Efficacy of Dose Escalation of Oral 5-Aminosalicylic Acid for Ulcerative Colitis With a Mayo Endoscopic Subscore of 1: An Open Label Randomized Controlled Trial

BACKGROUND

Endoscopic healing is generally defined as Mayo endoscopic subscore (MES) ≤1 in ulcerative colitis (UC). However, patients with an MES of 1 are at higher relapse risk than those with an MES of 0. This study evaluated the therapeutic efficacy of proactive dose escalation of oral 5-aminosalicylic acid (5-ASA) in UC patients with an MES of 1.

METHODS

An open-label, randomized controlled trial was conducted in 5 hospitals between 2018 and 2022. Ulcerative colitis patients in clinical remission under oral 5-ASA therapy and diagnosed as having an MES of 1 were enrolled. Patients receiving maintenance therapy other than 5-ASA and immunomodulator were excluded. Patients were randomly assigned in a 1:1 ratio to receive either a dose-escalated (intervention) or constant dose (control) of 5-ASA. Concomitant immunomodulator was used as the stratification factor in the randomization. The primary end point was relapse within 1 year. The subgroup analysis was stratified for the use of immunomodulators.

RESULTS

The full analysis set included 79 patients (39 intervention and 40 control). Immunomodulators were used in 20 (25.3%) patients. Relapse was less in the intervention group (15.4%) than the control group (37.5%; P = .026). In the subgroup with concomitant immunomodulators, relapse was also less in the intervention group (10.0%) than the control group (70.0%; P = .020). In patients without immunomodulators, the difference was not significant between 2 groups (intervention, 17.2%; control, 26.7%; P = .53).

CONCLUSIONS

Dose escalation of 5-ASA reduced relapse within 1 year in UC patients in clinical remission with an MES of 1.

Perspectives of East Asian patients and physicians on complementary and alternative medicine use for inflammatory bowel disease: results of a cross-sectional, multinational study

Background/Aims

Complementary and alternative medicine (CAM) is prevalent in East Asia. However, information on CAM in East Asian patients with inflammatory bowel disease (IBD) is scarce. We aimed to profile the prevalence and pattern of CAM use among East Asian IBD patients and to identify factors associated with CAM use. We also compared physicians’ perspectives on CAM.

Methods

Patients with IBD from China, Japan, and South Korea were invited to complete questionnaires on CAM use. Patient demographic and clinical data were collected. Logistic regression analysis was applied for predictors of CAM use. Physicians from each country were asked about their opinion on CAM services or products.

Results

Overall, 905 patients with IBD participated in this study (China 232, Japan 255, and South Korea 418). Approximately 8.6% of patients with IBD used CAM services for their disease, while 29.7% of patients sought at least 1 kind of CAM product. Current active disease and Chinese or South Korean nationality over Japanese were independent predictors of CAM use. Chinese doctors were more likely to consider CAM helpful for patients with IBD than were Japanese and South Korean doctors.

Conclusions

In 8.6% and 29.7% of East Asian patients with IBD used CAM services and products, respectively, which does not differ from the prevalence in their Western counterparts. There is a significant gap regarding CAM usage among different Asian countries, not only from the patients’ perspective but also from the physicians’ point of view.

Predictors of necessity for endoscopic balloon dilatation in patients with Crohn's disease-related small bowel stenosis

BACKGROUND AND AIM

In patients with Crohn's disease (CD) and small bowel stenosis, endoscopic balloon dilation (EBD) is considered to be useful in improving stenotic symptoms and avoiding surgery. However, it carries risks such as bleeding and perforation. The aim of this study was to identify the indications for endoscopic intervention in patients with CD and small bowel stenosis.

METHODS

From November 2007 to March 2020, 143 CD patients with small bowel stenosis were enrolled in this study. We identified the factors associated with not requiring endoscopic intervention during long-term follow-up of these patients.

RESULTS

Forty of the 143 patients had abdominal symptoms of stenosis and had undergone EBD, whereas the remaining 103 were asymptomatic and had not undergone endoscopic intervention. During long-term follow-up, 95 of those 103 patients never required endoscopic or surgical intervention. Multivariate logistic regression analysis revealed that not consuming an elemental diet (OR 3.18, 95% CI 1.48-6.82; p < .01) and ileocecal valve (ICV) stenosis (OR 0.30, 95% CI 0.11-0.83; p = .02) were independently associated with not requiring EBD. The cumulative emergency hospitalisation-free rate also tended to be higher in patients not consuming an elemental diet or with ICV stenosis.

CONCLUSIONS

Two factors, namely not consuming an elemental diet and ICV stenosis, predict a long-term intervention-free prognosis in CD patients with small bowel stenosis.Key messagesWhen an endoscopically impassable small bowel stenosis is found in a CD patient, long-term follow-up without endoscopic intervention may be possible if the patient is asymptomatic, is not using an elemental diet, and the stenosis is ICV.

Efficacy of Novel Ultrathin Single-Balloon Enteroscopy for Crohn's Disease: A Propensity Score-Matched Study

Background/Aims

The evaluation of small bowel lesions of Crohn's disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient's pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD.

Methods

This single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared.

Results

Before propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005).

Conclusions

Novel ultrathin SBE may be less painful for CD patients than conventional SBE.

Development of an Indigo Naturalis Suppository for Topical Induction Therapy in Patients with Ulcerative Colitis

BACKGROUND

Indigo naturalis (IN) consists of ligands for the aryl hydrocarbon receptor and exhibits anti-inflammatory effects. Previously, we demonstrated that an 8-week treatment with oral IN is effective in inducing a clinical response in patients with ulcerative colitis (UC). Some UC patients with proctitis are refractory to topical mesalamine or corticosteroids and therefore require an alternative topical treatment.

OBJECTIVES

We aimed to prospectively evaluate the safety and efficacy of IN suppositories in UC patients.

METHOD

We performed an open-label, single-center, prospective pilot study from February 2018 to October 2018. A total of 10 patients with active UC, who had moderate to severe inflammation from the rectum to the sigmoid colon, were enrolled. The patients received a daily dose of 50 mg IN suppository for 4 weeks. The primary endpoint was safety at week 4.

