Primary hepatic chronic expanding hematoma: a case report and literature review

Chronic expanding hematoma (CEH), first reported in 1968, is a hematoma that gradually enlarges over a long course of time after an initial period of bleeding. It can occur anywhere in the body; however, there are many reports of its occurrence in the thoracic cavity. Primary hepatic CEH is extremely rare. In this current study, we report on a case of primary hepatic CEH diagnosed preoperatively, with a review of the literature. A 68-year-old man presented with liver dysfunction. Abdominal computed tomography revealed a giant cystic tumor in the left lobe of the liver, with a longer axis of approximately 12 cm. Magnetic resonance imaging revealed a mosaic pattern with a mixture of high and low signals within the tumor on T1-weighted images and a high signal at the tumor margin on T2-weighted images. Based on these findings, primary hepatic CEH was suspected. However, other malignant tumors could not be excluded owing to tumor compression resulting in bile duct dilatation. Left trisectionectomy was performed, followed by bile duct drainage and percutaneous transhepatic portal vein embolization. Intraoperative hemorrhage was controlled by the Pringle maneuver and with temporary clamping of the inferior vena cava. Pathological examination revealed a pseudocyst containing a clot, consistent with CEH. In conclusions, the case report illustrates the potential to enhance preoperative diagnosis, inform surgical approaches, and minimize associated risks. Furthermore, it highlights the importance of increasing awareness and research on this condition for improved clinical decision-making and patient care.

Efficacy of CT Value Along Portal Vein for Preoperative Prediction of Portal Vein Resection in Pancreatic Head Cancer

BACKGROUND

It is important for surgeons to determine whether combined portal vein (PV) resection (PVR) is necessary before surgery. The present study aimed to determine the ability of computed tomography (CT) value along the PV in predicting the necessity for concomitant PVR.

METHODS

A total of 107 consecutive patients who underwent pancreaticoduodenectomy (PD) for invasive ductal carcinoma of the pancreatic head at our institute between September 2007 and September 2020 were reviewed retrospectively. Univariate analysis to predict PVR was performed with preoperative radiological valuables acquired by Synapse Vincent. The resected specimen near the PV or the PV notch was analyzed by histopathological findings.

RESULTS

Only the CT value of the PV was independently associated with PVR (Mann-Whitney U test; P = .045, logistic regression test; P = .039). The outer boundary of the PV was unclear in the cases without pathological PV invasion and PVR due to the development of smooth muscle in the outer membrane of the PV and the proliferation of collagen fibers. The elastic fibers were arranged regularly in the notch portion of the PV in cases wherein PVR was not performed.

DISCUSSION

The CT value along the PV was independently associated with PVR and is the only predictor of PVR. These results were very useful in predicting PVR preoperatively and were histopathologically supportive.

Early Identification of Patients with Potential Failure of Nonoperative Management for Gastroduodenal Peptic Ulcer Perforation

INTRODUCTION

We aimed to identify objective factors associated with failure of nonoperative management (NOM) of gastroduodenal peptic ulcer perforation (GDUP) and establish a scoring model for early identification of patients in whom NOM of GDUP may fail.

METHODS

A total of 71 patients with GDUP were divided into NOM (cases of NOM success) and operation groups (cases requiring emergency operation or conversion from NOM to operation). Using logistic regression analysis, a scoring model was established based on the independent factors. The patients were stratified into low-risk and high-risk groups according to the scores.

RESULTS

Of the 71 patients, 18 and 53 were in the NOM and operation groups, respectively. Ascites in the pelvic cavity on computed tomography (CT) and sequential organ failure assessment (SOFA) score at admission were identified as independent factors for NOM failure. The scoring model was established based on the presence of ascites in the pelvic cavity on CT and SOFA score ≥2 at admission. The operation rates for GDUP were 28.6% and 86.0% in the low-risk (score, 0) and high-risk groups (scores, 2 and 4), respectively.

CONCLUSION

Our scoring model may help determine NOM failure or success in patients with GDUP and make decisions regarding initial treatment.

Preoperative scoring system for prediction of extended resection during emergency surgery for acute appendicitis

PURPOSE

Appendicectomy is the primary treatment for acute appendicitis. However, extended resection (ER) may be required in difficult cases. Preoperative prediction of ER may identify challenging cases but remains difficult. We aimed to establish a preoperative scoring system for ER prediction during emergency surgery for acute appendicitis.

METHODS

This was a single-center retrospective study. Patients who underwent emergency surgery for acute appendicitis between January 2014 and December 2022 were included and divided into ER and appendicectomy groups. Independent variables associated with ER were identified using multivariate logistic regression analysis. A new scoring system was established based on these independent variables. The discrimination of the new scoring system was assessed using the area under the receiver operating characteristic curve (AUC). The risk categorization of the scoring system was also analyzed.

RESULTS

Of the 179 patients in this study, 12 (6.7%) underwent ER. The time interval from symptom onset to surgery ≥ 4 days, a retrocecal or retrocolic appendix, and the presence of an abscess were identified as independent preoperative predictive factors for ER. The new scoring system was established based on these three variables, and the scores ranged from 0 to 6. The AUC of the scoring system was 0.877, and the rates of ER among patients in the low- (score, 0-2), medium- (score, 4), and high- (score, 6) risk groups were estimated to be 2.5%, 28.6%, and 80%, respectively.

CONCLUSION

Our scoring system may help surgeons identify patients with acute appendicitis requiring ER and facilitate decision-making regarding treatment options.

Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis

BACKGROUND

The mortality rate of gangrenous/perforated appendicitis is higher than that of uncomplicated appendicitis. However, non-operative management of such patients is ineffective. This necessitates their careful exam at presentation to identify gangrenous/perforated appendicitis and aid surgical decision-making. Therefore, this study aimed to develop a new scoring model based on objective findings to predict gangrenous/perforated appendicitis in adults.

METHODS

We retrospectively analyzed 151 patients with acute appendicitis who underwent emergency surgery between January 2014 and June 2021. We performed univariate and multivariate analyses to identify independent objective predictors of gangrenous/perforated appendicitis, and a new scoring model was developed based on logistic regression coefficients for independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were performed to assess the discrimination and calibration of the model. Finally, the scores were classified into three categories based on the probability of gangrenous/perforated appendicitis.

RESULTS

Among the 151 patients, 85 and 66 patients were diagnosed with gangrenous/perforated appendicitis and uncomplicated appendicitis, respectively. Using the multivariate analysis, C-reactive protein level, maximal outer diameter of the appendix, and presence of appendiceal fecalith were identified as independent predictors for developing gangrenous/perforated appendicitis. Our novel scoring model was developed based on three independent predictors and ranged from 0 to 3. The area under the ROC curve was 0.792 (95% confidence interval, 0.721-0.863), and the Hosmer-Lemeshow test showed a good calibration of the novel scoring model (P = 0.716). Three risk categories were classified: low, moderate, and high risk with probabilities of 30.9%, 63.8%, and 94.4%, respectively.

CONCLUSIONS

Our scoring model can objectively and reproducibly identify gangrenous/perforated appendicitis with good diagnostic accuracy and help in determining the degree of urgency and in making decisions about appendicitis management.

Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia

PURPOSE

The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC.

METHODS

This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC.

RESULTS

The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI.

CONCLUSION

The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.

Prediction model for irreversible intestinal ischemia in strangulated bowel obstruction

Background

Preoperatively diagnosing irreversible intestinal ischemia in patients with strangulated bowel obstruction is difficult. Therefore, this study aimed to establish a prediction model for irreversible intestinal ischemia in strangulated bowel obstruction.

