Publications by authors named "Alan Kawarai Lefor"

250 Publications

Evaluating the mental health of children in a local hospital outpatient clinic.

Pediatr Int 2021 Apr 8. Epub 2021 Apr 8.

Department of Pediatrics, Haga Red Cross Hospital, 271 Nakagou Mouka, Tochigi, 321-4306, Japan.

Background: The Questionnaire for Triage and Assessment with 30 items (QTA30) is a standardized triage and assessment tool to assess pediatric psychosomatic disorders. It was estimated that one in ten children experience difficulties with regard to their school life in Japan. We evaluated mental health in children at an outpatient clinic in a local hospital with the QTA30.

Methods: All elementary and junior high school students 9 years of age or older who visited our institution between December 1, 2019 and March 31, 2020 were asked to complete the QTA30.

Result: A total of 372 children responded. Half of the children with a psychosomatic disorder and 9% of children with other chronic disorders were suspected to have poor mental health. Suspected having poor mental health was associated with higher odds of female gender (OR 1.89, 95% CI 1.07-3.39), junior high school students (OR 3.73, 95% CI 2.11-6.73), and not enjoying exercise (OR 2.13, 95% CI 1.16-3.9). The total QTA30 score was significantly worse in children with psychosomatic disorders (38.0±19.1) among children with other chronic diseases, however, only that in children with central precocious puberty (27.4±13.7) showed no differences.

Conclusion: The percentage of children suspected to have mental health problems manifest as non-psychosomatic chronic disorder was similar to the proportion of children suspected to experience difficulties with regard to their school life based on a survey. Pediatricians should carefully consider the possibility of mental health problems when children are seen in regular visit at the outpatient clinic.
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http://dx.doi.org/10.1111/ped.14723DOI Listing
April 2021

Clinical predictors of gangrenous appendicitis: elevated total bilirubin level and computed tomography scan findings.

Acute Med Surg 2021 Jan-Dec;8(1):e620. Epub 2021 Apr 1.

Department of Surgery Jichi Medial University Tochigi Japan.

Aim: Patients with gangrenous appendicitis usually require emergency surgery. Preoperative diagnosis of gangrenous appendicitis is clinically important but not always straightforward. We undertook this study to identify preoperative predictors of gangrenous appendicitis.

Methods: This was a single-center case-control study. We identified 162 patients who underwent appendectomy between September 2011 and August 2014 after the diagnosis of acute appendicitis was established. We identified laboratory parameters and computed tomography (CT) scan findings predictive of histologically or surgically diagnosed gangrenous appendicitis by univariable and multivariable analyses.

Results: Of 146 study patients, gangrenous appendicitis was confirmed in 102. Univariable analysis showed that two laboratory factors (C-reactive protein []and total bilirubin [T-Bil]) and three CT scan findings were significant predictors for gangrenous appendicitis. Multivariable analysis showed that T-Bil and two CT scan findings (appendicolith and fat stranding around the appendix) were independent predictors. The combination of "T-Bil ≥ 1.0 mg/dL or appendicolith" was able to predict gangrenous appendicitis with a sensitivity of 90.5%, positive predictive value of 80.4%, and accuracy of 77.8%. The combination of "T-Bil ≥ 1.0 mg/dL or fat stranding around the appendix" was able to predict gangrenous appendicitis with a sensitivity of 98.9%, positive predictive value of 76.4%, and accuracy of 71.9%.

Conclusion: These combinations of laboratory and CT scan findings could be valuable as predictors of gangrenous appendicitis.
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http://dx.doi.org/10.1002/ams2.620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013822PMC
April 2021

Pancreatic Ductal Adenocarcinoma: Epidemiology and Risk Factors.

Diagnostics (Basel) 2021 Mar 20;11(3). Epub 2021 Mar 20.

Department of Medicine, Division of Gastroenterology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.

The number of new cases of pancreatic ductal adenocarcinoma is increasing with a cumulative total of 495,773 cases worldwide, making it the fourteenth most common malignancy. However, it accounts for 466,003 deaths per year and is the seventh leading cause of cancer deaths. Regional differences in the number of patients with pancreatic ductal adenocarcinoma appear to reflect differences in medical care, as well as racial differences. Compared to the prevalence of other organ cancers in Japan, pancreatic ductal adenocarcinoma ranks seventh based on the number of patients, eighth based on morbidity, and fourth based on the number of deaths, with a continuing increase in the mortality rate. Risk factors for developing pancreatic ductal adenocarcinoma include family history, genetic disorders, diabetes, chronic pancreatitis, and intraductal papillary mucinous neoplasms. An issue that hinders improvement in the prognosis of patients with pancreatic ductal adenocarcinoma is the development of a strategy to identify patients with these risk factors to facilitate detection of the disease at a stage when intervention will improve survival.
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http://dx.doi.org/10.3390/diagnostics11030562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8003883PMC
March 2021

Cardiac Arrest due to Failed Pacemaker Capture After Peripheral Nerve Blockade With Levobupivacaine: A Case Report.

A A Pract 2021 Apr 1;15(4):e01445. Epub 2021 Apr 1.

Department of Surgery, Jichi Medical University, Tochigi, Japan.

We describe a patient with a pacemaker who developed cardiac arrest shortly after ultrasound-guided rectus sheath block for postoperative analgesia. The cause of cardiac arrest was capture failure due to an increased pacing threshold, and the patient was promptly treated by increasing the pacing amplitude. Local anesthetics used for rectus sheath block might have affected the pacing threshold and caused pacing capture failure, since local anesthetics can block cardiac sodium channels. Anesthesiologists should recognize the risk of pacemaker capture failure when a large amount of local anesthetic is given to patients with a cardiac pacemaker.
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http://dx.doi.org/10.1213/XAA.0000000000001445DOI Listing
April 2021

Successful living donor liver transplantation for liver failure due to maternal T cell engraftment following cord blood transplantation in X-linked severe combined immunodeficiency disease: case report.

