Novel Advances in Qualitative Diagnostic Imaging for Decision Making in Multidisciplinary Treatment for Advanced Esophageal Cancer

Background: Recently, neoadjuvant therapy and the succeeding surgery for advanced esophageal cancer have been evaluated. In particular, the response to the therapy has been found to affect surgical outcomes, and thus a precise evaluation of treatment effect is important for this strategy. In this study, articles on qualitative diagnostic modalities to evaluate tumor activities were reviewed, and the diagnostic indices were examined. Methods: For prediction of the effect, perfusion CT and diffusion MRI were estimated. For the histological response evaluation, perfusion CT, diffusion-MRI, and FDG-PET were estimated. For downstaging evaluation of T4, tissue-selective image reconstruction using enhanced CT was estimated and diagnostic indices were reviewed. Results: The prediction of the effect using perfusion CT with 'pre CRT blood flow' and diffusion MRI with 'pre CRT ADC value'; the estimation of the histological response using perfusion CT with 'post CRT blood flow reduction, using diffusion MRI with 'post CRT ADC increasing', and using FDG-PET with 'post CRT SUV reduction'; and the downstaging evaluation of T4 using CT image reconstruction with 'fibrous changed layer' were performed well, respectively. Conclusions: Qualitative imaging modalities for prediction or response evaluation of neoadjuvant therapy for progressive esophageal cancer were useful for the decision making of the treatment strategy of the multidisciplinary treatment.

Safety and effectiveness of metabolic surgery in older Japanese patients

Aim

According to the current guidelines in Japan, the upper age limit for bariatric and metabolic surgery is 65 y. This study aimed to examine the appropriateness of this upper age limit.

Methods

Using the database maintained by the Japanese Society for Treatment of Obesity, we conducted an analysis of patients in two age groups: those aged <65 y and those aged ≥65 y. Our analysis focused on postoperative weight loss, improvement in comorbidities, and frequency of perioperative complications.

Results

A total of 2885 patients aged <65 y (mean, 43.9 ± 9.5 y) with a preoperative body mass index of 42.4 ± 8.1 kg/m2, while 56 aged ≥65 y (mean, 67.3 ± 3.2 y; maximum, 78 y) with a preoperative body mass index of 40.5 ± 6.6 kg/m2. Patients aged ≥65 y had a higher rate of dyslipidemia and hypertension. The rates of reoperation, surgical complications, and postoperative complications did not differ between the age groups. Both groups achieved significant weight loss postoperatively, and no differences in the improvement of comorbidities were noted. After adjusting the covariate balance via propensity score matching, no age-related differences in perioperative and postoperative complications were observed.

Conclusion

Metabolic surgery is safe and effective for older patients with clinically severe obesity. Weight loss was less in patients aged ≥65 y, but the percentage of total weight loss did not differ between the groups.

Verification of Safety and Efficacy of Sleeve Gastrectomy Based on National Registry by Japanese Society for Treatment of Obesity

In Japan, bariatric surgical treatment was started in 1982. The Japanese Society for Treatment of Obesity (JSTO) was established in 2007, and then, JSTO started the national registry of bariatric surgery cases and multidisciplinary educational program. A total of 44 facilities registered 4055 bariatric surgical cases until 2021. In this study, the purpose is to clarify the indication, the safety and the effectiveness of the sleeve gastrectomy using national registry database compiled by JSTO. Preoperative BMI ranged from 27.6 to 90.7 kg/m², and the mean value was 42.7. With regard to gender, men/women was 1/1.3. Age was 42.2 as mean. As preoperative comorbidities, DM ratio was 54.4% of the patients, hypertension 64.5%, dyslipidemia 65.1%, and sleep apnea syndrome 69.8%. As an operation method, laparoscopic method was conducted in 99.7% of the cases. The intraoperative incidence rate was 0.9%. Conversion rate to open method was 1.1%. Postoperative morbidity ratio was 5.6%, and mortality was 0%. Reoperations were performed in 1.5% of the cases. Postoperative hospital stay was 5 days in median value. Body weight loss was 27.6 kg in the mean value after follow-up days of 279 ± 245. As the effect on the preoperative metabolic comorbidities, DM has improved in 82.9% of the cases, hypertension 67.9% and dyslipidemia 66.6%. In conclusion, using JSTO database, we evaluated the indication, postoperative complications and weight loss effect of sleeve gastrectomy in Japan. Regarding the evaluation of the effect on preoperative comorbidities, future follow-up based on more detailed criteria was considered to be necessary.

Treatments for Staple Line Leakage after Laparoscopic Sleeve Gastrectomy

The number of laparoscopic sleeve gastrectomies (LSGs) performed in patients with obesity who are eligible for bariatric and metabolic surgery is currently much lower in Japan than in other countries. Considering the large number of potential patients with obesity and type 2 diabetes and the unique Japanese national health insurance system that guarantees fair healthcare delivery, there is room to increase the number of LSGs in Japan in the near future. However, strict health insurance regulations may limit access to mandatory devices needed to treat postoperative complications, such as staple line leakage, which can cause severe morbidity and even mortality. Therefore, understanding the pathogenesis and treatment options for this complication is crucial. This article examined the current situation in Japan and its impact on staple line leakage management, including the role of endoscopic treatment in reducing reoperation. The authors suggest increasing education and collaboration between healthcare professionals to optimize management and improve patient outcomes.

Feasibility of Laparoscopic Sleeve Gastrectomy for Patients with Obesity and Disorders of Intellectual Development: a Single Institutional Experience

BACKGROUND

Owing to their difficulty following clinical advice for procedural safety and ideal surgical outcomes, bariatric and metabolic surgery (BMS) for patients with disorders of intellectual development (DID) is concerning. Studies reporting the feasibility of BMS for this population remain scarce. This study aims to clarify the feasibility of laparoscopic sleeve gastrectomy (LSG) for patients with clinically severe obesity and DID.

METHODS

A retrospective analysis of a single institutional prospective database collected from 2010 to 2022 was performed. The Wechsler Adult Intelligence Scale (WAIS) was used to measure intellectual ability before LSG. A multidisciplinary team approach was implemented to give special support and care to patients with DID. Patients were categorized into groups according to their WAIS scores. LSG outcomes were statistically compared between the DID and average intellectual ability groups.

RESULTS

Using the WAIS to measure intellectual ability among patients who underwent LSG, we identified 14 patients with DID (IQ score: < 69, mean IQ: 63.4) and 71 with average intellectual ability (IQ score: 90-109, mean IQ: 98.9). Operative outcomes were comparable between the groups as follows: operation time (DID: 163 ± 41 min, average intelligence: 162 ± 30 min), hospital stay (DID: 4 [4-5] days, average intelligence: 5 [4-6] days), and total comorbidities (DID: 7.1%, average intelligence: 8.4%). No reoperations were performed, and no mortalities were observed.

CONCLUSIONS

With medical and social support and care, performing LSG on patients with clinically severe obesity and DID is safe, with good short-term results.

