We encountered a case of hypercobalaminemia induced by oral intake of an energy drink after total gastrectomy. The patient was referred to our hospital due to findings suspicious for gastric cancer on screening. A 20 mm type 0-IIc lesion was detected in the gastric subcardia on esophagogastroduodenoscopy. Total gastrectomy followed by Roux-en-Y reconstruction was performed. He was discharged without complications. His basal serum vitamin B₁₂ level was initially maintained with monthly intramuscular injections of vitamin B₁₂. After 9 months, his serum vitamin B₁₂ level suddenly increased up to 36-fold higher than the normal range and persisted there for one year without vitamin B₁₂ injections. The patient ultimately reported consuming half a bottle of an energy drink each day during this time period. This case demonstrates the risk of unexpected hypervitaminemia resulting from self-administration of nutritional supplements.

A 71-year-old woman underwent gastrostomy due to malnutrition resulting from impaired esophageal peristalsis due to scleroderma. However, the gastrostomy tube was removed due to worsening of difficult-to-treat dermatitis around the gastrostomy. An intractable gastrocutaneous fistula with persistent gastric juice leakage and peri-gastrostomy dermatitis was treated with fistulotomy and local negative pressure closure therapy under local anesthesia. Spontaneous closure of an intractable fistula after gastrostomy removal can be difficult due to underlying malnutrition and exposure to leaking gastric juice, among other factors. The present case suggests that fistulectomy followed by local negative pressure closure therapy for an intractable fistula after gastrostomy removal can enable oral intake in the early postoperative period and also facilitate wound management.

PURPOSE: In cardiac 2-[F-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) examination, interpretation of myocardial viability in the low uptake region (LUR) has been difficult without additional perfusion imaging. We evaluated distribution patterns of FDG at the border zone of the LUR in the cardiac FDG-PET and established a novel parameter for diagnosing myocardial viability and for discriminating the LUR of normal variants. MATERIALS AND METHODS: Cardiac FDG-PET was performed in patients with a myocardial ischemic event (n = 22) and in healthy volunteers (n = 22). Whether the myocardium was not a viable myocardium (not-VM) or an ischemic but viable myocardium (isch-VM) was defined by an echocardiogram under a low dose of dobutamine infusion as the gold standard. FDG images were displayed as gray scaled-bull's eye mappings. FDG-plot profiles for LUR (= true ischemic region in the patients or normal variant region in healthy subjects) were calculated. Maximal values of FDG change at the LUR border zone (a steepness index; S(max) scale/pixel) were compared among not-VM, isch-VM, and normal myocardium. RESULTS: S(max) was significantly higher for n-VM compared to those with isch-VM or normal myocardium (ANOVA). A cut-off value of 0.30 in Smax demonstrated 100% sensitivity and 83% specificity for diagnosing n-VM and isch-VM. S(max) less than 0.23 discriminated LUR in normal myocardium from the LUR in patients with both n-VM and isch-VM with a 94% sensitivity and a 93% specificity. CONCLUSION: S(max) of the LUR in cardiac FDG-PET is a simple and useful parameter to diagnose n-VM and isch-VM, as well as to discriminate thr LUR of normal variants.
Aged ; Aged, 80 and over ; Echocardiography ; Female ; Fluorodeoxyglucose F18/*metabolism ; Humans ; Male ; Middle Aged ; Myocardial Infarction/metabolism/pathology ; Myocardium/*metabolism/*pathology ; Positron-Emission Tomography ; Young Adult

OBJECTIVE: To examine the surgical-pathological predictors of para-aortic lymph node (PAN) metastasis at radical hysterectomy, and for PAN recurrence among women who did not undergo PAN dissection at radical hysterectomy. METHODS: This is a retrospective analysis of a nation-wide cohort study of surgically-treated stage IB–IIB cervical cancer (n=5,620). Multivariate models were used to identify independent surgical-pathological predictors for PAN metastasis/recurrence. RESULTS: There were 120 (2.1%) cases of PAN metastasis at surgery with parametrial involvement (adjusted odds ratio [aOR]=1.65), deep stromal invasion (aOR=2.61), ovarian metastasis (aOR=3.10), and pelvic nodal metastasis (single-node aOR=5.39 and multiple-node aOR=33.5, respectively) being independent risk factors (all, p<0.05). Without any risk factors, the incidence of PAN metastasis was 0.9%, while women exhibiting certain risk factor patterns (>20% of the study population) had PAN metastasis incidences of ≥4%. Among 4,663 clinically PAN-negative cases at surgery, PAN recurrence was seen in 195 (4.2%) cases that was significantly higher than histologically PAN-negative cases (2.5%, p=0.046). In clinically PAN-negative cases, parametrial involvement (adjusted hazard ratio [aHR]=1.67), lympho-vascular space invasion (aHR=1.95), ovarian metastasis (aHR=2.60), and pelvic lymph node metastasis (single-node aHR=2.49 and multiple-node aHR=8.11, respectively) were independently associated with increased risk of PAN recurrence (all, p<0.05). Without any risk factors, 5-year PAN recurrence risk was 0.8%; however, women demonstrating certain risk factor patterns (>15% of the clinically PAN-negative population) had 5-year PAN recurrence risks being ≥8%. CONCLUSION: Surgical-pathological risk factors proposed in this study will be useful to identify women with increased risk of PAN metastasis/recurrence.
Cohort Studies ; Female ; Humans ; Hysterectomy ; Incidence ; Lymph Nodes ; Neoplasm Metastasis ; Odds Ratio ; Recurrence ; Retrospective Studies ; Risk Factors ; Uterine Cervical Neoplasms

