scale (VAS), leg VAS, bone fusion rate, and perioperative complications., Results: The upper instrumented vertebra was T4, T7, T8, and T9 in two cases, whereas lower instrumented vertebra was the pelvis in all the cases. The average numbers of fixed vertebrae and segments that underwent LLIF were 13.3 ± 2.0 and 4.6 ± 0.7, respectively. All spinopelvic parameters improved significantly after surgery (thoracic kyphosis: P < 0.05, lumbar lordosis, cobb angle, pelvic tilt, pelvic incidence-lumbar lordosis, sagittal vertical axis: P < 0.001), and good alignment was achieved. The Oswestry Disability Index and VAS scores improved significantly (P < 0.001). The bone fusion rates achieved in the lumbosacral and thoracic spine were 100% and 88%, respectively. Only 1 patient showed postoperative coronal imbalance., Conclusions: The 2-year postoperative results of CMIS for AS were good, and spontaneous bone fusion was confirmed in the thoracic spine without bone grafting. In this procedure, sufficient intervertebral release with LLIF and a percutaneous pedicle screw device translation technique enabled adequate global alignment correction. Therefore, correcting the global imbalance of the coronal and sagittal planes is more crucial than correcting scoliosis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This study aimed to devise measures and investigate their effect on coronal imbalance (CI) after circumferential minimally invasive correction surgery (CMIS) with lateral lumbar interbody fusion and percutaneous pedicle screw for adult spinal deformity (ASD). A total of 115 patients with ASD who underwent CMIS from the lower thoracic spine to the ilium were included. Patients were stratified based on the distance between the spinous process of the upper instrumented vertebra and central sacrum vertical line (UIV-CSVL) after the first intraoperative rod application into groups P (UIV-CSVL > 10 mm, n = 50) and G (UIV-CSVL < 10 mm, n = 65). Measures to correct postoperative CI introduced during surgery, preoperative and postoperative UIV-CSVL, and changes in UIV-CSVL after various measures (ΔUIV-CSVL) were investigated in group P. Rod rotation (RR), S2 alar-iliac screw distraction (SD), and kickstand-rod (KR) technique were performed in group P. Group P was further divided into group RR ( n = 38), group SD (RR and SD) ( n = 7), and group KR (RR and KR) ( n = 5); the ΔUIV-CSVLs were 13.9 mm, 20.1 mm, and 24.4 mm in these three groups, respectively. Postoperative C7-CSVL < 10 mm was achieved in all three correction groups. In conclusion, our measures enabled sufficient correction of the UIV-CSVL and are useful for preventing CI after CMIS for ASD.