Methods

We included 83 patients who underwent emergency surgery for strangulated bowel obstruction between January 2014 and March 2022. The predictors of irreversible intestinal ischemia in strangulated bowel obstruction were identified using logistic regression analysis, and a prediction model for irreversible intestinal ischemia in strangulated bowel obstruction was established using the regression coefficients. Receiver operating characteristic analysis and fivefold cross-validation was used to assess the model.

Results

The prediction model (range, 0–4) was established using a white blood cell count of ≥ 12,000/µL and the computed tomography value of peritoneal fluid that was ≥ 20 Hounsfield units. The areas of the receiver operating characteristic curve of the new prediction model were 0.814 and 0.807 after fivefold cross-validation. A score of ≥ 2 was strongly suggestive of irreversible intestinal ischemia in strangulated bowel obstruction and necessitated bowel resection (odds ratio = 15.938). The bowel resection rates for the prediction scores of 0, 2, and 4 were 15.2%, 66.7%, and 85.0%, respectively.

Conclusion

Our model may help predict irreversible intestinal ischemia that necessitates bowel resection for strangulated bowel obstruction cases and thus enable surgeons to recognize the severity of the situation, prepare for deterioration of patients with progression of intestinal ischemia, and select the appropriate surgical procedure for treatment.

Prognostic Impact of N2 of the Primary Tumour in Surgical Resection for Colorectal Liver Metastases

BACKGROUND/AIM

The status of lymph node metastasis of primary tumours remains to be completely investigated. This study investigated the prognostic impact of the degree of primary lymph node metastasis in patients with colorectal liver metastasis.

PATIENTS AND METHODS

We retrospectively analysed the clinical data of 106 patients with colorectal liver metastases who underwent surgical resection. Prognostic factors, including the degree of the positive primary lymph nodes, positive lymph node ratio, and log odds of positive lymph nodes, were evaluated.

RESULTS

The T factor and N2 status were independent risk factors for overall survival in patients who underwent surgical resection. Survival was significantly lower in the N2 group than in the N0-1 group. Additionally, ≥N2 status showed better prognostic performance than ≥N1 status.

CONCLUSION

N2 of primary tumours is an independent useful prognostic factor in colorectal liver metastasis and can help determine the indication of surgical resection and pre/post-operative chemotherapy.

Prediction Model for Failure of Nonoperative Management of Uncomplicated Appendicitis in Adults

BACKGROUND

Prediction of failure of nonoperative management (NOM) in uncomplicated appendicitis (UA) is difficult. This study aimed to establish a new prediction model for NOM failure in UA.

METHODS

We included 141 adults with UA who received NOM as initial treatment. NOM failure was defined as conversion to operation during hospitalization. Independent predictors of NOM failure were identified using logistic regression analysis. A prediction model was established based on these independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were used to assess the discrimination and calibration of the model, respectively, and risk stratification using the model was performed.

RESULTS

Among 141 patients, NOM was successful in 120 and unsuccessful in 21. Male sex, maximal diameter of the appendix, and the presence of fecalith were identified as independent predictors of NOM failure for UA. A prediction model with scores ranging from 0 to 3 was established using the three variables (male sex, maximal diameter of the appendix ≥ 15 mm, and the presence of fecalith). The area under the ROC curve for the new prediction model was 0.778, and the model had good calibration (P = 0.476). A score of 2 yielded a sensitivity of 71.4% and a specificity of 90.8%. Patients were stratified into low (0-1), moderate (2), and high (3) risk categories, which had NOM rates of 5.2%, 47.1%, and 77.8%, respectively.

CONCLUSIONS

Our prediction model may predict NOM failure in UA with good diagnostic accuracy and help surgeons select appropriate treatments.

New risk factors of postoperative complications in elective gastrointestinal surgery of elderly patients: a prospective cohort study

BACKGROUND

Gastrointestinal surgery in elderly individuals presents unexpected postoperative complications. However, predicting postoperative complications in elderly patients undergoing gastrointestinal surgeries is challenging because of the lack of a reliable preoperative evaluation system. We aimed to prospectively evaluate three new preoperative assessment methods to predict the postoperative complications in elderly patients undergoing elective gastrointestinal surgery. Moreover, we aimed to identify new risk factors of postoperative complications in this patient group.

METHODS

This prospective cohort study enrolled 189 patients (age ≥ 65 years) who underwent elective gastrointestinal surgery at Tokyo Medical University Hachioji Medical Center between April 2017 and March 2019. Assessments performed preoperatively included the biological impedance analysis for evaluating the skeletal muscle mass, the SF-8 questionnaire for evaluating the subjective health-related quality of life, and the blood pressure/pulse wave test for assessing arteriosclerosis. The risk factors for Clavien-Dindo Grade ≥ III postoperative complications were assessed using these new evaluation methods.

RESULTS

Clavien-Dindo Grade ≥ III postoperative complications were observed in 28 patients (14.8%). Univariate and multivariate analyses identified male sex, low skeletal muscle mass, and cardio-ankle vascular index ≥ 10 (arteriosclerosis) as significant independent risk factors of developing Grade ≥ III complications.

CONCLUSIONS

Male sex, low skeletal muscle mass, and arteriosclerosis were significant risk factors of postoperative complications in elderly patients undergoing elective gastrointestinal surgery. The obtained knowledge could be useful in identifying high-risk patients who require careful perioperative management.

[A Case of Left Transverse Colon Cancer Safely Resected Using Three-Dimensional CT Angiography and Indocyanine Green Fluorography]

A 77-year-old man was admitted to our hospital because of a positive occult blood test result and diagnosed as having left transverse colon cancer(cT2N0M0)on detailed examination. The patient underwent a sigmoidectomy for colon cancer 24 years previously. Three-dimensional(3D)-CT angiography was performed before the present operation. The left branch of the middle colic artery, which was independently branched, and the marginal artery of the colon were found to be supplying blood from the left side of the transverse colon to the anastomosis of the sigmoid colon. In addition, the root of the left branch of the middle colic artery arose from the caudal side of the first jejunal vein. Therefore, a left hemicolectomy was performed. In accordance with the preoperative simulation, we safely resected the left branch of the middle colic artery at the root. Intraoperative blood flow evaluation using indocyanine green(ICG)fluorography clearly displayed the demarcation of the oral blood flow and the point of anastomosis. No notable complications occurred after the surgery. The results of the pathological analyses indicated a pT1bN0M0 tumor stage. Therefore, we conclude that 3D-CT angiography and ICG fluorography are useful for performing safer operations for left transverse colon cancers.

The ability of positron emission tomography/computed tomography to detect synchronous colonic cancers in patients with obstructive colorectal cancer

Positron emission tomography/computed tomography (PET/CT) is frequently used to detect colorectal cancer. The present retrospective study assessed the ability of PET/CT to identify synchronous colonic lesions in 72 patients with obstructive colorectal cancer. All patients had undergone surgical resection without undergoing preoperative total colonoscopy (TCS) at the Digestive Disease Center (April 2007 to September 2016), and subsequently underwent TCS of the proximal colon within 2 years post-surgery. A total of 11 patients exhibited 18F-fluorodeoxyglucose uptake during PET/CT of the proximal colon (4 invasive cancers, 3 advanced adenomas and 4 false-positive results), and 61 patients had no uptake in the proximal colon. Among these 61 patients, postoperative TCS revealed 2 invasive cancers and 4 advanced adenomas. The sensitivity of PET/CT for detecting synchronous invasive cancers was 66.6% (4/6), with a specificity of 89.4% (59/66), a positive predictive value of 36.4% (4/11), a negative predictive value of 96.7% (59/61), and an accuracy of 87.5% (63/72). Negative PET/CT results indicated a low probability of synchronous lesions in the proximal colon. Thus, PET/CT may be a useful tool for detecting synchronous colonic cancers in patients with obstructive colon cancer.

