Analysis of Recurrence Patterns After Anatomical or Non-anatomical Resection for Hepatocellular Carcinoma

BACKGROUND

Recurrence patterns after hepatic resection has been poorly understood in view of tumor blood flow drainage (TBFD) area. Our goal was to clarify the recurrence patterns after anatomical versus nonanatomical hepatic resection for hepatocellular carcinoma (HCC).

METHODS

A total of 424 consecutive patients with HCC, who were treated by curative resection (R0) at our hospital from 2001 to 2012, were evaluated. Among these, we compared the outcomes of the anatomical resection group (AR group, n = 243) and the nonanatomical resection group (NR group, n = 181). We performed an analysis of the recurrence patterns of HCC based on the preoperative CT during hepatic arteriography in these 424 patients.

RESULTS

Preoperative liver function was better in the AR group than the NR group (P < 0.001), and tumor size was larger in the AR group than the NR group (P < 0.001). HCC recurrence was recorded in 145 patients (59.7 %) of the AR group and 102 patients (56.4 %) of the NR group with no significant differences between the two groups (P = 0.590). The incidences of extrahepatic and intrahepatic recurrence (solitary/multiple) were similar between the two groups. In addition, the rate of recurrences by local dissemination, either recurrences in the same subsegment in the NR group or recurrences in the TBFD area in the AR group, was sufficiently low (1.4 %) as to be considered negligible.

CONCLUSIONS

The incidence and patterns of HCC recurrence were similar between the anatomical and nonanatomical resection. Recurrence by local dissemination may be considered to be negligible in both surgical methods.

[Long-term outcomes and risk factors of lymph node metastases in invasive submucosal colorectal cancer]

To evaluate the risk factors associated with lymph node(LN)metastases described in the Japanese Society for Cancer of Colon and Rectum (JSCCR) guidelines, we retrospectively analyzed 40 patients with submucosal invasive colorectal cancer who underwent surgical resection after endoscopic resection at Osaka Medical Center for Cancer and Cardiovascular Diseases between 2006 and 2008. We examined clinicopathological factors such as sex, age, tumor diameter, morphology, histological grade, submucosal invasion, lymphatic invasion, venous invasion, and LN metastasis and 5-year disease-free survival(DFS) and overall survival (OS). All patients had tubular adenocarcinoma. Ten patients had LN metastasis. Histological grade, tub2, and a positive vertical margin were significant risk factors. Submucosal invasion was greater than 1,000 µm in patients with LN metastasis. There was no difference in clinicopathological factors between patients with colon cancer and those with rectal cancer, but LN metastasis occurred in 18.7% and 50.0% of colon cancer and rectal cancer patients, respectively. There were no recurrences or cancer-related deaths, although one patient died of other causes. In conclusion, patients who were treated according to the JSCCR guidelines had a favorable prognosis.

[Usefulness of laparoscopy endoscopy cooperative surgery for gastric gastrointestinal stromal tumor]

BACKGROUND

Laparoscopy endoscopy cooperative surgery (LECS) for gastrointestinal stromal tumors (GIST) is an established technique for safe tumor resection, with lesser surgical margin than laparoscopic wedge resection (WR). We report the usefulness of LECS for GIST compared with WR.

METHOD

Between 2008 and 2012, 8 patients with GIST underwent LECS and 11 patients underwent laparoscopic WR. Intraoperative blood loss, surgical margin, and operation time were compared between LECS and WR.

RESULTS

Patients undergoing LECS had significantly less surgical margin compared with those undergoing WR (mean 5.6mm versus 28.0 mm, p<.05). The difference in operation time between LECS and WR (214 min versus 112min)was also significant. Intraoperative blood loss was very little and not significantly different between both groups.

CONCLUSION

LECS for GIST was a safe procedure with lesser surgical margins.

[Comparison of early clinical outcomes between laparoscopic total gastrectomy and open total gastrectomy for early-stage gastric cancer]

BACKGROUND/AIMS

Recently, laparoscopic distal gastrectomy has become one of the standard therapies for early gastric cancer. However, there are still some obstacles in performing laparoscopic total gastrectomy (LTG) as a standard therapy due to the difficulties in surgical techniques. We have performed LTG for patients with early gastric cancer in the upper portion of the stomach since 2010. In this study, we compared early clinical outcomes of LTG with those of open total gastrectomy (OTG) for patients with cT1N0 gastric cancer.

METHODOLOGY

We reviewed 69 patients who had gastric cancer of cStage IA between January 2010 and December 2013. We performed a comparative study of short-term clinical outcomes, quantity of dissected lymph nodes, and in-hospital costs between patients undergoing LTG (n=34) and those undergoing OTG (n=35).

RESULTS

The clinical characteristics of patients were well matched in the LTG and OTG groups. The median operating time was significantly longer for the LTG group (p<.0001). The estimated blood loss was significantly reduced in the LTG group (p< 0.0001). The postoperative morbidity rate was 14.7% in the LTG group and 14.2% in the OTG group with no significant difference. There were no differences in the total cost for hospital stay between the LTG and OTG groups.