Estrogen receptor beta expression in colitis-associated carcinoma in comparison with sporadic colonic tumor: An immunohistochemical study

Background and Aim

The rate of ulcerative colitis (UC)-related colorectal cancer (colitis-associated carcinoma) is increasing. Estrogen receptor (ER) beta expression has been studied separately in patients with sporadic colorectal cancer and those with colitis-associated carcinoma. However, no study has compared the expression in both of these cancer types. The present study aimed to evaluate the relationship between colitis-associated carcinoma and ERs and assess whether the expression of ER beta influences cell proliferation.

Methods

This study included 45 surgically operated colitis-associated carcinomas, 43 high-grade dysplasias, 34 low-grade dysplasias, 36 sporadic colorectal cancers, 44 high-grade adenomas, and 34 low-grade adenomas. ER beta expression was evaluated with immunohistochemistry.

Results

Colitis-associated carcinoma showed significantly lower ER beta immunoexpression than sporadic colorectal lesions and high- and low-grade dysplasia. In seven colitis-associated carcinoma harboring both intensity score 3 (strong immunoexpression) and score 1 (weak immunoexpression) areas, the correlation among ER beta intensity, Ki-67, and p21 labeling index was assessed; an area with an ER beta intensity score of 3 showed a higher Ki-67 labeling index than that with score 1. In four out of the seven lesions, p21 labeling index was higher in the area of ER beta score 1 than in that of ER beta score 3.

Conclusions

The data suggest that ER beta expression is an accelerating factor in colorectal tumors. This association may be lower in colitis-associated carcinoma than in sporadic colorectal cancer.

Factors Associated with Relapse of Type 2 Diabetes Mellitus after Laparoscopic Sleeve Gastrectomy in Japanese Subjects: A Subgroup Analysis of J-SMART Study

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients often results in remission of type 2 diabetes (T2DM), but diabetes relapses in some of those patients. The frequency of T2DM relapse in Asians and the factors involved have not been adequately investigated.

METHODS

The J-SMART study was conducted on 322 Japanese subjects with body mass index (BMI) ≥32 kg/m2 who underwent LSG at 10 accredited centers in Japan between 2011 and 2014. Of these, 82 T2DM subjects with diabetes in complete or partial remission at 1 year after LSG and followed postoperatively for 5 years were included in the subgroup analysis and classified into two groups: diabetes remission-maintained and diabetes relapse.

RESULTS

The mean age of all included subjects was 49.2 years, median BMI was 41.5 kg/m2, and median HbA1c was 6.7%. Compared with the diabetes remission-maintained group, the diabetes relapse group at 5 years after LSG had significantly higher preoperative HbA1c, number of antidiabetic medications, and high-density lipoprotein cholesterol level; and lower BMI and homeostasis model assessment-beta cell function (HOMA-β). As many as 83.0% of the subjects were able to achieve HbA1c <7% at 5 years after LSG, but 26.8% of the subjects had diabetes relapse. Preoperative HbA1c significantly contributed to diabetes relapse (odds ratio 1.54, p = 0.049). In addition, the diabetes relapse group tended to have lower percentage total weight loss (%TWL) at 1 year after LSG and higher percentage weight regain (%WR) from postoperative nadir weight, compared with the diabetes remission-maintained group. The hazard ratio for diabetes relapse was 3.14-fold higher in subjects with %TWL ≥20% and %WR ≥25%, and 5.46-fold higher in those with %TWL <20% and %WR ≥25%, compared with %TWL ≥20% and %WR <25%.

CONCLUSION

While LSG provides a high remission rate for T2DM, relapse is not uncommon. Preoperative HbA1c, poor weight loss, and excess weight regain after LSG contribute to diabetes relapse, suggesting the importance of treatment strategies focusing on these factors.

Signet-ring cell carcinoma of the appendix with ganglioneuromatosis: a case report

Background

Primary cancer of the appendix, especially signet-ring cell carcinoma, is an uncommon disease, and it is rarely suspected before surgery. Diffuse intestinal ganglioneuromatosis that is not associated with neurofibromatosis-1 or multiple endocrine neoplasia 2b is also rare. The most frequent symptoms caused by it are changes in bowel habits, abdominal pain, and occlusive episodes.

Case presentation

The patient was a 48-year-old woman who had a month-long history of chronic abdominal pain, fullness, constipation, and diarrhoea. Enhanced computed tomography showed a 100-mm irregular swelling in the appendix and thickening of the appendiceal wall with cystic dilatation. Based on a preoperative diagnosis of appendiceal cancer, the patient underwent laparoscopic ileocecal resection with D3 lymph node dissection. Pathological diagnosis revealed a signet-ring cell carcinoma of the appendix with ganglioneuromatosis. The patient completed four courses of capecitabine plus oxaliplatin (CAPEOX) as postoperative adjuvant chemotherapy, and 23-month postoperative outcome was noneventful without recurrence.

Conclusion

We report a signet-ring cell carcinoma of the appendix that was detected early because of its presence with ganglioneuromatosis.

Cancer stem cell markers CD44v9+/CD133- are associated with low apoptosis in both sporadic and ulcerative colitis-associated colorectal cancers

OBJECTIVE

To elucidate tumor cell behavior associated with cancer stem cell (CSC) marker expression, the expression of CD133, CD44v9, and ALDH1A1, which are considered markers of CSCs, was examined in sporadic and ulcerative colitis (UC)-associated colorectal tumors.

METHODS

A total of 23 cases of sporadic colorectal cancer and 44 cases of adenoma were collected. Additionally, 22 cancer lesions and 38 dysplasia lesions were selected from 28 colectomy cases of UC with neoplastic lesions. Lesions were examined by immunohistochemistry using primary antibodies against CD133, CD44v9, ALDH1A1, Ki-67, cleaved-Caspase 3, and p53.

RESULTS

CD133, CD44v9, and ALDH1A1 showed higher expression in both sporadic and UC-associated tumors than in the normal mucosa. ALDH1A1 expression in sporadic cancer was higher in the right colon than in the left colon (p=0.0089). ALDH1A1 expression in UC-associated cancer was higher in those with longer disease duration than in those with shorter disease duration (p=0.019). The CD44v9+/CD133- region had fewer cleaved-Caspase 3 positive cells in both sporadic and UC-associated cancers. In sporadic cancer, CD133+/ALDH1A1+ regions had fewer apoptotic cells than CD133+/ALDH1A1- regions, while CD133+/ALDH1A1- regions were less proliferative than CD133+/ALDH1A1+ regions in UC-associated cancer.

CONCLUSION

CD44+/CD133- regions were commonly associated with low apoptosis in sporadic and UC-associated cancers; thus, these were considered target areas for CSCs. Additionally, the combination of markers comprising CSCs may differ between sporadic and UC-associated cancers.

Characteristics of Childhood Onset and Post-Puberty Onset Obesity and Weight Regain after Laparoscopic Sleeve Gastrectomy in Japanese Subjects: A Subgroup Analysis of J-SMART

INTRODUCTION

The psychosocial background of subjects with severe obesity developed from childhood onset obesity (CO) and their outcomes after bariatric surgery have not been fully investigated.

