This study aimed to investigate problems and learning curves experienced by a single surgeon performing robotic-assisted rectal surgery （RRS） for the first time. Among 62 consecutive patients who underwent RRS between May 2021 and December 2022, 30 with high anterior resection （HAR） performed by a single surgeon qualified according to the endoscopic surgical skill qualification system were retrospectively reviewed. Operative feasibility and surgical outcomes were evaluated. The cumulative sum （CUSUM） was used to visualize the learning curve of the operation time. No cases were converted to open surgery. The operative time （median, range） was 313 （163-645） min, the amount of blood loss was 5 （5-550） ml, and postoperative complications occurred in 10 （16.1％） of all 62 patients. Among 30 patients with HAR, the surgeon console time for the 10 patients in the early period was 160 （78-271） min, and that in the later period was 118 （86-234） min for 20 （P＝0.03）. The differences in the duration of lymph node dissection and mesorectal transection were significant between the early and later periods （P＜0.01）. No difference in the frequency of postoperative complications was found. RRS is a minimally invasive and safe technique even for an inexperienced surgeon according to the rectal endoscopic educational system. To shorten the learning curve, mastery of the surgical procedure of lymph node dissection and mesorectal dissection is necessary.

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Despite occasional observations of sudden or unexpected deaths and deaths occurring shortly after hospitalization, studies on sudden in-hospital deaths in adults, particularly those that have been autopsied, are scarce. This study investigated 112 consecutive autopsy cases to determine the cause of death at our hospital. The cases were divided into three groups: sudden death （death within 24h of symptom onset, regardless of the duration of hospitalization; n＝9）, short-term death （death within 2-5 days after admission, excluding sudden death; n＝24）, and others （n＝79）. No differences were observed in age, sex, season, or time of death between the groups. The sudden-death group included the following cases: aortic dissection （n＝3）, acute pneumonia （n＝2）, asphyxia （n＝2）, other cause （n＝1）, and unknown cause （n＝1）. The short-term death group, on the other hand, consisted of brain disease （n＝8）, digestive disease （n＝7）, cardiovascular disease （n＝6）, respiratory disease （n＝1）, and other causes （n＝2）. The discordance rates between the clinical and pathological diagnoses were 22.2％, 29.2％, and 44.3％ for sudden death, short-term death, and others, respectively. We found that the causes of sudden and short-term deaths were not only cardiogenic but also involved other diseases. The discordant diagnoses were aortic dissection and acute pneumonia in sudden death. Myocardial infarction was the most common cause of short-term death. To prevent sudden in-hospital deaths, not only cardiovascular diseases, such as aortic dissection and acute myocardial infarction, but also noncardiovascular ones, such as acute pneumonia, should be considered as differential diagnoses.

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This cohort study examined the validity of our new classification system in predicting the difficulty level of laparoscopic cholecystectomy （LC）. We enrolled consecutive patients who underwent cholecystectomy at the Division of Gastroenterological and General Surgery in Showa University Hospital, Japan. Severe-grade LC was classified according to cholecystitis severity according to the 2013 Tokyo Guidelines, preoperative imaging findings, cystic duct depiction, and anatomical anomalies of the bile duct. Cases were categorized according to the degree of difficulty as follows: E （easy）, C （moderate）, and D （difficult）. Moreover, preoperative prediction accuracy was evaluated by determining the degree of inflammation and presence of anatomical variation based on operative data. Operative variables and morbidity were retrospectively evaluated. LC was performed in 534 patients, 424 of whom were assessed. The accuracy of the correlation between the classification system and intraoperative findings was as follows: E, 77%, C, 61%, and D, 76%. The average operative time was 109±44, 134±43, and 172±58 min for E, C, and D levels, respectively （P＝0.0022; E/C, P＜0.0001; C/D, P＜0.0001; E/D, P＝0.00017）. The average blood loss was 17±31, 43±61, and 71±53ml for E, C, and D levels, respectively （P＝0.0020; E/C, P＜0.0001; C/D, P＝0.0201; E/D, P＜0.0001）. The surgical outcomes significantly differed between the levels; however, the conversion and morbidity rates did not. In conclusion, our classification system was correlated with intraoperative findings and surgical outcomes, thereby contributing to improved LC outcomes.

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Hepatic steatosis following pancreatic resection is a growing concern. Pancreatic enzyme replacement effectively treats the problem; however, the risks of hepatic steatosis remain unknown. In this study, we evaluated the risks of hepatic steatosis on 104 patients who underwent pancreatic surgery. Moreover, the effect of pancrelipase administration at 900mg/day, one of the pancreatic enzyme replacement therapies, on hepatic steatosis was evaluated. Twenty-one patients （20％） developed hepatic steatosis following pancreatic surgery. Low neutrophil-to-lymphocyte ratio （NLR）（p＝0.027） was identified as a risk factor for postoperative hepatic steatosis in the 104 participants following pancreatectomy. Particularly, in the 62 participants who underwent pancreaticoduodenectomy, younger age （p＝0.045）, lymphocyte-to-monocyte ratio （p＝0.029）, and lymph node metastasis （p＝0.026） were identified as risk factors for postoperative hepatic steatosis. Of the 10 patients with newly developed liver steatosis following pancreatoduodenectomy who could be evaluated, 6 improved with pancrelipase dose escalation, whereas 4 improved without escalation. In conclusion, this study suggested that immune-nutritional parameters including low NLR or high NMR can be closely associated with risk factors for hepatic steatosis following pancreatic surgery. Pancrelipase administration following pancreatic surgery may be optimal with doses starting at 900mg/day and increased when steatosis occurs.

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Intensive care unit-acquired delirium can lead to persistent cognitive dysfunction. Although it impedes independent mobilization at hospital discharge, the effects in intensive rehabilitation in the recovery phase remain unclear. An 84-year-old male was admitted to our intensive care unit with dyspnea. He was diagnosed with influenza-related pneumonia and sepsis and was placed on a mechanical ventilator for complete respiratory support. On day 14 （D14） of illness, rehabilitation was initiated. On D33, reductions in physical and cognitive functions were observed through Medical Research Council and Mini-Mental Statement Examination scores of 34 and 11 points, respectively. During his intensive care unit stay, he showed signs of delirium for 27 consecutive days. On D47, he was admitted to a postacute rehabilitation hospital where he underwent physical （strength training; basic movement, balance, and gait exercises; and endurance training）, occupational （activities of daily living training）, and speech （cognitive training, primarily higher-order tasks） therapies for 90 min daily. On D115, his physical function was markedly improved （Medical Research Council score, 57 points）; however, his cognitive impairments persisted. On D124, he was transferred to a long-term care facility. Seamless rehabilitation from the acute to the convalescent phase was performed; however, the improvement in cognitive impairment following intensive care unit-acquired delirium was less than the improvement in physical function. Even after discharge from recovery hospitals, rehabilitation should be continued in addition to interventions in the intensive care unit aimed at preventing delirium and cognitive impairment and hastening recovery.

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The present study aimed to determine the frequency of drug use with devices, such as inhalers and self-injectors, and use of two or more topical agents with similar formulations in patients who required ophthalmological operations. We retrospectively surveyed the medical charts of 1,244 patients admitted at Showa University Hospital East Branch between January 2018 and May 2019. Of these patients, 40.2％ （n＝500） received medications through devices and two or more topical agents with similar formulations. In general, the patients who underwent ophthalmological operations had poor vision or loss of vision. To avoid misuse or underuse of devices and topical agents, pharmaceutical companies need to consider universal designs for patients with poor vision or loss of vision.

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