High Serum CA19-9 Concentration Predicts Poor Prognosis in Elderly Patients with Stage IV Colorectal Cancer

BACKGROUND/AIM

The optimal treatment strategy for elderly patients with stage IV colorectal cancer (CRC) remains controversial due to limited research data. The purpose of this study was to evaluate treatment results and to clarify the prognostic factors, especially poor prognosis factors, in elderly patients with stage IV CRC.

METHODS

We retrospectively reviewed the data of 82 elderly patients (aged ≥75 years) with stage IV CRC who underwent surgical treatment at our hospital between April 2001 and March 2017. Factors that affected prognosis and the ability to undergo treatment were analyzed via multivariate analysis.

RESULTS

The median overall survival (OS) in the patients with high pretreatment serum carbohydrate antigen 19-9 (CA19-9) concentration (> 370 U/mL) was significantly worse than in those with lower serum CA19-9 concentration (0-370 U/mL) (8.5 vs. 19.2 months, p = 0.0059). In univariate analysis, age (≥80 years) (p = 0.014), performance status of 1-3 (p = 0.028), and high pretreatment serum CA19-9 concentration (p = 0.014) were significant prognostic factors for poor OS. By contrast, resection of the primary tumor (p = 0.024), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0005) were significant prognostic factors for favorable OS. Multivariate analysis showed that a high pretreatment serum CA19-9 concentration was an independent prognostic factor for poor OS (p = 0.01). Meanwhile, resection of the primary tumor (p = 0.033), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0008) were prognostic factors for favorable OS.

CONCLUSIONS

A high pretreatment serum CA19-9 concentration (> 370 U/mL) was a reliable predictive factor for poor prognosis, and aggressive treatments should be performed carefully in these patients. Moreover, various treatments, including surgery and chemotherapy, might improve OS in elderly patients with stage IV CRC.

Artificial intelligence may help in predicting the need for additional surgery after endoscopic resection of T1 colorectal cancer

BACKGROUND AND STUDY AIMS

Decisions concerning additional surgery after endoscopic resection of T1 colorectal cancer (CRC) are difficult because preoperative prediction of lymph node metastasis (LNM) is problematic. We investigated whether artificial intelligence can predict LNM presence, thus minimizing the need for additional surgery.

PATIENTS AND METHODS

Data on 690 consecutive patients with T1 CRCs that were surgically resected in 2001 - 2016 were retrospectively analyzed. We divided patients into two groups according to date: data from 590 patients were used for machine learning for the artificial intelligence model, and the remaining 100 patients were included for model validation. The artificial intelligence model analyzed 45 clinicopathological factors and then predicted positivity or negativity for LNM. Operative specimens were used as the gold standard for the presence of LNM. The artificial intelligence model was validated by calculating the sensitivity, specificity, and accuracy for predicting LNM, and comparing these data with those of the American, European, and Japanese guidelines.

RESULTS

Sensitivity was 100 % (95 % confidence interval [CI] 72 % to 100 %) in all models. Specificity of the artificial intelligence model and the American, European, and Japanese guidelines was 66 % (95 %CI 56 % to 76 %), 44 % (95 %CI 34 % to 55 %), 0 % (95 %CI 0 % to 3 %), and 0 % (95 %CI 0 % to 3 %), respectively; and accuracy was 69 % (95 %CI 59 % to 78 %), 49 % (95 %CI 39 % to 59 %), 9 % (95 %CI 4 % to 16 %), and 9 % (95 %CI 4 % - 16 %), respectively. The rates of unnecessary additional surgery attributable to misdiagnosing LNM-negative patients as having LNM were: 77 % (95 %CI 62 % to 89 %) for the artificial intelligence model, and 85 % (95 %CI 73 % to 93 %; P < 0.001), 91 % (95 %CI 84 % to 96 %; P < 0.001), and 91 % (95 %CI 84 % to 96 %; P < 0.001) for the American, European, and Japanese guidelines, respectively.

CONCLUSIONS

Compared with current guidelines, artificial intelligence significantly reduced unnecessary additional surgery after endoscopic resection of T1 CRC without missing LNM positivity.

Local control of sphincter-preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

Sphincter‐preserving procedures (SPPs) for surgical treatment of low‐lying rectal tumors have advanced considerably. However, their oncological safety for locally advanced low rectal cancer compared with abdominoperineal resection (APR) is contentious. We retrospectively analyzed cohort data of 1500 consecutive patients who underwent elective resection for stage II‐III rectal cancer between 2010 and 2011. Patients with tumors 2‐5 cm from the anal verge and clinical stage T3‐4 were eligible. Primary outcome was 3‐year local recurrence rate, and confounding effects were minimized by propensity score matching. The study involved 794 patients (456 SPPs and 338 APR). Before matching, candidates for APR were more likely to have lower and advanced lesions, whereas SPPs were carried out more often following preoperative treatment, by laparoscopic approach, and at institutions with higher case volume. After matching, 398 patients (199 each for SPPs and APR) were included in the analysis sample. Postoperative morbidity was similar between the SPPs and APR groups (38% vs 39%; RR 0.98, 95% CI 0.77‐1.27). Margin involvement was present in eight patients in the SPPs group (one and seven at the distal and radial margins, respectively) and in 12 patients in the APR group. No difference in 3‐year local recurrence rate was noted between the two groups (11% vs 14%; HR 0.77, 95% CI 0.42‐1.41). In this observational study, comparability was ensured by adjusting for possible confounding factors. Our results suggest that SPPs and APR for locally advanced low rectal cancer have demonstrably equivalent oncological local control.

Accuracy of diagnosing invasive colorectal cancer using computer-aided endocytoscopy

Background and study aims Invasive cancer carries the risk of metastasis, and therefore, the ability to distinguish between invasive cancerous lesions and less-aggressive lesions is important. We evaluated a computer-aided diagnosis system that uses ultra-high (approximately × 400) magnification endocytoscopy (EC-CAD). Patients and methods We generated an image database from a consecutive series of 5843 endocytoscopy images of 375 lesions. For construction of a diagnostic algorithm, 5543 endocytoscopy images from 238 lesions were randomly extracted from the database for machine learning. We applied the obtained algorithm to 200 endocytoscopy images and calculated test characteristics for the diagnosis of invasive cancer. We defined a high-confidence diagnosis as having a ≥ 90 % probability of being correct. Results Of the 200 test images, 188 (94.0 %) were assessable with the EC-CAD system. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were 89.4 %, 98.9 %, 94.1 %, 98.8 %, and 90.1 %, respectively. High-confidence diagnosis had a sensitivity, specificity, accuracy, PPV, and NPV of 98.1 %, 100 %, 99.3 %, 100 %, and 98.8 %, respectively. Conclusion: EC-CAD may be a useful tool in diagnosing invasive colorectal cancer.

Impact of obesity on short- and long-term outcomes of laparoscopy assisted distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopy assisted distal gastrectomy (LADG) for gastric cancer has been rapidly adopted for the treatment of both early and advanced gastric cancers which need lymph node dissection, but remains difficult procedure, especially in patients with obesity. We evaluated the impact of obesity on short- and long-term outcomes of LADG for gastric cancer.

METHODS

We retrospectively investigated 243 patients who underwent LADG for gastric cancer between January 2007 and December 2014. The patients were classified based on their body mass index (BMI) into the Obese (BMI ≥ 25) and Non-Obese (BMI < 25) Groups. Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the groups.

