[A case of hepatocellular carcinoma with gall bladder metastasis]

A 74-year-old male was admitted to Osaka University Hospital for advanced hepatocellular carcinoma in April 2007. CT and MRI scan showed the tumor was located mainly in posterior segment and had portal vein tumor thrombus, and the wall of gall bladder was edematous and thick, but seemed not to be close to the main tumor. We performed an extended posterior segmentectomy, tumor thrombectomy and cholecystectomy. Pathological examination showed that poorly differentiated hepatocellular carcinoma cells, which were same as the main tumor, existed in lamina propria and muscle layer of gall bladder, and invaded the submucosal vessels. So we diagnosed it as gall bladder metastasis from hepatocellular carcinoma.

[A case of synchronous triple cancer involving advanced hepatocellular carcinoma]

We report herein a case of advanced hepatocellular carcinoma (HCC) with gastric cancer and rectal cancer. A 68-year-old man was diagnosed with advanced HCC and gastric cancer. At first, he was planned to be treated by trans-catheter arterial chemoembolization (TACE). After TACE, he was diagnosed with rectal cancer by following abdominal computed tomography (CT) and colonoscopy. Then, he was diagnosed with synchronous triple cancer. To avoid bleeding and obstruction, a resection of rectal cancer was performed secondly. After the surgery, he was treated by TACE for three times. HCC was well-controlled, but there remained a small active HCC lesion. Gastric cancer had little progressed, but was still resectable. Finally, we performed a partial hepatectomy and a distal gastrectomy simultaneously. Both of cancer stage and progression-related multimodal treatment is necessary in synchronous cancer.

[Surgical repair of type A aortic dissection with severe atherosclerosis; report of a case]

We report a case of type A aortic dissection with severe atherosclerosis. An 81-year-old man with acute type A aortic dissection was referred to our hospital. Computed tomography revealed DeBakey type II dissection with severe atherosclerosis. Ascending aortic replacement was performed urgently, and an autologous pericardium strip was placed in the lumen to prevent atheroembolization and to reinforce the friable atherosclerotic intima This technique was useful for avoiding cerebral vascular accidents. The patient was discharged on the 24th operative day with no complications.

[Colopleural fistula caused by recurrence of gastric cancer; report of a case]

Perforation of colon into the pleural space without diaphragmatic hernia is extremely rare. This report illustrates a case of pneumo-pyothorax caused by perforation of metastatic tumor of the transverse colon of a 67-year-old woman with a history of total gastrectomy and splenectomy for advanced gastric carcinoma 4 years before. The patient was admitted to our hospital presenting with fever and dyspnea, which subsided after a thoracic drainage. Cultures of drained effusion revealed Escherichia coli, Klebsiella and Bacteroides. An emergent laparotomy for treatment of mechanical ileus 2 weeks after her admission disclosed a tumor obstructing the splenic flexure of the transverse colon, and a double-barreled colostomy was made. Pathologic examination of the tumors obtained from colon, mesocolon and the parietal peritoneum revealed poorly differentiated adenocarcinoma that was the same as her primary gastric cancer.

Long-term follow-up study of patients with phenylketonuria detected by the newborn screening programme in Japan

The objective of this report is to determine the need for and value of the long-term follow-up study of phenylketonuria (PKU) patients detected by newborn screening (NBS) in Japan. NBS was started in 1977 and the nationwide follow-up study of the identified patients was introduced into the NBS system. Outcome data from the continuous follow-up study showed in 1993 that IQ of PKU patients was inversely correlated with blood phenylalanine levels. Accordingly, in 1995, new treatment guidelines were issued that involved more stringent restriction of phenylalanine levels. Follow-up data confirmed that mean blood phenylalanine levels decreased after the introduction of the new guidelines, which included the recommendation to start dietary treatment within 20 days postpartum. Follow-up data also confirmed that dietary treatment did in fact commence earlier after the guidelines were issued. The need for lifelong dietary treatment is a difficult issue and the number of patients who stop dietary treatment was found to increase gradually with age. At present 60% of PKU patients born between 1977 and 1981 have stopped their dietary restriction of phenylalanine. The data gained from NBS and the long-term follow-up study were found to be valuable for the improvement of blood phenylalanine levels for patients with PKU, indicating the need for parties responsible for NBS and the follow-up study of the identified patients to work cooperatively. Further, the evaluations of the effectiveness of the two initiatives as well as the treatment guidelines issued should be based on outcome data, which depend on the continuation of the follow-up study of patients with PKU.

