[A Case of Primary Liver Cancer and Gastric Glomus Tumor Diagnosed Preoperatively and Treated with Liver Segmentectomy and Local Gastrectomy]

A man in his 70s was concurrently suspected of having a submucosal tumor(SMT)of the stomach and a liver tumor during a medical examination. Abdominal contrast-enhanced CT scan revealed S8 hepatocellular carcinoma(HCC)and an SMT of the stomach, which was strongly enhanced from the early to the later phase. Upper gastrointestinal endoscopy revealed a 20 mm SMT in the antrum of the stomach. Endoscopic ultrasonography showed a hyperechoic tumor in the fourth layer of the gastric wall. T2-weighted MRI showed a 25 mm SMT in the antrum of the stomach with a faint high signal intensity compared with that of the gastric wall. The patient was diagnosed with HCC and gastric glomus tumor, and a liver segmentectomy and a local gastrectomy were performed. Immunohistochemistry of the SMT revealed the expression of α-SMA but no expression of desmin, c-kit, CD34, or S-100. Therefore, a diagnosis of a Glomus tumor of the stomach was made. Gastric Glomus tumors are very rare; therefore, we have reviewed some citations and would like to discuss our case.

[A Case of Small Thymic Carcinoma with Pleural Dissemination Preoperatively Suspected as Pulmonary Metastasis from Rectal Cancer]

A case was 73-year-old man, who had history of laparoscopic high anterior resection surgery for rectal cancer, followed by adjuvant chemotherapy 2 years ago. Preoperative diagnosis was anterior mediastinal tumor, with multiple intrapulmonary nodules noted, though no increasing tendency. During adjuvant chemotherapy for colorectal cancer, the anterior mediastinal tumor showed some shrinkage, while that and 3 intrapulmonary nodules slowly increased in size after completion, thus rectal cancer pulmonary and mediastinal metastasis were suspected. Complete resection of the intrapulmonary nodules and anterior mediastinal tumor was considered feasible. Thoracoscopic observation revealed multiple small pleural seeding lesions and all speculated to be intrapulmonary metastases before surgery were also pleural lesions. Intraoperative rapid diagnostic findings of a biopsy section revealed possible colorectal cancer metastasis, though histological type was not revealed. Final histopathological diagnosis was pleural dissemination of thymic carcinoma. Lenvatinib was introduced 2 months later for thymic carcinoma with pleural dissemination. Two years after surgery, the anterior mediastinum primary tumor had slightly decreased and the pleural nodules also showed a shrinking tendency. In such cases of small tumor with increasing tendency and irregular margins, thymic carcinoma should be considered when planning treatment.

[A Case of Hypertrophic Pulmonary Osteoarthropathy Associated with Pulmonary Pleomorphic Carcinoma]

Hypertrophic pulmonary osteoarthropathy(HPO)is a tumor-associated syndrome that features the triad of clubbed fingers, periosteal bone growth in long bones, and arthritis, and is often associated with an adenocarcinoma or squamous cell carcinoma. This report presents details of a case of HPO associated with pleomorphic carcinoma, which was relieved by treatment. A 47-year-old woman was presented with a complaint of generalized arthralgia. A physical examination showed swollen joints in the body and clubbed fingers. Chest CT revealed a mass shadow in the left upper lobe and ultrasound- guided biopsy findings led to a diagnosis of non-small cell lung cancer. Furthermore, bone scintigraphy indicated symmetrical accumulation in bones and joints throughout the body. A right upper lobectomy was performed along with combined chest wall resection and mediastinal lymph node dissection with an open chest, and the presence of lung cancer complicated with HPO was indicated. Pathological examination results revealed a diagnosis of pleomorphic carcinoma(pT4N0M0, Stage ⅢA). Systemic arthralgia was resolved on the first postoperative day. One year after surgery, a solitary brain metastasis developed and was removed, with no recurrence at the time of writing. Joint symptoms related to HPO can be expected to improve with treatment of pulmonary lesions, thus aggressive procedures for diagnosis and treatment are desirable.

[Two Cases of Recurrent Colon Cancer with BRAF Mutation]

We report 2 cases of recurrent colon cancer with BRAF mutation. Case 1, a 75-year-old man, had rapid progress of multiple liver metastasis 5 months after curative resection, and died on 37 days after recurrence without induction of systemic therapy. Case 2, a 67-year-old man with diagnosis of peritoneal dissemination at 8 months after curative resection, received encorafenb and cetuximab (doublet-therapy) with certain effect, nevertheless advanced triplet-therapy with binimetinib was forced to pause due to severe skin disorders and he died on 123 days after recurrence. We considered that closed follow- up should be required after curatively resected colorectal cancers with BRAF mutation for early detection of recurrence, and prompt induction and evaluation of systemic treatment also should be required after unresectable recurrence including careful management with the attention to the features of doublet and triplet-therapy.

[Could Preoperative Conditions Be Preserved or Improved by the Support of Preoperative ONS Administration in Patients with Gastric Cancer?]

INTRODUCTION

In our hospital, we measure the body composition of patients undergoing gastrointestinal surgery. For patients who have a skeletal muscle mass(SMM)of less than 90% of the ideal, we provide them with guidance on having oral nutritional supplements(ONS)and self-exercise therapy. Therefore, we perform operations after taking measures on preserving/improving patient's preoperative conditions. This study was aimed to evaluate the effects on body weight, SMM, and fat mass(FM)in the patients scheduled for gastrectomy.

PATIENTS AND METHODS

From January 2017 to December 2020, we retrospectively analyzed 64 gastric cancer patients whose body composition changes were measured at the time of initial diagnosis and immediately before surgery. The body composition was measured by a nutritionist using the BIA method, while the self-exercise therapy was instructed by a rehabilitation therapist.

RESULTS

A total of 64 patients were divided into 2 groups: ONS group(36 patients)and Non-ONS group(28 patients). The median preoperative ONS administered to the ONS group was 15 packs. Body weight change showed a significant difference between the 2 groups(+0.73% and -0.91%[p<0.01]in the ONS group and Non-ONS group respectively). SMM change showed no significant difference between the 2 groups(+1.18% and +0.64%[p=0.19]in the ONS group and Non-ONS group respectively). Likewise, FM change showed no significant difference between the 2 groups(-1.08% and -3.50%[p=0.39]in the ONS group and Non-ONS group respectively).

CONCLUSION

This study suggested that SMM and FM could be preserved, and body weight could be increased by the support of preoperative ONS administration even in patients with gastric cancer close to having sarcopenia.