Objective: Reconstruct compound median nerve action currents using magnetoneurography to clarify the physiological characteristics of axonal and volume currents and their relationship to potentials., Methods: The median nerves of both upper arms of five healthy individuals were investigated. The propagating magnetic field of the action potential was recorded using magnetoneurography, reconstructed into a current, and analyzed. The currents were compared with the potentials recorded from multipolar surface electrodes., Results: Reconstructed currents could be clearly visualized. Axonal currents flowed forward or backward in the axon, arcing away from the depolarization zone, turning about the subcutaneous volume conductor, and returning to the depolarization zone. The zero-crossing latency of the axonal current was approximately the same as the peak of its volume current and the negative peak of the surface electrode potential. Volume current waveforms were proportional to the derivative of axonal ones., Conclusions: Magnetoneurography allows the visualization and quantitative evaluation of action currents. The currents in axons and in volume conductors could be clearly discriminated with good quality. Their properties were consistent with previous neurophysiological findings., Significance: Magnetoneurography could be a novel tool for elucidating nerve physiology and pathophysiology., (Copyright © 2023 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Objective: The mechanism underlying the generation of P9 far-field somatosensory evoked potentials (SEPs) is unresolved. Accordingly, we used magnetoneurography to visualize the current distribution in the body at the P9 peak latency and elucidate the origin of P9 generation., Methods: We studied five healthy male volunteers without neurological abnormalities. We recorded far-field SEPs after median nerve stimulation at the wrist to identify the P9 peak latency. Using magnetoneurography, we recorded the evoked magnetic fields in the whole body under the same stimulus conditions as the SEP recording. We analyzed the reconstructed current distribution at the P9 peak latency., Results: At the P9 peak latency, we observed the reconstructed current distribution dividing the thorax into two parts, upper and lower. Anatomically, the depolarization site at the P9 peak latency was distal to the interclavicular space and at the level of the second intercostal space., Conclusions: By visualizing the current distribution, we proved that P9 peak latency originates in the change in volume conductor size between the upper and lower thorax., Significance: We clarified that magnetoneurography analysis is affected by the current distribution due to the junction potential., (Copyright © 2023 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Local recurrence is common after curative resection for rectal cancer. Although one expects radical resection of locally recurrent rectal cancer to be curative, the postoperative re-recurrence rate is relatively high. Therefore, identifying risk factors for recurrence may improve the prognosis of locally recurrent rectal cancer with early therapeutic intervention., Objective: This study aimed to evaluate the relationship between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis in locally recurrent rectal cancer to validate their usefulness for postoperative surveillance in locally recurrent rectal cancer., Design: This was a single-center retrospective cohort study., Setting: The study is based on data obtained from procedures at the Osaka University Hospital., Patients: Ninety patients underwent radical resection for locally recurrent rectal cancer between January 2000 and January 2015., Main Outcome Measures: We evaluated the correlation between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis after complete resection of locally recurrent rectal cancer and the serum CEA and carbohydrate antigen 19-9 levels at the diagnosis of postoperative re-recurrence., Results: The median preoperative serum CEA level was 4 ng/mL and carbohydrate antigen 19-9 level was 12 U/mL. Of the 90 patients, 43.3% had serum CEA ≥5 ng/mL, and 15.6% had serum carbohydrate antigen 19-9 ≥37 U/mL. Preoperatively, this serum carbohydrate antigen 19-9 level strongly correlated with poorer prognoses regarding cancer-specific survival. Postoperatively, serum CEA ≥5 ng/mL significantly correlated with a worse prognosis. At the time of diagnosis of re-recurrence after resection of locally recurrent rectal cancer, 53.2% of patients had serum CEA ≥5 ng/mL, and 23.4% of patients had serum carbohydrate antigen 19-9 ≥37 U/mL., Limitations: The study was limited by its single-center retrospective design, an insufficient sample size, and a relatively long study period., Conclusions: High serum levels of carbohydrate antigen 19-9 preoperatively and CEA postoperatively are associated with poor prognosis after locally recurrent rectal cancer. Furthermore, we found a high rate of serum CEA elevation in the diagnosis of postoperative re-recurrence. See Video Abstract at http://links.lww.com/DCR/C106 ., Importancia Clnica De Los Niveles Sricos Preoperatorios Y Posoperatorios De Cea Y Ca En Pacientes Sometidos a Reseccin Curativa De Cncer De Recto Localmente Recurrente: ANTECEDENTES:La recurrencia local es común después de la resección curativa del cáncer de recto. Aunque se espera que la resección radical del cáncer rectal localmente recurrente sea curativa, la tasa de recurrencia posoperatoria es relativamente alta. Por lo tanto, la identificación de los factores de riesgo de recurrencia puede mejorar el pronóstico del cáncer de recto localmente recurrente con una intervención terapéutica temprana.OBJETIVO:Evaluamos la relación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico en el cáncer de recto localmente recurrente para validar su utilidad para la vigilancia posoperatoria en el cáncer de recto localmente recurrente.DISEÑO:Este fue un estudio de cohorte retrospectivo de un solo centro.AJUSTE:El estudio se basa en datos obtenidos de procedimientos en el Hospital Universitario de Osaka.PACIENTES:Noventa pacientes fueron sometidos a resección radical por cáncer de recto localmente recurrente entre Enero de 2000 y Enero de 2015.PRINCIPALES MEDIDAS DE RESULTADOS:Evaluamos la correlación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico después de la resección completa del cáncer de recto localmente recurrente y los niveles séricos de CEA y CA19-9 en el diagnóstico de recurrencia posoperatoria.RESULTADOS:La mediana de los niveles séricos preoperatorios de CEA y CA19-9 fueron de 4 ng/mL y 12 U/mL, respectivamente. De los 90 pacientes, el 43,3 % tenía CEA sérico ≥5 ng/mL y el 15,6 % tenía CA19-9 sérico ≥37 U/mL. Antes de la operación, este nivel sérico de CA19-9 se correlacionó fuertemente con peores pronósticos con respecto a la supervivencia específica del cáncer. Después de la operación, el CEA sérico ≥5 ng/mL se correlacionó significativamente con un peor pronóstico. En el momento del diagnóstico de recurrencia después de la resección del cáncer de recto localmente recurrente, el 53,2 % de los pacientes tenían CEA sérico ≥5 ng/mL y el 23,4 % de los pacientes tenían CA19-9 sérico ≥37 U/mL.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro, un tamaño de muestra insuficiente y un período de estudio relativamente largo.CONCLUSIONES:Los niveles séricos altos de CA19-9 antes de la operación y de CEA después de la operación están asociados con un mal pronóstico después del cáncer de recto localmente recurrente. Además, encontramos una alta tasa de elevación del CEA sérico en el diagnóstico de recurrencia posoperatoria. Consulte el Video Resumen en http://links.lww.com/DCR/C106 . (Traducción-Dr. Yesenia Rojas-Khalil )., (Copyright © The ASCRS 2022.)

