Effective Management of an Advanced Gastric Cancer Patient by TS-1 Combined Chemotherapy Using Nasojejunal Tube and Successful Transfer to Home Care after Percutaneous Transesophageal Gastro-tubing (PTEG): A Case Report

A 67-year-old woman with debilitation and massive ascites was admitted to our hospital and diagnosed with stage IV scirrhous gastric cancer with peritoneal dissemination. After successful nasojejunal tube feeding because of oral intake disability, TS-1 combined with paclitaxel chemotherapy was selected. TS-1 at 80mg/m2 was given daily via nasojejunal tube for 2 weeks, followed by a 1-week rest, and paclitaxel at 50mg/m2 was administered intravenously on day 1 and 8. There were no serious side effects. After 4 cycles, a partial response was observed and percutaneous transesophageal gastro-tubing (PTEG) was placed. After the fifth cycle, she was transferred to her home and received chemotherapy in an outpatient clinic. After 7 cycles, the disease progressed, and TS-1 combined with low-dose cisplatin was administered for 3 cycles. However, the patient died 16 weeks after discharge. PTEG was useful not only for a route of TS-1 administration, but also for receiving chemotherapy at home to maintain her quality.</p

Incarcerated Amyand’s Hernia

A 76-year-old Japanese man was transferred to our hospital to undergo rehabilitation after traffic accident-related injuries. Seven days post-admission, he presented with abdominal pain and an 8-cm lump in the right inguinal region. He was diagnosed with an incarcerated inguinal hernia and underwent elective surgery the day after manual reduction. He had a normal vermiform appendix which was observed to have adhered to the right indirect hernia sac. An appendectomy and hernia repair using lightweight mesh were performed. We discuss the surgical management of this rare incarcerated Amyand’s hernia and the relevant literature

A Rare Case of Gastrojejunocutaneous Fistula after Percutaneous Endoscopic Gastrostomy

We report a rare case of fistulation to the jejunum after percutaneous endoscopic gastrostomy (PEG). An 85-year-old man with previous cerebral infarction and swallowing disturbance underwent PEG. Nine months later, he developed a high fever and discharge around the gastrostomy button. He was diagnosed with aspiration pneumonia, and administered antibiotic therapy. Examination showed digestive fluid around the gastrostomy button. Gastrointestinal contrast-enhanced CT revealed a gastrojejunocutaneous fistula. The button was removed, and the fistula closed naturally. PEG was performed again. The patient’s postoperative course was uneventful. Gastrojejunocutaneous fistula should be considered in cases involving increased discharge from a gastrostomy fistula

Unusual abscesses associated with colon cancer: report of three cases

Three cases of colon cancer accompanied by unusual abscess formation are reported. Case I : A 77-year-old man was diagnosed with a paracolic abscess formation behind the cecum and a swollen appendix by computed tomography (CT) scan. Case II : An 85-year-old woman was diagnosed with an abscess formation of the right iliopsoas muscle, a swollen appendix, and a thickened right colon wall by CT scan. After antibiotic therapy failed, both patients underwent ileocecal resection urgently under suspicion of appendicitis, but cecal cancer around the entrance to the appendix caused secondary appendicitis in both cases. Case III : A 50-year-old woman was diagnosed with sigmoid colon cancer with an abscess formation in the pelvic cavity concomitant with ovarian tumor. A Hartmann procedure was performed, and a pathological examination revealed that a subserosal abscess behind the sigmoid colon cancer perforated the rectum with abscess formation. All cases were definitively diagnosed intraoperatively. The cancer recurred in cases I and III. We emphasize that precise surgical evaluation has an important role in the diagnosis of these complicated diseases. In addition, surgery affords the patient the best chance of recovery, and in these advanced cases radical treatment is recommended as early as possible

Efficacy and Tolerability of Weekly Paclitaxel in Combination with High-dose Toremifene Citrate in Patients with Metastatic Breast Cancer

Toremifene citrate is expected to prevent drug resistance in cancer patients by inhibiting p-glycoprotein activity. The safety and efficacy of combination therapy with high-dose toremifene citrate and paclitaxel were investigated. Between December 2003 and June 2004, 15 women with a mean age of 53 years old with metastatic breast cancer were enrolled. The administration schedule was 80mg/m2 of paclitaxel given on Days 1, 8, and 15, and 120mg/day of toremifene citrate orally administered starting on Day 18. On Days 32 and 39, paclitaxel was concurrently administered again. Toxicities, response rate, and time to treatment failure were assessed. All patients had been treated with endocrine or chemotherapy. Grade 3 leukopenia occurred in 2 patients on the administration of paclitaxel alone, and grade 3 febrile neutropenia occurred in 1 patient given the combination therapy. There was no grade 3 or greater non-hematological toxicity. There was no complete response and 1 partial response, producing a response rate of 6.7%. Median time to treatment failure was 2.7 months. Combination therapy of paclitaxel and toremifene was safe and well tolerated with minimal toxicity. Further clinical trials targeting patients with functional p-glycoprotein are warranted.</p

Early patency rate and fate of reattached intercostal arteries after repair of thoracoabdominal aortic aneurysms

