The advantages of circular stapling instrument compared with Albert-Lembert suture for anastomosis of Billroth I gastrectomy for gastric cancer

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Background: In Japan, reconstruction with Billroth I using Albert-Lembert suture had been usually performed in distal gastrectomy for gastric cancer. However stapling instruments have within recent years gained wide acceptance not only in total gastrectomy but also in distal gastrectomy. We have introduced circular stapling instrument for anastomosis reconstructed with Billroth I since June 2001. Methods: 111 and 222 patients with gastric cancer underwent distal gastrectomy reconstructed with Billroth I using Albert-Lembert suture from June 1999 to May 2001 (Group A) and using circular stapling instrument from June 2001 to December 2003 (Group B) for anastmosis in our institute, respectively. Albert-Lembert suture was performed as end-to-end gastroduodenostomy followed by resection of proximal line stapled across with liner cutter instrument. The procedure of anastomosis using circular stapling instrument was as followed; the distal duodenum was clamped with the purse-string instrument, divided proximally, the anvil was attached, the purse-string was tied down, the circular stapler without anvil was inserted through a gastrotomy, brought out through a stab wound at the anastomosis site, the instrument was closed and fired, and gastrectomy involving the site of gastrotomy was closed with linear cutter instrument. The followed-up periods of all patients from surgery were more than 2 years. We retrospectively compared the incidence of anastomosis-related complications within 2 years from surgery consisting of anastomotic bleeding, leakage, and stenosis. P-values were calculated statistically using χ2-test. Results: Anastomotic bleeding occurred in 1 (0.45%) patient of Group B, but in none of Group A (P=0.48). Anastomotic leakage occurred in 2 patients (1.80%) of Group A, but in none of Group B (P=0.045). Anastomotic stenosis occurred in 2 patients (0.90%) of Group B, but in none of Group A (P=0.32). All complications were recovered and all patients left hospital in the safety. Conclusions: Our data indicated that circular stapling instrument for anastomosis of Billroth I gastrectomy for gastric cancer significantly reduced the incidence of anastomotic leakage compared with Albert-Lembert suture.

No significant financial relationships to disclose.

Preoperative Estimation of Right Lateral Sector Graft by Three-Dimensional Computed Tomography

The right lateral sector is an alternative graft for living donor liver transplantation. Three-dimensional image reconstruction of right lateral sector grafts was performed to reveal vascular anatomy and volume using three-dimensional computed tomography software in three donors. There was a correlation between actual and estimated volume (r=.93), although actual graft volume tended to be larger than the preoperative estimated volume. In one donor, a portal branch of the right lateral sector was independently ramified. The branch was sacrificed in the operation because its territory volume was only 44 cm3. Three-dimensional images matched the shape of the right lateral sector graft. Three-dimensional computed tomography might be useful before donor hepatectomy, providing important information for decisions regarding the operative procedure.

Hemophagocytic Syndrome After Adult-to-Adult Living Donor Liver Transplantation

Hemophagocytic syndrome is a fatal complication after liver transplantation that is rarely reported. Among 260 adult patients who underwent living donor liver transplantation at our hospital, three cases (1%) were complicated with hemophagocytic syndrome. Intensive investigation revealed Aspergillus, cytomegalovirus, and hepatitis C virus as the most likely causative organisms in each patient. Despite the immediate initiation of anti-infectious treatment and supportive care, all patients died. When pancytopenia with possible underlying infectious disease is observed in liver transplant recipients, hemophagocytic syndrome should be suspected and bone marrow biopsy considered. The prognosis of hemophagocytic syndrome remains poor and further investigations are required to establish effective therapeutic options.

Neuronal intranuclear hyaline inclusion disease showing motor-sensory and autonomic neuropathy

BACKGROUND

Neuronal intranuclear hyaline inclusion disease (NIHID), a rare neurodegenerative disease in which eosinophilic intranuclear inclusions develop mainly in neurons, has not yet been described to present as hereditary motor-sensory and autonomic neuropathy.

METHODS

Patients in two NIHID families showing peripheral neuropathy were evaluated clinically, electrophysiologically, and histopathologically.