Objective: Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy., Methods: This report included the authors' first 5 patients with more than 2 years (range 27-48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors' single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4-percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS-rod fixation with patients in the prone position., Results: Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty-related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of -3.8 to -2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures., Conclusions: The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors' recent procedural modification eliminated step 3 by performing loose PPS-rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

Purpose: To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain., Methods: Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra., Results: Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05)., Conclusions: Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence., (© 2022. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Percutaneous pedicle screw (PPS) placements in the lumbosacral spine generally rely on fluoroscopy at the expense of radiation exposure. Our accumulated experience in open PS placements without fluoroscopic guidance realized a consistent shift toward PPS insertion with newly developed devices, which require neither fluoroscopy nor navigation. We wish to report our new technique and evaluations of its accuracy., Methods: Our equipment consisted of a pedicle targeting tool to identify and escort the cannulated awl to the correct starting point for cortical bone perforation and a cannulated awl-probe system with a guidewire to maintain the optimal position throughout the subsequent surgical steps. The surgeon could advance the blunt-tipped probe searching for the cancellous bone track using tactile feedback as experienced in open techniques. A 2-year period of transition from a free-hand (1169 screws in 286 patients) to the new PPS technique (1933 screws in 413 patients) allowed accuracy comparison between the two procedures using postoperative CT scans., Results: Compared with the open-group, the PPS-group showed a lower rate of fully contained intrapedicular PS placements at L1 through S1, as a whole (90.7% vs 85.4%), but not at L4 through S1 (89.9% vs 90.2%). Less-accurate PPS placements at upper than lower lumbar spines in part reflect intended pedicle perforations laterally as a trade-off for avoiding facet violation immediately above the most cephalad screw. The PPS-group also had a higher incidence of PS-related transient nerve root complications (0% vs 1.7%). These values for the PPS-group, however, fell within those previously reported for free-hand or fluoroscopy techniques., Conclusions: Our new PPS technique, although useful for eliminating the potential risk of repeated radiation exposure, fell short of reaching the accuracy of the free-hand technique. Nerve integrity monitoring with PS stimulation, which we currently use, will help further improve the technical precision., Study Design: Original Article. The study was approved by our institutional review boad (2,019,231)., Competing Interests: Declaration of competing interest The authors declare that no benefits in any form that are related directly or indirectly to the subject on this manuscript have been or will be received from a commercial party., (Copyright © 2021 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Study Design: A prospective analysis., Objective: To test if threshold-based monitoring of compound muscle action potentials (CMAPs) by stimulating the screw loaded to uninsulated extender sleeve provides a valid safety warning for percutaneous pedicle screw (PPS) placements in the lumbosacral spine., Summary of Background Data: Utility of the CMAP monitoring to PPS procedures remains controversial., Methods: A series of 202 patients underwent a total of 1664 lumbosacral PPS placements under CMAP monitoring without fluoroscopic guidance. The monitoring consisted of stimulating the PPS assembled to uninsulated extender sleeve and recording CMAPs from the vastus medialis, biceps femoris, tibialis anterior, and medial gastrocnemius. Automated steps of a threshold hunting algorithm using 0.2-ms duration pulses of increasing intensities delivered at 2/s allowed quick determination of a minimum stimulation current to evoke >100-μV amplitude CMAPs., Results: At L2 through S1 spines, postoperative CT scans identified 51 medial or inferior pedicle wall breaches of 1536 screws (3.3%) without neurologic complications. The receiver operating characteristic curve analysis determined the critical cutoff threshold value of 27 mA (74% sensitivity and 95% specificity) for predicting 35 breaches of 627 screws (5.6%) at L2 and L3, and of 17 mA (100% sensitivity and 98% specificity) for 16 of 909 (1.8%) at L4 through S1. While advancing the screw, three breaches (5.9%) showed a particularly low threshold of ≤6-mA, allowing the surgeon to immediately redirect the screw and retest the new trajectory as safe., Conclusion: Screw stimulation with threshold hunting algorithm has a distinct advantage over the time-consuming insulated pilot hole stimulation, allowing an uninterrupted flow of the surgery. The present findings have documented practical usefulness and reliability of CMAP monitoring using direct stimulation of the PPS assembled to uninsulated extender sleeve., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The anterior column realignment (ACR) procedure, which consists of sectioning the anterior longitudinal ligament/annulus and placing a hyperlordotic interbody cage, has emerged as a minimally invasive surgery (MIS) for achieving aggressive segmental lordosis enhancement to address adult spinal deformity (ASD). Although accumulated evidence has revealed indirect neural decompression after lateral lumbar interbody fusion (LLIF), whether ACR serves equally well for neural decompression remains to be proven. The current study intended to clarify this ambiguous issue., Methods: A series of 36 ASD patients with spinopelvic mismatch, defined as pelvic incidence (PI) minus lumbar lordosis (LL) > 10°, underwent a combination of ACR, LLIF, and percutaneous pedicle screw (PPS) fixation. This "MIS triad" procedure was applied over short segments with mean fusion length of 3.3 levels, and most patients underwent single-level ACR. The authors analyzed full-length standing radiographs, CT and MRI scans, and Oswestry Disability Index (ODI) scores in patients with minimum 1 year of follow-up (mean [range] 20.3 [12-39] months)., Results: Compared with the preoperative values, the radiographic and MRI measurements of the latest postoperative studies changed as follows. Segmental disc angle more than quadrupled at the ACR level and LL nearly doubled. MRI examinations at the ACR level revealed a significant (p < 0.0001) increase in the area of the dural sac that was accompanied by significant (p < 0.0001) decreases in area and thickness of the ligamentum flavum and in thickness of the disc bulge. The corresponding CT scans demonstrated significant (all p < 0.0001) increases in disc height to 280% of the preoperative value at the anterior edge, 224% at the middle edge, and 209% at the posterior edge, as well as in pedicle-to-pedicle distance to 122%. Mean ODI significantly (p < 0.0001) decreased from 46.3 to 26.0., Conclusions: The CT-based data showing vertebral column lengthening across the entire ACR segment with an increasingly greater degree anteriorly suggest that the corrective action of ACR relies on a lever mechanism, with the intact facet joints acting as the fulcrum. Whole-segment spine lengthening at the ACR level reduced the disc bulge anteriorly and the ligamentum flavum posteriorly, with eventual enlargement of the dural sac. ACR plays an important role in not only LL restoration but also stenotic spinal canal enlargement for ASD surgery.