ObjectivesThe present study analyzes the early patency of intercostal artery reconstruction, using graft interposition and aortic patch anastomosis, and determines the fate of reattached intercostal arteries after repair of thoracoabdominal aortic aneurysms.MethodsWe selected 115 patients (mean age, 63 ± 15 years; range, 19-83 years; male, n = 83) treated by thoracoabdominal aortic aneurysm repair with 1 or more reconstructed intercostal arteries at the Kobe University Graduate School of Medicine between October 1999 and December 2012. The intercostal arteries were reconstructed using graft interposition (n = 66), aortic patch anastomosis (n = 42), or both (n = 7).ResultsThe hospital mortality rate was 7.8% (n = 9). Eleven patients (9.6%) developed spinal cord ischemic injury (permanent, n = 6, transient, n = 5). The average number of reconstructed intercostal arteries per patient was 3.0 ± 1.5 (1-7), and 345 intercostal arteries were reattached. The overall patency rate was 74.2% (256/345) and that of aortic patch anastomosis was significantly better than that of graft interposition (90.8% [109/120] vs 65.3% [147/225], P < .01), but significantly worse for patients with than without spinal cord ischemic injury (51.9% [14/27] vs 76.1% [242/318], P = .01). There was no patch aneurysm in graft interposition during a mean of 49 ± 38 (range, 2-147) postoperative months, but aortic patch anastomosis including 4 intercostal arteries became dilated in 2 patients.ConclusionsAortic patch anastomosis might offer better patency rates and prevent spinal cord ischemic injury compared with graft interposition. Although aneurysmal changes in intercostal artery reconstructions are rare, large blocks of aortic wall reconstruction should be closely monitored

Effect of atherothrombotic aorta on outcomes of total aortic arch replacement

ObjectiveThe effect of an atherothrombotic aorta on the short- and long-term outcomes of total aortic arch replacement, including postoperative neurologic deficits, remains unknown. We evaluated this relationship and also elucidated the synergistic effect of multiple other risk factors, in addition to an atherothrombotic aorta, on the neurologic outcome.MethodsA group of 179 consecutive patients undergoing total aortic arch replacement were studied. An atherothrombotic aorta was present in 34 patients (19%), more than moderate leukoaraiosis in 71 (39.7%), and significant extracranial carotid artery stenosis in 27 (15.1%). In-hospital deaths occurred in 2 patients, 1 (2.9%) of 34 patients with and 1 (0.7%) of 145 patients without an atherothrombotic aorta (P = .26). Permanent neurologic deficits occurred in 4 (2.2%) and transient neurologic deficits in 17 (9.5%) patients. Multivariate analysis demonstrated that the risk factors for transient neurologic deficits were an atherothrombotic aorta (odds ratio, 4.4), extracranial carotid artery stenosis (odds ratio, 5.5), moderate/severe leukoaraiosis (odds ratio, 3.6), and cardiopulmonary bypass time (odds ratio, 1.02). To calculate the probability of transient neurologic deficits, the following equation was derived: probability of transient neurologic deficits = {1 + exp [7.276 − 1.489 (atherothrombotic aorta) − 1.285 (leukoaraiosis) − 1.701 (extracranial carotid artery stenosis) − 0.017 (cardiopulmonary bypass time)]}−1. An exponential increase occurred in the probability of transient neurologic deficits with presence of an atherothrombotic aorta and other risk factors in relation to the cardiopulmonary bypass time. Survival at 3 years after surgery was significantly reduced in patients with vs without an atherothrombotic aorta (75.0% ± 8.8% vs 89.2% ± 3.1%, P = .01).ConclusionsPatients with an atherothrombotic aorta and associated preoperative comorbidities might be predisposed to adverse short- and long-term outcomes, including transient neurologic deficits

An Assessment Rubric for a Resident Training Program in Surgery: A Single-Institution Experience

Using a Collaborative Action Research model, our research team established a one-month clinical resident training program for first- and second-year clinical residents. We created and implemented an assessment rubric to assess the residents’ progress toward independent practice in surgery, and thereby, to evaluate the program itself. The program included training in three areas: basic techniques and procedures in the operating room, surgical ward management, and academic activities. The rubric measured the residents’ performance according to three achievement levels: Level 1 (demonstration), Level 2 (active help) and Level 3 (passive help). The program and rubric implementation began in June 2019 and continued until March 2020, when the program outcomes and shortcomings were analyzed. Among nineteen clinical residents, a total of nine clinical residents participated in the study. Most participants reached achievement Level 3 for their performance of basic techniques in the operating room. Finally, we discussed ideas for improvement and drafted plans for an improved rubric to complete the action research cycle. Our research team found the rubric to be a useful tool in evaluating the status of the new clinical resident training program

Automatic evaluation of atlantoaxial subluxation in rheumatoid arthritis by a deep learning model

Background: This work aims to develop a deep learning model, assessing atlantoaxial subluxation (AAS) in rheumatoid arthritis (RA), which can often be ambiguous in clinical practice. Methods: We collected 4691 X-ray images of the cervical spine of the 906 patients with RA. Among these images, 3480 were used for training the deep learning model, 803 were used for validating the model during the training process, and the remaining 408 were used for testing the performance of the trained model. The two-dimensional key points’ detection model of Deep High-Resolution Representation Learning for Human Pose Estimation was adopted as the base convolutional neural network model. The model inferred four coordinates to calculate the atlantodental interval (ADI) and space available for the spinal cord (SAC). Finally, these values were compared with those by clinicians to evaluate the performance of the model. Results: Among the 408 cervical images for testing the performance, the trained model correctly identified the four coordinates in 99.5% of the dataset. The values of ADI and SAC were positively correlated among the model and two clinicians. The sensitivity of AAS diagnosis with ADI or SAC by the model was 0.86 and 0.97 respectively. The specificity of that was 0.57 and 0.5 respectively. Conclusions: We present the development of a deep learning model for the evaluation of cervical lesions of patients with RA. The model was demonstrably shown to be useful for quantitative evaluation.Okita Y., Hirano T., Wang B., et al. Automatic evaluation of atlantoaxial subluxation in rheumatoid arthritis by a deep learning model. Arthritis Research and Therapy 25, 181 (2023); 10.1186/s13075-023-03172-x