RESULTS

In both families, patients had severe muscle atrophy and weakness in limbs, limb girdle, and face; sensory impairment in the distal limbs; dysphagia, episodic intestinal pseudoobstruction with vomiting attacks; and urinary and fecal incontinence. No patients developed symptoms suggesting CNS involvement. Electrophysiologic study showed the reduced motor and sensory nerve conduction velocities and amplitudes, and also extensive denervation potentials. In sural nerve specimens, numbers of myelinated and unmyelinated fibers were decreased. In two autopsy cases, eosinophilic intranuclear inclusions were widespread, particularly in sympathetic and myenteric ganglion neurons, dorsal root ganglion neurons, and spinal motor neurons. These neurons also were decreased in number.

CONCLUSION

Patients with neuronal intranuclear hyaline inclusion disease (NIHID) can manifest symptoms limited to those of peripheral neuropathy. NIHID therefore is part of the differential diagnosis of hereditary motor-sensory neuropathy associated with autonomic symptoms. Intranuclear hyaline inclusions in Schwann cells and in the myenteric plexus may permit antemortem diagnosis of NIHID.

Long-Term Survival and Causes of Late Graft Loss After Adult-to-Adult Living Donor Liver Transplantation

The vast amount of experience with deceased donor liver transplantation allows for the evaluation of the causes underlying late graft loss and the adoption of strategies for its prevention. In contrast, the long-term results or causes of late graft loss after adult-to-adult living donor liver transplantation have not been fully examined. Thus, we analyzed 176 adult recipients who survived at least 1 year after living donor liver transplantation. The median follow-up period was 33 months. Of the 176 recipients, eight died and three others underwent retransplantation. The most common cause of graft loss in our series was cholangitis (n = 4), which might be due partly to technical problems. The 3-year and 5-year patient survival rates of the subjects were 95% and 90%, respectively. Long-term survival after living donor liver transplantation was satisfactory in our series. Further improvement of surgical techniques for biliary reconstruction may reduce late graft loss.

Expression of a CD44 variant and VEGF-C and the implications for lymphatic metastasis and long-term prognosis of human breast cancer

The aim of the present study was to determine whether expression of the CD44 variant v7-v8 (CD44v7-v8) or vascular endothelial growth factor-C (VEGF-C) is associated with long-term prognosis in breast cancer patients. A 10-year follow-up of 91 patients with primary breast cancer who were previously assessed for CD44 expression was undertaken. Immunohistochemical evaluation of VEGF-C expression was performed in 87 of these patients and their long-term prognosis was assessed. The disease-free and overall survival rates were significantly poorer for the CD44v7-v8-positive patients than for the patients negative for this marker. VEGF-C expression was detected in 38 out of the 87 patients (43.7%) with primary human breast cancer. There were no significant differences in tumor size, histological type, axillary lymph node status, presence of lymphatic or venous invasion, or presence of estrogen receptors and progesterone receptors between the VEGF-C-positive and -negative patients. There were also no significant differences in the disease-free or overall survival rates in these patient groups. In conclusion after the 10-year follow-up, expression of CD44v7-v8 was associated with poor prognosis for breast cancer patients. However, there was no association between VEGF-C expression and the clinicopathological factors or prognosis of breast cancer patients.

Proposal of a new prognostic model for hepatocellular carcinoma: an analysis of 403 patients

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) is highly dependent on tumour extension and liver function. Recently, two new prognostic scoring systems-the CLIP score, developed by Italian investigators and the BCLC score, developed in Barcelona-have been widely used to assess prognosis in patients presenting with hepatocellular carcinoma. Each system has its own relative limitations.

AIMS

To create a new prognostic scoring system which is simple, easy to calculate, and suitable for estimating prognosis during radical treatment of early HCC.

METHODS

A total of 403 consecutive patients with HCC treated by percutaneous ablation at the Department of Gastroenterology, University of Tokyo Hospital, between 1990 and 1997 were used as the training sample to identify prognostic factors for our patients and used to develop the Tokyo score. As a testing sample, 203 independent patients who underwent hepatectomy at the Department of Hepato-Biliary-Pancreatic Surgery were studied. Prognostic factors were analysed by univariate and multivariate Cox proportional hazard regression.

RESULTS

The Tokyo score consists of four factors: serum albumin, bilirubin, and size and number of tumours. Five year survival was 78.7%, 62.1%, 40.0%, 27.7%, and 14.3% for Tokyo scores 0, 1, 2, 3, and 4-6, respectively. The discriminatory ability of the Tokyo score was internally validated by bootstrap methods. The Tokyo score, CLIP score, and BCLC staging were compared by Akaike information criterion and Harrell's c index among training and testing samples. In the testing sample, the predictive ability of the Tokyo score was equal to CLIP and better than BCLC staging.