METHODS

305 subjects were enrolled in the J-SMART study, which examined the effects of laparoscopic sleeve gastrectomy (LSG) in Japan, and categorized into two groups: CO defined as onset up to 13 years of age (CO group) and post-puberty onset obesity defined as onset after 13 years of age (PPO group). The subjects were followed up for at least 2 years and up to 5 years after LSG. Changes in physical parameters and remission of obesity-related comorbidities were assessed at 2 years after LSG. Weight regain (WR) was also assessed by evaluating the nadir weight after LSG and maximum weight thereafter during follow-up period.

RESULTS

The mean postoperative follow-up period was 3.0 ± 1.1 years. 40.0% of the subjects had CO and these subjects had higher BMI and HOMA-β and lower age, HbA1c, HDL cholesterol, and visceral/subcutaneous fat area ratio compared to those with PPO. The CO group was also characterized by having higher rates of mental retardation, developmental disorders, and obesity in either parent and lower rate of marriage compared to the PPO group. Two years after LSG, there were no differences in total weight loss and remission rates of diabetes, dyslipidemia, and sleep apnea syndrome between the two groups, although remission rate of hypertension was higher in the CO group. The CO group also had a higher rate of WR after LSG than the PPO group, with CO, BMI, mental disorder, and binge eating contributing to WR.

CONCLUSION

This study suggests that CO might be associated with genetic and psychosocial factors. CO and PPO probably differ in pathogenesis and may require different treatment strategies.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

Background characteristics and diabetes remission after laparoscopic sleeve gastrectomy in Japanese patients with type 2 diabetes stratified by BMI: subgroup analysis of J-SMART

Aim

The J-SMART study was the first national survey of Japanese patients undergoing laparoscopic sleeve gastrectomy (LSG). We performed a subgroup analysis of J-SMART focusing on the differences in patient background and diabetes remission between patients with BMI 32-34.9 kg/m² and those with higher BMI.

Methods

In this multi-institutional retrospective study at 10 certified bariatric institutions, 203 Japanese with type 2 diabetes (T2D) and BMI of 32 kg/m² or higher were analyzed (mean age: 49.2 years, BMI: 43.8 kg/m², HbA1c: 7.6%). Patients were stratified into five groups according to preoperative BMI.

Results

Background characteristics in BMI 32.0-34.9 group were higher adjusted HbA1c, higher visceral/subcutaneous fat area ratio, higher prevalence of diabetic retinopathy, higher frequency of insulin use and lower serum C-peptide. Although 2-year percent total weight loss (21.7%) and diabetes complete remission (CR) rate (52.4%) were lower in BMI 32.0-34.9 group, diabetes improvement rate was 81.0%, and the decrease in HbA1c and number of antidiabetic drugs were comparable or greater than those with higher BMI. Higher BMI and no insulin use were significant independent predictors of diabetes CR. No significant independent predictor was identified for diabetes improvement.

Conclusion

The patients with 32-34.9 kg/m² were characterized by more severe visceral obesity, T2D and the complications, and lower intrinsic insulin secretion capacity. LSG should be considered as a treatment option for patients with BMI 32-34.9 kg/m², to improve diabetes control.

A wearable lower extremity support for laparoscopic surgeons: A pilot study

Surgeons have increased physical stress during laparoscopic surgery due to operative site constraints. We developed a wearable device to reduce the physical stress on surgeons' lower extremities. The device mechanically facilitates maintaining a near-upright posture. The surgeon's knees are gently bent by a knee-joint locking mechanism, and fixing and releasing are performed independently on each side. The subjects were one female and two male surgeons, who wore the device during laparoscopic inguinal hernia repair or high anterior resection. Surface electromyogram (EMG) was conducted for both iliopsoas muscles. Control values were determined with the subject not wearing the device. Participants completed a post-procedure questionnaire. With the device, EMG activity had a tendency to decrease in the left iliopsoas muscle (P = .055), but it changed little on the right (P = .406). The post-procedure questionnaire showed an overall positive impression, although subjects reported some difficulty walking. This device decreases EMG activity and may improve a surgeon's work environment.

Risk factors for postoperative stoma outlet obstruction in ulcerative colitis

BACKGROUND

Current medical treatments can achieve remission of ulcerative colitis (UC). Surgery is required when potent drug treatment is ineffective or when colon cancer or high-grade dysplasia develops. The standard procedure is restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, commonly performed as two- or three-stage RPC with diverting ileostomy. Postoperative stoma outlet obstruction (SOO) is frequent, but the causes are not well known.

AIM

To identify the risk factors for SOO after stoma surgery in patients with UC.

METHODS

We retrospectively reviewed the files of 148 consecutive UC patients who underwent surgery with stoma construction. SOO was defined as small bowel obstruction symptoms and intestinal dilatation just below the penetrating part of the stoma on computed tomography. Patients were divided into two groups: Those who developed SOO within 30 d after surgery and those who did not. Patient characteristics, intraoperative parameters, the stoma site, and rectus abdominis muscle thickness were collected. Moreover, we identified the patients who repeatedly developed SOO. Univariate and multivariate analyses were performed to identify risk factors for SOO and recurring SOO.

RESULTS

Eighty-nine patients who underwent two-stage RPC were included between January 2008 and March 2020. Postoperatively, SOO occurred in 25 (16.9%) patients after a median time of 9 d (range 2-26). Compared to patients without SOO, patients with SOO had a significantly higher rate of malignant tumors or dysplasia (36.0% vs 17.1%, P = 0.032), lower total glucocorticoid dose one month before surgery (0 mg vs 0 mg, P = 0.026), higher preoperative total protein level (6.8 g/dL vs 6.3 g/dL, P = 0.048), higher rate of loop ileostomy (88.0% vs 55.3%, P = 0.002), and higher maximum stoma drainage volume (2300 mL vs 1690 mL, P = 0.004). Loop ileostomy (OR = 6.361; 95%CI 1.322–30.611; P = 0.021) and maximum stoma drainage volume (OR = 1.000; 95%CI 1.000–1.001; P = 0.015) were confirmed as independent risk factors for SOO. Eighteen patients with SOO were treated conservatively without recurrence (sSOO group). Seven (28.0%) patients repeatedly developed SOO (rSOO group) during the observation period. A significant difference was observed in the rectus abdominis muscle thickness between the two groups (sSOO 9.3 mm, rSOO 12.7 mm, P = 0.006). Muscle thickness was confirmed as an independent risk factor for recurring SOO (OR = 2.676; 95%CI 1.176-4.300; P = 0.008).

CONCLUSION

In this study, high maximum stoma drainage volume and loop ileostomy are independent risk factors for SOO. Additionally, among patients with a thick rectus abdominis muscle, the risk of SOO recurrence is high.

New Assay System Elecsys Anti-p53 to Detect Serum Anti-p53 Antibodies in Esophageal Cancer Patients and Colorectal Cancer Patients: Multi-institutional Study

BACKGROUND

Several recent studies suggest that serum anti-p53 antibodies (s-p53-Abs) may be combined with other markers to detect esophageal and colorectal cancer. In this study, we assessed the sensitivity and specificity of s-p53-Abs detection of a new electrochemiluminescence immunoassay (ECLIA; Elecsys anti-p53).