Background: Low anterior resection syndrome (LARS) is the most common complication after rectal cancer resection. We aimed to identify LARS' predictive factors and construct and evaluate a predictive model for LARS., Methods: This retrospective study included patients with rectal cancer more than 1 year after laparoscopic or robotic-assisted surgery. We administered a questionnaire to evaluate the degree of LARS. In addition, we examined clinical characteristics with univariate and multivariate analysis to identify predictive factors for major LARS. Finally, we divided the obtained data into a learning set and a validation set. We constructed a predictive model for major LARS using the learning set and assessed the predictive accuracy of the validation set., Results: We reviewed 160 patients with rectal cancer and divided them into a learning set (n = 115) and a validation set (n = 45). Univariate and multivariate analyses in the learning set showed that male (odds ratio [OR]: 2.88, 95% confidence interval [95%CI] 1.11-8.09, p = 0.03), age < 75 years (OR: 5.87, 95%CI 1.14-47.25, p = 0.03) and tumors located < 8.5 cm from the AV (OR: 7.20, 95%CI 2.86-19.49, p < 0.01) were significantly related to major LARS. A prediction model based on the patients in the learning set was well-calibrated., Conclusions: We found that sex, age, and tumor location were independent predictors of major LARS in Japanese patients that underwent rectal cancer surgery. Our predictive model for major LARS could aid medical staff in educating and treating patients with rectal cancer before and after surgery., (© 2022. The Author(s).)