CONCLUSIONS

The Tokyo score is a simple system which provides good prediction of prognosis for Japanese patients with HCC requiring radical therapy.

Self-assembly of the ionic peptide EAK16: the effect of charge distributions on self-assembly

Amphiphilic peptides suspended in aqueous solution display a rich set of aggregation behavior. Molecular-level studies of relatively simple amphiphilic molecules under controlled conditions are an essential step toward a better understanding of self-assembly phenomena of naturally occurring peptides/proteins. Here, we study the influence of molecular architecture and interactions on the self-assembly of model peptides (EAK16s), using both experimental and theoretical approaches. Three different types of EAK16 were studied: EAK16-I, -II, and -IV, which have the same amino acid composition but different amino acid sequences. Atomic force microscopy confirms that EAK16-I and -II form fibrillar assemblies, whereas EAK16-IV forms globular structures. The Fourier transform infrared spectrum of EAK16-IV indicates the possible formation of a beta-turn structure, which is not found in EAK16-I and -II. Our theoretical and numerical studies suggest the underlying mechanism behind these observations. We show that the hairpin structure is energetically stable for EAK16-IV, whereas the chain entropy of EAK16-I and -II favors relatively stretched conformations. Our combined experimental and theoretical approaches provide a clear picture of the interplay between single-chain properties, as determined by peptide sequences (or charge distributions), and the emerging structure at the nano (or more coarse-grained) level.

Simulation Study of Distal Balloon Protection Systems during Carotid Artery Stenting

The purpose of our experimental study was to assess the pitfalls of distal balloon protection systems and to learn any technique tips to increase safety.

Silicone carotid artery models were connected to a circulatory system to simulate arterial flow. A distal balloon protection device, PercuSurge GuardWire Plus (GWP, Medtronic Vascular) was delivered to the internal carotid artery (ICA), then was inflated to occlude ICA flow temporarily. A debris aspiration catheter (Export catheter) was delivered just proximal to the GuardWire Plus balloon coaxially, in order to introduce and diffuse particulate debris (200–500 micro meter in diameter) in the ICA stump. Then, after debris in the stump was aspirated, the GWP balloon was deflated. We recorded all the processes of our simulation experiments on a digital video and observed the movements of debris during these experiments.

Exp 1) We simulated the movements of debris in the ICA stump when the GWP balloon was gradually deflated to produce a crevice between the balloon and vessel wall, simulating accidental movement of the GWP balloon during the procedure.

Exp 2) In order to assess the optimal placement of the tip of aspiration catheter, the debris in the ICA stump was aspirated from three different sites (from just below the GuardWire balloon, from 2 cm below it, and from 5 cm below it).

Exp 1) When the crevice appeared between GuardWire balloon and silicone tube, simulated debris began to concentrate just below the balloon. Then, some debris migrated distally from the crevice, and another part crowded in the crevice so that was impossible to aspirate and migrated in the end.

Exp. 2) Debris aspiration was most effective from immediately below the GuardWire balloon, and the aspiration ability declined as the distance between the balloon and aspiration catheter became longer. According to our simulation studies, when the GWP balloon was moved accidentally during CAS procedures, or when the aspiration catheter was not delivered all the way to the GuardWire Plus balloon, distal embolization might still occur, even under protection.

Effect of moderate exercise on excess post-exercise oxygen consumption and catecholamines in young women

AIM

The purpose of this study was to examine the effects of moderate exercise on the magnitude and duration of excess post-exercise oxygen consumption (EPOC) and catecholamine concentrations in 7 young women.

METHODS

The subjects performed 30 or 60 minutes of exercise (30-ME and 60-ME, respectively) on separate days at an intensity of 60% of maximal oxygen uptake on a cycle ergometer. The glucose, epinephrine and norepinephrine in the plasma, and free fatty acids and glycerol in the serum were measured at the end of the 60 min of the rest period before each exercise, immediately after the performance of each exercise and 30 min, 1, 2 and 24 h time points after each exercise.