CONCLUSIONS

We were able to perform LTG safely and successfully for early gastric cancer in our institute. The total cost of the treatment was almost the same between LTG and OTG. We conclude that LTG is a potential alternative in the management of early gastric cancer.

[Irradiation with carbon ions for locally recurrent rectal cancer]

A female patient in her 70s underwent an abdominoperineal resection and bilateral lymph node dissection for advanced lower rectal cancer. The patient did not receive neoadjuvant therapy. In the Japanese classification of colorectal carcinoma (8th Edition), the tumor was a moderately differentiated type 2 adenocarcinoma, and was 4.5 cm in size. Histologically, the tumor was considered to be Stage IIIb (T3N0M0). She received no adjuvant chemotherapy. After 39 months, pelvic computed tomography (CT ) revealed a 29 mm tumor in the right pelvic wall. The patient declined surgery for recurrence so radiotherapy was planned. First, chemotherapy with mFOLFOX6 was administered for 4 courses to reduce tumor size. Consequently, irradiation with carbon ions was given to the site of recurrence at a total dose of 74 GyE in 37 fractions. There were no severe complications. Carcinoembryonic antigen (CEA) level decreased to the lower limit of the normal range from a maximum of 4.9, and no progression of the recurrent tumor was detected on CT for approximately 4 years. Systemic chemotherapy followed by irradiation with carbon ions may be effective for recurrent rectal cancer.

[Successful treatment of advanced gallbladder cancer involving the extrahepatic bile duct with neoadjuvant chemoradiation therapy - a case report]

A 57-year-old man with jaundice was diagnosed as having advanced gallbladder cancer involving the extrahepatic bile duct.We initiated neoadjuvant chemoradiation therapy with 3-dimensional conformal irradiation (2 Gy × 25 Fr/5 weeks)and gemcitabine (1,000 mg/m²) on days 1, 8, and 15, every 28 days for 3 courses. After percutaneous transhepatic portal vein embolization (PTPE), we performed right hepatectomy with extrahepatic bile duct resection. A follow-up examination 5 years after the operation showed no evidence of recurrence. Therefore, neoadjuvant chemoradiation therapy has the potential to improve the prognosis of patients with advanced gallbladder cancer involving the extrahepatic bile duct.

[A case of HCC with portal vein thrombosis treated with multidisciplinary treatment combined with preoperative SBRT and radical resection]

A 70s man with advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) (Vp-HCC) in the main trunk (Vp4) was referred to our hospital. He was negative for hepatitis C virus (HCV) and hepatitis B virus (HBV), and his liver function was well preserved. The main tumor was in the right lobe and exceeded 10 cm in diameter. There were no intrahepatic metastases to the left lobe. The patient underwent stereotactic body radiation therapy (SBRT) (48 Gy/4 fractions) to the area of the PVTT. Six days after SBRT, the patient underwent right lobectomy for removal of PVTT. The postoperative course was uneventful, and low-dose 5-fluorouracil and cisplatin(FP)intra-arterial chemotherapy was administered for 3 months. Histopathological findings for the tumor indicated a poorly differentiated HCC, vp4, with moderate to severe tumor necrosis or degeneration in the area that received SBRT. Tumor markers (alpha-fetoprotein [AFP], proteins induced by vitamin K absence [PIVKA-II]) decreased within the normal range, and there was no apparent HCC recurrence 6 months after the hepatectomy. Multidisciplinary treatment combined with preoperative SBRT and radical resection for Vp-HCC was feasible and effective in this case.

[Self-expandable metallic stent therapy for obstructive colon cancer]

Patients with colon cancer who present with stenosis are treated with emergency surgery. Colostomy or Hartmann's operation are commonly performed, but are associated with an increased risk of complications such as anastomotic leakage, which reduce the quality of life of the patient. In our patient, emergency surgery was avoided by metallic stent placement. Metallic stents can be an effective bridge to surgery in colon cancer patients with ileal symptoms.

[Multiple extracranial metastases from meningioma treated with surgical resection - a case report]

A 73-year-old woman underwent a craniotomy for an atypical meningioma in 1993, and underwent re-excision for local recurrence 4 years later. In 2008, a chest X-ray film revealed 2 nodules in the right lung. A wedge resection of S2 and a middle lobectomy of the right lung were performed. Pathological findings indicated that the 2 tumors originated from the intracranial meningioma resected in 1993. In 2013, a computed tomography (CT) scan demonstrated hypervascular masses in the liver (S4), pancreatic body, and lower portion of the right kidney. She underwent partial hepatectomy, distal pancreatectomy, and partial nephrectomy, and the final diagnosis was hepatic, pancreatic, and renal metastases from meningioma. After 10 months, a transcatheter arterial embolization (TAE) was performed for hepatic recurrence (S5). She is presently doing well, 5 months after TAE, without any signs of recurrence.