[A Case of Rectal Neuroendocrine Tumor with a Major Axis of 10.7 mm with Lymph Node Metastasis]

The case is a 50-year-old woman. Colonoscopy performed by a local doctor for the purpose of stool occult blood positive revealed a 15 mm tumor in the lower rectum, biopsy showed chromogranin positive, synaptophysin positive, and Ki-67 index<1% showed a neuroendocrine tumor(NET), G1 was diagnosed and introduced. Colonoscopy revealed a smooth- surfaced circular hemispherical tumor with a lower edge 30 mm from the anal margin and 20 mm from the dentate line, and EUS showed 10.7×5.2 mm in layers 2 to 3. It was visualized as a well-defined hypoechoic tumor. Contrast-enhanced CT examination showed a 12×5 mm mass showing a contrast-enhancing effect, and no lymphadenopathy or distant metastasis was observed. Contrast-enhanced MRI showed no evidence of pelvic lymphadenopathy. Based on the above, it was diagnosed that NET, G1, and infiltration to the submucosa exceeding 10 mm. Although endoscopic resection as a diagnostic treatment was also an option, we determined surgical resection policy, therefore we performed laparoscopic rectal intersphincteric resection and upper D2 dissection. Histopathological findings showed a tumor of 11×8 mm infiltrating the submucosa( 5,000μm)with metastasis to the pararectal lymph nodes, and the diagnosis was T1b, N1, Ki-67 index 3%, Ly1, V1a, NET G2, pStage ⅢB. Her postoperative course was uneventful, and 6 months later, we performed her artificial anal closure. One year after the operation, there are frequent bowel movements but no fecal incontinence and she is alive without recurrence. For rectal NET with a tumor diameter of 10 mm or more, radical surgery with dissection is recommended because of the high risk of lymph node metastasis. In this case lymph node metastasis was observed surgical resection according to the above reason, but endoscopic resection was possible except that the preoperative size exceeded 10 mm to 0.7 mm and the distance from the anus was short, therefore it took some thought to decide the policy.

[A Case of Cytomegalovirus Reactivation after Chemoradiotherapy for Esophageal Cancer]

An 80-year-old man visited our hospital because of abdominal distension and epigastralgia. He was diagnosed esophageal cancer(Mt, SCC, T3N0M0, Stage Ⅱ). Because he was elderly, he received chemoradiotherapy(CRT)with S-1. At 54 Gy/27 Fr, he was admitted to the hospital because of cough exacerbation, fever, and food intake loss. A chest and abdominal CT showed a pneumonia pattern. First, antibiotics were started for suspected bacterial pneumonia. Nevertheless, elevation of inflammatory reactions and continuous fever were observed. As interstitial pneumonia was suspected, we started to administer an injection of prednisolone 60 mg. His respiratory symptoms were improved. However, we observed that disseminated erythema of the trunk spread throughout the body and liver enzymes further increased. As blood examination revealed elevated CMV-IgG antibody and C7-HRP positive, we diagnosed cytomegalovirus(CMV)reactivation. Administration of ganciclovir improved liver damage and disseminated erythema. He discharged our hospital while the steroid dose was reduced and valganciclovir continued administrating. The therapeutic effect of esophageal cancer was partial response(PR). We are following his symptoms and CT scan while adjusting the steroid dose. This is a rare case of CMV reactivation due to immunosuppression caused by steroids therapy during CRT against esophageal cancer. We should be aware of CMV infection during CRT and steroid therapy.

Effects of Daikenchuto on postoperative gastrointestinal motility in colorectal carcinoma patients with abdominal pain and distension: a prospective, randomized trial

PURPOSE

To investigate the efficacy and safety of Daikenchuto (DKT) for colorectal cancer patients undergoing surgery with the potential risk of postoperative ileus (POI).

METHODS

Colorectal cancer patients with abdominal pain and distention, scheduled for surgery, were randomly assigned to a DKT group or a control group. Patients assigned to the DKT group were given 15 g of DKT per day during the perioperative period. We then compared the perioperative gastrointestinal symptoms between the two groups.

RESULTS

The aim for a sample size of 30 patients per group was not reached in time, so we conducted an analysis on 16 patients in each group. The visual Analogue Scale scores for abdominal pain and distention were similar in the two groups. The number of bowel movements per day on postoperative days (PODs) 1, 2, and 6 were significantly lower in the DKT group. The incidence of a sensation of incomplete bowel evacuation on PODs 3 and 28 was also significantly lower in the DKT group. There were no adverse events thought to be related to DKT.

CONCLUSIONS

DKT could potentially inhibit diarrhea and reduce the number of bowel movements per day and the sensation of incomplete bowel evacuation after colorectal surgery. Thus, the perioperative use of DKT may be safe for colorectal cancer patients with abdominal pain and distention, who undergo surgery.

[Three Cases of Advanced Gastric Cancer with Peritoneal Dissemination Successfully Treated with S-1 and Docetaxel Combination Chemotherapy]

Case 1: A 74-year-old man underwent total gastrectomy for gastric cancer, but peritoneal dissemination(P1c)was con- firmed intraoperatively in July 2011. Postoperatively, S-1/docetaxel(DTX)combination chemotherapy was administered; after 32 courses of treatment, S-1 was continued as monotherapy. However, in November 2013, CT scan showed a portal vein tumor. We modified the chemotherapy regimen, but he died 3 years and 7 months after the operation. Case 2: A 77-year-old man underwent distal gastrectomy for gastric cancer with peritoneal dissemination(P1b)in September 2013. He was treated with S-1/DTX/trastuzumab(Tmab)combination chemotherapy. After 5 courses of treatment, S-1was continued as monotherapy until October 2015. He has since survived without recurrence. Case 3: A 75-year-old woman was diagnosed with gastric cancer with peritoneal dissemination(P1c)by laparotomy in September 2014. She was treated with S-1/DTX combination chemotherapy. After 23 courses of treatment, chemotherapy was discontinued according to the patient's wish. She died 2 years and 6 months after the surgery. We suggest S-1/DTX combination chemotherapy as an option for advanced gastric cancer with peritoneal dissemination.

[Experience of Perioperative Status for Super Elderly Colorectal Patients in Our Facility]

We examined the perioperative situation according to estimation of physiologic ability and surgical stress(E-PASS)score of 35 colon cancer patients aged 85 years or older who underwent operation in our facility. The incidence of Grade 2 and Grade 3 complications according to Clavien-Dindo classifications increased with age. The preoperative risk score(PRS)also increased with age; however, the surgical stress score(SSS)did not. The comprehensive risk score(CRS)also increased with age. Because the PRS was already high in these elderly patients, since 2016, we implemented methods to lower the SSS to reduce patient risk, including decreasing the operative time and increasing the laparoscope rate. Compared to before these efforts, the SSS decreased, resulting in a reduced incidence of Grade 3 complications.

Expression and Characterization of Clustered Charge-to-Alanine Mutants of Low Mr Single-Chain Urokinase-Type Plasminogen Activator

In an effort to modify the fibrinolytic and/or pharmacokinetic properties of recombinant low M r single-chain urokinase-type plasminogen activator (rscu-PA-32k), mutants were prepared by site-directed mutagenesis of clusters of charged amino acids with the highest solvent accessibility. The following mutants of rscu-PA-32k were prepared: LUK-2 (Lys 212, Glu 213 and Asp 214 to Ala), LUK-3 (Lys 243 and Asp 244 to Ala), LUK-4 (Arg 262, Lys 264, Glu 265 and Arg 267 to Ala), LUK-5 (Lys 300, Glu 301 and Asp 305 to Ala) and LUK-6 (Arg 400, Lys 404, Glu 405 and Glu 406 to Ala).