Am J Transplant 2021 Apr 1. Epub 2021 Apr 1.

Department of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Tochigi-ken, Japan.

Maternal T-cells from perinatal transplacental passage have been identified in up to 40% of patients with severe combined immunodeficiency (SCID). Although engrafted maternal T cells sometimes injure newborn tissue, liver failure due to maternal T cells has not been reported. We rescued a boy with X-linked SCID who developed liver failure due to engrafted maternal T-cell invasion following living donor liver transplantation (LDLT) following unrelated umbilical cord blood transplantation (UCBT). After developing respiratory failure 3 weeks postpartum, he was diagnosed with X-linked SCID. Pathological findings showed maternal T cells engrafted in his liver and hepatic fibrosis gradually progressed. He underwent UCBT at 6-months, but hepatic function did not recover and liver failure progressed. Therefore, he underwent LDLT using an S2 monosegment graft at age 1.3 years. The patient had a leak at the Roux-en-Y anastomosis which was repaired. Despite occasional episodes of pneumonia and otitis media, he is generally doing well 6 years after LDLT with continued immunosuppression agents. In conclusion, the combination of hematopoietic stem cell transplantation (HSCT) and liver transplantation may be efficacious, and HSCT should precede liver transplantation for children with X-linked SCID and liver failure.
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http://dx.doi.org/10.1111/ajt.16588DOI Listing
April 2021

Mental health in Japanese children during school closures due to the COVID-19.

Pediatr Int 2021 Mar 31. Epub 2021 Mar 31.

Department of Pediatrics, Haga Red Cross Hospital, 271 Nakagou Mouka, Tochigi, 321-4306, Japan.

Background: Changes in relationships, sleep rhythms, and physical activity caused by school closures instituted to curb the spread of COVID-19 influenced children's mental health. We explored changes in children's daily life and effects on their mental health during school closures.

Methods: Participants included elementary and junior high school students 9 years of age and older seen in the outpatient clinic during school closures and were required to complete the Japanese version of WHO Five Well-Being Index (WHO-5-J). The results were compared with those of students seen after schools reopened.

Results: Participants included 78 students in the school closure group and 113 in the school reopening group. Although those in the closure group devoted more time to family and sleep, their sleep rhythms, eating habits, and physical activities were disrupted. Although there were no significant differences between the two groups in total WHO-5-J scores, single WHO-5-J items such as activity and vigor and interest were significantly worse and rest was significantly better in the school closure group.

Conclusion: Although school closures resulted in elementary and junior high school students spending more time with family and sleeping, their sleep rhythms, eating habits, and physical activities were disrupted. As the children's living environment changed, they felt less active and vigorous and had difficulty finding things that interested them. However, their sleep improved and overall, the number of children with potential mental health problems did not change.
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http://dx.doi.org/10.1111/ped.14718DOI Listing
March 2021

ABCDEF Bundle and Supportive ICU Practices for Patients With Coronavirus Disease 2019 Infection: An International Point Prevalence Study.

Crit Care Explor 2021 Mar 12;3(3):e0353. Epub 2021 Mar 12.

Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan.

Objectives: To investigate implementation of evidence-based and supportive cares in ICUs, such as the ABCDEF, nutrition therapy, and ICU diary, for patients with coronavirus disease 2019 infection in ICUs and their association with ICU clinical practice and setting.

Design: A worldwide, 2-day point prevalence study.

Setting: The study was carried out on June 3, 2020, and July 1, 2020. A total of 212 ICUs in 38 countries participated. Clinicians in each participating ICU completed web-based online surveys.

Patients: The ICU patients with coronavirus disease 2019.

Interventions: None.

Measurements And Main Results: The implementation rate for the elements of the ABCDEF bundle, other supportive ICU care measures, and implementation-associated structures were investigated. Data were collected for 262 patients, of whom 47.3% underwent mechanical ventilation and 4.6% were treated with extracorporeal membrane oxygenation. Each element was implemented for the following percentages of patients: elements A (regular pain assessment), 45%; B (both spontaneous awakening and breathing trials), 28%; C (regular sedation assessment), 52%; D (regular delirium assessment), 35%; E (early mobility and exercise), 47%; and F (family engagement and empowerment), 16%. The implementation of element E was 4% for patients on mechanical ventilation and 8% for patients on extracorporeal membrane oxygenation. Supportive care, such as protein provision throughout the ICU stay (under 1.2 g/kg for more than 50% of the patients) and introduction of ICU diary (25%), was infrequent. Implementation rates of elements A and D were higher in ICUs with specific protocols and fewer ICU beds exclusively for patients with coronavirus disease 2019 infection. Element E was implemented at a higher rate in ICUs that had more ICU beds assigned for them.

Conclusions: This point prevalence study showed low implementation of the ABCDEF bundle. Specific protocols and the number of ICU beds reserved for patients with coronavirus disease 2019 infection might be key factors for delivering appropriate supportive care.
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http://dx.doi.org/10.1097/CCE.0000000000000353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994035PMC
March 2021

Obstructive jaundice due to acute acalculous cholecystitis: 'Mirizzi-like syndrome'.

BMJ Case Rep 2021 Mar 30;14(3). Epub 2021 Mar 30.