RESULTS

EPOC lasted for 46.1+/-25.4 and 116.1+/-79.8 min after the 30- and 60-ME, respectively. Corresponding total EPOC were 2636+/-1125 and 5208+/-1880 ml, respectively. The mean differences were statistically significant (p<0.05 each). The serum free fatty acids significantly increased immediately after the 60-ME. The serum glycerol was significantly increased immediately after the 30-ME and was also significantly increased immediately after and 30 min time point after the 60-ME. The plasma epinephrine and norepinephrine significantly increased immediately after the 30- and 60-ME, respectively. The plasma epinephrine at the 30 min time point after the 60-ME significantly correlated with the magnitude (r=0.955) and duration (r=0.897) of EPOC. Norepinephrine at the 30 min time point after the 60-ME also significantly correlated with the magnitude (r=0.774) of EPOC.

CONCLUSION

The results indicate that longer duration exercise results in a greater and longer EPOC, and the plasma catecholamines may possibly contribute to EPOC in young women. Although, the overall magnitude of EPOC is small, if exercise frequency and compliance are strong, some long term benefits may accrue.

[A device to prevent an air-leakage after a thoracoscopic surgery for spontaneous pneumothorax]

PURPOSE

In a thoracoscopic surgery for the patient with spontaneous pneumothorax, an air-leakage from the staple-line is one of the most troublesome complications. Recently we have been using a polyglycolic acid (PGA) sleeve for staple-line reinforcement. The purpose of this study was to investigate an efficacy of staple-line reinforcement in the patients who underwent thoracoscopic lung resection using an automatic stapler.

OBJECTS

Last 4 years, 55 patients with primary spontaneous pneumothorax underwent thoracoscopic surgery using an automatic stapler. PGA sleeve was used in 19 patients as PGA group, fibrin glue was applied to the staple-line in 6 patients as fibrin group and no staple-line reinforcement was applied in 30 patients as no-reinforce group. We investigated the efficacy of staple-line reinforcement according to the results after surgery in these 3 groups.

RESULTS

Average drainage time in PGA group, fibrin group and no-reinforce group were 2.1, 2.2 and 2.8 days, respectively. In PGA group, the drainage time after surgery tended to be short term. The relapse of pneumothorax after surgery developed in 2 patients in PGA group (10.5%) and 8 patients in non-reinforce group (26.7%). In PGA group, the relapse after surgery tended to be low rate.

CONCLUSIONS

Bioabsorbable PGA sleeve could be an useful device for a staple-line reinforcement in the patients who underwent lung resection using automatic stapler.

Kondo effect in quantum dots coupled to ferromagnetic leads

We study the Kondo effect in a quantum dot coupled to ferromagnetic leads and analyze its properties as a function of the spin polarization of the leads. Based on a scaling approach, we predict that for parallel alignment of the magnetizations in the leads the strong-coupling limit of the Kondo effect is reached at a finite value of the magnetic field. Using an equation of motion technique, we study nonlinear transport through the dot. For parallel alignment, the zero-bias anomaly may be split even in the absence of an external magnetic field. For antiparallel spin alignment and symmetric coupling, the peak is split only in the presence of a magnetic field, but shows a characteristic asymmetry in amplitude and position.

[Anomalous systemic arterial supply to the basal segment of the left lung; report of a case]

A 35-year-old female was admitted to our hospital for hysteromyoma. Chest X-ray showed a mass shadow in the left lung field. A thorough examination revealed anomalous systemic arterial supply to the basal segment of the left lung with 2 abnormal arteries. Because the patient had no symptoms, no operation was performed. After 9 months however, the patient had bloody phlegm and chest pain and received an operation. Thus, we propose that the operation for the pulmonary sequestration is to be performed when such a diagnosis is made.

EBAG9/RCAS1 expression in hepatocellular carcinoma: correlation with tumour dedifferentiation and proliferation

The oestrogen-responsive gene, EBAG9, whose product is identical to the cancer cell surface antigen RCAS1, is reported to be associated with tumour progression and invasiveness in various carcinomas. In this study, we examined the expression of EBAG9/RCAS1 in hepatocellular carcinoma (HCC), with special reference to its relationship with the stepwise evolution of HCC. Expression was examined by immunohistochemistry and western blotting analysis in 143 HCCs, as well as in non-cancerous liver tissues. After which, the association between enhanced EBAG9/RCAS1 expression and various clinicopathological parameters including Ki-67 labelling index (LI), a marker of proliferative activity, was evaluated. There was a constant low level of EBAG9/RCAS1 expression in non-cancerous liver tissues, with a regular cytoplasmic distribution. Positive immunoreactivity for EBAG9/RCAS1 was detected on the surface and in the cytoplasm of 84 HCC tumours, with an irregular staining pattern. Enhanced EBAG9/RCAS1 expression was correlated with a lower degree of differentiation and Ki-67 LI. Interestingly, expression was enhanced specifically in the less differentiated lesions within 'nodule-in-nodule' tumours. In conclusion, EBAG9/RCAS1 was associated with HCC tumour dedifferentiation and increased proliferative activity. Its exact functional role remains to be established.