The rscu-PA 32k moictic3 were expressed in High Five Ttichoplasiani cells, and purified to humugciicily from the conditioned cell culture medium, with recoveries of 0.8 to 3.7 mg/1. The specific fibrinolytic activities (220,000 to 300,000 IU/mg), the rates of plasminogen activation by the single-chain moieties and the rates of conversion In lwo chain moieties by plasmin were comparable for mutant and wild-type rscu PA 32k moieties, with the exception of LUK-5 which was virtually inactive. Equi-effective lysis (50% in 2 h) of 60 pi 125I-fibrin labeled plasma clots submerged in 0.5 ml normal human plasma was obtained with 0.7 to 0.8 μg/ml of wild-type or mutant rscu-PA-3?.k, except with LUK-5 (no significant lysis with 16 pg/ml). Following bolus injection in hamsters, all rscu-PA-32k moieties had a comparably rapid plasma clearance (1.3 to 2.7 ml/min), as a result of a short initial half-life (1.4 to 2.5 min). In hamsters with pulmonary embolism, continuous intravenous infusion over 60 min at a dose of 1 mg/kg, resulted in 53 to 72% clot lysis with the mutants, but only 23% with LUK-5, as compared to 36% for wild-type rscu-PA-32k.

These data indicate that clustered charge-to-alanine mutants of rscu-PA-32k, designed to eliminate charged regions with the highest solvent accessibility, do not have significantly improved functional, fibrinolytic or pharmacokinetic properties.

Molecular Conversions of Recombinant Staphylokinase During Plasminogen Activation in Purified Systems and in Human Plasma

Recombinant staphylokinase (STAR) is produced as a 136 amino acid protein with NH2-terminal sequence Ser-Ser-Ser (mature STAR, HMW-STAR), which may be converted to lower molecular weight forms (LMW-STAR) by removal of the first six residues (yielding STAR-Δ6 with NH2-terminal Gly-Lys-Tyr-) or the first ten residues (yielding STAR-Δ10 with NH2-terminal Lys-Gly-Asp-). In the present study the occurrence and effects of these conversions during plasminogen activation by HMW-STAR were studied in purified systems and in human plasma.

In stoichiometric mixtures of HMW-STAR and native human plasminogen (Glu-plasminogen), rapid and quantitative conversion of HMW-STAR to LMW-STAR occurred, concomitant with exposure of the active site in the plasmin-STAR complex. NH2-terminal amino acid sequence analysis revealed the sequence Lys-Gly-Asp- in addition to the known sequences of the Lys-plasmin chains, identifying STAR-Δ10 as the derivative generated from HMW-STAR. In mixtures of catalytic amount of HMW-STAR and human plasminogen, plasmin generation occurred progressively, following an initial lag phase, during which HMW-STAR was converted to LMW-STAR. Plasmin-mediated conversion of HMW-STAR to LMW-STAR obeyed Michaelis-Menten kinetics with K m = 3.6 μM and k 2 = 0.38 s−1. The specific clot lysis activities of HMW-STAR (122,000 ± 8,000 units/mg) and LMW-STAR (129,000 ± 8,000 units/mg) were indistinguishable.

In an in vitro system consisting of a 60 μl plasma clot submerged in 250 μl plasma, 80% clot lysis within 1 h was obtained with 70 nM HMW-STAR. This was associated with fibrinogen depletion and conversion of 20% of the HMW-STAR to LMW-STAR. Addition of 100 nM HMW-STAR to human plasma in the absence of a clot did not induce significant fibrinogen breakdown (≥ 90% residual fibrinogen after 2 h), and was not associated with significant coversion to LMW-STAR (≤10% within 2 h). With 400 nM HMW-STAR, fibrinogen depletion in plasma occurred within 1 h, and 80% conversion to LMW-STAR was observed. Thus, at fibrinolytically active concentrations which do not cause fibrinogen breakdown, no significant conversion of HMW-STAR to LMW-STAR occurs in human plasma in the absence of a clot.

These findings indicate that the conversion of HMW-STAR to LMW-STAR may occur in association with clot lysis, but is not required to induce it.

[Indication of Palliative Gastrojejunostomy for Unresectable Advanced Gastric Cancer with Obstruction from the View Point of Preoperative Inflammatory Biomarkers]

Palliative surgery for advanced gastric cancer with serious symptoms such as hemorrhage or obstruction may be meaningful in the point of improving quality of life(QOL). However, the meaning of palliative gastrojejunostomy for unresectable gastric cancer with obstruction is controversial. We retrospectively evaluated the effectiveness of gastrojejunostomy for unresectable gastric cancer with obstruction using preoperative inflammatory biomarkers. Blood lymphocyte monocyte ratio(LMR), neu- trophill ymphocyte ratio(NLR)and C-reactive protein/albumin ratio(CAR)were analyzed as inflammatory biomarkers in this study. The percentage of improvement in food intake, discharge from the hospitaland performance of chemotherapy were significantly higher in the patients without any preoperative inflammatory reaction compared to those with any inflammation. Moreover, the survival of the patients without any inflammatory change was significantly longer compared to those with any inflammation. In conclusion, preoperative status of inflammation may be a useful marker to predict the effect and outcome of palliative gastrojejunostomy for unresectable gastric cancer with obstruction. Especially when there is any inflammation, the surgical indication should be carefully judged.

[A Case of Surgical Treatment of Pulmonary Metastasis from Gastric Cancer]

An 87-year-old woman was diagnosed with advanced gastric cancer and primary lung cancer in November 2012. She underwent distal gastrectomy for the gastric cancer in December 2012, and right upper wedge resection for the primary lung cancer in February 2013. After surgery, the patient received S-1 chemotherapy. However, she subsequently experienced adverse effects, and so S-1 chemotherapy was stopped. In February 2016, a computed tomographic scan of the chest showed a nodular shadow at S8 in the left lung. Because the nodular shadow gradually increased in size, we suspected that the diagnosis would be either primary lung cancer or metastatic lung cancer arising from gastric cancer. In July 2016, we performed left lower wedge resection. Histopathological examination of the resected specimen resulted in a diagnosis of metastatic lung cancer arising from gastric cancer. After pulmonary resection, the patient had no recurrent tumor. It is thought that surgery is an effective treatment for solitary pulmonary metastasis arising from gastric cancer.

[A Difficult Case of Invagination of the Protruding Colon Cancer]

A 88-year-old female suffered of ileus due to advanced transverse colon cancer. Pneumonia was observed and nutrient condition was bad. Operation was found to be difficult because of the bad condition with complication on this present time. Self-expandable metallic stent(SEMS)was inserted to extend obstruction. But SEMS dropped out next day and SEMS, thicker than previous one, was reinserted. Main tumor was huge protruding tumor and the reason of ileus was invagination of the cancer. The fixation of SEMS was not so good, but the generalcondition was improved while a week after reinsertion of SEMS. Laparoscopic colon partial resection was performed safely. Bridge to surgery with SEMS for the case of invagination of protruding colon cancer was thought to be useful.

[A Case of Successful Treatment of Liver Metastases from Gastric Cancer with Chemotherapy]

A 69-year-old man was diagnosed with advanced gastric cancer accompanied by multiple liver metastases in April 2009. Because of worsening anemia due to bleeding from the primary tumor, we performed a distal gastrectomy. After gastrecto- my, he underwent S-1/CDDP combination chemotherapy. After 5 courses of chemotherapy, the size of the liver metastases was reduced. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy, but he developed grade 3 diarrhea, and the S-1/irinotecan combination chemotherapy was immediately stopped.Weekly paclitaxel chemother- apy was administered as third-line chemotherapy, and S-1/docetaxel combination chemotherapy was administered as fourth-line chemotherapy. After 11 courses of S-1/docetaxel combination chemotherapy, the liver metastases could not be detected by CT and PET-CT in October 2012, and it was concluded that a complete response(CR)had been obtained. He receive maintenance therapy with S-1 chemotherapy for 10 months. Now, he is alive without chemotherapy and has maintained a CR for 4 years 8 months after achieving a CR.