RESULTS

Although 1 patient experienced anal pain, no serious adverse events were observed. At week 4, the rates of clinical remission and mucosal healing were 30 and 40%, respectively. Mayo rectal bleeding subscores significantly improved after treatment (1.80 ± 0.13 vs. 0.90 ± 0.28; p = 0.009). Approximately 80% of the patients with a baseline Mayo endoscopic subscore in the rectum (r-MES) of 2 achieved mucosal healing, but those with a baseline r-MES of 3 did not.

CONCLUSIONS

We found that 4 weeks of IN suppository can be tolerated by UC patients, but its efficacy was limited by the severity of the disease. Further investigation will be needed in order to confirm the optimum dose of IN suppository for patients with UC.

Significance of endoscopic deep small bowel evaluation using balloon-assisted enteroscopy for Crohn's disease in clinical remission

BACKGROUND

Small bowel lesions of Crohn's disease (CD) are known to be associated with a poor prognosis; however, endoscopic healing leads to favorable patients' outcome. The aim of this study was to clarify the clinical impact of assessing deep small bowel lesions (DSB) using balloon-assisted enteroscopy (BAE) on CD patients in clinical remission.

METHODS

From January 2012 to July 2018, a total of 100 CD patients in clinical remission were enrolled to undergo trans-anal enteroscopy using single-balloon enteroscope. Endoscopic evaluations at the terminal ileum (TI) were performed using a partial Simple Endoscopic Score for CD (pSES-CD). Endoscopic evaluations at the DSB used a modified partial SES-CD (mpSES-CD). We evaluated the factors associated with relapse, and the correlation of endoscopic score between the TI and DSB. For this study, relapse was defined as hospitalization within a year from enteroscopy.

RESULTS

30 patients (30.0%) relapsed within a year from enteroscopy. Multivariate logistic regression analysis revealed that the Harvey-Bradshaw Index (OR 1.77, 95% CI 1.18-2.65; p = 0.003) and an mpSES-CD at DSB (OR 3.10, 95% CI 1.86-5.15; p = 0.001) were independent predictors for relapse, whereas a SES-CD at the TI did not exhibit independence. There was a significant correlation trend between the relapse rate and greater than 5 points of an mpSES-CD at DSB; however, there was no correlation between the relapse rate and pSES-CD at the TI.

CONCLUSION

Even when Crohn's disease is in remission, it is important to evaluate DSB using BAE to assess endoscopic mucosal healing.

Mucosal concentrations of N-acetyl-5-aminosalicylic acid related to endoscopic activity in ulcerative colitis patients with mesalamine

BACKGROUND AND AIM

5-Aminosalicylic acid (5-ASA) is a fundamental treatment for mild-to-moderate ulcerative colitis (UC). 5-ASA is taken up into the colonic mucosa and metabolized to N-acetyl-5-ASA (Ac-5-ASA). Few studies have assessed whether mucosal 5-ASA and Ac-5-ASA concentrations are associated with endoscopic remission. This study aimed to investigate differences in 5-ASA and Ac-5-ASA concentrations according to endoscopic activity.

METHODS

This single-center, prospective, cross-sectional study was conducted between March 2018 and February 2019. UC patients who were administered with 5-ASA medication for at least 8 weeks before sigmoidoscopy were enrolled. Mucosal 5-ASA and Ac-5-ASA concentrations were measured using liquid chromatography with tandem mass spectrometry. The primary endpoint was defined as the difference in mucosal concentrations of 5-ASA and Ac-5-ASA, according to the Mayo endoscopic subscore (MES).

RESULTS

Mucosal concentrations were analyzed in 50 patients. In the sigmoid colon, the median 5-ASA concentration in patients with MES of 0 (17.3 ng/mg) was significantly higher than MES ≥ 1 (6.4 ng/mg) (P = 0.019). The median 5-ASA concentrations in patients with Ulcerative Colitis Endoscopic Index of Severity ≤ 1 (16.4 ng/mg) were also significantly higher than in patients with Ulcerative Colitis Endoscopic Index of Severity ≥ 2 (4.63 ng/mg) (P = 0.047). In the sigmoid colon, the concentration of Ac-5-ASA was higher in patients with MES of 0 (21.2 ng/mg) than in patients with MES ≥ 1 (5.81 ng/mg) (P = 0.022).

CONCLUSIONS

The present study showed that mucosal Ac-5-ASA concentrations, as well as 5-ASA concentrations, are higher in UC patients with endoscopic remission. Ac-5-ASA may be useful for a biomarker of 5-ASA efficacy.

Endoscopic removal of foreign bodies: A retrospective study in Japan

BACKGROUND

The ingestion of foreign bodies (FBs) and food bolus impaction (FBI) in the digestive tract are commonly encountered clinical problems. Methods to handle such problems continue to evolve offering advantages, such as the avoidance of surgery, reduced cost, improved visualization, reduced morbidity, and high removal success rate. However, to date, no studies have evaluated the endoscopic management of FBs in Japan.

AIM

To elucidate level of safety and efficacy in the endoscopic management of FBs and FBI.

METHODS

A total of 215 procedures were performed at Keio University Hospital between November 2007 and August 2018. Data were collected from medical charts, and endoscopic details were collected from an endoscopic reporting system. Procedures performed with a flexible gastrointestinal endoscope were only taken into account. Patients who underwent a technique involving FB or FBI from the digestive tract were only included. Data on patient sex, patient age, outpatient, inpatient, FB type, FB location, procedure time, procedure type, removal device type, success, and technical complications were reviewed and analyzed retrospectively.

RESULTS

Among the 215 procedures, 136 (63.3%) were performed in old adults (≥ 60 years), 180 (83.7%) procedures were performed in outpatients. The most common type of FBs were press-through-pack (PTP) medications [72 (33.5%) cases], FBI [47 (21.9%)], Anisakis parasite (AP) [41 (19.1%) cases]. Most FBs were located in the esophagus [130 (60.5%) cases] followed by the stomach [68 (31.6%) cases]. AP was commonly found in the stomach [39 (57.4%) cases], and it was removed using biopsy forceps in 97.5% of the cases. The most common FBs according to anatomical location were PTP medications (40%) and dental prostheses (DP) (40%) in the laryngopharynx, PTP (48.5%) in the esophagus, AP (57.4%) in the stomach, DP (37.5%) in the small intestine and video capsule endoscopy device (75%) in the colon. A transparent cap with grasping forceps was the most commonly used device [82 (38.1%) cases]. The success rate of the procedure was 100%, and complication were observed in only one case (0.5%).