Impact of long-term enteral nutrition on clinical and endoscopic recurrence after resection for Crohn's disease: A prospective, non-randomized, parallel, controlled study

BACKGROUND

The impact of enteral nutrition on post-operative recurrence has not been properly examined.

AIM

To investigate the impact of enteral nutrition using an elemental diet on clinical and endoscopic recurrence after resection for Crohn's disease.

METHODS

Forty consecutive patients who underwent resection for ileal or ileocolonic Crohn's disease were studied. After operation, 20 patients continuously received enteral nutritional therapy (EN group), and 20 had neither nutritional therapy nor food restriction (non-EN group). In the EN group, enteral formula (Elental) was infused through a nasogastric tube in the night-time, and low fat foods were taken in the daytime. All patients were followed up regularly for 1 year after operation. Ileocolonoscopy was performed at 6 and 12 months after operation.

RESULTS

One patient (5%) in the EN group and seven (35%) in the non-EN group developed clinical recurrence during 1-year follow-up (P = 0.048). Six months after operation, five patients (25%) in the EN group and eight (40%) in the non-EN group developed endoscopic recurrence (P = 0.50). Twelve months after operation, endoscopic recurrence was observed in six patients (30%) in the EN group and 14 (70%) in the non-EN group (P = 0.027).

CONCLUSIONS

Our long-term enteral nutritional therapy significantly reduced clinical and endoscopic recurrence after resection for Crohn's disease.

Motility of the pouch correlates with quality of life after total gastrectomy

BACKGROUND

Jejunal pouch reconstruction is used to provide reservoir function after total gastrectomy, but controversy remains regarding pouch functions and quality of life (QOL). In this study, pouch motility was studied in conjunction with postoperative QOL.

METHODS

Pouch motility of 23 patients with jejunal pouch interposition after total gastrectomy was examined by manometry under fasting conditions and by an emptying test using dual-scintigraphy under postprandial conditions. Residual food was graded by endoscopic examinations. QOL was evaluated using the Gastrointestinal Quality of Life Index, and a stasis- or dumping-related symptom score.

RESULTS

The pouch showed interdigestive contractile activity. Bursts of contractile activity occurred frequently and were long-lasting compared with the migrating motor complex phase III of the control jejunum. The percentage of time of contractile bursts correlated with postprandial pouch emptying (liquid: R(2) = 0.229, P < .03; solid: R(2) = 0.243, P < .02). Patients with little or no residual food had more percentage of time of contractile bursts than those with moderate residual food (P < .01). The percentage of time of contractile bursts was correlated with the Gastrointestinal Quality of Life Index score (R(2) = 0.262, P < .02), stasis-related symptoms (R(2) = 0.279, P < .01), and dumping-related symptoms (R(2) = 0.218, P < .03).

CONCLUSIONS

An interposed jejunum pouch showed bursts of contractile activity that affected postoperative gastrointestinal function and patient QOL.

Dai-kenchu-to, a Chinese herbal medicine, improves stasis of patients with total gastrectomy and jejunal pouch interposition

BACKGROUND

Intestinal motility after gastric surgery frequently is disturbed and results in postoperative intestinal symptoms and poor quality of life (QOL). The purpose of this study was to examine the effects of Dai-kenchu-to on intestinal motility and postoperative QOL of patients.

METHODS

Seventeen patients who underwent total gastrectomy with jejunal pouch interposition for gastric cancer in the Department of Surgery of Osaka University Medical Hospital were enrolled. The patients were assigned randomly to the cross-over study with or without 15 g/d of Dai-kenchu-to. Questionnaires and emptying tests using (111)In-labeled liquid and (99m)Tc-labeled solid test meal were performed at the end of each treatment period. A manometric study was performed in 6 patients to measure contractile activity with or without Dai-kenchu-to.

