Impact of fundus-first laparoscopic cholecystectomy for severe cholecystitis

BACKGROUND

The Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis.

METHODS

This study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2 years [early period group (EG)], whereas FFLC was predominantly used for the last 2 years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed.

RESULTS

The difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4 days, p < 0.001).

CONCLUSION

After the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension

INTRODUCTION

Recent reports have shown laparoscopic gastric devascularization and splenectomy (Hassab's procedure) to be a safe and effective treatment for esophagogastric varices with portal hypertension. However, the long-term postoperative results remain unclear.

METHODS

Between 2009 and 2015, 17 patients with portal hypertension and esophagogastric varices underwent laparoscopic Hassab's procedure at our institution. Two patients were lost to long-term follow-up (at least 2 years) and excluded. The remaining 15 patients' data and endoscopic findings were retrospectively reviewed.

RESULTS

The median postoperative follow-up period was 56 months. The median spleen volume, operation time, blood loss, and length of postoperative hospital stay were 651 (320-1,265) mL, 305 (275-547) minutes, 347 (24-1,131) mL, and 20 (8-41) days, respectively. According to the endoscopic findings 1 year after surgery, the esophagogastric varices disappeared in three patients and improved in 12 patients. The median platelet count was significantly higher 1 year after surgery (19.7 × 10⁴ /dL) than before surgery (5.5 × 10⁴ /dL) (P < .001) and remained stable 2 years after surgery. Two patients died of liver disease. The remaining 13 patients, with a median postoperative follow-up of 57 months, were alive without bleeding from esophagogastric varices.

CONCLUSION

Laparoscopic Hassab's procedure is a feasible treatment for esophagogastric varices with portal hypertension in terms of both short- and long-term results.

Blumgart anastomosis with polyglycolic acid felt reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: A propensity score analysis

Polyglycolic acid (PGA) felt has been used to prevent clinically relevant postoperative pancreatic fistula (CR‐POPF) after pancreaticoduodenectomy (PD). However, there has been no related research on Blumgart anastomosis. Therefore, this study aimed to investigate the practical significance of Blumgart anastomosis with our new method involving PGA felt to prevent CR‐POPF following PD. Data from 133 consecutive patients who underwent Blumgart anastomosis during PD between June 2015 and November 2021 were reviewed. We applied PGA felt to 35 of these patients starting from July 2020. Surgical outcomes were analyzed by propensity score matching. Thirty‐five (35.7%) of the 98 patients in the without‐PGA group were matched with an equal number from the with‐PGA group after adjusting for covariates. CR‐POPF was found in 17 patients (49%) in the without‐PGA group and two patients (6%) in the with‐PGA group (P < .001). The multivariate analysis results indicated that male sex, pancreatic duct size <3 mm, soft pancreatic texture, and nonuse of PGA were independently associated with CR‐POPF after PD. In conclusion, Blumgart anastomosis with our new penetrating method for PGA felt reduces the incidence of CR‐POPF after PD.

Prognostic factors for the successful conservative management of nonocclusive mesenteric ischemia

Background

The criteria for deciding upon non-operative management for nonocclusive mesenteric ischemia (NOMI) are poorly defined. The aim of this study is to determine the prognostic factors for survival in conservative treatment of NOMI.

Methods

Patients with bowel ischemia were identified by searching for “ICD-10 code K550” in the Diagnosis Procedure Combination database between June 2015 and May 2020. A total of 457 patients were extracted and their medical records, including the clinical factors, imaging findings and outcomes, were analyzed retrospectively. Diagnosis of NOMI was confirmed by the presence of specific findings in contrast-enhanced multidetector-row CT. Twenty-six patients with conservative therapy for NOMI, including four cases of explorative laparotomy or laparoscopy, were enrolled.

Results

Among the 26 cases without surgical intervention, eight patients (31%) survived to discharge. The level of albumin was significantly higher, and the levels of lactate dehydrogenase, total bilirubin, C-reactive protein, and lactate were significantly lower in the survivors than the non-survivors. Sepsis-related Organ Failure Assessment (SOFA) score was significantly lower in the survivors than the non-survivors. The most reliable predictor of survival for NOMI was SOFA score (cutoff value ≤ 3 points), which had the highest AUC value (0.899) with odds ratio of 0.075 (CI: 0.0096–0.58).

Conclusions

The SOFA score and several biological markers are promising predictors to determine a treatment plan for NOMI and to avoid unnecessary laparotomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00436-w.

Laparoscopic Hartmann's reversal combined with interval lymphadenectomy after emergency surgery for perforated colon cancer: A case report

A 55-year-old man underwent Hartmann's procedure for generalized peritonitis caused by perforation of sigmoid colon cancer, which was histologically diagnosed as tubular adenocarcinoma penetrating the muscularis propria (T3). The extent of lymph node dissection was insufficient for the advanced cancer, according to the concept of complete mesocolic excision. Two months after surgery, he underwent laparoscopic Hartmann's reversal, combined with interval lymphadenectomy. En bloc resection of the colostomy, rectal stump and associated mesentery was performed with high ligation of the inferior mesenteric artery. Subsequently, the intestinal continuity was restored by end-to-end anastomosis. The postoperative course was uneventful except for infection at the stoma site. No lymph node metastasis was found by histological examination of the resected specimen, with no evidence of cancer recurrence 8 months after the initial surgery.

Comparison of VWF-ADAMTS13 axis involvement in atrial fibrillation and sinus rhythm in patients with ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

 Previous studies have shown that von Willebrand factor (VWF) increases, and a disintegrin-like and metalloproteinase with thrombospondin type-1 motifs 13 (ADAMTS13) decreases in myocardial infarction. Few studies have examined the involvement of the VWF-ADAMTS13 axis in ST-elevation myocardial infarction (STEMI) patients with atrial fibrillation (AF).

Purpose

 Our aim was to investigate VWF-ADAMTS13 axis involvement in atrial fibrillation in STEMI. 

Methods

 The subjects of this study were participants in an observational study for investigating the difference in the pathology of thrombus retrieved from infarct-related artery between AF and sinus rhythm (SR). From June 2019 to August 2020, patients who underwent thrombus aspiration for STEMI at our hospital. Only subjects whose thrombus could be confirmed were enrolled. They were divided into two groups, the AF group, and the SR group. Serum biomarkers, including ADAMTS13 activity, and VWF were evaluated. 