Navigation Guidance Using Polyglycolic Acid Felt in Pure Laparoscopic Partial Hepatectomy

BACKGROUND

Appropriate determination of the dissecting plane for removing the tumor blood flow drainage area (TBF-D area) around a hepatocellular carcinoma as well as the tumor itself is essential in pure laparoscopic hepatectomy, but it is often difficult with the usual devices. Navigation technologies have been developed in an attempt to improve the technical accuracy, but they are still under development and cannot be easily applied yet in current clinical practice. To resolve this problem, we created a novel method of using absorbable polyglycolic acid felt (PGA felt) as a navigation guide in pure laparoscopic partial hepatectomy (PLH).

METHODS

We used a PGA felt cut into the appropriate shape in accordance with the shape determined preoperatively by simulation computed tomography in each case. We applied the felt on the surface of the liver intraoperatively as a guide for PLH.

RESULTS

The PGA felt was placed on the surface of the liver, with the central portion of the felt aligned to the central portion of the tumor. The resection line was marked around the felt using monopolar electrocautery. Then, after removing the PGA felt, PLH was successfully performed along the marked line. The surgical margin was confirmed to be adequate in the resected specimen, which showed complete resection of the TBF-D area as well as of the tumor in a comparison with the preoperative computed tomography angiography images.

CONCLUSION

This new technique is easy and safe and enables resection of both the tumor(s) and the TBF-D area appropriately and accurately in PLH.

Solitary mediastinal lymph node recurrence after curative resection of colon cancer

We report two cases of solitary mediastinal lymph node recurrence after colon cancer resection. Both cases had para-aortic lymph node metastasis at the time of initial surgery and received adjuvant chemotherapy for 4 years in case 1 and 18 mo in case 2. The time to recurrence was more than 8 years in both cases. After resection of the recurrent tumor, the patient is doing well with no recurrence for 6 years in case 1 and 4 mo in case 2. Patients should be followed up after colon cancer surgery considering the possibility of solitary mediastinal lymph node recurrence if they had para-aortic node metastasis at the time of initial surgery.

Diagnostic laparoscopy with 5-aminolevulinic-acid-mediated photodynamic diagnosis enhances the detection of peritoneal micrometastases in advanced gastric cancer

OBJECTS

Recently, we reported that diagnostic laparoscopy with photodynamic diagnosis using oral 5-aminolevulinic acid (ALA-PDD) is a promising tool for diagnosing early peritoneal metastases in gastric cancer. The present study evaluated the usefulness of adding ALA-PDD to conventional diagnostic laparoscopy and assessed the association of the ALA-PDD results with peritoneal fluid cytology and molecular diagnostic testing.

METHODS

Diagnostic laparoscopy using sequential white light (WL) and ALA-PDD observations was performed in 52 advanced gastric cancer patients, and the sensitivity of ALA-PDD for detecting peritoneal disease was compared to WL. Peritoneal fluid samples from the same patients were also subjected to cytological examination and molecular diagnosis using a transcription-reverse transcription concerted reaction (TRC).

RESULTS

Twenty-four of the 52 patients (46%) had no macroscopic evidence of peritoneal metastases on WL examination; however, ALA-PDD detected dissemination in 5 of these 24 patients (21%) (pd-P). Cytological examination was negative in 4 of the 5 pd-P patients, and molecular testing using TRC was negative in 3 of the 5 pd-P patients.

CONCLUSIONS

This study demonstrated that diagnostic laparoscopy with ALA-PDD improved the sensitivity for the detection of peritoneal metastases. ALA-PDD may be a useful technique for the preoperative staging of advanced gastric cancer and can complement examinations of peritoneal lavage fluids.

Inferolateral marginal orbitectomy: a simple adjuvant technique for orbital decompression

The number of patients with mild exophthalmos, without severe eye symptoms, who wish to undergo aesthetic orbital decompression, is increasing. Removal of the lateral and inferior orbital walls is a common procedure for mild to moderate exophthalmos. However, the limited space between the globe and the orbital wall is often troublesome for surgeons introducing surgical devices. As a result, the decompression tends to be insufficient in the posterior region of the orbit. We describe a simple adjuvant surgical technique to address this limitation. Through a laterally extended, transconjunctival approach, the inferior and lateral margins of the orbit are removed in a crescent shape before the actual decompression. This manoeuvre widens the working space and offers better visibility, enabling sufficient removal of the orbital walls. The technique presented facilitates the approach to the posterior regions of the orbit, enabling surgeons to more easily perform orbital decompression.

Randomized controlled trial of the LigaSure vessel sealing system versus conventional open gastrectomy for gastric cancer

PURPOSE

LigaSure, a bipolar electronic vessel sealing system, has become popular in abdominal surgery but few clinical studies have been conducted to evaluate its effectiveness in radical gastrectomy for gastric cancer.

METHODS

In this multicenter, prospective, randomized controlled trial, patients with curative gastric cancer were randomly assigned to undergo gastrectomy either with LigaSure or a conventional technique.

RESULTS

Of the 160 patients enrolled, 80 were randomized to the LigaSure group and 78 to the conventional group. Patient characteristics were well balanced in the two groups. There were no significant differences between the LigaSure and conventional groups in blood loss (288 vs. 260 ml, respectively; P = 0.748) or operative time (223 and 225 min, respectively; P = 0.368); nor in the incidence of surgical complications or duration of postoperative hospital stay. In a subgroup analysis of patients who underwent gastrectomy that preserved the distal part of the greater omentum, the use of LigaSure significantly reduced blood loss (179 vs. 245 ml; P = 0.033), and the duration of the operation (195 vs. 221 min; P = 0.039).