CONCLUSION

Endoscopic management of FBs and FBI in our Hospital is extremely safe and effective.

Determination of Total Dietary Fiber in Selected Foods Containing Resistant Maltodextrin by Enzymatic-Gravimetric Method and Liquid Chromatography: Collaborative Study

A method was developed for determination of total dietary fiber (TDF) in foods containing resistant maltodextrin (RMD) which includes nondigestible carbohydrates that are not fully recovered as dietary fiber by conventional TDF methods such as AOAC 985.29 or 991.43. Because the average molecular weight (MW) of RMD is 2000 daltons, lower MW soluble dietary fiber components do not precipitate in 78% ethanol; therefore, RMD is not completely quantitated as dietary fiber by current AOAC methods. The accuracy and precision of the method was evaluated through an AOAC collaborative study. Ten laboratories participated and assayed 12 test portions (6 blind duplicates) containing RMD. The 6 test pairs ranged from 1.5 to 100% RMD. The method consisted of the following steps: (1) The insoluble dietary fiber (IDF) and high MW soluble dietary fiber (HMWSDF) were determined by AOAC 985.29. (2) Ion exchange resins were used to remove salts and proteins contained in the AOAC 985.29 filtrates (including ethanol and acetone). (3) The amount of low MWRMD (LMWRMD) in the filtrates were determined by liquid chromatography. (4) The TDF was calculated by summation of the IDF, HMWSDF, and LMWRMD fractions having nondigestible carbohydrates with a degree of polymerization of 3 and higher. Repeatability standard deviations (RSDr) were 1.33–7.46%, calculated by including outliers, and 1.33–6.10%, calculated by not including outliers. Reproducibility standard deviations (RSDR) were 2.48–9.39%, calculated by including outliers, and 1.79–9.39%, calculated by not including outliers. This method is recommended for adoption as Official First Action.

Endoscopic characteristics of small intestinal malignant tumors observed by balloon-assisted enteroscopy

BACKGROUND

Capsule endoscopy and balloon-assisted enteroscopy (BAE) enable visualization of rare small bowel conditions such as small intestinal malignant tumors. However, details of the endoscopic characteristics of small intestinal malignant tumors are still unknown.

AIM

To elucidate the endoscopic characteristics of small intestinal malignant tumors.

METHODS

From March 2005 to February 2017, 1328 BAE procedures were performed at Keio University Hospital. Of these procedures, malignant tumors were classified into three groups, Group 1: epithelial tumors including primary small intestinal cancer, metastatic small intestinal cancer, and direct small intestinal invasion by an adjacent organ cancer; Group 2: small intestinal malignant lymphoma; and Group 3, small intestinal gastrointestinal stromal tumors. We systematically collected clinical and endoscopic data from patients’ medical records to determine the endoscopic characteristics for each group.

RESULTS

The number of patients in each group was 16 (Group 1), 22 (Group 2), and 6 (Group 3), and the percentage of solitary tumors was 100%, 45.5%, and 100%, respectively (P < 0.001). Patients’ clinical background parameters including age, symptoms, and laboratory data were not significantly different between the groups. Seventy-five percent of epithelial tumors (Group 1) were located in the upper small intestine (duodenum and ileum), and approximately 70% of gastrointestinal stromal tumors (Group 3) were located in the jejunum. Solitary protruding or mass-type tumors were not seen in malignant lymphoma (Group 2) (P < 0.001). Stenosis was seen more often in Group 1, (68.8%, 27.3%, and 0%; Group 1, 2, and 3, respectively; P = 0.004). Enlarged white villi inside and/or surrounding the tumor were seen in 12.5%, 54.5%, and 0% in Group 1, 2, and 3, respectively (P = 0.001).

CONCLUSION

The differential diagnosis of small intestinal malignant tumors could be tentatively made based on BAE findings.

A pilot study of evaluation of the antioxidative activity of resveratrol and its analogue in a 6-month feeding test in young adult mice

Resveratrol, a polyphenolic phytoalexin, has free-radical scavenging activity and we found that it induces chromosomal aberrations, micronuclei, and sister chromatid exchanges in vitro. We synthesized its analogue 4-hydroxy-trans-stilbene (4-OH) and found that it has the same in vitro clastogenic activities as resveratrol, suggesting that the 4' hydroxy group of resveratrol is responsible for the effect. We fed resveratrol and 4-OH to young adult ICR mice at 0, 0.2, 2, or 20 ppm in their standard powder diet for 6 months and investigated the antioxidative effects. Half of each group was given 3000 ppm potassium bromate (KBrO(3)) in water for the last week to cause oxidative damage. Body weight gain tended to increase in males at 0.2 ppm resveratrol or 4-OH, and in females at 2 ppm 4-OH. Micronucleus (MN) analysis in bone marrow erythrocytes showed that the KBrO(3) tendency to induce MN was not prevented by the dietary resveratrol or 4-OH, which themselves did not induce MN under the present conditions. In this pilot study, resveratrol and 4-OH showed no obvious effect, either beneficial or adverse, at doses that are feasible in daily life for humans.