Department of Gastroenterology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan.

A 78 year-old female status post subarachnoid haemorrhage developed abdominal pain and obstructive jaundice. CT scan showed acute cholecystitis and dilation of the intrahepatic ducts. Endoscopic retrograde cholangiography revealed hepatic duct stenosis due to compression by an enlarged gallbladder. No stones were seen in the common hepatic duct and the cystic duct was patent. An endoscopic retrograde biliary drain was placed to relieve the obstructive jaundice due to acute acalculous cholecystitis. Percutaneous transhepatic drainage was performed to treat the acute acalculous cholecystitis. Hepatic duct stenosis was improved on endoscopic retrograde cholangiography performed 19 days after percutaneous transhepatic drainage. It may be reasonable to treat 'Mirizzi-like syndrome' non-operatively.
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http://dx.doi.org/10.1136/bcr-2020-239564DOI Listing
March 2021

Intestinal mucosa staple line integrity and anastomotic leak pressure after healing in a porcine model.

Surg Today 2021 Mar 20. Epub 2021 Mar 20.

Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.

Purpose: The aim of this study was to evaluate both the intestinal mucosa staple line integrity and anastomotic leak pressure after healing in a porcine survival model.

Methods: We used two suture models using two different size staples (incomplete mucosal closure model: group G [staple height 0.75 mm], complete mucosal closure model: group B [staple height 1.5 mm]) in the porcine ileum. Five staple lines were created in each group made in the ileum for each model, and the staple sites harvested on days 0, 2, and 7. The leak pressure at the staple site was measured at each time point.

Results: On day 0, the leak pressure for group G (79.5 mmHg) was significantly lower than that for group B (182.3 mmHg) (p < 0.01). On days 2 and 7, there was no significant difference between groups G and B (171 mmHg and 175.5 mmHg on day 2, 175.5 mmHg and 175.5 mmHg on day 7, p > 0.05). The histological findings in both groups showed similar healing at postoperative days 2 and 7.

Conclusion: The integrity of the mucosal staple lines was associated with the postoperative leak pressure on day 0. However, there was no association with the leak pressure at two days or more postoperatively in a porcine model.
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http://dx.doi.org/10.1007/s00595-021-02267-9DOI Listing
March 2021

Motion analysis of the JHU-ISI Gesture and Skill Assessment Working Set II: learning curve analysis.

Int J Comput Assist Radiol Surg 2021 Mar 15. Epub 2021 Mar 15.

Mechanical Engineering, School of Engineering, The University of Tokyo, Tokyo, Japan.

Purpose: The Johns Hopkins-Intuitive Gesture and Skill Assessment Working Set (JIGSAWS) dataset is used to develop robotic surgery skill assessment tools, but there has been no detailed analysis of this dataset. The aim of this study is to perform a learning curve analysis of the existing JIGSAWS dataset.

Methods: Five trials were performed in JIGSAWS by eight participants (four novices, two intermediates and two experts) for three exercises (suturing, knot-tying and needle passing). Global Rating Scores and time, path length and movements were analyzed quantitatively and qualitatively by graphical analysis.

Results: There are no significant differences in Global Rating Scale scores over time. Time in the suturing exercise and path length in needle passing had significant differences. Other kinematic parameters were not significantly different. Qualitative analysis shows a learning curve only for suturing. Cumulative sum analysis suggests completion of the learning curve for suturing by trial 4.

Conclusions: The existing JIGSAWS dataset does not show a quantitative learning curve for Global Rating Scale scores, or most kinematic parameters which may be due in part to the limited size of the dataset. Qualitative analysis shows a learning curve for suturing. Cumulative sum analysis suggests completion of the suturing learning curve by trial 4. An expanded dataset is needed to facilitate subset analyses.
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http://dx.doi.org/10.1007/s11548-021-02339-8DOI Listing
March 2021

Cholangiocarcinoma Presenting after Eight Years of Treatment of IgG4-Related Autoimmune Pancreatitis with Steroids.

Case Rep Gastroenterol 2021 Jan-Apr;15(1):154-162. Epub 2021 Feb 5.

Department of Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan.

Autoimmune pancreatitis (AIP) is characterized by pancreatic manifestations of IgG4-related disease. Malignancies in patients with AIP have been reported, but carcinoma of the bile duct is extremely rare. We report a patient with IgG4-related AIP who developed cholangiocarcinoma after 8 years of steroid treatment. A 76-year-old male presented with fever (37.8°C) due to biliary obstruction and cholangitis. He had been treated with steroids for 8 years to control inflammation due to IgG4-related AIP. During 8 years of treatment, hepatobiliary enzyme levels were well controlled within their normal range, but serum IgG4 levels remained elevated. A computed tomography scan showed intrahepatic bile duct dilatation. Magnetic resonance cholangiopancreatography showed obstructive changes at the junction of the cystic and common ducts. To relieve biliary obstruction, endoscopic bile duct drainage using a nasobiliary tube was performed, and cytology was Class IV. Aorto-caval lymph node enlargement was found at laparotomy, intraoperatively diagnosed as adenocarcinoma, and resection was abandoned. He died 4 months postoperatively. We report a patient with IgG4-related AIP complicated by cholangiocarcinoma which developed after 8 years of steroid treatment. Even if hepatobiliary markers are well controlled, periodic follow-up with imaging studies may facilitate detection of an early cholangiocarcinoma.
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http://dx.doi.org/10.1159/000512402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923704PMC
February 2021

Cystic Pancreatic Neuroendocrine Tumor in a Patient with Neurofibromatosis Type 1.