METHODS

Elecsys anti-p53 assay was used to analyze the level of s-p53-Abs in blood sera from patients with esophageal or colorectal cancer taken before treatment. Control blood sera from healthy volunteers, patients with benign diseases, and patients with autoimmune diseases served as a reference. In addition, squamous cell carcinoma antigen (SCC-Ag) and cytokeratin 19 fragments (CYFRA21-1) were assessed in patients with esophageal cancer, and carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 were assessed in patients with colorectal cancer.

RESULTS

Samples from 281 patients with esophageal cancer, 232 patients with colorectal cancer, and 532 controls were included in the study. The median value of s-p53-Abs in control samples was < 0.02 μg/mL (range < 0.02-29.2 μg/mL). Assuming 98% specificity, the cut-off value was determined as 0.05 μg/mL. s-p53-Abs were detected in 20% (57/281) of patients with esophageal cancer and 18% (42/232) of patients with colorectal cancer. In combination with SCC-Ag and CEA, respectively, s-p53-Abs detected 51% (144/281) of patients with esophageal and 53% (124/232) of patients with colorectal cancer.

CONCLUSIONS

The new s-p53-Abs assay Elecsys anti-p53 was useful in detecting esophageal and colorectal cancers with high specificity. Adding s-p53-Abs to conventional markers significantly improved the overall detection rates.

Current Status and Issues Associated with Bariatric and Metabolic Surgeries in Japan

Among Asian countries, laparotomic and laparoscopic bariatric surgeries were introduced in Japan after its establishment in Taiwan. However, despite high prevalence of potential patients with obesity and diabetes, the wider incorporation of surgery into treatment regimen has been stalling for decades in Japan. While the unique Japanese national health insurance system has guaranteed fair healthcare delivery, it might have worked as a barrier to the development of bariatric and metabolic surgeries (BMS). The present article reviews the status of BMS in Japan and discusses recent issues related to its use. To focus on and identify the major obstacles inhibiting the widespread use of BMS, we have comprehensively covered some major areas including the insurance system, surgical indication, accreditation and training system, original research, and national registry.

Diagnostic performance of diffusion-weighted magnetic resonance imaging in assessing lymph node metastasis of esophageal cancer compared with PET

BACKGROUND

Although diffusion-weighted magnetic resonance imaging (DWI) for detecting lymph node (LN) metastasis is reported to be a successful modality for primary malignant tumors, there are few studies relating to esophageal cancer. This study aimed to clarify the diagnostic performance of DWI for assessing LN metastasis compared with positron emission tomography (PET) in patients with esophageal squamous cell cancer (eSCC).

METHODS

Seventy-six patients with histologically proven eSCC who underwent curative esophagectomy without neoadjuvant treatment were reviewed retrospectively. Harvested LNs were divided into 1229 node stations with 94 metastases. Diagnostic abilities and prognostic significance were compared.

RESULTS

In a station-by-station evaluation, the sensitivity was higher in DWI than PET (67% vs. 32%, P < 0.001). DWI showed more than 80% sensitivity for middle- and large-sized cancer nests and large area of cancer nests. The DWI-N0 group had a better 5-year relapse-free survival rate than the DWI-N+ group (78.5% vs. 34.2%, P < 0.001), as did the PET-N0 group. DWI-N status was an independent prognostic factor (hazard ratio [HR], 2.642; P = 0.048), as was PET-N status (HR 2.481; P = 0.033).

CONCLUSIONS

DWI, which depends on cancer cell volume followed by elevated intranodal density, is a non-invasive modality and showed higher sensitivity than PET. It has clinical impact in predicting postoperative survival for patients with eSCC alongside its diagnostic ability and has significant performance in clinical practice.

Background characteristics and postoperative outcomes of insufficient weight loss after laparoscopic sleeve gastrectomy in Japanese patients

AIM

Laparoscopic sleeve gastrectomy (LSG) is becoming popular in Japan, but insufficient weight loss is often observed in patients after LSG. We investigated the effect of LSG on obesity-related comorbidities and identified the background characteristics of Japanese patients with insufficient weight loss after LSG.

METHODS

In this multi-institutional retrospective study at 10 certified bariatric institutions, 322 Japanese patients who underwent LSG with a follow-up period of more than 2 years were analyzed. Anthropometry, obesity-related comorbidities and psychosocial background data were collected. Weight loss was expressed as 2-year percent total weight loss (%TWL).

RESULTS

Mean age, body weight, body mass index (BMI) and glycated hemoglobin were 46.9 years, 119.2 kg, 43.7 kg/m2 and 7.1%, respectively. Prevalence of mental disorders was 26.3%. Mean BMI declined to 30.3 kg/m2 at 2 years and %TWL was 29.9%. Improvements in the markers and prevalence of obesity-related comorbidities were observed. Remission rates of diabetes, dyslipidemia and hypertension were 75.6%, 59.7% and 41.8%, respectively. %TWL at the respective cut-off level of diabetes remission was 20.8%. Lower remission rates of diabetes in patients with %TWL <20%, and less calorie restriction and higher prevalence of mental disorders (46.9%) in patients with %TWL <15% were observed. Frequencies of %TWL <15% and <20% were 6.5% and 18.5%, respectively.

CONCLUSION

%TWL 20% was a candidate cut-off point of insufficient weight loss for diabetes remission after LSG, and mental disorders might be relevant to intractable obesity in Japanese patients.

Morphological and Biological Characteristics of Staphylococcus aureus Biofilm Formed in the Presence of Plasma

Characteristics of Staphylococcus aureus infections include biofilm formation, leading to the spread of bacteria to the bloodstream causing sepsis and metastatic infections. In particular, in methicillin-resistant S. aureus (MRSA) infections, biofilm formation critically hampers treatment and causes poor prognosis. We explored the biofilm formation of MRSA in the presence or absence of plasma and compared morphological characteristics, accumulation of antibiotics, and resistance to bactericidal activity, using continuous optimizing confocal reflection microscopy. Addition of plasma significantly increased biofilm formation, which is characterized by an uneven surface and aggregation of bacteria (hereafter plasma biofilm). The flow-cell system, which enabled a continuous supply of plasma, accelerated biofilm formation in both the tested strains of MRSA (BAA1556 and N315). Accumulation of green fluorescence-labeled vancomycin was observed within 5 minutes in the plasma-free biofilm, but not in the plasma biofilm. Delay of accumulation was also observed for daptomycin in plasma biofilm. Plasma biofilm bacteria were more resistant to anti-MRSA antibiotics than plasma-free biofilm bacteria. These data demonstrate that the plasma biofilm of S. aureus is substantially different from the plasma-free biofilm. Plasma biofilm, especially in the flow-cell system, could be a clinically relevant model to analyze MRSA infections and treatment.

Salvage Carbon-ion Radiotherapy for Isolated Lymph Node Recurrence Following Curative Resection of Esophageal Cancer

AIM

Evaluation of the therapeutic efficacy of carbon-ion radiation therapy for isolated lymph node recurrence following curative resection of esophageal cancer.