Increased cyclooxygenase-2 expression is correlated with suppressed antitumor immunity in cervical adenocarcinomas

Cyclooxygenase-2 (COX-2) inhibition suppressed the growth of various tumors. The augmentation of antitumor immunity by increasing cytotoxic lymphocytes may be an important mechanism for COX-2 inhibition. Among cervical cancers, adenocarcinomas present more aggressive behavior and overexpressed COX-2. The expression of COX-2 and the CD8+ lymphocyte infiltrations were evaluated in this study by immunohistochemistry. We studied COX-2 expression and CD8+ lymphocyte infiltration in 55 women with cervical adenocarcinomas. COX-2 expression and tumor stromal CD8+ lymphocytes were evaluated by semiquantified methods. Tumor intraepithelial lymphocytes were counted under microscopic field of x200. Correlations between these data and other clinicopathologic features were investigated. Thirty-seven out of 55 (67.3%) cervical adenocarcinomas significantly expressed COX-2. Patients who died within 5 years showed higher percentage of COX-2 expression than survivors (100% vs 58.1%, P < 0.05). Victims also showed lesser intraepithelial CD8+ lymphocyte counts than survived patients (3.4 vs 26.4, P < 0.05). COX-2 expression and tumor intraepithelial lymphocyte count were reversely correlated with each other (correlation index: -0.38, P < 0.01). Up-regulated COX-2 expression and lesser tumor intraepithelial CD8+ lymphocyte count are poor prognostic indicators for cervical adenocarcinoma patients. COX-2 may play an important role in the suppression of host antitumor immunity in cervical adenocarcinomas.

Ectopically located gonads in a patient with mixed gonadal dysgenesis: detection by diffusion-weighted MRI

We report a case of mixed gonadal dysgenesis in which diffusion-weighted magnetic resonance imaging played a major role in the detection of ectopically located gonads. Magnetic resonance imaging may have a potential in detecting ectopically located gonads and may provide important information for the management of patients with mixed gonadal dysgenesis.

[Extrapleural pneumonectomy of malignant pleural mesothelioma]

We analyzed 7 patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy. Six men and a woman had a mean age of 65 years old. The postoperative mortality rate was 14% (1 death) and morbidity, 43% (3 cases). According to staging of International Mesothelioma Interest Group, 2 patients had stage I disease, 1 did stage II, 3 did stage III and 1 did stage IV. Local recurrences were found in 3 patients and metastasis in 2. In patients with local recurrences, 2 had irradiation with chemotherapy and 1, irradiation. In patients with recurrences of metastasis, 1 had chemotherapy and 1, supportive care. Seven patients with extrapleural pneumonectomy and 10 without surgery had median survivals of 16 months and 10 months, 1-year survival rates of 71% and 40% and 2-year survival rates of 57% and 0% respectively (p=0.071). Extrapleural pneumonectomy with adjuvant therapy could be effective treatment for malignant pleural mesothelioma.

Reconstructive procedure after distal gastrectomy to prevent remnant gastritis

BACKGROUND/AIMS

Gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II) after distal gastrectomy is associated with duodenogastric reflux and remnant gastritis. This study sought to determine which reconstructive procedure is least likely to cause remnant gastritis and to determine the correlation between duodenogastric reflux and remnant gastritis.

METHODOLOGY

Sixty patients who underwent curative distal gastrectomy for gastric cancer were classified into three groups by reconstructive procedure: group A, Roux-Y (n=18); group B, Billroth I (n=25); group C, Billroth II (n=17). Intragastric bile reflux was monitored using the Bilitec 2000 14 days after surgery, and endoscopy was performed and a patient questionnaire was completed 12 weeks after surgery.

RESULTS

Bile reflux occurred in 23.9%, 40.4%, and 73.4% of the time (p<0.001), and remnant gastritis developed in 33%, 76%, and 100% of patients (p<0.001), in groups A, B, and C, respectively. Helicobacter pylori infection did not correlate with remnant gastritis (p=0.57). Symptoms following Roux-Y reconstruction were comparable to those following Billroth I and II reconstructions.

CONCLUSIONS

Roux-Y reconstruction following distal gastrectomy is superior to Billroth I and II reconstruction in preventing remnant gastritis because it reduces duodenogastric reflux.

C-erbB-2 or mutant Ha-ras induced malignant transformation of immortalized human ovarian surface epithelial cells in vitro

Ovarian cancer is believed to develop from the ovarian surface epithelium through the accumulation of aberrations of oncogenes and/or tumor suppressor genes. However, it is unclear how the gene abnormalities are involved in ovarian carcinogenesis. To elucidate the process, we transfected genes reported to show their abnormalities in human ovarian cancers into human ovarian surface epithelial cells. Immortalization of the cells was achieved by the transfection of SV40 large T antigen (LT) and human telomerase reverse transcriptase (hTERT); however, the resultant cells showed no tumorigenesis. Additional transfection of either c-erbB-2 or mutant Ha-ras into the immortalized cells showed the anchorage-independent growth and tumorigenesis in mice with the incidence of 50% and 40%, respectively. Histologically, all the tumours were undifferentiated. In association with the tumorigenesis, the cells expressing c-erbB-2 or mutant Ha-ras demonstrated increased vascular endothelial growth factor secretion under hypoxia and enhanced resistance to apoptosis compared with the immortalized cells. Collectively, the introduction of either c-erbB-2 or mutant Ha-ras in the cells, which were efficiently immortalized by the transfection of LT and hTERT, showed tumorigenicity, suggesting that c-erbB-2 or mutant Ha-ras genes might be involved in ovarian carcinogenesis.

[Lung cancer with both sarcoid reaction and metastasis in the mediastinal lymph nodes; report of a case]

A 66-year-old man was admitted to our hospital for detailed investigation of an abnormal shadow on his chest X-ray. Chest radiography and computed tomography(CT) of the chest showed mediastinal lymphadenopathy and a tumor shadow in the left upper lobe. Biopsy of the mediastinal lymph nodes by mediastinoscopy showed that sarcoid nodules existed in all the biopsies nodes. Therefore, the lymphadenopathy was thought to be sarcoidosis or sarcoid reaction accompanied with lung cancer. Left upper lobectomy and dissection of hilar and mediastinal lymph nodes were performed. Although sarcoid nodules were seen in all the dissected lymph nodes, the cancer involved #5 and #14 lymph nodes. He died of brain metastasis 10 months after surgery.

Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results

BACKGROUND

The efficacy of thoracoscopic radical esophagectomy for cancer of the thoracic esophagus and the learning curve required have yet to be clearly established.

METHODS

Eighty treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm minithoracotomy and four trocar ports. The outcomes in the first 34 patients (group 1) and the last 46 patients (group 2) were compared.