Case Rep Gastroenterol 2021 Jan-Apr;15(1):108-114. Epub 2021 Feb 1.

Department of Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan.

Neurofibromatosis type 1 (NF-1) is strongly associated with neurofibromas and malignancies. Solid pancreatic neuroendocrine tumors (PanNETs) have been recently reported in patients with NF-1. PanNETs are always solid and rarely present with a cystic appearance due to central necrosis and hemorrhage caused by rapid growth. A 33-year-old female diagnosed with NF-1 at age 16 was referred for evaluation of a pelvic mass found on abdominal ultrasound. Magnetic resonance imaging showed a 6 cm solid pelvic mass adjacent to the left external iliac artery, and contrast-enhanced computed tomography scan showed a 3-cm solid para-aortic mass and a 3-cm cystic mass in the pancreatic tail. Endoscopic ultrasonography showed a cystic tumor with necrotic tissue and septa. Preoperative diagnosis was pancreatic cystic malignancy with para-aortic lymph node metastasis accompanied with a pelvic neurofibroma. These lesions were resected simultaneously. The specimen resected from the pancreas showed a necrotizing cystic tumor invading abutting lymph nodes. Immunohistochemical analysis showed positive chromogranin A and synaptophysin. The Ki-67 index was <1%, and the mitotic count was 1/10 in high power field. Therefore, a non-functional PanNET (grade G1) was diagnosed. The pelvic and para-aortic tumors were both neurofibromas. A cystic appearance is atypical for PanNET and makes preoperative diagnosis difficult. To the best of our knowledge, this is the first report of a cystic PanNET in a patient with NF-1.
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http://dx.doi.org/10.1159/000510210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923728PMC
February 2021

Ultrasonographically guided percutaneous transhepatic liver biopsy after pediatric liver transplantation.

Pediatr Transplant 2021 Mar 11:e13997. Epub 2021 Mar 11.

Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan.

Background: Complications associated with ultrasonographically guided percutaneous transhepatic liver biopsy (PTLB) after liver transplantation (LT) have been rarely reported, and there is no consensus about its safety. We retrospectively reviewed the safety and outcomes of PTLB after pediatric LT.

Methods: Between January 2008 and December 2019, 8/1122 (0.71%) pediatric patients who underwent ultrasonographically guided PTLB after LT developed complications. The median age at PTLB was 7.8 years (range 0.1-17.9). Grafts included left lobe/left lateral segment in 1050 patients and others in 72. PTLB was performed using local anesthesia±sedation in 1028 patients and general anesthesia in 94.

Results: Complications after PTLB included acute cholangitis in 3 patients, sepsis in 2, respiratory failure due to over-sedation in 1, subcapsular hematoma in 1, and intrahepatic arterioportal fistula in 1. The incidence of complications of PTLB in patients with biopsy alone and those with simultaneous interventions was 0.49% and 3.19%, respectively (p = .023). Patients who developed acute cholangitis, respiratory failure, subcapsular hematoma, and arterioportal fistula improved with non-operative management. Of two patients with sepsis, one underwent PTLB and percutaneous transhepatic portal vein balloon dilatation and developed fever and seizures the following day. Sepsis was treated with antibiotic therapy. Another patient who underwent PTLB and exchange of percutaneous transhepatic biliary drainage catheter developed fever and impaired consciousness immediately. Sepsis was treated with antibiotic therapy, mechanical ventilation, and continuous hemofiltration.

Conclusions: Percutaneous transhepatic liver biopsy after pediatric LT is safe. However, combining liver biopsy with simultaneous procedures for vascular and biliary complications is associated with an increased risk of complications.
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http://dx.doi.org/10.1111/petr.13997DOI Listing
March 2021

Duodenal sessile serrated adenoma/polyp with characteristic endoscopic and pathologic features.

Clin J Gastroenterol 2021 Apr 1;14(2):531-537. Epub 2021 Mar 1.

Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.

Sessile serrated adenomas/polyps (SSA/Ps), recently called sessile serrated lesions, have a neoplastic pathway in the large intestine and are treated as lesions with malignant potential. There are a few reports of traditional serrated adenomas in the duodenum but no reports of duodenal SSA/Ps. A 66-year-old man underwent screening upper gastrointestinal endoscopy and was found to have a white elevated lesion in the second portion of the duodenum. Magnifying blue laser imaging showed various sized villous-like structures with dilated crypt openings in the white surface mucosa, similar to a SSA/P. Based on these images, a duodenal adenoma was suspected at the time of endoscopic resection. Pathological findings of the resected specimen showed a saw-tooth structure corresponding to basal crypt dilatation and branching with mucus and positive immunostaining for MUC6 and MUC2, similar to a colonic SSA/P. MUC5AC did not stain the glandular crypt cells. KRAS mutation was detected. Immunohistochemical expression of Annexin A10 was clearly identified in the lesion. Although not all of molecular biological features were satisfied, these findings were similar to a colonic SSA/P which has malignant potential. This is the first report of a duodenal SSA/P which should be considered when evaluating elevated duodenal lesions.
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http://dx.doi.org/10.1007/s12328-021-01358-xDOI Listing
April 2021

A structured program for teaching pancreatojejunostomy to surgical residents and fellows outside the operating room: a pilot study.

BMC Surg 2021 Feb 25;21(1):102. Epub 2021 Feb 25.

Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.

Background: Pancreatojejunostomy (PJ) is one of the most difficult and challenging abdominal surgical procedures. There are no appropriate training systems available outside the operating room (OR). We developed a structured program for teaching PJ outside the OR. We describe its development and results of a pilot study.