MATERIALS AND METHODS

Ten cases with lymph node recurrence after esophageal cancer surgery were treated with carbon-ion radiation therapy. A total of 48.0 Gy [relative biologic effectiveness (RBE)] was delivered over 3 weeks with a daily dose of 4.0 Gy (RBE).

RESULTS

The median follow-up duration was 27.1 months (range=3-92.0 months) after carbon-ion radiation therapy. The local control rates at 2, 3 and 5 years were 92.4%. The overall survival rates at 2, 3 and 5 years were 70.0%, 58.3% and 21.9%. The median survival period was 45.3 months after carbon-ion radiation therapy. There were no toxicities of grade 3 or higher.

CONCLUSION

Carbon-ion radiation therapy may be a safe and effective treatment option for isolated lymph node recurrence after radical surgery for esophageal cancer.

Proximal Gastrectomy with Double Tract Reconstruction Is an Alternative Revision Surgery for Intractable Complications After Sleeve Gastrectomy

Gastric leakage and stricture are challenging complications of sleeve gastrectomy (SG). Failure of endoscopic intervention necessitates revision surgery. We describe two cases in which proximal gastrectomy with double tract reconstruction (PG with DTR) was performed in patients with chronic gastric fistula and twisted gastric tube after SG. Following resection of the affected part of the proximal stomach, reconstruction was achieved with three anastomoses [esophagojejunostomy (EJ), gastrojejunostomy (GJ), and jejunojejunostomy]. DTR provides two exit routes, the remnant stomach and the distal jejunum. The GJ was created 15 cm below the EJ with a stoma 10 mm in diameter, which can pass a standard endoscope. Both cases were a success without any short-term complications. PG with DTR could be an alternative option for refractory complications of SG.

[A Case of Advanced Gastric Cancer Responding Effectively to Neoadjuvant Chemotherapy]

A 78-year-old man underwent an upper gastrointestinal endoscopy for evaluation of epigastralgia. Endoscopy revealed a bulky type 3 tumor in the lesser curvature of the upper body. A biopsy showed a poorly differentiated adenocarcinoma with signet ring cell carcinoma. Additionally, abdominal computed tomography(CT)showed bulky lymph node metastases leading to a diagnosis of cT3N2M0, Stage III A carcinoma. Following administration of 2 courses of neoadjuvant chemotherapy (NAC)using S-1/cisplatin(CDDP), CT revealed significant regression of the primary lesion and lymph nodes. Eventually, laparoscopic total gastrectomy was performed. Histopathologically, almost all viable cancer cells had been cleared from the primary lesion, and no cancer cells were found in the lymph nodes, which indicated a pathological partial response(Grade 2). NAC could be a valid option for the treatment of advanced gastric cancer.

Heterogeneity of Glucose Metabolism in Esophageal Cancer Measured by Fractal Analysis of Fluorodeoxyglucose Positron Emission Tomography Image: Correlation between Metabolic Heterogeneity and Survival

BACKGROUND

Intratumoral heterogeneity is a well-recognized characteristic feature of cancer. The purpose of this study is to assess the heterogeneity of the intratumoral glucose metabolism using fractal analysis, and evaluate its prognostic value in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) studies of 79 patients who received curative surgery were evaluated. FDG-PET images were analyzed using fractal analysis software, where differential box-counting method was employed to calculate the fractal dimension (FD) of the tumor lesion. Maximum standardized uptake value (SUVmax) and FD were compared with overall survival (OS).

RESULTS

The median SUVmax and FD of ESCCs in this cohort were 13.8 and 1.95, respectively. In univariate analysis performed using Cox's proportional hazard model, T stage and FD showed significant associations with OS (p = 0.04, p < 0.0001, respectively), while SUVmax did not (p = 0.1). In Kaplan-Meier analysis, the low FD tumor (<1.95) showed a significant association with favorable OS (p < 0.0001). In wthe multivariate analysis among TNM staging, serum tumor markers, FD, and SUVmax, the FD was identified as the only independent prognostic factor for OS (p = 0.0006; hazards ratio 0.251, 95% CI 0.104-0.562).

CONCLUSION

Metabolic heterogeneity measured by fractal analysis can be a novel imaging biomarker for survival in patients with ESCC.

Percutaneous transesophageal gastro-tubing for management of gastric leakage after sleeve gastrectomy

Gastric leakage is a challenging complication of sleeve gastrectomy. Multimodal approaches, including drainage, clipping, and stenting of the leak, are occasionally insufficient. We report successful management of refractory gastric leakage using percutaneous transesophageal gastro-tubing (PTEG). Drainage and stenting proved inadequate for treating sleeve leakage near the esophagogastric junction in two patients. PTEG was finally performed, and enteral feeding was started on the following day. The patients were discharged within 1 week. The PTEG-tube was removed after confirming oral food intake. Both patients continue to do well without recurrence. PTEG was developed for patients who are unsuitable for percutaneous endoscopic gastrostomy. PTEG provides decompression and permits enteral feeding in patients refractory to other endoscopic treatments. PTEG is an option for managing intractable sleeve leakage without surgery.

[Usefulness of FDG-PET for superficial esophageal squamous cell carcinoma]

We investigated the usefulness of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for superficial esophageal squamous cell carcinoma after resection via endoscopic submucosal dissection (ESD). Our case study included 37 patients and 49 tumors resected via ESD in our hospital between January 2012 and December 2013. Histopathological diagnosis confirmed squamous cell carcinoma in all cases. Tumors located near the esophago cardiac junction were excluded. We investigated retrospectively whether the standardized uptake value (SUV) obtained by using FDG-PET could be the criterion to decide whether to perform ESD. At first, the tumor was examined via endoscopy. If tumor depth (T status)was less than cSM1, we performed ESD. When the tumor depth was less than pSM1, no infiltration of the vessel or lymph duct was observed, and the surgical margin was free; therefore, we did not perform any further therapy. On the other hand, we measured the SUV obtained via FDG-PET. The cut-off value was set as 3.0 based on the correlation between the SUV and tumor depth. We investigated if SUV<.0 could be the criterion for further therapy after ESD. In our results, the sensitivity was 95%, specificity was 67%, and accuracy was 90%. The SUV also helped to identify the malignancy of the superficial esophageal cancer and could help to decide whether ESD should be undertaken.