CONCLUSIONS

LigaSure did not contribute to reducing intraoperative blood loss, operative time, or other adverse surgical outcomes. The usefulness of the device may be limited to a specific part of the surgical procedure in open gastrectomy.

Evaluation of the effects of postoperative oral nutrition support on body weight in gastric cancer patients by using an elemental diet: A randomized study

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Background: Postoperative weight loss causes deterioration in the patient’s quality of life and influences long-term prognosis in gastric cancer patients who have undergone gastrectomy. Moreover, recent retrospective studies indicated postoperative weight loss as a risk factor for premature interruption of S-1 adjuvant chemotherapy. We conducted a prospective randomized controlled study to examine whether the early institution of nutritional support comprising an oral elemental diet (ED) prepared for post-gastrectomy patients with depressed digestive/absorptive function would help prevent postoperative weight loss. Methods: After surgery, patients were randomly assigned to the ED or control groups. The groups were divided according to the surgical methods used (total/distal gastrectomy), clinical stage (≤Ia/>Ia), and patients’ body mass index (<18.5/>18.5). In patients assigned to the ED group (Elental, 300 kcal) was provided in addition to the regular diet from the day starting soft rice diet or equivalent diet to 6–8 weeks after surgery. The primary endpoint was the percentage of body weight change from the pre-surgical body weight to that at 6–8 weeks after surgery. The secondary endpoints were ED adherence, nutrition-related blood parameter changes, and adverse effects. Results: The study included 112 patients from eight hospitals. There was a significant difference in the percentage of body weight loss (%BWL) between the ED and control groups (4.88±3.41% and 6.91±5.06%; P=0.015). Sub-group analysis showed a significant difference in the %BWL in patients who underwent total gastrectomy (5.31±3.43% and 9.11±5.57%; P=0.016). Multivariate analysis demonstrated ED treatment and surgery type as independent factors that affect body weight changes. The mean treatment compliance rate in the 58 ED-group patients was 72.9±33.1%, with a favorable median value of 90.8%. No significant differences were observed in any parameter analyzed, including hematological and non-hematological adverse events, between the two groups. Conclusions: The ED product can prevent postoperative weight loss in gastric cancer patients undergoing gastrectomy. Clinical trial information: 000008056.

Pathological findings of gastric mucosa in patients with gastric remnant cancer

BACKGROUND/AIMS

The mechanism of remnant gastric cancer development has not yet been well established. In this study, we compared the background gastric mucosa of remnant gastric cancer with that of upper lesion-restricted gastric cancer to determine the difference in the pathogenesis of naive gastric cancer and remnant gastric cancer.

METHODOLOGY

Twenty-five patients with gastric remnant cancer after distal gastrectomy and a control group of 29 patients with naive gastric cancer restricted to the upper part of the stomach who underwent gastrectomy were enrolled in this study. We evaluated the gastric mucosa adjacent to cancerous tissues using the updated Sydney score system.

RESULTS

The surrounding gastric mucosa in the remnant gastric cancer group was significantly less atrophic than that of the group with gastric cancer restricted to the upper part of the stomach. In remnant gastric cancer, patients who underwent Billroth II (B-II) reconstruction at first gastrectomy developed cancer at the anastomotic site more frequently than those with Billroth I (B-I) reconstruction.

CONCLUSIONS

The surrounding gastric mucosa was significantly less atrophic in remnant gastric cancer than naïve gastric cancer, which indicates that remnant gastric cancer might possess a different pathogenesis.

[A case of pathological complete response with neoadjuvant mFOLFOX6 chemotherapy for advanced lower rectal cancer]

A 69-year-old man diagnosed with lower rectal cancer was referred to our hospital. Rectal examination and colonoscopy showed a type 2 circular tumor, 2.5 cm from the anal verge. Biopsy led to a diagnosis of moderately differentiated adenocarcinoma. Computed tomography (CT) and magnetic resonance imaging (MRI) showed signs of invasion to the surrounding organs and metastasis to the mesorectal fascia and left obturator lymph node (cAI, cN3). Therefore, we decided to start neoadjuvant chemotherapy with leucovorin calcium( folinic acid), fluorouracil, and oxaliplatin( mFOLFOX6). The patient received six courses of chemotherapy. CT and MRI after chemotherapy showed a reduction in tumor size. Six weeks after chemotherapy, the patient underwent intersphincteric resection with ileostomy. Pathological examination demonstrated no residual cancer cells in the primary lesion or lymph node (Grade III, pathological complete response [pCR]). This study demonstrates that neoadjuvant chemotherapy can be a promising option for locally advanced rectal cancer.