Methods: We have created this structured program to help surgical residents and fellows acquire both didactic knowledge and technical skills to perform PJ. A manual was created to provide general knowledge about PJ and the specific PJ procedure used in our institution. Based on questionnaires completed by trainers and trainees, the procedure for PJ was divided into twelve steps and described in detail. After creating the manual, we developed organ models, needles and a frame box for simulation training. Three residents (PGY3-5) and three fellows (PGY6 or above) participated in a pilot study. Objective and subjective evaluations were performed.

Results: Trainees learn about PJ by reading the procedure manual, acquiring both general and specific knowledge. We conducted simulation training outside the OR using the training materials created for this system. They simulate the procedure with surgical instruments as both primary and assistant surgeon. In this pilot study, as objective assessments, the fellow-group took less time to complete one anastomosis (36 min vs 48 min) and had higher scores in the objective structured assessment of technical skill (average score: 4.1 vs 2.0) compared to the resident-group. As a subjective assessment, the confidence to perform a PJ anastomosis increased after simulation training (from 1.6 to 2.6). Participants considered that this structured teaching program is useful.

Conclusion: We developed a structured program for teaching PJ. By implementing this program, learning opportunities for surgical residents and fellows can be increased as a complement to training in the OR.
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http://dx.doi.org/10.1186/s12893-021-01101-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908720PMC
February 2021

Optimal Upper Limits of Plateau Pressure for Patients With Acute Respiratory Distress Syndrome During the First Seven Days: A Meta-Regression Analysis.

J Clin Med Res 2021 Jan 12;13(1):48-63. Epub 2021 Jan 12.

Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken 329-0498, Japan.

Background: The effects of plateau pressure during the initial days of mechanical ventilation on outcomes for patients with acute respiratory distress syndrome have not been fully examined. We conducted meta-regression analysis of plateau pressure during the first 7 days using randomized control trials to investigate the optimal upper limits of plateau pressure on different days of mechanical ventilation.

Methods: Randomized controlled trials comparing two mechanical ventilation strategies with lower and higher plateau pressures in patients with acute respiratory distress syndrome were included. Meta-regression analysis was performed to determine the association of plateau pressure with mortality on days 1, 3, and 7 of mechanical ventilation.

Results: After evaluation of 2,975 citations from a comprehensive search across electronic databases, 14 studies were included in the final qualitative analysis. A total of 4,984 patients were included in the quantitative analysis. As a result of the pairwise comparison, overall short-term mortality was significantly higher for patients with plateau pressures over 32 cm HO during the first 3 days after intensive care unit (ICU) admission (day 1: relative risk (RR), 0.77; 95% confidence interval (CI), 0.66 - 0.89; I = 0%; day 3: RR, 0.76; 95% CI, 0.64 - 0.90; I = 0%), but not on day 7 (RR, 0.82; 95% CI, 0.65 - 1.04; I = 16%). Plateau pressures below 27 cm HO and 30 cm HO were not associated with an absolute risk reduction of short-term mortality. According to univariable meta-regression analysis, mortality was significantly associated with plateau pressure on day 1 (β = 0.01 (95% CI, 0.002 - 0.024), P = 0.02). On days 3 and 7, however, no significant difference was detected. When the cutoffs were set at 27, 30 and 32 cm HO on day 1, which showed a significant difference, plateau pressure tended to be associated with increased mortality at pressures above the cut-off values, and there were no significant differences at pressures below the cut-off values, regardless of the cutoff used.

Conclusions: This study suggests that the optimal cut-off value for plateau pressure may be 27 cm HO especially during the initial period of mechanical ventilation, although this association may not continue during the latter period of mechanical ventilation.
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http://dx.doi.org/10.14740/jocmr4390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869567PMC
January 2021

Long-term vonoprazan therapy is effective for controlling symptomatic proton pump inhibitor-resistant gastroesophageal reflux disease.

Biomed Rep 2021 Mar 1;14(3):32. Epub 2021 Feb 1.

Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Tochigi 329-0498, Japan.

Vonoprazan, a novel potassium-competitive acid blocker, results in greater inhibition of gastric acid secretion than proton pump inhibitors (PPI). The aim of this study was to assess the long-term outcomes of patients with PPI-resistant gastroesophageal reflux disease (GERD) treated with vonoprazan. The medical records of patients with symptomatic GERD treated with vonoprazan for 1 year were retrospectively reviewed. Changes in abdominal symptoms were assessed using the Izumo scale, a self-reported questionnaire which is useful in evaluating the symptoms of GERD, epigastric pain, postprandial distress, constipation and diarrhea, and is commonly used in routine clinical practice. A total of 30 patients were included and stratified into a non-erosive (n=22) and erosive group (n=8). At baseline, postprandial distress symptoms were significantly greater in the non-erosive group compared with the erosive group (P=0.013). Even with vonoprazan therapy, symptoms of GERD in the non-erosive group were refractory compared with the erosive group, and required additional treatment in a larger proportion of patients (45 vs. 13%). GERD symptoms in the non-erosive group significantly improved from baseline and remained better after 1 year of vonoprazan therapy, similar to the erosive group. In addition, vonoprazan improved epigastric pain and postprandial distress symptoms in the non-erosive group, and 1 year of vonoprazan therapy did not aggravate constipation or diarrhea. In conclusion, 1 year of vonoprazan therapy improves GERD symptoms in patients with PPI-resistant GERD.
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http://dx.doi.org/10.3892/br.2021.1408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873583PMC
March 2021

Back to basics: what is needed for optimal use of ultrasound in the evaluation of pancreatobiliary diseases?