Background and Objectives : This study aimed to investigate the process and morphology of thoracic and lumbosacral bone fusion in patients with adult spinal deformity (ASD) who underwent circumferential minimally invasive spine surgery (CMIS) by lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screws (PPSs) without bone grafting in the thoracic spine and who have risk factors for bone fusion failure in the thoracic spine. Materials and Methods : This retrospective study included 61 patients with spinal deformities (46 women and 15 men) who underwent CMIS with LLIF and PPSs at our hospital after 2016 and completed a 3-year postoperative follow-up. The rate and morphology of bone fusion and rod fracture rate in the thoracic and lumbosacral vertebrae were evaluated. Patients were divided into the thoracic spine spontaneous bone fusion group and the bone fusion failure group. The data of various spinopelvic parameters and the incidence of complications were compared. The vertebral body conditions in the thoracic spine were classified as less degenerative (type N), osteophyte (type O), and diffuse idiopathic skeletal hyperostosis (DISH) (type D). Results : After three postoperative years, the bone fusion rates were 54%, 95%, and 89% for the thoracic, lumbar, and lumbosacral spine, respectively. Screw loosening in the thoracic vertebrae was significantly higher in the bone fusion failure group, while no significant differences were observed in the spinopelvic parameters, Oswestry Disability Index (ODI), and rate of proximal junctional kyphosis and rod fractures. Type N vertebral body condition and screw loosening were identified as risk factors for spontaneous bone fusion failure in the thoracic spine. Conclusion : This study indicated that spontaneous bone fusion is likely to be obtained without screw loosening, and even if bone fusion is not obtained, there is no effect on clinical results with the mid-term (3-year) results of CMIS without bone grafting in the thoracic spine.

Background and Objectives: Spinal minimally invasive surgery (MIS) experts at the university hospital worked as a team to develop a new treatment algorithm for pyogenic spondylodiscitis in lumbar and thoracic spines. They modified a flow chart introduced for this condition in a pre-MIS era to incorporate MIS techniques based on their extensive experiences accumulated over the years, both in MIS for degenerative lumbar diseases and in the treatment of spine infections. The MIS procedures incorporated in this algorithm consisted of percutaneous pedicle screw (PPS)-rod fixation and transpsoas lateral lumbar interbody fusion (LLIF). The current study analyzed a series of 34 patients treated with prospective selection of the methods according to this new algorithm. Materials and Methods: The algorithm first divided the patients into those who had escaped complicated disease conditions, such as neurologic impairment, extensive bone destruction, and the need to be mobilized without delay (Group 1) (19), and those with complicated pyogenic spondylodiscitis (Group 2) (15). Group 1 had image-guided needle biopsy followed by conservative treatment alone with antibiotics and a spinal brace (12) (Group 1-A) or a subsequent addition of non-fused PPS-rod fixation (7) (Group 1-B). Group 2 underwent an immediate single-stage MIS with non-fused PPS-rod fixation followed by posterior exposure for decompression and debridement through a small midline incision (12) (Group 2-A) or an additional LLIF procedure after an interval of 3 weeks (3) (Group 2-B). Results: All patients, except four, who either died from causes unrelated to the spondylodiscitis (2) or became lost to follow up (2), were cured of infection with normalized CRP at an average follow up of 606 days (105-1522 days). A solid interbody fusion occurred at the affected vertebrae in 15 patients (50%). Of the patients in Group 2, all but two regained a nearly normal function. Despite concerns about non-fused PPS-rod instrumentation, only seven patients (21%) required implant removal or replacement. Conclusions: Non-fused PPS-rod placements into infection-free vertebrae alone or in combination with posterior debridement through a small incision worked effectively in providing local stabilization without contamination of the metal implant from the infected tissue. MIS LLIF allowed for direct access to the infected focus for bone grafting in cases of extensive vertebral body destruction.

This retrospective study aimed to evaluate the clinical outcomes of circumferential minimally invasive surgery (CMIS) using lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw (PPS) in adult spinal deformity (ASD) patients, and to clarify the conditions for achieving postoperative pelvic incidence-lumbar lordosis (PI-LL) < 10°. Demographics and other parameters of ASD patients who underwent CMIS and who were divided into groups G (achieved postoperative PI-LL < 10°) and P (PI-LL ≥ 10°) were compared. Of the 145 included ASD patients who underwent CMIS, the average fused level, bleeding volume, operative time, and number of intervertebral discs that underwent LLIF were 10.3 ± 0.5 segments, 723 ± 375 mL, 366 ± 70 min, and 4.0 segments, respectively. The rod material was titanium alloy in all the cases. The PI-LL significantly improved from 37.3 ± 17.9° to 1.2 ± 12.2° postoperatively. Pre- and postoperative PI, postoperative LL, preoperative PI-LL, PI-LL after LLIF, and postoperative PI-LL were significantly larger in group P. PI-LL after LLIF was identified as a significant risk factor of postoperative PI-LL < 10° by logistic regression, and the cut-off value on receiver operating characteristic curve analysis was 20°. Sufficient correction was achieved by CMIS. If PI-LL after LLIF was ≤20°, it was corrected to the ideal alignment by the PPS procedure.