Results

 34 patients with STEMI who were able to aspirate thrombus were enrolled in the study. They were divided into two groups: 6 patients with AF (AF group, mean age 72.5 years, 100% male) and 28 patients with SR (SR group, mean age 63.0 years, 100% male). ADAMTS13 activity was significantly lower in AF group than SR group (AF: 0.63 ± 0.14 vs. SR: 0.77 ± 0.13 U / mL, p = 0.037). There was no significant difference in VWF antigen between the two groups (AF: 251 ± 56 vs. SR: 204 ± 69%, p = 0.170). VWF/ADAMTS13 activity in AF group were significantly higher than in SR group.

Conclusion

 Our study suggests an association between the VWF-ADAMTS13 axis and atrial fibrillation in STEMI. Abstract Table. Comparison of serum biomarkers

Current status and future perspectives of robotic inguinal hernia repair

With more than 5500 da Vinci Surgical System (DVSS) installed worldwide, the robotic approach for general surgery, including for inguinal hernia repair, is gaining popularity in the USA. However, in many countries outside the USA, robotic surgery is performed at only a few advanced institutions; therefore, its advantages over the open or laparoscopic approaches for inguinal hernia repair are unclear. Several retrospective studies have demonstrated the safety and feasibility of robotic inguinal hernia repair, but there is still no firm evidence to support the superiority of robotic surgery for this procedure or its long-term clinical outcomes. Robotic surgery has the potential to overcome the disadvantages of conventional laparoscopic surgery through appropriate utilization of technological advantages, such as wristed instruments, tremor filtering, and high-resolution 3D images. The potential benefits of robotic inguinal hernia repair are lower rates of complications or recurrence than open and laparoscopic surgery, with less postoperative pain, and a rapid learning curve for surgeons. In this review, we summarize the current status and future prospects of robotic inguinal hernia repair and discuss the issues associated with this procedure.

Which is the best predictor of clinically relevant pancreatic fistula after pancreatectomy: drain fluid concentration or total amount of amylase?

AIM

Drain fluid amylase concentration (DFAC) has been reported as a predictor of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatectomy. However, the clinical significance of measuring the total drain fluid amylase amount (DFAA) considering the daily drainage volume of CR-POPF remains unclear.

METHODS

Data from 216 consecutive patients who underwent pancreaticoduodenectomy (PD) (n = 126) or distal pancreatectomy (DP) (n = 90) between August 2014 and November 2020 were reviewed. All drains were closed but not suctioned. DFAA was calculated by multiplying the DFAC and daily drainage fluid volume. DFAC and DFAA were recorded on d 1 and 3 after pancreatectomy. The cutoff value of CR-POPF was determined using the receiver operating characteristic curve.

RESULTS

CR-POPF was found in 75 patients (35%) (PD: 30%, DP: 41%, P = .111); the mortality rate was zero. The cutoff value of DFAC-day 1 was 1757 U/L (sensitivity [SE]: 84%, specificity [SP]: 62%, and accuracy [AC]: 69%). The cutoff value of DFAA-day 1 was 139 U (SE: 71%, SP: 72%, and AC: 71%). The cutoff value of DFAC-day 3 was 1044 U/L (SE: 73%, SP: 79%, and AC: 78%). The cutoff value of DFAA-day 3 was 21 U (SE: 68%, SP: 72%, and AC: 70%). Multivariate analysis indicated that a nondilated pancreatic duct and high DFAC-day 3 were independently associated with CR-POPF after PD, indicating that a prolonged operative duration, massive blood loss, and high DFAC-day 3 are independently associated with CR-POPF after DP.

CONCLUSION

DFAC is more reliable than DFAA for predicting CR-POPF after both PD and DP.

Risk factors for thrombocytopenia and analysis of time to platelet transfusion after azacitidine treatment

The use of azacitidine (AZA) has been known to lead to a high incidence of hematotoxic adverse events. The aims of this study were to identify the risk factors for thrombocytopenia after the administration of AZA and to analyze time to the initial platelet transfusion. Sixty-two patients with myelodysplastic syndrome (MDS), who were treated with AZA in Gifu Municipal Hospital between March 2012 and June 2020, were included in this study. The risk factors for thrombocytopenia were identified using univariate analysis of patient characteristics, disease type, and laboratory values immediately before the start of treatment. Variables with p<0.2 identified in the univariate analysis were used as independent variables in the multivariate analysis. This analysis identified "creatinine clearance (CCr) <60 mL/min" as a significant factor (odds ratio, 4.790; 95% confidence interval [CI], 1.380-16.70; p=0.014). Subsequently, time in days to the initial platelet transfusion after the initial administration of AZA was analyzed using the log-rank test. The overall median time in days to platelet transfusion was 370 days. The log-rank test was used to determine the influence of patient characteristics, disease type, and laboratory values immediately before the start of treatment. The subsequent Cox proportional hazard regression analysis using variables with p<0.2 as independent variables identified "hemoglobin (Hb) <8.0 g/dL" as a significant factor (hazard ratio, 2.143; 95% CI, 1.001-4.573; p=0.048). The results of this study led to the following clinical implications: first, patients with CCr of <60 mL/min at the start of treatment should be treated with caution due to the risk of thrombocytopenia. Second, patients with Hb of <8.0 g/dL at the start of treatment may require platelet transfusion in the early stage of treatment.

Correlation of foetal body weight by coronet width measurement using ultrasonography in prepartum cows: a pilot study

This study aimed to clarify the effectiveness of foetal body weight estimation by measuring foetal coronet width using transrectal ultrasonography in beef cows during near-term pregnancy. A characteristic 'gull wing' pattern was obtained from the foetal coronet cross-section from the dewclaw side using ultrasonography. This pattern was matched to the bone surface of the distal part of the middle phalanx. Then, the relationship between coronet width and body weight at birth of 22 Japanese Brown calves was analysed and a high correlation coefficient of 0.8965 (P < 0.001) was obtained. In conclusion, the coronet width of the fetus is depicted as a 'gull wing' hyperechoic structure and can be measured by ultrasonography per rectum during near-term pregnancy. This technique may be a useful tool to identify high-risk cows with dystocia before calving. High foetal coronet values may predispose cattle to dystocia.