RESULTS

The groups did not differ in age, sex, American Society of Anesthesiologists score, the presence of comorbidities, or pathologic stage. Operative time (265 ± 46.6 vs. 244 ± 55.6 min; P = 0.007) and estimated blood loss (113 ± 101.4 vs. 66.5 ± 95.2 ml; P = 0.007) were greater in the Obese Group. Fewer lymph nodes were retrieved in the Obese Group (38 ± 23.7 vs. 47.5 ± 24.3; P = 0.004). No differences were evident in postoperative complication rate (20% vs. 17%; P = 0.688) or the duration of postoperative hospital stay (9 ± 8.5 vs. 9 ± 5.1 days; P = 0.283) between the two groups. In the Obese Group, the 5-year overall survival rate was significantly lower than in the Non-Obese Group (67.6% vs. 90.3%; P = 0.036). Furthermore, 5-year disease-specific survival was significantly lower in the Obese Group than in the Non-Obese Group (72.7% vs. 94.9%; P = 0.015).

CONCLUSIONS

LADG in patients with obesity could be performed as safe as in patients without obesity, with comparable postoperative results. But obesity may be a poor prognostic factor in gastric cancer.

Retrospective analysis of large bowel obstruction or perforation caused by oral preparation for colonoscopy

BACKGROUND AND STUDY AIMS

 Patients undergoing bowel preparation for colonoscopy are at risk of potentially severe adverse events such as large-bowel obstruction (LBO) and perforation. These patients usually need emergency surgery and the consequences may be fatal. Little is known about the risk factors for LBO and perforation in these circumstances. We sought to establish the natural history of LBO and perforation caused by oral preparation for colonoscopy.

PATIENTS AND METHODS

 We retrospectively analyzed data from 20 patients with LBO or perforation associated with oral preparation for colonoscopy. All patients were treated at the Showa University Northern Yokohama Hospital (SUNYH) between April 2001 and December 2015. Drugs used for bowel preparation, age, sex, indication for colonoscopy, pathogenesis and treatment were recorded.

RESULTS

 Eighteen of the patients had LBO and 2 had perforation. Fourteen events occurred at SUNYH, which accounted for 0.016 % of patients who underwent bowel preparation during this period. Seventeen patients were symptomatic when the decision to undertake colonoscopy was made (including 7 who complained of constipation and 4 who complained of abdominal pain; 3e were asymptomatic). Nineteen patients ultimately required surgery, 13 within 3 days of presentation. Eleven patients ultimately required colostomy. There was no perioperative mortality in our cases.

CONCLUSION

 Large bowel obstruction and perforation are rare events associated with oral preparation for colonoscopy, but frequently require surgery. Exacerbation of constipation might be a risk factor for LBO or perforation. Potentially catastrophic situations can be avoided by early detection and treatment.

'Head Invasion' Is Not a Metastasis-Free Condition in Pedunculated T1 Colorectal Carcinomas Based on the Precise Histopathological Assessment

BACKGROUND/AIM

Previous reports stated that pedunculated T1 colorectal carcinomas with 'head invasion' showed almost no nodal metastasis, requiring endoscopic treatment alone. However, clinically, some lesions develop nodal metastasis. We aimed to validate the necessity of distinguishing between 'pedunculated' and 'non-pedunculated' lesions, and also between 'head' and 'stalk' invasions.

METHODS

Initial or additional surgery with lymph node dissection was performed in 76 pedunculated and 594 non-pedunculated cases. Among pedunculated lesions, the baseline was defined as the junction line between normal and neoplastic epithelium (Haggitt's level 2). The degree of invasion was classified as 'head invasion' (above the baseline) or 'stalk invasion' (beyond the baseline). Clinicopathological factors were analyzed with respect to nodal metastasis.

RESULTS

Nine of 76 (11.8%) pedunculated cases and 52/594 (8.8%) non-pedunculated cases developed nodal metastasis (p = 0.40). No significant differences were found in the rate of nodal metastasis between 'head invasion' (4/30, 13.3%) and 'stalk invasion' (5/46, 10.9%). All the 4 cases with 'head invasion' had at least one pathological factor.

CONCLUSIONS

'Head invasion' was not a metastasis-free condition. Even for pedunculated T1 cancers with 'head invasion', additional surgery with lymph node dissection should be considered if these have pathological risk factors.

Fecal Volume after Laparoscopic Low Anterior Resection Predicts Anastomotic Leakage

BACKGROUND/AIM

Anastomotic leakage (AL) is a major complication after laparoscopic low anterior resection (Lap-LAR). Many surgeons encounter AL following severe postoperative diarrhea. However, little is known about the relationship between postoperative fecal volume and AL. This study determined whether postoperative fecal volume can predict AL.

METHODS

A retrospective assessment was performed with data from 176 patients with rectal cancers who underwent Lap-LAR between April 2011 and August 2015. A transanal tube was routinely placed in all cases. The fecal volume from the transanal tube was measured daily. The total fecal volume for 3 days after surgery was compared between the AL and non-AL groups.

RESULTS

AL occurred in 11 patients. There were 3 patients with a fecal volume ≥1,000 mL for 3 days after surgery. AL occurred in these 3 patients. In patients with a fecal volume <1,000 mL, the total fecal volume was significantly greater in the AL group than that in the non-AL group (p = 0.0003). The cut-off value of the total fecal volume in AL was 118 mL.

CONCLUSIONS

The volume of fecal discharge for 3 days after surgery is associated with the incidence of AL, and a fecal volume ≥118 mL may be a reliable predictor for AL.

Comparative clinicopathological characteristics of colon and rectal T1 carcinoma

Lymph node metastasis significantly influences the management of patients with colorectal carcinoma. It has been observed that the biology of colorectal carcinoma differs by location. The aim of the current study was to retrospectively compare the clinicopathological characteristics of patients with colon and rectal T1 carcinomas, particularly their rates of lymph node metastasis. Of the 19,864 patients who underwent endoscopic or surgical resection of colorectal neoplasms at Showa University Northern Yokohama Hospital, 557 had T1 surgically resected carcinomas, including 457 patients with colon T1 carcinomas and 100 patients with rectal T1 carcinomas. Analysed clinicopathological features included patient age, gender, tumor size, morphology, tumor budding, invasion depth, vascular invasion, histological grade, lymphatic invasion and lymph node metastasis. Rectal T1 carcinomas were significantly larger than colon T1 carcinomas (mean ± standard deviation: 23.7±13.1 mm vs. 19.9±11.0 mm, P<0.01) and were accompanied by significantly higher rates of vascular invasion (48.0% vs. 30.2%, P<0.01). Significant differences were not observed among any other clinicopathological factors. In conclusion, tumor location itself was not a risk factor for lymph node metastasis in colorectal T1 carcinomas, even though on average, rectal T1 carcinomas were larger and accompanied by a significantly higher rate of vascular invasion than colon T1 carcinomas.

Positive detection of exfoliated colon cancer cells on linear stapler cartridges was associated with depth of tumor invasion and preoperative bowel preparation in colon cancer

BACKGROUND

The aim of this study was to investigate exfoliated cancer cells (ECCs) on linear stapler cartridges used for anastomotic sites in colon cancer.

METHODS

We prospectively analyzed ECCs on linear stapler cartridges used for anastomosis in 100 colon cancer patients who underwent colectomy. Having completed the functional end-to-end anastomosis, the linear stapler cartridges were irrigated with saline, which was collected for cytological examination and cytological diagnoses were made by board-certified pathologists based on Papanicolaou staining.

RESULTS

The detection rate of ECCs on the linear stapler cartridges was 20 %. Positive detection of ECCs was significantly associated with depth of tumor invasion (p = 0.012) and preoperative bowel preparation (p = 0.003). There were no marked differences between ECC-positive and ECC-negative groups in terms of the operation methods, tumor location, histopathological classification, and surgical margins.