Background and Objectives: Clinicians are required to manage a growing number of elderly patients with several medical comorbidities, and invasive surgical treatments are sometimes not advisable for these patients. The aim of this study was to evaluate the efficacy of minimally invasive intraspinal canal treatment, trans-sacral canal plasty (TSCP), for patients with and without failed back surgery syndrome (FBSS). Materials and Methods: A multicenter analysis was conducted. TSCP was performed in patients with chronic low back pain and leg pain due to lumbar spinal disorders. An adhesiolysis by TSCP was carried out, then a mixture of steroid and local anesthesia was injected. Visual Analog Scales (VAS) for low back pain and leg pain, and complications were evaluated. Results: A total of 271 patients with a minimum 6-month follow-up were enrolled. There were 80 patients who had a history of previous lumbar spinal surgery (F group), and 191 patients without previous lumbar spinal surgery (N group). There were no significant differences in sex and age between the two groups. VAS scores for low back pain (N group/F group) preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively, were 51/52 mm, 24/26 mm, 33/34 mm, 30/36 mm, and 30/36 mm, respectively. VAS scores for leg pain were 69/67 mm, 28/27 mm, 39/41 mm, 36/43 mm, and 32/40 mm, respectively. Both VAS scores for low back pain and leg pain were significantly decreased from baseline to final follow-up in both groups ( p < 0.01). However, VAS scores for leg pain at 3 months and 6 months postoperatively were significantly higher in F group ( p < 0.05). There were three catheter breakages (2/3 in F group), and one dural tear in F group. Conclusions: TSCP significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. However, co-existence of intractable epidural adhesion might be associated with less improvement in FBSS.

We experienced a case of laparoscopic left hemicolectomy for advanced descending colon cancer in patient with idiopathic pulmonary arterial hypertension(IPAH). The patient was a 39-year-old woman. She visited her family doctor in November 201X because of bowel movement disturbance and melena. She was diagnosed as advanced descending colon cancer. Although intraoperative management for hemodynamic stability was expected to be difficult due to IPAH, hemodynamic stability was achieved under 10 mmHg pneumoperitoneum. During the operation noradrenaline and phenylephrine were used for hemodynamic management. Laparoscopic left hemicolectomy was performed safely. Postoperative histopathological findings were as follows; Type 2, tub1>tub2, pT4a(SE), pN1a(1/65), int, INF b, ly1, v1, Pn1b, pPM0, pDM0, pStage Ⅲb(the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma, 9th edition). The patient was discharged from the hospital on the 18th day after surgery without any complications except for Grade 2 diarrhea, which was considered a side effect of PGI2 preparation.

Background: Anticancer drugs generate excessive reactive oxygen species (ROS), which can cause cell death. Cancer cells can resist this oxidative stress, but the mechanism of resistance and associations with chemoresistance are unclear. Here, we focused on Sirtuin 3 (SIRT3), a deacetylating mitochondrial enzyme, in oxidative stress resistance in colorectal cancer (CRC)., Methods: To evaluate SIRT3-related changes in mitochondrial function, ROS (mtROS) induction, and apoptosis, we used the human CRC cell lines HT29 and HCT116 transfected with short-hairpin RNA targeting SIRT3 and small interfering RNAs targeting superoxide dismutase 2 mitochondrial (SOD2) and peroxisome proliferator-activated receptor γ coactivator-1 (PGC-1α). In 142 clinical specimens from patients with CRC, we also assessed the association of SIRT3 protein levels (high/low) and prognosis., Results: SIRT3 expression correlated with mtROS generation and apoptosis induction in cells treated with anticancer agents. Suppressing SIRT3 increased mtROS levels and cell sensitivity to anticancer agents. SIRT3 knockdown decreased SOD2 expression and activity, and suppressing SOD2 also improved sensitivity to anticancer drugs. In addition, SIRT3 was recruited with PGC-1α under oxidative stress, and suppressing SIRT3 decreased PGC-1α expression and mitochondrial function. PGC-1α knockdown decreased mitochondrial activity and increased apoptosis in cells treated with anticancer drugs. In resected CRC specimens, high vs low SIRT3 protein levels were associated with significantly reduced cancer-specific survival., Conclusions: SIRT3 expression affected CRC cell chemoresistance through SOD2 and PGC-1α regulation and was an independent prognostic factor in CRC. SIRT3 may be a novel target for CRC therapies and a predictive marker of sensitivity to chemotherapy.