[Repeated occlusion of the intraperitoneal access port for intraperitoneal chemotherapy in a patient with gastric cancer with peritoneal dissemination]

A phase III clinical trial to evaluate the efficacy of combination chemotherapy with intraperitoneal administration of paclitaxel for gastric cancer with peritoneal metastasis has been ongoing in Japan. A male patient in his 50s who was diagnosed as having advanced gastric cancer with peritoneal metastasis was enrolled in this trial. The patient was assigned to receive a regimen of intravenous and intraperitoneal paclitaxel combined with S-1. Although an intraperitoneal access port had been implanted to provide access to the peritoneal cavity, tube obstruction occurred twice. Laparoscopic examination revealed that the tube in the abdominal cavity had been totally covered with the great omentum. Therefore, the intraperitoneal regimen was discontinued. Although intraperitoneal chemotherapy for the treatment of peritoneal dissemination in gastric cancer is promising, precaution should be taken to avoid tube obstruction, which is a complication of the intraperitoneal tube placement.

The clinical importance of a transcription reverse-transcription concerted (TRC) diagnosis using peritoneal lavage fluids in gastric cancer with clinical serosal invasion: a prospective, multicenter study

PURPOSE

We have developed a novel molecular method of diagnosis using the technique of transcriptase-reverse transcriptase concerted reaction (TRC) for the detection of cancer micrometastasis. This study prospectively examined the clinical importance of the TRC diagnosis with peritoneal lavage fluids collected from gastric cancer operations at multiple institutes.

METHODS

TRC amplification targeting carcinoembryonic antigen mRNA was applied to detect gastric cancer cells in peritoneal lavage fluids obtained during gastric cancer resections from nine different hospitals. A total of 137 patients with a clinical diagnosis of serosa-invading neoplasms were enrolled to investigate the correlation between the TRC diagnosis and patient prognosis.

RESULTS

Of the 137 patients, 27 (20%) were positive by cytologic examination. In contrast, TRC targeting carcinoembryonic antigen mRNA was positive in 59 of 137 (54%) patients. TRC positivity was associated with a poorer overall survival in all patients and in the 104 patients who underwent a curative operation. TRC positivity also was associated with the peritoneal recurrence-free survival rate in the 104 curative cases. Multivariate analysis showed that TRC positivity and the pathologic N factor were prognostic factors for the overall survival time.

CONCLUSION

Our prospective multicenter study showed that the TRC test using peritoneal lavage fluids could be a potential prognostic factor to predict patient survival and peritoneal recurrence with clinically diagnosed, serosa-invading gastric cancer.

Boerhaave's syndrome in a tracheoesophageal speaker: report of a case

Boerhaave's syndrome is still associated with a high mortality rate and remains a therapeutic challenge. Pharyngo-laryngo-esophagectomy is performed as the standard treatment for advanced hypopharyngeal cancer and tracheoesophageal speech is an option for esophageal speech rehabilitation. We report what, to our knowledge, is the first case of Boerhaave's syndrome developing in a tracheoesophageal speaker.

Visceral fat changes after distal gastrectomy according to type of reconstruction procedure for gastric cancer

BACKGROUND

Noncancerous causes of death, such as cerebrovascular or cardiac disease, are not rare in patients with gastric cancer who had undergone curative gastrectomy. Metabolic syndrome, characterized by visceral fat accumulation, is a risk factor for cerebrovascular and cardiac diseases. However, there is limited information on the effects of reconstruction procedures on changes in visceral fat after distal gastrectomy. The aim of this study was to analyze the impact of the reconstruction procedure (Roux-en-Y reconstruction (RY) and Billroth I reconstruction (BI)) on changes in visceral fat, as determined using computed tomography.

METHODS

The study subjects were 152 patients with gastric cancer who underwent distal gastrectomy with lymphadenectomy between 2002 and 2007. The visceral fat area was measured for one cross-sectional computed tomogram obtained at the level of the umbilicus.

RESULTS

Adjuvant chemotherapy (yes vs. no, P = 0.0006), type of reconstruction (BI vs. RY, P = 0.0146), field of lymph node dissection (<D2 vs. ≥D2, P = 0.0020), omentectomy (yes vs. no, P = 0.0003), and pathological stage (1/2 vs. 3/4; P = 0.0023) correlated significantly with postoperative visceral fat loss. Multivariate logistic regression analysis identified reconstruction (BI vs. RY; P = 0.0232) and adjuvant chemotherapy (yes vs. no, P = 0.0330) as the significant determinants of visceral fat loss after surgery.

CONCLUSIONS

Visceral fat loss after RY was larger than that after BI. Further prospective studies are needed to confirm the effects of reconstruction after distal gastrectomy on visceral fat.

Efficacy of subcutaneous penrose drains for surgical site infections in colorectal surgery

AIM: To investigate whether a subcutaneous penrose drain would decrease the superficial surgical site infection (s-SSI) rate in elective colorectal surgery.

METHODS: This is a comparative study of the historical control type. Intervention consisted of the use of penrose drain in elective open colorectal surgical wounds. The outcome was an incidence of s-SSI. The patients were risk stratified according to the depth of subcutaneous tissue.