J Med Ultrason (2001) 2021 Jan 13;48(1):1-2. Epub 2021 Feb 13.

Department of Surgery, Jichi Medical University, Shimotsuke, Japan.

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http://dx.doi.org/10.1007/s10396-020-01068-wDOI Listing
January 2021

Solid-pseudopapillary neoplasm of the pancreas in a patient with familial adenomatous polyposis: a case report.

Surg Case Rep 2021 Jan 28;7(1):35. Epub 2021 Jan 28.

Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University School of Medicine, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.

Background: Familial adenomatous polyposis (FAP) is characterized by the presence of hundreds to thousands of colonic polyps, and extracolonic manifestations are likely to occur. Pancreatic tumors are rare extracolonic manifestations in patients with FAP, among which solid-pseudopapillary neoplasm (SPN) are extremely rare. We report here a patient with an SPN of the pancreas found during the follow-up of FAP.

Case Presentation: A 20-year-old woman was diagnosed with FAP 3 years previously by colonoscopy which revealed less than 100 colonic polyps within the entire colon. She complained of left upper abdominal pain and a 10-cm solid and cystic pancreatic tumor was found by computed tomography scan. Solid and cystic components within the tumor were seen on abdominal magnetic resonance imaging. Simultaneous laparoscopic resection of the distal pancreas and subtotal colectomy was performed. Histopathological findings confirmed the pancreatic tumor as an SPN without malignancy. Abnormal staining of beta-catenin was observed by immunohistochemical study. Multiple polyps in the colorectum were not malignant. Molecular biological analysis from peripheral blood samples revealed a decrease in the copy number of the promoter 1A and 1B region of the APC gene, which resulted in decreased expression of the APC gene.

Conclusions: A rare association of SPN with FAP is reported. The genetic background with relation to beta-catenin abnormalities is interesting to consider tumor development. So far, there are few reports of SPN in a patient with FAP. Both lesions were treated simultaneously by laparoscopic resection.
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http://dx.doi.org/10.1186/s40792-021-01121-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843828PMC
January 2021

Perforation of intestinal leiomyosarcoma: A case report.

Int J Surg Case Rep 2021 Feb 19;79:327-330. Epub 2021 Jan 19.

Department of Surgery, Tokyo Bay Medical Center, 3-4-32 Todaijima, Urayasu, Chiba, 279-0001, Japan. Electronic address:

Introduction And Importance: The majority of gastrointestinal sarcoma is gastrointestinal stromal tumors and intestinal leiomyosarcoma is rare. Small intestinal mesenchymal tumors are often large at diagnosis, and they commonly present with bleeding or intussusception. We report a perforation associated with intestinal leiomyosarcoma.

Case Presentation: A 66-year-old man presented with severe epigastric pain. A physical examination showed tachycardia and a diffusely tender and rigid abdomen. Computed tomography showed a massive tumor and free air. A laparotomy was performed to treat lower digestive perforation. Massive tumor, which invaded surrounding intestine, was 20 cm in size at the ileum. The involved intestine was perforated. We confirmed that feeding artery was superior mesenteric artery and performed partial intestinal resection. His clinical course was uneventful and discharged 10 days postoperatively. The pathological findings showed spindle shaped and the tumor invaded the mucosa at the perforated site. Immunohistochemical spectrum resulted c-kit negative, S-100 negative, Desmin positive, alpha smooth muscle actin(αSMA) positive and Ki-67 30-40 %. The pathological findings were leiomyosarcoma.

Discussion: Gastrointestinal sarcoma is sometimes found by bleeding. In our patient, leiomyosarcoma invaded surrounding intestine, it made the intestine wall frail and caused perforation. The intestinal perforation which was involved by leiomyosarcoma has been rarely reported to the best of our knowledge since WHO refined leiomyosarcoma.

Conclusions: Although intestinal leiomyosarcoma is rare, we should know that it can involve surrounding intestines and make them perforated.
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http://dx.doi.org/10.1016/j.ijscr.2021.01.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840855PMC
February 2021

Long-term survival after surgical resection of metachronous lung, brain and thyroid gland metastases from rectal cancer: A case report.

Int J Surg Case Rep 2021 Feb 19;79:318-322. Epub 2021 Jan 19.

Department of Surgery, Jichi Medical University, 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. Electronic address:

Introduction And Importance: Brain and thyroid metastasis from rectal cancer are uncommon, and the prognosis is poor. We report a patient with rectal cancer who developed metachronous lung, brain and thyroid metastases. Each metastatic lesion was curatively resected resulting in prolonged survival.

Case Presentation: A 60-year-old male underwent rectal cancer resection, and the pathological diagnosis was tubular adenocarcinoma, pT2,pN1a,M0, pStageⅢa. Ten years after rectal resection, a solitary tumor in the left lung was detected. The tumor was resected thoracoscopically and the pathological diagnosis was metastatic tumor. Three years after the pulmonary resection, a solitary brain tumor was detected. The tumor was removed surgically, and the pathology was metastatic tumor. Two years after brain resection, a thyroid mass was detected. A partial thyroidectomy was performed and the pathology with immunohistochemical staining confirmed the thyroid lesion as a metastasis from the previous rectal cancer. Four years after thyroid resection (19 years after the initial rectal resection), he died from multiple lung and bone metastases.

Clinical Discussion: Colorectal metastases to the brain and thyroid gland are uncommon and are usually found with other distant metastases. Overall survival has been reported to be extremely poor. In this patient, lung, brain, and thyroid metastases were solitary and metachronous, and each lesion was curatively resected. Surgical treatment might contribute to prolonged survival.