Purpose: To examine the risk factors of proximal junctional kyphosis (PJK) after surgery for adult spinal deformity (ASD) focusing on rod contour., Methods: Sixty-three patients with ASD who underwent surgery using lateral lumbar interbody fusion and percutaneous pedicle screws were analyzed. Fixation range was from the lower thoracic spine to the pelvis in all cases. Patients were divided into two groups. The PJK group consisted of 16 patients with PJK. The non-PJK group had 47 patients without PJK. We examined various spinopelvic parameters and parameters related to rod contour., Results: Among the various spinal and pelvic parameters, those in the PJK group were significantly larger in terms of preoperative SVA and were significantly smaller in terms of postoperative "PI-LL." For parameters related to rod contour, the rod kyphotic curve at the thoracic spine in the PJK group was significantly less than that in the non-PJK group. The inclination of the pedicle screw at the upper instrumented vertebra (UIV) was significantly more cranial in the PJK group than in the non-PJK group. The kyphotic curve of the rod at the UIV was more parallel in the PJK group than in the non-PJK group. On logistic regression analysis, insufficient kyphotic curve at the thoracic spine along with UIV and overcorrection of the lumbar spine were identified as significant risk factors., Conclusions: Insufficient kyphotic curve of the rod in the thoracic spine along with UIV and overcorrection of the lumbar spine were noted as significant risk factors of PJK.

Background: Local recurrence is common after curative resections for rectal cancer. Surgical intervention is among the best treatment choices. However, achieving a negative resection margin often requires extensive pelvic organ resections; thus, the postoperative complication rate is quite high. Recent studies have reported that the inflammatory index could predict postoperative complications. This study aimed to validate the correlation between clinical factors, including inflammatory markers, and severe complications after surgery for local recurrent rectal cancer., Methods: This retrospective study included 99 patients that underwent radical resections for local recurrences of rectal cancer. Postoperative complications were graded according to the Clavien-Dindo classification. Grades ≥3 were defined as severe complications. Risk factors for severe complications were identified with univariate and multivariate logistic regression models and assessed with receiver-operating characteristic curves., Results: Severe postoperative complications occurred in 38 patients (38.4%). Analyses of correlations between inflammatory markers and severe postoperative complications revealed that the strongest correlation was found between the prognostic nutrition index and severe postoperative complications. The receiver-operating characteristic analysis showed that the optimal prognostic nutrition index cut-off value was 42.2 (sensitivity: 0.790, specificity: 0.508). In univariate and multivariate analyses, a prognostic nutrition index ≤44.2 (Odds ratio: 3.007, 95%CI:1.171-8.255, p = 0.02) and a blood loss ≥2850 mL (Odds ratio: 2.545, 95%CI: 1.044-6.367, p = 0.04) were associated with a significantly higher incidence of severe postoperative complications., Conclusions: We found that a low preoperative prognostic nutrition index and excessive intraoperative blood loss were risk factors for severe complications after surgery for local recurrent rectal cancer.

Objective: To evaluate the efficacy and safety of CAPOX plus bevacizumab as second-line chemotherapy for metastatic colorectal cancer., Methods: In this multicenter phase Ⅱ study, the planned number of patients was 48, but owing to poor case accumulation, registration was discontinued for 20 patients. The primary endpoint was the response rate(RR). Secondary endpoints were progression-free survival(PFS), overall survival(OS), disease control rate(DCR), and safety., Results: First-line treatment was combined with irinotecan in 14 cases and bevacizumab in 12 cases. The median number of second- line treatment courses was 7, and the median treatment period was 203 days. The reason for discontinuation of treatment was disease progression in 13 cases, adverse events in 4 cases, and other reasons in 3 cases. The best response was PR in 5 cases, SD in 8 cases, and NE in 4 cases. The RR was 25%, and the DCR was 65%. The median PFS was 7.2 months, and the median OS was 18.6 months. Grade≥3 adverse events were neutropenia in 3 cases and diarrhea and peripheral neuropathy in 2 cases each. There were no treatment-related deaths., Conclusion: CAPOX plus bevacizumab was a safe and effective second-line treatment option for metastatic colorectal cancer.

