Hideya Kashihara

Introduction: We present a case of simultaneous ureterovaginal and rectovaginal fistulas caused by continuous placement of a cube pessary without daily removal, successfully managed through a multidisciplinary approach. Case Presentation: An 84‐year‐old female managed with a cube pessary presented with hematochezia. Initial imaging revealed simultaneous pessary penetration into the rectum and right ureterovesical junction. A previous hospital first performed a sigmoid colostomy and an unsuccessful transvaginal rectovaginal fistula closure. Following this, a ureteral stent was placed for the ureterovaginal fistula, but it also failed to close due to extensive tissue defects. She was referred to our hospital, where a multidisciplinary surgery incorporating retroperitoneal extravesical ureteroneocystostomy, transvaginal fistula closure, and anterior colporrhaphy was performed. Conclusion: Cube pessaries require daily self‐management, and continuous placement in elderly patients can lead to severe ischemic complications. Multidisciplinary surgical reconstruction is crucial to preserve renal function and restore quality of life.

To investigate the effect of vagotomy on duodenal-jejunal bypass (DJB) during the early postoperative period in a rat model of type 2 diabetes mellitus (T2DM). Nonobese T2DM rats were allocated to three groups: sham, DJB, and DJB with vagotomy. On postoperative day 1, oral glucose tolerance tests were performed, and changes in glucose transporter expression in the small intestine were evaluated. The expression of c-Fos, a nerve activation marker, was evaluated in the nucleus tractus solitarius. DJB surgery improves glucose tolerance and alters glucose transporter expression in the alimentary limb. However, these effects were not observed in the DJB surgery with vagotomy group. c-Fos expression was lower in the DJB with vagotomy group than in the DJB group. The results suggest that the effect of DJB surgery on the blood glucose levels in the very early postoperative period may be associated with the vagal nerve system.

Patients' characteristics in hinotori and dV cases.

Background: The concepts examined in tumor metabolism research have been moving away from cancer cells themselves and the tumor microenvironment has become a focus of investigation. Epigenetic changes affecting glucose metabolism in cancer‐associated fibroblasts (CAFs) in the tumor microenvironment regulate the malignancy of cancer cells. Light‐emitting diode (LED) have several functional effects, including anti‐tumor effects, through a variety of mechanisms. We previously reported that blue LED irradiation had an anti‐tumor effect via Opsin 3 that suppress CAF function in vivo and in vitro. However, the detailed mechanism by which LED affect CAF regulation remained unclear.Methods: CAFs were induced from human intestinal fibroblasts co‐cultured with colon cancer cells. Using lactate assays and reverse transcription‐quantitative PCR, the effects of LED irradiation on glycolysis in CAFs were investigated. The effects of LED irradiation for metabolic coupling were evaluated in vitro.Results: Reverse transcription‐quantitative PCR showed higher expression of CAF marker genes in induced CAFs. Blue LED irradiation of induced CAFs suppressed their ability to promote characteristics of tumor malignancy of colon cancer cell line. LED treatment decreased expression of glycolysis markers, including phosphofructokinase and monocarboxylate transporter 4, indicating inhibition of glycolytic activity in CAFs. Extracellular secretion of lactate from CAFs was decreased by LED irradiation.Conclusions: Blue LED irradiation targeted metabolic coupling between CAFs and colon cancer cells, thereby reducing the promotion of tumor progression by CAFs. Blue LED targeting glucose metabolism in CAFs is a promising anti‐cancer treatment option.

Purpose To investigate the feasibility of combined robotic rectal surgery and transanal total mesorectal excision (hybrid robotic surgery). Methods Among 143 robotic rectal surgeries performed from 2017 to 2022, 85 were hybrid robotic surgeries and were analyzed in this study. The cohort comprised 59 males and 26 females with a mean age of 65.8 years old and a mean body mass index of 22.6 kg/m². The cStage was I in 20 cases, II in 21, III in 36, IV in 4, and other in 4. The operation types were low anterior resection in 21 cases, intersphincteric resection in 27, abdominoperineal resection in 32, total pelvic exenteration in 2, and other in 3. Twelve patients (14.1%) received neoadjuvant chemotherapy or chemoradiotherapy, and 39 (45.9%) underwent lateral lymph node dissection. Results The mean operation time for total mesorectal excision was 302.7 min, and the median blood loss was 71.5 ml. No cases required conversion to laparotomy. The median length of postoperative hospital stay was 15.9 days. Complications of Clavien-Dindo grade ≥ 3 occurred in 3 cases (4.2%). Urinary dysfunction occurred in 6 cases (8.3%). Three (4.2%) patients were diagnosed with positive circumferential resection margins. Conclusion Hybrid robotic surgery is safe and oncologically feasible.

Background: The use of robotic surgery (RS) for gastric cancer (GC) has been rapidly increasing. However, the utility of RS for advanced GC (AGC), especially T3 or more AGC, is unclear. Methods: Ninety patients who underwent curative upfront minimally invasive surgery (MIS) (D2 lymph node dissection) for fStage II or III GC were enrolled in this study. Among these patients, 68 underwent MIS for T3 or more AGC. Thirty‐six patients underwent RS, and 32 patients underwent laparoscopic surgery (LS). The short‐term and long‐term surgical outcomes were compared between the two groups. Results: In the T3 or more AGC cohort, there were no significant intergroup differences in the operative time or blood loss volume. The number of retrieved lymph nodes tended to be higher in the RS than LS group (38.5 vs. 33.0, p = .11). The drain amylase content on postoperative day 1 was significantly lower in the RS than LS group (243.5 vs. 521.0 IU/L, p < .01). The morbidity rate (Clavien–Dindo grade ≥2) was similar between the groups. There were no significant differences between the LS and RS groups in the 3‐year overall survival rate (80.7% vs. 74.5%, respectively; p = .95) or 3‐year disease‐free survival rate (75.0% vs. 69.7%, respectively; p = .95). Conclusions: RS for primary T3 or more AGC was safe and contributed to similar short‐term and long‐term outcomes compared with LS.