Efficacy and tolerability of oxycodone for oxaliplatin-induced peripheral neuropathy and the extension of folfox therapy in colorectal cancer patients

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Background: The oxaliplatin-based regimen FOLFOX is widely used to treat patients with advanced colorectal cancer (CRC). However, dose-limiting toxicity after continuous oxaliplatin administration can lead to peripheral neuropathy. Several agents, including opioids, that have been employed to treat oxaliplatin-induced peripheral neuropathy (OIPN) have been examined in clinical settings regarding their protective and therapeutic effects. However, the pharmacotherapy of these agents has not yet been established. Therefore, we investigated the efficacy and tolerability of oxycodone for OIPN and subsequently with FOLFOX therapy in CRC patients. Methods: This was a single-center retrospective study of 64 CRC patients who underwent FOLFOX therapy at the Toho University Sakura Medical Center (Sakura, Japan). Controlled-release (CR) oxycodone was concomitantly administered to 29 patients (OXY group), whereas the additional 35 patients (non-OXY group) were not given oxycodone during the FOLFOX treatment course. The incidence and severity of OIPN and the number of FOLFOX cycles were measured and compared between the two groups. Neurological toxicities were assessed according to the Common Terminology Criteria for Advanced Events, version 3.0. Results: All study patients had OIPN. Most patients experienced grade 1 or 2 sensory neuropathy. Grade 3 sensory neuropathy was observed in two patients in the non-OXY group. All patients in the OXY group completed the scheduled FOLFOX therapy, whereas FOLFOX therapy was discontinued in ten patients in the non-OXY group due to severe peripheral neuropathy. The median numbers of FOLFOX cycles in the OXY and non-OXY groups were 13 (range, 6–46) and 7 (range, 2–18), respectively (P < 0.05). The median cumulative oxaliplatin doses were 1072.3 mg/m2 (range, 408.7–3385.3 mg/m2) in the OXY group and 483.0 mg/m2 (range 76.2–1414.1 mg/m2) in the non-OXY group (P < 0.05). Conclusions: Our findings indicate that CR oxycodone might attenuate the severity of OIPN and extend the use of FOLFOX therapy.

Efficacy and tolerability of controlled-release oxycodone for oxaliplatin-induced peripheral neuropathy and the extension of FOLFOX therapy in advanced colorectal cancer patients

Background

The oxaliplatin-based regimen FOLFOX is widely used to treat patients with advanced colorectal cancer (CRC). However, dose-limiting toxicity after continuous oxaliplatin administration can lead to peripheral neuropathy. Several agents, including opioids, that have been employed to treat oxaliplatin-induced peripheral neuropathy (OIPN) have been examined in clinical settings regarding their protective and therapeutic effects. However, the pharmacotherapy of these agents has not yet been established. Therefore, we investigated the efficacy and tolerability of oxycodone for OIPN and subsequently with FOLFOX therapy in CRC patients.

Methods

This was a single-center retrospective study of 64 CRC patients who underwent FOLFOX therapy at the Toho University Sakura Medical Center (Sakura, Japan). Controlled-release (CR) oxycodone was concomitantly administered to 29 patients (OXY group), whereas the additional 35 patients (non-OXY group) were not given oxycodone during the FOLFOX treatment course. The incidence and severity of OIPN and the number of FOLFOX cycles were measured and compared between the two groups. Neurological toxicities were assessed according to the Common Terminology Criteria for Advanced Events, version 3.0.

Results

All study patients had OIPN. Most patients experienced grade 1 or 2 sensory neuropathy. Grade 3 sensory neuropathy was observed in two patients in the non-OXY group. All patients in the OXY group completed the scheduled FOLFOX therapy, whereas FOLFOX therapy was discontinued in ten patients in the non-OXY group due to severe peripheral neuropathy. The median numbers of FOLFOX cycles in the OXY and non-OXY groups were 13 (range, 6–46) and 7 (range, 2–18), respectively (P < 0.05). The median cumulative oxaliplatin doses were 1072.3 mg/m² (range, 408.7–3385.3 mg/m²) in the OXY group and 483.0 mg/m² (range 76.2–1414.1 mg/m²) in the non-OXY group (P < 0.05).

Conclusions

Our findings indicate that CR oxycodone might attenuate the severity of OIPN and extend the use of FOLFOX therapy.

[Evaluation of false-negative lymph nodes diagnosed by fludeoxy glucose-positron emission tomography in cases of metastatic esophageal squamous cell carcinoma]

We have encountered many cases wherein the metastatic nest of esophageal squamous cell carcinoma occupied only a small space in the lymph nodes because of which computed tomography( CT) and fludeoxy glucose( FDG)-positron emission tomography( PET) could not detect the lymph node metastasis satisfactorily. The false-negative lymph nodes that were not detected by FDG-PET before surgery were smaller in diameter, rate of occupation, and area of occupation than the true-positive lymph nodes. The smallest area of the cancer nest in the true-positive group was 7.5 mm2, and therefore, it was reasonable to consider a 5-mm diameter area as the criteria for correct diagnosis by FDG-PET. Most of the false-negative lymph nodes with a large area of carcinoma were attached to the primary tumor; therefore, they could not be precisely identified. The detection of false-negative lymph nodes by FDG-PET was not precise because of increases in the quantity of stroma-like cells in poorly differentiated carcinomas and in fibrosis caused by neoadjuvant therapy in the lymph nodes.

[Evaluation of tumor heterogeneity for esophageal squamous cell cancer by dynamic FDG-PET]

The aim of this study is to assess the tumor heterogeneity of esophageal squamous cell cancer by dynamic FDG-PET (dPET). Thirty patients were enrolled in this study. Images were obtained after intravenous injection of 370 MBq of 18F-FDG for 1 h. The time-density curve of the standardized uptake value( SUV) was evaluated quantitatively by fractal analysis. Tumor fractal dimension (FD) maps were acquired, and the FD of the tumor was measured. There was a significant correlation between FD and the clinical response to adjuvant therapy. The FD reduction rates of adjuvant therapy were 23.23% in the responder group and 5.83% in the nonresponder group. FD may be a valid imaging biomarker for assessing the response to neoadjuvant therapy.

Tumor-like growth of giant inflammatory polyposis in a patient with ulcerative colitis

We report a unique case of giant obstructing inflammatory polyposis associated with ulcerative colitis (UC). A 25-year-old Japanese man with an UC history of 2 years and 6 months was referred to our institution because of diarrhea and melena. His computed tomography scan showed marked dilation of the transverse and descending colon; therefore, we performed total colectomy. Macroscopic evaluation of the excised specimen indicated constricting lesions with giant polyposis in the transverse and descending colon. The polyposis consisted of narrow worm- or noodle-like polyps that bridged over the irregular ulcers. Histologic evaluation of the excised specimen indicated transmural inflammation with a thickened proper muscular layer overlaid with inflammatory polyposis. Based on these data, a diagnosis of giant inflammatory polyposis should be considered in patients who have had UC. Although giant inflammatory polyposis is considered benign, surgical treatment may be indicated to avoid serious complications.

β-2 microglobulin is unsuitable as an internal reference gene for the analysis of gene expression in human colorectal cancer

It is well-known that gene expression levels should be normalized to a carefully selected and appropriately stable internal control gene. However, numerous studies have demonstrated that the expression of housekeeping (HK) genes, typically used as internal control genes varies considerably. A number of studies have shown that β-2 microglobulin (B2M), an HK gene, frequently used as an internal reference gene, is expressed at low levels in colorectal cancer tissue, when assessed using real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Due to the fact that the expression levels of various HK genes vary depending on the tissue type or experimental conditions, it has been suggested that several control genes should be analyzed in parallel for certain tissues. In the present study, mRNA expression levels of toll-like receptors 2 (TLR2) and 4 (TLR4) in sporadic human colorectal cancerous and non-cancerous tissues were analyzed relative to three HK genes, β-glucuronidase (GUS), β-actin (BA) and B2M, using a commercially available tool. Relative expression levels were quantified using the three genes individually and together, and TLR2 as well as TLR4 expression was compared in cancerous and non-cancerous colorectal tissue specimens. Consistent data were obtained in most cases when GUS and BA were used as internal control genes. When B2M was used as the internal control gene, TLR2 and TLR4 expression was demonstrated to be higher in cancerous compared to non-cancerous colorectal tissues. These results were consistent with previous observations of low-level B2M expression in cancerous colorectal tissue and suggest that B2M may be inappropriate as an internal control gene for gene expression studies of colorectal cancer.