RESULTS: There were 131 patients (40 patients with high s-SSI risk) in the prior period (from July 2008 to June 2009, when no penrose drains were inserted) and 151 patients (75 patients with high s-SSI risk) in the latter period (from June 2010 to November 2011, when penrose drains were inserted). The overall s-SSI rate was 6.1% and 5.3% during the two periods (P = 0.770), and the s-SSI rate in the high s-SSI risk group was 15.0% and 8.0% (P = 0.242).

CONCLUSION: Although penrose drain was not observed to significantly reduce s-SSI, there tended to be a reduced risk of s-SSI in the high s-SSI risk group.

Dose-saving isolation procedure in percutaneous ethanol sclerotherapy for venous malformations

OBJECTIVES

To evaluate the feasibility and effectiveness of an isolation technique during ethanol injection sclerotherapy for venous malformations (VMs) in the head and neck region.

METHODS

The subjects were 23 patients with 35 VM lesions in the head and neck, treated between 1999 and 2012. The mean lesion area was 3.75 ± 3.09 cm(2) (±standard deviation). We confirmed the contour of the lesions to be treated on a fully filled image on direct injection cisternography, and observed patterns of communicating drainage to systemic veins. The cisterns were evacuated by squeezing and were isolated by manual compression of the communicators. Ethanol (94.5%) with a contrast agent was then injected into both isolable and unisolable lesions, up to a total volume of 1 mL/cm(2), avoiding complications. We investigated the relationship between lesion size and injected ethanol dose, and also dose per unit area.

RESULTS

Both manual evacuation by compression and isolation were performed in 20 (57.1%) isolable lesions, but not in 15 unisolable lesions. The mean injected ethanol dose was 0.65 ± 0.31 mL/cm(2) overall, 0.70 ± 0.32 in isolable and 0.59 ± 0.30 in unisolable lesions (NS). However, the injected ethanol dose was significantly lower for lesions sized >6 cm. Complete to near-complete shrinkage was observed in all isolable lesions, and in 60% of unisolable lesions (P < 0.05). Clinical outcome seemed unrelated to the injected ethanol dose or the dose per unit area. There was one case of recurrence and one complication in the unisolable lesions. No further relapses or complications were observed during the follow-up period of 38.6 ± 12.3 months.

CONCLUSIONS

Clinical outcome was related to the isolability not to the injected dose. The isolation appears useful for improving the safety and effectiveness of ethanol sclerotherapy for VM.

[A case of rectal cancer with long-term disease-free survival following resection of the right iliac artery due to isolated para-aortic lymph node recurrence]

A 79-year-old man was diagnosed with infrarenal abdominal aortic aneurysm extending to the right common iliac artery and rectal cancer. He underwent a Y graft replacement for abdominal aortic aneurysm and an anterior resection for rectal cancer after 1 month. No adjuvant therapy was performed. Eleven months after the operation to remove the rectal cancer, computed tomography examination revealed isolated para-aortic lymph node recurrence. The mass involved the right bundle branch of the synthetic graft and the right external and internal iliac artery. Therefore, we resected the area from the right bundle branch of the synthetic graft to the right external and internal iliac artery en bloc. Pathological examination of the resected specimen showed metastatic adenocarcinoma. No additional therapy was performed. As of 10 years after the second operation, the patient is alive and recurrence free. Isolated aortic lymph node recurrence may be cured by resection; hence, surgical resection should be considered if possible.

Comparison between radical esophagectomy and definitive chemoradiotherapy in patients with clinical T1bN0M0 esophageal cancer

BACKGROUND

Esophagectomy remains the mainstay treatment for clinical T1bN0M0 esophageal cancer because pathologic lymph node metastases in these patients are not negligible. Recently, chemoradiotherapy (CRT), which can preserve the esophagus, has been reported to be a promising therapeutic alternative to esophagectomy. However, to our knowledge, no comparative studies of esophagectomy and CRT have been reported in clinical T1bN0M0 esophageal cancer.

METHODS

A total of 173 patients with clinical T1bN0M0 squamous cell carcinoma of the thoracic esophagus were enrolled in this study, 102 of whom were treated with radical esophagectomy (S group) and 71 with definitive CRT (CRT group). Treatment results of both groups were retrospectively compared.

RESULTS

No statistically significant difference was found in overall survival, but the S group displayed significantly better progression-free survival than the CRT group. Disease recurrence was observed in 12 S group patients and 20 CRT group patients. The incidence of distant recurrence was similar, while local recurrence and lymph node recurrence were significantly more frequent in the CRT group. In the S group, 20 patients had pathologic lymph node metastasis. The progression-free survival of patients with pathologic lymph node metastasis did not differ from those without nodal metastasis. In the CRT group, local recurrence could be controlled by salvage esophagectomy, but treatment results of lymph node recurrence were poor; only 4 of 12 patients with lymph node recurrences were cured.

CONCLUSIONS

Selection of patients at high risk of pathologic lymph node metastasis is essential when formulating treatment decisions for clinical T1bN0M0 esophageal cancers.