Deexcitation Dynamics of Muonic Atoms Revealed by High-Precision Spectroscopy of Electronic K X Rays

We observed electronic K x rays emitted from muonic iron atoms using superconducting transition-edge sensor microcalorimeters. The energy resolution of 5.2 eV in FWHM allowed us to observe the asymmetric broad profile of the electronic characteristic Kα and Kβ x rays together with the hypersatellite K^{h}α x rays around 6 keV. This signature reflects the time-dependent screening of the nuclear charge by the negative muon and the L-shell electrons, accompanied by electron side feeding. Assisted by a simulation, these data clearly reveal the electronic K- and L-shell hole production and their temporal evolution on the 10-20 fs scale during the muon cascade process.

A case of resected hepatocellular carcinoma with gallbladder metastasis

Background

Advanced hepatocellular carcinoma (HCC) can often spread as intrahepatic metastases. Extrahepatic metastasis (e.g., lung, lymph nodes, and bones) is rare, and gallbladder metastasis from HCC is extremely rare.

Case presentation

A 66-year-old woman who presented with right hypochondrial pain was referred to our hospital for further examination of a liver tumor. The blood chemistry data showed elevated levels of serum α-fetoprotein (AFP) (3730 ng/mL), protein induced by vitamin K absence or antagonist II (PIVKA-II) (130 mAU/mL), and carcinoembryonic antigen (CEA) (358.6 ng/mL). Hepatitis B surface antigen and hepatitis C virus antibody were negative. Dynamic computed tomography (CT) showed a tumor measuring 12 × 7 cm in the right lobe of the liver. This tumor was contrast-enhanced in the hepatic arterial phase and then became less dense than the liver parenchyma in the portal phase. A well-enhanced tumor was found in the gallbladder. No regional lymph nodes were enlarged. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated that the liver tumor showed a pattern of early enhancement and washout. The gallbladder tumor was also detected as an enhanced mass. Endoscopic retrograde cholangiography (ERC) showed compression of the left hepatic duct due to the liver tumor. The patient was diagnosed with simultaneous HCC and gallbladder cancer. Right hepatic trisectionectomy and caudate lobectomy with extrahepatic bile duct resection were performed. Histopathological examination of the resected liver specimen showed a poorly differentiated HCC cell component with a trabecular and solid growth, and diffuse invasion of the portal vein. The same tumor cells were found in the gallbladder, but no continuity with the liver tumor was identified. Immunohistochemistry of the liver tumor and gallbladder was positive for AFP, Glypican 3, and CK7, and negative for CK19. The final pathological diagnosis was the gallbladder metastasis from HCC. A follow-up diagnostic image 33 months after surgery showed a mass in the upper lobe of the left lung. The patient underwent left upper lobectomy. Postoperative pathology revealed that the lung lesion was a metastasis of HCC. The patient was still alive with lung metastasis and was being treated with a molecular-targeting drug in good health 42 months after the initial surgery.

Conclusions

The standard treatment for advanced HCC with extrahepatic metastases is molecularly targeted drugs, but surgery is also an option if the lesion can be resected en bloc without remnants.

Effects of polypharmacy on the prevalence of adverse drug events resulting in outpatient visits and hospitalization

A high proportion of hospitalizations is attributable to the prevalence of adverse drug events. This retrospective study included outpatients and inpatients to determine the prevalence of adverse drug events and if polypharmacy increases it. The prevalence, classification, and causality of adverse drug events were assessed based on medical records, laboratory values, and other data. Multivariate analysis (multiple logistic regression analysis) was performed with the presence or absence of adverse drug events at the time of the visit as the dependent variable and items for which the P-value was <0.25 in the univariate analysis as independent variables. The prevalence of adverse drug events was 13.0%, 10.9%, and 16.0% among all patients, the outpatient group, and the inpatient group, respectively. Multivariate analysis showed that polypharmacy (≥5 drugs) significantly increased the risk of adverse drug events in all patients. The prevalence of adverse drug events significantly increased with each additional drug used. We expect that minimizing the number of medications through moderation of the number of prescription drugs and elimination of polypharmacy will reduce the number of outpatient visits and hospitalizations due to adverse drug events.

Calcium bilirubinate sludge causes early onset of congenital biliary dilatation: a report of two cases

Background

Symptomatic congenital biliary dilatation (CBD) during early infancy is always characterized by cystic dilation of the common bile duct with a narrow segment connecting the pancreatic duct.

Case presentation

In two consecutive infants with a prenatal diagnosis of CBD, we found that biliary sludge had formed in the cyst upon the appearance of symptoms including acholic stool and hypertransaminasemia. Infrared absorption spectrometry revealed that the sludge consisted of calcium bilirubinate.

Conclusion

We suggest that overproduction of bilirubin by neonatal hemolysis causes sedimentation of bilirubin calcium, resulting in obstruction of the narrow segment and development of symptoms.

Ruptured intra-abdominal testicular seminoma with hemorrhage shock, after inadequate surgical exploration for undescended testis: a case report

BACKGROUND

Undescended testes are associated with an increased risk of malignancy and infertility, and surgical treatment in childhood is recommended.

CASE PRESENTATION

A 35-year-old man presented to the emergency department with abdominal pain and vomiting. Despite a history of surgery for a left undescended testis in infancy, his left-sided scrotum appeared underdeveloped. Contrast-enhanced computed tomography showed a pelvic mass, involving a major axis of approximately 15 cm, with high-density ascites suggestive of hemorrhage. A ruptured gastrointestinal stromal tumor was suspected. As he was in hemorrhagic shock, an emergency laparotomy was indicated. The active bleeding mass was controlled through complete resection. A pathological evaluation of the mass revealed a seminoma arising from an undescended testis. His post-operative course was uneventful, and he was discharged on post-operative day 6. Recurrence on the retroperitoneal lymph nodes was detected 1 year postoperatively, and a retroperitoneal lymph node dissection was performed after chemotherapy. He remains well without any apparent signs of recurrence.

CONCLUSIONS

Paying close attention to an empty scrotum is advisable, even postoperatively, for undescended testis because of possible subsequent potential malignancy presenting with hemorrhage, as our patient demonstrated.

Preoperative Controlling Nutritional Status plus Tumor Burden Score for the Assessment of Prognosis after Curative Liver Resection for Hepatocellular Carcinoma

OBJECTIVE

There are no previous studies analyzing the prognostic predictive value of adding the tumor factor (i.e., Tumor Burden (TB) score) to the Controlling Nutritional Status (CONUT) score for patients with hepatocellular carcinoma (HCC). This study aimed to investigate the value of the CONUT plus TB (CONUT-TB) score as a prognostic predictor in patients with HCC undergoing liver resection.