CONCLUSIONS

Since ECCs were identified on the cartridge of the linear stapler used for anastomosis, preoperative mechanical bowel preparation using polyethylene glycol solution and cleansing at anastomotic sites using tumoricidal agents before anastomosis may be necessary to decrease ECCs in advanced colon cancer.

Positive detection of exfoliated colon cancer cells on linear stapler cartridges was associated with depth of tumor invasion and preoperative bowel preparation in colon cancer

Background

The aim of this study was to investigate exfoliated cancer cells (ECCs) on linear stapler cartridges used for anastomotic sites in colon cancer.

Methods

We prospectively analyzed ECCs on linear stapler cartridges used for anastomosis in 100 colon cancer patients who underwent colectomy. Having completed the functional end-to-end anastomosis, the linear stapler cartridges were irrigated with saline, which was collected for cytological examination and cytological diagnoses were made by board-certified pathologists based on Papanicolaou staining.

Results

The detection rate of ECCs on the linear stapler cartridges was 20 %. Positive detection of ECCs was significantly associated with depth of tumor invasion (p = 0.012) and preoperative bowel preparation (p = 0.003). There were no marked differences between ECC-positive and ECC-negative groups in terms of the operation methods, tumor location, histopathological classification, and surgical margins.

Conclusions

Since ECCs were identified on the cartridge of the linear stapler used for anastomosis, preoperative mechanical bowel preparation using polyethylene glycol solution and cleansing at anastomotic sites using tumoricidal agents before anastomosis may be necessary to decrease ECCs in advanced colon cancer.

Spontaneously ruptured hepatic cyst treated with laparoscopic deroofing and cystobiliary communication closure: A case report

The rupture of a nonparasitic hepatic cyst with biliary communication is rare. We report the case of a patient with a hepatic cyst with biliary communication that spontaneously ruptured and was successfully treated by laparoscopic deroofing and closure of the communication. A 61-year-old woman presented at our hospital with a chief complaint of right upper abdominal pain. Enhanced abdominal CT showed a collapsed hepatic cyst and fluid collection. Drip infusion CT cholangiography showed contrast medium pooling in the collapsed cyst. Therefore, hepatic cyst rupture with biliary communication was diagnosed, and laparoscopic deroofing and closure of the communication were performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. In cases of hepatic cyst rupture, even in the presence of biliary communication, laparoscopic deroofing and closure of the communication should be recommended as the first-choice treatment.

Morphology as a risk factor for the malignant potential of T2 colorectal cancer

Currently, depressed type T1 colorectal cancer is often detected and its malignant potential is being revealed. However, few reports have focused on the morphology of T2 colorectal cancer types. The aim of the present retrospective study was to clarify the characteristics of colorectal T2 cancer types derived from depressed type T1 cancer. The present study included 195 patients with colorectal T2 cancer surgically resected at a referral hospital between April 2001 and April 2009. A total of 48 lesions (25%) with lymph node metastasis and 4 (2%) with distant metastasis were found. The lesions were classified by their form during endoscopy into four categories: Group A, depressed type (the periphery consists of normal mucosa); group B, laterally spreading type; group C, protruded type; group D, ulcerative type (the periphery consists of neoplastic mucosa). Tumor size, lymphatic and venous involvement, lymph node metastasis, and distant metastasis were compared between the four categories. The distribution of patients were as follows: Group A, 73 (37%), group B, 26 (13%), group C, 24 (12%) and group D, 72 (37%). The average tumor size for each category was 23, 51, 30 and 36 mm for groups A, B, C and D, respectively. The number of positive findings for lymphatic involvement, venous involvement, lymph node metastasis and distant metastasis for each category were: Group A, 50 (69%), 54 (74%), 19 (26%) and 1 (1%); group B, 14 (54%), 12 (46%), 8 (31%) and 0 (0%); group C, 14 (58%), 8 (33%), 6 (25%) and 0 (0%); group D 35 (49%), 41 (57%), 16 (22%) and 3 (4%). Group A demonstrated a significantly smaller tumor size (P<0.01), and higher rates of lymphatic and venous involvement (P=0.0333 and P=0.0019, respectively). No significant differences were observed between categories with regards to nodal and distant metastases. Of the T2 cancer types, ~40% were the depressed type. Compared with the other forms, depressed type lesions exhibited a smaller tumor size, and higher rates of lymphatic and venous involvement, which suggested these lesions were of a more malignant nature.

Donor Left-Sided Heptectomy by Use of the Real-Time Moving Windows Method With 8-Centimeter Transverse Skin Incision

BACKGROUND

In this study, we demonstrated our new device for open donor liver surgery with left-sided heptectomy by use of the real-time moving windows (RTMW) method with 8-cm transverse skin incision for living donors from the viewpoints of cosmetic, economic, and safety procedures.

METHODS

After the upper abdominal 8-cm transverse skin incision was made, the subcutaneous area was exfoliated and the reverse T-shaped-abdominal incision was made, as in open surgery. After that, the 2 Kent hooks for the upper region and the 2 surgical arms for the lower region were placed. The operative fields of hepatic vein, hepatic hilus, and common hepatic artery were explored, respectively, by use of the RTMW method with the use of the 4 surgical hooks. Hepatic parenchymal dissection was carried out with the use of CUSA and laparosonic coagulating shears. Manipulations of 3 hepatic vessels and the hepatic duct were done by the usual procedure of open surgery.

RESULTS

This operative procedure could be performed without laparoscopic techniques. The operative time was 7 hours, without blood transfusion. The operative course was uneventful, and the patient was discharged on postoperative day 11.

CONCLUSIONS

Our RTMW method for donor left-sided hepatectomy is considered to be a useful operative procedure from the viewpoints of donor safety, cosmetic advantage, and cost performance.

Management of T1 colorectal cancers after endoscopic treatment based on the risk stratification of lymph node metastasis

BACKGROUND AND AIM

Recent advances in endoscopic technology have allowed many T1 colorectal carcinomas to be resected endoscopically with negative margins. However, the criteria for curative endoscopic resection remain unclear. We aimed to identify risk factors for nodal metastasis in T1 carcinoma patients and hence establish the indication for additional surgery with lymph node dissection.

METHODS

Initial or additional surgery with nodal dissection was performed in 653 T1 carcinoma cases. Clinicopathological factors were retrospectively analyzed with respect to nodal metastasis. The status of the muscularis mucosae (MM grade) was defined as grade 1 (maintenance) or grade 2 (fragmentation or disappearance). The lesions were then stratified based on the risk of nodal metastasis.

RESULTS

Muscularis mucosae grade was associated with nodal metastasis (P = 0.026), and no patients with MM grade 1 lesions had nodal metastasis. Significant risk factors for nodal metastasis in patients with MM grade 2 lesions were attribution of women (P = 0.006), lymphovascular infiltration (P < 0.001), tumor budding (P = 0.045), and poorly differentiated adenocarcinoma or mucinous carcinoma (P = 0.007). Nodal metastasis occurred in 1.06% of lesions without any of these pathological factors, but in 10.3% and 20.1% of lesions with at least one factor in male and female patients, respectively. There was good inter-observer agreement for MM grade evaluation, with a kappa value of 0.67.

CONCLUSIONS

Stratification using MM grade, pathological factors, and patient sex provided more appropriate indication for additional surgery with lymph node dissection after endoscopic treatment for T1 colorectal carcinomas.

Comparison of the endocytoscopic and clinicopathologic features of colorectal neoplasms

BACKGROUND AND AIM

Permeation of a vein or lymphatic vessel by a tumor is a key risk factor for lymph node metastasis. We examined the features of colorectal tumor vessel permeation using endocytoscopy, an ultra-high magnifying endoscopic system combined with a narrow-band imaging capability (EC-NBI).