Conclusion: The treatment strategy of each patient should be individualized and depends on the timing of metastasis development. Selected patients with complete resection of metachronous metastases may have prolonged survival.
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http://dx.doi.org/10.1016/j.ijscr.2021.01.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840810PMC
February 2021

Peliosis Hepatis in a Child with X-Linked Myotubular Myopathy Treated with Living-Donor Liver Transplant: A Case Report.

Transplant Proc 2021 Jan 16. Epub 2021 Jan 16.

Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Tochigi-ken, Japan.

Background: Myotubular myopathy is a rare disease sometimes accompanied by peliosis hepatis, a leading cause of fatal liver hemorrhage.

Case Report: We present a case of a 2-year-old boy with myotubular myopathy who developed liver hemorrhage because of peliosis hepatis and was successfully treated with living-donor liver transplant. The patient initially presented with fever, anemia, and liver dysfunction. A computed tomographic scan revealed hemorrhages in the liver, and the patient underwent hepatic artery embolization twice. After the second embolization, multiple peliosis hepatis cavities appeared in the left lobe of the liver that had increased in size. Therefore, the patient underwent ABO-incompatible living-donor liver transplant using a lateral segment graft from his father. The patient developed severe septic shock with an unknown focus on postoperative day 18, which resolved with antibiotic therapy. On postoperative day 62, he was discharged. Fourteen months after undergoing living-donor liver transplant, the patient showed no recurrence of peliosis hepatis.

Conclusions: Although the long-term prognosis of peliosis hepatis due to myotubular myopathy after living-donor liver transplant remains unclear, liver transplant may be a curative treatment for patients with myotubular myopathy who have uncontrollable peliosis hepatis.
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http://dx.doi.org/10.1016/j.transproceed.2020.10.033DOI Listing
January 2021

Flow cytometry detection of cell type-specific expression of programmed death receptor ligand-1 (PD-L1) in colorectal cancer specimens.

Heliyon 2021 Jan 31;7(1):e05880. Epub 2020 Dec 31.

Department of Gastrointestinal Surgery, Jichi Medical University, Japan.

Aim: PD-1/PD-L1 blockade therapy is now widely used for the treatment of advanced malignancies. Although PD-L1 is known to be expressed by various host cells as well as tumor cells, the role of PD-L1 on non-malignant cells and its clinical significance is unknown. We evaluated cell type-specific expression of PD-L1 in colorectal cancer (CRC) specimens using multicolor flow cytometry.

Methods: Single cell suspensions were made from 21 surgically resected CRC specimens, and immunostained with various mAbs conjugated with different fluorescent dyes. Tumor cells, stromal cells, and immune cells were identified as CD326(+), CD90(+) and CD45(+) phenotype, respectively. CD11b(+) myeloid cells, CD19(+) B cells and CD4(+) or CD8(+) T cells were also stained in different samples, and their frequencies in the total cell population and the ratio of PD-L1(+) cells to each phenotype were determined.

Results: PD-L1 was expressed by all the cell types. The ratio of PD-L1(+) cells to CD326(+) tumor cells was 19.1% ± 14.0%, lower than those for CD90(+) stromal cells (39.6% ± 16.0%) and CD11b(+) myeloid cells (31.9% ± 14.3%). The ratio of PD-L1(+) cells in tumor cells correlated strongly with the ratio in stromal cells, while only weakly with that in myeloid cells. Tumor cells were divided into two populations by CD326 expression levels, and the PD-L1 positive ratios were inversely correlated with the rate of CD326 highly expressing cells as well as mean fluorescein intensity of CD326 in tumor cells, while positively correlated with the frequencies of stromal cells or myeloid cells in CRC.

Conclusion: PD-L1 is differentially expressed on various cell types in CRC. PD-L1 on tumor cells may be upregulated together with CD326 downregulation in the process of epithelial mesenchymal transition. Quantification of cell type-specific expression of PD-L1 using multicolor flow cytometry may provide useful information for the immunotherapy of solid tumors.
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http://dx.doi.org/10.1016/j.heliyon.2020.e05880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797507PMC
January 2021

Factors associated with difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases: A nationwide population-based observational study.

PLoS One 2021 12;16(1):e0245318. Epub 2021 Jan 12.

Department of Emergency Medicine, International University of Health and Welfare, Nasushiobara, Tochigi, Japan.

Although it is essential to shorten the interval to initial treatment in the care of acute ischemic stroke, some hospitals in Japan reject requests for hospital acceptance from on-scene emergency medical service personnel because of limited resources, which can cause delays in care. We aimed to assess the risk factors for difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases. We conducted a retrospective analysis of the national ambulance records of the Fire and Disaster Management Agency in Japan in 2016. Multivariable logistic regression analysis was used to assess the association between difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases and prehospital factors. During the study period, a total of 222,926 patients were included, and 5283 patients (2.4%) experienced difficulties in hospital acceptance. In multivariable analysis, nights (adjusted odds ratio [AOR] 1.54, 95% confidence interval [CI] 1.45-1.64), weekends (AOR 1.32, 95% CI 1.24-1.40), <25 percentile ratio of emergency physicians and neurosurgeons to all physicians (AOR 1.13, 95% CI 1.03-1.23) (AOR 1.36, 95% CI 1.25-1.48), and mean age of physicians (AOR 1.06, 95% CI 1.05-1.07) were significantly associated with difficulties of hospital acceptance of patients suspected to have cerebrovascular disease. There was a marked regional variation in the difficulties of hospital acceptance. Among the national ambulance records of patients suspected to have cerebrovascular diseases, certain prehospital factors such as weekends were positively associated with difficulty of hospital acceptance. A comprehensive strategy for hospital acceptance of patients with cerebrovascular diseases considering regional variation is required.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245318PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802939PMC
January 2021

ASO Author Reflections: Repeated Intraperitoneal Paclitaxel with Systemic Chemotherapy as the First-Line Treatment for Peritoneal Malignancy.