METHODS

Between 2015 and 2018, 96 consecutive patients with HCC underwent liver resection at our institution. Patients undergoing repeated liver resection and combined resection of a metastatic lesion were excluded. Patients were divided into 2 groups according to their CONUT-TB scores according to a cutoff value. Clinicopathologic prognostic factors for survival were analyzed using a database containing the medical records.

RESULTS

The optimal cutoff value of the CONUT-TB score determined by using a minimum p value approach was 13 points. Among the 81 patients included in the analytic cohort, 71 patients had low (<13) and 10 patients had high (>13) CONUT-TB scores. The overall 3-year survival rate of patients following liver resection for HCC in the high-CONUT-TB group was significantly worse than that of patients in the low-CONUT-TB group (62.5 vs. 89.3%, p = 0.003). Multivariate analysis indicated that a high CONUT-TB score was independently associated with overall survival after liver resection (p = 0.010).

CONCLUSION

The CONUT-TB score is a valuable predictor of survival in patients with HCC after liver resection.

A novel Killian-Jamieson diverticulectomy using a thyroid gland flap: a case report

Background

A Killian–Jamieson diverticulum is a rare pharyngoesophageal diverticulum that is radically treated by diverticulectomy. However, there is no consensus on whether cricopharyngeal myotomy is necessary, and the optimal surgical methods that prevent postoperative complications such as leakage are undetermined.

Case presentation

A 49-year-old man was referred to our hospital with oropharyngeal dysphagia while eating. The patient was preoperatively diagnosed with a Killian–Jamieson diverticulum based on radiographic and clinical findings and underwent a transcervical diverticulectomy. The recurrent laryngeal nerves were preserved using an intraoperative nerve monitoring system, and the diverticulum was identified without difficulty. A partial cricopharyngeal myotomy was performed to expose the base of the diverticulum. The diverticulum was transected transversally using a linear stapler under the guidance of intraoperative upper intestinal endoscopy. A thyroid gland flap supplied by the superior thyroid artery was harvested and placed overlapping the area of the partial cricopharyngeal myotomy. Due to the proximity of the recurrent laryngeal nerve course to the diverticulum stump, the staple line was not buried with sutures. The thyroid gland flap with its rich vascular supply was fixed to completely cover the staple line on the cut surface of the thyroid gland. The postoperative course was uneventful, without vocal cord paralysis. The patient was discharged on postoperative day 8. He developed no clinical signs suggesting leakage, recurrence, or adverse events.

Conclusion

Killian–Jamieson diverticulectomy using a thyroid gland flap and partial cricopharyngeal myotomy is a valid treatment option that may prevent complications and recurrence. Precise evaluation of the diverticulum using an intraoperative nerve monitoring system is crucial for the repair.

European Society for Clinical Nutrition and Metabolism (ESPEN) Malnutrition Criteria for Predicting Major Complications After Hepatectomy and Pancreatectomy

BACKGROUND

Recently, diagnostic criteria for malnutrition have been proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN). This study aimed to investigate the utility of the ESPEN malnutrition criteria as a predictor for major complications following hepatectomy and pancreatectomy.

METHODS

Data were reviewed from 176 consecutive patients who underwent hepatectomy (n = 103) or pancreatectomy (n = 73) between November 2017 and December 2019. Patients were divided into two groups according to the ESPEN malnutrition criteria using a prospectively collected database. The clinical data and the surgical outcomes of patients in the malnourished and normal groups were retrospectively analyzed.

RESULTS

Thirty-five (20%) patients were diagnosed with malnourishment according to ESPEN criteria. The malnourished group had a significantly low preoperative albumin concentration (p = 0.001). After hepatectomy, major complications (Clavien grade ≥ 3a) occurred significantly more frequently in the malnourished group than in the normal group (p = 0.013). Multivariate analysis indicated that operative duration ≥ 300 min (hazard ratio: 22.47, 95% CI: 2.17 to 232.73, p = 0.009) and malnourishment (hazard ratio: 14.56, 95% CI: 2.58 to 82.17, p = 0.002) were independently associated with major complications after hepatectomy. On the other hand, malnutrition was not associated with major complications after pancreatectomy.

CONCLUSIONS

The ESPEN malnutrition criteria are a valuable predictor for major complications following hepatectomy.

Genetic parameters for conception rate and milk production traits within and across Holstein herds with different housing types and feeding systems during the first 3 lactations

The housing types (HST) in which dairy cows are kept and the feeding systems (FDS) used differ among farmers in Japan. Here, we investigated the genetic relationships among conception rate at first insemination (CR) and milk production traits (PROD) during the first 3 lactations of Holstein cows by using a multiple-trait model that considered the trait values of herds with different HST [tiestall (TSL) barn, freestall (FS) barn, or grazing (GZ)] and FDS as separate traits. Milk production and conception records of Holstein cows in the Hokkaido region of Japan (283,611 records for first lactation, 253,902 for second, and 181,197 for third) were analyzed. We categorized herds with TSL or FS into 2 types of FDS for cows: separate feeding (SF) of roughage plus concentrate or feeding of total mixed ration, in which roughage and concentrates were mixed before feeding. The PROD analyzed were cumulative milk, fat, and protein yields within 305 d and lactation persistency, which we defined as the difference between milk yields at 240 and 60 d in milk. We estimated the heritabilities for CR or PROD within each HST or HST × FDS group and the genetic correlations between these traits within each group or across different groups within each lactation by using a 3-HST (TSL, FS, and GZ) × 2-trait (CR and each PROD) or 2-HST (TSL and FS) × 2-FDS × 2-trait animal model. Heritability estimates for CR in GZ were higher than those in TSL or FS, and genetic correlations for CR between GZ and TSL or FS barns were weaker than those between TSL and FS barns. In addition, genetic correlations between CR and PROD in GZ were weaker than those in TSL and FS barns. In the comparison among the 4 HST × FDS except GZ, heritability estimates for CR in FS × SF were higher than those in the others, and genetic correlations for CR between FS × SF and the other systems were relatively weak. These results indicated that differences in the production system for Holstein cows influence genotypic effects in terms of the cows' ability to conceive and the genetic relationships between fertility traits and milk production traits.