RESULTS

Stasis-related symptoms were reduced significantly by Dai-kenchu-to (P = .032). In the emptying test, Dai-kenchu-to accelerated emptying of both liquid (P < .01) and solid (P = .015) meals from the pouch. The pouch showed bursts of contractions, which were increased significantly by oral intake of Dai-kenchu-to (P = .028).

CONCLUSIONS

Dai-kenchu-to increased intestinal motility and decreased postoperative symptoms of patients with total gastrectomy with jejunal pouch interposition.

Gastric ciliated metaplasia. A study of 3406 gastrectomy specimens from dwellers of the Atlantic and the Pacific basins

BACKGROUND

Ciliated cells in gastrectomies from patients dwelling in the Pacific and Atlantic basins have been reported previously.

AIM

To compare all the results in an attempt to explain the findings.

METHODS

Sections from 3406 gastrectomies were reviewed: 1966 and 1440 from the Atlantic and Pacific basins, respectively. Ciliated cells and intestinal metaplasia (IM) were recorded; IM was classified into focal or extensive IM. The total number of sections/gastrectomy was noted.

RESULTS

In the Atlantic basin, 5% of specimens had ciliated metaplasia (CM); it was more frequent in intestinal carcinoma (IC; 9%) than diffuse carcinoma (DC; 3%) or miscellaneous gastric diseases (MGD; 3%). In the Pacific basin, the frequency of specimens with CM was 29%: it was more frequent in IC (43%) than in DC (16%) or MGD (10%). The difference between the frequency of CM in specimens with IC or with DC/MGD in the Atlantic and the Pacific basins was significant (p < or = 0.05). The presence of CM was influenced by age and the extent of IM in both basins, but not by sex or the number of sections investigated.

CONCLUSIONS

CM-apparently an independent microscopic marker-was significantly higher in the Pacific than in the Atlantic basin. Environmental carcinogens involved in the evolution of IM and IC seem to be implicated in gastric ciliogenesis. Carcinogens that differ in nature and/or in strength in both basins might activate the latent natural genes encoding ciliated processes in gastric cells in patients subsequently developing gastric carcinoma, more notably of intestinal type.

Suppression of PI3K/mTOR pathway rescues LLC cells from cell death induced by hypoxia

Cancer cells in solid tumors are challenged by various microenvironmental stresses, including hypoxia, and cancer cells in hypoxic regions are resistant to current cancer therapies. To investigate the mechanism of resistance to hypoxia in cancer cells, we examined mouse Lewis lung carcinoma (LLC) cells, which died due to necrosis at high density under hypoxic but not under normoxic conditions. Levels of mammalian target of rapamycin (mTOR), a central regulator of cellular energy, are reported to be suppressed in hypoxia. We found that phosphorylation of two molecules downstream to it, ribosomal p70 S6 kinase (S6K) and ribosomal protein S6, was markedly suppressed by hypoxia. Overexpression of the active form of S6K increased the sensitivity of LLC cells to hypoxia. On the other hand, inhibition of PI3K or mTOR dramatically reduced hypoxia-induced cell death under hypoxic conditions. Under hypoxic conditions, blockade of the PI3K or mTOR pathway increased levels of intracellular ATP and delayed decreases in pH and glucose level in culture medium, without affecting the cell cycle.

A simple technique for circular-stapled Billroth I reconstruction in laparoscopic gastrectomy

A simple surgical technique that facilitates circular-stapled Billroth I gastroduodenostomy in laparoscopic distal gastrectomy is described. After standard laparoscopic mobilization of the distal stomach, a small duodenotomy is made just distal to the pyloric ring. The anvil of a circular-stapling device, secured with a Vicryl suture, is introduced via the duodenotomy. The Vicryl suture is advanced anteriorly so that a center rod penetrates the anterior duodenal wall. The duodenum is staple-transected at this point, and the center rod is wrapped with the stapled duodenal stump by approximation of both edges using a suturing device. The circular-stapled gastroduodenostomy then is completed in a standard fashion. The authors have used this technique for three patients, and their early outcomes are promising.