[Liver Metastases from Pancreatic Neuroendocrine Tumor(P-NET)Treated with Surgery and Chemotherapy]

Pancreatic neuroendocrine tumor(P-NET)often involve liver metastases. We report a 52-year-old woman who underwent distal pancreatectomy for a pancreatic body tumor with a diameter of 8 cm. The pathological findings were P-NETG2 . After 1 year 6 months, a liver metastasis was detected. We performed partial hepatectomy. The pathological findings showed a Ki-67 index of 23%. After surgery, CPT-11 plus CDDP therapy and AMR therapy were administered.

CONCLUSION

Multimodal therapies should be considered for P-NETliver metastases based on the Ki-67 index.

[Three Cases of Gastric Cancer with Rare Presentation of Oncologic Emergency]

We report 3 cases of gastric cancer with rare presentations of oncologic emergency. Case 1 involved cardiac tamponade caused by mediastinitis-induced pericarditis. Metastatic lymph nodes became enlarged after total gastrectomy and invaded the esophagojejunal anastomotic region. Then, a fistula to the mediastinum occurred, resulting in mediastinitis. The drainage was efficacious, but the patient died of cancer 1 month after admission. Case 2 involved cardiac tamponade caused by invasion of metastatic peritoneal tumor into the pericardium. The drainage was successful, but the patient died of cancer 2 weeks after drainage. Case 3 involved perforation of the stomach during the third course of chemotherapy. A total gastrectomy was urgently performed. Thereafter, chemotherapy was continued. However, the patient died of cancer 6 months later. These oncologic emergencies should be considered, although they are rare.

[A Case of Successful Treatment of Metachronous Liver Metastasis from Gastric Cancer with Hepatectomy]

A 77-year-old man was found to have advanced gastric cancer and underwent total gastrectomy (pT4aN2H0P0M0, Stage ⅢB). Two years after gastrectomy, we found an elevated tumor marker level, and a liver metastasis appeared in segment 5 (20 mm in diameter). He was treated with S-1/CDDP combination chemotherapy. After 2 courses of chemotherapy, the tumor marker level kept rising and a CT scan detected a progressive tumor. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy. After 6 courses of chemotherapy, the size of the liver metastasis was reduced and the tumor marker level normalized. Because lymph node metastasis or peritoneal recurrence was observed, a partial resection of the liver (S5) was performed. After the operation, he was treated with S-1 chemotherapy again for 1 year and has had no recurrence.

Nitric oxide-mediated injury of interstitial cells of Cajal and intestinal dysmotility under endotoxemia of mice

Gastrointestinal dysmotility is frequently observed under septic conditions, yet its precise mechanisms remain to be elucidated. In this study, we have investigated the mechanisms of intestinal dysmotility by lipopolysaccharides (LPS) and the role of the interstitial cells of Cajal (ICCs) in motility disorders using a mouse endotoxin model. The injection of LPS caused time- and dose-dependent decreases in the intestinal contractility, which was associated with similar time- and dose-dependent decreases in the number of KIT-positive fibroblast-like cells located in the intermuscular layer. iNOS inhibitors, L-NAME and aminoguanidine (AG), but not 7-nitroindazole (7NI), a specific nNOS inhibitor, inhibited the LPS-induced decreases in both the contractility and the number of KIT-positive cells. A spontaneous NO releaser, FK409, not only diminished spontaneous electrical potential and phasic contractions, but also decreased the number of KIT-positive cells. Pretreatment with gadolinium inhibited the activation of macrophages and the induction of iNOS in intestinal resident macrophages, and restored the number of KIT-positive cells and intestinal contractions. These results suggested that NO produced from intestinal macrophages via iNOS induced by LPS, may be involved in the ICCs injury and intestinal dysmotility under septic conditions.

Long-term survival outcomes of advanced gastric cancer patients who achieved a pathological complete response with neoadjuvant chemotherapy: a systematic review of the literature

BACKGROUND

A pathologic complete response (pCR) can sometimes be induced by intensive or long-term neoadjuvant chemotherapy (NAC). This prognostic research study based on a systematic review of the literature evaluated the impact of a pCR on the long-term survival of gastric cancer (GC) patients.

METHODS

Articles were extracted from PubMed and the Japanese medical search engine "Ichu-shi," using the terms "GC," "NAC," and "pCR." Articles were selected based on the following criteria: (1) full-text case report, (2) R0 resection following NAC for locally advanced GC, and (3) pathological complete response in both the primary stomach and in the lymph nodes. A questionnaire regarding the patients' prognoses was sent to the corresponding authors of the articles selected in July 2013.

RESULTS

Twenty-four articles met the criteria. Twenty authors responded to the questionnaire. Finally, 22 patients from 20 articles were entered into the present study. The median follow-up time (range) of the survivors was 76 (range 13-161) months. Tumors that were stage III/IV (86%: 19/22) and of an undifferentiated histology (61.9%: 13/21) were dominant. An S1-based regimen was frequently selected for the NAC. All patients underwent R0 resection and D2/D3 lymphadenectomy. The overall survival and recurrence-free survival rates at 3 and 5 years were 96% and 85% and 91% and 75%, respectively.

CONCLUSIONS

Although a pCR was a relatively rare event, a high pCR rate would be helpful to select the regimen and courses of NAC, especially when the pathological response rates are similar.

Cyclin-Dependent Kinase Activity Correlates with the Prognosis of Patients Who Have Gastrointestinal Stromal Tumors

BACKGROUND

The estimation of recurrence risk remains a critical issue in relation to gastrointestinal stromal tumors (GISTs) treated with adjuvant therapy. The accuracy of the commonly used risk stratifications is not always adequate.

METHODS

For this study, data were prospectively collected from 68 patients with GISTs who underwent R0 surgery between 2004 and 2009. The results from this analysis cohort were evaluated using the data obtained from an additional 40 patients in the validation cohort. Cyclin-dependent kinase 1 (CDK1)- and CDK2-specific activities were measured using a non-RI kinase assay system.

RESULTS

The specific activities of CDK1 and CDK2, but not their expression, significantly correlated with recurrence. The specific activities of both CDK1 and CDK2 were independently correlated with mitosis and significantly correlated with recurrence-free survival (RFS). In the multivariate analysis, CDK2-specific activity (P = 0.0006), tumor size (P = 0.0347), and KIT deletion mutations (P = 0.0006) were significantly correlated with RFS in the analysis cohort. In the validation cohort, CDK2-specific activity (P = 0.0368) was identified as an independent prognostic factor for tumor recurrences with tumor location (P = 0.0442).

CONCLUSION

The results suggest that the specific activities of CDK1 and CDK2 may reflect the proliferative activity of GISTs and that CDK2-specific activity is a good prognostic factor predicting recurrence after macroscopic complete resection of GISTs.

Single-incision laparoscopic totally extraperitoneal obturator hernia repair in a patient on antiplatelet therapy: a case report

An 83-year-old woman who complained of right lower limb discomfort was diagnosed with a right obturator hernia by CT scan. On examination, she had a soft and flat abdomen without signs of peritoneal irritation. The Howship-Romberg sign was present. She had a history of vasospastic angina and paroxysmal supraventricular tachycardia, and took aspirin and dipyridamole until she was admitted to the hospital. Exploratory laparoscopy identified a spontaneously reduced small bowel from the right obturator canal, but there were no signs of ischemic and necrotic bowel. The patient underwent SILS for totally extraperitoneal obturator hernia repair without a dissection balloon. The patient recovered without perioperative complications such as hemorrhage and thrombotic episodes. She remains well, and CT scans showed no signs of obturator hernia recurrence at the 7-month follow-up.

Multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor successfully treated by laparoscopic surgery: Report of a case

•

Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer.

•

Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

•

This report is the first to describe multiple hepatic sclerosing hemangiomas treated by laparoscopic surgery.

Introduction

Hepatic sclerosing hemangioma is a very rare benign tumor, characterized by fibrosis and hyalinization occurring in association with degeneration of a hepatic cavernous hemangioma. We report here a rare case of multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor that was successfully treated using laparoscopic surgery.

Presentation of case

A 67-year-old woman with multiple liver tumors underwent single-incision laparoscopic sigmoidectomy under a diagnosis of advanced sigmoid cancer with multiple liver metastases. Examination of surgical specimens of sigmoid colon revealed moderately differentiated adenocarcinoma invading the serosa, and no lymph node metastases. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 remained within normal limits throughout the course. Two months after sigmoidectomy, the patient underwent laparoscopic partial hepatectomy of S1 and S6 of the liver and cholecystectomy. Histopathological examination showed that the tumors mainly comprised hyalinized tissue and collagen fibers with sporadic vascular spaces on hematoxylin and eosin-stained sections, yielding a diagnosis of multiple hepatic sclerosing hemangioma. No evidence of recurrence has been seen as of 21 months postoperatively.

Discussion

Differentiating multiple sclerosing hemangiomas from metastatic liver tumors was quite difficult because the radiological findings were closely compatible with liver metastases. Laroscopic hepatectomy provided less blood loss, a shorter duration of hospitalization, and good cosmetic results.

Conclusion

Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer. Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

Safety of fondaparinux to prevent venous thromboembolism in Japanese patients undergoing colorectal cancer surgery: a multicenter study

PURPOSE

To investigate the safety and efficacy of fondaparinux (FPX) for venous thromboembolism (VTE) prophylaxis in Japanese patients undergoing colorectal cancer surgery.

METHODS

The subjects of this multicenter, open-label, prospective observational study were patients undergoing resection of the colon/rectum for colorectal cancer. All patients were given FPX 2.5 or 1.5 mg by subcutaneous injection, once daily for 4-8 days, starting 24 h after surgery. The primary endpoint was any major bleeding event and the secondary endpoint was any symptomatic VTE event.

RESULTS

Between February 2009 and December 2010, 619 patients from 23 institutions were enrolled in this study. The median duration of FPX prophylaxis was 4 days. The incidence of major bleeding was 0.81 % [5/619, 95 % confidence interval (CI) 0.3-1.9] and the incidence of minor bleeding was 9.5 % (59/619, 95 % CI 7.3-12.1). There was no fatal bleeding or symptomatic VTE. Multivariable analysis revealed the following to be risk factors for bleeding events: preoperative platelet count <15 × 10(4)/µl [odds ratio (OR) 4.521], male sex (OR 2.078), and blood loss during surgery <50 ml (OR 2.019).

CONCLUSION

The administration of 2.5/1.5 mg FPX 24 h after colorectal cancer surgery is safe and effective.

Laparoscopic distal pancreatectomy for multiple epithelial cysts in an intrapancreatic accessory spleen. A case report and review of literature

CONTEXT

Accessory spleen is a congenital abnormality consisting of normal splenic tissue in ectopic sites that is found in approximately 10-15% of the general population. However, an intrapancreatic accessory spleen has seldom been reported and multiple epithelial cysts in the intrapancreatic accessory spleen are extremely rare.

CASE REPORT

A 37-year-old woman with no clinical manifestations presented with two cystic lesions in the tail of the pancreas. The tumor markers CA 19-9 (251 U/mL) and SPAN-1 (38 U/mL) were increased. Computed tomography showed a multilocular cyst, 40 mm in size, and a unilocular cyst, 20 mm in size, in the tail of the pancreas and gallstones. The cystic component was hypointense on T1-weighted magnetic resonance images and hyperintense on T2-weighted magnetic resonance images. A laparoscopic distal pancreatectomy was performed with the presumptive diagnosis of a mucinous cystic neoplasm or an intraductal papillary mucinous neoplasm with gallstones. The pathological examination showed that the walls of the two cysts were covered with non-keratinized stratified squamous epithelium, surrounded by normal splenic tissue. The final pathological diagnosis was two epithelial cysts originating from an intrapancreatic accessory spleen.

CONCLUSIONS

Even though multiple masses were detected in the pancreatic tail, the possibility of epithelial cysts originating from an accessory spleen should be considered. Laparoscopic distal pancreatectomy might be a safe and effective procedure and provide good cosmetic result for a benign or low-grade malignant tumor in the pancreas.

Short-term outcome of single-incision laparoscopic totally extra-peritoneal inguinal hernia repair

We performed single-incision laparoscopic surgery for totally extra-peritoneal (SILS-TEP) repair using a lightweight mesh fixed by absorbable tacks and without balloon dilation. Thirty-four patients (mean age, 66.5 years) underwent SILS-TEP repair in our hospital between September 2011 and April 2012; 30 patients had unilateral hernia and 4 had bilateral hernias. Mean operative time was 85.6 min for unilateral hernia and 137.7 min for bilateral hernias. All patients underwent successful SILS-TEP repair. Mean hospital stay was 3.4 days. Mean duration of follow-up was 7.1 months. Four seromas were observed, but no recurrences or major complications occurred. SILS-TEP is an economical and useful method for decreasing postoperative complications, such as neuralgia and recurrence, and it could be an attractive approach for inguinal hernia.

[Responses to treatment and switching tyrosine kinase inhibitors in gastrointestinal stromal tumor(GIST)]

GIST is driven by a gain-of-function mutation either in the KIT or PDGFRA gene. Atpresent , advanced and/or metastatic GIST is primarily treated by medical therapy of imatinib and sunitinib, both of which are re-imbursed by the government in Japan. Tumor responses are usually evaluated by contrast-enhanced CT scan with RECIST criteria, which cannot always predict patients with long SD showing similar prognostic effects to CR or PR. For early detection of drug activities, Choi's criteria with enhanced CT scan, as well as FDG-PET(or PET-CT), are considered to be useful. Choi's criteria also works for the early detection of resistance. When resistance and/or unmanagable adverse events are observed, early switching of drugs without any delay is recommended if there is another line of treatment.

Gallbladder metastasis from hepatocellular carcinoma: Report of a case and review of literature

INTRODUCTION

The incidence of metastasis of hepatocellular carcinoma (HCC) to the gallbladder is low. Here, we report a case of HCC with metastasis to the gallbladder and discuss the pattern of spread and the treatment.

PRESENTATION OF CASE

A 74-year-old man was diagnosed with advanced hepatocellular carcinoma. Computed tomography and magnetic resonance imaging demonstrated a tumor in the right lobe of the liver with a thrombus in the bifurcation of the portal vein. Because intraoperative ultrasonography showed portal vein tumor thrombosis from the main tumor reaching the umbilical portion, we performed only a cholecystectomy for the elimination of postoperative cholecystitis. Pathological examination showed gallbladder vein tumor thrombosis from poorly differentiated hepatocellular carcinoma.