PATIENTS AND METHODS

We examined 188 colorectal lesions using EC-NBI before treatment was started. We measured the diameters of tumor vessels on EC-NBI images. We used the tumor vessel diameter (the mean diameter of four tumor-associated vessels) and the variation in tumor vessel caliber (the difference between the maximum and minimum diameters of the vessels expressed as a proportion) to judge changes in vessel formation. We examined the relationship between these variables and the extent of venous or lymphatic vessel permeation (vessel invasion) established by immunohistochemical examination of the resected specimen using monoclonal antibodies against the CD34 and D2 - 40 antigens. We also analyzed the relationships between tumor vessel diameter, tumor vessel caliber variation, and depth of tumor invasion.

RESULTS

There were significant differences in tumor vessel diameter and caliber variation between tumors in situ and T1 - T3 carcinomas. In T1 carcinomas, larger tumor vessel diameter and greater tumor vessel caliber variation were significantly associated with venous permeation. In T2 and T3 carcinomas, greater tumor vessel caliber variation was significantly associated with venous permeation.

CONCLUSIONS

The vessel diameter and caliber variation of colorectal tumor microvasculature are associated with depth of invasion and venous permeation, especially in T1 carcinomas.

Factors related to allergic transfusion reactions and febrile non-haemolytic transfusion reactions in children

BACKGROUND AND OBJECTIVES

Allergic transfusion reactions (ATRs) and febrile non-haemolytic transfusion reactions (FNHTRs) are the two major types of transfusion-related adverse reactions (TRARs). Although prestorage leucocyte reduction and diversion of the first aliquot of blood (LR/D) could reduce FNHTRs and bacterial contamination in adult transfusion, ATRs are still problematic. In addition, there is little information about TRARs in paediatric population.

MATERIALS AND METHODS

We conducted a single-centre retrospective analysis of all transfusions, except washing products, and TRARs for 153 months to evaluate related factors such as delivery of treatment and the characteristics of recipients.

RESULTS

Most TRARs were FNHTRs and/or ATRs in children. In delivering blood products with LR/D, the frequencies of not only FNHTRs but also ATRs were significantly reduced with both platelet concentrates (PCs) and red cell concentrates (RCCs). TRARs of fresh-frozen plasma were infrequent in children. In addition, even after the introduction of LR/D, ATRs were significantly more frequent in patients with primary haematological and malignant diseases who received PCs and RCCs, older patients who received PCs and patients who received frequent RCCs.

CONCLUSION

These results suggest that leucocytes or mediators from leucocytes are underlying cause of ATRs in addition to FNHTRs in children. Furthermore, particular characteristics of patients would be other risk factors for ATRs.

Practical problems of measuring depth of submucosal invasion in T1 colorectal carcinomas

PURPOSE

Submucosal invasion depth (SID) in colorectal carcinoma (CRC) is an important factor in estimating risk of lymph node metastasis, but can be difficult to measure, leading to inadequate or over-extensive treatment. Here, we aimed to clarify the practical aspects of measuring SID in T1 CRC.

METHODS

We investigated 568 T1 CRCs that were resected surgically at our hospital from April 2001 to December 2013, and relationships between SID and clinicopathological factors, including the means of measurement, lesion morphology, and lymph node metastasis.

RESULTS

Of these 568 lesions, the SID was ≥1000 μm in 508 lesions. SIDs for lesions measured from the surface layer were all ≥1000 μm. Although lesions with SIDs ≥1000 μm were associated with significantly higher levels of unfavorable histologic types and lymphovascular infiltration than shallower lesions, a depth of ≥1000 μm was not a significant risk factor for lymph node metastasis (LNM) (6.7 vs. 9.8 %; P = 0.64), and no lesions for which the sole pathological factor was SID ≥1000 μm had lymph node metastasis. Protruded lesions showed deeper SIDs than other types.

CONCLUSIONS

Although we found several problems of measuring SID in this study, we also found, surprisingly, that SID is not a risk factor for lymph node metastasis, and its measurement is not needed to estimate the risk of lymph node metastasis.

Laparoscopic surgery for sigmoidocutaneous fistula due to diverticulitis: A case report

Sigmoidocutaneous fistulas due to sigmoid colon diverticulitis are very rare. Here we report a case in which laparoscopic sigmoidectomy was used to successfully treat a sigmoidocutaneous fistula due to diverticulitis. A 41-year-old man was admitted to our hospital because of redness and swelling of the left inguinal skin. Enhanced abdominal CT revealed a subcutaneous abscess in the left lower abdomen. Percutaneous drainage was performed, and fistulography revealed a fistula between the sigmoid colon and left inguinal skin. Therefore, a sigmoidocutaneous fistula was diagnosed, and laparoscopic sigmoidectomy and fistulectomy were performed. The sigmoid colon had several diverticula, and a pathological examination revealed that the sigmoidocutaneous fistula was due to diverticulitis. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. In cases of sigmoidocutaneous fistula, laparoscopic treatment can be safely performed.

Tumor Diameter is an Easy and Useful Predictor of Recurrence in Stage II Colorectal Cancer

BACKGROUND/AIMS

Adjuvant chemotherapy for stage II colorectal cancer (CRC) can generally be administered to high-risk subgroups. To better identify these patients, we aimed at assessing factors that affect recurrence.

METHODS

In our hospital, 432 colon and 96 rectal stage II cancer patients who underwent surgical resection between 2001 and 2011 were divided into recurrence and non-recurrence groups. Age, sex, lymphatic vessel invasion, venous invasion, tumor diameter, tumor depth, histological type, preoperative carcinoembryonic antigen level, number of sampled nodes, adjuvant chemotherapy, morphology, surgical approach, anastomotic leakage, preoperative bowel obstruction, and preoperative perforation were retrospectively compared between the groups.

RESULTS

For colon cancer, multivariate analysis revealed a significant association between tumor diameter ≥40 mm and recurrence (p = 0.039). For rectal cancer, multivariate analysis revealed that tumor diameter ≥50 mm (p = 0.001) and ≤12 sampled nodes (p = 0.021) were associated with recurrence. Tumor diameter in rectal cancer was associated with worse disease-free survival (p = 0.026).

CONCLUSION

Tumor diameter is a significant predictor of recurrence in stage II CRC. This is an important finding because tumor diameter is easy to evaluate clinically and might help to identify candidates for adjuvant chemotherapy.

Transverse colon cancer occurring at a colostomy site 35 years after colostomy: a case report

Background

Carcinomas occurring at colostomy sites are rare, and most of these are metachronous colorectal cancers. The median time between colostomy and development of a carcinoma at a colostomy site is 22 years, which exceeds the length of the recommended follow-up period. We report a rare case of a carcinoma of the transverse colon occurring at a colostomy site in a patient without a history of colorectal cancer.

Case report

An 89-year-old woman presented with a tumor occurring at a colostomy site. Thirty-five years previously, she had undergone a transverse loop colostomy for an iatrogenic colon perforation that occurred during left ureteral lithotomy. Upon physical examination, the patient had a hard nodule measuring 3 cm at the colostomy site. A biopsy of the nodule suggested adenocarcinoma, and the preoperative diagnosis was transverse colon cancer. A laparotomy was performed via a peristomal incision with 5-mm skin margins, and the tumor was covered by a surgical glove to avoid any tumor seeding. The colon was separated from the tumor by 5-cm margins, and the specimen was removed en bloc. An end colostomy was constructed to a new site on the right side of the abdomen. The deficit in the abdominal wall was repaired, and the skin was closed via a purse-string suture. The final diagnosis of the stoma tumor was transverse colon cancer (T2, N0, M0, stage I). One year and five months after surgery, there was no evidence of recurrence.