RESULTS

There were no differences in background or clinicopathologic factors between the two groups. The duration of the thoracoscopic procedure and blood loss were less (p <0.0001), the incidence of postoperative pulmonary infection was less (p = 0.0127), and the number of mediastinal nodes retrieved was greater (p = 0.0076) in group 2. Multivariate analysis demonstrated that surgical experience (number of cases performed) predicted the risk of pulmonary infection (p = 0.0331).

CONCLUSION

Video-assisted thoracoscopic radical esophagectomy can be performed with safety and efficacy comparable to those of open esophagectomy. Morbidity decreases with the surgeon's experience.

[Intrapleural streptokinase-streptodornase in the treatment of empyema and hemothorax]

Fourteen of 15 patients (93%) with retained pleural collections underwent successful enzymatic debridement and tube drainage with streptokinase-streptodornase (SK-SD) injections. No significant adverse reactions occurred. One patient required decortication when SK-SD therapy failed. Intrapleural SK-SD is a safe, effective means of removing retained proteinaceous collections in the pleural space. It may obviate the need for more invasive procedures.

Video-assisted thoracoscopic esophagectomy and radical lymph node dissection for esophageal cancer. A series of 75 cases

BACKGROUND

The efficacy of thoracoscopic radical esophagectomy for cancer has yet to be established, mainly because previous reports have not included a sufficient number of cases.

METHODS

Seventy-five treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm mini-thoracotomy and four trocar ports.

RESULTS

Video-assisted thoracoscopic surgery was performed without major intraoperative complications or emergency conversion to open surgery. We retrieved 34.1+/-13.0 mediastinal nodes, including 11.5+/-3.8 tracheobronchial nodes and 6.2+/-3.0 recurrent laryngeal nodes. Mean time of operation and blood loss were less in the last 39 patients than the first 36 (186.7+/-25.3 min and 165.4+/-101.8 g vs 270. 2+/-96.0 min and 421.5+/-31.2 g, respectively: p <0.0001 and p <0.001). Pulmonary morbidity was 5% in the later 39 patients. Survival was 90%, 80%, and 57% at 1, 2, and 5 years after surgery.

CONCLUSION

Thoracoscopic radical esophagectomy has less morbidity and comparable survival to conventional surgery, after a moderate amount of experience. Mini-thoracotomy is essential to perform the procedure safely and effectively.

Three-color flow cytometric study on lymphocytes derived from thymic diseases

BACKGROUND

Anterior mediastinal masses derive from a variety of diseases. Thymomas have been shown to commonly hold CD4(+)CD8(+) double-positive (DP) lymphocytes, and identification of this subset by two-color flow cytometric study was suggested to help diagnosis of thymoma. Several other thymic diseases, however, possibly hold CD4(+)CD8(+) DP lymphocytes. In this study, we utilized the three-color flow cytometric method for further examination of the phenotypes of lymphocytes in the thymic diseases.

MATERIALS AND METHODS

One hundred eight specimens (77 primary and 10 metastatic thymomas, 10 thymic carcinomas, 2 thymic carcinoids, 4 malignant lymphomas, 2 seminomas, an inflammatory pseudotumor, and 2 nonneoplastic thymic hyperplasias) were subjected to the study. The expressions of CD3, CD4, and CD8 on tumor-associated lymphocytes were evaluated by three-color flow cytometric study.

RESULTS

The proportion of the CD4(+)CD8(+) DP subset was more than 30% in all 78 lymphocyte-rich thymomas, in 2 malignant lymphomas, and in both thymic hyperplasias. CD3 expression of the CD4(+)CD8(+) DP subset ranged from a negative to a high level in thymomas and thymic hyperplasias, while it was restricted to a particular level in CD4(+)CD8(+) DP-type malignant lymphomas. The proportion of CD3(+) cells in the CD4(+)CD8(-) single-positive subset was consistently less than 90% in the lymphocyte-rich thymomas, while it was more than 90% in the thymic hyperplasias.

CONCLUSION

Although identification of the CD4(+)CD8(+) DP subset in the tumor-associated lymphocytes does not necessarily indicate thymoma, a further characterization of thymic neoplasms possessing the CD4(+)CD8(+) DP subset was enabled by three-color flow cytometric study, suggesting the utility of this method as an ancillary tool for differential diagnosis of these diseases.

Bilirubin as a tracer for detecting gastroesophageal reflux

PURPOSE

The usefulness of intraesophageal monitoring of bilirubin, in diagnosing gastroesophageal reflux, was studied.

PATIENTS AND METHODS

Bilirubin concentration and pH at 5 cm oral and anal to the esophagogastric junction were monitored for 24 hours in 19 patients with reflux esophagitis. The duration of bilirubin presented and pH less than 4.0 were obtained as the holding time (HT) of bilirubin and acid, respectively.

RESULTS

There was no difference between HT of bilirubin and acid in the stomach and esophagus. In the stomach, HT of bilirubin did not correlate with acid. Whereas, in both of bilirubin and acid, HT in the esophagus correlated significantly with that in the stomach. The correlation was more definite for bilirubin than acid.

CONCLUSIONS

Bilirubin and acid presented in the upper stomach for sufficient period independently. Bilirubin monitoring was useful to evaluate the etiology of damaging the esophageal mucosa and causes of symptoms by estimating duodenogastro-esophageal reflux, which has synergistic effect with acid.

[Examination of the power of families taking care of patients at home at peace]

OBJECTIVE

We examined the power of families who take care of a patient at home. We wanted to know how much caring power patients needed to stay at home at peace.

PATIENTS AND METHODS

The subjects were 150 patients who visit the hospital for day care or are taken care of at home under our management. We examined their age, sex, main disease, the points of their families power for their care, the assessment of how peaceful at home, use of care services, and special things.

RESULTS

Most of the patients were in their 80's or 70's. Stroke was the main disease. The most care grade are second grade. Higher care grade are smaller number. About 50% of the families paid for care services. The assessment of low care grade patients did not depend on the power of the families. But the assessment of high care grade patients did depend on that. We concluded that it is difficult to take care at home of high care grade patients who does not have some powers on families for his care. If the patient and his/her family want to use care services, they have to pay 10% charge. It is difficult to alleviate the burden they pose on their family.

