Recent Changes and Improvements in Multidisciplinary Perioperative Management From a Nutritional Perspective: Dental Specialty Should Be Considered Important

Purpose of review Recently, multidisciplinary strategies on accelerated recovery postoperatively have been provided, and management of the perioperative period has changed and improved dramatically. We summarize the enhanced recovery after surgery (ERAS®) protocol and its outcomes from a nutritional perspective. We established the perioperative management center (PERiO), much of whose work contents conform to ERAS®, but intensive dental staff involvement is characteristic. We also summarize its outcomes. Recent findings ERAS® is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing a major surgery. Nutrition is a key pillar for patient-care. Throughout the perioperative period, oral nutrition is suggested as well as possible. Good outcomes have been reported by a meta-analysis of randomized controlled trials. However, dental staff are not regarded as part of the professional team. PERiO reported good outcomes of care bundles and suggested the importance of dental staff contribution. The Japanese social insurance system began to cover involvements of dental staff for perioperative oral management since 2012. Analysis of the nationwide administrative claims database in Japan concluded that preoperative oral care by a dentist significantly reduced postoperative complications in patients undergoing cancer surgery. Summary Currently, dental staff are not regarded as key professionals of ERAS®, although dental staff can contribute to good outcomes in the perioperative period and PERiO, and consequently the Japanese universal health insurance coverage system covering involvements of dental staff for perioperative oral management showed good outcomes. Therefore, further clinical studies involving the dental specialty should be considered important for perioperative management from nutritional perspectives

コロナ禍における医学教育への取り組み

The COVID-19 pandemic has profoundly changed medical student clinical practice and limited hospital clinical practice. In order to make student training more meaningful, we have introduced medical education using a laparoscopic simulator. We conducted a student questionnaire on the usefulness of this training and evaluated the degree of understanding. For students who were able to practice at the hospital, they practiced using a laparoscopic simulator（Lap Mentor™）. A questionnaire survey was conducted on the presence or absence of interest in surgery. Student understanding of laparoscopic surgery improved 100％. 91％ understood the surgical procedure, 91％ improved technique and 97％ understood pelvic anatomy. In the training at Lap Mentor™, medical students were able to experience surgery while viewing images of the inside of the pelvis, which served as a means to increase their interest in surgery and obstetrics and gynecology

Jejunal interposition reconstruction with a stomach preserving esophagectomy improves postoperative weight loss and reflux symptoms for esophageal cancer patients

Background: Conventional reconstruction after an esophagectomy uses a gastric tube, which commonly causes several postoperative complaints such as gastric acid reflux in long-term survival cases. Intestinal interposition between the remnant esophagus and the stomach is an option to reduce complaints, and in this study, the advantages of jejunal interposition reconstruction with a stomach preserving esophagectomy (SPE) were assessed. Materials and methods: Eleven cases of jejunal interposition with an SPE and 16 cases with gastric tube reconstruction as a control were subject to a comparison of operation time, amount of bleeding, postoperative quality of life, and endoscopic findings. Results: The SPE group had a longer operation time (SPE: 560 +/- 121 min, control 414 +/- 83 min, P = 0.038), whereas there was no significant difference in blood loss. Postoperative weight loss was significantly recovered in the SPE group (SPE versus control = 94.0 +/- 5.4% versus 87.5 +/- 4.7% at 3 mo, P = 0.017; 97.2 +/- 7.5% versus 85.0 +/- 5.2% at 6 mo, P = 0.010), and there was a significant decrease in the occurrence of reflux symptoms such as heartburn, odynophagia, and cough when jejunal interposition with an SPE was done. Furthermore, reflux esophagitis and Barrett's epithelium were found in six out of 12 cases (50%) of the control group by postoperative endoscopy, while no cases in the SPE group had either condition (P < 0.01). Conclusions: This reconstruction method is a promising option to improve postoperative quality of life, mainly due to the long-term elimination of reflux esophagitis, which assists in the recovery of postoperative weight loss