Conclusions

The occurrence of carcinomas at colostomy sites in patients without a history of colorectal cancer is rare. It is important to train ostomates to monitor the stoma for possible tumor recurrence.

Efficacy of transanal tube for prevention of anastomotic leakage following laparoscopic low anterior resection for rectal cancers: a retrospective cohort study in a single institution

BACKGROUND

Anastomotic leakage is one of the most serious complications following laparoscopic low anterior resection (LAR) for rectal cancers. The purpose of this study was to investigate whether transanal tube placement can reduce anastomotic leakage following laparoscopic LAR.

METHODS

Retrospective assessment was performed on 205 patients with rectal cancers who underwent laparoscopic LAR. A transanal tube was placed after anastomosis in 96 patients (group A). Another 109 patients were operated on without a transanal tube (group B). Clinicopathological and operative variables, the frequencies of anastomotic leakage and re-operation after leakage were investigated.

RESULTS

Patient age, gender, body mass index, tumor size, Dukes' stage, intra-operative blood loss, and the rate of left colic artery preservation were comparable between the two groups. Tumor location was lower and operative time was significantly longer in group A than group B (p < 0.001). Overall rate of leakage was 9.3 % (19/205). The frequency of leakage was 4.2 % (4/96) in group A and was 13.8 % (15/109) in group B. The rate of leakage was significantly lower in group A (p < 0.05). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 0 % (0/4) in group A, while in contrast it was 73.3 % (10/15) in group B. The rate of re-operation was lower in group A than group B (p < 0.05) and all cases with symptomatic leakage in group A were cured by conservative treatment.

CONCLUSIONS

Transanal tube placement was effective for prevention of anastomotic leakage following laparoscopic LAR and avoiding re-operation after symptomatic leakage.

[A case of severe enteritis induced by adjuvant chemotherapy for colon cancer]

A 77-year-old man underwent surgery for sigmoid colon cancer. He was diagnosed with Stage IIIa colon cancer; there- fore, we initiated oral administration of adjuvant chemotherapy comprising uracil/tegafur(UFT)plus Leucovorin(LV). However, chemotherapy was stopped after 21 days because of fatigue and diarrhea. He recovered after 3 weeks, and we administered the same regimen with a dose reduction. However, he again experienced fatigue and diarrhea after 20 days; therefore, chemotherapy was discontinued. Subsequently, he was hospitalized 8 times for conditions such as diarrhea, hypoalbuminemia, and fever. Computed tomography revealed thickening of the transverse colonic wall and colonoscopy revealed colitis, which we believe was induced by UFT plus LV. Twelve months after the last chemotherapy session, he was diagnosed with Clostridium difficile colitis. Therefore, we initiated the oral administration of vancomycin, which resulted in rapid recovery from colitis. However, he developed liver metastasis and died 29 months after the initiation of chemotherapy. We believe that this severe case of intractable colitis was caused by UFT plus LV. Therefore, we report this case with a review of the literature on enteritis induced by fluorouracil-based anticancer agents in Japan.

Complete laparoscopic surgery for early colorectal cancer after endoscopic resection

INTRODUCTION

Laparoscopic-assisted colorectal surgery requires a mini-laparotomy to extract the specimen and insert the anvil head of the circular stapler into the proximal colon. However, such a mini-laparotomy occasionally causes local pain and surgical-site infection. To avoid mini-laparotomy, we invented a new laparoscopic technique, complete laparoscopic surgery for colorectal cancer.

MATERIALS AND SURGICAL TECHNIQUE

Sigmoid colon or rectal cancer patients who had undergone colonoscopic excision for T1 cancer and subsequently required bowel resection due to unfavorable histology were recruited. This new procedure used both the double stapling technique and the rectal-prolapsing technique, where the anvil was transanally inserted into the proximal colon and bowel resection was extracorporeally performed after pulling out the colon-rectum via the anus.

DISCUSSION

This procedure was attempted in 17 patients and successfully achieved in 13 patients. Total laparoscopic colorectal surgery has some problems such as bacterial contamination or infection, as well as dissemination caused by intraluminal exfoliated cancer cells. This procedure is limited to post-endoscopic resection patients who are suited for reconstruction by double stapling technique, and it may be impossible in patients with thick mesentery or anal stenosis. Moreover, this method resolves issues of peritoneal contamination and dissemination. However, a new protection method for implantation of exfoliated cancer cells needs to be established, so that complete laparoscopic surgery can be employed in patients with small cancers.

[A case of cecal cancer with abdominal wall abscess]

A 63-year-old woman was admitted to our hospital for a palpable mass and abdominal pain. Abdominal CT showed an abscess in the abdominal wall and a contiguous mass in the intraperitoneal cavity. After drainage of the abscess was performed, we conducted a colonoscopy to investigate the cause of the mass. It revealed a type 2 tumor and a whole-circumferential stenosis in the cecum. It required preoperative chemotherapy with CPT-11 and S-1 to achieve radical cure characteristics with the operation. Because there was tumor reduction, right hemicolectomy and resection of the abdominal wall were performed. The patient was discharged 15 days after the operation with an eventful clinical course. Although 5 years have passed since the operation, she is alive and has had no recurrence. This patient accepted tumor reduction by chemotherapy , and the abdominal wall deficit that resulted from excision did not have it was it with a small range, and to rebuild the abdominal wall. The utility of preoperative chemotherapy is recommended in colon cancer which invades other organs.

[A case or resection of synchronous multiple liver metastases from rectal cancer after FOLFOX4 therapy]

A 7 0-year-old man with multiple liver metastases from rectal cancer was admitted to our hospital. From imaging inspection, a resection was determined to be difficult, so he was treated with FOLFOX4 therapy. After ten courses of FOLFOX4, the liver metastases showed 52% reduction in size and were judged to be PR. Therefore low anterior resection of the rectum, left lobectomy of the liver and partial resection of the liver(S7, S8)were performed. He was able to undergo curative surgery after FOLFOX4 therapy.

First case of bacteremia due to chromosome-encoded CfxA3-beta-lactamase-producing Capnocytophaga sputigena in a pediatric patient with acute erythroblastic leukemia

Bacteremia due to Capnocytophaga sputigena occurred in a 4-year and 9-month-old Japanese girl patient with acute erythroblastic leukemia in Shinshu University Hospital, Japan. On her admission to the hospital, she had a temperature of 38.2 degrees C with canker sore. Prior to the commencement of chemotherapy, peripheral blood culture was carried out with the BacT/Alert 3D System ver. 4.00D (bioMerieux Japan Ltd., Tokyo, Japan) using both the PF and the SN bottles. At 48 hrs of incubation, the System showed the positive sign only in the anaerobic SN bottle for bacterial growth. The strain isolated from the SN bottle was morphologically, biochemically, and genetically characterized, and finally identified as Capnocytophaga sputigena. The causative Capnocytophaga sputigena isolate was found to be a beta-lactamase-producer demonstrating to possess cfxA3 gene. The gene responsible for the production of CfxA3-beta-lactamase was proved to be chromosome-encoded, by means of southern hybridization analysis. This was the first case of bacteremia caused by chromosome-encoded CfxA3-beta-lactamase-producing Capnocytophaga sputigena.

Real-time in vivo virtual histology of colorectal lesions when using the endocytoscopy system

BACKGROUND

The histological findings of GI lesions are based on light-microscopic examination of H&E-stained thin-slice specimens. Recently, a concept of optical biopsy has been advocated. A study of the observation of colorectal lesions using endocytoscopy to obtain real-time histological images in vivo during endoscopy was performed.