Photochemical generation of nitric oxide from 6-nitrobenzo[a]pyrene

Photolabile 6-nitrobenzo[a]pyrene (6-nitroBaP) released nitric oxide (NO) under visible-light irradiation. The generation of NO and the concomitant formation of the 6-oxyBaP radical were confirmed by ESR. BaP quinones were also detected as further oxidized products of the 6-oxyBaP radical. No such photodegradation was observed with other nitrated BaPs, such as 1-nitroBaP and 3-nitroBaP. DNA-strand breakage, caused by photoexcited 6-nitroBaP, was closely related to its NO-releasing activity. MO calculations of nitrated BaP suggest that the perpendicular conformation of the nitro substituent to the aromatic ring is important for the release of NO with light. These findings may be useful for the development of a new type of NO donor.

Resveratrol, a naturally occurring polyphenol, induces sister chromatid exchanges in a Chinese hamster lung (CHL) cell line

We tested the genotoxicity of 3,5,4'-trihydroxystilbene (resveratrol), a polyphenolic phytoalexin found in grapes, in a bacterial reverse mutation assay, in vitro chromosome aberration (CA) test, in vitro micronucleus (MN) test, and sister chromatid exchange (SCE) test. Resveratrol was negative in the strains we used in the bacterial reverse mutation assay (S. typhimurium TA98 and TA100 and E. coli WP2uvrA) in the absence and presence of a microsomal metabolizing system. It induced structural CAs at 2.5-20 microg/ml and showed weak aneuploidy induction in a Chinese hamster lung (CHL) cell line. It induced MN cells and polynuclear and karyorrhectic cells after 48h treatments in the in vitro MN test. In the SCE test, resveratrol caused a clear cell-cycle delay; at 10 microg/ml, the cell cycle took twice as long as it did in the control. Resveratrol induced SCEs dose-dependently at up to 10 microg/ml, at which it increased SCE six-fold, and the number was almost as large as mitomycin C, a strong SCE inducer. No second mitoses were observed at 20 microg/ml even after 54h. Cell cycle analysis by FACScan indicated that resveratrol caused S phase arrest, and 48h treatment induced apoptosis. Our results suggest that resveratrol may preferentially induce SCE but not CA, that is, it may cause S phase arrest only when SCEs are induced.

Micronucleus induction and chromosomal aberration of 1- and 3-nitroazabenzo[a]pyrene and their N-oxides

Nitro-azabenzo[a]pyrenes, 1- or 3-nitro-azabenzo[a]pyrene and their N-oxides are nitrated derivatives of azabenzo[a] pyrene (ABP) containing nitrogen in the 6-position of benzo[a]pyrene (B[a]P). The nitro-ABP-N-oxides (ABPOs) were formed by reaction of ABP with excess HNO(3). These derivatives were noteworthy as potent mutagens for Salmonella strains, and were present in fine particles of diesel particulates. In this study, micronucleus induction in mice and chromosomal aberrations due to means of Chinese hamster lung fibroblast (CHL) cells were investigated to determine genotoxicity in order to define the relationship with the mutagenic potency of these derivatives. The induction of micronucleus polychromatic erythrocytes (MNPCEs) was dependent on the dose response of 10-40 mg for 3-N-6-ABP, and of 10-40 mg for 1-N-6-ABP, and in addition, 1- and 3-N-6-ABPOs markedly induced MNPCEs in a dose range of 10-400 mg and from 1 to 80 mg, respectively, when the compound was intraperitoneally administrated in two mice at each dose. The results show that of the four compounds, 3-N-6-ABPO demonstrated a marked increase in MNPCES: On the other hand, chromosomal aberrations of the four compounds were investigated by the duplicate tests using CHLS: The results after a 48 h treatment induced aberrations of the chromatid type, chromatid breaks and exchanges for 1- and 3-N-6-ABP, and mainly chromatid exchanges for 1- and 3-N-6-ABPO. The frequency of chromosomal aberrations associated with nitro substitution on the ABPO structure. Chromosomal aberrations of nitro derivatives of ABPO substituted at the 3-position on the structure were more potent than those at the 1-postion. N-oxide derivatives have been found to be reduced to anion radicals much more easily than azaB[a]P and its nitro derivatives. This suggests that the electrochemical reduction of the chemicals plays an important role in the metabolic activation of nitrated B[a]P derivatives.

The role of galectin-3 in endocytosis of advanced glycation end products and modified low density lipoproteins

Galectin-3, a member of beta-galactoside-binding lectin family, is suggested to be an AGE-receptor. To examine this possibility, we prepared CHO cells overexpressing human galectin-3 (galectin-3-CHO cells). Galectin-3-CHO cells showed a specific and saturable binding to (125)I-AGE-BSA with Kd of 3.1 microg/ml. (125)I-AGE-BSA was endocytosed by galectin-3-CHO cells and underwent lysosomal degradation. The endocytosis of (125)I-AGE-BSA was inhibited not only by unlabeled AGE-BSA but also by acetylated LDL and oxidized LDL, ligands for the scavenger receptor family. Furthermore, (125)I-oxidized LDL and (125)I-acetylated LDL were actively endocytosed by galectin-3-CHO cells and the incubation with acetyl-LDL led to intracellular accumulation of cholesteryl esters, indicating the role of galectin-3 in endocytosis of AGE-proteins and modified LDLs. Since galectin-3 was localized and up-regulated in foam cells at human atherosclerotic lesions, the present results suggest that galectin-3 plays an important role in formation of atherosclerotic lesions in vivo, by modulating endocytic uptake of AGE-proteins and modified LDLs.