DISCUSSION

A preoperative diagnosis of metastatic HCC to the gallbladder is difficult because there are no specific findings in the imaging tests. Cancer cells in the liver were thought to migrate to the gallbladder via the connection between the portal system and the cholecystic veins, and grow in the lumen of the veins in our case. The survival rate, in all reported cases including the present case, was increased in patients who underwent radical resection, compared to patients who underwent palliative surgery.

CONCLUSION

The resection of metastatic HCC to the gallbladder might appear to prolong survival.

Urokinase-type plasminogen activator and plasminogen mediate activation of macrophage phagocytosis during liver repair in vivo

Urokinase-type plasminogen activator (u-PA) and plasminogen play a primary role in liver repair through the accumulation of macrophages and alteration of their phenotype. However, it is still unclear whether u-PA and plasminogen mediate the activation of macrophage phagocytosis during liver repair. Herein, we investigated the morphological changes in macrophages that accumulated at the edge of damaged tissue induced by a photochemical reaction or hepatic ischaemia-reperfusion in mice with u-PA ( u-PA-/- ) or plasminogen ( Plg-/- ) gene deficiency by using transmission electron and fluorescence microscopy. In wild-type mice, the macrophages aligned at the edge of the damaged tissue and extended a large number of long pseudopodia. These macrophages clearly engulfed cellular debris and showed well-developed organelles, including lysosome-like vacuoles, nuclei, and Golgi complexes. In wild-type mice, the distribution of the Golgi complex in these macrophages was biased towards the direction of the damaged tissue, indicating the extension of their pseudopodia in this direction. Conversely, in u-PA-/- and Plg-/- mice, the macrophages located at the edge of the damaged tissue had few pseudopodia and less developed organelles. The Golgi complex was randomly distributed in these macrophages in u-PA-/- mice. Furthermore, interferon γ and IL-4 were expressed at a low level at the border region of the damaged tissue in u-PA-/- mice. Our data provide novel evidence that u-PA and plasminogen are essential for the phagocytosis of cellular debris by macrophages during liver repair. Furthermore, u-PA plays a critical role in the induction of macrophage polarity by affecting the microenvironment at the edge of damaged tissue.

A prospective randomized controlled trial comparing 4-weekly versus 3-weekly adjuvant chemotherapy with gemcitabine after curative resection of biliary tract cancer

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Background: Resection of biliary tract cancer, employing pancreatoduodenectomy and major hepatectomy, is highly aggressive. Thus, postoperative gemcitabine cannot be administered employing a routine dosage protocol. We theorized that a 3-weekly protocol (days 1 and 8, every 3 weeks) of gemcitabine as adjuvant chemotherapy would be superior to the usually administered 4-weekly protocol (days 1, 8, and 15 every 4 weeks).

Methods: The outcomes of 6 cycles of the 4-weekly protocol and 9 cycles of the 3-weekly protocol were compared in a prospective randomized clinical setting. The primary endpoint was the treatment completion rate, while secondary endpoints were adverse events and recurrence-free survival.

Results: We enrolled a total of 27 patients. Only two patients (14%) on the 4-weekly protocol and three (23%) on the 3-weekly protocol (p=0.8099) completed treatment with no omissions and/or dose modifications. Most of the remaining patients (70%) experienced grade 3/4 neutropenia. Relative dose intensities were 72% and 78%, respectively, with the 4-weekly and 3-weekly protocols. Recurrence-free survival rates did not differ significantly between the two protocols.

Conclusions: Contrary to our hypothesis, the 3-weekly protocol did not produce superior results in terms of completion, adverse events or recurrence-free survival rates as compared to the standard 4-week protocol.

Infected pancreatic necrosis occurring in a jejunal aberrant pancreas: report of a case

Acute pancreatitis occurring in an aberrant pancreas (acute aberrant pancreatitis) is a rare clinical condition. A 67-year-old male was referred to the emergency department complaining of severe epigastralgia. He was evaluated by computed tomography, and the findings suggested jejunal penetration into the mesentery and abscess formation. We performed emergency surgery and found a mass located in the jejunal mesentery. Intraoperatively, we diagnosed it to be a malignant tumor complicated by penetration, and we performed a partial resection of the jejunum to remove the mass. Based on the pathological results, it was evident that this was a case of acute aberrant pancreatitis occurring on a background of chronic pancreatitis. The patient had an uneventful postoperative course. This report is the first presentation describing the possible mechanism that contributes to the process of infected pancreatic necrosis in an aberrant pancreas.

Intracorporeal circular-stapled Billroth I anastomosis in single-incision laparoscopic distal gastrectomy

PURPOSE

The intracorporeal anastomotic procedure is one of the most difficult components in single-incision laparoscopic gastrectomy. We describe a simple surgical technique for intracorporeal circular-stapled Billroth I gastroduodenostomy with transumbilical introduction of the instrument.

SURGICAL TECHNIQUE

After standard laparoscopic mobilization of the distal stomach using a mini-loop retractor (diameter, 2 mm), a semi-circumference duodenotomy was made just distal to the pyloric ring. The anvil of a circular stapling device, secured with a Prolene suture with a needle, was introduced via the duodenotomy. The suture was advanced anteriorly such that an anvil shaft transfixed the anterior duodenal wall. The duodenum was staple-transected at this point, and the anvil shaft was removed from the duodenum by pulling the thread. The anvil shaft was advanced against the posterior wall of the stomach and tightly grasped by the mini-loop retractor to avoid slippage. After the cartridge-carrying instrument was introduced transumbilically with the pneumoperitoneum maintained using a surgical glove, the anvil shaft was connected with the center rod of the instrument under fine laparoscopic view. The instrument was fired to complete the circular-stapled gastroduodenostomy.

RESULTS

We employed this technique in 20 patients. Neither postoperative complications, including anastomotic leakage and stricture, nor postoperative mortality were observed.

CONCLUSIONS

Our modified technique for intracorporeal Billroth I reconstruction in single-incision laparoscopic distal gastrectomy is safe and feasible. This technique could be an attractive surgical option for all laparoscopic reconstructive procedures using circular stapling devices.

[Evidence-based treatment of gastrointestinal stromal tumor (GIST) with tyrosine kinase inhibitors-imatinib and sunitinib]

Gastrointestinal stromal tumors (GIST) are sarcoma in the gastrointestinal tract which may be caused by somatic gain-of-function mutations in the KIT or PDGFRA gene. Imatinib mesylate has shown significant safety and great effectiveness for patients with KIT-positive unresectable, advanced, or metastatic GIST. The response rate (RR) was no less than 50%, disease control rate (DCR) of more than 85%, and the median progression-free survival (PFS) has been nearly two years. Also, imatinib has been shown to improve the prognosis of GIST patients. Meanwhile, sunitinib malate, used for patients with imatinib-resistant GIST or imatinib-intolerant patients, has also shown modest tolerability and fairly good outcomes. Sunitinib shows a less than 10% RR, a 30% to 40% DCR, and a median of nearly 8 months of PFS. Molecularly targeted therapy has prolonged overall survival of advanced GIST patients from 1. 5 years in the pre-imatinib era to 5 years after the introduction of imatinib. There remains, however, a great unmet medical need for new agents and/or multidisciplinary treatments for advanced GIST patients.