DESIGN

Prospective study.

AIM

To evaluate the usefulness of optical biopsy of colorectal lesions with the endocytoscopy (E-C) system.

PATIENTS

The subjects were 113 consecutive patients who underwent a complete colonic examination, from April 2003 to March 2004, performed by a single colonoscopist.

SETTING

Digestive Disease Center of Showa University Northern Yokohama Hospital.

RESULTS

With E-C, it was possible to observe lesions at the cellular level and evaluate cellular atypia in addition to structural atypia in vivo. The correlation was statistically significant between the endocytoscopic diagnosis and the histological diagnosis.

LIMITATIONS

The endocytoscope had to be touched to the target colonic glands.

CONCLUSIONS

It was possible to distinguish neoplastic from non-neoplastic lesions, and also possible to distinguish invasive cancer from adenoma. "Ultra-high" magnifying endoscopy, the E-C system, provides real-time histological images in vivo, which correspond well with those of H&E-stained microscopic images.

Laparoscopic sentinel node mapping for colorectal cancer using infrared ray laparoscopy

BACKGROUND

Sentinel lymph node (SN) mapping by dye injection on conventional laparoscopy (CL) is often precluded by the presence of mesenteric adipose tissue in patients with colorectal cancer. SN mapping on CL was compared with that on infrared ray laparoscopy (IRL) during laparoscopy-assisted colectomy (LAC).

PATIENTS AND METHODS

Forty-eight patients with colorectal cancer who underwent LAC were enrolled. The tumor was identified by intra-operative fluoroscopy with marking clips. The tumor was stained intra-operatively by peritumoral injection of indocyanine green dye. SNs were observed by CL and by IRL.

RESULTS

In all 48 patients, dye injection and tumor localization during LAC were successful. The identification of SNs on IRL was approximately five times better than that on CL. There were no false-negative cases in T1 and T2 disease by IRL.

CONCLUSION

SN mapping on IRL is superior to that on CL. SN mapping by IRL might be feasible for T1 and T2 tumors.

Chromosomal change during 6-mercaptopurine (6-MP) therapy in juvenile myelomonocytic leukemia: the growth of a 6-MP-refractory clone that already exists at onset

Among 11 JMML children, two had an abnormal karyotype, and nine had a normal karyotype at onset. In one patient with trisomy 8 and four patients with a normal karyotype, a new clone with an aberrant karyotype emerged 1-14 months after 6-mercaptopurine (6-MP) therapy as shown by G-banding analyses. Fluorescence in situ hybridization disclosed that an abnormal clone existed in approximately 3-6% of bone marrow cells at onset or before 6-MP therapy in all the four cases examined, and increased to approximately 12-90% during the treatment. In culture with granulocyte-macrophage colony-stimulating factor, cytogenetically abnormal clones that proliferated during 6-MP therapy possessed significantly less sensitivity to the antimetabolite, compared with cells that decreased in numbers after the therapy. A PTPN11 mutation was detected in all of granulocyte-macrophage colonies irrespective of karyotypic aberration in one patient, whereas approximately 80% of erythroid colonies and 20% of mixed colonies possessed neither a PTPN11 mutation nor chromosomal abnormalities. The appearance of chromosomal aberrations shown by G-banding during 6-MP therapy in some JMML cases may result, in part, from the growth of a 6-MP-refractory clone that already exists at onset. It is possible that treatment with 6-MP promotes progression of the disease.

Internal hernia through the mesenteric opening after laparoscopy-assisted transverse colectomy

We report a case of a rare complication in laparoscopic colectomy. A 55-year-old woman underwent a laparoscopy-assisted transverse colectomy for transverse colon cancer. On the 5th postoperative day, she developed bowel obstruction. Decompression by a long intestinal tube failed to resolve the bowel obstruction. She underwent operative intervention. Abdominal exploration showed jejunal loop caused by a strangulation forming on an internal hernia through the mesenteric opening at the anastomotic colonic stumps, which had not been sutured during the previous operation. Our experience might indicate the need for closure of small mesenteric opening after laparoscopic colectomy.

Virtual histology of colorectal lesions using laser-scanning confocal microscopy

BACKGROUND AND STUDY AIMS

Histological examination of gastrointestinal lesions is currently based on light-microscopic examination of thin-slice specimens, with hematoxylin and eosin staining. A study of the use of laser-scanning confocal microscopy (LCM) to obtain immediate microscopic images of untreated specimens for examining colorectal lesions was carried out. A probe-type LCM prototype endomicroscope that can be passed through the working channel of an endoscope has also been developed.

MATERIALS AND METHODS

The study materials consisted of colorectal lesions resected either endoscopically or surgically at Showa University Northern Yokohama Hospital. One hundred untreated specimens were examined using LCM. The histopathological findings in the lesions were seven cases of normal colonic mucosa, five hyperplastic polyps, 68 adenomas with low-grade dysplasia, 10 adenomas with high-grade dysplasia, and 10 adenocarcinomas. An argon laser beam with a wavelength of 488 nm was used for the LCM study. Observation of the resected normal colonic mucosa (in vitro) and the rectal mucosa of a healthy volunteer (in vivo) was possible using the endomicroscope. The LCM images for each specimen were compared with the hematoxylin-eosin-stained histopathological cross-sections.

RESULTS

The LCM images corresponded well with the conventional hematoxylin-eosin light-microscopic images. The nuclei were not visualized in normal mucosa or hyperplastic polyps. In adenomas with high-grade dysplasia and carcinomas, nuclei were more often visible than in adenomas with low-grade dysplasia. The rate of visualization of nuclei was significantly different ( P < 0.01) between these two groups (60.0 % vs. 10.3 %). In LCM images using endomicroscope, it was possible to recognize the orifices of the colonic glands and goblet cells both in vitro and in vivo.

CONCLUSIONS

Laser-scanning confocal microscopy provides immediate images that correspond well with those of hematoxylin-eosin staining. An improved probe-type LCM endomicroscope is being developed which should provide better histological images of colorectal lesions in vivo.

Development of virtual histology and virtual biopsy using laser-scanning confocal microscopy

The aim of this project is to acquire a direct image of histology from in vivo gastrointestinal mucosa. In other words, the task of 'endo-microscope' is to observe the cellular architecture of tissue in vivo during routine endoscopic examination. As the first step to completing this study, resected fresh specimens from the oesophagus. stomach and colon were examined by laser-scanning confocal microscopy (LCM) (Fluoview, Olympus, Tokyo). Fresh untreated mucosal specimens obtained by endoscopic pinch biopsy, polypectomy or endoscopic mucosal resection were collected and placed in normal saline and examined by LCM, collecting the reflective light of a 488-nm wavelength argon laser beam. As the second step, a probe-type LCM 'endo-microscope' was designed and applied to observe the human oral-cavity mucosa. The probe has 4.5-mm outer diameter and 20-cm length, which enables easy access to oral cavity mucosa. The estimated special resolution of the probe is 1-5 microm. A real-time microscopic image directly from ex vivo fresh specimens was acquired. The acquired LCM images corresponded well with the conventional H-E light microscopic images. Cell wall, nucleus and cytoplasm were simultaneously visualized by LCM scanning. This novel method enables serial imaginary microscopic sections on fresh specimens. In addition, a probe-type LCM 'endo-microscope' was designed and was applied to observe human oral cavity mucosa. Virtual histological images from the living oral squamous cell were successfully obtained. LCM images from ex vivo fresh specimens demonstrated the features of the H-E staining histological image. In the next step to accomplish our project, we developed a LCM probe with 4.5-mm outer diameter to obtain a virtual image of human oral cavity mucosa.