Oxidative DNA damage by a metabolite of carcinogenic 1-nitropyrene

Nitropyrenes are carcinogenic pollutants. Adduct formation following nitro-reduction is considered to be a major cause of nitropyrene-mediated DNA damage. We investigated the role of 1-nitrosopyrene, a metabolite of 1-nitropyrene, in causing oxidative DNA damage, using 32P-5'-end-labeled DNA. 1-Nitrosopyrene was found to facilitate Cu(II)-mediated DNA damage in the presence of NADH. Catalase and a Cu(I)-specific chelator attenuated DNA damage, indicating the involvement of H2O2 and Cu(I). Typical *OH scavenger did not have a significant effect. These results suggest that the main reactive species is probably a DNA-copper-hydroperoxo complex. We also measured 8-oxo-7,8-dihydro-2'-deoxyguanosine formation by 1-nitrosopyrene in the presence of Cu(II) and NADH, using an electrochemical detector coupled to a high-pressure liquid chromatograph. We conclude that oxidative DNA damage, in addition to DNA adduct formation, may play an important role in the carcinogenesis of nitropyrenes.

Clinical and functional significance of WHO classification on human thymic epithelial neoplasms: a study of 146 consecutive tumors

We examined the clinical and functional significance of histologic classification of thymic epithelial neoplasms proposed by the World Health Organization (WHO), based on an analysis of 146 consecutive tumors derived from 141 patients and 47 normal thymuses derived from children ranging in age from 1 to 9 years. Invasive tumors were seen in 12.5%, 38.6%, 40.0%, 69.4%, 80.0%, and 100% of type A, AB, B1, B2, B3, and C primary tumors, respectively. All of six recurrent or metastatic lesions were type B2 tumors. Myasthenia gravis was associated in 0%, 6.8%, 40.0%, 55.6%, 10.0%, and 0% in patients with type A, AB, B1, B2, B3, and C tumors, respectively. The average number (x10(6)) of tumor-associated CD4+CD8+ cells present in 1 g of tumor tissue was 1.5, 391.1, 1041.7, 333.9, 24.5, and 0.2 in type A, AB, B1, B2, B3, and C, respectively, and it was 1168.2 in the normal thymuses. Thus, type B1 tumor retained the function to induce CD4+CD8+ double-positive cells at a level comparable to that of the normal thymic cortical epithelial cells, followed by type AB and type B2 tumors. Type A and B3 tumors had this function at a barely detectable level, and type C tumor was nonfunctional. WHO histologic classification was shown to reflect the clinical features and the T-cell-inducing function of thymic epithelial tumors.

Repeated immobilization stress reduces rat vertebral bone growth and osteocalcin

We previously showed that psychological stressors alter plasma levels of osteocalcin (pOC), a bone-specific mineral binding protein, in ways that differ with the type of stressor. To determine effects of chronic stress, we examined vertebrae, pOC, and corticosterone levels from conscious rats subjected to foot-restraint immobilization (Immo) daily for 1-42 times. After 40-42 Immo, basal pOC was decreased by 25% compared with unstressed rats, and the subsequent rise in pOC during Immo was blunted. Corticosterone was elevated 10-fold during Immo. Immo for seven times did not change vertebral OC concentration, but caused a slight decrease in calcium and phosphorous concentrations in younger rats. Rats Immo for 42 times exhibited reduced body weight, vertebral weight, and vertebral OC concentration but no significant differences in vertebral mineral concentrations. Body fat content was visibly decreased. We do not know the source of or the stimulus for the initial rise in pOC. We conclude that both decreased growth and bone OC concentration are due to repeatedly elevated stress hormones.

Results of preoperative mediastinoscopy for small cell lung cancer

BACKGROUND

The significance of mediastinoscopy for small cell lung cancer is unclear owing to the small number of surgical cases.

METHODS

To determine the N component of the TNM staging system, computed tomographic findings and the results of mediastinoscopy were compared with the pathologic examination of surgical specimens.

RESULTS

Four cases among 37 patients (10.8%) were determined as inoperable by mediastinoscopy because of mediastinal lymph node metastasis. A thoracotomy was performed in 33 patients. Six patients (18.2%) who had been judged to have no metastasis by mediastinoscopy were found to have N2 disease after examination of the surgical specimens. In the identification of all mediastinal metastases, mediastinoscopy was 40.0% sensitive, 100% specific, and 83.8% accurate. When the superior mediastinal, paratracheal, pretracheal, tracheobronchial, and subcarinal lymph nodes were defined as approachable nodes, mediastinoscopy was 66.7% sensitive, 100% specific, and 94.6% accurate in the evaluation of these restricted nodes. Four cases among 8 patients with cN1 lesions resulted in a designation as pN2.

CONCLUSIONS

Mediastinoscopy is useful for the diagnosis of an approachable mediastinal lymph node in small cell lung cancer cases. This exploration is necessary for patients with small cell lung cancer who are diagnosed as cN1 before thoracotomy.

Hydroxylation of nitrated naphthalenes with KO2/crown ether

Superoxide radical anion (O2*-), generated by KO2/crown ether, is effective for hydroxylation of nitronaphthalenes. When mono- and di-nitronaphthalenes are treated with KO2/crown ehter, hydroxylation results at the electron-deficient site caused by the electron withdrawing effect of the substituted nitro group. Kinetic experiments suggest that the hydroxylation proceeds by two different mechanisms dependent on the first one-electron reduction potential of nitronaphthalenes.

[Clinical significance of ambulatory intraesophageal bilirubin monitoring in diagnosis of gastroesophageal reflux]

To evaluate the usefulness of ambulatory intraesophageal bilirubin monitoring in the diagnosis of GER, 38 patients with reflux symptoms and 7 controls were studied, using Bilitec 2000. The % time of bilirubin and acid reflux was less than 5% in all of the controls. In 3 patients of NUD, % time of acid reflux was less than 5%, but that of bilirubin was more than 8% in 2 patients. Acid reflux was found only in 1 of 4 patients who had a history of subtotal gastrectomy, but abnormal bilirubin reflux was found in all of 4 patients. In the other 31 patients, a significant difference was found in the % time of bilirubin reflux by the severity of reflux esophagitis, whereas this difference was not found in that of acid reflux. Intraesophageal bilirubin monitoring is useful in the diagnosis of GER and is essential in patients with hypochlorhydria or minimal reflux.