Preliminary results of robotic inguinal hernia repair following its introduction in a single-center trial

AIM

Robotic surgery using the da Vinci system has markedly increased worldwide. However, robotic inguinal hernia repair remains unpopular outside the United States. We introduced and evaluated a robotic transabdominal preperitoneal repair (R-TAPP) technique for inguinal hernia in our hospital.

METHODS

First, we designed a task protocol according to the surgical results of 388 laparoscopic TAPP (L-TAPP) procedures performed during the 4 years prior to introducing R-TAPP. Our task protocol included several time limitations during a step-wise procedure: creating the peritoneal flap (<60 minutes), mesh placement with fixation (<30 minutes), and peritoneal suture closure (<30 minutes) under experienced supervision. We investigated the preliminary clinical results of R-TAPP performed by a single operator between December 2018 and January 2020.

RESULTS

We identified 27 lesions in 20 patients (unilateral in 13 and bilateral in seven). According to the Japan Hernia Society Classification, our cohort included eight type I, five type II, and seven bilateral hernias (nine type I, four type II, and one type IV). The median operation time was 124 minutes (range, 81-164 minutes), and the median console operation time was 85 minutes (range, 50-132). The median time required for the peritoneal incision was 30 minutes (range, 18-54 minutes), that for mesh placement (including tucking) was 13 minutes (range, 7-27 minutes), and that for peritoneal suturing was 9 minutes (range, 3-20 minutes).

CONCLUSION

Our preliminary results suggest that our task protocol for R-TAPP is feasible. However, refinement of our task protocol is essential for standardization.

A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy

BACKGROUND

Based on the spatial relationship of an aberrant right hepatic duct (ARHD) with the cystic duct and gallbladder neck, we propose a practical classification to evaluate the specific form predisposing to injury in laparoscopic cholecystectomy (LC).

METHODS

We retrospectively investigated the preoperative images (mostly magnetic resonance cholangiopancreatography) and clinical outcomes of 721 consecutive patients who underwent LC at our institute from 2015 to 2018. We defined the high-risk ARHD as follows: Type A: communicating with the cystic duct and Type B: running along the gallbladder neck or adjacent to the infundibulum (the minimal distance from the ARHD < 5 mm), regardless of the confluence pattern in the biliary tree. Other ARHDs were considered to be of low risk.

RESULTS

A high-risk ARHD was identified in 16 cases (2.2%): four (0.6%) with Type A anatomy and 12 (1.7%) with Type B. The remaining ARHD cases (n = 34, 4.7%) were categorized as low risk. There were no significant differences in the operative outcomes (operative time, blood loss, hospital stay) between the high- and low- risk groups. Subtotal cholecystectomy was applied in four cases (25%) in the high-risk group, a significantly higher percentage than the low-risk group (n = 1, 2.9%). In all patients with high-risk ARHD, LC was completed safely without bile duct injury or conversion to laparotomy.

CONCLUSIONS

Our simple classification of high-risk ARHD can highlight the variants located close to the dissecting site to achieve a critical view of safety and may contribute to avoiding inadvertent damage of an ARHD in LC.

Outcome of maintenance systemic chemotherapy with drug-free interval for metastatic urothelial carcinoma

OBJECTIVE

Aiming to achieve long-term disease control, maintenance systemic chemotherapy (MSC) with a 1-3-month drug-free interval is continued in selected patients. We report our experience of MSC for metastatic urothelial carcinoma (UC).

METHODS

Of 228 metastatic UC patients treated with systemic chemotherapy, 40 (17.5%, 40/228) had continuously undergone MSC. Data on the regimen, cycle number, and reason for the discontinuation of MSC were also collected. We analyzed OS from the initiation of MSC until death or the last follow-up, using the log-rank test to assess the significance of differences.

RESULTS

The median number of cycles of chemotherapy was 6, and the responses were CR in 6, PR in 20, SD in 13, and PD in 1 before MSC. Gemcitabine plus CDDP or carboplatin was mainly performed as MSC (70%, 28/40). MSC was repeated quarterly in 30 (75%, 30/40), every two months in 8 (20%, 8/40), and with other intervals in 2 (5%, 2/40). Overall, a median of 3.5 cycles (range: 1-29) of MSC was performed. The reason for the discontinuation of MSC was PD in 24 (60%, 24/40), favorable disease control in 9 (22.5%, 9/40), and myelosuppression in 3 (7.5%, 3/40), and for other reasons in 2 (5%, 2/40). MSC was ongoing in 2 (5%, 2/40). The median OS was 27 months from the initiation of MSC. PS0 (P = 0.0169), the absence of lung metastasis (P = 0.0387), and resection of the primary site (P = 0.0495) were associated with long-term survival after MSC.

CONCLUSIONS

In selected patients, long-term systemic chemotherapy could be performed with a drug-free interval. Our maintenance strategy with cytotoxic drugs may become one of the treatment options for long-term disease control.

Nutritional factors affecting length of hospital stay in patients undergoing cardiovascular surgery

Cardiovascular surgery is a highly invasive intervention that is often performed in elderly patients at risks of complications because of malnutrition and reduced immunity. This study investigated nutritional factors that affected length of hospital stay in patients undergoing cardiovascular surgery. Among 68 patients who underwent surgery at the Department of Cardiovascular Surgery of Gifu Municipal Hospital between April 2013 and March 2015, 55 with complete data were included in the analysis. Data on serum albumin (ALB), transferrin (Tf), pre-albumin (PA) and retinol binding protein (RBP) levels were collected. The median length of hospital stay was 29 days (stays of ≥30 days were considered long-term hospitalization). Multivariate analysis (multiple logistic regression) included age (≥ 65 years), sex (female), and ALB (≤ 3.0 g/dL), Tf (≤ 150.0 mg/dL), PA (≤ 10.0 mg/dL) and RBP (≤ 1.5 mg/dL) levels. ALB [odds ratio (OR) 10.37, 95% CI (confidence interval): 1.185-90.80, P = 0.035] and Tf [OR 4.743, 95% CI: 1.375-16.36, P = 0.014] were significantly associated with length of hospital stay. Nutritional management of patients and careful monitoring of ALB and Tf levels can shorten length of hospital stay in patients undergoing cardiovascular surgery.