A synthetic peptide derived from staphylokinase enhances plasminogen activation by tissue-type plasminogen activator

BACKGROUND

A synthetic nonadecapeptide (SP; GPYLMVNVTGVDGKGNELL) previously enhanced the activation of plasminogen by the SAK/plasmin complex.

OBJECTIVES

To identify the binding site for SP on plasminogen and elucidate the effects of SP on plasminogen activation by the tissue-type plasminogen activator (t-PA).

METHODS

The effects of SP on plasminogen activation were estimated using a chromogenic substrate and from the cleavage of plasmin on SDS-PAGE under reduced conditions. The binding to SP of various peptides derived from the amino acid sequence of plasminogen was analyzed with an IAsys biosensor. The SP-mediated structural change to plasminogen was analyzed by circular dichroism (CD) spectroscopy. The thrombolytic effects of SP were examined using a mouse model of thrombosis.

RESULTS

SP enhanced the activation of plasminogen by t-PA. The catalytic efficiency (k(cat)/K(m)) of Glu-plasminogen activation by t-PA was 11.4-fold higher in the presence than absence of SP. The binding of SP to plasminogen was greatly inhibited by a synthetic peptide, FEKDKYILQGVTSWGLG, located close to the C-terminal of the plasminogen B region. Near-ultraviolet CD spectra of the complex between SP and Glu-plasminogen significantly differed from those of Glu-plasminogen. When SP was administered in a mouse model of thrombosis, early recanalization was observed in a dose-dependent manner. However, SP did not cause recanalization in t-PA gene-deficient mice.

CONCLUSIONS

SP bound to the B region and promoted the activation of plasminogen by t-PA, and then induced effective thrombolysis.

Urokinase-type plasminogen activator contributes to heterogeneity of macrophages at the border of damaged site during liver repair in mice

Urokinase-type plasminogen activator (u-PA) plays an important role in tissue remodelling through the activation of plasminogen in the liver, but its mechanisms are less well known. Here, we investigated the involvement of u-PA in the accumulation and phenotypic heterogeneity of macrophages at the damaged site during liver repair. After induction of liver injury by photochemical reaction in mice, the subsequent pathological responses and expression of phenotypic markers in activated macrophages were analysed histologically. Fibrinolytic activity at the damaged site was also examined by fibrin zymography. In wild-type mice, the extent of damage decreased gradually until day 14 and was associated with an accumulation of macrophages at the border of the damaged site. In addition, the macrophages that accumulated near the damaged tissue expressed CD206, a marker of highly phagocytic macrophages, on day 7. Further, macrophages that were adjacent to CD206-positive cells expressed inducible nitric oxide synthase (iNOS), a pro-inflammatory marker. u-PA activity increased at the damaged site on days 4 and 7, which distributed primarily at the border region. In contrast, in u-PA-deficient mice, the decrease in damage size and the accumulation of macrophages were impaired. Further, neither CD206 nor iNOS was expressed in the macrophages that accumulated at the border region in u-PA-deficient mice. Mice deficient for the gene encoding either u-PA receptor (u-PAR) or tissue-type plasminogen activator experienced normal recovery during liver repair. These data indicate that u-PA mediates the accumulation of macrophages and their phenotypic heterogeneity at the border of damaged sites through u-PAR-independent mechanisms.

A case of Helicobacter pylori infection complicated with gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and idiopathic thrombocytopenic purpura successfully treated with laparoscopy-assisted total gastrectomy and splenectomy

Helicobacter pylori infection plays a key role in the pathogenesis of H. pylori-associated diseases, including gastroduodenal and non-gastroduodenal diseases. A 71-year-old man was evaluated for a positive fecal occult blood test by upper gastrointestinal endoscopy, which revealed H. pylori infection, two adenocarcinomas and two gastric mucosa-associated lymphoid tissue lymphomas. Hematological examination revealed low platelet-count, elevated platelet-associated immunoglobulin G and anti-H. pylori immunoglobulin G antibodies. We diagnosed H. pylori infection complicated by simultaneous occurrence of gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and idiopathic thrombocytopenic purpura. These diseases were successfully treated with laparoscopy-assisted total gastrectomy and splenectomy, and there was no evidence of recurrence for about 2 years. This is the first reported case of H. pylori infection complicated by these three diseases and cured with laparoscopic surgery.

Plasminogen is essential for granulation tissue formation during the recovery process after liver injury in mice

SUMMARY BACKGROUND

The involvement of plasminogen in liver repair has been reported, but its exact role in promoting this process is unknown.

OBJECTIVE

To elucidate the underlying mechanism, we examined the dynamics of liver repair by using a reproducible liver injury model in plasminogen gene-deficient mice and their wild-type littermates.

METHODS

Liver injury was induced by photochemical reaction and the subsequent responses were histologically analyzed.

RESULTS

In wild-type animals, the area of the damage successively decreased, and the repair process was associated with macrophage accumulation at its border. Neutrophils were also attracted to the damaged region on day 1 and were evident only at its border by day 4, which spatially and temporally coincided with the expression of macrophage chemoattractant protein-1 (MCP-1). Neutrophil depletion suppressed recruitment of macrophages at the border between the damaged and the normal tissues. These changes were followed by activated hepatic stellate cell accumulation, collagen fiber deposition and angiogenesis at the boundaries of the injured zone. In contrast, in plasminogen gene-deficient mice, the decrease in the area of damage, macrophage accumulation, late-phase neutrophil recruitment, hepatic stellate cell accumulation, collagen fiber deposition and angiogenesis were all impaired.

CONCLUSION

Our data suggest that accumulated neutrophils at the border of the damaged area may contribute to macrophage accumulation at granulation tissue via the production of MCP-1 after liver injury. The plasminogen system is critical for liver repair by facilitating macrophage accumulation and triggering a cascade of subsequent repair events.

Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis

BACKGROUND

Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described.

METHODS

After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique.

RESULTS

Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series.

CONCLUSIONS

The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).

Totally laparoscopic low anterior resection for lower rectal cancer: combination of a new technique for intracorporeal anastomosis with prolapsing technique

BACKGROUND

Laparoscopically assisted low anterior resection is difficult even for experienced surgeons because of difficulties in selecting the appropriate transection line and completing anastomosis in the narrow pelvic space. The prolapsing technique resolves these problems. We combined our new technique for intracorporeal anastomosis with this prolapsing technique and achieved a totally laparoscopic low anterior resection.

METHODS

After the total mesorectal excision, a semi-circumferential colotomy is made at the anterior colonic wall just proximal to the proximal transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the anvil penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. The distal rectum is everted and pulled transanally outside the body using a grasping forceps inserted from the anus. Staple-closure and transection of the distal rectum is performed under direct vision. Anastomosis is established using the double-stapling technique.

RESULTS

Totally laparoscopic low anterior resections using this technique were performed for 7 patients with rectal cancer. There was no anastomotic leakage/stenosis.

CONCLUSIONS

Our procedure can be performed easily, which enables surgeons to achieve minimal invasiveness compared with hybrid NOTES.

A simple and safe method for gastrojejunostomy in laparoscopic distal gastrectomy using the hemidouble-stapling technique: efficient purse-string stapling technique

AIM

To describe a simple technique for intracorporeal circular-stapled gastrojejunostomy in laparoscopic distal gastrectomy with Roux-en-Y reconstruction.