Tissue expression of Toll-like receptors 2 and 4 in sporadic human colorectal cancer

Background

Toll-like receptors (TLRs) play an important role in innate immunity by sensing a variety of pathogens and inducing acquired immunity. To test our hypothesis that dysregulation of innate immune responses acts to trigger carcinogenesis, we studied the expression of TLR2 and 4 in sporadic human colorectal cancer tissue.

Methods

In specimens of cancerous and noncancerous colorectal tissue obtained at surgery, mRNA expression levels of TLR2 and 4 were quantified by TaqMan real-time polymerase chain reaction and compared between the two types of tissue. To confirm TLR2 and TLR4 protein expression levels, immunohistochemical analysis was performed using the same samples.

Results

TLR2 mRNA expression was significantly higher in cancerous tissue than in noncancerous tissue, while TLR4 mRNA expression did not differ significantly. Immunohistochemical analysis revealed stronger staining for TLR2 in cancerous mucosal epithelial cells than in noncancerous tissue. Staining for TLR4 in the lamina propria of the mucosa was equally weakly positive in noncancerous tissue and cancerous tissue. This TLR-specific difference in expression suggested that such expression does not only reflect a local inflammatory response to cancer infiltration, i.e., if this was the case, both TLR2 and 4 expression would probably be up-regulated. Our results suggest that TLR2 expression might be involved in sporadic colorectal carcinogenesis, whereas TLR4 is not.

Apparent diffusion coefficient values measured by diffusion-weighted imaging predict chemoradiotherapeutic effect for advanced esophageal cancer

BACKGROUND

The purpose of this study was to assess whether apparent diffusion coefficient (ADC) values of esophageal squamous cell carcinoma (ESCC) predict responses to chemoradiotherapy (CRT) and/or patient prognosis.

METHODS

Magnetic resonance images were acquired to construct the diffusion-weighted images, and the ADC values were calculated before CRT in 80 patients with ESCC. A high-ADC group responded better to CRT than did a low-ADC group (p < 0.01). We divided the 80 patients into two groups based on the operating characteristic analysis: one group comprised patients with ADC values higher than the average ADC of the esophageal cancer tissue (1.10 × 10(-3) mm2/s), and the other group comprised those whose ADC values were less than the average value. A Kaplan-Meier analysis showed that the survival rate in the high-ADC group was significantly better than that in the low-ADC group (p = 0.04).

CONCLUSION

Our results indicate that the ADC value may be a useful marker to predict treatment response as well as survival for patients with ESCC.

Abdominal wall infiltration by small bowel adenocarcinoma in a patient with Crohn's disease--a case report

A 46-year-old man with Crohn's disease was referred to our hospital. In 2007, abdominal pain accompanied by redness and swelling of the right lower quadrant developed. A small bowel series and computed tomography of the abdomen revealed a stricture in the terminal ileum, suggesting a penetration of the abdominal wall. He was transferred to the department of surgery, and the affected portion of the bowel was resected to eliminate the stricture. At laparotomy, the ileum 35 cm proximal to the ileocecal valve adhered to the abdominal wall in the right lower quadrant. The involved site of the ileal wall and a portion of the abdominal wall were resected. Postoperative microscopic examination revealed an invasion of the abdominal wall by an ileal adenocarcinoma; reoperation was therefore performed. Histopathological examination revealed an adenocarcinoma at the previously sutured site of the ileal wall, against a backdrop of Crohn's disease. The postoperative recovery was good, and the patient received chemotherapy. During follow-up, computed tomography and positron emission tomography demonstrated abnormal changes of the abdominal wall, suggesting a recurrence. He received radiotherapy of the abdominal wall. Although he had tentative regression, the patient died 1 year and 9 months after the first operation.

Japanese Gastric Cancer Association Task Force for Research Promotion: clinical utility of ¹⁸F-fluoro-2-deoxyglucose positron emission tomography in gastric cancer. A systematic review of the literature

Since April 2010, the Japanese Public Health Insurance System has covered the costs incurred for performing ¹⁸F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) imaging for patients with advanced gastric cancer. The aim of this review was to evaluate the clinical impact of PET for patients with gastric cancer. A systematic literature search was performed in PubMed/MEDLINE using the keywords "gastric cancer" and "PET" to search for relevant articles published from January 2000 to September 2010. The clinical impact of selected articles was assessed by the authors to evaluate the following: (a) tumor staging, (b) diagnosis for recurrent disease, (c) evaluation of treatment response, and (d) screening for gastric cancer. FDG uptake increases in papillary adenocarcinoma, tubular adenocarcinoma, and solid-type poorly differentiated adenocarcinoma. This uptake is also associated with glucose transporter 1 expression. The sensitivity and specificity of FDG-PET for metastatic lymph node detection were 21-40% and 89-100%, respectively. The sensitivity and specificity for distant metastasis detection were 35-74% and 74-99%, respectively. Treatment response can be detectable at an earlier stage by PET than by computed tomography (CT), because FDG uptake by cancer cells decreases according to the treatment response. In summary, although PET has limitations such as frequent false-negative cases in signet-ring cell carcinoma and non-solid type poorly differentiated carcinoma, it can contribute to the selection of a more appropriate treatment modality by detecting distant metastases and treatment response.

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.

[Regional treatment of esophageal liver metastasis by intra-arterial low-dose 5-FU therapy]

The prognosis of esophageal liver metastasis remains poor because of the high incidence of synchronous metastasis in other area and insufficient response to systemic chemotherapy. We assessed loco-regional anticancer potential of intra-arterial 5-FU chemotherapy for esophageal liver metastasis aimed at combination with systemic chemotherapy, radiotherapy and ablation therapy as a multidisciplinary treatment. Six patients of esophageal cancer with liver metastasis and without extra-hepatic metastasis were enrolled. Intra-aortic chemotherapy consisted of 5-FU (250 mg/body) in a one-shot infusion or a continuous infusion for 7 days with 2-week intervals until failure. The responses of liver metastasis were 2 cases of CR, 3 of PR and 1 of SD. The response rate and the local control rate were 83% and 100%, respectively. The maximum time to progression was 53 months. Grade 3/4 toxicity was not observed. Two cases had catheter failure and the treatment was interrupted. Liver metastases were controlled well until death in all cases except one. Low-dose intra-aortic 5-FU chemotherapy provided a good regional response and a combination with systemic chemotherapy may prolong survival for the patients of liver metastasis of esophageal cancer.