Prototype of simulation of orthognathic surgery using a virtual reality haptic device

A maxillofacial simulator can support education and training. In the present study, cutting, separation, and quantitative rearrangement of bone during orthognathic surgery were simulated by means of a haptic device with virtual tactile perception. Computed tomographic (CT) images of two patients with severe jaw deformity, one women and one man, were input into the device. In the woman, Le Fort I osteotomy of the maxilla and sagittal splitting ramus osteotomy of the mandible were initially simulated. During surgery with the haptic device, separation and rearrangement of the maxilla and the ramus of the mandible were initially processed. However, there was discrepancy and overlapping of the ramus with the mandible. Intraoral vertical osteotomy of the right ramus was then performed, with satisfactory results and less discrepancy and interference. The simulation was referred to at surgery, and satisfactory surgical assistance was postoperatively confirmed on CT images. The male patient had severe jaw deformity due to unequal growth between the ramuses, resulting in anterior crossbite. Sagittal splitting ramus osteotomy with rotation of the mandible was successfully simulated. Because of its versatility and functions, the present device was found to be useful for simulating various procedures for orthognathic surgery and thereby three-dimensionally determine surgical movements.

Enzyme replacement therapy in Japanese Fabry disease patients: the results of a phase 2 bridging study

Fabry Disease (alpha-galactosidase A deficiency) is an X-linked hereditary disorder leading to the pathological accumulation of globotriaosylceramide (GL-3) in lysosomes, particularly in the vascular endothelium of the kidney, heart and brain. We report the results of an open-label phase 2 study that was undertaken to evaluate whether ethnic differences exist that would affect agalsidase beta (Fabrazyme) treatment of Fabry patients in the Japanese population, relative to safety and efficacy. The study design mirrored the design of the completed phase 3 clinical trial that led to approval of the product agalsidase beta. The 13 Japanese, male Fabry patients enrolled in the study received the enzyme replacement therapy over a period of 20 weeks as biweekly infusions. All selected efficacy end points showed improvements that were comparable with findings from the phase 3 study. These improvements included reductions of GL-3 accumulation in both kidney and skin capillary endothelial cells to (near) normal levels (92% of patients). Kidney and plasma GL-3 levels decreased by 51.9% and 100%, respectively, by ELISA. Renal function remained normal. Fabry-associated pain, and quality of life, showed improvement over baseline in multiple categories. Related adverse events were mild or moderate in intensity and mostly infusion-associated (fever and rigors). As expected, IgG antibody formation was observed in 85% of the patients, but had no effect on treatment response. These results suggest that treatment with agalsidase beta is safe and effective in Japanese patients with Fabry disease. With regard to safety and efficacy, no differences were observed as compared to the caucasian population.

Contralateral stenosis as a risk factor for carotid endarterectomy measured by near infrared spectroscopy

AIM

It is still controversial whether the existence of a contralateral stenosis is a risk factor during carotid endarterectomy (CEA). We used a near infrared spectroscopy (NIRS) monitoring system during CEA to evaluate the hemodynamic effect of contralateral stenosis during cross clamping of the carotid arteries.

METHODS

We monitored 34 consecutive cases of CEA, using NIRS. Tissue oxygen index (TOI), as a parameter of oxygenation, and total hemoglobin index (THI), as a parameter of blood volume, were measured during cross-clamping the carotid arteries. We evaluated the relationship between these results and the pre- and intraoperative characteristics including the existence of a contralateral stenosis and the results of single-photon emission computed tomography (SPECT).

RESULTS

Bilateral TOI and THI correlated well with the severity of the stenosis of the contralateral internal carotid artery, and ipsilateral THI correlated with the cerebrovascular reserve measured by SPECT.

CONCLUSIONS

A contralateral stenosis is a risk factor for CEA from the hemodynamical point of view, and extreme care should be taken when performing CEA in patients with bilateral stenoses.