Physiological responses during and following karate training in women

BACKGROUND

The purpose of this study was to examine whether each exercise and an entire karate training session can achieve: 1). accepted training intensity thresholds for effective aerobic capacity training; 2). energy expenditure (EE) thresholds for total body mass and fat weight loss; and, 3). elevation in excess postexercise oxygen consumption (EPOC).

METHODS

We investigated physiological responses during 5 types of karate training in female karate practitioners: basic techniques without (S-Basics) and with (M-Basics) movements, sparring techniques without (TECH I) and with (TECH II) an opponent, and kata.

RESULTS

The mean percent of maximum oxygen uptake reserve (%VO2R), percent of maximum heart rate (%HRmax), and maximum heart rate reserve (%HRR) for S-Basics were below the accepted threshold and for M-Basics were marginal or above the threshold for increasing VO2max. For TECH I, TECH II, kata, and the entire 70-min practice, the mean %HRmax and %HRR were well above the threshold, however, %VO2R was below the threshold. Although the mean EPOC measured for 5 min immediately following the entire 70-min karate training did not differ from resting VO2. The blood lactate responses to the 5 types of karate exercises ranged from 1.2+/-0.3 to 2.2+/-0.8 mmol L(-1). The mean EE for each karate exercise ranged from 157+/-10 kJ to 314+/-16 kJ. The mean EE for the entire 70 min practice and EPOC were 1120+/-64 kJ and 28+/-2 kJ, respectively.

CONCLUSIONS

The training intensities of karate exercises studied in women were light to moderate, effects of karate training on EPOC was minimal, and the mean EE was marginal to the accepted threshold for total body mass and fat weight loss.

Long-term results of chronic hemodialysis patients with isolated coronary artery bypass grafting performed by the same surgeon. A comparative study

BACKGROUND

The aim of this study was to examine the long-term results of isolated coronary artery bypass grafting (CABG) patients who required chronic hemodialysis.

METHODS

From May 1990 to June 2000, 23 hemodialysis patients received isolated CABG performed by the same surgeon. Postoperative follow-up was completed with maximum duration of 122 months.

RESULTS

Operative deaths (n=2) were due to acute circulatory failure related to hemodialysis. The most frequent cause of late deaths (n=10) was infection. Five (50%) patients died of sepsis, and 80% of sepsis was caused by leg infection associated with arteriosclerosis obliterans. There were 6 late cardiac events including 3 cardiac deaths. The actual survival rates 1, 3, 5 and 7 years after CABG were 68.6%, 42.5%, 35.4% and 35.4%, respectively. And the actual cardiac event free rates 1, 3, 5 and 7 years after CABG were 77.6%, 77.6%, 46.6% and 46.6%, respectively. Operative mortality (p=0.019), long-term survival (p<0.001) and cardiac event free rate (p=0.002) were significantly poorer in hemodialysis patients than in non-hemodialysis patients. However, the long-term survival rate of our hemodialysis patients receiving isolated CABG was almost similar to that in dialysis patients without CABG. The etiology of chronic renal failure did not significantly affect long-term RESULTS. Using internal thoracic artery graft significantly (p=0.02) decreased the late cardiac event in hemodialysis patients, although it did not improve late survival.

CONCLUSIONS

Primary CABG followed by aggressive re-intervention have the benefit of preventing late cardiac death in hemodialysis patients. However, prevention of sepsis and treatment of arteriosclerosis obliterans are important for improving the late survival in hemodialysis patients receiving isolated CABG.

Spontaneous revascularization of arterial thrombosis after living donor liver transplantation

Hepatic artery thrombosis remains a significant cause of graft loss in liver transplantation. We describe a case with thrombosis of the middle hepatic artery that revascularized spontaneously. Close follow-up with duplex ultrasound enabled us to treat the patient promptly and successfully with anticoagulants and antibiotics.