Cost utility analysis of pharmacist counseling care for breast cancer chemotherapy outpatients

Chemotherapy for cancer is increasingly implemented in the outpatient setting. Pharmacists contribute to cancer treatment by conducting counseling during outpatient chemotherapy visits. They provide guidance on drug treatment, side effects, and side effect countermeasures on every visit. However, there have been few economic evaluations of pharmacist involvement in outpatient chemotherapy. Therefore, we performed a cost utility analysis. We assigned usual care (control) and pharmacist counseling to two groups of 19 patients receiving outpatient chemotherapy for breast cancer at Gifu Municipal hospital. Quality of life was measured at three timepoints before and during chemotherapy treatment using the EuroQol 5 dimension instrument (EQ-5D). EQ-5D values across the timepoints were 0.831, 0.757, and 0.791 for the control group, and 0.882, 0.883, and 0.921 for the pharmacist counseling group. The additional cost in the pharmacist counseling group was 2,227 yen per counseling session. The change in quality-adjusted life years (QALY) was a maximum of -0.021±0.186 in the control group and 0.007±0.199 in the pharmacist counseling group. The maximum cost for one QALY was 1,360,558 yen (≈12,460 US dollars). Pharmacists' counseling in outpatient cancer chemotherapy for breast cancer patients had an acceptable incremental cost-effect ratio, contributing to improved patient quality of life without significant additional expenditure to healthcare.

The surface composition of asteroid 162173 Ryugu from Hayabusa2 near-infrared spectroscopy

The near-Earth asteroid 162173 Ryugu, the target of the Hayabusa2 sample-return mission, is thought to be a primitive carbonaceous object. We report reflectance spectra of Ryugu's surface acquired with the Near-Infrared Spectrometer (NIRS3) on Hayabusa2, to provide direct measurements of the surface composition and geological context for the returned samples. A weak, narrow absorption feature centered at 2.72 micrometers was detected across the entire observed surface, indicating that hydroxyl (OH)-bearing minerals are ubiquitous there. The intensity of the OH feature and low albedo are similar to thermally and/or shock-metamorphosed carbonaceous chondrite meteorites. There are few variations in the OH-band position, which is consistent with Ryugu being a compositionally homogeneous rubble-pile object generated from impact fragments of an undifferentiated aqueously altered parent body.

Factors influencing the use of over-the-counter drugs and health foods/supplements

Over-the-counter (OTC) drugs and health foods/supplements are used as means of self-medication with the aim of preventing diseases and maintaining health. No reports have yet addressed the relationship between healthcare systems and self-medication. Here, we carried out a retrospective survey to identify healthcare system factors affecting OTC drug and health food/supplement usage. Patients hospitalized at Gifu Municipal Hospital between October 1, 2014 and March 31, 2015 were given a survey. The items surveyed were age, gender, disease, alcohol intake/smoking status, insurance classification, and medical pharmaceuticals, OTC drugs, and health foods/supplements used immediately before hospitalization. We performed multiple logistic regression analysis using OTC drugs and health foods/supplements as dependent variables with patient attributes, medical insurance, etc. as independent variables. A total of 5,965 patients were analyzed. OTC users comprised 2.6 % (156 people) of the total. The use of OTC drugs was significantly higher for females and alcohol consumers than in other categories. In contrast, the use of OTC drugs was significantly lower for participants in public expense/medical subsidy programs. Health foods/supplements were used by 4.0 % of all subjects (240 people); their use was significantly higher among females and users of medical pharmaceuticals. On the other hand, the use of health foods/supplements was significantly lower for smokers, users of the latter-stage elderly healthcare system, and users of public expense/medical subsidy programs.

Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSC) has been recognized as an alternative to conversion to laparotomy for severe cholecystitis. However, it may be associated with an increased risk of recurrent stones in the gallbladder remnant. The objective of this study was to evaluate the safety and feasibility of the complete removal of the gallbladder cavity in LSC for severe cholecystitis using the cystic duct orifice suturing (CDOS) technique.

METHODS

In a consecutive series of 412 laparoscopic cholecystectomies that were performed from January 2015 to June 2017, 12 patients who underwent LSC with CDOS were enrolled in this retrospective study. In this procedure, Hartmann's pouch was carefully identified, and the infundibulum-cystic duct junction was transected while the posterior wall adherent to Calot's triangle was left behind. The clinical records, including the operative records and outcomes, were analyzed.

RESULTS

The median operating time and blood loss were 158 min and 20 mL, respectively. In all cases, LSC with CDOS was completed without conversion to open surgery. No injuries to the bile duct or vessels were experienced. The median postoperative hospital stay was 6 days. Postoperative complications occurred in two patients (bile leakage, n = 1: common bile duct stones, n = 1) and were successfully treated by endoscopic management. A gallbladder remnant was not delineated by postoperative imaging in any of the cases.

CONCLUSION

These results suggest that LSC with CDOS is a promising approach that can avoid dissection of Calot's triangle and achieve the complete removal of the gallbladder cavity in patients with severe cholecystitis.

Association of interservice interval with conception rate in Japanese Black cattle

This study aimed to clarify the association of interservice interval (ISI) with conception rate (CR) and to evaluate factors affecting ISI in Japanese Black cattle. Data used in this study covered 32,639 artificial insemination (AI) records on 972 farms. The mean ± SEM of ISI and CR was 57.0 ± 0.3 days and 44.6 ± 0.3%, respectively. The relative frequency of ISI differed significantly between parity groups (p < .05). For parity 0, the proportion of ISI at an 18- to 24-day interval was 43.6%, whereas the proportions in the other parity groups ranged from 27.2% to 29.1%. The CR was associated significantly with ISI, parity and AI number (p < .05), but not with season. Cows reinseminated at an 18- to 24-day interval had the highest CR (46.8%; p < .05). Cows reinseminated at a 39- to 45-day interval had a similar CR to those reinseminated at 25- 38-day and 46- to 59-day intervals. Cows reinseminated at 11-17, 60-66 and 67 days or longer intervals had the lowest CR (p < .05). Thus, cows returning to oestrus in a normal cycle tended to have a higher probability of conceiving compared with those that returned to oestrus after a normal cycle for any degree of parity and at any number of AI.

Characterization of anti-Müllerian hormone in a case of bovine male pseudohermaphroditism

The current report aimed to characterize plasma anti-Müllerian hormone (AMH) in bovine male pseudohermaphroditism. The blood AMH concentration in a Japanese Black male pseudohermaphrodite calf was compared with pre- and post-pubertal male and female calves and castrated calves. The concentration in the case was higher than in post-pubertal males, castrated males, and pre- and post-pubertal female calves (p < .05), but similar to that in pre-pubertal male calves. After extraction of the testes, the concentration in the case dropped to a certain extent. The extracted testes expressed AMH, as detected by immunohistochemistry. This study is the first to show the characterization of AMH in a male pseudohermaphrodite calf. AMH levels in peripheral blood might be useful to diagnose male pseudohermaphroditism in cattle.