We retrospectively evaluated the cases of 169 hip fracture patients, their previous fractures, and the contralateral hip joint's morphology. A history of contralateral hip fracture was present in 23 patients (Contra group). The other patients had a unilateral hip fracture: a trochanteric fracture (Troch group, n=73) or a femoral neck fracture (Neck group, n=73). In the Troch and Neck groups, we used anteroposterior and cross-table axialview radiographs of the contralateral hip to evaluate the proximal femur's anatomy. In the Contra group, the concordance rate between the first and second types of hip fracture was 65.2%, and the second hip fracture's morphology indicated that the trochanteric fracture had a cam deformity in terms of the femoral head-neck ratio. The average alpha angle and femoral head-neck offset in the Troch group were significantly larger than those in the Neck group. In the Neck group, pistol-grip deformities of Arbeitsgemeinschaft für Osteosynthesefragen types B1 (subcapital), B2 (transcervical), and B3 (displaced) were observed in 42.1%, 75%, and 6% of cases, respectively. There was a smaller alpha angle and a larger femoral head-neck offset in the contralateral hip of femoral neck fractures; thus, the "cam deformity" may protect against femoral neck fractures., Competing Interests: No potential conflict of interest relevant to this article was reported.

Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

We report a surgical case of active infective prosthetic mitral valve endocarditis with cardiogenic shock. The causative organism was methicillin-resistant coagulase negative Staphylococci (MRCNS) During medical treatment, the prosthetic valve was abruptly detouched partially from the mitral annulus, and the patient developed rapid hemodynamic deterioration. We performed emergency re-do mitral valve replacement. The postoperative course was uneventful. Rapid establishment of femoro-femoral bypass was very effective for the emergency re-do valve surgery.

We report 2 cases of ruptured type B aortic dissection with thrombosed pseudolumen presenting hemodynamic deterioration which is a life-threatening condition. In such cases, surgical treatment often resulted in high mortality rates. We underwent total arch replacement via median sternotomy. In both cases, postoperative courses were uneventful. This approach ensured us wider operative field to establish cardiopulmonary bypass quickly, and to perform distal anastomosis without much difficulty.

Tricuspid valve infective endocarditis( IE) accounts for 5 to 10% of all IE. We encountered a 50-year old man who suffered from tricuspid valve IE presenting paradoxical multiple cerebral embolism with intracranial hemorrhage. On 6th day from his admission, we performed valve replacement for intractable tricuspid infective endocarditis regardless of acute phase of intracranial hemorrhage. The patient had an uneventful postoperative course with no neurological symptoms.

The number of patients undergoing combined aortic valve replacement (AVR) for aortic stenosis (AS) and coronary artery bypass grafting (CABG) has been increasing. In CABG, the internal thoracic artery (ITA) is the preferred conduit for its long-term patency. Although Doppler studies on ITA have been widely used, flow characteristics of the vessel in patients with AS have not been reported. To evaluate blood flow pattern of the ITA in AS, duplex scanning was performed in 10 patients before and after AVR. Peak systolic velocity was measured, and blood flow was calculated from mean velocity and cross-sectional area. The mean diameters of the vessels were approximately 1.8 mm on both sides. AVR caused an increase in systolic velocities from 61.2 cm/sec to 85.5 cm/sec in right ITA and from 58.4 cm/sec to 84.7 cm/sec in left ITA. The flow volumes increased from 32.2 ml/min to 46.7 ml/min in right and increased from 31.6 ml/min to 46.3 ml/min in left after AVR. In simultaneous AVR for AS and CABG, suitability of the ITA should be assessed before its use, and concomitant AVR may be quite important to provide adequate flow of the ITA as a conduit.

The flow reactivity of a left internal thoracic artery graft (LITAG) in response to atrial pacing was evaluated in 14 patients who underwent coronary artery bypass grafting (CABG) with LITAG to left anterior descending artery (LAD). Systolic peak velocity and diastolic peak velocity were recorded using a duplex scanner of 7.5 MHz, and flow volumes in each phase and flow ratio were calculated. The external temporary atrial pacing was used to increase heart rates 25 and 50%. Diastolic peak velocity and flow volume increased predominantly on both pacing rates. In contrast, systolic peak velocity decreased when heart rate was raised 50%, and there was no significant difference between the pacing modes in systolic flow volumes. As a result, flow ratio increased predominantly on both pacing rates. Based on the present studies, there may be some advantages with atrial pacing to increase the LITAG flow in response to the myocardial oxygen demand.

We reported a case of malignant lymphoma originating from the right atrium. The patient was a 71-year-old man who had no symptoms associated with heart failure and arrhythmias. At the time of admission the patient was suggested the presence of a tumor in the right atrium by an echocardiogram accidentally. Coronary angiography revealed a feeding artery to a tumor. Although cytological confirmation was not obtained, diagnostic extirpation of tumor was performed under cardiopulmonary bypass. The histological diagnosis was malignant lymphoma of B-cell origin. His postoperative course was uneventful and no recurrence had been observed one year postoperatively without chemotherapy.