Objective: The purposes of this trial were to demonstrate the feasibility and effectiveness of the hybrid of intracavitary and interstitial brachytherapy (HBT) for locally advanced cervical cancer patients in the phase I/II prospective clinical trial. Methods: Patients with FIGO stage IB2-IVA uterine cervical cancer pretreatment width of which was ≥5 cm measured by magnetic resonance imaging were eligible for this clinical trial. The protocol therapy included 30–30.6 Gy in 15–17 fractions of whole pelvic radiotherapy concurrent with weekly CDDP, followed by 24 Gy in 4 fractions of HBT and pelvic radiotherapy with a central shield up to 50–50.4 Gy in 25–28 fractions. The primary endpoint of phase II part was 2-year pelvic progression-free survival (PPFS) rate higher than historical control of 64%. Results: Between October 2015 and October 2019, 73 patients were enrolled in the initial registration and 52 patients proceeded to the secondary registration. With the median follow-up period of 37.3 months (range, 13.9–52.9 months), the 2- PPFS was 80.7% (90% confidence interval [CI]=69.7%–88%). Because the lower range of 90% CI of 2-year PPFS was 69.7%, which was higher than the historical control ICBT data of 64%, therefore, the primary endpoint of this study was met. Conclusion The effectiveness of HBT were demonstrated by a prospective clinical study. Because the dose goal determined in the protocol was lower than 85 Gy, there is room in improvement for local control. A higher dose might have been needed for tumors with poor responses.

Simultaneous creation of an enterostomy for enteral nutrition during esophagectomy has been useful in our experience, but bowel obstruction associated with intestinal fistula remains a problem. Therefore, in this study, we retrospectively reviewed 18 patients with esophageal cancer who underwent transdiaphragmatic transgastric tube enteral feeding catheter placement during gastric tube reconstruction via the mediastinal route after esophagectomy from November 2012 to March 2014. The catheter was guided from the gastric tube into the gastrointestinal tract, with the tip placed in the jejunum distal to the ligament of Treitz. From the gastric tube, the catheter was guided along the diaphragm to the anterior abdominal wall through the extraperitoneal route. No bowel obstruction associated with catheter placement has been observed in any of the patients from the time of surgery to this writing. Also, the procedure enabled jejunostomy use for more than 5 years, similar to conventional jejunostomy. We experienced 1 case of catheter deviation into the mediastinum. Overall, transgastric tube enteral feeding catheter placement for reconstruction of the posterior mediastinal gastric tube was useful for avoiding intestinal obstruction associated with jejunostomy. However, there may be a risk of catheter displacement into the mediastinum.

We report here 2 cases of traumatic diaphragmatic hernia. Case 1 was a 76-year-old man who was injured in a road traffic accident (RTA). Chest X-ray and computed tomography (CT) revealed prolapse of the stomach into the left thoracic cavity. We performed laparotomy with a diagnosis of traumatic left diaphragmatic hernia. A 12-cm hole was seen in the central tendon of the left diaphragm and this was repaired by suturing. Case 2 was a 75-year-old man who was also injured in an RTA. Chest X-ray and CT revealed prolapse of the stomach and transverse colon into the left thoracic cavity. We performed laparotomy with a diagnosis of traumatic left diaphragmatic hernia. A 15-cm hole was seen in the central tendon of the left diaphragm and this was repaired by suturing. Traumatic diaphragmatic hernia is a relatively rare condition and one that requires surgical repair. It is important to make prompt diagnosis with appropriate radiological investigations. Additionally, patients with diaphragm hernia caused by blunt trauma often have injuries to other organs. Care should be taken so as not to miss associated injuries.