Androgen’s effects in female

The metabolic effects of androgens and their underlying mechanisms in females have been revealed by recent studies. An excess of androgens can have adverse effects on feeding behavior and metabolic functions and induce metabolic disorders / diseases, such as obesity, insulin resistance, and diabetes, in women and experimental animals of reproductive age. Interestingly, these effects of androgens are not observed in ovariectomized animals, indicating that their effects might be dependent on the estrogen milieu. Central and peripheral mechanisms, such as alterations in the activity of hypothalamic factors, reductions in energy expenditure, skeletal muscle insulin resistance, and β-cell dysfunction, might be related to these androgens’ effects

Utilizing Dynamic Phosphorous-31 Magnetic Resonance Spectroscopy for the Early Detection of Acute Compartment Syndrome: A Pilot Study on Rats

Introduction: Disasters, including terrorism and earthquakes, are significant threats to people and may lead to many people requiring rescue. The longer the rescue takes, the higher the chances of an individual contracting acute compartment syndrome (ACS). ACS is fatal if diagnosed too late, and early diagnosis and treatment are essential. Objective: To assess the ability of dynamic phosphorus magnetic resonance spectroscopy (31P-MRS) in the early detection of muscular damage in ACS. Materials and Methods: Six ACS model rats were used for serial 31P-MRS scanning (9.4 Tesla). Skeletal muscle metabolism, represented by the levels of phosphocreatine (PCr), inorganic phosphate (Pi), and adenosine triphosphate (ATP), was assessed. The PCr/(Pi + PCr) ratio, which decreases with ischemia, was compared with simultaneously sampled plasma creatine phosphokinase (CPK), a muscle damage marker. Results: The PCr/(Pi + PCr) ratio significantly decreased after inducing ischemia (from 0.86 ± 0.10 to 0.18 ± 0.06; p &lt; 0.05), while CPK did not change significantly (from 89 ± 29.46 to 241.50 ± 113.28; p &gt; 0.05). The intracellular and arterial pH index decreased over time, revealing significant differences at 120 min post-ischemia (from 7.09 ± 0.01 to 6.43 ± 0.13, and from 7.47 ± 0.03 to 7.39 ± 0.04, respectively). In the reperfusion state, the spectra and pH did not return to the original values. Conclusions: The dynamic 31P-MRS technique can rapidly detect changes in muscle bioenergetics. This technique is a promising non-invasive method for determining early muscular damage in ACS

Difficulty in diagnosis of black pigmentation in the peritoneal cavity : A case report

The occurrence of black pigmentation in the peritoneal cavity is rare, and its rapid clinical diagnosis may be difficult. Here, we report a case with pigmented peritoneal deposits diagnosed via a histopathological examination at postoperative period. A 74-year-old woman was diagnosed with stage 2 pelvic organ prolapse on the POP-Q system, and planned to undergo a laparoscopic sacrocolpopexy. She had an obstetric history of two uncomplicated vaginal births, and a medical history of colon cancer. During the surgery, variously sized, irregularly shaped and partially swollen black pigments were observed mainly in the small pelvic cavity. Because malignant melanoma dissemination was suspected by macroscopic findings, sampling tissues were submitted to the rapid histopathological examination with frozen sections. However, the histopathological examination could not rule out malignancy because of the presence of cell nests similar to melanocytes with large nucleoli. Thereafter, to prevent the spread of the suspected cancer cells, the surgical procedure was switched to a vaginal approach. No malignant lesions were observed in a whole-body examination performed after the operation. Additionally, immunohistochemistry showed no evidence of malignancy or atypia in black pigmented tissues. When we checked the colon cancer operation records and pictures at 5 years ago, it was revealed that the black pigments were markings painted during this surgery. The present case serves as a reminder for differential diagnosis of black pigments in the abdominal cavity