We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

Background/Aims: High-grade pancreatic intraepithelial neoplasia and invasive pancreatic duc-tal adenocarcinoma ≤10 mm are targets for early detection of pancreatic cancer. However, their imaging characteristics are unknown. We aimed to identify endoscopic ultrasound findings for the detection of these lesions. Methods: Patients diagnosed with high-grade pancreatic intraepithelial neoplasia (n=29), pan-creatic ductal adenocarcinoma ≤10 mm (n=11) (who underwent surgical resection), or benignmain pancreatic duct stenosis (n=20) between January 2014 and January 2021 were retrospectively included. Six features differentiating these lesions were examined by endoscopic ultraso-nography: main pancreatic duct stenosis, upstream main pancreatic duct dilation, hypoechoic areas surrounding the main pancreatic duct irregularities (mottled areas without demarcation or round areas with demarcation), branch duct dilation, prominent lobular segmentation, and atrophy. Interobserver agreement was assessed by two independent observers. Results: Hypoechoic areas surrounding the main pancreatic duct irregularities were observedmore frequently in high-grade pancreatic intraepithelial neoplasia (82.8%) and pancreatic ductal adenocarcinoma ≤10 mm (90.9%) than in benign stenosis (15.0%) (p<0.001). High-grade pan-creatic intraepithelial neoplasia exhibited mottled hypoechoic areas more frequently (79.3% vs 18.9%, p<0.001), and round hypoechoic areas less frequently (3.4% vs 72.7%, p<0.001), than pancreatic ductal adenocarcinoma ≤10 mm. The sensitivity and specificity of hypoechoic areas for differentiating high-grade pancreatic intraepithelial neoplasia, pancreatic ductal adenocarci-noma ≤10 mm, and benign stenosis were both 85.0%, with moderate interobserver agreement. Conclusions The hypoechoic areas surrounding main pancreatic duct irregularities on endo-scopic ultrasound may differentiate between high-grade pancreatic intraepithelial neoplasia, pan-creatic ductal adenocarcinoma ≤10 mm, and benign stenosis (Trial Registration: UMIN Clinical Trials Registry (UMIN000044789).

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.

Objective: Frailty has been noticed as an important preoperative risk factor for cardiac surgery. The purpose of this study was to evaluate the effect of frailty on the rehabilitation process and walking ability after cardiac surgery. Methods: A total of 213 patients aged 65 years or older who underwent elective cardiac surgery at our hospital between August 2018 and October 2020 and who underwent a preoperative frailty assessment were included. The patients were divided into two groups: group F with frailty and group N without frailty, and the perioperative factors, postoperative course, and walking ability in both groups were examined. Results: Of all patients, 70 (33%) were diagnosed as frail. In the preoperative factors, gait speed and grip strength were significantly lower in group F, and there were more cases of sarcopenia and malnutrition. There was no significant difference in surgical factors between the two groups, except for a bias in the surgical category. In the postoperative course, there were no significant differences in intubation time, ICU stay, postoperative complications, or hospital stay between the two groups, but more patients in group F were transferred to another hospital. In the F group, the start of walking and the day of achieving 100 m walking were significantly delayed, and the number of patients who achieved 300 m walking was 52 (74%), which was significantly lower than 197 (89%) in the N group. The cutoff value of gait speed was 0.88 m/s. Conclusions: Frailty was associated with delayed rehabilitation and reduced walking ability after cardiac surgery, and increased hospital transfers. In addition, the preoperative gait speed was adopted as one of the factors related to the possibility of a 300 m walk after surgery. We believe that preoperative rehabilitation is a promising strategy to improve the condition of frail patients who require cardiac surgery.

Methods: Five formalin-embalmed human cadavers were used. We assessed the proportion of segmental arteries and veins that intersected the IVD in the L2–L5 range and their course on the anterior part of the spinal column. Results: The segmental arteries and veins commonly intersect the anterior part of the IVD (artery, 28.1%; vein, 42.1%). Seven of 10 (70%) segmental arteries at L2 intersected the IVD, but only one artery intersected the IVD at L3 and L4. The proportions of segmental veins that intersected the IVD were 60%, 50%, and 16.7% at L2, L3, and L4, respectively. Conclusions The segmental arteries and veins frequently intersect the IVD in the anterior part of the spinal column. Therefore, it is necessary to consider these individual anatomical features to prevent vascular damage during lateral lumbar interbody fusion surgery.

Methods: HFCs were obtained from patients with LSS who underwent surgery. HFCs were stimulated by tumor necrosis factor-α (TNF-α) and a p38 MAP kinase inhibitor, SB203580. Phosphorylation of the p38 MAP kinase was analyzed by western blotting. The concentration of interleukin-6 (IL-6) in the conditioned medium was measured by enzyme-linked immunoassay and IL-6 messenger RNA expression levels were determined by real-time polymerase chain reaction. Results: TNF-α induced the phosphorylation of p38 MAP kinase in a time-dependent manner, which was suppressed by the p38 MAP kinase inhibitor, SB203580. TNF-α also stimulated IL-6 release in both a time- and dose-dependent manner. On its own, SB203580 did not stimulate IL-6 secretion from HFCs; however, it dramatically suppressed the degree of IL-6 release stimulated by TNF-α from HFCs. Conclusions This is the first report suggesting that TNF-α stimulates the gene expression and protein secretion of IL-6 via p38 MAP kinase in HFCs. A noted association between tissue hypertrophy and inflammation suggests that the p38 MAP kinase inflammatory pathway may be a therapeutic molecular target for LSS.

This study aimed to explore the association between various levels of training-energy expenditure (TrEE) and nutritional response during the phases of periodization among male collegiate rugby players. Seventeen Japanese male collegiate rugby players were enrolled in the study. Their TrEE and dietary intake were assessed each day during three separate microcycle training phases in the preparatory phase of periodization (P1 and P2: general training phase consisting of two sessions per day over the term during which the school held classes and during a summer vacation, respectively; and P3: intensive training phase consisting of four sessions per day during a summer vacation) using the factorial method and dietary records, respectively. The TrEE for P3 (1644±273 kcal) was significantly higher than that for P1 (891±230 kcal). However, the total energy intake (EI) for P3 (3274±889 kcal) was significantly lower than that for P1 (3978±938 kcal). The daytime (after waking in the morning and before the evening training session) EI (242±159 kcal) and protein intake (19±12 g) from the ‘high-protein foods group’ during P3 was significantly reduced compared with that during P1 (465±252 kcal, 37±15 g), whereas, EI and carbohydrate intake from the ‘supplements group’ of P3 was significantly increased compared with P1. The increased TrEE during P3 was not compensated by EI; instead, there was a decreased nutrient intake from the high-protein foods group and increased intake from the supplements group. The time of day of multiple or intensive training sessions, i.e. different TrEE, might affect the food choices made by male rugby players.