Role of perfusion CT in assessing tumor blood flow and malignancy level of gastric cancer

BACKGROUND/AIMS

Intratumoral hemodynamics or tumor perfusion is useful in understanding the pathological background of the cancer. A parameter for a non-invasive, preoperative assessment of tumor perfusion has yet to be developed.

METHODS

The study included 50 patients who underwent surgery for gastric cancer. Perfusion computed tomography (P-CT) was performed using a 16-row multidetector CT, and tumor blood flow (ml/min/100 g tissue) values were measured. We compared blood flow with histopathological characteristics and evaluated its correlation with microvessel density and tumor stromal density and calculated the ratio of vessels and stromal tissue.

RESULTS

There was a significant decrease in blood flow in advanced tumor depth, peritoneal dissemination and undifferentiated subtypes. Cases with Lauren's diffuse type carcinoma were found to have decreased blood flow compared to the mixed or intestinal type. As for the stromal structure, despite the lack of correlation with microvessel density, blood flow significantly decreased with increased stromal density.

CONCLUSIONS

Decreased blood flow value acquired from P-CT may reflect a progressive state of gastric cancer. The pathological background for this relation involves the tumor stroma. Tumor perfusion decreased as the stage and malignant character of the tumor advanced, and therefore P-CT could be a better strategy to estimate the malignancy level of cancer.

Evaluation of ulcerative colitis using diffusion-weighted imaging

BACKGROUND/AIMS

The aims of this study were to determine the feasibility of diffusion-weighted imaging (DWI) for detecting bowel inflammation and to investigate the changes in the apparent diffusion coefficient (ADC) values in the inflamed bowel of patients with ulcerative colitis (UC).

METHODOLOGY

Seven patients, who underwent DWI for UC and curative total colectomy because of insistence on conservative therapy, were enrolled in this study. The resected specimens were examined histopathologically to determine the degree of inflammation and the presence of malignancy. The ADC values of the lesions were calculated and compared among UC lesions.

RESULTS

The mean ADC value of the active UC lesions was significantly (p < 0.01) lower than that of the normal colorectal tissue (1.12 +/- 0.14 x 10(-3) mm2/s vs. 1.60 +/- 0.21 x 10 (-3) mm2/s, respectively). The mean ADC value of the active lesions was significantly (p < 0.01) lower than that that of the healing lesions (1.12 +/- 0.14 x10(-3) mm2/s vs. 1.62 +/- 0.28 x 10(-3) mm2/s, respectively).

CONCLUSIONS

DWI may be valuable for following patients with UC, and the stage of UC may be diagnosed easily based on the ADC values.

Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy

BACKGROUND

Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of technical difficulties, especially esophagojejunal anastomosis. Various modified procedures for reconstruction have been reported, but an optimal method has not been established. The authors report a circular-stapled anastomosis using hand-sewn purse-string sutures, which is a simple and classic method. However, no previous study has assessed its reliability.

METHODS

From September 2008 to May 2009, 10 consecutive patients (9 men and 1 woman) with gastric cancer underwent LTG at the authors' institution. These patients had a median age of 63.7 years (range, 45-80 years) and a body mass index of 22.4 kg/m(2) (range, 18-26 kg/m(2)). After transection of the abdominal esophagus, a hand-sewn purse-string suture along the cut end of the esophagus was performed using 3-0 monofilament thread. An anvil head then was inserted into the esophagus, and the thread was tied. A monofilament pretied loop suture was added to reinforce the ligation. After the creation of an Roux-en-Y jejunal limb, laparoscopic esophagojejunal anastomosis was performed using a circular stapler inserted via a surgical glove attached to a wound retractor at the incision point at the umbilicus. The jejunal stump was closed with an endoscopic linear stapler.

RESULTS

Laparoscopic esophagojejunostomy was performed successfully for all the patients. No postoperative complications related to anastomosis occurred. In one patient, an intraabdominal abscess developed postoperatively and was treated conservatively. The mean operation time was 257 min, and the estimated blood loss was 69 ml.

CONCLUSIONS

With the described method, esophagojejunostomy can be performed as in conventional open surgery. Hand-sewn purse-string suturing is demanding technically, but it can be performed safely by experienced laparoscopic surgeons. This technique is feasible and can lower the cost of the laparoscopic procedure. It may be considered in countries with limited access to other special devices.

Intersigmoid hernia: Report of a case

A 28-year-old man with no previous history of abdominal surgery presented at a local hospital with abdominal pain. He was diagnosed to have an intestinal obstruction and was treated conservatively. However, the symptoms persisted, and he was thereafter referred to this hospital. Plain abdominal radiographs demonstrated small-bowel gas. A computed tomographic scan of the abdomen disclosed wall thickening of an edematous, fluid-filled ileum. An exploratory laparotomy was performed to determine the cause of the intestinal obstruction. The ileum had herniated into the intersigmoid fossa, 100 cm proximal to the ileocecal valve, and the patient was diagnosed to have an intersigmoid hernia. Since the incarcerated portion of the small bowel was viable, reduction of the hernia and closure of the defect in the sigmoid mesocolon were performed. The postoperative course was uneventful. A sigmoid mesocolon hernia is an uncommon condition. This report presents a case of intersigmoid hernia and a review of 60 cases of sigmoid mesocolon hernia reported in Japan.

[Ten cases of advanced gastro-intestinal cancer that required preoperative dosage of PSK]

We examined ten convalescent cases of local progression digestive organ cancer, which required a radical operation after a 2-week administration of preoperative dosage of PSK. Because adjuvant chemotherapy was performed for all of the cases, 3 out of 5 advanced gastric cancer patients and 4 out of 5 advanced colorectal cancer patients had more than 5-year survival. We might be effective in controlling a host immune compromise for the lap art period, which was our aim, how long preoperative PSK dosage has contributed for the extension of survival duration. We also examined the influence of the dosage in this study in preoperational of PSK, which gave a host immune compromise by the operational aggression so far, and we reported it as well.

A case of ectopic breast cancer with a literature review

A 63-year-old woman was referred to our hospital because of a right axillary nodule in 2004. Physical examination showed a spherical nodule measuring 0.5cm in diameter in the right axilla. No mass was palpable in either breast. Mammograms were normal. Ultrasonography revealed a subcutaneous hypoechoic mass 0.7mm in maximum diameter in the right axilla. The patient underwent an excisional biopsy. Histological examination revealed an invasive ductal carcinoma (scirrhous carcinoma) in ectopic breast tissue. The patient subsequently underwent a wide local excision of the tissue surrounding the biopsy scar, with axillary lymph node dissection. Histologically, no residual tumor or nodal metastasis was found. Postoperatively, she received endocrine therapy and remains well, without any evidence of recurrence 4 years 10 months after operation. Cancer of the ectopic breast tissue is rare, and most cases present as a solitary axillary mass. Long-term outcomes remain unclear. We present a case of breast carcinoma in the axillary ectopic mammary gland and summarize the clinical features of 94 cases, including ours, in Japan. We also compare long-term survival between ectopic breast cancer and usual breast cancer according to TNM T stage and lymph node metastasis.