Impact of body mass index and metabolic phenotypes on coronary artery disease according to glucose tolerance status

OBJECTIVE

This study aimed to examine the impact of obesity, as defined by body mass index (BMI), and a metabolically unhealthy phenotype on the development of coronary artery disease (CAD) according to glucose tolerance status.

METHODS

. Metabolically unhealthy individuals were defined as those with one or more of the following conditions: hypertension, hypertriglyceridaemia and/or low HDL cholesterol. A Cox proportional hazards regression model identified variables related to CAD incidence.

RESULTS

The prevalences of obese subjects with normal glucose tolerance, prediabetes and diabetes were 21%, 34% and 53%, whereas those for metabolically unhealthy people were 43%, 60% and 79%, respectively. Multivariate analysis showed that a metabolically unhealthy phenotype increases hazard ratios (HRs) for CAD compared with a metabolically healthy phenotype, regardless of glucose tolerance status (normal glucose tolerance: 1.98, 95% CI: 1.32-2.95; prediabetes: 2.91, 95% CI: 1.85-4.55; diabetes: 1.90, 95% CI: 1.18-3.06). HRs for CAD among metabolically unhealthy non-obese diabetes patients and obese diabetes patients with a metabolically unhealthy status were 6.14 (95% CI: 3.94-9.56) and 7.86 (95% CI: 5.21-11.9), respectively, compared with non-obese subjects with normal glucose tolerance and without a metabolically unhealthy status.

CONCLUSION

A metabolically unhealthy state can associate with CAD independently of obesity across all glucose tolerance stages. Clinicians may need to consider those with at least one or more conditions indicating a metabolically unhealthy state as being at high risk for CAD regardless of glucose tolerance status.

Effects of service number on conception rate in Japanese Black cattle

The conception rate (CR) of Japanese Black cattle has been decreasing since 1990. The objectives of this study were to compare CR by artificial insemination (AI) number, and to assess the interaction between AI number and possible factors related to CR in Japanese Black cattle. Records of 11,182 AI records for 6,741 heifers and 61,302 AI records for 13,139 cows on 977 farms were analysed. The average CR of heifers was 47.0%, and CR at the first, second and third AI was higher than at the fourth or subsequent AI (p < 0.05). The average CR of cows was 47.8%, and their CR at first and second AI was higher than the fourth or subsequent AI (p < 0.05). Data analysis with CR as the dependent variable revealed significant interactions of AI number with interval from calving to first AI and AI season. Cows first serviced at ≤48 days post-partum had lower CR than those at ≥90 days at first AI (p < 0.05), but the interval from calving to first AI did not affect CR at second AI. Cows serviced in the autumn had a higher CR at first AI than those serviced in the spring and winter (p < 0.05); however, there was no seasonal difference in CR at the second AI. In summary, CR began to decrease from the fourth AI in heifers and the third AI in cows. The AI season and the interval from calving to first AI significantly affected CR only at the first AI.

Relationship between plasma anti-Müllerian hormone concentrations during the rearing period and subsequent embryo productivity in Japanese black cattle

To use plasma anti-Müllerian hormone (AMH) concentrations as early-stage markers for donor cow selection, we investigated the relationship between plasma AMH concentrations in Japanese black heifers and subsequent embryo productivity following superovulation treatment. Plasma AMH and nonesterified fatty acid (NEFA) concentrations in 6 heifers were evaluated once per month from 3 mo before successful AI for primiparity to 3 mo postpartum. Following calving, embryo collection by superovulation treatment was performed at 3- to 4-mo intervals. There were no significant differences in plasma AMH concentrations between the time points throughout the study period. There were, however, significant inter-animal differences in plasma AMH concentrations (P < 0.05). These findings suggest that plasma AMH concentrations were stable over time and individually specific. There were significant positive correlations between plasma AMH concentrations before AI and embryo productivity variables, including the number of ova/embryos (number of transferable embryos, degenerated embryos, and unfertilized oocytes) and numbers/proportions of fertilized and transferable embryos. There was no significant correlation between plasma AMH and NEFA concentrations throughout the study period. These findings reveal that plasma AMH concentrations during the rearing period can be used to predict subsequent embryo productivity following superovulation treatment, suggesting that these concentrations are useful early-stage markers for selecting donor cows.

Feasibility of umbilical loop ileostomy in overweight and obese patients with rectal cancer during laparoscopic surgery: Preliminary results

We examined the feasibility of umbilical diverting ileostomy for overweight and obese patients with rectal cancer undergoing laparoscopic surgery. Four patients who were overweight or obese (BMI > 27 kg/m² ) were initially scheduled for the creation of a conventional loop ileostomy. Intraoperatively, however, this was considered too complicated because of thick subcutaneous fat, bulky mesentery, or both. Instead, patients received a diverting ileostomy with the placement of an umbilical stoma. All patients had protruding umbilical ileostomies. No severe stoma-related complications were encountered. One patient had minor skin dehiscence, and another had paralytic ileus but resumed oral intake after a short time. Performing a temporary loop ileostomy at the umbilicus was safe and feasible in this small group of overweight and obese patients. This stoma placement may avoid the problems inherent to conventional loop ileostomy in obese subjects.