Potential pitfalls in volume reduction for the treatment of Proteus syndrome

Proteus syndrome is a rare congenital hamartomatous condition that is characterised by a wide range of malformations. Skin and skeletal developmental malformations are common and may manifest as significant physical anomalies. However, few reports have discussed surgical treatment. A 37-year-old woman presented with disproportionate enlargement of the right buttock, which required volume reduction. The overgrown tissue was combined with vascular malformations, which in our patient were extremely thick. The patient experienced massive blood loss during the procedure, due to which a blood transfusion was performed. Pathological findings revealed partial lipohyperplasia with venous malformations. Thus, during operations including incomplete excision, massive bleeding is always a possibility, but is not commonly described in these instances.

Multimodal treatment of hepatic metastasis in the form of a bile duct tumor thrombus from pancreatic acinar cell carcinoma: case report of successful resection after chemoradiation therapy

Pancreatic acinar cell carcinoma (ACC) is a rare tumor, and its pathophysiology has not been well understood. Treatment strategies for hepatic metastasis originating from ACC remain controversial. We report the case of a 66-year-old woman who had undergone total pancreatectomy from ACC 7 years prior to clinical presentation. Contrast-enhanced computed tomography imaging revealed a tumorous lesion measuring 7 cm in length and 1 cm in diameter and extending along the intrahepatic bile duct (B6), which showed mild enhancement in the early phase and modest washout in the late phase. This lesion was diagnosed as hepatic metastasis primarily in the form of a bile duct tumor thrombus originating from the prior ACC by the pathological evaluation of the fine needle biopsy specimen. The patient underwent preoperative gemcitabine-based chemoradiation therapy followed by subsequent surgical resection, which included subsegmentectomy (S6) of the liver and complete removal of the bile duct tumor thrombus. The patient has had no recurrence during the past 8 months since her last surgery. Multimodal treatment including preoperative chemoradiation therapy might be beneficial especially for marginally resectable cases of ACC.

Intraoperative diagnosis using sentinel node biopsy with indocyanine green dye in gastric cancer surgery: an institutional trial by experienced surgeons

BACKGROUND

Reliable indicators that can intraoperatively determine the absence of nodal metastasis are in great demand to avoid unnecessary lymphadenectomy. However, little has been reported about the intraoperative diagnostic performance of sentinel node (SN) biopsy.

METHODS

Sentinel node biopsy by subserosal or submucosal injection of indocyanine green (ICG) was performed in 241 patients with American Joint Committee on Cancer tumor, node, metastasis staging system, 7th edition, clinical T1 (n = 190) and T2 (n = 51) gastric cancer by two experienced surgeons. All nodes that stained green (green node, GN), representing SNs, were excised before gastrectomy and were sliced into 2-mm sections for intraoperative histological examinations with hematoxylin and eosin staining. The sliced GNs were also examined simultaneously by imprint cytology.

RESULTS

The GNs were detectable in 240 patients (3.8 ± 2.4 nodes per patient; range 1-17 nodes; median 3 nodes), and the success rate of detection was 99.6 % (240 of 241). Of 240 patients with a successful detection, 29 were found to have lymph node (LN) metastases; 16 were diagnosed with LN metastases in both GNs and non-GNs, 12 in GNs alone, and 1 in non-GNs alone. The false-negative rate based on the SN concept was 3.4 % (1 of 29). However, two patients with cT1 gastric cancer were diagnosed as intraoperative GN negative but were later confirmed as GN positive by histological examinations of paraffin sections. As an intraoperative diagnosis, the false-negative rate was 10.3 % (3 of 29).

CONCLUSIONS

Sentinel node biopsy using ICG could be performed intraoperatively within reasonable limits under certain conditions, such as multiplanes for detection, combination use of imprint cytology, and open surgery by experienced surgeons.

Inhibitory effect of statins on inflammatory cytokine production from human bronchial epithelial cells

Statins are 3-hydroxy-3-methylglutaryl-co-enzyme A reductase inhibitors of cholesterol biosynthesis, and have been reported to exert pleiotropic effects on cellular signalling and cellular functions involved in inflammation. Recent reports have demonstrated that previous statin therapy reduced the risk of pneumonia or increased survival in patients with community-acquired pneumonia. However, the precise mechanisms responsible for these effects are unclear. In the present study, we examined the effects of statins on cytokine production from lipopolysaccharide (LPS)-stimulated human bronchial epithelial cells (BEAS-2B). Interleukin (IL)-6 and IL-8 mRNA expression and protein secretion in LPS-stimulated cells were inhibited significantly by the lipophilic statin pitavastatin and the hydrophilic statin pravastatin. As these inhibitory effects of statin were negated by adding mevalonate, the anti-inflammatory effects of statins appear to be exerted via the mevalonic cascade. In addition, the activation levels of Ras homologue gene family A (RhoA) in BEAS-2B cells cultured with pitavastatin were significantly lower than those without the statin. These results suggest that statins have anti-inflammatory effects by reducing cytokine production through inhibition of the mevalonic cascade followed by RhoA activation in the lung.

Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux-en-Y anastomosis

Reflux of gastroduodenal contents and delayed gastric emptying are the most common and serious problems after esophagectomy with gastric reconstruction. However, attempts to reduce the above symptoms, surgically as well as non-surgically, had no or limited effect. To address this issue, we performed retrosternal gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis (RY) in eight patients with thoracic esophageal cancer and compared the outcomes with control patients who underwent standard reconstruction. The procedure is simple, safe, and not associated with any postoperative complications. The pancreatic amylase concentrations in the gastric juice samples on postoperative day 2 were slightly lower in the non-RY group than in the RY group (1884 ± 2152 vs. 25,790 ± 23,542IU/mL, respectively, P= 0.07). Postoperative endoscopic examination showed neither reflux esophagitis nor residual gastric content in the RY group. Quality of life assessed by the Dysfunction After Upper Gastrointestinal Surgery-32 questionnaire postoperatively was significantly better in the RY group than in the non-RY group for 'decreased physical activity,''symptoms of reflux,''nausea and vomiting,' and 'pain.' The results of this pilot study suggest that gastric reconstruction with duodenal diversion plus RY seems effective in improving both the reflux and delayed gastric emptying. The benefits of this procedure need to be further assessed in a large-scale, randomized controlled trial.

Cortactin, an actin binding protein, regulates GLUT4 translocation via actin filament remodeling

Insulin regulates glucose uptake into fat and skeletal muscle cells by modulating the translocation of GLUT4 between the cell surface and interior. We investigated a role for cortactin, a cortical actin binding protein, in the actin filament organization and translocation of GLUT4 in Chinese hamster ovary (CHO-GLUT4myc) and L6-GLUT4myc myotube cells. Overexpression of wild-type cortactin enhanced insulin-stimulated GLUT4myc translocation but did not alter actin fiber formation. Conversely, cortactin mutants lacking the Src homology 3 (SH3) domain inhibited insulin-stimulated formation of actin stress fibers and GLUT4 translocation similar to the actin depolymerizing agent cytochalasin D. Wortmannin, genistein, and a PP1 analog completely blocked insulin-induced Akt phosphorylation, formation of actin stress fibers, and GLUT4 translocation indicating the involvement of both PI3-K/Akt and the Src family of kinases. The effect of these inhibitors was even more pronounced in the presence of overexpressed cortactin suggesting that the same pathways are involved. Knockdown of cortactin by siRNA did not inhibit insulin-induced Akt phosphorylation but completely inhibited actin stress fiber formation and glucose uptake. These results suggest that the actin binding protein cortactin is required for actin stress fiber formation in muscle cells and that this process is absolutely required for translocation of GLUT4-containing vesicles to the plasma membrane.

Staging laparoscopy using ALA-mediated photodynamic diagnosis improves the detection of peritoneal metastases in advanced gastric cancer

BACKGROUND

This study evaluated the usefulness of photodynamic diagnosis (PDD) using oral 5-aminolevulinic acid (ALA) for the detection of peritoneal metastases in advanced gastric cancer.

METHOD

First, the numbers of peritoneal metastatic nodules that were visible under conventional white light (WL) and ALA-induced fluorescence (ALA-F) were quantified in a mouse model of peritoneal metastasis to compare the tumor detection rate. Next, staging laparoscopy (SL) using ALA-PDD was performed in 13 advanced gastric cancer patients with serosa-invading tumors, and the detection sensitivity of ALA-PDD was compared to the observations using WL.

RESULTS

The tumor detection rate using ALA-F was significantly higher than the detection rate using WL (72% vs. 39%, respectively, P < 0.0001). Peritoneal metastases were detected in five patients using SL with ALA-PDD, and liver metastases were detected in one patient. These metastases were confirmed using histological examination. Three metastatic lesions that were invisible under WL were detected under ALA-F.

CONCLUSION

This study demonstrated that SL with ALA-PDD improved the detection sensitivity for peritoneal metastases. ALA-PDD may be an important technique for the preoperative staging of advanced gastric cancer, and ALA-PDD will provide useful information for the selection of therapeutic modality.

Subtotal gastrectomy for gastric tube cancer after esophagectomy: a safe procedure preserving the proximal part of gastric tube based on intraoperative ICG blood flow evaluation

Recent improvements in the survival of patients after esophagectomy have led to an increase in the occurrence of gastric tube cancer (GTC). Total resection of the gastric tube with lymphadenectomy is a standard and reliable treatment for GTC, but problems may arise during or after surgery, such as laryngeal nerve injury, reduced selection of organs for reconstruction, and impaired swallowing function. We recently performed a less invasive procedure, subtotal gastrectomy with preservation of the upper region of the gastric tube, in two patients. In these patients, blood supply to the gastric tube was evaluated by indocyanine green fluorescence imaging. Blood flow was confirmed as passing from the remnant esophagus to the upper region of the gastric tube through the esophago-gastric anastomotic site by indocyanine green fluorescence imaging. Therefore, we resected the gastric tube while preserving the upper region of the gastric tube. There was no necrosis of the remnant gastric tube or anastomotic leakage postoperatively, and postoperative swallowing and eating functions were quite good in both patients. In summary, subtotal gastrectomy as a treatment for GTC is potentially safe, curative, and beneficial for the patient's quality of life.

The significance of abdominal para-aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para-aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.