[Computational study on antioxidation mechanism of catechins]

All C-H and O-H bond dissociation enthalpies (BDE's) in catechins, (-)-epigallocatechin) were calculated by semi-empirical molecular orbital calculation using the SPARTAN program. The BDE's of benzyl hydrogens (C-2 position in catechins) were found to be quite low. This suggests that abstraction of benzyl hydrogen is crucial step for antioxidative activity. This is corroborated by the reported results of LC/MS and spectrophotometric analysis of reaction intermediates from catechins treated with AAPH.

Surgery for pulmonary metastases from colorectal carcinoma

BACKGROUND

This study aims to clarify which patients would benefit by surgery for pulmonary metastases from colorectal carcinoma.

METHODS

A retrospective study was undertaken in 25 patients who had undergone complete resection. In all cases, prethoracotomy carcinoembryonic antigen (CEA) level was measured and mediastinal or hilar lymph nodes were histologically examined.

RESULTS

Overall 5-year survival was 39.2%. The 5-year survival rate for patients with a normal CEA level was 61.1%, as compared with 19.0% for patients with an elevated CEA level (p = 0.0423). The 5-year survival rate for patients without a lymph node metastasis was 49.5%, as compared with 14.3% for patients with a lymph node metastasis (p = 0.0032). No lymph node metastasis was a predictor of longer survival by univariate and multivariate analyses. The primary site, disease-free interval, and number and size of the metastasis were not significant prognostic factors.

CONCLUSIONS

A resection for pulmonary metastasis from colorectal carcinoma is effective in patients with a normal CEA level and without a lymph node metastasis.

Rapid detection of the gene of Legionella pneumophila using the fluorescence polarization with the asymmetric PCR

We attempted the rapid detection method of Legionella pneumophila by the asymmetric PCR and the fluorescence polarization. Eleven extracted DNAs from L. pneumophila serogroup 1 to approximately 6, L. bozemanii, L. dumoffii, L. gormanii, L. micdadei, and Pseudomonas aeruginosa were amplified by asymmetric PCR, and the polarization of those products were measured. Only the polarization of L. pneumophila serogroup 1 to approximately 6 rose within a few minutes after the beginning of measurement. The sensitivity to L. pneumophila using this method was 10(3) cells.

Correlation between plasma and hepatic phosphatidylcholine hydroperoxide, energy charge, and total glutathione content in ischemia reperfusion injury of rat liver

BACKGROUND/AIMS

Oxygen-derived free radicals are believed to be responsible for the hepatocellular injury leading to liver failure following ischemia-reperfusion in liver, endotoxemia and many other life-threatening illnesses. This study was designed to investigate the reactive oxygen species interaction in lipid peroxidation, the adenosine and energy charge levels of liver cells, and total glutathione content in ischemic-reperfusion injury of liver in rat.

METHODOLOGY

To prevent intestinal congestion during the clamping of vascular structures, subcutaneous transposition of the spleen was done beforehand. Four to six weeks later, after the development of natural portal-systemic shunts, occlusion of the portal vein, hepatic artery and bile duct was performed for different periods; blood and liver samples were taken at different intervals after the release. On the basis of the ischemia-reperfusion time, the rats were divided into the following 9 groups: 30/0, 30/30, 30/60, 60/0, 60/30, 60/60, 90/0, 90/30, and 90/60. The following parameters were measured: total hepatic glutathione content, adenosine values (ATP, ADP, AMP), energy charge, phosphatidylcholine hydroperoxide (PCOOH) concentrations in liver and plasma, and serum transaminases (AST, ALT). Decreased liver glutathione stores (an indicator of increased oxidative stress), increased serum hepatic transaminases (an indicator of hepatocellular injury), and increased PCOOH (an indicator of cellular-membrane lipid peroxidation) were noted.

RESULTS

The ATP level and energy charge diminished significantly with the increase in duration of ischemia and reperfusion. A close correlation between the PCOOH levels in plasma and liver was observed. Extreme damage was noted in the 90-minute ischemia with 60-minute reperfusion group. The hepatic total glutathione level was reduced to the lowest level in the 90/60 group and it correlated with the energy charge level, denoting the highest degree of oxidative stress sustained by the liver cells in this group.

CONCLUSIONS

These results indicated that prolonged hepatic ischemia with reperfusion produced bursts of oxygen-derived free radicals which overwhelmed the defense mechanisms of the cells, with a resultant decrease in energy charge associated with an increase in membrane lipid peroxidation. These findings not only provide confirmation of previously reported hepatocellular injury by free radicals generated after reperfusion, but they also establish the use of PCOOH analysis in liver and plasma as a sensitive and specific indicator of the injury process in time. The plasma PCOOH level may be a useful indicator of free radical induced hepatic membrane lipid peroxidation during ischemia-reperfusion, and might be employed in clinical studies of the therapeutic effects of drugs in various liver diseases, as well as for determining the prognosis after different kinds of hepatic operations.

Intermediate state during the crystal transition in aspartame, studied with thermal analysis, solid-state NMR, and molecular dynamics simulation

Aspartame (L-alpha-aspartyl-L-phenylalanine methyl ester) is a dipeptide sweetener about 200 times as sweet as sugar. It exists in crystal forms such as IA, IB, IIA, and IIB, which differ in crystal structure and in the degree of hydration. Among these, IIA is the most stable crystal form, and its crystal structure has been well determined (Hatada et al., J. Am. Chem. Soc., 107, 4279-4282 (1985)). To elucidate the structural factors of thermal stability in the IIA form of aspartame and to examine the physical process in the crystal transformation between the IIA and IIB forms, we performed a thermal analysis and solid-state NMR measurements. We found that a quasi-stable intermediate state exists in the transformation, and it has the same crystal lattice as the usual IIA form, despite the dehydration from 1/2 mol to 1/3 mol per 1 mol of aspartame. The results of the energy component analysis and the molecular dynamics simulation suggest that the entropic effect promotes the generation of the intermediate state, which is presumably caused by the evaporation of the water of crystallization and the increase of molecular motion in aspartame. Thus, the thermal stability of the IIA form is attributable to a structural property, i.e., the crystal lattice itself is retained during the above dehydration. Moreover, the molecular dynamics simulations suggest that the aspartame molecules have two kinds of conformational flexibility in the intermediate state.