Changes in peripheral anti-Müllerian hormone concentration and their relationship with testicular structure in beef bull calves

The aim of this study was to clarify the time-course of changes in anti-Müllerian hormone (AMH) and testosterone (T) concentrations in peripheral blood and to determine the relationships between blood AMH concentration and testicular development during the early postnatal and prepubertal periods in beef bull calves. A total of 17 Japanese Black bull calves were enrolled in this study. The wk in which the calf was born (within 6 d after birth) was defined as M 0. Blood samples were taken once in every mo from M 0 to M 6 from each bull calf, and plasma AMH and T concentrations were determined. Of the 17 calves, 10 were castrated at 6 mo of age (prepuberty) and the right testis was histologically examined. Plasma AMH concentration (means ± SE) at M 0, 1, and 2 were 123.5 ± 9.8, 189.6 ± 18.7, and 254.6 ± 14.1 ng/mL, respectively. From M 0 through M 2, plasma AMH concentration was significantly greater each mo than in the previous mo (P < 0.05); however, plasma AMH concentration significantly decreased over the last 3 mo of the study (P < 0.05). The average age at which plasma AMH concentration was the highest was 2.3 ± 0.1 mo of age. Plasma T concentration significantly increased from M 0 (0.18 ± 0.02 ng/mL) until M 6 (6.52 ± 1.41 ng/mL). Plasma AMH and T concentrations at M 4, 5, and 6 were significantly negatively correlated (P < 0.05). Linear regression did not reveal a significant relationship between Sertoli or Leydig cell numbers and plasma AMH or T concentrations, respectively. In conclusion, blood AMH concentration peaks at 2 mo of age and is negatively correlated with blood T concentration from 4 to 6 mo of age. Although prepubertal blood AMH or T concentrations did not reflect Sertoli or Leydig cell numbers at the end of the prepubertal period, blood AMH concentration may be indicative of abnormal Sertoli cells function.

[A Case of Local Recurrence and Lung Metastasis from a Rectal Cancer Treated with Systemic Chemotherapy and Cyberknife]

A 73-year-old man underwent abdominoperineal resection for a rectal cancer. He developed a hip pain 3 years and 6 months after the surgery. A CT scan revealed a local recurrence in the perineum and multiple lung metastases in the bilateral lung. He received systemic chemotherapy consisting of XELOX with bevacizumab. Thereafter, the hip pain was slightly relieved. The hip pain worsened 1 year and 6 months after the recurrence. The border between the perineal tumor and skin was very narrow, and conventional radiation therapy could cause a perineal skin necrosis and subsequent poor wound healing. Therefore, we selected a Cyberknife treatment. The hip pain was relieved and a CT scan showed a reduction of the perineal tumor's size after the Cyberknife treatment. A Cyberknife treatment may be effective and promising as palliation for patients with local recurrence of rectal cancer.

Risk factors for developing infusion reaction after rituximab administration in patients with B-cell non-Hodgkin's lymphoma

Rituximab (RTX), a monoclonal antibody against CD20, is known to cause fewer side effects than conventional anti-cancer drugs; however, infusion reaction (IR), which is specific to monoclonal antibody therapy, is frequently triggered by RTX. Therefore, we designed this study to identify risk factors based on clinical test values for developing IR after RTX administration. Eighty-nine patients with B-cell non-Hodgkin's lymphoma who had received RTX for the first time between February 2010 and March 2013, at the Gifu Municipal Hospital were enrolled as subjects. Analysis of data was conducted for 87 patients, after excluding patients whose data were missing. Univariate analysis showed significant differences in the number of patients exhibiting a soluble interleukin-2 receptor (sLL-2R) level > 2,000 U/L and hemoglobin (Hb) < lower standard limit (LSL) between the IR and non-IR groups. Multivariate analysis showed significant differences with respect to slL-2R > 2,000 U/L [odds ratio (OR), 4.463; 95% confidence interval (Cl), 1.262-15.779; P = 0.020], Hb < LSL [OR, 3.568; 95% CI, 1.071-11.890; P = 0.038], and steroid administration [OR, 0.284; 95% Cl, 0.094-0.852; P = 0.025]. Our findings show that sIL-2R > 2,000 U/L, Hb < LSL, and a lack of steroid premedication are risk factors for developing IR following RTX treatment.

Evidence of Spontaneous Recovery of Granulosa-Theca Cell Tumour in a Heifer: A Retrospective Report

A 14-month-old Japanese Black heifer was evaluated on Day 0 (D 0) for enlargement of the right ovary (RO). Transrectal ultrasonography (TRUS) revealed that the RO was markedly enlarged and multicystic, while the left ovary (LO) was small and inactive. The presumptive diagnosis was granulosa-theca cell tumour (GTCT), which was confirmed by markedly elevated plasma anti-Müllerian hormone (AMH) of 4.42 ng/ml. Therefore, ovariectomy of the RO was the treatment of choice. The heifer was checked by TRUS and blood sampling on D 42, D 63 and immediately before ovariectomy on D 85. On D 42, TRUS did not show marked changes in either ovary in comparison with D 0. However, on D 63, the RO had transformed into a single cyst, and on D 85, the LO had resumed cyclic activity. The RO was extracted on D 85 by hand-assisted laparoscopic ovariectomy to allow better control. Unexpectedly, histopathology revealed the lesion to be a fluid-filled cystic structure, with no neoplastic proliferation of follicular epithelium that would indicate GTCT. The wall of the cystic structure consisted of collagen fibres and a few degenerated granulosa cells. The retrospective hormonal analysis revealed that the AMH concentrations had markedly dropped on D 63 and 85, which coincided with resumption of cyclicity in the LO. These findings suggest that the GTCT had self-cured and transformed into a cyst-like structure. The heifer then received an oestrous synchronization regime on D 105, was artificially inseminated on D 115 and became pregnant.

[Long-term survival of a patient with sigmoid colon cancer showing multiple liver metastases treated by performing partial hepatectomy, five years after achieving a complete response via hepatic arterial infusion chemotherapy]

Although systemic multidrug chemotherapy is the first-line therapy for unresectable colorectal cancer, hepatic arterial infusion chemotherapy(HAI)may be a potential alternative treatment for patients with unresectable colorectal liver metastasis. A 65-year-old man underwent sigmoidectomy for sigmoid colon cancer with bilobar, multiple liver metastases. Postoperatively, an HAI regimen of 5-fluorouracil(5-FU, 1,000mg/m²/5 h/every week)was administered for 26 weeks; the total dose of 5-FU administered was 52 g. Complete response(CR)was achieved, according to an imaging diagnosis technique. Thereafter, the patient was followed-up in an outpatient setting, without any further anti-cancer treatment. A solitary liver metastasis was identified by using magnetic resonance imaging(MRI), 6 years 6 months after achieving CR. The patient underwent partial liver resection for the recurrent liver metastasis. Histological diagnosis revealed an adenocarcinoma, consistent with the findings for metastatic sigmoid colon cancer. The patient's postoperative recovery was uneventful, and he remains alive 5 years after liver resection, without any evidence of tumor recurrence. Further long-term follow-up might be advisable considering the slow-growing nature of this tumor.

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: a case report and literature review

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.