METHODS

After the stomach and duodenum were mobilized, gastrotomy was established in the anterior gastric wall. An anvil, which was secured with a suture needle, was inserted completely through the gastrotomy. The needle was advanced to the greater curvature of the gastric wall to enable penetration of the central rod into the gastric wall. Subsequently, the stomach was cut using a linear stapler to secure the anvil on the stomach and was sequentially transected using another linear stapler to achieve distal gastrectomy. Circular-stapled gastrojejunostomy was then performed intracorporeally using the hemidouble-stapling technique, while handling the shaft of the instrument via the umbilical incision. The jejunal stump was closed using a linear stapler.

RESULTS

Gastrojejunostomies were successfully performed in 20 gastric cancer patients using this technique. None of the patients showed anastomotic leakage and/or stenosis. There were no mortalities in this series.

CONCLUSIONS

Gastrojejunostomy performed using the above-mentioned technique was safe and simple. The most important feature of the technique was the elimination of the need for purse-string suture placement, as well as the achievement of better cosmesis using the transumbilical approach.

[An autopsied case of giant small cell carcinoma of the pancreas]

A 58-year-old man who complained of an abdominal tumor was admitted to our hospital. Abdominal CT scan showed that a 15-cm tumor occupied the entire right upper abdomen and that there were ascites and liver metastases. A liver biopsy was performed. The liver biopsy showed a small cell carcinoma pattern, but no definitive origin of the tumor was determined. Considering the extensive peritoneal invasion and multiple liver metastases, he received 2 / courses of cisplatin/etoposide chemotherapy, but his tumor became larger with concomitant abdominal pain and nausea. The patient suddenly died due to multiple organ failure caused by tumor necrosis. The autopsy revealed a pathological diagnosis of primary small cell carcinoma of the pancreas.

Recurrent Ascending Colon Cancer Manifesting as Inferior Vena cava Thrombus

We report an extremely rare case of recurrent ascending colon cancer manifesting as inferior vena cava (IVC) thrombus. A 77-year-old woman previously diagnosed with ascending colon cancer underwent right hemicolectomy with lymph node dissection. Though the tumor invaded the retroperitoneum and involved the right ovarian artery and vein, curative operation was performed. The patient took 5-FU p.o. Two and a half years later, tumor thrombus in the IVC extending into the right atrium was incidentally found and diagnosed as recurrence of colon cancer by biopsy. RF-induced hyperthermia using 5-FU and CDDP i.v. was immediately performed, but she died after 6 months because of multiple liver and pulmonary metastases. In treating colon cancers invading the retroperitoneum, it should be recalled that some cases recur as tumor thrombus in the IVC and that close follow-up is therefore necessary.

Characterization of non-linear relationship between total and unbound serum concentrations of valproic acid in epileptic children

OBJECTIVE

To establish a regression equation to properly estimate the unbound serum concentration of valproic acid (VPA) from its total serum concentration; the relationship between total and unbound serum VPA concentrations was retrospectively characterized.

METHODS

Data were obtained from the clinical examination records that were routinely archived during therapeutic drug monitoring. The screening encompassed 342 records of 108 paediatric patients whose total and unbound VPA concentrations had been determined. The relationship between total and unbound VPA concentrations was characterized according to the Langmuir equation by taking account of inter-individual variability with the nonmem program.

RESULTS

The total VPA concentration (C(t)) in the screened patients ranged from 5.5 to 179.8 microg/mL, and the unbound VPA concentration (C(f)) increased in a non-linear manner as the total VPA concentration increased. Taking account of the effects of antiepileptics concurrently administered, the VPA dissociation constant (K(d)) and maximum binding site concentration (B(m)) were 7.8 +/- 0.7 and 130 +/- 4.5 microg/mL respectively, for the regression equation, C(t) = C(f) + B(m) x C(f)/(K(d) + C(f)). An alteration in the unbound concentration was seen in patients who were treated with the combination of VPA and ethosuximide and in those who received two additional antiepileptics.

CONCLUSIONS

A regression equation for estimation of the unbound VPA concentration, based on total VPA concentration collected during routine therapeutic drug monitoring was established. Use of two additional antiepileptics and ethosuximide treatment was considered as potential factors affecting unbound VPA concentration.

A case of takotsubo cardiomyopathy after surgery for common bile duct stones

Takotsubo cardiomyopathy (TC) is a rare reversible circulatory syndrome often detected in elderly patients after general surgery. We report the case of an 85-year-old woman who was admitted for obstructive jaundice and underwent ERCP and ENBD before operation. She finally underwent cholecystectomy and choledocholithotomy with the diagnosis of gallbladder and common bile duct stones. In the evening just after the operation, without symptoms of cardiac failure, her ECG suddenly exhibited abnormal ST-T elevation in leads II, III, and V2-V6, though neither CPK(MB) nor troponin T was elevated. Echocardiogram demonstrated basal hyperkinesis and apical dyskinesis, suggesting TC. Conservative treatment enabled recovery, ECG was normalized in a month, and the postoperative course was satisfactory. The stress on her during treatment might have been a cause of this unique cardiomyopathy, and it should be recalled that TC is a potential complication of hepato-biliary-pancreatic surgery.

[A case of advanced gastric cancer with peritoneal dissemination responding to S-1/CDDP neoadjuvant chemotherapy]

The patient was a 72-year-old male diagnosed with type III poorly-differentiated adenocarcinoma in the lesser curvature by gastric fiberscopy. An abdominal computed tomography (CT) scan showed the thickness of the gastric wall and the enlarged lymph node around the stomach and laparoscopic examination revealed peritoneal dissemination. The patient received neoadjuvant combined chemotherapy with S-1 and CDDP. S-1 (100 mg/day) was orally administered for 3 weeks followed by 2 drug-free weeks as a course, and CDDP (100 mg/body) was administered by intravenous drip on day 8. After the third course, significant tumor reduction was obtained. Total gastrectomy, splenectomy and D2 nodal dissection were performed. Peritoneal dissemination disappeared, and the histological diagnosis revealed complete disappearance of cancer cells in the ascites and no metastasis in all lymph nodes. The patient has now been in good health with no recurrence for 22 months after surgery. The combined neoadjuvant chemotherapy with S-1 and CDDP can be an effective treatment of choice for advanced gastric carcinoma with peritoneal dissemination.

Alpha2-antiplasmin is involved in the production of transforming growth factor beta1 and fibrosis

BACKGROUND

Fibrotic disease occurs in most tissues. Transforming growth factor (TGF)-beta is the major inducer of fibrosis. The fibrinolytic system is considered to play an important role in the degradation of extracellular matrices. However, the detailed mechanism of how this system affects fibrosis remains unclear.

METHODS AND RESULTS

We examined experimental fibrosis in mice with a deficiency of alpha(2)-antiplasmin (alpha2AP), which is a potent and specific plasmin inhibitor. We found that the lack of alpha2AP attenuated bleomycin-induced TGF-beta(1) synthesis and fibrosis. In addition, the production of TGF-beta(1) from the explanted fibroblasts of alpha2AP(-/-) mice decreased dramatically as compared to that in wild-type mice. Moreover, we found that alpha2AP specifically induces the production of TGF-beta(1) in fibroblasts.

CONCLUSION

The lack of alpha2AP attenuated TGF-beta(1) synthesis, thereby resulting in attenuated fibrosis. This is the first report to describe the crucial role that alpha2AP plays in TGF-beta(1) synthesis during the process of fibrosis. Our results provide new insights into the role of alpha2AP in fibrosis.