Granulocyte and monocyte adsorptive apheresis in the treatment of active distal ulcerative colitis: a prospective, pilot study

AIM

To assess safety and clinical efficacy of granulocyte and monocyte adsorptive apheresis for distal ulcerative colitis.

METHODS

Granulocyte and monocyte adsorptive apheresis therapy (five aphereses for 5 consecutive weeks) was performed for 30 consecutive patients with active distal ulcerative colitis. Patient compliance, adverse effects and clinical symptoms were regularly assessed.

RESULTS

Adverse effects were noted during nine (6%) apheresis sessions in eight patients; slight headache five, transient abdominal pain with tenesmus two, fever (38 degrees C) one and mild liver dysfunction one. None of these adverse effects was serious and all patients could complete five aphereses. Clinical symptoms (stool frequency and consistency, rectal bleeding, tenesmus and mucus in stools) significantly improved after the third apheresis. Clinical remission (normal stool frequency and no rectal bleeding) was achieved in 21 patients (70%) after five aphereses. The median Disease Activity Index score significantly decreased; from 6 [interquartile range (IQR): 4-7] to 2 (IQR: 1-3) (P < 0.0001).

CONCLUSION

In the treatment of active distal ulcerative colitis, granulocyte and monocyte adsorptive apheresis is safe and well-tolerated. Granulocyte and monocyte adsorptive apheresis had a beneficial effect on clinical remission and symptoms. However, randomized-controlled trials would be necessary to assess a definite efficacy of granulocyte and monocyte adsorptive apheresis.

Laparoscopic intragastric resection of gastric stromal tumor located at the esophago-cardiac junction

We performed laparoscopic intragastric surgery (LIGS) for gastric stromal tumors located at the esophago-cardiac junction (ECJ) in 7 patients. The tumors measured 27 to 75 mm in diameters. Histologically, there were 4 cases of gastrointestinal stromal tumors, 2 leiomyomas, and 1 schwannoma. LIGS was performed with 1 camera port (10 mm) inserted by the open method and two 5-mm working ports inserted by puncturing the stomach. Tumors were enucleated or resected with appropriate margins confirming the muscle layer of the stomach wall and retrieved orally by gastrofiberscope. The mean surgical duration was 141.4 minutes. Recent patients took their first meal on day 3 postoperatively and were discharged within a week. There were no complications including stenosis or gastroesophageal reflux in any patient to date. LIGS is a feasible surgical option for gastric stromal tumors located at ECJ.

Extended intestinal metaplasia. A survey of 1392 gastrectomies from dwellers of the Pacific basin

BACKGROUND

To assess the extent of gastric intestinal metaplasia (IM) in gastrectomy specimens in populations of the Pacific basin having different incidence of gastric carcinoma.

MATERIALS AND METHODS

One thousand three hundred and nine-two gastrectomies were investigated: 1088 had a gastric carcinoma and 304 miscellaneous gastric diseases. Twenty-one thousand three hundred and fourteen histological sections were reviewed under low-power (4X). IM was either spotty (SIM) or extended (EIM= encompassing one or more entire low-power fields/section). Widespread IM (WIM) was regarded as EIM if present in > or =5 histological sections.

RESULTS AND CONCLUSION

The percent of gastrectomies harboring a carcinoma increased significantly with increasing age more notably in those with diffuse carcinomas (DC) than in those with intestinal carcinomas (IC). The percent of gastrectomies with EIM was significantly higher in specimens with IC than with DC, particularly among elderly patients, and in specimens from countries with a high cancer incidence. The percent of gastrectomies with WIM was higher in specimens having IC than in those having DC. Migration per se did not influence the frequency of specimens with EIM in elderly Japanese patients: Japanese migrants to Hawaii had a similarly high frequency of EIM as those dwelling in Japan. Japanese patients with a gastric carcinoma showed atypical mitoses in areas with EIM far from the tumor, suggesting that cellular mutation(s) play a role in the evolution of EIM towards gastric dysplasia and carcinoma in that ethnic group. The drawback of gastric biopsies in assessing the extent of gastric intestinal metaplasia and, thereby, estimating possible cancer risk in long-term studies has been stressed.