Ann Surg Oncol 2021 Jan 11. Epub 2021 Jan 11.

Department of Gastrointestinal Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan.

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http://dx.doi.org/10.1245/s10434-020-09417-2DOI Listing
January 2021

What is the background for the histological diagnosis of autoimmune pancreatitis?

Dig Endosc 2020 Dec 30. Epub 2020 Dec 30.

Division of Gastroenterology, Departments of, Department of, Medicine, Jichi Medical University, Tochigi, Japan.

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http://dx.doi.org/10.1111/den.13917DOI Listing
December 2020

The provisional extension to induce complete attachment technique is associated with abdominal aortic remodeling and reduces aorta-related adverse events after aortic dissection.

J Vasc Surg 2020 Dec 16. Epub 2020 Dec 16.

Department of Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan.

Objective: This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique.

Methods: In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively.

Results: Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64).

Conclusions: This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.
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http://dx.doi.org/10.1016/j.jvs.2020.11.038DOI Listing
December 2020

Flow cytometry-based analysis of tumor-leukocyte ratios in peritoneal fluid from patients with advanced gastric cancer.

Cytometry B Clin Cytom 2020 Dec 4. Epub 2020 Dec 4.

Department of Gastrointestinal Surgery, Jichi Medical University, Shimotsuke, Japan.

Background: The frequency of tumor cell dissemination in the peritoneal cavity is critically related to the progression of peritoneal metastases (PM). Recently, flow cytometry (FCM) has been successfully used to detect tumor cells in malignant effusions.

Methods: A total of 143 single cell suspensions derived from ascites or peritoneal lavages from patients with advanced gastric cancer (GC) were stained with monoclonal antibodies to CD45 and to CD326 as well as 4,6-diamidino-2-phenylindole (DAPI) and FVS780. Using FCM, tumor-leukocyte ratio (TLR) were calculated from CD45(-)CD326(+) tumor cell counts/ CD45(+)CD326(+) leukocyte counts in DAPI (+) FVS780(-) gated area. In 54 patients, the ratios of CD11b(+), CD4(+) and CD8(+) cells in CD45(+) leukocytes were evaluated in parallel.

Results: TLR of 69 patients with PM were significantly higher than those of 74 without PM (p < .001) and log(TLR) showed strong correlation with peritoneal cancer index scores in 51 PM (+) patients (r = 0.439). TLR in PM (+) patients also correlated with the ratio of CD11b (+) myeloid cells (r = 0.547), and correlated inversely with those of CD4(+) (r = -0.490) and CD8(+) T cells (r = -0.648). In PM (-) patients who underwent gastrectomy, TLR never exceeded 0.1% in patients with primary GC without serosal involvement (
Conclusion: TLR in peritoneal fluid reflects tumor burden and the immune environment in peritoneal cavity. Multicolor FCM may provide additional information which can be used for the treatment of the patients with PM.
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http://dx.doi.org/10.1002/cyto.b.21978DOI Listing
December 2020

Intraperitoneal Administration of Paclitaxel Combined with S-1 Plus Oxaliplatin as Induction Therapy for Patients with Advanced Gastric Cancer with Peritoneal Metastases.

Ann Surg Oncol 2020 Dec 3. Epub 2020 Dec 3.

Department of Gastrointestinal Surgery, Jichi Medical University, Tochigi, Japan.

Background: Intraperitoneal (IP) administration of paclitaxel (PTX) has a great pharmacokinetic advantage to control peritoneal lesions and can be combined with various systemic chemotherapies. In this study, we evaluate the efficacy and tolerability of a combination of IP-PTX and systemic S-1/oxaliplatin (SOX) for induction chemotherapy for patients with peritoneal metastases (PM) from gastric cancer (GC).

Patients And Methods: Patients with GC who were diagnosed as macroscopic PM (P1) or positive peritoneal cytology (CY1) by staging laparoscopy between 2016 and 2019 were enrolled. PTX was IP administered at 40 mg/m on days 1 and 8. Oxaliplatin was IV administered at 100 mg/m on day 1, and S-1 was administered at 80 mg/m/day for 14 consecutive days, repeated every 21 days. Survival time and toxicities were retrospectively explored.

Results: Forty-four patients received SOX + IP-PTX with a median (range) of 16 (1-48) courses, although oxaliplatin was suspended due to the hematotoxicity or intolerable peripheral neuropathy in many patients. The 1-year overall survival (OS) rate was 79.5% (95% CI 64.4-88.8%) with median survival time of 25.8 months. Gastrectomy was performed in 20 (45%) patients who showed macroscopic shrinkage of PM with a 1-year OS rate of 100% (95% CI 69.5-100%). Grade 2 and 3 histological responses was achieved in four (20%) and one (5%) patients. Grade 3/4 toxicities included neutropenia (11%), leukopenia (39%), and anemia (14%). There were no treatment-related deaths.

Conclusions: Combination chemotherapy using SOX + IP-PTX regimen is highly effective and recommended as induction chemotherapy for patients with PM from GC.
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http://dx.doi.org/10.1245/s10434-020-09388-4DOI Listing
December 2020