Introduction:We investigated the effect of Daikenchuto (TU-100) on the early postoperative period in duodenal-jejunal bypass (DJB). Methods:Study 1:The effect of TU-100 on diabetic rats was investigated. Rats were sacrificed after receiving TU-100 for one week. Study 2:The effect of TU-100 on DJB was investigated. Rats in the DJB and TU-100 treated DJB groups were sacrificed 24 hours postoperation to evaluate blood glucose, cytokine expression, and gut microbiome. Results:Study 1:TU-100 did not affect glucose or body weight. TU-100 suppressed intestinal inflammation and modified the gut microbiome. Specifically, Bifidobacterium and Blautia were increased, and Turicibacter were decreased in this group. Study 2:Both DJB and TU-100 treated DJB rats showed lower blood glucose at 24 hours postoperation than at preoperation. Cytokine expression in the liver and small intestine of the TU-100 treated DJB group was significantly lower than that of the DJB group. The gut microbiome composition in TU-100 treated DJB rats was altered. In particular, Bifidobacterium and Blautia were increased in this group. Conclusion:DJB suppressed blood glucose during the early postoperative period. TU-100 may enhance the anti-diabetic effect of metabolic surgery by changing the gut microbiome and suppressing inflammation in the early postoperative period. J. Med. Invest. 71 : 210-218, August, 2024

Metabolic surgery is an effective treatment for patients with type 2 diabetes mellitus (T2DM). The aim of this study was to investigate the effect of duodenal-jejunal bypass (DJB) in a rat model of T2DM during the early postoperative period. A rat model of non-obese T2DM was allocated to two groups: a sham group and a DJB group. On postoperative day 1 (1POD), oral glucose tolerance testing (OGTT) was performed and the changes of glucose transporter expressions in the small intestine was evaluated. [18F]-fluorodeoxyglucose ([18]-FDG) uptake was measured in sham- and DJB-operated rats using positron emission tomography-computed tomography (PET-CT). DJB improved the glucose tolerance of the rats on 1POD. The expression of sodium-glucose cotransporter 1 (SGLT1) and glucose transporter 1 (GLUT1) was high, and that of GLUT2 was low in the alimentary limb (AL) of rats in the DJB group. PET-CT showed that [18F]-FDG uptake was high in the proximal jejunum of DJB-operated rats. These results may show that DJB improve glucose tolerance in very early postoperative period as the result of glucose accumulation in the AL because of changes in glucose transporter expression.

Background The aim of this study is to investigate the factors correlated with long-term weight loss and diabetes mellitus (DM) remission after laparoscopic sleeve gastrectomy (LSG). Methods Sixteen obese patients who underwent LSG were enrolled in this study (male/female: 5/11, mean age: 44.0 years, mean body weight: 127.5 kg, mean body mass index: 47.4 kg/m², DM: n = 11). We investigated the percent excess weight loss (%EWL), %TWL, and DM remission 3 years post-operation and the factors correlated with long-term weight loss and DM remission after LSG. Results The %EWL 3 years post-operation was 49.6%, while the %TWL was 24.0%. Complete remission (CR) of DM was 54.5% and an improvement occurred in 18.2% of cases 3 years post-operation, whereas there was no change in 27.3% of cases. The factor correlated with a %EWL ≥ 50% 3 years post-operation was a better %EWL at 1 year post-operation. Factors correlated with DM remission 3 years post-operation were a low preoperative neutrophil-lymphocyte ratio and DiaRem score and CR or partial remission 1 year post-operation. Conclusion Regarding long-term weight loss after LSG, better weight loss 1 year post-operation was important. In terms of long-term DM remission, a low preoperative neutrophil-lymphocyte ratio and DiaRem score and achieving CR or partial remission 1 year post-operation were key factors.

Purpose : The aim was to investigate the impact of the neutrophil-lymphocyte ratio (NLR) in sleeve gastrectomy (SG). Methods : 15 obese patients were enrolled in this study ; mean body weight (BW) 127.5kg ; mean body mass index (BMI) 46.7kg/m2. 10 of these were diabetics who underwent a SG. The impact of the pre-operative NLR on the percentage of excess weight loss (%EWL) and remission of diabetes 1 year post-operative were examined. Results : The %EWL at 1 year post-operative were 46.3%. Improvements were also evident in the diabetes at 1 year post-operative : complete remission (CR) 40%, partial remission (PR) 20% and Improve 40%. Comparing pre-operative NLR in %EWL<50% and ≧50% in 1 year post-operative, <50% was 2.64 and ≧50% was 2.03. The NLR in CR and PR was significantly lower than that in Improve. Conclusions : The pre-operative NLR may be a predictive marker of weight loss and improving diabetes after SG. J. Med. Invest. 70 : 140-144, February, 2023